Lung cancer is the most frequently diagnosed cancer in New Brunswick (NB) men, and the second most common cancer diagnosed in NB women. It is also a lethal cancer, with an estimated 600 deaths from the disease provincially in 2017. Unfortunately, 44% of New Brunswickers are diagnosed with advanced (Stage IV) lung cancer which is associated with an approximately 1% chance of 5-year survival. Without treatment, the median survival rate for Stage IV lung cancer is 3.9 months; this short time span highlights the narrow window of opportunity to achieve a timely diagnosis and treatment initiation in this population. The purpose of this study was to describe the time through the lung cancer pathway for lung cancer patients seeking treatment at the Saint John Regional Hospital. We did a retrospective chart review to identify the dates of diagnostic and treatment points for lung cancer patients in 2018. We used these to quantify the time between: (1) initial chest x-ray suspicious for lung cancer to treatment initiation, (2) initial chest x-ray to CT, (3) CT to first diagnostic biopsy, (4) CT to PET, and (5) biopsy to treatment. The information is important in its own right as it identifies areas for improvement. It can also be used as baseline data in future studies to investigate the effects of interventions (e.g., centralized referral models) or other extraneous circumstances (e.g., COVID-19).

1. DISEASE PATHWAY MANAGEMENT IN LUNG CANCER
CARE: REDUCING WAIT TIME FOR DIAGNOSIS AND
TREATMENT
DR. AMY GROOM, DR. TONY REIMAN, SAMANTHA FOWLER, SARAH BRIDGES, LAUREN MCLAUGHLIN,
NICOLE BARRY &
LILLIAN MACNEILL

2. BACKGROUND
LUNG CANCER IS COMMON
• Lung cancer is the most
frequently diagnosed
cancer in NB men and the
second most commonly
diagnosed cancer among NB
women
LUNG CANCER IS LETHAL
• The most lethal cancer in
NB, accounting for 600
deaths in 2017

3. BACKGROUND
Lung Cancer Canada, September 29, 2021

4. BACKGROUND
• Without treatment, the median survival for Stage IV lung
cancer is 3.9 months
• This short time span highlights the narrow window of
opportunity that exists to achieve a timely diagnosis
and treatment initiation
• Achieving timely diagnosis for lung cancer is challenging
in our current system
• Several specialized investigations required to achieve
accurate diagnosis
• Several specialist consultations are needed to
determine optimal treatment
September 29, 2021

6. SJRH LUNG CANCER WORKING GROUP
• Formed at SJRH in November 2017 to address inefficiencies in lung
cancer care
• Joint initiative involving:
– Thoracic surgery
– Radiation oncology
– Medical oncology
– Respirology
– Radiology
– Primary care – family medicine, emergency medicine
• Inspired by The Ottawa Lung Cancer Model

7. THE OTTAWA MODEL
• Identified timely lung cancer as a SYSTEM DESIGN PROBLEM
• REDESIGNED regional diagnostic processes
• Included input from the following stakeholders:
• PATIENTS
• FAMILIES
• Clinicians (over 200 were engaged)
• Non-clinicians
September 29, 2021

8. THE OTTAWA MODEL - WHAT DID THEY
DO?
Centralized referrals
Involves:
1) Chest radiologist
2) Thoracic surgeon
3) Nurse navigator
 Diagnostic plan dictated
 Orders initiated
Includes:
1) PFTs, PET, MR brain,
blood work
2) Dedicated diagnostic
slots
3) Social work
4) Smoking cessation
5) Meeting with RN
RN triage
1) Consultation referrals
2) Biopsy referrals
Fung-Key-Fung et al., Current Oncology 2018

9.  Percentage of patients receiving some treatment increased from 78% in 2014
to 83% in 2016
Referral to treatment decreased from a median of 92
days pre-implementation to 47 days post-
implementation
Credit: Dr. Donna Maziak, TOH

10. WHAT IS OUR GOAL?
Interval from first specialist referral to
treatment initiation of 2 months or less!
Referral to diagnosis – 4 weeks
Diagnosis to treatment – 4 weeks

11. PARTICIPANTS
• Patients with a pathologically
confirmed diagnosis of primary
lung cancer who were cared for
at the SJRH in 2018
• Oncology consult list and list
of patients who received lung
cancer surgery
• N = 246 September 29,
2021
DETERMINING OUR STARTING
POINT

12. VARIABLES & OUTCOME MEASURES
The number of days between:
• XRAY and CT scan
• CT scan and PET scan
• CT scan and biopsy
September 29,
2021
• XRAY to treatment
• CT scan and treatment
• Biopsy and treatment
XRAY CT
Biopsy
PET
Treatment

13. X-RAY TO CT SCAN (N
= 143)
Mean (SD) 31.49 (48.14)
Median (days) 15.00
Percentiles
10th 0.00
20th 3.00
30th 6.00
40th 10.00
50th 15.00
60th 20.00
70th 30.00
80th 48.00
90th 89.50

