Standards of
Service Provision for
Upper Gastrointestinal
Cancer Patients
in New Zealand Provisional
National HBP/Upper GI Tumour
Standards Working Group
2013
Citation: National HBP/Upper GI Tumour Standards Working Group. 2013. Standards of Service
Provision for Upper Gastrointestinal Cancer Patients in New Zealand - Provisional.
Wellington: Ministry of Health.
Published in December 2013 by the
Ministry of Health
PO Box 5013, Wellington 6145, New Zealand
ISBN 978-0-478-41583-4 (online)
HP 5783
This document is available through the Ministry of Health website: www.health.govt.nz
or from the regional cancer network websites:
www.northerncancernetwork.org.nz
www.midland cancernetwork.org.nz
www.centralcancernetwork.org.nz
www.southerncancernetwork.org.nz
Contents
Introduction ............................................................................................................... 1
Background ..................................................................................................... 1
Objective ......................................................................................................... 2
How the HBP/upper gastrointestinal cancer service standards were
developed ........................................................................................................ 2
Equity and Whānau Ora .................................................................................. 3
Summary of the clinical standards for the management of HBP/upper
gastrointestinal cancer services ....................................................................... 4
Summary of standards..................................................................................... 5
1
Prevention and Early Identification................................................................... 9
Rationale ....................................................................................................9-10
Good practice points ...................................................................................9-10
2
Timely Access to Services ............................................................................. 13
Rationale ....................................................................................................... 13
Good practice points ...................................................................................... 14
3
Referral and Communication ......................................................................... 15
Rationale ....................................................................................................... 15
Good practice points ...................................................................................... 15
4
Investigation, Diagnosis and Staging ............................................................. 18
Rationale .................................................................................................. 18-23
Good practice points ................................................................................. 18-23
5
Multidisciplinary Care ..................................................................................... 25
Rationale .................................................................................................. 25-28
Good practice points ................................................................................. 25-28
6
Supportive Care............................................................................................. 29
Rationale ....................................................................................................... 29
Good practice points ...................................................................................... 29
7
Care Coordination ......................................................................................... 31
Rationale ....................................................................................................... 31
Good practice points ...................................................................................... 31
8
Treatment ...................................................................................................... 33
Rationale .................................................................................................. 33-40
Standards of Service Provision for Upper Gastrointestinal Cancer Patients in New Zealand
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Good practice points ................................................................................ 33-40
9
Follow-up and Surveillance ........................................................................... 42
Rationale .................................................................................................. 42-45
Good practice points ................................................................................ 42-45
10
Clinical Performance Monitoring and Research ............................................. 46
Rationale .................................................................................................. 46-48
Good practice points ................................................................................ 46-48
Appendix 1: National HBP/Upper GI Tumour Standards Working Group
Membership .................................................................................................. 49
Appendix 2: Glossary ............................................................................................. 51
Appendix 3: References ......................................................................................... 59
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Standards of Service Provision for Upper Gastrointestinal Cancer Patients in New Zealand
- Provisional
Introduction
Background
Cancers of the upper gastrointestinal tract mostly arise in the oesophagus, stomach,
liver, biliary system, pancreas and duodenum. (Cancers covered in these standards
include hepatobiliary, pancreaticoduodenal and gastro-oesophageal cancers; the
group as a whole is referred to as ‘HBP/upper GI’ throughout this document.) These
cancers are particularly formidable to treat because of the many different types of
cancer involved, complex anatomy, the magnitude of surgical treatment required,
the requirement for multi-modal management and a generally poor prognosis
relative to most other cancers. The median survival of patients with pancreatic
cancer in New Zealand is only 92 days (Phillips et al 2002); as such, pancreatic
cancer is the most common cause of HBP/upper GI cancer death. In comparison
with the five-year survival rate for patients with all cancers in New Zealand,
60 percent, the five-year survival rate for patients with stomach cancer is 20 percent
(Ministry of Health 2006). Māori have 25 percent worse survival than non-Māori after
diagnosis (Soeberg et al 2012).
Another challenge is that HBP/upper GI cancers are not common. In 2009, there
were 253 new cases of primary liver and biliary cancers, 472 new cases of
pancreatic cancer, 370 new cases of stomach cancer and 257 new cases of
oesophageal cancer (Ministry of Health 2012a). Individual district health boards
(DHBs) therefore do not see high volumes of them. When this is coupled with higher
treatment-related morbidity and mortality, especially for oesophagectomy,
hepatectomy and pancreatoduodenectomy, it is no surprise that there is a
relationship between hospital and surgeon volume and patient outcome. The debate
about the best model for the delivery of cancer care for rare and complex tumours in
New Zealand (Beenen et al 2013) emphasises the need to make best use of our
available expertise and facilities and strive to provide the best quality care, and
equitable access to it.
There is also variation in intervention rates and outcomes between DHBs and,
overall, these may be less than they should be. Data suggest that the resection rate
for gastro-oesophageal cancers in New Zealand is 15 percent (34–53 patients per
year) – this is lower than it should be when compared with the international
published literature (Martin 2002).
There are incidence inequalities between Māori and non-Māori for these cancers.
For example, between 1988 and 1997, Māori had higher standardised incidence
rates of pancreatic cancer (7.3 per 100,000) compared with other ethnic groups, and
Māori females had the highest reported female rate in the world (7.2 per 100,000)
(Phillips et al 2002). Most of the survival disparity between Māori and non-Māori
patients is accounted for by higher rates of co-morbidity, more limited health service
access, and lower rates of cancer treatment (Hill et al 2012).
Standards of Service Provision for Upper Gastrointestinal Cancer Patients in New Zealand
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Another challenge is the high rates of chronic hepatitis B and C infections in New
Zealand, which account for 75 percent of all primary liver cancers (Weir et al 2002).
Virtually all hepatocellular carcinoma in Māori is caused by chronic hepatitis B
infection; alcoholic liver disease is less prevalent in these patients than in non-Māori
(Chamberlain et al 2013). Half of patients living with hepatitis B infection are not
aware of it. Similarly high rates of gastric cancer are also seen in Māori. Most are
distal cancers, rather than proximal tumours, and are associated with high rates of
infection with helicobacter pylori.1
Improving the outcomes of patients with HBP/upper GI cancer requires useful data
on the process, treatment and outcomes of the cancer journey. By defining and
monitoring standards it will, in time, be possible to make informed decisions about
best treatment for these patients in New Zealand, and to find ways to improve
cancer care.
Objective
Tumour standards for all cancers are being developed as a part of the Ministry of
Health’s ‘Faster Cancer Treatment’ (FCT) programme’s approach to ensuring timely
clinical care for patients with cancer. The standards will promote nationally
coordinated and consistent standards of service provision across New Zealand.
They aim to ensure efficient and sustainable best-practice management of tumours,
with a focus on equity.
The standards will be the same for all ethnic groups. However, we expect that in
implementing the standards DHBs may need to tailor their efforts to meet the
specific needs of populations with comparatively poorer health outcomes, such as
Māori and Pacific people.
How the HBP/upper gastrointestinal cancer service standards
were developed
These standards were developed by three working groups – gastro-oesophageal,
hepatobiliary and pancreaticoduodenal – representing key specialities and interests
across the HBP/upper GI cancer pathway of care. Each group was chaired by a lead
clinician (see Appendix 1), and had access to expert advisors in key content areas,
including the Northern Cancer Network’s Māori Leadership Group.
These standards recognise the need for evidence-based practice. Numerous
evidence-based guidelines and standards already exist, so the standards in this
document have largely been developed by referring to established national and
international guidelines in the HBP/upper GI tumour stream (see Appendix 4).
Where no clear evidence was available, expert opinion was obtained through the
National HBP/Upper GI Tumour Standards Working Group and its advisors.
1
2
Personal communication D Sarfati and T Blakely 2013.
Standards of Service Provision for Upper Gastrointestinal Cancer Patients in New Zealand
- Provisional
Tumour-specific national standards were first developed for lung cancer in the
Standards of Service Provision for Lung Cancer Patients in New Zealand (National
Lung Cancer Working Group 2011); these standards have already made
improvements to service delivery and clinical practice.
Subsequently provisional standards have been developed for an additional ten
tumour types: bowel, breast, gynaecological, lymphoma, melanoma, myeloma, head
and neck, sarcoma, thyroid and upper gastrointestinal.
The Ministry of Health required all tumour stream work groups to:
Maintain a focus on achieving equity and whānau ora when developing
service standards, patient pathways and service frameworks by ensuring an
alignment with the Reducing Inequalities in Health Framework and its
principles (Ministry of Health 2002).
Equity and Whānau Ora
Health inequities or health disparities are avoidable, unnecessary and unjust
differences in the health of groups of people. In New Zealand, ethnic identity is an
important dimension of health disparities. Cancer is a significant health concern for
Māori, and has a major and disproportionate impact on Māori communities (Ministry
of Health 2008).
Inequities exist between Māori and non-Māori in exposure to risk and protective
factors for cancer, in incidence and outcomes, and in access to cancer services.
Barriers to health care are recognised as multidimensional, and include health
system and health care factors (eg, institutional values, workforce composition,
service configuration and location), as well as patient factors (eg, socioeconomic
position, transportation and patient values). Addressing these factors requires a
population health approach that takes account of all the influences on health and
how they can be tackled to improve health outcomes.
A Whānau Ora approach to health care recognises the interdependence of people;
health and wellbeing are influenced and affected by the ‘collective’ as well as the
individual. It is important to work with people in their social contexts, and not just
with their physical symptoms.
The outcome of the Whānau Ora approach in health will be improved health
outcomes for family/whānau through quality services that are integrated (across
social sectors and within health), responsive and patient/family/whānau-centred.
Standards of Service Provision for Upper Gastrointestinal Cancer Patients in New Zealand
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In preparing these standards, the Northern Cancer Network’s Māori Leadership
Group provided expert advice to the working groups based on eight principles to
identify and address issues of equity in access, process and outcome. These
principles were specifically a commitment to mana whenua and Māori communities,
Whānau Ora, health equity, self-determination, indigeneity, ngā kaupapa tuku iho,
whole-of-system responsibility and evidence-based approaches. These principles
are woven throughout the standards, and support the inclusion of supporting
rationale, good practice points and monitoring.
These standards will address equity for Māori patients with HBP/upper GI cancers in
the following ways.

The standards suggest offering screening to Māori 10 years earlier than for
non-Māori.

The standards focus on improving access to diagnosis and treatment for all
patients, including Māori and Pacific.

Barriers to attendance (eg, mobility, cost, co-morbidities and compliance issues)
will be identified at patients’ first specialist assessment (FSA).

Ethnicity data will be collected on all access measures and the FCT indicators,
and will be used to identify and address disparities.

Good practice points include health literacy and cultural competency training for
all health professionals involved in patient care.

Information developed or provided to patients and their family/whānau will meet
Ministry of Health guidelines (Ministry of Health 2012c).
Summary of the clinical standards for the management of
HBP/upper gastrointestinal cancer services
Format of the standards
Each cluster of standards has a title that summarises the step of the patient journey
or the area on which the standards are focused. This is followed by the standard
itself, which explains the level of performance to be achieved. The rationale section
explains why the standard is considered to be important.
Attached to most of the clusters of standards are good practice points. Good
practice points are either supported by the international literature, the opinion of the
National Upper GI Tumour Standards Working Group or the consensus of feedback
from consultation with New Zealand clinicians involved in providing care to patients
with HBP/upper GI cancer. Also attached to each cluster are the requirements for
monitoring the individual standards.
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Standards of Service Provision for Upper Gastrointestinal Cancer Patients in New Zealand
- Provisional
Standards of service provision pathway
The HBP/upper GI cancer standards are reflected in the following pathway.
Summary of standards
The standards of service provision for the management of upper gastrointestinal
cancer have been divided into 10 clusters:

prevention and early identification

timely access to services

referral and communication

investigation, diagnosis and staging

multidisciplinary care

supportive care

care coordination

treatment

follow-up and surveillance

clinical performance monitoring and research.
The standards are as follows.
Standards of Service Provision for Upper Gastrointestinal Cancer Patients in New Zealand
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Prevention and early identification
Standard 1.1: People are offered evidence-based information on risk factors,
prevention and early detection of HBP/upper GI cancer.
Standard 1.2: People at significantly increased risk of HBP/upper GI cancer are
offered screening for HBP/upper GI cancer.
Timely access to services
Standard 2.1: Patients referred urgently with a high suspicion of HBP/upper GI
cancer receive their first cancer treatment within 62 days.
Standard 2.2: Patients referred urgently with a high suspicion of HBP/upper GI
cancer receive their FSA within 14 days.
Standard 2.3: Patients with a confirmed diagnosis of an HBP/upper GI cancer
receive their first treatment within 31 days of the decision to treat.
Referral and communication
Standard 3.1: Patients with suspected HBP/Upper GI cancer are referred to
secondary and tertiary care following an agreed referral pathway.
Standard 3.2: Patients and their general practitioners (GPs) are provided with verbal
and written information about HBP/upper GI cancer, diagnostic procedures,
treatment options (including effectiveness and risks), final treatment plan and
support services.
Standard 3.3: Communications between health care providers include the patient’s
name, date of birth, national health index (NHI) number and contact details, and are
ideally electronic.
Investigation, diagnosis and staging
Standard 4.1: Patients with HBP/upper GI cancer have timely access to experts
(including radiologists, endoscopists, pathologists and surgeons) who are
appropriately trained and credentialed.
Standard 4.2: Patients with HBP/upper GI cancer are diagnosed, investigated and
staged in facilities, and with equipment, that meet nationally agreed standards.
Standard 4.3: Patients with HBP/upper GI cancer are diagnosed, investigated and
staged using nationally standardised protocols.
Standard 4.4: The results of the diagnosis, investigations and staging of patients
with HBP/upper GI cancer are reported by experts in a standardised and agreed
format, encompassing all relevant aspects, and are interpreted in the light of all
relevant clinical information.
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Standards of Service Provision for Upper Gastrointestinal Cancer Patients in New Zealand
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Multidisciplinary care
Standard 5.1: All patients with the following are presented at a multidisciplinary
meeting (MDM):

