South West Strategic Clinical Network Somerset, Wiltshire, Avon and Gloucestershire (SWAG) Cancer Services

Transcription

1 Meeting of the SWAG Network Skin Cancer Site Specific Group (SSG) 17 th May 2016, Jurys Inn, Gloucester Road, Cheltenham, GL51 0TS, 09:30-13:00 This meeting was sponsored by DERMAL, PROSTRAKAN and BRISTOL MYERS SQUIBB by purchase of stand space Chair: Dr Amrit Darvay Notes (To be agreed at the next SSG Meeting) Actions 1. Welcome and apologies Please see the separate list of attendees and apologies uploaded on to the South West Strategic Clinical Network website here. 2. Review of previous notes and actions As there were no amendments or comments following distribution of the minutes from the meeting on the 24 th September 2015, the notes were accepted. All notes, meeting documents and other key documents for the Skin SSG can be accessed via the SWSCN website. Medical illustration: It is hoped that the Gloucestershire team will be able to review images within MDT meetings once the Trust has installed a new hospital information system called TrakCare. The lack of a medical illustration service at Royal United Hospitals Bath remains unresolved, despite being on the Trust s 2015/16 Work Programme and Risk Register. The risk of non-compliance with the NICE guidance is to be escalated again to the Trusts Cancer Manager. HD Taunton and Somerset Trust do not have a medical illustration service but have their own camera, and permission to take and store images. It is hoped that a service can be developed to ensure local and specialist MDTs can share images across the region. The quality of images taken in the Bristol Royal Infirmary was excellent due to the medical illustration team being available in clinic. Clinical Guidelines: Review of the squamous cell carcinoma guidelines for follow up of scalp lesions was requested. This will be addressed when the British Association of Dermatologists (BAD) guidance has been updated. Page 1 of 8

2 Photodynamic Therapy (PDT) service: Pawel Bogucki (PB) will be asked to give an update at the next SSG meeting on the establishment of a PDT service in UH Bristol. Primary care: There is disparity between Gloucestershire and Bristol services; a community based low risk BCC skin cancer service has yet to be developed in the Bristol area. It is hoped to explore this as a possibility, with advice from the Gloucestershire team, in the near future. PB Chairmanship: As there had been no responses to the recent request for expressions of interest in the role of SSG Chair, AD has agreed to continue as Chair for It is hoped that it may be of interest to an SSG member who could volunteer for the position in the near future. 3. Service development 3.1 Agenda of the next Skin Cancer Education Day The next Skin Cancer Education and Business meeting will be held at the Holiday Inn, Filton, on Thursday 22 nd September The invitation will be extended to the Peninsula and Swindon teams. The agenda will include the following: Melanoma update Chris Herbert Radiotherapy in non-melanoma skin cancer Amar Challapalli Patients living well education CNS team Rare skin tumours Pawel Bogucki Network Audit David de Berker Case discussions and presentations Amrit Darvay. 3.2 Proposed Skin Cancer NICE quality standards 2016 The following quality standards are high-priority areas for quality improvement. They contain concise measureable statements drawn from the existing NICE guidance: Local authorities and CCG to commission health promotion activities on prevention of skin cancer and recognition of early signs Low risk BCCs are only to be removed by clinicians linked to local skin cancer MDTs Suspected SCC and melanoma are to be referred via a cancer pathway Pigmented lesions are to be assessed with dermoscopy All patients with SCC and melanoma are to have a named CNS Melanoma patients with Stage 1B-IIC with a Breslow of >1mm receive verbal and written information on the advantages and disadvantages of Page 2 of 8

