Initial Management Pathway for TYA Patients And Follow up Pathway for TYA patients following completion of first line treatment.

Transcription

1 Initial Management Pathway for TYA Patients And Follow up Pathway for TYA patients following completion of first line treatment. Contents: Page 2 Initial Management Pathway for TYA Patients Page 3 Follow up pathway for TYA patients following completion of first line treatment Page 4 TYA MDT Details Page 5 Page 6 Page 7 Page 8 Page 9 Page 10 Page 11 Page 12 Page 13 Page 14 Page 15 Page 16 Page 17 Site Specific MDT Details: Breast Colorectal Gynaecology Head and Neck Haematology (including Leukaemia & Lymphoma) Hepatobiliary Lung Oesophago-Gastric Sarcoma Skin Urology Initial Management Pathway for TYA Patients: Neuro-Oncology Neuro oncology MDT details 1 Author: Laura Elder,

2 Initial Management Pathway for TYA Patients Suspected cancer referral (GP/A&E/screening/other referral route) Patient registration to CCC and COSD TYA MDT outcome form sent to referring MDT Notify TYA MDT when diagnosis confirmed, complete TYA referral form Fax or to MDT coordinator. TYA MDT weekly Tuesday am CCC All TYA patients will be discussed at this MDT. Member of site specific team to present patient. Agree treatment plan made by site specific MDT. Team to discuss patients individual support networks, identify any psychosocial issues to address. Clinical trials to be considered Identify TYA team members input (Social Worker, Psychologist, Lead Nurse, Youth Support) TYA team to make contact with patient and discuss required support Diagnostic tests leading to confirmed diagnosis (final responsibility for diagnostic process lies with site specific MDT) Cancer Diagnosis Treatment Planning (Communication, agreed plan and key worker recorded by both MDT s) In Treatment Post Treatment Site specific MDT meeting Patient discussed and treatment plan identified as per clinical guidelines The agreed site specific consultant is the person who remains in overall charge of the patients treatment Fertility discussion (if appropriate) Clinical trials to be considered TYA MDT member present if appropriate Agree place of care with patient Aged years treatment at Principal Treatment Centre in age appropriate setting Support from TYA MDT members throughout patients treatment as required. Responsibility to provide age approprite support and envirnoment lies with the TYA MDT years treatment location choice at principal treatment centre in age appropriate setting or designated hospital 2 Follow up pathway Palliative care/ end Progression/ Author: Laura Elder, according to site of life care relapse specific protocols

3 Follow up Pathway for Teenagers and Young Adults (TYAs) Following Completion of First Line Treatment TYA MDT Continuing TYA team involvement, coordination of age appropriate clinical and psychological care Patient completed first line treatment. (Could include any combination of surgery, chemotherapy and/or radiotherapy) Site specific MDT End of treatment summary (disease status/ prognosis, treatments recorded, toxicities) and care plan produced by medical team within six months of treatment CLIC Sargent social worker will send introduction letter with information and offer initial grant for a person 16 to 24 years at diagnosis and relapse. A more in-depth service will be offered on assessed needs. Peer Support: Young people will be invited to peer support activities for 2 years post treatment and can access the Youth Support Co-ordinator in this time Discussion and outcomes sent to GP and site specific consultant as appropriate CLIC Sargent TYA Psychologist will continue to provide support and accept new referrals for those completing treatment Disease progression supportive care only Local palliative care team referral and discussion at palliative care MDT, symptom management Clinical follow up as per tumour pathway Outpatient clinic reviews, toxicity monitoring, late effects Surveillance monitoring; imaging and/or laboratory investigations as protocol Recurrent disease or new primary via self referral, GP or surveillance. Refer back to responsible consultant Re-referred to TYA MDT, continue as TYA initial management pathway as appropriate Re-referred to TYA MDT, continue as TYA initial management pathway Refer to tumour support groups as appropriate 3 as appropriate Author: Laura Elder, Notes: -There will be unhindered access into the TYA MDT if clinicians have concerns about any patient after completion of first line treatment or if the patient wishes to be discussed -Late effects: 5 years post diagnosis, the TYA MDT co-ordinator will contact the site specific team to consider referral to the late effects service and late effects MDT if appropriate as part of the patients care plan.

