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HEAPHY 2 RADIOTHERAPY Glenys ROUND Charleen CASSON Fri 30 th Aug 2013 Session 2 / Talk 1 10:30 – 10:50 Abstract Traditionally wait times for palliative.

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Presentation on theme: "HEAPHY 2 RADIOTHERAPY Glenys ROUND Charleen CASSON Fri 30 th Aug 2013 Session 2 / Talk 1 10:30 – 10:50 Abstract Traditionally wait times for palliative."— Presentation transcript:


2 HEAPHY 2 RADIOTHERAPY Glenys ROUND Charleen CASSON Fri 30 th Aug 2013 Session 2 / Talk 1 10:30 – 10:50 Abstract Traditionally wait times for palliative radiotherapy can be a lengthy process. It can involve several visits to the Oncology department, delaying a patients treatment when time is precious. In keeping with clinics established overseas (Canada & Brisbane) we have implemented a rapid access palliative clinic (RAPC) at Waikato Hospital. This paper describes the implementation of the clinic and assessment of the outcomes of the RAPC seen between 2009-2011. It will also discuss the multidisciplinary nature of such a clinic, the future for our RAPC and the advances that can be made to improve our patients journey.












14 Presented by Dr Glenys Round & Charlene Casson Waikato Regional Cancer Centre Rapid Access Palliative Clinic (RAPC)

15 Background Referrer sends referral Wait list for FSA Seen by Radiation Oncologist Waitlist for simulation Simulated Waitlist for radiation therapy Treatment

16 Background Palliative patients considered non-urgent (Cat 4 – National prioritisation criteria) Wait times to FSA therefore can be long, as radical patients take priority unless Cat A (Spinal cord compression, uncontrolled bleeding) Wait time to treatment vary widely- same day to several weeks Up to 3 visits to treatment

17 Background All this on a background of patients in a palliative phase of their disease process, where quality of life and time are important Frequently elderly, frail, weak from end-stage disease, age and co-morbidities Frequently an elderly exhausted spouse/partner Frequently from a rural area Patients have to travel up to 4-5hours

18 Background Common around the world to have waiting times for FSA and treatment exceeding acceptable lengths of time Pressure to increase patient throughput. Multiple studies have shown efficacy of single 8Gy fraction cf. longer fractionations for bone pain Widely accepted, although in spite of evidence, use of longer fractionations is common ( 20Gy in 5 fractions, 30Gy in 10 fractions)

19 Canada Saw a need to do better Set up Rapid Access Palliative Radiotherapy Programme Patients seen very quickly after referral Consultation, simulation, treatment all in one day for appropriate patients Better programmes, offer multidisciplinary assessment Some centres - patients offered access to a clinical trial

20 Aims Rapid assessment and treatment Multidisciplinary approach Rapid pain relief Improve quality of life Increase satisfaction of referrer Increase proportion of rural referrals

21 Aims Separate clinic at a separate time could save FSA for radical patients Separate simulation time could save allocated simulation space for radical patients

22 Rapid Access Palliative Clinic April 2009

23 Initial Criteria Known Carcinoma Not be a current patient Bony pain Diagnostic evidence No more than 3 painful sites Single fraction Patients transferred back to referring service

24 Clinic Pathway Patients are booked into 3 time slots on a Tuesday Team Meeting @ 8.30am Process: - Consultation - Simulation - Planning - Treatment

25 Patients characteristics Diagnosis Site of disease Analgesic medication Initial/ follow up Pain Score Treatment Information Further investigations ie bone scone, MRI 3 week follow up telephone call Tracking Form

26 AgeGender - Average 69 yrs- Male 65% - Range 30 – 94 yrs- Female 35% Main DiagnosisReferrers - Prostate 30%- MO 23% - Breast 17%- GP 21% - Lung 16%- Urology 20% Statistics 2009 – 2012 (261 Patients)

27 Spine147 (T Spine = 76) Pelvis/Hips78 Ribs21 Shoulders17 Femur/Knee13 Chest12 Other19 Treated Sites (patients = 226, treated sites = 307)

28 Prescriptions

29 63% CTd & treated same day 46% single fractions 13% no treatment Same Day Sim & Treat

30 Distance to RAPC

31 Pain Score

32 Increase - 15% Decrease - 28% Same - 44% Unknown - 13% Medication

33 Reduce visits to the department Immediate multidisciplinary approach Pain management reviewed Continuity of care Positive comments from patients/families Benefits of RAPC

34 RAPC was implemented successfully Data collected, further improvements have been made to the clinic to benefit the patient. Conclusion

35 RAPC is not... Radiation Oncologist seeing patient and simulating quickly, and then patient waits for treatment.

36 Imperatives Deliberate Multidisciplinary Regular Investigates Admits Manages medical problems esp. analgesia, nausea and bowels. Supports (relatives),

37 Imperatives Refers – Med Onc, Palliative Care, physio, dietician, Maori support, chaplain. Does not take ownership Refers back to referrer, but follows up patients as required Communicates with referrer Prospectively gathers data Audit Reviews itself, adapts as required.

