This transcript was automatically generated from the video recording and may contain inaccuracies, including errors or typographical mistakes.

Reshaping Cancer Care: A Multisite Quality Improvement Initiative to Improve Clinical Outcomes in Patients With Advanced Solid Tumors Harboring Actionable Genomic Alterations

So we're going to dive into our first topic, which is challenges in cancer biomarker testing.

[00:06:27]

Poll 3

To get us started, we do have one more polling question. So describe how biomarker testing is usually performed for most of your patients who have advanced non-small cell lung cancer? Go ahead and select all that apply. We're going to start some of our discussions talking about lung cancer, but we are also going to talk about other tumor types as well. So the answer choice is:

1. Sending tissue samples out to a reference lab;
2. Doing the tissue testing in-house;
3. There's also plasma or CT - circulating tumor DNA, whether you're sending that out to a reference lab; or
4. Are you doing plasma ctDNA in-house; or
5. You're not sure.

Okay, so these are the responses. And you'll see that we've got a good sort of mix of a lot of you doing testing in-house as well as sending it out to reference lab. And the same is also true both for tissue as well as for ctDNA. A lot of you also are not sure which is completely understandable.

And so with that, let's move to our first topic which is around the different challenges.

[00:07:40]

Key Challenges in Biomarker Testing

And these are some of the themes that emerged as we worked with these cancer centers, whether it was around testing delays or the process of even test ordering, as well as just that coordination with the reference lab or even internal pathology.

So I want to ask each of the panelists to just share what are some of the challenges that your institution faced when we started this project back in 2024, and what were some of the issues that you were dealing with? And we'll go in the same order. I'll ask Dr Caughron to begin and, you know, talk about some of the challenges that your institution was faced with.

Dr Caughron: Thanks, Joe. Yes, all of the above. And I think what - I do feel I'm privileged to get to work with cancer programs across the country, and our - our program has the same challenges, I think, that I've heard so often talking to those other programs and are reflected in this slide.

So the - the testing delays are certainly one of the challenges. And it's not just the delay but the different timeline for when results come back. So, for example, when we looked at this PD-L1 testing, which is done by immunohistochemistry, and in our environment, we can actually do it locally vs the comprehensive genomic profiling, which would be standard of care in a non-small cell lung cancer, it sits out to a reference lab.

We found that that inconsistency of the timeline creates challenges - pardon me - for how this result - how these results then make it back to the - actually to the treating physician to coordinate the - the appropriate selection of testing or the appropriate selection of therapies.

The inconsistent ordering - I was a little bit surprised that this emerged within our institution as much of an issue as it did, although we have been growing and we have added additional providers since I've been involved. It highlighted to me the need to keep this a dynamic ongoing process by which you are reviewing regularly and continuing to educate the entire team on what the standard practice needs to be and how it potentially has changed.

And then finally, with regard to lab coordination, you know, as chair of pathology, medical director of our lab, I do have a little bit more of an ability to impact this maybe than some outside the lab. And for those who are outside the lab, I strongly encourage you to build a good relationship with your laboratory.

Nonetheless, we have a different electronic record system in the hospital from the oncology practice, and we ran into issues of ordering, and the lab is in the hospital. So orders placed in - because of a lack of interface, it was - it was still challenging to get that coordinated. Some of the ref - and by the way, since this study we've gone on to make additional improvements. But at the time, we - we were using a number of different reference labs. They each had a little bit of a different process that they wanted the oncologists to potentially use, where we have our pathologists ordering some of the testing.

So that the - the complex logistics, without a doubt, we found - I think we're - we're not so much impacting whether the testing got done, but just not - the - the turnaround time is probably the biggest impact that the - the lab coordination have. So happy to dig into any of these, but want to hear from my colleagues what their experiences were. Those - you know, all of this resonated with or were present in our practice.

Dr Kim: Well, thank you so much, Dr Caughron, for getting us started. And we're eager to dive more into these issues, given the local contexts of each institution. So let's hear from Dr Keruakous now - next regarding some of the challenges that your institution faces, just in terms of the whole biomarker testing process.

