Click here for Draft Full Guideline

35,846 views

Published on

0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total views
35,846
On SlideShare
0
From Embeds
0
Number of Embeds
1
Actions
Shares
0
Downloads
11
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide

Click here for Draft Full Guideline

  1. 1. 1DRAFT FOR CONSULTATION 1 2 3 4Clinical Guideline 5 6Metastatic spinal cord compression: 7diagnosis and management of patients 8at risk or of with metastatic spinal cord 9compression 10 11 12Full Guideline 13 14 15Draft for consultation 2Metastatic spinal cord compression: full guideline DRAFT (May 2008) Page 1 of 200
  2. 2. 1DRAFT FOR CONSULTATION 1Contents 2 Appendix 6 - Glossary...............................................................................................180 3 2Metastatic spinal cord compression: full guideline DRAFT (May 2008) Page 2 of 200
  3. 3. 1DRAFT FOR CONSULTATION 1Key priorities 21. Every cancer network should ensure that the appropriate services for the 3 efficient and effective diagnosis, treatment, rehabilitation and ongoing care of 4 patients with MSCC are commissioned, in place and regularly monitored 5 through prospective audit of the care pathway. 62. If MSCC is confirmed, definitive treatment should always start before any 7 neurological deterioration and ideally within 24 hours of first presentation. 83. Patients with diagnosed bone metastases or at high risk of developing bone 9 metastases should be given an information leaflet which explains the early 10 symptoms of MSCC, and advises them (and their treating doctors) what to do 11 should they develop these symptoms. See Appendix 2 of the full guideline. 124. Patients with cancer and any of the following symptoms should be discussed 13 with the MSCC coordinator urgently (within 24 hours): 14 o pain situated in the middle or upper spine 15 o progressive lower spinal pain 16 o severe unremitting lower (lumbar) spinal pain 17 o spinal pain aggravated by straining 18 o localised spinal tenderness on examination 19 o nocturnal pain preventing sleep 20 o radicular pain. 215. Patients with cancer and any of the following symptoms or signs should be 22 discussed with the MSCC coordinator immediately and viewed as an 23 oncological emergency: 24 o neurological symptoms including difficulty in walking, motor 25 symptoms, sensory loss or bladder or bowel dysfunction 26 o neurological signs of spinal cord compression. 276. Patients with suspected MSCC should have MRI of the whole spine (unless 28 there is a specific contraindication). This should be done in time to allow 29 definitive treatment to be planned within 24 hours of the suspected diagnosis. 307. Patients with severe mechanical pain suggestive of vertebral bony structural 31 instability or any neurological impairment suggestive of spinal cord functional 32 instability, and suspected to have, or newly diagnosed with, MSCC should be 33 nursed flat with neutral spine alignment (including ‘log rolling’ and use of a 34 slipper pan for toilet) until bony and neurological stability is confirmed and 35 cautious remobilisation may begin. 2Metastatic spinal cord compression: full guideline DRAFT (May 2008) Page 3 of 200
  4. 4. 1DRAFT FOR CONSULTATION 18. Surgery should be carefully planned to maximise the probability of preserving 2 spinal cord function without undue risk to the patient, taking into account the 3 overall prognosis, patient fitness and the surgeon’s familiarity with the 4 procedure planned. 59. Urgent access to radiotherapy and simulator facilities should be available for 6 patients with MSCC requiring active treatment and unsuitable for surgery 7 (including daytime out of hours facility). 810. Discharge planning and ongoing care for patients with MSCC should start 9 early, led by a named individual from within the responsible clinical team and 10 involving the patient and carers, their primary oncology site team and 11 community support including primary and palliative care as required. 12 2Metastatic spinal cord compression: full guideline DRAFT (May 2008) Page 4 of 200
  5. 5. 1DRAFT FOR CONSULTATION 1Key research recommendations 2 1. Further research should be undertaken into the reasons why patients with 3 MSCC present late. 4 5 2. The use of radiotherapy to prevent the development of MSCC in patients 6 with identified spinal metastases but no pain should be investigated in 7 prospective randomised trials. 8 9 3. The use of surgery to prevent the development of MSCC in patients with 10 identified spinal metastases but no pain should be investigated in 11 prospective randomised trials. 12 13 4. Further research should investigate what are the most clinically and cost 14 effective regimens of radiotherapy to treat patients with established MSCC 15 and investigate the use of new techniques, such as IMRT. 16 17 5. The use of vertebroplasty and kyphoplasty in preventing MSCC in patients 18 with vertebral metastases should be investigated in prospective, 19 comparative studies. 20 21 2Metastatic spinal cord compression: full guideline DRAFT (May 2008) Page 5 of 200
  6. 6. 1DRAFT FOR CONSULTATION 1Recommendations 2 3Chapter 2: Service configuration and urgency of treatment 4• Every cancer network should ensure that the appropriate services for the 5 efficient and effective diagnosis, treatment, rehabilitation and ongoing care of 6 patients with MSCC are commissioned, in place and regularly monitored 7 through prospective audit of the care pathway. 8• Every cancer network should have a clear pathway for the diagnosis, 9 treatment, rehabilitation and ongoing care of patients with MSCC. 10• Cancer networks should ensure that there is access to urgent MRI for all 11 patients with suspected MSCC. This service should be available outside 12 normal working hours. 13• Every cancer network should have a Network Site Specific Group (NSSG) for 14 MSCC, including representatives from primary, secondary and tertiary care. 15• The cancer network should appoint a network lead for MSCC whose 16 responsibilities will include: 17 o Advising the cancer network, commissioners and providers about the 18 provision and organisation of relevant clinical services. 19 o Ensuring that the local pathways for diagnosis and management are 20 documented, agreed and consistent across the network. 21 o Ensuring that there are appropriate points of telephone contact to an 22 MSCC coordinator and to senior professional advice. 23 o Maintaining a network-wide audit of the incidence, timeliness of 24 management, and outcomes of patients with MSCC. 25 o Arranging and chairing bi-annual meetings of the Network Site Specific 26 Group for MSCC, at which the arrangements for care of these patients 27 across the network will be discussed, agreed and outcomes evaluated. 28• Every secondary or tertiary care centre should have an identified lead 29 healthcare professional (usually, but not necessarily, medical) for MSCC 30 whose responsibilities will include: 31 o Representing the hospital at network level in the development of clinical 32 pathways. 33 o Disseminating and implementing local pathways for the diagnosis and 34 appropriate management of patients with known or suspected MSCC. 35 o Ensuring timely and effective communication between all relevant 36 healthcare professionals, including primary care and palliative care. 2Metastatic spinal cord compression: full guideline DRAFT (May 2008) Page 6 of 200
  7. 7. 1DRAFT FOR CONSULTATION 1 o Raising and maintaining the awareness and understanding among all 2 clinical staff across the locality. 3 o Contributing to regular network audits of the care of patients with MSCC. 4• Commissioners should establish a joint approach with councils that have 5 social services responsibilities for the planning and delivery of care to ensure 6 efficient provision of equipment and support to meet the individualised needs 7 of people with MSCC. 8MSCC coordinator and senior professional advice (SPA) – role and 9responsibilities 10• Each centre treating MSCC should identify the individuals responsible for 11 performing the role of MSCC coordinator and ensure its availability at all 12 times. 13• Each centre treating MSCC should have a single point of contact to provide 14 advice and coordinate the patient pathway at all times. 15Senior professional advice 16• The optimal care of patients with MSCC should be decided by senior 17 professional advisers (SPA); these include senior clinical oncologists, spinal 18 surgeons and radiologists with experience and expertise in the treatment of 19 MSCC, taking into account all aspects of the patient’s condition. 20• Every centre treating patients with MSCC should ensure that there are 21 consultant clinical oncologists, spinal surgeons and radiologists available at 22 all times to give advice and help inform the decision-making process in 23 patients with proven MSCC. 24 25Chapter 3: The patient’s experience of MSCC 26Supporting patient decisions 27• Health professionals should ensure that communication with patients with 28 known or suspected MSCC should be, as far as possible, explicit and 29 consistent, and that the patients and their families are fully informed and 30 involved in important decisions about treatment. 31Emotional and family support 2Metastatic spinal cord compression: full guideline DRAFT (May 2008) Page 7 of 200
  8. 8. 1DRAFT FOR CONSULTATION 1• The psychological and spiritual needs of people with MSCC and their families 2 should be assessed following diagnosis of MSCC, and at other key points 3 including the end of rehabilitation and on discharge from hospital. 4• Patients with MSCC or their family members who report significant levels of 5 distress should be referred to specialist psychological support services and/or 6 spiritual support services appropriate to their needs. 7• Information should be provided explaining to patients with MSCC how to 8 access psychological support services when needed. 9• Bereavement support services based on the three component model outlined 10 in the NICE guidance on ‘Improving supportive and palliative care for adults 11 with cancer’ should be available to patients’ families. 12Effects of delayed diagnosis and treatment 13• Patients with cancer at risk of developing MSCC who have severe back pain 14 or spinal nerve root pain, or the beginnings of spinal cord dysfunction should 15 be urgently assessed at the cancer unit or cancer centre. 16• Imaging departments should configure MRI lists to permit time for 17 examination of these patients at short notice (displacing routine cases into ad 18 hoc overtime). 19• If MRI is not available on site at the acute hospital, patients with suspected 20 MSCC should be transferred to a unit with 24-hour capability for urgent MRI 21 and definitive treatment. 22• If MSCC is confirmed, definitive treatment should always start before any 23 neurological deterioration and ideally within 24 hours of first presentation. 24Chapter 4: Early detection 25Communicating symptoms and risks 26• Patients with diagnosed bone metastases or at high risk of developing bone 27 metastases should be given an information leaflet which explains the early 28 symptoms of MSCC, and advises them (and their treating doctors) what to do 29 should they develop these symptoms. See Appendix 2 of the full guideline. 30• Patients with cancer who present with spinal pain should be made aware of 31 the symptoms of MSCC and given clear information about whom to contact if 32 those symptoms develop. 2Metastatic spinal cord compression: full guideline DRAFT (May 2008) Page 8 of 200
