Problem Solving in Acute Oncology

Problem Solving in Acute Oncology

Second Edition

Problem Solving

in Acute Oncology

Second Edition

Edited by

Alison Young, MBChB, MD, FRCP

Consultant in Medical Oncology, Leeds Cancer Centre, St James’s University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds

Ruth E. Board, BSc, MBChB, PhD, FRCP

Consultant in Medical Oncology, Rosemere Cancer Centre, Royal Preston Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Preston

Pauline Leonard, MBBS (Hons), MD, FRCP

Consultant in Medical Oncology, Whittington Health NHS Trust, London

Tim Cooksley, MBChB (Hons), FRCPE

Consultant in Acute Medicine, Manchester University NHS Foundation Trust, Manchester; The Christie NHS Foundation Trust, Manchester

Andrew Stewart, BA, MBChB, MD, FRCPE, FRCPath

Consultant in Haematology, Bristol Haematology and Oncology Centre, University Hospitals Bristol NHS Foundation Trust, Bristol; Weston General Hospital, Weston Area Health NHS Trust, Weston-super-Mare

Caroline Michie, MBChB, MRCP (UK), FRCPE

Consultant in Medical Oncology, Edinburgh Cancer Centre, Western General Hospital, NHS Lothian, Edinburgh; Honorary Clinical Senior Lecturer, University of Edinburgh, Edinburgh

Published in association with the Association of Cancer Physicians

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Contents

Contributors

Preface

Acknowledgements

Abbreviations

SECTION ONE Perspectives

01 Acute Oncology Services: Past, Present and Future, Ruth E. Board

02 Nursing Developments in Acute Oncology, Jo Wilkinson, Christine Rhall

03 Carcinoma of Unknown Primary, Pauline Leonard, Christine Rhall

04 The Oncology Patient in the Acute Medical Unit, Will Marshall, Tim Cooksley

05 Which Cancer Patients Should Be Admitted to Critical Care?Phil Haji-Michael

06 Acute Oncology Services in the Devolved Nations, Rosie Roberts, Cathy Hutchison, Moyra Mills

07 Cancer Emergencies in the Community, Sinead Clarke, Joanne Stonehouse, Joanne Wilkinson, Susan Jones

SECTION TWO Case Studies

Complications of Systemic Therapy

01 Febrile Neutropenia, Rohan Shotton, Amy Ford

02 Tumour Lysis Syndrome, Christopher Parrish, Gordon Cook

03 Antiangiogenic Therapy, Louise McKee, Gordon Urquhart

04 Cardiac Toxicity, Pankaj Punia, Chris Plummer

05 Liver Problems, Gemma Dart, Dan Swinson, Rebecca Jones

06 Acute Kidney Injury, Lucy Wyld, Christy Ralph, Andrew Lewington

07 Anticancer Treatment and the Kidney, Lucy Wyld, Christy Ralph, Andrew Lewington

08 Metabolic Complications, Mahabuba Hossain, Carmel Pezaro, Jennifer Walsh, Emma Rathbone, Janet Brown

09 Diabetes, Jenny Seligmann, Dan Swinson, Stephen Gilbey

10 Cutaneous Manifestations of Systemic Cancer Therapy, Mehran Afshar, Laura Camburn

11 Acute Diarrhoea and Mucositis, Jordan Appleyard, Daniel Lee, D. Alan Anthoney

12 Peripheral Neurotoxicity, Greg Heath, Susan Short, Helen Ford

13 Central Neurotoxicity, Greg Heath, Susan Short, Helen Ford

14 Chemotherapy-Induced Lung Toxicity, Lisa Owen, Satiavani Ramasamy, Dan Stark, Martyn Kennedy

15 Metastatic Melanoma with Rash and Diarrhoea after Treatment with Immune Checkpoint Inhibitors, Nadina Tinsley, Ruth E. Board

16 Side Effects of Complex Treatment of Metastatic Lung Cancer with Chemotherapy and an Immune Checkpoint Inhibitor, Ajay Sudan, Alastair Greystoke

