CUP Pathways

Dr Syed ZubairConsultant Medical Oncologist

The James Cook University Hospital

Overview

Is CUP relevant and do we need pathways

CUP pathways as recommended by NICE

Real life CUP scenarios Local pathways

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

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

Inpatient episodes

Inpatient episodes per 1000 population per year (2000 – 2007)

The highest rate was seen in the North East SHA.

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.

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

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

Diagnosis and management of metastatic malignant disease

of unknown primary originImplementing NICE guidance

July 2010

NICE clinical guideline 104

NICE Recommendations

Definitions

Epidemiology

Organisation of services and support

Diagnosis

Factors influencing management decisions

Managing specific presentations

Systemic treatment

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.

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

Real life CUP scenarios

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

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

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

Concerns IP/OPD:

Prolonged IP stay Multiple investigations Multiple MDTs

GP: Who to refer How far to investigate

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

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

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

CUP @ South NECN

CUP service rolled out to All patients from south

NECN JCUH / Friarage Darlington / Bishop North Tees / Hartlepool

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

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

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

CUP Diagnostic & Referral Pathways

Inpatient Pathway - Cancer Centre Outpatient Pathway - Cancer Centre

Inpatient Pathway - Cancer Unit Outpatient Pathway - Cancer Unit

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

Cancer Centre In patient Pathway for CUP

Cancer Centre Outpatient Pathway for CUP

Cancer Unit In patient Pathway for CUP

Cancer Unit Outpatient Pathway for CUP

Acknowledgements

Dr Nicola StoreyNicky Hand

Thank you

Discussion