- 2021 Facility Engagement (FE) Evaluation Survey
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.”