Local Multidisciplinary Team Research Articles

Abstract OT1-04-01: Cambridge brain mets trial 1 (CamBMT1): A proof-of-principle phase 1b / randomised phase 2 study of afatinib penetration into brain metastases for patients undergoing neurosurgical resection, both with and without prior low-dose, targeted radiotherapy

Abstract Background Failure of drugs to cross the blood brain barrier (BBB) can be a major reason for treatment failure for patients with brain tumors. For most patients who don't respond to treatment, it is not known whether this is due to inadequate drug concentrations in the tumor, or due to drug resistance. Preliminary data suggest that low-dose radiotherapy may disrupt the BBB, and could facilitate increased drug delivery into brain tumors. Afatinib is a potent, irreversible inhibitor of EGFR / HER2 / HER4 and takes approximately 8 days to achieve steady-state concentrations in cancer patients. Aims CamBMT1 has been designed to investigate the delivery of afatinib into brain metastases and whether this might be enhanced by low dose-radiotherapy. Patient Population Key eligibility criteria Patients with operable brain metastases from breast or lung primaries for whom neurosurgical resection would be standard of care, as determined by the local multi-disciplinary team. ECOG PS 0, 1 or 2. Trial design After a phase 1b safety run- in, the phase 2 part of the trial randomises patients (n=60) into 3 pre-operative arms: Arm 1afatinib alone for 11 days, then neurosurgery on day 12Arm 2afatinib for 11 days plus a single 2 Gy fraction on day 10, then neurosurgery on day 12Arm 3afatinib for 11 days plus a single 4 Gy fraction on day 10, then neurosurgery on day 12 Primary endpoint: to compare steady-state afatinib concentration in resected brain metastases, following afatinib administered alone, or in combination with radiotherapy (2 Gy or 4 Gy). Afatinib concentrations are measured in the resected brain metastases and in plasma. Secondary endpoints: safety of afatinib administration in combination with radiotherapy; and multi-sequence MRI (optional) to detect changes in perfusion, vascular density, blood-brain-barrier permeability and interstitial pressure. Exploratory endpoints: molecular profiling of resected brain metastases, for comparison with paired primary lung and breast cancers; the establishment and study of patient-derived xenografts. Statistical methods With 20 patients randomised in each of 3 arms in the phase 2 part of CamBMT1, the trial has a power of 84% at a significance level of 20% (one-sided) to detect an increase in afatinib concentrations with targeted radiotherapy, measured as a Cohen's D (standardised mean difference) ≥0.5. Accrual By the end of q2 2016, phase 1b had nearly completed enrolment. The randomised phase 2 part of CamBMT1 is due to open by q4 2016 at additional Experimental Cancer Medicine Centres. Acknowledgments CamBMT1 is funded by Cancer Research UK, the Brain Tumour Charity and Boehringer-Ingelheim. Citation Format: Baird RD, Ramenatte N, Watts C, Jonson A, Jones L, Biggs H, Harrison E, Oberg I, Bullen G, Williams M, Qian W, Gilbert F, Jodrell D, Caldas C, Karabatsou K, Dunn L, Jena R, Whitfield G, Chalmers A, Jefferies S, Price S. Cambridge brain mets trial 1 (CamBMT1): A proof-of-principle phase 1b / randomised phase 2 study of afatinib penetration into brain metastases for patients undergoing neurosurgical resection, both with and without prior low-dose, targeted radiotherapy [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr OT1-04-01.

Cardio-Onco-Hematología en la práctica clínica. Documento de consenso y recomendaciones

Improvements in early detection and treatment have markedly reduced cancer-related mortality. However, improving cancer prognosis not only depends on an effective cure, but also on the prevention, diagnosis, and treatment of cancer-related complications. Although cardiovascular toxicity is a widespread problem across many classes of therapeutic regimens, scientific evidence on the management of cardiovascular complications in onco-hematology patients is scarce because these pati ents 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 the cancer itself. Excessive concern for the occurrence of cardiovascular toxicity can hamper the use of potentially curative therapies, while underestimation of this risk increases the long-term mortality of cancer survivors. The objective of this consensus document, developed in collaboration with 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 in order to improve the cardiovascular health of patients with cancer.Full English text available from: www.revespcardiol.org/en

Reducing RBC Transfusion in Cardiac Surgery: A Single Centre's Experience in a Multicentre Quality Improvement Initiative of The Australian and New Zealand Collaborative Perfusion Registry (ANZCPR)

