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Palliative External Beam Radiotherapy for Painful Bone Metastases
Clinical Oncology 26 (2014) S1eS10 Contents lists available at ScienceDirect
Clinical Oncology journal homepage: www.clinicaloncologyonline.net
Reducing the Door to Needle Time for Antibiotics in Suspected Neutropenic Sepsis using a Dedicated Clinical Pathway A. Williams *, C. Candish *, C. Ayrton *, G. Naylor y, S. Lam y, R. Counsell * * Cheltenham General Hospital Oncology Centre, United Kingdom y Gloucestershire Hospitals NHS Foundation Trust, United Kingdom
Background: Neutropenic sepsis is a potentially fatal complication of cytotoxic chemotherapy requiring rapid, specialist input. The NICE Clinical Guideline 1511 advises door to needle antibiotic time of less than one hour in patients with suspected neutropenic sepsis. This is a clear quality standard for oncology services2. It is well established that dedicated clinical pathways/care bundles improve patient safety and clinical performance. Aim: Develop a clinical pathway based on ‘Sepsis Six Care Bundle’3 to treat patients with suspected neutropenic sepsis and reduce time to antibiotics. Standard: 100% of patients presenting to an oncology helpline, who have received chemotherapy within six weeks, and have infective symptoms or pyrexia of 38 C, have antibiotics within one hour of arrival. Target: 100% Methodology: Baseline Retrospective Audit. Clinical notes review of patients attending oncology helpline with suspected neutropenic sepsis over two-week period. Results: 31% of patients received antibiotics in less than an hour. Action Plan: 1) Multidisciplinary Neutropenic Clinical Pathway created with principles of the Sepsis Six Care Bundle. Antibiotics given before knowledge of neutrophil count in eligible patients. 2) Patient Group Direction (PGD) for nurse led prescribing/delivery of first dose of antibiotics. 3) Multidisciplinary Team Education programme developed for all staff. 4) Prospective re-audit. Results of Re-audit: Demographics e mean age 62.5 yrs, Palliative versus Adjuvant chemotherapy, 65% versus 35% respectively. 97% patients received antibiotics in less than one hour with 0% mortality/ referral to critical care department. There was no increase in time to antibiotics out of hours. Two further audits have demonstrated sustained clinical performance. This audit cycle, with development of a dedicated clinical pathway/care bundle involving nurse-led prescribing/delivery of treatment, has significantly improved door to needle time for antibiotics in patients with suspected neutropenic sepsis. It has led to improved patient experience/safety with implementation of NICE Guidance. Key references [1] National Institute for Health and Care Excellence (NICE) CG151 http:// www.nice.org.uk/nicemedia/live/13905/60866/60866.pdf [2] NHS England Standard Contract for Cancer: Chemotherapy (Adult). Section B Part 1 e Service Specifications, http://www.england.nhs.uk/wpcontent/uploads/2013/06/b15-cancr-chemoth.pdf. [3] Sepsis six care bundle http://www.survivingsepsis.org.
http://dx.doi.org/10.1016/j.clon.2014.04.005
Audit of Patients Receiving Palliative Chemotherapy for Oesophagogastric Cancer at Velindre Cancer Centre in 2012 C. Powell, R. Trickey, C. Morgan Velindre Cancer Centre, Wales
Background: The annual UK incidence of oesophago-gastric cancer (OGC) is 7,2001 and outcomes remain poor as >50% present with metastatic or inoperable disease. Median survival for patients receiving palliative chemotherapy is 9e11 months compared with 3e4 months with best supportive care (BSC)2. Aim: To evaluate the outcome of patients with OGC treated with palliative chemotherapy at Velindre cancer centre (VCC) in 2012 in terms of survival, toxicity and appropriate patient selection. Standard: Improvement in survival of 6 months compared with BSC2. Methodology: A retrospective audit using the Canisc database of all patients referred to VCC for treatment with OGC from 1st January-31st December 2012. Patients were excluded if their treatment was with radical intent or non-squamous/adenocarcinoma histology. Results: Median survival for all 69 patients was 10.1 months with improved outcomes seen in patients: <65 years, performance status 1 and HER-2 negative tumours. Twenty three percent of patients with adenocarcinoma were HER-2 positive (51% negative, 26% unknown). Both Her-2 positive and negative patients received a median of 4 cycles of chemotherapy (ranges 1e6) and 6 cycles of herceptin (range 1e23) in Her2 positive tumours. In this cohort Median survival for Her-2 positive patients was lower than the Her-2 negative patients (8.75 vs 11 months). Forty five percent of patients experienced grade 3 or 4 toxicity, most frequently diarrhoea and neutropenic sepsis. The most common reasons for stopping chemotherapy were; toxicities, decline in performance status or disease progression. Action Plan: Audit presented at local upper gastrointestinal clinical effectiveness meeting to discuss importance of robust assessment of fitness for chemotherapy irrespective of Her-2 status with the aim of maintaining quality of life in this poor prognosis patient group. Unexpected poorer outcomes in Her-2 positive patients may be related to low patient numbers but a larger re-audit is planned to confirm this. Key references [1] Cancer research: infocancer researchuk.org/cancerstats/types/oesophagus/incidence. [2] Wagner et al. Chemotherapy in advanced gastric cancer: a systematic review and meta-analysis based on aggregate data. J Clin Oncol 2006; 24 (18): 2903e9.
