Health Board/Region: Cardiff & Vale University Health Board Main Hospital Base: University Hospital of Wales, Llandough. Date of review: 28 June 2018

Transcription

1 Peer Review: Cancer Sub-site: Breast Health Board/Region: Cardiff & Vale University Health Board Main Hospital Base: University Hospital of Wales, Llandough Cycle: Second Date of review: 28 June 2018

2 REVIEWEES SERVICE DESCRIPTION KEY THEMES STRUCTURE AND FUNCTION OF THE SERVICE brief overview, including objective of the service Cardiff and Vale University Health Board covers the areas of Cardiff and the Vale of Glamorgan serving a population of around 489,931, which is 15.7% of the population of Wales 1. Of the 2,837 breast malignancies audited during the reporting period or 13.7% of patient were treated within the Health Board. Cardiff and Vale Breast Centre assesses symptomatic patients presenting from the Cardiff and Vale area. In addition, it is part of the Breast Test Wales screening services. The Cardiff and Vale MDT covers all patients from these two routes. The purpose of the MDT is to ensure rapid access to the service for all those requiring a specialist opinion for a breast problem, facilitate multidisciplinary management of patients with breast cancer, newly diagnosed or recurrent, ensuring that the patients experience an efficient service which is of the highest quality and adheres to current clinical guidance. Central to this is the weekly MDT meeting where cases are discussed at diagnosis, following completion of treatment modalities and on suspicion of disease recurrence or progression. The MDT also aims to collect high quality clinical information on its patients to support and inform all of those involved in the patient s care and to allow clinical audit. PATHWAY describe links between primary care, diagnostics, MDT and treatment Cardiff and Vale Breast Centre (C&V-BC) assesses symptomatic patients referred by General Practitioners (GPs) in the C&V area. There are > 400 new referrals/ month. These are referred as USC or Urgent / Routine by GPs using Wales Clinical Portal (WCP) electronic referral service. The team also works closely with Breast Test Wales (BTW) NHS Breast Screening Programme. We provide surgical support for 2 screening clinics / week and some of our radiology team work with BTW as well. This maintains the team s expertise in the diagnosis and management of screen detected problems. 1 Stats Wales: 2 New patients diagnosed from 01 April 2016 to 31 March 2017

3 The Breast Centre provides a diagnostic service for all GP referrals and a treatment service for those who are diagnosed with Breast cancer. The team provides a full range of surgical procedures, including oncoplastic procedures. The team provides follow up for patients who have been treated for breast cancer. We also co-ordinate a service for women in SE Wales, with genetic mutations (about 25 referrals/yr). This involves the All Wales Genetics Service, a Plastic Surgeon from Morriston Hospital, 2 Breast Consultants and a Consultant Nurse. Joint clinics (three monthly) review patients considering risk reducing surgery. The purpose of the MDT is to ensure rapid access to the service for all those requiring a specialist opinion for a breast problem, facilitate multidisciplinary management of patients with Breast cancer, symptomatic or screen detected, newly diagnosed or recurrent, ensuring that the patients experience an efficient service which is of high quality and adheres to current clinical guidance. Central to this is the weekly MDT meeting where cases are discussed at diagnosis, following completion of treatment and on suspicion of disease recurrence or progression. Clinical colleagues from Velindre NHS Trust are key members of the MDT to enable smooth transfer of patients to specialist treatments. The MDT collects clinical information on its patients, to support and inform all those involved in the patient s care and to allow clinical audit. IMPROVEMENTS/CHANGES SINCE LAST REVIEW refer to last Action Plan 1. The Health Board/MDT reported progress to the concerns raised from their peer review of 2015, including: a. Improved resources and support for oncology patients; b. Ratification of the MDT follow up protocol; c. The addition of a breast surgeon and oncologist to the MDT since the last review; d. The use of Canisc MDM module during the MDT in a fully functioning MDT room 2. The MDT reported the completion of seventeen (17) clinical audits or service improvements since the last review. CANCER SERVICE Specifics Diagnosing Cancer Details Referral guidelines for symptomatic patients are based on the NICE guidelines for USC referrals. GP referrals are via Welsh Clinical Portal (WCP), which allows dialogue with a GP if necessary. 28 June

