Advanced Ovarian Cancer Pathway (AOCP) - Gateshead

Case Study Title:  Advanced Ovarian Cancer Pathway (AOCP)

Project Lead & Pilot location: Dr Dominic Blake & Mr Stuart Rundle from Northern Gynaecological Oncology Centre, Queen Elizabeth Hospital, Gateshead Health NHS Foundation Trust

Inequality Criteria: Age and location

Objective Criteria: Improve survival rates & access to care as well as improve patient experience

Pioneering a Streamlined Pathway for Advanced Ovarian Cancer: The innovative AOCP project aimed to improve the patient journey and access to care for advanced ovarian cancer patients. The project focused on addressing various issues and inequalities in healthcare provision, with the ultimate goal of improving survival and patient experience.

Advanced Ovarian Cancer Pathway (AOCP)

Full QI Project Read (10 minute read)

Project Aims:

Streamline the patient journey and improve survival by:

• Establishing a dedicated MDT for optimal treatment decisions and data collection.
• Ensuring histological diagnosis prior to treatment, including genomic testing.
• Providing pre-treatment optimisation through dietary interventions.

Enhance the patient experience by:

• Reducing hospital visits and financial burden.
• Decreasing time to diagnosis and treatment decisions.

Achieve equity in access to care by:

• Standardising care and management across healthcare providers.
• Addressing geographical challenges in accessing services.
• Incorporating prehabilitation, nutritional assessment, and physical activity.
• Enhancing data collection, including frailty assessments and patient-reported outcomes.

Issues & Background Information:

The Northeast and North Cumbria region of the UK experiences higher levels of social and economic deprivation compared to other parts of the country. This is associated with poorer cancer survival outcomes. Specialist gynaecological cancer surgery for the region is concentrated at the Gateshead Health NHS Foundation Trust. There are inequalities in healthcare provision across the region, leading to differences in patient care and experience. The proposed project aims to address these issues for patients with advanced ovarian cancer in several ways:

• Reducing financial burden and stress by minimising hospital visits through same day appointments.
• Speeding up diagnosis and treatment decision-making.
• Improving access to clinical trials, which are associated with better patient outcomes.
• Establishing equity of access to healthcare across the region.
• Incorporating prehabilitation early on to address nutrition and physical activity.
• Collecting patient data on frailty and quality of life to inform care.

The overall goals are reducing regional disparities in ovarian cancer care and improving patient experience and survival outcomes.

Significant Facts

Following the publication of data from the National Cancer Registration and Analysis Service (NCRAS) ovarian cancer audit feasibility pilot in January 2020, it was concluded that despite performing a higher than average proportion of upfront surgery, this did not translate to a survival advantage for the population, as would be expected.

Completion rates for upfront surgery and primary chemotherapy were suboptimal.  We discovered that 7% of patients undergoing upfront surgery did not go on to complete chemotherapy. Furthermore, 50% of patients having chemotherapy as primary treatment did not undergo interval surgery, potentially impacting survival outcomes.

There was an urgent need to address this through attention to several interrelated factors, including selection of patients into the best evidence-based initial treatment modality, pathway redesign, and streamlining of decision making. Detailed data collection was also necessary to allow future informed decisions for quality improvement processes.

Patient management needs to be prompt, streamlined and individualised to avoid issues:

• Most ovarian cancer patients present with advanced stage disease and have frailty, anaemia and nutritional depletion.
• Rapid deterioration of clinical fitness can render patients unfit for surgery or chemotherapy.
• Management decisions between primary cytoreductive surgery and neo-adjuvant chemotherapy are crucial. 
• Data analysis revealed a need for improved treatment selection and pathway redesign.
• Completion rates for upfront surgery and primary chemotherapy were suboptimal, potentially impacting survival outcomes.

Solution - project design

Context and Rationale:

The ovarian cancer service aims to develop a new pathway for the treatment of women with advanced ovarian cancer. The rationale behind this project is to establish a "single point of decision" clinic and multidisciplinary team (MDT) that can streamline the treatment process and incorporate comprehensive information on diagnosis, staging, and fitness for treatments. The goal is to provide a more efficient and supportive approach for women referred from various secondary care providers.

Description of Intervention:

Current Standard Pathway:

Currently, the standard pathway involves referral to the gynaecology MDT, followed by treatment recommendations based on CT scan findings and tumour markers.

The pathway may include neoadjuvant chemotherapy, primary cytoreductive surgery or best supportive care, with additional steps and discussions required for individualised treatment plans. The new pathway, known as the Advanced Ovarian Cancer Pathway (AOCP), identifies patients likely to have advanced ovarian cancer at the point of referral. These patients are appointed dedicated AOCP clinic slots, where they undergo a detailed clinical-surgical history, discuss treatment options, and attend a pre-assessment/CPEX clinic on the same day.

