YCN MSCC PathwayYCN MSCC PathwayImplementation of NICE CG75Implementation of NICE CG75

Level 2: DiagnosticLevel 2: Diagnostic

Dr Rob TurnerDr Rob Turner

Chair YCN MSCC GroupChair YCN MSCC GroupUnits to localise slides to clarify responsibilities of the MSCC Units to localise slides to clarify responsibilities of the MSCC

Coordinator and specify points of referral from the initial Coordinator and specify points of referral from the initial triage to the MSCC Coordinator and then on to the AOL / triage to the MSCC Coordinator and then on to the AOL /

AOTAOT

YCN MSCC Competency for Local MSCC YCN MSCC Competency for Local MSCC Coordinators Coordinators

Local Acute Oncology Team MSCC Coordinators

Competencya)Knowledge and understanding of which patient groups are at a higher risk of developing MSCC

b)Knowledge and Understanding of the signs and symptoms of MSCC

c)Understanding of the appropriate aspects of the MSCC pathwaya) Escalation to the local coordinator

b) Escalation to investigation

c) Referral process to Leeds

d) Specialist MSCC coordinators – assessment and referral for treatment

d) Knowledge and understanding of the MSCC treatment options and specialist service processes for delivering treatment

EducationE - Learning Level 1- Early Warning

Level 2 – Diagnostic

YCN MSCC PathwayYCN MSCC Pathway

Components of the pathwayComponents of the pathway

Overall goalsOverall goals

YCN implementation of the GuidelineYCN implementation of the Guideline

SJIO implementation of the GuidelineSJIO implementation of the Guideline

Future developmentsFuture developments

MSCC Pathway ComponentsMSCC Pathway Components

1.1. Education and early warningEducation and early warning

2.2. TriageTriage

3.3. Diagnosis & generic careDiagnosis & generic care

4.4. Specialist interventionSpecialist intervention Spinal surgerySpinal surgery RadiotherapyRadiotherapy

5.5. RehabilitationRehabilitation

Overall goalsOverall goals

Earlier diagnosis and treatmentEarlier diagnosis and treatment– Outcomes linked to pre-treatment statusOutcomes linked to pre-treatment status

Faster access to diagnostic MRIFaster access to diagnostic MRI– SuspectedSuspected

MSCC within 24 hoursMSCC within 24 hoursVBM within 7 daysVBM within 7 days

Rapid escalation to definitive therapyRapid escalation to definitive therapy– ProvenProven

MSCC within 24 hoursMSCC within 24 hoursVBM within 7 daysVBM within 7 days

Definitive therapy case-appropriateDefinitive therapy case-appropriateCo-ordinated case-appropriate rehabCo-ordinated case-appropriate rehab

YCN implementation of the GuidelineYCN implementation of the Guideline

Devolved responsibilitiesDevolved responsibilities– Cancer Unit AOTsCancer Unit AOTs

Early warningEarly warning

TriageTriage

Diagnostics and generic careDiagnostics and generic care

RehabilitationRehabilitation

– CentreCentreMSCC senior medical advisorsMSCC senior medical advisors

– Spinal surgerySpinal surgery– RadiotherapyRadiotherapy

SJIO implementation of the GuidelineSJIO implementation of the Guideline

Must work both as Cancer Unit Must work both as Cancer Unit andand Centre Centre

SJIO implementation of the GuidelineSJIO implementation of the Guideline

Cancer UnitCancer Unit– ALL MEDICAL STAFFALL MEDICAL STAFF– In- and out-patientsIn- and out-patients– Leeds basedLeeds based

BreastBreast

LungLung

UrologyUrology

ColorectalColorectal

HaematologicalHaematological

– CentreCentre-based MDTs-based MDTsUnder active reviewUnder active review

Cancer CentreCancer Centre– CLINICAL CLINICAL

ONCOLOGY ON-ONCOLOGY ON-CALL TEAMCALL TEAM

– ProvenProven MSCC only MSCC onlyImagedImaged

– ReportedReported

– TransferredTransferred

Education and early warningEducation and early warning

High-risk patient groupsHigh-risk patient groups– Agreed by YCN SSG ChairsAgreed by YCN SSG Chairs

Face-to-face discussionFace-to-face discussion

Common format patient informationCommon format patient information– Symptoms of MSCC and VBMSymptoms of MSCC and VBM– Instructions about action to take Instructions about action to take (add local process)(add local process)