  9. 9. 1DRAFT FOR CONSULTATION 1• Healthcare professionals should make patients aware whom they should 2 contact if their symptoms progress while they are waiting for urgent 3 investigation of suspected MSCC. 4Early symptoms and signs 5• Patients with cancer and any of the following symptoms should be discussed 6 with the MSCC coordinator urgently (within 24 hours): 7 o pain situated in the middle or upper spine 8 o progressive lower spinal pain 9 o severe unremitting lower (lumbar) spinal pain 10 o spinal pain aggravated by straining 11 o localised spinal tenderness on examination 12 o nocturnal pain preventing sleep 13 o radicular pain. 14• Patients with cancer and any of the following symptoms or signs should be 15 discussed with the MSCC coordinator immediately and viewed as an 16 oncological emergency: 17 o neurological symptoms including difficulty in walking, motor symptoms, 18 sensory loss or bladder or bowel dysfunction 19 o neurological signs of spinal cord compression. 20• Patients without a prior cancer diagnosis with symptoms and/or signs 21 suggestive of MSCC should be referred for urgent investigation. 22• Patients with cancer who develop lower (lumbar) spinal pain that is clinically 23 thought to be of degenerative origin (i.e. that is not progressive, severe or 24 aggravated by straining and with no accompanying neurological symptoms) 25 should be reviewed frequently for persistence or progression of pain or the 26 development of neurological symptoms or signs. 27Routine MRI and early detection of MSCC 28• In patients with a previous diagnosis of malignancy, routine imaging of the 29 spine is not recommended if they are asymptomatic. 30• Serial imaging of the spine in asymptomatic patients with a high risk of 31 developing spinal metastases should only be done as part of a properly 32 planned and funded research programme. 33• Patients with suspected MSCC should have MRI of the whole spine (unless 34 there is a specific contraindication). This should be done in time to allow 35 definitive treatment to be planned within 24 hours of the suspected diagnosis. 36Chapter 5: Choice of imaging 2Metastatic spinal cord compression: full guideline DRAFT (May 2008) Page 9 of 200
  10. 10. 1DRAFT FOR CONSULTATION 1• MRI of the spine in patients with suspected MSCC should be supervised and 2 reported by a radiologist and should include sagittal T1 or STIR sequences of 3 the whole spine, to prove or exclude the presence of spinal metastatic 4 disease. Sagittal T2 weighted sequences should also be performed to show 5 the level and degree of compression of the cord or cauda equina by a soft 6 tissue mass and to detect lesions within the cord itself. Supplementary axial 7 imaging should be performed through any significant abnormality noted on 8 the sagittal scan. 9• For patients with suspected MSCC in whom MRI is contraindicated, the 10 centre at which the patient is most likely to receive treatment (either surgery 11 or radiotherapy) should be contacted to decide on the most appropriate 12 method of imaging and where this should be carried out. 13• Targeted CT scan with three plane reconstruction should be performed to 14 assess spinal stability and plan vertebroplasty or spinal surgery in MSCC. 15• Myelography in suspected spinal cord compression should only be 16 undertaken at a neuroscience or spinal surgical centre, because of the 17 technical expertise required and because patients with MSCC may deteriorate 18 following myelography and require urgent decompression. 19• Plain radiographs of the spine should not be done either to make or to 20 exclude the diagnosis of metastatic involvement of the spine or MSCC. 21Chapter 6: Treatment strategies/selection 22Analgesia 23• Conventional analgesia should be used as required in patients with vertebral 24 metastases in escalating doses as described by the WHO three-step pain 25 ladder. 26• Specialist pain care including invasive procedures and neurosurgical 27 interventions should be available for patients with intractable pain from 28 vertebral metastases. 29Bisphosphonates 30• Patients with vertebral involvement from myeloma or breast cancer should be 31 treated with bisphosphonates to reduce pain and the risk of vertebral fracture/ 32 collapse. 33• Patients with vertebral metastases from prostate cancer should be treated 34 with bisphosphonates to reduce pain only when other analgesics have failed. 2Metastatic spinal cord compression: full guideline DRAFT (May 2008) Page 10 of 200
  11. 11. 1DRAFT FOR CONSULTATION 1• Bisphosphonates should not be used to treat pain or with the intention of 2 preventing MSCC in patients with vertebral involvement from tumour types 3 other than myeloma, breast cancer or prostate cancer (when other analgesics 4 have failed), except as part of a randomised controlled trial. 5Radiotherapy 6• Patients with spinal metastases and non-mechanical vertebral pain should be 7 offered 8 Gy single fraction palliative radiotherapy. 8• Patients with asymptomatic vertebral metastases should not have 9 radiotherapy with the intention of preventing MSCC except as part of well- 10 designed randomised trials. 11Vertebroplasty and kyphoplasty 12• Patients with vertebral metastases, mechanical pain resistant to analgesia, 13 and/or vertebral body collapse, and no evidence of spinal instability or MSCC 14 should be considered for vertebroplasty or kyphoplasty. 15• Vertebroplasty or kyphoplasty for vertebral metastases should only be 16 performed after discussion between appropriate specialists including an 17 oncologist, interventional radiologist, and spinal surgeon, and in facilities 18 where there is good access to spinal surgery. 19Surgery 20• Patients with vertebral metastases and mechanical pain resistant to other 21 forms of treatment should be considered for spinal stabilisation surgery 22 irrespective of the degree of neurological disability and even if completely 23 paralysed. 24• Patients with vertebral metastases causing mechanical pain and/or imaging 25 evidence of structural spinal failure or instability should be urgently 26 considered for surgical treatment to stabilise the spine and prevent MSCC. 27• Patients with MSCC with severe mechanical pain and/or imaging evidence of 28 spinal instability, but unsuitable for surgery should be considered for some 29 form of external spinal support (i.e. halo vest, or appropriate variations of 30 cervico-thoraco-lumbar orthosis). 31• Patients with vertebral metastases without pain or instability should not be 32 operated on with the intention of preventing MSCC except as part of well- 33 designed randomised trials. 34Combination therapy 2Metastatic spinal cord compression: full guideline DRAFT (May 2008) Page 11 of 200
  12. 12. 1DRAFT FOR CONSULTATION 1• All decisions to treat pain or prevent progression of metastatic spinal cancer 2 when there are different options available should be made by a multi- 3 disciplinary team in consultation with the patient. 4Definitive treatment of spinal cord compression 5Mobilisation 6• Patients with severe mechanical pain suggestive of vertebral bony structural 7 instability or any neurological impairment suggestive of spinal cord functional 8 instability, and suspected to have, or newly diagnosed with, MSCC should be 9 nursed flat with neutral spine alignment (including ‘log rolling’ and use of a 10 slipper pan for toilet) until bony and neurological stability is confirmed and 11 cautious remobilisation may begin. 12• For patients with MSCC, once any spinal shock has settled and neurology is 13 stable, on-going assessment and close monitoring during gradual sitting from 14 supine to 60 degrees over a period of 3–4 hours should be carried out by a 15 physiotherapist. 16• When patients with MSCC begin gradual sitting, if their blood pressure 17 remains stable and no significant increase in pain or neurological symptoms 18 occurs, progression to unsupported sitting, transfers and mobilisation can be 19 carried out as muscle power allows. 20• When mobilising patients with MSCC, if a significant increase in pain or 21 neurological symptoms occurs, patients should be returned to a position 22 where these changes reverse, and the stability of their spine reassessed. 23Corticosteroids 24• All patients with suspected MSCC should be given a loading dose of at least 25 16 mg of dexamethasone as soon as possible after assessment. 26• Patients awaiting surgery or radiotherapy for MSCC should receive 27 dexamethasone 16 mg daily. After surgery or the start of radiotherapy the 28 dose should be gradually reduced and stopped. If neurological function 29 deteriorates at any time the dose should be increased temporarily. 30• For patients with MSCC who do not have surgery or radiotherapy, 31 dexamethasone 16 mg daily should be gradually reduced and stopped. If 32 neurological function deteriorates at any time the dose should be 33 reconsidered. 34• Blood glucose should be monitored in all patients receiving corticosteroids. 2Metastatic spinal cord compression: full guideline DRAFT (May 2008) Page 12 of 200
  13. 13. 1DRAFT FOR CONSULTATION 1Surgery (general principles) 2• Patients with MSCC should be treated with surgery that ensures both spinal 3 cord decompression and durable spinal column stability. 4Surgery (neurological ability) 5• Patients with MSCC should have surgery before they lose the ability to walk. 6• Patients with MSCC and residual distal sensory or motor function should have 7 surgery, regardless of their ability to walk, provided that the prognosis would 8 otherwise justify this. 9• Patients with MSCC and no distal neurological function for more than 24 10 hours should not have surgery unless stabilisation is required for pain relief. 11• Patients with suspected MSCC who have been completely paraplegic or 12 tetraplegic for more than 24 hours should be discussed urgently with a senior 13 oncologist before any imaging or hospital transfer. 14• Patients with suspected MSCC, a poor performance status and widespread 15 metastatic disease should be discussed with a senior oncologist before any 16 urgent imaging or hospital transfer. 17Surgery (timing) 18• The speed of onset, duration, degree and site of origin (cord/cauda) of 19 neurological symptoms and signs should be considered when assessing the 20 urgency of surgery. 21Surgery (tumour factors) 22• Surgery should be carefully planned to maximise the probability of preserving 23 spinal cord function without undue risk to the patient, taking into account the 24 overall prognosis, patient fitness and the surgeon’s familiarity with the 25 procedure planned. 26• Posterior decompression (in the form of laminectomy) alone should not be 27 performed except in rare circumstances of isolated epidural tumour or neural 28 arch metastases without bony instability. 29• If metastatic tumour involves the vertebral body or otherwise threatens spinal 30 stability, posterior decompression should always be accompanied by internal 31 fixation with or without bone grafting. 32• In patients with MSCC with vertebral body involvement who are expected to 33 survive for a year or longer and who are fit to undergo a more prolonged 2Metastatic spinal cord compression: full guideline DRAFT (May 2008) Page 13 of 200
