1. Skin Cancer and Rehabilitation Report to Skin NSSG Sally Donaghey Macmillan AHP Lead, Ang CN sally.donaghey@suffolkpct.nhs.uk/Tel: 01638 608218

2. Skin and Rehabilitation Lymph node dissection – risk of lymphoedema Lymph node dissection – risk of lymphoedema Disease and treatment related management issues – nausea/vomiting; fatigue, weight loss, mobility, pain, prosthesis, reconstruction. Disease and treatment related management issues – nausea/vomiting; fatigue, weight loss, mobility, pain, prosthesis, reconstruction. Supportive care is key element of clinical management in skin cancer – OT, physio, prosthetics (IOG 2006) Supportive care is key element of clinical management in skin cancer – OT, physio, prosthetics (IOG 2006)

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. Establishment of evidence base and National Cancer Rehabilitation Pathways. Establishment of evidence base and National Cancer Rehabilitation Pathways. Development of tumour specific local rehabilitation pathways Development of tumour specific local rehabilitation pathways Need for pathways to be integrated into main care pathway and practice. Need for pathways to be integrated into main care pathway and practice.

4. Workforce Mapping

5. 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? Variablity in specialist service provision between localities Variablity in specialist service provision between localities –Consider referral pathways Setting - 53% Acute. 2009 figures indicate slightly higher then national average cancer rehab services in community Setting - 53% Acute. 2009 figures indicate slightly higher then national average cancer rehab services in community –Care closer to home?

8. Rehabilitation Triggers

9. Rehabilitation Triggers.. Lymphoedema – Lymph node dissection, risk assessment for lymphoedema Lymphoedema – Lymph node dissection, risk assessment for lymphoedema Physiotherapy – Difficulties with movement, weakness, fatigue, exercise advice and information. Physiotherapy – Difficulties with movement, weakness, fatigue, exercise advice and information. OT – Difficulties with ADL, leisure and work, functional assessment, equipment needs OT – Difficulties with ADL, leisure and work, functional assessment, equipment needs Dietietics – Nutrition, appetite, nausea, weight loss/gain, fatigue, swallowing Dietietics – Nutrition, appetite, nausea, weight loss/gain, fatigue, swallowing SLT – Swallowing, impaired speech SLT – Swallowing, impaired speech Prosthetics Prosthetics

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

11. National Rehabilitation Care Pathway - Lymphoedema

12. Prevalence of Lymphoedema in Melanoma Urist et.al. Cancer (1983) Urist et.al. Cancer (1983) –Inguinal LND 26% leg oedema –Axillary LND 1% arm oedema –Total group 8% oedema Wrone et.al. Arch Dermatol (2000) Wrone et.al. Arch Dermatol (2000) –SLNB (axillary and inguinal) 1.7% Starritt et.al. Ann Surg (2004) Starritt et.al. Ann Surg (2004) –ALND 10% –ALND + RT 53% De Vries et.al. Euro Jnl Surg Onc (2006) De Vries et.al. Euro Jnl Surg Onc (2006) –SLNB 6% –SLNB + groin dissection 64% Sabel et.al. Surgery (2007) Sabel et.al. Surgery (2007) –ILND 30% De Vries et.al. Ann Surg Oncol (2009) De Vries et.al. Ann Surg Oncol (2009) –SLNB (axillary and inguinal) 8.9% –CLND (axillary and inguinal) 37% Chang et.al. Ann Surg Oncol (2010) Chang et.al. Ann Surg Oncol (2010) –ILND 30% mild 15% moderate

13. Costs of lymphoedema 472 melanoma incidence p.a in Anglia CN (ECRIC accessed 21.11.11) 472 melanoma incidence p.a in Anglia CN (ECRIC accessed 21.11.11) Lymphoedema related cellulitis: Lymphoedema related cellulitis: –In pt £700 = 2.03 bed days –2 GP consultations pp/p.a. £100 –Provision of diuretics pp/p.a. (Todd et.al. Jnl Lymph 2010) NHS In pt £365-482 per day NHS In pt £365-482 per day New Pt £153-227 New Pt £153-227 FUP £69-115 FUP £69-115 Intensive 10 day programme @ 1hr per day £844-1196 Intensive 10 day programme @ 1hr per day £844-1196 Arm Sleeve £15-29 Arm Sleeve £15-29 Glove £38-65 Glove £38-65 Below Knee Stocking £22-35 Below Knee Stocking £22-35 Full Thigh £50 pair (Macmillan NLCN Lymphoedema Project 2007-10) Full Thigh £50 pair (Macmillan NLCN Lymphoedema Project 2007-10)

14. Key Points NICE (IOG 2006) NICE (IOG 2006) –Lymphoedema Therapist as part of extended MDT. –Access to lymphoedema services as required Best Practice for the Management of Lymphoedema (Lymphoedema Framework 2006) Best Practice for the Management of Lymphoedema (Lymphoedema Framework 2006) –Those at risk identified early – staff awareness and knowledge of appropriate pathway –Pts and carers provided with information/education for early signs and management NCAT (Lymphoedema Rehabilitation Care Pathway 2009) NCAT (Lymphoedema Rehabilitation Care Pathway 2009) –At risk pts should be screened and advised of risks –At risk pts to be provided with information of signs/symptoms and encouraged to make early presentation.

15. Barriers to Rehabilitation Implementation. AHP attendance at MDT/clinics AHP attendance at MDT/clinics Awareness of rehabilitation needs Awareness of rehabilitation needs Co-ordination of rehabilitation needs Co-ordination of rehabilitation needs Lack of resources Lack of resources

16. What Can the NSSG Do? NSSG Workplan and guidelines NSSG Workplan and guidelines Endorsement of needs analysis and service development Endorsement of needs analysis and service development Skin Care pathway – specific reference to rehab Skin Care pathway – specific reference to rehab Locality/clinician engagement Locality/clinician engagement Audit of referrals/interventions/patient surveys Audit of referrals/interventions/patient surveys

17. Useful Links Local Skin Rehabilitation Pathway: http://www.angliacancernetwork.nhs.uk/documents/AngCN- CCG- PS28%20Rehabilitation%20Pathway%20for%20Skin%20Canc er_v2.pdf Local Skin Rehabilitation Pathway: http://www.angliacancernetwork.nhs.uk/documents/AngCN- CCG- PS28%20Rehabilitation%20Pathway%20for%20Skin%20Canc er_v2.pdf NCAT. Supporting and Improving Commissioning of Cancer Rehabilitation Services Guidelines: http://ncat.nhs.uk/sites/default/files/NCAT_Rehab_Commissio ning.pdf NCAT. Supporting and Improving Commissioning of Cancer Rehabilitation Services Guidelines: http://ncat.nhs.uk/sites/default/files/NCAT_Rehab_Commissio ning.pdf http://ncat.nhs.uk/sites/default/files/NCAT_Rehab_Commissio ning.pdf http://ncat.nhs.uk/sites/default/files/NCAT_Rehab_Commissio ning.pdf NICE IOG 2006: http://guidance.nice.org.uk/CSGSTIM/Guidance/Standard2006 /pdf/English NICE IOG 2006: http://guidance.nice.org.uk/CSGSTIM/Guidance/Standard2006 /pdf/English