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Supporting Strategies and Frameworks
The National Cancer Framework 2017-2022
As first defined in the NCS, treatment must be patient cente red. To achieve the very best clinical outcomes, treat ment must also be multidisciplinary, specialized, ev idence-based and rapid. Over the last five years, the en vironment in which cancer patients are treated has c hanged beyond recognition, with the introduction of n ew facilities and treatments such as minimally invasive s urgery, Cyberknife and Hematopoietic Stem Cell and Bo ne marrow transplants.
HMC has developed 15 cancer site specific MDTs, made up of physicians, surgeons, radiologists, pathologists,nurses and oncologists with specialist knowledge and skills in a specific cancer type. The MDTs focus on the clinical,radio logical and pathological features of each individual patient and make recommendations about treatment to ensure care is tailored to individual needs. Patients, as well as being discussed at an MDT review, now have a named Patient Pathway coordinator who guides them through the Patient Pathway. This achievement must now be maintained considering the number of patients discussed at MDT meetings has almost doubled in five years
While not complete sub-specialization has been achieved among physicians, supported by the development and recruitment of the new role of Patient Pathway coordinators. Thirteen (13) Advanced Clinical Nurse Specialists graduated from the University of Calgary –Qatar and a further seven are expected to graduate in 2017 and 2018.
To date, 14 guidelines, (11 clinical management, 3 screening and 1 urgent suspected referral), have been developed and published. These guidelines are reviewed on a bi-annual basis to reflect ongoing changes to patient care. The development of guidelines for other specific cancers must continue and an ongoing program of education seminars is required to enhance understanding and adoption of guidelines across the sector. To inform the ongoing development of guideline regulation a compliance audit should be undertaken to assess adherence and implementation of guidelines.
Peer review is a quality assurance program for MDTs that uses 'self-assessment’ by teams against national measures and an external review by clinical experts.MDTs are expected to demonstrate specific evidence of meeting required standards. Where standards are not currently being met, the teams are expected to have an action plan in place to work towards compliance in an agreed timeframe, thus ensuring ongoing development of the team and service. The results of the peer review process have been instrumental in driving improvement in relation to complete membership of all MDT teams,including the development of the breast assessment clinic , the publication of patient resources, the ongoing sub-s pecialization of care and the publication of clinical guidelines.
Similar to rapid timing to diagnosis, the speed with which a patient begins treatment is also important and wherever possible, delays should be avoided. In Qatar, the goal has been for patients to begin treatment within 14 days of d efinitive diagnosis. Despite these improvements, a small number of rare or complex cancer cases still require over seas expertise, technology or clinical trials to achieve the best outcomes. However, some patients are still trav eling abroad for treatment that could be provided in Qatar.
The International Medical Affairs Office (IMAO) has provide d significant advances in the management of patients travelling abroad. The IMAO process for ap proving treatment overseas is now uniform and requires that every application for treatment overseas pass through two layers of clinical decision making. The num ber of doctors initiating the request for a patient to travel overseas for treatment has decreased from 51% in 2013, to just 7.5% in 2015.The clinical decision making pro cess adopted by the IMAO should be considered by all a pproving authorities which together, approved over 300
applications for cancer treatment overseas in 2015. The challenge remains to convince patients that the quality of care provided in Qatar is equal to and in some instances, better than the care they are requesting overseas.
Collaborating with international organizations has been in strumental in the development of cancer services over the past five years. The foundations for the success of this partnership are centered on a robust governance Framework with agreed deliverables, which are monitored on an ongoing basis and which, ultimately are linked to payment. The three work streams of nursing, medical oncology and hematology and the department of laboratory medicine and pathology, have been the focus of the program thus far. Smaller be spoke partnerships have also been established to focus on specific clinical programs and have supported the development of excellent clinical care.
