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The purpose of this study is to evaluate the rate of minimally invasive biopsy for diagnosis of breast cancer at an interdisciplinary breast center.Percutaneous core needle biopsy (CNB) is optimal for minimizing surgery for the diagnosis of benign and malignant lesions of the breast while preserving surgery for definitive resection. Core needle biopsy increases patient satisfaction and reduces the cost of diagnosis and treatment. Despite the endorsement of CNB by many professional organizations, the literature documents underutilization.Institutional review board approval was obtained. An audit of a single institution's prospectively maintained cancer databases was performed for all breast cancers diagnosed in 2007 and 2008. Methods of diagnosis included image-guided and freehand-guided CNB, image-guided vacuum assisted needle biopsy, image-guided fine needle aspiration, punch biopsy, and open surgical biopsy.Three hundred sixty new breast cancers were diagnosed in 2007 and 2008. Malignancy was diagnosed by minimally invasive techniques in 350/360 (97%) cancers.A very high rate of accurate tissue diagnosis of breast cancer by minimally invasive techniques is achievable.

Measurement of quality indicators and peer comparison has been demonstrated to improve quality of care. The goal of this study was to determine whether a community breast center, in collaboration with the National Consortium of Breast Centers (NCBC), could voluntarily audit the quality of breast cancer care, confidentially transmit quality information to the NCBC, and receive peer performance comparisons. Quality indicator metrics from consecutive breast cancer patients undergoing care at a community interdisciplinary breast center were entered into a prospective database of quality measures that were defined by the NCBC. Retrospective review of patients from 2004 to 2006 was performed and subsequent quality indicator data was submitted electronically to the NCBC National Quality Measures for Breast Centers (NQMBC(TM) ) program. The percentage of new cancer diagnoses made by needle biopsy techniques was 94%, 95% and 96% from 2004 to 2006. Sentinel lymph node utilization in eligible patients was 93%, 96% and 91% from 2004 to 2006 and the immediate intraoperative pathologic frozen section false negative rate of the sentinel lymph node was 6.5%, 4.7% and 4%. Chart documentation of "patient participation in shared decision making for breast conserving therapy versus mastectomy" improved from 74% to 99% (p

Background and Objectives Recent preclinical basic science studies suggest that patient tumor immunity is altered by general anesthesia (GA), potentially worsening cancer outcomes. A single retrospective review concluded that breast cancer patients receiving paravertebral block and GA had better cancer outcomes compared with patients receiving GA alone. This study has not been validated. We hypothesized that local or regional anesthesia (LRA) would be associated with better cancer outcomes compared with GA. Methods We retrospectively reviewed a prospectively collected database to identify all stage 0-III breast cancer patients undergoing surgery in a single center during a 9-year period ending January 1, 2010. Patients were divided into 2 groups: those who received only LRA and those who received GA. Overall survival (OS), disease-free survival (DFS), and local regional recurrence (LRR) were calculated using the Kaplan-Meier method with log-rank comparison before and after propensity score matching. Results Median age of the 1107 patients who met study criteria was 64 years (range, 24–97 years). Median and longest follow-up were 5.5 and 12.5 years, respectively. General anesthesia was used for 461 patients (42%), and 646 (58%) received LRA. The point estimates of cumulative OS, DFS, and LRR “free” rates at 5 years for the GA and LRA groups were 85.5% and 87.1%, 94.2% and 96.1%, and 96.3% and 95.8%, respectively. Cox regression showed no significant differences between the 2 groups (GA and LRA) for the 3 outcomes: OS (hazard ratio [HR], 0.81; 95% confidence interval [CI], 0.59–1.10; P = 0.17), DFS (HR, 0.91; 95% CI, 0.55–1.76; P = 0.87), and LRR (HR, 1.73; 95% CI, 0.83–3.63; P = 0.15). Conclusions Breast cancer OS, DFS, and LRR were not affected by type of anesthesia in our institution. This result differs from that of the only prior published clinical report on this topic and does not provide clinical corroboration of the basic science studies that suggest oncologic benefits to LRA.

