Quality Of Breast Cancer Care Research Articles

Muddy Water? Variation in Reporting Receipt of Breast Cancer Radiation Therapy by Population-Based Tumor Registries

To evaluate, in the setting of breast cancer, the accuracy of registry radiation therapy (RT) coding compared with the gold standard of Medicare claims. Using Surveillance, Epidemiology, and End Results (SEER)-Medicare data, we identified 73,077 patients aged ≥66 years diagnosed with breast cancer in the period 2001-2007. Underascertainment (1 - sensitivity), sensitivity, specificity, κ, and χ(2) were calculated for RT receipt determined by registry data versus claims. Multivariate logistic regression characterized patient, treatment, and geographic factors associated with underascertainment of RT. Findings in the SEER-Medicare registries were compared with three non-SEER registries (Florida, New York, and Texas). In the SEER-Medicare registries, 41.6% (n=30,386) of patients received RT according to registry coding, versus 49.3% (n=36,047) according to Medicare claims (P<.001). Underascertainment of RT was more likely if patients resided in a newer SEER registry (odds ratio [OR] 1.70, 95% confidence interval [CI] 1.60-1.80; P<.001), rural county (OR 1.34, 95% CI 1.21-1.48; P<.001), or if RT was delayed (OR 1.006/day, 95% CI 1.006-1.007; P<.001). Underascertainment of RT receipt in SEER registries was 18.7% (95% CI 18.6-18.8%), compared with 44.3% (95% CI 44.0-44.5%) in non-SEER registries. Population-based tumor registries are highly variable in ascertainment of RT receipt and should be augmented with other data sources when evaluating quality of breast cancer care. Future work should identify opportunities for the radiation oncology community to partner with registries to improve accuracy of treatment data.

Mediation of the effects of living in extremely poor neighborhoods by health insurance: breast cancer care and survival in California, 1996 to 2011.

BackgroundWe examined the mediating effect of health insurance on poverty-breast cancer care and survival relationships and the moderating effect of poverty on health insurance-breast cancer care and survival relationships in California.MethodsRegistry data for 6,300 women with breast cancer diagnosed between 1996 and 2000 and followed until 2011 on stage at diagnosis, surgeries, adjuvant treatments and survival were analyzed. Socioeconomic data were obtained for residences from the 2000 census to categorize neighborhoods: high poverty (30% or more poor), middle poverty (5%-29% poor) and low poverty (less than 5% poor). Primary payers or health insurers were Medicaid, Medicare, private or uninsured.ResultsEvidence of survival mediation was observed for women with node negative breast cancer. The apparent effect of poverty disappeared in the presence of Medicare or private health insurance. Women who were so insured were advantaged on 8-year survival compared to the uninsured or those insured by Medicaid (OR = 1.89). Evidence of payer moderation by poverty was also observed for women with node negative breast cancer. The survival advantaging effect of Medicare or private insurance was stronger in low poverty (OR = 1.81) than it was in middle poverty (OR = 1.57) or in high poverty neighborhoods (OR = 1.16). This same pattern of mediated and moderated effects was also observed for early stage at diagnosis, shorter waits for adjuvant radiation therapy and for the receipt of sentinel lymph node biopsies. These findings are consistent with the theory that more facilitative social and economic capital is available in low poverty neighborhoods, where women with breast cancer may be better able to absorb the indirect and direct, but uncovered, costs of care. As for treatments, main protective effects as well as moderator effects indicative of protection, particularly in high poverty neighborhoods were observed for women with private health insurance.ConclusionsAmerica’s multi-tiered health insurance system mediates the quality of breast cancer care. The system is inequitable and unjust as it advantages the well insured and the well to do. Recent health care reforms ought to be enacted in ways that are consistent with their federal legislative intent, that high quality health care be truly available to all.

