Local Multidisciplinary Team Research Articles

Receipt of Curative Resection or Palliative Care for Hepatopancreaticobiliary Tumours (RICOCHET): Protocol for a Nationwide Collaborative Observational Study.

BackgroundThere are variations in the management of patients with suspected pancreatic and periampullary cancers and/or malignant biliary obstruction. These differences may be due to a number of organizational, institutional, and patient factors that could affect outcomes for those with curable or incurable disease. The Receipt of Curative Resection or Palliative Care for Hepatopancreaticobiliary Tumours (RICOCHET) study will be the first to provide a snapshot of investigative pathways across the United Kingdom to reflect the real-world practice in these patients. The RICOCHET study is contemporary to new national and international clinical guidance and can potentially inform future local and national strategic planning to optimize care for patients with suspected hepatopancreaticobiliary (HPB) malignancies.ObjectiveThe aim of this study is to define national variation in the investigative and management pathways of patients with suspected HPB malignancies and to determine the effect of these variations on patient outcomes.MethodsThe RICOCHET study is a nationwide, multicenter, prospective study. It is led by trainees through collaboration between surgical and medical specialties. Patients with suspected pancreatic cancer, other periampullary cancer, or extrahepatic cholangiocarcinoma presenting to hospitals in the United Kingdom will be identified over 90 days. Each case will be followed up for 90 days to collect data on the mode of presentation, investigations, interventions, use of local and specialist multidisciplinary team meetings, and transfer of care between hub and spoke sites. Furthermore, the study will define dates and intervals between key points in the patient pathway.ResultsThe RICOCHET study results and analyses will be subject to peer review by presenting them at international cross-specialty conferences and by submitting them for publication in open-access journals. Moreover, our findings will be presented to patient groups and sponsoring charities (eg, Pancreatic Cancer UK), who in turn will disseminate key findings to the primary beneficiaries of the results: the patients. The RICOCHET study was funded in September 2017. Data collection started in April 2018 and the planned end date for data upload is spring 2019. Data analysis will take place in the summer of 2019 and the first results are expected to be published in late 2019 or early 2020.ConclusionsThe RICOCHET study is a multidisciplinary, prospective, observational study that aims to highlight variability in practice and to determine whether these affect the outcomes of patients with HPB malignancies. This is a trainee-led initiative that utilizes a novel design to achieve full coverage of the differences in diagnostic and management pathways. The RICOCHET study may provide evidence to develop a more standardized approach to managing patients with suspected HPB malignancy.International Registered Report Identifier (IRRID)DERR1-10.2196/13566

Colorectal Cancer Stratification in the Routine Clinical Pathway: A District General Hospital Experience

Colorectal cancer (CRC) has many subtypes with different prognoses and response to treatment. Patients must be characterized to access the most appropriate treatment and improve outcomes. An increasing number of biomarkers are required for characterization but are not in routine use. We investigated whether CRC can be stratified routinely within a small district general hospital to inform clinical decision making at local multidisciplinary team meeting/tumor board level. We evaluated mismatch repair (MMR) and EGFR signaling pathways using predominantly in-house immunohistochemical (IHC) tests (MSH2, MSH6, MLH1, PMS2, BRAF-V600E, Her2, PTEN, cMET) as well as send away PCR/NGS tests (NRAS, KRAS, and BRAF). We demonstrated that many of the tests required for personalized treatment of CRC can be done locally and timely. Send away tests need to be requested shortly after cut-up and this needs to be firmly established in the tissue pathways for the results to be considered at multidisciplinary team meeting/tumor board. We have shown that MMR IHC combined with BRAFV600E IHC is practical and easy to perform in a small district general hospital, has full concordance with DNA-based tests and satisfies the latest NICE requirements for the identification of potential Lynch syndrome patients. We provide a framework for the interpretation and presentation of test results. It is a practical classification that clinical pathologists can use to communicate effectively with the clinical team. It is broadly based on molecular subtyping, firmly focused on treatment decisions and dependent on the panel of molecular tests currently available.

