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Kilsdonk MJ, Siesling S, van Dijk BAC, Wouters MW, van Harten WH. What drives centralisation in cancer care? PLoS One 2018; 13:e0195673. [PMID: 29649250 PMCID: PMC5896991 DOI: 10.1371/journal.pone.0195673] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Accepted: 03/27/2018] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND To improve quality of care, centralisation of cancer services in high-volume centres has been stimulated. Studies linking specialisation and high (surgical) volumes to better outcomes already appeared in the 1990's. However, actual centralisation was a difficult process in many countries. In this study, factors influencing the centralisation of cancer services in the Netherlands were determined. MATERIAL AND METHODS Centralisation patterns were studied for three types of cancer that are known to benefit from high surgical caseloads: oesophagus-, pancreas- and bladder cancer. The Netherlands Cancer Registry provided data on tumour and treatment characteristics from 2000-2013 for respectively 8037, 4747 and 6362 patients receiving surgery. By plotting timelines of centralisation of cancer surgery, relations with the appearance of (inter)national scientific evidence, actions of medical specialist societies, specific regulation and other important factors on the degree of centralisation were ascertained. RESULTS For oesophagus and pancreas cancer, a gradual increase in centralisation of surgery is seen from 2005 and 2006 onwards following (inter)national scientific evidence. Centralisation steps for bladder cancer surgery can be seen in 2010 and 2013 anticipating on the publication of norms by the professional society. The most influential stimulus seems to have been regulations on minimum volumes. CONCLUSION Scientific evidence on the relationship between volume and outcome lead to the start of centralisation of surgical cancer care in the Netherlands. Once a body of evidence has been established on organisational change that influences professional practice, in addition some form of regulation is needed to ensure widespread implementation.
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Affiliation(s)
- Melvin J. Kilsdonk
- Netherlands Comprehensive Cancer Organisation, dept. of research, Utrecht, the Netherlands
- University of Twente, School for Management and Governance, dept. of Health Technology and Services Research, Enschede, The Netherlands
| | - Sabine Siesling
- Netherlands Comprehensive Cancer Organisation, dept. of research, Utrecht, the Netherlands
- University of Twente, School for Management and Governance, dept. of Health Technology and Services Research, Enschede, The Netherlands
| | - Boukje A. C. van Dijk
- Netherlands Comprehensive Cancer Organisation, dept. of research, Utrecht, the Netherlands
- University of Groningen, University Medical Centre Groningen, dept. of epidemiology, Groningen, the Netherlands
| | | | - Wim H. van Harten
- University of Twente, School for Management and Governance, dept. of Health Technology and Services Research, Enschede, The Netherlands
- The Netherlands Cancer Institute, Amsterdam, The Netherlands
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Beek MA, Verheuvel NC, Luiten EJT, Klompenhouwer EG, Rutten HJT, Roumen RMH, Gobardhan PD, Voogd AC. Two decades of axillary management in breast cancer. Br J Surg 2015; 102:1658-64. [DOI: 10.1002/bjs.9955] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2015] [Revised: 05/26/2015] [Accepted: 08/27/2015] [Indexed: 02/06/2023]
Abstract
Abstract
Background
Axillary lymph node dissection (ALND) in patients with breast cancer provides prognostic information. For many years, positive nodes were the most important indication for adjuvant systemic therapy. It was also believed that regional control could not be achieved without axillary clearance in a positive axilla. However, during the past 20 years the treatment and staging of the axilla has undergone many changes. This large population-based study was conducted in the south-east of the Netherlands to evaluate the changing patterns of care regarding the axilla, including the introduction of sentinel lymph node biopsy (SLNB) in the late 1990s, implementation of the results of the American College of Surgeons Oncology Group Z0011 study, and the initial effects of the European Organization for Research and Treatment of Cancer AMAROS study.
Methods
Data from the population-based Eindhoven Cancer Registry of all women diagnosed with invasive breast cancer in the south of the Netherlands between January 1993 and July 2014 were used.
Results
The proportion of 34 037 women staged by SLNB without completion ALND increased from 0 per cent in 1993–1994 to 69·0 per cent in 2013–2014. In the same period the proportion undergoing ALND decreased from 88·8 to 18·7 per cent. Among women with one to three positive lymph nodes, the proportion undergoing SLNB alone increased from 10·6 per cent in 2011–2012 to 37·6 per cent in 2013–2014.
Conclusion
This population-based study demonstrated the radical transformation in management of the axilla since the introduction of SLNB and following the recent publication of trials on management of the axilla with a low metastatic burden.
