HPB Cancer Pathway Board Annual Report 2015/16

Transcription

1 HPB Cancer Pathway Board Annual Report 2015/16 Pathway Clinical Director: Mr. Derek O Reilly Pathway Manager: Rebecca Price Version 1.0 1

2 Executive summary: HPB Pathway Board 1. The Hepato-Pancreato-Biliary (HPB) Pathway Board has active representation for all ten trusts in Greater Manchester and Cheshire that comprise Manchester Cancer. There is also patient and primary care representation. 2. From October 6, 2014, a single IOG compliant HPB Service has been located at the Manchester Royal Infirmary, Central Manchester NHS Foundation Trust (CMFT). This is now a well-established and successful unit. 3. The HPB Board have embraced the principle of wider engagement and educational meetings. HPB Pathway Board meetings take place at two monthly intervals at each of the ten participating Trusts, with the additional feature of an educational event for the benefit of the local MDT. 4. We held our main educational event Manchester Pancreatic Cancer Symposium 2016 in Manchester Town Hall on 14 th April We have delivered on our annual plan of 2015; making significant progress on implementing a regional jaundice pathway; establishing a prehabilitation programme; addressing patient experience; succeeding in recruiting to clinical trials and delivering a wide range of educational events throughout the region. 6. Research and Innovation is strength of the HPB Pathway board with a strong track record of leadership in academic activities: we are the lead recruiter for NIHR portfolio studies for HPB cancers. 7. We have successfully implemented the regional Jaundice Pathway through the Acceleration, Coordination and Evaluation (ACE) program. This provides one-stop jaundice clinics and fast-track surgery. We urgently need to establish a source of ongoing funding 8. We have successfully established a prehabilitation programme for patients about to undergo HPB cancer surgery. This optimises patients for surgery through physical, nutritional and psychological support. 9. A comprehensive set of clinical guidelines and chemotherapy algorithms for HPB has been created. 2

3 1. Introduction the Pathway Board and its vision This is the annual report of the Manchester Cancer HPB Pathway Board for 2015/16. This annual report is designed to: Provide a summary of the work programme, outcomes and progress of the Board alongside the minutes of its meetings, its action plan and it scorecard it is the key document for the Board. Provide an overview to the hospital trust CEOs and other interested parties about the current situation across Manchester Cancer in this particular cancer area Meet the requirements of the National Cancer Peer Review Programme Be openly published on the external facing website. This annual report outlines how the Pathway Board has contributed in 2015/16 to the achievement of Manchester Cancer s four overarching objectives: Improving outcomes, with a focus on survival Improving patient experience Increasing research and clinical innovation Delivering compliant and high quality services 1.1. Vision Our key aims and vision are: Better Patient Outcomes Better Patient Experience Research and Innovation 1.2. Membership Table1.1 The membership of the Pathway Board and the trusts/specialties of all individuals. Name Role Organisation Rep or Deputy Mr Derek CMFT/Manchester HPB Pathway Clinical Director O Reilly Cancer Rebecca Price Pathway manager Manchester Cancer Dr Mahesh Consultant Bhalme Gastroenterologist/Hepatologist Bolton Rep Amanda Corfield- Clinical Nurse Specialist Halliwell Bolton Deputy Professor Juan Consultant Medical Oncologist/Pathway Valle Board Research Lead Christie Rep Dr Mairead MacNamara Consultant in Medical Oncology Christie Deputy Professor Ajith Consultant Hepato-Pancreato-Biliary CMFT Rep 3

4 Name Role Organisation Rep or Deputy Siriwardena Surgeon Mr Saurabh Consultant Hepato-Pancreato-Biliary Jamdar Surgeon CMFT Deputy Dr Konrad Koss Consultant Gastroenterologist East Cheshire Rep Dr Adrian Tang Consultant Radiologist East Cheshire Deputy Dr Emma Donaldson Consultant Gastroenterologist SRFT Rep Luke Williams Consultant Radiologist SRFT Deputy Lucie Francis User Involvement Manager Manchester Cancer Mr Steven Sawyer Patient representative Rep Dr Mong-Yang Loh Consultant Radiologist Stockport Rep Stephanie HPB Cancer Nurse Specialist Gooder Stockport Deputy Dr Harry Kaltsidis Consultant Gastroenterologist UHSM Rep Dr Guvinder Banait Consultant Gastroenterologist WWL Rep Vicki Stevenson- Hornby Clinical Nurse Specialist WWL Deputy Dr Rafik Filobbos Consultant Radiologist/Radiology Lead PAT/CMFT Dr Vinod Patel Consultant Hepatologist Tameside Rep Melanie Dakha- Taeidy Clinical Nurse Specialist Tameside Deputy Dr Rebecca Leon GP Representative - Rep Dr Jo Puleston Consultant Gastroenterologist/ co-opted member CMFT - Dr Sajjad Mahmood Consultant Gastroenterologist PAT Rep Debbie Clark Clinical Nurse Specialist CMFT Deputy Aileen Aherne Regional Jaundice CNS CMFT Gary Morris Prehabilitation Physiotherapist CMFT AHP rep Neil Bibby Prehabilitation Dietitian CMFT AHP rep Table 1.2 Individuals who have been appointed as lead for research, education, early diagnosis, living with and beyond cancer, palliative care, etc. Early diagnosis Pathology Surgery Vicki Stevenson-Hornby TBC Prof. Ajith Siriwardena 4

