Developing Cancer Services at UCLH in partnership with UCL, - - PowerPoint PPT Presentation

Developing Cancer Services at UCLH in partnership with UCL, Macmillan and London Cancer

14th January 2013 Martin Lerner, Divisional Manager Kirit Ardeshna, Consultant Haematologist and Clinical Lead for the Cancer Centre Lallita Carballo, Head of Service, Macmillan Centre

What we are going to talk about

• UCLH cancer services
• Cancer Centre opened April 2012
• Strategy to develop services
• Achieving the best outcomes working with UCL
• Providing the best support working with

Macmillan Cancer Support

• Providing the best pathways working with

London Cancer

• Challenges for the future

How many Cancer Patients

• 3,000 new patients with cancer referred to

UCLH every year

• Over half of these patients are seen at

another hospital first and come to UCLH for specialist treatment

• Patients are surviving longer and receiving

more treatment

Oncology and Haematology activity

Historic annual growth in inpatient days = 3% Overall growth in treatment days - 7% per annum Will continue as more new treatments become available

2008 2012

Inpatient bed days Day cases

Best outcomes Best pathways Best patient experience

Cancer Strategy

Cancer Centre successes

Art Ambulatory care Business model Light and space Patient Experience Board Prizes Macmillan Support and Information Volunteer Service

Ambulatory Care

Delivering treatments in day care which were historically administered in a inpatient setting Patients reside at the Cotton Rooms or at home Daily patient assessments by nursing and medical team Twice weekly Consultant ward round review One bed kept open for immediate ward transfer 24 hour access to clinical team

Phase 4

Proton Beam therapy RNTNE Eastman Dental

UCLH and UCL Cancer in Huntley Street

Cancer Research Team at UCLH

• 70% Nurses
• Oncology – 27 Staff
• Haematology – 11 Staff
• Paediatric Oncology (TYA) – 5 Staff
• Cancer Clinical Research Facility – 18 Staff

Cancer clinical trials at UCLH

ACTIVITY

• 2011/12 – 520 patients recruited to 88

trials

• 2012/13 – first half of the year – 60

patients a month in 91 trials

• Clinical trials cover all types of cancer
• Run by medical staff, UCL, other

Universities and drug companies

T-cells

Tumour cell

Tumour antigen T-cell T-cell T-cell T-cell T-cell T-cell



T-cells recognize and kill tumour Tumour-specific receptor non-specific receptor non-specific receptor non- specific receptor

How Engineering T-cells works

T-cells extracted Blood sample Genetically Modified Administered back to patient Modified T-cells recognize and kill tumour

Basic Strategy of Immunotherapy

Targeting CD19 with T-cells

Low grade Lymphomas

• Many patients well with no symptoms
• No advantage of immediate chemotherapy

vs deferral until progression

• Deferral avoids side effects of chemo &

thought to improve quality of life

• Can we extend the period before

chemotherapy is necessary?

UCL sponsored international randomised study

• Patients randomly assigned to

– Watch and Wait – Rituximab x4 – Prolonged rituximab – Rituximab is a manufactured antibody which kills lymphoma cells with minimal side effects

Proportion

• f patients

with no new treatment initiated

0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0

Years from randomisation

1 2 3 4 5

% not requiring Rx at 3yr W+W=48% R4=80% R4+RM=91%

Time to Initiation of New Therapy (TTINT)

HR (Rituximab vs W+W) = 0.37, p<0.001 HR (Rituximab + M vs W+W) = 0.20, p <0.001 HR (Rituximab + M vs Rituximab) = 0.57, p =0.10

Cellular therapy for viral infections

• Some viral infections persist lifelong after initial infection
• Under the control of the immune system
• e.g

cold sore (HSV) and chicken pox (VZV) viruses

• These viruses can reactivate when the immune system is

weakened, particularly after bone marrow transplantation

• Aciclovir

prevents the development of problems with HSV & VZV

Cytomegalovirus (CMV)

• CMV is the same family
• f viruses and infects

60‐70% of normal individuals

• If untreated when it

reactivates it can cause life‐threatening lung infection

• It is not sensitive to aciclovir, and the effective drugs often require

intravenous administration, hospital admission, and have significant side effects

