Plan for the Evolution of Integrated Diagnostic Centers Beyond Breast Clinics

Dr. Mark Pool, who blogs over at The Daily Sign-Out, has developed an interest in Integrated Diagnostic Centers which have been covered extensively here. My most recent note addressed whether currently existing diagnostic breast centers could, or should, evolve into centers addressing a broader range of diseases (see: Can Existing Breast Clinics Evolve into Integrated Diagnostic Centers?). Below is his reaction to this question (see: Integrated diagnostic centers beyond focusing on breast). It's longish but worth the time.

How could the pulmonologists and bronchoscopy/mediastinoscopy be integrated with radiology and pathology into an integrated lung disease diagnostics center?  There seems to be a natural convergence that could really be beneficial for thoracic surgeons, oncologists and radiation therapists--and patients.  This occurred to me, especially after reading the recent study by Baumann et al in July 10, 2009, Journal of Clinical Oncology, showing in a phase II trial the amazing effectiveness of stereotactic body radiation in medically inoperable stage I NSCLC  patients.  Imagine the coordination and logistics of getting something like this to come off in a timely manner at this point!  Further, if we can sort out the avalanche of predictive and prognostic serum and tissue biomarkers and analysis of mutations emerging in lung cancer diagnostics and integrate these with histopathology and radiology, we might just have something approaching personalized medicine.  At this point, however, even if not performed "in-house," we pathologists should be considering how to integrate this information within the diagnostic stream and present it coherently and contextually to our colleagues.

I do agree with Dr. Friedman that it doesn't seem likely that multidisciplinary integrated breast clinic will evolve into more broader clinics.  But the concept of an integrated diagnostic center (IDC) may just be the DNA for other location-/disease-specific integrated diagnostics that will have to be reintepreted and modified to fit the specific needs of that site or disease group.

Upon further reflection, lung "lesions" have crucial differences from breast "lesions" that I suspect would also impact the organization of IDCs and, moreover, implies that the "architecture" of an IDC revolving around breast may not be appropriate for another site/disease process. The decision-making point for a breast lesion is basically malignant vs benign; if the lesion is benign, then, in general, really not too much else happens with respect to additional therapy.  However, the decision-making around a lung lesion (or lesions) is more complex--clinically, radiographically and pathologically.  It's not a binary decision because the range of benign lesions is much greater with multivarious treatment options.  An ill-defined localized mass/infiltrate could be a drug reaction (stop drug), bronchioloalveolar-type adenocarcinoma (surgery), infection (anti-infectives), collagen vascular (steroid/cytotoxic), etc.   Yet the complexity of lung diagnostics emphasizes the need for the close collaboration between clinicians, radiologists, and pathologists, ideally in some sort of IDC.  It's just that this is not likely to simply evolve from the breast IDC.

Very thoughtful insights about the diagnosis of lung disease as opposed to breast disease. I think that there were two major reasons for the emergence and success of breast centers: (1) mammography screening for breast disease became the standard for care and was accepted by payers; (2) the notion and culture of women's health also became popular. How often to you hear anyone speaking about men's health? Women also suffer from lung cancer but the disease is rarely mentioned in the context of women's health. How about a "walk" for lung cancer?

Mark and I are in total agreement that it would make sense for some of the next generation of Integrated Diagnostic Centers (IDCs) to focus on lung lesions and particularly lung cancer. Such centers would most likely arise within specialized cancer hospitals. An interesting question at this point is whether "integrated diagnostics" is already occurring in cancer hospitals as a facet of the multidisciplinary team (MDT) approach that is the norm. My sense is that these MDTs tend to focus more on therapy than diagnosis and that the pathologists and radiologists continue to work, for the most part, in their silos until a malignant diagnosis is rendered. Please correct me if I am wrong about this.

Comments

[EM]

Another thought from the understaffed frontier.

Our integrated breast clinic works very well. Among other gains, we significantly reduced the delay between presentation and treatment because we put breasts biopsies on the fast track. But doing this, other tumours wait longer. If all tumours had their clinic, these gains will not be reproducible.