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A manifesto for consistent, superior and multidisciplinary breast cancer care

Submitted by on 14 Jul 2017 – 09:15

While Europe boasts of many good breast cancer services, wide inequality exists in quality of treatment across EU countries. Some member states continue to lack access to specialist units. Fatima Cardoso et al., from the European Society for Medical Oncology, call on policymakers to ensure high-quality breast cancer care throughout Europe

 The 2016 deadline for all patients in EU member states to access specialist, multidisciplinary breast cancer units or centres, was missed by most countries, despite numerous resolutions and declarations issued since the year 2000 that called for universal specialist services. This means that many women and some men, do not receive optimal breast cancer care in Europe.

In the year 2000, the European Society of Mastology (EUSOMA), published a position paper ent itled ‘The requirements of a specialist breast unit’, which set out the standards for establishing high-quality breast cancer centres, or units, across Europe. (1)  The paper followed a consensus statement drawn up at the first European Breast Cancer Conference in Florence in 1998. (2)The conference had set up a working group tasked with ‘forging the way ahead for more research and better care in breast cancer’, and highlighted the pivotal role of the dedicated breast cancer unit. The conference demanded that those responsible for organising and funding breast cancer care ensure that all women have access to fully equipped multidisciplinary and multiprofessional breast clinics.

EUSOMA’s definition of a breast unit or centre is worth quoting in full: ‘The place where breast cancer is diagnosed and treated. It has to provide all the services necessary, from genetics and prevention, through the treatment of the primary tumour, to care of advanced disease, palliation and survivorship. The breast centre is generally made up by a cohesive group of dedicated breast cancer specialists working together as a multidisciplinary team with access to all the facilities required to deliver high quality care throughout the breast cancer pathway.’

Further, the guidelines list no fewer than 16 types of professionals that should make up a team, including radiologists, radiographers, pathologists, surgeons, reconstructive surgeons, medical oncologists, radiation oncologists, breast nurses, data managers, geneticists, psychologists and physiotherapists. Note that it is recommended that mammography screening services should be part of or closely located with breast units, partly because of the pivotal role that radiologists play in screening and symptomatic imaging, and also because of the convenience for women of a seamless service.

A key factor for most specialist cancer work is a minimum number of cases needed to ensure that all team members maintain expertise. It is recommended that at least 150 newly diagnosed cases of primary breast cancer are seen each year from a population of about 250,000.

All breast centres must achieve minimum standards for the mandatory quality indicators (3), which are used for benchmarking and certification/accreditation of the breast centres.

By the late 1990s, there was evidence that for optimal care, patients with breast cancer must be treated and cared for by specialist, multidisciplinary teams in dedicated breast units. Reports from the United Kingdom (UK), in particular, and guidelines from the European Society of Surgical Oncology and from the European Union on mammography screening, built on this evidence in recommending specialist units as a priority for breast cancer, as it is a major cancer with many and rapidly changing treatment options, has screening standards, and a wide range of psychosocial impacts.

For this reason, policymakers, advocates and breast cancer professionals have had to make repeated calls for universal implementation. In particular, European Parliament resolutions of 2003 (4) and 2006 (5) included calls on the member states to ‘establish a network of multidisciplinary breast centres’ and to ‘ensure nationwide provision of interdisciplinary breast centres in accordance with EU [European Union] guidelines by 2016’. Written declarations on breast cancer in the EU of 2010 (6) and 2015 (7) called on member states to ensure that all women and men in the European Union have access to treatment in units set up in accordance with the ‘European guidelines for quality assurance in breast cancer screening and diagnosis’, by 2016, including those with advanced breast cancer.

International consensus conferences for early stage (St Gallen Conference) and metastatic (ABC Conference) breast cancer stress multidisciplinary team working as critical to outcomes.

The ‘European guidelines for quality assurance in breast cancer and diagnosis’, currently in a fourth edition (8), included a revision of the EUSOMA paper on the requirements of a specialist breast unit, and in 2013, the EUSOMA updated these guidelines. (9)

The European Commission Initiative on Breast Cancer (ECIBC) is currently developing a comprehensive quality assurance scheme for breast cancer services underpinned by accreditation. (10)

The Florence statement of 1998 was direct in demanding, not requesting, that patients with breast cancer must have care in specialist breast units. This manifesto is a repeat of that demand in the light of more evidence for the superiority of such specialist care and the failure over the past 15 years or so to deliver it to all breast cancer patients in Europe.

