Dr Jerome Coffey MD, FRCPI, FRCR, FFR RCSIRadiation Oncology Advisor

on behalf of

Dr Susan O’Reilly MB, FRCPC, FRCPINational Director, National Cancer Control Programme

Breast Cancer Services in Ireland

European Commission Joint Research Centre, Ispra

March 14th

2013

The Challenges in Ireland 2013

•

Growth in incidence and prevalence of cancer.

•

Mediocre survival up to 2006.

•

Growth in cancer services.

•

Fiscal constraints and recruitment moratorium.

•

Rapid emergence of effective new diagnostic tests and treatments

for cancer –

all at significant additional costs.

Growth in Incidence of Invasive Cancers

2010 2020 2030

All invasive 26,283 38,379 54,780

20 year growth rate 108%

The Opportunities

•

Increasing International and National focus on cancer prevention: education, facilitation and empowerment of society to address tobacco (Public Health Act 2004), alcohol, obesity, diet, exercise and sun exposure.

•

Population screening

programmes –

BreastCheck, CervicalCheck, BowelScreen (2012).

•

Strong Department of Health and Health Service Executive support for the National Cancer Control Programme’s new and existing

strategies and services.

The Opportunities 2

Collaborative initiatives to improve population and patient pathways for diagnosis and care (public health, primary care, acute hospital services).

-Building on base of successful implementation of the National Strategy for Cancer Control.-Referral to Designated Cancer Centres (8).-High volume, expert oncologists.-Multidisciplinary review.

BreastCheck –

National Screening Programme

•

Free digital mammogram every 2 years for women aged 50-64•

Women invited either to a mobile or screening unit

•

Aim to detect breast cancer at the earliest possible stage –

when easier to treat with a higher chance of a good outcome

In 12 years of breast screening, BreastCheck has –

•

Screened over 371,200 women aged 50-64.•

Provided over 835,500 mammograms.

•

Detected over 5,400 breast cancers. •

Major expansion 2007.

•

Completed national rollout 2011.

BreastCheck –

National Screening Programme

In 2011, BreastCheck –

•

Invited 172,076 women for a free mammogram

•

72.2% of women accepted their invitation

•

Screened 125,329 women (4,500 more than 2010)

•

Detected 832 breast cancers

•

Annual Report

BreastCheck –

National Screening Programme

Comparison No. hospitals carrying out surgery 2005, 2010, 2013

6

3230

811

48

23

7 74

810

74

0

5

10

15

20

25

30

35

Lung Breast Rectal Prostate OesophagealCancer Surgery

No.

hos

pita

ls

2005 2010 2013

Symptomatic Breast Clinics

•

Electronic referral from GPs to 8 hospitals.

•

GP Guidelines.

•

Rapid access to diagnosis and treatments.

•

Key Performance Measurements –

published monthly.

•

Annual Quality, Audit & Safety Conference.

•

Annual Reports

Healthlink in conjunction with the NCCP and the GPIT Group

•e-referrals from accredited GP software systems to the 8 designated cancer centres•Breast, Prostate & Lung•Referral generated from within the patient file, delivered to the cancer team, response within 5 working days•Immediate acknowledgment indicating successful delivery of referral •Response from the cancer team integrated with the patient file providing a complete record of the referral/response process.

Attendances 2010 2011 2012*

Urgent 12,533 13,759 14,087

Non urgent 25,078 24,196 24,279

All attendances 37,631 37,955 38,336

no. primary cancers 2,012 2,145 2,118

% primary cancers 5.4% 5.7% 5.5%

Symptomatic Breast Clinics 2010 -

2012

Standard 1. Access

1(a) Urgent attendances seen in < 10 working daysTarget: > 95%

1(b) Routine attendances seen in <12 weeksTarget: > 95%

1(c) Urgent imaging (mammo or ultrasound) if S4/S5Target: > 90%

1(d) Routine imaging (mammo or ultrasound)

<12 weeksTarget: > 90%

Standard 2. Imaging

2(a) Pre-op assessment. Patients with primary operable breast cancer shall have pre-op mammo and U/S Target: >95%

2(b) Targeted imaging. A patient >35 years with a clinically palpable focal abnormality shall have mammo and targeted U/STarget: >95%

2(c) Core biopsies

shall be image-guided if R3, R4 or R5 imaging abnormality identified. Target: >90%

2(d) Every consultant radiologist shall report >1,000 mammos per

year

Standard 3. Diagnosis

3 (a) Non operative diagnosis Patients with invasive breast cancer shall be diagnosed without an operative procedure [open biopsy]. Target >90%

3(b) Timely discussionFor patients urgently triaged by the cancer centre and subsequently diagnosed with a primary breast cancer, the interval between attendance at the first clinic and discussion at the MDM shall not exceed 10 working days.Target >90%

Standard 4.

