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OBJECTIVE: Test the effectiveness of benchmarked performance reports based on existing discharge data paired with a statewide intervention to implement evidence-based strategies on breast re-excision rates. BACKGROUND: Breast-conserving surgery (BCS) is a common breast cancer surgery performed in a range of hospital settings. Studies have demonstrated variations in post-BCS re-excision rates, identifying it as a high-value improvement target. METHODS: Wisconsin Hospital Association discharge data (2017-2019) were used to compare 60-day re-excision rates following BCS for breast cancer. The analysis estimated the difference in the average change preintervention to postintervention between Surgical Collaborative of Wisconsin (SCW) and nonparticipating hospitals using a logistic mixed-effects model with repeated measures, adjusting for age, payer, and hospital volume, including hospitals as random effects. The intervention included 5 collaborative meetings in 2018 to 2019 where surgeon champions shared guideline updates, best practices/challenges, and facilitated action planning. Confidential benchmarked performance reports were provided. RESULTS: In 2017, there were 3692 breast procedures in SCW and 1279 in nonparticipating hospitals; hospital-level re-excision rates ranged from 5% to >50%. There was no statistically significant baseline difference in re-excision rates between SCW and nonparticipating hospitals (16.1% vs. 17.1%, P =0.47). Re-excision significantly decreased for SCW but not for nonparticipating hospitals (odds ratio=0.69, 95% confidence interval=0.52-0.91). CONCLUSIONS: Benchmarked performance reports and collaborative quality improvement can decrease post-BCS re-excisions, increase quality, and decrease costs. Our study demonstrates the effective use of administrative data as a platform for statewide quality collaboratives. Using existing data requires fewer resources and offers a new paradigm that promotes participation across practice settings.
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Neoplasias de la Mama , Carcinoma Ductal de Mama , Neoplasias de la Mama/cirugía , Carcinoma Ductal de Mama/cirugía , Femenino , Hospitales , Humanos , Mastectomía , Mastectomía Segmentaria , Reoperación , Estudios RetrospectivosRESUMEN
BACKGROUND: One in five patients undergoing initial lumpectomy for invasive breast cancer subsequently undergoes re-excision or mastectomy. A lack of clarity of when to re-excise based on lumpectomy margin width contributes to this high rate of reoperation. We sought to determine the impact of the Society of Surgical Oncology (SSO) and American Society of Radiation Oncologist (ASTRO) margin guideline on reoperation rates after lumpectomy. The guideline recommended omission of routine re-excision in specimens with "no ink on tumor". METHODS: A systematic literature review was performed. For eligible studies, a random-effects model was used for a meta-analysis of lumpectomy re-excision prevalence before and after publication of the SSO-ASTRO margin guideline. Study heterogeneity was measured by the Cochran's Q test. RESULTS: Five institutional, one population-based, and one national registry study met inclusion requirements. Sample size per study ranged from 237 to 26,102. There was significant interstudy heterogeneity (Q = 19.779; p = 0.003). Pooled re-excision prevalence was 22% (confidence interval [CI] 20-23) before and 14% (CI 12-15) after guideline publication. With the pre-guideline re-excision prevalence used as the reference value, the associated odds ratio for re-excision after the guideline was 0.65 (CI 0.54-0.78; p < 0.0001). CONCLUSIONS: The findings of a 35% reduction in the odds of re-excision after the guideline publication and a reduction in re-excision prevalence from 22 to 14% supports the notion that the SSO-ASTRO margin guideline was impactful. These findings are congruent with the projected reductions in re-excision at the time of guideline publication.
