Annelotte van Bommel

12 use of immediate breast reconstruction across the Netherlands. In addition, the increasing use of systemic therapy in the neo-adjuvant setting andmore extensive radiotherapy following breast conserving surgery as well as after mastectomy are to be addressed in a national audit to understand variation in treatment patterns over time or between hospitals. The ultimate treatment goals in breast cancer care are to improve survival and the quality of life of patients. The risk of life-threatening short-term treatment- related complications is very low and long-term prognosis is very good in patients diagnosed with primary breast cancer. Therefore, there is an increasing interest in patient-reported outcome measures (PROMs) as a means to better understand the effects of the disease and its treatment on the quality of life as perceived by patients. For example, esthetic outcomes after breast cancer surgery and breast reconstruction are undoubtedly important from a patient perspective and should therefore also be considered by clinicians together with patients in the decision- making process. The aims of this thesis were to describe the nationwide implementation of clinical auditing of breast cancer treatment in the Netherlands, to investigate the hospital variation of (reconstructive) surgical breast cancer care, and to identify factors which may reduce the variation found and may optimize the use of breast reconstructive surgery. This is outlined in the following chapters: - The institution of the NBCA, the initially used quality indicators and the results of the first four years of nationwide clinical auditing are reported in Chapter 2 . - The evolution of meaningful quality indicators is an ongoing process. The NBCA traditionally used the quality indicator “proportion of patients undergoing breast conserving surgery” as cosmetic outcome of breast cancer surgery, however, other treatment modalities may contribute to a favorable cosmetic outcome as well. Chapter 3 describes the development of a quality indicator that comprises all efforts to preserve or restore the breast contour: Breast-contour-preserving procedure (BCPP).