  14. 14. 1DRAFT FOR CONSULTATION 1 procedure, anterior column (vertebral body) reconstruction should be 2 performed. 3• In patients with MSCC with vertebral body involvement who are not expected 4 to survive for a year or longer, anterior column (vertebral body) reconstruction 5 with cement may be considered. 6• Except in very rare circumstances (such as confirmed solitary renal 7 metastasis following complete staging) en bloc excisional surgery with the 8 objective of curing the cancer should not be attempted. 9Surgery (patient factors) 10Tumour 11• Attempts should be made to establish the primary histology of vertebral 12 metastases when planning definitive treatment. 13Extent of metastases 14• Patients with MSCC should be staged to determine the number, anatomical 15 sites, and extent of vertebral and visceral metastases when planning definitive 16 treatment. 17Functional ability, general fitness, previous treatments, fitness for anaesthesia 18• Patients with MSCC should have their neurological ability, functional status, 19 general health and fitness, previous treatments, magnitude of surgery, 20 likelihood of complications, and fitness for general anaesthesia taken into 21 account when planning treatment for MSCC. 22Age 23• Patients with MSCC should not be denied either surgery (if fit enough) or 24 radiotherapy on the basis of age alone. 25The role of scoring systems 26• When assessing and treating patients with MSCC, recognised prognostic 27 factors including the revised Tokuhashi scoring system, ASA grading and 28 relevant comorbidities should be systematically recorded and taken into 29 account to decide whether surgery is appropriate and if so the type and 30 extent. 31• Surgical treatment should not be considered for patients with MSCC whose 32 prognosis is assessed as being less than 3 months. 2Metastatic spinal cord compression: full guideline DRAFT (May 2008) Page 14 of 200
  15. 15. 1DRAFT FOR CONSULTATION 1Radiotherapy 2• Urgent access to radiotherapy and simulator facilities should be available for 3 patients with MSCC requiring active treatment and unsuitable for surgery 4 (including daytime out of hours facility). 5• Pre-operative radiotherapy should not be carried out. 6• All patients with satisfactory surgical outcome should receive routine post- 7 operative fractionated radiotherapy once the wound has healed. 8• Patients with epidural tumour without neurological disability, mechanical pain 9 or bony instability should be offered fractionated radiotherapy. 10• Patients with good prognostic features should be treated with fractionated 11 rather than single fraction radiotherapy. 12• Patients treated for pain control without any prospect of retaining or improving 13 mobility should receive a single fraction of 8 Gy. 14• All patients with MSCC who are not suitable for spinal surgery should receive 15 emergency radiotherapy unless: 16 o they have had complete paraplegia for more than 24 hours and their 17 pain is well controlled 18 o their overall prognosis is judged to be too poor. 19Re-irradiation 20• Patients who have responded well to previous radiotherapy and develop 21 recurrent symptoms after at least 3 months should be considered for further 22 localised radiotherapy or surgery. 23• If patients are re-irradiated, the total dose should be kept below a biologically 24 equivalent dose of 100 Gy where possible. Clinicians should discuss the 25 possible benefits and contraindications with the patient before agreeing a 26 treatment plan. 27Chapter 7: Supportive care 28Interventions for thrombo-prophylaxis 29• All patients with MSCC likely to be immobile for more than 3 days and those 30 awaiting spinal surgery should have thigh length graduated 31 compression/antiembolism stockings and either passive leg movements or 32 intermittent pneumatic compression or foot impulse devices. 2Metastatic spinal cord compression: full guideline DRAFT (May 2008) Page 15 of 200
  16. 16. 1DRAFT FOR CONSULTATION 1• Patients who are immobile with MSCC who are not treated surgically, and 2 those 24 hours after surgery should be treated with subcutaneous thrombo- 3 prophylactic dose low molecular weight heparin. 4• For patients with MSCC the duration of thrombo-prophylactic treatment 5 should be individually assessed, based on the presence of ongoing risk 6 factors, overall clinical condition and return to mobility. 7Management of pressure ulcers 8• A risk assessment for pressure ulcers should be undertaken and documented 9 (using a recognised assessment tool) at the beginning of an episode of care 10 for patients with MSCC and thereafter at each turn while the patient is on bed 11 rest and at least daily thereafter. 12• While on bed rest, patients with MSCC should be turned using safe turning 13 procedures at least every 2 hours. Patients who are not on bed rest should be 14 encouraged to mobilise regularly (every few hours). Those who are unable to 15 stand or walk should be encouraged and assisted to perform pressure 16 redistribution activities such as forward/sideways leaning at least hourly when 17 they are sitting out. 18• Patients with MSCC should be provided promptly with pressure relieving 19 devices appropriate to their pressure risk assessment score. For most 20 patients this will mean cushions and mattresses with very high grade pressure 21 relieving properties. 22• Pressure sore healing protocols according to the NICE clinical guideline 23 (2001) ‘Pressure ulcer risk assessment and prevention’ and NICE clinical 24 guideline (2005) ‘The management of pressure ulcers in primary and 25 secondary care’ should be adhered to for patients with MSCC. 26Bladder and bowel continence management 27• All patients with MSCC should have their bowel and bladder function 28 assessed on initial presentation and a plan of care should be started. 29• Patients with MSCC who are continent, without urinary retention or disturbed 30 bowel function should be monitored at least daily for changes in bladder and 31 bowel function. 32• Bladder dysfunction in patients with MSCC should be managed initially by a 33 urinary catheter on free drainage. If long-term catheterisation is required, 34 intermittent catheterisation or suprapubic catheters should be considered. 2Metastatic spinal cord compression: full guideline DRAFT (May 2008) Page 16 of 200
  17. 17. 1DRAFT FOR CONSULTATION 1• Controlled faecal continence should be achieved by a mixture of faecal 2 softeners to prevent constipation and suppositories every 2–3 days 3 depending on comfort and food intake in patients with MSCC. 4• Patients with MSCC and a distended bladder or bowel are at risk of 5 autonomic dysreflexia. If this occurs the underlying cause should be treated 6 immediately and if necessary hypertension treated with nifedipine or GTN. 7Maintaining circulatory and respiratory functioning 8• Initial assessment and routine monitoring of all patients with MSCC should 9 include heart rate and blood pressure measurement, respiratory rate and 10 pulse oximetry. 11• Symptomatic postural hypotension in patients with MSCC should be managed 12 by patient positioning and devices to improve venous return (such as foot 13 pumps and thromboembolic support stockings) in the short term, avoiding 14 overhydration which may provoke pulmonary oedema. 15• Prophylactic respiratory management in patients with MSCC should include 16 clearing of secretions by breathing exercises, assisted coughing and 17 suctioning, and re-expansion of affected lung by deep breathing, positioning, 18 and where necessary supplement by intermittent positive pressure ventilation 19 and bi-phasic positive airway pressure. 20Access to specialist rehabilitation and transition to care at home 21• All patients admitted to hospital with MSCC should have access to both 22 physiotherapy and occupational therapy services for assessment, advice and 23 rehabilitation. 24• The rehabilitation of patients with MSCC should be focused on short term, 25 realistic goals aimed at promoting functional independence, participation in 26 normal activities of daily life, and quality of life. 27• Admission to a specialist rehabilitation unit should be offered to those patients 28 with MSCC who are most likely to benefit, taking into account factors 29 including prognosis, activity tolerance and rehabilitation potential. 30• Discharge planning and ongoing care for patients with MSCC should start 31 early, led by a named individual from within the responsible clinical team and 32 involving the patient and carers, their primary oncology site team and 33 community support including primary and palliative care as required. 34• Referral to community-based rehabilitation and supportive care services 35 should be offered to people with MSCC following their return home, in order to 2Metastatic spinal cord compression: full guideline DRAFT (May 2008) Page 17 of 200
  18. 18. 1DRAFT FOR CONSULTATION 1 maximise their quality of life and continued involvement in activities that they 2 value. 3• Patients with MSCC should be provided with the equipment and care they 4 require in a timely fashion to maximise their quality of life at home. 5• The carer(s) of patients with MSCC who are being discharged home who 6 need to participate in the patient’s care, should be offered support and 7 training before discharge. 8• Clear pathways for patients with MSCC should be established between 9 hospitals and community-based health and social services teams to ensure 10 that equipment and support for patients returning home are arranged in an 11 efficient and coordinated manner. 2Metastatic spinal cord compression: full guideline DRAFT (May 2008) Page 18 of 200
  19. 19. 1DRAFT FOR CONSULTATION 1Methodology 2What is a clinical guideline? 3Guidelines are recommendations for the care of individuals in specific clinical 4conditions or circumstances – from prevention and self-care through to primary 5and secondary care and onto more specialised services. NICE clinical guidelines 6are based on the best available evidence of clinical and cost effectiveness, and 7are produced to help healthcare professionals and patients make informed 8choices about appropriate healthcare. While guidelines assist the practice of 9healthcare professionals, they do not replace their knowledge and skills. 10 11Clinical guidelines for the NHS in England, Wales and Northern Ireland are 12produced as a response to a request from the Department of Health (DH). They 13approve topics for guideline development and before deciding whether to refer a 14particular topic to the National Institute for Health and Clinical Excellence (NICE) 15they consult with the relevant patient bodies, professional organisations and 16companies. Once a topic is referred, NICE then commissions one of seven 17National Collaborating Centres (NCCs) to produce a guideline. The Collaborating 18Centres are independent of government and comprise partnerships between a 19variety of academic institutions, health profession bodies and patient groups. The 20National Collaborating Centre for Cancer (NCC-C) was referred the topic of 21metastatic spinal cord compression in January 2006 as part of NICE’s 12th wave 22work programme. However the guideline development process began officially 23on 19th September 2006 when sufficient capacity became available at the NCC- 24C. 25 26Who is the guideline intended for? 27This guideline does not include recommendations covering every detail of the 28diagnosis and treatment of metastatic spinal cord compression. Instead we have 29tried to focus on those areas of clinical practice that are (i) known to be 30controversial or uncertain; (ii) where there is identifiable practice variation; (iii) 31where there is a lack of high quality evidence; or (iv) where NICE guidelines are 32likely to have most impact. More detail on how this was achieved is presented 33later in the section on ‘Developing Clinical Evidence Based Questions’. 34 35The guideline is relevant to all healthcare professionals who come into contact 36with patients with metastatic spinal cord compression, as well as to the patients 37themselves and their carers. It is also expected that the guideline will be of value 38to those involved in clinical governance in both primary and secondary care to 39help ensure that arrangements are in place to deliver appropriate care to this 40group of patients. 41 42The remit of the guideline 2Metastatic spinal cord compression: full guideline DRAFT (May 2008) Page 19 of 200