Palliative External Beam Radiotherapy for Painful Bone Metastases I. Phillips, I. Locke, A. Kirby, F. Rahman Royal Marsden Hospital, United Kingdom
Background/Aim: External Beam Radiotherapy (EBRT) is an effective, well tolerated, inexpensive treatment for painful bone metastases with response rates of 60e80%. 25% of patients report complete resolution of pain. 1 2 Results are similar with an 8Gy single fraction (#) vs 20Gy in 5#. Single treatments are quicker, less expensive and minimise patient travel.
Abstracts / Clinical Oncology 26 (2014) S1eS10 This audit describes Royal Marsden (RM) prescribing practice, and documentation of performance status (PS) and pain response. Standard: Audit standards are RCR guidelines.3 Patients with an uncomplicated painful bone metastasis receive a single 8Gy fraction, good prognosis patients with MSCC (malignant spinal cord compression) receive 20Gy/5# or 30Gy/10# of EBRT4 and all patients should have documented PS and treatment response. Methodology: Retrospective audit using electronic patient records to collect data for April and May 2012. Results: 114 patients (125 sites) were treated at RM. The commonest tumour site was prostate, commonest fractionation schedules were 8Gy/1# (46%) and 20Gy/5# (43%) and commonest site of treatment was spine(63%). 68% patients with uncomplicated bone metastasis received 8Gy/1#. All good prognosis patients with MSCC received 20Gy/5# or 30Gy/10#. Pain responses were documented in 55% of patients, the response rate being 76% of those with documentation. PS was documented in 54% of cases. Using 8Gy /1# appropriately could free one linear accelerator for one day a month. Action Plan: We aimed to improve education through discussion at the Clinical Oncology Consultants Meeting and departmental audit meeting. Particular points for discussion included appropriate use of an 8Gy single fraction and the most appropriate follow-up after EBRT. Results of Re-audit: In April and May 2013, 147 patients received 163 treatments. 70% patients received 8Gy /1# (previously 68%). 98% patients with MSCC received 20Gy/5 or 30Gy/10 #. Pain response was documented in 48%. Documented pain response was 90%. PS documentation significantly improved to 77%. Key references [1] Wu et al. Meta-analysis of dose-fractionation radiotherapy trials for the palliation of painful bone metastases. Int J Radiat Oncol Biol Phys 2003, 55(3) 594e605. [2] Chow et al. Update on the systematic review of palliative radiotherapy trials for bone metastases. Clin Oncol, 24(2012)112e124 [3] Royal College Radiologists Guidelines on treatment of bone metastases with radiotherapy, July 2006, http://www.rcr.ac.uk/docs/oncology/pdf/ DoseFract_415_Bone.pdf [4] NICE, 2010, CG75 Metastatic spinal cord compression, http://guidance. nice.org.uk/CG75/NICEGuidance/pdf/English
The Impact of Colleague Peer-review on the Radiotherapy Treatment Planning Process in the Radical Treatment of Lung Cancer K.P. Rooney *, G.G. Hanna y, *, J. Harney *, R.L. Eakin *, V.A. Linda Young *, M. Dunn *, R.E. Johnston *, J. McAleese * * Cancer Centre, Belfast City Hospital, Lisburn Road, Belfast BT9 7AB, United Kingdom y Centre for Cancer Research and Cell Biology, Queen’s University of Belfast, 97 Lisburn Road, Belfast BT9 7AE, United Kingdom
Background: Advanced radiotherapy techniques permit accurate delivery of radiotherapy to lung tumours thus increasing the possibility of geographic miss. One source of error is the accuracy of target volume (TV) delineation. Colleague peer-review (CPR) of all curative intent lung cancer plans has been mandatory in our institution since May 2013. At least 2 clinical oncologists review plans checking treatment paradigm, TV delineated, prescription dose tumour and critical organ tolerances. Aim: To assess the impact of CPR on the lung radiotherapy planning process. Standard: Regional agreed standard: Less than 10% of treatment plans should be modified by CPR. Methodology: Radiotherapy treatment plans of all patients receiving radical radiotherapy were presented at weekly CPR meetings after their TVs volumes were provisionally signed off by the treating consultant. All cases and any resultant change to the treatment plan were recorded in our prospective CPR database. We audited the impact of CPR over a 9 month period from May 2013 to January 2014. Results: 74 patients (59 NSCLC, 15 SCLC) were analysed. On average 3.5 cases were discussed per meeting (range 1e8). CPR resulted in modification of 22% of cases. 4% had a change in treatment paradigm (1 patient proceeded to induction chemotherapy, 2 patients had high dose palliative radiotherapy). 15% had a change in TV delineated and 7% a change in dose prescription.
