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Acute Oncology
What is it?
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
Acute oncology presentations
The following, as caused by the systemic treatment of cancer:
• Neutropaenic sepsis.• Uncontrolled nausea and vomiting.• Uncontrolled diarrhoea.• Complications associated with venous access devices.• Uncontrolled mucositis.• Hypomagnesaemia.• Extravasation injury. •Acute hypersensitivity reactions including anaphylactic shock.
Acute oncology presentations
The following, as caused by radiotherapy:
• Acute skin reactions.• Uncontrolled nausea and vomiting.• Uncontrolled diarrhoea.• Uncontrolled mucositis.• Acute radiation pneumonitis.• Acute cerebral/other CNS, oedema.
Acute oncology presentations
The following, as caused directly by malignant disease and presenting as an urgent acute problem.
•Pleural effusion•Pericardial effusion•Lymphangitis carcinomatosa•Superior superior vena caval obstruction•Abdominal ascites•Hypercalcaemia•Spinal cord compression including MSCC•Cerebral space occupying lesion(s)
Referral guidelines
The Acute Oncology Service is intended for ACUTE problems
It doses not replace existing pathways for the diagnosis of new cancers or their planned treatment
•During treatment and after treatment, patients and GPs are advised to contact the original treating hospital.
•All patients receiving chemotherapy and radiotherapy will have been given the relevant contact numbers
•GPs and patients will also be advised to refer to/attend their local hospital/A&E department if patients present with immediate life threatening complications
Assessment of treatment complications
All patients should be issued with an alert card with
24 hour contact numbers. Chemo units should
rehearse situations with patients to ensure that they understand when and who they should contact if they have a problem
04/18/23 Philippa Jones Chemotherapy Redesign Manager, Greater Midlands Cancer Network 10
G eneric manag ement g uidelines for c hemotherapy toxic ities(see specific algorithms for management of each toxic ity)
G rade 1 (G reen) G rade 2 (Amber) G rade 3 (R ed) G rade 4 (R ed)Mild Moderate S evere L ife threatening
Als o c ons ider fac tors whic h lower thres hold for inpatient admis s ion:
S ymptoms needing urgent admiss ion – temperature, chest pain, bleeding?
Might be neutropenic?
More than one G rade 2 toxic ity?
P oor historian/ difficult to assess on phone?
C ompliance of patient / ability to understand and follow instruc tions
G rade 2 toxic ity not settling despite maximal outpatient efforts ?
B ecoming weak/dehydrated?
Als o c ons ider fac tors whic h lower thres hold for inpatient admis s ion:
S ymptoms needing urgent admiss ion – temperature, chest pain, bleeding?
Might be neutropenic?
More than one G rade 2 toxic ity?
P oor historian/ difficult to assess on phone?
C ompliance of patient / ability to understand and follow instruc tions
G rade 2 toxic ity not settling despite maximal outpatient efforts ?
B ecoming weak/dehydrated?
NB Neutropenic s eps is needs urgent admiss ion and immediate iv broad
spectrum antibiotics/fluids.
•Do not get G P out first. •Do not wait for F B C before giving antibiotics.•S ee specific guideline for further detail.
NB Neutropenic s eps is needs urgent admiss ion and immediate iv broad
spectrum antibiotics/fluids.
•Do not get G P out first. •Do not wait for F B C before giving antibiotics.•S ee specific guideline for further detail.
AC T ION: G rade 1
S ee s pec ific toxic ity g uidelines
Advis e patient to phone bac k if g etting wors e
Doc ument c all and advic e g iven
AC T ION: G rade 1
S ee s pec ific toxic ity g uidelines
Advis e patient to phone bac k if g etting wors e
Doc ument c all and advic e g iven
AC T ION: G rade 2
S ee specific toxic ity guidelines
Assess for admiss ion if two grade 2 toxic ities or toxic ity not settling despite initial advice
Advise patient to phone back if getting worse
P hone/review patient within 24 hours to ensure settling
Document call and advice g iven
AC T ION: G rade 2
S ee specific toxic ity guidelines
Assess for admiss ion if two grade 2 toxic ities or toxic ity not settling despite initial advice
Advise patient to phone back if getting worse
P hone/review patient within 24 hours to ensure settling
Document call and advice g iven
AC T ION: G rade 3 and 4
Admit for assessment, investigation andparenteral management.
