Reducing Time to Treatment for Cancer Patients

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 I and Sarcoma Programs. Today, I'm excited to welcome Dr. Brian Bolwell, Chair of Cleveland Clinic Taussig Cancer Institute to the podcast. He's here today to discuss time to treat. Brian, tell me a little bit about your role here at Cleveland Clinic.

Brian Bolwell, MD: Number one, thanks for having me on this. I appreciate the opportunity. I've been chairman of the Taussig Cancer Institute for close to 11 years, and I also am Director of Executive Physician Leadership for Cleveland Clinic.

Dale Shepard, MD, PhD: Excellent. Well, thanks for joining. So to start, we're going to be talking about time to treat. So what is time to treat?

Brian Bolwell, MD: Time to treat is defined as the interval between the date of a diagnosis of cancer and the initial treatment. The initial treatment is frequently surgical to remove a solid tumor, but it also can be radiation therapy or infusional therapy, which we used to call chemotherapy, but these days is probably even more often immunological therapy or genomic-based therapy.

Dale Shepard, MD, PhD: Certainly, time to treatment has sort of captured everyone's attention nationally and it's a top priority here at Cleveland Clinic. So how did this really be something that you became so interested in and why is it so important here at Cleveland Clinic?

Brian Bolwell, MD: Well, we were trying to launch what we call cancer programming about 10 years ago, so we wanted to do is make every disease-based entity, such as colon cancer or breast cancer have the physicians involved in caring for patients with those diseases act as a true team, a program, a unit. And in order to do that, we thought it was important that there were initiatives that each program had that would be useful to work on, such as developing tumor boards that were accessible, not just for physicians on our main campus downtown, but were accessible to all of our physicians treating these diseases in the region. And we really wanted to make the programs real because when I actually took over the cancer center, 11 years ago, we had a wonderful group of clinicians, but the idea of working collectively as a team was kind of in its infancy. It really wasn't very well developed.

About the same time, I actually didn't know what time to treat was, Dale, but I learned about it through a couple of different means. And what caught my attention was that time to treat in the United States was actually getting worse by the year. And it was worse of all in the famous academic cancer centers that are in the US News and World Report, top 20, top 30, et cetera. I was kind of appalled that our peers, that cancer centers like ours had an average time to treat of six weeks or longer. And, one of my visions for the cancer center was always to kind of walk in the shoes of a patient. And, boy, if you're a new patient with cancer and we know that these people have one primary emotion and that's that they're scared and that they have fear and anxiety, waiting six weeks to get treated is just going to make all that worse. And so that seemed to be a good thing for our cancer program effort to work on.

And then the corollary to that was we were wondering if this potential delay actually could affect survival because one of the initial pushbacks that we heard was, yeah, it's a long time, but it doesn't really affect survival. And so I actually never liked that argument for a couple reasons. One is I wanted to find out back then if it can affect survival and it turns out that in some cancers it does. But more importantly, the people who said, "Oh, it doesn't really matter," totally flunk the integrity test.

And so if one of their immediate relatives have cancer, I guarantee they're not going to be satisfied waiting for six weeks to get initial treatment. They're going to do everything they can, because they're a physician, to try to get their first-degree relative treated quicker. So if they're going to do that for their relatives, then they should do that for everybody, whether they're a relative or not, whether they're a person of means, or whether they have nothing, because we want to give everybody great care. So those are the reasons why time to treat kind of got my attention and then why it became really important to me.

Dale Shepard, MD, PhD: I mean, when you sort of take a step back and you figure six weeks, that really is appalling. Like you say, everyone that comes in, they want it taken out two weeks ago. To think about six weeks is a little crazy. So from a patient standpoint, I mean, we're very patient-centric, what do you think has been the biggest impact in addressing this with patients and what does this mean to them?

