Useful information about working in Oncology

See also oncology intranet site

Who to call

On-call Registrars

0800-2200h Radiation Oncology Registrar

0800-2200h Medical Oncology Registrar

2200-0800h Medical Specialties Registrar

On weekends: 0800-1600: there is both an on call Medical Oncology and Radiation Oncology registrar available for advice. But 1600-2200, both Oncology specialties are covered by only one of these registrars.

Referrals

Written referrals for outpatient consultation

eReferrals via RCP

Information to have available when making an initial referral to the Oncology Service:

• Established diagnosis of malignant disease

• Histology (operative histology or FNA/core biopsy results)

• Staging information (operation findings, CXR, CT, bone scan or other imaging)

• Information about current symptoms and co-morbidities and functional status

A written referral is not appropriate in the following circumstances – please call the on-call Registrar directly regarding:

1. Patient is suspected to have a malignancy that is curable by chemotherapy or radiotherapy (see below).

2. Urgent chemotherapy or radiotherapy is indicated (see below)

If in doubt, preliminary advice regarding the general approach to investigation and staging of a patient with suspected cancer, or questions about when and how to refer, can be provided by telephone consultation.

Multidisciplinary meetings

Patients need to be presented at MDM. Please refer to the appropriate team. Please ensure that you know any comorbidities and the functional status of the patient.

Malignancies curable with chemotherapy or radiotherapy

Early discussion and referral to specialist is recommended for any patient with a potentially curable malignancy. This facilitates investigations, staging and initiation of treatment. Please do not wait until all investigations or histology reports are complete. All require specialist consultation for staging and treatment.

These include:

• Testicular cancer

• Germ cell tumours: ovary, extra-gonadal, retroperitoneal and mediastinal

• Gestational trophoblastic malignancy including choriocarcinoma

• Small cell cancer (usually lung)

• Undifferentiated cancers, especially in younger patients

• Any malignancy in children or teenagers (discuss with Paediatrics if less than 15 years old)

• Osteosarcoma, Ewing's sarcoma and rhabdomyosarcoma

• Lymphomas: Hodgkin’s and non-Hodgkin’s (Haematology)

• Early stage head and neck cancer

• Cervical cancer

• Leukaemias (seen by Haematology)

Indications for urgent chemotherapy/radiotherapy

There are a few situations in which inpatient chemotherapy is indicated to reverse complications of chemo-sensitive cancers, even though the aim of treatment is not cure.

• Respiratory distress due to chemosensitive mediastinal or lung malignancy e.g. germ cell tumour, choriocarcinoma, small cell lung carcinoma

• Occasionally spinal cord compression due to chemosensitive malignancies, as above

• Ascites or bowel obstruction due to gynaecological malignancies

• For lymphoma-related complications please call Haematology

Indications for urgent radiotherapy

• Spinal cord compression (see section below)

• Bleeding e.g. gynaecological, lung or GI

• Superior vena cava obstruction (see section below)

Oncology emergencies

Below is a list of common oncology emergencies, which are further described in the individual clinical guidelines

• Febrile neutropenia

• Spinal cord compression

• Bowel obstruction

• Diarrhoea

• Ureteric obstruction

• Superior Vena Cava Obstruction (SVCO)

• Biliary obstruction

• Hypercalcaemia

• Cardiac Tamponade

The following issues are also important oncology emergencies but are not further described in the guidelines:

• Raised intracranial pressure: increasing tumour oedema after starting radiotherapy for brain tumours. Closely monitor GCS, consider CT scan (to exclude hydrocephalus or acute haemorrhage) and call Radiation Oncology Registrar. Usual initial treatment is with high dose corticosteroids and proton pump inhibitor cover, but may be amenable to surgical intervention so discuss with Neurosurgery.

• Respiratory distress due to pneumonitis or lymphangitis carcinomatosis: pneumonitis may be caused by certain chemotherapy drugs (e.g. gemcitabine) or radiotherapy to the chest. Stop offending drug and start high dose steroids. *Remember oncology patients are also at increased risk of pulmonary embolism

• Anaphylaxis: caused by many chemotherapy drugs; call the Oncology Registrar immediately and start resuscitation measures.

• Chest pain: in patients receiving 5FU (fluorouracil) or capecitabine any chest pain (however atypical) should be treated as serious – these patients are at risk of coronary artery spasm and fatal myocardial infarction. If serial ECGs and Troponins are negative, patient may be considered for further investigations such as exercise tolerance test or CTCA or angiography before re-trialling 5FU or capecitabine. Please discuss with Cardiology team

Mucositis pathway

Tissue biopsies or aspirates

• House Officers may be involved in making histological diagnoses of cancer where they perform procedures such as pleural aspirates, ascitic paracentesis, LP, or arrange FNA or CT/USS-guided biopsies.

• Request cytology, and ensure an adequate quantity of fluid or specimen is sent (if in doubt, ring the laboratory to ask how much is required). When performing thoracocentesis or paracentesis, send as much fluid as possible to the lab, i.e. entire amount drained (refer to Gastroenterology/Respiratory for procedure technique).

In specific circumstances, such as where lymphoma or other haemopoietic malignancy is a possibility, fresh tissue may be needed for surface markers, cytogenetic and DNA analyses. Other samples may need to be cultured. It is recommended that a pathologist is contacted for advice.