Download Stratified Breast Pathways

Stratified Breast Pathways
Catherine Neck
Macmillan Cancer Rehabilitation/
Recovery Package Project Lead
27th January 2017
Recovery Package & Stratified
Pathway Recommendations:
• ‘Cancer Taskforce is working with Macmillan to
roll out the ‘Recovery Package’… a set of actions
that ensure the individual needs of all people
going through cancer treatment are met by
tailored support and services’
• ‘We know that risk stratified pathways for breast
cancer patients can not only improve care for
patients after treatment, but create more
efficient pathways that can reduce unnecessary
hospital appointments’
• By March 2017, NHS England, through Cancer
Alliances, will drive the spread of riskstratified pathways, including supported selfmanagement, for breast cancer, including
assessing the role of commissioning incentives
to encourage implementation
• In subsequent years we will focus energy of
rolling out this approach to other cancer sites
SWAG Cancer Alliance
• Living With & Beyond Cancer (LWBC) working
group
• Aiming to deliver Taskforce recommendations on
a local level
• Sub-groups focussing on content and quality of
Recovery Package delivery across Alliance (HNA,
TS and H&WB events)
• Stratified Pathway review – aim to standardise
approaches to follow-up across the Alliance
Review of Current Pathways
• Call for examples of current pathways
including evidence of any stratification across
both SWAG and Peninsula Cancer Alliances
• Trusts at different stages but breast further
ahead of other cancer sites
• Examples where teams have fully stratified
breast pathways
• Others moving toward this
Examples of good practice
Tumour Group:
Breast Non-Metastatic
Risk Stratified
Group
All patients are stratified to self-management on completion of treatment
Patient stratification and criteria
Description risk stratified criteria:
Supportive self-management
Curative intent
No routine outpatient appointment
Stable disease pattern
Treatment with curative intent
Annual mammogram or MRI for an agreed period with results by post or phone
Open access to breast service via breast care nurse – via email and/or phone?
Supported self-management with remote surveillance is the default
Routine surgical review for those following bilateral mastectomy who are not eligible for
mammographic surveillance – annual for 5 years.
Stratification to self-management supported through the recovery package (holistic needs
assessments with care plans, treatment summaries and health and well being events), remote
surveillance and telephone access to CNS with rapid access back to specialist care where
required, without need for GP referral.
Follow up procedures
Consultant led face-to-face follow up for this group?
No patients receive routine face to face follow up. However all have ‘open appointments’
following completion of treatment forever.
Do any of the groups receive other follow up? Please list the group, frequency and type of
follow up – for example Nurse led, Telephone follow up, etc.
On completion of all treatment each patient has an appointment with their CNS for a holistic
needs assessment.
Please list the type and frequency of diagnostic follow up for each of the groups:
All breast patients (unless a double mastectomy) will have annual mammograms for 5 years postsurgery
Younger breast patients will have either MRI or mammograms until the age of 50
Do patients have access to health and well-being clinics? If so are they generic or site
specific? How frequently are these clinics held? Please list all clinics and their frequency.
After completion of treatment all patients are invited to attend a Health & Wellbeing clinic run by
the Breast Care Team .
Site specific Health & Wellbeing clinics are held every 6 weeks – could these be linked to existing
appointments?
4 week post-op group clinic review which covers post-op issues and introduces future planning
including the Recovery Package and self-management courses
Look at linking with other third sector/ community groups
If patients experience any signs for concern how do they re-access the service? Please
give examples of how and what the process is.
They are all given written information on how to contact the service.
They can go through their CNS
They can phone or email? admin directly for an appointment
Do your patients have access to follow up from other organisations? E.g. Third sector
organisations. Please specify the organisation and the service they deliver.
(Examples of local/ national services are)
Lymphoedema service for assessment and treatment of lymphoedema.
Breast Cancer Care workshops for younger patients and metastatic patients.
Breast Cancer Haven free programme offering support, therapies and classes to patients during
and after breast cancer treatment.
The Harbour (Bristol) offers free counselling and psychotherapy.
Macmillan/RNHRD Step Up Fatigue & Lifestyle Management Programme – providing treatment
and support for patients that have completed primary cancer treatment to reduce cancer related
fatigue. (Not available for BANES patients currently, due to funding issues).
Macmillan Citizens Advice Bureau – Financial/Benefits Advice service.
Macmillan Bath Buddies - volunteer service providing support, including practical light help
around the home/ garden.
We Hear You – free professional counselling service for cancer patients and their families..
Penny Brohn UK – free Courses (both day and residential) offering treatment support, including
alternative therapies, nutrition, and counselling for patients before, during and after treatment.
Dorothy House Hospice – provides emotional, psychological, practical and social support,
symptom control, therapies and treatments for palliative patients and their relatives/ carers.
Keeping Abreast breast cancer reconstruction support group for the south west.
Examples of good practice
Tumour Group:
Breast cancer
Risk Stratified
Group
Metastatic breast cancer
Diagnosis of metastatic breast cancer / local recurrence
Patient stratification and criteria
Description risk stratified criteria:
Complex care
Patients have individualised care plans which can be complex and their care is managed/
shared by health care professionals within the MDT team
Advanced disease or ongoing treatment – remain on regular oncology review at a frequency
dependent on clinical circumstances
Follow up procedures
Consultant led face-to-face follow up for this group
All Metastatic breast cancer patients will receive face to face follow up in a consultant led clinic
either with the consultant or registrar, the frequency of a patients appointments are determined by
the treatment regime, disease progression, on-going symptoms and the information/ support
required by each individual patient
Do any of the groups receive other follow up? Please list the group, frequency and type of
follow up – for example Nurse led, Telephone follow up, etc.
All metastatic breast patients have a Clinical Nurse Specialist allocated as a keyworker who will
initially meet with them face to face and then provide on-going support as required by the
individual patient ( face to face, telephone and email)
They may also be followed up by other members of the MDT team
Please list the type and frequency of diagnostic follow up for each of the groups:
The diagnostic follow up is managed on an individual patient basis, but usually metastatic breast
cancer patients are assessed by regular scans (CT, PET, MRI and Bone, 3-6 monthly), bloods
tests, tumour markers and review in a consultant led oncology outpatient clinic.
Do patients have access to health and well-being clinics? If so are they generic or site
specific? How frequently are these clinics held? Please list all clinics and their frequency.
Metastatic breast cancer patients have access to a monthly Living with Secondary Breast Cancer
Support Group (Held in Bristol, which is free)
If patients experience any signs for concern how do they re-access the service? Please
give examples of how and what the process is.
N/A
Do your patients have access to follow up from other organisations? E.g. Third sector
organisations. Please specify the organisation and the service they deliver.
Breast Cancer Charities (stage 3&4)
Support groups locally
Future:
• Can we agree to an Alliance-wide approach to
stratification in breast cancer?
• What steps are needed?
• Comments please……….