Aggressive Lymphoma Early Alert Process

Podcast Transcript

Dale Shepard, MD, PhD: Cancer Advances, a Cleveland Clinic podcast for medical professionals, exploring the latest innovative research and clinical advances in the field of oncology. Thank you for joining us for another episode of Cancer Advances, I'm your host, Dr. Dale Shepard, a medical oncologist here at Cleveland Clinic, overseeing our Taussig phase one and sarcoma programs. Today, I'm happy to be joined by Dr. Allison Winter, a member of the Cleveland Clinic Lymphoma and BMT Cellular Therapy groups. She was a guest on this podcast last year, when she talked about the central nervous system lymphoma transplant program, she's here today to talk to us about an early alert system for aggressive lymphomas. So welcome back, Allison.

Allison Winter, MD: Thank you. Thanks for having me.

Dale Shepard, MD, PhD: Absolutely, so maybe remind us, what is your role here at Cleveland Clinic?

Allison Winter, MD: I am an associate staff physician in the lymphoma group and the BMT cellular therapies. So I see patients with all kinds of lymphomas, as well as some chronic leukemias, and then if necessary can provide transplant care and cellular therapies like CAR T-cell immunotherapy.

Dale Shepard, MD, PhD: Excellent. So today we're going to talk about aggressive lymphoma, so I have a number of people that may be listening in and when they hear aggressive lymphoma, they don't really know what that means. So tell us, what is aggressive lymphoma?

Allison Winter, MD: So when I approach a new diagnosis of lymphoma, that is one of the first questions I ask, what type is it? And not just this specific histologic diagnosis, but one of the first major pathways is, is this a low grade lymphoma, or a high grade lymphoma? So aggressive lymphomas are high grade lymphomas, meaning they grow in a matter of hours to days, much, much faster than my low grade lymphomas, which grow in a matter of months to years, very, very slowly. So how we approach those patients and the urgency of which we need to initiate treatment is much, much different. But within that category of high grade lymphomas or aggressive lymphomas, there's a number of specific histologic diagnoses, such as diffuse large B-cell lymphoma, which would be the most common, mantle cell lymphomas, burkitt lymphomas, et cetera. But the importance is, they grow fast and you need to do something about it, fast.

Dale Shepard, MD, PhD: That being said, how quickly do patients get to you? I mean, are there sometimes delays and you're behind the game before you get there?

Allison Winter, MD: Exactly, so how fast someone comes to see the medical oncologist for the new diagnosis of lymphoma is highly variable. So there's a whole timeline of events that I've heard patients tell me went very smoothly, and other patients who tell me it was the most stressful thing in their life. Even more stressful than actually going through chemotherapy, because they're in limbo, waiting for the next step. So the process goes from a patient having symptoms, maybe they feel their own lymph node. And then they seek attention from a medical provider, often a PCP or maybe express care, which prompts often some type of imaging, usually an ultrasound or perhaps a cat scan, which then prompts that provider to send the patient for a biopsy, either through something like an interventional radiologist, or more frequently a surgeon, because the standard of care diagnosis for lymphoma is an excisional lymph node biopsy.

So then once they get the referral to the surgeon, they meet the surgeon and then they have the appointment to actually have the biopsy, and then it goes to pathology, which can take a number of days. And then the alert that the pathology is finalized, letting the patient know the diagnosis and the next steps, which is the referral to a medical oncologist. So there's a number of steps along that process that can lead to delays, and that's one area where we can hopefully make some improvements.

Dale Shepard, MD, PhD: And we're going to talk a little bit about this alert system, and I know that part of that is time to treat and how quickly we treat, but it sounds like there's maybe a lot of work that could be done, just time to diagnose. I guess if you could throw out any thoughts in terms of how do we raise awareness on, "Hey, these symptoms are concerning, maybe we need to step up the pace in diagnosing a bit". What kind of symptoms might that be?

Allison Winter, MD: So symptoms of lymphoma can be variable. Most common symptoms are enlarged lymph nodes, and people don't always realize that we have an entire lymphatic system. So lymph nodes are not just in our neck, but our armpits, our groin, and then inside where you can't always feel. Drenching night sweats or losing weight without trying. So this is the United States of America, it's very hard to lose weight when you are trying, so if you're losing weight without trying, that's always a big red flag. So those are the standard B symptoms that we think about with new lymphoma. But I also tell my patients who've had lymphoma who are worrying about it coming back, anything that's persistent and not explainable needs to be evaluated, and if you're not getting that evaluation seek another opinion.

Dale Shepard, MD, PhD: There you go, good advice. You mentioned before pathology finally is read and then there's a trigger, tell me about that.

