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.
The following section highlights the positive outcomes, achievements, and impact of the AOCP project, underscoring its successful implementation. However, it is equally important to acknowledge the key challenges encountered during the project. By listing these challenges, healthcare professionals reading this document can be informed and better equipped to mitigate them when considering the replication of similar quality improvement projects.
The Advanced Ovarian Cancer Pathway (AOCP) project was a critical initiative undertaken by Dr Dominic Blake and Mr Stuart Rundle from the Northern Gynaecological Oncology Centre in the UK. The core objective of this project was to streamline the patient journey, minimise healthcare inequalities, and optimise the survival rates for advanced ovarian cancer patients. The project's focus was on the Northeast and North Cumbria region, known for its higher-than-average upfront surgery rate without a correlating survival advantage for the population.
To tackle these issues, the project implemented several key measures, including the establishment of a dedicated Multidisciplinary Team (MDT) involving experts in gynaecological oncology, radiology, pathology, medical oncology, clinical nurse specialist teams, and anaesthetics. This team was designed to facilitate optimal treatment decisions and data collection, enabling faster decision-making processes and prompt execution of interval surgeries.
In addition, the project introduced pre-treatment optimisation via dietary interventions and physiotherapy, known as a prehabilitation service. This measure was to maintain patients' physical conditions before treatment, an important factor considering the strain that cancer treatments often put on patients' bodies. Implementation, however, faced hurdles such as staff shortages and a lack of a sustainable dietetic pathway. Nevertheless, the project continued with funding from the Northern Cancer Alliance for a pilot study.
Furthermore, to reduce the financial burden on patients and improve access to clinical trials, AOCP developed a unique "single point of decision" clinic, aiming to establish a streamlined process for the treatment of advanced ovarian cancer patients. This clinic allowed prompt histological diagnosis and offered a treatment decision on the same day, considerably reducing the time from assessment to diagnosis and treatment.
Data collection and analysis played a vital role in the project. Measures were implemented to comprehend survival outcomes for advanced ovarian cancer patients. These included MDT discussions, diagnostic biopsies, access to a dietician, anaesthetic assessments, and the collection of cancer target data. To support this, a dedicated data manager was assigned to facilitate data collection and analysis for continuous improvement.
Despite its significant achievements, the project faced several challenges. These included re-arranging working patterns within the teams, adjusting clinic templates for new patient clinics, evaluating radiological staging investigations, and overcoming communication difficulties as patients moved between different departments on the same day. Furthermore, the project did not decrease the rate of open/close laparotomy, nor the time to treatment interval. Additionally, an unexpectedly high number of patients underwent neoadjuvant chemotherapy, and the influence of post-pandemic systemic stresses on treatment decisions is still under investigation.
Nevertheless, the AOCP project has been instrumental in transforming advanced ovarian cancer patient care in the region. The creation of an efficient, robust standard operating procedure, enhanced patient engagement in pathway development, and the establishment of a beneficial prehabilitation program are just a few of the project's significant successes. It also ensured equal access to prehabilitation resources for all women preparing for radical treatment, an important step in addressing healthcare inequalities.
Looking towards the future, the project team has learned several valuable lessons, such as the need for earlier involvement of a wider clinical team, more regular meetings and data reviews, and balanced imaging discussions. Improvements on the horizon include assigning a dedicated project manager, fostering wider team participation, enhancing team communication, improving the imaging review process, and developing a reliable patient tracking system. The high rate of patients undergoing neoadjuvant chemotherapy will also be investigated to better optimise treatment decisions.
In conclusion, the AOCP project represents a significant stride forward in the treatment and care of advanced ovarian cancer patients. It underscores the necessity for continuous improvement, adaptability, and data-driven decision making in the rapidly evolving landscape of healthcare. It has set a benchmark for future healthcare projects, demonstrating the impact that thoughtful, patient-centred pathways can have on patient outcomes and experiences.
Key Factors for success of AOCP are:
The success of the AOCP project can be attributed to these key factors, which contributed to enhanced collaboration, patient-centred care, and improved treatment outcomes for patients with advanced ovarian cancer.
Dedicated Multidisciplinary Team (MDT):
- Establishment of a collaborative MDT comprising various specialties.
- Effective communication and coordination among team members.
- Involvement of patients in the pathway development process.
- Placing patient experience and needs at the centre of the project.
Standard Operating Procedures (SOPs):
- Development of robust SOPs for advanced ovarian cancer patients.
- Clear guidelines and protocols for consistent and streamlined care.
- Accelerated the decision-making process for complex patients.
- Reduced the number of discussions before reaching treatment decisions.
Interval Surgery Pathway:
- Successful implementation of a pathway for patients suitable for interval debulking surgery.
- Timely and coordinated surgical planning and execution.
- Incorporation of a prehabilitation program for advanced ovarian cancer patients.
- Equal access to prehabilitation resources for all patients preparing for radical treatment.
- Monitoring and evaluation of patient outcomes and data analysis.
- Identification of areas for improvement and ongoing refinement of the pathway.
Key Questions and Limitations Encountered in the AOCP Project were:
The AOCP project faced several issues and limitations during its implementation, including challenges in working patterns, communication, staffing, and resource allocation. Delays and dissatisfaction were experienced in areas such as radiological staging evaluation and internal pathway communication. Surgical outcomes, time to treatment, and the need for comprehensive data analysis were also important considerations for improvement.
