Chemotherapy delivery: challenges for the future

Chemotherapy delivery: challenges for the future

Gill Donovan, Director of Patient Services, Cancer Care Cymru and Velindre Cancer Centre, Cardiff

Introduction

As a result of the rising incidence of cancer and the expanding range of treatments available, UK cancer services are working under growing pressure.^1,2 In this article I will discuss national and local strategies for coping with the demand for cancer care, looking specifically at the issues of patient capacity and the drive to deliver cancer treatments nearer to patients’ homes. I will also reflect on examples of practices that have had a positive impact on service delivery.

The size of the challenge

It is estimated that 1 million people alive now in the UK have been diagnosed with cancer, and that a further 250,000 people a year will develop a malignant condition.¹ The incidence of cancer is rising—the overall rate has increased by 31% since the 1970s, but mortality has fallen by 12% during the same time period.² Moreover, as the population ages, the numbers diagnosed with cancer will increase.¹ Knowledge about cancer is also on the increase, bringing greater ability to provide effective treatments—curative interventions and those that slow disease progression or mitigate its effects. Patients with cancer are now offered multiple interventions that were not possible just a few years ago. However, these new treatments are often in addition to, rather than a replacement for, existing options, and they are given over a prolonged period of time, again increasing the pressure on cancer services. The Commission for Health Improvement has estimated that more than 50% of people diagnosed with cancer will be given chemotherapy,³ a number that is expected to increase in the near future.² All of these factors place additional demands on already overstretched services.

A survey of 42 hospitals, published in 2003, found a huge increase in the use of intravenous chemotherapy over the previous 3 years. The average increase was 200%, with some hospitals reporting a 500% rise. Unsurprisingly, this increase has had a significant impact on the pressures faced by the cancer care workforce.²

Current chemotherapy pathways

The exact details of how individuals progress through an outpatient chemotherapy clinic depend on the specific treatments being administered, but there are some distinct steps in the typical patient pathway (Figure 1).

The pathway summarised in Figure 1 is time-consuming and requires patients and their families to be in the hospital for up to 8 hours.

Many cancer services rely on outdated systems that do not address issues of current pressing concern, such as capacity, delays in starting potentially curative treatments or meeting patients’ wishes for treatment delivery closer to their homes.

Scheduling of chemotherapy

Staff and patients in our clinics say that problems with the scheduling of chemotherapy are a major contributory factor to poor service delivery. Indeed, many of the systems designed to enable nurses to schedule chemotherapy are prone to error, awkward to use and limited in the information they display.⁴

More efficient scheduling of chemotherapy appointments is one of the aims of the Chemotherapy Oncology Planning Resource Tool (C-PORT), which has been designed by the Pharmaceutical Oncology Initiative Partnership (POIP) in association with the Cancer Action Team and the NHS.⁵ The benefits of C-PORT became clear when it was piloted in a small number of cancer networks in 2005, and the system is now being rolled out to 34 other cancer networks throughout the UK. C-PORT is a simulator that allows networks to model how different drug regimens, patient flows, resource levels and unit organisation can affect the chemotherapy unit. For example, it can forecast how each individual patient will experience care, how long they will wait and how much care they will receive. It can be used to recreate real life situations such as equipment breakdown or absenteeism to see how they will affect treatment. It can also be used to compare differences at local, regional and national level allowing comparisons between NHS trusts.

Capacity issues

Moving cancer treatments into the community setting, when clinically appropriate, can reduce demands on specialist centres² as well as improving patient and family experiences. Delivery of chemotherapy in the community is not a new concept; the NHS Cancer Plan⁶ and the NHS Manual of Cancer Service Standards⁷ both recognised that initiatives were needed to address the emerging issues of providing oncology treatments in more efficient and effective ways.

There is a distinct lack of research into the delivery of chemotherapy outside of traditional settings. However, investigators have identified that some fundamental issues need to be addressed when considering the delivery of cytotoxic treatments in the community.^8-10 For example, appropriate infrastructures must be put in place,⁸ effective communication is essential between primary and secondary care, and there is a need to prioritise the education of all those involved in the delivery of oncology treatments.¹⁰

The issues highlighted above mirror those discussed in the Cancer Reform Strategy of 2007.¹¹ There is now a need to deliver these reforms and monitor their effectiveness.

