Quality Assurance Report
TTUHSC Breast Center of Excellence
January 1, 2014 – December 31, 2014
Compiled by L.Day, RN BSN CCM CCRP OCN
1
Stage Distribution
Total Number of Patients =55
Time
Frame
Stage 0
Stage I
Stage II
Stage III
Stage IV
Stage
Unassigned
Total
5/27
(18.52%)
13/27
(48.15%)
*8/27
(29.63%)
0/27
(0%)
1/27
(33.3%)
0/27
(3.7%)
27/27
(100%)
7/28
(25%)
8/28
(28.57%)
11/28
(39.29%)
1/28
(3.57%)
*1/28
(3.57%)
0/28
(0%)
28/28
(100%)
12/55
(21.8%)
21/55
(38.2%)
*19/55
(34.55%)
1/55
(1.82%)
*2/55
(3.64%)
0/55
(0%)
55/55
(100%)
Jan – Jun
Jul - Dec
Jan-Dec
* One patient added based on clinical staging
Compiled by L. Day, RN BSN CCM CCRP OCN
2
Mode of Diagnosis
Total Number of Patients =55
Time Frame
Stage 0
Stage I
Stage II
Stage III
Stage IV
Stage
Unassigned
Total
Jan – Jun
Preoperative
Core
5/5
(100%)
13/13
(100%)
*8/8
(100%)
0/0
(0%)
1/1
(100%)
0/0
(0%)
27/27
Jul – Dec
Preoperative
Core
7/7
(100%)
8/8
(100%)
11/11
(100%)
1/1
(100%)
*1/1
(100%)
0/0
(0%)
Jan-Dec
Preoperative
Core
12/55
(21.82%)
21/55
(38.2%)
*19/55
(34.55%)
1/55
(1.82%)
*2/55
(3.64%)
0/0
(0%)
(100%)
28/28
(100%)
55/55
(100%)
100% of patients had diagnosis established on preoperative core needle biopsy
*1 patient added from clinical stage who did not have surgery.
Compiled by L. Day, RN BSN CCM CCRP OCN
3
Tumor Board Discussion
Total Number of Patients =55
Time
Frame
Stage 0
Stage I
Stage II
Stage III
Stage IV
Stage
Unassigned
Total
Jan – Jun
Discussed
4/5
(80%)
13/13
7/7
(100%)
0/0
(0%)
1/1
(100%)
*1/1
(100%)
26/27
(96.3%)
Jul – Dec
Discussed
7/7
(100%)
(100%)
11/11
(100%)
1/1
(100%)
0/0
(0%)
*1/1
(100%)
28/28
(100%)
Jan-Dec
Discussed
11/12
(91.67%
)
21/21
(100%)
18/18
(100%)
1/1
(100%)
1/1
(100%)
*2/2
(100%)
54/55
(98.2%)
(100%)
8/8
98.2% of patients were discussed in the multidisciplinary tumor conference
* clinical staging-patient did not have surgery.
Compiled by L.Day, RN BSN CCM CCRP OCN
4
Multidisciplinary Assessment
(Surgical, Medical and Radiation Oncologist)
Total Number of Patients = 55
Time
Frame
Stage 0
Stage I
Stage II
Stage III
Stage IV
Stage
Unassigned
Total
Jan – Jun
MDC seen
4/5
(80%)
11/13
6/7
(84.62%) (85.7%)
0/0
(0%)
1/1
(100%)
*0/1
(0%)
22/27
(81.48%)
Jul – Dec
MDC seen
7/7
(100%)
8/8
(100%)
10/11
(90.9%)
1/1
(100%)
0/0
(0%)
*1/1
(100%)
27/28
(96.43%)
Jan-Dec
MDC seen
11/12
19/21
16/18
(90.48%)
(88.89%)
1/1
(100%)
1/1
(100%)
*1/2
(50%)
49/55
(89.1%)
(91.67%)
Exceptions:
•
Mastectomy
•
Patients with DCIS
•
Patient choice
•
Patient transferred
•
Patient with comorbidities
*clinical staging-patient did not have surgery
6/55
2/6
1/6
1/6
1/6
1/6
Compiled by L.Day, RN BSN CCM CCRP OCN
5
Nurse Navigation
Total Number of Patients = 55
Time Frame
Stage 0
Stage I
Stage II
Stage III
Stage IV
Stage
Unassigned
Total
Jan – Jun
Assigned
5/5
(100%)
12/13
(92.31%)
7/7
(100%)
0/0
(0%)
1/1
(100%)
*1/1
(100%)
26/27
(96.3%)
Jul – Dec
Assigned
7/7
8/8
(100%)
(100%)
11/11
(100%)
1/1
(100%)
0/0
(0%)
*1/1
(100%)
28/28
(100%)
Jan-Dec
Assigned
12/12
(100%)
20/21
18/18
(100%)
1/1
(100%)
1/1
(100%)
*2/2
(100%)
54/55
(98.2%)
(95.24%)
Exceptions
1/55 (1.82%)
Patient sought second opinion out of area/second primary cancer
