Quality Assurance Report
TTUHSC Breast Center of Excellence
January 1, 2011 – December 31, 2011
Compiled by Lynn Day, RN BSN CCM CCRP
Stage Distribution
Total Number of Patients = 107
Time
Frame
Stage 0
Stage I
Stage II
Stage III
Stage IV
Stage
Unassigned
Total
Jan – Jun
12
(22.22%)
22
(40.74%)
11
(20.37%)
4
(7.41%)
0
(0%)
5
(9.26%)
54
(100%)
Jul - Dec
8
(15.09%)
19
(35.85%)
10
(18.87%)
2
(3.77)
0
(0%)
14
(26.42%)
53
(100%)
Jan-Dec
20
(18.69%)
41
(38.32%)
21
(19.63%)
6
(5.61%)
0
(0%)
19
(17.76%)
107
(100%)
Compiled by Lynn Day, RN BSN CCM CCRP
Mode of Diagnosis
Total Number of Patients = 107
Time Frame
Stage 0
Stage I
Stage II
Stage III
Stage IV
Stage
Unassigned
Total
Jan – Jun
Preoperative
Core
11
(20.37%)
22
(40.74%)
10
(18.52%)
4
(7.41%)
0
(0%)
5
(9.26%)
52
(96.3%)
Jul – Dec
Preoperative
Core
6
(11.32%)
19
(35.85%)
10
(18.87%)
2
(3.77%)
0
(0%)
13
(24.53%)
50
Jan-Dec
Preoperative
Core
17
(15.88%)
41
(38.32%)
20
(18.69%)
6
(5.61%)
0
(0%)
18
(16.82%)
95.33% of patients had diagnosis established on preoperative
core needle biopsy
Exceptions – discordant core biopsy
Compiled by Lynn Day, RN BSN CCM CCRP
(94.34%)
102
(95.33%)
Tumor Board Discussion
Total Number of Patients = 107
Time
Frame
Stage 0
Stage I
Stage II
Stage III
Stage IV
Stage
Unassigned
Total
Jan – Jun
Discussed
6/6
(50.0%)
13/22
9/11
(81.82)
4/4
(100%)
0
(0%)
4/5
(80%)
36/54
(66.67%)
Jul – Dec
Discussed
4/8
(50.0%)
9/10
(90.0%)
2/2
(100%)
0
(0%)
11/14
(78.57%)
40/53
(75.47%)
Jan-Dec
Discussed
10/20
(50.0%)
18/21
(85.71)
6/6
(100%)
0
(0%)
15/19
(78.95%)
76/107
(71.03%)
(59.09%)
14/19
(73.68%)
27/41
(65.85%)
71.03% of patients were discussed prospectively in the
multidisciplinary tumor conference
Compiled by Lynn Day, RN BSN CCM CCRP
Multidisciplinary Assessment
(Surgical, Medical and Radiation Oncologist)
Total Number of Patients = 107
Time
Frame
Stage 0
Stage I
Stage II
Stage III
Stage IV
Stage
Unassigned
Total
11/11
(100%)
3/4
(75%)
0
(0%)
1/5
(20%)
43/54
(79.63%)
(73.68%)
7/10
(70.0%)
2/2
(100%)
0
(0%)
7/14
(50.0%)
35/53
(66.04%)
34/41
18/21
5/6
(82.93%
(85.71%)
(83.33%)
0
(0%)
8/19
(42.11%)
78/107
(72.9%)
Jan – Jun
MDC seen
8/12
20/22
(66.67%)
(90.91%)
Jul – Dec
MDC seen
5/8
(62.5%)
14/19
Jan-Dec
MDC seen
13/20
(65.0%)
Exceptions
29/107 (27.1%)
•No radiation oncology evaluation (mast./ high-risk)
•No documentation in the chart
•Patient non-compliance
•Continuing chemotherapy
16/29 (55.17%)
5/29 (17.24%)
5/29 (17.24%)
3/29 (10.34%)
Compiled by Lynn Day, RN BSN CCM CCRP
Nurse Navigation
Total Number of Patients = 107
Time Frame
Stage 0
Stage I
Stage II
Stage III
Stage IV
Stage
Unassigned
Total
Jan – Jun
Assigned
10/12
(83.33%)
22/22
(100%)
11/11
(100%)
4/4
(100%)
0
(0%)
2/5
(40%)
49/54
(90.74%)
2/2
(100%)
0
(0%)
12/14
(85.71%)
47/53
(88.68%)
6/6
(100%)
0
(0%)
14/19
(73.68%)
96/107
(89.72%)
Jul – Dec
Assigned
7/8
17/19
(87.50%)
(89.47%)
9/10
(90.0%)
Jan-Dec
Assigned
17/20
(85.0%)
39/41
20/21
(95.12%)
(95.24%)
Exceptions
11/107 (10.28%)
