Download Guidance on Cancer Services

Guidance on Cancer Services
Improving Outcomes for People with
Skin Tumours including Melanoma
NICE Stateholder Consultation version
July 2005
Cancer networks should establish
two levels of multidisciplinary
teams:
i. Local Hospital Skin Cancer Multidisciplinary Teams (LSMDT)
ii. Specialist Skin Cancer Multidisciplinary Teams (SSMDT)
All clinicians who treat patients with
any type of skin cancer should be
members of one of these teams,
whether they work in the
community or in the hospital setting
Cancer networks should ensure
that LSMDTs and SSMDTs work
to network agreed protocols for
referral, Multidisciplinary Team
(MDT) review, management and
audit of skin cancer services
Local Skin Multidisciplinary Teams
(LSMDTs) should be established in
cancer units and link with all those
engaged in skin cancer care in the
community and primary care
Specialist Skin Cancer Multidisciplinary Teams (SSMDTs)
should be based usually in cancer
centres and plastic surgery
centres. Those teams can also
serve as the LSMDT for the local
population. These teams should
include appropriate non-surgical
oncology support
Patients should be referred for
review from LSMDT to SSMDT
according to the complexity of their
disease. There should be flexibility
in these arrangements to allow for
local circumstances
Local Hospital Skin Cancer
Multidisciplinary Team
Patients to be referred for LSMDT
review:
• All patients with high risk BCCs and
SCC that involved the excision
margins or all that are recurrent
• Patients suitable for Mohs’ surgery
• All patients with melanoma – primary,
recurrent and metastatic
• Patients with multiple atypical naevi
• Patients with skin lesions of uncertain
but possible malignant potential
• Cases for node dissection including
sentinel node biopsy
• Immunocompromised patients with
skin cancer patients who have Gorlin’s
syndrome or other genetic conditions
in which predisposition occurs
• Patients with rare skin cancers
including lymphoma
Core membership of the LSMDT:
• Lead clinician (normally a consultant
dermatologist)
• Dermatologists
• Skin cancer clinical nurse specialist
• Histopathologist with lead interest in
skin disease
• Primary care accredited practitioners,
Trust clinical assistants and associate
specialists
• Surgeons
• Oncologist
• Team Co-ordinator/Secretary
For each of these specialties there
should be a nominated lead and
deputy
Members of the extended LSMDT:
• Specialists in palliative care
• Trained counsellors with experience
in cancer
• Psychologists
• Cosmetic camouflage advisors
• Clinical geneticist/genetics counsellor
• Occupational therapists
•
•
•
•
Prosthetics and orthotics staff
Physiotherapists
Lymphoedema therapists
Pharmacists
Audit of activities:
• Audit of treatment and in particular
surgical wider/re-excisions
• Audit of BCCs and SCCs to be
presented quarterly, including those not
discussed at MDT
• Audit of low risk BCCs and SCCs
involving the excision margins
• Excision margins according to
published guidelines and network
protocol
• Waiting times
• Proportion of cases actually reviewed
by the MDT according to criteria listed
• Critical incidents where treatments
were judged to be outside
recommended network guidelines.
Network meeting should take place
annually to review such incidents
• Audit of histopathology reporting
times
Role of the SSMDT
The SSMDT will also act as the
LSMDT for its catchment area.
They should in addition manage
other specific groups of patients
referred from other LSMDTs
SSMDT meetings should
be held fortnightly
SSMDTs should:
• provide a rapid diagnostic and
assessment service for patients referred
from LSMDTs
• provide specialist investigations and
treatment not available to LSMDTs
• Undertake research including entering
patients into trials
• collect data for network wide audit
• play a lead role in teaching and training
Patients for review by SSMDTs:
• Patients referred from the LSMDT
• Patients with metastatic BCC
• Patients with high risk SCCs that pose
difficulty in management
• Patients with melanoma managed by other
site specialist teams (eg sarcoma,
gynaecological)
• Patients newly diagnosed with melanoma
stage 1B or higher, those with multiple
melanomas and children under 19 years
with melanoma
• Any patient with metastatic melanoma or
SCC diagnosed at presentation or follow-up
• Patients with giant congenital naevi where
there is suspicion of malignant
transformation
• Patients with malignant skin lesions of
uncertain pathological diagnosis
• Patients with rare skin cancers including
lymphoma and sarcoma
• For periodic review, patients developing skin
cancer who are immunocompromised, have
Gorlin’s syndrome or other genetic predisposing syndromes
• Patients needing node dissection including
sentinel lymph node biopsy
• Patients who may benefit from radiotherapy
• Patients who may be eligible for entry into
clinical trials
• Patients who require adjuvant treatment
Core Membership of the SSMDT
• Dermatologists – at least two, one with a
major interest in skin cancer surgery and
another with a major interest in lymphoma
• Surgeons – at least two with an interest in
skin cancer and perform at least 15 block
dissections per year. Could include plastic
surgeons, surgical oncologists, oral and
maxillofacial surgeons, occuloplastic
surgeons, RNT surgeons
• Skin cancer clinical nurse specialists
• Histopathologists – ideally at least two
dermatopathologists
• Radiologists
• Clinical oncologists
• Palliative care specialists
• Team co-ordinator/secretary
For each of these specialties described
there should be a nominated local and
deputies
Extended SSMDT may include:
• Medical oncologist
• Trained counsellors with experience in
cancer
• Psychologists
• Pharmacists
• Cosmetic camouflage service providers
• Clinical geneticist/genetic counsellor
•
•
•
•
•
•
Lymphoedema therapists
Occupational therapists
Prosthetics and orthotics staff
Physiotherapists
Radiographers
Speech and language therapists
Meeting Schedule
Core LSMDT/SSMDT should
meet at least every two weeks.
At least once a year the
extended team should meet
with the core team to discuss
team and organisational issues
Decisions about management
and standards for therapy should
follow documented clinical
protocols which have been
agreed throughout the network