Background

Cancer Australia Statements – Influencing best practice in cancer care reflect Cancer Australia’s commitment to leadership in cancer control.  The purpose of the Statement is to support improved, evidence-informed decisions for cancer care and to engage consumers in their care.  

The Cancer Australia Statements aim to build a knowledge base to drive improvements which reduce unwarranted variations in cancer care and outcomes, maximise clinical benefit, minimise harm and deliver patient-centred care.

Women diagnosed and treated for metastatic breast cancer face many of the same issues as those treated for early breast cancer. However, there can be a number of additional emotional, physical and practical challenges specific to metastatic breast cancer. Issues include managing symptoms of metastatic disease and its treatment, adjusting to living with metastatic breast cancer and coping with concerns about facing an uncertain future.  

Cancer Australia has developed the Cancer Australia Statement – Influencing best practice in metastatic breast cancer that identifies 10 key appropriate and inappropriate metastatic breast cancer practices, to influence and enhance best practice metastatic breast cancer care across the continuum and in the Australian context.

The Cancer Australia Statement – Influencing best practice in metastatic breast cancer was developed through an evidence-informed, collaborative process.

 

Steering Group

Cancer Australia established a Steering Group to provide expert advice on the approach to developing the Statements, informed by key learnings from similar healthcare improvement initiatives, both nationally and internationally.

It was agreed that the following definitions would be applied:

  • an appropriate practice is one that provides patient benefit; is effective (based on valid evidence, including evidence of benefit); efficient (cost-effectiveness); equitable and consistent with the ethical principles and preferences of the individual patient;

  • an inappropriate practice is one that may cause harm or provides little benefit to patients and may be frequently misused in clinical practice. It is a practice that does not meet the requirements for an appropriate practice.

 

Metastatic Breast Cancer Expert Group

A Metastatic Breast Cancer Expert Group (Expert Group) was convened to provide specialist input and advice on the selection of appropriate and inappropriate metastatic breast cancer practices for the Statement.  

The membership included representatives from: 

  • Breast Cancer Network Australia

  • BreastSurgANZ

  • Cancer Australia Breast Cancer Advisory Group.

  • Cancer Nurses Society of Australia

  • Clinical Oncology Society of Australia

  • Medical Oncology Group of Australia

  • Royal Australian & New Zealand College of Radiologists (Radiology & Radiation Oncology)

  • Royal Australian College of General Practitioners

  • Royal College of Pathologists of Australasia.

 

Meta-list and shortlisting of key practices

A meta-list of potential metastatic breast cancer practices was developed by Cancer Australia based on relevant national and international guidelines, college recommendations and position statements. Additional practices were also nominated by the Expert Group. 

Criteria for inclusion of potential practices in the meta-list were: 

  • Is there evidence to support the appropriateness or inappropriateness of the practice?

  • Is there evidence of unwarranted variation in practice at the population level that is unexplained by patient characteristics?

  • Is the practice measurable?

  • Is the practice consistent with clinical guidelines, clinical college position statements or Cochrane review recommendations?

  • Is the relevant professional group supportive of, and committed to, promoting the practice?

Criteria for prioritising the selection of key candidate practices included the following considerations:

  • Is the practice inequitable across patient populations?

  • Is the practice highly valued but underused or not consistently used?

  • Is there evidence of clear and meaningful benefit to specific patient populations?

  • Does the practice allow for consideration of patient preferences and personal values?

  • Does the practice enhance safety and minimise harm?

  • Does the practice have a high potential positive/negative impact on health/costs/equity of access?

  • Is there a cost-effective alternative?

  • Does the practice concern conditions with a high disease burden?

From the meta-list, a short list of key candidate practices was agreed by the Expert Group by consensus, informed by the inclusion and prioritisation criteria.

 

Supporting evidence and assessment of practices

For each practice candidate shortlisted by the Expert Group, national and international cancer organisations and guidelines were searched to assess the alignment and consistency of the practice with clinical guidelines, college position statements or recommendations. 

Cancer Australia developed evidence summaries for the shortlisted candidate practices that identified evidence to March 2019 to support the practice and to assess against the prioritisation criteria. Search strategies were developed for each practice and included key search terms specific to each practice. PubMed and the Cochrane Library were searched using the search strategy to identify high level evidence, where available. Input on available evidence, including evidence on unwarranted variation in practice, was sought from Expert Group members, other experts and from organisations such as Breast Cancer Network Australia. Stakeholders also provided feedback on the short-listed candidate practices. 

The evidence summaries included high level evidence such as systematic reviews, meta-analyses and prospective studies, and Australian data where available. The evidence for each candidate practice was assessed against the prioritisation criteria to guide and inform the final selection of key appropriate and inappropriate practices.

The final list of 10 key practices for metastatic breast cancer was agreed in July 2019 with input from the Expert Group and informed by consideration of the prioritisation criteria.  Key stakeholders also provided feedback and support.

 

Expert review and stakeholder input

The Expert Group included representatives of relevant colleges and organisations. Expert input and advice on the selection, final wording and supporting text for the 10 key appropriate and inappropriate metastatic breast cancer practices was provided by the Expert Group.

Input and support on the 10 key practices was also sought from key stakeholders, including directly from colleges and organisations, and from additional stakeholders:

  • Australian College of Rural & Remote Medicine

  • Breast Cancer Network Australia

  • BreastSurgANZ

  • Cancer Nurses Society of Australia

  • Clinical Oncology Society of Australia

  • McGrath Foundation

  • Medical Oncology Group of Australia

  • Royal Australian & New Zealand College of Radiologists (Radiology & Radiation Oncology)

  • Royal Australian College of General Practitioners

  • Royal College of Pathologists of Australasia.

Input was also provided by the Cancer Australia Statement Steering Group and Cancer Australia’s Breast Cancer Advisory Group.

The Statement was endorsed by Cancer Australia’s Advisory Council.

The Cancer Australia Statement – Influencing best practice in metastatic breast cancer was finalised and released in October 2019.