Myeloma pathways to diagnosis UCLP audit

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Deirdre Charles
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1 Myeloma pathways to diagnosis UCLP audit Dr Neil Rabin Consultant Haematologist University College London Hospitals & North Middlesex University Hospital

2 Myeloma Clinical Features Bone pain (70%) High calcium levels Recurrent infections Pathological fractures Kidney dysfunction (70%) Bone marrow failure (anaemia) Hyperviscosity

3 Spectrum of Disease NO TREATMENT REQUIRED OBSERVATION ONLY Normal MGUS Asymptomatic myeloma TREATMENT REQUIRED Myeloma No bone lesions < 10% plasma cells No bone lesions > 10% plasma cells Related Organ or Tissue Impairment: HyperCalcemia Renal failure Anaemia Bone pain

4 Pathway to diagnosis Patients newly diagnosed with sympt. myeloma Feb to Aug 2014 Case note review UCLH Barts Health (not Whipps X or Newham sites) Patients were excluded if: Referred for salvage chemotherapy / transplant Asymptomatic / Smoldering myeloma / MGUS Amyloidosis (often diagnosed elsewhere and referred) Solitary plasmacytoma Referral pathway Healthcare professional seen previously (duration) Symptoms related to myeloma (duration) Myeloma staging / response to treatment / impact morbidity/response

5 Patient characteristics 36 patients identified (20 pts Barts Health, 16 pts UCLH) Median age at diagnosis = 65 years (range 37 to 90 yrs) Male = 20 pts, Female = 16 pts (ratio 1.2:1) Isotype IgG 14 (39%) IgA 12 (33%) Light Chain (BJP) 8 (22%) IgM 1 (3%) Non-secretor 1 (3%) International Staging System (ISS) 1 14 (39%) 2 5 (14%) 3 14 (39%) Unknown 3 (8%)

6 Patient characteristics 36 patients identified (20 pts Barts Health, 16 pts UCLH) Myeloma defining symptoms (CRAB criteria): Bone disease Anaemia Calcium Renal dysfunction Hyperviscosity 26 (72%) patients 20 (55%) patients 12 (33%) patients 13 (36%) patients 2 ( 5%) patients

7 Patient characteristics 36 patients identified (20 pts Barts Health, 16 pts UCLH 35 patients -chemotherapy 1 patient radiotherapy alone (declined chemotherapy) Response 29 (80%) patients responded (PR or better) 7 (20%) patients progressed 2 (5%) patients salvage treatment 5 (14%) patients died (myeloma related) Alive - 31(86%) patients Dead 5 (14%) patients

8 Referral pathway to haemato-oncologist Primary care 2WW Primary care not 2WW Outpatient - 2WW Outpatient - not 2 WW Outpatient - MGUS/smMM Inpatient - A+E Inpatient - other team

9 Which healthcare professional did patient see before diagnosis made? 36 patients identified (20 pts Barts Health, 16 pts UCLH) 28 (78%) patients seen by GP / primary care (underestimate) 10 (28%) patients seen their GP at least on 2 occasions 16 (44%) patients seen in other clinics 5 (14%) haematology 4 (12%) surgical / orthopaedic 2 (5%) chest clinic 2 (5%) neurology 2 (5%) rheumatology 1 (3%) oncology 4 (11%) patients seen in A+E and discharged home Time interval from first contact to diagnosis, 1 to 8 months Median number of visits to healthcare professional = 3 (range 1 to 8)

10 Symptoms at diagnosis Bone pain Pathological fracture Cord / nerve Anaemia Renal Calcium Infection

11 Symptom lead to referral 36 patients identified (20 pts Barts Health, 16 pts UCLH) Bone pain 25 (69%) Pathological fracture 11 (30%) Cord / nerve 7 (19%) Anaemia 18 (50%) Renal dysfunction 12 (33%) Hypercalcaemia 16 (44%) Infection 2 ( 5%) Duration of symptoms available (from notes) for 20 patients Median duration = 3 months (range 1 to 12 months)

12 Impact on morbidity and response to treatment 36 patients identified (20 pts Barts Health, 16 pts UCLH) Subjective assessment 15 (41%) patients delay in diagnosis had an impact on morbidity Bone disease Cord compression Pathological fracture Renal function 3 (8%) patients impacted on response to treatment On dialysis and difficult to deliver chemotherapy

13 Case history 47 year old man 6 month history of chest wall and back pain Seen by GP 3 occasions Referred by GP 2WW to chest clinic (?lung ca) CXR unremarkable Bloods clinic unremarkable CT requested from clinic lytic bone disease?follow up Admitted under general medics Bone pain, pathological fracture Hypercalcaemia Renal failure

15 Conclusion Patients identified in 2 large hospitals Need to include DGH Patients were seen on multiple occasions before diagnosis Median of 3 occasions by healthcare professional Commonly diagnosed as present via A+E 48 % pts diagnosed as an emergency presenting through A+E Despite previous contact with healthcare professional 2 WW (consultant upgrade) pathway underutilised 8 % pts referred using 2 week wait pathway Unusual to have referral from GP (11% referred from primary care) Patient seen in other OPD (surgical commonest) Follow up of patients with smoldering myeloma / MGUS allows early initiation of therapy 17% pts regular haematology f/u (prevented problems) Data not captured Referred for MGUS / sm. myeloma / other plasma cell disorders

16 THANK YOU Heather Oakervee (Barts Health) Data managers identifying patients

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