1. YCN MSCC Pathway Implementation of NICE CG75 Level 1: Early warning Dr Rob Turner Chair YCN MSCC Group Units to localise slides to clarify responsibilities of the MSCC Coordinator and specify points of referral from the initial triage to the MSCC Coordinator and then on to the AOL / AOT

2. YCN MSCC Competency for Initial Identification The Local Cancer Unit Acute Oncology Team (AOT) take responsibility for the diagnosis and transfer of appropriate patients Competency has been defined for the staff groups involved in the diagnosis, management and treatment of MSCC patients Staff involved in the initial identification of potential MSCC including A&E and Acute medical Unit staff Competency a) a) Knowledge and understanding of which patient groups are at a higher risk of developing MSCC b) b) Knowledge and Understanding of the signs and symptoms of MSCC c) c) Understanding of the appropriate aspects of the MSCC pathway d) d) Escalation process to the Local MSCC Coordinator Education E - Learning level 1- Early Warning

3. What is MSCC? Malignant (metastatic) Spinal Cord Compression Basically a complicated bony metastasis as a consequence of advancing malignancy

4. Mechanism Predictable symptomatic course –Three phases of patho-physiology Vertebral infiltration/expansion Axonal compression Vascular compromise (esp. mid thoracic) –Arterial –Venous –Influenced by Vertebral anatomy (local & spinal) Biomechanical compromise

5. MSCC: Anatomical heterogeneity

6. MSCC

7. MSCC: Symptomatic course Bone pain Radicular pain –Band-like/belt-like –Sciatica Motor weakness –With preserved gait function –With paraplegia –With paralysis Sensory loss Autonomic dysfunction (loss of sphincters)

8. MSCC: Motor symptom evolution Invariably presents late

9. MSCC: Time-course (from first symptom) Symptom Rate of change Motor weakness 40% presentation 50% within 7 days 80% within 80 days Loss of gait function 50% within 38 days Paralysis 50% within 12 days

10. Outcome by ambulation Ambulant state pre-RT Ambulant post-RT Walking90% Walking with help 60% Unable to walk 40% Paraplegic10%

11. Goals of YCN MSCC Pathway 1. Patient education for early presentation 2. Diagnosis at an early phase of process 3. Treatment with greater success 4. Improved function and QoL E – Learning Training Packs on the YCN website Level 1- Early Warning Level 2 – Diagnostic Level 3 – Specialist Intervention

12. Patient Education Predictable clinical course Suitable for screening –Symptomatic patients –MRI imaging for those who need –Rapid access to diagnosis and treatment

13. Patient Education Concerns –Bony metastases present in 30% cancer patients –Non-malignant back pain common in population –Generalised weakness common in advanced cancer Solution –Identify high risk groups and target them Improved specificity of screening Reduced anxiety in patient population as a whole

14. High Risk Patient Groups Any patient who has had prior MSCC Any patient with known bony metastases at any site from any primary site Known cancer awaiting investigation for suspicious spinal pain Tumour site-specific recommendations –Prostate:Hormone resistant prostate cancer –Renal:Metastatic renal cell cancer –Lung:Any metastatic lung cancer –Breast:Any metastatic breast cancer –Myeloma:Any myeloma

15. High-risk patient groups High-risk patients identified clinically Face-to-face discussion Provided with MSCC Early Warning Leaflet Features of MSCC –What to do if they are worried –How to access help Via 24-hour SINGLE POINT CONTACT NUMBER Insert local contact point

16. LTHT MSCC Early Warning Booklet – Substitute Local Version & Title

17. Overall goals Earlier diagnosis and treatment –Outcomes linked to pre-treatment status Faster access to diagnostic MRI –Suspected MSCC within 24 hours VBM within 7 days Rapid escalation to definitive therapy –Proven MSCC within 24 hours VBM within 7 days Definitive therapy case-appropriate Co-ordinated case-appropriate rehabilitation

18. MSCC Pathway Components 1.Education and early warning 2.Triage 3.Diagnosis & generic care 4.Specialist intervention Spinal surgery Spinal surgery Radiotherapy Radiotherapy 5.Rehabilitation

19. MSCC symptoms & signs

20. Triage: Mechanism (Insert Local Process Below) Nursing staff will take basic details Escalate to on-call clinical oncology team –In hours to be handled immediately Contact - Insert Local Information –Overnight (Local Number) Escalate to resident/duty ward medical staff –Insert Local Procedure –Priority Immediate or deferred? –Ward or clinic for clinical assessment Is MRI required and how quickly?

21. Nursing Triage (Insert Local process) Question & Answer data recording form –Patient & referrer details –LOCATION & CONTACT DETAILS –Patient symptoms/features –Advice/instruction as to what will happen next Complete for ALL MSCC related calls Hand-over to medical staff / MSCC Coordinator

22. Local Process for Escalation to Local MSCC Co-ordinator

23. Triage: Need for MRI Probability MRI shows neural compression (after Lu, J Sup Care 2005;3:305-312) Neurological deficit PresentAbsent High-risk & suspicious pain 81%69% Suspicious pain only 44%33%

24. Triage: Endpoints MSCC possible – Refer to Local MSCC Co-ordinator –Urgent clinical assessment –Urgent in-patient MRI (within 24 hours) Admission may be required MSCC less likely but VBM possible –Prompt outpatient assessment –Prompt outpatient MRI (within 7 days)

25. Further information YCN Website EQMS YCN MSCC Lead (rob.turner@leedsth.nhs.uk)