Appendix E. Evidence Tables

Howard M Schachter; Vasil Mamaladze; Gabriela Lewin; Larry Paszat; Shailendra Verma; Cathy DeGrasse; Ian Graham; Melissa Brouwers; Margaret Sampson; Andra Morrison; Li Zhang; Peter O'Blenis; Chantelle Garrity

Evidence Table 1. Definition, developmental history, and adherence data revealed by quality measures/measurements

Author, Year, Location	Title of Quality Measures-Measurements (Organized by Domain)	Performance: Overall/By Stratification(s)/Other Data/Links to Outcome	Reference Standard(s) (Publication Date)/Data Source(s)/Developmental History/Status	Use Parameters: Eligibility Criterial/Measurement Period/Sample(s) Characteristics/Funding Sources
Appleton, 1998, UK	Process:	• Overall: NR	• Standard: NHSBSP guidelines, 1991-1992	• Inclusion: convenience sample mastectomy specimens reports of invasive tumor, ALND issued by non-specialist pathologists, 1992, 1994, & 1996
	• % reporting nature of specimen^IV	• by y:	• Data sources: pathology reports	• Exclusion: NR
		1992: 60%	• Developmental period: NR	• Period: 4 y (1992-1996)
		1994: 40%	• Reference standard(s) (publication date): NR	• n specimens (enrolled/evaluated): 40/30 (10 for each y)
		1996: 100%	• Data sources: NR	• Age (mean & range): NR
		• Links: NA	• Psychometric properties: NR	• Race/ethnicity: NR
	• % reporting type of tumor^IV	• Overall: NR	• Links to outcomes: NR	• Case characteristics: NR
		• by y:	• Funding source: NR	• Socioeconomic status: NR
		1992: 100%	• State of use: NR	• Funding: NR
		1994: 100%	• Current use: research; internal quality improvement; quality of care reporting
		1996: 100%	• Care setting: pathology centers
		• Links: NA	• Professionals: pathologists
	• % reporting grade of tumor^IV	• Overall: NR
		• by y:
		1992: 90%
		1994: 80%
		1996: 100%
		• Links: NA
	• % reporting size of tumor^IV	• Overall: NR
		• by y:
		1992: 80%
		1994: 70%
		1996: 100%
		• Links: NA
	• % reporting number of involved & sampled LN^IV	• Overall: NR
		• by y:
		1992: 100%
		1994: 100%
		1996: 100%
		• Links: NA
	• % reporting involvement of resection margins^IV	• Overall: NR
		• by y:
		1992: 90%
		1994: 90%
		1996: 100%
		• Links: NA
	• % reporting side of mastectomy^IV	• Overall: NR
		• by y:
		1992: 60%
		1994: 50%
		1996: 100%
		• Links: NA
	• % reporting size of specimen (macroscopic) ^IV	• Overall: NR
		• by y:
		1992: 100%
		1994: 90%
		1996: 100%
		• Links: NA
	• % reporting of affected quandrant (gross exam) ^IV	• Overall: NR
		• by y:
		1992: 80%
		1994: 60%
		1996: 100%
		• Links: NA
	• % reporting size of overlying skin^IV	• Overall: NR
		• by y:
		1992: 100%
		1994: 100%
		1996: 100%
		• Links: NA
	• % reporting distance of tumor from nipple^IV	• Overall: NR
		• by y:
		1992: 50%
		1994: 30%
		1996: 100%
		• Links: NA
	• % reporting description of cut surface of tumor^IV	• Overall: NR
		• by y:
		1992: 80%
		1994: 80%
		1996: 10%
		• Links: NA
	• % reporting description of skin^IV	• Overall: NR
		• by y:
		1992: 0%
		1994: 20%
		1996: 0%
		• Links: NA
	• % reporting description of nipple^IV	• Overall: NR
		• by y:
		1992: 50%
		1994: 50%
		1996: 100%
		• Links: NA
	• % reporting presence or absence of fascia or skeletal muscle^IV	• Overall: NR
		• by y:
		1992: 0%
		1994: 0%
		1996: 10%
		• Links: NA
	• % reporting presence or absence of vascular invasion^IV	• Overall: NR
		• by y:
		1992: 90%
		1994: 60%
		1996: 100%
		• Links: NA
	• % reporting involvement of apical LN^IV	• Overall: NR
		• by y:
		1992: 40%
		1994: 80%
		1996: 80%
		• Links: NA
	• % reporting distance of tumor to resection margins^IV	• Overall: NR
		• by y:
		1992: 100%
		1994: 80%
		1996: 100%
		• Links: NA
	• % reporting presence or absence of concurrent DCIS^IV	• Overall: NR
		• by y:
		1992: 100%
		1994: 70%
		1996: 100%
		• Links: NA
	• % reporting size of concurrent DCIS^IV	• Overall: NR
		• by y:
		1992: 38%
		1994: 33%
		1996: 100%
		• Links: NA
	• % reporting description of background breast^IV	• Overall: NR
		• by y:
		1992: 90%
		1994: 90%
		1996: 80%
		• Links: NA

NR = not reported; NA = not assessed; S = significant difference/trend; NS = nonsignificant difference/trend; n = number of patients; pts = patient; enrolled = n qualified; evaluated = n analyzed; NHSBSP = National Health Service Breast Screening Programme; LN = lymph nodes; DCIS = ductal carcinoma in situ; state of use = last 3 y; Level Ia = pre-study data indicating consistently sound psychometric properties; Iac = pre- and on-study data indicating consistently sound psychometric properties; IV = no pre- or on-study psychometric data
Bernhard, 1997, Netherlands	Process:	• Overall: NR	• Standard: IBCSG form for assessing impact of adjuvant therapy on QOL; LASA scales (physical well-being; mood; appetite)	• Inclusion: convenience sample pre- & postmenopausal women with operable BC
	• Change in QOL by time & treatment arm; postmenopausal women, node(-) BC who underwent adjuvant therapy^Ia	• Physical well-being:	• Data sources: pts self-reported status using IBCSG form	• Exclusion: pts who completed no 1993 version QOL forms; completed forms in multiple languages
		Tamoxifen: 83.4 (1 mo)	• Developmental period: NR	• Period: 2 y (1993-1995)
		Tmx + CM: 83.2 (1 mo)	• Reference standard(s) (publication date): NR	• n patients (enrolled/evaluated): 345/312
		Tamoxifen: 85.5 (3 mo)	• Data sources: NR	• Age (mean & range): (NR)
		Tmx + CMF: 78.2 (3 mo)	• Psychometric properties: NR	• Race/ethnicity: NR
		Tamoxifen: 86.5 (6 mo)	• Links to outcomes: NR	• Case characteristics: women with operable BC
		Tmx + CMF: 85.3 (6 mo)	• Funding source: NR	• Socioeconomic status: NR
		• Mood:	• State of use: NR	• Funding: ACS; NHMRC of Australia grants
		Tamoxifen: 78.8 (1 mo)	• Current use: research
		Tmx + CMF: 78.2 (1mo)	• Care setting: hospitals; cancer centers;
		Tamoxifen: 80.7 (3 mo)	• Professionals: oncologists
		Tmx + CMF: 76.8 (3 mo)
		Tamoxifen: 81.8 (6 mo)
		Tmx +CMF: 82.0 (6 mo)
		• PACIS:
		Tamoxifen: 78.1(1 mo)
		Tmx + CMF: 71.2 (1 mo)
		Tamoxifen: 81.0 (3 mo)
		Tmx + CMF: 69.5 (3 mo)
		Tamoxifen: 80.8 (6 mo)
		Tmx + CMF: 78.7 (6 mo)
		• Links: NA

NR = not reported; NA = not assessed; S = significant difference/trend; NS = nonsignificant difference/trend; n = number of patients; pts = patients; enrolled = n qualified; evaluated = n analyzed; PACIS = Perceived Adjustment to Chronic Illness Scale; ACS = American Cancer Society; NHMRC = National Health and Medical Research Council; state of use = last 3 y; LASA = Linear analogue self-assessment; Higher scores in scale = better quality of life; QOL = quality of life; Level Ia = pre-study data indicating consistently sound psychometric properties; Iac = pre- and on-study data indicating consistently sound psychometric properties; IV = no pre- or on-study psychometric data
Bickell, 2000, US	Process:	• Overall: 59%	• Standard: Mount Sinai Health Final Guidelines for Stage I & II BC treatment, 1994-1995	• Inclusion: convenience sample women BC receiving definitive surgical treatment of primary stage I or II in 4 hospitals in NY
	• % appropriate use of BCS^IV	• by hospital: 49–69%	• Data sources: tumor registries; hospital discharge & pathology databases from 4 teaching hospitals NY area	• Exclusion: treatment in other hospital; recurrent cancers; males; DCIS
		• Links: NA	• Developmental period: NR	• Period: 2 y (1995-1996)
	• % appropriate use of RT after BCS^IV	• Overall: 81%	• Reference standard(s) (publication date): NR	• n patients (enrolled/evaluated): 1,258/723
		• by hospital: 69–87%	• Data sources: NR	• Age (mean & range): 65 (NR) y
		• Links: NA	• Psychometric properties: NR	• Race/ethnicity: Black (5–12%)
	• % appropriate use of adjuvant systemic treatment , stage ≥ 1B^IV	• Overall: 78%	• Links to outcomes: NR	• Case characteristics: stage I or II BC
		• by hospital:	• Funding source: NR	• Socioeconomic status: Medicaid 4–23%
		71–86 %	• State of use: NR	• Funding: United Hospital Fund
		• by age:	• Current use: internal quality improvement; external quality oversight; research
		<50 y: 59–87%	• Care setting: hospitals; cancer centers; RT centers
		≥50 y: 65–85%	• Professionals: oncologists; surgeons; GPs; RT oncologists
		• Links: NA
	• % appropriate use of ALND^IV	• Overall: 87%
		• by hospital: 79–92%
		• Links: NA
	• % quality of hormone receptor assay^IV	• Overall: 85%
		• by hospital: 56–99%
		• Links: NA
	Access:	• Overall: 64%
	• % referral to oncologist^IV	• by hospital: 50–81%
		• Links: NA
	• % evidence of surgical options discussion^IV	• Overall: NR
		• by hospital: 65–100%
		• Links: NA

NR = not reported; NA = not assessed; S = significant difference/trend; NS = nonsignificant difference/trend; n = number of patients; pts = patients; enrolled = n qualified; evaluated = n analyzed; ESBC = early stage breast cancer; BCS = breast- conserving surgery; RT = radiotherapy; GP = general practitioner; NY = New York; DCIS = ductal carcinoma in situ; state of use = last 3 y; Level Ia = pre-study data indicating consistently sound psychometric properties; Iac = pre- and on-study data indicating consistently sound psychometric properties; IV = no pre- or on-study psychometric data
Bickell, 2003, US	Structure:	• Overall: 32% (14/44)	• Standard: Mount Sinai Health Final Guidelines for Stage I–II BC treatment, 1994-1995	• Inclusion: convenience sample women ESBC who had under-use of treatment; RT or adjuvant therapy not recommended when indicated
	• % cases not receiving recommended treatment (RT after BCS or systemic therapy) due to system failure^IV	• Links: NA	• Data sources: Interview of 13 surgeons who treated pts	• Exclusion: NR
			• Developmental period: NR	• Period: 2 y (1998-1999)
			• Reference standard(s) (publication date): NR	• n patients (enrolled/evaluated): NR/44
			• Data sources: NR	• Age (mean & range): NR
			• Psychometric properties: NR	• Race/ethnicity: NR
			• Links to outcomes: NR	• Case characteristics: stage I or II BC
			• Funding source: NR	• Socioeconomic status: NR
			• State of use: NR	• Funding: Department of Health Policy, Mount Sinai School of Medicine & the Mount Sinai NYU Health System
			• Current use: internal quality improvement
			• Care setting: hospitals; cancer centers; RT centers
			• Professionals: oncologists; surgeons; GPs; RT oncologists

NR = not reported; NA = not assessed; S = significant difference/trend; NS = nonsignificant difference/trend; n = number of patients; pts = patients; enrolled = n qualified; evaluated = n analyzed; ESBC = early stage breast cancer; BCS = breast-conserving surgery; RT = radiotherapy; GP = general practitioner; state of use = last 3 y; BC = breast cancer; MD = medical doctor; NYU = New York University; Level Ia = pre-study data indicating consistently sound psychometric properties; Iac = pre- and on-study data indicating consistently sound psychometric properties; IV = no pre- or on-study psychometric data
Bower, 2000, US	Outcome:	• Overall: NR	• Instrument(s): RAND 36-item Health Survey 1.0 (physical; role function-physical; body pain; social functioning; emotional well-being; role function-emotional; energy/fatigue; general health perceptions)	• Inclusion: convenience sample women ESBC (stage 0–II); diagnosed <5 y; completed adjuvant therapy; currently disease-free; only treated with tamoxifen (cancer survivors)
	• % change in QOL over time^Iac	• Energy/fatigue: 60	• Data sources: tumor registry; medical records; self-reported questionnaires	• Exclusion: no English-spoken
		• Physical functioning: 80.35	• Developmental period: NR	• Period: 3 y (1994-1997)
		• Role limitation- physical: 75.80	• Reference standard(s) (publication date): NR	• n patients (enrolled/evaluated): NR/1,957
		• Emotional well-being: 75	• Data sources: NR	• Age (mean & range): 55 (NR) y
		• Role limitation- emotional: 77	• Psychometric properties: NR	• Race/ethnicity: White (80%); Black (12.5%)
		• Social functioning: 86	• Links to outcomes: NR	• Case characteristics: BC survivors; currently tamoxifen (47.5%)
		• Bodily pain: 78.60	• Funding source: NR	• Socioeconomic status: married (70%); employed (45%); income/ y > U$ 75,000 (36.5%)
		• General health: 73	• State of use: NR	• Funding: NCI
		• Links: NA	• Current use: external quality oversight; research
			• Care setting: hospitals; cancer centers; RT centers
			• Professionals: oncologists; surgeons; GPs; RT oncologists

NR = not reported; NA = not assessed; S = significant difference/trend; NS = nonsignificant difference/trend; n = number of patients; pts = patients; enrolled = n qualified; evaluated = n analyzed; QOL = quality of life; state of use = last 3 y; GP = general practitioner; NCI = National Cancer Institute; ESBC = early stage breast cancer; RT = radiotherapy; Level Ia = pre-study data indicating consistently sound psychometric properties; Iac = pre- and on-study data indicating consistently sound psychometric properties; IV = no pre- or on-study psychometric data
Brenin, 1999, US	• % appropriate use of axillary lymph node dissection^IV	• Overall: 93.2% (n = 15,992)	• Standard: NIH Consensus Development Conference, 1990	• Inclusion: national convenience sample women BC, stage I or II treated in US hospitals, 1994
		• by age (y):	• Data sources: National Cancer Data Base	• Exclusion: not eligible; stage III or IV; subcutaneous mastectomy; not lymph nodes examined undergoing ALND
		<70: 97%	• Developmental period: NR	• Period: 1 y (1994)
		>70: 86%	• Reference standard(s) (publication date): NR	• n patients (enrolled/evaluated): 17,931/17,151
		• by payer:	• Data sources: NR	• Age (mean & range): 61.3 (22 –103) y
		Private vs. Government: OR 1.4 S	• Psychometric properties: NR	• Race/ethnicity: NR
		• Links: NA	• Links to outcomes: NR	• Case characteristics: women BC stage I or II; node (+) 5.2%;
	• % appropriate use of BCS^IV	• Overall: 44.5%	• Funding source: NR	• Socioeconomic status: NR
		• Links: NA	• State of use: NR	• Funding: CCACS; ACR
	• % appropriate use of RT on axilla^IV	• Overall: 5.2% (n = 899)	• Current use: external quality oversight; research; decision-making
		• Links: NA	• Care setting: hospitals; cancer centers; RT centers
			• Professionals: clinicians; oncologists; RT oncologists; surgeons

NR = not reported; NA = not assessed; S = significant difference/trend; NS = nonsignificant difference/trend; n = number of patients; pts = patients; enrolled = n qualified; evaluated = n analyzed; RT = radiotherapy; DCIS = ductal carcinoma in situ; BC = breast cancer; CCACS = Commission on Cancer of the American College of Surgeons; ACR = American College of Radiology; BCS = breast-conserving surgery; NIH = National Institute of Health; ALND = axillary lymph node dissection; state of use = last 3 y; Level Ia = pre-study data indicating consistently sound psychometric properties; Iac = pre- and on-study data indicating consistently sound psychometric properties; IV = no pre- or on-study psychometric data
Cheung, 1999, Hong Kong	Process:	• Overall: 32%	• Standard: BASO guidelines, 1995	• Inclusion: convenience sample women on whom author operated post CPG; women operable primary BC <5 cm; for BCS only tumor size, 3 cm
	• % appropriate use of BCS^IV	• Links: NA	• Data sources: medical records	• Exclusion: NR
	• % appropriate use of mastectomy^IV	• Overall: 68%	• Developmental period: NR	• Period: NR
		• Links: NA	• Reference standard(s) (publication date): NR	• n patients (enrolled/evaluated): 100/100
	• % appropriate use of CT^IV	• Overall: 30%	• Data sources: NR	• Age (mean & range): 53 (25–83) y
		• Links: NA	• Psychometric properties: NR	• Race/ethnicity: NR
	• % appropriate use of tamoxifen^IV	• Overall: 28%	• Links to outcomes: NR	• Case characteristics: BC Grade I–III; node (-) (57%); invasive ductal (72%); vascular invasion (34%); ER (+) (58%)
		• Links: NA	• Funding source: NR	• Socioeconomic status: NR
	• % (>90%) quality of FNA samples from lesions which subsequently prove to be BC should be adequate as deemed by the breast pathologist^IV	• Overall: 99%	• State of use: NR	• Funding: NR
		• Links: NA	• Current use: internal quality improvement; research
	• % (90%) appropriate use of cytology or needle histology in palpable BC diagnosed pre-operatively ^IV	• Overall: 82%	• Care setting: hospitals; cancer centers; RT centers
		• Links: NA	• Professionals: GPs; oncologists; surgeons
	• % (<10%) quality of breast biopsy: primary operable BC receives frozen section^IV	• Overall: 0%
		• Links: NA
	• % gross margins identified without incision into de specimen; & carefully orientated for the pathologist^IV	• Overall: 100%
		• Links: NA
	• % (90%) appropriate number of therapeutic operations (≤2) for women having BCS^IV	• Overall: 100%
		• Links: NA
	• % quality of technique to determine histological node status for all invasive tumors, by sampling or clearance^IV	• Overall: 100%
		• Links: NA
	Access:	• Overall: 95%
	• % (>80%) urgent referrals seen within 5 working d of referral receipt^IV	• Links: NA
	• % (70%) all other new referrals seen within 15 working d^IV	• Overall: 50%
		• Links: NA
	• % appropriate use of imaging &/or cytology or needle biopsy, if required; to be performed at the initial visit^IV	• Overall: 0%
		• Links: NA
	• % (<10%) all new women BC should attend the clinic/hospital on >2 occasions for diagnostic purposes^IV	• Overall: 41%
		• Links: NA
	• % pts attending for diagnostic purposes seen at least on 1 occasion by breast specialist surgeon^IV	• Overall: 100%
		• Links: NA
	• %(>90%) women requiring an operation for diagnostic purposes should be admitted 14 d of investigations leading to surgical decision^IV	• Overall: 68%
		• Links: NA
	• %(>90%): BC pts or an abnormality requiring diagnostic operation; told within 5 working d leading diagnosis^IV	• Overall: 67%
		• Links: NA
	• % (100%) BC pts given opportunity to see a BC nurse^IV	• Overall: 100%
		• Links: NA
	• % (90%) women admitted for operation within 21 d of surgical decision to operate for therapeutic purposes^IV	• Overall: 93%
		• Links: NA
	Outcome:	• Overall: 0%
	• % (<10%) pts developing local recurrence after BCS within 5 y^IV	• Links: NA
	• % (<10%) pts developing local recurrence after mastectomy within 5 y^IV	• Overall: 2.6%
		• Mastectomy cases: 36%
		• Links: NA
	• % appropriate use of prophylactic RT employed in women with high risk of flap recurrence^IV	• Overall: 2% (36% of mastectomies 7)
		• Links: NA
	• % (<10%) regional recurrence needing further surgery or RT; at 5 y^IV	• Overall: 0%
		• Links: NA

