1. Cancer Education Day Diagnostic Assessment Programs DAPs May 13, 2016

2. DAPs In the Per-Diagnostic period, patients can present with: – Abnormal screening results – OR – Signs or symptoms suspicious for cancer

3. Disclosures No Disclosure to report No conflict of interest

4. Abnormal Follow-up Rates for: Breast, Cervical and CRC Screening

5. Primary Care Factors Shown to Delay Cancer Diagnosis Not recognizing signs/symptoms suggestive of cancer Co-morbidity of conditions Multiple consecutive investigations in primary care Over-reliance on diagnostic imaging Imaging follow-up failure Initial referral to a physician unrelated to final diagnosis Patient Factors Shown to Delay Cancer Diagnosis Lack of appreciation of association of symptoms with cancer Fear of cancer diagnosis

6. What is the Problem We’re Trying to Solve? “This was really my first introduction to the cancer system and I saw very quickly how overwhelming it was to keep track of things when you’re not only feeling unwell, but are also under stress from the fear and anxiety of what’s going on. It would be very easy to get lost along the way.” – DAP Patient

7. What are Diagnostic Assessment Programs (DAPs)? WHAT IS A DAP? Diagnostic Assessment Programs (DAPs) are designed to improve the experience of patients with suspected cancer as they go through the diagnosis process. These programs are based in hospitals and are made up of multi-disciplinary healthcare teams that manage and coordinate a patient’s diagnostic care from testing to a definitive diagnosis, leading to improved access to care. DAPs also provide the necessary support and information about cancer to patients and their families THE DAP PROGRAM AT CCO HAS THREE OBJECTIVES: Decrease time from suspicion to diagnosis or resolution Improving patient outcomes where possible Optimize the patient experience during the diagnostic process Optimize satisfaction and experience among Primary Care Providers and Specialists DAP STATS: 17lung/thoracic, 14 colorectal, and 6 prostate DAPS across Ontario

8. How do Regional DAPs Function? DAPs are: Evidence-based programs based on CCO’s disease pathway maps and developed by Regional Cancer Programs across Ontario Made up of multidisciplinary health care teams that manage and coordinate a patient’s diagnostic care from testing to a definitive diagnosis or rule-out of cancer

9. Erie St Clair (ESC) DAPs LungColorectalProstate Nurse Navigators – Julie Meloche and Melissa Capogna

10. ESC DAPs Nurse Navigators – Julie Meloche and Melissa Capogna

11. Suspicious Lung Cancer Signs and Symptoms in Primary Care Hemoptysis New finger clubbing Suspicious lymphadenopathy Dysphagia Features suggestive of cancer metastasis to or from the lung Features suggestive of paraneoplastic syndromes OR

12. Suspicious Lung Cancer Signs and Symptoms in Primary Care Any of following unexplained signs or symptoms lasting more than three weeks (patients with known risk factors may be considered sooner): Cough Weight loss/loss of appetite Shortness of breath Chest and/or shoulder pain Abnormal chest signs (e.g. crackles or wheezes) Hoarseness

13. Indications for Referral – Lung Persistent hemoptysis A chest X-ray suggestive/suspicious lung cancer including: A nodule or mass Multiple pulmonary nodules Non-resolving pleural effusion Mediastinal or contralateral hilar adenopathy Interstitial infiltrates Slowly or non-resolving pneumonia or consolidation Fibroapical disease suggesting possible tuberculosis Unexplained elevated diaphragm A normal chest X-ray, but there is a high suspicion of lung cancer, based on clinical judgement

14. Indications for Referral – Colorectal Positive FOBT result First Degree Family History (Mother, Father, Sibling, Child)

15. Indications for Referral – Prostate Currently work with 5 Urologists offices Referral into the program usually happens with a positive Digital Rectal Exam and 3 increasing PSA results – Biopsy is scheduled followed by a post biopsy to the patient to see how they’re doing – Biopsy pathology review by the DAP Nurse – Office is called when there is a positive pathology, and the date the patient will be told of their diagnosis confirmed – Patient is then given their surgical options – The DAP office coordinates any required bone scan, CT scan, etc. – These appointments are provided to the patient by the DAP nurse – A consultation appointment is then scheduled with a Radiation Oncologist at the Cancer Centre – The DAP nurse attends that appointment along with the patient to review the options

16. DAP –Wait Time Reporting There are Wait Times associated with the DAP program  Lung: 65% must be diagnosed within 28 days  Colorectal 1: – FOBT Positive must be seen within 8 weeks – Family History must be seen within 26 weeks This data is currently reported to Cancer Care Ontario every month

17. High Risk Lung Cancer Screening (HRLCS) CCO - Status Screening pathway Eligibility criteria Pilot site selection criteria Evaluation committee Evaluation criteria for pilots RFP Issued end of March Next Step-selection of pilot sites

18. HRLCS Pilot Site Requirements 1.Smoking cessation will be embedded 2.Navigator will assess eligibility 3.Navigator will be smoking cessation counsellor 4.Nodule management algorithm (LungRADS) 5.Seamless link with DAP 6.Recruitment of hard to reach high risk populations

19. Subset of pilot minimum requirements* Hospital stand-alone or hub and spoke models Primary care and community led recruitment PCP roster for unattached patients Screening navigator support On-site smoking cessation Standardized reporting template for LDCT On-site lung DAP On-site thoracic level 1 centre CCO led joint planning, recruitment, evaluation and ongoing performance management