NORTH EAST WALES NHS TRUST UPPER GASTROINTESTINAL …



NORTH EAST WALES NHS TRUST UPPER GASTROINTESTINAL CANCERS CLINICAL CARE GUIDELINES

CREATED: SEPTEMBER 2006

REVIEW DATE: SEPTEMBER 2007

Signed on behalf of the North East Wales Trust by Mr Jonathan Pye, Lead Clinician for the Upper GI MDT - NEWT.

Signed:

Date:

Signed on behalf of the Countess of Chester NHS Foundation Trust by Mr David Monk, Lead Clinician for the Countess of Chester Upper GI MDT.

Signed:

Date:

Signed on behalf of the Conwy and Denbighshire NHS trust by Mr Richard Morgan, Lead Clinician for the Ysbyty Glan Clwyd Upper GI MDT.

Signed:

Date:

Signed on behalf of the North West Wales Trust by Dr Rachel Williams, Lead Clinician for the Ysbyty Gwynedd Upper GI MDT.

Signed:

Date:

Contents

1: Background 8

|Upper Gastrointestinal Cancers Patient Flows and Multidisciplinary Teams | |

| |9-10 |

2: NICE Referral Guidelines for Upper Gastrointestinal (UGI) Cancers

|General recommendations | 11 |

|Specific recommendations | 11 |

|Risk factors | 12 |

|Investigations |12 |

3: UGI Supra Network Multi Disciplinary Team (MDT) Operational Policy

|Purpose of the meeting | 13 |

|NEWT Upper Gastrointestinal Multi Disciplinary Team |14 |

|Roles of individual team members |15 |

|Types of meetings |15 |

|Frequency of meetings |16 |

|Leave cover |16 |

|Identifying patients for discussion |16 |

|GP notification, documentation of key worker and contact details |13 |

|Minimum data set requirements |17 |

|Information available at MDT meeting |18 |

|Documentation of outcomes |18 |

|Service improvement |18 |

4: Cross Border Upper Gastrointestinal Surgical Centre MDT Referral Guidelines

|Standard of UGI |19 |

|Patient assessment |19 |

|Standard of CT |20 |

|Referral to the Surgical Centre |20 |

|MDT Exclusion Criteria |20 |

|Endoscopic ultrasound and PET CT |20 |

|Initial surgical consultation |21 |

|Standard of staging laparoscopy |21 |

|Treatment |21 |

|Post treatment follow-up |22 |

|Palliative interventions |22 |

|Investigation and treatment flow charts |23-24 |

5: Oncology Treatment Guidelines

Oesophageal Cancer Chemotherapy Regimes 25

Oesophagogastric Cancer Chemotherapy Regimes 29

6: Surgical Treatment and Follow Up Guidelines

Operative protocol 30

Follow up protocol after surgery 31

7: Communication policy

Purpose 34

Methods of communication including responsibility 34

How information should be communicated 36

Supra network UGI Communication Flowchart 37

8: Patient and Public Involvement

Introduction 39

Patient Support Group 39

Holistic needs assessment 39

UGI Audit/ Patient satisfaction questionnaire 40

Patient information 40

9: Quality Assurance Framework

Introduction 42

Summary of Recommendations 43

What is Quality Assurance? 45

Quality Assurance through Service Organisation 46

Quality Assurance through Audit 48

Quality Assurance through Performance Management 51

Making it Happen 54

Appendices

Appendix 1: Pre-assessment care pathway

Appendix 2: Stent ICP

Appendix 3: Physiotherapy Guidelines

Appendix 4: Dietetic Guidelines

Appendix 5: Peer Review Measures for the Upper GI Specialist Team

Appendix 6: Peer Review Measures for the Upper GI Local Teams

Appendix 7: Proposed Canisc MDS for Specialist Upper GI MDT

Appendix 8: Imaging Guidelines

Appendix 9: Pathology Guidelines

Appendix 10: Referral Proforma

1. Background

The cross-border oesophago-gastric cancer service is being established in response to national guidelines published in 2001. Although oesophago-gastric cancers are not rare, the guidelines state that the ‘numbers are too small for staff in most hospitals to develop and maintain expertise, and probably too small to justify setting up specialist facilities – yet the nature of the disease is such that expert management is crucial’.[1]

