london cancer: pathway specification for · london cancer: pathway specification for urological...

London Cancer:

Pathway specification for urological cancers

Originally published May 2012, updated December 2012

Version 2.0

2

Contents

1. Introduction ................................................................................................................................... 2 1.1. London Cancer ................................................................................................................................. 2 1.2. Pathway specifications .................................................................................................................... 3

2. Pelvic cancer pathway specification ................................................................................................. 5

3. Renal cancer pathway specification ............................................................................................... 13

Appendix: London Cancer Urology Technical Group .............................................................................. 19

1. Introduction

1.1. London Cancer

The cancer care providers of North East London and North Central London and West Essex agreed in July 2011 to develop an integrated cancer system in response to the requirements of London’s Strategic Health Authority and commissioners. Since April 2012 this integrated cancer system, London Cancer, has been commissioned to provide cancer services for a resident population of 3.2 million. Its mission is to drive superior outcomes and experience for our patients and local communities, and thereby position its staff as leaders in cancer care – locally, nationally and globally. London Cancer will be underpinned by patient-empowerment, research, evidence and information sharing. It will radically refocus hospitals into working in partnership with each other, primary care and patients, to deliver coordinated, comprehensive pathways of excellent care for every patient irrespective of where they access our system or the type of cancer that they have. The agreed priorities of the integrated cancer system are:

Being patient-focused through listening, communication, involvement, information, education, choice, and personalisation

Optimising care along a co-ordinated pathway – earlier diagnosis, exceptional treatment for all, local treatment where appropriate, compassionate aftercare and empowering/supporting patient self-management

Embedding research for personalised care, equitable access to trials, the discovery of new treatments and evaluating new ways of working together with patients

Increasing value – superior outcomes for patients per pound invested.

3

In addition to these priorities, London Cancer has carried out extensive research on what matters to patients and has distilled this work into ten key themes that will be central to everything that we do:

1. Diagnosis – patients are diagnosed at an earlier stage 2. Ethos – patients are treated holistically as individuals, and with dignity, sensitivity and respect, so that they do not feel that they are treated as a set of

cancer symptoms 3. Communication – patients receive written and verbal information about diagnosis and all treatment options, including side effects and quality of life

implications 4. Choice – patients and carers are fully involved in the choice of hospital and treatment options 5. Support – patients are given information on support groups, benefits entitlement and are offered emotional and psychosocial support 6. Carers – carers are fully involved and supported throughout the pathway 7. Holistic assessment – patients have holistic assessments at appropriate stages throughout the pathway, with action to meet their needs taken as a result 8. Seamless care – all patients are assigned a CNS when diagnosed and a community keyworker on discharge 9. Transport – patients should only travel when necessary and appropriate arrangements should be made for the immunosuppressed; patients should be

provided with free parking or transport vouchers 10. Discharge – patients and their GPs should be provided with discharge information and follow-up advice.

1.2. Pathway specifications

London Cancer will deliver a step-change in cancer services in North East London and North Central London and West Essex. It will do this through empowering clinicians and placing patients at the heart of cancer care. Clinically led pathway boards will be constituted for each cancer pathway and these boards will, under the leadership of a pathway director, lead service improvement and change across the pathway. The focus of pathway boards will be the whole patient pathway, including:

The diagnostic interface with the public

Primary care and accident and care in emergency departments

Initial assessment and appropriate rapid onward referral where necessary

The provision of various aspects of patient treatment

Follow-up or supporting end of life care. To instigate change pathway boards may constitute sub-groups, called technical groups, which are responsible for developing specifications for the future delivery of services along their pathways within the integrated cancer system. The organisations of London Cancer that contribute to the pathway will then be invited to demonstrate how they could meet the requirements of these specifications for the components of the pathway that they wish to provide. The London Cancer Urology Technical Group was the first to be constituted. It met during a four-month period between December 2011 and March 2012 to develop the specification for the future delivery of urological cancer services. A full list of those who sat on the group and the dates on which it met can be found in the appendix.

