Over a 32-month period, 100 patients were referred to the hotline.
A total of 16 patients were referred from their GP (either directly or by a community nurse), 16 were referred from the hospice and 68 from the hospital. Of the hospital referrals, 51 were referred by a hospital doctor or a nurse and 17 by the hospital palliative care team. In one case referred from the community, the diagnosis was suggested by an oncologist's secretary on receiving a request from a GP for an early outpatient appointment.
Underlying malignancies included lung (31), breast (13), prostate, (18), colorectal (7), upper GI (6), myeloma (6), kidney (3), lymphoma (2), other (10) and unknown (4). There were proportionally more patients with lung cancer in the hotline group (31%; 31 out of 100) than in the CRAG reference group (21%; 67 out of 319), a statistically significant difference (P=0.041, two-sided Fisher's exact test (2FET)). Analyses were therefore carried out for the population as a whole and for subgroups (patients with lung cancer vs the rest). A total of 94 patients referred to the hotline had localised back pain, 89 had nerve root pain and 84 had both.
A total of 95 patients had an urgent MRI. The results are shown in and compared with MRI results of patients referred for imaging of possible cord compression before the hotline was introduced. Of the five patients who were referred but did not have an urgent MRI scan, one was frail and had already been treated to radiotherapeutic tolerance, the other four did not subsequently develop clinical evidence of MCC during their lifetime.
A comparison of the first 100 patients referred to the Tayside hotline and those referred over the preceding 2 years for ‘query cord compression' (n=104)
A total of 44 out of 95 patients (46.3%) referred via the hotline had MCC compared with 18 out of 104 patients (17.3%) referred before the hotline system was introduced. This is a statistically significant difference (P<0.0001, 2FET). If we include those with MCC or malignant nerve root compression (MNRC) in the comparison, then the rates are 23 out of 104 patients (22.1%) before the introduction of the hotline and 50 out of 95 patients (52.6%) afterwards (P<0.0001, 2FET).
The frequency of patients having normal or benign degenerative changes on MRI results decreased markedly on the introduction of the MCC hotline from 42.3% (pre-hotline) to 14.7% (hotline), and this change was statistically significant (P<0.001, 2FET). The frequency of major pathology, unrelated to cancer, seen on MRI reduced dramatically with the introduction of the hotline process from 15.4 to 0% (P<0.001, 2FET).
Hotline patients with MRI diagnosis of MCC (n=44) or MNRC (n=6) Outcome 1. Reduce time from a GP or a hospital doctor referral to diagnosis
The time from the GP or a hospital doctor referring the patient to the hotline, to diagnosis, was a median of 1 day (range: 0–21). One patient waited 9 days – this was a clinical decision by the palliative medicine/hotline consultant. One patient with claustrophobia needed three scans to establish a diagnosis 21 days later. Two patients waited 7 days (one had claustrophobia and the other patient's scan was delayed). This was considerably shorter than the median time of 15 days from referral to diagnosis in the CRAG audit (IQ range: 3–66 days); and significant at P<0.002 (Mann–Whitney U-test, MW) for each subgroup: overall (15 days vs 1 day), lung cancer (20 days vs 1 day) and non-lung cancer (14.5 days vs 1 day).
Outcome 2. Reduce the number of patients unable to walk at diagnosis
Of the 44 patients with proven MCC, all of whom had mobility recorded at diagnosis, 10 patients (22.7%) were unable to walk at the time of MRI diagnosis compared with 46.0% in the CRAG audit (). The overall mobility rate in the group diagnosed via the hotline is significantly better than that in the CRAG audit group (P=0.003, 2FET). Thirty-four patients had some mobility and 15 (34.1% of all patients with MCC) were able to walk unaided compared with only 18.8% in the CRAG audit, and once again this difference is statistically significant (P=0.028, 2FET). In the subgroup of patients with lung cancer, there was no statistically significant difference in the rate of ability to walk unaided (P=0.91, 2FET) between patients referred via the hotline and those analysed as part of the CRAG audit; this lack of statistical significance is probably because of the small numbers involved in the comparison. In the subgroup of patients who did not have lung cancer, the difference in rates was statistically significant (P=0.002, 2FET).
Mobility at the time of diagnosis of MCC
Outcome 3. Reduce time interval between the onset of symptoms and diagnosis of MCC or MNRC
Back pain: All 44 patients with diagnosed MCC reported back pain. For 41 of the patients, we had information on the date of onset of the back pain. The median length of time patients reported back pain before a diagnosis was established was 32 days (). This was significantly shorter than the 89 days observed in the CRAG audit (P=0.002, MW).
A comparison of time periods (in days) between the onset of pain (back pain and nerve root pain) to diagnosis by MRI in the Tayside hotline and the CRAG audit
Patients with lung cancer diagnosed with MCC via the hotline had back pain for a median of 18 days, and this was significantly shorter than the length of time (113 days) for which the corresponding patients in the CRAG study experienced back pain (P=0.001, MW). Patients with cancers other than lung cancer had back pain for a median of 41.5 days, and although this was shorter than in the CRAG study (72 days), it did not reach statistical significance (P=0.255, MW).
Root pain: Forty-one out of 44 (84%) patients who had an MRI diagnosis of MCC via the Tayside hotline reported nerve root pain. For one patient no data regarding root pain were recorded, for another a report of root pain was given but no date to calculate duration of pain. The median duration of nerve root pain in the 39 patients for whom information was available was 28 days, and this compares favourably (and significantly) with a median of 89 days in the CRAG audit (P<0.001, MW).
In the lung cancer subgroup, the mean time from reporting root pain to diagnosis was 17.2 days in the hotline and 181.2 days in the CRAG audit, and this difference was statistically significant (P=0.012, two-sample t-test). For patients with cancers other than lung cancer, the reported median time of root pain before diagnosis was 30 days via the hotline and 72 days in CRAG, and was, again, statistically significant (P<0.001, MW).
An 83-year-old man with a history of prostate cancer presented to his GP with severe pain in the right renal area. A renal ultrasound showed multiple cysts in the right kidney. An intravenous urogram was subsequently performed, during which the patient experienced transient loss of sensation in his legs. On further enquiry, he had experienced a previous reaction to intravenous contrast. In view of the patient's continuing severe pain, the GP queried unilateral root pain and, bearing in mind the patient's history of cancer, telephoned the Tayside hotline. An MRI scan was carried out the same day and confirmed complete obliteration of the cord at T9. The cord compression team arranged the MRI, collected the result, discussed management with the patient's oncologist and notified the GP. The patient was treated with five fractions of radiotherapy, remained fully mobile and was discharged home after completion of the treatment.