Dr Keruakous: Yes, absolutely. And I will reflect on what Dr Caughron just said, because from the clinical side, what we have realized when we started this QI project, that there are significant testing delays from the time of diagnosis to the time when we get the results. The delays are actually not only because of the turnaround time, but because also delays in orders ordering the test, and because some of the solid cancers are very complex, that there are so many multispecialties are involved in this care. That's why a lot of things that can get missed.

So the inconsistent ordering that was - we encountered was because the surgeons, the pulmonologist and the hematologist-oncologist, sometimes the radiologist there, everyone is trying to do their best. However, because the guidelines are moving too fast, we didn't know what is the best time to actually order the gene sequencing for patients. We didn't know how should it be ordered?

So when we started the project, we didn't have any policy. It was our pathologist. When they find any solid tumor on the pathology, they actually send it for reflex. And it was a single gene testing and not a lot of comprehensive gene testing. So we've learned that this was not the best approach for our patients and we started to improve on that.

The communication gap between the clinic side, the hematology-oncology side and the pathology side. It was the main issue why we had those testing delays and the long turnaround time from date of diagnosis until we actually realized what - if there is any targeted therapy for - for our patients.

Dr Kim: Thank you so much. And just so that the audience is also aware, while there was a heavy focus on non-small-cell lung cancer, we also looked at other solid tumors as well. So some cancer centers focused exclusively on non-small cell lung. Others looked at multiple tumor types. But as part of this initial assessment, we were reviewing how biomarker testing was happening for patients across multiple types of advanced solid tumors.

So, Wendi, we'd love to hear from you to either build on some of the comments that have already been said, or you're certainly welcome to speak on some new topics as well.

Wendi Waugh: Yes, absolutely. So I heard similarities and differences from - from what we've experienced. I'm going to start with lab coordination. And probably different from my colleagues, most of what we decided to do with the outside reference labs, and I'm one of those centers that if I were asking the polling question, I would say that we do 100%, even PD-L1s, at an outside reference lab.

So we're not doing any internal testing. So all of the testing was ordered by our medical oncologists. And what really the medical oncologists were deciding what testing companies or lab coordination they wanted to do. And then we were almost a middleman between pathology and those outside reference labs, which specimen do we send, how do we send, where's - and one of the lab coordination problems that we have, because we send almost everything out, is that there's often limited tissue.

And so you may have tissue over here for some reason, and it needs to be over there. So we experience significant delays, not necessarily because we weren't ordering it in time, but because we didn't have the tissue or the tissue we couldn't re-obtain it from a different company to send to this company.

And often, as a rural facility, you'll have patients going for a second opinion, maybe to a tertiary care. And that tertiary care center has also requested the slides. So you can imagine that there's a lot of lab coordination involved in that. And - and that really showed up in our testing delays and getting what we could do to be actionable for the patient because of some of that.

I feel like we were relatively consistent with our orders because we had a small group of medical oncologists, and they were on board with what they wanted to order and how they wanted to order. So from that perspective, we were pretty consistent. And we had a navigator that was placing the orders, so we were pretty adamant that we wanted to limit the amount of reference labs that we used and that we were coordinating with, and we wanted them to have an online portal that we can order and - and receive results in.

So from that, I feel like we were relatively consistent, yet we were still experiencing considerable testing delays. So there you go. Different in the same, but the same - same problems.

Dr Kim: Yeah. Thank you, Wendi. So it's sometimes hard to remember what was 2024 really like. And as several of you have mentioned, you know, both sending out to reference labs for the tissue, there's a lot of issues and logistics there. There was also a growing use in the circulating tumor DNA, the ctDNA, particularly for patients who have lung cancer, since the tissue samples are often very small and - and - and things have certainly changed in that regard.

So we're going to dive into essentially the kinds of projects that each institution developed and how they were able to make some improvements. And along the way, part of the structure of this program involved some targeted continuing education, both in terms of the importance of biomarker testing, but also in terms of how that information is used when it comes to treatment decisions.

So let's move on to the next slide. And we've got a polling question to sort of set the stage on the framework as well as the discussions on quality improvement.

[00:18:07]

Poll 4

So here's the polling question. Has your organization conducted a formal QI project focused on cancer biomarker testing?

1. Yes;
2. No; or
3. You're not sure.

So go ahead and take a moment now to answer the poll. Okay. So many of you said not sure. Most of you said no. And then a small percentage said yes. So thank you for responding to the poll. We hope that based on today's discussion, you get some - some tangible ideas that you can then take back to your institution.

