Clinical

Chronic management

Chronic GI morbidity after cancer treatment

Background

  • 2 million long term survivors of cancer live in the UK
  • Improvement in treatment means that numbers of cancer survivors are increasing by 1% per year
  • 25% of long-term survivors are left with chronic physical problems affecting daily activity.
  • 15,000 new survivors / year have GI problems affecting quality of life to a moderate or severe extent
  • 7,000 patients per year are left with “toilet dependency”.

Patient View

  • Clinicians focus on detecting cancer recurrence and it is often difficult to discuss side effects of treatment with them
  • It is difficult to find gastroenterologists or surgeons with expertise in treating complications of cancer therapies
  • Advice or treatment when given is often unhelpful, wrong or dangerous.
  • Clinicians rarely appreciate the impact of chronic GI symptoms on daily living

Current Practice

  • There is inadequate training or knowledge about advances in the management of late effects of cancer treatments for gastroenterologists or surgeons
  • Identifying relapse and managing chronic symptoms require different skills and multidisciplinary input.
  • Most patients with chronic GI symptoms can be helped or cured if a systematic approach to investigation and treatment is adopted (eg the Royal Marsden Hospital algorithm for managing GI late effects).
  • Lack of training results in futile or dangerous treatments being prescribed
  • Adequately trained and supported specialist nurses can deal with 75% of the physical GI issues

Recommended Practice and Opportunities for Integrated Working

  • All patients surviving cancer treatment require adequate holistic assessment of their residual problems
  • All units seeing patients after all cancer therapies need to have established referral pathways to gastroenterologists with expertise in managing late effects of cancer therapies
  • Clinics which manage these patients should be developed regionally
  • Clinics managing these patients need to have appropriately skilled multidisciplinary input
  • Practice guidance on managing late effects of cancer therapies affecting the GI tract has been published jointly by the Association of Coloproctology of Great Britain and Ireland, Association of Upper GI Surgeons, the British Society of Gastroenterology and the Oncology Faculty of the Royal College of Radiologists – see: http://www.bsg.org.uk/clinical-guidelines/radiology/practice-guidance-on-the-management-of-acute-and-chronic-gastrointestinal-problems-arising-as-a-result-of-treatment-for-cancer.html

Opportunities for Savings

  • The Department of Health estimates that £40million is wasted annually in futile and dangerous treatments for Pelvic Radiation Disease alone; academic estimates suggest this is closer to £80 million
  • Many people incapacitated by their symptoms are unable to work; proper assessment and treatment has a high chance of improving their productivity
  • Inadequately treated morbidity of cancer treatments has huge social costs.
  • Specialist Centres could offer cost effective care if Integrated Care Pathways were embraced by both primary and secondary care in each area.
  • If the Map of Medicine was developed to address the needs of this patient group, it could be used to optimize management

Quality Indicators (Outcomes)

  • Algorithms for the management of GI symptoms have been published and have been developed through multiple peer-reviewed versions.
  • The continued development and validation of the clinical algorithms will ensure that these clinical standards continue to evolve to meet emerging needs.

Social Policy & Understanding

  • Two UK audits of gastroenterology consultants and clinical oncologists demonstrates no improvement in provision of specialist services between 2003 and 2010
  • Modern cancer treatments have not reduced the degree of clinical need nor the severity of the side effects developed after cancer treatments and there are increasing levels of unmet clinical need
  • The impact of the symptoms on daily living are highlighted by the recent National Cancer Survivorship Initiative report.

References