version no: 1.2 healthcare performance measurement page …...number of pages: 31 investigators,...

Version No: 1.2 Healthcare Performance Measurement

& Report for Breast Cancer services

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Ver.Date: 7 Sep 2013 Protocol No.:HR2011-02

1

Report Title: Healthcare Performance Measurement & Reporting for Breast Cancer

services in Malaysia, for 2011-2012

Protocol

number:

HR 2011-02

Document

type:

Healthcare Performance Report

Document

status:

Draft

Report

period

2011-2012 data

Database As of 6 September 2013

Release

Date:

Version 1.2 6 September 2013

Number of

pages:

31

Investigators,

Site

Coordinator

and Hospital

management

# Investigators: Institution:

1. Dato Dr Ibrahim A. Wahid Beacon International Specialist Centre

2. Dr Azura Rozila Ahmad Beacon International Specialist Centre

3. Dr Chong Kwang Jeat Mahkota Medical Centre

4. Dr Jayendran s/o Dharmaratnam Mahkota Medical Centre

5. Dr Ho Kean Fatt Mount Miriam Cancer Hospital

6. Dr Amir Shah Mount Miriam Cancer Hospital

7. Dr Kananathan s/o Ratnavelu NCI Hospital

8. Dr Gerard Lim Chin Chye Hospital Kuala Lumpur

9. Dr. Nor Aina Emran Hospital Kuala Lumpur

10. Dr Amin Hospital Kuala Lumpur

11. Dr Azizah Ahmad Hospital Kuala Lumpur

12. Dr Chan Wee Han Hospital Kuala Lumpur

13. Dr Hayani Hospital Kuala Lumpur

14. Dr Lau Fen Nee Hospital Kuala Lumpur

15. Dr Lau Kah Liew Hospital Kuala Lumpur

16. Dr Lim Boon Leong Hospital Kuala Lumpur

17. Dr Mohd Faisal Hospital Kuala Lumpur

18. Dr Nik Abdullah Hospital Kuala Lumpur

19. Dr Rachael Khong Kit-tsan Hospital Kuala Lumpur

20. Dr Ros Suzanna Hospital Kuala Lumpur

21. Dr Zabedah Hospital Kuala Lumpur

22. Dr Abel Arumugam Sime Darby Medical Centre

23. Dr Cha Kar Huei Sime Darby Medical Centre

24. Dr Foo Kin Keong Sime Darby Medical Centre



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25. Dr Lyou Yen Tian Sime Darby Medical Centre

26. Dr Ong Kee Thiam Sime Darby Medical Centre

27. Dr Samuel Tay Kwan Sim Sime Darby Medical Centre

28. Dr. Matin Mellor Abdullah Sime Darby Medical Centre

29. Dr. Ahmad Kamal Mohamed Sime Darby Medical Centre

30. Dr. Foo Yoke Ching Sime Darby Medical Centre

31. Dr. Leong Kin Wah Gleneagles Medical Centre Pinang

32. Dato’ Dr Mohamed Adel Mohd Zaatar Gleneagles Medical Centre Pinang &

Mount Mariam Cancer Hospital

33. Prof Dr Yip Cheng Har University Malaya Medical Centre

34. Prof. Dr. Nur Aishah University Malaya Medical Centre

35. Dr. Ho Gwo Fuang University Malaya Medical Centre

36. Dr Teh Yew Ching University Malaya Medical Centre

37. Dr See Mee Hong University Malaya Medical Centre

Site

Coordinator

# Site Coordinators: Institution:

1. Ms Umadewi A/P Ravindranathan Beacon International Specialist Centre

2. Ms Harisah Binti Ab Rahman Mahkota Medical Centre Melaka

3. Ms Rashidah Abd Rashid Mahkota Medical Centre Melaka

4. Ms Lim Sheau Yong Mahkota Medical Centre Melaka 5. Ms Zaharah Binti Mohd Mahkota Medical Centre Melaka 6. SR Kanageswari Ramasamy Mount Miriam Cancer Hospital 7. Ms Tamil Selvi Aruguman NCI Hospital 8. Ms Satwant Kaur NCI Hospital 9. Ms Catherine Lee May Ling Sime Darby Medical Centre 10. Ms. Annie Kahar Sime Darby Medical Centre 11. Ms. Siah Ning Sing Sime Darby Medical Centre 12. Ms Parameswary A/P Ellamaran Sime Darby Medical Centre 13. Ms Mandy Yap Seen Mun Sime Darby Medical Centre 14. Ms Ester Ho Siow Yean Sime Darby Medical Centre 15. Ms Mabel Keay Pei Pei Gleneagles Medical Centre Pinang

Consultant Lim T.O. FRCP, M.Stat

Statisticians Hoo LP PhD, Lena Yeap MSc, Stats Consulting

Data

manager

Teo JS MSc,ClinData Consulting

Project

manager and

staff

Ms Iris Tan Guak Wah, MySMO

Ms Intan Munirah Mohd Murad, MySMO

Ms Chin Mei Lin, MySMO

Mr Leslie Bong, MySMO

Ms Jacelyn Tan Ying Ling, MySMO



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Contents Introduction and Rationale ........................................................................................................................... 4 Data ............................................................................................................................................................... 5 Results & Discussion ..................................................................................................................................... 5 Conclusion ..................................................................................................................................................... 5 References .................................................................................................................................................... 6 Tables and Graphs ......................................................................................................................................... 7

Table 1.0: Data reporting for Breast cancer .............................................................................................. 7 Table 1.1: Missing Data precluding Breast Cancer Care performance analysis for Patients diagnosed in year 2011-H1 2012 .................................................................................................................................... 8 Table 2.0: Patients’ Characteristics at diagnosis, All Patients diagnosed in 2011-H1 2012 ..................... 9 Table 3.0: Tumor Characteristics at diagnosis, Patients diagnosed in year 2011-H1 2012 .................... 10 Table 4.0: Treatment of Breast Cancer Patients diagnosed in year 2011-H1 2012 ................................ 11 Table 5.0: Summary of Breast Cancer care performance for Patients diagnosed in year 2011 (H1+H2) and 2012 (H1 only) .................................................................................................................................. 15

Appendix 1: Definition of Performance Measures for Breast Cancer care................................................. 17 Appendix 2: Breast Cancer care Performance results for year 2011 and year 2012 .................................. 19