a confirmed diagnosis of HBP/upper GI cancer

a high suspicion of HBP/upper GI cancer.
Standard 5.2: The MDM comprises members of the multidisciplinary team (MDT),
including surgeons, radiologists, gastroenterologists, medical and radiation
oncologists, cyto/histopathologists and cancer care coordinators.
Standard 5.3: Data are available in standardised electronic format for MDM
discussion, and include all relevant information about patients and investigations.
Standard 5.4: All patients with confirmed HBP/upper GI cancer have their treatment
plan discussed at an MDM; recommendations are clearly documented in the
patient’s medical records and communicated to the patient and their GP.
Supportive care
Standard 6.1: Patients with HBP/upper GI cancer and their family/whānau have
equitable and coordinated access to appropriate medical, allied health and
supportive care services, in accordance with Guidance for Improving Supportive
Care for Adults with Cancer in New Zealand (Ministry of Health 2010).
Care coordination
Standard 7.1: All patients with HBP/upper GI cancer have access to an HBP/upper
GI cancer clinical nurse specialist or other health professional who is a member of
the MDM to help coordinate all aspects of their care.
Standard 7.2: Each regional cancer centre or unit managing patients with
HBP/upper GI cancer has designated lead clinicians with specialist knowledge of
HBP/upper GI cancers to provide necessary leadership.
Treatment
Standard 8.1: The treatment of patients with HBP/upper GI cancer is performed by
appropriately trained and credentialed experts (surgeons, medical and radiation
oncologists, gastroenterologists and interventional radiologists), with a specialty
commitment to this field. Access to specialist expertise is available at all times.
Standard 8.2: Patients with HBP/upper GI cancer are treated in appropriately
equipped facilities offering the required range of services, including interventional
radiology and a level one or two intensive care unit.
Standard 8.3: Patients with HBP/upper GI cancer are treated according to evidencebased and agreed protocols.
Standards of Service Provision for Upper Gastrointestinal Cancer Patients in New Zealand
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Standard 8.4: Reports of treatment by all specialties of patients with HBP/upper GI
cancer (including operation notes) are in a standardised electronic format, and
include all of the relevant prognostic criteria.
Standard 8.5: Patients with HBP/upper GI cancer have access to a dietitian for
assessment and nutritional support before, during and after their treatment.
Standard 8.6: Patients with HBP/upper GI cancer are offered early access to
palliative care services when there are complex symptom control issues, when a
curative treatment cannot be offered or if curative treatment has been declined.
Follow-up and surveillance
Standard 9.1: When appropriate, patients treated for HBP/upper GI cancer are
offered ongoing follow-up at their original referring centre.
Standard 9.2: Patient follow-up after HBP/upper GI cancer for the detection of local
recurrence and metastases takes place in accordance with international consensus
guidelines.
Standard 9.3: Follow-up plans include clinical review by appropriate members of the
MDT, working in conjunction with the patient, their family/whānau and their GP.
Clinical performance monitoring and support
Standard 10.1: Data relating to HBP/upper GI cancer beyond the fields required by
the Cancer Registry, including treatment data, are reported to existing and planned
national repositories using nationally agreed data set fields.
Standard 10.2: Data on treatment, clinical outcomes and patient satisfaction are
regularly monitored and reported as part of a national audit.
Standard 10.3: Patients with HBP/upper GI cancer are offered the opportunity to
participate in research projects and clinical trials where these are available.
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Standards of Service Provision for Upper Gastrointestinal Cancer Patients in New Zealand
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1
Prevention and Early Identification
Standard 1.1
People are offered evidence-based information on risk factors,
prevention and early detection of HBP/upper GI cancer.
Rationale
There is strong evidence to demonstrate improved peri-operative and long-term
outcomes in patients with HBP/upper GI cancer who stop smoking and reduce their
alcohol intake.
Good practice points
1.1
People are informed that exposure to smoking and alcohol may predispose
them to HBP/upper GI cancer.
1.2
Advice on smoking cessation and reducing consumption of alcohol is provided
to all those who would benefit from it (Ministry of Health 2011b).
1.3
Primary care clinicians screen for known risk factors for HBP/upper GI cancer,
and intervene when they identify people at risk.
Monitoring requirements
MR1A
Monitor smoking cessation initiatives.
MR1B
Audit results of national public health campaigns for identified risk factors (such
as smoking and alcohol consumption).
Standards of Service Provision for Upper Gastrointestinal Cancer Patients in New Zealand
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Standard 1.2
People at significantly increased risk of HBP/upper GI cancer
are offered screening for HBP/upper GI cancer.
Rationale
The early detection of cancer in high-risk individuals is a strategy that will improve
patients’ chances of earlier treatment, and their prognosis. Screening should be
carried out where it can be undertaken in a cost-effective manner, and should be
supported by evidence where possible. Screening should only be undertaken if
treatment options are available.
Good practice points
Gastric cancer
1.4
People at increased risk of gastric cancer are referred to the New Zealand
Familial Gastrointestinal Cancer Service according to accepted criteria (Kluijt
et al 2012).
1.5
People with a known or suspected E-cadherin mutation are referred to Genetic
Health Service New Zealand, the New Zealand Familial Gastrointestinal
Cancer Service and a tertiary service managing these patients for
consideration of endoscopic screening and prophylactic total gastrectomy.
1.6
Screening gastroscopy is considered for people with Lynch syndrome, familial
adenomatous polyposis (FAP), MYH-associated polyposis, Li-Fraumeni
syndrome, Peutz-Jeghers syndrome and BRCA2-associated cancer.
1.7
People with known high-risk factors, such as chronic Helicobacter pylori
infection (particularly Māori), high alcohol use, heavy smoking, chronic reflux
and previous gastric ulcer surgery, are offered early gastroscopy with any new
upper GI symptoms.
1.8
Clinicians consider offering screening to Māori 10 years earlier than non-Māori
(NZGG 2009).
Oesophageal cancer
1.9
Gastroscopy screening for oesophageal cancer is not offered to asymptomatic
patients.
1.10 Patients with Barrett’s oesophagus are considered for regular endoscopic
screening on a case-by-case basis, in conjunction with international guidelines
(AGA 2011; Bennett et al 2012).
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Standards of Service Provision for Upper Gastrointestinal Cancer Patients in New Zealand
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1.11 Patients with known high-risk factors, including high alcohol use, heavy
smoking, chronic reflux, achalasia, tylosis and metabolic syndrome, are
triaged for rapid access endoscopy if they present with symptoms consistent
with upper GI cancer.
Hepatocellular carcinoma
1.12 Screening is considered for people at high risk of hepatocellular carcinoma
(HCC) in high risk individuals, including those with established liver cirrhosis,
regardless of aetiology.
1.13 Ultrasound screening for HCC is performed every six months by appropriately
trained personnel in accordance with a standardised protocol covering recall
procedures for patients with screening-detected abnormalities (EASL-EORTC
2012; Bruix and Sherman 2011).
1.14 Hepatitis B is a major risk factor for the development of HCC, including in noncirrhotic HBsAg positive patients. The risk of hepatitis B is managed according
to the Ministry of Health immunisation schedule and guidelines (Ministry of
Health 2013b).
1.15 Patients with the chronic hepatitis B virus receive six-monthly blood tests (from
a primary care physician or the Hepatitis Foundation of New Zealand) to
monitor liver enzymes and alfa-fetoprotein.
Secondary hepatic cancer
1.16 Surveillance for liver metastases in patients with a personal history of
colorectal cancer is carried out in accordance with the follow-up
recommendations in Management of Early Colorectal Cancer (NZGG 2011).
Pancreatic cancer
1.17 People with two or more first-degree relatives who have died of pancreatic
cancer and those who have a familial cancer syndrome known to be
associated with an increased risk of pancreatic cancer are referred to Genetic
Health Service New Zealand and the New Zealand Familial Gastrointestinal
Cancer Service (Canto et al 2013).
1.18 Screening of those at high risk commences 10 years earlier than the age at
diagnosis of the youngest first-degree relative with pancreatic cancer, and is
brought forward a further 10 years if the person is a long-standing smoker.
1.19 Screening of those at high risk is done by magnetic resonance imaging (MRI)
scanning, with endoscopic ultrasound with or without fine needle aspiration
(FNA) to further investigate any abnormalities detected through MRI (one- to
three-yearly).
Standards of Service Provision for Upper Gastrointestinal Cancer Patients in New Zealand
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1.20 A high index of suspicion of pancreatic cancer is maintained for patients with
idiopathic acute pancreatitis (over the age of 40), those with new onset
diabetes (over the age of 40) and those with chronic pancreatitis (especially
when associated with a mass).
Pancreatic cystic lesions
1.21 Patients with non-inflammatory pancreatic cystic lesions are investigated in
accordance with international guidelines to identify the likelihood of cancer or
the risk of developing it (Tanaka et al 2006).
Duodenal cancer
1.22 Patients are screened for syndromes that increase the risk of duodenal
cancer, including duodenal polyposis and/or some familial cancer syndromes,
including FAP, hereditary nonpolyposis colorectal cancer and Peutz-Jeghers.
1.23 Upper gastrointestinal endoscopic screening intervals for duodenal cancer are
in accordance with the Spigelman classification (Vasen et al 2008).
Monitoring requirements
MR1C
12
Monitor extent to which identified population at increased risk are enrolled in
surveillance programmes.
Standards of Service Provision for Upper Gastrointestinal Cancer Patients in New Zealand
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Timely Access to Services
Standard 2.1
Patients referred urgently with a high suspicion of HBP/upper GI
cancer receive their first cancer treatment within 62 days.
Standard 2.2
Patients referred urgently with a high suspicion of HBP/upper GI
cancer receive their FSA within 14 days.
Standard 2.3
Patients with a confirmed diagnosis of HBP/upper GI cancer
receive their first treatment within 31 days of the decision to
treat.
Rationale
Timely and equitable access to quality cancer management is important to support
good health outcomes for New Zealanders and to reduce inequalities.
Key components of successful cancer management include early recognition and
reporting of symptoms, expertise in identifying patients requiring prompt referral and
rapid access to investigations and treatment.
A suspicion of cancer or cancer diagnosis is very stressful for patients and
family/whānau. It is important that patients, family/whānau and GPs know how
quickly patients can receive treatment. Long waiting times may affect local control
and survival for some cancer patients, and can result in delayed symptom
management for palliative patients.
The standards in this cluster ensure that:

patients receive quality clinical care

patients are managed through the pathway, and experience well-coordinated
service delivery

