The National Mastectomy & Breast Reconstruction Audit (NMBRA) has been commissioned and funded by the Healthcare Commission to answer three primary questions:

- Is the provision of breast reconstruction services uniform across England and Wales?  

- Do women undergoing mastectomy have enough information to make an informed
  decision about breast reconstruction, and are they happy with that decision?  

- What are the outcomes following mastectomy with or without breast reconstruction?  

It is being led by BAPRAS and the Association of Breast Surgery at BASO, with support from the Clinical Effectiveness Unit of The Royal College of Surgeons of England and the Information Centre for Health and Social Care.  

Background

Breast reconstruction is an evolving area of care in England and Wales. New reconstructive techniques have been introduced in recent years, and there is currently disagreement about the peri-operative, oncological, and cosmetic outcomes following immediate reconstruction in certain patient groups.  

As a result there is considerable variation in the practice of different healthcare providers, with the likelihood of being offered reconstruction (whether immediate or delayed) dependent on the hospital at which a patient is treated.  

In such a rapidly evolving area an information deficit inevitably develops, and establishing basic descriptive data on reconstructive practices in England and Wales is therefore a key feature of the Audit.  

By quantifying those outcomes currently being achieved and identifying determinants of variation in outcome, we hope to be able to support the development of future evidence-based care standards and inform and advance training in breast reconstruction.  

Objectives

The primary objective of this audit will be to describe access to breast reconstruction surgery amongst women who have had a mastectomy for breast cancer. It will attempt to quantify the current volume of reconstruction surgery performed in England and Wales (at both NHS and private centres) and investigate the basis for differential service provision, such as patient characteristics, care processes, and the local clinical expertise available.  

A second objective will be to describe current clinical practice in mastectomy and breast reconstruction, and to explain any variation from nationally agreed standards using data on patient characteristics and healthcare provider identity.  

A third objective will be to describe outcomes following mastectomy with or without reconstruction.  Both patient-reported outcomes (e.g. satisfaction and quality of life), and clinical outcomes (e.g. peri-operative complications) will be measured. We will attempt to explain variation in outcomes using data on patient characteristics, clinical practices and identity of healthcare provider.  

Methodology

We are to commence a national prospective cohort study (NHS and private sector) in January 2008, for which recruitment is currently taking place. Peri-operative clinical data will be collected and entered at the Unit level for all of these patients.  

All patients entered into the cohort will subsequently be followed up at three and eighteen months through specially developed and validated patient-reported outcome questionnaires – these will be distributed and analysed centrally by the Clinical Effectiveness Unit.  

Prior to the start of the cohort study, we are undertaking three important Audit modules:  

A qualitative study exploring attitudes to breast reconstruction and current difficulties with service provision has already been undertaken through systematic interviews with key stakeholders, including both clinicians and patients.  

An organisational study to identify and describe practice at the Unit level is currently ongoing, with a specially developed questionnaire and data collection from alternative sources helping to explain variation in reconstructive provision and practice throughout the NHS and private sectors.  

A national retrospective cohort study of all women undergoing mastectomy and breast reconstruction in England between 1997 and 2006 will be conducted by merging the national Hospital Episode Statistics and Cancer Registry datasets. This important component of the Audit is being undertaken in collaboration with the West Midlands Cancer Intelligence Unit (WMCIU), nominated by the United Kingdom Association of Cancer Registries (UKACR) as the lead Registry for this project.  

Inclusion criteria

Our prospective cohort study in 2008 will include all women undergoing mastectomy for primary breast cancer with or without immediate reconstruction. It will also include all women undergoing delayed breast reconstruction. All women treated within the NHS and the private sector in England and Wales are eligible for inclusion in the study.  

Further information

Please e-mail rjeevan@rcseng.ac.uk or call 0207 869 6619 with any queries or to register your interest in participating in the prospective cohort study.