Treating nasoethmoidal encephalocele in a low-resource country: a surgical experience from a Philippine multidisciplinary craniofacial team.

It was described that nasoethmoidal encephalocele repair in the Philippines has been limited by insufficient resources, financial constraints, and a lack of surgical expertise. The purpose of this study was to report initial results and complications of Philippine patients with nasoethmoidal encephalocele surgically managed with an approach adapted to an environment with limited financial resources. All patients (n = 21) with nasoethmoidal encephalocele who underwent intracranial and extracranial repairs (frontal wedge osteotomy to access the encephalocele cyst and cranial base defect, dural defect repair, split frontal grafts fixed with polydioxanone sutures to reconstruct the cranial defect and nasal dorsum, and medial canthopexy) from January 2015 to May 2017 were included. The correlations between sizes of masses and cranial defects with the occurrence of complications were tested. The surgical results were classified based on a previously published outcome grading scales I-IV on the need for additional surgery. Nineteen patients (90.5%) had unremarkable post-operative course. Two patients (9.5%) presented with complications (cerebrospinal fluid leak and surgical site infection) which were successfully managed with no additional surgery. The sizes of masses and cranial defects were not correlated (p > 0.05) with complications. The overall rate of surgical results ranked according to the need for additional surgery was 2.4 ± 0.5 (between categories II and III). We reported successful surgical repair of nasoethmoidal encephaloceles in Philippine patients by a local multidisciplinary craniofacial team.

Improvement in staff behavior during surgical procedures to prevent post-operative complications (ARIBO2): study protocol for a cluster randomised trial

BackgroundInappropriate staff behaviour during surgical procedures may disrupt the surgical performance and compromise patient safety. We developed an innovative monitoring and feedback system combined with an adaptive approach to optimise staff behaviour intraoperatively and prevent post-operative complications (POC) in orthopaedic surgery.Methods/designThis protocol describes a parallel-group, cluster randomised, controlled trial with orthopaedic centre as the unit of randomisation. The intervention period will last 6 months and will be based on the monitoring of two surrogates of staff behaviour: the frequency of doors opening and the level of noise. Both will be collected from incision to wound closure, using wireless sensors and sonometers, and recorded and analysed on a dedicated platform (Livepulse®). Staff from centres randomised to the intervention arm will be informed in real time on their own data through an interactive dashboard available in each operating room (OR), and a posteriori for hip and knee replacement POC. Aggregated data from all centres will also be displayed for benchmarking. A lean method will be applied in each centre by a local multidisciplinary team to analyse baseline situations, determine the target condition, analyse the root cause(s), and take countermeasures. The education and awareness of participants on the impact of their behaviour on patient safety will assist the quality improvement process. The control centres will be blinded to monitoring data and quality improvement approaches. The primary outcome will be any POC occurring during the 30 days post operation. We will evaluate this outcome using local and national routinely collected data from hospital discharge and disease databases. Thirty orthopaedic centres will be randomised for a total of 9945 hip and knee replacement surgical procedures.DiscussionThe field of human factors and behaviour in the OR seems to offer potential room for improvement. An intervention providing goal-setting, monitoring, feedback and action planning may reduce the traffic flow and interruptions/distractions of the surgical team during procedures, preventing subsequent POCs. The results of this trial will provide important data on the impact of OR staff behaviour on patient safety, and promote best practice during surgical procedures.Trial registrationClinicalTrials.gov, NCT03158181.

Treatment: the role of contact X-ray brachytherapy (Papillon) in the management of early rectal cancer.

Treatment: the role of contact X-ray brachytherapy (Papillon) in the management of early rectal cancer.

