Developing and measuring a set of process and outcome indicators for breast cancer

360 Health Analysis (H360)-A Comparison of Key Performance Indicators in Breast Cancer Management across Health Institution Settings in Portugal

BACKGROUND

The increased focus on quality indicators (QIs) and the use of clinical registries in real-world cancer studies have increased compliance with therapeutic standards and patient survival. The European Society of Breast Cancer Specialists (EUSOMA) established QIs to assess compliance with current standards in breast cancer care.

METHODS

This retrospective study is part of H360 Health Analysis and aims to describe compliance with EUSOMA QIs in breast cancer management in different hospital settings (public vs. private; general hospitals vs. oncology centers). A set of key performance indicators (KPIs) was selected based on EUSOMA and previously identified QIs. Secondary data were retrieved from patients' clinical records. Compliance with target KPIs in different disease stages was compared with minimum and target EUSOMA standards.

RESULTS

A total of 259 patient records were assessed. In stages I, II, and III, 18 KPIs met target EUSOMA standards, 5 met minimum standards, and 8 failed to meet minimum standards. Compliance with KPIs varied according to the type of hospital (particularly regarding diagnosis) and disease stage. Although small differences were found in KPI compliance among institutions, several statistical differences were found among treatment KPIs according to disease stage, particularly in stage III.

CONCLUSIONS

This study represents the first assessment of the quality of breast cancer care in different hospital settings in Portugal and shows that, although most QIs meet EUSOMA standards, there is room for improvement. Differences have been found across institutions, particularly between oncology centers and general hospitals, in diagnosis and compliance with KPIs among disease stages. Stage III showed the greatest variability in compliance with treatment KPIs, probably related to the lower specificity of the guidelines in this disease stage.

Use of Routine Health Datasets to Assess the Appropriateness of Diagnostic Tests in the Follow-Up of Breast Cancer Patients: A Population-Based Study on 3930 Patients

Purpose

Clinical practice guidelines (CPGs) recommend against intensive follow-up in asymptomatic women with breast cancer (BC). The present study assessed the adherence to CPGs of diagnostic tests ordering during BC follow-up by exploring routinely collected health data through an algorithm developed to distinguish patients according to their status at follow-up.

Patients and Methods

A retrospective population-based cohort study was performed monitoring the diagnostic tests ordered during 5 years of follow-up in all BC cases incident in 2013 in the Veneto Region, Italy. Data were extracted from the Veneto Tumour Registry, the Hospital Discharge Records and the Outpatients’ Records of Diagnostic and Therapeutic Procedures. The algorithm was developed using information on infusion of anticancer agents, imaging exams ordered, and death.

Results

The algorithm classified patients by status at follow-up in four groups: (i) probably no-evidence-of-disease (NED), (ii) suspicious signs of relapse not confirmed, (iii) increased risk of relapse and (iv) advanced disease at presentation or progressive disease. A total of 3930 consecutive incident cases were followed-up for 5 years, corresponding to 17,184 person-years, 15,345 of which pertaining to NED cases. In NED cases, 32,900 tumour markers and 15,858 imaging exams were ordered. Liver ultrasonography and chest radiography were most frequently ordered.

Conclusion

In contrast with recommendations of CPGs, a substantial overordering of tumour markers and imaging exams occurred in NED BC patients. The developed algorithm can be repeatedly applied to routine health datasets for regular monitoring of the adherence to CPGs and of the impact of interventions to improve appropriateness.

Quality Standards for Surgery of Colorectal Peritoneal Metastasis After Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy

BACKGROUND

The standardization of surgical outcomes throughout surgical procedures is mandatory. Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS + HIPEC) should provide proficient oncological and surgical outcomes.

STUDY DESIGN

The aim of this study was to identify clinically relevant quality indicators and their quality standard, and to determine their acceptable quality limit. A systematic review on cytoreductive results from 2000 to 2018 was performed focusing on clinical guidelines, consensus conferences, and publications. After the selection of quality indicators, a systematic review of indexed references was performed in order to calculate the quality standard for each indicator.

STUDY SELECTION

Unicentric/multicentric series, comparative studies, and clinical trials. Studies were to include outcomes after cytoreduction of colorectal origin and series with more than 50 patients. Quality indicators with at least 10 series were mandatory and objective measurements were also mandatory for inclusion.