4 TYA MDT Details- Time of MDT- Location- 9am every Tuesday JKD meeting room at Clatterbridge Cancer Centre BT Conference call details- Free phone number Participant Pass code then # TYA MDT co-ordinator Theresa Otty TYA MDT Lead Clinician Dr Nasim Ali TYA MDT Referrals via clinical referral/ notification form to TYA MDT co-ordinator fax Referrals should be made to the TYA MDT for all patients across Merseyside, Cheshire and North Wales who have a cancer diagnosis aged between years. Referrals should be made within one month of diagnosis. 4 Author: Laura Elder,

5 Breast MDT Details- Aintree- TYA lead Clinician: Dr Lynny Yung ( ) MDT Lead Clinician: Mr Lee Martin Countess of Chester- ( ) MDT Lead Clinician: Miss Elizabeth Redmond Royal Liverpool & Broadgreen- TYA Lead Clinician: Dr Nagesh Kalakonda ( ) MDT Lead Clinician: Mr Chris Holcombe Southport & Ormskirk- ( ) MDT Lead Clinician: Mr Martin Shaw St Helens & Knowsley- TYA Lead Clinician: Dr Majed Gharib ( ) MDT Lead Clinician: Miss Leena Chagla Warrington & Halton- ( ) MDT Lead Clinician: Mr Naoman Sarfraz Wirral University Teaching Hospital- TYA Lead Clinician: Dr Ranjit Dasgupta ( ) MDT Lead Clinician: Dr Joyce Magennis Surgical option 16-24yrs in accordance with local site specific pathways Chemotherapy 16-24yrs delivered by Clatterbridge Cancer Centre 5 Author: Laura Elder,

6 Colorectal MDT Details- Aintree- TYA lead Clinician Dr Lynny Yung ( ) MDT Lead Clinician: Mr Paul Skaife Countess of Chester- ( ) MDT Lead Clinician: Mr Michael Johnson Royal Liverpool & Broadgreen- TYA Lead Clinician Dr Nagesh Kalakonda ( ) MDT Lead Clinician: Mr Paul Rooney Southport & Ormskirk- ( ) MDT Lead Clinician: Mr Dmitri Artioukh St Helens & Knowsley- TYA Lead Clinician: Dr Majed Gharib ( ) MDT Lead Clinician: Mr Ajai Samad Warrington & Halton- ( ) MDT Lead Clinician: Mr Mark Tighe Wirral University Teaching Hospital- TYA Lead Clinician: Dr Ranjit Dasgupta ( ) MDT Lead Clinician: Mr Liviu Titu Surgical option 16-24yrs in accordance with local site specific pathways Chemotherapy 16-24yrs delivered by Clatterbridge Cancer Centre 6 Author: Laura Elder,

7 Gynaecological MDT Details- Countess of Chester- ( ) MDT Lead Clinician: Mr Jed Hawe St Helens & Knowsley- Lead TYA Clinician: Dr Majed Gharib ( ) MDT Lead Clinician: Mr Tim Kundodyiwa Wirral University Teaching Hospital- Lead TYA Clinician: Dr Ranjit Dasgupta ( ) MDT Lead Clinician: Miss Nahid Gul Specialist Gynaecological MDT Details- Liverpool Womens- TYA Lead Clinician: Dr Bridget De Cruze ( ) MDT Lead Clinician: Mr Robert McDonald Surgical option 16-24yrs at designated specialist trust the Liverpool Womens Chemotherapy 16-24yrs delivered by Clatterbridge Cancer Centre 7 Author: Laura Elder,

8 Head and Neck MDT Details- Aintree- UAT/skull based head and neck MDT lead clinician: Prof J S Brown ( ) Thyroid MDT lead clinician: Dr L Smith TYA lead Clinician Dr Lynny Yung Upper-aero digestive tract (UAT) tumours- Surgical options 16-24yrs at Aintree designated specialist trust Chemotherapy 16-24yrs delivered by Clatterbridge Cancer Centre Thyroid Tumours years old Thyroid Surgery at a principal treatment centre- RLBUHT Alder Hey Radio Iodine at RLBUHT year olds Thyroid Surgery at principal treatment centre or designated hospital- RLBUHT Aintree STH&K Wirral Hospital Radio Iodine at RLBUHT 8 Author: Laura Elder,

9 Haematology MDT Details- Aintree- TYA lead Clinician Dr Lynny Yung ( ) MDT Lead Clinician: Dr Lynny Yung Countess of Chester- ( ) MDT Lead Clinician: Dr Salaheddin Tueger Royal Liverpool & Broadgreen- TYA Lead Clinician Dr Nagesh Kalakonda ( ) MDT Lead Clinician: Dr Nauman Butt Southport & Ormskirk- ( ) MDT Lead Clinician: Dr David O Brien St Helens & Knowsley- TYA lead Clinician Dr Majed Gharib ( ) MDT Lead Clinician: Dr Toby Nicholson Warrington & Halton- ( ) MDT Lead Clinician: Dr Mohamed Kaleel Rahman Wirral University Teaching Hospital- TYA lead Clinician Dr Ranjit Dasgupta ( ) MDT Lead Clinician: Dr David Galvani Chemotherapy: 16-18yrs Alder Hey or Royal Liverpool and Broadgreen University Hospital 19-24yrs Royal Liverpool and Broadgreen University Hospital or designated local hospital which includes Wirral University Teaching Hospital, Aintree, St Helens and Knowsley Non malignant Haematological Conditions- From January 2015 CLIC Sargent an essential member of the TYA MDT extended their eligibility criteria to include bone marrow failure syndromes and lymphoproliferative conditions. These patients can access through the TYA MDT a CLIC Sargent social worker and the TYA team as required. Conditions included- Langerhans Cell Hystiocytosis (LCH), Haemophagacytic Lymphohistiocytosis (HLH), Aplastic Anaemia, Fanconi Anaemia, Dyskeratosis Congenita 9 Author: Laura Elder,