•Lateral entry into the system
11/11 (100%)*
* modifications made to ensure assignment of a nurse navigator for every patient
Compiled by Lynn Day, RN BSN CCM CCRP
CAP Compliance
Total Number of Patients = 107
Time Frame
Stage 0
Stage I
Stage II
Stage III
Stage IV
Stage
Unassigned
Total
Jan – Jun
Yes
1/12
(8.33%)
22/22
(100%)
9/11
(81.82%)
4/4
(100%)
0
(0%)
0/5
(0%)
36/54
(66.67%)
Jul – Dec
Yes
0/8
(0%)
18/19
(94.74%)
10/10
(100%)
2/2
(100%)
0
(0%)
0/14
(0%)
30/53
(56.6%)
Jan-Dec
Yes
1/20
(5%)
40/41
19/21
(97.56%)
(90.48%)
6/6
(100%)
1/2
(50.0%)
0/19
(0%)
66/107
(89.6%)
Exceptions
41/107 (38.32%)
•Progesterone receptor not reported
•Complete response, no margins
•Final surgery not done yet (neoadjuvant)
•Patient non-compliance, no follow up
17/41
8/41
14/41
2/41
Compiled by Lynn Day, RN BSN CCM CCRP
(41.5%)
(19.5%)
(34.1%)
(4.9%)
Axillary Staging
Total Number of Patients = 107
Total Number of Patients with Invasive Cancer = 87
•
•
Number node positive patients on needle biopsy
Number of patients eligible for SLNB
– Number of patients with SLNB
11/87 (12.6%)
76/87 (87.4%)
54/87 (62.1%)
•
Exceptions
Determined low risk (unlikely to change treatment plan)
Final surgery not done yet
Patient non-compliance, no follow up
12/87 (13.79%)
4/12 (33.3%)
5/12 (41.7%)
2/12 (16.7%)
Compiled by Lynn Day, RN BSN CCM CCRP
Axillary Dissection
Total Number of Patients = 107
Total Number of Patients with Invasive Cancer = 87
•
•
Number of Patients with node positive disease
Number of patients eligible for ALND
– Number of patients with ALND
25/87 (28.7%)
25
14/25 (56%)
•
Exceptions
Low risk for non-SLN mets. on MSKCC nomogram
Final surgery not done yet
Patient refused completion ALND
11/25 (44%)
7/25 (28%)
3/25 (12%)
1/25 (4%)
Compiled by Lynn Day, RN BSN CCM CCRP
Breast Conservation
Total Number of Patients = 107
Time
Frame
Stage 0
Stage I
Stage II
Stage III
Stage IV
Stage
Unassigned
Total
Jan – Jun
Yes
8/12
(66.67%)
19/22
8/11
(86.36%)
(72.73%)
1/4
(25.0%)
0
(0%)
0/5
(0%)
36/54
(66.67%)
Jul – Dec
Yes
6/8
(75.0%)
12/19
(63.16%)
3/10
(30.0%)
0/2
(0%)
0
(0%)
3/14
(21.43%)
24/53
(45.28%)
Jan-Dec
Yes
14/20
(70.0%)
31/41
11/21
1/6
(75.61%)
(52.38%)
(16.67%)
0
(0%)
3/19
(15.79%)
60/107
(56.07%)
Number of early stage patients (0, I and II) with breast conservation 56/82 (68.29%)
Compiled by Lynn Day, RN BSN CCM CCRP
Post-lumpectomy Radiation
Total Number of Patients = 107
•
•
Number of patients with lumpectomy
Number of patients eligible for Radiation
– Number of patients radiated
60/107 (56.1%)
60
50/60 (83.33%)
•
Exceptions
Low risk malignancy
age group 75 – 93 years
severe co morbidities
Radiation pending
Patient non-compliance
10/60 (16.7%)
Number of patients radiated within 12 months
48/50 (96%)
•
Compiled by Lynn Day, RN BSN CCM CCRP
6/10 (60%)
3/10 (30%)
1/10 (10%)
Post-Mastectomy Radiation
Total Number of Patients = 107
•
•
Number of patients with mastectomy
Number eligible for radiation (>T3 or >N2)
– Number of patients radiated