Abstract TP383: Development of Continuous Quality Improvement in a Telestroke Network

Introduction: Continuous Quality Improvement (CQI) in Telestroke across diverse institutions requires reliable data abstraction, centralized analysis and interactive multidisciplinary review of metrics. Data abstraction depends on each site’s resources and accountability, and is facilitated through network support. Central analysts provide site-specific, interactive dashboards with network benchmarks. Evidenced-based data reviews with local multidisciplinary care teams provide ongoing monitoring of quality measures and support site- and network-driven CQI. Reviews are supplemented by clinical education and sponsorship to a statewide conference and summit to share best practices and honor high performers. We examine the impact of a telestroke CQI process on acute stroke care across our multistate network by comparing quality measures from initiation in 2011 to those in 2017. Methods: Ischemic stroke patients presenting to 13 emergency departments (ED) were included. Inpatient, age <18, non-ischemic stroke, and non-acute patients (last known well-to-door > 4.5 hours) were excluded. Quality measures included door-to-CT (DCT) and door-to-IV-alteplase (tPA) times (DTN), and percentage transferred, treated with tPA, and treated in <60 and <45 minutes. Chi-squared, Fisher’s exact, and Mann-Whitney U tests were used to compare quality measures between patients discharged in 2011 and 2017. Results: Overall, 143 patients discharged in 2011 and 260 in 2017 presented with acute ischemic stroke within the tPA treatment window. There were no differences in gender, age, or admission NIHSS between years. In 2017, median DCT times were shorter (16.0 vs 29.0 min, p<.001) as were median DTN times (56.0 vs 75.0 min, p<.001) compared to 2011. In 2017, more patients were transferred (40% vs. 26%, p=0.035) and treated by tPA overall (51% vs. 29%, p<.001), in under 60 minutes (57% vs. 23%, p<.001) and in under 45 minutes (27% vs. 8%, p=0.009). Conclusions: Collaborative, interactive data processes, including reliable data abstraction and utilization, support both site-specific and network-wide quality improvement.

Bevacizumab Plus Chemotherapy versus Chemotherapy Alone As First-Line Treatment for Patients with <i>RAS</i> Mutant Unresectable Colorectal Liver-Limited Metastases: The BECOME Single Center Randomized Control Trial

Background: To assess the effects of bevacizumab plus chemotherapy as first-line treatment for RAS mutant unresectable colorectal liver metastases (CLMs). Methods: From October 2013 to December 2017, patients with RAS mutant unresectable liver-limited metastases from colorectal cancer were randomly assigned to receive mFOLFOX6 (modified fluorouracil, leucovorin,and oxaliplatin) plus bevacizumab (arm A) or mFOLFOX6 alone (arm B). The resectability of liver metastases was determined by a local multidisciplinary team. The primary end point was the rate of patients converted to resection for liver metastases. Secondary end points included tumor response, survival and toxicity. Block randomization method was used. Result: The intent-to-treat population comprised 241 patients. 121 patients were randomly assigned to arm A and 120 to arm B. For all patients, 35.7% (86/241) had right-sided colon cancer; 47.3% (114/241) had primary tumor resection before randomization; 86.3% (208/241) had liver metastases more than three; 33.2 (80/241) with the largest diameter of liver metastases more than 5 cm; 78.4% (189/241) were bilobar metastases. The median follow-up time was 37.0 months for all patients. The R0 resection rates for LMs were 22.3% (27 of 121 patients) in arm A and 5.8% (7 of 120 patients) in arm B, with significant difference (P < 0.01). Patients in arm A had significantly better objective response rates (54.5% v 36.7%; P < 0.01), median PFS (9.5 v 5.6 months; P < 0.01) and median OS (25.7 v 20.5 months; P =0.03) compared with those in arm B. Addition of bevacizumab was associated with more frequent proteinuria (9.9% v 3.3%; P = 0.04) and hypertension (8.3% v 2.5%; P < 0.05). Conclusion: For patients with initially unresectable RAS mutant CLMs, bevacizumab combined with chemotherapy improved the resectability of liver metastases and improved response rates and survival compared with chemotherapy alone. Trial Registration: This study was registered on ClinicalTrials.gov (NCT01972490). Funding Statement: This work was supported by grants from National Natural Science Foundation of China (8147222); Clinical science and technology innovation project of Shanghai (SHDC12016104); Shanghai Science and Technology Committee Project (17411951300); The National Key Research and Development Program of China (2017YFC0908205). Declaration of Interests: The author(s) indicated no potential conflicts of interest. Ethics Approval Statement: The protocol was approved by the local ethic committees.

