Ambulatory lung biopsy: a new model for the NHS. Dr Sam Hare Barnet Hospital Royal Free London NHS Trust

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1 Ambulatory lung biopsy: a new model for the NHS Dr Sam Hare Barnet Hospital Royal Free London NHS Trust

2 Lung cancer Leading cause of UK cancer mortality UK: 2 nd lowest European survival rate 62-day RTT is worse than other major cancers (78.5%) Many advances in non-surgical Rx Early diagnosis is key to improving survival rate

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6 Percutaneous CT-guided lung biopsy Pivotal in lung cancer diagnosis Increasing demand for tissue Patients with poor lung function are often delayed/ declined biopsy a paradoxical practice Can t get treated quicker unless you have a diagnosis

7 Referral Lung function Book bed Biopsy Inpatient bed 4-6 hours 4-6 hours No PTx Significant PTx Admit for underwater seal drain for hours Discharge

8 Referral Lung function Book bed Biopsy Inpatient bed 4-6 hours 4-6 hours No PTx Significant PTx Admit for underwater seal drain for hours Discharge

9 Is there another way?

10 Can it work in the NHS? Barnet model Integrated in-house radiology-delivered service No bed requirement No lung function requirement Early minute discharge (>99% patients) Biopsy performed as standard (no new expensive kit) HVCD for lung collapse patient still goes home

11 Results

12 Barnet Model Referral Biopsy 30 mins No pneumothorax & well Discharge

13 Heimlich valve chest drain (HVCD) Improved patient experience at a fraction of the cost

14 Outcomes - clinical 1032 outpatient lung biopsies since 2011 (231 in last 6 months) >99% successful early discharge rate >98% biopsies diagnostic MDT: tissue already available (gold standard) Smaller cancers & patients previously not biopsied Access new treatments: RFA; SABR; gene therapies Lung metastases (colorectal; melanoma; endometrial) A game changer

15 Outcomes - clinical Pathological confirmation rate in lung cancer >92% 73% increase in resection rates (2013) T1a (<2cm) cancers No intra-operative frozen section for 5 years huge efficiency savings in operating theatre time 85% lung biopsy referrals performed <7 days 38% performed <4 days Current service: ~10-12 outpatient lung biopsies/wk Earlier lung cancer diagnosis with cost savings

16 Outcomes - financial Saving at least bed hours per case in uncomplicated biopsy Saving at least 400/day (inc. a bed) in cases of significant pneumothorax Productivity allows 10x increased number of biopsies Referral of patients declined biopsy elsewhere More for less

17 Benefits- Patients Improved patient experience Avoids hospital admission Reduced psychological burden Earlier lung cancer diagnosis Access to novel treatments More tissue gained at 1 biopsy sitting

18 Case study: TG Lung biopsy procedure much quicker All patients should have access to the small drain

19 Benefits- respiratory service Safe biopsy even in more complex patients Expeditious, self-sufficient lung biopsy service Eliminated bed related delays in biopsy scheduling Respiratory inpatient bed day savings Respiratory clinical time savings Transformed the diagnostic pathway Biopsies done without delay

20 Benefits- NHS World class lung biopsy practice: early diagnosis Frees up beds Efficiency savings (QIIP) 90% direct cost-saving using ambulatory HVCD ( 36) versus standard inpatient management of PTx ( 400) Shorter RTTs Shorter operating times (45 mins frozen section = 1 lung resection or 2 VATS lung surgeries)

21 NHS 5-year Forward View What will the future look like? Networks of care -> Scaleable nationally in small and large hospitals (infrastructure already in place; no real barriers) Out of hospital care needs to become a much larger part -> Ambulatory PTx management at home Integrate services around patient; best experience for patients -> Patient-centred management reduces psychological burden We should learn much faster from the best examples, not just from within the UK but internationally -> Pioneered in Ottawa (Canada) but this is a European first Best value for money -> 90% cost savings vs. standard practice

22 Scaleable

23 Throughout pathway: consider entry into a research trial offer supportive & palliative care, e.g. by LCNS, GP, specialists in palliative care encourage smoking cessation NICE referral guidance CT not indicated National Optimal Clinical Pathway for suspected and confirmed lung cancer: Referral to treatment Maximum times High clinical suspicion? Yes No No GP Urgent or routine CXR CXR (reported before patient leaves dept.) suspicious of lung cancer? Direct referral criteria (NICE) Hospitals referrals (A&E, internal or incidental findings) for suspected lung cancer CT within 24 hours if clinically indicated; inpatients seen within 48 hours by acute oncology, respiratory and/or palliative services Day -3-0 Y CT same day / within es 72 hours CT suspicious of lung cancer? Day 0-3 CT abnormal? Yes No TRIAGE (by radiology or respiratory medicine according to local protocol) Lung cancer suspected? Ye s No Manage Yes No Day 1-5 Fast track lung cancer clinic. Meet LCNS. Diagnostic process plan / diagnostic planning meeting prior to clinic Treatment of co-morbidity and palliation / treatment of symptoms Suitable for potentially curative treatment?+ Yes No Lung cancer unlikely Further management according to local protocol with options of further management of CT findings by primary care or secondary care (see separate detailed algorithm) Curative Intent Management pathway* Test bundle requested at first OPA including at least: PET-CT and as required: detailed lung function and cardiac assessment / ECHO. Meet with LCNS and receive information. Further investigation(s) indicated? No Yes Will pathological diagnosis influence treatment and is potential treatment appropriate to patient s wishes? Yes No Investigations to yield maximum diagnostic AND staging information with least harm. Results available within 3 days for subtype and 10 days for molecular markers. Clinical diagnosis or patient preference means biopsy not required. Day 21 Day 28 Full MDT discussion of treatment options Further investigation(s)? No Yes Follow-up Lung Cancer Clinic Cancer Confirmed and treatment options discussed. Research trial considered. LCNS present Further discussion needed? No Yes No cancer: Manage/discharge Day 33 OPA with treating specialist (within 3 working days) *Refer to further pathway detail Day 42 Day 62 Maximum times Specialist palliative care Other palliative treatments Further investigation(s)? No First Treatment Chemotherapy Radiotherapy Yes Surgery + Low threshold for curative intent pathway; may discuss with wider MDT if unsure $ Some or all diagnosis and staging tests may be in a tertiary centre

24 Direct to biopsy variation?

25 STT plus ALB National Cancer Diagnostic Capacity Funding (NC&E London)

26 Summary Current lung biopsy practice: contributing to poorer lung cancer outcomes failed to evolve alongside new lung cancer treatments Early discharge & ambulatory HVCD to treat lung collapse are both safe Cost; efficiency; clinical time; and bed savings Improved patient experience and patient focused Earlier lung cancer diagnosis in more patients

27 @lungdiagnosis