Orris

Good — final year, aiming for publication or presentation. That changes things meaningfully. You can be more ambitious than a basic portfolio piece, but the project still needs to be something *you* can realistically execute on a clinical attachment. Here is a scaled, publishable version: --- # Quality Improvement Project ## **Adherence to Evidence-Based Breast Tumour Marker Testing at Initial Diagnosis: A Clinical Audit in an Oncology Outpatient Setting** **Project Type:** Prospective/Retrospective Clinical Audit **Specialty:** Oncology — Breast Cancer **Setting:** Oncology outpatient clinic or breast MDT, single centre **Estimated Duration:** 6–8 weeks data collection; 2–3 months full write-up **Student Role:** Data collector, analyser, presenter, first/co-author --- ## 1. Background Breast tumour markers are essential tools in guiding treatment decisions for breast cancer. Current guidelines — including the ESMO Clinical Practice Guideline (2024) and ASCO-CAP (2023) — mandate that **all newly diagnosed breast carcinomas** should have ER, PR, HER2, and Ki-67 assessed at diagnosis before any treatment planning. These four markers collectively determine: - Eligibility for endocrine therapy (ER/PR positive) - Eligibility for anti-HER2 therapy (trastuzumab, pertuzumab, T-DXd) - Chemotherapy intensity (Ki-67 proliferation index) - Prognostic subtype (Luminal A/B, HER2-enriched, Triple Negative) Despite clear guidance, real-world studies and local experience suggest that documentation of these results in clinical notes at the time of treatment planning is inconsistent. Missing or delayed biomarker results can delay treatment initiation or lead to suboptimal therapy selection. A secondary issue is the inappropriate ordering of **serum tumour markers** (CA 15-3, CEA) for primary diagnosis or screening — a practice not supported by ASCO or ESMO guidelines, which recommend serum markers only for monitoring response in established metastatic disease. --- ## 2. Aim > *"To audit whether patients with newly diagnosed breast cancer discussed at the oncology MDT or seen in clinic have a complete, documented tissue biomarker panel (ER, PR, HER2, Ki-67) available at the time of initial treatment planning, and to identify whether serum tumour markers (CA 15-3, CEA) are being ordered appropriately."* --- ## 3. Standards (Audit Criteria) | # | Standard | Source | Target | |---|---|---|---| | 1 | ER status documented before treatment planning | ESMO 2024, ASCO-CAP 2023 | 100% | | 2 | PR status documented before treatment planning | ESMO 2024, ASCO-CAP 2023 | 100% | | 3 | HER2 status documented before treatment planning | ESMO 2024, ASCO-CAP 2023 | 100% | | 4 | Ki-67 documented before treatment planning | ESMO 2024 | 95% | | 5 | HER2 FISH/ISH performed when IHC is 2+ (equivocal) | ASCO-CAP 2023 | 100% | | 6 | CA 15-3 / CEA only requested for monitoring in metastatic disease (not for screening/primary diagnosis) | ASCO Tumour Marker Guidelines | 100% appropriate indication | --- ## 4. Method ### Data Collection - **Sample size:** 30–50 consecutive newly diagnosed breast cancer patients discussed at MDT or seen in oncology clinic during your attachment - **Data source:** Electronic patient records / MDT records / pathology system - **Design:** Retrospective case note review (no patient contact needed — this usually avoids formal ethics approval and falls under local clinical audit registration) ### Data Points to Record (per patient, anonymised) - Age, tumour stage (I–IV) - Date of pathological diagnosis - Date of MDT/first oncology clinic - ER documented: Yes / No / Date - PR documented: Yes / No / Date - HER2 IHC documented: Yes / No / Date - HER2 FISH performed (if IHC 2+): Yes / No / N/A - Ki-67 documented: Yes / No / Date - Serum CA 15-3 ordered: Yes / No → if yes, documented indication: Monitoring / Screening / Primary diagnosis / Unclear - Serum CEA ordered: Yes / No → if yes, documented indication - Interval from biopsy to full biomarker panel available (days) - Treatment decision documented: Yes / No ### Tool Design a simple **data collection proforma** (spreadsheet) — one row per patient, one column per standard. --- ## 5. Analysis This is straightforward