5 Radiology Oncology Specialist nursing Patient Mentor Living with and beyond cancer ( survivorship ) Research Data collection (clinical outcomes/experience and research input) Palliative Care Education Dr. Rafik Filobbos Prof. Juan Valle Sr. Debbie Clark Melanie Dakha-Taeidy TBC Prof Juan Valle Mr Derek O Reilly Sr. Sharan Ingram TBC 1.3. Meetings Table 1.3 A list of the meetings that have taken place this year and the frequency of future meetings. A link to the minutes of meetings on the Manchester Cancer website is included. Pathway Board meetings and papers Date Meeting Venue 6th May 2015 HPB Pathway Board Macclesfield General Hospital Meeting 4th September 2015 HPB Pathway Board Bolton Royal Hospital Meeting 18th November 2015 HPB Pathway Board Tameside Hospital Meeting 22nd January 2016 HPB Pathway Boards The Christie Meeting 24th March 2016 HPB Pathway Boards Central Manchester Foundation Trust Meeting 14 April 2016 The Manchester Pancreatic Cancer Symposium Town Hall, Manchester 19th May 2016 HPB Pathway Boards Meeting Pennine Acute Trust Future Pathway Board meetings: 23rd September 2016, Central Manchester Foundation Trust 18th November 2016 The Christie 5

6 1-2 December 2016 The Pancreatic Society of Gt.Britain and Ireland Annual meeting, Hilton Hotel, Manchester 24th Jan 2017, : Wigan Infirmary The record of the attendance at each meeting to-date is in Appendix 1. The HPB Board have embraced the principle of wider engagement and educational meetings. HPB Pathway Board meetings take place at two monthly intervals at each of the ten participating Trusts, with the additional feature of a wider meeting/educational event for the benefit of the local MDT. Table 1.4 Educational events organised by the HPB Pathway Board. Date Venue Speakers & Lecture 06 th May 2015 Macclesfield 1. HPB Services and Strategy in the Manchester Cancer Region Mr. Derek O Reilly, 2. Improving Outcomes in Pancreatic Cancer Prof. Juan Valle, Professor of Medical Oncology, Christie Hospital Lecture theatre, Werneth House, Tameside Hospital The Nowgen Centre, 29 Grafton Street, Manchester 14 April 2016 Town Hall, Manchester 1. HPB Services and Strategy in the Manchester Cancer Region Mr. Derek O Reilly, HPB Pathway Clinical Director, Manchester Cancer 2. An Insight into HCC: Past, Present & Future Dr Vinod Patel, Consultant Gastroenterologist, Tameside Hospital A CMFT HPB Unit and Manchester Cancer Research Event Guest Speaker: Andrew G Renehan PhD FRCS Professor of Cancer Studies and Surgery Manchester Academic Health Science Centre Obesity & HPB Cancers See appendix 2 The Manchester Pancreatic Cancer Symposium 2016 see appendix 3 6

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8 2. Summary of delivery against 2014/15 plan No Objective Alignment with Provider Board objectives 1 Implement a regional jaundice pathway 2 To implement a Prehabilitation Programme: Nutritional Exercise and Psychological Assessment & Support. 1. Improving outcomes, with a focus on survival 2. Improving patient experience 3. Increasing research and innovative practice 4. Delivering high quality, compliant, coordinated and equitable services 1. Improving outcomes, with a focus on survival 2. Improving patient experience 3. Increasing research and innovative practice 4. Delivering high quality, compliant, coordinated and equitable services Tasks By Status Green = achieved Amber = partially achieved Red = not achieved Recruitment of Jaundice CNS August 2015 Recruitment of data collector August Establish on-going funding commitments from local commissioners Establishment of fast track pancreatic surgery at CMFT Establishment of further one-stop diagnostic sites Data analysis and completion of initial report To establish funding for additional personnel (Physio, dietician) To establish a Prehabilitation programme at CMFT To ensure elements of the program continue into LW&BC phase Initial data collection and analysis in annual report 2015 Feb 2016 Mar 2016 Mar 2016 July 2016 Nov 2015 Feb 2016 July 2016 July To conduct a regional EUS audit 1. Improving To send EUS document and August 8

9 4 To improve Patient representation on the pathway board and patient experience 5 To maintain a high level of engagement in all ten trusts, including the provision of educational events. outcomes, with a focus on survival 2. Improving patient experience 3. Increasing research and innovative practice 4. Delivering high quality, compliant, coordinated and equitable services 2. Improving patient experience 4. Delivering high quality, compliant, coordinated and equitable services 1. Improving outcomes, with a focus on survival 2. Improving patient experience 3. Increasing research and innovative practice 4. Delivering high quality, compliant, covering letter to all Trust Medical Directors To send Organisational 2015 August 2015 questionnaire to all Trusts Data analysis Jan 2016 Report & paper written June 2016 Report Launch June 2016 Macmillan User Involvement team to present at HPB Pathway Board Presentation of National CPES data at HPB Pathway Board meeting Manchester Cancer badged Patient information leaflets Provision of training and mentorship to patient representative Educational Event, Bolton Educational Event, Tameside HPB Research Prize event GP Educational Event Manchester Pancreas Cancer Symposium 2106 Sept 2015 Jan 2016 Jan 2016 Mar

