Quality Assurance Report
TTUHSC Breast Center of Excellence
January 1, 2010 – December 31, 2010
Compiled by Lynn Day, RN BSN CCM CCRP
Stage Distribution
Total Number of Patients = 121
Time
Frame
Stage 0
Stage I
Stage II
Stage III
Stage IV
Stage
Unassigned
Total
Jan – Jun
7
(10.94%)
25
(39.06%)
13
(20.31%)
8
(12.5%)
0
(0%)
11
(17.19%)
64
(100%)
Jul - Dec
10
(17.54%)
22
(38.6%)
13
(22.8%)
3
(5.26%)
0
(0%)
9
(15.79%)
57
(100%)
Jan-Dec
17
(14.05%)
47
(38.84%)
26
(21.48%)
11
(9.09%)
0
(0%)
20
(16.53%)
121
(100%)
Compiled by Lynn Day, RN BSN CCM CCRP
Mode of Diagnosis
Total Number of Patients = 121
Time Frame
Stage 0
Stage I
Stage II
Stage III
Stage IV
Stage
Unassigned
Total
Jan – Jun
Preoperative
Core
12
(18.75%)
27
(42.19%)
14
(21.87%)
8
(12.5%)
0
(0%)
3
(4.69%)
64
(100%)
Jul – Dec
Preoperative
Core
12
(21.05%)
23
(40.35%)
15
(26.31%)
3
(5.26%)
0
(0%)
2
(3.51%)
55
Jan-Dec
Preoperative
Core
24
(19.83%)
50
(41.32%)
29
(23.96%)
11
(9.09%)
0
(0%)
5
(4.13%)
98.35% of patients had diagnosis established on preoperative
core needle biopsy
Exceptions – excisional biopsy by other MD and shave biopsy
Compiled by Lynn Day, RN BSN CCM CCRP
(96.49%)
119
(98.35%)
Tumor Board Discussion
Total Number of Patients = 121
Time
Frame
Jan – Jun
Discussed
Stage 0
Stage I
Stage II
Stage III
Stage IV
Stage
Unassigned
Total
7/12
4/27
(58.33%)
(14.81%)
8/14
(57.14)
4/8
(50%)
0
(0%)
0/3
(0%)
23/64
(35.94%)
6/15
(40%)
2/4
(50%)
0
(0%)
0/2
(0%)
40/57
(75.47%)
14/29
(48.28)
6/12
(50%)
0
(0%)
0/5
(0%)
44/121
(36.36%)
Jul – Dec
Discussed
5/12
8/24
(41.66%)
(33.33%)
Jan-Dec
Discussed
12/24
(50.0%)
12/51
(23.53%)
36.36% of patients were discussed prospectively in the
multidisciplinary tumor conference
14.05% of patients were discussed retrospectively in the
multidisciplinary tumor conference
Compiled by Lynn Day, RN BSN CCM CCRP
Multidisciplinary Assessment
(Surgical, Medical and Radiation Oncologist)
Total Number of Patients = 121
Time
Frame
Jan – Jun
MDC seen
Jul – Dec
MDC seen
Jan-Dec
MDC seen
Stage 0
Stage I
Stage II
Stage III
Stage IV
Stage
Unassigned
Total
9/12
24/27
10/14
(75%)
(88.89%)
(71.43%)
8/8
(100%)
0
(0%)
1/3
(33.33%)
52/64
(81.25%)
10/12
21/24
12/15
(83.33%)
(87.5%)
(80%)
3/4
(75%)
0
(0%)
1/2
(50.0%)
47/57
(82.46%)
19/24
45/51
22/29
11/12
(79.17%)
(88.24%)
(75.86%)
(91.67%)
0
(0%)
2/5
(40%)
82/121
(67.77%)
Exceptions
22/121 (18.18%)
•No radiation oncology evaluation (mast./ high-risk)
•No documentation in the chart
•Patient non-compliance
•Continuing chemotherapy
•Deceased during treatment
Compiled by Lynn Day, RN BSN CCM CCRP
9/22 (40.9%)
8/22 (36.36%)
2/22 (9.09%)
1/22 (4.55%)
2/22 (9.09%)
Nurse Navigation
Total Number of Patients = 121
Time Frame
Stage 0
Stage I
Stage II
Stage III
Stage IV
Stage
Unassigned
Total
Jan – Jun
Assigned
11/12
(91.67%)
27/27
(100%)
14/14
(100%)
8/8
(100%)
0
(0%)
3/3
(100%)
63/64
(98.44%)
12/12
23/24
(100%)
(95.83%)
15/15
(100%)
4/4
(100%)
0
(0%)
1/2
(50%)
55/57
(96.49%)
23/24
50/51
29/29
(95.83%)
(98.04%)
(100%)
12/12
(100%)
0
(0%)