delays are avoided as far as possible.
Shorter waits for cancer treatments is a government health target. The FCT
indicators (the standards in this cluster) adopt a timed patient pathway approach
across surgical and non-surgical cancer treatment, and apply to inpatients,
outpatients and day patients.
Standards of Service Provision for Upper Gastrointestinal Cancer Patients in New Zealand
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Good practice points
2.1
When there is a suspicion of HBP/upper GI cancer, the GP or referring
specialist refers to, and the referral is received by, the appropriate
secondary/tertiary care services within one working day (expert opinion).
2.2
Referrals and reports are distributed electronically (expert opinion).
2.3
Referrers identify barriers to attendance at FSAs (such as mobility, cost,
co-morbidities and compliance issues), and address them where possible.
2.4
Strategies are in place to avoid did-not-attends (DNAs), including coordinated
clinic times (so that family/whānau can attend together), reminder systems,
culturally appropriate information and support services.
2.5
Confirmation of a diagnosis of cancer is tissue diagnosis whenever
appropriate.
2.6
If any uncertainty exists regarding a histological diagnosis of cancer,
especially in regards to associated precursor lesions and/or marked
inflammation, the tissue is reported on by an independent histopathologist.
2.7
Specialists identify barriers to timely assessment and investigation (such as
availability of expertise, cost, mobility and language), and address them where
possible.
2.8
Specialists primarily responsible for the coordination of assessment,
investigation, staging and treatment explicitly and routinely discuss processes
with patients and family/whānau.
2.9
Subsequent cancer therapy, such as adjuvant chemotherapy or surgery
following neo-adjuvant chemotherapy, is coordinated to avoid clinically
unnecessary delay.
Monitoring requirements
14
MR2A
Track FCT indicators.
MR2B
Collect and analyse ethnicity data on all access targets and indicators.
Standards of Service Provision for Upper Gastrointestinal Cancer Patients in New Zealand
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Referral and Communication
Standard 3.1
Patients with suspected HBP/upper GI cancer are referred to
secondary and tertiary care following an agreed referral
pathway.
Standard 3.2
Patients and their GPs are provided with verbal and written
information about HBP/upper GI cancer, diagnostic procedures,
treatment options (including effectiveness and risks), final
treatment plan and support services.
Standard 3.3
Communications between health care providers include the
patient’s name, date of birth, NHI number and contact details,
and are ideally electronic.
Rationale
Good communication skills are fundamental to the development of an effective
relationship between a patient and health practitioners.
Good communication is likely to reduce anxiety, and increase patients’ trust and
confidence in cancer care providers. This will increase the chance that they receive
the treatment that is most appropriate for them. Good information may improve
compliance with treatment, reduce complaints and enhance health outcomes.
Communications with other health care professionals
There should be rapid and effective two-way information flow between service
providers transferring and sharing information on referral, diagnosis, treatment,
follow-up and supportive/palliative care.
Good practice points
Referrals
3.1
All communications between health care providers are electronic where
possible (expert opinion).
3.2
The standardised referral letter contains information as to where it should be
sent.
3.3
Clinical information provided in the referral letter is agreed by experts in the
primary, secondary and tertiary sectors to ensure appropriate prioritisation and
decision-making.
Standards of Service Provision for Upper Gastrointestinal Cancer Patients in New Zealand
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3.4
Clinical information is presented in a standardised format.
3.5
A mechanism is in place to ensure that the referrer receives confirmation of
the receipt of the referral within one working day of it being sent.
3.6
Where high suspicion of cancer is associated with an inherited pattern or
associated with a recognised cancer syndrome, Genetic Health Service New
Zealand is involved.
Information provided to patients
3.7
Patients specify the way they would like communication to take place early in
the care pathway; all patients are entitled to a professional interpreter.
Communication may occur through a family member. In some cases, a patient
will not want to be informed of the diagnosis or details of their treatment or
prognosis (Windsor et al 2008).
3.8
Family/whānau meetings are arranged whenever a patient requests them, and
patients determine who attends such meetings.
3.9
The information, treatment and care that patients receive is always culturally
appropriate (expert opinion).
3.10 Each new patient with cancer receives information in a language and format
appropriate to them; such information meets Ministry of Health guidelines
(Ministry of Health 2012c) and covers:

general background information about the specific cancer

details of treatment options and specific local arrangements, including
information about the MDT, support services and whom the patient should
contact if necessary

details of available support groups and other appropriate organisations

details as to when any procedure, test and/or treatment will be undertaken.
3.11 Patients are allowed adequate time to consider treatment options (NHS Wales
2005).
3.12 A professionally trained interpreter is available for all interactions with health
care professionals when English is not a patient’s first language.
3.13 All clinicians acknowledge the rights of patients to refuse investigation or
treatment. Any discussions on refusal are recorded in a patient’s medical
record. Guidance follows the Health and Disability Commissioner Act 1994.
3.14 In the consent process, patients are allowed adequate support, time and
information to make informed decisions. Consent discussions are clearly
documented.
16
Standards of Service Provision for Upper Gastrointestinal Cancer Patients in New Zealand
- Provisional
3.15 Processes are in place to incorporate information and feedback gained
through patient satisfaction surveys.
3.16 All clinicians responsible for communicating with patients and their
family/whānau complete health literacy training.
Communications between health care providers
3.17 Communications between specialists and referrers occur at least after first
assessments, after MDMs and after completion of treatment.
3.18 Communications contain a clear indication of what further role referrers will
play in ongoing care.
3.19 Referrers are informed if specialists downgrade an urgent suspected cancer
referral to non-urgent (NHS Wales 2005).
3.20 When the referrer is not the GP, all correspondence is copied to the GP.
3.21 Hospital administrative systems have a did-not-attend (DNA) reduction and
follow-up policy that entails equity-focused quality assurance.
Monitoring requirements
MR3A
Provide evidence of clear and accessible referral pathways.
MR3B
Audit actual patient pathways through records of registration of referral, FSAs,
dates of diagnosis and first cancer treatments.
MR3C
Audit correspondence between secondary/tertiary care and GPs.
MR3D
Provide evidence of culturally appropriate patient and family/whānau satisfaction
surveys, and audit complaints processes.
MR3E
Audit documentation between health care providers.
Standards of Service Provision for Upper Gastrointestinal Cancer Patients in New Zealand
- Provisional
17
4
Investigation, Diagnosis and Staging
Standard 4.1
Patients with HBP/upper GI cancer have timely access to
experts (including radiologists, endoscopists, pathologists and
surgeons) who are appropriately trained and credentialed.
Rationale
It is important that patients with HBP/upper GI cancers have ready access to
necessary expertise to allow for efficient, accurate and timely diagnosis,
investigation and staging. Incorrect or delayed diagnosis and staging can impair
patient outcomes. These cancers are relatively rare, and individual health
professionals may have limited experience in diagnosis and staging of them, which
makes prompt multidisciplinary review important, in order to ensure optimal
treatment decisions are made.
Good practice points
4.1
All specialists responsible for the diagnosis, investigation and staging of
patients with HBP/upper GI cancers are appropriately qualified, have specialist
expertise and are credentialed by the appropriate regulatory body.
4.2
If this expertise is not available, there is an established line of referral to a
centre where appropriate expertise is available.
Monitoring requirements
MR4A
18
Ensure that departments maintain a record of appropriately trained and
credentialed staff.
Standards of Service Provision for Upper Gastrointestinal Cancer Patients in New Zealand
- Provisional
Standard 4.2
Patients with HBP/upper GI cancer are diagnosed, investigated
and staged in facilities, and with equipment, that meet nationally
agreed standards.
Rationale
Appropriately resourced facilities are required to accurately diagnose, investigate
and stage patients with HBP/upper GI cancers in an acceptable timeframe.
Good practice points
4.3
All services involved in the diagnosis, investigation and staging of patients with
HBP/upper GI cancer work to high standards of service delivery that
encompass management systems, waiting list management, procedural work,
examination reporting, provision of clinical advice and quality assurance.
Radiology
4.4
Appropriate imaging modalities, such as computed tomography (CT), MRI and
positron emission tomography and computed tomography (PET-CT) are
provided in accordance with the guidance of local credentialing bodies.
Gastroenterology
4.5
Diagnosis of early malignant or highly dysplastic lesions, in particular, is
dependent on high-quality endoscopic images, and may require advanced
diagnostic endoscopic technologies (including chromoendoscopy, endoscopic
ultrasonongraphy and endoscopic mucosal resection); such technologies are
available to patients who need them in their regional cancer centre.
4.6
Endoscopic ultrasound with or without FNA is used in preference to CT in the
locoregional staging of oesophageal cancer (this is of particular help in
identifying more advanced (T4) disease compared to early (T1) disease).
Laboratory processes
4.7
Biochemical and immunology testing facilities ensure the availability of agreed
tumour markers, so that timely reporting is compliant with nationally agreed
investigation pathways.
Standards of Service Provision for Upper Gastrointestinal Cancer Patients in New Zealand
- Provisional
19
4.8
Fluorescence in situ hybridisation (FISH) and other advanced methodologies
are available in regional cancer centres to facilitate further categorisation of
tumours for targeted therapies.
4.9
Lines of referral to a reference laboratory in New Zealand are established, to
ensure timely processing of less frequently performed assays.
Histopathology
4.10 Histology specimens are processed in an accredited laboratory with adequate
fixation and sampling, including specimen photography for complex
specimens, to provide high-quality histology slides, including
immunohistochemically stained slides.
4.11 Frozen section facilities are available in all centres undertaking surgery for
HBP/upper GI cancer.
Monitoring requirements
MR4B
20
Ensure that departments maintain facilities and equipment against agreed
standards.
Standards of Service Provision for Upper Gastrointestinal Cancer Patients in New Zealand
- Provisional
Standard 4.3
Patients with HBP/upper GI cancer are diagnosed, investigated
and staged using nationally standardised protocols.
Rationale
Variation in practice contributes to worse patient outcomes. Standardisation of
protocols for the diagnosis, investigation and staging of HBP/upper GI cancers
should improve patient outcomes, ensure equivalent access to appropriate
investigation, avoid over-investigation and reduce costs.
Good practice points
4.12 Services across the country involved in the diagnosis, investigation and
staging of patients with HBP/upper GI cancer unify their protocols, to avoid
additional unnecessary studies, make clinically meaningful comparison, permit
review of services and outcomes, and facilitate accurate MDM review (NHS
Wales 2005).
Radiology
4.13 Diagnostic percutaneous liver biopsy may adversely affect prognosis in
patients who are potentially eligible for curative surgical treatment; this is only
offered following MDM review (expert opinion).
4.14 Contrast-enhanced multiphasic CT and/or MRI is undertaken for the primary
diagnostic evaluation of all patients with suspected HBP cancer (NCCN
2011a; 2011b).
4.15 Contrast-enhanced CT of the chest, abdomen and pelvis is undertaken for
staging in patients with confirmed HBP cancer (NCCN 2011a; 2011b).
4.16 PET-CT is used for staging of patients with HBP/upper GI cancer on the basis
of nationally agreed protocols.
Gastroenterology
4.17 Endoscopic retrograde cholangiopancreatography (ERCP) for diagnosis of a
dominant biliary stricture is undertaken after an MDM to direct which duct(s)
requires drainage and to obtain histological specimens.
4.18 Advanced technical procedures, including cholangioscopy, are available to
patients for acquisition of appropriate histology where the clinical suspicion is
high but biopsy and cytology specimens are non-diagnostic.
4.19 Serum IgG4 is measured in all patients with a cholangiopathy and/or dominant
stricture. In patients where IgG4 disease is suspected, biopsy samples are
considered for IgG4 immunostaining.
Standards of Service Provision for Upper Gastrointestinal Cancer Patients in New Zealand
- Provisional
21
Laboratory
4.20 Genetic testing is available according to nationally agreed guidelines.
Cytology
4.21 Nationally agreed protocols are developed for the collection of cytology
samples to provide well-preserved morphology and cell block material for
immunohistochemistry.
Histopathology
4.22 Specimen handling and processing takes place according to nationally agreed
protocols, especially to ensure adequate lymph node yield and evaluation of
resection margin status.
Surgery
4.23 Staging laparoscopy is indicated prior to resection in most patients with
HBP/upper GI cancer; clinicians consider performing this in the referring
centre prior to MDM discussion, to avoid the need for patient transfer.
Monitoring requirements
MR4C
22
Ensure that departments work to written standardised protocols, and supply
local copies of documentation to the appropriate MDM (NHS Wales 2005).
Standards of Service Provision for Upper Gastrointestinal Cancer Patients in New Zealand
- Provisional
Standard 4.4
The results of the diagnosis, investigations and staging of
patients with HBP/upper GI cancer are reported by experts in a
standardised and agreed format, encompassing all relevant
aspects, and are interpreted in the light of all relevant clinical
information.
Rationale
Standardised reporting will decrease error and omissions and help ensure that all
relevant information is available for treatment decision-making at MDMs. Waits for
imaging investigations may introduce significant delays before clinical diagnosis is
confirmed and appropriate treatment can be instituted. This is particularly true for
complex investigations (NHS Wales 2005).
Good practice points
4.24 Dual reporting of all complex tests takes place, to reduce error.
4.25 Test reports are produced in electronic format within 24 hours of reporting
where possible (depending on the test), and are made available to the MDM.
4.26 Reports are supported by relevant clinical information.
Radiology
4.27 Imaging review is carried out by a radiologist with a subspecialist interest, to
provide the most accurate imaging diagnosis and pre-treatment staging and,
through the MDM, facilitate appropriate decisions on further imaging
investigations.
4.28 Reports follow the Tumour, node, metastasis staging system (Gormly 2009;
Goergen et al 2013), except for HCC, where the Barcelona Clinic Liver Cancer
(BCLC) staging system is used (Bruix and Sherman 2011).
4.29 Imaging reports are received by the referrer within two working days of the
examination being performed.
Gastroenterology
4.30 A structured electronic report is available within two hours of the procedure.
Standards of Service Provision for Upper Gastrointestinal Cancer Patients in New Zealand
- Provisional
23
Histopathology
4.31 Reporting of histopathology is standardised, synoptic and structured, and
incorporates all relevant criteria as specified in current international consensus
guidelines from the American Joint Committee on Cancer (Edge et al 2010).
4.32 Structured reporting protocols are based on agreed protocols published by the
Royal College of Pathologists of Australasia. Where these do not currently
exist, pathologists consult other appropriate protocols, such as those of the
Royal College of Pathologists or the College of American Pathologists.
Monitoring requirements
MR4D
24
Ensure that MDMs audit diagnostic and investigative results.
Standards of Service Provision for Upper Gastrointestinal Cancer Patients in New Zealand
- Provisional
5
Multidisciplinary Care
Standard 5.1
All patients with the following are presented at an MDM:

