Acute Oncology Service at UHL

Helen GuyattAcute Oncology CNS

Dr Eleni Karapanagiotou Medical Oncologist

Acute Oncology: a new subspecialty in Oncology developed from reports

• NCEPOD report• NPSA report• Cancer peer reviews

Systematic approach to deal with cancer-related emergencies

Acute Oncology Service (AOS)

• Development of acute oncology teams in every hospital with an ED/acute admitting beds

• Access to oncology review within 24hrs of admission

• Clear guidance on management of Neutropaenic sepsis Metastatic cord compression

MMP CMT teaching Feb 2012 4

For better, for worse

Inclusion criteria

• Patients aged 16 years or over

• Solid tumours or haematological malignancies

• Received chemotherapy, monoclonal antibodies or immunotherapy during the study period

• Died within 30 days of receiving treatment

Main Outcomes

• 2% of pts died within 30 days of SACT

• 86% of pts received SACT with

palliative intent .

• 30-40% mortality from sepsis alone!

Room for improvement

• Decision to treat• Process of care

– Prescribing, dispensing and administration of SACT

• Communication– Patient information, medical records

• SACT toxicity– Admission, assessment and treatment – Management of neutropenic sepsis– Urgent recognition and appropriate treatment of MSCC

• End of life decisions

Uurgent referral to ED

communication Oncology and GPb

Acute Oncology Service (AOS)

Development of acute oncology teams in every hospital with an ED/acute admitting beds

Access to oncology review within 24hrs of admission

Clear guidance on management of Neutropenic sepsisMetastatic cord compression

Components of Acute Oncology Service

AOS

Fast-track clinics

CUP pathway24/7

telephone advice

Neutropenic sepsis

MSCC pathway

Flagging system

AOT

Management protocols

Training

Aims of an Acute Oncology Service

Better communication between treating teams Increased patient safety Prevention of unnecessary admissions Reduced length of stay Minimised unnecessary investigations To improve patient experience Appropriate and prompt referrals to other specialties

/ hospitals as required

The Acute Oncology Team at UHL

Managerial structure:Dr Naheed Mir, Lead for Cancer ServicesJulie Baker, Lead Macmillan Nurse

Clinical Structure:Dr Eleni Karapanagiotou, Medical OncologistDr Dan Smith, Clinical OncologistHelen Guyatt, AOS CNSDian Welch, Administrator

AOS: dealing with treatment related-complications

Systemic treatment-related:• Neutropenic sepsis

• Uncontrolled nausea and vomiting

• Extravasation injury

• Acute hypersensitivity reactions including anaphylactic shock

• Complications associated with venous access devices

• Uncontrolled diarrhoea

• Uncontrolled mucositis

• Hypomagnesaemia

Radiotherapy-related• Acute skin reactions

• Uncontrolled nausea and vomiting

• Uncontrolled diarrhoea

• Uncontrolled mucositis

• Acute radiation pneumonitis

• Acute cerebral/other CNS, oedema

AOS: dealing with cancer-related complications

Presentations as caused directly by malignant disease and presenting as an urgent acute problem

• Pleural effusion• Pericardial effusion• Lymphangitis carcinomatosa• Superior mediastinal obstruction syndrome, including superior vena

caval obstruction• Abdominal ascites• Hypercalcaemia• Spinal cord compression including MSCC• Cerebral space occupying lesion(s)

Growing AOS in UHL

• AOS reviews on average 41 patients per month at UHL site.

• 855 patients seen between 06/13 - 02/15.

Jun-13

Aug-13

Oct-13

Dec-13

Feb-14

Apr-14

Jun-14

Aug-14

Oct-14

Dec-14

Feb-15

020406080

No. of patients seen by AOS

Referrals to AOS

• Referrals are made via fax, email and phone calls.

• Referrals from A+E, Admitting medical and surgical teams, Cancer CNS, Community palliative care teams, Other AOS teams.

AOS: specific areas of interest

• Cancer of unknown primary• Neutropenic sepsis• MSCC

Carcinoma of unknown primary (CUP)

• Confirmed carcinoma of unknown primary origin (CUP): Metastatic epithelial or neuro-endocrine malignancy identified on the basis of final histology, with no primary site detected despite a selected initial screen of investigations, specialist review, and further specialised investigations as appropriate.

