Predictive Molecular Markers in Lung Cancer – 80% Decrease in Diagnosis to Treatment Decision Times by Streamlining EGFR and ALK Testing Protocols
Milena Cankovic, Lisa Whiteley, Susan Michalowski, Chad H Stone, Richard J Zarbo, Dhananjay A Chitale. Henry Ford Hospital, Detroit, MI
Background: Lung cancer is one of the deadliest cancers and starting treatment soon after diagnosis can be critical to patient survival. Mutations in epidermal growth factor receptor (EGFR) and EML4/ALK are detected in 15% and 1% of patients with lung adenocarcinoma, respectively. Both mutations are now used as targets for new anti-cancer drugs. Molecular genotyping can immediately predict which patients are likely to respond as well as identify those who are likely to experience resistance.
Design: The aim was to perform trend analysis using a value stream map and determine turn around times (TATs) from patient's surgery/diagnosis to the time treatment decisions can be made (both EGFR and ALK results available). Study period lasted from March 1, 2011 to September 5, 2012, divided in 4 phases: Phase 1 (3/1/11 to 8/22/11) - no established pathway; lack of familiarity with process; lack of coordination; EGFR performed in AP Molecular Lab; ALK a send out test. Phase 2 (8/23/11 to 4/30/12) - ALK brought in house; Phase 3 (5/1/12 to 7/31/12) - increase system clinicians' awareness (consultations, tumor boards, internet resources); ALK becomes a reflex test when EGFR negative. Phase 4 (8/1/12 to 9/5/12) - test requesting process streamlined; specimen handoffs between AP Molecular Lab and Cytogenetics Lab redesigned.
Results: Diagnosis-to-treatment-decision turn around times (TATs): Phase 1=61 days (6 cases); Phase 2=35 days (25 cases); Phase 3=17 days (56 cases); Phase 4=12 days (24 cases)
-80% decrease in time from surgery/diagnosis to start of treatment (shortened from 61 days to 12 days).
-Patients with a deadly cancer are treated much more quickly - increase in patients' quality of life and possibly overall survival.
-43% decrease in handoffs (14 steps cut to 8 steps - $200/case x 150 cases/year = $30,000/year saved)
-Outsourced testing brought in house ($500/case x 130 EGFR negative cases/year = additional $65,000 saved).
Conclusions: Value stream maps helped us to redesign processes, lower costs, and improve TATs. Clinicians' close communication with pathology staff ensures that testing is ordered in a timely manner. Paths for specimen handoffs and result reporting are well defined. By systematically focusing on the entire testing process we were able to decrease diagnosis to treatment decision times for lung adenocarcinomas from 61 to 12 days, eliminating $95,000/year of unnecessary expenses. This project necessitated coordinated efforts of different individuals across the system separated by geography, specialty and leadership structure.
Category: Quality Assurance
Monday, March 4, 2013 2:45 PM
Proffered Papers: Section G, Monday Afternoon