Table A2.1 Summary of Breast Cancer care performance for Patients diagnosed in year 2011 .......... 20 Table A2.2: Summary of Breast Cancer care performance for Patients diagnosed in year H1 2012 ..... 22

Appendix 3: Detailed Performance results by Individual Performance measures ..................................... 25 Table A3.1: Pathology Report confirming diagnosis for Breast Cancer (BC) patients in year 2011-H1 2012 ........................................................................................................................................................ 25 Table A3.2: Surgery treatment for Stage I to III breast cancer within 2 months of diagnosis for Breast Cancer (BC) patients in Year 2011-H1 2012 ............................................................................................ 25 Table A3.3: Radiation therapy for Stage I to III breast cancer after breast conserving surgery within 1 year of diagnosis for Breast Cancer (BC) patients in year 2011-H1 2012 ............................................... 26 Table A3.4: Radiation therapy for Stage I to III breast cancer with node positive after breast mastectomy surgery within 1 year of diagnosis for Breast Cancer (BC) patients in Year 2011-H1 2012 28 Table A3.5: Combination chemotherapy for Stage I to III ER/PR negative cancer within 4 months of diagnosis for Breast Cancer (BC) patients in year 2011-H1 2012 ........................................................... 30 Table A3.6: Tamoxifen or AI for Stage I to III ER or PR positive cancer within 1 year of diagnosis for Breast Cancer (BC) patients in year 2011-H1 2012 ................................................................................. 31 Table A3.7: Trastuzumab for Stage I to III HER2 positive cancer within 1 year of diagnosis for Breast Cancer (BC) patients in year 2011-H1 2012 ............................................................................................ 32



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Introduction and Rationale Measuring the performance of health services and using these measurements for accountability

purposes or to promote improvements in the delivery of care, are increasingly evident in

developed countries. Malaysia has lagged behind in this area until in recent years when our

government introduced KPI to measure the performance of government services as part of the

Government Transformation Programme. This has provided the impetus for measuring the

performance of our health services. HPMRS (more at www.hpmrs.com.my ) the local healthcare

performance measurement system was developed to meet the increasing demands from clients’

for such services. Several projects are underway targeting cancer, cardiac, eye and orthopedic

health services in Malaysia. Cancer care services, and specifically breast cancer services, is the

subject of this report.

For the purpose of measuring breast cancer care performance, we mostly adopted the

performance measures developed by Quality Oncology Practice Initiative (QOPI) [1,2] and

American Society of Clinical Oncology/National Comprehensive Cancer Network (ASCO-

NCCN) [3,4] and NAPBC [5] while taking into account local clinical practice guideline [6].

These measures have also been adopted by national bodies tasked with healthcare quality

oversight such as the National Quality Forum in US [7].

These performance measures are listed in the Table below; refer Appendix for their definitions.

# Performance measure Source

1. Pathology report confirming malignancy QOPI [1,2]

2. Corticosteroids and serotonin antagonist prescribed with

moderate/high emetic risk chemotherapy

QOPI [1,2]

3. Surgery for women under age 70 with Stage I to III breast cancer

within 60 days of date of diagnosis

Malaysian guideline [6]

4. Adjuvant multi-agent (combination) chemotherapy for women

under age 70 with Stage I (Tc) to III ER/PR negative breast

cancer within 120 days of date of diagnosis

ASCO-NCCN [3,4]

5. Radiation therapy for women under age 70 with Stage I toIII

breast cancer who had breast conserving surgery for breast

cancer within 1 year (365 days) of date of diagnosis

ASCO-NCCN [3,4]

6. Radiation therapy for women under age 70 who had mastectomy

for breast cancer with node+ (four or more positive regional

lymph nodes) within 1 year (365 days) of date of diagnosis

NAPBC [5]

7. Tamoxifen or Aromatase Inhibitor for women greater than age

17 with Stage I to III ER or PR positive breast cancer within 1

year (365 days) of date of diagnosis

ASCO-NCCN [3,4]

8. Trastuzumab therapy for women greater than age 17 with Stage I

(Tc) to III HER2 positive breast cancer within 1 year (365 days)

of date of diagnosis

QOPI [1,2]

9. Risk adjusted 5-year relative survival International Cancer

Benchmarking Partnership

[8] & CONCORD [9]

http://www.hpmrs.com.my/



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Data In 2011 and 2012, data were collected from 2171 patients diagnosed to have breast cancer at 8

cancer treatment centres in Malaysia. For the purpose of performance measurement, the data

were usable from 1281 eligible patients. 384 patients were excluded because of ineligibility and

another 179 patients were potentially eligible but had incomplete data and were thus excluded

from analysis (154 patients for date of diagnosis data, 25 for tumor staging data).

Results & Discussion The mean age of these patients with breast cancer diagnosed in 2011 was only 54 years; 37%

were aged <50 years. 60% of patients were diagnosed with Early Breast Cancer (Stage 1 or 2,

EBC), another 27% with Locally Advanced Cancer and only 13% with late stage metastatic

cancer. 69% were ER+, 58% PR+, 33% HER2+ and 16% triple negative.

Breast Cancer care performance

Table 5.0 summarizes the performance results. Overall, Breast Cancer care result is 87%. A 87

percent composite score means that the centres provided an evidence-based Breast cancer

treatment 87 times for every 100 opportunities to do so.

Performance for the 7 individual performance measures (excluding survival outcome and

Steroids/Serotonin antagonist prescribed) varies from as low as 23% (Trastuzumab treatment) to

a perfect score of 100% (Pathology report confirming malignancy). Surgical service for breast

cancer was commendable with a score of 94%, while the other 3 modalities (chemo, radiation

and hormonal therapies) perform similarly wioth scores between 80 and 85%.

Cancer survival outcome

We have no data on patient survival outcomes yet

Conclusion It has been shown that without clear target and in-built performance monitoring and data

collection system, health services for any particular patient groups will invariably fail to improve

[10]. The HPMRS is specifically designed to measure the performance of our cancer services

through monitoring access to diagnostic and treatment services and survival outcome of

representative cohorts of patients diagnosed with breast cancer, and on this basis motivate the

improvement in health services for these patients. A high performing health service will ensure

that patients be diagnosed early and have timely access to needed treatment, and thereby ensure

optimal cancer survival and minimal avoidable deaths.

