1. Breast Cancer: Rehabilitation and Lymphoedema Services Breast NSSG Educational Meeting 10 February 2012 Sally Donaghey Macmillan AHP Lead, Ang CN sally.donaghey@suffolkpct.nhs.uk/Tel: 01638 608218

2. 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. Rankin 2008, NCAT 2009 Unique Unique Ability to be anticipatory Ability to be anticipatory 4 stages: 4 stages: –Preventative –Restorative –Supportive –Palliative

3. Issues and Initiatives in Rehabilitation Cancer rehabilitation nationally is poorly developed, evidenced and under recognised/utilised. Cancer rehabilitation nationally is poorly developed, evidenced and under recognised/utilised. Publication of National Cancer Rehabilitation pathways and evidence guide. Publication of National Cancer Rehabilitation pathways and evidence guide. Development of tumour and symptom specific local rehabilitation pathways Development of tumour and symptom specific local rehabilitation pathways Need for pathways to be integrated into main care/referral pathways and practice Need for pathways to be integrated into main care/referral pathways and practice –Guidance/Protocols at trusts as per pathway –Services directory – links to local pathway –Audits –Patient/User experiences Workforce Modelling Workforce Modelling

4. Breast Cancer and Rehabilitation Evidence based Rehabilitation Care Pathway – local version agreed by NSSG 2010 Evidence based Rehabilitation Care Pathway – local version agreed by NSSG 2010 Optimise treatment (RoM post tx, lymphoedema pre-emptive assessment and advice) Optimise treatment (RoM post tx, lymphoedema pre-emptive assessment and advice) QoL, ADL, physical, social, psychological and functional support QoL, ADL, physical, social, psychological and functional support 23 hour surgery – enhanced recovery 23 hour surgery – enhanced recovery Cost-effectiveness/benefits realisation – reduce hospital stays/interventions, prevent re-admission, vocational rehabilitation, economic independence. Cost-effectiveness/benefits realisation – reduce hospital stays/interventions, prevent re-admission, vocational rehabilitation, economic independence. QIPP QIPP NHS Outcomes Framework 2012/13 NHS Outcomes Framework 2012/13

5. Workforce Mapping

6. Workforce Mapping cont..

7. Findings Relatively low numbers of AHP’s for population against national average Relatively low numbers of AHP’s for population against national average –Unmet need or –Need provided by generalist workforce? Variability in specialist service provision between localities Variability in specialist service provision between localities –Consider referral pathways

8. Workforce Modelling – Breast ANG CN Incidence 2008 = 2474

9. Physiotherapy Pre-op assessment: ROM, muscle tone, pre-existing issues. Pre-op assessment: ROM, muscle tone, pre-existing issues. Optimise physical and respiratory fitness Optimise physical and respiratory fitness Post-op exercise advice and education Post-op exercise advice and education Enable RT Enable RT Exercise and well-being Exercise and well-being Mobility Mobility Reduce impact of side effects Reduce impact of side effects Reduced risk of breast cancer specific mortality and recurrence Reduced risk of breast cancer specific mortality and recurrence Reduced hospital stays/GP appointments Reduced hospital stays/GP appointments NCAT 2009, Macmillan Physical Activity Evidence Review 2011

10. Physiotherapy NICE Guidance 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)

11. Physiotherapy 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.

12. Workforce Modelling Specialist Lymphoedema Practitioners Locality WTE (Actual) WTE (Modelled) Beds1.352.3 Cambs1.354.3 GTYW1.051.8 Norfolk1.057.2 Peterborough1.01.4 Suffolk0.955.0 Total6.7522.0

13. Modelled against Actual Provision

14. Further Modelling (Moffatt 2003) Prevalence at 1.33/1000 Pop Secondary Lymphoedema (@ 66%) Recommended Workforce @ 150 pts/practitioner Actual Specialist WTE in Cancer Care Beds3982631.751.35 GTYW2851881.251.05 P’boro2301511.01.0 Norfolk10176714.471.05 Suffolk8005283.520.95 Cambs8195403.61.35

