Quality Assurance Report
TTUHSC Breast Center of Excellence
January 1, 2013 – December 31, 2013
Compiled by Uzma Nazim, M.D.
Stage Distribution
Total Number of Patients =74
Time
Frame
Stage 0
Stage I
Stage II
Stage III
Stage IV
Stage
Unassigned
Total
12/37
(32.43%)
12/37
(32.43%)
4/37
(10.81%)
3/37
(8.10%)
5/37
(13.5%)
1/37
(2.7%)
37/37
(100%)
10/37
(27.02%)
12/37
(32.43%)
9/37
(24.3%)
4/37
(10.8%)
2/37
(5.40%)
0/37
(0%)
37/37
(100%)
22/74
(29.7%)
24/74
(32.43%)
13/74
(17.5%)
7/74
(9.4%)
7/74
(9.4%)
1/74
(1.3%)
74/74
(100%)
Jan – Jun
Jul - Dec
Jan-Dec
Compiled by Uzma Nazim, M.D.
Mode of Diagnosis
Total Number of Patients =74
Time Frame
Stage 0
Stage I
Stage II
Stage III
Stage IV
Stage
Unassigned
Total
Jan – Jun
Preoperative
Core
12/12
(100%)
15/15
(100%)
4/4
(100%)
2/3
(66.7%)
2/2
(100%)
1/1
(100%)
36/37
Jul – Dec
Preoperative
Core
9/10
(90%)
13/13
(100%)
9/9
(100%)
4/4
(100%)
1/1
(100%)
0/0
(0%)
Jan-Dec
Preoperative
Core
21/22
(95.5%)
28/28
(100%)
13/13
(100%)
6/7
(85.7%)
3/3
(100%)
1/1
(100%)
97.3% of patients had diagnosis established on preoperative
core needle biopsy
Exceptions
2/74
Pts. established diagnosis on excisional biopsy as the primary site is
not amenable to image guided biopsy
Compiled by Uzma Nazim, M.D.
(97.3%)
36/37
(97.3%)
72/74
(97.3%)
Tumor Board Discussion
Total Number of Patients =74
Time
Frame
Stage 0
Stage I
Stage II
Stage III
Stage IV
Stage
Unassigned
Total
Jan – Jun
Discussed
11/12
(91.6%)
11/12
4/4
(100%)
3/3
(100%)
5/5
(100%)
0/1
(0%)
34/37
(91.9%)
Jul – Dec
Discussed
9/10
(90%)
(100%)
9/9
(100%)
4/4
(100%)
2/2
(100%)
0
(0%)
36/37
(97.3%)
Jan-Dec
Discussed
20/22
(90.9%)
23/24
(95.8%)
13/13
(100%)
7/7
(100%)
7/7
(100%)
0/1
(0%)
70/74
(94.5%)
(91.66%)
12/12
94.5% of patients were discussed in the multidisciplinary tumor
conference
Compiled by Uzma Nazim, M.D.
Multidisciplinary Assessment
(Surgical, Medical and Radiation Oncologist)
Total Number of Patients = 74
Time
Frame
Stage 0
Stage I
Stage II
Stage III
Stage IV
Stage
Unassigned
Total
Jan – Jun
MDC seen
8/12
(66.6%)
14/15
(93.3%)
4/4
(100%)
3/3
(100%)
0/2
(0%)
0/1
(0%)
29/37
(78.3%)
Jul – Dec
MDC seen
8/10
(80%)
7/13
(53.8%)
7/9
(77.7%)
3/4
(75%)
0/1
(0%)
0/0
(00%)
25/37
(67.57%)
Jan-Dec
MDC seen
16/22
(72.7%)
21/28
(75%)
11/13
(84.6%)
6/7
(85.7%)
0/3
(0%)
0/1
(0%)
54/74
(72.97%)
•
•
•
•
•
•
Exceptions:
Mastectomy
Patients with DCIS
Patient deceased
Patient transferred
Patients with advanced metastatic disease
Compiled by Uzma Nazim, M.D.
