1

Malignant Spinal Cord CompressionPast, Present and Future (South East of Scotland)

Jackie WhighamMacmillan Project Manager for Malignant

Spinal Cord Compression Edinburgh Cancer Centre

May 2010

2

Overview

Facts and Figures

Driver for Change

Scotland’s MSCC Projects

South East Scotland MSCC Project

Jackie’s crystal ball!

Incidence: ?80/million/year

Cancers: breast, prostate, lung, haematological, Renal, GI……….

Symptoms: Pain (radicular), weakness, sensory loss, sphincter disturbance

Diagnosis: MRI whole spine

Treatment: Radiotherapy / Surgery

Prognosis: Mobility after treatment α mobility at diagnosis 3 – 6 months (in relation to cancer stage)

Facts and Figures

23%

77%

Known Cancer Diagnosis

First Presentation of Cancer

Incidence in Relation to Cancer

MSCC within Spinal ColumnMSCC within Spinal Column

1

3

2Copyright J. Armstrong 2006

Malignant Spinal Cord Compression

1

23

4

Copyright J. Armstrong 2006

1. Lack of recognition by primary and secondary care of the early symptoms

2. Lack of appropriate referral pathway once MSCC

suspected

3. Lack of awareness of the most effective investigation for diagnosing MSCC

A guideline for the early diagnosis recommended

Driver for Change Clinical Research Audit Group 97/98 (CRAG audit)

Levack et al 2001 (CRAG Audit 97/98)

1st symptom

tells GP Referred Diagnosis

Patient 3 wks

GP + hospital system 9 weeks

Back pain

Neurogenic pain - 2 months

--------------3 months ----------------

Weakness 3 wks

Sequence of Events

http://www.nice.org.uk/

Cancer Networks in Scotland

Local and National Education Programmes

SCAN

Regional Referral pathway ‘s

Audit

WO Scan

Management Guidelines

Audit

NO Scan

Rapid Referral Hot line Audit

Scottish MSCC Projects

SCANMSCC Steering Group

CHANGE TIME LINE OF EVENTS TO MSCC DIAGNOSIS?

Levack et al 2001 (CRAG Audit 97/98)

1st symptom

tells GP referred diagnosis

patient 3 wks GP + hospital system 9 weeks

back pain

neurogenic pain - 2 months

--------------3 months ----------------

weakness 3 wks

15

What did we set out to do?

1. Develop and Implement Referral Pathways in Four Regions

Referral Pathways in each region

18

Provisional Interim Findings July - December 2010

References:How to... Implement a rapid referral hotlineTrudy McLeay; Graeme Houston; Pamela Levack; Rosie Conway. Synergy; Feb 2008How to... benefit from a rapid referral hotlineTrudy McLeay; Graeme Houston; Wendy Milne; Pamela Levack; Sean KellySynergy; Mar 2008

19

Site of MRI

20

MRI Findings

21

n=324

Mobile18%N=58

Assistance34%

n= 110

Unable to walk48%

n=156

Functional status – CRAG 97/98

22

Functional status – MRI

23

Functional Status 6 week Follow Up

2. Sustainable Education

25

Education- Healthcare Professionals

Basic presentation delivered to healthcare professional who may see patients with suspected MSCC symptoms (identify champion)

GP receives a letter with copy of pathway for any patient who has an MRI for suspected MSCC

Informal opportunities as they arise – talking to GP on phone or staff on ward

CHANGE TIME LINE OF EVENTS TO MSCC DIAGNOSIS?

