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Feature

The BMJ Awards 2020: Cancer care team of the year

BMJ 2020; 368 doi: https://doi.org/10.1136/bmj.m843 (Published 12 March 2020) Cite this as: BMJ 2020;368:m843
  1. Jacqui Wise, freelance journalist
  1. London, UK

Jacqui Wise meets the nominees for the cancer care award, who have found new ways to improve cancer diagnosis and treatment

Lung cancer emergency pathway

Many patients with lung cancer present with severe symptoms requiring emergency admission to hospital without ever having seen a lung cancer specialist.

One of the delays in the traditional lung cancer pathway often results in patients waiting weeks between an abnormal chest radiograph arranged by their general practitioner triggering a computed tomography (CT) scan in the hospital, before a diagnosis of lung cancer can be made. To speed up this process and reduce emergency lung cancer presentations, University Hospitals of Leicester NHS Trust implemented a direct-to-CT pathway.

Under the new pathway, if a radiograph indicates possible lung cancer the hospital automatically arranges a CT scan within three days. A lung cancer specialist nurse meets with the patient at the time of the scan to obtain a brief history. The patient’s case is reviewed at a triage meeting led by a respiratory physician. If there are any concerns or the CT scan shows advanced cancer, patients are reviewed urgently in clinic the same day or admitted straight away.

The new pathway has resulted in patients being diagnosed with lung cancer earlier. Data from the first 11 months have shown a 25% reduction in the emergency presentation of lung cancer.

“Patients who are admitted via the emergency route do worse as they tend to be presenting at a very late stage,” says Muhammad Tufail, consultant respiratory physician. “By making specific changes to our pathway we have been able to diagnose lung cancer much earlier and prevent the emergency presentations of lung cancer for many patients.”

Transforming cancer in Greater Manchester

Eight years ago cancer services in Greater Manchester were fragmented and had some of the worst patient survival rates in England. To tackle this, GM Cancer was established with the aim of transforming cancer outcomes through a coordinated series of projects.

Since the programme began, Greater Manchester’s cancer survival rate has improved each year about 30% faster than the average for England and it currently diagnoses 2% more cancers at an earlier stage than the national average.

A core element is the unique service user involvement programme, which has over 100 cancer patients and carers who sit on every board and are equal partners. “If you want to improve services you have to have people involved who have been through the system,” says Claire O’Rourke, associate director of GM Cancer.

The close knit clinically led team has delivered a number of innovative projects. One programme, CURE—a scheme to support patients in hospital to quit smoking—helped 900 patients to stop smoking in 2019. A revolutionary Prehab4Cancer service has also been launched helping prepare people effectively for their cancer treatment, with over 700 patients already accessing the service in the first eight months, well ahead of schedule and with excellent feedback to date.

Other projects making a difference include community based lung health checks, rapid diagnosis centres, accelerated diagnostic pathways, and a primary care programme to support quicker cancer referral processes.

Rapid diagnosis centre

After a Welsh delegation visited Denmark to learn from their success in improving cancer outcomes, it highlighted the need for an alternative to urgent cancer pathways for patients with non-specific cancer symptoms.

A rapid diagnosis centre opened in June 2017 at Neath and Port Talbot Hospital with funding from the Wales Cancer Network. “Fifty percent of patients don’t present with the traditional red flag cancer symptoms,” says Catherine Lloyd-Bennett, Macmillan cancer nurse specialist. “The centre was set up to try and address the unmet needs of patients with vague symptoms and the GP’s gut feeling of underlying cancer.”

Patients are booked in for a whole morning and have a nurse assessment, consultant review, and CT scan or ultrasound examination. Eighty five per cent of patients receive their results on the same day as the clinic. Data from the first two years of the pilot scheme show that the centre has a high cancer conversion rate of 11.3%. In addition, 35% of patients receive a non-cancer diagnosis such as HIV.

A cost effectiveness study showed that the centre reduces time to diagnosis in those patients with vague symptoms who are subsequently found to have cancer from 84.22 days in usual care to 5.90 days when the diagnosis is made at the clinic. It is also significantly cheaper, costing £646 (€741; $826) for a cancer diagnosis at the centre compared with £2400 with usual care.

