Reviewing deaths within 30 days of systemic anti-cancer therapy: Driving quality in a regional chemotherapy service.

Abstract

112 Background: Systemic anti-cancer therapy (SACT) administration rate at the end of life has been deemed a key metric for assessing quality of cancer care. A structured peer review process has been developed within the Cancer Centre, Belfast City Hospital, to discuss all patient deaths occurring within 30 days of SACT across Northern Ireland at a monthly, multidisciplinary, educational mortality meeting. We aimed to review cases discussed, characterising patients, causes of death and the role of SACT in patients’ deaths. Methods: A retrospective analysis was undertaken of 282 solid tumour patients, whose deaths were discussed at the mortality meetings from January 2013 to August 2016. Results: The 30-day mortality rate for the Cancer Centre was 4.5%. Most commonly represented tumour sites were gastrointestinal (39%), lung (22%) and breast (17%) with 96% receiving palliative treatments. WHO Performance Status (PS) was 0-2 at final SACT cycle in 83% (8% PS 3, unknown 9%). 43% of patients were receiving their first cycle and 56% receiving first line treatment for advanced disease. 77% of deaths occurred in hospital with 57% attributed to progressive disease. Other causes of death included infection (7% neutropenic, 11% non-neutropenic) and thromboembolism (12%). In 10% SACT was deemed to have caused or hastened death whereas in 65% SACT was non-contributory. In 25% SACT did not play a major role, but a contributory role could not be confidently excluded. Conclusions: SACT related death rate appears comparable to other institutions’ published routine outcomes. Robust review of SACT mortality encourages service improvement and individual reflection. Prescribers are reminded of the critical importance of carefully balancing patients’ needs and concerns with realistic outcomes and treatment risks, particularly in heavily pretreated or poor PS patients. Case discussions have generated service improvements including site and regimen specific prepopulated consent forms, a standardised SACT assessment proforma and mandatory response assessments as part of SACT protocols. Neutropenic sepsis remains the leading cause of SACT related mortality and further innovative improvements in care are required.