S3
The introduction of CPR in our centre has resulted in a change in a component of the treatment plan for 22% of patients receiving curative-intent lung radiotherapy. Action Plan: Continue with CPR as standard of care, continue with database collection and plan to re-audit to assess resultant change in practice.
Optimal Duration of Cardiac Monitoring in Metastatic HER2-positive Breast Cancer Patients Receiving Trastuzumab K. Chiu, S. Dubey, D. Bull Department of Clinical Oncology, Derriford Hospital, Plymouth, United Kingdom
Background: Patients with metastatic HER2-positive breast cancer commonly receive trastuzumab therapy longer than the adjuvant 12-month period. As trastuzumab is given to these patients with palliative intent, the duration of routine clinical investigations could potentially be reduced. Aim: To audit the use of cardiac assessments during trastuzumab treatment for patients with metastatic HER2-positive breast cancer. Standard: NICE recommends 3-monthly cardiac-function assessments during adjuvant trastuzumab treatment, though there is no guidance for duration of cardiac monitoring in patients with advanced breast cancer. Cardiotoxicity occurs when left ventricular ejection fraction (LVEF) drops by 10% from baseline and to below 50%. Methodology: 61 metastatic HER2-positive breast cancer patients received trastuzumab in our centre between Jan-2008 and Dec-2012. These patients’ baseline and serial LVEF readings with echocardiogram were noted. Their risk factors for cardiotoxicity, and the events leading to cardiotoxicity, were identified. Results: Total number of 3-weekly trastuzumab cycles delivered ranged from 3 to 151. 90% of all patients received 3-monthly echocardiograms. 11 of the 61 patients (18%) needed interruption of treatment due to cardiotoxicity. The median number of cycles received by patients who had cardiotoxicity was 17, in contrast to 37 cycles in cohort with no cardiotoxicity (p-value ¼ 0.043). 8 of the 11 patients (72%) developed cardiotoxicity within 18 months and 9 (82%) within 24 months of the start of trastuzumab. Of these 11 patients, 8 recovered and were re-challenged with trastuzumab after a median of 2month interval. The proportion of patients with previous ischaemic heart disease (IHD) was significantly higher in the cohort who developed cardiotoxicity (p-value ¼ 0.037):
IHD Median Age Median Baseline-LVEF Hypertension Previous Anthracycline Exposure Diabetes
Cardiotoxicity Cohort (Proportion)
Non-toxicity Cohort (Proportion)
p-value
27% 54 63%
4% 58 65%
0.037
45% 36%
26% 58%
0.275 0.317
9%
4%
0.455
Routine 3-monthly cardiac monitoring is recommended for at least 18e24 months. The incidence and Time to Presentation of Capecitabine Induced Cardiovascular Toxicity in Rectal Cancer Patients Receiving Concurrent Chemo-radiotherapy L. Davidson, M. Saunders, C. McBain, N. Alam, V. Misra, C. Arthur The Christie NHS Foundation Trust, United Kingdom
Background: Chemo-radiotherapy with capecitabine is standard treatment for locally advanced rectal cancer1. Coronary vasospasm is a recognised
Clinical Oncology journal homepage: www.clinicaloncologyonline.net
Reducing the Door to Needle Time for Antibiotics in Suspected Neutropenic Sepsis using a Dedicated Clinical Pathway A. Williams *, C. Candish *, C. Ayrton *, G. Naylor y, S. Lam y, R. Counsell * * Cheltenham General Hospital Oncology Centre, United Kingdom y Gloucestershire Hospitals NHS Foundation Trust, United Kingdom
