1. Quality Assurance Report TTUHSC Breast Center of Excellence January 1, 2014 – December 31, 2014 Compiled by L.Day, RN BSN CCM CCRP OCN 1

2. Stage Distribution Total Number of Patients =55 Time Frame Stage 0Stage IStage IIStage IIIStage IVStage Unassigned Total Jan – Jun 5/27 (18.52%) 13/27 (48.15%) *8/27 (29.63%) 0/27 (0%) 1/27 (33.3%) 0/27 (3.7%) 27/27 (100%) Jul - Dec 7/28 (25%) 8/28 (28.57%) 11/28 (39.29%) 1/28 (3.57%) *1/28 (3.57%) 0/28 (0%) 28/28 (100%) Jan-Dec 12/55 (21.8%) 21/55 (38.2%) *19/55 (34.55%) 1/55 (1.82%) *2/55 (3.64%) 0/55 (0%) 55/55 (100%) Compiled by L. Day, RN BSN CCM CCRP OCN 2 * One patient added based on clinical staging

3. Time FrameStage 0Stage IStage IIStage IIIStage IVStage Unassigned Total Jan – Jun Preoperative Core 5/5 (100%) 13/13 (100%) *8/8 (100%) 0/0 (0%) 1/1 (100%) 0/0 (0%) 27/27 (100%) Jul – Dec Preoperative Core 7/7 (100%) 8/8 (100%) 11/11 (100%) 1/1 (100%) *1/1 (100%) 0/0 (0%) 28/28 (100%) Jan-Dec Preoperative Core 12/55 (21.82%) 21/55 (38.2%) *19/55 (34.55%) 1/55 (1.82%) *2/55 (3.64%) 0/0 (0%) 55/55 (100%) Compiled by L. Day, RN BSN CCM CCRP OCN 3 Mode of Diagnosis Total Number of Patients =55 100% of patients had diagnosis established on preoperative core needle biopsy *1 patient added from clinical stage who did not have surgery.

4. Tumor Board Discussion Total Number of Patients =55 Time Frame Stage 0Stage IStage IIStage IIIStage IVStage Unassigned Total Jan – Jun Discussed 4/5 (80%) 13/13 (100%) 7/7 (100%) 0/0 (0%) 1/1 (100%) *1/1 (100%) 26/27 (96.3%) Jul – Dec Discussed 7/7 (100%) 8/8 (100%) 11/11 (100%) 1/1 (100%) 0/0 (0%) *1/1 (100%) 28/28 (100%) Jan-Dec Discussed 11/12 (91.67% ) 21/21 (100%) 18/18 (100%) 1/1 (100%) 1/1 (100%) *2/2 (100%) 54/55 (98.2%) Compiled by L.Day, RN BSN CCM CCRP OCN 4 98.2% of patients were discussed in the multidisciplinary tumor conference * clinical staging-patient did not have surgery.

5. Time Frame Stage 0Stage IStage IIStage IIIStage IVStage Unassigned Total Jan – Jun MDC seen 4/5 (80%) 11/13 (84.62%) 6/7 (85.7%) 0/0 (0%) 1/1 (100%) *0/1 (0%) 22/27 (81.48%) Jul – Dec MDC seen 7/7 (100%) 8/8 (100 %) 10/11 (90.9%) 1/1 (100%) 0/0 (0%) *1/1 (100%) 27/28 (96.43%) Jan-Dec MDC seen 11/12 (91.67%) 19/21 (90.48%) 16/18 (88.89%) 1/1 (100%) 1/1 (100%) *1/2 (50%) 49/55 (89.1%) Compiled by L.Day, RN BSN CCM CCRP OCN 5 Multidisciplinary Assessment (Surgical, Medical and Radiation Oncologist) Total Number of Patients = 55 Multidisciplinary Assessment (Surgical, Medical and Radiation Oncologist) Total Number of Patients = 55 Exceptions: 6/55 Mastectomy 2/6 Patients with DCIS 1/6 Patient choice 1/6 Patient transferred 1/6 Patient with comorbidities 1/6 *clinical staging-patient did not have surgery

