management of carcinoma of unknown primary within the ... · proposed definitions • malignancy of...

Management of Carcinoma of Unknown Primary within the

Acute Oncology Framework

ACP Acute Oncology Update

March 2010

CUP and Acute Oncology

• NICE CUP Guideline overview

• Non-elective admissions with CUP

• NICE CUP Guideline outputs

• Organisation of CUP services

• Interface between AO and CUP

NICE CUP Guideline overview

• Why are we failing CUP patients?

– Lack of an agreed definition

– Lack of evidence base / accurate epidemiology

– Lack of biological understanding and research

– Lack of designated funding / resources

– Lack of a “site-specific” system for clinical care

– Lack of support for patients and families

– Lack of defined treatments

– Therapeutic nihilism

NICE CUP Guideline overview

• Why are we failing CUP patients?


– Lack of evidence base / accurate epidemiology

– Lack of a “site-specific” system for clinical care

• Clinical specialists

• Referral processes

• “Site-specific team” and structure

– MDT, SSG, Keyworker

Why are we failing CUP patients ?


Proposed DefinitionsBased on clinical course, clinical findings and outcome of investigations, over time

Detection of metastatic malignancy on clinical examination

or by imaging, without an obvious primary site

Metastatic epithelial / neuro-endocrine malignancy on

histology. Specialist review and all relevant investigations

completed. No primary detected.


histology. No primary detected despite initial investigations.

Specialist review and possible further investigations pending

Proposed Definitions

• Malignancy of undetermined primary origin (MUO)

– Metastatic malignancy identified on the basis of a limited number

of tests, prior to comprehensive investigation

• Provisional Carcinoma of Unknown Primary (pCUP)

– Metastatic epithelial or neuro-endocrine malignancy identified on

the basis of histology / cytology, with no primary detected

despite an initial screen of investigations, prior to specialist

review and possible further specialised investigations

• Confirmed Carcinoma of Unknown Primary (cCUP)

– Metastatic epithelial or neuro-endocrine malignancy identified on

the basis of definitive histology, with no primary detected despite

a selected screen of investigations, specialist review, and

completion of further appropriate specialised tests

Proposed DefinitionsBased on clinical course, clinical findings and outcome of investigations, over time

Detection of metastatic malignancy on clinical examination

or by imaging, without an obvious primary site


histology. Specialist review and all relevant investigations

completed. No primary detected.


histology. No primary detected despite initial investigations.

Specialist review and possible further investigations pending

MUO

pCUP

cCUP

Why are we failing CUP patients ?

– Lack of evidence base / epidemiology

CUP Epidemiology

– What do we know?

• ICD-10 codes covering CUP

– C77 – secondary malignancy in nodes

– C78 – secondary malignancy – respiratory / GI systems

– C79 – secondary malignancy – other sites

– C80 – malignant neoplasm without specified site

• Accuracy of coding very dubious

• Final C77-80 code underestimates MUO admissions

CUP Epidemiology - Incidence

– UK Incidence from cancer registration

• 13,000 cases annually (ICD-10 C77 - 80)

