Chemotherapy Audit

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Chemotherapy Audit

• Audit of patients who died within three months of
  their last dose of chemotherapy at Airedale
  General Hospital
• The records of 50 patients who had died within
  three months of their last dose of chemotherapy
  were identified and then examined according to a
  proforma.
• The aim was to have an estimate of the incidence
  of this occurrence, to audit record keeping,
  decision making, and to try and assess if
  chemotherapy had been appropriately given.

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Chemotherapy Audit

• Reviewing the literature there is very little
  information on what the expected percentage of
  cancer patients who die within three months of
  chemotherapy is.
• A study from Massachussetts in 1996, looking at a
  population of 8,000 cancer patients found that
• 41 of patients received chemotherapy in the last
  year of life
• 33 in the final 6 Months
• 25 in the final 3 months
• 9 in the last month
• They tried to assess if chemotherapy had been
  given appropriately dividing patients in to
  groups of tumours thought to be sensitive to
  chemothotherapy and those not . They found no
  difference in rates of treatment given

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Chemotherapy Audit

• No comparable data could be found for the UK or
  more recent.
• The population served by AGH is approximately
  205,000
• Approx Number of Deaths from Cancer per year
• Craven 145
• Airedale 341
• Pendle 47
• Total 533

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Chemotherapy Audit

• 48 sets of notes found and audited
• Covering a period from 4/4/02 to 31/01/03
  approximately 10 months All patients were
  receiving palliative chemotherapy not adjuvant
• Equivalent to 1.2 X 48 deaths per year 58
  deaths per year within 3 months of chemotherapy.
• 11 of patients dying from cancer had
  chemotherapy within the last 3 months within AGH
  catchment area.( This does not include private
  patients or those receiving chemotherapy else
  where)

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Audit

• Sex
• Female 26(54)
• Male 22 (45)
• Age Range
• 41 - 50 4 (8)
• 51 - 60 11(23)
• 61 - 70 13(27)
• 71 - 80 17(36)
• 81 90 3 (6)

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Cancers treated over the last 5 years 2000 to Oct
31st 2004

• Sex Ratio F 688(61) M 434(39)
• Age Ranges
• 0-30 7 (.6)
• 31-40 41 (4)
• 41-50 117 (10)
• 51-60 299 (27)
• 61-70 323 (29)
• 71-80 289 (29)
• 81-90 43 (4)

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Oncology Inpatient Deaths 03/04(All Deaths 830)
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Diagnosis of Patients who died within 3 months of
their chemotherapy

• Cancer Diagnosis Number of Patients (days
  from last chemotherapy to
  death)
• Non small cell lung 14 (4, 10, 16, 21, 23, 26,
  26, 34, 38, 46,
• 
  49,54, 73,84)
• Colo-Rectal 9 (9, 18, 21, 21, 23, 36, 41, 55,
  58)
• Ca Pancreas 7 (1, 8, 9, 11, 15, 20, 59)
• Small Cell Ca Lung 5 (2, 4, 5, 37, 5)
• Breast Cancer 5 (9, 13, 27, 42, 5)
• Ovarian 4 (13, 27, 40, 4)
• Bladder 1 (12)

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Chemotherapy Given by Diagnosis 2000 to Oct 31st
2004
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Diagnosis of Patients who died within 1 month of
their chemotherapy

• Cancer Diagnosis Number of Patients (days
• from last
  chemotherapy to death)
• Non small cell lung 7 (4, 10, 16, 21, 23,26, 26)
• Ca Pancreas 6 (1, 8, 9, 11, 15, 20)
• Colo-Rectal 5 (9, 18, 21, 21, 23)
• Small Cell Ca Lung 3 (2, 4, 5)
• Breast Cancer 3 (9, 13, 27)
• Ovarian 2 (13, 27)
• Bladder 1 (12)

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Diagnosis of Patients who died within 1 week of
their last dose of chemotherapy

