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Type and Title of Submission


Title:

Options for provision of MRI surveillance in Wales to women with a family history of breast cancer as recommended in NICE guidance 41

Description:

Women under 50 years with a family history of breast cancer which suggests they have an increased risk of developing the disease compared with the population as a whole are offered annual mammography by Breast Test Wales, although this is not funded. NICE clinical guidance 41 published in July 2006 recommended these women should receive annual MRI surveillance in addition to mammography, at present there is no system in Wales to provide this level of surveillance. This project explores the options for implementing the NICE guidance across Wales.

Category:

Clinical

Does the submission relate to the general implementation of all NICE guidance?

No

Does the submission relate to the implementation of a specific piece of NICE guidance?

Yes

Full title of NICE guidance:

CG41 - Familial breast cancer

Category(s) that most closely reflects the nature of the submission:

needs assessment and option appraisal

Is the submission industry-sponsored in any way?

No


Description of submission


Aim

To devise and appraise the options for the provision of MRI surveillance to women with a family history of breast cancer across Wales in line with NICE clinical guidance 41

Objectives

1. Describe current system of surveillance for women with a family history of breast cancer and determine the current number of women identified as eligible for breast surveillance and how many would be expected for a population equivalent to Wales 2. Describe the location and specification of current MRI scanners, and compare with the UK standards for breast MR imaging. 3. Identify and appraise possible options for provision

Context

Breast screening by mammography is provided by Breast Test Wales (BTW) for women aged 50 and over. Women under 50 years with a family history of breast cancer which suggests they have an increased risk of developing the disease compared with the population as a whole are also offered annual mammography by BTW, although this is not funded. Women with a family history of cancer access the current system of surveillance through their general practitioner and the cancer genetics network for Wales. Once an individual's risk is estimated through ascertainment of their family pedigree they can be offered genetic testing and surveillance as appropriate. The age at which annual mammography is commenced is determined by the estimated level of risk for the individual from their family history. NICE clinical guidance 41 published in July 2006 recommended these women should receive annual MRI surveillance in addition to mammography. At present there is no system in Wales to provide this level of surveillance.

Methods

1. The Family History Programme began in 2001. Since 2001, 2363 women have been registered in the Family History programme. 1080 assessed as at high risk of developing breast cancer due to their family history, and the remainder at moderate risk. The Welsh Cancer Genetics Service assesses women on their lifetime risk using Cyrillic software. Women are classified as high risk, moderate risk or population risk. For the purpose of estimating the number of women requiring annual MRI surveillance in Wales, the NICE guidance is equivalent to recommending that all women assessed as high risk by the AWCGS require annual surveillance from 30 years and all women assessed as moderate risk require annual MRI surveillance from 40. The number of mammograms performed in the Family History Program is 1400 per year. Women with TP53 gene mutations currently receive annual MRI surveillance on an ad hoc basis outside of BTW. These women need to receive annual breast MRI surveillance from 20 years, and this would add a further 10 MR scans to the annual total. The age of first screening for high risk women, under the NICE guidance, would be reduced from 35 to 30 years. This would generate an approximate additional 100 screens per annum for high risk women. Finally, epidemiology suggests that 1% of the population of England and Wales are at high risk of breast cancer due to inherited factors and 9-13% are at moderate risk. This suggests that 25 - 30% of women eligible for annual surveillance are not currently known to the service. 2. At present there are 14 MR scanners in Wales capable of breast imaging and biopsy, however only one site currently performs MR guided breast biopsy. The number of scans needed to provided surveillance to women already known to the family history programme is 7 to 8 per day across Wales, and if provision is to be made for the current unmet need then this figure rises to 9 to 10 MR scans per day.

Results and evaluation

Options considered included: 1. BTW providing call/recall, mammography, MRI and biopsy in its three centres 2. Acute trusts providing call/recall, mammography, MRI and biopsy 3. Acute trust/ BTW hybrid where BTW oversees the call/recall and mammography, with MRI scanner time and radiographer support purchased from the acute Trust In evaluating the options for provision the following were considered: 1. Call/recall system The management of a secure, systematic surveillance programme requires that a central list of patients is collated and managed effectively 2. Radiology expertise Breast MRI is a specialist field in which not all radiologists are experienced. The RCR breast group recommends that in order to remain competent radiologists should read more than 50 breast MR scans per year 3. Staffing Recruitment of additional specialist staff is applicable to trusts and BTW in order to operate the surveillance programme 4. MRI Capacity BTW does not have MRI scanners and current centres do not have the space to easily accommodate such new equipment. Although several trusts have MRI scanners capable of performing breast imaging and biopsy. There is not the capacity within the system to provide the additional number of scans necessary to operate this surveillance programme 5. Standards and quality assurance The NICE guidance states that where mammographic imaging is indicated, it is to be done to NHS Breast Screening Programme standards. 6. Access In order to optimise accessibility it is necessary to create MRI capacity in each of the three regions of Wales The best model of provision combines the expertise of BTW in managing a call/recall system and operating quality assured screening services, with the capacity of the trusts to accommodate new MRI scanners and utilize their full capacity. Three centres for breast surveillance are needed, situated in specialist breast units in the North, South and West of Wales, to ensure equality of access to the service

Key learning points

1. Consultation with all stakeholders, including patient groups, was essential to gain a true picture of all elements of the patient journey, and potential problems in provision of surveillance. 2. An independent overview was needed to bring together expertise from screening; genetics; radiology; patient groups and surgery. As well as consideration of the wider health service and changes in provision and demand for imaging. 3. It was crucial to consider the specialist symptomatic services that patients will be referred to when a lesion is detected, and how surveillance and these services would dovetail. 4. Finally, there had to be a national commitment to funding for this NICE guidance to be implemented.

View the supporting material

Contact Details

Name:Joanna L. Cartwright
Job Title:Specialist Registrar in Public Health
Organisation:National Public Health Service for Wales
Address:Preswylfa, Hendy Road
Town:Mold
County:Flintshire
Postcode:CH7 1PZ
Phone:01352 803345
Email:joanna.cartwright@nphs.wales.nhs.uk

 

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This page was last updated: 30 September 2008

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Copyright 2014 National Institute for Health and Care Excellence. All rights reserved.