  20. 20. 1DRAFT FOR CONSULTATION 1Guideline topics selected by the DH identify the main areas to be covered by the 2guideline in a specific remit. The following remit for this guideline was received as 3part of NICE’s 12th wave programme of work: 4 5To develop a guideline on: ‘Diagnosis and management of patients with 6metastatic spinal cord compression, including service delivery where 7appropriate.’ 8What the guideline covers - the scope 9The remit was then translated into a scope document by the Guideline 10Development Group (GDG) Chair and Clinical Lead and staff at the NCC-C. The 11purpose of the scope was to: 12 • provide an overview of what the guideline would include and exclude 13 • identify the key aspects of care that must be included 14 • set the boundaries of the development work and provide a clear 15 framework to enable work to stay within the priorities agreed by NICE and 16 the NCC-C and the remit 17 • inform the development of the clinical questions and search strategy 18 • inform professionals and the public about the expected content of the 19 guideline. 20 21Prior to the start of the guideline development process, the scope was subject to 22a four week stakeholder consultation in accordance with processes established 23by NICE in the ‘NICE guidelines manual’ (NICE, 2005, NICE 2006, NICE 2007). 24The full scope is shown in Appendix 7. During the consultation period, the scope 25was posted on the NICE website (www.nice.org.uk). Comments were invited from 26registered stakeholder organizations, the NICE Guideline Review Panel (GRP) 27and the Patient and Public Involvement Programme (PPIP) at NICE. Further 28information about the GRP can also be found on the NICE website. The NCC-C 29and NICE reviewed the scope in light of comments received, and the revised 30scope was signed off by the GRP; signed off by NICE and posted on the NICE 31website. 32 33Involvement of stakeholders 34Key to the development of all NICE guidance are the relevant professional and 35patient/carer organisations that register as stakeholders. Details of this process 36can be found on the NICE website or in the ‘NICE guidelines manual‘ (NICE 372007). In brief, their contribution involves commenting on the draft scope, 38submitting relevant evidence and commenting on the draft version of the 39guideline during the end consultation period. A full list of all stakeholder 40organisations who registered for the metastatic spinal cord compression cancer 41guideline can be found in Appendix 9.2. 42 43Needs assessment 44As part of the guideline development process the NCC-C invited Specialist 45Registrars from Velindre NHS Trust in Cardiff to undertake a needs assessment. 2Metastatic spinal cord compression: full guideline DRAFT (May 2008) Page 20 of 200
  21. 21. 1DRAFT FOR CONSULTATION 1The needs assessment aims to describe the burden of disease and current 2service provision for people with metastatic spinal cord compression in England 3and Wales, which informed the development of the guideline. This document 4forms a supplement to the full guideline and will also appear on an 5accompanying CD-ROM when the guideline is published. 6 7Assessment of the effectiveness of interventions is not included in the needs 8assessment, and was undertaken separately by researchers in the NCC-C as 9part of the guideline development process. 10 11The information included in the needs assessment document was presented to 12the GDG. Most of the information was presented in the early stages of guideline 13development, and other information was included to meet the evolving 14information needs of the GDG during the course of guideline development. 15 16The process of guideline development – who develops the guideline? 17 18Overview 19The development of this guideline was based upon methods outlined by the 20‘NICE guidelines manual’ (NICE 2007). A team of health professionals, lay 21representatives and technical experts known as the GDG (see appendix 9.1), 22with support from the NCC-C staff, undertook the development of this clinical 23guideline. The basic steps in the process of developing a guideline are listed and 24discussed below: 25 • using the remit, define the scope which sets the parameters of the 26 guideline 27 • forming the guideline development group (GDG) 28 • developing clinical questions 29 • systematically searching for the evidence 30 • critically appraising the evidence 31 • incorporating health economic evidence 32 • distilling and synthesising the evidence and writing recommendations 33 • agreeing the recommendations 34 • structuring and writing the guideline 35 • updating the guideline. 36 37The Guideline Development Group (GDG) 38The metastatic spinal cord compression GDG was recruited in line with the 39existing NICE protocol as set out in the ‘NICE guidelines manual’ (NICE 2007). 40The first step was to appoint a Chair and a Lead Clinician. Advertisements were 41placed for both posts and candidates were informally interviewed prior to being 42offered the role. The NCC-C Director, GDG Chair and Lead Clinician identified a 43list of specialties that needed to be represented on the GDG. Requests for 44nominations were sent to the main stakeholder organisations and patient 45organisations/charities (Appendix 9.2). Individual GDG members were selected 46by the NCC-C Director, GDG Chair and Lead Clinician, based on their application 2Metastatic spinal cord compression: full guideline DRAFT (May 2008) Page 21 of 200
  22. 22. 1DRAFT FOR CONSULTATION 1forms, following nomination from their respective stakeholder organisation. The 2guideline development process was supported by staff from the NCC-C, who 3undertook the clinical and health economics literature searches, reviewed and 4presented the evidence to the GDG, managed the process and contributed to 5drafting the guideline. At the start of the guideline development process all GDG 6members’ interests were recorded on a standard declaration form that covered 7consultancies, fee-paid work, share-holdings, fellowships and support from the 8healthcare industry. At all subsequent GDG meetings, members declared new, 9arising conflicts of interest which were always recorded (see Appendix 9.1). 10 11Guideline Development Group meetings 12Thirteen GDG meetings were held between 19 September 2006 and 21 April 132008. During each GDG meeting (either held over one day or two days) clinical 14questions and clinical and economic evidence were reviewed and assessed and 15recommendations formulated. At each meeting patient/carer and service-user 16concerns were routinely discussed as part of a standing agenda item. 17 18NCC-C project managers divided the GDG workload by allocating specific topics, 19relevant to their area of clinical practice, to small sub-groups of the GDG in order 20to simplify and speed up the guideline development process. These groups 21considered the evidence, as reviewed by the systematic reviewer, and 22synthesised it into draft recommendations prior to presenting it to the GDG as a 23whole. Each topic group was led by a GDG member with expert knowledge of the 24topic area (usually one of the healthcare professionals). The GDG sub-groups 25often helped refine the clinical questions and the clinical definitions of treatments. 26They also assisted the NCC-C team in drafting the section of the guideline 27relevant to their specific topic. 28 29Patient/carer representatives 30Individuals with direct experience of MSCC services gave an integral user focus 31to the GDG and the guideline development process. The GDG included two 32patient/carer representatives. They contributed as full GDG members to writing 33the clinical questions, helping to ensure that the evidence addressed their views 34and preferences, highlighting sensitive issues and terminology relevant to the 35guideline and bringing service-user research to the attention of the GDG. 36 37Expert advisers 38During the development phase of the guideline the GDG identified areas where 39there was a requirement for expert input on particular specialist topic areas. The 40topics were addressed by either the production of a position paper or a formal 41presentation by a recognised expert (Appendix 9.4) who had been identified via 42the relevant registered stakeholder organisation. All relevant position papers are 43presented as part of the evidence review. 44 45Developing clinical evidence-based questions 46 2Metastatic spinal cord compression: full guideline DRAFT (May 2008) Page 22 of 200
  23. 23. 1DRAFT FOR CONSULTATION 1Background 2The scope, as described in Appendix 7, needs to be very clear about which 3patient groups are included and which areas of clinical care should be 4considered. But within these boundaries it does not usually specify which topics 5that are considered a priority. 6 7It was recognised by the NCC-C at an early stage that in order to complete the 8guideline development work to an appropriate standard the GDG needed to 9restrict its work to approximately 30 clinical questions. Previously this 10prioritisation would have been carried out by the GDG at its first two meetings but 11it was clear from some guidelines already published that this approach had 12resulted in a much larger number of questions than 30 being addressed. 13 14Clinical guidelines should be aimed at changing clinical practice and should avoid 15ending up as ‘evidence-based textbooks’ or making recommendations on topics 16where there is already good clinical practice. It was therefore felt important that 17the 30 clinical questions should be prioritised into areas that were known to be 18controversial or uncertain, where there was identifiable practice variation, or 19where NICE guidelines were likely to have most impact 20 21Method 22An extensive list of potential topics for the guideline to investigate was complied 23by the NCC-C Director and GDG Chair and Clinical Lead. This list was 24incorporated into a questionnaire which asked respondents to rate each topic on 25a five point Likert scale ranging from 0 (not a priority) to 5 (very high priority). It 26was made clear that respondents would be rating the priority for each topic to be 27included in a clinical guideline to be published in two years’ time. The 28questionnaire also asked respondents to suggest any additional topics they 29would like to see included with an equivalent assessment of their priority. 30 31Questionnaires were subsequently sent to all members of the MSCC GDG in 32advance of the first GDG meeting. 33 34The scores from each completed questionnaire was aggregated by NCC-C staff 35and ranked. These results together with information on identifiable practice 36variation (see needs assessment) were presented to the GDG at its first meeting. 37The list of prioritised topics produced via the questionnaire survey was in no way 38definitive and the GDG used these results to agree their final priorities for the 39clinical questions. 40 41For clinical questions about interventions, the PICO framework was used. This 42structured approach divides each question into four components: the patients 43(the population under study - P), the interventions (what is being done - I), the 44comparisons (other main treatment options - C) and the outcomes (the measures 45of how effective the interventions have been - O). Where appropriate, the clinical 2Metastatic spinal cord compression: full guideline DRAFT (May 2008) Page 23 of 200
