Service
Breast Cancer Services
Commissioner Lead
Name
Provider Lead
Name Integrated Cancer System
Period
2012/2013
Date of Review
Annually
1. Purpose of Service
1.1 Aims and objectives of service
The overall aim of the service is “to improve cancer outcomes through seamlessly delivered
pathways, providing high quality care to patients with breast cancer throughout their journey”.
The service will have the following objectives:
 Enhance the management of patients within the system, and actively manage the
demand for secondary care and follow-up services ensuring patients have speedy
access to appropriate treatment.
 Reduce variation in access to and experience of care through consistent application
of best practice.
 Improve the patient experience.
 Provide clinical assessment and treatment within an Integrated Cancer System.
 Monitor and review agreed models of care and pathways for breast cancer patients
across the Integrated Cancer Systems.
1.2 Whole pathway commissioning
Improving cancer outcomes through seamlessly delivered pathways that run from prevention
through to end of life care remains an important vision for commissioning cancer. It is
important, therefore, that cancer site specific pathways are collaboratively commissioned and
delivered by providers working in partnership in an integrated system. This requirement is
covered in Schedule 20 of the NHS Contract.
The nature of the disease and its treatment means that there will be a plurality of providers.
This approach ensures that all parties, commissioners, service users and providers recognise
the whole patient pathway, the duty for partnership working and the need for seamless care
across organisational boundaries.
The ICS pathway groups will be responsible for managing the whole pathway, agreeing the
approach to delivering clinical best practice pathways, and providing clinical leadership to
coordinate delivery across the Integrated Cancer Systems.
2. Scope
The service specification covers both early and locally advanced disease and advanced
disease and covers the patient pathway from point of referral to follow – up / end of life care.
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Specifications for prophylactic surgery pathways and for benign disease patients are out of
scope.
The service description does not cover emergency presentations based on the assumption
that Acute Oncology Services (AOS) will pick up this cohort of patients.
Providers will have in place co-morbidity assessment pathways to all relevant specialities that
demonstrate minimised pathway delay. Co-morbidity pathways are not covered in the service
description.
3. Service description – early and locally advanced breast cancer
3.1 Service model - general
The required service model is outlined in the clinically effective pathway on map of medicine.
In addition to this specification, there are a number of other criteria set out in NICE guidance
that must be met by any provider offering services for breast cancer patients.
Different elements of the cancer treatment might be delivered on different provider sites.
There are a number of criteria that must be met by any provider offering services for breast
cancer patients ensuring high quality cost effective care and in accordance with NICE
Guidance.
Ref. Appendix 1 Commissioning best practice pathway for early and locally advanced breast
cancer
Ref.1-3. Presentation
ICSs are required to meet the national average for presentation through screening (21%)
Ref.4 Referral
Referral processes are required to follow the current NICE guidelines for breast cancer
symptoms ensuring that all patients are seen within 14 days of the referral.
Patients diagnosed though the national screening programme are required to be referred
onto the breast cancer service for further assessment, and treatment must commence within
the 62 day deadline specified in the cancer waiting time targets for an urgent referral. This is
calculated from the date of the decision to refer for assessment.
Ref.5 Triple assessment
All patients who require triple assessment should have a consultation and clinical
examination, mammography and/or ultrasound, and core biopsy/fine needle aspiration
cytology. There should be a risk stratification approach to triple assessment so only those
patients requiring all three assessments undergo them and these should be provided on the
same day.
Ref.7 Multidisciplinary team (MDT)
NICE guidance states that MDTs should see 100 new cancer cases p.a., 30 of which should
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be screening cases. If caseloads are large enough then there should be separate MDTs for
screening, symptomatic, and advanced disease. The MDT should record disease staging
and percentage of new patients entered into clinical trials. The MDT should also ensure that
the results of ER and HER2 assessments are available and recorded at the MDT meeting to
inform decisions about systemic treatment. ICSs should ensure that all MDTs are given a
central role in coordinating patient care.
