1. Breast reconstruction in the UK new data and new challenges Third EASO Educational Workshop on Breast Cancer Reconstructive Surgery Cairo 28-29 March 2011 Dick Rainsbury

2. NHS Breast Screening Programme Audit 93 Units 2004/2005 Some stark statistics from the UK... ‘ discuss immediate breast reconstruction with all patients who are being advised to have a mastectomy, and offer it except where significant comorbidity or adjuvant therapy may preclude this option’ ‘ all appropriate breast reconstruction options should be offered and discussed with patients, irrespective of whether they are all available locally ‘ Early and locally advanced breast cancer. Diagnosis and treatment. February 2009. www.nice.org.uk/CG80

3. £2.5 million NMBRA to answer 3 key questions: access? numbers techniques variations variations access type variations PROMS complications information? outcomes? Healthcare Commission: London, 2007

4. National Mastectomy and Breast Reconstruction Audit 2010. www.ic.nhs.uk/mbr data collected from hospitals patient demographics type of operation co-morbidities tumour characteristics peri-operative morbidity data collected from patients information choices management of pain postoperative complications overall experience smoking obesity diabetes ASA 3/4 0 10 patients with risk factors (%) mastectomy immediate reconstruction 20

5. Participation: 15 month data collection 2008-9 156 NHS Hospitals 114 Independent Hospitals 18,000 patients 7,000 patient questionnaires National Mastectomy and Breast Reconstruction Audit 2010. www.ic.nhs.uk/mbr 30 English Cancer Networks

6. access?

7. Access: offer versus uptake of immediate reconstruction in 30 UK Cancer Networks National Mastectomy and Breast Reconstruction Audit 2010. www.ic.nhs.uk/mbr offer IBR 75% 23% P <0.001 62% 17% P <0.001 uptake IBR

8. Access: frequency of different surgical procedures total mastectomy immediate reconstruction 0 100 50 type of operation (%) 13096 3389 delayed reconstruction 1731 18216 expander or implant only 1527 free flap from distant site 1042 pedicle and implant or expander 1173 pedicle no implant or expander 1378 National Mastectomy and Breast Reconstruction Audit 2010. www.ic.nhs.uk/mbr

9. Access: impact of timing on type of reconstruction? implant expanderonly pedicle and implant pedicle only free flap 0 40 20 type of reconstruction (%) immediate delayed National Mastectomy and Breast Reconstruction Audit 2010. www.ic.nhs.uk/mbr

10. information?

11. Patient experience: proportion of patients receiving information about reconstruction... verbal information 0 100 50 (%) mastectomy only Immediate reconstruction written information photographic information delayed reconstruction healing time recovery complications scars and pain what other women experience 66% 50% 33% National Mastectomy and Breast Reconstruction Audit 2010. www.ic.nhs.uk/mbr

12. Patient experience: when mastectomy only patients were asked why they didn’t choose immediate reconstruction... not offered given no information offered but rejected told to wait told too risky told not available told preference not available contributing reason (%) 55 44 43 41 19 9 6 National Mastectomy and Breast Reconstruction Audit 2010. www.ic.nhs.uk/mbr

13. clinical outcomes?

14. Clinical outcomes: serious events serious event death ITU/HDU % <0.3 <1.0 National Mastectomy and Breast Reconstruction Audit 2010. www.ic.nhs.uk/mbr

15. Clinical outcomes: inpatient complications requiring intervention mx only (12,146) mx + implant 0 20 10 (%) immediate (3,389) delayed (1,731) mx + pedicle flap mx + pedicle flap/implant mx + free flap 25 inpatient complications requiring intervention (%) National Mastectomy and Breast Reconstruction Audit 2010. www.ic.nhs.uk/mbr

16. Clinical outcomes: flap failure rates partial flap failure total flap failure overall flap failure 0 10 event (%) 0.2 1.4 1.2 5 return to theatre partial flap failure total flap failure 2.0 4.2 2.2 overall flap failure 11.8 pedicle flap reconstruction (2507) free flap reconstruction (1009) National Mastectomy and Breast Reconstruction Audit 2010. www.ic.nhs.uk/mbr

17. 3 month patient reported outcomes? experience of care National Mastectomy and Breast Reconstruction Audit 2011 www.ic.nhs.uk/mbr

18. PROMS at 3 months: high proportion of women reported post-discharge complications requiring intervention... Mx 10 19 - - IBR 16 25 10 4 DBR 15 28 7 6 post-discharge complication (%) readmission for treatment or surgery wound infection requiring antibiotics unplanned removal of implant surgery to remove some or all of flap National Mastectomy and Breast Reconstruction Audit 2011 www.ic.nhs.uk/mbr

19. PROMS at 3 months: proportion reporting severe post-operative pain severe pain first 24hr 0 100 50 (%) severe pain first week ‘ staff did everything they could to control pain’ mastectomy only Immediate reconstruction delayed reconstruction overall rating of care ‘excellent’ National Mastectomy and Breast Reconstruction Audit 2011. www.ic.nhs.uk/mbr

20. PROMS at 3 months: satisfaction with consultant surgeon at national level competent 50 100 0 thorough answered questions made time available proportion very satisfied with consultant (%) National Mastectomy and Breast Reconstruction Audit 2011. www.ic.nhs.uk/mbr

