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In 1995, when the National Health and Medical Research Council
(NHMRC) released Clinical practice guidelines for the
management of early breast cancer,1 the first of their
evidence-based recommendations, the initial response by
clinicians was very positive: 97% regarded them as a good summary of
recent evidence and 85% believed they would be useful in improving
management.2
This was encouraging, but the more important question was whether the
guidelines would result in evidence-based care for women with breast
cancer. Until recently, there has been little national information
about breast cancer management in Australia, a lack noted by the House
of Representatives in 1995, whose response was to recommend a
comprehensive national monitoring system.3
However, it was not until 1999 that an accurate national picture of
breast cancer management emerged. A report by the NHMRC National
Breast Cancer Centre,4 analysing the surgical
management of 4237 women with breast cancer in 1995 (ie, 88% of all
women in Australia diagnosed with breast cancer in the six months
before release of the guidelines), showed that, at that time, most
women were receiving care in accord with most of the recommendations.
However, some aspects of care were not in line with the guidelines: for
example, the report highlighted the need to encourage the use of
tamoxifen in women with oestrogen receptor positive tumours
(particularly in women less than 50 years); to decrease rates of
testing for distant metastases at the time of diagnosis of early
breast cancer; and to increase participation in clinical trials.
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Information about current practice plays a key role in supporting
evidence-based care. It enables the best use of scarce resources, as
costly implementation strategies can be targeted at aspects of care
not in accord with the recommendations. The process of audit itself is
also effective in changing practice, particularly if individual
clinicians can compare their own practice with evidence-based
recommendations or with the practice of their peers.5,6
In this context, the article in this issue of the Journal by Craft et al
7
is of considerable significance, as it
demonstrates the feasibility of a community-based audit of breast
cancer management by a multidisciplinary team (the Australian
Capital Territory and South Eastern New South Wales [ACT and SE NSW]
Breast Cancer Treatment Group). The Group is to be commended both for
its meticulous approach to encouraging evidence-based care through
local audit and for the high standards of care provided.
The results presented by Craft et al7 suggest that more women than
in the national survey were managed in accordance with the NHMRC
guidelines. For example, in the national data, 85% of women with
breast-conserving therapy received radiotherapy, compared with
98% of the sample studied by Craft et al, and all women in the sample aged
under 50 with axillary node involvement received adjuvant
chemotherapy. We do not know, of course, to what extent these results
can be generalised to the 21% of cases occurring in the region and not
included in the audit.
Although these differences may show an embracing of the guidelines
since their release, it is unclear whether these changes would be
apparent across Australia or whether they are due to intensive
efforts within the ACT and SE NSW region. However, an audit conducted
in a surgical practice in Echuca, a rural town in Victoria, also
demonstrated patterns of care generally in accordance with the
guidelines.8
The report by Craft et al also shows the role of local ownership of
guidelines and a multidisciplinary team approach to management. The
ACT and SE NSW Breast Cancer Treatment Group was formed to consider
priorities within the region and to select indicators of local
significance for inclusion in their audit. Consumer input was
included. Further, the audit was not limited to one institution, but
attempted to include all clinicians, including potentially more
isolated clinicians in the region, making it more likely to have an
impact on outcomes. The strategies used by the Group appear to have
been successful, with 23 of 24 clinicians participating and the
identification of an estimated 79% of all cases of breast cancer
occurring in the region.
There is some evidence that a multidisciplinary team approach is more
likely to result in evidence-based care and better patient outcomes
than clinicians working in isolation.9,10 Recent initiatives
within Australia are designed to foster multidisciplinary care,
including Victoria's Breast Care Enhancement Program and the
federally funded National Multidisciplinary Care Demonstration
Project coordinated by the National Breast Cancer Centre.
After Craft et al's conclusive demonstration of the value of local
audit, the challenge now is to develop and sustain other audit
programs on a continuing basis. There is a real danger that the
evidence-based approach will founder from a lack of resources for
guideline implementation at the local level and for support of audit
programs. A commitment from State and local health services to
resourcing these programs is vital.
The recent initiative by the Royal Australasian College of Surgeons
in developing an audit system for breast cancer should prove
particularly valuable in future assessment of guideline adherence.
The audit is national and provides contributing surgeons with
feedback about their practice compared with that of their peers.
There are also benefits to daily clinical practice: the audit
provides a standardised record, which can be used in patient notes or
to inform general practitioners or patients. Apart from surgery,
other disciplines are also considering developing similar
approaches to audit in breast cancer, notably the Royal Australian
and New Zealand College of Radiologists (Faculty of Radiation
Oncology) and the Medical Oncology Group, all in association with the
National Breast Cancer Centre.
Progress will occur only if other local groups also see value in
promoting evidence as their masthead and recognising the
fundamental role of audit in evidence-based treatment. In
demonstrating the feasibility of this approach, the achievement of
the ACT and SE NSW Breast Cancer Treatment Group could serve as a model
for other regions.
Sally Redman
Director, NHMRC National Breast Cancer Centre, Sydney, NSW
Tom S Reeve
Executive Officer, Australian Cancer Network, Sydney, NSW
- National Health and Medical Research Council. The management of
early breast cancer. Clinical Practice Guidelines. Canberra:
NHMRC/AGPS, 1995.
-
Carrick S, Bonevski B, Redman S, et al. Surgeons' opinion about the
NHMRC clinical practice guidelines for the management of early
breast cancer. Med J Aust 1998; 169: 300-305.
-
House of Representatives Standing Committee on Community
Affairs. Report on the management and treatment of breast cancer in
Australia. Canberra: AGPS, 1995.
-
Hill D, Jamrozik K, White V, et al. Surgical management of breast
cancer in Australia in 1995. Sydney: NHMRC National Breast Cancer
Centre; 1999.
-
Thomson MA, Oxman AD, Davis DA, et al. Audit and feedback to improve
health professional practice and health care outcomes (Parts I and
II) (Cochrane Review). Oxford: The Cochrane Library 1999: Issue 1.
-
NHS Centre for Reviews and Dissemination, University of York.
Getting evidence into practice. Effective Health Care 1999;
5(1).
-
Craft PS, Zhang Y, Brogan J, et al, and the Australian Capital
Territory and South Eastern New South Wales Breast Cancer Treatment
Group. Implementing clinical practice guidelines: a
community-based audit of breast cancer treatment. Med J Aust
1999; 172: 213-216.
-
Tulloh BR, Goldworthy ME. Breast cancer management: a rural
perspective. Med J Aust 1997; 166: 26-29.
-
Sainsbury R, Haward B, Rider L, et al. Influence of clinician
workload and patterns of treatment on survival from breast cancer.
Lancet 1995; 345: 1251-1252.
-
Gillis CR, Hole DJ. Survival outcome of care by specialist
surgeons in breast cancer: a study of 3786 patients in the west of
Scotland. BMJ 1996; 312: 145-148.
©MJA 2000
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