NR = not reported; NA = not assessed; S = significant difference/trend; NS = nonsignificant difference/trend; n = number of patients; pts = patients; enrolled = n qualified; evaluated = n analyzed; CT = chemotherapy; RT = radiotherapy; HT = hormone therapy; GP = general practitioner; ER = estrogen receptor; PR = progesterone receptor; CPG = clinical practice guidelines; DCIS = ductal carcinoma in situ; BC = breast cancer; BASO = British Association of Surgical Oncology; FNA = fine-needle aspiration; state of use = last 3 y; BCS = breast-conserving surgery; Level Ia = pre-study data indicating consistently sound psychometric properties; Iac = pre- and on-study data indicating consistently sound psychometric properties; IV = no pre- or on-study psychometric data
Chie, 1999, China	Outcome:	• Overall: NR	• Instrument(s): SF-36 Chinese version; EORTC-QLQ-C30*	• Inclusion: convenience sample women diagnosed or treated for BC in breast surgery; RT & oncology outpatients departments; or in general surgical wards of National Taiwan University Hospital
	• % women with significant improvement in QOL scores in clinical phases of BC: diagnosis; surgery; initial CT; initial RT; follow-up; recurrence**^Iac	• Links: NA	• Data sources: self- reported questionnaires to pts before RT (pretest); after RT (post-test) & recall of pretest; cancer registry	• Exclusion: high-dose regimens that necessitated hospitalization & terminal pts in palliative care unit
			• Developmental period: NR	• Period: 2 mo (1997)
			• Reference standard(s) (publication date): NR	• n patients (enrolled/evaluated): 115/115
			• Data sources: NR	• Age (mean & range): NR (<40–>65) y
			• Psychometric properties: NR	• Race/ethnicity: NR
			• Links to outcomes: NR	• Case characteristics: clinical phases: diagnosis (35.7%); surgery (9.6%); initial CT (13%); initial RT (7%); follow-up after treatment (27.8%); recurrence (7%)
			• Funding source: NR	• Socioeconomic status: married (73.9%); employed (50.4%%)
			• State of use: NR	• Funding: NR
			• Current use: internal quality improvement
			• Care setting: hospitals; cancer centers; RT centers
			• Professionals: oncologists; surgeons; GPs; RT oncologists

NR = not reported; NA = not assessed; S = significant difference/trend; NS = nonsignificant difference/trend; n = number of patients; pts = patients; enrolled = n qualified; evaluated = n analyzed; ESBC = early stage breast cancer; BCS = breast-conserving surgery; RT = radiotherapy; CT = chemotherapy; QOL = quality of life; EORTC-QLQ-C30 = European Organization for Research and Treatment of Cancer Quality of Life Questionnaire - cancer 30; SF-36 = medical outcome survey 36-item short form health surveys; state of use = last 3 y; * Validated for BC patients; *Includes: Role functioning; emotional functioning; cognitive functioning; global quality of life; nausea & vomiting; loss of appetite; constipation; GP = general practitioner; Level Ia = pre-study data indicating consistently sound psychometric properties; Iac = pre- and* on-study data indicating consistently sound psychometric properties; IV = no pre- or on-study psychometric data
Christensen, 2002, Denmark	Process:	• Overall: 100%	• Standard: European Guidelines for Quality Assurance in Mammography screening, 1996; Guidelines for cytology procedures and reporting in BC screening, 1993	• Inclusion: women with (+) mammography screening followed by surgery
	• % appropriate use of preoperative diagnosis by FNA cytology, needle histology or biopsy^IV	• Links: NA	• Data sources: hospital registries of Copenhagen (pathology & mammography screening program)	• Exclusion: data missing; lymphoma
			• Developmental period: NR	• Period: 6 y (1991-1997)
			• Reference standard(s) (publication date): NR	• n patients (enrolled/evaluated): 4,111/4,111
			• Data sources: NR	• Age (mean & range): 61 (50–72) y
			• Psychometric properties: NR	• Race/ethnicity: NR
			• Links to outcomes: NR	• Case characteristics: NR
			• Funding source: NR	• Socioeconomic status: NR
			• State of use: NR	• Funding: NR
			• Current use: internal quality improvement; external quality oversight
			• Care setting: hospitals; cancer centers; RT centers
			• Professionals: oncologists; surgeons; GPs; RT oncologists; pathologists

NR = not reported; NA = not assessed; S = significant difference/trend; NS = nonsignificant difference/trend; n = number of patients; pts = patients; enrolled = n qualified; evaluated = n analyzed; NCI = National Cancer Institute; state of use = last 3 y; FNA = fine- needle aspiration; FP = false positive; FN = false negative; BC = breast cancer; (+) = positive; GP = general practitioner; Level Ia = pre-study data indicating consistently sound psychometric properties; Iac = pre- and on-study data indicating consistently sound psychometric properties; IV = no pre- or on-study psychometric data
Cochrane, 1997, UK	Process:	• Overall: 60%	• Standard: NHSBSP breast referral guidelines, 1995	• Inclusion: random sample women > 35 y with breast problems referred to surgeon by GP in Rapid Access Breast Clinic in Cardiff, UK
	• % appropriate use of referrals to surgeon by GP according to breast referral guidelines^IV	• by age:	• Data sources: referral database	• Exclusion: screening cases; tertiary referrals; abnormal Mx
		<40 y: 54%	• Developmental period: NR	• Period: 8 mo (1995)
		>40 y: 64% S	• Reference standard(s) (publication date): NR	• n patients (enrolled/evaluated): 2,332/2,332
		• Links: NA	• Data sources: NR	• Age (mean & range): 44 (11–90) y
			• Psychometric properties: NR	• Race/ethnicity: NR
			• Links to outcomes: NR	• Case characteristics: women with BC symptoms: lumps (60%); pain (32%); nipple discharge (8%); skin change (5.2%)
			• Funding source: NR	• Socioeconomic status: NR
			• State of use: NR	• Funding: Patterns of Care Study
			• Current use: internal quality improvement
			• Care setting: hospitals; cancer centers
			• Professionals: surgeons; oncologists; RT oncologists; GPs

NR = not reported; NA = not assessed; S = significant difference/trend; NS = nonsignificant difference/trend; n = number of patients; pts = patients; BC = breast cancer; enrolled = n qualified; evaluated = n analyzed; RT = radiotherapy; state of use = last 3 y; Mx = mammogram; NHSBSP = NHS Breast Screening Programme; GP = general practitioner; Level Ia = pre-study data indicating consistently sound psychometric properties; Iac = pre- and on-study data indicating consistently sound psychometric properties; IV = no pre- or on-study psychometric data
Cornfeld, 2001, US	Structure:	• Overall: 100%	• Standard: NCCN Guidelines, 1999	• Inclusion: convenience sample women with nonmetastatic BC treated in private practice of 11 oncologists surveyed
	• % board certified MDs in medical oncology^IV	• Links: NA	• Data sources: survey delivered to private practice oncologists (n = 11); medical records	• Exclusion: NR
	• % availability of office procedure manual used for CT administration^IV	• Overall: 100%	• Developmental period: NR	• Period: 9 mo (1999-2000)
		• Links: NA	• Reference standard(s) (publication date): NR	• n participants (enrolled/evaluated): NR/220
	• % documentation of CME credits 2 y preceding each audit^IV	• Overall: 100%	• Data sources: NR	• Age (mean & range): NR
		• Links: NA	• Psychometric properties: NR	• Race/ethnicity: NR
	• % present CT flow sheets on active treatment charts^IV	• Overall: 99%	• Links to outcomes: NR	• Case characteristics: NR
		• Links: NA	• Funding source: NR	• Socioeconomic status: NR
	Process:	• Overall: 90%	• State of use: NR	• Funding: NR
	• % present body surface area calculations on CT flow sheets^IV	• Links: NA	• Current use: internal quality improvement
	• % appropriate use of tamoxifen BC ER (+)^IV	• Overall: 100%	• Care setting: hospitals; cancer centers
		• Links: NA	• Professionals: oncologists; surgeons
	• % appropriate use of guidelines for follow-up surveillance of BC^IV	• Overall: NR
		• by practice:
		PE: 100%
		Mammography: 98%
		Gynecologic follow-up: 76%
		• Links: NA
	Outcome:	• Overall: 4.91*
	• % participation of oncologists in pts satisfaction survey^IV	• Links: NA

NR = not reported; NA = not assessed; S = significant difference/trend; NS = nonsignificant difference/trend; n = number of patients; pts = patients; enrolled = n qualified; evaluated = n analyzed; CT = chemotherapy; CME = continuing medical education; BC = breast cancer; HT = hormone therapy; ER (+) = estrogen receptor positive; SD = standard deviation; * = number of participants were 3; state of use = last 3 y; NCCN = National Comprehensive Cancer Network; PE = physical examination; Level Ia = pre-study data indicating consistently sound psychometric properties; Iac = pre- and on-study data indicating consistently sound psychometric properties; IV = no pre- or on-study psychometric data
Craft, 2000, Australia	Process:	• Overall: 98% (85/87)	• Standard: NHMRC CPG for the management of early BC, 1995	• Inclusion: convenience sample women newly diagnosed primary localized invasive BC treated in ACT, 1997-1998
	• % appropriate use of RT after BCS^IV	• Links: NA	• Data sources: dataset of survey conducted by the Provincial Surgeons of Australia; pathology reports; treatment facility records	• Exclusion: males; distant metastases; in situ
	• % appropriate use of ALND for invasive BC^IV	• Overall: 91% (173/190)	• Developmental period: NR	• Period: 14 mo (1997-1998)
		• Links: NA	• Reference standard(s) (publication date): NR	• n patients (enrolled/evaluated): 217/191
	• % appropriate use of some form of adjuvant systemic therapy in node (+) or tumor >2 cm^IV	• Overall: 96% (95/99)	• Data sources: NR	• Age (mean & range): 57 (25–88) y
		• Links: NA	• Psychometric properties: NR	• Race/ethnicity: NR
	• % appropriate use of adjuvant CT in <50 y; node (+)^IV	• Overall: 100% (27/27)	• Links to outcomes: NR	• Case characteristics: women premenopausal (29%); postmenopausal (57%); invasive BC (93%); HR (+) (81%); tumor size 1.1–2 cm (43%); node (-) (56%); tumor type (invasive ductal) grade 2 (35%)
		• Links: NA	• Funding source: NR	• Socioeconomic status: urban (67%)
			• State of use: NR	• Funding: Commonwealth Department of Health and Aged Care Cancer Screening Unit
			• Current use: internal quality improvement
			• Care setting: hospitals; cancer centers; RT centers
			• Professionals: surgeons; RT oncologists; oncologists; pathologists; nurses

NR = not reported; NA = not assessed; S = significant difference/trend; NS = nonsignificant difference/trend; n = number of patients; pts = patients; BC = breast cancer; BCS = breast-conserving surgery; ALND = axillary lymph node dissection; ACT = Australian capitol territory; enrolled = n qualified; evaluated = n analyzed; NHMRC = National Health and Medical Research Council; CPG = clinical practice guideline; CT = chemotherapy; RT = radiotherapy; state of use = last 3 y; HR = hormone receptor; Level Ia = pre-study data indicating consistently sound psychometric properties; Iac = pre- and on-study data indicating consistently sound psychometric properties; IV = no pre- or on-study psychometric data
DeMichele, 2003, US	Process:	• Overall: 74% (156/208)	• Standard: St. Gallen Consensus Conference, 1992-1995 (update)*	• Inclusion: convenience sample women BC ≥ 50 y evaluated at UPCC 1993-1997 & eligible for adjuvant chemotherapy
	• % appropriate use of CT (recommended)^IV	• by age:	• Data sources: University of Pennsylvania pt information system database	• Exclusion: missing data
		50–54 y: 98% (57/58)	• Developmental period: NR	• Period: 5 y (1993-1997)
		55–60 y: 85% (47/55)	• Reference standard(s) (publication date): NR	• n patients (enrolled/evaluated): 367/208
		61–69 y: 52% (40/52)	• Data sources: NR	• Age (mean & range): 59(50–86) y
		70+: 23% (10/43)	• Psychometric properties: NR	• Race/ethnicity: NR
		• Links: NA	• Links to outcomes: NR	• Case characteristics: women BC node (+) (61%); ER&PR (+) (46%); tumor size T1 (47%)
	• % non–eligible pts receiving CT (over treatment)^IV	• Overall: 11% (23/132)	• Funding source: NR	• Socioeconomic status: NR
		• Links: NA	• State of use: NR	• Funding: NR
	• % appropriate use of CT (received) (patient acceptance)^IV	• Overall: 74% (154/208)	• Current use: external quality oversight
		• by age:	• Care setting: cancer centers; hospitals; RT centers
		50–59 y: 74% (72/97)	• Professionals: oncologists; surgeons; RT oncologists
		60–69 y: 74% (36/47)
		70–86 y: 70% (7/10)
		• Links: NA

NR = not reported; NA = not assessed; S = significant difference/trend; NS = nonsignificant difference/trend; n = number of patients; pts = patients; RT = radiotherapy; HR = hormone receptor; state of use = last 3 y; UPCC = University of Pennsylvania Cancer Center; ER = estrogen receptor; PR = progesterone receptor; BC = breast cancer; Recommendations for women <65 y; Level Ia = pre-study data indicating consistently sound psychometric properties; Iac = pre- and* on-study data indicating consistently sound psychometric properties; IV = no pre- or on-study psychometric data
Du, 2001, US	Process:	• Overall: 12.4% (708/5,697)	• Standard: NIH Consensus Conference Development, 1990	• Inclusion: population-based sample women ≥ 65 y diagnosed BC, 1991-1996
	• % appropriate use of CT within 6 mo of diagnosis^IV	• by Stage (1996):	• Data sources: SEER registry; Medicare claim data	• Exclusion: women with no full coverage of Medicare; members of HMO
		I: 3%	• Developmental period: NR	• Period: 6 y (1991-1996)
		II: 19.5%	• Reference standard(s) (publication date): NR	• n patients (enrolled/evaluated): 35,060/5,697
		III: 43.7%	• Data sources: NR	• Age (mean & range): NR (>65) y
		IV: 40.9%	• Psychometric properties: NR	• Race/ethnicity: NR
		• by age:	• Links to outcomes: NR	• Case characteristics: women BC stage I–IV; > 65 y
		65–69 y: 20.5%	• Funding source: NR	• Socioeconomic status: Medicare 100%
		70–74 y: 13.9%	• State of use: NR	• Funding: Department of Defense; NCI; Sealy & Smith Foundation
		75–79 y: 8.7%	• Current use: external quality oversight
		>80 y: 3.3%	• Care setting: hospitals; cancer centers
		• Links: NA	• Professionals: oncologists; surgeons; GPs
	• % appropriate use CT in node (+); ER (+); within 6 mo of diagnosis^IV	• Overall: 27% (1996)
		• Links: NA
	• % appropriate use CT in node (+); ER (-); within 6 mo of diagnosis^IV	• Overall: 61.5% (1996)
		• Links: NA
	• % appropriate use CT in node (-); ER (+); within 6 mo of diagnosis^IV	• Overall: 2% (1996)
		• Links: NA
	• % appropriate use CT in node (-); ER (-); within 6 mo of diagnosis^IV	• Overall: 17.9% (1996)
		• Links: NA

NR = not reported; NA = not assessed; S = significant difference/trend; NS = nonsignificant difference/trend; n = number of patients; pts = patients; enrolled = n qualified; evaluated = n analyzed; BC = breast cancer; state of use = last 3 y; GP = general practitioner; NCI = National Cancer Institute; SEER = Surveillance, Epidemiology, and End Results; CT = chemotherapy; HMO = Health Maintenance Organization; ER = estrogen receptor; Level Ia = pre-study data indicating consistently sound psychometric properties; Iac = pre- and on-study data indicating consistently sound psychometric properties; IV = no pre- or on-study psychometric data
Du, 2003, US	Process:	• Overall: 28.7%	• Standard: NIH Consensus Development Conference, 1990	• Inclusion: population-based sample women ≥20 y stage I–IIIA BC treated & registered in New Mexico tumor registry, 1991-1997
	• % appropriate use of CT^IV	• by stage:	• Data sources: New Mexico tumor registry; pathology laboratories & hospitals in New Mexico	• Exclusion: stage other than I–IIIA, <20 y
		I: 11.3%	• Developmental period: NR	• Period: 7 y (1991-1997)
		II: 47%	• Reference Standard(s) (Publication Date): NR	• n patients (enrolled/evaluated): NR/5, 101
		IIIA: 68%	• Data sources: NR	• Age (mean & range): 61(20–98) y
		• by age:	• Psychometric properties: NR	• Race/Ethnicity: NR
		<45 y: 66%	• Links to outcomes: NR	• Case characteristics: NR
		45–49 y: 54.9%	• Funding source: NR	• Socioeconomic status: NR
		50–54 y: 44.2 %	• State of use: NR	• Funding: NCI, NIH, Smyth Foundation
		55–59 y: 31%	• Current use: internal quality improvement
		60–64 y: 18.1%	• Care setting: hospitals; cancer centers
		65–69 y: 12.3%	• Professionals: oncologists
		70–74 y: 7.1%
		> 75 y: 3.4%
		• Links: NA
	• % appropriate use of CT + HT (tamoxifen) ^IV	• Overall: 9.6%
		• by age:
		<45 y: 15.8%
		45–49 y: 17%
		50–54 y: 18.5 %
		55–59 y: 11.7%
		60–64 y: 8%
		65–69 y: 5.4%
		70–74 y: 4.0%
		> 75 y: 0.8%
		• Links: NA

NR = not reported; NA = not assessed; S = significant difference/trend; NS = nonsignificant difference/trend; n = number of patients; pts = patients; enrolled = n qualified; evaluated = n analyzed; NCI = National Cancer Institute; NIH = National Institute of Health; CT = chemotherapy; BC = breast cancer; CPG = clinical practice guideline; state of use = last 3 y; HT = hormone therapy; Level Ia = pre-study data indicating consistently sound psychometric properties; Iac = pre- and on-study data indicating consistently sound psychometric properties; IV = no pre- or on-study psychometric data
Edge, 2002, US	Process:	• Overall: 63.4% (294/464)	• Standard: NIH Consensus Development Conference 1990; Steering committee on CPGs for the care & treatment of BC, CARO	• Inclusion: convenience sample women ≥67 y stage T1–T2 (N0N1) M0, newly diagnosed histologically confirmed invasive BC who underwent BCS
	• % appropriate use of ALND after BCS^IV	• by age:	• Data sources: pt interviews; medical records	• Exclusion: DCIS; bilateral, multicentric, locally advanced disease; incomplete data; history of prior or secondary BC; surgery other than BCS
		67–69 y: 84%	• Developmental period: NR	• Period: 2 y (1995-1997)
		70–74 y: 73%	• Reference standard(s) (publication date): NR	• n patients (enrolled/ evaluated): 1,377/464
		75–79 y: 62%	• Data sources: NR	• Age (mean & range): NR
		> 80 y: 33% S	• Psychometric properties: NR	• Race/ethnicity: White (91%); Black (9%)
		• by race/ethnicity:	• Links to outcomes: NR	• Case characteristics: stage I (84.9%); stage IIA (9%); stage IIB (1.7%); HR (+) (69.4%)
		White: 64%	• Funding source: NR	• Socioeconomic status: education: < High school (66.4%); HMO (73.2%)
		Black: 60 % NS	• State of use: NR	• Funding: AHRQ & Department of the Army grants
		• by education:	• Current use: decision-making; external quality oversight
		< High school: 60%	• Care setting: hospitals; pathology centers
		≥ High school: 66%	• Professionals: oncologists; surgeons; RT oncologists; GPs
		• by Payer:
		HMO: 64%
		Private: 65%
		• Links: NA
	• % appropriate use of RT after BCS^IV	• Overall: 77.8% (361/464)
		• With ALND 54.7%
		• Links: NA
	• % appropriate use of adjuvant systemic therapy after BCS^IV	• Overall: 70.7% (328/464)
		• by treatment:
		CT: 10.1%
		Tamoxifen: 89.9%
		• Links: NA

