Download Urology Care Pathways

NICaN Regional Urology Group
Final Care Pathways for Urological Cancer
Urology Care Pathways
Cancer Care Pathways outline the steps and stages in the patient journey from referral
through to diagnostics, staging, treatment, follow up, rehabilitation and if applicable onto
palliative care.
Timed effective care pathways are central to delivering quality and timely care to
patients throughout their cancer journey and to the delivery of an equitable service.
These pathways have been developed following with reference to available best practice
guidance. They represent an ‘ideal’ pathway that can be adapted for local use. The
timelines on the pathway are intended to facilitate the proactive management of patients
within the access standards and it is to be noted that for some urological tumours, the
patient will move much quicker through the pathway (e.g. testicular cancer).
The pathways are in draft form and amendments have been made following discussion
at the workshop of the NICaN Regional Urology group held on Thursday 2nd October,
2008.
Document History
V1 Draft discussed at workshop 2/10/08
V2 Draft discussed 29/1/09 and amendments noted
Version 3 circulated for final comments 26/02/09
Pathways agreed at regional meeting 23/4/09
♦ Indicates point of holistic assessment
∆ Inter-Trust transfer by Day 28
NICaN Regional Urology Group
Final Care Pathways for Urological Cancer
Prostate Pathway
GP referral – triage by Urology Consultant
Day 0
Day 7
Day 14
OPA – biopsy may be required
OPA –biopsy definitely required
History/DRE/counselling
History/DRE/counselling/TRUS Biopsy
Benign pathology
Follow up clinic with nurse specialist or
patient letter informing of benign pathology
Pre-booked results clinic
Diagnosis discussed with patient ♦
Local MDT
Next available
Day 21
Staging
*MRI/CT & Bone scan if appropriate
Localised
Locally advanced
Metastases
Day 28
Local/Specialist MDT*
Day 31
Decision to treat – at pre-booked OPA ♦
Day 62
Radical Prostatectomy
Radical Radiotherapy
(+/-) Hormone Therapy
Brachytherapy
Active Surveillance
Clinical Trials
Radiotherapy
Hormone therapy
Active Surveillance
Clinical Trials
Hormone therapy
Oncology
Palliation
Active Surveillance
Clinical Trials
Clinical trials
♦ Indicates point of holistic assessment
∆ Inter-Trust transfer by Day 28
* CT necessary only when clinically indicated
MAXIMUM WAIT
GOOD PRACTICE &
QUALITY PARAMETERS
PATHWAY
See NICaN referral
guidelines, 2007
1/62
GP referral
7/62
One Stop Haematuria Clinic
Flexible cystoscopy + Upper
Tract Imaging/ History Physical
Inform MDT coordinator on receipt
of results.
Renal Tumour
Stage tumour
Patient discussed at
MDT ∆
28/62
31/62




Other point of
entry (A&E,
Incidental
Findings
PT1a
B
Laparoscopic
Treatment of choice
Outpatient’s appointment
Treatment options discussed
Decision to treat ♦
PT2
PT3a
Laparoscopic
? Open
Open
? Laparoscopic
? Partial
? Open Surgery
? Laparoscopic
Letter from MDT to GP
Proactive pathway management
PACS
Regionally agreed dataset and
d’base (NICR)
*** Manual of Cancer Service
Standards
Oncology Protocols (to include
Clinical Trials)
PT3b
Open
? Laparoscopic
Vascular Surgeon
Cardiac Bypass
PT4
M1
? Debulk
+ Immunotherapy
Embolisation
Radiotherapy
Palliative Care
New drugs
62/62
Renal Preservation
Follow UP ♦
♦ Indicates point of holistic assessment
Partial Nephrectomy
Open/ Laparoscopy
Auto transplant
Radio Frequency Ablation
Cryotherapy
∆ Inter-Trust transfer by Day 28
Patient support & information at all stages; Patient details recorded; Patient informed at appropriate points *****NICE
Renal Tumour
MAXIMUM WAIT
GOOD PRACTICE &
QUALITY PARAMETERS
PATHWAY
1/62
NICaN Referral Guidelines, 2007
Swelling or mass in body of testis
GP Referral received
Testicular Cancer suspected
Improving Outcomes guidance
in Urological cancers, 2002
Assessment of clinical
presentation (Lump)
7/62
Equivocal
Inform MDT coordinator on receipt
of results.
Diagnostic tests
Ultrasound
Orchidectomy +- Prosthesis
Testicular Cancer Confirmed
Decision to treat




