Annelotte van Bommel

164 GENERAL DISCUSSION AND FUTURE PERSPECTIVES This thesis describes the constitution and results of the first four years of the Dutch Breast Cancer Audit (NBCA), together with factors that may optimize the use of breast reconstructive surgery. In the years preceding the NBCA, the National Health Care Inspectorate had started to query individual hospitals regarding the possible relationship between volume and outcomes of provided care for patients with various oncologic conditions. 1,2 The results were published in national media and presented as “rankings” that assumedly reflected the quality of care. In 2011, the endeavors of many clinicians resulted in the constitution of a nationwide breast cancer audit. 3 The joined effort of these clinicians originating fromall involved specialties and stakeholders (patients, insurance companies, government) led to a set of 32 quality indicators to gain insight in all aspects of the multidisciplinary care for patients diagnosed with breast cancer ( Chapter 2 ). Full participation of the 92 Dutch hospitals was accomplished within two years, resulting in NBCA data of the breast cancer work-up and treatment of 56,927 patients who had been treated between 2011 and 2014. Many indicators showed improvements within the first four years of auditing: the proportion of individual patient cases being discussed in pre-and postoperative multidisciplinary teammeetings (from 83% to 98%), the guideline-directed use of BI-RADS (Breast Imaging-Reporting and Data System) classification in the radiological assessment of breast imaging (from 97% to 99%), the proportion of pathology reports containing all clinically relevant items (from 83% to 97%) as well as the rate of tumor-positive margins after first primary breast conserving surgery for invasive breast cancer (from 5.9% to 4.6%). The percentage of patients treated by breast conserving surgery remained stable during these four years. Hypothesizing that the mere breast conserving surgery rate does not adequately represent the esthetic outcome of local treatment, the rate of undergoing a breast-contour-preserving procedure (BCPP) was coined as an alternative local outcome parameter ( Chapter 3 ). The definition of BCPP