Review of Quality Measures for Breast Cancer Care by Country Income Level
Authors: Schleimer Lauren E. , Keating Nancy L. , Shulman Lawrence N. , Anderson Ben O. , Duggan Catherine , O’Neil Daniel S. , Pace Lydia E. 
Published: October 2018

Purpose Measurement of the quality of cancer care is essential for quality improvement and is widely implemented in oncology programs in high-income countries. Growing efforts are being made to measure care quality in emerging cancer care delivery systems in low- and middle-income countries (LMICs). This will require the development of measures that are clinically important, actionable, relevant to existing resources, and feasible to routinely evaluate. As part of a project to develop resource-adapted quality measures for Rwanda and other LMICs, we conducted a systematic review of the literature to identify published quality measures for the diagnosis and treatment of breast cancer. Methods We performed a literature search in accordance with PRISMA guidelines using the following terms in PubMed: ‘breast cancer’ and ‘quality indicator,’ ‘quality measure,’ or ‘quality metric’; and the following MeSH terms: ‘breast neoplasms’ and ‘healthcare quality indicator.’ We included English-language articles published before August 2017 that described the systematic identification of process measures for breast cancer diagnosis or treatment through literature review, clinical validation, and/or expert panel determination. We directly searched the Web sites of prominent cancer care organizations to identify additional publicly available measures. Income level was classified using World Bank definitions. Results We identified 521 published quality measures, including 419 measures from 27 peer-reviewed journal articles and 102 measures from the Web sites of national and international cancer care organizations. Twenty-five peer-reviewed publications (93%) originated from high-income countries, one from an upper-middle income country (People’s Republic of China), and one from the international Breast Health Global Initiative with process measures to assess the phased implementation of breast cancer services. No resources or articles other than that from the Breast Health Global Initiative provided suggestions for adapting measures to limited resources. Conclusion A large number of quality measures for breast cancer care have been identified and published in high-income countries; however, no breast cancer care quality measures have been systematically developed and validated for use in settings where resource limitations crucially affect care delivery and measurement feasibility. We are collaborating with clinicians in LMICs and global breast cancer experts to develop and validate quality measures that will enable quality improvement initiatives in Rwanda and other emerging cancer care delivery systems. AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated. Relationships are self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO's conflict of interest policy, please refer to www.asco.org/rwc or ascopubs.org/jco/site/ifc . No COIs from the authors.