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Neoplasias de la Mama/cirugía , Adhesión a Directriz/normas , Márgenes de Escisión , Mastectomía/normas , Guías de Práctica Clínica como Asunto/normas , Pautas de la Práctica en Medicina/normas , Neoplasias de la Mama/patología , Femenino , Humanos , Oncólogos de Radiación , Reoperación , Oncología Quirúrgica , Estados UnidosRESUMEN
BACKGROUND: More than 20% of patients undergoing initial breast-conserving surgery (BCS) for cancer require reoperation. To address this concern, the American Society of Breast Surgeons (ASBrS) endorsed 10 processes of care (tools) in 2015 to be considered by surgeons to de-escalate reoperations. In a planned follow-up, we sought to determine which tools were associated with fewer reoperations. METHODS: A cohort of ASBrS member surgeons prospectively entered data into the ASBrS Mastery® registry on consecutive patients undergoing BCS in 2017. The association between tools and reoperations was estimated via multivariate and hierarchical ranking analyses. RESULTS: Seventy-one surgeons reported reoperations in 486 (12.3%) of 3954 cases (mean 12.7% [standard deviation (SD) 7.7%], median 11.5% [range 0-32%]). There was an eightfold difference between surgeons in the 10th and 90th percentile performance groups. Actionable factors associated with fewer reoperations included routine planned cavity side-wall shaves, surgeon use of ultrasound (US), neoadjuvant chemotherapy, intra-operative pathologic margin assessment, and use of a pre-operative diagnostic imaging modality beyond conventional 2D mammography. For patients with invasive cancer, ≥ 24% of those who underwent reexcision did so for reported margins of < 1 or 2 mm, representing noncompliance with the SSO-ASTRO margin guideline. CONCLUSIONS: Although ASBrS member surgeons had some of the lowest rates of reoperation reported in any registry, significant intersurgeon variability persisted. Further efforts to lower rates are therefore warranted. Opportunities to do so were identified by adopting those processes of care, including improved compliance with the SSO-ASTRO margin guideline, which were associated with fewer reoperations.
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Neoplasias de la Mama/cirugía , Mastectomía Segmentaria/normas , Guías de Práctica Clínica como Asunto/normas , Pautas de la Práctica en Medicina/normas , Reoperación , Cirujanos/normas , Anciano , Anciano de 80 o más Años , Neoplasias de la Mama/patología , Carcinoma Ductal de Mama/patología , Carcinoma Ductal de Mama/cirugía , Carcinoma Lobular/patología , Carcinoma Lobular/cirugía , Femenino , Estudios de Seguimiento , Humanos , Márgenes de Escisión , Persona de Mediana Edad , Pronóstico , Estudios Prospectivos , Sociedades MédicasRESUMEN
The Disclosures in the original article are incomplete. Not included is the following information.
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PURPOSE: To improve understanding of how people diagnosed with cancer perceive the term "cancer survivor" and what influences those perceptions. DESIGN: Patients' reactions to the term were surveyed quantitatively and qualitatively. SAMPLE: Women who have primarily experienced breast cancer belonging to The Dr. Susan Love Research Foundation's Army of Women. METHODS: An online survey including fixed-alternative and open-ended questions. CONCLUSIONS: Using the blanket term "survivor" to label a diverse group is problematic; although the term offers a positive identity for some, others reject it or find it offensive, at least for patients like those represented in this study. If cancer patients are going to be labeled, they should choose the one that is most empowering and reflective of their experience. Implications for Psychosocial Providers: Language used in providing care or describing patients is controllable. If evidence exists that a particular term has the potential to inflict psychological harm, why use the term?
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Supervivientes de Cáncer/psicología , Terminología como Asunto , Adulto , Anciano , Anciano de 80 o más Años , Neoplasias de la Mama/diagnóstico , Neoplasias de la Mama/terapia , Femenino , Humanos , Masculino , Persona de Mediana Edad , Neoplasias/diagnóstico , Neoplasias/terapia , Investigación Cualitativa , Encuestas y CuestionariosRESUMEN
In the original article the correct citation for where Massachusetts General Hospital (MGH) is mentioned throughout the text.