Allison Winter, MD: So when a pathology report is finalized, it goes to the in-basket in the electronic medical record of the ordering provider, whether that was the interventional radiologist who performed the procedure, or the perhaps surgeon that performed the excisional lymph node biopsy. Once that is finalized, then it's up to that provider to take the next steps, alert the patient of the diagnosis and send a referral to a medical oncologist.

Dale Shepard, MD, PhD: And so what kind of delays do you see in that process?

Allison Winter, MD: So that process can actually have a lot of delays, and that is because physicians are very busy, not that I'm making any excuses, but we have all kinds of inboxes to check on a daily basis. Even within the electronic medical record, as you know, there are about six different parts of that inbox, the pager, the email, all kinds of things that we need to check, and that's challenging.

Dale Shepard, MD, PhD: Yeah.

Allison Winter, MD: So before this program, the average time from the final diagnosis being signed out to the patient being alerted was five days, but notably there are about 12% of patients where it was nine plus days. So that's too long, and that's definitely an area that was easy to intervene upon when we think about the whole time to treatment trajectory. If we can make it where people are not waiting nine plus days to have the notification of their final diagnosis, then we can speed up the time to the medical oncology referral, and hopefully the time to treatment.

Dale Shepard, MD, PhD: Yeah, and I know on the solid tumor side, sometimes I will request the biopsy, but the order ends up being from the radiologist or a surgeon, and then the pathology goes to them and it never shows up in my inbox.

Allison Winter, MD: Exactly.

Dale Shepard, MD, PhD: So that can be a problem.

Allison Winter, MD: Another challenge of the electronic medical record.

Dale Shepard, MD, PhD: So, tell me about what's in place now. What are we doing now?

Allison Winter, MD: So our program director, Dr. Brian Hill, our program manager, Becky Haybecker, and our new position that they created, which was the patient liaison coordinator, which was headed up by Raven McGinney, all came up with ideas to improve this system, this early alert system. So basically it's a couple of different steps to help improve the notification process to the patient. The first step is the hematopathologists, if they are highly likely to sign out a case's aggressive lymphoma, they send an email to the lymphoma program. So the lymphoma program has an email, the inbox is monitored by several people like Raven and Becky and Dr. Hill... And so the email will come in from the pathologist saying, "We wanted to let you know that this patient is highly likely to have an aggressive lymphoma final diagnosis". That then will prompt Raven to send a templated email to the ordering provider saying, "We wanted to let you know that this biopsy is preliminary, but highly likely to be aggressive lymphoma. If you would like to already take steps to refer to medical oncology, here's a number as well as an email address".

And it makes it very easy because that email address to Cancer Answer, which is our team that creates new medical oncology appointments, it's a hyperlink. The provider can just click that, and get the process rolling. So that's one step, that's for preliminary cases where the pathology is helping us. Another step is, Raven actually gets a report of pathology cases every day from the CoPath system, and she specifically looks for aggressive lymphoma diagnoses on that daily report. And then she looks in the electronic medical record to see if the patient has been notified, or if a referral to medical oncology has been placed. If that has not been completed within two days, then we have another templated email that is sent to the ordering provider to say, "This pathology is final, and we'd like to help you refer to medical oncology". That's another way to make sure that people are getting alerted and getting the help they need.

Dale Shepard, MD, PhD: And so this applies to... Essentially, since it's pathology based, it would apply to people within Cleveland Clinic that have ordered those biopsies, but does that also trigger for people in a community that might be having the slides read here at the Cleveland Clinic?

Allison Winter, MD: Good question, so that's definitely within the Cleveland Clinic enterprise. So, that includes a lot of the regional cases within Cleveland Clinic, and that's where Raven has found really good feedback because a lot of times with a lymphoma case, you may want to be referring down to main campus. I don't know the answer to the second part because I know a number of pathology cases come to Cleveland Clinic.

Dale Shepard, MD, PhD: Yeah, second opinion consults. What kind of impact has it made so far?

Allison Winter, MD: Yeah, so it has definitely made an impact, and we have some data to show that, especially because Raven was with us for a couple of years and then departed for a little bit and then has returned. So in terms of numbers, the average time for a patient notification after a final pathology report was five days, and that has gone down to two days.

Dale Shepard, MD, PhD: Wow.

Allison Winter, MD: But as I mentioned before, there was 12% of patients who were being notified nine plus days after that pathology was signed out, and that has gone down to 1%, so that's a big improvement. And there's been a 30% increase in the patients who are notified same day as the biopsy result, so that's great as well. And this has helped to drive patients to their first medical oncology consultation faster. We also have graphs of these timelines when Raven left us for a little bit, and so we made improvements. Things got a little worse after she left and now things are getting better now that she's back with us.