  24. 24. 1DRAFT FOR CONSULTATION 1questions were refined once the evidence had been searched and, where 2necessary, sub-questions were generated. 3 4The final list of clinical questions can be found in Appendix 8 of the evidence 5review. 6 7Care pathway 8Early in the development process the GDG designed an outline care pathway (or 9algorithm) in order to explore how people with metastatic spinal cord 10compression might access and be dealt with by the NHS. 11 12Review of Clinical Literature 13 14At the beginning of the development phase, initial scoping searches were carried 15out to identify any relevant guidelines (local, national or international) produced 16by other groups or institutions. Additionally, stakeholder organisations were 17invited to submit evidence for consideration by the GDG, provided it was relevant 18to the agreed list of clinical questions. 19 20In order to answer each question the NCC-C information specialist developed a 21search strategy to identify relevant published evidence for both clinical and cost 22effectiveness. Key words and terms for the search were agreed in collaboration 23with the GDG. When required, the health economist searched for supplemental 24papers to inform detailed health economic work, for example modeling (see 25section on ‘Incorporating Health Economic Evidence’). 26 27Papers that were published or accepted for publication in peer-reviewed journals 28were considered as evidence. Search filters, such as those to identify systematic 29reviews (SRs) and randomised controlled trials (RCTs) were applied to the 30search strategies when necessary. No language restrictions were applied to the 31search; however, foreign language papers were not requested or reviewed 32(unless of particular importance to that question). 33 34The following databases were included in the literature search: 35 • The Cochrane Library 36 • Medline and Premedline 1950 onwards 37 • Excerpta Medica (Embase) 1980 onwards 38 • Cumulative Index to Nursing and Allied Health Literature (Cinahl) 1982 39 onwards 40 • Allied & Complementary Medicine (AMED) 1985 onwards 41 • British Nursing Index (BNI) 1994 onwards 42 • Psychinfo 1806 onwards 43 • Web of Science1970 onwards. [specifically Science Citation Index 44 Expanded (SCI-EXPANDED) and Social Sciences Citation Index (SSCI)] 45 • System for Information on Grey Literature In Europe (SIGLE) 1980–2005 46 • Biomed Central 1997 onwards 2Metastatic spinal cord compression: full guideline DRAFT (May 2008) Page 24 of 200
  25. 25. 1DRAFT FOR CONSULTATION 1 • National Research Register (NRR) 2 • Current Controlled Trials 3 4From this list the information specialist sifted and removed any irrelevant material 5based on the title or abstract before passing to the researcher. All the remaining 6articles were then stored in a Reference Manager electronic library. 7 8Searches were updated and re-run 6–8 weeks before the stakeholder 9consultation, thereby ensuring that the latest relevant published evidence was 10included in the database. Any evidence published after this date was not 11included. For the purposes of updating this guideline, 18 April 2008 should be 12considered the starting point for searching for new evidence. 13 14Further details of the search strategies, including the methodological filters used, 15are provided in the evidence review (and will also appear on the accompanying 16CD-ROM to this guideline). 17 18Critical Appraisal and Evidence Grading 19Following the literature search one researcher independently scanned the titles 20and abstracts of every article for each question, and full publications were 21obtained for any studies considered relevant or where there was insufficient 22information from the title and abstract to make a decision. The researcher then 23individually applied the inclusion/exclusion criteria to determine which studies 24would be relevant for inclusion and subsequent appraisal. Lists of excluded 25papers were generated for each question and the rationale for the exclusion was 26presented to the GDG when required. 27 28The researcher then critically appraised the full papers. Critical appraisal 29checklists were compiled for each paper and one researcher undertook the 30critical appraisal and data extraction. 31 32The researcher assessed the quality of eligible studies by referring to the SIGN 33quality checklist for systematic reviews/meta-analyses and randomised control 34trials (Table A). Evidence relating to clinical effectiveness was classified using 35this established hierarchical system. However this checklist is less appropriate for 36studies reporting diagnostic tests of accuracy. In the absence of a validated 37hierarchy for this type of test, NICE suggests levels of evidence that take into 38account the factors likely to affect the validity of these studies1. 39 40 41Table A Levels of evidence for intervention studies Level Source of evidence 1++ High-quality meta-analyses, systematic reviews of randomised controlled trials (RCTs) or RCTs with a very low risk of bias 21 National Institute for Health and Clinical Excellence (April 2007) The guidelines manual. London: National 3Institute for Health and Clinical Excellence. Available from: www.nice.org.uk 4Metastatic spinal cord compression: full guideline DRAFT (May 2008) Page 25 of 200
  26. 26. 1DRAFT FOR CONSULTATION 1+ Well-conducted meta-analyses, systematic reviews of RCTs or RCTs with a low risk of bias 1− Meta-analyses, systematic reviews of RCTs or RCTs with a high risk of bias 2++ High-quality systematic reviews of case–control or cohort studies; high- quality case–control or cohort studies with a very low risk of confounding, bias or chance and a high probability that the relationship is causal 2+ Well-conducted case–control or cohort studies with a low risk of confounding, bias or chance and a moderate probability that the relationship is causal 2− Case–control or cohort studies with a high risk of confounding, bias or chance and a significant risk that the relationship is not causal 3 Non-analytical studies (for example, case reports, case series) 4 Expert opinion, formal consensus 1 2For all the relevant appraised studies for a particular question, data on the type of 3population, intervention, comparator and outcomes (PICO) was recorded in 4evidence tables and an accompanying evidence summary prepared for the GDG 5(see evidence review). All the evidence was considered carefully by the GDG for 6accuracy and completeness. 7 8All procedures were fully compliant with NICE methodology as detailed in the 9‘NICE guidelines manual’ (NICE 2007). 10 11In general, no formal contact was made with authors, however, there were ad 12hoc occasions when this was required in order to clarify specific details. 13 14Incorporating Health Economics Evidence 15The aim of the economic input into the guideline was to inform the GDG of 16potential economic issues relating to metastatic spinal cord compression. It is 17important to investigate whether health services are both clinically effective and 18cost effective, i.e. are they ‘value for money’. 19 20The health economist helped the GDG by identifying priority topics within the 21guideline that might benefit from economic analysis, reviewing the available 22economic evidence and, where necessary, conducting economic analysis. Where 23published economic evaluation studies were identified that addressed the 24economic issues for a clinical question, these are presented alongside the clinical 25evidence wherever possible. 26 27In order to assess the cost-effectiveness of each priority topic, a comprehensive 28systematic review of the economic literature was conducted. For those clinical 29areas reviewed, the information specialists used a similar search strategy as 30used for the review of clinical evidence but with the inclusion of a health 31economics and quality of life filter. 32 2Metastatic spinal cord compression: full guideline DRAFT (May 2008) Page 26 of 200
  27. 27. 1DRAFT FOR CONSULTATION 1Each search strategy was designed to find any applied study estimating the cost 2or cost effectiveness of the topic under consideration. A health economist 3reviewed abstracts and relevant papers were ordered for appraisal. 4 5Published economic evidence was obtained from a variety of sources: 6 • Medline 1966 onwards 7 • Embase 1980 onwards 8 • NHS Economic Evaluations Database (NHS EED) 9 • EconLit 1969 onwards 10 11Economic Modeling 12In addition to the review of the relevant clinical evidence, the GDG were required 13to determine whether or not the cost-effectiveness of each of the individual 14clinical questions should be investigated. After the clinical questions were 15decided, the GDG agreed which topics were an ‘economic priority’ for modeling. 16These ‘economic priority’ topics were chosen on the basis of the following 17criteria, in broad accordance with the NICE guidelines manual: 18Overall relevance of the topic 19 • The number of patients affected: interventions affecting relatively large 20 numbers of patients were given a higher economic priority than those 21 affecting fewer patients 22 • The health benefits to the patient: interventions that that were considered 23 to have a potentially significant impact on both survival and quality of life 24 were given a higher economic priority 25 • The per patient cost: interventions with potentially high financial 26 (cost/savings) implications were given high priority compared to 27 interventions expected to have lower financial implications 28 • Likelihood of changing clinical practice: priority was given to topics that 29 were considered likely to represent a significant change to existing clinical 30 practice. 31Uncertainty 32 • High level of existing uncertainty: higher economic priority was given to 33 clinical questions in which further economic analysis was considered likely 34 to reduce current uncertainty over cost-effectiveness. Low priority was 35 given to clinical questions when the current literature implied a clearly 36 ‘attractive’ or ‘unattractive’ incremental cost-effectiveness ratio, which was 37 regarded as generalisable to a UK healthcare setting 38 • Likelihood of reducing uncertainty with further analyses (feasibility issues): 39 when there was poor evidence for the clinical effectiveness of an 40 intervention, then there was considered to be less justification for an 41 economic analysis to be undertaken. 2Metastatic spinal cord compression: full guideline DRAFT (May 2008) Page 27 of 200
