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Improving Cancer Diagnosis and Care: Patient Access to

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National Academies of Sciences, Engineering, and Medicine
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Improving Cancer Diagnosis and Care: Patient Access to Oncologic Imaging and Pathology Expertise and of a...
Erin Balogh, Margie Patlak, and Sharyl J. Nass, Rapporteurs
National Cancer Policy Forum
Board on Health Care Services
Health and Medicine Division
Copyright National Academy of Sciences. All rights reserved.

Improving Cancer Diagnosis and Care: Patient Access to Oncologic Imaging and Pathology Expertise and of ...
THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001
This activity was supported by Contract No. 200-2011-38807 (Task Order No. 0051)
and Contract No. HHSN263201200074I (Task Order No. HHSN26300120) with
the Centers for Disease Control and Prevention and the National Cancer Institute/
National Institutes of Health, respectively, and by the American Association for Cancer
Research, American Cancer Society, American College of Radiology, American Society
of Clinical Oncology, Association of American Cancer Institutes, Bristol-Myers Squibb,
Cancer Support Community, CEO Roundtable on Cancer, Flatiron Health, Helsinn
Therapeutics (U.S.), Inc., LIVESTRONG Foundation, Merck, National Comprehen-
sive Cancer Network, Novartis Oncology, Oncology Nursing Society, and Pfizer Inc.
Any opinions, findings, conclusions, or recommendations expressed in this publication
do not necessarily reflect the views of any organization or agency that provided support
for the project.
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Improving cancer diagnosis and care: Patient access to oncologic imaging and pathology
expertise and technologies: Proceedings of a workshop. Washington, DC: The National
Academies Press. doi: https://doi.org/10.17226/25163.

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Academies, please visit www.nationalacademies.org/about/whatwedo.

WORKSHOP PLANNING COMMITTEE1
HEDVIG HRICAK (Workshop Chair), Chair, Department of Radiology,

Memorial Sloan Kettering Cancer Center
JAMES A. BRINK, Radiologist-in-Chief, Massachusetts General
Hospital; Juan M. Taveras Professor of Radiology, Harvard Medical
School; Chair, American College of Radiology Board of Chancellors
CHRISTOPHER R. COGLE, Professor of Medicine, Pierre Chagnon
Professor of Stem Cell Biology and Bone Marrow Transplant,
University of Florida; Scholar in Clinical Research, Leukemia &
Lymphoma Society
MICHAEL B. COHEN, Interim Chair and Director, Anatomic
Pathology, Wake Forest School of Medicine
MICHAEL J. DILL, Director, Workforce Studies, Association of
American Medical Colleges
KOJO S. J. ELENITOBA-JOHNSON, Professor, Perelman School
of Medicine; Director, Center for Personalized Diagnostics and
Division of Precision and Computational Diagnostics, University of
Pennsylvania
CURTIS P. LANGLOTZ, Professor of Radiology and Biomedical
Informatics, Associate Chair for Information Systems, Department
of Radiology, Stanford University; Medical Informatics Director,
Stanford Hospital and Clinics
RICHARD L. SCHILSKY, Senior Vice President and Chief Medical
Officer, American Society of Clinical Oncology
WILLIAM W. STEAD, Chief Strategy Officer and McKesson
Foundation Professor of Biomedical Informatics and Medicine,
Vanderbilt University Medical Center
ROBERT A. WINN, Associate Vice Chancellor, Community Based-
Practice; Professor of Medicine, Division of Pulmonary and Critical
Care Medicine, University of Illinois at Chicago; Director, University
of Illinois Cancer Center
1 The National Academies of Sciences, Engineering, and Medicine’s planning committees

are solely responsible for organizing the workshop, identifying topics, and choosing speakers.
The responsibility for the published Proceedings of a Workshop rests with the workshop rap-
porteurs and the institution.

WENDY A. WOODWARD, Associate Professor and Service Chief,

Clinical Breast Radiation, Department of Radiation Oncology,
The University of Texas MD Anderson Cancer Center
Project Staff
ERIN BALOGH, Senior Program Officer
NATALIE LUBIN, Senior Program Assistant
CYNDI TRANG, Research Assistant
SHARYL J. NASS, Forum Director and Director, Board on Health Care
Services
vi

NATIONAL CANCER POLICY FORUM1
EDWARD J. BENZ, JR. (Chair), President and Chief Executive Officer

Emeritus, Dana-Farber Cancer Institute; Richard and Susan Smith
Distinguished Professor of Medicine, Genetics and Pediatrics,
Harvard Medical School
AMY P. ABERNETHY, Chief Medical Officer, Chief Scientific Officer,
and Senior Vice President, Oncology, Flatiron Health
LUCILE L. ADAMS-CAMPBELL, Professor of Oncology, Associate
Director for Minority Health and Health Disparities Research,
Georgetown University Lombardi Cancer Center
GARNET L. ANDERSON, Senior Vice President and Director,
Public Health Sciences Division, Fred Hutchinson Cancer Research
Center; Affiliate Professor, Department of Biostatistics, University of
Washington
KENNETH ANDERSON, Kraft Family Professor of Medicine,
American Cancer Society Clinical Research Director, Jerome Lipper
Multiple Myeloma Center, Harvard Medical School, Dana-Farber
Cancer Institute
KAREN BASEN-ENGQUIST, Annie Laurie Howard Research
Distinguished Professor, Professor of Behavioral Science, and
Director, Center for Energy Balance in Cancer Prevention and
Survivorship, The University of Texas MD Anderson Cancer Center
CATHY J. BRADLEY, Associate Director, Cancer Prevention and
Control, University of Colorado Cancer Center
OTIS W. BRAWLEY, Chief Medical and Scientific Officer, American
Cancer Society
ROBERT W. CARLSON, Chief Executive Officer, National
Comprehensive Cancer Network
CHRISTOPHER R. COGLE, Professor of Medicine, Pierre Chagnon
Professor of Stem Cell Biology and Bone Marrow Transplant,
University of Florida; Scholar in Clinical Research, Leukemia &
Lymphoma Society
1 The National Academies of Sciences, Engineering, and Medicine’s forums and round-
tables do not issue, review, or approve individual documents. The responsibility for the pub-
lished Proceedings of a Workshop rests with the workshop rapporteurs and the institution.
vii

NANCY E. DAVIDSON, President and Executive Director, Seattle

Cancer Care Alliance; Senior Vice President, Director, and Full
Member, Clinical Research Division, Fred Hutchinson Cancer
Research Center; Head, Department of Medicine, Division of
Medical Oncology, University of Washington
GEORGE D. DEMETRI, Professor of Medicine and Director,
Ludwig Center, Harvard Medical School; Senior Vice President for
Experimental Therapeutics, Dana-Farber Cancer Institute; Associate
Director for Clinical Sciences, Dana-Farber/Harvard Cancer Center
JAMES H. DOROSHOW, Deputy Director for Clinical and
Translational Research, National Cancer Institute
NICOLE F. DOWLING, Associate Director for Science, Division of
Cancer Prevention and Control, Centers for Disease Control and
Prevention
SCOT W. EBBINGHAUS, Vice President and Therapeutic Area Head,
Oncology Clinical Research, Merck Research Laboratories
KOJO S. J. ELENITOBA-JOHNSON, Professor, Perelman School
of Medicine; Director, Center for Personalized Diagnostics and
Division of Precision and Computational Diagnostics, University of
Pennsylvania
STANTON L. GERSON, President, Association of American Cancer
Institutes; Director, Case Comprehensive Cancer Center; Professor of
Hematological Oncology, Case Western Reserve University; Director,
University Hospitals Seidman Cancer Center
LORI HOFFMAN HŌGG, Veterans Health Administration National
Oncology Clinical Advisor and Program Manager, Prevention Policy,
Department of Veterans Affairs
LINDA HOUSE, President, Cancer Support Community
HEDVIG HRICAK, Chair, Department of Radiology, Memorial Sloan
Kettering Cancer Center
LISA KENNEDY SHELDON, Chief Clinical Officer, Oncology
Nursing Society
SAMIR N. KHLEIF, Director, Loop Immuno-Oncology Lab, Biomedical
Scholar, and Professor of Oncology, Lombardi Comprehensive
Cancer Center, Georgetown University Medical Center
RONALD M. KLINE, Medical Officer, Patient Care Models Group,
Center for Medicare & Medicaid Innovation, Centers for Medicare
& Medicaid Services
viii

LEE M. KRUG, Program Leader, NKTR-214, Oncology Clinical

Development, Bristol-Myers Squibb
MICHELLE M. LE BEAU, Arthur and Marian Edelstein Professor of
Medicine and Director, The University of Chicago Comprehensive
Cancer Center
MIA LEVY, Director, Cancer Health Informatics and Strategy; Ingram
Associate Professor of Cancer Research; Associate Professor of
Biomedical Informatics and Medicine, Vanderbilt-Ingram Cancer
Center
MARTIN J. MURPHY, Chief Executive Officer, CEO Roundtable on
Cancer
RICHARD PAZDUR, Director, Oncology Center of Excellence; Acting
Director, Office of Hematology and Oncology Products, Food and
Drug Administration
MACE L. ROTHENBERG, Chief Development Officer, Oncology,
Pfizer Global Product Development, Pfizer Inc.
RICHARD L. SCHILSKY, Senior Vice President and Chief Medical
Officer, American Society of Clinical Oncology
DEBORAH SCHRAG, Chief, Division of Population Sciences, Professor
of Medicine, Department of Medical Oncology, Harvard Medical
School, Dana-Farber Cancer Institute
LAWRENCE N. SHULMAN, Professor of Medicine, Deputy Director
for Clinical Services, and Director, Center for Global Cancer
Medicine, Abramson Cancer Center, University of Pennsylvania
DAN THEODORESCU, Director, Samuel Oschin Comprehensive
Cancer Institute, Cedars-Sinai Medical Center
VERENA VOELTER, Head, United States Oncology Clinical
Development & Medical Affairs, Novartis Pharmaceuticals
Corporation
GEORGE J. WEINER, C.E. Block Chair of Cancer Research, Professor
of Internal Medicine, and Director, Holden Comprehensive Cancer
Center, The University of Iowa
ROBERT A. WINN, Associate Vice Chancellor, Community Based-
Practice; Professor of Medicine, Division of Pulmonary and Critical
Care Medicine, University of Illinois at Chicago; Director, University
of Illinois Cancer Center
ix

National Cancer Policy Forum Staff

ERIN BALOGH, Senior Program Officer
PATRICK BURKE, Financial Officer
NATALIE LUBIN, Senior Program Assistant
CYNDI TRANG, Research Assistant
SHARYL J. NASS, Forum Director and Director, Board on Health Care
Services

Reviewers
This Proceedings of a Workshop was reviewed in draft form by indi-

viduals chosen for their diverse perspectives and technical expertise. The
purpose of this independent review is to provide candid and critical com-
ments that will assist the National Academies of Sciences, Engineering, and
Medicine in making each published proceedings as sound as possible and
to ensure that it meets the institutional standards for quality, objectivity,
evidence, and responsiveness to the charge. The review comments and draft
manuscript remain confidential to protect the integrity of the process.
We thank the following individuals for their review of this proceedings:
BIBB ALLEN, JR., Grandview Medical Center

JEFFREY MYERS, University of Michigan
RITU NAYAR, Northwestern University
Although the reviewers listed above provided many constructive com-

ments and suggestions, they were not asked to endorse the content of the
proceedings nor did they see the final draft before its release. The review
of this proceedings was overseen by DANIEL R. MASYS, University of
Washington. He was responsible for making certain that an independent
examination of this proceedings was carried out in accordance with stan-
dards of the National Academies and that all review comments were care-
fully considered. Responsibility for the final content rests entirely with the
rapporteurs and the National Academies.
xi


Acknowledgments
Support from the many annual sponsors of the National Academies

of Sciences, Engineering, and Medicine’s National Cancer Policy Forum is
crucial to the work of the forum. Federal sponsors include the Centers for
Disease Control and Prevention and the National Cancer Institute/National
Institutes of Health. Non-federal sponsors include the American Associa-
tion for Cancer Research, American Cancer Society, American College of
Radiology, American Society of Clinical Oncology, Association of American
Cancer Institutes, Bristol-Myers Squibb, Cancer Support Community,
CEO Roundtable on Cancer, Flatiron Health, Helsinn Therapeutics (U.S.),
Inc., LIVESTRONG Foundation, Merck, National Comprehensive Cancer
Network, Novartis Oncology, Oncology Nursing Society, and Pfizer Inc.
The forum wishes to express its gratitude to the expert speakers whose
presentations helped further the dialogue and advance progress in improv-
ing patient access to appropriate expertise and technologies in oncologic
pathology and imaging. The forum also wishes to thank the members of
the planning committee for their work in developing an excellent workshop
agenda.
xiii


Contents
ACRONYMS AND ABBREVIATIONS xix
WORKSHOP OVERVIEW 1
CURRENT DIAGNOSTIC CHALLENGES IN CANCER CARE 6
Diagnostic Errors and Uncertainty in Diagnostic Findings, 8
The Changing Landscape of Oncologic Imaging, Pathology, and
Precision Oncology Care, 10
Uneven Access to Oncologic Imaging and Pathology Expertise and
Technologies, 14
Lack of Collaboration Among Radiologists, Pathologists, and
Oncologists, 15
ENSURING THE QUALITY AND ACCESSIBILITY OF
DIAGNOSTIC EXPERTISE AND TECHNOLOGIES 16
Improving Education and Training, 16
Improved Communication and Collaboration, 16
Molecular Diagnostics and Pathology Informatics, 17
Competency-Based Medical Education, 18
Pathology and Radiology Training, Subspecialization, and
Integration, 19
Training for Practice in Community Versus Academic Settings of
Care, 23
xv

xvi CONTENTS
Potential Strategies to Expand Patient Access to Subspecialty

Expertise in Oncologic Imaging and Pathology, 25
Second Opinions, 25
Oncology Expertise Within Practices and Academic
Departments, 26
Diagnostic Management Teams, 27
Telementoring, 28
Telehealth, 30
Clinical Decision Support, 30
Challenges with Developing and Implementing Clinical
Decision Support Tools, 32
QUALITY IMPROVEMENT EFFORTS 36
Measurement and Feedback, 37
Peer Learning and Second Reviews, 38
Continuous Learning and Assessment, 39
INTEGRATION AND COLLABORATION OF SPECIALTIES 41
Rationale for Collaboration and Integration, 41
Challenges to Integration, 42
Alternative Payment Models to Promote Collaboration and
High-Quality Care, 46
Real-World Data and Computational Oncology, 49
Real-World Data, 49
Computational Oncology and Machine Learning, 51
Data Sharing and Standardization, 54
WRAP-UP 56
REFERENCES 58
APPENDIX A: STATEMENT OF TASK 65

APPENDIX B: WORKSHOP AGENDA 67

Boxes and Figures
BOXES
1 Suggestions from Individual Workshop Participants to Improve
Patient Access to Appropriate Expertise and Technologies in
Oncologic Pathology and Imaging, 3
2 Cancer Imaging Fellowship Program at Brigham and Women’s
Hospital/Dana-Farber Cancer Institute, 21
3 Text Information Extraction System, 55
FIGURES
1 Interoperability of health information systems for active clinical
decision support, 34
2 Standards-enabled workflow of genomic data, 44
3 The traditional workflow for slides from the histology laboratory
versus the workflow for digital slides, 54
xvii


Acronyms and Abbreviations
ACR American College of Radiology

AI artificial intelligence
ASCO American Society of Clinical Oncology
CME continuing medical education

CMS Centers for Medicare & Medicaid Services
CPT Current Procedural Terminology
CRICO Controlled Risk Insurance Company
CT computed tomography
DMT Diagnostic Management Team
ECHO Extension for Community Healthcare Outcomes

EHR electronic health record
EPA entrustable professional activity
FAIR findable, accessible, interoperable, and reusable

FDA Food and Drug Administration
FHIR Fast Healthcare Interoperability Resources
GENIE Genomics Evidence Neoplasia Information Exchange
xix

xx ACRONYMS AND ABBREVIATIONS
MOC Maintenance of Certification

MRI magnetic resonance imaging
OCM Oncology Care Model
PET positron emission tomography

PROM patient-reported outcome measure
TIES Text Information Extraction System

Proceedings of a Workshop
WORKSHOP OVERVIEW1
Rapid advances in cancer research, the development of new and more
sophisticated approaches to diagnostic testing,2 and the growth in targeted
cancer therapies are transforming the landscape of cancer diagnosis and care
(Lowy and Collins, 2016; NASEM, 2016). Hedvig Hricak, chair of the
department of radiology at Memorial Sloan Kettering Cancer Center, said
these innovations have contributed to improved outcomes for patients with
cancer, but they have also increased the complexity involved in diagnosis
and subsequent care decisions.
The National Academies of Sciences, Engineering, and Medicine
define the diagnostic process as “a complex, patient-centered, collaborative
activity that involves information gathering and clinical reasoning with the
goal of determining a patient’s health problem. This process occurs over
time, within the context of a larger health care work system” (NASEM,
1 The planning committee’s role was limited to planning the workshop, and the Proceed-
ings of a Workshop was prepared by the workshop rapporteurs as a factual summary of what
occurred at the workshop. Statements, recommendations, and opinions expressed are those
of individual presenters and participants, and are not necessarily endorsed or verified by the
National Academies of Sciences, Engineering, and Medicine, and they should not be con-
strued as reflecting any group consensus.
2 In this proceedings, the term “diagnostic testing” is intended to be broadly inclusive of
all types of testing, including medical imaging, anatomic pathology, and laboratory medicine.