Background: Neutropenic sepsis is a potentially fatal complication of cytotoxic chemotherapy requiring rapid, specialist input. The NICE Clinical Guideline 1511 advises door to needle antibiotic time of less than one hour in patients with suspected neutropenic sepsis. This is a clear quality standard for oncology services2. It is well established that dedicated clinical pathways/care bundles improve patient safety and clinical performance. Aim: Develop a clinical pathway based on ‘Sepsis Six Care Bundle’3 to treat patients with suspected neutropenic sepsis and reduce time to antibiotics. Standard: 100% of patients presenting to an oncology helpline, who have received chemotherapy within six weeks, and have infective symptoms or pyrexia of 38 C, have antibiotics within one hour of arrival. Target: 100% Methodology: Baseline Retrospective Audit. Clinical notes review of patients attending oncology helpline with suspected neutropenic sepsis over two-week period. Results: 31% of patients received antibiotics in less than an hour. Action Plan: 1) Multidisciplinary Neutropenic Clinical Pathway created with principles of the Sepsis Six Care Bundle. Antibiotics given before knowledge of neutrophil count in eligible patients. 2) Patient Group Direction (PGD) for nurse led prescribing/delivery of first dose of antibiotics. 3) Multidisciplinary Team Education programme developed for all staff. 4) Prospective re-audit. Results of Re-audit: Demographics e mean age 62.5 yrs, Palliative versus Adjuvant chemotherapy, 65% versus 35% respectively. 97% patients received antibiotics in less than one hour with 0% mortality/ referral to critical care department. There was no increase in time to antibiotics out of hours. Two further audits have demonstrated sustained clinical performance. This audit cycle, with development of a dedicated clinical pathway/care bundle involving nurse-led prescribing/delivery of treatment, has significantly improved door to needle time for antibiotics in patients with suspected neutropenic sepsis. It has led to improved patient experience/safety with implementation of NICE Guidance. Key references [1] National Institute for Health and Care Excellence (NICE) CG151 http:// www.nice.org.uk/nicemedia/live/13905/60866/60866.pdf [2] NHS England Standard Contract for Cancer: Chemotherapy (Adult). Section B Part 1 e Service Specifications, http://www.england.nhs.uk/wpcontent/uploads/2013/06/b15-cancr-chemoth.pdf. [3] Sepsis six care bundle http://www.survivingsepsis.org.
http://dx.doi.org/10.1016/j.clon.2014.04.005
Audit of Patients Receiving Palliative Chemotherapy for Oesophagogastric Cancer at Velindre Cancer Centre in 2012 C. Powell, R. Trickey, C. Morgan Velindre Cancer Centre, Wales
Background: The annual UK incidence of oesophago-gastric cancer (OGC) is 7,2001 and outcomes remain poor as >50% present with metastatic or inoperable disease. Median survival for patients receiving palliative chemotherapy is 9e11 months compared with 3e4 months with best supportive care (BSC)2. Aim: To evaluate the outcome of patients with OGC treated with palliative chemotherapy at Velindre cancer centre (VCC) in 2012 in terms of survival, toxicity and appropriate patient selection. Standard: Improvement in survival of 6 months compared with BSC2. Methodology: A retrospective audit using the Canisc database of all patients referred to VCC for treatment with OGC from 1st January-31st December 2012. Patients were excluded if their treatment was with radical intent or non-squamous/adenocarcinoma histology. Results: Median survival for all 69 patients was 10.1 months with improved outcomes seen in patients: <65 years, performance status 1 and HER-2 negative tumours. Twenty three percent of patients with adenocarcinoma were HER-2 positive (51% negative, 26% unknown). Both Her-2 positive and negative patients received a median of 4 cycles of chemotherapy (ranges 1e6) and 6 cycles of herceptin (range 1e23) in Her2 positive tumours. In this cohort Median survival for Her-2 positive patients was lower than the Her-2 negative patients (8.75 vs 11 months). Forty five percent of patients experienced grade 3 or 4 toxicity, most frequently diarrhoea and neutropenic sepsis. The most common reasons for stopping chemotherapy were; toxicities, decline in performance status or disease progression. Action Plan: Audit presented at local upper gastrointestinal clinical effectiveness meeting to discuss importance of robust assessment of fitness for chemotherapy irrespective of Her-2 status with the aim of maintaining quality of life in this poor prognosis patient group. Unexpected poorer outcomes in Her-2 positive patients may be related to low patient numbers but a larger re-audit is planned to confirm this. Key references [1] Cancer research: infocancer researchuk.org/cancerstats/types/oesophagus/incidence. [2] Wagner et al. Chemotherapy in advanced gastric cancer: a systematic review and meta-analysis based on aggregate data. J Clin Oncol 2006; 24 (18): 2903e9.