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BACKGROUND: Patients want information to search for destination of care for breast-conserving surgery (BCS). To inform patients wanting a lumpectomy, we aimed to develop a pilot project that communicated composite quality measure (QM) results using a '4-star' rating system. Two patient-centered QMs were included in the model-reoperation rate (ROR) and cosmetic outcome (COSM). METHODS: A prospective database was reviewed for stage 0-3 patients undergoing initial lumpectomy by three surgeons from 2010 to 2015. Self-reported COSM was assessed by survey. Multivariate analyses were used to test for interactions between surgeon and other variables known to influence RORs and COSMs. Models of surgeon profiling were developed that summed the ROR and COSM performance scores, then reported results using a Centers for Medicare and Medicaid Services (CMS) star-type system. Functionality for a patient to 'weight' the importance of the ratio of ROR:COSM before profiling was introduced. RESULTS: The unadjusted ROR for stage 1-3 patients for three surgeons was 9.5, 13.0, and 16.3%, respectively (p = 0.179) [overall rate 10.4% (38/366)]. After risk adjustment, differences between surgeons were observed for RORs, but not COSMs. Overall, patients reported excellent, good, fair, and poor COSMs of 55, 30, 11 and 4%, respectively. Composite star scores reflected differences in performance by surgeon, which could increase, or even disappear, dependent on the patient's weighting of the ROR:COSM ratio. CONCLUSION: Composite measures of performance can be developed that allow patients to input their weighted preferences and values into surgeon profiling before they consider a destination of care for BCS.
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Neoplasias de la Mama/patología , Neoplasias de la Mama/cirugía , Cosméticos , Mastectomía Segmentaria , Prioridad del Paciente , Reoperación/estadística & datos numéricos , Cirujanos/normas , Anciano , Carcinoma Ductal de Mama/patología , Carcinoma Ductal de Mama/cirugía , Carcinoma Intraductal no Infiltrante/patología , Carcinoma Intraductal no Infiltrante/cirugía , Carcinoma Lobular/patología , Carcinoma Lobular/cirugía , Competencia Clínica , Femenino , Estudios de Seguimiento , Humanos , Persona de Mediana Edad , Invasividad Neoplásica , Evaluación de Resultado en la Atención de Salud , Pronóstico , Estudios ProspectivosRESUMEN
BACKGROUND: Up to 50% of all women encounter benign breast problems. In contrast to breast cancer, high-level evidence is not available to guide treatment. Management is therefore largely based on individual physician experience/training. The American board of internal medicine (ABIM) initiated its Choosing Wisely® campaign to promote conversations between patients and physicians about challenging the use of tests or procedures which may not be necessary. The American society of breast surgeons (ASBrS) Patient safety and quality committee (PSQC) chose to participate in this campaign in regard to the management of benign breast disease. METHODS: The PSQC solicited initial candidate measures. PSQC surgeons represent a wide variety of practices. The resulting measures were ranked by modified Delphi appropriateness methodology in two rounds. The final list was approved by ASBrS and endorsed by the ABIM. RESULTS: The final five measures are as follows. (1) Don't routinely excise areas of pseuodoangiomatous stromal hyperplasia (PASH) of the breast in patients who are not having symptoms from it. (2) Don't routinely surgically excise biopsy-proven fibroadenomas that are < 2 cm. (3) Don't routinely operate for a breast abscess without an initial attempt to percutaneously aspirate. (4) Don't perform screening mammography in asymptomatic patients with normal exams who have less than a 5-years life expectancy. (5) Don't routinely drain nonpainful, fluid-filled cysts. CONCLUSIONS: The ASBrS Choosing Wisely® measures that address benign breast disease management are easily accessible to patients via the internet. Consensus was reached by PSQC regarding these recommendations. These measures provide guidance for shared decision-making.
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Neoplasias de la Mama/terapia , Conducta de Elección , Toma de Decisiones , Guías de Práctica Clínica como Asunto/normas , Oncología Quirúrgica/normas , Neoplasias de la Mama/psicología , Femenino , Humanos , Participación del Paciente , Sociedades Médicas , Estados UnidosRESUMEN
BACKGROUND: Nine breast cancer quality measures (QM) were selected by the American Society of Breast Surgeons (ASBrS) for the Centers for Medicare and Medicaid Services (CMS) Quality Payment Programs (QPP) and other performance improvement programs. We report member performance. STUDY DESIGN: Surgeons entered QM data into an electronic registry. For each QM, aggregate "performance met" (PM) was reported (median, range and percentiles) and benchmarks (target goals) were calculated by CMS methodology, specifically, the Achievable Benchmark of Care™ (ABC) method. RESULTS: A total of 1,286,011 QM encounters were captured from 2011-2015. For 7 QM, first and last PM rates were as follows: (1) needle biopsy (95.8, 98.5%), (2) specimen imaging (97.9, 98.8%), (3) specimen orientation (98.5, 98.3%), (4) sentinel node use (95.1, 93.4%), (5) antibiotic selection (98.0, 99.4%), (6) antibiotic duration (99.0, 99.8%), and (7) no surgical site infection (98.8, 98.9%); all p values < 0.001 for trends. Variability and reasons for noncompliance by surgeon for each QM were identified. The CMS-calculated target goals (ABC™ benchmarks) for PM for 6 QM were 100%, suggesting that not meeting performance is a "never should occur" event. CONCLUSIONS: Surgeons self-reported a large number of specialty-specific patient-measure encounters into a registry for self-assessment and participation in QPP. Despite high levels of performance demonstrated initially in 2011 with minimal subsequent change, the ASBrS concluded "perfect" performance was not a realistic goal for QPP. Thus, after review of our normative performance data, the ASBrS recommended different benchmarks than CMS for each QM.