21. PROMS at 3 months: satisfaction with consultant surgeon at hospital level National Mastectomy and Breast Reconstruction Audit 2011. www.ic.nhs.uk/mbr

22. 18 month patient reported outcomes? quality of life National Mastectomy and Breast Reconstruction Audit 2011. www.ic.nhs.uk/mbr

23. PROMS at 18 months: satisfaction with the options given about breast reconstruction at national level 0 50 patients very satisfied (%) MX IBR DBR 100 National Mastectomy and Breast Reconstruction Audit 2011. www.ic.nhs.uk/mbr

24. PROMS at 18 months: satisfaction with appearance of the breast area at national level 0 50 100 patients satisfied or very satisfied (%) MX IBR DBR National Mastectomy and Breast Reconstruction Audit 2011. www.ic.nhs.uk/mbr clothed unclothed

25. PROMS at 18 months: functional impairment of donor site assessed using range of symptoms National Mastectomy and Breast Reconstruction Audit 2011. www.ic.nhs.uk/mbr ILD/ALD TRAM/DIEP pain stiffness tightness lifting carrying reaching weakness bloating bulging tightness pulling back pain

26. PROMS at 18 months : functional impairment and dissatisfaction with donor site appearance at national level 0 10 20 respondents reporting problems (%) ILD/ALD TRAM/DIEP functional impairment most or all of the time dissatisfaction with donor site appearance National Mastectomy and Breast Reconstruction Audit 2011. www.ic.nhs.uk/mbr

27. 50 60 adjusted mean score MX 70 IMP ILD ALD FF 80 PROMS at 18 months: satisfaction with appearance of breast area at national level National Mastectomy and Breast Reconstruction Audit 2011. www.ic.nhs.uk/mbr

28. 50 60 MX 70 IMP ILD ALD FF 80 PROMS at 18 months: emotional well-being at national level adjusted mean score National Mastectomy and Breast Reconstruction Audit 2011. www.ic.nhs.uk/mbr

29. PROMS at 18 months: emotional well-being at hospital level National Mastectomy and Breast Reconstruction Audit 2011. www.ic.nhs.uk/mbr

30. 50 60 MX 70 IMP ILD ALD FF 80 adjusted mean score National Mastectomy and Breast Reconstruction Audit 2011. www.ic.nhs.uk/mbr PROMS at 18 months: physical well-being at national level

31. PROMS at 18 months: physical well-being at hospital level National Mastectomy and Breast Reconstruction Audit 2011. www.ic.nhs.uk/mbr

32. 30 40 MX 50 IMP ILD ALD FF 60 PROMS at 18 months: sexual well-being at national level adjusted mean score National Mastectomy and Breast Reconstruction Audit 2011. www.ic.nhs.uk/mbr

33. National Mastectomy and Breast Reconstruction Audit 2011. www.ic.nhs.uk/mbr PROMS at 18 months: sexual well-being at hospital level

35. patients undergoing breast reconstruction experience improved quality of life National Mastectomy and Breast Reconstruction Audit 2011. www.ic.nhs.uk/mbr

36. challenges?

37. Eur J Surg Oncol 2007;33:Suppl 1 Challenges: to develop new standards for oncoplastic breast surgery... ‘ The Surgical Associations and Royal Colleges involved in mastectomy and breast reconstruction surgery should consider issuing new guidance on patient selection, operative techniques and postoperative care…’ National Mastectomy and Breast Reconstruction Audit 2010. www.ic.nhs.uk/mbr

38. implant based 1527 pedicle + implant based 1173 autologous pedicle 1378 autologous free flap 1042 mastectomy 13096 ? longterm patient reported outcomes quality of life clinical outcomes cost analysis volume replacement volume displacement Challenges: to follow up this unique cohort...

39. Clinical Effectiveness Unit Royal College of Surgeons of England Ranjeet Jeevan David Cromwell John Browne Jan van der Meulen Association of Breast Surgery Jerome Pereira British Association of Plastic Reconstructive and Aesthetic Surgeons Christopher Caddy Royal College of Nursing Carmel Sheppard NHS Information Centre for Health and Social Care Kimberly Greenaway Rose Napper Steve Dean Clinical Reference Group Dick Rainsbury (Chair) Chris Holcombe Emma Pennery Elaine Sassoon Eva Weiler-Mithoff Di Riley Lucy Elliss-Brookes Gillian Ross Karen Woo Bethan Lloyd Owen Catherine Boyle Christianne Forrest Kate Jones Helen Mcleod Peter Venn Maria Noblet Janet Litherland Gill Lawrence Ian Monypenny Association of Breast Surgery Association of Breast Surgery Breast Cancer Care British Association of Plastic Reconstructive and Aesthetic Surgeons British Association of Plastic Reconstructive and Aesthetic Surgeons Cancer Action Team Cancer Networks Faculty of Clinical Oncology Independent Sector Independent Sector Macmillan Cancer Support Patient Representative Chartered Society of Physiotherapists Chartered Society of Physiotherapists Royal College of Anaesthetists Royal College of Nursing Royal College of Radiologists UK Association of Cancer Registries Cancer Services Group Wales >18,000 patients >500 surgeons and their multidisciplinary teams Thanks to 30 people and 16 organisations... www.ic.nhs.uk/mbr