3 Sentinel Lymph Node Biopsy (SLNB) as a staging procedure Patients having a lymph node dissection are operated on by a surgeon who is a core member of the SSMDT, and who performs at least 15 dissections a year Patients with melanoma are offered molecular testing if targeted systemic therapy is a treatment option. A patient information leaflet on the advantages and disadvantages of SLNB has been produced by the CNS team at NBT. This includes information on percentage mortality rates to ensure that the patient has understood the potential risks and benefits. It is not given to the patient in isolation, but after talking through it with their surgeon and CNS. It contains a link to a video of what to expect and an introductory chat about clinical trials. The leaflet will be shared with Glos CNS, Louise Pound. NBT CNSs It was noted that the mortality rate for ulcerated melanoma was considerably higher than for non-ulcerated lesions, but the guidance currently groups their outcomes together. 3.3 Mohs Micrographic Surgery Please see the presentation uploaded on to the SWSCN website Presented by Adam Bray (AB) The Bristol Mohs micrographic surgery service commenced in February There is approximately a three month waiting list for referrals, with the exception of eyelids, which can generally be seen within a shorter time period. Until recently, the service was run solely by AB, but now Pawel Bogucki (PB) is in post. The service, which is based in Southmead Hospital, has excellent links with the maxillafacial and plastic teams. All clinical SSG members are welcome to visit for their professional development. Referrals should be sent via to: NBT.outpatientbookings@nhs.net and need to be addressed to AB and state in the subject line Referral for Moh s surgery, Dermatology Department. Most referrals are received from Bristol, but referrals have also been received from RUH Bath, Great Western Hospital and Gloucestershire Hospitals. 110 cases have been treated so far. The outcomes of the first 81 cases have been analysed, 91% of which have been reconstructed by dermatology, with the rest being combined cases with plastics and oculoplastic surgery. The criteria for referral is for skin cancer tumours that you cannot confidently excise within the recommended margins and optimally repair. Further details are available on the SWSCN website. Page 3 of 8

4 3.4 Genomic Medicine Centre proposal Please see the presentation uploaded on to the SWSCN website Presented by Catherine Carpenter-Clawson The West of England Genomic Medicine Centre, hosted by UH Bristol, with support from Gloucestershire, North Bristol, Weston and RUH Bath, came to fruition in February The service will be rolled out in stages, starting with breast cancer patients in North Bristol Trust. A breast cancer pathway has been designed and validated. A dry and wet practice run of the actual pathway processes needs to be signed off by NHS England before recruitment can commence. Eligible patients, with an excisable tumour that is treatment naïve and of sufficient size, will be identified within MDT meetings. The consent process is complex; when to approach people needs to be established. The workload will be undertaken by existing research teams who will receive additional funding. The process needs to be built into standard practice. The other cancer sites currently on the list are ovarian, colorectal, lung, sarcoma and prostate, and it is hoped to expand to other sites, including skin cancer. A cold tissue sample of a certain size needs to be sent to the laboratory at North Bristol Trust within 6 hours to ensure that quality DNA can be extracted. In the event that a small sample is taken that is difficult to analyse, the diagnostic biopsy will always be prioritised over the GMC sample. The time frame for feedback of results is currently months, but it is planned that the process should provide results in time to influence clinical decision making. Patients can consent for certain findings which are routinely looked for, and can be acted upon, to be reported back to them and their GP. For example, familial hypercholesterolemia. A website for the service has just been published: This contains links to information for staff, patients and relatives regarding eligibility criteria for potential participants. A free two hour online training package, which is CPD accredited, is available to all staff. There is also funding available for interested staff members to pursue a Masters in Genomic Medicine. Page 4 of 8

5 3.5 Update on Electro-Chemotherapy (ECT) in Bristol Please see the presentation uploaded on to the SWSCN website Presented by Antonio Orlando (AO) ECT is a NICE approved treatment delivered under general anaesthetic for metastatic nodule deposits. The bleomycin is given intravenously during the procedure. It has been found that this increases in-vitro cytotoxicity by 1000 fold. Different shaped needles that can be adjusted to the length appropriate for the tumour site fit onto the electrodes. The treatment can be used on any neoplastic lesion within the skin or subcutaneous tissue. It can be used as an adjunct to normal treatment options or as an additional option for patients unresponsive or unfit for normal treatment regimes. Standard operating procedures for ECT are available from the European Journal for Cancer (EJC). It is important that anaesthetists read these. AO is currently the only person in NBT consented to prescribe and administer the bleomycin for use with ECT. Referrals to the SSMDT have been received from across the region. Each patient has a consultation with a plastic surgeon, and a lung function test at pre-op assessment, before every treatment. When under anaesthetic, the patient is maintained on the lowest oxygen saturation level possible to prevent the potential side effect of pulmonary fibrosis. Gabapentin is given prior to the procedure, which was noted to be very painful. The pulses are administered in a minute interval. Patients are followed up after 6 weeks. It is possible to repeat the treatment after 8-12 weeks. Necrosis of tumour, plus inflammatory and necrosis of surrounding tissues have been reported in the patients treated, with the normal tissue healing relatively quickly. Pigmentation that results from treatment can show if the recurrence in within or outside the treatment area. The service is not commissioned at present. Currently the Cliniporator is on loan from the pharmaceutical company, at no expense. The electrodes cost each making the treatment less expensive than other oncological treatments. A referral information sheet will be produced for the regional MDTs. AO Page 5 of 8

