urgent thoracic assessment proforma · time for decalcification and inability to do molecular...

Greater Manchester Cancer

Urgent Thoracic Assessment ProformaPatient Addressograph Patient Age:

Date of Assessment: __ / __ / __

Trust:

Clinician:

Initial Assessment: Baseline Physiology Initial Assessment: G8 Questionnaire (Patients >=65yrs old)

Initial Assessment: Nutrition

Blood Pressure: ____ /____

Pulse: ................bpm

Pulse: oRegular oIrregular

Respiratory Rate: ............................

Oxygen Saturations: ....................%

Temperature:.....................................

Height (cm): .............

Weight (kg): .............. BMI:............

Unplanned weight loss in the last 3-6 months? oYes oNo

% weight loss: o <5% o 5-10% o <10%

MUST SCORE: .............................Please see Nutritional Care Pathway for appropriate interventions based on MUST score

All patients should have an ECG & routine blood testing (FBC, U&Es, LFTs, Bone Profile, Clotting) unless there is a specific reason not to.

ECG performed: oYes oNo Bloods

Taken: oYes oNo

BMI Score Weight Loss Score Acute disease effect scoreStep 1

+ +Step 2

Overall risk of malnutritionStep 4

Step 3

‘Malnutrition Universal Screening Tool’ (‘MUST’) Flowchart

Add Scores together to calculate overall risk of malnutritionScore 0 Low Risk Score 1 Medium Risk Score 2 or more High Risk

Unplanned weight loss in past 3-6 months

%<5

5-10>10

Score= 0= 1= 2

BMI/kg/m2

<20 (>30 Obese)18.5 -20

<18.5

Score= 0= 1= 2

If patient is acutely ill and there has been or is likely to be no nutritional intake for >5 days

Score 2

Items Possible answers Score

1

Has food intake declined over the pas 3 months due to loss of appetite, digestive problems, chewing or swallowing difficulties?

0: severe decrease in food intake

1: moderate decrease in food intake

2: no decrease in food intake

2 Weight loss during the last 3 months

0: weight loss >3kg

1: does not know

2: weight loss between 1 & 3kgs

3: no weight loss

3 Morbidity

0: bed or chair bound

1: able to get out of bed/chair but does not go out

2: goes out

4 Neurophyschological problems

0: severe dementia or depression

1: mild dementia or depression

2: no physchological problems

5 Body Mass Index (BMI (Weight in kg) / (height in m2)

0: BMI <19

1: BMI = 19 to BMI <21

2: BMI = 21 to BMI <23

3: BMI = 23 and > 23

6 Takes more than 3 medications per day

0: yes

1: no

7

In comparison with other people of the same age, how does the patient consider his/her health status?

0: not as good

0.5: does not know

1: as good

2: better

8 Age

0: >85

1: 80-85

2: <80

Total Score between 0-17

A score <=14 identifies patients that may benefit from a Comprehensive Geriatric Assessment


First presenting symptom and history of presenting complaints:

Past Medical History:

Presentation: Symptomatic o Asymptomatic o

First presenting symptom:

Duration of symptoms (months):

Drug History:

Anticoagulants: Yes o No o Details: .........................

Antiplatelets: Yes o No o Details: .........................

Allergies: Yes o No o Details: .........................


WHO Performance Status MRC Dyspnoea Scale

Fully active, able to carry on all pre-disease performance without restriction

Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work.

Ambulatory and capable of all selfcare but unable to carry out any work activities. Up and about more than 50% of working hours

Capable of only limited self care, confined to bed or chair more than 50% of waking hours

Completely disabled. Cannot carry on any self care. Totally confined to bed or chair

Tick Tick

Not troubled by breathlessness except on strenuous exercise

Short of breath when hurrying or walking up a slight uphill

Walks slower than contemporaries on level ground because of breathlessness, or has to stop for breath when walking at own pace

Stops for breath after walking about 100m or after a few minutes on the level ground

Too breathless to leave the house, or breathless when dressing/undressing

o 0

o 1

o 2

o 3

o 4

o 1

o 2

o 3

o 4

o 5

Smoking History:

Asbestos Exposure Yes No

Family History:

Exercise tolerance:

Social History:

Smoker? Current Former Never

How long from waking do you smoke your first cigarette? o<30 mins o>30 mins

Duration ....................................................................... Cigarettes no. per day .............. Oz/week...............

Year stopped ............................................

Occupation ....................................................................... Age of exposure .................................................

Duration of asbestos exposure.............................. Years since exposure .......................................

Details of asbestos exposure:

Family history of lung cancer in a first degree relative? Yes o No o

Age of first degree relative at diagnosis (youngest if multiple) ..............................

