Quality Assurance ReportTTUHSC Breast Center of Excellence

January 1, 2012 – December 31, 2012

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 – 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.

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

Total

Jan – JunPreoperativeCore

9/9(100%)

22/22(100%)

9/9(100%)

3/4(75%)

1/1(100%)

1/1(100%)

45/46(97.82%)

Jul – DecPreoperativeCore

4/6(66.6%)

9/10(90%)

9/9(100%)

0/0(0%)

0/0(0%)

2/3(66.6%)

24/28(85.71%)

Jan-DecPreoperativeCore

13/15(86.6%)

31/32(96.8%)

18/18(100%)

3/4(75%)

1/1(100%)

3/4 (75%)

69/74(93.24%)

Mode of DiagnosisTotal Number of Patients = 74

93.24% of patients had diagnosis established on preoperative core needle biopsyExceptions•Pt. with ADH on core biopsy 1/5•Pts. with implants 2/5 •Pt. with recurrence after 2009 palliative excision done 1/5•Pt. unable to lie prone for stereotactic bx. 1/5

Compiled by Uzma Nazim, M.D.

Tumor Board DiscussionTotal Number of Patients =74

Time Frame

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

Total

Jan – JunDiscussed

8/9(88.8%)

20/22(90.9%)

9/9(100%)

3/4(75%)

1/1(100%)

1/1(100%)

42/46 (91.3%)

Jul – DecDiscussed

4/6(66.6%)

6/9(66.6%)

7/9(77.7%)

0(0%)

1/1(100%)

3/3(100%)

21/28(75%)

Jan-DecDiscussed

12/15(80%)

26/31(83.8%)

16/18(89%)

3/4(75%)

2/2(100%)

4/4(100%)

63/74 (85.1%)

85.1% of patients were discussed in the multidisciplinary tumor conference

Compiled by Uzma Nazim, M.D.

Time Frame

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

Total

Jan – JunMDC seen

8/9(88.8%)

19/22(86.3%)

7/9(77.7%)

4/4 (100%)

1/1(100%)

0/1(0%)

39/46(84.78%)

Jul – DecMDC seen

5/6(83.3%)

8/10(80%)

6/9(66.6%)

0(0%)

0(0%)

3/3(100%)

22/28(79%)

Jan-DecMDC seen

13/15(87%)

27/32(84%)

13/18(72.22%)

4/4(100%)

1/1(100%)

3/4(75%)

61/74(82.4%)

Multidisciplinary Assessment(Surgical, Medical and Radiation Oncologist)

Total Number of Patients = 74

Exceptions: 13/74 (17.56%) • Older than 70 yrs. declined radiation appointment in favor of mastectomy 7/13(53.84%) • Under 70 yrs. declined radiation appointment in favor of mastectomy 5/13(38.46%)• Patient transferred 1/13(7.6%)Compiled by Uzma Nazim, M.D.

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

Total

Jan – JunAssigned

9/9(100%)

21/22(95.4%)

9/9(100%)

3/4(75%)

1/1(100%)

1/1(100%)

44/46(95.65%)

Jul – DecAssigned

6/6(100%)

9/10(90%)

9/9(100%)

0(0%)

0(0%)

3/3(100%)

27/28(96.4%)

Jan-DecAssigned

15/15(100%)

30/32(93.7%)

18/18(100%)

3/4(75%)

1/1(100%)

4/4(100%)

71/74(95.9%)

Nurse NavigationTotal Number of Patients = 74

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.

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

Total

Jan – JunYes

9/9(100%)

22/22(100%)

8/9(88.8%)

4/4(100%)

0/1(0%)

0/1(0%)

43/46(93.4%)

Jul – DecYes

6/6(100%)

10/10(100%)

9/9(100%)

0(0%)

0(0%)

0/3(0%)

25/28(89.3%)

Jan-DecYes

15//15(100%)

32/32(100%)

17/18(94.4%)

4/4(100%)

0/1(0%)

0/4(0%)

68/74(92%)

CAP ComplianceTotal Number of Patients = 74

Compiled by Uzma Nazim, M.D.

Exceptions 6/74 (8.1%)

•Final surgery not done 5/6 (83.3%)•Patient transferred 1/6 (16.66%)

Axillary StagingTotal Number of Patients = 74

Total Number of Patients with Invasive Cancer = 59

• Number node positive patients on needle biopsy 5/59 (8.47%)• Number of pts. with Stage IV disease 1/59(1.69%)• Number of patients eligible for SLNB 53/59(89.8%)

– Number of patients with SLNB 46/53 (86.79%)

• Exceptions 7/53(13.2%) Determined low risk (unlikely to change treatment plan) 6/7(85.7%)

Patient transferred 1/7(14.28%)

Compiled by Uzma Nazim, M.D.