The age of the patient should not be a deciding factor for the treatment plan by the clinical
team. The fitness of the patient and the presence or otherwise of co-morbidities is of far
greater importance when making treatment recommendations. The issues of patient fitness
and co-morbidities should become a routine part of the multidisciplinary team discussion.
The MDT should record disease staging based on diagnostic and staging tests before
surgery, and correct this if necessary after surgery and pathological analysis of the
specimen.
The breast IOG states a recommended minimum volume of 30 procedures per surgeon per
year.1 As multidisciplinary teams should not rely solely on one surgeon, each
multidisciplinary team should be advising at least 60 procedures a year.
Ref.6 Staging tests
NICE guidance sets out a selective approach to undertaking staging tests. Only if staging is
not clear, should patients be offered an MRI. PET-CT should only be used to make a new
diagnosis of metastases, if there is suspicious imaging. Pre-treatment ultrasound evaluation
of the axilla should be performed for all patients being investigated for early invasive breast
cancer and, if abnormal lymph nodes are identified, ultrasound-guided needle sampling
should be offered.
Ref.8 Second outpatient
Patients should attend two outpatient appointments pre-surgery unless further appointments
are clinically required. Patients requiring more psychological support and reassurance may
warrant several pre-op outpatient appointments.
A holistic needs assessment should be undertaken whereby the patient should have an
agreed, written care plan, recorded by a named healthcare professional (or professionals),
with a copy sent to the GP and a personal copy given to the patient.
All patients should be assigned to a named breast care nurse specialist and be offered
prompt access to specialist psychological support.
Ref. 9a-9e. Surgery
Low complexity breast surgery should be available locally to patients, as a day case where
clinically appropriate. The patient’s personal circumstances must be taken into account
when planning surgical interventions on the 23-hour model. It must be ensured that
appropriate support arrangements are fully in place prior to discharge.
Intra-operative sentinel node biopsy (SNB) should be considered for all women and adopted
to avoid a second operation. Sentinel node biopsy should be offered to all women who are
eligible. A combination of patent blue dye and technetium colloid should be used to
maximise the likelihood of identification of the sentinel node.
9a. Conservation surgery: Treatment should be as a 12 hour day case procedure for
conservation surgery with Sentinel Node Biopsy (SNB) and 23 hour surgery for conservation
1
NICE, Improving outcomes in breast cancer: manual update, 2002
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surgery with Axillary Lymph Node Clearance (ALNC).
9b / 9d. Mastectomy: A 23-hour stay model for mastectomy without reconstruction should be
available locally to patients, where appropriate.
9c / 9e. Mastectomy with reconstruction: All patients undergoing mastectomy should have
the opportunity to discuss their breast reconstruction options and have immediate breast
reconstruction if appropriate. Complex immediate breast reconstructive surgery, specifically
free flap surgery, should be undertaken in specialist centres with dedicated plastic surgery
and rehabilitation teams. Rapid-access pathways must be in place across Integrated Cancer
Systems between providers offering reconstructive surgery and those who do not provide
the full range of breast cancer surgery options.
Complex surgery service co-dependencies
The breast cancer surgical service must be collocated with the following support services, as
set out in the cancer co-dependencies framework: pathology, specialist imaging (for IMRT
and EMRT), CNS support, and lymphoedema (specifically for procedures involving lymph
node dissection).
There are a number of additional desirable service collocation requirements for the specialist
surgical service and the ICS will agree service configuration and location with
commissioners.
Ref. 10a. Radiotherapy
After mastectomy radiotherapy should not be offered to patients at low risk of local
recurrence.
Ref.10b Systemic therapy
Chemotherapy should be delivered in a community setting and close to home, where
appropriate. Adjuvant chemotherapy or radiotherapy should commence as soon as clinically
possible within 31 days of completion of surgery in patients with early breast cancer having
these treatments.
