Collaborative approach to national implementation of Standardization Pathology Reporting. June 2014 Avril Kwiatkowski

Transcription

1 Collaborative approach to national implementation of Standardization Pathology Reporting June 2014 Avril Kwiatkowski

2 Overview 1. Partnership role and mandate 2. Clinical value and impact of Synoptic Reporting 3. National Initiative Strategies 4. Current State Summary and Future directions 5. Successes and Lessons learned to date 2

3 Canadian Partnership Against Cancer Funded as arms length not-for-profit organization by the Federal government of Canada The Partnership works on a collaborative model through interactions with varying levels across jurisdictions to support actions to strengthen the cancer control system 3

4 The Partnership: A brief history 44

5 Cancer Control Portfolios Person-Centred Perspective Prevention : CLASP Canadian Partnership for Tomorrow Project Screening Diagnosis and Clinical Care System Performance First Nations, Inuit and Métis Includes Synoptic Reporting Initiatives 5

6 Standardizing the format and content of pathology reports Narrative Report Narrative - not divided into question/answer pairs Synoptic Report Diagnostic or prognostic parameter pair listed on separate lines Narrative Report Patient Name: Jane Doe Date of Birth: 14/11/51 Age/Sex: 52/F Unit Number: Location: LAB Status: REG REF Health Card#: DIAGNOSIS: MODIFIED RADICAL MASTECTOMY SPECIMEN (LEFT): - INVASIVE DUCTAL CARCINOMA. (see microscopic) - METASTATIC DUCTAL CARCINOMA INVOLVING AXILLARY LYMPH NODE. (see microscopic) GROSS DESCRIPTION: This modified radical mastectomy consists of an ellipse of skin measuring 13 cm ML x 7 cm SI with underlying fibrofatty breast tissue measuring 18 cm ML x 8.5 cm SI x 4.5 cm AP. There is an axillary tail measuring 8 x 5 x 3 cm. A normal nipple and areola, the latter measuring 2.8 cm in diameter are present. On the upper outer aspect of the skin, there is a 2 cm healed transverse scar. The outer aspect of the specimen is painted with marking ink. On sectioning the breast, there is a firm tan-gray tumour nodule measuring 3 x 2 x 1 cm, located in the left upper quadrant. The remainder of the breast consists of fatty tissue admixed with white streaks of breast stroma. The tumour is 1 cm from the closest (deep) margin. Nine lymph nodes are identified in the axillary fat. They range from 0.5 to 1.2 cm in greatest dimension. MICROSCOPIC DESCRIPTION: Sections of the breast reveal an infiltrating ductal carcinoma of usual type. There is moderate tubule formation (2/3) and the nuclei show moderate degree of pleomorphism. There are approximately 8 mitoses per 10 high power fields. The modified Bloom-Richardson grade is 2/3. A minor intraductal component with a cribriform and comedo growth patterns, nuclear grade 2, is present. Focal lymphovascular space invasion is seen. There is no involvement of the skin or nipple. The margins are clear. One of 9 lymph nodes from the axilla contains metastatic ductal carcinoma. The greatest diameter of the tumour is 5 mm and there is no evidence of extranodal spread. True Synoptic Report Specimen type left modified radical mastectomy Tumour site left outer upper quadrant Tumour size 3 x 2 x 1 cm Histologic type ductal, NOS Histologic grade 2/3 (modified SBR) tubules 2/3; nuclei 2/3; mitoses 2/3 Margins uninvolved by invasive carcinoma Distance to closest margin 1 cm to deep margin Number of nodes examined 9 Immunohistochemistry for estrogen receptor (ER) shows extensive positive nuclear staining. The progesterone receptor and Her-2 (CerB2) markers are negative. 6

7 Key dimensions of quality Timeliness The amount of time to generate/obtain the final pathology report. Accuracy Describes accurate diagnosis of a specific cancer and accurate prognostic and predictive factors Completeness Reports are complete with all required diagnostic, prognostic and predictive information for the purpose of clinical decisionmaking. Usability Ease of reading reports and finding information required for clinical decision making Source: Cancer Care Ontario 7