15. Lymphoedema http://wales.gov.uk

16. Lymphoedema Swelling due to damage/failure of the lymphatic system Swelling due to damage/failure of the lymphatic system Major causes/risks (secondary): Major causes/risks (secondary): –Trauma eg surgery, radiotherapy –Disease eg mets, infiltration, obstructive pressure –Infection including wound complications –Immobility/obesity Impact: Impact: –Physical –Psychological –Socio-economic Chronic, incurable, debilitating. Chronic, incurable, debilitating.

17. Lymphoedema and Breast Cancer

18. Management of Patients at Risk of Lymphoedema International Consensus – Best Practice for the Management of Lymphoedema – Lymphoma Framework (2006)

19. Lymphoedema NICE Guideline 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)

20. Signs and Symptoms Clothing/Jewellery becoming tighter Clothing/Jewellery becoming tighter Feelings of heaviness, tightness, fullness, stiffness Feelings of heaviness, tightness, fullness, stiffness Aching Aching Observable swelling Observable swelling International Consensus – Best Practice for the Management of Lymphoedema – Lymphoma Framework (2006)

21. Interventions Assessment Assessment Discussion Discussion Skin care Skin care Exercise/mobility Exercise/mobility Compression garments Compression garments Multi-layer bandaging Multi-layer bandaging Lymphatic drainage Lymphatic drainage Support Support Self-management Self-management

22. How big is the problem? Moffatt 2003: Moffatt 2003: – 1.33/1000 prevalence total population all lymphoedema –5.4/1000 >65 NICE 2002: NICE 2002: –Breast cancer prevalence 25-28% –Anglia – 600 pts at risk year on year

23. How big is the problem? Incidence rates vary from 2-65% Incidence rates vary from 2-65% SLNB SLNB – 8% 3yrs; 4.6% 10yrs ALND ALND –14% 3yrs; 34% 10yrs Mixed tx sample: Mixed tx sample: 1yrs234 200ml LVC 40566688 10% LVC 22364355 Armer (2010), Shah and Vicini (2011), Ashikaga et al (2010), Wernicke et al (2011)

24. What is the answer? Awareness Awareness Early Intervention Early Intervention Recognise the impact Recognise the impact

25. Barriers Awareness of rehabilitation needs Awareness of rehabilitation needs AHP attendance at MDT/clinics AHP attendance at MDT/clinics Co-ordination of rehabilitation needs Co-ordination of rehabilitation needs Commissioning of rehabilitation Commissioning of rehabilitation Network Guidelines – treatment/diagnostic focus Network Guidelines – treatment/diagnostic focus Lack of resources Lack of resources

26. What Can the NSSG Do? NSSG Workplan NSSG Workplan Breast Care Pathway – specific reference to rehab Breast Care Pathway – specific reference to rehab Locality/clinician engagement Locality/clinician engagement Rehabilitation awareness Rehabilitation awareness Audit of referrals/interventions/patient surveys Audit of referrals/interventions/patient surveys

27. Links and References NCAT(2009). Supporting and Improving Commissioning of Cancer Rehabilitation Services Guidelines: http://ncat.nhs.uk/sites/default/files/NCAT_Rehab_Commissioning.pdf NCAT(2009). Supporting and Improving Commissioning of Cancer Rehabilitation Services Guidelines: http://ncat.nhs.uk/sites/default/files/NCAT_Rehab_Commissioning.pdf 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(2009). Cancer Rehabilitation Services Evidence Review: http://ncat.nhs.uk/sites/default/files/NCAT_Rehab_EvidenceReview.pdf 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 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.pdfhttp://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 http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_131723.pdf QIPP: https://www.qippeast.nhs.uk/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 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 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/CG80http://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 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):300- 13. 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