Correspondence
Recalibrating emergency care in the UK: pulling our weight Noticeably absent from the February Lancet Oncology Editorial1 were any suggestions for contributions that might be made by the oncology specialties to improve the situation in emergency care. A firm understanding of the problem is needed for a meaningful discussion of solutions. However, teasing apart the factors that contribute to the overwhelming of emergency services is difficult, and is more often dictated by conflicting political narratives than by the available evidence. The Editorial emphasises “better resourcing, co-ordination, and integration of GP services, secondary care, and social services”. In terms of co-ordination and integration of services, two ways exist for oncology services to ease pressure on emergency service, improve patient experience, and possibly improve even outcomes. The first of these approaches is direct engagement of oncology specialists with emergency specialties through the establishment of acute oncology services. Data from one of the largest regional oncology networks in the UK showed that the introduction of an acute oncology service led to a reduction in the mean length of stay from 12·8 days to 9·7 days, an improvement of 24%.2 This extra capacity can be used to improve patient flow through the hospital to admit patients in accident and emergency more rapidly. These services are also well placed to identify common reasons cancer patients attend emergency services and to develop strategies to reduce attendances. The second approach is to improve engagement of oncology specialists with palliative care. In addition to the observed reduced emergency attendance in patients with www.thelancet.com/oncology Vol 16 May 2015
palliative care support mentioned in the Editorial, early involvement with palliative care has been shown to improve quality of life, and even overall survival, in the setting of metastatic non-smallcell lung cancer.3 The additional finding by Temel and colleagues, whereby improved overall survival was associated with a significant reduction in aggressive treatment in terminal patients, makes uncomfortable reading for oncologists, especially with the increasing trend in aggressive end-of-life care and its associated increases in emergency department attendances.4 Oncologists are usually the gatekeepers of palliative care for patients with cancer, but often fail to communicate prognoses to patients or ensure realistic expectations for treatment, providing a barrier to the early involvement of palliative care.5 Early engagement with palliative care will benefit both patients and oncology services alike. Doubtless key strategic decisions are needed to improve the situation in emergency care, but all health care specialties have a part to play, oncology included. I declare no competing interests. I am funded by an NIHR Academic Clinical Fellowship.
Ben O’Leary [email protected] Royal Marsden Hospital, Sutton, Surrey, UK; and The Institute of Cancer Research, London SW3 6JB, UK 1 2
3
4
5
The Lancet Oncology. Recalibrating emergency care in the UK. Lancet Oncol 2015; 16: 117. Neville-Webbe H, Carser J, Wong H, et al. The impact of a new acute oncology service in acute hospitals: experience from the Clatterbridge Cancer Centre and Merseyside and Cheshire Cancer Network. Clin Med 2013; 13: 565–69. Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non–small-cell lung cancer. New Engl J Med 2010; 363: 733–42. Ho TH, Barbera L, Saskin R, Lu H, Neville BA, Earle CC. Trends in the aggressiveness of endof-life cancer xare in the universal health care system of Ontario, Canada. J Clin Oncol 2011; 29: 1587–91. Weeks JC, Catalano PJ, Cronin A, et al. Patients’ expectations about effects of chemotherapy for advanced cancer. New Engl J Med 2012; 367: 1616–25.
