About 40,000 women - and about 250 men - are diagnosed with breast cancer every year. It is the most common form of cancer in women. For everyone, the diagnosis brings fear, emotional upheaval and months - sometimes years - of disabling treatments.
However, advances in screening and treatment mean that a diagnosis of cancer is no longer seen as the end of the road. Improvement in breast cancer services in the UK has been a particular success story with more early diagnosis and better outcomes. The UK now has the fastest falling breast cancer mortality rate in the world and is no longer far behind other countries in Europe.
At the same time, there is variation in the quality of services across the UK and it is right that people have this information - if only so that a patient who has doubts about the service they are receiving can at least get an independent view. Inevitably services do fall short in places. This should not be seen as a reflection on the people providing those services. As likely as not, it is an issue of who gets more resources and who gets less. Whatever the cause, it is beyond question that the public should know and start asking the right questions.
The Observer Guide to Breast Cancer Treatment includes the first public audit of the quality of breast cancer services across the country. Overall there are some very encouraging aspects. In many areas, waiting times are very good. The overwhelming majority of patients diagnosed with suspected breast cancer are now seen within two weeks. As a rule, those who need surgery are operated on within two, or at a stretch, three weeks. There are still bottlenecks, such as waiting times for radiotherapy. We have looked at the waiting time for radiotherapy as a first treatment. This is relatively unusual and the waiting times should in general be very short. However, in some cases they are as long as 10 weeks.
Also, although urgent referrals are generally handled quickly, waiting times for non-urgent referrals - where the doctor does not believe the patient has cancer but would like this diagnosis confirmed - can be much longer. For example a referral for a non-urgent mammogram can be as high as two months and for a non-urgent consultation even longer. In London and the West Midlands the average non-urgent wait is over five weeks with a few hospitals having a three month wait. In most cases the patient does not have cancer. But sometimes the initial diagnosis is proved wrong. Either way, the wait can still be emotionally draining.
Despite this, in general, waiting times for breast cancer treatment are among the best in the NHS and impressive for a service that is free to all. There is still, however, much to be done and this survey has helped to identify some particular areas of concern.
The national lack of radiologists has long been a problem. On average radiologists look at each patient's screening images for just a couple of minutes, during which time they have to decide whether or not there are signs of cancer. (Every image should be looked at separately by two radiologists and if they disagree, it should get referred to a third.)
The result of this is that some units are not able to screen women every three years as planned. In some cases, the gap between screens is up to 42 months, meaning that the unit is about six months behind.
The most common reason for the delay is the shortage of radiologists. The Royal Devon and Exeter Hospital, where the screening interval is now two months, has been operating with one radiologist instead of the three it is supposed to have. 'We have covered with locum doctors and by getting radiographers to extend their role,' said a spokesman for the trust, 'although we have now managed to recruit two new radiologists who will start to bring down the backlog.'
The West of London breast screening unit where the screening interval has stretched to 42 months, was disrupted by an investigation following a failure to recall a patient. The systems have now been overhauled, but the process has resulted in delays which the unit is working to reduce.
Most parts of the country are managing to keep the average screening interval at or close to 36 months. Both the West Midlands and London Hospitals have screening intervals of over 37 months. London also has a lower standardised detection rate than the rest of the country. The standardised detection rate is the main measure of how well screening units are picking up cancer. It shows how many cancers were diagnosed by a unit, compared to the number that would be expected to be found given the local population. A unit that detects exactly the number of cancers expected has a score of 1, those that detect less a lower score, and those that detect more a higher score.
There are very wide variations between units, with rates as low as 0.8 and as high as 1.6. In other words, some units are detecting twice as many cancers as others for the given population. The North has had the best detection rate over the last three years, consistently above 1.2. London has had the lowest detection rate on average, although it has been steadily rising from 1.06 in 1999 to 1.10 last year.
The small cancer detection rate measures a screening unit's success at detecting very small cancers. But again, there is significant variation, with some units detecting three times as many cancers as others. London, which has relatively low standardised detection rates, also has lower small cancer detection rates. It should be noted, however, that these figures are not standardised, so variation can reflect differences in the populations served by different units.
When it comes to treatment, as with screening, there is much to praise. In many areas, there is strong evidence of high standards. For example, there are only 10 hospitals in England without multidisciplinary teams in place and meeting every week. Moreover, most hospitals ensure that only suitably qualified surgeons perform breast surgery. There are only 20 trusts in the UK where some surgery is performed by doctors who do not meet the training recommendations of the British Association of Surgical Oncologists. But, of course, that is 20 too many.
The pre-operative diagnosis rate is one measure of how effectively a hospital is working. Ideally, before people are operated on, there is a definitive diagnosis of cancer. This will never always be possible and there will inevitably be variation between hospitals. But, in general, the pre-operative diagnosis rate should be high. The national average is 96 per cent, which is good. But some units are still far below this level, with a handful having rates less than 80 per cent.
In some cases, you may be sufficiently dissatisfied with a service to want an alternative. There are a number of steps in place to try to improve choice in the NHS. However, in the treatment of cancer it is worth remembering that speed, above all, is key and any decisions that delay treatment are unlikely to be in your own interests. However, GPs do have the power to refer patients to one consultant rather than another and to one hospital rather than another if they feel it is in the patient's best interests.
The NHS is becoming increasingly aware that it needs to be open about the quality of the service it provides and allow the public access to information that will help them and their GPs protect their health as best they can. This guide is another step forward in that process. Use it wisely.
