Sample Jack W, Hoskin Tanya L, Johnson Jeffrey E, Mrdutt Mary M, Piltin Mara A, Boughey Judy C, Degnim Amy C, Hieken Tina J
Division of Breast and Melanoma Surgical Oncology, Department of Surgery, Mayo Clinic, Rochester, MN, USA.
Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA.
Ann Surg Oncol. 2025 Feb;32(2):944-951. doi: 10.1245/s10434-024-16477-1. Epub 2024 Nov 10.
Efforts to define the key technical elements of breast cancer surgery, the foundation of curative treatment, have been recognized recently by the Commission on Cancer (CoC). Effective 1 January 2023, surgeon documentation in synoptic format of specific technical elements of axillary surgery for breast cancer became a CoC accreditation requirement (standards 5.3 and 5.4).
After Institutional Review Board approval, the study identified patients from the authors' prospective breast surgery database granting research consent who underwent axillary surgery for breast cancer from 1 January 2023 to 31 December 2023. Operative reports, which since 2017 have been standardized templates, were reviewed for compliance.
The study identified 592 eligible patients who had 623 axillary operations (76 % cN0, 24 % cN+). Full compliance with standard 5.3 was met in 71 % of cases and with standard 5.4 in 97 % of cases. Regarding standard 5.3, a mid-year internal review and subsequent individual surgeon-level communication significantly increased full synoptic documentation compliance to 98 % in quarter 4 (p < 0.001). The most common reasons for non-compliance were failure to record a response as "not applicable" regarding tracer use to identify sentinel lymph nodes in the neoadjuvant setting (the most deficient element, 81 % deficient) and failure to record "not applicable" for elements conditional on setting (upfront vs neoadjuvant surgery). Regarding standard 5.4, which has fewer elements overall, none of which are conditional, compliance was high throughout 2023.
Mid-year audit and individual surgeon-level communication successfully improved compliance with standard 5.3 to meet the required threshold for accreditation. Prior practice adoption of templated operative notes likely facilitated integration of the synoptic standards into surgeon workflow.
癌症委员会(CoC)最近认可了确定乳腺癌手术关键技术要素的努力,而乳腺癌手术是根治性治疗的基础。自2023年1月1日起,以概要形式记录乳腺癌腋窝手术特定技术要素的外科医生文件成为CoC认证要求(标准5.3和5.4)。
在获得机构审查委员会批准后,该研究从作者的前瞻性乳腺手术数据库中识别出在2023年1月1日至2023年12月31日期间接受乳腺癌腋窝手术并给予研究同意的患者。自2017年以来一直采用标准化模板的手术报告接受了合规性审查。
该研究确定了592例符合条件的患者,他们共进行了623例腋窝手术(76%为cN0,24%为cN+)。71%的病例完全符合标准5.3,97%的病例完全符合标准5.4。关于标准5.3,年中内部审查及随后的个体外科医生层面沟通使第四季度的完整概要文件合规率显著提高至98%(p<0.001)。不合规的最常见原因是在新辅助治疗中未能将使用示踪剂识别前哨淋巴结的反应记录为“不适用”(最欠缺的要素,81%欠缺),以及未能将取决于手术情况(初始手术与新辅助手术)的要素记录为“不适用”。关于标准5.4,其总体要素较少且均无条件,2023年全年的合规率都很高。
年中审核和个体外科医生层面沟通成功提高了对标准5.3的合规性,以达到认证所需的阈值。先前采用模板化手术记录可能有助于将概要标准融入外科医生的工作流程。