Monday 22nd September 2014
Mac Voice, the magazine for Macmillan professionals: Autumn 2014
Ernie Marshall and Alison Young outline the background to acute oncology and the evidence that is currently available for this emerging area of care
Cancer remains a major cause of morbidity and mortality on a global scale. In the UK alone, 325,000 new cases of cancer are diagnosed each year, contributing 28% of all deaths each year. The drive to improve cancer outcomes has delivered an ever-increasing level of sub-specialisation and individualised care, underpinned by remarkable progress in our understanding of cancer biology. As a consequence, there has been an inevitable increase in the number of patients receiving systemic anti-cancer chemotherapy (SACT) over the last 10–20 years. SACT now accounts for approximately £1 billion expenditure annually in the UK alone, demonstrating the financial burden of excellent cancer care.
While the focus on personalised medicine and the increasing delivery of SACT has undoubtedly improved outcomes for people with cancer, it has also resulted in an increasing burden of cancer treatment complications. The 2008 National Confidential Enquiry into Patient Outcomes and Death (NCEPOD) highlighted the fragmented care pathways often faced, with many patients interfacing with multiple institutions and departments within a given institution. In the report, 42% of all sick people with cancer were admitted under general medicine rather than to a specialist oncology ward, with 43% of these patients recorded as having grade three or four toxicity on admission from SACT before death. 86% of patients were being treated with palliative intent, with almost half on their second or subsequent line of SACT. 15% of patients were not admitted to the organisation where their SACT was administered.
In response to these findings, the National Chemotherapy Advisory Group (NCAG) produced their report Chemotherapy Services in England: Ensuring quality and safety in 2009. This led to the concept of acute oncology, with its key recommendation that every Acute Hospital Trust with an emergency department should establish an acute oncology service.
The NCEPOD and NCAG reports have rightly focused attention on the emergency cancer journey, at a time when late presentation of newly diagnosed cancer is also viewed as a major challenge for the UK. Data from the National Cancer Intelligence Network (NCIN) reports that approximately 25% of all new cancers diagnosed per year in England are diagnosed following an emergency admission to hospital. This group of patients often presents to hospital acutely unwell, via a wide range of different routes including the emergency department, with a constellation of symptoms. They are then subsequently found to have cancer. Such patients often experience poorly co-ordinated care and delayed referral to oncology and palliative care services.
While the concept of acute oncology remains in its infancy, it is underpinned by a number of core principles. They promote education, awareness and early access to specialist oncology input, as well as a more integrated way of working amongst acute specialties within hospital trusts.
The need for greater integration of services appears indisputable. However, at present there is a distinct lack of evidence to support the solution proposed by the NCAG. Acute oncology binds together many aspects of emergency presentation that span diagnostic pathways, treatment complications and end-of-life care, and in many ways it highlights the need for greater cohesion and continuity of care for vulnerable patients who frequently move between disciplines and organisations. Published evidence is lacking, with only a limited number of publications, which are based largely around service description and retrospective audit.
Published data on acute oncology patterns and workload remain sparse. A 12-month report from a newly-formed regional cancer network acute oncology service (AOS) identified 3,013 new patient admissions across seven hospitals, from a population of 2.3 million, and equating to approximately 500 admissions per hospital emergency site. 5 51% of admissions were due to complications of cancer. 30% were considered complications of treatment and 19% were new diagnoses of malignancy. Lung cancer represented the most common primary tumour diagnosis.
Intuitively, the establishment of an AOS appears very rational. But what evidence do we have to support the investment? The report Routes to Diagnosis reveals the stark consequences of late presentation, with poorer one-and five-year survival across all cancers.
Cancer of unknown primary represents a distinct subset that has been highlighted as an area of development for AOS, with 57% of patients diagnosed following emergency presentation. Qualitative research into this vulnerable group of patients highlights the lack of continuity, accountability and timeliness of care, often in a setting of ‘multidisciplinary team tennis’. An AOS may deliver early oncology (and palliative care) expertise combined with reduced length of hospital stay. But improved outcomes may only be realised by a more comprehensive infrastructure that is aligned to other site specific cancers, as is explicitly described in the NICE cancer of unknown primary guideline CG104.[8, 9]
The principle justification for an AOS, as described within NCAG, was the potential to improve safety and quality of care, in the context of managing emergency presentation of the complications of cancer treatment. Is there evidence that an AOS promotes more effective care, resulting in reduced morbidity or 30-day mortality? General principles of care would suggest improved outcomes in early suspected febrile neutropenia should result from early diagnosis, coupled with immediate antibiotics.