To our knowledge, this is the first time cancer care in Malaysia has ever been subjected to

performance monitoring. Beginning from January 2011, 8 hospitals in Malaysia from the MOH,

University and Private sectors embark on routine measurement of the performance of their

cancer care services. Breast cancer patients took as long as a year to complete their treatments;



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we could therefore only present the results in this report for patients enrolled in year 2100 and

January to June 2012.

The results clearly show that the performance of breast cancer services in Malaysia are creditable

for a middle income country though there is room for improvement, and certainly we have some

way to go before we could meet world class benchmark

The results from this first effort to measure the performance of our breast cancer service will

serve as the baseline against which future improvement will be assessed.

The large sample of patients enrolled in this study will have their long term survival outcomes

determined through record linkage (National Death Index). This will in time provide estimate of

cancer survival and enable the investigation of the influence of baseline characteristics

(demographics, tumor markers etc) and exposure to treatment on long term survival outcome.

Reliable data on both (survival and prognostic factors) are still lacking for all cancers in

Malaysia,

References 1. Campion FX, Larson LR, Kadlubek PJ, Earle CC, et al. Advancing Performance

Measurement in Oncology: Quality Oncology Practice Initiative (QOPI) Participation and

Quality Outcomes. J Oncol Pract 2011;7:31S-35S

2. QOPI Quality Measures. Available at:

http://qopi.asco.org/Documents/QOPISpring2012MeasuresSummary_000.pdf

3. Desch CE, McNiff KK, Schneider EC, Schrag D et al. American Society of Clinical

Oncology/National Comprehensive Cancer Network Quality Measures. J Clin Oncol 2008;

26:3631-3637

4. ASCO-NCCN Quality Measures for Breast and Colorectal cancer care. Available at:

http://www.asco.org/ASCOv2/Practice+%26+Guidelines/Quality+Care/Quality+Measureme

nt+%26+Improvement/ASCO-NCCN+Quality+Measures

5. National Accreditation Program for Breast Centers (NAPBC). 2012 Breast Center Standards

Manual. Available at: http://napbc-breast.org/

6. MOH and AMM Malaysia. Clinical Practice Guidelines: Management of Breast Cancer 2nd

edition. 2010

7. National Quality Forum. www.qualityforum.org/projects/ongoing/cancer/index.asp

8. Coleman MP, Forman D, Bryant H, Butler J et al, and the ICBP Module 1 Working Group.

Cancer survival in Australia, Canada, Denmark, Norway, Sweden, and the UK, 1995–2007

(the International Cancer Benchmarking Partnership): an analysis of population-based cancer

registry data. Lancet 2010; Published Online

9. Coleman MP, Quaresma M, Berrino F, Lutz JM, et al. Cancer survival in five continents: a

worldwide population-based study (CONCORD). Lancet Oncol 2008; 9: 730–56

10. Editorial. Neurological diseases remain neglected and ignored Lancet 2012;379:287

http://qopi.asco.org/Documents/QOPISpring2012MeasuresSummary_000.pdf

http://www.asco.org/ASCOv2/Practice+%26+Guidelines/Quality+Care/Quality+Measurement+%26+Improvement/ASCO-NCCN+Quality+Measures

http://www.asco.org/ASCOv2/Practice+%26+Guidelines/Quality+Care/Quality+Measurement+%26+Improvement/ASCO-NCCN+Quality+Measures

http://napbc-breast.org/

http://www.qualityforum.org/projects/ongoing/cancer/index.asp



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Tables and Graphs

Table 1.0: Data reporting for Breast cancer

2011 2012

2011+

2012

Centre

Jan-

June

(H1

cohort)

July-

Dec. (H2

cohort)

Total*

Jan-

June

(H1

cohort)

July-

Dec. (H2

cohort)

Total* Total

1. Hospital Kuala

Lumpur 184(52) 144(40) 357(100) 226(70) 78(24) 325(100) 682

2. University Malaya

Medical Centre 143(44) 135(42) 322(100) 132(66) 59(29) 201(100) 523

3. Sime Darby Medical

Centre 63(45) 75(54) 139(100) 92(49) 90(48) 187(100) 326

4. Mount Mariam

Cancer Hospital 56(52) 52(48) 108(100) 57(43) 69(52) 133(100) 241

5. Mahkota Medical

Centre Melaka 63(47) 36(27) 133(100) 38(97) 0(0) 39(100) 172

6. NCI Nilai 23(34) 44(66) 67(100) 37(71) 15(29) 52(100) 119

7. Gleneagles Medical

Centre Penang 22(44) 26(52) 50(100) 8(80) 2(20) 10(100) 60

8. Beacon International

Specialist Centre 11(48) 12(52) 23(100) 11(44) 14(56) 25(100) 48

Total 565(47) 524(44) 1199(100) 601(62) 327(34) 972(100) 2171

*Total may be more than H1 +H2 cohort because of imprecise dates



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Table 1.1: Missing Data precluding Breast Cancer Care performance analysis for

Patients diagnosed in year 2011-H1 2012

2011 (H1+H2) and

2012 (H1 only) Cohort

N=1844

Exclusion from analysis

N=384

Ineligible for analysis

(Non-epithelial tumor, Non-primary tumor)

N=179

Incomplete data

Refer Table for details

N=1281

Overall analysis set

# Data quality & Documentation issues No (%) missing

Total number of potential patients in 2011-H1 2012 cohort 1844(100)

Ineligibility Data

1. Non-primary tumor 111(6)

2. Non-epithelial tumor 23(1)

3. Medical tourists (foreigners) 144(8)

4. Outsourcing patients 140(8)

Total number of patients excluded because of ineligibility* 384(21)

Variables with Missing Data

1. Date of diagnosis invalid or missing 154(8)

2. Staging 25(1)

Total number of patients excluded because of missing data 179(10)

*1 patient may have more than 1 type of ineligibility criteria.



