K. Schreuder

Clinical auditing as an instrument for quality improvement in breast cancer care in the Netherlands: The national NABON Breast Cancer Audit

In 2011, the NABON Breast Cancer Audit (NBCA) was instituted as a nation‐wide audit to address quality of breast cancer care and guideline adherence in the Netherlands. The development of the NBCA and the results of 4 years of auditing are described.

Large variation between hospitals in immediate breast reconstruction rates after mastectomy for breast cancer in the Netherlands

BACKGROUND The present study aimed to describe the use of immediate breast reconstruction (IBR) after mastectomy for invasive breast cancer and ductal carcinoma in situ (DCIS) in hospitals in the Netherlands and determine whether patient and tumor factors account for the variation. METHODS Patients undergoing mastectomy for primary invasive breast cancer or DCIS diagnosed between January 1, 2011 and December 31, 2013 were selected from the NABON Breast Cancer Audit. All the 92 hospitals in the Netherlands were included. The use of IBR in all hospitals was compared using unadjusted and adjusted analyses. Patient and tumor factors were evaluated by univariate and multivariate analyses. RESULTS In total, 16,953 patients underwent mastectomy: 15,072 for invasive breast cancer and 1881 for DCIS. Unadjusted analyses revealed considerable variation between hospitals in postmastectomy IBR rates for invasive breast cancer (mean 17%; range 0-64%) and DCIS (mean 42%; range 0-83%). For DCIS, younger age and multifocal disease were factors that significantly increased IBR rates. For patients diagnosed with invasive breast cancer, IBR was more often used in younger patients, multifocal tumors, smaller tumors, tumors with a lower grade, absence of lymph node involvement, ductal carcinomas, or hormone-receptor positive/HER2-positive tumors. After case-mix adjustments for these factors, the variation in the use of IBR between hospitals remained large (0-43% for invasive breast cancer and 0-74% for DCIS). CONCLUSIONS A large variation between hospitals was found in postmastectomy IBR rates in the Netherlands for both invasive breast cancer and DCIS even after adjustment for patient and tumor factors.

Factors Associated with the Use of Gene Expression Profiles in Estrogen Receptor-Positive Early-Stage Breast Cancer Patients: A Nationwide Study

Background: Breast cancer guidelines suggest the use of gene expression profiles (GEPs) in estrogen receptor-positive (ER+) breast cancer patients in whom controversy exists regarding adjuvant chemotherapy benefit based on traditional prognostic factors alone. We evaluated the current use of GEPs in these patients in the Netherlands. Patients and Methods: Primary breast cancer patients treated between January 1, 2011 and December 31, 2014 and eligible for GEP use according to the Dutch national breast cancer guideline were identified in the Netherlands Cancer Registry: ER+ patients <70 years with grade 1 tumors >2 cm or grade 2 tumors 1-2 cm without overt lymph node metastases (pN0-Nmi). Mixed-effect logistic regression analysis was performed to associate characteristics of patients, tumors and hospitals with GEP use. Results: GEPs were increasingly deployed: 12% of eligible patients received a GEP in 2011 versus 46% in 2014. Lobular versus ductal morphology (OR 0.58, 95% CI 0.47-0.72), pN1mi status (versus pN0, OR 0.52, 95% CI 0.40-0.68), and tumor size (>3 cm vs. >2 cm, OR 0.33, 95% CI 0.14-0.88) were inversely associated with GEP use. High socioeconomic status (SES) (OR 1.32, 95% CI 1.06-1.64) and younger age (OR 0.96/year increasing age, 95% CI 0.95-0.96) were positively associated with GEP use. GEP use per hospital did vary, but no predefined institutional factors remained independently associated with GEP use. Conclusion: GEP use increased over time and was influenced by patient- and tumor-associated factors as well as by SES.

Hospital organizational factors affect the use of immediate breast reconstruction after mastectomy for breast cancer

Background: Aims of the current study were to identify which hospital organizational factors determine the variation in the use of immediate breast reconstruction (IBR) after mastectomy for ductal carcinoma in situ (DCIS) or invasive breast cancer and to investigate whether these factors explain the variation in IBR between hospitals in the Netherlands. Material and Methods: From the NABON Breast Cancer Audit (NBCA) patients with DCIS or primary invasive breast cancer without distant metastatic disease, diagnosed between January 1, 2011 and December 31, 2013 were selected. Hospital organizational factors were identified with an online web-based survey on different organization factors such as the number of weekly multidisciplinary team (MDT) meetings, number of (breast and plastic) surgeons in the hospital and the presence of plastic surgeons in weekly MDT. Logistic regression analyses were used to analyze whether the identified organizational factors significantly affected IBR rates. Patient, tumor and hospital organizational factors that demonstrated to significantly affect IBR rates in univariate analyses were included in the multivariate analyses. Results: In total, 72 hospitals (78% of all Dutch hospitals) participated in the survey. In these hospitals 16,471 female patients were treated with a mastectomy for DCIS (n = 1,980) or non-metastatic breast cancer (n = 14,491) during the study period. In total 20% (n = 3,244) of these patients underwent IBR for DCIS (mean, 42%; hospital range, 0−80%) or invasive breast cancer (mean, 17%; hospital range, 0−62%). Patients who underwent a mastectomy in a teaching (OR=2.6, 95% CI: 1.8−3.7) or university hospital (OR=10.8, 95% CI: 5.7–20.5) or in an intermediate volume (OR=2.0, 95% CI: 1.5−2.8) or high volume hospital (OR=3.0, 95% CI: 2.0−4.5) had a significantly higher chance of receiving IBR compared to patients treated in a district or low volume hospital, respectively. More often IBR was performed in hospitals having 3−4 MDT meetings/week organized compared to hospitals with 1−2 MDT meetings/week (OR=1.4, 95% CI: 1.1−1.8). The number of plastic surgeons in-house did not significantly affect the chance of IBR. In almost 70% of the hospitals, a plastic surgeon structurally attended the weekly MDT meeting, which was prognostic for performing more IBRs compared to MDTs with no or incidental plastic surgeon attendance (OR=3.89, 95% CI: 3.00–5.04). Conclusion: Hospital organizational factors affect the use of IBR and consequently could be subject for improvement to make IBR available to more breast cancer patients.