Developing Cancer Services at UCLH in partnership with UCL, - PowerPoint PPT Presentation

Developing Cancer Services at UCLH in partnership with UCL, Macmillan and London Cancer 14 th January 2013 Martin Lerner, Divisional Manager Kirit Ardeshna, Consultant Haematologist and Clinical Lead for the Cancer Centre Lallita Carballo, Head of Service, Macmillan Centre

What we are going to talk about • UCLH cancer services • Cancer Centre opened April 2012 • Strategy to develop services • Achieving the best outcomes working with UCL • Providing the best support working with Macmillan Cancer Support • Providing the best pathways working with London Cancer • Challenges for the future

How many Cancer Patients • 3,000 new patients with cancer referred to UCLH every year • Over half of these patients are seen at another hospital first and come to UCLH for specialist treatment • Patients are surviving longer and receiving more treatment

Oncology and Haematology activity Overall growth in treatment days - 7% per annum Will continue as more new treatments become available Historic annual growth in inpatient days Day cases = 3% Inpatient bed days 2008 2012

Cancer Strategy Best outcomes Best pathways Best patient experience

Cancer Centre successes Art Ambulatory care Business model Light and space Patient Experience Board Prizes Macmillan Support and Information Volunteer Service

Ambulatory Care Delivering treatments in day care which were historically administered in a inpatient setting Patients reside at the Cotton Rooms or at home Daily patient assessments by nursing and medical team Twice weekly Consultant ward round review One bed kept open for immediate ward transfer 24 hour access to clinical team

UCLH and UCL Cancer in Huntley Street Phase 4 Proton Beam therapy RNTNE Eastman Dental

Cancer Research Team at UCLH • 70% Nurses • Oncology – 27 Staff • Haematology – 11 Staff • Paediatric Oncology (TYA) – 5 Staff • Cancer Clinical Research Facility – 18 Staff

Cancer clinical trials at UCLH ACTIVITY • 2011/12 – 520 patients recruited to 88 trials • 2012/13 – first half of the year – 60 patients a month in 91 trials • Clinical trials cover all types of cancer • Run by medical staff, UCL, other Universities and drug companies

T-cells

How Engineering T-cells works T-cell T-cell T-cell non-specific receptor Tumour-specific receptor  T-cell Tumour non- cell specific receptor Tumour T-cells recognize antigen T-cell and kill tumour T-cell non-specific receptor

Basic Strategy of Immunotherapy Blood T-cells sample extracted Modified T-cells recognize and Genetically Modified kill tumour Administered back to patient

Targeting CD19 with T-cells

Low grade Lymphomas • Many patients well with no symptoms • No advantage of immediate chemotherapy vs deferral until progression • Deferral avoids side effects of chemo & thought to improve quality of life • Can we extend the period before chemotherapy is necessary?

UCL sponsored international randomised study • Patients randomly assigned to – Watch and Wait – Rituximab x4 – Prolonged rituximab – Rituximab is a manufactured antibody which kills lymphoma cells with minimal side effects

Time to Initiation of New Therapy (TTINT) 1.0 0.9 0.8 Proportion 0.7 of patients 0.6 with no new 0.5 treatment 0.4 initiated 0.3 % not requiring Rx at 3yr W+W=48% 0.2 R4=80% 0.1 R4+RM=91% 0.0 0 1 2 3 4 5 Years from randomisation HR (Rituximab vs W+W) = 0.37, p<0.001 HR (Rituximab + M vs W+W) = 0.20, p <0.001 HR (Rituximab + M vs Rituximab) = 0.57, p =0.10

Cellular therapy for viral infections • Some viral infections persist lifelong after initial infection • Under the control of the immune system • e.g cold sore (HSV) and chicken pox (VZV) viruses • These viruses can reactivate when the immune system is weakened, particularly after bone marrow transplantation • Aciclovir prevents the development of problems with HSV & VZV

Cytomegalovirus (CMV) • CMV is the same family of viruses and infects 60 ‐ 70% of normal individuals • If untreated when it reactivates it can cause life ‐ threatening lung infection • It is not sensitive to aciclovir, and the effective drugs often require intravenous administration, hospital admission, and have significant side effects

