Breast cancer quality standard

1. People presenting with symptoms that suggest breast cancer are referred to a unit that performs diagnostic procedures in accordance with NHS Breast Screening Programme guidance.

2. People with early invasive breast cancer are offered a pre-treatment ultrasound evaluation of the axilla and, if abnormal lymph nodes are identified, ultrasound-guided needle biopsy (fine needle aspiration or core). Those with no evidence of lymph node involvement on needle biopsy are offered sentinel lymph node biopsy when axillary surgery is performed.

3. People with early breast cancer undergoing breast conserving surgery, which may include the use of oncoplastic techniques, have an operation that both minimises local recurrence and achieves a good aesthetic outcome.

4. People with early breast cancer who are to undergo mastectomy have the options of immediate and planned delayed breast reconstruction discussed with them.

5. People with newly diagnosed invasive breast cancer and those with recurrent disease (if clinically appropriate) have the ER and HER2 status of the tumour assessed and the results made available within 2 weeks to allow planning of systemic treatment by the multidisciplinary team.

6. People with early invasive breast cancer, irrespective of age, are offered surgery, radiotherapy and appropriate systemic therapy, unless significant comorbidity precludes it.

7. People with early invasive breast cancer do not undergo staging investigations for distant metastatic disease in the absence of symptoms.

8. People with early invasive breast cancer are involved in decisions about adjuvant therapy after surgery, which are based on an assessment of the prognostic and predictive factors, and the potential benefits and side effects.

9. People having treatment for breast cancer are offered personalised information and support, including a written follow-up care plan and details of how to contact a named healthcare professional.

10. Women treated for early breast cancer have annual mammography for 5 years after treatment. After 5 years, women who are 50 or older receive breast screening according to the NHS Breast Screening Programme timescales, whereas women younger than 50 continue to have annual mammography until they enter the routine NHS Breast Screening Programme.

11. People who develop local recurrence, regional recurrence and/or distant metastatic disease have their treatment and care discussed by the multidisciplinary team.

12. People with recurrent or advanced breast cancer have access to a ‘key worker´, who is a clinical nurse specialist whose role is to provide continuity of care and support, offer referral to psychological services if required and liaise with other healthcare professionals, including the GP and specialist palliative care services.

13. People who have a single or small number of potentially resectable brain metastases, a good performance status and who have no (or minimal) other sites of metastatic disease are referred to a neuroscience brain and other rare CNS tumours multidisciplinary team.

Full breast cancer quality standard (PDF format)

This NICE quality standard defines clinical best practice within this topic area. It provides specific, concise quality statements, measures and audience descriptors to provide the public, health and social care professionals, commissioners and service providers with definitions of high-quality care.

Scope of the quality standard

This quality standard covers the management of early (ductal carcinoma in situ[1] and invasive), locally advanced and advanced breast cancer in adults. This includes the management of both screen-detected and symptomatic breast cancers from the point of referral to a specialist team. The scope does not include adults with rare breast tumours, benign breast disease, lobular carcinoma in situ, or the care of women with an increased risk of breast cancer due to family history.

Breast cancer quality statements

The quality standard for breast cancer requires that services should be commissioned from and coordinated across all relevant agencies encompassing the whole breast cancer care pathway. An integrated approach to provision of services is fundamental to the delivery of high quality care to people with breast cancer.

NICE has produced a support document to help commissioners and others consider the commissioning implications and potential resource impact of this quality standard, available from www.nice.org.uk.

NICE quality standards are for use by the NHS in England and do not have formal status in the social care sector. However, the NHS will not be able to provide a comprehensive service for all without working with social care communities. In this quality standard care has been taken to make sure that any quality statements that refer to the social care sector are relevant and evidence-based. Social care commissioners and providers may therefore wish to use them, both to improve the quality of their services and support their colleagues in the NHS.

Subject to legislation currently before Parliament, NICE will be given a brief to produce quality standards for social care. These standards will link with corresponding topics published for the NHS. They will be developed in full consultation with the social care sector and will be presented and disseminated in ways that meet the needs of the social care community. As we develop this library of social care standards, we will review and adapt any published NICE quality standards for the NHS that make reference to social care.

It is important that the quality standard is considered by commissioners, healthcare professionals and patients alongside current policy and guidance documents, including 'Improving outcomes in breast cancer' (NICE cancer service guidance, 2002) and the 'Manual for cancer services: breast measures' (National Cancer Peer Review Programme, 2008), listed in the evidence sources section.

