Breast Cancer Quality Indicators Research Articles

Towards the improvement of breast cancer management based on EUSOMA quality indicators: Insights from a 15-year institutional experience.

e13662 Background: Breast cancer (BC) is the most common female malignancy and the leading cause of cancer-related deaths among women worldwide. Quality indicators (QIs) are evidence-based measures in healthcare used to track and improve patient care. In 2010, the European Society of Breast Cancer Specialists (EUSOMA) identified several quality indicators that could be adopted by breast cancer dedicated institutions. These QIs allow standardized clinical performance and quality assurance for BC care. We assessed the compliance of EUSOMA QIs published in 2017 by the Hospital de los Valles (HDLV), an Ecuadorian private institution, as a tool to assess BC management. This is the first project in Ecuador and South America that evaluates breast cancer quality indicators. The importance of this project is to create a foundation to identify areas for the improvement of breast cancer care in Ecuador. Methods: Women between 20 and 80 years of age with a histopathological diagnosis of BC and surgically treated at HDLV between 2007 and 2022 were included and analyzed in compliance with the updated EUSOMA QIs (2017). Exclusion criteria: male patients, breast cancer cases diagnosed by core biopsy only and without surgical excision, previous chemotherapy exposure. The number of cases meeting each criteria for EUSOMA QIs is expressed as percentages. Results: 137 women with breast cancer were included for analysis. Based on available information and resources, we were able to assess 14 out of the 34 QIs proposed by EUSOMA. Six indicators reached the minimum standard suggested by EUSOMA: 3 out of 7 QIs for diagnosis, 2 out of 3 for surgical and locoregional treatment, and 1 out of 4 for surgical and quality of life. Standards in triple diagnosis, waiting time, and surgical approaches were accomplished, while standards for surgical over-treatment and simultaneous reconstructive surgery did not meet standards. Conclusions: The lack of data about treatment, follow-up, and low access to standardized procedures limited the number of QIs assessed. This study marks a milestone towards continuous BC care improvement and indicates the need for local QIs and their regional implementation.

Breast Cancer Care Quality Indicators in Spain: A Systematic Review.

Breast cancer (BC) management care requires an increment in quality. An initiative to improve the BC quality care is registered, and quality indicators (QIs) are studied. We appraised the appearance of QIs and their standards systematically in Spain. A prospective systematic search (Prospero no: CRD42021228867) for clinical pathways and integrated breast cancer care processes was conducted through databases and the World Wide Web in February 2021. Duplicate data extraction was performed with 98% reviewer agreement. Seventy-four QIs (QI per document mean: 11; standard deviation: 10.59) were found in 15 documents. The Catalonian document had the highest number of QIs (n = 30). No QI appeared in all the documents. There were 9/74 QIs covering structure (12.16%), 53/74 covering process (71.62%), and 12/74 covering outcome (16.22%). A total of 22/66 (33.33%) process and outcome QIs did not set a minimum standard of care. QIs related to primary care, patient satisfaction, and shared decision making were deficient. Most of the documents established a BC QI standard for compliance, but the high variability hinders the comparison of outcomes. Establishing a consensus-based set of QIs needs urgent attention.

Real-world practice patterns in community U.S. oncology practices: A quality improvement approach in HER2-positive breast cancer.

e18196 Background: In breast cancer (BC), quality measures related to care coordination (CC), HER2 testing (testing) and use of HER2-targeted therapy (Tx), provide parameters for assessing care quality. We assessed the influence of quality improvement education (QIE) on alignment with BC quality indicators. Methods: 20 community oncologists participated in an IRB-approved QIE program. At baseline, 200 randomly selected charts of women with HER2+ invasive BC were retrospectively reviewed for adherence to quality measures pertaining to testing, Tx and CC. The cohort participated in accredited QIE activities for developing action plans for improvement. Follow-up chart reviews were completed 6 months after the QIE. Results: Patient and disease characteristics were generally similar across the 2 cohorts. At baseline, documentation of cancer staging was 90%, ECOG functional status assessment was 67% and cardiac testing was 33%. Treatment in the adjuvant setting was most common, followed by neoadjuvant, and metastatic. Documentation of CC varied greatly across specialties, and was highest for primary care physicians. At follow-up, randomly selected charts (n=60 to date) revealed increases in documentation of patient assessments and care coordination. A shift towards increased treatment in the neoadjuvant setting was also observed. Conclusions: QIE interventions that engaged oncology teams showed a positive impact on documentation across several parameters. A complete analysis of follow-up charts (n=200) will be presented. [Table: see text]

