MacDonald C, Duggan K, Sharmin M, Avery S. SSWAHS Clinical Cancer Registry, Liverpool Hospital, NSW.

INTRODUCTION • The Sydney South West Area Health

Service (SSWAHS) is one of the most populous Areas in NSW providing healthcare to 1.4m residents.

• The Clinical Cancer Registry (ClinCR)

collects a minimum data set for each new breast cancer that is diagnosed and/or treated within SSWAHS public facilities.

• The Western Zone facilities of

SSWAHS include:

In NSW, Breast cancer has the second highest incidence rate of all cancers and is overwhelmingly the most common cancer diagnosed in women, with close to 30% of all female cancer diagnoses being made in the Breast [1]. These statistics are found similarly in the SSWAHS population. Breast Conserving Surgery (BCS) is routinely performed to:

• remove the primary tumour • remove any local extension to achieve total

disease control • decrease the impact of the cancer/surgery on

the patient’s quality of life [3]

Fig 2 . Breast conserving surgery [4] NHMRC guidelines for the management of Early Breast Cancer [3] recommends that following BCS, adjuvant therapy should be undertaken in the majority of cases to improve survival and disease control.

METHODS Our investigation focused on the subset of the early stage breast cancer population who reside in the south western suburbs of Sydney and received BCS within SSWAHS public facilities between 2005-2008. Data from the ClinCR was extracted for analysis according to:

• residence at diagnosis • date of diagnosis • stage of disease at diagnosis and • the receipt of breast conservation

surgery (BCS)

Table 1. TNM Stage Groups included [2]

1932 patients were identified with a diagnosis of breast cancer within SSWAHS from July 2005 to June 2008. • 67% (n= 1294) of the registered breast cancer patients had in-situ and early stage

disease .

• 35% (n=672) of these patients resided in the western zone of the area health service (postcodes south west of and including Bankstown to Bowral. See Fig.1).

• 552 of these patients received breast conservation surgery in SSWAHS facilities.

• Upon closer examination, a further 127 patients went on to receive a later

mastectomy, and were excluded from this study

432 tumours were included in the final analysis which examined treatment modalities, patterns of care, and quality of care indicators such as presentation at multi-disciplinary care meetings.

POPULATION

Table 2. Patient Characteristics

• The age range for this group of patients was 29-92.

• Less than 1% of all cases were male. • Nearly 80% of all tumours were

classified as Ductal histological type, and 40% were located in the Upper Outer Quadrant of the breast.

• 55% of patients had a documented

ECOG score. Most were of good performance status.

• 47% of patients were born in Australia, while 55% were born overseas.

• 43% of patients were referred for psychosocial care. The most common referrals were to Specialist Nursing and Social Work. Christine.MacDonald@sswahs.nsw.gov.au

SSWAHS Clinical Cancer Registry, PO Box 7103, Liverpool, NSW BC1871 Phone: 9612 0617, Website: www.sswahs.nsw.gov.au/SSWAHS/cancer/

1. Tracey E, Ling L, Baker D, Dobrovic A, Bishop J, December 2009, Cancer in New South Wales: Incidence and Mortality 2007. Cancer Institute NSW. Available at: www.statistics.cancerinstitute.org.au/prodout/top20/top20_arhsres_incid_dstd_2004-2008_extall_NSW_P.htm

2. American Joint Commission on Cancer, 2002. AJCC Cancer Staging Manual, 6th ed. Springer-Verlag 3. National Breast Cancer Centre, 2001, NHMRC clinical practice guidelines for management of early breast cancer 2nd edition. Available at:

http://www.nhmrc.gov.au/_files_nhmrc/file/publications/synopses/cp74.pdf 4. Health Central, 2008, [online picture] ‘Lumpectomy diagram’. Available at: www.healthcentral.com/breast-cancer/h/lumpectomy.html

Kind thanks to Dr Denise Lonergan, who provided assistance with a clinical overview and editing.

REFERENCES & CONTACT DETAILS

CONCLUSIONS

Treatment Modality In Situ Invasive

Surgery + Radiotherapy + Hormones 2 (3) 110 (30)

Surgery + Radiotherapy 33 (54) 99 (27)

Surgery + Radiotherapy + chemotherapy + Hormones 55 (15)

Surgery + Radiotherapy + chemotherapy 39 (10)

Surgery Only 26 (43) 21 (6)

Surgery + Hormones 16 (4)

Surgery + Radiotherapy + chemotherapy + Hormones + Immunotherapy 14 (3)

Surgery + Radiotherapy + chemotherapy + Immunotherapy 9 (2)

Surgery + chemotherapy 5 (1)

Surgery + chemotherapy + Hormones + Immunotherapy 1 (<1)

Surgery + Hormones + Immunotherapy 1 (<1)

Surgery + Radiotherapy + Hormones + Immunotherapy 1 (<1)

• 89% of breast cancer patients in the selected population went on to receive adjuvant therapy following their BCS.

• Many of those that did not continue to have adjuvant therapy, were stage 0 (in-situ) cancers.

• Radiotherapy was the most common adjuvant

treatment utilised following BCS (84%). • Immunotherapy was least often utilised (6%). • The most commonly provided adjuvant therapy

modality combination overall following BCS was either Radiotherapy (31%) or Radiotherapy and Hormone therapy (26%).

