Breast cancer quality of care in Kingdom of Saudi Arabia

1. Quality of Breast CancerQuality of Breast Cancer
Care in KFSH, Al-QassimCare in KFSH, Al-Qassim
Dr. Shad Salim Akhtar
MB, MD, FRCP, MUICC(Fellows)
Consultant Medical Oncologist
Medical Director
Prince Faisal Oncology Center &
King Fahd Specialist Hospital
Buraidah, Al-Qassim

2. Poor Quality-DefinitionPoor Quality-Definition
Too much care
Too little care
Wrong care
IOM. Measuring the quality of health care 1999.

3. Quality of Care-DefinitionQuality of Care-Definition
IOM Medicare: A strategy for quality assurance. Vol 1; 1990
“The degree to which health
services for individuals and
populations increase the
likelihood of desired outcome
and are consistent with current
professional knowledge”

4. 110
You are the best of peoples, evolved for
mankind, enjoining what is right,
forbidding what is wrong,, and believing
in Allah. If only the People of the Book
had faith, it were best for them: among
them are some who have faith, but most
of them are perverted transgressors.
Holy Quran Surah Al-ImranHoly Quran Surah Al-Imran

5. Narrated Hadhrate Aisha (RAA)
The Prophet (SAW) said, “Indeed Allah
loves among you the one who does the
work (what ever he does) in the best
way”

6. Measures of QualityMeasures of Quality
Best Process Measure!
Better
process
Better
outcome
That measures
quality!!
Compared to a standard
Process
Structure
Outcome
Implicit
Explicit

7. Screening
Diagnosis
Surgery
Adjuvant therapy
Quality of life
Early
detection
Type
of surgery
Chemotherapy
Radiotherapy
Reconstruction
End of life-care quality
Pain
control

8. Al Qassim-common cancers in femalesAl Qassim-common cancers in females
Akhtar SS et al. Ann Saudi Med 1997;17:595
1 2 . 6 5
9 . 4 8
8 . 5 1
7 . 2 9
5 . 8 4
5 . 1 1
4 . 1 43 . 8 9
Thyroid
Breast
Oesophagus
NHL
Stomach
HD
Skin
Colorectal

9. FACCT-Quality Indicators-steps to good careFACCT-Quality Indicators-steps to good care
Measure Perform value Data source
Mammography 52-69 within 2 yrs Bills, claims record
Early detection Stage 0, I Ca regis pt records
Informed about
rad therapy
Stage I,II pts having
information….
Pt satisfaction survey
BCS Stage I, II with BCS Ca reg recds, claims
RT after BCS BCS pts recd RT Ca reg recds, claims

10. Hillner Proposed Report CardHillner Proposed Report Card
Issue Expert
target
BCBS Cohort
Evaluation
Biopsy before
mastectomy
>95% 92%
Treatment
Ax. Dissection >90% 88%
BCS 50% 33%
RT after BCS >95% 86%
Hillner BE et al. J Clinic Oncol 1997;15:1401

11. Hillner Proposed Report CardHillner Proposed Report Card
Issue Expert
target
BCBS Cohort
Staging
Peri-op bone scan <10% 34%
Peri-op ab. CT <10% 12%
Adj Chemotherapy >90% 88%
Premenop >1node >90% 83%
Postmenop>1node 50% 52%
Hillner BE et al. J Clinic Oncol 1997;15:1401

12. Source of DataSource of Data
Administrative records
Medical records
Patient surveys
Cancer registries

13. Breast Cancer-Age DistributionBreast Cancer-Age Distribution
1994-20001994-2000
8
25 25
8 8
3
1
21-30 31-40 41-50 51-60 61-70 71-80 >80
Total no=78
<=50 yrs=58/78 (73%)
Mean age= 46.5+14.77
Age range=(23-110)

14. Breast Cancer-Pt CharacteristicsBreast Cancer-Pt Characteristics
Lump = 74/78
Post menopausal = 21
Premenopausal = 57
Three with metastatic symptoms
Nulliparous = 3

15. Lump
Screening
Was not available at the time
of this presentation
Decreased mortality
20-30% (>50 yrs age)
Does it really?
Early Detection

