Dr Pauline Leonard, Consultant Medical Oncologist, The Whittington Hospital

1. Direct to Oncology referral
Dr Pauline Leonard MD FRCP
Consultant Medical Oncologist
Whittington Health
p.leonard@nhs.net

2. Describe briefly the background of how AOS
got involved in the management of patients who
present with a suspected new cancer diagnosis
Share the pathways set up
-benefits for patients
-Positives for organisation
Share the learning from new pathways of care
Address the myths & concerns
Over the next 30mins…

3. A key recommendation from
National Chemotherapy Advisory
Group report 2009
• Development of an Acute Oncology Service
– Management of patients who develop severe
complications following chemo or as a consequence of
their cancer
– Management of patients who present as emergencies
with previously undiagnosed cancer
• AOS brings together expertise from oncology disciplines,
emergency medicine, and general medicine and general surgery

4. Type 1 Patients who present who a new
diagnosis of cancer
Type 2 Patients who present with toxicities
of treatment
- Chemotherapy
- Radiotherapy
Type 3 Patients who present with symptoms
from disease
Three types of Cancer emergencies

5. Our experience at WH
• Four not three types of patient presentations
– 53% of all patients who present to ED with a
diagnosis of cancer have an unrelated problem
• Survivors of disease
• Living with disease but present
– Accident
– Exacerbation of co-morbidity
– New pathology
• Type 1 28%
• Type 2 22%
• Type 3a 50%
– 20% EOLC

6. The Gatekeepers are the Radiologists
• Referral direct from Cons
Radiologist
– 35 yr old female
• 6m history back pain &
lethargy
– GP referred for CT on
basis of abnormal CXR
– Called on day of CT to
explain
– Within 24 hrs
mediastinoscopy
– Within 4 working days
diagnosis
• HD

7. Created a generic e-mail nhs.net
address
The aim to enable reporting Radiologists to have a team to recommend
GP to refer patient to
• Radiologists copies patient detail to
– whh-tr.malignancyunknownorigin2@nhs.net
• Radiologists add contact detail of AOS team to bottom of Radiology
report
• AOS team contact GP and offer fast track appointment to review
patient
– Ask GP to see patient first and explain likelihood of malignancy
• Four fast track slots per week
– Three solid tumours & 1 haem malignancy
– End of existing clinics

8. How it works in practise

9. How it works in practise

10. MR WM 71yrs Non-smoker Hx RUQ pain
06.1.12 GP rang for advice – liver mets on US
10.1.12 Seen by PL Fast track OPA (4/7)
PS 1 Keen for all interventions understood treatment
plan and intention
17.1.12 CT results & diagnostic plan (11/7)
18.1.12 EBUS UCLH (12/7)
27.1.12 EBUS results & 1st day treatment (21/7)
1.2.12 Lung MDT presentation (26/7)
Moving the pathway at pace

11. Compare & contrast
Fast track v Best 2WW
• MR WM 71yrs Non-smoker Hx RUQ pain
• 06.1.12 GP rang for advice – liver mets on US
• 10.1.12 Seen by PL Fast track OPA
(4/7)
• PS 1 Keen for all interventions understood
treatment plan and intention
• 17.1.12 CT results & diagnostic plan
(11/7)
• 18.1.12 EBUS UCLH
(12/7)
• 27.1.12 EBUS results & 1st day treatment
(21/7)
• 1.2.12 Lung MDT presentation
(26/7)
• MR WM 71yrs Non-smoker Hx RUQ pain
• 06.1.12 GP sends 2WW - liver mets on US
• 20.1.12 Seen by Gastro team
(14/7)
• PS 1 Keen for all interventions understood
treatment plan and intention
• 27.1.12 CT results & discussion at unknown
primary MDT
(21/7)
Outcome refer Lung MDT
• 1.2..12 MDT discussion - outcome refer EBUS
UCLH
(26/7)
• 8.2.12 EBUS UCLH
(33/7)
• 15.2.12 MDT presentation
(40/7)
• 21.2.12 PL Onco clinic & 1st day treatment
(46/7)
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12. What have we learnt from these cases added
to Malignancy of unknown origin MDT?

