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International Journal for Quality in Health Care Advance Access originally published online on March 23, 2005
International Journal for Quality in Health Care 2005 17(4):301-305; doi:10.1093/intqhc/mzi035
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International Journal for Quality in Health Care vol. 17 no. 4 © The Author 2005. Published by Oxford University Press on behalf of International Society for Quality in Health Care; all rights reserved

Assessment of the quality of breast cancer care: a single institutional study from Saudi Arabia

Shad Salim Akhtar and Hisham Mohammed Nadrah

King Fahd Specialist Hospital, Prince Faisal Oncology Center, Buraidah, Al-Qassim, Saudi Arabia

Objective. To evaluate the quality of operable breast cancer care in a tertiary care institution.

Design. A retrospective analysis of all breast cancer patients seen in our institution between 1995 and 2000. Data were abstracted from the charts of these patients. Indicators were based on an international consensus conference and other publications.

Setting. A tertiary care health care institution.

Main measures. We evaluated the charts and calculated the percentage for which the internationally accepted quality care indicators were followed during the continuum of care. We also reviewed the histopathological reports to evaluate conformation with the accepted indicators.

Results. Charts of 75 patients (four exclusions, three metastatic, and one male), diagnosed to have breast cancer during the study period were reviewed. Only 28 (37%) patients had triple assessment before a definitive surgical procedure. Pre-operative staging including a CT and bone scan was performed in 58 (77.3%). Among the 50 patients who had definite surgical intervention, the majority had mastectomy (44/50, 88%) whereas axillary dissection was performed in 46 (46/50, 92%). Estrogen and progesterone receptor status was reported in only four (4/50, 8%) and the exact tumor size in 24 (24/50, 48%) of the histopathological reports. Adjuvant chemotherapy was used in accordance with the international standards but radiotherapy was under-utilized.

Conclusion. Our study demonstrated that the quality of breast cancer care in this institution was below the accepted international standards. This study may be used to make interventions for improvement of quality in similar institutions all over the kingdom.

Keywords: assessment of care, breast cancer, care quality, health care quality, quality assessment

Address reprint requests to S. S. Akhtar, P. O. Box 2290, King Fahd Specialist Hospital, Prince Faisal Oncology Center, Buraidah, Al-Qassim, Saudi Arabia. E-mail: shadsalim{at}go.com

Accepted for publication February 4, 2005.

Defined as ‘the degree to which health services for individuals and populations increase the likelihood of the desired outcomes and are consistent with current professional knowledge’; quality of care is a matter of concern both for the care providers and the health care recipients [1–3]. Process quality, which refers to what health care workers do, and how well they do it, both technically as well as interpersonally, is commonly used to assess the quality of care. Particularly the quality of the technical process is measured, which refers to whether the right choices are made in diagnosing and treating the patient and whether care is provided in an effective and skillful manner. Obviously the best process measures are those for which there is evidence from research that a better process leads to an improved outcome [4]. Breast cancer is the most common cancer diagnosed in the world among women. During all phases of continuum of breast cancer care, an association between the process and outcome is supported by extensive scientific literature including many randomized trials, meta-analyses, and international guidelines [5–8]. It therefore provides an excellent opportunity to assess the quality of care among this group of oncological patients. For this reason, even though the age-standardized rate for breast cancer is quite low (4.73/100 000) in the Al-Qassim region of Saudi Arabia [9], we conducted a retrospective study to assess the quality of care offered to these patients at the King Fahd Specialist Hospital and its Prince Faisal Oncology Center.


   Patients and methods
Top
 Patients and methods
Results
 Discussion
 Conclusion
 References
 
According to the 1999 census, the population of the Al-Qassim region was 933 146, of which 427 507 were females [10]. The King Fahd Specialist Hospital, run by the Ministry of Health, is the main referral hospital of the region. To streamline the management of cancer patients the Prince Faisal Oncology Center was commissioned within this institution in 1998. The King Fahd Specialist Hospital and its Prince Faisal Oncology Center at Buraidah receive the majority of patients suspected or diagnosed to have malignant disease, from all over Al-Qassim region. The latter also maintains a hospital-based cancer registry for the region. We identified breast cancer patients from our medical record indexing system and the database of Prince Faisal Oncology Center. Data abstracted from the charts of 78 breast cancer patients, seen in our institution between 1995 and 2000, were copied into a blank proforma. To study the quality of care in this group of patients, indicators proposed by the National Cancer Policy Board [4] and Hillner et al. [11] were used. In addition, standards of practice outlined in various guidelines and reviews were utilized to assess other parameters of breast cancer care (Table 1) [8,12–15].