  28. 28. 1DRAFT FOR CONSULTATION 1 2Once the economic priority topics had been chosen, the next task was to perform 3a systematic review of the cost-effectiveness literature. When relevant published 4evidence was identified and considered to be of sufficient quality, this information 5was used to inform the recommendation for that specific clinical question. When 6no relevant cost-effectiveness evidence was identified, or when it was not 7considered to be of reasonable quality, consideration was given to building a de 8novo economic model. This decision was made by the GDG based on an 9assessment of the available evidence required to populate a potential economic 10model. 11 12For those clinical questions where an economic model was required, the 13information specialist performed supplemental literature searches to obtain 14additional data for modeling. Assumptions and designs of the models were 15explained to and agreed by the GDG members during meetings, and they 16commented on subsequent revisions. 17 18The clinical questions in this guideline selected for modelling were chosen 19because at the time it was considered likely that the recommendations under 20consideration could substantially change clinical practice in the NHS and have 21important consequences for resource use. The details of the model are 22presented in the evidence review (Appendices 1 and 4). During the modeling 23process the following general principles were adhered to: 24 • the GDG Chair and Clinicial Lead were consulted during the construction 25 and interpretation of the model 26 • the model was based on the best evidence from the systematic review. 27 • model assumptions were reported fully and transparently 28 • the results were subject to thorough sensitivity analysis and limitations 29 discussed 30 • costs were calculated from a health services perspective. 31 32Agreeing the Recommendations 33For each clinical question the GDG were presented with a summary of the clinical 34evidence, and where appropriate economic evidence, derived from the studies 35reviewed and appraised. From this information the GDG were able to derive the 36guideline recommendations. The link between the evidence and the view of the 37GDG in making each recommendation is made explicit in the accompanying 38qualifying statement. 39 40Qualifying Statements 41As clinical guidelines are currently formatted, there is limited scope for 42expressing how and why a GDG made a particular recommendation from the 43evidence of clinical and cost-effectiveness. To make this process more 44transparent to the reader, the NCC-C felt the need for an explicit, easily 45understood and consistent way of expressing the reasons for making each 46recommendation. 2Metastatic spinal cord compression: full guideline DRAFT (May 2008) Page 28 of 200
  29. 29. 1DRAFT FOR CONSULTATION 1 2The way we have chosen to do this is by writing a ‘qualifying statement’ to 3accompany every recommendation and will usually cover: 4 • the strength of evidence about benefits and harms for the intervention 5 being considered 6 • the degree of consensus within the GDG 7 • the costs and cost-effectiveness (if formally assessed by the health 8 economics team). 9 10Where evidence was weak or lacking the GDG agreed the final 11recommendations through informal consensus. Shortly before the consultation 12period, ten key priorities and five key research recommendations were selected 13by the GDG for implementation and the patient algorithms were agreed (see 14pages 32 – 36 for algorithms). To avoid giving the impression that higher grade 15recommendations are of higher priority for implementation, NICE no longer 16assigns grades to recommendations. 17 18Consultation and Validation of the Guideline 19The draft of the guideline was prepared by NCC-C staff in partnership with the 20GDG Chair and Lead Clinician. This was then discussed and agreed with the 21GDG and subsequently forwarded to NICE for consultation with stakeholders. 22 23Registered stakeholders (see Appendix 9.2) had one opportunity to comment on 24the draft guideline and this was posted on the NICE website between 23rd May 252008 and 18th July 2008. The GRP also reviewed the guideline and checked that 26stakeholder comments had been addressed. 27 28Following the consultation period the GDG will finalised the recommendations 29and the NCC-C will provide the final document. This was then be submitted to 30NICE for approval and publication on their website. The other versions of the 31guideline (see below) will also be discussed and approved by the GDG and 32published at the same time. 33 34Other Versions of the Guideline 35This full version of the guideline will be available to download free of charge from 36the NICE website (www.nice.org.uk) and the NCC-C website (www.wales.nhs.uk/ 37nccc) when published. 38 39NICE also produces three versions of the metastatic spinal cord compression 40guideline which will be available from the NICE website: 41 • the NICE guideline, which is a shorter version of this guideline, containing 42 the key priorities, key research recommendations and all other 43 recommendations 44 • the Quick Reference Guide (QRG), which is a summary of the main 45 recommendations in the NICE guideline 2Metastatic spinal cord compression: full guideline DRAFT (May 2008) Page 29 of 200
  30. 30. 1DRAFT FOR CONSULTATION 1 • Understanding NICE Guidance (UNG), which describes the guideline 2 using non-technical language. It is written chiefly for patients but may also 3 be useful for family members, advocates or those who care for patients 4 with metastatic spinal cord compression. 5 6Updating the Guideline 7Literature searches were repeated for all of the clinical questions at the end of 8the GDG development process, allowing any relevant papers published before 918 April 2008 to be considered. Future guideline updates will consider evidence 10published after this cut-off date. 11 12Two years after publication of the guideline, NICE will commission a National 13Collaborating Centre to determine whether the evidence base has progressed 14significantly to alter the guideline recommendations and warrant an early update. 15If not, the guideline will be updated approximately 4 years after publication. 16 17Funding 18The National Collaborating Centre for Cancer was commissioned by NICE to 19develop this guideline 20 21Disclaimer 22The GDG assumes that healthcare providers will use clinical judgement, 23knowledge and expertise when deciding whether it is appropriate to apply these 24guidelines. The recommendations cited here are a guide and may not be 25appropriate for use in all situations. The decision to adopt any of the 26recommendations cited here must be made by the practitioner in light of 27individual patient circumstances, the wishes of the patient and clinical expertise. 28 29The NCC-C disclaims any responsibility for damages arising out of the use or 30non-use of these guidelines and the literature used in support of these 31guidelines. 32 33 34 35 2Metastatic spinal cord compression: full guideline DRAFT (May 2008) Page 30 of 200
  31. 31. 1DRAFT FOR CONSULTATION 1Algorithms 2 DECISION FLOWCHART Patient with suspected MSCC (including patients with known cancer – those at high risk will have an information card) Co-ordinator Healthcare professional (single contact no available 24 hours) (GPs, secondary care, tertiary care, key worker (this could be a specialist nurse , etc) radiographer, on call oncology team etc) Acute Receiving Team Appropriate other Negative MRI Most appropriate hospital Positive MRI management and Senior Professional MRI within 24hrs ! probable discharge Advice (available 24 hours) • Consultant oncologist • Spinal surgeon • Radiologist Other appropriate Nearest place for active Rx, RT Nearest RT surgery or surgery Supportive care e.g home, hospice, DGH, care home Patients with symptoms of advanced MSCC not suitable for MRI Telephone conversations 3 2Metastatic spinal cord compression: full guideline DRAFT (May 2008) Page 31 of 200
  32. 32. 1DRAFT FOR CONSULTATION 1 2 3 4 5 Flow diagram for primary care management of MSCC 6 7 8 9 10 Clinical Suspicion of MSCC 11 12 13 14 15 16 17 Pain Only Pain and Neurological 18 Symptoms and /or Signs 19 20 21 22 Action - Lie flat Action - Lie flat 23 Give Dexamethasone 16 mg 24 25 26 27 28 Contact MSCC Coordinator who should 29 1) Assess requirement for and urgency of 30 potential admission 31 2) Seek Senior Clinical advice if required 32 3) Identify appropriate bed for admission 33 Either to Oncology 34 Or to Spinal Surgery Unit dependent on 35 clinical circumstance 36 4) Contact GP to agree organisation of 37 admission and mode of transport 38 39 40 41 42 2Metastatic spinal cord compression: full guideline DRAFT (May 2008) Page 32 of 200
  33. 33. 1DRAFT FOR CONSULTATION 1 Flow chart for decisions about the timing and safety of mobilisation 2 once MSCC suspected 2Metastatic spinal cord compression: full guideline DRAFT (May 2008) Page 33 of 200
  34. 34. 1DRAFT FOR CONSULTATION 1 Suspected spinal cord compression (severe mechanical pain or abnormal neurology) Lie flat with neutral spine alignment. ‘Log rolling’ when required for pressure relief and toileting Conduct and review MRI Are surgery Spine and / or assessed as Yes radiotherap Start medical management (16 y Yes mg dexamethasone, surgery being appropriate and / or radiotherapy as unstable? appropriate). (bony or ? neurological No No Graduated assessment of sitting Does spine once spinal shock settled or Fit brace or collar Yes remain neurology stable (up to 60° over 4 unstable? hours) No Significant increases Yes in pain or neurologic al No Ongoing assessment and rehabilitation in unsupported sitting, standing, walking and ADLs Discharge planning 2Metastatic spinal cord compression: full guideline DRAFT (May 2008) Page 34 of 200
  35. 35. 1DRAFT FOR CONSULTATION 1 Management of Autonomic dysreflexia (AD) 2 Symptoms or signs of AD 3 (e.g. pounding headache, flushing, sweating 4 or blotching skin above injury level, pale, cold, goosebumps) 5 6 7 Check Blood Pressure 8 • Confirm Diagnosis (blood pressure greater than 200/100 or 20-40mm Hg higher than normal) 9 10 11 If spine stable sit the patient up 12 13 14 For15 patients with catheter: For patients without catheter • Empty leg bag and note volume • If bladder distended and patient unable to 16 Check tubing not blocked / kinked • pass urine insert catheter using lubricant • 17 If catheter blocked remove and re-catheterise containing lignocaine using lubricant containing lignocaine 18 19 20 If bladder distension excluded - Gently examine per rectum. For faecal mass in rectum, 21 • gently insert gloved finger covered in lignocaine jelly into 22 rectum and remove faecal mass 23 24 If symptoms persist or cause unknown, 25 Give nifedipine or glyceryl trinitrate (GTN). In adults, place sublingually: 26 • The contents of a 10mg sublingual nifedipine capsule OR 27 • 1-2 GTN tablets Repeat dose can be given after 20 minutes, if symptoms persist 28 29 If BP remains high, then an IV hypotensive may be required: 30 • Hydralazine 20mg IV slowly OR 31 • Diazoxide 20mg bolus. Continue to search for cause and monitor BP 32 33 May require management on high dependency unit if problem persists 34 2Metastatic spinal cord compression: full guideline DRAFT (May 2008) Page 35 of 200