13. Distribution of cases
MUO
Primary site identified
CUP
Benign
MUO 7
Primary site identified 16(17)
cCUP* 6(5)
Benign 6
35
* 1 patient PM treated as cCUP first line then repeat
Biopsy pre 2nd line chemo – immuno met CRC
35 cases presented at MUO/CUP MDT April 2015-March 2016

14. Primary site identified
n=16
Gynae 4
Lung 2
Upper GI 1
HPB 2
Urological 2
NHL 1
Meyloma 1
Germ cell 1
Nasopharygeal 1
Anal 1
* plus CRC first treated
as cCUP
Final n=17
Gynae
Lung
HPB
Urological
Upper GI
Myeloma
NHL
Germ cell
Naso-Pharygeal
Anal
CRC

15. Interface with Primary and Ambulatory care

16. Referred by GP on a Friday
32 yrs female
c/o Increasing fatigue 3/12 & abdominal pain
• Day 1 – examined in Ambulatory care
– Blood tests & liver ultrasound booked
for after weekend – home with analgesia
• Day 4 Ultrasound showed multiple liver metastases & blood
tests showed abnormal liver function
• Day 6 CT Thorax/Abdo & Pelvis
– Acute Oncology team
called due to CT findings

17. In Ambulatory care
• Day 6 Consultant Oncologist met patient with
partner with AOS CNS present
– Bad news broken
– Plan for moving forward shared
• Patient wanted to take planned holiday
– Further analgesia & steroids started
• Day 7 Liver biopsy performed
• Day 15 Discussed at Malignancy unknown
Origin (MUO) MDT
– Metastatic Breast Cancer
• Further testing requested HER2
– Dr L booked OPA chemo slot & New patient appt
for Specialist colleague

18. In Ambulatory care
• Day 19 Dr L met patient with partner to
discuss biopsy findings
• Day 20 Biphosphonates started as Calcium
raised
• Day 27 Further pre-treatment investigations
performed & met Specialist Consultant
• Day 28 Tailored chemotherapy started

19. What was value added?
Improved patient experience – “safe in your
hands”
Improved pace in pathway including
planned holiday

20. 6/35 new cases presented were not cancer
All 6 were GP CT requests for suspected
cancer
Need to link these cases with wider
mulitidisciplinary team

21. Patients with benign disease don’t want to meet
an Oncologist or Macmillan clinical nurse
specialist
You might miss a potentially manageable non-
cancer diagnosis
Oncologists are not diagnositicians
The flood gates will open and my practice will
become unmanageable
Discomforts raised by colleagues

22. Direct to Oncology referrals
• First launched June 2009
– 3 new patient slots created in a new dedicated weekly
clinic Monday am
• 4 referrals in 6m
• Dedicated fast-track clinic stopped
• January 2010 relaunched as extra fast track slot at
end of exisitng clinics
– By 2014
• 3 slots for patients suspected solid tumours
• 1 suspected haem-onc
– Flexibility between teams
• Analysing audit data on all referrals 2010-2014
– 73
• 31/73 deceased

23. MUO requires early symptom control
• 89 yrs female
• Short history fatigue, nausea &
reduced appetite
• 28.6.12 GP U/S
– Peritoneal cake
– CT done same day
• 29.6.12 MUO MDT (D2)
– PL rang GP to offer fast-track
OPA for assessment on 3.7.12
(D6)
– Informed by GP for PP
• Saw HPB surgeon - biopsy
• 20.7.12 Meets PL (D23)
– PS 2
– Doesn’t want chemo
– GFR 29 mls/min
– Dex& community Pall care

24. Managing patients with suspicious symptoms
but no proven cancer
-Direct access to diagnostic tests
-For 2WW or suspected cancer diagnostic
clinic
Radiology suggestive of malignancy
GP must share with patient suspicion of cancer
& nature of specialist
Clarity with roles & boundaries for referral

25. Addresses the forthcoming 28 day standard
Enables AOS QST measure
Manages patient expectations and anxieties
Supports Primary care in a range of referral
pathways
Reduces delays
Enables symptom control to be addressed
in parallel with pursuing diagnosis
In summary what can be achieved?

26. In essence
Careful provision of care by teams
who communicate well