The electronic database searches resulted in 1158 potentially relevant articles with three articles identified through the search of the reference lists for a total of 1161 articles. After duplicates were excluded (266 articles), title and abstract screening by the team yielded 101 possible articles and therefore 101 full-text articles were finally screened for eligibility. There were 93 articles excluded for the following reasons: adherence to rather than the development of QI measures (69), breast cancer management guidelines (16), indicator measure for other cancer types and incomplete information (4), non-cancers (3) and non-English articles (1). A total of eight articles were included in the final review (see Figure 1).
Characteristics of included studies
The main characteristics of the studies included are presented in Table 1a. The supplementary Table 1b briefly describes the main methodological approaches utilized. Studies included consisted of two papers from China and one each from the Netherlands, Belgium, Scotland, and Canada. The further two emanated from a collaboration between the European Society of Breast Cancer Specialists (EUSOMA). Of note is that one paper was an update on an earlier publication. It was agreed through consensus to include both versions to identify the updated information and any other relevant characteristics of the studies. Most of the studies included used a combination of literature review and consensus, such as the Delphi consensus methods to create the final set of QIs. Two of the studies focused on assessing care for patients with invasive breast cancer or ductile carcinoma in-situ (DCIS) (16,17) whilst one study focused on QIs for vulnerable elderly patients with breast cancer (18).
[Insert Table 1a and 1b]
The QIs developed ranged from eight (17) to thirty-two (16) items within the studies reviewed. Overall, a total of 38 QIs were identified and summarized (Appendix 1) which were classified as: structure (n = 3); process (n = 30); and outcome (n = 5) (see Figure 2).
Structure indicators for breast cancer care
Seven studies reported on structure indicators for breast cancer care. These included: the availability of multidisciplinary team (MDT) meetings (8,18,19-23); information system and medical records for documentation (18); and breast cancer research infrastructure (20).
Process indicators for breast cancer care
Most of the QIs identified were process-related (30 QIs). These were classified under three domains: diagnosis (8), treatment (15), and follow-up (7) (Figure 2)
Outcome indicators for breast cancer care
The outcome indicators for breast cancer was reported by three studies (8,20,21). This indicator was focused on the overall five-year survival of breast cancer, 5-year survival by stage, disease-free 5year survival by stage, 5-year local recurrence rate after curative surgery and 5-year survival for BC presenting symptomatically.
[Insert Figure 2]
Diagnostic QIs for breast cancer care
A total of 8 QIs were identified and classified as relating to diagnosis including medical imaging (mammography/MRI/USG – 4QIs) and medical laboratory (histopathology/ cytology – 4QIs). Medical imaging diagnosis indicators emerged in all studies except in the study conducted by Bao and team (8). The diagnostic indicators focused on the assessment of breast cancer patients and the completeness of clinical and imaging diagnostic workup using mammogram, ultrasound, physical examination, breast MRI (16-22). The other three indicators included: the complete evaluation of comorbid illness and overall performance status (18), the performance of a bone scan to detect locally invasive early breast cancer (18) and radiological reporting using BI-RADS classification (16).
One of the studies reported all four QIs related to histopathology and cytology (8). Seven studies focused on the completeness of prognostic or predictive characterization involving the performance of human epidermal growth factor receptor 2 (HERS 2), Oestrogen (ER), Progesterone receptor status (PgR) testing histological type, grading, pathological stage, tumor size and margins (8,16,18-22). The evaluation of pathology report status for a surgical margins indicator was identified in two studies (8,20) whilst the evaluation of the number of breast lymph nodes and axillary lymph nodes dissected and staging indicators were identified in four studies (8,19,20,22).
Treatment QIs for breast cancer care
The treatment domains identified within the review included radiotherapy, systemic therapy, and surgery. Overall, 15 QIs were identified constituting radiotherapy (4), systemic therapy (5) and surgery (6) respectively.
Breast cancer surgical indicators covered a wide range of surgical procedures including sentinel lymph node biopsy (SLNB), mastectomy and lumpectomy. Surgical indicators emerged from seven out of the eight studies. Patients undergoing conserving surgery for DCIS or early-stage invasive disease emerged as an indicator from seven studies (16–22). The four QIs concerning mastectomy emerged in all the studies whilst lumpectomy indicators were identified in two (17,18).
There were five systematic therapy-related QIs identified. Receiving intravenous chemotherapy (adjuvant or neoadjuvant chemotherapy); was one of the indicators that was identified in seven studies (8,16,18–22). Other indicators identified included: women who received neoadjuvant or adjuvant systemic therapy (18,20); women with hormone receptor-positive invasive breast cancer or DCIS who received adjuvant endocrine treatment (Tamoxifen/AI) or hormonal therapy or chemotherapy or aromatase inhibitor treatment (8,18–20,22); women treated by trastuzumab in whom cardiac function was monitored every three months ( 8,20) and women with metastatic breast cancer and lytic bone metastases who received bisphosphonates (18,20).
Radiotherapy QIs were identified within seven studies (8,16,17,19-22). Women who received a standard dose of radiotherapy after breast-conserving surgery, mastectomy and axillary lymph node dissection (ALND) were identified in four studies (8,16,19–22). The QIs identified in only a single study included; women patients who received adjuvant radiotherapy to the chest wall after mastectomy (8) and radiotherapy for locally advanced breast cancer (excluding T3N0) following mastectomy (16). Radiation oncology referral after lumpectomy and surgical resection for postoperative radiotherapy emerged in three studies (17,19,22)
Seven QIs related to follow-up were identified in the studies. The QI on clinical evaluation and rehabilitation was identified in four (8,19,20,22). Two studies (19,22) focused on staging procedures for patients who may or may not undergo baseline staging tests (US of liver, chest x-ray and bone scan), administrative management and a data manager being responsible for breast centre data and genetic counselling for referrals. The follow-up indicator on communication, availability of information and counselling among breast cancer patients were also identified (21). Another follow-up QI that emerged was the transit times of less than or equal to five weeks between various breast cancer managements. This included transit times of ≤5 weeks between each diagnosis and the start of neoadjuvant chemotherapy or primary surgery (without immediate reconstruction) or transit time ≤5 weeks between final operation and the start of radiotherapy etc. (19).