14. Mean (SD) 43.56 (55.48)
Median (days) 28.00
Percentiles
10th 12.00
20th 16.80
30th 20.00
40th 25.60
50th 28.00
60th 33.00
70th 37.00
80th 48.00
90th 96.40
CT SCAN TO PET SCAN (N = 178)

15. Mean (SD) 44.59 (53.60)
Median 28.00
Percentiles
10th 4.00
20th 10.00
30th 14.00
40th 21.00
50th 28.00
60th 37.00
70th 46.20
80th 59.80
90th 108.60
CT SCAN TO BIOPSY (N = 225)

16. X-RAY TO TREATMENT (N = 124)
Mean (SD) 119.30
(113.98)
Median (days) 81.50
Percentiles
10th 22.00
20th 39.00
30th 50.50
40th 65.00
50th 81.50
60th 107.00
70th 130.50
80th 175.00
90th 269.50

17. CT TO TREATMENT (N = 198)
Mean (SD) 99.43 (92.90)
Median (days) 75.00
Percentiles
10th 18.00
20th 32.80
30th 44.80
40th 63.00
50th 75.00
60th 89.20
70th 115.30
80th 145.20
90th 199.40

18. BIOPSY TO TREATMENT (N = 190)
Mean (SD) 53.39
Median 38.00
Percentiles
10th 7.00
20th 15.00
30th 22.00
40th 30.40
50th 38.00
60th 47.00
70th 55.70
80th 71.00
90th 103.00

19. COMPARING HEALTH ZONES
September 29,
2021
T-Test Results Comparing Saint John and Fredericton on the Time Between Diagnostic and
Imaging Procedures
Saint John Fredericton t value
(p )
d
Mean SD Mean SD
XRAY to CT 19.33 25.82 43.36 47.33 3.18
(0.002)
0.70
CT to PET 33.76 31.91 35.20 29.62 0.28
(0.781)
0.05
CT to Biopsy 35.10 36.05 38.31 34.93 0.61
(0.544)
0.09
XRAY to Treatment 93.84 81.51 118.45 98.52 1.42
(0.160)
0.28
CT to Treatment 91.72 83.41 87.71 66.52 0.33
(0.742)
0.05
Biopsy to 43.51 33.47 48.29 45.27 0.72 0.13
Zone 1 (Moncton)
Zone 2 (Saint
John)
Zone 3
(Fredericton)
Zone 4
(Edmunston)
Zone 5
(Campbellton)

20. COMPARING TREATMENT MODALITIES
• None: 29 (12%)
• Surgery: 64 (26.6%)
• Systemic Therapy: 40 (16.6%)
• Radiation: 71 (29.5%)
• Chemoradiation: 37 (15.4%)
September 29,
2021
None
Surgery
Systemic
Therapy
Radiation
Chemoradiation

21. COMPARING TREATMENT MODALITIES
September 29,
2021
One-Way ANOVA Results Comparing Treatment Modalities on the Time Between Diagnostic and Imaging
Procedures
Chemoradiation Systemic
therapy
Radiation Surgery F value
(p)
η2
Mean SD Mean SD Mean SD Mean SD
XRAY to CT 18.38 21.67 24.14 31.55 29.16 42.84 37.59 40.59 1.33
(0.267)
0.0
3
CT to PET 35.36 30.42 39.90 44.22 34.28 31.77 44.12 37.42 0.78
(0.505)
0.0
2
CT to Biopsy 35.19 28.48 28.41 42.31 42.51 41.20 50.52 34.13 2.67
(0.049)
0.0
4
XRAY to Treatment 75.30 40.51 86.39 83.35 107.46 110.54 158.14 84.29 4.73
(0.004)
0.1
1
CT to Treatment 66.83 44.39 68.42 85.95 91.18 86.67 131.33 71.98 7.20 (<
0.001)
0.1
0
Biopsy to
Treatment
33.14 23.69 32.50 29.90 44.40 45.32 66.62 34.43 8.71 (<
0.001)
0.1
3
The good news – the sickest patients are moving through the system the
fastest
The bad news – the patients with the highest chance of long term cure are
waiting the longest

22. SO WHAT ARE WE DOING AT THE SJRH TO GET ON TRACK?
1. Centralized referral of new lung cancer consults
• Started September 3, 2019
• Daily physician duty roster to review new referrals and decide best first
specialist contact according to a standardized pathway
• COVID-19 has limited ability to collect meaningful post-implementation
data
2. Proposal put forward to obtain funding for a nurse navigator
• Critical component to move forward with formal diagnostic assessment
program
3. Research project underway to further examine chest x-ray to CT process
4. Research project underway to examine the impact of the COVID-19
pandemic September 29, 2021

23. IMPLICATIONS AND CONCLUSIONS
• Foundation for data driven quality initiatives to inform
improvements to the diagnostic and treatment pathway of
lung cancer patients
• Act as a baseline to study the effects of:
• Future quality improvement initiatives
• COVID-19
• Lung cancer screening (eventually)
September 29,
2021

24. THANK YOU
To all of our collaborators and to those listening in the audience today
Questions?
September 29, 2021