The Search for Quality in Breast Cancer Care

Quality medical care is not a new topic for this blog. 


I have previously written about Medicare’s demonstration project designed to test the feasibility of collecting data from oncologists regarding their willingness to follow established practice guidelines as part of their routine patient care.


I have just spent the past two days involved in a (relatively) small group discussion about how we could improve our abilities to measure the quality of care received by women with breast cancer.  It was an interesting and productive session, including presentations and participation by some of the leading experts in quality improvement in medicine and other professions.


This is not a new interest for me.  Back in the early 1990’s I was a member of a guideline panel that looked at how we could improve the quality of mammograms.


The American College of Radiology had developed recommendations for quality mammography, and there was growing national concern that we were not doing our best to assure women that the mammogram they received met minimal quality standards.


To address the issue, the government decided that standards were necessary.  A panel was brought together to review the evidence as to what constituted “quality mammography.”  Following that exercise, the Congress passed the Mammography Quality Standards Act, which remains in force to the present time and is considered part of the “routine course of business” by radiologists and others interested in this question.


That process is not necessarily the best it could be, but it was a start in a nascent field of trying to get everyone on the same page as to what constituted quality care when performing a mammogram.


In the interval, we have come a long way.  The quality of our mammography machines has improved, more women are getting mammograms, and more tumors are found before they can be felt by the woman or her doctor.


Some other things have transpired from then until now. 


For example, there is now rapidly growing interest in determining how we can measure the quality of care we provide our citizens.   We have increasing computer sophistication and capability and more medical practices are implementing electronic medical records.


So, one would think, we are moving to make obsolete the comment of one of our congressmen, Fortney Stark, who many years ago made the observation to the effect that we know more about the shortstop of the Oakland A’s than we do about our doctors.


Obsolete?  The unfortunate answer is: far from it.


My perspective on this dates back to prior to the days I participated in the guidelines panel I mentioned above.  


My dream seemed sort of obvious to me: If I was looking at a process of care, I would want to have basic information about the care provided a woman from the time before she gets a mammogram, through her diagnosis and treatment to when/if the cancer came back, and, unfortunately for too many women, when she died.  Using that information, I would want to analyze the process of care to see how it could be improved.


I would want to know if her primary care doctor routinely referred his/her female patients age 40 and over for a screening mammogram.  I would want to know whether the doctor who reads the mammogram is competent, and how many mammograms he/she reads every year.  I would want to know how many women are referred for biopsy for suspicious lesions on the mammogram, and how many of those turn out to be positive.  I would want to know if the doctor missed a cancer on a mammogram, and understand why the doctor missed it.


 I would want to know if the woman with breast cancer was offered the appropriate options for treatment, and how many breast operations her surgeon performed every year.  I would want to know whether the surgeon performs more mastectomies than lumpectomies, which might indicate he/she is not offering their patients the appropriate options.  I would also want to know whether the woman got the appropriate treatment after her surgery, and ultimately I would want to know how long she lived after her surgery and what her cause of death was.


I would want to be able to monitor every aspect of care from beginning to end, and then I would want to analyze that information to see what I could do better.  Most importantly, I would want to have a feedback loop that gives the woman appropriate information about her care, and let her doctors know where they stand relative to others in their field of expertise, and how they could improve their care. 


I would want to know the woman received the appropriate care for her condition, which in turn would give her the best chances of a cancer-free long term survival.


It is good to want, but unfortunately we are no where near making my dream a reality.


How could that be?


It fundamentally starts with the way our health care “system” is structured.  If you go to a major center for your care, there is a reasonably good chance your doctors have looked at what they do, how they do it, and what they need to do to do it better.


But most of our care is not delivered in large hospitals in major metropolitan cities.  Most of it is delivered in a system made up of individual practitioners in individual offices who refer to each other, and often don’t get together to take a hard look at the same questions.  There is really no incentive to do so.  So, the opportunity to get a comprehensive view of what is going on in the care of many of our patients is lost.