Palliative External Beam Radiotherapy for Painful Bone Metastases I. Phillips, I. Locke, A. Kirby, F. Rahman Royal Marsden Hospital, United Kingdom
Background/Aim: External Beam Radiotherapy (EBRT) is an effective, well tolerated, inexpensive treatment for painful bone metastases with response rates of 60e80%. 25% of patients report complete resolution of pain. 1 2 Results are similar with an 8Gy single fraction (#) vs 20Gy in 5#. Single treatments are quicker, less expensive and minimise patient travel.
Abstracts / Clinical Oncology 26 (2014) S1eS10 This audit describes Royal Marsden (RM) prescribing practice, and documentation of performance status (PS) and pain response. Standard: Audit standards are RCR guidelines.3 Patients with an uncomplicated painful bone metastasis receive a single 8Gy fraction, good prognosis patients with MSCC (malignant spinal cord compression) receive 20Gy/5# or 30Gy/10# of EBRT4 and all patients should have documented PS and treatment response. Methodology: Retrospective audit using electronic patient records to collect data for April and May 2012. Results: 114 patients (125 sites) were treated at RM. The commonest tumour site was prostate, commonest fractionation schedules were 8Gy/1# (46%) and 20Gy/5# (43%) and commonest site of treatment was spine(63%). 68% patients with uncomplicated bone metastasis received 8Gy/1#. All good prognosis patients with MSCC received 20Gy/5# or 30Gy/10#. Pain responses were documented in 55% of patients, the response rate being 76% of those with documentation. PS was documented in 54% of cases. Using 8Gy /1# appropriately could free one linear accelerator for one day a month. Action Plan: We aimed to improve education through discussion at the Clinical Oncology Consultants Meeting and departmental audit meeting. Particular points for discussion included appropriate use of an 8Gy single fraction and the most appropriate follow-up after EBRT. Results of Re-audit: In April and May 2013, 147 patients received 163 treatments. 70% patients received 8Gy /1# (previously 68%). 98% patients with MSCC received 20Gy/5 or 30Gy/10 #. Pain response was documented in 48%. Documented pain response was 90%. PS documentation significantly improved to 77%. Key references [1] Wu et al. Meta-analysis of dose-fractionation radiotherapy trials for the palliation of painful bone metastases. Int J Radiat Oncol Biol Phys 2003, 55(3) 594e605. [2] Chow et al. Update on the systematic review of palliative radiotherapy trials for bone metastases. Clin Oncol, 24(2012)112e124 [3] Royal College Radiologists Guidelines on treatment of bone metastases with radiotherapy, July 2006, http://www.rcr.ac.uk/docs/oncology/pdf/ DoseFract_415_Bone.pdf [4] NICE, 2010, CG75 Metastatic spinal cord compression, http://guidance. nice.org.uk/CG75/NICEGuidance/pdf/English
The Impact of Colleague Peer-review on the Radiotherapy Treatment Planning Process in the Radical Treatment of Lung Cancer K.P. Rooney *, G.G. Hanna y, *, J. Harney *, R.L. Eakin *, V.A. Linda Young *, M. Dunn *, R.E. Johnston *, J. McAleese * * Cancer Centre, Belfast City Hospital, Lisburn Road, Belfast BT9 7AB, United Kingdom y Centre for Cancer Research and Cell Biology, Queen’s University of Belfast, 97 Lisburn Road, Belfast BT9 7AE, United Kingdom
Background: Advanced radiotherapy techniques permit accurate delivery of radiotherapy to lung tumours thus increasing the possibility of geographic miss. One source of error is the accuracy of target volume (TV) delineation. Colleague peer-review (CPR) of all curative intent lung cancer plans has been mandatory in our institution since May 2013. At least 2 clinical oncologists review plans checking treatment paradigm, TV delineated, prescription dose tumour and critical organ tolerances. Aim: To assess the impact of CPR on the lung radiotherapy planning process. Standard: Regional agreed standard: Less than 10% of treatment plans should be modified by CPR. Methodology: Radiotherapy treatment plans of all patients receiving radical radiotherapy were presented at weekly CPR meetings after their TVs volumes were provisionally signed off by the treating consultant. All cases and any resultant change to the treatment plan were recorded in our prospective CPR database. We audited the impact of CPR over a 9 month period from May 2013 to January 2014. Results: 74 patients (59 NSCLC, 15 SCLC) were analysed. On average 3.5 cases were discussed per meeting (range 1e8). CPR resulted in modification of 22% of cases. 4% had a change in treatment paradigm (1 patient proceeded to induction chemotherapy, 2 patients had high dose palliative radiotherapy). 15% had a change in TV delineated and 7% a change in dose prescription.
