PET CT audit report

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Audit of the first 100 PET CT scans
performed by the Christie Hospital
NHS Trust on patients from North
Wales
By Sue Armstrong
Audit Facilitator
Contents:
1) Executive Summary
2) Introduction and Background
2.1) PET CT Technology
2.2) Commissioning and Planning guidance
2.3) Service Provision
3) Aims and Objectives
4) Methodology
4.1) Stage 1 – Establishing standard questions
4.2) Stage 2 – Collection of data
4.3) Stage 3 – Satisfaction levels
5) Results and analysis
5.1) Stage 1 & 2
5.2) Satisfaction levels
6) Discussion
7) Conclusion and recommendations
8) Appendices
Appendix
Appendix
Appendix
Appendix
1
2
3
4
Cancer Network internal PET CT referral procedure
PET CT request form template
Patient Register (Log of referrals)
Consultants Questionnaire
1.
Executive Summary
PET CT is a new technology that is better able to stage cancer and detect metastasis
and as such may be considered superior to CT imaging alone. No PET-CT service exists
in Wales and as such patient from across Wales have travelled to Cheltenham for a
service delivered in accordance with Welsh clinical guidelines.
From April 2008 the North Wales Cancer Network, on behalf of its stakeholders
commissioned a service from the Christie Hospital in Manchester.
This audit proposed to assess the first 100 scans delivered by the Christie analysing,

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Access
Utilisation and activity
Clinical satisfaction
Clinical, patient and financial implications
Upon analysis of all the data collated, the Cancer Network findings are as follows;
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2.
PET CT scans satisfactorily staged cancer in 88% of all cases.
The evidence suggests that PET CT scanning had a positive influence on the
management of patients through staging cancer more accurately
It is suggested that PET CT informed alternative treatment options in 29% cases
with the greatest impact being suggested within Haematological cancers where
75% of PET scans informed potentially alternative treatment options.
Overall, clinicians exhibited high levels of satisfaction with the current referral
mechanism.
Overall, clinicians were satisfied with the service provided from Christie NHS
Trust.
PET prevented potential co-morbidties in patients as a result of confirming
disease stage and indicating alternative treatment pathways.
Introduction and context
2.1) PET CT technology
PET images demonstrate the chemistry of organs and other tissues such as tumors. A
radiopharmaceutical, such as FDG (fluorodeoxyglucose), which includes both sugar
(glucose) and a radionuclide (a radioactive element) that gives off signals, is injected
into the patient, and its emissions are measured by a PET scanner. Because Cancer
cells have a higher metabolic rate than other organs or tumours they can then be
highlighted on a PET-CT scan following the injection of the radioactive tracer into the
patient. This is beneficial for a variety of reasons;

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it can help identify cancer earlier than other techniques
it can also differentiate between malignant and benign tumours
determine the location and extent of a cancer
reveal how a type of cancer is responding to treatment.
These benefits enable a more precise staging of disease to the extent that some
treatment can be modified or eliminated a factor that obviously has benefits to the
patient in terms of co-morbidities but also to the service in terms of reduction of costs.
2.2) Commissioning and Planning guidance
The Welsh Health Circular (63) of 2003 identifies Health Commission Wales (HCW) as
the designated commissioners of PET services in Wales. There was to be a phased
introduction of PET, with the initial Phase 1 restricted to HCW funding only the strongly
evidence-based clinical conditions from July 2005. Phase 1, which incorporates the first
100 scans within this audit includes the following clinical criteria;
Lung cancer:




Investigation of the solitary pulmonary nodule in cases where a biopsy is not
possible or has failed, depending on nodule size, position and CT characterisation
Investigation of patients with non-small cell lung cancer who are staged as
candidates for surgery on CT, to look for involved intrathoracic lymph nodes and
distant metastases
Investigation of patients with non-small cell lung cancer who are otherwise
surgical candidates and have, on CT, limited (1–2 stations) N2/3 disease of
uncertain pathological significance
Investigation of patients with non-small cell lung cancer who are candidates for
radical radiotherapy on CT
Colorectal cancer:


Re-staging of colorectal cancer prior to surgery for the removal of solitary
metastasis from the liver or lung or radical extensive pelvic surgery
Re-staging of known colorectal cancer when conventional imaging has failed to
show the cause of rising tumour markers
Lymphoma:


