The Use of Hospital Services by Patients With Muscle Invasive Bladder Cancer in the Last Year of Life: Identifying the Areas to Improve Care.

INTRODUCTION: Muscle-invasive bladder cancer (MIBC) is associated with significant morbidity. However, patients' specific health needs have not been well defined. This study analyses the utilisation of hospital resources by MIBC patients in the 12 months before death, informing healthcare modelling and enabling service redesign to improve their quality of life. MATERIALS AND METHODS: All patients who died after being diagnosed with MIBC at a single hospital in the United Kingdom within four years were included. Patients' electronic health records were reviewed to collect data on all interactions with hospital services in their last year of life. RESULTS: A total of 41 patients were included, with survival times ranging from one to 88 months (with a median of nine months). In the last year of life, a patient from this cohort had an average of 5.2 outpatient appointments and 2.3 emergency admissions leading to 17.1 days of inpatient stay and 1.3 operations/procedures. The most common reasons for emergency admission were for the management of haematuria (23%), urinary tract infection (23%), or chest infection (12%). CONCLUSION: Patients with MIBC demonstrate significant utilisation of healthcare resources in their last year of life. An awareness of this should inform honest discussions with patients, earlier provision of palliative care, and proactive management of haematuria and urinary tract infections to improve care in this important stage of life.

Developing and centralising a nurse-led local anaesthetic transperineal biopsy service during COVID.

Introduction: Transperineal (TP) biopsy has recently replaced the transrectal ultrasound (TRUS) approach as the ideal method of biopsy in the United Kingdom with growing trends to adopt. To minimise transmission of COVID-19 during the first wave of the pandemic, the British Association of Urological Surgeons Section of Oncology issued guidelines reducing general anaesthesia (GA) procedures and initiate COVID-secure 'green' site diagnostics. As a result of these guidelines and reduction in clinical diagnostics trust-wide, we ceased all TRUS diagnostics and implemented a centralised, nurse-led LA TP biopsy service. Materials and methods: A waiting list was developed for those awaiting prostate cancer diagnostics across the network. A COVID-secure 'green' site was quickly identified with TP biopsies starting soon after. Quality improvement methodology was utilised and a run chart was used to show if changes were sustainable. Results: Successful implementation and centralisation of a TP biopsy service occurred with TRUS guided biopsies ceasing across all sites on 12 May 2020. The procedures were carried out by urology advanced nurse practitioners under local anaesthesia with a select few occurring under GA. Centralising the service in a COVID-secure manner freed up dedicated theatre sessions and personal leading to increased efficiency elsewhere. The service was robust and was maintained upon lifting of COVID restrictions. Conclusions: A centralised, nurse led LA TP biopsy service in a procedural unit was implemented successfully. The service has remained resilient upon lifting of restrictions and return to business as usual. This led to improved performance across trust by freeing up valuable resources and staff to undertake more duties. The service remains highly valued trust-wide.

The effectiveness of the Guy's Rapid Diagnostic Clinic (RDC) in detecting cancer and serious conditions in vague symptom patients.

BACKGROUND: Rapid Diagnostic Clinics (RDC) are being expanded nationally by NHS England. Guy's RDC established a pathway for GPs and internal referrals for patients with symptoms concerning for malignancy not suitable for a site-specific 2WW referral. However, little data assessing the effectiveness of RDC models are available in an English population. METHODS: We evaluated all patients referred to Guy's RDC between December 2016 and June 2019 (n = 1341) to assess the rate of cancer diagnoses, frequency of benign conditions and effectiveness of the service. RESULTS: There were 96 new cancer diagnoses (7.2%): lung (16%), haematological (13%) and colorectal (12%)-with stage IV being most frequent (40%). Median time to definitive cancer diagnosis was 28 days (IQR 15-47) and treatment 56 days (IQR 32-84). In all, 75% were suitable for treatment: surgery (26%), systemic (24%) and radiotherapy (14%). Over 180 serious non-neoplastic conditions were diagnosed (35.8%) of patients with no significant findings in two-third of patients (57.0%). CONCLUSIONS: RDCs provide GPs with a streamlined pathway for patients with complex non-site-specific symptoms that can be challenging for primary care. The 7% rate of cancer diagnosis exceeds many 2WW pathways and a third of patients presented with significant non-cancer diagnoses, which justifies the need for rapid diagnostics. Rapid Diagnostic Centres (RDCs) are being rolled out nationally by NHS England and NHS Improvement as part of the NHS long-term plan. The aim is for a primary care referral pathway that streamlines diagnostics, patient journey, clinical outcomes and patient experience. This pilot study of 1341 patients provides an in-depth analysis of the largest single RDC in England. Cancer was diagnosed in 7% of patients and serious non-cancer conditions in 36%-justifying the RDC approach in vague symptom patients.

The Use of Healthcare Services by Prostate Cancer Patients in the Last 12 Months of Life: How Do We Improve the Quality of Care During This Period?