10 (DKC), Shwachmann-Diamond Syndrome (SDS), Congenital Amegakaryocytic Thrombocytopenia (CAMT), Diamond-Blackfan Anaemia and Congenital Neutropenia 10 Author: Laura Elder,

11 Specialist Hepatobiliary (Liver) MDT Details: Aintree- TYA lead Clinician Dr L Yung ( ) MDT Lead Clinician: Mr S Fenwick Specialist Pancreatic MDT Details- Royal Liverpool & Broadgreen- TYA Lead Clinician Dr Nagesh Kalakonda ( ) MDT Lead Clinician: Prof J Neoptolemos Upper GI MDT Details- Countess of Chester- ( ) MDT Lead Clinician: Mr D Monk Surgical option 16-24yrs in accordance with local site specific pathways Chemotherapy 16-24yrs delivered by Clatterbridge Cancer Centre 11 Author: Laura Elder,

12 Lung MDT Details- Aintree- TYA lead Clinician Dr Lynny Yung ( ) MDT Lead Clinician: Dr Seamus Grundy Countess of Chester- ( ) MDT Lead Clinician: Dr Ian Benton Liverpool Heart & Chest- ( ) MDT Lead Clinician: Dr Martin Walshaw Southport & Ormskirk- ( ) MDT Lead Clinician: Dr Christopher McManus St Helens & Knowsley- TYA Lead Clinician: Dr Majed Gharib ( ) MDT Lead Clinician: Dr Julie Hendry Warrington & Halton- ( ) MDT Lead Clinician: Dr Mithin Murthy Wirral University Teaching Hospital- TYA Lead Clinician: Dr Ranjit Dasgupta ( ) MDT Lead Clinician: Dr Andrew Wright Surgical option 16-24yrs in accordance with local site specific pathways Chemotherapy 16-24yrs delivered by Clatterbridge Cancer Centre 12 Author: Laura Elder,

13 Specialist Oesophagogastric MDT Details- Aintree- TYA lead Clinician Dr L Yung ( ) MDT Lead Clinician: Dr N Kapoor Betsi Cadwalader University Health Board- ( ) MDT Lead Clinician: Mr A Baker Liverpool Heart & Chest- ( ) MDT Lead Clinician: Mr N R Howes Upper GI MDT Details- Countess of Chester- ( ) MDT Lead Clinician: Mr D Monk Surgical option 16-24yrs in accordance with local site specific pathways Chemotherapy 16-24yrs delivered by Clatterbridge Cancer Centre 13 Author: Laura Elder,

14 Specialist Soft Tissue Sarcoma MDT Details- Royal Liverpool & Broadgreen- Lead TYA Clinician Dr Nagesh Kalakonda ( ) MDT Lead Clinician: Mr Qi Yin Bone sarcoma- Surgical option 16-24yrs in accordance with specialised services pathway for primary malignant bone cancer treatment (University Hospitals Birmingham or The Robert Jones and Agnes Hunt Orthopaedic Hospital (Oswestry)) Other tumour surgical option 16-24yrs in accordance with specialist MDT recommendations. Chemotherapy 16-18yrs Alder Hey or Clatterbridge Cancer Centre 19-24yrs delivered by Clatterbridge Cancer Centre 14 Author: Laura Elder,

15 Local Skin MDT Details- Bridgewater Community Trust- ( ) MDT Lead Clinician: Dr John Ashworth Countess of Chester- ( ) MDT Lead Clinician: Dr Asad Salim Royal Liverpool & Broadgreen- TYA lead Clinician: Dr Nagesh Kalakonda ( ) MDT Lead Clinician: Dr Niall Wilson Southport & Ormskirk- ( ) MDT Lead Clinician: Dr Aamir Memon Wirral University Teaching Hospital- TYA lead Clinician: Dr Ranjit Dasgupta ( ) MDT Lead Clinician: Dr Boon Tan Specialist Skin MDT Details- St Helens & Knowsley- TYA lead Clinician: Dr Majed Gharib ( ) MDT Lead Clinician: Dr Elaine Hindle Surgical option 16-24yrs in accordance with local site specific pathways, designated specialist hospital is St Helens and Knowsley Chemotherapy 16-24yrs delivered by Clatterbridge Cancer Centre 15 Author: Laura Elder,

