Strategies to Improve CancerStrategies to Improve Cancer
CareCare
The Treatment of Breast Cancer in MaineThe Treatment of ...
Data SourceData Source
 Breast cancer data for the State of MaineBreast cancer data for the State of Maine
37 hospitals ...
2
2
2
2
2
3
5
3
1
1
3
1
4
1
1
Maine HospitalsMaine Hospitals
Counties & HospitalsCounties & Hospitals
AndroscogginAndroscoggin
 Central Maine Medical CenterCentral Maine Medical Cent...
Treatment WorkgroupTreatment Workgroup
 State tumor registrars, ACS staff and OISState tumor registrars, ACS staff and OI...
Treatment Workgroup GoalsTreatment Workgroup Goals
 Analyze collected dataAnalyze collected data
 Derive focused inquiri...
Accepted AssumptionsAccepted Assumptions
 Support Breast Conservation TherapySupport Breast Conservation Therapy
(BCT)(BC...
Stage at DiagnosisStage at Diagnosis
Lumpectomy vs. MastectomyLumpectomy vs. Mastectomy
Post-lumpectomy Radiation Thera...
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 1...
ConclusionsConclusions
Stage at DiagnosisStage at Diagnosis
Majority present with early stageMajority present with early ...
LumpectomyLumpectomy
vs.vs.
MastectomyMastectomy
Surgery by StageSurgery by Stage
Surgery/StageSurgery/Stage 00 11 22 33 44 unkunk TotalTotal
LumpectomyLumpectomy 473473 1...
Surgery by Stage (%)Surgery by Stage (%)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0 1 2 3 4
Stage
% of
Cases
lumpectomy...
Surgery by YearSurgery by Year
0
100
200
300
400
500
600
700
800
type of
surgery
2002 2003 2004
year
lumpectomy mastectomy...
Surgery by AgeSurgery by Age
Surgery/ageSurgery/age 0-390-39 40-4940-49 50-6450-64 65-7565-75 75+75+ TotalTotal
Lumpectomy...
Lumpectomy by ACS RegionsLumpectomy by ACS Regions
0
10
20
30
40
50
60
70
80
90
100
%
lumpectomy
Androscoggin
Kennebec
Aro...
Overall Breast Conservation RateOverall Breast Conservation Rate
 Benchmark = 80%Benchmark = 80%
 National average = 65%...
Conclusions on Lumpectomy vs.Conclusions on Lumpectomy vs.
MastectomyMastectomy
 StageStage
 MaineMaine exceedsexceeds n...
Post-lumpectomy RadiationPost-lumpectomy Radiation
Radiation Status OverallRadiation Status Overall
(lumpectomy cases)(lumpectomy cases)
StatusStatus TotalTotal
Administered...
Radiation Status by StageRadiation Status by Stage
0
200
400
600
800
1000
1200
# of
Cases
0 1 2 3 4
Stage
cases XRT
60%
83...
Stage 0: Radiation StatusStage 0: Radiation Status
40% XRT
Not Given
60% XRT
Given
Stage 0: Radiation StatusStage 0: Radiation Status
age>70
29% XRT
Not Given71% XRT
Given
Radiation by ACS RegionsRadiation by ACS Regions
0
10
20
30
40
50
60
70
80
90
100
% Radiation
given
Androscoggin
Kennebec
...
Post-lumpectomy RadiationPost-lumpectomy Radiation
StandardsStandards
 BenchmarkBenchmark
 Stage 0 = 95%Stage 0 = 95%
 ...
ConclusionsConclusions
Post-lumpectomy radiation therapyPost-lumpectomy radiation therapy
 StageStage
The administration...
Sentinel vs. RegionalSentinel vs. Regional
Lymph Node BiopsyLymph Node Biopsy
Lymph Node Dissection by StageLymph Node Dissection by Stage
0
10
20
30
40
50
60
70
80
90
100
% of
Cases
0 1 2 3 4
Year
Se...
SLN in Stage 1 & 2 by YearSLN in Stage 1 & 2 by Year
Biopsy/Biopsy/
YearYear
20022002 20032003 20042004 TotalTotal
Sentine...
Sentinel vs. Regional NodeSentinel vs. Regional Node
DissectionDissection
 Sentinel nodes for all stage 1 & 2Sentinel nod...
ConclusionsConclusions
Sentinel vs Regional Lymph NodeSentinel vs Regional Lymph Node
 StageStage
Focus on Stage 1 and 2...
StrategiesStrategies
 Comprehensive data analysisComprehensive data analysis
 Identified areas for improvementIdentified...