S3
The introduction of CPR in our centre has resulted in a change in a component of the treatment plan for 22% of patients receiving curative-intent lung radiotherapy. Action Plan: Continue with CPR as standard of care, continue with database collection and plan to re-audit to assess resultant change in practice.
Optimal Duration of Cardiac Monitoring in Metastatic HER2-positive Breast Cancer Patients Receiving Trastuzumab K. Chiu, S. Dubey, D. Bull Department of Clinical Oncology, Derriford Hospital, Plymouth, United Kingdom
Background: Patients with metastatic HER2-positive breast cancer commonly receive trastuzumab therapy longer than the adjuvant 12-month period. As trastuzumab is given to these patients with palliative intent, the duration of routine clinical investigations could potentially be reduced. Aim: To audit the use of cardiac assessments during trastuzumab treatment for patients with metastatic HER2-positive breast cancer. Standard: NICE recommends 3-monthly cardiac-function assessments during adjuvant trastuzumab treatment, though there is no guidance for duration of cardiac monitoring in patients with advanced breast cancer. Cardiotoxicity occurs when left ventricular ejection fraction (LVEF) drops by 10% from baseline and to below 50%. Methodology: 61 metastatic HER2-positive breast cancer patients received trastuzumab in our centre between Jan-2008 and Dec-2012. These patients’ baseline and serial LVEF readings with echocardiogram were noted. Their risk factors for cardiotoxicity, and the events leading to cardiotoxicity, were identified. Results: Total number of 3-weekly trastuzumab cycles delivered ranged from 3 to 151. 90% of all patients received 3-monthly echocardiograms. 11 of the 61 patients (18%) needed interruption of treatment due to cardiotoxicity. The median number of cycles received by patients who had cardiotoxicity was 17, in contrast to 37 cycles in cohort with no cardiotoxicity (p-value ¼ 0.043). 8 of the 11 patients (72%) developed cardiotoxicity within 18 months and 9 (82%) within 24 months of the start of trastuzumab. Of these 11 patients, 8 recovered and were re-challenged with trastuzumab after a median of 2month interval. The proportion of patients with previous ischaemic heart disease (IHD) was significantly higher in the cohort who developed cardiotoxicity (p-value ¼ 0.037):
IHD Median Age Median Baseline-LVEF Hypertension Previous Anthracycline Exposure Diabetes
Cardiotoxicity Cohort (Proportion)
Non-toxicity Cohort (Proportion)
p-value
27% 54 63%
4% 58 65%
0.037
45% 36%
26% 58%
0.275 0.317
9%
4%
0.455
Routine 3-monthly cardiac monitoring is recommended for at least 18e24 months. The incidence and Time to Presentation of Capecitabine Induced Cardiovascular Toxicity in Rectal Cancer Patients Receiving Concurrent Chemo-radiotherapy L. Davidson, M. Saunders, C. McBain, N. Alam, V. Misra, C. Arthur The Christie NHS Foundation Trust, United Kingdom
Background: Chemo-radiotherapy with capecitabine is standard treatment for locally advanced rectal cancer1. Coronary vasospasm is a recognised