8 Impacts to Completeness Percentage Complete (%) Disease site Synoptic Narrative Source: Srigley JR, McGowan T, et al.: Standardized Synoptic Cancer Pathology Reporting: A Population-Based Approach. J. Surg. Oncol. 2009;99:

9 Prostate margin rates can be analyzed without labour-intensive manual audits Percent of Reports with Postive Margins Data use: Informing indicators to change practice Report by period in Time Percentage of pt2 radical prostatectomy reports with positive margins, by year for Ontario (June 2008 December 2011) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Grand Total Negative Positive % Margin Positive 37% 22% 20% 21% 21% Report by Region Percent of synoptic pt2 radical prostatectomy reports with positive margins, by LHIN (Jan Dec 2011). Report by hospital Percent of synoptic pt2 radical prostatectomy reports with positive margins by hospital, within Region D (Jan Dec 2011) Data Source: Cancer Care Ontario 9

10 Surgical indicators are being drilled down to MD level, with possible dissemination directly to physicians Report by Pathologist Report by Surgeon Data Source: Cancer Care Ontario 10

11 Showcasing implementation & demonstrating value Examples of success with pilot implementations of synoptic pathology reporting in Ontario and New Brunswick during the National Staging Initiative: 1. Video was developed showcasing the value of synoptic reporting based New Brunswick s experience: /chi12_124_4_cpac_en.wmv 11

12 Showcasing implementation & demonstrating value 2. Article published by Cancer Care Ontario in the Journal of Oncology Practice Highlights indicators and outcomes 12

13 Physician survey in June 2010 confirmed preference for synoptic reporting of cancer pathology Survey sample size = 27 hospitals; 970 Clinicians Speciality Area Correlation between overall satisfaction with the level of information provided by standardized synoptic reports. Reports are complete for the purpose of clinical decision making Ease of finding information required for clinical decision making Facilitates consistent approach to Clinician diagnostic and prognostic factors ** Correlation is significant at the 0.01 level Response Rate Pathologist 171/252 (68%) Surgeon 180/462 (39%) Medical Oncologist 58/128 (45%) Radiation Oncologist 69/128 (55%) Overall 51%.750** NA Pathologist.663**.510**.717**.638** Overall Satisfaction Score (Scale 1-5; with 5 = significantly better than narrative reports) Your overall satisfaction with synoptic pathology reporting process* Your overall satisfaction level with the information provided by synoptic reports. Clinicians Mean (SD) Pathologists Mean (SD) 4.52 (.991) 4.08 (1.34) 4.85 (.901) 4.08 (1.44) * Dependent t-tests were conducted to compare the differences in the mean scores of pathologists and clinicians perceptions of overall satisfaction indicating a statistically significant difference in scores for overall satisfaction with the synoptic reporting process [ t (169) = 3.044, p =.003]. Data Source: Cancer Care Ontario 13

14 Goals of the ESPRI Initiative Support adoption & advance implementation of electronic synoptic pathology reporting for Breast, Colorectal, Lung, Prostate & Endometrial cancers Maintain and promote adoption of standards Advance the use of standardized data through performance indicators 14

15 Scope of Initiative work 1. Planning and implementation of electronic synoptic pathology resection reporting in discrete field formats (level 5-6) for Breast, Colorectal, Lung, Prostate and Endometrial cancers utilizing the mandatory elements of the CAP Cancer protocols 2. Enabling the electronic generation of indicators to measure: Compliance to the CAP Cancer protocols (% of reports and institutions leveraging discrete field formats) Completeness (% of mandatory fields complete) Potentially derivable clinical indicators 3. Integration of electronic synoptic pathology data into existing e- Health infrastructure 15

