Quality indicators in breast cancer care: An update from the EUSOMA working group

Quantifying the impact of treatment delays on breast cancer survival outcomes: a comprehensive meta-analysis

Treatment delay in breast cancer care represents a significant concern in oncology, potentially impacting patient survival outcomes. While various factors can contribute to delayed treatment initiation, the quantitative relationship between specific delay intervals and survival remains incompletely understood in breast cancer management. Our study aims to explore the impact of treatment delays on survival outcomes in breast cancer. A comprehensive literature search was conducted in PubMed, Scopus, and Web of Science databases, covering publications from 2000 to 2025. From an initial 6222 records, 18 eligible studies comprising 25 cohorts were included. Hazard ratios (HRs) for all-cause and breast cancer-specific mortality were extracted or calculated for treatment delays of 4, 8, and 12 weeks. Random-effects meta-analyses were performed, and heterogeneity and publication bias were assessed using I2 statistics, funnel plots, and Egger's test. This meta-analysis revealed progressively increasing mortality risks with longer treatment delays. For all-cause mortality, HRs increased from 1.12 (95% CI 1.08-1.15) at 4 weeks to 1.25 (95% CI 1.17-1.33) at 8 weeks, and 1.39 (95% CI 1.26-1.53) at 12 weeks. Breast cancer-specific mortality showed more pronounced effects, with HRs of 1.20 (95% CI 1.06-1.36), 1.43 (95% CI 1.11-1.84), and 1.71 (95% CI 1.18-2.49) for 4-, 8-, and 12-week delays, respectively. Analyses combining both survival outcomes demonstrated consistent risk elevation across all time intervals (4 weeks: HR = 1.12, 95% CI 1.09-1.16; 8 weeks: HR = 1.26, 95% CI 1.18-1.34; 12 weeks: HR = 1.41, 95% CI 1.29-1.55). While heterogeneity was significant (I2 = 54-92%), no substantial publication bias was detected. Delays in initiating breast cancer treatment are associated with significantly worse survival, particularly for cancer-specific mortality. Each additional 4-week delay increases the hazard of death by over 10%, underscoring the urgency of minimizing delays in diagnosis-to-treatment pathways. These findings have critical implications for healthcare systems, clinical decision-making, and public health policy.

Evaluating the breast cancer quality of care indicators in Iran; multicenter study

BACKGROUND

Data on quality-of-care indicators for breast cancer patients is limited in low-and middle-income countries. We evaluated the indicators in Iran.

METHOD

A total of 21 quality-of-care indicators of breast cancer management defined by EUSOMA 2017 were selected. The indicators were retrospectively evaluated based on the data from the Clinical Breast Cancer Registry established in 11 provinces of Iran.

RESULT

In the study of 6,293 patients evaluated on 21 indicators, 15 indicators were more than 5% below EUSOMA's standard levels.

CONCLUSION

The defined indicators had a value lower than the suggested standards by EUSOMA. This study's results highlight important clues for intervention in improving breast cancer outcomes in Iran and other low-and middle-income countries.

Developing Cancer Quality of Care Indicators to Quantify the Impact of a Global Destabilization of the Care System (COLLAT-COVID)

BACKGROUND/OBJECTIVES

The COVID-19 pandemic led to significant disruptions in healthcare systems, particularly impacting cancer care through delays in diagnoses and treatments. Quality indicators (QIs) are essential tools for monitoring healthcare performance, yet existing QIs may not be suited for crises. This study aimed to develop a set of hospital-based QIs tailored to assess the impact of care reorganization during health crises across four cancer types: breast cancer, hepatocellular carcinoma, gynecological cancers (excluding ovarian cancer), and peritoneal carcinomatosis.

METHODS

A multidisciplinary steering committee (SC) conducted a five-stage process, including a literature review, indicator selection, content validation via the RAND/UCLA method, final validation by the SC, and a pilot feasibility study. QIs were assessed based on clinical relevance, reproducibility, sensitivity to change, and feasibility. Expert panels evaluated and validated the indicators in two rounds of voting.

RESULTS

Among 150 initially identified QIs, 49 were validated: 12 for breast cancer, 11 for hepatocellular carcinoma, 8 for gynecological cancers, and 18 for peritoneal carcinomatosis. Most (92%) were process indicators, covering diagnosis, treatment, and care delays. Two common indicators were identified across all four cancers: multidisciplinary team meeting discussions and psychological support consultations.

CONCLUSIONS

This study demonstrates the feasibility of developing crisis-responsive QIs to monitor cancer care during health system disruptions. Future work will focus on their real-time implementation, validation in international settings, and integration into healthcare policies to enhance crisis preparedness.

The Evaluation of a Nursing Care Model for Breast Cancer: What Are Women's Priorities?

Aim: To assess patient satisfaction with the breast care nurse (BCN) model and its adequacy in meeting patients' needs for information and support. Background: The BCN is a core multidisciplinary member of the breast cancer team. The evaluation of care models is necessary to detect gaps and improve the quality of care. Material and Methods: This cross-sectional descriptive study took place in a breast pathology unit and included patients with early breast cancer seen between 1 July 2016 and 30 June 2017 after finishing their treatment. Between July and December 2018, sociodemographic and clinical variables were collected from the clinical history, and satisfaction was measured using a questionnaire sent to the patients. Results: Of the 139 patients included, 99.3% reported that the BCN provided information correctly, 96.2% reported that she provided adequate information on self-care at home (96.2%), and 97.8% reported that the words of the BCN helped them feel better. However, some patients were unsure whether the BCN would have been willing to discuss alternative therapies (41%). Conclusions: Patients were satisfied with the BCN, including her role in meeting information and support needs. However, some issues needed to be sufficiently addressed. Comprehensive, continuous assessment is required to understand patient needs. Training and specific studies on topics that are of interest to patients can help respond to these needs. Implications for Nursing Management: BCN functions are being developed in some countries. BCN results make it easier for healthcare managers to commit to this role and for nurses to develop all their competencies. BCN models must respond to international guidelines but are also determined by organizational resources. The evaluation of these models is essential and must be considered by users. Advanced practice nursing roles, including the BCN, are well established in some countries but developing in others. BCN results make it easier for healthcare managers to commit to this role and for nurses to develop all their skills. BCN models must respond to the elements determined by organizations that work to improve the quality of care for patients with breast cancer. However, they are also determined by organizational resources. The evaluation of these models is essential to correct deficiencies and improve the quality of care. An important part of the evaluation must take into account the user who receives the care, in terms of satisfaction and the form of patient-reported outcome measures (PROMs).

Adjuvant systemic therapy in early breast cancer and results of a prospective observational multicenter BRIDE study: patients outcome and adherence to guidelines in cancer clinical practice

Introduction

Evaluation of every breast cancer (BC) patient by multidisciplinary team and application of guidelines are very important to ensure the best treatment and achieve the best outcome.

Methods

The multicenter prospective observational BRIDE study enrolled, from 01/2018 to 02/2021, 1633 BC patients from 19 Italian cancer centers. To evaluate the clinical and biopathological characteristics of BC patients with pathological stage I-II-III treated with surgery followed by adjuvant systemic therapy, type of therapies delivered, outcome and adherence to guidelines, an analysis of 1123 patients out of 1633 patients enrolled in BRIDE study was conducted.

Results

The 1123 patients with stage I-II-III BC had a median age of 61.2 years (Q1-Q3: 50.6-71.7); 70.2% were postmenopausal, 92.1% had ECOG PS 0, 68.4% pT1 disease, 70.7% pN0, 91.7% pathological stage I-II; 68.9% underwent conservative breast surgery and 79.8% sentinel lymph node biopsy alone. According to phenotypic subgroup, 80.6% of patients had a HER2-negative/HR-positive, 10.4% HER2-positive/HR-positive, 6.4% triple negative and 2.6% HER2-positive/HR-negative BC. In clinical practice, the phenotypic tumoral subgroup influenced oncologists in the choice of the type of adjuvant systemic therapy (p<0.0001) according to ESMO and AIOM Guidelines. Adjuvant radiotherapy was administered to 85.5% patients undergoing breast-conserving surgery. At the median follow up of 41.4 months (Q1: 35.3 months - Q3: 57.9 months), the DFS at 48 months was 92.8%, with different rates in the phenotypic subgroups. The adherence to AIOM Guidelines in clinical practice was ≥ 70% for the four evaluated quality indicators of treatment process.

Discussion

In patients with pathological stage I-II-III BC, the phenotypic subgroup influenced the oncologists' decision on the choice of type of adjuvant systemic therapy, as also indicated by international and national guidelines. In our patients, the DFS rate at 24 and 48 months after surgery was 95.4% and 92.8% respectively. The adherence to the AIOM Guidelines in clinical practice was high but having both quality indicators (shared at international and national level) to evaluate the quality of care in BC and standardized threshold levels to evaluate adherence to guidelines is very important today because this type of evaluation will increase in the coming years.

