NW Region Breast Screening Quality Assurance Reference Centre
Breast Screening Surgical
Quality Assurance Visit Questionnaire
Date of QA Visit:
………………………………………………………………………………………
Breast Screening Service:
………………………………………………………………………………………
Signature:
__________________________
Screening Service
(Persons completing questionnaire)
Data is required for the screening period
1 April 2013 – 31 March 2014 unless otherwise
stated
Please return completed questionnaire via email to
anne.reid@phe.gov.uk
Your Screening office manager /Programme manager has been
provided with a master list of all evidence required for the QA visit.
Please liaise with them accordingly.
North West Breast Screening QARC
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Section Seven - Surgery
The information provided in this questionnaire will be reviewed in confidence by members of staff
from the QA Reference Centre and the regional QA Team, including deputies if they are required.
Information supplied will form the basis of the final QA Team Visit report. For clarification purposes,
some of the information obtained from this questionnaire and used in the final report may be
referenced to the reporting member of staff. As part of the pre-publication validation process, a
copy of the draft report will be sent to the Director of Breast Screening to check for accuracy. At this
point any concerns regarding named information may be made in writing to the QA Director at the
QA Reference Centre. The QA Reference Centre will store all completed questionnaires
indefinitely; paper copies will be transferred to electronic versions and stored on a secure server.
North West Breast Screening QARC
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Section Seven - Surgery
SECTION 7 –SURGERY QA
(This section to be completed by the Lead Surgeon for Breast Screening)
Name of Lead Surgeon for Breast Screening:
Name(s) of surgeon(s) involved in the management of breast disease at this unit
Name(s) of surgeon(s) and number of contractual
sessions for symptomatic work:
Name(s) of surgeon(s) and number of contractual
sessions for screening work:
Name of surgeon
No. of sessions
1)
2)
3)
4)
5)
6)
7)
8)
Name of surgeon
No. of sessions
1)
2)
3)
4)
5)
6)
7)
8)
What arrangements are there to cover consultant
absences, leave etc:
Which days are the screening assessment clinics held?
North West Breast Screening QARC
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Section Seven - Surgery
Does a Surgeon see the patient at the first assessment
clinic visit?
When is the patient discussed at the MDT?
How many days after the 1st assessment clinic is the
patient brought back to be informed of the results?
Is a BCN present when the patient is informed of the
results of the screening assessment needle biopsy?
If you not have a breast care nurse specialist what
arrangements exist for supporting patients?
Are you satisfied with the facilities and working
arrangements for assessment?
Proportion of women for whom the time interval
between non-operative biopsy and the result being
given to the patient is one week or less
Proportion of women for whom the time interval
between the decision to refer to a surgeon and surgical
assessment is one week or less
Are women given the choice as to where they have their
surgical treatment?
At what point in the patient pathway is choice provided?
What % of the screen detected cancers diagnosed within
your unit are treated at other breast units?
North West Breast Screening QARC
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Section Seven - Surgery
What arrangements are in place for these units to link
into the MDT meeting of your screening programme?
For those screening patients that are treated elsewhere,
who is responsible for providing treatment and follow up
data back to your breast screening unit?
Is there a room available with sufficient privacy to
discuss diagnosis and treatment with patients?
How long does it take to report cytology or core biopsy?
How often are MDTs held?
Are all non- operative patients discussed?
Are you satisfied with the way these multi-disciplinary
meetings are run and attended?
Who keeps a formal written record of these multidisciplinary meetings?
Do you have a computerised system to record MDT
outcomes? (eg Somerset & Avon Database)
Do you have any problems with collection and retrieval
of surgical data?
North West Breast Screening QARC
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Section Seven - Surgery
Please provide the following data for each Surgeon in your unit. (2013-14)
Surgeon Name
No. of symptomtic
cancers
No. of screening
cancers
Average waiting time between
assessment and 1st surgical
procedure
North West Breast Screening QARC
Average waiting time between
diagnosis and 1st definitive
therapeutic intervention
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Section Seven - Surgery
Please provide the following data for each Surgeon in your unit for the Treatment of screen detected DCIS (2013-2014):
Surgeon
Name
Total No. of
Cases
% of patients with a
positive nonoperative diagnosis
Mastectomies
No.
North West Breast Screening QARC
%
WLEs
No.
Other treatments
%
No.
%
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Section Seven - Surgery
Please provide the following data for each surgeon in your unit for the treatment of screen detected Invasive cancers (2013-14):
% of patients
Surgeon
Total No. of
with a
Mastectomy
WLE
Name
Cases
positive nonoperative
diagnosis
alone
& SLN Bx
& ANC
alone
& SLN Bx
& ANC
number (%)
number (%)
number (%)
number (%)
number (%)
number (%)
North West Breast Screening QARC
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Section Seven - Surgery
Please provide the following data for each surgeon in your unit. For the treatment of ALL screen detected breast cancers (2013-14)
Surgeon
Name
Total No. of
Cases under
going
immediate
breast
reconstruction
No. of operations per patient for the treatment of screen detected breast cancers
patients having 1 operation
No.
%
patients having 2 operations
No.
North West Breast Screening QARC
%
patients having 3 or more
operations
No.
%
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Section Seven - Surgery
Please provide the following data for each surgeon in your unit. For the treatment of ALL screen detected breast cancers (2013-2014):
Surgeon Name
5 year local recurrence rate for
patients treated by breast
conserving surgery
5 year local recurrence rate for patients
treated by mastectomy
North West Breast Screening QARC
5 year axillary recurrence
rates
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Section Seven - Surgery
Please provide the following data for each surgeon in your unit. (2013-14)
Name of Surgeon
No of operative
benign biopsies
No of operative benign
biopsies >20g (as stated
on pathology report)*
No of operative benign
biopsies >40g (as stated
on pathology report)*
* Whilst the NHSBSP
Surgical Guidelines state that
the biopsy specimens should
be weighed fresh in theatre it
is recognised that this data
may be difficult to obtain for
the QA visit. Therefore the
specimen weight from the
histopathology report is
accepted.
North West Breast Screening QARC
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Section Seven - Surgery
Do your patients with screen detected invasive disease
routinely get preoperative axillary u/s? Do they proceed
to nodal FNA if indicated?
What localisation does your unit employ for lymph node
mapping – Blue dye/radioactive tracer/both?
For which breast cancer trial(s) does this unit have
ethical committee approval?
How many patients have been entered into the trial(s)
mentioned above in the last year?
Are there any problems with trial entry?
Is the unit participating in the Sloane Project?
Is the unit participating in the BCCOM audit?
How many cases have been submitted so far?
How do you intend to implement
1. The Cancer Reform Strategy recommendations re
family history mammographic screening? Please
detail
2.
MRI screening as per the family history NICE
guidance?
North West Breast Screening QARC
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Section Seven - Surgery
In what way(s) have you and your colleagues ensured
your continuing medical education in breast cancer in
the last year (please detail meetings, courses etc)?
Do you have any difficulty in obtaining either study leave
or financial support from your employers for CME?
What do you believe are the weaknesses of this unit?
What do you believe are the strengths of this unit?
Are there any other comments you would wish to make?
Signed By
LEAD SURGEON ………………………………………………………………. DATE:………………………………………….
North West Breast Screening QARC
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Section Seven - Surgery