NR = not reported; NA = not assessed; S = significant difference/trend; NS = nonsignificant difference/trend; n = number of patients; pts = patients; BC = breast cancer; BCS = breast-conserving surgery; ALND = axillary lymph node dissection; NIH = National Institute of Health; CARO = Canadian Association of Radiation Oncologists; GP = general practitioner; MO = non-metastatic; DCIS = ductal carcinoma in situ; RT = radiotherapy; state of use = last 3 y; Level Ia = pre-study data indicating consistently sound psychometric properties; Iac = pre- and on-study data indicating consistently sound psychometric properties; IV = no pre- or on-study psychometric data
Engel, 2002, Germany	Process:	• Overall: NR	• Standard: NIH Consensus Development Conference, 1990; St. Gallen's Consensus for adjuvant systemic therapy, 1995-1998 (update)	• Inclusion: convenience sample women any stage BC residing in one of 6 regions*, Germany
	• % appropriate use of BCS^IV	• by region: 39.3%–57.7%	• Data sources: data submitted by pathologists, gynecologists, surgeons & radiologists, 6 regions in Germany	• Exclusion: NR
		• Links: NA	• Developmental period: NR	• Period: 3 y (1996-1998)
	• % appropriate use of RT after BCS^IV	• Overall: NR	• Reference standard(s) (publication date): NR	• n patients (enrolled/ evaluated): 9,210/8,661
		• by region: 80.6%–85.0%	• Data sources: NR	• Age (mean & range): NR (<50–>70) y
		• Links: NA	• Psychometric properties: NR	• Race/ethnicity: NR
	• % appropriate use of RT after mastectomy^IV	• Overall: NR	• Links to outcomes: NR	• Case characteristics: HR (+) 80%; stage 0–IV; LN status known
		• by region: 10.4%–32.2%	• Funding source: NR	• Socioeconomic status: NR
		• Links: NA	• State of use: NR	• Funding: German Federal Ministry of Health
	• % appropriate use of CT in premenopausal; node (+); HR (+) (1995) ^IV	• Overall: NR	• Current use: external quality oversight; decision-making; quality of care reporting; research
		• by region: 42.9%–84.6%	• Care setting: hospitals; cancer centers; RT centers
		• Links: NA	• Professionals: oncologists; RT oncologists; surgeons; GPs
	• % appropriate use of CT & HT in premenopausal; node (+); HR (+) (1995-1998) ^IV	• Overall: NR
		• by region: 10.3%–57.1%
		• Links: NA
	• % appropriate use of CT in premenopausal; node (+); HR (-) (1995/1998) ^IV	• Overall: NR
		• by region: 63.6%–92.3%
		• Links: NA
	• % appropriate use of tamoxifen in postmenopausal; node (+); HR (+) (1995) ^IV	• Overall: NR
		• by region: 30.1%–61.5%
		• Links: NA
	• % appropriate use of CT & HT in postmenopausal; node (+); HR (+) (1995/1998) ^IV	• Overall: NR
		• by region: 9.1%–32.2%
		• Links: NA
	• % appropriate use of CT in postmenopausal; node (+); HR (-) (1995/1998) ^IV	• Overall: NR
		• by region: 38.5%–69.6%
		• Links: NA

NR = not reported; NA = not assessed; S = significant difference/trend; NS = nonsignificant difference/trend; n = number of patients; pts = patients; enrolled = n qualified; evaluated = n analyzed; BC = breast cancer; HR (+) = hormone receptor positive; ER (-) = hormone receptor negative; FI = family income; BCS = breast-conserving surgery; RT = radiotherapy; CT = chemotherapy; HT = hormone therapy; node (+) = lymph node positive; NIH = national health institute; state of use = last 3 y; GP = general practitioner; 6 regions = Aachen; Dresden; Jena; Marburg; Munich; Stuttgart; Level Ia = pre-study data indicating consistently sound psychometric properties; Iac = pre- and* on-study data indicating consistently sound psychometric properties; IV = no pre- or on-study psychometric data
Foroudi, 2002 Canada	• % appropriate use of RT^IV	• Overall: 56.3%–72.4%*	• Standard: North American CPG (n = 12); others	• Inclusion: population-based sample women with BC eligible for RT from North American population
		• Initial: 50%–59.2%*	• Data sources: North American population- based cancer registries (SEER & Ontario Cancer registry); National Cancer database; single institutions; multi-institution databases	• Exclusion: NR
		• Later: 6.3%–13.3%*	• Developmental period: NR	• Period: NR
		• Links: NA	• Reference standard(s) (publication date): NR	• n patients (enrolled/ evaluated): NR
	• % appropriate use of RT; in situ; moderate risk, prefer BCT (i) ^IV	• Overall: 37.7%*	• Data sources: NR	• Age (mean & range): NR
		• Links: NA	• Psychometric properties: NR	• Race/ethnicity: NR
	• % appropriate use of RT: stage I & II (pN0), prefer BCT ; receiving BI (i) ^IV	• Overall: NR	• Links to outcomes: NR	• Case characteristics: NR
		• Stage I: 57%*	• Funding source: NR	• Socioeconomic status: NR
		• Stage II: 52.2%*	• State of use: NR	• Funding: NR
		• Links: NA	• Current use: internal quality improvement; external quality oversight, decision-making; research
	• % appropriate use of RT: stage I &II (pN0), postmastectomy, R1 or 2, receiving RI (i) ^IV	• Overall: NR	• Care setting: hospitals; cancer centers; RT centers
		• Stage I: 0.6–0.8%*	• Professionals: surgeons; oncologists; RT oncologists; GPs
		• Stage II:0. 77–0.83
		• Links: NA
	• % appropriate use of RT: stage II (pN1); <4N(+); postmastectomy, R1 or 2, receiving RI (i) ^IV	• Overall: 0.3%*
		• Links: NA
	• % appropriate use of RT: stage II (pN1); <4N(+); postmastectomy, R0, receiving RI (i) ^IV	• Overall: 3.9–4.2%*
		• Links: NA
	• % appropriate use of RT: stage II (pN1); >3N(+); postmastectomy, receiving RI (i) ^IV	• Overall: 5.7–6.1%*
		• Links: NA
	• % appropriate use of RT: stage II (pN1), prefer BCT, receiving BI (i) ^IV	• Overall: 31.1%*
		• Links: NA
	• % appropriate use of RT: stage IIIB (pT4 or pN3),w/wo mastectomy, receiving RI (i) ^IV	• Overall: 42%*
		• Links: NA
	• % appropriate use of RT stage IIIA, < 4N(+), postmastectomy, R1 or 2; receiving RI (i) ^IV	• Overall: 0.24–0.35%*
		• Links: NA
	• % appropriate use of RT: stage IIIA; < 4N(+), postmastectomy; R0, prefer BCT; receiving RI (i) ^IV	• Overall: 3.5–5.1%*
		• Links: NA
	• % appropriate use of RT: stage IIIA; >3N(+), postmastectomy, receiving RI (i) ^IV	• Overall: 5.1–7.4%*
		• Links: NA
	• % appropriate use of RT: stage IIIA; prefer BCT, receiving BI (i) ^IV	• Overall: 27.8%*
		• Links: NA
	• % appropriate use of RT: stage IV, brain metastases at diagnosis, receiving PRT (i) ^IV	• Overall: 1.8%*
		• Links: NA
	• % appropriate use of RT: stage IV; symptomatic bone metastasis at diagnosis; receiving PRT (i) ^IV	• Overall: 10%*
		• Links: NA
	• % appropriate use of RT: LCIS; recur with DCIS or invasive carcinoma; receiving BI (r) ^IV	• Overall: 0.7%*
		• Links: NA
	• % appropriate use of RT: DCIS, post-BCS, recur with DCIS or invasive carcinoma; receiving BI (r) ^IV	• Overall: 1.2%*
		• Links: NA
	• % appropriate use of RT: DCIS, postmastectomy; locoregional relapse, receiving RI (r) ^IV	• Overall: 0. 02–0.1%*
		• Links: NA
	• % appropriate use of RT: stage I & II (pN0), postmastectomy, receiving PRT (r) ^IV	• Overall: 2.9–4.2%*
		• Links: NA
	• % appropriate use of RT: stage I & II (pN0), postmastectomy, locoregional relapse; receiving RI (r) ^IV	• Overall: NR
		• Stage I: 1.3–1.9%*
		• Stage II: 1.7–1.9%*
		• Links: NA
	• % appropriate use of RT: stage II (pN1); postmastectomy; receiving PRT^IV	• Overall: 0.5%*
		• Links: NA
	• % appropriate use of RT: stage II (pN1); postmastectomy (locoregional relapse); receiving RI (r) ^IV	• Overall: 1.35%*
		• Links: NA
	• % appropriate use of RT: stage III; postmastectomy; receiving PRT (r) ^IV	• Overall: 0.39–0.57%*
		• Links: NA
	• % appropriate use of RT: stage III; postmastectomy; locoregional relapse; receiving RI (r) ^IV	• Overall: 1.2–1.7%*
		• Links: NA
	• % appropriate use of RT: stage IV, delayed symptoms from bone metastasis; receiving PRT (r) ^IV	• Overall: 10.4–21.7%*
		• Links: NA
	• % appropriate use of RT: stage IV, delayed brain metastasis; receiving PRT (r) ^IV	• Overall: 4.8–10%*
		• Links: NA
	• % appropriate use of RT: stage IV, delayed cord compression; receiving PRT (r) ^IV	• Overall: 0.4–0.8%*
		• Links: NA

NR = not reported; NA = not assessed; S = significant difference/trend; NS = nonsignificant difference/trend; n = number of patients; pts = patients; enrolled = n qualified; evaluated = n analyzed; LN = lymph nodes; BCS = breast conserving surgery; RT = radiotherapy; HR = Hormone receptor; CI = contraindication; CT = chemotherapy; HT = hormone therapy; CPG = clinical practice guidelines; BI = breast irradiation; BCT = breast-conserving therapy; R0 = no residual tumor; R1 = microscopic residual tumor; R2 = macroscopic residual tumor; RI = radiation therapy; (i) = initial treatment; PRT = any palliative RT; LCIS = lobular carcinoma in situ; (r) = progression or relapse; state of use = last 3 y; GP = general practitioner; * Estimates of the rate in a decision-making tree analysis; Level Ia = pre-study data indicating consistently sound psychometric properties; Iac = pre- and on-study data indicating consistently sound psychometric properties; IV = no pre- or on-study psychometric data
Frazer, 1998 US	Outcome:	• Overall: NS changes over time in all subscales & overall.	• Instrument: 39-item Guttman scaled HSQ Questionnaire form (health perception; social & physical functioning; physical & emotional role limitations; mental health; bodily pain; energy-fatigue)	• Inclusion: convenience sample women ESBC diagnosed, 1993, & treated by surgery & HT at MDACCO, Orlando, Florida
	• % change (improvement) in QOL over time^Iac	• Links: NA	• Data sources: pts self-reported status using Guttman scaled HSQ questionnaire form	• Exclusion: non-responders
			• Developmental period: NR	• Period: 3 y (1993-1996)
			• Reference standard(s) (publication date): NR	• n patients (enrolled/evaluated): NR/70
			• Data sources: NR	• Age (mean & range): 61.4 (37–80) y
			• Psychometric properties: NR	• Race/ethnicity: NR
			• Links to outcomes: NR	• Case characteristics: ESBC women with operable BC; treated by surgery & HT
			• Funding source: NR	• Socioeconomic status: married; not employed; HMO
			• State of use: NR	• Funding: NR
			• Current use: internal quality improvement
			• Care setting: hospitals; cancer centers
			• Professionals: oncologists; surgeons

NR = not reported; NA = not assessed; S = significant difference/trend; NS = nonsignificant difference/trend; n = number of patients; pts = patients; enrolled = n qualified; evaluated = n analyzed; ESBC = early stage breast cancer; HSQ = Health Status Questionnaire; MDACCO = M.D. Anderson Cancer Center Orlando; state of use = last 3 y; HT = hormone therapy; Level Ia = pre-study data indicating consistently sound psychometric properties; Iac = pre- and on-study data indicating consistently sound psychometric properties; IV = no pre- or on-study psychometric data
Guadagnoli 1997, US	Process:	• Overall: 62%	• Standard: EBCTCG meta-analysis, 1992	• Inclusion: convenience sample postmenopausal women newly diagnosed invasive ESBC; stage I–II at 30 hospitals, Minnesota, 1993
	• % appropriate use of any adjuvant systemic therapy in node (-)^IV	• by age:	• Data sources: medical records; interviews	• Exclusion: diagnosis of carcinoma in situ; inflammatory cancer; bilateral synchronous carcinoma; premenopausal women
		50–59 y: 73%	• Developmental period: NR	• Period: 1 y (1993)
		60–69 y: 67%	• Reference standard(s) (publication date): NR	• n patients (enrolled/evaluated): 746/632
		70–79 y: 56%	• Data sources: NR	• Age (mean & range): NR (50–>80) y
		>80 y: 36% S	• Psychometric properties: NR	• Race/ethnicity: NR
		• Links: NA	• Links to outcomes: NR	• Case characteristics: tumor size >1 cm (67%); node (+) (25%); LVN (9%); ER (+) (64%)
	• % appropriate use of tamoxifen in node (-)^IV	• Overall: 51%	• Funding source: NR	• Socioeconomic status: married (54%); income > $30,000 (70%); HMO (37%)
		• by age:	• State of use: NR	• Funding: NCI
		50–59 y: 52%	• Current use: external quality oversight
		60–69 y: 55%	• Care setting: hospitals
		70–79 y: 51%	• Professionals: medical oncologists; oncological radiologists
		>80 y: 34% S
		• Links: NA
	• % appropriate use any adjuvant systemic therapy in node (+)^IV	• Overall: 92%
		• by age:
		50–59 y: 93%
		60–69 y: 96%
		70–79 y: 89%
		>80 y: 85% NS
		• Links: NA
	• % appropriate use any adjuvant systemic therapy in node (+) BC^IV	• Overall: 71%
		• by age
		50–59 y: 61%
		60–69 y: 70%
		70–79 y: 81%
		>80 y: 74% S
		• Links: NA

NR = not reported; NA = not assessed; S = significant difference/trend; NS = nonsignificant difference/trend; n = number of patients; pts = patients; enrolled = n qualified; evaluated = n analyzed; BC = breast cancer; NCI = National Cancer Institute; EBCTCG = early breast cancer trialists’ collaborative group; HT = hormone therapy; CT = chemotherapy; state of use = last 3 y; ESBC = early-stage BC; LVN = lymphatic- vessel invasion; ER = estrogen receptor; Level Ia = pre-study data indicating consistently sound psychometric properties; Iac = pre- and on-study data indicating consistently sound psychometric properties; IV = no pre- or on-study psychometric data
Guadagnoli, 1998a US,	Process:	• Overall: 84% (MA) 86% (MN)	• Standard: NIH Consensus Development Conference, 1990	• Inclusion: convenience sample women ESBC (stage I or II) in 2 states of US (MA & MN), 1993-1995
	• % appropriate use of RT after BCS^IV	• by age (OR):	• Data sources: hospital tumor registries; medical records; patient survey; patient income & education US census data; physician survey	• Exclusion: DCIS; bilateral synchronous BC; inflammatory carcinoma
		50–59 y: 0.4 S (MA); 4.2 NS (MN)	• Developmental period: NR	• Period: 2 y (1993-1995)
		60–69 y: 0.5 NS (MA); 2.6 NS (MN)	• Reference standard(s) (publication sate): NR	• n patients (enrolled/evaluated): 2,575/2,575 (MA = 1,514; MN = 1,061)
		70–79 y: 0.3 S (MA); 0.3 NS (MN)	• Data sources: NR	• Age (mean & range): NR (<50 – > 80) y
		>80 y: 0.05 S (MA); 0.03 S (MN)	• Psychometric properties: NR	• Race/ethnicity: White 96% (MA); 99% (MN); Black 4% (MA); 1% (MN)
		• Links: NA	• Links to outcomes: NR	• Case characteristics: women > 60 y; stage I–II BC
	• % appropriate use of axillary lymph node dissection^IV	• Overall: 81% (MA); 94% (MN)	• Funding source: NR	• Socioeconomic status: income <$40,000 54%(MA); 67% (MN); urban 95%
		• by age (OR)	• State of use: NR	• Funding: NCI grants
		50–59 y: 0.8 NS (MA); 5.3 NS (MN)	• Current use: external quality oversight; research
		60–69 y: 0.3 NS (MA); 0.9 NS (MN)	• Care setting: hospitals; cancer centers; RT centers
		70–79 y: 0.1 S (MA); 0.2 S (MN)	• Professionals: clinicians; oncologists; surgeons; RT oncologists
		>80 y: 0.03 S (MA); 0.1S (MN)
		• Links: NA
	• % appropriate use of CT*^IV	• Overall: 97% (MA); 94% (MN)
		• Links: NA
	• % appropriate use of tamoxifen^IV	• Overall: 63% (MA); 59% (MN)
		• Links: NA

NR = not reported; NA = not assessed; S = significant difference/trend; NS = nonsignificant difference/trend; n = number of patients; pts = patients; enrolled = n qualified; evaluated = n analyzed; CT = chemotherapy; RT = radiotherapy; HT = hormone therapy; ER = estrogen receptor; PR = progesterone receptor; CPG = clinical practice guidelines; DCIS = ductal carcinoma in situ; BC = breast cancer; NCI = National Cancer Institute; MA = Massachusetts; MN = Minnesota; OR = odds ratio; state of use = last 3 y; GP = general practitioner; * premenopausal; node (+); ** postmenopausal nodes (+) & ER (+); BCS = breast-conserving surgery; Level Ia = pre-study data indicating consistently sound psychometric properties; Iac = pre- and on-study data indicating consistently sound psychometric properties; IV = no pre- or on-study psychometric data
Guadagnoli, 1998b, US	Process:	• Overall: 74%(MA); 48% (MN)	• Standard: NIH Consensus Development Conference, 1990	• Inclusion: convenience sample women BC stage I or II in hospitals of 2 US states (MA & MN), 1993-1995
	• % appropriate use of BCS^IV	• by age (OR):	• Data sources: medical records; patient survey	• Exclusion: bilateral disease; prior BCS in same breast; prior RT; pregnancy; central tumor; multifocal; etc
		50–59 y: 0.9 NS (MA); 0.9 NS (MN)	• Developmental period: NR	• Period: 2 y (1993-1995)
		60–69 y: 0.9 NS (MA); 0.7 NS (MN)	• Reference standard(s) (publication date): NR	• n patients (enrolled/evaluated): MA: 1,514/1,299; MN: 1,061/836
		70–79 y: 0.6 NS (MA); 0.6 S (MN)	• Data sources: NR	• Age (mean & range): NR (<50–>80) y
		≥80 y: 0.8 NS (MA); 0.4 S (MN)	• Psychometric properties: NR	• Race: White (96%); Black (4%)
		• by residence:	• Links to outcomes: NR	• Case characteristics: mostly women > 60 y, stage I disease
		Urban: 1.5 NS (MA); 2.2 S (MN)	• Funding source: NR	• Socioeconomic status: income < U$ 40,000 (MA: 55%; MN: 67%); urban (MA: 95%; MN: 91%); comorbid disease (MA: 63%; MN: 67%)
		• by income (OR):	• State of use: NR	• Funding: NCI
		<$40,000: 0.7 NS (MA); 1.4 NS (MN)	• Current use: external quality oversight
		By HMO member: 1.4 NS (MA); 0.9 NS (MN)	• Care setting: hospitals; cancer centers; RT centers
		• by education (% High school) (OR):	• Professionals: oncologists; surgeons; GPs; RT oncologists
		70–79: 0.9 NS (MA); 1.5 NS (MN)
		80–89: 0.9 NS (MA); 1.4 NS (MN)
		≥90: 1.4 NS (MA); 2.6 NS (MN)
		• Links: NA
	• % appropriate use of RT after BCS^IV	• Overall: 84% (MA); 86% (MN)
		• Links: NA