10 coordinated and equitable services 10

11 3. Improving outcomes, with a focus on survival 3.1. Information Pancreatic cancer (PC) is the deadliest of cancers; it has been described as the greatest oncological challenge. It has the worst 5 year survival of any cancer in Europe (Fig 3.1). Other primary HPB malignancies, such as gallbladder or liver cancer, also have exceptionally poor survival outcomes and are located close to pancreatic cancer to the right of the graph in Fig 3.1 Fig 3.1 Pancreatic Cancer Europe: 5-year survival. De Angelis et al; Lancet Oncol 2014; 15: PC is a common malignancy, with around 280,000 new cases being diagnosed worldwide in 2008, and 70,000 cases seen in the European Union alone. Although PC is the twelfth most common cancer worldwide, its low survival rate means that it is currently the fourth leading cause of cancer-related death in Western countries. This disease is an unfortunate exception to the general trend of improvement in cancer-related mortality. Indeed, one estimate suggests that pancreatic cancer will become the second leading cause of cancer-related death in within the next decade. With estimated deaths in 2012, the neoplasm presently ranks in fourth place ahead in terms of total deaths from prostate cancer ( deaths). It has been demonstrated that the annual number of pancreatic cancer deaths will likely surpass those of breast cancer as early as the year 2017 (Fig 3.2). 11

12 Figure 3.2. Recorded ( ) and projected (up to 2025) number of breast and pancreatic cancer deaths (both males and females) in the EU. J. Ferlay, C. Partensky & F. Bray (2016): More deaths from pancreatic cancer than breast cancer in the EU by 2017, Acta Oncologica, DOI: / X The 5-year overall survival rate (OS) for PC remains less than 4% in the UK, with a median survival time of 3 to 6 months for metastatic disease (Fig 3.3). Approximately 20% of patients present with potentially curable surgically resectable pancreatic cancers. However, even after multimodality therapy that includes surgical resection, 5-year OS rates only reach 25% to 30% at best. 12

13 Fig 3.3 Pancreatic Cancer (C25): Age-Standardised Five-Year Net Survival, England and Wales. Prepared by Cancer Research UK There has been little progress in improving outcomes in PC over the past 30 years. One reason is the lack of survivors to lobby for funding. The lack of funding is a particular problem because research is needed to develop new approaches to earlier diagnosis and treatment. But this is also a result of delays to diagnosis and treatment, caused by lack of coordination of the patient pathway. National data on clinical outcomes is hampered by collection and presentation of results for HPB under the umbrella term Upper Gastrointestinal Cancer. This also includes oesophago-gastric cancer, an entirely different tumour group. Nonetheless, according to data from the National Cancer Intelligence Network (NCIN) data, age-standardised incidence, emergency presentation and mortality for upper GI cancers in the Greater Manchester Area exceed the national average. Prevention and survival are correspondingly lower. For further detail, see HPB Pathway board Annual Report Progress The Manchester Cancer HPB Pathway board is committed to measuring and monitoring what is important to both them and their patients. Previously, many cancer-related measures were related to service targets we wish to change this emphasis. We are also committed to openly publishing data to illustrate to the Manchester Cancer Provider Board and other stakeholders that we are making a difference. Data will be made publicly available via the website: 13

14 The HPB Pathway Board has agreed a small number of meaningful measures that it will monitor closely. This set of measures will cover the whole cancer pathway, including where appropriate, measures for early diagnosis, patient experience and survivorship as well as the treatment phase of the pathway. Core measures include: Percentage of cancers diagnosed by stage Percentage of cancers diagnosed as emergencies Resection rates Operative morbidity and mortality Cancer survival (at 1, 3 and 5 years) measures of patient satisfaction the research involvement of patients CMFT HPB SMDT WORKLOAD The HPB MDT takes place each Wednesday morning at 8am. The cut off point for referring any patient to the MDT is 1pm on a Monday; this is to allow for sufficient time for clinicians / MDT co-ordinators to review the imaging or pathology and to prepare the agenda. A web-based electronic referral proforma (ERP) has been developed and is accessible from each referring Trust at: All new HPB cancer patients are reviewed by the HPB smdt for discussion of initial treatment plan. Urgent cases can also be discussed outside of the MDT meeting, through the on-call HPB surgeon. The local referral/diagnostic teams are the local Upper GI and Colorectal Multidisciplinary teams at: Bolton NHS Foundation Trust Central Manchester University Hospitals NHS Foundation Trust East Cheshire NHS Trust Pennine Acute NHS Trust Salford Royal NHS Foundation Trust Stockport NHS Foundation Trust Tameside Hospital NHS Foundation Trust The Christie NHS Foundation Trust University Hospital of South Manchester NHS Foundation Trust; Wrightington, Wigan and Leigh NHS Foundation Trust Urgent cases can be discussed outside of the formal MDT, however in this case the following protocol is to be followed: 14

15 Telephone discussion between the relevant treating consultant or their deputy and another SMDT surgeon/clinical oncologist/medical oncologist. This discussion to include all available radiology and pathology evidence. Formal written letter to follow telephone discussion as a permanent record. The case will be discussed at the next scheduled SMDT meeting. Moreover, GP s and hospital consultants can refer patients directly to the One-Stop Jaundice clinic (Monday 9-12pm Main Out-patients MRI), using the 2ww form, or by contacting the Jaundice CNS directly on Table 3.1 CMFT HPB SMDT WORKLOAD MDT Workload Total patients discussed at HPB MDT 2298 Total patients diagnosed with an HPB malignant neoplasm Liver (C22) Gallbladder (C23) 47 - Other Biliary Tract (C24) Pancreas (C25) Other Digestive Organs (C26) 5 - Secondary Neoplasms (C78, C79) 108 Total patients with a benign diagnosis 12 Total patients with an "in-situ" diagnosis 0 Total patients with neoplasms of uncertain/unknown behaviour 4 There were an additional 1335 patients that had no diagnosis and 118 patients that had diagnosis different to those listed above Survival data from the NMGH and CMFT units prior to the merger on 6 October 2014 can be found in the HPB Annual Report for Since then, ongoing data collection of survival outcomes post resectional surgery is taking place and will be presented when more mature data is available Challenges The key challenge identified by the HPB Pathway Board is to obtain sufficient resources to implement clinical improvements that lead to better outcomes. The resources necessary include: additional personnel for better coordination of patient care, accurate data collection to measure progress. 15