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Benchmarking , Neoplasias de la Mama/diagnóstico , Neoplasias de la Mama/terapia , Garantía de la Calidad de Atención de Salud , Mejoramiento de la Calidad , Indicadores de Calidad de la Atención de Salud , Cirujanos/normas , Femenino , Humanos , Evaluación de Resultado en la Atención de Salud , Sistema de Registros , Mecanismo de Reembolso , Autoinforme , Estados UnidosRESUMEN
INTRODUCTION: Past studies indicate delays in adoption of consensus-based guideline updates. In June 2016, the National Comprehensive Cancer Network changed its guidelines from routine testing to omission of ordering complete blood cell count (CBC) and liver function tests (LFT) in patients with early breast cancer. In response, we developed an implementation strategy to discontinue our historical practice of routine ordering of these tests in asymptomatic patients. METHODS: The ordering of CBC and LFT for clinical stage I-IIIA breast cancer patients was audited in 2016. In June 2016, we utilized the levers of the National Quality Strategy implementation methodology to enact a system-wide change to omit routine ordering. To measure the plan's effectiveness, guideline compliance for ordering was tracked continually. RESULTS: Of 92 patients with early stage cancer in 2016, the overall rate of compliance with guidelines for ordering a CBC and LFT was 82% (88/107) and 87% (93/107), respectively. Segregated by the pre- and post-guideline change time period, the compliance rates for ordering a CBC and LFT were 78% and 87% (P = 0.076). CONCLUSION: In contrast to historical reports of delays in adoption of new evidence-based guideline changes, we were able to quickly change provider practice during the transition from routine ordering to omission of ordering screening blood tests in newly diagnosed patients with early breast cancer.
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Neoplasias de la Mama/diagnóstico , Neoplasias de la Mama/economía , Pruebas Diagnósticas de Rutina/economía , Pruebas Diagnósticas de Rutina/normas , Adhesión a Directriz , Tamizaje Masivo/economía , Tamizaje Masivo/normas , Pautas de la Práctica en Medicina/economía , Pautas de la Práctica en Medicina/estadística & datos numéricos , Adulto , Anciano , Neoplasias de la Mama/patología , Análisis Costo-Beneficio , Medicina Basada en la Evidencia , Femenino , Humanos , Persona de Mediana Edad , Estadificación de Neoplasias , Estados UnidosRESUMEN
BACKGROUND: In February 2014 , the Society of Surgical Oncology and the American Society for Radiation Oncology released guidelines standardizing a negative margin after breast-conserving surgery (BCS) as "no ink on tumor" in patients with early-stage invasive cancer. We sought to determine whether reexcision rates after initial BCS decreased after guideline publication, using the ASBrS MasterySM of Breast Surgery Program. METHODS: Between January 2013 and June 2015, data from the ASBrS MasterySM database was analyzed to determine reexcision rates pre and post guideline publication. Reasons for reexcision were evaluated as were the associations with patient and provider characteristics. Chi square test, Fisher's exact test, Student's t test, ANOVA, and multivariable logistic regression were used as appropriate. All analyses were performed using Microsoft Excel and SPSS, with p value <0.05 as significant. RESULTS: Among 252 providers, the overall reexcision rate after initial BCS decreased by 3.7 % from 20.2 to 16.5 % (p < 0.001). Notable was a 13.8 % decrease (p < 0.001) in reexcisions being done for close margins. Of the analyzed physician and patient characteristics the majority of subgroups showed decreases between the two time periods; however, only "Percent Breast Surgery in Practice" was significant. On adjusted analysis, there were no specific patient factors associated with a reduction in reexcision rates. CONCLUSIONS: Following the SSO-ASTRO "no ink on tumor" guideline publication, a reduction in overall reexcision rates and reexcision rates for close margins after initial BCS was observed in the ASBrS MasterySM database. More widespread implementation outside this group of early adopters is anticipated with ongoing dissemination.