MAIN OUTCOME MEASUREMENTS

Quality indicators selected were 1- to 5-year survival, overall disease-free survival, 1- to 5-year disease-free survival, complete surgical resection, duration of surgery, length of stay, overall morbimortality, major morbidity, re-intervention, postoperative hemorrhage, intestinal fistula, anastomotic leakage, wound infection, postoperative medical complications, overall recurrence, and failure to rescue.

RESULTS

The most relevant quality indicators and critical quality limits were overall disease-free survival and 5-year overall disease-free survival (14 months and <10 months, and 14% and <4%, respectively), completeness of surgical resection (89% and <80%, respectively), overall mortality (3% and >8%, respectively), overall morbidity (47% and >63%, respectively), failure to rescue (12% and <30%, respectively), reintervention (13 and <22%, respectively), anastomotic leakage (6% and <13%, respectively), and overall recurrence (60% and <74%, respectively).

CONCLUSION

This is the first study to assess quality standards in CRS + HIPEC for colorectal peritoneal metastases. The current data are of particular relevance for future studies to control the variability of this surgery.

Assessment of potential process quality indicators for systemic treatment of breast cancer in Belgium: a population-based study

BACKGROUND

Quality indicators (QIs) for the management of breast cancer (BC) have been published in Europe and internationally. In Belgium, a task force was established to select measurable process indicators of systemic treatment for BC, focusing on appropriateness of delivered care. The objective of this study was to evaluate the results of the selected QIs, both nationally and among individual centres.

PATIENTS AND METHODS

Female Belgian residents with unilateral primary invasive BC diagnosed between 2010 and 2014 were selected from the Belgian Cancer Registry database. The national number enabled linkage with the national reimbursement database, which contains information on all reimbursed medical procedures. A total of 12 process indicators were measured on the population and hospital level. Intercentre variability was assessed by median results and interquartile ranges.

RESULTS

A total of 48  872 patients were included in the study. QIs concerning specific BC subtypes only applied to patients diagnosed in 2014 (n = 9855). Clinical stage (cStage) I patients (n = 17 116) were staged with positron emission tomography/computed tomography. Among patients who were pT1aN0 human epidermal growth factor receptor 2 (HER2) positive (n = 47), 25.5% (n = 12) received adjuvant trastuzumab. Among patients with de novo metastatic luminal A/B-like HER2-negative BC (n = 295), 17.3% (n = 51) received upfront chemotherapy. (Neo)adjuvant chemotherapy was administered in 52.4% (n = 12 592) of operated women with cStage I-III, in 37.0% (n = 1270) of operated women with cStage I-III luminal A/B-like HER2-negative BC, and in 19.1% of operated women with cStage I luminal A/B-like HER2-negative BC. In the population of operated patients with cStage I-III, of those younger than 70 years that started adjuvant endocrine therapy (n = 3591), 81.7% (n = 2932) continued treatment for ≥4.5 years. Among patients in cStage I-III older than 70 years (n = 8544), 19.0% (n = 1622) received (neo)adjuvant chemotherapy, whereas among patients with cStage I-III luminal A/B-like HER2-negative BC (n = 1388), 13.0% (n = 181) received (neo)adjuvant chemotherapy. In patients with cStage I-II luminal A/B-like HER2-negative BC older than 70 years (n = 1477), 11.6% (n = 171) were not operated and received upfront endocrine treatment.

CONCLUSION

Well-considered QIs using population-based data can evaluate quality of care and expose disparities among treatment centres. Their use in daily practice should be implemented in all centres treating BC.

Quality indicators for breast cancer care: A systematic review

Objectives

We evaluated breast cancer (BC) care quality indicators (QIs) in clinical pathways and integrated health care processes.

Methods

Following protocol registration (Prospero n^o: CRD42021228867), relevant documents were identified, without language restrictions, through a systematic search of bibliographic databases (EMBASE, Scopus, Web of Science, MEDLINE), health care valuable representatives and the World Wide Web in April 2021. Data concerning QIs, measurement tools and compliance standards were extracted from European and North American sources in duplicate with 98% reviewer agreement.