• Around 4% of all cancers

CUP: diagnostic algorithmPatient identified:

Previous cancer diagnosis which may explain metastatic disease e.g. relapsed breast, colorectal, lung cancer

If suspected primary identifiable, refer to relevant team for further work-up and diagnosis eg: suspected lung primary refer to chest physician

AOS NOT INVOLVED IN 2WW REFERRALS!! No

Yes

Involve AOS

Collaboration between AOS and medical/surgical team to assess fitness for investigation and treatment, with imaging and biopsy arranged as indicated

with multiple lung metastases with multiple liver metastases with multiple bone metastases with single/ multiple nodal stations involved with multiple brain metastases

When to stop investigations?

Perform investigations only if:

• the results are likely to affect a treatment decisionEg are they fit for any treatment. Involve AOS/palliative care

• the patient understands why the investigations are being carried out

• the patient understands the potential benefits and risks of investigation and treatment and

• − the patient is prepared to accept treatment

CUP: clinical management

Specific subset of CUP:

Women with peritoneal papillary serous carcinoma

Women with adenocarcinoma involving axillary LN

SCC involving cervical LN

Neuro-endocrine CUP

CUP of a single location

Specific treatment according to presumed primary

Patient with suspected carcinoma of unknown primary

Exclude a non-CUP neoplasm:

Non-epithelial cancer (lymphoma, sarcoma, melanoma)

Extragonadal germ-cell tumour

Non-specific subset of CUP

Discuss treatment options based on PS and prognosis

UHL links to GSTT CUP MDM

CUP: a case presentationA fit 84 yo lady (LA) presents with bilateral neck lymphadenopathy Head and neck examination: -ve LN excision biopsy: adenocarcinoma CK7+ve, CK20-ve, EMA+ve, TTF-1 -ve, thyroglobulin -ve, ER-ve CT TAP: Bilateral neck and SCF LN and Rt axilla LN

!AOS

Mammogram and US: -ve

Discuss at MDM: not further investigations required CONFIRMED CUP

Discuss treatment

CUP CASES IN UHL

• 18 Patients linked to GSTT CUP MDM since June 2013 with suspected CUP.

• 8 of these Patients confirmed CUP

Neutropenic sepsis Neutropenic sepsis MUST be treated quickly (within 60 mins)

haematology and oncology patients recent chemotherapy or immunosuppressant drugs WITHIN 6/52 any patient who is pyrexial (38ºC) or clinically septic and neutrophil count of <0.5 x 109/L

1. History –has patient been on chemotherapy and how long ago?2. Examine –Urgent bloods (FBC, Cultures), TPR, ports for infection, 3. Action –get Antibiotics prescribed (do not wait for bloods)4. Treat –Antibiotics +? Fluids within 60 minutes of arrival

The interval between patient's arrival and commencement of antibiotic treatment (‘door-to-needle time') should not exceed 1 hour!!!

Neutropenic sepsis: Abx

No penicillin allergy

• Piperacillin/tazobactam 4.5 g QDS

Mild penicillin allergy

• Ceftriaxone 2g IV OD• Gentamicin IV OD

Severe penicillin allergy

• Teicoplanin 400mg IV(If> 70 Kg give 6mg/Kg every 12 h for 3 doses then OD

• Gentamicin• ± Ciprofloxacin 400mg

IV BD

* NEUTROPENIC SEPSIS GUIDELINES AVAILABLE ON INTRANET

Risk assessment: MASCC scoreCharacteristic Yes No Point scoreBurden of illness

*No or mild symptoms (not interfering with daily routine)

5

*Moderate symptoms (patient uncomfortable and symptoms influencing daily routine)

3

*Severe symptoms (severly limiting daily activity)

0

Does patient have hypotension (Systolic <90mmHg)

0 5

Does patient have chronic obstructive pulmonary disease

0 4

Does patient have a solid tumor or no previous fungal infection in haematological tumor

4 0

Outpatient status at time of presentation 3 0

Is the patient dehydrated or requiring IV fluids 0 3

Aged <60 years 2 0Total MASCC score

Neutropenic sepsis: risk assessmentCriteria Yes No

1 MASCC score < 21

2 Profound neutropenia (ANC ≤ 100cells/mm3) anticipated to extend >7 day

3 Severe mucositis that interferes with swallowing

4 Severe diarrhoea

5 New-onset neurological changes

6 Intravascular catheter related infection

7 New pulmonary infiltrate or hypoxaemia

8 Hepatic insufficiency (aminotransferase levels > 5 × normal values)

9 Renal insufficiency (eGFR <30ml/min or on dialysis)

NO to all these criteria will put the patient in a low risk categoryConsider de-escalation of antimicrobials.

