Patient Navigation and the Quality of Breast Cancer Care: An Analysis of the Breast Cancer Care Quality Indicators

Abstract

Purpose

Patient navigation programs are initiated to help guide patients through barriers in a complex cancer care system. We sought to analyze the impact of our patient navigator program on the adherence to specific Breast Cancer Care Quality Indicators (BCCQI).

Methods

A retrospective cohort of patients with stage I–III breast cancer seen the calendar year prior to the initiation of the patient navigation program were compared with patients treated in the ensuing two calendar years. Quality indicators deemed appropriate for analysis were those associated with overcoming barriers to treatment and those associated with providing health education and improving patient decision-making.

Results

A total of 134 consecutive patients between January 1, 2006 and December 31, 2006 and 234 consecutive patients between January 1, 2008 and December 31, 2009 were evaluated for compliance with the BCCQI. There was no significant difference in the mean age or race/ethnic distribution of the study population. In all ten BCCQI evaluated, there was improvement in the percentage of patients in compliance from pre and post implementation of a patient navigator program (range 2.5–27.0 %). Overall, compliance with BCCQI improved from 74.1 to 95.5 % (p < 0.0001). Indicators associated with informed decision-making and patient preference achieved statistical significance, while only completion axillary node dissection in sentinel node-positive biopsies in the process of treatment achieved statistical significance.

Conclusions

The implementation of a patient navigator program improved breast cancer care as measured by BCCQI. The impact on disease-free and overall survival remains to be determined.

Appendix: Quality Indicators Interpreted as Potentially Impacted by the Patient Navigation Program

• 1. BR-1B1: IF a patient with new diagnosis of stage I–III breast cancer meets all of the following criteria:

  • 1. Age <70 years AND

  • 2. Tumor size >1 cm AND

  • 3. No evidence of metastatic disease within 3 months of diagnosis AND

  • 4. There is no documentation in the medical record that axillary lymph node sampling would not change treatment, THEN the patient should have axillary lymph node sampling.

• 2. BR-1B2: IF a patient has a SN biopsy that is positive, THEN the patient should undergo axillary lymph node dissection.

• 3. BR-2A4: IF a patient has new diagnosis of stage I–III breast cancer, THEN the patient should receive one of the following surgical treatments:

  • 1. BCS OR

  • 2. Mastectomy

• 4. BR-2B1: IF a patient newly diagnosed with stage I–III breast cancer meets all of the following criteria:

  • 1. ER+ or PR+ breast cancer AND

  • 2. Tumor size ≥1 cm or involved axillary lymph nodes AND

  • 3. Was not taking tamoxifen WITHIN 6 MONTHS before diagnosis, THEN the patient should be started on tamoxifen or an aromatase inhibitor.

• 5. BR-2B3: IF a patient newly diagnosed with stage II–III breast cancer is <50 years old AND the tumor is >2 cm or the tumor involves the lymph nodes, THEN the patient should receive chemotherapy.

• 6. BR-2B4: IF a patient is newly diagnosed with stage I–III breast cancer and the tumor is ≥1 cm or involves the lymph nodes, THEN a physician should have a discussion with the patient regarding possible treatment with chemotherapy.

• 7. BR-2B5: IF a patient newly diagnosed with stage II–III breast cancer is <50 years old and the tumor is >2 cm or the tumor involves the lymph nodes, THEN the patient should start adjuvant chemotherapy within 8 weeks of the last therapeutic surgery.

• 8. BR-2C2a: IF a patient with diagnosis of stage I–III breast cancer has BCS, THEN the patient should receive local radiation therapy.

• 9. BR-2C3a: IF a patient with invasive breast cancer who undergoes mastectomy has any of the following:

  • 1. Positive margins on the surgical specimen OR

  • 2. Tumor size >5 cm OR

  • 3. Four or more involved lymph nodes OR

  • 4. A T4 lesion, THEN the patient should receive radiotherapy.

• 10. BR-2C5: IF a patient begins radiation therapy treatments and does not meet one of the following exclusion criteria:

  • 1. Hospitalized during treatment OR

  • 2. Grade 4 toxicity, THEN the planned radiation therapy should be completed.

• 11. BR-3B2: IF a patient who is postmenopausal taking tamoxifen has vaginal bleeding, THEN the patient should have had at least one of the following evaluations:

  • 1. Endometrial biopsy

  • 2. Pelvic transvaginal ultrasound

  • 3. Referrals

• 12. BR-4-1: IF a patient with stage I–III breast cancer undergoes BCS and did not receive radiation therapy, THEN the patient should have a consultation with a radiation oncologist.

• 13. BR-4-2: IF a patient with invasive breast cancer:

  • A. Undergoes a mastectomy AND

  • B. Has any of the following:

  • 1. Positive margins on the surgical specimen OR

  • 2. Tumor size >5 cm OR

  • 3. Four or more involved lymph nodes OR

  • 4. A T4 lesion, THEN the patient should have a consultation with a radiation oncologist.

• 14. BR-5-2: IF a patient has a new diagnosis of stage I–III breast cancer and does not undergo axillary lymph node sampling, THEN the patient should be informed about the options of a surgical check or removal of lymph nodes under the arm.

• 15. BR-5-4: IF a patient with stage I–III breast cancer undergoes mastectomy as first therapeutic procedure, THEN before undergoing mastectomy, the patient should be informed about the options to have either BCS followed by radiation therapy or mastectomy.

• 16. BR-5-5-1: IF a patient with stage I–II breast cancer undergoes mastectomy, THEN before undergoing mastectomy, the patient should be informed about the option of breast reconstruction after mastectomy.

• 17. BR-7-2: If a patient has stage I–III breast and has not had bilateral mastectomies, then they should have a mammogram in the last 12 months.