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Affiliation(s)
- M A Beek
- Department of Surgery, Amphia Hospital, Breda, The Netherlands
| | - N C Verheuvel
- Department of Surgery, Maastricht University, Maastricht, The Netherlands
| | - E J T Luiten
- Department of Surgery, Amphia Hospital, Breda, The Netherlands
| | - E G Klompenhouwer
- Departments of Radiology, Catharina Hospital, Eindhoven, The Netherlands
| | - H J T Rutten
- Department of Surgery, Maastricht University, Maastricht, The Netherlands
- Departments of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - R M H Roumen
- Department of Surgery, Máxima Medisch Centrum, Veldhoven, The Netherlands
| | - P D Gobardhan
- Department of Surgery, Amphia Hospital, Breda, The Netherlands
| | - A C Voogd
- Department of Epidemiology, Faculty of Health Medicine and Life Sciences, School for Oncology and Developmental Biology (GROW), Maastricht University, Maastricht, The Netherlands
- Department of Research, Netherlands Comprehensive Cancer Organization, Eindhoven, The Netherlands
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Saadatmand S, Bretveld R, Siesling S, Tilanus-Linthorst MMA. Influence of tumour stage at breast cancer detection on survival in modern times: population based study in 173,797 patients. BMJ 2015; 351:h4901. [PMID: 26442924 PMCID: PMC4595560 DOI: 10.1136/bmj.h4901] [Citation(s) in RCA: 187] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/04/2015] [Indexed: 01/16/2023]
Abstract
OBJECTIVES To assess the influence of stage at breast cancer diagnosis, tumour biology, and treatment on survival in contemporary times of better (neo-)adjuvant systemic therapy. DESIGN Prospective nationwide population based study. SETTING Nationwide Netherlands Cancer Registry. PARTICIPANTS Female patients with primary breast cancer diagnosed between 1999 and 2012 (n=173,797), subdivided into two time cohorts on the basis of breast cancer diagnosis: 1999-2005 (n=80,228) and 2006-12 (n=93,569). MAIN OUTCOME MEASURES Relative survival was compared between the two cohorts. Influence of traditional prognostic factors on overall mortality was analysed with Cox regression for each cohort separately. RESULTS Compared with 1999-2005, patients from 2006-12 had smaller (≤ T1 65% (n=60,570) v 60% (n=48,031); P<0.001), more often lymph node negative (N0 68% (n=63,544) v 65% (n=52,238); P<0.001) tumours, but they received more chemotherapy, hormonal therapy, and targeted therapy (neo-adjuvant/adjuvant systemic therapy 60% (n=56,402) v 53% (n=42,185); P<0.001). Median follow-up was 9.8 years for 1999-2005 and 3.9 years for 2006-12. The relative five year survival rate in 2006-12 was 96%, improved in all tumour and nodal stages compared with 1999-2005, and 100% in tumours ≤ 1 cm. In multivariable analyses adjusted for age and tumour type, overall mortality was decreased by surgery (especially breast conserving), radiotherapy, and systemic therapies. Mortality increased with progressing tumour size in both cohorts (2006-12 T1c v T1a: hazard ratio 1.54, 95% confidence interval 1.33 to 1.78), but without a significant difference in invasive breast cancers until 1 cm (2006-12 T1b v T1a: hazard ratio 1.04, 0.88 to 1.22), and independently with progressing number of positive lymph nodes (2006-12 N1 v N0: 1.25, 1.17 to 1.32). CONCLUSIONS Tumour stage at diagnosis of breast cancer still influences overall survival significantly in the current era of effective systemic therapy. Diagnosis of breast cancer at an early tumour stage remains vital.
