Introduction to Acute

Oncology

Objectives
By the end of this session participants should have
an awareness and understanding of;
The local development of Acute Oncology Services (AOS)
the AOS referral guidelines
How to contact the local AOS for advice / refer for acute oncology
assessment
Cancer patient flagging system / rapid alert system
The AOS protocols and how to access them
The 24/7 advice lines
How to access the consultant oncologist on call service
The current care pathway for patients with suspected or confirmed
MSSC (this will change as the service evolves)
Planned development of fast-track referral to OP clinics

Background
Increase in the variety of anti-cancer treatments
- undoubted benefits for 1000s
Massive increase in the use of chemotherapy
60% increase in 4 years
BUT significant concerns about the quality and
safety of some services in 2008

Chemotherapy Safety
Concerns 2008
National Confidential Enquiry Patient Outcome and Death
(NCEPOD)

Audit during June 2006

47,050 chemotherapy cycles given
1415 patients died within 30 days of treatment
In approx 25% of these the treatment may have hastened death or been
caused by poor management of toxicities

National Cancer Peer Review chemotherapy national summary poor

governance structure, safety concerns with overstretched services.
NPSA Oral Chemotherapy Alert 3 deaths and 400 incidents over 4 years

National Chemotherapy
Advisory Group NCAG
report (2009)
Responded to the issues outlined in the reports from 2008
Key Recommendation
To develop Acute Oncology Services
Involve A&E and acute medicine in conjunction with
oncology

What is Acute
Oncology?
Better co-ordination of services, better care and
better outcomes for patients.

NCIG
Chemo.
Toxicity +
safety

Acute Medicine
Urgent diseaseRelated
problems

Malignancy of
Undefined
origin
MUO/CUP

the needs of a patient with

cancer who becomes acutely
unwell or develops a new
problem that needs urgent
care.

the management of
complications and management
of emergency admissions with
previously undiagnosed cancer.

Clinical Trials
R&D

Urgent
Symptom
Control
& End of Life

Acute
Oncology
Metastatic
Spinal
Cord
Compression

Admission
Avoidance
(Transforming
In-patient Care)

Scheduled Care
Patient with
Acute
Oncology
symptoms

Acute Oncology Patients

- Patients often cared for on general medical wards
- Variations in care given
- Can be delays in referral to oncology / palliative care
teams
- Patients with CUP often experienced multiple
investigations, lengthy admissions and poor prognosis
Early evidence suggests referral AOS can:
1.
2.
3.
4.

Reduce length of stay (LOS)

Improve patient outcomes
Improve patient experience
Facilitate improved access to palliative care & oncology services

Challenges in caring
for oncology patients

Cancer management is complex

Difficulties in accessing current oncology information
Who to contact and how?
Dilemmas over how far to investigate or escalate care
What does the patient / family understand?
Unrealistic expectations

The Acute Oncology

Service provides
Early review provides a member of the Acute Oncology
Team
24/7 access to telephone advice from an oncologist
Fast track clinic access from A&E/MAU
Access to information on individual patients across the
Trust
Protocols for the management of oncological
emergencies and referral pathways from A&E and MAU
Specific pathways for the investigation and treatment of
malignant spinal cord compression (MSCC)

The Macmillan AO Nursing Service;

Prompt assessment & review of patients with acute
oncology presentations
Promote use of appropriate guidelines and pathways
Provide acute oncology advice for clinical teams
Fast track / expedite oncology clinic appointments
Locally agreed and adopted protocols for the
management of acute oncology presentations
Education and training
Enhance communication between the Trust oncology
team and primary care when patients present with AO
problems

Patient Flagging System

/ Rapid Alert System
The patient flagging / rapid alert system supports the coordination and timely
care for patients admitted as an emergency, alerting the emergency teams &
AOS when previously diagnosed cancer patients present as an emergency.
Benefits:
Alert EDs staff (symphony - flag) & AOS (email alert) are notified about
patients
Enable some patients to be discharged with early planned review in oncology
clinics
Ensure early involvement with appropriate specialist team
Ensure use of protocols (cancer / treatment emergencies, end of life care)
Triage process:
- May not always be an AO related presentation
- AOS will contact clinical area to ascertain if involvement needed
- If patient is not flagged but needs AOS input referral is needed

Referrals to AOS
The Acute Oncology Service is intended for ACUTE problems and will see /
advise on patients presenting with;
Complications resulting from chemotherapy
Complications resulting from radiotherapy
Complications resulting from any other cancer treatment e.g. monoclonal
antibodies
Complications from the cancer itself e.g. MSCC
A new cancer of unknown primary
If a patients clinical team are able to manage a patient - AOS assessment may
not be needed
We will aim to see any patients requiring assessment within 1 working day/ 24
hours
We will not take overall responsibility for the patients care this will remain with
the treating team
We will work closely with site specific cancer terms and refer on promptly as
necessary

Acute Oncology
Presentations
The following, as caused by the systemic treatment of cancer:
Neutropenic sepsis.
Uncontrolled nausea and vomiting.
Uncontrolled diarrhoea.
Complications associated with venous access devices.
Uncontrolled mucositis.
Hypomagnesaemia.
Extravasation injury.
Acute hypersensitivity reactions including anaphylactic shock.
Remember there is an on-call oncologist available for
telephone advice 24/7

Acute Oncology
Presentations
Caused by radiotherapy

Acute skin reactions

Uncontrolled nausea and vomiting
Uncontrolled diarrhoea
Uncontrolled mucositis
Acute radiation pneumonitis
Acute cerebral/other CNS oedema

Acute Oncology
Presentations
The following, are caused directly by malignant disease and presenting
as an urgent acute problem.