Perioperative anesthesia management for pulmonary endarterectomy: Adopting an established European Protocol for the Asian Population.

Background:Anesthesia for pulmonary endarterectomy (PEA) has always been one of the challenges of anesthesia. As one of the leading cardiothoracic institutions in Southeast Asia, our hospital has vast interest in this subject. A local multidisciplinary team was deployed to an expert center in the United Kingdom (UK), and the experience was then integrated to the care of our patients. We present a case series of ten patients undergoing anesthesia for PEA, a first for our institution, and discuss techniques as well as potential complications.Methods:Patients with chronic thromboembolic pulmonary hypertension were reviewed by a multidisciplinary team, and those who were suitable for surgical intervention subsequently underwent PEA. A total of ten patients were identified and operated on. The perioperative management and conduction of anesthesia for all patients followed a protocol adapted from the expert center in the UK, with revisions to cater to our Asian population.Results:In the ten patients operated on, eight of them were successfully extubated on the first postoperative day. Apart from one incident of prolonged ventilator usage due to reperfusion lung injury and pneumonia, there were no major respiratory or hemodynamic complications. Certainly, six of the ten patients developed subdural hemorrhage after the commencement of enoxaparin, although none of them sustained any permanent neurological deficits.Conclusion:We have demonstrated that with careful planning and a well-outlined protocol, anesthesia for PEA in an Asian population can be achieved with favorable outcomes. Further fine-tuning of the protocol is still required based on local expertise.

Seeding after US-guided biopsy

Percutaneous needle biopsy is almost exclusively performed under imaging guidance, using either ultrasound or computed tomography. Although accepted as a relatively safe procedure, percutaneous needle biopsy is certainly not risk-free. One of the potential serious complications after a percutaneous biopsy is tumor seeding which is relatively poorly understood and documented. Neoplasm seeding is defined as a local implantation of tumor cells by contamination of instruments and surgical equipment resulting in local growth of the cells and tumor formation (according to the National Library of Medicine of the National Institutes of Health, USA). Frequency and mechanisms behind tumor seeding after biopsy are poorly elucidated. In the four largest surveys the range of the needle tract seeding after biopsy of abdominal lesions was miniscule (0–0.009%). Common to these relatively old studies was that they were based on patient and doctor reporting, without performing an active cross-sectional imaging verified tracing of seeding; and therefore the true seeding rate was probably greatly underestimated. Sparsely documented incidences in the more recent studies of the colorectal neoplasm seeding following liver biopsy vary between 10% and 19%. These data consist primarily of relative small case series and reports limited by small sample size. The reported high seeding rates are therefore probably greatly overestimated in these studies. Some authors suggest that invasive diagnostic procedures should be carefully considered due to risk of seeding which can change a potentially respectable localized cancer to an unrespectable one. Neoplasm seeding has been a subject of particular concern for liver surgeons. Tumor seeding is a well-known phenomenon after traditional open surgical procedures as well as after laparoscopic procedures. Tumor seeding has also been reported after ultrasound guided radiofrequency ablative procedures. Experimental studies have shown cancer cell leakage in the needle tract in the majority of biopsy cases. How do we reduce tumor seeding? The co-axial biopsy technique, whereby the biopsy needle is inserted through an introducing needle, is popular with many practitioners who cite improved needle stability and the ability to obtain multiple cores using only one initial puncture as strong advantages of this system. It has been suggested that the co-axial technique reduces the risk of needle tract seeding by isolating the biopsy specimen from the needle tract when the sample is withdrawn. Unfortunately no randomized studies have proved this yet. Furthermore, seeding after using the co-axial biopsy technique has been described. The use of contrast enhanced ultrasound can reduce the need for ultrasound guided liver biopsy in many cases, and this procedure should be reserved to unclear cases approved by the local multidisciplinary team and to cases where oncologic treatment is planned.

