Purpose: To streamline the diagnostic evaluation of lung cancer.
Background: Lung cancer remains the leading cause of cancer death in the United States. Although more than half of cases present with metastatic disease, prognosis is still poor for earlier stage tumors. While most guidelines recommend a multidisciplinary approach to the diagnostic evaluation, recommendations and data for the timeliness of the process are lacking. Highly specialized diagnostic imaging tests and procedures are required to make the diagnosis, which can result in delays in the initiation of treatment. In the metastatic setting, the emergence of immunotherapies and targeted therapies requires additional tissue testing for predictive biomarkers and molecular alterations, increasing the importance of adequate biopsy specimens and tissue preservation. We reviewed the diagnostic evaluation process at our hospital in order to formulate a Plan, Do, Study, Act (PDSA) quality improvement project aimed at improving the efficiency of our process.
Methods: We performed a retrospective analysis of all cases of non-small cell lung cancer (NSCLC) diagnosed at the Birmingham VA Medical Center (BVAMC) from 2015-2017. Cases for which the entire evaluation was not performed at BVAMC were excluded. Outcomes of interest were time from imaging suggestive of lung cancer (T1) to pathologic diagnosis (T2) and to date of first treatment (T3).
Results: At the time of data submission, 171 cases had been analyzed. Mean time from suspicious imaging to pathologic diagnosis (T1-T2) was 59.5 days. Mean time from pathologic diagnosis to treatment initiation (T2-T3) was 69.4 days. Mean time spent in the diagnostic evaluation
(T1-T3) was 128.9 days. The data will be stratified further to identify opportunities for improvement. We have since instituted a multidisciplinary lung tumor board and are using CPRS-based tracking software to prospectively analyze cases and improve the efficiency of our process.
Conclusions: The diagnostic evaluation of lung cancer is a multi-step process, and unique factors contribute to delays at each step. It is essential to have a multidisciplinary team to help identify, predict and alleviate these barriers. Analysis of other variables including age, performance status, pulmonary function tests (PFTs), smoking, number of biopsies performed and utilization of positive emission tomography (PET) scans is underway.
