Meeting of the London Cancer Breast Cancer Pathway Board meeting Date: Wednesday 20 th September 2017, 15:00-17:00 Venue: 6 th floor east, 250 Euston Road, London, NW1 2PG Chair: Rebecca Roylance 1. Welcome and apologies Apologies mentioned. 2. Minutes of last meeting and matters arising The board accepted the previous minutes as an accurate record. Radiology guidelines; o This work is ongoing. The guidelines will be discussed at the next meeting. Chest wall guidelines; o There were no additional comments from the board. The guidelines have now been signed off by the board. Systemic treatment for breast cancer guidelines o These guidelines are now complete and ready to upload Radiology guidelines to be discussed at the next board meeting 3. Metastatic breast cancer report The board briefly discussed the metastatic breast cancer report which looks at ways to improve the pathway. RR requested that the group review the paper which needs to be circulated to the group, share with their teams and feedback their comments at the next meeting. RR suggested teams give an update on where they are with their metastatic service and how to optimise the pathway. AP explained that they have a metastatic coordinator and metastatic CNS at BHRUT. AP discussed the secondary breast cancer pledge; which is a service improvement project lead by Breast Cancer Now reviewing the metastatic pathway. One of the outcomes is a booklet given to patients when they come to the unit detailing what they can expect. BHR will be having an event to launch the work. Barts did the pledge a few years ago and are now about to re-review the work. LCF mentioned she had not received any information about the pledge when attending clinics at Barts. JJ will look into this further. JJ will be attending a pledge lead focus group in November. At the next board, Barts and BHR will discuss their launches. Metastatic breast cancer report to be circulated to the board and discussed at the next meeting with comments
Trusts to update on their metastatic service Secondary cancer pledge launches at BHR and Barts to be discussed at the next board meeting 4. Denosumab update Pinkie Chambers lead this project which allows patients to self-administer Denosumab. The new model was discussed at the last NCL board meeting and has been approved with an implementation date of 1 st October agreed, for all Trusts in NCL. The pilot results found that patients were happy with selfadministration, it was easy and no risks were reported. The new model has been costed and found to be cost saving. New model costing document to be sent to members. The board are aware that not all patients would want to self-administer so they will stay on their current administration pathway. Once this has been implemented across NCL the group will work to get implementation in NEL agreed. HS is developing the protocols and processes document to assist the implementation. The board felt that GP s will require this information very soon. The new model costing document to be sent to board. 5. Audits Risk reducing mastectomy audit o AP explained that this audit requires more feedback from hospitals. AP and his team are awaiting feedback from HUH and Whittington. VW to discuss with HUH team at MDT meeting. ES will send the information to the appropriate person at Whittington. o AP will send reminder email to the group for more responses. Oral chemotherapy audit o MN presented initial details on the Vinorelbine audit. To date, the audit has reviewed 140 patients at Barts and UCLH over the last few years. Patient are usually administered Vinorelbine on their 2 nd or 3 rd line of therapy. o The audit showed a difference in how the chemotherapy is administered. At Barts it is almost always via IV. At UCLH the route of administration was more balanced between IV previously and oral. MN felt that the reason Barts patients were given Vinorelbine IV could be because the cost to administer orally was previously high and although it has become cheaper, behaviours and protocols have not changed. o The audit highlighted that there were some patients that stopped treatment as they had finished the course however the licensed indication is only stopping due to progression or toxicity. MN found that the drug also isn t being used as per its license; weekly and continuously. However some clinicians feel it s too toxic to do this o MN to look at efficacy and to check if anything has been published on different dosing o MN will contact ES and Fharat Raja for Whittington and NMUH data to add to the audit. MN will present this completed data at the next meeting.
