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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