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Neoplasias de la Mama/cirugía , Mastectomía Segmentaria/normas , Guías de Práctica Clínica como Asunto , Pautas de la Práctica en Medicina/estadística & datos numéricos , Femenino , Humanos , Márgenes de Escisión , Invasividad Neoplásica , ReoperaciónRESUMEN
BACKGROUND: Reoperations occur frequently after initial lumpectomy for breast cancer. The authors hypothesized that the receipt of neoadjuvant chemotherapy (NAC) is associated with fewer reoperations. METHODS: The association between timing of chemotherapy and reoperation rates (ROR) after lumpectomy was investigated for patients with stages 1-3 breast cancer in the National Cancer Database (NCDB) from 2010 to 2013 by multivariable logistic regression modeling. Then propensity score-matching was performed. RESULTS: The unadjusted ROR for 71,627 stages 1-3 patients was 11.4% for those who had NAC compared with 20.3% for those who had postoperative chemotherapy (p < 0.001) (odds ratio [OR] 0.53; 95% confidence interval [CI] 0.49-0.57; p < 0.001). The ORs for the reoperations performed for patients with stages 1, 2, and 3 cancers who received NAC were respectively 0.65 (95% CI 0.56-0.75), 0.50 (95% CI 0.45-0.56), and 0.27 (95% CI 0.19-0.38) The p values for all were lower than 0.001. CONCLUSION: For a population of patients receiving chemotherapy, the receipt of chemotherapy before instead of after surgery was associated with fewer reoperations after initial lumpectomy for breast cancer.
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Neoplasias de la Mama/cirugía , Quimioterapia Adyuvante/estadística & datos numéricos , Bases de Datos Factuales , Mastectomía , Terapia Neoadyuvante/estadística & datos numéricos , Reoperación/estadística & datos numéricos , Segunda Cirugía/estadística & datos numéricos , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Neoplasias de la Mama/tratamiento farmacológico , Neoplasias de la Mama/patología , Femenino , Estudios de Seguimiento , Humanos , Persona de Mediana Edad , Pronóstico , Tasa de Supervivencia , Adulto JovenRESUMEN
BACKGROUND: To identify and remediate gaps in the quality of surgical care, the American Society of Breast Surgeons (ASBrS) developed surgeon-specific quality measures (QMs), built a patient registry, and nominated itself to become a Center for Medicare and Medicaid Services (CMS) Qualified Clinical Data Registry (QCDR), thereby linking surgical performance to potential reimbursement and public reporting. This report provides a summary of the program development. METHODS: Using a modified Delphi process, more than 100 measures of care quality were ranked. In compliance with CMS rules, selected QMs were specified with inclusion, exclusion, and exception criteria, then incorporated into an electronic patient registry. After surgeons entered QM data into the registry, the ASBrS provided real-time peer performance comparisons. RESULTS: After ranking, 9 of 144 measures of quality were chosen, submitted, and subsequently accepted by CMS as a QCDR in 2014. The measures selected were diagnosis of cancer by needle biopsy, surgical-site infection, mastectomy reoperation rate, and appropriateness of specimen imaging, intraoperative specimen orientation, sentinel node use, hereditary assessment, antibiotic choice, and antibiotic duration. More than 1 million patient-measure encounters were captured from 2010 to 2015. Benchmarking functionality with peer performance comparison was successful. In 2016, the ASBrS provided public transparency on its website for the 2015 performance reported by our surgeon participants. CONCLUSIONS: In an effort to improve quality of care and to participate in CMS quality payment programs, the ASBrS defined QMs, tracked compliance, provided benchmarking, and reported breast-specific QMs to the public.
