Transcript Colorectal Cancer and Rehabilitation

Breast Cancer:
Rehabilitation and
Lymphoedema Services
Breast NSSG Educational Meeting
10 February 2012
Sally Donaghey
Macmillan AHP Lead, Ang CN
[email protected]/Tel: 01638 608218
What is rehabilitation in
cancer?
Supports the patient; contributes to adaptation to
their condition; with the intention of maximising
function, independence and quality of life.
 Unique
 Ability to be anticipatory
 4 stages:
Rankin 2008, NCAT 2009
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Preventative
Restorative
Supportive
Palliative
Issues and Initiatives in
Rehabilitation
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Cancer rehabilitation nationally is poorly developed,
evidenced and under recognised/utilised.
Publication of National Cancer Rehabilitation
pathways and evidence guide.
Development of tumour and symptom specific local
rehabilitation pathways
Need for pathways to be integrated into main
care/referral pathways and practice
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Guidance/Protocols at trusts as per pathway
Services directory – links to local pathway
Audits
Patient/User experiences
Workforce Modelling
Breast Cancer and
Rehabilitation
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Evidence based Rehabilitation Care Pathway – local
version agreed by NSSG 2010
Optimise treatment (RoM post tx, lymphoedema
pre-emptive assessment and advice)
QoL, ADL, physical, social, psychological and
functional support
23 hour surgery – enhanced recovery
Cost-effectiveness/benefits realisation – reduce
hospital stays/interventions, prevent re-admission,
vocational rehabilitation, economic independence.
QIPP
NHS Outcomes Framework 2012/13
Workforce Mapping
Workforce Mapping cont..
Findings
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Relatively low numbers of AHP’s for
population against national average
– Unmet need or
– Need provided by generalist workforce?
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Variability in specialist service
provision between localities
– Consider referral pathways
Workforce Modelling –
Breast ANG CN Incidence 2008 = 2474
Lymphoedema Therapists
Total
FTE
21.9
FTE by professional group, showing break down by pathway
stages
30
Pal & EoL
25
Survivorship
Physiotherapists
Total
FTE
28.4
FTE
Treatment
20
Diagnosis
Pre Diagnosis
15
10
Occupational Therapists
Total
FTE
15.8
5
0
Diet
Lymph
OT
Physio
SaLT
Physiotherapy
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Pre-op assessment: ROM, muscle tone, pre-existing
issues.
Optimise physical and respiratory fitness
Post-op exercise advice and education
Enable RT
Exercise and well-being
Mobility
Reduce impact of side effects
Reduced risk of breast cancer specific mortality and
recurrence
Reduced hospital stays/GP appointments
NCAT 2009, Macmillan Physical Activity Evidence Review 2011
Physiotherapy
NICE Guidance
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Arm mobility
1.13.4 All breast units should have written local guidelines
agreed with the physiotherapy department for postoperative
physiotherapy regimens.
1.13.5 Identify breast cancer patients with pre-existing
shoulder conditions preoperatively as this may inform further
decisions on treatment.
1.13.6 Give instructions on functional exercises, which should
start the day after surgery, to all breast cancer patients
undergoing axillary surgery. This should include relevant
written information from a member of the breast or
physiotherapy team.
1.13.7 Refer patients to the physiotherapy department if they
report a persistent reduction in arm and shoulder mobility
after breast cancer treatment.
NICE 2009 (Clinical Guideline CG80)
Physiotherapy
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An RCT of a12 week group exercise sessions for women with
early stage breast cancer as an addition to standard care.
Found significant improvements in physical functioning, active
daily living, shoulder range of movement, cardio-vascular
fitness, positive mood, and breast cancer-specific quality of
life. There were no adverse events reported.
Evidence that the intervention group spent fewer nights in
hospital and made fewer visits to their GP than the control
group. 10% in intervention group and 20% in control group
reported at least one night in hospital
72% and 84% respectively reported at least one visit to their
GP.
Potential for cost savings to the NHS
Mutrie, Campbell et al. Benefits of supervised group exercise programmes for women being treated for early stage breast
cancer: pragmatic randomised controlled trial. BMJ. 2007.334:517; Macmillan 2011.
Workforce Modelling
Specialist Lymphoedema Practitioners
Locality
WTE (Actual)
WTE (Modelled)
Beds
Cambs
GTYW
Norfolk
Peterborough
Suffolk
Total
1.35
1.35
1.05
1.05
1.0
0.95
6.75
2.3
4.3
1.8
7.2
1.4
5.0
22.0
Modelled against Actual Provision
Actual WTE Specialist Posts vs Modelled Posts
25
20
WTE
15
Actual
Modelled (NCAT)
10
5
No
rfo
lk
Su
ffo
lk
Ca
m
bs
W
G
TY
Be
ds
Pe
te
rb
or
ou
gh
0
Further Modelling
(Moffatt 2003)
Secondary
Prevalence
at 1.33/1000 Lymphoedema
(@ 66%)
Pop
Recommended
Workforce @
150
pts/practitioner
Actual
Specialist WTE
in Cancer Care
Beds
398
263
1.75
1.35
GTYW
285
188
1.25
1.05
P’boro
230
151
1.0
1.0
Norfolk
1017
671
4.47
1.05
Suffolk
800
528
3.52
0.95
Cambs
819
540
3.6
1.35
Lymphoedema
http://wales.gov.uk
Lymphoedema
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Swelling due to damage/failure of the lymphatic
system
Major causes/risks (secondary):
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Trauma eg surgery, radiotherapy
Disease eg mets, infiltration, obstructive pressure
Infection including wound complications
Immobility/obesity
Impact:
– Physical
– Psychological
– Socio-economic
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Chronic, incurable, debilitating.