Brian Bolwell, MD: Well, I think there's a couple of things, Dale. One of the things that we're really concerned about is access in general. And I think the time to treat is a very important component of access. We pride ourselves at the Cleveland Clinic Cancer Center of having the best access of any major cancer center in the United States and probably the world and we do that because we pay attention to it every day. And we have our own team of people that make sure that we can get people in as quickly as we can, and that we can get their records so that when people do show up that we actually have a useful visit. And of course, these days now, since everything's happened with the coronavirus, we have some visits that are virtual and that's sometimes very useful too. But access is a really big deal.

And so again, if you're a patient, the first thing to do is to see a doc, because number one, you need to have a treatment plan. You need to know that somebody's there for you, that they're going to try to do everything they can to help, to establish rapport, to generate trust. I think that trust is really important in everything we do in oncology. And then once you get people in and you start a relationship and they meet a physician, then it's just incredibly important from a patient perspective to do things quickly, and delays are just no fun for anybody. I mean, not too many people like to wait in lines for anything. But people, when they have newly diagnosed cancer are uniformly incredibly scared, but also they tend to imagine things that may or may not be true, these catastrophic things, what happens if X, Y, or Z happens, plus it's not uncommon that they get advice from people that may be ill-advised.

And I just think that all the patient really wants is to get things taken care of as soon as possible by somebody who's really good at what they do. And so we're really good at what we do here and so the idea of trying to speed up time to treat seemed to be a pretty good idea, especially given that when we looked at our own data, initially, we weren't very much better than anybody else. Our time to treat was 39 days, which is pretty close to six weeks so we certainly had opportunities for improvement. And to your point, the driver is it's the right thing to do for patients.

Dale Shepard, MD, PhD: So how have we managed to have some of these reductions? So we've certainly had some successes. And so what are some examples of things we've been able to do to make that happen?

Brian Bolwell, MD: Well, the first thing we did was, was realized that each cancer program was a little different. And so there were some things that we could try to do across all programs, but it was important that each program started to dive into the work as a program. And so, one of the byproducts of that is it certainly generated a sense of team, which is very good. For some programs, we used some modern business tools, such as value stream mapping to actually identify all access points for patients. So, for colon cancer, this gets very complicated because we do endoscopies at so many different sites within the enterprise, but it was important to try to identify them all and to try to identify what the potential bottlenecks were. For lung cancer, it turned out that the key point that we needed to pay attention to is the bronchoscopy suite.

Then we socialized these, Dale. We have a cancer center executive committee, and for most of the past few years, it met every other night and we would share best practices. We talked about time to treat a lot. Of course, we had to measure it, that's number one. And unfortunately, it's not easy to measure prospectively. But we came up with a way to measure it retrospectively, and we socialized number one, what the data was, and number two, approaches to try to make it better. So, there's different time intervals, right? There's a time interval from hearing about a patient to actually getting them into seeing a doc. There's a time interval for from seeing a doc to getting them to the operating room.

One of the bigger wins was the breast cancer program started to assign patients to surgeons with operating room availability, as opposed to surgeons with clinic availability because the key was to get them to the OR. OR, meaning the operating room for their initial surgery. And things like that, we socialized and we resourced it too, Dale. The cancer center actually pays for four program managers that help assist with all sorts of operational things, including time to treat. And we also hired a bunch of navigators, which was also important.

Because one of the keys for me was to reduce outliers. So when I first got this job, it was really disheartening to hear a handful of stories about patients who got lost in the system and wound up waiting very long times to get any sort of treatment and I didn't want that to happen anymore. And so we hired a bunch of navigators to try to make sure that nobody got lost in the system, and also to try to deal with what we call outliers, which are people who seem to be waiting a really long time to get anything done. And we defined outliers as people waiting more than 45 days to get their first treatment. And we paid a lot of attention to them, and happily, we've been able to drive down the number of outliers dramatically in the past five to seven years.