Preoperative clinical pathway of breast cancer patients: determinants of compliance with EUSOMA quality indicators

Background:The European Society of Breast Cancer Specialists (EUSOMA) has defined quality indicators for breast cancer (BC). The aim of this study was to describe the preoperative clinical pathway of breast cancer patients and evaluate the determinants of compliance with EUSOMA quality indicators in the Optisoins01 cohort.Methods:Optisoins01 is a prospective, multicentric study. Data from operable BC patients were collected, including results from before surgery to 1 year follow-up. Seven preoperative EUSOMA quality indicators were compared with the clinical pathways Optisoins01.Results:Six hundred and four patients were included. European Society of Breast Cancer Specialists targets were reached for indicator 1 (completeness of clinical and imaging diagnostic work-up), 3 (preoperative definitive diagnosis) and 5 (waiting time). For indicator 8 (multidisciplinary discussion), the minimum standard of 90% of the patients was reached only in general hospitals and comprehensive cancer centres. Having more than 1 medical examination within the centre was associated with an increased waiting time for surgery, whereas it was reduced by having an outpatient breast biopsy. The comprehensive cancer centre type was the only parameter associated with the other quality indicators.Conclusions:European Society of Breast Cancer Specialists quality indicators are a useful tool to evaluate care organisations. This study highlights the need for a standardised and coordinated preoperative clinical pathway.

Using a disease pathway management approach to improve the quality of breast cancer care in Ontario.

109 Background: Disease Pathway Management (DPM) is used by Cancer Care Ontario (CCO) to set priorities for cancer control, plan cancer services, and improve the quality of care in Ontario by promoting standardization. The DPM approach applies a framework to examine the performance of the entire system from prevention to end of life care, and to identify any gaps within the system. In 2014, DPM began its breast cancer pathway initiative by mapping the patient journey, depicting evidence-based best practice along the breast cancer care continuum, identifying where further guidance is needed for clinical decision making, and identifying gaps in quality of care and performance measurement indicators. Objective: To evaluate the impact of DPM on quality assessment of breast cancer care in Ontario. Methods: DPM convened a multidisciplinary breast cancer working group (WG) of 40 experts from across Ontario. The WG held 12 meetings and used guidelines developed by CCO’s Program in Evidence Based Care (or other sources as needed) to generate pathways for the prevention, screening and diagnosis, treatment, and follow-up care for breast cancer. The pathways were used as a framework to review the existing inventory of provincial breast cancer quality indicators, and to identify areas where evidence based guidance is needed. The pathways were subjected to an extensive review process before publication. Results: The expert WG identified 28 priority areas, including opportunities to develop guidance in areas where it is lacking (e.g. role of perioperative breast MRI; indications for contralateral prophylactic mastectomy) and system barriers that may hinder optimal care (e.g. biomarker assessment). The WG also used the pathways as a framework for evaluating performance measurement indicators by mapping 48 existing quality indicators for breast cancer to the pathway. Conclusions: The CCO DPM Breast Cancer pathways facilitated a province-wide, multidisciplinary process to promote quality standards, to identify gaps and overlaps in performance and quality measurement, and to recommend additional indicators more relevant to the quality of breast cancer care in Ontario.