How to Improve Breast Cancer Care Measurement and Reporting: Suggestions from a Complex Urban Hospital

Increasing scrutiny of clinical data reporting by healthcare accrediting organizations is challenging hospitals to improve measurement and reporting, especially in the area of cancer care. We sought to explore barriers to breast cancer adjuvant treatment measurement and reporting to a hospital tumor registry (TR) and to identify opportunities to improve these processes. We conducted 31 key informant interviews with administrators and clinicians associated with a large urban hospital that treats a high volume of breast cancer patients. In this setting, up to 40 percent of early-stage breast cancer cases are treated by community-based oncologists, but reporting to the hospital's TR has been problematic. We asked about barriers to treatment measurement and reporting and sought suggestions to improve these processes. We used deductive and inductive methods to analyze interview transcripts. We found seven management barriers to adjuvant treatment measurement and reporting: process complexity, limited understanding of TR reporting, competing priorities, resource needs, communications issues, lack of supporting information technologies (IT), and mistrust of management. The four facilitators of measurement and reporting we noted were increasing awareness, improving communications and relationships, enhancing IT, and promoting the value of measurement and reporting. Four factors deemed critical to successful improvements were organizational commitment, leadership support, resources, and communication. Organizations striving to improve cancer care quality must overcome key barriers, especially those involving gaps in understanding and communication. In practice, hospitals should make explicit efforts to educate physicians and administrators about the importance of treatment reporting and to improve communications between the hospital's TR and physicians to ensure that needed adjuvant therapies are appropriately delivered.

Standardizing quality breast cancer care throughout all New York university facilities.

160 Background: NYU physicians provide breast cancer care (BCC) at several locations throughout New York. The NYU Clinical Cancer Center (NYUCCC) is a private, university-based facility while Bellevue and Woodhull Hospitals are city hospitals. The diversity of BCC provided to patients (pts) in city hospitals can vary greatly from that of private centers and intra-center physician variability also diversifies care. This variability can impact on pt satisfaction and outcomes. Breast cancer (Br Ca) pts make up the greatest number of pts seen and treated at all NYU affiliated sites, therefore, a "Br Ca Quality of Care Program" will be incorporated into the electronic medical record (EMR) at all facilities. A treatment algorithm based on the pt’s stage and a simple "drop-down menus" will simplify use. It will encompass diagnostic imaging, pathology, biopsy procedures, surgery, radiation, chemo, and hormonal therapy as well as survivorship guidelines for maintaining wellness. Methods: Leaders of each Br Ca program have identified potential barriers to care and rectifiable issues. Algorithms and “drop down menus” in the EMR will be presented to the NYUCCC Br Ca physicians for feedback. This tool will then be refined and launched at NYUCCC. After evaluating this program at NYUCCC, the data will be presented to the all NYUCCC faculty. Achieving the city hospitals to adopt this EMR program will be the ultimate success and standardized quality care will be the result. Results: An assessment of the endpoints of physician adherence to guidelines, cost effectiveness and pt/provider satisfaction will be conducted 6 months later. Random audits of breast cancer pt charts will evaluate provider compliance. A cost analysis of this care will be done and compared to a random sampling of previously treated pt charts. Review and analysis of this data would be presented to the NYUCCC faculty, then programs launched at both city-hospitals. Conclusions: If the endpoints of quality standardized care, cost effectiveness and pt/provider satisfaction are met, incorporation of similar programs into other high volume oncologic disease entities seen at all NYU facilities would be developed.

Brustkrebszentren in Nordrhein-Westfalen – Fallzahlentwicklung 2004–2010

To improve quality of breast cancer care, in 2004 the state of North Rhine-Westphalia (NRW), Germany, began to appoint 51 breast cancer centres. These centres comprise 91 hospitals performing breast cancer surgery which have - amongst other things - to fulfill minimum volume standards. The aim of our study was to analyse if the intended regionalisation of care from 252 hospitals performing breast cancer surgery formerly to the appointed hospitals had taken place by the year 2010. We used data for the years 2004-2010 from the agency for quality assurance in North Rhine-Westphalia concerning breast cancer care and analysed trends concerning the number of hospitals performing breast cancer surgery, case volumes, and achievement of minimum volume standards by performing descriptive and inferential statistics. Between 2004 and 2010 the number of breast cancer cases increased by 36.6% from 12 975 to 17 724 cases (p<0.001, Wilcoxon test). Simultaneously, the number of hospitals performing breast cancer surgery decreased from 252 to 208 whereby more than double the number of planned hospitals still performed breast cancer surgery. The case volumes of the 71 appointed hospitals for which we had individual data over the entire period of time increased by 49.4% from 8 103 cases in year 2004 to 12 105 cases in 2010. Assuming that case volume trends of those 20 appointed hospitals of which we did not have individual data developed uniformly to all other appointed hospitals, the proportion of cases that were operated in not appointed hospitals decreased from 20% in year 2004 to 12.5% in 2010 (p<0.001, χ2 test). Simultaneously, the proportion of cases that were operated in hospitals not achieving minimum volume standards decreased from 42.7% in year 2004 to 12.1% in 2010 (p<0.001, χ2 test). The establishment of breast cancer centres in NRW regionalised breast cancer surgery. In fact, in 2010 breast cancer surgery still took place in more than 100 not appointed hospitals. However, these hospitals were responsible for only a small proportion of breast cancer surgery.

