Cancer of Unknown Primary Service

Transcription

1 Cancer of Unknown Primary Service Dr Maurice Fernando Consultant In Specialist Palliative Care and CUP lead Doncaster and Bassetlaw Hospitals NHS FT Wakefield meeting

2

3

4

5

6 CUP service CUP MDT Tuesday ( DRI) CUP clinic (Primary diagnostic) pilot Thursday/ runs along Oncology clinic (DRI) Telephonic discussion- Primary & secondary care South Yorkshire Guidelines for MUO/CUP CUP peer review July 2016

7 Cancer of Unknown Primary and Malignancy of Undefined Origin Assessment Checklist MUST DO for all patients Review History Cancer symptoms confirm absence of especially: o Haemoptysis / cough o Hematemesis /dysphagia o Haematuria / abnormal vaginal bleeding o Altered Bowel habit / malena / rectal bleeding Risk factors - especially o Smoking history: o Industrial chemicals/ asbestos exposure: Family history o Cancers especially breast cancer include age of onset: Comorbidities o Especially cardiac disease, renal or hepatic impairment: Confirm Performance Status (PS) o 0 - Asymptomatic (Fully active, able to carry on all predisease activities without restriction) o 1 - Symptomatic but completely ambulatory (Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature. For example, light housework, office work) o 2 - Symptomatic, <50% in bed during the day (Ambulatory and capable of all self care but unable to carry out any work activities. Up and about more than 50% of waking hours) o 3 - Symptomatic, >50% in bed, but not bedbound (Capable of only limited self-care, confined to bed or chair 50% or more of waking hours) o 4 - Bedbound (Completely disabled. Cannot carry on any self-care. Totally confined to bed or chair) o 5 - Death Review Examination findings Confirm that examination has included o breast examination o genital examination o digital rectal examination including prostate assessment in males o lymph nodes examination - consider U/S guided or surgical biposy if abnormal Review investigations request where not performed as directed clinically Patients PS 0-3 FBC, U+E, LFTs, LDH, CRP, Urinalysis CT scan chest / abdomen / pelvis Specific presentations:in patients with isolated or multiple lytic bone lesions - Immunoglobulin levels & Bence Jones Symptom-directed endoscopy.only if significant local symptoms in women presenting with clinical or pathological features compatible with breast cancer - Mammography In men with a presentation compatible with germ cell tumour - Testicular ultrasound Marker tests in patients with presentations compatible with germ cell tumours (particularly those with mediastinal and / or retroperitoneal presentations) AFP and hcg In patients with presentations compatible with hepatocellular cancer AFP. in men with presentations compatible with prostate cancer (bone, nodal and or lung) PSA in women with presentations compatible with ovarian cancer (including those with inguinal node, chest, pleural, peritoneal or retroperitoneal presentations) CA125 Carefully interpret the results because of limited test specificity Upgrade and refer o Upgrade all patients immediately to the MDT Co-ordinators o Refer to AOS CNS DRI Bassetlaw o Refer to the unknown primary team (Speak to Dr M Fernando CUP Lead and Specialist Palliative Care Consultant or Palliative Care Consultant colleages via switchboard)