North East Wales NHS Trust has been nominated as the centre to serve the populations of North Wales and West Cheshire. Clinicians from the Countess of Chester NHS Foundation Trust will join colleagues at the Wrexham Maelor Hospital to undertake complex surgery at the centre. The combined population covered by this arrangement is 865,000 and the implementation plans have the approval of both the Department of Health and the Cancer Services Co-ordinating Group.

The national guidelines need to be complied with by June 2007, but it is anticipated that the centre will be fully operational ahead of this date.

Patients with oesophago-gastric cancers are already managed by North East Wales NHS Trust, which has a well established Upper GI clinical team. Becoming a ‘centre’, however, will require additional capacity, new operational procedures, redesigned patient-pathways, more in-depth data collection, complex commissioning arrangements and co-operation from a large number of organisations.

Establishing the new service will be complex, and there will be many risks associated with it. It is important, therefore, that effective ways of defining and measuring quality are established, and that systems are in place to redress poor quality should it arise. This document aims to provide a framework for assuring the quality of the new service, both during its establishment and into the future.

Upper Gastro-Intestinal Cancers Patient Flows and Multidisciplinary Teams

Diagnostic / Local MDTs

|Name of | | |Population Referred |

|Hospital / MDT |Name of Trust |Referring PCTs / LHBs | |

|Southport & Ormskirk |Southport & Ormskirk Hospitals |Southport & Formby PCT |115,000 |

| |NHS Trust |West Lancashire PCT |110,000 |

| | | |225,000 |

|St Helens & Knowsley |St Helen & Knowsley Hospitals |St Helens PCT |180,000 |

| |NHS Trust |Knowsley PCT |150,000 |

| | | |330,000 |

|Warrington |North Cheshire Hospitals NHS |Warrington PCT |190,000 |

| |Trust | | |

|Halton |North Cheshire Hospitals NHS |Halton PCT |120,000 |

| |Trust | | |

|Broadgreen |Cardiothoracic Centre NHS Trust|North Liverpool PCT (20%) |20,000 |

| | |Central Liverpool PCT |240,000 |

| | |South Liverpool PCT |100,000 |

| | | |360,000 |

|Aintree |Aintree University Hospitals |North Liverpool PCT (80%) |80,000 |

| |NHS Trust |South Sefton PCT |170,000 |

| | | |250,000 |

|Countess of Chester |Countess of Chester NHS |Ellesmere Port & Neston PCT (66%) |55,000 |

