Shared learning database

Merseyside and Cheshire Cancer Network
Published date:
January 2012

This case study describes the Merseyside and Cheshire Cancer Network model for establishing early rectal cancer multidisciplinary teams. Although cited in 'Improving outcomes in colorectal cancers' (NICE cancer service guidance 2004) very few early rectal cancer multidisciplinary teams have been established. This case study has been compiled to demonstrate how early rectal cancer multidisciplinary teams can be established, so that the following recommendation from NICE Clinical Guideline 131 on early rectal cancer MDTs can be implemented in practice. An early rectal cancer MDT should decide which treatment to offer to patients with stage I rectal cancer, taking into account previous treatments, such as radiotherapy [Recommendation]

Guidance the shared learning relates to:
Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?


Aims and objectives

To ensure that all patients with stage T1 tumours (see below staging of colorectal cancer) that are suitable for local resection are managed by a multidisciplinary team that has, and can further develop, expertise in the management of early rectal cancer, in line with NICE guidance and peer review measures for colorectal cancer.

Staging of colorectal cancer - Tumour (T), Nodal (N), Metastases (M)

Stage 0- Carcinoma in situ
Stage I- No nodal involvement, no distant metastasis
- Tumour invades submucosa (T1, N0, M0)
- Tumour invades muscularis propria (T2, N0, M0)
Stage II - No nodal involvement, no distant metastasis
- Tumour invades into subserosa (T3, N0, M0)
- Tumour invades into other organs (T4, N0, M0)
Stage III - Nodal involvement, no distant metastasis
- 1 to 3 regional lymph nodes involved (any T, N1, M0)
- 4 or more regional lymph nodes involved (any T, N2, M0)
Stage IV - Distant metastasis (any T, any N, M1)

Cancer Research UK - Bowel cancer symptoms and treatment [online]. Available here [accessed October 2011] Within the Merseyside and Cheshire Cancer Network (MCCN) to:
- agree a clinical pathway for early rectal cancer from diagnosis to treatment, with all colorectal MDTs
- ensure access to appropriate assessment including rectal endosonography and magnetic resonance imaging (MRI)
- establish a trans-anal endoscopic microsurgery (TEMS) service within the network
- ensure that curative local resection of appropriate cases is managed by a limited number of specialist practitioners.

Reasons for implementing your project

MCCN is one of the largest cancer networks in England, serving a population of 2.3 million. There are approximately 1300 newly diagnosed colorectal cancers each year, managed by colorectal MDTs within each of the seven acute hospitals in Merseyside and Cheshire. At network level, there is a well-established colorectal cancer clinical network group (CNG) with membership drawn from each MDT lead, clinical nurse specialists and patient representatives. The CNG provides expert clinical opinion on a wide range of service issues including clinical guidelines and treatment options, adopting the National Institute for Health and Clinical Excellence as its reference for determining common standards and pathways for cancer patients.

Prior to 2008, the care and treatment of patients with early rectal cancer was managed by their local colorectal MDT who performed local (trans-anal) resection for low-risk cases. In the absence of a local TEMS service, patients with high-risk rectal cancer were referred to a neighbouring network for their procedure.

For the purposes of peer review in 2008, each MDT nominated a lead surgeon to perform curative local resection of T1 rectal cancer. However, reviewers raised concerns about this configuration and the network was asked to ensure that cases were in the hands of a limited number of practitioners. MDTs were to ensure consolidation of specialist expertise.

Planning for the development of an early rectal cancer MDT coincided with implementation of the Merseyside Bowel Cancer Screening Programme (BCSP). The BCSP is based at Aintree University Hospitals NHS Foundation Trust, with colonoscopies performed at Aintree and Royal Liverpool University Hospital. More

How did you implement the project

In order to address the issues raised by peer review in 2008, the colorectal cancer CNG began to explore possible options for the management of early rectal cancer. It was felt that the case for development of the service was best served by establishing a CNG subgroup of interested stakeholders across Merseyside and Cheshire, nominated and chaired by the network's medical director. Two meetings were held with representation from MDT leads in each colorectal MDT in MCCN. A 6-month timescale was proposed to develop plans to address the peer review report.

In recognition of the skills and capacity available within MCCN, the following was agreed:
-A single early rectal cancer MDT would be established and hosted at the Royal Liverpool and Broadgreen University Hospitals NHS Trust, in recognition of the clinical expertise that existed-in particular pathological, radiological and gastroenterological expertise through the BCSP and National Endoscopy Training Centre.
- It was agreed that a TEMS service would be re-established within Merseyside and Cheshire to avoid the need for patients to travel. This procedure would be undertaken by a small number of surgeons as core members of the early rectal cancer MDT. Surgery would be performed on two sites, at Aintree University Hospital and Royal Liverpool Hospital by core surgical members of the MDT.
- A clinical pathway of care and clinical criteria for referral were subsequently developed:
- histologically and clinically indeterminate neoplastic lesions of greater than 3 cm diameter sessile rectal polyps of under 3 cm diameter that are suspicious for malignancy on endoscopy
- biopsy confirmed rectal cancers of under 3 cm diameter that are cT2cNO or better on MRI scanning and/or endorectal ultrasound
- rectal polyps removed by local excision that show unexpected pT1 malignancy on histology. More criteria

Key findings

The early rectal cancer MDT was established in November 2008 and meets in alternate weeks prior to the colorectal MDT. Membership includes surgeons, a gastroenterologist, medical oncologist, and there is clinical nurse specialist input. The MDT coordinates and provides treatment for patients who require specialist surgical and endoscopic procedures, and provides advice to local MDTs regarding further management. Some cases are referred back for definitive major surgery as part of agreed network guidelines.

From November 2008 to August 2011 there were 137 referrals to the early rectal cancer MDT, of which 48 were for carcinoma. The vast majority of cases with a potentially malignant diagnosis were in fact been benign. All colorectal teams have referred to the MDT although some teams more than others.

Of the 137 referrals to the MDT, there were 48 malignant cases, 23 of these were deemed suitable for TEMS, 20 for trans-anal resection and 17 for EMR (see results below). All of these procedures must be available for the MDT to work comprehensively. Radiotherapy has been appropriate in some circumstances where patients have had an aversion to stoma or have been deemed high-risk for surgical intervention.

Referrals to MCCN for small and early rectal cancer MDT activity: November 2008 to August 2011 - Treatment received (benign and malignant cases)

- Transanal endoscopic microsurgery (TEMS) = 23
- Trans-anal resection = 20
- Advice = 34
- Endoscopic mucosal resection (EMR) = 17
- Radiotherapy = 14
- Surgery = 9

Key learning points

The following points were key to the implementation and successful functioning of the early rectal cancer MDT:
- good communication and governance arrangements between local MDTs and the ER-MDT
- clarity regarding clinical responsibility and the point at which this transfers along the pathway
- clear arrangements for informing patients pre- and post-MDT discussion, agreed between the teams involved
- video links to enable referring clinicians to present their case
- agreed processes to support access to imaging, for example picture archiving and communication systems and timely transfer of histology reports
- good MDT coordination.

Contact details

Linda Devereux
Associate Director
Merseyside and Cheshire Cancer Network

Secondary care
Is the example industry-sponsored in any way?