YCN MSCC Pathway
Implementation of NICE CG75
Level 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
YCN MSCC Competency for Local MSCC
Coordinators
Local Acute Oncology Team MSCC Coordinators
Competency
a)Knowledge and understanding of which patient groups are at a higher risk of
developing MSCC
b)Knowledge and Understanding of the signs and symptoms of MSCC
c)Understanding of the appropriate aspects of the MSCC pathway
a)
b)
c)
d)
Escalation to the local coordinator
Escalation to investigation
Referral process to Leeds
Specialist MSCC coordinators – assessment and referral for treatment
d) 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
YCN MSCC Pathway
Components of the pathway
Overall goals
YCN implementation of the Guideline
SJIO implementation of the Guideline
Future developments
MSCC Pathway Components
1.
2.
3.
4.
Education and early warning
Triage
Diagnosis & generic care
Specialist intervention
 Spinal surgery
 Radiotherapy
5. Rehabilitation
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
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
SJIO implementation of the Guideline
Must work both as Cancer Unit and Centre
SJIO implementation of the Guideline
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 ONCALL TEAM
– Proven MSCC only
Imaged
– Reported
– Transferred
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
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:
Renal:
Lung:
Breast:
Myeloma:
HRPC
Metastatic renal cell cancer
Any metastatic lung cancer
Any metastatic breast cancer
Any myeloma
MSCC symptoms & signs
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?
Triage: Need for MRI
Probability MRI shows neural compression
(after Lu, J Sup Care 2005;3:305-312)
Neurological deficit
Present
Absent
High-risk & suspicious pain
81%
69%
Suspicious pain only
44%
33%
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)
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
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 oncall team:
Arrange a whole spine MRI and escalate the result
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
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
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
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
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
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
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
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
Establish most appropriate intervention
See EQMS
Radiotherapy
– Radiotherapy quality system
Radiotherapy protocols
– Palliative
MSCC_Palliative_RTAlone_Unplanned
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
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/ortho StR
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
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
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
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
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?
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