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

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

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

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

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

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

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

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

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

TYPE I AO Emergency Presentation of New Cancers

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

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

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

TYPE II AO Treatment Complications

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

Neutropenic Sepsis NICE CG 151 (2012) Life threatening complication of chemotherapy. Mortality doubled in 2001-10 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

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

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?

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

TYPE III AO Complications of Cancer

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

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

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)

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

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