The next slide is a pre-test question.

[00:18:56]

Pretest 1

And part of the reason for this is that we are going to talk about different quality domains. So which of the following are healthcare quality domains from the Institute of Medicine or the IOM, now called the National Academy of Medicine:

1. The first option: safe, affordable, effective, efficient and equitable;
2. The next option: safe, timely, effective, efficient, equitable, patient-centered;
3. The third option: safe, affordable, timely, effective, equitable; and
4. The last option: safe, affordable, effective, efficient, patient-centered.

So go ahead and take a moment to answer this pre-test question. Okay, great. So it looks like about half got it correct. Then the other certainly have an opportunity to learn more and to reinforce the quality domains.

[00:19:57]

Healthcare Quality Domains

So let's move on to the next slide, which reminds us that when it comes to the healthcare quality domains, it often is useful to remember this acronym STEEEP. And there are three E's in this acronym. So there's patient safety; the timeliness of care; effectiveness of care, making sure that it's evidence based; efficient care, so reducing waste whenever possible; making care equitable; and then ultimately, patient-centered.

So this acronym, STEEEP, I think, is a good reminder because it helps us frame how we went about both developing as well as working on these different quality improvement projects at each respective institution.

A couple more pre-test questions real quick. So the next one here is a little case.

[00:20:40]

Pretest 2

Suppose that you are a cancer center with a median biomarker reporting turnaround time of 120 days from the time of diagnosis to complete results. And this is in patients with advanced non-small cell lung cancer. Thinking about it from a QI perspective, what should be the next step to work to improve this issue as soon as you discover this finding? So:

1. Would you reinforce the importance of testing;
2. Spend time identifying the reasons why the delays are occurring;
3. Switch to a different reference lab;
4. Launch a pathology-driven reflex biomarker testing protocol;
5. Remind oncologists to order testing during tumor boards.

So go ahead and think about what would be the next step in terms of QI project planning.

All right. And it looks like 44% selected the option to say, you know what? We want to spend time identifying the reasons why these delays are occurring. And while those other things that have been mentioned are certainly potentially very effective interventions, rather than jumping right to interventions, it's really important to spend some time talking about root causes. And we'll talk about that in a moment.

[00:22:07]

Pretest 3

We've got one more pre-test question. So this one is, which QI intervention aimed to improve the rate of comprehensive biomarker testing in advanced non-small cell lung cancer, addresses the domains, the quality domains of timeliness, effectiveness, and efficiency? So these are different QI interventions.

1. The first option, only order testing in younger, age less than 50 patients or non-smokers;
2. The next one, use a multigene panel that only includes common mutations;
3. Replace tissue testing with ctDNA, circulating tumor DNA;
4. Complement tissue testing with ctDNA.

Go ahead and take a moment now and answer that poll. All right. Great. It's great to see that many of you or most of you are very familiar with the recommendations around complementary testing. I don't know if people would have responded back like this back in early 2024, but it's good to see that here in early 2026 that this is certainly what's expected.

[00:23:19]

Quality Improvement (QI)

So let's move to the next slide where we're going to set the stage, you know, how did we actually go about and make improvements? And what was it that we were actually changing and improving?

So when we talk about QI, it's important to remind everyone that here we are talking about a systematic, data-driven approach. It's not clinical research. And at the same time, it's also not just purely education, but rather it requires us to bring together a group of people who are going to work on something and they know what they're going to aim to improve.

This project began in July of 2024, where each institution looked at things like their - how they were performing testing, as well as what was the turnaround time, when were patients receiving biomarker testing across advanced non-small cell lung cancer, but also a subset of other types of solid tumors? The program recently wrapped up in December 2025.

The baseline data was looking at patients diagnosed and treated in 2022 and 2023. So keep that in mind as you reflect on what was actually the findings, and then how could we then learn from these findings and then act on it?

We know that particularly around biomarker testing and precision medicine and oncology, a lot has changed from 2022. So please keep that factor that in as you - as you hear about the findings and sort of put everything into context. Every center reviewed 50 patients with advanced small solid tumors, which included a subset of patients with non-small cell lung cancer, but also other solid tumors like breast cancer, as well as upper GI cancers and so forth.