Breast cancer patients' rights: How can they be respected in Iran?

81 Background: The revolutionary concept in breast cancer diagnosis and treatment has significantly changed many aspects of cancer treatment in favor of patients' rights. The best useful targeted treatment is offered to them with the least harm and invasion. As the most common cancer, breast cancer incidence is 24/100, 000 or one-fourth of all new cancers. The aim of this study is to compare the international rights for breast cancer patients with actual situation in Iran. Methods: All published data in Iran are reviewed since 2001 to 2012 to see the actual care in Iran. Codification of new radiology, surgical and pathologic procedure and insurance coverage are searched through available national references. These data are compared with international references. Results: Diagnosis is done by excisional/incisional biopsy or frozen section. Trucut biopsy is done in a low minority of cases. Insurance system does not cover vacuum assisted biopsy. Only mastectomy and axillary dissection are accepted by insurance. No codification exists for conservative surgery, oncoplastic surgery and sentinel node biopsy and the rate for these surgeries are low. Breast reconstruction, conservative surgery as bilateral mammoreduction, and symmetrization of controlateral breast are considered as cosmetic surgery with no coverage. The majority of cases are treated in general surgical wards. There are very few breast nurses and few centers for rehabilitation, lymphedema treatment, and psychological support of survivor. Conclusions: The ministry of health insists on full respection of the patient’s rights in medical practice. The new rights of breast cancer patients based on new treatment strategy are not highlighted in Iran. Valid evidence must be provided for policy makers about the rights of these vulnerable patients to consider them in Iranian health care delivery system. Specialized breast unit can improve significantly the quality of breast cancer care toward the patients' right. Pre-operative confirmation of cancer by trucut biopsy seems to be the key point. This gives the patient the opportunity to know more about the disease and to search for the best therapeutic plan according to international guideline.

Patient Navigation and the Quality of Breast Cancer Care: An Analysis of the Breast Cancer Care Quality Indicators

Patient navigation programs are initiated to help guide patients through barriers in a complex cancer care system. We sought to analyze the impact of our patient navigator program on the adherence to specific Breast Cancer Care Quality Indicators (BCCQI). A retrospective cohort of patients with stage I-III breast cancer seen the calendar year prior to the initiation of the patient navigation program were compared with patients treated in the ensuing two calendar years. Quality indicators deemed appropriate for analysis were those associated with overcoming barriers to treatment and those associated with providing health education and improving patient decision-making. A total of 134 consecutive patients between January 1, 2006 and December 31, 2006 and 234 consecutive patients between January 1, 2008 and December 31, 2009 were evaluated for compliance with the BCCQI. There was no significant difference in the mean age or race/ethnic distribution of the study population. In all ten BCCQI evaluated, there was improvement in the percentage of patients in compliance from pre and post implementation of a patient navigator program (range 2.5-27.0 %). Overall, compliance with BCCQI improved from 74.1 to 95.5 % (p < 0.0001). Indicators associated with informed decision-making and patient preference achieved statistical significance, while only completion axillary node dissection in sentinel node-positive biopsies in the process of treatment achieved statistical significance. The implementation of a patient navigator program improved breast cancer care as measured by BCCQI. The impact on disease-free and overall survival remains to be determined.

Participation in adjuvant clinical breast cancer trials: Is there a difference in survival compared to guideline adherent adjuvant treatment? A retrospective multicenter cohort study of 5,326 patients.

