Acute Oncology

Dr Nicola Storey

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Overview of Acute Oncology

• Encompasses management of patients with severe complications following the treatment of, or as a consequence of their previously diagnosed cancer

• Management of patients who present as emergencies with previously undiagnosed cancer

• AOS brings together expertise from oncology disciplines, emergency medicine, palliative care, and general medicine and general surgery

Key Features of an Acute Oncology Service:

(NCAG Report)

• Early review by an oncologist or oncology nurse specialist (within 24 hours)

• 24/7 access to telephone advice from an oncologist• Fast track clinic access from A&E• Access to information on individual patients across the Trust• Protocols for the management of oncological emergencies and

referral pathways from A&E and acute admissions unit• Specific pathways for the investigation and treatment of

malignant spinal cord compression

Patient in A&E/AAU

AOS review/AO Specialist nurse

Advice/review by Consultant Oncologist

24/7

On activetreatment

Referralto AOS

Identified by alert

Review in rapid access clinic/

acute oncologyassessment unit

Acute medical review/AOS review

Transfer tospecialist ward

Complication of known cancer

IS THIS NEUTROPENICSEPSIS

>TREAT WITH ANTIBIOTICS< SPINAL CORDCOMPRESSION

MSCCco-ordinator/

On-call oncologist

MRI scan

Transfer to MSCC treatment centre Spinal surgeons/

Radiotherapy

Pericardial effusionPleural effusionBrain metsAscities

Fast trackprotocols

Triage Tool• A tool that will determine “the patient’s level of risk”

• Prompt the practitioner with appropriate questions to ask in order to gain information from the patient

• Provide a reliable guide to toxicity/problem grading

• Prioritise the level of urgency indicated by the presenting symptoms and will aid in identifying potential emergency situations

04/20/23Philippa Jones Chemotherapy Redesign

Manager, Greater Midlands Cancer Network 10

Acute Oncology Management G uidelines

G uideline 1. NE UTR OP E NIC S E P S IS requires UR G E NT medic al as s es s ment/interview! P atients on chemotherapy or immunocompramised patients (H IV , known immune deficiency, malignancy) with

or without a fever are at higher risk of serious problems if neutrophil count falls to <1 x 109/L , a patient becomes immunocompramised and at risk of serious infections which may be fatal.

G uideline 1. NE UTR OP E NIC S E P S IS requires UR G E NT medic al as s es s ment/interview! P atients on chemotherapy or immunocompramised patients (H IV , known immune deficiency, malignancy) with

or without a fever are at higher risk of serious problems if neutrophil count falls to <1 x 109/L , a patient becomes immunocompramised and at risk of serious infections which may be fatal.

T riag e as s es s mentIdentify: All patients within 6/52 chemotherapyAssume: Neutropenic S eps is until proven otherwiseObservations : T emp,P ulse,B P ,R R ,O 2sats ,AVP UC ommence: E arly Warning S core chartI.V.Access : B lood rapidly to L abB lood C ultures ,F B C ,C oag,U&E s,G luc,L F Ts ,C a2+,P O4-,Mg2+,Urate

T riag e as s es s mentIdentify: All patients within 6/52 chemotherapyAssume: Neutropenic S eps is until proven otherwiseObservations : T emp,P ulse,B P ,R R ,O 2sats ,AVP UC ommence: E arly Warning S core chartI.V.Access : B lood rapidly to L abB lood C ultures ,F B C ,C oag,U&E s,G luc,L F Ts ,C a2+,P O4-,Mg2+,Urate

S evere S eps is ?Altered mental s tate or

Hypoxia ( O 2 sats< 94% ) orS hock (S ys B P < 90 mmHg)

S evere S eps is ?Altered mental s tate or

Hypoxia ( O 2 sats< 94% ) orS hock (S ys B P < 90 mmHg)

R es us c itation Manag ement:•Triage R ed•R esuscitation room•Optimise haemodynamics & O 2 delivery•Initiate 1st line antibiotics•Transfer HDU/IC U

