Metastatic spinal cord compression

Implementing NICE guidance

2008

NICE clinical guideline 75

Related NICE guidanceThis guideline is related to the following guidance:

•Improving outcomes for people with brain and other CNS tumours. NICE cancer service guidance (2006)

•Improving outcomes for people with sarcoma. NICE cancer service guidance (2006)

•Improving supportive and palliative care for adults with cancer. NICE cancer service guidance (2004)

What this presentation covers

Background

Key priorities for implementation

Costs and savings

Discussion

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Background• MSCC is a rare complication of cancer and is usually an

oncological emergency.

• Some patients experience significant delays from the time when they first develop symptoms to referral.

• Nearly half of all patients with MSCC are unable to walk at the time of diagnosis.

• Early detection, treatment and care can reduce the risk of developing avoidable disability and premature death.

• Early surgery may be more effective than radiotherapy at maintaining mobility.

Key priorities for implementation

The areas identified as key priorities for implementation are:

• Service configuration and urgency of treatment• Early detection• Imaging• Treatment of spinal metastases and MSCC• Supportive care and rehabilitation

• Every cancer network should ensure that appropriate services are commissioned and in place for the efficient and effective diagnosis, treatment, rehabilitation and ongoing care of patients with MSCC. These services should be monitored regularly through prospective audit of the care pathway.

Service configuration and urgency of treatment

• Inform patients with cancer who are at risk of MSCC information about the symptoms of MSCC and what to do and who to contact if those symptoms develop.

• Discuss with the MSCC coordinator immediately patients with cancer who have symptoms of spinal metastases and neurological symptoms or signs suggestive of MSCC and view as an emergency.

• Discuss with the MSCC coordinator within 24 hours patients with cancer who have symptoms suggestive of spinal metastases.

Early detection

• It is important that MRI should be done quickly, dependent upon signs and symptoms.

Imaging

• Nurse flat with spine in neutral alignment patients with severe mechanical pain suggestive of spinal instability or neurological symptoms or signs suggestive of MSCC until spinal and neurological stability are ensured.

Treatment of spinal metastases and MSCC: 1

Treatment of spinal metastases and MSCC: 2

• Start definitive treatment, if appropriate, before any further neurological deterioration and ideally within 24 hours of the confirmed diagnosis of MSCC.

• Carefully plan surgery to maximise the probability of preserving spinal cord function without undue risk to the patient, taking into account their overall fitness, prognosis and preferences.

Treatment of spinal metastases and MSCC: 3

Treatment of spinal metastases and MSCC: 4

• Ensure urgent (within 24 hours) access to and availability of radiotherapy and simulator facilities in daytime sessions, 7 days a week, for patients with MSCC requiring definitive treatment or who are unsuitable for surgery.

• Start discharge planning and ongoing care including rehabilitation on admission.

Supportive care and rehabilitation

Costs and savingsEstimated cases per year in England: 3,100

Recommendations with significant costs

Estimated annual incremental costs resulting from increase in surgical activity(£000s per year)

Surgery for treatment and prevention of MSCC14,023

Recommendations with significant savingsSavings (£000s per year)

Supportive care and rehabilitation post discharge of patients

-17,513

Net resource impact of MSCC guideline -3,490

Costs and savings

Recommendations that may result in additional costs depending on local circumstances:

- Early diagnosis: improving access to MRI scanning services

-Treatment: increasing number of surgical procedures

Recommendations that may result in additional savings include preventing late crisis intervention or need for supportive care.

Discussion• How can cancer networks coordinate and audit the pathway?

• How do we ensure 24-hour availability of senior clinical advisers in centres treating patients with MSCC?

• How do we ensure 24-hour provision of the role of MSCC coordinator?

• How do we raise primary care awareness of significant symptoms?

• How can we improve timeliness of referral and imaging?

• What is the current provision of community-based rehabilitation and supportive care services and do we need to improve this?

Find out more

Visit www.nice.org.uk/CG75 for:

•the NICE guideline •the quick reference guide•‘Understanding NICE guidance’•local patient information template•implementation advice•costing report and template•audit support