Florida Initiative for Quality Cancer Care: Improvements in Breast Cancer Quality Indicators During a 3-Year Interval

The Florida Initiative for Quality Cancer Care (FIQCC), composed of 11 practice sites across Florida, conducted its initial evaluation of adherence to breast cancer quality of care indicators (QCI) in 2006, with feedback provided to encourage quality improvement efforts at participating sites. In this study, our objective was to reassess changes over time resulting from these efforts. Quality care indicators were derived from the Quality Oncology Practice Initiative, the National Comprehensive Cancer Network, the American College of Surgeons, and expert panel consensus. Medical records were reviewed for breast cancer patients first seen by medical oncologists in 2009 at the FIQCC sites, using the same performance indicators as in 2006. Statistical comparisons of 2006 vs 2009 data across sites were made by Pearson chi-square exact test using Monte Carlo estimation. Charts of 602 patients in 2006 and 636 patients in 2009 were compared. Performance on medical oncology QCI improved over time for documentation of clinical trial participation discussion (p = 0.001), documentation of consent for chemotherapy (p = 0.047), definitive surgery done after neoadjuvant chemotherapy (p = 0.017), and planned dose of chemotherapy consistent with published regimens (p = 0.02). Improvements in surgical QCI were seen for documentation of specimen orientation (p < 0.001), inking of margins (p < 0.0001), and performance of sentinel lymph node biopsy (p = 0.035). The 2006 FIQCC study identified several medical and surgical oncology QCI improvement needs. Quality improvement efforts resulted in better performance for numerous metrics, therefore speaking to the benefits of reassessment of adherence to performance indicators to guide QCI efforts.

Surgeon-Level Variation in Patients’ Appraisals of Their Breast Cancer Treatment Experiences

While variation in breast cancer quality indicators has been studied, to date there have been no studies examining the degree of surgeon-level variation in patient-reported outcomes. The purpose of this study is to examine surgeon-level variation in patient appraisals of their breast cancer care experiences. Survey responses and clinical data from breast cancer patients reported to Detroit and Los Angeles Surveillance, Epidemiology and End Results registries from 6/2005 to 2/2007 were merged with attending surgeon surveys (1,780 patients, 291 surgeons). Primary outcomes were patient reports of access to care, care coordination, and decision satisfaction. Random-effects models examined variation due to individual surgeons for these three outcomes. Mean values on each patient-reported outcome scale were high. The amount of variation attributable to individual surgeons in the unconditional models was low to modest: 5.4% for access to care, 3.3% for care coordination, and 7.5% for decision satisfaction. Few factors were independently associated with patient reports of better access to or coordination of care, but less-acculturated Latina patients had lower decision satisfaction. Patients reported generally positive experiences with their breast cancer treatment, though we found disparities in decision satisfaction. Individual surgeons did not substantively explain the variation in any of the patient-reported outcomes.

An overview of breast medical oncology documentation through the Florida Initiative on Quality Cancer Care (FIQCC): The Phase II 2009 results.

73 Background: Following feedback provided to each site of their 2006 compliance results and enactment of improvement plans, the FIQCC re-evaluated the quality of documentation of specific quality indicators for breast cancer in the medical records of 11 participating FIQCC sites in 2009. Quality indicators were based upon ASCO, ACOS, NCCN, and expert-consensus panel recommendations. The findings were compared with 2006 results. Methods: Chart reviews from the same 2006 FIQCC sites for pre-specified Breast Medical Oncology quality indicators were performed by trained abstractors on patients first seen in 2009. The indicators included: clinical trial decisions, consent for treatment, definitive surgery after neo-adjuvant chemotherapy, published regimen dose plan, and chemotherapy selected from a published list. Statistical comparisons of 2006 and 2009 data were performed using the Pearson chi-square exact test based on Monte Carlo estimation. Results: 636 pts (99% female) [average age of 60.7 years (range 24-94)] were evaluated, with the 2009 number of cases per site ranging from 59 to 97. Significant improvements in treatment planning and administration were seen over time when comparing 2006 (n=602) to 2009 charts. This included signed chemotherapy consent (2006: 74%; 2009: 81% p=0.047), definitive surgery after neo-adjuvant chemotherapy (2006: 88%; 2009:100% p=0.017), and the planned dose being from a published list (2006: 74%;200: 84% p=0.020). Strides were also made in documenting that patients were evaluated for clinical trial enrollment (2006:13%; 2009: 21% p=0.001). Declines were seen in chemotherapy selections from an approved list (2006:94%; 2009: 82% p&lt;0.001). Further investigations into this finding are underway and will be presented at the meeting. Conclusions: With the adoption of specific quality indicators, evaluation of a specified number of cases across multiple practices, and then providing feedback on documentation to providers and medical teams, here we demonstrate that significant improvements in medical charting and thus quality cancer care can be made.