| |Foundation Trust |Cheshire West PCT |150,000 |

| | | |205,000 |

|Wirral |Wirral Hospitals NHS Trust |Birkenhead & Wallasey PCT |200,000 |

| | |Bebington & West Wirral PCT |120,000 |

| | |Ellesmere Port & Neston PCT (33%) |25,000 |

| | | |345,000 |

|Wrexham Maelor |North East Wales NHS Trust |Wrexham LHB |140,000 |

| | |Flintshire LHB |160,000 |

| | | |300,000 |

|Ysbyty Glan Clwyd |Conwy and Denbighshire NHS |Conwy LHB |120,000 |

| |Trust |Denbighshire LHB |130,000 |

| | | |250,000 |

|Ysbyty Gwynedd |North West Wales NHS Trust |Gwynedd LHB |110,000 |

Specialist MDTs

|Name of | | |Population Referred |

|Hospital / MDT |Name of Trust |Referring PCTs | |

|Pancreas |Royal Liverpool & Broadgreen |All Network |2,300,000 |

| |University Hospitals NHS Trust |Gwynedd LHB |110,000 |

| | |Conwy LHB |120,000 |

| | |Denbighshire LHB |130,000 |

| | |Flintshire LHB |160,000 |

| | |Wrexham LHB |140,000 |

|Liver |Aintree University Hospitals |All Network |2,300,000 |

| |NHS Trust |Gwynedd LHB |110,000 |

| | |Conwy LHB |120,000 |

| | |Denbighshire LHB |130,000 |

| | |Flintshire LHB |160,000 |

| | |Wrexham LHB |140,000 |

|Oesophago-gastric |Cardio-Thoracic Centre NHS |North Liverpool PCT |20,000 |

| |Trust |Central Liverpool PCT |240,000 |

| | |South Liverpool PCT |100,000 |

| | |Warrington PCT |190,000 |

| | |Halton PCT |120,000 |

| | |Conwy LHB* |120,000 |

| | |Denbighshire LHB* |110,000 |

|Oesophago-gastric |North East Wales NHS Trust |Gwynedd LHB |110,000 |

| | |Conwy LHB |120,000 |

|Currently being | |Denbighshire LHB |130,000 |

|commissioned. | |Flintshire LHB |160,000 |

| | |Wrexham LHB |140,000 |

|Operational by April 2007 | |Ellesmere Port & Neston PCT (66%) |55,000 |

| | |Cheshire West PCT |150,000 |

|Oesophago-gastric |Aintree University Hospitals |Southport & Formby PCT |115,000 |

| |NHS Trust |West Lancashire PCT |110,000 |

|Currently being | |St Helens PCT |180,000 |

|commissioned. | |Knowsley PCT |150,000 |

| | |North Liverpool PCT (80%) |180,000 |

|Operational by June 2007 | |South Sefton PCT |150,000 |

| | |Birkenhead & Wallasey PCT |200,000 |

| | |Bebington & West Wirral PCT |120,000 |

| | |Ellesmere Port & Neston PCT (33%) |25,000 |

*Conwy and Denbighshire patients will transfer into the North East Wales centre by April 2007

2. NICE Referral Guidelines for Upper Gastrointestinal Cancers

In June 2005, the National Institute for Clinical Excellence published the update

guidance on referral for suspected cancers in adults and children. The following summarises the best practice guidance for referrals for suspected Upper GI cancers.

General recommendations

A patient who presents with symptoms suggestive of upper gastrointestinal cancer should be referred to a team specialising in the management of upper gastrointestinal cancer, depending on local arrangements.

Specific recommendations

An urgent referral for endoscopy or to a specialist with expertise in upper gastrointestinal cancer should be made for patients of any age with dyspepsia who present with any of the following:

• chronic gastrointestinal bleeding

• dysphagia

• progressive unintentional weight loss

• persistent vomiting

• iron deficiency anaemia

• epigastric mass

• suspicious barium meal result.

In patients aged 55 years and older with unexplained and persistent recent-onset dyspepsia alone, an urgent referral for endoscopy should be made. In patients aged less than 55 years, endoscopic investigation of dyspepsia is not necessary in the absence of alarm symptoms. In patients presenting with dysphagia (interference with the swallowing mechanism that occurs within 5 seconds of having commenced the swallowing process), an urgent referral should be made.

Helicobacter pylori status should not affect the decision to refer for suspected cancer. In patients without dyspepsia, but with unexplained weight loss or iron

deficiency anaemia, the possibility of upper gastrointestinal cancer should be recognised and an urgent referral for further investigation considered. In patients with persistent vomiting and weight loss in the absence of dyspepsia, upper gastro-oesophageal cancer should be considered and, if appropriate, an urgent referral should be made. An urgent referral should be made for patients presenting with either:

• unexplained upper abdominal pain and weight loss, with or without back pain, or

• an upper abdominal mass without dyspepsia.

In patients with obstructive jaundice an urgent referral should be made depending on the patient’s clinical state. An urgent ultrasound investigation may be considered if available.