16 4. Improving patient experience 4.1. Information Sr. Debbie Clark presented the data from the National Cancer Patient survey for HPB, prepared September 2015 (from the CMFT 2015 Bespoke Cancer Patient Experience Survey) at the meeting of the HPB Pathway Board on 18 th November The key findings that arose from the survey were: 81% of patients thought they were seen as soon as necessary Overall improvement with written and verbal communication / explanation for patients undergoing diagnostic test 59% (93% 2014) of patients told they could bring a friend when first told they had cancer (75% national average) 81% of patients completely understood the explanation of what was wrong (73% national average) 95% of patients felt they received understandable answers to important questions all / most of the time from their CNS (average 91%) 90% of patients felt their CNS listened carefully the last time spoke to (comparable with national average) 63% (57% 2014) felt more involvement in decisions about care and treatment (72% national average) 81% of patients saw cancer research (71% 2014) information in the hospital (national average 86%) Overall improvement with ward nurses care / communication although remains lower than national average Overall improvement with information provided prior to discharge 72% (67% 2014) of patients given clear written information about what should / should not do post discharge (85% national average) 73% (50% 2014) of patients felt day care / outpatient staff did everything they could to help control pain (comparable to national average 73%) Overall improvement with care from GP / practice staff 77% of patients given the name of their CNS (89% national average) 62% of patients received information about support groups ( 83% national average) 50% of patients received information about the impact of cancer on work life or education (75% national average) 26% of patients received information on getting financial help (national average 54%) 29% of patients told they could get free prescriptions (national average 91%) Taking part in research discussed with 30% of patients (average 31%) 46% of patients asked what name they preferred to be called by (national average 60%) 67% patients got understandable explanation of how operation had gone (national average 78%) 36% (50% 2014) patient s family definitely had the opportunity to talk to a doctor (67% national average) 16

17 56% of patients felt day care / outpatient staff gave enough emotional support (national average 70%) 11% of patients offered written assessment and care plan (national average 22%) 83% (86% 2014) of patients rated their care excellent / very good (national average 89%) 4.2. Progress The Pathway Board has discussed the poor return to the national survey and the limited coverage of HPB patients. A range of solutions were discussed and it was agreed that a shorter web based questionnaire for all patients with HPB cancers would be developed This can be accessed at: Challenges The HPB Pathway Board has identified that there is an unequal provision of HPB Clinical Nurse Specialists (CNS) across the region. This has been escalated to the Manchester Cancer Medical Director for discussion at Provider and Cancer Lead Boards. 17

18 5. Increasing research and innovative practice 5.1 Research Report The HPB Board regularly receives research reports and discusses these at Pathway board meetings. The research lead is Prof. Juan Valle, Professor & Honorary Consultant in Medical Oncology, University of Manchester. Greater Manchester is the lead recruiting LCRN for HPB. The Hepato-pancreato-biliary Portfolio trials report is displayed in Table 5.1 of this annual report. Table 5.2 outlines Greater Manchester activity by Trust. Data source: NIHR Portfolio - Open Data Platform Table 5.1 National (England) analysis by LCRN. Recruitment activity window to Data source: NIHR portfolio Open data platform 18

19 Table 5.2 Local (Greater Manchester) analysis by Trust. Recruitment activity window to Data source: NIHR portfolio Open data platform Publications Peer reviewed publications by HPB smdt & Pathway Board members are attached in Appendix The Manchester Cancer Jaundice Pathway The Manchester Cancer Jaundice Pathway sits within the HPB Pathway board s strategy for improving outcome in HPB cancer (Figure 5.1). Briefly, research, early diagnosis, timely referral and improved pathways, reduction in post-operative morbidity and mortality and improved oncology, have been identified as the five key areas by which this may be achieved. The MC Jaundice Pathway provides for earlier diagnosis as well as timely referral and improved pathways. 19

20 Figure 5.1. Manchester Cancer Strategy for improving outcomes in HPB cancer The MC Jaundice Pathway provides for earlier diagnosis as well as timely referral and improved pathways (Figure 5.2). The key innovations are twofold: 1. Same day definitive radiological imaging for patients presenting with obstructive jaundice not due to gallstones. The purpose is to provide for earlier diagnosis and timely referral and to improve patient experience. 2. Fast-track referral for jaundiced patients with pancreatic cancer for early surgery. The aim is to reduce overall complications and prolong survival. 20

21 Figure 5.2. The Manchester Cancer Jaundice Pathway. The Manchester Cancer Jaundice Pathway - Progress to date: We have successfully obtained funding for implementation of the Jaundice Pathway through the Acceleration, Coordination and Evaluation (ACE) program. This is co-funded by NHS England, Cancer Research UK and Macmillan Cancer Support. Application Reference: C48863/A20664 Funding Scheme: Cancer Research UK s Executive Board - ACE Programme Application Title: The Manchester Cancer Jaundice Pathway Award Review Category: Full Duration Expected Start Date: 1 February 2015 Total Duration of Agreed Support: 12 months Instalment Financial Summary: 68, Jaundice Pathways 21