2 IMPROVING CANCER DIAGNOSIS AND CARE
2015, p. 32). Hricak stressed that “the diagnostic process is complex and
it’s getting even more complex.” In the context of high-quality cancer care,
the diagnostic process requires a high degree of specialized knowledge
and effective collaboration among the members of a patient’s care team in
order to inform diagnostic test selection; sample collection, preparation,
and analysis; and the interpretation and communication of results and the
implications for subsequent care decisions. Radiologists and pathologists are
essential members of the care team because accurate imaging and pathology
results are critical for establishing a correct diagnosis and treatment plan
for patients with cancer, as well as assessing prognosis, treatment response,
disease progression, and recurrence (Harris and McCormick, 2010; IOM,
2013b; NASEM, 2015).
To examine opportunities to improve cancer diagnosis and care, the
National Cancer Policy Forum developed a two-workshop series.3 The first
workshop, held on February 12–13, 2018, in Washington, DC, focused on
potential strategies to ensure that patients have access to appropriate exper-
tise and technologies in oncologic pathology and imaging to inform their
cancer diagnosis and treatment planning, as well as assessment of treatment
response and surveillance. This proceedings chronicles the presentations and
discussions at the workshop.
The workshop convened a number of stakeholders with a broad range
of views and perspectives, including radiologists, pathologists, oncologists,
and patient advocates, as well as representatives of health care organizations,
academic medical centers, community practices, and federal agencies. These
thought leaders were asked to discuss current challenges to cancer diagnosis
and to share their insights and perspectives—based on their involvement in
efforts to improve cancer diagnosis and care—on opportunities to expand
access to high-quality diagnostic expertise and technologies in cancer care.
Presentations and panel discussions examined
• Current diagnostic challenges and the risk for diagnostic errors;

• The changing landscape of pathology and radiology in cancer care;
• Ways to improve cancer diagnosis through education, training, and
quality improvement efforts;
3 The second workshop, The Clinical Application of Computational Methods in Preci-
sion Oncology, is planned for October 29–30, 2018. See http://nationalacademies.org/hmd/

Activities/Disease/NCPF/2018-OCT-29.aspx (accessed July 16, 2018).

PROCEEDINGS OF A WORKSHOP 3
• Opportunities to ensure the quality and accessibility of diagnostic

expertise and technologies, including clinical decision support,
telementoring, and telemedicine;
• Strategies to improve collaboration among the pathologists,
radiologists, and oncologists involved in cancer diagnosis; and
• The role of computational oncology and integrated diagnostics in
cancer care, including recent developments in artificial intelligence
(AI).
This workshop proceedings highlights a number of suggestions from

individual participants regarding potential ways to improve patient access
to expertise and technologies in oncologic imaging and pathology. These
suggestions are discussed throughout the proceedings and are summarized
in Box 1. Appendix A includes the Statement of Task for the workshop. The
BOX 1
Suggestions from Individual Workshop Participants to
Improve Patient Access to Appropriate Expertise and
Technologies in Oncologic Pathology and Imaging
Improving Education and Training in Oncologic Pathology

and Imaging
• Ensure pathology, radiology, and oncology education and
training programs emphasize communication and intra- and
interdisciplinary collaboration. (Fennessy, Nayar, Siegal)
• Facilitate more subspecialization in radiology through onco-
logic imaging fellowships and provide more opportunities for
training via mini-fellowships in the fourth year of radiology
residency or as a rotation during a standard fellowship, peer
learning, and continuing medical education. (Fennessy,
Hricak)
• Use competency-based education, entrustable professional
activities, and lifelong learning approaches. (Nayar)
• Use peer-learning programs to improve training and pro-
ficiencies in oncologic pathology and imaging. (Fennessy,
Hricak)
• Develop a new medical specialty in diagnostic oncology
that works at the intersection of pathology, radiology, and
oncology. (Becich, Fennessy, Schilsky, Stead)
continued

BOX 1 Continued
• Prepare radiologists and pathologists to use machine learning in

clinical imaging practice. (Langlotz)
Expanding Access to Expertise in Oncologic Pathology and

Radiology
• Form second-opinion networks and cancer imaging consortia to
increase access for those who would like second opinions for
suspected cancer diagnoses. (Hricak)
• Develop and support programs such as Project ECHO, which
build community capacity and enable patient access to the spe-
cialized services and expertise of major cancer centers. (Baker,
Schilsky)
• Develop tools and mechanisms to help community clinicians
refer patients to larger cancer centers when appropriate.
(Elenitoba-Johnson)
• Create oncologic imaging expertise within radiology depart-
ments, especially in academic settings where it is more feasible
than community practices. (Hricak)
• Designate local experts in oncology imaging or pathology who
can teach and provide feedback to others in smaller general
practices. (Larson)
• Use the Diagnostic Management Teams approach to optimize
diagnostic testing and support clinicians in test ordering and
interpretation. (Zutter)
Increasing the Integration and Collaboration Among Specialties in

Cancer Care
• Encourage a multidisciplinary approach to care with integrative
teams of radiologists, pathologists, oncologists, primary care
clinicians, and bioinformaticians. (Hricak, Larson)
• Integrate pathology, radiology, and oncology reports to develop
a more unified and informed diagnostic interpretation. (Cohen,
Shulman, Stewart, Zutter)
• Engage tumor boards to help integrate specialties for diagnosis.
(Warner)
• Provide incentives, including payment mechanisms, for interdis-
ciplinary collaboration to further integrate pathology, radiology,
and oncology in cancer diagnosis and care. (Becich, Brkljačić,
Cohen, Grubbs, Hofmann, Larson, Sause, Zutter)
• Conduct financial analyses to determine whether increased col-
laboration can result in greater savings for health care systems.
(Grubbs)

Improving and Increasing the Use of Clinical Decision Support

• Ensure that decision support tools are efficiently embedded into
a clinician’s workflow, reduce redundant data entry, and provide
brief, actionable, and unambiguous advice. (Brinks, Khorasani,
Shirts)
• Use decision support to aid clinicians, particularly those with less
specialization, in appropriately ordering, interpreting, and acting
on diagnostic results to reduce variation in care and improve
adherence to best practices. (Khorasani, Schilsky, Shirts)
• Ensure that decision support tools are developed by physicians
with a board specialty in informatics. (Becich)
• Ensure that electronic health record (EHR) vendors build deci-
sion support options directly into their systems and support them.
(Becich)
• Collaborate with patients in designing decision support tools and
incorporate patient-reported outcome measures (PROMs) within
these systems. (Khorasani, Riely)
• Create machine-readable clinical practice guidelines that can be
disseminated quickly into decision support tools. (Shirts)
• Improve data interoperability and interinstitution collaboration to
reduce the costs of decision support. (Shirts)
• Foster better alignment among payers, regulators, and profes-
sional societies to increase uptake of clinical decision support.
(Elenitoba-Johnson)
Promoting Lifelong Learning, Assessment, and Quality

Improvement Efforts
• Facilitate and support lifelong learning to enable clinicians to
master the rapidly accumulating new knowledge in medicine.
(Brink, Nayar, Wagner)
• Measure performance and assess whether clinicians are adher-
ing to evidence-based practices. (Khorasani)
• Include a clinical practice area for ongoing assessment of radi-
ologists’ proficiencies and maintenance of certification. (Hricak)
• Hold practices accountable for diagnostic performance using a
blended model in which specialists supervise, coach, and pro-
vide feedback to generalists. (Larson)
• Provide feedback on clinician performance and patient out-
comes, supported by data and measurement, to support quality
improvement efforts. (Hricak, Sause, Stead)
• Include PROMs in quality improvement efforts. (Hofmann)
• Solicit the leadership and engagement of clinicians and adminis-
trators in quality improvement efforts. (Hricak, Sause)
continued

BOX 1 Continued
• Address cultural and organizational challenges to improving

cancer diagnosis and care. (Schilsky)
Supporting Innovation in Oncologic Pathology and Imaging

• Enhance partnerships among the fields of computational pathol-
ogy, genomics, and radiology to facilitate innovation and improve
patient care. (Becich)
• Create competitions that draw together engineers and clinicians
to solve interoperability issues. (Cader)
• Create a digital architecture for imaging and analysis that encom-
passes pathology and radiology. (Becich)
• Develop new tools for machine learning that can process com-
plex, multimodality, and time-based data. (Langlotz)
• Use artificial intelligence, interconnectivity, and better computer
systems to further enable precision oncology and create a more
dynamic, smarter, and more efficient healthcare workforce.
(Hricak, Sause, Warner)
• Ensure adequate validation and workforce training before dis-
seminating new technologies into clinical practice. (Becich,
Brawley, Langlotz, Hricak)
Improving Data Curation, Integration, and Sharing

• Engage bioinformatics specialists and professional societies to
develop systematic curation and integration of data into large
aggregated databases. (Abernethy, Becich)
agenda is provided in Appendix B. Speakers’ presentations and the webcast

have been archived online.4
CURRENT DIAGNOSTIC CHALLENGES IN CANCER CARE

“Good care starts with a good diagnosis,” said Hricak, who added that
an estimated 60 to 70 percent of all decision making in health care is influ-
enced by diagnostic testing (Dzau et al., 2016; Forsman, 1996). Stephen
4 See http://www.nationalacademies.org/hmd/Activities/Disease/NCPF/2018-FEB-12.
aspx (accessed April 24, 2018).

• Increase efforts to collect health data directly from patients for

the EHR. (Khorasani, Riely)
• Link different types of data, such as genomics and clinical imag-
ing, in the EHR. (Langlotz)
• Make databases interoperable by using the same nomenclature
and information elements. (Abernethy, Warner)
• Create national standards and checklists for ensuring data com-
pleteness and quality in shared databases. (Abernethy, Langlotz,
Warner)
• Encourage academic–industry partnerships to develop data-
bases that adhere to the FAIR (findable, accessible, interoper-
able, and reusable) principles. (Becich)
• Ensure that databases include data from diverse populations.
(Cox, Levy)
Engaging Patients
• Communicate complex diagnostic information to patients in an
understandable way. (Spears)
• Increase patient awareness of the availability of subspecialists in
cancer diagnosis and care. (Hofmann)
• Incorporate patient input when developing better tools and sys-
tems for diagnostic integration. (Cox, Hofmann, Spears)
• Consider patient accessibility when planning and developing new
technologies. (Spears)
Grubbs, vice president of clinical affairs at the American Society of Clinical

Oncology (ASCO), agreed, adding: “When I order the right test, I [need
to] know I am getting the right answer” to inform subsequent decision
making in cancer care.
However, a number of workshop speakers described challenges to
ensuring high-quality diagnosis in cancer care, such as
• Diagnostic uncertainty and the potential for diagnostic errors;

• The rapidly changing landscape of oncologic imaging, pathology,
and precision oncology care;

• Disparities in patient access to oncologic imaging and pathology

expertise and technologies; and
• Lack of adequate communication and collaboration among
oncologists, pathologists, and radiologists in cancer care.
Diagnostic Errors and Uncertainty in Diagnostic Findings

Despite the importance of an accurate diagnosis for subsequent care,
several speakers noted that some patients with cancer experience diagnostic
errors.5 Patty Spears, scientific research manager and patient advocate at the
University of North Carolina at Chapel Hill Lineberger Comprehensive
Cancer Center, stressed that patients often assume their diagnosis is accu-
rate, and may not realize that their diagnosis could be incorrect, “making it
especially important that there are systems in place to ensure such accuracy.”
She added that reaching an accurate and complete diagnosis is critical so
that the patients have “all the information that they need to make the cor-
rect decisions during their whole continuum of cancer care.”
Dana Siegal, director of patient safety services at Controlled Risk
Insurance Company (CRICO) Strategies, reviewed findings from CRICO’s
Comparative Benchmarking System, a national database of medical mal-
practice claims from captive and commercial insurers across the United
States.6 Siegal reported that diagnostic-related claims are the third largest
in volume and the first largest in dollars lost (based on indemnity and
expenses) compared with other types of medical malpractice claims (e.g.,
surgical treatment or medical care). She added that the failure to diagnose
cancer and delays in a cancer diagnosis represent approximately 30 percent
of all diagnostic-related malpractice claims. Among all cancer-related mal-
practice cases, Siegal said that clinical judgment contributed to 72 percent
of these cases, including the misinterpretation of diagnostic testing. For
both the pathology and radiology specialties, misinterpretation of diagnos-
tic testing was the primary cause of cancer-related malpractice claims. In
the pathology specialty, additional contributing factors included insufficient
communication to the ordering clinician and poor technique; in radiology,
5 According
to Improving Diagnosis in Health Care, a diagnostic error is “the failure to (a) estab-
lish an accurate and timely explanation of the patient’s health problem(s) or (b) communicate that
explanation to the patient” (NASEM, 2015, p. xiii).
6 See https://www.rmf.harvard.edu/Malpractice-Data/Annual-Benchmark-Reports#CF
(accessed June 18, 2018).

another factor included insufficient communication to the ordering clini-

cian, especially regarding the management of incidental findings.7,8
Michael Cohen, interim chair and director of anatomic pathology at
Wake Forest School of Medicine, reported that diagnostic error rates in
anatomic pathology9 range from 1 percent to 6 percent, depending on
factors such as anatomic site and the definition of diagnostic error that is
used (Frable, 2006). He added that a study on mandatory review of surgical
pathology reports found major disagreements (e.g., a change in diagnosis)
in 2.3 percent of the cases; in 9 percent of cases, there were minor disagree-
ments (e.g., a change in cancer staging, margin status, or other aspects that
influence decision making in cancer care) (Manion et al., 2008).
Otis Brawley, chief medical officer of the American Cancer Society,
added that a study of diagnostic concordance in breast pathology found that
the overall agreement among individual pathologists and consensus panel
reference diagnoses was approximately 75 percent (Elmore et al., 2015).
Disagreement from the consensus panel reference diagnosis was greatest for
pathologists who had lower weekly case volumes for interpretation, worked
in smaller practices, or worked in non-academic settings. Brawley noted
that these findings are likely because pathologists in high-volume settings or
who practice in academia see more cases of breast cancer than pathologists
who practice in community settings.
Hricak highlighted a number of studies that have found discrepancies
in imaging interpretations between general radiologists and those with
expertise in oncology (Coffey et al., 2017; Corrias et al., 2018; Hatzoglou et
al., 2016; Horvat et al., 2018; Lakhman et al., 2016; Lorenzen et al., 2012;
Lysack et al., 2013; Spivey et al., 2015). Depending on the study, second
reviews by oncologic radiologists led to a change in treatment planning
for a substantial portion of patients (13 to 53 percent). Hricak also cited
a study showing that radiologists with a specialty in genitourinary systems
who interpreted magnetic resonance imaging (MRI) added incremental
value to the assessment of prostate cancer, while general radiologists did
not (Mullerad et al., 2004). This finding “makes you realize the gaps in
7 Incidental findings are potentially abnormal results that are found unintentionally during
diagnostic testing.
8 This paragraph was updated since the prepublication release.
9 Anatomic pathology addresses the microscopic examination of tissues, cells, or other solid
specimens, sometimes with the aid of ancillary testing to detect specific genes or molecules,
said Cohen.

knowledge and in the importance of special expertise in oncologic imag-

ing,” Hricak said. Another study showed that when subspecialty radiologists
read images, the turnaround time of radiology reports is significantly faster
because they are more familiar with possible findings, and consequently, the
time to diagnosis is quicker (Stern et al., 2018).
Radiology has been moving more toward subspecialization in the
United States, Hricak noted. In 2012, a workforce survey found more than
35 percent of radiologists reported they were general radiologists; in 2017,
fewer than 10 percent of radiologists reported they were generalists (Bluth
et al., 2017). She pointed out that the majority of patients with cancer are
treated in community settings, suggesting the need for strategies to extend
oncologic imaging expertise from academic medical centers and cancer
centers to community settings of care.
Brawley also noted that diagnostic testing has performance limitations
(e.g., the potential of a diagnostic test to yield a false-positive or false-
negative result), and interpretation of results can be subjective. “Uncer-
tainty in medicine is just not appreciated and everybody thinks everything
is binary,” he said, adding that many molecular tests for predicting cancer
recurrence divide patient populations into low, middle, or high risk of
recurrence, but the thresholds for these categories can be difficult to deter-
mine and may not always reflect clinical differences among the population
subgroups. Brawley said there also can be differences in the performance of
a diagnostic test within clinical trials that have highly selected populations
compared to its performance in clinical practice settings.
The Changing Landscape of Oncologic Imaging,

