Diagnostic Assessment Programs › mon › 24003 › 299728.pdf · 2020-02-07 · Based Care (PEBC)...

Diagnostic Assessment Programs

An Environmental Scan

December, 2009

Cancer Care Ontario Division of Regional Programs & Planning

DAP Environmental Scan - 2 - December 2009

Executive Summary

Cancer Care Ontario is presently working towards implementation of Diagnostic Assessment

Programs (DAPs) through the province of Ontario. DAPs provide a single point of access by

concentrating and coordinating diagnostic processes thereby improving the quality of care and the

patient experience.

An environmental scan was conducted by searching the literature and polling the regions across

Ontario for activity in diagnostic assessment. This information formed the basis for a brief

history of DAPs as well as a snapshot of programs currently in existence.

Programs in cancer-focused diagnostic assessment first emerged in the area of breast cancer,

where early screening programs have evolved into more comprehensive assessment initiatives. In

prostate cancer, screening and assessment programs emerged in response to the development of

the Prostate-Specific Antigen (PSA) test but then waned as the effectiveness of the test as a

screening modality was called into question.

In the United Kingdom, diagnostic assessment programs have become prevalent as the National

Health Service has pushed forward its wait times and process improvement initiatives. Rapid-

access diagnostic clinics have been developed in breast, colorectal, lung and prostate cancer.

In Ontario, the Breast Assessment Initiative was introduced in 2004 by the Ontario Breast

Screening Program and currently includes 30 Breast Assessment Affiliates across Ontario,

including one rapid diagnostic clinic where patients can be diagnosed within one day. DAPs in

Ontario have been guided by organizational standards developed by the Program in Evidence

Based Care (PEBC) in 2007. In this province, DAPs have emerged primarily in lung cancer, with

some activity in colorectal and prostate cancer as well. Toronto East General Hospital’s ‘Time to

Treat’ program was an early DAP for lung cancer that has seen sustained reductions in diagnostic

wait times since 2005. Currently, there are 8 Lung DAP programs in existence; 2 DAPs in

colorectal cancer and 3 DAPS in prostate cancer. Additional programs in each of these areas are

under development.

Outside of Ontario, British Columbia, Saskatchewan and Quebec have developed DAPs in breast

cancer but there is very little evidence of DAP implementation beyond this clinical area. In the

United States and Australia, we found only a few examples of DAPs, mostly in the area of lung

cancer and mostly concentrated in large academic teaching centres.


1. Diagnostic Assessment in Cancer

The interval from suspicion to diagnosis is a complex and important phase of cancer care. It is

characterized by the need for a multitude of tests and consultations, and often provokes

considerable anxiety among patients. Furthermore, diagnosis delays may in some cases result in

a greater likelihood of disease progression, leading to poorer patient outcomes.

Diagnostic assessment programs (DAPs) provide a single point of access by concentrating and

coordinating diagnostic processes. The objective of these programs is to improve the quality of

care through the coordination of diagnostic tests and appointments, engagement of multi-

disciplinary expertise, improved availability of resources for both patients and referring

physicians, and psychosocial support. These programs seek to improve the patient experience

through shorter wait times and improved coordination of care.

2. Purpose of the Environmental Scan

Cancer Care Ontario is working towards implementation of DAPs throughout the province of

Ontario. To improve our understanding, we undertook an environmental scan to look at the

origins of diagnostic assessment and the extent to which DAPs have been implemented around

the globe. The scope of this environmental scan included programs that could be considered

DAPs, whether or not they carry that label, in all forms of cancer throughout the world.

3. Approach and Methodology of the Scan

An initial inventory of DAPs was created by polling the Vice Presidents of each of the Regional

Cancer Programs throughout Ontario. This process provided a snapshot of programs currently in

existence or in development, as well as the disease sites they are focused on.

The scan used a variety of additional sources including program descriptions, published reports

and articles from scientific publications. Where required, key individuals were contacted to

provide information that was otherwise unavailable.


The following set of criteria was used to distinguish DAPs from traditional screening programs or

other diagnostic clinics. They are adapted from the organizational standards developed in 2007

by CCO’s Program in Evidence-Based Care1.

