Quality Measures

Imaging Measures

Imaging 1: Imaging Timeliness of Care - Time Between Screening Mammogram and Diagnostic Imaging

Imaging 2: Mammography Recall rate

Imaging 3: Imaging Timeliness of Care

Imaging 4: Surgical Timeliness of Care - Time Between First Positive Needle Biopsy and Initial Breast Cancer Surgery

Imaging 5: Needle Biopsy Use Rate

Imaging 6: (New) Cancer Detection Rate

Imaging 7: (New) Positive Biopsy Rate (PPV2)

Imaging 8: (New) Percent Use of Screening Tomosynthesis

Imaging 9: (New) Breast Center of Excellence Designation

Pathology Measures

Pathology 1: Pathology Timeliness of Care for Breast Cancer - Time Between Initial Needle Breast Biopsy (excluding open surgical) and Pathology Results

Pathology 2: Pathology Timeliness of Care - Time Between Initial Breast Cancer Surgery and Pathology Result

Pathology 3: Cancer Pathology Report Completeness - Tumor Size

Pathology 4: Cancer Pathology Report Completeness - Lumpectomy Closest Margin Analysis

Pathology 5:Cancer Pathology Report Completeness - All Lumpectomy Margins Identified

Pathology 6: Cancer Pathology Report Completeness - Lymph Node Analysis

Pathology 7: Cancer Pathology Report Completeness - ER AND PR Receptor Measurement for Invasive Disease

Pathology 8: Cancer Pathology Report Completeness - ER Receptor Measurement for In Situ Disease

Surgery Measures

Surgery 1: Surgical Timeliness of Care - Time Between First Positive Needle Biopsy and Initial Breast Cancer Surgery

Surgery 2: Surgical Care - Sentinel Node Biopsy

Surgery 3: Breast Conservation Surgery - Overall Rate (administered)

Surgery 4: Breast Conservation Surgery - Re-Excision Rate

Surgery 5: (New) Axillary dissection AFTER positive sentinel node biopsy if not receiving radiation therapy.

Surgery 6: (New) Negative Margin Rate for Initial Breast Lumpectomy

Surgery 7: (New) Use of Nipple Sparing Mastectomy

Surgery 8: (New) Contralateral Prophylactic Mastectomy

*** Surgery 9 New Measure Pending***

Surgery 10: Five Year Stage Specific Survival Rate

Medical Oncology Measures

Medical Oncology 1: Chemotherapy Use - Rate for women under 70 with AJCC T1cN0M0 or Stage IB - III hormone receptor negative breast cancer. (administered)

Medical Oncology 2: Adjuvant Endocrine Therapy - Rate for Invasive Breast Cancer (Administered)

Medical Oncology 3: Adjuvant Endocrine Therapy - Rate for Invasive Breast Cancer (Recommended)

Medical Oncology 4: (New) Use of Genomic Assay in ER+/PR+ Node negative tumors

Medical Oncology 5: (New) Use of Trastuzumab based Chemotherapy immunotherapy in conjunction with chemotherapy.

Medical Oncology 6: (New) Fertility preservation prior to systemic chemotherapy in age appropriate (or fertile) patients.

***Medical Oncology 7 New Measure Pending***

Medical Oncology 8: (New) Five Year Stage Specific Survival Rate

Radiation Oncology Measures

Radiation Oncology 1: Post-Lumpectomy Radiation - Rate for Invasive Breast Cancer (Administered)

Radiation Oncology 2: (New) Post Mastectomy Radiation is administered within 1 year of diagnosis for women with 4 or more positive regional nodes (administered)

Radiation Oncology 3: (New) Radiation Consultation is provided for post mastectomy patients with positive nodes.

Radiation Oncology 4: (New) Percent Hypofractionation treatment.

Radiation Oncology 5: (New) Percent Partial Breast Irradiation treatment.