Acute Oncology:

local issues for District General

Hospitals

Chris Bradley

Bradford Teaching Hospitals23 March 2010

Provision of oncology service in district hospitals

Chemotherapy

Integration with MDTs

Advanced cancer/links to palliative care

“Acute Cancer Service”

Optimising care of all cancer patients admitted acutely

Evolution of Yorkshire model

Resident non-surgical oncology

Network population 2.6 million

History of devolved oncology services

9 district general hospitals

Several large population centres outside Leeds ca. 500k

Natural alliances between neighbouring hospitals

Subsequent mergers into larger Trusts

York – Harrogate

5 Oncologists

18 bed ward

Bradford/Airedale

6 Oncologists

21 bed ward

Hudderfield/

Calderdale

4 Oncologists

22 bed ward

Mid-Yorkshire

No resident

oncologists

(2.9 wte visiting)

10 years later…

Integrated oncology services

Critical mass of consultants/specialist nurses

Site specialised service – 2-3 consultants/site

Day case chemotherapy in both hospitals

Dedicated inpatient ward on one site

SpR/SHO level support

Mature service well integrated with MDTs

Settled structure of chemotherapy services

Acute pathway for chemotherapy complications well developed Patients, GPs, A&E well informed and make direct contact

What about cancer patients not

under care of oncology?

“Expert oncological assessment within

24 hours?”

What is a cancer patient?

Elderly medicine admission

78 year old woman

Breast cancer 2008

Surgery

Radiotherapy

Anastrazole

Breathless

AF

Hypoxic and raised D-dimers

But also…

Scan showed lung and

pleural metastases

Referred to

Breast surgery

Medical oncology

Seen same day

Discussed at MDT

within 48h

What is appropriate acute care?

What if:

Metastatic disease was primary problem?

New breast lump as incidental finding?

No evidence of new cancer related problem?

What sort of cancer patients are

admitted acutely to hospital?

Retrospective audit of all acute admissions over 7 day

period in September 2009

Cross referenced with Trust cancer database

Included all patients discussed at MDT/with a cancer

diagnosis in the preceding 12 months

Also all patients coded as a new cancer diagnosis during

this admission

Acute cancer admissions

0

1

2

3

4

30-39 40-49 50-59 60-69 70-79 80-89

oncology

haematology

other

8

421

2

21 1

0ncology

elderly medicine

general medicine

thoracic

medicine

haematology

general surgery

urology

gynaecology

Acute Cancer admissions

21 admissions

Notes available on 17 6 oncology

2 haematology

3 known to oncology and reviewed on ward

6 others 89 yr old - squamous Ca skin

82 yr old - Ca ureter and CVA

47 yr old - urgent colonoscopy for Ca colon

59 yr old - transferred back after surgery for MSCC from prostate Ca

52 yr old - abdo abscess after anterior resection for stage A colon Ca

63 yr old - Ca vulva

Acute cancer admissions

4 patients with new/suspected cancer

87 year old woman – dementia/general deterioration – CLL

on blood film

73 year old man with DVT and lymphadenopathy/prostatic

mass on scans – metastatic prostate cancer

67 year old man with abdo pain and uncontrolled

hypertension – renal cancer on CT

67 year old man with abdo pain – R ureteric stone/bladder

wall thickening. Subsequent OP cystoscopy – bladder cancer

Integrated primary care/palliative

care record Electronic patient record

Used by 95% GPs across Bradford/Airedale

Out of hours service across SHA

12 palliative care services across Yorkshire

Available in A&E, MAU

Patient’s current treatment plan available in summary care record

Eventually link to PPM?

What sort of Acute Cancer Service do

we need?

Depends on starting point

Different models for different situations

Address existing local deficiencies

Recognise expertise of all members of MDTs

Use existing pathways and systems

Cost efficiency in selection of Acute

Cancer Service Model?

“Difficult decisions”

Common sense approach

If limited local oncology – get more

If already adequate - invest in

good links with specialist teams