Annelotte van Bommel

170 Figure 2. Funnel plot of variation between hospitals in the percentage of patients diagnosed with invasive breast cancer and with a standardized pathology report. The 95% confidence intervals are displayed around the standard (90%). In close cooperation with the stakeholders, proper definitions of standards, statistical limitations of data analysis, thorough exploration and interpretation of results are responsibilities of the Clinical Audit Board that accompany its task to publish annual NBCA results. Within theNBCA, not only quality indicators with clear standards aremonitored, but also data are collected regarding the care of all involved disciplines. Much variation is observed in this data and the observed variationmay reflect better or innovative care. Inmany cases the reasons of this variation and a possible association with quality of care are unclear. In that perspective, variation of IBR was extensively investigated in this thesis while others have studied the use of neo-adjuvant chemotherapy 14 , radiotherapy 12 and the use of Magnetic Resonance Imaging (MRI)-scanning in the work-up of breast cancer. Current guidelines advise to use MRI-scanning in case of discrepancy between clinical examination and radiology results in patients with lobular carcinoma or high grade ductal carcinoma in situ (DCIS) with an indication for breast conserving surgery, 15 but there is not a clear standard for its use and this lack of consensus is reflected in the observed use of MRI-scanning. Evaluation of NBCA A D B C Hospital Mean Standard90% 95%Cl Percentage of patients with standard pathology report including information about estrogen receptor percentage, progesterone receptor percentage, HER2, grade, tumor size, resection margin and number of positive lymph nodes Number of patients with a pathology report of invasive breast cancer at least 1cm without neo-adjuvant therapy (2013)