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2011. Welcome to The 4 th Annual Chemotherapy Conference Friday 18th March , Foresight Centre, Liverpool. A Conference Hosted by Merseyside and Cheshire Cancer Network

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Welcome to

The 4th Annual Chemotherapy Conference

Friday 18th March , Foresight Centre, Liverpool

A Conference Hosted by Merseyside and Cheshire Cancer Network

Sponsored by: Amgen, Astra Zeneca, Bristol-Myers Squib, Celgene, GlaxoSmithKline, Janssen-Cilag, Lilly, Napp, Novartis, Shire

merseyside merseyside cancer network

Merseyside & Merseyside Cancer Network

Acute Oncology Update 2011

Ernie Marshall

Macmillan Consultant in Medical Oncology

the cancer journey
The Cancer Journey

Significant progress in elective cancer care



Follow up

New Cancers (UKP)


Complications of Cancer

Complications of treatment

  • Lack of focus on emergency Inpatient Care: Prolonged stay, poorly coordinated, poor pt experience
    • Inpt cancer care ~12% acute inpt beds,
    • Admissions up 25% in 8yrs,
    • 40% inpatient cancer is emergency,
    • 60% managed by GIM
    • 60% chemotherapy 2002-06
aspects of ao
Aspects of AO

Transforming Inpatient Care


Management of inpatients

Aim is to incorporate oncology input early in the inpatient journey rather than near the end

New cancers (UKP) – not on established pathway

Complications of chemo (radiotherapy)

Complications of cancer (recurrence)

chemotherapy services in england ensuring quality and safety ncag aug 2009
Chemotherapy Services in England: Ensuring quality and safety: NCAG Aug 2009
  • Key Recommendations:
    • Chemotherapy pathway measures
    • Acute Oncology: All hospitals with emergency depts should establish AO Teams
  • MCCN Recommendation (Oct 2009)
    • 12month funding pump primed via CQUIN with cash releasing efficiency in 2011/12
    • Aim to recruit AO team 01/04/10
    • (NCAG- Aim for AOTs by 2011)
estimated savings from aot
Estimated savings from AOT

Cost per AO team 131K =915K across network

ao peer review 2011
AO Peer Review 2011
  • SA to be completed August 2011

Key Measures for Network, CCO and Units

    • Establishment of
      • AO Teams
      • Patient Flagging system (Alerts)
      • 24/7 Advice Line and Consultant Oncology On-Call
      • Pathways, protocols, training
      • MSCC pathway
      • Acute Oncology Fast Track Clinics
      • FN: 1hr target (‘door to needle time’)
mccn ao teams

6 Medical Oncologists appointed at CCO 2010/11

Major job plan review completed (>15 consultants)

5 sessions Oncology

1 wte CNS

Admin Support (office)

Established in:


Aintree (3)

STHK (2)

S&O (2)

APH (2)






Minimum dataset

5 sessions Oncology released for:

NCH (3)

COCH (1)

network ao structure
Network AO Structure

Network AO Group












AO Team

Steering Grp

flagging system alerts
Flagging System: Alerts

New Chemo


Hospital PAS


A&E attendance

Email alert to CNS

Early review


StHK: Well established (1/3 of referrals)

roll out to Haem, palliative care, trials

APH: rolling out via CCO Data Warehouse

Network solution: central alert system linked to CCO IM& T strategy (TPoulter)

mccn ao activity
MCCN AO Activity

Median LOS by type

Type I (new cancer) =14days

Type II (treatment complication) = 4days

Type III (cancer complication) = 6days

Estimated numbers per year: StHK 536 ( vs 359NatCatSat)

referral and review
Referral and Review

NCAG: Hospitals should aim to provide expert Oncological assessment within 24hours at least 5 days per week

