Lung Cancer 2019 Summit


The Lung Cancer 2019 Summit was held Friday 22 February at RACV City Club, Melbourne. The summit was an opportunity to review data on patterns of care for lung cancer in Victoria, and if there has been a shift towards optimal care in the areas highlighted at the first summit in 2014. The summit showcased examples of clinician-led improvements and a facilitated discussion on where to focus future improvement efforts. For more information, please contact NEMICS on (03)9496 3322.

Summit working party

Summit highlights
Opening presentation by consumer Dr Lisa Briggs
Policy context by Acting Assistant Director of Cancer Strategy & Development Melissa Arduca
Summit data presented by Associate Professor Gavin Wright

Summit themes, learnings and advice, and local action
Data themes
Project learnings and advice
Consumer themes
Local action

Videos
Data Presentation
Opening Presentation
Policy Context Presentation

Related documents
Data Presentation
Summit Agenda
Summit Summary Report
Summit Evaluation

 

Summit highlights
 

Opening presentation: How does it feel to navigate the health care system in Victoria?

Dr Lisa Briggs is an osteopath and exercise physiologist. She is a passionate patient advocate who has been living with stage IV lung cancer for four and a half years, and offers these suggestions for improvement. Lisa opened the summit with a 13-minute video presentation, sharing cancer treatment plan experiences of Victorian lung cancer patients and carers.

'The work that each one of you do is so incredibly inspiring and important to us, and we know you’re often doing the best you can with what you know and the time that you have. But try to remember to just step back for a moment, pause, and ask yourself, "What’s missing for this patient in their care, and what are the little things I can do to help better support them?" I think this will create greater feelings of trust, satisfaction and support, which are invaluable for both parties... and minimises feelings of frustration, isolation and lack of self-worth. It doesn’t take much to ask a patient what their personal preferences and needs are throughout their care... keeping in mind that preferences and needs will change over time. This should be an ongoing question you ask your patient, not just a one-off.'

‘Get to know your patients. Not just what type of lung cancer they have or treatment they are on, but who they really are as a person and what they value in life.  When you truly know what’s important to someone, and you can reaffirm this with them... it it will help everything else fall into place, and help make the journey ahead a more satisfying one for everyone involved.'

Related documents
Opening presentation Lisa Briggs slides

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Policy context: Victorian cancer policy towards optimal care

Ms Melissa Arduca, Acting Assistant Director of Cancer Strategy & Development, Department of Health & Human Services, spoke on the policy context of the Lung Cancer 2019 Summit.  There is still work to be done to ensure equitable access and outcomes for cancer patients in regional and lower socio-economic areas, as well as Aboriginal and Torres Strait Islander (ATSI) communities, and to reduce variations in outcomes between tumour streams. The goal of this work is to give all patients timely access to the best care. Optimal Care Pathways for ATSI communities are now available.

Highlighting the Lung Cancer Framework , a national resource for health professionals and service providers to support local adoption of delivery of best practice, is in alignment with nationally-endorsed optimal care pathways is a reminder that Australia as a whole is engaged in a long-term and ongoing effort to shift to optimal cancer care.

The current iteration of the Victorian Cancer Plan (2016–2020) has five priority action areas: prevention, screening, early detection, treatment and wellbeing, and support and research. These areas are underpinned by principles in person-centred, prevention-focused and evidence-informed care, and sustainable systems and optimal care pathways.
 
Victorian Tumour Summits inform part of the work done to implement and redesign optimal care pathways. Redesign grants, to assist with implementing the lung optimal care pathway, were informed by the Lung Cancer 2014 Summit. One such program of work was the health pathways electronic referral system. A collaboration between Integrated Cancer Services and primary health networks, the program took information from the lung optimal care pathway and incorporated it into the health pathways website — an evidence-based tool that helps GPs assess, manage and refer patients into tertiary care. 

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Data presentation: Lung cancer care in Victoria

Associate Professor Gavin Wright presented on patterns of care for lung cancer in Victoria (2013–2016). This summit focused on facilitated small group work discussion of variations presented, in order to determine if variations are unwarranted and plan clinician-led local action for improvement.

Summit data showed there is an overall decline in lung cancer and mortality but an increase in female lung cancer. Five-year overall survival has improved to 18% (2015), with a higher survival rate in metro areas. Fifty percent of lung cancer diagnoses are still stage IV.  Overall tissue diagnosis has increased to 91% (2016), with a goal of continuing this upward trend. Documented MDM discussion of patients has an increased statewide average of 69% (2017), with a target of 80%. Documented supportive care screening has a low statewide average of 52% (2017).  Further data is available in the video below.

Timecode

Subject

Notes

   00:00    

Introduction    

As a repeat summit, the data presented can show where lung cancer care in Victoria has and has not improved. Data only shows variations — further local investigations of variations to determine if they are warranted or unwarranted is required.   

