Benchmark Method for Cost Computations Across Health Care Systems: Cost of Care per Patient per Day in Breast Cancer Care

2021 ◽  
pp. OP.20.00462
Author(s):  
Douglas W. Blayney ◽  
Tina Seto ◽  
Nhat Hoang ◽  
Craig Lindquist ◽  
Allison W. Kurian
Keyword(s):  
Breast Cancer ◽  
Cancer Care ◽  
Initial Treatment ◽  
Cost Of Care ◽  
Third Party ◽  
Survivorship Care ◽  
Her2 Positive ◽  
Curative Intent ◽  
Social Security Death Index ◽  
Episodes Of Care

PURPOSE: To estimate the value of cancer care and to compare value among episodes of care, a transparent, reproducible, and standardized cost computation methodology is needed. Charges, claims, and reimbursements are related to cost but are nontransparent and proprietary. We developed a method to measure the cost of the following phases of care: (1) initial treatment with curative intent, (2) surveillance and survivorship care, and (3) relapse and end-of-life care. METHODS: We combined clinical data from our electronic health record, the state cancer registry, and the Social Security Death Index. We analyzed the care of patients with breast cancer and mapped Common Procedural Terminology (CPT) codes to the corresponding cost conversion factor and date in the CMS Medicare fee schedule. To account for varying duration of episodes of care, we computed a cost of care per day (CCPD) for each patient. RESULTS: Median CCPD for initial treatment was $29.45 in US dollars (USD), the CCPD for surveillance and survivorship care was $2.45 USD, and the CCPD for relapse care was $13.80 USD. Among the three breast cancer types (hormone receptor-positive or human epidermal growth factor receptor 2 [HER2]-negative, HER2-positive, and triple-negative), there was no difference in CCPD. Relapsed patients in the most expensive surveillance CCPD group had significantly shorter survival. CONCLUSION: We developed a method to identify high-value oncology care—cost of care per patient per day (CCPD)—in episodes of initial, survivorship, and relapse care. The methodology can help identify positive deviants (who have developed best practices) delivering high-value care. Merging our data with claims data from third-party payers can increase the accuracy and validity of the CCPD.

Computing the cost of care per day of breast cancer survivor care.

2018 ◽  
Vol 36 (7_suppl) ◽  
pp. 10-10 ◽  
Author(s):  
Douglas W. Blayney ◽  
Craig Lindquist ◽  
Tina Seto ◽  
Nhat Minh Hoang ◽  
Allison W. Kurian
Keyword(s):  
Breast Cancer ◽  
Cancer Survivor ◽  
Breast Cancer Survivor ◽  
Radiation Treatment ◽  
Cost Of Care ◽  
Survivorship Care ◽  
Co Morbidity ◽  
Social Security Death Index ◽  
The Cost ◽  
The Impact

10 Background: Cost of breast cancer survivor surveillance, of survivorship care and of variation in care practices are unknown. Furthermore, it is not known whether intense surveillance care adds value. We developed a method to measure the cost of surveillance to account for varying follow-up duration [cost of care per day (CCPD)], and explored the impact of surveillance cost on survival. Methods: We queried the Oncoshare database {Kurian et al Cancer 2014}, which amalgamates data from Stanford Health Care’s (SHC) electronic health record (EHR) (imaging, infused drugs, inpatient and outpatient facility and professional services), from the California Cancer Registry, and the Social Security Death Index. We included breast cancer patients diagnosed 2000-2014, Stages 0-III who had surgery, chemotherapy or radiation treatment at SHC, and who had more than two visits at SHC within 3 years of their treatment completion. We tallied Common Procedural Terminology (CPT©) codes assigned to each service, and mapped each CPT code to the corresponding code and date in the CMS Medicare fee schedule. For patients with breast cancer relapse, we explored the post-relapse survival of the costliest 20% compared with the other patients. Results: CCPD was $2.45 for care delivered at SHC. Among the three breast cancer subtypes (luminal, Her-2 over-expressed and triple negative) there was no difference in cost. Among patients who relapsed, those in the most expensive 20% CCPD had significantly shorter survival than other patients. The high-cost patients had more co-morbidity [cerebrovascular disease (4% for low cost vs 7% for high), chronic pulmonary disease (5% vs 10%), CHF (2% vs 7%), diabetes (4% vs 7%), liver disease (4% vs 9%)]. Conclusions: Cost of care per day (CCPD) is a useful metric to assess value of surveillance and survivorship care, and is also applicable to initial treatment and post-relapse care, to identify “positive deviants” ( those who have developed best practices) in high value care delivery. We captured only costs for treatment at SHC, and merging our data with claims data from 3rd party carriers could increase the accuracy and validity of the CCPD. We identified a model for further testing to reduce total spending for high-quality oncology care.

scholarly journals Loss of HER2 Positivity after Trastuzumab in HER2-Positive Gastric Cancer: Is Change in HER2 Status Significantly Frequent?

