ANALYSIS:Patients have reported a high level of satisfaction with their breast cancer treatment, writes MUIRIS HOUSTON
THE IMPORTANCE of yesterday’s report from the Health Information and Quality Authority (Hiqa) into the performance of breast disease treatment services in the Republic cannot be overestimated. The eight designated cancer centres under the Hiqa microscope will ultimately specialise in the treatment of all types of cancer and not just breast tumours. However, given the lapses in breast cancer care identified in a number of our hospitals in 2007 and 2008 and the unacceptable personal experiences of women such as Rebecca O’Malley, the report is first and foremost an opportunity to assess whether women with symptoms of breast disease can now access quality treatment.
O’Malley underwent a mastectomy and chemotherapy for breast cancer 14 months after she was told a breast lump was benign. It subsequently emerged that a human error was made in the interpretation of a tissue sample following a fine-needle biopsy of the lump. But there was clear evidence of a systems failure because, contrary to best practice guidelines, the tissue sample was assessed by a pathologist working at a separate hospital from the one where O’Malley underwent clinical assessment. Crucially, she did not undergo a triple assessment by a multidisciplinary team in a specialist breast unit. Such assessments have been shown to reduce mortality from breast cancer by over 20 per cent. The triple assessment of a breast lump in a dedicated clinic means that a woman will undergo radiology (usually a mammogram), examination by a specialist breast surgeon and a biopsy of the lump which will be examined by a pathologist specially trained in breast pathology. Clinics offering triple assessment aim to carry out all elements of the assessment at a single visit.
A key factor in good breast cancer care is to have all health professionals involved in a woman’s care located in one place, enabling multidisciplinary teamwork to take place. At the centre of this concept is the holding of a weekly conference of all staff at which both the diagnosis and the future treatment of the patient are discussed. But in June 2007 there were 33 public hospitals providing services to women with symptoms of breast disease, many of which did not have the staff or facilities to provide the standard of care required by best practice. And many private hospitals were treating small numbers of women with breast cancer on an ad hoc basis, with Barrington’s Hospital in Limerick coming under particular scrutiny.
Under guidelines issued by the National Quality Assurance Group for Symptomatic Breast Disease Services, the eight dedicated breast centres should be staffed by at least two consultant breast surgeons, two specialist radiologists, a team of specialist nurses and at least two consultants with an expertise in breast pathology. The reason for this is to ensure that no one specialist operates in isolation and can discuss difficult cases with a colleague working on the same site. In addition, individual consultant surgeons must treat at least 50 new patients with breast cancer each year, while breast pathology reports must contain a minimum set of data. And radiologists reporting mammograms should not work in isolation. These standards were subsequently put in place by the National Cancer Control Programme under Prof Tom Keane.
So, has it made a difference? Is an Irish woman who discovers a breast lump in 2010 assured of a better and more uniform standard of care than someone in a similar situation in 2007?
The report suggests this is largely the case, although the units in Cork, Waterford and Limerick are lagging behind other locations in their pace of implementation. Hiqa asked patients for feedback, and while it would have been helpful to hear some of their narrative, the report says they reported high levels of satisfaction with their treatment. But they did express concern about aspects of their care.
Specifically, patients pointed to an impaired flow of information about their condition within and outside the treatment centres. It was precisely this aspect of care that emerged as the key problem in the case of Edel Kelly and Ann Moriarty, patients whose breast cancer diagnosis was delayed at Ennis General Hospital in 2008. Not having all relevant information about a patient to hand is a recipe for error.
Some four of the centres saw in excess of 95 per cent of patients rated as urgent cases within 10 days of referral to the service. This is a key performance indicator; ask any woman with a newly identified breast lump and she will confirm that waiting for assessment is one of the most distressing aspects of the experience. However, both Waterford and Letterkenny hospitals missed the 95 per cent waiting target by some margin.
Scrutiny of the figures reveals further discrepancies. In the Mater hospital, just 50 per cent of women with operable breast cancer had surgery within the recommended 20 days after diagnosis. Limerick and St Vincent’s hospital, Dublin, also had difficulty meeting this target.
It is a pity the report omits information on the number of cancer patients in each centre who received chemotherapy and radiotherapy. Women facing breast cancer treatment would also like to know the percentage of patients offered reconstructive breast surgery at each centre. And it would be helpful to have a table setting out the staffing levels in each unit, if only to confirm that guidelines are being met.
Overall, however, Hiqa has endorsed the quality of breast cancer services in our public hospitals. This is good news for the 2,500 or so women diagnosed with breast cancer in the State each year.
Dr Muiris Houston is an Irish Timeshealth analyst