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

Treatment Workgroup GoalsTreatment Workgroup Goals

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)

Lumpectomy Lumpectomy vs. vs.

MastectomyMastectomy

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

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

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%

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 34834856.4%56.4%

84484461.2%61.2%

49049060.0%60.0%

46946955.0%55.0%

22142214

MastectomyMastectomy 848454.9%54.9%

244244 472472 297297 301301 13981398

NoneNone 66 2525 6363 2929 8282 205205

TotalTotal 153153 617617 13791379 816816 852852 38173817

Lumpectomy by ACS RegionsLumpectomy by ACS Regions

0102030405060708090

100

% lumpectomy

AndroscogginKennebec

AroostookWashington

CumberlandYorkSagadahocLincoln

SomersetFranklinOxford

PiscataquisHancockKnoxWaldoPenobscot

▼ 58.0%58.0%

▼▼= significantly lower than state avg.= significantly lower than state avg.

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%

Conclusions on Lumpectomy vs. Conclusions on Lumpectomy vs. MastectomyMastectomy

StageStage Maine Maine exceedsexceeds national average (>65%) for national average (>65%) for

Stage 0 = 67.8%Stage 0 = 67.8% Stage 1 = 71.8%Stage 1 = 71.8%

Maine is Maine is lowelower than national average for r than national average for Stage 2 = 49.3%Stage 2 = 49.3%

Year Year DecreasingDecreasing trend in breast conservation rate 2002-2004 trend in breast conservation rate 2002-2004

AgeAge YoungerYounger age (<40 yo) age (<40 yo) lowerlower rate of lumpectomy rate of lumpectomy

SurveillanceSurveillance Inconvenience of XRTInconvenience of XRT

RegionRegion AccessAccess

ReconstructionReconstruction Radiation TherapyRadiation Therapy

Post-lumpectomy RadiationPost-lumpectomy Radiation

Radiation Status OverallRadiation Status Overall(lumpectomy cases)(lumpectomy cases)

StatusStatus TotalTotal

AdministeredAdministered 16501650

74.5%74.5%

Planned, not Planned, not administeredadministered

121121

5.5%5.5%

Not PlannedNot Planned 226226

9.7%9.7%

XRT XRT contraindicatedcontraindicated

1212

0.5%0.5%

UnknownUnknown 217217

9.8%9.8%

TotalTotal 22142214

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%

Stage 0: Radiation StatusStage 0: Radiation Status

40% XRT Not Given

60% XRTGiven

Stage 0: Radiation StatusStage 0: Radiation Status

age>70

29% XRT Not Given 71% XRT

Given

Radiation by ACS RegionsRadiation by ACS Regions

0102030405060708090

100

% Radiation given

AndroscogginKennebec

AroostookWashington

CumberlandYorkSagadahocLincoln

SomersetFranklinOxford

PiscataquisHancockKnoxWaldoPenobscot

▼

▲▲ ▲▲

▼▼▲ ▲ = statistically significant= statistically significant

74.5%74.5%

Post-lumpectomy Radiation Post-lumpectomy Radiation StandardsStandards

Benchmark Benchmark Stage 0 = 95%Stage 0 = 95% Stage Stage ≥1 = 100%≥1 = 100%

Best PracticeBest Practice Stage 0 = 91%Stage 0 = 91% Stage Stage 1 = 85%1 = 85%

MaineMaine Stage 0 = 60% (subtracted >70 yo = 71%)Stage 0 = 60% (subtracted >70 yo = 71%) Stage Stage 1 = 83%1 = 83% Stage 2 = 78%Stage 2 = 78%

ConclusionsConclusionsPost-lumpectomy radiation therapyPost-lumpectomy radiation therapy

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

Sentinel Lymph Node BiopsySentinel Lymph Node Biopsy

LimitationsLimitationsNuclear MedicineNuclear Medicine

Work forceWork force

TrainingTrainingDidactic and ProctoringDidactic and Proctoring

PathologyPathologyShared protocolsShared protocols

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