Autologous Stem Cell Transplantation Your Treatment Explained

Transcription

1 Autologous Stem Cell Transplantation Your Treatment Explained Patient Information

2 Introduction This booklet has been written to help you understand what is involved in a stem cell transplant using your own cells (often referred to as an autograft ). For some patients this is an important part of the treatment of lymphoma, myeloma or leukaemia. This booklet does not replace the discussion between you and your doctor but helps you to understand more about what is discussed. Transplantation is a complicated process and we hope that this leaflet will act to help guide you through each stage. You will be in the care of an experienced team of professionals who will be dedicated to your needs from referral through to discharge and outpatient care. Do not hesitate to ask any questions that you may have. What is an autologous stem cell transplant? An autologous stem cell transplant is a treatment, which allows very high doses of chemotherapy to be given to you whilst your own bone marrow cells are protected. In order to protect the cells from the chemotherapy they are removed and stored in a special liquid nitrogen freezer until they are needed. The cells can be collected for storage months or even years before they are used. They are then defrosted on the day of the transplant and are given back to you. What are stem cells? The bone marrow is a special soft tissue in the middle of the bones and is made up of billions of cells. These cells divide to make new blood cells, replacing those that have died naturally. The stem cell is a normal immature cell that is able to replace all of the different types of mature cells in the blood, including the white cells, the red cells and the platelets. It is like a seed cell that germinates in the marrow soil and from which a whole plant can grow. The stem cells can be moved out of the marrow into the blood stream using a special factor called G-CSF (granulocyte-colony stimulating factor). Other names that you may see are growth factor, Lenograstim, Neupogen or Filgrastim. Once this has happened they can be collected or harvested using a machine and then frozen until they need to be used. 1

3 Why do I need a stem cell transplant? The reason for using a stem cell transplant and its timing vary from patient to patient and is different with different diseases. In some cases it has been shown that it is the best way to allow enough chemotherapy to be given to kill cancer cells right from the start of treatment. In other cases it is used because the first chemotherapy treatment has not killed enough cells and a more intensive chemotherapy treatment is needed. How are the stem cells released and then harvested? There are two ways in which the stem cells can be released or mobilised into the bloodstream: Stem cells can be released following chemotherapy and then stimulated by growth factors, which increase the production of blood cells. Generally, on the fifth day after your chemotherapy, daily injections of growth factors will start and be given under the skin. You or a family member can be taught to do these injections at home. Alternatively, injections can be given by our nurses on the day unit or by your district nurse or at your local hospital. Your blood count will be checked on days 8, 9 and 10 after chemotherapy and once the blood count and stem cell level are high enough the cells will be collected from your blood using the cell separator machine. Another way in which the stem cells can be released is by using growth factor injections alone. The injections are given for five days as an injection under the skin. Again, you or a relative can be taught to do this at home or we can arrange for your district nurse to come and give the injections or you can attend the day unit. On the fifth day a blood test will be taken to check that the stem cells have been released. Usually this sample is taken at the hospital where you are having your treatment, but occasionally it can be arranged with your local hospital. The exact way in which we plan your stem cell harvest will be individual to you. Your doctor will tell you whether you need to have chemotherapy and if so how many courses. 2

4 As a precaution against getting any other cells in the harvest, it is critical that any blood you receive in the two weeks before the transplant must be irradiated to kill any white cells. If you receive a transfusion at your local hospital, let them know you have a stem cell harvest planned. With your consent, your blood will be routinely tested for transmissible viruses such as hepatitis and HIV, just as we do with blood donors to make sure that there is no risk to samples in storage. What is the procedure if I need chemotherapy to collect the stem cells? This usually means coming into hospital overnight. There are two main schedules that may be used, either the chemotherapy drug cyclophosphamide or a combination of chemotherapy drugs which are individual to your needs. Some hospitals will give the chemotherapy locally but should let us know in advance so that we can plan the harvest at a time when our facilities are available. The stem cell harvest On the day that your blood reaches the optimum level for collection you will need to come into the day unit. Your blood is usually taken with a needle from veins at the elbow and re-enters your body through a needle in the other arm. Sometimes if the veins are not good on the day of the harvest we need to put a temporary vascular dialysis catheter into a vein in the groin area. If you already have a Hickman (also known as a Central or Groshong line) or a PICC line (peripherally inserted central catheter) then this can sometimes be used to return the blood to you. The blood circulates in a machine by a continual process lasting for three to four hours. The stem cells are collected into a bag. How do you know whether there are enough stem cells? A test is done on the initial blood sample taken on the first harvest day, which may predict whether the harvest is likely to be good on that day. During the process we will take a small sample from the bag and test it to see how many cells are likely to have been harvested. We should get the results that evening and will call you when you get home to let you know whether you will need to come in for another one or two days. We can only plan your transplant if we get enough cells. A few patients do not get enough cells in the first attempt. 3