Pathology, and Precision Oncology Care
Several speakers noted how rapidly the landscape of oncologic imaging
and pathology is changing, as well as the growth in precision oncology care.
“We are in the era of the convergence of life sciences, physical sciences, and
engineering, and each is essential to proper diagnosis,” said Hricak. “There
will not be precision oncology without precision diagnostics, and bioengi-
neering and computational methods are essential for next-generation diag-
nostics,” she said, adding, “The time has never been better to understand the
importance of diagnostics—which is pathology and imaging—in moving
cancer care forward.”
Digitization is changing the nature of the fields of radiology and pathol-
ogy, several speakers noted. Ronald Kline, medical officer at the Center for

Medicare & Medicaid Innovation at the Centers for Medicare & Medicaid
Services (CMS), said the digitization of radiologic images has helped to
enable patients to receive second opinions by oncologic radiologists: “The
ease of moving digital images to different hospitals in different locations
allows you to get better care,” Kline said. Although the field of pathology is
not as far along as radiology, efforts to digitize pathology are also under way,
said Richard Friedberg, professor and chair of the department of pathology
at the University of Massachusetts Medical School at Baystate. In April
2017, the Food and Drug Administration (FDA) approved the first digital
pathology system to review and interpret whole-slide images prepared from
biopsied tissue.10
Jeremy Warner, associate professor of medicine and biomedical infor-
matics at Vanderbilt University, said the goal of precision oncology care is
to ensure the delivery of the right care to the right patient at the right time.
Precision oncology therapies target specific abnormalities in a patient’s
cancer, facilitated by diagnostic testing that characterizes that cancer.
Friedberg noted that “our pathology world is changing dramatically by get-
ting more molecular, [more] scientific, and more technical.” He added that
morphology11—the physical characteristics of a patient’s biopsy tissue—was
once the primary data element in pathology, but now it is just one of many
data elements. He said there is much greater reliance on molecular testing in
pathology, and with this testing, the number of distinct subtypes of various
cancers has grown remarkably. Brawley pointed out that when he gradu-
ated from medical school 30 years ago, only two types of lung cancer had
been discovered; now there are dozens of subtypes of lung cancer, including
those defined by the genetic abnormalities that can be targeted by certain
therapies. “Lung cancer has gotten incredibly complicated in a very short
time, and the ability of the pathologists to do these tests with certainty is
guiding how medical oncologists treat the disease,” Brawley said. He added
that such testing is being used to help estimate the risk of recurrence of an
individual’s cancer, such as with Oncotype DX12 or MammaPrint.13 “This
understanding of the differences in genomics among cancers is giving us a
10 See https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm552742.
htm (accessed April 24, 2018).

11 The science of the form and structure of organisms.
12 See http://www.genomichealth.com/en-US/oncotype_iq_products/oncotype_dx.aspx
(accessed April 24, 2018).

13 See http://www.agendia.com/diagnostic-products/mammaprint.html (accessed April
24, 2018).

21st-century definition of cancer that depends not just on the biopsy but
also on the genomics,” Brawley stressed.
Warner noted that the complexity of such testing is continuing to
increase: In just the past few years, molecular testing has grown from the
testing of individual genes or several genes to include multiplex omics pan-
els with hundreds of genes. He added that the FDA approval of the cancer
immunotherapy pembrolizumab14 for patients whose cancers harbor bio-
markers indicating high microsatellite instability or mutations in mismatch
repair genes, rather than on where a cancer originated in the body, signaled
a new era of biomarker-based treatment assignment. Also in 2017, the
FDA approved the first in vitro diagnostic test capable of detecting genetic
mutations in 324 genes and 2 genomic signatures in any solid tumor type.15
Warner said this will prompt a “vastly increased uptake of these large gene
panels in the coming year.”
Michael Becich, chair and distinguished university professor in the
department of biomedical informatics at the University of Pittsburgh
School of Medicine, noted that computational pathology—which he
described as an approach to diagnosis that incorporates multiple sources
of data (e.g., hematoxylin and eosin staining, immunohistochemistry,
immunofluorescence, and genomic data), presents clinically actionable
knowledge, and provides decision support for precision medicine—is also
helping to redefine the field (Louis et al., 2014, 2016).
Oncologic imaging is also increasing in complexity, said Hricak and
Fiona Fennessy, director of the Cancer Imaging Fellowship Program at
Brigham and Women’s Hospital/Dana-Farber Cancer Institute. Imaging
is used in oncology to detect tumors, determine their size, and determine
whether lymph nodes have been affected. In addition, Hricak noted that
expertise in oncologic imaging requires a thorough understanding of
cancer biology, including the disease’s ability to affect multiple anatomic
systems. Oncologic imaging also requires knowledge of treatment options,
given the advent of molecular imaging methods that can be used to select
specific treatments. “The oncologic report has to not only be accurate, but
be clinically relevant and actionable,” Hricak said. She added that the need
for oncology training and expertise is not widely recognized because “you
14 See https://www.fda.gov/Drugs/InformationOnDrugs/ApprovedDrugs/ucm560040.

15 See https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm587273.

usually don’t realize what you are missing.” At the end of their fellowship
training, Hricak said that fellows often remark that they did not realize how
much knowledge oncologic imaging requires.
New technologies and techniques in imaging are enabling greater preci-
sion and additional insights from imaging. For example, some new imaging
techniques can detect early, subtle tissue changes indicative of a response
to treatment, Fennessy said. With the advent of functional imaging, also
called physiologic imaging—such as positron emission tomography (PET)
or various forms of MRIs—radiologists can also assess tumor biology based
on uptake of glucose or blood flow, presence of specific receptors, or other
molecular features of interest. “In the past, most X-ray or ultrasound imag-
ing has been structural or anatomic, but some of nuclear medicine imaging
is more and more becoming imaging that’s both anatomic as well as physi-
ologic, which is a new frontier,” Brawley said. Hricak added that much of
that physiologic imaging is still only used in clinical trials and is not yet
approved for more general clinical use.
Hricak and Becich added that a number of efforts are under way to
integrate machine learning and AI with imaging technologies. Becich said
the field of radiomics attempts to extract and analyze large amounts of
quantitative data from medical images, using algorithms that may identify
features associated with disease characteristics that human interpretation
may fail to appreciate (Kumar et al., 2012). Becich noted that the increased
complexity associated with the introduction of computational pathology
and radiomics contributes to cognitive overload among pathologists, radi-
ologists, and oncologists. Hricak suggested that there is a need to facilitate
the development of AI and machine learning to take over some relatively
straightforward repetitive tasks, such as tumor measurement and summariz-
ing pertinent history, in order to give radiologists the time to focus on more
challenging diagnostic tasks.
Given the rapid growth in complexity in imaging and pathology,
several speakers said that a major challenge is how to convey complex
diagnostic testing results to clinicians who are unfamiliar with emerging
technologies. William Sause, director of radiation oncology at Intermoun-
tain Healthcare, noted that with the “explosion of scientific knowledge,
the clinician is overwhelmed with the amount of information that can be
provided. Trying to sort through that [information] and provide a succinct
meaningful interpretation of the data is truly a problem.” Spears noted that
conveying this complex information to patients in an understandable way
is also critically important.

Despite the promise of newer diagnostic technologies, Brawley also cau-

tioned against premature adoption and dissemination before they have been
adequately vetted. Brawley gave historic examples of premature adoption of
technologies and their potential for harm. For example, when mammogra-
phy was first introduced, Brawley said that women with non-invasive breast
lesions unnecessarily received mastectomies; in addition, after introduction
of the Pap smear,16 some women with mild cervical dysplasia received radi-
cal hysterectomies or radiation therapy because it was not well understood
that the majority of these cervical abnormalities regress without treatment.
“We need to be very careful in how we disseminate these new technologies
into the community,” said Brawley. Cohen pointed out that the field of
molecular diagnostics is a rapidly evolving area, and many companies are
offering omics-based tests with proprietary algorithms whose results cannot
be reproduced in the scientific literature. He added that there is an element
of subjectivity in this testing, especially in how cut points are determined,
but there is limited or no information about how these decisions were made
because of the proprietary nature of the tests. This testing can add value,
“but they need to be incorporated very carefully,” Cohen said.
Uneven Access to Oncologic Imaging and

Pathology Expertise and Technologies
Brawley said there are disparities in access to high-quality diagnostic
services for people with cancer. To receive high-quality imaging results,
the necessary components include well-trained radiologists and radiologic
technologists, adequate time for them to do their job properly, up-to-date
and well-maintained equipment, and access to necessary contrast agents,
Brawley said. Similar components are needed for pathology, including
high-quality reagents. But some of these components can be lacking in
community hospitals, especially those considered safety-net hospitals that
offer access to care regardless of ability to pay and thus have a substantial
share of patients who have low incomes, are uninsured, or are otherwise
vulnerable, Brawley stressed.
He noted that in a study of the quality of colon cancer surgery, ade-
16 Also
called a Papanicolaou test, in which cells from the cervix are examined under a
microscope for cervical cancer or cell changes that may lead to cervical cancer. See https://
www.cancer.gov/publications/dictionaries/cancer-terms/def/pap-test (accessed June 18,
2018).

quate cancer staging (the evaluation of at least 12 lymph nodes) occurred

in fewer than half of the patients, and people who were African American
or Hispanic were more likely to have inadequate lymph node examina-
tion after resection for colon cancer (Rhoads et al., 2011). Brawley noted
that this could have contributed to understaging in cancer diagnosis, and
thus undertreatment, of some people if additional lymph nodes had been
examined and found to contain cancer cells. Brawley added that inadequate
examination of lymph nodes was associated with the hospital where care
was received, suggesting that understaging was related to workload, or inad-
equate time for lymph node examination during surgery.
Both Brawley and Richard Schilsky, senior vice president and chief
medical officer of ASCO, noted that the introduction of innovative technol-
ogies can exacerbate health disparities because of the lag in their adoption
in cancer care facilities with limited finances. “Worsening health disparities
might signal the onset of new technologies, because new technologies often
have their most immediate uptake in populations most easily able to access
them,” Schilsky said.
Spears added, “We want the outcome to be better for the patient, and
as technologies move forward, we need to be intentional and include every-
body, because we know that [all] patients are not treated the same. We need
to even that playing field and make sure everything is accessible, because
right now, where you live and who you are matters, and you don’t want to
make [disparities] bigger by adding new technologies.”
Sause noted that the new technologies to improve cancer diagnosis
hold a great deal of potential, but their costs may impede “our ability to do
a lot of other things and we have to . . . come to grips with this.” Schilsky
added that it will be important to consider the value of new technologies
and not just their costs.
Lack of Collaboration Among Radiologists,

Pathologists, and Oncologists
Several workshop participants said a major diagnostic challenge is the
lack of collaboration and communication among pathologists, radiolo-
gists, and oncologists (NASEM, 2015). Even within a single specialty, the
work culture and time pressures can discourage collaboration. For example,
David Larson, vice chair for education and clinical operations in the depart-
ment of radiology at Stanford University, said radiologists generally work
in parallel, meaning they tend not to consult each other except within

practices that have established mechanisms for second readings of images.

“There needs to be a deliberate focus on teamwork and collaboration,” he
said. Cohen and Mary Zutter, vice president of integrative diagnostics at the
Vanderbilt University Medical Center and professor of pathology, microbi-
ology, and immunology at the Vanderbilt University School of Medicine,
stressed that high-quality diagnosis requires a team effort: “Integration of
knowledge across disciplines is essential both for the patient and for the
learning health care system,” said Zutter (see also the section on Integration
and Collaboration of Specialties).
ENSURING THE QUALITY AND ACCESSIBILITY OF

DIAGNOSTIC EXPERTISE AND TECHNOLOGIES
A number of workshop participants examined strategies to enhance
expertise in oncologic imaging and pathology, including improving educa-
tion and training, expert consultations, telemedicine and telementoring,
and clinical decision support.
Improving Education and Training

Several workshop participants described opportunities to improve
oncologic imaging and pathology through education and training efforts,
including
• Greater emphasis on improved communication and sharing of

diagnostic testing results;
• Additional resources and training opportunities on molecular
diagnostics and pathology informatics;
• Adoption of competency-based medical education approaches; and
• More opportunities for subspecialization in imaging and pathology
and for cross-discipline education.
Improved Communication and Collaboration

Siegal noted that a significant percentage of diagnostic errors are due to
inadequate communication in medical care (e.g., ensuring that the diagnos-
tic testing results from radiologists and pathologists are received by a patient
and the ordering clinician). She noted that at one hospital, radiology and
emergency department residents are taught “to have open communication

between two services that often see themselves as very separate.” She added
that when root cause analyses17 are performed to identify how diagnostic
errors occurred, having multiple specialties present a case provides powerful
lessons about how communication breakdowns contribute to diagnostic
error.
To strengthen communication skills, Ritu Nayar, professor and vice
chair of pathology at the Northwestern University Feinberg School of
Medicine and director of cytopathology at Northwestern Memorial Hos-
pital, reported that pathology residents and fellows participate in simula-
tions and daily clinical practice, and then receive constructive feedback on
their performance. They are also taught how to prepare their reports in a
standardized fashion, communicate critical results to clinicians, and learn
about factors that contribute to communication gaps. Fennessy added that
appropriate communication of results is also emphasized in the Cancer
Imaging Fellowship Program at Brigham and Women’s Hospital/Dana-
Farber Cancer Institute. Fellows are required to produce templated reports
that summarize their findings, as well as suggest next steps oncologists
might want to take with their patients.
Interdisciplinary team approaches to cancer diagnosis and treatment
are part of the program requirements for a pathology training program
accreditation, Nayar noted. Trainees actively present cases and interact
with radiologists, oncologists, and other health care professionals in mul-
tidisciplinary tumor board meetings, at which patient treatment planning
is discussed. Residents are also expected to attend and present at inter and
intradepartmental meetings and quality assurance activities in which cancer
cases are reviewed.
Nayar said Northwestern has a 24/7 call center staffed by nurses to
help radiologists and pathologists reach clinicians to whom they need to
report their results. “We make sure that those who need to know a result
get it,” she said.
Molecular Diagnostics and Pathology Informatics

Nayar reported on a survey of “new in practice” pathologists (practic-
ing in both academic and community hospitals) that has been conducted
in concert with the Maintenance of Certification (MOC) program for the
17 A root cause analysis is a structured method used to analyze serious adverse events. See
https://psnet.ahrq.gov/primers/primer/10/root-cause-analysis (accessed July 13, 2018).

past 4 years. This survey asks respondents to rate 42 areas of training to

determine if residency training provided adequate preparation for their
practice. In the 2016 survey, most respondents reported that residency
training was about right, but a number of respondents suggested training
should include a greater emphasis on molecular diagnostics and pathology
informatics. In response, Nayar noted that training resources in these areas
are being developed and promulgated. She added that future survey results
will be used to help define the core training pathologists need to practice
competently; continue to identify areas where more training is needed, as
well as which training areas should be removed; and determine which com-
petencies should be part of specialty fellowships versus residency programs.
Competency-Based Medical Education

Nayar also discussed the increased focus on competency-based medi-
cal education in medical school, as well as during residency and fellowship
training (Powell and Carraccio, 2018). She said competency-based medical
education recognizes that not all students or trainees master skills at the
same pace, and aims to create a learner-centric education system that, in
turn, can promote patient-centered care. The Accreditation Council for
Graduate Medical Education/American Board of Medical Specialties specify
six core competencies in medical education, including patient care, medical
knowledge, practice-based learning and improvement, interpersonal and
communication skills, professionalism, and systems-based practice. During
their training, residents and fellows receive semiannual milestone reporting
on their progress in acquiring these competencies.
She also described entrustable professional activities (EPAs), which
have been defined as observable, measurable units of work that require the
integration of many competencies (ten Cate, 2005, 2013). “Right now, we
are judging people on individual competencies based on passing their boards
after a specific amount of time served in training, and we may be better off
judging them through these EPAs that require integration of several com-
petencies and correlate better with the actual work that we do,” Nayar said.
The American Board of Pathology issued a position statement supporting
its participation in the further development of EPAs in pathology, includ-
ing consideration of a pilot project.18 Four EPAs in anatomic and clinical
18 See http://www.abpath.org/index.php/announcements/255-abp-position-statement-
on-epas (accessed April 25, 2018).

pathology (e.g., a medical autopsy, intraoperative diagnosis, workup of a

non-major transfusion reaction, and a clinical pathology diagnostic study)
have been suggested as potential options for a pilot project (McCloskey
et al., 2017). Nayar noted that the field of pediatrics is already using this
approach—from medical school through residency and fellowship—and
plans to evaluate how this training compares to conventional approaches.
“The American Board of Pathology is committed to exploring the EPAs and
working with our organizations to see how these pilots might work out and
how they might affect training and certification of individuals,” Nayar said.
Pathology and Radiology Training, Subspecialization, and Integration

