Quality Improvement in Stages III & IV Non-Small Cell Lung Cancer Care

Care optimization is everything in today’s rapidly changing healthcare landscape. While cancer programs and practices are seeking new ways to step up care delivery and in recognition of this demand, the Association of Community Cancer Centers (ACCC) launched a nationwide quality improvement (QI) initiative to develop and implement plans to support the optimization of care for patients diagnosed with Stages III and IV non-small cell lung cancer (NSCLC). Six cancer programs varying in location and size across the United States were selected to participate in this initiative over a six-month period, including:

• FirstHealth of the Carolinas, Moore Regional Hospital (Pinehurst, N.C.)
• O’Neal Comprehensive Cancer Center at the University of Alabama (Birmingham, Ala.)
• Saint Francis Cancer Center (Tulsa, Okla.)
• Southern Ohio Medical Center, Southern Ohio Medical Center Cancer Center (Portsmouth, Ohio)
•  Sutter Cancer Center (Sacramento, Calif.)
• Tennessee Oncology (Nashville, Tenn.).

During a recent LinkedIn Live event hosted by ACCC, moderators, including Wendi Waugh, BS, RT(R)(T), CMD, CTR, administrative director of Southern Ohio Medical Center Cancer Care Services and Ambulatory Infusion at Southern Ohio Medical Center Cancer Center, and Joseph Kim, MD, MPH, MBA, ACCC consultant and president at Xaf Solutions, highlighted lessons learned from this initiative and the effects this project had Southern Ohio Medical Center Cancer Center. 

“The goal of this multiphase initiative was to optimize care for patients with advanced non-small cell lung cancer,” Dr. Kim said. “This included improving the coordination as well as communication within the multidisciplinary cancer care team and refining the processes of care along the journey.” 

Biomarker Testing

Seeking to improve biomarker testing in patients with NSCLC, enhanced integration of clinicians and pathologists was identified as a major vehicle for achieving this goal. “Biomarker testing is new for us all,” Waugh said. “In the last five years, we have all had to try to figure out how we are going to get these reports in front of our physicians so that we can make a real difference in the patient’s care.” 

At Southern Ohio Medical Center Cancer Center, physicians were ordering biomarker tests but were not always able to get patients’ results on time. Upon enrollment in ACCC’s QI initiative, the cancer center conducted an analysis of how much time elapsed between the process of ordering biomarker tests to the patient receiving their results—as well as a review of any applicable changes in the patient’s treatment plan based on those results. “What we found is that we had a lot of work to do,” Waugh said. “The way that we fixed it was to assign responsibility to our lung health navigator.”

Waugh describes the process of hiring a lung health navigator as difficult. Because the cancer center did not have lung health navigators or a nodule program in place already, staff began with their lung cancer screening program. “We got our screening up and running first, and I made the case,” Waugh said. Southern Ohio Medical Center Cancer Center sought the aid of the GO2 Foundation (which has since merged with LUNGevity), who provided a complete business plan regarding how to make the case for hiring a lung health navigator, outlining the benefits of having these dedicated navigators, including downstream revenue, patient satisfaction, and improved turnaround times from diagnosis to treatment.

Next came the establishment of an electronic portal to transmit biomarker test results to providers via the lung health navigators. “We made sure that the lung health navigator and a backup got an email saying that there was a result available,” Waugh shared. Once results are available, lung health navigators are responsible for downloading the report and reviewing it before sending it to the ordering physician. The navigator would also check for the patient’s next appointment and check if the appointment could be moved up,” Waugh said. “We were focused on what we could do to reduce the days in not only just the order, [but also considering] the order result, what does the result mean, and the patient appointment,” Waugh explained.

Once this navigation was established, the cancer center identified an external testing company that would handle their biomarker tests. “We are a rural community cancer center, so we were not doing the testing ourselves,” Waugh said. The team conducted these tests using tissue samples, with Waugh describing it as the gold standard. “We were only reflexing to blood if there was not significant tissue to get the result,” she said. This decision reduced variability in the method and type of tests that are ordered (e.g., tissue testing, use of next-generation sequencing, or liquid biopsy).

A Constant Evolution

Waugh wagers that with new information, the protocols around biomarker testing are bound to evolve. “I think we are going to have to evaluate this every one to two years, and maybe sooner, depending on how quickly this landscape continues to change,” Waugh said. Dr. Kim echoed this sentiment, while also highlighting the difficulties some clinicians may face when trying to keep up with the science. “When it comes to biomarker testing, there are so many things happening in the landscape,” he said. “While we are all expected to keep up with the latest science and guidelines, busy clinical settings can make that challenging.” 

Improvements with Identifying and Managing IrAEs

The conversation around quality improvement also included discussion on the identification and management of immune-related adverse events (irAEs) for patients with cancer receiving immunotherapy. Waugh described an innovation designed to keep these patients out of the emergency department (ED). Working with EDs in the area and the information technology staff at her cancer center, Waugh was able to gather information about which patients with lung cancer were presenting to the ED, including how often they were presenting. “This gave me a springboard to start looking at who the patients were and why they were going to the ED. And what could we do about it,” Waugh explained.  

In a bid to reduce and prevent some of those admissions, Southern Ohio Medical Center Cancer Center launched an initiative that required advanced practice providers (APPs) to conduct new medication teaching sessions with every new patient diagnosed with lung cancer. “We really wanted them [APPs] to talk to those patients about their potential for visiting the emergency department,” Waugh explained. “We wanted our APPs to lay down a foundation that said, ‘I’m here for you. We want to do acute care for you. We want you to call us first, and we will triage whether or not you need to go to the emergency room.’” 

Patients are also given a card to carry on their person that they can share with their ED provider to inform them that the patient is undergoing active anti-cancer treatment. This card also lists the medication(s) patients are receiving. “We want to avoid unnecessary CT [computed tomography] scans and work that the patient might do,” Waugh said. “We also spoke with the ED providers and asked them to call us if anything happened.” 

Learn More 

To discover more about how ACCC facilitated a full range of quality improvements through this initiative, watch the recording of the LinkedIn Live event: “Fostering Excellence in Care and Outcomes in Stage III IV NSCLC.” 

This initiative is part of the Fostering Excellence in Care and Outcomes in Patients with Stage III and IV NSCLC initiative, and it is made possible in partnership with the American College of Chest Physicians, International Association for the Study of Lung Cancer, and LUNGevity, as well as support from AstraZeneca.