Defining the quality of surgical breast cancer care

In Part 1 of this thesis, we focus on various aspects of the implementation of SNB as an innovative method in axillary staging. The Dutch national guideline on SNB was released in 1999.8 Chapter 2 provides an overview of SNB implementation over the period 1998 – 2003 in the Netherlands. Patient and tumour characteristics that are associated with the procedure of SNB are described, and region-specific patterns of introduction are visualised. To aid the implementation, seven hospitals in the Utrecht region (formerly known as CCCMN) jointly developed local sentinel node protocols. Not all hospitals had a nuclear department and pathology laboratory on site, so tailored procedures were needed. Treatment results for all hospitals were monitored through a registration study coordinated by CCCMN. The results are presented in Chapter 3. Sentinel nodes generally are more thoroughly examined than lymph nodes from a complete axillary dissection. As pathologists receive only a few lymph nodes for investigation, standard dissection of nodes evolved into serial sectioning with immunohistochemistry staining, with potential increase of diagnosing small deposits of tumour metastases (between 0.2 and 2 mm) or even isolated tumour cells (single cells or small clusters of cells