Quality objectives for the Breast Cancer Registry of Norway
The recommendations in the Breast Cancer Action Programme and EUSOMA's quality objectives (European guidelines) form the basis for registration of quality objectives in the National Breast Cancer Registry.
The Breast Cancer Registry also includes several time measures, including time from primary examination to diagnosis, time to surgical treatment, time from completion of surgical treatment to further oncological treatment (both chemotherapy and radiotherapy).
Quality goals of the National Quality Registry for Breast Cancer:
From Annual Report 2022 Breast Cancer, fig. 1.1.
The figure shows coverage ratio analyses for assessment, surgery, first post-operative check-up and radiology in 2022. Of 4129 unique patients, assessment reports have been submitted for 3792 patients, and the coverage rate for the entire country in 2022 is 91.8%, which means high goal attainment. Two hospitals do not have a satisfactory coverage of ≥ 80 % (see Figure 5.1 in the report).
The process indicator breast-conserving surgery for breast cancer cases with tumour size 0-30 mm is a national quality indicator where the goal is that ≥ 85 % should undergo breast-conserving surgery. In 2022, 87.4 % of patients with this tumour size underwent breast-conserving surgery in Norway (cf. Fig. 3.21 in the report).
The Norwegian Directorate of Health has also defined 5-year relative survival for patients diagnosed with breast cancer as the national quality indicator.
The quality target for relative survival for 5 years is ≥ 88% in the period 2018-2022. There were a total of 18 252 breast cancer patients in this period. 5-year relative survival for the country as a whole is 92 % and 10-year relative survival is 87 % (see Fig. 3.45 in the report).
An estimate of 5 and 10 years of relative survival is not a good measure of differences in breast cancer treatment. There is variation in support for the public screening programme in Norway, and therefore the women who belong to the various hospitals may have a skewed spread of disease. This affects the outcome for relative survival.
The registry has access to data to perform analyses of demographic differences such as age, gender, place of residence at the time of diagnosis, treatment institution and date of death. Analyses of any differences between hospitals will depend on the degree of clinical reporting. It is a prerequisite that the completeness of the data is high in order to assess whether patients have access to equally good assessment, treatment and follow-up/control throughout the country.
There is reason to believe that the introduction of the Breast Cancer Registry, with annual reports on the practice of the individual hospitals, has been and will continue to be of great importance in order to achieve as much practice as possible in Norway and that new practice is implemented more quickly.
The results of this year's report so far show that the recommendations related to surgical treatment are largely complied with, with some exceptions and with some variation.
Some hospitals treat too few breast cancer patients. The academic community has had a clear focus on operational volume in recent years. The Møre og Romsdal Health Trust has decided to discontinue breast cancer surgery in Molde as of 01.01.2022. Most people will now undergo breast cancer surgery in Ålesund, which has built up a robust professional environment. The hospitals work closely with joint MDT meetings.
Fewer hospitals now have volumes below the minimum requirement of 100 surgeries per year. The fact that some hospitals have small volumes means that treatment given to patients at these hospitals cannot be evaluated
Results in 2021 showed a low proportion of breast-conserving operations of DCIS with a tumour size between 0–20 mm at Telemark Hospital. The Cancer Registry has provided information on a low proportion. Telemark Hospital requested lists for review in April 2022, and that this was raised at a professional meeting in Telemark on 23.9.2022. The hospital has followed up on the reason why they have so few DCIS. Among other things, radiologists will be more observant. The hospital has had problems with vacuum biopsies. Results in this year's report show that the hospital has increased its proportion from 69.2% in 2021 to 83.3% in 2022.
There are large variations in the use of MRI for women with operable disease, this is an important patient-oriented area of improvement. There should be more uniform MRI practice at the breast diagnostic centres (BDS) and increased collaboration between these. Efforts to find the right use of MRI breasts and increase reporting should continue with radiologists, surgeons and oncologists.
An annual reminder is sent out to radiologists to record MRI. The radiologists focus on uniform coding of examinations, procedures and findings.
Efforts to find the right use of MRI breasts and increase reporting should continue with radiologists, surgeons and oncologists.
The reporting of MRI has increased in recent years and is stable. Many hospitals achieve high achievement rates, but there are still variations between hospitals. This will be followed up in forthcoming reports.
The National Action Programme has expanded the indication for the use of systemic pretreatment. The proportion who have received neoadjuvant therapy varies considerably (9 %-37 %). This may be contingent on several factors such as participation in clinical trials, patient-related factors and possibly also organisational factors.
The national action programme states that complete multidisciplinary teams should be present for the implementation of neoadjuvant therapy. Such treatment is recommended at the regional centres for locally advanced (primarily unresectable) breast cancer, but it is also possible to be provided at hospitals that possess expertise and sufficiently robust environments for patients with HER2 positive or triple negative breast cancer with T2 tumours or cT1N1 stage.
The indication for neoadjuvant therapy was expanded in the course of 2020, and it may take time before new routines are incorporated in all hospitals. The medical community wants the proportion of patients receiving neoadjuvant therapy to increase over the next few years. Furthermore, it is important that robust, competent lines of treatment are established so that all patients receive a uniform offer of this type of treatment.
Reporting of oncology information for breast cancer remains low and absent at some hospitals. Work on the revision and simplification of oncology reports, as well as the introduction of INSPIRE for breast cancer (data collection on drug cancer treatment), we see that can affect the completeness and quality of the oncology data.
There is still variation between the departments for histological grading of tumours. A national project has been initiated that will evaluate and compile a number of tumour analyses with a view to ensuring as good as possible decision-making basis for assessment of adjuvant therapy. The process is ongoing.
Some departments of pathology show large variations in relation to the median value for Ki67. Clinicians at individual hospitals have been encouraged to look at the local median Ki67 value to assess what is high and low Ki67 with respect to for adjunctive therapy. One sees significant improvement over the last couple of years in comparison to variations between pathology departments, except for individual hospitals, which vary greatly in the mean value for Ki67.
Reexcision after breast-conserving surgery shows large variations among hospitals. The Cancer Registry encouraged surgeons and pathologists to submit information about reexcisions. In 2022, a validity study has been carried out where we have quality assured 3 hospitals with regard to reporting practice and clinical assessment-ring of resection margins. Deficiencies in reporting practices have been revealed, both
for surgery and pathology data.
In order to further strengthen the quality of health services, the Cancer Registry of Norway worked in 2019 and 2020 to plan and build infrastructure for collecting PROMs (patient-reported outcome and experience measures), including integration with ePROM, which is the national solution for collecting PROMs.
In 2022, the Cancer Registry of Norway invited people with newly diagnosed prostate cancer, breast cancer, colorectal cancer, melanoma or lung cancer to participate in a digital population survey on health and quality of life. This constitutes more than half of all cancer patients, and the goal is to collect PROMs (Patient Reported Outcome Measures) and PREMs (Patient Reported Experience Measures) in all the Cancer Registry's quality registries.
There is no legal basis in the Cancer Registry Regulations for collecting PROMs/PREMs, and the collection therefore has its basis for treatment in the Regulations relating to population-based health surveys.
Collection of PROM and PREM data for breast cancer began in the fall of 2020 for women diagnosed in 2020. There is an increased focus on providing information about late effects and on involving patients in treatment decisions. The results of this year's report show that patients have to a greater extent now been informed about this in the clinics by both surgeons and oncologists.