NR = not reported; NA = not assessed; S = significant difference/trend; NS = nonsignificant difference/trend; n = number of patients; pts = patients; enrolled = n qualified; evaluated = n analyzed; ESBC = early stage breast cancer; BCS = breast-conserving surgery; RT = radiotherapy; NCI = National Cancer Institute; MA = Massachusetts; MN = Minnesota; NIH = National Institute of Health; state of use = last 3 y; GP = general practitioner; OR = odds ratio; Level Ia = pre-study data indicating consistently sound psychometric properties; Iac = pre- and on-study data indicating consistently sound psychometric properties; IV = no pre- or on-study psychometric data
Haas, 2000, US	Process:	• Overall: 69.1%	• Standard: Harvard Risk Management Foundation guidelines, 1995	• Inclusion: convenience sample women referred for at least 1 visit to GP, 1 y prior to Mx; abnormal screening Mx or underwent Mx for clinical breast concern (lump, thickening, breast pain) regardless of result, Greater Boston area
	• % appropriate use of evaluation in compliance with guidelines (biopsy; imaging evaluation; breast exam)^IV	• by consultation:	• Data sources: medical records; baseline & follow-up telephone surveys	• Exclusion: previously diagnosed BC; evaluated for abnormal Mx or breast complaint within preceding y
		Abnormal Mx: 74%	• Developmental period: NR	• Period: 1 y (1996 -1997)
		Clinical breast complaint: 58.8%	• Reference standard(s) (publication date): NR	• n patients (enrolled/evaluated): 751/579
		• by age:	• Data sources: NR	• Age (mean & range): NR
		<50 y: 63.8%	• Psychometric properties: NR	• Race/ethnicity: White (74.4%); Black (14.5%); Hispanic (5.7%)
		≥50 y: 74.5 %	• Links to outcomes: NR	• Case characteristics: NR
		• by race/ethnicity:	• Funding source: NR	• Socioeconomic status: ≥ high school (50%); HMO (60%)
		White: 71%	• State of use: NR	• Funding: Harvard Risk Management Foundation
		Black: 59.5%	• Current use: internal quality improvement
		Hispanic: 75.8%	• Care setting: hospitals; cancer centers
		• by payer:	• Professionals: GPs; oncologists; surgeons
		HMO: 73.3%
		other: 62%
		• Links: NA
	Outcome:	• Overall: excellent care 46.8% (baseline)
	• % women reporting overall satisfaction with quality of breast care^IV	45.8% (follow-up survey)
		• by age:
		<50 y: 44.4% (b)- 46.6%(F)
		≥ 50 y: 49.3% (b)- 44.9% (F)
		• by Race/ethnicity:
		White: 51.9% (b)- 49.8% (F)
		Black: 35.9% (b)- 35.6% (F)
		Hispanic: 33.3% (b)-25% (F)
		• by payer:
		HMO: 42.9% (b) - 42.4% (F)
		other: 52.8% (b) – 50.7% (F)
		• Links: NA

NR = not reported; NA = not assessed; S = significant difference/trend; NS = nonsignificant difference/trend; n = number of patients; pts = patients; enrolled = n qualified; evaluated = n analyzed; BC = breast cancer; Mx = mammogram; state of use = last 3 y; GP = general practitioner; HMO = health maintenance organization; Level Ia = pre-study data indicating consistently sound psychometric properties; Iac = pre- and on-study data indicating consistently sound psychometric properties; IV = no pre- or on-study psychometric data
Harlan, 2002, US	Process:	• Overall: 70%	• Standard: NIH Consensus Development Conference, 1990	• Inclusion: population-based sample women stage I, II & IIIA BC diagnosed, 1987-1991 & 1995
	• % appropriate use of any adjuvant systemic therapy in node (+)^IV	• by age	• Data sources: NCI- SEER cancer registries	• Exclusion: pts who did not undergo surgery; participation in clinical trials
		<51y: 82%	• Developmental period: NR	• Period: 5 y (1987-1991 & 1995)
		51–64 y: 73%	• Reference standard(s) (publication date): NR	• n patients (enrolled/evaluated): 8,106/7,724
		≥65 y: 63% S	• Data sources: NR	• Age (mean & range): NR
		• by race/ethnicity:	• Psychometric properties: NR	• Race/ethnicity: White (83.2%); Black (9.3%); other (7.5%)
		White: 72%	• Links to outcomes: NR	• Case characteristics: women stage I–IIIA BC; ER (+) (59.2%); tumor size 1–2 cm (47.7%); node (-) (63.4%)
		Black: 69%	• Funding source: NR	• Socioeconomic status: NR
		other: 72% NS	• State of use: NR	• Funding: NCI
		• Links: NA	• Current use: external quality oversight; research
	• % appropriate use of any adjuvant systemic therapy in node (-)^IV	• Overall: NR	• Care setting: hospitals; cancer centers
		• by age:	• Professionals: oncologists; GPs
		<51 y: 45%
		<65 y: 46%
		≥65 y: 41%
		• by race/ethnicity:
		White: 44%
		Black: 40%
		other 45% NS
		• Links: NA
	• % appropriate decision not to provide adjuvant systemic therapy in node(-); tumor <1cm^IV	• Overall: 52.2%
		• Links: NA

NR = not reported; NA = not assessed; S = significant difference/trend; NS = nonsignificant difference/trend; n = number of patients; pts = patients; enrolled = n qualified; evaluated = n analyzed; BC = breast cancer; node (+) = lymph node positive; node (-) = lymph node negative; NIH = National Health Institute; NCI SEER = National Cancer Institute Surveillance, Epidemiology, and End-Results; state of use = last 3 y; GP = general practitioner; Level Ia = pre-study data indicating consistently sound psychometric properties; Iac = pre- and on-study data indicating consistently sound psychometric properties; IV = no pre- or on-study psychometric data
Hassey Dow, 2000, US	Outcome:	• Overall: NR; NS changes over time in QLI scales	• Instrument(s): Ferrans Quality-of-Life Index- cancer version (QLI) 1990	• Inclusion: convenience sample women ESBC beginning course of RT after BCS at a major urban teaching hospital in US Northeast. 21–45 y; newly diagnosed stage I or II BC; not undergoing CT or HT
	• % women reporting changes in QOL overtime (from start of RT; during RT & 6 mo post)^Ia	• Links: NA	• Data sources: questionnaires; demographic data form	• Exclusion: no previous diagnosis or treatment for any cancer
			• Developmental period: NR	• Period: 6 mo
			• Reference standard(s) (publication date): NR	• n patients (enrolled/evaluated): 28/23
			• Data sources: NR	• Age (mean & range): 37.8 (25–45) y
			• Psychometric properties: NR	• Race/ ethnicity: White (91%); Hispanic & Russian (4%)
			• Links to outcomes: NR	• Case characteristics: women BC stage I or II; BCS & RT; <45 y
			• Funding source: NR	• Socioeconomic status: single (40%)
			• State of use: NR	• Funding: ONS Foundation/Laderle Research
			• Current use: external quality oversight; research
			• Care setting: hospitals; cancer centers; RT centers
			• Professionals: oncologists; surgeons; GPs; RT oncologists

NR = not reported; NA = not assessed; S = significant difference/trend; NS = nonsignificant difference/trend; n = number of patients; pts = patients; enrolled = n qualified; evaluated = n analyzed; ESBC = early stage breast cancer; BCS = breast-conserving surgery; RT = radiotherapy; CT = chemotherapy; HT = hormone therapy; QOL = quality of life; QLI = Ferrans Quality-of-Life Index - Cancer version; state of use = last 3 y; GP = general practitioner; Level Ia = pre-study data indicating consistently sound psychometric properties; Iac = pre- and on-study data indicating consistently sound psychometric properties; IV = no pre- or on-study psychometric data
Hebert-Croteau, 1999, Canada	Process:	• Overall: NR	• Standard: NIH Consensus Development Conference, 1990	• Inclusion: random sample newly diagnosed stage I–II BC women ≥50 y receiving treatment in 5 sanitary regions of Quebec: Montreal, Quebec, Laval, Monteregie & Chadiere/Appalaches
	• % appropriate use of definitive locoregional therapy (total mastectomy + ALND or BCS + ALND + RT) ^IV	• by age:	• Data sources: Quebec tumor registry (1988-89); Quebec hospital admission/discharge database (1993-1994)	• Exclusion: pts in long term or convalescent hospitals; diagnostic errors; multiple primary tumors; recurrent BC; regional or distant extension; multicentric, inflammatory, Stage III–IV; no pathological confirmation of disease; tumor not originated in mammary gland; phyllodes tumor or lobular carcinoma
		50–69 y: 83.5%	• Developmental period: NR	• Period: 2 y (1993-1994)
		≥70 y: 48.7% S	• Reference standard(s) (publication date): NR	• n patients (enrolled/evaluated): 1,732/1,174
		• Links: NA	• Data sources: NR	• Age (mean & range): NR (50–>70) y
	• % appropriate use of alternative definitive therapy (RT after BCS + ALND or adjuvant treatment)^IV	• Overall: NR	• Psychometric properties: NR	• Race/ethnicity: NR
		• by age:	• Links to outcomes: NR	• Case characteristics: Stage I–II BC node (-); ER (+) (70–79%); tumor size 1–2 cm (41–48%)
		50–69 y: 90.9%	• Funding source: NR	• Socioeconomic status: NR
		≥70 y: 60.9% S	• State of use: NR	• Funding: Research in Health Quebec
		• Links: NA	• Current use: research; external quality oversight
	• % appropriate of use of BCS^IV	• Overall: NR	• Care setting: hospitals; cancer centers
		• by age:	• Professionals: oncologists; GPs; RT oncologists; surgeons
		50–69 y: 90.9%
		≥70 y: 80.1% S
		• Links: NA
	• % appropriate use of RT after BCS^IV	• Overall: NR
		• by age:
		50–69 y: 89.6%
		≥70 y: 59% S
		• Links: NA
	• % appropriate use of ALND^IV	• Overall: NR
		• by age:
		50–69 y: 82.4%
		≥70 y: 46.9% S
		• Links: NA
	• % appropriate use of any adjuvant systemic therapy^IV	• Overall: NR
		• by age:
		50–69 y: 74.2%
		≥70 y: 72.1% NS
		• Links: NA

NR = not reported; NA = not assessed; S = significant difference/trend; NS = nonsignificant difference/trend; n = number of patients; pts = patients; BC = breast cancer; LN = lymph nodes; LND = lymph node dissection; ALND = axillary lymph node dissection; RT = radiotherapy; enrolled = n qualified; evaluated = n analyzed; completed = n completing the study; GP = general practitioner; state of use = last 3 y; BCS = breast -conserving surgery; Level Ia = pre-study data indicating consistently sound psychometric properties; Iac = pre- and on-study data indicating consistently sound psychometric properties; IV = no pre- or on-study psychometric data
Hislop, 2003, Canada	Process:	• Overall: NR	• Standard: BCCA cancer treatment policy manual, 1995	• Inclusion: Population-based sample women histologically confirmed BC diagnosed, British Columbia, 1995
	• % appropriate use of BCS^IV	• by extent of disease:	• Data sources: British Columbia cancer registry; medical records; interviews of MDs	• Exclusion: diagnosed out of province; at death; previous synchronous cancer
		LCIS: 56%	• Developmental period: NR	• Period: 1 y (1995)
		DCIS: 39%	• Reference standard(s) (publication date): NR	• n patients (enrolled/ evaluated): 2,563/1,159
		Metastatic: 8%	• Data sources: NR	• Age (mean & range): NR
		M0 invasive: 57%	• Psychometric properties: NR	• Race/ethnicity: NR
		Node (-): 60%	• Links to outcomes: NR	• Case characteristics: DCIS or LCIS (n = 152); invasive non metastatic (n = 967); node (-) (n = 496); metastatic (n = 40)
		• By age:	• Funding source: NR	• Socioeconomic status: NR
		<40 y: 42%	• State of use: NR	• Funding: British Columbia Health Research
		40–49 y: 51%	• Current use: external quality oversight
		50–59 y: 58%	• Care setting: hospitals; cancer centers; RT centers
		60–69 y: 50%	• Professionals: oncologists; surgeons; RT oncologists; GPs
		70–79 y: 42%
		• > 80 y: 41%
		• by family income:
		<$35,000: 44%
		$35,000–44,999: 46%
		$45,000–54,999: 46%
		≥$55,000: 55%
		• Links: NA
	• % appropriate use of RT after BCS + ALND in M0 invasive BC^IV	• Overall: 38%
		• by family income:
		<$35,000: 100%
		$35,000–44,999: 80%
		$45,000–54,999: 89%
		≥$55,000: 82%
		• Links: NA
	• % appropriate use of RT after BCS in DCIS^IV	• Overall: 38%
		• Links: NA
	• % appropriate use of mastectomy ± RT + ALDN in M0 invasive^IV	• Overall: 46%
		• Links: NA
	• % appropriate use of mastectomy ± RT in LCIS or DCIS^IV	• Overall: 21%
		• Links: NA
	• % no BCS or mastectomy in metastatic disease^IV	• Overall: 65%
		• Links: NA
	• % appropriate use of treatment sequences according to guidelines^IV	• Overall: 81%
		• By extent of disease:
		LCIS: 78%
		DCIS: 71%
		Metastatic: 73%
		M0 invasive: 83%
		• Links: NA

NR = not reported; NA = not assessed; S = significant difference/trend; NS = nonsignificant difference/trend; n = number of patients; pts = patients; enrolled = n qualified; evaluated = n analyzed; BC = breast cancer; state of use = last 3 y; GP = general practitioner; BCCA = British Columbia Cancer Agency; DCIS = ductal carcinoma in situ; LCIS = lobular carcinoma in situ; BCS = breast-conserving surgery; RT = radiotherapy; ALND = axillary lymph node dissection; M0 = non-metastatic; MD = medical doctor; Level Ia = pre-study data indicating consistently sound psychometric properties; Iac = pre- and on-study data indicating consistently sound psychometric properties; IV = no pre- or on-study psychometric data
Imperato, 2002, US	Process:	• Overall: 99.3% (551/555)	• Standard: CAP & ADASP guidelines 1997/2000 (update)	• Inclusion: random sample Medicare Individuals BC who underwent total mastectomy with LND, NY State hospitals, 1999
	• % reporting laterality of specimen (right or left breast)^IV	• Links: NA	• Data sources: Medicare pts, NY State acute care hospitals, 1999 (n=1,718); medical records	• Exclusion: other type of surgery, missing data from records, no residual cancer present in individuals with prior lumpectomy or excisional biopsy
	• % reporting gross observation of lesion^IV	• Overall: 60.5% (336/555)	• Developmental period: NR	• Period: 1 y (1999)
		• Links: NA	• Reference standard(s) (Publication date): NR	• n patients (enrolled/ evaluated): 1718/555*
	• % reporting dimension of tumor (largest)^IV	• Overall: 93.5% (314/336)\	• Data sources: NR	• Age (mean & range): 73.7 (NR) y
		• Links: NA	• Psychometric properties: NR	• Race/ethnicity: White (80.9%); Black (8.5%) Asian (1.1%); unknown (9.5%)
	• % reporting identification of affected quadrant^IV	• Overall: 30.7% (103/336)	• Links to outcomes: NR	• Case characteristics: NR
		• Links: NA	• Funding source: NR	• Socioeconomic status: NR
	• % reporting LN (presence/absence)^IV	• Overall: 83.7% (465/555)	• State of use: NR	• Funding: Health Care Financing Administration
		• Links: NA	• Current use: external quality oversight; quality of care reporting
	• % reporting presence of carcinoma^IV	• Overall: 100% (555/555)	• Care setting: hospitals; pathology centers
		• Links: NA	• Professionals: pathologists; oncologists; surgeons
	• % reporting histological type^IV	• Overall: 95.9% (532/555)
		• Links: NA
	• % reporting histological grade^IV	• Overall: 59.1% (328/555)
		• Links: NA
	• % reporting nuclear grade^IV	• Overall: 44.3% (246/555)
		• Links: NA
	• % reporting mitotic rate^IV	• Overall: 22.5% (125/555)
		• Links: NA
	• % reporting extent of tubule formation^IV	• Overall: 19.6% (109/555)
		• Links: NA
	• % reporting verification tumor size^IV	• Overall: 63.0% (349/555)
		• Links: NA
	• % reporting angiolymphatic invasion^IV	• Overall: 45.6% (253/555)
		• Links: NA
	• % reporting resection margin status^IV	• Overall: 69.4% (385/555)
		• Links: NA
	• % reporting n LN present^IV	• Overall: 93.5% (519/555)
		• Links: NA
	• % reporting n node (+)^IV	• Overall: 98.6% (217/220)
		• Links: NA

NR = not reported; NA = not assessed; S = significant difference/trend; NS = nonsignificant difference/trend; n = number of patients; pts = patients; enrolled = n qualified; evaluated = n analyzed; LN = lymph nodes; LND = lymph node dissection; (+) = positive; CAP = College of American Pathology; ADASP = Association of Directors of Anatomic and Surgical Pathology; state of use = last 3 y; NY = New York; Level Ia = pre-study data indicating consistently sound psychometric properties; Iac = pre- and on-study data indicating consistently sound psychometric properties; IV = no pre- or on-study psychometric data
Jackson, 1999, Canada	Process:	• Overall: 82.5% (4%–95.5%)	• Standard: BCCA guidelines, 1986, update in 1989 & 1993	• Inclusion: population-based sample women receiving “radical” or “adjuvant” postoperative RT treatments for BC in 3 clinics in British Columbia inclusive, 1985-1996
	• % appropriate use of RT post-mastectomy on chest wall^IV	• Links: NA	• Data sources: CAIS, Radiation Therapy Warehouse Table	• Exclusion: pts receiving palliative treatment or treatment for other disease sites; referrals to other hospitals
	• % appropriate use of RT on regional LN^IV	• Overall: 75% (3%–92%)	• Developmental period: NR	• Period: 12 y (1985-1996)
		• Links: NA	• Reference standard(s) (publication date): NR	• n patients (enrolled/ evaluated): 9,748/9,351
	• % quality of RT after BCS^IV	• Overall: 95% (69%–99.5%)	• Data sources: NR	• Age (mean & range): NR
		• Links: NA	• Psychometric properties: NR	• Race/ethnicity: NR
			• Links to outcomes: NR	• Case characteristics: NR
			• Funding source: NR	• Socioeconomic status: NR
			• State of use: NR	• Funding: NR
			• Current use: external quality oversight
			• Care setting: hospitals; cancer certers; RT oncologists;
			• Professionals: RT oncologists; oncologists; surgeons; GPs

NR = not reported; NA = not assessed; S = significant difference/trend; NS = nonsignificant difference/trend; n = number of patients; pts = patients; enrolled = n qualified; evaluated = n analyzed; BC = breast cancer; RT = radiotherapy; CAIS = Cancer Agency Information System; LN = lymph nodes; BCS = breast-conserving surgery; state of use = last 3 y; GP = general practitioner BCCA = British Columbia Cancer Agency; Level Ia = pre-study data indicating consistently sound psychometric properties; Iac = pre- and on-study data indicating consistently sound psychometric properties; IV = no pre- or on-study psychometric data
Jansen, 2000, Netherlands	Outcome:	• Overall: QOL scale: 38% (worse); 40% (stable); 22% (improvement)	• Instrument(s): Rotterdam Symptom Checklist (RSCL); SF-36	• Inclusion: convenience sample women ESBC who underwent surgery (BCS or mastectomy)
	• Overall changes in QOL overtime; before & after RT^Iac	• Links: NA	• Data sources: pt self-report questionnaires before RT (pretest); after RT (post-test) & recall of pretest	• Exclusion: previous CT or RT; DCIS; no speak Dutch
			• Developmental period: NR	• Period: 2 y (1997-1999)
			• Reference standard(s) (publication date): NR	• n patients (enrolled/evaluated): 76/46
			• Data sources: NR	• Age (mean & range): 55 (28–77) y
			• Psychometric properties: NR	• Race/ethnicity: NR
			• Links to outcomes: NR	• Case characteristics: women BC stage I or II; BCS (n=37); mastectomy (n=9)
			• Funding source: NR	• Socioeconomic status: married (72%); full-time employment (17%)
			• State of use: NR	• Funding: Dutch Cancer Society
			• Current use: external quality oversight; research
			• Care setting: hospitals; cancer centers; RT centers
			• Professionals: oncologists; surgeons; GPs; RT oncologists