22 Data from the initial site (Macclesfield General Hospital) to provide a one-stop diagnostic service for jaundiced patients was presented at the Manchester Cancer HPB Pathway Board meeting on 6 May Of 28 patients referred, 7 had a diagnosis of cancer. All had completion of investigation within 2 weeks. Similar pathways have now been established at PAT and CMFT (Figure 5.3). Fast track Surgery Number of Referrals: 26 Number proceeding to Surgery: 9 Number not having fast track surgery: 17 Table 5.3 Reasons patients did not undergo fast track surgery Stone disease 1 Bilirubin excessively elevated (>250) 3 Comorbidity preventing Fast track 3 Uncertainty of diagnosis 3 Advanced disease 5 Psychological well being 1 Failed to follow pathway 1 Patient experience of the Jaundice Pathway This is on-going using the ACE Survey Monkey tool to monitor patient experience. In addition, the CMFT Quality Team undertaking patient stories to evaluate patient experience. Some patient experiences are quoted as follows:.the waiting times and timescales for appointments and referrals and subsequent surgery had been fantastic and he could not have asked for better treatment..over the moon with the care and treatment I received.i could have paid privately but would not have got better care 22

23 Figure 5.3 The CMFT One-Stop Jaundice Clinic 23

24 5.4 The Manchester Cancer Prehabilitation Program The HPB Pathway Board successfully obtained a grant from Macmillan to commence our prehabilitation programme. This was An Integrated program of Nutritional support; Exercise and improved general well-being; and Screening for anxiety and depression, right across the four phases of: Prehabilitation, Enhanced recovery, Recovery/reablement and Living with and beyond cancer. Since , all new patients being considered for cancer resectional surgery are seen in a prehabilitation clinic at first hospital consultation, prior to commencement of planned treatment. Patients with HPB cancer who are about to undergo surgery have a comprehensive prehabilitation programme, providing: A structured exercise regimen supported by the use of the international physical activity questionnaire (IPAQ) Nutritional assessment and food diaries Management of malnutrition caused by exocrine failure in pancreatic cancer Physiotherapy advice Psychological support (including for smoking and alcohol dependency) Figure 5.3: overview of the integrated programme of exercise and wellbeing, nutritional support and screening for anxiety and depression 24

25 5.1. Challenges Research and Innovation is strength of the HPB Pathway board with a strong track record of leadership in academic activities: exceeding trial recruitment targets; high impact peerreviewed publications; and the introduction of innovative treatments. The challenges for the next year are: 1. To increase recruitment to clinical trials and observational studies 2. To obtain high impact peer reviewed publications 3. To fully implement the Jaundice Pathway in as many trusts within the region as possible 4. Above all, to obtain on-going funding for our innovative jaundice and prehabilitation programmes once the pilot study funding expires. 25

26 6. Delivering complaint and high quality services 6.1. Information Since October 6, 2014, a single IOG compliant HPB Service has been located at the Manchester Royal Infirmary, Central Manchester NHS Foundation Trust (CMFT). This is the result of the merger of the two previous HPB Units at the MRI and North Manchester General Hospital, Pennine Acute Trust. This is now a well-established and successful unit. The new merged single HPB multidisciplinary team (smdt) and the HPB Pathway Board has been designed to be meet: NICE Cancer Service Guidance Improving Outcomes of Upper GI Cancers The NHS Commissioning Board Specialised Services Specification The NHS Greater Manchester Framework Commissioning Specification The Delivery of World Class Specialist Cancer Surgery Services in the Greater Manchester and Cheshire Cancer System. NHS England National Peer Review Programme Manual for Cancer Services. Manchester Cancer is an integrated cancer system for Greater Manchester and East Cheshire. The Hepato-Pancreato-Biliary (HPB) Pathway Board includes active representation for all ten trusts in Greater Manchester and Cheshire that comprise Manchester Cancer. A full description of the HPB smdt membership and service may be found in the CMFT HPB MDT Operational Policy document Progress The Manchester Cancer Hepato-Pancreato-Biliary (HPB) Pathway Board meets regularly and has active representation from all ten trusts in Greater Manchester and Cheshire; primary care; and patient representation. The Jaundice Pathway has now been implemented, funded by the Acceleration, Coordination and Evaluation (ACE) programme. This provides for a regional jaundice clinical nurse specialist (Aileen Aherne) and a data co-ordinator (Karen Ridyard), to implement one-stop clinics and fast-track surgery (see Section 5.3). A Prehabilitation dietitian (Neil Bibby) and physiotherapist (Gary Morris) have been appointed to optimise patients fitness prior to surgery. This project has been funded by Macmillan (see Section 5.4). The HPB Quality Improvement programme, a system for recording, analysing and reducing post-operative morbidity and mortality, has become an established part of the weekly activity. Our first year data was presented as a poster at the Pancreatic Society of Great Britain & Ireland Annual Scientific meeting, Norwich, November The unit is participating in the following NIHR badged clinical trials that have opened in the past year: PANasta; ESPAC-5F. 26

