Clinical Oncology Services in the Hospital Authority

Transcription

1 Clinical Oncology Services in the Hospital Authority CC Yau

2 Rising demand Population growth Population ageing Increasing incidence of cancer Expanding indications for radiotherapy and chemotherapy Increasing treatment complexity

3 Cancer incidence New Cancer Case Trend in Hong Kong Latest 2004 figure Cancer Registry Data Forecast *Projection by simple linear regression on 1993 to 2003 data

4 Common Cancers

5 Oncology Service in HA Six Oncology Centres Pamela Youde Nethersole Eastern Hospital (PYNEH) Princess Margaret Hospital (PMH) (opened 2006) Prince of Wales Hospital (PWH) Queen Mary Hospital (QMH) Queen Elizabeth Hospital (QEH) Tuen Mun Hospital (TMH)

6 Inpatient beds PMH 68 PWH 66 PYNEH 50 QEH 85 QMH 26 TMH 48 Overall 343

7 Projected SOP total attendances

8 Projected IP Patient Days

9 Costing 2004/05 Services Radiotherapy & Oncology In patient Radiotherapy & Oncology Out patient No. of Patients Cost per patient (Range) 8,111 $22,000 - $30,400 65,422 $7,600 - $10,200

10 HA Cancer Services Costs (2005) Inpatient HKE HKW KC NTE NTW Total Total No. of patient 1, ,382 2,009 1,615 8,111 Cost ($Mn) Outpatient HKE HKW KC NTE NTW Total Total No. of patient 9,268 9,843 22,180 13,967 10,164 65,422 Cost ($Mn) New centre in PMH - ~80M-100M/year Total 850M per year (HA annual budget in excess of 30B) Based on data for 2004/05

11 The team Medical Clinical Oncologists Radiotherapy, chemotherapy and palliative care Medical Oncologists Chemotherapy Surgical Oncology Nurses Allied Health Pharmacists, clinical psychologists, radiation therapists

12 Current medical workforce Registered (HKMA) HA total HA (Cons/AC) University (FTE) Clinical Oncology (1.5) Medical Oncology (2)

13 Medical Workforce QEH, QMH, TMH, PYNEH Clinical Oncologists Only PMH Mixed, integrated PWH Both For historical reasons, clinical oncologists predominant

14 HA Profile on Medical Workforce (Oncology) 30/11/2006 Consultant 13 Senior Medical Officer / Associate Consultant 24 MO/Resident with FHKAM 27 MO/Resident without FHKAM 46 Grand total 110 HKE 14 HKW 13 KC 29 KW 12 NTE 26 NTW 16 Subtotal 110

15 HA Profile on Medical Workforce (Oncology) To tal Sex Age group 30/11/ F 37 M Median 37 Co ns ultant 47 SMO/As s o ciate Co ns ultant 42 MO/Resident with HKAM fellowship 37

16 More doctors needed Projected Demand and Supply of Oncologist S3: 8 intake / yr Number Projected Demand S2: 6 intake / yr S1: 4 intake / yr Projected Baseline - assume no intake Year

17 Modern Cancer Treatment - a changing scene Multidisciplinary Team Work A major workload for Hospital Authority, especially in acute hospitals More and more expensive More and more lines of treatment Prolonged survival and/or suffering New agents with shorter development cycles Enhanced public expectation and the impact of enhanced information

18 Radiotherapy unmet needs

19 Radiotherapy Conformal Radiotherapy IMRT, IGRT, Tomotherapy, Cyberknife Concurrent Chemo-Radiotherapy Time-Dose-Fractionation Remote afterloading brachytherapy More demanding on facility, manpower and QA

20 Current status 25 Linear Accelerator in six oncology Serves 92% of all cancer cases in Hong Kong (Hong Kong Cancer Registry figures)

21 Linear Accelerators in HA QMH 4 4 QEH 7 7 PWH 4 4 TMH 4 4 PYNEH 3 3 PMH 3 TOTAL % increase can barely compensate the rise in demand over last 7 years

22 Current problems Long waiting time Low access rate Differences among clusters (Post code lottery) Wait time

23 Waiting Time Targets National Cancer Plan 2000 (UK) From decision to treat to treatment in 31 days By 2008: GP referral to treatment < 1 mths In HK, current maximum waiting time up to 2 months. Medium WT around 20 days in most centers Only 70 to 80% can start treatment within 28 days Wait time

24 Target To target maximum wait of 28 days (from RTT) for radical RT

25 Chemotherapy

26 Chemotherapy demand increases No. No. of of Patients Patients started started on on Chemo Chemo in in HA HA Oncology Oncology Department Department No. of Patients No. of Patients EIS Data EIS Data Projection Projection Year Year *Projection by simple linear regression on 2004 to 2006 data

27 Total IP + OP Chemotherapy Prescriptions Oncology 05/06+06/ Total IP+OP Chemo Prescriptions Q Q Q Q Q Q Q Q HKE HKW KC KW NTE NTW Period CDARS Data

28 Effective Anti-cancer Drugs Chemotherapeutic agents Hormonal Therapy Molecular Targeted Drugs Improve cure rate Prolong survival Improve quality of life by reducing side effects Money is the issue