There are many examples of chemotherapy being delivered outside of specialist cancer units, for example, treatment in haematology units, and the outreach services that most cancer centres offer to district general hospitals within their geographical locations. Several oral treatment formulations are now available for patients with cancer, for example, certain chemotherapy agents, bisphosphonates and monoclonal antibodies, enabling administration in local settings, including patients’ homes. Some patients in the west of England now even have access to a mobile chemotherapy unit (Panel 1).¹² There can be reluctance to deliver certain intravenous chemotherapy agents, for example, docetaxel (Taxotere™), outside of the specialist setting. However, no such restrictions exist in the private sector, where well run, structured services are being delivered in patients’ homes by specialist chemotherapy nurses. This policy suggests that consultant oncologists who treat private patients are confident of the safe delivery of Taxotere and other treatments in the home. Clearly some questions need to be asked:

• Why is Taxotere considered safe to use in the community in the private sector but not in the NHS?
• Is there an educational issue for NHS outreach chemotherapy nurses in the community setting?

Nevertheless, there is a need for caution when seeking solutions to capacity issues and trying to comply with government initiatives. It is important to make sure the safety and efficacy of treatments are not compromised by use of novel treatment settings. For example, some authors suggest that oral and intravenous chemotherapy require similar levels of care, and that community-based treatment may require greater attention to patient education and involvement.¹³

More localised care could also have implications for cancer centres themselves. For example, there is a risk that the deployment of chemotherapy staff in the community could create skill-mix problems in the specialist base. The overall impact of community initiatives will be monitored with interest.

The national agenda

The National Chemotherapy Advisory Group (NCAG) is considering all aspects of chemotherapy, using a care pathway approach (i.e. assessment, decision making, prescribing, dispensing, delivery, reassessment and management of complications),¹¹ and its report is due soon. It is expected to call for new models of chemotherapy delivery.

Meanwhile, the Cancer Reform Strategy sets out a range of ways in which service models for cancer can be improved,¹¹ based on two key principles:

• Care should be delivered locally wherever possible to maximise patient convenience
• Services should be centralised where necessary to improve outcomes

The strategy also highlights the treatment safety concerns expressed by the National Patient Safety Agency (NSPA), and stresses the important role for specialist nurses in delivering the national recommendations on chemotherapy. (See Panel 2 for an outline of a successful breast cancer clinic run by a specialist nurse and specialist pharmacist.¹⁴)

Full implementation of the Working Time Directive¹⁶ in the NHS will mean that more full-time equivalent staff will be needed to provide the same level of capacity as before. It is therefore imperative that extended roles for nurses and pharmacists become a part of the normal specialist training for these professionals.

Panel 2: A specialist nurse/pharmacist clinic¹⁴

Meeting the challenges

The Cancer Reform Strategy is ambitious. However, it has been written in consultation with all stakeholders, which may improve the likelihood that some of its plans will be delivered.

As a specialist breast oncology nurse, I feel the profession has to rise to the current challenges, and deliver a high-quality service to patients. We need to:

• Address the issues of funding and affordability in an open and honest way, but also look at new ways of delivering care within our current structures and resources
• Learn from the many outstanding examples of good practice in the oncology setting—in the UK and in other parts of the world
• Support, motivate and educate the workforce
• Forge strong partnerships between primary and secondary care and be willing to learn from each other
• In this way, we can deliver cancer services that not only give patients the most effective treatment for their cancer, but also choose methods and settings that are acceptable to them

Conclusions

I have described some of the challenges that face professionals working in oncology. The rise in cancer incidence and the emergence of newer and targeted treatments mean there is now a need to address how to deliver the best and most effective treatments to patients using the resources allocated. There are many obstacles to overcome, but all of us who work in the 21st century health service can contribute to finding—and implementing—the solutions. These are exciting times indeed.

This article was previously published in Issue 24 of Breast Cancer Forum.

References

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