Cancer Survivorship: Transforming how we deliver cancer care Catherine Neck Macmillan Cancer Rehabilitation/ Recovery Package Project Lead

The Current Picture 2 million people currently living with and beyond cancer now in UK Predicted to reach 4 million by 2030 More new patients and more living much longer lives following a cancer diagnosis/ treatment Many patients are experiencing negative consequences of treatment which may continue for years post treatment

My Role Funded by Macmillan to assist clinical teams to process map and redesign pathways of care across ASW region Involves the introduction of the ‘Recovery Package’ into the pathway Supports teams to adjust to new ways of working that are better for the patient and result in increased clinical capacity Reduces unnecessary waste in the system

The Recovery Package The recovery package consists of 4 key elements: Holistic Needs Assessment Treatment Summary to patient AND a GP / Cancer Care Review by GPs An education event such as Health and Wellbeing event that includes physical activity and lifestyle information

The Recovery Package Risk stratification of patients Holistic Needs Assessments Health & Wellbeing advice Treatment summaries Remote Surveillance Cancer Care reviews

Improve Information and Support at the outset Prehabilitation – encourage patients to take an active role in improving their outcomes at the start Provide a clear pathway of care from the outset. Manage patient expectations Provide early health & wellbeing advice around consequences of treatment, physical activity, nutrition, work & finance support, emotional support

End of Treatment Holistic Needs Assessment including Care Plan Provide clear and comprehensive information to the patient and GP – Treatment Summary Support the patient to self-manage by being able to identify signs and symptoms of recurrence and providing timely open access support Identify and act on early negative consequences of treatment/ late effects

‘Prehab’ Support to increase physical activity levels and optimise physical function from diagnosis Includes input from dietetics, smoking cessation, work & finance support Fast track to existing pulmonary rehab programmes – ideal model Pilot in Birmingham demonstrated positive results

Birmingham results Reduced post-operative complication rates from 18.7% to 11.4% Reduced length of stay from 7.2 days to 5.7 days Reduced intensive care admissions from 3.2% to 2.9% Fewer readmissions from 16.1% to 5.7% Achieved per patient savings of £1257.42

Current Local Pilots UHB Upper GI, HPB and gynae-oncology teams have begun pilots Using Macmillan Cancer Support Worker to deliver home-based walking and exercise programmes, plus offer wider holistic support Support from physiotherapy dept

Results Improved physical function at point of surgery Reduced hospital LOS (average 6 days) Reduced post-operative complications Improved patient & carer experience Programme is cost-effective to deliver and easily replicable across other cancer sites

Contact Details If you and your team want support to process map and look at pathway redesign, introduction of the Recovery Package and prehab please contact me on: Email: Catherine.neck@nbt.nhs.uk Phone: 07730 286356

Prehabilitation Smoking cessation Nutrition Patient education Pulmonary rehabilitation

National perioperative outcomes of pulmonary lobectomy for cancer: the influence of nutritional status Thomas PA et al Eur J Cardiothorac Surg 2014 Apr;45(4):652 Association of body mass index and outcomes after major lung resection Ferguson MK et al Eur J Cardiothorac Surg 2014 Apr;45(4):e94-9 If BMI < 18.5: Increased mortality (OR 1.89-2.96) Increased pulmonary complications

Improved VO2max of 2.8 with unchanged spirometry and gas transfer 12 high risk patients VO2max <15 4 weeks pulmonary rehab Improved VO2max of 2.8 with unchanged spirometry and gas transfer No deaths, but long LOS and significant post op respiratory morbidity EJCTS 2008

40 patients with COPD undergoing lobectomy 20 randomised to pre-op pulmonary rehab Cardiopulmonary exercise testing performed Before intervention After intervention Post-op Standard group 14.8 14.5 11.4 Pre-op pulmonary rehab 14.9 17.8 15.1 VO2 max (ml/kg/min) EJCTS 2013

Outpatient-based pre-op intervention: Pulmonary rehab Smoking cessation Nutritional assessment Patient education Improvement in pre-op FEV1 and 6MW Trend towards: reduced pulmonary complications Reduced re-admissions EJCTS 2013