Download presentations from the event are available here

LCA Breast Pathway 7th Clinical
Forum
17th September 2014
Welcome
Breast Pathway Update
Dr Will Teh
Chair, LCA Breast Pathway Group
Consultant Radiologist, North West London Hospitals NHS Trust
Breast metrics
Dr Will Teh
Chair, LCA Breast Pathway Group
Consultant Radiologist, North West London Hospitals NHS Trust
The London Cancer Alliance West and South
Breast Metrics Highlights Q1 2014-2015
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Cancer Waiting Times
COSD MDT feeds
Diagnosis data
HNA
For more information on these slides please contact
[email protected]
Senior Cancer Information Analyst, LCA
Pathway audit of women
undergoing mastectomy
February – May 2014 data
Miss Nicola Roche
Consultant Breast Surgeon
The Royal Marsden NHS Foundation Trust
The London Cancer Alliance West and South
Pathway audit of women undergoing mastectomy
• Monthly audit returns collecting data for women
undergoing mastectomy by originating Trust
• Data collected included: patient age, type of
mastectomy, type of reconstruction (if any), hospital
where mastectomy was performed, whether cancer was
screen detected or symptomatic and days from referral
(or date of decision to recall) to date of surgery.
The London Cancer Alliance West and South
Plastic Surgical Centres and referral patterns
• GSST
– KCH, PRH, QEH (Greenwich)
• Imperial
– Ealing, West Mid, NWLH
• RMH
– Kingston
• SGH
– CUH
• Other
– Hillingdon: RFH
– PRH / QMS: East Grinstead
Table Discussion – Immediate
Breast Reconstruction
Day case Mastectomy at
Birmingham City Hospital
Jevan Taylor
Consultant Oncoplastic and Reconstructive Breast Surgeon,
Worcestershire Acute Hospitals NHS Trust
The London Cancer Alliance West and South
Motivation
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Patients genuinely don’t want to be in hospital
Breast surgery is short duration
Post-operative pain is minimal
Early mobilisation is possible
Adverse post-operative events are rare
Frees up inpatient beds
Attracts enhanced ‘Best Practice Tariffs’
The London Cancer Alliance West and South
Current situation
National audit 11/2010 – 03/2011: 666
mastectomy and 1421 ‘other’
15% Day case, 75% overnight stay, 10% 72 hours
The London Cancer Alliance West and South
Current situation
Patient Pathway at City
The London Cancer Alliance West and South
Results clinic
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Day case is the default position
Informed consent
Agree surgery date
Breast care nurses vital
MRSA and MSSA swabs
Day case admission card
List scheduling
The London Cancer Alliance West and South
Pre-op assessment clinic
• Discharge planning vital
• Written protocols for managing co-morbidities and
Rapid referral routes (ECHO, lung function etc.)
• Prescribe TTOs
• Physio assessment
• VTE assessment
• MRSA and MSSA swab results and eradication
• Confirm admission details, fasting instructions etc.
The London Cancer Alliance West and South
Day of surgery
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Staggered admissions, mastectomy patients early
Bespoke fasting instructions
All-day lists
Avoid pre-medication
Pre-operative analgesia
Short-acting opiate intra-operatively
Local anaesthetic ‘rib blocks’
No drains default policy
The London Cancer Alliance West and South
Post-operatively
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Nurse-led discharge
TTO analgesia pack
Clear instructions about wound care, exercises etc.
Follow up clinic booked
Telephone follow-up at 48 hours
Easy access to advice or review
Teamwork
Outcomes
The London Cancer Alliance West and South
Internal audit
• 221 consecutive ‘day case’ mastectomy patients April
2008- April 2011 vs. 221 matched inpatients
• Mean age 60.3 years (±12.1)
• 123 Mx+ALND, 48 Mx+SLN, 50 simple Mx
• 86% discharged same day, 14% within 23 hours vs.
