1 malignant spinal cord compression past, present and future (south east of scotland) jackie whigham...
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Malignant Spinal Cord CompressionPast, Present and Future (South East of Scotland)
Jackie WhighamMacmillan Project Manager for Malignant
Spinal Cord Compression Edinburgh Cancer Centre
May 2010
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Overview
Facts and Figures
Driver for Change
Scotland’s MSCC Projects
South East Scotland MSCC Project
Jackie’s crystal ball!
Incidence: ?80/million/year
Cancers: breast, prostate, lung, haematological, Renal, GI……….
Symptoms: Pain (radicular), weakness, sensory loss, sphincter disturbance
Diagnosis: MRI whole spine
Treatment: Radiotherapy / Surgery
Prognosis: Mobility after treatment α mobility at diagnosis 3 – 6 months (in relation to cancer stage)
Facts and Figures
23%
77%
Known Cancer Diagnosis
First Presentation of Cancer
Incidence in Relation to Cancer
MSCC within Spinal ColumnMSCC within Spinal Column
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3
2Copyright J. Armstrong 2006
Malignant Spinal Cord Compression
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Copyright J. Armstrong 2006
1. Lack of recognition by primary and secondary care of the early symptoms
2. Lack of appropriate referral pathway once MSCC
suspected
3. Lack of awareness of the most effective investigation for diagnosing MSCC
A guideline for the early diagnosis recommended
Driver for Change Clinical Research Audit Group 97/98 (CRAG audit)
Levack et al 2001 (CRAG Audit 97/98)
1st symptom
tells GP Referred Diagnosis
Patient 3 wks
GP + hospital system 9 weeks
Back pain
Neurogenic pain - 2 months
--------------3 months ----------------
Weakness 3 wks
Sequence of Events
http://www.nice.org.uk/
Cancer Networks in Scotland
Local and National Education Programmes
SCAN
Regional Referral pathway ‘s
Audit
WO Scan
Management Guidelines
Audit
NO Scan
Rapid Referral Hot line Audit
Scottish MSCC Projects
SCANMSCC Steering Group
CHANGE TIME LINE OF EVENTS TO MSCC DIAGNOSIS?
Levack et al 2001 (CRAG Audit 97/98)
1st symptom
tells GP referred diagnosis
patient 3 wks GP + hospital system 9 weeks
back pain
neurogenic pain - 2 months
--------------3 months ----------------
weakness 3 wks
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What did we set out to do?
1. Develop and Implement Referral Pathways in Four Regions
Referral Pathways in each region
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Provisional Interim Findings July - December 2010
References:How to... Implement a rapid referral hotlineTrudy McLeay; Graeme Houston; Pamela Levack; Rosie Conway. Synergy; Feb 2008How to... benefit from a rapid referral hotlineTrudy McLeay; Graeme Houston; Wendy Milne; Pamela Levack; Sean KellySynergy; Mar 2008
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Site of MRI
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MRI Findings
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n=324
Mobile18%N=58
Assistance34%
n= 110
Unable to walk48%
n=156
Functional status – CRAG 97/98
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Functional status – MRI
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Functional Status 6 week Follow Up
2. Sustainable Education
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Education- Healthcare Professionals
Basic presentation delivered to healthcare professional who may see patients with suspected MSCC symptoms (identify champion)
GP receives a letter with copy of pathway for any patient who has an MRI for suspected MSCC
Informal opportunities as they arise – talking to GP on phone or staff on ward
CHANGE TIME LINE OF EVENTS TO MSCC DIAGNOSIS?
