Key message:
From December 2010, the time between the date when a person is determined to be ‘fit to treat’ after surgery and the start of radiotherapy should be no more than 31 days (Cancer Reform Strategy 2007).
Considerable reductions in the time between final surgery and radiotherapy will be required if this standard is to be met.
Multi-disciplinary teams should plan radiotherapy well ahead to try to ensure that women have their treatment at the earliest appropriate time.
Time from final surgery to radiotherapy for screen-detected breast cancers
Introduction
In the Cancer Reform Strategy published in December 2007, a radiotherapy waiting times standard was announced which specifies that in England from December 2010 the time between the date when a person is determined to be ‘fit to treat’ after surgery and the start of radiotherapy should be no more than 31 days. Although the ‘fit to treat’ date is defined by local protocols and is not collected by the NHS Breast Screening Programme (NHSBSP) and Association of Breast Surgery (ABS) annual audit of screen-detected breast cancers, the date of final surgery and the radiotherapy start date are recorded.In the 2012 NHSBSP/ABS national audit of adjuvant therapy for screen-detected breast cancers diagnosed in 2009/10, 7,124 women with invasive breast cancer treated with breast conserving surgery and radiotherapy were eligible for the analysis. Women who received chemotherapy before or after their operation, neo-adjuvant or intra-operative radiotherapy were excluded.
Figure 1 : Median days from final surgery to radiotherapy for women with screen-detected invasive breast cancer treated with breast conserving surgery (BCS) (Bars show inter-quartile range)
Time from Final Surgery to Radiotherapy
In the UK as a whole, the median time from final surgery to radiotherapy was 60 days (inter-quartile range 48-74 days) (Figure 1). Fewer than 50% of women received radiotherapy within eight weeks of their final surgery. The median number of days from final surgery to radiotherapy was 59 days in England, 66 days in Wales, 68 days in Northern Ireland and 60 days in Scotland. Within English regions, the median number of days varied from 53 days in North West, to 69 days in South East Coast.Working on the broad assumption that the ‘fit to treat’ date is three weeks (21 days) after final surgery, a proxy standard of 52 days (21 days + 31 days) from final surgery to radiotherapy can be proposed.
In 2009/10, 58% of screen-detected invasive breast cancers were in the Excellent and Good Nottingham Prognostic Groups, and 74% of women diagnosed with a screen-detected invasive breast cancer underwent breast conserving surgery.
It would not, therefore be unreasonable to assume that the majority of these women would be judged to be ‘fit to treat’ with radiotherapy 21 days after their final breast conserving surgery and therefore radiotherapy should start 52 days after final surgery. Figure 2 shows how performance against this proxy 52-day standard varied across the UK. In 21 NHS breast screening units fewer than 10% of women with invasive breast cancer started their radiotherapy within 52 days of their final breast conserving surgery. There were only 5 breast screening units in the UK where 80% or more women met the proxy standard. Figure 3 shows how performance against the proxy standard varied between NHS breast screening units within each English region and in Wales, Northern Ireland and Scotland.
Figure 2 : Proportion of women with screendetected invasive breast cancer treated with breast conserving surgery (BCS) who received radiotherapy within 52 days of their final surgery
Figure 3 : Variation between English regions and in Wales, N Ireland and Scotland in the proportion of women with screen-detected invasive breast cancer treated with breast conserving surgery (BCS) who received radiotherapy within 52 days of their final surgery
There is conflicting evidence regarding the impact of delays between surgery and radiotherapy on outcomes. However, on the basis of Guideline Development Group consensus in the absence of good quality evidence, the NICE Guidelines on Early Breast Cancer recommended that adjuvant radiotherapy should be started as soon as clinically possible within 31 days of completion of surgery in patients with early breast cancer.
This audit of adjuvant radiotherapy for invasive screen-detected breast cancers diagnosed in 2009/10 and treated with breast conserving surgery, suggests that considerable reductions in the time between final surgery and radiotherapy will be required if the new 31-day standard is to be met by all English NHS breast screening units, the impact of which may not be seen until 2012.
Treatment pathway management can minimise the total time from final surgery to the start of radiotherapy. Multi-disciplinary teams should plan radiotherapy well ahead to try to ensure that women have their treatment at the earliest appropriate time. For example, in some centres radiotherapy is pre-booked at or shortly after the post-operative MDT meeting. Sharing this good practice may help to overcome regional differences in service provision.
Further Information
This data briefing is based on “An audit of screen-detected breast cancers for the year of screening 1 April 2010 to 31 March 2011”, NHSBSP & ABS, May 2012. The full publication, including methodology, is available to download from the NHS Breast Screening Programme website and the WMCIU website.
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The West Midlands Cancer Intelligence Unit is the National Cancer Intelligence Unit Lead Cancer Registry for Breast Cancer.