CUP Pathways
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Transcript of CUP Pathways
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CUP Pathways
Dr Syed ZubairConsultant Medical Oncologist
The James Cook University Hospital
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Overview
Is CUP relevant and do we need pathways
CUP pathways as recommended by NICE
Real life CUP scenarios Local pathways
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Is CUP relevant? In England: 9,778 new cases registered in 2006 (2.7%)
4th most common cause of cancer death
No discrete classification within the ICD nomenclature C77 to C80 usually cover registrations
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Use of resources
HES (Hospital Episode Statistics) for England (06-07) 25,318 episodes of care 308,359 NHS bed-days
Admissions with CUP (2007): 365,197 patients 72% as emergencies 28% were elective admissions
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Inpatient episodes
Inpatient episodes per 1000 population per year (2000 – 2007)
The highest rate was seen in the North East SHA.
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Experience of patients
Lengthy diagnostic process with little new information discovered.
Disquiet at a string of investigations which may cause
discomfort, adding little to care. Confusion - who is in charge of care.
Long periods of inpatient stay with little perceived benefit. Feel lack of fitting into a defined system when they meet
other cancer patients.
Absence of an organised research programme.
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Patient journey
Mr HR, 69 years old, previous history of prostate cancer on hormonal treatment Presented to GP with intermittent dysphagia, clinically palpable nodes in the neck, 2nd week July: Referred to Gastroenterology at North Tees 18th July: OGD , soft tissue lesion around epiglottis 20th July : Referred to ENT by GP 25th July: Seen in ENT clinic, FNA of neck node 4th Aug: Nasolaryngoscopy and Panendoscopy.No epiglottic lesions and normal larynx 9th Aug: CT of TAP 15th Aug: ENT clinic 16th Aug: H&N MDT, NSC cancer, refer to upper GI MDT 19th Aug : Upper GI MDT, PET and US core biopsy 26th Aug: PET scan 2nd Sep: Upper GI MDT, Radiological no evidence of upper GI cancer 8th Sep: US guided neck node biopsy 23rd Sep: Upper GI MDT, Likely CUP 4th OCT H&N MDT: 06th Oct: Combined clinic 07th Oct: Referral to CUP team 14th Oct : Seen in CUP clinic
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Why are we still failing CUP patients?
Lack of a system for clinical care
Site-determined Cancer
• Specialist Oncologist• Specialist Nurse• Multi-disciplinary team• MDT management approach• Rapid systematic investigation• Site-specific protocols• Site-specific audit• Site-specific research• Cancer measures• Site-specific information + support• Accurate epidemiology
Unknown Primary Cancer
• No Specialist Oncologist• No Specialist Nurse• No Multi-disciplinary team• No MDT management approach• No Rapid systematic investigation• No Site-specific protocols• No Site-specific audit• No Site-specific research• No Cancer measures• No Site-specific information + support• No Accurate epidemiology
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Diagnosis and management of metastatic malignant disease
of unknown primary originImplementing NICE guidance
July 2010
NICE clinical guideline 104
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NICE Recommendations
Definitions
Epidemiology
Organisation of services and support
Diagnosis
Factors influencing management decisions
Managing specific presentations
Systemic treatment
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Definitions
MUO
pCUP
cCUP
Detection of metastatic malignancy on clinical examination or by imaging, without an obvious
primary site
Metastatic epithelial / neuro-endocrine malignancy on
histology. No primary detected despite initial investigations. Specialist review and possible further investigations pending
Metastatic epithelial / neuro-endocrine malignancy on histology. Specialist review and all relevant investigations completed. No primary detected.
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Organisation of CUP services
NSSG Every hospital with a cancer centre
or a cancer unit should establish CUP team CUP specialist nurse Outpatients and inpatients with CUP
O/P : rapid referral pathway(2W). I/P : assess by end of the next working day.