NR = not reported; NA = not assessed; S = significant difference/trend; NS = nonsignificant difference/trend; n = number of patients; pts = patients; enrolled = n qualified; evaluated = n analyzed; ESBC: early stage breast cancer; BCS: breast-conserving surgery; RT: radiotherapy; CT: chemotherapy; QOL: Quality of life; DCIS: ductal in situ carcinoma; state of use: last 3 y; GP = general practitioner; Level Ia = pre-study data indicating consistently sound psychometric properties; Iac = pre- and on-study data indicating consistently sound psychometric properties; IV = no pre- or on-study psychometric data
Keating, 2001, US	Process:	• Overall: 73.8% (MA); 48% (MN)	• Standard: NIH Consensus Development Conference, 1990	• Inclusion: convenience sample women diagnosed stage I & II BC at 17 hospitals in MA & 30 hospitals in MN
	• % appropriate use of BCS^IV	• Links: NA	• Data sources: medical records; telephone interview with pts	• Exclusion: women BC DCIS; bilateral synchronous carcinoma; inflammatory carcinoma; women interview non-responders (no permission by surgeon, not located, unavailable)
	Outcome:	• Overall: Very satisfied:	• Developmental period: NR	• Period: 2 y (1993-1995)
	• % satisfaction of women with treatment choice after discussing with oncologist or surgeon^IV	80% (MA); 76% (MN)	• Reference standard(s) (publication date): NR	• n patients (enrolled/evaluated): 1,498/792 (MA); 2,330/1,634 (MN)
		• Links: NA	• Data sources: NR	• Age (mean & range): 56.6 y (SD 13.5) MA; 59.4 y (SD 13.6) MN
	• % participation of women with BC in decision-making as much as they wanted^IV	• Overall: 83% (MA); 81% (MN)	• Psychometric properties: NR	• Race/ethnicity: White 94% (MA); 98% (MN) S
		• Links: NA	• Links to outcomes: NR	• Case characteristics: women BC stage I 58% MA; 60% MN; stage II 42% MA; 40% MN
	• % received enough information about surgery & RT^IV	• Overall: 80% (MA); 80% (MN) appropriate	• Funding source: NR	• Socioeconomic status: income < U$20,000/y: 17% MA; 22% MN; U$20,000–40,000/y: 29% MA; 34% MN; >U$40,000/y: 54% MA; 44% MN (p<0.05); HMO insurance 33% MA; 43% MN (p<0.05)
		• Links: NA	• State of use: NR	• Funding: NCI; Doris Duke Charitable Foundation
			• Current use: external quality oversight
			• Care setting: hospitals; pathology centers
			• Professionals: pathologists; oncologists; surgeons

NR = not reported; NA = not assessed; S = significant difference/trend; NS = nonsignificant difference/trend; n = number of patients; pts = patients; MA = Massachusetts; MN = Minnesota LN = lymph nodes; BCS = breast-conserving surgery; RT = radiotherapy; n = number; HR = hormone receptor; DCIS = ductal carcinoma in situ; BC = breast cancer; NIH = National Institute of Health; state of use = last 3 y; Level Ia = pre-study data indicating consistently sound psychometric properties; Iac = pre- and on-study data indicating consistently sound psychometric properties; IV = no pre- or on-study psychometric data
Khawaja, 2001, UK	Access:	• Overall: 100% (22/22)	• Standard: BASO breast group recommendations 1995/1998 (update)	• Inclusion: convenience sample women BC referred by GP to specialist to diagnose: breast lump; suspicion of malignant change; other breast symptoms
	• % women BC to be seen by specialist within 2 wks of referral (standard: ≥80%) for diagnostic purposes^IV	• Soon (<10 d):	• Data sources: referrals faxed to breast clinic	• Exclusion: benign disease
		>65 y: 18.2% (4/22)	• Developmental period: NR	• Period: 3 mo (1998)
		• Links: NA	• Reference standard(s) (publication date): NR	• n patients (enrolled/evaluated): 100/22
	• % urgent referrals seen within 5 working d (standard: ≥80%)^IV	• Overall: 82%	• Data sources: NR	• Age (mean & range): 50 (22–90) y
		• by age:	• Psychometric properties: NR	• Race/ethnicity: NR
		41–65 y: 27.3% (6/22)	• Links to outcomes: NR	• Case characteristics: NR
		>65 y: 54.5% (12/22)	• Funding source: NR	• Socioeconomic status: NR
		• Links: NA	• State of use: NR	• Funding: NR
			• Current use: research; internal quality improvement; external quality oversight
			• Care setting: hospitals; cancer centers
			• Professionals: GPs; oncologists; surgeons

NR = not reported; NA = not assessed; S = significant difference/trend; NS = nonsignificant difference/trend; n = number of patients; pts = patients; enrolled = n qualified; evaluated = n analyzed; BC: breast cancer; BASO: British Association of Surgical Oncology; state of use: last 3 y; GP = general practitioner; Level Ia = pre-study data indicating consistently sound psychometric properties; Iac = pre- and on-study data indicating consistently sound psychometric properties; IV = no pre- or on-study psychometric data
Lagorreta, 2000, US	Process:	• Overall: 63% (474/748)	• Standard: NIH Consensus Conference recommendations, 1990	• Inclusion: convenience sample women ≥ 21 y ESBC detected, 1994-1996, with invasive carcinoma (any histological subtype); DCIS; stages 0–II; primary tumor ≤ 5 cm; no evidence multicentricity of tumor; no CI to RT; Paget's disease of breast; eligible for BCS
	• % appropriate use of BCS when indicated^IV	• by stage: Stage 0 & I were 16% (OR: 1.16; S)& 21 % (OR: 1.21; S) respectively, more likely to receive BCS vs stage II pts	• Data sources: claims data of Health Net (~1.3 million member); HMO of California; medical records	• Exclusion: lobular carcinoma in situ; phyllodes tumor, or sarcoma; primary tumor > 5 cm &/or stage III or IV
		• by race/ethnicity:	• Developmental period: NR	• Period: 2 y (1994-1996)
		Hispanic women 36% less likely to receive BCS vs White women (OR: 0.36; S)	• Reference standard(s) (publication date): NR	• n patients (enrolled/ evaluated): 1,017/753
		By Marital Status (OR):	• Data sources: NR	• Age (mean & range): NR (≤ 39– ≥ 65) y
		Married: 0.93	• Psychometric properties: NR	• Race/ethnicity: White (72.6%); Hispanic (6.8%); Black (5.2%); unknown (8.5%)
		Not married/widowed: 1.00	• Links to outcomes: NR	• Case characteristics: ESBC stage 0 (8.2%); I (50.1%; II (41.7%), tumor size 1.1–2 cm (45.3%)
		• Links: NA	• Funding source: NR	• Socioeconomic status: Married (61.8%)
			• State of use: current	• Funding: NR
			• Current use: external quality oversight
			• Care setting: hospitals; cancer centers
			• Professionals: oncologists; surgeons; GPs

NR = not reported; NA = not assessed; S = significant difference/trend; NS = nonsignificant difference/trend; n = number of patients; pts = patients; enrolled = n qualified; evaluated = n analyzed; BCS = breast-conserving surgery; CI = contraindication; CT = chemotherapy; NIH =National Health Institute; ESBC = early stage breast cancer; DCIS = ductal carcinoma in situ; RT = radiotherapy; OR = odds ratio; HMO = Health Maintenance Organization; state of use = last 3 y; GP = general practitioner; Level Ia = pre-study data indicating consistently sound psychometric properties; Iac = pre- and on-study data indicating consistently sound psychometric properties; IV = no pre- or on-study psychometric data
Lazovich, 1997, US	Process:	• Overall: NR	• Standard: NIH Consensus Development Conference, 1990	• Inclusion: national population-based sample women ESBC stage I or II diagnosed in 13 western, Washington counties, 1983-1993
	• % appropriate use of BCS^IV	• by stage:	• Data sources: SEER cancer registries; medical records	• Exclusion: locally advanced BC; distant metastases; no measurable breast mass; data missing
		Stage I: 54.9%	• Developmental period: NR	• Period: 3 y (1990-1993)
		Stage II: 35.2%	• Reference standard(s) (publication date): NR	• n patients (enrolled/evaluated): 18,664/13,541
		• by age:	• Data sources: NR	• Age (mean & range): NR
		<50 y: 52.1%	• Psychometric properties: NR	• Race/ethnicity: NR
		50–59 y: 54.9%	• Links to outcomes: NR	• Case characteristics: women BC stage I or II; <5 cm
		60–69 y: 47.4%	• Funding source: NR	• Socioeconomic status: NR
		70–79 y: 39.1%	• State of use: NR	• Funding: NCI
		> 80 y: 31.7% S	• Current use: external quality oversight; research
		• by payer:	• Care setting: hospitals; cancer centers; RT centers
		Private: 46.2%	• Professionals: oncologists; surgeons; GPs; RT oncologists
		HMO: 69.9% S
		• by education:
		Lowest tertile: 44.9%
		Middle tertile: 49.9%
		Highest tertile: 50.9% S
		• Links: NA
	• % appropriate use of RT after BCS^IV	• Overall: 94.1%
		• Links: NA

NR = not reported; NA = not assessed; S = significant difference/trend; NS = nonsignificant difference/trend; n = number of patients; pts = patients; enrolled = n qualified; evaluated = n analyzed; ESBC = early stage breast cancer; BCS = breast-conserving surgery; RT = radiotherapy; NIH = National Institute of Health; SEER = Surveillance, Epidemiology and End Results; NCI = National Cancer Institute; state of use = last 3 y; GP = general practitioner; Level Ia = pre-study data indicating consistently sound psychometric properties; Iac = pre- and on-study data indicating consistently sound psychometric properties; IV = no pre- or on-study psychometric data
Lazovich, 1999, US	Process:	• Overall: NR	• Standard: NIH Consensus Conference recommendations, 1990	• Inclusion: national population-based sample women ESBC diagnosed in 9 US regions, 1983-1995
	• % appropriate use of BCS^IV	• by stage:	• Data sources: SEER cancer registries (9 US regions)	• Exclusion: DCIS; Paget's disease; non measurable tumor; tumor > 5 cm; stages III or IV; data missing
		Stage I: 53.4%(29,234/55,984)	• Developmental period: NR	• Period: 5 y (1990-1995)
		Stage II: 32.7%(22,746/53,896)	• Reference standard(s) (publication date): NR	• n patients (enrolled/evaluated): 110,235/109,880
		• by age:	• Data sources: NR	• Age (mean & range): NR
		<50 y: 48%	• Psychometric properties: NR	• Race/ethnicity: White, non-white
		50–59 y: 49%	• Links to outcomes: NR	• Case characteristics: women BC stage I or II; <5 cm
		60–69 y: 44.6%	• Funding source: NR	• Socioeconomic status: NR
		70–79 y: 39.2%	• State of use: NR	• Funding: NIH
		≥ 80 y: 34.7%	• Current use: external quality oversight; research
		• by Race/ethnicity:	• Care setting: hospitals; cancer centers; RT centers
		White: 44.5%	• Professionals: oncologists; surgeons; GPs; RT oncologists
		Non-White: 43.1%
		• Per Registry:
		lowa; 26.7%
		Atlanta:42.1%
		Utah: 35%
		New Mexico: 40.1%
		Hawaii: 46.9%
		Detroit: 41.2%
		Connecticut: 55.6%
		SanFranscisco/Oakland: 50.8%
		Seattle/Puget Sound: 50%
		• Links: NA
	• % appropriate use RT after BCS^IV	• Overall: 81.5% (23,042/37,196)
		• by Stage:
		Stage I: 83.5%
		Stage II: 77.4% S
		• by Age:
		<50 y: 82.4%
		50–59 y: 86.1%
		60–69 y: 86.6%
		70–79 y: 80.2%
		≥80 y: 48.5% S
		• by Race/ethnicity:
		White: 81.7%
		Non-White: 80.7% NS
		• Links: NA

NR = not reported; NA = not assessed; S = significant difference/trend; NS = nonsignificant difference/trend; n = number of patients; pts = patients; enrolled = n qualified; evaluated = n analyzed; BCS = breast-conserving surgery; RT = radiotherapy; NIH = National Institute of Health; SEER = surveillance, epidemiology and end results; state of use = last 3 y; GP = general practitioner; Level Ia = pre-study data indicating consistently sound psychometric properties; Iac = pre- and on-study data indicating consistently sound psychometric properties; IV = no pre- or on-study psychometric data
Mandelblatt, 2001, US,	Process:	• Overall: 35.5%	• Standard: NIH Consensus Development Conference, 1990	• Inclusion: national random sample, Medicare beneficiaries, ≥ 67 y, newly diagnosed ESBC, 1992-1994; surgeons treating above mentioned group of pts
	• % appropriate use of BCS^IV	• by surgeon profile:	• Data sources: claims data from FFS Medicare sector; surveys sent to treating surgeons; telephone surveys with surgeons	• Exclusion: women ≥ 67 y Stage I, IIA, or IIB BC; bilateral BC; multicentricity of cancer
		surgeons with BCS propensity: 44.4%	• Developmental period: NR	• Period: 6 y (1992-1998)
		surgeons with mastectomy propensity: 26.8% S	• Reference standard(s) (publication date): NR	• n patients (enrolled/evaluated): 3,851/3,851
		• Links: NA	• Data sources: NR	• n surgeons (enrolled/evaluated): 1,531/1,000
	• % appropriate use of RT after BCS^IV	• Overall: 72.1%	• Psychometric properties: NR	• Age (mean & range): NR
		By surgeon profile:	• Links to outcomes: NR	• Race/ethnicity: NR
		surgeons with BCS+ RT propensity: 75.1%	• Funding source: NR	• Case characteristics: NR
		surgeons with no RT propensity: 63.2% S	• State of use: NR	• Socioeconomic status: NR
		• Links: NA	• Current use: research	• Funding: grants: AHRQ & Department of the Army grants
			• Care setting: hospitals; cancer centers
			• Professionals: surgeons; oncologists; RT oncologists; GPs

NR = not reported; NA = not assessed; S = significant difference/trend; NS = nonsignificant difference/trend; n = number of patients; pts = patients; enrolled = n qualified; evaluated = n analyzed; BC = breast cancer; NIH = National Institute of Health; FFS = fee-for-service; BCS = breast-conserving surgery; RT = radiotherapy; AHRQ = Agency for Healthcare Research and Quality; state of use = last 3 y; GP = general practitioner; Level Ia = pre-study data indicating consistently sound psychometric properties; Iac = pre- and on-study data indicating consistently sound psychometric properties; IV = no pre- or on-study psychometric data
Mandelblatt, 2002, US	Process:	• Overall: 33% (599/1,833)	• Standard: NIH Consensus Development Conference, 1990	• Inclusion: national random sample, fee-for service Medicare beneficiary women ≥67 y newly diagnosed primary, unilateral, histologically confirmed stage I–II BC treated, 1994
	• % apropriate use of BCS^IV	• by race/ethnicity:	• Data sources: Medicare data; surgeon contacts; surviving women contacts; 1990 Census File; 1993 & 1995 data from Area Resource File	• Exclusion: previous BC; DCIS without invasive disease; metastatic or multicentric BC; bilateral breast procedures; women BC without surgical procedure; breast surgery not 1^st procedure; BC not primary diagnosis; missing data
		Black: 31% (300/984)	• Developmental period: NR	• Period: 1 y (1994)
		White: 35% (299/849) NS	• Reference standard(s) (publication date): NR	• n patients (enrolled/evaluated): 6,998/1,833
		• Links: NA	• Data sources: NR	• Age (mean & range): 74.4 (68.1–80.7) y
	• % appropriate use of RT after BCS^IV	• Overall: 66.6% (399/599)	• Psychometric properties: NR	• Race/ethnicity: Black (53.7%); White (46.3%)
		• by race/ethnicity:	• Links to outcomes: NR	• Case characteristics: stage I: Black (53%); White (60%); stage IIA: Black (35%); White (33%); stage IIB: Black (12%); White (7%)
		Black: 61% (183/300)	• Funding source: NR	• Socioeconomic status: women < poverty level: Black (15.2±7.3%); White (11.8±5.8%); monthly income <U$1,000: Black (54%); White (24%); ≥U$1,000: Black (27%); White (56%); ≤ High school: Black (76%); White (64%); married: Black (32%); White (46%); Medicaid: Black (25%); White (6%); private insurance: Black (43%); White (84%)
		White: 72.2% (216/299) S	• State of use: NR	• Funding: AHRQ; FCCBC; Department of the Army; & NCI grants
		• Links: NA	• Current use: external quality oversight
	• % appropriate use of ALND after BCS or mastectomy^IV	• Overall: 86% (1,579/1,833)	• Care setting: hospitals; cancer centers; RT centers
		• by race/ethnicity:	• Professionals: oncologists; RT oncologists; surgeons; GPs
		Black: 88% (867/984)
		White: 84% (712/849) S
		• Links: NA
	• % appropriate use of CT^IV	• Overall: 9% (172/1,833)
		• by race/ethnicity:
		Black: 11% (112/984) S
		White: 7% (60/849)
		• Links: NA
	• % appropriate use of tamoxifen^IV	• Overall: 62%
		• by race/ethnicity:
		Black: 58% (193/331) S
		White: 66% (263/401)
		• Links: NA

NR = not reported; NA = not assessed; S = significant difference/trend; NS = nonsignificant difference/trend; n = number of patients; pts = patients; enrolled = n qualified; evaluated = n analyzed; BC = breast cancer; DCIS = ductal carcinoma in situ; BCS = breast-conserving surgery; RT = radiotherapy; ALND = axillary lymph node dissection; NIH = National Institute of Health; NCI = National Cancer Institute; AHRQ = Agency for Healthcare Research and Quality; FCCBC = Federal Coordinating Committee on Breast Cancer; state of use = last 3 y; GP = general practitioner; CT = chemotherapy; Level Ia = pre-study data indicating consistently sound psychometric properties; Iac = pre- and on-study data indicating consistently sound psychometric properties; IV = no pre- or on-study psychometric data
McCarthy, 1997, UK	Access:	• Overall: 45.5% (5/11)	• Standard: quality assurance guidelines (NHSBSP), 1994	• Inclusion: convenience sample women operable BC <70 y treated at Nottingham City Hospital's, 1994 Professional Unit of Surgery
	• %(>90%) of women requiring operation for diagnostic purposes should be admitted within 14 d of surgical decision^IV	• Links: NA	• Data sources: Professional Unit of Surgery's database of Primary Breast Cancers; the Helen Garrod Breast Screening Unit's computerized database; pathology department's computerized histology database; individual hospital case notes	• Exclusion: NR
	• % (90%) of women admitted for operation within 21 d of surgical decision to operate for therapeutic purposes^IV	• Overall: 90.4% (75/83)	• Developmental period: NR	• Period: 1 y (1994)
		• Links: NA	• Reference standard(s) (publication date): NR	• n patients (enrolled/evaluated): 251/251
	Process:	• Overall: 42.7% (32/75)	• Data sources: NR	• Age (mean & range): NR
	• % (>90%) women BC detected by screening should attend assessment center within 3 wks of mammography^IV	• Links: NA	• Psychometric properties: NR	• Race/ethnicity: NR
	• % (>70%) appropriate use of pre-operative diagnosis of cancer by cytology or needle histology^IV	• Overall: 86.7% (72/83)	• Links to outcomes: NR	• Case characteristics: NR
		• Links: NA	• Funding source: NR	• Socioeconomic status: NR
	• % (>95%) appropriate use of first localization biopsy operation to correctly identify impalpable lesions^IV	• Overall: 100% (11/11)	• State of use: NR	• Funding: NR
		• Links: NA	• Current use: external quality oversight; research; internal quality improvement
	• % (90%) appropriate use of operations carried out with proven pre-operative diagnosis of cancer (in situ or invasive) should not require a further operation for incomplete excision^IV	• Overall: 80.3% (49/61)	• Care setting: hospitals; cancer centers
		• Links: NA	• Professionals: oncologists; GPs; surgeons