And the main questions that we were aiming to answer were, you know, which patients with solid tumors are receiving biomarker testing? We were not looking at early stage. We kept this focused on advanced stage. What type of biomarker testing is being performed in these patients? When is the test actually ordered and when do the results come back?

And then we also looked to see when there was an actionable genomic alteration, how were oncologists using these test results?

[00:25:33]

Root Causes

So if we move to the next slide here, we see that the root causes of - once we looked at that data and sort of we did the analysis, we identified some potential gaps. Earlier you heard a lot about testing delays as well as operational and logistical challenges. So we wanted to know why is that problem happening? What is causing that problem? And this is what's called a root cause analysis in the world of quality improvement.

So in this example, if we see that there are significant delays in when biomarker tests are ordered, as well as when the results come back across a subset of patients with solid - advanced solid tumors, we want to know why.

And here, you see some different reasons why. Patient - the tests may not get ordered until perhaps much later as opposed to near the time of diagnosis. Or maybe it takes a quite a bit of time for pathology to either send the sample out, or even to send it to get the sample, and to then be able to send it out.

Oncologists may be ordering the wrong test. There are all sorts of ways that they may be ordering tests, from ordering it on a portal, to even just filling out a paper form and faxing it in, vs entering it via the electronic record. The test order may have incomplete information, in which case it gets delayed and - and put on hold.

And then we heard a lot about this tissue quantity not being sufficient, the QNS, particularly in non-small cell lung. So once again what do you do when it's not sufficient? Do you just act on the incomplete information or do you say, well, if the tissue isn't sufficient, then perhaps we should go ahead and order a ctDNA and complement that test?

So these are some of the examples. Not everyone focused on the delays, but I will say that across all three centers we aggregated some of the key findings. So I'm going to share some of those findings with you and then we're going to have discussions, hearing more about the actual improvement efforts as well as the local contexts that led to those changes.

[00:27:38]

Aggregate Findings: Timeliness of Testing

So on the next slide here, we're going to see the aggregate findings regarding the timeliness of testing. On the top, you see patients who have advanced non-small cell lung cancer. And on the bottom, you see it's the total of all the different solid tumors that each institution studied.

The charts reflect the aggregate. So across all three centers, as we aggregated all these data, what we found was that the median number of days from diagnosis to test results at baseline was around 55 days for non-small cell lung cancer and 128 days for patients across all solid tumors.

Now, both of these metrics changed dramatically in the post-intervention period, and part of this is also understandable given, as I said earlier, the rapid pace of change in cancer precision medicine.

But once again, unless your institution stops to actually look at what is our testing sort of timeliness, it may not be evident until you actually go in and look at some of this data, and it may even surprise some of your staff when they see what it actually looks like, particularly across other solid tumors. So just kind of spend some time reflecting on how well do you know your timeliness of testing at your cancer center, and is that possibly an area for improvement for quality improvement project?

[00:29:01]

Aggregate Findings: Timeliness of Testing

The next slide here looks at aggregate findings when we - when - when we ask the question what happened to patients if they had an actionable genomic alteration, where you could target - where you could treat that patient with an FDA-approved targeted therapy.

And what you'll see here, once again, is that at baseline, about 72% patients with advanced non-small cell lung cancer were receiving appropriate targeted therapy. For the lung cancer cohort, we did not include immunotherapy for this analysis. We were just looking at therapies where there was a genomic alteration along with the targeted therapy. And you see that that increased up to 93%.

And then on the bottom you'll see across all the different solid tumors. Once again, did - did a patient have an actionable genomic alteration with an FDA-approved targeted therapy. And you'll see that change from 61% up to 82%.

So once again, as we think about, you know, how are oncologists coming up with treatment plans and what might lead to some of these changes? One of the findings was that, in some cases, it was taking too long for the results to come in, hence the treatment would begin, then the result might come in. They may not necessarily act on that information right away.

We also recognize that some of these therapies are indicated in the first-line setting. Others are indicated in second-line and beyond. So we took all these factors into consideration. But this is also another example, where, unless you actually ask the question and look at the data, it may be hard to know, you know, what percentage of our patients who have an actionable genomic alteration are receiving appropriate therapy. And then you do this analysis in this exercise.

