Urgent Care and Cancer

What’s New in Acute Oncology?

Dr Ernie Marshall

Medical Oncologist

Clatterbridge Cancer Centre

Merseyside

AO What’s happening?

AIMS TODAY

• AO service development

– What was the problem we set out to fix?

• What is an AO patient?

• Treatment-related Complications

• Emergency presentation of new cancers

• The challenge ahead

What is AO and what wasthe Problem?

Dislocated Care in DGHs

Lack of information

Poor communication

Lack of Oncology oversight

Reliance on General Medicine

Poor patient experienceTime to review by oncology/haemato-oncology team

Speciality of first admission during last 30 days of life

Majority of patients enter via ED

National Chemotherapy Advisory Group Recommendations

To Improve quality and safety for Cancer Patients:• Every Hospital with ED should develop an AO

service (185-173)– 5 PAs Consultant Oncology ( =92.5 new

oncologists)– 1 wte ‘AO Nurse’ (now 7% cancer nursing

workforce)

• A System-wide approach:– Brings together expertise from emergency

medicine, general medicine, oncological disciplines

– Every hospital should have a single multi-professional AO steering Grp to oversee AO (18-001 QS)

– Develop local policies to support training and access to urgent advice

AO Service Achievements

173 AO services established70% median compliance (2017 QS)

Reduced LOS 3 days per episode

Access to advicePatient Alert cardsAccess to Protocols24/7 access

oncologist on –callCancer/chemotherapy helpline

Access to specialist services – eg MSCC Access to AOS on the ground

5 day serviceMove towards 7 day nurse-delivered

What is an AO Patient ?

Type I : Patients who present for the first time following an

emergency presentation ie NEW CANCERS

Type II: Patients who present with Complications of cancer

treatment – typically chemotherapy (SACT)

Type III: Patient who present as a complication of their cancer

(eg MSCC) or progression/comorbidity

Type I

Type II

Type III

Differing presentations, needs, LOSDiffering outcomes & solutions

What’s happening with

Cancer treatment complications?

TYPE II AO

Nearly all drug-related

Short stay

Potential to ambulate

New toxicities

Neutropenic Sepsis:NICE Guidance CG 151

• Typically occurs 7-14 days post chemotherapy

• May be Ill-defined symptoms (30% afebrile)– Diarrhoea– confusion

• Treat suspected NS ‘immediately’ with empirical broad spectrum Abs – do not wait for blood counts

• NOT a problem with new therapies

NS – Review of NICE Guidance (2018)

FINDINGSHigh Compliance with standards BUT……• Risk stratification (MASCC) not routinely

used• Lack of standards for isolation, step down

and discharge policies• Variable G-CSF policies (no role in

‘uncomplicated NS’)• NS is not well aligned with UK Sepsis

Developments• ‘Recent Chemo’ is a RED Flag to

initiate SEPSIS 6Drives inpatient care

Limited development of low risk pathways

Management of the deteriorating patient and sepsis

Low risk ‘neutropenic sepsis’: Principles for ambulatory care

Ambulatory Care outpatient care in Low risk Neutropenic Fever

Klastersky et al, 2006, Tueffel, et al. Ann Oncol 2011

Safety and cost benefit of an ambulatory programme for patients with low risk neutropenic fever at an Australian centre. The et al, 2018

Application of the MASCC and CISNE Risk-Stratification Scores to Identify Low-Risk Febrile Neutropenic Patients in the Emergency Department Coyne et al

Characteristic score

Mild or no symptomsModeratesevere

530

No hypotension 5

No COPD 4

Solid or haem with no prior fungal infection

4

No dehydration –requiring iv fluids

3

Outpatient status 3

Age less 60years 2

Follow suspectedSepsis pathway

Recent ChemoSuspected NS

Stat iv antibiotics

MASCC Score ≥21

Eligible for safe discharge?

Safety netting and follow up

The Changing Landscape of Cancer Drug Therapy

Figure 1. Growth of the cancer immunotherapy space based on publications. [Select Biosciences]

New indications for I-OFirst and second line Lung CancerRenal & Bladder CancerHead and neck CancerGastric CancerSkin cancer (merkel cell)

METASTATIC MELANOMA

Case Study I

• JOHN : 54 year old male• Metastatic melanoma• Completed 2 cycles Ipilimumab & Nivolumab 5

days ago• 3 day history of watery diarrhoea (6 x per day),

urgency and lower abdominal pain • Clinically well

• Bloods – NAD• Diagnosed – viral gastroenteritis.

