Open Access Open Badges Research article

Compliance with clinical practice guidelines for breast cancer treatment: a population-based study of quality-of-care indicators in Italy

Carlotta Sacerdote16*, Rita Bordon2, Sabina Pitarella2, Maria Piera Mano2, Ileana Baldi1, Denise Casella2, Daniela Di Cuonzo1, Alfonso Frigerio3, Luisella Milanesio3, Franco Merletti1, Eva Pagano1, Fulvio Ricceri4, Stefano Rosso2, Nereo Segnan2, Mariano Tomatis2, Giovannino Ciccone1, Paolo Vineis45 and Antonio Ponti2

Author Affiliations

1 Cancer Epidemiology Unit, San Giovanni Battista Hospital, CPO Piemonte and University of Turin, Turin, Italy

2 Cancer Epidemiology Unit, San Giovanni Battista Hospital, CPO Piemonte, Turin, Italy

3 Screening Centre, Department of Cancer Prevention, San Giovanni Battista Hospital, CPO Piemonte, Turin, Italy

4 HuGeF Foundation, Via Nizza 52, 10126, Torino, Italy

5 Department of Epidemiology and Biostatistics, School of Public Health, Imperial College, London, UK

6 Cancer Epidemiology Unit, San Giovanni Battista Hospital, Via Santena 7, 10129, Torino, Italy

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BMC Health Services Research 2013, 13:28  doi:10.1186/1472-6963-13-28

Published: 25 January 2013



It has been documented that variations exist in breast cancer treatment despite wide dissemination of clinical practice guidelines. The aim of this population-based study was to evaluate the impact of regional guidelines (Piedmont guidelines, PGL) for breast cancer diagnosis and treatment on quality-of-care indicators in the Northwestern Italian region of Piedmont.


We included two samples of women aged 50–69 years with incident breast cancer treated in Piedmont before and after the introduction of PGL: 600 in 2002 (pre-PGL) and 621 in 2004 (post-PGL). Patients were randomly selected among all incident breast cancer cases identified through the hospital discharge records database. We extracted clinical data on breast cancer cases from medical charts and ascertained vital status through linkage with town offices. We assessed compliance with 14 quality-of-care indicators from PGL recommendations, before and after their introduction in clinical practice.


Among patients with invasive lesions, 77.1% (N = 368) and 77.5% (N = 383) in the pre-PGL and post-PGL groups, respectively, received breast conservative surgery (BCS) as a first-line treatment. Following BCS, 87.7% received radiotherapy in 2002, compared to 87.9% in 2004. Of all patients at medium-to-high risk of distant metastasis, 65.5% (N = 268) and 63.6% (N = 252) received chemotherapy in 2002 and in 2004, respectively. Among the 117 patients with invasive lesions and negative estrogen receptor status in 2002, hormonal therapy was prescribed in 23 of them (19.6%). The incorrect prescription of hormonal therapy decreased to 10.8% (N = 10) among the 92 estrogen receptor-negative patients in 2004 (p < 0.01).

Compliance with PGL recommendations was already high in the pre-PGL group, although some quality-of-care indicators did not reach the standard. In the pre/post analysis, 8 out of 14 quality-of-care indicators showed an improvement from 2002 to 2004, but only 4 out of 14 reached statistical significance. We did not find any change in the risk of mortality in the post-PGL versus the pre-PGL group (adjusted hazard ratio 0.94, 95%CI 0.56–1.56).


These results highlight the need to continue to improve breast cancer care and to measure adherence to PGL.

Breast cancer; Guideline adherence; Population-based; Evidence-based medicine; Quality of care