Risk factors

In patients with unexplained worsening of their dyspepsia, an urgent referral should be considered if they have any of the following known risk factors: C

• Barrett’s oesophagus

• known dysplasia, atrophic gastritis or intestinal metaplasia

• peptic ulcer surgery more than 20 years ago.

Investigations

Patients being referred urgently for endoscopy should ideally be free from acid suppression medication, including proton pump inhibitors or H2 receptor antagonists, for a minimum of 2 weeks. In patients where the decision to refer has been made, a full blood count may assist specialist assessment in the outpatient clinic. This should be carried out in accordance with local arrangements. All patients with new-onset dyspepsia should be considered for a full blood count in order to detect iron deficiency anaemia.

3. Upper GI Supra Network Multidisciplinary Team (MDT)

Purpose of the UGI MDT Meeting

An MDT team is deemed an essential part of the management of patients with cancer. An effective well functioning MDT will ensure that all relevant disciplines are able to contribute to and participate in discussion and decisions made on the clinical management of patients.

The North East Wales Trust has been nominated as the surgical centre to serve the populations of North Wales and West Cheshire. Clinicians from the Countess of Chester NHS Foundation Trust will join colleagues at the Wrexham Maelor Hospital to undertake complex surgery at the centre. Therefore, the North East Wales Trust will continue to hold their ‘local’ MDT in order to manage their local patients with oesophago-gastric cancers. However, the Supra MDT will also link with 2 further North Wales Trusts and 1 Chester Trust in order to discuss patients who may be potential surgical candidates or for second opinion. Patients referred into the surgical centre will have been previously discussed at local MDT level and only those patients who are potential surgical candidates will be discussed at supra MDT level; palliative patients will remain under the management of local MDT.

In order to promote an efficient and high standard of care for patients with Upper GI cancer the Supra Multidisciplinary Team (MDT) has been established.

The aim of the Supra MDT is to ensure a co-ordinated service for patients from diagnosis onwards for Wrexham patients, and from referral to centre onwards for those patients referred into the centre via the feeder trusts. The Supra MDT has the combined function of the diagnostic team to rapidly assess and achieve histological confirmation of cancer and the specialist team for patient assessment and treatment. The MDT is involved in the management of all patients with Upper GI Cancer and in liaising with identified primary care teams and hospices if necessary (consider any other teams liaise with). Decisions about management and standards for therapy will follow Cancer Network Policy and Guidelines.

NB: MDT meetings are recognised as a unique learning opportunities and often students and junior doctors are encouraged attend.

NB: The Supra MDT Coordinator also acts as the local MDT Co-ordinator for Wrexham patients).

North East Wales NHS Trust Upper Gastrointestinal Multidisciplinary Team (2F206)

All members of the team should be specialists in Upper GI Cancer or in the case of diagnostics have a special interest/ expertise in Upper GI. The team will comprise of the following core members:

Numbers in blue cross-refer to the Peer Review Number·

|Core team |Named team member |Cover in absence |

| | |(2F214) |

|Lead Clinician |Mr Jonathan Pye |Mr Andrew Baker |

|(2F2 01) | | |

|Designated UGI surgeons | Mr Andrew Baker | Mr Jonathan Pye |

| |Mr David Monk (COCH) |Mr James Evans (COCH) |

| |Mr James Evans (COCH) |Mr David Monk (COCH) |

|Clinical Oncologist |Dr Simon Gollins |Meeting arranged for 6/12/06 to confirm |

