A model of fast-track surgery for pancreatic cancer to implement the NICE guideline recommendations for the management of operable patients

The team in Birmingham carried out a pilot study to develop a model of fast-track surgery where individuals can have surgery faster and without the need of endoscopic stenting. The aim of the fast-track surgery pathway was to a) reduce time to treatment from the time of initial CT scan to surgery, b) avoid the need for endoscopic stenting, c) reduce healthcare costs by avoiding endoscopic stenting, associated complications and hospital readmissions, d) improve patient care experience and d) improve survival outcomes. All the aims and objectives of the study fall under the recommendations stated in the NICE guidelines for pancreatic cancer that recommend surgery rather than endoscopic stenting for people who have operable pancreatic cancer and obstructive jaundice, are well enough for the procedure and are not enrolled in a clinical trial that requires an endoscopic stent. 

Moreover, implementation of this guideline has also been recognised as a priority area for improvement of care in the NICE Quality Standard for pancreatic cancer (QS177, Quality statement 3). The rationale highlighted by NICE is that surgery has the potential to increase positive outcomes for adults with operable pancreatic cancer. Unnecessary endoscopic stenting can delay surgery, increase complications and hospitalisations, and raise the risk of pre‑surgery pancreatitis compared with surgery alone. It also increases costs. The model developed in Birmingham achieved a) surgery within 16 days as opposed to 65 days for those who underwent stenting, b) more patients receiving surgery (97% of the fast-track group versus 75% of the non fast-track group), c) total cost is £3,200 less for the fast-track surgery per person due to lower pre-surgery costs associated with endoscopic stenting. In this pilot, 31 patients were treated with the fast-track surgery pathway within a year, saving around £100,000.

Pancreatic cancer can cause jaundice. When people with pancreatic cancer present with jaundice, they are referred for endoscopic stenting to alleviate jaundice before referral to the specialist centre for consideration of surgery. This procedure is invasive, associated with clinical complications, especially cholangitis and pancreatitis, which may delay surgery or even preclude it. Studies have associated stenting with serious morbidities as opposed to patients who had surgery directly (73.5% vs 39%). These complications may require hospital admission and intravenous antibiotics, which not only delay the surgery but also increase clinical costs.

The team at the Liver and Hepato-Pancreato-Biliary (HPB) Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Trust implemented a fast-track surgery pathway that reduced time from diagnosis to potentially curative surgery to 16 days without the need for endoscopic stenting. A dedicated Clinical Nurse Specialist was essential for successful implementation of the pathway. This allowed 20% more individuals to have potentially curative surgery and a cost-saving benefit of £3,200 per person fast-track group. In the pilot in Birmingham, 31 patients were fast-tracked treated in a year, saving around £100,000, recuperating the costs of the project.

If fast-track surgery is rolled out across the 29 specialist Hepato-Pancreatic Biliary centres across the UK it will allow more people with pancreatic cancer with jaundice to have surgery annually in the UK. Re-investment of the money saved from endoscopic stenting will enable the appointment of an extra Clinical Nurse Specialist. Our forecast analysis shows that rolling out the fast-track will provide a cost-saving benefit of £1.9M per year in England and this is on the top of the cost of the appointment of a dedicated Clinical Nurse Specialist.

This is a pathway developed in Birmingham. Pancreatic Cancer UK financially supported the pathway and closely worked with the team in Birmingham to ensure that the pathway is shared and promoted to NHS healthcare policy and clinical stakeholders discussed in the following sections.

Pancreatic cancer is the 11th most common cancer and the 5th biggest cancer killer in England. Around 7,800 people dying every year with mortality closely paralleling incidence. The pathway was initially developed in the specialist Hepato-Pancreatic Biliary centre in the University Hospitals Birmingham NHS Trust covering around a population of two million.