• Clinical units that provide multiple diagnostic services in one place and, where clinically

appropriate, within one patient visit

• Virtual programs that provide central coordination of diagnostic services spread out

geographically (where geographic dispersion does not permit a single-location DAP)

• Central, coordinated referral process from various points of entry, with the availability

of rapid access and priority booking

• Availability of a range of clinical diagnostic and supportive care services, appropriate

for the disease site, or linkage to necessary services.

4. What We Found

a. A Brief History of Diagnostic Assessment in the Canadian Context

Diagnostic assessment as a focus in cancer care first emerged in the area of breast cancer, where

population-based screening programs have been in place in Canada since the early 1990’s.

Following a 1997 national workshop on organized breast cancer screening, the Working Group

on the Integration of Screening and Diagnosis was convened to assess the patterns and timeliness

of diagnosis after an abnormal breast screening result. The findings from this work revealed wide

variation in the diagnostic interval (time from the abnormal screen to resolutiona) across the

country. Based on these findings and a review of the evidence around the physical and

psychosocial implications of diagnostic delay, the Working Group proposed a set of timeliness

targets2 that were adopted by the Canadian Breast Cancer Screening Initiative in 1999. Since that

time, initiatives have been undertaken across the country to reduce the time to diagnosis.

Through their provincial breast screening programs, the provinces of Nova Scotia3, Manitoba

4,

Ontario5 and British Columbia

6 have either tested and/or implemented new processes geared

towards improving diagnostic testing of breast abnormalities.

a Resolution of abnormal screen is based on the date of the first pathological biopsy result of breast cancer

or the date of the last benign test or pathological biopsy.


With the development of the Prostate-Specific Antigen (PSA) test in the early 1990’s there grew

an increasing interest in prostate cancer screening and diagnosis. The principles of diagnostic

assessment were soon applied to prostate cancer diagnosis. An early rapid-access program in

Manitoba focused on PSA testing and rapid-response/follow-up of men whose PSA was over a

certain threshold7. Recent evidence has however called into question the usefulness of PSA

testing8 and because of this controversy, provinces have been reluctant to make recommendations

around prostate cancer testing9. In recent years, prostate diagnostic assessment (including that in

Manitoba) has shifted its focus away from reliance on PSA results and towards increased use of

multidisciplinary expertise, patient education and supportive care. DAPs in prostate cancer have

emerged in Alberta, Saskatchewan and Ontario (see Tables 1, 2, and 3).

b. Diagnostic Assessment and the U.K. Wait Times Initiatives

Since the mid-to-late 1990’s, the United Kingdom has been focused on reducing wait times for

health services including cancer diagnosis and treatment. Clinical recommendations have

strongly supported rapid diagnostic assessment and reducing diagnostic delay10

specifically in

cases of suspected lung cancer, where surgical resection carries the best chance of curing non-

small cell lung cancer. Rates of surgical resection in the U.K. have been persistently low, in the

order of 9-10% of cases,11

trailing the U.S. rate of 28% reported in the literature12

.

Policy directions taken in the U.K. have resulted in a greater emphasis on rapid referral of

patients with suspicion of cancer. In 1990, a maximum wait of 2 weeks was put into effect from

urgent GP referral to first outpatient appointment. A maximum of 13 weeks was announced in

2007 for the time in which diagnostic tests should be carried out. Further, there has been

increasingly strong emphasis on multidisciplinary approaches to care13

. The Cancer Services

Collaborative was established by the U.K.’s National Health Service (NHS) in 1999 to improve

the efficiency and the quality of expertise and outcomes of care for patients with suspected or

diagnosed cancer14

. As part of the Collaborative, and its “Improvement Partnership” over 200

specific improvement projects have been implemented, including rapid access diagnostic clinics

in breast, colorectal, lung and prostate cancer. Many of these have contributed to improved

access to and quality of diagnostic services15,16

. Table 4 presents a sample of these programs.

The U.K.’s approach to system change has been through the redesign of familiar clinical

processes. Their quality improvement program, strongly rooted in the work of the U.S.-based

Institute for Healthcare Improvement (IHI), has served as a template for other health systems


around the world. The U.K. has also introduced patient choice, personalized care and better

access to diagnostics from primary care17,18

as complements to multidisciplinary care and system

efficiency.