Overall survival and disease-free survival prediction in Chinese women with breast cancer aged 70 years or older by using nomograms

PURPOSE

By analyzing the existing data of this study, a prediction tool for the overall breast cancer survival and disease-free survival (DFS) of elderly women was established.

PATIENTS AND METHODS

Clinicopathologic data were collected from elderly women with BC who were admitted to the Tianjin Medical University Cancer Institute and Hospital from August 2014 to December 2017. Independent prognostic factors for BC in elderly patients were confirmed using the Cox proportional hazards model. Nomograms were developed with these factors for predicting the 3- and 5-year overall survival (OS) as well as DFS. The nomograms' discrimination ability and calibration were assessed through the area under the curve (AUC), concordance index (C-index), decision curve analysis (DCA), and calibration plots.

RESULTS

We enroled 889 elderly patients with BC, and the results showed that the 3-year OS rate was 93.4% (95%CI = 91.8%-95.1%), the 3-year DFS rate was 87.8% (95%CI = 85.7%-90.0%), the 5-year OS rate was 85.6% (95%CI = 83.3%-87.9%), and the 5-year DFS rate was 80.1%(95%CI = 77.5%-82.8%). The corrected C-indices of the OS and DFS nomograms were 0.799 and 0.667, respectively (95%CI = 0.767-0.830 and 0.632-0.702, respectively). Relatively high AUC values were shown by the nomograms for estimating OS and DFS. The DCA revealed that the constructed nomograms had net benefits for clinical application. The calibration curves demonstrated an excellent correspondence between the data predicted by the nomograms and the actual survival data. Survival curves indicated that risk stratification could differentiate OS and DFS.

CONCLUSIONS

This study developed novel and practical nomograms for individual prediction of DFS and OS in elderly BC patients. These nomograms can predict 3- and 5-year OS as well as DFS in the elderly BC patient population, thereby enabling personalized risk assessment and risk-based therapy.

The Challenge of Calculating EUSOMA Quality Indicators with Administrative Data: A Pilot Study in Belgium

Introduction

The study aimed to assess the feasibility of calculating the European Society of Breast Cancer Specialists (EUSOMA) quality indicators (QIs) using Belgian Cancer Registry data coupled to administrative health data and to provide national results.

Methods

Women diagnosed with ductal carcinoma in situ (DCIS) or invasive breast cancer (IBC) in 2014-2018 were selected from the cancer registry. Fourteen EUSOMA QIs were chosen to assess the quality of care.

Results

Overall, 46,035 patients with IBC and 3,973 patients with DCIS were included. Most QIs had to be rephrased so that they could be calculated with the available data. None of the selected QIs on systemic treatment could be calculated due to a lack of reliable receptor status information. For some Qis, there is ample room for improvement in Belgian clinical practice: cTNM stage reporting, multidisciplinary team meetings, sentinel lymph node biopsy only in IBC with clinically negative lymph nodes. The result was 1-5% lower than the target for mammography and breast ultrasound, pTNM reporting, start of treatment, single breast surgery in DCIS, and no axillary clearance in DCIS. For histological or cytological assessment, receptor status assessment, start of radiotherapy, and single breast surgery in IBC, the results were at or above the target.

Conclusion

Several EUSOMA QIs can be calculated with routinely collected data, while for several important aspects of care additional data collection is indicated so that its quality can be assessed. The validity of the obtained results depends on the reporting accuracy.

[Time intervals for diagnosis and treatment in breast cancer patients]

OBJECTIVE

To describe the delay in the diagnosis of breast cancer in primary care and to identify the patient, care process and disease variables involved in the delay to diagnosis and treatment.

DESIGN

Retrospective study with follow-up of a cohort of women with breast cancer, from the first symptoms to the start of treatment. SITE: In total 24 family medicine practices with information from both primary care and hospital settings.

PARTICIPANTS

446 women were evaluated (period 2014-2023).

MAIN MEASUREMENTS

Patient characteristics (age, history and comorbidity), care process (screening, consultation site and referral priority) and disease characteristics (stage, presentation and risk factors) were included. Time intervals considered included, among others, «primary care interval», «health system interval», «diagnosis interval» and «treatment interval».

RESULTS

The mean value of the «primary care interval» was 24.7days (median: 16); that of the «hospital care interval», 77.2days (median: 68); and that of the «health system interval», 93.6days (median: 83). Multiple linear regression showed a significantly shorter duration of the interval in women referred preferentially, in advanced stages, with a breast lump at presentation and with risk factors.

CONCLUSIONS

Most are diagnosed in early stages at the health centre. The duration of the «health system interval» is shorter in preferential referrals, when the form of presentation is a breast lump, with risk factors and in advanced stages.

Spatial and temporal changes of breast-conserving surgery rates and its influential factors among Chinese patients with breast cancer from 2013 to 2019: a registry-based study

OBJECTIVE

Our study aims to evaluate the spatial and temporal changes of breast-conserving surgery (BCS) rates and influential factors of BCS in Guangdong Province, China.

DESIGN, SETTING AND PARTICIPANTS

This registry-based cohort study analysed the data of patients of all age groups, from the medical record cover page, which was mandatorily collected for inpatients by the Health Administrative Department of Guangdong Province, China. Patients with non-metastatic breast cancer, who underwent breast surgery between 2013 and 2019, were included.

MAIN OUTCOMES AND MEASURES

We analysed the BCS rate in Guangdong Province between 2013 and 2019. Logistic regression was applied to investigate the association between patient-level influential factors and BCS, respectively. We used restricted cubic spline regression to model the non-linear association between hospital volume rank with BCS rate. Linear regression was used to evaluate the association between city-level parameters with BCS rate of each city.

RESULTS

A total of 93 521 patients with non-metastatic breast cancer, who underwent breast surgery, were included in the analyses. Among them, 10 949 (11.7%) had BCS, with the BCS rates increasing from 0.8% in 2013 to 19.2% in 2019. Patients who were older (vs <40 years, 40-49 years: adjusted OR 0.72, 95% CI 0.68 to 0.76; 50-59 years: 0.51, 95% CI 0.48 to 0.54; ≥60 years: 0.37, 95% CI 0.35 to 0.40) and married (vs unmarried, 0.64, 95% CI 0.59 to 0.70) were less likely to undergo BCS. Patients who were employed (vs unemployed, 1.58, 95% CI 1.49 to 1.68), received cross-city surgery (vs local surgery, 1.37, 95% CI 1.31 to 1.44), lived in a high-income city (vs low-income city, β=4.40, 95% CI 1.55 to 7.24) or in a city with a higher number of physicians per 100 000 residents (0.57, 95% CI 0.31 to 0.82) were more likely to receive BCS.

CONCLUSIONS AND RELEVANCE

This study suggests a significant increase in BCS rates from 2013 to 2019 in Guangdong, China. Promotion of BCS is needed, particularly among older patients, lower-volume hospitals and economically underdeveloped areas. Healthcare system should be prepared to support the increased awareness of seeking BCS among younger patients with breast cancer by improving the availability of radiotherapy, multidisciplinary team and patients' education programme.

The influence of treatment intervals on prognosis in young breast cancer patients: Insights from the French National cohort

BACKGROUND

Suboptimal treatment delays is known to impact prognosis of patients with cancer but optimal timing in specific subgroups remains poorly studied. This study aimed to analyze treatment delays in young women treated for a breast cancer (BC) on and its impact on their prognosis using French Nationwide Data.

METHODS

Using the CAREPAT-YBC Cohort based on the French National Healthcare System Database, we analyzed disease-free survival (DFS) in 22,093 young women (18-45 years) who underwent either surgery-chemotherapy-radiotherapy pathway (adjuvant setting, 15,433 patients) or chemotherapy-surgery-radiotherapy pathway (neoadjuvant setting, 6660 patients), according to delays between the different pathways.

RESULTS

For the adjuvant chemotherapy-radiotherapy interval, the best timing was 17-31 days with increased risk above this delay. For the neoadjuvant setting, the optimal neoadjuvant chemotherapy-surgery interval was 17-31 days, while ≤15 days (HR 1.44, 95%CI 1.21-1.71) or ≥62 days (HR 2.07, 95%CI 1.36-3.15) showed poorer prognosis. Combining best timing into an "optimal pathway" was associated with respectively a 1.2-fold decreased risk for recurrence or mortality.

CONCLUSION

Optimizing treatment intervals enhance BC survival in younger age.

Neoadjuvant chemotherapy for breast cancer in Italy: A Senonetwork analysis of 37,215 patients treated from 2017 to 2022

BACKGROUND

Adoption of neoadjuvant chemotherapy (NACT) in the "real world" has been poorly investigated. Aim of this study was to examine the rate of NACT in Italy, trends over time and determinants of therapeutic choices.

