Question

What does the organisation of care look like in the treatment phase?

 

Recommendation

The guideline development group recommends establishing the organisation of care around surgical procedures in such a way, that:

  • information is repeatedly provided that is tailored to the specific phase of treatment
  • this verbal information is supported with written information and/or a website

 

If a comprehensive care package can be compiled in consultation with the patient, home care, physiotherapist and general practitioner, breast surgery can be recommended in a short stay admission programme. Conditions are:

  • home care is involved in planning of the surgery
  • the use of opiates are avoided during surgery
  • there are clearly formulated criteria to describe recovery, and therefore for discharge
  • this information is also available in writing or via a website
  • the postoperative phase has a decision moment for discharge, in which the patient has an important input
  • the specialised nurse maintains regular postoperative (telephone) contact with the patient

 

If this package cannot be guaranteed, then outpatient admission or 24-hour admission cannot be recommended.

Conclusions

 

Level 1

It is worthwhile to get details on existing shoulder complaints, comorbidity, high BMI and pain prior to treatment.

 

A1        Chlebowski 2002

A2        Box 2002, Harris 2001, Kellen 2009

B          Swenson 2009, McLaughlin 2005

 

Level 1

Providing information after an axillary node dissection on the use of the affected arm is important to promote recovery and prevent lymphoedema.

 

Information regarding physical activities, a healthy diet and weight management leads to a positive change in lifestyle. A lifestyle with moderately intensive exercise gives a longer survival.

 

A2        Harris 2001, Kellen 2009

B          Swenson 2009, McLaughlin 2005, Box 2002

 

Level 2

A care programme, consisting of careful and repeated provision of information to the patient, close collaboration with home care organisations and an outpatient admission or 24-hour admission for   surgical interventions, is safe, cost-effective and patient-friendly.

 

A2        Bundred 1998

B          de Kok 2007, de Kok 2010

Literature summary

The chosen treatment is determined by the patient, who is fully informed about the benefits (sparing the breast) and the disadvantages (side effects) of the treatment proposed, preferably in combination with written and/or internet information. Age and general condition are included in the considerations. The increased risk of a second primary tumour if there is a mutation of the BRCA1/2 gene or a strongly burdened family history must, if applicable, be discussed with the patient. It must also be discussed that choosing a mastectomy in combination with ALND does not influence the risk of a contralateral carcinoma and survival. It must be made clear that radiotherapy is an inherent component of the BCT (see chapter 3).

The possibilities for direct or secondary reconstruction must be discussed with the patient prior to treatment. In women under 40 years of age, the consequences of fertility treatment and possibilities in case there is a desire to have children are a fixed item when discussing treatment (see chapter 11).

 

Various studies [Kellen, 2009; Swenson, 2009; McLaughlin, 2005; Box, 2002; Chlebowski, 2002; Harris, 2001] have shown the importance of pre-treatment risk estimation and/or detection of any existing complaints. It is recommended to detail any existing shoulder complaints, comorbidity, BMI and pain prior to treatment. Monitoring lymphoedema is effective with circumference measurements of both arms every 10 cm. A referral to an oedema physiotherapist is recommended at a circumference difference of more than 5%.

 

Providing the patient with information is an essential component of treatment. The provision of information within a multidisciplinary setting must be univocal, so that each professional knows what information has been provided to the patient, when and who is responsible for doing so. It is important to draw the patient’s attention to healthy behaviour regarding exercise and nutrition, as well as risk factors that may cause or worsen health problems. Lifestyle and occupation/work should also be discussed. Care of the wound, scar and skin is important, because infections and traumas are risk factors for development of lymphoedema. To avoid fear of exercise, it is important to separate information about lymphoedema from exercise behaviour. The lymphatic system is explained, and information is provided about early detection and risk reduction strategies.

 

Breast surgery in a short admission programme

A short admission programme was setup in the Maastricht University Medical Centre, in which an outpatient admission or 24-hour admission was combined with a care programme in which the patient received careful and repeated information and the postoperative care was organised with input from the patient and in collaboration with home care organisations where required [de Kok, 2007]. This programme is safe, cost-effective and patient-friendly. It resulted in a reduction in the average length of admission from 3.6 to 1.1 days. Day surgery was considered possible for more than 90% of the patients programmed for breast surgery and 65% of patients received day surgery. Given the size of the surgical trauma is limited, even with MRM, the clinical care required is limited [Bundred, 1998; Purushotham, 2002].