  36. 36. 1DRAFT FOR CONSULTATION 1 21. Epidemiology 3 41.1 Introduction 5Metastatic spinal cord compression (MSCC) is a well recognised complication of 6cancer and is usually an oncological emergency. MSCC was first described by 7Spiller in 1925 as progressive paraplegia in cancer patients (Loblaw et al. 2003). 8 9Metastases to the spinal column occur in 3-5% of all patients with cancer (most 10commonly those with breast cancer, prostate cancer and lung cancer, in whom 11the incidence may be as high as 19%) and may cause pain, vertebral collapse 12and MSCC. 13 14Patients with breast, lung and prostate cancer account for more than 50% of 15MSCC cases but it can be caused by any solid tumour. Patients who present with 16widespread malignancy and those with known vertebral metastases are also at 17higher risk. The risk of MSCC is also proportionally related to the duration of 18disease and therefore, as cancer survival times increase, so too might the 19incidence of MSCC. 20 21MSCC occurs when there is pathological vertebral body collapse or direct tumour 22growth causing compression of the spinal cord or cauda equina. Irreversible 23neurological damage ensues with resulting paraplegia (Levack et al. 2002). Early 24diagnosis and treatment is essential to prevent neurological damage and to 25achieve this, early recognition and reporting of symptoms, simple and rapid 26referral pathways, urgent and appropriate investigations and prompt treatment 27are all needed. 28 29Therefore it is important that the patient and all health care professionals are 30aware of the early symptoms and signs of MSCC (Husband 1998, Bucholtz 1999, 31Loblaw et al. 2003, Levack et al. 2002). Unfortunately, the symptoms and signs 32that are usually taught are those of established MSCC such as weakness of the 33limbs, bladder and bowel dysfunction and sensory loss. 34 35There is a significant association between the ability to walk at the time of 36diagnosis and the ability to walk following treatment (Brown P et al. 1999, 37Hacking H et al. 1993, Huddart R et al. 1997, Kim R et al. 1990). Furthermore, 38data from the Clinical Resource Audit Group (CRAG audit) (Levack et al. 2001) 39suggest that the ability to walk at the time of diagnosis is a statistically significant 40predictor of outcome in terms of survival. 41 42Once paraplegia develops it is usually irreversible. This can affect the quality of 43life of both the patient and also of their carers. These patients may often need 24 44hour nursing care either in hospital or in the community setting, which can have 45major resource implications on the National Health Service (NHS). 46 2Metastatic spinal cord compression: full guideline DRAFT (May 2008) Page 36 of 200
  37. 37. 1DRAFT FOR CONSULTATION 1The key investigation for the diagnosis of MSCC is magnetic resonance imaging 2(MRI) of the whole spine (Levack et al. 2001, Cook et al. 1998). Once a diagnosis 3of MSCC has been made, the treatment goals include pain relief, restoration of 4neurological status, prevention of further neurological damage and stabilisation of 5the spine (Held and Peahota 1993, Bucholtz 1999, Royal College of Radiologists 62006). 7 8When deciding the most appropriate treatment option for a patient it is important 9to consider quality of life (QOL) issues. Although there have been many studies 10that have assessed QOL in patients with advanced cancer, few have been on 11patients with MSCC (Levack et al. 2001). 12 131.2 Incidence 14 15The true incidence of MSCC is unknown. Post mortem evidence indicates that it 16is present in 5-10% of patients with advanced cancer. Levack et al. (2001) have 17also estimated similar figures in terms of incidence. In their report of a population 18based study from Ontario Canada, Loblaw et al. (2003) described a cumulative 19probability of experiencing at least one episode of MSCC in the 5 years 20preceding death from cancer of 2.5% overall with a 40-fold variation in the 21cumulative incidence of MSCC among different types of cancer. The authors 22acknowledged that they may have underestimated the true incidence by at least 2315%, as the detection rate depended on admission to hospital, correct diagnosis, 24and entry into coding systems (Loblaw et al. 2003). One of the main reasons for 25the uncertain incidence of MSCC in the UK is the lack of a recognised coding 26system for the diagnosis. It is likely the incidence of MSCC will increase in the 27future with constantly improving cancer treatments resulting in better survival and 28outcomes. 29 30The median age at time of MSCC diagnosis is 65 years (Levack et al. 2001, 31Loblaw et al. 2003). Data from the Levack et al. audit (2001) suggest that 77% of 32patients diagnosed with MSCC had an established diagnosis of cancer whereas 3323% presented with MSCC as the first presentation of malignancy. 34 351.3 Aetiology and pathophysiology 36 37Loblaw et al. (2003) define MSCC as compression of the dural sac and its 38contents, namely the spinal cord and cauda equina, by an extradural mass. 39Lung, breast and prostate cancers are the commonest malignancies causing 40MSCC and account for over 50% of cases (Loblaw et al. 2003, Levack et al. 412001). In 7% of patients the site of primary tumour may remain unidentified 42(Levack 2002, Levack et al. 2001). 43 44Three mechanisms are responsible for MSCC. The commonest is 45haematogenous spread to the vertebral spine causing collapse and compression, 46accounting for over 85% of cases (Bucholtz 1999, Levack et al. 2001). Less 2Metastatic spinal cord compression: full guideline DRAFT (May 2008) Page 37 of 200
  38. 38. 1DRAFT FOR CONSULTATION 1common spread is by direct tumour extension into the vertebral column or by 2direct deposition of tumour cells (Bucholtz 1999). 3 4The cause of damage to the spinal cord from compression is complex and 5multifactorial. Direct compression results in oedema, venous congestion and 6demyelination. If the compression is of gradual and of recent onset with some 7preservation of neurological function, the effects are often reversible. With 8prolonged compression, secondary vascular injury ensues causing infarction of 9the spinal cord. After this type of injury any meaningful recovery is unlikely 10(Patchell et al. 2005). Paradoxically, slow onset compression which permits a 11degree of cord adaptation usually predicts a better outcome than sudden onset 12neurological loss. 13 141.4 Clinical symptoms and signs 15 16Back pain is the most frequent first symptom occurring in 95% of patients and 17usually precedes signs related to MSCC by prolonged periods (Levack et al. 182001, Portenoy et al.1997, Byrne et al. 1997, Quinn and DeAngelis 2000). The 19pain is described either as localised or neurogenic. Spinal pain is defined as pain 20in and around the spinal column area in distinction to neurogenic pain, which is 21spinal cord or nerve root pain affecting one or both sides of the body (Levack et 22al. 2001). In the Levack et al. audit (2001) 37% of patients with MSCC had nerve 23root pain, 15% had localised spinal pain on its own and 47% had spinal pain and 24nerve root pain. The median pain intensity was 8 on a scale of 0 to 10 with 0 25being ‘no pain’ and 10 ‘the worst imaginable pain’. 26 27Weakness of the limbs is the second most common symptom of cord 28compression. Eighty five percent of patients in the Levack et al. (2001) audit 29experienced weakness and in the majority pain preceded weakness. Only 18% of 30patients were able to walk without help at the time of diagnosis of MSCC (Levack 31et al. 2001). 32 33Another common symptom is sensory deficit including paraesthesia, decreased 34sensation and numbness of toes and fingers which may extend to the level of 35cord compression (Held and Peahota 1993). Fifty two percent of patients had a 36clinical sensory level but this varied by up to ten dermatomes below or above the 37true compressive lesion (Levack et al. 2001). Autonomic dysfunction is a late 38consequence and rarely isolated symptom of MSCC. Autonomic abnormalities 39include impotence, bladder and bowel dysfunction presenting as urinary 40retention, incontinence or constipation (Bucholtz 1999). Constipation was the 41commonest bowel symptom and occurred in 67% of patients (Levack et al. 422001). 43 44Over two thirds of cases of MSCC occur in the thoracic spine and between 4 and 457% occur in the cervical cord (Cook et al. 1998, Levack et al. 2002, Loblaw et al. 2Metastatic spinal cord compression: full guideline DRAFT (May 2008) Page 38 of 200
  39. 39. 1DRAFT FOR CONSULTATION 12003). Seventeen percent of patients have two or more levels of cord 2compression (Levack et al. 2002). 3 41.5 Survival/mortality 5 6Median survival following a diagnosis of MSCC is reported as being around 2 to 3 7months (Levack et al. 2001, Loblaw et al. 2003) with 17% patients alive at one 8year and 10% patients at 18 months (Levack et al. 2001). The median survival of 9untreated patients from a diagnosis of MSCC is one month (Loblaw et al. 2003) 10but this may reflect selection bias for treatment. Several studies have reported 11survival to be significantly associated with the ability to walk at time of diagnosis. 12The Levack et al. audit (2001) found primary tumour site and ability to walk at 13diagnosis of MSCC as independent predictors of survival. 14 15Loblaw et al. (2003) reported large differences in survival following MSCC in 16different disease groups. Longest survival was reported in patients with 17haematological malignancies (lymphoma, leukaemia and multiple myeloma) and 18prostate cancer whereas lung cancer patients had the shortest survival. Similar 19results were reported by Levack et al. (2001) with 66% survival at 3 months for 20patients with haematological malignancies and 22% survival at 3 months in 21patients with lung cancer. 22 23Survival time is also related to the type of treatment. Surgically treated patients 24had significantly better survival at one year (57.4% vs 13.3%) than patients not 25surgically treated (Levack et al. 2001) but this may reflect selection bias for 26treatment. 27 281.6 Service provision 29 30To inform the development of this guideline a questionnaire survey of incidence, 31availability of resources and variation in clinical practice in relation to MSCC in 32England and Wales was carried out. The aim of this survey was to determine 33differences in service provision, specifically access to: 34 - MRI 35 - Spinal surgical services 36 - Oncological services 37 - Other services. 38 39Detailed questionnaires were sent to cancer centres, orthopaedic and 40neurosurgical spinal surgery units, palliative care units and rehabilitation units. 41Copies of these quesitonnaires will be reproduced in the full needs assesment 42which will form part of the evidence review. As part of the questionnaire 43departmental studies or audits were also requested. In total, replies were 44received from 27/57 (47%) of cancer centres, 21/61 (34%) of spinal surgery units, 45116/353 (33%) palliative care departments and 7/10 (70%) of specialist 46rehabilitation units. 2Metastatic spinal cord compression: full guideline DRAFT (May 2008) Page 39 of 200