And if it shows that there is an opportunity for improvement, make sure you start with that root cause analysis. Make sure you understand why the problem exists so that you can then tailor interventions accordingly.

[00:31:03]

Other Improvements

The next slide here just outlines a couple of other improvements that we noticed. So many institutions had, what I would call, a fairly standard or appropriate way for testing in advanced non-small cell lung cancer, but they really didn't have that for other solid tumors. So some of the institutions worked to see what can we do for some other common tumor types. So that was some improvements that were made.

And then there's going to be some discussion around the use of ctDNA, particularly as the quantity not sufficient problem continues to increase as there are more IHC based tests now for advanced non-small cell lung cancer. And so either you have to get more tissue or you have to use that tissue judiciously and then balance that with ctDNA testing.

[00:31:52]

Panel Discussion

So with all that being said, let's now move to the next slide where we're going to hear from the panelists, you know, the - some of the common themes when it comes to ways that they made improvements included working on areas of test ordering or standardizing workflows, in other cases, educating care teams and tracking things like the turnaround time.

So I'm going to ask each panelist to share some findings. And we're going to go around a few times on different themes and topics. So I'm going to actually go in reverse order this time and ask Wendi to start us off.

You know, what were some of the changes and improvements that your institution worked on, and which of these themes or topics does it reflect on?

Wendi Waugh: Well, I'll start with the test ordering process. And we did work really hard on getting someone internally to be the navigator who was ordering through the portal, who received the results, who entered those results, and who notified the oncologist. Not only notified the oncologist, but looked at the appointment and adjusted the appointment based on when those results came back.

We wanted to make sure that as soon as we had those results for discussion comprehensively, that the next available appointment with the oncologist was secured. So that navigator that really controlled that process or helped to manage that process was key in our whole test ordering process.

She also really helped us to standardize our workflows, to be completely honest. She became that liaison between pathology and the reference labs. She was the one that when there was something like a QNS, or simply an ABN from Medicare that was needed by the reference lab, she was the one. So she was that single point of contact who could then communicate with the patient. She intimately understood what we were testing, why we were testing it. She could talk it not only to pathology and that group, but she could talk it to the patients and the clinical staff as well. So I would say the - that was a very key component.

And that - that also impacted our turnaround times because she was watching and so she knew that this test result had been out there for 14 days, 21 days, 28 days, whatever. And so she was constantly looking and/or making sure to obtain the pathology slide from another reference lab, so that the reference lab that we need the results from was there. But I can tell you none of this did we know until we did the study.

And then what we did is go, are you kidding? Like, why would this be 200 days? And yes, it happened. And then it was just doing that root cause analysis, really that Dr Kim mentioned and - and going back and going what was happening here? And learning and then putting those things in place. So - so there you go. That's how I'll start off.

Dr Kim: Thank you so much, Wendi. Dr Keruakous, would you like to go next?

Dr Keruakous: Yeah, absolutely. Well, the - the single point of contact that is actually one key for success into getting the - the - the workflow organized because a lot of the time that the oncologist ordered the right test, but there are missing information, as Dr Wendi just mentioned. It's - and that also exhaust the tissue. You know, the longer the tissue is in the lab and all of that, that - and the - the reliability of the results becomes less and less useful for the patient.

So that single point of contact is a key. We use the same strategy, but we also work more into educating the care team. We have done a lot of meetings with all of the - the care teams that are involved into the solid oncology world, and our fellows actually led that initiative and teaching all the care teams, starting from pathology, from the nurses, our oncology nurses, from pulmonology team, all of them, to know the significance of why the gene testing is very important, knowing that back in 2024, it - there wasn't the same body of evidence of how it is used right now, because now we have more studies that actually we need to do it from the initial diagnosis of any cancer, right?

Back - back two years ago, we were only ordering it for metastatic patients who maybe progressed on the first-line of therapy but that's changed. I think that timing for the quality improvement project came perfectly aligned, where the - the growth of the data and the maturity of the data about molecular testing for all of the solid oncology patients came in to be - and now it's a standard guidelines.

So working with the test ordering process, having a single point of contact, educating the care team, that helped us quite a lot. We started having molecular tumor board, where we actually meet once a month and discuss cases to continue that educating the care team, continue - letting everyone know what is the significance of what we're doing.

