1. Quality Assurance Report TTUHSC Breast Center of Excellence January 1, 2010 – December 31, 2010 Compiled by Lynn Day, RN BSN CCM CCRP

2. Stage Distribution Total Number of Patients = 121 Time Frame Stage 0Stage IStage IIStage IIIStage IVStage Unassigned Total Jan – Jun7 (10.94%) 25 (39.06%) 13 (20.31%) 8 (12.5%) 0 (0%) 11 (17.19%) 64 (100%) Jul - Dec10 (17.54%) 22 (38.6%) 13 (22.8%) 3 (5.26%) 0 (0%) 9 (15.79%) 57 (100%) Jan-Dec17 (14.05%) 47 (38.84%) 26 (21.48%) 11 (9.09%) 0 (0%) 20 (16.53%) 121 (100%) Compiled by Lynn Day, RN BSN CCM CCRP

3. Time FrameStage 0Stage IStage IIStage IIIStage IVStage Unassigned Total Jan – Jun Preoperative Core 12 (18.75%) 27 (42.19%) 14 (21.87%) 8 (12.5%) 0 (0%) 3 (4.69%) 64 (100%) Jul – Dec Preoperative Core 12 (21.05%) 23 (40.35%) 15 (26.31%) 3 (5.26%) 0 (0%) 2 (3.51%) 55 (96.49%) Jan-Dec Preoperative Core 24 (19.83%) 50 (41.32%) 29 (23.96%) 11 (9.09%) 0 (0%) 5 (4.13%) 119 (98.35%) Mode of Diagnosis Total Number of Patients = 121 98.35% of patients had diagnosis established on preoperative core needle biopsy Exceptions – excisional biopsy by other MD and shave biopsy Compiled by Lynn Day, RN BSN CCM CCRP

4. Tumor Board Discussion Total Number of Patients = 121 Time Frame Stage 0Stage IStage IIStage IIIStage IVStage Unassigned Total Jan – Jun Discussed 7/12 (58.33%) 4/27 (14.81%) 8/14 (57.14) 4/8 (50%) 0 (0%) 0/3 (0%) 23/64 (35.94%) Jul – Dec Discussed 5/12 (41.66%) 8/24 (33.33%) 6/15 (40%) 2/4 (50%) 0 (0%) 0/2 (0%) 40/57 (75.47%) Jan-Dec Discussed 12/24 (50.0%) 12/51 (23.53%) 14/29 (48.28) 6/12 (50%) 0 (0%) 0/5 (0%) 44/121 (36.36%) 36.36% of patients were discussed prospectively in the multidisciplinary tumor conference 14.05% of patients were discussed retrospectively in the multidisciplinary tumor conference Compiled by Lynn Day, RN BSN CCM CCRP

5. Time Frame Stage 0Stage IStage IIStage IIIStage IVStage Unassigned Total Jan – Jun MDC seen 9/12 (75%) 24/27 (88.89%) 10/14 (71.43%) 8/8 (100%) 0 (0%) 1/3 (33.33%) 52/64 (81.25%) Jul – Dec MDC seen 10/12 (83.33%) 21/24 (87.5%) 12/15 (80%) 3/4 (75%) 0 (0%) 1/2 (50.0%) 47/57 (82.46%) Jan-Dec MDC seen 19/24 (79.17%) 45/51 (88.24%) 22/29 (75.86%) 11/12 (91.67%) 0 (0%) 2/5 (40%) 82/121 (67.77%) Multidisciplinary Assessment (Surgical, Medical and Radiation Oncologist) Total Number of Patients = 121 Exceptions22/121 (18.18%) No radiation oncology evaluation (mast./ high-risk) 9/22 (40.9%) No documentation in the chart 8/22 (36.36%) Patient non-compliance 2/22 (9.09%) Continuing chemotherapy 1/22 (4.55%) Deceased during treatment 2/22 (9.09%) Compiled by Lynn Day, RN BSN CCM CCRP

