Annelotte van Bommel

34 seen for the indicators reflecting the process of provided care. Over time, all hospitals reached the norm of 90% of patients being discussed in MDT meetings. This demonstrates that a multidisciplinary approach is widely adopted in the Netherlands as is advised by national guidelines. A similar study reported a variety of patients being discussed in anMDTmeeting in Belgium, with improvement from 61.4% in 2003 to 80% in 2006. 7 Although a slight improvement was seen in the time to operation, in 2014 still a number of hospitals were not able to reach the 90% norm of patients undergoing surgical treatment within 5 weeks after diagnosis. It was also shown that a number of factors, such as combining surgical resection with reconstructive surgery, affect this process indicator. Outcome indicators The consistent low rate of tumor-positive margins in patients who underwent breast conserving surgery for invasive breast cancer is remarkable as well as reassuring, since concerns about the rate of incomplete resections were one of the drivers to initiate this clinical audit. Compared to earlier studies in the Netherlands, improvement was observed, although various definitions of margin involvement have been applied over the years, making direct comparison difficult. 17 The NBCA adheres to the current guideline, defining a positive margin for invasive breast cancer as a margin that is more than focally (>4 mm) involved, because this is the cut offwhere re-excision or continuation of treatment with radiotherapy is advised. Altogether, a positive margin rate for invasive breast cancer of 5% in the 4 years’ study period, with no hospital performing significantly worse than the 15% norm was seen. Room for further improvement seems limited. The same applies to the positive margin rate following breast conserving surgery for DCIS. Apart from the quality indicators with a standardized norm, other indicators were designed to explore current patterns of care. Some of these indicators showed large variation between hospitals and its causes and clinical relevance need to be explained. The preoperative use of breast MRI varied from 4% to 85% between hospitals. Routine use of breast MRI in the preoperative setting is discouraged by national guidelines, while MRI is considered to be indicated in patients who receive chemotherapy in a neo-adjuvant context (for patients treated with neo-