News and Updates

Over the past decade, options for the diagnosis and treatment of lung cancer have expanded rapidly. While that’s good news for patients, the health care system hasn’t always kept pace with the moving parts. Oncologists have been challenged to get the diagnostic information they need in a timely way to start treatment with patients. And with lung cancer, there’s no time to lose.

It's why Dr. Jeremy Ho, an Oncologist at Richmond Hospital (RH) paired up with Dr. Karen Ung, an RH Pathologist, for a Facility Engagement project where they engaged interdisciplinary colleagues in the creation of a new pathway for the diagnosis and treatment of lung cancer. Together, they reduced the average turnaround time from biopsy to treatment from 55.7 days to 34.5 days – a drop of more than 21 days - and stellar success that has potential to be used for other cancers and at other hospitals.

WAIT TIMES FOR PATIENTS: UNACCEPTABLE

Dr. Ho explains that a patient who presents to their family doctor or the emergency room needs to pass through a number of tests and specialists. They might get a CT scan, see a respirologist, get a bronchoscopy, an EBUS or a CT guided biopsy. But it doesn’t stop there.

“It’s not sufficient now to get just a biopsy that says ‘lung cancer’. Cancer care is very protocolized; we have to be strategic in how we plan our treatments. So we need to send tissue off to the BC Cancer Agency (BCCA) for more tests;  to do biomarker or molecular testing and look at the specifics of the cancer itself. That tells us what treatments are best directed at it.”

The back and forth takes time, and Dr. Ho says the process was cumbersome. Ideally, oncologists should have all of the information needed for a treatment plan at the first appointment; but in reality, it could take up to eight weeks to get that information back. 

“That is obviously a very long time when we’re dealing with an aggressive type of cancer. Families don’t understand why things are taking so long. Imagine you get a shocking diagnosis, and someone tells you, ‘we’re going to have to wait another one or two months for your molecular results to come back before we can plan for treatment’.”

“I can try to explain and address their anxieties, but at the end of the day, I agree, it’s too long,” he says. And just because it’s the way it’s always been, it doesn’t mean we just have to accept it.” 

He discussed the problem with Dr. Karen Ung, who drew inspiration from developments in breast cancer diagnosis and treatment. “It used to be all over the place, but now has a standard of care. So how can we do the same for lung cancer?  What can we do to make the process more streamlined to gain some time for our patients?”

ENGAGING COLLEAGUES AND PARTNERS IN SOLUTIONS

With the support of the Richmond Hospital Physician Society Facility Engagement funding and a project manager – they brought together cancer specialists from RH Radiology, Respirology, Oncology and Pathology to talk.  Each typically provided services independently, but this was an opportunity  to work together as a coordinated, comprehensive team to improve diagnoses and management pathway for patients. BCCA joined the discussions as a key diagnostic partner.

Over three multidisciplinary meetings held between November 2019 to February 2020, they laid out the pathway visually to consider barriers and solutions to save time and improve the standard of care:  How long from when the patient first presents with either cough or a lung nodule to when they first get the first treatment? What are the steps? What is the speed of the tumor sample getting to the BCCA?

Discussions were eye-opening. Hearing from each other’s perspectives served to flag mistaken assumptions about what actually happens along the patient pathway, and increased everyone’s knowledge about respective roles and requests. Physicians started to see themselves in the bigger picture and the impact of each of their decisions on the overall patient journey.

They identified where delays were occurring, and where small shifts in each of their roles could make a difference. Examples ranged from having respirologists take multiple biopsy tissue in the initial diagnostic for BCCA molecular testing; to having investigations occur in parallel instead of waiting for one test result before performing the next; to improving coordination of processes with the BCCA.

In 2020, the collective efficiencies started to add up. Dr. Ho says: “I was hearing less of, ‘Why are the results not here yet?’” 

But even more telling was the data. It showed the turnaround time from biopsy to starting treatment had been reduced from 55.7 days to 34.5 days – a drop of more than 21 days. “We didn’t think that we would see something as dramatic as we did.”

LOOKING FORWARD: THE BIGGER PICTURE

What’s next?  Plans include looping in emergency department colleagues, and reaching out to the community family physicians to further refine the pathway.  There’s also potential for scalability.

“This success gives us the momentum to be able to keep doing it for other things – apply to other oncological treatments that might use this similar type of testing,” says Dr. Ung.  “It’s portable and replicable across everyone in the community or in a big centre.”

“While we made individual changes, we’re hoping for more systematic changes. It is good to shine light on the system itself, because ultimately, our patients benefit from it.”

WHAT FACTORS MADE THIS PROJECT A SUCCESS?

THE PASSION AND INTEREST OF DOCTORS WHO WANT TO DO BETTER:  Dr. Ung: “A big highlight is that these efficiencies were gained, and in the end it doesn’t really matter if people are remunerated. Because we see that there’s an impact to the hospital, the work, and the patient, ultimately.”

A SUPPORTIVE PROVINCIAL PARTNER:  Dr. Ung: “A BC Cancer Agency partner who was passionate and eager to align goals and priorities. In the past this was not possible.”

RHPS FACILITY ENGAGEMENT FUNDING: Dr. Ung: “Funding was fuel and allowed for a venue to happen.”