Longitudinal study to assess impact of smoking at diagnosis and quitting on 1-year survival for people with non-small cell lung cancer

ObjectivesTo update the prevalence of smoking in people as they were diagnosed with non-small cell lung cancer (NSCLC) and to see whether smoking status at baseline and quitting are independently associated with 1-year survival. DesignA real-world cohort study following patients from diagnosis for up to 1 year or until death. SettingUK multi-centre study (28 sites) based in secondary and primary care. Participants1124 patients with newly diagnosed NSCLC between 2010-2016. Main outcome measuresSmoking status was validated at diagnosis and at every routine and emergency hospital visit. Cancer treatments were offered according to local multi-disciplinary team decisions following UK guidelines and smoking cessation treatments offered according to local practice /availability. Survival analysis and Cox Proportional Hazards Modelling examined the associations of a) smoking at baseline and b) quitting smoking, on survival at 1 year. Results77% of never smokers, 60% of ex-smokers and 57% of current smokers, were alive at 1 year (p = 0.01). After adjusting for age, stage, EGOG, surgery and gender, ex smokers (adjusted HR 1.96, 95% CI 1.16–2.31) and current smokers (aHR 2.04, 1.19–3.48) were both more likely to die within one year.23% of smokers with NSCLC quit within 3 months of diagnosis. At 1 year, 69% of those who quit were alive versus 53% of those who continued to smoke (p < 0.01). After adjusting the risk of dying was lower (aHR 0.75), in those who quit smoking, although this was not statistically significant (p = 0.23). ConclusionsThis is the largest prospective study that validates smoking in NSCLC; it shows a third of people are smoking at the time of diagnosis. Smokers have lower 12-month survival than never and ex -smokers. Quitting smoking was associated with 25% reduction in mortality which may be clinically important although not statistically significant, after adjusting for other factors.

How can patient empowerment be integrated into change management while scaling-up an integrated care program?

Introduction: It is a challenge to ensure transferability of successful integrated care services to a new healthcare setting. The ACT@Scale program aims to identify, transfer and scale-up mature integrated care and telehealth practices in different regions in Europe. Patient empowerment PE, representing the process through which greater control over health is gained, is one of the target areas for successful integrated care deployment. In ACT@Scale, five integrated care programs, represented by a local multidisciplinary team, identified the key issues related to PE and required changes to improve the program in order to scale it up. Short description of practice change implemented: During the ACT@Scale project, programs apply collaborative methodologies CM to stimulate rapid process improvement. It encompasses routine data collection and assessment, provision of training material and communication channels. Regions develop and apply changes to improve the level of patient empowerment in their programs. Various surveys that measure PE level are used patient activation PAM[1]; psycho-social profile MAY[2]; program satisfaction NPS[3]; and staff attitude on PE CSPAM[2]. Aim and theory of change: Regions use CM to apply process improvements while learning cycles are managed by Plan-Do-Study-Act PDSA cycles. Evidence from the data is used to start subsequent improvement cycles. We monitor PE during the upscaling process. Targeted population and stakeholders: Implemented changes target patients of five integrated care programs, healthcare providers and program managers. Timeline: Total project duration is three years. Two full one-year PDSA cycles will be completed by participating programs. Highlights: The approach is complemented by an ICT solution for data collection and visualization to support decision-making. ICT data management allows distributed analysis of patient outcomes and resource utilization. This data remains in the regions, while a central engine runs remote analysis and displays aggregated results across regions. Comments on sustainability: The ACT@Scale program has a dedicated work package to address sustainability.Some participating programs are addressing this topic by applying changes in this area. Comments on transferability: Sharing of good practices within the consortium is part of collaborative methodology. During the final phase of ACT@Scale, specific local and international activities on dissemination and knowledge transferability will be organized. Conclusions: By using surveys, we can measure patient empowerment level in the program staff and patients and the regional level of adoption. Tools for monitoring progress of these levels and impact on outcomes during process improvement are essential to support the decision making process. Discussions: The data collection and regional implementation of the ICT technology are in progress. When completed, it will allow a more detailed analysis of patient empowerment levels into integrated care programs. Lessons learned: Distributed analysis can be a solution when data sharing is not allowed.

