1. Malignant Spinal Cord Compression Past, Present and Future (South East of Scotland)
Jackie Whigham
Macmillan Project Manager for Malignant Spinal Cord Compression
Edinburgh Cancer Centre
May 2010

2. Overview Facts and Figures Driver for Change Scotland’s MSCC Projects
South East Scotland MSCC Project
Jackie’s crystal ball!

3. Facts and Figures Incidence: Cancers: Symptoms: Diagnosis: Treatment:
?80/million/year
Cancers:
breast, prostate, lung, haematological, Renal, GI……….
Symptoms:
Pain (radicular), weakness, sensory loss, sphincter disturbance
Diagnosis:
MRI whole spine
Treatment:
Radiotherapy / Surgery
Prognosis:
Mobility after treatment α mobility at diagnosis
3 – 6 months (in relation to cancer stage)

4. Incidence in Relation to Cancer

5. MSCC within Spinal Column3 1
Slide 4
This diagram, demonstrates the most common levels of the spine affected by MCC with the thoracic affected in 70% of cases followed by the lumbar spine 20% the cervical last with 10% of cases 2
Copyright J. Armstrong 2006

6. Malignant Spinal Cord Compression4 1 2 3
Copyright J. Armstrong 2006

7. Driver for Change Clinical Research Audit Group 97/98 (CRAG audit)
1. Lack of recognition by primary and secondary care of the early symptoms
2. Lack of appropriate referral pathway once MSCC
suspected
3. Lack of awareness of the most effective investigation for diagnosing MSCC
Large national prospective audit that looked at 324 patients diagnosed with MCC.
Three cancer centres in Scotland with Glasgow and Edinburgh providing the largest numbers. Aberdeen also involved.
Looked at what had happened to these patient s in the course of their referral into the system. Also studied what happened to the patients post diagnosis.
A guideline for the early diagnosis recommended

8. Sequence of Events GP + hospital system 9 weeks
tells GP
Referred
1st symptom
Diagnosis
Patient 3 wks
GP + hospital system 9 weeks
months
Back pain
what’s the sequence of events?
Historically the following has taken place
The median time from the patient developing their first symptom until the confirmation of a diagnosis was 90 days - 3 months
The patient tells someone - usually their GP after a median of 25 days
and the GP refers to someone - usually a hospital doctor after a median of 20 days
The hospital doctor tries to manage the patients pain, perhaps with physio and analgesia. This type of pain is not sorted using normal alalgesia. X-ray usually is carried out of lumbar spine- This is predominantly the area that the majority of patients complain about. 70% compressions are thoracic although the pain is lumbar. X-ray is usually negative. More than 50% of the vertebral body needs to be collapsed before one can see collapse on x-ray. The next step in getting an answer is bone scanning. Not really useful. Most patients will have hot spots. If the patient has multiple hot spot levels, how does one know which level is the compressive level. You are probably looking at a picture of multiple metastases. What if it is just osteoporosis, disc disease causing marrow odoema in the vertebral body, old fracture. How can you be sure. MRI sometimes does not happen until the patient is too advanced to give good treatment outcomes and we are reduced to palliative radiotherapy or pain management using drivers and drug combinations.
Neurogenic pain - 2 months
Weakness 3 wks
Levack et al 2001 (CRAG Audit 97/98)

10. Cancer Networks in Scotland
North 1.4 million, South east 1.6, West is 2.6million

11. Local and National Education Programmes
Scottish MSCC Projects
SCAN
Regional Referral pathway ‘s
Audit
WO Scan
Management Guidelines
NO Scan
Rapid Referral Hot line
Local and National Education Programmes