6. Time FrameStage 0Stage IStage IIStage IIIStage IVStage Unassigned Total Jan – Jun Assigned 5/5 (100%) 12/13 (92.31%) 7/7 (100%) 0/0 (0%) 1/1 (100%) *1/1 (100%) 26/27 (96.3%) Jul – Dec Assigned 7/7 (100%) 8/8 (100%) 11/11 (100%) 1/1 (100%) 0/0 (0%) *1/1 (100%) 28/28 (100%) Jan-Dec Assigned 12/12 (100%) 20/21 (95.24%) 18/18 (100%) 1/1 (100%) 1/1 (100%) *2/2 (100%) 54/55 (98.2%) Compiled by L. Day, RN BSN CCM CCRP OCN 6 Nurse Navigation Total Number of Patients = 55 Exceptions 1/55 (1.82%) Patient sought second opinion out of area/second primary cancer *clinical staging-patient did not have surgery

7. Time FrameStage 0Stage IStage IIStage IIIStage IVStage Unassigned Total Jan – Jun Yes 0/5 (0%) 13/13 (100%) 7/7 (100%) 0/0 (0%) 1/1 (100%) *0/1 (0%) 21/27 (77.78%) Jul – Dec Yes 0/7 (0%) 8/8 (100%) 11/11 (100%) 1/1 (100%) 0/0 (0%) *0/1 (0%) 20/28 (71.43%) Jan-Dec Yes 0/12 (0%) 21/21 (100%) 18/18 (100%) 1/1 (100%) 1/1 (100%) *0/2 (0%) 41/55 (74.55%) Compiled by L.Day, RN BSN CCM CCRP OCN 7 CAP Compliance Total Number of Patients = 55 Exceptions14/55(25.5%) Margins can not be assessed 4/14 Patient transferred 1/14 Patient deceased during treatment 1/14 DCIS 8/14 *clinical staging-patient did not have surgery

8. Axillary Staging Total Number of Patients = 55 Total Number of Patients with Invasive Cancer = 47 Number node positive patients on needle biopsy 3/47 (6.38%) Number of pts. with Stage IV disease 1/47 (2.13%) Number of patients eligible for SLNB40/40 (100%) Number of patients with SLNB33/40 (82.5%) Exceptions 7/40 (17.5%) Pathological stage 0 post-neoadjuvant 4/7 (57.14%) SLN during mastectomy for DCIS to avoid missed opportunity 1/7 (14.28%) Patient transferred 1/7 (14.28%) Patient deceased during treatment 1/7 (14.28%) Compiled by L. Day, RN BSN CCM CCRP OCN 8

9. Axillary Dissection Total Number of Patients = 55 Total Number of Patients with Invasive Cancer = 43 Axillary Dissection Total Number of Patients = 55 Total Number of Patients with Invasive Cancer = 43 Number of patients with stage IV1/43 (2.33%) Number of patients with node positive disease 17/43 (39.53%) Number of patients eligible for ALND 17 Number of patients with ALND9/17 (52.94%) Exceptions10/17 (58.82%) Patient opted for radiation/hormonal treatment instead of ALND 7/10 (70%) Patient comorbidities1/10 (10%) Pathological stage 0 after neo-adjuvant, negative SLNB2/10 (20%) Compiled by L. Day, RN BSN CCM CCRP OCN 9

10. Time Frame Stage 0Stage IStage IIStage IIIStage IVStage Unassigned Total Jan – Jun Yes 2/5 (40%) 11/13 (84.62%) 4/7 (57.14%) 0/0 (0%) 0/1 (0%) 0/1 (0%) 17/27 (62.96%) Jul – Dec Yes 6/7 (85.71%) 7/8 (85.7%) 5/11 (45.5%) 1/1 (100%) 0/0 (0%) 0/1 (0%) 19/28 (67.86%) Jan-Dec Yes 8/12 (66.67%) 18/21 (85.7%) 9/18 (50%) 1/1 (100%) 0/1 (0%) 0/2 (0%) 36/55 (65.5%) Compiled by L. Day, RN BSN CCM CCRP OCN 10 Breast Conservation Total Number of Patients = 55 Number of early stage pts. (0, I and II) with breast conservation 35/51 (68.6%) Mastectomies done 17/55 (30.9%) Exceptions 2/55 Transferred Care 1/2 Deceased during treatment 1/2

11. Post-lumpectomy Radiation Total Number of Patients =55 Number of patients with lumpectomy 36/55 (65.5%) Number of patients eligible for Radiation 36 Number of patients radiated 32/36 (88.9%) Number of patients radiated within 12 months 31/32 (96.9%) Exceptions 4/36 (11.1%) Patient with comorbidities 1/4 (25%) Patient refused to get radiation 2/4 (50%) Low risk malignancy 1/4 (25%) Compiled by L. Day, RN BSN CCM CCRP OCN 11

