NICE CG 2009 Early and locally advanced breast cancer: diagnosis and treatment

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1 Modernising Follow Up Breast Cancer Tom Crosby

2 Purpose of Follow Up Benefits Offer holistic support for patient post treatment Physical: Psychological: Social: Secondary screening toxicities anxiety re recurrence, sexual function rehab back to normality, financial support Events related to previous disease or treatment, where evidence exists that early intervention beneficial

3 Purpose of Follow Up Harms Patient Physical: Psychological: Social: NHS Cost: Resource: Of intervention Prevents normalisation Costs Secondary care precious resource Inappropriate use of limited capacity

4 How do we do in relation to breast cancer follow up? Good Radiographer led practice Audit high patient satisfaction Bad One size fits all that doesn t account for: Risk (DCIS vs IDC, G1 vs 3) Patient wishes, no key worker assigned No care plans agreed with patients and primary care Ugly Variation 5 vs 10 years (NICE - 5) It doesn t work!

5 NICE CG 2009 Early and locally advanced breast cancer: diagnosis and treatment Recommendations Offer annual mammography to all patients with early breast cancer, including DCIS, until they enter the NHSBSP/BTWSP. Patients diagnosed with early breast cancer who are already eligible for screening should have annual mammography for 5 years. On reaching the NHSBSP/BTWSP screening age or after 5 years of annual mammography follow-up we recommend the NHSBSP/BTWSP stratify screening frequency in line with patient risk category.

6 It doesn t work! Detecting recurrence 104 recurrences out of 16,924 (6.3/1000 (vs 7.9/1000 BTW) 111 false +ve 77% recurrences after 5 years 62% new primary cancers 50% within 6 months of 3-yearly service (BTW) Detrimental effect to symptomatic service Up to 5000 unnecessary mammograms per year per breast unit Difficulty in radiology support for metastatic MDT Delays in referral to symptomatic service Patient support No audit of rehabilitation to normal functioning Doesn t address psychosocial needs Gaps in Key Worker support for patients with disease No clear care plan communicated between health professionals empowering patients through information towards choice and control

7 Bid to Macmillan 2011 Project Lead: Dr Jaz Abraham Aims To define follow up for early breast cancer according to the individual patient need, risk and treatment stratified group. Objectives To define the risk and treatment stratified groups To develop and implement a pathway of follow up for each group To develop and implement individual care plans To support each pathway with a comprehensive patient information To implement pathways across South Wales through SWCN

8 Project Plan Stage I [Months 0-3] Brief and educate the Project manager Establish more detailed collection of baseline activity, protocols and resource Engage all members of the Breast Teams (including the patient s voice) by holding a South Wales Cancer Network workshop with the following aims To present the project aims and debate controversial areas. eg the length of mammographic follow up required To achieve a consensus agreement on the principles of risk and treatment stratified follow up. To present an outline of the proposed pathways To incorporate existing models already developed that may be adapted and used eg self management/telephone assessments. Stage II [Months 3-6] Set out the agreed Model Of Individualised follow up for South Wales Informatics around care plans Stage III [Months 6-18] Pilot the pathways in 2 hospital sites: Velindre Cancer Centre: Oncology led: Clinical trial pathway and Complex care pathway. (Herceptin pathway and Mammographic led pathway already exists) Royal Glamorgan: Surgical led: Low risk pathway. This will include self management/ clear programme of hormone therapy and bone health review at points(eg3 and 5 years) Stage IV [Months 18-36] Obtain patient feedback and clinical feedback Repeat South Wales Network workshop to present pilot results Initiate and Roll out pathways to all breast cancer sites across South Wales

9 The Development and Implementation of All Wales Integrated Oncology/Palliative Care Multi-disciplinary Careplans Partnership: VCC, SWCN, NWIS, 1000 lives Bid to Health Foundation for Shared Purpose proposal, 0.42m an Idea that can be progressed into large scale organisational change that will impact on patient experience corporate services working with clinical teams to improve patient care. The development will: document and validate care plans for patients Enable care plan e-communication between primary (Gateway), secondary (WCP), tertiary/third sector (CANISC), patients (MHOL) The implementation will: train clinical teams in Continuous Quality Improvement methodology ensure linkage between Patient Experience, Outcome Indicators and Process Measures identify critical factors across the Network (finance, workforce and management) for sustainability and dissemination