Objective The effect of surgery resident participation on breast cancer recurrence has not been previously reported. The objectives of this study were to determine if resident participation was associated with either immediate postoperative or long-term breast cancer outcomes. Design We retrospectively reviewed a prospectively collected breast center database to identify all patients with breast cancer undergoing surgery in a single center during a 9-year period ending 1 January 2010. Patients were divided into 2 groups based on whether surgery residents completed more than 50% of the critical portions of the case (Resident group) or not. The outcomes of operation length, reoperative rates, morbidity, and the long-term outcomes of cancer recurrence were compared by group. Comparisons of immediate postoperative outcomes were made with chi-square and Fisher exact tests. Comparisons of operation length were analyzed by Wilcoxon rank-sum testing. Survival analyses were calculated using the Kaplan-Meier method with log-rank comparison. Multivariate analysis with Cox regression was also performed. Setting The study occurred at a community-based hospital that has an accredited general surgery training program. Participants In all, 1107 consecutive patients with stage 0–3 breast cancer undergoing breast cancer operations were included. Results Median age of patients was 64 years (range: 24-97). Median and longest follow-up were 5.5 and 12.5 years, respectively. Initial operation was breast conserving in 796 (72%) and mastectomy in 311 (28%). Of the 1107 patients, 887 (80.1%) had resident participation. The Resident group was associated with longer operative times. We identified no differences in operative morbidity, reoperations, overall survival, disease-free survival, or local-regional recurrence in the Resident and No Resident groups. Conclusions Resident involvement in breast cancer operations was associated with longer operative times but did not affect any other perioperative or cancer outcome in our institution. This information can be used to reassure program directors, attending surgeons, and patients if they have questions or concerns about the safety or effectiveness of cancer surgery when there is surgical resident participation.

Background Variations exist in compliance with NCCN Guidelines. Prior reports of adherence to NCCN Guidelines contain limitations because of lack of contemporary review and incomplete listing of reasons for noncompliance. Purpose To assess institutional compliance and assist national quality improvement strategies through identifying valid reasons for noncompliance. Methods Compliance with NCCN Guidelines was recorded prospectively using electronic synoptic templates for patients with newly diagnosed breast cancer treated at a single institution between January 2010 and December 2011. Compliance with NCCN Guidelines was recorded. The accuracy of real-time synoptic auditing methods compared with retrospective chart review and reasons for noncompliance was assessed. SAS 9.3 software was used for data analysis. Results Compliance with NCCN Guidelines among 395 patients was 94% for initial staging evaluation, 97% for surgery, 91% for chemotherapy, 89% for hormone therapy, 91% for radiation therapy, 85% for follow-up, and 100% for determination of estrogen receptor/progesterone receptor and HER2 status. Age, comorbidities, and stage influenced guideline compliance. The most common reasons for noncompliance were patient refusal, patient choice after shared decision-making, and overuse of testing. Synoptic templated reporting was accurate in 97% patients. Conclusions High compliance with NCCN Guidelines was demonstrated. Reasons for noncompliance were identifiable. Compliance and nonadherence can be evaluated quickly with electronic synoptic reporting. This allows real-time action plans to address quality concerns and aids national risk adjustment for comparison and benchmarking.

Fibroepithelial lesions (FELs) are a common histologic finding on core needle biopsy (CNB) of the breast. Fibroepithelial lesions include fibroadenoma and phyllodes tumor, which can be difficult to distinguish with an initial CNB. An institutional experience was reviewed from February 12, 2001, to January 4, 2007, to determine the safety of selective rather than routine excision of FELs and to determine the factors associated with upgrading diagnosis of FELs to phyllodes tumors without definitive phyllodes tumor diagnosis by CNB. Of 313 patients, 261 (83%) with FELs diagnosed by CNB received observation with long-term follow-up (mean, 8 years). Of the observed patients, 3 (1%) were diagnosed with phyllodes tumor on follow-up. Eighteen of 52 patients (35%) who received excision had an upgrade of diagnosis to phyllodes tumor. Sensitivity and specificity of the pathologist’s comment of concern for phyllodes tumor on a CNB demonstrating FELs without definitive phyllodes tumor diagnosis were 82% and 93%, respectively. Our policy of selective excision of FELs without definitive phyllodes tumor diagnosis resulted in safe avoidance of many surgical procedures.