and manageable without specialist statistics: - **Descriptive statistics:** Percentage compliance for each standard, presented as bar charts - **Turnaround time:** Mean and range of days from biopsy to complete biomarker result - **Appropriateness of serum markers:** Frequency table of indication categories - **Gap analysis:** Which standard shows the lowest compliance? Which patient subgroup is most affected? No statistical software needed beyond Excel or SPSS. For a publishable piece, a simple table + run chart showing compliance across the audit period is sufficient. --- ## 6. Expected Findings (Based on Literature) From the 2025 EQA harmonisation study (Van Rossum et al., *Clin Chem Lab Med*) and ESMO 2024: - ER/PR/HER2 documentation is generally high in well-organised centres but Ki-67 and FISH reflex rates are more variable - Serum CA 15-3 over-ordering for non-metastatic patients is a recognised problem in several audits - Turnaround time gaps are common when IHC and FISH are processed by different laboratories Whatever you find, **any deviation from 100% compliance** is a valid finding worth reporting and recommending improvement for. --- ## 7. Recommendations (to Generate from Your Findings) You will formulate these based on your results, but likely candidates include: 1. Implement a **standardised pathology request form** that automatically includes ER/PR/HER2/Ki-67 as a bundle for all breast core biopsies 2. Introduce a **MDT checklist item** — "Complete biomarker panel available? Y/N" — before treatment decisions are recorded 3. Develop a **departmental guideline** for serum marker ordering with clear indication criteria 4. Feed findings into the **oncology governance/audit meeting** as a change recommendation --- ## 8. Pathway to Publication or Presentation | Venue | Suitable For | |---|---| | **Local hospital audit day / grand round** | First step — present findings to department | | **Medical student conference** (e.g. BMJ Student, AMSA, national oncology student events) | Abstract + poster/oral presentation | | **BASO – The Association for Cancer Surgery annual meeting** | Audit/QI abstract submission | | **Clinical Oncology / EJSO / BMJ Open Quality** | Written audit report (case note audit with recommendations) | | **BMJ Open Quality** | Specifically designed for QI reports; student-led audits are regularly published here | For publication, you will need a **consultant/registrar supervisor as co-author** who can verify data access and governance registration. This is standard and expected. --- ## 9. Ethical Considerations - Register the project with the **local clinical audit department** (not formal ethics — case note review is audit, not research in most jurisdictions) - All data must be **anonymised** (use a patient ID number, never name or NHS/hospital number in your spreadsheet) - Store data on a **trust-approved, password-protected** system — not personal devices or personal email - Confirm data access permission with your clinical supervisor before starting --- ## 10. Why This Project Works for a Final-Year Student | Feature | Why it matters | |---|---| | **No patient contact required** | Simpler governance; no consent issues | | **Achievable in one placement** | 6–8 weeks is sufficient for 30–50 cases | | **Clinically meaningful** | Directly tied to treatment outcomes; supervisors take it seriously | | **Guideline-anchored** | ASCO/ESMO 2024 standards give you solid, citable benchmarks | | **Publication-ready format** | Fits BMJ Open Quality / conference abstract format exactly | | **Demonstrates QI literacy** | Shows audit cycle awareness, not just data collection | --- ## Quick Summary — What You Need to Do 1. **Week 1:** Register with local audit department; get supervisor sign-off; build your data collection spreadsheet 2. **Weeks 2–7:** Collect anonymised data from 30–50 case notes 3. **Week 8:** Analyse, produce bar charts, calculate compliance rates 4. **Week 9–10:** Write up findings + recommendations; present at local audit meeting 5. **Month 3:** Submit abstract or manuscript to a suitable journal/conference Based on this QI idea, can you make a presentation to present the idea to a supervising consultant

