Strategies to Improve Strategies to Improve Cancer Care Cancer Care The Treatment of Breast Cancer in Maine The Treatment of Breast Cancer in Maine Maine Cancer Consortium Maine Cancer Consortium Annual Meeting Annual Meeting November 7, 2007 November 7, 2007 Lisa Rutstein, MD FACS Lisa Rutstein, MD FACS
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Strategies to Improve Cancer Strategies to Improve Cancer CareCare
The Treatment of Breast Cancer in MaineThe Treatment of Breast Cancer in Maine
Maine Cancer ConsortiumMaine Cancer ConsortiumAnnual MeetingAnnual Meeting
November 7, 2007November 7, 2007
Lisa Rutstein, MD FACSLisa Rutstein, MD FACS
Data SourceData Source
Breast cancer data for the State of Maine Breast cancer data for the State of Maine 37 hospitals (11 ACoS)37 hospitals (11 ACoS)Diagnosed cases 2002-2004 Diagnosed cases 2002-2004 Data blinded between each institutionData blinded between each institution
22
2
2
2
3
5
3
1
1
3
1
4
1
1
Maine HospitalsMaine Hospitals
Counties & HospitalsCounties & HospitalsAndroscoggin Androscoggin Central Maine Medical CenterCentral Maine Medical Center St. Mary’s Regional Medical CenterSt. Mary’s Regional Medical CenterKennebecKennebec MaineGeneral Medical CenterMaineGeneral Medical Center AroostookAroostook Cary Medical CenterCary Medical Center Northern Maine Medical CenterNorthern Maine Medical Center Houlton Regional HospitalHoulton Regional Hospital Aroostook Medical CenterAroostook Medical CenterWashingtonWashington Calais Regional HospitalCalais Regional Hospital Down East Community HospitalDown East Community HospitalCumberlandCumberland Bridgton HospitalBridgton Hospital Mid Coast HospitalMid Coast Hospital Park View Adventist Medical CenterPark View Adventist Medical Center Maine Medical CenterMaine Medical Center Mercy HospitalMercy HospitalYorkYork SMMCSMMC Henrietta D. Goodall HospitalHenrietta D. Goodall Hospital York HospitalYork Hospital LincolnLincoln St. Andrews HospitalSt. Andrews Hospital Penobscot Valley HospitalPenobscot Valley Hospital
SagadahocSagadahocSomersetSomerset Sebasticook Valley HospitalSebasticook Valley Hospital Redington-Fairview General Redington-Fairview General
HospitalHospitalFranklinFranklin Franklin Memorial HospitalFranklin Memorial HospitalOxfordOxford Stephens Memorial HospitalStephens Memorial Hospital Rumford HospitalRumford HospitalPiscataquisPiscataquis Mayo Regional Hospital.Mayo Regional Hospital.HancockHancock Mt. Desert Island HospitalMt. Desert Island Hospital Blue Hill Memorial HospitalBlue Hill Memorial Hospital Maine Coast Memorial HospitalMaine Coast Memorial HospitalKnoxKnox Penobscot Bay Medical CenterPenobscot Bay Medical CenterWaldoWaldo Waldo County General HospitalWaldo County General HospitalPenobscotPenobscot EMMCEMMC St. Joseph HospitalSt. Joseph Hospital Millinocket Regional HospitalMillinocket Regional Hospital
Treatment WorkgroupTreatment Workgroup
State tumor registrars, ACS staff and OIS State tumor registrars, ACS staff and OIS specialist specialist
Cancer Liaison Physicians from each Cancer Liaison Physicians from each hospitalhospital
Quarterly meeting Quarterly meeting Sponsor: American Cancer SocietySponsor: American Cancer SocietyEstablished guidelines for retrospective Established guidelines for retrospective
data collection at each hospital data collection at each hospital
Analyze collected dataAnalyze collected dataDerive focused inquiriesDerive focused inquiriesDraw conclusions from the data inquiriesDraw conclusions from the data inquiriesCompare results to national benchmarksCompare results to national benchmarksDevelop strategies to improve care in Develop strategies to improve care in
identified areasidentified areasAdvance breast cancer care statewideAdvance breast cancer care statewide
Accepted AssumptionsAccepted Assumptions
Support Breast Conservation Therapy Support Breast Conservation Therapy (BCT)(BCT)
Radiation therapy (XRT) after lumpectomy Radiation therapy (XRT) after lumpectomy EXCEPTION 70 yo, small tumor size, ER (+) 70 yo, small tumor size, ER (+)
