Lung Cancer Pathway Meeting

DRAFT: Lung Cancer Pathway Meeting NICaN

7th November 2006

Record of Comments Received following circulation on 15th November of the Draft Notes of Lung Pathway Meeting held on 7th November

(Notes can be found on pages 3 &4)

General Responses

• I doubt that any radiology department can/will operate by allowing us to directly book such requests for CT without a radiologist seeing the request. In the RVH there is one radiologist responsible for grading/prioritising outpatient CT requests and it doesn't hinder the process. The radiologist in question receives the request, the clinical priority will be documented by me and also the proposed clinic/bronch date and, more often than not, the date of the CT scan is arranged to facilitate this. Yet it still has to be seen/vetted/prioritised/accepted (whatever word one wants to choose) by a consultant radiologist.

• This discussion was made in the presence of a radiologist whose current practice is the same as RVH. However, he indicated that he would take the proposal back to his colleagues at his base and discuss that as an option. The assumption was that the requests would be made by respiratory consultants and that re-grading of the priority would not be deemed necessary.

• The summary was meant to be taken as a series of principles which would facilitate the smooth transition of the patient along the pathway which, for that individual, was most appropriate. I think that the consensus was that these principles were not unreasonable but the local implementation would be for each of the five Trusts to define.

• If the guidelines stipulate that red flagged patients need this investigation within a certain time span, what is the advantage in putting it into a vetting pile? Surely the priority of the request is determined by the fact that it has been red flagged? Would the radiologist then second guess the guidelines with less info than is available to the clinician? I think in some trusts, including mine, the vetting of requests may take some time and add to delays. If vetting is same day and we are flexible about our time lines the existing system would be preferable. If vetting is not the same day and our timelines are tight I think we need to consider this change in practice. The answer may vary between trusts.

• I personally feel VERY STRONGLY that we should NOT rush headlong into the 'CT first' issue - the evidence base is not there for this course of action!

The 25day rule is an example of 'postcode medicine'. It isinequitable and should be actively discouraged.

• The important word is "Justification" , IR(ME)R 2000. In the specific case of a reported chest X ray abnormality "Suspicious of carcinoma" that report is justification in it's self. Many colleagues would book the CT directly or even given the unusual luxury of a space "do it now"! Similar justification is obtained when a chest physician colleague reviews a patient and a film. Whilst I recognise it was not referred to in the notes, such justification could not be obtained form a referral letter alone, even if it possesses a red flag.

It is a requirement that all medical exposures are justified to a Practitioner (radiologist in most circumstances). That justification has to be recorded usually by their signature. On occasion delegation is possible(to a practitioner) but only within rigorously drafted protocols, approved by radiation protection, and the request must still be justified. Clinical and governmental convenience cannot circumvent what is now enshrined in European law and enforceable under UK criminal law.

CT first in all cases would not be appropriate. CT Before Brochoscopy is desirable as shown in some chest centres, however much information can be gained from the chest X-ray so it is not necessary for CT to precede Bronchoscopy in all cases. I hesitate to say it but the latteral film can also be highly helpful , even if it does sound a little ancient .

Great care is needed with the exact wording of a recommendation so that it does not immediately breach many regulations.

• Unfortunately unless the patient sees the referring clinician in the interval before CT or other tests are performed then informed consent and appropriate patient information is lacking, this would not be acceptable, regardless of source. Red flag referrals to radiology from consultants can be preconsented/informed that follow on exams may be performed. This a separate issue from the straight forward situation of justification.

• The IRMER regulations must be followed

Comments on FNA

• RVH- we currently would have roughly a 7-14 day wait for FNA. Extra requests on the current basis of capacity would therefore worsen that waiting time. Whether there is the potential for more radiological capacity to be identified is something I don't know. Also there would be the knock-on effect on beds as currently the patients are admitted the evening before their procedure, have it the next morning and are kept overnight, being discharged the morning after the procedure - assuming no complications. The patient also requires a ward nurse to accompany them to Radiology for the duration of their procedure so has nursing resource implications too.

Hence identifying extra FNA capacity for inter-trust patients would require a significant amount of negotiation/discussion I would imagine. If that's what is felt to be needed though, perhaps it needs explored.

• BCH - We (unfortunately perhaps) do not have the same resource usage! We are very lucky if we can get a ward nurse. If there is no pneumothorax the patient can often go home later the same day. Also as long as everything is properly worked up beforehand there is no reason in many cases why the patient cannot go to the ward early on the morning of the procedure. My big issue with FNAs is that I think that we should discuss potential FNAs at the MDM in accordance with 2003 BTS guidelines.

Lung Cancer Pathway Meeting

7th November 2007

Fern House, Antrim Area Hospital

Record of Attendees

Apologies received: Dr Andrew Baltrop, Northern Trust and Dr Rory Convery, Southern Trust

Background and Tabled Information

The Belfast Trust recently re-iterated the need for ‘inter-trust’ transfer patients to have their diagnostic and staging procedures completed by ~ day 25 of the ‘62-day cancer access standard’.

Data from Mick Peake forwarded before the meeting demonstrated the beneficial effect of pre-clinic CT scans and the lack of adverse impact on radiology services.

Michelle Doherty and Robert Jackson showed the data for FNA activity (1 May through 31 October 2007): - 15 requests from the Lung Team (12 NSCLC; 1 SCLC; 1 rheumatoid nodule; 1 Granuloma) and, hence, the accuracy of FNA post-PET.

The PET Data showed an average request to report receipt time of 26 days for the total period and 24 days for the requests placed in September 2007 (17 days from request to test and 7 days from test to report).

Way Forward

It was agreed to operate on principles of good practice and the expectation would be that adherence to such principles would necessitate Trusts to make available the resources to facilitate good practice. The Principles are as follows:

• To improve timelines, patients with a CXR suspicious of lung cancer should have a CT scan done before or at first clinic date. This will allow best initial diagnostic test to be arranged and should facilitate earlier requesting of PET scans in appropriate cases.(Obviously, local referral patterns may influence how to address issues of Performance Status – and hence the appropriateness of that investigation for a particular patient - recognition and Renal Function awareness.) The request for such would be made by the consultant physician receiving the referral letter and the Imaging Departments are to be asked to accept such requests without the need for further consultant radiologist validation/prioritisation.
• Inappropriate use of “red flags” are to be highlighted to GPs via Trust’s Cancer Management Structures
• All patients whose initial CXR and performance status suggest they may be suitable for radical therapy should have their exercise performance assessed as soon as possible.
• Patients with CXR and findings suggestive of lung cancer should not have a Bronchoscopy or FNA without prior CT scan being performed and available for perusal/discussion with a radiologist.
• A regional review of radiology-guided FNA capacity to be undertaken, led by the Managers of Imaging services.
• Appropriate personnel should be in attendance at MDMs and have appropriate time to prepare for the MDMs

ACTIONS

1. A note of this meeting is to be forwarded to attendees/ lead respiratory physicians
2. The Lead Respiratory Physicians are to distribute this information to the relevant Cancer Management, Diagnostics and Imaging personnel.
3. Correspondence will be forwarded to the Imaging Directors of the Trusts re: CT-Guided, Fine Needle Lung Biopsy
4. Comments with regards to the Principles outlined should be forwarded to before end November 2007.
5. Principles will be reflected within the Care Pathway and the lung standards within the Service Framework