Purpose: To reduce RBC transfusion within a multicentre project of the Australian and New Zealand Collaborative Perfusion Registry (ANZCPR) through implementation of industry guidelines and avoidance of anaemia. Methodology: This multicentre project was modelled on a single centre 3 phase study, where current processes were identified (phase I) then new protocols implemented (phase II) and follow-up monitoring of progress was undertaken (phase III) [[1]Likosky D.S. Surgenor S.D. Dacey L.J. et al.Rationalizing the treatment of anaemia in cardiac surgery: short and mid-term results from a local quality improvement initiative.Qual Saf Health Care. 2010; 19: 392-398Crossref PubMed Scopus (12) Google Scholar]. Local sites formed a local multi-disciplinary quality improvement team to review current practice and incidence of transfusion for their site (phase 1). Our team included cardiac surgery, anaesthetics, CICU, haematology, blood bank and perfusion. This team would then review current literature and guidelines and select initiatives and changes in practice they considered worthwhile (phase II). These were then relayed to staff and introduced. Then a 3- and 6-month follow-up reporting changes in incidence of RBC transfusion fed back to team members and their staff was undertaken (phase III). Concurrently, indications for each transfusion were also recorded in line with the project model. Results: At our centre, each discipline was involved in introducing a variety of simple wide-reaching evidence-based strategies with very small costs with spectacular results. Our centre has had a 57% reduction in the number of RBC units transfused for our open heart, RBC transfusion rate per 6 months has fallen 20%, and of those transfused, patients receiving more than 2 units has dropped 13%. Also, a 34% reduction in units of platelets given, 50% reduction in cryoprecipitate units and 49% reduction in units of FFP transfused. These changes in practice continue to improve transfusion rates. Conclusion: A multidisciplinary team approach to RBC conservation using well established evidence-based guidelines can effectively optimise the use of blood products in a cardiac surgical setting and in a cost effective manner.

OP13. GLIOBLASTOMA IN THE OLDER PERSON – HOW DO WE PREDICT THOSE WHO WILL BENEFIT FROM TREATMENT?

INTRODUCTION: Glioblastoma (GBM) is the commonest primary malignant brain tumour among the adult population. Incidence peaks in the 7th and 8th decades of life and as our global population ages, rates are increasing. GBM is an almost universally fatal disease with life expectancy in the range of 3–5 months amongst the elderly. There is a distinct lack of evidence to support treatment choices for elderly patients. Options include best supportive care, radiotherapy alone, chemotherapy alone or combined modality treatment, and emerging evidence indicates that MGMT promoter methylation status may be a useful biomarker. Crucially, however, methods and tools for holistic assessment of older patients with GBM prior to treatment decisions have been poorly researched. While multi-dimensional geriatric assessment has been shown to predict treatment tolerance and survival in other tumour types, these assessment tools are likely to be less valid within the GBM cohort because of the unique and potentially isolated deficits caused by the disease itself. In order to begin tackling this issue we performed a cross-sectional survey of UK based consultant neuro oncologists to obtain information about current practices for assessing elderly GBM patients. METHODS: A questionnaire was designed by the principal investigator and the validity of the questions was assessed by 3 consultant co-investigators from 3 different centres. The final version was distributed as an electronic survey to all practising consultant neuro-oncologists in England, Scotland, Wales and Northern Ireland. RESULTS: There were 56 respondents from a total of 93 recipients (60% response rate). All respondents confirmed that at least some patients aged 70 or over were referred to their clinics from the local multidisciplinary team meeting (MDT). Only 18% of consultants routinely performed a cognitive or frailty screening test at initial consultation. Of those who performed a screening test, the majority reported that the results of the test changed their treatment decision in approximately 50% of cases. Despite the publication of the NORDIC and NOA-08 trials, there was a marked difference in how responders ranked the importance of MGMT methylation status in making treatment decisions. 6% of responders did not routinely test for MGMT status whereas 48% felt that MGMT status was very or extremely important. When making treatment decisions, participants ranked performance status as the most important clinical factor. CONCLUSION: In the first survey of this kind, we have shown a marked disparity in assessment techniques across the UK. While performance status was ranked as the most important factor, we argue that it is a crude measure of vulnerability within this cohort. Elderly GBM patients represent a uniquely challenging clinical population because of the complexity of distinguishing neuro oncology related symptoms from general frailty. There is a need for specific geriatric assessment models tailored to the elderly neuro oncology population which could be used alongside existing and emerging molecular biomarkers to facilitate treatment decisions on an individual basis.

