Quality Assurance Report TTUHSC Breast Center of Excellence January 1, 2013 – December 31, 2013...

Quality Assurance ReportTTUHSC Breast Center of Excellence

January 1, 2013 – December 31, 2013

Compiled by Uzma Nazim, M.D.

Stage DistributionTotal Number of Patients =74

Time Frame

Stage 0 Stage I Stage II Stage III Stage IV Stage Unassigned

Total

Jan – Jun12/37

(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%)

Jul - Dec10/37

(27.02%)12/37

(32.43%)9/37

(24.3%)4/37

(10.8%)2/37

(5.40%)0/37(0%)

37/37(100%)

Jan-Dec22/74

(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%)


Time Frame Stage 0 Stage I Stage II Stage III Stage IV Stage Unassigned

Total

Jan – JunPreoperativeCore

12/12(100%)

15/15(100%)

4/4(100%)

2/3(66.7%)

2/2(100%)

1/1(100%)

36/37(97.3%)

Jul – DecPreoperativeCore

9/10(90%)

13/13(100%)

9/9(100%)

4/4(100%)

1/1(100%)

0/0(0%)

36/37(97.3%)

Jan-DecPreoperativeCore

21/22(95.5%)

28/28(100%)

13/13(100%)

6/7(85.7%)

3/3(100%)

1/1 (100%)

72/74(97.3%)

Mode of DiagnosisTotal Number of Patients =74

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


Tumor Board DiscussionTotal Number of Patients =74

Time Frame


Total

Jan – JunDiscussed

11/12(91.6%)

11/12(91.66%)

4/4(100%)

3/3(100%)

5/5(100%)

0/1(0%)

34/37 (91.9%)

Jul – DecDiscussed

9/10(90%)

12/12(100%)

9/9(100%)

4/4(100%)

2/2(100%)

0(0%)

36/37(97.3%)

Jan-DecDiscussed

20/22(90.9%)

23/24(95.8%)

13/13(100%)

7/7(100%)

7/7(100%)

0/1(0%)

70/74(94.5%)

94.5% of patients were discussed in the multidisciplinary tumor conference


Time Frame


Total

Jan – JunMDC 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 – DecMDC 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-DecMDC 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%)

Multidisciplinary Assessment(Surgical, Medical and Radiation Oncologist)

Total Number of Patients = 74

• Exceptions: 20/74 • Mastectomy 6/20• Patients with DCIS 6/20• Patient deceased 2/20 • Patient transferred 2/20 • Patients with advanced metastatic disease 4/20



Total

Jan – JunAssigned

12/12(100%)

15/15(100%)

4/4(100%)

3/3(100%)

2/2(100%)

0/1(0%)

36/37(97.3%)

Jul – DecAssigned

10/10(100%)

13/13(100%)

9/9(100%)

4/4(100%)

1/1(100%)

0(0%)

37/37(100%)

Jan-DecAssigned

22/22(100%)

28/28(100%)

13/13(100%)

7/7(100%)

3/3(100%)

0/1(0%)

73/74(98.65%)

Nurse NavigationTotal Number of Patients = 74

Exceptions 1/74 (1.35%)

Patient sought treatment in Mexico



Total

Jan – JunYes

0/12(0%)

15/15(100%)

4/4(100%)

3/3(100%)

0/2(0%)

0/1(0%)

22/37(59.4%)

Jul – DecYes

1/10(10%)

11/13(84.6%)

8/9(88.9%)

3/4(75%)

0/1(0%)

0(0%)

23/37(62.16%)

Jan-DecYes

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%)

CAP ComplianceTotal Number of Patients = 74


Exceptions 29/74(39%)

•Margins can not be assessed 9/29 •Patient transferred 3/29•Patient deceased during treatment 3/29•Mastectomy 5/29•Surgery not done 3/29•DCIS 6/29

Axillary StagingTotal Number of Patients = 74

Total Number of Patients with Invasive Cancer = 52

• Number node positive patients on needle biopsy 9/52(17.30%) • Number of pts. with Stage IV disease 3/52(5.76%)•

• Number of patients eligible for SLNB 40/74(54.05%)• Number of patients with SLNB 31/40(77.5%)

Exceptions 9/40(22.5%)• Determined low risk (unlikely to change treatment plan) 7/9(77.7%)• Patient transferred 2/9(22.22%)


Axillary DissectionTotal Number of Patients = 74

Total Number of Patients with Invasive Cancer =52

• Number of patients with stage IV 3/52(5.76%)• Number of patients with node positive disease 18/52(34.61%) • Number of patients eligible for ALND 18 • Number of patients with ALND 7/18(38.9%)

