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D. Maziak



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    OA 11 - Reducing Burden: Patient-Centered Care (ID 682)

    • Event: WCLC 2017
    • Type: Oral
    • Track: Nursing/Palliative Care/Ethics
    • Presentations: 1
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      OA 11.06 - Lung Cancer Diagnosis and Assessment as a System Design Problem: Creating an Award Winning Program with Patient Advocates as Co-Designers (ID 10203)

      11:55 - 12:05  |  Author(s): D. Maziak

      • Abstract
      • Presentation
      • Slides

      Background:
      Lung cancer continues to have a high mortality in Canada, with many patients presenting with advanced stage disease. The Ottawa Hospital (TOH) used a learning health systems (LHS) approach to redesign regional diagnostic processes to reduce the overall time from presentation with a suspicious lung mass to diagnosis and treatment. As previously published by our group, an LHS approach is driven by feedback utilizing operational and clinical information to drive system optimization and innovation. TOH is the only provider of cancer services for a population of 1.3 million people in eastern Ontario and hence the need for an integrated patient journey from regional health facility to tertiary care centre was identified. Patient advocates have been incorporated as key members of the LHS from inception to implementation to post-implementation review.

      Method:
      The Ottawa Health Transformation model (OHTM) was developed as a means of operationalizing a LHS. A kick off meeting brought together cancer patients and their families to map out existing processes and document the patient experience. A regional lung cancer Community of Practice (CoP) of clinical and non-clinical stakeholders was then established to guide and approve the work of a core transformation team. The team had patient and family advocates as key members and they were tasked with identifying appropriate wait time targets and vetting proposed processes. A consensus approach was used to address process barriers, resistance to change and conflicting priorities in regular meetings spanning over two years. Commercially available software was used to track patient progress through the diagnostic process and to report real time metrics to the transformation team.

      Result:
      The project operationalized lung cancer diagnostic pathway guidance and optimized patient flow from referral to initiation of treatment. Twelve major processes in referral, review, diagnostics, assessment, triage and consult were redesigned. TOH now provides a diagnosis to 80% of referrals within the provincial target of 28 days and leads all other jurisdictions in Ontario in this metric by a wide margin. The median patient journey from referral to initial treatment decreased 48% from 92 to 47 days. In 2016 this work was recognized by a provincial cancer agency with a quality award.

      Conclusion:
      A learning health system has significantly reduced the time from referral with suspicion of lung cancer to diagnosis to treatment. Achievements require a multi-disciplinary approach with a regional perspective. Patient and family advocates have an important voice in re-designing health care systems.

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    P3.16 - Surgery (ID 732)

    • Event: WCLC 2017
    • Type: Poster Session with Presenters Present
    • Track: Surgery
    • Presentations: 1
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      P3.16-007 - Incidence and Outcomes of Positive Parenchymal Margins after Lung Resection – an Analysis of 1428 Cases (ID 7932)

      09:30 - 09:30  |  Author(s): D. Maziak

      • Abstract

      Background:
      Positive margins after pulmonary resection for cancer is an uncommon and challenging occurrence, with no consensus currently available to guide best adjuvant treatments. Our objective was to determine the rate of positive parenchymal margins after non-pneumonectomy lung resection with an assessment of adjuvant treatment strategies and outcomes.

      Method:
      Ethics board approval was obtained for a retrospective analysis of prospectively collected data on all lung resections performed at the Ottawa Hospital during the period 2008-2014. Individual patient records were then examined to confirm margin status by a review of the final pathology report. Survival and disease-free intervals were analysed using log-rank statistics, with significance set at 5%.

      Result:
      Over the study period, 1428 patients underwent non-pneumonectomy lung resection. A total of 29 cases (2%) were identified with a positive lung parenchymal margin (PPM). A matched subset (n=662) of the remaining 1379 patients with negative parenchymal (NPM) were used as control group. Median followup for NPM was 36.7 [0-105.6] and for PPM was 29.1 [0.5-71.5]. Overall, lobectomy was the most common pulmonary resection performed; wedge resections represented the majority of the PPM (n=16, 55%) followed by lobectomy (n=9; 31%) and segmental resections (n=1; 3%). Overall survival (Figure) and disease-free survival (not shown) were significantly (p<0.0001) worse for the PPM (Hazard ratio 5.59, 95%CI [2.05-15.6]) with a median survival of 31.5 months; the control group had not reached median survival. Stage I and II NSCLC were predominant in both groups; however postive margins were more often associated with metastatic disease (24% in PPM; 0.9% in NPM). The majority of PPM went on to receive additional treatment (n=17; 68%) consisting of adjuvant chemotherapy (n=7; 28%), radiotherapy (n=4; 16%), chemoradiotherapy (n=5; 20%) and re-resection in one case. The remaining patients were observed. Recurrence was found at the staple line in 7 cases (24%); the remainder recurred at distant sites.

      Conclusion:
      The overall rate of PPM in this study is low (2%) as compared to reported rates of 5-15%. Wedge resection for metastases was associated with most cases of PPM; most patients received additional treatment and had distant sites of recurrence. Overall survival was significantly worse for PPM despite adjuvant therapy, which likely reflects the underlying disease.