1. Acute Oncology Challenges & Solutions
3 useful Actions from today
Know the contact details for your local AO Team and Chemotherapy Triage
Get a copy of the Acute Oncology protocols
If in doubt, stop oral anticancer drugs and call triage

2. What do primary care need?
Advice line
Toxicity protocols
Recognise emergencies
Access to procedures
Home visits
Early appointments
? Is it cancer pathway
Strategic advice and opinion

3. Emergency Cancer & Acute Hospitals
The Burden of Cancer
Emergency Cancer & Acute Hospitals
Inpatient care
25% increase, mainly emergency
6 million bed days per year
12% all acute inpatient beds
60% cared for by Gen Med.
50% cancer expenditure
Start with some background on burden of emergency cancer care
Inpatient care accounts for 50% expenditure
UK has one of highest rates of emergency presentation, linked to poor outcomes
Tackling burden of inpatient cancer care is now key strategy of NHS policy
New Cancer Diagnosis
23% new cancers
Present via emergency
pathways
Cancer Complication
MSCC
Brain Metastases
Treatment Complication
60% increase in SACT
New drugs 3

4. unavoidable admission and poor patient experience
Service Configuration & Decentralised Care
Central control & delivery via fixed Oncology OPD sessions
Local Admission
Lack of information
Lack of expertise
Dislocated care
unavoidable admission and poor patient experience

5. What is Acute Oncology?
A new hospital-based service recommended in 2009 to provide:
Additional oncology sessions (medical/nursing)
Facilitate early specialist review
To support education , pathway development & protocols
To improve access to cancer information
To improve quality, safety and reduce hospital length of stay

6. Acute Oncology Teams Nurse delivered Consultant Oncology Admin/office
NCH
Ford
APH
Griffiths
COCH
Abdallah
StHK
Marshall
RLUH
Madi
Aintree
Ton
Southport
Neville-Webb
CCC
24hr triage
Acute Oncology Teams
Nurse delivered
Consultant Oncology
Admin/office
5 day 9-5

7. Generic Roles of AO where can we help?
AO is currently focussed on inpatient care
Provide oncology information, prognostication and ceiling of care
Specific advice on clinical scenarios
Acute oncology treatment guidelines
Patient and family support
Continuity of care, facilitate follow up and links with primary oncology team (MDT)
Early discharge
Access to urgent radiotherapy pathways
If in doubt, let us know of admission

8. Generic Roles of AO What we can’t do?
Do home visits or admit
No inpatient beds
But we are developing ambulatory care options
Review every cancer in patient
We need to prioritise resource
We need to engage primary site key workers
Offer specialist palliative care
But we work closely with palliative care teams
Always give a straight answer due to MDT care!
Rare cancers, complex cases, different opinions

9. Helpful Resources CCC 24/7 Triage Primary Care UKONS triage risk
Assessment tool
Network protocols:
Acute Care Toolkit 7– acute oncology
Acute Oncology Problem solving handbook
Clinical Publishing
On line learning
Macmillan learn zone: learnzone.org.uk
Acute Oncology Apps
Acute Oncology Guidelines

10. TYPE I AO Emergency Presentation of New Cancers

11. New Suspected Cancers Cancer of Unknown Primary
Mr M, 76 year old male, weight loss, deranged LFTs, Ultrasound liver suspicious of metastases
CUP presentation is typically liver, bone or ‘stroke syndrome’
? Is it Cancer ? Where is the Primary ? Which referral pathway
Poor patient experience
Late presentation and emergency admission
MDT ‘tennis’ and late referral to palliative care services

12. Carcinoma Unknown Primary
NICE CG104 - Principles
Every hospital to establish a CUP team –usually AO driven
Only perform investigations if results affect treatment decision and the patient is prepared to accept treatment
Routine tumour markers unhelpful
Tumour markers lack specificity
Do not ‘hunt’ the primary’
Consider CT chest/abdo/pelvis as first test
Refer or chat to local AO services

13. St Helen’s & Knowsley NHS Trust CUP Pathway
LOS reduced
26days -11 days
Raise Awareness
Radiology Alert
GP referral*
Rapid assessment by joint Oncology/Palliative Care TEAM
Musculoskeletal
Pathway*
Day*
Biopsy ?
Patient Information & Support
Site Specialist MDT link
investigation based upon PS and pattern of disease
Early Discharge Planning
Early Treatment