Levack et al 2001 (CRAG Audit 97/98)
1st symptom
tells GP referred diagnosis
patient 3 wks GP + hospital system 9 weeks
back pain
neurogenic pain - 2 months
--------------3 months ----------------
weakness 3 wks
Known Metastatic Disease
0
5
10
15
20
25
30
35
40
45
50
Yes No
26% Breast
33% Prostate
n=45n=23
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Education - Patients
Face to Face discussion with patients (and relative if appropriate) diagnosed with Vertebral metastases, MSCC, Impending or nerve root compression
Leaflet to support the discussion
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3. National Minimum Dataset Audit(SCAN, WoSCAN and NOSCAN)
National Minimum Dataset AuditStarted July 2009 – July 2010
SCAN – 6 months 139 patients’ (MSCC, Impending and treated nerve roots)
Analysis will answer lots of questions including:
Symptom to diagnosis
Functional status at various time points
Steroid practices
Multiprofessional referral
Treatments………………………………
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What else have we managed to do?
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The Future for SCAN
Build on the foundation
Consider further development of the service and how this will be taken forward
Add to the evidence base
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Jackie’s Crystal Ball Advice?Coordinator/Navigator/Specialist
Improve the care for patients with MSCC Collaborate with other networks Build a strong foundation Set standards Develop the service, local policies and protocols Assess educational needs Add to evidence base!
FINALLY
“Metastases to the spine can cause severe pain,
paralysis, and impairment of activities of daily living.
The treatment paradigm for spinal metastases involves
a cohesive multidisciplinary approach that allows
treatment plans to be made in the context of a patient's
overall condition”.
Meyer, Singh and Jenkins 2010
For further information/feedback contact:
Levack, P., Graham, J., Collie, D., Grant, R., Kidd, J., Kunkler, I., Gibson, A.,
Hurman, D., McMillan, N., Rampling, R., Slider, L., Statham, P. and Summers, D. 2001. A prospective audit of diagnosis, management and outcome of malignant spinal cord compression. Clinical Resource and Audit Group (CRAG) 97/98.
Levack, P., Garham, J., Collie, D., Grant, R., Kidd, J., Kunkler, I., Gibson, A., Hurman, D., McMillan, N., Rampling, R.., Slider, L., Statham, P. and D. Summers. 2002. Don't wait for a sensory level-listen to the symptoms: a prospective audit of the delays in diagnosis of malignant cord compression. Clinical Oncology, 14: pp.472-80.
Levack, P., Graham, J. and Kidd, J. 2004. Listen to the patient: quality of life of patients with recently diagnosed malignant cord compression in relation to their disability. Palliative Medicine, 18 pp. 594-601.
Loblaw, D.A., Perry, J., Chambers, A. and Laperriere. N.J. 2005. Systematic review of the Diagnosis and management of malignant extradural spinal cord compression: the Cancer Care Ontario Practice Guidelines Initiatitive’s Neuro Oncology Disease Site Group. Journal of Clinical Oncology, pp. 2028-2037.
References
References
McLeay, T., Houston, G., Levack, P., Conway, R. 2008. How to... Implement a rapid referral hotline Synergy; Feb 2008
McLeay, T., Houston, G., Milne, W., Levack, P. and Kelly, S. 2008 How to... benefit from a rapid referral hotline. Synergy; Mar 2008
McClinton, A. and Hutchison, C.2006. Malignant spinal cord compression, a retrospectiveaudit of clinical practice at the Beatson Oncology Centre. British Journal of Cancer, 94 pp. 486-91.
Meyer, Scott A. Singh, Harshpal. Jenkins, Arthur L.2010. Surgical treatment of metastatic spinal tumours. Mount Sinai Journal of Medicine. 77(1),124-9.
NICE consultation document http://www.nice.org.uk/guidance/index.jsp?action=folder&o=40703
WO SCAN Guidelines for MSCChttp://www.palliativecareglasgow.info/pdf/MSCC%20Guidelines.doc
Warnock, C., Cafferty, C., Hodson, S., Kirkam, E., Osguthorpe, C., Siddal, J., Walsh, R. and Foran.B. Evaluating the care of patients with malignant spinal cord compression at a regional cancer centre. 2008. International Journal of Palliative Nursing, 14 (10) pp. 510 515.