Paediatric Oncology MDT

**MDT Minutes** 1 November 2024 **Haematology Patients** **Alice Smith, 15/03/2018, MRN: P1234567** - Diagnosis: Acute Lymphoblastic Leukaemia (ALL), B-cell precursor, standard risk, in first relapse (day +60 post-CAR T-cell therapy). - Current treatment status: Inpatient at St. Jude's Children's Hospital, undergoing consolidation phase of CAR T-cell therapy. Receiving daily oral chemotherapy (Mercaptopurine) and weekly intravenous Methotrexate. Frequency of hospital visits is three times per week for blood tests and monitoring. - Future treatment plans: Await bone marrow biopsy results on 15 November 2024 to confirm remission. If in remission, plan for transfer of care to local oncology unit for ongoing maintenance therapy, anticipated to begin in December 2024. No further procedures currently planned. - Recent appointments/events: Attended a successful art therapy session on 30 October, appeared engaged and happy. Parents present. Well-being generally good, though some fatigue noted. Home visit by specialist nurse on 28 October for line care education with parents. - Current medication regimen: Mercaptopurine 50mg daily, Methotrexate 15mg IV weekly, Ondansetron 4mg PRN for nausea. Treatment adjustment: Methotrexate dose reduced due to transient transaminitis (ALT 120 U/L, AST 105 U/L) on 29 October. Reason for adjustment: minimise hepatic toxicity. - Changes in laboratory results: Platelet count stable at 150 x 10^9/L, WBC 4.5 x 10^9/L (ANC 2.8 x 10^9/L). Liver enzymes elevated as above, trended down slightly today (ALT 98 U/L, AST 89 U/L). - Health status in relation to household contacts/infections: No known household contacts with recent infections. Alice developed a mild upper respiratory tract infection (URTI) last week, managed with symptomatic treatment; cleared with no complications. - Home treatment: Parents confidently managing oral Mercaptopurine. Demonstrated good understanding of infection precautions. Actively involved in recording Alice's daily fluid intake and output, and symptom monitoring. - Significant past medical events: Experienced Grade 2 Cytokine Release Syndrome (CRS) immediately post-CAR T-cell infusion in September 2024, managed successfully with Tocilizumab and steroids. Fully recovered. - End-of-treatment discussions: Initial discussions regarding long-term follow-up and potential late effects have commenced with parents. Future clinic appointments scheduled for follow-up with CAR T-cell team in 3 months. - Patient's emotional state: Alice has been observed to be generally cheerful and cooperative, though occasionally expresses frustration with hospital routine. Sleep patterns are good. Demeanour is bright, often drawing pictures for nurses. - Parental emotional state: Mother appears anxious about the upcoming bone marrow biopsy results, expressing fears of further relapse. Father is more stoic, focusing on practical aspects of care. Both are coping well but show signs of stress related to the long-term nature of treatment. Perceive continued stability as contingent on negative MRD results. - Family struggles: Siblings (aged 10 and 12) have exhibited some behavioural changes at home, including increased irritability and clinginess. Family routine significantly disrupted by Alice's hospitalisations. Family concerned about Christmas plans due to potential ongoing treatment. - Parental openness to external support: Parents are open to psychological support, specifically requesting a referral for sibling support services. They declined a general peer support group initially, preferring individual counselling for themselves first. They have requested information on art therapy resources for Alice post-discharge. - Considerations for psychological support: Referral to child psychology team for sibling support has been actioned. Ongoing support for parents will continue via ward psychologist. Discussion held with parents regarding coping strategies for anxiety. Clinician recommends continued regular check-ins with parents to assess their emotional well-being. - Psychology team's considerations: Psychology team notes resource constraints for immediate intensive sibling therapy but will prioritise based on clinical need. Options for group-based sibling support are being explored for January 2025. - Insights from play therapy: Alice stated, "I wish I could go home and play with my dog." Interpretation suggests longing for normalcy and home environment. Discussion regarding funding for a potential 'make-a-wish' experience post-treatment completion is underway. Family contact for this initiated. - Agreements regarding follow-up care: Agreed follow-up with haematology-oncology team at regional hospital, commencing upon transfer of care. Local GP will be updated regularly. - Specific requests from other institutions: Dr. Thomas Kelly from Great Ormond Street Hospital requested Alice's most recent bone marrow biopsy slides for review as part of a national research initiative. Expected