Chemotherapy AuditChemotherapy Audit Audit of patients who died within three Audit of patients who died within three

months of their last dose of chemotherapy months of their last dose of chemotherapy at Airedale General Hospital at Airedale General Hospital

The records of 50 patients who had died within The records of 50 patients who had died within three months of their last dose of chemotherapy three months of their last dose of chemotherapy were identified and then examined according to a were identified and then examined according to a proforma.proforma.

The aim was to have an estimate of the incidence The aim was to have an estimate of the incidence of this occurrence, to audit record keeping, of this occurrence, to audit record keeping, decision making, and to try and assess if decision making, and to try and assess if chemotherapy had been appropriately given.chemotherapy had been appropriately given.

Chemotherapy AuditChemotherapy Audit Reviewing the literature there is very little information on Reviewing the literature there is very little information on

what the expected percentage of cancer patients who die what the expected percentage of cancer patients who die within three months of chemotherapy is.within three months of chemotherapy is.

A study from Massachussetts in 1996, looking at a A study from Massachussetts in 1996, looking at a population of 8,000 cancer patients found thatpopulation of 8,000 cancer patients found that

41% of patients received chemotherapy in the last year of 41% of patients received chemotherapy in the last year of lifelife

33% in the final 6 Months33% in the final 6 Months 25% in the final 3 months25% in the final 3 months 9% in the last month9% in the last month They tried to assess if chemotherapy had been given They tried to assess if chemotherapy had been given

appropriately dividing patients in to groups of tumours appropriately dividing patients in to groups of tumours thought to be sensitive to chemothotherapy and those not . thought to be sensitive to chemothotherapy and those not . They found no difference in rates of treatment givenThey found no difference in rates of treatment given

Chemotherapy AuditChemotherapy Audit

No comparable data could be found for the No comparable data could be found for the UK or more recent.UK or more recent.

The population served by AGH is The population served by AGH is approximately 205,000approximately 205,000

Approx Number of Deaths from Cancer per Approx Number of Deaths from Cancer per year year

Craven : 145Craven : 145 Airedale : 341Airedale : 341 Pendle : 47Pendle : 47 Total : 533Total : 533

Chemotherapy AuditChemotherapy Audit 48 sets of notes found and audited48 sets of notes found and audited Covering a period from 4/4/02 to 31/01/03 Covering a period from 4/4/02 to 31/01/03

approximately 10 months All patients were approximately 10 months All patients were receiving palliative chemotherapy not adjuvantreceiving palliative chemotherapy not adjuvant

Equivalent to 1.2 X 48 deaths per year = 58 Equivalent to 1.2 X 48 deaths per year = 58 deaths per year within 3 months of deaths per year within 3 months of chemotherapy. chemotherapy.

11% of patients dying from cancer had 11% of patients dying from cancer had chemotherapy within the last 3 months within chemotherapy within the last 3 months within AGH catchment area.( This does not include AGH catchment area.( This does not include private patients or those receiving chemotherapy private patients or those receiving chemotherapy else where)else where)

AuditAudit

SexSex Female : 26(54%)Female : 26(54%) Male : 22 (45%)Male : 22 (45%) Age RangeAge Range 41 - 5041 - 50 4 (8%)4 (8%) 51 - 6051 - 60 11(23%)11(23%) 61 - 7061 - 70 13(27%)13(27%) 71 - 8071 - 80 17(36%)17(36%) 81 – 9081 – 90 3 (6%)3 (6%)

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

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

All Trust Patients

Oncology Deaths 0304

monthyeardisch Total

Apr-03 2

May-03 3

Jun-03 1

Jul-03 8

Aug-03 5

Sep-03 3

Oct-03 5

Nov-03 2

Dec-03 2

Jan-04 5

Feb-04 6

Mar-04 8

Grand Total 50

Oncology Inpatient Deaths 03/04Oncology Inpatient Deaths 03/04(All Deaths : 830)(All Deaths : 830)

