Every October, we’re reminded that it is breast cancer awareness month— an annual, worldwide campaign aimed at promoting regular screening and early detection of breast cancer. It’s an important reminder for women to listen to their bodies, perform self-checks and maintain regular mammograms. When breast cancer is caught early, chances of survival for localized cancer that hasn't spread is 90 percent, according to the American Cancer Society.
There are more than 260,000 women in the U.S. diagnosed with breast cancer each year and they all begin the journey of screening, diagnosis and finally treatment.
In the U.S., it can take an average of 26 days between the time a woman has an abnormal screening mammogram and receives a biopsy; 31.6 days for the first surgeon visit; and 52.6 days for breast surgery, with far higher delays for women of color.1,2,3 This, in turn, leads to significant anxiety and stress for women and their families. How do we close this gap and provide a coordinated patient journey in one location from the initial appointment through diagnosis and treatment plan, with one team?
Answering the Challenge
The answer came in two parts. The first part came from work that GE Healthcare had been engaged in with the Breast Cancer Department at Gustave Roussy in Paris, where Dr. Suzette Delaloge invented the concept of rapid diagnosis in the One-Stop Clinic (OSC). The second part came in 2018 when GE Healthcare approached Premier’s PINC AI Applied Sciences (PAS) team asking the question, “How can we partner to build a OSC in the U.S.?”
The team couldn’t adopt the full French model utilized at the Gustave Roussy Cancer Center because fine needle aspiration (FNA) is not a standard of practice in the U.S. National Comprehensive Cancer Network (NCCN) guidelines. This meant they would need to adapt and redesign the model for it to be successful in the U.S.
The PAS team started with a rapid evidence review, which included a comprehensive evaluation of expedited diagnoses for patients with breast cancer in the U.S. Utilizing PINC AI healthcare data, they were able to verify that women can potentially wait as long as 21 days to receive a diagnosis from a diagnostic mammography. This is 21 days in addition to the time the woman waited prior to scheduling, completing a mammography screening, scheduling and completing a diagnostic mammography, and finally waiting for results.
Adapting the Model
To adapt the model, PAS needed a partner. PAS identified St. Luke's University Health Network (SLUHN) as the initial pilot location to implement this One-Stop Clinic model based on their commitment to education, existing regional breast center infrastructure, better-than-average results, reduced wait times and strong clinical and operational support from Dr. Joseph Russo, Dr. Karl Yaeger and Michele Brands.
The PAS team confirmed through robust data that the delay in breast cancer diagnoses existed and then, together with GE Healthcare and SLUHN, they defined how they would move forward and create clinical change. They started with understanding the reasons for delays in turnaround time (TAT) and response rates, and to find out where changes could make the most impact.
PAS worked with SLUHN to support GE Healthcare to redesign practice workflow based on data and feedback from SLUHN executives, clinical leaders, administrative leaders, schedulers, care coordinators, ultrasound techs, lab services and community members.
They mapped the current process and identified opportunities for improvement. They recognized that scheduling, lab courier services and staff commitment would be key cornerstones in creating and embracing this new model of care.
The team considered everything from clinical workflows, patient engagement strategies, IT supports, job descriptions and staff skills to the placement and location of equipment, the patient’s overall experience and how to replicate changes from the main regional hub to other regional centers.
Closing Gaps while Staying Patient Centric
With early detection, still one of the most important processes that can impact short- and long-term outcomes, closing the gaps in breast cancer diagnosis were obvious. PAS used the 3Is Framework, a tool developed by the PAS team that helps design rapid cycle changes to close gaps in care.
The Framework helped to organize SLUHN’s approach for applying care pathways and focusing on process change to yield improved patient outcomes. They began by identifying the right patient population and the people in the health system who need to understand why they should be focused on certain types of patient outreach in a timely manner. Then, they helped the SLUHN team understand how to intervene during all aspects of the new care pathway. Lastly, the team adopted new strategies to interact with patients in an empathetic manner while enhancing efficiency in the process.
This helped the team become more purposeful about providing the right care at the right time. They considered everything from how they would message and schedule to how they would share results and follow up with OSC patients. They knew they needed to engage the patients and give them more control over the process to help reduce their anxiety.
“Our number one guiding light for this program is to reduce the time patients wait for results and to reduce their anxiety around the entire process, said Michele Brands Network Director of Women's Imaging at SLUHN. “Ideally, my dream goal is to have no woman wait for results over a weekend, when you can really allow yourself to get anxious.”