• 4% of all cancer diagnoses

• Incidence falling over past 10 years

• BUT – MUO presentations >13,000

CUP Epidemiology - Mortality

– Mortality rate

• 12,000 deaths annually in UK

• 8% of all cancer deaths

• 4th most common cause of cancer death– Lung 34,500

– Colorectal 16,000

– Breast 12,500

– CUP 12,000

CUP Epidemiology - Admissions

– HES data for 169 acute Trusts in England

– Non-elective admissions

– Finally coded as C77-C80

– 25,318 episodes in 2007

– 3 per week for each acute Trust

– Mean length of stay = 9 days

– Underestimates total “MUO” admissions

CUP Epidemiology - Admissions

– HES data for Dorset Cancer Network

– Non-elective admissions to 3 acute Trusts

– Finally coded as C77-C80

– 1100 episodes in 2006

– 7 per week for each acute Trust

– Mean length of stay = 13 days

– Underestimates total “MUO” admissions

NICE CUP Guideline outputs

NICE CUP Guideline outputs

• Definitions

• Needs Assessment / Epidemiology

• Organisation of Services along “site-specialty” lines

– CUP Oncology specialist and CUP Team

– CUP Specialist nurse

– CUP Network SSG

– Referral timescale standards

• Optimised diagnostic process

• Management recommendations

• Treatment recommendations

• Research

– New NCRI Clinical Studies Group for unknown primary cancer

– Studies: Gene-expression based profiling, PET-CT, Treatment

Organisation of CUP Services


Current Situation

• No Referral guidelines

• No Specialist Oncologists

• No Specialist Nurses

• No Multi-disciplinary team

• No MDT management approach

• No Rapid systematic investigation

• No Site-specific treatment protocols

• No Network Site-specific Group

• No Site-specific audit

• No Site-specific research

• No Cancer measures

• No Site-specific information + support

• No Accurate epidemiology


• Establish CUP Team

– Oncologist, Palliative Care Physician, Nurse

– Based at every Cancer Centre and Unit

• Establish CUP as a “site-specialty”

– Designated specialist Oncologists

– Standards / processes (eg SSG) as other sites

• Rapid referral of MUO patients

– Within 1 working day for inpatients

– Outpatient Fast-track referral to CUP clinic

Elements of a successful MUO / CUP approach*

• Prompt patient identification and oncology referral

• CUP Specialist Oncologists

• Keyworker / coordinator

• Establishment of small, dynamic “CUP Team”

• Oncology-directed management

• Oncology and Palliative Care collaboration

• Real-time management

• SMDT approach for relevant patients / problems

• Avoid management within existing site MDT

* see: Ernie Marshall, St Helens and Knowsley Hospitals, Judy King, Whittington Hospital

Implementation

2010 - A conjunction of opportunities

• Cancer Reform Strategy

– Motivation for efficiency and reduced stays

• MDT re-engineering

– Smarter MDT working: real-time management

• NCAG report implementation

– Acute Oncology Service mandated

– (BUT: MUO management undersold!)

• NICE CUP Clinical Guideline

– Specialist management for a significant

proportion of the acutely presenting patients

Implementation

• Acute Oncology Cancer Measures

– Consultation on draft: mid 2010

– Adequate coverage of issues relating to newly

presenting MUO should be a priority

• CUP Guideline (July 2010) to emphasise:

– New Site-specialty, potentially alongside

specialist Acute Oncology role

– CUP teams

Implementation

NCAG

Report

Acute

Oncologist

↑Work

force

Chemotherapy

Quality

and

Safety

Reform

Strategy

Implementation

NICE

CUP

Guideline

NCAG

Report

Acute / CUP

Oncologist

Chemotherapy

Quality

and

Safety

Reform

Strategy

MUO / CUP

Services

↑Work

force

From NCAG report section 2.7 page 18

Missed from Key Recommendation 7,

page 7 in Executive Summary

Section 2.7 page 18

“All hospitals with A&E Departments should

establish an Acute Oncology Service and/or

a pathway to ensure the rapid appropriate

management of patients presenting with

previously undiagnosed cancer”

13,000 cases of CUP annually

4th most common cause of cancer death

Crude survival for South East England (Kaplan

Meier) by period of registration

0.0

20.0

40.0

60.0

80.0

100.0

120.0

0 1 2 3 4 5

Years since diagnosis

% S

urv

iva

l

1992-1996

1997-2001

2002-2006

25,318 admissions annually

Only 8% of CUP patients

receive chemotherapy

8% 5-year survival

Unchanged for 20 years 200,000

bed days annually

Role mandated

in NCAG report

Organisation of CUP ServicesPatient with

malignancy of

undefined primary

origin (MUO)

Patient registered

with and referred

to CUP team (1)

Assessment of patient by member of CUP team by the end of next working

day as an inpatient or within 2 weeks as an outpatient (2). Initial management

plan including further investigations as appropriate devised by CUP team (3).

For inpatients, management plan implemented by responsible medical/

surgical team.

Appointment of key worker.

Review of results by CUP team with

involvement of extended team members e.g.

pathologist, radiologist

Palliative and

supportive care only

Investigations

completed. Diagnosis

of confirmed CUP

CUP network MDT

discussion to guide

specialised test(s)

CUP network MDT

review to agree

management plan

Primary identified or

non carcinoma

malignancy. Site

specific referral

Non-malignant

diagnosis

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management of carcinoma of unknown primary within the ... · proposed definitions • malignancy of...

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