And of course, it helps us to get the EHR integrated test, where the oncologist can put in the order themselves so they can actually follow up and the results come straight to them, not to a middleman that forward the results to the oncologist.

Dr Kim: Thank you so much. Dr Caughron?

Dr Caughron: Yeah, thanks. The - at our institution, we had actually had, over the last several years, previous quality improvement initiatives, looking at our ordering process and our workflows. So we have had pathologists initiated testing on some tumor types. We have met between the meetings quarterly, between the pathologists and oncologists to define how it was - or to talk about how it was going and define what standardized workflows would look like.

What I think made the biggest impact, and we saw a significant impact through this quality improvement project in this - in the pre and post data was the educational focus and specifically around the integration of the circulating tumor DNA or liquid biopsies.

So previously - and not to suggest that our previous quality improvement projects, as you, you know, had created a perfect environment, certainly that's - you're never going to get there. But we - we knew what we were dealing with on that front. So the focus was really on the education. And we saw a significant impact in the patients who were getting the liquid biopsies, which had not previously been seen as a much - a backbone of the testing algorithm, integrating that liquid biopsy in the circulating tumor DNA, not just in cases where there was insufficient or QNS, but even more broadly than that, we began to look at - in fact, we're now moving towards that even more aggressively, being used across the patient, you know, earlier in the patient's journey.

So that education around the value of the circulating tumor DNA testing or liquid biopsy testing was a crucial part. And then also connecting the dots across the care continuum so that when the mutations were identified that had treatment implications. Those findings, we ensured, were being communicated back to the treating providers. We saw a significant increase as well in the number of patients who, when a mutation was identified, were getting appropriate therapy.

So again, I guess this was a great - the timing, it was said before, the timing of this was excellent. And really, I almost don't think you could do a bad QI project at any site with the pace of change in precision medicine and the biomarkers, etc.. I mean, this is - this is a continual need for effort and kudos to this project for - for the effort and the success we were able to derive from it. Our - the backbone of our process was education and revisiting the previous work we had done. So.

Dr Kim: Thank you.

Wendi Waugh: Yeah, I just want to dovetail, if you don't mind, Dr Kim, on a couple of things that I heard. And that is, first, I can't imagine and I noticed on the poll that we had a lot of people that had not done a QI project know, and others that were unsure. And actually the minority was yes. And I - and I try to think of where we are today and where we might not be, had we not instituted this QI project and really started.

And where - here we are in 2026. Like - like my colleague mentioned. And that is we're really all at liquid and - and tissue and the coordination of both. And all - across all solid tumors. And - and I really try to imagine what if I were just starting today. Like what if. But we have to start. This age is definitely upon us. So if you haven't or if you're unsure, let's ask some questions in your areas and get something going.

The other thing that I wanted to talk about was the EHR. And so I mentioned early on when I introduced myself that I had a particular interest in health informatics. And so I just got involved early, and not only were we taking the - I'm going to call it the PDF or the picture of the result and making sure that it was in the chart, and we did have a different oncology chart from our main enterprise chart as well.

But we created discrete fields in which we were entering all of these results in our oncology. And that has really paid off for us now long term down the road, because we're now able to run aggregate reports on how many of these we have or those we have that might now have significance in that patient journey or a family member's journey.

And what we have been doing, and the way that we put those in discrete fields now has dovetailed into some of our germline testing and genetics. That is also, of course, part of this precision medicine. So I thought I wanted to mention that just related to standardizing workflows. And when you're thinking about that, thinking about how you are integrating those results into your medical record.

And, you know, some of our vendors have platforms or genomic platforms that are helping with that and some do not. So - but definitely a consideration as you're looking at this landscape.

Dr Kim: Thank you, Wendi. Yeah, I think definitely a big part of several institutions involved that integration with the electronic record for both the test ordering to really work directly with that reference lab, but also to make sure that the results are easier to find so that the oncologists can act on that information, because otherwise, in the past, maybe those results simply just got scanned and perhaps lost, or it's easy to overlook.

So I think there were definitely a number of process-related issues that emerged from this. For the sake of time, I am going to move us along, but I really - we're going to hear from the panelists again in just a moment.

