CANCERS

Health Evidence Bulletins - Wales
Team Leader: Dr. Gordon Avery

Date of Completion: 17.09.98

Chapter 3: BREAST CANCER

Breast Cancer is the most common cancer experienced by women in Wales. The annual average registration rate for breast cancer in women for 1984-1988 was 114.4 per 100,000 this being the highest of the regions in England and Wales.1
Registrations of breast cancer have been rising in Wales and show no signs yet of reaching a peak.2
The average annual number of deaths from breast cancer in women during the 5 year period 1992-1996 was 776.3
The annual average age standardised death rate for the same period was 37.2 per 100,000 The death rate in Wales is amongst the highest in the United Kingdom but it has been falling steadily since 1988.4
These falling trends are mainly related to improvements in treatment. The effects of the introduction of regular screening by mammography in Wales in 1995 have not yet been fully realised.
The five year survival rate for breast cancer in women in Wales was 50% for cancers diagnosed between 1984 and 1988.2

Breast Cancer in men
is rare with an annual average of 17 new registrations recorded in Wales between 1986-1990.

  1. Welsh Cancer Intelligence & Surveillance Unit: Cancer Registrations in Wales 1974-1990. Cardiff: WCISU, 1998

  2. Welsh Health Common Services Authority. Cancer Registrations in Wales 1984-1988. Cardiff: Welsh Office, 1994.

  3. Welsh Health Common Services Authority. Health Show. Welsh Public Health Common Data Set. Cardiff: WHCSA, 1997.

  4. Welsh Office. Welsh Health. Annual Report of the Chief Medical Officer 1996. Cardiff: Welsh Office, 1997.

A source document for several statements in this chapter (Cancer Guidance Sub-Group of the Clinical Outcomes Group. Improving Outcomes in Breast Cancer: the Research Evidence. London: NHS Executive, Department of Health, 1996) is summarised in an Effective Health Care bulletin (NHS Centre for Reviews and Dissemination, University of York. The management of primary breast cancer. Effective Health Care 1996; 2(6)) http://www.york.ac.uk/inst/crd/ehc26.htm

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This bulletin is a supplement to, not a substitute for, professional skills and experience. Users are advised to consult the supporting evidence for a consideration of all the implications of a recommendation.

The Statements The Evidence
3.1 RISK FACTORS & PREVENTION
3.1a. There has been a slow increase in the incidence of breast cancer over the last two decades which may be associated with changes in hormonal factors eg late age at first pregnancy, early menarche, prolonged use of oral contraceptives, Hormone Replacement Therapy (HRT).i, ii, iii
The systematic review of more than 15,000 women who were currently using combined oral contraceptives or had used them in the previous 10 years showed a small increase in the relative risk of having breast cancer.
Current users, Relative Risk, RR =1.24 (95%CI 1.15-1.33)
1-4 years after stopping, RR=1.16 (95%CI 1.08-1.23)
5-9 years after stopping, RR=1.10 (95%CI 1.02-1.13) ii
There is a small increase in the risk of developing breast cancer in women using HRT and the risk increases with duration of use.
Current users or those who ceased use 1-4 years ago, RR=1.023 (95%CI 1.011-1.036)
for each year of use
HRT use for 5 years or longer, RR=1.35 (95%CI 1.21-1.49) for each year of use. iii
(Health gain notation – 3 "trade-off between beneficial and adverse effects")
i. Garfinkel L, Buring C, Heath CW. Changing trends: An overview of breast cancer incidence and mortality. Cancer Supplement 1994; 74(1): 222-7
(Type V evidence - expert opinion, influential report)
ii. Collaborative Group on Hormonal Factors in Breast Cancer. Breast cancer and hormonal contraceptives: collaborative reanalysis of individual data on 53297 women with breast cancer and 100239 women without breast cancer from 54 epidemiological studies. Lancet 1996; 347: 1713-1727
(Type IV evidence - systematic review of prospective and case control studies)
iii. Collaborative Group on Hormonal Factors in Breast cancer. Breast cancer and hormone replacement therapy: collaborative reanalysis of data from 51 epidemiological studies of 52705 women with breast cancer and 108411 women without breast cancer. Lancet 1997; 350: 1047-1059
(Type IV evidence - systematic review of observational studies)