31/107 (29%)
5/31 (16.1%)
3/5 (60%)
•
Exceptions
2/5 (40%)
- Radiation pending
- Patient non-compliance
•
Number of patients radiated within 12 months
Compiled by Lynn Day, RN BSN CCM CCRP
1/5 (20%)
1/5 (20%)
5/5 (100%)
Systemic Chemotherapy - I
Total Number of Patients = 107
 ER negative patients with cancer
• Number eligible for chemotherapy (exclude DCIS)
– Number treated with chemotherapy
10/107 (9.35%)
7/10 (70%)
6/7 (85.7%)
•
1/7 (14.29%)
1/1 (100%)
Exceptions
Patient refused (1 stage I)
 Number with chemotherapy within 4 months
6/6 (100%)
•
0 (none)
0 (none)
Exceptions
Patient non-compliance
Compiled by Lynn Day, RN BSN CCM CCRP
Systemic Chemotherapy - II
Total Number of Patients = 107
 ER positive patients with cancer
• Number eligible for chemotherapy (exclude DCIS)
• Number treated with chemotherapy
94/107 (87.9%)
77/94 (81.9%)
45/77 (58.4%)
 Number with chemotherapy within 4 months
43/45 (95.5%)
•
2/45 (4.4%)
1/2 (50%)
1/2 (50%)
Exceptions
Prevented by patient comorbidities (stage III)
Postop. wound complications (stage I)
Compiled by Lynn Day, RN BSN CCM CCRP
Systemic Endocrine Therapy
Total Number of Patients = 107
 Number of ER positive patients
• Number treated with endocrine therapy
94/107 (89.7%)
69/94 (73.4%)
•
25/94 (26.6%)
4/25 (16%)
1/25 (4%)
17/25 (68%)
1/25 (4%)
2/25 (8%)
Exceptions
Determined risk > benefit
No documentation in the chart
Hormonal therapy pending
Patient sought treatment elsewhere
Patient non-compliance
 Number with endocrine therapy within 1 year
Compiled by Lynn Day, RN BSN CCM CCRP
69/69 (100%)
Rehabilitation
Total Number of Patients = 107
•
Number enrolled in CPRP (PT/OT)
24/107 (22.43%)
•
Exceptions
83/107 (77.6%)
•
Services were available but structured program is pending definitive
establishment, whereby every patient gets a baseline arm girth and
shoulder range of motion documented; prospective data is maintained
with a pre-designed schedule.
Improvement over 2009
10.2%
Compiled by Lynn Day, RN BSN CCM CCRP
Genetic Counseling
Total Number of Patients = 107
•
•
Number of patients with family history or < 45 years
Number received genetic counseling
– Number tested
• Positive
• Negative
– Number refused testing
65/107 (60.75%)
20/65 (30.77%)
17/20 (85%)
2/17 (11.76%)
15/17 (88.23%)
3/20 (15%)
•
Exceptions
Did not meet NCCN criteria
No documentation in the chart
45/65 (69.23%)
34/45 (75.5%)
9/45 (20%)
Compiled by Lynn Day, RN BSN CCM CCRP
Trial Participation
Total Number of Patients = 107
Time
Frame
Trial / Study
Eligible
N (%)
Participation
N (%)
Jan – Jun
B-SMART
18 (38.3%)
15 (38.5%)
SPOC
40 (85.1%)
36 (92.3%)
ACOSOG Z1071
7 (14.9%)
7 (17.9%)
47 (87%)
39 (72.2%)
B-SMART
13 (27.7%)
10 (27%)
SPOC
37 (78.7%)
34 (91.9%)
ACOSOG Z1071
-
-
47 (88.68%)
37 (69.81%)
Total
Jul - Dec
Total
Total Number of patients enrolled in trials in 2011
Increase of patients enrolled over the year 2009
Compiled by Lynn Day, RN BSN CCM CCRP
94/107 (87.85%)
79/15 (526.6%)