17 Rare Immune-Related Adverse Events Associated with Immune Checkpoint Inhibitors, Anna Claire Olsson-Brown

18 Complications of CAR T Cell Therapy, Adam Bond, Rachel Protheroe

Complications of Radiotherapy

19 Radiation Pneumonitis, Saif Yousif, P. Hadjiyiannakis

20 Radiation-Induced Head and Neck Mucositis, Arafat Mirza

21 Management of Radiotherapy-Related Acute Skin Reactions, Deborah Williamson, Rachel Rigby

22 Toxicity Related to Pelvic Radiotherapy, Rohan Iype, Alison Birtle

23 CNS Toxicity of Radiotherapy, Simon Gray, Chin Chin Lim, Catherine Mitchell

Complications of Cancer

24 Metastatic Spinal Cord Compression, Richard Heywood, Vinton Cheng, Naveen Vasudev

25 Superior Vena Cava Obstruction, Rachel Bird, Jane Hook

26 Brain Metastases, Allison Hall, Pooja Jain, Andrew Brodbelt

27 Paraneoplastic Syndromes, Greg Heath, Susan Short, Helen Ford

28 Venous Thromboembolism, Nick Wreglesworth, Anna Mullard, Helen Innes

29 Malignant Renal Obstruction, Andrew Viggars, Sunjay Jain, Naveen Vasudev

30 Management of Malignant Ascites, Benjamin Pickwell-Smith, Alison Young

31 New Pleural Effusion, Keith Howell, Pooja Jain

32 Metabolic Complications of Malignancy: Hypercalcaemia, Eliyaz Ahmed, Richard Griffiths, Sid McNulty

33 Metabolic Complications of Malignancy: Hyponatraemia, Richard Griffiths, Sid McNulty

34 Bowel Obstruction, Gemma Dart, Alison Young

35 Malignant Pericardial Effusion, Madhuchanda Chatterjee, Judith Carser, Nick Palmer, Chris Campbell, Simon Williams

36 Hyperviscosity Syndrome, Hyperleucocytosis and Leucostasis, Nikesh Chavda, Andrew Stewart

Acute Palliative Care and Pain Control

37 Metastatic Small Cell Lung Cancer and Chest Wall Pain, Tammy Oxley, Karen Neoh, Michael Bennett

38 Neuropathic Cancer Pain, Adam Hurlow, Michael Bennett

Index

Contributors

Dr Mehran Afshar, Consultant in Medical Oncology, St George’s University Hospitals NHS Foundation Trust, London

Dr Eliyaz Ahmed, Specialist Registrar in Clinical Oncology, Clatterbridge Cancer Centre NHS Foundation Trust, Wirral

Dr D. Alan Anthoney, Consultant in Medical Oncology, Leeds Cancer Centre, St James’s University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds

Mr Jordan Appleyard, Medical Student, Barts and The London School of Medicine and Dentistry, Queen Mary University of London; Leeds Cancer Centre, St James’s University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds

Professor Michael Bennett, St Gemma’s Professor of Palliative Medicine, University of Leeds, Leeds

Dr Rachel Bird, Staff Grade in Oncology, Leeds Cancer Centre, St James’s University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds

Dr Alison Birtle, Consultant in Clinical Oncology, Rosemere Cancer Centre, Royal Preston Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Preston; Honorary Senior Lecturer, University of Manchester, Manchester

Dr Ruth E. Board, Consultant in Medical Oncology, Rosemere Cancer Centre, Royal Preston Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Preston

Dr Adam Bond, Registrar in Haematology, Bristol Haematology and Oncology Centre, University Hospitals Bristol NHS Foundation Trust, Bristol

Mr Andrew Brodbelt, Consultant in Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool; Honorary Clinical Senior Lecturer, University of Liverpool, Liverpool

Professor Janet Brown, Honorary Consultant in Medical Oncology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield; Professor of Translational Medical Oncology, University of Sheffield, Sheffield

Dr Laura Camburn, Specialist Registrar in Medical Oncology, St George’s University Hospitals NHS Foundation Trust, London

Dr Chris Campbell, Foundation Year 2 Doctor, The Christie NHS Foundation Trust, Manchester

Dr Judith Carser, Consultant in Medical Oncology, Clatterbridge Cancer Centre NHS Foundation Trust, Wirral

