Dr. Smith called us on a Tuesday afternoon. “I have a patient who has an abnormal mammogram showing a large mass. I’m suspecting cancer and am referring her to you for diagnosis and treatment. She’s very anxious. I hope you can help.”
Jame Abraham, MD, FACP
Brian J. Bolwell, MD, FACP
We were able to get Dr. Smith’s patient in the next day for appointments with our multidisciplinary team, which included an ultrasound-guided biopsy, and consultations with breast surgery, medical oncology, and radiation oncology—all in her first visit. By Friday, we confirmed her diagnosis, and the biopsy showed a HER2-positive and estrogen receptor/progesterone receptor–negative tumor. The patient’s tumor was clinically staged as IIIA, so staging scans and an echocardiogram were performed the following Monday and an appointment was scheduled on Tuesday to finalize decisions about neoadjuvant chemotherapy. The patient’s scans were negative for metastasis, and she was started on chemotherapy that Thursday.
In less than 2 days from the patient’s diagnosis of breast cancer, she was seen by four doctors at the Cleveland Clinic Cancer Center and their teams in a multidisciplinary clinic, had a biopsy, underwent scans, and a received a definite treatment plan. She started chemotherapy less than 1 week after confirmation of the diagnosis. We refer to this time period from diagnosis of cancer to initial treatment as “time to treatment.” This was an ideal scenario for this patient, but that’s not always the case.
The national average for time to treat at large academic medical centers is approximately 6 weeks. Several studies, including our own,1 have shown that this delay in time to treatment is potentially detrimental to survival. In 2014, our average time to treat at Cleveland Clinic was similar to the national average. We had work to do. So, we asked the question, if we can shorten time to treatment for some patients, why can’t we do it for every patient?
“The national average for time to treat at large academic medical centers is approximately 6 weeks. This delay in time to treatment is potentially detrimental to survival.”— Jame Abraham, MD, FACP, and Brian J. Bolwell, MD, FACP
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Priority Plan of Action
Like Many comprehensive cancer centers, at Cleveland Clinic it is a priority to get patients in quickly for an initial consultation. Our average time to see a patient with a new diagnosis of cancer is less than 7 days. In many cases, we are able to get these new patients in just days later to begin treatment as well. How can we make this the standard for every patient? Over the past 3 years, we have experimented with this idea and reduced the average time to treatment by 33%, with the largest cancer programs (breast, colorectal, and lung) showing the greatest improvement in time to treatment.
To make this happen, we started at the top. Buy-in from leadership across all specialties was important, as it set the tone for the entire enterprise. As cancer program leaders and teams intensely focused on improving time to treatment, we examined hundreds of operational opportunities across all disciplines and worked together to create efficiencies, from coordinating clinic visits for patients to aligning OR times for breast surgeons and plastic surgeons. As the results of our improvements became clear, our caregivers started to understand the driving force. It wasn’t about the data; it was about improving care for our patients.
Cultural Shift and a New Mindset
Why is this so important? When patients are diagnosed with cancer, waiting for answers is one of the most stressful experiences. We need to get patients into our multidisciplinary clinics and give them a disease management plan as soon as possible. Creating well-functioning multidisciplinary teams, with patients at the center, is critical.
In the end, the cornerstone of reducing time to treatment at Cleveland Clinic was a shift in culture and a new mindset. Key takeaways from this initiative, as outlined in NEJM Catalyst,2 follow:
- Create a “team of teams.” Creating multidisciplinary teams organized by sites of disease is critical to effect change, but it is equally important to share data, successes, failures, and best practices among disease groups for sustained improvement. Creating teams and supporting these teams with data infrastructure, and regular meetings and huddles, as well as resources including program managers and patient navigators is vital.
- There is no “one thing” to fix. Delays in time to treatment are a result of multiple, seemingly small, process issues that add up to several days’ worth of lost time. Continuous improvement processes and value-stream mapping can help identify inefficiencies. The goal should be to map across the patient’s entry into the health-care system and not simply focus on one or two steps.
- Account for patient preferences. An unexpected finding was that some patients chose to delay treatment for varying reasons, including preference for a specific physician, work-related issues, or family commitments. In setting realistic goals for reductions in time to treatment, these preferences need to be anticipated.
- Change will occur. Our work has led to a sustained reduction of 13 days in the median time to treatment. We have also cut the number of patients experiencing delays of over 45 days in half, from 30% to 14%.
“Our motto became ‘treat our patients as we would our family.’ Wouldn’t you want your family member to be treated as soon as possible?”— Jame Abraham, MD, FACP, and Brian J. Bolwell, MD, FACP
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Ultimately, when time to treatment was outlined as a priority, a noticeable change happened. The whole team—schedulers, nurses, care coordinators, doctors, operating room staff, infusion team members, and financial navigators—made time to treatment a priority. Our motto became “treat our patients as we would our family.” Time to treatment can affect survival. Wouldn’t you want your family member to be treated as soon as possible?
Dr. Abraham is Chairman of the Department of Hematology & Medical Oncology in the Taussig Cancer Institute at Cleveland Clinic and Professor of Medicine at the Cleveland Clinic Lerner College of Medicine. Dr. Bolwell is Chairman of the Taussig Cancer Institute at Cleveland Clinic and Professor of Medicine at the Cleveland Clinic Lerner College of Medicine. Cleveland Clinic is a top 10 cancer hospital according to U.S. News & World Report.
Disclaimer: This commentary represents the views of the author and may not necessarily reflect the views of ASCO or The ASCO Post.
DISCLOSURE: Drs. Abraham and Bowell reported no conflicts of interest.
REFERENCES
1. Khorana AA, Tullio K, Elson P, et al: Time to initial cancer treatment in the United States and association with survival over time: An observational study. PLOS One 14:e0215108, 2019.
2. Khorana AA, Bolwell BJ: Reducing time-to-treatment for newly diagnosed cancer patients. NEJM Catalyst, February 14, 2019. Available at https://catalyst.nejm.org/time-to-treatment-cancer-patients/. Accessed November 21, 2019.
