National Quality Measures for Breast Centers (NQMBC): a robust quality tool: breast center quality measures.

INTRODUCTION: Measuring and improving quality of care is of primary interest to patients, clinicians, and payers. The National Consortium of Breast Centers (NCBC) has created a unique program to assess and compare the quality of interdisciplinary breast care provided by breast centers across the country. METHODS: In 2005 the NCBC Quality Initiative Committee formulated their initial series of 37 measurements of breast center quality, eventually called the National Quality Measures for Breast Centers (NQMBC). Measures were derived from published literature as well as expert opinion. An interactive website was created to enter measurement data from individual breast centers and to provide customized comparison reports. Breast centers submit information using data they collect over a single month on consecutive patients. Centers can compare their results with centers of similar size and demographic or compare themselves to all centers who supplied answers for individual measures. New data may be submitted twice yearly. Serially submitted data allow centers to compare themselves over time. NQMBC random audits confirm accuracy of submitted data. Early results on several initial measures are reported here. RESULTS: Over 200 centers are currently submitting data to the NQMBC via the Internet without charge. These measures provide insight regarding timeliness of care provided by radiologists, surgeons, and pathologists. Results are expressed as the mean average, as well as 25th, 50th, and 75th percentiles for each metric. This sample of seven measures includes data from over 30,000 patients since 2005, representing a powerful database. In addition, comparison results are available every 6 months, recognizing that benchmarks may change over time. CONCLUSIONS: A real-time web-based quality improvement program facilitates breast center input, providing immediate comparisons with other centers and results serially over time. Data may be used by centers to recognize high-quality care they provide or to identify areas for quality improvement. Initial results demonstrate the power and potential of web-based tools for data collection and analysis from hundreds of centers who care for thousands of patients.

Cost-effective screening for breast cancer worldwide: current state and future directions.

Affordability of healthcare is highly limited by its skyrocketing cost. Access to screening and diagnostic medical equipment and medicine in developing countries is inadequate for the majority of the population. There is a tremendous worldwide need to detect breast cancer at its earliest stage. These needs must be balanced by the ability of countries to provide breast cancer screening technology to their populations. We reviewed the diagnostic accuracy, procedure cost and cost-effectiveness of currently available technique for breast screening and diagnosis including clinical breast examination, mammography, ultrasound, magnetic resonance imaging, biopsy and a new modality for cancer diagnostics termed elasticity imaging that has emerged in the last decade. Clinical results demonstrate that elasticity imaging even in its simplest and least sophisticated versions, like tactile imaging, has significant diagnostic potential comparable and exceeding that of conventional imaging techniques. In view of many countries with limited resources, effective yet less expensive modes of screening must be considered worldwide. The tactile imaging is one method that has the potential to provide cost-effective breast cancer screening and diagnostics.

Cryoablation of benign breast tumors: evolution of technique and technology.

We report on improvements in cryoprobe design and techniques of cryoablation as a minimally invasive alternative to open surgery for the treatment of benign breast tumors. In the study, which was conducted in 12 centers, 124 lesions in 102 patients were monitored for a period of 12 months after cryoablation. Two different treatment techniques were used: Double HI FREEZE and Tailored Freeze. In patients treated with the Tailored Freeze technique significantly better results were recorded 12 months after the procedure: the median reduction in tumor volume was 91%, 73% of all tumors treated were nonpalpable, 84% of lesions less than 2.5 cm in maximum diameter were nonpalpable, and none of the 31 mammograms performed yielded abnormal findings. Patient satisfaction was good to excellent in 92% of the patients. The safety profile of this technique was excellent; all complications were minor. Evolution of cryoablation freezing techniques, coupled with improvements in cryoprobe design, has resulted in significant improvements in both safety and effectiveness.

Clinical assessment of a radiolucent cushion for mammography.

PURPOSE: To determine whether use of a radiolucent cushion could significantly decrease pain during screening mammography without compromising image quality or other technical factors. MATERIAL AND METHODS: 838 patients presenting for routine screening mammography were evaluated. The radiolucent cushions were placed on the compression surfaces of the mammographic equipment and were used while imaging the right breast. No pads were used while imaging the left breast. Patient age, hormonal status, compression force, and radiation dose values were collected on all patients. Each subject completed a visual analog pain scale (VAS) rating the degree of pain experienced with and without the cushions. All mammographic images obtained (CC and MLO views) were compared, side by side (cushioned versus non-cushioned) by the readers. RESULTS: Use of radiolucent cushions reduced pain by 10% or more in 66% (555/838) of women. Patients in this "benefited group" experienced an average pain reduction of 53%. No compromise of image quality was observed. Compression force and radiation dose values were highly correlated between the cushioned and non-cushioned sides. CONCLUSION: Two-thirds of women experienced a significant reduction of pain when the radiolucent cushions were used during mammography. Pain reduction was accomplished without any clinically significant change in compression force, radiation dose values, or image quality.

A treatment scale for axillary management in breast cancer.

