Evidence has shown that multidisciplinary specialist team evaluation and management for cancer results in better patient outcomes. For breast cancer, breast centers are where this evaluation and management occurs. The National Accreditation Program for Breast Centers has helped standardize multidisciplinary breast cancer care by defining services and standards required of accredited breast centers.
Key points
- •
Multidisciplinary team approach is the preferred method of cancer care both nationally and internationally.
- •
Multidisciplinary care has resulted in better outcomes.
- •
The National Accreditation Program for Breast Centers has helped standardized multidisciplinary breast cancer care.
History of multidisciplinary care
The concept of establishing a multidisciplinary approach to cancer care initiated in the early 1990s after observational evidence identified better outcomes among patients treated by specialists for various common cancers. The Calman-Hine report was published in the European system to address discrepancies of cancer care. This report proposed that all patients with cancer should be seen by surgeons who specialized in their type of cancer, who worked with colleagues in multidisciplinary teams. Specifically for breast cancer, the multidisciplinary approach was introduced following report of better local and regional treatment of disease by specialist surgeons, with a reported 11% to 17% reduction in risk of death among women treated for breast cancer by specialist surgeons and a survival benefit between specialist and nonspecialist breast cancer surgeons.
Today many countries, including the United States, use multidisciplinary teams as the preferred method of delivering cancer care. The team is composed of surgeons, clinical and medical oncologists, specialist nurses, radiologists, pathologists, and others who operate along the whole care pathway from diagnosis to follow-up and beyond. Patients are discussed at many points along the treatment pathway, initially at diagnosis, following each treatment, and also at times of recurrence or progression. The key task of the team during a multidisciplinary team meeting, often under the leadership of a surgical oncologist, is to collate and review information about the patient and their disease, discuss it, and make a decision for further investigation and treatment.
History of multidisciplinary care
The concept of establishing a multidisciplinary approach to cancer care initiated in the early 1990s after observational evidence identified better outcomes among patients treated by specialists for various common cancers. The Calman-Hine report was published in the European system to address discrepancies of cancer care. This report proposed that all patients with cancer should be seen by surgeons who specialized in their type of cancer, who worked with colleagues in multidisciplinary teams. Specifically for breast cancer, the multidisciplinary approach was introduced following report of better local and regional treatment of disease by specialist surgeons, with a reported 11% to 17% reduction in risk of death among women treated for breast cancer by specialist surgeons and a survival benefit between specialist and nonspecialist breast cancer surgeons.
Today many countries, including the United States, use multidisciplinary teams as the preferred method of delivering cancer care. The team is composed of surgeons, clinical and medical oncologists, specialist nurses, radiologists, pathologists, and others who operate along the whole care pathway from diagnosis to follow-up and beyond. Patients are discussed at many points along the treatment pathway, initially at diagnosis, following each treatment, and also at times of recurrence or progression. The key task of the team during a multidisciplinary team meeting, often under the leadership of a surgical oncologist, is to collate and review information about the patient and their disease, discuss it, and make a decision for further investigation and treatment.
Standardization of the multidisciplinary breast cancer care
Since the introduction of multidisciplinary teams in breast cancer care, there have been concerns as to whether improved survival is due to earlier detection, improved treatment, improved organized care, or a combination of each. An international review of 21 studies in 2010, including 5 on breast cancer, cited 3 reasons for inability to identify a causal relationship between multidisciplinary teams and cancer survival, including an imprecise and heterogeneous definition of multidisciplinary care. An intervention study in 2012 aimed to address this dilemma found that multidisciplinary teams for breast cancer were associated with 18% lower breast cancer mortality at 5 years and 11% lower all-cause mortality at 5 years. Although evidence suggests survival advantage due to local and regional treatment by specialist surgeons, surgical specialty alone is unlikely to explain the survival advantage seen with a multidisciplinary team.
Breast care deficiencies, including fragmented evaluation and management, led Silverstein to pioneer the first free-standing breast center in the United States in 1979, the Van Nuys Breast Center. Since Silverstein’s center, there has been an exponential increase in the number of breast centers across the United States with the purpose of conducting high-quality, timely multidisciplinary team evaluation and management of both benign and malignant breast disease. These breast centers were focused multidisciplinary facilities of excellence that dealt with the complete range of breast problems; however, there was diversity across the centers and across their stated missions without an established definition of what constitutes a quality program. Recognizing that evidence-based and consensus-developed standards have gained increasing importance and recognition, the US health care system has concentrated on quality measurement and improvement with documentation of adherence to accepted standards of care. Accreditation of facilities and provider reporting are becoming expectations.