Reading File
Reading File
Running Command

mkdir -p /home/daytona/workspace/breast-audit-pptx && ls /home/daytona/workspace/breast-audit-pptx/

Writing File

~/breast-audit-pptx/build.js

const pptxgen = require("pptxgenjs");

const pres = new pptxgen();
pres.layout = "LAYOUT_16x9";
pres.title = "Breast Tumour Marker Audit – Consultant Pitch";
pres.author = "Final Year Medical Student";

// ─── COLOUR PALETTE ───────────────────────────────────────────────────────────
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  gold:    "E8A020",   // highlight / callout
};

// ─── REUSABLE HELPERS ─────────────────────────────────────────────────────────
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// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 1 — TITLE
// ═══════════════════════════════════════════════════════════════════════════════
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// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 2 — THE CLINICAL PROBLEM
// ═══════════════════════════════════════════════════════════════════════════════
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    { label:"ER / PR", sub:"Eligibility for\nendocrine therapy", col: C.teal },
    { label:"HER2", sub:"Eligibility for\ntrastuzumab / T-DXd", col: C.rose },
    { label:"Ki-67", sub:"Chemotherapy intensity\n& proliferation index", col: "2266CC" },
    { label:"Subtype", sub:"Luminal A/B · HER2-enriched\nTriple Negative", col: "6A3FA0" },
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  s.addText([
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    { text: "before any treatment planning begins.", options:{ bold:true, color: C.white } },
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// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 3 — THE PROBLEM IN PRACTICE
// ═══════════════════════════════════════════════════════════════════════════════
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  s.addText("The Gap Between Guidelines and Real-World Practice", {
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  tealAccentBar(s, 1.2, 5.0);

  const issues = [
    {
      icon:"⚠", title:"Incomplete Documentation",
      body:"Ki-67 and HER2 FISH reflex results are inconsistently recorded in clinical notes at the point of treatment planning — even when results exist in pathology systems."
    },
    {
      icon:"🔬", title:"Serum Marker Over-Ordering",
      body:"CA 15-3 and CEA are frequently ordered at primary diagnosis. ASCO guidelines restrict their use to monitoring in established metastatic disease only — not screening or diagnosis."
    },
    {
      icon:"⏱", title:"Turnaround Time Delays",
      body:"When IHC and FISH are processed by separate laboratories, delays in biomarker availability can postpone MDT decisions and treatment initiation."
    },
  ];

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  slideNumber(s, 3);
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// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 4 — AIM & AUDIT STANDARDS
// ═══════════════════════════════════════════════════════════════════════════════
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    "To audit whether patients with newly diagnosed breast cancer discussed at MDT have a complete, documented tissue biomarker panel (ER, PR, HER2, Ki-67) available at the time of initial treatment planning — and to identify whether serum tumour markers (CA 15-3, CEA) are being ordered appropriately.",
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  s.addText("Target", { x:7.7, y:2.38, w:2.0, h:0.36, fontSize:9.5, bold:true, color: C.white, valign:"middle", align:"center" });

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    ["PR status documented before treatment planning  (ESMO 2024, ASCO-CAP 2023)", "100%"],
    ["HER2 status documented before treatment planning  (ESMO 2024, ASCO-CAP 2023)", "100%"],
    ["Ki-67 documented before treatment planning  (ESMO 2024)", "95%"],
    ["HER2 FISH/ISH performed when IHC is 2+ equivocal  (ASCO-CAP 2023)", "100%"],
    ["CA 15-3 / CEA ordered only for metastatic monitoring  (ASCO Tumour Marker Guidelines)", "100%"],
  ];

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}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 5 — METHOD
// ═══════════════════════════════════════════════════════════════════════════════
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    { h:"Sample", b:"30–50 consecutive newly diagnosed breast cancer patients discussed at MDT or seen in oncology clinic during the attachment." },
    { h:"Data Sources", b:"Electronic patient records · MDT records · Pathology / LIMS system" },
    { h:"Data Points", b:"Age, stage, diagnosis date, MDT date, ER / PR / HER2 / Ki-67 / FISH documented (Yes/No/Date), serum marker indication, biopsy-to-panel turnaround time." },
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    "Age",
    "TNM Stage (I–IV)",
    "Date of biopsy",
    "Date of MDT",
    "ER documented  ☐ Yes  ☐ No",
    "PR documented  ☐ Yes  ☐ No",
    "HER2 IHC documented  ☐ Yes  ☐ No",
    "HER2 FISH (if IHC 2+)  ☐ Yes  ☐ N/A",
    "Ki-67 documented  ☐ Yes  ☐ No",
    "CA 15-3 ordered  ☐ Yes  ☐ No",
    "If yes — indication: ________________",
    "CEA ordered  ☐ Yes  ☐ No",
    "Biopsy → full panel (days): ___",
    "Treatment decision documented  ☐ Y  ☐ N",
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}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 6 — ANALYSIS PLAN
// ═══════════════════════════════════════════════════════════════════════════════
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    {
      num:"02", title:"Turnaround Time Analysis",
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      num:"03", title:"Serum Marker Appropriateness",
      body:"Frequency table: Monitoring / Primary diagnosis / Screening / Unclear.\nFlags inappropriate ordering patterns directly.",
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    {
      num:"04", title:"Gap Analysis",
      body:"Which standard has lowest compliance? Which patient subgroup (stage, age) is most affected?\nGenerates targeted, evidence-based recommendations.",
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    s.addText(a.body, { x: x+0.15, y: y+0.5, w:4.25, h:1.15, fontSize:9.8, color: C.darkGrey, lineSpacingMultiple:1.3 });
  });

  s.addText("No specialist statistics required — Excel or SPSS is sufficient for a publishable audit report.", {
    x:0.35, y:5.3, w:9.3, h:0.22, fontSize:8.5, color: C.midGrey, italic:true, align:"center"
  });
  slideNumber(s, 6);
}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 7 — EXPECTED FINDINGS
// ═══════════════════════════════════════════════════════════════════════════════
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  s.addText("What the Evidence Suggests We Will Find", {
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  tealAccentBar(s, 1.2, 5.5);