 

3.1b. A diet high in fibre (fruit and vegetables) and low in fat has the potential for preventing a number of cancers, including breast. i, ii
(Health gain notation -2 "likely to be beneficial")
i. Department of Health. Nutritional Aspects of the Development of Cancer. Report of the Working Group on Diet and Cancer of the Committee on Medical Aspects of Food and Nutrition Policy. Nutritional Aspects of the Development of Cancer. London: The Stationery Office, 1998
(Type V evidence -expert opinion based on observational studies)
ii. World Cancer Research Fund/American Institute of Cancer Research. Food Nutrition and the Prevention of Cancer: a Global perspective. Washington DC: AICR, 1997
(Type V evidence -expert opinion based on observational studies)

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3.1c. There is evidence for a positive association between Body Mass Index (BMI) and postmenopausal breast cancer. The avoidance of obesity helps to prevent breast cancer. i, ii
(Health gain notation -2 "likely to be beneficial")
i. Report of the Working Group on Diet and Cancer of the Committee on Medical Aspects of Food and Nutrition Policy. Nutritional Aspects of the Development of Cancer. London: The Stationery Office, 1998
(Type V evidence - expert opinion based on observational studies)
ii. World Cancer Research Fund /American Institute of Cancer Research. Food Nutrition and the Prevention of Cancer: a Global perspective. Washington DC: AICR, 1997
(Type V evidence - expert opinion based on observational studies)
3.1d. Individuals with certain genetic mutations have a higher risk of developing breast cancer at a very young age. For some genetic mutations the lifetime cumulative risk exceeds 80%.
Caveat: Genetic counselling should be considered for all those at high risk. Firm guidelines are awaited.i
(Health gain notation -2 "likely to be beneficial")
i. Ford D, Easton,DF,Bishop DT, Narod SA,Doldgar DE, and the Breast Cancer Linkage Consortium. Risks of cancer in BRCA1-mutation carriers. Lancet 1994; 343: 692-695
(Type IV evidence - observational study)
3.1e. The evidence on the use of tamoxifen in the prevention of breast cancer is uncertain. British i and Italian trials have been unable to reproduce the reduction in incidence shown in the prematurely closed American trial. ii The differences may be due to differences in the population studied (risk levels, family history, age of participants) study compliance and size of the studies. iii
(Health gain notation - 4 "unknown")
caveat: Longer follow-up of completed and current trials, such as the International Breast Cancer Intervention Study (IBIS)iv is needed to clarify the benefits and risks in different populations.
i. Powles T, Eeles R, Ashley S et al. Interim analysis of the incidence of breast cancer in the Royal Marsden Hospital tamoxifen randomised chemoprevention trial. Lancet 1998; 352:98- 101
(Type II evidence - randomised controlled trial of 2494 healthy women at increased risk of developing breast cancer)
ii. National Cancer Institute. Breast Cancer Prevention Trial shows major benefit, some risk.
http://cancertrials.nci.nih.gov
iii. Pritchard KI. Is tamoxifen effective in prevention of breast cancer? Lancet 1998; 352: 80-81
(Type V evidence - expert opinion based on randomised trials)
iv. International breast cancer intervention study (IBIS) (Tamoxifen trial). National Research Register Project No. N0395034666, ends 30/06/2002
(Type II evidence – randomised controlled trial in progress) http://www.update-software.com/National/

