Palliative radiotherapy is a large proportion of our radiotherapy work. We often do it well, but there are circumstances where patient and staff experience can be improved. The focus of this work is around the timely planning and delivery of high quality radiotherapy for patients who are symptomatic from metastatic cancer, as such RT needs to be discussed, agreed, planned and delivered rapidly. This is somewhat reactive work as by definition, it is not planned far in advance (typical turnaround is within a week). It is often ambulatory/OP based but does overlap a lot with IP/AOS work as how we manage emergency RT also needs to be considered.
Pathways often work well, for example if a patient is in clinic with an experienced oncologist who can discuss/decide/consent/plan easily. We do not need to change this or interfere when things are done smoothly and well.
There are other situations where it is not so easy to deliver palliative radiotherapy to symptomatic/emergency patients. Our focus is to improve those areas where the pathway does not work so well – which can impact on patient experience or staff wellbeing (through the additional work of planning this urgent work).
Examples of clinical situations where an enhanced palliative RT service may be of use:
- New cancer diagnosis in HB setting, eg via rapid diagnostic centre or other route, where a patient has symptoms needing RT urgently (as an OP)
- Typically these patients may be referred to multiple oncologists/have long email trails to organise clinic review, especially if they have not got a primary tumour site identified
- Patients under the community palliative care team, not known to an oncologist who need review re possible palliative RT
- Emergency RT cover to build team resilience, training – delivering emergency RT via a multi-professional team
- Supports junior StR clinical oncology trainees who are unable to plan/prescribe independently, medical oncology trainees and consultant who share the on call rota but who are unable to plan/prescribe emergency radiotherapy
- Supports days when demand is high eg when we have multiple emergencies in a short period
- Patients under a medical oncologist where there may not be a readily available clinical oncologist to see/plan
- Periods when staff are away – annual/study/sick leave, working from home/shielding
A palliative radiotherapy service would be beneficial to support both emergency RT for MESCC and other emergency RT situations and also more elective palliative radiotherapy. This needs to be fit alongside other aspects of care and should not disrupt situations when RT can be planned and delivered smoothly and efficiently for example patient with minimal symptoms, known to a clinical oncologist who can be reviewed, consented, planned and treated well and efficiently without any additional input.
It also provides excellent teaching opportunities for all members of the multidisciplinary team.
Important Areas for Consideration
- Patient experience
- We often do this well, but treatment can be delayed eg if a patient is not known to Velindre teams, if staff are away or if clinics are full
- RT bookings tend to be cautious when booking treatment as the date/time when a patient will be planned by a clinician is not guaranteed. Having a more formal pathway will reduce such unnecessary delays and also prevent lost treatment slots as there will be greater reassurance that RT will be ready on time
- Our response to a patient needing urgent RT is often to overbook clinics/squeeze an additional patient in
- This can impact on patient experience (of all patients in that clinic) and staff wellbeing due to delays and workflow
- The other option is to delay seeing the patient which will impact on their treatment timing and quality of life (as the focus in this is patients with symptomatic metastatic cancer)
- Multi-professional service delivery provides career progression opportunities
- Fits with an overall national workforce strategy, prudency, resilience
- Radiotherapy satellite centre
- A purely medical model will be complex and costly across two sites. Developing additional, multi-professional skills around palliative RT will support our workforce planning for the new satellite centre
- Single cancer pathway/regional clinical model
- More rapid review and treatment of newly diagnosed patients eg metastatic cancer, FDT is palliative RT to symptomatic sites
- Development of rapid diagnostic centres in HBs wold align well with a rapid radiotherapy review/consent/planning clinic
- AOS
- Ambulatory care shift. A service focussing on palliative RT can speed discharge from HB hospitals, can avoid admission and shift care to an OP, ambulatory setting
- Supports medical on call rotas (eg medical oncologists on call, junior StRs who cannot plan/prescribe RT) – rota management is easier, reduces the need for 2nd on call
- Can work well with rapid diagnostic centres and developing CUP services (eg GP-RDC-rapid access pall RT service could work very well)
- CUP service
- In development, most likely medical oncology lead
- Large proportion of patients will need palliative radiotherapy
- Timing for palliative radiotherapy
- We need greater flexibility and speed in the pathway to meet the new JCCO targets. An enhanced palliative RT service will help to meet those in a more robust fashion
- Covid surge – more advanced disease/emergencies etc
- Training
- With the new oncology curriculum requiring improved palliative RT experience for both clinical and medical oncology trainees, an enhanced palliative RT pathways helps deliver this
- There is a need to train non-medical professionals to develop new roles, creates career opportunities to develop local talent and attract new talent in.
- Service resilience, wellbeing/leadership, prudency
- A well functioning multi-disciplinary approach can enhance service resilience, helping wellbeing (reducing burden of urgent/unscheduled work on top of scheduled work), enhance leadership opportunities (for example, non-medical colleagues developing advanced/leadership skills plus also creates space for medical staff to deliver leadership roles without the constant need to be available to manage different aspects of the RT pathway)
- Planning things to involve non-medical professionals is a prudent approach
- Further service improvement and research
- A focus on palliative radiotherapy may create opportunities for further service improvement in this area (eg more technical RT planning) and possibly even research projects around palliative radiotherapy – not something we can offer at present.
- Wider developments
- We are currently supporting similar developments in Swansea and N Wales, building on our experiences
- Our involvement in this is not crucial, but without ongoing development at VCC we will be left behind.
Potential risks/down-sides of a palliative radiotherapy service:
- Need to avoid a general, palliative RT team giving simple palliative RT if a more complex, tumour site specific treatment is better;
- Need to avoid disrupting good clinical pathways e.g. patients who can readily be treated without additional support
- Complexity of communication/decision making between ‘parent’ oncology teams and the palliative RT team