a confirmed diagnosis of HBP/upper GI cancer

a high suspicion of HBP/upper GI cancer.
Rationale
The management of HBP/upper GI cancer involves many different specialties, and
evidence shows that multidisciplinary care is important in providing best treatment
planning and provision along the care continuum.
International evidence shows that multidisciplinary care is a key aspect to providing
best-practice treatment and care for patients with cancer. Multidisciplinary care
involves a team approach to treatment planning and care provision along the
complete patient cancer pathway.
Cancer MDMs are part of the philosophy of multidisciplinary care. Effective MDMs
result in positive outcomes for patients receiving the care, for health professionals
involved in providing the care and for health services overall. Benefits include
improved treatment planning, improved equity of patient outcomes, more patients
being offered the opportunity to enter into relevant clinical trials, improved continuity
of care and less service duplication, improved coordination of services, improved
communication between care providers and more efficient use of time and
resources.
Good practice points
5.1
Agreed terms of reference govern MDMs, based on Ministry of Health
guidelines (Ministry of Health 2012b); these include written protocols that
describe the conduct and content of the meeting, including criteria outlining
which patients should be discussed.
5.2
A designated chairperson guides discussion and encourages consensus
within the MDM.
5.3
Each case is presented by the referring doctor or designee, unless the patient
has already been seen by a specialist.
5.4
An optimal number of cases is discussed at each MDM.
5.5
The MDM meets weekly, and not less frequently than bimonthly.
5.6
The MDM discusses patients prior to their first cancer treatment, to ensure
they are staged appropriately and can be offered neo-adjuvant therapy if
appropriate.
Standards of Service Provision for Upper Gastrointestinal Cancer Patients in New Zealand
- Provisional
25
Monitoring requirements
26
MR5A
Ensure that MDMs audit patients registered at MDMs.
MR5B
Report on cases discussed at MDMs each month (including core data such as
referrers, centres, patient data (age, NHI number and date of birth),
co-morbidities, diagnoses (provisional or confirmed) and management plans).
Standards of Service Provision for Upper Gastrointestinal Cancer Patients in New Zealand
- Provisional
Standard 5.2
The MDM comprises members of the MDT, including surgeons,
radiologists, gastroenterologists, medical and radiation
oncologists, cyto/histopathologists and cancer care
coordinators.
Rationale
A team of specialists with a range of expertise ensures shared responsibility and
optimal decision-making.
Good practice points
5.7
The cancer care coordinator attending the MDM is the individual identified in
Standard 7.1.
5.8
The attendance of other health professionals involved in the care of patients
with HBP/upper GI cancer is encouraged. This includes dietitians, palliative
care specialists, psychologists, nurses, physiotherapists and whānau support
services personnel, as well as representatives from primary health care.
5.9
Māori expertise, including the range of relevant Māori services and providers,
is involved in MDMs and networks where appropriate.
5.10 Referring doctors attend MDMs where possible, through videoconferencing
where necessary.
5.11 Collaboration between teams supports cover for annual leave, sick leave and
public holidays, to avoid cancellation of MDMs (NHS Wales 2005).
5.12 Employers recognise, and resource the amount of time required of certain
members of the MDM (eg, histopathologists and radiologists) to prepare for
the MDM.
Monitoring requirements
MR5C
Provide minuted evidence of attendance/involvement at MDMs.
Standards of Service Provision for Upper Gastrointestinal Cancer Patients in New Zealand
- Provisional
27
Standard 5.3
Data are available in standardised electronic format for MDM
discussion, and include all relevant information about patients
and investigations.
Standard 5.4
All patients with confirmed HBP/upper GI cancer have their
treatment plan discussed at a MDM; recommendations are
clearly documented in the patient’s medical records and
communicated to the patient and their GP.
Rationale
In order to ensure that the best recommendations are made, all relevant information
should be made available in a standardised, preferably electronic format. Timely
communication of MDM recommendations will minimise treatment delay.
Good practice points
5.13 Patients with suspected or confirmed HBP/upper GI cancer are registered at
least 48 hours before the scheduled MDM, to ensure adequate time for
radiologists and pathologists to prepare their material.
5.14 Data related to the patient, diagnosis and staging are submitted in a
standardised electronic format and distributed to attendees of the MDM.
5.15 Consensus recommendations regarding referrals, further investigations and
treatment plans are clearly captured during the meeting and entered into the
electronic record, so that they can be collated and analysed locally, regionally
and nationally.
5.16 The MDM’s recommendations are distributed to referrers and copied to all
members of the MDM and other health professionals involved in patients’
care, within two days of the MDM.
5.17 Consensus recommendations made at the MDM are discussed with patients,
so that plans for treatment and care can be made with the involvement of the
patient and their family/whānau (expert opinion).
5.18 When a treating clinician does not follow a treatment plan recommended by
the MDM, he or she records the reason (expert opinion).
Monitoring requirements
28
MR5D
Ensure that MDMs audit treatment recommendations and the detail of following
communications.
MR5E
Ensure that MDMs audit their adherence to clinical policies (NHS Wales 2005).
Standards of Service Provision for Upper Gastrointestinal Cancer Patients in New Zealand
- Provisional
6
Supportive Care
Standard 6.1
Patients with HBP/upper GI cancer and their family/whānau
have equitable and coordinated access to appropriate medical,
allied health and supportive care services, in accordance with
Guidance for Improving Supportive Care for Adults with Cancer
in New Zealand (Ministry of Health 2010).
Rationale
The psychological, social, physical and spiritual needs of cancer patients are many
and varied. These needs can to a large extent be met by allied health care teams in
hospitals and in the community. Adults with cancer enjoy improved quality of life
following needs assessment and provision of supportive care.
Non-government organisations, including the Cancer Society, perform an important
role in providing supportive care.
Good practice points
6.1
All patients and their family/whānau have access to culturally appropriate
support services (such as whānau supportive services and Māori patient
navigators/cancer coordinators for Māori patients and their family/whānau)
and spiritual services (Ministry of Health 2010).
6.2
All patients and their family/whānau have access to support services, including
psychology services, appropriate to their needs. Those experiencing
significant distress or disturbance are referred to health practitioners with the
requisite specialist skills (Ministry of Health 2010).
6.3
Supportive care assessments and interventions are undertaken in suitable
facilities and locations that take into consideration patients’ needs for privacy,
comfort and mobility.
6.4
Tools (such as Whānau Ora assessments) are developed to meet the
supportive care needs of Māori; these are used to inform patient treatment
plans and care coordination.
6.5
All staff responsible for engagement with patients and/or their families/whānau
undertake cultural competency training.
Standards of Service Provision for Upper Gastrointestinal Cancer Patients in New Zealand
- Provisional
29
6.6
Patients and their families/whānau are involved in advance care planning and
end-of-life care planning, where appropriate.
6.7
All staff responsible for engagement with patients and/or their families/whānau
hold Level 2 Advance Care Planning and end-of-life care planning
competencies.2
Monitoring requirements
MR6A
2
30
Provide evidence of culturally appropriate patient and family/whānau satisfaction
surveys, and audit complaints processes.
Through the National Advance Care Planning Cooperative: see www.advancecareplanning.org.nz.
Standards of Service Provision for Upper Gastrointestinal Cancer Patients in New Zealand
- Provisional
7
Care Coordination
Standard 7.1
All patients with HBP/upper GI cancer have access to an
HBP/upper GI clinical nurse specialist or other health
professional who is a member of the MDM to help coordinate all
aspects of care.
Standard 7.2
Each regional cancer centre or unit managing patients with
HBP/upper GI cancer has designated lead clinicians with
specialist knowledge of HBP/upper GI cancers to provide
necessary leadership.
Rationale
The cancer journey is complex, and it is not uncommon for a patient to be seen by
many specialists within and across multiple DHBs and across the public and private
sectors.
‘Care coordination’ refers to a system or a role primarily intended to expedite patient
access to services and resources, improve communication and the transfer of
information between services, address patients’ information needs and improve
continuity of care throughout the cancer continuum.
Patients and caregivers should be able to access care coordination through a single
point of contact through the various stages of the HBP/upper GI cancer journey.
Good practice points
7.1
All regional cancer centres have access to a sufficient number of cancer nurse
specialists with expert knowledge of HBP/upper GI cancers to work with care
coordinators.
7.2
Cancer clinical nurse specialists work collaboratively and in close clinical
partnership with lead clinicians (see Standard 7.2).
7.3
Patients are introduced to their cancer care coordinator within seven days of
their initial diagnosis, and are provided with their contact details.
7.4
All patients have their supportive care and psychosocial needs assessed
utilising validated tools and documented at each stage of their cancer journey,
and have access to services appropriate to their needs.
Standards of Service Provision for Upper Gastrointestinal Cancer Patients in New Zealand
- Provisional
31
7.5
Systems are in place to develop and implement cultural concordance (where
possible) among health care professionals (Jansen et al 2008).
7.6
Patients who travel long distances to regional treatment services have access
to information on the Ministry of Health’s National Travel Assistance Scheme
(Ministry of Health 2006).
Lead clinicians
7.7
Lead clinicians work to a clear job description, have dedicated sessional time
allocated for this role and receive management support.
7.8
Lead clinicians coordinate services and ensure that strategies are in place to
improve overall coordination of care.
7.9
Lead clinicians are responsible for the allocation of patients to treatment
providers, if required.
7.10 Lead clinicians are responsible for the coordination of the care of individual
patients through the cancer care coordinator.
7.11 Lead clinicians are responsible for the running of the regional MDM.
7.12 Lead clinicians are responsible for monitoring standards and data collection.
Monitoring requirements
32
MR7A
Ensure that MDMs provide records of identified care coordinators.
MR7B
Audit database records and clinical notes on contact points between care
coordinators and patients.
MR7C
Provide evidence of culturally appropriate patient and family/whānau satisfaction
surveys, and audit complaints processes.
MR7D
Ensure that regional cancer provide evidence of job plans, identifying specific
roles, allocating sessional time and providing management support.
Standards of Service Provision for Upper Gastrointestinal Cancer Patients in New Zealand
- Provisional
8
Treatment
Standard 8.1
The treatment of patients with HBP/upper GI cancer is
performed by appropriately trained and credentialed experts
(surgeons, medical and radiation oncologists,
gastroenterologists and interventional radiologists), with a
specialty commitment to this field. Access to specialist expertise
is available at all times.
Rationale
Better clinical outcomes for patients will be achieved if complex care is carried out
by expert MDTs. Centres need to be large enough to provide the necessary
experience to maintain expertise and to justify the number of specialists required to
provide cover at all times. Prompt access to expertise is essential, to minimise
morbidity, reoperation rates, lengths of hospital stay and mortality.
Good practice points
Surgery
8.1
Appropriate surgical expertise is available at all times for post-operative care,
and appropriate expertise is available to the MDT.
8.2
Surgery is undertaken in accordance with best practice, and in keeping with
international guidelines.
8.3
Surgeons undertaking oesophageal surgery are supported by anaesthetists
experienced in one-lung ventilation, thoracic epidural and spinal analgesia
techniques (NHS Wales 2005).
8.4
Surgeons undertaking hepatobiliary procedures are supported by
anaesthetists experienced in low central venous pressure liver surgery and
advanced haemostasis support.
8.5
Surgeons undertaking HBP/upper GI cancer surgery work as a team;
experienced surgical colleagues are available in the same hospital to manage
complications if the operating surgeon is unavailable or on leave.
8.6
Surgeons are supported by appropriately trained theatre staff and surgical
assistants (usually training registrars).
Standards of Service Provision for Upper Gastrointestinal Cancer Patients in New Zealand
- Provisional
33
Medical oncology
8.7
Systemic therapy (including chemotherapy, biologicals and small molecules) is
prescribed, administered and monitored by appropriately trained medical
oncologists.
8.8
If systemic therapy is prepared on site, a pharmacist is involved who has
adequate training in systemic therapy medications, including dosing
calculations according to protocols, formulations and/or preparation.
8.9
Nurses have appropriate training in systemic therapy administration, and the
handling and disposal of cytotoxic waste.
Radiation oncology
8.10 Radiotherapy is prescribed and supervised by appropriately trained and
credentialed radiation oncologists.
8.11 If a radiation oncologist is not considered an HBP/upper GI sub-specialist
expert, they consult with a colleague who is.
Interventional radiology
8.12 Patients with HBP/upper Gl cancer have access to interventional radiology at
all times for life-threatening complications.
8.13 Therapeutic interventional radiology procedures (including percutaneous
