Minutes Bristol Testicular Cancer Service AGM – 9th July 2010 ...

Attendees (part one)Attendees (part two)ApologiesPart One: discussion ofPoor Prognosis patientsand other patients ofsignificance.Minutes Bristol Testicular Cancer Service AGM – 9 th July 2010Dr Jeremy Braybrooke Consultant Medical Oncologist (Lead Clinician)(JPB)Sue Brand Germ Cell CNS (SB)Dr Anne Hong Consultant Oncologist (Exeter)AHDr Susanna Alexander Locum Consultant Medical Oncologist (SA)Dr Anna Sanders SPR (AS)Dr Waheeda Owadally SPR (WO)Tristan Grey Research Nurse (TG)Dr Rachel McCoubrie Consultant Palliative Care Team (RM)Dr Gareth Ayres SPR (GA)Dr Jeremy Braybrooke Consultant Medical Oncologist (Lead Clinician)(JPB)Sue Brand Germ Cell CNS(SB)Dr Anne Hong Consultant Oncologist (Exeter)(AH)Dr Susanna Alexander Locum Consultant Medical Oncologist (SA)Dr Amit Bahl Consultant Clinical Oncologist (AB)Dr Anna Sanders SPR (AS)Dr Waheeda Owadally SPR (WO)Tristan Grey Research Nurse (TG)Dr Rachel McCoubrie Consultant Palliative Care Team (RM)Dr Gareth Ayres SPR (GA)Julia Hardwick Uro-oncology CNS (JH)Mr Mike Morgan Patient Representative (MM)Dr Julian Kabala Consultant Radiologist (JK)Susie Heyworth Sperm Storage Specialist Counsellor (SH)Cathy Chesham Service Improvement(CC)Teresa Levy Cancer Services Manager (TL)Patricia McClarnon ASWCS Lead manager (PM)Toni-Marie Harvey – MDT coordinator (TMH)Mr Tim Whittlestone Urology Specialist SurgeonDr Roger Owen Consultant Oncologist (Cheltenham)Ian Ingledew Consultant Nurse (Cheltenham)Dr Duncan Wheatley Consultant Oncologist (Truro)1. Patient 1. (Referral Yeovil District Hospital): Open discussion about this young man who was diagnosedwith an Intermediate Prognosis NSGCT. Tumour Markers AFP 4223, HCG 1419 & LDH 1640. CT scanshowed metastasis in Retroperitoneal Lymph Nodes and Chest. Received primary orchidectomy prechemotherapy,then developed wound breakdown and subsequent wound infections, involving a very

prolonged stay in hospital. Whilst the patient required morphine for pain relief for his metastatic disease,he then required intensive pain management to change his wound dressings. AH commented that thesecases are rare and some teams find decision making hard, especially when the onus is on histology formost cancers.Recommendation: The team advised that all patients who fall into the Intermediate or Poor Prognosisstage of disease, or those with systemic symptoms, should be discussed with the Testicular Cancerconsultants prior to primary surgery. To be added to the referral guidelines and clinical guidelines.2. Patient 2: (Referral from Weston General Hospital): Admitted to WGH as an emergency with left sidedgroin and abdominal pain and raised HCG & LDH. Remained there for 3 days and then reviewed byurologist; discharged to have orchidectomy 6 days later. Dr Hillman discussed his case with Dr SusannaAlexander; he was admitted to ward 61 as an emergency and chemotherapy started immediately.Recommendation: The team advises primary referral centres that if they suspect a germ cell cancer andthe patient has pain and other symptoms to discuss with the Testicular Cancer consultants immediately.3. Patient 3: (Referral from Royal United Hospital): See attached slides.There was a very long discussion around the issues of drug toxicity, CT scans and symptoms, the MDTdiscussions relating to the dry cough and subsequent ADR. SA raised the issue of O2 therapy andbleomycin toxicity and JPB talked about the risks during anaesthetic. SB relayed to the team that the familywere not angry and fully understood that participating in the CT was patient choice and wanted us to knowthey were happy with his care and wanted to thank us for our care.Recommendation: The recommendation from RM was to consider earlier referral to their services;however SB stated how difficult this can be when the treatment aim remains radical/curative, but wouldhave benefited from the support from another team. SB has also spoken with the GP and with thepatient’s mother to arrange a mediated discussion with the initial GP as they still quite angry about hisdiagnosis and delays in referral.4. Patient NC (referral Royal United Hospital Bath): See attached slides.No problems to date with NC. SB said she has spoken with him at length he is coping psychologically verywell.Part TwoSpeaker Subject Discussion Action PointsDr Jeremy Braybrooke Introduction, agenda for theafternoon and what we doCathy Chesham MDT attendance and cancellationsReview of Current Clinical GuidelinesDr Susanna Alexander TIP Protocol (see slides) SB: thought that patients did cope well with the Action SB & SAtoxicity of the regimen better that BEP & EP andmost agreed.