procedures: review of slides within 2 weeks. - Requests for psychological notes: Request received from a solicitor (Ms. Sarah Jenkins) on behalf of the family for all psychological notes pertaining to Alice for a potential insurance claim. Unusual circumstances: Request received directly from solicitor, not via family. Clinician plans to clarify the scope of the request and gain explicit written consent from both parents before releasing any notes, in adherence to hospital policy and safeguarding guidelines. **Solid Tumour Patients** **Ben Davies, 02/08/2020, MRN: S7654321** - Diagnosis: Neuroblastoma, Stage 4, High-risk, located in the abdomen with bone marrow metastases. Confirmation status: confirmed via biopsy and MIBG scan. - Patient's current condition: Ben is stable post-induction chemotherapy cycle 4. Eating well, energy levels improving. No fever or signs of infection. Tumour markers (urine VMA/HVA) show significant reduction. - Recent treatment: Completed Cycle 4 of Rapid COJEC chemotherapy last week. Ben tolerated treatment well overall, with only mild nausea and fatigue. He expressed dislike for the nasogastric tube, leading to some emotional distress. Disruption to well-being was minimal due to proactive antiemetic management and play therapy support. - Discussion details with parents: Extensive discussion held with parents regarding response to induction chemotherapy and next steps. Expert opinion from the national neuroblastoma panel confirms good response, recommending high-dose chemotherapy with stem cell rescue. Parents understand the intensity but are determined to proceed. - Decision regarding change in treatment regimen: No change in current regimen. Decision is to progress to high-dose chemotherapy (Busulfan/Melphalan) followed by autologous stem cell transplant. Planned duration: approximately 4-6 weeks for transplant phase. Conditions for early cessation: severe unmanageable toxicity or disease progression. - Scheduled treatment plans: High-dose chemotherapy to commence 15 November 2024 at the specialist transplant unit. Stem cell rescue planned for 22 November 2024. No delays anticipated. - Medication: Currently on prophylactic antibiotics (Ciprofloxacin), antifungal (Fluconazole), and antiviral (Aciclovir) due to neutropenia. Granulocyte-colony stimulating factor (G-CSF) will be started post-transplant to aid engraftment. Dosage adjustments: G-CSF dosage will be weight-based. - Upcoming surgical plans: No immediate surgical plans. Planning for future tumour resection surgery post-transplant and consolidation. Involved specialties: Paediatric Surgery, Oncology. Confirmation status: Surgical review scheduled for January 2025. Timing TBD. - Main surgical risks: Potential for significant blood loss, infection, damage to adjacent organs (kidney, bowel), nerve damage, and incomplete tumour resection. Post-operative complications: ileus, anastomotic leak, pain, prolonged hospital stay. - Potential need for post-operative radiotherapy: Yes, post-operative radiotherapy to the primary tumour bed is highly likely, pending surgical margins and MIBG scan results. - Required post-operative assessments: Regular MIBG scans (3-monthly for 2 years), bone marrow aspirations (6-monthly for 2 years), full body MRI (yearly for 5 years). Timing: First post-transplant MIBG scan in February 2025. Location: Imaging department at tertiary centre. - Required follow-up with specific specialties: Endocrine follow-up (due to potential late effects of chemotherapy), Cardiology (for anthracycline cardiotoxicity monitoring), Audiology (cisplatin ototoxicity monitoring). Plans: Referrals to be made prior to transplant discharge. Oncology nurses will coordinate appointments. - Postponed imaging appointments: A routine surveillance MRI scheduled for 25 October 2024 was postponed due to Ben's neutropenia. New scheduling: Rescheduled for 8 November 2024. - Assessment of impact of imaging delay: Minimal impact on treatment phase as it was a surveillance scan, not critical for immediate treatment decisions. Next treatment phase (high-dose chemo) was not dependent on this specific imaging result. - Details of care team: Transplant team at specialist unit will take over care. Paediatric Oncology team will continue to provide oversight. Location: St. Mary's Hospital Transplant Unit. - Required end-of-treatment planning: Discussion about long-term surveillance, late effects clinic referrals, and transition to adult services will commence around 1-year post-transplant. - Treatment and surveillance location: High-dose chemotherapy and transplant at St. Mary's Hospital. Subsequent surveillance and maintenance therapy at local paediatric oncology unit. - Recent social events: Ben attended a hospital-organised Halloween party on 31 October with his family. He dressed as a superhero and appeared very happy. - Scheduled procedures and celebratory plans: Planned 'ring the bell' ceremony upon completion of all active treatment, anticipated late 2025. Family is