Histological diagnosis is arranged promptly, and all relevant information is discussed at the AOCP MDT, leading to an individualised treatment decision communicated to the patient on the same day.

New AOCP Pathway:

The AOCP pathway offers an efficient process with comprehensive assessments and decision-making, including surgical, radiological, anaesthetic, and nutritional input. It ensures timely diagnosis and treatment, regardless of geographical location, addressing current access inequalities.

The pathway aims to reduce the risk of operating on patients with non-gynaecological primary tumours and minimise open and close laparotomies by conducting detailed preoperative radiological assessments.

Additionally, AOCP improves healthcare provision by facilitating image-guided biopsy and access to allied health professions such as dietetics and physiotherapy.

Why the new Intervention will lead to Improvement:

The AOCP pathway is expected to improve survival outcomes by reducing the time from assessment to diagnosis and definitive treatment, minimising clinical deterioration after diagnosis. It addresses access inequalities to surgical teams and provides a targeted MDT discussion of patient and disease factors, resulting in a comprehensive treatment plan.

The pathway also aims to enhance surgical outcomes by identifying those unsuitable for surgery in the primary setting, either due lack of fitness or distribution of disease. By streamlining the management of advanced ovarian cancer, the intervention seeks to address healthcare inequalities and improve patient care.

Additional benefits of the new pathway:

In the long term, the AOCP pathway offers several additional benefits. Prospective enrolment of all patients allows measurement of key metrics, including time to treatment and pathway milestones. This data helps identify reasons for deviations from expected pathway goals, facilitating the development of interventions to overcome these challenges.

The pathway also aligns with key quality indicators outlined by the British Gynaecological Cancer Society, based on the NCRAS ovarian cancer audit feasibility pilot. Furthermore, the pathway ensures appropriate discussion and assessment of disease response for patients undergoing neoadjuvant chemotherapy, reducing treatment interruptions and optimising care.

The AOCP team is supported by a dedicated data manager to facilitate data collection and analysis for continuous improvement.

Implementation:

The AOCP pathway clinic and MDT required additional staffing resources and time commitment above normal and essential input into the decision-making process from AHP’s that do not usually contribute to core cancer MDT’s.

• Core MDT members: gynae-oncology, medical oncology, radiology, histopathology, oncology clinical nurse specialists.
• Non-core MDT members: pre-operative assessment anaesthetists, dietician, prehabilitation physiotherapist.

A project steering group was appointed to ensure clear decision making and accountability. The steering group also formulated and updated a set of clinical and administrative SOP’s for distribution to stakeholders to aid with the function of the pathway and to act as a reference for all involved clinical and administrative staff.

The Development of the AOCP MDT and 'One-Stop' Clinic:

The development of the AOCP clinic and MDT was aimed at streamlining the assessment process for patients with advanced ovarian cancer. The goal was to provide clinical-surgical evaluation, anaesthetic assessment, and objective measures of fitness for major surgery in a single day for patients with stage IIIB or above ovarian cancer.

1. Gynae-oncology clinic for clinical-surgical evaluation and discussion of preferences with a gynae-oncologist.
2. Operative pre-assessment and cardio-pulmonary exercise test (CPEX) with a consultant anaesthetist.
3. Consultation to receive the MDT outcome following discussion of the above, as well as the radiological staging CT scan +/- histology where a diagnostic biopsy had already been undertaken.

However, this ambitious project faced several challenges that needed to be overcome to ensure that patients received the best possible care.

Radiological Staging evaluation as part of MDT:

The evaluation of radiological staging investigations was also crucial to decision-making at the ovarian cancer MDT. Moving this evaluation to the AOCP MDT to enable the 'one-stop' decision model required adjustment to working practices for the consultant radiologist core MDT members. Initial challenges brought about by changes in radiology working primarily involved the availability of and time-for evaluation of relevant radiological investigations (staging CT scans). Failure to ensure clear deadlines for both referral into the AOCP MDT and sourcing of externally performed imaging (CT scans) at the start of the project led to some dissatisfaction with the AOCP MDT that allowed ad-hoc cases to be added and potentially impacted upon the quality of the MDT discussion until this issue was resolved.

Internal Pathway Communication:

Communication difficulties as patients transferred between departments as part of the same-day pathway were also a challenge. In the initial phase of the project, multiple anaesthetic CPEX pre-assessment appointments were wasted due to patients not attending, patients attending for gynae-oncology but being immediately evaluated as not suitable for surgery, or patients who were not suitable for surgery perceiving no value in operative pre-assessment at this point in the pathway. This led to understandable dissatisfaction with the pathway within the anaesthetic team due to the loss of valuable appointment time at a point when there was a co-incidental pressure from the COVID-19 recovery plan in elective surgery.