There are many good breast cancer services, but there is a wide variation of breast cancer care among and within European countries, and in particular still a lack of access to specialist units as set out in the EUSOMA guidelines.

Some countries do not yet have national cancer plans and networking of cancer units, or may have only recently introduced these.

Wide variations in healthcare systems and professional working can mean that many patients are not treated according to multidisciplinary guidelines, even in high-resource countries that have cancer plans, and even in cancer departments, as there can be national and institutional variability.

In particular, many women are not offered breast conserving surgery despite being good candidates for that procedure, partly due to lack of radiotherapy equipment, and also because of lack of multidisciplinary expertise and adherence to guidelines. There are also variations in the use of adjuvant chemotherapy, hormone therapy and targeted therapy.

Apart from a lack of vital therapy, in particular radiotherapy and certain drugs, there can be a lack of integrated care for often-complex advanced breast cancer, and lack of ancillary services that add much to quality of life such as specialist breast nurses, psycho-oncologists, patient support groups, physiotherapists, among others.

The wide range of shortcomings for care of metastatic breast cancer patients is detailed in the largest report so far on this growing number of patients, ‘Global status of advanced/metastatic breast cancer: 2005 e 2015 decade report’ (11), which includes several European countries in its surveys.

We call on policymakers and politicians to ensure, as soon as possible, that all women and men with breast cancer in Europe are treated in a specialist breast unit.

To do this, we ask that policymakers and politicians, together with healthcare professionals and patient advocates:

– Promote, in public and professional settings, the evidence that breast units staffed with specialist multidisciplinary teams deliver superior care and quality of life to women and men with breast cancer.

– Acknowledge the evidence that treatment in multidisciplinary units lead to overall cost savings as well as higher quality of care.

– Audit the current national provision of breast cancer care using accredited auditors.

– Implement mandatory reimbursement and care models that mean treatment can only be carried out in specialist breast units.

– Introduce a breast unit quality certification scheme that is accredited by an accreditation body.

– Join European-wide scientific societies and groups that promote the availability and quality of breast units, and together commit to providing access to such units for all patients.

We hope this manifesto and supporting evidence will encourage policymakers, health professionals and advocates to investigate their own national and local provision of specialist breast units and the tools and criteria currently in use for developing consistent, high-quality breast cancer care.

Apart from the imperative to care for all breast cancer patients in specialist units, according to our call to action, it is important that thorough European-wide research is carried out to quantify and qualify the exact provision of breast cancer services in each country so that better comparisons of health systems policy can be made, and more examples of best practice generated.

This article is a shorten revised version of the position paper “European Breast Cancer Conference manifesto on breast centres/units” (EJC 721 (2017) 244-250

Elsevier has approved the preparation of this article. The article was co-authored by Luigi Cataliotti, Alberto Costa, Susan Knox, Lorenza Marotti, Emiel Rutgers, Marc Beishon.


1. EUSOMA. The requirements of a specialist breast unit. Eur JCancer 2000;36:2288e93. http://bit.ly/21sjm33.

2. EUSOMA. Florence statement on breast cancer: forging the way ahead for more research on and better care in breast cancer. 1998.http://bit.ly/1oQhrUI.

3. Rosselli Del Turco M, Ponti A, Bick U, Biganzoli L, Cserni G,Cutuli B, et al. Quality indicators in breast cancer care. Eur J Cancer 2010;46(13):2344e56.

4. European Parliament resolution on breast cancer in the European Union. Text adopted 5 June 2003. http://bit.ly/1QEU860.

5. European Parliament resolution on breast cancer in the enlarged European Union. 18 October 2006. http://bit.ly/1XT0WTu.

6. Declaration of the European Parliament of 5 May 2010 on the fight against breast cancer in the European Union. http://bit.ly/1OFqKva.

7. Written declaration submitted under rule 136 of the rules of procedure on the fight against breast cancer in the European Union. 27 April 2015. http://bit.ly/1zS6aHB.

8. European Commission. European guidelines for quality assurance in breast cancer screening and diagnosis. 2006. http://www.euref.org/european-guidelines.

9. Wilson ARM, Marotti L, Bianchi S, Biganzoli L, Claassen S, Decker T, et al. The requirements of a specialist breast centre. Eur J Cancer 2013;49(17):3579e87. http://bit.ly/1KUKGQ4.

10. See http://ecibc.jrc.ec.europa.eu.

11. Global status of advanced/metastatic breast cancer: 2005-2015 decade report. http://www.breastcancervision.com.