4

The resulting pathway specification was published internally to London Cancer in May 2012. In August trusts were invited to express their interest in hosting a local unit or specialist centre that met the specification. Following these expressions of interest, trusts were given further time to strengthen the clinical consensus on the proposed model and to try and achieve consensus on the location of the specialist centres. Consensus on the clinical model was achieved during these discussions in autumn 2012. It has been possible therefore to clarify the pathway specification in light of this consensus. This update has been carried out by the Urology Pathway Co-Directors and Pathway Manager. The update also provided opportunity to add further detail on key areas such as leadership and partnership working across the system as well as specialist MDT clinic, on-call and readmission arrangements.

5

2. Pelvic cancer pathway specification

Where a provider serves both as a local unit and specialist centre then it must meet both local unit and specialist centre specification.

POINT IN THE PATHWAY LOCAL PROSTATE/BLADDER UNIT SPECIALIST PROSTATE/BLADDER CENTRE

Leadership Named leader who takes responsibility for system-wide collaborative working to ensure availability of relevant specialist expertise at local units and equitable access to best practice and research

Implements the pathway across all providers

Demonstrates leadership in clinical and non-clinical innovations across the system

Maintains and develops the multidisciplinary team

Partnership working All providers work together in an integrated team

Demonstrates commitment to partnership when developing plans against the specification

All providers work together in an integrated team


Primary care Makes specialist urological advice available to GPs by telephone and email

GPs use NICE 2-week urology referral criteria and London Cancer agreed forms and criteria

GPs use national guidelines for monitoring minor PSA rises

Diagnosis of cancer Adheres to agreed London Cancer diagnostic guidelines

Clinical nurse specialist present at all cancer diagnoses

Clinical workforce trained in advanced communication

Provides full written information about tumour type and treatment options through designated specialised staff skilled in counselling patients on treatment options

Rapid onward referral to specialist centre

Written confirmation of diagnosis and responsible consultant sent to GPs within 24 hours of patients being informed of new cancer diagnosis

6


MDT Composition Local MDT with membership as per Peer Review measures

Weekly pelvic cancer-specific specialist MDT with professional constitution including:

Specialist surgeons

Specialist oncologists

Interventional radiologist

Organ-specific histopathologist

Clinical nurse specialist

Clinical trials nurses

Palliative care professional

MDT co-ordinator


Provides access to a key worker for all patients (usually a clinical nurse specialist) who shares information freely with specialist centre

Clinical nurse specialists work as collective network across system

Provides access to a key worker for all patients (usually a clinical nurse specialist) who shares information freely and gives support and advice to referring unit


Holistic care Carries out holistic assessment, including palliative care and travel needs

Refers to appropriate cancer rehabilitation specialists

Carries out holistic assessment at key points in treatment pathway


Information Capacity for reliable videoconferencing with specialist centre and other local units

Capacity for real-time electronic recording of discussions and decisions

Sends all MDT letters detailing decision and tests requested to GPs electronically (e.g. via systems such as Path Links)

Capacity for reliable videoconferencing with local units



Specialist MDT clinic Develops a network of multi-professional specialist MDT clinics across the system

Treatment decision

Prostate cancer Trained unbiased professional to use specialist MDT guidance to discuss treatment options with patients between diagnosis and multi-professional specialist MDT

Trained unbiased professional uses specialist MDT guidance to discuss treatment options with patients between diagnosis and multi-professional specialist MDT

7


clinic

Patients informed of all treatment options

Clear protocol for ‘watch and wait’ decision, including access to psychosocial support

Gives patients a treatment plan, including responsible consultant and hospital site of any therapy, and copies it electronically to GP

clinic


Clear protocol for ‘watch and wait’ decision, including access to psychosocial support


Bladder cancer Trained unbiased professional to use specialist MDT guidance to discuss treatment options with patients between diagnosis and multi-professional clinic



Trained unbiased professional to use specialist MDT guidance to discuss treatment options with patients between diagnosis and multi-professional clinic



Timeliness of treatment Capacity to assess and treat patients with minimum delay and at least within 62 days of urgent referral and 31 days of diagnosis

Capacity to assess and treat patients with minimum delay and at least within 62 days of urgent referral and 31 days of diagnosis

Surgery Population Single centre serves whole population of London Cancer

Centre carries out a cumulative total of ca. 350 radical prostate and bladder procedures a year