Cellular therapy for viral infections • We have developed techniques to isolate the cells that give protective immunity against CMV in normal donors, and can then re ‐ infuse these cells to patients following transplantation • Following infusion these cells recognise the virus, multiply, and eradicate infected cells, restoring long term immunity • Avoids repeated infections, reduces hospital admissions, and the need for toxic antiviral drugs Viral load (genomes/ml of plasma) Tetramer + cells/  l blood + 17 days Pre ‐ treatment + 3 days +10 days + 24 days 0.2% 4.8% 3.7% 8.7% 13% CMV CTL CD8 Viral load CMV ‐ CTL return number 0.4% of CD8 + 7.3% of CD8 + 8.5% of CD8 + 17.3% of CD8 + 17% of CD8 + HLA ‐ A*0201 NLVPMVATV pentamer Days post allograft

Cellular therapy for viral infections • We are conducting 2 national randomised multi ‐ centre studies in collaboration with a biotech industry partner in order to establish these therapies as a standard of care • We have developed a national immunotherapy network of centres in order to deliver this vision • The technology platforms are also translatable to other viral infections • Our mantra: “From proof of concept to standard of care”

ABC02-run by UCL-CTC New treatment for inoperable advanced gallbladder & bile duct cancer 2005-08 400 patients recruited • Gemcitabine & Cisplatin v Gemcitabine • Results : Combined treatment improved survival by a 1/3 rd (3 months longer) Set a new standard of international care

‘Intratumor Heterogeneity and Branched Evolution Revealed by Multiregion Sequencing’ First ever genome-wide analysis of the genetic variation between different regions of the same tumour using kidney cancer samples Professor Charles Swanton based at UCL Cancer Institute

TRACERx

Macmillan Support and Information Service Dr Hilary Plant and Lallita Carballo Clinical Heads of Macmillan Support and Information

What do we do? They say life is hard, well at times Cancer is hard. Living under a cloud that seems to follow you wherever you go. I have been in twice this week and a few closed doors have been opened in my mind. Thank you for hearing me there is so much to say. From Visitor book Macmillan Support and Information Service

What we offer in the Macmillan Support and Information Centre? In the moment support by a multi professional team working o in the Living Room Guided Information on all aspects of cancer o Welfare and Benefits Advice o Volunteering roles to support the professional services o Complementary Therapy team o Medical Specialist in Complementary Therapy o Counsellors o Psychologists o Lymphoedema Specialists o Wig fitting o Programme of Support o

How many people do we see ? 400-500 patients a day come to the cancer centre 25 of these come into the Living Room for support and information Another 50 a day attend for booked support individually or in teams

Who do we see? • More women than men • Less elderly • Ethnic mix reflects the community • 20% not English as a first language, 10% do not read English well • Some people come back regularly • Flow with the clinics in the Cancer Centre • Breast, Gynae, Sarcoma and Haematology

What happens in the living room? • New service for patients and families • Environment – flowers, no uniform and a wooden floor • In the moment experienced , informed, empathic professional support • Assess, listen, holding, inform, educate, rehabilitate, refer, reframe, empower • Individuals and groups • Volunteers • Peer support • The ‘forever table’ • We liaise and work closely with other clinical staff • We deliver something unique that complements the care delivered by clinical teams • Constantly reviewed ground rules!

The Programme • Underpinned by evidence from survivorship research • What we have learnt together (patients/families & clinical teams • Structured programme of support and education • Respects individuality • Enabled to recognise own strengths • Empower to self manage care • Rebuild confidence and sense of well being • Assessment and evaluation

The Programme Support Groups HOPE (Helping overcome problems effectively) Getting started and what next workshops Relaxation, mindfulness and yoga Physical activity and fatigue management Healthy eating workshops Creative groups Support for parents Red cell strategy Carers group Taking care of yourself Returning to work

Linking to other areas in UCLH • Starting to create a liaison infrastructure • Link team members with all MDTs and wards • Attendance at MDTs • Link ward nurses (pilot in Cancer Centre) • Working alongside CNSs to respond to concerns (e.g. advanced breast cancer, prostate) • Support for staff • Posters and leaflets • Phone us 020 3447 8663