The Cambridge Breast Unit

Transcription

1 The Addenbrooke s Hospital Cambridge Cambridge

2 Follow up- Why?- Medical Monitor and treat Acute side effects of treatment Early detection of Local and Regional Recurrences (Curative) Early detection of metastatic disease Assess Late effects

3 Follow up- Why?-Patient Reassurance Help side effects of treatment Emotional support

4 Standard FU Schema 3 monthly for 2 years 6 monthly up to 5 years? Yearly up to 10 years

5 2004 What CBU wanted to achieve Meet new targets Free up space for symptomatic patients Define group of patients suitable for less intensive follow up

6 What the Papers Say Donnelly et al. Int.J.Clin. Practice 2001 Sept; 55(7):431 recurrences' usually present to an interval clinic. Most that present to routine clinic are symptomatic. Grunfeld et al. BMJ.1996 Sept 14: 313 (7058): GP follow up of breast cancer in remission is not associated with increase time to diagnosis of recurrence or anxiety, or deterioration in quality of life

7 Benefits of adopting a self management model Increased patient satisfaction and quality of care Individualised support that meets patients needs Reduced OP follow up/unplanned admissions 7

8 Focus Groups Share information Rapid access back to specialist care

9 Percent net survival Net survival* for breast cancer diagnosed at Cambridge University Hospitals NHS Foundation Trust 120% 100% 80% 60% 5 year net survival EPG 103.5% GPG 103.8% MPG % EPG GPG MPG1 MPG2 PPG VPPG 40% MPG2 87.4% PPG 73.4% 20% VPPG 60.3% 0% Survival in years

10 Local Recurrence following breast conserving surgery for invasive breast cancer. CBU 5-year LR = 1.13% NPI Groups NPI groups 4-6 NPI Groups censored Time to local recurrence (months) censored Ann R Coll Surg England 2010 Oct;92(7):562-8

11 Follow up NPI Groups 1-3 Mammographic FU only. Patient led follow up NPI Groups 4-6 Mammographic FU yearly clinic visit up to year 3 then discharge to patient led Follow up

12 Patient-Led Follow-Up PLFU Regular mammographic surveillance No routine clinical breast examination Written information Contact telephone number for specialist nurse Rapid access to clinic for specialist surgeon/oncologist/nurse Sep 2005 NPI <3.4; Sep 2007 NPI <4.4

13 Results of Audit PLFU Telephone Contact September 05 December patients Telephone contact 49 patients Side effects medication/complimentary therapies New lumps/chest wall pain/seromas/lymph nodes Lymphoedema Vaginal bleeding Bony pain Plastic surgery referral request

14 Results of Audit PLFU Clinic Visits 32 patients attended clinic 20 making 1 clinic visit 5 making 2 clinic visits 5 making 3 clinic visits 1 making 5 clinic visits 1 making 7 clinic visits During the 3 year period a total of 1125 patient visits were saved, a reduction of 92.4% in clinical attendance for this group of patients

15 Results of Audit PLFU Letters of Referral from GPs 37 letters of referral from GPs 7 did not need to attend clinic 16 made 1 clinic visit 10 made 2 clinic visits 2 made 3 clinic visits

16 Results of PLFU New Breast Primaries 6 new Breast Primaries 2 found by patient 1 contralateral breast primary at 36 months 1 contralateral breast DCIS at 54 months 4 detected by screening contralateral DCIS at 12, 14, 23 months Invasive breast cancer at 37 months

17 Results of Audit PLFU Local/Systemic Recurrence 3 local/systemic recurrences 2 found by patient Lung metastasis at 1 month Chest wall recurrence in mastectomy scar at 39 months 1 referred by GP with liver/bony metastasis at 13 months

18 Results of Audit PLFU Deaths 4 deaths 1 cardiac 1 liver/bony metastasis from breast 2 unknown

19 Results of Audit PLFU Mammogram Attendance Wide Local excision annually for 5 years Mastectomy biennially for 5 years 312 patients had all mammograms 77 did not need mammograms Mammogram not yet due Bilateral mastectomies 2 had partial mammographic follow up 15 had no mammographic follow up

20 Number of patients seen per month in surgical follow-up clinic after introduction of PLFU patients S O N D J F M A M J J A S O N D

21 Summary 406 patients in 3 year study period 86 telephone consultations 93 clinic appointments 21.2% of patients required additional support or access to diagnostic services clinic appointments avoided over 3 years Mammographic surveillance important modality Patients and GPs were able to access specialist help and advice easily and quickly without compromising patient safety

22 Conclusion Patient-led (reduced clinical) follow up is an effective and safe way to follow up patients with an excellent or good prognosis following completion of breast cancer treatment. The reduction in routine clinic appointments allows time to be spent with those patient who require additional support or to create extra clinic slots for new patients.