  40. 40. 1DRAFT FOR CONSULTATION 1 2Incidence 3The average catchment area for cancer centres is 1.2 million people (median 1 4million, range 0.3 to 3 million). On average 80 MSCC cases are seen per year in 5each centre (median 55, range 10 to 250). Prostate cancer was the commonest 6primary tumour site in 15 (55%) units. 7 8The average catchment area for spinal surgery units is 2.4 million people 9(median 2.2 million range 1.2 to 4.2 million). On average 56 MSCC cases are 10seen per year in each unit (median 50, range 5 to 150). Breast cancer was the 11commonest primary tumour site in 13 (62%) units. Prostate cancer was not 12reported as the commonest primary site in any unit. 13 14The average catchment area for a palliative care department is 0.42 million 15people (median 0.35 million, range 0.1 to 2.6 million). On average 16 MSCC 16cases are seen per year in each department (median 12, range 3 to 150). 17Prostate cancer was the commonest primary tumour site in 45 (39%) units. 18 19Specialist spinal rehabilitation units have large catchment areas, with an average 20of 6.4 million people (median 6 million, range 3 to 10 million). The average 21number of MSCC patients seen in the 3 units accepting these patients is only 4 22per year. 23 24MRI 25 26Cancer Centres 27Of those centres which responded to the questionnaire 23/27 (85%) have a 28written policy on the investigation of possible MSCC. Before a confirmed 29diagnosis 18 (67%) centres routinely keep patients lying flat. Interestingly 8 30centres (35%) with a written policy do not recommend patients lie flat before a 31diagnosis is made. 32 33In all the 27 centres who responded, MRI is available during weekday working 34hours and 23 (85%) reported that it is ‘easy’ or ‘very easy’ to access. A weekday 35out-of-hours service is available in 16 (59%) centres. All other centres wait until 36the following morning. An on-site weekend service is available in 16 (59%) 37centres. Of the remainder, 6 (22%) refer patients to another hospital for scanning 38over the weekend, and 5 (19%) wait up to 48 hours until Monday morning. In 39total 19 centres (70%) are able to organise an MRI scan within 24 hours of the 40medical decision to request one. One centre did however report a delay of up to 4172 hours. As might be expected, this centre did not provide an out-of-hours or 42weekend service. In 23 centres (85%), the whole spine is scanned, in 3 (11%) a 43limited scan is performed. One centre did not know the extent of scanning. 44 45 46 2Metastatic spinal cord compression: full guideline DRAFT (May 2008) Page 40 of 200
  41. 41. 1DRAFT FOR CONSULTATION 1Spinal Surgery Units 2Of those units which responded to the questionnaire 10/21 (48%) have a written 3policy on the investigation of possible MSCC. Before a confirmed diagnosis, 13 4units (62%) routinely keep patients lying flat. Eight of the 10 units (80%) with a 5written policy recommend that patients lie flat before a diagnosis is made, which 6is higher than in cancer centres. In all 21 units who responded to the 7questionnaire MRI scanning was available on-site and all patients with suspected 8MSCC had an MRI scan. In 19 units (90%), MRI is available outside of normal 9working hours. On a weekday, the remaining 2 units (10%) wait until the following 10morning, and over the weekend patients are referred to another hospital for 11scanning. Twelve units (57%) are able to organise an MRI scan within 24 hours 12of the medical decision to request one. Surprisingly, 3 units (14%) did report a 13delay of up to 72 hours and in all three cases, MRI was available on site and 14outside working hours. In 19/21 centres (90%), the whole spine is scanned, in 2 15(10%) a limited scan is performed. 16 17Palliative Care Departments 18It was reported that in 99/116 departments (85%) which responded to the 19questionnaire more than 75% of patients have an MRI scan to confirm their 20diagnosis. Only 32 units (28%) routinely lie patients flat (17 or 15% of 21respondents were unsure). This is much lower than in Cancer Centres or Spinal 22Surgery Units. Fifty three units (46%) have a written policy on the management of 23MSCC (8 or 7% of respondents were unsure). On-site MRI is available in 72 units 24(62%) (24 of 116 departments or 21% of respondents were unsure). In 110 units 25(95%) MRI is available during normal working hours. Access during working 26hours was deemed as ‘very easy’ or ‘easy’ in 96/116 units (83%). The whole 27spine is scanned in 90 units (78%). 28 29Surgical Services 30 31Cancer Centres 32In total, 19 centres (70%) report it is ‘easy’ or ‘very easy’ to contact the surgical 33team. On site surgical review is available in 10 centres (37%). The average 34distance to a spinal unit is 10 miles (range 0 to 60 miles). Only a minority of 35patients are referred for review; in 18 (centres 67%) less than 25% are assessed 36by the surgical team. Of those patients reviewed, 14 of centres (52%) report that 37over 50% are operated on. 38 39Spinal Surgery Units 40In total, 16 units (76%)do not have a defined policy for selecting patients for 41surgery. Five units (24%) use the Tokuhashi score. In 11 units (52%) over 75% of 42the patients referred for surgical review are not operated on. Only 4 units (19%) 43operated on more than half of the patients seen which is much lower than the 44surgical rates reported by cancer centres. Surgery is carried out within 72 hours 45of the decision to operate in all but one centre. In cancer centres and palliative 46care units prostate cancer seems to be the commonest primary site. However, no 2Metastatic spinal cord compression: full guideline DRAFT (May 2008) Page 41 of 200
  42. 42. 1DRAFT FOR CONSULTATION 1spinal unit reported prostate cancer as the commonest malignancy. Breast 2cancer was the commonest primary tumour site in 13 units (62%). This suggests 3that either proportionally more breast cancer patients are referred or accepted for 4surgical review than other primary sites. 5 6Palliative Care Departments 7Surgery is an uncommon treatment for patients, with 104 units (90%) reporting 8that 25% or less are operated on (9 or 8% of respondents were unsure). This 9reflects the small number of patients referred for surgical review. In total, 62 10centres (53%) report it is ‘easy’ or ‘very easy’ to contact the surgical team. The 11average distance to a Spinal Surgery Unit is 14.5 miles (range 0 to 100 miles). 12 13Oncology Services 14 15Cancer Centres 16Most centres (23 or 85%) reported that patients with a diagnosis of MSCC are 17seen within 24 hours by an oncologist. No centre reported a wait of more than 48 18hours. Patients are usually treated with radiotherapy; more than 75% of patients 19in 25 centres (93%) and 50-75% of patients in 2 centres (7%). Overall, 11 centres 20(41%) will treat some patients without radiological confirmation of MSCC. The 21decision to treat without a radiological diagnosis may depend on the availability 22of MRI; seven centres (26%) treating without MRI wait more than 24 hours for a 23scan compared to only one (6%) of the remaining centres. It was not asked 24whether these patients go on to have MRI scans once the radiotherapy has 25begun. Radiotherapy is started within 24 hours of the diagnostic MRI scan in 25 26centres (93%). No centre reported a delay of more than 48 hours in starting 27radiotherapy. Treatment can start on Saturday in 26 centres (96%) and on 28Sunday in 22 centres (85%). Various radiotherapy dose regimens are used, but 29by far the commonest is 20Gy in 5 fractions, which is the schedule of choice in 23 30centres (85%). A written policy on steroid usage exists in 20 centres (74%). All 31centres use dexamethasone and 21 centres (78%) recommend a total daily dose 32of 16mg. 33 34Spinal Surgery Units 35In total, 13 centres (62%) routinely refer more than 75% of patients for post- 36operative radiotherapy while 8 (38%) refer 25-50% of patients for radiotherapy. 37Access to radiotherapy is reported as ‘very easy’ or ‘easy’ in 20 units (95%). A 38written policy on steroid usage exists in 9 units (43%). Somewhat surprisingly, 39two units (10%) do not routinely use steroids. All other 19 units use 40dexamethasone and 15 centres (79%) recommend a total daily dose of 16mg. 41 42Palliative Care Departments 43Access to oncology services is reported as ‘very easy’ or ‘easy’ in 84 units (72%). 44Surprisingly, 29 departments (25%) report access to oncology services as 45‘difficult’. Despite this, 90 departments (78%) have oncology review within 48 46hours (6 or 5% of respondents were unsure). Radiotherapy is the commonest 2Metastatic spinal cord compression: full guideline DRAFT (May 2008) Page 42 of 200
  43. 43. 1DRAFT FOR CONSULTATION 1treatment for patients with MSCC, with 106 centres (91%) reporting over 50% of 2patients being treated in this way (4 or 3% of respondents were unsure). Twenty 3five departments (22%) reported that some patients are treated without prior MRI 4scanning. Waiting times for radiotherapy are generally good; in 63 units (54%) 5patients wait less than 24 hours before starting radiotherapy. In only 3 6departments (2%) is the wait more than 48 hours (21 or 18% of respondents 7were unsure). Seventy three departments (63%) reported that radiotherapy can 8be started on a Saturday (28 or 24% of respondents were unsure). 9Encouragingly, only 15 departments (13%) reported that radiotherapy cannot 10start on a Saturday, which is similar to the proportion of cancer centres unable to 11provide this service. This suggests that patients in palliative care units may get 12similar access to radiotherapy as those in cancer centres. In total, 56 (48%) have 13a written policy on steroid usage (30 or 26% of respondents were unsure). All 14116 units use dexamethasone and 110 centres (95%) recommend a total daily 15dose of 16mg. 16 17Other Services 18 19Cancer Centres 20Access to specialist physiotherapy is variable with only 13 centres (48%) 21providing this service (6 or 22% of respondents were unsure). Daily 22physiotherapy is available in 17 centres (63%) and 8 centres (30%) have a 23written policy on mobilisation. Occupational therapy is available in 25 centres 24(93%) (2 respondents were unsure). Only 8 centres (30%) have a continence 25adviser (13 or 48% of respondents were unsure). Referral to specialist 26rehabilitation services is available to patients in 17 centres (63%) (5 or 19% of 27respondents were unsure). An average of 5 patients per year (range 1 to 10) 28were referred for specialist rehabilitation in the 9 centres (30%) that provided this 29information. 30 31Spinal Surgery Units 32Access to specialist physiotherapy is available in 10 units (48%) (2 or 10% of 33respondents were unsure). Daily physiotherapy is available in 17 units (81%) and 345 units (24%) have a written policy on mobilisation (2 or 40% of respondents 35were unsure). Occupational therapy is available in 19 units (90%) (1 or 5% of 36respondents were unsure). In total, 15 units (71%) have a continence adviser (3 37or 14% of respondents were unsure). Referral to specialist rehabilitation services 38is available to patients in 16 units (76%) (1 or 5% of respondents were unsure). 39An average of 5 patients per year (range 2 to 10) were referred for specialist 40rehabilitation in the 10 centres (48%) that provided this information. 41 42Palliative Care Departments 43Access to specialist physiotherapy is available in 65 departments (56%) (15 or 4413% of respondents were unsure). Overall, 69 departmenst (59%) reported that 45patients are assessed by a physiotherapist within 48 hours of referral. Fourteen 46departments reported waiting more than 72 hours for physiotherapy review after 2Metastatic spinal cord compression: full guideline DRAFT (May 2008) Page 43 of 200

×