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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
MTReC
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
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