How a fully integrated Acute Oncology Service can benefit the busy medical unit

Transcription

1 How a fully integrated Acute Oncology Service can benefit the busy medical unit Dr. Pauline Leonard MD FRCP Consultant Medical Oncologist Whittington Health

2 Over the next 35 mins Briefly remind you of the evidence that led to the development of Acute Oncology services Describe the three types of Cancer emergencies To help define the importance of collaborative working Focus on one area that is under recognised Illustrate challenges with case presentations Interactive questions

3 NCEPOD % admitted during last 30 days 52% after #1 43% admitted with G3/4 toxicity 34% admitted General Medicine 21% treated were PS 3 or 4 15% admitted to another Trust 19% assessors felt Systemic Anti Cancer Therapy (SACT) inappropriately given

4 A key recommendation from National Chemotherapy Advisory Group (NCAG) report 2009 Development of an Acute Oncology Service in all Trusts which have an Emergency department for Management of patients who develop severe complications following chemo or as a consequence of their cancer Management of patients who present as emergencies with previously undiagnosed cancer AOS brings together expertise from oncology disciplines, emergency medicine, and general medicine and general surgery

5 Three types of Cancer emergencies Type 1 Patients who present who a new diagnosis of cancer Type 2 Patients who present with toxicities of treatment - Chemotherapy - Radiotherapy Type 3 Patients who present with symptoms from disease

6 What is the most common type of Cancer presentation? Type 1 ( new cancer diagnosis) Type 2 (treatment toxicity) For e.g. febrile neutropenia Type 3 ( disease related symptom) Pain, breathlessness

7 Our experience at WH Four not three types of patient presentations 53% of all patients who present to ED with a diagnosis of cancer have an unrelated problem Survivors of disease Living with disease but present Accident Exacerbation of co-morbidity New pathology Type 1 28% Type 2 22% Type 3a 50% 20% EOLC

8 Managing emergency presentations of Cancer on the Acute take

9 Routes to Diagnosis GP/OP referral Two Week Wait Emergency presentation Acute leukaemia 17% 3% 61% 12% 0% 4% 0% 4% 100% 380 Bladder 22% 36% 18% 13% 0% 6% 1% 5% 100% 1,167 Brain & CNS 18% 2% 49% 20% 0% 5% 0% 5% 100% 740 Breast 8% 40% 5% 5% 28% 2% 0% 13% 100% 5,646 Cervix 21% 17% 12% 8% 23% 3% 1% 15% 100% 308 Chronic leukaemia 26% 6% 45% 13% 0% 4% 1% 4% 100% 629 Colorectal 19% 29% 24% 12% 0% 8% 0% 7% 100% 4,515 Kidney 22% 26% 23% 16% 0% 5% 0% 8% 100% 928 Larynx 35% 34% 8% 14% 0% 5% 0% 3% 100% 216 Lung 15% 26% 38% 10% 0% 4% 1% 7% 100% 3,893 Melanoma 23% 39% 4% 8% 0% 5% 0% 22% 100% 1,686 Multiple myeloma 20% 14% 44% 13% 0% 4% 1% 5% 100% 606 Non-Hodgkin's lymphoma 25% 22% 25% 13% 0% 6% 1% 9% 100% 1,349 Oesophagus 15% 32% 21% 14% 0% 13% 0% 4% 100% 912 Oral 32% 27% 5% 14% 0% 4% 1% 17% 100% 458 Ovary 20% 29% 28% 11% 0% 3% 1% 8% 100% 853 Pancreas 13% 20% 45% 10% 0% 5% 1% 7% 100% 917 Prostate 26% 28% 11% 11% 0% 7% 0% 16% 100% 4,865 Stomach 14% 24% 31% 13% 0% 11% 1% 6% 100% 801 tbc (other) 21% 18% 34% 12% 0% 4% 1% 9% 100% 4,323 Testis 14% 47% 9% 15% 0% 4% 0% 11% 100% 259 Uterus 28% 36% 8% 12% 0% 5% 0% 12% 100% 918 Total 19% 28% 22% 11% 5% 5% 1% 10% 100% 36,369 Other outpatient Screen detected Inpatient elective DCO Unknown Total Number of patients All cancer Routes to Diagnosis: by cancer type All malignant registrations South West 2007 excluding C44 and multiples

