Quality indicators
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The recommendations in the National Breast Cancer Treatment Guidelines and EUSOMA's quality indicatores (European guidelines) form the basis for registration of quality indicators in the National Breast Cancer Registry.
The Breast Cancer Registry also includes several time measures, including time from primary examination to diagnosis, time to surgical treatment, time from completion of surgical treatment to further oncological treatment (both chemotherapy and radiotherapy).
National treatment guidelines for diagnosis, treatment and follow-up of patients with breast cancer
Quality indicators of the National Quality Registry for Breast Cancer:
From Annual Report of Breast Cancer 2023, fig. 1.1.
The reporting coverage rate for radiology is 77.8 %, indicating a moderate achievement and an increase from 2022. There is a high coverage rate for imaging and tissue examinations for breast cancer detected in the Mammography Program, with nearly all breast diagnostic centers achieving a coverage rate of over 90 %, which is well above the target coverage rate of 80 %.
The coverage rate for reporting breast cancer detected outside the Mammography Program is 70.6 %, which is lower than desired.
The coverage rate for primary examination and primary surgery is high, at 93.1 % and 88.9 % respe-ctively. The coverage rate for the first postoperative check-up also shows high achievement at 87.0 %. Simplified reminder routines have likely contributed to the good coverage rate.
Breast MRI is an important part of the evaluation for selected patient groups. The use of MRI for breast cancer patients who did not receive neoadjuvant treatment has been removed from the new EUSOMA criteria. However, we believe this remains an important quality measure and have chosen to retain the old requirement of ≥ 10 % as moderate achievement and add ≥ 20 % as high achievement. This is justified, among other things, by the fact that according to the National treatment guidelines, MRI should be performed on lobular cancers, which alone account for more than 10 % of breast cancer cases. For women who received neoadjuvant treatment, the proportion evaluated with MRI has increased in recent years and is now 96.5 %, which exceeds EUSOMA's quality target of ≥ 90 %.
The proportion of women undergoing breast-conserving surgery when the tumor size is ≤ 30mm is 89.5%, which is close to the desired achievement of 90 % and an increase from 2022. EUSOMA's quality target has increased from ≥ 85 % to ≥ 90 % in 2023. There are minor variations between hospitals, but a few hospitals could likely perform more breast-conserving surgeries. 91.6% of women with DCIS ≤ 20mm underwent breast-conserving surgery, indicating a high achievement. The proportion who underwent primary reconstruction after mastectomy for DCIS and invasive disease in patients who did not receive radiotherapy is 53.3 %, indicating moderate achievement. EUSOMA recommends that primary reconstructions after mastectomy should be performed in at least 40 % of cases, with a target of 60 %. Several hospitals have fluctuating results from year to year. It is important to establish robust services for this patient group.
94.1 % of patients with cN0 stage had ≤ 5 lymph nodes removed in total during sentinel lymph node diagnostics, indicating moderate achievement. EUSOMA's quality target recommends this should apply to at least 90 %, with a goal of 95 %. Considering arm morbidity following surgical treatment for breast cancer, this is an important treatment goal.
Read more about quality indicators in the annual report (Norwegian only).
Quality improvements
The registry has access to data to perform analyses of demographic differences such as age, gender, place of residence at the time of diagnosis, treatment institution and date of death. Analyses of any differences between hospitals will depend on the degree of clinical reporting. It is a prerequisite that the completeness of the data is high in order to assess whether patients have access to equally good assessment, treatment and follow-up/control throughout the country.
There is reason to believe that the introduction of the Breast Cancer Registry, with annual reports on the practice of the individual hospitals, has been and will continue to be of great importance in order to achieve as much practice as possible in Norway and that new practice is implemented more quickly.
Surgery
Operating volume distributed by operating hospital, year of operation 2023. From figure 2.20 from the annual report.
The surgical volume at the various hospitals in Norway still varies significantly. The increased complexity of treatment protocols is a reason to consider reducing the number of hospitals that diagnose and treat breast cancer. The increasing use of neoadjuvant systemic therapy, which requires broad multidisciplinary teams, the need for plastic surgery expertise for primary reconstructions, and de-escalated axillary surgery with a resulting low number of axillary dissections at small hospitals are all examples of this.