Results

There were 89 QIs found from 22 selected documents (QI per document mean 13.5 with standard deviation 11.9). The Belgian (38 QIs) and the EUSOMA (European Society of Breast Cancer Specialists) (34 QIs) documents were the ones that best reported the QIs. No identical QI was identified in all the documents analysed. There were 67/89 QIs covering processes (75.3%) and 11/89 (12.4%) for each structure and outcomes QIs. There were 21/89 QIs for diagnosis (30.3%), 43/89 for treatment (48.3%), and 19/89 for staging, counselling, follow-up and rehabilitation (21.4%). Of 67 process QIs and 11 outcome QIs, 20/78 (26%) did not report a minimum standard of care. Shared decision making was only included as a QI in the Italian document.

Conclusion

More than half of countries have not established a national clinical pathway or integrated breast cancer care process to achieve the excellence of BC care. There was heterogeneity in QIs for the evaluation of BC care quality. Over two-thirds of the clinical pathways and integrated health care processes did not provide a minimum auditable standard of care for compliance, leaving open the definition of best practice. There is a need for harmonisation of BC care QIs.

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The quality of breast cancer care has become a preference for health systems.

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There was no established set of quality indicators to harmonise BC quality management’s evaluation. A consensus is needed.

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Most of the integrated breast cancer care processes or clinical pathways did not indicate any standard for care compliance.

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No quality indicators specifically related to patient satisfaction or Primary care were found in our study.

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Shared decision making was only included as a QI in the Italian document.

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There is a vast space for improvement, and future studies should pay attention to this issue.

Breast Cancer Care Quality Indicators in Spain: A Systematic Review

Breast cancer (BC) management care requires an increment in quality. An initiative to improve the BC quality care is registered, and quality indicators (QIs) are studied. We appraised the appearance of QIs and their standards systematically in Spain. A prospective systematic search (Prospero no: CRD42021228867) for clinical pathways and integrated breast cancer care processes was conducted through databases and the World Wide Web in February 2021. Duplicate data extraction was performed with 98% reviewer agreement. Seventy-four QIs (QI per document mean: 11; standard deviation: 10.59) were found in 15 documents. The Catalonian document had the highest number of QIs (n = 30). No QI appeared in all the documents. There were 9/74 QIs covering structure (12.16%), 53/74 covering process (71.62%), and 12/74 covering outcome (16.22%). A total of 22/66 (33.33%) process and outcome QIs did not set a minimum standard of care. QIs related to primary care, patient satisfaction, and shared decision making were deficient. Most of the documents established a BC QI standard for compliance, but the high variability hinders the comparison of outcomes. Establishing a consensus-based set of QIs needs urgent attention.

Effect of multidisciplinary team care on the risk of recurrence in breast cancer patients: A national matched cohort study

BACKGROUND

Cancer has been the leading cause of death in the past decade in Taiwan, with breast cancer being the most common type of cancer in females. Very few studies looked at the risk of recurrence in patients who received multidisciplinary team (MDT) care. We analyzed the influence of MDT on the risk of recurrence and death in breast cancer patients.

METHOD

In this retrospective study, we included newly diagnosed patients from 2004 to 2010. The study included 9,266 breast cancer patients who were enrolled in MDT care and 9,266 patients who were not. The study used log-rank test to analyze patients' characteristics, hospital characteristics, cancer staging, and treatment methods to compare the recurrence rates in MDT care and non-MDT care participants. We used Cox proportional hazards model to examine the effect of MDT and associated factors on the risk of recurrence and mortality of breast cancer patients.

RESULTS

Relative risk of recurrence was lower for patients who received MDT care than for patients who did not (HR, 0.84; 95%CI: 0.70-0.99) after matching. The mortality risk for breast cancer patients with relapse was 8.48 times (95%CI: 7.53-9.54) than that for patients without relapse.

CONCLUSIONS

The relative risk of recurrence and death was significantly lower for breast cancer patients who received MDT care than for those who did not. We suggest that MDT care be implanted in the National Health Policy settings of breast cancer patients.

Breast Cancer Care in Jordan

Breast cancer is the most common malignancy in Jordan and the third leading cause of cancer death after lung and colorectal cancers. Although the incidence of breast cancer in Jordan is lower than that in industrialized nations, the number of new cases has been significantly increasing, and women present with breast cancer at a younger age and with more advanced disease than women in Western countries. Jordan is a medium-income country with limited resources and a young population structure. Therefore, breast cancer poses a particularly challenging burden on the country's health care system. Despite ongoing endeavors to improve breast cancer care at both public and private levels, more work is needed to achieve downstaging of the disease and improve access, awareness, and participation in early detection. Multimodality treatment facilities and supportive care are available; however, the quality of care varies widely according to where the patient is treated, and most treatment facilities remain located centrally, thus, creating access difficulties. The King Hussein Cancer Center, the only comprehensive cancer center in Jordan, has changed the practice of oncology in the country via implementation of a multidisciplinary approach to treatment, monitoring of treatment outcomes, and investments in ongoing cancer research. However, there remains no national system for ensuring provision of high-quality cancer care nationwide. Here, we review the epidemiology of breast cancer and the current status of breast cancer care in Jordan, we compare our treatment outcomes with international ones, and we highlight challenges and improvement opportunities.