Nerve Transfer for Restoration of Upper Limb Function in Traumatic Cervical Spinal Cord Injury

Introduction: Cervical spinal cord injury (CSCI) is a devastating consequence of trauma that results in disabling loss of upper limb function. Surgical restoration can improve quality of life, reduce long-term care needs, and is highly rated by patients. Historically, expert opinion has recommended tendon transfer procedures, but there is now a renaissance of interest in selective nerve fascicle transfer to restore prehensile grip, maintain donor muscle function, and better serve patients. Due to a long-standing geographical and professional disconnect between spinal injury professionals and reconstructive hand surgeons, limited information exists regarding the number of CSCI patients eligible for nerve transfer surgery, extent of current service provision, and contemporaneous surgical practices. Objectives: (1) Conduct a survey of UK spinal cord injury centres (SCICs) to understand the number of CSCI patients eligible for nerve transfer surgery annually. (2) Survey UK health care professionals to understand the current provision of services and range of surgical interventions performed. Methodology: SCIC Questionnaire—This was distributed to the clinical leads of each UK and Éire SCIC between February and May 2015. Information was requested on the local CSCI caseload, referrals to upper limb services, and surgical procedures undertaken locally during January to December 2014. Nonresponders were followed up with freedom of information requests. Clinician Questionnaire—This was distributed to 18 spinal injury rehabilitation consultants and upper limb surgeons identified as having a relevant professional interest through a specialist interest meeting at the British Society for Surgery of the Hand Spring Meeting (BSSH) Spring Meeting 2015 and the SCIC questionnaire. The questionnaire requested information on clinician caseload, previous training, local multidisciplinary team (MDT) support, functional gains prioritized, and surgical interventions undertaken. Results: SCIC Questionnaire—In all, 11/12 SCICs responded (response rate [RR] 92%) with a mean of 49.6, any-level CSCI patients admitted annually (>C5: 27.9 patients, C5/6: 18 patients, <C6: 6.5 patients). No SCIC reported referring CSCI patients for nerve transfer or awareness of any peripheral nerve service. In all, 5/11 SCICs stated that they referred CSCI patients for surgery to restore upper limb function. Clinician Questionnaire—Seven surgeons and 1 rehabilitation consultant responded (RR: 44%). Each surgeon assessed a mean of 5.7 patients annually with ~60% of patients proceeding to surgery. Achieving elbow extension, wrist extension, and key pinch were the most frequently prioritized functional gains. These were pursued through deltoid to triceps transfer, tenodesis surgery, and brachioradialis to flexor pollicis longus (FPL) transfer, respectively. No surgeons reported undertaking nerve transfer but three-quarters expressed a willingness to do so. Conclusions: Surgery to restore upper limb function following CSCI is a developing area of hand surgery that will revolutionize functional outcomes for this small but important patient group. Clinical expertise is currently limited to only a handful of surgeons. Provision of services is sparse, uncoordinated, and regionally serendipitous. Most surgeons predominantly pursue tendon transfer strategies but recognize nerve transfer surgery represents a paradigm shift in the outcomes that may be achieved. It is clear that there is a willingness among surgeons to pursue nerve transfer with appropriate support. Awareness must be raised within the professional and patient spinal injury communities regarding this important treatment option.

Glioblastoma in the elderly - How do we choose who to treat?

Glioblastoma (GBM) is the commonest primary malignant brain tumour amongst the adult population. Incidence peaks in the 7th and 8th decades of life and as our global population ages, rates are increasing. GBM is an almost universally fatal disease with life expectancy in the range of 3-5months amongst the elderly. The assessment of elderly GBM patients prior to treatment decisions is poorly researched and unstandardised. In order to begin tackling this issue we performed a cross-sectional survey across all UK based consultant neuro-oncologists to review their current practice in assessing elderly GBM patients. There were 56 respondents from a total of 93 recipients (60% response rate). All respondents confirmed that at least some patients aged 70 or over were referred to their clinics from the local multidisciplinary team meeting (MDT). Only 18% of consultants routinely performed a cognitive or frailty screening test at initial consultation. Of those who performed a screening test, the majority reported that the results of the test changed their treatment decision in approximately 50% of cases. Participants ranked performance status as the most important factor in determining treatment decisions. Considering the heterogeneity of this patient population, we argue that performance status is a crude measure of vulnerability within this cohort. Elderly GBM patients represent a unique clinical scenario because of the complexity of distinguishing neuro-oncology related symptoms from general frailty. There is a need for specific geriatric assessment models tailored to the elderly neuro-oncology population in order to facilitate treatment decisions.

Telemedicine for Specialist Geriatric Care in Small Rural Hospitals: Preliminary Data.

Small rural hospitals admit and manage older adults who, in city hospitals, would usually be offered geriatrician-supported comprehensive geriatric assessment and coordinated subacute care if required. Distance and diseconomies of scale prohibit access to the conventional in-person approach. A telegeriatric service model involving a geriatrician consulting remotely using wireless, mobile, high-definition videoconferencing; a trained host nurse at the rural site; structured geriatric assessment configured on a web-based clinical decision support system; routine weekly virtual rounds; and support from a local multidisciplinary team was established to overcome these barriers. This was a prospective observational study to examine the feasibility and sustainability of the model. Patient characteristics were recorded using the interRAI Acute Care assessment system. Usage patterns were derived from health service data sets and a service statistics database. Patients had characteristics that are consistent with characteristics of individuals typically referred for geriatric assessment. Overall, 53% of patients had cognitive impairment, 75% had limitations with activities of daily living, and the average Frailty Index was 0.44±0.12. Stable patterns ofconsultation occurred within 6months of start-up andcontinued uninterrupted for the remainder of the 24-month observation period. The estimated overall rate of initial consultation was 1.83 cases per occupied bed per year and 2.66 review cases per occupied bed per year. The findings indicate that the model was feasible and was sustained throughout and beyond the study period. This telegeriatric service model appears suitable for use in small rural hospitals.

