Explaining variation in quality of breast cancer care and its impact: a nationwide population-based study from Slovenia

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.

Breast cancer care and surgery in Australia and New Zealand: compliance of the BreastSurgANZ quality audit with international standards

BACKGROUND

The Breast Surgeons of Australia and New Zealand (BreastSurgANZ) Quality Audit (BQA) of Breast Cancer Care is a prospective population-based database designed for annual audit of compliance with internally derived Quality Indicators (QI)s. While there is no international consensus for QIs, audit against an external international benchmark is possible through use of QIs defined by the 2017 European Society of Breast Cancer Specialists (EUSOMA) Guidelines.

METHODS

BQA data from 29,088 female patients between 1/1/2018 and 31/12/2019 were stratified by the EUSOMA definition of low-volume hospitals (LVH <150 patients p.a.) and high-volume hospitals (HVH ≥150 patients p.a.), and percentage compliance (±95% CI) with 14 mandatory EUSOMA QI sub-parts were determined.

RESULTS

ANZ LVH met the quality threshold for 10, and HVH for 8 EUSOMA QI that assessed MDT, surgical approach, adjuvant radiotherapy in the LVH setting, avoidance of overtreatment, and use of endocrine therapy. ANZ did not meet the quality thresholds for QIs assessing use of neoadjuvant chemotherapy, and adjuvant radiotherapy in the HVH setting.

CONCLUSION

Breast cancer care in ANZ is comparable with an international standard. ANZ surgeons performed at a high standard in discussion of breast cancer patients by MDT, and appropriate use of adjuvant radiotherapy by LVH. Improvements can be made in completeness of data capture, and inclusion of genetic syndrome and Ki67% in data collection. Due to the rapid evolution of breast cancer treatments, there is need for contemporary update of QI relating to the use of neoadjuvant systemic therapies.

A scoping review of ageism towards older adults in cancer care

INTRODUCTION

Ageism towards older adults with cancer may impact treatment decisions, healthcare interactions, and shape health/psychosocial outcomes. The purpose of this review is twofold: (1) To synthesize the literature on ageism towards older adults with cancer in oncology and (2) To identify interventions that address ageism in the healthcare context applicable to oncology.

MATERIALS AND METHODS

We conducted a scoping review following Arksey and O'Malley and Levac methods and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We conducted an exhaustive multi-database search, screening 30,926 titles/abstracts. Following data abstraction, we conducted tabular, narrative, and textual synthesis.

RESULTS

We extracted data on 133 papers. Most (n = 44) were expert opinions, reviews, and letters to editors highlighting the negative impacts of ageism, expressing the need for approaches addressing heterogeneity of older adults, and calling for increased clinical trial inclusion for older adults. Qualitative studies (n = 3) described healthcare professionals' perceived influence of age on treatment recommendations, whereas quantitative studies (n = 32) were inconclusive as to whether age-related bias impacted treatment recommendations/outcomes or survival. Intervention studies (n = 54) targeted ageism in pre/post-licensure healthcare professionals and reported participants' improvement in knowledge and/or attitudes towards older adults. No interventions were found that had been implemented in oncology.

DISCUSSION

Concerns relating to ageism in cancer care are consistently described in the literature. Interventions exist to address ageism; however, none have been developed or tested in oncology settings. Addressing ageism in oncology will require integration of geriatric knowledge/interventions to address conscious and unconscious ageist attitudes impacting care and outcomes. Interventions hold promise if tailored for cancer care settings. 249/250.

Evaluation of Quality Indicators of Breast Cancer Management at a Tertiary Cancer Center in Nepal

Breast cancer is the second commonest cancer among female in Nepal. This is our first attempt to audit breast cancer management in our institute and compare with standard quality indicators (QIs) available.

Quality indicators in breast cancer management were assessed in Bhaktapur Cancer Hospital, Nepal. Inadequacy of documentation of staging workup, very low compliance to neoadjuvant chemotherapy and targeted therapy, low rate of BCS, and absence of MDT discussion before management are our key findings of the study. We have identified significant rooms for improvement. Proper recording of staging investigation and establishment of MDT will be the initial steps for improvement of care. Identification and management of patient-related factors with involvement of stakeholders for policy-making work may further supplement the need of quality care.

The association between guideline adherence, age and overall survival among women with non-metastatic breast cancer: A systematic review

INTRODUCTION

Conformity with treatment guidelines should benefit patients. Studies have reported variation in adherence to breast cancer (BC) guidelines, particularly among older women. This study investigated (i) whether adherence to treatment guideline recommendations for women with non-metastatic BC improves overall survival (OS), (ii) whether that relationship varies by age.

METHODOLOGY

MEDLINE and EMBASE were systematically searched for studies on guideline adherence and OS in women with non-metastatic BC, published after January 2000, which examined recommendations on breast surgery, chemotherapy, radiotherapy or endocrine therapy. Study results were summarised using narrative synthesis.