Axillary DissectionTotal Number of Patients = 74

Total Number of Patients with Invasive Cancer = 59

• Number of patients with stage IV 1/59 (1.69%)• Number of patients with node positive disease 20/59(33.8%)• Number of patients eligible for ALND 20• Number of patients with ALND 13/20 (65%)

• Exceptions 7/20 (35%) Low risk for non-SLN mets. on MSKCC nomogram 6/7 (85.7%)

Final surgery not done yet 1/7 (14.28%)

Compiled by Uzma Nazim, M.D.

Time Frame

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

Total

Jan – JunYes

6/9(66.66%)

18/22(81.8%)

5/9(56%)

2/4(50%)

0/1(0%)

0/1(0%)

31/46(67.39%)

Jul – DecYes

4/6(66.6%)

8/10(80%)

5/9(56%)

0(0%)

0(0%)

0/3(0%)

17/28(60.71%)

Jan-DecYes

10/15(66.6%)

26/32(81.25%)

10/18(56%)

2/4(50%)

0/1(0%)

0/4(0%)

48/74(64.9%)

Breast ConservationTotal Number of Patients = 74

•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 RadiationTotal Number of Patients =74

• Number of patients with lumpectomy 48/74 (64.8%)• Number of patients eligible for Radiation 48

– Number of patients radiated 44/48 (91.66%)

Exceptions 4/48(8.3%)• Co-morbidity and age >70 yrs. 1/4 (25%)• Patient had mastectomy after initial lumpectomy 3/4 (75%)

• Number of patients radiated within 12 months 44/44(100%)

Compiled by Uzma Nazim, M.D.

Post-Mastectomy RadiationTotal Number of Patients = 74

• Number of patients with mastectomy 20/74 (27%)• Number eligible for radiation (>T3 or >N2) 2/20(10%)

• Number of patients radiated 2/2(100%)

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

Compiled by Uzma Nazim, M.D.

Systemic Chemotherapy - ITotal Number of Patients = 74

ER negative patients with cancer 13/74 (17.56%)• Number eligible for chemotherapy (exclude DCIS) 12/13 (92.3%)

– Number treated with chemotherapy 9/12 (75%)

• Exceptions 3/12 (25%) Patient refused 1/3 (33.3%) Severe co-morbidities and age 2/3(66.6%)

Number with chemotherapy within 4 months 9/9(100%)

• Exceptions 0 (none)

Compiled by Uzma Nazim, M.D.

Systemic Chemotherapy - IITotal Number of Patients = 74

ER positive patients with cancer 61/74 (82.43%)

• Number treated with chemotherapy 23/61 (37.78%)

Number with chemotherapy within 4 months 20/23 (87%)

• Exceptions 3/23(13%)• Pt. developed mirizzi’s syndrome 1/3(33.3%)• Pt. had wound infection 1/3(33.3%)• Chemo was within 4 months from cancer diagnosis original biopsy showed ADH 1/3(33.3%)

Compiled by Uzma Nazim, M.D.

Systemic Endocrine TherapyTotal Number of Patients = 74

Number of ER positive patients 61/74 (82.43%)• Number treated with endocrine therapy 52/61 (85.24%)

• Exceptions 9/61 (14.75%) Determined risk > benefit 5/9 (55.6%) Patients with co morbidities 3/9 (33.33%)

Patient non compliant 1/9 (11.11%)

Number with endocrine therapy within 1 year 52/52 (100%)

Compiled by Uzma Nazim, M.D.

RehabilitationTotal 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 24/107 (22.43%)• Pts. enrolled in CPRP in 2012 36/74 (49%)• Improvement over 2011 26.57%

Compiled by Uzma Nazim, M.D.

Genetic CounselingTotal Number of Patients = 74

• Number of patients with family history or < 45 years 49/74 (66.2%)• Number received genetic counseling 19/49(39%)

– Number tested 14/19(74%)• Positive 3/14(21.4%)• Negative 11/14(79%)

– Number refused testing 5/19(26.3%)

• Exceptions 30/49(61.2%) Did not meet NCCN criteria 24/30(80%) No documentation in the chart 6/30(20%)

Compiled by Uzma Nazim, M.D.

Compiled by Uzma Nazim, M.D.

Trial ParticipationTotal Number of Patients = 74

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