There is a lot of positive momentum to build on, howeve r there is still more to do. Continuing to raise the conf idence of patients and their families of the care prov ided in Qatar will help reduce treatment overseas. En hanced collaborations not just internationally, but also w ithin Qatar, will improve consistency of service provision ac ross all aspects of the pathway. Qatar must stay at the le ading edge of technological and service developments,
increasing access to the necessary investment and training to pr ovide new services safely within the country. Where a pati ent has to be sent overseas, it will be important to ensur e it is for the shortest period necessary, with staff in Qata r being fully involved in the process, enabling early r etu rn and quality ongoing treatment.
Ensuring Continued Delivery of high-quality Treatment
As cancer care continues to develop and improve, there is also potential for the structure and role of the MDT to be reviewed and modified. Allowing cancer patients to be managed within the MDT via well developed, tested and inter nationally benchmarked care pathways, would allow a greater proportion of the team’s time to be dedicated to managing more complex, challenging cases. To be fully implemented, it is essential that all providers, including the private sector, are active contributors to MDTs.
A significant program of work is currently underway to digitize the MDT site-specific dataset, which will ensure all information relating to patients is held centrally, rather than on separate electronic viewing platforms. The availability of complete patient data sets will increase efficiency at the MDT meetings and enhance ongoing care once the patient begins treatment, as all diagnostic and staging data will be centrally located. The benefit will also be translated to the patient, as it will ensure all healthcare professionals involved will be fully informed of the patient’s status. Being able to digitally access uniform data sets for patien ts will provide a new opportunity to use that data to inform internal audits, educate, review and improve the working of the MDT. It is not just clinicians who can benefit however and thought should be given to enabling patients to access appropriate data through a digital application. All MDTs will be trained on digital access, entry and analysis of patient diagnostic and treatment data.
Sub-specialization in healthcare professionals
In recognition of the maturation of locally trained cancer nurse specialists, it is recommended that the focus begin to shift from solely on training new Advanced Clinical Nurse Specialists, to develop ongoing further sub-specialization of A dvanced Clinical Nurse Specialists. This will enable them to provide excellent care in their chosen specialist cancer field.
While great progress has been made in sub-specialization at both the physician and nurse levels, it is recognized that more can be done to ensure that all health care professionals are provided with continued professional development opportunities so they too can become site specific cancer specialists.
The introduction of Oncology Clinical Pharmacy Specialists as core members of the different cancer specialties at NCCCR, (i.e. breast, lymphoma, leukemia), has enabled patients to receive more comprehensive care. Providing clinic-based, patient-specific counselling by Clinical Pharmacists for cancer patients in NCCCR should improve compliance, enhance response to medications, reduce side effects and deliver cost savings associated with reducing unplanned admissions. It is therefore recommended that other site-specific clinics include Clinical Pharmacy Specialists.
Best-practice pathways /clinical guidelines
Further work will be required to ensure Urgent Suspect Cancer guidelines are fully disseminated and implemented across the healthcare system to ensure all patients are being referred appropriately and in a timely way. Pandisease clinical management guidelines for the treatment of oncological emergencies such as neutropenic sepsis and malignant spinal cord compression and palliative care guidelines need to be developed and disseminated across all health care settings. The treatment management guidelines already developed for tertiary care teams require supporting audit programs.
Peer review and tumor boards
To ensure the continuing validity and value of the peer review, the selection process of international peers should be refreshed and kept under bi-annual review. Selection of peers should be jointly approved and an aligned timeline for publishing work created.
The adoption of the peer review process will continue to be supported by the National Tumor boards. These boards, com prised of relevant stakeholders across public and private providers, support the development and adoption of international best practices and set standards for each of the disease specific tumor groups. It is recommended that where possible, stakeholder representation and membership should increase to include new and allied
partners. These groups will be essential in driving the adoption of peer reviewed recommendations and changes in international best practice. In recognition of the expanded role of these highly specialized groups, it is proposed that they be renamed as National Clinical Advisory Groups
(NCAGs). To drive the ongoing development of NCAGs, a program of site-specific international observation visits should be arranged to share best practices and support international collaboration.
Revising the time-to-treatment target
The importance of the patient experience and in particular having time to think about diagnosis and treatment options, cannot be understated. While the current targets have helped drive service redesign and increase the operational standard, there is a need to review the current criteria and introduce a degree of flexibility in the system to support patients who have requested more time to consider their treatment options. It is hoped that this will be achieved with the adoption of a new pathway.
