In the following explanation each plan corresponds to the PROforma plan in extended TA guideline which is available in repository.
A. Screening pathway
Screening plan
The starting point of this scenario is breast cancer screening service (part of NHSBSP screening programme). All women(these are not patients) aged between 50 and 75 are invited every 3 yrs to undergo screening mammography ( a type of X ray). Mammography is done by a technician at screening centre( many times mobile vans) and patient goes home immediately after x ray. The mammograms( either in the form of X ray films or digital images) are then reported by either two qualified radiologists or one radiologist using computer assisted diagnosis CAD system.
Centralized: Each screening centre has allocated radiologist who report all mammograms done in that centre.
Distributed: Assumed a pool of qualified radiologist across NHS, and screening centre can select those who are most appropriate (availability? Experience? Reported outcomes? etc could be criteria for appropriateness?)//
Once reported, the need for further testing is assessed according to guidelines and if further assessment is recommended then woman is referred to the assessment clinic in the screening centre. Appointment is booked and woman is notified by letter.
Assessment clinic or triple assessment (History clinical examination plan + Radiology plan + Biopsy plan + Radiology plan)
Clinical examination, further imaging and biopsy are done using various clinical guidelines. This is essentially same as original triple assessment. The main differences are a) clinical examination is done by nurse practitioner instead of breast surgeon and the entire assessment takes place in screening centre and not in a acute trust.
Centralized: A single centralized management protocol or guideline is used by all involved clinicians e.g. radiologist, pathologist and nurse practitioners.
Distributed: There are various (competing?) knowledge services out there and clinicians can choose most appropriate guidelines based on some criteria (e.g. specificity of a guideline to the patient in question, currency or last updating, backing by organisations, validation methods used by guidelines etc. could be criteria for deciding appropriateness?)
Those women with positive biopsy (i.e. cancer diagnosis) are referred to the breast clinic and MDT in an acute trust. Appointment is booked and patient is notified. All relevant data, images and results need to transfer from screening data base to the hospital data base or EPR
B. Acute trust pathway
Pre treatment MDM plan
The case is discussed in Multi Disciplinary Meeting (MDM) and appropriate treatment options (according to guidelines) are recommended. Breast surgeon then conveys cancer diagnosis and MDM recommendations to the patient in the breast clinic. Patient decides the best option for her. The treatment is planned and implemented
Centralized: A single guideline/protocol is in place. Patient trusts her doctors recommendation and agrees to the recommended plan.
Distributed: Patient can access various patient services to find out more about recommended options and could also select the acute trust hospital (provider) with best reported outcomes ( Something like NHS choice) for her treatment.
Surgery plan
The surgery is planned and carried out including pre and post surgical care. The tumour is sent for histology examination and patient is referred to MDT for further management.
Histology plan
Pathologist processes and studies the tumour specimen and provides a detailed histology report (in accordance with some guideline).
Post treatment MDM plan
Breast Multi Disciplinary Team (MDT) discusses the case in MDM where various knowledge services ( adjuvantonline, cancer math, Nottingham prognostic index etc)are used to decide risks of relapse and mortality and to recommend appropriate adjuvant treatment and follow-up.
Centralized: A single guideline/protocol is in place for a hospital and all patients follow the guideline.
Distributed: MDT members can choose appropriate knowledge service/guidelines (prognostication services etc) and available research trials and also may want to offer the new services under research which are available in other acute trusts to the patient.
Adjuvant therapy
Oncologist then conveys MDM recommendations to the patient in the oncology clinic and most appropriate option is selected. Chemotherapy is then prescribed and given after initial tests. The patient receives the designated number of chemotherapy cycles at the designated time interval. (usually between 18 weeks up to one year based on the type of chemo)
C. Home pathway
Home monitoring plan
Chemotherapy could potentially have serious side effects and patient needs to be monitored.
Centralized: The only point of contact for the patient is the treating oncologist or nurse, however given the patient load its not practical for them to see patient frequently as they would like. The quality of life data and other valuable data id often not collected and the system relies on patient reported adverse events.
Distributed: Patient could access various support services for her, available out there and could also report her daily progress by means of some sort of electronic daily diary. The quality of life data and other clinical data is automatically stored in a data ware house where pharmaco-vigilance and other data mining services could monitor patient data more closely. Appropriate alerts are sent to her oncologist when potential adverse events are picked up early. Also data mining services could look at a population level data and report mined knowledge to the research committee for validation and further action. The committee responds by either incorporated this scrutinised new knowledge into new guidelines or setting up a research trial to validate this new knowledge.