24 hour SINGLE POINT CONTACT NUMBER24 hour SINGLE POINT CONTACT NUMBER

Add Local NumberAdd Local Number

High Risk Patient GroupsHigh Risk Patient Groups

Any patient who has had Any patient who has had prior MSCCprior MSCCAny patient with Any patient with known bony metastasesknown bony metastases at any at any site from any primary sitesite from any primary siteKnown cancer Known cancer awaiting investigation for awaiting investigation for suspicious spinal painsuspicious spinal painTumour site-specific recommendationsTumour site-specific recommendations– ProstateProstate:: HRPCHRPC– RenalRenal:: Metastatic renal cell cancerMetastatic renal cell cancer– LungLung:: Any metastatic lung cancerAny metastatic lung cancer– BreastBreast:: Any metastatic breast cancerAny metastatic breast cancer– MyelomaMyeloma:: Any myelomaAny myeloma

MSCC symptoms & signsMSCC symptoms & signs

Triage: MechanismTriage: Mechanism

Nursing staff will take basic detailsNursing staff will take basic detailsEscalated to Local Details Escalated to Local Details In hours to be handled immediatelyIn hours to be handled immediately– Overnight (22.30-09.00) defer until handoverOvernight (22.30-09.00) defer until handover

On-call Local team to triageOn-call Local team to triage– Ring back for more detailRing back for more detail

PriorityPriority– Immediate or deferred?Immediate or deferred?

Ward or clinic for clinical assessmentWard or clinic for clinical assessment– Is MRI required and how quickly?Is MRI required and how quickly?

Triage: Need for MRITriage: Need for MRI

Probability MRI shows neural compressionProbability MRI shows neural compression(after Lu, J Sup Care 2005;3:305-312)(after Lu, J Sup Care 2005;3:305-312)

Neurological deficitNeurological deficit

PresentPresent AbsentAbsent

High-risk & suspicious painHigh-risk & suspicious pain 81%81% 69%69%

Suspicious pain onlySuspicious pain only 44%44% 33%33%

Triage: Endpoints Triage: Endpoints

MSCC possibleMSCC possible– Urgent clinical assessmentUrgent clinical assessment– Urgent in-patent MRI Urgent in-patent MRI (within 24 hours)(within 24 hours)

Admission may be requiredAdmission may be required– You MUST discuss with a Consultant COYou MUST discuss with a Consultant CO

MSCC less likely but VBM possibleMSCC less likely but VBM possible– Prompt outpatient assessmentPrompt outpatient assessment– Prompt outpatient MRI Prompt outpatient MRI (within 7 days)(within 7 days)

MRIMRI

Whole spine MRI imagingWhole spine MRI imaging– MSCC (Rx within 24 hours)MSCC (Rx within 24 hours)

With/without features of spinal instabilityWith/without features of spinal instability

– Non-compressive VBM (Rx within 7 days)Non-compressive VBM (Rx within 7 days)– Off-pathway findingsOff-pathway findings

Non-malignant neural compressionNon-malignant neural compression

Non-malignant spinal diseaseNon-malignant spinal disease

YCN radiology group have agreedYCN radiology group have agreed– YOU WILL NEED TO DISCUSS WITH A YOU WILL NEED TO DISCUSS WITH A

RADIOLOGIST FACE-TO-FACERADIOLOGIST FACE-TO-FACE

CaveatCaveat

If you are an oncologist but not part of the If you are an oncologist but not part of the on-call CO team and you are concerned on-call CO team and you are concerned about MSCC or VBM do not delay the about MSCC or VBM do not delay the process by ringing ward 96 or the CO on-process by ringing ward 96 or the CO on-call team:call team:

Arrange a whole spine MRI and escalate the resultArrange a whole spine MRI and escalate the result

Diagnostics and generic careDiagnostics and generic care

Whole spine MRI is gold-standardWhole spine MRI is gold-standard– CT or isotope bone scan is notCT or isotope bone scan is not

In In all casesall cases– AnalgesiaAnalgesia

In In suspected MSCCsuspected MSCC– DEXAMETHASONE 16mg od plus HDEXAMETHASONE 16mg od plus H22RB/PPIRB/PPI

– ThromboprophylaxisThromboprophylaxis– Encourage mobilisationEncourage mobilisation

Mobilisation & suspected MSCCMobilisation & suspected MSCC

Flat bed-rest is Flat bed-rest is notnot the default the default– Position/mobilise as pain permitsPosition/mobilise as pain permits

