Nurse led colorectal cancer follow up

The Colorectal Cancer Clinical Nurse Specialists (CNS) role has been developed to enable them to work as part of the multidisciplinary team reviewing patients with colorectal cancer. By providing nurse-led clinics and reviewing patients as non-medical prescribers, the CNSs are responsible for reviewing and assessing patients with known colorectal cancer for any signs of recurrent disease¹. As part of the clinic process they provide information on various aspects of their cancer journey and provide support and onward referral as required.

Historically, nurses did not request clinical imaging; this was seen as a doctor’s role. However, as autonomous practitioners and in order to provide seamless care this has now became an accepted part of their workload, as long as they have the appropriate skills and training^2,3.

Regular review of patients by experienced nurses can facilitate access to the appropriate medical staff for confirmation of recurrence so that prompt salvage therapy¹; be that with palliative or radical intent.

Nurse led colorectal cancer follow-up has been shown to be safe, effective and to offer cost savings in other Scottish Cancer Centres⁴.

The purpose of this document is:

1. For clinical nurse specialists to facilitate and lead the care and management of colorectal cancer patients attending a cancer review follow-up, either in surgical, oncology lead clinics or during telephone consultation².
2. To provide a safe and efficient service to patients requiring further clinical imaging investigations.
3. For the clinical nurse specialist to refer patients for clinical imaging⁵:
   • As per patient’s routine follow-up guideline: West of Scotland Managed Clinical Network (MCN) Colorectal Cancer Follow-up Algorithm.
   • As per guideline for complete clinical response in rectal cancer patients following neo-adjuvant treatment.
   • In accordance with guidelines for adjuvant and palliative patients on treatment to assess response to treatment.
   • Metastatic patients on follow-up, to assess rate of progression or to assess new symptom following assessment.
   • As per Basingstoke follow-up guidelines for appendiceal cancers and psueudomyxomas.
4. Clinical Nurse Specialists new to the colorectal cancer service should have a period of clinical supervision and established competency prior to undertaking the clinic independently. The CNS must also have completed Ionising Radiation (Medical Exposure) Regulations (IR(ME)R) training in accordance with local policy.

Follow-up:

• The colorectal oncology nursing service reviews patients at independent nurse-led clinics as per protocol with surgical/oncology consultant/medical review only as required.
• This can be patients with any colorectal malignancy, at any stage and receiving or have received any treatment.
• At these clinics CT scans may be required for routine assessment, staging, re-staging, symptom management or assessment of treatment.
• Within IRMER guidelines scans be requested out with previous mentioned protocols if carcino embryonic antigen (CEA) is raised or the patient reports concerning symptoms. Discussion with appropriate consultant will also take place and the GP will be updated.
• Colorectal oncology nurses will make these requests independently as agreed within the referral criteria stated within this document.

2.1 Inclusion

• All non-trial patients considered for adjuvant oncological therapy (systemic anti-cancer therapy (SACT) / radiotherapy or chemo-radiotherapy).
• All non-trial patients who have completed adjuvant oncological therapy (SACT/radiotherapy or chemo-radiotherapy).
• All patients treated by surgery alone.
• Palliative patients.
• Patients treated in tertiary centres are now receiving follow-up e.g. patients with resected lung metastasis, liver metastasis or post ablation.
• Tertiary centre post operative patients.

2.2 Exclusion

Clinical trial patients will be excluded if their follow-up is different from local standard guidelines. Any other patients the oncologist or surgeon feels should not be nurse-led reviewed for any other reason e.g. very high risk patient, comorbidities. 

Following MDT discussion, a decision will be made regarding follow-up pathway for each individual patient. This will outline the intensity, duration and method of follow-up.

The decision about appropriateness for nurse led follow up clinic will ultimately be decided by the consultant. The specialist nurses have clinics based at University Hospital Ayr and University Hospital Crosshouse and will review patients throughout their follow up either at these locations or by video or telephone consultation.

Summary of clinical process for Ayrshire colorectal cancer (CRC) nurse led adjuvant follow-up in oncology clinic

• Patients who do not require adjuvant SACT will be followed up according to the West of Scotland Managed Clinical Network (WOSMCN) colorectal cancer follow-up algorithm. This is determined at Multi-disciplinary Team (MDT) meeting. At first post-op visit the consultant surgeon will determine if the patient is suitable for nurse-led follow-up.
• Patients who choose not to have adjuvant SACT or are deemed unsuitable will be assigned a follow-up strategy by the consultant oncologist depending on their suitability for surgical resection of isolated metastatic disease. This is in line with the West of Scotland MCN colorectal cancer follow-up algorithm.
• Following adjuvant SACT a follow-up strategy will be assigned depending on the patient’s risk and suitability for surgical resection of isolated metastatic disease according to the consultant oncologist and West of Scotland MCN Colorectal Cancer Follow-Up Algorithm.
• Post operative patients from tertiary centres will be referred by consultant surgeon/oncologist for ongoing follow-up as per West of Scotland MCN Colorectal Cancer Follow-Up Algorithm.