10 Relative one year survival: by cancer type Malignant registrations, South West 2007, excluding multiples and DCOs Cancer type GP/OP referral (+TWW) Relative 95% CIs Survival Emergency Relative 95% CIs Survival Other route Relative 95% CIs Survival Acute leukaemia 39.7 ( ) 39.4 ( ) 40.4 ( ) EUROCARE Relative Survival Bladder 78.3 ( ) 34.0 ( ) 79.2 ( ) 85.3 Brain & CNS 68.4 ( ) 34.0 ( ) 60.6 ( ) 39.1 Breast 97.7 ( ) 50.8 ( ) 98.2 ( ) 95 Colorectal 84.5 ( ) 48.4 ( ) 79.5 ( ) 74.7 Kidney 81.1 ( ) 24.0 ( ) 72.4 ( ) 74.7 Lung 39.8 ( ) ) 32.4 ( ) 36.1 Multiple myeloma 83.6 ( ) 53.1 ( ) 73.0 ( ) 70.5 Non-Hodgkin's lymphoma 86.6 ( ) 43.7 ( ) 80.9 ( ) 73.1 Oesophagus 43.8 ( ) 22.4 ( ) 45.5 ( ) 36.3 Other 81.1 ( ) 27.2 ( ) 77.8 ( ) Ovary 83.4 ( ) 38.8 ( ) 72.1 ( ) 70.7 Pancreas 21.0 ( ) 6.0 ( ) 22.3 ( ) 19.2 Prostate 98.0 ( ) 48.2 ( ) 98.3 ( ) 92.2 Stomach 49.1 ( ) 17.7 ( ) 47.6 (41-54) 44.1

11 The older person is over represented in Emergency presentations of cancer

12 Survival decreases with age

13 Time to appreciate each others perspective by understanding the interpretation of specific assessment tools

14 Survival by Charslon Index at Diagnosis: All cases Kaplan-Meier; Charlson Index at diagnosis 1 y r analysis time CI=0 CI=2-3 CI=1 CI=4+ N=34,513 Courtesy: Anna Rich et al, Nottingham University

15 Prospective audit of emergency admissions of cancer Dec 2012 March 2013 Cancer New ED diagnoses Total Dec Feb Percentage of diagnoses by ED (Dec Feb) National figure for percentage of diagnoses by ED (06-08) Examples of CUP pathways which ensure early triage to specific tumour MDT Lung % 39% Pancreas % 50% Hepatobiliary + GB % 48% NHL % 27% Myeloma % 37% MUO % 37% Gynae % 15% Colorectal % 26% CNS % 62% AML % 54% Bone sarcoma % 25% H&N- Oropharynx % 9% Mesothelioma % 36% Oesophagus % 22% Stomach % 33% Prostate % 10%

16 Prospective audit of emergency admissions of cancer Dec 2012 March 2013 Cancer New ED diagnoses (RIP) Total Dec Feb Percentage of diagnoses by ED (Dec Feb) National figure for percentage of diagnoses by ED (06-08) Examples of CUP pathways which ensure early triage to specific tumour MDT Lung % 39% Pancreas % 50% Hepatobiliary + GB 3 (2) 5 60% 48% NHL % 27% Myeloma % 37% MUO % 37% Gynae % 15% Colorectal 2 (1) 14 14% 26% CNS % 62% AML 2 (1) 2 100% 54% Bone sarcoma % 25% H&N- Oropharynx % 9% Mesothelioma % 36% Oesophagus % 22% Stomach % 33% Prostate % 10%

17 Histological confirmation Treatment Frequency How many had histology? Radical chemo/radiotherapy 6 6 Potentially curative surgery 6 6 Palliative chemo/radiotherapy 10 9 Palliative surgery/ therapeutic intervention 2 1 Symptom control (75%) 33/44 patients had histological confirmation

18 MUO NICE guidance 2010

19 Why are clinicians reluctant to tailor investigations to the individual patient? Fear of missing the treatable? may not be cancer may have a better prognosis mutation positive cancer Belief that histological diagnosis a stronger determinant than prognosis determined by PS/comorbidities? Clinician discomfort with a clinical diagnosis Do something is easier than having an honest discussion about poor prognosis?

