2994 - Development and Evaluation of a Quality Improvement Program to Minimize Time from Breast Conserving Surgery to Adjuvant Radiation

Purpose/Objective(s):

In August 2023, the American College of Surgeons (ACS) and Commission on Cancer (CoC) updated the quality measure Breast BCSRT, stating that “patients undergoing breast-conserving surgery [BCS] without adjuvant chemo or immunotherapy for clinical stage I-III breast cancer, radiation therapy [RT], when administered, is initiated = 60 days of definitive surgery.” The full standard is awaiting publication as part of the National Accreditation Program for Breast Centers. In 2023, the compliance rate was 65% among all CoC-accredited hospitals, highlighting the challenge and need for improved compliance. We partnered with the ACS to proactively evaluate compliance at our community based, academically affiliated cancer center, identifying barriers and implementing targeted quality improvement (QI) interventions.

Materials/Methods:

In our tumor registry database, we identified patients with stage 0-III breast cancer who underwent BCS followed by RT without adjuvant chemo or immunotherapy between 2023-2024. We retrospectively collected patient, tumor, and treatment data. Those with > 60 days between BCS date and RT start date were identified as noncompliant (nCL) with the standard. This subset was retrospectively analyzed for barriers to timely RT initiation.

Results:

Of the 202 patients meeting inclusion criteria, 108 (54%) were nCL, with those being older (70+), uninsured, and single, having the highest nCL rates. Median days from BCS to RT was 79 (range 61-139, IQR 19). The most common barriers included scheduling delays (35%), wound healing (31%), and delayed Oncotype results (16%). The remaining 18% included patient preference or other medical issues. We developed a process map and performed cause/effect analysis. Potential solutions were mapped to a matrix of high to low impact versus difficult to easy implementation on a scale of 1-5. Five QI measures with highest ease and impact were identified and assigned to a cancer center team champion for implementation, as in the table below.

Conclusion:

We have successfully identified patients at risk for noncompliance with the CoC BCSRT quality measure and implemented high impact/low cost, targeted, and measurable QI interventions to improve compliance. Effect of these interventions will be measured and reported in Q2 of 2025.

Abstract 2994 - Table 1

QI Measure	Description	Impact	Ease	Lead Personnel	Completion Date
Standardized scheduling	Up front scheduling and education about expected appointments	4	4	Patient Navigators	1/15/25
Early referrals	Placing RT referrals prior to post-op visits	3	4	Patient navigators Schedulers	1/15/25
Timely simulation	Scheduling CT simulation prior to final surgery check or Oncotype	4	4	Radiation oncologist	1/1/25
Early genomic testing	Early Oncotype ordering	4	2	Surgeon Medical Oncologist	3/1/25
Wound management	Early ultrasound evaluation, proactive seroma management	5	4	Surgeon	2/13/25