Dorset County Hospital Cancer of Unknown Primary (CUP) Service JW. 10/11/15

Classification MUO – Malignancy of unknown origin. pCUP – Provisional Cancer of Unknown Primary Confirmed cCUP – No primary site found Continuing investigations to find the primary are only carried out if 1. the patient is fit enough to undergo treatment if the primary is found. 2.The results are likley to affect a treatment decision. 3.The patient understands why the investigations are being performed and the potential risks and benefits in investigation and treatment.

DCH CUP MDT Core Members: Dr Richard Osborne – (MDT Lead) Consultant Medical Oncologist Dr Tom Marsh – Consultant Radiologist Dr Teresa Thomas - Consultant Histopathologist Dr Sandra Pepper – Speciality Doctor, Hospital Palliative Care Team Ann Dixon - Palliative Care Specialist Nurse Jane Wraight – CUP (and Upper GI) CNS Ellie Goff – MDT Facilitator Much smaller MDT than most, and numbers of patients discussed are smaller than other sites however, because of the often complex nature of them, discussions can sometimes be more lengthy. MDTs are held on a Thursday 11.45 and we also have a “virtual” MDT on Tuesdays when our MDT Facilitator, Dr Osborne and I get together to review any patients newly referred and any undergoing investigation.

Accessing the CUP service Fast track referral In-patient referral Inter-MDT referral from other cancer sites Referral to members of the MDT e.g. Palliative care team Via radiology reporting Patients come from all over the place and all different. As soon as a patient is referred to the service, one of the CUP team will review, usually contacting Dr Osborne, getting rapid guidence over next steps. This may be getting specific tests requested or preventing further tests if they are not appropriate. – One of the most important aspects from my point of view is to try and meet or speak to the patient and identify myself as their key worker. sometimes it is more appropriate for the palliative care team to be their key worker.

CUP – Peer Review Cancer of Unknown Primary is now being managed as all other site specific cancers. CUP is subject to peer review. This year we had internal validation and were pleased to have very positive feedback. In 2016 we will be externally peer reviewed with a National Team on site on 4th April 2016.

Metastatic site cCUP 67% (6) Peritoneal (9) Ovarian 22% (2) Lung 11% (1) I have to admit that these next two slides are actually Poole’s data, but as they are similar to West Dorset’s and the graphs give a good demonstration of the different primary sites found and those that are confirmed CUP cCUP 63% (5) Lymph Node(s) (8) Ovarian 13% (1) Haem 25% (2)

Metastatic site Liver (14) Bone (13) cCUP 71% (10) Small Bowel 7% (1) Pancreas 21% (3) cCUP 25% (3) Lung 25% (3) Pancreas 15% (2) Bone (13) Renal 15% (2) Ovarian 8% (1) Prostate 8% (1) Small Bowel 7% (1)

DCH CUP Patient timeline (W165445) PRESENTING SYMPTOMS; Referred to Urology by GP with increasing Urinary tract symptoms. Seen in Urology O.P 2.04.15 Previous heavy smoker stopped 3 months ago. Serum PSA 3.04.14 = 6.04. Serum PSA 18.11.14 = 8.07 MRI & Urology MDT planned. 14/04/15 MRI PELVIS 15/04/15 Urology MDT: Discuss at following days MDT 16/04/15 Specialist Urology MDT: MR showed extensive bone mets – for urgent CT (requested) 21/04/15 CT scan chest abdo pelvis 22/04/14 Urology MDT – CT shows bone mets. No primary. For TRUS and biopsies re-discuss at MDT following this. TRUS & biopsy requested 5/05/15 Prostate biopsy 13/05/15 Urology MDT: No primary identified. Normal trans rectal biopsies. For CT of right pubic bone. Refer to CUP MDT 13/06/15 Prostate biopsy reported no malignancy. For bone biopsy right pubic bone. Referred to CUP MDT 14/05/15 CUP MDT - Imaging of MRI and CT Remain under Urology team pending bone biopsy 3/06/15 Urology MDT: TRUS biopsies do not show any malignancy but has metastatic disease. Query origin – CUP MDT tomorrow 04/06/15 CUP MDT - Await bone biopsy. CUP team take over management, For femoral X-Rays to assess fracture risk. Repeat LFTs calcium and U&Es. for Dr Osborne OPA. 11/06/15 CUP MDT - Possible risk of fracture. For urgent Ortho opinion. Biopsy delayed deliberately in case Ortho procedure provided material 12/06/15 Orth opinion - no immediate fracture risk. For analgesia and observe 02/07/15 bone biopsy 09/07/15 CUP MDT - Histology pubic bone suggests diffuse large B-cell lymphoma – referred to Haematology. This demonstrates the complexity of some patients pathway, this patient was discussed at 8 MDTs – his pathway seemed frustratingly slow at times. As Key worker, This is a 77 year old man. I was able to speak to his GP on 13th May – same days as MDT. This enabled out CUP discussion the following day to have greater insight into this man, his understanding and general wellbeing. He was seen in the heamatology outpatients on 10th July and I was able to havdover the keyworker role to the haematology CNS