• Cancer Diagnosis Number
  of Patients
• 
  (days from last chemotherapy to death)
• Small Cell Ca Lung 3 (2, 4, 5)
• Non Small Cell Lung 1 (4)
• Pancreas 1 (1)

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Diagnosis of Patients who died within 1 to 2
weeks of their last dose of chemotherapy

• Cancer Diagnosis Number of Patients (days from
  last
• 
  chemotherapy to death)
• Pancreas 3 (8, 9, 11)
• Breast 2 (9,13)
• Colon 1 (9 )
• Bladder 1 (12)
• Non Small Cell Ca Lung 1 (10)
• Ovary 1 (13)

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Chemotherapy Regimen and Death within three
months

• Regime Number of
  Deaths within 3 months
• Vinorelbine 6
• 5 FU and Folinic Acid 5
• (Mitomycin,Vinblastin, 5
• Cisplatin)
• ECF 5
• Carboplatin 4
• Gemcitabine 3
• (Doxorubicin,Vincristine 3
• /-Cyclophosphamide)
• (Vinorelbine,Cisplatin) 2
• Liposomal Doxirubicin 2
• Exatecan 2
• Irinotecan 2
• Others 9

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Number of patients NeutropenicNear to or on day
of death

• 5 patients were neutropenic at death
• Patient No Diagnosis Last Chemo
  Days from
• 
  
  death
  
• 17 Pancreas Exatecan 8
• 44 NSCCL Vinorelbine 10
• 42 Ovary Lip Doxorubicin
  13
• 5 Colorectal 5FU
  Folinic acid 18
• 26 Breast FEC 62
• 6 other patients were
  neutropenic within 2 weeks of death but their
  counts had risen prior to death

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Conclusions 1

• All patients were having palliative chemotherapy
• NSCLC and Pancreatic cancers high risk
• Recording of information not always sufficient
• No clear documentation of decision making
• This does not mean appropriate decisions were not
  made but they were not recorded

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Conclusions 2

• Difficult to assess appropriateness of
  chemotherapy as information not there
• Profroma needed to capture information
• CPR decisions need to be made more routinely
• Deaths within 3 weeks should be routinely audited
• Need to compare results with other units
• Need for separate audit of outcomes from
  neutropenic sepsis
• Place of death more likely to be in hospital

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Conclusions 3

• Need for MDT discussion for patients with poor
  performance status
• ? Review with each cycle
• Consent clinic
• Survey of patients/carers views
• Role of Palliative care team in these decisions?

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Role of Palliative Care

• Palliative Chemotherapy becoming more common.
  e.g. Lung (NSCCL), Pancreas, 2nd 3rd 4th 5th
  line Rx for breast, ovary, colorectal.
• Some evidence it can improve quality of life
• Balance between benefits and burdens becoming
  more difficult to assess.
• Needs ongoing research and collaboration33

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Possible Proforma 1

• Palliative chemotherapy assessment for ongoing
  treatment
• Should treatment continue, stop or be changed
• Performance status (last 4)
• QOL question (last 4)
• Tumour markers last 4 results (or graph)
• Recent radiology Summary of findings
• Disease responding
• Stable
• Progressive

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Possible Proforma 2

• Side effects from treatment
• Recent episodes of Neutopenia/thrombocytopenia/ana
  emia
• Dose reduction considered
• Patients view on continued treatment
• Keen
• Ambivelent
• Not keen
• CPR status

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Possible Proforma 3

• Overall aim of treatment
• Symptom Control
• Prolong life by
  weeks
• Prolong life by
  months
• Known to specialist palliative care service
• Views of other HCPs
• Is patient well informed of the above
• Conclusion

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Check List Prior To Each Dose Chemotherapy

• Performance status ? Barthel Score
• Evidence of disease status, clinical and
  objective (radiological, tumour markers etc)
• Side Effects of Treatment (toxicity)
• Patients Views and understanding
• Support Mechanisms