Quality Assurance Report
TTUHSC Breast Center of Excellence
January 1, 2012 – December 31, 2012
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
Jan – Jun
9/46
(19.6%)
22/46
(47.8%)
9/46
(19.6%)
4/46
(8.7%)
1/46
(2.17%)
1/46
(2.17%)
46/46
(100%)
Jul - Dec
6/28
(21.4%)
10/28
(36%)
9/28
(32.1%)
0/28
(0%)
0/28
(0%)
3/28
(10.7%)
28/28
(100%)
Jan-Dec
15/74
(20.2%)
32/74
(43.2%)
18/74
(24.32%)
4/74
(5.40%)
1/74
(1.35%)
4/74
(5.4%)
74/74
(100%)
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
9/9
(100%)
22/22
(100%)
9/9
(100%)
3/4
(75%)
1/1
(100%)
1/1
(100%)
45/46
Jul – Dec
Preoperative
Core
4/6
(66.6%)
9/10
(90%)
9/9
(100%)
0/0
(0%)
0/0
(0%)
2/3
(66.6%)
Jan-Dec
Preoperative
Core
13/15
(86.6%)
31/32
(96.8%)
18/18
(100%)
3/4
(75%)
1/1
(100%)
3/4
(75%)
93.24% of patients had diagnosis established on preoperative
core needle biopsy
Exceptions
• Pt. with ADH on core biopsy
• Pts. with implants
• Pt. with recurrence after 2009
palliative excision done
• Pt. unable to lie prone for stereotactic bx.
Compiled by Uzma Nazim, M.D.
1/5
2/5
1/5
1/5
(97.82%)
24/28
(85.71%)
69/74
(93.24%)
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
8/9
(88.8%)
20/22
9/9
(100%)
3/4
(75%)
1/1
(100%)
1/1
(100%)
42/46
(91.3%)
Jul – Dec
Discussed
4/6
(66.6%)
7/9
(77.7%)
0
(0%)
1/1
(100%)
3/3
(100%)
21/28
(75%)
Jan-Dec
Discussed
12/15
(80%)
16/18
(89%)
3/4
(75%)
2/2
(100%)
4/4
(100%)
63/74
(85.1%)
(90.9%)
6/9
(66.6%)
26/31
(83.8%)
85.1% 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
7/9
(77.7%)
4/4
(100%)
1/1
(100%)
0/1
(0%)
39/46
(84.78%)
(80%)
6/9
(66.6%)
0
(0%)
0
(0%)
3/3
(100%)
22/28
(79%)
27/32
13/18
4/4
(84%)
(72.22%)
(100%)
1/1
(100%)
3/4
(75%)
61/74
(82.4%)
Jan – Jun
MDC seen
8/9
19/22
(88.8%)
(86.3%)
Jul – Dec
MDC seen
5/6
(83.3%)
8/10
Jan-Dec
MDC seen
13/15
(87%)
•
•
•
Exceptions:
Older than 70 yrs. declined radiation
appointment in favor of mastectomy
Under 70 yrs. declined radiation
appointment in favor of mastectomy
Patient transferred
Compiled by Uzma Nazim, M.D.
13/74 (17.56%)
7/13(53.84%)
5/13(38.46%)
1/13(7.6%)
Nurse Navigation
Total Number of Patients = 74
Time Frame
Jan – Jun
Assigned
Stage 0
Stage I
Stage II
Stage III
Stage IV
Stage
Unassigned
Total
9/9
(100%)
21/22
(95.4%)
9/9
(100%)
3/4
(75%)
1/1
(100%)
1/1
(100%)
44/46
(95.65%)
0
(0%)
0
(0%)
3/3
(100%)
27/28
(96.4%)
3/4
(75%)
1/1
(100%)
4/4
(100%)
71/74
(95.9%)
Jul – Dec
Assigned
6/6
9/10
(100%)
(90%)
9/9
(100%)
Jan-Dec
Assigned
15/15
(100%)
30/32
18/18
(93.7%)
(100%)
Exceptions
3/74(4.05%)
* HCC pts. did not have full navigation by the nurse through treatment ----HCC notified.
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
9/9
(100%)
22/22
(100%)
8/9
(88.8%)
4/4
(100%)
0/1
(0%)
0/1
(0%)
43/46
(93.4%)
Jul – Dec
Yes
6/6
(100%)
10/10
(100%)
9/9
(100%)
0
(0%)
0
(0%)
0/3
(0%)
25/28
(89.3%)
Jan-Dec
Yes
15//15
(100%)
32/32
17/18
(100%)
(94.4%)
4/4
(100%)
0/1
(0%)
0/4
(0%)
68/74
(92%)
Exceptions
6/74 (8.1%)
•
•
5/6 (83.3%)
1/6 (16.66%)
Final surgery not done
Patient transferred
Compiled by Uzma Nazim, M.D.
Axillary Staging
Total Number of Patients = 74
Total Number of Patients with Invasive Cancer = 59
•
•
•
Number node positive patients on needle biopsy
Number of pts. with Stage IV disease
Number of patients eligible for SLNB
– Number of patients with SLNB
5/59 (8.47%)
1/59(1.69%)
53/59(89.8%)
46/53 (86.79%)
•
Exceptions
Determined low risk (unlikely to change treatment plan)
Patient transferred
7/53(13.2%)
6/7(85.7%)
1/7(14.28%)
Compiled by Uzma Nazim, M.D.