PTU-019 Quality of Upper Gastrointestinal Endoscopy Reporting in Suspected Cancer Patients

Introduction Accurate endoscopy reporting is vital for upper gastrointestinal (GI) cancer management decisions. Effects of poor reporting are unknown but they are likely to cause delay in providing definitive treatment plans. Methods The Somerset Upper GI cancer database was used to identify patients between March 2014 and February 2015. Endoscopy report obtained from Endobase, radiological imaging report from PACS and local cancer multi-disciplinary team (MDT) index outcomes were then used to assess reporting quality and draw comparison. Reports were assessed against an expected ideal reporting criteria (anatomic extent of examination and its limitations, tissue samples obtained, description of findings, diagnostic impression and photodocumentation), against which the crucial computed tomography (CT) findings and subsequent MDT decisions could be made. Results A 12 month sample size of 84 confirmed upper GI cancer patients were identified (68% males; median age 70 years). Median time difference between endoscopy and staging CT scan was 7 days (range 0–46 days). In 86% (n = 72) the endoscopist reported the exact tumour location when correlated to CT findings. Only 56% (n = 47) mentioned that biopsies had been taken but of these only 51% (n = 24) mentioned the number of biopsies taken. All the visualised lesions had a reported description of how the lesion appeared i.e. malignant features. In total, 19 (23%) patients were identified having repeat gastroscopies and of these 6 (7%) were felt to be avoidable repeats. Of these, 2 were repeated for clarification of previous endoscopy reports while 4 were required due to insufficient biopsies for adequate histological confirmation of cancer. Overall the delay in organising these avoidable repeat gastroscopies ranged from 14–69 days (median 16.5). Of the 6 index gastroscopies that required repeating, 3 were undertaken by GI consultants (two surgeons, one physician), 1 trainee endoscopist, 1 nurse endoscopist, 1 acute physician consultant endoscopist. Conclusion Poor endoscopy reporting practice can cause significant delays in cancer diagnosis and management. Some technical difficulties are inevitable in clinical practice however attention to details in report is important. We recommend that every endoscopy unit must ensure that regular internal audits on endoscopy reporting are undertaken for quality assurance. Disclosure of Interest None Declared

Coordinating care in acute diabetes foot problems: no mean feet!

A multidisciplinary foot care team exists to coordinate specialist care for people with complex diabetes-related foot problems. The local multidisciplinary diabetes foot care team (MDFT) consists of a diabetes specialist, diabetes specialist nurse, orthopaedic surgeon, a visiting vascular surgeon and a podiatrist. Concerns around inpatient care were raised following a man who presented with a foot attack who underwent major limb amputation and subsequently died. A root cause analysis and Serious Untoward Incident panel identified reasons for delays in good clinical care. Undue emphasis on the need for further imaging, lack of urgency to surgically debride and request for other specialty assessments contributed to the delay in providing potentially life-saving treatment. Specialist ownership of patients with multidisciplinary input and lack of a clear management pathway also contributed. The Guildford Footpath is a clinical decision tool for acute diabetes foot problems developed by physicians and surgeons working together. It is a practical and safe way of helping non-specialists to assess patients presenting with acute diabetes foot problems. It clearly assigns responsibilities amongst specialist teams and provides a route for each specialist team to access members of the MDFT in a timely manner. It has streamlined care and given those involved more confidence in making decisions. We hope that ongoing audit will show a reduction in length of stay and amputation rates.