Implementing the OSC
SLUHN has constantly strived to reduce TAT for mammography screening to pathology for its patients. They initially started with a hub-and-spoke model that allowed for central control (hub) of policies and procedures while creating a similar experience at other regional centers (spoke). If any woman seen in its 16 screening clinics needed a second-level screening or diagnostic workup, she went to a consolidated center where clinicians, technologists and nurses worked together to offer rapid turnaround to diagnosis, including same-day biopsy, and a treatment plan to the highest-risk patients.
During the pandemic, many patients put off routine testing, but early detection is still the best detection. SLUHN recommends annual screening and hopes through their OSC approach to lessen anxiety around the whole process. They took on this initiative during the COVID-19 pandemic and operated the first-in-the-nation OSC one day a week, providing a way to triage and move the critical patients through the system swiftly.
Their patients initially meet with a breast nurse navigator that guides them through the entire process from initial concern through completion of all imaging and biopsy.
Patients are prepared for appointments in advance, greeted by their care team, and presented with the appointment plan. The plan typically includes a diagnostic mammogram as well as a diagnostic ultrasound and, if needed, a biopsy. If a biopsy is performed, pathology results are shared with the patient within 48 hours. In cases where further intervention is warranted, the team assists the patient in securing an appointment with a breast surgeon.
“Providing individualized breast care to patients ensures that no matter what a patient’s results are, the dedicated team at St. Luke’s will expertly and compassionately walk with our patients through the process and assist them in getting the results they need,” said Brands.
The team implemented the OSC and had a general assumption that at least one third of their patients would end up with a benign finding and two thirds would end up with a malignant finding. However, following the traditional diagnostic work-up, the team saw more of a 50/50 split with patients. Forty-eight percent were benign, and 52 percent were malignant. The team was perplexed and knew they had to try something different.
Customizing the OSC
SLUHN took things a step further and customized the One-Stop Clinic model to include GE Healthcare’s SenoBright contrast-enhanced mammography - an imaging technique that uses iodinated intravenous (IV) contrast in combination with a digital mammogram. The contrast helps illuminate cancer growth causing it to stand out against background tissue.
“It’s highly accurate, and it helps us to see very early on in the diagnostic process whether or not a patient has cancer, or if further testing is needed,” said Dr. Karl Yaeger, radiologist and Section Chief of Women’s Imaging at St. Luke’s University Health Network.
They got exactly what they expected. By adding contrast-enhanced mammography to the program, “There have been times when we have been able to determine immediately that there is no problem,” said Brands. “We were able to let the patient know, ‘You are good!’”
In addition to being the first in the region to adopt contrast-enhanced mammography, SLUHN also employs GE Healthcare’s Pristina Dueta device. Many women delay mammograms because they don’t like the pain associated with compression of their breasts. The Pristina Dueta is the first wireless remote-control device that gives the patient the opportunity to play an active role in determining their level of breast compression with the help of a hand-held remote and a technologist’s guidance.
“It’s been wonderful,” said Brands. “We’ve found that some patients would opt for more compression since it offers them some level of control.” With more compression, image quality is improved for the radiologist and dose is reduced for the patient.
The Future of the One-Stop Clinics for Breast
By the time the team had seen its 100th patient since the launch of the OCS, SLUHN was diagnosing 30 percent of patients within 36 hours and 100 percent were diagnosed within 48 hours.
As of September 2022, they continue to maintain a 48 hour or less diagnosis time with close to 300 patients benefiting from the OSC. This rapid diagnostic approach has lessened the average wait time for a diagnosis from a national average of 26 days to just approximately 48 hours or less.
Individualized care continues to be at the core of oncology, but early detection and rapid diagnosis is about managing populations. It’s about proactive, preventative interventions that create an opportunity for the patient to work in partnership with their provider on a long-term plan for well-being. SLUHN continues to see support from throughout their organization and across their oncology service line. This One-Stop Clinic U.S. model provides a comprehensive approach to breast cancer screening and diagnosis that creates a One-Stop experience for the patient’s entire care plan through to survivorship.
The PAS, GE Healthcare and SLUHN teams continue to look for ways to use implementation science techniques and process redesign workflows to test solutions, research and provide real-world data to help streamline this OSC effort.
In addition, the PAS team is helping develop, teach, test and research care delivery practices through real-world interventions and prospective research and clinical trials to help improve patient outcomes.