LyingLying

Inclined sitInclined sit

Sitting balanceSitting balance

Assisted transferAssisted transfer

Independent transferIndependent transfer

Assisted mobilityAssisted mobility

Independent mobilityIndependent mobility

Specialist InterventionSpecialist Intervention

All MRI proven MSCC should be escalated All MRI proven MSCC should be escalated to Leeds - the CO StR on-call to Leeds - the CO StR on-call – Agreed YCN access-point to therapyAgreed YCN access-point to therapy– Spinal surgery should NOT be approached Spinal surgery should NOT be approached

directly for MSCC casesdirectly for MSCC cases– The need for a spinal surgical review will be The need for a spinal surgical review will be

established according to agreed criteria by the established according to agreed criteria by the Leeds CO teamLeeds CO team

Specialist InterventionSpecialist Intervention

Key stepsKey steps– Confirm diagnostic criteria are metConfirm diagnostic criteria are met– Establish fitness for transfer/treatmentEstablish fitness for transfer/treatment– Establish most appropriate interventionEstablish most appropriate intervention– Escalate for surgical opinion if indicatedEscalate for surgical opinion if indicated– Transfer if not already at SJIOTransfer if not already at SJIO– Deliver definitive therapyDeliver definitive therapy– Initiate rehabilitation process Initiate rehabilitation process

Confirm diagnosisConfirm diagnosis

MSCC is not MSCC untilMSCC is not MSCC until– There image proven neural compressionThere image proven neural compression

Images are reportedImages are reported

Images and report are availableImages and report are available

– The malignant diagnosis is not in doubtThe malignant diagnosis is not in doubt

Confirm diagnosis: IssuesConfirm diagnosis: Issues

No MRINo MRI– Unit has responsibility to perform imagingUnit has responsibility to perform imaging

If no MRI service availableIf no MRI service available– Establish name of unit radiologist who has sanctioned Establish name of unit radiologist who has sanctioned

the need for an MRI but agrees no facility to scanthe need for an MRI but agrees no facility to scan– Establish fitness to transferEstablish fitness to transfer– Transfer to SJIO for MRI imagingTransfer to SJIO for MRI imaging

MRI but no reportMRI but no report– Establish name of unit radiologist who has sanctioned Establish name of unit radiologist who has sanctioned

the need for an MRI but is unable to reportthe need for an MRI but is unable to report– Ask referring unit to transfer imagesAsk referring unit to transfer images– Discuss with SJIO radiology on-callDiscuss with SJIO radiology on-call

Confirm diagnosis: IssuesConfirm diagnosis: Issues

No malignant histologyNo malignant histology– Clinical contextClinical context

History, examinationHistory, examination

– Radiological contextRadiological contextOligometastatic or multi-levelOligometastatic or multi-levelSimple imagingSimple imagingCT imagingCT imaging

– If the diagnosis is in doubt and there is either no clear If the diagnosis is in doubt and there is either no clear candidate primary or target for biopsy (that would not candidate primary or target for biopsy (that would not be within the RT field)be within the RT field)

Needs surgical intervention for decompression and tissueNeeds surgical intervention for decompression and tissue– Unless PS/co-morbidity preclude Unless PS/co-morbidity preclude

Establish fitnessEstablish fitness

Do not transferDo not transfer if if– Against patient’s wishesAgainst patient’s wishes– Medically unstableMedically unstable– Established paresis >48 hours and no painEstablished paresis >48 hours and no pain

Treat as day-caseTreat as day-case if if– AmbulantAmbulant– Self-caring/self-medicatingSelf-caring/self-medicating

Discuss with PR/RTBODiscuss with PR/RTBO if if– Single fraction proposedSingle fraction proposed– Nurse escort availableNurse escort available

Other cases to transfer into Other cases to transfer into Bexley Wing BedBexley Wing Bed– Same priority as neutropenicSame priority as neutropenic– Patient to be at Bexley Wing to enable RT simulation by 12.00Patient to be at Bexley Wing to enable RT simulation by 12.00– Referring hospital to hold bed pending transfer backReferring hospital to hold bed pending transfer back

Establish most appropriate interventionEstablish most appropriate intervention

See EQMSSee EQMSRadiotherapyRadiotherapy– Radiotherapy quality systemRadiotherapy quality system

Radiotherapy protocolsRadiotherapy protocols– PalliativePalliative

MSCC_Palliative_RTAlone_UnplannedMSCC_Palliative_RTAlone_Unplanned

Escalate for surgical opinion if indicated – Units to Escalate for surgical opinion if indicated – Units to escalate to the Leeds StR as Guidelinesescalate to the Leeds StR as Guidelines