Through a program known as the Institute for Improvement and Innovation, the NHS continues to

focus on improving efficiency and productivity in a variety of healthcare settings, including those

that focus on providing diagnostic services. Recent work has identified key characteristics of

high performing organizations with regard to the optimal management of patients with a

suspicion of cancer19

. These include:

1. Early identification of potential cancer

2. Prevention of unnecessary emergency admissions

3. Alert and tracking systems to drive responsive care

4. Rapid access to assessment and diagnostics (ideally within 6-12 hours)

5. Getting patients on the right pathway at the earliest opportunity

6. Supporting organizational factors

b. A Scan of the Ontario Environment

In Ontario, the motivation for improving the efficiency of diagnostic care comes as a result of the

work done in breast cancer (as described above) as well as a provincial wait times initiative. In

2004, the Ontario Wait Time Strategy was created and two years later, Cancer Care Ontario laid

out targets for cancer surgery that focused not only on the time to surgery but also the time

leading up to diagnosis, which has a strong relationship with patient outcomes.20

As defined by

the Wait Times Strategy, the diagnostic interval is defined as the wait from surgical consult to

decision-to-treat and does not include the time leading up to the patient’s first encounter with the

surgeon. Thus there remains a policy gap in that cancer programs have had little guidance and

support for improving the diagnostic wait prior to patients’ entry into the cancer system.

The community-based Ontario Breast Screening Program (OBSP) has been offering women

breast screening services since 1990. In keeping with the national and provincial focus on

improving the timeliness of diagnosis, the OBSP developed the Breast Assessment Initiative,

which provides incentives for facilities who provide care according to the Canadian Association

of Radiologist (CAR) standards, multidisciplinary expertise and patient navigation for their

patients. The Breast Assessment Initiative was introduced in 2004 and currently includes 30

Breast Assessment Affiliates across Ontario (see Appendix 1 for criteria for Breast Assessment


Affiliation with the OBSP and Appendix 2 for a current list of the Breast Assessment Affiliates in

Ontario). A very recent development in breast DAPs has been the emergence of a rapid

diagnostic clinic where patients have a physical exam, mammogram and/or ultrasound, and tissue

biopsy (if necessary) all in one day. Pathology results may be made available within 24 hours

with the use of state-of-the-art equipment. Several of the larger DAPs in Ontario – including the

rapid diagnostic clinic described above - have been strongly supported by funds from either

private donors or corporations.

Diagnostic Assessment Programs in Ontario have recently spread beyond breast cancer and into

the fields of lung, colorectal and prostate cancer. The main focus to date (following breast

cancer) has been in the area of lung cancer. There has been a strong interest in this province in

improving diagnostic assessment in lung cancer by coordinating processes and strengthening

multidisciplinary practice. An early example of a lung DAP in Ontario was the Toronto East

General Hospital’s ‘Time to Treat’ program, implemented in 2004, and based on the UK model of

process improvement through program redesign21

. This program was followed by thoracic

programs at two other facilities in Ontario. All three of these innovative programs began as pilot

projects funded by Cancer Care Ontariob. These two later programs made use of the newly

published ‘Organizational Standards for Diagnostic Assessment Programs’ produced by CCO’s

Program in Evidence-Based Care (PEBC) in 2007. At the time of writing, four additional lung

DAPs have since been introduced around the province and at least two more are in the planning

stages.

In addition to DAP implementation, recent developments in the detection of lung cancer have

focused on spiral CT technology, which is said to have “the potential to revolutionize the

detection and treatment of lung cancer”.22

Spiral CT is being tested in the U.S., Europe and

Japan. In Canada, a multi-centre study is underway evaluate a program that involves identifying

individuals at high risk (based on risk factors and blood biomarkers) and screening them with

spiral CT and autofluorescence bronchoscopy.

DAPs have been slowly emerging in Ontario for other disease sites as well. In the area of

colorectal cancer, one program was introduced as a CCO-sponsored demonstration project in

b More details about the CCO-funded demonstration projects in DAP (previously referred to as

Organized Diagnostic Assessment) can be found in a companion report called “Organized

Diagnostic Assessment. Summary of Findings from Demonstration Projects (2007-2008).”