- Challenges in re-arranging working patterns within the teams involved.
- Difficulties in embedding changes into routine practice after the project.
Communication and Coordination:
- Challenges in communication as patients transferred between departments.
- Issues with appointment attendance and patient perception of value in certain assessments.
Staffing and Resource Allocation:
- Staff shortages affecting the incorporation of prehabilitation aspects.
- Reluctance to allocate staff from ward-based activity to the clinic.
Radiological Staging Evaluation:
- Challenges in the availability and evaluation of radiological staging investigations.
- Delays and dissatisfaction caused by unclear deadlines and sourcing of imaging.
Internal Pathway Communication:
- Difficulties in triaging cases into the AOCP pathway within the wider gynae-oncology service.
- Challenges in transportation and availability of patient records during the pathway.
- Failure to reduce the rate of open/close laparotomy.
- Unexpectedly high rate of patients undergoing neoadjuvant chemotherapy.
Time to Treatment:
- Inability to reduce the patient's time to treatment interval.
- Influence of systemic stresses in cancer treatment on decision-making timelines.
Data Analysis and Patient Outcomes:
- Need for further analysis and reflection on outcomes related to neoadjuvant chemotherapy.
- Patient impact, survival, quality of life, and experience requiring ongoing analysis as data matures.
Advanced Ovarian Cancer Pathway (AOCP)
Full Case Study (5-10 minute read)
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.
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.
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.
- Gynae-oncology clinic for clinical-surgical evaluation and discussion of preferences with a gynae-oncologist.
- Operative pre-assessment and cardio-pulmonary exercise test (CPEX) with a consultant anaesthetist.
- 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
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.
The One-Stop Clinic is an important aspect of the AOCP project that aims to help patients retain their physical condition before treatment.
The prehabilitation plan includes dietary interventions and physiotherapy. However, the incorporation of these aspects was challenging due to staff shortages.
Hospitals were reluctant to allocate staff from ward-based activity into the clinic. This led to patchy input from the team until late in the project. Despite sourcing the time of a dietician, a robust sustainable dietetic pathway was not achieved.
In the latter stages of the project, the trust was awarded funding for a prehabilitation pilot study for cancer patients from the Northern Cancer Alliance.
The colorectal and gynaecological oncology teams were offered to be part of the pilot. As the prehabilitation service became more established, it was found that there was capacity to offer all patients with advanced ovarian cancer receiving treatment prehabilitation.
Overall, prehabilitation is an important aspect of the AOCP project that requires adequate staffing and resources for its successful implementation.
Development of an interval surgery pathway:
For women with advanced ovarian cancer undergoing neoadjuvant chemotherapy has shown promising results. By streamlining the referral pathway and offering individualised surgical consultations prior to the third cycle of chemotherapy, a greater proportion of patients were listed for surgery within 4-6 weeks of administration of chemotherapy, avoiding treatment interruptions.
The pathway achieved this through these specific steps:
- Patient details were notified to the project leads after completing cycle two of chemotherapy.
- Patients underwent surgical consultations with a gynae-oncologist before cycle three and were listed for cytoreductive surgery four weeks after the planned date for cycle three of chemotherapy.
- MDT review of the interval CT scan took place before the proposed surgical date.
- A second consultation was arranged following MDT review to discuss the outcome, confirm the plan for surgery or continuation of chemotherapy.
Achievements of the interval surgery pathway:
- Identification and tracking of all referred patients with advanced ovarian cancer.
- Individualised timed surgical consultations and prospective surgical listing.
- MDT review of interval CT scans for surgical planning.
- Improved coordination and timely surgical planning to avoid treatment interruptions.
- Enhanced patient experience through clear communication and involvement in treatment decisions.
Challenges with communication were addressed by offering a telephone consultation with the surgical team prior to treatment to explain the process of work-up for interval surgery.
The pathway has the potential to achieve equivalent survival outcomes to primary surgery and adjuvant chemotherapy, provided a response to chemotherapy is seen at an interval assessment CT scan. Further research is needed to fully evaluate the effectiveness of this pathway.
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.
- Firstly, histopathology and medical oncology were incorporated into the MDT on a project-specific basis, which exceeded the project team's expectations.
- Secondly, dedicated same-week biopsy slots were underutilised, so this aspect of the pathway was withdrawn.
- 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.
- 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.
- 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
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 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.
Key findings include:
- 106 patients were identified for the advanced ovarian cancer MDT, with three later found to have non-gynaecological primary cancers.
- The median number of MDT discussions was two.
- Preoperative biopsies were performed for 99% of patients to ensure appropriate treatment.
- Treatment allocation: 25% underwent upfront surgery, 64% received neoadjuvant chemotherapy, and 9% had palliative treatment or no treatment.
- Out of 25 patients planned for primary debulking surgery, 23 received it as planned.
- Among 66 patients planned for neoadjuvant chemotherapy, six did not receive the intended treatment.
- The median time to starting neoadjuvant chemotherapy was 31 days from the first AOCP MDT, with some delays due to additional discussions and diagnostic requirements.
- The number of patients with histological ovarian cancer diagnoses exceeded initial plans, requiring adjustments in resource allocation.
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.
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.
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.