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Benchmarking , Neoplasias de la Mama/cirugía , Mastectomía , Garantía de la Calidad de Atención de Salud , Mecanismo de Reembolso/normas , Cirujanos/normas , Neoplasias de la Mama/diagnóstico , Femenino , Humanos , Medicare , Indicadores de Calidad de la Atención de Salud , Sistema de Registros , Reoperación , Sociedades Médicas , Estados UnidosRESUMEN
The purpose of this study was to determine if receipt of chemotherapy was associated with utilization of the 21-gene recurrence score assay (RS assay) or with recurrence score (RS) in eligible patients. Using the National Cancer Data Base (NCDB), we identified female patients eligible for RS assay based on National Comprehensive Cancer Network (NCCN) guidelines: age 18-70, ER-positive and HER2-negative early-stage breast cancer diagnosed during 2010-2013. We excluded patients not meeting testing guidelines. Inclusion required result of RS in patients who underwent RS assay and status for receipt of chemotherapy. Multivariable logistic regression models and propensity matched analysis were used to determine associations between RS assay and RS with receipt of chemotherapy. Among 129,765 patients who were eligible, 74,778 underwent RS assay and had results available. Of these, 59.5 % (44,505) had low-risk, 32.0 % (23,920) had intermediate-risk, and 8.5 % (6353) had high-risk RS. Patients with intermediate- and high-risk RS were more likely to receive chemotherapy [OR 12.9 (CI 12.2-13.6), p <0.001 and OR 87.2 (CI 79.6-95.6), p <0.0001], respectively. In both low- and intermediate-risk groups, increasing RS score was significantly associated with increasing odds of receiving chemotherapy [OR 1.10 (CI 1.09-1.12), p <0.0001 and OR 1.26 (CI 1.25-1.27), p <0.0001, respectively, for each point increase in RS]. Receipt of chemotherapy was more likely in patients who did not undergo RS assay compared to those who did, OR 1.21 (CI 1.175-1.249) p <0.0001. The utilization of RS assay and the RS were both strongly associated with chemotherapy receipt. Patients eligible for chemotherapy, based on NCCN criteria, were more likely to receive chemotherapy if they did not undergo RS assay or they had a high RS.
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Neoplasias de la Mama/genética , Predisposición Genética a la Enfermedad , Receptores de Estrógenos/metabolismo , Adulto , Anciano , Neoplasias de la Mama/tratamiento farmacológico , Neoplasias de la Mama/metabolismo , Quimioterapia , Femenino , Pruebas Genéticas , Humanos , Modelos Logísticos , Persona de Mediana Edad , Estadificación de Neoplasias , Oportunidad Relativa , Adulto JovenRESUMEN
BACKGROUND AND OBJECTIVE: There is variability in physician practice regarding delivery method and timeliness of test results to cancer patients. Our aim was to survey patients to determine if there was a difference between actual and preferred care for disclosure of test results. METHODS: A de-identified survey was distributed to online cancer support groups to query patients about their experience regarding communication of cancer testing and timeliness. Analyses of the differences between actual and preferred communication and wait times were performed. RESULTS: Overall, 1000 patients completed the survey. The analysis herein was restricted to 784 breast cancer survivors. Survey responders were predominately White (non-Hispanic; 89 %), college educated (78 %), and media 'savvy' (online medical media usage; 97 %). Differences between actual and preferred care were identified for the domains of mode of communication and wait times for initial breast cancer diagnostic biopsies and other tests. A total of 309 (39 %) of 784 patients received face-to-face communication for a new cancer diagnosis, with 394 (50 %) patients preferring this option (p < 0.0001). In addition, 315 (40 %) of 784 patients received their cancer biopsy result within 2 days, with 646 (82 %) patients preferring this option (p < 0.0001). Differences were also identified between actual and preferred care for multiple other test types. CONCLUSIONS: Actual care for timeliness and modes of communication did not reflect patient-desired care. National and local initiatives to improve performance are needed. As a first step, we recommend that each patient be queried about their preference for mode of communication and timeliness, and efforts made to comply.
