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Breast Care / Breast Cancer BREAST CARE / BREAST CANCER Overview The Kaiser Permanente Breast Care Management Algorithm provided on this site was developed by the Inter-Regional Breast Cancer leaders group (IRBC). This multidisciplinary group includes physicians from Primary Care, Surgery, Oncology, Obstetrics and Gynecology, Radiology, Mammography, Genetics and Women’s Services and representatives from various regional Breast Cancer Task force groups, Clinical Nursing, Quality Resource & Risk Management, Public Relations & Issues Management, Prevention Services, and the Permanente Federation. The algorithm was developed to: • Improve the quality of care for our members with breast complaints, • Improve the timeliness of the identification of breast abnormalities and diagnosis of breast cancer, • Improve the satisfaction of members with breast complaints, and • Respond to the increase in malpractice allegations of failure to diagnose breast cancer. In 2002, the IRBC group held periodic conference calls to develop information to assist primary care clinicians in improving the quality of care for patients with breast complaints. A multidisciplinary consensus-based method was used to develop the content of the algorithm. The group also identified additional information and resources available internally and externally which would support implementation.The Breast Care Leaders in each Region have been encouraged to review and modify the algorithm to reflect local operations. Therefore, prior to use, PCPs are advised to contact a Regional member of the Inter-Regional Breast Care leaders group about revisions for your Region This site is for use within Kaiser Permanente only. What is Available on this Site? The IRBC group and the project management staff from the Permanente Federation worked together to define the project scope and develop the following products and information: I. Rationale II. Breast Care Management Algorithm: The Algorithm provides suggestions to help primary care providers along a care path for evaluating a patient’s breast complaint (e.g., Clinical Breast Exam, abnormal screening mammogram follow-up suggestions, inflammation, breast mass/lumps, spontaneous nipple discharge, and breast pain) to the point where cancer is ruled in or out. III. Information Related to Clinical Practice Guidelines for Breast Cancer Screening: Contact information regarding regional Clinical Practice Guidelines for Breast Cancer Screening. IV. New Technology Report: This section provides information regarding new technologies used to diagnose breast cancer. V. Breast Cancer Tracking System : Information regarding various computer tracking systems for breast cancer is provided in this section. Version 2.0 October, 2003 - 1 - VI. Sample Presentations, Additional Resources and Regional Continuing Medical Education (CME) Contact information : Sample presentations describing Issues in Breast Cancer and Risk Management information and other available resources to support Breast Care are listed in this section. Contacts for regional CME are provided. VII. Bibliography : This section contains the list of references utilized for development of the algorithm VII. Inter-Regional Breast Cancer leaders group (IRBC): Contact information for the IRBC. Version 2.0 October, 2003 - 2 - I. Rationale • Breast cancer is the most frequently diagnosed cancer and the second leading cause of cancer death in women. • 205,000 new cases of breast cancer will be diagnosed in the U.S. in 2002 • An average women has a 2.5% chance of developing breast cancer between the ages of 35 and 55. • Approximately 70-75% of breast cancers are diagnosed in women over the age of 50. • There are 127 cases per 100,000 women age 40-44 years compared to 450 per 100,000 cases in women age 70-74 years. • Although a woman, between 25 and 34 years of age, has a relatively low risk of developing breast cancer compared to older women, nationally, KP can expect 100 women in this age group to be diagnosed with breast cancer in 2002.1,2, Therefore, complete follow-up and documentation of care to the point of normal findings, is essential for all breast complaints, regardless of a woman’s age. • Family history of breast cancer predicts approximately 15% of all cases. A positive family history of breast cancer is defined as having a first-degree relative who developed breast cancer before the age of 50. Those with relatives whose onset of breast cancer was after age 50 are not considered at higher risk. The risk for women with a first-degree relative with early breast cancer is increased fourfold. Other risk factors include history of previous breast cancer, women with atypical hyperplasia on breast biopsy, late age of first pregnancy, nulliparity, and high socioeconomic status. 