2015 ◽  
Vol 2015 ◽  
pp. 1-6 ◽  
Author(s):  
Yu Ishimine ◽  
Akira Goto ◽  
Yoshito Watanabe ◽  
Hidetaka Yajima ◽  
Suguru Nakagaki ◽  
...  
Keyword(s):  
Breast Cancer ◽  
Gastric Cancer ◽  
Residual Tumor ◽  
Her2 Status ◽  
Resected Specimen ◽  
Her2 Positive ◽  
Curative Intent ◽  
Course Of Disease ◽  
Trastuzumab Therapy ◽  
Her2 Positivity

Trastuzumab has recently been introduced as a treatment for HER2-positive metastatic and/or unresectable gastric cancer (MUGC); however, compared with breast cancer, some issues concerning HER2 and trastuzumab therapy for gastric cancer remain unclear. A 74-year-old woman received trastuzumab-containing chemotherapy for HER2-positive MUGC. She had a marked response to 8 months of chemotherapy, and gastrectomy and hepatic metastasectomy with curative intent were performed. The resected specimen showed complete loss of HER2 positivity in the residual tumor. For MUGC, a change in HER2 status during the course of the disease with or without chemotherapy has rarely been reported. However, in breast cancer, a significant frequency of change in HER2 status during the course of disease has been reported, and reevaluation of HER2 positivity in metastatic/recurrent sites is recommended. The choice of trastuzumab for MUGC is currently based on the HER2 status of the primary tumor at the time of initial diagnosis, without reassessment of HER2 status during the course of disease and/or in metastatic/recurrent sites, on the assumption that HER2 status is stable. However, our case casts doubt on the stability of HER2 in gastric cancer.

Patient preferences for provider roles in collaborative breast cancer survivorship care.

2016 ◽  
Vol 34 (7_suppl) ◽  
pp. 184-184
Author(s):  
Lauren P. Wallner ◽  
Paul Abrahamse ◽  
Christopher Ryan Friese ◽  
Steven J. Katz ◽  
Sarah T. Hawley
Keyword(s):  
Breast Cancer ◽  
Los Angeles ◽  
Preventive Care ◽  
Patient Preferences ◽  
Cancer Care ◽  
Multinomial Logistic Regression ◽  
Physical Symptoms ◽  
Current Response ◽  
Survivorship Care ◽  
Emotional Symptoms

184 Background: Prior studies have exploredbarriers to collaborative cancer care and suggest a need for greater clarity about clinician roles. However, little is known about patient’s preferences and expectations for which clinicians handle various aspects of care after primary cancer treatment. Methods: A weighted random sample of newly diagnosed breast cancer patients in the Georgia and Los Angeles SEER registries were surveyed approximately 6 months after diagnosis (expected final N = 2600, 70% current response rate). Patient preferences for which clinician handles the following aspects of care after treatment were ascertained: follow-up mammograms, screening for other cancers, general preventive care, treatment of comorbidities, physical symptoms, emotional symptoms, and reassurance about their breast cancer. Response categories included primary care clinician (PCP), cancer doctors, either or both. The associations between patient demographic and clinical factors with preferences for clinician roles were assessed using multinomial logistic regression. Results: In a preliminary sample (N = 1038), the majority of women preferred to see oncologists for mammograms (63%), other cancer screening (67%) and reassurance about their cancer (75%) and PCPs for general preventive care (80%), comorbid care (85%) and emotional symptoms (67%). Black women (vs. White) were more likely to prefer to see both clinicians for mammograms (OR: 3.7, 95%CI: 2.5, 5.5), screening for other cancers (OR: 2.1, 95%CI: 1.3, 3.2), reassurance about their cancer (OR: 2.1, 95%CI: 1.3, 3.2), and general preventive care (OR: 4.0, 95%CI: 2.1, 7.8). Black and Hispanic women were more likely to prefer to see both for comorbidity care (Black OR: 3.2, 95%CI: 1.6, 6.3; Hispanic OR: 2.6, 95%CI: 1.1, 6.3). Less than a high school education was also associated with a preference for seeing both clinicians for comorbidity care. Conclusions: While patients report clear preferences for which clinicians handle various aspects of their collaborative survivorship care, variation exists by race and education. Targeting these patients to clarify clinician roles may be particularly effective in interventions to improve collaborative cancer care.