Should patients with melanoma brain metastases receive adjuvant whole-brain radiotherapy? In a Comment, Arjun Sahgal and colleagues1 state that patients with limited brain metastases who are suitable for stereotactic radiosurgery should be treated with such therapy alone, and not with whole-brain radiation therapy (WBRT). They suggest that the American Society for Radiation Oncology (ASTRO)’s 2014 Choosing Wisely recommendation2— “Don’t routinely add adjuvant WBRT to stereotactic radiosurgery for limited brain metastases”—does not go far enough in recommending stereotactic radiosurgery alone for limited brain metastases. They accuse previous providers of indiscriminate use of WBRT, with a substantial effect on quality of life and neurocognitive function. We write to point out that the Comment and the ASTRO recommendation are not based on rigorous evidence of the effect of WBRT on neurocognitive function, particularly in patients with melanoma. The studies that Sahgal and colleagues mention were of WBRT for brain metastases from cancers of all histologies (mainly breast and lung). Many of these patients are likely to have had chemotherapy before radiotherapy, and lifestyle factors (eg, smoking) might have affected neurocognitive function and quality of life. Patients with brain metastases from these malignancies usually have extracranial disease, which is important in determination of survival. Patients with metastatic melanoma tend to be younger than are patients with other metastatic cancers and their brains are often the only site of metastasis.3 A review of the studies on which both the ASTRO recommendation2 e195
Recalibrating emergency care in the UK: pulling our weight Noticeably absent from the February Lancet Oncology Editorial1 were any suggestions for contributions that might be made by the oncology specialties to improve the situation in emergency care. A firm understanding of the problem is needed for a meaningful discussion of solutions. However, teasing apart the factors that contribute to the overwhelming of emergency services is difficult, and is more often dictated by conflicting political narratives than by the available evidence. The Editorial emphasises “better resourcing, co-ordination, and integration of GP services, secondary care, and social services”. In terms of co-ordination and integration of services, two ways exist for oncology services to ease pressure on emergency service, improve patient experience, and possibly improve even outcomes. The first of these approaches is direct engagement of oncology specialists with emergency specialties through the establishment of acute oncology services. Data from one of the largest regional oncology networks in the UK showed that the introduction of an acute oncology service led to a reduction in the mean length of stay from 12·8 days to 9·7 days, an improvement of 24%.2 This extra capacity can be used to improve patient flow through the hospital to admit patients in accident and emergency more rapidly. These services are also well placed to identify common reasons cancer patients attend emergency services and to develop strategies to reduce attendances. The second approach is to improve engagement of oncology specialists with palliative care. In addition to the observed reduced emergency attendance in patients with www.thelancet.com/oncology Vol 16 May 2015
palliative care support mentioned in the Editorial, early involvement with palliative care has been shown to improve quality of life, and even overall survival, in the setting of metastatic non-smallcell lung cancer.3 The additional finding by Temel and colleagues, whereby improved overall survival was associated with a significant reduction in aggressive treatment in terminal patients, makes uncomfortable reading for oncologists, especially with the increasing trend in aggressive end-of-life care and its associated increases in emergency department attendances.4 Oncologists are usually the gatekeepers of palliative care for patients with cancer, but often fail to communicate prognoses to patients or ensure realistic expectations for treatment, providing a barrier to the early involvement of palliative care.5 Early engagement with palliative care will benefit both patients and oncology services alike. Doubtless key strategic decisions are needed to improve the situation in emergency care, but all health care specialties have a part to play, oncology included. I declare no competing interests. I am funded by an NIHR Academic Clinical Fellowship.
Ben O’Leary [email protected] Royal Marsden Hospital, Sutton, Surrey, UK; and The Institute of Cancer Research, London SW3 6JB, UK 1 2
3
4
5
The Lancet Oncology. Recalibrating emergency care in the UK. Lancet Oncol 2015; 16: 117. Neville-Webbe H, Carser J, Wong H, et al. The impact of a new acute oncology service in acute hospitals: experience from the Clatterbridge Cancer Centre and Merseyside and Cheshire Cancer Network. Clin Med 2013; 13: 565–69. Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non–small-cell lung cancer. New Engl J Med 2010; 363: 733–42. Ho TH, Barbera L, Saskin R, Lu H, Neville BA, Earle CC. Trends in the aggressiveness of endof-life cancer xare in the universal health care system of Ontario, Canada. J Clin Oncol 2011; 29: 1587–91. Weeks JC, Catalano PJ, Cronin A, et al. Patients’ expectations about effects of chemotherapy for advanced cancer. New Engl J Med 2012; 367: 1616–25.
Should patients with melanoma brain metastases receive adjuvant whole-brain radiotherapy? In a Comment, Arjun Sahgal and colleagues1 state that patients with limited brain metastases who are suitable for stereotactic radiosurgery should be treated with such therapy alone, and not with whole-brain radiation therapy (WBRT). They suggest that the American Society for Radiation Oncology (ASTRO)’s 2014 Choosing Wisely recommendation2— “Don’t routinely add adjuvant WBRT to stereotactic radiosurgery for limited brain metastases”—does not go far enough in recommending stereotactic radiosurgery alone for limited brain metastases. They accuse previous providers of indiscriminate use of WBRT, with a substantial effect on quality of life and neurocognitive function. We write to point out that the Comment and the ASTRO recommendation are not based on rigorous evidence of the effect of WBRT on neurocognitive function, particularly in patients with melanoma. The studies that Sahgal and colleagues mention were of WBRT for brain metastases from cancers of all histologies (mainly breast and lung). Many of these patients are likely to have had chemotherapy before radiotherapy, and lifestyle factors (eg, smoking) might have affected neurocognitive function and quality of life. Patients with brain metastases from these malignancies usually have extracranial disease, which is important in determination of survival. Patients with metastatic melanoma tend to be younger than are patients with other metastatic cancers and their brains are often the only site of metastasis.3 A review of the studies on which both the ASTRO recommendation2 e195
