In total, one primary audit standard and six secondary audit standards were derived from the Medway hospital Multidisciplinary Team (MDT) consensus agreement and the reasons for non-conformity to these standards were audited.

Primary audit standard. All patients should have a time to surgery within 28 days of completion of the last cycle of neoadjuvant chemotherapy.

Secondary audit standards. i) All cases should undergo MDT discussion prior to the completion of the last cycle of neoadjuvant chemotherapy; ii) all cases should be added to the surgical waiting list prior to the completion of the last cycle of neoadjuvant chemotherapy; iii) all cases should have surgery <4 weeks following the addition to the waiting list; iv) all cases should have tumour coil insertion prior to the commencement of the first cycle of neoadjuvant chemotherapy; v) all cases should have mid-chemotherapy imaging to assess the tumour response to neoadjuvant chemotherapy; vi) all cases should have post-neoadjuvant chemotherapy imaging to aid in surgical planning.

The time to surgery following the completion of neoadjuvant chemotherapy, the timing of surgical planning multidisciplinary team meeting, the time to addition to the surgical waiting list, tumour coil insertion timing, percentage of cases who had mid-chemotherapy imaging and post-neoadjuvant chemotherapy imaging were audited. The percentage of conformity to the aforementioned standards was calculated and factors contributing to non-conformity were investigated. Data were extracted by the reviewing of existing medical records, clinical letters, radiology reports, laboratory reports and the trust oncology database. All data and records generated during the study were kept secure and confidential in accordance with trust policies on information governance and data protection.

All cases should have surgery ≤28 days following the completion of the last cycle of neoadjuvant chemotherapy. In the present audit, only 14% of patients conformed to this standard. The details of non-conformed cases (86%) are illustrated in Fig. 1.

The causes for delays in time to surgery were adverse events (16%), surgical planning delays in bilateral mastectomy patients (12%), issues related to wire localization in wide local excision cases (37%) and unknown causes (35%). The adverse events noted were side-effects from chemotherapy and persistent symptoms requiring additional imaging to rule out metastasis. In total, three quarters of the non-conformed cases with adverse events (75%) had surgery at ≥6 weeks following the completion of the last cycle of neoadjuvant chemotherapy. Furthermore, 37% of these cases waited >4 weeks on the waiting list, resulting in further delays. The causes for surgical delays in the non-conformed cases are illustrated in Fig. 2.

Time to surgery delays in bilateral mastectomy patients were secondary to the need for multiple patient consultations, such as genetic counselling, genetic testing and to facilitate the patient's informed choice of reconstruction.

The cases with wire localised wide local excision had surgery >6 weeks following the completion of their last cycle of neoadjuvant chemotherapy in 53% of the cases and waited >4 weeks after being added to the waiting list in 79% of cases, resulting in further delays.

For cases undergoing wire guided wide local excision, both a surgical theatre slot and a wire localisation radiology appointment on the day of surgery is a necessity. This is an important contributing factor for non-conformity in the present cohort of patients. Wire localization procedures are only performed by radiologists at Medway Hospital. This issue may have been overcome by dedicated wire localization slots for these high-risk patients. Some hospitals have trained radiographers taking over these lists, offloading already strained consultant-led radiology services.

A total of 35% of the non-conformity cases were due to unknown causes. Over-booked clinics and long surgical waiting lists and communication delays between oncologists and surgeons may have contributed to the delays in these cases.

Achieving the target time to surgery interval of ≤28 days is inter-dependent on other factors, including an efficient multidisciplinary approach and effective waiting list management. Further studies with larger sample sizes are required to provide insight into the ideal time to surgery following the completion of neoadjuvant chemotherapy and its effect on survival outcomes.