Re-staging of Hodgkin’s lymphoma after induction therapy
Re-staging of high grade non-Hodgkin’s lymphoma after induction therapy
The consultation document ‘A Framework for the Development of Positron Emission
Tomography (PET) Services in England’, issued by the Department of Health in July
2004 suggested wider criteria than the Welsh guidance and on this basis recommended
approximately 600 scans per annum for the population of North Wales.
In part reflecting the above and the rationalisation of oesophageal surgery to Wrexham
the LHBs in North Wales agreed to commission PET-CT for oesophageal cancer. Outside
the HCW criteria, and this activity is included in the audit sample.
2.3) Service provision
As described the PET CT scanning facility for the population of North Wales is now
provided by Christies NHS Trust at a cost of £895 per scan. This service commenced in
April 2008 and has a number of distinct features,
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Referrals from MDTs are faxed through to the Cancer Network office where they
are transcribed and logged.
Referrals are analysed for their compliance with Welsh criteria
Transcribed referrals are e-mailed to the PET-CT department at the Christie
The Christie attempt to scan within one week and report within two days
Reporting is in the form of a paper report and two CD roms with images
contained.
Previously scanning was provided by the Cheltenham Imaging Centre and The Paul
Strickland Scanner Centre at Mount Vernon Hospital in Middlesex, but due to problems
with capacity and unreasonable travel distance for patients, the NWCN commissioned
Christies NHS Trust based in Withington.
3.
Aims and Objectives
The aim of the project is to analyse the details around the first 100 scans referred to the
Christie and if possible explore the assumption that utilising PET CT will inform the
decision making on treatment in a manner that reduces radical treatment associated
with significant co-morbidity.
Objectives are:
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To measure the usefulness of PET CT scans in staging cancer
To establish whether management of cancer patients is improved/altered by the use
of PET CT scanning
To provide firm evidence of the benefits to the Network and it’s Stakeholders
To assess the attitude of clinicians toward the logistics of accessing a PET CT scan
To ascertain any potential cost savings
Intended Outcome:
The project should help identify any issues with the newly established service, confirm
the level of utilisation and identify any benefits and savings.
4.
Methodology
As stated previously this project aims to prove the benefits of utilising PET CT scans for
cancer patients. In order to test this theory a sample of the first 100 patients referred
since the period April 2008 were taken from the Cancer Networks internal log.
Standard questions were then established for each referral criteria to determine the
outcome and allow the data to be quantifiable, see below:
4.1) Stage 1 – Establishing standard questions
Criteria 1.
Staging of non small cell lung cancer prior to surgery or radical radiotherapy
Standard Questions:
Was satisfactory staging achieved?
Did the patient go on to have Radiotherapy?
Did the patient go on to have Surgery?
Did the patient go on to have treatment other than Surgery or Radiotherapy?
Criteria 2.
Assessment of solitary pulmonary nodule only when biopsy not safe or practical
Standard Questions:
No question just the number of referrals
Criteria 3.
Re-staging of colon cancer prior to surgery for removal of metastatic disease
from liver or lungs
Standard Questions:
Was satisfactory staging achieved?
Did the patient go on to have Surgery on liver or lungs?
Did the patient go on to have other treatment?
Did the patient go on to have no treatment?
Criteria 4.
Re-staging of colon cancer when conventional imaging has failed to show the
cause of rising tumour markers
Standard Questions:
Was satisfactory staging achieved?
Cause of rising tumour markers shown?
Did the patient go on to have no treatment?
Criteria 5.
Re-staging of Hodgkin and high grade non Hodgkin lymphoma after induction
Therapy
Standard Questions:
Was satisfactory staging achieved?
Did the patient go on to have treatment?
Criteria 6.
Staging of oesophageal cancer prior to radical surgery
Standard Questions:
Was satisfactory staging achieved?
Did the patient go on to have Surgery?
4.2) Stage 2 – Collection of data
A spreadsheet was designed to capture all the information and the patient notes on the
CANISC system were interrogated to gain answers to the standard questions. The
CANISC system was the main source of data for this investigation, but in some
instances, where the data could not be found or where patient notes were insufficient,
the information was sought from the MDT co-ordinators or the Trust Cancer Managers.
Once all the data was obtained the spreadsheet was updated and the results analysed.
4.3) Stage 3 – Satisfaction levels
The next step was to compile a questionnaire to gauge the opinions of the referring
clinicians for the method of accessing the service (see appendix 4) and to see whether
there were any differences in opinion between sites. The questionnaire was then
emailed out to the referring consultants for completion.
5.
Results and analysis
5.1) Stage 1 & 2
Percentage of scans per hospital
25%
41%
Glan Clwyd
Countess of Chester
Bangor
Wrexham Maelor
27%
7%