Table 3. Treatment modality combinations

0

50

100

150

200

250

300

350

400

No AdjRx

R H C I

47

362

200

123

25

Fig 3. Adjuvant therapy utilisation after BCS

• The ClinCR is a valuable resource for cancer specific data for population, staging, treatment and quality of care information. Registry data can be used as an adjunct to existing programs to review data in support of patient care.

• As AJCC TNM stage at diagnosis increases, treatment modalities become more complex and more patients are discussed at MDT and referred for psychosocial support.

• Clinician engagement is requisite to continue to improve the quality and efficacy of the SSWAHS ClinCR dataset.

Stage 0 Stage 1 Stage 2 n = 61 n = 189 n = 182 Age at Diagnosis

20 to 29 years 1 (1) 3 (2)

30 to 39 years 1 (1) 3 (2) 18 (10)

40 to 49 years 5 (8) 34 (18) 36 (20)

50 to 59 years 25 (41) 64 (34) 53 (29)

60 to 69 years 26 (43) 61 (32) 37 (20)

70 to 79 years 4 (7) 19 (10) 28 (15)

80 + years 7 (4) 7 (4)

Sex Female 61 (100) 187 (99) 182 (100)

Male 2 (1)

ECOG at Diagnosis 0 18 (30) 88 (47) 78 (43)

1 2 (3) 22 (12) 22 (12)

2 1 (2) 5 (3)

3 2 (1) 1 (<1)

4

Not Doc’d 40 (65) 77 (40) 76 (42)

Country of Birth Australia 22 (36) 85 (45) 80 (44)

Overseas 39 (64) 103 (54) 99 (54)

Unknown 1 (<1) 3 (2)

Psychosocial Referral 16 (26) 88 (47) 125 (69)

Values given as n (% by Stage group)

0% 5% 10% 15% 20% 25% 30%

S, C

S, R, C, I

S, H

S, R

S

S, R, C, H, I

S, R, C

S, R, H

S, R, C, H

Fig 12. Stage II Treatment patterns

0

10

20

30

40

50

60

20 -

29

30 -

39

40 -

49

50 -

59

60 -

69

70 -

79

80 +

Actual AgeDist

Chemogiven

• The two most common treatment combination options given following BCS were Radiotherapy, Chemotherapy and Hormone therapy (27%), and Radiation with Hormones (26%).

• The proportion of Stage II

tumours receiving Chemotherapy decreased with patient age.

• 70% of patients received a referral to support services.

• 83% were presented at MDT.

Presented 83%

Not Presented

17%

Fig 14. Presented at MDT

Referred 69%

Not Referred

31%

Fig 15. Referred to Psychosocial Care

Stage II

Fig 13. Stage II Chemotherapy givven by Age Group

Stage I

0% 20% 40% 60%

S, C, H, I

S, H, I

S, R, H, I

S, C

S, R, C,…

S, R, C, I

S, R, C,…

S, H

S, R, C

S

S, R, H

S, R

Fig 8. Stage I Treatment Patterns

• 47% received a single modality of Radiotherapy following surgery and 33% had a combination of Radiotherapy and Hormones therapy.

• 90% of Stage I tumours

received RT following BCS. The most common course received was 42.4 Gy.

• 81% of patients were presented at an MDT

• 47% of Stage I patients were

identified as requiring Psychosocial care

Presented 81%

Not Presented

19%

Fig 10. Presented at MDT

Referred 47%

Not Referred

53%

Fig 11. Referred to Psychosocial Care

Fig 9. Stage I Radiotherapy given by T value and Received Dose

0 20 40 60 80 100

T1c

T1b

T1a

T1

42.4 Gy

42.4 Gy +Boost46 Gy + Boost

50 Gy

50 Gy + Boost

No RT

• Following BCS, 54% received adjuvant Radiotherapy and 3% received Radiotherapy with Hormone treatment.

• No other adjuvant therapies

were received. • The proportion of Stage 0

patients receiving radiotherapy increased with age.

• Of the 61 tumours, 69% were

presented at a Multidisciplinary Team Meeting (MDT)

• Psychosocial referral was received by 26%

0% 20% 40% 60%

S, R, H

S

S, R

Fig 4. Stage 0 Treatment Patterns

Presented 69%

Not Presented

31%

Fig 6: Presented at MDT

Referred 26%

Not Referred

74%

Fig 7: Referred to Psychosocial Care

Stage 0

RESULTS

Adjuvant therapy following Breast Conservation Surgery for early stage breast cancer patients: 3 year data from the Sydney South West Area Health Service

Clinical Cancer Registry

Stage T N M

Stage 0 Tis N0 M0

Stage I T1 (incl. mic)

N0 M0

Stage IIA

T0 N1 M0

T1 (incl. mic)

N1 M0

T2 N0 M0

Stage IIB T2 N1 M0

T3 N0 M0

This investigation into the types of adjuvant therapy received after initial breast conserving surgery in the Western Zone of SSWAHS, aims to inform

and assist clinicians in improving quality of patient care and service delivery.

0

5

10

15

20

25

30

20 -

29

30 -

39

40 -

49

50 -

59

60 -

69

70 -

79

80 +

ActualAge Dist

RT given

Fig 5. Stage 0 Radiotherapy given by Age group

• Bankstown • Fairfield • Liverpool

• Campbelltown • Camden • Bowral

Fig 1: Geography of SSWAHS facilities