Management of Carcinoma of Unknown Primary within the ... · Proposed Definitions • Malignancy of...
Transcript of Management of Carcinoma of Unknown Primary within the ... · Proposed Definitions • Malignancy of...
Management of Carcinoma of Unknown Primary within the
Acute Oncology Framework
ACP Acute Oncology Update
March 2010
CUP and Acute Oncology
• NICE CUP Guideline overview
• Non-elective admissions with CUP
• NICE CUP Guideline outputs
• Organisation of CUP services
• Interface between AO and CUP
NICE CUP Guideline overview
• Why are we failing CUP patients?
– Lack of an agreed definition
– Lack of evidence base / accurate epidemiology
– Lack of biological understanding and research
– Lack of designated funding / resources
– Lack of a “site-specific” system for clinical care
– Lack of support for patients and families
– Lack of defined treatments
– Therapeutic nihilism
NICE CUP Guideline overview
• Why are we failing CUP patients?
– Lack of an agreed definition
– Lack of evidence base / accurate epidemiology
– Lack of a “site-specific” system for clinical care
• Clinical specialists
• Referral processes
• “Site-specific team” and structure
– MDT, SSG, Keyworker
Why are we failing CUP patients ?
– Lack of an agreed definition
Proposed DefinitionsBased on clinical course, clinical findings and outcome of investigations, over time
Detection of metastatic malignancy on clinical examination
or by imaging, without an obvious primary site
Metastatic epithelial / neuro-endocrine malignancy on
histology. Specialist review and all relevant investigations
completed. No primary detected.
Metastatic epithelial / neuro-endocrine malignancy on
histology. No primary detected despite initial investigations.
Specialist review and possible further investigations pending
Proposed Definitions
• Malignancy of undetermined primary origin (MUO)
– Metastatic malignancy identified on the basis of a limited number
of tests, prior to comprehensive investigation
• Provisional Carcinoma of Unknown Primary (pCUP)
– Metastatic epithelial or neuro-endocrine malignancy identified on
the basis of histology / cytology, with no primary detected
despite an initial screen of investigations, prior to specialist
review and possible further specialised investigations
• Confirmed Carcinoma of Unknown Primary (cCUP)
– Metastatic epithelial or neuro-endocrine malignancy identified on
the basis of definitive histology, with no primary detected despite
a selected screen of investigations, specialist review, and
completion of further appropriate specialised tests
Proposed DefinitionsBased on clinical course, clinical findings and outcome of investigations, over time
Detection of metastatic malignancy on clinical examination
or by imaging, without an obvious primary site
Metastatic epithelial / neuro-endocrine malignancy on
histology. Specialist review and all relevant investigations
completed. No primary detected.
Metastatic epithelial / neuro-endocrine malignancy on
histology. No primary detected despite initial investigations.
Specialist review and possible further investigations pending
MUO
pCUP
cCUP
Why are we failing CUP patients ?
– Lack of evidence base / epidemiology
CUP Epidemiology
– What do we know?
• ICD-10 codes covering CUP
– C77 – secondary malignancy in nodes
– C78 – secondary malignancy – respiratory / GI systems
– C79 – secondary malignancy – other sites
– C80 – malignant neoplasm without specified site
• Accuracy of coding very dubious
• Final C77-80 code underestimates MUO admissions
CUP Epidemiology - Incidence
– UK Incidence from cancer registration
• 13,000 cases annually (ICD-10 C77 - 80)
• 4% of all cancer diagnoses
• Incidence falling over past 10 years
• BUT – MUO presentations >13,000
CUP Epidemiology - Mortality
– Mortality rate
• 12,000 deaths annually in UK
• 8% of all cancer deaths
• 4th most common cause of cancer death– Lung 34,500
– Colorectal 16,000
– Breast 12,500
– CUP 12,000
CUP Epidemiology - Admissions
– HES data for 169 acute Trusts in England
– Non-elective admissions
– Finally coded as C77-C80
– 25,318 episodes in 2007
– 3 per week for each acute Trust
– Mean length of stay = 9 days
– Underestimates total “MUO” admissions
CUP Epidemiology - Admissions
– HES data for Dorset Cancer Network
– Non-elective admissions to 3 acute Trusts
– Finally coded as C77-C80
– 1100 episodes in 2006
– 7 per week for each acute Trust
– Mean length of stay = 13 days
– Underestimates total “MUO” admissions
NICE CUP Guideline outputs
NICE CUP Guideline outputs
• Definitions
• Needs Assessment / Epidemiology
