One million question: How would you reduce admission rate for toxicity from Systemic Anti-Cancer Treatment (SACT) to negligible levels?

A novel initiative of independently reviewing each Systemic Anti-Cancer Treatment (SACT) initiation has been implemented in Gibraltar since December 2021; the so-called 'pre-chemo MDT'. Clinical Nurse Specialist, Oncology Pharmacist and an alternative Oncology Consultant to the prescriber appraise each treatment decision; following a structured checklist that includes indication, treatment intent, two validated scores for thrombotic risk (Khorana/Onkotev), baseline scans, blood and urine tests before initiating treatment. Adequate route of administration and venous access are reflected upon; nutritional and frailty scales (Nutri-score and Rockwood) as well as G8 geriatric screening tool are completed. These scores aide holistic and supportive care; involving Dietician, Physiotherapy, Occupational Therapy, Palliative Care, Social Services or Geriatrician as appropriate. Regulatory approvals, support medications, drug interactions and allergies are also double-checked in the process. Electronic records on 188 'pre-chemo MDTs' from December 2021 to November 2023 have been retrospectively audited on the impact of this intervention. NHS England Digital Hospital Episode Statistics - Admitted Patient Care and Outpatient statistics 2020-21 - have otherwise estimated a Medical Oncology rate of admission of 20.5%. There have been 86 Admission episodes over an Outpatient activity (first + subsequent visits) of 3,459 from December 2021 to November 2023; which means a negligible admission rate of 2.5% with most patients (67%) only been admitted once. On-site criteria of admission into Oncology are those of routine UK practice (on-treatment toxicity or within 1–2 months from completion, malignancy-related symptoms and complications, social unmet needs or intercurrent infections); with the caveat that there is no availability of inpatient Hospice for complex terminal care and end of life. Breast and Lung Cancer (both Non-Small and Small-Cell Lung Cancer) represent the two most common tumour sites prompting admission, with 24.4% and 21% of episodes respectively. Eighty five per cent of these have been found to relate to palliative-intent treatment, where progression accounts for 64% of inpatient episodes. Toxicity admissions in these tumour sites have been evenly divided between non-neutropenic temperature and intercurrent infection; confirming that no admission for toxicity could have been prevented at pre-chemo MDT in hindsight. Hence pre-chemo MDTs have represented a paradigm shift in Oncology activity and Outpatient management; re-shuffling resources towards Research & Innovation (R&I) with prospects of a Smart App and machine-learning from global data input.