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3.2 SCREENING

3.2a. Single view mammography, repeated every three years, has proved to be beneficial in reducing the death rate for breast cancer (by as much as 25%). i
(Health gain notation - 1 "beneficial")
i. Kerlikowske K, Grady D, Rubin S, Sandrock C, Ernster VL. Efficacy of screening mammography. A meta-analysis. Journal of the American Medical Association 1995; 273 (2):149-54
(Type I evidence - systematic review of 13 randomised controlled trials and case control studies)
3.2b. Taking two mammographic views of the breast instead of one increases the detection rate of breast cancer by 24% (95% CI, 16% -31%). The number of women recalled for further investigation is reduced by 15% (95% CI, 6% -23%) in women aged 50 -64.i
(Health gain notation - 1 "beneficial
i. Wald NJ, Murphy P, Major P, Parkes C, Townsend J, Frost C. UKCCCR multicentre randomised controlled trial of one and two view mammography in breast cancer screening. British Medical Journal 1995; 311: 1189-1192
http://www.bmj.com/cgi/content/full/311/7014/1189
(Type II evidence - well designed randomised controlled trial. A multicentre trial in the United Kingdom of 40163 women aged 50-64 attending first breast screening examination)
3.2c. Reducing the screening interval from 3to 2 years would reduce the incidence of interval cancers. i,ii
The optimum screening interval may vary for different age groups. The relative risk (observed interval cancers/ expected number of cancers in the absence of screening) of a breast cancer occuring within 3 years of a negative screen was 0.523 in women aged 50-59 and 0.317 in those aged 60-64. ii
(Health gain notation - 3 "trade off between beneficial and adverse effects")
caveat: The effect of reducing the screening interval on the stage distribution of breast cancers is the subject of a UKCCCR multicentre randomised controlled trial. This trial, involving Breast Test Wales, is comparing a one year and a three year screening interval. iii
i. Woodman CBJ, Threlfall AG, Boggis CRM, Prior P. Is the three year breast screening interval too long? Occurrence of interval cancers in NHS breast screening programme’s North Western Region. British Medical Journal 1995; 310: 224-26
http://www.bmj.com.cgi.content/full/310/6974/224
(Type IV evidence- well designed observational study)
ii. Threlfall AG, Woodman CBJ, Prior P. Breast screening programme: should the interval between tests depend on age? Lancet 1997; 349: 472
(Type IV evidence- well designed observational study)
iii. UKCCCR ‘The Frequency Trial’
Contact: Professor N Day, Institute of Public Health, Cambridge CB2 2SR.
(Type II evidence – randomised controlled trial in progress)

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3.2d. There is currently insufficient evidence to support mammographic screening in the general population of women under the age of 50. i,ii,iii,iv
(Health gain notation -3 ""trade off between beneficial and adverse effects")
caveat: A current UKCCCR trial ‘The Age Trial’, involving Breast Test Wales, will compare the benefits and costs of annual screening starting at age 40 with the standard UK programme. v
i. Fletcher S. Breast cancer screening in women under 50. British Medical Journal 1997; 14 : 764-5.
(Type V evidence - expert opinion)
ii. National Institute of Health Consensus Development Panel. National Initiatives of Health Consensus Development Conference Statement: Breast cancer screening for women aged 40-49. Journal of the National Cancer Institute 1997; 89: 1015-20.
(Type V evidence - expert opinion)
iii. Elmore JG, Barton MB, Moceri VM, Polk S, Arena PJ, Fletcher SW. Ten-year risk of false positive screening mammography and clinical breast examinations. New England Journal of Medicine 1998; 338:1089-96.
(Type IV evidence - retrospective cohort study)
iv. Sox HC. Benefit and harm associated with screening for breast cancer.
New England Journal of Medicine 1998; 338: 1145-46
(Type V evidence - expert opinion)
v. The UKCCCR Age Trial. National Research Register Project: N0084011553, ends 31.7.2002
(Type II evidence – randomised controlled trial in progress)
http://www.update-software.com/National/
3.2e. There is a case for increasing the age of routine invitation for screening to include the 65-74 year group.i
A significant reduction in mortality of between 20-39% has been obtained from a number of studies. ii
(Health gain notation - 2 "likely to be beneficial")
caveat: There is to be an evaluation of the pilot projects of breast cancer screening of women aged 65 to 69 years. iii
i. Kerlikowske K, Grady D, Rubin S, Sandrock C, Ernster VL. Efficacy of screening mammography. A meta-analysis. Journal of the American Medical Association 1995; 273 (2): 149-54
(Type I evidence - systematic review of 13 randomised controlled trials and case control studies)
ii. Sutton CG. Will you still need me, will you still screen me, when I’m past 64?
British Medical Journal 1997; 315: 1032-3.
(Type V evidence - expert opinion)
iii. Evaluation of pilot projects of breast cancer screening of women aged 65-69 years. National Research Register Project: A0300771, ends 31.12.2000
(Type II evidence – randomised controlled trial in progress)
http://www.update-software.com/National/