scholarly journals Healthcare use and costs in early breast cancer: a patient-level data analysis according to stage and breast cancer subtype

ESMO Open ◽  
2020 ◽  
Vol 5 (6) ◽  
pp. e000984
Author(s):  
Mariana Brandão ◽  
Samantha Morais ◽  
Luísa Lopes-Conceição ◽  
Filipa Fontes ◽  
Natália Araújo ◽  
...  
Keyword(s):  
Breast Cancer ◽  
Early Breast Cancer ◽  
Cancer Care ◽  
Cost Of Care ◽  
Stage I ◽  
Breast Cancer Care ◽  
Intrinsic Subtypes ◽  
Patient Level ◽  
Level Data ◽  
The Cost

BackgroundThe cost of breast cancer care rises with higher stage at diagnosis; however, there are no real-world data regarding the cost of care according to breast cancer subtypes. This study aimed to estimate direct medical costs for early breast cancer care in the first 3 years after diagnosis according to subtype and stage, using patient-level data.MethodsWomen with newly diagnosed stage I–III breast cancer, admitted in 2012 to a Portuguese cancer centre were prospectively followed within the NEON-BC cohort. The use of health resources was obtained from each patient’s clinical and administrative records and costs were computed. Tumours were classified into the classic subtypes (hormone receptor-positive (HR+)/HER2−; HER2-positive (HER2+); triple-negative breast cancer (TNBC)) and surrogate intrinsic subtypes (luminal A-like; luminal B-like; HER2 enriched; basal like).ResultsA total of 703 patients were included: 48.9% had stage I, 35.8% stage II and 15.2% stage III breast cancer; 76.4% had HR+/HER2−, 15.9% HER2+ and 7.7% TNBC. Median cost of care was €9215/patient in stage I, €13 019/patient in stage II and €15 011/patient in stage III and €10 540/patient in HR+/HER2−, €11 224/patient in TNBC and €41 513/patient in HER2+ breast cancer. Systemic therapy accounted for 69.2% of the cost of care among patients with HER2+, 12.0% among HR+/HER2− and 7.5% among TNBC patients. Similar differences were observed across surrogate intrinsic subtypes.ConclusionsThe cost of early breast cancer care was mainly driven by the tumour subtype and, to a lesser extent, by stage. The median cost of care was fourfold higher among patients with HER2+ tumours compared with those with HR+/HER2− and TNBC. These data provide information for the economic evaluation of innovative treatments for early breast cancer and highlight the weight that targeted systemic therapy might have in the overall cost of care among patients with early breast cancer.

Pertuzumab and trastuzumab as adjuvant treatment for HER2-positive early breast cancer: outcomes in Chinese patients in the APHINITY study

2021 ◽  
Vol 51 (3) ◽  
pp. 345-353
Author(s):  
Zhimin Shao ◽  
Ling-Ming Tseng ◽  
Chiun-Sheng Huang ◽  
Da Pang ◽  
Youngsen Yang ◽  
...  
Keyword(s):  
Breast Cancer ◽  
Early Breast Cancer ◽  
Adjuvant Treatment ◽  
Statistical Significance ◽  
Disease Free Survival ◽  
Chinese Patients ◽  
Primary Analysis ◽  
Her2 Positive ◽  
Curative Intent ◽  
Global Population