Implementation of National Health Reform on China Genitourinary Multidisciplinary Team Consultation Platform

Background and context:: Comprehensive management of multidisciplinary team (MDT) is the most effective mode in genitourinary(GU) cancers. Due to the uneven level in the management of GU cancers in China, top GU MDT services do not meet the medical needs of people. The blooming of “Internet+” mode promotes remote medical services, and is supported by health administrations. Aim: The country wide accessibility of high level medical services, and national health reform, especially in the field of GU cancers, will be addressed by the project. Strategy/Tactics: We developed an Internet platform of MDT management for GU cancers across China: “China GU MDT Consultation Platform (CUMP)”. Led by senior clinical staffs, and based on advanced internet and mobile technologies, CUMP is to meet the needs of clinical practices. With compatibility, universality and practicality, CUMP has the following advantages: unified data management, flexible models, stable and reliable remote video conference system, efficient cooperation, and convenient participation. Program/Policy process: Recruit top GU MDT and experts in China, and make consensus and guidelines of the implementations of MDT in GU cancers; Help other local institutions develop GU MDT and provide services, which are authenticated by the platform; Build a system that a single patient can receive top level GU MDT service locally and remotely, provided by the platform. Outcomes: Since April 2017, CUMP has successfully carried out remote MDT consultations involved 16 medical centers with GU MDT services or individual GU experts across China. As a start, 18 difficult cases were discussed and managed. More than 600 Chinese GU experts from medical institutions at all levels, have registered on CUMP, ready for submitting or accepting MDT service; another 34 top Chinese GU MDT units are on the waiting list to be technically authorized on CUMP. One Chinese consensus on the implementation of GU MDT was released last December. What was learned: The project was relevant to current obstacles in China's health reform by greatly enhancing the accessibility of GU MDT service. The majority of GU cancer patients can receive domestic top-level MDT service in a local institution; this project also helped to provide a great convenience to the development of local MDT service, so as to improve medical qualities, especially in GU cancers in different regions of China. The project made the technology and medical service transcend the boundary of administrative division and institution.

Head and Neck Cancer Survivorship Care: A Review of the Current Guidelines and Remaining Unmet Needs.

A larger proportion of patients with head and neck cancers (HNC) are now surviving, constituting up to 3% of all cancer survivors. This is likely due in part to the increase in HPV-related oropharyngeal cancers affecting younger individuals and with a better prognosis and to the improved outcomes of other HNCs as well over the last two decades. Most studies have previously been focusing on improving risk stratification, treatment and disease-related outcomes. Over the last decade, there has been an evolving interest in the field of survivorship care. Despite the collaborative efforts from a multidisciplinary team in managing cancer and treatment-related side-effects and in improving survivors' overall quality of life (QOL), it has been reported that up to 60-65% of patients have at least one unmet need. The purpose of this article is to review current guidelines for HNC survivorship care and identify areas of unmet need. Over the last 5 years, multiple groups have published guidelines describing survivorship care issues and their possible management. Although a very comprehensive and informative first initiative, multiple issues need to be further evaluated. These include how to best support patients and their partners' fear of cancer recurrence, to provide coordinated care among all physicians, to identify and meet patients' needs in local multidisciplinary teams and to institute measures to ensure every individual's access to high-quality patient-centred care. Furthermore, experts may consider engaging in further dialog with primary care physicians (PCP) to improve sharing of survivorship care. More should be learned about PCPs' comfort levels in providing such care and whether further steps are required to facilitate a seamless. Transition of care and accessibility to specialized care as needed.

A practical approach to managing diabetes in the perioperative period

Diabetes mellitus (DM) is a common multisystem disease with hyperglycaemia as the hallmark. It is a modifiable risk factor of complications after surgery. The incidence of DM and its impact on public health are steadily increasing globally. In South Africa (SA), it is estimated that a large proportion of people living with DM are undiagnosed. A number of international groups have addressed the problem of DM in the perioperative period, proposing guidelines for optimisation and management of these patients. The guidelines fail to address the variety of contexts within which surgery is delivered in SA. In this review, the authors discuss DM within the SA context. The article provides a range of approaches to managing the patient with DM in the perioperative period. Importantly, the perioperative healthcare provider’s approach should be steered by a local multidisciplinary team that considers the evidence base in light of their resource and patient context.