20 Role of Oncologist in AOS Sharing expertise in managing Oncological emergencies irrespective of tumour type Sub-specialisation has eroded confidence in generic skills Advisory capacity in how best to proceed in patients who present with a new suspected cancer Where case does not fit into recognised established pathways Individualised treatment plans incorporating PS & comorbidities

21 Managing emergency presentations of MUO/CUP

22 Routes to Diagnosis: Cancer unknown Primary 57% of all CUP/MUO present via ED Compared with 23% all cancers 45% were older than 85 years 4% under 50 yrs CUP accounts for 9% of all ED presenting cancers Compared to 23% Lung 11% CRC 1 year survival is 16% Better survival via managed routes 24-37%

23 Cerebral metastasis or primary brain cancer? Patient JM Patient AA

24 Which patient has a Primary Cerebral Lymphoma? Patient JM Patient AA Can t tell

25 What would you do next? Urgent referral to Neurosurgical unit Start high dose dexamethasone & refer to Neurosurgical unit Start high dexamethasone and request full staging CT Thorax, abdomen & Pelvis Start high dose Dexamethasone and request MRI head

26 Suggested next steps Assess patients fitness and wishes Trial 16mg dexamethasone stat then 8mg BD If keen and fit for treatment Needs full Thorax, Abdo & pelvis staging CT If no disseminated disease refer to neurosurgical centre or brain mets MDT Biopsy of brain mass Optimal surgical debulking

27 Metastatic Spinal cord compression 59yrs female Short history of weakness & loss of sensation right hand with pain in neck Contacted directly by MRI Vertebral collapse C7, T1,T2 & T3 with impending cord compression Organised by phone urgent RT & team approach Patient transferred UCLH and treated Post RT biopsy Metastatic breast ca

28 Suggested approach Clinical suspicion Assess PS, overall fitness and patients wishes If poor PS, multiple co-morbidities surgery will not be offered Give stat dose of Dexamethasone 16mg po with PPI cover Request WHOLE SPINE MRI Reserved 8am slot in MRI If previously undiagnosed cancer Needs full staging with CT Thorax/Abdo & Pelvis Known cancer Need to liaise with pt oncologist re: appropriateness Consider updated staging

29 When to transfer? Once all info collated needs local discussion with AOS and admitting team Prognosis Patient wishes Referapatient Neurosurgery Surgeons do not operate on MSCC out of hours operating times Prefer a stabilised patient Radiotherapy 7 day service

30 Liver metastases only How do we manage this case? -determine fitness -PS -renal & liver function -assess symptoms -explore wishes -Biopsy if chemo appropriate Unless management can be enhanced by addressing symptoms - There is no routine role for top & tail

31 No role for routine use of screening tumour markers Unless Suspected germ cell tumour AFP, bhcg, LDH Hepatocellular carcinoma AFP Equivocal Pancreatic mass** Ca 19.9 MSCC PSA Medullary cell thyroid carcinoma Serum Calcitonin

32 Superior venal caval obstruction 80 yrs Increasing SOB CT shows SVCO What about a diagnosis? First priority is patient safety and comfort?svc stent Steroids RT Biopsy confirmed adeno Lung EGFR WT

33 Stratified medicine project - CRUK 8.3%

34 Early AOS can improve experience of care yrs female 6m history back pain Abnormal x-ray reported & orthopaedic team alerted MRI pelvis & CT Thorax/Abdo done AOS involved Seen at RNOH Sarcoma MDT Prof no chemo RIP

35 Type 2 presentations

36 Toxicities of treatment Patient alerts Early recognition of emergency Specialist management Assess to agreed pathways of care Updated easy accessible protocols Sepsis 6 Regular education Shared knowledge Recognition of newer treatments

37 Type 3 presentations

38 Symptoms of disease Manage symptom Investigate appropriately Understand ceilings of care Early involvement of palliative care services

39 AOS meets Acute Medical take - celebrating our shared expertise

40 Take home messages AOS brings together expertise from oncology disciplines, emergency medicine, and general medicine, care of the elderly, palliative care and general surgery The way we have previously done things needs to be challenged Integrated working (when done well) can Provide a better experience of care Ensure patient centred pathways Improve outcomes and avoid potentially avoidable co-morbidity and death Provide educational opportunities Embed value based care

41 Whittington Health AOS? Adam Belton CNS Haem/AOS Dr Ali Rismani Haem /AOS Cons Dr Pauline Leonard AOS Lead Medical Oncologist Lung/GI/HPB & CUP Dr Emma Spurrell Consultant Medical Oncologist Breast/AOS Dr Mulyati Mohamed Speciality Dr Oncology