2007-2008. Despite reductions in wait times from GP referral to colonoscopy, this project,

known as the Streamlined Centre for Out-Patient Endoscopy (SCOPE) had difficulty maintaining

patient volumes throughout the lifespan of the project and ceased its operations after one year.

Another colorectal cancer DAP has been introduced as part of a larger Cancer Assessment Clinic

(CAC), streamlining the process from suspicion (based on positive pathological finding from

colonoscopy) to a definitive diagnosis that includes stage of disease. In the area of prostate

cancer, there have been a small number of DAPs, including the CAC mentioned above and two

others, located at community hospitals. Regional Cancer Centres have been slow to initiate

implementation of organized diagnostic assessment programs outside of lung and breast cancer.

d. The Rest of Canada (and beyond)

British Columbia, Saskatchewan and Quebec have developed DAPs in breast cancer in a small

number of sites within their respective provinces. There is very little evidence of DAP

implementation, beyond the areas of breast and prostate cancer outside of Ontario (see Tables 1

and 3). In the United States and Australia, we found only a few examples of DAPs, mostly in the

area of lung cancer and mostly concentrated in large academic teaching centres. One example of

a DAP in colorectal cancer was found and it involved not only screening with colonoscopy but

also screening for genetic susceptibility (see Table 5).

5. Summary

Diagnostic assessment has increasingly been the focus of attention in cancer care as health

systems strive to reduce wait times and reorient themselves towards more multidisciplinary care.

We have seen this happening both in Ontario and abroad. There has been a considerable amount

of work done in the U.K. that might be leveraged by Ontario as this province moves forward. As

this happens, it will also be important to look at the impact that DAPs have had in their respective

areas, specifically on diagnostic waits, on the patient experience and on clinical outcomes.


Table 1. Diagnostic Assessment Program Development in Various Jurisdictions

Jurisdiction DAP Disease Sites Details

Ontario Breast, Lung, Prostate,

Colorectal

Ontario Breast Screening

Program has an Assessment

Initiative

DAP has also been tested for

skin cancer

Quebec Breast

Manitoba Prostate, Breast

Alberta Breast, Prostate

Saskatchewan Breast, Prostate

BC Breast

Some of the diagnostic

assessment in breast is operated

by a private diagnostics clinic

Australia Lung

Ireland Breast, Prostate

U.K. Breast, Colorectal, Lung,

Prostate, Gynecological,

Hematological

Programs developed in

response to targets of 18 weeks

from referral by GP to

treatment in hospital; and 2

weeks from referral by GP to

specialist visit for patients with

suspicion of bowel cancer

U.S. Lung, Colorectal


Table 2. Diagnostic Assessment Programs in Ontario, by LHIN and Disease Site, as of October, 2009

Currently operating?

LHIN Program Name

Facility Disease Site

Operating as of

Description

�� 1 Windsor Regional & Chatham Kent Health Alliance.

Breast 2004 Full range diagnostic and surgical and reflect key components of DAP standards

�� 1 Erie St. Clair Lung DAP

Windsor Regional Cancer Centre

Lung Jun-07 Centralized access, defined referral criteria, diagnostic pathways, nurse coordination & support, performance targets, MCC case presentation/pathway planning and patient satisfaction evaluation

�� 3 Waterloo Wellington Breast Centre

Freeport Health Centre (Grand River Hospital)

Breast Feb-07 Timely access, assessment, diagnosis and follow-up.

�� 3 Thoracic DAU

Grand River Hospital

Lung Jun-07 Timely access, assessment, diagnosis and follow-up. Referral of any person in Waterloo Wellington LHIN with abnormal chest image.

NO 3 GI DAU Colorectal

n/a Under development: DAU currently in the planning stages in conjunction with the current mapping of the colorectal diagnostic pathway by CCO.

NO 3 Skin DAU (SDAU)

Grand River Hospital

Skin n/a The Cancer Program is currently reviewing the functions and processes of this DAU to be able to revamp the clinic to serve the needs of the community.

