2. Ontario SLNB Quality Data: A Provincial Snapshot May Lynn Quan MD, MSc, FRCSC 1 Why it matters to YOU!

3. 2

4. 3

6. Improving the Quality of SLNB in Ontario How can we measure quality? What is the quality of SLNB? Where can we improve? What are the barriers/enablers? 5

7. 6

8. Improving the Quality of SLNB in Ontario Stakeholder interviews Population based evaluation Quality indicator development Modified Delphi Consensus ICES Data Linkages Clinicians Primary Chart Review Administrators 7

9. Development of Quality Indicators Modified Delphi expert panel LHIN and practice type representation – Surgeons – Pathologists – Nuclear Medicine – Medical Oncology – Radiation Oncology 11 quality indicators developed

10. Final Quality Indicators #Quality Indicator 1Axillary node positivity rate 2Proper identification of SLN 3SLNB on eligible patients 4Number of nodes removed >1 5Pathology evaluation protocol 6Pathology reporting as per AJCC 7SLNB concurrent with breast surgery 8Axillary recurrence rate 9Completion ALND for + SLNB 10SLNB on ineligible patients 11Radiocolloid injection protocol 9

11. Feasibility study Bryan Wells, MD, MSc Retrospective chart review Academic Cancer Centre n = 490 10

12. QI Feasibility #Quality Indicator Measurable? 1Axillary node positivity rateYES: Chart 2Proper identification of SLNYES: Chart 3SLNB on eligible patientsNO 4Number of nodes removed >1YES: Chart 5Pathology evaluation protocolYES: Institution 6Pathology reporting as per AJCCYES: Chart 7SLNB concurrent with breast surgeryYES: Chart 8Axillary recurrence rateNO 9Completion ALND for + SLNBYES: Chart 10SLNB on ineligible patientsYES: Chart 11Radiocolloid injection protocolYES: Institution 11

13. QI Feasibility #Quality Indicator Measurable? 1Axillary node positivity rateYES: Chart 2Proper identification of SLNYES: Chart 3SLNB on eligible patientsNO 4Number of nodes removed >1YES: Chart 5Pathology evaluation protocolYES: Institution 6Pathology reporting as per AJCCYES: Chart 7SLNB concurrent with breast surgeryYES: Chart 8Axillary recurrence rateNO 9Completion ALND for + SLNBYES: Chart 10SLNB on ineligible patientsYES: Chart 11Radiocolloid injection protocolYES: Institution 12

14. QI Feasibility #Quality Indicator Measurable? 1Axillary node positivity rateYES: Chart 2Proper identification of SLNYES: Chart 3SLNB on eligible patientsNO 4Number of nodes removed >1YES: Chart 5Pathology evaluation protocolYES: Institution 6Pathology reporting as per AJCCYES: Chart 7SLNB concurrent with breast surgeryYES: Chart 8Axillary recurrence rateNO 9Completion ALND for + SLNBYES: Chart 10SLNB on ineligible patientsYES: Chart 11Radiocolloid injection protocolYES: Institution 13

15. Population based evaluation 14

16. Cohort 15

17. Methods Volume Urban/rural LHIN, Age Tumour size OHIP CIHI Census 16

18. Results 5134 cases 2323 SLNB 8 quality indicators 17

19. Final Quality Indicators Quality IndicatorProportion Axillary node positivity rate28% Proper identification of SLN95% Number of nodes removed >164% Pathology evaluation protocol59% Pathology reporting as per AJCC38% SLNB concurrent with breast surgery94% Completion ALND for + SLNBMacromet 85% Micromet 59% ITCs 32% SLNB on ineligible patients2% 18

20. 19

21. 20

22. Quality indicators in everyday practice Helping YOU do a high quality SLNB Giving you tools to determine if you are! Providing excellent patient care 21

23. Putting quality indicators to work for you 22 EXCELLENT PATIENT CARE

24. Case Audit - personal review Eligible patients – Offered to all? Ineligible patients – Who are they? Concurrent breast surgery – Core needle biopsy when possible? Proper ID of SLNs 23

25. Case Audit - personal review Node positive rate – As expected? > 1 SLN – What’s my average? Completion ALND for + SLNs Axillary recurrences?? 24

26. Summary Quality of SLNB in Ontario is pretty good! – Population data can provide a snapshot – Provides baseline measure for comparison Moving forward, improvements With individual practice Quality indicators can help in day to day practice – Self audit – mental checklist – Communication with the team key 25

27. Acknowledgements Anna Gagliardi Frances Wright David McCready David Urbach Novlette Fraser Bryan Wells Refik Saskin Nadia Gunraj 26

28. Expert Panel 27