Dr Hilary Williams.

Consultant in Medical Oncology at Velindre Cancer

Centre

Hilary.williams4@wales.nhs.uk

Thinking about Acute Oncology….

- 1 -

1 2 3 4

Why do we need

acute oncology

locally?

What the ‘Hub’

VCC provides

5

The Future

Where acute oncology began for me ~ (2000)

- 2 -

Maggie’s Centre Kirkcaldy opened 2006

Why do we need acute oncology locally?

•“But doctor if I had been diagnosed earlier would any of this be different ?”

- 3 -

NCIN briefing on colorectal cancer Feb 2012.

• KEY MESSAGES:

• Almost 10% of people diagnosed with colorectal cancer

die within one month of diagnosis.

• 56% of people dying within one month are 80 or more

years old.

• 60% of early deaths present initially as emergencycases to hospital.

• At least 50% of patients who die within one month

receive no active treatment.

• Raising the level of public awareness of colorectal

cancer and increasing early diagnosis may help to

improve survival rates for colorectal cancer.

The data behind the ‘patient stories’

• 3 Sources

–ABHB activity figures

–Outcome of calls to 24 hour chemotherapy patient

support line (Viv Cooper)

–Cancer Unknown Primary data for SE Wales (Dr

Paul Shaw)

- 5 -

10% of emergency admissions to ABHB have diagnosis of

cancer e.g. ~ 6000 pts a year or 17 pts a day.

2010/2011 Admissions

Cancer All admissions

%

Emerg adm,

primary

diagnosis

cancer

1985 58561 3%

Emerge adm,

All cancer

diagnosis

3891 58561 7%

Total 10% of

emergency

pts have

active

cancer

- 6 -

Thanks to Sarah

Thatcher & Jayne

Harding at ABHB

Length of stay by cancer site and admission

- 7 -

Cancer

site

Royal Gwent Nevill Hall

Total Avg LoS Total Avg loS

Lung 194 10.8 125 10.5

Colorectal 143 15.0 98 13.4

Upper GI 133 10.2 61 15.1

Other GI 113 14.0 77 14.5

Haematolo

gy 125 15.4 61 9.3

CUP 60 17 108 16

Total 12.5 11.6

Average LoS in ABHB –

12.3 days

17% of patients LoS > 22

days

SE Wales Site of CUP Emergency Admissions

General surgery

Thoracic medicine

Gastroenterology

Geriatric medicine

Endocrinology

Gynaecology

Cardiology

General medicine

Trauma and orthopaedics

Urology

Ear, nose and throat

Infectious diseases

Clinical haemotology

SE Wales Site of Colorectal Cancer Emergency Admissions

General surgery

Gastroenterology

Geriatric medicine

Endocrinology

General medicine

Thoracic medicine

Gynaecology

Cardiology

Infectious diseases

Urology

Accident and emergency

Clinical haemotology

What happens to patients admitted following call to

‘Chemotherapy pager’ ?

• Audit of all calls to emergency chemotherapy support

pager. April 2010-2011.

• 941patients were admitted following a call

• Around 50% admitted outside Cancer Centre (VCC)

• ~ 200 patients a year admitted to ABHB with acute

complication of chemotherapy

• Length of stay available on 37 patients admitted to

RGH

• Average LoS of 6-7 days, range 1-20 days

• (Nb- other patients admitted directly & aim for 50% of chemotherapy to be given outside VCC. ).

- 10 -

Audit of CUP in SE Wales Cancer Network (Dr Paul Shaw)

• Reviewed management of CUP patients referred to VCC over 12 months

• 166 patients identified

• Median age 68

• Patients on average received a total of:

• 19 investigations for metastatic carcinoma unknown

primary, liver

• 13 investigations for metastatic carcinoma unknown primary, bone

• In addition Data from PEDW (Patient Episode Data

Wales)

• 944 admissions in 2009

• Length of stay (average) 9 days- 11 -

- 12 -

• 10% of emergency admissions to ABHB have

diagnosis of active cancer

• ~ 6000 pts a year or 17 pts a day with active

cancer

• Acute care takes 25% of NHS cancer spend

• 10-15% of all acute beds used for ‘cancer care’

• Can we afford not to invest in AOS?

Anecdotally patient experience ‘variable’

So how do we do it?