Assessment Carries out pre-operative assessment

Admission Enhanced recovery protocol in place covering whole admission

Enhanced recovery protocol in place covering whole admission

Treatment for prostate cancer

Carries out trans-urethral resection

Does not carry out radical prostatectomies

Carries out radical prostatectomies

Capacity for robotic surgery

Treatment for bladder cancer

Trans-urethral resection carried out by nominated surgeons only

Does not carry out radical cystectomies

Carries out radical cystectomies

Carries out bladder reconstruction


Theatre capacity

Capacity to carry out diagnostic and therapeutic procedures as day cases

Capacity to carry out a total of ca. 350 pelvic cancer procedures a year at 7/8 a week

8


Inpatient care Capacity to carry out diagnostic and therapeutic procedures as day cases

Median lengths of stay of 2.5 days for radical prostatectomy and 12 days for radical cystectomy

Sufficient dedicated ring-fenced beds (estimated at 5 to 8 beds)

Capacity to deal with surgical readmissions efficiently and effectively within 24 hours of admission to local unit

Ward nursing capacity for level 1 patients

Intensive care capacity for median stay of 1 night for radical cystectomy

Provides access to specialist rehabilitation service adhering to NCAT rehab pathway

Skills and workforce

A minimum of 2 nominated surgeons to carry out transurethral resection of bladder

Dedicated team to carry out ca. 350 procedures a year across the system

Sufficient specialist pelvic surgeons

Consultant specialist pelvic surgical on-call rota (with no duties elsewhere)

Sufficient anaesthetists and skilled theatre teams

Enhanced recovery nurse

Co-locations Access to pelvic emergency surgeon

24-hour interventional radiology

Mandatory co-dependency with specialist gynaecological cancer surgery

Ablative therapies Provides ablative therapies or has a referral pathway to a site that does

Provides ablative therapies or has a referral pathway to a site that does

Specialist surgeon not required and delivery on specialist site not necessary

System-wide capacity for ca. 250 procedures a year on sites seeing sufficient volume to provide a critical mass

Systemic therapy


Delivers chemotherapy and hormone therapy where deemed appropriate by the specialist MDT

Issues patient-held records

Refers new cases of castrate-resistant prostate cancer for

Protocols to allow specialist management of patients with safe local delivery where appropriate

Delivers targeted therapy and hormone targeted therapy

Reviews all new cases of castrate-resistant prostate cancer

9


review at specialist centre

Refers new cases of Gleason sum 8,9&10 for review at specialist centre

and delivers targeted hormone therapy (CYP-17 inhibitors) for castrate-resistant prostate patients

Reviews all new cases of Gleason sum 8,9&10


Makes clinical trials available for patients with advanced and metastatic prostate cancer


Delivers systemic therapy for only metastatic/advanced disease where deemed appropriate by the specialist multidisciplinary team

Delivers intravesical agents as deemed appropriate by the specialist MDT


Protocols to allow specialist management of patients with safe local delivery where appropriate

Delivers neo-adjuvant chemotherapy within the context of multidisciplinary team

Delivers systemic therapy for advanced/metastatic disease

Delivers intravesical agents as appropriate

Makes clinical trials available



Dedicated oncology clinical nurse specialist

Chemotherapy pharmacist

Expertise in targeted therapy and hormone targeted therapy for prostate cancer

Expertise in neo-adjuvant chemotherapy for bladder cancer

Dedicated oncology clinical nurse specialist with expertise in hormone therapy, targeted therapy and chemotherapy

Chemotherapy pharmacist

Specialist histopathology and dedicated genito-urinary radiology

Infrastructure Capacity to deliver ambulatory chemotherapy

Capacity to recruit into national trials investigating systemic therapy

Capacity to deliver ambulatory chemotherapy

Capacity for multidisciplinary clinics

Facilities for tissue banking

Links with clinical trials unit

External beam radiotherapy


Not necessary on site

IMRT available on all radiotherapy sites

10



Not necessary on site

Brachytherapy for prostate cancer

Referral Assesses suitability for brachytherapy

Written protocols for referral to brachytherapy centre(s)

Assesses suitability for brachytherapy

Written protocols for referral to brachytherapy centre(s )

Population Brachytherapy takes place in dedicated centre(s) with a minimum throughput of 50 patients per year

Brachytherapy centres do not need to be located with specialist prostate surgery centre(s)