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3.3 DIAGNOSIS

3.3a. The combination of clinical examination, mammography and fine needle aspiration cytology, known together as triple assessment, should be available for women with suspected breast cancer at a single visit. When all three tests are positive, the probability that the patient has breast cancer is over 99%. i
(Health gain notation 1 - "beneficial")
i. NHS Executive. Cancer Guidance Sub-group of the Clinical Outcomes Group. Guidance for Purchasers. Improving Outcomes in Breast Cancer: The Research Evidence. London: NHS Executive, Department of Health, 1996
(Type III evidence - expert opinion based on 15 prospective and retrospective studies and one review)
3.3b. There is evidence that the use of triple assessment leads to a decrease in the surgical biopsy rate. The accuracy of triple assessment depends on the skills of those who carry out procedures and assess the results.i
(Health gain notation - 1 "beneficial")
i. NHS Executive. Cancer Guidance Sub-group of the Clinical Outcomes Group. Guidance for Purchasers. Improving Outcomes in Breast Cancer: The Research Evidence. London: NHS Executive, Department of Health, 1996
(Type IV evidence - expert opinion based on observational studies)
3.4 TREATMENT
3.4a. Randomised controlled trials comparing mastectomy with breast conserving surgery plus radiotherapy show very similar five and ten year survival rates.i
Surgical margin status is a strong predictor of long term local recurrence rates, which can vary from 5% to 20% at ten years when breast conserving surgery is given with radiotherapy ii and 30% at five years without radiotherapy. iii
(Health gain notation - 2 "likely to be beneficial")
i. NHS Executive. Cancer Guidance Sub-group of the Clinical Outcomes Group. Guidance for Purchasers. Improving Outcomes in Breast Cancer: The Manual. London: NHS Executive, Department of Health, 1996
(Type I evidence - expert opinion based on randomised controlled trials)
ii. NHS Executive. Cancer Guidance Sub-group of the Clinical Outcomes Group. Guidance for Purchasers. Improving Outcomes in Breast Cancer: The Research Evidence. London: NHS Executive, Department of Health, 1996
(Type I evidence - described in Smitt MC, Nowels KW, Zdeblick MJ et al. The importance of the lumpectomy surgical margin in long term results of breast conservation. Cancer 1995;76:250-67)
iii. NHS Executive. Cancer Guidance Sub-group of the Clinical Outcomes Group. Guidance for Purchasers. Improving Outcomes in Breast Cancer: The Research Evidence. London: NHS Executive, Department of Health, 1996
(Type I evidence - described in Macmillan RD, PurushothAm AD, George WD. Local recurrence following breast conserving surgery for breast cancer. British Journal of Surgery 1996; 83: 149-155)
3.4b. Studies suggest that women who have breast conserving surgery report better body image and greater satisfaction than those who have undergone mastectomy and immediate reconstruction. However the studies are small and include women who are likely to be self -selected. Evidence in favour of reconstruction is weak since women who have had breast reconstruction do not report better psychological adjustment. There is no clear cut answer as to whether immediate reconstruction is better than later reconstruction. i
(Health gain notation - 4 "unknown")
caveat: Reconstruction should be available for those patients who wish to have it.
i. NHS Executive. Cancer Guidance Sub-group of the Clinical Outcomes Group. Guidance for Purchasers. Improving Outcomes in Breast Cancer: The Manual. London: NHS Executive, Department of Health, 1996
(Type V evidence - expert opinion)

 