The chart above shows what percentage of the 100 scans examined were requested
by each hospital, Glan Clwyd requested the most scans at 41%. The chart below
shows the percentage of scans conducted for each cancer site clearly showing that
lung scans account for just less than half of all scans requested.
Percentage of scans per cancer site
19%
26%
3%
8%
44%
Colorectal
Head & Neck
Haem
Lung
UGI
The pie chart below illustrates the percentage of scans which were definitely successful
in staging cancer; this figure could be higher though, as the 10% that represents the
‘unknown’ category relates to data that is unobtainable rather than truly not known.
Percentage of PET CT scans that helped to stage cancer satisfactorily
10%
3%
Yes
No
Unknown
87%
The table and chart below show within which criteria (or cancer site) the PET CT
scan may have been influential in informing a treatment decision choice that altered
a clinical pathway that might have otherwise been followed without a PET- scan e.g.
oesophagectomy.
Most cases of treatment pathways being altered were within criteria 6 which relates
to cancers of the oesophagus. Within this cancer site potentially 14 clinical
pathways were altered which may not only have resulted in a cost saving to the NHS
(see table below) in terms of avoiding significant and traumatic surgery but also
caused less co-morbidity for patients found to have extensive disease.
Number of unnecessary invasive treatments prevented per criteria
16
14
Treatments prevented
12
10
8
6
4
2
0
1
2
3
4
5
6
Criteria
TREATMENT CRITERIA
1
Staging of non small cell lung cancer prior to surgery or radical radiotherapy
2
Assessment of solitary pulmonary nodule only when biopsy not safe or practical
3
Re-staging of colon cancer prior to surgery for removal of metastatic disease from liver or lungs
4
Re-staging of colon cancer when conventional imaging has failed to show the cause of rising tumour markers
5
Re-staging of hodgkin and high grade non hodgkin lymphoma after induction therapy
6
Staging of oesophageal cancer prior to radical surgery
The table below shows 3 of the 6 criteria within which scans are requested, these have
been chosen as it is possible to postulate a course of treatment action that might
previously have been taken had the scan not taken place. It is possible to conclude that
management of patients within the other criteria was also altered as a result of the
scan, but this is more difficult to place a cost on. The costings are taken from the 200809 Admitted Patient Care Tariff which is used in England; this has been used as there
isn’t a national tariff for Wales. The potential cost savings achieved are shown in the
table below:
Costings for surgeries prevented by PET CT scanning
Criteria
1
3
6
Staging of non small cell lung
cancer prior to surgery or radical
radiotherapy
Re-staging of colon cancer prior to
surgery for removal of metastatic
disease from liver or lungs
Staging of oesophageal cancer
prior to radical surgery
*Cost
(£)
No. of
procedures
prevented
Potential
cost
***Cost of
PET CT
scans
Potential
savings
Major Thoracic Procedures
£4,090
4
£16,360
£3,580
£12,780
Liver - Complex Procedures
£5,956
D03
Major Thoracic Procedures
£4,090
2
**£20,092
£1,790
£18,302
F02
Oesophagus - Very Major
Procedures
£3,574
14
£50,036
£12,530
£37,506
20
£86,488
£17,900
£68,588
HRG
Code
Narrative
D03
G02
Totals
* costs taken from 2008.09 Admitted Patient Care Tariff used in England
** this cost represents the maximum potential cost if both procedures were required i.e. surgery on both liver and lungs
*** based on £895 per scan
The potential savings have been calculated by selecting the appropriate procedure from
the tariff and multiplying by the number of procedures that were prevented to derive the
potential cost, then the cost of the PET CT scans was calculated and deducted from the
potential cost to give the potential savings.
5.1) Stage 3 Satisfaction levels
The chart below shows a selection of questions asked of the referring clinicians to
assess their perceptions of the new referral mechanism. Overall, it demonstrates quite a
high level of satisfaction with the service, with most clinicians rating the pro-forma as
clinically appropriate and only highlighting a small number of problems which will be
discussed later on. On the whole, the clinicians indicate that they receive reports within
a reasonable time period and that the reports are of a satisfactory nature.
Feedback from satisfaction survey on 35 clinicians
120%
100%
Percentage of clinicians
80%
Yes
No
60%
40%
20%
0%
Satisfied with pro-forma
Problem with referrals
Reasonable timescale for
receiving reports
Satisfied with standard of
reports
Overall satisfied with new
system
Questions asked
When the referral mechanism changed in April 2008, one of the main concerns was the
incorporation of yet another administrative layer into the process; that being the
requirement to fax the completed pro-forma request to the Cancer Network with
someone there forwarding it on to Christies NHS Trust. The concern being that there
was the potential for delay. It is clearly demonstrated below though, that this concern
has not materialised as 46% of referring clinicians say the new system is better than the
old system and 26% saying it is at least the same and no worse. Fewer than 3% (1
response) say that the new system is not as good as the previous system.
Satisfaction with new referral system compared with previous system