Additional relevant family history:


Examination:

Investigations

CT Thorax

General

Clubbing?

Lymphadenopathy?

Hoarse voice?

Signs of SVCO?

Hearing aids?

Hearing impairment?

Cardiovascular

Murmur?

o

o

o

o

o

o

o

o

Respiratory

Abdomen

Neuro

CXR

Performed: Yes o No o

Normal: Yes o No o

Findings:

T Stage:

N Stage:

M Stage:

Overall Stage:

Other relevant investigations:

Stair climb assessment: .................................................. flights of stairs

Starting saturations: .............................. % Finishing saturations: .............................. %

Emphysema? Yes o No o

Comments:

Formal report? Yes o No o

ECG

Performed: Yes o No o

Normal: Yes o No o

Findings:

Greater Manchester Cancer Which disease pattern is present

on the CT scan?

0 Group 1: Peripheral tumor & normal hilum/mediastinum, no metastases

0 Group 2: Central tumuor or N1 disease and normal mediastinum, no metastases

0 Group 3: Discrete mediastinum lymph node enlargement, no metastases

0 Group 4: Conglomerate, invasive nodal disease, no metastases

0 Group 5: Distant metastases

0 None of the above, doesn’t fit into these groups

Group 1


GROUP 1:Peripheral tumour with normal hilar and mediastinum on staging CT with no distant metastasesIncluding: solid pulmonary nodules ≥5mm diameter / ≥80mm3 volume and BROCK risk ≥10% and persistent sub-solid nodules for ≥3months and solid component ≥5mmExcluding: pure ground glass nodules, and sub-solid nodules with solid component <5mm

Diagnostic tests(request simultaneously)

Physiology tests(request simultaneously)

Notes andguidance

• PET-CT

• Percutaneous image-guide biopsy OR radial EBUS bronchoscopy

Factors favouring radial EBUS:Presence of a bronchus sign ± central position ± high risk of pneumothorax from percutaneous approach e.g. severe emphysema.

Mandatory dataset for MDT discussion: • PET-CT results • Performance status, FEV1 and DLCO, post-operative predicted FEV1 and DLCO

• Spirometry and diffusing capacity

• Shuttle walk or stair climbing test

• Cardiac examination

• ECG

• Creatinine clearance / eGFR

Request echocardiogram if:

• Age ≥70

• Heart murmur

• Abnormal ECG

• Known ischaemic heart disease / valvular disease

• Possibility of pneumonectomy

Peripheral tumour = positioned in the outer 2/3 of the thorax based on axial CT image (blue area):

If biopsy is considered high risk or probability of malignancy is borderline it may be appropriate await PET results prior to biopsy.

If any positive hilar / mediastinal nodes on PET request staging EBUS.

Example of a bronchus sign

Group 2


GROUP 2:Central tumour or N1 lymphadenopathy with normal mediastinum on staging CT with no distant metastasesPET-CT has a 15% false positive rate and 25% false negative rate for N2/3 disease in this category, therefore EBUS is required regardless of PET findingsPrevalence of N2/3 disease in this category is 20-25%



Notes andguidance

• PET-CT

• Bronchoscopy & Staging EBUS

Staging EBUS definition:

Systematic examination of all N3, N2 followed by N1 nodes and sampling of any node ≥5mm, targeting a minimum of 3 lymph node stations.

Mandatory dataset for MDT discussion: • PET-CT results, EBUS pathology results • Performance status, FEV1 and DLCO, post-operative predicted FEV1 and DLCO




• ECG



• Age ≥70

• Heart murmur

• Abnormal ECG



Central tumour = positioned in the inner 1/3 of the thorax based on axial CT image (red area):

If staging EBUS is negative (including N1 nodes) and no pathology from bronchoscopy then percutaneous image biopsy may be required

Group 3


GROUP 2:Central tumour or N1 lymphadenopathy with normal mediastinum on staging CT with no distant metastasesPET-CT has a 15% false positive rate and 25% false negative rate for N2/3 disease in this category, therefore EBUS is required regardless of PET findingsPrevalence of N2/3 disease in this category is 20-25%



Notes andguidance

• PET-CT

• Bronchoscopy & Staging EBUS



Mandatory dataset for MDT discussion: • PET-CT results, EBUS pathology results • Performance status, FEV1 and DLCO, post-operative predicted FEV1 and DLCO




• ECG



• Age ≥70

• Heart murmur

• Abnormal ECG



Central tumour = positioned in the inner 1/3 of the thorax based on axial CT image (red area):

If staging EBUS is negative (including N1 nodes) and no pathology from bronchoscopy then percutaneous image biopsy may be required


