HEAPHY 2 RADIOTHERAPY Glenys ROUND Charleen CASSON

1. Abstract Traditionally wait times for palliative radiotherapy can be a lengthy process. It can involve several visits to the Oncology department, delaying a patient’s treatment when time is precious. In keeping with clinics established overseas (Canada & Brisbane) we have implemented a rapid access palliative clinic (RAPC) at Waikato Hospital. This paper describes the implementation of the clinic and assessment of the outcomes of the RAPC seen between 2009-2011. It will also discuss the multidisciplinary nature of such a clinic, the future for our RAPC and the advances that can be made to improve our patient’s journey. HEAPHY 2 RADIOTHERAPY Glenys ROUND Charleen CASSON Fri 30th Aug 2013 Session 2 / Talk 1 10:30 – 10:50

13. Presented by Dr Glenys Round & Charlene Casson Waikato Regional Cancer Centre Rapid Access Palliative Clinic (RAPC)

14. Background Referrer sends referral Wait list for FSA Seen by Radiation Oncologist Waitlist for simulation Simulated Waitlist for radiation therapy Treatment

15. Background Palliative patients considered non-urgent (Cat 4 – National prioritisation criteria) Wait times to FSA therefore can be long, as radical patients take priority unless Cat A (Spinal cord compression, uncontrolled bleeding) Wait time to treatment vary widely- same day to several weeks Up to 3 visits to treatment

16. Background All this on a background of patients in a palliative phase of their disease process, where quality of life and time are important Frequently elderly, frail, weak from end-stage disease, age and co-morbidities Frequently an elderly exhausted spouse/partner Frequently from a rural area Patients have to travel up to 4-5hours

17. Background Common around the world to have waiting times for FSA and treatment exceeding acceptable lengths of time Pressure to increase patient throughput. Multiple studies have shown efficacy of single 8Gy fraction cf. longer fractionations for bone pain Widely accepted, although in spite of evidence, use of longer fractionations is common ( 20Gy in 5 fractions, 30Gy in 10 fractions)

18. Canada Saw a need to do better Set up “Rapid Access Palliative Radiotherapy Programme” Patients seen very quickly after referral Consultation, simulation, treatment all in one day for appropriate patients Better programmes, offer multidisciplinary assessment Some centres - patients offered access to a clinical trial

19. Aims Rapid assessment and treatment Multidisciplinary approach Rapid pain relief Improve quality of life Increase satisfaction of referrer Increase proportion of rural referrals

20. Aims Separate clinic at a separate time could save FSA for radical patients Separate simulation time could save allocated simulation space for radical patients

21. Rapid Access Palliative Clinic April 2009

22. Initial Criteria • Known Carcinoma • Not be a current patient • Bony pain • Diagnostic evidence • No more than 3 painful sites • Single fraction • Patients transferred back to referring service

23. Clinic Pathway Patients are booked into 3 time slots on a Tuesday Team Meeting @ 8.30am Process: - Consultation - Simulation - Planning - Treatment

24. Tracking Form • Patients characteristics • Diagnosis • Site of disease • Analgesic medication • Initial/ follow up Pain Score • Treatment Information • Further investigations ie bone scone, MRI • 3 week follow up telephone call

25. Statistics 2009 – 2012(261 Patients) Age Gender - Average 69 yrs - Male 65% - Range 30 – 94 yrs- Female 35% Main Diagnosis Referrers - Prostate 30% - MO 23% - Breast 17% - GP 21% - Lung 16% - Urology 20%

26. Treated Sites(patients = 226, treated sites = 307)

27. Prescriptions

28. Same Day Sim & Treat 63% CT’d & treated same day 46% single fractions 13% no treatment

29. Distance to RAPC

30. Pain Score

31. Medication Increase - 15% Decrease - 28% Same - 44% Unknown - 13%

32. Benefits of RAPC • Reduce visits to the department • Immediate multidisciplinary approach • Pain management reviewed • Continuity of care • Positive comments from patients/families

33. Conclusion • RAPC was implemented successfully • Data collected, further improvements have been made to the clinic to benefit the patient.

34. RAPC is not . . . Radiation Oncologist seeing patient and simulating quickly, and then patient waits for treatment.

35. Imperatives Deliberate Multidisciplinary Regular Investigates Admits Manages medical problems esp. analgesia, nausea and bowels. Supports (relatives),

36. Imperatives Refers – Med Onc, Palliative Care, physio, dietician, Maori support, chaplain. Does not take ownership Refers back to referrer, but follows up patients as required Communicates with referrer Prospectively gathers data Audit Reviews itself, adapts as required.

37. Imperatives Lesser options CANNOT be called a “Rapid Access Palliative Clinic” or” Programme”.

38. Future Onboard imaging to plan and deliver palliative radiotherapy in a single, cohesive patient appointment – Perth. ( Hopefully soon for us. Note extra machine time). Stereotactic body radiotherapy – limited application in most of these patients. Similar clinics for brain metastases – Canada. ( Truly multidisciplinary – Neurosurgery, Rad Onc, Med Onc, RT, Pall Care, Nurse, Allied Health)

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