Measurement of quality indicators and peer comparison has been demonstrated to improve quality of care. The goal of this study was to determine whether a community breast center, in collaboration with the National Consortium of Breast Centers (NCBC), could voluntarily audit the quality of breast cancer care, confidentially transmit quality information to the NCBC, and receive peer performance comparisons. Quality indicator metrics from consecutive breast cancer patients undergoing care at a community interdisciplinary breast center were entered into a prospective database of quality measures that were defined by the NCBC. Retrospective review of patients from 2004 to 2006 was performed and subsequent quality indicator data was submitted electronically to the NCBC National Quality Measures for Breast Centers (NQMBC(TM) ) program. The percentage of new cancer diagnoses made by needle biopsy techniques was 94%, 95% and 96% from 2004 to 2006. Sentinel lymph node utilization in eligible patients was 93%, 96% and 91% from 2004 to 2006 and the immediate intraoperative pathologic frozen section false negative rate of the sentinel lymph node was 6.5%, 4.7% and 4%. Chart documentation of "patient participation in shared decision making for breast conserving therapy versus mastectomy" improved from 74% to 99% (p0.05) from 2004 to 2006. Adjuvant systemic treatment for stage 2 breast cancer occurred in 76%, 89% and 77% of patients from 2004 to 2006. Neutropenia requiring hospital admission occurred in no patients in 2004 but in 4.8% and 2.9% in 2005 and 2006. The re-excision lumpectomy rates for stage 0, 1, 2, and 3 breast cancer patients from 2004 to 2006 was 14.2%, 22% and 24.8%. Quality indicator data was submitted to the NQMBC(TM) with successful confidential receipt of peer performance comparisons. Voluntary interdisciplinary institutional audits of breast cancer quality can be successfully submitted to the NQMBC(TM) with confidential peer performance comparison.

Background The National Consortium of Breast Centers defines "quality" of breast cancer care as "accurate evaluation and appropriate services … in a timely manner." We sought to determine timeliness of care and relationship to patient satisfaction. Study Design The electronic medical records of breast cancer patients seen at a breast center from 2004 through 2007 were retrospectively reviewed. Dates of patient service were audited. A postal survey was then conducted to determine patient satisfaction with timeliness. Results Median time interval in business days from abnormal screening mammogram to diagnostic evaluation and core needle biopsy was 6 days. Median time intervals from core needle biopsy to core needle biopsy pathology report and then subsequent surgical consultation and breast cancer operation were 1, 3, and 7 days, respectively. Breast MRI, systemic imaging, plastic surgery consultation, type of surgery, and patient choice prolonged time to treatment. More than 90% of breast cancer patients who responded to our postal survey had their expectations met or exceeded for the dates of service provided for diagnostic evaluation and treatment. Conclusions Evaluation of timeliness as a quality indicator for breast cancer care is complex and requires an assessment of whether patient expectations were met for dates of service. Factors that prolong time to treatment, such as additional imaging, should be considered for risk adjustment for peer performance comparison and compliance with published timeliness target goals.