Introducing Novel Technologies and Services
Understanding technology needs
The treatment environment for cancer continues to rapidly evolve, whether that is latest technology, precision treatment modalities, or access to new drug therapies. To avoid duplication of potentially high cost investment, or investment in unnecessary equipment, a situational analysis of diagnostic, therapeutic and capital equipment in Qatar should be undertaken and assessed against projected needs analysis for the next six years. This
should built on the similar work undertake for research by Qatar Foundation in the development of the R&D Asset Management Portal which lists all the research equipment available within Qatar to ensure that all researchers have a ccess to it.
HSCT- Cellular therapies and biotherapies delivered through clinical trials
Capitalising on the achievements of the Hematopoietic Stem Cell and Bone Marrow Transplant (HSCT) program thus far, a national, quality assured, accredited service and research facility should be developed. The current program is expanding its operational, clinical and scientific complexity to meet all levels of international practice in HSCT . Upon completion of this expansion, the program at NCCCR would be able to provide the national leadership, quality and governance platform of HSCT, for all patients in Qatar.
This program is supported by a collaborative network, which includes Oxford University NHS Trust, the Solid Organ Transplant Donation program and registry, the Qatar Red Crescent and other partners. The network aims to integrate relevant institutions with clinical, stemcell processing and
banking facilities that can further developed to their full potential. The program is pioneering a patient and donor awareness project on disease and stemcell donation, identifying eligible donors for patients in need. Qatar has also invested extensively in research facilities, particularly in relation to genetic and genomic programs. A national cancer-specific stemcell program making use of these facilities could be valuable.
Advanced HSCT services provide a platform for the launch of novel therapies through clinical research protocols, two compatible, inter-related and inter-connected components
of translational research are proposed:
A. Ex-vivo development of therapeutic strategies based on the exploitation of the power of the immune system leading towards immunotherapies (immune cells against cancer)
B. In-vivo therapeutic interventions based on developed clinical research protocols for human use involving cellular therapies and investigational agents / protocols
Minimally Invasive surgery
Surgery, undertaken by sub-specialist expert surgeons, remains the treatment modality that delivers the largest number of curative outcomes for patients with cancer. This is likely to increase with the successful uptake of population based screening services, which result in cancer being detected earlier where a potentially curative surgery is more likely to be an option. Surgical oncology services, in partnership with the Qatar Science and Technology Park (QSTP), have made considerable strides in sub-specialization. The use of emergent technologies has enabled the provision of a range of sophisticated and
minimally invasive techniques in clinical practice, such as those available in Uro-oncology. Minimally invasive surgical options should be further developed, studied, evaluated and formally linked into the research and academic agenda. This will be supported by the reporting of 30, 60 and 90-day post-operative outcomes.
Providing new pediatric and young adult cancer services
The transition between pediatric, young adult and adult services for those with cancer is of vital importance and clear plans need to be made to ensure the transition is smooth. From 2018, Sidra will assume care for this small and highly specialized group of patients. Due to the physical separation of facilities, careful transition of care will require significant collaboration between HMC and Sidra. It i s recommended that HMC and Sidra work together to develop clear pathways of care. MDT meetings should be attended by both pediatric and adult providers to act as the forum through which plans of care for individual patients are made. It would also be considered good practice for there to be joint clinic appointments for those transitioning between services in the year prior to transition. Consideration should also be given to ensure support with late effects of treatment for those who have had cancer in childhood or adolescence.
Introducing psychological assessment to understand patient needs
Understanding the ongoing and often changing psychological needs of cancer patients can be challenging. Not all patients will require the same level of support but assessing the needs of individual patients is of critical importance in delivering patient centered care. This program will be based on National Institute of Clinical Excellence guidelines, to provide a structured approach to ongoing psychological assessment of cancer patients from diagnosis, through to ongoing care. Use of the holistic need s assessment tool will be used to support this effort.
