Invited Service Review Report: Report on the Breast Surgery Service County Durham and Darlington NHS Foundation Trust

There should be a protocol for patients that no axillary clearance happens without preoperative evidence of nodal involvement, together with clear, informed consent. Specifically:
o If a sentinel node is not identified by whichever localisation technique is used, only a 4-node sample should be undertaken.
o The protocol should reflect the latest evidence.

Until the breast service can offer VAB/VAE inhouse, the Trust should establish referral pathways for patients to receive these investigations at other breast screening centres.

The clinical record review and feedback from some interviewees indicated that certain members of the surgical team may benefit from refreshing their knowledge and skills in areas such as:
o mastectomy (e.g. case A10) and reconstruction
o indications for sentinel lymph node / axillary node clearance (case A16) in modern breast cancer practice
o what action to take when sentinel lymph node identification fails (case A15).

The Trust should consider its responsibilities set out in the Duty of Candour Procedure under Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 20 in the following cases:
o Case A2
o Case A16
o Case A25

The Trust should introduce changes to the format of the breast MDT. Specifically:
o Core participants should have allocated job planned time for MDT preparation.
o Breast care nurses should play a role in screening the MDT list for cases that are not ready for discussion (e.g., where investigations are incomplete) and these cases should be deferred until the next meeting.
o The meeting should have a strictly observed start time. The aim should be to conclude the meeting in three to four hours. Necessary and reliable IT support should be provided to ensure optimum MDT functioning.
o Job plans should enable core members to participate in 75% of MDT meetings and for the entire duration of the MDT for surgical and radiological colleagues. A record of attendance should be formally received by the MDT every six-months and provide an opportunity to discuss any barriers to participation.

The following information should form part of the recorded MDT discussion:
o Breast size, shape and potential surgical options.
o The reasons for the planned surgical intervention.
o Patient comorbidity factors, frailty scoring and, ideally, photographs.
o Accurate recording of the size of cancers and possible DCIS on both mammography and ultrasound, and in proportion to the whole breast size.
o The proportion of the breast that needs to be treated (e.g. 20% volume).
o The appropriateness of neoadjuvant therapy.

The Trust should introduce changes to the leadership of the breast MDT. Specifically:
o There should be a clear distinction between the person/people responsible for the overall MDT process (including governance, data and linkages with regional cancer meetings), and the role of chairing an individual MDT meeting and the person responsible for recording the MDT discussions contemporaneously.
o There should be discussion within the breast team regarding meeting chairing options (including whether one person assumes this responsibility for a fixed term or whether it is shared amongst senior team members on rotation, as part of efforts to strengthen teamworking).
o The MDT Chair will need expert support so that they can contribute to the patient discussion while the Somerset Cancer Register record is completed contemporaneously and agreed by all those in the room.
o There should be a ‘wash-up’ immediately after the MDT meeting, between the Chair and MDT coordinator, to ensure accurate capture of outcomes (and reasons) on Somerset Cancer Register.
o There should be a consistent MDT coordinator whilst transformation of the breast MDT takes place.

Consideration should be given to establishing a dedicated oncoplastic MDT (or a dedicated section within the breast MDT for discussion of oncoplastic patients
o The two new oncoplastic surgeons should work with plastic surgeons, radiologists and oncologists, to develop a pathway for all oncoplastic/reconstruction procedures.

A demand and capacity analysis should be undertaken to inform the required capacity within the Trust to meet patient demand for 2WW one-stop breast clinics. Specifically:
o Investment in staffing (clinical, managerial and administrative), equipment, and estate, is needed to ensure that capacity is commensurate with that needed to meet patient demand.
o Outsourcing and insourcing should be limited to periods of unexpected variability in demand and commissioned on an exception basis (not part of routine clinic provision).
o The allocation of new patients to clinics should be considered, with a view to providing a more equitable distribution of patients to consultant surgeons. This is important to ensure safe and effective care for patients and to avoid overreliance on any one clinician (and related risk to service continuity).
o Emphasis should be given to reducing unnecessary follow up (see recommendation 8), including imaging follow up of fibroadenoma, which is not evidence based and would free up imaging capacity.