transhepatic cholangiography, percutaneous transhepatic biliary drainage,
radiofrequency ablation and angioembolisation) are available to all patients
with HBP/upper GI cancer.
Gastroenterology
8.14 Patients with HBP/upper GI cancer have access to interventional endoscopy
(including endoscopic stenting, dilation, mucosal resection and radiofrequency
ablation) at all times for life-threatening complications.
8.15 Patients have round-the-clock access to procedures for emergency
management of complications (including ERCP).
8.16 Gastroenterology services are readily available, in case of the need to
intervene for urgent problems including cholangitis, bleeding and obstruction.
Monitoring requirements
MR8A
34
Ensure that departments maintain a record of appropriately trained and
credentialed staff, and supply copies of local documentation to the appropriate
MDM (NHS Wales 2005).
Standards of Service Provision for Upper Gastrointestinal Cancer Patients in New Zealand
- Provisional
Standard 8.2
Patients with HBP/upper GI cancer are treated in appropriately
equipped facilities offering the required range of services,
including interventional radiology and a level one or two
intensive care unit.
Rationale
Appropriately resourced facilities, including equipment, are required to treat patients
with HBP/upper GI cancer to an acceptable standard and in an acceptable
timeframe.
Level one and two intensive care units should align with the Joint Faculty of
Intensive Care Medicine’s definition of an intensive care unit (Joint Faculty of
Intensive Care Medicine 1997).
Good practice points
Surgery
8.17 Resectional surgery of complex HBP/upper GI cancers is supported by a level
one or two intensive care unit, a high-dependency unit and round-the-clock
access to interventional radiology and interventional endoscopy.
8.18 Operating theatres are equipped with technologies for the treatment of
HBP/upper GI cancers, including radiofrequency ablation, argon beam
coagulation and high-definition laparoscopy for advanced procedures.
Medical oncology
8.19 Systemic therapy is administered in an appropriately accredited facility.
8.20 Medical oncologists have access to timely preparation of cytotoxic agents,
nuclear medicine facilities to assess organ function and adequate nursing staff
within a dedicated unit.
Radiation oncology
8.21 All radiotherapy centres meet the current Radiation Oncology Practice
Standards set by the Tripartite Initiative (Tripartite Committee 2011).
8.22 Expert bodies such as the Office of Radiation Safety periodically assess
quality assurance for all radiotherapy treatment equipment; such equipment
meets the requirements of the New Zealand Radiation Protection Act 1965.
8.23 All radiotherapy centres treat their patients with modern techniques to best
meet their cancer, and have access to equipment capable of delivering
4D conformal radiotherapy and intensity modulated radiotherapy.
Standards of Service Provision for Upper Gastrointestinal Cancer Patients in New Zealand
- Provisional
35
Interventional radiology
8.24 Diagnostic and therapeutic interventional radiology procedures are readily
available in centres treating patients with HBP/upper GI cancer.
8.25 Elective interventional radiology procedures are performed at centres with
appropriate interventional radiology and clinical (hepatobiliary surgery and/or
gastroenterology/hepatology) expertise following multidisciplinary patient case
review.
8.26 Emergency interventional radiology procedures are performed at centres with
appropriate interventional radiology and clinical (hepatobiliary surgery and/or
gastroenterology/hepatology) expertise following patient clinical review and
referral.
8.27 Transfer to a tertiary-level centre is considered if appropriate interventional
radiology and/or clinical (hepatobiliary surgery and/or
gastroenterology/hepatology) expertise is not available.
8.28 Outcomes are assessed according to an agreed system of quality
improvement guidelines and standards of practice.
Gastroenterology
8.29 Therapeutic endoscopic facilities and equipment allow the provision of
advanced procedures, including endoscopic mucosal resection,
radiofrequency ablation, endoscopic stenting and endoscopic ultrasoundguided coeliac plexus neurolysis.
Monitoring requirements
MR8B
36
Ensure that departments assess facilities and equipment against agreed
standards.
Standards of Service Provision for Upper Gastrointestinal Cancer Patients in New Zealand
- Provisional
Standard 8.3
Patients with HBP/upper GI cancer are treated according to
evidence-based and agreed protocols.
Rationale
The standardisation of treatment protocols is important for many reasons, including
optimising patient care; avoiding overtreatment; monitoring the safety, quality and
efficacy of treatment; improving outcomes; and comparing outcomes over time and
between treatment centres.
Good practice points
Surgery
8.30 Surgery for HBP/upper GI cancer is based on best current practice and
conforms to international consensus guidelines (ANZGOSA 2013a; 2013b).
8.31 Surgeons consult with all patients undergoing surgery and their family/whānau
about final disposal of tissue or body parts surgically removed following
appropriate pathological examination (some tissue may be retained for future
histological reference) (modified NZGG 2009).
Medical oncology
8.32 Protocols are in place to cover generic issues pertinent to systemic therapy
such as staff grading, training and competencies; prescribing; preparation and
dispensing; administration; and disposal of waste and spillage.
Radiation oncology
8.33 Formal written treatment protocols specify dose, fractionation, overall
treatment time, planning technique and means of verification, plus other
appropriate quality assurance measures.
Gastroenterology
8.34 ERCP for therapeutic intervention of a dominant biliary stricture is undertaken
after the case has been discussed at an MDM and the treatment plan agreed.
8.35 In patients with a resectable tumour who require preoperative biliary drainage,
the biliary stent is placed in the ‘non-diseased’ (future liver remnant) lobe of
the liver.
8.36 Patients with suspected IgG4 disease are first managed with a trial of
corticosteroid therapy.
Monitoring requirements
MR8C
Ensure that MDMs document treatment protocol regarding tumour site and
stage, and note any treatment that is outside the MDM’s protocol.
Standards of Service Provision for Upper Gastrointestinal Cancer Patients in New Zealand
- Provisional
37
Standard 8.4
Reports of treatment by all specialties of patients with
HBP/upper GI cancer (including operation notes) are in a
standardised electronic format, and include all of the relevant
prognostic criteria.
Rationale
Standardised reporting is essential for communication between colleagues within
MDTs and for meaningful clinical audit and clinical research.
Good practice points
8.37 Standardised operation reports are developed.
Monitoring requirements
MR8D
38
Ensure that MDMs audit diagnostic and investigative reports.
Standards of Service Provision for Upper Gastrointestinal Cancer Patients in New Zealand
- Provisional
Standard 8.5
Patients with HBP/upper GI cancer have access to a dietitian for
assessment and nutritional support before, during and after their
treatment.
Rationale
Patients with HBP/upper GI cancer are prone to nutritional depletion, through the
effect of cancer itself and through reduced intake. Such patients are more prone to
infection, reduced response to treatment, impaired recovery and worsening
prognosis. Nutritional repletion improves quality of life and promotes recovery.
Good practice points
8.38 All patients with HBP/upper GI cancer are assessed for nutritional status using
a validated nutrition screening tool.
8.39 Patients with significant nutritional depletion are referred for consideration of
nutritional support before, during and after treatment.
8.40 A dedicated nutritional support team is available in all centres undertaking
treatment of patients with HBP/upper GI cancer, especially if parenteral
nutrition is to be provided.
8.41 Nutritional supplementation is offered to all patients, even in the absence of
marked weight loss, to improve outcomes, whatever modality of treatment
patients has decided (including no treatment).
8.42 Patients have access to a dietitian throughout their recovery period.
8.43 Pancreatic enzyme replacement therapy (as recommended by the Pancreatic
Section of the British Society of Gastroenterology) is considered where
appropriate, to maintain patients’ weight and increase their quality of life.
Monitoring requirements
MR8E
Ensure that MDMs document nutritional assessments.
Standards of Service Provision for Upper Gastrointestinal Cancer Patients in New Zealand
- Provisional
39
Standard 8.6
Patients with HBP/upper GI cancer are offered early access to
palliative care services when there are complex symptom
control issues, when a curative treatment cannot be offered or if
curative treatment has been declined.
Rationale
A diagnosis of cancer and its subsequent treatment can have a devastating impact
on the quality of a person’s life, as well as on the lives of families/whānau and other
carers. Patients may face new fears and uncertainties, and may have to undergo
unpleasant and debilitating treatments. Patients should expect to be offered optimal
symptom control and psychological, cultural, social and spiritual support. They may
want to be assured that their families/whānau and carers will receive support during
illness and, if they die, following bereavement.
Palliative care is the care of people who are dying from active, progressive diseases
or other conditions that are not responsive to curative treatment. Palliative care
embraces the physical, social, emotional and spiritual elements of wellbeing –
tinana, whānau, hinengaro and wairua – and enhances a person’s quality of life
while they are dying. Palliative care also supports the bereaved family/whānau
(Ministry of Health 2001).
The objective of palliative care is to alleviate suffering and provide compassionate
care for the patient and their family/whānau. Competence in palliative medicine and
sensitivity to people’s beliefs and values are two key prerequisites for a provider of
palliative care. Clinicians should form a care plan for palliative patients with a view to
ensuring that pain and other potentially distressing symptoms are relieved, dignity is
preserved and there is engagement with family/whānau (Ministry of Health 2001).
Good practice points
8.44 Screening for palliative care needs, comprehensive assessment and care
planning are undertaken at appropriate intervals, to meet the needs and
wishes of patients and their family/whānau (NCCN 2012c; Palliative Care
Australia 2005).
8.45 Prompt and effective communication takes place between all involved parties
(NCCN 2012c; NICE 2004).
8.46 Access to palliative care, decision-making and care planning are based on a
respect for the uniqueness of the patient and their family/whānau, independent
of their current health status, diagnosis, age, gender, cultural background or
geography. Patients’ and their family/whānau’s needs and wishes guide
decision-making and care planning (Hospice New Zealand 2012).
40
Standards of Service Provision for Upper Gastrointestinal Cancer Patients in New Zealand
- Provisional
8.47 Patients and carers have access to spiritual care, either from their MDT or
from community spiritual care resources (NICE 2004).
8.48 Patients and their family/whānau are offered a range of free, culturally and
educationally appropriate high-quality information materials about cancer and
palliative care services in a variety of formats (NICE 2004).
8.49 Systems are in place to ensure the views of patients and their family/whānau
are taken into account when developing and evaluating cancer and palliative
care services. All such services support patients to participate in their own
care by offering a range of informal opportunities, such as self-help activities
and peer support schemes with community settings (NICE 2004).
8.50 Formal mechanisms are in place to ensure that patients, their carers and
family/whānau have access to bereavement care, information and support
services (NICE 2004; Hospice New Zealand 2012).
8.51 Interdisciplinary palliative care teams, including New Zealand Medical Councilregistered palliative care physicians and skilled palliative care nurses, are
readily available to provide consultative or direct care to patients and their
family/whānau (NCCN 2012c).
8.52 All health care professionals take part in educational programmes to develop
effective palliative care knowledge, skills and attitudes, covering protocols for
the management of cancer pain (World Health Organization), neuropathic pain
and the route of referral to palliative care services (NCCN 2012c).
8.53 All health care professionals recognise dying patients in a timely manner, and
discuss advance care planning and end-of-life goals of care with patients and
their family/whānau, using end-of-life care pathways.
8.54 Palliative care services are consulted at any stage through a patient’s cancer
journey if symptoms are complex and/or prove difficult to treat.
Monitoring requirements
MR8F
Audit records of proposed plans of care, onward referrals and follow-up
responsibilities recorded at MDT reviews and in patients’ notes.
Standards of Service Provision for Upper Gastrointestinal Cancer Patients in New Zealand
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41
9
Follow-up and Surveillance
Standard 9.1
When appropriate, patients treated for HBP/upper GI cancer are
offered ongoing follow-up at their original referring centre.
Rationale
Follow-up promotes recovery and improved quality of life. It is also useful to detect
disorders of function, to assess nutritional status, to provide psychosocial support
and to audit treatment outcomes (SIGN 2006). The ongoing support of patients with
cancer after definitive treatment should ideally take place close to home and
family/whānau support, and involve the referring specialist or GP.
Good practice points
9.1
Follow-up occurs as close to home and family/whānau as possible.
9.2
Where appropriate, and to reduce travel costs and inconvenience to the
patient, shared follow-up arrangements are considered, in which patients have
alternating visits with treating specialists and the referring specialist/GP.
Monitoring requirements
MR9A
42
Audit follow-up practices and the timeliness and appropriateness of
investigations.
Standards of Service Provision for Upper Gastrointestinal Cancer Patients in New Zealand
- Provisional
Standard 9.2
Patient follow-up after HBP/upper GI cancer for the detection of
local recurrence and metastases takes place in accordance with
international consensus guidelines.