Abstract Background The addition of pertuzumab to trastuzumab plus standard chemotherapy as adjuvant therapy following surgery significantly improved invasive disease-free survival (IDFS) in patients with HER2-positive early breast cancer in the multinational randomized APHINITY trial (NCT01358877, BIG 4–11/BO25126/TOC4939G). We analyzed clinical outcomes in the subgroup of patients recruited at Chinese sites. Methods Patients were randomized to standard adjuvant chemotherapy plus 1 year of trastuzumab with pertuzumab or placebo. Patients recruited in mainland China, Hong Kong and Taiwan are included in this descriptive analysis. Results Chinese patients had similar demographic characteristics to the global population, but a higher proportion had nodal involvement. Although this subgroup analysis was not powered to detect statistical significance, a numerical improvement in IDFS was observed with the addition of pertuzumab to trastuzumab in Chinese patients (hazard ratio, 0.69; 95% confidence interval: 0.39–1.19; 3-year IDFS event-free estimates 92.5% [pertuzumab] and 91.7% [placebo]), which was consistent with the primary analysis of the global population. Further subgroup analyses showed numerical improvements in the Chinese node-positive, hormone receptor-negative and -positive subgroups, although confidence intervals were wide due to the low number of events. The incidence of diarrhea was higher in the pertuzumab arm, and no primary cardiac events occurred in Chinese patients in either arm. Conclusions Pertuzumab, used in combination with trastuzumab and chemotherapy in APHINITY, is effective as an adjuvant treatment regimen for Chinese patients with HER2-positive early breast cancer in a setting with curative intent. The safety profile in Chinese patients was consistent with that of the global population.

Preliminary results from a comparative effectiveness study of breast cancer survivorship care: A University of California (UC) ATHENA Breast Health Network project.

2011 ◽  
Vol 29 (27_suppl) ◽  
pp. 212-212
Author(s):  
E. E. Hahn ◽  
P. A. Ganz ◽  
M. E. Melisko ◽  
J. P. Pierce ◽  
M. M. Von Friederichs-Fitzwater ◽  
...  
Keyword(s):  
Breast Cancer ◽  
Care Coordination ◽  
Cancer Care ◽  
Post Treatment ◽  
Breast Health ◽  
Survivorship Care ◽  
Breast Cancer Care ◽  
Preliminary Results ◽  
Key Informant

212 Background: The ATHENA Breast Health Network collaboration is a large scale, UC system-wide project initiated with the intent to drive innovation in breast cancer prevention, screening and treatment. An IRB approved research protocol was developed to examine survivorship care across Network sites, which includes key informant interviews at each site and patient/survivor surveys. This abstract presents preliminary analyses from the key informant interviews. Methods: Investigators at each site conducted semi-structured interviews with oncology specialists and primary care providers (PCPs). Interviews used case study examples and open and closed-ended questions on the delivery of post-treatment breast cancer care. Informant responses were manually recorded by the interviewer, compiled in a database, then coded and analyzed using NVIVO9 software. Results: There were 39 key informants across five participating UC sites: 14 medical oncologists, 7 radiation oncologists, 11 surgeons, 3 oncology nurses, and 4 PCPs. Care coordination is a major unprompted theme identified in the interviews. 85% of all participants reported using shared care coordination between PCP and oncology for post-treatment follow-up. 49% report the need for greater care coordination in general, and 28% report the need for greater care coordination within oncology, particularly to help avoid duplication of follow-up care and services. The responses demonstrate wide variability among provider types and institutions (Table). Additional analyses from this study will be updated in our presentation. Conclusions: These preliminary results identify the need for focus on care coordination during the post-treatment phase of breast cancer care within the UC system. [Table: see text]

A proposed multidisciplinary model providing comprehensive breast cancer care.

2018 ◽  
Vol 36 (7_suppl) ◽  
pp. 43-43 ◽  
Author(s):  
Lauren Cornell ◽  
Sandhya Pruthi ◽  
Dawn Mussallem
Keyword(s):  
Breast Cancer ◽  
Cancer Care ◽  
Breast Cancer Survivors ◽  
Integrative Approach ◽  
Survivorship Care ◽  
Breast Cancer Care ◽  
Care Plans ◽  
Late Treatment ◽  
Multidisciplinary Model ◽  
Lifestyle Education

