Head and Neck Cancer

HNC clinical networks should be consolidated, where indicated, and aligned with Cancer Alliances, to deliver a world-class service for patients and staff. Each HNC clinical network should establish a working group comprising key personnel from Cancer Alliances, ICSs, and the major surgical centre (or the MDT host) to drive the necessary changes across providers and systems. We will work collaboratively with Cancer Alliances, commissioners and HNC clinical networks to deliver this. GIRFT recommends that: • This group should include a specialty lead from each Cancer Alliance, relevant representatives from ICSs, and operational and clinical leaders from the HNC centre as well as from each local hospital. • For networks that span multiple Cancer Alliances or ICSs, each body should ensure its personnel are represented or agree on a lead to act on their behalf. Each HNC clinical network should be assessed against the following standards, and (where indicated) plans should be developed to ensure services align with them. A single HNC clinical network should: • provide all treatment modalities for upper aerodigestive tract (UADT) HNC, including complex surgery with composite microvascular reconstruction; • serve a population of at least one million; • have a single designated hospital site to perform major HNC surgery, ensuring all patients can be treated within the network. The major surgical centre should: o perform at least ten laryngectomy procedures per year (with higher volumes preferred); o perform at least 25 microvascular free-flap surgeries per year; o employ at least four HNC specialist microvascular surgeons; • provide oncology services (RT and SACT); • hold regular network meetings (at least three per year, and within working hours) focusing on strategy, operational issues and governance. These should be carried out in collaboration with the Cancer Alliance; • ensure that each trust refers patients to a centre within the network, avoiding split referrals to centres outside the network.

The quality, completeness, and utilisation of data should be improved to ensure it effectively supports both current and future pathway improvements. GIRFT will work to: • encourage data attribution to discrete HNC clinical networks; • promote improved HES surgical coding in collaboration with the National Consultant Information Programme (NCIP); • explore the commissioning of a national vehicle for collecting currently available and additional HNC outcomes data for the purposes of audit, quality assurance, peer review and knowledge acquisition. This must include additional data reflecting functional outcomes, including restorative dentistry (currently absent from national data sets). HNC clinical networks should: • audit compliance against agreed national quality and performance indicators that will be based on this GIRFT national report. Trusts performing reconstructive HNC surgery should: • provide the necessary administrative support and ensure that microvascular surgical teams enter their data on flaps into an appropriate UK-wide flap registry (the UK National Flap Registry is the currently recommended vehicle). All trusts should: • conduct local audits (at least annually) to help HNC clinical networks understand and improve their services, augment and inform the case for specialty funding, and enable teams to identify opportunities for improvement; • facilitate all specialities in routinely conducting service audits.