• Patients will be reviewed as per follow-up protocol for signs and symptoms of recurrence of cancer as per the West of Scotland Managed Clinical Network colorectal cancer follow-up algorithm/other pre-mentioned protocols.
• If any concerning issues e.g. new symptoms, complicated symptoms, concern regarding recurrence of disease arise during the nurse-led consultation, a doctor will be asked for advice and/or to review the patient. It is up to the CNS to decide how urgently this advice/review is sought.
• Order investigations as per West of Scotland Managed Clinical Network colorectal cancer follow-up algorithm/other pre-mentioned protocols
• Correct and appropriate information on requests for clinical imaging investigations for patients requiring further investigation.
• If further discussion or clarification is required ensure the patient is added to the next multidisciplinary meeting.
• Discuss outcome with patient and arrange appropriate follow-up and documentation, ensuring the GP is updated.
• Refer to other specialties as appropriate e.g. palliative care, stoma care, physiotherapy, social work.
• Nurse led clinics will dictate own letters under relevant consultant surgeons name and these are typed locally.

Nurses requesting clinical imaging requests will be audited on a 6 monthly basis ensuring:

• Adherence to follow-up guideline.
• Referral quality according to IR (ME) R i.e. quality of patient details, quality of information given.
• Monitoring of the number of referrals.

Employees are reminded that they may have patients/carers who require communication in an alternative format e.g. other languages or signing. Additionally, some patients/carers may have difficulties with written material.

At all times communication and material should be in the patient’s/carer's preferred format. This may also apply to patients with learning difficulties.

In some circumstances there may be religious and/or cultural issues which may impact on clinical guidelines e.g. choice of gender of health care professional. Consideration should be given to these issues when treating/examining patients.

Some patients may have a physical disability or impairment that makes it difficult for them to be treated/examined as set out for a particular procedure requiring adaptations to be made.

Patients’ sexual orientation may or may not be relevant to the implementation of this guideline, however, non-sexuality specific language should be used when asking patients about their sexual history. Where sexual orientation may be relevant, tailored advice and information may be given.

This guideline has been impact assessed using the NHS Ayrshire and Arran Equality Impact Assessment Tool Kit. No additional equality and diversity issues were identified.

References

1. Taylor C, Stiff, D, Garnham, J. Gastrointestinal Nursing 2014 12 (6) P. Sustaining colorectal cancer nurses’ specialist practice.
2. Casey, N., Editorial. Nursing Times, 1996. 10: p.34.
3. Gee, C., The case for nurse led follow-up. Cancer Nursing Practice 2004. 10: p. 29-33.
4. Knowles, G., et al., Developing and piloting a nurse-led model of follow- up in the multidisciplinary management of colorectal cancer. European Journal of Oncology Nursing, 2007. 11(3): p. 212-23; discussion 224-7.
5. Royal College of Nursing. Clinical imaging requests from non-medically qualified professionals. 3rd edition. 2021. 

Bibliography

• Department of Health. Ionising Radiation (Medical Exposure) Regulations 2017. Available from: https://www.legislation.gov.uk/uksi/2017/1322/contents/made
• Nursing and Midwifery Council Jan 2015 The Code. London.
• Department of  Health  2017  The  Ionising  Radiation  (Medical  Exposure) Regulations together with notes on good practice. Available from: https://www.dh.gov.uk/Publications and Statistics/Publications.
• Royal College of Radiologists. Making the best use of a department of clinical radiology. 8th ed. London, The Royal College of Radiologists, 2017.

West of Scotland Cancer Network MCN Colorectal cancer follow-up guidelines 

Complete clinical response follow-up protocol – West of Scotland Cancer Network v2.8 2024

Follow up protocol for year 1:

- Flexible sigmoidoscopy (with photographs) and rectal exam at:

• 6 weeks after the post treatment assessment
• 12 weeks
• 18 weeks
• 26 weeks (6 months)
• 38 weeks (9 months)
• 52 weeks (12 months)

- MRI assessment at:

• 4 months after the post treatment assessment
• 8 months
• 12 months.

Follow up protocol for year 2:

- Flexible sigmoidoscopy at 4 monthly intervals
- MRI at 6 monthly intervals.

Follow up protocol for year 3-5:

- Flex sigmoidoscopy at 6 monthly intervals
- MRI at 6-12 monthly intervals.

Basingstoke low grade appendix mucineal neoplasm follow-up protocol

Basingstoke complete cytoreduction follow-up protocol