   02:28    

Data sources    

     

   04:04    

Data limitations    

Recommendation is for more quality indices, such as appropriate targeted immunotherapy with target tests.  

   05:42    

Incidence, demographics and survival    

Approximately fifty percent of all diagnosed patients have metastatic disease, regardless of region.  

   10:10    

Tissue diagnosis    

It is still difficult to safely use tissue diagnosis in patients aged 85 and above. This will be difficult to improve other than by advancing minimally invasive techniques. Below 75 years of age, the state average for tissue diagnosis is good. There has been improvement in tissue diagnosis rates in SMICS and GICS.  

   12:40    

Multidisciplinary team meetings    

MDMs are a feature of high level cancer care in Victoria. Randomly selected histories were audited for 2017. Documented MDMs in in GRICS, HRICS, LMICS and GICS were below the state average. WCMICS was below the target of 80%. Given the small sample size of the audit, further local investigation is required.Minimal retrospective MDM discussion is desired, and there should not be significant variation in the rates of retrospective MDM discussions across the state.   

   15:20    

Documented treatment plan to GPs    

Ninety percent of treatment plans are going to GPs — the aim should be 100%.   

   16:00    

Time from diagnosis to first treatment by campus    

Sixty percent are getting surgery within 14 days. There is a statistical trend demonstrating a slow improvement in timeliness. Hospitals use a 30-day rule for a Category 1 patient on a waiting list. There is no statewide imperative in practice to work to a 14-day rule.   

   17:40    

   Equity of access to surgery    

This data is for patients recorded as non-metastatic within one month before and four months after surgery. There is variation in access across the state. This could be a variation due to patients' staging diagnosis, but we cannot get this detail from the data we currently have.  

   18:57    

Survival for non-metastatic disease by region    

There is better survival for patients treated in a metropolitan region. It appears the less access patients have to surgery in a region, the lower the survival for non-metastatic patients. This could be an issue for local investigation.  

   19:40    

Survival for metastatic disease by region    

Survival for metastatic patients does not vary significantly across the state, although it could be worth investigating access to chemotherapy in GICS.  

   20:00    

Survival for non-metastatic surgical and non-surgical patients    

Survival for non-metastatic surgical patients was similar across the state, indicating if there is an issue, it may be with access to care, not quality of care.  

   21:05    

Flow of patients with non-metastatic disease    

     

   22:25    

Non-metastatic disease surgery types    

There is statistically significant higher volumes of sub-lobar surgery in regional centres than metropolitan centres. It may be worth considering if patients should receive surgery in metropolitan centres.   

   23:50    

Average annual lung surgery volume    

There has been a reduction in low-volume lung surgery, however, there is still a 'tail' in some regional and private hospitals that requires local investigation.  

   24:53    

   Radiotherapy utilisation    

HUMERICS has lower use of radiation. GICS and BRICS could investigate variation.  

   26:35    

Time from diagnosis to radical RT/CRT    

There are some campus outliers in time from diagnosis to radical RT/CRT — two regional and one metro.   

   27:10    

Chemotherapy utilisation    

GICS has a higher rate of small cell chemotherapy utilisation. HUMERICS has a data limitation.  

   28:04    

Palliative care for metastatic diagnosis    

State average for referral to palliative care is 35%. Do we need to 'aim higher'?  

   29:02    

Supportive care    

     

Related documents
Lung Cancer 2019 Summit Data Presentation slides

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Summit themes, learnings and advice, and local action
 

Data 

  • There is a true increase in diagnosis of lung cancer in Victorian women. These diagnoses are not related to smoking. Despite this increase there is a positive takeaway that survival rates for women are also increasing due to improvements in lung cancer treatment. It was noted that women who do smoke are more susceptible to the carcinogenic effects of cigarettes at lower pack years than men. 
  • Every patient is unique and has needs specific to their situation. There is value in the depth of information available from their individual experiences, as well as from available patient surveys. Quality improvement projects do not only have to improve outcomes—the time from GP referral to diagnosis/treatment planning is often the most difficult period for patients, and improvements to timeliness in care can also improve patient experience. 
  • Administrative data has been shown to have an accuracy rate of ~90% compared to clinical data on some metrics for colorectal cancer. Clinicians have the power to drive change at a local level now, and can use administrative data presented at summits to create better care for patients with cancer now, rather than waiting to act. 