Dr Madhuchanda Chatterjee, Specialist Registrar in Clinical Oncology, Clatterbridge Cancer Centre NHS Foundation Trust, Wirral

Dr Nikesh Chavda, Lymphoma Clinical Fellow, Bristol Haematology and Oncology Centre, University Hospitals Bristol NHS Foundation Trust, Bristol

Dr Vinton Cheng, Specialty Registrar in Medical Oncology, Leeds Cancer Centre, St James’s University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds

Dr Sinead Clarke, GP Adviser, Treatment and Recovery, Macmillan Cancer Support, London

Professor Gordon Cook, Professor of Haematology and Myeloma Studies, Leeds Cancer Centre, Leeds Teaching Hospitals NHS Trust, Leeds

Dr Tim Cooksley, Consultant in Acute Medicine, Manchester University NHS Foundation Trust, Manchester; The Christie NHS Foundation Trust, Manchester

Dr Gemma Dart, Registrar in Medical Oncology, Leeds Cancer Centre, St James’s University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds

Dr Amy Ford, Consultant in Medical Oncology, Royal Lancaster Infirmary, University Hospitals of Morecambe Bay NHS Foundation Trust, Lancaster

Dr Helen Ford, Consultant in Neurology, Leeds Centre for Neurosciences, Leeds Teaching Hospitals NHS Trust, Leeds

Dr Stephen Gilbey, Consultant in Endocrinology, Leeds Teaching Hospitals NHS Trust, Leeds

Dr Simon Gray, Academic Foundation Doctor, Rosemere Cancer Centre, Royal Preston Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Preston

Dr Alastair Greystoke, Senior Lecturer and Honorary Consultant in Medical Oncology, Northern Centre for Cancer Care, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne

Dr Richard Griffiths, Consultant in Medical Oncology, Clatterbridge Cancer Centre NHS Foundation Trust, Wirral

Dr P. Hadjiyiannakis, Consultant in Clinical Oncology, Lancashire Teaching Hospitals NHS Foundation Trust, Preston

Dr Phil Haji-Michael, Consultant in Anaesthesia and Critical Care, The Christie NHS Foundation Trust, Manchester

Dr Allison Hall, Consultant in Clinical Oncology, Clatterbridge Cancer Centre NHS Foundation Trust, Wirral

Dr Greg Heath, Consultant in Medical Ophthalmology, York Teaching Hospitals NHS Foundation Trust, York

Dr Richard Heywood, Core Medical Trainee, Leeds Cancer Centre, St James’s University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds

Dr Jane Hook, Consultant in Medical Oncology, Leeds Cancer Centre, St James’s University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds

Dr Mahabuba Hossain, Researcher in Clinical Oncology, Barisal Biotechnology UK Ltd, Bangladesh

Dr Keith Howell, Staff Grade in Oncology, Leeds Cancer Centre, St James’s University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds

Dr Adam Hurlow, Consultant in Palliative Medicine, Leeds Teaching Hospitals NHS Trust, Leeds

Dr Cathy Hutchison, Cancer Consultant Nurse, Beatson West of Scotland Cancer Centre, NHS Greater Glasgow and Clyde, Glasgow

Dr Helen Innes, Consultant in Medical Oncology, Clatterbridge Cancer Centre NHS Foundation Trust, Wirral

Dr Rohan Iype, Registrar in Clinical Oncology, Rosemere Cancer Centre, Royal Preston Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Preston

Dr Pooja Jain, Consultant in Clinical Oncology, Leeds Cancer Centre, St James’s University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds

Mr Sunjay Jain, Consultant in Urology, St James’s University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds

Dr Rebecca Jones, Consultant Hepatologist, Liver Unit, St James’s University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds

Ms Susan Jones, Macmillan Cancer Support Acute Oncology Clinical Nurse Specialist, Mid Cheshire Hospitals NHS Foundation Trust

Dr Martyn Kennedy, Consultant in Respiratory Medicine, Leeds Centre for Respiratory Medicine, St James’s University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds

Dr Daniel Lee, Consultant in Medical Oncology, Leeds Cancer Centre, St James’s University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds

