More care, less pathway. . .More plans?

Treatment Escalation Plans (TEPs) risk becoming the next 'tick box exercise', if not supported by open and compassionate conversations by healthcare teams brave enough to adequately address the culturally taboo subject of death. This requires a wider system of ongoing support, education and clinical leadership to create a culture of open communication. While excellent to read the emphasis that palliative treatments should not be reserved for the terminally ill, further advancements would see 'Supportive Care' move from the lowest levels of escalation to becoming embedded as standard practice for all deteriorating patients. This supportive element of care, underpinned by clear communication, could accompany patients regardless of their level of escalation. Through adopting the Palliative and Supportive Care ethos, addressing not only physical symptom needs, but also exploring social, psychological and spiritual concerns, be it in the ICU or on a general ward, we may move closer towards offering the truly individualised plans of care that TEPs promise.

Integration of a patient-centred MUO/CUP service within a new acute oncology service: challenges and rewards.

BACKGROUND: Holistic approach to the clinical management pathway for malignancy of undefined primary origin (MUO)/carcinoma of unknown primary (CUP) patients remains an unmet clinical need. To address this, an MUO/CUP service was implemented during conception of a new acute oncology service (AOS). METHODOLOGY: Over a comparable 17 months' duration, patient outcomes pre-MUO/CUP service implementation was retrospectively analysed and compared prospectively with post-service implementation database. Performance measures of MUO/CUP service were compared against national recommendations. RESULTS: In the retrospective cohort (n=32), median age was 71.5 years and median length of hospital stay (LOS) was 11.25 days. In the prospective cohort (n=42), median age was 75.5 years, median LOS was 7.75 days (p=0.037). Post-service implementation, 100% patients were discussed in MUO/CUP multidisciplinary team meeting; 96% of inpatient referrals were reviewed by oncology within 24-48 hours. In the prospective group, median overall survival (OS) was 73 days vs 35 days in the retrospective group (p=0.045; hazard ratio (HR) 1.61). Out of 20 patients suitable for anti-cancer treatment in the prospective group, 85% were treated within 31 days from the decision-to-treat; 90% were treated within 62 days of referral. Within the prospective group, median OS was 214 days in the treated sub-group, compared with 44 days in patients receiving best supportive care only (p<0.0001; HR 3.19). CONCLUSION: Timely specialised input from AOS with a dedicated MUO/CUP team can achieve enhanced patient-centred and healthcare-centred outcomes, both in terms of survival and hospital stay. However, heterogeneity in both retrospective and prospective study groups, as well as discrepancies in coding, makes direct comparison between both groups challenging.