2011 challenges
2011 Challenges
  • Peer Review
    • Alerts: optimise efficiency and develop local IT solution for all AO patients
    • 24/7 Triage: definition, funding, links to CCO Oncology on call
    • Protocols (overlap with Triage/Pall Care)
    • Clinic capacity (‘fast track’)
  • Registration: ownership and funding
  • Outcome measures: ?LOS, resource use, quality measures
  • Funding: 1year funding to be replaced by efficiency savings
febrile neutropenia
Febrile Neutropenia
  • Key aspect of NCAG and NCEPOD Reports
  • Evidence for Fragmented care and delayed antibiotics despite FN protocols
    • 24 hour triage
    • FN pathway,
    • 1 hour door to needle time
    • No defined code for FN -
cco triage for suspected fn audit findings ford 2009
CCO Triage for Suspected FNAudit findings ( Ford, 2009)
  • 3 month Triage calls (164 calls)
  • 73 attended CCO: majority low risk
  • 66 ‘other’: hospital, GP, community nurse
  • 50% of cases not neutropenic
  • Average Time from triage call to arrival 4 hours (range - 13hours)
  • Low risk LOS = 2.7days, High risk LOS = 7days
  • Examples of dislocated care at DGH
dgh case i
DGH: Case I
  • Cancer Centre Triage call 16.30
  • Advised to attend local A&E 18.30
  • ‘Low risk’ :
  • CCO informed and advice sought
  • Patient commenced oral antibiotics at 22.00
  • On call pharmacy input with switch to Imipenem and G-CSF
  • Patient continued capecitabine further 24hrs
  • Hospital LOS : 9days
mccn fn audit
  • Methods
    • 3 month retrospective audit (feb-Apr10)
    • Weaknesses: Data incomplete, retrospective
    • 97 Patient episodes (91pts )
    • 67 Oncology; 32 Haematology
  • 5 Trusts
    • Aintree (20)
    • CCO (39)
    • COCH (17)
    • Southport (7)
    • St H&K (14)
summary i
Summary I
  • Multiple routes of admission
    • 48% admitted via A&E. (55-85% for units)
  • 60% via Triage (except CCO)
  • Median Neutrophil count = 0.3
  • MEWS = 87.6% (44/85= 0-2)
  • MASCC= 12.4%
summary ii
Summary II
  • Time to Abs:
    • 0-1hr -23%,
    • 0-2hr 45%
    • 0-4hr 60%
  • Median inpatient stay = 6days (1-43)
    • Haem :Acute Leuk=12d, others=8d
    • Solid : 5days
    • Intravenous Ab = 6d, oral Ab (24) = 4d
  • Deaths =9 (10%)
next steps
Next Steps
  • Small numbers and patchy data
    • Requires more analysis
  • Multiple pathways but A&E critical
  • 1hr target not achieved (not realistic?)
  • Scope for risk stratification ?
  • 10% Mortality – relate to risk
  • Need for prospective audit
  • (capecitabine toxicity)
  • AO evolving rapidly across MCCN
  • Evidence for Increasing activity and awareness
  • Evidence for speedy review
  • Improved communication
  • Reduce admission rate ?
    • Yes but difficult to quantify
  • Reduce LOS ?
    • Probably, but little impact on hospital bed base
  • Improve quality and safety ?
    • Yes, intuitively but needs Qualitative R&D,
    • AO ‘major benefit’ 50% cases (St H&K)
  • Save Money ?
    • Not easily realised but good value ?
national cancer peer review programme

National Cancer Peer Review Programme

Millie Forde – Assistant Quality Manager - North Zone

what is cancer peer review
What is Cancer Peer Review?
  • A quality assurance process for cancer services
  • An integral part of Improving Outcomes – A Strategy for Cancer
  • Assesses compliance against IOG for NHS patients in England
  • A driver for service development and quality improvement
  • Supported by a set of measures
measures development
Measures Development
  • Developed by an expert group
  • Aimed to measure areas detailed in the national documentation e.g. NICE Improving Outcomes Guidance and national reports such as NCAG and NRAG reports.
  • Three month consultation on new measures
self assessment report36
Self Assessment Report
  • Will be a public document
  • Will form basis of Annual Peer Review Report for those teams not subject to internal validation
  • Handbook contains guidance on identifying Immediate Risks, Serious Concerns and Concerns
demonstrating agreement
Demonstrating Agreement
  • Where agreement to guidelines and policies is required there should be a statement on the front cover of the document indicating the groups and individuals that have agreed the document and the date of agreement.
  • Evidence Guides will indicate the groups and individuals that need to be documented as agreeing the key evidence documents.
the internal validation report
The Internal Validation Report
  • Will be a public document
  • Will form basis of Annual Peer Review Report for those teams not subject to external review
  • Handbook contains guidance on identifying Immediate Risks, Serious Concerns and Concerns
using cquins v4
Using CQuINS V4

Available via the web site at:

Secure web based database supporting each stage of the cancer peer review process

Records assessments, compliance with the measures and reports

Provides information for national analysis and reporting

completing the self assessment
Completing the Self Assessment
  • Upload Key Documents - (Alternate years only)
  • Enter Compliance on CQuINS
  • Complete Team Report
self assessment evidence
Self Assessment - Evidence

Key Documents - teams/services should ensure the evidence requirement stated for each measure is included either in one of the key documents i.e. operational policy, annual report, work programme or if not in one of these key documents it should be included as an appendix.