Exceptions 11/18(61.11%) Low risk for non-SLN mets. on MSKCC nomogram 7/11(63.6%) Patient deceased before final surgery 1/11(9%) Surgery done at some other facility 1/11(9%) Final surgery not done yet 2/11(18.18%)


Time Frame


Total

Jan – JunYes

9/12(75%)

15/15(100%)

4/4(100%)

1/3(33.3%)

0/2(0%)

0/1(0%)

29/37(78.4%)

Jul – DecYes

8/10(80%)

6/13(46.1%)

6/9(66.6%)

2/4(50%)

0/1(0%)

0(0%)

22/37(59.5%)

Jan-DecYes

17/22(77.27%)

21/28(75%)

10/13(76.9%)

3/7(42.8%)

0/3(0%)

0/1(0%)

51/74(69%)

Breast ConservationTotal Number of Patients = 74

•Number of early stage pts. (0, I and II) with breast conservation 48/63(76.1%)•Mastectomies done 18/74(24.3%)


Post-lumpectomy RadiationTotal Number of Patients =74

• Number of patients with lumpectomy 51/74 (68.9%)• Number of patients eligible for Radiation 51• Number of patients radiated 43/51(86.2%)

Number of patients radiated within 12 months 43/43(100%)

Exceptions 8/51(15.7%)

• Patient had mastectomy after initial lumpectomy 2/8(25%)• Patient with small DCIS in prior radiation field 1/8(12.5%)• Patient deceased during chemotherapy 1/8(12.5%)• Patient refused to get radiation 4/8(50%)


Post-Mastectomy RadiationTotal Number of Patients = 74

• Number of patients with mastectomy 18/74 (24.3%)• Number eligible for radiation (>T3 or >N2) 5/18(27.7%)• Number of patients radiated 2/5(40%)

Number of patients radiated within 12 months 2/2 (100%)

Exceptions 3/5(60%)

•Patient refused radiation 1 /3(33.3%)•Patient got treatment from other facility 1/3( 33.3%)•Patient deceased during chemotherapy 1/3(33.3%)


Systemic Chemotherapy - ITotal Number of Patients = 74

• ER negative patients with cancer 12/74 (16.2%)

• ER negative patients with DCIS 2/12(16.66%) • Number eligible for chemotherapy (exclude DCIS) 10/12(83.3%)• Number treated with chemotherapy 10/10 (100%)

Exceptions 0 Number with chemotherapy within 4 months 10/10(100%)


Systemic Chemotherapy - IITotal 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%)


Systemic Endocrine TherapyTotal Number of Patients = 74

• Number of ER positive patients 62/74 (83.78%)• Number treated with endocrine therapy 48/62 (77.4%)


• Determined risk > benefit 3/14 (21.4%) • Patients with co morbidities 3/14 (21.4%)• Patient non compliant 2/14(14.2%)• Patient transferred 3/14(21.4%)• Patient deceased 3/14(21.4%) • Number with endocrine therapy within 1 year 48/48 (100%)


RehabilitationTotal Number of Patients =74

• Number enrolled in CPRP (PT/OT) 44/74 (59.5%)

Exceptions 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 24/107 (22.43%)• Pts. enrolled in CPRP in 2012 36/74 (49%)• Pts. enrolled in CPRP in 2013 44/74(59.5%)• Improvement over 2012 10 .5%


Genetic CounselingTotal Number of Patients = 74

• Number of patients with family history or < 45 years 49/74 (66.2%)

Number received genetic counseling 20/49(41%)• Number tested 13/20(65%)

Positive 4/13(30%) Negative 9/13(70%)

• Number refused testing 3/20(15%)• Patient transferred to Mexico 1/20(5%)• No documentation in the chart 3/20(15%)

Exceptions 29/49(59%)


Reconstruction For MastectomyTotal Number of Patients = 74

• Number of patients with mastectomy 18/74 (24.32%)• Number of patients with reconstruction 12/18(66.66%)


• Pts. Offered but refused 5/6(83.33%)• Stage IV patient with palliative mastectomy 1/6(16.66%)

Number of patients with reconstruction in 2012 9/20(45%) Improvement over 2012 21.66%



Trial ParticipationTotal Number of Patients = 74

Patients participated in trials for 2012 53/71(75%)

Quality Assurance Report TTUHSC Breast Center of Excellence January 1, 2013 – December 31, 2013...

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