METHODS

Senonetwork, the recognized network of Breast Centers in Italy, has developed a voluntary national data warehouse with the aim to monitor and improve treatments quality. A retrospective analysis was conducted among 58,661 breast cancer (BC) patients treated between 2017 and 2022 by 24 high-volume Breast Centers participating in the project.

RESULTS

After subset exclusion, 37,215 primary BC patients were analysed, 32,933 underwent primary-breast-surgery and 4,282 underwent NACT. From 2017 to 2022, the overall NACT incidence increased particularly for HR-/HER2+, Triple-Negative, and HR+/HER2+ BC (p < 0.001). In cN + patients the recommendation to axillary lymph-node dissection after NACT decreased over time along with an increase of <4 lymph-nodes removed (p < 0.001). Immediate breast reconstruction and indication for nipple sparing mastectomy increased significantly over time (OR = 1.10, p = 0.011 and OR 1.14, p < 0.001, respectively). On multivariate analysis, there was a trend towards an increased adoption of conservative treatment for HR-/HER2+ (p = 0.01) and Triple Negative tumors (p = 0.06). Implementation of NACT varied significantly among Breast-Centers from 3.8 to 17.7 % (p < 0.001).

CONCLUSION

The impact of NACT on the subsequent surgical management is substantial and continues to evolve over time, resulting in less-extensive surgery. Even among high-volume Centers NACT implementation rate is still highly variable. Although we registered a significant increase in its use during the study period, these results need to be further improved.

Challenges and improvements in HER2 scoring and histologic evaluation: insights from a national proficiency testing scheme for breast cancer diagnosis in China

BACKGROUND

In 2022, our team launched the pioneering national proficiency testing (PT) scheme for the pathological diagnosis of breast cancer, rapidly establishing its credibility throughout China. Aiming to continuously monitor and improve the proficiency of Chinese pathologists in breast pathology, the second round of the PT scheme was initiated in 2023, which will expand the number of participating institutions, and will conduct a nationwide investigation into the interpretation of HER2 0, 1+, and 2+/FISH- categories in China.

METHODS

The methodology employed in the current round of PT scheme closely mirrors that of the preceding cycle in 2022, which is designed and implemented according to the "Conformity assessment-General requirements for proficiency testing"(GB/T27043-2012/ISO/IEC 17043:2010). More importantly, we utilized a statistics-based method to generate assigned values to enhance their robustness and credibility.

RESULTS

The final PT results, published on the website of the National Quality Control Center for Cancer ( http://117.133.40.88:3927 ), showed that all participants passed the testing. However, a few institutions demonstrated systemic biases in scoring HER2 0, 1+, and 2+/FISH- with accuracy levels below 59%, considered unsatisfactory. Especially, the concordance rate for HER2 0 cases was only 78.1%, indicating challenges in distinguishing HER2 0 from low HER2 expression. Meanwhile, areas for histologic type and grade interpretation improvement were also noted.

CONCLUSIONS

Our PT scheme demonstrated high proficiency in diagnosing breast cancer in China. But it also identified systemic biases in scoring HER2 0, 1+, and 2+/FISH- at some institutions. More importantly, our study highlighted challenges in the evaluation at the extreme lower end of the HER2 staining spectrum, a crucial area for further research. Meanwhile, it also revealed the need for improvements in interpreting histologic types and grades. These findings strengthened the importance of robust quality assurance mechanisms, like the nationwide PT scheme conducted in this study, to maintain high diagnostic standards and identify areas requiring further training and enhancement.

The importance of the multidisciplinary team in the decision-making process of patients undergoing neoadjuvant chemotherapy for breast cancer

BACKGROUND AND OBJECTIVES

Recent literature suggests that rates of breast conservation surgery (BCS) are lower than expected in patients submitted to neoadjuvant chemotherapy (NAC) for breast cancer. The aim of this study was to underscore the role of the multidisciplinary team (MDT) in the decision-making process of patients who underwent breast surgery after NAC.

METHODS

We conducted a retrospective study on patients with breast cancer treated according to an algorithm developed at the Breast Unit of Northern Sardinia between January 2019 and May 2023. Data collected included demographics, tumor characteristics, upfront treatment (surgery or NAC), type of primary surgery (BCS or mastectomy [Ma]) and patients' adherence to the treatment proposed by the MDT.

RESULTS

Overall, 1061 women were treated during the study period, of whom 164 received NAC (Group A) and 897 upfront surgery (Group B). In group A, conversion from BCS ineligibility to BCS eligibility was observed in 47 patients (40.1%). Final surgery in patients who became BCS-eligible after NAC was BCS in 42 cases (89.3%) and Ma in 5 (10.6%). Rates of patients' adherence to the treatment proposed by the MDT were significantly better in the Group A (p = 0.02).

CONCLUSIONS

Our results suggest that the MDT has a pivotal role in increasing the rates of breast conservation in women submitted to NAC.

Understanding breast cancer patient pathways and their impact on survival in Mexico

BACKGROUND

Understanding patient pathways from discovery of breast symptoms to treatment start can aid in identifying ways to improve access to timely cancer care. This study aimed to describe the patient pathways experienced by uninsured women from detection to treatment initiation for breast cancer in Mexico City and estimate the potential impact of earlier treatment on patient survival.

METHODS

We used process mining, a data analytics technique, to create maps of the patient pathways. We then compared the waiting times and pathways between patients who initially consulted a private service versus those who sought care at a public health service. Finally, we conducted scenario modelling to estimate the impact of early diagnosis and treatment on patient survival.

RESULTS

Our study revealed a common pathway followed by breast cancer patients treated at the two largest public cancer centres in Mexico City. However, patients who initially sought care in private clinics experienced shorter mean wait times for their first medical consultation (66 vs 88 days), and diagnostic confirmation of cancer (57 vs 71 days) compared to those who initially utilized public clinics. Our scenario modelling indicated that improving early diagnosis to achieve at least 60% of patients starting treatment at early stages could increase mean patient survival by up to two years.

CONCLUSION

Our study highlights the potential of process mining to inform healthcare policy for improvement of breast cancer care in Mexico. Also, our findings indicate that reducing diagnostic and treatment intervals for breast cancer patients could result in substantially better patient outcomes.

POLICY SUMMARY

This study revealed significant differences in time intervals along the pathways of women with breast cancer according to the type of health service first consulted by the patients: whether public primary care clinics or private doctors. Policies directed to reduce these inequities in access to timely cancer care are desperately needed to reduce socioeconomic disparities in breast cancer survival.

HER2-low and tumor infiltrating lymphocytes in triple-negative breast cancer: Are they connected?

Most patients with triple-negative breast cancer (TNBC) are not candidates for targeted therapy, leaving chemotherapy as the primary treatment option. Recently, immunotherapy has demonstrated promising results in TNBC, due to its immunogenicity. In addition, a novel antibody-drug conjugate, namely, trastuzumab-deruxtecan, has shown effectiveness in TNBC patients with low-HER2 expression (HER2-low). These novel treatment options raise the question about the potential association between the density of stromal tumor-infiltrating lymphocytes (sTILs) and the level of HER2 expression. We aimed to evaluate the association between the level of HER2 expression (HER2-low versus HER2-0) and density of sTILs in TNBC patients, and how they impact the response to neoadjuvant chemotherapy (NAC). This was a retrospective multicenter study including all TNBC patients diagnosed between 2018 and 2022. Central pathology review included sTILs percentages and level of HER2 expression. Tumors were reclassified as either HER2-0 (HER2 IHC 0) or HER2-low (IHC 1 + or 2 + with negative reflex test). Various clinicopathologic characteristics, including sTILs density, and response to NAC were compared between HER2-0 and HER2-low cases. In total, 753 TNBC patients were included in this study, of which 292 patients received NAC. Interobserver agreement between the original pathology report and central review was moderate (77% had the same IHC status after reclassification in either HER2-0 or HER2-low; k = 0.45). HER2-low TNBC represented about one third (36%) of the tumors. No significant difference in sTILs density or complete pathologic response rate was found between HER2-0 and HER2-low cases (p = 0.476 and p = 0.339, respectively). The density of sTILs (≥ 10% sTILs vs. < 10%) was independently associated with achieving a pCR (p = 0.011). In conclusion, no significant association was found between HER2-low status and density of sTILs nor response to NAC. Nonetheless, sTILs could be an independent biomarker for predicting NAC response in TNBC patients.

