LCA Lung Clinical Forum. 21 st October 2014

LCA Lung Clinical Forum 21 st October 2014

Welcome Dr Liz Sawicka Chair - LCA Lung Pathway Group

Succession planning Dr Kate Haire Consultant in Public Health Medicine, LCA

Commissioning Intentions for Lung Cancer 2015/16 S U E M A U G H N, C L I N I C A L A D V I S O R, T R A N S F O R M I N G C A N C E R S E R V I C E S T E A M F O R L O N D O N

Commissioning Intentions In high level terms, how the commissioner intends to commission services from Providers during 2015/16. In line with the NHS Standard Contract, providers are given six months notification for any potential changes to services. Overarching principles Compliance with NICE Introduction of timed pathways Follow up in line with NCSI

16 pan-london cancer commissioning intentions- 4 highly relevant to lung To support the delivery of the Pan London Cancer Strategy and to reduce variation across providers: 1. All GPs to have direct access to same day chest x-ray for high risk of cancer and access for low risk, not no risk of cancer a) In order to support the reduction of the risk of delayed diagnosis, all commissioned services will be required to formally report A&E, Urgent Care Centres and inpatient chest x-rays (CxR) 2. All commissioned cancer services will participate in the National Cancer Peer Review Programme (NCPR) or other quality assurance programme as defined by commissioners 3. All cancer services commissioned will be required to demonstrate robust treatment decision making through MDT 4. All lung cancer services will be commissioned in line with best practice through a timed pathway a) Endobronchial US (EBUS) services are commissioned to an agreed service specification and tariff

Pathway elements In addition pathways to include: 1. Abnormal CxR straight to CT 2. Abnormal CxR flagged to MDT plus GP (? Use of consultant upgrade) 3. CT prior to first OPA

Lung Quality requirements Need to be reported to commissioners quarterly - Quality /Information items aligned with the requirements of LUCADA or peer review where possible In addition an annual audit of 30 cases against the key elements For example: - 95% CT prior to Bronchoscopy - 80% CNS present at diagnosis - A thoracic surgeon is present at all MDTs All cancer MDTs to be quorate with core membership present at 95% of meetings and that individual core members attend 66% of meetings

Lung Quality requirements Questions

Priorities for the next 6 months, implementation and support required Dr Liz Sawicka Chair - LCA Lung Pathway Group

Priorities for next 6 months Succession Planning Commissioning Intentions Implementation and compliance against 62 day timed pathway CT before 1 st appointment Review of clinical guidelines Mesothelioma guidelines and set up of subgroup Lung survivorship work programme Lung Palliative Care work programme Palliative Lead required End of life care prompt tool GP education programme Pathology and Radiology standards

Pathology Standards - recap Quality Standard 1 Patients with lung cancer should have their diagnosis confirmed histologically unless patient is unwilling or investigation is too dangerous. Quality Standard 1 Measure: The proportion of all lung cancer patients who have a histological diagnosis Notes: This measure should reflect the functioning of the MDT as a whole

Pathology Standards - recap Quality Standard 2 Patients with histologically confirmed non-small cell lung cancer should be assigned an accurate histological sub-type, according to WHO and IASLC recommendations Quality Standard 2 Measures: The proportion of non-small cell carcinoma patients assigned a diagnosis of non-small cell carcinoma NOS The relative proportions of non-small cell NOS, squamous cell carcinoma, adenocarcinoma and other subtypes Notes: Reflects quality of samples taken by clinicians and experience of pathologists

Pathology Standards - recap Quality Standard 3 Patients with histologically confirmed non-small cell non-squamous lung cancer who are treated with palliative systemic therapy should be tested for EGFR prior to treatment commencing It is recommended that ALK testing should also be undertaken in this group Quality Standard 3 Measures: The proportion of patients with histologically confirmed non-small cell non-squamous lung cancer who are treated with palliative systemic therapy who have an EGFR test result available prior to first-line treatment. The proportion of patients with histologically confirmed non-small cell non-squamous lung cancer who are treated with palliative systemic therapy who have an ALK test result available prior to second-line treatment. The proportion of EGFR and ALK tests requested that are deemed inadequate or fail analysis Notes Reflects effectiveness of testing policy, sample quality and whether pathologists are preserving tissue Any accredited testing methodology may be used

Pathology Standards - recap Quality Standard 4 Pathologists reporting lung cancer samples should participate in the specialist lung cancer EQA scheme. Quality Standard 4 Measure: The proportion of pathologists reporting lung cancer specimens who participate in the lung EQA scheme