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24 100% patients were satisfied/very satisfied with PLFU 97% had clear idea how to contact the unit Patients concerns 1. Additional psychological support 2. Advice about treatment side effects

25 Percent net survival Net survival* for breast cancer diagnosed at Cambridge University Hospitals NHS Foundation Trust 120% 100% 80% 60% 40% 5 year net survival EPG 100.0% GPG 102.7% MPG1 99.3% EPG GPG MPG1 MPG2 PPG VPPG 20% MPG2 93.4% PPG 86.3% 0% VPPG 62.0% Survival in years

26 PLFU- Audit 2 January December Further patients 406 original patients 125/479 patients contacted CBU 26% compared to 21.5% in the previous audit

27 PLFU- Audit -2 - Trials IMRT, Import High and Low Trials Yearly Follow up Radiographer Practitioner. Trial related only 53 patients

28 PLFU- Audit-2 MMG Attendance Failed to attend for any follow up MMGs 29/479 6% Audit cycle 2 15/406-3% Audit cycle 1

29 PLFU- Audit -2 MMG recalls Recurrences found on FU MMGs 1/ 479 audit cycle 2 4/406 audit cycle 1

30 PLFU- Audit 2 Deaths 9 deaths audit cycle 2 4 breast cancer related 4 unrelated to Breast Cancer 1 unknown 4 deaths audit cycle 1 1 breast cancer related 1 unrelated to breast cancer 2 unknown

31 PLFU recurrences PLFU audit cycle 2 2 new primaries 5 local/systemic PLFU audit cycle 1 6 new primaries 3 local/systemic

32 PLFU Audit 2 Misc 16/ % of patients returned to annual FU Small cohort unable to cope with out routine yearly outpatient visits Small cohort ended up having yearly visits to the new patient 2 week wait clinic with a new problem Small number with recurrences returned to yearly FU

33 PLFU- Investigations Routine yearly MMGs for 5 years. Organised at exit interview DEXA scan follow up for those on AIs

34 Setting up PLFU : Mammograms 1. Regular recall system in place for the full 5 years instigated at the exit interview 2. Method of sending results to GP and Patient

35 Resource pack Personal information file Treatment diary This file provides information about individual s condition and treatment Belongs to the patient.

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37 Specialist nurse Contact numbers of CNS Key worker Explain Follow up Post-op surgical & RT changes Lymphoedema/Body image/sexuality Endocrine treatment

38 Patient comments; At the end of Radiotherapy it felt as though I dropped into a black hole. The arrangements for follow up could have been better explained. However, this session did provide a valuable opportunity to discuss what s next and specifically what things to look out for regarding getting my life back on track

39 Dietician Advice on Diet and Nutrition WCRF guidelines on functional foods Dairy, Soya, Complimentary and alternative diets Alcohol YES NO Not much

40 Physio Nicola Hopkins Why should breast cancer survivors exercise? Improvements seen in Reduced fatigue, tiredness Mood, anxiety, depression Weight control Overall Quality of life Bone health Reduced risk of relapse

41 Exercise for life DVD and booklet produced by Sarah Tunnicliffe active.html

42 Life Coaching- Sue Rae 6 sessions. 1:1. over 10 weeks 2 follow up sessions 1 & 3 months later Wed/Thurs afternoons in Breast Unit. Evaluation - HADDS questionnaire. - Patient written/oral feedback. Began Jan Currently 13 participants

43 PLFU : Parallel Help Wallace Cancer Centre- Maggie s Wallace Cambridge Cancer Help Centre at Scotsdales Garden Centre

44 To follow-up or not: that is the question NICE guidelines 2009 Follow-up has no effect on Detection of recurrence Overall survival Serious clinical events Follow-up may be in primary, secondary or tertiary care

45 PLFU What next? PLFU for all what ever the risk Patients in trials as per the trial protocol HOPE Macmillan self management course.