All cases should be discussed in surgical planning multidisciplinary meetings prior to the completion of the last cycle of neoadjuvant chemotherapy. Multidisciplinary meetings for surgical planning should be ideally timed close to the completion of the last cycle of chemotherapy. This will facilitate the addition of these cases promptly to the waiting list and reduce time to surgery delays. Mid-treatment multidisciplinary meetings in non-responsive cases provides an opportunity to determine whether surgery is an option. These discussions were usually planned by the oncologists to expedite surgery in these unresponsive cases. The policy is to discuss all neoadjuvant chemotherapy cases in multidisciplinary meetings for surgical planning prior to the completion of the last dose of chemotherapy and mid-treatment multidisciplinary meetings are held for unresponsive cases.

In the present audit, only 25% of the patients conformed to this standard. Out of the 75% non-conforming cases, no multidisciplinary meetings were held for 7% of the cases. These cases were added to the waiting list directly from the clinic. No apparent reason was found in these cases The details of non-conformed cases (75%) are illustrated in Fig. 3

All cases should be added to the waiting list prior to the completion of last cycle of neoadjuvant chemotherapy. Adding these high-risk patients to the waiting list soon after their surgical planning multidisciplinary team meeting and effective waiting list management will reduce the delays in time to surgery. The unit policy is to add all neoadjuvant chemotherapy cases to the waiting list prior to completion of the last cycle for effective patient flow management. This is done in the next available breast clinic by breast surgeons.

In the present audit, only 20% of patients conformed to this standard. The details of non-conformed cases (80%) are illustrated in Fig. 4.

All cases should have surgery <4 weeks after being added to the waiting list. The trust policy is to perform surgery within 4 weeks after being added to the waiting list. Effective waiting list management is a key element in reducing time to surgery delays in this high-risk cohort of patients. This is mainly performed by consultant secretaries and managerial staff. Good communication is crucial for optimal outcomes. Maintaining pooled surgical consultant waiting list and dedicated wire localisation slots for neoadjuvant chemotherapy cases may reduce time to surgery delays.

In the present audit, only 66% of patients conformed to this standard; 34% of non-conformity cases were due to oversubscribed surgical waiting lists and issues related to overbooked wire localisation lists. Some of these non-conformity cases also had delays being added to the waiting list, which further contributed to the delays in time to surgery with on obvious reason. These results are illustrated in Fig. 5.

The results of the present audit revealed very poor conformity with the audit standards. Multidisciplinary coordination appears to be the means with which to improve the conformity to the standards for better patient outcomes of these high-risk patients. These results were discussed in the Medway hospital NHS trust audit and clinical governance meeting and MDT recommendations were drawn to achieve the target of time to surgery of ≤28 days.

All cases should have tumour coil insertion before the commencement of the first cycle of NAC. Conformity to this standard was 36%.

All cases should have mid-chemotherapy imaging to assess the tumour response Conformity to this standard was 98%.

All cases should have post-NAC imaging to aid surgical planning. Conformity to this standard was 30%.

Medical oncologists need to ensure that coil insertion is performed prior to the commencement of chemotherapy, mid-chemotherapy imaging is performed to assess the tumour response and imaging is performed following the penultimate cycle of neoadjuvant chemotherapy; multidisciplinary meetings should also be booked following the treatment scan results in order to aid surgical planning in collaboration with radiologists and breast surgeons.

Breast surgeons need to ensure the addition to the waiting list following surgical planning multidisciplinary meetings. Pooled waiting lists for all consultants may be helpful for reducing the surgical waiting time to <28 days. Radiologists also need to ensure dedicated slots on wire localization lists to reduce further delays. The results of the present audit were discouraging. Recommendations were drawn with the aim of re-auditing following the implementation of the changes agreed upon by the MDT.

In conclusion, achieving a time to surgery of <28 days following the completion of neoadjuvant chemotherapy is a complex and challenging process, which is inter-dependent on a variety of factors. An effective multidisciplinary approach with efficient patient flow management and prioritising high-risk patients is necessary to achieve this target. The team efforts of oncologists, radiologists and breast surgeons will help to overcome the challenges involved and to provide improved patient care.