Monitoring evolving breast cancer care: reconstructive surgery, radiotherapy and gene profiling

Kay Schreuder

Research output: ThesisPhD Thesis - Research UT, graduation UT

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Breast cancer is the most common cause of cancer among women worldwide and is responsible for over one million of the approximately 10 million cancers diagnosed yearly.

The last fifteen years are characterized by many refinements of diagnostic test and treatment modalities. In this thesis, variation in the use of three novel test or treatment modalities and the adherence to changed recommendations in the guideline were assessed in daily practice. This thesis addressed the use of an immediate breast reconstruction, radiotherapy and gene-expression profiles.

Immediate breast reconstruction
Variation in the use of an immediate breast reconstruction was observed between hospitals in the Netherlands. After annihilating the intended variation by case-mix correction for these factors, the remaining unintended variation could be attributed to hospital factors such as hospital type and number of plastic surgeons available in the hospital. Furthermore, it was demonstrated that the decision to offer an immediate breast reconstruction was affected by multiple factors weighed differently by surgical oncologists and plastic surgeons involved.

An increase in utilization rate of radiotherapy was observed in the Netherlands and was specifically associated by the finding that more patients underwent radiotherapy after mastectomy. Variation in a radiation boost was observed between institutions. Different patient- and tumour- related factors affected the use of a boost and logistic regression analysis revealed that substantial institutional variation remained that could not be explained by differences in patient, tumour or predefined institutional characteristics. Following the implementation of a national guideline for boost use in patients with invasive cancers, the use and variation of administered boost decreased for invasive breast cancer, but remained unchanged for Ductal Carcinoma in Situ.

Gene-expression profile
Variation in relation to a prevailing guideline was observed for the use of a gene-expression profiling in Dutch hospitals. In 2014 nearly half of all patients for whom gene-expression profiles are considered worthwhile received a gene-expression profile. Gene-expression profiles were applied both inside and outside the guideline directed area and gene-expression profile test result yields to lower use of chemotherapy.

Insight in the variation in breast cancer care between Dutch hospitals and the identification of unintended variation is important. Transparency regarding existing variance may help to reduce the bandwidth of the variation and ultimately improve breast cancer care.
Original languageEnglish
QualificationDoctor of Philosophy
Awarding Institution
  • University of Twente
  • Siesling, Sabine, Supervisor
  • Struikmans, Henk, Supervisor, External person
  • van Dalen, Thijs, Supervisor, External person
Award date6 Jul 2018
Place of PublicationEnschede
Print ISBNs978-90-365-4531-0
Publication statusPublished - 6 Jul 2018


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