Implementing a Timed Head and Neck Cancer Diagnostic Pathway

Overview

This specialist Guidelines summary covers NHS England advice on how diagnosis within 28 days can be achieved for the suspected head and neck cancer pathway. This summary also covers upper aerodigestive tract squamous cell carcinomas. Best practice timed pathways aim to shorten diagnosis times, reduce variation, and improve experience of care, and meet the Faster Diagnosis Standard (FDS).

This is a summary of the guidance for secondary care oncology teams. For further information, please refer to the full guideline.

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The Faster Diagnosis Standard

• The FDS should ensure people are told they have cancer, or that cancer is excluded, within a maximum of 28 days from referral. The new standard is intended to:
  • reduce the time between referral and diagnosis of cancer
  • reduce anxiety for the cohort of people who will be diagnosed with cancer or receive an ‘all clear’
  • reduce unwarranted variation in England by understanding how long it takes people to receive a diagnosis or ‘all clear’ for cancer
  • represent a significant improvement on the current 2-week wait to first appointment target, and a more person-centred performance standard.

28-Day Best Practice Diagnosis Pathway

Figure 1: 28-Day Best Practice Timed Head and Neck Cancer Diagnostic Pathway

Detailed Information

Referral from General Practice

• Urgent GP or general dental practitioner (GDP) referral pathway should be used for patients who meet the criteria in the NICE Guideline on Suspected Cancer (NG12) for suspected cancer pathway referrals [1] 
• The National Cancer Waiting Times Monitoring Dataset Guidance sets out consultant upgrade rules, including from non-GP scenarios such as A&E and acute settings. Cancer alliances may agree local arrangements to facilitate patient self-referral, community diagnostic centres, and other referral routes, including non-GDP members of the dental team, to access this pathway. It is noted with the implementation of community diagnostic centres that referral pathways may be subject to change [1]
• Primary care should inform the patient that they are being referred for an urgent suspected cancer pathway, although stating that the vast majority of referrals result in non-cancer diagnoses [1]
• Primary care should also make the patient aware of their responsibilities to make themselves available for the first 4 weeks for full diagnostic testing [1]
• A minimum dataset should be agreed locally with GPs, to accompany the referral, and facilitate straight to clinic and diagnostic testing, which includes: [2]
  • patient symptoms in line with the NICE NG12 guideline
  • patient demographics
  • anticoagulant status
  • World Health Organization performance status
  • comorbidity
  • smoking status and alcohol intake
  • prescribed medication (when auto-populated, if possible, in practice IT system)
  • need for interpreter
  • mental capacity to consent
  • (where IT systems support) to also include pictures of visible index lesion as part of surface anatomy
• Referrals from dental teams may not include all the minimum dataset, as they will not have access to test results. Capacity will need to be considered for completing missing dataset tests in the first outpatient appointment or one-stop clinic, following referral from primary care [2]
• For suspected neck lumps, the minimum dataset should also include sizing and shape of neck lump, duration of lump, and B symptoms where possible [2]
• Clinical triage can be done by a suitably experienced clinician, including a Clinical Nurse Specialist. Patients should be triaged based on NICE NG12 symptoms, with persistent, unexplained hoarseness going to an ear, nose, and throat clinic, unexplained ulceration in the oral cavity lasting for more than 3 weeks, a lump on lip or oral cavity, or red (or red and white) patch in oral cavity going to oral and maxillofacial clinic, and unexplained lump in the neck going to the neck lump clinic [3]
• If a patient is medically unfit for straight to one-stop clinic, the patient should be reviewed in clinic. If deemed medically fit, the appropriate first-line investigations should be performed and reported within 7 days of triage, so this cohort can progress on the pathway in the same timeframes [3]
• Patients should have same day investigations to reduce repeat visits and improve patient experience. Telephone or video consultation could be used to determine suitability for straight to one-stop clinic and pre-assessment. Preparation for any tests can be communicated to patients at this stage [3]
• Patients and caregivers should be asked what information they require about the pathway, provided with standard leaflets about investigations when sending confirmation of appointment, confirmation of next step(s) and any patient needs required to prepare for the day (for example, can they eat and drink beforehand), and whether they have any disabilities or language barriers [4]
• Preferences for amount of information and when it is provided will vary, and therefore it will help to provide caseworker/navigator telephone contact details to provide support throughout the pathway and outside of clinic times, provide signposting to charities and support services, provide information about caregivers attending appointments, and offer follow-up if patients do not receive confirmation of appointment in expected timescale [4]
• Where possible, continuity of caseworker/navigator should be provided to enable familiar contact and to build trust. Patients should also be informed that it is likely they will receive one or more procedures and/or diagnostic tests on the same day, at the first face-to-face appointment [4]
• One-stop clinic for neck lumps should have a radiologist present to provide immediate support and decision making to interpret ultrasound and undertake biopsy. There should be facility for patients to be booked in for examination under anaesthesia within 7 calendar days of the one-stop clinic, where the clinician deems it necessary to make robust therapeutic decisions. Although this guidance does not formally cover suspected thyroid cancer, the British Thyroid Association Guidelines for the Management of Thyroid Cancer sets out investigative tests, which could align to the test and timings outlined in this pathway [5]

