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.