50.00%
45.00%
40.00%
35.00%
Percentage
30.00%
25.00%
20.00%
15.00%
10.00%
5.00%
0.00%
About the same as the previous
system
Better than the previous system
Not as good as the previous system
Don't Know
Responses
When examining the negative response, it becomes apparent from the comments made
that the problems arise once the service has been accessed and the PET CT scan has
happened, see extract below;
‘In comparison with Cheltenham the service was almost as good after the initial glitches. Over the
past month or 2, since the discussion with Christies about how to send the images, the delivery of
the discs has been suboptimal. Reading the report does not indicate the actuality in all cases.
There is a tendency to read the images rather than to give an opinion. This became worse after
the discussion about how to send the images. The reports arrive, but the discs often are not
timely, this has been most noticeable over the past month. Also there is a tendency to report the
images rather than to give an opinion on the interpretation of the images (which is the point of
having expert opinion).’
These comments indicate that there have been issues with delivery of the discs and
reports and also dissatisfaction with the content of the reports. While this is an
interesting point though, it is only 1 opinion and was not echoed in any of the other 34
responses.
The pie chart below illustrates the reaction to the question of responsiveness, with 77%
of referring clinicians saying that the system is very responsive compared to 23% saying
it varies. This further reinforces that the concerns around delays, anticipated as a result
of adding another stage in the process, have not had a detrimental effect on accessing
the service and overall the referring clinicians are happy with the turnaround of
processing the forms.
Responsiveness of new system
23%
Very responsive
Varies
77%
The small number of issues highlighted by clinicians of problems with referrals is shown
in the extract below, 3 clinicians out of the 35 surveyed responded that there had been
a problem. Upon further analysis of the comments made, it becomes apparent that the
problems raised are not around access or responsiveness but rather separate issues.
One response refers to a problem with handwriting being difficult to read which can
result in delays or errors as the person in the Network office who is transcribing the
faxed pro-forma onto an electronic template often will have to contact the person who
faxed the form to confirm what is actually written. The second issue highlighted refers
to the delivery of the service from the providing trust as opposed to problems with
accessing the service which will be discussed in more detail later. Lastly the third
response refers to a dispute between the Network and a clinician regarding the need in
a certain case for the patient to have a PET CT scan.
Problems with referrals and explanation
Site
Yes
My illegible handwriting
Lung
Yes
In comparison with Cheltenham the service was almost as good after the initial glitches. Over
the past month or 2, since the discussion with Christies about how to send the images, the
delivery of the discs has been suboptimal. Reading the report does not indicate the actuality in
all cases. There is a tendency to read the images rather than to give an opinion. This became
worse after the discussion about how to send the images. The reports arrive , but the discs
often are not timely, this has been most noticeable over the past month. Also there is a
tendency to report the images rather than to give an opinion on the interpretation of the
images (which is the point of having expert opinion).
Upper GI
Yes
North Wales Cancer Network vetoed a request that the MDT had agreed.
Upper GI
Also analysed was the satisfaction levels between cancer sites with the service, as
illustrated in the table below. Interestingly, this clearly shows that problems are within
2 distinct sites; Lung and Upper GI as these are the only sites that have had problems
with the service. The issue within the Lung site, as explained in the extract above
relates to handwriting and overall does not affect satisfaction levels for the service.
However, the issues within the Upper GI site are, as outlined above, more complex and
do have a detrimental effect upon the users satisfaction with the service and the referral
mechanism.
% of
responses for
each site
Problems
with
referrals
Reports
received
within
reasonable
timescale
Colorectal
8.6%
No
Yes
Yes
Yes
Haematological
17.1%
No
Yes
Yes
Yes
Cancer site
Reports of
a
satisfactory
standard
Happy
with the
system
overall
Head & Neck
5.7%
No
Yes
Yes
Yes
Lung
37.1%
Yes
Yes
Yes
Yes
Upper GI
28.6%
Yes
No
No
No
Other
2.9%
No
Yes
Yes
Yes
Total
100.0%
What do you believe would improve the service?
My patients and team seem very happy with the service
Web based reporting access
There are occasionally some situations where the scenarios provided in the relevant form do
not cover the clinical situation. I think there should be an 'other' column with free text space
available. Otherwise the form is well set out.
Need to be able to do this electronically
Need to extend the agreed indications for PET scans to include what is currently best practice
in other centres and other countries. i.e. upfront PET scans for Hodgkins gives more accurate
staging and usually increases the staging and may modify treatment. There are other
