This article was originally featured in Brigham Health Hub.
Louise I. Schneider, MD, Division of Internal Medicine and Primary Care at BWH, and member of the Dana-Farber/Brigham and Women’s Cancer Center
Sometimes, a routine medical examination leads to more questions than answers. But for patients with suspicious and complex symptoms that point to cancer, not receiving concrete answers about their diagnosis right away can be especially scary.
Take, for instance, a patient who met with her primary care physician (PCP) for a routine lung cancer screening. While a chest CT scan didn’t show signs of lung cancer, it did reveal a bone lesion and pathologic rib fracture, a form of rib injury caused by disease rather than blunt trauma. Additional tests suggested cancer, but her doctor wasn’t sure.
Such a patient poses an unusual challenge. A referral to an appropriate oncologist is difficult because a cancer diagnosis has not been made, but the next steps in the diagnostic workup aren’t always clear either for PCPs. Yet the prospect of a cancer diagnosis also creates stress, so everyone wants answers as soon as possible.
The Cancer Diagnostic Service (CDS) at Dana-Farber/Brigham and Women’s Cancer Center (DF/BWCC) aims to alleviate that uncertainty and make the determination of a cancer diagnosis faster and simpler for patients and their providers. Initially piloted as a virtual clinic to help Partners-affiliated PCPs streamline and expedite a diagnosis for patients with suspected cancer, the CDS recently graduated from its pilot phase and began seeing patients in its new physical space on the main campus.
While the service’s biggest users at the moment are PCPs within Partners, including those at Brigham and Women’s Hospital (BWH), it is expected to grow into a regional resource for referring physicians at other healthcare organizations as well.
“When there is a strong suspicion of cancer without a definitive diagnosis, it can be difficult for patients and physicians,” says Lindsay Carter, MD, MBA, medical director of the Cancer Diagnostic Service (CDS). “As doctors order additional diagnostics test for their patients or seek input on the appropriate next steps, there can be significant delays and unnecessary tests. We created the Cancer Diagnostic Service to streamline the process to help doctors reach a timely diagnosis so that treatment can begin without delays.”
The patient with suspicious findings on her lung CT was referred to the CDS, where she was diagnosed with adenocarcinoma—a form of cancer—following a CT-guided biopsy. She was then seamlessly transferred to a thoracic oncologist at Dana-Farber Cancer Institute (DFCI) to begin treatment.
During the center’s six-month pilot, which began in October 2016, providers used Epic’s E-consult function to consult virtually with CDS staff. Of the 82 cases evaluated by the clinic’s staff—an internist, physician assistant, and consulting BWH and DFCI oncology specialists—70 percent of patients were recommended for and received a full diagnostic work-up. Among that group, nearly two-thirds were ultimately diagnosed with cancer and referred to oncologists or surgeons.
The pilot generated an overwhelmingly positive response from PCPs. “It’s scary when your patient has cancer, and it was really nice to have someone guide you as you make diagnostic decisions,” wrote one physician in a feedback survey. Others praised the rapid response and seamless process in reaching a diagnosis.
With funding from the Brigham Care Redesign Incubator Startup Program (BCRISP) and DFCI, the CDS opened its physical space on October of 2017 in the Brigham Medical Specialties Suite at 45 Francis St. The team sees patients on Wednesday mornings and Friday afternoons. Patients are scheduled for an appointment within five business days of the referral.
“After a referral, the CDS takes ownership of each patient’s case and coordinates the diagnostic work-up. We communicate detailed results and a suggested treatment plan to both patients and referring providers,” says Ryan Leib, MBA, administrator for the CDS and director of analytics at Dana-Farber Cancer Institute.