Breast cancer guidelines in action

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.

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

1. National Health and Medical Research Council. The management of early breast cancer. Clinical Practice Guidelines. Canberra: NHMRC/AGPS, 1995.
2. 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.
3. House of Representatives Standing Committee on Community Affairs. Report on the management and treatment of breast cancer in Australia. Canberra: AGPS, 1995.
4. Hill D, Jamrozik K, White V, et al. Surgical management of breast cancer in Australia in 1995. Sydney: NHMRC National Breast Cancer Centre; 1999.
5. 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.
6. NHS Centre for Reviews and Dissemination, University of York. Getting evidence into practice. Effective Health Care 1999; 5(1).
7. 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.
8. Tulloh BR, Goldworthy ME. Breast cancer management: a rural perspective. Med J Aust 1997; 166: 26-29.
9. 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.
10. 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.

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