INTRODUCTION: Current research on prostate cancer is heavily focused on early detection and new treatments. There is a lack of research on the overall morbidity prostate cancer survivors face and the amount of healthcare treatment they receive toward the end of their lives. Identifying these care needs will allow appropriate healthcare modeling, resource allocation and service re-design to ensure higher quality care toward the end of life. The aim of this study is to quantify and analyze the use of healthcare services by patients dying with but not necessarily of prostate cancer. METHODS: All patients who died with a diagnosis of prostate cancer during a 2-year period at a single hospital were included. Data on outpatient attendances, elective and emergency admissions and palliative care involvement in the 12 months prior to death were collected. RESULTS: A total of 77 patients were included and of these, 60 (78.0%) had 545 scheduled appointments with 473 (86.8%) attendances. More non-attendances occurred in the last 6 months of life; 56 vs 16, p < 0.001. Nurse led clinics doubled in the last 6 months of life, 117 vs 66. There were 173 admissions from 63 (81.8%) patients resulting in 1816 days inpatient stay. This averaged to 2.7 admissions per patient for 10.5 days per episode. 32 (41.6%) patients were seen by palliative care resulting in 192 visits in total. 78 (40.6%) were inpatient and 114 (59.4%) were community reviews. CONCLUSIONS: In the last year of life, prostate cancer patients use a considerable amount of healthcare resources. Understanding this clinical and economical burden is important for healthcare remodeling to provide better quality care that is cost effective.

Prescription switching: Rationales and risks.

BACKGROUND: Therapeutic drug switching is commonplace across a broad range of indications and, within a drug class, is often facilitated by the availability of multiple drugs considered equivalent. Such treatment changes are often considered to improve outcomes via better efficacy or fewer side effects, or to be more cost-effective. Drug switching can be both appropriate and beneficial for several reasons; however, switching can also be associated with negative consequences. AIM: To consider the impact of switching in two situations: the use of statins as a well-studied example of within-class drug switching, and gonadotropin-releasing hormone (GnRH)-targeting drug switching as an example of cross-class switching. RESULTS: With the example of statins, within-class switching may be justified to reduce side effects, although the decision to switch is often also driven by the lower cost of generic formulations. With the example of GnRH agonists/antagonists, switching often occurs without the realisation that these drugs belong to different classes, with potential clinical implications. CONCLUSION: Lessons emerging from these examples will help inform healthcare practitioners who may be considering switching drug prescriptions.

Identifying Unmet Care Needs of Patients with Prostate Cancer To Assist with Their Success in Coping.

In the United Kingdom, our Health Needs Assessment survey return rate of 42% identified unmet needs in subjects with prostate cancer. Subjects reported the greatest unmet need was related to erectile dysfunction. Other unmet needs were related to incontinence, tiredness, hot flashes, lower urinary tract symptoms, rectal bleeding, and relationship issues.

Immunotherapy for bladder cancer.

It is nearly 40 years since Bacillus Calmette-Guérin (BCG) was first used as an immunotherapy to treat superficial bladder cancer. Despite its limitations, to date it has not been surpassed by any other treatment. As a better understanding of its mechanism of action and the clinical response to it have evolved, some of the questions around optimal dosing and treatment protocols have been answered. However, its potential for toxicity and failure to produce the desired clinical effect in a significant cohort of patients presents an ongoing challenge to clinicians and researchers alike. This review summarizes the evidence behind the established mechanism of action of BCG in bladder cancer, highlighting the extensive array of immune molecules that have been implicated in its action. The clinical aspects of BCG are discussed, including its role in reducing recurrence and progression, the optimal treatment regime, toxicity and, in light of new evidence, whether or not there is a superior BCG strain. The problems of toxicity and non-responders to BCG have led to development of new techniques aimed at addressing these pitfalls. The progress made in the laboratory has led to the identification of novel targets for the development of new immunotherapies. This includes the potential augmentation of BCG with various immune factors through to techniques avoiding the use of BCG altogether; for example, using interferon-activated mononuclear cells, BCG cell wall, or BCG cell wall skeleton. The potential role of gene, virus, or photodynamic therapy as an alternative to BCG is also reviewed. Recent interest in the immune check point system has led to the development of monoclonal antibodies against proteins involved in this pathway. Early findings suggest benefit in metastatic disease, although the role in superficial bladder cancer remains unclear.

Venous thromboembolism (VTE) prophylaxis and urological pelvic cancer surgery: a UK national audit.

OBJECTIVES: To evaluate the use of post-discharge venous thromboembolism (VTE) prophylaxis in UK pelvic cancer centres consistent with national guidelines. METHODS: Data was collected from healthcare professionals from 64 UK pelvic cancer centres. RESULTS: After radical cystectomy (RC), all cancer centres routinely use low-molecular-weight heparin (LMWH) in the perioperative period. After RC 67% of cancer centres use post-discharge LMWH routinely. After radical prostatectomy (RP), 98% of units use perioperative LMWH VTE prophylaxis routinely. After RP, 61% of hospitals always use post-discharge LMWH. In all, 27% of all UK cancer centres reported deaths or serious VTE complications from urological pelvic cancer surgery in the last 2 years. CONCLUSIONS: The National Institute for Health and Care Excellence (NICE) issued explicit guidance of VTE prophylaxis after pelvic and abdominal cancer surgery. Conversion of national guidance into local policy is ≈60% for UK pelvic cancer centres. A lack of good quality evidence is cited as a reason for not adhering to NICE guidance.

Cancer patients' perspectives on multidisciplinary team working: an exploratory focus group study.

This qualitative, focus-group study explores what patients understand about the multidisciplinary team (MDT) in cancer care. Participants were positive towards MDT working, and by strengthening the role of nurses in MDT decision-making, the representation of patients' interests can be improved.

Initial experience of intravesical gemcitabine for patients with high-risk superficial transitional cell carcinoma of the bladder following BCG failure.

This study reports the use of intravesical gemcitabine in managing patients with high-risk bladder cancer, refractory to Bacillus Calmette-Guerin (BCG). Patients were given gemcitibine; treatment response was evaluated by fluorescence-cystoscopy biopsy and urine cytology. Time to reoccurrence increased with instillation time.