CXR Tumor Marker
Book CT
28/62
Patient discussed at
MDT ∆
31/62
Outpatient’s appointment ♦
CT/Histology
Metastatic
*** Manual of Cancer Service
Standards
Oncology Protocols (to include
Clinical Trials)
Oncology Outpatient’s
appointment ♦
Oncology
GP letter from MDT
Proactive pathway management
PACS
Regionally agreed dataset and
d’base (NICR)
Patient discussed at
MDT
62/62
Surveillance
Chemotherapy
Radiation
Clinical Trial
Sperm Bank
Post Chemo
Mass/ RPLND
Follow UP ♦
♦ Indicates point of holistic assessment
∆ Inter-Trust transfer by Day 28
Patient support & information at all stages; Patient details recorded; Patient informed at appropriate points *****NICE
Testicular Cancer Pathway
MAXIMUM WAIT
GOOD PRACTICE &
QUALITY PARAMETERS
PATHWAY
GP referral / other point of entry
(A&E, incidental findings)
1/62
One Stop Haematuria Clinic
Flexible cystoscopy + Upper
Tract Imaging/ History Physical
Upper
Tract
See NICaN referral
guidelines, 2007
Improving outcomes for
Urological cancers, 2002
Bladder Tumour
Superficial
TURBT
7/62
Muscle Invasive
CT Chest,
Abdomen
Single shot
MitomycinC
Inform MDT coordinator on receipt
of results.
Grade and stage tumour
28/62
31/62
Laser
Local Excision
NephoUreterectomy
Laparoscopy
Pluck




Patient discussed at
MDT ∆
Outpatient’s appointment
Treatment options discussed
Decision to treat ♦
Superficial treatment
options
Letter from MDT to GP
Proactive pathway management
PACS
Regionally agreed dataset and
d’base (NICR)
*** Manual of Cancer Service
Standards
Oncology Protocols (to include
Clinical Trials)
Invasive treatment
options
62/62
PTa
Eastoscopic
Follow up
PTaG3
BCG
PT1G3
Re-resect
BCG
? Bladder
Preservation
/radio/chemo
? Radical
Surgery/
reconstruction
Palliation
Neo-adjuvant
Chemo
Follow UP ♦
Register only
♦ Indicates point of holistic assessment
∆ Inter-Trust transfer by Day 28
Patient support & information at all stages; Patient details recorded; Patient informed at appropriate points *****NICE
Transitional Cell Carcinoma
GOOD PRACTICE &
QUALITY PARAMETERS
Rising PSA/New Symptoms
Inform MDT coordinator on receipt
of results.
GP referral/ OP Referral




Patient re-presented at
MDT
Staging *
MRI
Bone Scan
Outpatient’s appointment
Treatment options discussed
Decision to treat ♦
Letter from MDT to GP
Proactive pathway management
PACS
Regionally agreed dataset and
d’base (NICR)
*** Manual of Cancer Service
Standards
Oncology Protocols (to include
Clinical Trials)
Oncology Referral
Conservative
Management
Radiotherapy
Palliative Care
Chemotherapy
Hormone
therapy
Bisphosphonates
Follow UP ♦
* MRI/Bone Scan as clinically indicated
♦ Indicates point of holistic assessment
∆ Inter-Trust transfer by Day 28
Clinical
Trials
Patient support & information at all stages; Patient details recorded; Patient informed at appropriate points *****NICE
Castration Resistant Prostate Cancer
MAXIMUM WAIT
GOOD PRACTICE &
QUALITY PARAMETERS
PATHWAY
NICaN Referral Guidelines, 2007
1/62
GP Referral received
Penile Cancer suspected
Improving Outcomes guidance
in Urological cancers, 2002
Biopsy/Stage Tumour
CT/MRI
Inform MDT coordinator on receipt
of results.
Results Clinic
Option for local review ♦
28/62




Patient discussed at
MDT ∆
31/62
Outpatients Appointment
Decision to treat ♦
62/62
Localised
Groins*
GP letter from MDT
Proactive pathway management
PACS
Regionally agreed dataset and
d’base (NICR)
Advanced*
Surgery
- Amputation
- Penile preservation
- Glansectomy
Lymph Node
Dissection
- Therapeutic
- Prophylactic
Pelvic Lymph
Node Dissection
Open Laparoscopy
Radiation
Chemo
Radiation
Chemo Radiation
*** Manual of Cancer
Service Standards
Oncology Protocols (to
include Clinical Trials)
Palliative Care
Clinical Trials
Follow UP ♦
♦ Indicates point of holistic assessment
∆ Inter-Trust transfer by Day 28
Patient support & information at all stages; Patient details recorded; Patient informed at appropriate points *****NICE
Penile Cancer Pathway
References

NICE (2002) Improving Outcomes in Urological Cancer
http://www.nice.org.uk/guidance/index.jsp?action=byID&o=10889
 NICE (2008) Prostate Cancer: Diagnosis and Treatment
http://www.nice.org.uk/guidance/index.jsp?action=byID&o=11924
 British Association Of Urological Surgeons Guidelines
http://www.baus.org.uk/
 European Association Of Urology
http://www.europeanurology.com/
♦ Indicates point of holistic assessment
∆ Inter-Trust transfer by Day 28