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Table 2.0: Patients’ Characteristics at diagnosis, All Patients diagnosed in 2011-

H1 2012

Patient

characteristics Statistics Results

2011 H1 2012 Total

Number of patients Number 847(100%) 434(100%) 1281(100%)

Age, years Mean (SD) 53(11) 54(12) 54(11)

Median (IQR) 53(45, 60) 54(46, 63) 53(46, 61)

(Min, Max) (23, 87) (26, 91) (23, 91)

Age distribution No. (%) Age<40 102(12) 43(10) 145(11)

No. (%) Age 40 to 49 226(27) 108(25) 334(26)

No. (%) Age 50 to 59 297(35) 130(30) 427(33)

No. (%) Age>=60 222(26) 153(35) 375(29)

Sex No. (%) Male 3(0) 6(1) 9(1)

No. (%) Female 844(100) 428(99) 1272(99)

Race No. (%) Malay 277(33) 152(35) 429(33)

No. (%) Chinese 397(47) 203(47) 600(47)

No. (%) Indian 101(12) 36(8) 137(11)

No. (%) Orang Asli 1(0) 1(0) 2(0)

No. (%) Bumiputera

Sabah No data 1(0) 1(0)

No. (%) Foreigner No data 1(0) 1(0)

No. (%) Others 51(6) 35(8) 86(7)

No. (%) Missing 20(2) 3(1) 23(2)

Origin No. (%) Local No data 2(0) 2(0)

No. (%) Referral 521(62) 250(58) 771(60)

Duration from first

presentation at site to

diagnosis, in days (for

patients from

reporting centre only)

Number of patients first

presenting at Reporting

Centre with

326(38) 184(42) 510(40)

Mean (SD) 188 41 229

Median (IQR) 12(12) 17(15) 13(13)

(Min, Max) 7(1, 21) 14(2, 31) 8(1, 21)



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Table 3.0: Tumor Characteristics at diagnosis, Patients diagnosed in year 2011-

H1 2012

Tumor

characteristics

Statistics Results

2011 H1 2012 Total

Number of

patients

Number (%)

847(100) 434(100) 1281(100)

Stage at diagnosis No. (%) Early Breast Cancer

(EBC) 508(60) 257(59) 765(60)

No. (%) Locally Advanced Breast

Cancer (LABC) 235(28) 116(27) 351(27)

No. (%) Metastatic Breast Cancer

(MBC) 104(12) 61(14) 165(13)

Tumor size No (%) T1 (1 to 20mm) 227(27) 66(15) 293(23)

No (%) T2 (21 to 50mm) 262(31) 96(22) 358(28)

No (%) T3 (> 50mm) 83(10) 17(4) 100(8)

No (%) Unknown 275(32) 255(59) 530(41)

Tumor histology No (%) Infiltrating duct

carcinoma, NOS 738(87) 340(78) 1078(84)

No (%) Intraductal carcinoma,

noninfiltrating, NOS 26(3) 13(3) 39(3)

No (%) Other Carcinomas 83(10) 81(19) 164(13)

Grading No (%) Grade 1 56(7) 16(4) 72(6)

No (%) Grade 2 285(34) 94(22) 379(30)

No (%) Grade 3 278(33) 83(19) 361(28)

No (%) No information 228(27) 241(56) 469(37)

Biomarkers Number (%) 847(100) 434(100) 1281(100)

No. (%) ER+* 554(69) 257(69) 811(69)

No. (%) PR+** 488(61) 191(52) 679(58)

No. (%) HER2 ISH+ or IHC+ if

ISH missing or unknown† 233(36) 84(27) 317(33)

No. (%) Triple positive (ER+,

PR+ HER+)†† 106(16) 27(9) 133(14)

No. (%) Triple negative (ER-,

PR- HER-) 100(15) 53(17) 153(16) * Total patients performed ER for 2011 & H1 2012 is 803 & 373 respectively.

** Total patients performed PR 2011 & H1 2012 is 800 & 364 respectively.

† Total patients performed HER2 2011 & H1 2012 is 653 & 310 respectively

†† Total patients performed all ER, PR & HER2 2011 & H1 2012 are 647 & 303 respectively.



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Table 4.0: Treatment of Breast Cancer Patients diagnosed in year 2011-H1

2012

Treatment of BC

patients

Statistics

Results

2011 H1 2012 Total

Surgical

treatment

Number of patients

746(100) 364(100) 1110(100)

Number of patients

who had surgery

Number of patients

with data on duration 653 326 979

Duration from

diagnosis to

surgery, in day

Number of patients

without data on

duration 93 38 131

Mean (SD) 16(17) 19(18) 17(18)

Median (IQR) 11(0, 24) 14(3, 30) 12(1, 27)

(Min, Max) (0, 73) (0, 72) (0, 73)

No. (%) Duration less

or equal to 60 days 636(97) 315(97) 951(97)


or equal to 120 days 653(100) 326(100) 979(100)


or equal to 180 days 653(100) 326(100) 979(100)

Type of Surgical

treatment

No. (%) Breast

conserving surgery 195(26) 93(26) 288(26)

No. (%) Radical

surgery 533(71) 261(72) 794(72)

No. (%) Axillary

nodes surgery 584(78) 239(66) 823(74)

No. (%) Others 7(1) 1(0) 8(1)

No. (%) No

information 14(2) 5(1) 19(2)

Radiotherapy

Number of patients

who had

radiotherapy

Number of patients

(%)

517(100) 256(100) 773(100)

Duration from

diagnosis to

starting

Radiotherapy, in

day

Number of patients

with data on duration

502 252 754

Number of patients

without data on

duration 15 4 19



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Mean (SD) 184(89) 192(91) 187(89)

Median (IQR) 194(126,

241) 210(112, 260) 199(125, 248)

(Min, Max) (0, 460) (3, 443) (0, 460)


or equal to 60 days 64(13) 27(11) 91(12)


or equal to 120 days 119(24) 66(26) 185(25)


or equal to 180 days 219(44) 99(39) 318(42)

Duration from

surgery to starting

Radiotherapy, in

day

Number of patients

who available with

duration

459 222 681

Number of patients

who not available with

date radiotherapy 11 5 16

Mean (SD) 161(84) 166(79) 163(83)

Median (IQR) 172(98, 210) 184(91, 221) 174(95, 214)

(Min, Max) (0, 693) (0, 365) (0, 693)


or equal to 60 days 76(17) 26(12) 102(15)


or equal to 120 days 130(28) 66(30) 196(29)


or equal to 180 days 255(56) 109(49) 364(53)

Type of

Radiotherapy

treatment

No (%) Chest wall

and/or Supraclavicular

fossa (SCF) irradiation 244(49) 144(57) 388(51)

No (%) Whole breast

external irradiation 195(39) 83(33) 278(37)

No (%) Tumour bed

(boost) irradiation 67(15) 28(13) 95(15)