Axillary Dissection
Total Number of Patients = 74
Total Number of Patients with Invasive Cancer = 59
•
•
•
•
Number of patients with stage IV
Number of patients with node positive disease
Number of patients eligible for ALND
Number of patients with ALND
1/59 (1.69%)
20/59(33.8%)
20
13/20 (65%)
•
Exceptions
Low risk for non-SLN mets. on MSKCC nomogram
Final surgery not done yet
7/20 (35%)
6/7 (85.7%)
1/7 (14.28%)
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
6/9
(66.66%)
18/22
5/9
(81.8%)
(56%)
2/4
(50%)
0/1
(0%)
0/1
(0%)
31/46
(67.39%)
Jul – Dec
Yes
4/6
(66.6%)
8/10
(80%)
5/9
(56%)
0
(0%)
0
(0%)
0/3
(0%)
17/28
(60.71%)
Jan-Dec
Yes
10/15
(66.6%)
26/32
10/18
2/4
(81.25%)
(56%)
(50%)
0/1
(0%)
0/4
(0%)
48/74
(64.9%)
• Number of early stage pts. (0, I and II) with breast conservation
48/65(74%)
• Mastectomies done
20/74(27%)
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
48/74 (64.8%)
48
44/48 (91.66%)
Exceptions
• Co-morbidity and age >70 yrs.
• Patient had mastectomy after initial lumpectomy
4/48(8.3%)
1/4 (25%)
3/4 (75%)
•
44/44(100%)
Number of patients radiated within 12 months
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
20/74 (27%)
2/20(10%)
2/2(100%)
•
Number of patients radiated within 12 months
2/2 (100%)
Compiled by Uzma Nazim, M.D.
Systemic Chemotherapy - I
Total Number of Patients = 74
 ER negative patients with cancer
• Number eligible for chemotherapy (exclude DCIS)
– Number treated with chemotherapy
13/74 (17.56%)
12/13 (92.3%)
9/12 (75%)
•
3/12 (25%)
1/3 (33.3%)
2/3(66.6%)
Exceptions
Patient refused
Severe co-morbidities and age
 Number with chemotherapy within 4 months
9/9(100%)
•
0 (none)
Exceptions
Compiled by Uzma Nazim, M.D.
Systemic Chemotherapy - II
Total Number of Patients = 74
 ER positive patients with cancer
61/74 (82.43%)
•
23/61 (37.78%)
Number treated with chemotherapy
 Number with chemotherapy within 4 months
20/23 (87%)
•
•
•
•
3/23(13%)
1/3(33.3%)
1/3(33.3%)
Exceptions
Pt. developed mirizzi’s syndrome
Pt. had wound infection
Chemo was within 4 months from cancer diagnosis
original biopsy showed ADH
Compiled by Uzma Nazim, M.D.
1/3(33.3%)
Systemic Endocrine Therapy
Total Number of Patients = 74
 Number of ER positive patients
• Number treated with endocrine therapy
61/74 (82.43%)
52/61 (85.24%)
•
9/61 (14.75%)
5/9 (55.6%)
3/9 (33.33%)
1/9 (11.11%)
Exceptions
Determined risk > benefit
Patients with co morbidities
Patient non compliant
 Number with endocrine therapy within 1 year
Compiled by Uzma Nazim, M.D.
52/52 (100%)
Rehabilitation
Total Number of Patients =74
•
Number enrolled in CPRP (PT/OT)
36/74 (49%)
•
Exceptions
37/74 (50%)
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
Improvement over 2011
Compiled by Uzma Nazim, M.D.
24/107 (22.43%)
36/74 (49%)
26.57%
Genetic Counseling
Total Number of Patients = 74
•
•
Number of patients with family history or < 45 years
Number received genetic counseling
– Number tested
• Positive
• Negative
– Number refused testing
49/74 (66.2%)
19/49(39%)
14/19(74%)
3/14(21.4%)
11/14(79%)
5/19(26.3%)
•
Exceptions
Did not meet NCCN criteria
No documentation in the chart
30/49(61.2%)
24/30(80%)
6/30(20%)
Compiled by Uzma Nazim, M.D.
Trial Participation
Total Number of Patients = 74
Time
Frame
Jan – Jun
Trial / Study
Eligible
N (%)
Participation
N (%)
B-SMART
3
3(100%)
CCIP
2
0(0%)
SPOC
17
12(70.6%)
MULTIPLE STUDIES
22
19(86.4%)
44/46(96%)
34/44(77%)
B-SMART
3
2(66.66%)
CCIP
5
5(100%)
SPOC
6
2(33.3%)
MULTIPLE STUDIES
11
10(90.9%)
27/28(96.4%)
19/27(70.3%)
71/74(95.9%)
53/71(75%)
Total
Jul - Dec
Total
TOTAL
Patients participated in trials for 2012
Compiled by Uzma Nazim, M.D.
53/71(75%)