Lung Cancer Care in Southeastern Ontario: An Improvement Journey
Written by: Dylan Zhao, MSc '25 (Candidate)
From understanding local and regional improvements to appreciating innovations in lung cancer biopsies, the TMED cohort had the pleasure of attending Dr. Geneviene Digby’s Grand Round where she spoke about the translational impact of quality improvement (QI) work in lung cancer care for Southeastern Ontarians.
Her enthusiasm and dedication to bridging gaps in lung cancer care were clear as she introduced the Lung Diagnostic Assessment Program (LDAP) – a rapid assessment clinic that diagnoses ~50% of lung cancer in Southeastern Ontario.1 Pioneered in 2016, this clinic was designed to (1) serve a predominately rural, elderly population with the 2nd highest incidence of lung cancer in Ontario and (2) streamline the timeframe between diagnosis and the first treatment. Following QI-based recommendations, local improvements to the LDAP included the transformation to a multidisciplinary clinic with a standardized triage pathway and early pain management through palliative care.
Notably, the ability for patients to meet with their respirologist, oncologist, thoracic surgeon, and other support staff in parallel reduced the timeframe between diagnosis and first treatment by an astounding 67%, from an average of 45 days to a mere 15. Moreover, the average duration between the 1st abnormal image and first treatment was also reduced by 58%, from 133 days to 77. Not only did patients revere in the unbelievably efficient nature of their care through the LDAP, but clinicians also reported that the LDAP system “strengthened relationships with their colleagues,” building “better teams” in the process as well.2 Echoed by Dr. Kain in the audience afterward, integrating early pain management by palliative care was further shown to improve survival outcomes by decreasing pain as a significant barrier to accessing treatment.3
With overwhelming evidence supporting the efficacy of the LDAP, Dr. Digby then spoke about regional improvements that sought to increase patient volume by designing new referral criteria with the help of a cardiothoracic radiologist. Not only did LDAP referrals significantly increase following this QI recommendation, the time between a thoracic computerized tomography (CT) and a LDAP referral/assessment significantly decreased as well. Despite these improvements, the fact that only ~50% of Southeastern lung cancer patients were managed via LDAP left Dr. Digby and her team in search of potential systemic factors that influenced LDAP utilization. With subsequent population-level analyses revealing physical distance to be the main deterrent for an LDAP referral,4 the LDAP outreach clinic at Lennox & Addington County General Hospital (LACGH) was developed to better serve patients located further West. Although this data is unpublished, Dr. Digby showcased that patients preferred the outreach clinic if it was closer to home, decreasing total travel by ~6000km and travel costs by ~$6000.
As a capstone to the improvement of lung cancer care in Southeastern Ontario, Dr. Digby highlighted three ongoing projects aimed at developing biomarker assays to further improve the timeliness of diagnoses, increase diagnostic options for patients unable to undergo a biopsy, and reduce resource utilization. Specifically, collaborations with the Feilotter, Mates, and Renwick labs aim to (1) develop a cell-free DNA assay to detect lung cancer driver mutations, (2) implement next-generation sequencing tools to improve timeliness of molecular biomarker profiling, and (3) identify micro-RNAs implicated in lung cancer for a molecular triaging tool that risk-stratifies neuroendocrine tumors.
However, it’s critical to recognize that the LDAP clinic is only one small piece of the puzzle when it comes to the multifaceted nature of addressing, preventing, and treating cancer. In our post-round discussion, Dr. Digby highlighted how we each carry the responsibility to advocate for more funding needed to spur and sustain innovative, paradigm-shifting cancer initiatives like the LDAP. In the myriad of ways this could be achieved, creating public momentum to lobby for grassroots funding through community seminars that highlight the benefits of LDAP is just an example. Perhaps the benefits of interdisciplinary, parallel-structured visits can be extended to breast, colorectal, and prostate cancer clinics, which collectively diagnosed 46% of all cancers in Canada in 2023.5 Outreach clinics similar to LACGH could be developed to better serve rural communities (Hastings, etc.) that still rely on Kingston Health Sciences Centre for their cancer care. Beyond cancer, however, such a care structure may even benefit the world of post-ICU care, where Dr. Boyd previously highlighted the current lack of post-ICU clinics and the various physical and mental hurdles patients experience throughout recovery.6
Overall, the journey of lung cancer care in Southeastern Ontario illustrates the eloquent cycle of translational QI work and is a true example of implementing change based on the needs of patients and the community.
(750 words before references)
1. Lofters, A.K., et al. Lung cancer inequalities in stage of diagnosis in Ontario, Canada. Current Oncology 28, 1946-1956 (2021).
2. Linford, G., et al. Patient and physician perceptions of lung cancer care in a multidisciplinary clinic model. Curr Oncol 27, e9-e19 (2020).
3. O'Neill, H., et al. Improving Access and Timeliness of Early Palliative Care Specialist Assessment for Patients With Advanced Lung Cancer in a Rapid Assessment Clinic. Journal of Palliative Medicine 26, 1365-1373 (2023).
4. AlGhamdi, S., et al. Characterizing Variability in Lung Cancer Outcomes and Influence of a Lung Diagnostic Assessment Program in Southeastern Ontario, Canada. Current Oncology 30, 4880-4896 (2023).
5. Brenner, D. Canadian Cancer Statistics. ed. Society, C.C. Government of Canada., (Avaliable at cancer.ca/Canadian-Cancer-Statistics-2023-EN) ISSN 0835-2976 (2023).
6. Stapleton, K., Jefkins, M., Grant, C. & Boyd, J.G. Post-intensive care unit clinics in Canada: a national survey. Canadian Journal of Anesthesia/Journal canadien d'anesthésie 67, 1658-1659 (2020).