No (%) Brachytherapy 0(0) 0(0) 0(0)

No (%) Bolus

radiation therapy 17(4) 0(0) 17(3)

No (%) Others 31(7) 19(9) 50(8)

No. (%) No

information 42(10) 25(12) 67(10)

Radiotherapy

treatment regimen

Number of patients

who do not have total

dose 14 5 19



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Mean Total dose in

Gy (SD) 41(14) 44(26) 42(19)

Median (IQR) 40(40, 45) 40(40, 45) 40(40, 45)

(Min, Max) (6, 300) (8, 425) (6, 425)

Number of patients

who do not have

number of fractions 16 4 20

Mean Number of

fractions (SD) 16(5) 17(6) 17(6)

Median (IQR) 15(15, 20) 15(15, 20) 15(15, 20)

(Min, Max) (1, 50) (1, 50) (1, 50)

Number of patients

who do not durations 15 7 22

Mean duration in

weeks (SD) 3(2) 4(1) 3(2)

Median (IQR) 3(3, 4) 3(3, 4) 3(3, 4)

(Min, Max) (0, 23) (1, 13) (0, 23)

Systemic

therapies

Number of patients

who had Systemic

therapy

Number of patients

744(100) 372(100) 1116(100)

Duration from

diagnosis to

starting Systemic

therapy, in day

Number of patients

with data on duration

686 350 1036

Number of patients

without data on

duration 58 22 80

Mean (SD) 66(46) 71(47) 68(46)

Median (IQR) 55(34, 89) 59(38, 95) 56(35, 90)

(Min, Max) (0, 224) (0, 223) (0, 224)


or equal to 60 days 381(56) 181(52) 562(54)


or equal to 120 days 608(89) 297(85) 905(87)


or equal to 180 days 659(96) 335(96) 994(96)

Duration from

surgery to starting

Systemic therapy,

in day

Number of patients

who available with

duration

576 293 869



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Number of patients

who not available with

date systemic therapy 79 20 99

Mean (SD) 63(60) 64(57) 63(59)

Median (IQR) 45(30, 71) 46(33, 67) 45(30, 70)

(Min, Max) (0, 435) (0, 361) (0, 435)


or equal to 60 days 380(66) 198(68) 578(67)


or equal to 120 days 512(89) 263(90) 775(89)


or equal to 180 days 545(95) 276(94) 821(94)

Type of Systemic

therapy

No (%) Chemotherapy

539(72) 261(70) 800(72)

No (%) Hormonal

therapy 477(64) 222(60) 699(63)

No (%) Targeted

therapy 52(7) 23(6) 75(7)

Exposure to drug

classes of

chemotherapy

No (%) Anthracycline

antibiotics

464(86) 225(86) 689(86)

No (%)

Antimetabolites 405(75) 198(76) 603(75)

No (%) Alkylating

agents 511(95) 244(93) 755(94)

No (%) Vinca

alkaloids 4(1) 2(1) 6(1)

No (%) Taxane 268(50) 120(46) 388(49)

No(%) Platinum

compounds 9(2) 6(2) 15(2)

No (%)

Topoisomerase

inhibitors T1 0(0) 0(0) 0(0)

No (%) T1 II 1(0) 0(0) 1(0)

No (%) Others 5(1) 0(0) 5(1)

Exposure to drug

classes of hormonal

therapy

No (%) Oestrogen

receptor antagonist

407(85) 192(86) 599(86)

No (%) Aromatase

Inhibitor 64(13) 29(13) 93(13)

No (%)

Gonadotrophin 2(0) 0(0) 2(0)



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No (%) Progestogens 0(0) 0(0) 0(0)

No (%) Anti

Androgens 0(0) 0(0) 0(0)

No (%) Others 11(2) 0(0) 11(2)

No. (%) No

information 6(1) 2(1) 8(1)

Table 5.0: Summary of Breast Cancer care performance for Patients diagnosed

in year 2011 (H1+H2) and 2012 (H1 only) Refer Appendix for

Results by individual years (2011 and 2012) separately

Detailed results by individual performance measures

# Performance measure Denomin-

ator*

Numerator-

Rx administered

only(%)**

Numerator-

Rx considered

OR administered

(%)**

1. Pathology report confirming

malignancy

1281 1281(100) 1281(100)

2. Corticosteroids and serotonin antagonist

prescribed with moderate/high emetic

risk chemotherapy

No data No data No data

3. Surgery for Stage I to III breast cancer

within 2 months of diagnosis

1014 825(81) 954(94)

4. Combination chemotherapy for Stage I

to III ER/PR negative breast cancer


265 191(72) 216(82)

5. Radiation therapy for Stage I to III

breast cancer after breast conserving

surgery within 1 year of diagnosis

272 207(76) 217(80)

6. Radiation therapy for Stage I to III

breast cancer with node positive after

mastectomy within 1 year of diagnosis

139 109(78) 115(83)

7. Tamoxifen or AI for Stage I to III ER

or PR positive breast cancer within 1

year of diagnosis

696 525(75) 557(80)

8. Trastuzumab for Stage I to III HER2

positive breast cancer within 4 months

of diagnosis

260 52(20) 59(23)

Composite score 3927 3190(81) 3399(87)

*Number of eligible patients

** Number (%) of eligible patients whose care adhere with performance measure



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16

Remarks 1. None

2. None

3. Surgery

According to patient's relative, patient will continue treatment in Jakarta-1 patient.

Back to Indonesia-1 patient.

Came for check up on 26/9/12 then on will continue check in surabaya-1 patient.

Completed Radiotherapy and will continue follow up in Lam Wah Ee Hospital-1 patient.

Continue with follow up 3monthly in MMCH-1 patient.

Patient came to SDMC in 2009 but defaulted until 2012-1 patient.

Patient will come for 6monthly check up to MMCH-1 patient.

Radiotherapy completed and will continue follow up in GH Pulau Pinang-1 patient.

Referred back to H. Temerloh. After chemo, tamoxifen was to be given-1 patient.

Rip on 21/7/12 in Elizabeth Hosp Medan-1 patient.

Treatment performed but not within the required period-20 patients.

Treatment performed but treatment date not available-98 patients.

to follow up on treatment part on H2-1 patient.

4. Chemotherapy

Patient not keen on chemo-1 patient.



5. Radiation therapy after breast conserving surgery

Lost to followup.-1 patient.