GROUP 3:Primary tumour and discrete mediastinal lymphadenopathy on staging CT with no distant metastasesPET-CT has a 15% false positive rate and 25% false negative rate for N2/3 disease in this category, therefore EBUS is required regardless of PET findingsPrevalence of N2/3 disease is this category is 60%



Notes andguidance

• PET-CT

• Staging EBUS

• Contrast enhanced brain imaging (CT or MR)



Mandatory dataset for MDT discussion: • PET-CT results, EBUS pathology results, brain-imaging results • Performance status, FEV1 and DLCO, post-operative predicted FEV1 and DLCO, renal function




• ECG



• Age ≥70

• Heart murmur

• Abnormal ECG



Discrete mediastinal lymphadenopathy has well defined borders allowing easy measurement and is not conglomerate with other lymph node stations. It is non-bulky (<3cm).

Group 4


GROUP 4:Conglomerate and invasive nodal malignancy on staging CT with no distant metastasesRadiology is considered diagnostic for malignancy and pathological confirmation only requiredPrevalence of N2/3 disease is this category is 100%



Notes andguidance

• PET-CT

• Diagnostic EBUS

• Contrast enhanced brain imaging (CT or MR)

Diagnostic EBUS definition:

Targeted sampling of nodal disease for pathological confirmation, tumour sub-typing and molecular pathology.

Mandatory dataset for MDT discussion: • PET-CT results, EBUS pathology results, brain imaging results • Performance status, FEV1 and DLCO, renal function



Invasive mediastinal lymphadenopathy has poorly defined borders and cannot be easily measured. It forms conglomerate disease with other nodal stations.

Group 5


GROUP 5:Distant metastases on staging CT

Follow this algorithm in cases where there is clear evidence of stage 4 disease on CT. In cases of uncertain findings there may need to additional clarification tests e.g. liver USS/MR, triple phase adrenal wash out CT or PET-CT.



Workup ofoligometastatic disease

Choose most appropriate sampling technique to yield adequate pathology for tumour sub-typing and targeted therapy assessment:

Consider:

Pleural aspiration ± Medical thoracoscopy if symptomatic pleural effusion.

Avoiding bone biopsy (lacking a significant soft tissue component) given time for decalcification and inability to do molecular pathology.

Ensure non-MDT clinicians performing biopsies are informed about tissue requirements for targeted therapy.

Mandatory dataset for MDT discussion: • Pathology results • Performance status, renal function

• Creatinine clearance / eGFR Definition of oligometastatic disease = single metastases in a single organ

In patients that may be suitable for a high grade palliative approach request the following investigations in addition to those performed for Group 5 (request simultaneously):

PET-CT

Contrast-enhanced brain imaging

Staging EBUS

Spirometry and diffusing capacity

Shuttle walk or stair climbing test

Echocardiogram


Opinion at first assessment:

Investigations required:

Information given to patient:

Interventions required:

0 PET-CT

0 Image-guided biopsy - lung

0 Radial EBUS

0 Staging EBUS

0 Diagnostic EBUS

0 Contrast enhanced MR brain

0 USS-guided neck nodule biopsy

0 Image-guided biopsy - other

Details: ...............................

0 Serum EGFR testing

0 Spirometry and diffusion studies

0 Shuttle walk test

0 Echocardiogram

Comments:

0 Smoking CessationAdvise smokers that the best way to treat tobacco addiction is with medications and support. Offer referral to cessation services. Prescribe medications if required using the CURE Tobacco Addiction Treatment Guidance Overleaf. Provide patient information leaflet

0 Prehabilitation

Consider referral to local exercise programmes through ERAS referral form for Manchester, Tameside, Stockport and Salford patients. Consider alternative pathways e.g. pulmonary rehabilitation.

0 Nutritional Interventions

Provide interventions guided by the Nutritional Care Pathway in this document

Macmillan Lung Cancer Specialist Nurse (key worker) in clinic? Yes o No o

Written record of consultation offered to the patient? Yes o No o

Greater Manchester Cancer CURING TOBACCO ADDICTION IN GREATER MANCHESTERTHE CURE PROJECT

Treatment Pathway for Tobacco Addiction

Varenicline prevents the feeling of pleasure during smoking by reducing dopamine release in the brain triggered by nicotine. This also prevents the subsequent drop in dopamine that triggers cravings and withdrawal. Varenicline is commenced 1-2 weeks prior to stopping smoking although Nicotine Replacement Therapy and/or e-cigarettes can be used alongside varenicline in this initial period.