Nayar said most pathology residencies are 4 years long and focus on
both anatomic and clinical pathology, which includes training in onco-
logic pathology. A small percentage of residents pursue a 3-year residency,
which focuses only on anatomic pathology or clinical pathology. Nearly
all residents pursue subspecialty fellowship training after residency, and 46
percent of residents complete two or more fellowships. The American Board
of Pathology certifies 11 pathology fellowships, and there are a number of
additional subspecialty fellowships relevant to oncology, she said.
Nayar described current residency training in oncologic pathology,
including the requirement to use standardized reporting formats with
tumor staging information for resected specimens: “During residency, the
utilization of templates and standardized reporting is common . . . in both
academic centers as well as private practice settings that residents and train-
ees may rotate through,” Nayar said. Residents also perform and analyze
core biopsies and body fluids obtained by minimally invasive techniques for
advanced disease diagnosis, prognosis, or therapeutic decision making. She
added that a key to current pathology training is correlation with ancillary
studies, such as next-generation sequencing, immunohistochemistry, in situ
hybridization, flow cytometry, and cytogenetics.
Brent Wagner, president-elect of the American Board of Radiology and
visiting lecturer at the American Institute of Radiologic Pathology, reported
on radiology residency and subspecialty fellowship requirements. He noted
that radiology has four disciplines: diagnostic radiology, radiation oncol-
ogy, medical physics, and interventional radiology. He said for diagnostic
radiology, residents are trained in 18 content areas that include both organ
systems and imaging modalities. Typically, after a 1-year internship and 4
years of residency, fellows select up to three specific clinical areas in which

they intend to specialize, and take a certifying exam in these areas and in
the core elements of diagnostic radiology. This certifying exam is given
after the completion of a residency and/or fellowship. “At that point, you
are starting to subspecialize because you are picking areas that you think
will comprise your practice moving forward based on your training and
interests,” Wagner said.
Boris Brkljačić, vice president of the European Society of Radiology,
said the European Society of Radiology has an online learning platform19
with more than 260 learning modules that include sections on oncology
imaging. According to Brkljačić, many radiologists are using these online
courses to prepare for the European radiology diploma exam. The Society
also provides training in oncologic imaging at the annual European Con-
gress of Radiology. In 2011, the European Society of Oncologic Imaging20
was established to promote research activities and other advances related to
cancer imaging.
Several workshop participants discussed whether pathology and radiol-
ogy residencies should have a greater focus on oncology, as well as the need
for subspecialty fellowships in oncologic pathology and imaging. Hricak
said there is a need for specialized expertise in oncologic imaging, and there
should be educational opportunities to facilitate development of this exper-
tise, such as offering more oncologic imaging fellowships; offering oncologic
imaging training as a fourth-year mini-fellowship during radiology resi-
dency or as a rotation during a fellowship; and providing peer learning and
continuing medical education (CME) courses in oncologic imaging. She
said there are only 5 oncologic imaging fellowships in the United States,
but more than 250 types of other imaging fellowships.
Fennessy agreed that oncologic imaging fellowships are important
because cancer can affect the entire body, and traditional imaging subspe-
cialty fellowships focus on specific body areas or systems. “It is not a disease
just of the chest if the patient has lung cancer, or a disease of the abdomen
and pelvis if the patient has liver cancer. We need to be able to consider the
body as a whole when we give a report,” she said. Consequently, the Dana-
Farber Cancer Institute has moved away from organ-based or technology-
based fellowships, and instead offers more disease-centric fellowships, in
which fellows receive education and training in imaging and interpretation
of multiple body parts and organs using different imaging modalities (see
19 See https://cslide.ctimeetingtech.com/library/esr/home (accessed April 30, 2018).

20 See http://esoi-society.org/index.php (accessed April 30, 2018).

BOX 2
Cancer Imaging Fellowship Program at
Brigham and Women’s Hospital/Dana-Farber
Cancer Institute
Fiona Fennessy, director of the Cancer Imaging Fellowship

Program at Brigham and Women’s Hospital/Dana-Farber Cancer
Institute, reported that the fellowshipa is tailored toward preci-
sion medicine in cancer imaging (Krajewski et al., 2017; Van den
Abbeele et al., 2016). The program has eight cancer imaging fel-
lows: four fellows are on the general track, where they will learn
to read computed tomography (CT), magnetic resonance imaging
(MRI), and ultrasound imaging for patients with cancer. Two of the
fellows specialize in reading positron emission tomography (PET)
and CT scans. One fellow specializes in women’s oncology—half
of the fellowship is devoted to breast imaging and the remainder
is focused on reading CT, MRI, and ultrasound scans in general
oncology. The final cancer imaging fellow has a translational focus,
with one-third of the fellowship devoted to research, and the other
two-thirds split between nuclear imaging (e.g., PET scans) and
cross-sectional imaging (e.g., CT and MRI scans).
The fellowship program has several learning objectives, includ-
ing developing an understanding of the critical role of imaging in
cancer care, understanding the rapid evolution in cancer biology
and innovative therapies, and becoming familiar with the genomic
classification of tumor types. Fellows learn about all modalities of
cancer treatment, anatomical and functional criteria for assess-
ment of tumor response, potential adverse events and oncologic
emergencies, and the role of radiology in clinical trials. Fellows also
attend journal clubs and seminars to learn the latest information
relevant to their field.
a See http://www.dana-farber.org/for-physicians/education-and-training/
fellowships-and-training-programs/cancer-imaging-program-fellowships (accessed
April 30, 2018).
SOURCE: Fennessy presentation, February 12, 2018.
Box 2). Fennessy noted that these oncology fellows are expected to prepare
templated reports with standardized language. Hricak and Curtis Langlotz,
professor of radiology and biomedical informatics at Stanford University
and medical informatics director for radiology at Stanford Health Care, said

that the uptake of structured reporting in radiology has generally been slow,
but there are professional society initiatives to increase their use.21
Fennessy added that radiologists also need to understand the changing
paradigm of cancer care that has been brought about by precision medicine.
“When we consult with our oncology colleagues, we want to have an idea of
what they are talking about,” for example, with regard to the genomic basis
of a cancer, Fennessy stressed. She added that radiologists need to learn and
use the technical language that their oncology and pathology colleagues use.
Several workshop participants suggested that integrating radiology and
pathology disciplines in clinician training programs has the potential to
improve cancer diagnosis and care. Fennessy suggested that future training
programs for cancer imaging should incorporate pathology information to
better evaluate whether a tumor is actively growing, or whether a response
to treatment has occurred. “Digitized correlation and registration with
pathology and imaging will be key to figuring out what we are missing
in radiology and how we can improve upon that,” Fennessy said. William
Stead, chief strategy officer at the Vanderbilt University Medical Center,
suggested the creation of a new medical specialty in diagnostic oncology
that could provide a collaborative track for experts who work at the intersec-
tion of those two fields (Jha and Topol, 2016). He suggested creating pilot
training programs, and applying lessons learned when other disciplines were
combined into the same training program, such as pediatrics and internal
medicine. Becich responded that he has suggested that the Society for
Imaging Informatics in Medicine create a postdoctoral or research training
program that combines both radiology and pathology disciplines. “I don’t
know what we’ll call them yet, but we’ve got to start the revolution through
an evolution in training,” Becich said. He added that 10 years ago, Yale
University explored the possibility of having a common diagnostic platform
for pathology and radiology training, but it was not implemented. Becich
suggested that informatics could play a critical role in merging training
programs by developing an overall digital imaging and analysis architecture
that encompasses pathology and radiology and would require training in
both. “If you put [the fields of radiology and pathology] together around
common tools, then a lot can happen,” he said. “We’re going to need [these]
trainees to help fuel the advances, so this is really important.”
21 See http://www.radreport.org/specialty/oi (accessed August 17, 2018).

Training for Practice in Community Versus Academic Settings of Care

Several workshop participants discussed whether subspecialization in
oncologic imaging and pathology is appropriate or feasible in all settings
of care (e.g., community practice versus academic medical centers or large
cancer centers). James Brink, radiologist-in-chief at the Massachusetts
General Hospital and chair of the American College of Radiology (ACR)
Board of Chancellors, noted that the American Board of Radiology and the
American Board of Pathology devise their core competencies based on the
needs of the whole country, and not for one type of setting.
Schilsky asked, “What are the core competencies with respect to can-
cer that a radiologist or pathologist working in a community setting needs
to have in order to best meet the needs of the patient population they are
serving?” He added, “It’s just not going to be possible to take the kind of
radiology and pathology training and practice that exist at Dana-Farber,
Memorial Sloan Kettering, and the other big freestanding cancer centers
and put that out in the community. I am also not convinced that it is neces-
sary because the case mix is very different. If you work at a big cancer center,
you have 100 percent prevalence of cancer in your practice. That is not the
case in most of the community hospitals around the country.”
Kojo Elenitoba-Johnson, founding director of the Center for Personal-
ized Diagnostics and director of the Division of Precision and Computa-
tional Diagnostics at the University of Pennsylvania Perelman School of
Medicine, indicated that the complexity and rapidly evolving nature of
genomic diagnostics in oncologic pathology requires expertise and infra-
structure that only exists in larger academic medical centers. He said that
the duplication of such infrastructure in community settings may be pro-
hibitively expensive and inefficient. He suggested it might be more feasible
to develop mechanisms for community physicians to refer certain patients
for testing and care available at larger academic institutions and comprehen-
sive cancer centers if they do not have the expertise or technologies available
in the community setting.
Wagner noted that “most radiology care is still provided locally—
within a 50-mile radius of where you are.” He added that in some com-
munity settings, radiologists and pathologists do not see enough of certain
cancers to be comfortable distinguishing normal from abnormal findings.
“No matter your knowledge and training, if you are only reading 200 mam-
mograms a year, you are not going to be good at it,” he said.
Lawrence Hofmann, co-founder of Grand Rounds and chief of inter-

ventional radiology at Stanford Hospital, added that patients also need

information about the availability of subspecialists, especially for cancer care
that requires a high degree of specialized expertise. “Part of the solution may
be enabling the patient to seek out more specialized care when appropriate,”
Hofmann said. But Sause noted that insurers may not reimburse for care
that is out of network.
Ellen Baker, director of Project ECHO (Extension for Community
Healthcare Outcomes) at The University of Texas MD Anderson Cancer
Center, noted that “we’ll never have enough subspecialists to cover the
country evenly . . . there’s got to be a way to find some middle ground so
that local physicians will be able to provide more [care] than they can now.”
She said this is the purpose of Project ECHO, a telementoring program (see
the section on Telementoring).
Cohen added that the issue is not just about whether an individual
clinician has subspecialty training, but about taking a systems approach to
improving patient access to oncologic pathology and imaging. Larson sug-
gested holding practices collectively accountable using a blended model, in
which specialists supervise and provide feedback and coaching to general-
ists. Brink asked whether merging practices could help ensure sufficient
subspecialty expertise. Even if radiologists or pathologists have subspecialty
training, he noted that they may not have the scale in small practices for this
expertise to be leveraged. Larson responded that there has been significant
consolidation of practices, not only for purposes of aggregating expertise,
but also for economic reasons. As that occurs, he suspects large private prac-
tice groups will function more like academic departments, but he cautioned
that heavy coordination costs are involved.
Bruce Stewart, president of the Massachusetts Radiological Society,
noted that although he is “a big fan of subspecialization, there’s a sweet
spot for it,” and he cautioned against having “super specialized radiologists
who are not comfortable with anything outside their realm.” For example,
he pointed out that a chest CT also images the kidneys, liver, and other
organs in the abdomen, so radiologists who specialize in reading chest CTs
also have to recognize and evaluate abdominal lesions. “Subspecialization is
critical, but at the same time, you also need to have some general radiology
skills,” Stewart said.

Potential Strategies to Expand Patient Access to Subspecialty

Expertise in Oncologic Imaging and Pathology
A number of workshop participants described potential strategies to
expand patient access to oncology diagnostic expertise, including expert
consultations that can be facilitated by telemedicine or second opinion
networks, incorporating subspecialty expertise within practices, facilitating
Diagnostic Management Teams (DMTs), and using telementoring.
Second Opinions
Several workshop participants discussed opportunities to leverage
technology and consortia to facilitate access to second opinions in onco-
logic imaging and pathology. Nayar said that second opinions in pathology
are often sought when a cancer diagnosis is suspected (see section on Peer
Learning and Second Reviews). She added that a number of institutions are
starting to use real-time digital pathology tools, such as telepathology and
whole-slide imaging, within their institutions, as well as for expert consul-
tation outside their systems (Volynskaya et al., 2017). “These tools have
started making their way into pathology, but are not mainstreamed yet. . . .
This is what ultimately will need to happen with personalized and preci-
sion medicine as things become more and more complex,” Nayar noted.
She added that in addition to real-time approaches, access to subspecialty
expertise will also require referrals and the development of consultation
networks for subspecialty support.
Hricak suggested forming second opinion networks and cancer imag-
ing consortia so that those who lack oncologic imaging expertise in their
own practices have an easy mechanism to request second opinions for
suspected cancer diagnoses. Fennessy noted that radiologists with Brigham
and Women’s Hospital read any cancer-related images generated by its
community radiology division in Foxborough. “They are not familiar or
comfortable with reading these cases, so we have taken them over and our
oncologists prefer that,” Fennessy said. She also reported that the Dana-
Farber Cancer Institute has a consultation service in which their radiolo-
gists, as part of a multidisciplinary team, are embedded in the clinic to
interpret imaging in real time. “This allows for open dialogue with the clini-
cians, and for quality assurance of the peer reads,” she said, while decreasing
interruptions in the reading room.

Hofmann reported on Grand Rounds,22 which provides second

opinions and treatment decision support services to large, self-insured
companies. He said companies are increasingly seeking out these services
due to the high economic costs businesses incur (e.g., disability claims,
absenteeism, and health care costs) when employees are diagnosed with
serious conditions such as cancer and receive poor-quality or low-value care.
He said approximately 20 percent of Grand Rounds second opinions are
for patients with cancer. For approximately 36 percent of oncology cases,
a Grand Rounds second opinion changes the treatment plan, Hofmann
reported. He added that in those cases in which an in-house Grand Rounds
pathologist deems that another review of the pathology is necessary, the new
review leads to a change in the cancer diagnosis approximately 40 percent
of the time.
Becich asked how Grand Rounds keeps up with and curates the tre-
mendous amount of constantly evolving knowledge about cancer biology
and treatment. Hofmann responded that it relies on their experts to be up to
date on the knowledge related to their specialties. “We hope over time that
we will have a large enough corpus of data that we will be able to automate
some of these processes or disease states that are relatively straightforward,
but right now we’re relying on the experts,” Hofmann said.
Oncology Expertise Within Practices and Academic Departments

Hricak suggested instituting oncologic imaging expertise within radi-
ology departments, and she noted that this may be more feasible in large
academic settings than in small community practices. In smaller practice
settings, Larson suggested that practices designate local experts in oncologic
imaging or pathology who can teach and provide feedback to others in their
practice. Fennessy noted that community radiologists who are part of the
Brigham and Women’s Hospital/Dana-Farber Cancer Institute system can
participate in educational seminars via video conferencing to stay informed
and receive CME credits.
But Fennessy questioned whether community practices provide ade-
quate learning opportunities for physicians. “Those learning opportunities
may be available to them, but they often are not as aware of them. They may
attend CME courses, but that does not necessarily keep them up to date,
which is problematic. Potentially, you could champion a leader in those
22 See https://www.grandrounds.com (accessed April 30, 2018).

community divisions, but that person really needs to [receive] dedicated

education and know how to keep up with what is new and have a formal
plan. It cannot just be the assigned person in a practice because that would
get lost pretty quickly,” Fennessy said. Hricak agreed, noting that an onco-
logic imaging fellowship is not sufficient over time, given the fast pace of
cancer research. She said organized ways to ensure clinicians are keeping up
with the rapidly changing knowledge base are needed.
Diagnostic Management Teams

Zutter said the complexities involved in cancer diagnosis have chal-
lenged the traditional paradigm of pathology testing, in which a clinician
orders a test, a lab performs the ordered tests and returns results, and an
individual clinician collates and interprets the information. She noted that
there is a large, complex, and rapidly expanding menu of potential diag-
nostic tests for clinicians to consider and few evidence-based guidelines to
help with test selection. In addition, numerous laboratories may be involved
in testing, and they might provide a clinician with multiple reports, which
may be difficult for clinicians to collate and interpret.
To ensure that patients receive the correct diagnostic testing and
that clinicians are supported in test ordering and interpretation, Zutter
said that Vanderbilt developed DMTs through a collaboration among
pathologists, clinicians, and biomedical informaticians. The goals of this
program are to:
• Develop the right pattern of diagnostic testing for a patient, using

standard test ordering algorithms;
• Create a single, evidence-based, comprehensive report of integrated
diagnostic data to guide treatment and disease monitoring; and
• Iteratively improve the algorithms as evidence-based practices
evolve.
Zutter said clinicians have the option to order hemato-malignancy

testing individually or via DMT, but she has found wide acceptance of the
DMT approach. She added that DMT guidance is estimated to save clini-
cians approximately 10 minutes per patient, and ordering clinicians are
reassured that the correct tests will be ordered (Seegmiller et al., 2013). “We
have physician support and enthusiasm because we are not costing them
any extra time,” Zutter noted.