The National Consortium of Breast Centers has defined many breast center variations. The European Accreditation of Breast Units was founded in 1986 to establish breast center standards in Europe. No similar body existed in the United States until 2008 when the National Accreditation Program for Breast Centers (NAPBC) was strategically built by the experts that deliver breast disease care to offer credible evidence-based standards for existing breast centers. Getting there started with Silverstein’s Van Nuys Breast Center, the prototype model for most breast centers developed in the United States. The evaluation and management offered in these centers have been standardized with the establishment the NAPBC.
The national accreditation program for breast centers
The NAPBC Mission Statement states the following: The NAPBC is a consortium of national, professional organizations focused on breast health and dedicated to the improvement of quality care and outcomes of patients with diseases of the breast through evidence-based standards and patient and professional education.
The NAPBC Standards Manual clearly defines the standards of what accredited centers demonstrate. These standards include a multidisciplinary team approach to coordinate the best care and treatment options available. These centers provide access to breast cancer–related information, education, and support. All the subspecialties involved in breast cancer diagnosis and treatment undergo data collection for quality indicators. The centers will have information about clinical trials and new treatment options, and there is ongoing monitoring and improvement of care. Accreditation is only awarded after a successful survey process and thorough full-day site visit. It maintains annual reporting and regular reaccreditation.
NAPBC accreditation for a breast center is accomplished once this high level of standardized care is met by commitment to 17 component services offered ( Box 1 ) and 6 categories of standards ( Box 2 ) as defined by the NAPBC Standards Manual. The categories include center leadership (3 standards), clinical management (19 standards), research (2 standards), community outreach standards (1 standard), professional education (1 standard), and quality improvement (2 standards).
- 1.
Imaging
- a.
Screening mammography
- b.
Diagnostic mammography (additional views beyond screening mammography and workup of a clinical abnormality)
- c.
Ultrasound
- d.
Breast magnetic resonance imaging (MRI)
- a.
- 2.
Needle biopsy
- a.
Needle biopsy—palpation-guided
- b.
Image guided—stereotactic
- c.
Image guided—ultrasound
- d.
Image guided—MRI
- a.
- 3.
Pathology
- a.
Report completeness/College of American Pathologists (CAP) protocols
- b.
Radiology-pathology correlation
- c.
Prognostic and predictive indicators
- d.
Gene studies (if available)
- a.
- 4.
Interdisciplinary conference
- a.
History and findings
- b.
Imaging studies
- c.
Pathology
- d.
Pretreatment and posttreatment interdisciplinary discussion
- a.
- 5.
Patient navigation
- a.
Facilitates navigation through system
- a.
- 6.
Genetic evaluation and management
- a.
Genetic risk assessment
- b.
Genetic counseling
- c.
Genetic testing
- a.
- 7.
Surgical care
- a.
Surgical correlation with imaging/concordance
- b.
Preoperative planning after biopsy
- c.
Breast surgery: lumpectomy or mastectomy
- d.
Lymph node surgery: sentinel node/axillary dissection
- e.
After initial surgical correlation/treatment planning
- a.
- 8.
Plastic surgery consultation/treatment
- a.
Tissue expander/implants
- b.
Transverse rectus abdominis myocutaneous (TRAM)/latissimus flaps
- c.
Deep inferior epigastric perforator (DIEP) flap/free flap (if available)
- a.
- 9.
Nursing
- a.
Nurses with specialized knowledge and skills in diseases of the breast
- a.
- 10.
Medical oncology consultation/treatment
- a.
Hormone therapy
- b.
Chemotherapy
- c.
Biologics
- d.
Chemoprevention
- a.
- 11.
Radiation oncology consultation/treatment
- a.
Whole breast irradiation with or without boost
- b.
Regional nodal irradiation
- c.
Partial breast irradiation treatment or protocols
- d.
Palliative radiation for bone or systemic metastasis
- e.
Stereotactic radiation for isolated or limited brain metastasis
- a.
- 12.
Data management
- a.
Data collection and submission
- a.
- 13.
Research
- a.
Cooperative trials
- b.
Institutional original research (not part of national trials)
- c.
Industry sponsored trials
- a.
- 14.
Education, support, and rehabilitation
- a.
Education along continuum of care (pretreatment, during, after treatment)
- b.
Psychosocial support
- i.
Individual support
- ii.
Family support
- iii.
Support groups
- i.
- c.
Symptom management
- d.
Physical therapy (ie, lymphedema risk, shoulder range of motion)
- a.
- 15.
Outreach and education
- a.
Community at-large education (including low-income/medically underserved)
- b.
Patient education
- c.
Physician education
- a.
- 16.
Quality improvement
- a.
Continuous quality improvement through annual studies
- a.
- 17.
Survivorship program
- a.
Follow-up surveillance
- b.
Rehabilitation
- c.
Health promotion/risk reduction
- a.
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