A Multidisciplinary Evaluation of a Web-based eLearning Training Programme for SAFRON II (TROG 13.01): a Multicentre Randomised Study of Stereotactic Radiotherapy for Lung Metastases

AimsIn technically advanced multicentre clinical trials, participating centres can benefit from a credentialing programme before participating in the trial. Education of staff in participating centres is an important aspect of a successful clinical trial. In the multicentre study of fractionated versus single fraction stereotactic ablative body radiotherapy in lung oligometastases (TROG 13.01), knowledge transfer of stereotactic ablative body radiotherapy techniques to the local multidisciplinary team is intended as part of the credentialing process. In this study, a web-based learning platform was developed to provide education and training for the multidisciplinary trial teams at geographically distinct sites. Materials and methodsA web-based platform using eLearning software consisting of seven training modules was developed. These modules were based on extracranial stereotactic theory covering the following discrete modules: Clinical background; Planning technique and evaluation; Planning optimisation; Four-dimensional computed tomography simulation; Patient-specific quality assurance; Cone beam computed tomography and image guidance; Contouring organs at risk. Radiation oncologists, medical physicists and radiation therapists from hospitals in Australia and New Zealand were invited to participate in this study. Each discipline was enrolled into a subset of modules (core modules) and was evaluated before and after completing each module. The effectiveness of the eLearning training will be evaluated based on (i) knowledge retention after participation in the web-based training and (ii) confidence evaluation after participation in the training. Evaluation consisted of a knowledge test and confidence evaluation using a Likert scale. ResultsIn total, 130 participants were enrolled into the eLearning programme: 81 radiation therapists (62.3%), 27 medical physicists (20.8%) and 22 radiation oncologists (16.9%). There was an average absolute improvement of 14% in test score (P < 0.001) after learning. This score improvement compared with initial testing was also observed in the long-term testing (>4 weeks) after completing the modules (P < 0.001). For most there was significant increase in confidence (P < 0.001) after completing all the modules.

Achieving behaviour change for detection of Lynch syndrome using the Theoretical Domains Framework Implementation (TDFI) approach: a study protocol.

BackgroundLynch syndrome is an inherited disorder associated with a range of cancers, and found in 2–5 % of colorectal cancers. Lynch syndrome is diagnosed through a combination of significant family and clinical history and pathology. The definitive diagnostic germline test requires formal patient consent after genetic counselling. If diagnosed early, carriers of Lynch syndrome can undergo increased surveillance for cancers, which in turn can prevent late stage cancers, optimise treatment and decrease mortality for themselves and their relatives. However, over the past decade, international studies have reported that only a small proportion of individuals with suspected Lynch syndrome were referred for genetic consultation and possible genetic testing. The aim of this project is to use behaviour change theory and implementation science approaches to increase the number and speed of healthcare professional referrals of colorectal cancer patients with a high-likelihood risk of Lynch syndrome to appropriate genetic counselling services.MethodsThe six-step Theoretical Domains Framework Implementation (TDFI) approach will be used at two large, metropolitan hospitals treating colorectal cancer patients. Steps are: 1) form local multidisciplinary teams to map current referral processes; 2) identify target behaviours that may lead to increased referrals using discussion supported by a retrospective audit; 3) identify barriers to those behaviours using the validated Influences on Patient Safety Behaviours Questionnaire and TDFI guided focus groups; 4) co-design interventions to address barriers using focus groups; 5) co-implement interventions; and 6) evaluate intervention impact. Chi square analysis will be used to test the difference in the proportion of high-likelihood risk Lynch syndrome patients being referred for genetic testing before and after intervention implementation. A paired t-test will be used to assess the mean time from the pathology test results to referral for high-likelihood Lynch syndrome patients pre-post intervention. Run charts will be used to continuously monitor change in referrals over time, based on scheduled monthly audits.DiscussionThis project is based on a tested and refined implementation strategy (TDFI approach). Enhancing the process of identifying and referring people at high-likelihood risk of Lynch syndrome for genetic counselling will improve outcomes for patients and their relatives, and potentially save public money.

Ruptured aneurysm of sinus of Valsalva – an unexpected cause of tachycardia and severe dyspnea in a young patient (RCD code: I-1B.0)

The presented case report illustrates a rare and unexpected cause of tachycardia and exercise tolerance reduction in a young patient with noncoronary sinus of Valsalva aneurysm rupture. The patient was referred to our hospital due to complaints of palpitation, dyspnoea and severe reduction of exercise tolerance of acute onset. Transthoracic echocardiography revealed a shunt between aorta and right atrium, moderate aortic and tricuspid regurgitation and signs of hyperkinetic circulation. Transesophageal echocardiogram confirmed the presence of ruptured aneurysm. The patient was consulted by a local multidisciplinary Heart Team and referred for cardiac surgery, after which he recovered without any complications. JRCD 2016; 3 (1): 17–19

Think Stoma Nurse: a tool to trigger referral to specialist care.

This article describes the initial development and subsequent evolution of a simple referral assessment tool for stoma care. The first author's personal experience identified that there was widespread inconsistency in perceptions of local multidisciplinary teams as to when it was appropriate to refer to specific specialist nursing teams. This resulted in both inappropriate and delayed referrals. A 'Think Specialist Nurse' initiative was developed across the author's trust, building on the traffic light template from the 'ThinkGlucose' tool, to facilitate referrals to clinical nurse specialists. The stoma-care specific tool, 'Think Stoma Nurse', has subsequently evolved beyond its initial audience, and has been adapted into materials aimed at patients and carers.

