The BMJ Awards 2018: Cancer Care Team of the YearBMJ 2018; 360 doi: https://doi.org/10.1136/bmj.k1244 (Published 19 March 2018) Cite this as: BMJ 2018;360:k1244
Barts Health Cancer Care@Home
Many patients with non-aggressive cancers that are either in remission after treatment or have not been treated but need surveillance come to clinics once or twice a year to check for changes. Among patients at Barts Health NHS Trust with some blood cancers, these visits added up to around 1500 clinic appointments a year, says Samir Agrawal, consultant haemato-oncologist at the trust.
Visits often involved long waits in busy clinics that were running late. “There is really no reason to come in just to have a chat with a doctor,” he says. A survey showed that 82% of patients would be happy to be monitored remotely, with blood taken locally. “Barts is a huge trust so patients can either have blood taken at one of the trust’s other hospitals, and then the results are on our system, or we can send them blood bottles already labelled in the post, blood is taken at their GP surgery and sent back to us by post.”
Consultations are then conducted by phone or video. Advantages for patients include savings on travel time, less time taken off work, and appointment times that suit them.
Patients like the service, it saves money, and it eases pressure on the clinic—but medical colleagues have been harder to persuade. “To have a viable NHS we’ve got to move away from bringing patients in because it’s more convenient for us,” Agrawal says. “Colleagues say they might notice a change in a patient in a face-to-face consultation that they’d otherwise miss. But it’s the patient who knows when there’s something wrong, not us.”
Improving breast screening
When Rupika Mehta, a consultant radiologist, became director of the breast screening unit at Medway NHS Foundation Trust in Gillingham, targets were more honoured in the breach than the observance. Of 23 units in the south of England, Medway was in the bottom three.
“We were not telling women the results of their screening quickly enough,” she says. “It should be done within two weeks, and we were missing that for too many women.” Medway was also missing the national standard requiring that 90% of those who need a follow-up attend an assessment centre within three weeks. In 2014-15, its rate was as low as 41%, after several consecutive years of falling below the national average. “Whenever the phone rang, you knew it would be somebody asking how long the wait would be,” she says.
To turn things around required leadership, better training, the imposition of deadlines, and a system of alerts when breaches occurred. “The excuse that ‘we’ve always breached, let’s go on’ wasn’t acceptable anymore,” she says. “We all got together, found the loopholes, and changed the way we did things.”
Other changes were direct referrals to surgeons when cancer was suspected, rather than recalls to the clinic, and nurses reporting benign biopsy results to women by telephone. “That saved us a whole clinic, and patients were very happy with it.” The effect of the changes has been to move Medway from the bottom three to the top three, with 98% meeting the three week standard in 2017. “The phone doesn’t ring any longer,” she says.
Nurse led immunotherapy clinic
New immunological treatments for advanced melanoma have improved outcomes, but have created problems for those organising clinics. More patients are being treated for longer periods, and the need for regular monitoring for side effects makes for frequent clinic appointments. Maria Maples, consultant and honorary senior lecturer in medical oncology at St James’s University Hospital in Leeds, says, “We realised that we wouldn’t be able to accommodate the increase in existing clinic.”
The drugs are expensive and need to be made up for each patient, based on blood tests. They also have side effects that need to be monitored. That meant repeated visits to the clinic, where patient waiting times were already a source of complaint. “A lot of our patients don’t drive because of brain metastases, so it was even harder for them,” she says.
The solution was to establish a nurse led telephone service, using a validated questionnaire to ask patients about any side effects or symptoms of melanoma relapse. “This doesn’t eliminate all the clinic visits,” Maples explains. “Before they had to come once for the blood tests, then back for the treatment. Now they can have the bloods done near where they live—GPs have been very cooperative. Patients only need to see the doctor for scan results, or if there are any problems.” The number of visits for patients on pembrolizumab, the most frequently used drug, has been cut by 75%.
“It’s very safe for patients, and they like it,” she says. “We think it’s a model that could work for other cancers, too, such as lung cancer, head and neck cancer, and renal cancer.”