6. Time FrameStage 0Stage IStage IIStage IIIStage IVStage Unassigned Total Jan – Jun Assigned 11/12 (91.67%) 27/27 (100%) 14/14 (100%) 8/8 (100%) 0 (0%) 3/3 (100%) 63/64 (98.44%) Jul – Dec Assigned 12/12 (100%) 23/24 (95.83%) 15/15 (100%) 4/4 (100%) 0 (0%) 1/2 (50%) 55/57 (96.49%) Jan-Dec Assigned 23/24 (95.83%) 50/51 (98.04%) 29/29 (100%) 12/12 (100%) 0 (0%) 4/5 (80%) 118/121 (97.52%) Nurse Navigation Total Number of Patients = 121 Exceptions3/121 (2.48%) Lateral entry into the system1/3 (33.33%)* Patient moved care 2/3 (66.67%) *modifications made to ensure assignment of a nurse navigator for every patient Compiled by Lynn Day, RN BSN CCM CCRP

7. Time FrameStage 0Stage IStage IIStage IIIStage IVStage Unassigned Total Jan – Jun Yes 4/12 (33.33%) 27/27 (100%) 14/14 (100%) 8/8 (100%) 0 (0%) 0/3 (0%) 53/64 (82.81%) Jul – Dec Yes 1/12 (8.33%) 24/24 (100%) 15/15 (100%) 4/4 (100%) 0 (0%) 0/2 (0%) 44/57 (71.19%) Jan-Dec Yes 5/24 (20.83%) 51/51 (100%) 29/29 (100%) 12/12 (100%) 0/0 (0%) 0/5 (0%) 97/121 (80.17%) CAP Compliance Total Number of Patients = 121 Exceptions24/121(19.83%) Progesterone receptor not reported (DCIS)13/24 (54.17%) Complete response, no margins 6/24 (25%) Final surgery not done 4/24 (16.67%) Patient non-compliance, no follow up, moved 1/24 (4.17 %) Compiled by Lynn Day, RN BSN CCM CCRP

8. Axillary Staging Total Number of Patients = 121 Total Number of Patients with Invasive Cancer = 97 Number node positive patients on needle biopsy15/97 (15.47%) Number of patients eligible for SLNB85/97 (87.62%) – Number of patients with SLNB69/97 (71.13%) Exceptions16/97 (16.49%) Determined low risk (unlikely to change treatment plan)11/16 (68.75%) Final surgery not done 1/16 (6.25%) Patient non-compliance, no follow up, moved4/16 (25%) Compiled by Lynn Day, RN BSN CCM CCRP

9. Axillary Dissection Total Number of Patients = 121 Total Number of Patients with Invasive Cancer = 97 Number of Patients with node positive disease 34/97 (35.05%) Number of patients eligible for ALND 34 – Number of patients with ALND 25/34 (73.52) Exceptions9/34 (26.47%) Low risk for non-SLN mets. on MSKCC nomogram5/34 (14.7%) Final surgery not done 1/34 (2.94%) Patient refused completion ALND0/34 (0%) Patient high risk for completion ALND3/34 (8.82%) Compiled by Lynn Day, RN BSN CCM CCRP

10. Time Frame Stage 0Stage IStage IIStage IIIStage IVStage Unassigned Total Jan – Jun Yes 9/12 (75%) 27/27 (100%) 7/14 (50%) 4/8 (50%) 0 (0%) 0/3 (0%) 47/64 (73.44%) Jul – Dec Yes 7/12 (58.33%) 18/24 (75%) 6/15 (40%) 0/4 (0%) 0 (0%) 0/2 (0%) 31/57 (54.4%) Jan-Dec Yes 16/24 (66.67%) 45/51 (88.24%) 13/29 (44.83%) 4/12 (33.33%) 0 (0%) 0/5 (0%) 78/121 (64.46%) Breast Conservation Total Number of Patients = 121 Number of early stage patients (0, I and II) with breast conservation 74/104 (71.15%) Compiled by Lynn Day, RN BSN CCM CCRP

