British Association of Head and Neck Oncologists (BAHNO) standards 2020

Abstract

The Association was first constituted in 1967 as the Association of Head and Neck Oncologists of Great Britain and in 1995 changed its name to the British Association of Head and Neck Oncologists (BAHNO). The stimulus for its formation remains our aim, namely the need to encourage discussion and the sharing of knowledge between the various clinical and research specialties involved in the management of the diverse group of conditions that make up head and neck cancer. Although those of us working in the field have strong links with other relevant individual medical and paramedical specialties BAHNO remains the only truly multidisciplinary professional group which can represent the interests of head and neck cancer clinicians and patients in the United Kingdom. BAHNO first published a document on the provision and quality assurance for head and neck cancer as long ago as 2002, setting standards for multidisciplinary care in so doing. In 2009, it once again contributed to the continuing improvements in the management of our patients by publishing standards for the process of head and neck cancer care that have been used both within the United Kingdom and abroad as a vehicle for change over the past decade. I am delighted that BAHNO has once again been at the forefront of clinical improvement in publishing this document which continues the theme of the association in representing the multidisciplinary nature of our work in treating head and neck cancer. I would like to thank the contributors for their tireless work and in particular Stuart C Winter and Andrew Schache for overseeing the project and bringing this publication to the light of day. Professor Cyrus Kerawala BAHNO President This standards document represents the revised and updated BAHNO Standards previously published in 2009. These Standards pertain primarily, although not exclusively, to the configuration and organisation of services tasked with the management of individuals with squamous cell carcinoma of the head and neck. Within this context, salivary and regional metastases of cutaneous squamous cell carcinoma of the head and neck are also considered. The standards have taken reference from national published guidance to inform the recommendations.1-15 The 2020 BAHNO Standards have been updated to include thyroid malignancies in keeping with the role that members of specialities aligned to BAHNO play in the overwhelming majority of these cancers. Whilst there are elements of these Standards that might similarly be applicable to units/trusts providing management of sarcomas and/or lymphoproliferative diseases, these tumour types were not specifically considered within the remit of these BAHNO Standards. ALL units/centres should have a named head and neck clinical lead responsible for the overall unit. ALL units should have a named lead responsible for co-ordinating the local provision of care. ALL individuals should be seen by a specialist head and neck nurse/clinical nurse specialist (eg Macmillan nurses in the UK) whose contact details should be made available to the patient at the earliest opportunity. ALL centres should have a list of consultants who are designated to provide head and neck cancer care. Referrals should adhere to national and local guidelines. Referrals using the UK “Two-week wait (2WW)” pathway should have sufficient detail to allow for triage into the most appropriate clinic. Referrals should contain sufficiently detailed information such that pre-referral investigations can be completed if necessary. There should be a secure image transfer system so any accessible lesions (inc. oral cavity) can be assessed. There should be an agreed pathway for a senior clinician to downgrade 2WW referrals if considered benign. Referral outside the urgent pathway, particularly by routine mail, should be discouraged. However, where unavoidable, the same information is required. The referral system should be sufficiently robust to support referral from both general medical and dental practitioners. No patients presenting with the above conditions should be referred to general surgeons. There should be an awareness and consideration of the national guidance regarding the urgent cancer diagnostic services. ALL host trusts should provide funding for hardware, software, annual licenses and updates to maintain the services detailed in these Standards. ALL trusts should also provide adequate administrative support to collect and enter data into regional and national cancer registries. ALL units to have a named and dedicated IT co-ordinator. ALL trusts should have strategic plans to introduce IT and pathway solutions capable of continually optimising head and neck cancer pathways (diagnostic and therapeutic). All individuals should be made aware of their diagnosis unless they make an express wish to the contrary. The subsequent depth of detail provided should be tailored to the individual’s requests but must be sufficient to allow the making of informed decisions. All patient notes should document what the individual and his/her carers have been told about the diagnosis, the aims of treatment and the treatment being offered. Serious diagnosis communication should be made with primary care physicians in ALL instances following a new diagnosis of cancer. Patients should be provided with consistent information and support at diagnosis in line with the NICE service guidance on improving outcomes in head and neck cancer and recommendations of the National Peer Review Programme. Where appropriate, this should include details of disease aetiology (eg information about Human papillomavirus (HPV) to individuals with HPV-associated oropharyngeal squamous cell carcinoma). Information