14. TYPE II AO Treatment Complications

15. Treatment complications Generic guidance
Account for 40-50% of admissions
Risk of complications is greatest within 3-4 weeks following Chemotherapy
Determine the drugs/regimen and last treatment date
Patient held records/alert card
If in doubt - phone triage
High index of suspicion for neutropenic sepsis in all patients irrespective of fever
STOP all oral/infusional chemo drugs on admission and seek clarification
Is the patient on a trial? Inform triage

16. Neutropenic Sepsis NICE CG 151 (2012)
Life threatening complication of chemotherapy. Mortality doubled in
Uncommon (<5cases per week at DGH)
Typically occurs 10-14days
Fever, non specific symptoms
NICE guidance published:
Poor evidence base
offer empiric antibiotics immediately.
1 hour target

17. MCCN Neutropenic Sepsis Themes
Time to triage very quick
Majority of patients administered paracetamol within 1hr (medic not required)
Delay in medical review
Delay in prescribing A/Bs
30% not febrile (at presentation)
Gastrointestinal symptoms
Unwell, bruising
Cough, collapse, decreased mobility

18. MCCN NS Guidance Raise awareness Key Actions
Patient information, Alert Card, 24/7 triage,
chemotherapy alert system in development
Key Actions
Inform triage:
Treat suspected neutropenic sepsis as an acute medical emergency and offer empirical antibiotic therapy immediately. Do not wait for results of full blood count.
Scope for community/paramedic antibiotics?

19. Other Common Complications
Cardiac (5FU, capecitabine, cisplatin)
Arrhthymia (QT prolongation)
Oral ‘ibs’ – eg vemurafenib
Ischaemia (cardiac, stroke, limb)
Diarrhoea (5FU, oral capecitabine, Irinotecan)
Exclude infection (CDiff), Fluids, loperamide ,
Diabetes
Steroids, con meds, diet, GI toxicity
IF IN DOUBT: STOP ANTICANCER THERAPY AND CALL TRIAGE

20. TYPE III AO Complications of Cancer

21. Metastatic Spinal Cord Compression
NICE CG75 (2008)
MSCC is an medical emergency May lead to irreversible neurological damage damage
Progressive bone pain +/- neurological symptoms or signs
Most commonly thoracic vertebrae
Plain Xrays unhelpful
Patient information and alert cards
Prognosis correlated with functional reserve – loss of motor power >48hrs unlikely to recover

22. Metastatic Spinal Cord Compression Pathway ?
Is patient
Fit for
Treatment! ?
Progressive spinal pain
Progressive spinal pain
And neurological signs
MRI whole spine
Allow treatment
within 7 days
Urgent MRI whole spine
Allow treatment within
24hours
Confirmed MSCC
Admit
Nurse Flat*: NBM
LMWH
Dexamethasone 16mg
Contact Walton
*High risk patients provided with PIS
*Network MSCC coordinator (Walton)
Joint spinal surgeon/oncology opinion

23. Other Cancer Complications
Hypercalcaemia
Myeloma, breast, kidney, lung
Dehydration, confusion, constipation
Associated with poor prognosis
Rehydation + /- bisphosphonates
Brain metastases
Dexamethasone 16mg 48hrs and review
Review management plan with AO or primary team
SVCO: not an emergency
? Stent vs chemotherapy vs radiotherapy
Pulmonary embolus
LMWT heparin (withhold orals – interactions)
Consider Early discharge (asymptomatic)

24. What do primary care need?
Advice line
Ao office each hospital/bleep
CCC triage line 24/7
Toxicity protocols
Primary care UKONs tool
Acute Oncology – apps/links
Chemotherapy – apps/links
Recognise emergencies FN
MSCC
Access to procedures
BTF
Ascites/pleural
Home visits
Palliative care
Onco-geriatrics
Early appointments
Free up capacity and risk adapted follow up
? Is it cancer pathway
AO/CUP service
Strategic advice and opinion
AO on CCG

25. AO: Next Steps Develop Admission Avoidance Strategies
Access to Fast track oncology clinics (more capacity)
Align services with A&E/MAU/GPAU
Increase options for day procedures (drains, biopsy)
Unexpected radiology pathways
Electronic alert systems
Develop a comprehensive triage and helpline for professionals & linked to palliative care
Improve coordination of cancer care in community (& provide alternatives to admission)
Provide Out of hours provision