Breast Conservation &Breast Conservation &
Adjuvant RadiationAdjuvant Radiation
 Adjuvant RadiationAdjuvant Radiation
Ac...
Sentinel Lymph Node BiopsySentinel Lymph Node Biopsy
 LimitationsLimitations
Nuclear MedicineNuclear Medicine
Work forc...
Final ThoughtsFinal Thoughts
 Data AnalysisData Analysis
 Identify areas for improvementIdentify areas for improvement
...
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First Course of Treatment Results

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  • This study represents a remarkable effort to amass colon cancer data from 37 hospitals throughout the State of Maine. Of the 37 participating hospitals, only 11 hold prior accreditation from the American College of Surgeons. All data represents colon cancer cases diagnosed from in a 1 year period 2003 to 2004.
  • First Course of Treatment Results

    1. 1. Strategies to Improve CancerStrategies to Improve Cancer CareCare The Treatment of Breast Cancer in MaineThe Treatment of Breast Cancer in Maine Maine Cancer ConsortiumMaine Cancer Consortium Annual MeetingAnnual Meeting November 7, 2007November 7, 2007 Lisa Rutstein, MD FACSLisa Rutstein, MD FACS
    2. 2. Data SourceData Source  Breast cancer data for the State of MaineBreast cancer data for the State of Maine 37 hospitals (11 ACoS)37 hospitals (11 ACoS) Diagnosed cases 2002-2004Diagnosed cases 2002-2004 Data blinded between each institutionData blinded between each institution
    3. 3. 2 2 2 2 2 3 5 3 1 1 3 1 4 1 1 Maine HospitalsMaine Hospitals
    4. 4. Counties & HospitalsCounties & Hospitals AndroscogginAndroscoggin  Central Maine Medical CenterCentral Maine Medical Center  St. Mary’s Regional Medical CenterSt. Mary’s Regional Medical Center KennebecKennebec  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 Center WashingtonWashington  Calais Regional HospitalCalais Regional Hospital  Down East Community HospitalDown East Community Hospital CumberlandCumberland  Bridgton HospitalBridgton Hospital  Mid Coast HospitalMid Coast Hospital  Park View Adventist Medical CenterPark View Adventist Medical Center  Maine Medical CenterMaine Medical Center  Mercy HospitalMercy Hospital YorkYork  SMMCSMMC  Henrietta D. Goodall HospitalHenrietta D. Goodall Hospital  York HospitalYork Hospital LincolnLincoln  St. Andrews HospitalSt. Andrews Hospital  Penobscot Valley HospitalPenobscot Valley Hospital SagadahocSagadahoc SomersetSomerset  Sebasticook Valley HospitalSebasticook Valley Hospital  Redington-Fairview General HospitalRedington-Fairview General Hospital FranklinFranklin  Franklin Memorial HospitalFranklin Memorial Hospital OxfordOxford  Stephens Memorial HospitalStephens Memorial Hospital  Rumford HospitalRumford Hospital PiscataquisPiscataquis  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 Hospital KnoxKnox  Penobscot Bay Medical CenterPenobscot Bay Medical Center WaldoWaldo  Waldo County General HospitalWaldo County General Hospital PenobscotPenobscot  EMMCEMMC  St. Joseph HospitalSt. Joseph Hospital  Millinocket Regional HospitalMillinocket Regional Hospital
    5. 5. Treatment WorkgroupTreatment Workgroup  State tumor registrars, ACS staff and OISState tumor registrars, ACS staff and OIS specialistspecialist  Cancer Liaison Physicians from eachCancer Liaison Physicians from each hospitalhospital  Quarterly meetingQuarterly meeting  Sponsor: American Cancer SocietySponsor: American Cancer Society  Established guidelines for retrospectiveEstablished guidelines for retrospective data collection at each hospitaldata collection at each hospital
    6. 6. Treatment Workgroup GoalsTreatment Workgroup Goals  Analyze collected dataAnalyze collected data  Derive focused inquiriesDerive focused inquiries  Draw conclusions from the data inquiriesDraw conclusions from the data inquiries  Compare results to national benchmarksCompare results to national benchmarks  Develop strategies to improve care inDevelop strategies to improve care in identified areasidentified areas  Advance breast cancer care statewideAdvance breast cancer care statewide