4/5
(80%)
118/121
(97.52%)
Jul – Dec
Assigned
Jan-Dec
Assigned
Exceptions
3/121 (2.48%)
•Lateral entry into the system
•Patient moved care
1/3 (33.33%)*
2/3 (66.67%)
*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 = 121
Time Frame
Stage 0
Stage I
Stage II
Stage III
Stage IV
Stage
Unassigned
Total
4/12
27/27
(100%)
14/14
(100%)
8/8
(100%)
0
(0%)
0/3
(0%)
53/64
(82.81%)
4/4
(100%)
0
(0%)
0/2
(0%)
44/57
(71.19%)
12/12
(100%)
0/0
(0%)
0/5
(0%)
97/121
(80.17%)
Jan – Jun
Yes
(33.33%)
Jul – Dec
Yes
1/12
(8.33%)
(100%)
15/15
(100%)
Jan-Dec
Yes
5/24
51/51
29/29
(20.83%)
(100%)
(100%)
24/24
Exceptions
24/121(19.83%)
•Progesterone receptor not reported (DCIS)
•Complete response, no margins
•Final surgery not done
•Patient non-compliance, no follow up, moved
13/24
6/24
4/24
1/24
Compiled by Lynn Day, RN BSN CCM CCRP
(54.17%)
(25%)
(16.67%)
(4.17 %)
Axillary Staging
Total Number of Patients = 121
Total Number of Patients with Invasive Cancer = 97
•
•
Number node positive patients on needle biopsy
Number of patients eligible for SLNB
– Number of patients with SLNB
15/97 (15.47%)
85/97 (87.62%)
69/97 (71.13%)
•
Exceptions
Determined low risk (unlikely to change treatment plan)
Final surgery not done
Patient non-compliance, no follow up, moved
16/97 (16.49%)
11/16 (68.75%)
1/16 (6.25%)
4/16 (25%)
Compiled by Lynn Day, RN BSN CCM CCRP
Axillary Dissection
Total Number of Patients = 121
Total Number of Patients with Invasive Cancer = 97
•
•
Number of Patients with node positive disease
Number of patients eligible for ALND
– Number of patients with ALND
34/97 (35.05%)
34
25/34 (73.52)
•
Exceptions
Low risk for non-SLN mets. on MSKCC nomogram
Final surgery not done
Patient refused completion ALND
Patient high risk for completion ALND
9/34 (26.47%)
5/34 (14.7%)
1/34 (2.94%)
0/34 (0%)
3/34 (8.82%)
Compiled by Lynn Day, RN BSN CCM CCRP
Breast Conservation
Total Number of Patients = 121
Time
Frame
Stage 0
Stage I
Stage II
Stage III
Stage IV
Stage
Unassigned
Total
Jan – Jun
Yes
9/12
(75%)
27/27
7/14
(100%)
(50%)
4/8
(50%)
0
(0%)
0/3
(0%)
47/64
(73.44%)
Jul – Dec
Yes
7/12
(58.33%)
18/24
(75%)
6/15
(40%)
0/4
(0%)
0
(0%)
0/2
(0%)
31/57
(54.4%)
Jan-Dec
Yes
16/24
(66.67%)
45/51
13/29
4/12
(88.24%)
(44.83%)
(33.33%)
0
(0%)
0/5
(0%)
78/121
(64.46%)
Number of early stage patients (0, I and II) with breast conservation 74/104 (71.15%)
Compiled by Lynn Day, RN BSN CCM CCRP
Post-lumpectomy Radiation
Total Number of Patients = 121
•
•
Number of patients with lumpectomy
Number of patients eligible for Radiation
– Number of patients radiated
78/121 (64.46%)
78
72/78 (92.3%)
•
Exceptions
Low risk malignancy
age group 75 – 93 years
severe co morbidities
Progressed to mastectomy
Patient non-compliance/moved
History of past radiation
Number of patients radiated within 12 months
6/78 (7.69%)
•
Compiled by Lynn Day, RN BSN CCM CCRP
1/6 (16.67%)
2/6 (33.33%)
2/6 (33.33%)
1/6 (16.67%)
72/78 (92.3%)
Post-Mastectomy Radiation
Total Number of Patients = 121
•
•
