Children with cancer need a large number of specialist services, some of which must be on the same site as very specialist cancer treatment services, and some of which, if not on site, must be readily available for patients.
Both Evelina London Children’s Hospital and St George’s Hospital – the options for the proposed future Principal Treatment Centre that this consultation is about – provide specialist children’s services which are not available at The Royal Marsden, including a Level 3 children’s intensive care unit that can give life support to the most seriously ill children.
Whichever of them became the future Principal Treatment Centre, it would provide all the services that a Principal Treatment Centre must have on site once very specialist cancer treatment services transferred over from The Royal Marsden.
There are some differences between them on services that, if not on site, must be readily available for patients (we sometimes call these “interdependent services”.) Detail on this is set out below.
Surgery for children to remove or reduce tumours and manage side-effects of cancer is one of the services that must be readily available for children with cancer, if it is not provided on site.
Evelina London doesn’t currently provide this kind of surgery although it does have a team of 54 surgeons with expertise across the range of specialities required for children’s care.
If Evelina London became the proposed future Principal Treatment Centre, it would work with its surgeons and with others to create a surgical team to undertake this kind of surgery for children with cancer.
Evelina London has experience of successfully bringing in new surgical expertise and could build cancer-specific expertise in its surgical team through training, recruitment or a mixture of both. It would also explore options for support from St George’s Hospital and, potentially, other London hospitals, such as Great Ormond Street. Surgeons from these organisations could split their time, working at more than one hospital where their expertise is needed. If it became the site of the proposed future centre, Evelina London would have at least two and a half years to create a surgical team with expertise in operating on children’s cancer.
St George’s provides cancer surgery for children as part of the current Principal Treatment Centre. The children’s cancer surgeons who work at St George’s all spend more than half their time on non-cancer related surgery, so would not qualify formally to transfer to Evelina London, if it were to be the future Principal Treatment Centre. However, the Trusts that provide specialist children’s services in south London along with The Royal Marsden have agreed to work together to make best use of all the skills needed for children’s cancer care, and this includes cancer surgery.
For both options, it should be noted that children’s cancer surgery for some specific tumours, including eye, liver and bone tumours, and neurosurgery, would continue to be at other London hospitals, because of the specific expertise they have in these areas.
Heart and kidney services
Many children with cancer will require heart and kidney tests to see if different types of treatment will work for them or to assess the side effects of cancer treatments on them, including as part of long-term follow-up. Some will require treatment for heart and kidney conditions which may or may not be related to their cancer.
Evelina London Children’s Hospital is a tertiary (specialist) centre for children’s heart conditions. It provides a joint heart service with The Royal Marsden to discuss, care for and monitor individual patients with cancer. As part of this, Evelina London specialist cardiology staff run fortnightly clinics at The Royal Marsden for children who are inpatients or on long-term treatment who need heart checks. They also see children from the Principal Treatment Centre in consultant-led clinics at Evelina London.
Children need to have their heart function assessed before they can start treatments including chemotherapy, bone marrow transplants and surgery. This is particularly important because up to 70% of childhood cancers are treated with a group of drugs which are potentially cardio-toxic. Evelina London has specialist equipment to assess children’s heart function and can provide interventions from specialist cardiologists before, during and after the cancer treatment, depending on the needs of the child.
Evelina London is also the tertiary kidney centre for south London and much of the south east. Many cancer patients need long-term specialist follow-up for chronic kidney disease that develops as a direct result of their treatments. Some cancers can also directly involve the kidneys or their blood supply such as Wilms tumours or neuroblastomas. Treatments may include total removal of the affected kidney (or kidneys) and radiotherapy, resulting in a sudden decline in kidney function and, rarely, the need for long-term dialysis and kidney transplantation. This patient group all need long-term specialist kidney (nephrology) input.
In 2019/20 31 children with cancer who were treated at The Royal Marsden (as an inpatient or outpatient) also received inpatient care (including as day cases) at Evelina London for heart and kidney care, and 30 for other specialties. Of the heart and kidney patients, 28 were seen as day cases, mostly for diagnostic tests, one for a planned inpatient stay and three for an unplanned stay. (Some children had more than one type of care.)
St George’s provides paediatric diagnostic cardiology services such as echocardiograms. Where further specialist diagnostics, advice or intervention are needed, St George’s Hospital draws on the advice of specialists from Evelina London. It runs clinics on site with specialist input from clinicians from Guy’s and St Thomas’.
