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Adjuvant hormonal therapy is recommended or administered within 1 year (365 days) of diagnosis for women with AJCC T1cN0M0 or Stage IB – Stage III hormone receptor positive breast cancer

CBE ID
0220
Endorsement Status
1.1 New or Maintenance
Previous Endorsement Cycle
Is Under Review
No
Next Maintenance Cycle
Fall 2025
1.3 Measure Description

Percentage of female patients, age = 18 at diagnosis, who have their first diagnosis of cancer (epithelial malignancy), at AJCC T1cN0M0 or stage IB to IIIC, whose primary tumor is of the breast, and is progesterone or estrogen receptor positive with adjuvant hormonal therapy (recommended or administered) within 1 year (365 days) of diagnosis

        • 1.5 Measure Type
          1.7 Electronic Clinical Quality Measure (eCQM)
          1.8 Level Of Analysis
        • 1.14 Numerator

          Adjuvant hormonal therapy is administered within 1 year (365 days) of the date of diagnosis or it is recommended but not administered

        • 1.15 Denominator

          Include if all of the following characteristics are identified:
          Women
          Age = 18 at time of diagnosis
          Known or assumed to be first or only cancer diagnosis
          Epithelial malignancy only
          Invasive tumors
          Primary tumors of the breast
          AJCC T1cN0M0 or Stage IB – IIIC 
          Primary tumor is estrogen receptor positive or progesterone receptor positive
          All or part of 1st course of treatment performed at the reporting facility
          Known to be alive within 1 year (365 days) of date of diagnosis
          Surgical procedure of the primary site

        • Exclusions

          Exclude, if any of the following characteristics are identified:
          Men
          Under age 18 at time of diagnosis
          Second or subsequent cancer diagnosis
          Tumor not originating in the breast
          Non-epithelial malignancies, exclude malignant phyllodes tumors; 8940 - Mixed tumor, malignant, NOS; 8950 - Mullerian mixed tumor; 8980 - Carcinosarcoma; 8981 - Carcinosarcoma, embryonal
          Non-invasive tumors
          Stage 0, in-situ tumor
          Stage IV, metastatic tumor
          Primary tumor is estrogen receptor negative and progesterone receptor negative
          None of 1st course therapy performed at reporting facility
          Died within 1 year (365 days) of diagnosis,
          Patient enrolled in a clinical trial that directly impacts delivery of the standard of care
          No surgical procedure of the primary site
          Not AJCC T1cN0M0 or not AJCC stage IB-IIIC

        • 1.13a Data dictionary not attached
          No
        • Most Recent Endorsement Activity
          Endorsed Cancer Fall Cycle 2019
          Initial Endorsement
          Last Updated
        • Steward
          American College of Surgeons
          Steward Organization POC Email
              • Risk adjustment approach
                Off
                Risk adjustment approach
                Off
                Conceptual model for risk adjustment
                Off
                Conceptual model for risk adjustment
                Off