Oncology Deaths Average

Length of Stay(DAYS) 0304

monthyeardisch Total

Apr-03 9.0

May-03 12.7

Jun-03 11.0

Jul-03 11.3

Aug-03 7.8

Sep-03 7.0

Oct-03 11.2

Nov-03 7.5

Dec-03 10.5

Jan-04 9.8

Feb-04 14.5

Mar-04 12.0

Grand Total 10.8

Diagnosis of Patients who died within 3 Diagnosis of Patients who died within 3 months of their chemotherapymonths of their chemotherapy

Cancer DiagnosisCancer Diagnosis Number of Patients (days from last Number of Patients (days from last chemotherapy to chemotherapy to

death)death)

Non small cell lungNon small cell lung 14 (4, 10, 16, 21, 23, 26, 26, 34, 38, 46, 14 (4, 10, 16, 21, 23, 26, 26, 34, 38, 46, 49,54, 73,84)49,54, 73,84) Colo-RectalColo-Rectal 9 (9, 18, 21, 21, 23, 36, 41, 55, 58)9 (9, 18, 21, 21, 23, 36, 41, 55, 58)

Ca PancreasCa Pancreas 7 (1, 8, 9, 11, 15, 20, 59)7 (1, 8, 9, 11, 15, 20, 59)

Small Cell Ca LungSmall Cell Ca Lung 5 (2, 4, 5, 37, 5)5 (2, 4, 5, 37, 5)

Breast CancerBreast Cancer 5 (9, 13, 27, 42, 5)5 (9, 13, 27, 42, 5)

OvarianOvarian 4 (13, 27, 40, 4)4 (13, 27, 40, 4)

BladderBladder 1 (12)1 (12)

Diagnosis *2000 *2001 *2002 *2003 *2004 Total

Breast 63 72 51 57 88 331

Colon 25 35 24 23 33 140

NSCCL 13 23 28 16 43 123

SCLC 19 22 13 19 20 93

Ovary 10 12 14 5 40 81

Rectal 9 16 14 13 25 77

Pancreas 8 5 7 11 17 48

Bladder 5 8 11 14 6 44

Gastric 9 9 2 5 17 42

Oesophageal 6 11 5 4 11 37

Adeno 3 8 5 8 8 32

Prostate 1 1 0 6 9 17

Mesothelioma 0 3 1 3 7 14

Unknown 4 1 5 1 1 12

Endometrial 0 0 0 1 3 4

Malignant Melanoma 2 0 1 0 1 4

Cholangio 1 0 1 0 2 4

Peritoneal 0 0 2 1 1 4

Renal 1 1 1 0 0 3

Others 12

Total 1122

Chemotherapy

Given by

Diagnosis

2000 to

Oct 31st 2004

Diagnosis of Patients who died within 1 Diagnosis of Patients who died within 1 month of their chemotherapymonth of their chemotherapy

Cancer DiagnosisCancer Diagnosis Number of Patients (days Number of Patients (days

from last chemotherapy from last chemotherapy to death)to death)

Non small cell lungNon small cell lung 77 (4, 10, 16, 21, 23,26, 26) (4, 10, 16, 21, 23,26, 26) Ca PancreasCa Pancreas 66 (1, 8, 9, 11, 15, 20) (1, 8, 9, 11, 15, 20) Colo-RectalColo-Rectal 55 (9, 18, 21, 21, 23) (9, 18, 21, 21, 23) Small Cell Ca LungSmall Cell Ca Lung 33 (2, 4, 5) (2, 4, 5) Breast CancerBreast Cancer 33 (9, 13, 27) (9, 13, 27) OvarianOvarian 22 (13, 27) (13, 27) BladderBladder 11 (12) (12)

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

Cancer DiagnosisCancer Diagnosis Number of Number of PatientsPatients

(days from last (days from last chemotherapy to death)chemotherapy to death)

Small Cell Ca Lung Small Cell Ca Lung 3 (2, 4, 5)3 (2, 4, 5) Non Small Cell Lung Non Small Cell Lung 1 (4)1 (4) PancreasPancreas 1 (1)1 (1)

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

Cancer DiagnosisCancer Diagnosis Number of Patients (days from last Number of Patients (days from last

chemotherapy to death)chemotherapy to death)