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Project learnings and advice

Redesigning lung cancer care

  • Thinking through what is needed and how to get there can mean re-examining assumptions. For example, an MDM requires that all members be available at the same time but not necessarily in the same place. Virtual MDMs are effective at contributing to cancer care improvement where technology is adequate. For clinicians linking in to MDMs, clear imagery of radiology and pathology is required. Virtual MDMs can assist with increasing the frequency of MDMs, increasing the rate of patient presentation and reducing time from referral to treatment.
  • Gathering patient information for MDM discussion is still difficult. Health care providers may not have an easily accessible central database. Test results can come from outside institutions with their own data systems. This creates issues due to hospitals and radiology providers using in-house applications that make transferring and matching patient data difficult for the treating institution. Outsourced EBUS was noted as a cause of delay to patients.
  • The value of lung care co-ordinators has many precedents in lung cancer care and other tumour streams, yet funding is not easily available. There is considerable desire from both consumers and referring GPs to work with cancer care co-ordinators.

What contributed to redesign project success?

  • dedicated people working towards a common goal
  • optimism that improvement was coming and would be achieved
  • funding
  • a collaborative and collegiate workforce.

Quality improvement

  • Audits of practice prior to quality improvement implementation can demonstrate where and what is working well according to optimal care pathways as well as areas and processes for improvement. 
  • Consumer feedback remains difficult to obtain, with low percentages of responses, yet it is a vital component of quality improvement projects from the beginning. However, patient feedback after quality improvement project implementation has shown positive patient preference for MDM discussion and team work during treatment.
  • Stakeholder buy-in is essential from the beginning and consists of government, the DHHS, the institution in question and staff and consumers.
  • Quality improvement is a distinct science with tools, rules and definitions that can be engaged in project implementation.

What contributed to quality improvement project success? 

  • A full time lung care coordinator was a significant factor to improved care. 
  • Forming a steering committee at the beginning of a project created an avenue for non-MDM discussion, which allowed MDMs to function solely for their purpose.
  • Moving MDMs from monthly to weekly created time for the meeting to hold an education session once a month.
  • Real-time data analysis after initial quality improvement implementation allowed for reconfiguration of processes to achieve optimal results.

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Consumer 

Palliative care referral remains an issue with multiple considerations. Currently, many patients are discharged from a palliative care service after one month of no contact due to resource constraints. Clear guidelines on the right time to refer patients to palliative care do not yet exist. Patient preference may be to have initial contact, with follow up at the appropriate time if required. However, some patients may not wish to have a potentially confronting conversation at the time of diagnosis. There is some crossover with the theme of tailored patient communication and patient-centred care. Consumer preference is for clinicians to provide information on available support services. 

  • Patient experiences highlighted treating clinicians frequently assumed what logistical expenses, and diagnostic and treatment options a patient could and couldn’t afford. Australia-wide patient surveys have repeatedly demonstrated3 hospital parking prices are overlooked, leaving patients uninformed of opportunities for financial assistance. Patient preference may be for most-effective diagnostic testing rather than cost-effective options, and can have significant implications for patient outcome.
  • There is consumer desire for increased screening and testing after a cancer diagnosis to manage known cancer risks, i.e. proactive cancer care rather than reactive cancer care. 
  • Consumers, clinicians and GPs have all voiced the need for lung cancer care coordinators in order to give consumers and GPs a single point of contact, and clinicians support in the implementation and ongoing operation of improvement projects.

3Consumers Health Forum of Australia, 'Out of Pocket Pain: Research report', 2018, p.7. Available from Consumers Health Forum of Australia (accessed 31 May 2019).

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Small group work ideas for local clinician-led investigations and improvements

Overall ideas for improvement were:

  • To look at setting up prehabilitation clinics for pulmonary prehabilitation in patients with inoperable Stage III lung cancer. 
  • A same-day appointment model for patients, like some regional patients now use at rapid access clinics, could improve patient experience. Ultimately, a ‘one-stop shop’ for patients with urgent cancer needs is ideal.
  • Entry points into lung cancer care need to ensure an easy referral path for GPs and one point of contact for patients.One in four Victorian patients with lung cancer does not receive treatment. These patients need MDM discussion of no treatment. It is also important in a disease with poor outcomes to consider radical treatment where appropriate. 

Ideas for local improvement were:

  • WCMICS discussed the importance of communication between hospitals, patients and GPs, and the role of carers in patient diagnosis and treatment. They also noted the low use of supportive care screening in the region according to summit data—however, WCMICS uses an in-house supportive care tool equivalent.
  • NEMICS discussed variations from the data presented at the summit. Variations identified were the rate of retrospective MDM discussion, a higher rate of chemotherapy treatment for metastatic patients and a low uptake of supportive care screening. Other ideas for NEMICS were:
    • Northern Health did not have its own Lung MDM in 2017. Patients often had a retrospective discussion at Austin Health as a result. There will be a re-audit of 2018 data to see if there has been a change to the proportion of retrospective MDM presentation. 
    • Supportive care screening is mostly undertaken by day oncology and radiation oncology at Northern Health. There is currently no clearly identified time that is considered best to do screening and this is a barrier to a higher screening rate. Clinicians are also reluctant to screen patients due to the lack of resources available should a patient with needs be identified. 
    • A proper piece of work on patients who do not receive MDM presentation at all will be undertaken by Austin Health to identify who they are and the systemic causes for this. Strategies to improve the total presentation rate will be identified.
    • Mortality within 30 days of receiving chemotherapy and the proportion and patterns of patients receiving adjuvant therapy within NEMICS will be investigated. Chemotherapy treatment rate by hospital in NEMICS will be investigated for variation.
  • Hume Regional Integrated Cancer Services (HRICS) will draft a letter to the Victorian Department of Health and Human Services (DHHS) requesting they ask the DHHS (NSW) for missing NSW data on patients who receive partial treatment in HRICS, particularly data on surgical patients at Albury Health. A HRICS lung redesign project has resources for local alteration to be actioned. 