Patient was not seen by the Oncologists-1 patient.



6. Radiation therapy for node+ cancer

CT Thorax and Abdomen indicated patient had multiple liver mets and lung mets-1 patient.



7. Tamoxifen or AI treatment

Lost to followup. Patient did not turn up after completion of chemotherapy-1 patient.



Patient refused Tamoxifen-1 patient.

8. Trastuzumab treatment

Treatment was performed but not within the required period-6 patients.

Treatment performed but treatment date not available-1 patient.

9. None



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17

Appendix 1: Definition of Performance Measures for Breast Cancer care # Measure Denominator definition Numerator definition

1. Diagnostic

pathology

Inclusion criteria:

Patients with confirmed diagnosis of

primary cancer, any stages

Patient had Pathology report

confirming malignancy

2. Cancer

staging

Inclusion criteria:



Patient had Staging

documented within one

month of first visit to

reporting centre

3. Chemotherapy

Treatment

plan

Inclusion criteria:



Patient had documented plan

for chemotherapy, including

doses, route, and time

intervals

4. Anti- emetic

prescribed

Inclusion criteria:


primary cancer, any stages Received

moderate/high emetic risk chemotherapy

Patient received

Corticosteroids and serotonin

antagonist prescribed

5. Radiotherapy/

Median time

to starting

therapy

Inclusion criteria:

Stage I, II, or III

Contraindication to Radiotherapy or other

reasons for withholding therapy

Surgically treated by breast conservation

surgery (surgical excision less than

mastectomy)

Age 18-69 at time of diagnosis

Women

Known or assumed first or only cancer

diagnosis

Primary tumors of the breast

Epithelial malignancy only

All or part of first course of treatment

performed at the reporting facility

Known to be alive within 1 year (365 days)

of diagnosis

Patient under age 70 who had

breast conserving surgery for

breast cancer received

radiation therapy within 1

year (365 days) of date of

diagnosis

6. Chemotherapy

/ Median time

to starting

therapy

Inclusion criteria:

T1c, or Stage II or III

Primary tumor is estrogen receptor (ER)

negative and progesterone receptor (PR)

negative

Age 18-69 at time of diagnosis

Women


Patient received adjuvant

multi-agent (combination)

chemotherapy within 120

days of date of diagnosis



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18

# Measure Denominator definition Numerator definition

diagnosis

Primary tumors of the breast




Known to be alive within 4 months (120

days) of diagnosis

7. Hormonal

therapy/

Median time

to starting

therapy

Inclusion criteria:


Primary tumor is estrogen receptor (ER)

positive or progesterone receptor (PR)

positive

Women

Age >=18 at time of diagnosis


diagnosis



performed at the reporting facility Known

to be alive within 1 year (365 days) of

diagnosis Exclusion criteria:

Not documented drug name

Patient received Tamoxifen

or Aromatase Inhibitor within

1 year (365 days) of date of

diagnosis

8. Targeted

therapy/

Median time

to starting

therapy

Inclusion criteria:


Primary tumor is HER2 positive

Women

Age >=18 at time of diagnosis


diagnosis




Known to be alive within 1 year (365 days)

of diagnosis

Patient received Trastuzumab

therapy within 1 year (365

days) days of date of

diagnosis

9. Stage specific

Risk adjusted

5-year relative

survival



Age 15–99 years

Patients who died after cancer

diagnosis



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19

Appendix 2: Breast Cancer care Performance results for year 2011 and year 2012

Summary

2011 2012

# Performance measure Denomin-

ator*

Numerator-

Rx

administer-

ed (%)**

Numerator-

Rx

considered†

OR

administer-

ed (%)

Denomin-

ator*

Numerator-

Rx

administered

(%)**

Numerator

- Rx

considered

† OR

administer-

ed (%)

1. Pathology report confirming

malignancy

847 847(100) 847(100) 434 434(100) 434(100)

2. Surgery for Stage I to III breast

cancer within 2 months of

diagnosis

677 558(82) 646(95) 337 267(79) 308(91)

3. Combination chemotherapy for

Stage I to III ER/PR negative

breast cancer within 4 months

of diagnosis

184 137(74) 155(84) 81 54(67) 61(75)

4. Radiation therapy for Stage I to

III breast cancer after breast

conserving surgery within 1

year of diagnosis

186 142(76) 151(81) 86 65(76) 66(77)

5. Radiation therapy for Stage I to

III breast cancer with node

positive after mastectomy

within 1 year of diagnosis

102 83(81) 89(87) 37 26(70) 26(70)

6. Tamoxifen or AI for Stage I to III

ER or PR positive breast cancer


478 358(75) 387(81) 218 167(77) 170(78)

7. Trastuzumab for Stage I to III

HER2 positive breast cancer


190 38(20) 44(23) 70 14(20) 15(21)

8. Composite score 2664 2163(81) 2319(87) 1263 1027(81) 1080(86)



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20

Table A2.1 Summary of Breast Cancer care performance for Patients diagnosed

in year 2011

# Performance

measure

Denomin-

ator*

Numerator

- Rx

administere

d (%)**

Numerator-

Rx

considered†

OR

administer-

ed (%)

Remarks†

1. Pathology

report

confirming

malignancy

847 847(100) 847(100)

2. Surgery for

Stage I to III

breast cancer

within 2

months of

diagnosis

677 558(82) 646(95) 1. Came for check up on 26/9/12

then on will continue check in

surabaya-1 patient.

2. Completed Radiotherapy and will

continue follow up in Lam Wah Ee

Hospital-1 patient.

3. Continue with follow up

3monthly in MMCH-1 patient.

4. Patient will come for 6monthly

check up to MMCH-1 patient.

5. Radiotherapy completed and will

continue follow up in GH Pulau

Pinang-1 patient.

6. Referred back to H. Temerloh.

After chemo, tamoxifen was to be

given-1 patient.

7. Rip on 21/7/12 in Elizabeth Hosp

Medan-1 patient.

8. Treatment performed but not

within the required period-12

patients.

9. Treatment performed but

treatment date not available-68

patients.

10. to follow up on treatment part on

H2-1 patient.

3. Radiation

therapy for

186 142(76) 151(81) 1. Lost to followup.-1 patient.

