Background

Adrenocortical carcinoma (ACC) is a rare tumour originating from the adrenal cortex. The main treatments are surgery, radiotherapy and chemotherapy. Though the malignancy is aggressive and the prognosis poor, surgery to remove the cancerous adrenal gland (adrenalectomy) can cure the cancer if caught early. Due to its rarity, centres are likely to only see a small number of patients annually and optimum management of patients is yet to be achieved. The future adrenal cancer strategy is being designed to optimise and rationalise care for patients with this condition. Crucial to this is the availability of surgical expertise embedded within a team experienced in managing adrenal cancer.

Justification for service improvement

Though there are published guidelines for the management of adrenal cancer these are not being followed consistently. For example, one-third of the trusts visited as part of the Endocrinology GIRFT initiative were advised to cease adrenal surgery or consolidate with an adjacent trust to ensure adequate numbers to provide a safe service. The GIRFT report suggests that adrenal surgery is best performed by experienced surgeons in centres with dedicated adrenal multidisciplinary team’s expert in all aspects of care of the adrenal patient. The recommendation is for each centre to undertake a minimum of 20 adrenalectomies for primary adrenal disease (excluding adrenalectomy as part of nephrectomy) per year (average over a 3-year period) with each surgeon undertaking a minimum of 6 per year where adrenal cancer is known or suspected pre-operatively. These numbers are based on published evidence showing higher volumes are associated with lower complications (Anderson et al 2018; Palazzo et al 2016). Concentrating surgery in fewer trusts would allow for better specialisation which should lead to better outcomes and shorter lengths of stay. Continuation of surgery locally, by non-specialist surgeons is not in the best interest of patients nor cost-effective for the NHS. In addition, outcomes should be audited in accordance with the National Clinical Improvement Programme (NCIP).

A full service specification for the provision of surgery for primary adrenocortical carcinoma requiring endocrine assessment and surgical intervention has been drafted.

Aim

The aim of this project is to improve the management of ACC patients in the UK by:

• Reviewing and addressing inconsistencies in guideline adherence
• Developing and implementing a specialist adrenal surgery service model

Outputs

A single document (including implementation method and proposed impact measurement/review) with multidisciplinary buy in and endorsement.

If you have any questions or wish to be involved in this project please contact [email protected]