PWE-217 Pancreatic enzyme replacement therapy in chronic pancreatitis and pancreatic cancer – are we getting it right?: Abstract PWE-217 Table 1

<h3>Introduction</h3> Pancreatic enzyme insufficiency (PEI) is a well recognised cause of malnutrition in chronic pancreatitis and pancreatic cancer. Pancreatic enzyme replacement therapy (PERT) in the form of enteric coated pancreatin microspheres is recommended in both these groups of patients with symptoms of PEI to prevent weight loss and malnutrition and improve quality of life. Given that the probability of PEI is high in PC (80–90%), PERT is recommended without the use of formal diagnostic tests. The optimal starting dose of PERT is 40–50000 lipase units per main meal. The aim of this study was to evaluate the use of PERT including appropriate dosing in chronic pancreatitis (CP) and pancreatic cancer (PC) and to ascertain if there was a difference in prescribing practice between these groups. <h3>Method</h3> A single centre retrospective analysis of patients diagnosed with CP and PC since 2010 in a large North London district general hospital was performed using local upper gastrointestinal cancer multidisciplinary team records and clinical coding. We identified 149 patients with PC and 110 with CP though 32 patients from the PC group and 4 from CP were excluded from the study due to poor documentation in the records leading to insufficient information surrounding enzyme supplementation and dosages. Information was collected from electronic patient records on the patients’ symptoms, evidence of PERT and the dose prescribed. <h3>Results</h3> Symptoms of pancreatic enzyme insufficiency (abdominal pain, weight loss or steatorrhoea) were recorded in 72/117 (61.5%) of PC patients compared with 75/106 (70.8%) of CP patients. PERT was prescribed in 14/72 (19.5%) patients with PC versus 53/75 (70.7%) with CP. The Table 1shows the enzyme formulation and dosages used in both groups. <h3>Conclusion</h3> In our study we demonstrate that the majority of patients with PEI in CP are prescribed PERT, a stark contrast with a mere 20% in PC. However in both groups, most patients were not prescribed optimal doses of PERT though again, this figure was better in the CP group (14/53 or 26.4%) compared to the PC group (2/14 or 14.3%). This study highlights the missed opportunity to reduce symptoms and improve quality of life in CP and PC patients with a simple intervention. Increased awareness of the availability and appropriate dosing of PERT in conditions resulting in PEI is required. <h3>Disclosure of interest</h3> None Declared.

PTH-293 Surveillance after excision of malignant colorectal polyps – is there a need for standardisation?

<h3>Introduction</h3> Bowel cancer screening has resulted in a greater incidence of early colorectal cancers, or malignant polyps (MPs). Increasingly MPs are being resected endoscopically, hence avoiding the associated risks of major surgery. There remains, however, concern regarding local cancer recurrence and residual loco-regional lymph node disease, along with the future risk of metachronous disease in the remaining bowel. Detection of these adverse outcomes of endoscopic resection suggests a need for regular surveillance, though this has to be contrasted with the risks of unnecessary surveillance; e.g. morbidity, false negatives, and cost. The ACPGBI position statement¹gives guidance on post-resection colonoscopies, though there is little guidance on other surveillance modalities. This study aimed to review post-MP excision surveillance practice in a single NHS Trust. <h3>Method</h3> All excised MPs were identified from a prospective consecutive database of all colorectal cancers with a date of diagnosis 01/04/10 – 31/03/14 diagnosed in a UK NHS Foundation Trust. Electronic records were reviewed to ascertain the number of endoscopic and radiological tests that patients underwent post-MP excision (excluding initial staging scans). Primary outcomes were tumour recurrence, metastases or detection of metachronous disease. Investigations for reasons other than surveillance (e.g. emergency admission) were excluded. <h3>Results</h3> There were 130 MPs excised over a four year period, 96 of which were excised initially endoscopically (28 underwent further formal resection, in which there were four cases of residual disease: 3 nodal diseases and 1 local disease). Median follow-up was 34 months (range 3–58). A total of 106 surveillance CT scans were performed and eight surveillance MRI scans (range 0 to 5 CTs, and 0–3 MRIs per patient). 194 surveillance endoscopies were performed (98 colonoscopies, 96 flexible sigmoidoscopies), ranging from zero to seven per patient. There was no association with duration of follow-up for either scans or endoscopies, though on average, surgically managed patients had more surveillance scans, whereas those managed endoscopically had more surveillance endoscopies. In total there were no recurrences, 1 case of metastases and 2 detected metachronous tumours. <h3>Conclusion</h3> Surveillance of patients following MP excision remains controversial; this experience highlights a wide variation in practice, and low yield from surveillance tests. Although each case should be managed individually according to a local multi-disciplinary team, there appears to be a requirement for a larger evidence base and subsequent guidance on optimal surveillance for these patients. <h3>Disclosure of interest</h3> None Declared. <h3>Reference</h3> Williams JG, <i>et al</i>. Management of the malignant colorectal polyp: ACPGBI position statement. <i>Colorectal Dis.</i>2013;15(Suppl 2):1–38

Su1888 Pancreatic Enzyme Replacement Therapy in Chronic Pancreatitis and Pancreatic Cancer- Are We Getting It Right?