Dr Pauline Leonard, Consultant in Medical Oncology, Whittington Health NHS Trust, London

Dr Andrew Lewington, Consultant in Renal Medicine and Honorary Clinical Associate Professor, St James’s University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds

Dr Chin Chin Lim, Consultant in Clinical Oncology, Lancashire Teaching Hospitals NHS Foundation Trust, Preston

Louise McKee, Specialist Pharmacist in Oncology, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen

Dr Sid McNulty, Consultant in Diabetes and Endocrinology, St Helens and Knowsley Teaching Hospitals NHS Trust, St Helens

Dr Will Marshall, Clinical Fellow, Manchester University NHS Foundation Trust, Manchester

Dr Caroline Michie, Consultant in Medical Oncology, Edinburgh Cancer Centre, Western General Hospital, NHS Lothian, Edinburgh; Honorary Clinical Senior Lecturer, University of Edinburgh, Edinburgh

Dr Moyra Mills, Macmillan Cancer Support Improvement Manager, Northern Health and Social Care Trust, Northern Ireland

Dr Arafat Mirza, Consultant in Clinical Oncology, Lancashire Teaching Hospitals NHS Foundation Trust, Preston

Dr Catherine Mitchell, Consultant in Clinical Oncology, Rosemere Cancer Centre, Royal Preston Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Preston

Dr Anna Mullard, Consultant in Medical Oncology, Betsi-Cadwaladr University Health Board, Bangor

Dr Karen Neoh, Locum Consultant in Palliative Medicine, St Gemma’s Hospice, Leeds

Dr Anna Claire Olsson-Brown, Fellow in Clinical Research, University of Liverpool, Liverpool; Registrar in Medical Oncology, Clatterbridge Cancer Centre NHS Foundation Trust, Wirral

Dr Lisa Owen, Consultant in Clinical Oncology, Leeds Cancer Centre, St James’s University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds

Dr Tammy Oxley, Specialist Registrar in Palliative Medicine, St Gemma’s Hospice, Leeds

Dr Nick Palmer, Consultant in Cardiology, Liverpool Heart and Chest Hospital, NHS Foundation Trust, Liverpool

Dr Christopher Parrish, Consultant in Haematology, St James’s Institute of Oncology, Leeds Cancer Centre, St James’s University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds

Dr Carmel Pezaro, Locum Consultant in Oncology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield; Yorkshire Cancer Research Senior Research Fellow, University of Sheffield, Sheffield

Dr Benjamin Pickwell-Smith, Registrar in Medical Oncology, Leeds Cancer Centre, St James’s University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds

Dr Chris Plummer, Consultant in Cardiology, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne

Dr Rachel Protheroe, Consultant in Haematology, Bristol Haematology and Oncology Centre, University Hospitals Bristol NHS Foundation Trust, Bristol

Dr Pankaj Punia, Consultant in Medical Oncology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham

Dr Christy Ralph, Consultant in Medical Oncology, Leeds Cancer Centre, St James’s University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds

Dr Satiavani Ramasamy, Consultant in Clinical Oncology, Leeds Cancer Centre, St James’s University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds

Dr Emma Rathbone, Consultant in Medical Oncology, Calderdale and Huddersfield NHS Foundation Trust, Huddersfield

Ms Christine Rhall, Macmillan Acute Oncology Lead Nurse, St Helens and Knowsley Teaching Hospitals NHS Trust, Merseyside

Ms Rachel Rigby, Advanced Clinical Practitioner, Rosemere Cancer Centre, Royal Preston Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Preston

Ms Rosie Roberts, Chemotherapy Specialist Nurse and Acute Oncology Project Manager, Velindre Cancer Centre, Velindre University NHS Trust, Cardiff

Dr Jenny Seligmann, Clinical Lecturer in Medical Oncology, Leeds Cancer Centre, St James’s University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds

Professor Susan Short, Consultant in Clinical Oncology, St James’s University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds; Professor of Clinical Oncology and Neuro-Oncology, University of Leeds, Leeds

Dr Rohan Shotton, Specialty Registrar in Medical Oncology, The Christie NHS Foundation Trust, Manchester