and support should be tailored to the individual’s needs (including the benefits and side effects of treatment, psychosocial and long-term functional issues). Details of available peer-support services should be made available to patients for all standard treatment pathways—this may be in variable formats (eg written leaflets, brail and electronic) and languages. ALL units to have appropriate equipment such that clinical images can be taken and used and shared for disease monitoring and MDT discussion. It is desirable to have access to narrow band imaging. ALL outpatients should have video screens to support provision of nasendoscopy and rigid endoscopy of the nasal cavity. There should be facilities for photo-documentation with digital storage. There should be facility for ALL individuals to undergo examination under anaesthesia (EUA) where the clinician deems it necessary to make robust therapeutic decisions. Standard imaging protocols should be applied for ALL CT, MRI, ultrasound and FDG PET-CT studies, and these should comply with Royal College of Radiologists’ recommendations or equivalent. Cross-sectional imaging CT/MRI should be reported by a specialist head and neck radiologist. ALL head and neck imaging should be reported by this dedicated team. PET/CT should be reported by specialist head and neck nuclear medicine physician/radiologist. All staging scans should be reported prior to commencement of treatment and, ideally, prior to primary tumour biopsy. Systemic imaging (thoracic CT) should be available for ALL individuals with cancer of the upper aerodigestive tract. In early-stage disease (eg T1N0 or T2N0), this should not delay treatment. ALL sites must have access to CT/MRI for imaging of ALL individuals, to conform with RCR guidance. A DPT is required as a minimum for all patients prior to undergoing a dental assessment. This assessment should be supported by intra-oral radiographs where necessary. Provide fine-needle aspiration cytology/core biopsy analysis for ALL individuals with a neck lump that is suspected of being cancer of the upper aerodigestive tract. This should be performed by a specialist radiologist, pathologist or clinician. The biopsy laterality and biopsy site must be documented in ALL instances. Aim to perform ALL fine-needle aspiration cytology or core sampling under ultrasound guidance. ALL ultrasound-guided fine-needle aspiration cytology should be subject to rapid on-site evolution/assessment (ROSE/ROSA). Fine-needle aspiration or biopsies should be interpreted by a cytopathologist with head and neck interest and reported within 7 calendar days. In ALL units, capacity should be available to review biopsy specimens of cancer diagnosed in primary or secondary care. Where this deemed necessary, it should be by a specialist head and neck pathologist within the tertiary care setting. ALL new cases should have a histological diagnosis of cancer prior to treatment planning (except in exceptional circumstances, eg in individuals for whom an open or core biopsy is inappropriate or not possible). Surgical margins must be discussed for ALL patients within the MDT and documentation made of the significance and recommendation for acting on close or involved margins. ALL surgically resected cases should include all core data set items for head and neck cancer histopathology reporting. There should be at least one named pathologist per centre participating in the national external quality assurance scheme. ALL incisional biopsies and core biopsies for suspected cancer should be reported within 7 calendar days (confirming or excluding diagnosis of malignancy as a minimum). Reporting of definitive resection specimens should be reported within 10 calendar days where decalcification is not required. ALL squamous cell carcinomas of the oropharynx should be tested to determine HPV status. ALL individuals should be staged weekly in each unit undertaking head and neck cancer treatment using the current staging (TNM8 at time of publication). The structure of the multidisciplinary team (MDT) must allow capability for membership of the MDT to participate virtually (eg teleconference/video conference). *The number needs to be sufficient to cover the MDT at all times, for example leave and absence. ALL individuals with palliative care needs (anticipated or otherwise) should have both timely referral and clear access to their local palliative care services. Facility should be available for both a head and neck surgeon and a head and neck oncologist to undertake joint consultations (particularly where treatment equipoise exists or where support of combined treatment planning is necessary). ALL individuals with a new or recurrent head and neck cancer diagnosis should be discussed by an MDT prior to treatment; this discussion should be documented in MDT outcomes. Where treatment needs to be expedited (prior to or following MDT discussion) there should be an agreed pathway so as to not delay treatment. MDT discussion should still occur and be recorded. The agreed treatment pathway should ideally be formulated at the first MDT for ALL patients. That agreement must either prescribe definitive treatment OR outline necessary investigations leading to final treatment plan. The aim of treatment (curative/palliative) should be documented in MDT outcomes for ALL individuals being discussed within that MDT. In ALL cases, the recommended treatment plan should be communicated to the individual and carers verbally, to the GP in writing. The nurse in charge on each shift should have a specialist qualification in a related discipline and a minimum of 5 years of experience. Two other nurses on the staff should have, or be preparing for, a specialist qualification in related disciplines. Nursing staff (including health