Oxford Reproductive Tissue Cryopreservation programme
Children who are diagnosed with cancer stand an excellent chance of a cure, but there is a risk that they will suffer impaired fertility as a result of treatment. “It really changes their lives and affects how they form relationships with partners in the future,” says Sheila Lane, consultant paediatric oncologist at Oxford University Hospitals NHS Foundation Trust.
She is the clinical lead for the Oxford Reproductive Tissue Cryopreservation programme where ovarian and testicular tissue from patients too young to produce eggs or sperm can be preserved. “Most in vitro fertilisation centres won’t store tissue from people under 18,” she says. The technique works: around the world, 150 babies have been born from such tissues.
The Oxford centre is the first in England and provides a national service. “They can either come here to provide tissue, or we can go their local hospital. The tissues take ten hours to process and are then stored in Oxford.”
The centre was made possible, she says, by an incredible “can do” attitude. “To get a new service going under the current financial constraints is incredible. We also have a research programme on the best way to use this very precious tissue.”
The first tissue was stored in 2013 and the service has since grown fast, with more than 150 patients storing tissue in 2016-17. “It gives children hope, not just for the future but it also means that they suddenly believe they are going to survive their cancer. They will have the same options as all their peers. It makes a big difference to them.”
Papillon for rectal cancer
Some new treatments spring into use quickly, while others take years, and even decades, to be recognised. Arthur Sun Myint, consultant in clinical oncology at Clatterbridge Cancer Centre in Wirral, Merseyside, first treated a patient with rectal cancer using the Papillon technique in 1993. But it took more than 20 years for the National Institute for Health and Care Excellence (NICE) to recommend it.
Surgery is the gold standard of care for rectal cancer, but many elderly patients shrink from it, and with good reason. Mortality is higher than in younger patients, and the fear of having to manage a permanent stoma a worry. The Papillon technique, named for the French doctor who invented it in the 1940s, delivers soft x rays directly to the tumour, destroying it layer by layer. “The energy is very low, and very focused, so there is little collateral damage,” Myint says.
He does not claim that the results are as good as surgery in the long term but says that “if it doesn’t work they can still go for surgery later.” Nor is there any reason why it shouldn’t be used on younger people, although surgeons are, he says, reluctant to refer them. It takes a very determined patient to break through professional scepticism, but one who did, 31 year old Mark Davies, wrote a book about the successful procedure, entitled Saving my Arse.
Papillon treatment is much cheaper than surgery—£5600 (€6300; $7815) v £20 000—and, since NICE approval, it has become routine practice, with four centres providing the treatment in England. Bowel screening, which detects many smaller tumours, could multiply the numbers of suitable patients.
The targets set for cancer care, such as the 62 days between an urgent GP referral and the start of treatment, are often missed. Yet these unachieved targets fall below what patients expect, says Matthew Evison, consultant in respiratory medicine at South Manchester NHS Foundation Trust. “There’s a huge disconnect between expectations and targets.”
When the team looked at the data for its lung cancer patients, it became clear that it was system delays that were responsible. Speeding the pathways, he says, “is not about any kind of revolutionary technology or procedure; it’s simply about ensuring the right people and the right technology are in the right place at the right time.”
It was taking two weeks to get a computerised tomography (CT) scan and a clinic appointment. “By dramatically changing that—so that a CT scan was done the day after a referral, reported immediately, and the patient seen in clinic the same day—you cut out days of delay. Three quarters of patients who have a scan don’t have cancer. The results were there, but the patients weren’t being told. Now they are, right away. From the professional satisfaction point of view, it’s the best thing I’ve ever been involved with.”
Making this change and others, such as appointing a “patient navigator,” involved teamwork. “Radiology used to be separate from surgery, now we’re one team. I didn’t know the names of the people in the call centre who were making those referrals, now I do.”
Now 87% of patients have an outpatient appointment within seven days of referral, compared with 24% before. There is also emerging evidence that one year survival has improved. “It’s 50% against a national average of 38%. That’s very encouraging.”
The Cancer Care Team of the Year award is sponsored by Macmillan. The awards ceremony takes place on 10 May at the Park Plaza Hotel, Westminster. To find out more go to thebmjawards.bmj.com
Provenance and peer review: Commissioned; not externally peer reviewed
Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.