1082 Background: Clinical trials (CT) usually compare a standard treatment regime versus innovative new substances or regimens. However participation in CT is available for only few patients and exclusion criteria is usually very strict. Therefore this study tries to answer the following questions: (1) Does participation in adjuvant CT improve survival in breast cancer (BC)? (2) Is there a difference in survival compared to guideline adherence and what is the role of the other treatments surrounding adjuvant breast cancer treatment? Methods: This German multi-center [17 participating hospitals all are certified as breast cancer centers] retrospective cohort study called BRENDA (BRENDA = quality of breast cancer care under evidence-based guidelines) included 5326 patients obtained from 1992 until 2005. The definition of guideline adherence was based on the German national S3 guideline for diagnosis and treatment of breast cancer (2004). Results: 554 (10,4%) patients participated adjuvant clinical trials and 4772 (89,6%) not. There was a trend towards a significantly impaired RFS [p=0.17; HR=0.87 (95% CI: 0.71-1.06)] and OAS [p=0.65; HR=0.84 (95% CI: 0.65-1.09)] when comparing participants (PA) versus non-participants (NPA). When stratifying for guideline adherence (compared to PA-guideline conform in all adjuvant therapies) the outcome was not different in NPA-guideline adherent [RFS: p=0.13; HR=1.25 (95% CI: 0.94-1.67)] [OAS: p=0.83; HR=1.41 (95% CI: 0.96-2.06)]. However survival parameters were significantly impaired in non-guideline conform PA [RFS: p=0.005; HR=1.66 (95% CI: 1.16-2.38)] [OAS: p=0.01; HR=1.83 (95% CI: 1.15-2.92)] and non-guideline conform NPA [RFS: p&gt;0,001; HR=1.70 (95% CI: 1.27-2.26)] [OAS: p=0.002; HR=1.82 (95% CI: 1.24-2.67)]. Conclusions: There is a strong association between guideline adherence in adjuvant treatment in BC and survival. PA in clinical trials trended to an improved survival, but only if guideline adherent treatment was applied. Patients who don`t have access to clinical seem to profit substantially of guideline adherent adjuvant treatment.

Quality of breast cancer care: perception versus practice.

Because insurers use performance and quality metrics to inform reimbursement, identifying remediable causes of poor-quality cancer care is imperative. We undertook this descriptive cohort study to assess key predictors of women's perceived quality of their breast cancer care and actual guideline-concordant quality of care received. We surveyed inner-city women with newly diagnosed and surgically treated early-stage breast cancer requiring adjuvant treatment who were enrolled onto a randomized controlled trial (RCT) of patient assistance to reduce disparities in care. We assessed women's perceived quality of care and perceived quality of the process of getting care, such as getting referrals, test results, and treatments; we abstracted records to determine the actual quality of care. Of the 374 new patients with early-stage breast cancer enrolled onto the RCT, only a slight majority of women (55%) perceived their quality of care as excellent; 88% actually received good-quality, guideline-concordant care. Excellent perceived quality (P < .001) was significantly associated with patients' perception of the quality of the process of getting care (adjusted relative risk [RR], 1.78; 95% CI, 1.65 to 1.87). Also associated with perceived quality-and mediated by race-were trust in one's physician (adjusted RR, 1.43; 95% CI, 1.16 to 1.64) and perceived racism, which affected black women more than women of other races/ethnicities (black race-adjusted RR for perceived racism, 0.33 [95% CI, 0.10 to 0.87]; black race-adjusted RR for trust, 1.61 [95% CI, 0.97 to 1.90]; c = 0.82 for the model; P < .001). Actual quality of care provided did not affect perceived quality of care received. Patients' perceived quality of care differs from their receipt of high-quality care. Mutable targets to improve perceived quality of care include the processes of getting care and trusting their physician.

Breast care nurse. A new specialist in the multidisciplinary care of breast cancer patients

The uniform European structure and professional standards for high quality breast cancer care were established in conjunction with the European Organisation for Research and Treatment, the European Society of Mastology and the European Breast Cancer Coalition with the support of the European Parliament. Well-prepared professional teams including a new member called the breast care nurse serve as ground for special breast cancer centers with international accreditation that provide modern, evidence based, patient centered multidisciplinary oncological care. The responsibilities of the new qualified professional staff member include the psycho-social support of the patient and carers from the moment of diagnosis throughout the whole oncological treatment, the fostering of delivering information and communication between patients and specialists. As a result of the curriculum founded by the European Oncology Nursing Society, breast care nurses have become key members of the practice of holistic breast cancer care in countries where the European recommendations have already been implemented. Considering the expected rearrangement of national oncological care, the new sub-specialty is outlined for the first time in the light of the experiences gained at the National Institute of Oncology, Budapest, a comprehensive cancer center.