Assessment Pre-operative assessment takes place at brachytherapy centre(s)

Treatment Takes place at brachytherapy centre(s)

Theatre capacity

System-wide capacity to carry out ca. 100 cases a year in dedicated brachytherapy theatre lists

Capacity to grow service as demand increases

Inpatient care – low dose rate

Median length of stay for low dose rate brachytherapy of 24 hours

Carries out morning lists to allow discharge on same day where possible

Dedicated radiation protection rooms for patients

Ward staff (including junior doctors) trained in radiation protection and radiation protection supervisor in place

Inpatient care – high dose rate

Median length of stay of 3 days for temporary high dose rate brachytherapy boost administered as a single fraction under spinal anaesthetic

No requirement for radiation protection on ward as applicators removed in theatre


Dedicated team(s) to carry out ca. 100 procedures a year system-wide

Brachytherapy centres have:

A minimum of 2 trained radiation oncologists

A training specialist registrar in clinical oncology

A minimum of 2 trained radiologists or urologists

A urologist specialised in dealing with urological complications following brachytherapy

A clinical nurse specialist

A minimum of 3 trained physicists or dosimetrists (one of whom should be a trained radiation supervisor)

Trained theatre staff

Co-locations Access to radiation physics and urology

High dose rate brachytherapy for prostate co-located with brachytherapy procedures for other tumour types due to equipment

11


Acute oncology Full acute oncology service that meets Peer Review standards

Full acute oncology service that meets Peer Review standards

Post-treatment

Discharge Clear procedures for receipt of patients discharged from care of the centre

Provides electronic end of treatment summaries with accessible record of treatment for GPs and patients

Discharge carried out by skilled professionals

Provides electronic end of treatment summaries with accessible record of treatment for local units, GPs and patients

Ability to readmit any patient with a complication within 24 hours of presentation to a local provider

Follow-up for prostate cancer

Capacity to host specialist outreach clinics Not necessary for patients to return to specialist centre after treatment

Follow-up for bladder cancer

Care for patients once discharged from specialist centres Follows up patients who have undergone radical cystectomy for up to 2 years before transferring care to local units

Follows up patients who have undergone neo-bladder reconstruction for up to 3 years

Primary care

Follows NICE guidance on transferring prostate follow-up to primary care

Provides GP with clear details of primary care follow-up required for prostate patients

Provides primary care with clear details of how to reaccess secondary care

Follows NICE guidance on transferring prostate follow-up to primary care

Provides GP with clear details of primary care follow-up required for prostate patients


Palliative care

Clear referral pathways for patients with palliative and specialist palliative care needs

Clear referral guidance for management of:

End of life care

Complex symptom control

GP and palliative care team to manage patient as appropriate



End of life care



12


Research and innovation Access to multidisciplinary oncology service including:

Clinical trial research

Research nursing

Carries out prospective audit of service and publishes transparent outcomes data

Access to multidisciplinary oncology service including:

Tissue banking


Research nursing


Education and training Offers simulation training in new surgical techniques

Conducts training in delivery of systemic therapy

Patient travel Informs patients of support available for travel to specialist centre and radiotherapy units

Robust patient travel plan in place

13

3. Renal cancer pathway specification

Where a provider serves both as a local unit and specialist centre then it must meet both local unit and specialist centre specification.

POINT IN THE PATHWAY LOCAL RENAL UNIT SPECIALIST RENAL SURGERY CENTRE

Leadership Named leader who takes responsibility for system-wide collaborative working to ensure availability of relevant specialist expertise at local units and equitable access to best practice and research

Implements the pathway across all providers

Demonstrates leadership in clinical and non-clinical innovations across the system

Maintains and develops the multidisciplinary team

Partnership working All providers work together in an integrated team


All providers work together in an integrated team


Primary care Makes specialist urological advice available to GPs by telephone and email

GPs use NICE 2-week urology referral criteria and London Cancer agreed forms and criteria

Diagnosis of cancer Adheres to agreed London Cancer diagnostic guidelines

One-stop haematuria service for all patients within two weeks of receipt of referral

Clinical nurse specialist present at all cancer diagnoses

Clinical workforce trained in advanced communication skills

Provides full written information about tumour type and treatment options through designated specialised staff skilled in counselling patients on treatment options