European value-based healthcare benchmarking: moving from theory to practice

BACKGROUND

Value-based healthcare (VBHC) is a conceptual framework to improve the value of healthcare by health, care-process and economic outcomes. Benchmarking should provide useful information to identify best practices and therefore a good instrument to improve quality across healthcare organizations. This paper aims to provide a proof-of-concept of the feasibility of an international VBHC benchmarking in breast cancer, with the ultimate aim of being used to share best practices with a data-driven approach among healthcare organizations from different health systems.

METHODS

In the VOICE community-a European healthcare centre cluster intending to address VBHC from theory to practice-information on patient-reported, clinical-related, care-process-related and economic-related outcomes were collected. Patient archetypes were identified using clustering techniques and an indicator set following a modified Delphi was defined. Benchmarking was performed using regression models controlling for patient archetypes and socio-demographic characteristics.

RESULTS

Six hundred and ninety patients from six healthcare centres were included. A set of 50 health, care-process and economic indicators was distilled for benchmarking. Statistically significant differences across sites have been found in most health outcomes, half of the care-process indicators, and all economic indicators, allowing for identifying the best and worst performers.

CONCLUSIONS

To the best of our knowledge, this is the first international experience providing evidence to be used with VBHC benchmarking intention. Differences in indicators across healthcare centres should be used to identify best practices and improve healthcare quality following further research. Applied methods might help to move forward with VBHC benchmarking in other medical conditions.

Breast Magnetic Resonance Imaging for Preoperative Evaluation of Breast Cancer: A Systematic Review and Meta-Analysis

Purpose: Preoperative breast magnetic resonance imaging (MRI) is known to detect additional cancers that are occult on mammography and ultrasound. There is debate as to whether these additional lesions affect clinical outcomes. The objective of this systematic review was to summarize the evidence on whether additional information on disease extent obtained with preoperative breast MRI in patients with newly diagnosed breast cancer affects surgical management, rates of recurrence, survival, re-excision, and early detection of bilateral cancer. Methods: Embase, MEDLINE, and Cochrane Central Register of Controlled Trials were searched until January 2021 (partial update July 2022) for studies comparing outcomes with versus without pre-operative MRI. Included were both randomized controlled trials and other comparative studies provided MRI and control groups had equivalent disease and patient characteristics or methods such as multivariable analysis or propensity score matching were used to control potential confounders. Results: The search resulted in 26,399 citations, of which 8 randomized control trials, 1 prospective cohort study, and 42 retrospective studies met the inclusion criteria. Use of MRI resulted in decreased rates of reoperations (OR = 0.73, 95% CI = 0.63 to 0.85), re-excisions (OR = 0.63, 95% CI = 0.45 to 0.89), and recurrence (HR = 0.77, 95% CI = 0.65 to 0.90). Increased detection of synchronous contralateral breast cancers led to a reduction in metachronous contralateral breast cancer (HR = 0.71, 95% CI = 0.59 to 0.85). Hazard ratios for recurrence-free and overall survival were 0.77 (95% CI = 0.53 to 1.12) and 0.89 (95% CI = 0.74 to 1.07). Conclusion: This systematic review indicates substantial benefits of pre-operative breast MRI in decreasing reoperations and recurrence.

Omission of radiation therapy post breast conserving surgery

Radiation therapy (RT) after breast conserving surgery decreases the risks of local recurrence and breast cancer mortality in the multidisciplinary management of patients with breast cancer. However, breast cancer is a heterogeneous disease, and the absolute benefit of post-operative RT in individual patients varies substantially. Clinical trials aiming to identify patients with low-risk early breast cancer in whom post-operative RT may be safely omitted, based on conventional clinical-pathologic variables alone, have not provided sufficiently tailored information on local recurrence risk assessment to guide treatment decisions. The majority of patients with early breast cancer continue to be routinely treated with RT after breast conserving surgery. This approach may represent over-treatment for a substantial proportion of the patients. The clinical impact of genomic signatures on local therapy decisions for early breast cancer has been remarkably modest due to the lack of high-level evidence supporting their clinical validity for assessment of the risk of local recurrence. Efforts to personalise breast cancer care must be supported by high level evidence to enable balanced, informed treatment decisions. These considerations underpin the importance of ongoing biomarker-directed clinical trials to generate the high-level evidence necessary for setting the future standard of care in personalised local therapy for patients with early breast cancer.

Proficiency testing of diagnosis in histopathology and immunohistochemistry of breast pathology in China: results from a pilot work of National Single Disease Quality Control Program for breast cancer

AIM

Pathologists are currently supposed to be aware of both domestic and international guidelines for breast cancer diagnosis, but it is unclear how successfully these guidelines have been integrated into routine clinical practice in China. Thus, this national proficiency testing (PT) scheme for breast pathology was set up to conduct a baseline assessment of the diagnostic capability of pathologists in China.

METHODS

This national PT plan is designed and implemented according to the "Conformity assessment-General requirements for proficiency testing" (GB/T27043-2012/ISO/IEC 17043:2010). Five cases of breast cancer with six key items, including histologic type, grade, ER, PR, HER2, and Ki67, were selected for testing among 96 participants. The final PT results were published on the website of the National Quality Control Center for Cancer ( http://117.133.40.88:3927/cn/col22/362 ).

RESULTS

Our study demonstrated that the median PT score was 89.5 (54-100). Two institutions with scores < 67 were deemed unacceptable. The accuracy of histologic type, ER, PR, HER2, and Ki67 was satisfactory (all > 86%). However, the histologic grade showed low accuracy (74.0%). The unacceptable results mainly included incorrect evaluation of histologic grade (36.7%), inaccurate evaluation of ER/PR/HER2/Ki67 (28.2%), incorrect identification of C-AD as IBC-NST (15.7%), inappropriate use of 1+/2+/3+ rather than staining percentage for ER/PR (6.1%), misclassification of ER/PR < 1% weak expression as positive staining (1.4%), and no evaluation of histologic grade in ILC, MC, and IMC (5.8%).

CONCLUSIONS

our nationwide PT program exhibited a satisfactory baseline assessment of the diagnostic capability of pathologists in China. More importantly, we identify some areas for further improvement.

Concordance of breast cancer services in an urban tertiary care institute in India to EUSOMA guidelines: An audit of Indian breast cancer practices

ABSTRACT

The provision of breast cancer care tends to vary substantially from one breast unit to another. To provide state-of-the-art patient-centered care to women diagnosed with breast cancer, adoption and adherence to structured treatment algorithms, protocols, and international guidelines are essential. In this review, we endeavor to audit breast cancer care at our tertiary cancer center against published EUSOMA guidelines. This was a retrospective study with an observational design. All patients who completed recommended treatment for breast diseases at our institute from January 1, 2018 to December 31, 2018 were included and evaluated. Data were retrieved from patient e-prescriptions and medical records. Analysis was performed using Microsoft Office 2010 to measure how our practices compared to EUSOMA quality indicators (QIs). Clinical assessments, imaging, and preoperative work-up of breast cancer patients met EUSOMA standards. Prognostic and predictive characterization of tumors was performed in all cases. Surgical management of invasive cancer and ductal carcinoma in situ (DCIS) was in accordance with the guidelines. Adherence to postoperative radiation and adjuvant endocrine therapy was adequate. More mastectomies were performed in patients with invasive cancers measuring <3 cm. Overtreatment was avoided in every other subgroup. Adjuvant and neoadjuvant chemotherapy and targeted adjuvant therapy were adequately utilized unlike neoadjuvant targeted therapy. Minimal attrition was noted in patient follow-up. This extensive audit has set a benchmark for future annual audits and helped highlight areas where improvement of service delivery is needed.

Quality indicators for the diagnosis and treatment of breast cancer integrated assistance: A critical appraisal

INTRODUCTION

Quality indicators (QIs) are essential for adequate control of the health care management process, recognizing areas of improvement and providing solutions. We aimed to evaluate the Integrated Breast Cancer (BC) Care Process QIs.

METHODS

We studied 487 consecutive BC cases diagnosed from November 1st, 2013, to November 30th, 2019, in a Spanish healthcare area, and we estimated the associated QIs.

RESULTS

Four indicators did not meet the standards and were analysed based on related sociodemographic and clinical variables. The surgical delay after a multidisciplinary team discussion (mean 64%, IQR 59.6-68.5) was lower in elder people (p=0.027), and early histological grades (p=0.019) and stages (p=0.008). The adjuvant treatment delay (mean 55.7%, IQR 51.1-60.3) was lower in advance stages (p=0.002) and when there was no reoperation (p=0.001). The surgical delay after inclusion (mean 83.2%, IQR 79.3-87.2) was lower in early histological grades (p=0.048). The immediate reconstruction (mean 42.3%, IQR 34.0-50.5) reached 72.3% in young women compared to 11.8% in older than 70 years (p=0.001) and it was higher in early stages (45.3% vs 36.2%; p=0.049).