Introduction Pancreatic enzyme insufficiency (PEI) is a well recognised cause of malnutrition in chronic pancreatitis and pancreatic cancer. Pancreatic enzyme replacement therapy (PERT) in the form of enteric coated pancreatin microspheres is recommended in both these groups of patients with symptoms of PEI to prevent weight loss and malnutrition and improve quality of life. Given that the probability of PEI is high in PC (80–90%), PERT is recommended without the use of formal diagnostic tests. The optimal starting dose of PERT is 40–50000 lipase units per main meal. The aim of this study was to evaluate the use of PERT including appropriate dosing in chronic pancreatitis (CP) and pancreatic cancer (PC) and to ascertain if there was a difference in prescribing practice between these groups. Method A single centre retrospective analysis of patients diagnosed with CP and PC since 2010 in a large North London district general hospital was performed using local upper gastrointestinal cancer multidisciplinary team records and clinical coding. We identified 149 patients with PC and 110 with CP though 32 patients from the PC group and 4 from CP were excluded from the study due to poor documentation in the records leading to insufficient information surrounding enzyme supplementation and dosages. Information was collected from electronic patient records on the patients’ symptoms, evidence of PERT and the dose prescribed. Results Symptoms of pancreatic enzyme insufficiency (abdominal pain, weight loss or steatorrhoea) were recorded in 72/117 (61.5%) of PC patients compared with 75/106 (70.8%) of CP patients. PERT was prescribed in 14/72 (19.5%) patients with PC versus 53/75 (70.7%) with CP. The Table 1shows the enzyme formulation and dosages used in both groups. Conclusion In our study we demonstrate that the majority of patients with PEI in CP are prescribed PERT, a stark contrast with a mere 20% in PC. However in both groups, most patients were not prescribed optimal doses of PERT though again, this figure was better in the CP group (14/53 or 26.4%) compared to the PC group (2/14 or 14.3%). This study highlights the missed opportunity to reduce symptoms and improve quality of life in CP and PC patients with a simple intervention. Increased awareness of the availability and appropriate dosing of PERT in conditions resulting in PEI is required. Disclosure of interest None Declared.

Evaluating the effect of a web-based quality improvement system with feedback and outreach visits on guideline concordance in the field of cardiac rehabilitation: rationale and study protocol.

BackgroundImplementation of clinical practice guidelines into daily care is hampered by a variety of barriers related to professional knowledge and collaboration in teams and organizations. To improve guideline concordance by changing the clinical decision-making behavior of professionals, computerized decision support (CDS) has been shown to be one of the most effective instruments. However, to address barriers at the organizational level, additional interventions are needed. Continuous monitoring and systematic improvement of quality are increasingly used to achieve change at this level in complex health care systems. The study aims to assess the effectiveness of a web-based quality improvement (QI) system with indicator-based performance feedback and educational outreach visits to overcome organizational barriers for guideline concordance in multidisciplinary teams in the field of cardiac rehabilitation (CR).MethodsA multicenter cluster-randomized trial with a balanced incomplete block design will be conducted in 18 Dutch CR clinics using an electronic patient record with CDS at the point of care. The intervention consists of (i) periodic performance feedback on quality indicators for CR and (ii) educational outreach visits to support local multidisciplinary QI teams focussing on systematically improving the care they provide. The intervention is supported by a web-based system which provides an overview of the feedback and facilitates development and monitoring of local QI plans. The primary outcome will be concordance to national CR guidelines with respect to the CR needs assessment and therapy indication procedure. Secondary outcomes are changes in performance of CR clinics as measured by structure, process and outcome indicators, and changes in practice variation on these indicators. We will also conduct a qualitative process evaluation (concept-mapping methodology) to assess experiences from participating CR clinics and to gain insight into factors which influence the implementation of the intervention.DiscussionTo our knowledge, this will be the first study to evaluate the effect of providing performance feedback with a web-based system that incorporates underlying QI concepts. The results may contribute to improving CR in the Netherlands, increasing knowledge on facilitators of guideline implementation in multidisciplinary health care teams and identifying success factors of multifaceted feedback interventions.Trial registrationNTR3251.

