Health Care Needs Assessment

The Epidemiologically Based Needs Assessment Reviews

P. Dey

• Publisher: CRC Press
• Year: 2018
• Print ISBN:
  9781857752168
• eBook ISBN:
  9781315348803
• Edition: 1
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

This volume, focusing on breast cancer, is part of a survey of health care needs for specific conditions, published on behalf of the Department of Health. This study overall considers questions such as the population's needs, the services available or unavailable to them, the effectiveness of these services, and other perspectives in disease and service areas. This is the second series of needs assessment reviews.

Breast Cancer

P. Dey, E. Twelves and C.B.J. Woodman

1 Summary

Breast cancer is the most common cause of death from cancer in women in the UK.

Effective interventions exist:

• population-based breast cancer screening using mammography has been shown to reduce mortality in women aged 50–69 by 25–30%
• breast conservation therapy with post-operative radiotherapy is as effective as mastectomy in prolonging disease-free and overall survival in women with early breast cancer
• adjuvant therapies improve overall survival in women with early breast cancer. After ten years of follow-up adjuvant therapy will have:
  1. a) prevented ten deaths for every 100 women under the age of 50 treated with chemotherapy
  2. b) prevented 11 deaths for every 100 women under the age of 50 treated with ovarian ablation
  3. c) prevented eight deaths for every 100 women over the age of 50 treated with tamoxifen.

Ineffective interventions exist:

• there is no evidence to support the use of routine investigations to detect asymptomatic metastases in the follow-up of women with breast cancer.

The National Health Service Breast Screening Programme (NHSBSP) provides a co-ordinated mammographic breast cancer screening service for women aged between 50–64 years. Issues of relevance to purchasers include:

• the age limits for screening
• the interval between screens.

The diagnosis and treatment of women with breast cancer is often variable. Issues of relevance to purchasers include:

• paucity of information on hospital activity and costing information
• variations in provision leading to sub-optimum care or resulting in inefficient services
• the recommendations of the Report of the Expert Advisory Group on the Commissioning of Cancer Services.

Areas of current research which could have major resource implications for purchasers include:

• primary prevention with tamoxifen
• predictive genetic testing
• annual screening of women aged 40–49
• changes in the indications for chemotherapy in women with early breast cancer
• high-dose chemotherapy with autologous bone marrow treatment.

2 Statement of the problem

Breast cancer is a major public health problem. It is a significant cause of mortality and morbidity and is a national target area in the Government’s Health Strategy The Health of the Nation.¹ The Expert Advisory Group on the Commissioning of Cancer Services has recommended the establishment of breast cancer units situated in local trusts for the diagnosis and treatment of breast cancer.² Therefore the optimum configuration of services for women with breast cancer must be a prime concern for NHS purchasers.

Scale of the problem

One in 12 women in England and Wales will develop breast cancer during their lifetime. England and Wales have the highest mortality rates for breast cancer in the world.³ The number of years of life lost in women below the age of 65 is higher for breast cancer than for coronary heart disease.⁴

Strategies to reduce breast cancer mortality and morbidity

There are no proven primary preventive strategies.

Small localized breast cancers have a favourable prognosis.⁵ Mammography can be used as a screening test in population settings to detect asymptomatic breast cancers.⁶ The NHSBSP aims to reduce mortality from breast cancer by regularly screening women aged 50–64 in order to identify such lesions.⁷

Effective interventions exist for the treatment of women with early breast cancer.^8,9

Resource consequences

Breast cancer services consume substantial resources. The NHSBSP costs £29 million per annum.¹⁰ Women with breast cancer account for almost 1% of inpatient admissions.¹¹

Health care professionals and organizations involved in breast cancer services include family health services authorities (FHSAs), primary health care teams, public health physicians, health promotion officers, surgeons, radiologists, radiographers, breast care nurses, pathologists, medical and clinical oncologists, psychiatrists and palliative care teams. Voluntary agencies and social services provide information, psychosocial care and practical support.

Male breast cancer

Male breast cancer is rare accounting for less than 1% of new diagnoses of breast cancer.¹² Treatment strategies reflect those recommended for women.¹³ It is not considered further.

Classification

Appendix I lists the relevant coding classifications related to breast cancer.

Summary

The key issues for purchasers are:

• breast cancer is a significant public health problem
• health gain can be maximized through early detection and appropriate clinical management
• there are major resource implications relating to screening, diagnosis and treatment.

3 Sub-categories

There are four main sub-categories of women accessing breast cancer services:

1. 1 women attending the NHSBSP
2. 2 women with a family history of breast cancer
3. 3 women presenting for assessment of symptoms suggestive of breast cancer
4. 4 women requiring treatment for breast cancer.

Women attending the NHSBSP

The NHSBSP invites all women aged between 50–64 years for breast screening at intervals of three years and is responsible for the assessment and diagnosis of mammographically detected abnormalities.

Family history of breast cancer

Women with a first degree relative with breast cancer have a two- or three-fold increased risk of developing the disease. If two or more relatives are affected the risk of breast cancer may be more than ten-fold that of the general population.¹⁴

Women presenting with symptoms of breast cancer

The most common presenting symptom is a painless lump. Other symptoms include skin dimpling, bloody discharge from or retraction of the nipple.

A third of all women attending surgical outpatients with a breast-related problem will have a painless breast lump of whom one in eight or nine will have a breast cancer.^15,16,17

Women with breast cancer

Women with breast cancer can be allocated to one of five clinical staging groups according to the extent the disease has spread at time of presentation (Appendix II). When discussing treatment strategies it is more useful to collapse these into three subgroups:

1. 1 women with ductal carcinoma in situ (DCIS), Stage 0
2. 2 women with early breast cancer, Stages I and II
3. 3 women with advanced breast cancer, Stages III and IV.

The distribution of these subgroups in two population-based series of women with breast cancer is outlined in Table 1.

Table 1 Distribution of subgroups of women with breast cancer

	Number of women (%)
	Wessex^18	East Anglia...

Table of contents

• Cover
• Title Page
• Copyright Page
• Contents
• Foreword
• Preface
• Contributing authors
• Introduction
• Breast Cancer
• Appendix I Relevant coding classifications
• Appendix II Staging classifications
• Appendix III Age-specific incidence rates for breast cancer
• Appendix IV National Health Service Breast Screening Programme
• References
• Acknowledgements
• Index