Re-assessment of surgical breast cancer quality indicators by the Florida Initiative for Quality Cancer Care (FIQCC) consortium.

84 Background: In 2006, the FIQCC (comprised of 11 practice sites) initiated a comprehensive review of quality of care specific to breast cancer based on QOPI/NCCN/ACOS and panel consensus quality indicators. Feedback on indicator performance was provided to participating practices in 2007 to encourage quality improvement efforts. Re-assessment of adherence to the same performance indicators was conducted in 2009. Methods: Chart reviews were conducted for breast cancer patients (pts) seen by a medical oncologist at FIQCC sites in 2006(n=602) and 2009(n=636) Quality indicators included: 1) presence/completeness of pathology report; 2) documentation of surgery type; 3) documentation of sentinel lymph node biopsy (SLNB) and if SLNB positive documentation of a complete axillary node dissection; and 4) mammogram usage post surgery. Statistical comparisons of 2006 and 2009 data were performed using the Pearson chi-square exact test based on Monte Carlo estimation. Results: The median age of pts (99% female) was 60 years (range 24-94). Compared to 2006 data, improvements were made in specimen orientation (69%-2006, 78%-2009; p=0.001) and inking of margins (89%-2006, 96%-2009; p=&lt;0.001). In clinical node negative N0 pts, SLNB was performed in 87%, up from 82%-2006 (p=0.035). Of the pts with a metastatic SLNB, 86% went on to have a complete axillary node dissection, but not statistically significant compared to 79% in 2006 (p=0.10). Compliance continues to be highly variable across practice sites with obtaining a mammogram within 14 months of surgery (79%) (p=0.002); but the range narrowed: 26%-98% (2006) and 56%-92% (2009). Significant variances also continued in 2009 across practice sites for margin orientation (p&lt;0.001), inking of the margins (p=0.04), and performance of SLNB (p&lt;0.001). Conclusions: The FIQCC identified quality improvement needs in multiple aspects of breast cancer care. Improvements in margin orientation/inking, use of SLNB and follow-up mammograms after definitive surgery made over the course of this initiative speak to the benefits of continual re-assessment of adherence to performance indicators to guide quality improvement.

Developing and measuring a set of process and outcome indicators for breast cancer

PurposeThis study aimed at developing and measuring a set of indicators to monitor the quality of breast cancer care, to make comparisons over time and to support quality improvement for all practitioners and centres involved in the care of breast cancer women. MethodsQuality indicators were identified from a systematic literature search and the 2010 Belgian evidence-based clinical practice guideline. The selection process involved an expert panel evaluating reliability, relevance, interpretability and actionability of each indicator. The quality indicators were tested using the Belgian Cancer Registry data linked with claims data for all women registered with breast cancer in Belgium between 2001 and 2006 (n = 50,039). ResultsThe selection process led to a final set of 32 indicators. Of these, 12 were measurable using the available data, while 1 indicator was measurable using proxy information. Five-year relative survival was 98%, 87%, 68% and 29% for pStage I, II, III and cStage IV respectively. Overall 5-year survival slightly improved for pStage II, III and cStage IV between 2001 and 2004. Of the surgically treated women, 60% underwent breast conserving surgery, 85% received adjuvant systemic treatment and 86% were irradiated postoperatively. In 80% of women treated for breast cancer, at least one mammography was performed within one year after the last treatment. ConclusionThe present study demonstrates the feasibility to develop a multidisciplinary set of quality indicators for breast cancer. Using national cancer registry data linked to claims data, 13 indicators were measurable, showing results that largely correspond to other studies in the field.

Degree of variability in performance on breast cancer quality indicators: findings from the Florida initiative for quality cancer care.