  // Simulated bar chart — compliance expectations
  const bars = [
    { label:"ER Status", pct:0.96, col: C.teal },
    { label:"PR Status", pct:0.95, col: C.teal },
    { label:"HER2 IHC", pct:0.93, col: "2266CC" },
    { label:"HER2 FISH\n(if IHC 2+)", pct:0.82, col: C.rose },
    { label:"Ki-67", pct:0.78, col: C.rose },
    { label:"Appropriate\nSerum Marker", pct:0.65, col: "A03030" },
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  s.addText("Illustrative expected compliance rates based on Van Rossum et al. (Clin Chem Lab Med, 2025) and ESMO 2024 review data. Actual local results may differ.", {
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  });
  slideNumber(s, 7);
}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 8 — RECOMMENDATIONS
// ═══════════════════════════════════════════════════════════════════════════════
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  sectionTag(s, "ANTICIPATED RECOMMENDATIONS");

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      col: C.teal
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      n:"2", title:"MDT Checklist Item",
      body:"Add \"Complete biomarker panel available? Y/N\" as a compulsory field before any treatment decision is recorded in the MDT proforma.",
      col: C.rose
    },
    {
      n:"3", title:"Serum Marker Ordering Guideline",
      body:"Produce a single-page departmental guideline specifying that CA 15-3 / CEA are restricted to metastatic monitoring — not initial workup or surveillance.",
      col: "2266CC"
    },
    {
      n:"4", title:"Governance & Re-Audit",
      body:"Present findings at oncology audit/governance meeting. Implement changes and re-audit within 12 months to close the audit cycle.",
      col: C.gold
    },
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  slideNumber(s, 8);
}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 9 — TIMELINE
// ═══════════════════════════════════════════════════════════════════════════════
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  sectionTag(s, "PROJECT TIMELINE");

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    { label:"Weeks 2–7", title:"Data Collection", items:["30–50 case note reviews", "Anonymised proforma", "Pathology system access"], col: "2266CC" },
    { label:"Week 8", title:"Analysis", items:["Compliance rates", "Bar charts", "Turnaround time calc."], col: "6A3FA0" },
    { label:"Weeks 9–10", title:"Write-Up & Present", items:["Findings + recommendations", "Local audit meeting", "Governance submission"], col: C.rose },
    { label:"Month 3", title:"Publication", items:["Abstract to conference", "BMJ Open Quality MS", "Supervisor co-author"], col: C.gold },
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    x:0.65, y:2.85, w:8.7, h:0, line:{ color: C.lightGrey, width:2 }
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    const x = 0.45 + i * 1.85;
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    // label above
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  slideNumber(s, 9);
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// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 10 — PUBLICATION PATHWAY
// ═══════════════════════════════════════════════════════════════════════════════
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  sectionTag(s, "PATHWAY TO PUBLICATION & PRESENTATION");

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      step:"2", label:"Medical Student Conference\n(BMJ Student, AMSA, national oncology events)",
      note:"Abstract + poster or oral presentation. Peer-reviewed acceptance counts as a publication line.", col: "2266CC"
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      step:"3", label:"BASO Annual Meeting",
      note:"Audit / QI abstracts accepted. The Association for Cancer Surgery is a high-visibility surgical oncology audience.", col: "6A3FA0"
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      step:"4", label:"BMJ Open Quality\n/ Clinical Oncology / EJSO",
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// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 11 — GOVERNANCE & ETHICS
// ═══════════════════════════════════════════════════════════════════════════════
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  const points = [
    {
      icon:"📋", head:"Clinical Audit Registration (Not Full Ethics)",
      body:"Case note review for service evaluation qualifies as clinical audit in most NHS / hospital jurisdictions. Registration with the local clinical audit department is sufficient — no IRAS/ethics approval required."
    },
    {
      icon:"🔒", head:"Anonymisation",
      body:"All data recorded using a sequential patient ID number only. Name, NHS/hospital number, and date of birth are never entered into the analysis spreadsheet."
    },
    {
      icon:"💻", head:"Data Storage",
      body:"All data held on a trust-approved, password-protected system (e.g. shared hospital drive or trust-approved device). No personal devices or personal email addresses."
    },
    {
      icon:"✅", head:"Supervisor Sign-Off",
      body:"Data access confirmed in writing from supervising consultant or clinical audit lead prior to data collection commencing. Student acts under supervisor's governance remit."
    },
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  slideNumber(s, 11);
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// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 12 — CLOSING / WHAT I NEED
// ═══════════════════════════════════════════════════════════════════════════════
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  s.addText("Summary & Next Steps", {
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  s.addShape(pres.ShapeType.rect, { x:0.45, y:1.68, w:3.5, h:0.05, fill:{ color: C.rose } });