Ref. 11 - Third outpatient
Patients should attend a post-operative clinic to receive results from the surgeon and
discuss further MDT treatment options. The patient should then be referred to a clinical or
medical oncologist for further treatment if required.
Ref. 12 / 13. Follow-up, survivorship, End of life care
Providers will participate in the Inpatient Management Programme outlined in the Cancer
Reform Strategy. This includes access to enhanced recovery programmes, reduced length
of stay for breast surgery, and initiatives to reduce follow up in acute settings.
With the emerging national guidance cancer care pathways must include new models of
long term follow up and survivorship care.
Bespoke follow up in a primary care setting is recommended. An annual mammography to
all patients with early breast cancer, until they enter the NHS Breast Screening Programme
is the preferred care plan. Patients diagnosed with early breast cancer who are already
eligible for screening should have an annual mammography for 5 years.
The supportive and palliative care IOG should be implemented in London. All patients
should be offered a range of supportive care including psychosocial support and
individualised patient information.
Where appropriate, and in line with national guidance, all patients will have access to End of
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Life Care Services. All pathways and specifications will be assumed to link to the separate
pathway and specification for End of Life Care.
4. Service description – Advanced breast cancer
Ref. Appendix 2 Commissioning best practice pathway for advanced breast cancer
All service structure elements described for early and locally advanced disease and relevant
to the advanced breast cancer pathway must be followed. In addition:
- Imaging and pathological assessment may need to be undertaken for visceral and
bone metastases
- Those patients having biologics should have three MUGA scans during the course of
their treatment
- The management of complications should be discussed at the MDT meeting and
coordinated by the MDT including lymphoedema, cancer related fatigue, uncontrolled
local disease, and bone metastases
5. Quality Requirements
2.1 Service Description
There are a number of criteria that must be met by any provider offering services for breast
cancer patients ensuring high quality cost effective care and in accordance with NICE
Guidance.
1.1. There must be an established weekly MDT meeting, where all patients have their
treatment and care agreed, including any significant change to the treatment plan.
MDTs will consider each patient for the potential of entry into clinical trials.
1.2. Providers will formally adopt the agreed best practice clinical pathway and the
underlying clinical guidelines within their organisations’ clinical governance process.
These pathways will represent the key elements of the service being commissioned
and, together with guidelines and protocols, demonstrate the quality required.
1.3. All patients will have a named key worker to provide support at each stage of the
pathway.
1.4. Each patient must have their holistic needs assessed at key stages of the pathway
including survivorship and/or end of life care with formal care plans developed that
are communicated to all teams/professionals involved in the patient’s care and
shared with the patient (who will be free to share this with their carers/family)
1.5. The service must meet all current national quality standards, the recommendations
set out in the cancer model of care, and the relevant NICE Improving Outcome
Guidance. The service must be fully compliant with peer review measures.
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6. Key Service Outcomes
The key service outcome of this service specification is to “deliver high quality clinical
services for patients with breast cancer, following the agreed best practice breast cancer
pathway to ensure cancer survival rates in London are equal to or better than the best rates in
Europe”.
Any patient presenting with breast cancer will be placed on an agreed clinical pathway, to
receive the most appropriate care for their condition. The implementation of these pathways
will not only provide the best possible outcomes for the patients, but also allow NHS London
to use resources effectively within the health economy.
