NICE UK Updates its Quality Standard in Breast Cancer

List of six quality statements

In June 2016, NICE UK updated its breast cancer quality standard.

It was identified for update following the review of previous quality standards. The review identified that there had been changes in the areas for improvement for breast cancer. This quality standard covers the management of early (ductal carcinoma in situ and invasive), locally advanced and advanced breast cancer, recurrent breast cancer and familial breast cancer in adults. This includes breast cancer identified through screening and by assessment of symptoms, and covers care from the point of referral to a specialist team. It does not cover adults with non-cancerous breast tumours.

This quality standard is endorsed by NHS England. A number of organisations recognise the benefit of this quality standard in improving care (Association of Breast Surgery, British Society of Breast Radiologists, and Royal College of General Practitioners). 

NICE quality standards describe high-priority areas for quality improvement in a defined care or service area. Each standard consists of a prioritised set of specific, concise and measurable statements. They draw on existing guidance, which provides an underpinning, comprehensive set of recommendations, and are designed to support the measurement of improvement.

List of quality statements in breast cancer

Statement 1. People with suspected breast cancer referred to specialist services are offered the triple diagnostic assessment in a single hospital visit. [new 2016]

Triple diagnostic assessment consists of clinical assessment, mammography and/or ultrasound imaging, and fine needle aspiration or core biopsy.

Statement 2. People with biopsy-proven invasive breast cancer or ductal carcinoma in situ (DCIS) are not offered a preoperative MRI scan unless there are specific clinical indications for its use. [new 2016]

Carrying out an unnecessary preoperative MRI scan may cause additional stress without any benefit and waste healthcare resources.

Specific clinical indications for preoperative MRI scan are:

  • if there is discrepancy regarding the extent of disease from clinical examination, mammography and ultrasound assessment for planning treatment
  • if breast density precludes accurate mammographic assessment
  • to assess the tumour size if breast conserving surgery is being considered for invasive lobular cancer.

Statement 3. People with oestrogen receptor-positive (ER-positive), human epidermal growth factor receptor 2-negative (HER2-negative) and lymph node-negative early breast cancer who are at intermediate risk of distant recurrence are offered gene expression profiling with Oncotype DX. [new 2016]

Oncotype DX has been shown to be effective in predicting the course of disease in people with ER-positive, HER2-negative and lymph node-negative early breast cancer who have been assessed as being at intermediate risk of distant recurrence. This information can help with decisions about prescribing chemotherapy after surgery.

At the time of publication in June 2016, Oncotype DX was the only test (of four available to the NHS – MammaPrint, Oncotype DX, IHC4 and Mommostrat) recommended by NICE as an option for guiding adjuvant chemotherapy decisions for people with ER-positive, HER2-negative and lymph node-negative early breast cancer who are assessed as being at intermediate risk of distant recurrence.

Intermediate risk of distant recurrence is defined as a Nottingham Prognostic Index (NPI) score above 3.4. It is anticipated that an NPI score can be simply calculated from information that is routinely collected about people with breast cancer. The NICE diagnostics guidance also highlights other decision-making tools or protocols are also currently used in the NHS and these may also be used to identify people at intermediate risk.

Statement 4. People with newly diagnosed invasive breast cancer and those with recurrent breast cancer (if clinically appropriate) have the oestrogen receptor (ER) and human epidermal growth factor receptor 2 (HER2) status of the tumour assessed. [2011, updated 2016]

Information on the ER and HER2 status of breast cancer tumours is used to classify the primary tumour and decide how best to treat and manage the cancer. If breast cancer recurs, the ER and HER2 status of the tumour may be different from that of the original primary tumour. Therefore, recurrent tumours (either at the site of the primary tumour or metastatic tumours) should be assessed for their ER and HER2 status, if clinically appropriate.

Statement 5. People with breast cancer who develop metastatic disease have their treatment and care managed by a multidisciplinary team. [2011, updated 2016]

When a multidisciplinary team manages the treatment and care of people with advanced breast cancer who develop metastatic disease, health outcomes are improved. In particular, the role of the multidisciplinary team involves assessing the patient, discussing potential treatments for the cancer and symptom relief, and reviewing the impact of treatment across the whole care pathway.

Statement 6. People with locally advanced, metastatic or distant recurrent breast cancer are assigned a key worker. [2011, updated 2016]

Assigning key workers to people with locally advanced, metastatic or distant recurrent breast cancer leads to better health outcomes. Key workers provide information and support for the person with breast cancer throughout their care. This can help to improve patient experience because people know they have someone who they can discuss their care with. It also helps to ensure that any care takes the person's needs into account.

Key worker refers to a named healthcare professional (such as a clinical nurse specialist) who can give information and support throughout the patient pathway to the person with breast cancer and/or their carers.

Good communication between healthcare professionals and people with breast cancer and their families and carers (if appropriate), is essential. Treatment, care and support, and the information given about it, should be both age-appropriate and culturally appropriate. It should also be accessible to people with additional needs such as physical, sensory or learning disabilities, and to people who do not speak or read English. People with breast cancer and their families or carers (if appropriate) should have access to an interpreter or advocate if needed.