YCN MSCC PathwayYCN MSCC PathwayImplementation of NICE CG75Implementation of NICE CG75

Level 1: Early warningLevel 1: Early warning

Dr Rob TurnerDr Rob Turner

Chair YCN MSCC GroupChair YCN MSCC GroupUnits to localise slides to clarify responsibilities of the MSCC Units to localise slides to clarify responsibilities of the MSCC

Coordinator and specify points of referral from the initial triage to the Coordinator and specify points of referral from the initial triage to the MSCC Coordinator and then on to the AOL / AOTMSCC Coordinator and then on to the AOL / AOT

YCN MSCC Competency for Initial YCN MSCC Competency for Initial IdentificationIdentification

The Local Cancer Unit Acute Oncology Team (AOT) take responsibility for the The Local Cancer Unit Acute Oncology Team (AOT) take responsibility for the diagnosis and transfer of appropriate patients diagnosis and transfer of appropriate patients

Competency has been defined for the staff groups involved in the diagnosis, Competency has been defined for the staff groups involved in the diagnosis, management and treatment of MSCC patients management and treatment of MSCC patients

Staff involved in the initial identification of potential MSCC including A&E and Acute medical Unit staff

Competency

a) Knowledge and understanding of which patient groups are at a higher risk of developing MSCC

b) Knowledge and Understanding of the signs and symptoms of MSCC

c) Understanding of the appropriate aspects of the MSCC pathway

d) Escalation process to the Local MSCC Coordinator

Education

E - Learning level 1- Early Warning

What is MSCC?What is MSCC?

MMalignant (metastatic)alignant (metastatic)

SSpinalpinal

CCordord

CCompressionompression

Basically a complicated bony metastasis as Basically a complicated bony metastasis as a consequence of advancing malignancya consequence of advancing malignancy

MechanismMechanism

PredictablePredictable symptomatic course symptomatic course– Three phases of patho-physiologyThree phases of patho-physiology

Vertebral infiltration/expansionVertebral infiltration/expansion

Axonal compressionAxonal compression

Vascular compromise (esp. mid thoracic)Vascular compromise (esp. mid thoracic)– ArterialArterial– VenousVenous

– Influenced byInfluenced byVertebral anatomy (local & spinal)Vertebral anatomy (local & spinal)

Biomechanical compromiseBiomechanical compromise

MSCC: Anatomical heterogeneityMSCC: Anatomical heterogeneity

MSCCMSCC

MSCC: Symptomatic courseMSCC: Symptomatic course

Bone painBone painRadicular painRadicular pain– Band-like/belt-likeBand-like/belt-like– SciaticaSciatica

Motor weaknessMotor weakness– With preserved gait functionWith preserved gait function– With paraplegiaWith paraplegia– With paralysisWith paralysis

Sensory lossSensory lossAutonomic dysfunction (loss of sphincters)Autonomic dysfunction (loss of sphincters)

MSCC: Motor symptom evolutionMSCC: Motor symptom evolutionInvariably presents lateInvariably presents late

MSCC: Time-courseMSCC: Time-course(from first symptom)(from first symptom)

SymptomSymptom Rate of changeRate of change

Motor weaknessMotor weakness 40% presentation40% presentation

50% within 7 days50% within 7 days

80% within 80 days80% within 80 days

Loss of gait functionLoss of gait function 50% within 38 days50% within 38 days

ParalysisParalysis 50% within 12 days50% within 12 days

Outcome by ambulationOutcome by ambulation

Ambulant state pre-RTAmbulant state pre-RT Ambulant post-RTAmbulant post-RT

WalkingWalking 90%90%

Walking with helpWalking with help 60%60%

Unable to walkUnable to walk 40%40%

ParaplegicParaplegic 10%10%

Goals of YCN MSCC PathwayGoals of YCN MSCC Pathway

1.1. Patient education for early presentationPatient education for early presentation

2.2. Diagnosis at an early phase of processDiagnosis at an early phase of process

3.3. Treatment with greater successTreatment with greater success

4.4. Improved function and QoLImproved function and QoL

E – E – Learning Training Packs on the YCN websiteLearning Training Packs on the YCN website

Level 1- Early Warning

Level 2 – Diagnostic

Level 3 – Specialist Intervention

Patient EducationPatient Education

Predictable clinical coursePredictable clinical course

Suitable for screeningSuitable for screening– Symptomatic patientsSymptomatic patients– MRI imaging for those who needMRI imaging for those who need– Rapid access to diagnosis and treatment Rapid access to diagnosis and treatment

Patient EducationPatient Education

ConcernsConcerns– Bony metastases present in 30% cancer patientsBony metastases present in 30% cancer patients– Non-malignant back pain common in populationNon-malignant back pain common in population– Generalised weakness common in advanced cancerGeneralised weakness common in advanced cancer

SolutionSolution– Identify high risk groups and target themIdentify high risk groups and target them

Improved specificity of screeningImproved specificity of screening

Reduced anxiety in patient population as a wholeReduced anxiety in patient population as a whole