S ee specific toxic ity guidelines and sections on management of inpatients with chemotherapy toxic ities on page 3
If not needing admiss ion, ensure F B C , U+E checked, good oral intake and daily contact with patient until improving, with low threshold for admiss ion.
Document call and advice g iven and inform specialist team
NB – rapid deterioration poss ible. C hemotherapy toxic ities are revers ible but need aggress ive management
AC T ION: G rade 3 and 4
Admit for assessment, investigation andparenteral management.
S ee specific toxic ity guidelines and sections on management of inpatients with chemotherapy toxic ities on page 3
If not needing admiss ion, ensure F B C , U+E checked, good oral intake and daily contact with patient until improving, with low threshold for admiss ion.
Document call and advice g iven and inform specialist team
NB – rapid deterioration poss ible. C hemotherapy toxic ities are revers ible but need aggress ive management
P leas e ens ure that your A c ute Onc olog y T eam are informed of the patients admis s ion as s oon as pos s ible
P leas e ens ure that your A c ute Onc olog y T eam are informed of the patients admis s ion as s oon as pos s ible
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
04/18/23 Philippa Jones Chemotherapy Redesign Manager, Greater Midlands Cancer Network 12
Triage Log sheetContact Record• It is vitally important that the
data collection process is methodical and thorough in order for it to be useful and provide an accurate record of the triage assessment.
• A log sheet should be completed for all calls and unscheduled patient visits. This will facilitate audit of the helpline service.
• The Triage boxes MUST all be marked accordingly.
• IF YOU HAVEN’T TICKED IT,YOU HAVEN’T ASKED IT !!!
04/18/23 Philippa Jones Chemotherapy Redesign Manager, Greater Midlands Cancer Network 13
Assessment tool
• RED- any toxicities graded here take priority and assessment should follow immediately.
• 2 AMBER-Two or more amber toxicities should be escalated to red action and assessment should follow immediately..
• Amber one toxicity in amber should be reviewed/ followed up within 24 hours and the caller should be instructed to call back if they continue to have concerns or their condition deteriorates
• Green callers should be instructed to call back if they continue to have concerns or their condition deteriorates.
04/18/23 Philippa Jones Chemotherapy Redesign Manager, Greater Midlands Cancer Network 14
A patient has presented with an acute oncology problem
Is it neutropenic sepsis? Could it be neutropenic sepsis?
Do they need admission?
How do you treat the complications of chemotherapy?
Could their problem be dealt with by an early review in clinic?
Can they be discharged?
How can the Acute Oncology Service Help?
The Acute Oncology Assessment Service
Available Monday - Friday
•Acute oncology specialist nurses•Access to consultant oncologist advice and assessment if needed•Malignant spinal cord compression co-ordinator
Telephone advice is available from a consultant oncologist, 24 hours a day, seven days a week
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
CARCINOMA OFUNKNOWNPRIMARY
Carcinoma of unknown primary (CUP)
Most patients with newly diagnosed cancer are found to have a clearly defined primary tumour, and can then be swiftly referred on to a “site specialist team”
4% patients are found to have cancer without an identifiable primary site, despite exhaustive tests
Because of the lack of dedicated clinical services, patients who have malignancy without an identifiable primary site can be denied the care offered to patients with site-specific cancers
North of EnglandCancer Network
MSCC Centres NCC, Freeman Hospital James Cook Hospital
Radiotherapy Centres NCC, Freeman Hospital James Cook Hospital Cumberland Infirmary
LOCAL PATHWAYS????
Which services at which hospital
AOS team24/7 chemo advice serviceFast track clinicsConsultant oncologist on-call service
Out of hours
?