P05 * VARIABILITY IN FOLLOW UP IMAGING GUIDELINES AFTER THE COMPLETION OF PRIMARY THERAPY IN GLIOBLASTOMA MULTIFORME

INTRODUCTION: There is no clear definitive follow up surveillance imaging guideline after the completion of primary therapy in glioblastoma multiforme (GBM). Here we provide the first report analysing international, national and local guidelines in GBM imaging surveillance. METHOD: We performed a systematic review of GBM management guidelines indexed in PUBMED and EMBASE databases up until October 2013. We also searched for GBM guidelines on websites of relevant international and national societies. To clarify local recommendations within the UK, we reviewed all guideline documents produced by local neuro-oncology multidisciplinary teams (MDTs; n = 28) in the UK accessed via the Care Quality Improvement Network (CQuIN) database. For all the relevant guidelines identified, we extracted imaging recommendations for the period following completion of primary therapy. RESULTS: Out of the identified guidelines produced by international and national societies, only 6 had follow up imaging guidelines with variability in imaging frequency ranging from 1-2 monthly (1 guideline), 2-4 monthly (1), 2-3 monthly (2), to 3-4 monthly (2). Twenty out of the 28 neuro-oncology MDTs had imaging guidelines. Of these, 18 had guidelines on imaging after completion of primary therapy, with also a wide variability in imaging frequency from 2 monthly (2 guidelines), 2-4 monthly (1), 3 monthly (6), 3-4 monthly (1), 3-6 monthly (2), 6 monthly (4), and yearly (2). CONCLUSION: The guidelines for follow up imaging surveillance after the completion of primary therapy in GBM are variable. Future studies should assess effectiveness of these guidelines in detecting assymptomatic GBM recurrence.

Outcomes of surgical resection in the management of colorectal pancreatic metastases.

Colorectal pancreatic metastases (CRPM) are uncommon, thus the role of surgical resection is unclear. We present our experience of management outcomes of patients with CRPM in a regional pancreatic unit. Electronic records of all patients with colorectal cancer (n = 8,228) held by the cancer network were searched for evidence of CRPM. Retrospective analysis of each case was undertaken in relation to diagnosis, management and outcome of CRPM. Four cases of CRPM underwent resection (operative group). The interval between diagnosis of colorectal carcinoma and CRPM was 1, 6, 7 and 7 years. CRPM were identified on routine CT surveillance in asymptomatic patients. An additional 5 patients were managed palliatively (non-operative group). In the surgical cohort, median survival was 4 years. One patient remains disease free 4 years 3 months post-surgery. Of 3 patients with recurrent disease, 1 is alive with progressive disease 3 years 11 months post-operatively and 2 passed away at 18 months and 5 years 1 month respectively. Median survival in the palliative group from diagnosis of CRPM was 11 months. In selected patients with CRPM surgical resection does confer survival benefit. CRPM arise late in the disease course, with extra-pancreatic metastases frequently diagnosed in the interim. Surgeons outside of pancreatic units should refer cases to their local pancreatic multi-disciplinary team meeting for consideration of resection.

P16.13 * UNCERTAINTY AND VARIABILITY IN SURVEILLANCE IMAGING AFTER COMPLETION OF PRIMARY TREATMENT IN GLIOBLASTOMA MULTIFORME

INTRODUCTION: Clear and evidence-based follow up imaging guideline after the completion of primary therapy in glioblastoma multiforme (GBM) is lacking. Here we provide the first report analysing international, national and local guidelines in GBM imaging surveillance. METHODS: First we performed a systematic review of GBM management guidelines indexed in PUBMED and EMBASE databases up until October 2013. We then searched for GBM guidelines on websites of the relevant international and national societies. Next, to ascertain local recommendations within the UK, we reviewed guideline documents produced by the local neuro-oncology multidisciplinary teams (MDTs; n = 28) in the UK accessed via the Care Quality Improvement Network (CQuIN) database. For all the relevant guidelines identified, we extracted imaging recommendations for the period following completion of primary therapy. RESULTS: Of identified guidelines produced by international and national societies, only 6 had follow up imaging guidelines with variability in imaging frequency ranging from 1-2 monthly (1 guideline), 2-4 monthly (1), 2-3 monthly (2), to 3-4 monthly (2). Twenty out of the 28 neuro-oncology MDTs had imaging guidelines. Of these, 18 had guidelines on imaging after completion of primary therapy, with also a wide variability in imaging frequency from 2 monthly (2 guidelines), 2-4 monthly (1), 3 monthly (6), 3-4 monthly (1), 3-6 monthly (2), 6 monthly (4), and yearly (2). Most guidelines did not include references to any evidence base to inform the recommendations. CONCLUSIONS: The guidelines and recommendations for follow up imaging after the completion of primary therapy in GBM are variable and uncertain. Future studies should assess effectiveness of these guidelines in detecting assymptomatic GBM recurrence.