    7. 7. Accepted AssumptionsAccepted Assumptions  Support Breast Conservation TherapySupport Breast Conservation Therapy (BCT)(BCT)  Radiation therapy (XRT) after lumpectomyRadiation 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 staging False negative rate <7%False negative rate <7%
    8. 8. Stage at DiagnosisStage at Diagnosis Lumpectomy vs. MastectomyLumpectomy vs. Mastectomy Post-lumpectomy Radiation TherapyPost-lumpectomy Radiation Therapy Sentinel vs. Regional Node BiopsySentinel vs. Regional Node Biopsy Data InquiriesData Inquiries
    9. 9. Stage at DiagnosisStage at Diagnosis
    10. 10. 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%
    11. 11. ConclusionsConclusions Stage at DiagnosisStage at Diagnosis Majority present with early stageMajority present with early stage diseasedisease  Exclusions:Exclusions:  LCIS cases excludedLCIS cases excluded  ““Unstaged” casesUnstaged” cases (Phyllodes)(Phyllodes) were excluded fromwere excluded from remaining data inquiries (n=3817)remaining data inquiries (n=3817)
    12. 12. LumpectomyLumpectomy vs.vs. MastectomyMastectomy
    13. 13. Surgery by StageSurgery by Stage Surgery/StageSurgery/Stage 00 11 22 33 44 unkunk TotalTotal LumpectomyLumpectomy 473473 11231123 498498 4848 2525 4747 22142214 58.0%58.0% MastectomyMastectomy 202202 425425 487487 200200 2929 5555 13981398 36.6%36.6% NoneNone 2323 1616 2626 2121 7272 4747 205205 5.4%5.4% TotalTotal 698698 15681568 10111011 269269 126126 149149 38173817
    14. 14. Surgery by Stage (%)Surgery by Stage (%) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 0 1 2 3 4 Stage % of Cases lumpectomy mastectomy none 67.867.8 71.871.8 49.349.3
    15. 15. Surgery by YearSurgery by Year 0 100 200 300 400 500 600 700 800 type of surgery 2002 2003 2004 year lumpectomy mastectomy none 60.8% 58.0% 55.2%
    16. 16. Surgery by AgeSurgery by Age Surgery/ageSurgery/age 0-390-39 40-4940-49 50-6450-64 65-7565-75 75+75+ TotalTotal LumpectomyLumpectomy 6363 348348 56.4%56.4% 844844 61.2%61.2% 490490 60.0%60.0% 469469 55.0%55.0% 22142214 MastectomyMastectomy 8484 54.9%54.9% 244244 472472 297297 301301 13981398 NoneNone 66 2525 6363 2929 8282 205205 TotalTotal 153153 617617 13791379 816816 852852 38173817
    17. 17. Lumpectomy by ACS RegionsLumpectomy by ACS Regions 0 10 20 30 40 50 60 70 80 90 100 % lumpectomy Androscoggin Kennebec Aroostook Washington Cumberland York Sagadahoc Lincoln Somerset Franklin Oxford Piscataquis Hancock Knox Waldo Penobscot ▼ 58.0%58.0% ▼▼= significantly lower than state avg.= significantly lower than state avg.
    18. 18. Overall Breast Conservation RateOverall Breast Conservation Rate  Benchmark = 80%Benchmark = 80%  National average = 65%National average = 65%  Best practice = 90%Best practice = 90%  Maine = 58%Maine = 58%
    19. 19. Conclusions on Lumpectomy vs.Conclusions on Lumpectomy vs. MastectomyMastectomy  StageStage  MaineMaine exceedsexceeds national average (>65%) fornational average (>65%) for  Stage 0 = 67.8%Stage 0 = 67.8%  Stage 1 = 71.8%Stage 1 = 71.8%  Maine isMaine is lowelower than national average forr than national average for  Stage 2 = 49.3%Stage 2 = 49.3%  YearYear  DecreasingDecreasing trend in breast conservation rate 2002-2004trend in breast conservation rate 2002-2004  AgeAge  YoungerYounger age (<40 yo)age (<40 yo) lowerlower rate of lumpectomyrate of lumpectomy  SurveillanceSurveillance  Inconvenience of XRTInconvenience of XRT  RegionRegion  AccessAccess  ReconstructionReconstruction  Radiation TherapyRadiation Therapy
    20. 20. Post-lumpectomy RadiationPost-lumpectomy Radiation
    21. 21. Radiation Status OverallRadiation Status Overall (lumpectomy cases)(lumpectomy cases) StatusStatus TotalTotal AdministeredAdministered 16501650 74.5%74.5% Planned, notPlanned, not administeredadministered 121121 5.5%5.5% Not PlannedNot Planned 226226 9.7%9.7% XRTXRT contraindicatedcontraindicated 1212 0.5%0.5% UnknownUnknown 217217 9.8%9.8% TotalTotal 22142214
