Aiello Bowles et al. BMC Cancer 2012, 12:136 http://www.biomedcentral.com/1471-2407/12/136 participation rates among surgeons practicing in aca- demic settings was low [8]. Facilities may also receive certification from the National Accreditation Program for Breast Centers (NAPBC) [9]. Accredited breast cen- ters are required to meet certain surgical standards including > 50% of early stage breast cancer patients treated with breast conserving surgery, SNL for all patients with stage I or II disease, and diagnosis with palpation- or image-guided biopsy rather than open biopsy. Perhaps the most detailed surgical quality measures come from the National Consortium of Breast Centers, Inc. and its National Quality Measures for Breast Cen- ters (NQMBC) program [10]. The NQMBC’s quality measures include 37 measures for breast cancer diagno- sis and treatment including surgical timeliness, pathol- ogy timeliness, pathology report completeness (tumor size, margins, lymph nodes, and specimen sampling ade- quacy), sentinel node biopsy, breast conservation surgery rate, and re-excision rate. The program includes over 200 voluntary participants and allows them to compare their performance with other centers across the US. Members can collect all measures or a select few depending on their certification level. The validity of some of these measures as reasonable quality measures has not been tested in a broad population of patients. The data collected from the BRCASO study will enable us to evaluate a number of quality measures spe- cific to breast cancer surgery. Our three initial proposed surgical quality measures are 1) initial mastectomy rate, 2) initial partial mastectomy positive margin rate, and 3) initial partial mastectomy re-excision rate. At this time, we are not recommending benchmarks for these mea- sures, but instead, will evaluate variability in these mea- sures by patient-, surgeon-, facility-, and regional-level factors, and by invasive and in situ diagnoses that may inform future benchmarks. We will be able to control these outcomes for clinical factors such as estimated tumor size, known multi-centric disease, breast imaging, anesthesia, localization technique, neo-adjuvant treat- ment, and detailed tumor characteristics. We also have detailed data on timeliness of procedures, extent of lymph node procedures, positive node counts, and reconstruction, which may serve as additional surgical quality measures. Most importantly, we have collected margin status for each procedure performed, which is important in assessing surgical quality and cannot be extracted from tumor registry data. The BRCASO database has the potential to be one of the largest, multi-site breast cancer surgical quality research databases to-date. The research possibilities may extend even beyond surgical quality measures. One of the major differences between BRCASO and the national efforts described above is that BRCASO does Page 6 of 7 not rely on voluntary reporting. BRCASO includes a diverse geographic sample of all surgeons who practice at our varied institutions (health maintenance organiza- tion, university hospital, contracted community hospi- tals). In addition, a proportion of the data from the CRN sites were collected from electronic administrative data, a process that has the potential to be extended to other organizations with similarly organized billing data. However, the BRCASO database is not without limita- tions. Our electronic administrative data were less suffi- cient than we had hoped for in pre-filling the database. Thus our chart abstraction took longer than we antici- pated, and we fell short of the originally anticipated 6,095 cases. We have no detailed information on sur- geon training, surgeon specialty, patient breast size, family history or patient preferences - all of which can account for variability in surgical procedures and qual- ity. The focus of BRCASO was to collect data on speci- fic short-term surgical outcomes such as reexcisions rates; thus we do not have data on long-term outcomes of recurrence or mortality, but plan to expand our efforts to collect these data in the future. We learned several important lessons that others may want to consider when collecting surgical quality data. First, while electronic administrative data were useful in prefilling some of our data elements, they have serious limitations. Most importantly, there is no way to get accurate detailed margin or lymph node data from elec- tronic administrative data; re-excision data may also be inaccurate as repeat procedures do not appear to be well documented in electronic data. Tumor registry data generally represent final surgical procedure and final pathology, but do not offer a clear characterization of multiple procedures that a patient may receive. The CoC database does collect information on positive/nega- tive margin status, but does not include detail on mar- gin distance or direction. Until more detailed, standard definitions are developed and implemented, we can only obtain detailed surgical quality data through medical record abstraction; but these data are time consuming and expensive to collect. We noted modest variation in the information provided in pathology, surgical opera- tive, and other clinical reports between organizations and facilities. While standardizing these reports across institutions would be ideal, it was not possible in this retrospective study. Therefore, having highly trained medical record abstractors, a detailed coding manual, and regular channels for abstraction-related queries were invaluable to reducing data discrepancies in our studies. Collecting a large amount of multi-site surgical quality data is a complex task - but the potential benefits and knowledge gained may be substantial. While some of the national efforts mentioned here will provide larger