MTReC

TheBAHNOHeadandNeckCancer

SurveillanceAudit2018

Rationaleforaudit

Headandneckcanceristhesixthmostcommonmalignancyworldwide.IntheUK,itismanagedby

a multidisciplinary team of surgical oncologists, oncologists, radiologists, pathologists and allied

health professional. Post treatment surveillance is accepted as an essential element of patient

care(ref). Follow-up serves a number of functions including: assessing treatment response,

identification of recurrent or newprimary tumours,managing complications, facilitating ongoing

rehabilitationandaddressingpatients’andtheirfamilies’socialandpsychologicalneeds.Despitean

acknowledged limited evidence base, The Head and Neck Cancer: United Kingdom National

MultidisciplinaryGuidelines published in 2016 set out surveillance recommendations. This audit

seekstoassessnationalcompliancewiththisguidanceand,ifrequired,explorewaysinwhichthis

multifaceted surveillance model might be delivered more reliably in the context of stringent

economicforcesandanevolvingevidencebase.

Aims

• Toassessadherenceto‘Follow-upaftertreatmentforheadandneckcancer:United

KingdomNationalMultidisciplinaryGuidelines’2016

• Tohelpusunderstandcurrentpractices,andthegapsandareasofneed.

• Toexaminefollow-uppracticesforheadandneckcancerpatientsintheUK,withtheaimof

establishingaresearchprogrammetoimprovecurrentpractice

• Todeveloptraineecollaborativelinksinacrossspecialtysetting

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OfficialSupport

Theaudit isofficially supportedbyBAHNO (BritishAssociationofHeadandNeckOncology,who

maintainexecutivecontroloftheaudit).TheauditisbeingdeliveredbyINTEGRATE,whomanagea

collaborativeofENTtraineesacrosstheUKinterestedinresearch,inassociationwithMTReC,the

Maxillofacialtraineeresearchcollaborative.INTEGRATE,MTReCandtheAuditSteeringCommittee

willprovidesupportthroughouttheauditinitiationanddatacollectionperiod.Signatoriesfromall

involvedgroupscanbefoundattheendofthisdocument.

Generalapproach

The1stcycleoftheBAHNONationalHeadandNECKCancerSurveillanceAudit isacombinedtwo

weekretrospectiveandfourweekprospectiveauditofpractice.Thereafterfindingswillbepresented

totheBAHNOcouncilwithaviewtodevelopingappropriateinterventionspriortoanysubsequent

audit cycle. The audit will include all patients undergoing scheduled appointments for the

surveillanceoftreatedheadandneckcancer.Thiswillincludemultidisciplinary,subspecialistand

generalclinicsinbothOtorhinolaryngologyandMaxillofacialsurgery.

DatawillbecollectedfromacrosstheUK,a80-sitetargethasbeensetforthisproject.Clinicalcoding

will allow identification of all cases meeting the inclusion criteria in both audit windows. The

retrospectiveperiodwillinvolvethereviewofclinicalnotesalone,theprospectiveperiodwillinvolve

the completion of locally approved audit proformas, in-lieu of medical continuation sheets, for

inclusioninthepatients’medicalrecords.Dataextractedwillthenbeenteredintoauditresponse

formcommontobothauditperiodsandreturnedtotheauditteamasdetailedbelow.Thisdual

auditmethodologywillseektoquantifythelimitationsofclinicalnotescontaininginsufficientdetails

forauditpurposesversusthepotentialimpactofauditproformasonpatientcare.

Dates

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Theretrospectiveauditwindowwillbethe1sttothe14thofNovember2017.Theprospectiveaudit

windowwillbethe16thApriltothe11thMay2018.ThefindingswillbedisseminatedtotheBAHNO

councilandinterestedpartiesattheBritishAcademicConferenceinOtorhinolaryngology2018(4-6

July)andpublishedinthenationalliteraturethereafter.

AuditStandards

The 2016 ‘Follow-up after treatment for head and neck cancer: United Kingdom National

Multidisciplinary Guidelines’ forms the basis of the audited standards and makes the following

recommendations:

• Patientsshouldbefolloweduptoaminimumoffiveyearswithaprolongedfollow-upforselected

patients.(G)

• Patientsshouldbefollowedupatleasttwomonthlyinthefirsttwoyearsandthreetosixmonthly

inthesubsequentyears.(G)

• Patientsshouldbeseenindedicatedmultidisciplinaryheadandneckoncologyclinics.(G)

• Patientsshouldbefollowedupbydedicatedmultidisciplinaryclinicalteams.(G)

• The multidisciplinary follow-up team should include clinical nurse specialists, speech and

languagetherapists,dietitiansandotheralliedhealthprofessionalsintheroleofkeyworkers.(G)

• Clinical assessment should include adequate clinical examination including fibre-optic rigidor

flexiblenasopharyngolaryngoscopy.(R)

