Somerset Wilts Avon and Gloucester Cancer Services Living

Somerset, Wilts, Avon and Gloucester Cancer Services Living with and Beyond Cancer Dr Dorothy Goddard Macmillan Associate Medical Director for Cancer RUH

Somerset, Wilts, Avon and Gloucester Cancer Services The problem: increasing demand l. Increasing number of people developing cancer l. Increasing number of survivors 2

Somerset, Wilts, Avon and Gloucester Cancer Services The problem: unmet needs l. Conventional follow up not meeting people’s needs l. Recurrent or new disease not picked up at routine follow up visit 3

Somerset, Wilts, Avon and Gloucester Cancer Services Cancer Survivorship Living with and beyond cancer l. Supporting people from cancer diagnosis through treatment and beyond… n Includes l. New recovery and rehabilitation, (+/- pre-habilitation) models of after care: supported self management n Return to specialist care l. Supporting people with active or advanced disease 4

Somerset, Wilts, Avon and Gloucester Cancer Services Recovery and rehabilitation l. Survivorship recovery package n Holistic needs assessment and care planning – with referral as required n Treatment summary and GP cancer care review n Health and well being event 5

Holistic Needs Assessment and Care Plan National Cancer Survivorship Initiative

Electronic version National Cancer Survivorship Initiative

Somerset, Wilts, Avon and Gloucester Cancer Services Treatment summary l. Essential information for GP n Developed n Designed by Macmillan GP’s to inform GP primary care review 8

Treatment summary and care plan

Somerset, Wilts, Avon and Gloucester Cancer Services Moving On Day Opportunity for survivors to meet with professionals, ask questions, meet allied organisations

Somerset, Wilts, Avon and Gloucester Cancer Services Rehabilitation l. Services such as n ‘Step up’ chronic fatigue service based at RNHRD n Exercise programme with ‘Aquaterra’ service n Dietician n Benefits / advice service n Counselling services or Psychologist 11

Somerset, Wilts, Avon and Gloucester Cancer Services New models of Follow up care n Routine clinical follow up replaced by: Supported self-management for all suitable patients with discharge from clinical follow up on completion of primary treatment. Risk stratified model of care

Somerset, Wilts, Avon and Gloucester Cancer Services New models of Follow up care n ‘Remote’ monitoring (eg blood markers, PSA monitoring, CT scans, colonoscopies, mammography) n Requires effective IT systems to ensure surveillance tests are done, results checked, patient/GP informed n Nurse/Allied health professional follow up/often by telephone or at routine surveillance points » » such as mammography or PSA, CEA feedback include routine Patient Reported Outcome Measures (PROM’s – provide evidence of unmet needs or consequences of treatment)

Somerset, Wilts, Avon and Gloucester Cancer Services Return to specialist care l. Contact Information to patient and GP – in hours / out of hours n Telephone advice n Return for clinical review l. Support for active or advanced disease / late effects l Provided in partnership with primary care l Metastatic cancer nurse specialists l Development late effects services 14

Somerset, Wilts, Avon and Gloucester Cancer Services Late effects Some health and wellbeing issues attributed to consequences of cancer treatment – such as: Post breast cancer: Menopausal symptoms Osteoporosis Pain FATIGUE Lymphoedema – arm and/or breast Post colon cancer: 50% patients after pelvic radiotherapy - left with bowel problems affecting quality of life Post prostate cancer: Erectile dysfunction Post childhood cancer: 60% experience one or more late effects of treatment 10 years following treatment. 15

South West Strategic Clinical Networks ASW Cancer Network Survivorship Group: Identifying and meeting the diverse needs of cancer survivors Aim: To work collaboratively across the Network and Health Community involving all organisations caring for cancer survivors: acute providers, primary care, clinical commissioning groups, community services, charitable organisations and service users Objectives: To develop services within and across organisations to identify and meet the diverse needs of cancer survivors To develop a source of information for services available for cancer survivors First steps: To develop a work programme initially to support specific interventions such as health needs assessments, end of treatment summaries and health & well being clinics. To identify resource implications and process to support commissioning