Perspectives on the Governance and Management of Breast Care Services in the USA

Improving the quality, affordability and accessibility of breast care in the USA remains a high priority among health care leadership, the lay public, and those in elected office. The formulation of public policy in the USA, including federal and state legislation, is informed by a wide variety of public and private advisory and advocacy interests. Private-sector advocacy groups positively influence access, public awareness, and research prioritization. Evolving breast-specific clinical and administrative leadership models have facilitated an emerging management focus on quantifiable attributes of service, professional performance, clinical outcomes, and value. The diversity of breast care delivery environments in the USA adds considerable complexity to the task of improving value and access to care. With robust merger and affiliation activity among hospitals and clinics, health systems and alliances are evolving regionally and nationally to provide performance-based breast-centric management models across diverse populations and geographies.

Medicolegal Aspects

Breast cancer is the leading cause of malpractice claims for radiologists. The usual civil charge of negligence (malpractice) will be discussed. The most common complaint is delay in diagnosis. In symptomatic patients, this means failure to carry out the appropriate imaging investigation including biopsy. In screening, it usually means failure to detect the early signs of breast cancer. Three important principles in the law of civil negligence are present. There is the duty of the doctor for the treatment of his patient and his responsibility for giving the correct treatment. The failure to do so is judged by peers and is called breach of duty. The task of the patient to prove harm in a measurable way is called causation. Major differences in judicial structures and frequency of negligence claims exist between countries.

Moving from a ‘One Size Fits All’ to Personalized Follow-Up in Breast Cancer Survivors—Connecting Patient-Reported Outcomes with Economic Considerations

In the Netherlands, two studies were performed to investigate the effectiveness of several alternative follow-up strategies in terms of patient-reported outcomes (health-related quality of life and satisfaction), and to address economic considerations in breast cancer follow-up care. This chapter describes the economic evaluation of four follow-up strategies after breast cancer treatment. As such, it provides an example of the application of economic methods to evaluate the relative value of breast cancer care. Whereas economic evaluation is outcome-focused, the process of care delivery is also a major determinant of patient value. Insight into patients’ preferences for outcome and process is crucial in order to tailor care to individual patients’ needs. Therefore, in a second study, patients’ preferences for the process of care delivery were evaluated.

Palliative Care and End-of-Life Care

Quality palliative care requires the integration of palliative care into standard oncological care, an educated workforce, and access to essential drugs. Referral criteria for specialist palliative care include time- and needs-based criteria. Prognostic scores have been constructed to assist in prognostic assessment but remain inaccurate in the individual patient. Patient–clinician communication is essential; guidelines for effective communication have been developed, and communication skills training and early exposure are important. Advanced care planning is of paramount importance for patients and families, since it can reduce aggressiveness of end-of-life care. Barriers to the development of palliative care need to be addressed; a resource-stratified practice guideline has been developed making recommendations for model of care, staffing requirements, roles, and training needs of members. Quality indicators have been developed as well, and these focus mainly on outcome indicators. The movement to legalize assisted dying has met with much controversy, yet this may also be an opportunity for communication, transparency, and accountability.

Systemic Therapy

Quality management of systemic treatment of breast cancer is a high priority, but few quality indicators have been identified so far. As structure indicators, education, day clinic facilities, and a dedicated pharmacy are proposed. As process indicators, access to appropriate experts, equity, and report of the given treatment in accordance to the guidelines are suggested. Overuse can burden the patients with unnecessary toxicity and society with unnecessary costs. Overall survival is the reference standard of outcome, but this is difficult to compare. Just as important are quality of life, patient-reported outcome, and safety. The essential antineoplastic agents for breast cancer are regularly updated by the World Health Organization. Tailored therapy, optimal patient selection, and clinical benefit are becoming key factors for all patients. In the future, a new funding model, precision medicine, and the molecular revolution will require sufficient human resources and networks to organize the best strategies.