Dr Amit Bahl11A & 11B Seminoma RT alone versusRT + Carboplatin x 1 AUC 7AB: Not only to consider the toxicity of theregimen, but also the logistics of 24 hour Paclitaxel.JPB: Did not believe in change for change sake andsuggested review the toxicity and recurrence ratesof all patients who have received TIP in the last 10years to build a picture of the need to change.SA: Consider the Pharmacokinetics of Paclitaxel, asin USA administered over 24 hoursContinue with current practiceJPB: It would be very difficult to do a Clinical Trialdue to numbers, all agreed.SB: Felt there was a need for a systemic treatment,however did feel that BEP/EP seemed to be overtreating and this option was a compromise, withless late effects.SA: mentioned that the Royal Marsden hadpresented a poster regarding the schedule.AB: explained how give systemic treatment wouldreduce the RT field.AH: agreed that to reduce the RT field this wouldreduce toxicity.SB: asked which order they would be given in, JPB& AB stated Carboplatin to be given first.Also this change of practice would not changeSperm Storage procedures.All agreed that this would be recommended as anoption in the Clinical GuidelinesDr Jeremy Braybrooke The role of High Dose Treatment JPB: Was very keen to participate in the TICE studya National Study for relapsed patients.SB: Felt we should tighten up our guidelines inrelation to patients with Mediastinal Primary.JPB: agreed and felt we needed to promote thebest for patients.AH: felt the problem of changing practice was thevery small numbers of patients and she normallyreferred patients to a larger centre when theybecome very complex.AB: To word this inthe currentguidelines by 16 thJuly 2010.JPB: To discusswith theHaematologistsTandem High Doseand changing theregimen by endDecember 2010.

Continue with current practice, but tighten upguideline wording.Dr Susanna Alexander Female Germ Cell Cancers JPB: Chemotherapy regimens are agreed for thisgroup of patients, however small numbers make itvery difficult to carry out clinical trialsSA: feels we need a better referral pathway andguidelines. Specific chemotherapy regimens onChemo Care for female germ cell patientsJPB: Also mentioned the role of Tumour Markers infemale germ cell cancers, especially very high AFPand questioned the role of chemotherapy first aslike male germ cell cancers.Julia Hardwick for Mr TimWhittlestoneRPLND data and plans for the serviceJPB: Thanked Julia and expressed that TW isproviding a very good service. Concern aboutsustainability of continuing to work as a singlesurgeon. Would be happy to help develop a jointclinic.SB: Questioned what a centralised urology servicewould mean for the UHB service, as this was verygood for patients at the moment due to thelogistics of seeing patients post-op.TL: stated that consultation regarding thecentralising of services had just begun and this wasan opportunity for the team to express theirconcerns.JPB: Asked JH if a business plan had beenproduced/presented regarding a second surgeonfor the service and JH said she would ask TW on hisreturn.Dr Julian Kabala Seminoma and PET scanning AB: Asked if it was possible to PET scan all of theSeminoma stage 11A & 11B which were 1cm andabove.JK: concerned that this was to change treatmentpractice and should we think about a study.AB: stated that even a pilot study numbers wouldbe low and that this was for staging purposes, notto reduce the need for treatment. Also AB statedSA: to investigatethe referralpathway andguidelines with thegynaecology teamby end ofDecember 2010.JH: To check withTW the status ofBusiness planAB: To word thischange in currentClinical Guidelines

that this will help with RT fields.All agreed that this would be recommended as anoption in the Clinical GuidelinesDr Susanna Alexander Retrospective Audit SA: Limited data and analysis presented due to lackof time. Noted time from Orchidectomy to stagingCT needs to improve in referring centres.SB asked MM if there were any audits patientswould like the team to look at. MM: said that heand many of the guys in the user group foundthere were delays from seeing the GP to seeing theurologist/US scan.TL & SB: indicated the guidelines for TesticularCancer are very clear and patients should bereferred on the 2 week rule.SB: asked if it would be possible to do aretrospective audit of time from GP tospecialist/diagnosis.TL: believed this could be done.Tristan Grey ResearchNurseResearch Participation presentationJPB: Thanked Tristan for his presentation andstated that the TE24 study is nationally about oneyear behind recruitment targets.SB: stated that the option of one cycle ofCarboplatin was very tempting to men due theminimal toxicity with reduced recurrence rate.Some men had also did not like the idea of MRIdue to claustrophobia.JPB: believed our overall recruitment was verygood.SB: There were 10 patients in the Sexual FunctionStudy; this is a bit behind target due to the reducednumbers of patients presenting with stage onedisease. She asked the status of 111 Study, as theservice has had 2 referral who would have beeneligible.TG: It could be any time, now as CTU are ready,once the issues with the contract are resolved.SA & SB: to presentto the NSSGmeeting 17 thDecember 2010.SB & TL to look atlogistics of doingan audit GP –diagnosis by endNovember 2010.TG: to ensure teamare informed ofstart of 111 studyand ensure wesubmit anexpression ofinterest for TICEstudy.Dr Susanna Alexander and Results of Patient Survey JPB: good results, some more extraction of the SA & SB: to present

Sue BrandSue BrandIt’s in the bag, patient support andwebsitedata is possibleSB: Would like the survey to go online next yearand to look at some different parts of the service.AH & MM logistics of providing an extra page etc.for other hospitals in the supra-networkSB: Testicular Tool Kit for GP’s on the site andwould like referral guidelines and pathways onthere.MM: the group have worked hard to get theawareness and the Testicular Ball got goodpublicity.SB: The Ball raised approx 8-9K!to the NSSGmeeting 17 thDecember 2010.Teresa Levy Peer Review TL: Talked about the measures we would fail,however there were some improvements since lastyear and we did fair well overall.SB: stated how difficult it was to book on thecommunication course and felt in this was alsodifficult to arrange due to her working hours of22.5 per week and the course would mean a wholeweek out.Dates to remember:Peer Review Visit: 7 th September 2010Urology NSSG 17 th December 2010