Download the breast cancer areas of care map to see the quality statements mapped against the areas of breast cancer care.

Rationale for developing this quality standard

Breast cancer is the most common cancer in women in England and Wales and also affects a very small proportion of men. Some patients are diagnosed in the advanced stages, when the tumour has spread significantly within the breast or to other organs of the body. In addition, a considerable number of people who have been previously treated with curative intent subsequently develop either a local or regional recurrence or metastases. Breast cancer is the second biggest cause of death after lung cancer. In 2008, 39,972 people were diagnosed with breast cancer in England (39,681 women and 291 men). The lifetime prevalence is 1 in 8 women. There is a trend of increasing incidence because of lifestyle factors and improved detection, and decreasing mortality because of earlier detection and improvements in the quality and availability of effective treatments. There are more than 500,000 people in the UK today who have, or have had, a diagnosis of breast cancer. It is estimated that around 40 to 50% of these may develop metastases in the future, and therefore require treatment for advanced breast cancer^[^2]. Unusually, lifestyle and environmental issues mean that the prevalence of breast cancer is greater in higher socioeconomic groups. However, mortality is higher among lower socioeconomic groups, highlighting issues of later identification because of a lower uptake of screening, barriers to accessing treatment among these groups and the impact of comorbidities. This quality standard describes markers of high-quality, cost-effective care that, when delivered collectively, should contribute to improving the effectiveness, safety and experience of care for adults with breast cancer.

Policy context

Breakthrough Breast Cancer (2011) - Best practice diagnostic guidelines for patients presenting with breast symptoms.

Department of Health (2011) - Improving outcomes: a strategy for cancer.

Department of Health (2010) - The NHS outcomes framework 2011/12.

Department of Health, Macmillan Cancer Support and NHS Improvement (2010) - National cancer survivorship vision.

NHS Breast Screening Programme (2010) Clinical Guidelines for Breast Cancer Screening Assessment (third edition).

Department of Health (2008) - Manual for cancer services 2008: breast measures.

Department of Health (2007) Cancer reform strategy.

Department of Health (2004) - The NHS cancer plan and the new NHS: Providing a patient-centred service. Available from www.dh.gov.uk

Department of Health (2001) - Manual of cancer services standards. Available from www.dh.gov.uk

Department of Health (2001) The NHS cancer plan: making progress.

Commission for Health Improvement and Audit Commission (2001) National service framework assessments No. 1: NHS cancer care in England and Wales.

Department of Health (2000) The NHS cancer plan: a plan for investment, a plan for reform.

Department of Health (2000) Referral guidelines for suspected cancer.

Department of Health (2000) Cancer information strategy.

Key development sources

Advanced breast cancer: diagnosis and treatment. NICE clinical guideline 81 (2009; NHS Evidence accredited).

Early and locally advanced breast cancer: diagnosis and treatment. NICE clinical guideline 80 (2009; NHS Evidence accredited).

Referral for suspected cancer. NICE clinical guideline 27 (2005; NHS Evidence accredited).

Management of breast cancer in women. Scottish Intercollegiate Guidelines Network (SIGN) guideline No. 84, 2005 (update of SIGN guideline No, 29).

Development team

Director

Fergus Macbeth

Associate Director

Lorraine Taylor

Consultant Clinical Adviser

Tim Stokes

Lead Analyst

Anna Brett

Topic Expert Group: Breast cancer

Consultation feedback

Consultation and on the breast cancer quality standard took place from 6 April 2011 to 4 May 2011. In total, 762 stakeholders were contacted during consultation. All eligible comments were reviewed by the Topic Expert Group and the standard was updated accordingly.

Breast cancer consultation report

Implementation support materials

Publication partners

Many organisations share NICE's commitment to improve quality by making it clear what quality care is for patients and the public, health and social care professionals, commissioners and service providers.

So that these standards reach the widest possible audience, some of the organisations who have been involved in the development process, and who endorse the breast cancer quality standard, have become partners in its publication.

These organisations are:

Association of Breast Surgery
BASO - The Association for Cancer Surgery
Breakthrough Breast Cancer
The Society and College of Radiographers
The Royal College of Radiologists Breast Group
The British Association of Aesthetic Plastic Surgeons
Royal College of Physicians
Royal College of Pathologists
The British Dietetic Association	Image to follow