20/74
6/20
6/20
2/20
2/20
4/20
Nurse Navigation
Total Number of Patients = 74
Time Frame
Stage 0
Stage I
Stage II
Stage III
Stage IV
Stage
Unassigned
Total
Jan – Jun
Assigned
12/12
(100%)
15/15
(100%)
4/4
(100%)
3/3
(100%)
2/2
(100%)
0/1
(0%)
36/37
(97.3%)
4/4
(100%)
1/1
(100%)
0
(0%)
37/37
(100%)
7/7
(100%)
3/3
(100%)
0/1
(0%)
73/74
(98.65%)
Jul – Dec
Assigned
10/10
13/13
(100%)
(100%)
9/9
(100%)
Jan-Dec
Assigned
22/22
(100%)
28/28
(100%)
13/13
(100%)
Exceptions
1/74 (1.35%)
Patient sought treatment in Mexico
Compiled by Uzma Nazim, M.D.
CAP Compliance
Total Number of Patients = 74
Time Frame
Stage 0
Stage I
Stage II
Stage III
Stage IV
Stage
Unassigned
Total
Jan – Jun
Yes
0/12
(0%)
15/15
(100%)
4/4
(100%)
3/3
(100%)
0/2
(0%)
0/1
(0%)
22/37
(59.4%)
Jul – Dec
Yes
1/10
(10%)
11/13
(84.6%)
8/9
(88.9%)
3/4
(75%)
0/1
(0%)
0
(0%)
23/37
(62.16%)
Jan-Dec
Yes
1/22
(4.5%)
26/28
(92.8%)
12/13
(92.3%)
6/7
(85.7%)
0/3
(0%)
0/1
(0%)
45/74
(60.8%)
Exceptions
29/74(39%)
•
•
•
•
•
•
9/29
3/29
3/29
5/29
3/29
6/29
Margins can not be assessed
Patient transferred
Patient deceased during treatment
Mastectomy
Surgery not done
DCIS
Compiled by Uzma Nazim, M.D.
Axillary Staging
Total Number of Patients = 74
Total Number of Patients with Invasive Cancer = 52
•
•
•
•
•
•
•
Number node positive patients on needle biopsy
Number of pts. with Stage IV disease
9/52(17.30%)
3/52(5.76%)
Number of patients eligible for SLNB
Number of patients with SLNB
40/74(54.05%)
31/40(77.5%)
Exceptions
Determined low risk (unlikely to
change treatment plan)
Patient transferred
9/40(22.5%)
Compiled by Uzma Nazim, M.D.
7/9(77.7%)
2/9(22.22%)
Axillary Dissection
Total Number of Patients = 74
Total Number of Patients with Invasive Cancer =52
•
•
•
•
Number of patients with stage IV
Number of patients with node positive disease
Number of patients eligible for ALND
Number of patients with ALND
3/52(5.76%)
18/52(34.61%)
18
7/18(38.9%)
Exceptions
Low risk for non-SLN mets. on MSKCC nomogram
Patient deceased before final surgery
Surgery done at some other facility
Final surgery not done yet
11/18(61.11%)
7/11(63.6%)
1/11(9%)
1/11(9%)
2/11(18.18%)
Compiled by Uzma Nazim, M.D.
Breast Conservation
Total Number of Patients = 74
Time
Frame
Stage 0
Stage I
Stage II
Stage III
Stage IV
Stage
Unassigned
Total
Jan – Jun
Yes
9/12
(75%)
15/15
4/4
(100%)
(100%)
1/3
(33.3%)
0/2
(0%)
0/1
(0%)
29/37
(78.4%)
Jul – Dec
Yes
8/10
(80%)
6/13
(46.1%)
6/9
(66.6%)
2/4
(50%)
0/1
(0%)
0
(0%)
22/37
(59.5%)
Jan-Dec
Yes
17/22
(77.27%)
21/28
(75%)
10/13
(76.9%)
3/7
(42.8%)
0/3
(0%)
0/1
(0%)
51/74
(69%)
• Number of early stage pts. (0, I and II) with breast conservation 48/63(76.1%)
• Mastectomies done
18/74(24.3%)
Compiled by Uzma Nazim, M.D.
Post-lumpectomy Radiation
Total Number of Patients =74
•
•
•
Number of patients with lumpectomy
Number of patients eligible for Radiation
Number of patients radiated
Number of patients radiated within 12 months
51/74 (68.9%)
51
43/51(86.2%)
43/43(100%)
Exceptions
8/51(15.7%)
•
•
•
•
2/8(25%)
1/8(12.5%)
1/8(12.5%)
4/8(50%)
Patient had mastectomy after initial lumpectomy
Patient with small DCIS in prior radiation field
Patient deceased during chemotherapy
Patient refused to get radiation
Compiled by Uzma Nazim, M.D.