A PROJECT COORDINATOR - who pushed for meetings, navigated the project pieces and data gathering (arranged separately from Facility Engagement).  Dr. Ho: “Without that role, it is likely we all would have met, had one meeting, discussed the problems, and then it would likely have languished.”

DATA COLLECTION: Dr. Ung: “It reinforces that we’re on the right track; keeps the momentum going.”

In early 2020, Tla-o-qui-aht First Nation community members led a group of Tofino health care professionals through a cultural ceremony where they experienced traditional healing practices first-hand. Together, they wanted to explore how these practices and stronger cultural connections might blend with medical care to support people who experience trauma and pain. 

First Nations Healer Nora Martin and Cultural Worker Chris Seitcher led the ceremony, which included Tla-o-qui-aht members, physicians, nurses, X-ray and laboratory technicians, and a firefighter.

Martin explains that traditional cleansing ceremonies have been used by her ancestors for generations and continue today. “We carry trauma around with us, and sometimes never deal with it,” she explains. “In our community, if there is a serious incident or death, we do these kinds of ceremonies for community members right away. It makes a big difference.”

Those benefits caught the attention of Tofino primary care and emergency room physician Dr. Luke Williston. He had seen for himself how traditional cultural practices helped a group of patients who were struggling to deal with trauma and experiencing substance use that required frequent treatment in hospital. 

“A First Nations Cultural Worker came to the hospital to do a cleansing ceremony for some patients,” he says. “We didn’t see any of those patients for more than a year after. When I would see them in the community, I could see they were doing better. That is hard to ignore."

“While our current medical therapies are good, they do not always hit true with everyone.”

He observes that traditional practices help people reconnect with their identity, community and culture. “That, in turn, can give them more of an anchor and focus, so they can keep on track longer.”

VISION FOR A HEALING COMMUNITY

Williston wanted to learn more. With funding from Facility Engagement and the Rural and Remote Division of Family Practice, he connected with Martin and Seitcher to explore how they could work together to introduce health care colleagues to traditional practices, and over time, create a more connected healing community.

Chris Seitcher has worked in the helping field for many years, including as a care aid with Island Health, and for elders in the Tla-o-qui-aht Nation. He runs a weekly men’s group, which he describes as being a supportive, safe space for community members to share stories, history, traumas, and emotions. Traditional chanting and singing are also incorporated to help change the energy.

“This is how we deal with our trauma, our suffering, our pain,” he explains. “When we have safe space and support where we can share things that are happening inside—things we don’t usually talk about—then things start to slowly change.”

Williston feels that health care workers can also benefit from some of these approaches. “We get exposed to a lot of trauma at the hospital all day,” he says. “We all need to find healing for ourselves.”

EXPLORING THE OPPORTUNITY TOGETHER

A collaborative plan unfolded. Martin and Seitcher arranged to hold a traditional cultural ceremony  that was recorded on video. It incorporated a talking circle, breathing exercises, and drumming and singing led by Hayden Seitcher, also of the Tla-o-qui-aht First Nation.

Pools were set up at Načiks (Clayoquot Heritage Museum at Monks Point in Tofino) for the group to experience cold water cleansing.

 “Any time there was trauma in the community, or family, grief, or loss, we would bring members to the river or ocean to do a cleansing,” explains Martin. “Cold water rebalances us: it refocuses negative energy…to help clear the mind.”

The ceremony was an insightful learning experience for the guests. “It is quite different from our usual kind of medical work—a much slower pace,” says participant Dr. Pam Frazee. “A different part of your brain is working—your emotions are more present.”

STRENGTHENING CULTURAL CONNECTIONS

Over time, the aim of those involved is to introduce traditional healing practices more widely with health care professionals, ambulance crews, firefighters, the coast guard, and police officers—all of whom are exposed to emotional and physical trauma—and to create stronger cultural connections among patients, health care, and emergency professionals.

“These providers work in First Nations communities and may not have that connection yet,” says Williston, who sees benefits of making traditional, non-medical interventions more available to health professionals. He suggests that paramedics, for example, could introduce some of the techniques that help reduce a patient’s anxiety before getting to the hospital. 

Additionally, cultural workers could be integrated into the hospital to perform ceremonies for sick patients and those who are soon to be discharged. “That surrounding care might help [patients] stay better, longer,” says Williston. 

Seitcher also sees many benefits to blending in traditional practices. “Culture is always around us,” he says. “Culture means connection. We can bring our culture to the hospital and create a safe space to connect and work through some tough issues.”

Martin, reflecting on her first time working with the medical community, says she is pleased to see the openness to new ways and new learning.

It supports an aim of the First Nations Health Authority and BC’s health care system to have First Nations communities and members work in partnership with doctors and health care professionals to support people’s health, wellness and care. 

“We have a lot to offer,” she says. “We can help each other out – instead of living and working in isolation – and provide more services to many more people.”

Watch: Traditional Cleansing Ceremony>

This project was supported by Facility Engagement, a Specialist Services Committee (SSC) Initiative, and the Rural and Remote Division of Family Practice, an Initiative of the General Practice Services Committee (GPSC). The SSC and GPSC are Joint Collaborative Committees of the Government of BC and Doctors of BC.