Annelotte van Bommel

171 General discussion and future perspectives data revealed that MRI-scanning increased the number of mastectomies for ductal carcinomas, but decreased the mastectomy rate for lobular cancers. 16 The opposite was found after neo-adjuvant chemotherapy, with decreasedmastectomy rates for ductal carcinomas, but not for lobular carcinomas. 17 With evidence-based medicine as cornerstone for initiation of guidelines, this practice-based evidence of observed variation provides feedback on actual performances and strengthens the national guidelines (structuring the outer circle, Figure 1 ). These results show the delicate balance and weighing of audit results in terms of addressing quality of care, and demonstrate the importance of clear and uniform guidelines. Then again, it is not a goal in itself to eradicate all variation and set norms, because variation may also help us to explore new practice patterns and to learn from each other. Strengthening the inner circle: the role of Patient-Reported Outcomes Mea- sures (PROMs) The need for incorporating PROMs inmultidisciplinary registries such as the NBCA was called for by patients shortly after the initiation of the NBCA. Adding items that reflect the effects of their disease and its treatment on quality of life enhances the quality overview that the NBCA can deliver for an institution. In addition, the consequences of side-effects of local and systemic treatment, re-interventions, and complications such as breast implant removal or revision due to infection or capsular contracture on patients’ psychosocial or sexual well-being, body-image and other quality of life domains may be evaluated. The additional value of registering PROMs within the context of the NBCA speaks for itself.More important thanassessingoutcomes usingPROMs onanational level is their use in the intimacy of the doctors’ office where information regarding other patients’ experienceswith certain treatments and self-perceived quality of lifemay better guide shared treatment decisions for the individual patient. Also, PROMsmay beusedduring a patient journey or treatment to compare their quality of life with earlier evaluation moments or with other patients within a similar time frame during an identical treatment. By doing so, this information leads to a greater insight in the effect of the 9