16 Levels for Synoptic Pathology Reporting (Level 1-2) (Level 3-4) (Level 5-6) Narrative Report Patient Name: Jane Doe Date of Birth: 14/11/51 Age/Sex: 52/F Unit Number: Location: LAB Status: REG REF Health Card#: DIAGNOSIS: MODIFIED RADICAL MASTECTOMY SPECIMEN (LEFT): - INVASIVE DUCTAL CARCINOMA. (see microscopic) - METASTATIC DUCTAL CARCINOMA INVOLVING AXILLARY LYMPH NODE. (see microscopic) GROSS DESCRIPTION: This modified radical mastectomy consists of an ellipse of skin measuring 13 cm ML x 7 cm SI with underlying fibrofatty breast tissue measuring 18 cm ML x 8.5 cm SI x 4.5 cm AP. There is an axillary tail measuring 8 x 5 x 3 cm. A normal nipple and areola, the latter measuring 2.8 cm in diameter are present. On the upper outer aspect of the skin, there is a 2 cm healed transverse scar. The outer aspect of the specimen is painted with marking ink. On sectioning the breast, there is a firm tan-gray tumour nodule measuring 3 x 2 x 1 cm, located in the left upper quadrant. The remainder of the breast consists of fatty tissue admixed with white streaks of breast stroma. The tumour is 1 cm from the closest (deep) margin. Nine lymph nodes are identified in the axillary fat. They range from 0.5 to 1.2 cm in greatest dimension. MICROSCOPIC DESCRIPTION: Sections of the breast reveal an infiltrating ductal carcinoma of usual type. There is moderate tubule formation (2/3) and the nuclei show moderate degree of pleomorphism. There are approximately 8 mitoses per 10 high power fields. The modified Bloom-Richardson grade is 2/3. A minor intraductal component with a cribriform and comedo growth patterns, nuclear grade 2, is present. Focal lymphovascular space invasion is seen. There is no involvement of the skin or nipple. The margins are clear. One of 9 lymph nodes from the axilla contains metastatic ductal carcinoma. The greatest diameter of the tumour is 5 mm and there is no evidence of extranodal spread. Immunohistochemistry for estrogen receptor (ER) shows extensive positive nuclear staining. The progesterone receptor and Her-2 (CerB2) markers are negative. GROSS DESCRIPTION: Modified radical mastectomy consists of an ellipse of skin measuring 13 ML x 7 cm SI with underlying fibrofatty breast tissue measuring 18 cm ML x 8.5 cm SI x 4.5 cm AP. Axillary tail measures 8x5x3cm. Normal nipple and areola measuring 2.8 cm diameter. MICROSCOPIC DESCRIPTION: Invasive Tumour Size: 3 x 2 x 1 cm Type: infiltrating ductal carcinoma Grade: 2/3 (tubules 2/3; nuclei 2/3; mitoses 2/3; 8 mitoses/10 HPF) Lymph nodes: 1/9 contains metastatic ductal carcinoma. Specimen type radical mastectomy Tumour site upper quadrant Tumour size Histologic type - left modified - left outer - 3 x 2 x 1 cm - ductal, 16

17 Clinical Indicator Recommendations from Site-Specific Expert Panels Breast Expert Panel Histologic type distribution Histologic grade distribution Lymph vascular involvement Lymph node status Tumour size distribution Colorectal Expert Panel Lymph node retrieval Radial margins (rectal cancer) Quality of TME (rectal cancer) MSI immunohistochemistry Stage distribution Lung Expert Panel Number of lymph nodes examined Number of lymph nodes positive Histologic type distribution Stage distribution Margin status Prostate Expert Panel Gleason score distribution (total, primary, secondary & tertiary) Stage distribution Margin distribution PT2 margin positivity rate 17

18 Details to support standardized reporting 18

19 Phases of highly complex Initiative ESPRI divided into 2 phases planning & implementation Planning phase - analyze current state, identify desired outcomes, and develop detailed project plans. Implementation phase - put project plans into action and realize the goals of the earlier planning phase. Mar 2012 Jul 2012 Jul Oct 2013 Nov Mar 2017 Initiative Kick-off Provincial Planning Phase Provincial Implementation Phase 19

20 Accomplishments to Date July 2008 Feb 2009 Jul 2009 Jul 2010 Mar 2011 Sept 2011 Partnership introduces National Staging Initiative and role of Synoptic Pathology at annual CAP-ACP meeting National Pathology Standards Committee convened to inform Pathology Strategy Canadian Association of Pathologists (CAP-ACP) endorsed the College of American Pathologists (CAP) Cancer protocols as pan-canadian content standard for all cancer pathology reporting MOU was signed by CAP and CAP-ACP to gain additional Canadian representation to the CAP Cancer Committee and the CAP Protocol Review Panels CAP cancer protocols and staging protocols received Canadian Approved Standard (CAS) status from Canada Health Infoway (CHI). National Pathology and Staging Multidisciplinary Expert Panels for Breast, CRC, Lung and Prostate cancers convened and Canadian Reps to CAP Cancer Protocol Review Panels assigned 20