1. Actual membership from third quarter 2002 per Performance Analysis, Program Offices. 2. Surveillance, Epidemiology and End Results Program, National Cancer Institute, SEER Incidence Crude Rates, 11 Registries, Years of Diagnosis 1992 -1999, All Races, Females. Version 2.0 October, 2003 - 3 - II. Breast Care Management Algorithm • The Kaiser Permanente Breast Care Management Algorithm provides suggestions to help primary care providers along a care path for evaluating a patient’s breast complaint (e.g., Clinical Breast Exam, Abnormal Screening Mammogram Follow-up Suggestions, Breast Mass/Lumps, Inflammation, Spontaneous Nipple Discharge, and Breast Pain) to the point where cancer is ruled in or out. This algorithm is not an evidence based clinical practice guideline. A multidisciplinary consensus- based method was used to develop the algorithm. The suggestions provided in the algorithm do not replace the reasonable exercise of independent clinical judgment in any particular set of circumstances for each patient encounter. The Breast Care Leaders in each Region have been encouraged to review and modify the algorithm to reflect local operations. Therefore, prior to use, PCPs are advised to contact a Regional member of the Inter-Regional Breast Care leaders group about revisions for your Region. The algorithm may be viewed and navigated on this sight or viewed and printed using Adobe Acrobat: Algorithm: • Introduction/ Clinical Visit for Breast Complaint • Abnormal Screening Mammogram Follow-up Suggestions, • Breast Mass/Lumps • Inflammation • Spontaneous Nipple Discharge • Breast Pain Please direct any questions about the algorithm to Robin Cisneros, Director of Medical Technology Assessment, Quality and Performance Improvement, The Permanente Federation at 510-271-5863. Version 2.0 October, 2003 - 4 - Breast Care Management Algorithm CLINIC VISIT Evaluation of the Breast Complaint Obtain history including previous mammogram(s) (plus other imaging) findings, and follow-up; medication history including hormone and birth control; and onset and duration of symptoms of current complaint. If prior mammogram was abnormal determine if there is documented completion of follow-up. If not, proceed to page 3 for abnormal mammogram follow-up algorithm. Identify risk factors personal or family (first-degree relative) history of breast cancer including age of diagnosis, atypia on previous breast biopsies, age of menarche, age at first completed pregnancy, and breastfeeding history. Conduct a Clinical Breast Exam (CBE) Inspect both breasts (unaffected breast first) for ulceration or contour change, nipple skin changes, or nipple discharge. Palpate breast in both the upright and supine positions to determine the presence of a palpable mass/lump. Evaluate nodes (axillary, supraclavicular). Assess risk Consider history and physical findings, risk factors and patient concerns Link to NCI Risk Calculator: http://bcra.nci.nih.gov/brc/q1.htm Document all characteristics of the history and physical findings Document symptom characteristics such as size, location, texture, mobility and character for reference in follow-up examinations. A breast clinic record template is available for use. Order breast imaging if indicated or per regional screening/diagnostic guidelines. Signs of Inflammation No Signs of Inflammation (Redness, Warmth, Swelling, Purulent Discharge, Draining Wound) Characterize Primary Complaint Inflammation Breast Spontaneous Breast Pain Mass/Lump Nipple (without mass) Discharge If not palpable, (without mass) • Educate on risk and screening intervals • Re-examine in one month. If palpable, See page 7 See page 4 See page 5 See page 6 Version: January 28, 2003 ©2003 Kaiser Permanente Medical Care Program Next review: January 2004 —For use within Kaiser Permanente only— Breast Care Management Algorithm Abnormal Screening Mammogram Follow-up Abnormal Screening Mammogram Full Diagnostic Mammogram and/or Ultrasound Additional Additional Considerations Considerations If the patient is If the patient is pregnant or lactating, pregnant or lactating, consult the appropriate consult the appropriate specialist prior to Benign Probably Suspicious of Highly specialist prior to following this care Benign Malignancy Suggestive of following this care path. Malignancy pat h. BI RADS™ BI RADS™ BI RADS™ BI RADS™ Assessment Assessment Assessment Assessment Categories 1,2 Categories 3 Category 4 Category 5 SCPMG Breast Cancer Short-term follow-up Clinical breast exam Member per appropriate (f not previously completed) Satisfaction specialist’s Survey recommendations Biopsy findings suggests that the time frame Benign Indeterminate Malignant from Insufficient sample OR suspicion to Lack of imaging/ Any type of diagnosis pathology atypia should not correlation exceed
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