R es us c itation Manag ement:•Triage R ed•R esuscitation room•Optimise haemodynamics & O 2 delivery•Initiate 1st line antibiotics•Transfer HDU/IC U

Medic al As s es s mentIdentify: P otential s ources of infection

R x: P resenting C omplaint/C o-morbidityTx: C X R ,E C G ,AB G s L actate),Urinalys is , S wabs

Medic al As s es s mentIdentify: P otential s ources of infection

R x: P resenting C omplaint/C o-morbidityTx: C X R ,E C G ,AB G s L actate),Urinalys is , S wabs

Early Sepsis ?Temp> 380c or < 360c orPulse > 90 orRR > 20

Early Sepsis ?Temp> 380c or < 360c orPulse > 90 orRR > 20

C ommenc e NS R eg ime:•No delay for lab confirmation•S upplemental O 2 •Initiate 1st line antibiotics•1L 0.9% S aline over 1-2 hours•Admit to appropriate area •Differentiate between neutropeniaand neutropenic seps is•S upportive measures

C ommenc e NS R eg ime:•No delay for lab confirmation•S upplemental O 2 •Initiate 1st line antibiotics•1L 0.9% S aline over 1-2 hours•Admit to appropriate area •Differentiate between neutropeniaand neutropenic seps is•S upportive measures

C ons ider admiss ion if neutropenic& low grade pyrexia

C ons ider admiss ion if neutropenic& low grade pyrexia

Dis c harg e:•Only if phys iolog ic ally s table•When c o-morbidity treated•Neutropenic s eps is advic e

Dis c harg e:•Only if phys iolog ic ally s table•When c o-morbidity treated•Neutropenic s eps is advic e

L ab C onfirmationNeutrophils < 1.0 x 109/L

R egardless of overall WC C

L ab C onfirmationNeutrophils < 1.0 x 109/L

R egardless of overall WC C

T ime !

15 minutes

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60 minutes

Y es

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Is t line antibiotic s in neutropenic s eps isAs per loc al trus t polic y?

Is t line antibiotic s in neutropenic s eps isAs per loc al trus t polic y?

South Tees NHS FT

Day 89 year old lady

0 Admitted with abdominal pain, kidneys not working1 CT scan requested

CT scan performed – ?blocked kidneysEvidence of widespread cancerUltrasound scan requested

3 Blocked kidneys confirmedReferred to nephrologists

10 Nephrology review – likely cause of problems bladder or pelvic malignancyCT scan with contrast recommended

11 Xrays reviewed at meeting - ? Endometrial malignancyCT cancelled, MRI scan advised

12 Nephrostomies inserted to relieve blocked kidneys14 Referred to gynaecology15 Seen by gynaecology with MRI result

? Ovarian or peritoneal malignancyUS guided biopsy suggested

16-22 ? Gynaecology taken over care22 Urology review – patient probably has gynae malignancy,

chase gynaecology review

Day

23 Gynae review, US guided biopsy requested24-36 Not well, infections, biopsy postponed36 Biopsy attempted and abandoned38 Gynae Oncology MDT meeting – refer for supportive care

and to elderly care42 Elderly care referral44 Elderly care ward transfer56 Discharged to nursing home

What should an acute oncology service aim to deliver?

• Timely and approachable support from an experienced oncologist in managing acute treatment related emergencies

• Easy referral pathways that can be accessed by all• Rapid alert system to highlight when any patients known

to be receiving chemotherapy are admitted• Regularly updated, easy to follow, protocols for

managing oncological emergencies such as spinal cord compression

• Earlier involvement in the patient pathway in those suspected to have cancer

• Fast tract outpatient access for those who do not require admission

North of EnglandCancer Network

MSCC Centres NCC, Freeman Hospital James Cook Hospital

Radiotherapy Centres NCC, Freeman Hospital James Cook Hospital Cumberland Infirmary

What should today aim to deliver?

• An overview of the important acute oncological presentations

• A masterclass in how to manage some of the more serious of these

• A chance to talk to one another about how we continue to improve patient experience