4 Symptomatic patients are assessed by history, clinical examination and imaging - mammograms (from 40 years) and ultrasound if required at their first clinic appointment. Biopsies are performed as required in a triple assessment clinic. All patients who have had a biopsy are discussed at the next MDT and return for results. CT Staging is done preoperatively for patients with stage 3/4 disease, or who have symptoms suggestive of metastatic disease. Postoperatively, staging is done for cancers with > 4 positive axillary nodes. Cardiff & Vale University Health Board do not meet the Urgent Suspected Cancer (USC) target of 95%, but did meet the Non-Urgent Suspected Cancer (NUSC) target of 98%. The Health Board performed as well as other Health Boards in Wales for treating patients efficiently, however the Health Board had the highest average number of days to see patients recording a median of 29 days. During discussion delays in HER2 testing were reported by Health Boards within the region and seen as a sub-optimal delay for patients. The delay affected patients with a HER2 status of 2+ where the sample requires further immunohistochemistry known as FISH (Fluorescence In Situ Hybridization). Treating Cancer Patients diagnosed with cancer are managed according to current NICE guidelines, taking into account pathological characteristics, including ER and HER2 status. Decisions regarding postoperative adjuvant treatments are based on Predict and other algorithms. Oncotype DX is used if indicated as per NICE guidelines. Postoperative radiotherapy is given following breast conservation surgery and to the chest wall and supra-clavicular fossa if the cancer is 5cm or greater and/or where 4 or more lymph nodes are positive. If a patient is found to have possible breast pathology as an incidental finding after other radiological investigations, a referral is sent to the MDT co-ordinator, who alerts the MDT chair and breast team lead to discuss whether the patient needs a clinic appointment or discussion at MDT first. The Acute Oncology team also refer by direct contact or contact, for discussion at MDT and clinical review. Patients with screen detected cancers are diagnosed at BTW and are discussed preoperatively at BTW MDT and postoperatively at C&V. 28 June

5 MDT SERVICE Specifics Local / Regional VC Used with whom? Membership / attendance MDT Charter Observations MDM Module used Details The breast multidisciplinary team (MDT) is a multi-professional team based at University Hospital of Wales Llandough. This is a local MDT that links and works in partnership with the regional cancer centre of Velindre. Video conferencing is not routinely used, specialists in attendance.. The Health Board MDT reported all required members for the MDT and cover arrangements in place. During the MDT visit the following observations were noted: Good leadership. Mutual respect between colleagues. Outcomes are recorded and clinical history provided by notes, not Canisc MDM. Delays with HER2 reporting. Performance status and pre-treatment stage not captured. Staging captured for post op histology patients. Canisc MDM module is used and information is validated during the MDT. However, the MDT did not capture performance status and pre-treatment stage. Post op staging is recorded. Information summary 51 MDT Meetings 23 days Median days to first treatment 388 New diagnosis 33% Screen detected 67% Symptomatic 6.3% Conversion rate 90% USC (62 day target) 98% NUSC (31 day target) 54% Detection rate 3.6% Stage recorded 3 40% Mastectomy 60% Breast conservation 3 Stage recorded refers to pre-treatment stage or radiological stage. The relevant focus for breast teams has been to record post-treatment or pathological stage. 28 June