Multidisciplinary Care

4(a) Breast investigations that generate a histopathology report

shall be discussed at MDM. Target >95%

4(b) All patients with a diagnosis of breast cancer from the symptomatic service shall be discussed at MDM.Target >95%

Standard 5 Time to treatment 5(a) Surgery

5(a) Surgical intervention shall be carried out within 4 weeks (20 working days) of the MDM when a B5 or C5 is first identified, provided surgery is the first treatment

Target: >90%

Standard 5 Time to treatment 5(b,c) Time to radiotherapy

5(b) For patients, where adjuvant chemotherapy is not deemed necessary

but require radiation therapy, patients shall commence

RT within 12 weeks of the final surgical procedure.Target: >90%

5(c) For patients, requiring adjuvant chemotherapy and radiation therapy, patients shall RT within 4 weeks of the last

chemotherapy administration. Target: >90%

Standard 5 Time to treatment 5(d) Time to chemotherapy

5(d) For patients, where adjuvant chemotherapy is required, administration shall commence within 8 weeks of the final surgical procedure.

Target: >90%

Standard 6 Surgery –

Accurate Localisation

Patients with a clinically occult lesion, that is classified as an S2, shall have wire-guided localisation pre-operatively. Target: >95%

Patients with a clinically occult lesion who have a wire-guided wide local excision shall have specimen mammography. Target: >95%

Standard 7 Surgery –

Axillary Staging

Patients with a diagnosis of primary operable invasive breast cancer shall have an ultrasound of the axillary nodes.Target >95%

The number of patients with sonographically normal lymph nodes and where the FNA or core biopsy does not demonstrate metastases and

who have sentinel lymph node biopsies shall be documented.

Standard 8

All consultant surgeons should assess and operate on a minimum of 50 new patients with breast cancer per year.

Standard 9

For patients who have breast conserving surgery, 95% or more patients should have three or fewer therapeutic operations.

Standard 10: Pathology

Pathology reports shall include a standard set of prognostic indicators that will be available to the multidisciplinary team in a timely

fashion.

For patients with primary invasive breast cancer:Tumour type, grade, size, lymphovascular invasion and posterior margin status were recorded for their highest grade tumour.

Standard 10: Pathology

ER, HER-2 status is recorded for the highest grade tumour.

Axillary lymph node status, where sampled, shall be recorded.

Radial margin status shall be documented for all patients who have wide local excision of a primary invasive breast cancer.

The histopathology report will be available within 10 working days.

National Radiation Oncology Programme

St Luke’s Radiation Oncology Network now fully developed:2 new Dublin centres opened in 2011, in addition to St Luke’s Hospital. 50% increase in capacity.

€100 million approved to build new facilities in Cork and Galway to accommodate increase in demand (opening 2017).

National Treatment Guidelines developed and in final review.

Cross Border planning with Northern Ireland to address radiotherapy needs for the North West in new Altnagelvin centre (2016).

Evidence-based national guidelines, treatment protocols –

2013.

Quality and safety policies for safe drug delivery –

2013.

NCCP Technology Review Committee for oncology drugs and related molecular tests implemented March 2011.

National oncology drug budget implemented in 2013.

National Medical Oncology and Haemato- Oncology Programmes

National Cancer Drug Management

•

Oral drugs: PCRS ≥

50% of expenditure.•

Parenteral drugs: Individual hospitals.

•

Overall “spend”

≥

€150m per annum.•

Growth rate: 15% per annum in hospitals.

•

New drugs > €45,000/QALY.•

Patients increase by 5% per annum.

National Cancer Drug Management 2

1.

Implementation of central funding for high cost drugs 2013 onwards.

2.

Protocols / Order Sets / Patient information.

3.

Registration by diagnosis.

4.

Financial / reimbursement process for new drugs.

National Tumour Groups

Initiated May 2011: GI, Breast, GU, Lung, Gynaecology

Role:Development and promulgation of site-specific, evidence-based multidisciplinary clinical practice guidelines. Adopt / Adapt / Innovate

Initial leadership representatives from: Surgical, Medical & Radiation Oncology Pathology & Diagnostic ImagingRelated experts e.g. Respirology, Gastroenterology

Age standardised survival at 5 years for cancers diagnosed in 2000 -

2002 (all), 2002 -

2006 (Ireland) and 2005 –

2007 (others)

Source: Irish data NCRI 2008 & international data Lancet 2010

Irish cancer survival can improve by up to 10% by successful implementation of well-organised cancer control systems.

Critical Success Factors

Population-based screeningEarly diagnosis / Stage Shift Multidisciplinary TeamsHigh Volume / Expert CentresNational Standards / Guidelines / Protocols / Policies / Processes