Use of Electronic Administrative Databases to Measure Quality Indicators of Breast Cancer Care: Experience of Five Regional Oncology Networks in Italy

PURPOSE:

Assuring quality of care, while maintaining sustainability, in complex conditions such as breast cancer (BC) is an important challenge for health systems. Here, we describe a methodology to define a set of quality indicators, assess their computability from administrative data, and apply them to a large cohort of BC cases.

MATERIALS AND METHODS:

Clinical professionals from the Italian Regional Oncology Networks identified 46 clinically relevant indicators of BC care; 22 were potentially computable using administrative data. Incident cases of BC diagnosed in 2016 in five Italian regions were identified using administrative databases from regional repositories. Each indicator was calculated through record linkage of anonymized individual data.

RESULTS:

A total of 15,342 incident BC cases were identified. Nine indicators were actually computable from administrative data (two structure and seven process indicators). Although most indicators were consistent with guidelines, for one indicator (blood tumor markers in the year after surgery, 44.2% to 64.5%; benchmark ≤ 20%), deviation was evident throughout the five regions, highlighting systematic overlooking of clinical recommendations. Two indicators (radiotherapy within 4 months after surgery if no adjuvant chemotherapy; 42% to 83.8%; benchmark ≥ 90%; and mammography 6 to 18 months after surgery, 55.1% to 72.6%; benchmark ≥ 90%) showed great regional variability and were lower than expected, possibly as result of an underestimation in indicator calculation by administrative data.

CONCLUSION:

Despite highlighting some limitations in the use of administrative data to measure health care performance, this study shows that evaluating the quality of BC care at a population level is possible and potentially useful for guiding quality improvement interventions.

Compliance with clinical guidelines for breast cancer management: A population-based study of quality-of-care indicators in France

Background

The European Society of Breast Cancer Specialists (EUSOMA), which aims to standardize the quality of patient care in Europe, has defined quality indicators (QIs) for breast cancer (BC) care to assess compliance to current care standards. These QIs are a useful tool to evaluate care organizations. Only population-based studies are able to assess health system performance in “real-life” situations. This population-based study aimed to describe compliance with several EUSOMA QIs overall and according to patient and organizational factors in France.

Methods

1 560 adult women with primary invasive non-metastatic BC diagnosed in 2012 were randomly selected among all incident BC from 16 French geographical areas covered by cancer registries. Twelve EUSOMA QIs were selected regarding diagnosis, treatment and staging.

Results

The minimum standard as proposed by EUSOMA was met for nine QIs related to pre-operative definitive diagnosis, multidisciplinary discussion and treatment (single surgery, breast conserving surgery (BCS) for small BC (<3cm), radiotherapy after BCS or mastectomy for regional BC (pN≥2a), hormonotherapy, adjuvant chemotherapy and trastuzumab). Low compliance was observed for sentinel lymph node biopsy (SLNB) and staging imaging. Adherence to guidelines was usually lower in older patients and in patients with comorbidities. Multidisciplinary discussion was positively related to adherence to guidelines for diagnosis, staging practices (SNLB, imaging) and systemic treatments. Compliance also varied by area of residence and by place of first treatment.

Conclusion

This study provides the first current, comprehensive overview of BC quality care at a population level in France. The guidelines were correctly applied in percentage satisfying the EUSOMA standards for the diagnosis and treatment of BC, although staging practices (SLNB, imaging) can be improved. These results highlight the need for continuous measurement of adherence to guidelines to improve BC care.

Mastectomy versus breast-conservation therapy: an examination of how individual, clinicopathologic, and physician factors influence decision-making

Background

The choice of mastectomy compared with breast-conservation therapy (bct) in early-stage breast cancer (esbca) is a complicated decision-making process. Interprovincially, Canada's mastectomy rates vary from 25% to 68%, with Saskatchewan reporting the nation's second-highest mastectomy rate at 63%. The aim of our research was to better understand why women with esbca choose mastectomy rather than bct in Saskatchewan.