PancreasPancreas 3 (8, 9, 11) 3 (8, 9, 11) BreastBreast 2 (9,13) 2 (9,13) ColonColon 1 (9 ) 1 (9 ) BladderBladder 1 (12) 1 (12) Non Small Cell Ca Lung 1 (10)Non Small Cell Ca Lung 1 (10) OvaryOvary 1 (13) 1 (13)

Chemotherapy Regimen and DeathChemotherapy Regimen and Death within three months within three months

Regime Regime Number of Deaths within 3 monthsNumber of Deaths within 3 months

VinorelbineVinorelbine 66 5 FU and Folinic Acid5 FU and Folinic Acid 55 (Mitomycin,Vinblastin,(Mitomycin,Vinblastin, 55 Cisplatin)Cisplatin) ECFECF 55 CarboplatinCarboplatin 44 GemcitabineGemcitabine 33 (Doxorubicin,Vincristine(Doxorubicin,Vincristine 33 +/-Cyclophosphamide)+/-Cyclophosphamide) (Vinorelbine,Cisplatin)(Vinorelbine,Cisplatin) 22 Liposomal DoxirubicinLiposomal Doxirubicin 22 ExatecanExatecan 22 IrinotecanIrinotecan 22 OthersOthers 99

Number of patients NeutropenicNumber of patients NeutropenicNear to or on day of deathNear to or on day of death

5 patients were neutropenic at death 5 patients were neutropenic at death

Patient No DiagnosisPatient No Diagnosis Last Chemo Last Chemo Days from Days from deathdeath

17 Pancreas17 Pancreas ExatecanExatecan 8 8 44 NSCCL44 NSCCL VinorelbineVinorelbine 1010 42 Ovary42 Ovary Lip DoxorubicinLip Doxorubicin 1313 5 Colorectal5 Colorectal 5FU + Folinic acid 5FU + Folinic acid 1818

26 Breast26 Breast FECFEC 62 62 6 other patients were neutropenic within 2 weeks of death 6 other patients were neutropenic within 2 weeks of death

but their counts had risen prior to deathbut their counts had risen prior to death

Deaths Within Three Months of Last Dose of Chemotherapy Over a 10 Month Period from

04/04/02 to 31/01/03

4

9

7

6

1

7

2

1

3

0

2

1

0

1

2

3

4

5

6

7

8

9

10

Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 Week 9 Week 10 Week 11 Week 12

Weeks since last chemotherapy

Nu

mb

er o

f P

atie

nts

Time from first ever Chemotherapy to DeathIn Patients who died within three months of their last

chemotherapy

0

2

4

6

8

10

12

Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Month10

Month11

Month12

Greaterthan 1year

Time in Months

Nu

mb

er o

f P

atie

nts

Series1

Age Range of Patients Who Died Within Three Months of Receiving Chemotherapy

4

11

13

17

3

0

2

4

6

8

10

12

14

16

18

41-50 yrs 51-60 yrs 61-70 yrs 71-80 yrs 81- 90 yrs

Age

Nu

mb

er o

f P

atie

nts

Series1

Age of Patient and number of Days from Last Chemotherapy Until Death

0

10

20

30

40

50

60

70

80

90

0 10 20 30 40 50 60 70 80 90

Age Of Patient

Nu

mb

er o

f d

ays

fro

m la

st c

hem

oth

erap

to

dea

th

Series1

Number of Days spent in Hospital during the patients last 13 weeks before death

1

13

12

9 9

0

2

4

6

8

10

12

14

0 Days 1-7 Days 8 - 14 Days 15 - 31 Days > 31 Days

Number of Days

Nu

mb

er o

f P

atie

nts

Series1

Patients Performance Status Meausured at Last Medical Contact

Yes 42%(20)

No 48%(23)

Not Recorded 10%(5)

Evidence in the notes of discussion with the patient about stopping chemotherapy (N=48)

Yes42%

No52%

Not Recorded6%

Had a formal descision to stop chemotherapy been recorded in the notes (N = 48)