 

Pressure on the social network of the patients increases when breast surgery is provided in a short admission programme. These patients also have a greater need for information about home use and removal of drains, prostheses, exercises and physiotherapy [de Kok, 2010]. A sound care package must be compiled, also in consultation with the patient, home care, physiotherapist and general practitioner, before this care can be implemented as a standard.

Authorization date and validity

Last review : 13-02-2012

Last authorization : 13-02-2012

The national Breast Cancer guideline 2012 is a living guideline, in other words there is no standard term of revision. NABON continually watches at new developments and clinical problems in the areas of screening, diagnostics, treatment and aftercare, and whether this requires an update.

Initiative and authorization

Initiative : Nationaal Borstkanker Overleg Nederland

Authorized by:
  • Nederlandse Internisten Vereniging
  • Nederlandse Vereniging voor Heelkunde
  • Nederlandse Vereniging voor Psychiatrie
  • Nederlandse Vereniging voor Radiologie
  • Nederlandse Vereniging voor Radiotherapie en Oncologie

General details

Approximately 14,000 women (and 100 men) are diagnosed with invasive breast cancer each year in the Netherlands, and about 1,900 have an in situ carcinoma. A woman's risk of having breast cancer over the course of her life is 12-13%. This means that breast cancer is the most common form of cancer in women in the Netherlands. Early detection, particularly via national breast cancer screening, combined with adjuvant therapy followed by locoregional treatment, improves the prognosis in women with breast cancer

The guideline on Breast Cancer Screening and Diagnostics, published in 2000, was updated in 2007. In 2002, the first multidisciplinary National Breast Cancer Guideline was published, it was revised in 2004, 2005 and 2006. In 2008 both guidelines were combined to Breast Cancer Guideline, which 2012 revision is now effected.

Scope and target group

This guideline is written for all the members of the professional groups that have contributed to its development.

 

This guideline is a document with recommendations and instructions to support daily practice. The guideline is based on the results of scientific research and expert opinion, with the aim of establishing good medical practice. It specifies the best general care for women with (suspected) breast cancer and for those who are eligible for screening. The guideline aims to serve as a guide for the daily practice of breast cancer screening, diagnostics, treatment and aftercare. This guideline is also used in the creation of informational materials for patients, in cooperation with the KWF (Dutch Cancer Society).

Member of workgroup

A core group consisting of a radiologist, surgeon, pathologist, medical oncologist and radiation therapist began preparing for the revision of the breast cancer practice guidelines in 2009. A multidisciplinary guideline development group was formed in early 2010 to implement the revision. This group consisted of mandated representatives from all of the relevant specialisations concerned with breast cancer, plus two delegates from the BVN (Dutch Breast Cancer Society) (see list of guideline development group members). The benefits of such a multidisciplinary approach are obvious: not only does it best reflect the care, but it offers the greatest possible expertise for the guideline. In composing the development group, geographic distribution of the members, balanced representation of the various organisations and agencies concerned, and a fair distribution in academic background were taken into account as much as possible.

 

The guideline development group received procedural and administrative support from IKNL (Comprehensive Cancer Centre for the Netherlands) and support on methodology from Bureau ME-TA. Partial funding was obtained from SKMS (Quality Funds Foundation of Dutch Medical Specialists). This subsidy would not have been possible without the extensive assistance provided by the NVvR (Radiological Society of the Netherlands).

Declaration of interest

Partial funding for the guideline revision was obtained from the Society of Dutch Medical Specialists in the framework of the SKMS. IKNL sponsored some of the cost. On two occasions, as well as at the beginning and end of the process, all of the members of the guideline development group were asked to fill out a statement of potential conflicts of interest, in which they stated their relationship with the pharmaceutical industry. A list of these statements of interest can be found in the appendices.

Patient involvement

In developing this guideline, four clinical questions were formulated. These questions emerge from an inventory of clinical problems collected in the field from professionals, patients and patient representatives.

 

Also, A multidisciplinary guideline development group was formed in early 2010 to create and implement the revision. This group consisted of mandated representatives from all of the relevant specialisations concerned with breast cancer, plus two delegates from the BVN (Dutch Breast Cancer Society).