Children with retinoblastoma

Retinoblastoma is a rare eye cancer with 40-50 new cases a year in the UK, often affecting infants. Survival rates are high, but treatment may necessitate removal of the eye.

“These patients are young children who when they go to school are at risk of being bullied or developing psychosocial issues,” says Ashwin Reddy, consultant paediatric ophthalmologist and lead at the Royal London Hospital.

The team has helped develop national guidelines that have reduced eye removal rates from 80% in the 1990s to 40% currently. With or without enucleation, the team recognised it is important to support the child and family psychologically with resilience strategies. “These children may have had up to fifty examinations under anaesthesia and each one can be very traumatic and stressful for the whole family,” says Reddy.

In 2016 the hospital successfully applied for funding for a psychologist to work as part of the team for two days a week, and 92% of families now have their psychological needs assessed—up from 25%.

Charitable funding helps support regular Eye Club meetings, which allow children to teach other children how to look after their artificial eye and provide peer support. The service also runs a Sib Squad to support siblings of patients with retinoblastoma, a transition clinic for children who are about to transfer from primary to secondary school, and school visits by specialist nurses.

SCAN pathway

Cancer survival in the UK continues to lag behind other developed nations. Many patients still experience delays in diagnosis, and 21% of cancers present as emergencies.

There are clear urgent referral pathways for patients with suspected cancer if they have tumour site specific symptoms. However, patients with non-specific symptoms that the GP thinks may be due to cancer don’t have a good route into hospital, explains Fergus Gleeson, consultant radiologist.

Working across primary and secondary care, Oxfordshire has tackled the problem by developing the Suspected CANcer (SCAN) pathway specifically designed for eligible patients with “low risk but not no risk” cancer symptoms. GPs refer patients to the service within strict parameters. Patients are given a whole body low dose CT scan and then referred on to the appropriate consultant. The novel pathway is coordinated by a navigator—a radiographer—who guides patients through the journey.

The pathway has a higher pick-up of cancer diagnoses than the conventional two week wait cancer pathway, with a conversion rate from referral to cancer detection of 9.4%. It has identified patients with stage 4 cancer but no specific symptoms and some relatively early cancers, like pancreatic cancer, says Gleeson. It has also picked up a considerable number of non-cancer diagnoses such as active tuberculosis, pulmonary embolisms, and sarcoidosis. “These patients would previously have had multiple GP appointments or would have bumped around the system,” he adds.

National sarcoma multidisciplinary team project

Sarcomas are rare and diverse cancers that can develop in any part of the body. On average 350 patients are diagnosed with sarcoma each year in Scotland. These patients are managed in five centres: Glasgow, Edinburgh, Dundee, Aberdeen, and Inverness.

The Scottish sarcoma multidisciplinary team meets weekly and is the national forum for decision making on optimal therapy for all patients diagnosed with sarcoma. “The role of the MDT [multidisciplinary team] is to ensure we have a cohesive approach, use the same protocols and we deliver the same quality care for sarcoma patients across Scotland,” says Ioanna Nixon, consultant clinical oncologist and national clinical lead for sarcoma.

A baseline audit of the national sarcoma multidisciplinary team at the start of 2019 showed that 17% of cases due for discussion had to be deferred owing to lack of information. A process of quality improvement work with several “plan, do, study, act” cycles reviewed the referral form, referral pathway, and communication channels with patients and colleagues.

The improvement work led to an increase in cases discussed at the meeting to 97%. The referral form was co-designed with patients to ensure it incorporated questions that matter to the patient.

The team is now working with primary care to improve information shared with GP colleagues and to provide support with follow-up guidelines to allow patients to be followed up close to home.

Footnotes

  • The winners of the cancer care award will be announced at The BMJ Awards ceremony on 22 April 2020 at the Park Plaza Hotel, Westminster, London. To find out more go to thebmjawards.bmj.com.