Cellular therapy for viral infections

• We have developed techniques to isolate the cells that give

protective immunity against CMV in normal donors, and can then re‐infuse these cells to patients following transplantation

• Following infusion these cells recognise the virus, multiply, and

eradicate infected cells, restoring long term immunity

• Avoids repeated infections, reduces hospital admissions, and the

need for toxic antiviral drugs

Cellular therapy for viral infections

• We are conducting 2 national

randomised multi‐centre studies in collaboration with a biotech industry partner in order to establish these therapies as a standard of care

• We have developed a national

immunotherapy network of centres in

• rder to deliver this vision
• The technology platforms are also

translatable to other viral infections

• Our mantra: “From proof of concept to standard of care”

ABC02-run by UCL-CTC

New treatment for inoperable advanced gallbladder & bile duct cancer 2005-08 400 patients recruited

• Gemcitabine & Cisplatin v Gemcitabine
• Results:

Combined treatment improved survival by a 1/3rd (3 months longer) Set a new standard of international care

‘Intratumor Heterogeneity and Branched Evolution Revealed by Multiregion Sequencing’

First ever genome-wide analysis of the genetic variation between different regions of the same tumour using kidney cancer samples Professor Charles Swanton based at UCL Cancer Institute

TRACERx

Macmillan Support and Information Service

Dr Hilary Plant and Lallita Carballo Clinical Heads of Macmillan Support and Information

What do we do?

They say life is hard, well at times Cancer is hard. Living under a cloud that seems to follow you wherever you go. I have been in twice this week and a few closed doors have been opened in my mind. Thank you for hearing me there is so much to say. From Visitor book Macmillan Support and Information Service

What we offer in the Macmillan Support and Information Centre?

• In the moment support by a multi professional team working

in the Living Room

• Guided Information on all aspects of cancer
• Welfare and Benefits Advice
• Volunteering roles to support the professional services
• Complementary Therapy team
• Medical Specialist in Complementary Therapy
• Counsellors
• Psychologists
• Lymphoedema Specialists
• Wig fitting
• Programme of Support

How many people do we see? 400-500 patients a day come to the cancer centre 25 of these come into the Living Room for support and information Another 50 a day attend for booked support individually or in teams

Who do we see?

• More women than men
• Less elderly
• Ethnic mix reflects the community
• 20% not English as a first language, 10%

do not read English well

• Some people come back regularly
• Flow with the clinics in the Cancer Centre
• Breast, Gynae, Sarcoma and Haematology

What happens in the living room?

• New service for patients and families
• Environment – flowers, no uniform and a wooden floor
• In the moment experienced , informed, empathic professional support
• Assess, listen, holding, inform, educate, rehabilitate, refer, reframe, empower
• Individuals and groups
• Volunteers
• Peer support
• The ‘forever table’
• We liaise and work closely

with other clinical staff

• We deliver something

unique that complements the care delivered by clinical teams

• Constantly reviewed ground

rules!

The Programme

• Underpinned by evidence from survivorship research
• What we have learnt together (patients/families &

clinical teams

• Structured programme of support and education
• Respects individuality
• Enabled to recognise own strengths
• Empower to self manage care
• Rebuild confidence and sense of well being
• Assessment and evaluation

The Programme

Support Groups HOPE (Helping overcome problems effectively) Getting started and what next workshops Relaxation, mindfulness and yoga Physical activity and fatigue management Healthy eating workshops Creative groups Support for parents Red cell strategy Carers group Taking care of yourself Returning to work

Linking to other areas in UCLH

• Starting to create a liaison infrastructure
• Link team members with all MDTs and wards
• Attendance at MDTs
• Link ward nurses (pilot in Cancer Centre)
• Working alongside CNSs to respond to concerns (e.g.

advanced breast cancer, prostate)

• Support for staff
• Posters and leaflets
• Phone us 020 3447 8663

Our Partnership with Macmillan

Some examples....

• Volunteering in the cancer centre
• Developing models of care after treatment that support

patients and families to rebuild their lives

• A new model of communication skills training for all staff
• Supporting the key worker role “One to One support”
• Value based standards project with patients with Head

and Neck cancer

A personal experience..