To overcome these challenges, an iterative set of patient information included with the clinic appointments was developed, which included notification of the whole-day nature of the assessment, with verbal confirmation of intent to attend by telephone.

Other minor challenges to the same-day pathway that persisted throughout the project included:

• communication and understanding from the wider gynae-oncology service for appropriate 'triage' of cases into the AOCP pathway
• transport between clinic appointments for frail individuals within limited timescales
• ensuring the availability of patient records for each step of the pathway on the day
• ensuring timely phlebotomy for patients on arrival
• ensuring the safety of all staff within the COVID-19 pandemic with relevant pre-appointment COVID-19 testing to enable CPEX assessment

Conclusion:

While there were several challenges that needed to be overcome during the development of the AOCP MDT and 'one-stop' clinic, these challenges were addressed through negotiation, alteration of working patterns, and improved communication. The result was a streamlined assessment process that provided patients with advanced ovarian cancer with timely and efficient care. The lessons learned from this project can be applied to other areas of healthcare where multidisciplinary teams are involved in patient care.

Major deviations for AOCP – conception to practice:

The AOCP clinic and MDT were developed with a broad plan in mind, and overall, the one-stop nature of the clinic followed this plan. However, there were some major deviations from the initial plan.

1. Firstly, histopathology and medical oncology were incorporated into the MDT on a project-specific basis, which exceeded the project team's expectations.
2. Secondly, dedicated same-week biopsy slots were underutilised, so this aspect of the pathway was withdrawn.
3. Thirdly, patients who were obviously not surgical candidates based on radiological findings at referral were excluded due to the effect of cancellation later in the pathway and the effect on un-utilised clinic resources.
4. Lastly, the inclusion of the patient cohort from the South Tees MDT was not possible due to unpredictable fluctuations in service provision at that site.
5. These deviations demonstrate the importance of flexibility and adaptability in healthcare projects.

Data and Measures 

Following the publication of the NCRAS data showing regional variation in outcomes for patients with advanced ovarian cancer, our department took a deep dive into our cohort of women to establish if there were any underlying reasons for our poorer survival outcomes. In our cohort, most strikingly, a significant proportion of women received upfront cytoreductive surgery for ovarian cancer (much higher than the national average).

Following upfront cytoreductive surgery, a number of women were too unwell to receive optimum cancer treatment with adjuvant chemotherapy. In addition, a number of patients never received treatment or did not receive gold standard treatment for the management of advanced ovarian cancer, which includes a combination of surgery and chemotherapy. It appeared that there was a regional variation in the rate of patients receiving discussion for interval cytoreductive surgery, and the reasons for this were unclear.

For this reason, we felt that a dedicated MDT was required to focus on the decision making of these patients, to determine if patients were fit enough to undergo upfront cytoreductive surgery (or surgery at all), ensure swift decision to treatment, and track patients through the patient pathway to ensure that all patients have the opportunity for discussion for consideration of interval surgery.

Section 1: Data Measures Chosen

• To improve the understanding of survival outcomes for advanced ovarian cancer patients, our department implemented data measures, including:
  
  Timely Multidisciplinary Team (MDT) discussions for all patients
• Diagnostic biopsies to determine appropriate chemo’ or surgery treatment
• Access to a dietician if necessary
• Anaesthetic assessments for treatment decisions
• Collection of relevant cancer target data
• Limiting MDT discussions to prevent decision fatigue – 1 or 2 only
  

Section 2: Outcome Measures

• The department established outcome measures to assess the effectiveness of interventions and improve patient management, which included:
• Option for surgery following neoadjuvant chemotherapy
• Collection of baseline clinic-pathological and operative data
• Identification of untreated patients for analysis
• Assessment of quality of life data at various stages
• Consideration of additional patient data, such as HADs scores and patient satisfaction
• Evaluation of patient survival once data matured

Pathway development:

A Standard Operating Procedure (SOP) was developed for the Advanced Ovarian Cancer Pathway (AOCP), including administrative guidelines, MDT pathway guidelines, and interval surgery pathway.

The MDT was supported by the pathology and medical oncology teams, who found it beneficial for additional work up time and decision-making regarding suitability for surgery vs. chemotherapy.

The anaesthetic team suggested working closely with the theatre scheduling team to fill short notice appointments. Communication could be improved with earlier identification of patients for MDT and pre-assessment appointments.