care assistants) should have competencies associated with altered airway management and major haemorrhage in the head and neck setting. Nurses should be informed and aware of ongoing clinical research projects, audits and clinical trials. Higher advice at experienced specialist registrar AND consultant level to be available 24 hours a day, every day. Named speech and language therapist, dietitian/nutritional nurse specialist, physiotherapist, pharmacist, dental hygienist, psychologist and social worker. Multidisciplinary assessment in line with pre-habilitation and enhanced recovery protocols is to be encouraged in ALL units and for ALL individuals. Patients should be provided with proposed treatment dates within national targets/guidelines in ALL cases. Arrangements should be available for pre-operative assessment prior to admission in ALL units delivering surgical treatment for head and neck cancer. Comprehensive multidisciplinary discharge planning should be instigated at admission. This might include feeding arrangements, airway/tracheostomy care and mouth care. The senior nurse should have a specialist qualification in a related discipline. Staff should include one other nurse with or studying specialist qualification in a related discipline. Theatre staff should have an adequate skill set to manage the full range of head and neck cancer patients. Specialist ongoing training in head and neck procedures should be available for all members of the theatre staff. There should be one or more named consultant anaesthetist(s) with advanced expertise in head and neck anaesthesia and complex airway management (inc. jet ventilation, awake fibre-optic intubation). They should be responsible for directly or indirectly overseeing 100% of major head and neck operations. This is not an exhaustive list, and other available equipment should include all materials, technologies and resources befitting of a service delivering high-quality care. Adequate theatre capacity for extended day theatre session for major/complex procedures (eg three-session lists if needed). ALL units must retain availability of HDU and ITU in the same building. ALL individuals with early laryngeal cancer should have a pathway to discuss transoral laser surgery as well as radiotherapy. Units treating individuals with advanced disease should provide ALL individuals with access to resective and reconstructive surgical options, and appropriate adjuvant treatments. ALL units should offer or have a pathway to offer sentinel node biopsy for ALL individuals with early oral SCC ALL units should have a pathway for offering minimally invasive surgical alternatives—transoral robotic surgery (TORS) and/or transoral laser microsurgery (TLM). ALL individuals with early hypopharyngeal cancer should have a pathway to discuss organ-preservation treatment. Units treating individuals with advanced disease should provide ALL individuals with access to resective and reconstructive surgical options, and appropriate adjuvant treatments. ALL units treating individuals with unknown primary tumours of the head and neck should have access to 18-fluorodeoxyglucose positron emission tomography (FDG PET)-CT scanning facilities. biopsy of the or otherwise) neck must not be prior discussion in the specialist head and neck MDT. There should be an agreed for the surgical assessment of the primary site FDG PET-CT not a primary There should be an agreed pathway for a where ALL primary salivary malignancies must be discussed in the head and neck MDT. These tumours specialist care access to appropriate expertise and diagnostic a pathway to provide tertiary where not All units treating malignancies should have a pathway for of providing for head and neck must have a specialist interest in head and neck surgery with prior training and experience. The range of reconstructive by reconstructive must be with the and be deemed to be Where this is not units must be to offer or have documented referral pathways to specialist centres providing such ALL reconstructive are available for ALL individuals. ALL units providing this reconstructive service must have in to a timely AND to theatre where necessary, the appropriate surgical skill is available at all of a reconstructive service must be supported by a robust The minimum number of cases within an individual MDT structure should per for ALL units must and ideally be above ALL providing head and neck reconstructive services should maintain documented of the number of with associated so as to within their ALL units should be to their outcomes following for external in ALL cases where would not be by Peer review ALL treatment There should be a minimum of head and neck clinical in each unit to provide of service and ALL should within days of the to with of This pathway should be to to with palliative treatment should within days of the to All must be to RCR of adjuvant should aim to be within days of commencement of definitive in ALL cases. of this time should only be where this ALL centres to have written protocols for tumour sites and either or using national guidelines. These should be and updated in the light of research at least every for the of and for palliative should be in 100% of from national protocols needs to be documented and agreed within MDT All patients should be a needs assessment at diagnosis, and as required to needs and to other services as should prior to admission. ALL units should have a named speech and with at least of time dedicated to head and neck cancer care and with specialist surgical ALL individuals who are undergoing treatment to communication or should be seen by a speech and language for and a assessment of and clinician and ALL units should have a named with at least of time dedicated to head and neck cancer work