43 Background: Strategies to detect and treat breast cancer continue to improve, and as such, the number of survivors has grown dramatically. To date, there has not been a well-established model to provide cohesive care for breast cancer survivors. Care often feels fragmented and important issues are overlooked due to lack of continuity. The adoption of Survivorship Care Plans has aimed to fill this gap in care, but the literature still demonstrates that our patients’ needs are not being met. Methods: We present a comprehensive model for breast cancer care, within a multidisciplinary breast center, which incorporates consistent management from time of diagnosis through survivorship. This model utilizes the appointment of a dedicated breast internist that meets with each patient at the time of diagnosis and again assumes care at time of survivorship. The breast internists or “onco-generalists” have specialized training in breast cancer/survivorship and work alongside the entire multidisciplinary team. This unique approach incorporates individualized surveillance, integrative management of late treatment effects, and appropriate risk reducing lifestyle education. Results: The inclusion of a dedicated breast internist into survivorship care has been the standard within our center for over 10 years. With this model, we have found that survivorship care is more holistic with a focus on the patients’ overall needs. There is dedicated time to individualized risk assessment, appropriate surveillance, and modifiable risk factor education. The model also allows for incorporation of integrative medicine including mindfulness, acupuncture, and massage therapy to improve quality of life for patients. With this model, patients do not feel the abandonment that is so often experienced by survivors, but rather they feel empowered to enter their new life as a survivor. Conclusions: Continuity of care during and after breast cancer treatment remains a significant issue. By designating an internist with specialized breast training who initially meets with patients upfront, we have been able to create a more integrative approach to survivorship care, which encompasses the patients’ needs both surrounding and outside of their cancer diagnosis.

A national real-world prospective study to assess the effectiveness of adjuvant trastuzumab-dkst in HER2 breast cancer.

2020 ◽  
Vol 38 (15_suppl) ◽  
pp. e13023-e13023
Author(s):  
Leandro Ladislau Alves ◽  
Lara Lopes Facó ◽  
Ana Carolina Cardoso ◽  
Alexandre Alcantara ◽  
Augusto Theodoro Figueiredo ◽  
...  
Keyword(s):  
Breast Cancer ◽  
Survival Rate ◽  
Real World ◽  
Invasive Disease ◽  
Disease Relapse ◽  
Relapse Free Survival ◽  
Her2 Positive ◽  
Curative Intent ◽  
Free Survival ◽  
Her2 Breast Cancer

e13023 Background: Real-World Evidence (RWE) are gain importance once they are designed to evaluate the effectiveness of drugs whose efficacy has already been demonstrated in randomized controlled trials. In 2017, Brazil approved the first biosimilar of trastuzumab for treatment of breast cancer (BC) with overexpression of HER2. The anti-HER2 treatment significantly improves outcome in patients with HER2-positive BC. Trastuzumab-dkst is clinically effective biosimilar and help to increase access to BC treatment. The aim of this RWE is to address the effectiveness of adjuvant biosimilar trastuzumab-dkst in Brazilian women with early HER2+ BC. Methods: This is a national, multicenter, observational, prospective, RWE study conducted in Brazilian institutions. A hundred and seventy female adult patients, with diagnosis of early stage HER2-positive BC, who received at least one dose of trastuzumab-dkst as adjuvant therapy will be included. The follow-up period will be 5 years after the first dose of trastuzumab-dkst, unless tumor recurrence or death. The safety endpoints are the occurrence adverse events. The effectiveness endpoints are invasive disease relapse-free survival rate at 18, 24, 30 and 36 months after the start of biosimilar use, the invasive disease relapse-free survival after curative-intent surgery and overall survival after curative intent surgery. Given the inexistence of a specific hypothesis to be tested, sample size was based on the accuracy of the two-sided 95% confidence interval (95% CI) for the invasive disease relapse-free survival rate. Results: The recruitment planning covered 21 sites across the five regions of Brazil: North, Northeast, Midwest, Southeast, and South. From those 21 sites, 14 ( > 50%) have already been approved by their local ethical committee for patient recruitment. At 7 months, we have enrolled 50 patients over the five Brazilian regions, which means 29.4% of the total. Conclusions: To conduct RWE in Brazil is still challenging and we have listed 5 possible reasons: (1) there are few RWE studies running in the country, (2) we do not have trialists experienced in RWE design; (3) low medical commitment to adverse event report in RWE; (4) low budget for RWE; (5) slow ethics and regulatory process approval in Brazil. Considering the pioneering and challenges to develop the RWE in Brazil, we are achieving optimum adherence from medical sites. Moreover, roughly one quarter of the target recruitment was reached in the first 7 months after the study start date. Clinical trial information: NCT03892655 .

scholarly journals Results From a Health Insurer's Clinical Pathway Program in Breast Cancer

2018 ◽  
Vol 14 (11) ◽  
pp. e711-e721 ◽  
Author(s):  
Santosh Gautam ◽  
Gosia Sylwestrzak ◽  
John Barron ◽  
Xiaoxue Chen ◽  
Michael Eleff ◽  
...  
Keyword(s):  
Breast Cancer ◽  
Emergency Department ◽  
Quality Of Care ◽  
Cancer Care ◽  
Cost Of Care ◽  
Emergency Department Visits ◽  
Granulocyte Colony Stimulating Factor ◽  
Colony Stimulating Factor ◽  
Stimulating Factor