Written confirmation of diagnosis and responsible consultant sent to GPs within 24 hours of patients being informed of new cancer diagnosis

14


Rapid onward referral to specialist centre, including for patients with ultrasound with incidental findings

MDT Composition Local MDT with membership as per Peer Review measures Weekly renal specific specialist multidisciplinary team with professional constitution including:

Specialist upper tract surgeons

Specialist upper tract oncologists

Specialist clinical oncologists

Interventional radiologist

Organ specific histopathologist


Nephrologists/renal physicians

Clinical trials nurses

Palliative care professional

MDT co-ordinator


Provides access to a key worker for all patients (usually a clinical nurse specialist) who shares information freely with specialist centre


Provides access to a key worker for all patients (usually a clinical nurse specialist) who shares information freely and gives support and advice to referring unit


Holistic care

Carries out holistic assessment, including palliative care and travel needs


Carries out holistic assessment at key points in treatment pathway


Information

Capacity for reliable videoconferencing with specialist centre and other local units



Capacity for reliable videoconferencing with local units



15


Specialist MDT clinic Develops a network of multi-professional specialist MDT clinics across the system

Treatment decision Trained unbiased professional to use specialist MDT guidance to discuss treatment options with patients between diagnosis and multi-professional specialist MDT clinic



Trained unbiased professional to use specialist MDT guidance to discuss treatment options with patients between diagnosis and multi-professional specialist MDT clinic



Timeliness of treatment Capacity to assess and treat patients with minimum delay and at least within 62 days of urgent referral and 31 days of diagnosis

Capacity to assess and treat patients with minimum delay and at least within 62 days of urgent referral and 31 days of diagnosis

Surgery Assessment Carries out pre-operative assessment

Admission Enhanced recovery protocol covers whole admission Enhanced recovery protocol covers whole admission

Treatment of T1 and T2 disease

Does not carry out partial nephrectomies (nephron-sparing surgery) or nephro-ureterectomies

May carry out radical nephrectomies as agreed by specialist MDT and performed by specialist surgeons (i.e. those treating T3 and T4 disease at specialist centre)

Carries out appropriate surgery, including all nephron-sparing surgery and nephro-ureterectomies, with specialist team


Treatment of T3 and T4 disease

Carries out palliative treatments only Carries out appropriate surgery with specialist team


Benign disease Capacity to carry out surgery on complex benign renal disease (up to 100 cases per year)

Theatre capacity Capacity to carry out local radical nephrectomy, where appropriate

Capacity to carry out a total of ca. 400 procedures a year at 10 a week (includes up to 100 benign cases)

Inpatient care Capacity to care for patients following local radical nephrectomy, where appropriate

Median length of stay of 3.5 days for nephrectomy

Sufficient dedicated ring-fenced beds (estimated at 8 to 10 beds)

Capacity to deal with surgical readmissions efficiently and

16


effectively within 24 hours of admission to local unit

HDU capacity for a third of surgical patients

Provides access to specialist rehabilitation service adhering to NCAT rehab pathway


Sufficient specialist renal surgeons (urology and/or transplant)

Consultant specialist renal surgical on-call rota (with no duties elsewhere)

Surgical co-locations

Renal medicine – all aspects of renal replacement therapy

24-hour interventional radiology

Vascular surgery centre

Hepato-pancreato-biliary

Cardiac surgery

Pelvic cancer surgery co-location desirable but not mandatory

Support for other services

Provides support to centres performing complex procedures in other specialities, such as:

Urothelial (upper tract)

Retroperitoneal lymph node dissection

Sarcoma

Vascular

Hepato-pancreato-biliary

Pelvic cancer

Ablative therapies Delivers radiofrequency and cryotherapy ablation for eligible T1 patients

Systemic therapy

Targeted therapy Delivers targeted therapy and immune therapy for renal cancer patients

Issues patient held records

Makes available clinical trials

17



Two medical oncologists with recognised expertise in in targeted therapy and immune therapy in renal cancer

Dedicated oncology clinical nurse specialist with expertise in targeted therapy

Dedicated genito-urinary histopathology and radiology

Systemic therapy pharmacist

Infrastructure Capacity to deliver supportive measures Capacity for multidisciplinary clinics