Post-Mastectomy Radiation
Total Number of Patients = 74
•
•
•
Number of patients with mastectomy
Number eligible for radiation (>T3 or >N2)
Number of patients radiated
18/74 (24.3%)
5/18(27.7%)
2/5(40%)
Number of patients radiated within 12 months
2/2 (100%)
Exceptions
3/5(60%)
• Patient refused radiation
• Patient got treatment from other facility
• Patient deceased during chemotherapy
1 /3(33.3%)
1/3( 33.3%)
1/3(33.3%)
Compiled by Uzma Nazim, M.D.
Systemic Chemotherapy - I
Total Number of Patients = 74
•
ER negative patients with cancer
12/74 (16.2%)
•
•
•
ER negative patients with DCIS
Number eligible for chemotherapy (exclude DCIS)
Number treated with chemotherapy
2/12(16.66%)
10/12(83.3%)
10/10 (100%)
Exceptions
0
Number with chemotherapy within 4 months
10/10(100%)
Compiled by Uzma Nazim, M.D.
Systemic Chemotherapy - II
Total Number of Patients = 74
•
ER positive patients with cancer
62/74 (83.73%)
•
Number treated with chemotherapy
21/62(33.98%)
Number with chemotherapy within 4 months
21/21 (100%)
Exceptions
0(0%)
Compiled by Uzma Nazim, M.D.
Systemic Endocrine Therapy
Total Number of Patients = 74
•
•
•
•
•
•
•
•
Number of ER positive patients
Number treated with endocrine therapy
62/74 (83.78%)
48/62 (77.4%)
Exceptions
14/62(22.5%)
Determined risk > benefit
Patients with co morbidities
Patient non compliant
Patient transferred
Patient deceased
3/14 (21.4%)
3/14 (21.4%)
2/14(14.2%)
3/14(21.4%)
3/14(21.4%)
Number with endocrine therapy within 1 year
Compiled by Uzma Nazim, M.D.
48/48 (100%)
Rehabilitation
Total Number of Patients =74
•
Number enrolled in CPRP (PT/OT)
Exceptions
44/74 (59.5%)
30/74 (40.5%)
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.
•
•
•
•
Pts. enrolled in CPRP in 2011
Pts. enrolled in CPRP in 2012
Pts. enrolled in CPRP in 2013
Improvement over 2012
Compiled by Uzma Nazim, M.D.
24/107 (22.43%)
36/74 (49%)
44/74(59.5%)
10 .5%
Genetic Counseling
Total Number of Patients = 74
•
Number of patients with family history or < 45 years
49/74 (66.2%)
Number received genetic counseling
• Number tested
Positive
Negative
20/49(41%)
13/20(65%)
4/13(30%)
9/13(70%)
• Number refused testing
• Patient transferred to Mexico
• No documentation in the chart
3/20(15%)
1/20(5%)
3/20(15%)
Exceptions
29/49(59%)
Compiled by Uzma Nazim, M.D.
Reconstruction For Mastectomy
Total Number of Patients = 74
• Number of patients with mastectomy
• Number of patients with reconstruction
Exceptions
•
•
18/74 (24.32%)
12/18(66.66%)
6/18(33.3%)
Pts. Offered but refused
Stage IV patient with palliative mastectomy
Number of patients with reconstruction in 2012
Improvement over 2012
Compiled by Uzma Nazim, M.D.
5/6(83.33%)
1/6(16.66%)
9/20(45%)
21.66%
Trial Participation
Total Number of Patients = 74
Time
Frame
Jan – Jun
Trial / Study
Eligible
N (%)
Participation
N (%)
B-SMART
4
4(100%)
CCIP
2
1(50%)
SPOC
6
6(100%)
MULTIPLE STUDIES
22
22(100%)
34/37(91.9%)
33/34(97%)
B-SMART
7
3(43%)
CCIP
0
0(0%)
SPOC
11
10(91%)
MULTIPLE STUDIES
16
13(81.2%)
34/37(91.9%)
26/34(76.4%)
68/74(92%)
59/68(87%)
Total
Jul - Dec
Total
GRAND TOTAL
Patients participated in trials for 2012
Compiled by Uzma Nazim, M.D.
53/71(75%)