with specialist knowledge in feeding and altered ALL should be using a who are or at of should be referred to the for early and ALL individuals who are undergoing treatment to on their to their should be seen by a specialist for patients are to be referred on to local and speech and language should be available in a role to support in primary care. ALL units should have a named in to lead the dental and oral of patients. A in should lead oral and dental assessment and ALL patients undergoing treatment that oral and dental (including of and/or should also be for dental prior to treatment. for dental should be so as to to definitive cancer treatment. A should be available to ALL patients who may nasal and ALL Units should provide have a pathway to ALL individuals should be and their treatment, and this should be by a in ALL individuals should have access to a experienced dental or ALL individuals should have of The planning for ALL patients the should a All centres should have pathways for following training for with should be considered as as neck head and neck cancer care should have access to in particular a psychologist with a head and neck interest of ALL and health professional staff should be aware of written protocols and referral for should be to in line with the NICE on and services. ALL individuals and carers should be informed at the of diagnosis that continuing to outcomes side of and the of primary cancers. All patients with and/or should be local support treatment. and may need to be for days to and ALL centres to have written agreed with the local palliative care ALL units should provide staff training and necessary equipment to support of tumours to pathways should for advanced care ALL units and individuals with head and neck cancer should adhere to local for and major ALL specialist head and neck nurses should be aware of these their at of these should be made aware of the in ALL cases unless the patient has a wish to not be provided with this individual to of care of clear documentation and communication with each relevant team providing palliative must be for ALL individuals. This may include with primary care and specialist palliative care must be made to discuss and care plans with all patients. These may include of agreed or of treatment. those to be days of an care plan should support care for ALL individuals. The clinical management of thyroid cancer is not to be in detail within this on management of thyroid cancer are within a publication by the British Association BAHNO this on thyroid cancer to be to these and to the standards for the management of upper aerodigestive cancer. The management of thyroid cancer and of thyroid cancer should be the of a specialist MDT. The membership of this be by the regional cancer In this of management of thyroid cancer. of the from the in Head and Neck and the for Head and Neck NICE guidance is to be in ALL patients with thyroid those whose cancer is surgery for should be referred for discussion of the management by a thyroid cancer MDT. The management of thyroid cancer should be the of the specialist membership of which be agreed by the regional cancer and to the for Head and Neck services. are for a number of particularly in with clear to This to those with or This may be on patient and to undergo long-term Where patients should be considered for in clinical trials. for thyroid cancer may from those or as of a combined MDT with a team and they should cover a minimum of one for referral of thyroid cancer. All members of the MDT should maintain continuing professional Patients be seen by one or more members of the a combined is In cases, of a neck lump have a pathway both in and in thyroid cancer. The of or ultrasound is recommended for of malignancy and the need for fine-needle aspiration with fine-needle aspiration biopsy should be by a specialist, ideally with ultrasound guidance. This should be within a designated neck lump as a cytology should be reported by a cytopathologist with in thyroid disease and with access to with for The cytology should contain a the by the as by the Royal College of In the thyroid surgery is by specialties and oral and general ALL must have training and expertise in the management of thyroid cancer and be a core of the multidisciplinary team (MDT) thyroid cancer. It is that ALL involved in the care of patients with thyroid cancer their data to an for example that of British Association of and should perform a minimum of thyroid per for advanced thyroid cancer neck should be within each MDT under the care of surgeons. should be agreed within the MDT for the care of patients with thyroid cancer. thyroid tumours should have a interest in thyroid or participate in a with the of Reporting of specimens should include the agreed minimum data as per guidelines. A clinical oncologist or nuclear medicine treating thyroid cancer should have training and expertise in the management of thyroid cancer and be a core of the MDT thyroid cancer. Information on ALL patients diagnosed and for thyroid cancer should be using local cancer or national should be subject to There should be a named clinical lead and nurse for head and neck ALL head and neck clinicians (including should be encouraged to and standard to which all clinical research is ALL should be aware of the current head and neck in the national clinical Where a or research individuals should be provided with an to be referral to a unit that can offer in the where an individual There should be published of to clinical ALL clinicians should be involved in the process and of clinical The of and should be available and where appropriate, published in for and ALL units as a undertake an annual of clinical outcomes and a review of

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