pli project
TRANSCRIPT
Reflex EGFR/ALK Testing in Lung Cancer
PatientsClark McDonald, Pathology
Mathew Kang, Radiation OncologyLiChung Ku, Radiation Oncology
Tiffany Taylor, Radiation OncologySarah Dawson, Laboratory
Laura Duddy, Clinical Decision Support
Special thanks to: Sean Stack (Radiology), Kamran Firoozi (Pulmonology) and Adam Miller (IT)
AIM STATEMENT
• 100% of lung adenocarcinoma patients with known or clinically suspected stage IIIb and stage IV will have reflex EGFR/ALK testing sent at the time of pathologic diagnosis by January 15, 2015
Introduction
• Patients with stage IIIb or IV lung adenocarcinomas are eligible for novel treatment with EGFR tyrosine kinase inhibitors but only if the EGFR/ALK molecular status of the tumor is known
• New National Comprehensive Cancer Network Clinical Practice Guidelines recommend EGFR/ALK testing on all stage IIIb and IV lung adenocarcinomas
• Old practice was to wait for Oncologist to call and order EGFR/ALK testing which created delay of treatment planning up to 2-3 weeks after diagnosis
Results
• Average number of days from biopsy sign out to sent out for EGFR/ALK testing
Baseline Data
Old Process
Old Process Radiologist Pulmonologist
Transbronchial biopsy or lymph note
EBUS-FNA
Lung or Solid Organ biopsied
Pathology requisition filled out by Pulmonologist or
Pathologist without staging information
Send Sample to Pathology
Pathology does diagnostic review & creates report
Report goes to Oncologist, Oncologist sees patient and reviews staging information. If indicated, EGFR is
requested by Med/Onc and sent out by Pathology to OHSU
Time of Biopsy
Pathology requisition is completed in Epic without
staging information
Radiologist reviews any available imaging
Process Delay
Benefits of Change
• Having the EGFR/ALK status at the time of initial consultation with the treating Oncologist allows a treatment plan to be developed and initiated rather than having to order the EGFR/ALK testing and waiting for the results (7-10 days for testing)
• Reduces time to treatment• Reduce patient anxiety while waiting for
treatment plan• Compliance with the national treatment guideline
Test of Change #1
• Pathologists to reflexively send biopsy material for EGFR/ALK testing on cases with known stage IV lung adenocarcinoma- eg. Metastasis or positive pleural effusion- we know these are stage IV
Now what about the rest?
• The pathologists need to know the clinical staging at the time of tissue diagnosis to reflexively order EGFR/ALK testing on the lung biopsies
• Old standard work did not encourage clinical staging to be provided on the pathology requisitions
• Without this staging, appropriate reflex EGFR/ALK could not be accomplished
PROBLEM• Lung biopsies are performed by radiologists and
pulmonologists• Some cases (EBUS-FNA) have pathologists filling out the
pathology requisitions
Test of Change #2 Dr. Firoozi
• Dr. Kamron Firoozi agreed to begin staging his suspected lung cancer patients at the time of biopsy and provide the information on the pathology requisition
• 2/2 bronchoscopic lung biopsy cases were staged at the time of biopsy and documented on the pathology requisitions
Test of Change #3 Radiology
• Dr. Sean Stack agreed to communicate with all of the interventional radiologists that perform image guided lung biopsies to provide clinical staging of suspected lung cancer and include on the pathology requisition
• Staging tool was developed and posted at the work station as reminder for staging
Test of Change #4 Rest of Pulmonologists• Dr. Firoozi agreed to communicate with the
remaining pulmonologists to provide clinical staging of all suspected lung cancers on the pathology requisition at the time of biopsy
Test of Change #5 Pathologists-EBUS• Communicate with the pathologists that attend
Endobronchial Ultrasound Guided Fine Needle Aspiration Biopsies to query the pulmonologist about the clinical staging in suspected lung cancer cases at the time of the procedure and document on the pathology requisition
New Process
Radiologist Pulmonologist
Radiologist reviews any available imaging for clinical staging for
suspected lung cancers
Clinical evaluation of stage
Lung or solid organ biopsied
Transbronchial biopsy or lymph node EBUS-
FNA
If diagnosis is adenocarcinoma and the requisition clinical stage is 3b or 4, reflex EGFR/
ALK testing is sent same day to OHSU
Time of Biopsy
Pathology requisition is completed in Epic with staging
information
Sample sent to Pathology
Pathology does diagnositc review and creates report
Pathology requisition is completed by the Pulmonologist or Pathologist with
clinical staging
New Process
Balance Measures
• Avoid REFLEX testing on all lung adenocarcinomas regardless of stage
Lessons Learned
• Multiple locations and specialties are relied upon to provide appropriate staging made project challenging
• Education is not always the best way to initiate change
• Compliance diminished over time and needed strengthening
• Visual tool at the point of order was effective• Epic best practice alert would capture more staging
information • Current Epic transition will delay Epic best practice
tool
Next steps
• Build Epic best practice tool limited to practitioner and lung biopsy specific procedure
• Epic order build approved January 14, 2015, cannot begin work until March 10th, 2015 after go live date for Epic 2014
• Development and placement of staging visual aid tool pathologists and pulmonologists for bronchoscopy suites
• EGFR/ALK testing will be broadened to include stage 3A lung adenocarcinomas based on new clinical trial Salem Hospital is participating in