Number of patients with mastectomy
Number eligible for radiation (>T3 or >N2)
– Number of patients radiated
38/121 (31.4%)
9/38 (23.68%)
7/9 (77.78%)
•
Exceptions
2/9 (22.22%)
- History of prior radiation
- Patient non-compliance
•
Number of patients radiated within 12 months
Compiled by Lynn Day, RN BSN CCM CCRP
1/2 (50%)
1/2 (50%)
5/9 (55.56%)
Systemic Chemotherapy - I
Total Number of Patients = 121
 ER negative patients with cancer
• Number eligible for chemotherapy (exclude DCIS)
– Number treated with chemotherapy
18/121 (14.88%)
14/18 (77.78%)
9/14 (64.29%)
•
5/14 (35.71%)
2/5 (40%)
1/5 (20%)
2/5 (40%)
Exceptions
Patient refused chemo
Patient moved care
Chemo not recommended
 Number with chemotherapy within 4 months
9/9 (100%)
•
0 (none)
0 (none)
Exceptions
Patient non-compliance
Compiled by Lynn Day, RN BSN CCM CCRP
Systemic Chemotherapy - II
Total Number of Patients = 121
 ER positive patients with cancer
103/121 (85.12%)
•
•
83/103 (81.9%)
41/83 (49.41%)
Number eligible for chemotherapy (exclude DCIS)
Number treated with chemotherapy
 Number with chemotherapy within 4 months
39/41 (95.12%)
•
Exceptions
2/41 (4.88%)
Patient initiated treatment delay
(1 stage II, 1 stage III)
2/2 (100%)
Compiled by Lynn Day, RN BSN CCM CCRP
Systemic Endocrine Therapy
Total Number of Patients = 121
 Number of ER positive patients
• Number treated with endocrine therapy
103/121 (85.12%)
93/103 (90.29%)
•
10/103 (9.71%)
5/10 (50%)
1/10 (10%)
4/10 (40%)
Exceptions
Determined risk > benefit
Patient deceased during treatment
Patient non-compliance
 Number with endocrine therapy within 1 year
Compiled by Lynn Day, RN BSN CCM CCRP
90/93 (96.77%)
Rehabilitation
Total Number of Patients = 121
•
Number enrolled in CPRP (PT/OT)
36/121 (29.75%)
•
Exceptions
85/121 (70.25%)
•
Services were available but structured program was recently established,
whereby every patient gets a baseline exam documented; prospective data
is maintained with a pre-designed schedule.
Improvement over 2009
17.5%
Compiled by Lynn Day, RN BSN CCM CCRP
Genetic Counseling
Total Number of Patients = 121
•
•
Number of patients with family history or < 45 years
Number received genetic counseling
– Number tested
• Positive
• Negative
– Number refused testing
75/121 (61.98%)
37/75 (49.33%)
20/37 (54.05%)
5/20 (25%)
15/20 (75%)
22/37 (59.46%)
•
Exceptions
Did not meet NCCN criteria
No documentation in the chart
Patient deceased during treatment
37/75 (49.33%)
24/37 (64.86%)
13/37 (35.14%)
1/37 (2.70%)
Compiled by Lynn Day, RN BSN CCM CCRP
Trial Participation
Total Number of Patients = 121
Time
Frame
Trial / Study
Eligible
N (%)
Participation
N (%)
Jan – Jun
B-SMART
13 (20.64%)
12 (19.05%)
SPOC
22 (34.92%)
22 (34.92%)
35 (55.56%)
34 (53.97%)
B-SMART
16 (27.59%)
16 (27.59%)
SPOC
45 (77.59%)
45 (77.59%)
47 (81.03%)
47 (81.03%)
Total
Jul - Dec
Total
Total Number of patients enrolled in trials in 2010
Increase of patients enrolled over the year 2009
Compiled by Lynn Day, RN BSN CCM CCRP
78/121 (64.46%)
78/15 (520%)