• Organisation of Services along “site-specialty” lines
– CUP Oncology specialist and CUP Team
– CUP Specialist nurse
– CUP Network SSG
– Referral timescale standards
• Optimised diagnostic process
• Management recommendations
• Treatment recommendations
• Research
– New NCRI Clinical Studies Group for unknown primary cancer
– Studies: Gene-expression based profiling, PET-CT, Treatment
Organisation of CUP Services
Organisation of CUP Services
Current Situation
• No Referral guidelines
• No Specialist Oncologists
• No Specialist Nurses
• No Multi-disciplinary team
• No MDT management approach
• No Rapid systematic investigation
• No Site-specific treatment protocols
• No Network Site-specific Group
• No Site-specific audit
• No Site-specific research
• No Cancer measures
• No Site-specific information + support
• No Accurate epidemiology
Organisation of CUP Services
• Establish CUP Team
– Oncologist, Palliative Care Physician, Nurse
– Based at every Cancer Centre and Unit
• Establish CUP as a “site-specialty”
– Designated specialist Oncologists
– Standards / processes (eg SSG) as other sites
• Rapid referral of MUO patients
– Within 1 working day for inpatients
– Outpatient Fast-track referral to CUP clinic
Elements of a successful MUO / CUP approach*
• Prompt patient identification and oncology referral
• CUP Specialist Oncologists
• Keyworker / coordinator
• Establishment of small, dynamic “CUP Team”
• Oncology-directed management
• Oncology and Palliative Care collaboration
• Real-time management
• SMDT approach for relevant patients / problems
• Avoid management within existing site MDT
* see: Ernie Marshall, St Helens and Knowsley Hospitals, Judy King, Whittington Hospital
Implementation
2010 - A conjunction of opportunities
• Cancer Reform Strategy
– Motivation for efficiency and reduced stays
• MDT re-engineering
– Smarter MDT working: real-time management
• NCAG report implementation
– Acute Oncology Service mandated
– (BUT: MUO management undersold!)
• NICE CUP Clinical Guideline
– Specialist management for a significant
proportion of the acutely presenting patients
Implementation
• Acute Oncology Cancer Measures
– Consultation on draft: mid 2010
– Adequate coverage of issues relating to newly
presenting MUO should be a priority
• CUP Guideline (July 2010) to emphasise:
– New Site-specialty, potentially alongside
specialist Acute Oncology role
– CUP teams
Implementation
NCAG
Report
Acute
Oncologist
↑Work
force
Chemotherapy
Quality
and
Safety
Reform
Strategy
Implementation
NICE
CUP
Guideline
NCAG
Report
Acute / CUP
Oncologist
Chemotherapy
Quality
and
Safety
Reform
Strategy
MUO / CUP
Services
↑Work
force
Implementation
NICE
CUP
Guideline
NCAG
Report
Acute / CUP
Oncologist
Chemotherapy
Quality
and
Safety
Reform
Strategy
MUO / CUP
Services
↑Work
force
From NCAG report section 2.7 page 18
Missed from Key Recommendation 7,
page 7 in Executive Summary
Section 2.7 page 18
“All hospitals with A&E Departments should
establish an Acute Oncology Service and/or
a pathway to ensure the rapid appropriate
management of patients presenting with
previously undiagnosed cancer”
13,000 cases of CUP annually
4th most common cause of cancer death
Crude survival for South East England (Kaplan
Meier) by period of registration
0.0
20.0
40.0
60.0
80.0
100.0
120.0
0 1 2 3 4 5
Years since diagnosis
% S
urv
iva
l
1992-1996
1997-2001
2002-2006
25,318 admissions annually
Only 8% of CUP patients
receive chemotherapy
8% 5-year survival
Unchanged for 20 years 200,000
bed days annually
Role mandated
in NCAG report
Organisation of CUP ServicesPatient with
malignancy of
undefined primary
origin (MUO)
Patient registered
with and referred
to CUP team (1)
Assessment of patient by member of CUP team by the end of next working
day as an inpatient or within 2 weeks as an outpatient (2). Initial management
plan including further investigations as appropriate devised by CUP team (3).
For inpatients, management plan implemented by responsible medical/
surgical team.
Appointment of key worker.
Review of results by CUP team with
involvement of extended team members e.g.
pathologist, radiologist
Palliative and
supportive care only
Investigations
completed. Diagnosis
of confirmed CUP
CUP network MDT
discussion to guide
specialised test(s)
CUP network MDT
review to agree
management plan
Primary identified or
non carcinoma
malignancy. Site
specific referral
Non-malignant
diagnosis
On
go
ing
re
vie
w o
f re
su
lts o
f p
atie
nt m
an
ag
em
en
t p
lan
by C
UP
te
am
. O
ng
oin
g
su
pp
ort
an
d s
ym
pto
m m
an
ag
em
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t