Advised fluids and loperamide• Re-presented 5 days later :

Deterioration, collapse, acute abdomen

Final Diagnosis: I-O induced Colitis – leading to colonic perforation

Case Study II

• SUSAN: 45 year old female• Metastatic melanoma• Completed 3 cycles of Ipilimumab 2 months

ago• 4 day history of generalized headache,

extreme fatigue and nausea• Bloods NAD, Na 131• CT brain – NAD• Diagnosed migraine and discharged• Represented 1 week later with

collapse, hypotension

Final Diagnosis: I-O induced Hypophysitis

New Toxicities with I-O Therapies1,2

• 1. Opdivo Summary of Product Characteristics; 2. Yervoy Summary of Product Characteristics. Both available at: https://www.medicines.org.uk/emc/. Accessed October 2016

20%

15%

10%

5%

5%

<1%

Guillain-BarreUveitisPancreatitisencephalitis

Timing of IR toxicities

Key Message: Immune-related toxicities may occur at unpredictable times and may be delayed

Immune-related Adverse Events (irAEs): Guiding Principles

• Awareness, Awareness, Awareness…….– low threshold for considering I-O toxicity – Patient held information/alert cards/SACT details

• Ensure you have locally available protocols• Screening Bloods may help – U&E, LFTs, TFTs,

random cortisol• Early liaison with Oncology :

– Early initiation of high dose steroids with clinical suspicion (1-2mg/kg methylpred equivalent)

– Increasing role for immune modulators eg infliximab (colitis)

The UK Oncology Nursing Society Guidelines

Readily available (www. ukons.org)Colour-coded and RAG ratedLink to initial management guidelines

UKONS - Diarrhoea0 1 2 3 4

DiarrhoeaFrequency/24hrsBloodPain……

none Up to 3Mild

symptoms

4-6Nocturnal

Moderate symptoms

7-9Severe pain

or symptoms

>10bloody

Management1. Baseline bloods (FBC, U&E, LFTS, TFTs, cortisol, CRP2. Stool micro/culture3. Cdiff toxin4. Faecal calprotectin

Treatment1. Pred 0.5-1mg/kg/day + PPI2. Stop loperamide and codeine3. Daily telephone monitoring

Assess responseTo treatment within 72hours

Persistworsen

JOHN:CASE I

Not all new drugs are Immunotherapy!Tyrosine Kinase Inhibitors (THE ‘ibs’)

• Key mutational drivers in some Cancers– Melanoma (BRAF inhibitors)– Lung (EGFR, ALK inhibitors)

• Common side effects– Skin : Rash, erythema– Constitutional: fever, rigors– GIT: Diarrhoea– Cardiac – prolonged QT interval

• Daily oral therapy – chronic dosing– If in doubt - STOP

DABRAFENIBPAZOPANIBIMATINIBGEFITINIBAFATINIB

What about New Cancers (Type I) ?

Case study III

ALBERT: 76 year old man presents ED

PMH: COPD, NIDDM, AF

Symptoms: 10kg weight loss, fatigue.

Investigations: Hb 10.5, WBC 10, platelets 500, ESR 70, ALP 200, AST 90. CXR clear

Differential & Management Plan?

Final Diagnosis: CT CAP – mediastinal Lymph nodes, liver metastases – Lung Cancer stage 4

Emergency Presentation of Cancer

1 in 5 cancer patients presentVia Emergency routesAssociated with advanced stage and poor 1 year Survival

Unknown Primary

Admission Avoidance Improving Diagnostic Pathways for Patients

with Vague Symptoms (April 2017)www.cruk.org/ace-resources

Non-Specific symptoms correlate with increasing age, emergency & late presentation and poor survival

9 VS Pilot sites • coordinated triage (defined eligibility) • access to diagnostics (CT) • hot clinic or virtual

Reduced ED presentation, conversion rates 6.5-47%, improved experience.

‘Wave 2’ Multi-disciplinary Diagnostic Centres (MDCs) ongoing• 1034 referrals (Nov 17) with 8%

conversion rate

Achieving World-Class Cancer Outcomes: A

Strategy for England 2015-2020

An approach to building an MDC

Check out your nearest MDC

Why not build your own?

The Increasing Burden ofUrgent Cancer Care

Merseyside

AO

admissions

trebled since

2009-2017

2.5 million

people living

with cancer in

UK rising to

4.0 million by

2030

Older people

living with

cancer is set

to treble by

2040

Increasing SACT Delivery

And Complexity

9.2 million Bed Days For Cancer

EOL Care

Joined up Urgent Care Strategy and Cancer

• Cancer Help lines that support both professionals and patients and are linked to NHS III

• Ambulatory Capacity linked to paramedics, Urgent treatment Centres and Hospital ambulatory strategy

• Partnership working with Acute medicine and greater integration of pathways/protocols

A Few Useful Take Home Messages From Today

• Check if patients/carers have a ‘chemo alert card’

• Always consider potential immune toxicity

• If in doubt, stop oral anticancer therapy

• Check out CRUK website for MDC resources

• www.cancerresearchuk.org

• A Successful AOS needs strong partnership working

between Oncology & Acute/General Medicine

THANK YOU

FOR LISTENING