66 Background: Surgery maintains a central role in the local treatment of Stage 0-III breast cancer. Recent studies suggest patient immunity is altered by general anesthesia (GA), potentially worsening cancer outcomes. A single retrospective case review has concluded that breast cancer patients receiving regional anesthesia with paravertebral block (PVB) anesthesia had better cancer outcomes compared to patients receiving GA, but these conclusions have not been validated. We hypothesized that local regional anesthesia (LRA) would be associated with better cancer outcomes compared to GA. Methods: We performed a retrospective review of Stage 0-III breast cancer patients undergoing surgery in a single center during a nine year period ending 1/1/2010. Patients undergoing neoadjuvant therapy or major flap reconstruction were excluded. Data regarding patient, tumor and treatment factors known to influence cancer outcomes were collected. Overall survival (OS), disease free survival (DFS), local regional recurrence (LRR), and ipsilateral breast tumor recurrence (IBTR) were calculated by Kaplan-Meier method with Log-Rank comparison. Results: We analyzed 1,107 patients. Median age was 64 years (range 24-97). Median and longest follow-up were 5.5 and 12.5 years. GA was utilized for 461 (42%) patients, and 646 (58%) received LRA. Initial operation was breast conserving in 796 (72%) and mastectomy in 311 (28%). Forty two patients died from breast cancer (crude mortality 3.8%). LRR occurred in 34 patients (3%). LRA was used more than GA in patients with lower grade and stage, smaller tumors, positive hormone receptor status, and negative nodal status (p

e17583 Background: NCCN provides guidelines for breast cancer genetic risk assessment and testing. Measuring compliance with NCCN Guidelines (NG) can identify quality gaps. Methods: After IRB approval, a retrospective review of a prospective database of breast cancer patients was conducted to measure compliance with NG for genetic counseling and BRCA testing. Entry criteria were breast cancer patients with diagnosis and treatment at our center, during the 3 year period ending 12/31/11. Genetic counselors (GC) used NG and BRCAPRO modeling in all patients. Surgeon and GC pedigree analyses were compared. A change to the history was significant if the GC identified information that led to increased or decreased cases of breast or ovarian ca. Results: Surgeons constructed pedigrees in 675 breast cancer patients and referred 42% (286/675) to the GC. The decision to refer was NCCN compliant in 671/675 (99%). The GC corrected the pedigree in 14% (39/286); nearly all due to the GC identifying extra breast or ovarian cancers. The mean BRCAPRO probability in referred patients was 7.2%. Fifty-nine percent (170/286) of patients seen by the GC received a recommendation for BRCA testing. The NG compliance rate for testing was 98% (170/174). Of 174 BRCA tests offered to patients, 74% (128/174) underwent testing. In tested patients, there were 4% BRCA1+, 5% BRCA 2+, and 1% uncertain variants. Total patient charges for 128 tests were $696,000 ($4000/test). If the threshold for testing was BRCAPRO > 5% or >10%, then 69 ($276,000) and 45($180,000) (p

197 Background: There is a wide variation of compliance with National Comprehensive Cancer Network (NCCN) guidelines for diagnosis and treatment. Overutilization of preoperative testing and underutilization of adjuvant treatments have been documented. The former is associated with higher costs of care; the latter with poor patient outcomes. Prior reports of adherence to NCCN Guidelines contain methodological limitations due to lack of contemporary review and incomplete listing of reasons for non-compliance. This limits the “real time” analysis of breast cancer quality and delays action plans to address quality and cost issues of care. Methods: NCCN Guideline compliance was recorded prospectively by use of electronic synoptic templates for all newly diagnosed breast cancer patients treated at a single institution between January 2010 and December 2011. A retrospective review of the synoptic templates was then conducted. Accuracy of the synoptic auditing method was assessed as well as NCCN compliance and reasons for non-compliance. Results: A total of 312 new breast cancer patients who underwent surgery as initial treatment were identified. Compliance with NCCN Guidelines for preoperative testing, breast surgery and lymph node surgery was 98% (306/312), 99.7% (311/312) and 93% (290/312) respectively. Reasons for non-compliance include patient refusal, comorbidities, advanced age and overutilization of systemic imaging. There was 100% compliance to College of American Pathologist (CAP) molecular profile documentation for all breast cancer cases. There were two discrepancies noted between the prospective template reporting and medical record review. The average time needed to populate data into synoptic templates was less than 2 minutes per patient. Conclusions: Prospective auditing of adherence to NCCN Guidelines with electronic synoptic templates is accurate and time efficient. High compliance rates with NCCN Guidelines were demonstrated. Electronic synoptic NCCN templates potentially facilitate early recognition of quality gaps in compliance and provide a framework for peer performance comparison.