2. Patient was not seen by the



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21

# Performance

measure

Denomin-

ator*

Numerator

- Rx

administere

d (%)**

Numerator-

Rx

considered†

OR

administer-

ed (%)

Remarks†

Stage I to III

breast cancer

after breast

conserving

surgery

within 1 year

of diagnosis

Oncologists-1 patient.



patients.



patients.

4. Radiation

therapy for

Stage I to III

breast cancer

with node

positive after

mastectomy

within 1 year

of diagnosis

102 83(81) 89(87) 1. CT Thorax and Abdomen

indicated patient had multiple liver

mets and lung mets-1 patient.



patients.



patients.

5. Combination

chemotherapy

for Stage I to

III ER/PR

negative

breast cancer

within 4

months of

diagnosis

184 137(74) 155(84) 1. Patient not keen on chemo-1

patient.



patients.



patients.

6. Tamoxifen or

AI for Stage

I to III ER or

PR positive

breast cancer

within 1 year

of diagnosis

478 358(75) 387(81) 1. Lost to followup.Patient did not

turn up after completion of

chemotherapy-1 patient.



patients.



patients.

4. patient refused Tamoxifen-1

patient.



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22

# Performance

measure

Denomin-

ator*

Numerator

- Rx

administere

d (%)**

Numerator-

Rx

considered†

OR

administer-

ed (%)

Remarks†

7. Trastuzumab

for Stage I to

III HER2

positive

breast cancer

within 4

months of

diagnosis

190 38(20) 44(23) 1. Treatment performed but not


patients.



patient.

8. Composite

score

2664 2163(81) 2319(87)



Table A2.2: Summary of Breast Cancer care performance for Patients diagnosed

in year H1 2012

# Performance

measure

Denomi

n-ator*

Numerator

- Rx

administere

d (%)**

Numerator-

Rx

considered†

OR

administer-

ed (%)

Remarks†

9. Pathology report

confirming

malignancy

434 434(100) 434(100)

10. Surgery for

Stage I to III

breast cancer

within 2 months

of diagnosis

337 267(79) 308(91) 1. According to patient's relative will

be continue treatment in Jakarta-1

patient.

2. Back to Indonesia-1 patient.

3. Patient came to SDMC in 2009

but defaulted until 2012-1 patient.





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23

# Performance

measure

Denomi

n-ator*

Numerator

- Rx

administere

d (%)**

Numerator-

Rx

considered†

OR

administer-

ed (%)

Remarks†

patient.

11. Radiation

therapy for

Stage I to III

breast cancer

after breast

conserving

surgery within 1

year of diagnosis

86 65(76) 66(77)

12. Radiation

therapy for

Stage I to III

breast cancer

with node

positive after

mastectomy

within 1 year of

diagnosis

37 26(70) 26(70)

13. Combination

chemotherapy

for Stage I to III

ER/PR negative

breast cancer

within 4 months

of diagnosis


within the required period-7 patient.

14. Tamoxifen or AI

for Stage I to III

ER or PR positive

breast cancer

within 1 year of

diagnosis



15. Trastuzumab for

Stage I to III

HER2 positive

breast cancer

within 4 months

of diagnosis





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24

# Performance

measure

Denomi

n-ator*

Numerator

- Rx

administere

d (%)**

Numerator-

Rx

considered†

OR

administer-

ed (%)

Remarks†

16. Composite score 1263 1027(81) 1080(86)





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25

Appendix 3: Detailed Performance results by Individual Performance measures

Table A3.1: Pathology Report confirming diagnosis for Breast Cancer (BC) patients in year 2011-H1 2012 Pathology report

confirming diagnosis

Statistics Results

2011 H1 2012 Total

Number of BC patients

in the reporting period

Number of

patients 847 434 1281


ineligible for inclusion

Number of

patients 0 0 0


included in this

analysis

Number of

patients (%)

847(100) 434(100) 1281(100)


whose care met

performance standard

Number of

patients (%)

847(100) 434(100) 1281(100)

Table A3.2: Surgery treatment for Stage I to III breast cancer within 2 months of

diagnosis for Breast Cancer (BC) patients in Year 2011-H1 2012

Radiation therapy for

Stage I to III breast

cancer after breast

conserving surgery


Statistics Results

2011 H1 2012 Total

Number of BC patients in

the reporting period

Number of patients

847 434 1281


excluded because surgery

was NOT administered in

reporting centre

Number of patients

0 0 0


with contraindication to

surgery, or other reasons

for withholding therapy

Number of patients

0 0 0


ineligible for other reasons

(Age, Stage)

Number of patients

170 97 267


included in this analysis

Number of patients

(%) 677(100) 337(100) 1014(100)



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26



cancer after breast

conserving surgery


Statistics Results

2011 H1 2012 Total


who received surgery

Number of patients

(%) 638(94) 305(91) 943(93)


whose care met


Number of patients

(%)

558(82) 267(79) 825(81)

Duration from diagnosis to

starting Surgery, in day

Mean (SD)

15(17) 19(18) 17(17)

Median (IQR) 11(0, 24) 14(4, 30) 12(1, 27)

(Min, Max) (0, 73) (0, 72) (0, 73)

No. (%) Duration<=

60 days 558(82) 267(79) 825(81)

No. (%) Duration<=

120 days 570(84) 275(82) 845(83)

No. (%) Duration

<=180 days 570(84) 275(82) 845(83)

Table A3.3: Radiation therapy for Stage I to III breast cancer after breast

conserving surgery within 1 year of diagnosis for Breast Cancer (BC) patients in

year 2011-H1 2012



cancer after breast

conserving surgery


Statistics Results

2011 H1 2012 Total



Number of patients

847 434 1281


excluded because

radiotherapy was NOT

administered in reporting

centre

Number of patients

0 0 0



Radiotherapy, or other

reasons for withholding

Number of patients

0 0 0



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27



cancer after breast

conserving surgery


Statistics Results

2011 H1 2012 Total

therapy


who did not have prior

breast conserving surgery

Number of patients

652 341 993



(Age, Stage)

Number of patients

9 7 16



Number of patients

(%) 186(100) 86(100) 272(100)


who received radiation

therapy

Number of patients

(%)

149(80) 66(77) 215(79)


whose care met


Number of patients

(%)

142(76) 65(76) 207(76)


starting Radiotherapy, in

day

Mean (SD)

157(90) 172(90) 162(90)

Median (IQR) 158(75, 220) 183(90, 227) 164(76, 222)

(Min, Max) (20, 394) (14, 420) (14, 420)