I don’t think there is praise high enough from me. Wonderful team you have to help us here. I came alone and received news I didn't perhaps expect to hear and Vicki, Nikki, Emma Nicola and Katrina have showered me with love, advice and know just what to do. They are professional angels who have certainly pulled me back from the initial brink of shock and despair. If I can help in any way to sustain this wonderful service, and the volunteers must not be forgotten as Julie was unique, remembering my name after just one brief meeting! Please let me know. I thank everyone involved in providing this facility at a time the spirit is really in need of love, support and understanding. Thank you. My very appreciative wishes

From Visitor book Macmillan Support and Information Service

Come and meet with us...

So what is

Where are our cancer patients

• n their pathway?

• Our goal is to deliver high quality integrated cancer care

pathways:

• driven by patient and population need,
• evidence‐based practice
• adding value
• This

requires us to think radically about how cancer care is delivered, moving towards:

• A clinically‐led distributed network of ownership and responsibility
• enabled by partnership with commissioners, primary care, patients &

voluntary sector providers

• integrated and transparent information on quality and outcomes
• international benchmarking
• Success should have implications that go beyond our

sector and make a difference nationally and potentially internationally

What do we need to do to deliver great care?

Pathway Boards – clinicians, GPs, patients - working out how to improve patient experience and outcomes for each cancer type Example Urology Expert reference groups working on support services Example Radiotherapy

Diagnosis of Blood Cancers

• Is difficult

– 15-20% of diagnoses changed after Specialist review – May require results from different labs before a diagnosis can be made

• Morphology
• Immunophenotyping
• Cytogenetics
• Molecular tests

New DH requirements

• Central Specialist Lab to immediately

receive

– 1) all samples where Blood Cancer suspected – 2) any samples being processed in DGH when it becomes apparent that it could be a Blood Cancer

Problems

• Local pathologists feel de-skilled
• Unlikely to result in any change prior to

London Cancer

• With Chief Executive ‘buy-in’ this is likely

to change

Improving Outcomes Guidance (published in August 2005) NCAT TYA measures (published in July 2011)

Need to improve outcome in Teenagers & Young Adults with Cancer

Key recommendations from IOG

• Teenage Young Adult (TYA) Cancer Network

Commissioning Group

• Place of care

– 16-18 yr olds should be referred to TYA Primary Treatment Centre (PTC) – 19-24 yr olds should be offered choice between TYA PTC or a local designated hospital – Robust arrangements for transition

• Discussion at TYA MDT

– All patients 13/16-24 years inclusive should be discussed at both a tumour-specific MDT meeting and a TYA MDT meeting. – The TYA MDT should coordinate treatment, psychosocial care and peer contact/support for young people wherever they are treated

North Thames TYA Cancer Network

Total population = 6.7 million Patients aged 16‐24 years All tumour types Paediatricians and adult physicians

Essex

NWL London Cancer London Cancer Alliance

PTC TYA DH

Network TYA Designated NHS Trust(s)

London Cancer ICS Barking Havering and Redbridge Barts Health NHS Trust Royal Free (Skin Cancer only) Whittington (shared care only) London Cancer Alliance ICS (NWL part) Chelsea & Westminster (HIV and skin only) Imperial Essex Cancer Network Southend Hospital Colchester Hospital Mid Essex Hospital Basildon and Thurrock Hospital Mount Vernon CN Mount Vernon Cancer Centre Lister hospital

TYA designated Trusts

Best outcomes Best pathways Best patient experience

What are the challenges?

Challenge 1 - outpatients

Clinics still running late Productive Outpatient project to review every clinic

Challenge 2 – improve cancer patient survey

Guys & St.Thomas’ – notable improvement Barts – also improved Marsden - big improvement UCLH – bottom 10

Focused approach Address multiple questions Impact all tumour sites Affects whole pathway Issues important to patients Aim to match and overtake GSTT and Marsden

Challenge 2 – improve cancer patient survey

Challenge 3 - chemotherapy

Demand growing at 10% per year Same day and different day pathways

Challenge 4 – extend support across UCLH and beyond

Best outcomes Best pathways Best patient experience

Questions welcome

Challenges

• 1. Outpatients
• 2. Patient survey
• 3. Chemotherapy
• 4. Extend support
• 5. Funding