• Magnetic resonance imaging and positron emission tomography combined with computed

tomographyimagingshouldbeusedwhenrecurrenceissuspected.(R)

• Narrowbandimagingcanbeusedinthefollow-upinselectedsites.(R)

• Second primary tumours should be part of rationale of follow-up and therefore adequate

screeningstrategiesshouldbeusedtodetectthem.(G)

• Patientsshouldbeeducatedwithregardtotheappearanceanddetectionofrecurrences.(G)

• Patientswithpersistentpainshouldbeinvestigatedtoexcluderecurrentdisease.(R)

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• Patientsshouldbeofferedsupportwithtobaccoandalcoholcessationservices.(R)

DatatobeCollected

Thefollowingdatawillberecordedwhererelevant:

• AssignedconfidentialhospitalsiteID

• Dateofclinic

• Age

• Gender

• Smokingstatus

• Alcoholintake

• Typeofcancer

• HPVstatus

• Dateofdiagnosis

• Dateofcompletionoftreatment

• Typeoftreatmentreceived

o Surgery

o Radiotherapy

o Chemotherapy

• Gradeofclinicianseenatclinicappointment

• Typeofclinicappointment

• Symptomsidentifiedduringappointment

o Drymouth

o Neckpain/stiffness

o Shoulderpain/stiffness

o Mouth/Throatpain

o Dysphagia

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o Difficultyspeaking

o Difficultybreathing

o Bleeding

o Tiredness

o Other

• Methodsofclinicalexamination

• Detailsofpatienteducation

• Adviceregardingsmoking

• Otheralliedhealthprofessionalsseen

• Whethertheyhaverecurrenceornot

• Whetherthereissuspicionofrecurrence/2ndprimary

• Whatinvestigationsareinitiated

• Thefollowupinterval

Auditleads

EachparticipatingsitewillhaveanENTand/oramaxillofacialdoctorassignedasalocalsiteleadby

thecentralsteeringcommittee.Theseindividualsinmostcaseswillbeofspecialistregistrargrade.

Forsiteinclusionintheaudit,evidencemustbeprovidedpriortodatacollectiondemonstratinglocal

approvalfromthefollowing:

• Auditdepartment

• Caldicottguardian

• Healthcarerecordscommittee

• MDTchair

• Departmentalclinicaldirectors

Itisthelocalsiteleadswhowillsubmittheauditproposalformandactasapointofcontactforthe

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trustAuditDepartment.

Collectionandstorageofpatientinformation

Patient-identifiableinformationwillnotbeenteredintotheauditdatabase.Localsiteleadswillbe

responsibleforgeneratingauniqueauditIDcodeforeachparticipatingpatient.Thelocalsitelead

willalsokeepalocalauditIDcode‘key’whichrelatestheauditIDcodetothepatient’slocalmedical

recordnumber/identifier.Thiskeywillonlybestoredlocallyandheldsecurelyinamethodapproved

bythelocalclinicalgovernancedepartment.Thismaybeapaperrecordorofflineelectronicrecord

onanNHSTrustcomputer.Thiscodekeywillbegiventothelocalauditdepartmentattheendof

theaudit.

Datasecurity

Atemplatedatacollectionfilewillbedistributedtoallsiteleadspriortothedatacollectionperiod.

ThiswillbeintheformofalockedExcelspreadsheetwithintegrateddataentryandvalidationform.

Local site leads will store the file offline on an NHS computer approved by the local clinical

governance department. The fields available will only be those listed above; data validation

techniques will prevent entry of patient identifiable data to the locked file. Any incomplete or

potentiallyerroneousdatawillbehighlightedtothesiteleadtoensurethatthedatasubmittedis

completeandofhighquality.Oncedatacollectioniscomplete,theanonymisedfilewillbeencrypted

bythelocalleadandsentbyemailviaNHSemailaddresseswithintheNHSDigitalHealthandSocial

CareNetwork(HSCN)bythelocalsiteleadtotheprincipalinvestigatoroftheproject.Theproject

steering committeewill compile all responses into a single database stored securely on an NHS

computer.

The INTEGRATEwebsite (https://www.entintegrate.org)will be used to facilitate communication

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betweencollaboratorsbutnoauditdataorpatientdatawillbesentviathewebsiteorstoredonits

server.

Localsupportrequired

Limited support is required fromTrust auditdepartments. The site leadsmay request assistance

obtainingthenotesofcasesincludedintheauditinordertocompleteanymissingdata.

Localreporting

After the audit, site leads maintain access to local data and are encouraged to present at

departmental governance meetings, to aid with the introduction of local quality improvement

interventions.

Furtherinformation

Pleaseaddressanyqueriesviathesiteleadatyourtrust,ordirectlytotheAuditSteeringCommittee,

contactableviahttps://www.entintegrate.org/cancer-audit-2018