16. Lump Size
T Italy Al-Qassim
Tis 5 0
T1 412 3
T2 444 25
T3
95
23
T4 17
90%
59%
Montella M et al. Cancer 1995;76:1585

17. SurgeryLump
Diagnostic
Evaluation
Clinical examination
Mammograph
y
FNA
Process outcome link?
Appropriate procedure must be followed
Delayed diag- commonest cause of
litigation
Ultrasound

18. Clinical examination =lump
Mammogram
=39/75(52%)
FNAC =46/75(61%)
FNAC non-diagnostic =22/46(47.8%)
Biopsy =51/75(68%)
Triple assessment =28/75(37%)
Surgery
Lump Diagnostic
Evaluation

19. Stage Number
I 0
II 30
III 22(44%)
IV 13
Stage IV=13
Comp stag invest 78%(58/75)
Stage III (44%)
– <5% of mam diagnosed ca
– 30-50% in underprovided areas
Younger patients
– Higher stage of disease?
Stage

20. Surgery
BCS
Phase Three-
Therapy

21. Quality of Care Measures forQuality of Care Measures for
Breast SurgeryBreast Surgery
FACCT
Proportion of Stage I,II patients who
undergo breast conserving surgery
Hillner Report Card for ESBC
Breast conserving surgery for local
disease
Axillary dissection
Hillner BE et al. J Clin Oncol 1997;15-1401

22. Breast Cancer-Al-QassimBreast Cancer-Al-Qassim
Surgical InterventionSurgical Intervention
6
44
25
Lumpec
Mastect
None
The majority had
mastectomy

23. Target ~50% in early stage disease
Proportion of patients with ESBC
undergoing BCS
Surgery
BCS
T1 T2 T3 T4
Lump 0 2 4 0
Mast 0 21 13 10

24. Axillary node clearanceAxillary node clearance
Axillary dissection TARGET >90%
Our achievement
–Axillary clearance =46/50 (92%)
–Axillary sampling =3/50(6%)

25. Surgery
Histopathology
Parameter Q-probe audit Al-Qassim(%)
Size 77% 24/50(48)
Grade 83% 36/50(72)
I/duct comp 76% NA
Node no. NA 39/50(78)
ER/PR 75% 4/50(8)
Nakleh RE et al. Arch Path Lab Med 1997; 121:11

26. Breast Ca-Tumour Size Vs NodesBreast Ca-Tumour Size Vs Nodes
Tumour size (cms) Positive axilla (%)
<1 21
1-1.9 33
2-2.9 45
3-3.9 52
4-4.9 60
>5.0 70
Carter C et al. Cancer 1989;63:181

27. Breast Cancer-Nodal StatusBreast Cancer-Nodal Status
15
33
N0
N111
15
7
Unk
>3
1to3
69% node positive
Number of nodes=2-40
Number positive =1-23

28. Adjuvant therapy
Chemotherapy
Radiotherapy
Pre-men & > 1 node + chemo >90%
Post-men & >1 node + chemo =50%
Local RT post BCS* >95%
Hillner BE et al. J Clin Oncol 1997;15-1401 *FACCT

29. Breast Ca-Adjuvant TherapyBreast Ca-Adjuvant Therapy
Pre(%) Post(%)
Total 38 12
Adj CT 34(90) 7(55)
Adj HT 24(63) 11(90)
Adj RT 20(53) 5(41)

30. Chemotherapy Vs Nodal StatusChemotherapy Vs Nodal Status
11
1
2
1
8
2
1
2
3
8
2
1
1
3
1
2
NO 1TO3 >3 UNK
UNKN
NONE
OTHER
CM+CAF
CAF
CMF

31. Breast Cancer-ConclusionsBreast Cancer-Conclusions
Parameter INCR
%
Qassim
%
B/L mammogram 61 52
Clinical stage 37 78
Axillary node evaluation 89 99
T<2 cm no rad mast 84 NA
RT post quadr 65 100
Polychemo if <50, n+ 71 89
Italian National Cancer Research data 1987

32. Breast Cancer ConclusionsBreast Cancer Conclusions
Triple assessment underused
High failure rate of FNA *
Failure of early detection (late
presentation?
Under use of BCS
Inadequate pathology reporting *
Overuse of hormone therapy?
* Improving

33. Thank You
ALTO