NR = not reported; NA = not assessed; S = significant difference/trend; NS = nonsignificant difference/trend; n = number of patients; pts = patients; BC = breast cancer; BCS = breast-conserving surgery; n = number of participants; enrolled = n qualified; evaluated = n analyzed; NHSBSP = national coordination group for surgeons working in breast cancer screening; state of use = last 3 y; GP = general practitioner; Level Ia = pre-study data indicating consistently sound psychometric properties; Iac = pre- and on-study data indicating consistently sound psychometric properties; IV = no pre- or on-study psychometric data
McGlynn, 2003, US	Process:	• Overall: 89.1% (n = 77)	• Standard: from observational studies and expert opinion, to randomized controlled trials	• Inclusion: random sample women living in 12 US metropolitan areas
	• % (Appropriate use): If a palpable breast mass has been detected, at least one of the following procedures should be completed within 3 months: fine-needle aspiration, mammography, ultrasound, biopsy and/or a followup visit^IV	• Links: NA	• Data sources: telephone survey; medical records	• Exclusion: leaving the area; refusal to be interviewed
	Process:	• Overall: 81.6% (n = 13)	• Developmental period: NR	• Period: 2 y (1998-2000)
	• % (Appropriate use): If a breast mass has been detected on two separate occasions, then either a biopsy, fine-needle aspiration or ultrasound should be performed within 3 months of the second visit^IV	• Links: NA	• Reference standard(s) (publication date): NR	• n patients (enrolled/evaluated): 192/192
	Process:	• Overall: 50.2% (n = 33)	• Data sources: NR	• Age (mean & range): NR
	• % (Appropriate use): A biopsy or fine-needle aspiration should be performed within 6 weeks either when the mammography suggests malignancy or the persistent palpable mass is not cystic on ultrasound^IV	• Links: NA	• Psychometric properties: NR	• Race/ethnicity: NR
	Process:	• Overall: 100% (n = 2)	• Links to outcomes: NR	• Case characteristics: NR
	• % (Appropriate use): A biopsy should be performed within 6 weeks if fine needle aspiration cannot rule out malignancy^IV	• Links: NA	• Funding source: NR	• Socioeconomic status: NR
	Process:	• Overall: 50.2% (n = 13)	• State of use: NR	• Funding: Robert Wood Johnson Foundation
	• % (Appropriate use): Women with stage I or stage II breast cancer should be offered a choice of modified radical mastectomy or breast-conserving surgery, unless contraindications to breast-conserving surgery are present^IV	• Links: NA	• Current use: external quality oversight
	Process:	• Overall: 45.3% (n = 10)	• Care setting: hospitals; pathology centers
	• % (Appropriate use): Women treated with breast-conserving surgery should begin radiation therapy within 6 weeks of completing either of the following: the last surgical procedure on the breast (including reconstructive surgery that occurs within 6 wks of primary resection) or chemotherapy, if patient receives adjuvant chemotherapy, unless wound complications prevent the initiation of treatment^IV	• Links: NA	• Professionals: oncologists; surgeons GPs; RT oncologists
	Process:	• Overall: 85.1% (n = 13)
	• % (Appropriate use): Women with invasive breast cancer that is node-positive, or node-negative and primary tumor ≥ 1 cm, should be treated with adjuvant systemic therapy to include combination chemotherapy (and/or tamoxifen, 20mg/d) ^IV	• Links: NA
	Process:	• Overall: 84.6% (n = 99)
	• % (Appropriate use): Women with a history of breast cancer should have a yearly mammography^IV	• Links: NA
	Process:	• Overall: 82.6% (n = 4)
	• % (Appropriate use): Women with metastatic breast cancer should be offered hormonal therapy, chemotherapy, and/or enrollment in a clinical trial with documentation of informed consent within 6 wks of the identification of metastases^IV	• Links: NA

NR = not reported; NA = not assessed; S = significant difference/trend; NS = nonsignificant difference/trend; n = number of patients; pts = patients; BC = breast cancer; QI = quality indicator; CI = confidence interval; state of use = last 3 y; RT = radiotherapy; GP = general practitioner; Level Ia = pre-study data indicating consistently sound psychometric properties; Iac = pre- and on-study data indicating consistently sound psychometric properties; IV = no pre- or on-study psychometric data
Molenaar, 2001, Netherlands	Outcome:	• Overall: positive effect (CDROM) 0, 3 & 9 mo; no data	• Standard: IKA/IKST: Working group on Mamma Carcinoma; treatment guidelines; the Netherlands; Comprehensive Cancer Center, 1995	• Inclusion: convenience sample women, newly diagnosed stage I & II BC eligible for BCS or mastectomy
	• % satisfaction of women BC with treatment choice^Iac	• Links: NA	• Instrument(s): MOS20; EORTC QLQ-BR23	• Exclusion: no Dutch spoken
	• % change in QOL over time; generic QOL scales (higher scores = better QOL; except for pain scores)]^Iac	• Overall: positive effect (CDROM) 0, 3 & 9 mo; no data	• Data sources: pt self-reported questionnaires; 3 hospitals, Netherlands	• Period: 2 y (1996-1998)
		• Links: NA	• Developmental period: NR	• n patients (enrolled/evaluated): 180/167
	• % change in QOL over time; BC- specific QOL scales (higher scores = better functioning; except for symptoms scales)^Iac	• Overall: positive effect (CDROM) 0, 3 & 9 mo; no data	• Reference standard(s) (Publication Date): NR	• Age (mean & range): 55.4 (44.6–66.2) y (CDROM group); 54.6 (44–65.2) y (standard care)
		• Links: NA	• Data sources: NR	• Race/ethnicity: NR
			• Psychometric properties: NR	• Case characteristics: ESBC node (-) (52–57%)
			• Links to outcomes: NR	• Socioeconomic status: married (53–66%); employed (45–52%)
			• Funding source: NR	• Funding: Dutch Cancer Society
			• State of use: NR
			• Current use: internal quality improvement
			• Care setting: hospitals; cancer centers; RT centers
			• Professionals: oncologists; surgeons; GPs; RT oncologists

NR = not reported; NA = not assessed; S = significant difference/trend; NS = nonsignificant difference/trend; n = number of patients; pts = patients; enrolled = n qualified; evaluated = n analyzed; ESBC = early stage breast cancer; BCS = breast-conserving surgery; QOL = quality of life; MOS20 = medical outcomes study 20 (general health; physical functioning; pain; role functioning; social & psychosocial functioning); EORTC QLQ-BR23: European Organization for Research and Treatment of Cancer Quality of Life-specific for BC pts (body image; sexual functioning; arm symptoms; breast symptoms; systemic therapy symptoms; & future perspective); state of use = last 3 y; GP = general practitioner; Level Ia = pre-study data indicating consistently sound psychometric properties; Iac = pre- and on-study data indicating consistently sound psychometric properties; IV = no pre- or on-study psychometric data
Mor, 1994, US	Outcome:	• Overall: NR	• Instrument(s): MHI-5	• Inclusion: convenience sample women BC from 2 research samples
	• %change in QOL over time^Ia	• by age:	• Data sources: medical records; telephone interview with pts	• Exclusion: NR
		24–54 y: 67.6%	• Developmental period: NR	• Period: NR
		>55 y: 71%	• Reference standard(s) (publication date): NR	• n patients (enrolled/evaluated): 262/262
		• Links: NA	• Data sources: NR	• Age (mean & range): NR (24–>55) y
			• Psychometric properties: NR	• Race/ethnicity: White 92.4%
			• Links to outcomes: NR	• Case characteristics: women BC; local/regional disease; CT (80%)
			• Funding source: NR	• Socioeconomic status: employed (14.3–51.8%); married (52.9–67.7%); family income > U$ 30,000 (17.6–49.7%)
			• State of use: NR	• Funding: NCI
			• Current use: decision-making; research
			• Care setting: hospitals; cancer centers
			• Professionals: oncologists; surgeons; GPs

NR = not reported; NA = not assessed; S = significant difference/trend; NS = nonsignificant difference/trend; n = number of patients; pts = patients; QOL = quality of life; BC = breast cancer; state of use = last 3 y; NCI = National Cancer Institute; CT = chemotherapy; MHI-5 = Mental Health inventory (5-item scale for medically ill population); GP = general practitioner; Level Ia = pre-study data indicating consistently sound psychometric properties; Iac = pre- and on-study data indicating consistently sound psychometric properties; IV = no pre- or on-study psychometric data
Mor, 2000, US	Process:	• Overall: 64.1%	• Standard: NCI Consensus Conference for surgeons, 1993	• Inclusion: random sample women > 60 y BC stage I or II diagnosed at 6 hospitals, Providence, RI, Nov 1992 & Feb 1997
	• % appropriate use of BCS^IV	• Links: NA	• Data sources: hospital cancer registry (6 hospitals in Rhode Island, US); pathology reports; medical records; pt interviews	• Exclusion: women with BC <60 y; not eligible patients for intervention (low-volume surgeons)
	• % appropriate use of RT after BCS^IV	• Overall: 70.4 %	• Developmental period: NR	• Period: 5 y (1992-1997)
		• by age:	• Reference standard(s) (publication date): NR	• n patients (enrolled/evaluated): 1,144/350
		60–69 y: 94%	• Data sources: NR	• Age (mean & range): NR (60–>80 y)
		70–79 y: 83%	• Psychometric properties: NR	• Race/ethnicity: NR
		> 80 y: 34% S	• Links to outcomes: NR	• Case characteristics: women BC stage I, II or DCIS; >1cm (74.9%); ER/PR known (94.7%); node (-) (38.6%), node (+) (13.1%)
		• Links: NA	• Funding source: NR	• Socioeconomic status: NR
	• % appropriate use of any adjuvant systemic therapy (CT &/or HT); tumor ≥ 1 cm^IV	• Overall: 81.9%	• State of use: NR	• Funding: NCI
		• by age:	• Current use: internal quality improvement; external quality oversight, research
		60–69 y: 88%	• Care setting: hospitals; cancer centers
		70–79 y: 82%	• Professionals: surgeons; oncologists
		>80 y: 77% S
		• Links: NA
	• % appropriate use of treatment sequences recommended or received (if tumor <1 cm, then mastectomy or BCS + RT. If tumor ≥ 1 cm then mastectomy or BCS + RT & CT &/or HT) ^IV	• Overall: 72.9%
		• by age:
		60–69 y: 89%
		>80 y: 50% S
		• Links: NA

NR = not reported; NA = not assessed; S = significant difference/trend; NS = nonsignificant difference/trend; n = number of patients; pts = patients; enrolled = n qualified; evaluated = n analyzed; BCS = breast -conserving surgery; CT = chemotherapy; RT = radiotherapy; HT = hormone therapy; ER = estrogen receptor; PR = progesterone receptor; CPG = clinical practice guidelines; NCI = National Cancer Institute; state of use = last 3 y; DCIS = ductal carcinoma in situ; Level Ia = pre-study data indicating consistently sound psychometric properties; Iac = pre- and on-study data indicating consistently sound psychometric properties; IV = no pre- or on-study psychometric data
Morrow, 2001, US	Process:	• Overall: 42.6% (7,097/16,643)	• Standard: ACOS, ACR, CAP, SSO guidelines, 1992	• Inclusion: population-based sample women stage I–II BC receiving diagnosis & initial course of treatment at participating institution, 1994
	• % appropriate use of BCS^IV	• by age:	• Data sources: Medicare patients, NY State acute care hospitals, 1999 (n=1,718); medical records	• Exclusion: staging not performed or incomplete; pT3 tumours; surgery other than BCS or mastectomy
		21–49 y: 48.2%	• Developmental period: NR	• Period: 1 y (1994)
		50–69 y: 45%	• Reference standard(s) (publication date): NR	• n patients (enrolled/evaluated): 17,931/16,643
		> 70 y: 34% S	• Data sources: NR	• Age (mean & range): 60.8 (21–>70) y
		• by race/ethnicity:	• Psychometric properties: NR	• Race/ethnicity: White (85.9%); Black (7.8%); Hispanic (2.9%)
		White: 42.5%	• Links to outcomes: NR	• Case characteristics: clinical stage I (41.5%); stage II (20.8%); pT1 (68%); pT2 (32%); pN0 (75.5%); pN1 (24.5%); ER (+) (65.6%); PR (+) (56.7%); infiltrating ductal, lobular (92.6%); postmenopausal (70.9%)
		Black -H: 43.7%	• Funding source: NR	• Socioeconomic status: Medicare (42.1%)
		• by payer:	• State of use: current	• Funding: Patterns of Care Study
		Government: 36.9%	• Current use: external quality oversight
		Private: 48.4% S	• Care setting: hospitals; cancer centers; RT centers
		• Links: NA	• Professionals: surgeons; RT oncologists; oncologists
	• % appropriate use of RT after BCS^IV	• Overall: 86% (6,099/7,097)
		• by age:
		<70 y: 88.4%
		≥70 y: 78.9%
		• by race/ethnicity:
		White: 86.3%
		Black -H: 83.2%
		other: 81.9%
		• by payer:
		Government: 83.3%
		Private: 88.5% S
		• Links: NA

NR = not reported; NA = not assessed; S = significant difference/trend; NS = nonsignificant difference/trend; n = number of patients; pts = patients; BC = breast cancer; enrolled = n qualified; evaluated = n analyzed; ACOS = American College of Surgeons; ACR = American College of Radiology; CAP = College of American Pathologists; SSO = Society of Surgical Oncology; BCS = breast-conserving surgery; pT = pathologic tumour size; pN = pathologic nodal status; RT = radiotherapy; state of use = last 3 y; BCT = tumor excision; axillary dissection & breast irradiation for stage I & II BC; NY = New York; Level Ia = pre-study data indicating consistently sound psychometric properties; Iac = pre- and* on-study data indicating consistently sound psychometric properties; IV = no pre- or on-study psychometric data
Nattinger, 2000, US	Process:	• Overall: 78% (1995)	• Standard: NIH Consensus Development Conference, 1990	• Inclusion: national population-based sample women aged ≥30 y at time of first diagnosis of invasive local or regional unilateral BC, 1983-1995
	• % appropriate use of definitive locoregional therapy (total mastectomy + ALND, or BCS + ALND + RT)^IV	• Links: NA	• Data sources: NCI SEER registry; federal ARF information	• Exclusion: no primary BCS or mastectomy, or type of surgery unknown; date of diagnosis unknown; delivery of RT unknown
	• % appropriate use of mastectomy with ALND^IV	• Overall: 97.3%	• Developmental period: NR	• Period: 13 y (1983-1995)
		• Links: NA	• Reference standard(s) (publication date): NR	• n patients (enrolled/evaluated): 147,432/144,759
	• % appropriate use of BCS with ALND & RT^IV	• Overall: 65%	• Data sources: NR	• Age (mean & range): NR (30–>80) y
		• Links: NA	• Psychometric properties: NR	• Race/ethnicity: White (87.3%); Black (7.1%)
			• Links to outcomes: NR	• Case characteristics: BC local (65%); regional (35%)
			• Funding source: NR	• Socioeconomic status: NR
			• State of use: NR	• Funding: Department of Defence
			• Current use: external quality oversight
			• Care setting: hospitals; cancer centers; RT centers
			• Professionals: surgeons; oncologists; RT oncologists; GPs

NR = not reported; NA = not assessed; S = significant difference/trend; NS = nonsignificant difference/trend; n = number of patients; pts = patients; BC = breast cancer; enrolled = n qualified; evaluated = n analyzed; NCI = National Cancer Institute; SEER = Surveillance, Epidemiology, and End Results; ALDN = axillary lymph node dissection; BCS = breast-conserving surgery; RT = radiotherapy; state of use = last 3 y; GP = general practitioner; Level Ia = pre-study data indicating consistently sound psychometric properties; Iac = pre- and on-study data indicating consistently sound psychometric properties; IV = no pre- or on-study psychometric data
Northouse, 1999, US	Outcome:	• Overall: QOL (FACT-B):	• Standard: BC specific version of 37-item scale FACT-B, 1993 (physical & family well-being; relationship with MD; emotional & functional well-being)	• Inclusion: convenience sample of black women confirmed diagnosis of BC at least 1 mo post-diagnosis, Southeastern region, Michigan
	• % change in QOL after diagnosis of BC*^Iac	Mean: 116.5 (SD 20.7); (range 44–145)	• Data sources: medical oncology offices, Southeastern region, Michigan, pts self-reported status using Questionnaire forms	• Exclusion: pts refusal to participate in study
		In average: fairly high QOL scale	• Developmental period: NR	• Period: NR
		• by variables:	• Reference standard(s) (publication date): NR	• n patients (enrolled/evaluated): 140/98
		Node (+): lower QOL (mean: 110.8) than node (-) (mean: 120.7)	• Data sources: NR	• Age (mean & range): 55 (29–81) y
		Recurrence of cancer: lower QOL (mean: 107.1) vs no recurrence (mean: 118.2)	• Psychometric properties: NR	• Race/ethnicity: Black (100%)
		• Links: NA	• Links to outcomes: NR	• Case characteristics: BC radical mastectomy (70%); node (-) (57.4%)
			• Funding source: NR	• Socioeconomic status: working (54.2%); retired (38.6%); unemployed (7.2%); Income < U$15,000 29.7%); married (41%)
			• State of use: NR	• Funding: Dean's discretionary fund grant; Wayne State University
			• Current use: internal quality improvement
			• Care setting: hospitals; cancer centers;
			• Professionals: oncologists

NR = not reported; NA = not assessed; S = significant difference/trend; NS = nonsignificant difference/trend; n = number of patients; pts = patients; BC = breast cancer; enrolled = n qualified; evaluated = n analyzed; QOL = quality of life; FACT-B = functional assessment of cancer therapy scale (version 3); state of use = last 3 y; Higher scores = better QOL; MD = medical doctor; Level Ia = pre-study data indicating consistently sound psychometric properties; Iac = pre- and* on-study data indicating consistently sound psychometric properties; IV = no pre- or on-study psychometric data
Osoba, 1999, Canada & US	Outcome:	• Overall: NR	• Instrument: self-administered EORTC core QOLQ- C30 (30 items) (global score; physical; social; role functions & fatigue in phase II & III of clinical trial) scale 0–100*	• Inclusion: convenience sample women progressive HER-2- overexpressing metastatic BC previously treated with CT (phase II), or who had not had previous cytotoxic CT (phase III) received trastuzumab
	• change in QOL in women with metastatic BC treated with trastuzumab assessed by self-administered EORTC core QOLQ - C30 baseline & wks 12; 24; 36^Ia	By phase of study:	• Data sources: pts self-reported status using EORTC QOL questionnaire C30	• Exclusion: NR
		Phase II: no apparent worsening of scores	• Developmental period: NR	• Period: 32 wks
		Phase III: NS changes	• Reference standard(s) (publication date): NR	• n patients (enrolled/evaluated): 207/154
		• Links: NA	• Data sources: NR	• Age (mean & range): NR
			• Psychometric properties: NR	• Race/ethnicity: NR
			• Links to outcomes: NR	• Case characteristics: women with metastatic BC with or without previous CT
			• Funding source: NR	• Socioeconomic status: NR
			• State of use: NR	• Funding: Genentech, Inc.
			• Current use: internal quality improvement
			• Care setting: hospitals; cancer centers;
			• Professionals: oncologists

NR = not reported; NA = not assessed; S = significant difference/trend; NS = nonsignificant difference/trend; n = number of patients; pts = patients; enrolled = n qualified; evaluated = n analyzed; EORTC = European Organization for Research and Treatment of Cancer; QOL = quality of life; QOLQ = quality of life questionnaire; state of use = last 3 y; * Higher scores = better QOL (except in fatigue); Level Ia = pre-study data indicating consistently sound psychometric properties; Iac = pre- and on-study data indicating consistently sound psychometric properties; IV = no pre- or on-study psychometric data
Ottevanger, 2002, Netherlands	Process:	• Overall: 55.5% (141/254)	• Standard: Regional Guidelines (CCCE) (year: NR)	• Inclusion: population-based sample premenopausal women, node (+) BC stages II–IIIA treated in 9 hospitals using the guidelines, 1988-1992
	• % appropriate use of BCS^IV	• Links: 5-y OS	• Data sources: Regional Cancer Registry & PALGA (Dutch National Pathology Registration System)	• Exclusion: 1 hospital opposed to CT treatment of the CPG
		BCS 77% vs. mastectomy 77 % NS	• Developmental period: NR	• Period: 5 y (1993-1998)
		5-y DFS: BCS 59% vs. mastectomy 65% NS	• Reference standard(s) (publication date): NR	• n patients (enrolled/evaluated): 254/254
	• % appropriate use of mastectomy in large or multifocal tumors, tumor fixed to pectoral muscle or fascia or skin^IV	• Overall: 44.5% (113/254)	• Data sources: NR	• Age (mean & range): NR
		• Links: 5-y OS	• Psychometric properties: NR	• Race/ethnicity: NR
		BCS 77% vs. mastectomy 77% NS	• Links to outcomes: NR	• Case characteristics: premenopausal women, node (+) BC stages II–IIIA
		5-y DFS: BCS 59% vs. mastectomy 65% NS	• Funding source: NR	• Socioeconomic status: NR
	• % appropriate use of RT after BCS^IV	• Overall: 100% (141/141)	• State of use: NR	• Funding: Comprehensive Cancer Centre East (CCCE)
		• Links: NA	• Current use: external quality oversight; quality of care reporting; research
	• % appropriate use of RT in axilla for extracapsular extension of ALN metastases^IV	• Overall: 84.7% (72/85)	• Care setting: hospitals; pathology centers
		• Links: locoregional relapse rate: 9.4% (received) vs. 14.3% (not) NS	• Professionals: pathologists; oncologists; surgeons
		5-y OS: 76% (received) vs. 77% (not) NS
	• % appropriate use of parasternal RT for tumors located medial part of breast^IV	• Overall: 49.1% (56/114)
		• Links: NA
	• % quality of CT: proper doses administered (≥85% DI & RDI) of CMF^IV	• Overall: 78.9% (DI); 58.7% (RDI)
		• Links: 5-y OS
		<65% DI: 50% vs. >85%: 77% S
		5-y DFS: <65% DI: 44% vs. >85%: 61% S
	• % reporting n axillary LN investigated^IV	• Overall:
		• by n nodes:
		≥10: 59.2% (138/233)
		<10: 40.8% (95/233)
		• Links: 5-y OS: <10 nodes 72% vs. ≥10 nodes 81% NS
		5-y DFS: <10 nodes 59% vs. ≥10 nodes 64% NS