Rationale
Regular review makes it possible to diagnose early local recurrence and distant
metastases. A decision as to whether this will advantage a particular patient needs
to be made when developing the follow-up plan.
Good practice points
Palliative patients
9.3
When all possible curative treatment has been administered and no more
curative treatment will be offered, follow-up is based on the identification of
symptoms that can be palliated, rather than repeating tumour markers or
cross-sectional imaging.
9.4
For patients who have had palliative treatment, follow-up may be provided by
the GP, with the support of community and/or specialist palliative care
services. Patients are able to contact one MDT-designated hospital specialist
for advice on referral to appropriate hospital services in the event of
complications such as complex pain, cholestasis/cholangitis, duodenal
obstruction or bleeding.
Gastric and oesophageal cancer
9.5
After endoscopic treatment of early gastric and oesophageal cancer, a regular
surveillance programme is established according to international consensus
guidelines.
Secondary liver cancer
9.6
For patients who have undergone treatment for colorectal cancer, the
detection of liver metastases takes place in accordance with Management of
Early Colorectal Cancer (NZGG 2011).
9.7
Patients with resected colorectal liver metastases are followed up for further
recurrence, since treatment with curative intent is often possible.
Standards of Service Provision for Upper Gastrointestinal Cancer Patients in New Zealand
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43
Hepatocellular carcinoma
9.8
Contrast-enhanced multiphasic liver CT and/or MRI is undertaken for
surveillance of all patients following hepatic resection or locoregional (thermal
ablation) or trans-arterial (chemo/radio embolisation) therapy for HCC, in
accordance with international consensus guidelines (NCCN 2011a; Bruix and
Sherman 2011).
Pancreatic cancer
9.9
Patients who have completed treatment with curative intent and in whom
asymptomatic recurrence is identified to be followed up more intensively with
regular review by a cancer specialist if they would benefit from therapy in
terms of survival. Frequency of Ca19-9 and CT scanning is tailored to the
patient, based on international best practice.
Duodenal cancer
9.10 Patients who have had a pancreatoduodenectomy for duodenal cancer do not
receive follow-up for duodenal polyposis.
9.11 Depending on the clinical situation (particularly the presence of FAP), followup is considered for patients who have had a pancreatoduodenectomy for
duodenal cancer because of the possibility of colonic or gastric malignancies.
MR9B
44
Audit organisational compliance with surveillance protocol.
Standards of Service Provision for Upper Gastrointestinal Cancer Patients in New Zealand
- Provisional
Standard 9.3
Follow-up plans include clinical review by appropriate members
of the MDT, working in conjunction with the patient, their
family/whānau and their GP.
Rationale
The ongoing involvement of the health professionals who were involved in the
diagnosis and referral of a patient with HBP/upper GI cancer is usually important,
and is seen as ‘closing the loop’. Follow-up should be carried out as close as
possible to the family home.
Good practice points
9.12 Treating specialists, in consultation with referrers and GPs (if a GP was not
the referrer) makes a clear decision about the most appropriate person to take
primary responsibility for follow-up. The patient and their family/whānau are
involved in this decision.
9.13 Patients’ GPs receive written copies of follow-up plans within one day of
patients receiving the same information.
9.14 Follow-up plans include the frequency of visits; the tests required, and with
which designated service; and a nominated point of contact if there is clinical
concern.
9.15 Patients receive information about available culturally appropriate support.
9.16 Referral to a psychologist is considered, when appropriate, to promote more
effective coping strategies and improve patients’ self-esteem and mood.
9.17 Local palliative care services receive early notification of patients who have
undergone palliative treatment.
9.18 Patients and their family/whānau receive information on lifestyle factors,
including smoking cessation, exercise, nutrition and psychological support.
9.19 Patients receive equitable access to integrated rehabilitation services
(including education, housing, welfare and Whānau Ora services) in a
coordinated manner.
Monitoring requirements
MR9C
Audit provision of written follow-up information following agreed surveillance
protocols.
MR9D
Provide evidence of appropriate written information provided to patients and
families/whānau, and record names of nominated contacts.
Standards of Service Provision for Upper Gastrointestinal Cancer Patients in New Zealand
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45
10 Clinical Performance Monitoring and Research
Standard 10.1
Data relating to HBP/upper GI cancer beyond the fields required
by the Cancer Registry, including treatment data, are reported
to existing and planned national repositories using nationally
agreed data set fields.
Rationale
There is currently no national cancer database other than the New Zealand Cancer
Registry, which is a population-based register of all primary malignant tumours
diagnosed in New Zealand. This is a significant impediment to advancing cancer
care in this country. Cancer data-related projects are being undertaken or planned
by the Ministry of Health, Cancer Control New Zealand and regional cancer
networks.
Good practice points
10.1 Where data are collected, they are compiled in accordance with the National
Cancer Core Data Definition standards (IT Health Board 2011).
10.2 Dedicated database managers are employed in regional cancer centres to
oversee satisfactory data entry. Data veracity is confirmed clinically.
10.3 Patients are informed that their information is being recorded in an HBP/upper
GI cancer database to help the MDT propose a treatment plan and to monitor
and evaluate access to services.
10.4 Clinicians working in HBP/upper GI cancer treatment and care have access to
the database to help inform disease management.
Monitoring requirements
MR10A
46
Provide evidence of reporting of required patient data sets to national data
repositories (as available) at the agreed frequency.
Standards of Service Provision for Upper Gastrointestinal Cancer Patients in New Zealand
- Provisional
Standard 10.2
Data on treatment, clinical outcomes and patient satisfaction are
regularly monitored and reported as part of a national audit.
Rationale
Accurately recorded and good quality data are essential for monitoring outcomes
and comparing clinical services. Audits identify inequalities in service along the
patient pathway, including inequities in timely access to services and those based
on ethnicity.
One of the key findings of Access to Cancer Services for Māori (Ministry of Health
2005) was the limited nature of information on access to cancer services for Māori,
including discussion of interventions. Several areas arise from the project as
priorities for further research.
Good practice points
10.5 Data are reported according to an agreed system of quality improvement
guidelines and standards of practice.
10.6 All parts of the patient pathway are investigated and audited, including referral,
investigation, management of treatment and patient outcomes, with particular
emphasis on interventions to enhance the patient journey for Māori patients
and their family/whānau.
10.7 The results of audits are presented at a national multidisciplinary audit
meeting, and are available to clinicians within referring units, the cancer
networks and the public.
10.8 Surgical outcomes are monitored against international guidelines.
Monitoring requirements
MR10B
Ensure that MDMs provide evidence of participation in regular audits.
Standards of Service Provision for Upper Gastrointestinal Cancer Patients in New Zealand
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Standard 10.3
Patients with HBP/upper GI cancer are offered the opportunity
to participate in research projects and clinical trials where these
are available.
Rationale
Advances in evidence-based practice are largely dependent on clinical trials.
Although clinical trials are primarily focused on the improvement of care for future
patients, there is good evidence that patients treated within a trial setting fare better
than those treated outside of a trial setting. This is thought to be due in large
measure to the benefits of treatment that is carried out according to documented
protocols (NHS Wales 2005).
Good practice points
10.9
Information about available trials (regionally, nationally and internationally),
including eligibility criteria, is readily available to providers of cancer care,
preferably through a website.
10.10 Funds are allocated to support the costs of research personnel, such as
research nurses, to facilitate enrolment of patients into clinical trials, data
collection and adherence to compliance requirements.
10.11 A coordinated collaborative approach is taken to clinical trials, to ensure that
studies are conducted efficiently and results are available in a timely manner.
10.12 Regional cancer centres maintain a listing of clinical trials to which patients
are being recruited, and make this available for collation on a national basis.
10.13 Tissue is appropriately collected and stored, and good-quality clinical data is
appropriately collected, in order to enhance current and future research
opportunities.
Monitoring requirements
MR10C
48
Ensure that MDMs provide documentation of all open trials/research projects,
and record the number of patients entered per trial per year.
Standards of Service Provision for Upper Gastrointestinal Cancer Patients in New Zealand
- Provisional
Appendix 1:
National HBP/Upper GI Tumour Standards Working
Group Membership
Chair
Prof John Windsor, Consultant Surgeon, Auckland DHB/University of Auckland
Clinical leads
Mr Grant Coulter (gastro-oesophageal lead), Consultant Surgeon, Canterbury DHB
Mr Simon Bann (gastro-oesophageal deputy lead), Consultant Upper
Gastrointestinal and Laparoscopic Surgeon, Capital & Coast DHB
Prof John McCall (hepatobiliary lead), Hepatobiliary and General Surgeon, Southern
DHB/Dunedin School of Medicine
Associate Prof Jonathan Koea (hepatobiliary deputy lead), Hepatobiliary and
General Surgeon, Waitemata DHB
Prof John Windsor (pancreaticoduodenal lead), as above
Mr Kusal Wickremesekera (pancreaticoduodenal deputy lead), Consultant
Hepatobiliary/Upper Gastrointestinal/Laparoscopic Surgeon, Capital & Coast DHB
Members
Gastro-oesophageal
Sue Corkill, Cancer Information Nurse, Cancer Society (Christchurch)
Dr Jim Edwards, Consultant Medical Oncologist, Canterbury DHB
Dr Gabriel Lau, Consultant Radiologist, Southland DHB
Dr Paul Restall, Histopathologist, Auckland DHB
Mr Michael Rodgers, Clinical Director of General Surgery, Waitemata DHB
Dr David Rowbotham, Clinical Director of Gastroenterology and Hepatology,
Auckland DHB
Hepatobiliary
Mr Adam Bartlett, Consultant Surgeon, Auckland DHB
Dr Katriona Clarke, Consultant Medical Oncologist, Capital & Coast DHB
Dr Daniel Cookson, Consultant (Interventional) Radiologist, Counties Manukau DHB
Sue Lodge, Palliative Care Team Leader, Mary Potter Hospice (Kapiti)
Dr David Orr, Consultant Hepatologist and Gastroenterologist, Auckland DHB
Dr Stephen Williams, Consultant Radiation Oncologist, Canterbury DHB
Dr Mee Ling Yeong, Histopathologist/Clinical Director, Diagnostic MedLabs
Standards of Service Provision for Upper Gastrointestinal Cancer Patients in New Zealand
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Pancreaticoduodenal
Mr Saxon Connor, Consultant Surgeon, Canterbury DHB
Dr Susan Hamilton, Consultant Palliative Medicine, Mary Potter Hospice
(Wellington)
Dr Dean Harris, Consultant Medical Oncologist, Canterbury DHB
Dr Chris McKee, Consultant Radiologist, Waitemata DHB
Dr Andrew Miller, Consultant Anatomical Pathologist, Canterbury Health
Laboratories
Petro Nel, Clinical Nurse Specialist, Medical Oncology, MidCentral DHB
Dr Hermann van der Vyver, Consultant Radiation Oncologist, Waikato DHB
Dr Frank Weilert, Director of Endoscopy, Waikato DHB
Ex officio members
Sarah Bell, Project Manager, Northern Cancer Network
Deirdre Maxwell, Manager, Northern Cancer Network
Dr Richard Sullivan, Regional Clinical Director, Northern Cancer Network
Dr David Theobald, National Clinical Lead, Gastrointestinal Endoscopy, National
Endoscopy Quality Improvement Programme, Ministry of Health
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Standards of Service Provision for Upper Gastrointestinal Cancer Patients in New Zealand
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Appendix 2:
Glossary
Adjuvant therapy
Additional treatment to increase the effectiveness of the
main treatment (often surgery), such as chemotherapy,
systemic therapy or radiotherapy
Advance care planning
A process of discussion and shared planning for future
health care
Aetiology
The origins or causes of disease
Allied health professional
One of the following groups of health care workers:
physiotherapists, occupational therapists, dietitians,
paramedics, prosthetists/orthotists, psychologists, social
workers and speech and language therapists
Angioembolisation
A non-surgical, minimally invasive procedure performed by
an interventional radiologist
Asymptomatic
Without obvious signs or symptoms of disease. In early
stages, cancer may develop and grow without producing
symptoms
Barcelona Clinic Liver
Cancer staging system
A staging system used particularly when describing the
extent of liver cancer
Best practice
A method or approach that is accepted by consensus to be
the most effective way of doing something, in the
circumstances; may or may not be based on evidence
Biliary
Of the bile duct
Biopsy
Removal of a sample of tissue or cells from the body to
assist in the diagnosis of a disease
Cancer journey
The individual and personal experience of a person with
cancer throughout the course of their illness
Cancer Networks
Cancer Networks were formed in response to national
policy to drive change and improve cancer services for the
population in specific areas. There are four regional
networks: Northern, Midland, Central and Southern
Cancer service pathway
The cumulative cancer-specific services that a person with
cancer uses during the course of their experience with
cancer
Carcinoma
Cancer of the lining tissue that covers all the body organs.
Most cancers are carcinomas
Care coordination
Entails the organising and planning of cancer care, who
patients and family/whānau see, when they see them and
