Annelotte van Bommel

166 reported patient-related risk factors for wound healing problems as an important contra-indication towards advising IBR, while surgical oncologists more frequently underscored oncological contra-indications as reasons to advise against it. The strive for consensus between physicians regarding indications and contra-indications for IBRmay optimize patient counseling and shared decision-making. Moreover, being informed about IBR resulted in a 14 times higher chance to undergo IBR and this stresses the importance for clinicians to informpatients about this treatment option to optimize the decision-making process for surgical breast cancer treatment and IBR ( Chapter 7 ). In addition to themedical and technical considerations, knowledge about the self-perceived quality of life of patients who underwent IBR is important to take into account for both patients and surgeons in their respective decision and advice for or against reconstructive surgery. From a patient perspective, the self- perceived quality of life in relation to IBR was investigated using patient-reported outcome measures (PROMs). A nationwide quality of life survey was conducted in patients who had undergonemastectomy with or without IBR ( Chapter 8 ). Patients who had undergone IBR following mastectomy reported a better quality of life on important psychosocial, sexual and physical well-being domains than patients who had received a conventional mastectomy. Clinical auditing of breast cancer care in the Netherlands: structuring the outer circle The prelude to the institution of the NBCA was the initiative of the National Health Care Inspectorate to query individual hospitals about the rate of tumor positive margins following breast conserving surgery. The publication of the raw data led to much confusion and it proved to be a poor indicator, because the definition of positive margins turnedout tobe interpretedverydifferentlyby the respective institutions. 4 After the first year following the initiation of the NBCA and with the introduction of a clear definitionof a tumor positivemargin, the rateof tumor positivemargins following breast conserving surgery proved to be very lowand for all participating hospitalswell within the confidence interval of the predefined norm. The subsequent publication of the annual results of this indicator and other parameters objectively improved quality of diagnostic work-up and local treatment of breast cancer patients.