eMeasure Title

Breast Cancer: Hormonal Therapy for Stage IC-IIIC Estrogen Receptor/Progesterone Receptor (ER/PR) Positive Breast Cancer

eMeasure Identifier (Measure Authoring Tool) 140 eMeasure Version number 4.0.000
NQF Number 0387 GUID ac639794-cb3f-4f4f-8fa6-680300d5ed4e
Measurement Period January 1, 20XX through December 31, 20XX
Measure Steward American Medical Association-convened Physician Consortium for Performance Improvement(R) (AMA-PCPI)
Measure Developer American Medical Association-convened Physician Consortium for Performance Improvement(R) (AMA-PCPI)
Endorsed By National Quality Forum
Description
Percentage of female patients aged 18 years and older with Stage IC through IIIC, ER or PR positive breast cancer who were prescribed tamoxifen or aromatase inhibitor (AI) during the 12-month reporting period
Copyright
Copyright 2014 American Society of Clinical Oncology, National Comprehensive Cancer Network Association and American Medical Association. All Rights Reserved.
Disclaimer
Physician Performance Measures (Measures) and related data specifications have been developed by the American Medical Association (AMA) - convened Physician Consortium for Performance Improvement(R) (PCPI[R]), American Society of Clinical Oncology, and National Comprehensive Cancer Network. These Measures are not clinical guidelines and do not establish a standard of medical care, and have not been tested for all potential applications. The Measures, while copyrighted, can be reproduced and distributed, without modification, for noncommercial purposes, eg, use by health care providers in connection with their practices. Commercial use is defined as the sale, license, or distribution of the Measures for commercial gain, or incorporation of the Measures into a product or service that is sold, licensed or distributed for commercial gain. Commercial uses of the Measures require a license agreement between the user and the AMA, (on behalf of the PCPI). Neither the AMA, PCPI nor its members shall be responsible for any use of the Measures. 

THE MEASURES AND SPECIFICATIONS ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND. 

Limited proprietary coding is contained in the Measure specifications for convenience. Users of the proprietary code sets should obtain all necessary licenses from the owners of these code sets. The AMA, American Society of Clinical Oncology, National Comprehensive Cancer Network, the PCPI and its members disclaim all liability for use or accuracy of any Current Procedural Terminology (CPT[R]) or other coding contained in the specifications. 

CPT(R) contained in the Measure specifications is copyright 2004-2014 American Medical Association. LOINC(R) copyright 2004-2014 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2014 International Health Terminology Standards Development Organisation. ICD-10 copyright 2014 World Health Organization. All Rights Reserved.

Due to technical limitations, registered trademarks are indicated by (R) or [R].
Measure Scoring Proportion
Measure Type Process
Stratification
None
Risk Adjustment
None
Rate Aggregation
None
Rationale
Despite evidence suggesting the role of adjuvant endocrine therapy in lowering the risk of tumor recurrence, many female patients who should be receiving this therapy are not. 

This measure assesses whether patients with a certain stage of breast cancer (IC through IIIC) and ER/PR+ are currently receiving the therapy. 

There are allowable medical, patient, and system reasons to document instances in which a woman with stage IC through IIIC, ER/PR+ may not be a candidate for the therapy.
Clinical Recommendation Statement
I. Women diagnosed with hormone receptor-positive breast cancer who are pre- or perimenopausal should be offered adjuvant endocrine therapy with:
     a. Tamoxifen for an initial duration of 5 years.
     b. After 5 years, women should receive additional therapy based on menopausal status.
          i. If women are pre- or perimenopausal, or if menopausal status is unknown or cannot be determined, they should be offered continued tamoxifen for a total duration of 10 years. (Type: Evidence-Based, Evidence Quality: High, Strength of Recommendation: Strong)
          ii. If women have become definitively postmenopausal, they should be offered continued tamoxifen for a total duration of 10 years or switching to up to 5 years of an aromatase inhibitor (AI), for a total duration of up to 10 years of adjuvant endocrine therapy. (Type: Evidence-Based, Evidence Quality for tamoxifen: High, Evidence Quality for AI: High, Strength of Recommendation: Strong)

II. Women diagnosed with hormone receptor-positive breast cancer who are postmenopausal should be offered adjuvant endocrine therapy with one of the following options:
     a. Tamoxifen for a duration of 10 years. (Type: Evidence-Based, Evidence Quality: High, Strength of Recommendation: Strong) Or
     b. An AI for a duration of 5 years. There are insufficient data currently to recommend an AI for a duration of greater than 5 years. (Type: Evidence-Based, Evidence Quality: High, Strength of Recommendation: Strong) Or
     c. Tamoxifen for an initial duration of 5 years, then switching to an AI for up to 5 years, for a total duration of up to 10 years of adjuvant endocrine therapy. (Type: Evidence-Based, Evidence Quality: High, Strength of Recommendation: Strong) Or
     d. Tamoxifen for a duration of 2 to 3 years and switching to an AI for up to 5 years, for a total duration of up to 7 to 8 years of adjuvant endocrine therapy. (Type: Evidence-Based, Evidence Quality: High, Strength of Recommendation: Strong)