Trusts should adopt practices enabling an efficient pathway throughout from referral to post treatment. During the peer review visits, we identified a wide range of best practices across the pathway from referral to post treatment. We have summarised these below as a checklist that trusts and networks can work through according to the needs of their local service. Where relevant, we highlight practices that are quick and relatively straightforward to implement. Trusts should also continue to meet existing waiting time requirements, including the 31-day target for starting radiotherapy, and should aim to implement the 17-day target set out in the national Radiotherapy Service Specification (see Torbay case study). Best practice checklist: Patient pathway from referral to post-treatment Referral to Diagnosis • QUICK WIN Outpatient endoscopic biopsies: Trusts should deliver laryngeal and oropharyngeal endoscopic biopsies on an outpatient basis (see Manchester University case study for example). • HNC clinical networks and Cancer Alliances should optimise urgent suspected cancer referrals including from GDPs. • Trusts should use navigators to track the patient through the pathway (Best Practice Timed Pathway). • Trusts should offer patients with neck lumps: one stop clinics as best practice (alternatives include a straight-to-test pathway following initial triage); patient review with pathology results available within three to five days. • Trusts should offer transnasal laryngeal and pharyngeal biopsies to biopsy suspected laryngeal and pharyngeal lesions rapidly in clinic. • Each trust within a HNC clinical network should follow an agreed imaging protocol. Diagnosis to treatment - MDT meetings • MDTs should ensure complete staging according to agreed protocols to maximise meeting efficiency. • MDTs should minimise discussion of non-cancer cases. • MDT meetings should be quorate. • Work towards best practice recommendations for MDT meetings (see Appendix 2). Multidisciplinary pre-treatment clinics • Clinics should include surgeons, oncologists, CNSs, SLT, dietitians and consultants in restorative dentistry (CRD), or CRD may see the patient at a separate clinic after this. • Pre-treatment non-medical clinics are encouraged and offer many elements of prehabilitation. Surgery • Each major centre should have at least four microvascular HNC surgeons and perform the BAHNO recommendation of 25 microvascular HNC cases/year. • Each centre should routinely collect and audit surgical outcomes data including microvascular free flap outcome data. • Each centre performing laryngectomy operations should perform at least ten cases/year. • HNC surgery should only be performed by core HNC surgeons, although some intermediate or minor procedures can be performed by core surgeons who also work outside of a major centre. • Major surgical centres need to provide appropriately skilled staff, including nurses and AHPs, to manage complex airways. • Any change in HNC surgical provision must factor in the need for additional specialised nursing and allied health care. • A consultant(s) in restorative dentistry should be involved in surgical implant planning alongside reconstructive surgeons. Oncology • QUICK WIN Peer review of contours: RT centres should ensure all radical contours are peer-reviewed by at least two appropriately trained staff with specialist radiology advice in line with international consensus guidance. This may require collaboration with other centres (see UHBW and the RUHB case study for example). • All patients having curative radiotherapy should have prospective peer review of contours. • HNC clinical networks with more than one oncology site should offer treatment closer to home. Collaborative working including joint peer review of contours is recommended. • Each HNC clinical network should aim to start RT treatment within 17 days of decision to treat. • Radiotherapy-specific multidisciplinary care should be provided. Post-treatment • Formally coordinated post-treatment pathways should be established including provision for re-referral. • Trusts should offer local multidisciplinary follow-up clinics. • Patients should have access to well-being and self-management services. • Each clinical network should offer HNC patients late-effects clinics and appropriate re-referral pathways. • Patients seen by restorative dentistry prior to treatment should be reviewed by the restorative team post treatment and appropriate follow up care actioned.

Trusts should optimise care within the key disciplines which support quality of life, functional outcomes, and rehabilitation. Alongside the best practices already described chronologically across the pathway, we have highlighted the key pillars that support quality of life, functional outcomes, and rehabilitation. Below, we summarise the best practices identified during our visits in these areas. This checklist should be used together with the pathway checklist (covering practices from referral to post-treatment) as a tool to identify opportunities to improve local services. Best practice checklist: Key disciplines which support quality of life, functional outcomes, and rehabilitation • Trusts treating HNC should have access to lymphoedema therapy; ICBs should support commissioning to enable this. • Trusts should develop nurse-led clinics (see Epsom and St Helier case study for nurse-led diagnostic clinics and Royal Devon University Healthcare case study for nurse-led follow up clinics). • Trusts should ensure that SLTs lead Surgical Voice Restoration (SVR) clinics for laryngectomy patients; provide swallow safety management from diagnosis through to palliation and late effects with access to FEES and VF; deliver communication therapy for people with speech and voice compromise and are able to create protected space for rehabilitation. • Dietitians should consider and lead the transformation of gastrostomy insertion into a day-case procedure in collaboration with the MDT, reducing costs and improving patient outcomes26 (see North Middlesex case study). • Dietitians should provide close follow-up, preferably in collaboration with the MDT, to optimise post-treatment rehabilitation (see Royal Surrey MARS case study). • Consultants in restorative dentistry (CRD) and OMFS consultants should collaboratively decide whether primary/secondary or no implants are required in each individual case, prior to ablative surgery. The CRD should be involved in virtual surgical planning with OMFS and (where locally appointed) a reconstructive scientist. This will ensure postsurgical prosthetic rehabilitation is considered and optimised. CRDs and oncology consultants/SLTs/dietitians should collaborate to optimise oral health outcomes for non-surgical treatment. Funding for primary and secondary implants should be included in commissioned pathways and appropriate team-based training should be supported by job plans. • Consultants in restorative dentistry are encouraged to join the RD-UK HNC Clinical Excellence Network, to help CRDs across the UK work collaboratively to share best practice and improve quality of care.