A retrospective analysis found that DMT guidance reduced unneces-

sary testing, improved test concordance (consistency with standard test
ordering algorithms), and resulted in lower costs (Seegmiller et al., 2013). If
this approach were scaled nationally, she said it could result in an estimated
savings of up to $500 million per year (Seegmiller et al., 2013). Improve-
ments in the DMT standard test ordering algorithms continued to improve
test utilization and performance, and also lowered costs (Seegmiller et al.,
2016). When next-generation sequencing was incorporated into the DMT
standard ordering algorithm for suspected diagnoses of myeloid malignan-
cies, clinicians who used DMT guidance had a positive test concordance
rate of approximately 81 percent, compared to approximately 18 percent
for the clinicians who ordered next-generation sequencing testing a la
carte. “This suggests the use of these [standard ordering algorithms] is truly
remarkable in improving testing and ultimately, patient care,” Zutter said.
Vanderbilt recently started offering DMT guidance at affiliated health
centers, such as Jackson Memorial Hospital. Pathologists continue mor-
phology analyses at their own institutions, but Vanderbilt performs the
more complex testing and assembles comprehensive reports. “It’s saving
them money because we are doing so many fewer tests than when they
were sending their lab testing out to a variety of other larger commercial
laboratories,” Zutter said. Vanderbilt has also recently developed DMT
standard ordering algorithms for colorectal cancer and is in the process of
implementing this DMT. Plans are under way for DMTs for other gas-
trointestinal malignancies, as well as breast and lung cancers. “What we
are doing is an example that can scale much more broadly to other disease
processes,” she said.
Telementoring
Baker reported on Project ECHO,23 a teleconsulting and telementor-
ing partnership to disseminate knowledge and build capacity in regions
lacking specialty or subspecialty medical care. “We can’t duplicate what’s
available at the major cancer centers in every community in America,
but there is some middle ground where we can improve what is currently
available and provide resources to these communities so patients get better
care and physicians have more support,” Baker said. She noted that Project
23 See https://www.mdanderson.org/education-training/global-outreach/project-echo.
html (accessed April 30, 2018).

ECHO was developed in 2003 by Sanjeev Arora, a gastroenterologist at the

University of New Mexico, as a way for patients with hepatitis C in rural
parts of the state to receive the complex specialized care they needed from
primary care clinicians. Arora formed a partnership with 16 rural clinics
and 5 prisons in New Mexico, for which he served as a mentor, providing
case-based guidance in weekly teleconferences in order to provide the sup-
port needed to care for patients in their own communities. Baker added
that an evaluation of Project ECHO found that patients treated with the
telementoring support had similar outcomes compared with patients who
were treated at the University of New Mexico (Arora et al., 2011).
Baker stressed that Project ECHO is not telemedicine, which involves
long-distance interactions between patients and clinicians, but rather
clinician-to-clinician telementoring, which enables specialists to dissemi-
nate their knowledge to partners in the community who can then treat more
complex patients. “The goal is to take knowledge that usually sits at the
academic center and share it with the rest of the medical community, par-
ticularly in areas that don’t have that specialty or that knowledge. By doing
this, you build capacity outside of major medical centers to treat patients
with complex conditions safely and effectively in the community without
the need to refer them out,” Baker said. “The goal is to move knowledge
and not patients,” she said, and added that telementoring can help reduce
disparities in access to quality care.
The four pillars of Project ECHO are harnessing videoconference tech-
nology, sharing best practices, employing case-based learning, and monitor-
ing outcomes (Arora et al., 2007). The University of Texas MD Anderson
Cancer Center adopted Project ECHO 4 years ago to help underserved
communities manage cervical dysplasia, a precursor to cervical cancer, Baker
reported. Project ECHO has been expanded to other aspects of cancer care,
including prevention, treatment, palliative care, and cancer survivorship
care for several different types of cancer at a number of underserved regions
worldwide. There are currently more than 170 Project ECHO hubs for
more than 65 diseases in 23 countries, she said.
Baker noted that one of the challenges in implementing Project ECHO
is the need to identify champions both in academic centers and in the
community. To participate in Project ECHO, community clinicians need
to take time away from direct patient care, “so you have to find somebody
who is really passionately interested in moving up a notch and being able
to provide services they were not previously able to provide. Once you get

that community champion, they tend to be able to bring others in with

them,” Baker said.
Telehealth
Sause said that Intermountain Healthcare—which delivers health care
through a network of 22 hospitals in Utah and southern Idaho, and is an
insurance provider—originally began offering telehealth services to seven
community hospitals serving large geographic areas with intensive care
units staffed by non-intensivists. After the telehealth program to support
these intensive care units was instituted, Sause said that patient outcomes
improved, including a reduced risk of mortality.
Intermountain Healthcare has expanded its telehealth program to the
oncology setting as well by tapping into system resources and expertise,
including subspecialty expert opinions, in order to deliver cancer care in
four outpatient facilities in rural settings. Patients at these facilities have
participated in more than 500 telehealth visits, and report a high degree of
satisfaction with the program, Sause reported. He said telehealth can aug-
ment the capacity of a generalist, and also supplement care in communities
that have insufficient numbers of specialists.
Clinical Decision Support

A number of workshop participants discussed clinical decision support
tools in cancer care. Ramin Khorasani, professor and vice chair of radiol-
ogy at Harvard Medical School and co-founder and director of the Center
for Evidence-Based Imaging at Brigham and Women’s Hospital, described
clinical decision support as the iterative interaction of a clinician with a
computer to improve clinical decision making by reducing unwarranted
variation in care and improving adherence to what is known to benefit
patients. For example, he highlighted the uneven use of CTs and MRIs
nationwide among Medicare beneficiaries (Ip et al., 2015). Even within
his own institution, he found wide variation on follow-up recommenda-
tions among individual cancer imaging specialists. “We need to be able to
measure performance and assess whether our practitioners are adhering to
evidence to reduce unwarranted variations in care,” Khorasani said, stressing
that clinical decision support encourages evidence-based practice, which
is an essential attribute of high-quality care, as defined by the Institute of
Medicine (IOM, 2001).

Brian Shirts, assistant professor of laboratory medicine at the University

of Washington, defined clinical decision support as “knowledge and person-
specific information, intelligently filtered or presented at appropriate times,
to enhance health and health care” (Osheroff et al., 2007, p. 141). Gregory
Riely, medical oncologist at the Memorial Sloan Kettering Cancer Center,
stressed that clinical practice guidelines, such as those developed by the
National Comprehensive Cancer Network and ASCO, are the underpin-
nings for clinical decision support.
Shirts said decision support can help clinicians to appropriately inter-
pret and act on diagnostic testing results. Jordon Laser, senior director of
Cytogenetics & Molecular Pathology at Northwell Health, agreed and
added that the purpose of diagnostic clinical decision support is to provide
clinicians with sufficient and accurate information to order the right test at
the right time for the right patient. In imaging, Khorasani said that decision
support tools can be used when clinicians place orders for imaging, at the
time of image analysis and interpretation through tools such as computer-
aided detection or diagnosis, and at the time of results reporting, to help
improve recommendations for additional imaging.
Shirts said clinical decision support tools can either be passive (requir-
ing user effort to access or interpret) or active (pop-ups or flags that are
triggered by specific situations). Examples of passive clinical decision sup-
port are drug dosing calculators, disease risk calculators, and web addresses
to view additional information, but he noted that passive clinical decision
support may be accessed infrequently (Shirts et al., 2009). For clinical
decision support tools to be effective, Khorasani said they have to be effi-
ciently embedded into a clinician’s workflow, reduce redundant data entry,
and provide brief, actionable, and unambiguous advice (Bates et al., 2003;
Khorasani et al., 2014). In addition, Khorasani said these tools should
encourage or enforce clinicians to adopt evidence-based practices, and the
strength and source of the evidence should be transparent to the clinician.
He added that decision support tools should minimize “low-value” alerts
that exacerbate alert fatigue.
Several speakers said it was essential to collaborate with patients in
designing decision support tools, and to incorporate PROMs within
these systems. “It’s really important to engage patients in making these
recommendations applicable to the care of patients because not everybody
prefers the same treatment, and patient preferences are not embedded in
our guidelines and rules today,” Khorasani said. He noted that most EHRs
provide only the clinician’s perspective on patient presentation. He sug-

gested collecting patient-generated information on signs and symptoms

by having patients fill out an electronic form while waiting to be seen by
their clinicians. “Can we partner with patients in this way so they can help
us make decisions?” he asked. Riely agreed that this approach is critical to
improving patient engagement, and pointed to a review concluding that
PROMs appear to improve the quality of care delivered to patients with
cancer (Basch et al., 2017).
Brink added that clinical decision support can be useful in explaining
why a clinician may suggest a certain course of action. He gave an example
of a patient who wanted an MRI to assess her lower back pain. The clini-
cian showed the patient the computer screen with the decision support
tool indicating that ordering such imaging was in the “red zone” and not
recommended by clinical practice guidelines. “If you really bring it back to
making an informed decision with patients and shared decision making,
that can help promote cultural acceptance of decision support,” he said.
Khorasani noted that evidence on the effectiveness of clinical decision
support tools is beginning to be published. Evaluations of clinical deci-
sion support tools linked to the goals of the Choosing Wisely®24 initiative
to reduce unnecessary testing have found decreased use of imaging for
suspected pulmonary embolisms, lower back pain, and minor traumatic
brain injury. “We have had fairly significant impact in targeted interven-
tions across many of our leading- edge institutions but these findings
haven’t been replicated broadly across the country yet,” he said.
Challenges with Developing and Implementing Clinical Decision Support Tools

A number of workshop participants described challenges with clinical
decision support tools, including clinician acceptance, a lack of interoper-
ability within and among health systems, and development and mainte-
nance costs.
Shirts said clinician acceptance is one of the largest barriers to imple-
menting clinical decision support, noting that one review found clinicians
override drug safety alerts approximately 50 to 90 percent of the time
(van der Sijs et al., 2006). Brink stressed that clinicians will reject decision
support if it increases their work burden and will create work-arounds if
they do not believe it to be useful. Khorasani agreed and added that elec-
tronic medical records and clinical decision support are major drivers of
24 See http://www.choosingwisely.org (accessed May 1, 2018).

clinician burnout because they can cause distractions, interruptions, and

inefficiencies (Noseworthy et al., 2017). “They are getting in the way of our
physicians taking care of their patients,” Khorasani stressed.
Becich said most EHR systems are really billing systems. He stressed
that EHR vendors should better design EHRs for patient care: “We need
to compel the electronic health record companies to build decision sup-
port options directly into their systems and support them,” he said. Riely
emphasized that translation of clinical practice guidelines into clinical
decision support tools “is not something that can be handled by a software
engineer. It requires physicians at every step, but there aren’t a lot of physi-
cians trained to do this.” Becich suggested that physicians who are involved
in developing clinical decision support tools should obtain a board specialty
in informatics.
“Before we implement clinical decision support, we really should get
physician buy-in,” Shirts said. He noted that if clinical decision support
tools are specific, based on clinical evidence, and well designed, they are
likely to foster greater clinician acceptance (Hartzler et al., 2013). Khorasani
added that clinicians are also more likely to appreciate and use decision
support tools if they are tailored to their specialty. “The information you’re
putting in front of the person you’re trying to influence must fit their prac-
tice,” Khorasani said.
Brink added that implementation of clinical decision support will
require culture shifts championed by clinical practice and hospital leader-
ship. Khorasani agreed, adding, “Probably the most important part of [this]
is leadership. If there is no leadership in the institution, it’s going to be really
hard to implement decision support because these are cultural changes . . .
without leadership there to want and expect change, it’s really a challenge
to get some of these programs into place.”
Elenitoba-Johnson added that improved alignment among payers,
regulators, and professional societies is also needed to increase uptake
of clinical decision support. Because clinical decision support tools can
facilitate the insurance preauthorization process for genomic testing and
reimbursement, it can improve clinician acceptance and use of decision
support. He added that implementation of clinical decision support tools
can also foster acceptance by payers to reimburse complex genomic testing
in appropriate clinical contexts.
Stewart asked whether clinicians might resist clinical decision support
due to concerns about medical malpractice. For example, he wondered
whether a clinician would be liable if a patient with back pain turned out to

have cancer, but the clinician did not order imaging because it was not indi-
cated by the decision support tool. Khorasani responded that his institution
has used clinical decision support for more than two decades, and there has
not been a single case of medical malpractice due to following recommenda-
tions of the decision support system. Instead, he said that following clinical
decision support recommendations could be used to defend against medical
malpractice suits. However, this is dependent on a high-quality decision
support tool and ensuring that the information entered into the system is
“precise and of good integrity, and that the alert content is representative of
the patient. That’s why the clinical relevance of these alerts is crucial when
designing and deploying these systems,” Khorasani said.
Shirts said another challenge with clinical decision support is a lack
of interoperability, or the “ability of different information technology sys-
tems and software applications to communicate, exchange data, and use
information which has been exchanged” (HIMSS, 2018). Shirts noted that
even within a single institution, health information systems are complex,
with multiple different interfaces communicating different types of health
information from different sources (see Figure 1). Sharing information
Administrative Administrative Financial

Financial
Systems Systems Systems
Systems
Patient Patient
Portal Portal
Public Public
Departmental Departmental
Health Health
Systems Systems
Community Clinical Systems Community Clinical Systems

CCD/CDA
Connects Connects
Hospital System 1 Health Hospital System 2

Information
Exchange
Community
Providers
FIGURE 1 Interoperability of health information systems for active clinical decision

support.
NOTE: CCD = continuity of care document; CDA = clinical document architecture.
SOURCE: Created by David Chou, Department of Laboratory Medicine, University of
Washington; provided for Shirts presentation, February 12, 2018.

among health care systems can be even more challenging because there are
few incentives to share data. “So you could have a clinical decision sup-
port that works very well for a patient who has been at your institution
for many years and has had all [of his/her] health care at your institution,
but that isn’t necessarily always the case. It’s difficult to have good clinical
decision support for any type of pathology or molecular diagnostics that
goes across institutions,” Shirts stressed. But he added that interoperability
“is not an impossible task and many organizations are working toward it
and that should be supported.” A workshop participant, Muieen Cader,
suggested holding case competitions or hackathons to bring engineers and
clinicians together to solve challenges with interoperability and clinical
decision support.
Shirts pointed out that creating and maintaining a clinical decision
support system can be extremely costly. These costs include the work of
committees deciding on the clinical decision support rules, the alerts that
should be included, and how the system should be designed; the time and
effort to adapt the system based on pilot testing and clinician feedback;
and costs to make the decision support system interoperable. “The costs
of building and maintaining clinical decision support networks are often
ignored or minimized; however, these costs can be substantial, especially if
clinical decision support is implemented independently at each health care
institution,” Shirts said.
For a genomic clinical decision support system at the University of
Washington, Shirts said the estimated cost of communicating genomic
information support to a clinician at the point of care was $4,600 per alert
generated (Mathias et al., 2016). Shirts added that computer maintenance
and system updates were expected to add 20 percent to the cost of devel-
oping the initial system per year that the system was operational, because
maintenance can involve completely rebuilding the system every 3 or 4
years, or completely rebuilding decision support rule libraries to keep these
interoperable with other systems. “It’s very challenging to keep systems
connected with each other and to keep them up to date with current guide-
lines,” Shirts said. Every time a new guideline comes out, it must be trans-
lated into a computable language. “It would be wonderful if the guidelines
could come out in a machine-readable format,” he added (IOM, 2015).
Shirts said that dramatic improvements in data interoperability and
interinstitution collaboration will be necessary to drive decision support
costs down (Mathias et al., 2016). In order to increase efficiency and reduce
cost to less than $100 per alert, “we need to spread our efforts across mul-

tiple institutions in a collaborative effort to build these clinical decision

support rules.” He suggested creating and following best practices for clini-
cal decision support systems so that these tools can be disseminated quickly
across multiple institutions (IOM, 2015).
Khorasani added that Harvard Medical School has created a public
repository of evidence for clinical decision support that is machine read-
able, transparently graded, and continuously updated.25 Categories of evi-
dence in the repository include clinical decision rules, professional society
guidelines, and local best practices. He said Harvard curates and grades
the available evidence in order to promote collaboration to accelerate the
development of evidence-based clinical decision support tools.
Laser asked how long it should take for new clinical practice guidelines
to be embedded in clinical decision support systems. Khorasani responded
that for guidelines relating to imaging, vendors of imaging clinical decision
support systems will need to update their tools within 1 year, based on a
provision in the Protecting Access to Medicare Act.26 This law stipulates
that starting in January 2020, clinicians in ambulatory settings must use
certified clinical decision support tools with appropriate use criteria to order
advanced imaging tests. Brink noted that ACR Select is one of the certi-
fied clinical decision support tools, and is built on ACR’s Appropriateness
Criteria.27
QUALITY IMPROVEMENT EFFORTS

Several speakers discussed opportunities to promote high-quality
pathology and radiology care using quality improvement strategies such
as peer learning, feedback, and continuous education and assessment of
pathologists and radiologists.
25 Seehttp://libraryofevidence.med.harvard.edu (accessed July 5, 2018).