No. (%) Duration<=

60 days 29(16) 10(12) 39(14)

No. (%) Duration<=

120 days 51(27) 21(24) 72(26)

No. (%) Duration

<=180 days 84(45) 32(37) 116(43)



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28

Table A3.4: Radiation therapy for Stage I to III breast cancer with node positive

after breast mastectomy surgery within 1 year of diagnosis for Breast Cancer

(BC) patients in Year 2011-H1 2012



cancer after breast

conserving surgery

within 1 year of

diagnosis

Statistics Results

2011 H1 2012 Total



Number of patients

847 434 1281


excluded because

radiotherapy was NOT


centre

Number of patients

0 0 0



Radiotherapy, or other


therapy

Number of patients

0 0 0


who did not have prior

mastectomy surgery and or

no positive node

Number of patients

314 173 487



(Age, Stage)

Number of patients

431 224 655



Number of patients

(%) 102(100) 37(100) 139(100)


who received radiation

therapy

Number of patients

(%)

88(86) 26(70) 114(82)


whose care met


Number of patients

(%)

83(81) 26(70) 109(78)


starting Radiotherapy, in

day

Mean (SD)

219(62) 190(80) 212(67)

Median (IQR) 216(189, 214(152, 216(184,



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29



cancer after breast

conserving surgery

within 1 year of

diagnosis

Statistics Results

2011 H1 2012 Total

252) 231) 244)

(Min, Max) (20, 414) (4, 356) (4, 414)

No. (%) Duration<=

60 days 2(2) 2(5) 4(3)

No. (%) Duration<=

120 days 5(5) 6(16) 11(8)

No. (%) Duration

<=180 days 18(18) 9(24) 27(19)



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30

Table A3.5: Combination chemotherapy for Stage I to III ER/PR negative cancer

within 4 months of diagnosis for Breast Cancer (BC) patients in year 2011-H1

2012

Combination

chemotherapy for

Stage I to III ER/PR

negative breast cancer

within 4 months of

diagnosis

Statistics Results

2011 H1 2012 Total


in the reporting period

Number of

patients 847 434 1281


excluded because

chemotherapy was

NOT administered in

reporting centre

Number of

patients

0 0 0



Chemotherapy, or other


therapy

Number of

patients

0 0 0


who are ER positive

OR PR positive

Number of

patients

625 334 959


ineligible for other

reasons (Age, Stage)

Number of

patients

38 19 57



Number of

patients (%) 184(100) 81(100) 265(100)


who received

chemotherapy

Number of

patients (%)

154(84) 61(75) 215(81)


whose care met


Number of

patients (%)

137(74) 54(67) 191(72)

Duration from

diagnosis to starting

Chemotherapy, in day

Mean (SD)

59(33) 67(35) 61(34)

Median (IQR) 53(35, 78) 55(41, 93) 53(37, 81)

(Min, Max) (4, 145) (9, 153) (4, 153)

No. (%)

Duration<= 60 82(45) 37(46) 119(45)



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31

Combination

chemotherapy for

Stage I to III ER/PR

negative breast cancer

within 4 months of

diagnosis

Statistics Results

2011 H1 2012 Total

days

No. (%)

Duration<= 120

days 137(74) 54(67) 191(72)

No. (%) Duration

<=180 days 144(78) 61(75) 205(77)

Table A3.6: Tamoxifen or AI for Stage I to III ER or PR positive cancer within 1

year of diagnosis for Breast Cancer (BC) patients in year 2011-H1 2012

Tamoxifen or AI for

Stage I to III ER or PR

positive breast cancer


Statistics Results

2011 H1 2012 Total



Number of patients

847 434 1281


excluded because

hormonal therapy was

NOT administered in

reporting centre

Number of patients

0 0 0



Tamoxifen or AI, or other


therapy

Number of patients

0 0 0


who are ER negative AND

PR negative

Number of patients

267 163 430



(Age, Stage)

Number of patients

102 53 155



Number of patients

(%) 478(100) 218(100) 696(100)



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32

Tamoxifen or AI for

Stage I to III ER or PR

positive breast cancer


Statistics Results

2011 H1 2012 Total


who received Tamoxifen

or AI therapy

Number of patients

(%)

385(81) 170(78) 555(80)


who received Tamoxifen

or AI therapy within 365

days of date of diagnosis

Number of patients

(%)

358(75) 167(77) 525(75)


starting Tamoxifen or AI

therapy, in day

Mean (SD)

166(89) 165(94) 166(91)

Median (IQR) 176(89, 225) 173(79, 227) 175(83, 226)

(Min, Max) (0, 436) (14, 450) (0, 450)

No. (%) Duration<=

60 days 66(14) 29(13) 95(14)

No. (%) Duration<=

120 days 125(26) 62(28) 187(27)

No. (%) Duration

<=180 days 190(40) 90(41) 280(40)

Table A3.7: Trastuzumab for Stage I to III HER2 positive cancer within 1 year of

diagnosis for Breast Cancer (BC) patients in year 2011-H1 2012

Trastuzumab for Stage I

to III HER2 positive

breast cancer within 1

year of diagnosis

Statistics Results

2011 H1 2012 Total



Number of patients

847 434 1281


excluded because targeted

therapy was NOT


centre

Number of patients

0 0 0



Trastuzumab, or other


Number of patients

0 0 0



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33

Trastuzumab for Stage I

to III HER2 positive

breast cancer within 1

year of diagnosis

Statistics Results

2011 H1 2012 Total

therapy


who were HER2 negative

Number of patients

614 350 964



(Age, Stage)

Number of patients

43 14 57



Number of patients

(%) 190(100) 70(100) 260(100)


who received

Trastuzumab therapy

Number of patients

(%)

43(23) 15(21) 58(22)


whose care met

performance standard (ie

received Trastuzumab

with 12 months of

diagnosis)

Number of patients

(%)

38(20) 14(20) 52(20)


starting Trastuzumab

therapy, in day

Mean (SD)

140(117) 176(91) 149(112)

Median (IQR)

100(49, 217)

139(105,

239) 118(54, 221)

(Min, Max) (22, 476) (72, 370) (22, 476)

No. (%) Duration<=

60 days 18(9) 0(0) 18(7)

No. (%) Duration<=

120 days 25(13) 4(6) 29(11)

No. (%) Duration

<=180 days 30(16) 9(13) 39(15)