We also learned that some things are hard. And so one of the harder things is that it's not as easy to shorten the time to treat with somebody who has a diagnosis done externally, as opposed to somebody who has a diagnosis done within our health system, because there's a certain time lag for pathology review, but it's important to manage them as well. So we identified a lot of bottlenecks. We identified a lot of opportunities and we generated, I think a lot of momentum. And we were able to, ultimately, if you look across the entire cancer center across all the programs, we were able to drive downtime to treat by 33%, which we're pleased about. We always see opportunities for improvement, but getting it down from 39 days to 26 days was a win.

Dale Shepard, MD, PhD: Yeah, that's pretty impressive, Brian. And certainly, it has taken a lot of effort and the programming meetings have certainly been helpful. It's been great to have the surgeons, and the radiation oncologists, and the medical oncologists, and administration, everyone all in a room and talking about the issues and opportunities, so that's really helped out a lot. When we think about further barriers, there's certainly a finite amount of time that has to take place and there's certainly things like getting insurance authorizations for staging scans and things like that. What do you think are the next big barriers that we need to tackle to optimize this?

Brian Bolwell, MD: Well, I think you mentioned one of them, Dale. I think that insurance pre-authorization is a unnecessary challenge. I'd like to think that at some point going forward, the healthcare system in the United States will evolve in a positive way. And one of those positive ways is I think we need more collaboration between the insurance companies and the providers such as cancer centers. I think that for reasons that I don't really understand, it seems that the insurance companies love the way the healthcare economic system works and they're making an awful lot of money right now when a lot of the rest of the healthcare ecosystem is struggling. And so I think that there are real opportunities for more collaboration.

One of the things that's pretty important these days, especially if somebody is not a surgical candidate is getting genomic analysis of a tumor, and so I think that there's a certain lag time to do that and I think there's opportunities to accelerate that one as well. I think we can always do better with efficiency for getting people into the operating room.

The other thing is the more we can act as a system, the more likely we can continue to make progress. Some of our biggest challenges are when we're interacting with physicians outside of our healthcare organization, in our region, and just kind of educating them and getting them on board that this is a very important initiative for all concerned, but especially for the patients. So I think that there's many opportunities, but I think that the real key is to maintain the momentum and maintain the passion for the work because every patient who goes down this journey and starts it is really important. It's really important for us to try to take care of them in the best way that we possibly can and I think time to treat is one pretty essential way to do that.

Dale Shepard, MD, PhD: So you mentioned a passion for the work and, Brian, I know leadership is a really, really important topic that you address a lot. There's a lot of moving parts, as you mentioned with time to treat. And I think that one thing that we've done really well is get everyone to work well together. And so everyone does really seem to be very engaged and enthused. And what do you think has been the biggest sort of when, and how did you go about getting the level of engagement, the level of really making this a priority? Because I think everyone has really taken this to be a goal. So how do you think that you managed to pull that off and maybe how can others sort of do a similar thing for their patients?

Brian Bolwell, MD: Well, I believe in the concept called serving leadership or servant leadership, which has many different components. It's got one fundamental set which has kind of two-up in the pyramid, which basically means that my job is to set a vision, hire really good people, and then support them, give them whatever they need to succeed, remove barriers. If there's political barriers that need to be addressed, I need to be the one to address them, and then when success is achieved, let them receive the credit for it. And then the corollaries are is leadership is about character. Leadership development and character development are the same and so honesty and transparency are essential. All this kind of happened as I was trying to come up with my own vision for our cancer center and this became one of the key parts of our vision for the Taussig Cancer Institute.

It was we have to walk for a walk. We can't just talk about stuff. And if we really care about patients and we really think that we're a very patient-centric organization, our slogan is patients first, we have to make that real. And so time to treat became part of a vision. And if you're a leader, one thing you have to do is you have to talk about that vision over and over and over again. I mean, I write essays on the topic. One of the essays is about the art of preaching, that you've got to just become somewhat of a zealot about what the goal is.