26 Seehttps://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFee
Sched/PAMA-Regulations.html and https://www.congress.gov/bill/113th-congress/house-
bill/4302 (accessed May 2, 2018).
27 See https://www.acr.org/Clinical-Resources/Clinical-Decision-Support and https://
www.acr.org/Clinical-Resources/ACR-Appropriateness-Criteria (accessed July 5, 2018).

Measurement and Feedback

Larson noted that in general, there is very limited supervision of
clinician performance in clinical practice, and most often it is focused on
removing individual “bad apple” clinicians, but he said that this “is not
effective, nor is it the right approach to take.” Larson suggested that rather
than focusing on poorly performing individual clinicians, a systems-level
approach to improving performance should be used, in which whole
practices are held accountable. He also suggested employing a blended
model of accountability, in which specialists supervise, coach, and provide
feedback to generalists. Such a model would provide the monitoring and
feedback needed for improvement, he said. Stead added that feedback loops
are key to quality improvement efforts, and Sause agreed: “Feedback and
self-correction [are] absolutely critical to making [quality improvement]
dynamic and patient-centric.”
Sause reported on Intermountain Healthcare’s quality improvement
efforts, which rely on quality measurement using robust data systems and
reporting this information back to clinicians. “We look for variation in how
care is delivered, feed that back to the clinicians, and try and change their
behavior,” Sause said. For example, data collected by Intermountain Health-
care found that breast biopsies performed toward the end of the week were
much more likely to be estrogen receptor-negative. Sause said this led to the
realization that these biopsies often were not analyzed until the following
week, by which time they had deteriorated in quality. “This was a eureka
moment for us that reflects how this is a dynamic, living process. You have
to look and understand the data and use that understanding to change how
you’re practicing medicine,” Sause stressed.
Sause discussed a number of challenges in implementing quality
improvement efforts. He added that clinician leadership and engagement
are critical to quality improvement efforts, but can be challenging, especially
given the heavy workload clinicians face. “We can’t just layer on, but have
to figure out how to take some things away to make this work,” Sause said.
“We’re so focused on metrics that are imposed on us from payers and other
organizations that we’re losing the clinicians because we’re not providing
them real metrics to help them take care of their patients.” In addition,
he said that although he is in charge of the oncology quality improvement
program at Intermountain Healthcare, “most of what I have to do is be the
bully pulpit.” He said quality improvement efforts can be strengthened if

program managers are given more authority, provided a centralized budget,

and operate within a value-based reimbursement system.
Hofmann said PROMs should be included in quality improvement
activities. “We need to find out what the patient’s goals are and see how
we match up against that,” he stressed. However, Sause noted it can be
challenging to elicit patient responses to survey questions. Spears said that
a lack of response might be due to questions not being relevant, and rec-
ommended asking fewer, more pertinent questions. Hofmann suggested
applying computerized adaptive testing methods in patient surveys in order
to ensure questions are relevant to a patient and minimize the burden in
completing such surveys.28 Spears also noted that patient handouts may not
stress the importance of the questionnaire, and she encouraged clinicians
to convey that such surveys have the same importance as diagnostic testing
results. Baker added that “patients need to have confidence that somebody
is actually going to look at the form and maybe even act on it.”
Peer Learning and Second Reviews

Fennessy said the Dana-Farber Cancer Institute and Brigham and
Women’s Hospital try to ensure the quality of imaging interpretation
through a program called Worth Another Look. Through this program,
radiologists can share information about patients’ cases—marked as privi-
leged communications—in order to promote discussion and peer learning,
especially when imaging leads to conflicting or surprising findings. Fennessy
added that this program encourages radiologists who work in different
imaging modalities (e.g., CT, MRI, ultrasound) to review the same case,
and determine whether or not a different imaging modality might confirm
initial results and interpretation. Fennessy noted that community radiolo-
gists who are part of the Dana-Farber Cancer Institute and Brigham and
Women’s Hospital can also participate in the program.
Cohen said that second reviews were included in recommendations
from the College of American Pathologists and the Association of Directors
of Anatomic and Surgical Pathology to improve the accuracy of pathol-
ogy reports (Nakhleh et al., 2015). These recommendations included the
following:
28 See http://med.stanford.edu/researchit/infrastructure/choir.html (accessed August 14,
2018).

• Develop procedures for the review of selected cases to detect

disagreements and potential interpretive errors;
• Perform case reviews in a timely manner;
• Document case review procedures relevant to the practice settings;
• Continuously monitor and document the results of case review; and
• Take steps to improve agreement of pathology case reviews, if
needed.
However, Cohen noted that “having two pathologists read every

pathology specimen is impractical.” He said there could be mandatory sec-
ond review of all new cancer diagnoses, but this practice could also poten-
tially lead to delays in diagnosis. Nayar added that pathology organizations,
as well as many hospitals and institutions, have emphasized the importance
of timely secondary reviews of malignancies to improve patient care. Conse-
quently, many pathologists making a first-time diagnosis of cancer do have
a second pathologist review the case. Difficult or unusual cases often require
group consultations, she said.
Nayar added that when errors do occur, it is important to understand
the contributing factors. She said pathology residents and fellows are
encouraged to participate in root cause analyses to understand why errors
occurred and how they can be prevented in the future.
Continuous Learning and Assessment

Several speakers discussed efforts to move toward a more continuous
process of learning and assessment of clinician knowledge, judgment, and
skills through MOC programs, rather than relying on an initial board exam
and recertification exams every 10 years. Brink noted the importance of
more frequent learning and assessment, given the rapid accumulation of
new knowledge in medicine: “When I took my boards a few decades ago,
genomics was not an area of interest. Today, I would be grossly inadequate
for sophisticated cancer imaging if I was certified exclusively by that cre-
dential,” Brink said. Wagner noted that “we do not know what happens to
radiologists in the 10-year period after they take their test. We just know
what they were like on that day.” He added that another shortcoming to
10-year recertification exams is that they do not provide detailed feedback
to clinicians—a clinician is only informed whether he or she passed the
test.
“Longitudinal assessment is changing training and how we assess

competence in our diplomates,” Nayar stressed. Since 2006, all primary

and subspecialty certificates issued by the American Board of Pathology
require pathologists to participate in the MOC program (now called the
Continuing Certification program), which measures six core competencies
in a four-part framework (Johnson, 2014):
1. Professionalism and professional standing, such as hospital privileges

and an active medical license;
2. Lifelong learning and self-assessment through participation in CME
and adequate performance in self-assessment modules;
3. Assessment of knowledge, judgment, and skills; and
4. Improvement in medical practice.
Pathology diplomates report on parts 1, 2, and 4 of the MOC activi-

ties every 2 years, and for part 3, diplomates must pass an exam every 10
years, said Nayar. In 2017, the American Board of Pathology started a pilot
program to assess whether longitudinal assessment through ABPath Cert-
Link29 could replace the traditional 10-year recertification exam. Volunteers
participating in the pilot are asked to answer 20 questions per quarter. They
receive immediate feedback on whether they answered correctly or not, as
well as the key learning point for each question, an explanation of why the
correct answer is right and the others are not, and references for further
reading. Volunteers receive information on how their scores compare to that
of their peers, and are retested on key content they answered incorrectly in
previous tests. Nayar added that the participants also provide feedback to
the American Board of Pathology on the relevance of the questions to clini-
cal practice and their specialties.
In January 2019, Wagner said the American Board of Radiology will
transition to a lifelong longitudinal assessment process. Participants will be
provided two questions per week via email and will receive immediate feed-
back on their answers. He noted that radiologists can decline to answer cer-
tain questions that do not pertain to their practice, and will instead receive
more relevant questions. “It increases the number of questions that are built
around your practice environment,” he said. “We want radiologists to learn
what they need to know to be relevant and useful to their patients, and we
can’t ask them to be experts at everything,” he stressed, adding, “[The] new
29 See http://www.abpath.org/index.php/abpath-certlink/2017-09-15-13-21-49 (accessed
July 12, 2018).

online longitudinal assessment will allow for the development of increas-

ingly relevant content that is specific to the scope of specialized radiologist
practice patterns, including oncologic imaging.” Radiologists who do not
receive adequate results from this process will have to undergo a summa-
tive test at a test center of the American Board of Radiology, Wagner said.
INTEGRATION AND COLLABORATION OF SPECIALTIES

Many speakers at the workshop discussed integration and collaboration
among the specialties involved in cancer diagnosis and care, including the
rationale for greater integration and collaboration, challenges involved, and
potential strategies to facilitate better coordination among the diagnostic
specialties.
Rationale for Collaboration and Integration

Lawrence Shulman, professor of medicine and deputy director of
clinical services at the University of Pennsylvania Abramson Cancer Center,
said that greater integration of pathology, radiology, and oncology reports
is needed for a more unified interpretation of a patient’s disease and for
treatment planning. Stewart and Warner agreed, and added that multidis-
ciplinary conferences or tumor boards can be very helpful in facilitating
collaboration. “If we could figure out how to get every patient who has
imaging, pathology, and molecular testing into a tumor board situation—
where people get together and think about that patient—we’ll get to the
right place,” Warner said. Becich added that “pathologists and radiologists
have got to get out of their dark reading rooms and get [more] involved in
the care pathway.”
Cohen noted that there is growing overlap between the fields of radiol-
ogy and pathology. “As these molecular reagents [used in imaging] become
more sophisticated, the distinction between pathology and radiology is
going to narrow,” he said.
Becich suggested prioritizing image sharing as a method to integrate
the specialties: “We could have a flawed report, or the interpretation could
change, but the image doesn’t change. I’m going to focus on image democ-
ratization because we now have enough robust networks, scalable technolo-
gies, and deep learning, so putting the image at the center puts truth at the
center of our studies and eliminates the noise.”
Schilsky pointed out that some imaging studies are highly sensitive but

lack specificity,30 while some molecular tests, such as those for circulating
tumor DNA, have high specificity, but low sensitivity. He asked, “Are we
headed toward a time when we can begin to combine technologies to get an
optimal diagnostic assessment? If so, where does that integration occur, and
how do we prepare the workforce for that integrated diagnostic approach?”
Hricak responded that “we hope in the future we will have data analytics
that can help with this. Integrated diagnostics is unquestionably in our
future. But it will be at least 5 years before it is widely adopted because you
have to develop, validate, and disseminate, and this will take us awhile.”
Cohen noted that such integration may not always be possible in some
community settings. “If you are in a community hospital with a couple
hundred beds where you may have 3 or 4 pathologists and maybe 10 radi-
ologists, that type of work effort may not be feasible given limited health
care dollars,” he said. Friedberg added that clinicians in community practice
are integrating information from the diagnostic specialties, but may not be
trained in the latest tests and technologies.
John Cox, medical director of oncology services at Parkland Health
and Hospital System and professor of internal medicine at the University of
Texas Southwestern Medical Center, said there is a real need for integrated
reports in his community health care system, especially when test results
come from separate labs in different formats: “From a community delivery
system standpoint, integrating those reports into a common diagnostic
portfolio is really key and something our current technologies ought to help
us solve,” said Cox.
Challenges to Integration
Several workshop participants discussed challenges to integrating
the disciplines involved in cancer diagnosis. Brink and Friedberg noted
that it is difficult to foster interactions within an individual specialty, let
alone promote greater collaboration among multiple specialties. “We need
to start seeing ourselves as having different ways of looking at the same
elephant—microscopically and macroscopically with overlap in the middle
as the technology advances. But none of us are trained that way,” Friedberg
said. He added, “My colleagues who define themselves as microscopists are
30 Sensitivity is the proportion of people with a disease who are correctly identified from all
positive test results for the disease, and specificity is the proportion of people who are correctly
identified as not having a disease from all negative test results for the disease.

going to be a little too narrow for the future. They need to be diagnosti-
cians, using all available tools, as the line between radiology and pathology
continues to get blurred.”
Cox added that “specialization and how we are paid has put us in
many silos.” Becich agreed, and added that increasing subspecialization has
prevented the development of comprehensive patient reports. “We can talk
about wanting to improve the delivery of care, but really the enemy is us.
As we continue to subspecialize and fragment . . . we fail to take it back to
the context of the whole patient,” he said.
Several participants noted that data-sharing challenges impede com-
munication. “There are significant challenges related to sharing diagnostic
images between and across institutions,” Stewart stressed, despite the prog-
ress that has been made in digitizing radiographic images. For example,
Stewart said a patient may have an extensive imaging work-up at one
institution, but if that patient moves to another institution, obtaining the
prior images or reports in order to accurately stage or restage for compari-
son may be challenging. Some institutions have started importing outside
images into their computerized imaging archiving systems, but this is not
universal. Some patients may bring in compact discs of prior imaging,
but these images may be incomplete, or not viewable or importable, said
Stewart. Prior imaging may also be insufficient due to technique limitations,
such as a lack of contrast. “Sometimes, exams need to be repeated, which is
wasteful, duplicative, and results in increased radiation dose,” Stewart said.
Friedberg noted that anatomic pathology is further behind radiology
in terms of digitizing and sharing information, but predicted that “once
pathology becomes digital like radiology, the overlap between the two will
naturally disappear and AI will be very useful.” Brink agreed that AI is
merging pathology and radiology (see also the section on Computational
Oncology and Machine Learning).
Elenitoba-Johnson pointed out the need for greater sharing of genetic
data, but a lack of EHR interoperability among institutions prevents shar-
ing this information in a usable format. Warner added that in a 2016 ASCO
survey,31 less than one-quarter of respondents said their laboratory could
deliver genetic profiling data on a patient’s tumor in a format their EHRs
could receive. Interoperability has been impeded by a lack of reporting
standards for genetic tests, Warner stressed. He noted that if such standards
were in place, a clinician could receive results and use third-party applica-
31 Results from the survey are unpublished.

(a) Order
(c) Present & contextualize genetic test results
genetic tests EHR/
Clinical
SMART® on FHIR®
systems clinico-genomics apps
Diagnostic order app Diagnostic reporter app
FHIR® data FHIR® data
Sequencing Image: SMART Precision Cancer Medicine App

lab
(b) Return genetic test results
FIGURE 2 Standards-enabled workflow of genomic data.

NOTE: App = application; EHR = electronic health record; FHIR = Fast Health-
care Interoperability Resources; SMART = Substitutable Medical Apps, Reusable
Technologies.
SOURCES: Warner presentation, February 13, 2018; Reprinted with permission from
BioMed Central: Genome Medicine. Integrating cancer genomic data into electronic
health records. Warner, J. L., S. K. Jain, and M. A. Levy. © 2016.
tions to present and contextualize genetic test results (Warner et al., 2016)
(see Figure 2).
Warner said a recent President’s Cancer Panel report32 called for devel-
oping tools and applications that can facilitate oncologists’ use of genomic
data, and added that Vanderbilt-Ingram Cancer Center built the SMART
Precision Cancer Medicine33 application to incorporate genomic data into
its EHRs. Because this application was developed with a publicly available
application programming interface and uses the Fast Healthcare Interoper-
ability Resources (FHIR) interoperability standard, it can be adopted by
other health care systems. The DIGITizE Action Collaborative34 has also
convened experts from academic health centers and EHR vendors Cerner,
32 See https://prescancerpanel.cancer.gov/report/connectedhealth (accessed May 5, 2018).

33 See
http://www.vicc.org/smart-pcm (accessed May 4, 2018).
34 See
http://www.nationalacademies.org/hmd/Activities/Research/GenomicBased
Research/Innovation-Collaboratives/DIGITizE.aspx (accessed July 5, 2018).