| Physician Gastroenterologists | Dr P George | Dr P George |

| |Dr Mathialahan |Dr Mathialahan |

| | |(1 to be present at each MDT) |

|Histopathologist/ Cytopathologist |Dr Burdge |Dr Williams |

|(2F209;2F239)) | | |

|Imaging consultant | | |

| |Dr Corr |Dr Abbott – COCH |

| | | |

| |Dr Byrne (2F 225) | |

|(2F210, 2F223, 2F224) | | |

|Nurse Specialist |Ann Camps |Rachel Davison (COCH) |

|Dietician |Kate Howarth | |

| | |Jane Power |

|MDT Coordinator |Shelley Cheffings |MDT Co – ordinators (x4) |

|Palliative care member (2F239) |Dr M Makin | Jane Evans |

| |Jane Evans |Dr M Makin |

|Extended Team (2F239) |Named team member |

|Junior Doctors | |

|Radiolology Registrars | |

|Research Nurse |Arwel Lloyd |

|Anaesthetist/ Intensivist (2F239) |Dr Les Gemmell, Dr D Counsell |

Roles of Individual Team Members

Lead Clinician

Will act as chair of the meeting and ensure that the discussion is focused and that all patients are discussed.

Responsible Clinician

Will present the patient to the meeting, lead the discussion, summarise the patient's treatment plan and ensure appropriate follow up. The responsible clinician may be presenting the patient from another site via the use of video conferencing technology

Radiologist/ Histopathologist

All relevant reports will be presented where required to aid the discussion of the individual patient.

Supra Network MDT Coordinator

Will be responsible for listing patients, minuting and distributing the decisions of the MDT, ensuring all notes/xrays/reports/results are available at MDT for discussion. Liaise with the other sites to ensure all patients referred to surgical centre are discussed.

Other Team Members

Will contribute to the discussion and agreement of the patient’s treatment plan, ensuring that any other patient related issues are taken into account and discussed.

Types of Meetings

All meetings will be clinical meetings to discuss and agree the treatment, diagnostic options for all patients within the remit of the MDT. NEWT must receive formal referrals in the agreed format (completed referral proforma and all clinical information and documentation) by no later than midday on the Tuesday prior to the Thursday SMDT.

The Supra MDT will also have an annual business meeting to discuss a wide range of appropriate issues such as local protocols and guidelines for practice, as well as adoption of national and network guidelines. (2F215)

-

Frequency of Meetings (2F211)

The Supra MDT will have regular weekly meetings to discuss patient care and all core members are expected to attend (each Thursday, 08:00 – 10:00 hrs). The initial schedule is as follows and may change following discussion:

|08:00 - 09:00 | Wrexham (NEWT Local, including palliative cases) |

|09:00 - 09:20 | NWWT |

|09:20 - 09:40 | C&DT |

|09:40 - 10:00 | COCH |

** please note, where Trusts do not have patients to discuss at the SMDT, other Trusts will be given the opportunity of an earlier slot.

It is vital that an arranged deputy should attend if any of the core members are unable to do so (at least 1 upper GI surgeon and 1 gastroenterologist must be present). For those patients referred into the centre, it is vital that a local MDT member is available at the other end of the video conference link in order to present the patient – where this is not possible, it is the responsibility of the local MDT Coordinator to ensure that the patient notes are also tracked through to the supra MDT Coordinator by midday on the Tuesday prior to the Thursday SMDT to ensure that a clinician at the supra MDT can present the patient.

Facilities for the projection of imaging data and pathology slides, and video conferencing equipment will be made available at the meetings. Attendance at meetings will be recorded and attendance levels reviewed

Leave Cover (2F214)

All core members of the Supra MDT must ensure they arrange cover for any absences. In the event of cover not being possible the Supra MDT must agree how it will make treatment-planning decisions for all patients. This could include:

▪ Videoconferencing

▪ Teleconferencing

▪ Radiology/Pathology/lmaging cover - ensure reports are available for viewing

▪ Retrospective discussion at the next meeting

Identifying Patients for Discussion

It is intended that local MDTs will review all new UGI cancer patients and the Supra MDT will review patients referred to Supra MDT for potential surgery or a second opinion. (2F216, 2F220)

Patients can only be referred to Supra MDT following a decision to refer at local MDT. Patients must then be referred via faxing the agreed referral form to the Supra MDT Coordinator. The Supra MDT Coordinator will then list patients for discussion.