27 Prof. Ajith Siriwardena was elected President of the Pancreatic Society of Great Britain & Ireland and will host their annual scientific meeting in Manchester on 1-2 December Mr Derek O Reilly was appointed as the NCEPOD Clinical Co-coordinator for surgery and as a member of the NICE Clinical Guidelines Committee for pancreatic cancer. Figure 6. New members of the HPB Pathway Board, thanks to funding obtained by the HPB Pathway board, from the ACE programme and Macmillan Cancer. From left to right: Gary Morris (Prehabilitation physiotherapist), Aileen Aherne (Regional Jaundice CNS) and Neil Bibby (Prehabilitation dietitian) Challenges The key challenge identified by the HPB Pathway Board is to obtain sufficient resources to implement clinical improvements that lead to better outcomes. The resources necessary include: additional personnel for better coordination of patient care, accurate data collection to measure progress. Despite the current financially challenging environment for the NHS, the HPB Pathway Board is well placed to benefit from increased emphasis on to improving efficiency and eliminating waste, centralisation of complex services and the development of cancer networks and alliances. Our goals for clinical and academic development all fit with the strategic objectives of Central Manchester Foundation Trust and Manchester Cancer and will enable us to take full advantage of the opportunities that this and the devolution of health services present. 27

28 7. Objectives for 2015/16 To fully implement a Regional Jaundice Pathway. To implement a Prehabilitation Programme of Nutritional, Exercise and Psychological Assessment & Support To improve patient experience To maintain a high level of engagement in all ten trusts through the provision of educational events. To maintain a high level of patient involvement in research and clinical trials For full details see the HPB Pathway Board s full 2015/16 annual plan. 28

29 Appendix 1 Pathway Board meeting attendance NAME ROLE TRUST 06/05/ /09/ /11/ /01/ /03/206 Derek O'Reilly Pathway Director Rebecca Price Pathway Manager Tom Pharaoh Amanda Corfield- Halliwell CNS Bolton Mairead Macnamara Consultant Medical Christie Oncologist A Consultant Medical Christie Juan Valle Oncologist A A Professor Ajith Siriwardena Consultant HPB Surgeon CMFT Thomas Satyadas Consultant HPB Surgeon Dr Konrad Koss Consultant Gastroenterologist A A Mrs Anna Lewis Upper GI Clinical Nurse East Cheshire Specialist Dr Ramasamy Saravanan Consultant Gastroenterologist Debbie Clark Hepato-Biliary Nurse Pennine Specialist A Dr Emma Donaldson Consultant Gastroenterologist Sr Sharan Ingram Hepato-Biliary Specialist Nurse SRFT Dr Mong-Yang Loh Consultant Radiologist Stockport A 29

30 Harry Kaltsidis Consultant Gastroenterologist Dr G Banait Consultant, Gastroenterologist WWL Vicki Stevenson-Hornby HPB Cancer Nurse Specialist Hans-Ulrich Laasch Consultant Radiologist Christie Rafik Filobbos Radiology Lead Pennine Vinod Patel Consultant Gastro-enterologist Tameside Imran Alam Consultant Surgeon WWL Adrian Tang Radiologist Macclesfield Kirsty Williams CNS Stockport Carole Mula Palliative Care Pathway Director Manchester Cancer Jo Puleston Consultant Gastroenterologist CMFT Martin Prince Consultant Gastro-enterologist CMFT Luke Williams Consultant Radiologist SRFT Melanie Dadkhah-Taeidy Macmillan HPB CNS Tameside Khalid Barakat Consultant Gastroenterologist East Cheshire Rebecca Leon GP representative Stockport A A Steve Sawyer Patient Representative N/A Aileen Aherne Jaundice CNS CMFT Lucie Francis Manchester User Involvement Manager Cancer Michelle Storey HPB Cancer Nurse Specialist WWL A A Stephanie Gooder HPB Cancer Nurse Specialist SHH Karen Ridyard Jaundice pathway coordinator CMFT Sajjad Mahmood Consultant Gastro-enterologist PAT 30

31 Saurabh Jamdar Consultant HPB surgeon CMFT Neil Bibby Dietitian CMFT Garry Morris Physiotherapist CMFT 31

32 Appendix 2 A CMFT HPB Unit and Manchester Cancer Research Event Venue: The Nowgen Centre, 29 Grafton Street, Manchester, M13 9WU Date & Time: Wednesday 18 th November 2015, Registration. Tea & Coffee 18:00 to 20:00: Research Presentations & Guest Speaker followed by dinner at Ziya Restaurant, Wilmslow Road, Manchester M14 5TB Agenda: 8 x 7 mins presentations + 3 mins for questions 1. Angela Lamarca. Clinical biomarkers in patients with advanced hepatocellular carcinoma (HCC) receiving sorafenib; a single institution experience. 2. Peter Coe. Intra-pancreatic fat reduction within the Breast Risk Reduction Intermittent Dietary Evaluation-2 (BRRIDE-2) study 3. Minas Baltatzis. Antibiotic Use in Acute Pancreatitis: Global Overview of Compliance with International Guidelines 4. Giorgio Allessandri. Structural Postoperative Assessment after HPB Surgical Resections 5. Anthony Chan. Colorectal Cancer with Synchronous Liver-Limited Metastases: A novel Propensity Score to Stratify Patients to Sequence of Surgery 6. Grazia Saturno. Patient Derived Xenografts for Pancreatic Cancer 7. Raisah Sawati. A review of biliary drainage and stenting at MRI 8. Sumit Nandi. Use of gemcitabine-loaded superparamagnetic iron oxide nanoparticles against pancreatic cancer cells Guest Speaker: Andrew G Renehan PhD FRCS Professor of Cancer Studies and Surgery Manchester Academic Health Science Centre Obesity & HPB Cancers 32