Some hospitals have followed this recommendation and merged into larger, more robust units. In 2023, Helse Nord-Trøndelag decided to discontinue breast surgery in Namsos, and henceforth, breast cancer patients from Namsos will be operated on at St. Olavs Hospital. Additionally, the aspects of education and the requirement for robustness are challenging to meet with low surgical volumes.
The results in this year's report so far show that the recommendations related to surgical treatment are largely being followed, with some exceptions and some variation.
Proportion of breast-conserving operations among primary operated patients with DCIS and tumor size 0–20 mm, distributed by operating hospital, year of operation 2018–2023. From fig. 2.23 in the annual report.
Results in 2021 showed a low proportion of breast-conserving operations for DCIS with tumor size between 0-20 mm at Telemark Hospital.
The cancer registry has provided information on a low proportion. Telemark Hospital has actively worked to find out the reason why the proportion of DCIS has been low. Among other things, the radiologists have been more observant for possible DCIS. The hospital has had problems with vacuum biopsy, which may have been one of the reasons for the low proportion. The hospital has increased the proportion from 69.2 % in 2021 to 83.3 % in 2022 and in 2023 the proportion is 100 %.
Radiology
An annual reminder is sent to radiologists to register MRIs. The use of MRI before surgery was implemented in the surgical form in 2023. The radiologists are focused on uniformly coding of examinations, procedures and findings. The work to find the correct use of breast MRI and increase reporting should continue with both the interdisciplinary community with a focus on capacity and tradition in the use of MRI. Half-yearly data show significant improvement, high target attainment is achieved, but there are still variations between the hospitals.
Oncology
EUSOMA's quality indicator 35: Proportion of patients < 75 years of age with HER2-positive and triple-negative clinical stage II-III who have received neoadjuvant treatment. There are some variations between the hospitals. For stage II, a lower proportion receives neoadjuvant treatment.
Proportion of patients < 75 years of age with triple negative breast cancer who start adjuvant treatment within 6 weeks after surgery. Stage I-III patients who have not received neoadjuvant treatment. Here there are relatively large variations between the hospitals and it is clear that too few patients in Norway start treatment within 42 days.
Pathology
There are still differences between the pathology departments for the histological grading of tumours. This is pointed out at annual meetings and courses. There is a lack of resources in the pathology environment to initiate national improvement measures. This is an an ongoing process.
Patient-reported outcomes
In order to further strengthen the quality of health services, the Cancer Registry of Norway worked in 2019 and 2020 to plan and build infrastructure for collecting PROMs (patient-reported outcome and experience measures), including integration with ePROM, which is the national solution for collecting PROMs.
Collection of PROM and PREM data for breast cancer started in autumn 2020 for women diagnosed in 2020 through a fixed, three-year population survey on health and quality of life. For PROMs, women diagnosed with breast cancer are compared with a control group of women without breast cancer, but with matching age and residential composition.
Read more about the population surveys
We know from the past that younger women who have been treated for breast cancer report lower health and quality of life than the corresponding age group in the general population and lower than in the older age groups. Three years after diagnosis, however, the differences do not seem to be large in this material.
Self-reported health and quality of life three years after diagnosis for breast cancer patients, compared to women without breast cancer of the same age and place of residence. Invitation 1.1.2023–31.3.2024. From fig. 2.39 in Annual report for the Norwegian Breast Cancer Registry 2023.
In order to contribute to further strengthening the quality of health services, in 2019 and 2020 the Norwegian Cancer Registry worked to plan and build infrastructure for the collection of PROMs (patient-reported outcome and experience measures), including integration with ePROM, which is the national solution for collecting PROMs.
In 2022, the Norwegian Cancer Registry invited people with newly diagnosed prostate cancer, breast cancer, colon and rectal cancer, melanoma or lung cancer to participate in a digital population survey on health and quality of life. This makes up more than half of all cancer patients, and the aim is to collect PROMs (Patient Reported Outcome Measures) and PREMs (Patient Reported Experience Measures) in all the Cancer Registry's quality registers.
There is no authority in the Cancer Registry Regulations to collect PROMs/PREMs, and the collection therefore has its treatment basis in the Regulations on population-based health surveys.