Purpose: Pathway regimens are value-driven, evidence-based therapies that aim at high-quality, affordable cancer care. There are few real-world data to support the value of such regimens, especially for patients with breast cancer. Materials and Methods: Using nationally representative claims data from Anthem, together with clinical data from its Cancer Care Quality Program, we identified patients with breast cancer for whom chemotherapy was initiated between January 2015 and October 2016. On the basis of demographic and clinical characteristics, patients receiving a pathway regimen (on-pathway cohort) were matched to those who did not (off-pathway cohort) using 1:1 propensity score matching. We compared post–6-month quality-of-care outcomes including hospitalization, emergency department visits, need for supportive drugs such as granulocyte colony-stimulating factor, and cost outcomes between the cohorts. Results: There were 959 patients in each cohort after matching. Patients in both cohorts had a similar age distribution (median age, 52 years in the off-pathway cohort v 53 years in the on-pathway cohort), and most presented with stage II disease (49.4% in the off-pathway cohort v 49.8% in the on-pathway cohort); nearly two thirds of each cohort had hormone receptor positive cancer (67.3% in the off-pathway cohort v 64.9% in the on-pathway cohort). The two cohorts had similar rates of hospitalization and emergency department visits; however, the rate of granulocyte colony-stimulating factor use was significantly lower in the on-pathway cohort (72.5% in the on-pathway cohort v 82.8% in the off-pathway cohort; odds ratio, 0.55; P ≤ .0001). The average post–6-month cost of care was $16,176 lower (95% CI, −$24,291 to −$8,061; P ≤ .0001) in the on-pathway cohort. Conclusion: Pathway regimens for breast cancer demonstrate an example of high-value care. They are associated with a reduced cost of care without compromising quality of care.

scholarly journals Optimal systemic therapy for early breast cancer in women: a clinical practice guideline

2014 ◽  
Vol 22 ◽  
pp. 67 ◽  
Author(s):  
A. Eisen ◽  
G.G. Fletcher ◽  
S. Gandhi ◽  
M. Mates ◽  
O.C. Freedman ◽  
...  
Keyword(s):  
Breast Cancer ◽  
Systematic Review ◽  
Targeted Therapy ◽  
Hormonal Therapy ◽  
Systemic Therapy ◽  
Cancer Care ◽  
Early Stage ◽  
Pathologic Complete Response ◽  
Adjuvant Systemic Therapy ◽  
Her2 Positive

The Breast Cancer Disease Site Group of Cancer Care Ontario identified the need for new guidelines for the adjuvant systemic therapy of early-stage breast cancer. The specific question to be addressed was “What is the optimal adjuvant systemic therapy for female patients with early-stage operable breast cancer, when patient and disease factors are considered?”A systematic review was prepared based on literature searches conducted using the medline and embase databases for the period January 2008 to March 5, 2012, and updated to May 12, 2014. Guidelines were located from that search, from the Standards and Guidelines Evidence directory of cancer guidelines, and from the Web sites of major guideline organizations. The literature located was subdivided into the broad categories of chemotherapy, hormonal therapy, and therapy targeted to her2 (human epidermal growth factor receptor 2). Although several of the systemic therapies discussed in this guideline can be considered in the neoadjuvant setting, the review focused on trials with rates of disease-free and overall survival as endpoints and thus excluded several trials that used pathologic complete response as a primary endpoint.Based on the systematic review, the working group drafted recommendations on the use of chemotherapy, hormonal therapy, and targeted therapy; based on their professional experience, they also drafted recommendations on patient and disease characteristics and recurrence risk. The literature review and draft recommendations were circulated to a consensus panel of medical oncologists who had expertise in breast cancer and who represented the regions of Ontario. Items without initial consensus were discussed at an in-person consensus meeting held in Toronto, November 23, 2012. The final recommendations are those for which consensus was reached before or at the meeting. Some of the key evidence was revised after the updated literature search. Evidence reviews for systemic chemotherapy, endocrine therapy, and targeted therapy for her2-positive disease are reported in separate articles in this supplement. The full three-part 1-21 evidence-based series, including complete details of the development and consensus processes, can be found on the Cancer Care Ontario Web site at https://www.cancercare.on.ca/toolbox/qualityguidelines/diseasesite/breast-ebs.

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