Hub and spoke model

- 13 -

What is VCC providing & how is this developing?

- 14 -

Hilary Williams

Consultant Oncology at Velindre Cancer Centre

Acute Complications of Cancer

- What the Medical Team Needs

To Know

Thinking about shape acute oncology in AB Health Board….

- -

Predict5 patients admitted every 24 hours to

ABH with known or likely cancer

Predict5 patients admitted every 24 hours to

ABH with known or likely cancer

Patient focused careAppropriate rapid

decision making

Mon-Fri Service at RGH & NHH

Link with

Visiting Consultants

2 Specialist nurse

per hospital

AdminOffice & Clinic space

IT

Rapid liaison VCC & rapid access

clinics

Rapid liaison VCC & rapid access

clinics

EngagePalliative care

RadiologyCurrent pathways

EngagePalliative care

RadiologyCurrent pathways

Education Admitting & A & E

teams

Education Admitting & A & E

teams

Protocols e. g. Unknown primary

Spinal Cord Compression

Protocols e. g. Unknown primary

Spinal Cord Compression

Support management

complications of treatment

Support management

complications of treatment

Rapid focusedpathway cancer

unknown primary

Rapid focusedpathway cancer

unknown primary

Reduced length stayReduced investigationsReduced admissions

Benefit- Patient

Benefit- costCosts

Direct Clinical Role

Developmental Role

Education junior doctor teams

Education junior doctor teams

Engagement Management ReviewCONFIDENTIAL

In more detail

Key roles of CNS

• Review all admissions acute complications

chemotherapy

• New presentation metatastic disease

• MSCC co-ordinator

• Education

Challenges

• Establish key links with

–Chemo day unit

–Local palliative care

–VCC hub

• Link visiting consultants

• Link with established service’s

• Link with community

• Establishing outcomes’s

• Out of hours service

- 17 -

South East Wales Cancer Network CUP Pathway (

Patient with suspected Metastatic

Malignancy of undefined

Primary on imaging or pathology

PS3/4 or Unsuitable for cancer

specific Rx?

Pall care/oncology Review

need for

investigations/biopsy

Yes

No

Liase with site specific oncologist to consider special diagnostic tests (B) &

biopsy

Likely primary tumour

identified?

YesRefer to site specific cancer

MDT

Uncertain

Patient with specific CUP syndromes

No Patient with

confirmed CUP

Tel AEB sec and patient

allocated next available

Oncology OPC with

appropriate consultant

Squamous carcinoma

involving upper/mid head

and neck nodes

Adenocarcinoma involving

axillary nodes

Squamous carcinoma

involving inguinal nodes

Solitary metastasis (brain,

bone, skin, lung, liver) Radical

treatment

possibility

Poorly differentiated

carcinoma with a midline

nodal distribution

Female with predominant

peritoneal

adenocarcinoma

Poorly differentiated

neuroendocrine tumour

Dr M Evans/ Dr N

Paniapan

Sec

Head and Neck

Dr S Waters/ Dr H Passant

Sec (Daphe)

Breast

Dr E Hudson/ Dr R Jones

Sec (Name)

Gynaecology

Dr O Tilsley (BRAIN/BONE)

Sec

Dr A Brewster (LUNG) or Lung

MDT/Lung physcians

Sec

Dr H Williams (LIVER) or HPB MDT

Sec

Dr S Kumar (SKIN) & skin MDT

Sec

Dr M Button/ Dr J Lester

Sec

Urology

Dr E Hudson/ Dr R Jones’

Sec (Name)

Gynaecology

Dr H Williams

Sec

Gastrointestinal

Refer Non-epithelial malignancies to site

specific MDT/oncologist

Lymphoma Haematology team

Melanoma Dr Kumar

Sarcoma Dr Tilsley

With acute oncology service in place future opportunities…

- 19 -

Earlier cancer diagnosis metastati c disease & improved one year survivals

And measure it

all

And if you don’t remember anything else

- 20 -

• 10% of emergency admissions to ABHB have

diagnosis of active cancer

• ~ 6000 pts a year or 17 pts a day with active

cancer

• Acute care takes 25% of NHS cancer spend

• 10-15% of all acute beds used for ‘cancer care’

• Can we afford not to invest in AOS?

Anecdotally patient experience ‘variable’