CONCLUSION

The study of QIs evaluated their compliance and analysed the variables influencing them to propose improvement measures. Not all the indicators were equally valuable. Some depended on the available resources, and others on the mix of patients or complementary treatments. It would be essential to identify the specific target populations to estimate the indicators or provide standards stratified by the related variables.

Sentinel node in breast cancer as an indicator of quality in medical care: Evaluation of statistics in Colombia

BACKGROUND

Sentinel lymph node biopsy in breast cancer is considered the standard of staging in cases of clinically negative lymph nodes. Its omission in favor of axillary dissection generates significant morbidity.

OBJECTIVE

To determine the total number of sentinel node biopsy procedures in breast cancer in Colombia from 2017 through 2020, model and analyze them as if they were performed only in stage I breast cancer patients, and integrate their results into the concepts of quality of medical care.

METHODS

Search in a database of the Ministry of Health and Social Protection of Colombia with sentinel lymph node biopsy codes, and filters of breast cancer and year. Their results are contrasted with the number of cases in stage I of breast cancer.

RESULTS

Breast cancer TNM staging was reported in 22154 cases, 3648 stage I. In the same time frame, the number of sentinel lymph node biopsies for breast cancer in Colombia was 1045, 28.64% of the total cases reported in stage I.

CONCLUSIONS

Colombia is far from complying with the standard indicator of sentinel lymph node biopsy. It is recommended to concentrate breast cancer cases in hospitals that provide the conditions for its performance.

Treatment and outcomes in breast cancer patients: A cross section study from the EUSOMA breast centre network

INTRODUCTION

The present study was designed to describe tumour features and treatments for patients with breast cancer. It also aimed at assessing the risk of distant metastases in relation to biological profiles, disease stages and treatment.

METHODS

Data were analysed from 81,882 patients in the EUSOMA database (disease stages at diagnosis 0-IV; median age 61 years; range 20-100 years). All patients were treated between January 2016 and December 2021 in 53 Breast Centres within the EUSOMA certification process in 13 European countries. Cases were classified as HR+ /HER2-, HR+ /HER2 + , HR-/HER2 + or HR-/HER2- and data were analysed accordingly.

RESULTS

Univariable and multivariable analyses for distant metastases were conducted on a subset of 38,119 cases with information on whether or not they had developed them. Potential determinants included sub-group type, Ki67 value, disease stage, adjuvant systemic therapies and post-operative radiation therapy. In multivariable analysis, the HR-/HER2 + and HR-/HER2- sub-groups were associated with a higher risk of distant metastases than HR+ /HER2-. Ki67 > 20 % and advanced stage disease also carried a high risk. Radiation therapy emerged as a protective factor against distant metastases.

CONCLUSIONS

Present results show a large patient database offers an information stream that can be applied to reduce uncertainties in clinical practice. Database parameters need to be updated dynamically for outcome monitoring. Molecular prognostic factors, gene-expression signatures, tumour-infiltrating lymphocytes and circulating tumoral DNA should be added.

Adherence to Quality Indicators for Breast Cancer Management in a Multidisciplinary Training Program

Background: The management of early breast cancer (BC) needs supervision and skill maintenance, and should be performed by specialists working as a team in multidisciplinary breast units. This approach aims to improve the long-term survival and quality of life of patients with BC. Methods: This was a prospective observational study including patients newly diagnosed with operable BC. The study encompassed the pre-surgical phase, throughout the diagnostic and surgical workout, and included post-therapeutic master multidisciplinary team meetings (MTMs) sessions, between 2019 and 2022. Results: We enrolled 280 patients with BC from eight breast units. The Senonetwork indicators regarding diagnosis, waiting time, loco-regional treatment, and adjuvant therapy were collected for each patient discussed. Conclusions: Overall, the majority of quality indicators were respected among breast units. The most critical issue referred to timing indicators: more than 30 days from MTM to surgery, more than 42 days from diagnosis to surgery, and more than 60 days from the first screening mammogram to surgery for many patients. Some aspects of the histopathological diagnosis of intraductal BC also need to be improved. Furthermore, other critical issues in our study regarded some aesthetical indicators, demonstrating low interest in these essential quality indicators.

Rising age-specific rates of immediate breast reconstruction after mastectomy: Report from an Italian Breast Unit

BACKGROUND AND OBJECTIVES

Immediate breast reconstruction (IBR) represents a fundamental part in the management of patients receiving mastectomy. In recent years, there has been an increasing trend in the use of IBR in all age groups. The study aims were to evaluate the age-specific trend of IBR, and to discuss its effects in work organization at an Italian Breast Unit.

METHODS

We searched for women diagnosed with breast cancer between 2010 and 2019, focusing on IBR rates in patients who received mastectomy. Age-specific trends were assessed using the Cochrane-Armitage test. Differences in operative times and hospital stay between women undergoing mastectomy + IBR (Ma + IBR) or mastectomy alone (Ma) were evaluated by Student's t test or χ2 test.

RESULTS

Among 1915 patients, 62.4% underwent breast conserving surgery (BCS), and 37.6% mastectomy. Overall, rates of Ma + IBR increased from 32% in 2010 to 58% in 2019 (p < 0.001). Although rates of IBR rose in all age groups, the trend was significantly increased among patients aged 50-59 (p < 0.001), 60-69 (p < 0.0001), and 70-79 (p < 0.05).

CONCLUSIONS

Rates of Ma + IBR have increased over years, especially among older women. Ma + IBR resulted in longer operative times and hospital stay than Ma alone. These findings imply that, in the near future, resources should be implemented to improve and strengthen the surgical activity of Breast Units, to support the increasing use of IBR in women of all age groups.

Development of a natural language processing model for deriving breast cancer quality indicators : A cross-sectional, multicenter study

OBJECTIVES

Medico-administrative data are promising to automate the calculation of Healthcare Quality and Safety Indicators. Nevertheless, not all relevant indicators can be calculated with this data alone. Our feasibility study objective is to analyze 1) the availability of data sources; 2) the availability of each indicator elementary variables, and 3) to apply natural language processing to automatically retrieve such information.

METHOD

We performed a multicenter cross-sectional observational feasibility study on the clinical data warehouse of Assistance Publique - Hôpitaux de Paris (AP-HP). We studied the management of breast cancer patients treated at AP-HP between January 2019 and June 2021, and the quality indicators published by the European Society of Breast Cancer Specialist, using claims data from the Programme de Médicalisation du Système d'Information (PMSI) and pathology reports. For each indicator, we calculated the number (%) of patients for whom all necessary data sources were available, and the number (%) of patients for whom all elementary variables were available in the sources, and for whom the related HQSI was computable. To extract useful data from the free text reports, we developed and validated dedicated rule-based algorithms, whose performance metrics were assessed with recall, precision, and f1-score.

RESULTS

Out of 5785 female patients diagnosed with a breast cancer (60.9 years, IQR [50.0-71.9]), 5,147 (89.0%) had procedures related to breast cancer recorded in the PMSI, and 3732 (72.5%) had at least one surgery. Out of the 34 key indicators, 9 could be calculated with the PMSI alone, and 6 others became so using the data from pathology reports. Ten elementary variables were needed to calculate the 6 indicators combining the PMSI and pathology reports. The necessary sources were available for 58.8% to 94.6% of patients, depending on the indicators. The extraction algorithms developed had an average accuracy of 76.5% (min-max [32.7%-93.3%]), an average precision of 77.7% [10.0%-97.4%] and an average sensitivity of 71.6% [2.8% to 100.0%]. Once these algorithms applied, the variables needed to calculate the indicators were extracted for 2% to 88% of patients, depending on the indicators.

DISCUSSION

The availability of medical reports in the electronic health records, of the elementary variables within the reports, and the performance of the extraction algorithms limit the population for which the indicators can be calculated.

CONCLUSIONS

The automated calculation of quality indicators from electronic health records is a prospect that comes up against many practical obstacles.