It is certainly true that these principles hold in the most severe cases, but we have little evidence base for the majority of patients with low-risk febrile neutropenia. In some institutions, an AOS has undoubtedly raised awareness and facilitated early antibiotic therapy, but we have little evidence yet that this has resulted in lowering of mortality or reduction in hospital stay. Despite this, an AOS may be pivotal in developing and promoting the challenging, but necessary prospective, research, as highlighted by previous failed research (Cancer Research UK ORANGE Trial, 2007) and current NICE (CG151) recommendations. Similarly, the role of an AOS in cancer complications may facilitate patient support and pathway development in cancer complications such as metastatic spinal cord compression (MSCC). In this setting, an AOS may be pivotal in raising awareness and developing local pathways, but decision-making ultimately rests with joined-up clinical oncology and neurosurgical services. Formal evaluation of the benefits is also lacking and awaits prospective research on functional outcomes, patient experience and quality of life.
Few would argue that a key role of an AOS is improved coordination of care and early decision-making. A six-month pilot evaluating a new AOS reported significant statistical reduction in hospital length of stay and investigations in a relatively small cohort of patients, but highlighted the potential bene.ts of early oncology input.
More recently, a much larger cancer network reported a reduced length of stay of 3.1 days per acute oncology episode in a population of over 3,000 patients reviewed at multiple acute hospital trusts, and equating to a potential saving of £2million. In this study, 92% of patients were reviewed by a member of the AOS within 24 working hours and the majority of interventions were considered major (ie clinically significant impact on care). The study reported clear benefits and potential savings. However, 51% of patients were admitted with symptoms relating to progressive cancer and one quarter of all patients had a diagnosis of lung cancer, suggesting a complex interplay with palliative care services and the role of site-specific nurses and lung physicians.
The rising burden of emergency cancer care is widely recognised as a global problem. It poses key challenges for all healthcare services, against a backdrop of increasing cancer incidence in an aging population. A Canadian study found that 84% of patients who died of cancer in Ontario between 2002 and 2005 made 194,017 visits to the emergency department in the last six months of life, and that 40% of the visits were made in the last two weeks of life. Progress in cancer therapies has also led to a shift towards end of life prescribing and increased admissions for end of life care, in the context of multiple lines of SACT. End of life care is a major issue in oncology in North America. Studies have found a significant proportion of patients with end-stage cancer experience aggressive care at the end of life, defined as chemotherapy close to death, as well as admissions to hospital and intensive care units within the last few weeks of life, and underuse of hospice services.[15, 16] Recent studies have shown significant benefits to early introduction of palliative care and better end of life care on survival, quality of life and aggressiveness of care in patients with end-stage cancer.
The evolution of acute oncology in the UK is a welcome and necessary response to the challenge of emergency cancer care. It highlights the need to support greater continuity of care and greater access to oncology expertise and patient information. The challenges mirror those facing the developing specialty of acute medicine and the need to support greater elements of ambulatory care and community-based provision. Acute oncology services have a pivotal role to play in cancer services, but they must ensure delivery of a joined-up approach, aligned to acute medicine and the Future Hospitals Commission. The challenge for acute oncology services will be to ensure oncology leadership is delivered in a truly collaborative fashion, with the essential partners in palliative care, acute medicine and, increasingly, primary care.
About the authors
Ernie Marshall has been a Macmillan Consultant in Medical Oncology at the Clatterbridge Cancer Centre in Merseyside since 1997. He is currently the Centre's Clinical Director for Chemotherapy Services and its Network Lead for Acute Oncology Services in Mersey and Cheshire. He is the Chair of a National Acute Oncology Working Group within the NHS England Chemotherapy Clinical Reference Group.
Alison Young has been a consultant in medical oncology at the Leeds Cancer Centre since 2012. She specialises in gynaeoncology and acute oncology/carcinoma of unknown primary. She is the Clinical Lead for Acute Oncology for the Leeds Teaching Hospitals Oncologist Trust and has led the development and delivery of Oncology within the trust.
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3 National Chemotherapy Advisory Group/Department of Health. Ensuring quality and safety of chemotherapy services in England. 2009.
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9 National Institute for Health and Clinical Excellence (NICE). Metastatic malignant disease of unknown primary origin (CG104). 2010. Available at www.nice.org.uk/CG104 (accessed 4 August 2014)
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11 National Institute for Clinical Excellence (NICE). Neutropenic sepsis: Prevention and management of neutropenic sepsis in cancer patients. 2012.
12 National Institute for Clinical Excellence (NICE). Metastatic spinal cord compression: diagnosis and management of adults at risk of and with metastatic spinal cord compression. 2012.
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