title: [A set of indicators to monitor the adherence to the guidelines for the diagnosis and treatment of breast cancer].
abstract: OBJECTIVE
  to present a set of indicators developed from six Local Health Authorities of the Lombardy Region to monitor the diagnostic and therapeutic pathway of breast cancer patients, applied to 2007-2009 incident cases.
  
  
  METHODS
  retrospective cohort study.
  
  
  METHODS
  all subjects with primary breast cancer, incident in the period 2007-2009, and collected by cancer registries of Milano 1, Bergamo, Cremona, Milano, Milano 2 and Monza-Brianza (5,320,272 inhabitants) were included.
  
  
  METHODS
  through the use of combined current health databases (health registry, hospitalizations, outpatient, pharmaceutical prescription and specific database for anticancer drugs), for each incident case 34 different indicators have been developed to measure the appropriateness of the procedures provided for diagnosis, treatment (surgical and medical) and follow-up. For each indicator, we analyzed the relationship with age, stage, deprivation index, type of treatment, volume of the specific procedure of the hospital where primary surgery was performed. Estimates were adjusted using multilevel regression models.
  
  
  RESULTS
  12,988 incident cases, without metastatic diseases and other cancers, were included in the cohort: 62% were localized to the breast, 33% to the axillary lymph-nodes, 3% metastatic ab initio, and 2% with unknown stage. Deviations from the expected value of different magnitude depending on the type of indicator were observed: the most important differences were detected for the follow-up indicators. There was, in fact, an excess of several procedures in the first year of follow-up: 75% of the cases performed a dosage of a tumor marker, 67% an ecography or a CT scan or an MR, and 37% a bone scan. On the other hand, the access to neoadjuvant and adjuvant treatments in older women was far below the expected values.
  
  
  CONCLUSIONS
  the study presents data derived from a large cohort of population cases; the set of indicators was validated by a board of oncologists. The use of indicators calculated by linking the cancer registries (that provide staging) and administrative databases allows the assessment of compliance to the guidelines for diagnosis and treatment of tumours. This experience shows that it is possible to develop a methodology, shared with clinicians, to define indicators that measure the distance between guidelines and current clinical practice in order to decrease variability, to limit inappropriateness, and to reduce unnecessary diagnostic tests for patients (and, consequently, hospitals organizational overload). In order to be sustainable and equitable, a health care system must be able to ensure implementation of protocols/procedures based exclusively on the best available scientific evidences.
authors.affiliation: Osservatorio epidemiologico e registri specializzati, ASL Milano 1 antonio.russo@aslmi1.mi.it.
authors.forename: Antonio
authors.initials: A
authors.lastname: Russo
authors.forename: Anita
authors.initials: A
authors.lastname: Andreano
authors.forename: Emanuela
authors.initials: E
authors.lastname: Anghinoni
authors.forename: Mariangela
authors.initials: M
authors.lastname: Autelitano
authors.forename: Aldo
authors.initials: A
authors.lastname: Bellini
authors.forename: Maurizio
authors.initials: M
authors.lastname: Bersani
authors.forename: Sabrina
authors.initials: S
authors.lastname: Bizzoco
authors.forename: Luca
authors.initials: L
authors.lastname: Cavalieri d'Oro
authors.forename: Adriano
authors.initials: A
authors.lastname: Decarli
authors.forename: Silvia
authors.initials: S
authors.lastname: Lucchi
authors.forename: Salvatore
authors.initials: S
authors.lastname: Mannino
authors.forename: Emerico
authors.initials: E
authors.lastname: Panciroli
authors.forename: Magda
authors.initials: M
authors.lastname: Rognoni
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Sampietro
authors.forename: Maria Grazia
authors.initials: MG
authors.lastname: Valsecchi
authors.forename: Marco
authors.initials: M
authors.lastname: Villa
authors.forename: Carlo
authors.initials: C
authors.lastname: Zocchetti
authors.forename: Alberto
authors.initials: A
authors.lastname: Zucchi
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D014408:Biomarkers, Tumor / Q000032:analysis; D001943:Breast Neoplasms / Q000175:diagnosis* / Q000628:therapy*; D003131:Combined Modality Therapy; D019468:Disease Management; D055088:Early Detection of Cancer; D019317:Evidence-Based Medicine; D005260:Female; D005500:Follow-Up Studies; D006297:Health Services Accessibility; D006801:Humans; D007558:Italy; D008327:Mammography / Q000706:statistics & numerical data; D008408:Mastectomy / Q000706:statistics & numerical data; D008875:Middle Aged; D009367:Neoplasm Staging; D017410:Practice Guidelines as Topic; D019984:Quality Indicators, Health Care; D012189:Retrospective Studies; D016896:Treatment Outcome
chemical_list: D014408:Biomarkers, Tumor