6 4. Research 4.1 Clinical trials update Please see the presentation uploaded on to the SWSCN website Presented by Maxine Taylor (MT) The West of England Clinical Research Network (CRN) provides the resources for research across the region, is aligned with the Academic Health Science Networks. This does not exactly match with the SWAG region, as the West of England Network consists of Gloucester, Swindon, Bristol, Bath and Weston; Taunton and Yeovil are in South West Peninsula CRN. However, the Cancer Research Delivery Managers in both regions will provide the data for all Trusts. It is MTs role to provide local oversite of the cancer portfolio and performance and link with all networks and national teams. Dr Christopher Herbert (CH) is the Research Lead for the Skin SSG, representing the group at national annual meetings and engaging with local clinicians to forge a network wide approach to the portfolio and recruitment. Richard Mundy (RM) is the Cancer Portfolio Facilitator who has access to collate local and national data when required. Cancer Speciality Specific Objectives: Recruitment overall at 20% of cancer incidences Recruitment to interventional studies at 7.5% of cancer incidence Recruiting local portfolio to include: Surgical trials (4 recruits per 100,000 pop) Rare cancers (12 recruits per 100,000 pop) Children and young people (3 recruits per 100,000 pop) Radiotherapy (6 recruits per 100,000 pop). The list of open and recruiting studies, and studies in set-up, are documented within the presentation. The national data only includes studies that have recruited in the last 12 months. Ewan Wilson (EW) is developing a surgical study that is not on the list at present. Development of the portfolio has been complicated due to competing with centres such as Oxford and Birmingham for bids to be a South West recruitment centre for melanoma studies. There is a need to demonstrate that the region can deliver successful recruitment to such studies by cross referral, inviting all Trusts to open as patient identification centres. Patients need to be identified within the MDT meetings, and a regular update on relevant trials that give a simple overview of eligibility criteria needs to be circulated. Proactive collaboration between research nurses in each centre is to be encouraged. CH and MT will work together to achieve this. There is now an interactive website where eligibility criteria can be easily accessed: CH / MT Page 6 of 8

7 5. Teledermatology UH Bristol and NBT are currently discussing with Bristol, North Somerset and South Gloucestershire CCG, the possible use of Teledermatology in skin cancer triage. 6. Coordination of patient pathways 6.1 The South West two week wait referral form, version 9.2 The information on the form needs to be in the same format as the NICE guidelines, and the level of concern section should be removed. This will be amended by HD and circulated to the MDT leads for further feedback. 7. Quality indicators, audits and data collection 7.1 Annual audit update The regional data requested by the British Association of Dermatologists on excisions of non-melanoma skin cancer is also to be sent to David de Berker prior to the end of June, to inform the network audit for Results will be presented in the November 2016 meeting. 8. Patient experience 8.1 Regional Patient Experience Survey Presented by Elizabeth Metcalf A patient experience survey has been developed by the RUH CNS team to obtain feedback on any potential improvements required and on the maintenance of positive service provision. This was adapted from a previous survey that had be developed by the former ASWCS network. Take up of this survey had been very poor due to having to complete 47 questions. This has now been pared down to 16 questions, has a far better take up rate, can capture the many patients that are excluded from the National Cancer Patient Experience Survey, and collects information that the CNS teams can influence. This has also been adopted by UH Bristol and could potentially be used on a regional basis to share results and inform best practice. North Bristol Trust currently sends out questionnaires via post due to difficulties arising when completed in clinic, and would be happy to post the proposed regional survey. This will be circulated by HD. 8.2 Tattoo artist education sessions Presented by Joanne Watson The NBT team ran an education day for tattoo artists on the signs of potential skin cancer last month, inspired by Ogilvy Brazil: Page 7 of 8

8 It was initially difficult to attract attendees, until it was advertised on Twitter and Facebook, boosting numbers from 3 to around 30 in a matter of days. The event was then publicised in the local and national news. Beauticians will be invited to the next session. The importance of providing education to nurses throughout the hospitals was emphasised. 9. Any other business Antonio Orlando has been appointed as Chair of the Skin Cancer Research Fund (SCARF) and plans to expand the educational initiative. SSG members are to inform any trainees that might be interested. There is a website and research funding available. A Skin Lymphoma workshop will be held on Wednesday 28 th September 2016 in the Castle Hotel, Taunton. The flyer will be circulated by HD. Anita Takwale has stepped down as Lead Clinician for Cancer in Gloucestershire Hospitals, and will be replaced by William Porter. Date of next meeting: Thursday 22 nd September END- Page 8 of 8