Private Care SUMMER 2018
INNOVATORS IN IMAGING How we’re pioneering the latest diagnostic radiology techniques Safety first: our unique approach to anaesthetics
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SUMMER 2018
PRIVATE CARE AT THE ROYAL MARSDEN
THE FACTS
24/7
support is provided by our clinical nurse specialists
WELCOME As the Managing Director of Private Care, I’ m pleased to introduce the latest issue of Private Care magaz ine. W ith highly trained staff and state-of-theart eq uipment, The Royal Marsden has been at the forefront of diagnostic imaging for many years and is proud to have been one of the first centres in the world to develop and offer a whole-body MRI service. W e speak to the consultants setting international standards for imaging in our ISAS-accredited department. W e also focus on our expert anaesthetists, who deliver a uniq ue service of evidence-based care through a patient-focused approach. Finally, Dr Alison Tree, Consultant Clinical Oncologist, talks about her role in the U rology U nit. Dr Tree, who specialises in radiotherapy and chemotherapy treatment for urological malignancies, discusses the developments taking place – in particular, the start-up of the MR Linac this summer, which will see The Royal Marsden become the first U K centre to use this pioneering techniq ue. I hope you enjoy reading the updates and news in this issue. Shams Maladwala Managing Director of Private Care
1st
Robotic Surgery Fellowship of its kind in the UK was established here to train the surgeons of the future
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years of delivering highly accurate radiotherapy with CyberKnife
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patients have been scanned with whole-body MRI over the past 10 years
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beds are located in our newly opened facility in Chelsea for stem cell transplants
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consultants work in our Anaesthetic Department
FIND OUT MORE
ON THE COVER Professor Gina Brown, Consultant Radiologist
For referrals and enquiries, call 020 7811 8111 or email privatepatients@rmh.nhs.uk
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U P DAT E
OUR SURGEONS TRIAL AUGMENTED REALITY
THE ROYAL MARSDEN is trialling the use of augmented reality during robotic surgery for patients with prostate, testicular or kidney cancer. Scans taken before surgery are superimposed onto the surgeon’s ‘view’ inside a patient’s body. This is
displayed on a tablet device attached to the da Vinci Xi robot and within the robotic console itself. The image shows any target organs for the procedure, as well as the surrounding anatomy, to help guide the surgeon’s actions.
SCREEN TIME Mr Erik Mayer uses augmented reality at the da Vinci Xi console
Mr Erik Mayer, Consultant Surgeon, said: “Robotic surgical systems have rapidly advanced the field of minimally invasive surgery, but there is one key challenge compared to traditional open surgery: an increasing sensory distance between surgeon and patient. “As you lose the sensation of touch with robotic surgery and can’t feel the tissue, there is a growing interest in using augmented reality to enhance the surgeon’s vision, providing them with crucial information to better guide surgery.” This work is a collaboration between The Royal Marsden, Imperial College Healthcare NHS Trust and Imperial College London, supported jointly by the National Institute for Health Research (NIHR) Imperial Biomedical Research Centre (BRC) and the NIHR BRC at The Royal Marsden and The Institute of Cancer Research.
TALKING POINTS “The anaesthetic service we are offering really is unique compared with other centres” Page 6
“We combine image acquisition with leading radiology expertise to provide a world-class imaging service” Page 8
“Simply being able to say ‘hello’ in a patient’s language helps build a rapport” Page 12
“There has been an astounding pace of change in the management of prostate cancer over the past few years” Page 14
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IN BRIEF
IN TRAINING Mr Marc Bullock
Stem cell transplants
Thanks to a new five-bed facility, private patients at our Chelsea site now have access to our stem cell transplant service, which was previously available only in Sutton. So far, we have carried out 12 autografts (where the patient receives an infusion of their own healthy cells after chemotherapy) and one allograft (where donor cells are infused into the patient).
Re ucin si e effects
Our prostate cancer patients can now benefit from SpaceOAR, a biodegradable ‘ water cushion’ that adjusts the position of internal organs during radiotherapy in order to reduce damage to healthy tissue in the pelvic area. In clinical trials, SpaceOAR has reduced side effects such as bleeding from the rectum, pain, discomfort, and changes in bowel habit by 6 0 -8 0 per cent.