BACKGROUND: We have investigated a method, the Kaufman axillary treatment scale (KATS), to help assign patients with a clinically negative axilla to one of three current options of axillary management: standard axillary dissection, sentinel node sampling followed by axillary dissection if the sentinel node is positive, or no axillary surgery at all. The KATS score uses preoperative data to guide the choice of axillary treatment. METHODS: The KATS score is calculated by adding the preoperative values of tumor size, patient age, and pathologic grade. Values range from 1 to 4 for size (1 to 9 mm, 10 to 14 mm, 15 to 19 mm, and 20 to 30 mm), 1 to 3 for age (70 years and over, 50 to 69 years, less than 50 years), and 1 to 2 for grade (low or not low) to calculate the score. The KATS score ranges from 3 to 9. We have applied this score against the SEER (Surveillance, Epidemiology, and End Results) tumor registry of 529 patients with invasive breast cancer with known pathologic data. We then validated it by applying it to our own set of 190 patients using preoperative data. The chi-square test and logistic regression analysis were used for P values (all two sided), univariate and multivariate analysis, odds ratio and confidence intervals utilizing SPSS statistics software. RESULTS: In the SEER database using American Joint Committee on Cancer pathologic size alone, no sizable group was identified with a positive node rate neither below 8% (T1a) nor above 48% (T2). KATS scores of 3 and 4 (68 patients, group 1) identify patients with an average node positive rate of 4.4% (P <0.02, group 1 versus 2). Those patients with KATS scores of 5, 6, and 7 (341 patients, group 2) carry an average node positive rate of 22% (P <0.001, group 2 versus 3). KATS scores of 8 and 9 (120 patients, group 3) identify patients with an average node positive rate of 50% (P <0.001, group 3 versus 1). Similar results were found on our own group of 190 patients using preoperative available data. KATS scores of 3 or 4 (11 patients, group 1) had no positive nodes. Group 2 (100 patients, KATS score 5, 6, and 7) had an average 30% node positive rate. Group 3 (79 patients, KATS score 8 and 9) had 61% node positive rate. The KATS score allows the clinician to separate patients into three axillary management groups. Group 1 are those patients who may need no axillary surgery at all. Group 2 are patients who would benefit from sentinel node mapping. Group 3 has a node positive rate (61%) similar to that of clinically palpable nodes (since not all clinically palpable nodes are positive). Group 3 patients may be considered for standard axillary dissection, similar to the palpable node patient. If group 3 patients have sentinel node mapping, more than half of these patients require axillary dissection and the impact of false negative sentinel node procedures may become clinically significant. CONCLUSIONS: An axillary treatment score has been developed to aid in the triage of patients toward reasonable axillary treatment choices for the benefit of the patient. The KATS score is a guideline and not a mandate. The KATS score attempts to use breakpoints that are both clinically practical and validated by scientific data. Like many other attempts to categorize patients, there is a continuum of data points along any variable. The treating physician utilizing the full array of available data on each patient makes the final clinical decision of axillary management.

A new era in the diagnosis of breast cancer.

The regular use of high-quality mammography on asymptomatic women enables most breast cancers to be detected in the preclinical phase. Earlier detection dramatically rearranges the spectrum of breast cancer outcomes, resulting in better control of breast cancer. The new era requires a shift in thinking and a re-evaluation of the traditional diagnostic and therapeutic approaches to breast diseases. Tumors are smaller, less often node-positive, and have a more favorable malignancy grade. The challenge for diagnosticians is to find as many breast cancers as possible in the preclinical phase. The challenge for therapists is to adapt the treatment guidelines accordingly, in order to avoid over-treatment.

Excising the reexcision: stereotactic core-needle biopsy decreases need for reexcision of breast cancer.

There is debate regarding use of the stereotactic core-needle biopsy (SCNB) for highly suspicious mammographic lesions. This study compares a serial group of mammography-detected breast cancer patients treated before and after the use of SCNB. We studied 113 consecutive nonpalpable breast cancers between 1994 and 1996. Altogether 47 patients were diagnosed by wire-localized breast biopsy (wire group) and the next 66 consecutive breast cancer patients by SCNB (stereo group). Negative margins were found more often in the stereo group than in the wire group (77% vs. 38%, p < 0.001). Reexcision was required more frequently in the wire group than in the stereo group (68% vs. 21%, p < 0.001), and one-staged surgical procedures were done more often in the stereo group than the wire group (79% vs. 21%, p < 0.001). The volume of the initial wide excision was much larger in the stereo group than in the wire group (p = 0.002). Those in the wire group required 50% more operations per patient (1.8 vs. 1.2) than the stereo group. A significant cost savings can be estimated in the stereo group compared with the wire group. The use of SCNB was associated with breast excisions of larger volume, negative margins, and decreased need for reexcision. Simultaneous adjunct procedures resulted in one-stage operations, improving cost savings. The use of SCNB for nonpalpable breast cancer benefits the patient, the surgeon, and the payor. It should be undertaken prior to the first surgical procedure.