Escalation based uponEscalation based upon– Co-morbidity/fitnessCo-morbidity/fitness– Presence or possible mechanical instabilityPresence or possible mechanical instability

RadiologicalRadiological

ClinicalClinical

– Cancer survival estimateCancer survival estimate– Surgical risk factorsSurgical risk factors

Seeking a surgical opinion – Seeking a surgical opinion – responsibility of Leedsresponsibility of Leeds

Confirm appropriate with CO consultantConfirm appropriate with CO consultant

Access spinal surgical consultant directAccess spinal surgical consultant direct– Up to date mobile numbers are availableUp to date mobile numbers are available

Above D2: neurosurgicalAbove D2: neurosurgical

Below D2: spinal orthopaedicsBelow D2: spinal orthopaedics

– DO NOT use neuro/ortho StRDO NOT use neuro/ortho StR

Request image review via PACSRequest image review via PACS

If operable they will take to LGIIf operable they will take to LGI– Possible return to RT if patient declines risk or if not Possible return to RT if patient declines risk or if not

appropriate after face-to-face reviewappropriate after face-to-face review

Surgical opinion: IssuesSurgical opinion: Issues

Missing data for prognostic toolsMissing data for prognostic tools– Calculate maximum possible score based upon data Calculate maximum possible score based upon data

availableavailableIf missing data critical: defer Rx until availableIf missing data critical: defer Rx until available

No surgeon available and opportunity loss high No surgeon available and opportunity loss high – RT possibly inferiorRT possibly inferior

Retained ambulatory functionRetained ambulatory functionLong anticipated OS (TPS >12)Long anticipated OS (TPS >12)Low-risk surgical candidateLow-risk surgical candidate

– Liase with Sheffield or HullLiase with Sheffield or Hull– Maintain on DEX with regular (twice daily) review with Maintain on DEX with regular (twice daily) review with

default to RT if deterioratesdefault to RT if deteriorates

Deliver definitive therapy – Deliver definitive therapy – patient admitted to Leedspatient admitted to Leeds

Submit RT e-booking form via MosaiqSubmit RT e-booking form via Mosaiq– Palliative SpinePalliative Spine

Speak to booking office to establish timeSpeak to booking office to establish time

Liaise with bed coordinator/PR suiteLiaise with bed coordinator/PR suite– Patient must be simulated before 13.00Patient must be simulated before 13.00– Liaise with on-call radiographers if w/endLiaise with on-call radiographers if w/end

Initiate rehabilitation processInitiate rehabilitation process

As part of informed consent, discuss and As part of informed consent, discuss and document in case-notesdocument in case-notes– Goals of treatmentGoals of treatment

Anticipated ambulatory function post treatmentAnticipated ambulatory function post treatmentTime-scales for recoveryTime-scales for recovery

– Likely trajectory of underlying malignancyLikely trajectory of underlying malignancyFitness for further anticancer therapyFitness for further anticancer therapyFitness for active rehabilitationFitness for active rehabilitation

This will make onward support from AHPs This will make onward support from AHPs much more straightforwardmuch more straightforward

Do not forgetDo not forget

Tail-off DEXAMETHASONETail-off DEXAMETHASONE– Tumour may ‘flare’ soTumour may ‘flare’ so

Delay until 3-5 days post initial RT #Delay until 3-5 days post initial RT #

Reduce by 4mg every 3-5 daysReduce by 4mg every 3-5 days

Step up if neurology worsens after initial recoveryStep up if neurology worsens after initial recovery

Dictate a prompt transfer/discharge summary via Dictate a prompt transfer/discharge summary via PPMPPM

Arrange appropriate f/upArrange appropriate f/up– No f/up is not appropriateNo f/up is not appropriate

If not your team, then who is taking over?If not your team, then who is taking over?

Future developmentsFuture developments

Faxable referral/transfer proformasFaxable referral/transfer proformas

Framework for rapid handling of VBMFramework for rapid handling of VBM

Spinal MDTSpinal MDT– Surgical cases for adjuvant RTSurgical cases for adjuvant RT– Non-compressive VBM for surgeryNon-compressive VBM for surgery

Access to newer technologiesAccess to newer technologies– Minimally invasive techniquesMinimally invasive techniques

Faster recovery for less fit patientsFaster recovery for less fit patients

SBRT for spinal metastasesSBRT for spinal metastases

Feedback from Peer Review mandatory auditFeedback from Peer Review mandatory audit