Multidisciplinary breast centres in Germany: a review and update of quality assurance through benchmarking and certification

PurposeThis review summarizes the rationale for the creation of breast centres and discusses the studies conducted in Germany to obtain proof of principle for a voluntary, external benchmarking programme and proof of concept for third-party dual certification of breast centres and their mandatory quality management systems to the German Cancer Society (DKG) and German Society of Senology (DGS) Requirements of Breast Centres and ISO 9001 or similar. In addition, we report the most recent data on benchmarking and certification of breast centres in Germany.MethodsReview and summary of pertinent publications. Literature searches to identify additional relevant studies. Updates from the DKG/DGS programmes.Results and conclusionsImprovements in surrogate parameters as represented by structural and process quality indicators suggest that outcome quality is improving. The voluntary benchmarking programme has gained wide acceptance among DKG/DGS-certified breast centres. This is evidenced by early results from one of the largest studies in multidisciplinary cancer services research, initiated by the DKG and DGS to implement certified breast centres. The goal of establishing a nationwide network of certified breast centres in Germany can be considered largely achieved. Nonetheless the network still needs to be improved, and there is potential for optimization along the chain of care from mammography screening, interventional diagnosis and treatment through to follow-up. Specialization, guideline-concordant procedures as well as certification and recertification of breast centres remain essential to achieve further improvements in quality of breast cancer care and to stabilize and enhance the nationwide provision of high-quality breast cancer care.

Improving Breast Cancer Outcomes among Women in China: Practices, Knowledge, and Attitudes Related to Breast Cancer Screening

Background. Breast cancer is a major public health issue and the most commonly diagnosed cancer for women worldwide. Despite lower incidence rates than those living in Western countries, breast cancer incidence among Chinese women has increased dramatically in the past 20 years. Nevertheless, there is a paucity of studies reporting the attitudes toward and practices of breast cancer screening among Chinese women. Methods. This cross-sectional study examined the practices, knowledge, and attitudes toward breast cancer screening (BCS) on a convenience sample of 400 Chinese women. Results. Among study participants, 75% of the women never had a mammogram and the top three barriers reported were low priority, feeling OK, and lack of awareness/knowledge toward breast cancer screening. The results from the logistic regression model showed increased self-efficacy; having performed monthly self-exams, and having had clinical breast exams in the past two years were significant correlates while demographic variables were not correlated with screening behaviors. Conclusion. The findings provide a foundation to better understand beliefs and practices of Chinese women toward BCS and highlight the critical need for general public, health professionals, and the health care system to work collaboratively toward improving the quality of breast cancer care in this population.

P1-11-10: Quality of Breast Cancer Care in a Boston Area Patient Navigator Program.

Abstract Background: Elimination of disparities is critically important for lessening the burden of cancer. Patient navigator programs (PNPs) assist with all aspects of care, including access, cancer prevention, screening, post-diagnosis care, and survivorship care. Little is known about the effect of PNPs on patient care and outcomes following the diagnosis of breast cancer (BC). We examined quality measures (QMs) of breast cancer care among women participating in the Massachusetts General Hospital Avon Breast Care Patient Navigator Program (MABCP), which provides patient navigation services to disadvantaged minority communities in the greater Boston area. Methods: Women diagnosed with BC who participated in the MABCP from 2001 to 2011 were followed to determine the proportion whose care was concordant with American Society of Clinical Oncology/National Comprehensive Cancer Network (ASCO/NCCN) QMs. QMs included 1) hormonal therapy (HT) within 1 year of diagnosis for HR+ tumors &amp;gt; 1 cm; 2)chemotherapy within 120 days of diagnosis of HR- &amp;gt;1cm tumors for women &amp;lt;70 years; and 3) post-lumpectomy radiation therapy (XRT). Descriptive statistics were used to report characteristics of MABCP patients. Results: Of the 186 MABCP patients diagnosed with BC, some treatment data was available on 158 (85%) and race/stage information was available on 149 (80%) [Table 1]. Among the MABCP patients, concordant care was received by 70/74 (95%) for the HT QM, 15/17 (88%) for the chemotherapy QM, and 65/71 (92%) for the XRT QM. In comparison, available benchmark concordance rates of BC patients treated at 8 NCCN centers from 2003–6 are: 340/382 (89%) for the HT QM, 156/179 (87%) for the chemotherapy QM, and 141/148 (95%) for the XRT QM. Conclusions: Overall, breast cancer care in the MABCP PNP is concordant with published ASCO/NCCN quality measures. At present, the sample is insufficient to compare concordance rates with NCCN patients but preliminarily, it appears that the quality of care is comparable. Future research should include prospective analyses of quality metrics to assess the process and outcomes of patient navigation in diverse settings, compared with control populations. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P1-11-10.