On the Horizon
The Royal Marsden’s Oak Centre for Children and Young People (OCCYP) will feature in a forthcoming documentary in the BBC’s science series Horizon. Camera crews followed teenage and young adult patients and staff in the OCCYP for a month in late 2017 for the one-hour programme. It focuses on the impact a cancer diagnosis can have on patients aged 16 to 24 and how the treatments have developed.
NEW RECRUIT FOR ROBOTIC SURGERY A NEW ROBOTIC surgery fellow has joined The Royal Marsden as part of our unique programme to train the multidisciplinary robotic surgeons of the future. Mr Marc Bullock has been working as a Pelvic Exenteration Robotics Surgical Fellow since April. Funded by supporters of The Royal Marsden Cancer Charity, the Robotic Surgery Fellowship is made possible by the da Vinci Xi’s dual console capability, which allows consultants to supervise trainees during live surgery. Our da Vinci Xi was funded by a generous donation from the McCarthy family. Mr Bullock said: “The Royal
Marsden provides a unique blend of expertise unavailable elsewhere in the UK. “By integrating multiple disciplines of surgical oncology, this fellowship is exceptionally forward-thinking, and will help redefine what is considered possible. It is an exciting time to be a surgical trainee, with such technological innovation that extends and improves the lives of patients.” Robotic surgery has several benefits over open or keyhole surgery. Greater precision results in lower blood loss, less pain and smaller scars, which means patients recover faster and have shorter hospital stays.
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Myles Smith and Dr Kara
U P DAT E
Lymph node study success USING A FLUORESCENT green dye alongside robotic surgical technology can help to identify sentinel lymph nodes affected by cancer, according to new research from The Royal Marsden. The FRIENDS study found that in 95 per cent of the 160 women with early cervical and endometrial cancer, surgeons were able to successfully identify the nodes to which the cancer had spread. Usually, surgeons would carry out a radical lymphadenectomy – a removal of all nodes – to assess the spread of disease. This exposes patients to the risk of lymphedema,
“We hope that this will influence future lymph node procedures” RESEARCH HIGHLIGHT Ms Marielle Nobbenhuis
a major condition that can have a huge impact on day-to-day life. The new technique involves injecting the cervix with dye, which then spreads through to the nodes. Using the da Vinci Xi surgical robot, the surgeon can see the affected nodes – which can then be removed for further biopsy – and the unaffected nodes to leave. The da Vinci’s viewfinder features a black-and-white ‘filter’ that can be switched on and off during surgery, allowing the surgeon to see which nodes have responded to the dye. Lead author Ms Marielle Nobbenhuis, Consultant Gynaecological Oncology Surgeon, said: “As leaders in robotic surgery, we hope that this will influence the future of sentinel lymph node procedures, resulting in better care and treatment for patients.”
ACADEMY HONOUR FOR CONSULTANTS Two world-leading oncologists from The Royal Marsden have been elected as Fellows of the Academy of Medical Sciences. Professor Christopher Nutting, Consultant Clinical Oncologist, and Dr James Larkin (pictured), Consultant Medical Oncologist, have been chosen for their outstanding contributions to biomedical and health science, leading research discoveries, and translating developments into benefits for patients and the wider society. Dr Larkin said: “The Academy is a remarkable organisation that includes hundreds of clinicians and scientists who have made major contributions to understanding and treating disease. I feel extremely humbled and very much look forward to contributing to their incredible work.”
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IN SAFE HANDS Our anaesthetists aren’t limited to simply providing anaesthesia during surgery. In fact, these clinicians play a vital role in patient care and safety
IN THE ROYAL MARSDEN’S Anaesthetic Department, expert consultants provide an unparalleled service of evidence-based care through a patient-focused approach. “The anaesthetic service we are offering really is unique compared with other centres,” says Dr Matthew Hacking, Consultant Anaesthetist and Department Lead. “We’re now able to provide personalised care for patients, which means they have a better experience, a faster recovery and fewer complications.”