• 0.5mg once daily Day 1-3• 0.5mg twice daily day 4-7• 1mg twice daily day 8 – end of treatment (12 weeks)

One third of patients suffer nausea – minimise by having varenicline with a glass of water and food. Patients can suffer strange dreams but it is safe for use in patients with a Mental Health diagnosis who are on stable treatment (i.e no dosage changes or commencement of new medications in the last 3 months)

• E-cigarettes contain 95% less harmful chemicals than cigarettes and therefore represent a significant risk reducing behaviour compared to smoking. • It may be a potential method of risk reduction for those that are not ready to stop smoking.• Equally, e-cigarettes can help those trying to stop smoking. • E-cigarettes are not without risk and still contain 5% of the harmful chemicals of cigarettes. • E-Cigarettes can be used in combination with other tobacco addiction therapies including nicotine replacement and varenicline. • E-cigarettes cannot be prescribed and their use cannot be permitted on hospital grounds.

VARENICLINE (CHAMPIX) E-CIGARETTES

Moderate level addictionOptions are given below. MAX 1 patch and 1 reach for product per patient

10-19 Cigarettes/day Prescribe a long acting nicotine patch AND CONSIDER adding a short acting “reach for” nicotine replacement, the options are given below . Advise patients to use a clean & hairless area of skin to apply the patch.

Skin irritation can occur but is generally mild.

Discuss the following options with the patient (tick which one prescribed):o Nicotine inhalator 15mg – solo therapy max 6 cartridges 3 in combination therapy/24hrso Nicotine gum 2mg – solo therapy max 15 pieces 7 in combination therapy/24hrs o Nicotine lozenge 2mg – solo therapy max 15 lozenges 7 in combination therapy/24hrso Nicotine Patches 14mg/24hour (smokes within 30 minutes of waking)o Nicotine Patches 15mg/16hour (does NOT smoke within 30 minutes of waking)

24 hour patches are ideal for patients that smoke within 30 minutes of waking but can cause sleep disturbance. Discuss options, preferences and previous experiences with patient.

High level addictionOptions are given below. MAX 1 patch and 1 reach for product per patient

≥20 Cigarettes/day Prescribe a long acting nicotine patch AND a short acting “reach for” nicotine replacement, the options are given below.

Discuss the following options with the patient (tick which one prescribed):o Nicotine inhalator 15mg – solo therapy max 6 cartridges 3 in combination therapy/24hrso Nicotine gum 2mg – solo therapy max 15 pieces 7 in combination therapy/24hrs o Nicotine lozenge 2mg – solo therapy max 15 lozenges 7 in combination therapy/24hrso Nicotine Patches 21mg/24hour (smokes within 30 minutes of waking)o Nicotine Patches 25mg/16hour (does NOT smoke within 30 minutes of waking)

24 hour patches are ideal for patients that smoke within 30 minutes of waking but can cause sleepdisturbance. Discuss options, preferences and previous experiences with patient.

Low level addictionOptions are given below. MAX one “reach for” product per patient

≤10 Cigarettes/day Prescribe a short acting nicotine replacement (“reach for” nicotine)

Discuss the following options with the patient (tick which one prescribed):o Nicotine Inhalator 15mg – solo therapy max 6 cartridges in 24hrsAdvise patients not to inhale but to puff on the inhalator and the nicotine is absorbed through the lining of the mouth. Aim to use the inhalator little and often. More frequent uses gives better results. Cartridge lasts 40 mins of constant use.o Nicotine gum 2mg – solo therapy max 15 pieces in 24hrs Advice patients to chew the gum until there is a hot/peppery taste then rest the gum between the lip and gum – “chew and park”. Excessive chewing may cause indigestion & hiccups. Aim to have one piece on the hour every hour.o 2mg – solo therapy max 15 lozenges in 24hrs Aim to suck a lozenge on the hour every hour. If indigestion and hiccups occur try resting the lozenge in the side of the mouth.


Patients can be provided with a starter pack of Oral Nutritional Supplements whilst waiting formal dietician assessment:

Assess risk of malnutrition

Both starter packs can be ordered for free by healthcare professionals via an nhs email address at the website: https://nualtra.com/uk-healthcare-professional-samples/

7 x 63g Sachets, 385kcal per serving (made with 200ml whole milk), added 5g fiber

Flavours: Vanilla, Chocolate, Strawberry, Banana, Natural

4 x 120mls, 420kcal, 6g protein

Foodlink Complete Sachets with Fibre: Altrashot:

Nutritional Care Pathway

MUST Score 0 = Low Risk

MUST Score 1 = Moderate Risk

MUST Score ≥2 = High Risk

No action needed

Provide Patient Information Leaflet ‘Eating to be Stronger’ Consider dietician referral and oral

nutritional supplements (2xONS/day)

Provide Patient Information Leaflet ‘Eating to be Stronger’, refer to Dietician Team & commence oral nutritional supplements immediately (2xONS/day)

urgent thoracic assessment proforma · time for decalcification and inability to do molecular...

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