St George’s Hospital delivers a range of clinics for kidney care, it also provides acute renal replacement therapy in the paediatric intensive care unit for very unwell children.
If St George’s were to be the site of the proposed future centre, it could deliver some heart diagnostics and kidney care that patients need on site. Children who needed tertiary inpatient, day case and outpatient heart and kidney care would be transferred or referred to Evelina London, as they are at present. The exact arrangements for this would be agreed following detailed conversations between clinicians after a decision was made.
King’s College Hospital and St George’s both provide neurosurgery for children with cancer. In 2019/20, about one in five children under the care of the current Principal Treatment Centre had brain, nervous system or spinal cancer. Most children with those kinds of cancer, and some children experiencing side effects of treatment (such as complications from a shunt, swelling after radiotherapy or bleeding in the brain) need neurosurgery. Usually, this surgery is planned but occasionally it is needed urgently (for example, when a child comes to A&E with symptoms that need urgent attention). As a result, neurosurgeons are available 24/7.
Typically, a child under the care of the Principal Treatment Centre for south London and much of the south east who needs neurosurgery is seen at their local hospital and referred or, where necessary, transferred to the neurosurgical centres at King’s or St George’s, or admitted via A&E at King’s or St George’s.
Their surgery is carefully planned and undertaken, using expert technologies and techniques (such as neuroradiology). After surgery, they may need chemotherapy provided at The Royal Marsden and/or radiotherapy (either conventional (photon beam) radiotherapy at The Royal Marsden or proton beam therapy provided at University College London Hospitals). Their ongoing progress and treatment are carefully managed by a multidisciplinary team from King’s College, St George’s Hospital and The Royal Marsden. They continue to be seen by the neurosurgery team at the hospital where they had their initial operation. They may go to their nearest children’s cancer shared care unit for supportive care.
In 2019/20, 86 children had cancer-related neurosurgery. Around 20% of children had neurosurgery at St George’s. Although numbers vary year on year, the proportion of neurosurgery that both sites do is expected to remain similar.
Children with brain, nervous system and other cancers also had other kinds of admitted inpatient treatment at the two hospitals, including emergency care at A&E, neurology, and children’s surgery.
King’s and St George’s Hospital work very closely together as part of the children’s neuro-oncology multidisciplinary team for the Principal Treatment Centre catchment area and will continue to do so in the future. The neurosurgery service each of them provides is a key part of services for children in south London and much of the south east, including as part of the trauma services at both hospitals for children who have been badly injured.
Neurosurgery is not part of this consultation, it is a fixed point. This means it is going to stay at King’s College Hospital and St George’s Hospital. Patients will continue to go to both King’s and St George’s in similar proportions to now for their neurosurgical care.
Evelina London doesn’t provide cancer-related neurosurgery. It works very closely with King’s College Hospital which does, and Evelina London funds one consultant paediatric neurosurgeon in the King’s team. Planned neurosurgery for non-cancer patients is undertaken regularly by the King’s team at Evelina London.
If the future Principal Treatment Centre were to be at Evelina London, children would continue to go to King’s or St George’s, as now, for planned neurosurgery. In exceptional circumstances, emergency neurosurgery for children with cancer could be carried out on site at Evelina London by a neurosurgeon from King’s if the child could not be moved. This would be assessed on a case by case basis.
King’s and St George’s both provide a children’s cancer shared care unit as well as their neurosurgery services. The new service specification for children’s cancer shared care units offers an opportunity for shared care units to work towards attaining enhanced level B status. Enhanced level B shared care units can give children inpatient chemotherapy at their hospitals. King’s is working to achieve this status.
If both King’s and St George’s had enhanced level B status, children with brain tumours who needed inpatient chemotherapy would be able to receive it on site, reducing the number of transfers required and improving patient experience.
If St George’s Hospital became the future Principal Treatment Centre, chemotherapy would be available on site for its neurosurgical patients. However, as the majority of patients would continue to have their neurosurgery at King’s, there could still be transfers between King’s and St George’s for neurosurgical patients requiring chemotherapy. If King’s had enhanced level B status this need would be reduced.
A consultant neuro-oncologist, who is jointly employed by King’s and The Royal Marsden, is on site two and a half days a week at King’s, overseeing the care of children with cancer, including at tumour clinics, and would support the proposed development of the shared care unit there too.
Note – the enhanced paediatric oncology shared care unit configuration in the catchment area remains subject to a separate piece of work to implement the national service specification for shared care units; further detail on the future configuration is expected to be available in autumn 2023.