33 Appendix 3 The Manchester Pancreatic Cancer Symposium 2016 Agenda TIME Registration Tea & Coffee Mr. Derek O Reilly Introduction & Welcome Ms Anna Jewell PCUK Setting the Scene: The experience of Pancreatic Cancer in 2016 Chairs: Translational Research Dr Mairead McNamara (Manchester) Professor Martin J. Humphries (Manchester) Dr. Ged Brady CRUK Manchester Defining the role of CTCs & cfdna in Pancreatic Cancer Prof. Eithne Costello Prof. Hemant Kocher COFFEE BREAK Liverpool London The prospects for Biomarkers and early Diagnosis Tumour-Stromal interactions Chairs: Nutrition, Prehabilitation and Enhanced Recovery Miss Ambareen Kausar (Blackburn) Mr Keith Roberts (Birmingham) Prof. Andrew Renehan Christie Sarcopaenia and Obesity in Pancreatic Cancer Mrs. Mary Phillips Guildford Nutritional Assessment and Support for patients with Pancreatic Cancer Mr. Derek O Reilly CMFT Prehabilitation and Enhanced Recovery for Pancreatic Surgery LUNCH Chairs: Innovations in Treatment Prof Jorg Kleef (Liverpool) Mr Saurabh Jamdar (Manchester) Mr. Chris Halloran Liverpool The Use of Iron Oxide Nanoparticles for 33

34 14.30 Dr. Krijn Van Lienden Mr. Rahul Deshpande COFFEE BREAK Amsterdam CMFT Pancreatic Cancer Therapy Irreversible electroporation for locally advanced pancreatic cancer Innovations in Pancreatic Cancer Surgery Chairs: Personalised Medicine & Future Directions Mr Andy Smith (Leeds) Mr Nicola De Liguori Carino (Manchester) Prof. Juan Valle The Christie Clinical Trials in Pancreatic Cancer Past, Present & Future Prof. Andrew Biankin Prof. John Neoptolemos Glasgow Liverpool Precision Medicine in Pancreatic Cancer Prospects for Improved Outcomes in Pancreatic Cancer 34

35 Appendix 4 - Peer reviewed publications by members of the HPB SMDT : Ruszniewski P, Valle JW, Lombard-Bohas C, Cuthbertson DJ, Perros P, Holubec L, Delle Fave G, Smith D, Niccoli P, Maisonobe P, Atlan P, Caplin ME; SYMNET study group. Patient-reported outcomes with lanreotide Autogel/Depot for carcinoid syndrome: An international observational study. Dig Liver Dis. 2016May;48(5): : Bridgewater J, Lopes A, Beare S, Duggan M, Lee D, Ricamara M, McEntee D, Sukumaran A, Wasan H, Valle JW. A phase 1b study of Selumetinib in combination with Cisplatin and Gemcitabine in advanced or metastatic biliary tract cancer: the ABC-04 study. BMC Cancer Feb 24;16(1):153. 3: Lamarca A, Elliott E, Barriuso J, Backen A, McNamara MG, Hubner R, Valle JW. Chemotherapy for advanced non-pancreatic well-differentiated neuroendocrine tumours of the gastrointestinal tract, a systematic review and meta-analysis: A lost cause? Cancer Treat Rev Mar;44: : Lamarca A, Asselin MC, Manoharan P, McNamara MG, Trigonis I, Hubner R, Saleem A, Valle JW. (18)F-FLT PET imaging of cellular proliferation in pancreatic cancer. Crit Rev Oncol Hematol Mar;99: : McNamara MG, Lamarca A, Hubner RA, Valle JW. "If You Prick Us, Do We Not Bleed?" Whom Should We Choose? J Clin Oncol Feb 10;34(5): : Yao JC, Fazio N, Singh S, Buzzoni R, Carnaghi C, Wolin E, Tomasek J, Raderer M, Lahner H, Voi M, Pacaud LB, Rouyrre N, Sachs C, Valle JW, Delle Fave G, Van Cutsem E, Tesselaar M, Shimada Y, Oh DY, Strosberg J, Kulke MH, Pavel ME; RAD001 in Advanced Neuroendocrine Tumours, Fourth Trial (RADIANT-4) Study Group. Everolimus for the treatment of advanced, non-functional neuroendocrine tumours of the lung or gastrointestinal tract (RADIANT-4): a randomised, placebo-controlled, phase 3 study. Lancet Mar 5;387(10022): : Monaghan PJ, Lamarca A, Valle JW, Hubner RA, Mansoor W, Trainer PJ, Darby D. Routine measurement of plasma chromogranin B has limited clinical utility in the management of patients with neuroendocrine tumours. Clin Endocrinol (Oxf) Mar;84(3): : Bridgewater J, Lopes A, Wasan H, Malka D, Jensen L, Okusaka T, Knox J, Wagner D, Cunningham D, Shannon J, Goldstein D, Moehler M, Bekaii-Saab T, McNamara MG, Valle JW. Prognostic factors for progression-free and overall survival in advanced biliary tract cancer. Ann Oncol Jan;27(1): : Adaway JE, Dobson R, Walsh J, Cuthbertson DJ, Monaghan PJ, Trainer PJ, Valle JW, Keevil BG. Serum and plasma 5-hydroxyindoleacetic acid as an alternative to 24-h urine 5- hydroxyindoleacetic acid measurement. Ann Clin Biochem Oct 5. pii: : Valle JW, Wasan H, Lopes A, Backen AC, Palmer DH, Morris K, Duggan M, Cunningham D, Anthoney DA, Corrie P, Madhusudan S, Maraveyas A, Ross PJ, Waters JS, Steward WP, Rees C, Beare S, Dive C, Bridgewater JA. Cediranib or placebo in combination with cisplatin and gemcitabine chemotherapy for patients with advanced biliary tract cancer (ABC-03): a randomised phase 2 trial. Lancet Oncol Aug;16(8):