Additional Evidence - If the actual evidence is not included in the upload documents on CQuINS then the team should include a statement which makes clear this evidence requirement has been checked by the team/service and would be available if a peer review team were to visit.

Use of Internet Hyperlinks - it is acceptable for teams/services to include internet hyperlinks but these links must have open access and not be on the closed section of the trust or organisation intranet system.

internal validation evidence
Internal Validation - Evidence

Key Documents - Ensure all the evidence required against the measures for a team/service has been checked and is available on the CQuINS database via the key documents.

Additional Evidence - If any evidence is not available on the CQuINS system, the internal validation panel should confirm they have seen the evidence or give details of the spot checks they have undertaken.

Confirmation - This should be made clear on the internal validation report form. It is not sufficient to give an overall statement that all evidence has been seen. Details of the specific evidence seen against measures should be identified and noted on the compliance spreadsheet.

peer review visit evidence
Peer Review Visit - Evidence
  • Key Documents - A full copy of all evidence uploaded onto CQuINS must be available to reviewers on the peer review visit. This can be either hard copy or electronic.
  • Patient Records - Peer Review zonal teams will normally request 5 sets of patient notes in order to check compliance against the measures. Teams may sometimes require more than 5 set of patient notes but this should never exceed 10. Only clinical NHS staff will review patient notes.
general principles
General Principles

Personal details / patient information

  • It is essential that no identifiable patient data including hospital number should be uploaded on the CQuINS database.
  • The personal details of individual staff in a team/service should not be uploaded e.g. certificates or job plans.
  • Identification of individuals should not be made on reports uploaded onto CQuINS. Reports should refer to the roles they carry out.  
general principles57
General Principles


  • The role of the person indicated on the agreement should include any delegated role they are undertaking for others.
  • The front cover of any document uploaded should show the date, version and planned review date.
general principles58
General Principles

Configuration of the Network

  • The configuration of the network is essential to the review of a particular tumour site and ensuring compliance against the Improving Outcomes Guidance. Details of PCT referral pathway and populations are essential.


  • When a measure asks for the membership of a group then the name, role and organisation the individual represents should be indicated on the evidence.
general principles59
General Principles

Patient Information

  • Does not require uploading on CQuINS
  • Copies available for IV panel and Peer Review Team 
  • The IV report should confirm that the patient information has been seen and that it covers all the essential elements of the measure.
  • At self assessment the team/service should list the patient information they have in the key documents uploaded on CQuINS.

Patient Experience Exercise

  • A summary of the exercise including the key points and action implemented is sufficient in the key documents.
  • A copy of the patient exercise should be seen available for both peer review and IV
  • IV assessment should confirm this has been seen.
  • The national cancer patient survey would be acceptable for this measure.
specific evidence requirements
Specific Evidence Requirements

Working practice of a team/Spot checks

  • Where measures ask for reviewers to ask about working practice of teams/services or to undertake spot checks, they will do this when on a review.
  • IV should mirror this and include comments in the IV report.
  • For self assessment teams/services should state that they have completed a spot check and the results of the spot check or give details of the working practice.

Annual Meetings

  • It is only necessary to make a statement in the key documents to confirm the time/date of the meeting and that a record has been made.
  • IV should confirm this meeting has taken place.
  • If it is unclear that a meeting has taken place reviewers on a peer review visit may ask for minutes of the meeting.
specific evidence requirements61
Specific Evidence Requirements

Attendance records /Meeting dates

This can often be satisfied by one clear piece of evidence showing:

  • Dates of the meetings
  • Name, role and organisation represented of those who have attended each meeting
  • The SA report form should comment about any roles not covered or attending appropriately
  • Any summaries of attendance should demonstrate individual attendance at each meeting for all members as well as the summary

