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Urology Care Pathways

By Jonathan Murphy,2014-04-30 00:29
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Urology Care Pathways

NICaN Regional Urology Group

    Final Care Pathways for Urological Cancer

     Urology Care Pathways

    Cancer Care Pathways outline the steps and stages in the patient journey from referral through to diagnostics, staging, treatment, follow up, rehabilitation and if applicable onto palliative care.

    Timed effective care pathways are central to delivering quality and timely care to patients throughout their cancer journey and to the delivery of an equitable service. These pathways have been developed following with reference to available best practice guidance. They represent an ‘ideal’ pathway that can be adapted for local use. The

    timelines on the pathway are intended to facilitate the proactive management of patients within the access standards and it is to be noted that for some urological tumours, the patient will move much quicker through the pathway (e.g. testicular cancer).

The pathways are in draft form and amendments have been made following discussion ndat the workshop of the NICaN Regional Urology group held on Thursday 2 October,

    2008.

Document History

V1 Draft discussed at workshop 2/10/08

    V2 Draft discussed 29/1/09 and amendments noted

    Version 3 circulated for final comments 26/02/09

    Pathways agreed at regional meeting 23/4/09

     ? Indicates point of holistic assessment ? Inter-Trust transfer by Day 28

    NICaN Regional Urology Group

    Final Care Pathways for Urological Cancer

    Prostate Pathway Day 0 GP referral triage by Urology Consultant

     OPA biopsy may be required OPA biopsy definitely required Day 7 History/DRE/counselling History/DRE/counselling/TRUS Biopsy

    Pre-booked results clinic Benign pathology

    Day 14 Diagnosis discussed with patient ? Follow up clinic with nurse specialist or

     patient letter informing of benign pathology

    Local MDT Day 21 Next available

    Staging

    *MRI/CT & Bone scan if appropriate

    Localised Locally advanced Metastases

    * Local/Specialist MDTDay 28

    Day 31 Decision to treat at pre-booked OPA ?

    Hormone therapy Radical Prostatectomy Radiotherapy

    Oncology Radical Radiotherapy Hormone therapy Day 62 Palliation (+/-) Hormone Therapy Active Surveillance

    Active Surveillance Brachytherapy Clinical Trials Clinical Trials Active Surveillance

     Clinical Trials

     Clinical trials

     ? Indicates point of holistic assessment ? Inter-Trust transfer by Day 28 * CT necessary only when clinically indicated

     Patient support & information at all stages; Patient details recorded; Patient informed at appropriate points *****NICE

    Renal Tumour

    MAXIMUM WAIT OOD PRACTICE & GPATHWAY QUALITY PARAMETERS

    See NICaN referral GP referral 1/62 guidelines, 2007

    One Stop Haematuria Clinic Inform MDT coordinator on receipt

    Flexible cystoscopy + Upper of results.7/62

    Tract Imaging/ History Physical

    Renal Tumour

    Stage tumour

     ; Letter from MDT to GP

    ; Proactive pathway management Patient discussed at 28/62 ; PACS

     MDT ? ; Regionally agreed dataset and

    d’base (NICR)

     Other point of Outpatient’s appointment *** Manual of Cancer Service entry (A&E, Treatment options discussed 31/62 Standards Incidental Decision to treat ? Oncology Protocols (to include Findings Clinical Trials)

    PT3b PT1a PT4 PT2 PT3a

    B M1

    Laparoscopic Laparoscopic Open Open ? Debulk Treatment of choice ? Open ? Laparoscopic ? Laparoscopic + Immunotherapy Vascular Surgeon Embolisation ? Partial Radiotherapy Cardiac Bypass ? Open Surgery Palliative Care ? Laparoscopic New drugs

    62/62

    Renal Preservation

     Partial Nephrectomy Open/ Laparoscopy Auto transplant Follow UP ? Radio Frequency Ablation Cryotherapy

     ? Indicates point of holistic assessment ? Inter-Trust transfer by Day 28

     Patient support & information at all stages; Patient details recorded; Patient informed at appropriate points *****NICE

    Testicular Cancer Pathway

     OOD PRACTICE & GMAXIMUM WAIT PATHWAY QUALITY PARAMETERS

    NICaN Referral Guidelines, 2007 1/62 GP Referral received Swelling or mass in body of testis Testicular Cancer suspected

    Improving Outcomes guidance Assessment of clinical in Urological cancers, 2002

    presentation (Lump)

    Inform MDT coordinator on receipt

    of results. Diagnostic tests 7/62 Equivocal Ultrasound

    Orchidectomy +- Prosthesis Testicular Cancer Confirmed

    Decision to treat

    ; GP letter from MDT CXR Tumor Marker ; Proactive pathway management Book CT ; PACS

    ; Regionally agreed dataset and

    d’base (NICR) Patient discussed at 28/62 MDT ?