6 PATIENT CENTRED CARE AND EXPERIENCE Specifics Named Key Worker / contact details Care plans / holistic needs assessment Follow up process Details Named key worker from a point of diagnosis that continues through the patient pathway. Key worker and contact details recorded on all letters and recorded on Canisc. Holistic needs assessments (HNAs) are formally carried out at first assessment and following completion of treatment. The Health Board are also rolling out their ehna programme. Follow up protocol for 10 years where the consultant nurse leads the follow up clinics. Moving Forward courses are also run within the Health Board. SUPPORTIVE CARE Specifics Patient Questionnaire Prehabilitation / Rehabilitation Details Local questionnaire surveys were not discussed, but patient engagement was described within the submission. The Cancer Patient Experience Survey of 2017 was also acknowledged. Through follow up, patients have access to lymphoedema, physiotherapy, welfare and benefit advice, and psychological support. Access to all AHP groups is ad hoc and limited nearer to home, often utilising Velindre Cancer Centre (VCC) for more complex patient. VCC services are currently limited due to staffing. Inequity was highlighted if under a surgeon and not an oncologist. STRATEGIC INTERFACE Specifics Business meeting Details The MDT conducted formal business meetings. Clinicians, through varied membership, communicate through the cancer structure within Cardiff & Vale. 28 June

7 Policy Links to organisational strategy / planning NICE Guidelines; Best practice diagnostic guidelines for patients presenting with breast symptoms; National Guidance for the use of Endocrine Therapy in the Management of Early Breast Cancer; Protocol for Management of Bone Health in post-menopausal ladies starting on Aromatase Inhibitors; Protocol for Primary Hormone Therapy; Cancer Genetics Service for Wales Referral Guidelines. The Health Board have a structure within the organisation and peer review attended by Health Board lead cancer clinician and lead cancer nurse. Cardiff & Vale do not have a designated Cancer Manager, but do have a permanently funded AHP Lead. PATIENT AND STAFF ENGAGEMENT Specifics Patients engagement Staff survey Details In general, patients were very positive and complimentary for the service provision. The MDT have also engaged with patients to capture their views for improvement. Ten (10) Health Board and MDT members completed the staff survey with all positive responses supporting the MDT. GENERAL OBSERVATIONS A Clinical Nurse Specialist Chaired and Led the MDT, which was well supported by the team and works well. Consultant radiographers being used demonstrating a different way of working. Low percentage of screen detected breast cancers managed by the MDT. Access to clinical trials, albeit limited due to Health Board pathology and radiology capacity. 28 June

8 GOOD PRACTICE GOOD PRACTICE AND SIGNIFICANT ACHIEVEMENTS identify any areas of good practice A proactive MDT striving to improve all aspects of the patient pathway with involvement in studies around shared decision making led by the Breast Cancer Nurses. Additional Consultant Surgeon and Consultant Oncologist since last review, which leads to improved cross cover working. Metastatic breast forum at Velindre Cancer Centre. Development of the ehna programme. Consultant nurse roll with both diagnostic and follow up clinics, including service for BRCA patients and counselling. Ward nurses also cover clinics and upskilling of Healthcare Assistants (HCAs). The Health Board announced the permanent funding of the lead Allied Health Professional role. This role led to proactive National Exercise Referral Scheme (NERS) engagement, walking groups, a gym with temporary funding for physiotherapy within the breast centre, musculoskeletal (MSK) links and services with Velindre Cancer Centre including physiotherapy. Moving forward course is also run within the Health Board. IMMEDIATE RISKS TITLE Detail of the risk Rationale None None None SERIOUS CONCERNS TITLE Detail of the risk Rationale None None None 28 June

