Establishment of Malignancy Unknown Origin (MUO) referral pathway and service
Laura Jones, Specialist Oncologist, Swansea Bay University Health Board
Introduction
MUO and Carcinoma Unknown Primary (CUP) present diagnostic and therapeutic challenges. Swansea Bay University Health Board lacked an outpatient service, referral pathway, or key worker provision, leading to fragmented care and delays. Baseline data showed poor adherence to NICE guidelines, with delays in treatment and high rates of hospital admissions.
The median cancer pathway time was 44 days, with only 68% meeting the 62-day target, highlighting the need for a dedicated MUO service to improve care, streamline diagnostics, and achieve equitable 62-day Suspected Cancer Pathway (SCP) compliance (in 75% cases) within two years.
Methods
A structured PDSA approach was used, supported by the health board's six key steps for improvement. Charitable funding was secured for a 6-month pilot project to establish referral pathways and a clinic. Stakeholders, including oncologists, GPs, and the Rapid Diagnostic Centre (RDC), were involved in developing the pathway. Insights from Betsi Cadwaladr University Health Board's MUO team were incorporated.
A co-produced pathway with the RDC was created, ensuring appropriate patient routing. The pilot clinic, staffed by a GP with extended oncology training and an acute oncology nurse specialist, was established with a capacity for two patients per week. The pathway was published and shared with local GPs.
Outcomes
- Transformed care for MUO patients with equitable access to clinic, rapid diagnostics, coordinated care.
- Reduced SCP time by 7 days (median 44 to 37 days), with 72% achieving 62-day SCP.
- Shortened Point Of Suspicion (POS) to Systemic Anti-Cancer Therapy (SACT) by 20 days (median 83 to 63 days) and radiotherapy by 34.5 days (median 60 to 25.5 days).
- Reduced admissions during SCP from 74% to 60%, and average hospital stay from 13.8 to 8 days.
- Early oncology input helps avoid unnecessary treatments, reducing biopsy without active treatment from 43% to 32%.
- Positive patient feedback.
- Service expanded with a shared care model in collaboration with Hywel Dda University Health Board.
Learnings
- Evaluated through baseline and two subsequent audit cycles, with continuous improvements.
- Feedback from patients and colleagues collected via online surveys.
- Achieved 72% on the 62-day SCP, near the national aim of 75%, despite complexity.
- Would have included health economics and patient experience in initial impact analysis.
What next?
- Team members are developing a National Optimal Pathway for MUO/CUP through Wales National Strategic Clinical Network for Cancer using insights to improve and standardise care across Wales.
- SBUHB MUO, RDC, radiology teams, haematology colleagues, and management are collaborating to enhance the diagnostic pathway for suspicious lymphadenopathy.
