Download Cancer care review guidance

Cancer Care Reviews – a guide
The Cancer Care Review (CCR) has been modelled on a template which has been piloted
and evaluated by Macmillan. The patients surveyed were very positive about the process of
a review, with over 71% being ‘very satisfied’ with the process. Patients felt that the CCR
gave them an opportunity to discuss their cancer and general state of health with their GP
and appreciated the fact that their GP made the effort to contact them.
Why do we need this? Cancer survivors often describe the end of the active phase of their
diagnosis and treatment as being like falling off a cliff. The admissions and appointments
cease and there can be no point of reference, there is no one to turn to with their concerns;
people with cancer often feel lonely and cut adrift. The review enables the GP practice to
proffer a helping hand and to compliment the service provided by the Cancer CNSs (Clinical
Nurse Specialists) working within secondary care.
Salford Royal is proactive in the survivorship field; the Breast Service provides a 4 week
“Moving Forward” program, there is a similar Health and Wellbeing event for all tumour
groups and the CANMOVE program promotes the benefits of regular exercise.
The emphasis of the review is not about making complex treatment decisions; clearly
keeping abreast of the rapidly evolving treatment paradigms which are the norm in the
cancer field is well outside a GP’s role. What the review is about is giving the patient an
opportunity to air their concerns and taking a holistic approach to their problems. It really
should not be viewed as a tick box exercise but rather the patient should be allowed to set
the agenda. The template is a guideline not a tramline, this review should be “owned” by the
patient.
To facilitate this it is suggested, though it is not mandatory, that the “Concerns Checklist” is
sent to the patient prior to the appointment. This lists the common problems which face the
cancer survivor; few escape its pinch unscarred. Some of the problems listed are ones which
primary care is adept at managing, for example most GPs are confident at managing many
of the physical and mental issues health mentioned. There are, however, several areas
outside the competence of most family doctors where the appropriate response is to
signpost to other services and resources.
The following guidance about the individual items in the Salford Standard template may be
helpful; in general terms it is suggested that open questions are used rather than narrow,
specific ones. The order in which the questions are approached is not mandated and
practitioners are free to tackle the issues in any way they see fit.
READ CODE 8B3V
1. Reviewing any medication the patient is taking for their condition
It is not expected that the GP should be familiar with the medication prescribed in secondary
care; however he/she does have a responsibility for the medication prescribed by the GP
practice. With respect to Breast and Prostate cancer this is an ideal opportunity to consider
medication such as Gonadotropin-releasing hormone analogues (Zoladex, Prostap etc),
Tamoxifen and Aromatase inhibitors.
As well as discussing adverse symptoms the effect of these agents on bone health and
cardiovascular risk should be discussed. The NICE guidance on Osteoporosis states:
1.8 Consider measuring BMD with DXA before starting treatments that may have a rapid
adverse effect on bone density (for example, sex hormone deprivation for treatment for
breast or prostate cancer).
An initial DEXA scan will probably have been performed either before treatment has started
or shortly after; there is a case for considering bone density measurement every two years in
patients on long term Gonadotropin-releasing hormone analogues and Aromatase inhibitors.
The risk factors for cancer are the same as for cardiovascular disease demonstrated by the
fact that breast cancer sufferers are 50% more likely to suffer a stroke than matched
controls. The Gonadotropin-releasing hormone analogues cause weight gain and have an
adverse effect on lipid profile. Practices may wish to arrange a cardiovascular risk
assessment as part of the Cancer Care Reviews.
