DOMINICAN HOSPITAL QUALITY IMPROVEMENT STUDY BREAST CANCER CARE

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1 DOMINICAN HOSPITAL QUALITY IMPROVEMENT STUDY BREAST CANCER CARE STUDY COORDINATOR: Jimmy Chung, MD 234 Surgical breast cancer patients admitted Updated: 10/7/10 INTRODUCTION Breast cancer is the second leading cause of cancer deaths in women in the United States behind lung cancer. In 2008, over 240,000 new cases of breast cancer were diagnosed and over 40,000 women died from breast cancer. There are approximately 2.4 million women living with a history of or current diagnosis of breast cancer in the United States. There has been a steady decline in incidence and death rates from breast cancer since 2001, reversing a trend of increasing incidence and mortality from 1980 to The previous increase was not believed to be a result of higher rates of breast cancer, but more a reflection of better tools and techniques for screening and documentation. However, the recent improvement in survival appears to be a direct result of improvements in early detection programs and advancements in treatment. The cancer program at Dominican Hospital has a proud history of successful breast cancer treatment. In this study, we evaluated Dominican's patterns of breast cancer treatment with a special focus on lymph node removal, as well as 5-year survival rates by stage at diagnosis. We also compared these patterns with national standards and data to get a sense of how Dominican's breast cancer treatment and survival compare to national patterns. Sentinel lymph node biopsy (SLNB) is an appropriate initial alternative to routine staging axillary lymph node dissection (ALND) for patients with early stage breast cancer with clinically negative axillary nodes, as set forward by ASCO and CCO. Completion ALND remains standard treatment for patients with axillary metastases identified on SLNB. Appropriately identified patients with negative results of SLNB, when done under the direction of an experienced surgeon, need not have completion ALND. Isolated cancer cells detected by pathologic examination of the sentinel nodes with use of specialized techniques are currently of unknown clinical significance. Although such specialized techniques

2 are often used, they are not a required part of SLNB evaluation for breast cancer at this time. Data suggest that SLNB is associated with less morbidity than ALND, but the comparative effects of these two approaches on tumor recurrence or patient survival are unknown.

3 BREAST CANCER OVERVIEW Between 2004 and 2008, 234 newly diagnosed breast cancer patients received all or part of their surgical treatment at Dominican. Two patients were diagnosed at the end of 2003 but did not present to Dominican until early Most cases were diagnosed outside the facility and referred to Dominican for treatment.

4 The majority of patients in this study were white non-hispanic, which reflects the specific patient population at Dominican Hospital. The median age of diagnosis for this study was 63, which is comparable to the national median.

5 The cancer cases surgically treated at Dominican from consisted largely of invasive ductal carcinoma. The vast majority of breast cases diagnosed and treated at Dominican were either stage I or II, highlighting the successful implementation of screening and patient education programs, community outreach and early detection programs here and within the community. Only one patient (0.4%) could not be assigned a stage based on the information in the medical record.

6 SURGICAL TREATMENT For the purpose of this study, we only looked at breast cancer cases that had some form of surgery at Dominican Hospital, specifically whether or not a sentinel lymph node biopsy was performed in eligible patients. Although the decision to forgo SLNB in favor of an ALND depends on the patient s specific situation, SLNB remains the preferred approach in patients presenting with localized T1-T2 disease and clinically negative lymph nodes. Below are the major recommendations from ASCO and SSO for SLNB: 1. Axillary Staging. Sentinel lymph node biopsy (SLNB) is recommended for axillary staging of all patients with clinically node negative early-stage breast cancer. Patients with preoperative biopsy proven nodal metastases should undergo axillary lymph node dissection (ALND) upfront. 2. Special Clinical Scenarios. Described below are three clinical situations: those in which there is a clear role for SLNB, those in which SLNB is not recommended, and those in which the role of SLNB is unclear (see also Table 1 in the original guideline document). There is sufficient evidence to support the use of SLNB in patients with T1-2 tumours, multicentric tumours, ductal carcinoma in situ (DCIS) (with mastectomy), older age, obesity, and bilateral breast cancer. Clinicians and patients should note that older age and/or obesity are risk factors for failed SLN mapping. SLNB is not recommended for patients with inflammatory T4 breast cancer, clinically positive nodes, or prior axillary surgery. The role of SLNB is less clear in the following circumstances: internal mammary lymph nodes, before preoperative systemic therapy, T3 or T4 tumours, DCIS (without mastectomy), suspicious palpable axillary nodes, after preoperative systemic therapy, prior diagnostic or excisional breast surgery, prior non-oncologic breast surgery, and pregnancy. For pregnant patients, there are concerns about the safety of blue dye; decisions should be made on a case by case basis.

7 TYPE OF SURGERY The majority of patients in this study (129) were treated with a breast conserving approach. Comparatively, simple or radical mastectomy was performed in 93 patients. Several patients had definitive cancer directed surgery elsewhere and came to Dominican for re-excision. LYMPH NODE RESECTION Most patients in this study had SLNB or SLNB+ALND.

8 Of the 234 cases reviewed, 56 patients fell out of eligibility because there was clinical evidence of lymph node metastasis prior to surgery. Another 19 patients had documented contraindications to SLNB and therefore a full ALND was done. Of the remaining 159 patients, 110 patients had a SLNB, and 34 patients had SLNB followed by an ALND. 15 patients did not have SLNB and did not have documented contraindications to SLNB on record. Therefore, only 8% of patients presenting for surgery at Dominican, who were eligible for SLNB, did not have this performed. This finding demonstrates a very high adherence to the recommendations set forth by ASCO and SSO.

9 SURVIVAL Survival rates at Dominican were compared to 1322 national community hospital cancer programs. Although we did not include In-situ (stage 0) cases, rates were relatively comparable across the board.

10 SURVIVAL STATISTICS FROM THE NATIONAL CANCER DATABASE Dx 1 Year 2 Years 3 Years 4 Years 5 Years Stage 0 n= Stage I n= Stage II n= Stage III n= Stage IV n= SUMMARY Although SLNB remains standard of care for most patients presenting with localized, clinically lymph node negative disease, individual case scenarios will sometimes limit adherence to this recommendation. At Dominican hospital, only 8% eligible patients did not have SLNB and lacked documentation as to why, although this could also be the result of limited access to medical records.