Lymphoedema and Breast Cancer
Management of Patients at Risk
of Lymphoedema
International Consensus – Best Practice for the Management of Lymphoedema –
Lymphoma Framework (2006)
Lymphoedema
NICE Guideline
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Lymphoedema
1.13.1 Inform all patients with early breast cancer
about the risk of developing lymphoedema and give
them relevant written information before treatment
with surgery and radiotherapy.
1.13.2 Give advice on how to prevent infection or
trauma that may cause or exacerbate
lymphoedema to patients treated for early breast
cancer.
1.13.3 Ensure that all patients with early breast
cancer who develop lymphoedema have rapid
access to a specialist lymphoedema service.
NICE 2009 (Clinical Guideline 80)
Signs and Symptoms
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Clothing/Jewellery becoming tighter
Feelings of heaviness, tightness,
fullness, stiffness
Aching
Observable swelling
International Consensus – Best Practice for the Management of Lymphoedema – Lymphoma Framework
(2006)
Interventions
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Assessment
Discussion
Skin care
Exercise/mobility
Compression garments
Multi-layer bandaging
Lymphatic drainage
Support
Self-management
How big is the problem?
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Moffatt 2003:
– 1.33/1000 prevalence total population all
lymphoedema
– 5.4/1000 >65
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NICE 2002:
– Breast cancer prevalence 25-28%
– Anglia – 600 pts at risk year on year
How big is the problem?
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Incidence rates vary from 2-65%
SLNB
– 8% 3yrs; 4.6% 10yrs
ALND
– 14% 3yrs; 34% 10yrs
Mixed tx sample:
1yrs
2
3
4
200ml
LVC
40
56
66
88
10% LVC
22
36
43
55
Armer (2010), Shah and Vicini (2011), Ashikaga et al (2010), Wernicke et al (2011)
What is the answer?
 Awareness
Early
Intervention
 Recognise
the impact
Barriers
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Awareness of rehabilitation needs
AHP attendance at MDT/clinics
Co-ordination of rehabilitation needs
Commissioning of rehabilitation
Network Guidelines –
treatment/diagnostic focus
Lack of resources
What Can the
NSSG Do?
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NSSG Workplan
Breast Care Pathway – specific reference to
rehab
Locality/clinician engagement
Rehabilitation awareness
Audit of referrals/interventions/patient
surveys
Links and References
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NCAT(2009). Supporting and Improving Commissioning of Cancer Rehabilitation Services Guidelines:
http://ncat.nhs.uk/sites/default/files/NCAT_Rehab_Commissioning.pdf
NCAT(2009). Cancer Rehabilitation Services Evidence Review:
http://ncat.nhs.uk/sites/default/files/NCAT_Rehab_EvidenceReview.pdf
NCAT (2012) Cancer and Palliative Care Rehabilitation Evidence Review- Update:
http://ncat.nhs.uk/sites/default/files/NCAT_Rehab_EvidenceReview__2012FINAL24_1_12.pdf
NICE Supportive and Palliative Care IOG 2006: http://www.nice.org.uk/nicemedia/live/10893/28816/28816.pdf
DoH (2011) NHS Outcomes Framework 2012/13:
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_131723.pdf
QIPP: https://www.qippeast.nhs.uk/
NCAT (2011) Cancer Rehabilitation Workforce Model:
http://ncat.nhs.uk/sites/default/files/NCAT%20Rehab%20Workforce%20model%20Briefing%20Paper.pdf
Macmillan (2011) The importance of physical activity for people living with and beyond cancer: a concise evidence review:
http://www.macmillan.org.uk/Documents/AboutUs/Commissioners/Physicalactivityevidencereview.pdf
NICE (2009) Breast Cancer (Early and Locally Advanced) Clinical Guidance 80: http://www.nice.org.uk/guidance/CG80
Mutrie, Campbell et al. Benefits of supervised group exercise programmes for women being treated for early stage breast
cancer: pragmatic randomised controlled trial. BMJ. 2007.334:517
Welsh Assembly (2008) Strategy for Lymphoedema in Wales:
http://wales.gov.uk/docs/dhss/publications/091208lymphoedaemastrategyforwalesen.pdf
Lymphoedema Frameworrk. Best Practice for the Management of Lymphoedema. International Consensus. London: MEP Ltd
(2006)
Williams AF. Franks PJ. Moffatt CJ. (2005) Lymphoedema: estimating the size of the problem. Palliative Medicine. 19(4):30013.
Shah and Vicini (2011) Breast cancer-related arm lymphedema: Incidence rates, diagnostic techniques, optimal
management and risk reduction strategies. Int J Rad Biol. Phys. 81 (4) 907-914.
Armer and Stewart (2010) Post breast cancer lymphedema: incidence increases from 12 to 30 to 60 months. Lymphology
43. 118-127
Ashikaga et.al. (2010) Morbidity results form the NSABP-32 trial comparing sentinel lymph node dissection versus axillary
dissection. J Surg Oncol. 102,111-118
Wernicke et.al. (2011) A 10 year follow-up of treatment outcomes in patients with early stage breast cancer and clinically
negative axillary nodes treated with tangential breast irradiation following sentinel lymph node dissection or axillary
clearance. Breast Cancer Res Treat, 125. 893-902
With thanks to Rosie Collcott, Peterborough and Stamford Hospitals NHS Foundation Trust and Tracy Hancock,
Cambridgeshire Community Services NHS Trust