SLN provides accurate axillary stagingSLN provides accurate axillary stagingFalse negative rate <7%False negative rate <7%
Stage at DiagnosisStage at DiagnosisLumpectomy vs. Mastectomy Lumpectomy vs. Mastectomy Post-lumpectomy Radiation TherapyPost-lumpectomy Radiation TherapySentinel vs. Regional Node Biopsy Sentinel vs. Regional Node Biopsy
Data InquiriesData Inquiries
Stage at DiagnosisStage at Diagnosis
Stage DistributionStage Distribution
# Cases# Cases % of Total% of Total
Stage 0Stage 0 698698 18.2%18.2%
Stage 1Stage 1 15641564 40.8%40.8%
Stage 2Stage 2 10111011 26.4%26.4%
Stage 3Stage 3 269269 7.0%7.0%
Stage 4Stage 4 126126 3.3%3.3%
UnstagedUnstaged 1717 0.4%0.4%
UnknownUnknown 149149 3.9%3.9%
TOTALTOTAL 38343834 100%100%
Conclusions Conclusions Stage at DiagnosisStage at Diagnosis
Majority present with early stage Majority present with early stage diseasedisease
Exclusions:Exclusions: LCIS cases excluded LCIS cases excluded ““Unstaged” cases Unstaged” cases (Phyllodes)(Phyllodes) were excluded from were excluded from
remaining data inquiries (n=3817)remaining data inquiries (n=3817)
StageStageThe administration of post-lumpectomy The administration of post-lumpectomy
radiation therapy isradiation therapy is less than “benchmark” and less than “benchmark” and “best practice” “best practice”
AgeAgeProportion of “lumpectomy only” patients Proportion of “lumpectomy only” patients
> 70 years of age> 70 years of ageRegionRegion
AccessAccess to Radiation Therapy to Radiation Therapy
Sentinel vs. Regional Sentinel vs. Regional Lymph Node BiopsyLymph Node Biopsy
Lymph Node Dissection by StageLymph Node Dissection by Stage
0102030405060708090
100
% of Cases
0 1 2 3 4
Year
Sentinel Regional None
60.6%60.6%49.2%49.2%
SLN in Stage 1 & 2 by YearSLN in Stage 1 & 2 by Year
Biopsy/Biopsy/
YearYear
20022002 20032003 20042004 TotalTotal
SentinelSentinel 459459
50.9%50.9%
501501
56.0%56.0%
487487
62.3%62.3%
14471447
RegionalRegional 314314 274274 217217 805805
NoneNone 128128 120120 7878 326326
TotalTotal 901901 895895 782782 25782578
Sentinel vs. Regional Node Sentinel vs. Regional Node DissectionDissection
Sentinel nodes for all stage 1 & 2 Sentinel nodes for all stage 1 & 2 Ideal Benchmark = 100%Ideal Benchmark = 100%Maine:Maine:
Stage 1 = 60.6%Stage 1 = 60.6%
Stage 2 = 49.2%Stage 2 = 49.2%
ConclusionsConclusionsSentinel vs Regional Lymph NodeSentinel vs Regional Lymph Node
StageStageFocus on Stage 1 and 2 given less Focus on Stage 1 and 2 given less
controversial naturecontroversial natureStill far Still far belowbelow “benchmark”“benchmark”
YearYearSome Some improvementimprovement over study time over study time
Increase by Increase by 11% over 3 years11% over 3 years
StrategiesStrategies
Comprehensive data analysisComprehensive data analysis Identified areas for improvementIdentified areas for improvement
Comparision to “best practice” and Comparision to “best practice” and “benchmark”“benchmark”
Proposed strategies to optimize breast Proposed strategies to optimize breast cancer care in Mainecancer care in Maine
Breast Conservation & Breast Conservation & Adjuvant RadiationAdjuvant Radiation
Adjuvant RadiationAdjuvant RadiationAccessAccess
Increase # radiation centersIncrease # radiation centersImprove center and county relationshipImprove center and county relationshipHealth care policyHealth care policy
ConvenienceConveniencePartial Breast RadiationPartial Breast RadiationMammosite – 5 vs. 33 days of treatmentMammosite – 5 vs. 33 days of treatment
Final ThoughtsFinal ThoughtsData AnalysisData Analysis Identify areas for improvementIdentify areas for improvementPropose strategiesPropose strategiesDissemination of dataDissemination of data
Presented at the Maine Cancer Consortium Presented at the Maine Cancer Consortium meeting meeting
Newsletter publicationNewsletter publication Inter- & Intra-hospital InvolvementInter- & Intra-hospital InvolvementPartnership with CoC and ACSPartnership with CoC and ACS