Setting the Standard: Cleveland Clinic Children’s First-in-Nation Pediatric Cancer Accreditation

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, Director of International Programs for the Cancer Institute and co-director of the Sarcoma Program at Cleveland Clinic. Today I'm happy to be joined by Dr. Matteo Trucco, Director of Cleveland Clinic Children's Cancer Innovative Therapy Program. Matteo was previously a guest on this podcast to discuss the National Ewing Tumor Board and the early phase drug trials program in the Cleveland Clinic Children's Cancer Innovative Therapy Program. Those episodes are still available for you to listen to. He is here today to discuss advancing pediatric cancer care through Commission on Cancer's Pediatric Cancer Accreditation, so welcome back.

Matteo Trucco, MD: Great to be back. Thanks for having me.

Dale Shepard, MD, PhD: So remind us a little bit about what you do here at Cleveland Clinic.

Matteo Trucco, MD: So I am a pediatric oncologist. I take care of kids with bone and muscle tumors, same ones you take care of, but the younger variety. Because our therapies are not very good, I help develop new treatments and in recent years I've also taken some administrative roles within our department as well.

Dale Shepard, MD, PhD: Excellent. So today we're going to talk about the Cleveland Clinic Children's getting a recent accreditation, a pediatric cancer sub accreditation through the Commission on Cancer. So let's take a step back. What does this sort of accreditation in general mean and then talk a little bit about the pediatric side.

Matteo Trucco, MD: So the Commission on Cancer kind of sets guidelines of what a cancer center should be doing to say that they're performing at the highest bar. So there's a series of several standards that one needs to meet. And up until literally last year, there was no specific accreditation for pediatric cancer, which is different, similar but different, than adult cancer. And so when we first heard that they were coming out with this subcommittee accreditation, we actually worked very closely with the Commission on Cancer on actually developing those guidelines because they were trying to apply some adult standards to pediatric cancers which don't really line up. And so as we were going through the process of getting ready for the accreditation, we worked very closely with them on kind of adapting what they were asking to more align with pediatric cancer.

Dale Shepard, MD, PhD: And so what are some examples of things that maybe a pediatric program would need to have, but you would not need to have that would be required say in an adult program.

Matteo Trucco, MD: If anything I would say the needs are probably similar, it's how you're measuring them. But for example, we need all the psychosocial support just like the adult side does. One of the things that we look at, for example, is education for the patients is something that our patients need to continue their schooling, an adult patient probably does not. Rehab and rehabilitation is also very much built into it, nutritional support, all those things. It's just how exactly the nuances that they relate to pediatrics versus how they relate to the adult world. But then something as simple as how many cases you need to review. Well, when you're talking about breast cancer where you have 200 plus cases a year in the United States, that's fine. In pediatrics you only have 16,000 cases total of all pediatric cancer. So if you want to drill down to make sure you're meeting the guidelines for any specific histology, you're talking a much smaller number. And so nuances like that need to be adjusted for pediatrics.

Dale Shepard, MD, PhD: And I guess education came to mind as you were talking about it, I guess for most of the patients, it's educating the patient and parents. And so it takes on a little bit of a different tone. So you work closely with the Commission on Cancer and you were the first of the designated pediatric cancer centers to get the accreditation, correct?

Matteo Trucco, MD: Yeah. So we went through a whole year of meeting the standards, demonstrating that we meet the standards. And in a way, the way I've kind of looked at it, and the Commission also sort of looks at it this way, is you're probably doing the work already. You just need a document that you're doing it and make sure. And every once in a while you find something that, okay, you're not quite meeting the standard and so you have to troubleshoot, figure out why you're not meeting that.

So we went a whole year of having quarterly meetings, demonstrating that we're meeting the criteria and the standards, documenting all that. Then we submitted our application with all the documentation that we were meeting the standards. They reviewed those. We continued to meet quarterly and continued to meet those standards. And then they actually did a site visit back in the fall and went over everything with us, had a tour in conjunction with the visit they were doing to continue the accreditation that the adult cancer center had. And then a few weeks later we got notice that they approved our accreditation. So yes, we are technically the first ones.

Dale Shepard, MD, PhD: And then how long does that accreditation when you need to renew then?

Matteo Trucco, MD: They visit every three years, but in the meantime, you have to have these quarterly meetings where you have to specifically go over every single standard, split up among the four meetings every year. And then demonstrate that you have a quality improvement project, you have some kind of programmatic project that you're working on, all to try to advance the field and the work that we're doing to try to again, meet that highest level of care that we deliver for our patients.

Dale Shepard, MD, PhD: I guess as pioneers in the process, was there anything along the way that came up as like, maybe we should not necessarily emphasize this in the future, or we really need to take a closer look at something else?

Matteo Trucco, MD: Yeah, some of the pathology as mentioned, was challenging because again, they want you to do kind of deep dive to make sure you're meeting all the criteria for certain things and reviewing a certain number of cases. But then it dawned on the commission that the numbers we're expecting are not reachable by any pediatric program. We noticed something about attendance to say our tumor boards and we have great ancillary staff with radiology and then radiation oncology and surgeons of various kinds, except if that one person is on vacation or at a meeting or something, everything falls apart. That is our radiation oncologist. And so we've had to kind of build in alternates. So that was something that very much came into play. And again, it's probably unique to pediatrics because on the adult side, you guys have a lot more surgeons, you guys have a lot more radiologists and radiation oncologists versus we don't have that many pediatric subspecialized specialists.