Methods

We created a survey based on a previously developed framework that organizes influencing factors into 3 constructs: clinicopathologic, physician, and individual belief factors.

Results

Treatment choice was found to be influenced by disease stage and multiple individual belief factors. Compared with their counterparts having stage i disease, women with stage ii disease were significantly more likely to undergo mastectomy [odds ratio (or): 7.48]. Patients rating "worry about cancer recurrence" and "total treatment time" as more influential in their choice were also more likely to undergo mastectomy (or: 3.4 and 1.8 respectively). Conversely, women rating "wanting to keep own breast tissue," "tumour size," and "surgeon's opinion" as influential in their choice were more likely to undergo bct (or: 0.17, 0.66, and 0.69 respectively).

Conclusions

Our study demonstrates that treatment choices for Saskatchewan women with esbca are influenced primarily by disease stage and individual belief factors. Those findings suggest that women are making their treatment choices predominantly based on individual values and preferences. The use of rates of mastectomy and bct as indicators of quality of care might be misleading. Instead, a shift in attention toward patient-centred care might be more appropriate.

Quality indicators for responsible use of medicines: a systematic review

OBJECTIVE

All healthcare systems require valid ways to evaluate service delivery. The objective of this study was to identify existing content validated quality indicators (QIs) for responsible use of medicines (RUM) and classify them using multiple frameworks to identify gaps in current quality measurements.

DESIGN

Systematic review without meta-analysis.

SETTING

All care settings.

SEARCH STRATEGY

CINAHL, Embase, Global Health, International Pharmaceutical Abstract, MEDLINE, PubMed and Web of Science databases were searched up to April 2018. An internet search was also conducted. Articles were included if they described medication-related QIs developed using consensus methods. Government agency websites listing QIs for RUM were also included.

ANALYSIS

Several multidimensional frameworks were selected to assess the scope of QI coverage. These included Donabedian's framework (structure, process and outcome), the Anatomical Therapeutic Chemical (ATC) classification system and a validated classification for causes of drug-related problems (c-DRPs; drug selection, drug form, dose selection, treatment duration, drug use process, logistics, monitoring, adverse drug reactions and others).

RESULTS

2431 content validated QIs were identified from 131 articles and 5 websites. Using Donabedian's framework, the majority of QIs were process indicators. Based on the ATC code, the largest number of QIs pertained to medicines for nervous system (ATC code: N), followed by anti-infectives for systemic use (J) and cardiovascular system (C). The most common c-DRPs pertained to 'drug selection', followed by 'monitoring' and 'drug use process'.

CONCLUSIONS

This study was the first systematic review classifying QIs for RUM using multiple frameworks. The list of the identified QIs can be used as a database for evaluating the achievement of RUM. Although many QIs were identified, this approach allowed for the identification of gaps in quality measurement of RUM. In order to more effectively evaluate the extent to which RUM has been achieved, further development of QIs may be required.

Highly significant improvement in guideline adherence, relapse-free and overall survival in breast cancer patients when treated at certified breast cancer centres: An evaluation of 8323 patients

OBJECTIVES

Certified multi-disciplinary breast cancer centres (CBCs) have been established worldwide. Development of CBCs, guideline-adherent systemic therapy and surgical management should now show an impact on outcomes. This analysis aimed to investigate whether guideline adherence (GA) rates, relapse-free survival (RFS) and overall survival (OS) have significantly improved at CBCs compared to the pre-certification period.

MATERIALS AND METHODS

8323 patients with primary breast cancer were treated in 17 German CBCs, which had been certified between 2003 and 2007 [2003 (n = 1), 2004 (n = 6), 2005 (n = 3), 2006 (n = 6) and 2007 (n = 1)]. 3544 patients (42.6%) were treated before certification and 4779 patients (57.4%) after certification.