NO 4 Breast Assessment Centre

Juravinski Cancer Centre (Henderson Site)

Breast n/a Under development

�� 4 Firestone Clinic

St. Joseph Health Care

Lung 'recent' - Dedicated Diagnosis Assessment Program exists for patients with suspected lung cancer. - Ninety percent of these patients have completed their evaluation and received a diagnosis in 10 days. - Some but not all patients suspected of lung cancer have standardized diagnostic assessment.



LHIN Program Name


Operating as of

Description

- Lacking dedicated coordinator to assist patients through system

�� 6 Breast DAU Credit Valley Hospital

Breast 2007 Implemented as a demonstration project in organize diagnostic assessment; then affiliated with OBSP Assessment Initiative

�� 7 Rapid Diagnostic Breast Clinic

Princess Margaret Hospital

Breast Sep-06 Twice weekly clinic. Referred patients have physical, mammogram/ultrasound and tissue biopsy all on one day. Pathology provided within 24 hours.

�� 7 CIBC Breast Assessment Centre

St. Michael's Hospital

Breast Apr-04 Visit includes: interview with nurse examiner; review of breast self-examination, if appropriate. surgical consult; mammogram; ultrasounds or special views; film review and consultation between radiologist and surgeon; recommendation of surgeon for appropriate treatments and follow-ups; complete written reports sent to referring physician. Results of all reports within one week.

�� 7 Breast Clinic Toronto East General Hospital

Breast 2004 A patient may be referred by their GP or by a surgeon to a single phone number where a clerical navigator arranges for appointments according to a clinical pathway which will lead to a diagnosis. The outcome is expedited due to preferential agreements with radiology mostly for the required diagnostic interventions. The clinic runs once weekly in our OPD.

�� 7 Time to Treat

Toronto East General Hospital

Lung 2004 - new referral form to streamline referrals and create clinical pathway - use of clinical (clerical) navigator to facilitate referrals, track patient progress and ensure timely investigation - initiate booking of 1st specialist visit and CT at same time as chest x-ray interpretation or symptom ID - set interval wait time targets - pooled slots for specialist consult and diagnostic testing - weekly MCC as part of clinical pathway to integrate the management of diagnosis and treatment

�� 8 Gale & Graham Wright Prostate Centre

North York General Hospital

Prostate Jul-07

�� 9 Lakeridge Oshawa

Breast Jun-05 Piloting a virtual Breast DAU for 6 months while awaiting completion of new Breast assessment Centre - June 2010



LHIN Program Name


Operating as of

Description

NO 9 DRCC Colorectal DAU

Lakeridge Oshawa

Colorectal n/a under development – planned for Fall 2009

�� 9 Lakeridge Oshawa

Lung Jul-09 Planned expansion into Peterborough

�� 9 DRCC Prostate DAU

Lakeridge Oshawa

Prostate Jun-09

�� 10 Breast Assessment Program

Hotel Dieu Kingston

Breast GPs refer patients with abnormality for work up. Booking done in diagnostic radiology.

�� 10 Lung Clinic Kingston General Hospital

Lung Provides, wherever possible, examination, testing and diagnosis all on the same day or evening, or on the week-end. Run by respirologist. Referrals to clinic from GPs, ERs, hospitals or cancer centers. 2x week coordinator meets with respirologist & thoracic surgeon to triage patients. All are part of MCCs which involves pathology, M/O, R/O, diagnostic imaging & nursing

�� 11 Women's Breast Health Centre

The Ottawa Hospital

Breast Regional program that provides a comprehensive service to people with breast abnormalities; assists health professionals ensure a coordinated diagnostic work-up of breast problems.

�� 11 Cancer Assessment Ages Clinic (CAC)

The Ottawa Hospital

Lung, CRC, Prostate

Jun-07 Three hospitals feed into Central location - Queensway Carleton, Montfort and Ottawa. CAC provides surgical consultation, care, regional data collection, coordination and triage, coordination of new referrals between three hospitals, reduced surgical waits and increased referrals through central intake model

�� 12 Royal Victoria Hospital

Thoracic, Colorectal, Breast

Sep-09

NO 13 Sudbury Regional Hospital

Breast n/a In the process of aligning their Breast Health Assessment program with integrated diagnostic services



LHIN Program Name


Operating as of

Description

�� 14 Linda Buchan Centre for Breast Screening and Assessment

Thunder Bay Regional Cancer Centre

Breast Mar-06 Focus on coordination for service. 10 performance indicators that address timeliness, completeness of follow up, biopsy quality and completeness

NO 14 Thunder Bay Regional Cancer Centre

Colorectal Lung

n/a Under development


Table 3. Diagnostic Assessment Programs - Canada Outside Ontario, by Province

Currently Operating?