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.

Time interval as a quality measure: What is our baseline prior to nurse navigator implementation?

208 Background: There are various outcome measures to evaluate the quality of multidisciplinary care for breast cancer patients. The National Consortium of Breast Centers defines quality of breast cancer care as accurate evaluation and appropriate services in a timely manner. In a tertiary academic center a diverse referral pattern possibly influences time to treatment. We choose to examine two outcome measures before the start of a nurse navigator: Time from initial diagnosis to first consultation and if the pretreatment consultation for those receiving neoadjuvant chemotherapy or hormonal therapy included all subspecialists. Methods: Electronic medical records of female patients with breast cancer seen during January-June 2010 were reviewed. Patients with stage IV breast cancer were excluded. Results: 150 patients were divided into 4 categories: external pathology consult (B1), internally diagnosed with a primary care physician (PCP) at our institution (B2), evaluated by a surgical oncologist before the biopsy (B3), and internally diagnosed with PCP outside of the institution (B4). For B2, B3 and B4 we examined the time intervals to first surgical oncology appointment after diagnosis as shown in the table. For all patients (n=10) who received neoadjuvant therapy, 1 patient saw a surgical oncologist, medical oncologist and radiation oncologist, 9 patients saw 2 subspecialties prior to initiation of first treatment. Conclusions: Patients are seen within an average of 2 weeks whether they are diagnosed internally (B2, B3) or externally (B4). The group seen by a surgical oncologist prior to biopsy (B3) were seen sooner. For the patients receiving neoadjuvant therapy, 10% saw all 3 specialties prior to initiation of therapy. In July 2010 a nurse navigator was added to the care team. With this new position, our goal is to decrease the time from biopsy to visit by 33% and have 100% of patients receiving neoadjuvant therapy evaluated by all 3 specialists prior to treatment. Our intent is to quantify the effect of a nurse navigator in a large academic center as a quality metric in improving care. [Table: see text]

District-level variations in the quality of mortality data in thailand

Different studies on variations of cause-specific mortality provide different policy implications and suggestions. Some findings mirror existing health care and services. Costantini and others (2000) concluded that differences in proportions of cancer patients dying at home across 13 provinces in Italy could not be explained by the known determinants, suggesting inappropriate hospital admission in the terminal phase of cancer. A study on geographical variations in breast cancer mortality in older American women by Goodwin and others (2002) suggested ways to improve the quality of breast cancer care. Some studies suggest further research in specific areas.

Can We Measure the Quality of Breast Surgical Care?

Many studies have demonstrated gaps in healthcare quality for all medical and surgical specialties including breast surgical care. How to optimally measure and improve quality has generated debate at the local, state, and national level. Attempts to judge medical performance by private companies using non-risk-adjusted administrative databases may not be accurate and may unfairly penalize surgical care. An overview of concepts to measure and improve quality of breast cancer care is presented with specific examples relevant to breast surgeons. Breast surgeons and their professional organizations need to take ownership of quality measure programs because others will surely do so if we do not. Participation in one or more of these programs is beneficial because peer performance comparison allows identification of potential areas for individual or institutional improvement and demonstrates the commitment of breast surgeons to quality improvement. This commitment may gain even greater importance if trends continue toward performance-based physician payment, patient steerage, licensure, and board certification.