11.7%
• Fentanyl 90% vs. morphine 90% (p<0.001)
• Re-operation rate 1.8% vs. 3.2%
• Only 10 mastectomies had to be performed on inpatient
lists due to co-morbidity or obesity
The London Cancer Alliance West and South
Conclusions
• Same day discharge is safe
• Same day discharge is possible for most patients
• Must manage patients expectations from their first
contact, and then reinforce it at every opportunity
• Staff need to be enthusiastic about short stay
• Education events, feedback to ward staff patients’
positive comments
Table discussion – Day case and
overnight stay
Access to Specialist Metastatic
Services
Dr Marina Parton
Consultant Medical Oncologist
The Royal Marsden and Kingston Hospitals
The London Cancer Alliance West and South
Format for discussion today
• NICE advanced breast cancer guidance , Breast cancer care pledge
• LCA scoping audit 2013
Examples of MBC cancer services
At a centre-RMH
at KHT (satellite chemo services on site)business case and 2 years on
Table top discussion
The London Cancer Alliance West and South
MBC treatment and management consensus
•MBC mdt
•Access to a specialist
breast cancer nurse
•Participation in trials
The London Cancer Alliance West and South
NICE guidance
Patient focused careKey worker
The London Cancer Alliance West and South
Secondary Breast Cancer Pledge
‘Pledge Partnership’
Breakthrough Breast Cancer and Breast Cancer Care
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surveys, patient interviews and appointing patient representatives
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4 main areas
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services
• Discussion of health and social care needs, care and assistance at home
• Discussion of feelings and emotions
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information
• Diet/ exercise, financial support, psychological and emotional support
• Emotional support for patients and families
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Relationships/emotional support
• Length of time spent on giving the diagnosis
• Named breast care contact
• Coping with the effects of treatment
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autonomy
• Time to discuss decisions with doctors
The London Cancer Alliance West and South
Specialist metastatic services
core essentials and beyond
• secondary CNS
• MBC clinic with longer time slots for discussion and support (incl. access
to dietician, SW, counsellor, palliative care)
• MBC MDT- discussion of new /complex cases
• MBC database- new cases and outcomes and survival
• Clinical trials for MBC – easier access elsewhere (awareness and pathway)
or on site
• +/- chemotherapy on site.
The London Cancer Alliance West and South
What we have in the LCA : 2013 scoping audit
6 questions to assess the
current availability of services
in the LCA
The London Cancer Alliance West and South
Q1. CNS cover for metastatic patients. Do you have:
a. A dedicated CNS with specialist training in secondary breast cancer?
b. A Breast CNS who has dedicated time to see women with secondary breast cancer?
c. Ad hoc CNS cover
d. No CNS cover
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A dedicated CNS with specialist training A Breast CNS who has dedicated time to
in secondary breast cancer
see women with secondary breast cance
KHT
RMH
Imperial
WMUH (if at CXH)
NWLH
PRUH
GSST
CUH
St Georges
Hillingdon
Ealing
QEH
LewishamQMS
Kings
Adhoc CNS Cover
1. CNS Cover for Metastatic Patients
No CNS cover
The London Cancer Alliance West and South
Q2. Is a CNS present when a patient is told they have metastatic disease?
a. Always
b. If possible
c. Rarely
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10
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St Georges
Ealing
NWLH
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4
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Always
If possible
Rarely
2. Is a CNS present when a patient is told they have metastatic disease?
The London Cancer Alliance West and South
Q3. Do you have specialist metastatic breast clinic?
a. No
b. Yes for some patients
c. Yes for all patients
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No
Yes for some patients
Yes for all patients
3. Do you have a specialist Metastatic breast Clinic
RMH
St Georges
The London Cancer Alliance West and South
Q4. Which women with newly diagnosed metastases are discussed in a MDT
a. All patients with secondary disease
b. Selected patients
c. Rarely discuss secondary disease at MDT
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All patients with secondary disease
Selected patients
Rarely discuss secondary disease at
MDT
4. Which women with newly diagnosed metastases are discussed in an MDT?
The London Cancer Alliance West and South
Q5. Are patients with secondary breast cancer discussed in?
a. Specialist MDT
b. Main MDT
c. Not routinely discussed
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Specialist MDT
Main MDT
Specialist MDT & Main MDT
5. Are patients with secondary breast cancer discussed in?
Not routinely discussed
The London Cancer Alliance West and South
Q6. Do you keep a data base of women who have developed secondary
breast cancer?
