Memorial Göztepe Breast Cancer Center: Accreditation and Excellence Roadmap
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Why Are We Embarking on This Journey?
Accreditation means that a healthcare organization does not merely claim to be "good," but uses internationally recognized, evidence-based data to prove it. As Memorial Göztepe Cancer Center, our goal is to bring our Breast Cancer Unit up to EUSOMA (European Society of Breast Cancer Specialists) and NAPBC (National Accreditation Program for Breast Centers) standards, offering our patients "Gold Standard" care.
This comprehensive report was prepared through a detailed analysis of the current EUSOMA 2024, NAPBC 2024 and ECIBC 2025 guidelines. For every discipline, from medical oncology to surgery, radiology, pathology and nursing, the most critical, most measurable indicators with the greatest impact on patient outcomes, to be implemented within the first 6 months, "Key Performance Indicators" (KPI) have been identified.
At least 95% of patients diagnosed with breast cancer should be discussed by a team including a radiologist, surgeon, pathologist and oncologist before treatment (surgical or systemic) begins, and the decision should be documented in writing.
Adjuvant chemotherapy after surgery should begin no later than 8 weeks after the operation (ideally within 4-6 weeks). Delays have been shown to reduce survival.
Before a systemic treatment decision is made, the pathology report must clearly establish ER, PR, HER2 and Ki-67 status in 100% of invasive cancers (including FISH/CISH).
Patients meeting NCCN criteria (under age 40, TNBC <60 years, family history, etc.) should be referred for genetic counseling and offered testing.
Preoperative (neoadjuvant) treatment should routinely be offered to patients with stage II-III triple-negative and HER2+ disease. pCR (pathological complete response) rates should be monitored.
All invasive cancer reports should be written in a template format compliant with the CAP (College of American Pathologists) protocol. Free-text reporting should be avoided.
Biopsy reports should be completed within 5 working days and surgical resection reports within 10 working days.
A written policy and archiving system must be in place for retaining paraffin blocks and slides for at least 10 years and wet tissues for an appropriate period.
ER, PR and HER2 tests should be included in regular internal and external quality assurance (External QA) programs and certified.
The capacity to assess the sentinel lymph node during surgery by frozen section or other validated methods.
Every newly diagnosed patient should be introduced to a "Breast Care Nurse" (Navigator) who will guide them through treatment, and be given the nurse's contact details.
All patients undergoing axillary surgery should have measurements for lymphedema taken and documented preoperatively (baseline) and postoperatively.
The level of psychosocial stress in all patients should be assessed using the "Distress Thermometer" or a similar tool, and those scoring >4 should be referred to a psychologist.
Patients who have completed treatment should receive a written "Survivorship Care Plan" covering the treatments they received, the follow-up plan and side-effect management.
Nurses working in the breast unit should hold oncology nursing certification or attend regular annual breast cancer training.
Data are the foundation of accreditation. A "Breast Cancer Database" in which each department monitors its own KPIs (Key Performance Indicators) monthly must be established.
- Annual Audit: Review all targets (QI) and analyze deviations at least once a year.
- Patient Questionnaires (PROMs): Regularly measure patients' quality of life and satisfaction (BREAST-Q, etc.) (EUSOMA QI-55).
- Data Lead: Appoint a designated "Data Manager" to collect and analyze all these data.
MEMORIAL Göztepe Cancer Center Multidisciplinary Tumor Board Note
This report is the strategic action plan we have prepared for Memorial Göztepe Breast Cancer Center to be recognized internationally as a "Center of Excellence." These targets are not simply intended to satisfy assessors; they are intended to enable us to provide the "best, safest and most up-to-date" treatment we promise our patients.
The next 6 months will be a marathon of data collection and process improvement. Everyone, from surgeons to nurses and radiologists to data managers, adopting these standards is the key to our success. Remember, quality is not a destination, but an ongoing journey.
- Rubio IT, et al. EUSOMA quality indicators for non-metastatic breast cancer: An update 2024. European Journal of Cancer. 2024.
- American College of Surgeons. Optimal Resources for Breast Care (2024 Standards). National Accreditation Program for Breast Centers (NAPBC). 2024.
- European Commission Initiative on Breast Cancer (ECIBC). European Quality Assurance Scheme for Breast Cancer Services. 2025.
- Biganzoli L, et al. The requirements of a specialist breast centre. Breast. 2020.
- College of American Pathologists (CAP). Protocol for the Examination of Specimens from Patients with Invasive Carcinoma of the Breast. 2024.
- NCCN Clinical Practice Guidelines in Oncology. Breast Cancer. Version 1.2024.
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