Background
The National Chemotherapy Advisory Group 2009 report emphasised the need for expert oncological assessment of cancer patients presenting to hospital as emergencies within 24 hours;1 hence the establishment of the Acute Oncology Service (AOS) team in all NHS trusts that assess and admit cancer patients, where formerly such provision was not always available. However, in the majority of district general hospitals, out-of-hours management of oncological emergencies remains the responsibility of the admitting medical team. Our recently undertaken audit on hypercalcaemia of malignancy reveals that in our centre this oncological emergency was mismanaged by medical teams in a significant proportion of cases.
Hypercalcaemia of malignancy is a relatively common and potentially life threatening complication of cancer. Our audit was undertaken following the observation by the AOS that management of this condition on medical wards was often not in accordance with Trust guidelines.
Methodology
Cases were identified using pharmacy and AOS records over the preceding six months, giving a sample size of 20. Data was collected from electronic and paper patient records to assess compliance with management principles outlined in trust guidelines. These guidelines include treatment with zoledronate if there is no response to adequate fluid rehydration.
Results
A key finding was that in 40% of cases bisphosphonate treatment was with pamidronate, rather than zoledronate as is recommended by the guidelines. Furthermore none of the patients who were treated with pamidronate received the full dose of 90 mg, having been prescribed 30 mg or 60 mg instead. 37.5% of these patients required repeat bisphosphonate treatment compared with 9% of those treated with zoledronate. The median length of stay for those receiving pamidronate was 11.5 days, compared with 8.5 days for those receiving zoledronate.
Discussion
Zoledronate has been the pharmacological treatment of choice for malignant hypercalcaemia for several years. It is more potent than other bisphosphonate medications and is comparable in cost.2 This audit clearly shows that best practice is not always being followed in this area, leading to suboptimal patient care and possible increased length of stay. Lack of compliance with the trust guidelines for treatment of malignant hypercalcaemia may be due to lack of awareness of these guidelines and any new updates need to better disseminated. Throughout the UK it is a peer review requirement for AOS teams to regularly teach junior doctors on oncological emergencies, which should help improve guideline adherence. Alternatively, there may be awareness that the guidelines exist but there is no incentive to consult them, as clinicians feel that they know how to treat hypercalcaemia with the tried and trusted pamidronate rather than zoledronate. Every acute medical intake will have patients with acute oncological problems and ideally all general physicians should ensure their knowledge of current best practice for relevant oncological problems is as up to date as for any other specialty area. Inclusion of acute oncology into mandatory training for all physicians is one option all NHS trusts should consider.
Footnotes
Letters not directly related to articles published in Clinical Medicine and presenting unpublished original data should be submitted for publication in this section. Clinical and scientific letters should not exceed 500 words and may include one table and up to five references.
- © 2013 Royal College of Physicians
References
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