Treatment protocols
Complications of the systemic treatment of cancer:
• Neutropaenic sepsis.• Uncontrolled nausea and vomiting.• Uncontrolled diarrhoea.• Complications associated with venous access devices.• Uncontrolled mucositis.• Hypomagnesaemia.• Extravasation injury. Remember there is an on-call oncologist available fortelephone advice at the cancer centre 24/7
Acute oncology presentations
The following, as caused directly by malignant disease and presenting as an urgent acute problem.•Pleural effusion•Pericardial effusion•Lymphangitis carcinomatosa•Superior superior vena caval obstruction•Abdominal ascites•Hypercalcaemia•Spinal cord compression including MSCC•Cerebral space occupying lesion(s)
Known cancer patient (aware of risk)
Cancer patient unaware ofthe risk (undiagnosed)
Admission via A&E or Medical Admissions Unit
Patient attends GP
Ward patient
Co ordinator(collate clinical information)
Coordinator link with local /centre Oncologist
Oncology /Surgerypatient
discussion
Transfer patient toCentre fordefinitivetreatment
Supportive /Palliative care
Member ofPrimary Care
Team
Information pack for patients
Routine O.P. appt.
Not Appropriate foradmission / active
treatment
GP informed (+/- D.N. /Primary Care Team)
Discharge
Key worker
EOL
Rehab Centre(local unless
otherwise agreed)
Discharge
Key worker
MRIlocal /central
In Hours Metastatic Spinal Cord Compression High level Pathway
Known cancer patient (aware of risk)
Cancer patient unaware ofthe risk (undiagnosed)
Admission via A&E or Medical Admissions Unit
Patient attends GP
Ward patient
Co ordinator(collate clinical information)
Coordinator link with local /centre Oncologist
Oncology /Surgerypatient
discussion
Transfer patient toCentre fordefinitivetreatment
Supportive /Palliative care
Member ofPrimary Care
Team
Information pack for patients
Routine O.P. appt.
Not Appropriate foradmission / active
treatment
GP informed (+/- D.N. /Primary Care Team)
Discharge
Key worker
EOL
Rehab Centre(local unless
otherwise agreed)
Discharge
Key worker
MRIlocal /central
In Hours Metastatic Spinal Cord Compression High level Pathway
Known cancer patient(aware of risk)
Cancer patient(unaware of the risk)
Admission via A&E or MedicalAdmissions Unit
Patient contacts Primary Care
Ward patient with orwithout a known
cancer
ConsultantOncologist / SPR
on Call(at Centre)
SPR Review(Newcastle)
clinical informationwith on callConsultantOncologist
Transferpatient toCentre fordefinitivetreatment
Supportive&
PalliativeCare
Log call
Ensure MRIcompleted local
/ centre
Record clinicalinformation
Joint Oncology /Surgery patient
review
+/- review withpatients Oncologist
Key worker
Coordinator reviews log nextworking day
Rehab Centre (localunless otherwise
agreed)
EOL
Discharge
Discharge
Out of Hours Metastatic Spinal Cord Compression High Level Pathway
Known cancer patient(aware of risk)
Cancer patient(unaware of the risk)
Admission via A&E or MedicalAdmissions Unit
Patient contacts Primary Care
Ward patient with orwithout a known
cancer
ConsultantOncologist / SPR
on Call(at Centre)
SPR Review(Newcastle)
clinical informationwith on callConsultantOncologist
Transferpatient toCentre fordefinitivetreatment
Supportive&
PalliativeCare
Log call
Ensure MRIcompleted local
/ centre
Record clinicalinformation
Joint Oncology /Surgery patient
review
+/- review withpatients Oncologist
Key worker
Coordinator reviews log nextworking day
Rehab Centre (localunless otherwise
agreed)
EOL
Discharge
Discharge
Out of Hours Metastatic Spinal Cord Compression High Level Pathway
LOCAL CONTACT DETAILS FOR SPINAL CORD COMPRESSION PATHWAY ??????
SUMMARISE LOCAL INFORMATION
