Summary from the annual report 2021
Figure 1.3: Quality indicators for the Norwegian Breast Cancer Registry i 2021. (EUSOMA quality indicators in parentheses).
In 2021, there were 4011 women diagnosed with a first invasive breast cancer and 434 women with DCIS.
Covid-19 and prevalence
There were 578 more invasive breast cancer and 88 more DCIS cases diagnosed in 2021 than in 2020.
For women aged 50-69 years participating in BreastScreen Norway, there was an increase in the number of invasive breast cancer and DCIS cases, with 512 more cases detected in 2021 than in 2020, and 189 more cases than the average per year during 2017–2019. This increase in breast cancer cases in 2021 may be due to an increase in breast cancer incidence, as well as due to an increase in the number of mammograms conducted by BreastScreen Norway in 2021 compared to previous years. In 2021, 248 228 women were examined as part of BreastScreen Norway, compared to 172 217 in 2020 and 223 058 women per year during 2017–2019. BreastScreen Norway performed more mammagrams in 2021 than previously to catch up on delayed mammograms due to the Covid-19 pandemic and lockdown of Norway in March 2020, when BreastScreen Norway was closed for a few months.
For women below 50 years, the number of invasive breast cancer and DCIS cases in 2021 was similar to 2020 and 2017–2019. For women aged 50-69 years old, breast cancer detected outside of BreastScreen Norway increased by 37 cases in 2021 compared to 2020. For women aged 70 years and older, there were 121 more cases in 2021 than in 2020.
Radiology
Radiology examinations were reported for 75 % of breast cancer patients. This was a small increase from 2020, and is considered to be a moderate degree of goal achievement. The improved results follow an ongoing effort to increase reporting. For cases detected by BreastScreen Norway, all breast centers achieved the target level of 80 %.
For breast cancer patients that did not receive neoadjuvant systemic treatment, reporting indicated a high level of goal achievement for use of diagnostic MRI. However, there are still large differences between hospitals in reported use of diagnostic MRI. For breast cancer patients undergoing neoadjuvant systemic treatment, we have seen an increase in reported use of diagnostic MRI over the past few years. The current reported use is now 86.5 %, which is considered to be a moderate level of goal achievement.
Surgery
Clinical reporting is 94.6 % complete for primary diagnosis, 95.7 % complete for primary surgery, and 90.9 % for the first post-operative check-up. These are all considered to be high levels of goal achievement. For patients with invasive tumors < 30 mm, 87.5 % received breast-conserving surgery. For the first time, the EUSOMAS target of > 85 % was acheived. There were minor variations between the hospitals, and some hospitals could potentially perform more breast-conserving surgery. For patients diagnosed with ductal carcinoma in situ (DCIS), with a tumor size < 20 mm, 91.4 % received breast-conserving surgery during 2019–2021. This was considered a high degree of goal achievement.
Guidelines recommend that 40 % of mastectomies are performed with a primary reconstruction of the breast in women < 70 years. In 2021, 52.7 % of women with invasive breast cancer received such a primary reconstruction, which was a high degree of goal achievement. Several hospitals met this target.
There are reasonably large variations in the patient volume between hospitals that conduct breast cancer surgery in Norway. There was little difference in 5-year relative survival between larger and smaller hospitals. However, with the increasing complexity of treatment, reducing the number of hospitals diagnosing and treating breast cancer should be considered. The members of the Norwegian Breast Cancer Registry recommend that hospitals operate at least 100 patients per year, in line with the report “Kreftkirurgi i Norge”, with 150 operations per hospital per year as the desired level. Revision of this report commenced in 2021, with both larger and smaller hospitals represented. This work is not yet concluded.
Pathology
As seen in previous years reports, there is still variation between hospitals in the grading of tumors. As grade is used to determine treatment of patients, quality assurance of this variable is important. Previously, we observed large variations in median Ki67 between pathology laboratories. Many pathology departments now have a median Ki67 at, or close to, the national level. Some hospitals still have a somewhat low proportion of positive lymph nodes detected. As such, the pathologists are encouraged to revise their routines, and if needed, make the necessary adjustments.
Oncology
Radiation treatment after breast-conserving surgery was performed in 92.9 % of cases. This constitutes a moderate degree of goal achievement.
For the first time, reporting on medical treatment was possible due to INSPIRE (INcreaSe PharamaceutIcal REporting), a collaborative project between the Cancer Registry of Norway, the Norwegian Cancer Society, members of the pharmaceutical industry and the regional health trusts. This collaboration commenced in the autumn of 2020, with the aim to automatically gather data on medical treatment of cancer patients directly from the hospital’s own dedicated computer programs. The first report from INSPIRE was published in April 2022. Data on medical treatment is still not complete (for example, there is no data from hospitals in Northern Norway yet). From this report, we observed some variaton between hospitals with regards to neoadjuvant treatment of HER2 positive and triple negative breast cancers. In the years to come, this will be a subject of attention. Furthermore, we observe that there is a potential for improvement with respect to the time lapsed from surgery to initiation of adjuvant treatment.
Patient Reported Outcome Measures (PROM) and Patient Reported Experience Measures (PREM)
The results for PROM and PREM are somewhat better than in 2020, but PROMs results must still be interpreted with care due to a limited number of responses. Norwegian breast cancer patients are largely satisfied with the treatment they receive, but the PREMs results indicate that we as healthcare professionals can increase our focus on providing patients with information on late effects and the different treatment options.
