Can protocol development improve breast cancer and breast surgery quality measures?

119 Background: Since 2009, UF Health Jacksonville has made significant changes in the Breast Cancer Program. These changes spanned across multiple specialties and have focused on creating protocols, guidelines, checklists, and policies for the management of breast cancer. This study evaluated the effect of standardized institutional protocols on breast cancer quality measures. Methods: Tumor registry was used to identify 350 patients who were diagnosed and treated at UF Health Jacksonville for breast cancer from 2006-2012 (Stage 0-III excluding LCIS). A retrospective review of electronic health records was performed to compare the achievement of quality measures 2 years before program development (6/2006 – 6/2008) to that of 2 years after program development (6/2010 -6/2012). Results: There were significant improvements in breast cancer diagnosis and surgical treatment quality measures after establishment of standardized protocols. Performance of pre-surgical needle biopsies regardless of diagnostic outcome (90% vs. 96%, p=0.02), and diagnosis of carcinoma via needle biopsy (50% vs. 87%, p=0.04) both showed significant improvement. More patients underwent sentinel lymph node biopsy post-protocol (43% vs. 68%, p<0.001). There was improvement in surgical specimen orientation (58% vs. 88%, p<0.001), and image confirmation of the specimen post-protocol (86% vs. 97%, p=0.01). There was a reduction of second or additional operations (44% vs. 26%, p=0.004), which included a significant reduction in lumpectomy re-excisions for margins (30% vs. 14%, p=0.003). There was a non-significant improvement in attempted (64% vs. 71%, p=0.17), and successful breast conservation surgery (57% vs. 65%, p=0.10). There were no significant changes in the rates of recommendation for adjuvant radiation, endocrine, or chemotherapy. There was no improvement in patient adherence to the recommended adjuvant therapy based on protocol implementation. Conclusions: Implementation of standardized institutional protocols can significantly increase achievement of quality measures in breast cancer diagnosis and surgery. However, these protocols did not have a significant effect on systemic therapy or radiation therapy quality measures.

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An IMRT technique to increase therapeutic ratio of breast irradiation in patients with early stage left breast cancer: Limiting second malignancies

Journal of Clinical Oncology ◽

10.1200/jco.2006.24.18_suppl.10791 ◽

2006 ◽

Vol 24 (18_suppl) ◽

pp. 10791-10791 ◽

Cited By ~ 1

Author(s):

R. S. Ahmed ◽

J. B. Fiveash ◽

R. A. Popple ◽

S. A. Spencer ◽

J. F. De Los Santos

Keyword(s):

Breast Cancer ◽

Low Dose ◽

Early Stage ◽

Breast Conservation ◽

Left Breast ◽

Breast Conservation Surgery ◽

Adjuvant Radiation ◽

Target Coverage ◽

Second Malignancy ◽

Dose Levels

10791 Background: The clinical application of IMRT for adjuvant treatment of breast cancer has been the subject of increasing study in recent years. IMRT plans have improved target coverage and reduced dose inhomogeneities observed within the breast in standard plans. IMRT was able to reduce doses delivered to the heart, lungs, and right breast at clinically significant doses, but this has been at the cost of larger volumes of low dose radiation to these structures and thus, increasing the risk for second malignancy. Our goal was to develop an IMRT beam arrangement that did not result in additional low dose spill to risk organs while maintaining equal or better target coverage. Methods: Five patients with early stage left-sided breast cancer, who underwent breast conservation surgery, and adjuvant radiation using standard wedged tangential fields, were chosen for this comparative study. An IMRT plan consisting of 6 tangential beams (3 medial and 3 lateral) was generated by using the gantry, collimator and table angles of the standard plan used for the conventional radiation (CRT), and moving the table +10 and −10 degrees on each side. The prescription dose for both CRT and IMRT plans was 45 Gy, 1.8 Gy/fraction, prescribed to the isocenter which was placed near the center of the breast. Results: IMRT plans provided significantly better coverage of the left breast than CRT plans, (p=0.03). Although dose heterogeneity was greater with the IMRT plans, the difference was not significant (p = 0.68). The mean volumes of the heart, lung, and right breast were lower in patients planned with IMRT at all dose levels from 5% to 100% dose (5% increments). This difference was significant for volumes receiving 2.25 Gy for the heart (p = 0.003), volumes receiving 2.25 Gy, 4.5 Gy, 6.75 Gy, 33.75 Gy, 36 Gy, 38.25 Gy, and 42.75 Gy for the lung (p = 0.014, 0.04, 0.044, 0.05, 0.049, 0.045, 0.05, respectively). Surprisingly, breast IMRT resulted in significantly lower right breast volumes irradiated at all dose levels compared to CRT. Conclusions: A six-tangential field IMRT technique achieved significantly better left breast coverage while maintaining lower doses to risk organs at all dose levels and therefore, reducing the potential for induction of a second malignancy. No significant financial relationships to disclose.