38 Imperatives Lesser options CANNOT be called a Rapid Access Palliative Clinic or Programme.

39 Onboard imaging to plan and deliver palliative radiotherapy in a single, cohesive patient appointment – Perth. ( Hopefully soon for us. Note extra machine time). Stereotactic body radiotherapy – limited application in most of these patients. Similar clinics for brain metastases – Canada. ( Truly multidisciplinary – Neurosurgery, Rad Onc, Med Onc, RT, Pall Care, Nurse, Allied Health) Future

40 References Chow E, Wong R, Connolly R, Hruby G, Franssen E, Fung KW, Vachon M, Anderson L, Pope J, Holden L, Szumacher E, Schuller T, Stefaniuk K, Finkelstein J, Hayter C, Donjoux C. Prospective Assessment of Symptom Palliation for Patients Attending a Rapid Response Radiotherapy Program: Feasibility of Telephone Follow-up. Journal of Pain and Symptom Management 2001; 22, No 2 649-656. Danjoux C, Chow E, Drossos A, Holden L, Hayter C, Tsao M, Barnes T, Sinclair E, Farhadian M. An Innovative rapid response radiotherapy program to reduce waiting time for palliative radiotherapy. Supportive Care in Cancer 2006; 14, No 1 38-43. Fairfield A, Pitusin E, Rose B, Ghosh S, Dutka J, Driga A, Tachynski P, Borschneck J, Gagnon L, MacDonnell S, Middleton J, Thavone K, Carstairs S, Brent D, Seversin D. The rapid access palliative radiotherapy program: blueprint for initiation of a one-stop multidisciplinary bone metastases clinic, Supportive Care in Cancer 2008, 17, No 2 163-170. Haddad P, Wong RKS, Pond GR, Soban F, Williams D, Mclean M, Levin W, Bezjak A. Factors Influencing the Use of Single vs Multiple Fractions of Palliative Radiotherapy for Bone Metastases: A 5-Year Review, Clinical Oncology 2005, 17, 430-434. Pituskin E, Fairchild A, Dutka J, Tachynski P, Driga A, Borschneck J. Multidisciplinary Team Contributions within a Rapid Access Palliative Radiotherpy Program. I.J. Radiation Oncology Biology Physics 2008, 72, No 1, Supplement De Sa E, Sinclair E, Mitera G, Wong J, Danjoux C, Hird A, Hadi S, Barnes E, Tsao M, Chow E. Continued success of the rapid response radiotherapy program: a review of 2004-2008. Support Care Cancer 2009, 17, 757-762. Holt TR, Yau VKY. Onnovative program for palliative radiotherapy in Australia. Journal of Medical Imaging and Radiation Oncology 2010, 54, 76-81.

41 References Chow E, Wong R, Vachon M, Connolly R, Anderson L, Szumacher E, Franssen E, Danjoux C. Referring physicians satisfaction with the rapid response radiotherapy programme: Survey results at the Toronto-Sunnybrook Regional Cancer Centre. Support Care Cancer 2000, 8, 405-409. Fairchild A, Barnes E, Ghosh S, Ben-Josef E, Roos D, Hartsell W, Holt T, Wu, J, Janjan N, Chow E. International Patterns of Practice in Palliative Radiotherapy for Painful Bone Metastases: Evidence-Based Practice? Int. J. Radiation Oncology Biol. Phys. 2009, 75, 5, 1501-1510. Haddad P, Wong RKS, Pond GR, Soban F, Williams D, McLean M, Levin W, Bezjak A. Factors Influencing the Use of Single vs Multiple Fractions of Palliative Radiotherapy for Bone Metastases: A 5-Year Review. Clincial Oncology 2005, 17, 460-434. Vulto A, Bommel MV, Poortmans P, Lybreet M, Louwman M, Baart R, Coebergh JW. General practitioners and referral for palliative radiotherapy: A Population-based study. Radiotherapy and Oncology, 2009, 91, 267-260. Lavergne RM, Johnston GM, Gao J, Dummer TJB, Rheaume DE. Variation in the use of palliative radiotherapy at end of life: Examining demographic, clinical, health service, and geographic factors in a population-based study. Palliative Medicine 2011, 25,2, 101-110. Roos DE. Continuing reluctance to use single fraction of radiotherapy for metastaic bone pain: an Australian and New Zealand practice survey and literature review. Radiotherapy and Oncology, 2000, 56, 315-322. Sande TA, Ruenes R, Lund JA, Bruland OS, Hornslien K, Bremnes R, Kaasa S. Long-term follow- up of cancer patients receiving radiotherapy for bone metastases: Results from a randomised multicentre trial. Radiotherapy and Oncology 2009, 91, 261-266. Chow E, Fung KW, Bradley N, Davis L, Holden L, Danjoux C. Review of telephone follow-up experience at the Rapid Response Radiotherapy Program. Support Care Cancer 2005, 13 549-553.

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