5 What if there are not enough stem cells? If we cannot get enough stem cells on the first try then we may need to use a different approach. This can happen for many reasons some people s cells are just stubborn and will not release well into the blood stream but more usually it is because there has been chemotherapy or radiotherapy to the bones as part of the previous treatment. It is more difficult to mobilise stem cells in patients with some diseases than in others, for reasons we do not fully understand. If you do not have enough cells then we may try either doubling the dose of the G-CSF growth factor or giving chemotherapy to try to help the cells mobilise. In some instances we have to do a bone marrow harvest, which is done under full anaesthetic. Are there any alternatives to the transplant? Sometimes the doctor will need to consider the alternatives to having the transplant, such as more standard chemotherapy, if it proves impossible to collect a safe number of cells. If you have any questions about alternatives to this procedure then you should discuss them further with your medical team. Where are my stem cells stored? The bag of stem cells is removed from the machine and taken to the blood transfusion centre where the stem cells are then processed, counted and a chemical called DMSO (Dimethyl sulfoxide) is added. This stops the cells from breaking up when the freezing occurs. They are then frozen in liquid nitrogen at minus 180 º C in sterile containers until required. The cells can be stored indefinitely, however if they are not used after a period of time they may be discarded or if they are never likely to be needed. The cells can never be used for anyone else. If there are too many cells collected then we may ask your permission to use them in quality control or research in the laboratory. This is important to make sure that all of our procedures are accurate and of the best quality. Are there any side effects of harvesting the stem cells? If you need chemotherapy to mobilise the cells into the blood then there is a risk that you may have a temperature or infection whilst your neutrophil count is low. Neutrophils are white blood cells, which help to fight 4

6 infections, and their numbers should increase when the growth injections have worked. There may be specific side effects of the chemotherapy drugs used that your doctor will discuss with you. The growth factor injections can cause some bone pain as they start to work. This is a temporary effect and is usually helped by simple painkillers like paracetamol. During the stem cell harvest itself, to keep your blood thin and stop it from clotting, we use a short-acting blood thinning medicine. This can sometimes cause tingling around the mouth and face. This side effect is temporary and can be reversed by drinking a glass of milk or taking a soluble calcium tablet. Occasionally patients can feel a little faint or light-headed when they are using the machine. If this happens then we can quickly slow the process down and give extra fluid to make you feel better. Very occasionally patients can bleed from where the line has been put in. This can be stopped with some extra pressure on the site for a few minutes. If a line is needed in the groin we will usually let you go home with this overnight and will give you instructions in case there are any problems with it. We cannot take it out on the same day as the harvest as the blood thinning medicine will continue to operate for a few hours. It is important to let us know if you are taking Warfarin as this also thins the blood. We will ask you to stop this for about three days prior to the harvest and may need to arrange for injection of Heparin as a temporary measure. If you are taking a betablocker (a kind of heart tablet) or any other blood pressure medication we will need to know as this can lower the blood pressure and we may ask you to miss out morning doses on the harvest day. Preparing for the transplant: Pre-transplant visit Before your transplant we will give you an appointment to attend the clinic to see your transplant consultant. You will also be introduced to the transplant team members and will be shown round the unit so that you can see where you will be during the time of the transplant. There will be a lot of information to discuss during the first visit. You may well have a lot of questions. Do not be afraid to ask and if it helps, write these down before your visit to make sure we answer all of them. A copy of the letter after the consultation can be given to you if you like. It also helps to attend the clinic with a family member or close friend if possible. After you are happy that 5