Total intravenous anaesthesia (TIVA) makes up 85 per cent of the anaesthesia given at The Royal Marsden. By contrast, gas or volatile anaesthesia is more commonly used worldwide. Studies published by Dr Shaman Jhanji and Dr Tim Wigmore, Consultants in Intensive Care Medicine and Anaesthesia at The Royal Marsden, demonstrate that TIVA potentially has the significant benefit of better long-term survival in patients. Along with its academic partner The Institute of Cancer
FITNESS TEST Consultant Anaesthetist Dr Alex Oliver conducts a preassessment (above); Dr Ramanathan Kasivisvanathan (top)
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ANAESTHETICS
Research, The Royal Marsden is carrying out further research to investigate the advantages of TIVA by exposing cancer cells to two different types of anaesthesia. Working with patients Anaesthetic practice at The Royal Marsden is not just limited to time in theatre. Dr Ramanathan (Nathan) Kasivisvanathan, Consultant Anaesthetist and Lead for Preassessment, says: “We’re spending a lot of time with patients as part of a unique preassessment service. “We’re focused on ensuring we operate on patients at the right time and get them as well as possible before surgery. This means we do a lot of work with them when they first come in and after surgery, which ensures they have the best recovery possible.” Preassessment services include cardiopulmonary exercise testing, guidance on nutrition, or iron therapy for anaemic patients to lessen the need for blood transfusions. Dr Kasivisvanathan has devised and implemented the Marsden Morbidity Index, which helps to identify patients at high risk of complications after major surgery, meaning that consultants can be prepared to offer the necessary individualised treatment. Also, a team led by Dr Kasivisvanathan has recently been highly commended for the Anaesthesia and Perioperative Medicine Team of the Year prize at the BMJ Awards. The Surgical Frailty Transformation Programme identifies frail patients and implements a package of care, leading to improved outcomes.
A UNIQUE SERVICE Dr Matthew Hacking (left); Dr Rohit Juneja (below)
“We’re very patient focused, with the most experienced people collaborating during the decision-making process,” says Dr Kasivisvanathan. “I strongly believe that, for high-risk, complex surgery, we are one of the best providers in terms of overall outcomes and patient care.”
A culture of safety Patient safety is a Trust-wide priority, and anaesthetists play a vital role. Dr Rohit Juneja, Consultant Anaesthetist and Lead for Patient Safety, directs the Patient Safety Fellowship, the longest-running programme of its type in the UK. “We pride ourselves on a culture of safety, with a truly collaborative approach that sets us apart from other UK centres,” Dr Juneja says. “Through a multidisciplinary approach, we balance the urgency of cancer with an assurance of safety to our patients.” Simulation exercises are run twice a year by Dr Juneja and Dr Olivia Mingo, Consultant Anaesthetist and Medical Lead for Simulation, and attended by all theatre staff. The training aims to put people under pressure in rare emergency scenarios, helping them to develop skills in crisis resource management and human factors in a safe environment. The Royal Marsden was the first centre in the UK to host the Global Conference on Perioperative Care of the Cancer Patient, chaired by Dr Wigmore, in 2016. Our consultants contributed to the book Anaesthesia, Intensive Care, and Pain Management for the Cancer Patient – one of the most comprehensive publications in this field – and the department offers innovative fellowships that attract international trainees and fellows. Dr Juneja says: “The Royal Marsden is progressive and innovative. Our work in anaesthetics reflects everything we do in the Trust – always taking the lead in educating and developing expert clinicians in cancer care.”