Prosthetics audit o JJ went through the prosthetics audit results with the board. There were 85 responses overall, mainly patients from Barts and UCLH. o The audit was undertaken to see whether the recommendations that came out from the initial prosthetics audit had been implemented and whether the service for women had improved o Overall the audit showed that the service has improved but still has areas for development. The teams have introduced more choice for patients and where possible made sure reps are offering the appropriate products. o While the feedback is better JJ felt the team should be receiving 100% on some key questions, so those areas will have to be looked into further. o JJ explained that it is difficult to get a complete understanding of the reasons for some areas of low feedback as no qualitative questions were on the questionnaire. At the time of creating the survey it was felt that quantitative feedback would be better for analysis. However the team would need to look at the areas with low scores in more detail to ask services what happened. o The group discussed whether the nurses should have a checklist of everything they have gone through with the patient and a copy then given to the patient and kept in the notes as they may not realise they were offered options from different companies. o The board discussed giving patients their keyworker contact information in their discharge documents. o DG discussed the need to design a good data extracting questionnaire so no need to re-audit. DG suggested mixing quantitative and qualitative questions to design the best questionnaire. DG also highlighted that there is a lot of information given to patients when they are discharged. JJ explained that the breast care nurses will continue to monitor this service and will need to re-audit at some point with qualitative data to look at the areas and units with lower scores. o The audit results will be circulated to the board. Risk reducing mastectomy audit; HUH and Whittington to send data to AP. AP will send reminder email to the group for more responses. Vinorelbine audit; MN to contact ES and Fharat Raja for Whittington and NMUH data. MN to present complete data at next board meeting The prosthetic audit results will be circulated to the board. 6. MDT Improvement The board discussed the current MDT processes and whether there s a better way to work. RR presented the London cancer MDT Improvement report s recommendations. The board discussed the use of radiology and pathology time at the meeting, triaging and preparing for MDT meetings, missing information, IT support (video conferencing) and data capturing. The group also discussed Martin Gore s paper regarding MDTs. SW to circulate Martin Gore s letter to the board. RR explained the need to focus on difficult and metastatic cases and to have processes streamlined to reduce repeated and unnecessary discussions and protocolised pathways for early breast cancer patients. Patients could be triaged before the MDT meeting, with a team agreeing which patients will
go on to an agreed diagnostic or treatment pathway without wider discussion. This pathway would need to be developed and would need to decide who would attend the triage meetings. The group agreed that time is required in job plans and funding is needed for attendance at this extra meeting. JF noted that the national guidelines mention every case should be discussed and everyone should be attending the MDT meetings. AP; discussed a recent audit which showed a variation in surgery offered to patients. AP believes the MDT can challenge things like this so has concerns about cases not going to MDT. Some of the team felt that to drive quality it is appropriate to discuss each case. Although it was felt many discussions are not relevant to some members of the MDT. Some people suggested that the pathologist doesn t need to be there as the reports can be read out. The team discussed how expensive the AHPs time is as they re not needed for many discussions, they tend to be involved in complex cases. VW explained that protocolised pathways would work for screening patients and early cancers. And patients should only be added to MDT when they have had a full work up. Currently patients tend to be discussed week by week whilst waiting for results. VW explained that this is a way to make sure patients don t fall through the net. During this time patients already receive provisional plans this is like placing a patient on a protocolised pathway. AP believes that the MDT meetings are lengthy due to members not being fully prepared for the discussions. It was felt that the person who has seen the patient should present the case as they know the patient however this may not always be feasible especially for screening patients. The team discussed that the MDT is a recommendation. The clinician is responsible for the treatment decision. Martin Gore s paper expresses that there is too much leaning on the MDT. The team discussed how the protocolised pathway would work. The group questioned who would be adding patients to this pathway, would this need to be signed off by at least 2 clinicians and how would it be audited? It was suggested to pilot protocolising patients whilst still placing patients on the MDT agenda to check if the outcomes are the same. However some people felt it would be difficult to get a team of people together for pre-mdt meeting. VW and JF agreed to be part of a working group to discuss protocolisation further and to develop a strategy for a pilot. SW to send MDT Improvement link to board. SW to circulate Martin Gore s letter to the board. SW to send MDT Improvement link to board. VW and JF to be involved in working group for MDT Improvement 7. Updating guidance and education event The next Breast Cancer Education event will provisionally take place February/March 2018. There will be talks/presentations in the morning. In the afternoon there will be three breakout rooms for Surgery, Oncology and Radiology to review and update guidance. It was suggested to include a talk about the recovery package, treatment summaries and stratified pathways. And to also include the GP perspective, consequences of treatment and a session on late effects.