examples.
See comments made in response to Q6 and timely delivery of the discs to coincide with the
reports.
Above is an extract of the comments made by clinicians regarding what they think would
improve the service. The need to complete the forms electronically and email them is
mentioned as is Web based reporting access to remove the logistical problems with
posting the discs and reports.
6.
Discussion
This audit was devised to gain insight into how PET CT scanning assisted in the cancer
patients’ pathway; it can be argued from the findings, that the scans impacted on
patient care in 2 distinct ways. Firstly, the use of PET CT scanning definitely influenced
the management of patients by staging cancer more accurately resulting in a better
service for the patient. Secondly, the use of PET CT scans prevented unnecessary,
invasive procedures in 29% of cases, this is not to infer that the PET CT had a positive
outcome for the patient, merely that the scan showed that the option of invasive
treatment might not be beneficial and this finding altered the treatment pathway for
that patient. This has wider implications for the NHS as a whole in terms of ensuring
resources are better utilised. Although there is evidence to support this finding, it is,
however very difficult to attempt to place a cost upon it, with some criteria being more
calculable than others. This has been attempted in the ‘Costings for surgeries prevented
by PET CT scanning’ table in the results section of this report. This table shows a
potential saving to the NHS of just over £68,000. This figure however warrants a note
of caution as it is very difficult to predict what ‘might have been’ and it has been
calculated using a number of assumptions.
Firstly, it is assumed that each of the procedures ‘prevented’ would have definitely
resulted the significant treatment identifed. While this is a logical assumption in each
case, especially those within criteria 6 who had suspected oesophageal cancer, it cannot
be conclusively stated as fact. Secondly, the costing for criteria 3 ‘Re-staging of colon
cancer prior to surgery for removal of metastatic disease from liver or lungs’ assumes
that surgery was performed on both liver and lungs in both cases, whereas it might just
have been on one or the other.
There is also great difficulty in placing a cost saving on what might have been prevented
within criteria 4 – ‘Re-staging of colon cancer when conventional imaging has failed to
show the cause of rising tumour markers’ and criteria 5 – ‘Re-staging of hodgkin and
high grade non hodgkin lymphoma after induction therapy’. While a cost is can be
calculated it is difficult to predict with any degree of certainty the alternative treatment
that might have been undertaken, however there can be little doubt of the benefit to
patients, in terms of earlier intervention and more precise treatment.
The NWCN has benefitted patients by ensuring a more local service is provided by
Christies, but this has cost implications, as the cost per scan is more expensive now than
when it was provided by the voluntary sector. Does this demonstrate ‘value for money’
when the service could be provided for less or is providing a more local service for
vulnerable patients a more fundamental value that cannot be judged on cost alone?
However there is the alternative discussion regarding reduced ambulance costs though
again this is difficult to calculate in part because it is not clear how many patients have
used the ambulance service and which organisation has a role in monitoring it use.
When attempting to gauge the opinions of the clinicians who regularly use the service,
the findings strongly indicate a high level of satisfaction for the current referral
mechanism. Lung referrals were the most common with 44% of referrals being in this
area. The feedback obtained showed a high level of satisfaction among these clinicians
with the only negative comment made referring to the clinicians own illegible
handwriting. This comment does raise an interesting point which was echoed in other
responses. Specifically, the need for hand writing and faxing the forms which, given the
technology available, does seem questionable.
There would seem to be some merit in receiving the form electronically to cut out the
need for transcribing the form and this would also reduce the number of queries back to
the clinicians and secretaries regarding having to clarify hand writing which can delay
things. Some clinicians also commented on the need to evolve the process into a web
based reporting tool so that they could access the reports on the web themselves rather
than have to wait for a disc to be posted to them. The only negative feedback received
related to Upper Gastrointestinal clinicians whose comments reflected dissatisfaction
with the service once the PET CT scan had been done rather than problems with the
referral mechanism. They complained of the reports not being received within a
reasonable timescale and of the reports tending to read the images rather than give an
opinion. Overall though, these feelings were not in the majority with most clinicians
reporting they were happy with the system.
7.
Conclusion and recommendations
The results achieved support all the initial hypotheses made regarding the benefits of
PET CT scanning.
Upon reflection of the findings of this audit and the comments provided, the following
recommendations are made;