11. Post-lumpectomy Radiation Total Number of Patients = 121 Number of patients with lumpectomy78/121 (64.46%) Number of patients eligible for Radiation78 – Number of patients radiated72/78 (92.3%) Exceptions6/78 (7.69%) Low risk malignancy age group 75 – 93 years1/6 (16.67%) severe co morbidities Progressed to mastectomy2/6 (33.33%) Patient non-compliance/moved2/6 (33.33%) History of past radiation1/6 (16.67%) Number of patients radiated within 12 months72/78 (92.3%) Compiled by Lynn Day, RN BSN CCM CCRP

12. Post-Mastectomy Radiation Total Number of Patients = 121 Number of patients with mastectomy38/121 (31.4%) Number eligible for radiation (>T3 or >N2)9/38 (23.68%) – Number of patients radiated7/9 (77.78%) Exceptions2/9 (22.22%) - History of prior radiation1/2 (50%) - Patient non-compliance 1/2 (50%) Number of patients radiated within 12 months5/9 (55.56%) Compiled by Lynn Day, RN BSN CCM CCRP

13. Systemic Chemotherapy - I Total Number of Patients = 121  ER negative patients with cancer18/121 (14.88%) Number eligible for chemotherapy(exclude DCIS)14/18 (77.78%) – Number treated with chemotherapy9/14 (64.29%) Exceptions5/14 (35.71%) Patient refused chemo2/5 (40%) Patient moved care1/5 (20%) Chemo not recommended2/5 (40%)  Number with chemotherapy within 4 months9/9 (100%) Exceptions0 (none) Patient non-compliance 0 (none) Compiled by Lynn Day, RN BSN CCM CCRP

14. Systemic Chemotherapy - II Total Number of Patients = 121  ER positive patients with cancer103/121 (85.12%) Number eligible for chemotherapy (exclude DCIS)83/103 (81.9%) Number treated with chemotherapy41/83 (49.41%)  Number with chemotherapy within 4 months39/41 (95.12%) Exceptions2/41 (4.88%) Patient initiated treatment delay2/2 (100%) (1 stage II, 1 stage III) Compiled by Lynn Day, RN BSN CCM CCRP

15. Systemic Endocrine Therapy Total Number of Patients = 121  Number of ER positive patients103/121 (85.12%) Number treated with endocrine therapy93/103 (90.29%) Exceptions10/103 (9.71%) Determined risk > benefit 5/10 (50%) Patient deceased during treatment 1/10 (10%) Patient non-compliance 4/10 (40%)  Number with endocrine therapy within 1 year90/93 (96.77%) Compiled by Lynn Day, RN BSN CCM CCRP

16. Rehabilitation Total Number of Patients = 121 Number enrolled in CPRP (PT/OT)36/121 (29.75%) Exceptions85/121 (70.25%) Services were available but structured program was recently established, whereby every patient gets a baseline exam documented; prospective data is maintained with a pre-designed schedule. Improvement over 2009 17.5% Compiled by Lynn Day, RN BSN CCM CCRP

17. Genetic Counseling Total Number of Patients = 121 Number of patients with family history or < 45 years75/121 (61.98%) Number received genetic counseling37/75 (49.33%) – Number tested20/37 (54.05%) Positive 5/20 (25%) Negative15/20 (75%) – Number refused testing22/37 (59.46%) Exceptions37/75 (49.33%) Did not meet NCCN criteria24/37 (64.86%) No documentation in the chart13/37 (35.14%) Patient deceased during treatment1/37 (2.70%) Compiled by Lynn Day, RN BSN CCM CCRP

18. Time Frame Trial / StudyEligible N (%) Participation N (%) Jan – Jun B-SMART13 (20.64%)12 (19.05%) SPOC22 (34.92%) Total 35 (55.56%)34 (53.97%) Jul - Dec B-SMART16 (27.59%) SPOC45 (77.59%) Total 47 (81.03%) Trial Participation Total Number of Patients = 121 Total Number of patients enrolled in trials in 2010 78/121 (64.46%) Increase of patients enrolled over the year 200978/15 (520%) Compiled by Lynn Day, RN BSN CCM CCRP