NR = not reported; NA = not assessed; S = significant difference/trend; NS = nonsignificant difference/trend; n = number of patients; pts = patients; LN = lymph nodes; BCS = breast -conserving surgery; RT = radiotherapy; CPG = clinical practice guideline; ER = estrogen receptor; PR = progesterone receptor; BC = breast cancer; ALN = axillary lymph nodes; CMF= cyclophosphamide/methotrexate/5-fluorouracil; CT = chemotherapy; state of use = last 3 y; CCCE = Comprehensive Cancer Center East; DFS = disease-free survival; OS = overall survival; Level Ia = pre-study data indicating consistently sound psychometric properties; Iac = pre- and on-study data indicating consistently sound psychometric properties; IV = no pre- or on-study psychometric data
Palazzi, 2002, Italy	Process:	• Overall: 69% (59/85)	• Standard: SGCC, 1995	• Inclusion: convenience sample women with prescription of RT to breast after BCS for infiltrating carcinoma & known ALN status
	• % appropriate decision not to provide adjuvant systemic therapy for women node (-), low risk BC^IV	• Links: NA	• Data sources: database of 12 centers participating	• Exclusion: previous or synchronous surgery for cancer in contralateral breast
	• % appropriate use of tamoxifen in premenopausal women BC; node (-); intermediate risk^IV	• Overall: 33%	• Developmental period: NR	• Period: 1 y (1997)
		• Links: NA	• Reference standard(s) (publication date): NR	• n patients (enrolled/evaluated): 1,610/ 1,547
	• % appropriate use of tamoxifen postmenopausal women BC; node (-); intermediate risk^IV	• Overall: 59%	• Data sources: NR	• Age (mean & range): 55 (25–82) y
		• Links: NA	• Psychometric properties: NR	• Race/ethnicity: NR
	• % appropriate use of CT premenopausal women BC; node (-); high risk; ER (+)^IV	• Overall: 55%	• Links to outcomes: NR	• Case characteristics: women ESBC; premenopausal (31%); T1 stage (81%); ER (+) (65%); node (+) (31%)
		• Links: NA	• Funding source: NR	• Socioeconomic status: NR
	• % appropriate use of tamoxifen postmenopausal women BC; node (-); high risk; ER (+)^IV	• Overall: 59%	• State of use: NR	• Funding: NR
		• Links: NA	• Current use: external quality oversight; research
	• % appropriate use of CT women BC node (-); high risk; ER (-)^IV	• Overall: 59%	• Care setting: RT centers
		• Links: NA	• Professionals: RT oncologists; oncologists; surgeons; clinicians
	• % appropriate use of CT premenopausal women BC node (+); ER (-)^IV	• Overall: 90%
		• Links: NA
	• % appropriate use of CT &/or OA premenopausal women BC node (+); ER (+)^IV	• Overall: NR
		• by treatment:
		CT: 73%
		CT+ OA: 18%
		OA: 4%
		• Links: NA
	• % appropriate use of CT postmenopausal women BC node (+); ER (-)^IV	• Overall: 81%
		• Links: NA
	• % appropriate use of tamoxifen postmenopausal women BC node (+);ER (+)^IV	• Overall: 40%
		• Links: NA

NR = not reported; NA = not assessed; S = significant difference/trend; NS = nonsignificant difference/trend; n = number of patients; pts = patients; SGCC = St Gallen consensus conference; RT = radiotherapy; ESBC = early stage breast cancer; BCS = breast-conserving surgery; ER = estrogen receptor; CT = chemotherapy, OA = ovarian ablation; (+) = positive; (-) = negative; state of use = last 3 y; ALN = axillary lymph node; Level Ia = pre-study data indicating consistently sound psychometric properties; Iac = pre- and on-study data indicating consistently sound psychometric properties; IV = no pre- or on-study psychometric data
Perez, 2001, New Zealand UK	Outcome:	• Overall: NR	• Instrument: HRQOL scale: Spitzer QLI & uniscale questionnaire (scale 0–100); TTO	• Inclusion: Convenience sample women presenting at Dunedin Hospital, NZ, with metastatic symptoms BC
	• % change in QOL & TTO scales during 1 y in metastatic disease*^Iac	• Links: NA	• Data Sources: pts self-reported status (questionnaires)	• Exclusion: refused to complete TTO scale
			• Developmental period: NR	• Period: 1 y (NR)
			• Reference standard(s) (publication date): NR	• n patients (enrolled/ evaluated): 64/38
			• Data sources: NR	• Age (mean & range): 58.7 (30–80) y
			• Psychometric properties: NR	• Race/ethnicity: NR
			• Links to outcomes: NR	• Case characteristics: women advanced metastatic symptomatic BC
			• Funding source: NR	• Socioeconomic status: NR
			• State of use: NR	• Funding: Cancer Society of NZ
			• Current use: internal quality improvement
			• Care setting: hospitals; cancer centers
			• Professionals: oncologists

NR = not reported; NA = not assessed; S = significant difference/trend; NS = nonsignificant difference/trend; n = number of patients; pts = patients; enrolled = n qualified; evaluated = n analyzed; QLI = quality of life index; BC = breast cancer; state of use = last 3 y; HRQOL = health related quality of life; QOL = quality of life; * Higher scores = better QOL; NZ = New Zealand; TTO = time trade-off; Level Ia = pre-study data indicating consistently sound psychometric properties; Iac = pre- and on-study data indicating consistently sound psychometric properties; IV = no pre- or on-study psychometric data
Ray-Coquard, 1997, France	• % appropriate use of treatment sequences according to guidelines (including all medical decisions on surgery; RT; CT; HT; initial examination & follow-up) ^IV	• Overall: 54% (53/99)	• Standard: regional CPG, 1993; implemented, 1994	• Inclusion: random sample women newly diagnosed localized BC (DCIS to nonmetastatic invasive carcinoma) in cancer center, Rhone Alpes area, France
		• Links: NA	• Data sources: medical records	• Exclusion: concomitant health care (e.g. genetic counselling; pain treatment; plastic surgery); early death; missing data in records; tumor size not recorded
	• % appropriate use of initial examination^IV	• Overall: 86% (61/71)	• Developmental period: NR	• Period: 1 y (1995)
		• Links: NA	• Reference standard(s) (publication date): NR	• n patients (enrolled/ evaluated): 701/99
	• % appropriate use of surgery^IV	• Overall: 92% (91/99)	• Data sources: NR	• Age (mean & range): 51 (26–90) y
		• Links: NA	• Psychometric properties: NR	• Race/ethnicity: NR
	• % appropriate use of CT^IV	• Overall: 85% (84/99)	• Links to outcomes: NR	• Case characteristics: localized ESBC; node (-) 66%; ER (+) 57%, DCIS 18%
		• Links: NA	• Funding source: NR	• Socioeconomic status: NR
	• % appropriate use of RT^IV	• Overall: 93% (92/99)	• State of use: NR	• Funding: NR
		• Links: NA	• Current use: internal quality improvement; external quality oversight, decision-making; research
	• % appropriate use of HT (tamoxifen) ^IV	• Overall: 94% (93/99)	• Care setting: hospitals; cancer centers; RT centers
		• Links: NA	• Professionals: surgeons; oncologists; RT oncologists
	• % appropriate use of follow-up^IV	• Overall: 80% (68/85)
		• Links: NA

NR = not reported; NA = not assessed; S = significant difference/trend; NS = nonsignificant difference/trend; n = number of patients; pts = patients; enrolled = n qualified; evaluated = n analyzed; CT = chemotherapy; RT = radiotherapy; HT = hormone therapy; ER = estrogen receptor; PR = progesterone receptor; CPG = clinical practice guidelines; DCIS = ductal carcinoma in situ; BC = breast cancer; state of use = last 3 y; Level Ia = pre-study data indicating consistently sound psychometric properties; Iac = pre- and on-study data indicating consistently sound psychometric properties; IV = no pre- or on-study psychometric data
Ray-Coquard, 2002, France	Process:	• Overall: 36%	• Standard: Regional (ONCORA) CPG, 1995	• Inclusion: random sample women newly referred localized BC (in situ or invasive) treated in cancer network, Rhone-Alpes Area, France, 1996
	• % appropriate use of treatment sequences according to CPG (including surgery; RT; CT; HT; initial examination; follow-up) ^IV	• by intervention:	• Data sources: institutional records	• Exclusion: record with data missing (surgical biopsy), metastases, patients refused surgery, no axillary dissection, treatment CI
		Initial examination: 86%	• Developmental period: NR	• Period: 1 y (1996)
		Surgery: 94%	• Reference standard(s) (Publication Date): NR	• n patients (enrolled/ evaluated): 367/ 346
		CT: 78%	• Data sources: NR	• Age (mean & range): 60 (30–91) y
		RT: 77%	• Psychometric properties: NR	• Race/ethnicity: NR
		HT: 79%	• Links to outcomes: NR	• Case characteristics: women localized BC, T1–T3 or In situ, 17 mm, HR (+) 61%
		Follow-up: 81%	• Funding source: NR	• Socioeconomic status: NR
		• Links: NA	• State of use: NR	• Funding: Ministry of Health (France)
			• Current use: external quality oversight
			• Care setting: hospitals; cancer centers
			• Professionals: oncologists; surgeons; GPs

NR = not reported; NA = not assessed; S = significant difference/trend; NS = nonsignificant difference/trend; n = number of patients; pts = patients; enrolled = n qualified; evaluated = n analyzed; LN = lymph nodes; BCS = breast-conserving surgery; RT = radiotherapy; HR = Hormone receptor; CI = contraindication; CT = chemotherapy; HT = hormone therapy; CPG = clinical practice guidelines; state of use = last 3 y; GP = general practitioner; Level Ia = pre-study data indicating consistently sound psychometric properties; Iac = pre- and on-study data indicating consistently sound psychometric properties; IV = no pre- or on-study psychometric data
Sauven, 2003, UK	Process:	• Overall: NR	• Standard: NHSBSP surgical standards, 1992	• Inclusion: population-based sample BC women detected by screening UK, Wales, Scotland & Northern Ireland, 1996-2001
	• % appropriate use of preoperative diagnosis by FNA cytology, needle histology or biopsy (minimum: ≥70%; target standard: ≥90%)^IV	• by y:	• Data sources: regional boundaries; KC62 Korner returns; breast screening unit records	• Exclusion: NR
		1996/97: 63%	• Developmental period: NR	• Period: 5 y (1996-2001)
		1997/98: 71%	• Reference standard(s) (publication date): NR	• n patients (enrolled/ evaluated): 43,500/43,500
		1998/99: 81%	• Data sources: NR	• n surgeons (enrolled/ evaluated): 1,531/1,000
		1999/2000: 85%	• Psychometric properties: NR	• Age (mean & range): NR
		2000/01: 87%	• Links to outcomes: NR	• Race/ethnicity: NR
		• Links: NA	• Funding source: NR	• Case characteristics: NR
	• % quality of technique to determine histological node status obtained for all invasive tumors by sampling or clearance^IV	• Overall: NR	• State of use: NR	• Socioeconomic status: NR
		• by y:	• Current use: external quality oversight	• Funding: NHSBSP
		1996/97: 81%	• Care setting: hospitals; cancer centers; RT centers
		1997/98: 87%	• Professionals: surgeons; oncologists; pathologists
		1998/99: 90%
		1999/2000: 93%
		2000/01: 93%
		• Links: NA
	• % quality of sampling for invasive cancer: to include ≥ 4 nodes^IV	• Overall: NR
		• by y:
		1996/97: 89%
		1997/98: 91%
		1998/99: 93%
		1999/2000: 94%
		2000/01: 95%
		• Links: NA
	Structure:	• Overall: NR
	• % management of cases coming to surgery from screening program carried out by surgeons who have acquired necessary specialist knowledge^IV	• by y & case load:
		> 30 pts/y, high*:
		1996/97: 63%
		1997/98: 67%
		1998/99: 66%
		1999/2000: 71%
		2000/01: 72%
		< 10 pts/y, low:
		1996/97: 8%
		1997/98: 7%
		1998/99: 7%
		1999/2000: 6%
		2000/01: 5%
		• Links: NA
	Access:	• Overall: NR
	• % (≥90%) women requiring an operation for diagnostic purposes should be admitted within 14 d of surgical decision ^IV	• by y:
		1996/97: 60%
		1997/98: 52%
		1998/99: 52%
		1999/2000: 60%
		• Links: NA
	• % (≥90%) women admitted for operation within 21 d of surgical decision to operate for therapeutic purposes^IV	• Overall: NR
		• by y:
		1996/97: 82%
		1997/98: 81%
		1998/99: 80%
		1999/2000: 77%
		• Links: NA

NR = not reported; NA = not assessed; S = significant difference/trend; NS = nonsignificant difference/trend; n = number of patients; pts = patients; enrolled = n qualified; evaluated = n analyzed; BC = breast cancer; NHSBSP = national health service breast screening program; FNA = fine-needle aspiration; state of use = last 3 y; Level Ia = pre-study data indicating consistently sound psychometric properties; Iac = pre- and on-study data indicating consistently sound psychometric properties; IV = no pre- or on-study psychometric data
Sawka, 1997, Canada	Process:	• Overall: 84.9%	• Standard: Guidelines of British Columbia, 1991	• Inclusion: population-based sample women BC node (-) diagnosed, British Columbia, 1991
	• % appropriate decision not to provide adjuvant systemic therapy in <50 y; low risk^IV	• Links: NA	• Data Sources: Provincial Cancer Registry; medical records; other databases (e.g. drug data)	• Exclusion: age> 90 y; diagnosis by death certificate; death within 30 days of diagnosis; stage III or IV; in situ disease; non-epithelial malignancies & any previous invasive cancer or history of DCIS; node (+) or unknown nodal status
	• % appropriate use of CT in <50 y; high risk; presence of LVN invasion; or tumor > 2 cm; if ER (-)^IV	• Overall: 78.6%	• Developmental period: NR	• Period: 5 y (1993-1998)
		• Links: NA	• Reference standard(s) (publication date): NR	• n patients (enrolled/evaluated): 2,317/932
	• % appropriate decision not to provide adjuvant systemic therapy in 50–65 y low risk^IV	• Overall: 90.3%	• Data sources: NR	• Age (mean & range): NR (<50–>65) y
		• Links: NA	• Psychometric properties: NR	• Race/ethnicity: NR
	• % appropriate use of tamoxifen & CT or tamoxifen in 50–65 y; high risk; ER (+)^IV	• Overall: 6.6% (tamoxifen & CT) 62.3% (tamoxifen)	• Links to outcomes: NR	• Case characteristics: women BC node (-); tumor <2 cm (62.1%); LVN invasion (68.8%); ER (+) (60.4%); PR (+) (38.9%)
		• Links: NA	• Funding source: NR	• Socioeconomic status: income >U$ 50,000/ y (26.1%); rural residence (15.4%)
	• % appropriate use of CT in 50–65 y; high risk; ER (-)^IV	• Overall: 19.1%	• State of use: NR	• Funding: NCI of Canada (Canadian Cancer Society) & National Health Scholar Award from Health Canada
		• Links: NA	• Current use: external quality oversight
	• % appropriate use of adjuvant systemic therapy in >65 y; low risk^IV	• Overall: 85.9%	• Care setting: hospitals; oncology centers; RT centers
		• Links: NA	• Professionals: oncologists; surgeons; RT oncologists
	• % appropriate use of tamoxifen in >65 y; high risk; ER (+)^IV	• Overall: 56.5%
		• Links: NA
	• % appropriate decision not to provide adjuvant systemic therapy in > 65 y; high risk; ER (-)^IV	• Overall: 82.1%
		• Links: NA

NR = not reported; NA = not assessed; S = significant difference/trend; NS = nonsignificant difference/trend; n = number of patients; pts = patients; enrolled = n qualified; evaluated = n analyzed; LN = lymph nodes; LVN = lymph, vessels or nerves invasion; RT= radiotherapy; ER = estrogen receptor; PR = progesterone receptor; BC = breast cancer; CT = chemotherapy; NCI = National Cancer Institute; DCIS = ductal carcinoma in situ; state of use = last 3 y; Level Ia = pre-study data indicating consistently sound psychometric properties; Iac = pre- and on-study data indicating consistently sound psychometric properties; IV = no pre- or on-study psychometric data
Shank, 2000, US	Structure:	• Overall: 99.7% (725/727)	• Standard: ACR, ACS, CAP & SSO standards for breast conservation treatment, 1992	• Inclusion: random sample women stage I–II invasive BC treated, 1993-1994
	• % pathology reports on chart^IV	• Links: NA	• Data sources: survey; medical records	• Exclusion: pts not treated 1993-1994; males; purely non-invasive carcinoma; not stage I–II BC; gross multicentric disease; bilateral lesion; prior or concurrent malignancies; mastectomy as primary treatment
	Process:	• Overall: 91.5% (665/727)	• Developmental period: NR	• Period: 2 y (1995-1996)
	• % appropriate use of preoperative mammographic evaluation (performed ≤3 mo) ^IV	• Links: NA	• Reference standard(s) (publication date): NR	• n patients (enrolled/evaluated): 993/727
	• % reporting identification of affected quadrant^IV	• Overall: 97.8% (711/727)	• Data sources: NR	• Age (mean & range): NR (20–>80) y
		• Links: NA	• Psychometric properties: NR	• Race/ethnicity: White (84.2%); Black (7.3%); Hispanic (4.4%); Asian (2.8%)
	• % reporting clinical size of primary tumor^IV	• Overall: 45.9% (334/727)	• Links to outcomes: NR	• Case characteristics: age >50 y (70%); stage I or II invasive BC; postmenopausal (68.6%)
		• Links: NA	• Funding source: NR	• Socioeconomic status: NR
	• % reporting final gross surgical margins^IV	• Overall: 96.8% (704/727)	• State of use: NR	• Funding: NCI
		• Links: NA	• Current use: quality of care reporting; internal quality improvement
	• % reporting final microscopic surgical margins^IV	• Overall: 95.6% (695/727)	• Care setting: hospitals; cancer centers; pathology centers
		• Links: NA	• Professionals: RT oncologists, surgeons; pathologists; oncologists
	• % reporting histopathological type	• Overall: 99.7% (725/727)
		• Links: NA
	• % reporting intraductal carcinoma quantification^IV	• Overall: 8.5% (62/727)
		• Links: NA
	• % reporting of extent of primary tumor^IV	• Overall: 99.3% (722/727)
		• Links: NA
	• % reporting size of invasive component^IV	• Overall: 8.5% (62/727)
		• Links: NA
	• % reporting total pathological tumour size^IV	• Overall: 95.3% (693/727)
		• Links: NA
	• % reporting ER status^IV	• Overall: 89% (647/727)
		• Links: NA
	• % reporting PR status^IV	• Overall: 86.4% (628/727)
		• Links: NA
	• % reporting performing flow cytometry ^IV	• Overall: 95.3% (693/727)
		• Links: NA
	• % reporting cytometry ploidity^IV	• Overall: 98.9% (719/727)
		• Links: NA
	• reporting pathological note status^IV	• Overall: 92% (670/727)
		• Links: NA
	• % quality of RT: wedges on tangent breast fields^IV	• Overall: 92.8% (671/723)
		• Links: NA
	• % quality of RT: both tangent fields treated daily ^IV	• Overall: 99.9% (724/725)
		• Links: NA
	• % quality of RT: 4,500–5,000 cGy total breast dose given to 180–200 cGy fractions^IV	• Overall: 99% (723/725)
		• Links: NA
	• % quality of RT: electron beam breast radiation used^IV	• Overall: 94% (681/725)
		• Links: NA

