1. The role of cordotomy in the management of mesothelioma-related pain in the United Kingdom (The INPIC Pilot study)
Matthew K Makin
Consultant in Palliative Medicine
Marlise Poolman
Specialist Registrar in Palliative Medicine
Collaborators
Pain Group, Marie Curie Palliative Care Institute Liverpool

2. INPIC Pilot: Cordotomy
Makin MK, Ellershaw JE, Leach A, Poolman M, Sharma ML, Nurmikko T, Makin RD, Bridson J, Hugel H
NCRI SuPaC Lung Cancer Research Grant approved June 2008
61.4% of Total FEC (£ )

3. INPIC Background
Marie Curie Palliative Care Institute Liverpool Pain Group: 2005
Invasive Neurodestructive Procedures in Cancer Pain
NRCI Palliative Care Studies: Pain Group: Nov 2007
The role of cordotomy in the management of mesothelioma-related pain in the United Kingdom (The INPIC Pilot study)

4. INPIC Pilot: Cordotomy
Mesothelioma: 1800 new cases pa
Difficult pain syndromes
National Mesothelioma Framework (2007)
Cordotomy
Inequity in commissioning and availability
Level of evidence poor
Lack of consensus on use
Unquantified associated morbidity

5. Project Outline

6. 1. Literature review 2. Consensus study 3. Registry study
Measuring availability and attitudes
Developing clinical guidelines
3. Registry study
National/EU/International
Dendrite Clinical Systems

7. 1. Literature review 2. Consensus study 3. Registry study
Measuring availability and attitudes
Developing clinical guidelines
3. Registry study
National/EU/International
Dendrite Clinical Systems

8. Consensus study Letter of introduction
Selection of Experts/Participants

9. 1. Screening Questionnaire
2. Delphi study
3. Nominal Group Technique

10. Screening Questionnaire
Canvas
Availibility/Awareness
Grey literature
Current policies/guidelines
Telephone interview
Recorded on Teleform Sheet

11. Screening Questionnaire
Record
Demographics
Experience/Use of cordotomy
Request
Contributions towards Systematic literature review
Other known experts

12. Delphi study Measuring consensus
What is the role of cordotomy in the management of mesothelioma-related pain in the UK?
Web-based questionnaire
Hosted by the Pain Research Institute

13. Delphi study Ranking agreement with statements
Share ranking and reconsider
Re-ranking of statements
Several phases until consensus

16. Nominal Group Technique
Developing consensus
Where does cordotomy fit in the management of mesothelioma-related pain in the UK?
Develop clinical guidelines

17. Nominal Group Technique
Web-based questionnaire
With copy of literature review
Ranking of statements
Several phases

18. Nominal Group Technique
Cordotomy should be the first line analgesic for mesothelioma-related cancer pain (i.e. even before attempting the WHO ladder +/- adjuvants)
Cordotomy should be considered in patients on step 3 of the WHO ladder and still has uncontrolled pain at the oral morphine per 24 hr equivalent dose of: 20 mg, 50 mg, 100 mg, 150 mg, 200 mg, 500 mg (all scored Yes, No, Maybe)

19. Nominal Group Technique
National Study Day
Independent moderator
‘Champions for options’ speakers
Produce draft guidelines
Outline National Registry Study

20. 1. Literature review 2. Consensus study 3. Registry study
Measuring availability and attitudes
Developing clinical guidelines
3. Registry study
National/EU/International
Dendrite Clinical Systems

21. INPIC National Registry for Cordotomy
Industry Collaboration: Dendrite Clinical Systems

22. Registry Clinical Information System Disease Registries Benefits
Research
Benchmarking Clinical Performance
National Standards for outcomes
Risk stratification to guide decision-making

23. Registries (examples)
Cardiac Surgery 
International Atrial Fibrillation Surgery Registry
Interventional Radiology
Inferior Vena Cava Filter Registry
Respiratory Medicine
British Thoracic Society (BTS) - Difficult Asthma
British Thoracic Society (BTS) - UK Sarcoidosis Registry
Surgical and Interventional Oncology
Biliary Stent Registry
International Colorectal Stent Registry
British Association of Endocrine Surgeons (BAES) National Database
Minimally Invasive Gastro-Oesophageal Cancer Surgery (MIGOCS) National Database
ROST - Registry of Oesophageal Stenting
Venous Disease
International Venous Registry

24. Step 1: Harvest data

25. Step 2 - Import Data to create 'interim' databases

26. Step 3 - Correspond, run Validation Checks for Data Consistency and Merge Data

27. Step 4 - Data Analysis, Outcome Analysis & Risk Modelling

28. Registry: Sample Database
Demographic data
Diagnosis and Oncological management
Pain/Analgesic history
Referral data
Pre-procedure Assessment
Procedure
Follow-up
Discharge
Patient Satisfaction Questionnaire
Referrer Satisfaction Questionnaire

29. Next steps
Cordotomy in Mesothelioma-related pain in the UK

30. Next steps
Other neuro-destructive procedures in cancer pain management
Cordotomy in Mesothelioma-related pain in the UK

31. Next steps Other needle-invasive procedures in cancer pain management
Other neuro-destructive procedures in cancer pain management
Cordotomy in Mesothelioma-related pain in the UK

32. Next steps Interventions in Palliative Care
Including Paracentesis, Blood transfusion, Pleural aspiration
Other needle-invasive procedures in cancer pain management
Other neuro-destructive procedures in cancer pain management
Cordotomy in Mesothelioma-related pain in the UK

33. Thank you