Pancreatic Cancer UK have championed fast-track surgery in our Promoting Innovative Practice initiative and we have shared the practice with NHS policy and clinical stakeholders UK wide. We have called for its implementation in our Demand Faster Treatment campaign that has been signed by nearly 70,000 supporters. Moreover, adoption of the pathway is one of the key calls of the All Party Parliamentary Group on pancreatic cancer report the Need for Speed and patients having fast-track surgery have shared their positive experience in parliamentarian events. Also, other specialist centres have adopted the pathway developed in Birmingham such as the ones in Royal Free London, in Manchester and Leicester. Specialist centres such as King’s College Hospital and Royal Surrey County are trialling the pathway. We have also participated in webinars for Cancer Alliances where we have presented the pathway to NHS stakeholders across England. We have also presented the pathway as part of our health professional educational and training programme where we have promoted the NICE guidelines. The lead of the project has spoken at various events of the charity, such as the annual summit and parliamentarian events. Moreover, in the annual summit of Pancreatic Cancer UK ‘Accelerating Success’ we will bring together a panel of policy and clinical stakeholders to discuss pathway change in the NHS setting that will include implementation of NICE guidelines and the model of fast-track surgery.

The model developed in Birmingham achieved

• People affected received surgery in 16 days as opposed to 62 days.
• An increase of the number of those having surgery by more than a fifth (97% of the fast-track group versus 75% of the non fast-track group)
• A cost–saving benefit of £3,200 per patient associated with endoscopic stenting. In this pilot, 31 patients were treated with the fast-track surgery pathway within a year, saving around £100,000.
• The team at the Liver and Hepato-Pancreato-Biliary (HPB) Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Trust are currently analysing data looking at the impact of the pathway on survival.
• Moreover, the team currently has been in touch with patients of the pathway measuring experience in care and this data will be released soon.

Here in Pancreatic Cancer UK we have measured the impact of the pathway can have if it is rolled nationwide. We believe that if the model of fast–track surgery developed in Birmingham is rolled out across the 23 specialist Hepato-Pancreatic Biliary centres in England will enable more people to have the chance for potentially curative surgery. Over 1000 people with pancreatic cancer presenting with jaundice will be able to have fast–track surgery annually, representing 11.7% of overall people affected with the disease in the UK that is higher than the current rate.

“We have shown that it is possible to create a much faster path to surgery for pancreatic cancer patients within the NHS. This pathway avoids unnecessary, unpleasant and potentially dangerous interventions which therefore improves patient care, experience and outcome. There is a reduced cost of treatment to the NHS which could be redirected to further improving the pathway – these changes are desperately needed but are difficult to achieve hence the need to redirect any cost saving into ensuring the sustainable delivery of this fantastic service. It is possible that early surgery will improve survival. Certainly some 20% more patients are undergoing potentially curative surgery within this pathway than before. We are sharing the results of our pilot far and wide, in the hope that more trusts will roll it out.” – Mr. Keith Roberts, Consultant Hepatobiliary and Pancreatic Surgeon, University Hospitals Birmingham

This is a model developed by the team at the Liver and Hepato-Pancreato-Biliary (HPB) Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Trust. Pancreatic Cancer UK financially supported the pathway and closely worked with the team in Birmingham to ensure that all key learnings in setting up the pathway are shared to enable its adoption more widely by the NHS. Patient support, collaboration, communication and capacity were the main challenges to be addressed and the key factors for success of the pathway. Appointment of a dedicated pathway Clinical Nurse Specialist was fundamental to address these challenges.

The Clinical Nurse Specialist was key to establishing relationships with the patients during referral, diagnosis and treatment. Also, to meet patient expectations and maintain their wellbeing in a very short timeframe between diagnosis and surgery. Moreover, the Clinical Nurse Specialist role was necessary to build trusting relationships between referral teams and the specialist Hepato-Pancreatic Biliary centre. In our communications with healthcare professionals, lack of resources for additional staff such as an extra Clinical Nurse Specialist has been identified as the major barrier to implementing the pathway. Pro-activity, reactivity and flexibility are important components of the pathway success and brings additional workload to the specialist centre that needs to be absorbed by investing in extra capacity and resources.

Collaboration with the University of Birmingham Health Services Management team was also crucial to increasing engagement of referral teams and the number of people referred and also to address capacity issues in accommodating patients for fast-track surgery.