The breast service should develop a single Trust-wide policy on the pathway for patients undergoing breast surgery, including on the approach normally taken to day surgery, discharge and follow up.

The breast service should fully embrace PIFU, as part of efforts to personalise outpatient care, avoid unnecessary follow up, and make best use of clinical time. Specifically:
o Most of the breast cancer follow up should be under the PIFU pathway.
o The service should aim to reduce significantly rates of follow up for benign disease.
o A policy should be developed for the follow up required for patients on primary hormone treatment, with the aim of reducing existing follow up rates and requesting repeat ultrasound scans only where there are clinical concerns.

The breast care nurses should be provided with time, resource and a mandate to develop and extend their skillsets. Specifically:
o Opportunities should be explored for breast care nurses in such areas as seeing new patients, PIFU, and end of treatment.
o The breast care nursing team should be supported to develop specialist skills, for example, in genetic testing and around reconstruction.
o The breast care nurses should be regarded as core members of the breast service team and included in meetings relevant to the breast service, as well as in transformation plans.

The breast physician should be supported to provide services that reflect their breadth of expertise, as an integral part of the multidisciplinary team and an independent practitioner. Specifically:
o Providing outpatient clinics for new patients as an independent practitioner.
o Helping to develop the Trust’s breast pain service.
o Contributing to teaching (e.g. of breast care nurses), service development and research.

The breast service should develop a breast abscess pathway, reflecting NICE topic guidance on mastitis and breast abscess (revised 2025) and drawing on existing pathways at other units.

The Trust should engage the network in discussion to ensure the region is following the latest guidelines on neoadjuvant therapy, especially as these are rapidly changing. Indications for primary systemic therapy related to survival benefit were clearly offered to patients but indications related to surgical planning such as down staging to avoid a mastectomy or postponing surgery to allow for genetic testing and discussion of mastectomy and reconstruction were not observed in the review.

Aspirations to align the two CDDFT units with screening centres should be developed into strategic options. Potential benefits include:
o supporting the provision of radiology and helping to build the resilience needed for service continuity.
o improving localisation of difficult to feel / impalpable lesions (instead of relying on skin marking, which is unreliable).
o enabling screening patients diagnosed with breast cancer to receive treatment closer to home.

There should be dedicated quality improvement resource to drive transformation within the breast service. The Associate Director of Operations for the Surgery Care Group has a broad remit. Dedicated quality improvement expertise is required to deliver the level of service improvement required. This could offer a secondment opportunity for someone within the network.

The Trust should develop specialist clinical governance for the breast service. Specifically:
o This should involve the whole MDT and interdisciplinary team, including breast care nurses and other staff involved in providing the breast service.
o There should be focused governance for the oncoplastic surgery service as it becomes established within the Trust.

Team job planning should be undertaken for the breast surgical team, breast physician, and radiologists (including consultant radiographer) to deliver efficient and effective care, taking into consideration the recommendations for change outlined above. All members of the MDT should have the entirety of the MDT meeting in their job plan.

All clinicians should be supported to engage in continuing professional development (CPD) to enable ongoing learning and skills development. Specifically:
o contractual allocation of study leave averages 10 days per year. During the transformation process, all surgeons should demonstrate attendance at breast specific national and regional meetings for at least five days.
o the breast surgical team should reflect as a team on surgical practice identified in this report as outdated (e.g., some axillary clearance surgery) and demonstrate learning from the most up to date evidence.
o Specialist breast relevant CPD should be a feature of individual personal development plans, with reflection and learning.

The Trust should ensure that where outsourcing happens, there are clear protocols for information sharing regarding patient investigations. This will rely on having good communication links between difference providers and clear documentation of findings, reports and procedures.