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Case Histories

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Image not available. Patient 1: A 74-year-old man presents to primary care with a three-month history of progressive lumbar spine pain despite analgesia and physiotherapy. The patient has localizing tenderness but no neurological deficit and this leads the GP to request an MRI spine. The MRI report is faxed urgently to primary care stating that there are findings consistent with multiple metastases present throughout the spine.

Patient 2: A 54-year-old woman with Grade 3, T2 N1 breast cancer is undergoing adjuvant FEC chemotherapy and develops nausea and dizziness. The patient is hypotensive with a temperature of 39ºC and the GP requests an urgent ambulance to direct the patient to the nearest emergency department for review.

Patient 3: A 65-year-old woman, previously fit and well, presents to her local A&E department with acute abdominal pain, weight loss, anorexia, and increasing tiredness and lethargy. She is admitted acutely to the medical assessment unit and is found on CT scan to have liver metastases.

How do acute oncology models differ within and across cancer networks?

How would differing acute oncology models support the management of the above emergency presentations?

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Background

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Image not available. Cancer is a major health issue. In the UK there are 325000 new cases of cancer diagnosed annually. There are 157 000 deaths, contributing 28% of all deaths every year. With a wealth of possible curative and life-prolonging treatments it is estimated there are 1.7 million cancer survivors.1

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The National Audit Office Hospital Episode Statistics estimate that the number of patients receiving systemic anticancer chemotherapy (SACT) has been increasing year on year since 2001/02, accounting for £1 billion expenditure annually.

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The National Confidential Enquiry into Patient Outcome and Death (NCEPOD),2 published in 2008, provided uncomfortable reading regarding the quality and safety of care for patients who died within 30 days of receiving SACT. The enquiry was set up especially to understand precisely the care pathways for this group of sick cancer patients. In only 35% of patients was the care deemed to be acceptable. In the 49% of patients where care was less than optimal, factors relating to both the organization of emergency care and the specific care delivered by each institution were identified. The National Chemotherapy Advisory Group (NCAG)3 was formed to address how care should be delivered, not only to improve the outcome of the sick cancer patient, but to also address key issues in the organization of care to improve the patient experience.

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The development of an Acute Oncology Service (AOS) in every trust with an emergency department was a key recommendation of the NCEPOD report. It described an AOS as one that brings together the expertise from oncology disciplines, emergency medicine, general medicine and general surgery to ensure the rapid identification and prompt management of all patients who present with severe complications following chemotherapy or as a consequence of their cancer. Uniquely, it also ...

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