Haematological Malignancies/

Lymphoma

10.5.1 Introduction

Treatments for haematological malignancies³⁰ can vary significantly in intensity from surveillance, through outpatient chemotherapy and immunotherapy, to complex inpatient therapy up to the level of allogeneic stem cell transplantation. Administration of the most intensive curative treatments is influenced by the age of the patient and the co-morbidities involved. Diagnostics and therapeutics have developed hugely over the past five years resulting in improved outcomes for patients. However, haematology services in Ireland are now faced with severe challenges in coping with complex treatment programmes and increased patient numbers.

10.5.2 Organisation of clinical services

Haematology services have been provided using a hub and spoke configuration for many years. Current referral routes reflect functional relationships built over time. They may not always be aligned to hospital groups or to cancer centres.

Haematologists have a presence in smaller hospitals because of the need to provide clinical consultation and laboratory services. This presence has been leveraged to provide local care with links to larger cancer centres.

Acute haematological malignancies require complex

treatment and are resource intensive. Such treatment should be delivered in a limited number of centres.

10.5.3 Haematological malignancies: outcome- focused groupings

Haematological malignancies span a wide range of neoplasms, with varying levels of complexity and prognosis.

They can be roughly divided into three outcome-focused groups. These are:

• haematological malignancies treated with curative intent requiring complex inpatient care;

• Hodgkin Lymphoma and other aggressive non-Hodgkin lymphomas; and

• lower grade chronic haematological malignancies.

These cohorts should be considered separately when organising services, as patients will require different facilities depending on the type and aggressiveness of their cancer and the expected outcome.

Some haematological malignancies (such as acute

leukaemias in patients aged less than 65-70 years and some aggressive non-Hodgkin lymphomas) require comprehensive multidisciplinary team availability at all times, single high-efficiency particulate air-filtered (HEPA) rooms and day unit and admission facilities that are separate from the general hospital emergency department. The NCCP will examine the data available relating to patient outcomes for acute

30 Haematological malignancies are cancers that begin in blood forming tissues (such as bone marrow) or in the cells of the immune system and include acute leukaemia, lymphomas, multiple myeloma, myelodysplastic syndromes, myeloproliferative and

lymphoproliferative disorders.

CHAPTER 10 GETTING THE TREATMENT RIGHT

leukaemias/Burkitt/CNS lymphoma and, by end-2017, recommend a designated number of centres to deal with such patients. These centres will be capable of accepting patients on transfer within 24 hours of diagnosis.

Other haematological malignancies (such as Hodgkin lymphoma and other aggressive non-Hodgkin lymphomas) also require MDT discussion and planning but receive less complex treatment that can be delivered in haematology/

oncology day units. The NCCP will, by end-2017,

designate a limited number of centres for the treatment of patients with potentially curable high grade non-Hodgkin lymphomas and Hodgkin lymphoma. These patients will have their treatment directed by an MDT.

Lower grade chronic haematological malignancies have median survivals of five to 20 years. Most of these patients will have the majority of their care in hospitals where chemotherapy is administered in haematology/oncology

GETTING THE TREATMENT RIGHT

day units, and will require access to complex integrated diagnostic and surveillance expertise. The NCCP will ensure that patients with chronic and low grade malignant haematological disorders are managed in cancer hospitals where chemotherapy is administered. This treatment will be planned and conducted in collaboration with an MDT in a cancer centre.

Given the wide range of treatment modalities that are required for haematological malignancies, centralisation of these services is required. Arising from A Strategy for Cancer Control in Ireland (2006), it was recommended that haematology services be provided in four of the eight cancer centres. The NCCP will examine the data available relating to outcomes for each of the three patient cohorts and designate an appropriate number of centres to provide comprehensive care for all patients with haematological malignancies.

24

Recommendation

The NCCP will develop appropriate MDT, centralisation and treatment arrangements to meet the diverse needs of patients with haematological cancers.

Lead: NCCP

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10.5.4 Haematological malignancies: services for adolescents/young adults (AYA)

The development of the treatment of AYA patients with haematological malignancies will require strong working relationships and effective co-operation between the new children’s hospital and adult haematology services in designated cancer centres so that patients can be treated in a shared care context where appropriate (see Section 10.7).

10.5.5 Haematological malignancies/lymphomas: diagnostic services

Haematological malignancy diagnoses are complex and require integration of morphology, immunophenotyping, cytogenetics and molecular diagnostics to make an accurate diagnosis that will direct optimal therapy. The development of a national laboratory information system (MedLIS) will make integrated reporting more feasible and will aim to ensure that complex immunophenotyping and molecular diagnostics (even if performed centrally) will be uniformly available for all treating centres. Information on all elements of haematology diagnosis should ultimately be available through MedLIS.

The National Clinical Lead for Molecular Diagnostics (when appointed, see Section 9.5) should examine the centralisation of acute leukaemia immunophenotyping to ensure adequate throughput and expertise and to facilitate the management of minimal residual disease (MRD) monitoring. Such a service must focus on equitable provision of quality controlled critical results to treating centres in a timely, sustainable, auditable and resilient fashion. The potential to combine/

develop haematological cytogenetics (currently based at OLCHC) with malignant haematological molecular diagnostic services should be evaluated. As with other areas of cancer molecular diagnostics, the economic model elaborated must provide a sustainable funding stream to develop molecular assays which direct therapy. Specialist haematopathology review, particularly for patients with lymphomas, must be timely and integrated early into MDT planning. This may require the appointment of new staff as well as the more widespread use of telemedicine, virtual pathology and hub and spoke arrangements.

CHAPTER 10

GETTING THE TREATMENT RIGHT