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3.4c. The axilla should normally be staged by sampling at least four nodes or by clearance. i
A single randomised trial showed that axillary sampling followed by radiotherapy (if node-positive) resulted in similar rates of survival to axillary clearance after mastectomy. ii However this is a controversial area as others have shown an increase of axillary relapse in the negative node group.The possible advantages of complete dissection need to be weighed against the likelihood of substantial arm morbidity and the possible adverse effects and anticipated benefits should be discussed with patients. i
(Health gain notation -3 ""trade off between beneficial and adverse effects")
caveat: An ongoing trial is using a technique of sentinel node biopsy which identifies a single ‘lead’ or sentinel node in the axilla using radio isotopes. Early indications are that this node will predict the status of the remaining nodes, and in the node negative group avoid major surgery. iii
i. NHS Executive. Cancer Guidance Sub-group of the Clinical Outcomes Group. Guidance for Purchasers. Improving Outcomes in Breast Cancer: The Manual. London: NHS Executive, Department of Health, 1996
(Type V evidence - expert opinion)
ii. NHS Executive. Cancer Guidance of Sub-group of the Clinical Outcomes Group. Guidance for Purchasers. Improving Outcomes in Breast Cancer: The Manual. London: NHS Executive, Department of Health, 1996
(Type II evidence -described in Forrest APM, Everington D, McDonald CC, Steele RJC, Chetty U, Stewart HJ. The Edinburgh randomised trial of axillary sampling or clearance after mastectomy. British Journal of Surgery 1995; 82: 1504-8)
iii. Randomised trial of sentinel node biopsy in breast cancer. National Research Register Project: N0048037990, ends 14.2.2001
(Type II evidence – randomised controlled trial in progress) http://www.update-software.com/National/
3.4d. Adjuvant radiotherapy after surgery reduces local recurrence rates by more than two thirds. i The benefit on long term survival is less well established although recent trials suggest that lower breast cancer mortality does occur, with reduced adverse effects due to improved radiation techniques. ii
A further review is underway. iii
(Health gain notation - 2 "likely to be beneficial")
Another review is in progress to determine whether radiotherapy has a role in the management of women with ductal carcinoma in situ of the breast. iv
(Health gain notation - 4 "unknown")
i. Early Breast Cancer - Trialists’ Collaborative Group: Effects of radiotherapy and surgery in early breast cancer. An overview of the randomised trials. New England Journal of Medicine 1995; 333: 1444-55
(Type I evidence - systematic review of 36 randomised controlled trials including 17,273 women)
ii. Nuffield Institute for Health, University of Leeds & NHS Centre for Reviews and Dissemination, University of York. The management of primary breast cancer. Effective Health Care 1996; 2(6) :1- 16
(Type II evidence -described in Cuzick J, Stewart H, Rutqvist L et al. Cause-specific mortality in long-term survivors of breast cancer who participated in trials of radiotherapy. Journal of Clinical Oncology 1994;12: 447-453)
http://www.york.ac.uk/inst/crd/ehc26.htm
iii. Early Breast Cancer Trialists’ Collaborative Group. Early Breast Cancer Trialists’ Collaborative Group (EBCTCG) overview of radiotherapy in early breast cancer (Protocol). In : The Cochrane Library, Issue 3, 1998. Oxford: Update Software
(Type I evidence - systematic review in progress)
iv. Ghersi D, Simes RJ, Lockwood S. Post-operative radiotherapy in the treatment of DCIS (Protocol). In: The Cochrane Library, Issue 3,1998. Oxford: Update Software
(Type I evidence - systematic review in progress)

