EDITORIAL

Breast Cancer Quality Care: What is at Stake?

There is no question that quality of care is emerging

as a key issue that will touch everyone. With the

revolution in biotechnology, economic and cultural

globalization and the increasing accountability for

value—measured in tangible outcomes, the health care

enterprise and all its constituents will need to address

this issue of quality care. What is quality care and

how is it defined? Very simply put, it is the delivery of

care in a way that minimizes the burden of disease in

an efficient manner that can be justified and adopted

by society. Quality care is not simply about following

evidence-based guidelines, but extends into the frame-

work of biology, medical technology, economics,

demographics, and social structures. From a practical

standpoint, the field of breast cancer serves as an

excellent example as a model for quality care for sev-

eral reasons: (a) it is a common disease and increasing

in prevalence worldwide; (b) there is a large body of

evidence on the benefit and harms from many inter-

ventions ranging from prevention to screening, early

detection, and treatment; (c) many aspects of care and

decision making are multi-disciplinary.

Why do we need initiatives for improvements in

quality of care? The best evidence for this need is the

documented variations in cancer care delivered in pop-

ulation-based studies, and the demonstrated impact on

morbidity and mortality outcomes (1,2). A landmark

report by the Institute of Medicine raised concerns

about the significant holes in the quality of care deliv-

ered to cancer patients and the lack of systems to

measure quality of care (3). Most physicians simply

do not have access to reviewing their own care pat-

terns (4). The need for this access is illustrated by the

counterintuitive finding that physician knowledge and

performance actually decline over time, suggesting

that they are not capitalizing on their experience (5).

The good news is that quality improvement can

improve clinical skills and behaviors, even though we

are a long way from systematically measuring and

instituting quality care and proving that this improves

outcomes (6).

Several initiatives have been instituted to track

quality care metrics in the area of breast cancer and

as has been the case with quality care in general, these

have been rather diffuse in their aims and methods,

and have not been coordinated. These have originated

from several sectors including insurance carriers, gov-

ernment agencies, and professional societies. The

American Society of Clinical Oncology (ASCO) has

instituted the Quality Oncology Practice Initiative

(QOPI) for breast and colorectal cancer that involves

an iterative process of data abstraction, analysis, and

feedback on a variety of performance measures, as

well as benchmarking in three main domains-specific

modules related to clinical trial assessment, chemo-

therapy symptom ⁄ toxicity management, and end-of-

life care (7,8). The American College of Surgeons

Commission on Cancer (CoC) maintains a large data-

base and administers a long-standing program for

monitoring cancer care activity and services. The CoC

has developed quality care measures in a parallel

process with ASCO and the National Cancer Center

Network (NCCN)—involving the use of adjuvant

therapy in certain circumstances and within a pro-

scribed time frame (http://www.facs.org/cancer/ncdb/

breastmeasures.pdf). It has recently adopted a new set

of quality of care measures that involve end-of-life

care, clinical trial assessment, and symptom and toxic-

ity (9). The National Accreditation Association for

Breast Centers (NAPBC) is a consortium organization

that sets standard for breast centers including opera-

tional and care guidelines, but also requires the center

leadership to participate in interdisciplinary quality

improvement or outcomes projects (10). However,

comprehensive measures of implementation, and more

importantly, outcomes on disease burden have not yet

been reported in the early life cycle of these initiatives.

In this issue of the Journal, Neugut et al. describe

the early feasibility and enrollment results of the

Breast Cancer Quality of Care Study (B-QUAL), a

multicenter prospective cohort study of women diag-

nosed with early stage breast cancer at four centers

throughout the United States that represents a diverse

DOI: 10.1111/j.1524-4741.2012.01244.x

� 2012 Wiley Periodicals, Inc., 1075-122X/11The Breast Journal, Volume 18 Number 3, 2012 201–202

population and a spectrum of health care systems.

This project focuses on important measures of care

that have been shown to influence outcome—in partic-

ular, non-initiation and nonadherence or early discon-

tinuation of adjuvant chemotherapy and hormonal

therapy (11). The goal of this study is to more dis-

creetly define variation in these indices of care at a

very granular level and from the perspective of the

patient, physician, tumor characteristics, and host

genomics, specifically for pharmacogenomics explana-

tions of variation. Methods include systematic recruit-

ment of all newly diagnosed early stage breast and

enrollment within soon after diagnosis, collection of

blood or saliva, several phone interviews (during treat-

ment and long term), and physician interviews. Given

the documented systematic variations in care and

compliance in African-American breast cancer patients

(12–14), a special effort was made to recruit this

group of patients. The authors report rather good suc-

cess in the conduct of the trial, having enrolled 1158

patients, of which 15% are African-American, and

with 85.5% of recruited patients being eligible, and

89.6% of eligible patients agreeing to participate.

Compliance is good so far, with 97.5% and 92.5%

completing the first and second follow-up surveys.

Particularly commendable is the planned use of an

established simulation model to estimate the mortality

effects of the observed patterns of care (15). This

study will generate important prospective data that

can further inform best practice as well as mechanisms

to monitor quality of care and outcome.

Quality measures in breast cancer are here to stay

and will be increasingly used for reimbursement and

eventually, to allocate resources and to implement

new processes and policies (16). It will be up to the

oncology community to build a body of evidence and

prove the value for every aspect of care that we deliver.

From this, we expect that models and processes of

care from screening and diagnosis to the management

of breast cancer will continually evolve as new data

emerge and newer technologies become available.

Debu Tripathy, MD

Professor of Medicine

USC ⁄ Norris Comprehensive Cancer Center

University of Southern California

1441 Eastlake Ave. #3429

Los Angeles, CA 90033, USA

e-mail: tripathy@usc.edu

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