EPIC, and Meditech to develop a standard structure for reporting genetic

test results, which is being tested by several pilot sites, including Inter-
mountain Healthcare, Duke University, Johns Hopkins University, Mission
Health, Partners Healthcare, and St. Jude Children’s Research Hospital.
DIGITizE has been taken up by the FHIR Foundation, an implementation
body related to Health Level Seven International.35
Stewart pointed out that insurance coverage issues, such as out-of-
pocket costs or restrictions on additional testing, may prevent more com-
prehensive and integrated radiology and/or pathology reports. For example,
Cox said self-referral restrictions can impede genetic testing performed by
the same institution that performed the initial pathology testing. “When we
ask the pathology department to guide us on whether the sequencing should
be [conducted] or not, we are met with the barrier that they cannot easily
refer to their own lab at UT Southwestern to do the sequencing. As a result,
FoundationOne provides those services, but their genetic testing report
comes back in a non-integrated way with our systems,” Cox explained.
Misalignment of incentives can also hamper the integration of diag-
nostic testing results and communication among diagnostic specialists.
Stewart noted that cancer centers are more likely to repeat an imaging study
rather than try to acquire or discuss imaging results with radiologists from
another institution, in part due to reimbursement issues. Hricak agreed,
noting that payers will not reimburse radiologists for clinical consultations,
hindering collaboration among radiologists, pathologists, and oncologists.
Cohen stressed that “to integrate, we need to have alignment of the financial
incentives.”
Sause said that interdisciplinary teams are labor- and resource-intensive,
but “the way that most of the system is designed, you’re not paid for that
collaborative process,” which is a challenge in the current era of increasing
subspecialization. He suggested considering changes to payment to foster
more interdisciplinary collaboration. Grubbs agreed, and said, “The driving
force will be reimbursement. When we’re all responsible for the total cost
of care, you’ll find who you want to partner with very quickly to get the
job done quickly with high quality that reduces the cost. That will drive us
all to do it.” Kline added, “Payment does change the way people organize
themselves and does [help] overcome cultural barriers.” Hofmann added
that “a small change in payments can make a big difference.”
Becich pointed out that CMS increased reimbursement to pathologists
35 See http://www.hl7.org (accessed July 23, 2018).

who adopted standards for cytology reporting and quality measurement

and within 2 years, every pathology practice and cytology lab conformed to
these standards. Becich suggested that integrated pathology and radiology
reports could become a quality measure that CMS and other payers require
for payment. “We need systems to reimburse for integrated diagnostic
reports that are patient-centric and disease-centric,” Becich said. Larson
added that Medicare could require hospitals or practices to use integrated
diagnostic reports as part of their conditions of participation. “The solution
is not going to be piecework and individually focused, but moving toward
a whole organization working cohesively together to meet the needs of
patients and referring providers,” Larson said. Zutter added that leadership
is needed to promote interdisciplinary collaboration in cancer diagnosis.
“That’s one of the reasons it has worked at Vanderbilt,” she said.
Amy Abernethy, chief medical officer, scientific officer, and senior vice
president of oncology at Flatiron Health, stressed that once reimbursement
policies drive integrated diagnostic reports, “the tech industry will build the
solutions that will make that happen. Electronic health record companies
will build solutions into their systems when it goes along with what clini-
cians and health systems demand and need.” Becich stressed, “Pathology
and radiology can work together [for a] common purpose but they need to
partner aggressively.”
Hofmann recommended incorporating patient input when developing
better systems for diagnostic integration. “We need to start with the patient
and take a patient-centered approach to figuring out what’s wrong in order
to figure out how to fix things,” he said. Spears agreed and added, “When
you talk about taking a systems approach, make sure to include the patient
and make things patient-centered, and get information back to the patient
in a way they can understand it. The patient outcome is really what we are
going after.”
Alternative Payment Models to Promote

Collaboration and High-Quality Care
Hricak noted that major cancer centers can afford to have radiologists
integrated in their medical oncology clinics. This set-up enables more col-
laboration and interaction between radiologists and oncologists, she said,
adding, “It’s a luxury that is wonderful for patient care, but [one that] few
centers can afford.”
Grubbs suggested that greater collaboration could promote high-

quality care while also resulting in cost savings for health care systems,
and recommended financial analyses be conducted to create the business
case for better integration of the specialties. He added that this could
be a component of current efforts to move from volume- to value-based
payment in health care using alternative payment models, which aim
to reward health care systems and practices for delivering high-quality,
cost-efficient care.
Grubbs reported on the Health Care Payment Learning & Action
Network, which the Department of Health and Human Services launched
in 2015 to align public and private stakeholders in the transition toward
high-quality, value-based payment.36 The Network’s first initiative was the
development of a framework of the different types of payment models,
which include (Health Care Payment Learning & Action Network, 2017):
• Category 1: Fee-for-service, no link to quality and value

• Category 2: Fee-for-service, link to quality and value
• Category 3: Alternative payment models built on fee-for-service
architecture
• Category 4: Population-based payment
Grubbs also discussed the CMS Oncology Care Model (OCM),37 a

5-year voluntary pilot project initiated in 2016 with the goal of improv-
ing the quality of care and reducing Medicare spending. Features of OCM
include treatment based on clinical practice guidelines, the use of data and
feedback for continuous quality improvement, and the documentation and
reporting of clinical practice and patient care outcomes. Approximately 190
practices in 31 states have participated in the pilot program, said Grubbs.
Kline said that because OCM takes into account the total cost of care, it
has the potential to facilitate collaboration among pathologists, radiologists,
and oncologists. The model supports sharing of reports and other multidis-
ciplinary interactions to foster better value and efficiency. For example, an
oncologist who has a brief conversation with a radiologist may decide not
to order unnecessary and expensive imaging. “You may find that is the path
forward,” Kline said. Schilsky agreed that OCM could “foster team build-
ing because it provides [the] opportunity for reimbursement for physicians
36 See https://innovation.cms.gov/initiatives/Health-Care-Payment-Learning-and-Action-
Network (accessed July 14, 2018).

37 See https://innovation.cms.gov/initiatives/Oncology-Care (accessed May 4, 2018).

to spend time contributing to those teams. The big challenge is setting the
bundled payment at the right level.”
Kline stressed that paying for improved integration “by simply layer-
ing it on with another CPT [Current Procedural Terminology] code is not
going to happen. Our country can’t afford that,” noting that U.S. health
care expenditures equal approximately 18 percent of the gross domestic
product. He added that an Institute of Medicine report estimated that
approximately 30 percent of health care dollars spent in the United States
are wasteful (IOM, 2013a). “If we can reduce that waste by incentivizing
high-value care by aligning financial incentives appropriately, we’ll have the
money left to pay for some of these computational systems that will improve
the quality of care,” Kline said. Brkljačić added that European nations also
continue to wrestle with the rising costs of cancer care and stressed that
“value-based health care should be translated to all regions in the world.”
Grubbs also reported on ASCO’s efforts to develop an alternative pay-
ment model built on oncology clinical pathways, which are detailed pro-
tocols for delivering cancer care—including but not limited to anticancer
drug regimens—for specific patient populations, including the type, stage,
and molecular subtype of disease (Daly et al., 2018). Compared to clini-
cal practice guidelines that list several treatment options, Grubbs said that
clinical pathways narrow down these potential options to a single optimal
choice, with the goal of facilitating high-quality care (Lawal et al., 2016;
Rotter et al., 2012). He added that oncologists are increasingly using clinical
pathways in their practice; in 2016, approximately 60 percent of practices
reported compliance with clinical pathway programs (ASCO, 2017).
Grubbs said the goals of ASCO’s Patient-Centered Oncology Payment
Model include adherence to high-quality, evidence-based clinical pathways;
reducing unwarranted variation in oncology care; guiding appropriate sur-
vivorship care and monitoring; encouraging participation in clinical trials;
and eliminating care disparities and protecting against underutilization
(Zon et al., 2017). He noted that the payment model “still preserves physi-
cian and patient autonomy, because nobody is expected to be 100 percent
compliant with a pathway.” He said the model will also evaluate whether
cancer care is consistent with quality standards, using measures from the
Quality Oncology Practice Initiative38 and Choosing Wisely®.
38 See https://practice.asco.org/quality-improvement/quality-programs/quality-oncology-
practice-initiative (accessed May 4, 2018).

Real-World Data and Computational Oncology

A number of workshop participants discussed the roles of real-world
data, computational oncology, and data sharing and standardization in
improving cancer diagnosis and care.39
Real-World Data
Abernethy said large, interconnected datasets can facilitate cancer
diagnosis and care. She said Flatiron Health has compiled longitudinal
EHR data from more than 43,000 patients with lung cancer at multiple
sites in the United States. These data are linked to other data sources,
such as cancer registries and administrative claims databases. “Now that
we have aggregated data about patients receiving care in the lung cancer
setting across the country, we can start to understand histology at scale,”
she stressed. “Because as soon as you’re able to understand what exactly
happened to that patient across time and pull that back to the diagnostic
image or test, it starts to improve both how we evaluate the test and how
we understand images with machine learning algorithms. That made a big
difference,” she said.
Abernethy noted that in Flatiron Health’s datasets, the interpretation
of imaging and pathology results in lymphoma vary substantially over time
and among clinicians. She said large aggregated datasets with longitudinal
information could help mitigate diagnostic ambiguity in lymphoma by
understanding which interpretations are most accurate: “We’re really start-
ing to try and use the longitudinal understanding of the patient to get back
to improved diagnosis.”
Abernethy stressed that large datasets are only useful if the data are
properly collected, curated, and aggregated. Within a dataset, she noted
that it is important to understand the relationships among the diagnostic
event, the treatment event, and a patient’s outcome. Abernethy noted that
diagnostic events make up combinations of clinical, pathological, radiologi-
cal, and biomarker data, but these data can be collected at different points
in time. During that period of time, a patient’s cancer might progress or
interpretations of the data may evolve over time.
39 This topic will be explored in more detail at the second workshop, The Clinical Applica-
tion of Computational Methods in Precision Oncology. See http://www.nationalacademies.

org/hmd/Activities/Disease/NCPF/2018-OCT-29.aspx (accessed May 4, 2018).

A major challenge in curating large datasets using EHR data is the

plethora of unstructured data, Abernethy noted. Flatiron Health primar-
ily uses human abstractors to pull out essential information from patients’
pathology and radiology reports, as well as the notes from oncologists and
surgeons. These abstractors then translate this information into a machine-
readable form and feed it into a database, using AI to facilitate this process.
The accuracy of that curation is important, Abernethy explained. “We need
to think about data provenance or traceability back to the source, and all the
standards that are behind these datasets. If you want to have confidence in
the datasets that you are working with, you need to be able to look under
the hood and understand how you got there. You need to document back
to the source and maintain full provenance,” she said.
Data completeness and quality also has to be documented, she added,
including linking unstructured data from clinician notes to other sources of
data, such as reports for genetic testing, PROMs, and administrative claims
data. Abernethy suggested applying a consistent approach to ensuring data
completeness and quality, and relying on sources of data known for accu-
racy. “We need gold standards but we don’t have national gold standards
for many of the data points in these datasets, and that’s something we hope
the National Academies can help to shepherd forward,” Abernethy stressed.
She also suggested applying a checklist (Miksad and Abernethy, 2018) to
evaluate real-world data quality by considering factors such as
• Clinical depth: Data granularity to enable appropriate interpretation

and contextualization of patient information.
• Completeness: Inclusion of both structured and unstructured
information to provide a thorough understanding of patient clinical
experience.
• Longitudinal follow-up: Ability to review treatment history and
track a patient through time.
• Quality monitoring: Systematic processes implemented to ensure
data accuracy and quality.
• Timeliness/recency: Timely monitoring of treatment patterns and
trends.
• Scalability: Efficient processing of information with data model that
evolves with standard of care.
• Generalizability: Representativeness of the data cohorts to the
broader patient population.

• Complete provenance: Robust traceability throughout the chain of

evidence.
Computational Oncology and Machine Learning

Langlotz emphasized that AI will revolutionize clinical practice, and
radiologists and pathologists will need education and training on how to
effectively use these tools. Becich agreed, and said AI can help clinicians
overcome information overload. He noted that human cognitive capacity is
limited to considering approximately 5 to 10 facts per decision. But cancer
diagnosis can involve massive amounts of data: “We are swamped with data
and that’s why these algorithms applied to large datasets are important for
clinicians,” Becich said. Sause added that “we have to work smarter and
more efficiently, and AI, interconnectivity, and better computer systems are
going to help us create a more dynamic, smarter, and efficient workforce
that will allow us to bring experts to the patient.”
Warner pointed out that there were tens of thousands of distinct
genomic variants identified in the first public release of data from the Amer-
ican Association for Cancer Research Project GENIE (Genomics Evidence
Neoplasia Information Exchange) (AACR Project GENIE Consortium,
2017). Among the 19,000 samples, the top 100 variants accounted for only
10 percent of the distinct variants identified. “To think a clinician or any
other human could digest even a fraction of that information is impossible.
That’s why we need artificial intelligence,” Warner emphasized. “Artificial
intelligence and machine learning will be critical to the practice of precision
oncology,” he stressed.
Becich said that AI will not replace pathologists or radiologists. “The
number of diagnostic tests being interpreted by pathologists continues to
bloom,” he pointed out, and these professionals are needed to guide the
development of AI systems and in the interpretation of their findings.
Langlotz provided an overview of different types of AI, including
machine learning, neural networks, and deep learning. He said that machine
learning offers new opportunities to analyze large datasets. “If you have a
large enough dataset that has labeled images as ‘cancer’ or ‘no cancer,’ you
can feed it into a machine learning algorithm, and it will automatically learn
how to distinguish benign from malignant. . . . It’s the speed, scalability, and
scope of these systems that has really changed dramatically,” Langlotz said.
He said neural networks are a more sophisticated form of machine
learning, with millions of nodes that enable fine-tuned detection and clas-

sifiers. When those networks are compiled into multiple layers, Langlotz
said, deep learning can occur. Although the accuracy of deep learning
systems is impressive, he noted that neural networks are a form of “black
box” learning—the features that neural networks use to make classifications
are unknown. He discussed the ImageNet Large Scale Visual Recognition
Challenge,40 a yearly contest that evaluates algorithms for object detection
and image classification. He said that in 2015, a Microsoft deep learning
system achieved an error rate of less than 5 percent, which exceeds human-
level performance (He et al., 2015). “These are very powerful techniques,”
Langlotz stressed.
Langlotz and his colleagues are using deep learning systems to analyze
imaging data linked to EHRs, genomics, and biobank data through the
Medical Image Net repository.41 In this context, the goal of deep learning is
to improve clinical decision support tools and provide actionable advice to
clinicians. He provided several examples of deep learning in radiology. One
study found that a deep-learning neural network model estimating skeletal
maturity in pediatric hand radiographs performed with accuracy similar to
that of an expert radiologist (Larson et al., 2017). Another deep-learning
neural network algorithm was developed to detect pneumonia from a data-
set of more than 100,000 chest X-rays; researchers found that the model
outperformed radiologists (Rajpurkar et al., 2017).
He said machine learning is also being used to improve image quality
(Zaharchuk et al., 2018). This has the potential to reduce the time needed
to acquire quality images, and with CT and PET imaging, it could reduce
the radiation dose required, Langlotz noted. He added that computer-aided
detection and classification, facilitated by machine learning, could help
radiologists identify abnormalities when they are evaluating images outside
of their specialty.
He noted that none of the labeling techniques used in the development
of machine learning algorithms are perfect; however, he said that might not
matter for large datasets analyzed by neural networks. Because these systems
can process a large number of cases, even weakly labeled images might be
equivalent with human-based labeling. “You still need the human label—
the reference standard label—to validate the system. But to train the system,
you can use these weak labels,” Langlotz pointed out.
However, there are challenges with development and use of deep
40 See https://aimi.stanford.edu/medical-imagenet (accessed July 17, 2018).

