COMMENTORIES ON THE STAGES OF THE PATIENT PATHWAY (BOWEL AND ANAL CANCER) 1. Modes of Presentation: Emergencies (20%) If centres classify as emergency all patients who are admitted on an emergency basis, even if they subsequently have their operation on a scheduled operating list, then the numbers rise to 30%. Whereas if centres only classify as “emergency” those who actually have their operation on an urgent unscheduled list, then it is nearer 15%. Consequently we have taken 20% as a compromise. Patients are admitted under the Duty Surgical firm, if operation is required the same night this firm carries it out, but more usually, they are transferred next morning to the lower GI firm. Most patients with left sided large bowel obstruction should have preoperative contrast / CT studies etc., to identify the level of the obstruction. For some of these patients, stenting may be the best initial treatment. Most of these operations are best done during daylight hours and not in the middle of the night. In larger centres it may be possible to arrange some cross-specialty back-up at weekends. 2-Week Target OPD (20%) Various studies have confirmed that only a minority of CRC patients present with Target Wait (“2-week”) symptoms. The 2-week wait clinics work differently in the various centres, the following are options: a) Standard fax or electronically organised 2-week wait bookings according to National guideline criteria to colorectal surgical outpatients. b) All likely patients processed according to Protocol and given either a test as their first clinical encounter, or referral to the clinic with clinician intervention to decide unclear cases (Leicester 2003). c) Selected patients siphoned off to a one-stop rectal bleeding clinic, the rest sent to 2-week outpatient appointment. d) Other systems. Routine GI (surgical or medical) OPD (55%) These patients have not been identified as having red flag GI symptoms and go through the usual outpatient testing system. At present they constitute some 55% of patients who ultimately prove to have colorectal cancer. As selection is proving to be so difficult, it is highly desirable to shorten OPD waiting times for all patients with lower GI symptoms. GP direct open access (2%) A small number of patients have been given a GP open access test (barium enema, colonoscopy, flexible sigmoidoscopy etc.) where the result of a positive carcinoma diagnosis is usually unexpected; they are then fast-tracked to both the colorectal MDT and the appropriate colorectal outpatient clinic. Non-GI inpatient or outpatient departments (3%) Patients who present to other departments with non-specific symptoms such as anaemia, back pain, lethargy etc., in whom eventually a colorectal cancer is diagnosed usually as the result of a test. They are fast-tracked to the colorectal MDT and then to the appropriate colorectal consultant who may see them either in the clinic or as an inpatient, or in some other fashion. The fact that surgically curable right sided colon cancer may well present as iron deficiency anaemia needs to be appreciated by all chest and haematology departments, so that if they do decide themselves to commence diagnostic testing, they order colon imaging in preference to OGD. 2. First encounter with Secondary Care: Emergency Admissions: These either undergo tests leading to emergency surgery (the ultimate diagnostic test) or resolve temporarily and transferred to the colorectal team and discharged to colorectal outpatients, often with a diagnostic test “in the pipeline”. Target Wait Outpatients: Mostly 2-week wait patients are seen and then if the symptoms seem appropriate are fast-tracked to the appropriate diagnostic test. Patient Information Advocacy may start here with Specialist Nurses. Surgery, Medicine and other Outpatient Departments: Patients are seen and tests organised which frequently are not labelled urgent and come back a considerable length of time later. Radiology Department reconfiguration with much shorter access times for investigations, together with fast-track referral pathways for patients with positive tests is imperative if overall cancer waiting times are to be improved. 3. Initial Diagnostic Tests which prove Positive: These may arise either from the target wait outpatients, or the generality of surgery, medicine and other outpatient departments. The tests include endoscopies +/- biopsy, CT colonography, barium enema and histology. When a positive diagnosis is obtained it is essential to have a robust alert system for informing the MDT that this has occurred. One method is for a copy of the positive test to be sent as a fail-safe reminder to the colorectal MDT. Urgent notification being given to the colorectal surgeons at the same time. If the patient is not already in a colorectal clinic, then referral is made direct from the endoscopy or radiology departments, either to the colorectal nurse specialist or to the MDT. (Where such a system is not already in place, then some acceptable variant should be instituted urgently). Equivocal barium enemas must likewise be flagged up for either separate X-ray meetings or the MDT, or both. Most centres regarded as not necessary for patients with “typical” applecore lesion on barium enema to have a colonoscopy and biopsy as well. (Equivocal cases will usually need these after discussion at the appropriate meeting). 4 Failed Diagnostic Tests Where colonoscopy or barium enema fails to image either the whole colon, or the requisite piece of colon, ideally a mechanism should be in place to utilise the same bowel preparation for an alternative test. Some centres do have such catch-all arrangements. 