Clinical Data:

Clinical data showed that 99% of patients underwent preoperative biopsy, with 25% assigned to upfront surgery and 64% for neoadjuvant chemotherapy. QOL of life data and patient experience data are still being collected as more patients progress through the pathway.

Impacts & Results

What worked in the project

Successfully set up a dedicated multidisciplinary team (MDT) comprising gynaecological oncology, radiology, pathology, medical oncology, clinical nurse specialist teams, and anaesthetics.

• Engaged patients to ensure their experience was at the centre of pathway development.
• Developed robust standard operating procedures (SOPs) for advanced ovarian cancer patients.
• Implemented paired clinic appointments with anaesthetic pre-assessment slots to enable rapid assessment of fitness for surgery and pre-treatment optimisation.
• Established a pathway for patients suitable for interval debulking surgery.
• Incorporated the development of a prehabilitation program for advanced ovarian cancer patients.
• Speeded up the decision-making process for complex patients.
• Reduced the number of discussions before reaching a treatment decision.
• Facilitated interval surgery in a timely manner, bringing more patients within available evidence.
• Provided equal access to prehabilitation resources for all women in preparation for radical treatment.

Challenges within the project

• Did not reduce the rate of open/close laparotomy.
• Unexpectedly high rate of patients undergoing neoadjuvant chemotherapy (NACT) requires further analysis and reflection on outcomes.
• Did not reduce the patient’s time to treatment interval.
• Other systemic stresses in cancer treatment in the post-pandemic NHS may have affected the time to decision regarding optimal treatment.
• Impact on survival, patient outcomes, quality of life, and patient experience still needs to be analysed as the patient data matures.

Summary:

Upon reviewing the AOCP project, the steering group identified several areas for improvement. They recognised the need for earlier involvement of the wider clinical team to seek feedback and address potential issues in the pathway development. The importance of administrative staff was also acknowledged, emphasising the need for sufficient admin support during periods of sickness. The management of the MDT was found to be person-dependent, and it was recommended to manage it separately or with additional staff involvement to maintain the quality of MDT preparation. Involving allied health professionals and implementing rostered cover would help mitigate challenges during holidays and unplanned leave.

The discussion of imaging was a point of consideration, with the need for balancing the potential for overcalling or under calling CT findings, which would alter treatment strategy. More regular meetings and data reviews were deemed necessary to identify issues earlier and target units with capacity constraints. It was suggested that a project manager, separate from daily clinical care, should be assigned to facilitate regular stakeholder meetings. Person dependency within the pathway was recognised as a challenge, and efforts should be made to ensure sustainability and ongoing improvement in MDT triage.

Early involvement of wider MDT and service line managers was recommended to enhance understanding of influencing change and improve communication between departments. Patient engagement should be initiated earlier to ensure understanding and alignment with the proposed pathway plans. Providing regular updates and reminders to the wider team was seen as beneficial for change implementation and maintaining momentum. The difficulty in getting clinicians together due to schedules and work commitments highlighted the need to empower available team members to take a lead on specific aspects of the project, distributing responsibility rather than relying on a single leader.

These recommendations aim to enhance collaboration, communication, and sustainability within the project, ultimately improving the implementation and outcomes of the pathway.

Limitations – what we would do differently now:

Upon review of the AOCP pathway and the IMPROVEUK project, the following changes would be made in the future:

• Assign a dedicated project manager to oversee setup, implementation, and conclusion, allowing for greater oversight and flexibility in meeting with stakeholders.
• Increase administrative involvement in pathway development and establish separate steering groups for each MDT group during setup and implementation to identify logistical issues earlier.
• Conduct regular project meetings with the wider team for education and dissemination of information to foster better engagement and buy-in.
• Encourage wider team participation to avoid exclusion and logistical difficulties, ensuring that more members are involved in patient care and decision-making.
• Improve the imaging review process by allowing more time for discussion and planning, while avoiding overcalling or under calling of CT findings.
• Prevent aspects of the pathway from relying on specific individuals by creating dedicated time for weekly discussions to address any issues or concerns.
• Establish a reliable patient tracking system to ensure accurate monitoring of patients throughout their cancer journey, involving the entire hospital trust in achieving this goal.

Conclusion

In summary, the AOCP project successfully established a MDT and engaged patients to improve the pathway for advanced ovarian cancer patients. They developed standard operating procedures (SOPs) and implemented a prehabilitation program.

While they did not reduce the rate of open/close laparotomy or the time to treatment interval, the project aimed to speed up the decision-making process and facilitate interval surgery. The impact on survival, patient outcomes, quality of life, and patient experience will be analysed as the patient data matures. The unexpectedly high rate of patients undergoing neoadjuvant chemotherapy (NACT) will also be investigated further.