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Affiliation(s)
- Sepideh Saadatmand
- Department of Surgery, Erasmus University Medical Centre - Cancer Institute, 3075 EA, Rotterdam, Netherlands
| | - Reini Bretveld
- Department of Research, Netherlands Comprehensive Cancer Organization, 3511 DT, Utrecht, Netherlands
| | - Sabine Siesling
- Department of Research, Netherlands Comprehensive Cancer Organization, 3511 DT, Utrecht, Netherlands Department of Health Technology and Services Research, MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, 7500 AE, Enschede, Netherlands
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Cutuli B, Dalenc F, Cottu PH, Gligorov J, Guastalla JP, Petit T, Amrate A. Impact of screening on clinicopathological features and treatment for invasive breast cancer: results of two national surveys. Cancer Radiother 2015; 19:295-302. [PMID: 26188735 DOI: 10.1016/j.canrad.2015.02.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2014] [Revised: 02/22/2015] [Accepted: 02/25/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE Several studies showed a breast cancer downstaging due to screening. A first national survey was conducted in France in 2001-2002 to evaluate in the current clinical practice the clinicopathological features and treatments of 1049 firstly operated breast cancers. In order to assess the impact of the national screening program implemented in all regions in France in 2004, a new survey was performed in 2007-2008. MATERIAL The new survey included 1433 firstly operated breast cancers prospectively collected. These new data were compared to the results of the first national survey. RESULTS According to TN classification, we found in the second survey T0: 27.6%, T1: 48.6%, T2: 21.3%, T3T4: 3.8% and Tx: 0.7%. Infiltrating ductal and lobular carcinomas represented 80% and 13% of tumours. Hormone receptors were positive in 85.3% and Her-2 overexpressed in 12.4% of tumours (83.9% and 20.6% in the first survey); 68.2% and 32% were pN0 and pN1-3. Lumpectomy and mastectomy were performed in 77% and 23% of the cases. Axillary dissection, sentinel node biopsy or both were performed in 42.6%, 41% and 16.4% of the cases, respectively. Radiotherapy, chemotherapy, hormonotherapy and trastuzumab were given to 93%, 51%, 83% and 9.3% of the patients. Compared with the results from the first survey, we found an increase of infraclinical lesions (T0 from 8.4 to 27.6%) and a wide decrease of pN+ rate (from 44% to 32%). The mastectomy rate was constant (23%), as well as radiotherapy use, whereas chemotherapy use decreased from 62.8 to 55.6%. CONCLUSION A complete national screening coverage clearly provides a favourable modification of breast cancer clinicopathological features. Both locoregional and adjuvant treatments were greatly downscaled.
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Affiliation(s)
- B Cutuli
- Department of Oncology and Radiotherapy, institut du cancer Courlancy, 38, rue de Courlancy, 51100 Reims, France.
| | - F Dalenc
- Institut Claudius-Regaud, 33000 Toulouse, France
| | | | | | | | - T Petit
- Centre Paul-Strauss, 67000 Strasbourg, France
| | - A Amrate
- AstraZeneca, 92500 Rueil-Malmaison, France
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Population based study on sentinel node biopsy before or after neoadjuvant chemotherapy in clinically node negative breast cancer patients: Identification rate and influence on axillary treatment. Eur J Cancer 2015; 51:915-21. [DOI: 10.1016/j.ejca.2015.03.014] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Revised: 02/01/2015] [Accepted: 03/19/2015] [Indexed: 02/06/2023]
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Schrodi S, Niedostatek A, Werner C, Tillack A, Schubert-Fritschle G, Engel J. Is primary surgery of breast cancer patients consistent with German guidelines? Twelve-year trend of population-based clinical cancer registry data. Eur J Cancer Care (Engl) 2014; 24:242-52. [DOI: 10.1111/ecc.12194] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/27/2014] [Indexed: 02/06/2023]
Affiliation(s)
- S. Schrodi
- Munich Cancer Registry (MCR) of the Munich Cancer Centre (MCC); Department of medical Informatics, Biometry and Epidemiology (IBE); Ludwig-Maximilians-University (LMU), Großhadern Clinic; Munich Germany
| | - A. Niedostatek
- Regional Clinical Cancer Register Dresden (RKKRD); Dresden Germany
| | - C. Werner
- Regional Clinical Cancer Register Dresden (RKKRD); Dresden Germany
| | - A. Tillack
- Cancer Centre Brandenburg; Frankfurt (Oder) Germany
| | - G. Schubert-Fritschle
- Munich Cancer Registry (MCR) of the Munich Cancer Centre (MCC); Department of medical Informatics, Biometry and Epidemiology (IBE); Ludwig-Maximilians-University (LMU), Großhadern Clinic; Munich Germany
| | - J. Engel
- Munich Cancer Registry (MCR) of the Munich Cancer Centre (MCC); Department of medical Informatics, Biometry and Epidemiology (IBE); Ludwig-Maximilians-University (LMU), Großhadern Clinic; Munich Germany
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Pepels M, Vestjens J, de Boer M, Bult P, Van Dijck J, Menke-Pluijmers M, van Diest P, Borm G, Tjan-Heijnen V. Models predicting non-sentinel node involvement also predict for regional recurrence in breast cancer patients without axillary treatment. Eur J Surg Oncol 2013; 39:1351-7. [DOI: 10.1016/j.ejso.2013.09.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2012] [Revised: 07/29/2013] [Accepted: 09/05/2013] [Indexed: 12/31/2022] Open