Dr Dan Stark, Consultant in Medical Oncology, Leeds Cancer Centre, St James’s University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds

Dr Andrew Stewart, Consultant in Haematology, Bristol Haematology and Oncology Centre, University Hospitals Bristol NHS Foundation Trust, Bristol; Weston General Hospital, Weston Area Health NHS Trust, Weston-super-Mare

Ms Joanne Stonehouse, Macmillan Cancer Support Project Manager, South Western Ambulance Service NHS Foundation Trust, Exeter

Dr Ajay Sudan, Registrar in Medical Oncology, Northern Centre for Cancer Care, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne

Dr Dan Swinson, Consultant in Medical Oncology, Leeds Cancer Centre, St James’s University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds

Dr Nadina Tinsley, Specialist Registrar in Medical Oncology, The Christie NHS Foundation Trust, Manchester

Dr Gordon Urquhart, Consultant in Medical Oncology, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen

Dr Naveen Vasudev, Consultant in Medical Oncology, Leeds Cancer Centre, St James’s University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds

Dr Andrew Viggars, Specialty Registrar in Clinical Oncology, Leeds Cancer Centre, St James’s University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds

Dr Jennifer Walsh, Senior Clinical Lecturer, Academic Unit of Bone Metabolism, University of Sheffield, Sheffield

Ms Jo Wilkinson, Lead Acute Oncology/Chemotherapy Nurse, Lancashire Teaching Hospitals NHS Foundation Trust, Preston

Dr Simon Williams, Consultant in Cardiology, The Christie NHS Foundation Trust, Manchester; Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester

Dr Deborah Williamson, Consultant in Clinical Oncology, Rosemere Cancer Centre, Royal Preston Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Preston

Dr Nick Wreglesworth, Specialist Registrar in Medical Oncology, North Wales Cancer Treatment Centre, Glan Clwyd Hospital, Rhyl

Dr Lucy Wyld, Specialist Registrar in Palliative Medicine, St James’s University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds

Dr Alison Young, Consultant in Medical Oncology, Leeds Cancer Centre, St James’s University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds

Dr Saif Yousif, Consultant in Clinical Oncology, Rosemere Cancer Centre, Royal Preston Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Preston

Preface

The development and delivery of acute oncology services, both nationally and internationally, have undoubtedly improved the care of cancer patients, the management of acute complications of cancer and its treatment, and our approaches to diagnosing patients who present with cancer and no obvious primary site. The development of acute oncology services has addressed the needs of patients who present acutely to the healthcare system with findings that suggest the ­possibility of a malignancy, by ensuring they get access to early specialist oncology input. This reduces ­delays in diagnosis and in the inappropriate investigation of patients too unwell to be considered for ­systemic anticancer treatment, and facilitates the timely start of treatment. The development of acute oncology services has also ensured that patients who develop acute complications of their cancer or their treatment are seen, evaluated and managed promptly by clinicians with the right skills and facilities, and are provided with a supportive and holistic acute cancer care service throughout their journey. Key appointments in acute oncology, many at consultant and nurse practitioner level, have been made across the NHS and there is continued growth and expansion.

There remains a need to ensure that practitioners are kept fully informed and up-to-date about the appropriate clinical care to be provided in the setting of acute oncology. It is also ­important to continue a dialogue on the best way to deliver acute oncology services in a hard-pressed ­healthcare service. Since the first edition of Problem Solving in Acute Oncology was published in 2014, there has been continued development and expansion of services across the UK. The ­importance of the involvement of primary care in delivering acute oncology nationally has been increasingly ­recognized, leading to the development of ever stronger links between the two. Closer working with acute medicine physicians has also improved the care of acute oncology patients; work is ­ongoing to encourage closer collaboration between acute oncology services and clinical ­haematology.

The establishment of a biannual national acute oncology conference has provided a valuable opportunity for the multidisciplinary members of acute oncology teams nationally to share best practice and innovation. This updated text is particularly helpful and timely. It will again serve as a valuable resource for those who continue to develop excellent acute oncology services, as well as provide a source of training and an update for clinicians working in this challenging clinical area. The Association of Cancer Physicians is to be congratulated for bringing about this valuable additional resource, which is the seventh book in the Problem Solving series. We may look forward to further contributions in the future.