how this can be made as easy as possible. It may also
include identifying who patients and family/whānau need to
help them on the cancer pathway
Standards of Service Provision for Upper Gastrointestinal Cancer Patients in New Zealand
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52
Chemotherapy
The use of drugs that kill cancer cells, or prevent or slow
their growth (also see systemic therapy)
Cholangiopathy
Any disease of the bile ducts
Cholangioscopy
The examination of bile ducts using an endoscope
Chromoendoscopy
The examination of gastrointestinal tracts using a fibre-optic
endoscope and dyes
Clinical trial
An experiment for a new treatment
Co-morbidities
Two or more diseases existing at the same time in the body
Computed tomography
(CT)
A medical imaging technique using X-rays to create crosssectional slices through the body part being examined
Confirmed diagnosis (used
in FCT indicators)
The preferred basis of a confirmed cancer diagnosis is
pathological, noting that for a small number of patients
cancer diagnosis will be based on diagnostic imaging
findings
Curative
Aiming to cure a disease
Decision to treat (used in
FCT indicators)
A decision to begin a patient’s treatment plan or other
management plan, following discussion between the patient
and treating clinician.
DHB
District Health Board
End of life care
The provision of supportive and palliative care in response
to the assessed needs of the patient and family/whānau
during the end-of-life phase
Endoscope
A tubular device with a light at the end that transmits
images to aid diagnosis or therapy. Specialised
endoscopes may be threaded down the oesophagus to the
stomach or beyond, or inserted through an incision in the
abdomen. They may also be used to take samples of
tissues (see biopsy) or to carry out therapeutic functions,
such as inserting stents
Endoscopic mucosal
resection
A technique used to remove cancerous or other abnormal
lesions found in the digestive tract
Endoscopic retrograde
cholangiopancreatography
(ERCP)
A method by which the bile and pancreatic ducts may be
accessed using an endoscope
Endoscopic ultrasound
Imaging using high-frequency sound waves, carried out
inside the body using an endoscope
Endoscopist
A person trained in the use of the endoscope
Endoscopy
The examination of the upper gastro-intestinal tract
Excision
The removal of tissue by surgery
Standards of Service Provision for Upper Gastrointestinal Cancer Patients in New Zealand
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Familial adenomatous
polyposis (FAP)
An inherited disorder characterised by cancer of the large
intestine (colon) and rectum. People with the classic type of
FAP may begin to develop multiple non-cancerous (benign)
growths (polyps) in the colon as early as their teenage
years
Faster Cancer Treatment
(FCT)
A Ministry of Health programme that will improve services
by standardising care pathways and timeliness of services
for cancer patients throughout New Zealand
Faster Cancer Treatment
indicators
Measures of cancer care collected through DHB reporting
of timeframes within which patients with a high suspicion of
cancer access services. The indicators are internationally
established and provide goals for DHBs to achieve over
time
Fine needle aspiration
(FNA) cytology
The use of a fine needle to biopsy a tumour or lymph node
to obtain cells for cytological confirmation of diagnosis
First specialist
assessment (FSA)
Face-to-face contact (including telemedicine) between a
patient and a registered medical practitioner or nurse
practitioner for the purposes of first assessment for their
condition for that specialty
First treatment (used in
FCT indicators)
The treatment or other management that attempts to begin
the patient’s treatment, including palliative care
Fluorescence in situ
hybridisation (FISH)
A cytogenetic technique used to detect and localise the
presence or absence of specific DNA sequences on
chromosomes
Gastroenterology
The branch of medicine that deals with the digestive system
Gastroenterologist
A doctor who specialises in diseases of the digestive
system
Gastroscopy
A diagnostic test that enables the inside of the upper
digestive tract to be viewed
GP
General practitioner
Haemostasis
A process to stop bleeding
Hepatocellular carcinoma
(HCC)
The most common type of primary liver cancer. Most cases
of HCC are secondary to either a viral hepatitis infection
(hepatitis B or C) or cirrhosis (alcoholism is the most
common cause of hepatic cirrhosis). Also called malignant
hepatoma
Health equality/equity
Absence of unnecessary, avoidable and unjust differences
in health (Ministry of Health 2002)
Health inequality/inequity
Differences in health that are unnecessary, avoidable or
unjust (Ministry of Health 2002)
Hepatectomy
Surgical resection of the liver
High suspicion of cancer
(used in FCT indicators)
Where a patient presents with clinical features typical of
cancer, or has less typical signs and symptoms but the
clinician suspects that there is a high probability of cancer
Standards of Service Provision for Upper Gastrointestinal Cancer Patients in New Zealand
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54
Histological
Relating to the study of cells and tissue on the microscopic
level
Histopathologist
A doctor who specialises in examining tissue samples
microscopically in order to make a diagnosis and ensure
tumour excision is complete
Histopathology
The microscopic study of diseased tissue
Holistic
Looking at the whole system rather than just concentrating
on individual components
Hospice
Hospice is not only a building; it is a philosophy of care. The
goal of hospice care is to help people with life-limiting and
life-threatening conditions make the most of their lives by
providing high-quality palliative and supportive care
Immunohistochemistry
A technique that uses antibodies to show up specific
proteins in tissues seen down a microscope
Immunology
A branch of biomedical science that covers the study of all
aspects of the immune system in all organisms
Immunostaining
A term in biochemistry that applies to any use of an
antibody-based method to detect a specific protein in a
sample
Immunotherapy
Stimulation of a patient’s immune system to attack the
malignant tumour cells that are responsible for disease.
This can be either through immunisation of the patient, in
which case the patient's own immune system is trained to
recognise tumour cells as targets to be destroyed, or
through the administration of therapeutic antibodies as
drugs, in which case the patient’s immune system is
recruited to destroy tumour cells by the therapeutic
antibodies
Intensity modulated
radiotherapy
An attempt to optimise dose distribution during external
beam radiotherapy delivery. Each radiation field is divided
into small segments with varying radiation intensity, which
allows for target shape, location and the geometry of
overlaying tissues. Intensity modulated radio therapy fields
are typically designed using computer-driven (or -aided)
optimisation. This is often referred to as ‘inverse treatment
planning’
Interventional radiologist
A doctor who specialises in imaging and the use of imaging
techniques to guide the placement of therapeutic devices
like stents inside the body
Laparoscopy
Visualisation of the interior of the abdomen using a special
type of endoscope, inserted through a small incision in the
abdominal wall
Lesion
An area of abnormal tissue
Local recurrence
Local persistence of a primary tumour due to incomplete
excision
Standards of Service Provision for Upper Gastrointestinal Cancer Patients in New Zealand
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Magnetic resonance
imaging (MRI)
A non-invasive method of imaging, which allows the form
and metabolism of tissues and organs to be visualised (also
known as nuclear magnetic resonance)
Malignant
Cancerous. Malignant tumours can invade and destroy
nearby tissue and spread to other parts of the body
Medical oncologist
A doctor who treats cancer patients through the use of
chemotherapy and, for some tumours, immunotherapy
Medical oncology
The specialist treatment of cancer patients through the use
of chemotherapy and, for some tumours, immunotherapy
Metastases
Cancerous tumours in any part of the body that have
spread from the original (primary) origin. Also known as
‘secondaries’
Morbidity
The state of being diseased
Morphology
A branch of bioscience dealing with the study of the form
and structure of organisms and their specific structural
features
Mortality
Either (a) the condition of being subject to death or (b) the
death rate, which reflects the number of deaths per unit of
population in any specific region, age group, disease or
other classification, usually expressed as deaths per 1000,
10,000 or 100,000
Multidisciplinary meeting
(MDM)
A deliberate, regular, face-to-face meeting (which may be
through videoconference) to facilitate prospective
multidisciplinary discussion of options for patients’
treatment and care by a range of health professionals who
are experts in different specialties. ‘Prospective’ treatment
and care planning makes recommendations in real time,
with an initial focus on the patient’s primary treatment.
Multidisciplinary meetings facilitate a holistic approach to
the treatment and care of patients
Multidisciplinary team
(MDT)
A group of specialists in a given disease area. The MDT
meets regularly to plan aspects of patient treatment.
Individual patient cases might be discussed at an MDM, to
best plan approach to treatments
National Health Index (NHI)
number
A unique identifier for New Zealand health care users
Oesophagectomy
Removal of part of the oesophagus
Oncology
The study of the biological, physical and chemical features
of cancers, and of the causes and treatment of cancers
Palliative
Anything that serves to alleviate symptoms due to an
underlying cancer but is not expected to cure it
Standards of Service Provision for Upper Gastrointestinal Cancer Patients in New Zealand
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Palliative care
Active, holistic care of patients with advanced, progressive
illness that may no longer be curable. The aim is to achieve
the best quality of life for patients and their families/whānau.
Many aspects of palliative care are also applicable in earlier
stages of the cancer journey in association with other
treatments
Pancreaticoduodenectomy
Surgical removal of most of the pancreas, the encircling
loop of duodenum, the common bile duct and the pylorus
(also known as the Whipple procedure)
Pathologist
A doctor who examines cells and identifies them. The
pathologist can tell where a cell comes from in the body and
whether it is normal or a cancer cell. If it is a cancer cell, the
pathologist can often tell what type of body cell the cancer
developed from. In a hospital practically all the diagnostic
tests performed with material removed from the body are
evaluated or performed by a pathologist
Pathology
A branch of medicine concerned with disease; especially its
structure and its functional effects on the body
Patient pathway
The individual and personal experience of a person with
cancer throughout the course of their illness; the patient
journey
Positron emission
tomography (PET)
A highly specialised imaging technique using a radioactive
tracer to produce a computerised image of body tissues to
find any abnormalities. PET scans are sometimes used to
help diagnose cancer and investigate a tumour’s response
to treatment
Positron emission
tomography and computed
tomography (PET-CT)
An advanced imaging technique combining an injected
material (18 Fluorine) which is taken up by cancer cells and
a CT scan
Primary care
Primary-level health services provided by a range of health
workers, including GPs and nurses
Prognosis
A prediction of the likely outcome or course of a disease;
the chance of recovery or recurrence
Quality assurance
All the planned and systematic activities implemented within
the quality system, and demonstrated as needed
Radiation oncologist
A person who is registered as a medical practitioner by the
relevant medical board, is a fellow of the Royal Australian
and New Zealand College of Radiologists or equivalent and
is licensed to prescribe radiation therapy
Radiologist
A doctor who specialises in creating and interpreting
pictures of areas inside the body using X-rays and other
specialised imaging techniques. An interventional
radiologist specialises in the use of imaging techniques for
treatment; for example catheter insertion for abscess
drainage
Standards of Service Provision for Upper Gastrointestinal Cancer Patients in New Zealand
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Radiology
The use of radiation (such as X-rays, ultrasound and
magnetic resonance) to create images of the body for
diagnosis
Radiofrequency ablation
A procedure that uses a probe called an electrode to apply
an electrical current (radiofrequency) to a tumour
Radiotherapy (radiation
treatment)
The use of ionising radiation, usually X-rays or gamma
rays, to kill cancer cells and treat tumours
Recurrence
The return, reappearance or metastasis of cancer (of the
same histology) after a disease-free period
Referred urgently (used in
FCT indicators)
Describes urgent referral of a patient to a specialist
because he or she presents with clinical features indicating
high suspicion of cancer
Resection
Removal of tissue from the body by surgery
Stage
The extent of a cancer; especially whether the disease has
spread from the original site to other parts of the body
Staging
Usually refers to the Tumour, node, metastasis system for
grading tumours by the American Joint Committee on
Cancer
Stent
A tubular device made of metal or polythene designed to
hold open a tube or opening in the body, such as the
oesophagus (oesophageal stent) or bile duct (biliary stent)
Supportive care
Supportive care helps a patient and their family/whānau to
cope with their condition and treatment – from prediagnosis through the process of diagnosis and treatment to
cure, continuing illness or death, and into bereavement. It
helps the patient to maximise the benefits of treatment and
to live as well as possible with the effects of their disease
Synoptic report
A standardised proforma for reporting of cancer
Systemic therapy
Treatment using substances that travel through the
bloodstream, reaching and affecting cells all over the body
Tertiary
Third level. Relating to medical treatment provided at a
specialist institution
Tumour, node, metastasis
A staging system that describes the extent of cancer,
developed by the American Joint Committee on Cancer
Ultrasound
A non-invasive technique using ultrasound waves (highfrequency vibrations beyond the range of audible sound) to
form an image
Whānau