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  		Table 1 Indicators used for the assessment of quality of care in breast cancer patients 1995–2000

 

The quality of fine needle aspiration cytology was assessed by dividing our patients into two groups: those whose diagnosis was established by this procedure and others who needed a subsequent core or excision biopsy before a definitive surgical procedure due to non-diagnostic aspiration cytology.

The accuracy of clinical examination, mammography, and fine needle aspiration cytology increases when they are used together; a procedure called triple assessment or triple diagnosis. When the results of all the components of triple assessment indicate a benign lesion, cancer will be found in less than 0.5% of cases. On the other hand if all three indicate cancer the diagnosis is likely to be confirmed in more than 99% of cases [14,18]. The size of the tumor was abstracted from the pathological, surgical, or clinical record of the patient, whichever was available. When all three were documented pathological size took precedence.

Pre-operative staging was considered complete if the patient had a chest X-ray, liver function tests, abdominal ultrasound, computerized tomography scan, and a bone scan. Clinical and pathological staging information was additively utilized to identify the stage of disease according to the American Joint Committee for Staging (AJCC) classification [23]. We reviewed the histopathological reports of all the biopsies as well as post-operative specimens of those patients who had a definitive surgical procedure. Table 1 shows the criteria used to evaluate the quality of histopathological reporting.


   Results
Top
 Patients and methods
 Results
Discussion
 Conclusion
 References
 
During the 5-year period from 1995, 78 female breast cancer patients were seen in our institution. A lone male was excluded. As shown in Table 2 the mean age at diagnosis of our patients was 46 ± 14.7 years (range 23–110 years). Three of these patients were detected to have metastatic disease at presentation and were excluded from further analysis.


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  		Table 2 Characteristics of breast cancer patients 1995–2000

 
Pre-operative bilateral mammogram was performed in 39 (39/75, 52%) and fine needle aspiration cytology in 46 patients (46/75, 61.3%) (Table 3). Only 28 patients (28/75, 37.3%) had triple assessment before a definitive surgical procedure. A core biopsy (27/75, 36% ) or excisional biopsy (24/75, 32%), was performed in 51 (51/75, 68%) patients and 22 patients (22/46, 47.8%) had this procedure after a non-diagnostic aspiration biopsy. Exact tumor size, either clinically, peri-operatively, or pathologically, had been documented in 68 patients (68/75, 90.6%). The majority of these patients had large tumors (T3 + T4 = 40/68, 58.8%). Fifty-two of the 58 patients (58/75, 77.3%) who had complete pre-operative staging, had adequate data available for staging according to the AJCC. The majority had advanced stage disease (Table 2). Fifty (50/75, 66.6%) patients underwent a definitive surgical procedure in our institution, 44 (44/75, 58.7%) had mastectomy and the others (6/75, 8%) had only lumpectomy. The remainder (25/75, 33.3%) either refused surgery here or demanded referral elsewhere. No follow-up records were available for these patients. Table 3 also shows the indicators as recorded in the histopathological reports of these patients.


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  		Table 3 Compliance with the guidelines as observed in breast cancer patients 1995–2000

 

Of the 46 patients who had axillary dissection the number of nodes examined was documented in 39 patients and ranged from 2 to 40 (mean = 16). Thirty-three patients (33/46, 71.7%) were node positive and 15 had more than three nodes involved. Post-operative treatment consisting of adjuvant chemotherapy, radiotherapy, or hormone therapy, alone or in combination, was used in both pre-menopausal and post-menopausal patients. The type of chemotherapy varied according to the number of lymph nodes involved. Twelve of 15 patients who had more than three nodes positive received four cycles of a combination of adriamycin, cyclophosphamide, and 5-fluorouracil with an additional two cycles of cyclophosphamide, methotrexate, and 5-fluorouracil in 10 and four cycles of paclitaxel in two patients, while the other three patients received six cycles of adriamycin, cyclophosphamide, and 5-fluorouracil. A cyclophosphamide, methotrexate, and 5-fluorouracil combination was used in all other patients.

Adjuvant hormone therapy was used in 24 pre-menopausal (24/38, 63.2%) and 11 post-menopausal (11/12, 91.6%) patients. Rational use of hormone therapy could not be assessed because estrogen and progesterone receptor status was not available in the majority of these patients. Twenty-five patients (20/38, 52.6% pre-menopausal; 5/12, 41.6% post-menopausal) received adjuvant radiotherapy.