    31/62 Outpatient’s appointment ? CT/Histology Metastatic

    *** Manual of Cancer Service Oncology Outpatient’s Standards Oncology appointment ? Oncology Protocols (to include

     Clinical Trials)

    Patient discussed at

    MDT

    62/62

     Surveillance Chemotherapy Radiation Clinical Trial Sperm Bank

     Post Chemo

     Mass/ RPLND

    Follow UP ?

     ? Indicates point of holistic assessment ? Inter-Trust transfer by Day 28

     Patient support & information at all stages; Patient details recorded; Patient informed at appropriate points *****NICE

    Transitional Cell Carcinoma

     OOD PRACTICE & GMAXIMUM WAIT PATHWAY QUALITY PARAMETERS

    See NICaN referral GP referral / other point of entry 1/62 guidelines, 2007 (A&E, incidental findings)

    One Stop Haematuria Clinic Improving outcomes for Upper Flexible cystoscopy + Upper Urological cancers, 2002 Tract Imaging/ History Physical Tract

    Bladder Tumour

    Superficial Muscle Invasive

    TURBT CT Chest, Inform MDT coordinator on receipt 7/62 Abdomen of results.Single shot MitomycinC

    Grade and stage tumour

    ; Letter from MDT to GP

    Patient discussed at ; Proactive pathway management

    ; PACS 28/62 MDT ? ; Regionally agreed dataset and Laser

    d’base (NICR) Local Excision

    Nepho-

    *** Manual of Cancer Service Ureterectomy Outpatient’s appointment 31/62 Standards Laparoscopy Treatment options discussed Oncology Protocols (to include Pluck Decision to treat ? Clinical Trials)

     Superficial treatment Invasive treatment options options

    62/62

     ? Bladder ? Radical Palliation Neo-adjuvant Preservation Surgery/ Chemo PTaG3 PT1G3 /radio/chemo reconstruction PTa BCG Re-resect Eastoscopic BCG Follow up

    Follow UP ?

    Register only

     ? Indicates point of holistic assessment ? Inter-Trust transfer by Day 28

     Patient support & information at all stages; Patient details recorded; Patient informed at appropriate points *****NICE

    Castration Resistant Prostate Cancer

    GOOD PRACTICE & Rising PSA/New Symptoms QUALITY PARAMETERS

     Inform MDT coordinator on receipt

    of results. GP referral/ OP Referral

     ; Letter from MDT to GP

    ; Proactive pathway management Patient re-presented at Staging * ; PACS

    MRI MDT ; Regionally agreed dataset and

    d’base (NICR) Bone Scan

    *** Manual of Cancer Service Outpatient’s appointment

    Standards Treatment options discussed

    Oncology Protocols (to include Decision to treat ?

    Clinical Trials)

     Oncology Referral

    Conservative Hormone Clinical Radiotherapy Chemotherapy Bisphosphonates Management therapy Trials Palliative Care Follow UP ?

     * MRI/Bone Scan as clinically indicated

     ? Indicates point of holistic assessment ? Inter-Trust transfer by Day 28

     Patient support & information at all stages; Patient details recorded; Patient informed at appropriate points *****NICE

    Penile Cancer Pathway

     OOD PRACTICE & GMAXIMUM WAIT PATHWAY QUALITY PARAMETERS

    NICaN Referral Guidelines, 2007 1/62 GP Referral received Penile Cancer suspected

    Improving Outcomes guidance Biopsy/Stage Tumour in Urological cancers, 2002

    CT/MRI

    Inform MDT coordinator on receipt Results Clinic of results. Option for local review ?

    28/62

     ; GP letter from MDT Patient discussed at ; Proactive pathway management MDT ? ; PACS 31/62 ; Regionally agreed dataset and d’base (NICR) Outpatients Appointment

     Decision to treat ?

    Localised Groins* Advanced* 62/62

    Lymph Node Surgery *** Manual of Cancer Pelvic Lymph Service Standards - Amputation Dissection Node Dissection Oncology Protocols (to - Penile preservation - Therapeutic Open Laparoscopy include Clinical Trials) - Glansectomy - Prophylactic

Radiation Chemo Chemo Radiation

    Radiation

    Palliative Care

    Clinical Trials

    Follow UP ?

     ? Indicates point of holistic assessment ? Inter-Trust transfer by Day 28

References

    ; NICE (2002) Improving Outcomes in Urological Cancer

     http://www.nice.org.uk/guidance/index.jsp?action=byID&o=10889

    ; NICE (2008) Prostate Cancer: Diagnosis and Treatment http://www.nice.org.uk/guidance/index.jsp?action=byID&o=11924

    ; British Association Of Urological Surgeons Guidelines

     http://www.baus.org.uk/

    ; European Association Of Urology

     http://www.europeanurology.com/

     ? Indicates point of holistic assessment ? Inter-Trust transfer by Day 28

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