*clinical staging-patient did not have surgery
Compiled by L. Day, RN BSN CCM CCRP OCN
6
CAP Compliance
Total Number of Patients = 55
Time Frame
Stage 0
Stage I
Stage II
Stage III
Stage IV
Stage
Unassigned
Total
Jan – Jun
Yes
0/5
(0%)
13/13
(100%)
7/7
(100%)
0/0
(0%)
1/1
(100%)
*0/1
(0%)
21/27
(77.78%)
Jul – Dec
Yes
0/7
(0%)
8/8
(100%)
11/11
(100%)
1/1
(100%)
0/0
(0%)
*0/1
(0%)
20/28
(71.43%)
Jan-Dec
Yes
0/12
(0%)
21/21
(100%)
18/18
(100%)
1/1
(100%)
1/1
(100%)
*0/2
(0%)
41/55
(74.55%)
Exceptions
•
•
•
•
14/55(25.5%)
Margins can not be assessed
Patient transferred
Patient deceased during treatment
DCIS
4/14
1/14
1/14
8/14
*clinical staging-patient did not have surgery
Compiled by L.Day, RN BSN CCM CCRP OCN
7
Axillary Staging
Total Number of Patients = 55
Total Number of Patients with Invasive Cancer = 47
•
•
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
40/40 (100%)
33/40 (82.5%)
Exceptions
7/40 (17.5%)
Pathological stage 0 post-neoadjuvant
SLN during mastectomy for DCIS to avoid missed opportunity
Patient transferred
Patient deceased during treatment
4/7 (57.14%)
1/7 (14.28%)
1/7 (14.28%)
1/7 (14.28%)
•
•
•
•
Compiled by L. Day, RN BSN CCM CCRP OCN
3/47 (6.38%)
1/47 (2.13%)
8
Axillary Dissection
Total Number of Patients = 55
Total Number of Patients with Invasive Cancer = 43
•
•
•
•
Number of patients with stage IV
Number of patients with node positive disease
Number of patients eligible for ALND
Number of patients with ALND
Exceptions
•
•
•
1/43 (2.33%)
17/43 (39.53%)
17
9/17 (52.94%)
10/17 (58.82%)
Patient opted for radiation/hormonal treatment instead of ALND
Patient comorbidities
Pathological stage 0 after neo-adjuvant, negative SLNB
7/10 (70%)
1/10 (10%)
2/10 (20%)
Compiled by L. Day, RN BSN CCM CCRP OCN
9
Breast Conservation
Total Number of Patients = 55
Time
Frame
Stage 0
Stage I
Stage II
Stage III
Stage IV
Stage
Unassigned
Total
Jan – Jun
Yes
2/5
(40%)
11/13
4/7
(84.62%)
(57.14%)
0/0
(0%)
0/1
(0%)
0/1
(0%)
17/27
(62.96%)
Jul – Dec
Yes
6/7
(85.71%)
7/8
(85.7%)
5/11
(45.5%)
1/1
(100%)
0/0
(0%)
0/1
(0%)
19/28
(67.86%)
Jan-Dec
Yes
8/12
(66.67%)
18/21
(85.7%)
9/18
(50%)
1/1
(100%)
0/1
(0%)
0/2
(0%)
36/55
(65.5%)
• Number of early stage pts. (0, I and II) with breast conservation 35/51 (68.6%)
• Mastectomies done
17/55 (30.9%)
•
Exceptions
• Transferred Care
• Deceased during treatment
2/55
1/2
1/2
Compiled by L. Day, RN BSN CCM CCRP OCN
10
Post-lumpectomy Radiation
Total Number of Patients =55
•
•
•
Number of patients with lumpectomy
Number of patients eligible for Radiation
Number of patients radiated
Number of patients radiated within 12 months
•
Exceptions
•
•
•
36/55 (65.5%)
36
32/36 (88.9%)
31/32 (96.9%)
4/36 (11.1%)
Patient with comorbidities
Patient refused to get radiation
Low risk malignancy
1/4 (25%)
2/4 (50%)
1/4 (25%)
Compiled by L. Day, RN BSN CCM CCRP OCN
11
Post-Mastectomy Radiation
Total Number of Patients = 55
•
•
•
Number of patients with mastectomy
Number eligible for radiation (>T3 or >N2)
Number of patients radiated
17/55 (24.3%)
2/17 (27.7%)
2/2 (40%)
Number of patients radiated within 12 months
2/2 (100%)
Exceptions
NONE
Compiled by L. Day, RN BSN CCM CCRP OCN
12
Systemic Chemotherapy – ER Neg.