36 11: McNamara MG, Lamarca A, Hubner RA, Valle JW. To BRCA or Not to PALB. J Clin Oncol Aug 10;33(23): : Lamarca A, Benafif S, Ross P, Bridgewater J, Valle JW. Cisplatin and gemcitabine in patients with advanced biliary tract cancer (ABC) and persistent jaundice despite optimal stenting: Effective intervention in patients with luminal disease. Eur J Cancer Sep;51(13): : Primrose JN, Cunningham D, Garden OJ, Maughan TS, Pugh SA, Stanton L, Falk SJ, Rees M, Finch-Jones M, Valle JW, O'Reilly D, Hornbuckle J, Hickish T, Bridgewater JA. Cetuximab Is Contraindicated in the Perioperative Treatment of Colorectal Liver Metastases. J Clin Oncol Jul 20;33(21): : Carrato A, Falcone A, Ducreux M, Valle JW, Parnaby A, Djazouli K, Alnwick-Allu K, Hutchings A, Palaska C, Parthenaki I. A Systematic Review of the Burden of Pancreatic Cancer in Europe: Real-World Impact on Survival, Quality of Life and Costs. J Gastrointest Cancer Sep;46(3): : Grunnet M, Christensen IJ, Lassen U, Jensen LH, Lydolph M, Knox JJ, McNamara MG, Jitlal M, Wasan H, Bridgewater J, Valle JW, Mau-Sorensen M. Decline in CA19-9 during chemotherapy predicts survival in four independent cohorts of patients with inoperable bile duct cancer. Eur J Cancer Jul;51(11): : Howell M, Valle JW. The role of adjuvant chemotherapy and radiotherapy for cholangiocarcinoma. Best Pract Res Clin Gastroenterol Apr;29(2): : Abdel-Rahman O, Lamarca A, Valle JW, Hubner RA. Somatostatin receptor expression in hepatocellular carcinoma: prognostic and therapeutic considerations. Endocr Relat Cancer. 2014;21(6):R : Chan AK, Bruce JIe, Siriwardena AK. Glucose metabolic phenotype of pancreatic cancer. World J Gastroenterol Mar 28;22(12): : Baltatzis M, Jegatheeswaran S, O'Reilly DA, Siriwardena AK.Antibiotic use in acute pancreatitis: Global overview of compliance with international guidelines. Pancreatology Mar-Apr;16(2): : Baltatzis M, Chan AK, Jegatheeswaran S, Mason JM, Siriwardena AK. Colorectal cancer with synchronous hepatic metastases: Systematic review of reports comparing synchronous surgery with sequential bowel-first or liver-first approaches. Eur J Surg Oncol Feb;42(2): : Miranda CJ, Mason JM, Babu BI, Sheen AJ, Eddleston JM, Parker MJ, Pemberton P, Siriwardena AK. Twenty-four hour infusion of human recombinant activated protein C (Xigris) early in severe acute pancreatitis: The XIG-AP 1 trial. Pancreatology Nov- Dec;15(6): : James AD, Patel W, Butt Z, Adiamah M, Dakhel R, Latif A, Uggenti C, Swanton E, Imamura H, Siriwardena AK, Bruce JI. The Plasma Membrane Calcium Pump in Pancreatic Cancer Cells Exhibiting the Warburg Effect Relies on Glycolytic ATP. J Biol Chem Oct 9;290(41): : Halloran CM, Platt K, Gerard A, Polydoros F, O'Reilly DA, Gomez D, Smith A, Neoptolemos JP, Soonwalla Z, Taylor M, Blazeby JM, Ghaneh P. PANasta Trial; Cattell 36

37 Warren versus Blumgart techniques of panreatico-jejunostomy following pancreatoduodenectomy: Study protocol for a randomized controlled trial. Trials Jan 15;17:30. 24: Khaled YS, Malde DJ, Packer J, De Liguori Carino N, Deshpande R, O'Reilly DA, Sherlock DJ, Ammori BJ. A Case-matched Comparative Study of Laparoscopic Versus Open Distal Pancreatectomy. Surg Laparosc Endosc Percutan Tech Aug;25(4): : Parkin E, O'Reilly DA, Plumb AA, Manoharan P, Rao M, Coe P, Frystyk J, Ammori B, de Liguori Carino N, Deshpande R, Sherlock DJ, Renehan AG. Digital histology quantification of intra-hepatic fat in patients undergoing liver resection. Eur J Surg Oncol Aug;41(8): : O'Reilly DA, Bouamra O, Kausar A, Malde DJ, Dickson EJ, Lecky F. The epidemiology of and outcome from pancreatoduodenal trauma in the UK, Ann R Coll Surg Engl Mar;97(2): : Hamza N, Darwish A, O'Reilly DA, Denton J, Sheen AJ, Chang D, Sherlock DJ, Ammori BJ. Perioperative Enteral Immunonutrition Modulates Systemic and Mucosal Immunity and the Inflammatory Response in Patients With Periampullary Cancer Scheduled for Pancreaticoduodenectomy: A Randomized Clinical Trial. Pancreas Jan;44(1):