Then there is the hard reality that many doctors don’t have electronic systems in their offices.  Primary care physicians have a hard time getting the funds to pay for the systems, and many are reluctant to invest their “intellectual capital” to set up a system, for whatever reason.  As hard as it is to believe, as was noted at our meeting this week, the systems themselves are not even designed to capture and report the information, even if we had someone who was willing and able to receive it and analyze it.


And then there is the willingness and commitment to make this work.  Let’s call it “buy in”, but it is much more than that.  It is a fundamental belief that this type of information gathering and analysis is necessary, that we need to make commitments as a profession to demonstrating the quality of our care, and that we are able to engage in new types of partnership and trust that heretofore just haven’t existed.  In other words, a huge leap of faith and commitment.


Although many of my colleagues are fully aware of the need to participate in this process, there are also many who think any effort of this type is an intrusion into the sphere of their professional judgment. 


Doctors, after all, aren’t selected because they like to work in systems of care.  They are selected and trained because they are independent thinkers able and willing to make decisions about serious medical problems in the middle of the night while no one else is around.   A surgeon doing a major operation doesn’t seek the opinion of a committee in order to make a decision to tie off a bleeding vessel or resect a cancer when in the operating room faced with an open abdomen.


If you asked a room full of doctors which one(s) provided less than standard care, how many hands do you think would be raised?  One prominent medical leader recently opined in an editorial that every doctor is a quality physician, and that essentially all of these quality improvement activities were not necessary.  (This opinion piece had an immediate response from leaders in medicine and the quality health care movement.  Please see link.)


The evidence shows otherwise.  But that’s not really the point of this blog today.


The point is that we need to make it a national priority to get everyone on the same page.  We need a national commitment to say that we need this information, we need to analyze the information, and we need to work to improve our care without fear of retribution.  In other words, we need to develop a culture of improvement in health care.


When I think about these issues, I think of the over 260,000 women who will be diagnosed with breast cancer this year.  I think about the need for every eligible woman who needs a mammogram to be able to get one.  If she has cancer, I want her to get the right care.  It doesn’t have to come from the world’s leading expert.  But it should come from someone who is committed to applying the best skill and knowledge about the treatment that is available to us today.  And I know that unless we measure it, we have no assurance that it is happening—the doctors’ assurances notwithstanding.


So back to my meeting and the commitments of my colleagues, patients and others who participated.   The task to accomplish the goal is overwhelming, but as we all agreed we must start somewhere.


The betting is that the goal will not be achieved in my lifetime.  Too many barriers that are organizational, political, financial, legislative and regulatory for any expectation that I will see this influence the care I receive.


But it might—just might—influence the care of my wife and my children and their children.  To do our best, we must do the right thing, and that is for us to commit to this process and do everything in our power to make it happen.




My hat is off to Laura Esserman, MD from the University of California San Francisco who is the force behind the meeting I described above.  Her fortitude, will and commitment may be just what is needed to give people the push to move forward on the vision that many of us share.  I was honored to be asked to participate.



4 thoughts on “The Search for Quality in Breast Cancer Care

  1. Hey Dr. Len,
    I enjoy your blog however it seems to be a little long. I think most Blogs should be around 2-3 paragraphs at the most. Just a thought.

  2. John I think your comments are relevant to other blogs but this one is different. I believe that the material that is being covered demands more detailed attention and description than one paragraph. I commend Dr. Len for taking his valuable time to write all of the details out for us.

  3. High quality information, to be sure. I suppose the test of blog length or any other characteristic is:Do the readers you want to read it, read it? Maybe a reader survey in 3 months?

  4. Thanks to everyone for your thoughts and opinions. Yes, I am aware that many of these entries are longer than usual. But they are also trying to relay information about some difficult issues, and are used as references in a number of circumstances beyond the posting on this site. For example, several reporters have used this for background information on some of the topics that have been covered previously. Also, this was modeled after some other blogs targeted at similar audiences that were longer than “the usual.”

    In any event, the comments are indeed valid and I will try to be more succinct in my postings. The comment about a reader survey is also valuable and I will pass them along.

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