    22. 22. Radiation Status by StageRadiation Status by Stage 0 200 400 600 800 1000 1200 # of Cases 0 1 2 3 4 Stage cases XRT 60% 83% 78% 68% 48%
    23. 23. Stage 0: Radiation StatusStage 0: Radiation Status 40% XRT Not Given 60% XRT Given
    24. 24. Stage 0: Radiation StatusStage 0: Radiation Status age>70 29% XRT Not Given71% XRT Given
    25. 25. Radiation by ACS RegionsRadiation by ACS Regions 0 10 20 30 40 50 60 70 80 90 100 % Radiation given Androscoggin Kennebec Aroostook Washington Cumberland York Sagadahoc Lincoln Somerset Franklin Oxford Piscataquis Hancock Knox Waldo Penobscot ▼ ▲▲ ▲▲ ▼▼▲▲ = statistically significant= statistically significant 74.5%74.5%
    26. 26. Post-lumpectomy RadiationPost-lumpectomy Radiation StandardsStandards  BenchmarkBenchmark  Stage 0 = 95%Stage 0 = 95%  StageStage ≥1 = 100%≥1 = 100%  Best PracticeBest Practice  Stage 0 = 91%Stage 0 = 91%  StageStage 1 = 85%1 = 85%  MaineMaine  Stage 0 = 60% (subtracted >70 yo = 71%)Stage 0 = 60% (subtracted >70 yo = 71%)  StageStage 1 = 83%1 = 83%  Stage 2 = 78%Stage 2 = 78%
    27. 27. ConclusionsConclusions Post-lumpectomy radiation therapyPost-lumpectomy radiation therapy  StageStage The administration of post-lumpectomyThe administration of post-lumpectomy radiation therapy isradiation therapy is less than “benchmark” andless than “benchmark” and “best practice”“best practice”  AgeAge Proportion of “lumpectomy only” patientsProportion of “lumpectomy only” patients > 70 years of age> 70 years of age  RegionRegion AccessAccess to Radiation Therapyto Radiation Therapy
    28. 28. Sentinel vs. RegionalSentinel vs. Regional Lymph Node BiopsyLymph Node Biopsy
    29. 29. Lymph Node Dissection by StageLymph Node Dissection by Stage 0 10 20 30 40 50 60 70 80 90 100 % of Cases 0 1 2 3 4 Year Sentinel Regional None 60.6%60.6% 49.2%49.2%
    30. 30. 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
    31. 31. Sentinel vs. Regional NodeSentinel vs. Regional Node DissectionDissection  Sentinel nodes for all stage 1 & 2Sentinel 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%
    32. 32. ConclusionsConclusions Sentinel vs Regional Lymph NodeSentinel vs Regional Lymph Node  StageStage Focus on Stage 1 and 2 given lessFocus on Stage 1 and 2 given less controversial naturecontroversial nature Still farStill far belowbelow “benchmark”“benchmark”  YearYear SomeSome improvementimprovement over study timeover study time Increase byIncrease by 11% over 3 years11% over 3 years
    33. 33. StrategiesStrategies  Comprehensive data analysisComprehensive data analysis  Identified areas for improvementIdentified areas for improvement Comparision to “best practice” andComparision to “best practice” and “benchmark”“benchmark”  Proposed strategies to optimize breastProposed strategies to optimize breast cancer care in Mainecancer care in Maine
    34. 34. Breast Conservation &Breast Conservation & Adjuvant RadiationAdjuvant Radiation  Adjuvant RadiationAdjuvant Radiation AccessAccess Increase # radiation centersIncrease # radiation centers Improve center and county relationshipImprove center and county relationship Health care policyHealth care policy ConvenienceConvenience Partial Breast RadiationPartial Breast Radiation Mammosite – 5 vs. 33 days of treatmentMammosite – 5 vs. 33 days of treatment
    35. 35. Sentinel Lymph Node BiopsySentinel Lymph Node Biopsy  LimitationsLimitations Nuclear MedicineNuclear Medicine Work forceWork force TrainingTraining Didactic and ProctoringDidactic and Proctoring PathologyPathology Shared protocolsShared protocols
    36. 36. Final ThoughtsFinal Thoughts  Data AnalysisData Analysis  Identify areas for improvementIdentify areas for improvement  Propose strategiesPropose strategies  Dissemination of dataDissemination of data Presented at the Maine Cancer ConsortiumPresented at the Maine Cancer Consortium meetingmeeting Newsletter publicationNewsletter publication  Inter- & Intra-hospital InvolvementInter- & Intra-hospital Involvement  Partnership with CoC and ACSPartnership with CoC and ACS
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