YCN MSCC Pathway Implementation of NICE CG75 Level 2: Diagnostic

1. YCN MSCC PathwayImplementation of NICE CG75Level 2: Diagnostic Dr Rob Turner Chair YCN MSCC Group Units to localise slides to clarify responsibilities of the MSCC Coordinator and specify points of referral from the initial triage to the MSCC Coordinator and then on to the AOL / AOT

2. YCN MSCC Competency for Local MSCC Coordinators Local Acute Oncology Team MSCC Coordinators Competency • Knowledge and understanding of which patient groups are at a higher risk of developing MSCC • Knowledge and Understanding of the signs and symptoms of MSCC • Understanding of the appropriate aspects of the MSCC pathway • Escalation to the local coordinator • Escalation to investigation • Referral process to Leeds • Specialist MSCC coordinators – assessment and referral for treatment • Knowledge and understanding of the MSCC treatment options and specialist service processes for delivering treatment Education E - Learning Level 1- Early Warning Level 2 – Diagnostic

3. YCN MSCC Pathway • Components of the pathway • Overall goals • YCN implementation of the Guideline • SJIO implementation of the Guideline • Future developments

4. MSCC Pathway Components • Education and early warning • Triage • Diagnosis & generic care • Specialist intervention • Spinal surgery • Radiotherapy • Rehabilitation

5. Overall goals • Earlier diagnosis and treatment • Outcomes linked to pre-treatment status • Faster access to diagnostic MRI • Suspected • MSCC within 24 hours • VBM within 7 days • Rapid escalation to definitive therapy • Proven • MSCC within 24 hours • VBM within 7 days • Definitive therapy case-appropriate • Co-ordinated case-appropriate rehab

6. YCN implementation of the Guideline • Devolved responsibilities • Cancer Unit AOTs • Early warning • Triage • Diagnostics and generic care • Rehabilitation • Centre • MSCC senior medical advisors • Spinal surgery • Radiotherapy

7. SJIO implementation of the Guideline • Must work both as Cancer Unit and Centre

8. Cancer Unit ALL MEDICAL STAFF In- and out-patients Leeds based Breast Lung Urology Colorectal Haematological Centre-based MDTs Under active review Cancer Centre CLINICAL ONCOLOGY ON-CALL TEAM Proven MSCC only Imaged Reported Transferred SJIO implementation of the Guideline

9. Education and early warning • High-risk patient groups • Agreed by YCN SSG Chairs • Face-to-face discussion • Common format patient information • Symptoms of MSCC and VBM • Instructions about action to take (add local process) • 24 hour SINGLE POINT CONTACT NUMBER • Add Local Number

10. High Risk Patient Groups • Any patient who has had prior MSCC • Any patient with known bony metastases at any site from any primary site • Known cancer awaiting investigation for suspicious spinal pain • Tumour site-specific recommendations • Prostate: HRPC • Renal: Metastatic renal cell cancer • Lung: Any metastatic lung cancer • Breast: Any metastatic breast cancer • Myeloma: Any myeloma

11. MSCC symptoms & signs

12. Triage: Mechanism • Nursing staff will take basic details • Escalated to Local Details • In hours to be handled immediately • Overnight (22.30-09.00) defer until handover • On-call Local team to triage • Ring back for more detail • Priority • Immediate or deferred? • Ward or clinic for clinical assessment • Is MRI required and how quickly?

13. Triage: Need for MRI

14. Triage: Endpoints • MSCC possible • Urgent clinical assessment • Urgent in-patent MRI (within 24 hours) • Admission may be required • You MUST discuss with a Consultant CO • MSCC less likely but VBM possible • Prompt outpatient assessment • Prompt outpatient MRI (within 7 days)

15. MRI • Whole spine MRI imaging • MSCC (Rx within 24 hours) • With/without features of spinal instability • Non-compressive VBM (Rx within 7 days) • Off-pathway findings • Non-malignant neural compression • Non-malignant spinal disease • YCN radiology group have agreed • YOU WILL NEED TO DISCUSS WITH A RADIOLOGIST FACE-TO-FACE

16. Caveat • If you are an oncologist but not part of the on-call CO team and you are concerned about MSCC or VBM do not delay the process by ringing ward 96 or the CO on-call team: Arrange a whole spine MRI and escalate the result

17. Diagnostics and generic care • Whole spine MRI is gold-standard • CT or isotope bone scan is not • In all cases • Analgesia • In suspected MSCC • DEXAMETHASONE 16mg od plus H2RB/PPI • Thromboprophylaxis • Encourage mobilisation