7 your questions have been answered then we ask you to sign a consent form which documents some of the points that have been discussed and that in principle you agree to proceed with the arrangements for your transplant. We are happy to see you, as many times as necessary to answer any questions about the planned transplant but we do understand that many of our patients travel long distances. Do phone if you have any questions at all after you have left the clinic. Your stem cell harvest and the details regarding when you need to come into hospital for the transplant will be coordinated by our transplant co-ordinator and transplant fellow. They will keep in close contact with you to arrange visits and protocols for injections etc. We may need to organise specific tests to check you are fit and well and to make sure your body can tolerate the transplant and large doses of treatment. Where possible we involve your referring team so that you can get these done at your local hospital. The tests may include: Check your heart: using MUGA or ECHO scan. Check your kidney: 24 hour urine collection or GFR (glomerular filtration rate) test. Check your lungs: lung function tests. Your tests will depend on previous treatment and your medical history. In addition we may need to perform a bone marrow check. If you do not already have a Hickman line (also called a central venous catheter) or a PICC line this will need to be arranged (see patient information sheet on Insertion of a Central (Hickman/Groshong) Catheter or Peripherally Inserted Central Catheters (PICC lines) for more information). We will also advise that you have a dental check before coming for transplant as this is one area that infections can come from whilst your immune system is lowered. The transplant: How are the cells given back to me? Before the cells are given you will have intensive chemotherapy that will last for between one and five days. Several regimens are used and your doctor will explain which is best for you. The chemotherapy may be given 6

8 in the form of a bag of fluid to be infused through your line, injections into your line or as tablets. You may need to drink very high levels of fluid to flush harmful toxins and waste products away. The details will be explained by your doctor and you will receive a personal protocol explaining what is to happen on each day. We can give you a copy of this so that you will know what to expect on each day. Once you have finished the chemotherapy, replacing the cells, which have been taken from you, is quite simple. They are defrosted and then given like a blood transfusion through a drip into your central line. If a very large number of cells have been collected, we will only give some of them back to you. The rest will stay in storage. What happens when the cells are given back to me? Cells that have been frozen and stored have a preservative (called DMSO) added to them so that the freezing process does not damage the cells. This preservative carries a smell often described as being like boiled sweet corn. You may not notice, but relatives and visitors may comment. You excrete this for about 24 to 48 hours after the transplant. Occasionally this preservative can cause some nausea and an allergic reaction. We give medications to you before the cells are infused to prevent this. You will be closely monitored. This is an important stage but can feel like an anticlimax after all the preparation. Being in protective isolation During your transplant, once the cells have been given back to you, you will be looked after in protective isolation. This means that you will be in a special ward or single room where measures will be taken to protect you from infections. Some procedures have to be performed outside the room, for example some scans and X-rays and you will need to leave the isolation area for these. What to bring Personal items such as pictures of family, personal stereo, books. Soft toothbrush and toiletries, nightdress/pyjamas, slippers, towels. You can have a duvet/pillow provided a relative can wash and change the cover regularly. Computer consoles and games, laptop, DVDs, CDs all electrical items that plug into the mains will need to be checked for safety during the first available working day after your admission. 7

9 Mobile phone and charger can be used on the unit. Visitors Whilst you are in isolation we generally ask you to have only two visitors in the room at any given time. It is best to have just four key visitors during the transplant to limit your potential exposure to infections. It is also important that you feel that you have control over who visits at times when you may not be feeling well after the chemotherapy. Obviously anyone with a cough, cold or rash, or who has been in contact with someone with an infectious disease such as chickenpox must not visit. Hand washing and aprons For your protection staff and visitors will be asked to wash their hands before seeing you. They may also need to wear plastic aprons. Fresh flowers These are not allowed in your room as they can carry fungal germs. Diet Nutrition and diet are extremely important for patients undergoing transplant. The important considerations are to prevent the risk of picking up infections and to maintain a good intake of food for as long as possible. Our dietician may see you on the ward to discuss the best way to deal with this. If this does not happen routinely then you can ask to speak to a dietician if you would like some more information. There will be days when you will not feel like eating. If this continues for a period of time we may need to give nutrition either through a tube which is passed through the nose into the stomach or into the veins through the Hickman or PICC line. If your relatives want to bring in food items then please speak directly to the nursing staff. Immobility and exercise Although the rooms are small, it is important to be as mobile as possible to keep your muscles working. This helps your recovery once you are out of hospital so you should try to get up and walk about at least a few times a day. Even getting up to the toilet and to wash yourself helps with your future recovery. 8