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Yes
No
Not Specified
6. Do you keep a data base of women who have developed secondary breast cancer?
Imperial
NWLH
PRUH (CIMS+INFOFLEX)
Lewisham (CIMS+INFOFLEX)
GSST- bespoke
The London Cancer Alliance West and South
The Royal Marsden Hospital MBC services
• Dedicated MBC clinic at Chelsea (Monday and Wednesday)
and Sutton (Tuesday and Wednesday)
• Dedicated secondary breast cancer CNS + others
• Pre- clinic MDT with formal presentations
– Research team, palliative consultant or team member/clinical
oncology
• Access to on site dieticians, social worker, counselling, family
counselling, psychosexual health, acupuncture, Breast Cancer
Haven other local support groups nearby
• Several oncologists, dedicated secondary CNSs at both sites,
complement of medical staff
The Royal Marsden
Access to
Specialist
Metastatic
Services
Diane Mackie
Clinical Nurse Specialist
Secondary Breast
Cancer
LCA Breast Pathway 7th Clinical Forum 17/09/2014
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The Royal Marsden
LCA Breast Pathway 7th Clinical Forum 17/09/2014
Clinical Nurse Specialist Secondary Breast Cancer
– CNS SBC
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First post created in 1997 at Charing Cross Hospital
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Historically BCNs cover the whole disease trajectory
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Breast Cancer Care Secondary Breast Cancer Taskforce 2006
Final report 2008 a key recommendation was that all people with
secondary breast cancer have access to a specialist nurse, CNS SBC
the gold standard
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2014 there are 35 Clinical Nurse Specialists for Secondary Breast
Cancer and approximately 600 for early breast cancer
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The Royal Marsden
LCA Breast Pathway 7th Clinical Forum 17/09/2014
Challenges/Changes
– Increasing caseload numbers, busier clinics
– Managing patients expectations, increased awareness
– Increasingly complex treatments, consequences of chronic
treatments
– More treatments being delivered on an ambulatory care basis
– Less hospital admissions, liaising with community services
– Increasing constraints on social services and financial support
The Royal Marsden
Key Worker
Gold standard is CNS SBC
Where there are gaps in the provision of CNS SBC service
reconfiguring existing workforce to take on role of key
worker with additional training in;
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Knowledge of SBC treatment and disease trajectory
Understanding psychosocial impact
Palliative care knowledge
Ability to discuss end of life issues
Knowledge of local and national support services
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The Royal Marsden
LCA Breast Pathway 7th Clinical Forum 17/09/2014
Conclusion
In recent years there have been substantial developments in various
systemic therapies, which have improved the outlook for many
women with SBC. Despite this specialist nursing services for SBC
remain in their infancy and the momentum started by BCC and
others need to be maintained to promote the best possible support
to this growing group of patients.
The London Cancer Alliance West and South
DGH MBC at Kingston
• Kingston Hospital- RMH satellite on site providing all non-trial
therapy in common tumour types, limited NCRN trials
• Approx. 230 BCs per year- within 2-3 years sizable MBC
population in joint clinics
• 2011 proposal to fund MBC clinic within RMH services on site
• (switching MBC patients from Joint surgical clinic to RMH MBC
clinic)
The London Cancer Alliance West and South
Rationale and proposal
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Joint clinics–
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capacity, waiting, poor experience,
Losses due to bundle surgical tariff (scans)
MBC clinic
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Longer time slots
dedicated Breast Care Nurse available (multi skilled)
Access to trials on site and at RMH
Better communication with the chemo unit as on EPR
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1 clinic a week – 8-9 patient slots
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0.125wte Consultant Medical Oncologist (no cover)
0.2wte Breast Care Nurse (Band 7)
0.2wte secretary (Band 4)
0.2wte Radiology Admin (Band 3)
0.1wte Clinic Nurse (Band 6)
0.1wte Clinic Nurse (Band 6)
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Patient pathway outlined frequency of scans and FU (outlined costs for ER pos, HER2 pos and
survival)
The London Cancer Alliance West and South
DGH MBC clinic
Patients on follow-up in
existing JOC
Patients referred whilst
an Inpatient (AOS)
Breast Metastatic Clinic
Tuesday PM
Upstairs/downstairs - TBC
Patients referred following
presentation of metastatic
disease from Friday
diagnostic clinic
Support needed:
Medical Oncologist
CNS support
Research Nurse
Counselling
+/-Dietetics
Pathway
determined in clinic
Patient treatment pathways
according to tumour subtype
Complex cost modelling
over several years and
projected costs
Endocrine (hormone)
only therapy
May or may not require
chemotherapy in future
Chemotherapy
+/- Herceptin
(50% of patients)
Endocrine therapy in
conjunction with IV
bisphosphonates
Therapy prescribed by
GP on instruction from
Oncologist
Treatment on MDU-K
9 x RDA - 6# taxanes - 1 per 3
weeks (docetaxel, vinoralbine
or capecitabine)
8 x RDA herceptin - every 3
weeks, continuous
Treatment on MDU-K
12 x RDA – 12#
bisphosphonates – 1
per month
Follow-up in clinic
5 x OPA p.a.