18. Mobilisation & suspected MSCC • Flat bed-rest is not the default • Position/mobilise as pain permits • Lying • Inclined sit • Sitting balance • Assisted transfer • Independent transfer • Assisted mobility • Independent mobility

19. Specialist Intervention • All MRI proven MSCC should be escalated to Leeds - the CO StR on-call • Agreed YCN access-point to therapy • Spinal surgery should NOT be approached directly for MSCC cases • The need for a spinal surgical review will be established according to agreed criteria by the Leeds CO team

20. Specialist Intervention • Key steps • Confirm diagnostic criteria are met • Establish fitness for transfer/treatment • Establish most appropriate intervention • Escalate for surgical opinion if indicated • Transfer if not already at SJIO • Deliver definitive therapy • Initiate rehabilitation process

21. Confirm diagnosis • MSCC is not MSCC until • There image proven neural compression • Images are reported • Images and report are available • The malignant diagnosis is not in doubt

22. Confirm diagnosis: Issues • No MRI • Unit has responsibility to perform imaging • If no MRI service available • Establish name of unit radiologist who has sanctioned the need for an MRI but agrees no facility to scan • Establish fitness to transfer • Transfer to SJIO for MRI imaging • MRI but no report • Establish name of unit radiologist who has sanctioned the need for an MRI but is unable to report • Ask referring unit to transfer images • Discuss with SJIO radiology on-call

23. Confirm diagnosis: Issues • No malignant histology • Clinical context • History, examination • Radiological context • Oligometastatic or multi-level • Simple imaging • CT imaging • If the diagnosis is in doubt and there is either no clear candidate primary or target for biopsy (that would not be within the RT field) • Needs surgical intervention for decompression and tissue • Unless PS/co-morbidity preclude

24. Establish fitness • Do not transfer if • Against patient’s wishes • Medically unstable • Established paresis >48 hours and no pain • Treat as day-case if • Ambulant • Self-caring/self-medicating • Discuss with PR/RTBO if • Single fraction proposed • Nurse escort available • Other cases to transfer into Bexley Wing Bed • Same priority as neutropenic • Patient to be at Bexley Wing to enable RT simulation by 12.00 • Referring hospital to hold bed pending transfer back

25. Establish most appropriate intervention • See EQMS Radiotherapy • Radiotherapy quality system • Radiotherapy protocols • Palliative • MSCC_Palliative_RTAlone_Unplanned

26. Escalate for surgical opinion if indicated – Units to escalate to the Leeds StR as Guidelines • Escalation based upon • Co-morbidity/fitness • Presence or possible mechanical instability • Radiological • Clinical • Cancer survival estimate • Surgical risk factors

27. Seeking a surgical opinion – responsibility of Leeds • Confirm appropriate with CO consultant • Access spinal surgical consultant direct • Up to date mobile numbers are available • Above D2: neurosurgical • Below D2: spinal orthopaedics • DO NOT use neuro/orthoStR • Request image review via PACS • If operable they will take to LGI • Possible return to RT if patient declines risk or if not appropriate after face-to-face review

28. Surgical opinion: Issues • Missing data for prognostic tools • Calculate maximum possible score based upon data available • If missing data critical: defer Rx until available • No surgeon available and opportunity loss high • RT possibly inferior • Retained ambulatory function • Long anticipated OS (TPS >12) • Low-risk surgical candidate • Liase with Sheffield or Hull • Maintain on DEX with regular (twice daily) review with default to RT if deteriorates

29. Deliver definitive therapy – patient admitted to Leeds • Submit RT e-booking form via Mosaiq • Palliative Spine • Speak to booking office to establish time • Liaise with bed coordinator/PR suite • Patient must be simulated before 13.00 • Liaise with on-call radiographers if w/end

30. Initiate rehabilitation process • As part of informed consent, discuss and document in case-notes • Goals of treatment • Anticipated ambulatory function post treatment • Time-scales for recovery • Likely trajectory of underlying malignancy • Fitness for further anticancer therapy • Fitness for active rehabilitation • This will make onward support from AHPs much more straightforward

31. Do not forget • Tail-off DEXAMETHASONE • Tumour may ‘flare’ so • Delay until 3-5 days post initial RT # • Reduce by 4mg every 3-5 days • Step up if neurology worsens after initial recovery • Dictate a prompt transfer/discharge summary via PPM • Arrange appropriate f/up • No f/up is not appropriate • If not your team, then who is taking over?

32. Future developments • Faxable referral/transfer proformas • Framework for rapid handling of VBM • Spinal MDT • Surgical cases for adjuvant RT • Non-compressive VBM for surgery • Access to newer technologies • Minimally invasive techniques • Faster recovery for less fit patients • SBRT for spinal metastases • Feedback from Peer Review mandatory audit