Dale Shepard, MD, PhD: Makes sense. When you went through the process, I guess when you do this, it's a multidisciplinary approach and you have to be showing multidisciplinary care. Was it productive from the standpoint of team building?

Matteo Trucco, MD: Yeah, it was certainly like herding cats trying to get everybody, but even I know the radiologists that I interact with, but I met a lot more of them in the process of this. I got to know the rehab folk a lot better. Basically you just kind of put more of a face to the name and have a deeper dive in everything that everybody does as you're documenting how many of our patients they're seeing, how many lives they're touching in various aspects. And it's impressive to see how many people are collaborating to help each of our patients. So certainly it kind of helped bond everybody and everybody's seeing what everyone else is doing.

Dale Shepard, MD, PhD: So part of the process, there's a quality improvement project that's done as part of this. Is that correct?

Matteo Trucco, MD: Yeah.

Dale Shepard, MD, PhD: And so what did you guys do from a quality improvement project?

Matteo Trucco, MD: Yeah, so one of the ones we worked on was making sure that we do pregnancy testing on all of our patients of childbearing potential. Had not standardized that process, but we're giving potentially toxic medications to a fetus. We got to make sure the patient's not pregnant. And so coming up with a much more rigorous and standard approach for that was one of the projects we did.

Dale Shepard, MD, PhD: Yeah, that's good. To what extent are things like clinical research part of the accreditation?

Matteo Trucco, MD: That you have clinical research and the percentage of enrollments. So they want to show that at least 50% of eligible patients are enrolled on a clinical trial. And we actually far exceeded that, we were more like 75%. And they want to again show that you're keeping track of all the trials you have. You have a process for evaluating patients to see if they're eligible for a trial for approaching them. So we had to write SOPs for these various processes, which yes, I see a patient, mentally, I run through the trials we have, and I'll consider whether they're eligible or not. But they wanted to show that documentation and that process of formally writing down how we do it, is helpful to get everybody on the same page, for sure.

Dale Shepard, MD, PhD: Yeah. What are the sorts of things that maybe got put in place in terms of quality projects, like you just mentioned about the trial accruals and things like that. What's going to be continuing efforts and where is this going to grow to take the momentum that you built and keep it moving forward?

Matteo Trucco, MD: Yeah, so again, the biggest work involved was documenting what we're already doing, formalizing the processes that we're doing. Every year we're picking a quality improvement project or a programmatic goal or something that we're going to as a team work on, so that continues.

Now that we're accredited and as more pediatric sites get accredited, the nice thing is that they have a database, the Commission on Cancer has a database, where all the information from all the pediatric centers and the adult centers, gets collected so that then you can measure your performance against the mean or other centers. And so that is very helpful. And you can tap into it as like, are we seeing more of a certain histology in our center versus someone else? You can also evaluate how we're treating patients, how our outcomes are compared to other places, which again is all used to grow and improve.

Dale Shepard, MD, PhD: When you think about, you of course, work closely with the Commission on Cancer to set this up, what kind of guidance do you give other places? Wide range of people might be listening in, maybe someone says, "Hey, maybe we should start doing this." What's the best place you'd recommend to start? What are the kind of things that you thought were the biggest challenges or opportunities? What kind of advice would you give?

Matteo Trucco, MD: Yeah, so now going to their website, the Commission on Cancer has a website and they have their standards and really just sitting down and reading through them, you need to do that. The tricky thing was when we were starting to apply, we didn't have the pediatric standards yet, and so we were using the adult standards and trying to fit that in. Eventually we had the pediatric ones and that helped. So reading those standards is essential. It is telling you what they want and you can't achieve it until you know what they want. So that's incredibly helpful. And then get your ducks in a row, pick a champion from surgical oncology, radiology, radiation oncology, pathology, and build that core team, find the alternates which are essential and all the support teams, psychology, rehab, social work, nursing, and develop that team. And then the hardest part is find a time that you guys can all meet pretty regularly.

Again, it seems silly, but we meet at 7 o'clock on a Wednesday every three months. And then just start early and go through things systematically. And then having an administrator, we actually went through several, not because we burned through them, but Patty Balko was the one that kind of started in working with the Commission on Cancer. And then she was given an opportunity that she couldn't pass up, and so she took that job. We had Andrew fill in from Taussig to help out as we were in the application process. And then Jessica Price joined us as we were going through the site visit. But she's been fantastic ever since, keeping us all on task, keeping us on track, reminding us that, "Hey, you're due for X, Y and Z to present next week," or something like that. That's essential. So getting those people that really see the value of this and championing it.

Dale Shepard, MD, PhD: Well, it's always a pleasure to work with the multidisciplinary group over in pediatrics and so well-deserved. Congratulations on the accreditation.

Matteo Trucco, MD: And truly a team effort. I mean, everybody chipped in, everybody stepped up. And without everybody doing that, we wouldn't have gotten it. And again, I think it's a reflection of the great work we're already doing, just kind of making it formal.

Dale Shepard, MD, PhD: There we go. Well, again, congratulations and thanks for sharing your insights.

Matteo Trucco, MD: Thank you.

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