planning a small celebration upon discharge from transplant unit. - Patient's preferences: Ben has expressed a strong preference for 'fun' medical devices, choosing brightly coloured dressings and bandages. He prefers playing in the hospital playroom rather than staying in his room. He enjoys painting as a recreational activity. - Patient's wishes regarding recreational activities: Ben expressed a wish to visit a theme park with his family once he is well enough. Associated financial considerations: Charity application for funding for this wish has been initiated. Plans for fulfilling the wish: to be arranged with the 'Wish Upon a Star' charity after treatment completion. - Patient's emotional state: Generally good spirits, though occasionally becomes withdrawn when procedures are discussed. Demeanour is playful. Physical activity is increasing. No significant weight changes. Eager to return to school. - Online schooling and academic progress: Ben is receiving 2 hours of online tutoring per week. He is maintaining good academic progress, especially in maths, which he enjoys. The school liaison teacher provides regular updates. - Medical setbacks: Ben experienced an episode of febrile neutropenia in Cycle 3, requiring IV antibiotics and a 5-day hospital stay. This caused a 3-day delay in starting Cycle 4, but no long-term impact on overall treatment plan. - Central line issues: Ben's central line developed an exit-site infection two weeks ago, requiring removal. A new Broviac line was successfully placed on 29 October without complications. - Mother's emotional state: Mother is generally positive and highly motivated, expressing strong belief in Ben's recovery. She actively participates in all discussions and is a strong advocate for Ben. Father remains calm and supportive. - Mother's ongoing anxieties: Mother occasionally expresses anxiety about potential long-term side effects of chemotherapy, particularly fertility. Reassurances provided regarding ongoing monitoring and access to fertility preservation services in adulthood. Medical necessity of aggressive treatment for neuroblastoma was reiterated. - Family struggles: Siblings (aged 6 and 9) are having some difficulty adjusting to Ben's long hospital stays, exhibiting some acting out behaviours at home. Disruption to school routines for siblings noted. Family is finding it challenging to maintain a sense of normalcy. - Mother's openness to external support: Mother is open to connecting with other parents of neuroblastoma patients for peer support. She has expressed interest in a support group specifically for parents navigating stem cell transplant. She declined individual counselling at this time, preferring group support. - Family arrangements for support during treatment: Grandparents are providing significant support with sibling care and household duties. Family plans to stay in hospital accommodation during the transplant phase to be close to Ben. Travel plans: Grandparents will travel from Scotland to assist. - Challenges in managing relationships with family members: Occasional disagreements between parents and paternal grandparents regarding Ben's diet during treatment; grandparents express dissatisfaction with hospital food and offer 'comfort' foods. Complaints made about lack of traditional meals. Observed behaviours: grandparents bring in unauthorised food items despite clear instructions. Stress response: parents feel caught in the middle. - Pragmatic solutions for treatment continuation: Discussed the option of home-based maintenance chemotherapy for future cycles if appropriate, to reduce hospital burden. Rationale: improve quality of life and family routine. Proposed presentation to family: will be framed as a way to allow Ben more time at home. Long-term surveillance plans: will involve regular scans and specialist clinic visits for many years. - Involvement of other family members in care: Paternal grandmother is very involved, often calling the ward for updates and sometimes questioning treatment decisions. Her influence is significant on the father, who then seeks further clarification from the medical team. - Patient's bonding with staff: Ben has bonded particularly well with the play specialists and several of the nursing staff, often asking for them by name. **Any Other Business** - Discussion regarding the upcoming audit of chemotherapy prescribing practices within the department, with a focus on improving documentation accuracy and reducing transcription errors. Dr. Evans presented preliminary findings from the last quarter, highlighting areas for improvement in drug reconciliation processes. - Planning for the annual Paediatric Oncology Charity Ball in December, with roles assigned for various committee members. Fundraising targets were reviewed and strategies discussed to maximise donations. - Brief discussion on the new hospital policy regarding patient access to electronic medical records, with a focus on paediatric patients and parental consent.