RESULTS AND CONCLUSION

A highly significant (p < 0.001) difference in 100%-GA was found between the various hospitals before certification (min 25.0%; max 54.6%). In 2008, when all participating hospitals were certified, the GA rate was 61.8% (min 39.5%, max 74.4%) and 69.2% (min 45.9%, max 86.4%) for patients <75 y (n = 6675). The difference between pre-certification 100%-GA (46.9%) and post-certification (57.2%) was highly significant (p < 0.001). RFS and OS were both significantly better after certification compared to the pre-certification period (RFS: HR = 0.79; 95% CI: 0.68-0.92; p = 0.003; OS: HR = 0.75; 95% CI: 0.65-0.85; p < 0.001). 5-year RFS (OS) of patients <75 y was 89.6% (85.4%) pre-certification and 91.4% (89.5%) post-certification. Since improvement in GA and outcomes correlated as well, GA remains a highly significant prognostic factor for RFS and OS regardless of NPI, intrinsic subtype and adjuvant systemic therapy. This suggests that the certification process is strongly associated with improvements in outcome.

Catching and monitoring clinical innovation through performance indicators. The case of the breast-conserving surgery indicator

Background

The evolution in the surgical and diagnostic procedures, the attention to women’s preferences, the case mix, and differences in professional practices may lead to a variability in the quality of breast cancer clinical pathway. To catch and manage this variability it is important to use valid measures. The aim of this paper is to examine the concurrent validity of the breast-conserving surgery (BCS) indicator and to provide evidence to guide the quality improvement process.

Methods

The BCS indicator was calculated using hospital discharge records (HDRs) and was validated against surgical registry (SR) data in a random sample of 336 women undergoing breast cancer surgery in 2012 in two Tuscan teaching hospitals. The concurrent validity of BCS was examined by cross-tabulating patients using the ICD-9 CM codes for breast surgery obtained from the two data sources.

Results

The analysis, carried out involving breast cancer professionals, highlighted that the large majority of interventions coded as “mastectomies” in HDRs are in fact reconstructing procedures, including nipple-sparing, skin-sparing and skin-reducing mastectomies in SR. These results led us to refine the old algorithm, that calculates the proportion of breast-conserving surgery over the total number of breast interventions, and reclassify breast cancer surgical procedures into three categories: conservative, reconstructive and traditional mastectomy. Based on this new classification algorithm, the percentages of (I) reconstructive interventions were 16% at Florence TH and 38.3% at Pisa TH; (II) breast-conserving interventions were respectively 72.8 and 52.1%; and (III) mastectomies 11.2 and 9.6%. After adjusting for age in a logistic regression model, the percentages of reconstructive interventions at Florence and Pisa were respectively 22 and 34% and those of breast-conserving interventions 63 and 53%.

Conclusions

Our results indicate that breast cancer care indicators should be refined by distinguishing reconstructive procedures (nipple/skin-sparing surgery with implant or breast tissue expander insertion) from traditional mastectomy. The involvement of breast care professionals in the choice of indicators proved to be crucial to capture the up-to-date breast cancer surgical practice and inform the quality improvement process.

Indicators based on registers and administrative data for breast cancer: routine evaluation of oncologic care pathway can be implemented

RATIONALE, AIMS AND OBJECTIVES

Assuring the best standards of care - in a sustainable way - in chronic diseases as breast cancer is nowadays an important challenge for any health system. The aim of this study was to present the methodology used to define a set of quality indicators, computable from administrative data for the pathway of care of breast cancer, and its application at a population level.

METHOD

The cohort of 2007-2009 incident cases of breast cancer was identified through a network of six cancer registers in Northern Italy. Cases of sarcoma and lymphoma, patients with multiple primary cancers and those metastatic at diagnosis were excluded; 9614 women were retained for the analysis. For each indicator, the sub-cohort of women eligible for the diagnostic/therapeutic procedures was identified and calculations were performed through record linkage between the cohort and sources of health information. Data on potential available confounders or prognostic factors were also collected.

RESULTS

For a few indicators, such as cyto-histological assessment before surgery (62%) and intensive follow-up (79%), deviation from recommendations was evident. Younger patients (≤50 years) more frequently needed a short term re-intervention, while older patients less frequently underwent reconstructive surgery and received palliative care. Several indicators had a great variability across hospitals. In some cases, this heterogeneity appeared to be related to the hospital size, with high-volume hospitals being more compliant to guidelines.

CONCLUSION

It is possible to evaluate the quality of cancer care delivered in clinical practice in recent years, in order to implement interventions aimed to improve adherence to international standards of care.

Quality of pathology reporting is crucial for cancer care and registration: a baseline assessment for breast cancers diagnosed in Belgium in 2008

OBJECTIVES

Given the crucial role of pathology reporting in the management of breast cancers, we aimed to investigate the quality and variability of breast cancer pathology reporting in Belgium.