Follow-up in clinic
4 x OPA p.a.
Follow-up in clinic
4 x OPA p.a.
4 x CT scan p.a.
4 x CT scan p.a.
4 x CT scan p.a.
Prognosis:
approximately 5 years.
2 x echo in year 1
2 x bone scan p.a.
Prognosis: usually
between 2-4 years.
Prognosis: usually
between 2-4 years.
Patients likely to
progress within 12-18
months; 50% will move
to chemotherapy
Decrease of 30% of patients in
year 4; another 50% in year 5
Patients likely to
progress within 6-12
months; will then stop
Herceptin
Decrease of 50% of patients in year 3;
another 50% in year 4; No patients at year 5
The London Cancer Alliance West and South
2-3 years on
• Pros
– Better service for patients - longer slots, better
quality consultations/discussions and support
– Ability to introduce complex study discussionstrial discussions enabled
– Satisfying to provide care – enhances on site skills
of entire team
The London Cancer Alliance West and South
2-3 years on
• Cons
– Clinic at capacity most weeks- esp. after leave- no other
oncologists/cover
– Use of other local services- dietetics, social worker, physio
– Demands on support services at KHT not anticipated
• Complex radiology reporting- additional imaging -MRI spines
• biopsy of rec disease
• Demands on KHT AOS and medical teams with more complex patients
– Demands on CNS ++ no middle grade when consultant off site unless
known to chemo unit- arranging scans, referrals, admissions, and
forwarding blood tests as well as supportive calls’ little time for
supportive work!!
– Education and training for BCN- depends on background- palliative
care, psychosocial support, skills in managing the distress of patients
and peers
– Trial uptake
The London Cancer Alliance West and South
Summary
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Some provision of MBC services already in the LCA
• Recommendations
– Secondary CNS-with access to specific education, resources, updates incl.
national networking
– MDT (main MDT for all new presentations, main/MBC MDT for complex case
discussions)
• Record new presentations. Develop a database for outcomes and survival
– MBC clinics
• Anticipate the additional resources for support and treatment outside
chemotherapy
– Access to clinical trials- awareness of availability of local studies – network
with centres better, and aim to have some on site trials
• Highlight the challenges of implementing the recommendations across all
LCA trusts
Table Discussion - Access to
Specialist Metastatic Services
Commissioning Intention
2015-2016
Dr Will Teh
Chair, LCA Pathway Group
Consultant Radiologist, North West London Hospitals NHS Trust
The London Cancer Alliance West and South
Proposals for Cancer Commissioning Board
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Align best care pathways to Model of Care.
Ensure consistency across LC/LCA
Minimum 50 NHS breast cancers PA per surgeon (LC)
Plastic surgeon included as core member of MDT (LC)
Minimum 300,000 population
Align with CRG service specification for common cancers
The London Cancer Alliance West and South
New Areas For Inclusion
• MDT quorate for 95% of meetings (peer review).
• Implement NICE Familial Breast Cancer (June 2013)
– High quality risk assessment across London
– Surveillance of moderate risk
– Chemoprevention
The London Cancer Alliance West and South
Reaffirm MoC
• 23-hour stay model for mastectomy
• Accreditation scheme ‘low volume providers to grow or
to exit’ (including min surgical caseload and population,
one-stop clinics)
• IO SNA to be adopted when ‘shown to be worthwhile
and affordable’
• All patients undergoing mastectomy to have opportunity
to discuss reconstruction and offered IBR if appropriate
The London Cancer Alliance West and South
Recommendations to commissioners
• Each MDT to be quorate for 95% meetings, deliver onestop clinics, 23-hour mastectomy
• All surgeons meeting minimum numbers
• 70% new breast cancers – supported self management
• 60% all new cancers will have HNA and care plan by
March 2016 (via COSD)
• 75% all new cancers to have end of treatment summary
be March 2016
• All MDTs to have agreed pathway for lymphoedema
management
• Implement moderate risk FH surveillance