Develop a cardio-oncologic assessment program
Cardiovascular events can lead to treatment interruptions which can affect outcomes and cause long-term morbidity and mortality in people living with or surviving cancer. In recognition of this challenge, the new medical subspecialty of Cardio-Oncology has emerged and aims to promote cardiovascular heath, while facilitating the most effective delivery of cancer therapy. Therefore, a new cardi ovascular oncology service in partnership between the Heart Hospital and NCCCR will be developed, in volving the assessment of cardio-vascular health at the point of diagnosis and ongoing treatment to identify those at possible risk of cardiac complications because of chemotherapy.
Develop an oral health assessment program
Cancer and its treatments can directly affect the condition of dental health and the patient’s well-being. Those at greatest risk are patients who undergoradiation therapy for head and neck cancer, hematopoietic stemcell transplant patients and patients who receive chemotherapy. A program of dental and oral health management for cancer patients is under development to provide an ongoing assessment of oral health pre, during and post treatment.
This will help ensure effective monitoring and where necessary intervention to ensure continued delivery of cancer treatment and where possible, the prevention of side effects to treatment.
Treatment Abroad And Collaborative Partnerships
Aligning with Domain 5, the ongoing work of the IMAO should continue and adopted by all approving
authorities, based upon the following objectives:
Patients only travel to a defined number of approved international partnered centers
Patients leave with a defined treatment pathway
Qatari and overseas physicians practice according to mutually agreed protocols
Patients return with full treatment record and discharge summary
Overseas treatment data is recorded in the EMR and QNCR
To support these objectives, it is recommended that cost, duration of treatment, patient experience and outcome data be captured and reported to further inform change in this program. Treatment outcome data for both Qatar and international centers should be benchmarked against other developed geographies.
The positive patient experience of cancer treatment in Qatar should spread to the wider population and continue to build trust and confidence in the system, which will ensure the further reduction in patients seeking treatment overseas. To support the work of the IMAO, ongoing
education of the community must continue, but it must be led by patients who can describe the positive experience of being treated for cancer in Qatar. The Framework recognizes that changing perceptions and trust is not a straightforward process. A long-term plan will need to be developed and supported to improve perception, celebrate successes and engage with local communities, en couraging repatriation of activity.
The needs and requirements of partnerships will change with the ongoing maturation of services. The number and focus of partnerships will accordingly need to evolve. All partnerships should be reviewed to ensure that the focus will support the recommendations of this Framework.
Any new partnerships should be aligned with international partner centers to foster further collaboration and shared expertise across the pathway of care.
High Quality Treatment
Review end-to-end process for accessing new cancer drugs and develop rapid protocols as necessary
Establish a guideline and pathway compliance monitoring program which will be agreed and monitored through the Tumor Boards
Review Peer-Review teams and selection process, develop a process for regular review with an agreed governance structure pre-and post-Peer Review
Rename National Tumor Boards "National Clinical Advisory Groups" review membership and provide administrative support
Review the feasibility of a program of regular site specific intenational observation visits for NCAG leads
Review and revise time from diagnosis-to-treatment pathway
ovel Technologies and Services
Audit all diagnostic, therapeutic and research capital equipment in Qatar, model a 6-year capital equipment plan and conduct gap analysis to inform investment plans
Develop a national, quality assured, accredited Hematopoietic Stem Cell and Bone Marrow Transplant facility
Develop a National Hematopoietic Stem Cell Donor Registry linked with regional and international stem cell registries
Development of minimally invasive and robotic surgery
Agreed guidelines, pathways and protocols in place for patients
transitioning from pediatric to adult services to include late treatment effects for childhood cancers
Where indicated, expand psychological, cardio-oncology and
oral health assessments for cancer patients
Treatment abroad and partnerships
Record and report clinical, cost, duration of treatment and patient experience data associated with treatment overseas to further inform change
Deliver targeted education and awareness campaigns, promoting
cancer services available in Qatar with a communications plan
Review all current international partnership arrangements, conductassessment of partnership needs, gap analysis and amend partnerships accordingly
Develop a retrospective anonymous patient experience feedback
program targeting Qatari patients receiving treatment overseas