   Discussion
Top
 Patients and methods
 Results
 Discussion
Conclusion
 References
 
The large number of studies that have been conducted to assess the process of breast cancer care in different settings, makes this extensive literature difficult to summarize. Our study, a single institutional study, assessed the quality of care during a period of time using the data abstracted from the medical records of these patients. Like a recently published series, this study albeit small, confirms the feasibility of assessing the quality of cancer care by abstracting the data from the medical records of patients [3]. Similarly, the American Society of Clinical Oncology-sponsored National Initiative for Cancer Care Quality is currently evaluating the feasibility of getting information from the medical records of patients to assess the quality of care on a large scale [24].

This study highlights some of the unique epidemiological features of breast cancer seen in this region; younger age, large tumor size, and advanced stage at presentation. In contrast to data from the West, where more than half of breast cancer patients are above 50 years of age, the majority of our patients were younger than that (Table 2). This age distribution has been reported previously from this area [25]. Racial difference in stage at presentation and aggressive disease in younger patients have been described in the literature [26,27]. A younger age at presentation may be one of the reasons for the advanced stage of disease seen in our patients. However, lack of awareness regarding breast cancer and delay in seeking medical advice may be additional factors contributing to this late presentation [28].

Ideally, every breast cancer patient should have a bilateral mammogram before the definitive surgical procedure for primary disease [16]. Similarly, triple assessment is an important part of the evaluation of any breast lump [17]. Both mammography and as a result, the triple assessment, were under-utilized in our patients. Among other factors, temporary non-availability of mammography in our institution, at the time of referral of some of these patients, could have contributed to the low rate of pre-operative bilateral mammography seen in our patients.

Although an operator-dependent procedure, the diagnostic value of fine needle aspiration cytology is reported to be ~90% with a false-negative rate ranging between 0.4 and 35% [4,13]. As most of the clinicians would themselves carry out this procedure in this institution, the high rate of non-diagnostic fine needle biopsy seen by us may indicate an initial learning curve.

In order to plan adequate treatment, especially breast-conserving surgery, every breast cancer patient needs evaluation by a team consisting of a surgeon, medical oncologist, radiation oncologist, pathologist, and a radiologist. Non-availability of radiotherapy and barriers to patient follow-up may possibly explain why only a small proportion of patients undergoing surgery in our institution had lumpectomies. Nevertheless, patient preference and physician’s choice are two of the other factors that may override the medical criteria and affect the rate of breast-conserving surgery in an institution [29].

In conformity with international standards, all but four patients undergoing definitive surgery here had axillary dissection.

The pathological report is a critical link between pathologist and clinician. Deficits in pathological reports have, therefore, been the target of many quality improvement projects. In our study the histopathological reporting did not meet the expected international standards. Although a low rate of reporting of estrogen and progesterone receptor status could be due to non-availability of such marker studies until 1999 in our institution, other aspects of histopathological reporting were also below the acceptable standard (Table 3). The number of incomplete breast cancer pathology reports was recently reduced as reported by Hammond and Flinner [22] from 57/356 (16%) to 2/190 (1.1%) by instituting a template for reporting.

The rate of utilization of adjuvant chemotherapy both in pre-menopausal and post-menopausal patients met the expected target [11]. Because chemotherapy can be made easily available there is a high rate of concordance. Adjuvant radiotherapy is an integral part of the management of breast cancer, particularly in patients with large tumors and many positive nodes [30]. Most of our patients had large primary tumors with axillary lymph node involvement and were, therefore, candidates for local adjuvant radiotherapy. Again, perhaps due to non-availability of radiotherapy on site, it was under-utilized in this patient population.


   Conclusion
Top
 Patients and methods
 Results
 Discussion
 Conclusion
References
 
This small retrospective analysis shows that quality of breast caner care in this institution falls well below the accepted international standards, possibly due to non-availability of some of the facilities on site and the absence of local guidelines. Additionally, a low volume of breast cancer patients in this institution may have contributed. Since the compilation of this report a clinic for fine needle aspiration cytology has been established and local guidelines have been formulated including a template for histopathological reporting. Collaboration with an institution for radiotherapy facilities has been established. It would be interesting to review the status of practice in future and compare that with the present study.


   References
Top
 Patients and methods
 Results
 Discussion
 Conclusion
 References
 

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