Download for CUP? - Northern England Clinical Networks

Cancer of Unknown Primary
Dr Chris Jones
Consultant Medical Oncologist
North of England Cancer
Network Annual Conference
20 September 2013
Introduction
• what is cancer of unknown primary (CUP)?
 metastatic epithelial or neuroendocrine malignancy on biopsy
 no apparent primary site identified, despite investigations determined by
specialist review
• how big a problem is it?
 3% of total cancers registered
 7% (men) and 9% (women) of all cancer-related deaths
 fourth most common cause of cancer death (after lung, colorectal, breast
ca.)
 only 16% of patients survive for a year
 2% of all cancer-related inpatient episodes, mostly emergencies
2
NHS | Presentation to North of England Cancer Network Annual Conference – 20 September 2013
Where have we come from?
• How has CUP been managed in the past?
 few, if any, specialist CUP teams
 patients bounced between MDTs
 patients over- or under-investigated
 patients feeling “lost in the system”, “falling
through the cracks”
 best guess chemotherapy
 empiric cover-all chemotherapy (domestos!)
3 NHS | Presentation to North of England Cancer Network Annual Conference – 20 September 2013
What are we doing about this?
• NICE guidelines (CG104) 2010
• NCAT peer review measures 2012
 set up CUP assessment teams
• assess patient fitness for further investigation and treatment
• ensure initial investigations are performed
 set up CUP multi-disciplinary teams
• rational use of further specialised investigations
• identify best treatments
• access to clinical trials
 set up CUP NSSG
• standardise approach to investigating and managing CUP across the network
4 NHS | Presentation to North of England Cancer Network Annual Conference – 20 September 2013
What are we trying to achieve?
• rational decision making to select:
• patients who are too unwell to benefit from further investigation and cancer
treatment, and refer them early to palliative care
• patients with an identifiable primary, and refer them to a site-specific specialist team
• patients with a potentially curable presentation of CUP, and refer them to specialist
teams for radical treatment
 solitary metastases, resectable lymph node metastases, possible germ-cell
tumours
• patients with incurable but highly treatable CUP syndromes, and offer them specific
chemotherapy regimes
 high-grade neuroendocrine CUP, peritoneal adenocarcinoma in women
• patients with CUP who might benefit from empiric chemotherapy
5 NHS | Presentation to North of England Cancer Network Annual Conference – 20 September 2013
What have I achieved so far?
• prevented a lot of unnecessary investigations; about 20% of
referrals were too unfit to justify further tests
• identified a primary site in about 50% of referrals
• even found a few non-cancers!
• confirmed a diagnosis of CUP in about 30% of referrals
• support, information, explanation
• about 1 in 7 treated radically
• palliative chemotherapy and radiotherapy
• recruitment to clinical trials
6 NHS | Presentation to North of England Cancer Network Annual Conference – 20 September 2013
What would be the “Holy Grail” for CUP?
• if only we could identify the primary cancer in all CUP
patients!
• access to best evidence-based treatments
• dedicated specialist team
• accurate information about prognosis
• at the moment, our best assessment involves scans, biopsy,
endoscopy, specialist review
• what if there was a single test that could tell us exactly what
this cancer of unknown primary actually is?
7 NHS | Presentation to North of England Cancer Network Annual Conference – 20 September 2013
New technology for CUP
• New molecular tests for CUP may be the answer?
• different types of cancer tend to switch on certain parts of their DNA genetic code in
a typical pattern (gene expression)
• new tests on a CUP biopsy can “peer inside” the cancer cell, read the gene
expression pattern, and tell you what it is most likely to be
• early non-randomised data suggest that assay-directed site-specific therapy may
result in longer survival than with empiric chemotherapy (Hainsworth, JCO 2012)
• subgroup of assay-identified colon cancer have similar response and survival with
site-specific chemo compared with known metastatic colon cancer (Hainsworth, Clin
Colorectal Cancer 2011)
8 NHS | Presentation to North of England Cancer Network Annual Conference – 20 September 2013
Should we be using this new test for CUP?
• But…
• these tests are expensive
• not NICE approved as no randomised data to support their
use
• several different versions of the test – which is best?
• are they really giving the true answer?
• is a cancer which presents with metastases but no primary
going to respond to treatment in the same way as in a
conventional presentation, or are they different diseases?
• is assay-directed site-specific chemotherapy actually
better than empiric chemotherapy for CUP?
9 NHS | Presentation to North of England Cancer Network Annual Conference – 20 September 2013
UK national clinical trials for CUP
• CUP-1 study
 part 1 – collecting biopsy samples from potential CUP patients, to validate
the 3 different molecular diagnostic tests and pick a “winner”
 part 2 – treating CUP patients with empiric chemotherapy with close follow
up for response and survival to establish a “reference regime”
• CUP-2 study
 (in planning stage)
 randomise CUP patients to receive either empiric chemotherapy or assaydirected site-specific chemotherapy, to determine which approach gives the best
results for response and survival
10 NHS | Presentation to North of England Cancer Network Annual Conference – 20 September 2013
Summary – what is on the horizon for CUP patients?
•
•
•
•
CUP is on the agenda
new teams to support patients
new pathways to prevent delays
rational use of investigations
- to identify the primary
- to select CUP patients who could benefit from specific
treatment
• access to clinical trials
11 NHS | Presentation to North of England Cancer Network Annual Conference – 20 September 2013