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“We’re embracing imaging innovations that could have a huge impact on patient care”
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RADIOLOGY
A PICTURE OF HEALTH With highly trained staff and state-of-the-art equipment, our radiology service leads the way in pioneering new methods of diagnostic imaging
THE ROYAL MARSDEN’S Department of Diagnostic Radiology has been at the forefront of cancer imaging for many years, pioneering new techniques using state-of-the-art equipment at Chelsea and Sutton for the benefit of patients. Indeed, we were one of the first hospitals in the world to offer whole-body magnetic resonance imaging (MRI). We run a comprehensive imaging service for inpatients 24 hours a day, seven days a week, with many services also available six days a week for outpatients. Our skilled team of radiologists, radiographers and medical physicists are highly experienced in
IMAGE CONSULTANTS Professor Dow-Mu Koh (left) and Dr Christina Messiou (right)
working with oncology patients and understand their specific needs. We place quality at the centre of our working practice, as evidenced by the training, machine quality assurance and scanning techniques we employ, and the fact that the department was accredited by the Imaging Services Accreditation Service (ISAS) in March 2018. Imaging expertise Dr Angela Riddell, Consultant Radiologist and Clinical Lead for Radiology, says: “We combine image acquisition across X-ray, ultrasound, breast imaging, computed tomography [CT], PET-CT, MRI, interventional radiology and nuclear medicine with leading radiology expertise to provide a world-class imaging service.” Across our two sites, we have five mammography units, including contrastenhancing and tomosynthesis capabilities; four CT, five MRI and two PET-CT scanners; an interventional radiology suite; and seven ultrasound machines. Each technology is suited to a particular purpose. For example, CT provides a detailed three-dimensional view of the body’s interior and can be used to help make a cancer diagnosis >
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DR ANGELA RIDDELL Consultant Radiologist and Clinical Lead for Radiology Dr Angela Riddell is a core member of the multidisciplinary teams for upper gastrointestinal cancers, lung cancer, haemato-oncology, melanoma and skin cancer. Her main research interest is in MRI and its use in oesophageal cancer and liver disease. She regularly lectures nationally and internationally on aspects of upper gastrointestinal imaging.
or assess the effects of treatment. MRI, meanwhile, offers superior detail of soft tissues, so is used to scan brain, spinal cord, bowel, gynaecological and prostate cancers. “Many of our radiologists are involved in setting national and international guidelines for imaging, in terms of both diagnosis and follow-up for various tumour types,” says Dr Riddell. “This ensures that patients at The Royal Marsden are offered the most up-to-date imaging methods for their cancer care. “Our consultants are not only at the forefront of imaging expertise, but also in subspecialities within imaging.” This level of proficiency maximises patient care, according to Professor Gina Brown, a Consultant Radiologist specialising in gastrointestinal and colorectal cancers. “Our patients are fortunate that surgical and oncological colleagues liaise closely with the relevant imaging specialist to enable informed choices to be conveyed to the patient,” she says. “We receive a lot of private referrals from other hospitals, and a common
issue is a lack of detail and clarity on the diagnosis. This can result in a lack of certainty and an inability to define a clear plan to optimise the patient’s chances of being cured. Our patients benefit immensely from a highly specialist team planning their treatment.” Whole-body scanning As one of the first centres in the world to develop and offer a comprehensive whole-body MRI service, The Royal Marsden has been leading research into this technique for the past decade, and our radiologists have years of experience in reporting these scans. Whole-body scanning can provide views of the entire body without the need to use intravenous contrast or radiation. Our research has shown that this is the most sensitive technique for examining myeloma in the bone marrow, but it has also proven useful for assessing disease from cancers such as breast or prostate that may have spread to the bones. “Many other cancer centres in the UK will look for myeloma in the bone marrow
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RADIOLOGY
using X-rays,” explains Dr Christina Messiou, a Consultant Radiologist specialising in myeloma. “However, traditional X-rays may not show any disease in a patient, whereas whole-body MRI can highlight numerous deposits in the bone marrow. In these cases, we need to start treatment immediately to prevent the disease from causing irreversible damage to the bones and kidneys. “We are investigating whether whole-body MRI can be used to detect extremely tiny amounts of myeloma that might be left behind in the bones after chemotherapy but are not detected by other routine tests. This highly sensitive test would allow us to offer more treatment to those patients that need it.” New MRI techniques Whole-body scanning is just one example of The Royal Marsden’s efforts in testing and developing new MRI techniques. We work closely with industrial partners to introduce state-of-the-art scanning methods that improve patient experience and care. For instance, the work of Dow-Mu Koh, Professor of Functional Cancer Imaging, has led to the introduction of diffusion-weighted imaging (DWI) to our clinical service. This technique is highly sensitive to the cellular tissue typical of cancers and is now used in almost all of our MRI studies. It has also enhanced the detection of disease across the body and improved the way we assess how well drugs are working for multiple myeloma, prostate cancer and breast cancer patients. “Using functional imaging techniques helps us gain insights into the biological properties of tumours,” says Professor Koh. “For example, DWI tells us about the cellularity of tumours, which can be linked to tumour aggressiveness and growth behaviour. In addition, measuring changes in the tumour diffusion properties after treatment can tell us whether a drug is working before there is tumour shrinkage.”