10 Coping with isolation psychological support Being in isolation can be hard. We appreciate the difficulties that some patients will have with this. Our nursing team can help you overcome these difficulties and are keen at all times to make your stay as nontraumatic as possible. However, if you wish, we will be able to arrange for you to talk to a clinical psychologist to explore your feelings and try to help you to cope. What happens next? Once the cells have been given it is necessary to wait for them to seed into the prepared or conditioned bone marrow. This is a gradual process but usually by around 14 to 21 days after the cells have been given back to you we will be able to see the recovery of white cells (neutrophils) in the blood tests. Once they are at a safe level we can start to plan for you to be able to go home. During the first two to three weeks of the transplant the blood count is very low and there is a risk of infection. You will be in isolation to prevent the chance of getting infections and you will be given medication to reduce your risk of infection during the most vulnerable time. It is likely that you will need to have the support of blood and platelet transfusions and this may continue for a short time after leaving hospital. Your blood will be tested every day to determine whether you need any blood products. How long will I be in hospital? You can expect to be in hospital around three to four weeks. Once your white blood count is increasing and you are able to drink and eat enough you will be discharged home. What are the risks and side effects of this type of transplant? Your transplant consultant will specifically discuss these risks and how they may affect you in detail. Below are some of the common risks: Your white cell count will be very low and usually antibiotics need to be given to treat infection or a temperature. Sometimes a chest X-ray or lung scan is performed to try to locate the source of infection. The nurses will take blood cultures so that we can see what is causing the temperature and if necessary adjust the antibiotics. You may need platelets to prevent bleeding and blood transfusions for anaemia during the time after the transplant. Sore mouth occurs commonly this is known as mucositis. 9

11 This often requires strong morphine-based painkillers for a few days or even weeks, but does not last long and a new lining grows very quickly. There is frequently some taste disturbance and the duration of this is variable. Mouth care is important as infections can get into the blood from the mouth. Black spots on the tongue can occur after this treatment. You should not be alarmed by this and should consult your medical team who will advise you if you need any treatment for this. Sickness can occur although we try to give the most powerful antisickness medication to prevent this. If you do get sickness we can usually change to something that suits you better. Because the lining of the gut is affected in the same way as the lining of the mouth there is commonly a tendency for diarrhoea and crampy stomach pains during the first weeks after the conditioning. Poor appetite occurs commonly and for a few days it is expected that you will not want to eat and you could also find drinking fluids difficult. If this happens then you may need support with fluids in a drip. Hair loss. As many patients have already had chemotherapy before, they may have already lost their hair. Hair loss generally occurs but it usually starts to grow back normally once the transplant treatment has finished. Most people will not experience any serious complications from their treatment. However, risks do increase with age and for those who already have other medical conditions or who are overweight or smoke. Occasionally patients die as a result of autologous stem cell transplantation. Your consultant will discuss these risks with you. Fertility and sex There is a risk that the treatment involved in the transplant will cause infertility. This is not 100% certain so you should use a condom if you or your partner is of childbearing age and if you do not want to have children. In women the treatment may cause an early menopause with some hot 10

12 flushes and we will check your level of hormones to confirm this. Usually these settle down but sometimes your doctor may discuss hormone replacement for a short period to help these symptoms. Male patients should discuss sperm storage if they haven t arranged this during previous chemotherapy. If not, this can be arranged prior to the transplant. The options for female patients are often more complicated and can be difficult but should be discussed with your transplant consultant. More information is available and if you have a partner they should also be involved in your decision. Skin problems You may become very sensitive to sunlight and we suggest you wear a hat, cover up and use sun block if you are out in sunny conditions. What happens after I leave hospital? Outpatient visits Usually you will have an initial visit to the day unit to check your blood count then a visit to the transplant clinic. After this the doctor in the transplant clinic will decide how frequently you need to be seen. This is usually every few weeks until your blood count is stable and you are improving in strength. Medication Most of your medication will be stopped when you are discharged but you will usually be given a few drugs to prevent infection for the first few weeks after the transplant. As your blood becomes stronger we will be able to stop these. Hickman (central line) or PICC line flushing In general your Hickman line or PICC line will be left in if it is not causing problems until your platelet count is high enough to allow it to be removed. It will need to be cared for weekly with a flush and dressing change either on the day unit or as arranged with your own hospital. 11