8

9 GP referral of patients with Metastatic Malignancy of Undefined Primary Origin NICE guidance has recommended improving the pathway for Patients with Metastatic Malignancy of Undefined Primary Origin. In response to this Doncaster & Bassetlaw Hospital NHs Trust has refined the pathway for this previously poorly served group of patients. We are very pleased to announce the weekly Primary Diagnostic Clinic run by Dr.Maurice Fernando and CUP CNS Claire Garbutt and Lynda Pollard. There is also an Unknown Primary Multi Disciplinary Team weekly meetings where the investigation and management is discussed with a team of specialists including Oncologist, Pathologists, Radiologists, Physicians, Surgeons and Specialist Palliative care. The team also sees in-patients who present with metastatic malignancy with an aim of focussing investigations on those that are appropriate, managing investigation as much as possible as an outpatient, for those who are not suitable for oncological treatment fast tracking into palliative care and, where appropriate, supported discharge home at the earliest opportunity. GPs can refer directly into the Primary Investigation Clinic. Patients who are suitable for referral are those with metastatic malignancy on diagnostic imaging for whom there are no red flag symptoms or signs to direct to a site specific clinic. Those with red flag symptoms should still be referred to the appropriate site specific team (e.g. patients with liver metastases and rectal bleeding should be referred to colorectal.) There will be some patients in whom early investigation in primary care points to the primary and should be directed down established referral routes e.g. patients with bone metastases with a high PSA should be referred to Urology. Lymph nodes should be referred for biopsy before being labelled as metastatic and the established referral practice should be followed for these (e.g. Neck Nodes to ENT, Axillary Nodes in females to Breast assessment). Patients with bony lesions, brain metastasis or disseminated malignancy with no obvious primary site on initial investigation can be referred to the CUP service. Recent NICE guidance 2015 on Cancer explains about vague symptoms which follow a different pathway via Multidisciplinary Diagnostic centres in community rather than the CUP service. While one of the objectives of the NICE guidance is to get early Palliative Care and Oncology input into these patients cancer pathway, Dr Fernando will be acting in his role as Consultant Physician for Unknown Primary (although this will overlap with his role as Consultant in Palliative Medicine) so there need not be concern that patients will be confronted by a Palliative Care label when this is inappropriate. However the prognosis for this group of patients is generally poor (median survival less than two months) so identifying those for whom further investigation is not in their best interests and facilitating transition to a palliative care approach will be an important part of the role of the team. Details of how to access the Primary diagnostic clinic are available on the Trust Website. However, if you have any queries or questions about the new service, please so not hesitate to contact Dr. Fernando or CUP CNS on Tel (01302) , through the hospital switchboard.

10 Suspected Cancer referral for Metastatic Malignant Disease of Unknown Primary Origin (two-week wait referral) In accordance with NICE Guidance Please FAX within 24 hours to Specialtist Palliative Care Office Section 1: PATIENT INFORMATION (Please complete in BLOCK CAPITALS) SURNAME Date of Referral / / Date of Birth / / FIRST Name NHS Number Date patient unavailable in the next 14 days. MR MISS MRS MS OTHER M { } F { } ADDRESS Day time phone Mobile phone Language Interpreter Y N POST CODE: Transport Y N Ethnicity Section 2: Practice Information (Please use practice stamp if available) REFERRING GP Locum Y N Practice Address Telephone Post code: Fax address:

11 Section 3: CLINICAL INFORMATION (Please tick all applicable entries) Please enclose print outs of CURRENT medications, PAST MEDICAL HISTORY and RELEVANT IMAGING REPORTS Imaging suggestive of metastatic disease (and NO primary organ specific symptoms)* *If patient has a history of cancer please consider whether this is more likely to be a recurrence than a true unknown primary cancer. Patients with suspected recurrence should be referred back to the site specific team. [ ] USS: Specify site [ ] CT scan: [ ] Chest, abdomen and pelvis [ ] Chest and abdomen [ ] MRI: Specify site Symptoms [ ] Progressive unintentional weight loss [ ] anorexia [ ] Pain: Specify site [ ] other: Further Information** **The referral CANNOT be made unless ALL these are completed Current WHO Performance Status of patient (please tick one) [ ] 0 Able to carry out normal activity without restriction [ ] 1 Restricted in physical strenuous activity but ambulatory and able to carry out light work [ ] 2 Ambulatory and capable of self care but unable to carry out any work: up and about for more than 50% waking hours [ ] 3 Capable only of limited self care; confined to bed or chair for more than 50% waking hours [ ] 4 Completely disabled; cannot carry out any self-care; totally confined to bed or chair [ ] Patient aware of suspected diagnosis of cancer [ ] Patient understands that further tests may be required AND is willing to accept these [ ] Patient is fit enough to undergo further tests AND for consideration of treatment if cancer confirmed If your patient does not meet any of these criteria, or if the patient has severe symptoms, please contact the upper GI team to discuss the referral. Contacts numbers are included in Section 5 on this form. INVESTIGATIONS MEDICAL HISTORY KNOWN ALLERGIES AND MEDICATION

12

13

14 patients in CUP MDT 4-histological proven diagnosis of CUP-Oncologist 4-histological confirmed primary site- site specific team 10-radiological diagnosis site specific team 36 MUO Symptomatic and Palliative care support 5-died prior to discussion 4-no cancer

15

16 March to date-pilot 20 patients discussed at CUP MDT 2 referred directly from primary care 3 seen in CUP clinic 11 confirmed primary 4 confirmed CUP/MUO

17 Future Pilot to continue ~ 6-9 months Job plans to be reviewed Audit-local/network Education/ raising profile- GP ( TARGET& BEST ) Patient/carer survey

18 Thank you for listening Questions