Real-World Diagnostic Accuracy of the On-Site Cytopathology Advance Report (OSCAR) Procedure Performed in a Multidisciplinary One-Stop Breast Clinic

Fine-needle aspiration (FNA) cytology has been widely used for the diagnosis of breast cancer lesions with the objective of differentiating benign from malignant masses. However, the occurrence of unsatisfactory samples and false-negative rates remains a matter of concern. Major improvements have been made thanks to the implementation of rapid on-site evaluation (ROSE) in multidisciplinary and integrated medical settings such as one-stop clinics (OSCs). In these settings, clinical and radiological examinations are combined with a morphological study performed by interventional pathologists. The aim of our study was to assess the diagnostic accuracy of the on-site cytopathology advance report (OSCAR) procedure on breast FNA cytologic samples in our breast OSC during the first three years (April 2004 till March 2007) of its implementation. To this goal, we retrospectively analyzed a series of 1820 breast masses (1740 patients) radiologically classified according to the American College of Radiology (ACR) BI-RADS lexicon (67.6% being either BI-RADS 4 or 5), sampled by FNA and immediately diagnosed by cytomorphology. The clinicoradiological, cytomorphological, and histological characteristics of all consecutive patients were retrieved from the hospital computerized medical records prospectively registered in the central information system. Histopathological analysis and ultrasound (US) follow-up (FU) were the reference diagnostic tests of the study design. In brief, we carried out either a histopathological verification or an 18-month US evaluation when a benign cytology was concordant with the components of the triple test. Overall, histology was available for 1138 masses, whereas 491 masses were analyzed at the 18-month US-FU. FNA specimens were morphologically nondiagnostic in 3.1%, false negatives were observed in 1.5%, and there was only one false positive (0.06%). The breast cancer prevalence was 62%. Diagnostic accuracy measures of the OSCAR procedure with their 95% confidence intervals (95% CI) were the following: sensitivity (Se) = 97.4% (96.19-98.31); specificity (Sp) = 94.98% (92.94-96.56); positive predictive value (PPV) = 96.80% (95.48-97.81); negative predictive value (NPV) = 95.91% (94.02-97.33); positive likelihood ratio (LR+) = 19.39 (13.75-27.32); negative predictive ratio (LR-) = 0.03 (0.02-0.04), and; accuracy = 96.45% (95.42-97.31). The respective positive likelihood ratio (LR+) for each of the four categories of cytopathological diagnoses (with their 95% CI) which are malignant, suspicious, benign, and nondiagnostic were 540 (76-3827); 2.69 (1.8-3.96); 0.03 (0.02-0.04); and 0.37 (0.2-0.66), respectively. In conclusion, our study demonstrates that the OSCAR procedure is a highly reliable diagnostic approach and a perfect test to select patients requiring core-needle biopsy (CNB) when performed by interventional cytopathologists in a multidisciplinary and integrated OSC setting. Besides drastically limiting the rate of nondiagnostic specimens and diagnostic turn-around time, OSCAR is an efficient and powerful first-line diagnostic approach for patient-centered care.

Oncological status is not a determinant of refraining from breast reconstruction among 490 candidates for mastectomy and post-mastectomy radiotherapy

BACKGROUND

Although breast reconstruction in the setting of post-mastectomy radiotherapy (PMRT) is controversial, we offer nipple-sparing mastectomy and immediate implant-based breast reconstruction ([N]SSM/IIBR) to women needing primary mastectomy regardless of PMRT. Nevertheless, some of these women have no reconstruction.

PURPOSE

To assess the uptake of breast reconstruction in women who undergo PMRT and the patient characteristics associated with such uptake. Additionally, we assessed the determinants of forgoing breast reconstruction.

METHODOLOGY

Demographic, physical and oncological characteristics of women who underwent mastectomy, PMRT and breast reconstruction were compared to the characteristics of those who did not undergo breast reconstruction from 2013 through 2018. As determinants of delaying or refraining from breast reconstruction, we distinguished between an oncological reason, patient's preference, patient's co-morbidity, combined tobacco abuse and obesity and the need for PMRT.

RESULTS

490 women received PMRT. Of these, 396 women (81%) underwent combined [N]SSM/IIBR and PMRT or mastectomy and PMRT with delayed breast reconstruction. Ninety-four additional women (19%) did not undergo breast reconstruction. The latter group differed significantly from those who did in demographic and physical characteristics but not in terms of oncological diagnosis and history. Patient's preference was the single most frequent determinant of not performing either immediate or delayed breast reconstruction among these 94 women. Oncological status was not a major determinant in refraining from reconstruction.

CONCLUSION

The significant difference in non-oncological characteristics between the reconstructed and non-reconstructed women confirms the importance of these characteristics in the preference for either reconstruction or non-reconstruction.

Trends and variation in treatment of early breast cancer in European certified breast centres: an EUSOMA-based analysis

BACKGROUND

Practice indicators (PI) measure provided care making use of real-world data. This study describes trends and variations in adjuvant treatment of early breast cancer (EBC) using the European Society of Breast Cancer Specialists (EUSOMA) database.

METHODS

The analysis was conducted on anonymous cumulative data registered by 56 certified breast centres, which all entered at least 500 new diagnoses in the database in the 10-year period 2010-2019. Practice trends of radiotherapy, endocrine treatment, chemotherapy, and anti-HER2 therapy were evaluated. The association with age group (<50, 50-69, ≥70) and geographical area of the centre (Northern, Central, Southern Europe; NE, CE, SE) was assessed with the Pearson Chi2 test for independence in contingency tables.

RESULTS

In total, 150,150 patients with EBC were selected. Overall, radiotherapy was administered more frequently in NE centres, and conversely, endocrine, chemo-, and anti-HER2 therapy were used more frequently in SE centres (p<0.001). 46.9% of the pN1 patients received postmastectomy radiotherapy, with significant differences by age and geographical region (p < 0.001). Adjuvant endocrine treatment for endocrine-sensitive carcinoma in situ was administered in 46.1%, with a decreasing trend during the study period (58.5-34.5%; p < 0.001). Anti-HER2 therapy was delivered in 75.6% of all patients with HER2BC T1a/bN0, patients older than 70 received anti-HER2 in 67.6% in SE compared to 31.3% in NE centres.

CONCLUSION

Important variations in EBC management between European certified breast centres have been demonstrated. PI using real-world data can help to monitor, evaluate, and eventually guide and align good clinical practice in the management of breast cancer.

Comprehensive Geriatric Assessment for Older Women with Early-Stage (Non-Metastatic) Breast Cancer-An Updated Systematic Review of the Literature

BACKGROUND

A previous systematic review by our team (2012) undertook comprehensive geriatric assessment (CGA) in breast cancer and concluded there was not sufficient evidence to instate CGA as mandatory practice. SIOG/EUSOMA guidelines published in 2021 advocate the use of CGA in breast cancer patients. The aim is to perform an updated systematic review of the literature.

METHODS

A systematic review of studies published between 2012 and 2022 that assessed the use of CGA in breast cancer was performed on Cochrane, PubMed and Embase.

RESULTS

A total of 18 articles including 4734 patients with breast cancer were identified. The studies covered four themes for use of CGA in breast cancer: (1) to determine factors influencing survival (2) as an adjunct to treatment decision-making (3) to measure quality of life, and (4) to determine which tools should be included. There was evidence to support the use of CGA in themes 1-3; however, it is uncertain which assessment tools are best to use (theme 4).

CONCLUSIONS

CGA can be used to determine factors affecting survival and quality of life in breast cancer patients and can therefore be used to aid treatment decision-making. Further work is required to determine gold standard CGA.

Comparing quality of breast cancer care in the Netherlands and Norway by federated propensity score analytics

PURPOSE

The aim of the study was to benchmark and compare breast cancer care quality indicators (QIs) between Norway and the Netherlands using federated analytics preventing transfer of patient-level data.

METHODS

Breast cancer patients (2017-2018) were retrieved from the Netherlands Cancer Registry and the Cancer Registry of Norway. Five European Society of Breast Cancer Specialists (EUSOMA) QIs were assessed: two on magnetic resonance imaging (MRI), two on surgical approaches, and one on postoperative radiotherapy. The QI outcomes were calculated using 'Vantage 6' federated Propensity Score Stratification (PSS). Likelihood of receiving a treatment was expressed in odds ratios (OR).

RESULTS

In total, 39,163 patients were included (32,786 from the Netherlands and 6377 from Norway). PSS scores were comparable to the crude outcomes of the QIs. The Netherlands scored higher on the QI 'proportions of patients preoperatively examined with breast MRI' [37% vs.17.5%; OR 2.8 (95% CI 2.7-2.9)], the 'proportions of patients receiving primary systemic therapy examined with breast MRI' [83.3% vs. 70.8%; OR 2.3 (95% CI 1.3-3.3)], and 'proportion of patients receiving a single breast operation' [95.2% vs. 91.5%; OR 1.8 (95% CI 1.4-2.2)]. Country scores for 'immediate breast reconstruction' and 'postoperative radiotherapy after breast-conserving surgery' were comparable. The EUSOMA standard was achieved in both countries for 4/5 indicators.

CONCLUSION

Both countries achieved high scores on the QIs. Differences were observed in the use of MRI and proportion of patients receiving single surgery. The federated approach supports future possibilities on benchmark QIs without transfer of privacy-sensitive data.

Surgeon Factors Influencing Breast Surgery Outcomes: A Scoping Review to Define the Modern Breast Surgical Oncologist

BACKGROUND

Modern breast surgical oncology incorporates many aspects of care including preoperative workup, surgical management, and multidisciplinary collaboration to achieve favorable oncologic outcomes and high patient satisfaction. However, there is variability in surgical practice and outcomes. This review aims to identify modifiable surgeon factors influencing breast surgery outcomes and provide a definition of the modern breast surgical oncologist.

