A Statewide Approach to Reducing Re-excision Rates for Women With Breast-conserving Surgery.

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.

MRI and Prediction of Pathologic Complete Response in the Breast and Axilla after Neoadjuvant Chemotherapy for Breast Cancer.

BACKGROUND: In the setting where determining extent of residual disease is key for surgical planning after neoadjuvant chemotherapy (NAC), we evaluate the reliability of MRI in predicting pathologic complete response (pCR) of the breast primary and axillary nodes after NAC. STUDY DESIGN: Patients who had MRI before and after NAC between June 2014 and August 2015 were identified in a prospective database after IRB approval. Post-NAC MRI of the breast and axillary nodes was correlated with residual disease on final pathology. Pathologic complete response was defined as absence of invasive and in situ disease. RESULTS: We analyzed 129 breast cancers. Median patient age was 50.8 years (range 27.2 to 80.6 years). Tumors were human epidermal growth factor receptor 2 amplified in 52 of 129 (40%), estrogen receptor-positive/human epidermal growth factor receptor 2-negative in 45 of 129 (35%), and triple negative in 32 of 129 (25%), with respective pCR rates of 50%, 9%, and 31%. Median tumor size pre- and post-NAC MRI were 4.1 cm and 1.45 cm, respectively. Magnetic resonance imaging had a positive predictive value of 63.4% (26 of 41) and negative predictive value of 84.1% (74 of 88) for in-breast pCR. Axillary nodes were abnormal on pre-NAC MRI in 97 patients; 65 had biopsy-confirmed metastases. The nodes normalized on post-NAC MRI in 33 of 65 (51%); axillary pCR was present in 22 of 33 (67%). In 32 patients with proven nodal metastases and abnormal nodes on post-NAC MRI, 11 achieved axillary pCR. In 32 patients with normal nodes on pre- and post-NAC MRI, 6 (19%) had metastasis on final pathology. CONCLUSIONS: Radiologic complete response by MRI does not predict pCR with adequate accuracy to replace pathologic evaluation of the breast tumor and axillary nodes.

Periareolar or Peritumoral Injection of Isosulfan Blue and the Effect on the Number of Sentinel Lymph Nodes Examined.

The conduct of sentinel node biopsy (SLNBx) for breast cancer (BC) has evolved substantially since its original description. No national standards for the performance of SLNBx exist, therefore, we sought to determine the effect of isosulfan blue (ISB) injection technique on nodal harvesting and staging accuracy during SLNBx. Our main outcome measures included the number of SLNs examined and the number of positive axillae in patients undergoing SLNBx after injection of filtered sulfur colloid intradermally and either small volume ISB injected in the periareolar dermis (PA,∼0.75 cc) or large volume peritumoral (PT, 5 cc). Between January 1, 2009, and September 30, 2013, 1357 patients at an academic/community practice setting underwent SLNBx of which 966 (71.2%) were node negative. These patients ranged in age from 27 to 97 years (mean 60.1 years). The majority of patients (76%) underwent PT injection of ISB. There was no significant difference in the mean age of these two groups (61.2 PT vs 59.7 PA years). All were female. The majority of patients (72.7%) had T1 primaries. Nearly 73 per cent of patients were Luminal A/B, 10.8 per cent HER, and 16.4 per cent were triple negative. There was no significant difference in the distribution of T stage (P = 0.56) or breast cancer subtypes between the techniques (P = 0.59). The mean number of nodes examined was 3.1 (range, 1-18). PT patients had a mean of 3.5 (range, 1-18) nodes, whereas PA patients had a mean of 2.4 nodes (range, 1-10) (P < 0.001). The technical aspects of injecting ISB affect the number of nodes harvested during SLNBx but not staging accuracy.

Regional disparities in breast cancer outcomes and the process of care.