Patients with high-grade dysplasia in Barrett's oesophagus will also be discussed at Supra MDT, following discussion at local MDT.

Patients can be referred to the local MDT in the following ways:

* GP referrals to any of the core MDT Consultants

* From diagnostics

* From consultant to consultant

* From histopathology

* To Clinical Nurse Specialist from community team

* From Clinical Nurse Specialist to consultant

Any of the core members of the team can bring existing patients to the meeting if there is a need to discuss their plan of care.

The Supra MDT Coordinator will prepare the local MDT list for Wrexham patients in addition to the list discussing patients referred to the centre via feeder trusts.

Minutes of the meetings will be recorded and a record of each individual patient’s treatment plan will be recorded in the notes. All new patients will be discussed at the next Supra MDT Meeting following referral.

Referrals needing a treatment plan before the next scheduled meeting will be discussed by telephone or directly between colleagues. Any decision will then be ratified at the next MDT meeting and all conversations documented in the notes. (2F211)

GP Notification (2F217. 2F218, 2F219) documentation of key worker (2F230) and contact details (2F240, 2F245)

For all new patients once they have a confirmed diagnosis and been informed of this, the GP will be notified via the CNS within one working day. This information must include the name of the patient's key worker and contact details. A copy of this should be filed in the patient's notes and will be audited. The Upper GI CNS should be present if possible when patients are informed of their diagnosis. The patient is given the key workers details at this time along with patient information leaflets, including contact details and the way in which they can access members of the MDT to discuss problems or concerns if required. The MDT will provide information to referring general practitioners on the appropriateness of urgent suspected cancer GP referrals.

Minimum Data Set Requirements

All new patients must be entered onto the CaNISC database via the MDT Coordinator at the local unit with the exception of Countess of Chester patients, where the patient will be entered onto CaNISC by the Supra MDT Coordinator following receipt of the completed referral form. However, the Supra MDT Coordinator will be responsible for entering the surgical part of the journey onto CaNISC for all patients.

Information available at an MDT meeting

The Supra MDT Coordinator will ensure that notes, films, slides are available at the meeting for all patients put on the list for discussion.

The Supra MDT Coordinator will ensure the room is prepared for each meeting and will provide lists of patients to be discussed and ensure that video conferencing facilities are prepared. Local MDT Coordinators must ensure preparation of their rooms and video conferencing facilities.

Patients will be presented by the responsible clinician and the radiologist and pathologist where appropriate will present films and slides.

Once a decision has been made the responsible clinician should clearly summarise the planned course of action and document this in the patient notes, using the yellow MDT sheet (an outcome sheet will also be completed at Wrexham to ensure a record is available at the Centre for any future appointments etc)..

Documentation of Outcomes

Treatment decision will be documented in the following ways:

* Responsible clinician at the local unit will write outcomes on the yellow MDT sheet. The yellow sheet must also include the key worker name (2F230)

* The Supra MDT Coordinator will minute all decisions after MDT meeting (including key worker ) and circulate to local Coordinators within 48 hours

* All patients should be seen by their local Upper GI Cancer Nurse Specialist prior to referral to the Surgical Centre in order for treatment co-ordination and future patient support to be facilitated between the Surgical Centre and the local hospital in accordance with IOG and related cancer policies.

Service improvement (2F260)

Mr Jonathan Pye is responsible for ensuring that service improvement is part of the function of the MDT . Process mapping exercise should be performed regularly to address waiting times. (2F261)

4. Cross Border Upper GI Surgical Centre MDT Referral Guidelines

General comments about the Surgical Centre (Supra) Multi-disciplinary team meeting

• New patients with Upper GI malignancy will be discussed at their local (Unit) MDT meeting.

If the patients are suitable for referral as per agreed referral protocol to the Surgical Centre for consideration of surgery then their case will be discussed at the weekly held Surgical Centre (Supra) MDT.