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

The continued use of PET CT scanning should be supported and
funding should be provided to enable this.
There should be a further audit conducted on the next 100 patients.
The current referral mechanism should be refined to a) require that
the faxed referrals not be handwritten but completed electronically to
remove problems with legibility of the forms and b) allow these faxed
referrals to be scanned (via a networked scanner) and emailed to
Christies NHST, this will save time.
A further audit should be conducted concentrating on the provision of
the service from Christies NHS Trust and levels of satisfaction with it.
The satisfaction survey conducted within this audit concentrated on
satisfaction with the referral mechanism rather than service provision,
but this highlighted areas where further investigation would be
beneficial and recommendations for improvement could be made.
Appendix 1.
PET-CT – Christies Referrals Procedures
Receiving a Referral
Receiving a hand written faxed referral:

Transcribe fax to the electronic Christies request form

Ensure all mandatory items are completed – if not refer back to the
referring Clinician or Secretary
When the form has been approved input ‘Verified by D Heron’ within the
referrers signature section
Located on the Network drive – data on ‘nrcldc01’ (F:) > Cancer Network folder, File name –
Electronic referral form – Final PET CT Investigation Request.doc

Go to section: Encrypting Word Files
Receiving an electronic typed referral by email:
Note: this will only apply when it has been pre-arranged with a member of the
Cancer Network team


Ensure all mandatory items are completed – if not refer back to the
referrer
When the form has been approved input ‘Verified by D Heron’ within the
referrers signature section
Go to section: Encrypting Word Files
Encrypting Word Files – Password Protection


Open document, and complete necessary fields
Click ‘Tools’ located on the main menu bar, then ‘Options’
DRAFT 1 - 27.10.08

An information box will then appear, select the ‘Security’ tab

Enter in password: ****** (one word and all in caps) located under the heading –
File encryption for this document indicated by the arrow
Click ‘OK’, another information box will appear requesting you to re-type the
password for confirmation then click ‘OK’
Then save the document as usual


Emailing a request


PET CT requests must be encrypted before attaching to a mail message
Emails must be sent to: ******* & *******
Registering a request

Each PET CT request needs to be logged on the Network register

Complete all columns with the exception of the last, which will be completed at a
later date
Located on the Network drive – data on ‘nrcldc01’ (F:) > Cancer Network folder, File name – Electronic
referral form – PATIENT REGISTER FOR PET CT.doc
.
DRAFT 1 - 27.10.08
Appendix 2.
PET CT Investigation Request
Date
Target Patient?
N / 31 / 62
(please circle)
Patient Demographics
Consultant Referrer
Private Pt.