13. SCAN
MSCC Steering Group

14. CHANGE TIME LINE OF EVENTS TO MSCC DIAGNOSIS?
tells GP
referred
1st symptom
diagnosis
patient 3 wks
GP + hospital system 9 weeks
months
back pain
what’s the sequence of events?
Historically the following has taken place
The median time from the patient developing their first symptom until the confirmation of a diagnosis was 90 days - 3 months
The patient tells someone - usually their GP after a median of 25 days
and the GP refers to someone - usually a hospital doctor after a median of 20 days
The hospital doctor tries to manage the patients pain, perhaps with physio and analgesia. This type of pain is not sorted using normal alalgesia. X-ray usually is carried out of lumbar spine- This is predominantly the area that the majority of patients complain about. 70% compressions are thoracic although the pain is lumbar. X-ray is usually negative. More than 50% of the vertebral body needs to be collapsed before one can see collapse on x-ray. The next step in getting an answer is bone scanning. Not really useful. Most patients will have hot spots. If the patient has multiple hot spot levels, how does one know which level is the compressive level. You are probably looking at a picture of multiple metastases. What if it is just osteoporosis, disc disease causing marrow odoema in the vertebral body, old fracture. How can you be sure. MRI sometimes does not happen until the patient is too advanced to give good treatment outcomes and we are reduced to palliative radiotherapy or pain management using drivers and drug combinations.
neurogenic pain - 2 months
weakness 3 wks
Levack et al 2001 (CRAG Audit 97/98)

15. What did we set out to do?
Develop and implement referral pathway’s in each of the four region’s
Develop and implement sustainable education programmes
Develop in collaboration with other cancer networks a minimum dataset and audit tool

16. 1. Develop and Implement Referral Pathways in Four Regions

17. Referral Pathways in each region

18. Provisional Interim Findings
July - December 2010
References:
How to... Implement a rapid referral hotline
Trudy McLeay; Graeme Houston; Pamela Levack; Rosie Conway. Synergy; Feb 2008
How to... benefit from a rapid referral hotline
Trudy McLeay; Graeme Houston; Wendy Milne; Pamela Levack; Sean Kelly
Synergy; Mar 2008 18

19. Site of MRI
210 only 3 patients from other areas required MRI at ECC

20. MRI Findings

21. Functional status – CRAG 97/98

22. Functional status – MRI

23. Functional Status 6 week Follow Up

24. 2. Sustainable Education

25. Education- Healthcare Professionals
Basic presentation delivered to healthcare professional who may see patients with suspected MSCC symptoms (identify champion)
GP receives a letter with copy of pathway for any patient who has an MRI for suspected MSCC
Informal opportunities as they arise – talking to GP on phone or staff on ward

26. CHANGE TIME LINE OF EVENTS TO MSCC DIAGNOSIS?
tells GP
referred
1st symptom
diagnosis
patient 3 wks
GP + hospital system 9 weeks
months
back pain
what’s the sequence of events?
Historically the following has taken place
The median time from the patient developing their first symptom until the confirmation of a diagnosis was 90 days - 3 months
The patient tells someone - usually their GP after a median of 25 days
and the GP refers to someone - usually a hospital doctor after a median of 20 days
The hospital doctor tries to manage the patients pain, perhaps with physio and analgesia. This type of pain is not sorted using normal alalgesia. X-ray usually is carried out of lumbar spine- This is predominantly the area that the majority of patients complain about. 70% compressions are thoracic although the pain is lumbar. X-ray is usually negative. More than 50% of the vertebral body needs to be collapsed before one can see collapse on x-ray. The next step in getting an answer is bone scanning. Not really useful. Most patients will have hot spots. If the patient has multiple hot spot levels, how does one know which level is the compressive level. You are probably looking at a picture of multiple metastases. What if it is just osteoporosis, disc disease causing marrow odoema in the vertebral body, old fracture. How can you be sure. MRI sometimes does not happen until the patient is too advanced to give good treatment outcomes and we are reduced to palliative radiotherapy or pain management using drivers and drug combinations.
neurogenic pain - 2 months
weakness 3 wks
Levack et al 2001 (CRAG Audit 97/98) 26