Province Program Name Facility Disease Site

Affiliation Operating as of

Description

�� Quebec Cedars Breast Clinic

Royal Victoria Hospital and Montreal General Hospital

Breast McGill University Health Centre

2002

�� Sask Breast Assessment Centre

Pasqua Hospital (Regina)

Breast Regina Qu'Appelle Health Region

�� Sask Prostate Assessment Centre

Pasqua Hospital (Regina)

Prostate Regina Qu'Appelle Health Region

�� Alberta Prostate Cancer Rapid Access Clinic

Calgary Prostate Prostate Cancer Institute

2005 Sees ~1200 pts per year. A team of urologists rotate through the clinic. Every Calgary pt with suspicion of prostate ca is referred to RAC. Proposed expansion to Edmonton.

NO Alberta Rapid-Access Prostate Health Clinic

Edmonton General Hospital

Prostate Planned for 2010

�� Alberta Calgary Breast Health Program

Breast

�� BC Rapid access breast clinic

BC Women's Hospital & Health Centre

Breast BC Cancer Agency Aug-09 Will integrate 2 breast imaging centres in Vancouver with central nurse navigation, booking and access to GP oncologists


Mount Saint Joseph Hospital

Breast May-09 Funded by BC Lower Mainland Innovation & Integration Fund


Royal Columbian Hospital

Breast Fraser Health Region

Apr-09 Funded by BC Lower Mainland Innovation & Integration Fund


Currently Operating?

Province Program Name Facility Disease Site

Affiliation Operating as of

Description


Surrey Memorial Hospital

Breast Fraser Health Region

Apr-09 Funded by BC Lower Mainland Innovation & Integration Fund

�� BC Canada Diagnostic Breast Centre

Breast Jun-09 Operated by Canada Diagnostic, a private MRI & Ultrasound clinic in Vancouver

�� Manitoba Manitoba Prostate Cancer Project / Dr. Ernest W. Ramsey Manitoba Prostate Centre

Prostate - CNS available for assistance with decision making & counseling - psychosocial clinician - access to multidisciplinary team

�� Manitoba Manitoba Breast Health Centre

Breast Cancer Care Manitoba


Table 4. Diagnostic Assessment Programs - United Kingdom / Ireland

Country Program Name


Affiliation Description Statistics

Ireland Rapid Access Breast Clinic

Adelaide and Meath Hospitals

Breast

Ireland Specialist Breast Centre

Mater Private Hospital

Breast Offers 'triple assessment' - recognized as best practice for rapid diagnosis and treatment of the disease = Clinical examination + ultrasound or mammography+ biopsy if required

Ireland Rapid Access Diagnostic Clinic

Galway University Hospital

Prostate National Cancer Control Programme and All-Ireland Cancer Foundation

Patients will have definitive diagnosis established within 2 weeks of initial appointment; if they are confirmed as having cancer, they will have immediate access to multidisciplinary cancer care team to arrange appropriate treatment.

Ireland Rapid Access Diagnostic Clinic

St James Hospital

Prostate National Cancer Control Programme and All-Ireland Cancer Foundation

same as above

Scotland Colorectal Services

Colorectal

Scotland Urology Services

Prostate

England Newcastle upon Tyne Hospitals NHS Trust

Breast Direct electronic referral from GP to electronic breast clinic ('end-to-end' improved booking process over fax system. Patient leaves GP office with 'cast iron' appointment





England Burnley Breast Unit - Rapid Assessment Clinic

St Helens and Knowsley Teaching Hospital

Breast NHS Foundation Trust

England Rapid diagnosis symptomatic breast clinic

Luton & Dunstable Hospital

Breast

England University Hospitals of Leicester

Colorectal CRC team developed a 'Straight to Test' protocol (primary care, gastroenterology, radiology, surgery). New primary care referral proforma & admin processes

