heaphy 2 radiotherapy glenys round charleen casson fri 30 th aug 2013 session 2 / talk 1 10:30 –...
TRANSCRIPT
HEAPHY 2
RADIOTHERAPY
Glenys ROUND Charleen CASSON
Fri 30th Aug 2013
Session 2 / Talk 1
10:30 – 10:50
Abstract
Traditionally wait times for palliative radiotherapy can be a lengthy process. It can involve several visits to the Oncology department, delaying a patient’s treatment when time is precious. In keeping with clinics established overseas (Canada & Brisbane) we have implemented a rapid access palliative clinic (RAPC) at Waikato Hospital. This paper describes the implementation of the clinic and assessment of the outcomes of the RAPC seen between 2009-2011. It will also discuss the multidisciplinary nature of such a clinic, the future for our RAPC and the advances that can be made to improve our patient’s journey.
Presented by Dr Glenys Round & Charlene Casson
Waikato Regional Cancer CentreRapid Access Palliative Clinic (RAPC)
Background
Referrer sends referral Wait list for FSA Seen by Radiation Oncologist Waitlist for simulation Simulated Waitlist for radiation therapy Treatment
Background
Palliative patients considered non-urgent (Cat 4 – National prioritisation criteria)
Wait times to FSA therefore can be long, as radical patients take priority unless Cat A (Spinal cord compression, uncontrolled bleeding)
Wait time to treatment vary widely- same day to several weeks
Up to 3 visits to treatment
Background
All this on a background of patients in a palliative phase of their disease process, where quality of life and time are important
Frequently elderly, frail, weak from end-stage disease, age and co-morbidities
Frequently an elderly exhausted spouse/partner Frequently from a rural area Patients have to travel up to 4-5hours
Background
Common around the world to have waiting times for FSA and treatment exceeding acceptable lengths of time
Pressure to increase patient throughput. Multiple studies have shown efficacy of single 8Gy
fraction cf. longer fractionations for bone pain Widely accepted, although in spite of evidence, use
of longer fractionations is common ( 20Gy in 5 fractions, 30Gy in 10 fractions)
Canada
Saw a need to do better Set up “Rapid Access Palliative Radiotherapy
Programme” Patients seen very quickly after referral Consultation, simulation, treatment all in one day for
appropriate patients Better programmes, offer multidisciplinary
assessment Some centres - patients offered access to a clinical
trial
Aims
Rapid assessment and treatment Multidisciplinary approach Rapid pain relief Improve quality of life Increase satisfaction of referrer Increase proportion of rural referrals
Aims
Separate clinic at a separate time could save FSA for radical patients
Separate simulation time could save allocated simulation space for radical patients
Initial Criteria
Known Carcinoma Not be a current patient
Bony pain
Diagnostic evidence No more than 3 painful sites Single fraction Patients transferred back to referring service
Clinic Pathway
Patients are booked into 3 time slots on a Tuesday
Team Meeting @ 8.30am Process:- Consultation- Simulation- Planning- Treatment
Patients characteristics Diagnosis Site of disease Analgesic medication Initial/ follow up Pain Score Treatment Information Further investigations ie bone scone, MRI 3 week follow up telephone call
Tracking Form
Age Gender- Average 69 yrs - Male 65%- Range 30 – 94 yrs - Female 35%
Main Diagnosis Referrers- Prostate 30% - MO 23%- Breast 17% - GP 21%- Lung 16% - Urology 20%
Statistics 2009 – 2012(261 Patients)
Spine 147 (T Spine = 76)
Pelvis/Hips 78
Ribs 21
Shoulders 17
Femur/Knee 13
Chest 12
Other 19
Treated Sites(patients = 226, treated sites = 307)
Prescriptions
51%
38%
7%4%
8 Gy
20Gy
30Gy
Other
63% CT’d & treated same day
46% single fractions
13% no treatment
Same Day Sim & Treat
Distance to RAPC
0 20 40 60 80 100 120 140
0>10km
>10km
>50km
>100km
>150km
Dis
tan
ce
Tra
ve
lle
d
Number of Patients
Pain Score
INITIAL PAIN SCORE (300 Tmt Sites)
0
20
40
60
80
100
120
0 1 2 3 4 5 6 7 8 9 10
Pain Score
No
of
Pa
tie
nts
Initial
F/UP PAIN SCORE (273 Tmt Sites)
0
20
40
60
80
100
120
0 1 2 3 4 5 6 7 8 9 10
Pain Score
No
of
Pa
tie
nts
F/Up
Increase - 15%
Decrease - 28%
Same - 44%
Unknown - 13%
Medication
Reduce visits to the department
Immediate multidisciplinary approach
Pain management reviewed
Continuity of care
Positive comments from patients/families
Benefits of RAPC
RAPC was implemented successfully
Data collected, further improvements have been made to the clinic to benefit the patient.
Conclusion
RAPC is not . . .
Radiation Oncologist seeing patient and simulating quickly, and then patient waits for treatment.
Imperatives
Deliberate Multidisciplinary Regular Investigates Admits Manages medical problems esp. analgesia,
nausea and bowels. Supports (relatives),
Imperatives
Refers – Med Onc, Palliative Care, physio, dietician, Maori support, chaplain.
Does not take ownership Refers back to referrer, but follows up
patients as required Communicates with referrer Prospectively gathers data Audit Reviews itself, adapts as required.
Imperatives
Lesser options CANNOT be called a “Rapid Access Palliative Clinic” or” Programme”.
Onboard imaging to plan and deliver palliative radiotherapy in a single, cohesive patient appointment – Perth.
( Hopefully soon for us. Note extra machine time). Stereotactic body radiotherapy – limited application
in most of these patients. Similar clinics for brain metastases – Canada.
( Truly multidisciplinary – Neurosurgery, Rad Onc, Med Onc, RT, Pall Care, Nurse, Allied Health)
Future
References
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