The key performance and quality indicators are listed below:
Pathway
Measure
Data
source
Reporting
Benchmark
Presentation
Percentage patients diagnosed with
cancer who first present as an
emergency
HES
Quarterly
tbc
→
Percentage patients seen within 2
weeks for urgent referral
CWT
Quarterly
tbc
Diagnostics
Number of patients diagnosed at
each stage and proportion of all
cancers
Percentage patients treated within
31 days (from diagnosis to
treatm nt)
Percentage patients treated within
62 days from urgent referral
Number of new cases seen per
annum
Percentage patients entered into
clinical trials
Patient finds i easy to contact
their CNS / keyworker
Survival 30 days after surgery
TCR
Quarterly
tbc
CWT
Quarterly
tbc
CWT
Quarterly
tbc
Trust data
Annual
tbc
NCRN
Annual
tbc
NCPES
Annual
tbc
HES &
ONS
HES
Quarterly
tbc
Annual
tbc
Trust data
Annual
tbc
Percentage uptake immediate
reconstruction
HES
Annual
tbc
Percentage of patients receiving
radiotherapy delivered within 45
minutes of home
Trust data
Annual
tbc
Percentage of patients receiving
IMRT
Percentage patients being treated
by breast conservation receiving
radiotherapy for invasive cancer
HES
Quarterly
tbc
HES
Annual
tbc
→
MDT
→
Surgery
Percentage re-operation and readmission rates within 30 days
Percentage uptake 23 hour surgery
Radiotherapy
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Chemotherapy
Percentage of patients receiving
chemotherapy episodes delivered
within 30 minutes of home
Trust data
Quarterly
tbc
Trust data
Quarterly
tbc
Trust data
Quarterly
tbc
Survival
Door to needle for neutropenic
sepsis
Percentage patients undergoing
holistic needs assessment
1 year survival by stage
TCR
Annual
tbc
Survival
5 year survival by stage
TCR
Annual
tbc
Survivorship
10 year survival by stage
TCR
Annual
tbc
System
Percentage patients and carers
given clear and understandable
written and verbal information at
relevant stages of the pathway
NCPES
Annual
100%
Follow up
7. Service structure – Informatics requirements
Recording and collection of high quality data is essential to commissioners and providers. It
allows the quality of care to be assessed and determines the improvements required.
The providers within the Integrated Cancer Systems will provide agreed performance
monitoring data against the metrics below on a quarterly basis. Where any elements of this
deviate from the agreed plan, the service will provide a brief explanation accompanying the
submission of the report.
The provider shall ensure that standards of performance are routinely monitored and that
remedial action is promptly taken where these standards are not attained.
Providers, and their MDTs, will collect and submit data in line with both national and locally
agreed requirements and as per the requirements of Section 29 and Schedule 5 of the NHS
Contract.
In 2012/13 ICSs will be required to ensure the data collection systems and protocols are in
place to provide the following information to commissioners:
 Informing commissioners for new patients:
o the date a patient is diagnosed with breast cancer
o the stage at diagnosis
o their NHS number or an agreed pseudonymised alternative.

Informing commissioners for existing patients:
o the date the stage of the cancer is diagnosed as having changed
o the new stage.

Informing commissioners for all patients:
o the date a MDT ceases to have overall responsibility for the care of the
patient
o the reason for this (e.g. death/move away/patient chooses to stop having
treatment etc).

In addition:

Providers within the ICS will complete the Cancer Registration Dataset
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(CRDS) for all patients.

Providers within the ICS will submit the CRDS to the Thames Cancer
Registry, commissioners and local cancer network quarterly seven weeks
after the quarter end.

MDTs will be responsible for the completeness, quality and timeliness of
data.
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Appendix 1. Commissioning best practice pathway for early and locally advanced breast cancer
8b Re-excision of
margins
8a
9. Neoadjuvant
systemic
therapy
no cancer
10. Radiotherapy
9. Adjuvant
Systemic
Therapy
Advanced disease
9a
Mastectomy
5. Staging tests
(Imaging +
histology)
1. A&E
10. Radiotherapy
13.Survivorship
9b
4. 1st OPA:
Triple
assessment
2. GP
7. 2nd OPA:
Surgical
6. Breast MDT
(weekly)
4a. Biopsy
3. Screening
Programme
Conservation
surgery
Mastectomy
11. Outpatient
appt.
Reconstruction
12. Follow up
14.End of Life
9c
Mastectomy
4b. CT scan
4c. Examination
10. Radiotherapy
advanced
disease
15. Palliative care
9d
Mastectomy
Reconstruction
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Appendix 2 Commissioning best practice pathway for advanced breast cancer
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