Overall 85% of diagnoses are made within 1 month

England Whittington NHS Trust

Colorectal Patient pathway mapping & improvement with: protocol-driven nurse led clinic; triaging of referrals by gastroenterologist; nurse led rectal bleeding clinic; nurse endoscopists provide FS and biopsy; consultant available in clinic

non-urgent waits reduced from 15 to 8 weeks; urgent referrals seen within 2-week target

England Queen Alexandra hospital

Colorectal

England Rapid Access Clinic

Guy's and St Thomas' Hospitals

Gyne NHS Foundation Trust

Patients with suspected gyne cancers are seen in the Rapid Access Clinics and can be referred under the two week wait pathway - handled by designated team.

England Rapid Access Lymph Node Clinic

Hillingdon Hospital

Haematolo- gical Malignan- cies

NHS Trust

England Rapid Access Clinic

Birmingham Heartlands Hospital

Lung Features a multi-disciplinary Lung Investigation Day (LID) within 3 days of Clinic





England Lymph Node Diagnostic Clinic

Royal Marsden Hospital

Lymph- adenopathy

To reach rapid diagnosis in patients with lymphadenopathy using a concerted multidisciplinary approach.

- Median time between referral and 1st clinic visit: 6 days - median time from 1st clinic visit to reaching malignant dx: 15 days (2003)

England Rapid system

Royal Marsden Hospital

Lung

England Rapid Access Prostate Cancer Assessment Clinic

York Hospitals

Prostate specially trainer nurse, sonographer; standardised protocols for examination; new booking system

decrease waits from >20 to 4 weeks; booking system maximizes patient choice; reduced pt visits to hospital

England Rapid Access Lung clinic

Thoracic Medicine (Chest) at Aintree University Hospitals NHS Foundation Trust

Lung Rapid Access clinics (for anyone for whom lung cancer is suspected) are able to see patients and perform the tests for diagnosis within 2 weeks and to get patients to formal treatments (if needed) within 2 months thus meeting all the government targets.


Table 5. Diagnostic Assessment Programs identified – Rest of the World

Country State Program Name


Description

Australia Victoria East Melbourne Heart & Lung

Lung - Rapid diagnosis, staging and treatment - Genuine private multidisciplinary evidence-based cancer care - Clinical trials and translational research - Advanced minimally invasive techniques

USA Massachusetts Carole M. and Philip L. Lowe Thoracic Oncology Program

Dana Farber/Brigham & Women's Cancer Centre

Lung Each patient's status will be evaluated during a single outpatient visit to our ambulatory evaluation center. Each patient is assessed by a multidisciplinary team made up of health care professionals, including thoracic surgeons, medical oncologists, radiation oncologists, pulmonologists, radiologists, pathologists, nurses, physical therapists, respiratory therapists, dieticians and nutritionists, and social workers.

USA NY High-Risk Lung Assessment Program

Columbia University Medical Centre

Lung

USA Ohio OSU Pulmonary Oncology Clinic

Ohio State University Medical Centre

Lung The Clinic offers • Rapid assessment and diagnosis/staging of suspected cases of thoracic malignancy (time to diagnosis less than one week) and coordinated care through our multidisciplinary program • Medical optimization for patients undergoing treatment • Management of co-morbid diseases of the lung • Management of complications including malignant effusion and endobronchial disease • Management of complications of therapy

USA Oregon Cancer Assessment and Risk Evaluation Clinic(CARE)

Knight Cancer Institute - Oregon Health and Science University

Colorectal Purpose of the clinic is to: - Assess patient's cancer susceptibility - Provide a multidisciplinary approach to care - Discuss genetic testing options - Risk management for screening and treatment - Ongoing cancer prevention education

DAP Environmental - 20 - December 2009

Appendix 1. Criteria for Breast Assessment Affiliation with the Ontario Breast Screening Program

DAP Environmental - 21 - December 2009

Appendix 2. OBSP Breast Assessment Affiliates

Source: Ontario Breast Screening Program. Breast Assessment Affiliates Assessment Indicator Report. March 31, 2009.


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