Yes33%

No61%

Not Recorded6%

Was Palliative Care Team Involved with the Patient

Yes52%

No33%

Not Recorded15%

DNR Recorded in The Notes

Yes57%

No43%

Recent Performance Status Recorded

Yes45%

No55%

Patients Views On Treatmant Noted

Yes64%

No36%

At Last Medical Assessment Disease Considered To Be

61%

6%

17%

10%6%

Progressive Disease

Responding to Treatment

Stable Disease

To Early to Say

Not Recorded

Recent data On Tumour Markers

Yes73%

No27%

Recent Radiology

Yes64%

No36%

ConclusionsConclusions 1 1

All patients were having palliative All patients were having palliative chemotherapychemotherapy

NSCLC and Pancreatic cancers high riskNSCLC and Pancreatic cancers high risk Recording of information not always Recording of information not always

sufficientsufficient No clear documentation of decision No clear documentation of decision

makingmaking This does not mean appropriate decisions This does not mean appropriate decisions

were not made but they were not were not made but they were not recordedrecorded

Conclusions 2Conclusions 2 Difficult to assess appropriateness of Difficult to assess appropriateness of

chemotherapy as information not therechemotherapy as information not there Profroma needed to capture informationProfroma needed to capture information CPR decisions need to be made more CPR decisions need to be made more

routinelyroutinely Deaths within 3 weeks should be routinely Deaths within 3 weeks should be routinely

auditedaudited Need to compare results with other unitsNeed to compare results with other units Need for separate audit of outcomes from Need for separate audit of outcomes from

neutropenic sepsisneutropenic sepsis Place of death more likely to be in hospitalPlace of death more likely to be in hospital

Conclusions 3Conclusions 3

Need for MDT discussion for patients Need for MDT discussion for patients with poor performance statuswith poor performance status

? Review with each cycle? Review with each cycle Consent clinicConsent clinic Survey of patients/carer’s viewsSurvey of patients/carer’s views Role of Palliative care team in these Role of Palliative care team in these

decisions?decisions?

Role of Palliative CareRole of Palliative Care

Palliative Chemotherapy becoming more Palliative Chemotherapy becoming more common. e.g. Lung (NSCCL), Pancreas, 2common. e.g. Lung (NSCCL), Pancreas, 2ndnd 33rdrd 4 4thth 5 5thth line Rx for breast, ovary, line Rx for breast, ovary, colorectal.colorectal.

Some evidence it can improve quality of Some evidence it can improve quality of lifelife

Balance between benefits and burdens Balance between benefits and burdens becoming more difficult to assess.becoming more difficult to assess.

Needs ongoing research and collaborationNeeds ongoing research and collaboration3333

Possible Proforma 1Possible Proforma 1

Palliative chemotherapy assessment for ongoing Palliative chemotherapy assessment for ongoing treatmenttreatment

Should treatment continue, stop or be changedShould treatment continue, stop or be changed Performance status (last 4)Performance status (last 4) QOL question (last 4)QOL question (last 4) Tumour markers last 4 results (or graph)Tumour markers last 4 results (or graph) Recent radiology Summary of findingsRecent radiology Summary of findings Disease respondingDisease responding StableStable ProgressiveProgressive

Possible Proforma 2Possible Proforma 2

Side effects from treatmentSide effects from treatment Recent episodes of Recent episodes of

Neutopenia/thrombocytopenia/anaemiaNeutopenia/thrombocytopenia/anaemia Dose reduction consideredDose reduction considered Patients view on continued treatmentPatients view on continued treatment KeenKeen

AmbivelentAmbivelent Not keenNot keen

CPR statusCPR status

Possible Proforma 3Possible Proforma 3

Overall aim of treatmentOverall aim of treatment Symptom ControlSymptom Control Prolong life by weeksProlong life by weeks Prolong life by monthsProlong life by months Known to specialist palliative care Known to specialist palliative care

serviceservice Views of other HCP’sViews of other HCP’s Is patient well informed of the aboveIs patient well informed of the above Conclusion : Conclusion :

Check List Prior To Each Dose Check List Prior To Each Dose ChemotherapyChemotherapy

Performance status ? Barthel ScorePerformance status ? Barthel Score Evidence of disease status, clinical Evidence of disease status, clinical

and objective (radiological, tumour and objective (radiological, tumour markers etc)markers etc)

Side Effects of Treatment (toxicity)Side Effects of Treatment (toxicity) Patients Views and understandingPatients Views and understanding Support MechanismsSupport Mechanisms