  const bullets = [
    { icon:"📌", text:"Directly tied to patient outcomes — treatment delay has measurable harm" },
    { icon:"📚", text:"Anchored to ASCO-CAP 2023 & ESMO 2024 — strong, citable standards" },
    { icon:"🎓", text:"Achievable in one 6–8 week placement without patient contact" },
    { icon:"📰", text:"Publication-ready format for BMJ Open Quality or conference abstract" },
    { icon:"🔄", text:"Demonstrates full audit cycle awareness — a key QI competency" },
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  // Ask box
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}

// ─── WRITE FILE ───────────────────────────────────────────────────────────────
pres.writeFile({ fileName: "/home/daytona/workspace/breast-audit-pptx/BreastTumourMarkerAudit_Pitch.pptx" })
  .then(() => console.log("SUCCESS"))
  .catch(e => { console.error(e); process.exit(1); });
Running Command

cd /home/daytona/workspace/breast-audit-pptx && node build.js 2>&1

Running Command

ls -lh /home/daytona/workspace/breast-audit-pptx/

The presentation is ready — 271 KB, 12 slides.

BreastTumourMarkerAudit Pitch

Presentation · PPTX

What's in the deck (12 slides):
#SlidePurpose
1TitleNavy + rose accent — clean, clinical feel
2Why Tumour Markers Matter4 colour-coded boxes: ER/PR, HER2, Ki-67, Subtype — with the ESMO/ASCO mandate callout
3The Problem in Practice3 documented gaps: incomplete documentation, CA15-3 over-ordering, turnaround delays — sourced
4Aim & Audit StandardsAim statement box + full 6-standard table with targets
5MethodologyLeft: design/sample/data sources. Right: visual mock-up of the data collection proforma
6Analysis Plan4 numbered quadrant boxes: compliance rates, turnaround time, serum marker appropriateness, gap analysis
7Expected FindingsIllustrated bar chart showing anticipated compliance by marker type (with literature sourcing)
8Recommendations4 QI actions on dark navy — standardised request form, MDT checklist, serum marker guideline, re-audit
9Timeline5-phase horizontal timeline: Weeks 1 → Month 3
10Publication Pathway4-step ladder: Local grand round → Student conference → BASO → BMJ Open Quality
11Governance & Ethics4 points: audit registration, anonymisation, data storage, supervisor sign-off
12Closing / AskSummary bullets + explicit ask: "I am seeking your support as supervising consultant and co-author"
Design choices: Navy dominant background (authoritative/clinical), teal supporting, rose accent (cancer ribbon resonance), gold for key callouts. The colour palette is specific to this topic — not generic.
Tip for your meeting: Slides 4 and 12 are your anchor points — open with slide 4 to show you've done your homework on the guidelines, close with slide 12 to make the ask clear and professional. Keep the whole pitch under 10 minutes.

what is meant by MDT

MDT stands for Multidisciplinary Team.
In the context of this audit (and oncology generally), it refers to a regular meeting where specialists from different disciplines come together to review each cancer patient's case and agree on a treatment plan. For breast cancer, a typical MDT includes:
  • Breast surgeon
  • Medical oncologist
  • Clinical oncologist (radiotherapy)
  • Radiologist
  • Pathologist
  • Breast care nurse / CNS (Clinical Nurse Specialist)
  • Sometimes: plastic surgeon, geneticist, palliative care
Why it matters for this audit: The MDT meeting is the formal point at which treatment decisions are made. The audit standard is that the full biomarker panel (ER, PR, HER2, Ki-67) should be documented and available before that meeting — because if results are missing, the team either has to defer the decision or make a suboptimal one.
So when the audit criteria say "documented before treatment planning," that effectively means "available and recorded before the patient is discussed at MDT."
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