Pleural effusion
Pericardial effusion
Lymphangitis carcinomatosa
Superior superior vena cava obstruction (SVCO)
Abdominal ascites
Hypercalcaemia
Spinal cord compression including MSCC
Cerebral space occupying lesion(s)

End of Life Care

Patients & AOS
Approximately 30%-35% of cancer patients who are admitted as an
emergency are end of life care
AOS can play a key role in supporting and enabling emergency
department teams when decision making is difficult:
avoiding inappropriate investigations and treatments
support the ethos for patients to be cared for in their Preferred Place of
Care

Close working with the Specialist Palliative Care Team is essential

AO Treatment Protocols

AO Fast Track
Appointment Slots
For development and requires increase in
consultant oncologist input
Rapid access to oncology clinics slots within 7 days for
A&E and MEUs
Supports admission avoidance.

Communication

The AOS will inform the patient's Consultant Oncologist

and Cancer Team where appropriate, regarding ongoing
cancer management, when a patient is referred to them
for acute oncology assessment.
(Requirement for peer review)

Improved Communication

24 Hour Advice Line - AOMS

The One Hour to

Antibiotic Pathway
Neutropenic sepsis is a medical emergency therefore if it
suspected patients should received antibiotics within 1 hour of
presentation as per pathway
Consider neutropenic sepsis if the patient has received
chemotherapy anytime in the last 4-6 weeks (nadir usually 7-14
days)
Do not wait for blood results to start the patient on the pathway
and commence antibiotics as per protocol

Metastatic Spinal Cord

Compression (MSCC)
Compression, indentation or displacement of the dural sac and its
contents (spinal cord and / cauda equina) by an extradural tumour mass

MSCC is estimated to occur in 5 to 10% of all cancer

patients
Most common primary sites are Lung, Breast and Prostate
(50%), but can occur in any cancer that spreads to bone
MSCC may be the first presenting symptom of cancer (25%
of patients)
Early recognition is vital and over 90% present with back
pain (see Red Flags card)
Delay in treatment can result in paralysis and loss of
function (late signs)

Causes of MSCC
Vertebral metastases +/- collapse (85%)
15% other types of masses e.g. paraspinal
Non malignant causes are a possibility
Thoracic
Lumbar
Cervical

60-80%
15-30%
<10%

30-50% multiple levels of compression

Management of suspected MSCC

Assume spine unstable until proven otherwise
Flat bed rest / immobilisation (may need cervical collar or
brace)
Dexamethasone 16mg od
MR scan within 24 hours (CT if contra-indicated)
Patients may need full staging CT if suitable for surgery.
Referral to Physiotherapy (24 hrs), OT (48 hrs) for support
with immobilisation, assessment of stability, rehabilitation
and discharge planning
If confirmed contact central triage point at Christies as per
pathway recommendations

Metastatic Spinal Cord

Compression (MSCC)
Guidelines http://www.christie.nhs.uk/the-foundation-trust/treatmentsand-clinical-services/spinal-cord-compression.aspx
MSCC Pathway has been developed with a proposed single point of
access at the Christie when patient have confirmed MSCC and can be
accessed at
a single contact number for management advice 24 hours a day,
7 days a week
Treatment decision within 4 hours of all relevant information
being made available to the triage team at The Christie unless
after 9pm (next morning).

MSCC Pathway

Carcinoma of
Unknown Primary
(CUP)
Most patients with newly diagnosed cancer are found to have a
clearly defined primary tumour, and can then be swiftly referred
on to a site specialist team, however 4% patients are found to have cancer without an identifiable
primary site, despite exhaustive tests
Because of the lack of dedicated clinical services, patients who
have malignancy without an identifiable primary site can be
denied the care offered to patients with site-specific cancers
and potentially extensively investigated even though their
prognosis is very poor

Monitoring
& Outcomes
Relating to Acute Oncology Service activity
Network wide Acute Oncology Minimum Dataset
Key Performance Indicators including:
Length of Stay
Number of admissions avoided
Patients outcomes including reduced number of
deaths in hospital
Door to needle pathway for neutropenic sepsis
Standards for MSCC
End of Life Outcomes

Think list for cancer

patients presenting
as a emergency

Is the patients problem related to cancer treatment?

Could this unwell patient be neutropenic?
Is the problem infection? Have they got a CVAD?
Is the problem related to underlying cancer?
Is this a patient with advanced cancer who could be dying?
Is this a new problem, possibly unrelated to cancer?

Key Considerations
Does the patient need admission
Does the patient need an assessment by the Acute Oncology
Nursing Service?
Could the patients problem be dealt with by an early review in
clinic?
Can the patient be discharged?
Can the Macmillan Acute Oncology Nursing Service help?

Reference List
NCAT (2011) Manual of Cancer Services: Acute
Oncology Including MSCC version 1.0
NCAG (2009) Chemotherapy Services in England:
ensuring quality and safety
NCPEPOD (2008) For Better, For Worse