Breast Cancer Surgery

The role of the surgeon managing breast diseases has been the subject of continuous evolution, moving from the cancer-extirpative surgeon to a deeply informed surgical leader, who interacts in a multidisciplinary setting also encompassing tasks for risk assessment, genetic counselling, and new diagnostic approaches. Surgical removal of the tumour remains the cornerstone in treating early stage breast cancer. During the last century, breast cancer surgery became less radical, breast-conserving treatment emerged, and the role of axillary lymphadenectomy changed from a therapeutic procedure into a staging procedure with prognostic implications. Later, the sentinel node concept reduced the need for complete axillary clearance in most cases. Nowadays, thanks to breast-conserving surgery, oncoplastic techniques, and reconstructive procedures, most breast cancer patients can overcome this disease without serious permanent physical mutilation. A multidisciplinary approach, benchmarking, and quality assurance have improved outcomes markedly.

The Multidisciplinary Meeting

Team-based care for a patient diagnosed with breast cancer is critical. The breast cancer disease-based team is composed of physicians from different specialties as well as nurses and other support staff. Breast cancer conference and tumour boards allow experts to review a complex case and work together to develop and refine therapeutic strategy. In each case presented, patient history with clinical, radiological, and pathological findings should be reviewed. Applicable treatment algorithms or care paths should be discussed as part of the overall process and to elevate the standard of care. Patients can be given access to clinical trials and important research. The multidisciplinary team (MDT) should meet at a given time (whether physically in one place or by video or teleconferencing) to discuss patients with breast cancer. The presence of an MDT, which meets at least biweekly, is often a requirement or indicator for audits and accreditation. Breast conferences should be accessible to MDT members, participation should be tracked on scorecards, and MDT programmes should be accountable.

EUSOMA

The European Society of Breast Cancer Specialists (EUSOMA) is the only European multidisciplinary society dedicated to breast cancer. EUSOMA has defined the requirements for a Breast Centre. Basic requirements are: at least 150 new breast cancer cases per year, provision of all services necessary from genetics and prevention, through diagnosis and treatment of primary tumour, follow-up, care of advanced disease, and palliation. The Breast Centre must have a dedicated team of specialists who regularly meet in the multidisciplinary meeting. EUSOMA also defined a set of Quality Indicators (QIs) to allow standardized auditing and quality assurance. EUSOMA developed a voluntary certification process to evaluate Breast Centre compliance with EUSOMA requirements and QIs. This process has now become an accredited scheme run by a dedicated organization (www.breastcentrescertification.com). The Breast Centre certification scheme is focused on real data, essential clinical skills, structure, and procedure, aiming at improving the quality of care. Breast Centres undergoing certification send data to the EUSOMA data warehouse. The EUSOMA data centre performs an analysis and issues a report showing the performances of the selected EUSOMA QIs. Thanks to the availability of these data, Certified Breast Centres under the umbrella of EUSOMA collectively publish scientific papers on selected topics.

The Global Burden of Breast Cancer in Women

Breast cancer is the most frequently diagnosed cancer and the leading cause of death from cancer in women. The number of women diagnosed with breast cancer world-wide is projected to increase from an estimated 1.7 million per year in 2012 to 2.2 million new cases per year by 2035. The largest component of this increase relates to demographic change (increasing and ageing populations), changes in breast cancer risk factors linked to westernization, and adoption of unhealthy lifestyles. Although major successes have been observed in improving survival from breast cancer, with a consequent reduction in mortality, these gains have mainly been observed in high-income countries. The international range in population-based survival also remains wide: the most recent 5-year net survival estimates range from <60% in some regions of sub-Saharan Africa to >85% in many high-income countries. These disparities are undoubtedly linked to inadequate access to diagnostic and treatment facilities in low-resource regions, where the number of women being diagnosed each year is still increasing and breast cancer is becoming an urgent problem. Tackling the growing burden of breast cancer will require comprehensive programmes of cancer control, with primary prevention, screening, and treatment tailored to local risk factors and health system capacities. Ongoing global initiatives on breast cancer have developed resource-stratified guidelines to promote early detection and treatment that meet the local cultural and economic situation. Wider adoption and quality assurance of such programmes will be key to reducing the observed global disparities in breast cancer incidence and survival.

The Economic Impact of Breast Cancer in the South-East Asian Region

In many parts of the world, are not only the economic consequences of breast cancer a burden to society, but also patients and their families directly endure financial hardship after a breast cancer diagnosis. This chapter examines the economic consequences of breast cancer for patients and families in a low- and middle income setting. Results of a study on financial catastrophe and mortality after breast cancer diagnosis, conducted in several countries in South-East Asia, are described.