Certify it! Breast Cancer Units in Europe

The focus on breast centers in the current issue of Breast Care tries to offer an overview on the efforts of physicians to improve treatment of breast cancer by development and operation of Breast Units in different countries of the European Union. We must conclude that it is still an ongoing effort because every country interprets and implements the guidelines of the European Parliament regarding certification of Breast Units differently [1]. The development of multidisciplinary centers is based on the following premises: 1. Minimum numbers: treatment and diagnosis of many patients with the same disease leads to more experience compared to someone who treats fewer patients. 2. Interdisciplinarity: breast cancer is a complex disease with several aspects that require interdisciplinary work. 3. Diagnosis: breast cancer and its precursor lesions need to be diagnosed as early as possible in order to enable improvement of disease process and survival. 4. Equal opportunities: every patient in Europe should be able to get the same diagnosis and treatment opportunities, independently of the country of origin. Differences and errors can be detected and improved through benchmarking. 5. Control: Breast Units should be developed by specific guidelines and should undergo sporadic controls by independent organizations. Successful audits should be documented by certificates. 6. Costs: quality management and quality control enable better structures, avoid redundancy and lower costs. In some European countries, especially in university centers, the idea of superspecialization and development of centers was introduced as early as the 1970s and 1980s. Examples are the ‘Instituto Nationale dei Tumori’ in Milan, Italy, and its offspring, the European School of Oncology (its leading specialists are Umberto Veronesi and Gianni Bonadonna) and the Breast Center at the Women's University Hospital in Heidelberg, Germany (founder Fred Kubli). For decades, such units have clinicians at work dealing most of the time with benign and malignant breast disease. Early detection, diagnosis and multimodal therapy (imaging and invasive diagnostics, breast surgery, systemic therapy and radiation) are hereby interdisciplinary and under one roof. The term ‘Breast Unit’ is new and the idea of building such centers was pushed in Europe by the work of the consortium EUSOMA (European Society of Mastology), which in 2000 published a manuscript in the European Journal of Cancer (EJC) [2]. In this publication, the preconditions or rather the numbers (i.e. ‘minimum numbers’) were mentioned that are required to develop and build a Breast Unit. Basic data of such an ‘Exemplary Breast Unit based on EUSOMA Criteria’ includes the number of patients diagnosed and treated by surgery and systemic therapy per physician per center [2]. Several details were based on the personal experience and ideas of the authors and a few points were based on scientific data. In the same issue of the EJC, a remarkable editorial was published by M.J. Silverstein [3], a world-famous breast surgeon based in California. Unfortunately, his critique found little acknowledgement back then and still today. It would be worth revisiting his comments and critical questions before analyzing the actual state of breast units 9 years after the publication of both papers: ‘Who should tell the patient that she has breast cancer? – Who should discuss and decide adjuvant therapy? – Must a radiologist do 5,000 mammograms a year? Would 4,000 be sufficient? – Must a surgeon do 50 cases per year? What if he/she does 100, but does them all wrong? – How will new technology, like sentinel node biopsy, be incorporated? Will it be mandated throughout the system? Will some centers use it and others not? – One of my colleagues stated that the major defect with this protocol was that it focused on the structure of a multidisciplinary breast service, but not on the goals. – The document as written calls for protocols for the management of all stages of disease. How will this be done? Consider DCIS as an example. In 1997, a consensus conference regarding the pathology of the disease was held in Philadelphia. No agreement could be reached on a unified classification for the disease. Two years later, a second consensus conference was held, this time to discuss treatment. Again, no uniform agreement could be reached. Because breast cancer is a heterogeneous group of lesions, as the current cliche goes, written protocols for the management of all stages will be extremely challenging.’ When he wrote the editorial, Silverstein was a physician who 20 years before (in 1979) had established and run one of the first breast units in the world in Van Nuys, California and subsequently opened and headed another breast unit at the University of Southern California in 1998. He acknowledged the limitations of implementing the ‘American Breast Units’ in Europe due to differences in professional policies and structure, but you have here the voice of a very experienced person who knows what he is talking about and doesn't mince words. If you want to sum up Silverstein's comments in one sentence: he had apprehensions regarding a rigid theoretical concept that does not realign based on results, in addition to having specific local circumstances not taken into account. The objectives and results should drive the concept and structure, not the other way around. In daily practice every physician sees that the main objective for the patients is overall survival and that to achieve it, they are ready to endure mutilating surgeries, debilitating side effects of therapies, and severe restrictions in quality of life. Nonetheless, physicians often discuss other objectives like the rate of breast conserving surgery, sentinel node biopsy, breast reconstruction and much more. However, these should not be the main focus. Any good and reliable physician who treats patients with breast cancer should keep those objectives in mind. But, the point in question in this issue of Breast Care is how we should proceed in order to reach the objectives and if our system, with the development of breast units, is the answer to the numerous challenges that breast disease brings.