Quality control in breast cancer surgery

Quality assurance is the process by which quality care can be assessed. The general principles include setting a standard with the aim of achieving particular outcomes, followed by the evaluation of parameters that allow for quality assessment. Locoregional and survival outcomes are the major parameters but require years to evaluate and have other limitations. Other parameters therefore may assist in evaluation, such as the availability of the structures and processes required to achieve desired outcomes. Unlike chemotherapy and radiotherapy the quality of surgery is difficult to quantify, yet it is central to the issue of locoregional control and survival. In breast cancer surgery, quality control starts at the diagnostic service; from referral by the family practitioner to the appropriate triage of patients thereby preventing diagnostic delays. The surgical oncologist is pivotal in the multidisciplinary input necessary with both radiologists and pathologists in achieving the correct preoperative diagnoses of symptomatic and screen detected lesions as specified by many of the guidelines. Quality control of the operative surgery addresses issues such as training, volume and life audit of the surgeon. Standardisation of operative technique, pathology reporting with emphasis on specimen orientation and margins, management of the axilla and how it impacts on adjuvant treatment are other important issues. More recently, the availability of breast reconstruction services and the development of the oncoplastic surgeon is becoming an important quality issue. Finally, the quality of the follow up process provides the tools to assess the outcome of both the patient and the service.