Total Number of Patients = 55
•
•
•
ER negative patients with cancer
Number eligible for chemotherapy
Number treated with chemotherapy
8/55 (14.5%)
8/8 (100%)
8/8 (100%)
Number with chemotherapy within 4 months
8/8 (100%)
Exceptions
NONE
ER negative post neo-adjuvant stage 0
2/8 (25%)
Compiled by L. Day, RN BSN CCM CCRP OCN
13
Systemic Chemotherapy – ER Pos.
Total Number of Patients = 55
•
ER positive patients with cancer
47/55 (85.5%)
•
Number treated with chemotherapy
18/47(38.3%)
Number with chemotherapy within 4 months
17/18 (94.4%)
Exceptions
1/1 (100%)
Treatment delay due to competing comorbidity
1/1 (100%)
Compiled by L. Day, RN BSN CCM CCRP OCN
14
Systemic Endocrine Therapy
Total Number of Patients = 55
•
•
•
•
•
Number of ER positive patients
Number treated with endocrine therapy
47/55 (85.5%)
42/47 (89.4%)
Exceptions
5/47 (10.64%)
Determined risk > benefit
Patient non compliant
Patient transferred
2/5 (40%)
2/5 (40%)
1/5 (20%)
Number with endocrine therapy within 1 year
41/47 (87.2%)
Compiled by L. Day, RN BSN CCM CCRP OCN
15
Rehabilitation
Total Number of Patients =55
•
Number enrolled in CPRP (PT/OT)
Exceptions
22/55 (40%)
33/55 (60%)
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
Pts. enrolled in CPRP in 2014
Enrollment decline over 2013
24/107 (22.43%)
36/74 (49%)
44/74 (59.5%)
22/55 (40%)
19 .5%
Compiled by L. Day, RN BSN CCM CCRP OCN
16
Genetic Counseling
Total Number of Patients = 55
•
Number of patients with family history or < 45 years
Number received genetic counseling
• Number tested
Positive
Negative
• Number refused testing
• Exceptions-did not meet NCCN guidelines
39/55 (70.9%)
18/39 (46.2%)
16/18 (88.9%)
0/0 (0%)
16/16 (100%)
2/18 (11.1%)
21/39 (53.8%)
Compiled by L. Day, RN BSN CCM CCRP OCN
17
Reconstruction For Mastectomy
Total Number of Patients = 55
• Number of patients with mastectomy
• Number of patients with reconstruction
17/55 (30.91%)
13/17 (76.5%)
Exceptions
6/19 (31.6%)
•
3/6 (50%)
1/6 (16.67%)
2/6 (33.3%)
•
•
Pts. Offered but refused
Stage IV patient with palliative mastectomy
No surgery-deceased or transferred care
Number of patients with reconstruction in 2013
Number of patients with reconstruction in 2014
Improvement over 2013
12/19 (63.2%)
13/17 (76.5%)
13.3%
Compiled by L. Day, RN BSN CCM CCRP OCN
18
Trial Participation
Total Number of Patients = 55
Time
Frame
Jan – Jun
Trial / Study
Eligible
N (%)
Participation
N (%)
B-SMART
4
4 (100%)
NBRST
0
0 (0%)
SPOC
4
4 (100%)
MULTIPLE STUDIES
17
11 (100%)
25/27 (92.6%)
19/25 (76%)
B-SMART
4
4 (100%)
NBRST
2
2 (100%)
SPOC
1
1 (100%)
MULTIPLE STUDIES
17
12 (81.2%)
24/28 (85.7%)
19/24 (79.2%)
49/55 (89.1%)
38/49 (77.6%)
Total
Jul - Dec
Total
GRAND TOTAL
Patients participated in trials for 2014
Compiled by L.Day, RN BSN CCM CCRP OCN
38/55 (69.1%)
19