Dale Shepard, MD, PhD: It sounds like job security.

Allison Winter, MD: Yeah, she should just hand us that graph, "Look what happened when I was gone", she transitioned out because she wanted to spend a little more time at home, but then was ready to come back, and we were happy to have her back.

Dale Shepard, MD, PhD: There's been a big focus here at the clinic on time to treat, from diagnosis to when you get a treatment. I mean, clearly decreasing from five days to two helps out and a disease is growing so quickly, clearly time to treat must be important. Do we have data about that?

Allison Winter, MD: Great question, I have asked for that data, we know it's improved, but I don't have specific numbers, but I can tell you, even from our perspective as a program, it also lets us intervene in other ways as well. So for aggressive lymphomas, we always want a staging pet scan, and we're not allowed to put orders in if we haven't seen the patient. So sometimes we use this alert system to say, "Hey, ordering provider, do you mind placing an order for a pet scan as well?", because it's often at least a seven day window for insurance approval before that can be scheduled. So if a patient comes to me for an initial consultation and is already several days into that insurance approval process, that's sooner for me to say, "Okay, we can treat you", because we have to have that baseline pet scan.

Dale Shepard, MD, PhD: Well, I guess there's the intangibles just in terms of patients and their anxiety, you mentioned just their concerns about even getting the diagnosis and that just ramps up even higher once they have the diagnosis. So just being able to get in to see you faster must be reassuring to them.

Allison Winter, MD: Reassuring, and I don't know how many times I hear patients on their first day of chemo say they actually are just less anxious that day, which to me seems a little counterintuitive because it's a day they're starting chemo, but they're less anxious because they're like, "I'm done with that drawn out long process that it took, from the time my symptoms started to the time I get this treatment". And like I said, for some people that process goes really smoothly, but for other people, if there's delays in all of those time points, it can really be drawn out and very anxiety provoking.

Dale Shepard, MD, PhD: What's next on the horizon to improve things even more? There's always a quality improvement project, right?

Allison Winter, MD: Always a quality improvement project. So I think that one of the things that I was asking Raven about is automation. So automated systems are always better because they take out the human and human error. So we know technology and artificial intelligence is just growing, so if there could be some way, for instance, maybe we didn't have to rely on the pathologist to send that email that they think it's highly likely for aggressive lymphoma, or some type of trigger to prompt that referral without waiting for a provider to place that appointment, or referral, just automating it would be great, so looking into ways that we can improve there.

Dale Shepard, MD, PhD: Maybe the pathology read triggers a pet scan without needing insurance authorization.

Allison Winter, MD: Or maybe just the line diagnosis of aggressive lymphoma just triggers oncology appointment, you don't even need to have the middleman place the referral.

Dale Shepard, MD, PhD: That's excellent, so where are the biggest gaps? So certainly we can decrease that sort of thing, are there other things along the way? We talked about insurance authorization triggers, is there anything else we can be doing to get patients treated faster and improve their care?

Allison Winter, MD: I think there's always things like I said, along this window that we can improve. If we can make system changes like this, it can actually have a bigger impact. Of course, in Taussig we're always trying to get patients in within seven days. So another step that's been made is to have Cancer Answer, program specific coordinators. So we actually have a specific person who schedules lymphoma referrals, and it's really great because she knows our nuances, she knows what we're looking for, but she also just emails us if there's a question, "Hey, I don't know if it's too soon to schedule or not too soon to schedule". So for instance, a patient was waiting on a bone marrow biopsy report and she said, "Is it okay to schedule them? They have the lymph node report, but not the bone marrow", and I said, "Yes, get them in. Let's not wait, get them in, we'll get that information later". So communication and system base are certainly easier to intervene upon than waiting for insurance, because that's a little out of our hands, unfortunately, sometimes.

Dale Shepard, MD, PhD: Yeah, well it sounds like a great system. I can imagine there are people that might be listening in that said, "Wow, I wish I could set up something like that". What were the biggest challenges to setting something up, and I guess what advice would you give people.

Allison Winter, MD: Be willing to make changes and try something new. So this idea, they saw an area that we could make improvements. And we hired Raven in this patient liaison role, which had never been a role before, but we said, "Hey, let's try it". And she developed the role as we talked, how we could make this better, so don't be afraid of change and sometimes things can work.

Dale Shepard, MD, PhD: Very good. Well, great insights for us today, appreciate you being here.

Allison Winter, MD: Yeah, thanks for having me.

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