Policies /Guidelines/Plans

  • The date and version should be shown on all policies/guidelines and plans
  • These should be uploaded on CQuINS either as an internet hyperlink (see above) within the key documents or in the appendix
  • National guidelines should have been adopted the local context should be explained.
  • Flow charts are an acceptable means to explain details within guidelines
  • If it is unclear that a meeting has taken place to sign off the guidelines/policies and plans reviewers on a peer review visit may ask for minutes of the meeting
zonal team members annual meeting with n etwork representatives
Zonal team members annual meeting with network representatives
  • December each year
  • The purpose of the meeting will be to;
    • inform the Zonal team of key issues within the Network such as implementation of Improving Outcomes Guidance, Service Configuration changes
    • discuss the teams to be visited and schedule for the following year.
the peer review visit plan
The Peer Review Visit Plan


- 2 Weeks

Preparation for




Notification in January to teams to be peer reviewed during May - March

Deadline for submission of evidence for all teams to be visited

Self Assessment evidence and compliance matrix sent to reviewers and copied to teams



Each Network is allocated one month. Can take from 1 to 4 weeks to complete a Network – normally 1 day per Locality

Report published 8 weeks after last review day

peer review teams
Peer Review Teams
  • Between two and five reviewers per session
  • Plus a member of the Zonal Quality Team
  • Reviewers should normally include “Peers”

– people who are trained and working in the same discipline as those they are reviewing

outcomes of the process network reports
Outcomes of the Process – Network Reports
  • Published January and June each year
  • Including IV, EV and PR Visit Assessments
  • Executive Summary from Quality Director
  • Quality Director will discuss key issues with Network
recruitment drive
Recruitment Drive
  • Wednesday 11 May 2011 – Lancashire Teaching Hospitals (POSCU)
  • Wednesday 15 and Thursday 16 June 2011 – Sheffield Children’s Hospital (PTC)

Paediatric Oncologists / Haematologists required for above dates


Thank You

Any Questions ?

metastatic spinal cord compression

Metastatic Spinal Cord Compression

Martin Wilby

Consultant Neurosurgeon

The Walton Centre



A little bit of anatomy



Case examples


Large number of patients

4000 new cases per year in UK

Up to 25 % of patients with diagnosis of cancer develop MSCC

New and improved chemotherapy treatments are improving patient life expectancy

Adult spinal cord does not repair itself, likely that deficits are permanent

simple anatomy
Simple anatomy

Spinal cord ends L1/2, becomes “cauda equina”

which tumours go to bone
70% patients with primary tumour develop bony metastases

Spine most common

Thoracic spine 60 %






Which tumours go to bone?
  • If you don’t suspect the diagnosis, then you will miss it!
  • Symptoms
  • Signs
symptoms uk audit
Symptoms (UK Audit)
  • Seems to be a step-wise progression of symptoms
  • PAIN
    • Skeletal/bony pain
    • More commonly thoracic
    • Unremitting, present at night
    • May develop into nerve root related pain, trunk, arm/leg
  • Leg weakness/difficulty walking (Ataxia)
  • Sensory loss
  • Other (bladder/bowel)
  • Bony tenderness on spine palpation
  • Neurological deficits
  • LMN (weakness, numbness, wasting) at level
  • UMN (tone, brisk reflexes) below level
be suspicious
Be suspicious
  • Patients with known tumour…
  • …and objective neurological signs
  • Need urgent scan/MRI or seek advice

Thoracic back pain in patients with known primary malignancy = possible future MSCC until proven otherwise

Doesn’t matter if tumour not compressing cord, patients have better outcome when caught early

MRI scan/refer on for advice

goals of treatment
Goals of treatment
  • Preserve neurological function
    • Maintain independence
    • Maintain walking ability
    • Preserve patient dignity
  • Reduce pain
  • Allow patient to return home
treatment 1
Treatment 1
  • Some years ago…
  • Treat cord compression with posterior decompression
  • “Not good” G Findlay
treatment 2
Treatment 2

Radiotherapy and steroids

Can shrink the tumour/reduce oedema


Doesn’t really decompress the spinal cord

Doesn’t address instability/pain


Randomised control trial

51 MSCC patients treated with RT and steroids

50 MSCC patients treated with steroids, surgery and then RT

patchell evidence
Patchell evidence
  • Surgery significantly improved outcome
  • More patients walking (84 % vs 57%)
  • More patients walking longer (122 days vs 14 days)
  • 32 patients entered study “off legs”
    • RT alone: 3 patients able to walk
    • Sx + RT: 10 patients able to walk
patchell evidence89
Patchell evidence
  • No difference in overall survival
  • Continence more likely to be preserved
  • Reduces analgesia requirements
acute treatment stability
Acute treatment: Stability
  • When faced with a patient with MSCC, assume instability and keep patient in bed
  • Panjabi definition “physiological stability”
  • Normal ROM without
    • Deformity
    • Excessive pain
    • Neurological deficit
case example stability
Case example: stability

55 yrs old

Multiple myeloma

Neck pain

No neurological deficit

case stability ct
Case: stability, CT


How long?