Hot flushes can be a debilitating adverse effect of the Gonadotropin-releasing hormone
analogues. NICE guidance 1 suggests treatment with Medroxyprogesterone or Cyproterone
acetate
READ CODES 677H and 80AQ
2. Providing the patient with information about cancer
The Salford Macmillan Information & Support Centre is a drop in service that is open
Monday to Friday from 9am to 5pm. The service provides free information and support to
anyone affected by or living with cancer, there is wide range of information available about;
specific cancers and their treatments, living with cancer eg fatigue, diet, financial issues,
work, travel and emotional support. As well as providing free information resources the
service also runs a numbers of support groups and other services including Look Good Feel
Better, Headstrong, Health Walks, Cancer Health & Well Being program and a volunteer
driver scheme. The service can be contacted by:
Phone:
0161 206 1455
Email:
[email protected]
Address:
Salford Macmillan Information & Support Service
Salford Royal Hospital
Stott Lane
Salford
M6 8HD
There is also great deal of information available for people affect by cancer available on the
internet, however the quality and reliability of this can be variable for this reason it is
recommended that to signpost the following sources;
http://www.macmillan.org.uk/information-and-support/index.html
http://www.cancerresearchuk.org/about-cancer/
http://www.christie.nhs.uk/patients-and-visitors/your-treatment-and-care/patientinformation/
https://www.breastcancercare.org.uk/information-support
https://www.beatingbowelcancer.org/booklets-factsheets
http://www.roycastle.org/how-we-help/lung-cancer-information
http://prostatecanceruk.org/prostate-information
3. Providing information or signposting to sources of information about benefits the
patient may be entitled to
1
https://www.nice.org.uk/guidance/cg175/chapter/1-recommendations
The Salford Macmillan Information & Support Centre has a weekly CAB clinic for people
affected by cancer. The centre is also able to help with Macmillan Grants, these are means
tested grants of up to £400 for people living or beyond cancer.
http://be.macmillan.org.uk/Downloads/CancerInformation/FinancialSupport/MAC4026HWTC
OCe1320150501.pdf This free booklet is available to order via www.be.macmillan.org.uk
READ Code 918A
4. Recording the details of any carer(s) who are supporting the patient
Cancer does not just affect the patient. GPs will be well aware how illness impacts on
families
READ CODE 8BAV
5. Discussing the patient’s cancer diagnosis
It is important to understand where the patient sees themselves on their journey and there
can often be dissonance between what is said in hospital letters and what is believed by the
patient. Questions such as “What have the hospital said about your illness?” can be useful.
Is the patient aware that they have cancer or in denial? It is not necessary to challenge
erroneous beliefs but discussion with secondary care might be appropriate.
In general terms most patients will fall into one of the following groups:
a) Have undergone curative treatment but where there is a chance of recurrence.
b) Have a cancer which is incurable but treatable eg locally invasive Prostate cancer
receiving Gonadotropin-releasing hormone analogues.
c) Have primary or recurrent cancer which is active and progressive and treatment is
being given to attempt cure or improve prognosis.
d) Receiving palliative care.
Patients will often have questions about their illness; if the practitioner does not know the
answer then the resources listed above may be helpful.
6. Anything else?
If the Concerns Checklist is used then it is probably best used here.
If you need to “phone a friend” for advice then the following numbers may be useful2
Salford Royal Urology CNS Team 0161 206 5380
Salford Royal Breast CNS Team 0161 206 2224 (all patients will have a key worker who
can be identified via this number)
The sorts of problems the CNSs can help with or can access help for include:
Erectile dysfunction
Severe psychological distress
Lymphoedema
Body image/relationship issues
Incontinence
2
For patients not receiving care from Salford Royal FT contact details of CNSs will probably be on hospital
letters via consultant’s secretary.
Shoulder problems after treatment for breast cancer
The fear of recurrence is one which haunts many cancer survivors. If the practitioner feels
that there is evidence of recurrence then if the patient is still under Salford Royal then the
CNS team should be contacted but if the patient has been discharged then a new ? cancer
TWW referral should be made
For Breast patients “red flags” would include:
 A palpable lump
 Weight loss
 Upper body or spinal bone pain
 Persistent or escalating headache
For Prostate patients “red flags” would include:
 Visible haematuria
 New onset of bone related pain
 PSA double time <3 months
 Lymphodeama
 Be aware of DVT and Pulmonary Embolism risk
 Acute retention of urine
Metastatic Spinal Cord Compression (MSCC) is a recognised complication of both Breast
and Prostate cancer – the Red flags are:
 Referred pain that is multi-segmental or band-like
 Escalating pain which is poorly responsive to treatment (incl medication)
 Different character or site to previous symptoms
 Funny feelings, odd sensations or heavy legs (multi-segmental)
 Lying flat increases pain
 Agonising pain causing anguish and despair
 Gait disturbance, unsteadiness, especially on stairs (not just a limp)
 Sleep grossly disturbed due to pain being worse at night
Remember: Established motor/sensory/bladder/bowel disturbances are late signs of MSCC
and that MSCC is a neurosurgical emergency
(Taken from Greenhalgh S, Turnpenney J, Richards L, Selfe J (2010)
Steven Elliot
Macmillan GP
15 March 2016