Levack et al 2001 (CRAG Audit 97/98)

1st symptom

tells GP referred diagnosis

patient 3 wks GP + hospital system 9 weeks

back pain

neurogenic pain - 2 months

--------------3 months ----------------

weakness 3 wks

Known Metastatic Disease

0

5

10

15

20

25

30

35

40

45

50

Yes No

26% Breast

33% Prostate

n=45n=23

28

Education - Patients

Face to Face discussion with patients (and relative if appropriate) diagnosed with Vertebral metastases, MSCC, Impending or nerve root compression

Leaflet to support the discussion

29

3. National Minimum Dataset Audit(SCAN, WoSCAN and NOSCAN)

National Minimum Dataset AuditStarted July 2009 – July 2010

SCAN – 6 months 139 patients’ (MSCC, Impending and treated nerve roots)

Analysis will answer lots of questions including:

Symptom to diagnosis

Functional status at various time points

Steroid practices

Multiprofessional referral

Treatments………………………………

32

What else have we managed to do?

33

The Future for SCAN

Build on the foundation

Consider further development of the service and how this will be taken forward

Add to the evidence base

34

Jackie’s Crystal Ball Advice?Coordinator/Navigator/Specialist

Improve the care for patients with MSCC Collaborate with other networks Build a strong foundation Set standards Develop the service, local policies and protocols Assess educational needs Add to evidence base!

FINALLY

“Metastases to the spine can cause severe pain,

paralysis, and impairment of activities of daily living.

The treatment paradigm for spinal metastases involves

a cohesive multidisciplinary approach that allows

treatment plans to be made in the context of a patient's

overall condition”.

Meyer, Singh and Jenkins 2010

For further information/feedback contact:

jackie.whigham@luht.scot.nhs.uk

Levack, P., Graham, J., Collie, D., Grant, R., Kidd, J., Kunkler, I., Gibson, A.,

Hurman, D., McMillan, N., Rampling, R., Slider, L., Statham, P. and Summers, D. 2001. A prospective audit of diagnosis, management and outcome of malignant spinal cord compression. Clinical Resource and Audit Group (CRAG) 97/98.

Levack, P., Garham, J., Collie, D., Grant, R., Kidd, J., Kunkler, I., Gibson, A., Hurman, D., McMillan, N., Rampling, R.., Slider, L., Statham, P. and D. Summers. 2002. Don't wait for a sensory level-listen to the symptoms: a prospective audit of the delays in diagnosis of malignant cord compression. Clinical Oncology, 14: pp.472-80.

Levack, P., Graham, J. and Kidd, J. 2004. Listen to the patient: quality of life of patients with recently diagnosed malignant cord compression in relation to their disability. Palliative Medicine, 18 pp. 594-601.

Loblaw, D.A., Perry, J., Chambers, A. and Laperriere. N.J. 2005. Systematic review of the Diagnosis and management of malignant extradural spinal cord compression: the Cancer Care Ontario Practice Guidelines Initiatitive’s Neuro Oncology Disease Site Group. Journal of Clinical Oncology, pp. 2028-2037.

References

References

McLeay, T., Houston, G., Levack, P., Conway, R. 2008. How to... Implement a rapid referral hotline Synergy; Feb 2008

McLeay, T., Houston, G., Milne, W., Levack, P. and Kelly, S. 2008 How to... benefit from a rapid referral hotline. Synergy; Mar 2008

McClinton, A. and Hutchison, C.2006. Malignant spinal cord compression, a retrospectiveaudit of clinical practice at the Beatson Oncology Centre. British Journal of Cancer, 94 pp. 486-91.

Meyer, Scott A. Singh, Harshpal. Jenkins, Arthur L.2010. Surgical treatment of metastatic spinal tumours. Mount Sinai Journal of Medicine. 77(1),124-9.

NICE consultation document http://www.nice.org.uk/guidance/index.jsp?action=folder&o=40703

WO SCAN Guidelines for MSCChttp://www.palliativecareglasgow.info/pdf/MSCC%20Guidelines.doc

Warnock, C., Cafferty, C., Hodson, S., Kirkam, E., Osguthorpe, C., Siddal, J., Walsh, R. and Foran.B. Evaluating the care of patients with malignant spinal cord compression at a regional cancer centre. 2008. International Journal of Palliative Nursing, 14 (10) pp. 510 515.