21 Continuing Collaboration to support adoption Aug 2012 Mar 2013 Jul 2013 Dec 2013 Jan 2014 Feb 2014 ESPRI Introductory WebEx with launch of planning phase in Feb 2013 National clinical feedback from Multidisciplinary Expert Panels submitted to College of American Pathologists Communities of Practice for specific vendors launched CPAC Board approved funding for provincial implementations under ESPRI Membership for Multidisciplinary expert panel for Endometrial cancer finalized Agreement on governance change for National Pathology Standards Committee to joint CPAC/CAP-ACP Cancer Care Advisory committee 21

22 Understanding Current State: Reports by disease site Figure 2: Distribution of pathology reports by disease site and province Note: 1. Data for 2011/12 1. PE does not do lung resections. 2. Data for AB, BC, NB, NS are for year 2011; PE data for 2012; MB data for Apr2012-Mar Endometrial for Moncton is 1.9% 22

23 Distribution of Pathologists and public laboratories across Canada Canada # Pathologists = 941 (100%) # of Public Labs= (1.4%) (N/A) 193 (16.3%) (23) % (11) % (N/A) % (1) % (N/A) % (N/A) 7 0.6% (2) NA: Not available Note: 1. The number in the bracket is the number of public laboratory. 2. For the percentage of pathologist, NB data covers the whole province. However for the number of public laboratory in the bracket, NB data is only for Moncton area % (1) % (9) 23

24 Program s Reach: Where are we moving to? By 2017, approximately 80% of Canadian pathologists will be reporting synoptically!! 24

25 Enabling collaboration through Pan- Canadian Activities Focus: To support/inform clinical standards To promote adoption by pathologists To support implementation efforts 25

26 Expert Panels informs standards Expert Panels and Canadian representation on the CAP Cancer Protocol Review Panels provides Canadian perspective Membership includes Pathologists, Radiologists, Medical Oncologists, Surgeons, Urologists Panels currently established for ESPRI-related disease sites but Canadian representatives on all CAP Review Panels Panels provided feedback to CAP as part of review cycles 26

27 Enabling collaboration through Pan- Canadian Activities Focus: To support/inform clinical standards To promote adoption by pathologists To support implementation efforts 27

28 Education sessions to support adoption Pathologists-led CAP cancer protocol education sessions conducted regularly Provided by CPAC/CCO Eligible for CME credits 28

29 Enabling collaboration through Pan- Canadian Activities Focus: To support/inform clinical standards To promote adoption by pathologists To support implementation efforts 29

30 Education sessions to aid decision-making Vendor & Pathologist led demos of electronic tools Available on synoptic reporting microsite on cancerview.ca 30

31 Vendor Communities of Practice to enable information exchange Vendor-specific Communities of Practice Forum connecting vendors, CAP and provincial implementers Purpose is to resolve problems and exchange information Currently have Meditech and Cerner CoP 31

32 Information Exchange Sessions to aid problem solving National information exchange sessions bring provinces implementing standards together to share successes and enable collaborative problem solving 32

33 Canada s contribution to global standards International Collaboration on Cancer Reporting Joint input from Pathology Associations from Canada, US, UK, and Australasia. European Society of Pathologists has now also joined Goal: Develop internationally harmonized data sets Datasets completed for Endometrial, Invasive Melanoma, Lung and Prostate cancers. Additional datasets currently under development IARC agreement that ICCR datasets will be part of WHO Blue Books starting with Thoracic volume and followed by GU For more information: 33

34 Early Lessons Learned Clinical champions and early endorsement aided adoption Clearly articulated goals needs to address the sowhat Dedicated planning phase had very positive outcomes Resulted in engagement with all provincial entities Mechanisms for group problem solving essential 34

35 Questions? Avril Kwiatkowski, Manager, Synoptic Reporting