METHODS

A systematic literature search with additional backward citation searching was conducted. Studies describing modifiable surgeon factors with associated breast surgery outcomes such as rates of breast conservation, sentinel node biopsy, re-excision, complications, acceptable esthetic outcome, and disease-free and overall survival were included. Surgeon factors were categorized for qualitative analysis.

RESULTS

A total of 91 studies met inclusion criteria describing both modifiable surgeon factor and outcome data. Four key surgeon factors associated with improved breast surgery outcomes were identified: surgical volume (45 studies), use of oncoplastic techniques (41 studies), sub-specialization in breast surgery or surgical oncology (9 studies), and participation in professional development activities (5 studies).

CONCLUSIONS

On the basis of the literature review, the modern breast surgical oncologist has a moderate- to high-volume breast surgery practice, understands the use and application of oncoplastic breast surgery, engages in additional training opportunities, maintains memberships in relevant societies, and remains up to date on key literature. Surgeons practicing in breast surgical oncology can target these modifiable factors for professional development and quality improvement.

Differences among a Portuguese cohort of BRCA pathogenic/likely pathogenic variants carriers choosing risk-reducing mastectomy or intensive breast surveillance

PURPOSE

Women with BRCA1 and BRCA2 (BRCA1/2) pathogenic/likely pathogenic (P/LP) variants have a higher risk to develop breast and ovarian cancer. In structured high-risk clinics, risk-reducing measures are adopted. This study aimed at characterizing these women and identify factors that may have influenced their choice between risk reduction mastectomy (RRM) and intensive breast surveillance (IBS).

METHODS

This study reviewed retrospectively 187 clinical records of affected and unaffected women with P/LP variants of the BRCA1/2 genes, from 2007 to 2022, of which 50 chose RRM, while 137 chose IBS. The research focused on personal and family history and tumor characteristics and their relation with the preventive option chosen.

RESULTS

Among women with personal history of breast cancer, a higher proportion opted for RRM compared to those asymptomatic (34.2% vs 21.3%, p = 0.049), with younger age determining the option for RRM (38.5 years vs 44.0 years, p < 0.001). Among women with personal history of ovarian cancer, a higher proportion opted for RRM compared to those without that history (62.5% vs 25.1%, p = 0.033), with younger age determining the option for RRM (42.6 years vs 62.7 years, p = 0.009). Women who had bilateral salpingo-oophorectomy were more likely to choose RRM than those who did not (37.3% vs 18.3%, p = 0.003). Family history was not associated with preventive option (33.3% vs 25.3, p = 0.346).

CONCLUSIONS

The decision for the preventive option is multifactorial. In our study, personal history of breast or ovarian cancer, younger age at diagnosis, and previous bilateral salpingo-oophorectomy were associated with the choice of RRM. Family history was not associated with the preventive option.

European Society of Breast Cancer Specialists/Advanced Breast Cancer Global Alliance quality indicators for metastatic breast cancer care

AIMS

Improvement in the care of patients with metastatic breast cancer (MBC) can only occur if the adequate quality of care is implemented and verified, including access to multidisciplinary, specialised care given in accordance with high-quality guidelines. To this purpose, European Society of Breast Cancer Specialists and the Advanced Breast Cancer Global Alliance joined efforts to develop the first set of quality indicators (QI) specifically for MBC that should be routinely measured and evaluated to ensure that breast cancer centres meet the required standards.

METHODS

A working group of multidisciplinary European experts in breast cancer met to discuss each identified QI, reporting the definition, the minimum and target standard for breast cancer centres to achieve, and the motivation for selection. The level of evidence was determined according to the short version of the United States Agency for Healthcare Research and Quality classification.

RESULTS

QI to measure access to and involvement in multidisciplinary and supportive care, appropriate pathological characterisation of disease, systemic therapies and radiotherapy were developed with the consensus of the working group.

CONCLUSIONS

This is the first effort of a multistep project that aims to have QI for MBC routinely measured and evaluated to ensure that breast cancer centres achieve mandated standards in the care of patients with metastatic disease.

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.

Consensus views on an advanced breast cancer education curriculum for cancer nurses: A Delphi study

BACKGROUND

Specialist nursing care is a core indicator of quality care for people living with advanced breast cancer. However, access to and quality of nurse education programmes in advanced breast cancer is variable.

OBJECTIVES

This study aims to define the topics for inclusion in an international curriculum for an advanced breast cancer education programme.

METHODS

A modified four-round Delphi study was undertaken with experts by profession and experience in advanced breast cancer. Thirty-four topics related to advanced breast cancer and six online teaching and learning methods were pre-selected following a systematic review. Between September 2021 and March 2022, the expert panel determined the importance of topics for inclusion in the education programme. Consensus was defined by at least 80 % agreement on the highest three points on a 9-point Likert scale.

RESULTS

A total of 31 experts participated in rounds 1-3 of this study, and 156 experts by profession and experience participated in an additional fourth round, including people living with advanced breast cancer (n = 72, 46 %), healthcare professionals (n = 46, 29 %), family members or caregivers of a person diagnosed with advanced breast cancer (n = 30, 19 %) and advocacy professionals working in the area of advanced breast cancer (n = 8, 5 %). In round 4, 36 topics and five of six learning methods reached consensus.

CONCLUSIONS

The results of this study provide a framework to develop education programmes in advanced breast cancer, defining the essential elements of curriculum content for such programmes. The results highlight the need for advanced breast cancer education programmes to use multiple teaching and learning methods to promote nurses' understanding of person-centred supportive care and the physical, psychosocial and spiritual issues experienced by people living with advanced breast cancer.

What Is Known about Breast Cancer in Young Women?

Breast cancer (BC) is the second leading cause of cancer-related death in women under the age of 40 years worldwide. In addition, the incidence of breast cancer in young women (BCYW) has been rising. Young women are not the focus of screening programs and BC in younger women tends to be diagnosed in more advanced stages. Such patients have worse clinical outcomes and treatment complications compared to older patients. BCYW has been associated with distinct tumour biology that confers a worse prognosis, including poor tumour differentiation, increased Ki-67 expression, and more hormone-receptor negative tumours compared to women >50 years of age. Pathogenic variants in cancer predisposition genes such as BRCA1/2 are more common in early-onset BC compared to late-onset BC. Despite all these differences, BCYW remains poorly understood with a gap in research regarding the risk factors, diagnosis, prognosis, and treatment. Age-specific clinical characteristics or outcomes data for young women are lacking, and most of the standard treatments used in this subpopulation currently are derived from older patients. More age-specific clinical data and treatment options are required. In this review, we discuss the epidemiology, clinicopathologic characteristics, outcomes, treatments, and special considerations of breast cancer in young women. We also underline future directions and highlight areas that require more attention in future studies.

Women's choices of hospital for breast cancer surgery in Italy: Quality and equity implications

This paper employs mixed logit regression to investigate the effects of providers characteristics on women's choice of hospital for breast surgery. Patient level data are used to model choices in Tuscany region, Italy. In particular, we focus on the effects of travel time and hospital quality indicators including quality standard (volumes of breast surgery), measurement of process (waiting times) and quality of surgical procedures. Variation in preferences related to individual characteristics such as age, education and travel distance from the hospital are also considered. Findings show that, on average, women prefer closer hospital with longer waiting times and higher quality (high volumes of interventions). We found preference heterogeneity associated to education: travel distance affects choice especially among less educated women (regardless of age), while among younger women (<65 years), less educated ones prefer shorter waiting times. These results could be used to optimize the allocation of resources toward breast cancer units that meet quality and efficacy standards to increase the efficiency and responsiveness of breast cancer care.

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.

Overordering of tumor marker for outpatients revealed by performance indicators and the impact of a health policy intervention: An observational study using administrative records

PURPOSE

The overuse of laboratory tests contributes to impair health systems effectiveness, tumor markers (TMs) being a paradigmatic example. In the present study we applied indicators of TMs appropriateness developed from administrative datasets to appraise regionwide overordering in the clinical practice.

PATIENTS AND METHODS

TMs ordered to outpatients in the Veneto Region over 6 years were obtained from the eletronic Outpatients' Records of Diagnostic and Therapeutic Procedures. TMs orders were examined as aggregated data or stratified according to disease codes, gender, age, and requests per patient. TMs recommended only for specific malignancies were examined using epidemiological data obtained from Veneto Tumor Registry.