[00:44:56]

Posttest 1

So for the audience, go ahead and take a moment now to answer this post-test question. This question is, which of the following are the healthcare quality domains from the Institute of Medicine, now called the National Academy of Medicine:

1. Safe, affordable, effective, efficient, equitable;
2. Safe, timely, effective, efficient, equitable, patient-centered;
3. Safe, affordable, timely, effective, equitable;
4. Safe, affordable, effective, efficient, patient-centered.

All right. Great. It's good to see that many of you selected the correct response.

[00:45:44]

Posttest 1: Rationale

So let's go ahead and show the next slide, where the rationale. Once again, remember that STEEEP framework with the three E's.

[00:45:51]

Posttest 2

The next polling question - or sorry, the next post-test question is, you are at a cancer center. Median turnaround time is 120 days. What should be the next step as the cancer center works on a quality improvement project to address this issue? Is it:

1. To reinforce the importance of testing;
2. Spend time identifying the reasons why delays are occurring;
3. Switch to a different reference lab;
4. Launch a pathology-driven reflex testing protocol; or
5. Remind oncologists to order testing during tumor board.

[00:46:44]   

Posttest 2: Rationale

All right. And once again, good to see that every - most of you recognize the importance of doing that root cause analysis. And in terms of QI project planning, it may be tempting to - to jump right into interventions, but spending that time understanding the reason why the problem exists is critically important.

[00:47:01]

Posttest 3

The third post-test question is the question, which QI intervention is going to aim to improve the rate of comprehensive testing in advanced non-small cell lung cancer, addressing the domains of timeliness, effectiveness, and efficiency:

1. Only order testing in younger patients;
2. Use multigene panels that only include common mutations;
3. Replace tissue testing with ctDNA; or
4. Complement tissue testing with ctDNA.

[00:47:41]

Posttest 3: Rationale

All right. Great. Good to see that most of you once again recognize the importance of the complement tissue testing with CTNA - DD - DNA and how it balances out those different domains of healthcare quality and really leads to that effectiveness of care.

[00:47:53]

Future Directions

So we're going to now continue our conversation by talking about future directions. And several of the panelists have also mentioned how, you know, QI never stops. It's - it's an ongoing journey. There's always things to change and improve.

[00:48:06]

Examples of Newer Biomarkers in Solid Tumors

So this next slide just shows some examples. And this is once again just some examples of newer solid tumor biomarkers. Some are genes that are common genes. But perhaps it's new for a new type of tumor, for example, KRAS mutation in ovarian cancer now being actionable. Some are IHC-based tests as opposed to a gene mutation. Now you're looking for that protein overexpression. And once again seeing more of that in non-small cell lung cancer. So the need for the tissue based tests.

But I think what this emphasizes is that that change is ongoing. And there's always going to be opportunity to work on a project, especially when something new like this pops up and you want to know, how are we doing as it relates to testing and then treating patients based on those test results across a variety of different solid tumors.

[00:49:01]

Looking Ahead

So this next slide, we're going to go back to the panel, once again looking ahead and knowing that QI is this ongoing journey. You know, what are some areas where you would like to see ongoing changes and improvements within your institution? And perhaps it might tie into one of these themes, whether it's around the expanded use of liquid biopsy or using broader panels. You know, perhaps you're incorporating AI, or maybe there are even ways to ensure, from an equitable standpoint, that the appropriate patients are being tested.

So let's start with Dr Keruakous in terms of, as you think about what's ahead and, you know, into even 2026, you know, where would you like to see improvements at your institution?

Dr Keruakous: Absolutely. This - I think I would see - I would like to see improvements in all areas. Absolutely. But now with - with the evolving data, I think AI-driven decision support is one of the things that is going to significantly help a lot of patients because I would like to have AI-driven report on those multi-gene testing that actually tells me, okay, from all of the published data we have had this many patients, was treated with this drug and the outcomes that we saw one, two, three.

So we can actually report to the patients, what are the outcomes that was reported for the patients similar to your situation? I think AI has a lot of space there to just give us more measurable outcomes that we can present our patients, more prognostic reports to - to help our patients understand their disease more, understand the potential outcomes, even potential toxicities, using AI to predict what is potential toxicities from these treatments, given that we're using more and more of the targeted therapies nowadays.