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Update 25/01/2019: Lung Foundation Australia

Lung Foundation Australia is currently campaigning to end stigma of lung cancer. Listen to one consumer's experience and message below. For more information visit  www.fairgoforlungcancer.org.au/ourcampaign/

Ken from opr Agency on Vimeo .

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Redesigning lung cancer care

The 2014 Victorian Lung Cancer Summit yielded improvement opportunities in lung cancer care as identified by the 60 multidisciplinary clinicians in attendance. Following the summit, the lung tumour stream was prioritised for the Optimal Care Implementation Program, a coordinated improvement program of work across eight Integrated Cancer Services and six Victorian Primary Health Networks.  In 2016, grants for Victorian public health services were made available to support improved timeliness of and access to lung cancer treatment.

The Victorian Lung Cancer Service Redesign grant assisted hospitals to develop systems and measures that target improvements in the timeliness of lung cancer care. Alfred Health, Bendigo Health, Eastern Health, Goulburn Valley Health and Albury Wodonga Health were successful in obtaining a redesign grant in 2016.

Austin Health, Barwon Health, Ballarat Health and Monash Health received additional Department of Health and Human Services funding and ICS support to participate in baseline and final data collection, as well as service redesign activities.

The DHHS has funded the Victorian Lung Cancer Registry to support a standard approach to data collection and evaluation from these sites.

Project implementation began in March 2017. Lung multidisciplinary teams had an opportunity to examine their processes of care, from receipt of referral to diagnosis to treatment, and to design solutions to compress timelines between these points. Some examples of solutions are:

  • Implementation of nurse-led triage models and multispecialty clinics
  • New electronic referral systems
  • Increased frequency of multidisciplinary meeting reviews
  • Better utilisation of multidisciplinary meetings to track availability of diagnostic results

Most projects are expected to embed their new practice into current standard operations at some point this year.

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About the 2014 summit

Professor Robert Thomas, Chief Cancer Advisor Department of Health, opened the event highlighting the importance of clinical networks to drive statewide improvements in cancer care and outcomes.  Professor David Ball, chair of the lung summit working party, presented available data about the current state of lung cancer care and outcomes in Victoria.  A summary of key measures was available to participants as a quick reference.

Watch the lung cancer summit data presentation

Lung cancer care in Victoria presentation highlights:
  • Significant variation in five year survival between regional and metropolitan residents with lung cancer
  • Difference in the likelihood of receiving a tissue diagnosis across different ICS
  • Some data suggests timeliness of diagnosis and treatment is an issue
  • Low volumes of major lung surgery in a number of Victorian health services
  • Sixty eight percent of lung cases discussed at lung multidisciplinary treatment planning meetings
  • Variation in rates of adjuvant chemo across ICS
  • Underutilisation of radiation therapy
  • Low and variable uptake on formalised supportive care screening


Lung 2019 Summit Working Party

 
  Andreas Baisch   
 
  Co-chair David Ball   
 
  Andrew Barling   
 
  Richard De Boer   
 
  David Deutscher   
 
  Wasek Faisal   
 
  Michael MacManus   
 
  Danielle Mazza   
 
  Paul Mitchell   
 
  Gary Richardson   
 
  Jeremy Ruben   
 
  Rob Stirling   
 
  Craig Underhill   
 
  Co-chair Gavin Wright   
 
  Cheng-Hon Yap   
 
  Jackie Yoong  
 


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Lung 2014 Summit Working Party 

 
    Prof David Ball (Chair)     
 
    A/Prof Paul Mitchell     
 
    Dr Craig Underhill     
 
    Dr Jeremy Ruben     
 
    Dr Rob Stirling     
 
    Dr Andreas Baisch     
 
    Dr Richard De Boer     
 
    Dr Gary Richardson     
 
    Mr Gavin Wright     
 
    Dr Michael MacManus     
 
    Dr Jackie Yoong     
 
    Mr Andrew Barling     
 
    Dr Danielle Mazza     
 
  
 
  

 

 

 

 


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