MATERIALS AND METHODS

Detailed information on non-molecular and molecular parameters was retrieved from the pathology protocols available at the Belgian Cancer Registry for 10,007 breast cancers diagnosed in Belgium in 2008.

RESULTS

Substantial underreporting was shown for several clinically relevant non-molecular parameters, such as lymphovascular invasion. High-volume laboratories performed only slightly better than others, and analyses at the individual laboratory level showed clear inter-laboratory variability in reporting for all volume categories. Information on ER/PR and HER2 IHC was mentioned in respectively 91.7% and 90.8% of evaluative cases. HER2 ISH data were available for 78.5% of the cases judged to be 2+ for HER2 IHC. For cases with different specimens analysed, discordance between these specimens was highest for HER2, followed by PR. For HER2, results obtained from different laboratories were even less concordant. In addition, inter-laboratory differences were noted in the used ER/PR scoring systems, the proportion of ER-/PR+ cases, and the relation between histological grade and ER/PR positivity. Data on Ki67 were only available for 43.8% of the investigated cases, and showed inconsistent use of cut-off values.

CONCLUSION

Breast pathology reporting in Belgium in 2008 was suboptimal and showed considerable inter-laboratory variability. Synoptic reporting has been proposed as a facilitator towards increased reporting quality and harmonization, but the lack of aligned informatics remains a major hurdle in its concrete implementation.

Quality measurement in breast cancer

Variation in the quality of breast care affects outcomes. Objective measurement tools are central to this effort. Most quality measures are process measures. Application of these improves quality. Many national organizations are promoting them for purposes ranging from feedback to providers to public reporting and directing payment. Surgeons should evaluate their own practices and should be involved in local, regional and national efforts to assess and improve breast care.

Evaluation of the quality of the management of cancer of the corpus uteri--selection of relevant quality indicators and implementation in Belgium

OBJECTIVE

Describe the methodology and selection of quality indicators (QI) to be implemented in the EFFECT (EFFectiveness of Endometrial Cancer Treatment) project. EFFECT aims to monitor the variability in Quality of Care (QoC) of uterine cancer in Belgium, to compare the effectiveness of different treatment strategies to improve the QoC and to check the internal validity of the QI to validate the impact of process indicators on outcome.

METHODS

A QI list was retrieved from literature, recent guidelines and QI databases. The Belgian Healthcare Knowledge Center methodology was used for the selection process and involved an expert's panel rating the QI on 4 criteria. The resulting scores and further discussion resulted in a final QI list. An online EFFECT module was developed by the Belgian Cancer Registry including the list of variables required for measuring the QI. Three test phases were performed to evaluate the relevance, feasibility and understanding of the variables and to test the compatibility of the dataset.

RESULTS

138 QI were considered for further discussion and 82 QI were eligible for rating. Based on the rating scores and consensus among the expert's panel, 41 QI were considered measurable and relevant. Testing of the data collection enabled optimization of the content and the user-friendliness of the dataset and online module.

CONCLUSIONS

This first Belgian initiative for monitoring the QoC of uterine cancer indicates that the previously used QI selection methodology is reproducible for uterine cancer. The QI list could be applied by other research groups for comparison.

Quality of care indicators for the surgical treatment of gastric cancer: a systematic review

BACKGROUND

Quality assurance is increasingly acknowledged as a crucial factor for the (surgical) treatment of gastric cancer. The purpose of the current study was to define a minimum set of evidence-based quality of care indicators for the surgical treatment of locally advanced gastric cancer.

METHODS

A systematic review of the literature published between January 1990 and May 2011 was performed, using search terms on gastric cancer, treatment, and quality of care. Studies were selected based on predefined selection criteria. Potential quality of care indicators were assessed based on their level of evidence and were grouped into structure, process, and outcome indicators.

RESULTS

A total of 173 articles were included in the current study. For structural measures, evidence was found for the inverse relationship between hospital volume and postoperative mortality as well as overall survival. Regarding process measures, the most common indicators concerned surgical technique, perioperative care, and multimodality treatment. The only outcome indicator with supporting evidence was a microscopically radical resection.

CONCLUSIONS

Although specific literature on quality of care indicators for the surgical treatment of locally advanced gastric cancer is limited, several quality of care indicators could be identified. These indicators can be used in clinical audits and other quality assurance programs.