AOS UHL: neutropenic sepsis cases

Door to needle times for suspected neutropenic sepsis 02/14 – 02/15

Feb-14

Mar-

14

Apr-14

May

-14

Jun-14

Jul-1

4

Aug-14

Sep-14

Oct-14

Nov-14

Dec-14Jan

-15

Feb-15

00.5

11.5

22.5

Time in hours

Time in hours

Chemotherapy-related-diarrhoea

Grade 1 Grade 2 Grade 3 Grade 4

2-3 BM 4-6 BM 7-9 BM >10BM

↑in stoma output ↑↑ in stoma output

↑↑↑in stoma output

↑↑↑↑in stoma output

Moderate cramping Severe cramping Grossly bloody diarrhoea

Nocturnal stools Nocturnal stools, interfering with ADL

Parental support

Check:What chemotherapy?: capecitabine/irinotecan/erlotinib/ipilimumabWhen?RT? (abdomen?)Observations: temperature, pulse, BP, RR O2Investigations: FBC, U&E, CRP, stool sample

Chemotherapy-related-diarrhoea: treatment

Action:Stop chemotherapyStart fluidsStart loperamideConsider codeine phosphateDiet advise

STOP: Wait for C&S if:• Recent hospitalization• Recent AB• Bloody diarrhoea• Recent travelling abroad•History of contact of diarrhoea

INFORM AOS!!

MSCC: a neurosurgical/ radiotherapy emergency

• Step by step protocols in place for all the Trusts

• Clinical presentation/imaging protocols/immediate Rx

• Virtual Case discussion with radiologist/ surgeon/ clinical radiologist

• Determine spinal stability of patients for nursing/transfer

MSCC: pathwaySuspected MSCCPatient with prior diagnosis of cancer or unknown primary with symptoms suggestive of spinal metastases/MSCC:

•Severe intractable progressive pain- especially in thoracic region•New spinal nerve root pain( burning, shooting, causing numbness)•Altered sensation and/or reduced power in limbs•Bladder and/or bowel disturbance( i.e. new onset of incontinence)

Follow the MSCC protocol

MSCC: pathwaySymptoms suggestive of

spinal metastasis or MSCC

WITH

Neurological symptoms

Contact MSCC coordinator immediately.

Urgent MRI within 24 hours.

Transfer MRI/CT images to MSCC centre for urgent review. Fax referral form to MSCC centre

Symptoms suggestive of spinal metastasis or MSCC

WITHOUT new

neurological symptoms

MRI within 7 days

Contact MSCC coordinator immediately within 24 hrs of MRI scan.

Nonspecific lower back pain

Locally managed standard backcare (outside remit of MSCC Guidelines)

Continue frequent observation to monitor symptom progression. If symptoms persist or progress refer

Contact Network Metastatic Spinal Cord Compression Team at Kings College Hospital

Telephone: 02032995468 Fax Referrals: 020 3299 4197

Patient discussed with the on-call Clinical Advisor (Consultant neuro-surgeon/Clinical Oncologist/Radiologist. CONFIRMED MSCC

Network MSCC coordinator feeds back to referrer and initiates treatment plan

SURGERY RADIOTHERAPYDiscussion with AOS andtreating oncologists(histology needed, first presentation, prognosis)

MSCC: case presentation

Aug 2012: A 41 yo female (TS) presented with back pain gradually worsening 2/12

Previous diagnosis of Rt breast cancer in 2006Histology: IDC, ER+ve, HER2+veTreatment: neoadjuvant chemotherapy (ECX4 followed by DX4), WLE + AC, RT, adjuvant trastuzumab and Tamoxifen

MSCC: radiological findings

Walking affectedRt lower limb numbnessRt limb: Motor power 4/5

Dexamethasone 8mg bdUrgent MRI

MSCC pathway activated

NS: NOT for surgery

Urgent RT

MSCC cases in UHL

• 15 patients seen in UHL with impending and confirmed MSCC between 06/13 – 04/15

• 14 patients received Radiotherapy at GSTT• 1 patient transferred to KCH for surgery

Food for thought….

• No established pathway between AOS and GP practices• AOS inpatient service • Not enough AOS resources as yet• Established pathways still work between GPs and ED/2ww