The Florida Initiative for Quality Cancer Care (FIQCC) comprises 11 Florida practice sites that participate in comprehensive reviews of quality of care specific to patients with cancer. Here, we examined site adherence to performance indicators to assess quality of care for patients with breast cancer (BC). Quality indicators were scripted on the basis of accepted guidelines from the Quality Oncology Practice Initiative, National Comprehensive Cancer Network, American College of Surgeons, and site-specific expert panel consensus. Comprehensive chart reviews, including both medical and surgical oncology quality measures, were conducted for patients with BC first seen in 2006 by a medical oncologist at one of the sites. Statistical comparisons were made by the Pearson χ(2) exact test, using Monte Carlo estimation. Charts of 622 patients were reviewed. Of the 34 indicators, seven for medical oncology and four for surgical oncology fell below the 85% level of adherence. A statistically significant difference (P < .001) in variation of performance across the sites was found for the following medical and surgical oncology indicators: documentation of menopausal status, family history, informed consent, planned chemotherapy regimen and flow sheet, American Joint Committee on Cancer staging, HER2/neu status, reporting of margin orientation and inking of the margins, histological grade, having a sentinel lymph node biopsy for invasive BC, and obtaining a mammogram within 14 months of definitive surgery. The FIQCC has identified how multiple aspects of BC care can be improved. Findings are being used at the participating institutions to guide quality improvement efforts.

Using breast cancer quality indicators in a vulnerable population

Adherence to quality indicators may be especially important to disease-specific outcomes for uninsured, vulnerable patients. The objective of this study was to measure adherence to National Initiative for Cancer Care Quality (NICCQ) breast cancer quality indicators in a public hospital and compare performance to published rates in a previously collected 5-city cohort. One hundred five consecutive, newly diagnosed, stage I-III, breast cancer patients at a public hospital (from 2005 to 2007) were identified. Adherence rates to 31 quality indicators were measured by using medical record abstraction. Rates were calculated for individual indicators, aggregated domains, and components of care and were compared with the 5-city cohort results by using a 2-sided test of proportions. Overall adherence to the NICCQ indicators at the public hospital was 82%, versus 86% in the 5-city cohort. Public hospital adherence was better in 3 domains and components (Management of Treatment Toxicity 95% vs 73%, Referrals 76% vs 15%, and Documentation of Key Clinical Factors 72% vs 64%, P < .05 for all), but it was lower in others (Testing 82% vs 96%, Adjuvant Therapy 76% vs 83%, Surgery 72% vs 86%, Surveillance 63% vs 94%, and Respect for Patient Preferences 52% vs 72%, P < .001 for all). The results showed that it is possible to deliver breast cancer care to vulnerable patients comparable in quality to the care received by the broader population. Further study should identify the factors that lead to variation in adherence across domains of quality.

Improving Breast Cancer Quality of Care with the Use of Patient Navigators

The continuum of breast cancer care requires multidisciplinary efforts. Patient navigators, who perform outreach, coordination, and education, have been shown to improve some areas of care. However, little research has assessed the impact of navigators on breast cancer treatment in uninsured populations. Our objective is to report on the impact of a patient navigator program on breast cancer quality of care at a public hospital. One hundred consecutive newly diagnosed patients with breast cancer (Stages I to III) were identified (2005 to 2007). Forty-nine patients were treated before the use of navigators and 51 after program implementation. Nine breast cancer quality indicators were used to evaluate quality of care. Overall adherence to the quality indicators improved from 69 to 86 per cent with the use of patient navigators (P < 0.01). Only one individual indicator, use of surveillance mammography, improved significantly (52 to 76%, P < 0.05). All nine indicators reached 75 per cent or greater adherence rates after implementation of the navigator program compared with only four before implementation. Patient navigators appear to improve breast cancer quality of care in a public hospital. In populations in which cultural, linguistic, and financial barriers are prevalent, navigator programs can be effective in narrowing the observed gaps in the quality of cancer care.

Surgeon influence on patient appraisal of ASCO breast cancer quality indicators.