Alison Young, Ruth E. Board, Pauline Leonard, Tim Cooksley,

Andrew Stewart and Caroline Michie, Editors

Acknowledgements

Editors

The editors and authors are grateful to all the patients who have inspired them to prepare this book and work together to improve patient care.

The editors, authors and publisher are most grateful to the Executive Committee of the Associ­ation of Cancer Physicians for their support and advice during development of the book.

We are grateful to Duncan Enright and Beverley Martin at EBN Health for their expert work, support, goodwill and interest in our purpose in preparing the book, and Nicole Goldman, who coordinated and oversaw the book’s preparation and organization.

Dr Young would like to acknowledge the support of the University of Leeds and Leeds ­Teaching Hospitals NHS Trust. Dr Board would like to acknowledge the support of the University of ­Manchester and Lancashire Teaching Hospitals NHS Foundation Trust. Dr Michie would like to acknowledge the support of NHS Lothian and the Chief Scientist Office, NHS Research ­Scotland. Dr Leonard would like to acknowledge the support of the Whittington Health NHS Trust. Dr Cooksley would like to acknowledge the support of Manchester University NHS Foundation Trust and The Christie NHS Foundation Trust. Dr Stewart would like to acknowledge the support of University Hospitals Bristol NHS Foundation Trust and of former colleagues at the University Hospitals of North Midlands NHS Trust.

Alison Young, Ruth E. Board, Pauline Leonard, Tim Cooksley,

Andrew Stewart and Caroline Michie

Association of Cancer Physicians

The Problem Solving series of cancer-related books is developed and prepared by the Association of Cancer Physicians, often in partnership with one or more other specialist medical organizations. As the representative body for medical oncologists in the UK, the Association of Cancer ­Physicians has a broad set of aims, including education for its own members and for non-members, including interested clinicians, healthcare professionals and the public. The Problem Solving series is a planned sequence of publications that derive from a programme of annual scientific workshops initiated in 2014 with ‘Problem Solving in Acute Oncology’ followed by ‘Problem Solving in Older Cancer Patients’, ‘Problem Solving Through Precision Oncology’, ‘Problem Solving in Patient-Centred and Integrated Cancer Care’, ‘Problem Solving in Immunotherapy’ and, most recently, ‘Problem Solving in Acute Oncology, 2nd edition’.

The publications involve considerable work from members and other contributors; this work is done without remuneration, as an educational service. The books have been well received and we are delighted with their standard. Problem Solving in Older Cancer Patients, Problem ­Solving Through Precision Oncology and Problem Solving in Patient-Centred and Integrated ­Cancer Care were awarded the BMA prize for best oncology book of the year in 2016, 2017 and 2018, ­respectively.

The Association of Cancer Physicians wishes to thank all the contributors to this and previous publications and those yet to come.

David Cunningham, Chairman, Association of Cancer Physicians

Peter Selby, President, Association of Cancer Physicians

Abbreviations

This book is dedicated to

Dr Ernie Marshall, Consultant Medical Oncologist,

and Philippa Jones, Oncology Nurse Specialist, for their

work in developing acute oncology services in the UK.

S E C T I O N   O N E 01

PERSPECTIVE

01 Acute Oncology Services: Past, Present and Future

Ruth E. Board

Development of acute oncology services

The National Chemotherapy Advisory Group was established to advise the National Cancer ­Director and the Department of Health on the development and delivery of high-quality chemotherapy services. In 2009 it published a report recommending the development of acute oncology services to address the concerns raised in the 2008 National Confidential Enquiry into Patient ­Outcome and Death.¹,² The enquiry had raised concerns in a number of areas about the care of cancer patients. Specifically, in regard to deaths within 30 days of receiving systemic anticancer therapy (SACT), the enquiry reported that in only 35% of patients who died within 30 days of ­receiving SACT was their care judged to be good. There was room for improvement in the care provided to 49% of patients, and in 8% of cases the care provided was less than satisfactory. ­Alarmingly, in 27% (115/429) of cases, the enquiry found that SACT had caused or hastened death. Furthermore, it highlighted the fact that many patients received SACT in specialist cancer centres but ultimately were admitted with complications of cancer treatment to their local hospital. It was found that 42% of all unwell cancer patients were admitted under general medicine rather than to a specialist oncology ward, yet 43% had grade 3 or 4 SACT-related toxicity on admission; 15% of patients were not admitted to the centre where their SACT had been administered.