Innovation in pain management: connecting regional and rural community based care to specialist services

Introduction: In Australia 20% of the population live with disabling chronic pain, costing the health system $34 billion annually. Less than 0.1% are reviewed by specialist services due to limited availability of specialist consultants. Residents in Southern New South Wales (NSW) Local Health District (SNSWLHD) are challenged due to geographical isolation, travelling long distances to access specialist services. In 2015, NSW Minister for Health, provided recurrent funding of $100,000 p.a. to support the objectives of the Agency for Clinical Innovation (ACI) 2012 Pain Management Plan. The plan identified the need to improve access to pain services in rural and remote areas. The ACI and SNSWLHD collaboratively tendered to appoint a tertiary provider to deliver the service. St Vincent's Hospital Sydney was successful in the tender to establish a multidisciplinary outreach Pain Clinic in partnership with ACI, SNSWLHD, and South Eastern NSW Primary Health Network (SENSW PHN)-COORDINAIRE. The challenge is to shift the burden of chronic pain management from the hospital to a more consumer accessible community Model of Care. Practice change: The new model went live in 2016 and includes: upskilling of local primary multi-disciplinary care providers, assessment and self-management education and linking of general practice with tertiary specialists using telehealth. Aim/theory of change: The aim is to deliver evidence based, multidisciplinary pain management in primary care with access to pain specialists for complex patients. Using telehealth technology enables patients to remain close to home, reducing discomfort and costs. In theory, creating local primary care expert hubs, linked with a tertiary specialist centre, will enable early intervention thereby reducing the societal cost burden. Targeted population and stakeholders People suffering chronic pain > 6 months. Stakeholders: Patients, Families and Carers, SNSWLHD Clinicians, Primary Care providers. Timeline: The service has been operational for 12 months and formative evaluation shows that key deliverables are being met. Ongoing evaluation has been embedded in the model. Highlights: The provision of integrated pain management services in the community resulting in the positive response from both consumers and clinicians. Consumer feedback is extremely positive with a 100% satisfaction rating. Sustainability/transferability: The service agreement specifies a minimum number of multidiciplinary telehealth clinics per month plus three multidisciplinary outreach workshops per annum.The relatively low cost of service provision and simple model demonstrates ease of transferability within the region. Upskilling ensures sustainability by increasing capacity within the system together with service agreement monitoring to maintain quality. Conclusions: Since introduction there have been: a) 107 Telehealth consultations. b) Evaluation of positive patient experience = 100%. c) Evaluation of 71 Providers: Positive experience = 97%, Ability to support their patient more = 91%. Discussion/lessons learned: The move away from hospital to community care is a positive one. Skilled local multidisciplinary teams supported by telehealth enables the consumer to receive the best available service where they live. The partnership between specialists and local providers, with support of state & federal funding, is achieving outcomes through willingness to network, share new evidence and utilise technology with the consumer at the centre of the model.

Geographical variations in the use of cancer treatments are associated with survival of lung cancer patients

IntroductionLung cancer outcomes in England are inferior to comparable countries. Patient or disease characteristics, healthcare-seeking behaviour, diagnostic pathways, and oncology service provision may contribute. We aimed to quantify associations between...

Management of Incompletely Excised Skin Tumors: Our Experience.