NHS No:
Name:
Surname:
GMC No
Forename:
Signature:
Address:
Address for
VERIFIED BY DAMIAN HERON
Report:
Postcode:
DoB:
E-mail:
Home No:
Tel. No:
Mobile No:
Fax No:
Mandatory Information
Inpatient?
Hosp:
Contact No:
Diabetic?
If Yes,
specify?
Pt. weight (kg):
Yes 
Insulin 
Ward:
Pregnant?
Breast feeding?
Communicable
infection?
No 
Tablets 
Diet 
If Yes, specify:
Claustrophobic?
Yes 
Yes 
No 
No 
Yes 
No 
Yes 
No 
Clinical Indication






Staging of non-small cell lung cancer prior to surgery or radical radiotherapy
Assessment of solitary pulmonary nodule ONLY when biopsy not safe or practicable
Re-staging of colon cancer prior to surgery for removal of metastatic disease from liver or lungs
Re-staging of colon cancer when conventional imaging has failed to show the cause of rising tumour markers
Re-staging of Hodgkin and high grade non Hodgkin lymphoma after induction therapy
Staging of oesophageal cancer prior to radical surgery
Histology and Staging
Histologically confirmed
cancer?
Current clinical stage:
Treatment and Intervention
Has this patient had:
Surgery?
Yes 
Radiotherapy?
Yes 
Chemotherapy? Yes 
Yes 
No 
T
No 
No 
No 
Type:
N
Type:
Type:
Type:
M
Date complete:
Date complete:
Date complete:
Other Clinical Details
For Departmental Use Only
Christie Hospital No:
DB  LT 
Authorised:
FX 
Please ensure form is fully completed before referring. Thank you.
Date & Time of Appointment:
Fax requests to: 01745 589 917
DRAFT 1 - 27.10.08
Appendix 3. North Wales Cancer Network register of referrals.
NORTH WALES PET CT ACTIVITY
TREATMENT OPTIONS
1
STAGING OF NON SMALL CELL LUNG CANCER PRIOR TO SURGERY OR RADICAL RADIOTHERAPY
LUNG
2
ASSESSMENT OF SOLITARY PULMONARY NODULE ONLY WHEN BIOPSY NOT SAFE OR PRACTICAL
LUNG
3
RE-STAGING OF COLON CANCER PRIOR TO SURGERY FOR REMOVAL OF METASTATIC DISEASE FROM LIVER OR LUNGS
COLORECTAL
4
RE-STAGING OF COLON CANCER WHEN CONVENTIONAL IMAGING HAS FAILED TO SHOW THE CAUSE OF RISING TUMOUR MARKERS
COLORECTAL
5
RE-STAGING OF HODGKIN AND HIGH GRADE NON HODGKIN LYMPHOMA AFTER INDUCTION THERAPY
HAEM
6
STAGING OF OESOPHAGEAL CANCER PRIOR TO RADICAL SURGERY
UGI
NO
PATIENT
NHS NO
POST CODE/
LOCATION
REFERRING
CLINICIAN
SITE
TRUST
DATE
REC'D
DATE SENT
TO CHRISTIE
DATE
OF
PET
CRITERIA
PICK LIST
REF FORM
OUTCOME
EMAILED TO
CHRISTIE
DRAFT 1 - 27.10.08
Appendix 4.
Consultant Satisfaction Survey – Referrals for PET CT scans
1)
What cancer site do you work in?
Upper GI
Haematological
Lung
Head & Neck
2)
How often would you say you referred
patients for PET CT Scanning?
Frequently
3)
When referring patients for PET CT scans,
how would you describe the Investigation
request form that must be completed?
Insufficient Clinically Excessive Information
detail
appropriate
requirements
4)
How responsive do you think this new
system of referring is?
Very
5)
Have you had any problems with referrals
since the new system was implemented?
Yes
6) If so, what kinds of problems have you
had?
Please comment
7)
Do you receive the reports within a
reasonable timescale?
Yes
No
8)
Yes
No
9)
Overall, are you happy with the new
referral system?
Yes
No
10) Would you say the new system is better
than the old system?
Yes
11) If not, what do you believe would
improve the service?
Please comment
Are the reports of a satisfactory standard?
Regularly
Colorectal
Other
Not at all
Occasionally
Varies
No
No
About the same
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