• It is expected that all new patients discussed at the Surgical Centre (Supra) MDT will have been seen by a Unit MDT member to present their case and inform the Surgical Centre (Supra) MDT of the patients’ ability to undertake any proposed treatment.

• A letter documenting the Surgical Centre (Supra) MDT decision will be produced and faxed/emailed to the GP within 24 hours.

• The minutes of all the MDT decisions will be circulated electronically to the MDT members via local MDT Co-ordinator within 24 - 48 hours of the meeting.

The following notes refer to Oesophageal Cancer Management Flowchart

Note 1 Standard of Upper GI Endoscopy

• A minimum of six biopsies should be obtained whenever size of the lesion permits.

• Any other visible lesion should be biopsied.

• The distance from the incisor teeth to the upper and lower margins of the tumour should be recorded.

• Presence of any Barrett’s mucosa should be mentioned and its upper limit measured

• The position of the squamo-columnar (or oesophago-gastric junction if Barrett’s present) should be recorded.

• The extent of gastric involvement should be recorded.

Note 2 Patient Assessment

• History and examination to assess clinical extent of disease, co-morbid disease and overall fitness/performance status (see Supplementary Notes on Patient Risk stratification).

• Inform patient of diagnosis and introduce them to the local Cancer Nurse Specialist (All Wales/English Standard).

• Ensure direct referral to dietetic team (if clear indication of weight loss, eating difficulties, dysphagia). Refer to local nutritional screening guidelines.

• Inform General Practitioner that the patient has been told their diagnosis within 24 hours (All Wales/English Standard).

• After explanation of condition assess patient understanding and willingness to undergo further staging and treatment strategies.

Note 3 Standard of CT

• Most patients will require a CT scan for disease staging.

• The CT scan should include chest and abdomen views and be performed with oral and intravenous contrast (see supplementary note on CT imaging technique).

Note 4 Referral to the Surgical Centre Supra MDT

• Refer patients who are fit and willing to undergo attempts at curative treatment and have no evidence of disseminated disease. Also refer patients if there is uncertainty about either their fitness and/or evidence of disease dissemination or if the patient requests a second opinion.

• Discuss with the patient the diagnosis and the reasons for referral to the Surgical Centre so that they are aware of the reasons for further investigations and treatment away from the Local hospital.

• Patients will have been seen by local Upper GI Cancer Specialist Nurse before referral so that treatment co-ordination and future patient support can be facilitated between the Surgical Centre and the Local hospital.

Note 5 MDT Exclusion Criteria

• The following patients do not require discussion at the supra MDT. These patients are not suitable for surgery on one of two counts. The first is evidence of haematogenous spread of the disease, i.e. those with liver, lung or bone metastases. The second group are those patients with medical co-morbidity that render them unsuitable for any form of major surgery. All cases where doubt exists will be discussed in the supra MDT.

Note 6 Endoscopic Ultrasound

• The date for the EUS will have been arranged following investigations to confirm diagnosis and initial staging.

• EUS will determine T and N stage of tumour and, in addition, will assess unresectability due to direct invasion of vital structures (aorta, trachea etc). Full thickness disease communicating with the peritoneal cavity will prompt a staging laparoscopy to exclude peritoneal metastases.

• T4 (involvement of surrounding organs) will usually indicate non-curative disease. In some situations however curative surgery may still be possible (for example if there is pleural or crural involvement). After discussion at the MDT the patients may be offered neoadjuvant chemotherapy (OEO2 or OEO5) followed by surgery if there is no disease progression on restaging.

PET CT Scan

• The role of the SMDT will include recommending PETCT scanning for individual patients either when equivocal staging results are found or following staging and prior to radical surgery, and acting as the gatekeeper for this service for this cohort of patients. Robust and auditable policy will be developed to enable the audit of patient satisfaction, appropriate care and treatment as well as the assessment and evaluation of cost effectiveness.