Local and Specialist CUP MDT
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Real life CUP scenarios
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In patient referral Mrs LK, 63, HT, Type 2 DM, PS-1
Admitted to DMH, gen unwell, deranged BMS. Pain in left arm, enlarged liver with abnormal LFTs
CT: Multiple liver mets, extensive nodal disease in abdo, lytic lesion in left humerus
Bone scan: Further uptake in right femur USS guided liver biopsy: Mod diff adeno Ca, IHC
unhelpful
Poor PS, palliative RT to left humerus and referral to palliative care team
Transferred to nursing home, For BSC
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OPD referral Mr CS, 60, accountant, IDDM, PS-0, chest team
Lumps in neck, headache and abnormal CXR CT: disseminated malignancy with significant
nodal mets, bilateral adrenal, liver, pulmonary, and cerebellar mets
Biopsy of neck node: poorly differentiated adenocarcinoma, extensive panel of IHC
Currently on palliative chemo
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From Primary Care Mrs JR, 63, PS-0, Fit, school supervisor
Dizzy spells and forgetting things CT brain: 2 ring enhancing lesions in left temporal and
one in the left parietal lobe – multiple brain mets Staging CT: Possible lesion in Rt breast – workup NAD
MRI:Likely glioblastoma multiforme Biopsy confirmed
Neurosurgical MDT: Ongoing discussions re - concurrent chemo radiotherapy or palliative radiotherapy
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Concerns IP/OPD:
Prolonged IP stay Multiple investigations Multiple MDTs
GP: Who to refer How far to investigate
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Site specific cancer Mrs PI, 49, PS-0, Fit and well, GP referral 2-3 week h/o flashing lights and dizzy spells
CT Brain: 1 lesion in PO lobe and 2 in right frontal with extensive vasogenic oedema
No other sinister symptoms, stopped smoking in feb 20 cig/day
Staging CT: 34mm spiculated mass in LLL
Lung MDT: Radical appraocah ?gamma knife, further MRI brain at least 6 lesions
Rx: palliative chemo - PD after C2, Palliative RT to brain. ?2nd line Tarceva
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Non cancer patients as CUP
Mrs GD, 54, lupus, ?osteoporosis,PS-0, via GP
Pain in cervical spine radiating down left arm, chronic intermittent pain LS spine
MRI: wide spread bony lesions in thoracic and lumbar spine consistent with bony mets
Staging CT: NAD Bone scan : low grade uptake
Ankylosing spondylitis
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Peer review Primary care: current situation of referring to diagnosticians
or MDTs Pathway to start with diagnosis of MUO
NSSG in consultation with CUP MDT leads Agree network-wide patient pathways (indication for referral,
investigation and subsequent management) Hospital specialists or A&E department Acute Oncology
Pathways to include following specifications Assessed face to face by a core member OPD: R/v within 2 weeks of diagnosis of MUO I/P: R/v by the end of next working day
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CUP @ South NECN
CUP service rolled out to All patients from south
NECN JCUH / Friarage Darlington / Bishop North Tees / Hartlepool
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CUP service will be rolled out for
All patients with a diagnosis of MUO/pCUP/cCUP
Imaging suggestive of metastatic malignancy with no obvious primary (no histology or cytology obtained) e.g.
multiple liver, lung, bone or brain metastases
Histology/cytology suggestive of carcinoma with no obvious primary on imaging
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Outcomes of the CUP service
If PS 3 or more: Specialist palliative care.
cCUP: Assessment for systemic treatment.
Primary identified: Specialist MDT.
Non-malignant condition
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Potential radical treatment
Squamous carcinoma upper or mid neck nodes Head and neck MDT
Adenocarcinoma involving the axillary nodes Breast cancer MDT
Squamous carcinoma confined to inguinal nodes Specialist surgeon in an appropriate MDT
Solitary mets in liver/brain/lung Appropriate MDT
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CUP Diagnostic & Referral Pathways
Inpatient Pathway - Cancer Centre Outpatient Pathway - Cancer Centre
Inpatient Pathway - Cancer Unit Outpatient Pathway - Cancer Unit
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CUP @ South NECN Cancer Centre
CUP team CUP MDT Friday AM CUP clinic
Cancer Units DMH/Bishop Auckland
Lead Clinician /AONS / Visiting Oncologist North Tees/Hartlepool
Lead Clinician /AONS / Visiting Oncologist
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Cancer Centre In patient Pathway for CUP
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Cancer Centre Outpatient Pathway for CUP
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Cancer Unit In patient Pathway for CUP
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Cancer Unit Outpatient Pathway for CUP
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Acknowledgements
Dr Nicola StoreyNicky Hand
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Thank you
Discussion