The subsequent 2009 National Chemotherapy Advisory Group report gave a number of recommendations to improve patient care and safety and described the need for acute oncology services: ‘Acute oncology encompasses both the management of patients who develop severe complications following chemotherapy or as a consequence of their previously diagnosed cancer, as well as the management of patients who present as emergencies with previously undiagnosed cancer. Acute oncology therefore necessarily involves clinicians working in emergency departments and in acute medicine, as well as in oncology and related disciplines.’² The recommendations included the principles that all hospitals with emergency departments should establish an acute oncology service, the service should develop local policies and procedures for the treatment of cancer patients, there should be appropriate training for clinical staff in the identification and management of acute oncology presentations and there should be access to urgent specialist oncological advice on the care of cancer patients admitted as an emergency.

New national peer review measures reflected the National Chemotherapy Advisory Group ­recommendations and focused on the timely review of patients admitted as an emergency to hospital by a member of the acute oncology team and oncology consultant, the 1 h door-to-needle time for the treatment of neutropenic sepsis, timely investigation and management of metastatic spinal cord compression (MSCC), and development and training in acute oncology emergencies, at that time totalling 22 defined emergencies ranging from hypercalcaemia to pleural effusion and chemotherapy-related diarrhoea.³ These priorities, with specific targets to aim for and monitor, were reinforced by a 2008 NICE guideline on MSCC⁴ and a 2012 NICE guideline on prevention and management of neutropenic sepsis.⁵

However, the initial awareness and importance of acute oncology services was fragmented throughout the UK. Published evidence of the benefit of the services was sparse and there were differences around the country in both enthusiasm and financial support for them. The 2012/13 national acute oncology service peer review of the 183 services showed a median of only 50% compliance with nationally agreed measures, with some trusts achieving <20% of the required peer review indicators.⁶ Nevertheless, audits of newly developed services across the country demonstrated reduced length of stay and potential bed savings. A 6 month pilot study evaluating a new acute oncology service at a single hospital in a small patient cohort reported a significant reduction in length of hospital stay and time to investigations,⁷ and a larger cancer network-based study (Merseyside and Cheshire) reported a reduced length of stay of 3.1 days per inpatient ­episode in a population of over 3000 patients reviewed at multiple acute hospital trusts, equating to a potential saving of £2 million.⁸

One important aspect of acute oncology was the recognition that not only did known cancer patients require increased support by specialists but also there was an unmet need for patients admitted to hospitals with an emergency presentation of a new cancer. The audit of admissions to Merseyside and Cheshire demonstrated that 51% of acute oncology admissions were due to complications of cancer, 30% were considered complications of treatment and 19% were new diagnoses of malignancy. A subgroup of the new diagnoses was recognized to be patients with malignancy of unknown origin (MUO) or carcinoma of unknown primary (CUP), comprising a group lacking coordinated care, investigation and management. The NICE guideline on CUP⁹ expected that many consultant oncologists who developed a specialist interest in CUP would also be involved in organizing and delivering aspects of the acute oncology service for newly presenting patients with previously undiagnosed cancer, and indeed many acute oncology service teams embraced this new aspect of acute oncology.

Current status of acute oncology services

Acute oncology services in the UK have evolved into differing models depending on local ­resources and service design. The early proposed requirement for consultant oncology leadership and early face-to-face patient review in every hospital has posed logistical and financial problems ­compounded by the limited number of available trained oncologists. Many acute oncology services are predominantly nurse led, with variable input from consultant oncologists. While different models have developed across hospitals, in particular with differences between stand­a­lone cancer centres and traditional district general hospitals, the principles of providing acute oncology remain urgent triage and review of oncology inpatients, defined protocols and pathways for treatment, early specialist review and the availability of 24 h advice from an oncology consultant.

Acute oncology services are now embedded in most hospital trusts in England and development is gathering