HEAPHY 2RADIOTHERAPYGlenys ROUND

Charleen CASSON

Fri 30th Aug 2013Session 2 / Talk 1

10:30 – 10:50

AbstractTraditionally wait times for palliative radiotherapy can be a lengthy process. It can involve several visits to the Oncology department, delaying a patient’s treatment when time is precious. In keeping with clinics established overseas (Canada & Brisbane) we have implemented a rapid access palliative clinic (RAPC) at Waikato Hospital. This paper describes the implementation of the clinic and assessment of the outcomes of the RAPC seen between 2009-2011. It will also discuss the multidisciplinary nature of such a clinic, the future for our RAPC and the advances that can be made to improve our patient’s journey.

Presented by Dr Glenys Round & Charlene Casson

Waikato Regional Cancer CentreRapid Access Palliative Clinic (RAPC)

Background

Referrer sends referral Wait list for FSA Seen by Radiation Oncologist Waitlist for simulation Simulated Waitlist for radiation therapy Treatment

Background

Palliative patients considered non-urgent (Cat 4 – National prioritisation criteria)

Wait times to FSA therefore can be long, as radical patients take priority unless Cat A (Spinal cord compression, uncontrolled bleeding)

Wait time to treatment vary widely- same day to several weeks

Up to 3 visits to treatment

Background

All this on a background of patients in a palliative phase of their disease process, where quality of life and time are important

Frequently elderly, frail, weak from end-stage disease, age and co-morbidities

Frequently an elderly exhausted spouse/partner Frequently from a rural area Patients have to travel up to 4-5hours

Background

Common around the world to have waiting times for FSA and treatment exceeding acceptable lengths of time

Pressure to increase patient throughput. Multiple studies have shown efficacy of single 8Gy

fraction cf. longer fractionations for bone pain Widely accepted, although in spite of evidence, use

of longer fractionations is common ( 20Gy in 5 fractions, 30Gy in 10 fractions)

Canada

Saw a need to do better Set up “Rapid Access Palliative Radiotherapy

Programme” Patients seen very quickly after referral Consultation, simulation, treatment all in one day for

appropriate patients Better programmes, offer multidisciplinary

assessment Some centres - patients offered access to a clinical

trial

Aims

Rapid assessment and treatment Multidisciplinary approach Rapid pain relief Improve quality of life Increase satisfaction of referrer Increase proportion of rural referrals

Aims

Separate clinic at a separate time could save FSA for radical patients

Separate simulation time could save allocated simulation space for radical patients

Rapid Access Palliative Clinic April 2009

Initial Criteria

Known Carcinoma Not be a current patient Bony pain Diagnostic evidence No more than 3 painful sites Single fraction Patients transferred back to referring service

Clinic Pathway

Patients are booked into 3 time slots on a Tuesday

Team Meeting @ 8.30am Process:- Consultation- Simulation- Planning- Treatment

Patients characteristics Diagnosis Site of disease Analgesic medication Initial/ follow up Pain Score Treatment Information Further investigations ie bone scone, MRI 3 week follow up telephone call

Tracking Form

Age Gender- Average 69 yrs - Male 65%- Range 30 – 94 yrs - Female 35%

Main Diagnosis Referrers- Prostate 30% - MO 23%- Breast 17% - GP 21%- Lung 16% - Urology 20%

Statistics 2009 – 2012(261 Patients)

Spine 147 (T Spine = 76)

Pelvis/Hips 78

Ribs 21

Shoulders 17

Femur/Knee 13

Chest 12

Other 19

Treated Sites(patients = 226, treated sites = 307)

Prescriptions

51%

38%

7%4%

8 Gy

20Gy

30Gy

Other

63% CT’d & treated same day

46% single fractions

13% no treatment

Same Day Sim & Treat

Distance to RAPC

0 20 40 60 80 100 120 140

0>10km

>10km

>50km

>100km

>150km

Dis

tanc

e Tr

avel

led

Number of Patients

Pain Score

INITIAL PAIN SCORE (300 Tmt Sites)

0

20

40

60

80

100

120

0 1 2 3 4 5 6 7 8 9 10

Pain Score

No

of P

atie

nts

Initial

F/UP PAIN SCORE (273 Tmt Sites)

0

20

40

60

80

100

120

0 1 2 3 4 5 6 7 8 9 10

Pain Score

No

of P

atie

nts

F/Up

Increase - 15%

Decrease - 28%

Same - 44%

Unknown - 13%

Medication

Reduce visits to the department

Immediate multidisciplinary approach

Pain management reviewed

Continuity of care

Positive comments from patients/families

Benefits of RAPC

RAPC was implemented successfully

Data collected, further improvements have been made to the clinic to benefit the patient.

Conclusion

RAPC is not . . .

Radiation Oncologist seeing patient and simulating quickly, and then patient waits for treatment.

Imperatives

Deliberate Multidisciplinary Regular Investigates Admits Manages medical problems esp. analgesia,

nausea and bowels. Supports (relatives),

Imperatives

Refers – Med Onc, Palliative Care, physio, dietician, Maori support, chaplain.

Does not take ownership Refers back to referrer, but follows up

patients as required Communicates with referrer Prospectively gathers data Audit Reviews itself, adapts as required.

Imperatives

Lesser options CANNOT be called a “Rapid Access Palliative Clinic” or” Programme”.

Onboard imaging to plan and deliver palliative radiotherapy in a single, cohesive patient appointment – Perth.

( Hopefully soon for us. Note extra machine time). Stereotactic body radiotherapy – limited application

in most of these patients. Similar clinics for brain metastases – Canada.

( Truly multidisciplinary – Neurosurgery, Rad Onc, Med Onc, RT, Pall Care, Nurse, Allied Health)

Future

References

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