Facilities for tissue banking

Links with a clinical trials unit

Radiotherapy Not necessary on site Not necessary on site

Acute oncology Full acute oncology service Full acute oncology service

Post-treatment

Discharge Clear procedures for receipt of patients discharged from care of the centre

Provides electronic end of treatment summaries with accessible record of treatment for GPs and patients

Discharge carried out by skilled professionals

Provides electronic end of treatment summaries with accessible record of treatment for local units, GPs and patients

Ability to readmit any patient with a complication within 24 hours of presentation to a local provider

Follow-up Capacity to host specialist outreach clinics Follows up patients who have undergone treatment once, before transferring care to local units

Primary care Transfers care of low risk patients to primary care 5 years post-treatment and after 10 years for medium risk patients

Does not transfer follow-up of high risk patients to primary care



18


Palliative care Clear referral pathways for patients with palliative and specialist palliative care needs


End of life care





End of life care



Research and innovation Access to multidisciplinary oncology service including:


Research nursing


Access to multidisciplinary oncology service including:

Tissue banking

Clinical trial research and research nursing


Education and training Offers simulation training in new surgical techniques

Conducts training in delivery of ablative therapies

Conducts training in delivery of systemic therapies

Patient travel Informs patients of support available for travel to specialist centre and radiotherapy units

Robust patient travel plan in place

19

Appendix: London Cancer Urology Technical Group

London Cancer Urology Technical Group attendees

John Hines (Co-chair), Consultant Urologist, Whipps Cross University Hospital NHS Trust and London Cancer Urology Pathway Co-Director

Mark Emberton (Co-chair), Consultant Urological Surgeon, University College London Hospitals NHS Foundation Trust and London Cancer Urology Pathway Co-Director

Anand Kelkar, Consultant Urological Surgeon, Barking Havering and Redbridge Hospitals NHS Trust

Angela Lee, Clinical Nurse Specialist, Barking Havering and Redbridge Hospitals NHS Trust

Bruce Turner, Uro-oncology Nurse Practitioner, Homerton University Hospital NHS Foundation Trust

Colin Bunce, Consultant Urological Surgeon, Barnet and Chase Farm Hospitals NHS Trust

David Nicol, Consultant Urologist, The Royal Free Hampstead NHS Trust and University College London Hospitals NHS Foundation Trust

Faiz Mumtaz, Consultant Urologist, Barnet and Chase Farm Hospitals NHS Trust

Frank Chinegwundoh, Consultant Urological Surgeon, Newham University Hospital NHS Trust

Gillian Smith, Consultant Urological Surgeon, The Royal Free Hampstead NHS Trust

Guy Webster, Consultant Urologist, Barnet and Chase Farm Hospitals NHS Trust

Jaspal Virdi, Consultant Urological Surgeon, The Princess Alexandra Hospital NHS Trust

Jhumur Pati, Consultant Urological Surgeon, Homerton University Hospital NHS Foundation Trust

John Peters, Consultant Urologist, Whipps Cross University Hospital NHS Trust

Katharine Pigott, Consultant Clinical Oncologist, The Royal Free Hampstead NHS Trust

Maneesh Ghei, Consultant Urologist, The Whittington Hospital NHS Trust

Rateb Samman, Consultant Urologist, The Princess Alexandra Hospital NHS Trust

Sandeep Gujral , Consultant Urological Surgeon, Barking Havering and Redbridge Hospitals NHS Trust

Tim Briggs, Consultant Urologist, Barnet and Chase Farm Hospitals NHS Trust

Tom Powles, Consultant Medical Oncologist, Barts and the London NHS Trust

Patient representative input from:

Christopher Kennedy, Patient

Steve Johnson, Patient

Primary care input from:

Karen Sennet, General Practitioner, Islington

Mike Gocman, General Practitioner, Enfield

Palliative care input from:

Adrian Tookman, Consultant Physician in Palliative Medicine, The Royal Free Hampstead NHS Trust

Clare Phillips, Consultant in Palliative Medicine, Barts and the London NHS Trust and Newham University Hospital NHS Trust

London Cancer Urology Technical Group meeting dates

2nd December 2011 19th January 2012 20th February 2012 26th March 2012

london cancer: pathway specification for · london cancer: pathway specification for urological...

Documents