12. Post-Mastectomy Radiation Total Number of Patients = 55 Number of patients with mastectomy 17/55 (24.3%) Number eligible for radiation (>T3 or >N2) 2/17 (27.7%) Number of patients radiated 2/2 (40%) Number of patients radiated within 12 months 2/2 (100%) Exceptions NONE Compiled by L. Day, RN BSN CCM CCRP OCN 12

13. Systemic Chemotherapy – ER Neg. Total Number of Patients = 55 ER negative patients with cancer8/55 (14.5%) Number eligible for chemotherapy8/8 (100%) Number treated with chemotherapy8/8 (100%) Number with chemotherapy within 4 months 8/8 (100%) Exceptions NONE ER negative post neo-adjuvant stage 0 2/8 (25%) Compiled by L. Day, RN BSN CCM CCRP OCN 13

14. Systemic Chemotherapy – ER Pos. Total Number of Patients = 55 ER positive patients with cancer47/55 (85.5%) Number treated with chemotherapy18/47(38.3%) Number with chemotherapy within 4 months17/18 (94.4%) Exceptions 1/1 (100%) Treatment delay due to competing comorbidity 1/1 (100%) Compiled by L. Day, RN BSN CCM CCRP OCN 14

15. Systemic Endocrine Therapy Total Number of Patients = 55 Number of ER positive patients 47/55 (85.5%) Number treated with endocrine therapy 42/47 (89.4%) Exceptions 5/47 (10.64%) Determined risk > benefit 2/5 (40%) Patient non compliant 2/5 (40%) Patient transferred 1/5 (20%) Number with endocrine therapy within 1 year 41/47 (87.2%) Compiled by L. Day, RN BSN CCM CCRP OCN 15

16. Rehabilitation Total Number of Patients =55 Rehabilitation Total Number of Patients =55 Number enrolled in CPRP (PT/OT)22/55 (40%) Exceptions33/55 (60%) Services were available but structured program is pending definitive establishment, whereby every patient gets a baseline arm girth and shoulder range of motion documented; prospective data is maintained with a pre-designed schedule. Pts. enrolled in CPRP in 2011 24/107 (22.43%) Pts. enrolled in CPRP in 201236/74 (49%) Pts. enrolled in CPRP in 2013 44/74 (59.5%) Pts. enrolled in CPRP in 2014 22/55 (40%) Enrollment decline over 2013 19.5% Compiled by L. Day, RN BSN CCM CCRP OCN 16

17. Genetic Counseling Total Number of Patients = 55 Genetic Counseling Total Number of Patients = 55 Number of patients with family history or < 45 years39/55 (70.9%) Number received genetic counseling18/39 (46.2%) Number tested16/18 (88.9%) Positive 0/0 (0%) Negative16/16 (100%) Number refused testing 2/18 (11.1%) Exceptions-did not meet NCCN guidelines 21/39 (53.8%) Compiled by L. Day, RN BSN CCM CCRP OCN 17

18. Reconstruction For Mastectomy Total Number of Patients = 55 Reconstruction For Mastectomy Total Number of Patients = 55 Number of patients with mastectomy17/55 (30.91%) Number of patients with reconstruction13/17 (76.5%) Exceptions 6/19 (31.6%) Pts. Offered but refused 3/6 (50%) Stage IV patient with palliative mastectomy 1/6 (16.67%) No surgery-deceased or transferred care 2/6 (33.3%) Number of patients with reconstruction in 201312/19 (63.2%) Number of patients with reconstruction in 201413/17 (76.5%) Improvement over 2013 13.3% Compiled by L. Day, RN BSN CCM CCRP OCN 18

19. Compiled by L.Day, RN BSN CCM CCRP OCN 19 Time Frame Trial / StudyEligible N (%) Participation N (%) Jan – Jun B-SMART44 (100%) NBRST00 (0%) SPOC44 (100%) MULTIPLE STUDIES1711 (100%) Total 25/27 (92.6%)19/25 (76%) Jul - Dec B-SMART44 (100%) NBRST22 (100%) SPOC11 (100%) MULTIPLE STUDIES1712 (81.2%) Total 24/28 (85.7%) 19/24 (79.2%) GRAND TOTAL49/55 (89.1%)38/49 (77.6%) Trial Participation Total Number of Patients = 55 Patients participated in trials for 2014 38/55 (69.1%)