Questions

Lung Compliance Metrics What can I do to ensure compliance For more information on compliance metrics please contact stephenscott@nhs.net Stephen Scott Senior Cancer Information Analyst, LCA

What can I do to ensure compliance 1. Validate data to ensure accurate picture 2. Correct data flow issues 3. If data accurate consider any improvements in service

Questions

Optimal diagnostic pathways for lung cancer to deliver 62 day pathway

Radiology Standards Achieving 62 day pathway Role of CT and Radiology Dr Anand Devaraj Consultant Radiologist, St George s Healthcare NHS Trust

Background 62 day wait target across LCA Access to Diagnostics Audit Feb 2014

Patient with mass on CXR GP TWR referral to chest clinic Pt seen in clinic CT requested CT performed and reported Pt seen in clinic (Provisional diagnosis and next tests).

Proposed Pathway 62 Day Timed Pathway for Lung LCA Feedback Day 0 Moderate large pleural effusion Urgent 2ww referral with CXR Internal referrals A&E referrals Incidental findings Routine GP referral 1 st OPA* Referrals triaged, Screened, U&Es checked. CT ordered and booked prior to 1 st OPA No CT required /requested Max Day 14 Bloods Aspiration 1 st OPA clinic with CT result, Spirometry, Bloods CT suggests Cancer - Is Patient Likely to need radical treatment? Fit for radical treatment? Likely to want radical treatment? 1 st OPA clinic, spirometry, bloods, CT No cancer Discharge to GP or move to alternative pathway CT Yes No *Order concurrently PET scan * Bronchoscopy Image guided biopsy, EBUS * Assessment of fitness * Diagnostics- Bronchoscopy, Image guided biopsy, pleural biopsy MDM Discussion of treatment options No cancer Discharge to GP Day 28-35 Day 30-37 OPA Cancer Confirmed and treatment plan agreed with patient discussed (CNS present) Metastatic disease from alternative primary refer to appropriate MDT Suitable for radical treatment urgeon Suitable for palliative treatment or intervention Day 37-40 Refer surgeon Refer Oncologist Palliative intervention/ symptom control Specialist palliative care Palliative care Day 62 [Type text] Surgery Chemotherapy Radiotherapy

Proposed Pathway 62 Day Timed Pathway for Lung LCA Feedback Day 0 Moderate large pleural effusion Urgent 2ww referral with CXR Internal referrals A&E referrals Incidental findings Routine GP referral 1 st OPA* Referrals triaged, Screened, U&Es checked. CT ordered and booked prior to 1 st OPA No CT required /requested Max Day 14 Bloods Aspiration 1 st OPA clinic with CT result, Spirometry, Bloods CT suggests Cancer - Is Patient Likely to need radical treatment? Fit for radical treatment? Likely to want radical treatment? 1 st OPA clinic, spirometry, bloods, CT No cancer Discharge to GP or move to alternative pathway CT Yes No PET scan * Diagnostics- Bronchoscopy, Image

Scoping Exercise Questionnaire sent to all LCA MDTs Can you offer TWR referrals a CT before the clinic appointment? What are the obstacles?

Feedback Most TWR referrals are not lung cancer Requests not always immediately available to clinicians Requests need appropriate vetting Patients need to be contacted (who and how? /appropriate over telephone?) What matters is time to CT (not whether it is before of after clinic appointment).

Radiology Standards Timing of CT scan For appropriate referrals the CT scan should be performed before the outpatient appointment Ideally requires new 2ww proforma with EGFR measurements requested by GP Referrals need to be triaged and CT request made This may have resource implications such as nursing support to achieve this Access to PET Scanning Standard should be no more than 2 weeks Time to tissue Standard should be to have the biopsy result available for the MDT within 2 weeks of biopsy referral date regardless of method of sampling

Questions

Discussion Questions Is the implementation of CT prior to first appointment reasonable? What are the main problems? Would it help to implement the lung 2WW proforma? Process Agree 2ww proforma content and then work collaboratively with GP led group to understand their challenges for implementation and roll out Will this be enough to make earlier diagnosis of lung cancer? What else can we do or influence?

Summary and Close Dr Liz Sawicka Chair - LCA Lung Pathway Group

Thank you for coming today Presentations will be available on the website after a week www.londoncanceralliance.nhs.uk