  • No role in MSCC on its own (decompression)
  • Some role in reduction of pain in spine for non-surgical patients
  • Can be used surgically as “hybrid” procedure
case example
Case example
  • 66 yr old male
  • Known non small cell lung ca
  • Short Hx of back pain and inability to walk
  • Preservation of leg power
  • CT staging: liver/parietal metastases

Hybrid procedure

Ambulant and continent for

remainder of life (over 1 year)

Off pain meds

53 y o female
53 y.o. female
  • Presented acutely with sudden onset BP and weak legs power 2/5
  • Whole spine MRI; only abnormality seen L1/T12
  • No significant PMH
  • Urinary retention
  • Urgent surgery, staging done post procedure
  • Postero-lateral instrumented fusion and laminectomy L1, canal decompressed.
  • Patient recovered
    • Normal leg power
    • Fully continent
    • Ambulant
    • Minimal back pain
    • Quick return home
  • Remember diagnosis
  • Surgery + RT better than RT alone
  • Best outcomes occur before loss of ambulation and continence
the future
The future
  • Minimally invasive surgery?
the future106
The future
  • Role for Radiosurgery?
tumour lysis syndrome tls

Tumour Lysis Syndrome (TLS)

Daniel Collins

Haematology Pharmacist

what is it
What is it???
  • Severe metabolic derangements
  • Shortly after initiation of chemo
      • Oncology & malignant Haematology
  • Mainly seen alongside treatment of
      • Leukaemia
      • Lymphoma
  • Can occur spontaneously
      • “Pre-chemo”
why does it happen
Why does it happen???
  • Certain tumours
      • High proliferative rate
      • Large tumour burden
      • High sensitivity to Tx
  • Initiation of Tx
      • Intracellular anions & cations
      • Metabolic products of proteins and DNA
      • Hyperuricaemia
what happens to patients
What happens to patients???
  • Hyperuricaemia
  • Hyperphosphataemia
  • Hyperkalaemia
  • Hypocalcaemia
  • Renal impairment
  • Life-threatening…
how often does it happen
How often does it happen???
  • High grade NHL = 42%
      • Clinically significant 6%
  • More common in Haem malignancies
      • ALL
      • High grade NHL e.g. Burkitts
  • Some oncology patients
      • Testicular, breast, small cell lung
  • “High proliferative rates” & “Chemosensitivity”
can we classify tls
Can we classify TLS???
  • Laboratory TLS
  • Clinical TLS
  • Grades 0 – V
  • High / Intermediate / Low
  • Cairo-Bishop grading…???
how do we manage patients
How do we manage patients???
  • High index of suspicion
  • Proactively identify patients quickly
  • Prevent/reduce any acute TLS
  • Delay subsequent chemo…???
  • Treat in appropriate units
fluids fluids fluids
Fluids, fluids, fluids…
  • Vigorous hydration
  • Aggressive diuresis
  • Electrolyte management
  • Fluids
      • Omit potassium/calcium/phosphate
  • Adjust renally excreted drugs
  • Urine alkalinisation controversial…
  • Allopurinol…
  • Decreases formation of new urate
  • Reduces obstructive nephropathy
  • Limitations…???
  • Cheap as chips…
  • Hyperuricaemia (urate >450)
  • “Urate oxidase”
  • 75kg pt = 15mg stat dose
      • £580 per dose
  • Give daily for 5-7 days
      • ~£4000
  • Caution = hypersensitivity…
  • Bloods on ice!!!
case study
Case Study
  • JM 75yrs
      • CMML → AML
      • WBC = 103
  • High risk for TLS
  • Rx rasburicase 15mg stat
  • Rpt dose next day…???
  • Urate = 35

…does exactly what it says on the tin!!!

practical pointers
Practical Pointers
  • Prevention is better than cure
  • Tumour burden & proliferation
  • TLS can precede chemo
  • Well hydrated & good UO
  • Baseline & regular blds
practical pointers122
Practical Pointers
  • Rasburicase…???
  • Monitor urate closely – ICE!!!
  • Not for od dosing x 7/7…
  • Delay chemo
  • Omit nephrotoxic meds