Stratification of eye cancer patients into metastatic risk using the integrated Liverpool prognosticator tool

The University of Liverpool, together with its NHS supraregional referral centre for eye cancer, spearheaded the development and implementation of prognostic tests to predict metastasis likelihood in individual patients. Their tool is recommended in NICE guidelines and is now used worldwide.

The challenge

Uveal melanoma (UM) is the most common eye cancer in adults, with approximately 800 new cases per year diagnosed in the UK. Although treatment of the primary tumour is usually successful, this type of cancer kills around 50% of patients due to the development of secondary tumours (metastases), typically within the liver. These metastases are most successfully treated surgically when detected early, making the development of effective predictive screening tests critical.

Historically, it was not possible to classify patients into high and low risk groups due to imprecise prognostic methods. Therefore patients were routinely screened for metastases using low resolution imaging techniques (e.g. ultrasound) for approximately ten years following treatment of the primary tumour. Using ultrasound, detection rates of metastatic UM are low, particularly in patients with a large BMI, until there is advanced metastatic disease, making it an inefficient practice. However, by classifying UM patients into high and low-risk groups, appropriate screening practices can be implemented to benefit healthcare providers and patients.

Research in partnership

Professor Sarah Coupland, Professor Azzam Taktak and Dr Antonio Eleuteri of the Liverpool Ocular Oncology Research Group at the University of Liverpool, in collaboration with the Liverpool Ocular Oncology Centre at the Royal Liverpool University Hospital, have shown that by classifying UM patients into high and low metastatic risk groups, appropriate screening can be implemented, benefitting both patients and healthcare providers. They have spearheaded the development and implementation of prognostic tests to predict the likelihood of metastasis in individual patients. Their freely available prognostication tool: 'Liverpool Uveal Melanoma Prognosticator Online' (LUMPO), which is now recommended for use in NICE guidelines, is now being used around the world in ocular oncology units.

In 1999, Liverpool Ocular Oncology Centre (LOOC) was the first ocular oncology centre worldwide to implement cytogenetic prognostic testing for uveal melanoma into routine clinical practice. Since 2013, over 1,200 patients have received a LUMPO prognosis, resulting in patient stratification and personalised screening strategies.

Research with impact

Research by Professor Coupland and colleagues has contributed to two key texts - 'Tumour-Node-Metastasis (AJCC) 8th edition' and to the 'WHO Classification of the Tumours of the Eye (4th edition)', which are the globally recognised standard in clinical oncology, guiding patient diagnosis, treatment and prognosis.

In 2015, the use of stratification tools such as LUMPO were recommended in NICE-accredited guidelines and to date LUMPO has been applied to an estimated 9000 patients worldwide. 

The use of the LUMPO tool has resulted in patient stratification and changes in the management of metastatic screening. It has been demonstrated that patients who undergo surgery following detection of metastasis have a prolonged life expectancy compared to those who do not. Furthermore, there is evidence to suggest that the majority of UM patients feel better for knowing their outlook, even when it is poor.

Use of the tool has led to:

• Cost savings for health services - an estimated £100,000 per year 
• Improved quality of life and optimised patient management
• Prolonged life expectancy due to earlier detection and more effective treatment of metastasis - a recent audit at University Hospital Southampton found that patients who received a LUMPO prognosis survived longer on average than those referred for treatment of metastatic disease.