NR = not reported; NA = not assessed; S = significant difference/trend; NS = nonsignificant difference/trend; n = number of patients; pts = patients; BC = breast cancer; enrolled = n qualified; evaluated = n analyzed; ACR = American College of Radiology; ACS = American College of Surgeons; CAP= College of American Pathologists; SSO = Society of Surgical Oncology; ER = estrogen receptor; PR = progesterone receptor; state of use = last 3 y; RT = radiotherapy; Level Ia = pre-study data indicating consistently sound psychometric properties; Iac = pre- and on-study data indicating consistently sound psychometric properties; IV = no pre- or on-study psychometric data
Silliman, 1999, US	Process:	• Overall: 77.2% (234/303)	• Standard: NIH Consensus Development Conference, 1990	• Inclusion: convenience sample women ≥55 y newly diagnosed stage I or II BC treated in 1/5 academic centers, Boston
	• % appropriate use of definitive locoregional therapy (total mastectomy + ALND or BCS with ALND + RT) ^IV	• by surgery type:	• Data sources: medical records; 35-minute computer-assisted telephone interview with pts; Physicians Profiles database of the Board of Registration in Medicine of the Commonwealth of MA	• Exclusion: NR
		BCS + RT: 56%	• Developmental period: NR	• Period: NR
		Mastectomy: 22%	• Reference standard(s) (publication date): NR	• n patients (enrolled/evaluated): 303/303
		• by income:	• Data sources: NR	• Age (mean & range): 67.7 (55–97) y
		≤U$14,999: 55%	• Psychometric properties: NR	• Race: White (93%)
		$15,000–29, 999: 85%	• Links to outcomes: NR	• Case characteristics: stage I (64%)
		$30,000–49,999: 91%	• Funding source: NR	• Socioeconomic status: income:
		≥$50,000: 87%	• State of use: NR	≤ U$14,999 (17.5%);
		• by education:	• Current use: external quality oversight	$15,000–$29,999 (19.8%);
		<High school: 55%	• Care setting: hospitals; cancer centers; RT centers	$30,000–$49,999 (21.1%);
		High school: 75%	• Professionals: oncologists; RT oncologists; GPs	>$50,000 (17.5%); married (48.8%); ≥ High school (83%)
		Some College: 83%		• Funding: NCI, NHI; US ARDALC
		College: 82%
		• Links: NA
	• % appropriate use of any adjuvant systemic therapy (CT &/or HT) ^IV	• Overall: 67.3% (204/303)
		• by adjuvant therapy:
		HT alone: 76%
		CT alone: 13%
		HT + CT: 11%
		• by income:
		≤U$14,999: 64%
		$15,000–29,999: 60%
		$30,000–49,999: 77%
		≥$50,000: 73%
		• by education:
		< High school: 60%
		High school: 68%
		Some College: 64%
		College: 72%
		• Links: NA
	• % appropriate use of alternative definitive therapy (both tumor therapy & adjuvant systemic therapy) ^IV	• Overall: 51.8% (157/303)
		By age:
		55–64 y: 50% (78/157)
		65–74 y: 41% (65/157)
		75–84 y: 9%
		• Links: NA

NR = not reported; NA = not assessed; S = significant difference/trend; NS = nonsignificant difference/trend; n = number of patients; pts = patients; enrolled = n qualified; evaluated = n analyzed; BC = breast cancer; NCI = National Cancer Centre; NIH = National Health Institute; ARDALC = Army Research, Development, Acquisition and Logistic Command; MA = Massachusetts; state of use = last 3 y; GP = general practitioner RT = radiotherapy; CT = chemotherapy; HT = hormone therapy; BCS = breast-conserving surgery; ALND = axillary lymph node dissection; Level Ia = pre-study data indicating consistently sound psychometric properties; Iac = pre- and on-study data indicating consistently sound psychometric properties; IV = no pre- or on-study psychometric data
Solin, 1999, US	Process:	• Overall: 65% (62/95)	• Standard: NIH Consensus Development Conference, 1990	• Inclusion: convenience sample women ≥ 65 y, newly diagnosed stage 0–II BC <5cm in diameter
	• % appropriate use of BCS^IV	• Links: NA	• Data sources: HMO claim database; medical records	• Exclusion: LCIS; bilateral carcinoma
	• % appropriate use of RT after BCS^IV	• Overall: 89% (55/62)	• Developmental period: NR	• Period: 2 y (1993-1994)
		• Links: NA	• Reference standard(s) (publication date): NR	• n patients (enrolled/evaluated): 130/130
	• % appropriate use of definite breast irradiation in DCIS^IV	• Overall: 60% (3/5)	• Data sources: NR	• Age (mean & range): 72 (65–91) y
		• Links: NA	• Psychometric properties: NR	• Race/ethnicity: White (83%); Black (5%)
	• % appropriate use of definite breast irradiation in stage I–II ^IV	• Overall: 91% (52/57)	• Links to outcomes: NR	• Case characteristics: DCIS (6%); invasive BC (94%); tumor size (<1cm 23%; 1.1–2 cm 26%; 2.1–3 cm 12%); stages 0–IV; node (-) (73%)
		• Links: NA	• Funding source: NR	• Socioeconomic status: NR
			• State of use: NR	• Funding: NR
			• Current use: external quality oversight; research
			• Care setting: hospitals; pathology centers; RT centers; cancer centers
			• Professionals: pathologists; oncologists; surgeons; GPs

NR = not reported; NA = not assessed; S = significant difference/trend; NS = nonsignificant difference/trend; n = number of patients; pts = patients; BCS = breast-conserving surgery; RT = radiotherapy; DCIS = ductal carcinoma in situ; BC = breast cancer; NIH = National Institute of Health; state of use = last 3 y; GP = general practitioner; HMO = health maintenance organization; LCIS = lobular carcinoma in situ; Level Ia = pre-study data indicating consistently sound psychometric properties; Iac = pre- and on-study data indicating consistently sound psychometric properties; IV = no pre- or on-study psychometric data
Tyldesley, 2003, Canada	Process:	• Overall: 63%	• Standard: systematic review; evidence based recommendations for BCS in North America (US & Canada); CPG (n = 12); 1991-2001	• Inclusion: population-based samples women ESBC eligible for BCS in North American population
	• % appropriate use of BCS in DCIS; eligible & preferred*^IV	• Links: NA	• Data sources: several databases (SEER; OCR)	• Exclusion: NR
	• % appropriate use of BCS in stage; eligible & preferred**^IV	• Overall: 57%	• Developmental period: NR	• Period: NR
		• Links: NA	• Reference standard(s) (publication date): NR	• n patients (enrolled/evaluated): NR
	• % appropriate use of BCS in stage II; eligible & preferred**^IV	• Overall: 52%	• Data sources: NR	• Age (mean & range): NR
		• Links: NA	• Psychometric properties: NR	• Race/ethnicity: NR
	• % appropriate use of BCS in stage IIIA; eligible & preferred***^IV	• Overall: 27%	• Links to outcomes: NR	• Case characteristics: ESBC including DCIS; stage I–IIIA
		• Links: NA	• Funding source: NR	• Socioeconomic status: NR
			• State of use: NR	• Funding: Cancer Care Ontario; NCI of Canada
			• Current use: external quality oversight; research
			• Care setting: cancer centers; hospitals; RT centers
			• Professionals: oncologists; surgeons; RT oncologists

NR = not reported; NA = not assessed; S = significant difference/trend; NS = nonsignificant difference/trend; n = number of patients; pts = patients; RT = radiotherapy; CT = chemotherapy; HR = hormone receptor; state of use = last 3; ER = estrogen receptor; PR = progesterone receptor; BC = breast cancer; NCI = National Cancer Institute; SEER = surveillance epidemiology end results; OCR = Ontario cancer registry; BCS = breast-conserving surgery; DCIS = ductal carcinoma in situ; SLE = systemic lupus erithematous; SS = systemic sclerosis; DCIS: low/moderate risk; not pregnant; no prior RT; no SLE/SS; Stage I: not pregnant; no prior RT; solitary primary; no SLE/SS; negative margins; low tumor/breast size rate; ** Stage IIIA: not pregnant; no prior RT; solitary primary tumor; no SLE/SS; CR/PR (complete or partial response to neo-adjuvant CT that eliminates the need for mastectomy; Level Ia = pre-study data indicating consistently sound psychometric properties; Iac = pre- and on-study data indicating consistently sound psychometric properties; IV = no pre- or on-study psychometric data
White, 2003, US	Process:	• Overall: 88%	• Standard: ACOS; ACR; CAP; SSO standards for BCT, 1992	• Inclusion: convenience sample women BC Stage I–II diagnosed, 1994
	• % appropriate use of preoperative mammographic evaluation^IV	• by age:	• Data sources: cancer registries of 842 US hospitals	• Exclusion: incomplete pathologic reporting; not appropriate candidates for BCT based on standards; stage III–IV
		<70 y: 88.5%	• Developmental period: NR	• Period: 1 y (1994)
		≥70 y: 86.2%	• Reference standard(s) (publication date): NR	• n patients (enrolled/evaluated): 17,931/16,643
		• by race/ethnicity:	• Data sources: NR	• Age (mean & range): 62 (21–>70) y
		White: 88.4%	• Psychometric properties: NR	• Race/ethnicity: White (85.9%), Black (7.8%), Hispanic (2.9%), Asian (2%), other (1.3%)
		Black-H: 86.5%	• Links to outcomes: NR	• Case characteristics: NR
		other: 87.5%	• Funding source: NR	• Socioeconomic status: private insurance (34.5%); HMO (14.7%); Medicare (42.1%); Medicaid (7%)
		• by payer:	• State of use: NR	• Funding: NCI
		Government: 87.7%	• Current use: quality of care reporting; external quality oversight; research
		Private: 88.7%	• Care setting: hospitals; RT centers; cancer centers
		• Links: NA	• Professionals: RT oncologists; oncologists; surgeons; GPs
	• % reporting size of mammographic abnormality ^IV	• Overall: 47%
		• by age:
		<70 y: 45.9%
		≥70 y: 50.7%
		• by race/ethnicity:
		White: 47.5%
		Black-H: 46.3%
		other: 39.6%
		• by payer:
		Government: 50.3%
		Private: 44.8% S
		• Links: NA
	• % appropriate use of BCS^IV	• Overall: 42.6%
		• by age:
		<70 y: 46%
		≥70 y: 34%
		• by race/ethnicity:
		White: 43%
		Black-H: 44%
		other: 36%
		• by payer:
		Government: 37%
		Private: 48% S
		• Links: NA
	• % reporting laterality of surgical specimen^IV	• Overall: 98.3%
		• by age:
		<70 y: 98.2%
		≥70 y: 98.6%
		• by race/ethnicity:
		White: 98.2%
		Black-H: 98.5%
		other: 99.3%
		• by payer:
		Government: 98.4%
		Private: 98.3%
		• Links: NA
	• % reporting identification of affected quadrant^IV	• Overall: 21.1%
		• by age:
		<70 y: 21.1%
		≥70 y: 21.3%
		• by race/ethnicity:
		White: 20.5%
		Black-H: 26.3%
		other: 21.5%
		• by payer:
		Government: 22%
		Private: 20.4%
		• Links: NA
	• % reporting pathological specimen oriented^IV	• Overall: 67.1%
		• by age:
		<70 y: 68%
		≥70 y: 64.9%
		• by race/ethnicity:
		White: 67.6%
		Black-H: 64.2%
		other: 71.5%
		• by payer:
		Government: 67.5%
		Private: 67.1%
		• Links: NA
	• % reporting carcinoma microscopically confirmed^IV	• Overall: 97.8%
		• by age:
		<70 y: 97.7%
		≥70 y: 97.9%
		• by race/ethnicity:
		White: 97.9%
		Black -H: 96.7%
		other: 99.3%
		• by payer:
		Government: 98.1%
		Private: 97.7%
		• Links: NA
	• % reporting histological type^IV	• Overall: 98.8%
		• by age:
		<70 y: 98.8%
		≥70 y: 98.7%
		• by race/ethnicity:
		White: 98.8%
		Black -H: 99%
		other: 99.3%
		• by payer:
		Government: 99%
		Private: 98.7%
		• Links: NA
	• % reporting histological grade^IV	• Overall: 80.6%
		• by age:
		<70 y: 81.1%
		≥70 y: 79.3%
		• by race/ethnicity:
		White: 80.5%
		Black -H: 79.7%
		other: 88.9%
		• by payer:
		Government: 80.1%
		Private: 81.2%
		• Links: NA
	• % reporting LV invasion^IV	• Overall: 53.5%
		• by age:
		<70 y: 54.3%
		≥70 y: 51.5%
		• by race/ethnicity:
		White: 52.9%
		Black -H: 54.4%
		other: 70.8%
		• by payer:
		Government: 51.3%
		Private: 54.9% S:
		• Links: NA
	• % reporting size invasive carcinoma ^IV	• Overall: 91.8%
		• by age:
		<70 y: 91.6%
		≥70 y: 91.9%
		• by race/ethnicity:
		White: 91.7%
		Black -H: 91.2%
		other: 96.5%
		• by payer:
		Government: 91.6%
		Private: 92%
		• Links: NA
	• % reporting macroscopic margins of carcinoma measured^IV	• Overall: 72.4%
		• by age:
		<70 y: 72.5%
		≥70 y: 72.1%
		• by race/ethnicity:
		White: 72.5%
		Black -H: 73.5%
		other: 61.8%
		• by payer:
		Government: 73.1%
		Private: 72.3%
		• Links: NA
	• % reporting microscopic margins assessment^IV	• Overall: 89.5%
		• by age:
		<70 y: 90%
		≥70 y: 88.7%
		• by race/ethnicity:
		White: 89.7%
		Black -H: 86.8%
		other: 95.8%
		• by payer:
		Government: 89%
		Private: 90.2%
		• Links: NA
	• % reporting DCIS present/absent^IV	• Overall: 43.2%
		• by age:
		<70 y: 44.8%
		≥70 y: 38.6%
		• by race/ethnicity:
		White: 43.3%
		Black -H: 40.8%
		other: 49.3%
		• by payer:
		Government: 40.2%
		Private: 45.7% S
		• Links: NA
	• % reporting ER status^IV	• Overall: 91.7%
		• by age:
		<70 y: 91.9%
		≥70 y: 91.2%
		• by race/ethnicity:
		White: 91.8%
		Black -H: 90.4%
		other: 96.5%
		• by payer:
		Government: 91.4%
		Private: 92.3%
		• Links: NA
	• % reporting PR status^IV	• Overall: 90.6%
		• by age:
		<70 y: 90.9%
		≥70 y: 89.7%
		• by race/ethnicity:
		White: 90.7%
		Black -H: 89.6%
		other: 95.1%
		• by payer:
		Government: 90.1%
		Private: 91.4%
		• Links: NA
	• % appropriate use of RT after BCS^IV	• Overall: 85.9%
		• by age:
		<70 y: 88.4%
		≥70 y: 78.9%
		• by race/ethnicity:
		White: 86.3%
		Black -H: 83.2%
		other: 81.9%
		• by payer:
		Government: 83.3%
		Private: 88.6% S
		• Links: NA
	• % quality of RT: planning on a dedicated simulator^IV	• Overall: 88.9%
		• by age:
		<70 y: 89%
		≥70 y: 88.8%
		• by race/ethnicity:
		White: 89%
		Black -H: 87.7%
		other: 87.3%
		• by payer:
		Government: 89.1%
		Private: 88.8%
		• Links: NA
	• % quality of RT: homogenous dose distribution^IV	• Overall: 96.6%
		• by age:
		<70 y: 96.6%
		≥70 y: 96.8%
		• by race/ethnicity:
		White: 96.6%
		Black -H: 96.5%
		other: 97.5%
		• by payer:
		Government: 96.7%
		Private: 96.7%
		• Links: NA
	• % quality of RT: done 5 d/wk^IV	• Overall: 97.4%
		• by age:
		<70 y: 97.4%
		≥70 y: 97.4%
		• by race/ethnicity:
		White: 97.5%
		Black -H: 97.5%
		• by payer:
		Government: 97.1%
		Private: 97.1%
		• Links: NA
	• % quality of RT: use of wedges on tangent breast fields^IV	• Overall: 93.4%
		• by age:
		<70 y: 93.3%
		≥70 y: 93.8%
		• by race/ethnicity:
		White: 93.5%
		Black -H: 92.1%
		other: 97.5%
		• by payer:
		Government: 93%
		Private: 93.8%
		• Links: NA
	• % appropriate use of adjuvant systemic therapy in node (+) after BCT^IV	• Overall: 84.1%
		• by age:
		<70 y: 84.9–88.7%
		≥70 y: 72%
		• by race/ethnicity:
		White: 85.3%
		Black -H: 78.7%
		other: 78.3%
		• by payer:
		Government: 78.9%
		Private: 87.6% S
		• Links: NA

NR = not reported; NA = not assessed; S = significant difference/trend; NS = nonsignificant difference/trend; n = number of patients; pts = patients; enrolled = n qualified; evaluated = n analyzed; BC = breast cancer; LV = Lymphatic/Vascular; ER = estrogen receptor; PR = progesterone receptor; RT = radiotherapy; BCS = breast-conserving surgery; ACOS = American Collage of Surgeons; node (+) = lymph node positive; state of use = last 3 y; GP = general practitioner; NCI = National Cancer Institute; CAP = Collage of American pathologists; SSO = Society of Surgical Oncology; ACR = American Collage of radiology; BCT = breast-conservation therapy; Level Ia = pre-study data indicating consistently sound psychometric properties; Iac = pre- and on-study data indicating consistently sound psychometric properties; IV = no pre- or on-study psychometric data
Wilkinson, 2003, US	Process:	• Overall: 91%	• Standard: CAP guideline, 1998	• Inclusion: convenience sample women stage I–II breast infiltrative carcinoma referred to RPCI after excisional biopsy, 1998-1999
	• % reporting of size specimen in 3 dimensions^IV	• Links: NA	• Data sources: cancer database of Department of Surgery at Roswell Park Cancer Institute	• Exclusion: simultaneous axillary staging or mastectomy performed; preceding FNA or CNB performed; carcinoma in situ
	• % reporting tumor size^IV	• Overall: 40%	• Developmental period: NR	• Period: 2 y (1998-1999)
		• Links: NA	• Reference standard(s) (publication date): NR	• n patients: (enrolled/evaluated): 100/83
	• % reporting orientation of specimen (for margin analysis) ^IV	• Overall: 25%	• Data sources: NR	• Age (mean & range): NR
		• Links: NA	• Psychometric properties: NR	• Race/ethnicity: NR
	• % reporting microscopic margin status^IV	• Overall: 94%	• Links to outcomes: NR	• Case characteristics: infiltrating carcinoma; stage I–II
		• Links: NA	• Funding source: NR	• Socioeconomic status: NR
	• % reporting distance to closest margin^IV	• Overall: 69%	• State of use: NR	• Funding: NR
		• Links: NA	• Current use: internal quality improvement; quality of care reporting
	• % reporting specimen inked^IV	• Overall: 77%	• Care setting: hospitals; cancer centers; pathology centers
		• Links: NA	• Professionals: oncologists; pathologists; surgeons
	• % reporting histology type^IV	• Overall: 100%
		• Links: NA
	• % reporting histology grade^IV	• Overall: 90%
		• Links: NA
	• % reporting tumor size (microscopic) ^IV	• Overall: 90%
		• Links: NA
	• % reporting lymphovascular invasion (presence/absence) ^IV	• Overall: 47%
		• Links: NA
	• % reporting presence of in situ component^IV	• Overall: 71%
		• Links: NA
	• % reporting BSR scale (tumor grade) ^IV	• Overall: 6%
		• Links: NA
	• % reporting TNM staging^IV	• Overall: 9%
		• Links: NA

NR = not reported; NA = not assessed; S = significant difference/trend; NS = nonsignificant difference/trend; n = number of patients; pts = patients; enrolled = n qualified; evaluated = n analyzed; BC = breast cancer; RPCI = Roswell Park Cancer Institute; FNA = fine-needle aspiration; CNB = core-needle biopsy; CAP = College of American Pathologists; CPG = clinical practice guideline; state of use = last 3 y; BSR = Bloom Scarf Richardson Scale; Level Ia = pre-study data indicating consistently sound psychometric properties; Iac = pre- and on-study data indicating consistently sound psychometric properties; IV = no pre- or on-study psychometric data

Appendix E. Evidence Tables

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NLM Citation

Evidence Table 1. Definition, developmental history, and adherence data revealed by quality measures/measurements