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Skin Cancer and Rehabilitation Report to Skin NSSG Sally Donaghey Macmillan AHP Lead, Ang CN [email protected]/Tel: 01638 608218 Skin and Rehabilitation Lymph node dissection – risk of lymphoedema Disease and treatment related management issues – nausea/vomiting; fatigue, weight loss, mobility, pain, prosthesis, reconstruction. Supportive care is key element of clinical management in skin cancer – OT, physio, prosthetics (IOG 2006) Issues and Initiatives in Rehabilitation Cancer rehabilitation nationally is poorly developed, evidenced and under recognised/utilised. Establishment of evidence base and National Cancer Rehabilitation Pathways. Development of tumour specific local rehabilitation pathways Need for pathways to be integrated into main care pathway and practice. Workforce Mapping Workforce Mapping cont.. Workforce Mapping cont.. Findings Relatively low numbers of AHP’s for population against national average – Unmet need or – Need provided by generalist workforce? Variablity in specialist service provision between localities – Consider referral pathways Setting - 53% Acute. 2009 figures indicate slightly higher then national average cancer rehab services in community – Care closer to home? Rehabilitation Triggers Rehabilitation Triggers .. Lymphoedema – Lymph node dissection, risk assessment for lymphoedema Physiotherapy – Difficulties with movement, weakness, fatigue, exercise advice and information. OT – Difficulties with ADL, leisure and work, functional assessment, equipment needs Dietietics – Nutrition, appetite, nausea, weight loss/gain, fatigue, swallowing SLT – Swallowing, impaired speech Prosthetics Management of Patients at Risk of Lymphoedema International Consensus – Best Practice for the Management of Lymphoedema – Lymphoma Framework (2006) National Rehabilitation Care Pathway - Lymphoedema Prevalence of Lymphoedema in Melanoma Urist et.al. Cancer (1983) – Inguinal LND 26% leg oedema – Axillary LND 1% arm oedema – Total group 8% oedema – ILND 30% Wrone et.al. Arch Dermatol (2000) Starritt et.al. Ann Surg (2004) – ALND 10% – ALND + RT 53% De Vries et.al. Euro Jnl Surg Onc (2006) – SLNB 6% – SLNB + groin dissection 64% De Vries et.al. Ann Surg Oncol (2009) – SLNB (axillary and inguinal) 8.9% – CLND (axillary and inguinal) 37% – SLNB (axillary and inguinal) 1.7% Sabel et.al. Surgery (2007) Chang et.al. Ann Surg Oncol (2010) – ILND 30% mild 15% moderate Costs of lymphoedema 472 melanoma incidence p.a in Anglia CN accessed 21.11.11) Lymphoedema related cellulitis: – In pt £700 = 2.03 bed days – 2 GP consultations pp/p.a. £100 – Provision of diuretics pp/p.a. (Todd et.al. Jnl Lymph 2010) NHS In pt £365-482 per day New Pt £153-227 FUP £69-115 Intensive 10 day programme @ 1hr per day £844-1196 Arm Sleeve £15-29 Glove £38-65 Below Knee Stocking £22-35 Full Thigh £50 pair (Macmillan NLCN Lymphoedema Project 2007-10) (ECRIC Key Points NICE (IOG 2006) – Lymphoedema Therapist as part of extended MDT. – Access to lymphoedema services as required Best Practice for the Management of Lymphoedema (Lymphoedema Framework 2006) – Those at risk identified early – staff awareness and knowledge of appropriate pathway – Pts and carers provided with information/education for early signs and management NCAT (Lymphoedema Rehabilitation Care Pathway 2009) – At risk pts should be screened and advised of risks – At risk pts to be provided with information of signs/symptoms and encouraged to make early presentation. Barriers to Rehabilitation Implementation. AHP attendance at MDT/clinics Awareness of rehabilitation needs Co-ordination of rehabilitation needs Lack of resources What Can the NSSG Do? NSSG Workplan and guidelines Endorsement of needs analysis and service development Skin Care pathway – specific reference to rehab Locality/clinician engagement Audit of referrals/interventions/patient surveys Useful Links Local Skin Rehabilitation Pathway: http://www.angliacancernetwork.nhs.uk/documents/AngCNCCGPS28%20Rehabilitation%20Pathway%20for%20Skin%20Canc er_v2.pdf NCAT. Supporting and Improving Commissioning of Cancer Rehabilitation Services Guidelines: http://ncat.nhs.uk/sites/default/files/NCAT_Rehab_Commissio ning.pdf NICE IOG 2006: http://guidance.nice.org.uk/CSGSTIM/Guidance/Standard2006 /pdf/English