Consequences of cancer treatmentsKaren Morgan Macmillan Consultant RadiographerJan 13th 2015

Background - UK / year

Macmillan facts and figures – ▫2 million are living with consequences of

cancer treatment▫Estimated 500,000 people living with

more than one problem▫Physical and emotional ▫Cancer survivors estimated to rise to 4

million in next 20 years

(Source - Throwing light on the consequences of cancer and its treatment, Macmillan Cancer Support 2013)

Of those two million people......

•40% say they are unaware of long-term side effects.

•78% have experienced physical health problems in the last 12 months.

•40% with emotional problems have not sought help.

•71% of those who finished treatment 10 years ago have experienced physical health problems in the last 12 months(Source - Throwing light on the consequences of cancer and its

treatment, Macmillan Cancer Support 2013)

•Healthcare system facing financial pressure

•Innovation and reform •Redesign of services – quality, value for

money▫Pressure from follow up appointments

(1160 / month)▫Consequences of cancer treatment ▫Not good at picking up LE in FU

In addition….

NCSI Vision Document (2010)

“...current follow-up arrangements do not address the full range of physical, psychological, social, spiritual, financial and information needs that cancer survivors may have following their treatment.”

Quality of Life (Radiotherapy)

Acute toxicities •Occur in tissues with rapid cell turnover,

(eg mucous membranes)•Acute inflammatory response•Peaks at 2-3 weeks•Usually short lived, resolve within 3

months•Patients recover, but often need supportive

therapeutic and pharmacological strategies

Quality of Life (Radiotherapy)

Late effects•Can develop from 6 months to many years

later•Often progressive•Usually permanent•Often multi-factoral•Multi-modality treatments increase risk !

concurrent chemorad = risk of peripheral neuropathy / renal damage etc

Pre-exisiting injury – smoking, Diabetes

Pre-disposition (to late effects development) – inflammatory bowel disease, MS, genetic mutation (eg P53)

Isolation / loss of confidence

Employment issues / benefit burden

Memory / concentration

problems

Impact on families, social network

Body image issues

Not knowing who to approach for help

Sexual relationships

Additional co-morbidities associated with age

Physical symptoms

Emotional issues

Embarrassment / difficulty coping

‘How was I?On a good day uncomfortable, using pads, and planning carefully every time I went out of the house.On a bad day, I’d rather not eat than embarrass myself in front of family and friends and I sleep in a separate room now.’

Patient with lower GI symptoms

Main issues (1)

•Historical legacy – patient treated elsewhere

•SW – Age profile – LE combined with other co-morbidities

•Little information on the scale of the problem!

• Symptoms managed poorly, no guidance !•Unnecessary investigations / ineffective treatments

•Impact on NHS resources•Who takes responsibility ?

Main issues (2)

* LE services – few specialist services over large geographical area.

* Some services regionally (referrals, funding, travel)

* LE services traditionally associated with paediatric oncology

* NCSI recovery package (approach is not standardised)

Pandora’s box

Newer treatment techniques IMRT / VMAT / SABR/IGRT

New chemotherapy drugs

Survival rates = Consequences ?

Tiered model of care at The Beacon

During treatment - Information and resources• HNA

assessment• Radar key /

toilet card• Tailored

discussions re side effects

At the end of treatment - HNA and Treatment Summary • Include

potential future consequences

• How to minimise / monitor

• Healthy choices• Primary care

management• ?H + WB clinic

Late effects services Nationally –

Pelvic Radiation Disease Clinic – Royal Marsden 2.5 hours by train and tube !!!!

Hyperbaric Oxygen – Plymouth,

Merseyside 60 treatments is usual, no NICE approval

Virtual MDT – complex cases, online password protected platform. 7 day process

Regionally – •Fatigue and Life Style Management for

Cancer Survivors – Step Up Service, Bath•Breast Radiation Injury Service, Bath (Manchester

and London no longer taking referrals)

•Emotional wellbeing, comp therapies (Penny Brohn Cancer Care – Bristol and Talking therapies (Somerset Partnership) – CBT, psychological support

•Others? – adult LE clinics associated with childhood cancers, ProActive (GP exercise referral), CAB

Late effects services

Locally - •Gastroenterologist (interest in PRD)•Endocrinologist •Local therapists – (SLT, dietician, physio,

lymphoedema) •ED clinic •Pain clinic•Women’s health •Nurse Counsellors

Late effects services

Where are we now?• New guidance for LE symptoms,

other sites to follow – implementation? Succinct algorithms for ease ?

• Education for primary care / self development (RMH e module)

• Assessment / screening tools / PROMS vital !

• Tiered model of care • Utilisation of services and

resources• Referral pathways? CCG / Regional

Survivorship groups

* Prevention to minimise wherever possible

* Inform patients of potential LE* Identify those at risk* Assessment – HNA address unmet

needs* Support patients through local and

regional LE pathways* Patients gain independence /

return to work* Prevents unnecessary hospital

admissions / GP consultations* Saves NHS

money!............................

Making a difference !

•For every £1 spent on lymphoedema treatments, the service estimates the NHS saves £100 in reduced hospital admissions.

•If just half of breast cancer survivors who initially return to work but then leave were helped to stay in work, the economy could save £30M every year.

Reference: NHS London (2012) Allied Health Professional QIPP pathway for cancer

Golden nuggets !

Karen Morgan, Macmillan Consultant Radiographer (Late Effects),c/o The Radiotherapy Dept,The Beacon Centre,Taunton,TA1 5DA.Telephone 01823 342933Email: karen.morgan@tst.nhs.uk

Further information or direct referrals