Māori term for a person’s immediate family or extended
family group. In the modern context, sometimes used to
include people without kinship ties
Whānau Ora
An inclusive interagency approach to providing health and
social services to build the capacity of New Zealand
families. It empowers family/whānau as a whole, rather than
focusing separately on individual family members
Standards of Service Provision for Upper Gastrointestinal Cancer Patients in New Zealand
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X-ray
58
A photographic or digital image of the internal organs or
bones produced by the use of ionising radiation
Standards of Service Provision for Upper Gastrointestinal Cancer Patients in New Zealand
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Appendix 3:
References
Development of the HBP/upper GI cancer standards was informed by key national
and regional policy documents. Those documents that most directly influenced the
development of the standards are listed below.
Allum WH, Blazeby JM, Griffin SM, et al. 2011. Guidelines for the management of
oesophageal and gastric cancer. Gut 60: 1449–72.
Bruix J, Sherman M. 2011. Management of hepatocellular carcinoma: An update.
Alexandria: American Association for the Study of Liver Diseases.
Eckel F, Brunner T, Jelic S, et al. 2011. Biliary Cancer: ESMO Clinical Practice Guidelines
for diagnosis, treatment and follow-up. Annals of Oncology Suppl 5: v65–9.
European Association for the Study of the Liver, European Organisation for Research and
Treatment of Cancer. 2012. EASL–EORTC Clinical Practice Guidelines: Management of
hepatocellular carcinoma. Journal of Hepatology 56(4): 908–43.
IT Health Board. 2011. National Cancer Core Data Definitions, Interim Standard, HISO
10038.3. Wellington: Ministry of Health.
Ministry of Health. 2001. The New Zealand Palliative Care Strategy. Wellington: Ministry of
Health.
Ministry of Health. 2002. Reducing Inequalities in Health. Wellington: Ministry of Health.
Ministry of Health. 2005. Access to Cancer Services for Māori. Wellington: Ministry of Health.
Ministry of Health. 2010. Guidance for Improving Supportive Care for Adults with Cancer in
New Zealand. Wellington: Ministry of Health.
Ministry of Health. 2011a. Targeting Shorter Waits for Cancer Treatment. Wellington:
Ministry of Health.
Ministry of Health. 2012b. Guidance for Implementing High-Quality Multidisciplinary
Meetings: Achieving best practice cancer care. Wellington: Ministry of Health.
Ministry of Health. 2013a. Faster Cancer Treatment programme. URL:
www.health.govt.nz/our-work/diseases-and-conditions/cancer-programme/faster-cancertreatment-project (accessed 28 June 2013).
National Lung Cancer Working Group. 2011. Standards of Service Provision for Lung
Cancer Patients in New Zealand. Wellington: Ministry of Health.
NCCN. 2011a. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) –
Hepatobiliary Cancers: Version 2 2012. Fort Washington: National Comprehensive Cancer
Network (member access only).
NCCN. 2011b. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) –
Pancreatic Adenocarcinoma: Version 2 2012. Fort Washington: National Comprehensive
Cancer Network (member access only).
NCCN. 2012a. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) –
Esophageal and Esophagogastric Junction Cancers. Fort Washington: National
Comprehensive Cancer Network (member access only).
Standards of Service Provision for Upper Gastrointestinal Cancer Patients in New Zealand
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59
NCCN. 2012b. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) – Gastric
Cancer. Fort Washington: National Comprehensive Cancer Network (member access only).
NHS Wales. 2005. National Standards for Upper Gastro-intestinal Cancer Services. Cardiff:
NHS Wales.
Pancreatic Section of the British Society of Gastroenterology, Pancreatic Society of Great
Britain and Ireland, Association of Upper Gastrointestinal Surgeons of Great Britain and
Ireland, Royal College of Pathologists, Special Interest Group for Gastro-Intestinal
Radiology. 2005. Guidelines for the management of patients with pancreatic cancer
periampullary and ampullary carcinomas. Gut 54: 1–16.
SIGN. 2006. Management of Oesophageal and Gastric Cancer: A national clinical guideline.
Edinburgh: Scottish Intercollegiate Guidelines Network.
Statewide Cancer Clinical Network. 2010. South Australian Upper Gastrointestinal Cancer
Care Pathway. Adelaide: Department of Health, Government of South Australia.
Seufferlein T, Bachet JB, Van Cutsem E, et al. 2012. Pancreatic adenocarcinoma: ESMOESDO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Annals of
Oncology Suppl 7: vii33–40.
Verslype C, Rosmorduc O, Rougier P, et al. 2012. Hepatocellular carcinoma: ESMO-ESDO
Clinical Practice Guidelines for diagnosis, treatment and follow-up. Annals of Oncology
Suppl 7: vii41–8.
WoSCAN. 2007. The Management of Pancreatico-Biliary and Duodenal Tumours. Regional
protocol for the west of Scotland cancer network. Glasgow: West of Scotland Cancer
Network Upper GI Cancer Managed Clinical Network Advisory Board.
Introduction
Beenen E, Jao W, Coulter G, et al. 2013. The high volume debate in a low volume country:
centralisation of oesophageal resection in New Zealand. New Zealand Medical Journal
126(1374): 34–44.
Chamberlain J, Sarfati D, Cunningham R, et al. 2013. Incidence and management of
hepatocellular carcinoma among Māori and non-Māori New Zealanders. ANZ Journal of
Public Health (in press).
Hill S, Sarfati D, Robson B, et al. 2012. Indigenous inequalities in cancer: what role for health
care? ANZ Journal of Surgery 83(1–2): 36–41.
Martin IG. 2002. Gastro-oesophageal malignancy in New Zealand: 1995–97. New Zealand
Medical Journal 115(1148): 64–7.
Ministry of Health. 2002. Reducing Inequalities in Health. Wellington: Ministry of Health.
Ministry of Health. 2006. The National Travel Assistance Scheme: Your guide for claiming
travel assistance: brochure. URL: www.health.govt.nz/publication/national-travel-assistancescheme-your-guide-claiming-travel-assistance-brochure (accessed 14 August 2013).
Ministry of Health. 2008. Health Equity Assessment Tool: A User’s Guide. Wellington:
Ministry of Health.
Ministry of Health. 2012a. Cancer: New Registrations and Deaths 2009. Wellington: Ministry
of Health.
National Lung Cancer Working Group. 2011. Standards of Service Provision for Lung
Cancer Patients in New Zealand. Wellington: Ministry of Health.
60
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Phillips AJR, Lawes CM, Cooper GJ, et al. 2002. Ethnic disparity of pancreatic cancer in
New Zealand. Journal of Gastrointestinal Cancer 31(1–3): 137–45.
Soeberg M, Blakely T, Sarfati D, et al. 2012. Cancer Trends: Trends in cancer survival by
ethnic and socioeconomic group, New Zealand 1991–2004. Wellington: University of Otago
and Ministry of Health.
Weir RP, Brunton CR, Blakely TA. 2002. Chronic liver disease mortality attributable to
hepatitis B and C in New Zealand. Journal of Gastroenterology and Hepatology
17(5): 582–8.
Prevention and early identification
American Gastroenterological Association. 2011. American Gastroenterological Association
Medical Position Statement on the Management of Barrett’s Esophagus. Gastroenterology
140(3): 1084–91.
Bennett C, Vakil N, Bergman J, et al. 2012. Consensus statements for management of
Barrett’s dysplasia and early-stage oesophageal adenocarcinoma, based on a Delphi
process. Gastroenterology 143(2): 336–46.
Bruix J, Sherman M. 2011. Management of hepatocellular carcinoma: An update.
Alexandria: American Association for the Study of Liver Diseases.
Canto MI, Harinck F, Hruban RH, et al. 2013. International cancer of the pancreas screening
consortium summit on the management of patients with increased risk for familial pancreatic
cancer. Gut 62: 339–47.
European Association for the Study of the Liver, European Organisation for Research and
Treatment of Cancer. 2012. EASL–EORTC Clinical Practice Guidelines: Management of
hepatocellular carcinoma. Journal of Hepatology 56(4): 908–43.
Kluijt I, Sijmons RH, Hoogerbrugge N, et al. 2012. Familial gastric cancer: guidelines for
diagnosis, treatment and periodic surveillance. Familial Cancer 11: 363–9.
Ministry of Health. 2011b. Targeting Smokers: Better Help for Smokers to Quit. Wellington:
Ministry of Health.
Ministry of Health. 2013b. Hepatitis B. URL: www.health.govt.nz/your-health/conditions-andtreatments/diseases-and-illnesses/hepatitis-b?qt-moh_topic_sheet_tabs=3#qtmoh_topic_sheet_tabs (accessed 26 August 2013).
NZGG. 2009. Suspected Cancer in Primary Care: Guidelines for investigation, referral and
reducing ethnic disparities. Wellington: New Zealand Guidelines Group.
NZGG. 2011. Management of Early Colorectal Cancer – Evidence-based Best Practice
Guidelines. Wellington: New Zealand Guidelines Group.
Tanaka M, Chari S, Adsay V, et al. 2006. International consensus guidelines for
management of intraductal papillary mucinous neoplasms and mucinous cystic neoplasms of
the pancreas. Pancreatology 6: 17–32.
Standards of Service Provision for Upper Gastrointestinal Cancer Patients in New Zealand
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Referral and communication
Ministry of Health. 2012c. Rauemi Atawhai: A guide to developing health education
resources in New Zealand. Wellington: Ministry of Health.
NHS Wales. 2005. National Standards for Upper Gastro-intestinal Cancer Services. Cardiff:
NHS Wales.
Windsor JA, Rossaak JI, Chaung D, et al. 2008. Telling the truth to Asian patients in the
hospital setting. New Zealand Medical Journal 121(1286): 92–9.
Investigation, diagnosis and staging
Bruix J, Sherman M. 2011. Management of Hepatocellular Carcinoma: An update.
Alexandria: American Association for the Study of Liver Diseases.
Edge SB, Byrd DR, Compton CC, et al (eds). 2010. AJCC Cancer Staging Manual (7th
edition). New York: Springer.
Goergen SK, Pool FJ, Turner TJ, et al. 2013. Evidence-based guideline for the written
radiology report: Methods, recommendations and implementation challenges. Journal of
Medical Imaging and Radiation Oncology 57(1): 1–7.
Gormly KLM. 2009. Standardised tumour, node and metastasis reporting of oncology CT
scans. Journal of Medical Imaging and Radiation Oncology 53(4): 345–52.
NCCN. 2011a. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) –
Hepatobiliary Cancers: Version 2 2012. Fort Washington: National Comprehensive Cancer
Network (member access only).
NCCN. 2011b. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) –
Pancreatic Adenocarcinoma: Version 2 2012. Fort Washington: National Comprehensive
Cancer Network (member access only).
NHS Wales. 2005. National Standards for Upper Gastro-intestinal Cancer Services. Cardiff:
NHS Wales.
Multidisciplinary care
Ministry of Health. 2012b. Guidance for Implementing High-Quality Multidisciplinary
Meetings: Achieving best practice cancer care. Wellington: Ministry of Health.
NHS Wales. 2005. National Standards for Upper Gastro-intestinal Cancer Services. Cardiff:
NHS Wales.
Supportive care
Ministry of Health. 2010. Guidance for Improving Supportive Care for Adults with Cancer in
New Zealand. Wellington: Ministry of Health.
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Care coordination
Jansen P, Bacal K, Crengle S. 2008. He Ritenga Whakaaro: Māori experiences of health
services. Auckland: Mauri Ora Associates.
Ministry of Health. 2006. The National Travel Assistance Scheme: Your guide for claiming
travel assistance: brochure. URL: www.health.govt.nz/publication/national-travel-assistancescheme-your-guide-claiming-travel-assistance-brochure (accessed 14 August 2013).
Treatment
ANZGOSA. 2013a. Guidelines For Hospitals and/or Health Services to Assist in
Credentialing of Surgeons Performing Gastric Resection in Australia and New Zealand
(draft). Belair: Australian and New Zealand Gastric and Oesophageal Surgery Association.
ANZGOSA. 2013b. Guidelines for Hospitals and/or Health Services to Assist in Credentialing
of Surgeons Performing Oesophageal Resection in Australia and New Zealand (draft).
Belair: Australian and New Zealand Gastric and Oesophageal Surgery Association.
Hospice New Zealand. 2012. Standards for Palliative Care: Quality review programme and
guide. Wellington: Hospice New Zealand.
Joint Faculty of Intensive Care Medicine. 1997. Minimum Standards for Intensive Care Units.
Review IC-1. Melbourne: Faculty of Intensive Care, Australia and New Zealand College of
Anaesthetists.
Liverpool Care Pathway. 2009. New Zealand Integrated Care Pathway for the Dying Patient.
http://lcpnz.org.nz/pages/home (accessed 16 August 2013).
Ministry of Health. 2001. The New Zealand Palliative Care Strategy. Wellington: Ministry of
Health.
NCCN. 2012c. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) –
Palliative Care. Fort Washington: National Comprehensive Cancer Network (member access
only).
NHS Wales. 2005. National Standards for Upper Gastro-intestinal Cancer Services. Cardiff:
NHS Wales.
NICE. 2004. Guidance on Cancer Services: Improving Supportive and Palliative Care for
Adults with Cancer. London: National Institute for Clinical Excellence.
NZGG. 2009. Suspected Cancer in Primary Care: Guidelines for investigation, referral and
reducing ethnic disparities. Wellington: New Zealand Guidelines Group.
Palliative Care Australia. 2005. Standards for Providing Quality Palliative Care for all
Australians. Canberra: Palliative Care Australia.
World Health Organization. WHO’s Pain Ladder for Adults. URL:
www.who.int/cancer/palliative/painladder/en (accessed 26 August 2013).
Standards of Service Provision for Upper Gastrointestinal Cancer Patients in New Zealand
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Follow-up and surveillance
Bruix J, Sherman M. 2011. Management of hepatocellular carcinoma: An update.
Alexandria: American Association for the Study of Liver Diseases.
NCCN. 2011a. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) –
Hepatobiliary Cancers: Version 2 2012. Fort Washington: National Comprehensive Cancer
Network (member access only).
NZGG. 2011. Management of Early Colorectal Cancer. Wellington: New Zealand Guidelines
Group.
SIGN. 2006. Management of Oesophageal and Gastric Cancer: A national clinical guideline.
Edinburgh: Scottish Intercollegiate Guidelines Network.
Clinical performance monitoring and research
IT Health Board. 2011. National Cancer Core Data Definitions, Interim Standard, HISO
10038.3. Wellington: Ministry of Health.
Ministry of Health. 2005. Access to Cancer Services for Māori. Wellington: Ministry of Health.
NHS Wales. 2005. National Standards for Upper Gastro-intestinal Cancer Services. Cardiff:
NHS Wales.
Appendices
Ministry of Health. 2002. Reducing Inequalities in Health. Wellington: Ministry of Health.
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