13 Tiredness Almost all chemotherapy makes you feel tired but as the treatment involved in a transplant is very intensive this effect is magnified. You will probably find you have no energy and do not feel like doing anything initially. In fact, many patients find it the worst thing about the transplant after they have left hospital. This tiredness can last for a few months after treatment, but sometimes can take longer to overcome and many patients do not get back to normal until around six months. Appetite and sickness Your appetite may still be disturbed when you are home but should gradually improve. If you are not gaining weight as expected then our dietician may want to see you and give help with supplements and advice. Depression It is common particularly in the early stages to feel very low after the transplant is over. Psychological support can come from family and friends at this time or talking to the nursing staff. You may find a patient support group helpful. Anti-depressants can sometimes be beneficial for a short period. Everyone has a very different experience and we will try to individualise your care. Your treatment can also be a difficult time for your partner or for those who care for you. Support is also available for them and your medical team can advise you further. Vaccinations We recommend that you receive an annual flu vaccine. You will also need DTP, HiB and pneumovax II at one year after the transplant. Your GP can arrange for these vaccinations. Check-ups Cervical smears should be delayed for three to six months after the transplant and breast-screening mammography should proceed as arranged. These are especially important after the high dose treatment. Coming back into hospital It is common for patients to need to come back into hospital after a transplant, even if it is for a short time. There are many reasons for this but it may be because of infection or problems with eating and drinking. 12

14 Is there anything I should look out for? Shingles Let us know if you have an unusual or itchy/sore rash. Shingles can normally be successfully treated. Flu and colds If you have a runny nose or feel that you may have flu or a cold you should contact us. We will be able to take a sample of fluid from the nasal cavity and examine it to see if we can find out what specific virus is causing the problem. Some viruses need to be treated with nebulisers or tablets. How will I know if the new cells are working? The first sign that the transplant has engrafted successfully is when your blood counts increase. Sometimes after a transplant the cells never reach normal levels but usually they are high enough to be perfectly safe and acceptable. How will I be monitored for disease? It is likely that we will need to monitor you in the clinic for a long time after the transplant. This will depend very much on the original disease but you may need blood tests for paraprotein levels, bone marrow tests or CT scans. Stem cell transplants and getting back to everyday life: Social life If you feel well enough, there is no reason why you cannot carry on going out as normal once your neutrophil count has increased. Do remember, you are more prone to infection, so avoid visiting people who have colds, sore throats or flu. Working If you work you will need some time off until you feel well enough to return but employers should understand if you explain why. If you feel well enough and you do not have a very heavy, physical job, it is fine to carry on working as soon as you feel able but it is likely that you will feel too tired for a few months after the transplant. If you do decide to carry on working it is important to remember not to push yourself too hard and wear yourself out. It is best if your employer is able to let you come back part time initially so 13

15 that you can build your strength, stamina and confidence. We generally recommend three months off work after this type of transplant but every individual is different. The Information Centres listed at the back of this document can provide advice on benefits and employment rights. Shopping This is generally allowed although we would advise to stay out of very crowded spaces for the first few months to reduce the risk of infection. Diet In the initial phase, until your neutrophil count has recovered fully we would advise that you should stay on the neutropenic or clean diet. This means that you must not eat foods which could potentially carry germs. For example all fruits must be peeled, all meat must be well-cooked, foods must be consumed from packaging within 24 hours, no salads, no takeaway foods, no soft cheeses and no seafood. Your doctor will tell you when it is safe to eat salads etc. again. After recovery you can relax these rules but we would still advise against eating soft cheeses that may contain moulds and raw or undercooked eggs for at least six months. Exercise You will know how much exercise your body is able to cope with. Everyone is very different and this will depend on how fit you were before the transplant. You may find that small amounts of exercise tire you out for a day or two afterwards but it is important to keep trying to push yourself to build up your muscles back to full strength. Do not get disheartened by the feeling that things are progressing slowly this is quite normal initially but your body will be gradually getting stronger. Sex You may find that you have a reduced appetite for sex, or that the treatment has affected your sexual relations in other ways. This may improve in time. Your Clinical Nurse Specialist can offer you help and support with issues affecting your sex life or close relationships. This could include referral to counselling services or where appropriate treatments such as hormonal therapy for women and other treatments for men. Holidays Getting away, even if it is just for a few days, will be good for you. If you are planning a holiday or have one planned already, let us know. We 14

