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Medical

Scroll down for:

• NICE Guideline for CUP
• CUP-One Trial
• NHS White paper of 12 Jul 2010

NICE Guideline for CUP

The NICE Guideline for the management & treatment of CUP was introduced on 26 July 2010. This is the most important thing ever to happen for CUP in England & Wales (NICE does not cover Scotland and N. Ireland but it is likely that the other national authorities will be informed by this guidance). Of course, we have to recognise that this is Guidance and not mandatory but initial reactions to the recommendations are encouraging. Jo’s friends is a Stakeholder and the Director has been a member of the Guideline Development Group since it started work in 2008.

There will be costs involved in the implementation of the Guideline, but there should be savings from the more rational management of patients passing through the system with improved pathways for investigations and decreased length of hospital stays. In essence it is thought likely that implementing the Guideline will be cost neutral. The Coalition Government have committed to achieving “cancer survival rates among the best in the world” by 2015. Survival rates are presently amongst the worst in Western Europe but  the introduction of the CUP Guideline, if implemented, is an important step on the journey to achieve the Government's aspiration.

 Until now a patient presenting with CUP has suffered from ad hoc approaches. He or she has often “bounced” between site-specific Multi Disciplinary Teams as each tries to find a primary site of the cancer with different tests. Expertise should now become more focused; and patient support is clearly defined in this evidence-based approach to the management and treatment of CUP. The Guideline is very comprehensive and can be found here.

Highlights of the Guideline. We highlight some key points from the patient perspective:

• The diagnosis is defined in three distinct phases:
  • Malignancy of undefined primary origin. Metastatic malignancy without a probable primary site identified on the basis of a limited number of tests.  
  • Provisional carcinoma of unknown primary (provisional CUP). Metastatic epithelial or neuro-endocrine malignancy identified on the basis of histology/cytology, with no primary detected after an initial screen of investigations.
  • Confirmed carcinoma of unknown primary (confirmed CUP). No primary detected despite further specialised tests and specialist reviews. 
• Every hospital with a cancer centre or unit should establish a CUP team, and ensure that patients have access to the team when malignancy of undefined primary origin (MUO) is diagnosed.
• The CUP team should consist of an oncologist, a palliative care physician and a CUP specialist nurse or key worker as a minimum.
• The CUP specialist nurse or key worker should:
  • take a major role in co-ordinating the patient’s care in line with the guideline
  • liaise with the patient’s GP and other community support services
  • ensure that patient and carers can get information, advice and support about diagnosis, treatment, palliative care, spiritual and psychosocial concerns
  • meet with the patient in the early stages of the pathway and keep in close contact with the patient regularly by mutual agreement
  • be an advocate for the patient at CUP team meetings.
• The CUP team should take responsibility for ensuring that a management plan exists which includes:
  • appropriate investigations
  • symptom control
  • access to psychological support
  • providing information.
• A CUP network multidisciplinary team (MDT) should be set up to review the treatment and care of patients with confirmed CUP, or with MUO or provisional CUP with complex diagnostic or treatment issues.
• Every cancer network should establish a network site-specific group to define and oversee policies for managing CUP. [Posted Jul 10]

 For NICE press release with Q&A (26 Jul 10) see these documents:

CUP Guideline NICE Press Release for 26 July 2010.pdf

Cancer of Unknown Primary Guideline Q&A - 26 July 2010.pdf

CUP-One Trial

Trial centres are now open for the start of this important multi-centre, Phase II trial which is being lead by Dr Harpreet Wasan – a Member of our Advisory Board.

The study, of which Jo’s friends is a stakeholder, is in two parts: the aim of the first (translational) part is to validate prospectively new tools in diagnosis (including molecular profiling, metabonomics of blood and urine for response and toxicity prediction and a proposed immunohistochemistry classifier). The hope is that, in the future, scientists can find a diagnostic indicator of the primary site simply, rather than subjecting the patient to a whole barrage of investigations.

Patients in whom a primary site is not identified can then be entered into the second (clinical) part of the trial. The trial may help in the future with selecting the best chemotherapy for patients with CUP. This part of the trial aims to establish the efficacy of the ECX chemo regimen (ECX stands for the drugs: Epirubicin, Cisplatin and Capecitabine) with and without Vandetanib (an inhibitor of different intracellular signalling pathways involved in tumour growth, progression, and angiogenesis). The treatment will last initially for 3 months and there will be subsequent monitoring. Patients can withdraw from the trial at any time without giving a reason.

Overall, this study should allow a more logical framework to be derived, both clinically and biologically, as to how highly metastatic cancers may be efficiently and economically investigated and managed in the future. It will be some years before the findings are available from this trial.

Trial centres that are now open are within hospitals in: Hammersmith, Glasgow, Aberdeen, Manchester, Doncaster, Sheffield, Slough, Peterborough, Poole,  Kent. More details of the trial are shown here.

[Posted Jul 10]

NHS White Paper - Biggest changes since the NHS began

The Department of Health published the NHS White Paper, Equity and Excellence: liberating the NHS on 12 July 2010. Key points include:

• Putting patients first. “No decision about me, without me”  will be the guiding principle for patient involvement
• The use of patient experience data and clinical audit will be expanded, giving patients greater information on which to make choices
• Choice will be extended to cover treatment options, choice of team and choice of GP

• Improving healthcare outcomes.  A consultation on an outcomes framework will be launched shortly setting out quality benchmarks against which services should be commissioned and delivered

• Local authorities will provide local accountability and will be charged with ensuring greater integration across health and social care. PCTs and SHAs will be abolished
•  All trusts will become foundation trusts
• GP consortia will assume the statutory responsibility for commissioning
• Cancer Drug Fund (Interim measure) to operate from April 2011 to support patients to get the drugs their doctors recommend
• Management costs will be reduced by 45%, releasing £1 billion for patient care.

                                               

  [Posted Jul 10]

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The Wilson family present money raised in memory of Tracy. Photo: The Mansfield Chad and Hucknall Dispatch.

2010 Christmas card
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