 

Method of development

Evidence based

Implementation

Feasibility has been taken into account in developing the guideline. This included attention to factors that could promote or hinder putting the advice into practice. Examples include the implementation of an analysis of problems, the multidisciplinary composition of the guideline development group, and making active use of support from the guideline development group members. Presenting the draft guideline to the field and communicating what, if anything, is being done with the responses, also promotes implementation. In this manner, a guideline has been developed that answers current questions in the field.

The guideline is distributed widely and is available in digital form on the Dutch Guideline Database. The guideline may also be brought to the attention of a wider audience in other periodicals or continuing education sessions, for example. To promote use of the guideline, we recommend that the regional tumour working groups and group practices, as well as scientific and professional organisations, repeatedly bring the guideline to the attention of their members. Any problems that may arise in using the guidelines can then be discussed and, when appropriate, submitted to the national guideline development group, as it is a "living" guideline. If desirable, parts of the guideline can be made more explicit by formulating regional additions or translation to the local situation in departmental and/or hospital protocols.

In principle, indicators are determined during development of the guideline that can be used to monitor implementation of the recommendations. Via a documentation project, these indicators can then be used to determine the extent of compliance with the guideline. The information from the documentation project becomes input for the revision of the guideline.

Methods and proces

This module has been evidence-based revised in 2008 and consensus based updated in 2012.

 

A revision of an existing guideline consists of revised and updated text. Revised text is new text based on an evidence-based review of the medical literature; updated text is the old guideline text which has been edited by the experts without performing a review of medical literature. Each section of the guideline states what type of revision has taken place. Each chapter of the guideline is structured according to a set format, given below. The purpose of this is to make the guideline transparent, so that each user can see on what literature and considerations the recommendations are based on.

 

Description of the literature

To the greatest extent possible, the answers to the fundamental questions (and therefore the recommendations in this guideline) were based on published scientific research. The articles selected were evaluated by an expert in methodology for their research quality, and graded in proportion to evidence using the following classification system:

 

Classification of research results based on level of evidence

A1

Research   on the effects of diagnostics on clinical outcomes in a prospectively   monitored, well-defined patient group, with a predefined policy based on the   test outcomes to be investigated, or decision analysis research into the   effects of diagnostics on clinical outcomes based on results of a study of   A2-level and sufficient consideration is given to the interdependency of   diagnostic tests.

A2

Research   relative to a reference test, where criteria for the test to be investigated   and for a reference test are predefined, with a good description of the test   and the clinical population to be investigated; this must involve a large   enough series of consecutive patients; predefined upper limits must be used,   and the results of the test and the "gold standard" must be   assessed independently. Interdependence is normally a feature of situations   involving multiple diagnostic tests, and their analysis must be adjusted   accordingly, for example using logistic regression.

B

Comparison   with a reference test, description of the test and population researched, but   without the other features mentioned in level A.

C

Non-comparative   trials

D

Opinions   of experts, such as guideline development group members

 

Conclusions

Based on the medical literature, one or more relevant conclusions are made for each section. The most important literature is listed according to the level of evidential strength, allowing conclusions to be drawn based on the level of
evidence. All the medical literature included in the conclusion is described in the bibliography.

 

Classification of conclusions based on literature analysis

1

Based   on 1 systematic review (A1) or at least 2 independent A2 reviews.

2

Based   on at least 2 independent B reviews

3

Based   on 1 level A2 of B research, or any level C research

4

Opinions   of experts, such as guideline development group members

 

Other considerations

Based on the conclusion(s), recommendations are made. However, there are other considerations that contribute to formulation of the recommendation besides literature evidence, such as safety, the patients' preferences, professional expertise, cost-effectiveness, organisational aspects and social consequences. The other considerations are mentioned separately. In this manner, it is clear how the guideline development group arrived at a particular recommendation.

 

Recommendations

The final wording of the recommendation is the result of the scientific conclusion, taking into account the other considerations. The purpose of following this procedure and drawing up the guidelines  in this format is to increase transparency.

 

References

An alphabetical list of literature references can be found at the end of the guideline.

 

All draft texts have been discussed by the guideline development group.

Search strategy

Searches are available upon request. Please contact the Richtlijnendatabase.