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3.4e. Polychemotherapy (typically cyclophosphamide, methotrexate and 5-flurouoracil) improves annual survival rates by 16% 3% and reduces average recurrence rates by 28% 3% with greater benefits in younger women.i, ii, iii
A further review of multi-agent chemotherapy versus no such adjuvant treatment or one multi-agent chemotherapy regimen versus another will be reporting soon. iv
Under-utilisation of chemotherapy has been postulated as one of the explanations for poorer breast cancer survival rates in the United Kingdom compared with some other countries. v
(Health gain notation - 1 "beneficial")
i. Early Breast Cancer Trialists’ Collaborative Group. Systematic treatment of early breast cancer by hormonal, cytotoxic, or immune therapy. Lancet 1992; 339:1-15; 71-85
(Type I evidence - good systematic review)
ii. NHS Executive. Cancer Guidance of the Sub-group of the Clinical Outcomes Group. Guidance for Purchasers. Improving Outcomes in Breast Cancer: The Manual. London: NHS Executive, Department of Health, 1996
(Type I evidence - good systematic review)
iii. Muss HB. The role of chemotherapy and adjuvant therapy in management of breast cancer in older women. Cancer 1994; 74 (4) : 2105-2171
(Type III evidence - well designed other trials)
iv. Early Breast Cancer Trialists’ Collaborative Group. Early Breast Cancer Trialists’ Collaborative Group (EBCTCG) overview of multi-agent chemotherapy in early breast cancer (Protocol). In : The Cochrane Library, Issue 3,1998. Oxford: Update Software
(Type I evidence - systematic review in progress)
v. Review Group comment (see inside front cover)
3.4f. There is no evidence that immunotherapy is beneficial in the treatment of breast cancer. i
A review of all randomised trials of immunotherapy versus no such adjuvant treatment is in progress. ii
(Health gain notation - 4 "unknown")
i. NHS Executive. Cancer Guidance of the Sub-group of the Clinical Outcomes Group. Guidance for Purchasers. Improving Outcomes in Breast Cancer: The Manual. London: NHS Executive, Department of Health, 1996
(Type V evidence - expert opinion)
ii. Early Breast Cancer Trialists’ Collaborative Group. Early Breast Cancer Trialists’ Collaborative Group (EBCTCG) overview of immunotherapy in early breast cancer (Protocol). Cochrane Library, 1998, Issue 3 Oxford: Update Software
(Type I evidence – systematic review in progress)
3.4g. There are no benefits from ovarian ablation for women over 50 years, but in women aged under 50 years recurrence-free survival rates increase (45.0 vs 39.0%, 2p=0.0007). 15-year survival improved (52.4 vs 46.1%, 2p=0.001), with 6.3 (standard deviation, 2.3) fewer deaths per 100 women.i
(Health gain notation - 1 "beneficial")
i. Early Breast Cancer Trialists’ Collaborative Group. Ovarian ablation in early breast cancer: overview of the randomised trials. Lancet 1996 348: 1189- 96
(Type I evidence - systematic review of 3456 women in 12 randomised controlled trials)
3.4h. Some years of adjuvant tamoxifen treatment can improve the 10 year survival and reduce recurrence rates in women with oestrogen-receptor protein (ER) positive and untested tumours. The proportional recurrence reduction during 10 years of follow-up with 5 years of tamoxifen was 47% (standard deviation, 3%) . The corresponding proportional mortality reduction was 26% (standard deviation, 4%). The benefits appear to be largely irrespective of age, menopausal status, daily tamoxifen dose and use of adjuvant chemotherapy.i
(Health gain notation - 1 "beneficial")
caveat: An assessment of whether chemotherapy adds to the benefits of tamoxifen in different settings will be the subject of a future report by the Trialists’ Collaborative Group.
i. Early Breast Cancer Trialists’ Collaborative Group. Tamoxifen for early breast cancer: an overview of the randomised trials. Lancet 1998; 351: 1451-67
(Type I evidence - systematic review of well designed randomised controlled trials including 37,000 women in 55 RCTs)

 

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3.4i. Current evidence suggests that patients require more than 2 years of tamoxifen therapy but the optimum duration is not yet known. Both the adverse and protective long- term effects are likely to be greater with extended treatment.i
(Health gain notation - 4"unknown")
caveat: There are ongoing UK and worldwide trials in progress.
i. Early Breast Cancer Trialists’ Collaborative Group. Tamoxifen for early breast cancer: an overview of the randomised trials. Lancet 1998; 351: 1451-67
(Type I evidence - systematic review of well designed randomised controlled trials)
3.4j. There is no evidence that tamoxifen is effective for pre-menopausal women with oestrogen receptor negative tumours.i
(Health gain notation -4 " unknown")
i. Early Breast Cancer Trialists’ Collaborative Group. Tamoxifen for early breast cancer: an overview of the randomised trials. Lancet 1998; 351: 1451-67
(Type I evidence - systematic review of well designed randomised controlled trials including 37,000 women in 55 RCTs)
3.4k. A proportion of patients with metastatic disease benefit from systemic therapy in terms of tumour regression and/or improved quality of life. However there are no randomised controlled trials using control groups which did not receive chemotherapy. i There is evidence that polychemotherapy decreases mortality compared to single agent treatment. ii
(Health gain notation -3 ""trade off between beneficial and adverse effects")
i. NHS Executive. Cancer Guidance of the Sub-group of the Clinical Outcomes Group. Guidance for Purchasers. Improving Outcomes in Breast Cancer: The Evidence. London: NHS Executive, Department of Health, 1996
(Type V evidence -expert opinion)
ii. NHS Executive. Cancer Guidance of the Sub-group of the Clinical Outcomes Group. Guidance for Purchasers. Improving Outcomes in Breast Cancer: The Evidence. London: NHS Executive, Department of Health, 1996
(Type II evidence -randomised controlled trials)