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Predictors of adjuvant radiation therapy in the treatment of male breast cancer and its impact on outcomes: A propensity matched analysis.

Journal of Clinical Oncology ◽

10.1200/jco.2020.38.15_suppl.e12516 ◽

2020 ◽

Vol 38 (15_suppl) ◽

pp. e12516-e12516

Author(s):

Veli Bakalov ◽

Thejus Thayyil Jayakrishnan ◽

Stephen Abel ◽

Christie Hilton ◽

Bindu Rusia ◽

...

Keyword(s):

Breast Cancer ◽

Radiation Therapy ◽

Male Breast Cancer ◽

Cox Regression ◽

Breast Conservation ◽

Male Breast ◽

Breast Conservation Surgery ◽

P Value ◽

Adjuvant Radiation ◽

Adjuvant Radiation Therapy

e12516 Background: Male breast cancer (MBC) accounts for 1% of all breast cancers and there is a paucity of data on factors impacting the treatment strategies and outcomes. We hypothesized that adjuvant radiation therapy (Adj-RT) may improve survival outcomes and sought to examine predictive factors for Adj-RT receipt. Methods: We queried the National Cancer Database (NCDB) for patients with stages I-III MBC treated with surgery (breast conservation surgery- BCS or mastectomy-MS) within 180 days of diagnosis (years 2004-2015). Multivariable logistic regression identified predictors of adjuvant radiation therapy receipt. Multivariable Cox regression evaluated predictors of survival. Propensity matching for adj-RT accounted for indication biases. Results: We identified 6,217 patients meeting the eligibility criteria (1457 BCS vs. 4760 MS). The majority of patients were white (85%) and within the age range of 50-80 years (74%). Although Adj-RT was omitted for 30% of BCS patients, the utilization was higher compared to MS (OR=26, p-value=0.001). The predictors of Adj-RT use were – African American race, higher stage, higher grade, presence of lymphovascular invasion and ER/Her-2 positivity for the entire cohort and higher age, urban location and higher income for BCS. Adj-RT was associated with lower mortality in the propensity matched model (overall HR for BCS=0.28, p-value<0.001; overall HR for MS=0.62,p-value=0.001) and is shown in the table. Conclusions: This study demonstrates there may be an association between decreased mortality and Adj-RT in MBC undergoing BCS. Although this implies that Adj-RT should be routinely delivered, it appears to be omitted frequently and its use requires further investigation. The study also suggests a benefit to Adj-Rt after MS for stage-III MBC. [Table: see text]

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Clinical and Imaging Surveillance Following Breast Cancer Diagnosis

American Society of Clinical Oncology Educational Book ◽

10.14694/edbook_am.2012.32.220 ◽

2012 ◽

pp. 59-64 ◽

Cited By ~ 3

Author(s):

Chris I. Flowers ◽

Blaise P. Mooney ◽

Jennifer S. Drukteinis

Keyword(s):

Breast Cancer ◽

Cancer Diagnosis ◽

Clinical Symptoms ◽

Breast Conservation ◽

High Specificity ◽

Breast Cancer Diagnosis ◽

Breast Conservation Therapy ◽

Physical Exam ◽

Definitive Treatment ◽

Increased Risk

Overview: Breast cancer is the most common malignancy affecting women worldwide. Women have a 1 in 8 lifetime risk of breast cancer. Breast conservation therapy (BCT) is the most common method of definitive treatment. Patients who previously have had to undergo mastectomy may be now eligible for BCT or a multitude of options for reconstruction, either immediate or delayed. Surveillance imaging after a breast cancer diagnosis is important because there is an increased risk of recurrence developing in patients, and early detection has been shown to improve survival. There is currently no consensus on a protocol for imaging the postoperative breast. In patients who have undergone mastectomy, detection of recurrence has mostly been via clinical symptoms and physical exam, often at a later stage. New imaging modalities, such as magnetic resonance imaging (MRI), ultrasound (US), and positron emission mammography (PEM) are changing the way we image the postsurgical breast. MRI, coupled with physical exam and mammography, approaches 100% sensitivity and high specificity for the identification of recurrent disease. We present a review of major academic institutions' imaging protocols and discuss the advantages of including MRI in traditional mammographic and clinical exams.

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