The other thing is - that was actually mentioned. Having an EHR integrated reminders. And the - you know, the right now community oncologist office is - are extremely busy. It would be very useful to have a reminder that this patient had a solid oncology condition that you need to order a certain gene sequencing for this. And also having the - the back end of it, where it says, all right, this molecular gene testing, the payer is suggesting using this panel instead of that panel. So reduce the financial toxicity on the institution and increase the reimbursement for - for this test.

I really wish that this - this happened in the future. I wish there are some QI projects that we can address these challenges. So really, first, having more AI-driven reports and measurable outcomes, having reminders to check, you know, so we can increase the testing and, of course, increase the use of the - a lot of the targeted therapies that are available. And also giving them - having the payer-suggested option of what exactly we need to order for our patients.

Dr Kim: Thank you so much. Dr Caughron, what about for you as you look ahead?

Dr Caughron: Yeah. So there are three things I want to talk about. First, we continue to see expansion of the use of ctDNA, especially in non-small cell lung cancer. So as I mentioned, we're now moving towards a protocol that offers ctDNA and tumor biopsy. And we're collecting these samples concurrently, so at the same time that we do that initial biopsy. The patient isn't necessarily even diagnosed yet with non-small cell lung cancer.

We're collecting that sample to be able to get the ctDNA testing done promptly as soon as that diagnosis is made. So we are - and - and this is being driven by pathology. So - or, you know, I guess working closely in conjunction with pathology, one of the things I - I didn't mention last time, but - and I - it maybe doesn't need to be said, but I'm going to say it anyway.

Cancer is a multidisciplinary disease. We have to be working across our different departments. So we're looking at pulling our pulmonologists in. At the time they do the biopsy, we would have a peripheral blue tube collected so that we could also do ctDNA testing once a diagnosis is established, and then get those results over to our cancer team. So that's one thing we're focused on.

The second is we are part of a consortium where we're looking to - to - for our pathology group, we're part of a national consortium focusing on standardizing these tests and how they get resulted within the pathology report. So these additional reports that come in from the reference labs are great, but we - we feel the best practice and - is going to be to move those results more closely into that original pathology report and then to the comments already made, really have well-defined standards for the different solid tumor types, what biomarker testing should be done with a platform that allows us to continually update that?

Finally, with regard to the AI-driven technologies that are out there, I mean, it's so rapidly - it's hard - it's so rapidly moving. It's hard to know exactly how those AI tools are going to impact us. One way that we're - one of the things we're concerned about is the hallucinations, some of the issues we have with AI and making sure that our physicians are supported but not put at risk through the use of these AI tools.

But in that regard, where we think AI today has immediate high impact is our ability to look backwards and analyze data we already have in our charts to say, okay, where - where can we find or where can we use AI to look through that data and find opportunities to improve? So that's a - those are the tools that we're really focused on. And some of - as we look forward, we're already working on some of these things.

Dr Kim: Thank you, Dr Caughron. Wendi, how about for you as you look ahead?

Wendi Waugh: Well, I want to talk about health equity actually. Being at a rural center and, you know, hearing my colleagues talk, I - you know, I agree that it is absolutely multidisciplinary. And I don't always think that those resources are available in community, rural settings. And so there's so much - we talked early on about, you know, the education and putting someone in place and the navigation. That is not - it's not just for the patient. It's a lot - it can be for oncologists, pathologists, pharmacists, nurses across the board, all the way down to the patient.

And I - and I think that we have got to make sure that no matter where you are in this health continuum and wherever you're diagnosed and wherever your treatment is, that you have access to molecular pathologists and to this kind of testing. And - and to be quite honest in our small rural setting, I feel like I'm very grateful to the relationship that I've had with Dr Kim and some other colleagues who have really helped me get some of these studies going and identify some of these gaps.

And I think, what about those centers who don't have that or who don't have someone that is actively seeking that? And where would they be and where are they? And then how does that impact the patient, right? So - because these things we know are saving lives and continuing up and - and giving years to life. So - and it's only going to grow.

We have touched just a little bit on liquid and tissue and really around solid tumors. But there's a whole other domain out there with the pharmacogenetics and MRD testing that we didn't even have time to even brush the surface. That is all impacting the - it's a - it's a cancer care trend today that we - is not going away. So health equity.