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Safety of avoiding routine use of axillary dissection in early stage breast cancer: a systematic review. Breast Cancer Res Treat 2010; 125:301-13. [DOI: 10.1007/s10549-010-1210-7] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2010] [Accepted: 09/30/2010] [Indexed: 10/18/2022]
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van Steenbergen LN, van de Poll-Franse LV, Wouters MWJM, Jansen-Landheer MLEA, Coebergh JWW, Struikmans H, Tjan-Heijnen VCG, van de Velde CJH. Variation in management of early breast cancer in the Netherlands, 2003-2006. Eur J Surg Oncol 2010; 36 Suppl 1:S36-43. [PMID: 20620013 DOI: 10.1016/j.ejso.2010.06.021] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2010] [Accepted: 06/08/2010] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND To describe variation in staging and primary treatment by hospital characteristics including type and volume and region in patients with early breast cancer (BC) in the Netherlands, 2003-2006 after completion of national guidelines in 2002. METHODS All patients newly diagnosed with invasive BC in 2003-2006 and recorded in the Netherlands Cancer Registry were included (n = 51 354). Multivariable logistic regression analyses examined the influence of patient and hospital characteristics, also by region, on type of breast surgery, axillary lymph node dissection (ALND), sentinel node procedure (SNP), and adjuvant irradiation and/or systemic treatment. RESULTS Patients <40 years more often underwent breast conserving surgery (BCS) in general hospitals (OR 1.4 (95%CI 1.1-1.5)) than in teaching and academic hospitals, whereas patients of 40-69 years less often received BCS in an academic hospital (OR 0.9 (95%CI 0.8-1.0)) than in teaching hospitals. Patients with pT1-2N0 cancer more often underwent primary ALND in a general hospital than in a larger teaching or academic hospital. Type of hospital did not seem to affect utilization of adjuvant systemic therapy, but patient age and tumour size and grade did. Over time, patients more often received SNP, BCS, and adjuvant systemic therapy, primary ALND being on the decline, but with substantial regional variation between geographic regions. CONCLUSION With detailed evidence-based national guidelines since 2002 the considerable regional and hospital variation in staging procedures and primary treatment among newly diagnosed patients with early breast cancer in the Netherlands decreased markedly, suggesting the presence of late adaptors rather than specific hospital characteristics.
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Cserni G, Bori R, Sejben I, Boross G, Maráz R, Svébis M, Rajtár M, Tekle Wolde E, Ambrózay É. Analysis of predictive tools for further axillary involvement in patients with sentinel lymph node positive small (≤15 mm) invasive breast cancer. Orv Hetil 2009; 150:2182-8. [DOI: 10.1556/oh.2009.28699] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Small breast cancers often require different treatment than larger ones. The frequency and predictability of further nodal involvement was evaluated in patients with positive sentinel lymph nodes and breast cancers ≤15 mm by means of 8 different predictive tools. Of 506 patients with such small tumors 138 with positive sentinel nodes underwent axillary dissection and 39 of these had non-sentinel node involvement too. The Stanford nomogram and the micrometastatic nomogram were the predictive tools identifying a small group of patients with low probability of further axillary involvement that might not require completion axillary lymph node dissection. Our data also suggest that the Tenon score can separate subsets of patients with a low and a higher risk of non-sentinel node metastasis. Predictive tools based on multivariate models can help in omitting completion axillary dissection in patients with low risk of non-sentinel lymph node metastasis based on their small tumor size.
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Affiliation(s)
- Gábor Cserni
- Bács-Kiskun Megyei Önkormányzat Kórháza Patológiai Osztály Kecskemét Nyíri út 38. 6000
| | - Rita Bori
- Bács-Kiskun Megyei Önkormányzat Kórháza Patológiai Osztály Kecskemét Nyíri út 38. 6000
| | - István Sejben
- Bács-Kiskun Megyei Önkormányzat Kórháza Patológiai Osztály Kecskemét Nyíri út 38. 6000
| | - Gábor Boross
- Bács-Kiskun Megyei Önkormányzat Kórháza Sebészeti Osztály Kecskemét
| | - Róbert Maráz
- Bács-Kiskun Megyei Önkormányzat Kórháza Sebészeti Osztály Kecskemét
| | - Mihály Svébis
- Bács-Kiskun Megyei Önkormányzat Kórháza Sebészeti Osztály Kecskemét
| | - Mária Rajtár
- Bács-Kiskun Megyei Önkormányzat Kórháza Nukleáris Medicina Osztály Kecskemét
| | - Eliza Tekle Wolde
- Bács-Kiskun Megyei Önkormányzat Kórháza Nukleáris Medicina Osztály Kecskemét
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Abstract
Biopsy of the sentinel lymph node now forms part of routine management in many centres dealing with early stage breast cancer. This article seeks to discuss developments over the past number of years and to summarise current practice.
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