Early intervention can influence an outcome – time to introduce an alert system for all cancer patients?

The National Chemotherapy Advisory Group 2009 report¹ emphasised the need for all hospitals with an emergency department (ED) to establish an acute oncology service (AOS). An AOS brings together expertise from oncology disciplines, emergency medicine, general medicine and general surgery. An effective team is one which carefully coordinates care and communicates well.

We have introduced a cost-neutral patient alert system developed by simply linking the hospital number of all known oncology patients to the patient administration system (PAS). Every 24 hours a report is compiled of all tracked patients who have both attended and been admitted via the ED. This report is sent to all members of the acute oncology team (AOT) daily.

The value of such an alert system is epitomised by a case which presented over one weekend: a 40-year-old man known to the local oncologist, having recently undergone hepatic resection of colorectal liver metastases after resection of his primary, following neoadjuvant chemotherapy. He presented with a short history of headaches. He was discharged with simple analgesia with no plans to further investigate or refer back to his oncology team. This seemed highly appropriate as cerebral metastases are not typical of metastatic bowel cancer.

An alert of his attendance was received on Monday morning and followed up by the AOT by calling the patient at home to enquire further about the symptoms. An outpatient appointment was made for further investigations. Within four days of presentation to the ED, a magnetic resonance imaging (MRI) head scan was performed as his history was suggestive of an acute neurological event. The MRI revealed a two-cm solitary enhancing lesion within the right cerebellar lobe with local mass effect and effacement of the fourth ventricle. He was started on high-dose dexamethasone and his case referred to the specialist neurosurgical service. He underwent a cerebellar metastatectomy, histology of which confirmed a sigmoid metastasis. He recovered within days of surgery and has returned to work.

This case illustrates the need for robust systems to ensure that oncology patients are appropriately identified for any new symptoms which may indicate recurrent disease, particularly out of hours. If his isolated cerebellar metastasis was not detected early, as described above, he may have presented following a catastrophic bleed not amenable to a potentially curative procedure.

• Royal College of Physicians