Albert J. and Judith A. Dunlap Cancer Center at Mayo Clinic Health ...
Albert J. and Judith A. Dunlap Cancer Center at Mayo Clinic Health ...
Albert J. and Judith A. Dunlap Cancer Center at Mayo Clinic Health ...
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CANCER PROGRAM PRACTICE PROFILE REPORTS (CP3R) FOR BREAST<br />
LUTHER MIDELFORT - MAYO HEALTH SYSTEM, EAU CLAIRE, WI<br />
2004 2005 2006 2007 2008 2009 2010<br />
Radi<strong>at</strong>ion therapy is administered within 1 ye<br />
(365 days) of diagnosis for women under ag<br />
70 receiving breast conserving surgery for<br />
breast cancer. [BCS/RT] N/A N/A N/A N/A 100% 100% 100%<br />
Combin<strong>at</strong>ion chemotherapy is considered or<br />
administered within 4 months (120 days) of<br />
diagnosis for women under 70 with AJCC T1<br />
N0 M0, or Stage II or III ERA <strong>and</strong> PRA nega<br />
breast cancer. [MAC] N/A N/A N/A N/A 90.90% 100% 100%<br />
Tamoxifen or third gener<strong>at</strong>ion arom<strong>at</strong>ase<br />
inhibitor is considered or administered within<br />
year (365 days) of diagnosis for women with<br />
AJCC T1c N0 M0, or Stage II or III ERA <strong>and</strong><br />
PRA positive breast cancer. [HT] N/A N/A N/A N/A 100% 97.10% 94.60%<br />
B. The American Society of <strong>Clinic</strong>al Oncology (ASCO) has launched a Quality Oncology Practice<br />
Initi<strong>at</strong>ive (QOPI). This tracks additional measures as markers of quality for ensuring the best longterm<br />
outcomes for cancer p<strong>at</strong>ients. Included are <strong>Mayo</strong> <strong>Clinic</strong> <strong>Health</strong> System’s breast cancer results<br />
on the 80 cases reviewed.<br />
4. Additional quality efforts involving breast cancer care <strong>at</strong> <strong>Mayo</strong> <strong>Clinic</strong> <strong>Health</strong> System in Eau Claire are<br />
included in the list below.<br />
A. American College of <strong>Cancer</strong> accredit<strong>at</strong>ion.<br />
B. NAPBC accredit<strong>at</strong>ion.<br />
C. Number of quality improvement projects involving specific p<strong>at</strong>ient-rel<strong>at</strong>ed activities. This is a list of<br />
some, but not all, of the projects completed.<br />
i. Tracking <strong>and</strong> assuring the time to the starting of postoper<strong>at</strong>ive tre<strong>at</strong>ments are within the number<br />
of days or sooner than best practices recommended.<br />
ii. Reviewing <strong>and</strong> documenting the completeness of the consults we provide to women on genetic<br />
risks of breast cancer rel<strong>at</strong>ed issues.<br />
iii. P<strong>at</strong>hology h<strong>and</strong>ling <strong>and</strong> sample orient<strong>at</strong>ion of surgical samples to ensure accur<strong>at</strong>e<br />
document<strong>at</strong>ion of surgical margins.<br />
5. Summary.<br />
This summary indic<strong>at</strong>es th<strong>at</strong> <strong>Mayo</strong> <strong>Clinic</strong> <strong>Health</strong> System in Eau Claire meets or exceeds current<br />
st<strong>and</strong>ards of care for the breast cancer p<strong>at</strong>ients cared for in this area. We also go beyond n<strong>at</strong>ional<br />
st<strong>and</strong>ards by having a robust system to determine which of our p<strong>at</strong>ients may be <strong>at</strong> high risk of<br />
developing breast cancer <strong>and</strong> provide comprehensive management of th<strong>at</strong> risk. This process has been<br />
improved by a plan to review quality improvement project. The surgical <strong>and</strong> p<strong>at</strong>hology departments<br />
have coordin<strong>at</strong>ed specimen h<strong>and</strong>ling to ease <strong>and</strong> further guarantee accur<strong>at</strong>e margin determin<strong>at</strong>ion of<br />
breast specimens. We, as a group, underst<strong>and</strong> the importance of timeliness in the diagnosis <strong>and</strong><br />
tre<strong>at</strong>ment implement<strong>at</strong>ion for breast cancer p<strong>at</strong>ients. We have st<strong>at</strong>ed goals <strong>and</strong> tracked the number of<br />
days from an abnormal mammogram to a surgery consult <strong>and</strong> from surgery to initi<strong>at</strong>ion of definitive<br />
post-surgery therapy.<br />
6. Action plan.<br />
We will continue to track these critical measures as we reapply for the American College of Surgeons’<br />
CoC <strong>and</strong> NAPBC accredit<strong>at</strong>ions in the coming two years. We will develop annual plans to review<br />
projects involving breast cancer care as specific clinic departments <strong>and</strong> the cancer committee determines<br />
the need. We are currently formul<strong>at</strong>ing a timeline for accredit<strong>at</strong>ion by the American Society of <strong>Clinic</strong>al<br />
Oncology (ASCO) <strong>and</strong> Quality Oncology Practice Initi<strong>at</strong>ive (QOPI). This will give us feedback on how<br />
we compare to n<strong>at</strong>ionwide outcomes.