The MRI research team at The Royal Marsden is working on a number of technologies for faster, better scanning. Using ‘radial acquisition’, we can obtain high-quality MRI scans of the liver without requiring patients to hold their breath, making examinations easier. We are also introducing ‘compressed sensing’ for liver scans, which allows us to acquire more information than before in the same length of time for better disease characterisation. And our research into a novel ‘MR fingerprinting’ technique may help to reduce scanning times further. “The development of artificial intelligence will improve our work,” says Professor Koh. “We are only just beginning to harness information contained within medical images that is not perceptible to the human eye, and the study of this – known as radiomics – is likely to have a huge impact on patient care in the future. “It’s an exciting time as we embrace these innovations.”
LEADING INNOVATION Professor Gina Brown (left); a patient’s scan is overseen by Cheryl Richardson, Superintendent Radiographer for MRI (below)
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BECAUSE WE CARE Dedicated, compassionate and committed to delivering excellent care for patients, our nurses embody what The Royal Marsden stands for. Here, some of our nurses explain what their roles involve and tell us why they find nursing so fulfilling
Rose Juliet Asoro
Ward Sister I have the responsibility of co-ordinating care on the ward and constantly assessing how we can improve the patient treatment pathway. I have a lot of contact with patients, but some parts of my role are behind the scenes, such as managing resources and working with the matron and nursing team leaders to ensure that the care we provide is of a high standard. Everything is for our patients’ benefit. Ensuring that we can provide a smooth-running service for them is what really drives me. Because I co-ordinate care across so many areas, I’m in touch with several staff involved in patient care, from staff nurses to consultants. The level of expertise that we have here makes me confident in the standard of care we deliver.
Helen McCafferty
Matron I’m responsible for ensuring that my nurses deliver a high standard of care. We have such a dynamic and caring culture here, and when I speak to patients they really do feel that they are receiving an excellent service from a compassionate and competent team. It’s really important that I build strong relationships with all of my staff, and that they can learn from me. I’ve been in nursing for 27 years, and in oncology for 23 years. It’s something I personally feel
passionate about, and I make sure I still see patients. I have an active role in changes and developments of the service, ensuring it is responsive to the needs of patients, their families, and the staff that look after them. I also work closely with other departments and teams to maintain standards. What’s unique about The Royal Marsden is that during what can be a difficult time for patients and their families, our nursing staff have such a positive attitude, with their patients’ best interests at heart.
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NURSING
WHAT MAKES NURSING AT THE ROYAL MARSDEN SO SPECIAL?
Sarah Irving
Clinical Nurse Specialist I’ve worked across both NHS and private units at The Royal Marsden. I think having both in one location means that whether you’re an NHS or private patient, you are treated and cared for by consultants and nurses who are experts in their field, in a world-renowned hospital. Clinical nurse specialists have been described as the ‘glue’ between patients and all the other professionals involved in their treatment. As well as providing emotional and psychological support and ensuring patients’ voices are heard, we have an advanced practice, running clinics, prescribing, and providing continuity for specialist teams and patients alike. It’s really rewarding to help patients through their journey and support them as they come out the other side.
“NHS and private patients alike are cared for by nurses who are experts in their field”
Beccy Ulrich
Staff Nurse I work with private patients on Wiltshaw Ward in Chelsea. As well as looking after our patients’ daily needs, I support their families, too. If they can go home at night reassured that their loved one is receiving the best possible care, they can get some rest and come back the next day re-energised and ready to support the patient. I deal with many international patients, especially Arabic speakers. We have advocates to translate and mediate, but I’ve learned some basic nursing terms. Simply being able to say “hello” in a patient’s language helps build a rapport.
“The unique partnership between The Royal Marsden’s NHS and Private Care services ensures that we can offer all patients the highest standard of treatment and continue to be world leaders in cancer care,” says Mo Carruthers, Divisional Nurse Director for Private Care. “Our nurses are a crucial part of this service, providing compassionate and highly skilled care across a range of roles. “Through our partnership model, we are able to attract a high calibre of nursing staff who appreciate the benefits of belonging to an internationally renowned team while working in a hospital where both NHS and private services work in harmony.”