High Risk Patient GroupsHigh Risk Patient Groups

Any patient who has had Any patient who has had prior MSCCprior MSCCAny patient with Any patient with known bony metastasesknown bony metastases at any at any site from any primary sitesite from any primary siteKnown cancer Known cancer awaiting investigation for awaiting investigation for suspicious spinal painsuspicious spinal painTumour site-specific recommendationsTumour site-specific recommendations– ProstateProstate:: Hormone resistant prostate cancerHormone resistant prostate cancer– RenalRenal:: Metastatic renal cell cancerMetastatic renal cell cancer– LungLung:: Any metastatic lung cancerAny metastatic lung cancer– BreastBreast:: Any metastatic breast cancerAny metastatic breast cancer– MyelomaMyeloma:: Any myelomaAny myeloma

High-risk patient groupsHigh-risk patient groups

High-risk patients identified clinicallyHigh-risk patients identified clinically

Face-to-face discussionFace-to-face discussion

Provided with Provided with MSCC Early Warning MSCC Early Warning Leaflet Leaflet Features of MSCCFeatures of MSCC– What to do if they are worriedWhat to do if they are worried– How to access helpHow to access help

Via 24-hour SINGLE POINT CONTACT NUMBERVia 24-hour SINGLE POINT CONTACT NUMBER

Insert local contact pointInsert local contact point

LTHT MSCC Early Warning Booklet – LTHT MSCC Early Warning Booklet – Substitute Local Version & TitleSubstitute Local Version & Title

Overall goalsOverall goals

Earlier diagnosis and treatmentEarlier diagnosis and treatment– Outcomes linked to pre-treatment statusOutcomes linked to pre-treatment status

Faster access to diagnostic MRIFaster access to diagnostic MRI– SuspectedSuspected

MSCC within 24 hoursMSCC within 24 hoursVBM within 7 daysVBM within 7 days

Rapid escalation to definitive therapyRapid escalation to definitive therapy– ProvenProven

MSCC within 24 hoursMSCC within 24 hoursVBM within 7 daysVBM within 7 days

Definitive therapy case-appropriateDefinitive therapy case-appropriateCo-ordinated case-appropriate rehabilitationCo-ordinated case-appropriate rehabilitation

MSCC Pathway ComponentsMSCC Pathway Components

1.1. Education and early warningEducation and early warning

2.2. TriageTriage

3.3. Diagnosis & generic careDiagnosis & generic care

4.4. Specialist interventionSpecialist intervention Spinal surgerySpinal surgery RadiotherapyRadiotherapy

5.5. RehabilitationRehabilitation

MSCC symptoms & signsMSCC symptoms & signs

Triage: Mechanism Triage: Mechanism (Insert Local (Insert Local Process Below)Process Below)

Nursing staff will take basic detailsNursing staff will take basic detailsEscalate to on-call clinical oncology teamEscalate to on-call clinical oncology team– In hours to be handled immediatelyIn hours to be handled immediately

Contact - Contact - Insert Local InformationInsert Local Information– Overnight (Overnight (Local NumberLocal Number))

Escalate to resident/duty ward medical staffEscalate to resident/duty ward medical staff– Insert Local ProcedureInsert Local Procedure

– PriorityPriorityImmediate or deferred?Immediate or deferred?

– Ward or clinic for clinical assessmentWard or clinic for clinical assessmentIs MRI required and how quickly?Is MRI required and how quickly?

Nursing Triage Nursing Triage (Insert Local (Insert Local process)process)

Question & Answer data recording formQuestion & Answer data recording form– Patient & referrer detailsPatient & referrer details– LOCATION & CONTACT DETAILSLOCATION & CONTACT DETAILS– Patient symptoms/featuresPatient symptoms/features– Advice/instruction as to what will happen nextAdvice/instruction as to what will happen next

Complete for ALL MSCC related callsComplete for ALL MSCC related calls

Hand-over to medical staff / MSCC Hand-over to medical staff / MSCC CoordinatorCoordinator

Local Process for Escalation to Local MSCC Local Process for Escalation to Local MSCC Co-ordinatorCo-ordinator

Triage: Need for MRITriage: Need for MRI

Probability MRI shows neural compressionProbability MRI shows neural compression(after Lu, J Sup Care 2005;3:305-312)(after Lu, J Sup Care 2005;3:305-312)

Neurological deficitNeurological deficit

PresentPresent AbsentAbsent

High-risk & suspicious painHigh-risk & suspicious pain 81%81% 69%69%

Suspicious pain onlySuspicious pain only 44%44% 33%33%

Triage: Endpoints Triage: Endpoints

MSCC possible – Refer to Local MSCC MSCC possible – Refer to Local MSCC Co-ordinatorCo-ordinator– Urgent clinical assessmentUrgent clinical assessment– Urgent in-patient MRI Urgent in-patient MRI (within 24 hours)(within 24 hours)

Admission may be requiredAdmission may be required

MSCC less likely but VBM possibleMSCC less likely but VBM possible– Prompt outpatient assessmentPrompt outpatient assessment– Prompt outpatient MRI Prompt outpatient MRI (within 7 days)(within 7 days)

Further informationFurther information

YCN WebsiteYCN Website

EQMSEQMS

YCN MSCC LeadYCN MSCC Lead(rob.turner@leedsth.nhs.uk)(rob.turner@leedsth.nhs.uk)