16 would generally advise waiting for a few months before going abroad after this type of transplant. Please discuss with us what you would like to do. Alcohol It is perfectly all right to have alcoholic drinks as long as you do not overdo it. Some people find that they go off alcohol after the transplant. Smoking It is obviously better for your general health if you do not smoke. If you would like help quitting then speak to your medical team, who will be able to offer advice and support. Please ask any further questions This leaflet tries to cover the process of having a transplant in some detail but it is not possible to cover all possible questions. You are sure to have questions that have not been answered and some issues may not be explained clearly enough. All of these questions are important and we are happy to answer any issue that occurs to you. If you think about something but are unable to ask someone immediately, write it down to remind you to ask the nurses or doctor when you see them. It is natural to be worried and it can help to talk to a member of nursing or medical staff. You will find that you are less anxious and frightened by feeling well prepared for the transplant. If you are worried or unsure about anything, do not sit at home and worry, phone us we are happy to help you, this is why we are here. Do not forget advice, encouragement and support from staff and sometimes other patients who have had transplants are always available. Glossary of medical terms used in this information: Autologous stem cell transplant: stem cell transplant using the patient s own cells. Bone marrow: the spongy tissue and fluid, which is found inside the bones in the body. It makes cells found in the blood. Central line: see Hickman Line. 15

17 Chemotherapy: the treatment of cancer with drugs. DMSO (DiMethyl SulfOxide): a chemical added to extracted stem cells to prevent them being damaged when they are frozen. Hickman line: sometimes called a central venous catheter. A small, flexible plastic tube inserted into the large vein above the heart, through which access to the blood stream can be made. This allows drugs and blood products to be given and blood samples withdrawn painlessly. Neutrophils: one of a number of different kinds of white blood cell. PICC line: a PICC is a thin flexible tube that is used to give you treatments such as chemotherapy, antibiotics and/or Intravenous (IV) fluids. A PICC can also be used for taking blood samples. Radiotherapy: X-ray treatment that uses high-energy rays to damage or kill cancer cells. Stem cell: an immature cell that can replace all of the different types of mature cells in the blood including the white cells. Local and national support groups: UHB Haematology Support Group Local support group providing information, support and social events for patients with haematological conditions and their families. The group meets monthly. For more information about this group, speak to your key worker or ring Lymphoma Association PO Box No 396, Aylesbury, Bucks HP20 2GA The helpline freephone number is Website Macmillan Cancer Support Information line: (Monday-Friday, 9am-8pm) Website 16

18 Leukaemia Care Society One Birch Court Blackpole East Worcester WR3 8SG Free 24 hour careline: or Tel: Website Myeloma UK Broughton House 31 Dunedin Street Edinburgh EH7 4JG Information line: Tel: Website Leukaemia & Lymphoma Research 43 Great Ormond Street London WC1N 3JJ Tel: Website Local sources of further information You can visit any of the health/cancer information centres listed below: Heart of England NHS Foundation Trust Health Information Centre Birmingham Heartlands Hospital Bordesley Green Birmingham B9 5SS Telephone: Cancer Information and Support Centre Good Hope Hospital Rectory Road Sutton Coldfield B75 7RR 17

19 Telephone: Sandwell and West Birmingham Hospitals NHS Trust The Courtyard Centre Sandwell General Hospital (Main Reception) Lyndon West Bromwich B71 4HJ Telephone: Fax: University Hospital Birmingham NHS Foundation Trust The Patrick Room Cancer Centre Queen Elizabeth Hospital Edgbaston Birmingham B15 2TH Telephone: Walsall Primary Care Trust Cancer Information & Support Services Challenge Building Hatherton Street Walsall WS1 1YB Free phone: About this information This guide is provided for general information only and is not a substitute for professional medical advice. Every effort is taken to ensure that this information is accurate and consistent with current knowledge and practice at the time of publication. We are constantly striving to improve the quality of our information. If you have a suggestion about how this information can be improved, please contact us via our website: This information was produced by Pan Birmingham Cancer Network and was written by Consultant Haematologists, Clinical Nurse Specialists, Allied Health Professionals, Patients and Carers from the following Trusts: Heart of England NHS Foundation Trust 18

20 Sandwell and West Birmingham Hospitals NHS Trust University Hospital Birmingham Foundation Trust Walsall Hospital NHS Trust Worcestershire Acute Hospitals Trust We acknowledge the support of Macmillan in producing this information. Pan Birmingham Cancer Network 2010 Publication Date: July 2010 Review Date: July