There is a working group planning the event. 8. Gap analysis update Visits outstanding o Everyone in NCL has been visited. The findings will be shared. Visits to BHR, PAH and HUH are being arranged UCLH/Whittington collaboration o UCLH and Whittington are in talks about how to work together. Radiological capacity is an issue which is being discussed. 9. Screening update Barts Health screening service has been taken over by RFH. There are talks about where this screening service will take place. The screening update will be presented at the next meeting by SD. The screening update will be presented at the next meeting by SD 10. AOB Adjuvant bisphosphonates guidelines; all teams confirmed that they are prescribing it as per the guidelines. The group discussed whether there is a need for plastic surgeons at every MDT meeting. Some felt it may not be appropriate or feasible. The group agreed that it should be something to strive for to ensure timely access to plastic surgeons. May need to dedicate a section of the MDT agenda to patients potentially for plastic surgery input. 11. Next Meeting 11 th December 2017, 9.30am-11.30am, 6 th Floor East meeting room, 250 Euston Road, London NW1 2PG ACTION LOG Action reference Sept 2016-10 Sept 2016-11 Feb-01 Action Owner Date Due Mastectomy audit results to be presented MA Feb 2018 at the next Network Education Day Trust representatives to discuss the Trust 06-Dec consent audit with their teams and ask a reps 2016 named oncologist to carry out the audit to feed back names at the next meeting Update Dec: Deferred as Trusts at various stages of implementing new national consent process TD and ES to work to resolve family history referrals issue in BHRUT area TD/ESt 22-May- 17 Status Deferred to Sept 17
Feb-06 Feb-07 May-01 May-03 May-04 May-05 May-07 Sept01 Sept02 Sept03 Sept04 Sept05 Systemic guidelines to be circulated to medical oncologists for approval Update May 17: Comments from RFH not yet received. RC to update radiology guidelines within surgical guidance Pathway board reps to ensure audit completed by the RR MDM representative SC to circulate summary of lymphoedema commissioning guidance Board members to send MN comments on the oral chemotherapy audit proforma: Mark.nathan@bartshealth.nhs.uk HS to feed back on 2ww patient choice work at a future meeting. Breakout session leads to design session for education event JG surgery, ESp oncology, EH/MB psychology, CM/CG nursing, MN trainees Metastatic breast cancer report to be circulated to the board and discussed again at the next meeting with comments Trusts to update on their metastatic service Secondary cancer pledge launches at BHR and Barts to be discussed at the next board meeting The new model costing document to be sent to team. Risk reducing mastectomy audit; HUH and Whittington to send data to AP. AP will send reminder email to the group for more responses. Vinorelbine audit; MN to contact ES and Fharat Raja for Whittington and NMUH data. MN to present completed data at next board meeting ESp 22-Mar- 17 RC Update Sept 17 Trust Sept 17 reps SC Sept 17 All June 17 New deadline June 17 Deferred HS Sept 17 Deferred Session leads Dec 17 SW 06/10/17 AP/JJ 11/12/17 SW 06/10/17 AP 18/10/17 MN 11/12/17 Sept06 The prosthetic audit results will be SW 06/10/17 circulated to the board. Sept07 SW to circulate Martin Gore s letter to SW 06/10/17 the board. Sept08 SW to send MDT Improvement link to board. SW 06/10/17
Sept09 Sept10 VW and JF to be involved in working group for MDT Improvement The screening update will be presented at the next meeting by SD VWH/JF 01/11/17 SD 11/12/17 Attendees Name Initials Trust/Organisation Mark Nathan MN Barts Health Esther Hanson EH RFH Jasdeep Gahir JG NMUH Antony Pittathankal AP BHR Patricia Dean PD Patient Representative Faye Gishen FG RFH Joanne Franks JF UCLH Ash Mosahebi AM RFH Deborah Glover DG Patient Representative Kate Cavanagh KC NELCSU Lesley Cousins-Forrester LCF Patient Representative Sherrice Weekes SW London Cancer Rebecca Roylance RR UCLH Tina Dahs TD GP Virginia Wolstenholme VW Barts Health Emma Spurrell ES Whittington In attendance Name Initials Trust/Organisation Jacky Jones JJ Barts Health Apologies Name Initials Trust/Organisation Muhamed Al-Dubaisi MA RFH Rob Stein RS UCLH Ros Crooks RC RFH Claire Grainger CG PAH Claire Mabena CM RFH Mary Burgess MB UCLH Helen Saunders HS London Cancer Steve Davies SD RFH