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By systematic review we found no studies evaluating implementation of breast cancer management guidelines [ 23], and only two studies evaluating implementation for colorectal cancer management guidelines [ 24].
Greater specialisation in the management of breast cancer, with the formation of multidisciplinary teams, gradually followed the implementation of breast screening 10 12 years ago.
The successful implementation of breast screening (Forrest, 1986) over the period 1989 1991 exposed a contrast between well-planned arrangements for screen-detected disease and the variability of symptomatic services.
In the early nineties, meta-analyses of the randomised controlled trials (RCTs) confirmed the efficacy of mammographic screening for reducing primary breast cancer mortality, and led to the implementation of breast screening programmes in several regions of Europe.
External quality assurance is established through three measures: first, certification/accreditation of the pathologies according to DIN EN ISO 9001; second, implementation of breast cancer specific quality circles, and third, pathologists' participation in the German interlaboratory trials.
Although not yet clinically established, it is hoped that identification of common risk variants may eventually allow identification of women at higher risk of breast cancer and enable implementation of breast cancer screening, prevention or treatment strategies that provide clinical benefit.
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This further facilitated the implementation of breast-conserving surgery in clinical practice.
The introduction of a new surgical technique requires a process of quality-controlled implementation (preferably by treating patients in prospective studies) in order not to jeopardise, but to improve the level of care gained by the ALND, as has been achieved by the implementation of breast-conserving surgery [ 4].
According to the main challenges related to breast cancer diagnosis and treatment herein presented, we propose a realistic framework that would allow for the implementation of a breast cancer care program, built under a strong network based on cooperation, teaching, audit, good practices and the organization of health services.
Computer implementation of familial breast cancer guidelines is more likely therefore to have a positive effect.
17 20 32 Esserman et al proposed three hypothetical scenarios after implementation of a breast cancer screening programme in the overall population, independent of age.
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