RESULTS

Sixteen studies met the inclusion criteria. The recommendations for each treatment covered were similar, but studies differed in their definitions of adherence. 5-year OS rates among patients having compliant treatment ranged from 91.3% to 93.2%, while rates among patients having non-compliant treatment ranged from 75.9% to 83.4%. Six studies reported an adjusted hazard ratio (aHR) for non-compliant treatment compared with compliant treatment; all concluded OS was worse among patients whose overall treatment was non-compliant (aHR range: 1.52 [1.30-1.82] to 2.57 [1.96-3.37]), but adjustment for potential confounders was limited. Worse adherence among older women was reported in 12/16 studies, but they did not provide consistent evidence on whether OS was associated with treatment adherence and age.

CONCLUSIONS

Individual studies reported that better adherence to guidelines improved OS among women with non-metastatic BC, but the evidence base has weaknesses including inconsistent definitions of adherence. More precise and consistent research designs, including the evaluation of barriers to adherence across the spectrum of healthcare practice, are required to fully understand guideline compliance, as well as the relationship between compliance and OS following a BC diagnosis.

Evaluation of the breast cancer care network within the Lazio Region (Central Italy)

BACKGROUND AND OBJECTIVES

A summary indicator for evaluating the breast cancer network has never been measured at the regional level. The aim is to design treemaps providing a summary description of hospitals (including breast units) and Local Health Units (LHUs) in terms of their levels of performance within the breast cancer network of the Lazio region (central Italy). The treemap structure has an intuitive design and displays information from both general and specific analyses.

METHODS

Patients admitted to the regional hospitals for malignant breast cancer (MBC) surgery in 2010-2017 were selected in a population-based cohort study. These quality indicators were calculated based on the international guidelines (EUSOMA, ESMO) to assess the performance in terms of volume of activity, surgery procedure, post-surgery assistance and timeliness of medical therapy or radiotherapy beginning. The quality indicators were calculated using administrative health data systematically collected at the regional level and were included in the treemap to represent the surgery or the post-surgery areas of the breast cancer clinical pathway. In order to allow aggregation of scores for different indicators belonging to the same clinical area, up to five evaluation classes were defined using the "Jenks Natural Breaks" algorithm. A score and a colour were assigned to each clinical area based on the ranking of the indicators involved. The analyses were performed on an annual basis, by the LHU of residence and by the hospital which performed the surgical intervention.

RESULTS

In 2017, 6218 surgical interventions for MBC were performed in the hospitals of Lazio. The results showed a continuous increase of the level of performance over the years. Hospitals showed higher variability in the levels of performance than the LHUs. 36% of the evaluated hospitals reached a high level of performance. An audit of the S. Filippo Neri breast unit revealed incorrect coding of the input data. For this reason, the score for the indicator for the volume of wards was re-calculated and re-evaluated, with a subsequent improvement of the level of performance. Most LHUs achieved at least an average overall level of performance, with 20% of the LHUs reaching a high level of performance.

CONCLUSIONS

This is the first attempt to apply the treemap logic to a single clinical network, in order to obtain a summary indicator for the evaluation of the breast cancer care network. Our results supply decision makers with a transparent instrument of governance for heterogeneous users, directing efforts improving and promoting equity of care. The treemaps could be reproduced and adapted for other local contexts, in order to limit inappropriateness and ensure uniform levels of breast cancer care within local areas. The next step is the evaluation of audit and feedback interventions to improve the quality of care and to guarantee homogeneous levels of care throughout the region.

Does regular quality control improve the quality of surgery in Slovenian breast cancer screening program?

Background The aim of our study was to evaluate the quality of surgery of Slovenian breast cancer screening program (DORA) using the requested EU standards. Furthermore, we investigated whether regular quality control over the 3-year period improved the quality of surgical management. Patients and methods Patients who required surgical management within DORA between January 1st, 2016 and December 31st, 2018 were included in the retrospective study. Quality indicators (QIs) were adjusted mainly according to European Society of Breast Cancer Specialists (EUSOMA) and European Breast Cancer Network (EBCN) recommendations. Five QIs for therapeutic and two for diagnostic surgeries were selected. Additionally, variability in achieving the requested QIs among surgeons was analysed. Results Between 2016 and 2018, 14 surgeons performed 1421 breast procedures in 1398 women. There were 1197 therapeutical (for proven breast cancer) and 224 diagnostic surgical interventions respectively. Overall, the minimal standard was met in two QIs for therapeutic and none for diagnostic procedures. A statistically significant improvement in three QIs for therapeutic and in one QI for diagnostic procedures was observed however, indicating that regular quality control improves the quality of surgery. A high variability in achieving the requested QIs was observed among surgeons, which remained high throughout the study period. Conclusions Adherence to all selected surgical QIs in patients from screening program is difficult to achieve, especially to those specifically defined for screen-detected lesions. Regular quality control may improve results over time. Reducing the number of surgeons dedicated to breast pathology may reduce variability of management inside the institution.

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.