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3.5 CONTINUING CARE

3.5a. There is no evidence that routine intensive hospital follow-up, apart from regular mammography, improves outcomes after primary treatment when compared with General Practitioner led follow-up with ready access to specialist care. i, ii
(Health gain notation -5 "unlikely to be beneficial")
i. Nuffield Institute for Health, University of Leeds & NHS Centre for Reviews and Dissemination, University of York. The Management of Primary Breast Cancer. Effective Health Care 1996: 2(6) : 1-16
(Type V evidence - expert opinion)
http://www.york.ac.uk/inst/crd/ehc26.htm
ii. NHS Executive. Cancer Guidance of the Sub-Group of the Clinical Outcomes Group. Guidance for Purchasers. Improving Outcomes in Breast Cancer: The Manual. London: NHS Executive, Department of Health, 1996
(Type V evidence - expert opinion)
3.5b. The risk of local recurrence and primary cancer in the other breast are greater in treated breast cancer patients than the general population. As this risk is greatest in the first few years after surgery it is appropriate that mammography should be repeated yearly for the first five years and every two years thereafter. i,ii
(Health gain notation - 2 "likely to be beneficial")
i. Nuffield Institute for Health, University of Leeds & NHS Centre for Reviews and Dissemination, University of York. The Management of Primary Breast Cancer. Effective Health Care 1996: 2(6) : 1-16
(Type V evidence - expert opinion)
http://www.york.ac.uk/inst/crd/ehc26.htm
ii. NHS Executive. Cancer Guidance Sub - Group of the Clinical Outcomes Group. Guidance for Purchasers. Improving Outcomes in Breast Cancer: The Manual. London: NHS Executive, Department of Health, 1996
(Type V evidence - expert opinion)
3.5c. Patients benefit in terms of quality of life if they have access to a breast care nurse for at least a year after surgery. i
(Health gain notation -2 "likely to be beneficial")
i. McArdle JMC, George WD, McArdle CS et al. Psychological support for patients undergoing breast cancer surgery: a randomised study. British Medical Journal 1996; 312: 813-7
(Type II evidence-randomised controlled trial of 272 patients)
3.5d. The management of breast cancer and its outcomes can be improved if care is provided by specialists working in multidisciplinary teams with a sufficient throughput of new cases per year.i
(Health gain notation - 2 "likely to be beneficial")
i. Nuffield Institute for Health, University of Leeds & NHS Centre for Reviews and Dissemination, University of York. The Management of Primary Breast Cancer. Effective Health Care 1996: 2(6) : 1-16
(Type IV evidence - expert opinion based on observational and retrospective studies)
http://www.york.ac.uk/inst/crd/ehc26.htm
3.5e. As soon as a patient is diagnosed as having cancer, every effort must be made to ensure continuity of treatment with access to skilled palliative care where this is required.i,ii
(Health gain notation - 2 "likely to be beneficial")
i Department of Health / Welsh Office. a Policy Framework for Continuing Care Services. Calman-Hine Report. London, Department of Health, 1995.
(Type V evidence - expert opinion)
ii NHS Wales. Cancer Services in Wales. A Report by the Cancer Services Expert Group. Cameron Report. Cardiff: Welsh Office, 1996
(Type V evidence - expert opinion)

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Health Evidence Bulletins: Wales, Duthie Library, UWCM, Cardiff CF14 4XN. e-mail: weightmanal@cardiff.ac.uk