Note 7 Initial Surgical Consultation

• Initial consultation with the surgical team will be arranged ideally prior to the commencement of neoadjuvant chemotherapy, with possibly a second review with the surgeon following the completion of chemotherapy at around the time of pre assessment (see appendix 1) if the patient wishes.

Note 8 Standard of Staging Laparoscopy (if required)

• Perform staging laparoscopy for full thickness disease encroaching on the peritoneal cavity (determined by CT scan and/or EUS).

• The staging laparoscopy if required will be performed at the Surgical Centre.

• During the procedure carefully examine the peritoneal cavity for metastases (including ovaries if appropriate). Examine both lobes of the liver and enter the lesser sac through the lesser omentum to view the caudate lobe and crura. Examine the tumour extension onto the stomach, look for serosal involvement and assess oesophageal and cardial mobility. Look for any ascites and biopsy any suspicious lesions.

Note 9 Treatment

• From 2006 patients whose disease is staged as a T2N0 adenocarcinoma or worse (with potentially curable disease), and who fulfill the eligibility criteria, will be offered participation in the OEO5 neo-adjuvant chemotherapy trial. If they decline participation into the trial they will be offered the standard treatment for oesophageal adenocarcinoma of OEO2 neo-adjuvant chemotherapy followed by surgery. Patients with T1N0 disease who are willing and fit for radical surgery will be offered surgery alone. Patients with squamous carcinoma will be offered OEO2 chemotherapy followed by surgery or primary chemo-radiotherapy (with curative intent) as sole treatment.

• Patients with intramucosal carcinomas will be offered endoscopic mucosal resection or endoscopic submuscosal dissection if considered appropriate by the Supra MDT

Note 10 Post treatment follow-up

• After surgery or primary chemo/radiotherapy (as sole treatment) initial patient follow-up will be with patients’ primary clinician (Surgical Centre Surgeon, Clinical/Medical Oncologist). Patient choice will be recognized and taken into account.

• Outside of a clinical trial, patients will be referred back to the local base hospital for continued follow-up once post-treatment complications have settled (see ‘Follow-up guidelines’).

• The Surgical Centre Nurse Practitioner will liaise with the local Cancer Nurse Specialist (acknowledging their role as key worker) to hand over the continued patient care.

Note 11 Palliative Interventions

• Palliative interventions will include oesophageal stenting (see appendix 2, Stent ICP) for significant dysphagia, chemotherapy, radiotherapy and endoscopic ablative treatments. These will be discussed at the Unit or/and Surgical Centre Supra MDT and offered to the patient as appropriate.

• Some patients will elect for, or be only suitable for, supportive care such as palliative care or specialist palliative care.

2 Oesophageal Carcinoma

Investigation +/- treatment at local Unit or Surgical Centre

3 Oesophageal Carcinoma

Investigation and treatment at Unit and Surgical Centre

[pic]

5. OESOPHAGEAL CANCER CHEMOTHERAPY REGIMENS

Adjuvant

No proven role

Neoadjuvant

Cisplatin/5FU

Patient group: Standard first line, prior to surgery

PS 0-1

CrC l>50ml/min

Operable oesophageal cancer

Chemotherapy: Cisplatin 80mg/m2 day 1

5 fluorouracil 1000mg/m2 over 24 hours days 1 to 4

Urine output should be maintained above 100ml/hr throughout treatment. If output falls below 400mls in any 4 hour period, then give frusemide 20mg iv or 40mg po. Repeated as necessary.

Repeat at 21 day cycles for two cycles only

Anti-emetics: High emetic control

Investigations: Weight, FBC, U&E’s, LFT’s before each cycle

Calculate creatinine clearance prior to each cycle and administer cisplatin according to guidelines.

Dose modifications: CrCl >50mls/min full dose cisplatin

40-50ml/min reduce cisplatin 50%

50mls/min full dose cisplatin, full dose capecitabine

40-50ml/min reduce cisplatin 50%, and capecitabine 25%

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