29 FDA Approved Molecular Targeting Agents I Drug Indication Date of FDA approval EU approval Imatinib (Glivec) (SFI SN) Ckit +ve Gastrointestinal stromal tumour Advanced CML First line treatment of CML Feb 2002 May 2001 Dec 2002 Yes Trastuzumab (Herceptin) (SFI SN) 2 nd line monotherapy and 1 st line in combination with Paclitaxel in HER 2 overexpressed metastatic breast cancer Sept 1998 Yes Rituximab (Mabthera) Refractory CD 20 +ve B cell lymphoma 1 st line treatment of CD 20 +ve diffuse large cell lymphoma in combination with CHOP or other anthracycline based chemotherapy Nov 1997 Feb 2006 Yes SFI SN: Self Financed Item with safety net

30 FDA Approved Molecular Targeting Agents II Drug Indication Date of FDA approval EU approval Erlotinib (Tarceva) 2 nd line monotherapy in locally advanced or metastatic non-small cell lung cancer Nov 2004 Yes Sunitinib (Sutent) Glivec resistant gastrointestinal stromal tumour 2 nd line monotherapy for advanced renal cell carcinoma failing cytokine therapy Jan 2006 Jan 2006 Yes Cetuximab (Erbitux) 2 nd line monotherapy or combination with Irinotecan in metastatic colorectal carcinoma Feb 2004 Yes Bevacizumab (Avastin) 1 st line treatment in combination with chemotherapy in metastatic colo-rectal carcinoma Feb 2004 Yes Bortezomib (Valcade) Single agent therapy for relapse multiple myeloma after two prior drug treatment May 2003 Yes

31 HA drug Formulary

32 Ambulatory Chemotherapy Centre Hardware OP Clinics, reclining chairs, beds for infusion and minor procedures, reception, information corner, pharmacy for reconstitution, information and IT support, optional POC laboratory Software Dedicated pharmacists for handling chemotherapeutic agents Specialist nurses in chemotherapy delivery Multidisciplinary oncology team Psychosocial and volunteer support Firmware Workflow, clinical protocols, dedication and teamwork, top management support

33 Current Status 6 Ambulatory chemotherapy centres under the major oncology units PMH, PWH, PYNEH, QEH, QMH, TMH Scattered chemotherapy services as OP or day patients in some departments and hospitals Some hospitals 100% centralised, but up to 20-30% in some centres Bedside and clinic reconstitution not supervised by pharmacists is still being practiced in isolated location

34 Aseptic reconstitution of drugs Serious OSH and environmental concern for reconstitution of biologically toxic agents outside controlled area Risk management issue related to correct dosing, aseptic requirement, handling and transportation Conformance to GMP standard to ensure quality Cost consideration Wastage of expensive drugs (pooling for $ saving) Maintenance of multiple expensive isolators

35 Role of the pharmacists (Active) Member of a team and partner in delivery of the care process Facilitate communication and compliance Patient s advocate Psychosocial support and relieve of anxiety to treatment and disease Quality assurance and risk management Pill counting and syringe filling

36 The care process Decide on treatment Oncologists/patient Prescription Oncologists Check and verify Nurses Preparation and Pharmacists dispensing Pre-administration check Oncologists/Nurses Administration Oncologists/Nurses Monitoring and assessment Oncologists/Nurses

37 The care process Decide on treatment Prescription Check and verify Preparation and dispensing Pre-administration check Administration Oncologists/patient/Pharmacists Oncologists Nurses/Pharmacists Pharmacists Nurses/Pharmacists Oncologists/Nurses Monitoring and assessment Oncologists/Nurses/Pharmacists

38 Chemotherapy administration by Specialty Nurses Specially trained nurse consultant The oncology/chemotherapy nurse is an expert practitioner and resource person for patients and their families. Oncology nurses need expertise in the administration of cytotoxic chemotherapy, the management of symptoms and side effects of treatments, the management of symptoms of advanced cancer, and the provision of counselling and psychological support Local Training & Accreditation System Need to be developed

39 Nursing manpower PMH PWH PYNEH QEH QMH TMH No. of nurse with overseas chemotherapy training (With practicum) No. of nurse with certificate overseas chemotherapy training (Without practicum) Local well-structured in-service training No. of attendance / year (last 4 Q) No. of nurse in Chemo Centre

40 Protocols and guidelines

41 Patient information

42

43 Regimens

44 Charts

45 Electronic chemotherapy record Reliance of paper record Potential risk in protocol compliance, transcription, communication and documentation Need to develop electronic chemotherapy module with built-in decision support

46 Recommendations HA should take the lead and work with local and overseas training centres to develop our own training program for chemotherapy preparation and administration local professional standard manpower indicator The ultimate target is to set up centralised chemotherapy services manned by qualified nurses and supported by pharmacists to deliver the chemotherapy. The dilution and compounding of chemotherapy should be taken up by central pharmacist support.

47 Future One-stop patient-centred care in ambulatory setting Concentration of expertise in multidisciplinary setting Oncologists Specialist Nurses Pharmacists Other supports including psychosocial Efficiency gain and saving of resources Standardised clinical protocols for quality assurance as well as facilitating costing of expensive services Enhanced occupational and environmental safety related to reconstitution of drugs

48 Thank you