27. Known Metastatic Disease
26% Breast
33% Prostate
n=45
n=23

28. Education - Patients
Face to Face discussion with patients (and relative if appropriate) diagnosed with Vertebral metastases, MSCC, Impending or nerve root compression
Leaflet to support the discussion

30. 3. National Minimum Dataset Audit (SCAN, WoSCAN and NOSCAN)

31. National Minimum Dataset Audit
Started July 2009 – July 2010
SCAN – 6 months 139 patients’ (MSCC, Impending and treated nerve roots)
Analysis will answer lots of questions including:
Symptom to diagnosis
Functional status at various time points
Steroid practices
Multiprofessional referral
Treatments………………………………

32. What else have we managed to do?
Developed and implemented a successful pilot outpatient service for early MSCC symptoms
Developed and implemented a protocol for consistent steroid prescribing
Developed and in process of agreeing a mobility guideline
Agreed 4 standards 1. Steroid 2. MRI 3. Management 4. Referral to Physio

33. The Future for SCAN Build on the foundation
Consider further development of the service and how this will be taken forward
Add to the evidence base

34. Jackie’s Crystal Ball Advice?
Coordinator/Navigator/Specialist
Improve the care for patients with MSCC
Collaborate with other networks
Build a strong foundation
Set standards
Develop the service, local policies and protocols
Assess educational needs
Add to evidence base! 34

35. FINALLY “Metastases to the spine can cause severe pain,
paralysis, and impairment of activities of daily living.
The treatment paradigm for spinal metastases involves
a cohesive multidisciplinary approach that allows
treatment plans to be made in the context of a patient's
overall condition”.
Meyer, Singh and Jenkins 2010

36. For further information/feedback contact:

37. References
Levack, P., Graham, J., Collie, D., Grant, R., Kidd, J., Kunkler, I., Gibson, A., Hurman, D., McMillan, N., Rampling, R., Slider, L., Statham, P. and Summers, D A prospective audit of diagnosis, management and outcome of malignant spinal cord compression. Clinical Resource and Audit Group (CRAG) 97/98.
Levack, P., Garham, J., Collie, D., Grant, R., Kidd, J., Kunkler, I., Gibson, A., Hurman, D., McMillan, N., Rampling, R.., Slider, L., Statham, P. and D. Summers Don't wait for a sensory level-listen to the symptoms: a prospective audit of the delays in diagnosis of malignant cord compression. Clinical Oncology, 14: pp
Levack, P., Graham, J. and Kidd, J Listen to the patient: quality of life of patients with recently diagnosed malignant cord compression in relation to their disability. Palliative Medicine, 18 pp
Loblaw, D.A., Perry, J., Chambers, A. and Laperriere. N.J Systematic review of the Diagnosis and management of malignant extradural spinal cord compression: the Cancer Care Ontario Practice Guidelines Initiatitive’s Neuro Oncology Disease Site Group. Journal of Clinical Oncology, pp

38. References
McLeay, T., Houston, G., Levack, P., Conway, R How to... Implement a rapid referral hotline Synergy; Feb 2008
McLeay, T., Houston, G., Milne, W., Levack, P. and Kelly, S How to... benefit from a rapid referral hotline. Synergy; Mar 2008
McClinton, A. and Hutchison, C Malignant spinal cord compression, a retrospective
audit of clinical practice at the Beatson Oncology Centre. British Journal of Cancer, 94 pp
Meyer, Scott A. Singh, Harshpal. Jenkins, Arthur L Surgical treatment of metastatic spinal tumours. Mount Sinai Journal of Medicine. 77(1),124-9.
NICE consultation document
WO SCAN Guidelines for MSCC
Warnock, C., Cafferty, C., Hodson, S., Kirkam, E., Osguthorpe, C., Siddal, J., Walsh, R. and Foran.B. Evaluating the care of patients with malignant spinal cord compression at a regional cancer centre International Journal of Palliative Nursing, 14 (10) pp