RESULTS

A total of 5,821,251 TMs were ordered in 4,382,159 patients over 6 years. Overall, 3,252,389 (55.9%) TMs were ordered without appropriate disease codes (ranging from 77.0% for PSA to 17.5% for CA15.3). TM orders declined over 6 years (-13.4%), with a noticeable reduction of orders without appropriate disease codes (-21.3%). Orders decreased sharply from 2015 to 2016, after the enactment of a national Decree-Law aimed at improving appropriateness, and remained stable thereafter. However, the rate of inappropriate TMs requests still remained elevated (44.4%) in the last year of observation, with orders of TMs being much higher than expected on the basis of prevalence and incidence figures of specific malignancies.

CONCLUSIONS

Indicators developed from administrative datasets were effective in assessing the overordering of TMs and the impact of interventions to improve appropriateness. The developed indicators could be considered for other diagnostic tests.

Quality Indicators Compliance and Survival Outcomes in Breast Cancer according to Age in a Certified Center

Age as a breast cancer (BC) prognostic factor remains debatable. Several studies have investigated clinicopathological features at different ages, but few make an age group direct comparison. The European Society of Breast Cancer Specialists quality indicators (EUSOMA-QIs) allow a standardized quality assurance of BC diagnosis, treatment, and follow-up. Our objective was to compare clinicopathological features, compliance to EUSOMA-QIs and BC outcomes in three age groups (≤45 years, 46-69 years, and ≥70 years). Data from 1580 patients with staged 0-IV BC from 2015 to 2019 were analyzed. The minimum standard and desirable target on 19 mandatory and 7 recommended QIs were studied. The 5-year relapse rate, overall survival (OS), and BC-specific survival (BCSS) were also evaluated. No meaningful differences in TNM staging and molecular subtyping classification between age groups were found. On the contrary, disparities in QIs compliance were observed: 73.1% in ≤45 years and 46-69 years women vs. 54% in older patients. No differences in loco-regional or distant progression were observed between age groups. Nevertheless, lower OS was found in older patients due to concurrent non-oncological causes. After survival curves adjustment, we underscored evidence of undertreatment impacting BCSS in ≥70 years women. Despite a unique exception-more invasive G3 tumors in younger patients-no age-specific differences in BC biology impacting outcome were found. Although increased noncompliance in older women, no outcome correlation was observed with QIs noncompliance in any age group. Clinicopathological features and differences in multimodal treatment (not the chronological age) are predictors of lower BCSS.

Breast-Conserving Surgery with or without Irradiation in Early Breast Cancer

BACKGROUND

Limited level 1 evidence is available on the omission of radiotherapy after breast-conserving surgery in older women with hormone receptor-positive early breast cancer receiving adjuvant endocrine therapy.

METHODS

We performed a phase 3 randomized trial of the omission of irradiation; the trial population included women 65 years of age or older who had hormone receptor-positive, node-negative, T1 or T2 primary breast cancer (with tumors ≤3 cm in the largest dimension) treated with breast-conserving surgery with clear excision margins and adjuvant endocrine therapy. Patients were randomly assigned to receive whole-breast irradiation (40 to 50 Gy) or no irradiation. The primary end point was local breast cancer recurrence. Regional recurrence, breast cancer-specific survival, distant recurrence as the first event, and overall survival were also assessed.

RESULTS

A total of 1326 women were enrolled; 658 were randomly assigned to receive whole-breast irradiation and 668 to receive no irradiation. The median follow-up was 9.1 years. The cumulative incidence of local breast cancer recurrence within 10 years was 9.5% (95% confidence interval [CI], 6.8 to 12.3) in the no-radiotherapy group and 0.9% (95% CI, 0.1 to 1.7) in the radiotherapy group (hazard ratio, 10.4; 95% CI, 4.1 to 26.1; P<0.001). Although local recurrence was more common in the group that did not receive radiotherapy, the 10-year incidence of distant recurrence as the first event was not higher in the no-radiotherapy group than in the radiotherapy group, at 1.6% (95% CI, 0.4 to 2.8) and 3.0% (95% CI, 1.4 to 4.5), respectively. Overall survival at 10 years was almost identical in the two groups, at 80.8% (95% CI, 77.2 to 84.3) with no radiotherapy and 80.7% (95% CI, 76.9 to 84.3) with radiotherapy. The incidence of regional recurrence and breast cancer-specific survival also did not differ substantially between the two groups.

CONCLUSIONS

Omission of radiotherapy was associated with an increased incidence of local recurrence but had no detrimental effect on distant recurrence as the first event or overall survival among women 65 years of age or older with low-risk, hormone receptor-positive early breast cancer. (Funded by the Chief Scientist Office of the Scottish Government and the Breast Cancer Institute, Western General Hospital, Edinburgh; ISRCTN number, ISRCTN95889329.).

Self-assessment of a breast care nursing model within a Breast Unit: learning process and keys to improving breast care

AIM AND OBJECTIVES

To assess the adherence of a nursing care model in a multidisciplinary breast cancer unit in a tertiary hospital to the recommended competencies and quality indicators.

BACKGROUND

Aligning the competencies of the breast care nurse with international recommendations for this role helps better fulfil patient needs, increases satisfaction and ensures continuity of care.

DESIGN

Cohort study.

METHODS

Breast care nursing was assessed in all patients treated at the Functional Breast Unit from 1 July 2016 to 30 June 2017. Patients were followed for 1 year. Sociodemographic, clinical and pathological data, treatments performed and nursing interventions were collected. The strobe checklist has been used to report this study.

RESULTS

We analysed nursing interventions carried out in 382 patients attended over 1 year in a multidisciplinary breast cancer unit. All patients with early disease had contact with the nurse at different times during their primary treatment. Only 58% of patients with advanced disease had contact with the nurse during their first year of illness. Moreover, first contact with the nurse was delayed by more than a week from diagnosis, the interval recommended by international guidelines.

CONCLUSION

The nursing care model meets the core competencies defined for the breast care nurse in patients with early breast cancer, but the first visit should be organised earlier, and follow-up should extend beyond completion of primary treatment.

RELEVANCE TO CLINICAL PRACTICE

This study evaluated the breast care nurse model in one breast cancer unit according to international guidelines. Nursing care adhered to most guideline requirements in patients with early breast cancer, but not in those with advanced disease. New models of care need to be developed for women with advanced breast cancer in order to achieve true patient-centred care.

PATIENT OR PUBLIC CONTRIBUTION

No contribution from the patient or the public because the data collected was entered into the clinical history by the health professionals of the Breast Unit as part of their usual clinical practice.

Assurance of Timely Access to Breast Cancer Diagnosis and Treatment by a Regional Breast Health Clinic Serving Both Urban and Rural-Remote Communities

In response to breast cancer diagnostic regional wait times exceeding both national and provincial standards and to symptomatic patient referrals for diagnostic mammography taking longer than abnormal screening mammography referrals, the Rae Fawcett Breast Health Clinic (RFBHC) was opened in 2017 in a mid-sized Canadian hospital serving both urban and rural-remote communities. We investigated whether the RFBHC improved wait times to breast cancer diagnosis, improved compliance with national and provincial breast cancer standards, and decreased the wait time disparity associated with referral source. Statistical analyses of wait time differences were conducted between patients who were diagnosed with breast cancer prior to and after the RFBHC establishment. Study group compliance with national and provincial standards and wait time differences by referral source were also analysed. A survey was administered to assess overall patient experience with the RFBHC and clinic wait times. RFBHC patients had a shorter mean wait to breast cancer diagnosis (24.4 vs. 45.7 days, p ≤ 0.001) and a shorter mean wait to initial breast cancer treatment (49.1 vs. 78.9 days, p ≤ 0.001) than pre-RFBHC patients. After the RFBHC establishment, patients who attended the RFBHC had a shorter mean wait time to breast cancer diagnosis (24.4 vs. 36.9 days, p = 0.005) and to initial treatment (49.1 vs. 73.1 days, p ≤ 0.001) than patients who did not attend the clinic. Compliance with national and provincial breast cancer standards improved after the RFBHC establishment and the wait time disparity between screening mammography referrals and symptomatic patient referrals decreased. Survey results indicate that the RFBHC is meeting patient expectations. We concluded that the establishment of a breast health clinic in a Canadian center serving urban and rural-remote communities improved breast diagnostic services.

Patient experience of implant loss after immediate breast reconstruction: An interpretative phenomenological analysis

Immediate breast reconstruction (IBR) is an integral part of modern breast cancer treatment. Our aim was to investigate patient experience with implant loss after IBR by using interpretative phenomenological analysis (IPA). We conducted semi-structured interviews with eight informants. We analyzed data according to the IPA flexible seven-stage process and four main themes were developed: immediate breast reconstruction as the indisputable choice, a difficult experience, an altered body: redefining normality, and trying to cope. The experience of implant loss appears to affect women for many years and might overshadow some of the benefits of IBR.