Implementing Standardized Ordering Pathways in a Breast Cancer Multidisciplinary Clinic Lifespan Cancer Institute,...

Timeliness of cancer care from diagnosis to implementation of systemic therapy is a quality metric and may impact patient outcomes. Estrogen receptor-positive human epidermal growth factor receptor 2-negative early-stage breast cancer genomic assays including the 21 gene recurrence score (21-RS) are prognostic for chemotherapy benefit, and results impact shared medical decision making. The Lifespan Cancer Institute (LCI) Breast Cancer Steering Committee (BCSC) Quality Team noted significant variation in turnaround time (TAT) from time of surgery to 21-RS report, resulting in significant delay in care recommendation. Breast cancer patients are seen by multidisciplinary teams at 4 LCI sites which can contribute to variability in care processes. The LCI BCSC consists of a multidisciplinary team of surgeons, medical oncologists (MO), pathologists, Breast Cancer Navigators (BCN) and other members. The BCSC initiated a quality improvement project to address process variance and barriers to efficient and consistent 21-gene RS order and tissue send-out.

Two steps in 21-RS order were identified for intervention. 1. MO and BCN share an electronic medical record (EMR) results box including pathology reports. Breast surgeons will attach MO as electronic recipients to receive the surgical pathology report immediately on EMR sign out. MO and BCN will review pathology results and initiate 21-RS orders per American Society of Oncology (ASCO) guidelines. 2. Pathologists will identify appropriate tissue block for 21-RS at time of sign out to facilitate pathology staff block selection for tissue send out. Data was extracted by Exact Science (ES) from the 21-RS electronic order database. TAT from surgery to 21-RS ordering and TATf rom surgery to results return were provided. We examined TAT prior to intervention (January-April 2023 n = 69 orders) and after intervention (August-October 2023 n=53 orders).

The baseline average time from surgery to 21-RS order was 16 days preintervention and 10-days post-intervention, resulting in a total decrease of 6 days from surgery to order. As such, date of surgery to 21-RS report return decreased from 27 to 21 days.

Multidisciplinary discussion of quality issues in our LCI BCSC is an effective way to identify barriers to care and initiate a plan-do study-act quality improvement process. LCI BCSC has established a consistent streamlined process for 21-RS orders. Attaching MO to pathology reports and pre-selecting slides for send-out has reduced the internal processing time for 21-RS order results by 6 days. The process will be examined for TAT twice a year and presented to the BCSC for ongoing process improvement. This project focused on timely patient-centric care and reducing patient anxiety.