Current British Association of Dermatologists guidelines recommend that Mohs micrographic surgery should be considered for incompletely excised basal cell carcinomas and squamous cell carcinomas. Units that perform Mohs surgery are limited. In Teesside, the skin cancer multidisciplinary team discusses all incompletely excised skin tumors, considers all treatment options, provides recommendations, and initiates the agreed management plan. To assess the outcome and appropriateness of local surgical macroexcision for incompletely excised skin tumors. The authors performed a retrospective analysis of the local skin multidisciplinary team notes from July 2010 to July 2012 identifying all incompletely excised skin cancers. A total of 46 basal cell carcinomas and 27 squamous cell carcinomas were incompletely excised. Case note and pathology report review was used to identify the recommended management option and subsequent outcome. Fifty-four of the 73 incompletely excised tumor identified underwent further surgical excision locally. Fifty-one of 54 patients (94.4%) had successful completion of excision with a single procedure. The remaining 3 patients' required further surgery, performed locally, to completely excise their tumor. Average follow-up was 35 months with 1 (1.9%) recurrence. In the authors' region, local surgical management of incompletely excised skin tumors has yielded results comparable to Mohs surgery. Mohs surgery remains a viable option in specific cases.

Dose Escalation Using Contact X-ray Brachytherapy After External Beam Radiotherapy as Nonsurgical Treatment Option for Rectal Cancer: Outcomes From a Single-Center Experience

To review the outcomes of rectal cancer patients treated with a nonsurgical approach using contact x-ray brachytherapy (CXB) when suspicious residual disease (≤3cm) was present after external beam chemoradiation therapy/radiation therapy (EBCRT/EBRT). Outcome data for rectal cancer patients referred to our institution from 2003 to 2012 were retrieved from an institutional database. These patients were referred after initial local multidisciplinary team discussion because they were not suitable for, or had refused, surgery. All selected patients received a CXB boost after EBCRT/EBRT. Most patients received a total of 90Gy of CXB delivered in 3 fractions over 4weeks. The median follow-up period was 2.5years (range 1.2-8.3). Of 345 consecutive patients with rectal cancer referred to us, 83 with suspicious residual disease (≤3cm) after EBCRT/EBRT were identified for a CXB boost. Their median age was 72years (range 36-87), and 58 (69.9%) were men. The initial tumor stages were cT2 (n = 28) and cT3 (n = 55), and 54.2% were node positive. A clinical complete response (cCR) was achieved in 53 patients (63.8%) after the CXB boost that followed EBCRT/EBRT. Of these 53 patients, 7 (13.2%) developed a relapse after achieving a cCR, and the 6 patients (11.6%) with nonmetastatic regrowth underwent salvage surgery (100%). At the end of the study period, 69 of 83 patients (83.1%) were cancer free. Our data suggest that a CXB boost for selected patients with suspicious residual disease (≤3cm) after EBCRT/EBRT can be offered as an alternative to radical surgery. In our series, patients with a sustained cCR had a low rate of local regrowth, and those with nonmetastatic regrowth could be salvaged successfully. This approach could provide an alternative treatment option for elderly or comorbid patients who are not suitable for surgery and those with rectal cancer who wish to avoid surgery.

P088 Antiretroviral treatment algorithm compliance: a regional audit and survey

IntroductionIn 2015 BHIVA introduced new treatment guidelines and NHS England produced an algorithm for antiretroviral (ARV) treatment initiation, with a requirement to have regional and local multidisciplinary team (MDT) arrangements...

Cardio-Onco-Hematology in Clinical Practice. Position Paper and Recommendations

Improvements in early detection and treatment have markedly reduced cancer-related mortality. However survival not only depends on effectively cure cancer, but prevention, diagnosis and treatment of cancer-related complications is also needed. Cardiovascular toxicity is a widespread problem across many classes of therapeutic schemes, however scientific evidence in the management of cardiovascular complications of onco-hematological patients is scarce, as these patients have been systematically excluded from clinical trials and current recommendations are based on expert consensus. Multidisciplinary teams are mandatory to decrease morbidity and mortality from both cardiotoxicity and cancer itself. An excessive concern for the occurrence of cardiovascular toxicity, can avoid potentially curative therapies, while underestimating this risk, increases long-term mortality of cancer survivors. The objective of this consensus document, developed in collaboration of the Spanish Society of Cardiology, the Spanish Society of Medical Oncology, the Spanish Society of Radiation Oncology and the Spanish Society of Hematology, is to update the necessary concepts and expertise on cardio-onco-hematology that enable its application in daily clinical practice and to promote the development of local multidisciplinary teams, to improve the cardiovascular health of patients with cancer.