6016 Background: There has been no research evaluating provider level variation in patient appraisal of 3 key indicators of quality breast cancer care defined by ASCO: timely access, care coordination, and decision satisfaction. Methods: 3,133 women with nonmetastatic breast cancer diagnosed from 6/05-2/07 and reported to the Detroit and Los Angeles SEER registries were identified and surveyed after diagnosis. Latina and African American (AA) women were oversampled (N=2,268, response rate 72.4%). Patient survey and SEER data were merged with surveys of attending surgeons (N=311). Three multi-item patient-reported scales were adapted from ASCO's national initiative on cancer care quality: 1) timely access to care; 2) perceived care coordination; 3) decision satisfaction. Each continuous outcome (range 1 to 5) was analyzed using hierarchical regression to determine the amount of total variation explained by surgeons. Subsequent stepwise models controlled for patient factors (clinical and demographic), surgeon characteristics (specialization, gender, age), and two novel surgeon practice process measures (multidisciplinary communication scale, patient decision support scale). Results: Mean scores for the 3 outcomes were 4.2, 3.9 and 4.1 for access, coordination, and decision satisfaction. Individual surgeons explained a very small amount of the total variation in patient-reported timely access (4.7%), care coordination (3.8%), and decision satisfaction (1.3%) after controlling for patient factors. Adding surgeon characteristics and practice process measures to the models did not substantially affect between-surgeon variation in any of the outcomes (Table). Conclusions: Patients' appraisals of ASCO-based quality indicators for breast cancer were generally high. There was little surgeon influence on total variation in quality scores after controlling for patient factors. Surgeon practice processes appear to contribute minimally to patient perceptions of these quality measures. Amount of total variation in quality indicators explained by surgeons (%) Controlling for: Access Coordination Decision satisfaction Patient factors 4.7 3.8 1.3 Surgeon characteristics 4.3 2.1 0.6 Practice process measures 4.1 2.4 0.2 No significant financial relationships to disclose.

Medical Oncology Breast Cancer Quality Indicators: Adherence by the Florida Initiative for Quality Cancer Care (FIQCC) Consortium.

Abstract Background: The Florida Initiative for Quality Cancer Care (FIQCC) is comprised of 11 practice sites across the state that participate in a comprehensive review of quality of care specific to cancer patients across many disease sites. Quality indicators were scripted based on accepted QOPI, NCCN, ACOS, and site-specific PI panel consensus indicators for breast cancer (BRCA) patients. An evaluation was performed to assess adherence to the performance indicators across sites within the FIQCC.Methods: Comprehensive chart reviews were conducted for all patients with BRCA first seen in 2006 by a medical oncologist at one of the 11 FIQCC sites (3 academic/8 community). Quality measures included: 1) documentation of menopausal status; 2) documentation of receptor status in the chart and evidence that it guided treatment recommendations accordingly; 3) documentation that consent for chemotherapy was obtained; 4) documentation of the planned chemotherapy regimen; and 5) documentation that chemotherapy started within 8 weeks of surgery. A pilot measure included: 6) documentation of fertility preservation being addressed in pre-menopausal women. Pearson's Chi-square test was used to test variability on the quality measurements across practice sites.Results: Charts of 622 patients (99% female), median age of 60 years (range 22-95) were reviewed. Menopausal status was documented in 49% (307/622). Documentation of the receptor status (ER/PR/ Her2Neu) was excellent, 99% (532/537). For those with ER/PR positive, non-metastatic disease measuring at least 1cm, 98% (432/441) were considered for an aromatase inhibitor or tamoxifen within one year of diagnosis. For patients with Stage II-III BRCA with over-expression of Her2Neu (H2N), consideration or administration of trastuzumab was documented in 82% (95/116). With respect to chemotherapy, there was documentation of consent in 75% (247/330), planned chemotherapy regimen in 75% (226/302), and initiation of chemotherapy with 8 weeks of surgery in 84% (233/279). Fertility preservation was only addressed in 11% (10/88) of patients who were documented as pre-menopausal. A statistically significant difference (p&amp;lt; 0.05) across the sites was found for all quality indicators above, except two: documentation of consideration or administration of trastuzumab and discussions of fertility preservation.Discussion: The FIQCC allows for the identification of the need for quality improvements in multiple aspects of breast cancer care. Findings based on 2006 cases identified need for improvements in documentation and consenting for chemotherapy, reporting of menopausal status, consideration and administration of trastuzumab, and consideration of fertility counseling. These findings are now being used at the participating institutions to guide quality improvement efforts. Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 1078.