SVMC Launches Evidence-Based Care for High Risk Breast Lesions

The physicians in the Southwestern Vermont Regional Cancer Center discovered that a small segment of patients who are diagnosed with certain types of higher risk breast lesions are not always managed so as to meet the standard of “evidence-based practice”. Rather than tolerate this situation, they put together a quality improvement team to address this situation. The results of this 24 month effort show a remarkable improvement!

When a woman has been identified with a suspicious area in her breast, the recommendation is that she undergo a biopsy to determine whether that area harbors malignant cells. Sometimes the biopsy reveals tissue that is not malignant, but is considered to be of higher risk for eventually developing a malignancy.

At SVMC, there are only about 40 women each year in this situation, so each case was managed individually. This can mean that there can be some variation in the way physicians manage the care for these patients. Indeed, the quality improvement team conducted a review of cases for the preceding two years and learned that 70% of the women with high risk lesions did not received care that would meet the current “evidence-based practice”. They felt that this could be improved and set the following goals:

• Goal One: To reliably track 100% of cases where high risk lesions are identified.
• Goal Two: To establish an algorithm, used by caregivers, that guides clinical decisions consistent with the clinical evidence.
• Goal Three: To ensure that care for the women identified with high risk lesions is managed according to the evidence-based algorithm 100% of the time.

There were four key interventions put in place to achieve these goals:

1. Explicitly categorize high risk lesions, the algorithm for managing them, and make this known to community physicians.
2. Include a recommendation on the pathologist report for high risk lesions that states: “recommend surgical excision”.
3. Clarify the Breast Health Navigator role to include tracking and troubleshooting patients with high risk lesions.
4. Aggregate data from cases throughout the SVMC service area into one data base so that there is enough volume of cases for the physician team to identify patterns of care consistent (and inconsistent) with the evidence-based algorithm.

It has now been 24 months since the initiation of these improvements. The treatment algorithm was developed and distributed. There have been 50 women identified with high risk breast lesions in that time. All have been identified and tracked in the data base. In the baseline year, 70% of cases were managed consistent with the algorithm. In the first year following the changes, 88% were thus managed. And in the most recent year, 100% of cases were managed consistent with the algorithm, showing a steady and sustained improvement.

One footnote: The evidence for managing high breast lesions supports doing a surgical excision of the lesion. By removing the lesion, it further reduces the risk of developing into a malignancy. In our small cohort of cases, the second biopsies revealed eleven cases where the lesion was more significant, including three malignancies. By removing these lesions early in the course of disease, the women can benefit from more treatment options and can expect improved outcomes.