III. Women who are postmenopausal and are intolerant of either tamoxifen or an AI should be offered the alternative type of adjuvant endocrine therapy.
     a. If women have received an AI but discontinued treatment at less than 5 years, they may be offered tamoxifen for a total of 5 years. (Type: Informal consensus, Evidence Quality: Low, Strength of Recommendation: Weak)
     b. If women have received tamoxifen for 2 to 3 years, they should be offered switching to an AI for up to 5 years, for a total duration of up to 7 to 8 years of adjuvant endocrine therapy. (Type: Evidence-Based, Evidence Quality: High, Strength of Recommendation: Strong)

IV. Women who have received 5 years of tamoxifen as adjuvant endocrine therapy should be offered additional adjuvant endocrine treatment.
     a. If women are postmenopausal, they should be offered continued tamoxifen for a total duration of 10 years or switching to up to 5 years AI, for a total duration of up to 10 years of adjuvant endocrine therapy. (Type: Evidence-Based, Evidence Quality: High, Strength of Recommendation: Strong)
     b. If women are pre- or perimenopausal, or menopausal status cannot be ascertained, they should be offered 5 additional years of tamoxifen, for a total duration of 10 years of adjuvant endocrine therapy. (Type: Evidence-Based, Evidence Quality: High, Strength of Recommendation: Strong) (ASCO, 2014)

Patients with invasive breast cancers that are ER- or PR-positive should be considered for adjuvant endocrine therapy regardless of patient age, lymph node status, or whether adjuvant chemotherapy is to be administered. (NCCN, 2014)

The most firmly established adjuvant endocrine therapy is tamoxifen for both premenopausal and postmenopausal women. In women with ER-positive breast cancer, adjuvant tamoxifen decreases the annual odds of recurrence by 39% and the annual odds of death by 31% irrespective of the use of chemotherapy, patient age, menopausal status, or ALN status. In patients receiving both tamoxifen and chemotherapy, chemotherapy should be given first, followed by sequential tamoxifen. Prospective, randomized trials have demonstrated that 5 years of tamoxifen is more effective than 1 to 2 years of tamoxifen. (NCCN, 2014)

Patients with lymph node involvement or with tumors greater than 1cm in diameter are appropriate candidates for adjuvant systemic therapy (category 1). For women with lymph node-negative, hormone receptor-negative tumors greater than 1 cm in diameter, chemotherapy is recommended (category 1). For those with lymph node-negative, hormone receptor-positive breast cancer tumors greater than 1 cm, endocrine therapy with chemotherapy is recommended (category 1). (NCCN, 2014)
Improvement Notation
Higher score indicates better quality
Reference
Burstein HJ, Temin S, Anderson H, et al. Adjuvant endocrine therapy for women with hormone receptor-positive breast cancer: American Society of Clinical Oncology clinical practice guideline focused update. J Clin Oncol. 2014;32(21):2255-2269. doi:10.1200/JCO.2013.54.2258 
Reference
National Comprehensive Cancer Network (NCCN). Clinical Practice Guidelines in Oncology: Breast Cancer. Version 3.2014. Available at http://www.nccn.org. 
Definition
None
Guidance
For the eCQM version of this measure, the initial population for this measure has been limited to patients with a first recorded breast cancer diagnosis within the past 5 years, as opposed to accounting for that patient population through the use of an exception (as is the case for claims implementation). The numerator captures patients who are prescribed adjuvant tamoxifen or AI, or received adjuvant tamoxifen or AI during the 12 month period. Date of breast cancer diagnosis is defined as date of pathologic diagnosis.

The requirement of "Count >=2 of Encounter, Performed" is to establish that the eligible professional has an existing relationship with the patient.
Transmission Format
TBD
Initial Population
All female patients aged 18 years and older with a diagnosis of breast cancer
Denominator
Equals Initial Population with stage IC through IIIC, estrogen receptor (ER) or progesterone receptor (PR) positive breast cancer
Denominator Exclusions
None
Numerator
Patients who were prescribed tamoxifen or aromatase inhibitor (AI) during the 12-month reporting period
Numerator Exclusions
Not Applicable
Denominator Exceptions
- Documentation of medical reason(s) for not prescribing tamoxifen or aromatase inhibitor (eg, patient's disease has progressed to metastatic, patient is receiving a gonadotropin-releasing hormone analogue, patient has received oophorectomy, patient is receiving radiation or chemotherapy, patient's diagnosis date is within 120 days of the end of the 12 month reporting period, other medical reason)
- Documentation of patient reason(s) for not prescribing tamoxifen or aromatase inhibitor (eg, patient refusal, other patient reasons)
- Documentation of system reason(s) for not prescribing tamoxifen or aromatase inhibitor (eg, patient is currently enrolled in a clinical trial, other system reasons)
Measure Population
Not Applicable
Measure Population Exclusions
Not Applicable
Measure Observations
Not Applicable
Supplemental Data Elements
For every patient evaluated by this measure also identify payer, race, ethnicity and sex.

Table of Contents


Population Criteria

Data Criteria (QDM Variables)

Data Criteria (QDM Data Elements)

Supplemental Data Elements

Risk Adjustment Variables


Measure Set
None