Albert J. and Judith A. Dunlap Cancer Center at Mayo Clinic Health ...

CANCER PROGRAM PRACTICE PROFILE REPORTS (CP3R) FOR BREAST
LUTHER MIDELFORT - MAYO HEALTH SYSTEM, EAU CLAIRE, WI
2004 2005 2006 2007 2008 2009 2010
Radiation therapy is administered within 1 ye
(365 days) of diagnosis for women under ag
70 receiving breast conserving surgery for
breast cancer. [BCS/RT] N/A N/A N/A N/A 100% 100% 100%
Combination chemotherapy is considered or
administered within 4 months (120 days) of
diagnosis for women under 70 with AJCC T1
N0 M0, or Stage II or III ERA and PRA nega
breast cancer. [MAC] N/A N/A N/A N/A 90.90% 100% 100%
Tamoxifen or third generation aromatase
inhibitor is considered or administered within
year (365 days) of diagnosis for women with
AJCC T1c N0 M0, or Stage II or III ERA and
PRA positive breast cancer. [HT] N/A N/A N/A N/A 100% 97.10% 94.60%
B. The American Society of Clinical Oncology (ASCO) has launched a Quality Oncology Practice
Initiative (QOPI). This tracks additional measures as markers of quality for ensuring the best longterm
outcomes for cancer patients. Included are Mayo Clinic Health System’s breast cancer results
on the 80 cases reviewed.
4. Additional quality efforts involving breast cancer care at Mayo Clinic Health System in Eau Claire are
included in the list below.
A. American College of Cancer accreditation.
B. NAPBC accreditation.
C. Number of quality improvement projects involving specific patient-related activities. This is a list of
some, but not all, of the projects completed.
i. Tracking and assuring the time to the starting of postoperative treatments are within the number
of days or sooner than best practices recommended.
ii. Reviewing and documenting the completeness of the consults we provide to women on genetic
risks of breast cancer related issues.
iii. Pathology handling and sample orientation of surgical samples to ensure accurate
documentation of surgical margins.
5. Summary.
This summary indicates that Mayo Clinic Health System in Eau Claire meets or exceeds current
standards of care for the breast cancer patients cared for in this area. We also go beyond national
standards by having a robust system to determine which of our patients may be at high risk of
developing breast cancer and provide comprehensive management of that risk. This process has been
improved by a plan to review quality improvement project. The surgical and pathology departments
have coordinated specimen handling to ease and further guarantee accurate margin determination of
breast specimens. We, as a group, understand the importance of timeliness in the diagnosis and
treatment implementation for breast cancer patients. We have stated goals and tracked the number of
days from an abnormal mammogram to a surgery consult and from surgery to initiation of definitive
post-surgery therapy.
6. Action plan.
We will continue to track these critical measures as we reapply for the American College of Surgeons’
CoC and NAPBC accreditations in the coming two years. We will develop annual plans to review
projects involving breast cancer care as specific clinic departments and the cancer committee determines
the need. We are currently formulating a timeline for accreditation by the American Society of Clinical
Oncology (ASCO) and Quality Oncology Practice Initiative (QOPI). This will give us feedback on how
we compare to nationwide outcomes.