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Neoplasias de la Mama/diagnóstico , Neoplasias de la Mama/psicología , Comunicación , Prioridad del Paciente , Adulto , Anciano , Biopsia , Mama/patología , Neoplasias de la Mama/patología , Neoplasias de la Mama Masculina/diagnóstico , Neoplasias de la Mama Masculina/psicología , Femenino , Humanos , Masculino , Mamografía , Persona de Mediana Edad , Encuestas y Cuestionarios , Factores de Tiempo , Revelación de la VerdadRESUMEN
BACKGROUND: Current breast cancer care is based on high-level evidence from randomized, controlled trials. Despite these data, there continues to be variability of breast cancer care, including overutilization of some tests and operations. To reduce overutilization, the American Board of Internal Medicine Choosing Wisely (®) Campaign recommends that professional organizations provide patients and providers with a list of care practices that may not be necessary. Shared decision making regarding these services is encouraged. METHODS: The Patient Safety and Quality Committee of the American Society of Breast Surgeons (ASBrS) solicited candidate measures for the Choosing Wisely (®) Campaign. The resulting list of "appropriateness" measures of care was ranked by a modified Delphi appropriateness methodology. The highest-ranked measures were submitted to and later approved by the ASBrS Board of Directors. They are listed below. RESULTS: (1) Don't routinely order breast magnetic resonance imaging in new breast cancer patients. (2) Don't routinely excise all the lymph nodes beneath the arm in patients having lumpectomy for breast cancer. (3) Don't routinely order specialized tumor gene testing in all new breast cancer patients. (4) Don't routinely reoperate on patients with invasive cancer if the cancer is close to the edge of the excised lumpectomy tissue. (5) Don't routinely perform a double mastectomy in patients who have a single breast with cancer. CONCLUSIONS: The ASBrS list for the Choosing Wisely (®) campaign is easily accessible to breast cancer patients online. These measures provide surgeons and their patients with a starting point for shared decision making regarding potentially unnecessary testing and operations.
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Neoplasias de la Mama/cirugía , Toma de Decisiones , Mal Uso de los Servicios de Salud/prevención & control , Escisión del Ganglio Linfático/estadística & datos numéricos , Participación del Paciente , Oncología Quirúrgica/normas , Neoplasias de la Mama/diagnóstico por imagen , Técnica Delphi , Femenino , Pruebas Genéticas/estadística & datos numéricos , Humanos , Imagen por Resonancia Magnética/estadística & datos numéricos , Márgenes de Escisión , Mastectomía Segmentaria , Neoplasia Residual , Mastectomía Profiláctica/estadística & datos numéricos , Indicadores de Calidad de la Atención de Salud , Reoperación/estadística & datos numéricos , Sociedades Médicas/normasRESUMEN
BACKGROUND: Multiple recent reports have documented significant variability of reoperation rates after initial lumpectomy for breast cancer. To address this issue, a multidisciplinary consensus conference was convened during the American Society of Breast Surgeons 2015 annual meeting. METHODS: The conference mission statement was to "reduce the national reoperation rate in patients undergoing breast conserving surgery for cancer, without increasing mastectomy rates or adversely affecting cosmetic outcome, thereby improving value of care." The goal was to develop a toolbox of recommendations to reduce the variability of reoperation rates and improve cosmetic outcomes. Conference participants included providers from multiple disciplines involved with breast cancer care, as well as a patient representative. Updated systematic reviews of the literature and invited presentations were sent to participants in advance. After topic presentations, voting occurred for choice of tools, level of evidence, and strength of recommendation. RESULTS: The following tools were recommended with varied levels of evidence and strength of recommendation: compliance with the SSO-ASTRO Margin Guideline; needle biopsy for diagnosis before surgical excision of breast cancer; full-field digital diagnostic mammography with ultrasound as needed; use of oncoplastic techniques; image-guided lesion localization; specimen imaging for nonpalpable cancers; use of specialized techniques for intraoperative management, including excisional cavity shave biopsies and intraoperative pathology assessment; formal pre- and postoperative planning strategies; and patient-reported outcome measurement. CONCLUSIONS: A practical approach to performance improvement was used by the American Society of Breast Surgeons to create a toolbox of options to reduce lumpectomy reoperations and improve cosmetic outcomes.