I think the other thing though, is that wins generate wins. And the more we started to see success, the more people got engaged and said, "Wow, this is really cool." And another line that I really like is, great teams are a magnet for great talent. And so a lot of people wanted to join. I mean, when we first started the cancer center executive committee meetings at night, we had about seven people show up, and now it's pretty routine that we have over 50. And I think that's because once you have a bunch of great people who are committed to a goal and they start to see success, it's fun. It's fun to be part of that and you want to be part of it because it's meaningful work, it's important work, and you're succeeding, and you're achieving goals that are really good and they're important. And so, I think that's all part of it, and I think there's a lot of corollaries, right?

I mean, I think that we have to generate a place where people feel free to speak and create psychological safety for it. We have to try to engage people in the room. Not everybody's an extrovert, some people are introverts. But boy, I think that the real key is to articulate the vision. And boy, when you see results, and when you generate success, and you're working side by side with people who you really like and admire, that's pretty rewarding and that makes coming to work fun. And so I think all of these things were part of it, Dale. And we're not there, I mean, this is still a work in progress, but they all add up. And it's actually kind of gratifying to hear from, especially the surgeons who aren't, they're not direct reports to me, but they really enjoy the work and they very much enjoy working on time to treat.

Dale Shepard, MD, PhD: What part of this are you most proud of?

Brian Bolwell, MD: I'm always most proud of the people, Dale. I mean, I think that we've been able to add an awful lot of really good people within the cancer center and people who work in other institutes who are part of the cancer center. I'm very proud that we got the organization to start to focus on time to treat. So, I mean, it was a concept that nobody else at the Cleveland Clinic really knew much about. Now I think it's pretty common within our organization. And then we tried to make it national. We've published our results and we've shown that as I said earlier, that for some diseases, time to treat actually does influence survival.

And I'd like to think that we've made a part of the national dialogue. I'd actually like to see it a bigger part of the national dialogue because I think it's really important, but I think it's started. And I think that that's a good thing too. But at the end of the day, you do things because it's the right thing to do. And having values like integrity and honesty sound good, but you've got to live them. You can't just say them. And I'm very proud that collectively as a group, I think we live those values.

Dale Shepard, MD, PhD: I mean, clearly, this is a very, very important topic and initiative. And so I guess as a final question, what advice would you give to other physicians that may be listening, to other institutions that they try to set upon this? What sort of guidance would you give to them in terms of how to get this started?

Brian Bolwell, MD: Well, I think number one is you start with the vision and you've got to have people who say, "Yeah, it's important and let's dive in and do the work." And so if you can get that initial buy-in, that's step one. And then I think step two is that you've got to resource it. I mean, you've got to help docs out. They can't schedule meeting on their own, so you got to have some project managers to lend a hand and to kind of do a lot of operational things. And then I think you've got to generate the teams. I think that you've got to create a spirit of a program, so you've got stakeholders from surgery, from radiation, from medical oncology, from nursing, from imaging, from whatever, all participating as a group. And then you could see wins pretty quickly.

I think that for most cancer centers if their average time to treat is something like 44 days, there are probably some relatively low hanging fruit to generate some initial wins. And once you get those wins, then things really start to go forward in a very positive way. Because again, people enjoy working on meaningful work that's generating success. If you can do those things, I think anybody can do this work, but boy, you've got to stay committed and you've got to have a passion for it.

Dale Shepard, MD, PhD: Well, that's really great. And it's great that you've gotten this all put together and the patients are truly benefiting from it. So, thanks a lot for being with us today and discussing this important topic.

Brian Bolwell, MD: Thank you very much for having me, Dale.

Dale Shepard, MD, PhD: This concludes this episode of Cancer Advances. You will find additional podcast episodes on our website, clevelandclinic.org/canceradvancespodcast. Subscribe to the podcast on iTunes, Google Play, Spotify, SoundCloud, or wherever you listen to podcasts. And don't forget, you can access real-time updates from Cleveland Clinic's Cancer Center experts on our Consult QD website at consultqd.clevelandclinic.org/cancer. Thank you for listening. Please join us again soon.