Mortality from breast cancer in eastern North Carolina (ENC) surpasses the rest of North Carolina (RNC). We sought to identify modifiable factors associated with the increased mortality of women diagnosed with breast cancer in ENC. A retrospective cohort study of women diagnosed with breast cancer in North Carolina between January 1, 2004, and December 31, 2007 (n = 27,631) was studied. There was no difference in the pathologic T (P = 0.62), N (P = 0.26), or stage grouping (P = 0.25) at diagnosis. Women in ENC were less likely to be white (P < 0.001), estrogen receptor (ER)-positive (P < 0.001), progesterone receptor (PR)-positive (P < 0.001), or to receive adjuvant chemotherapy (P = 0.02). The median survival of ENC patients was worse than RNC patients (39 vs. 43 months, P = 0.003). Improved median survival was associated with ER status (P < 0.001), PR status (P < 0.001), race/ethnicity (P < 0.001), and delivery of timely chemotherapy (P < 0.0001). ER-negative status (P = 0.01), black race (P = 0.03), and adjuvant chemotherapy within 90 days of surgery (P < 0.001) remained significant predictors of survival. The poor outcomes observed in ENC can be attributed to recognized prognostic primary patient and tumor characteristics. However, a failure in process of care remains significantly associated with poorer outcomes. Improved timing of delivery of chemotherapy could affect breast cancer mortality.

Selective preoperative magnetic resonance imaging in women with breast cancer: no reduction in the reoperation rate.

HYPOTHESIS: The use of preoperative magnetic resonance (MR) imaging may have an effect on the reoperation rate in women with operable breast cancer. DESIGN: Retrospective cohort study. SETTING: University medical center. PATIENTS: Women with operable breast cancer treated by a single surgeon between January 1, 2006, and December 31, 2010. INTERVENTION: Selective preoperative MR imaging based on breast density and histologic findings. MAIN OUTCOME MEASURES: Reoperation rate and pathologically avoidable mastectomy at initial operation. RESULTS: Of 313 patients in the study, 120 underwent preoperative MR imaging. Patients undergoing MR imaging were younger (mean age, 53.6 vs 59.5 years; P < .001), were more often of non-Hispanic white race/ethnicity (61.7% vs 52.3%, P < .05), and more likely had heterogeneously dense or very dense breasts (68.4% vs 22.3%, P < .001). The incidence of lobular carcinoma (8.3% in the MR imaging group vs 5.2% in the no MR imaging group, P = .27) and the type of surgery performed (mastectomy vs partial mastectomy, P = .67) were similar in both groups. The mean pathological size of the index tumor in the MR imaging group was larger than that in the no MR imaging group (2.02 vs 1.72 cm, P = .009), but the extent of disease was comparable (75.8% in the MR imaging group vs 82.9% in the no MR imaging group had pathologically localized disease, P = .26). The reoperation rate was similar between the 2 groups (19.1% in the MR imaging group vs 17.6% in the no MR imaging group, P = .91) even when stratified by breast density (P = .76), pT2 tumor size (P = .35), or lobular carcinoma histologic findings (P = .26). Pathologically avoidable mastectomy (multifocal or multicentric MR imaging and unifocal histopathological findings) was observed in 12 of 47 patients (25.5%) with preoperative MR imaging who underwent mastectomy. CONCLUSION: The selective use of preoperative MR imaging to decrease reoperation in women with breast cancer is not supported by these data. In a considerable number of patients, MR imaging overestimates the extent of disease.

Patient navigation and the quality of breast cancer care: an analysis of the breast cancer care quality indicators.

PURPOSE: Patient navigation programs are initiated to help guide patients through barriers in a complex cancer care system. We sought to analyze the impact of our patient navigator program on the adherence to specific Breast Cancer Care Quality Indicators (BCCQI). METHODS: A retrospective cohort of patients with stage I-III breast cancer seen the calendar year prior to the initiation of the patient navigation program were compared with patients treated in the ensuing two calendar years. Quality indicators deemed appropriate for analysis were those associated with overcoming barriers to treatment and those associated with providing health education and improving patient decision-making. RESULTS: A total of 134 consecutive patients between January 1, 2006 and December 31, 2006 and 234 consecutive patients between January 1, 2008 and December 31, 2009 were evaluated for compliance with the BCCQI. There was no significant difference in the mean age or race/ethnic distribution of the study population. In all ten BCCQI evaluated, there was improvement in the percentage of patients in compliance from pre and post implementation of a patient navigator program (range 2.5-27.0 %). Overall, compliance with BCCQI improved from 74.1 to 95.5 % (p < 0.0001). Indicators associated with informed decision-making and patient preference achieved statistical significance, while only completion axillary node dissection in sentinel node-positive biopsies in the process of treatment achieved statistical significance. CONCLUSIONS: The implementation of a patient navigator program improved breast cancer care as measured by BCCQI. The impact on disease-free and overall survival remains to be determined.