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Neoplasias de la Mama/cirugía , Mamoplastia , Mastectomía Segmentaria/normas , Oncología por Radiación/normas , Reoperación , Congresos como Asunto , Consenso , Femenino , Humanos , Estadificación de Neoplasias , Guías de Práctica Clínica como Asunto , Sociedades Médicas , CirujanosRESUMEN
BACKGROUND: Variations exist in compliance with NCCN Guidelines. Prior reports of adherence to NCCN Guidelines contain limitations because of lack of contemporary review and incomplete listing of reasons for noncompliance. PURPOSE: To assess institutional compliance and assist national quality improvement strategies through identifying valid reasons for noncompliance. METHODS: Compliance with NCCN Guidelines was recorded prospectively using electronic synoptic templates for patients with newly diagnosed breast cancer treated at a single institution between January 2010 and December 2011. Compliance with NCCN Guidelines was recorded. The accuracy of real-time synoptic auditing methods compared with retrospective chart review and reasons for noncompliance was assessed. SAS 9.3 software was used for data analysis. RESULTS: Compliance with NCCN Guidelines among 395 patients was 94% for initial staging evaluation, 97% for surgery, 91% for chemotherapy, 89% for hormone therapy, 91% for radiation therapy, 85% for follow-up, and 100% for determination of estrogen receptor/progesterone receptor and HER2 status. Age, comorbidities, and stage influenced guideline compliance. The most common reasons for noncompliance were patient refusal, patient choice after shared decision-making, and overuse of testing. Synoptic templated reporting was accurate in 97% patients. CONCLUSIONS: High compliance with NCCN Guidelines was demonstrated. Reasons for noncompliance were identifiable. Compliance and nonadherence can be evaluated quickly with electronic synoptic reporting. This allows real-time action plans to address quality concerns and aids national risk adjustment for comparison and benchmarking.
Asunto(s)
Neoplasias de la Mama/diagnóstico , Neoplasias de la Mama/terapia , Adhesión a Directriz , Adulto , Anciano , Anciano de 80 o más Años , Neoplasias de la Mama Masculina/diagnóstico , Neoplasias de la Mama Masculina/terapia , Femenino , Humanos , Masculino , Persona de Mediana Edad , Guías de Práctica Clínica como AsuntoRESUMEN
BACKGROUND: Despite reported benefits, many women do not attend breast cancer support groups. Abundant online resources for support exist, but information regarding the effectiveness of participation is lacking. We report the results of a Twitter breast cancer support community participant survey. OBJECTIVE: The aim was to determine the effectiveness of social media as a tool for breast cancer patient education and decreasing anxiety. METHODS: The Breast Cancer Social Media Twitter support community (#BCSM) began in July 2011. Institutional review board approval with a waiver of informed consent was obtained for a deidentified survey that was posted for 2 weeks on Twitter and on the #BCSM blog and Facebook page. RESULTS: There were 206 respondents to the survey. In all, 92.7% (191/206) were female. Respondents reported increased knowledge about breast cancer in the following domains: overall knowledge (80.9%, 153/189), survivorship (85.7%, 162/189), metastatic breast cancer (79.4%, 150/189), cancer types and biology (70.9%, 134/189), clinical trials and research (66.1%, 125/189), treatment options (55.6%, 105/189), breast imaging (56.6%, 107/189), genetic testing and risk assessment (53.9%, 102/189), and radiotherapy (43.4%, 82/189). Participation led 31.2% (59/189) to seek a second opinion or bring additional information to the attention of their treatment team and 71.9% (136/189) reported plans to increase their outreach and advocacy efforts as a result of participation. Levels of reported anxiety before and after participation were analyzed: 29 of 43 (67%) patients who initially reported "high or extreme" anxiety reported "low or no" anxiety after participation (P<.001). Also, no patients initially reporting low or no anxiety before participation reported an increase to high or extreme anxiety after participation. CONCLUSIONS: This study demonstrates that breast cancer patients' perceived knowledge increases and their anxiety decreases by participation in a Twitter social media support group.