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DR ALISON TREE Consultant Clinical Oncologist
BASED IN THE ROYAL Marsden’s Urology Unit, Dr Alison Tree specialises in radiotherapy and chemotherapy treatment for urological malignancies. Prior to becoming a consultant in 2014, she spent most of the previous 12 years training in state-of-the-art chemotherapy and radiotherapy techniques at The Royal Marsden. Dr Tree uses radiotherapy to treat prostate and penile cancers, for the treatment of oligometastases and for symptom control. She has also been a lead investigator in several clinical trials that tested the patient benefit of stereotactic body radiotherapy (SBRT). Her research interests include technical radiotherapy
improvements in prostate cancer, the development of the MR Linac for prostate cancer treatment, and the use of SBRT to treat oligometastatic and oligoprogressive disease. Dr Tree is also one of The Royal Marsden’s lead clinical representatives at the international MR Linac consortium meetings. The MR Linac combines two technologies – magnetic resonance imaging and a linear accelerator – to enable a new level of precision in radiotherapy delivery, which will maximise cure rates while reducing the likelihood of side effects. The Royal Marsden will be the first UK centre to use this pioneering technology, and will treat the first patients later in 2018.
CAREER HIGHLIGHTS 1998 Graduates from Charing Cross and Westminster Medical School (now Imperial College) 2002 Completes general medical training at Chelsea and Westminster Hospital and King’s College London 2014 Completes 12 years of oncology training, including a three-year
Q&A research degree in stereotactic body radiotherapy at The Institute of Cancer Research 2014 Appointed as a Consultant Clinical Oncologist at The Royal Marsden 2017 Appointed to the National Prostate Clinical Studies Group
Q What services do you and The Royal Marsden offer to patients? A One of the best things about working at The Royal Marsden is that I am able to offer my patients the best treatment with the most up-to-date techniques. The clinicians here are frequently leading research to demonstrate the benefits of new techniques and therapies,
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C O N S U LTA N T F O C U S
“The MR Linac represents a step change in radiotherapy. We can only dream of where this technology will take us” hormone therapies, such as abiraterone, significantly prolongs the life of patients with metastatic prostate cancer.
so our patients are often able to access these treatments earlier.
Q What have been the highlights in the treatment of urological cancers during your career so far? A Being involved in the start-up of CyberKnife at The Royal Marsden, and being able to deliver radiation treatments that were previously impossible, was very exciting. I am hoping that the start-up of the MR Linac this summer will be just as exciting and will represent a similarly significant step change in radiotherapy techniques. We can only dream of where this technology will take us – for example, it will be able to adapt the radiotherapy field every day to account for anatomy changes. This not only means a personalised radiotherapy plan for each patient, but potentially a new personalised plan every single day.
Q What developments are now taking place in the treatment of urological cancers? A There has been an astounding pace of change in the management of prostate cancer over the past few years. We now have better ways of combining therapies to keep patients alive and well for longer. For example, including chemotherapy or advanced
Q What will the future look like for urological cancer patients? A Our research has shown that we can safely deliver curative prostate radiotherapy in four weeks, rather than the previous seven-and-a-half weeks. The Royal Marsden-led PACE trial is testing whether that can be reduced further – to just five treatments – using stereotactic body radiotherapy. If it works,
then the ultimate question is, can we cure prostate cancer in a single radiotherapy treatment? We don’t know the answer to this question yet, but I hope to be leading the trial that tells us. Q What is The Royal Marsden’s biggest strength? A The staff: they are well trained, motivated and, above all, kind. They are the reason I chose to work here, because I wanted my patients to be cared for by the types of people I would want to care for my family. For patients, coming to The Royal Marsden is an incredibly stressful time, so being treated with kindness and respect helps to lessen the distress. Sometimes, the most important thing we can do for patients is to carefully explain their disease and the possible treatment options – this empowers them and enables them to take control of the decisions about their care.
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As Europe’s largest cancer centre, The Royal Marsden has the expertise, facilities and technology to provide the highest standards of personalised care, and we treat more private patients than any other UK centre. By choosing The Royal Marsden, you are ensuring the best possible treatment and care, at the moment a patient needs it most. Because where a patient goes first really matters.
Life demands excellence
To refer a private patient, contact our Central Referral and Information Line on +44 (0)20 7811 8111 or email privatepatients@rmh.nhs.uk royalmarsden.nhs.uk/private
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