5. Working Diagnosis: Mostly made at the colorectal outpatient department but sometimes made at the interface with another department, and sometimes made at emergency surgery. For the majority the diagnosis is transmitted in the outpatient department by the colorectal surgeon, in the presence of the Specialist Bowel Nurse and/or Stoma Nurse who interacts with the patient and starts to form a relationship. Written, taped, or video patient information is provided. The Bowel Nurse Specialist conducts his/her own cancer news interview, and can provide useful patient information leaflets, together with contact details for bowel cancer support groups. Direct urgent (sometimes fax) notification of the GP should take place within 24 hours of the patient being told the cancer diagnosis. 6. MDT Involvement: The MDT becomes involved once the working diagnosis has been made. Sources of notification are:1. From emergency surgery 2. Positive diagnostic test either from the colorectal clinic or, direct from the departments (endoscopy, radiology, histology), direct notification by the Stoma Nurses and Specialist Colorectal Nurses. The patients are then discussed at the regular MDT meetings. These may be either weekly or fortnightly (occasionally less often). MDT meetings involve a variable number of people according to the “layout” of facilities at different sites. Core personnel include the colorectal surgeon, the colorectal nurse, the oncologist, and the clerk/co-coordinator. The emphasis on histology and radiology in the actual MDT Meeting varies between different centres (particularly where there is a separate X-ray or histology meeting). The MDT data is ideally kept on a database, which should interact with the general colorectal cancer database. Ideally there should be direct informing of GP’s after each MDT discussion. Progress reports and finally a summary should be placed in the case notes to record MDT decisions. 7. Staging: This takes place after the working diagnosis has been secured and consists of appropriate CT, ultrasound and MRI scans according to accepted protocols. Radiology access times must be short enough to enable these scans to take place within cancer target waiting times. 8. Treatment Plan: This is agreed and discussed, approved and modified by the MDT and patients are grouped into potentially curative, potentially palliative. Polyps with a cancer contained within them (malignant polyps) often attract quite detailed discussion in the MDT as several treatment options are often possible. Curative patients with colon cancer proceed directly to operation. Curative patients with rectal cancer should be referred to oncology for consideration of pre-operative adjuvant treatment. There is stoma nurse interaction at this point as well as specialist colorectal nurse involvement. Palliative patients are discussed with palliative care team, specialist nurses for palliative procedures and conservative treatments, which may involve surgery or radiotherapy or chemotherapy. Patients with squamous anal cancers are slightly different and are not fully covered under this pathway. The role of chemo radiotherapy is usually paramount. 9. Definitive Treatments: These include curative procedures, palliative procedures and medical procedures in palliation. 10. Histology Discussions at the MDT: After surgery histology becomes available and is discussed. Dukes’ A patients do not receive adjuvant chemotherapy. Dukes’ B & C are discussed and referred or not as the case may be. Patients with metastatic disease (Dukes’ “D”) and local tumour persistence are referred for definitive or palliative treatment. 11. Post Operative Adjuvant Therapy: This is organised at the last MDT meeting and at this point many patients are discharged from the MDT. 12. Follow-up and Data Base Arrangements: After completion of definitive curative treatment (surgery, surgery + adjuvant treatment) patients should be seen to agree their follow-up protocol, and both its purpose and its nature should be explained to them. Criteria need to be laid down to activate formal referral to the Clinical Genetics Department so that risk to other members of the family as well as follow-up of the index case can be determined. Such risk factors include index case less than 45 years, positive family history, multiple polyps etc. Follow-up may be pure surgical (Dukes’ A cases) (Dukes’ B without adjuvant chemotherapy), shared oncology and surgery (Dukes’ B & C), or shared modified palliative follow-up involving oncologists, radiotherapists, palliative care, surgeon’s etc. At this point the patient’s details are confirmed on the database, and the patients details downloaded into whatever citywide database is available. Many units regularly follow up CRC patients with regular colonoscopy, CEA and CT scans, together with chest X-ray/scans, although the costeffectiveness of such schedules remains controversial. These considerations inevitably tend to dictate an agreed selective policy. 13. Recurrence: When identified is reported back to the MDT for a joint decision on further treatment, (which may involve referral to the hepatic, thoracic and colorectal surgeons, etc.) There is an emerging role for PET scanning in confirming the extent of metastatic disease, particularly when planning major additional organ resections. Options for patients with locally recurrent, and / or metastatic disease can include further GI or liver surgery, radiofrequency ablation of liver metastases, and the newer chemotherapy regimens, which can significantly prolong survival. 14. Final Outcomes: The final outcomes are entered into the database. If at all possible, this should included notification and cause of death. 15. Pathways Going out of Date: Plainly pathways evolve (or put less charitably, “go out of date!”) We have therefore dated this pathway July 2004 and plan to revisit it for an update in eighteen months time.