9 CONCERNS TITLE Detail of the risk Rationale Pathway Performance Pathology service Data quality Radiology service USC performance is at 90% and it takes an average of 29 days to be seen. With a large number of people being referred and patients being managed by the MDT it is a challenge to see, diagnose and treat within the timescales defined by policy. Pathology department is short staffed, including pathologists and biomedical scientists. With much of the service reliant on good will the service is fragile. The pressures on pathology and within the processing lab are reportedly affecting FISH turnaround times from the University Hospital of Wales. This can lead to suboptimal care for patients who would be eligible for neoadjuvant therapy pertuzumab. Assurance should be provided for turnaround times to improve the care of patients within the region. The MDT Charter checklist noted that the MDT did not provide a performance status for recording and that preoperative staging was not always recorded. The MDT should ensure the accurate recording of all data items through validation. The Health Board and MDT are aware of the challenges to recruit consultant radiologists. There is a concern There is a national move to diagnose and treat patients quicker within Wales, which in turn will improve the health and outcomes of patients in Wales. All organisations are working to achieve high performance of these quality measures. Pathological input, provision and support for cancer MDTs is a national problem. The Health Board should continue to improve all aspects of this service where possible. Delays in HER2 status where it affects the MDTs ability to deliver neoadjuvant therapy is sub-optimal care as it may affect patient outcomes. Clinical audit provides a greater understanding and is the basis for any improvement. It is essential to have good quality accurate data to improve Healthcare services through audit. The MDT should ensure data accuracy and record management for all patients under their care. Using the appropriate systems in place. Radiological input, provision and support for cancer MDTs is a national problem. The 28 June

10 CONCERNS TITLE Detail of the risk Rationale Outpatient service / survivorship regarding the lack of succession planning and the ability to provide adequate radiological support with the current establishment of radiologists in the Health Board. The review panel noted a reduction in the availability and clarity of supportive therapeutic services available to breast cancer patients. Health Board should continue to improve all aspects of this service where possible. Continuation of this practice is a challenge to providers. However, enabling people who have had a diagnosis of cancer to continue with their life and recover from their treatment is an important aspect for healthcare services. PEER REVIEW PANEL NAME Position Organisation Damian Heron Network Director Wales Cancer Network Cath Bale Associate Medical Director / Consultant Oncologist Wales Cancer Network / Betsi Cadwaladr University Health Board Marianne Dillon Consultant Surgeon Abertawe Bro Morgannwg University Health Board Wynne Williams Consultant Pathologist Abertawe Bro Morgannwg University Health Board Gill Dazeley Breast Clinical Nurse Specialist Hywel Dda University Health Board Julie Cowling Information Specialist Wales Cancer Network Dana Knoyle Improvement Lead Wales Cancer Network 28 June

11 PEER REVIEW PANEL NAME Position Organisation Jo Horton Allied Health Professional Lead Abertawe Bro Morgannwg University Health Board HEALTH BOARD STAFF AND MULTIDISCIPLINARY TEAM MEMBERS NAME Position Organisation Sumit Goyal Consultant Surgeon Cardiff & Vale University Health Board Tina Bayliss Deputy Director of Operations, Surgery Cardiff & Vale University Health Board Jyoti Bansal Consultant Radiologist Cardiff & Vale University Health Board Cath Marshall Physiotherapy Service Clinical Lead Cardiff & Vale University Health Board Rhisian Otley Assistant Service Manager, Surgery Cardiff & Vale University Health Board Eleri Davies Consultant Surgeon Cardiff & Vale University Health Board Meriel Jenney Assistant Medical Director, Cancer Cardiff & Vale University Health Board Annette Beasley Lead Cancer Nurse Cardiff & Vale University Health Board Alyn Coles Service Improvement Manager Cardiff & Vale University Health Board Ioulia Evangelou Consultant Histopathologist Cardiff & Vale University Health Board Nicola West Consultant Nurse Cardiff & Vale University Health Board Annabel Borley Consultant Oncologist Velindre Cancer Centre 28 June

12 HEALTH BOARD STAFF AND MULTIDISCIPLINARY TEAM MEMBERS NAME Position Organisation Catherine Pembroke Consultant Oncologist Velindre Cancer Centre Helen Sweetland Consultant Surgeon Cardiff & Vale University Health Board Zoe Hilton Research Nurse Cardiff & Vale University Health Board Sharon Chapman Breast Care Nurse Cardiff & Vale University Health Board Grace Uruski Specialist Breast Cancer Nurse Cardiff & Vale University Health Board 28 June