Assessing the quality of breast cancer care in cancer center hospitals in Japan.

e16566 Background: Breast cancer is the most frequently occurring cancer among women in Japan and in many parts of the world. Advances in breast cancer care are expected to reduce the burden of the disease. To do so, however, the currently available knowledge must be applied to patients by their primary providers. We aimed to examine the current status of the quality of breast cancer care in community cancer center hospitals in Japan. Methods: A panel of multidisciplinary experts developed 43 process-of-care quality indicators based on clinical practice guidelines and the medical literature. Each quality indicator described target patients and the standards of care these patients should receive. We applied these quality indicators to the care provided to a cohort of patients diagnosed with breast cancer at the 17 participating cancer care hospitals in 2008 using medical record abstraction. Results: The care provided to a total of 1,051 breast cancer patients was examined. Overall, 76% of care processes were provided as indicated. Although many quality indicators appeared reasonably satisfied (e.g., trastuzumab for lymph node-positive patients, 96%, and hormone receptor test, 97%), we identified significant room for improvement in some areas of care. Patient explanation generally appeared insufficient; 37% of mastectomy patients received information on reconstruction surgery, and 54% of surgical patients were informed of both sentinel lymph node biopsy and lymph node dissection. Among patients with “2+” results in the HER-2 immunohistochemistry test, 64% were evaluated using fluorescence in situ hybridization. Patients who underwent breast-conserving surgery received radiation therapy 70% of the time. Type three 5-hydroxytryptamine (5-HT3) receptor antagonists were prescribed along with a highly emetic regimen 96% of the time, whereas steroids were prescribed 79% of the time. We also revealed a variation in quality across hospitals. Conclusions: There is room for improvement in the quality of breast cancer care provided in community cancer center hospitals. Systematic efforts to continuously monitor quality focusing on the identified gaps in care are necessary to improve breast cancer care in Japan.

Enhancing the quality of care for patients with breast cancer: Seven years of experience with a Dutch auditing system

Background Hospitals in the Midwestern part of the Netherlands carried out a clinical audit to monitor the quality of breast cancer care during the years 2002–2008. Compliance with the National Guideline was investigated together with improvement in quality over time. Methods Patients with a malignancy of the breast (including ductal carcinoma in situ) participated in this study. Nine quality indicators were evaluated over the years. In 2004 and 2005 the hospitals also carried out an intervention project aimed at improvement of the efficiency of both the diagnostic process and the surgical treatment. Results At the end of the project all nine indicators showed significant improvement compared to the start of the project. Discussion of treatment strategy in a multidisciplinary breast cancer team took place more often before surgery (83% versus 56%) as well as after surgery (98% versus 70%). The National Guideline for maximum waiting times was met more often for the outpatient clinic (74% versus 61%), time to diagnosis (92% versus 82%), and surgical treatment (52% versus 34%). More sentinel node procedures were performed successfully (92% versus 69%), and for more patients more than 10 lymph nodes were evaluated in case of axillary lymph node dissection (85% versus 58%). More patients had definitive surgical treatment consisting of one surgical intervention (87% versus 75%), and left the hospital within 7 days after hospital admission (98% versus 66%). Conclusion The clinical audit contributed to improvement of the quality of breast cancer care in the Midwestern part of the Netherlands between 2002 and 2008.

Adopting Guidelines into Clinical Practice: Implementation of Trastuzumab in the Adjuvant Treatment of Breast Cancer in Lower Saxony, Germany, in 2007

Background: Few studies have assessed the quality of medical care in breast cancer patients outside clinical studies and certified centres in German-speaking countries. We used ONkeyLINE, a voluntary tumour registry, to evaluate the rate of adoption into clinical practice of guidelines on the adjuvant use of trastuzumab and to estimate the reliability of ONkeyLINE in assessing quality of care. Material and Methods: Data from ONkeyLINE were analysed to answer questions on the quality of breast cancer care in daily practice in 2007. The influence of age and area (rural/urban) on treatment patterns was also evaluated. Results: Data from approximately 85% of patients diagnosed with breast cancer in Lower Saxony in 2007 were documented in ONkeyLINE. Within 1 year, more than 77% of patients received adjuvant trastuzumab according to the updated guidelines. Variations in chemotherapy and trastuzumab according to age were evident, in part but not fully attributable to comorbidities in the elderly. Access to trastuzumab therapy in rural areas was as high as in urban areas. Conclusions: Adoption of national guidelines into clinical practice was observed at a reasonable but still unsatisfactory rate in Lower Saxony. Although voluntary, ONkeyLINE covered most breast cancer cases and proved to be a reliable tool for assessing quality of care.