41 See http://langlotzlab.stanford.edu/projects/medical-image-net (accessed May 4, 2018).

learning algorithms, Langlotz noted. “The need for clinical validation is

still very important,” he stressed, adding, “These are black boxes. We don’t
understand how they’re working so we need to validate them.”
Mia Levy, director of cancer health informatics and strategy at the
Vanderbilt-Ingram Cancer Center, stressed the need to ensure patient
diversity in the datasets used to develop precision oncology tools: “We need
to make sure these publicly available datasets upon which we are training
all these algorithms have enough representation of minority populations.
We need to make sure we lift everyone up in the process and that we’re not
training [algorithms] only against a certain subset of our population,” Levy
stressed. Cox agreed and suggested the inclusion of data from safety-net
hospitals in training datasets.
Langlotz said that applying machine learning to the medical field will
require developing new tools that can process complex, multimodality,
and time-based data. He also suggested developing additional methods for
automated labeling as well as establishing linkages across various data types,
including EHRs, genomics, and imaging. Langlotz noted that deep learning
in cancer imaging, integrated with gene expression data, could provide use-
ful input for cancer diagnosis and subsequent care (Korfiatis et al., 2016):
“There may be some signal in these images that we’re not detecting with the
human eye that may correlate directly with genomic signatures, and that
would really change the way we stage cancer.”
In pathology, Cohen noted that a recent study found that some
deep-learning algorithms to detect lymph node metastases in women with
breast cancer performed better than a panel of 11 pathologists (Bejnordi
et al., 2017). Becich added that AI can also highlight areas of interest in a
specimen that pathologists should carefully review, so more time is spent
evaluating potentially invasive lesions versus those that are more likely to be
benign. “This won’t put the pathologist out of business, but will make sure
regions of interest are scanned by the pathologist,” Becich stressed.
Becich said the FDA’s recent approval of a whole-slide imaging plat-
form is a watershed moment for computational pathology, which he defined
as an approach to diagnosis that combines multiple sources of pathology
data and transforms them into clinically actionable knowledge that can
facilitate decision support (Louis et al., 2014). The whole-slide imaging
platform enables robotic scanning of histopathologic slides for digital dis-
tribution and review by pathologists (Hartman et al., 2017) (see Figure 3).
Becich added that this platform will enable the compilation of large digital
pathology datasets that can be analyzed with AI and facilitate computational

Accessioning / Grossing / Histology Pathologist

Case Assembly Quality Check
Slide Creation
Review slide quality

Stain and coverslip slides Sort slides to Cases
Enter Patient Review case quality
Enter Case Legacy Workflow
Enter Slides
Pathologist
Case Entry Imaging Case Assembly Quality Check
Enter Patient Load slides Sort images to cases Review slide quality
Enter Case Generate images Review image quality
Enter Slides Unload slides Review case quality
Digital Workflow
FIGURE 3 The traditional workflow for slides from the histology laboratory versus the
workflow for digital slides.
SOURCES: Becich presentation, February 13, 2018; Reprinted by permission from
Springer Nature: Journal of Digital Imaging. Enterprise Implementation of digital
pathology: Feasibility, challenges, and opportunities, Hartman, D. J., L. Pantanowitz,
J. S. McHugh, A. L. Piccoli, M. J. Oleary, and G. R. Lauro. © 2017.
pathology. “It’s a very exciting time in pathology, but it’s even a more excit-
ing time if we get the radiologists and pathologists to work together. We
think computational pathology, genomics, and radiology have an awesome
partnership that could provide a lot of clinical opportunity to make things
better for patients with cancer,” Becich said (see Box 3).
Data Sharing and Standardization

Several workshop participants discussed the importance of data sharing
and interoperability to develop and validate machine learning methodolo-
gies for cancer diagnosis and care. “No single organization, particularly for
low-prevalence conditions, is going to have all the training data needed to
develop the kinds of systems that are going to make the maximum impact,”
Langlotz said. Becich added, “Data sharing is going to be key in oncology.”
Becich recommended that academic–industry partnerships that
develop databases should adhere to FAIR data principles, which stands for

BOX 3
Text Information Extraction System
Michael Becich, chair and distinguished university professor

in the department of biomedical informatics at the University of
Pittsburgh School of Medicine, reported on the Text Information
Extraction Systema (TIES). TIES uses natural language processing
to automatically retrieve and de-identify information in pathology
and radiology reports and make them searchable. “It is a platform
that goes right into the clinical source documents and makes them
available for a search,” Becich said. He noted that with TIES, par-
affin blocks, fresh-frozen tissue, whole-slide images, and radiology
images can be annotated, indexed, and shared. TIES also links to
The Cancer Image Archives.b
Currently, TIES has more than 27 million radiology reports
and more than 5 million pathology reports from 6 cancer centers,
reported Becich. Researchers at these six institutions can access
and search each other’s pathology and radiology reports. This net-
work will soon expand to include data from other cancer centers:
“We are ready to take this to scale with the goal to share this with
open-data collections like The Cancer Genome Atlas.” He added,
“We are looking at diverse populations of patients to add to this
database, which will be a very valuable resource for both patholo-
gists and radiologists working together.”
a
See http://ties.dbmi.pitt.edu (accessed May 10, 2018).
b
See http://www.cancerimagingarchive.net (accessed May 10, 2018).
SOURCE: Becich presentation, February 13, 2018.
findable, accessible, interoperable, and reusable (Wilkinson et al., 2016).42

He said that bioinformatics specialists and professional societies will be
critical for developing large aggregated databases.
Warner noted that for databases to be interoperable they need to share
42 Examples of FAIR databases that Becich described included Project GENIE, CancerLinQ,
Genomic Data Commons, Health Care Systems Research Collaboratory, Oncology Research
Information Exchange Network, and National Patient-Centered Clinical Research Net-
work. See http://www.aacr.org/research/research/pages/aacr-project-genie.aspx, https://
cancerlinq.org, https://flatiron.com, https://gdc.cancer.gov, http://www.rethinkingclinical
trials.org, http://oriencancer.org, and http://www.pcornet.org (accessed May 10, 2018).

the same nomenclature and information elements, but many databases

use custom nomenclature and ontologies. To address this variability, par-
ticipants at the ASCO Omics and Precision Oncology Workshop recom-
mended that “standards development organizations should rapidly produce
generally accepted, comprehensive standards for transmitting genomic
information and should closely collaborate to avoid discrepancies between
competing standards. Naming conventions for genes and genomic abnor-
malities should be harmonized and should be accepted by all except in the
most exceptional of circumstances” (Hughes et al., 2017, p. 3154). Without
agreed-upon standards, “we will not be able to build large datasets that
inform cancer diagnosis, prognosis, and treatment,” Warner said.
WRAP-UP
Hricak said the complexity of cancer diagnosis and treatment requires
a multidisciplinary approach to care that encourages building integrative
teams of radiologists, pathologists, oncologists, primary care clinicians,
and bioinformaticians. She said that all patients with cancer need access
to a highly qualified workforce, but not all members of the care team have
formal training in oncology, and the quality of cancer diagnosis and care
can vary with factors such as case volume, experience, and time pressures.
Hricak stressed that access to high-quality cancer diagnosis and treatment
can be affected by a lack of insurance, narrow networks of clinicians within
an insurance plan, cost-sharing burdens, preauthorization requirements,
and prohibitions on self-referral. She added that these factors add complex-
ity and administrative burdens to the care of patients with cancer, and they
disproportionately affect those patients least able to navigate barriers to care.
Hricak summarized a number of strategies that could improve patient
access to expertise and technologies in oncologic imaging and pathology,
including enhanced education and training, clinical decision support tools,
models of care delivery and payment, computational oncology, and data
sharing.
In terms of education and training, Hricak said that oncologic imag-
ing needs to be fully integrated into the curriculum of radiology residency
programs, and should also be included as a clinical practice area for ongoing
longitudinal assessment through MOC. She suggested that ACR create a
certificate of special competency in oncologic imaging and recognize radiol-
ogists who obtain oncologic expertise, either through fellowship training or
CME. Hricak emphasized the importance of reporting standards and com-

munication in pathology education and training, and added that further

emphasis on molecular diagnostics and pathology informatics is warranted.
For both radiology and pathology, she stressed that peer learning should be
encouraged throughout academic and community settings of care.
Clinical decision support can also be leveraged to help non-expert cli-
nicians improve cancer diagnosis and care; reduce unwarranted variations
in care; and improve the accuracy, quality, and patient experience of care,
Hricak said. To be effective, she said that decision support tools need to be
efficient, evidence-based, educational, and either encourage or enforce the
adoption of evidence. She acknowledged a number of challenges related
to the implementation and scaling of clinical decision support, including
clinician acceptance, costs for development and maintenance, and interop-
erability barriers. Hricak added that ideally, clinical decision support will
shorten the amount of time it takes to disseminate new knowledge, but she
noted that clinical decision support will only be acceptable to clinicians if
it is simple and easy to use.
Hricak highlighted the importance of innovative models of care
delivery and payment for improving cancer diagnosis and care. She said
Vanderbilt’s DMT approach is an exemplar because it optimizes diagnostic
testing, provides a comprehensive, integrated report, and improves the
quality of care while also saving time and resources. She reiterated the goal
of Project ECHO—to move knowledge, not patients—and encouraged
clinician-to-clinician telementoring to build community capacity. She
added that value-based payment models are an opportunity to incentivize
collaboration among pathology, radiology, and oncology experts.
Hricak reported on essential elements for quality improvement efforts
in cancer diagnosis and care, including a constructive, non-punitive culture;
clinical and operational leadership; feedback on clinician performance and
patient outcomes supported by data systems and measurement infrastruc-
ture; and the bandwidth for clinicians to engage in quality improvement
efforts by removing burdensome non-patient care activities.
Hricak noted that machine learning and AI have the potential to
fundamentally change how cancer care is delivered and will facilitate uni-
fied diagnostics and precision oncology: “There’s no question that inte-
grated diagnostics is the future, but we are not there yet.” She noted that
interoperability and standardization remain major challenges that need to
be addressed in order to facilitate improved data sharing to study the inter-
relationships among diagnosis, treatment, and patient outcomes at scale.

But she also cautioned against the “dissemination of technology without

adequate evidence, validation, and training.”
Schilsky offered several scenarios that could be considered to improve
patient access to expertise and technologies in oncologic imaging and
pathology. These scenarios included the following:
• Building a specialized workforce, potentially by creating an

integrative medical specialty in diagnostic oncology, that trains
individuals in pathology, radiology, cancer biology, and new
computational methods involved in these fields;
• Supporting a less specialized workforce through the use of clinical
decision support tools and clinical pathways, facilitated by advances
in AI and machine learning; and
• Expanding capacity in community care settings and promoting
access to oncologic expertise through programs such as Project
ECHO.
“It may be some combination of these activities that is the optimal

strategy, and it is unlikely that any one particular strategy will work best in
every clinical venue,” Schilsky noted. He added that the primary challenges
in improving cancer diagnosis and care are primarily cultural and organi-
zational, rather than technological: “It’s rare in so many areas of medicine
that technology is the actual barrier to implementation. It’s almost always a
cultural or organizational barrier, and we need to think about overcoming
those barriers.” He also pointed out that “much of what we do in medicine
is determined by our payment models, and a lot of patient support services
in oncology are typically not well reimbursed, even though they are essential
to delivering high-quality care to cancer patients.” Hricak agreed, and said
the next steps are to operationalize and support these strategies to improve
cancer diagnosis and care.
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Appendix A
Statement of Task
An ad hoc committee will plan and host a 1.5-day public workshop

that will feature invited presentations and panel discussions. Workshop
participants will examine strategies to ensure that patients have access to
appropriate oncologic pathology and imaging expertise and technologies
to inform their cancer diagnosis, treatment planning, assessment of treat-
ment response, and oncologic surveillance. Potential strategies that will be
explored include opportunities to develop and maintain a workforce with
oncologic imaging and pathology competencies and the role of new tech-
nologies and models of care to improve access to this expertise. Participants
will be invited to discuss topics that may include
• Training needs for clinicians (specialists and generalists) who

interpret pathology and imaging results for patients with cancer.
• Models of care that can improve patient access to cancer specialists
in pathology and radiology (e.g., telemedicine), and implications on
patient outcomes and clinical practice.
• Opportunities to enhance collaboration among pathologists,
radiologists, and oncologists to improve diagnostic testing and
treatment decision making for patients with cancer.
• Challenges and opportunities for technologies to facilitate improved
diagnostic decision making among specialists and generalists (e.g.,
65

guidelines, appropriate use criteria, computer-aided detection,

diagnostic decision support).
• Potential role of new advances in imaging and pathology technologies
to improve decision making for patients with cancer.
The committee will develop the agenda for the workshop sessions,
select and invite speakers and discussants, and moderate the discussions.
A proceedings of the presentations and discussions at the workshop will
be prepared by a designated rapporteur in accordance with institutional
guidelines.

Appendix B
Workshop Agenda
February 12, 2018

7:30 am Registration
8:00 am Welcome from the National Cancer Policy Forum

Sharyl Nass
Director, National Cancer Policy Forum
Overview of the Workshop

Hedvig Hricak, Memorial Sloan Kettering Cancer Center
Planning Committee Chair
8:15 am
Session 1: Patient Access to Diagnostic Expertise in
Oncology
Moderator: Christopher Cogle, University of Florida
Challenges to Ensuring That Patients Have Access

to Diagnostic Expertise to Inform the Best Possible
Cancer Care
• Otis Brawley, American Cancer Society
Oncologic Imaging: Gaps and Challenges to High-

Quality Cancer Diagnosis in Clinical Practice
• H
edvig Hricak, Memorial Sloan Kettering Cancer
Center
67

Oncologic Pathology: Gaps and Challenges to High-

Quality Cancer Diagnosis in Clinical Practice
• M ichael Cohen, Wake Forest School of Medicine

Panel Discussion: Vision for the Future: Ensuring
Access to Diagnostic Expertise in Oncology
Includes speakers and
• J ohn Cox, Parkland Health and Hospital System/
UT Southwestern
• R ichard Friedberg, University of Massachusetts
Medical School–Baystate
• Bruce
Stewart, Massachusetts Radiological Society
10:15 am Break
10:30 am
Session 2A: Developing and Supporting a Workforce
for High-Quality Oncology Diagnosis and Care:
Education and Training
Moderator: James Brink, Massachusetts General
Hospital and American College of Radiology
Improving Education and Training for Pathologists

Who Interpret Information for Cancer Patients in
Academic and Community Settings of Care
• R
itu Nayar, American Board of Pathology and
Northwestern University
Improving Education and Training for Radiologists

Who Interpret Information for Cancer Patients in
Academic and Community Settings of Care
• F
iona Fennessy, Dana-Farber Cancer Institute and
Brigham and Women’s Hospital/Harvard Medical
School
Perspectives from the American Boards of Pathology

and Radiology
• R
itu Nayar, American Board of Pathology and
Northwestern University
• B
rent Wagner, American Board of Radiology and
American Institute of Radiologic Pathology

APPENDIX B 69
Panel Discussion: Improving Cancer Diagnosis

Through Quality Improvement and Peer Learning
Approaches
• K ojo Elenitoba-Johnson, University of
Pennsylvania Perelman School of Medicine and
Association for Molecular Pathology
• D avid Larson, Stanford University
• D ana Siegal, CRICO Strategies
12:45 pm Lunch
1:30 pm
Session 2B: Developing and Supporting a Workforce
for High-Quality Oncology Diagnosis and
Care: Role of Decision Support, Guidelines, and
Appropriate Use Criteria
Moderator: Kojo Elenitoba-Johnson, University
of Pennsylvania Perelman School of Medicine and
Association for Molecular Pathology
Clinical Decision Support Technologies for

Oncologic Imaging
• R
amin Khorasani, Brigham and Women’s
Hospital and Harvard Medical School
Clinical Decision Support Technologies for

Oncologic Pathology
• B
rian Shirts, University of Washington
Panel Discussion: How Guidelines and Appropriate

Use Criteria Can Support Oncologic Imaging and
Pathology Test Ordering/Decision Making
• J ames Brink, Massachusetts General Hospital and
American College of Radiology
• J ordan Laser, Northwell Health and Association
for Molecular Pathology
• G regory Riely, Memorial Sloan Kettering Cancer
Center
3:00 pm Break

3:15 pm
Session 3: Systems Approaches and Models of Care
Delivery for Cancer Diagnosis
Moderator: William Stead, Vanderbilt University
Medical Center
Diagnostic Management Teams

• M
ary Zutter, Vanderbilt University Medical Center
Integrated Delivery Systems Perspective on Systems

Approaches to Diagnosis
• W
illiam Sause, Intermountain Healthcare
The Potential of Telementoring to Extend Oncologic

Pathology and Imaging Expertise in Community
Settings
• E llen Baker, The University of Texas MD
Anderson Cancer Center, Project ECHO
Employer Use of Centers of Excellence/Second

Opinion Services for Cancer Diagnosis
• L
awrence “Rusty” Hofmann, Stanford School of
Medicine and Grand Rounds
Alternative Payment/Delivery System Models

to Promote Collaboration and Value in Cancer
Diagnosis
• S tephen Grubbs, American Society of Clinical
Oncology
Panel Discussion
5:30 pm Adjourn Day 1
February 13, 2018

7:30 am Registration
8:00 am
Session 4: Computational Oncology and Integrated
Diagnostics: Opportunities for New Technologies to
Improve Diagnostic Information and Inform Cancer
Care
Moderator: Curtis Langlotz, Stanford University

APPENDIX B 71
Data-Sharing Consortiums and Large Datasets to

Inform Cancer Diagnosis
• A
my Abernethy, Flatiron Health
Artificial Intelligence to Enhance Radiology Image

Interpretation
• C urtis Langlotz, Stanford University
Artificial Intelligence to Enhance Pathology

Diagnosis
• M ichael Becich, University of Pittsburgh School
of Medicine
Genomic Standards and Knowledge Bases for

Decision Support
• J eremy Warner, Vanderbilt University
Panel Discussion
10:00 am Break
10:15 am Session 5: Stakeholder Perspectives on the Path

Forward
Moderator: Richard L. Schilsky, American Society of
Clinical Oncology
Overview of Oncologic Imaging in Europe

• B
oris Brkljačić, European Society of Radiology
Panel Discussion
Panelists
• O tis Brawley, American Cancer Society
• B oris Brkljačić, European Society of Radiology
• J ohn Cox, Parkland Health and Hospital System/
UT Southwestern
• R onald Kline, Centers for Medicare & Medicaid
Services
• W illiam Sause, Intermountain Healthcare
• P atty Spears, University of North Carolina at
Chapel Hill

11:30 am Workshop Wrap-Up

Hedvig Hricak, Memorial Sloan Kettering Cancer Center
Planning Committee Chair
11:45 am Adjourn

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Erin Balogh, Margie Patlak, and Sharyl J. Nass, Rapporteurs

National Cancer Policy Forum

Board on Health Care Services

Health and Medicine Division

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