16 Urology MDT Details- Aintree- TYA lead Clinician Dr Lynny Yung ( ) MDT Lead Clinician: Mr Mahmoud Elfar Countess of Chester- ( ) MDT Lead Clinician: Mr Bo Pettersson Royal Liverpool & Broadgreen- TYA Lead Clinician: Dr Nagesh Kalakonda ( ) MDT Lead Clinician: Mr Phillip Cornford Southport & Ormskirk- ( ) MDT Lead Clinician: Mr Mohsen Gammal St Helens & Knowsley- TYA Lead Clinician: Dr Majed Gharib ( ) MDT Lead Clinician: Mr Altaf Khattak Warrington & Halton- ( ) MDT Lead Clinician: Mr Lee Robinson Wirral University Teaching Hospital- TYA Lead Clinician: Dr Ranjit Dasgupta ( ) MDT Lead Clinician: Mr Nigel Parr (MCCN Penile Cancer Lead) Specialist Testicular MDT Details- Royal Liverpool & Broadgreen- TYA Lead Clinician: Dr Nagesh Kalakonda ( ) MDT Lead Clinician: Professor Peter Clark Surgical option 16-24yrs in accordance with local site specific pathways Chemotherapy 16-24yrs delivered by Clatterbridge Cancer Centre 16 Author: Laura Elder,

17 17 Author: Laura Elder,

18 Neuro-Oncology Initial Management Pathway for TYA Patients Suspected cancer referral (GP/A&E/screening/other referral route) Patient registration to CCC and COSD TYA MDT outcome form sent to referring clinician Notify TYA MDT when diagnosis confirmed, complete TYA referral form Fax or to MDT coordinator. TYA MDT weekly Tuesday am CCC All TYA patients will be discussed at this MDT. Member of site specific team to present patient. Agree treatment plan made by site specific MDT. Team to discuss patients individual support networks, identify any psychosocial issues to address. Clinical trials to be considered Identify TYA team members input (Social Worker, Psychologist, Lead Nurse, Youth Support) TYA team to make contact with patient and discuss required support Palliative care/ end of life care Diagnostic tests leading to confirmed diagnosis (final responsibility for diagnostic process lies with site specific MDT) Cancer Diagnosis Treatment Planning (Communication, agreed plan and key worker recorded by both MDT s) In Treatment Post Treatment Follow up pathway according to site specific protocols, including monthly TYA transition clinic Neuroscience- Site specific MDT meeting Patient discussed and treatment plan identified as per clinical guidelines The agreed site specific consultant is the person who remains in overall charge of the patients treatment Fertility discussion (if appropriate) Clinical trials to be considered TYA MDT member present if appropriate Agree place of care with patient Aged years treatment at Principal Treatment Centre in age appropriate setting (xrt/chemotherapy) Surgical treatment at The Walton Centre or Alder Hey Progression/ relapse years treatment location choice at principal treatment centre in age appropriate setting or designated hospital (xrt/chemotherapy) Support from TYA MDT members throughout patients treatment as required. Responsibility to provide age approprite support and envirnoment lies with the TYA MDT Note: Input 18 and contact by the TYA team will only take place if the patient consents to this contact Author: Laura Elder, and support. If a patient initially declines support the service is still available to them at any stage of their treatment. Responsibility for the treatment plan is the decision of the Neuroscience MDT, this includes all

19 Specialist Neuroscience MDT Details- All patients aged years should be discussed jointly with adult and paediatric oncologist Patients aged years will have pre-operative MDT discussion (by the TYA team) to determine the optimal surgical management The Walton Centre Thursday 12.30pm MDT Lead Clinician: Mr Michael Jenkinson TYA Lead Clinician- Mr Michael Jenkinson CNS: Anna Crofton Jan Holding Antonia Thorpe Alison Rodway TYA Clinicians involved in care Neurosurgery Adult neuro oncology Michael Jenkinson Brian Haylock Andrew Brodbelt David Husband Conor Mallucci Adi Shenoy Benedetta Pettorini Paediatric neuro oncology Barry Pizer Nicky Thorp James Hayden Lisa Howell Surgical option 16-18yrs at Alder Hey or The Walton Centre yrs at the Walton Centre Chemotherapy 16-18yrs Alder Hey or Clatterbridge Cancer Centre yrs delivered by Clatterbridge Cancer Centre 19 Author: Laura Elder,