1. Acute Oncology Service at UHL
Helen Guyatt
Acute Oncology CNS
Dr Eleni Karapanagiotou
Medical Oncologist
2. 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
3. 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
4. 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 !
5. 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
6. 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 sepsis
Metastatic cord compression
7. Components of Acute Oncology Service
AOS
Fast-
track
clinics
CUP
pathway24/7
telephone
advice
Neutropenic
sepsis
MSCC
pathway
Flagging
system
AOT
Management
protocols
Training
8. 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
9. The Acute Oncology Team at UHL
Managerial structure:
Dr Naheed Mir, Lead for Cancer Services
Julie Baker, Lead Macmillan Nurse
Clinical Structure:
Dr Eleni Karapanagiotou, Medical Oncologist
Dr Dan Smith, Clinical Oncologist
Helen Guyatt, AOS CNS
Dian Welch, Administrator
11. 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)
12. Growing AOS in UHL
• AOS reviews on average 41 patients per
month at UHL site.
• 855 patients seen between 06/13 - 02/15.
0
20
40
60
80
No. of patients seen by AOS
13. 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.
14. AOS: specific areas of interest
• Cancer of unknown primary
• Neutropenic sepsis
• MSCC
15. 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
16. CUP: diagnostic algorithm
Patient 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
17. When to stop investigations?
Perform investigations only if:
• the results are likely to affect a treatment decision
Eg 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
18. 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
19. CUP: a case presentation
A 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
20. CUP CASES IN UHL
• 18 Patients linked to GSTT CUP MDM since
June 2013 with suspected CUP.
• 8 of these Patients confirmed CUP
21. 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!!!
22. 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
23. Risk assessment: MASCC score
Characteristic Yes No Point score
Burden 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 0
Total MASCC score
24. Neutropenic sepsis: risk assessment
Criteria 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 category
Consider de-escalation of antimicrobials.
25. AOS UHL: neutropenic sepsis cases
Door to needle times for suspected neutropenic
sepsis 02/14 – 02/15
0
0.5
1
1.5
2
2.5
Feb-14
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Time in hours
Time in hours
28. 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
29. MSCC: pathway
Suspected MSCC
Patient 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
30. MSCC: pathway
Symptoms 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 RADIOTHERAPY
Discussion with AOS and
treating oncologists
(histology needed, first
presentation, prognosis)
31. 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 2006
Histology: IDC, ER+ve, HER2+ve
Treatment: neoadjuvant chemotherapy (ECX4 followed by DX4),
WLE + AC, RT, adjuvant trastuzumab and Tamoxifen
32. MSCC: radiological findings
Walking affected
Rt lower limb numbness
Rt limb: Motor power 4/5
Dexamethasone 8mg bd
Urgent MRI
MSCC pathway activated
NS: NOT for surgery
Urgent RT
33. 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
34. 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
Notes de l'éditeur
NCEPOD: national confidential enquiry into patient outcome and death
EMA: epithelial membrane antigen: for epithelial tumours