Biopsy Procedure

• Biopsy should be undertaken for all patients with remaining clinical suspicion of cancer, unless sufficient tissue sampling is already obtained through fine needle aspiration cytology (FNAC) [6] 
• As biopsy can result in post-biopsy changes which prevent accurate staging, local anaesthetic (LA) biopsy should only be undertaken if it would not impact the staging performed on imaging. LA biopsy is normally appropriate if the tumour is large or exophytic in the upper airway, or clinically evident in the oral cavity [6]
• Histopathology reports for tissue sampling should usually be available in 7 calendar days. This may be longer if ancillary tests are required to establish a diagnosis or if the pathway for a sample reaching the reporting laboratory is delayed [6] 
• All histopathology should have a designated point of receipt, sign off, and management responsibility to ensure that reporting is not lost between different clinicians. Perioperative care of older people undergoing surgery assessment to be carried out by day 10, at or immediately following one-stop clinic to assess suitability for general anaesthesia biopsy for further investigations [6]

Imaging

• Ultrasound with FNAC should be carried out, if required, in one-stop clinic by a head and neck radiologist or clinical specialist ultrasound practitioner in head and neck. FNAC to be hot reported on the day using rapid on-site specimen evaluation [7]
• Alternatively, if ultrasound–guided biopsy is considered appropriate locally, this should be arranged as early as possible, and carried out no later than by day 15, to allow for full reporting and any further investigations to be carried out [7]
• Patients should be informed about cancer being ruled out, or diagnosed at the earliest face-to-face opportunity, unless the patient has expressed an alternative method of communication in order to speed up communication. In this timed pathway, this can be done at a one-stop clinic, a follow-up testing or results outpatient appointment [8] 
• Early consideration of patient’s fitness for radical therapy and requirements for pre-habilitation should be addressed as soon as possible in the pathway to minimise delays in expediting treatment [8]
• All patients diagnosed with cancer should have a referral to relevant allied health professionals, including a specialist dietitian, and speech and language therapist within 7 calendar days of diagnosis, and where required, will also be involved during treatment planning. Local protocols and initiatives should be developed in collaboration with perioperative medicine, elderly care, and specialist dietitians [8]
• When cancer is ruled out, in some cases it would be appropriate to provide a magnetic resonance imaging (MRI) or computed tomography (CT) scan before onward referral to a non-cancer routine pathway. Where cancer is excluded or confirmed, the FDS ‘clock stop’ can be completed at this point of communication with the patient. Cancer waiting time rules (including ‘clock start’, ‘adjustments’, and ‘clock stop’) are set out in the National Cancer Waiting Times Monitoring Dataset Guidance [8]
• Standard imaging protocols should be applied for all CT, MRI, ultrasound, and positron emission tomography–computed tomography (PET–CT), and these should comply with Royal College of Radiologists’ recommendations or equivalent. Systemic imaging (thoracic CT) should be available for all patients with cancer of the upper aerodigestive tract [9]
• Further information is available in BAHNO Standards 2020. Ring-fenced general cancer MRI slots should be considered to ensure that MRI capacity is available to deliver expected MRIs within 7 calendar days of biopsies [9]

Multidisciplinary Team

• The core roles at the full multidisciplinary team (MDT) (to be carried out following cancer diagnosis) are lead clinician, radiologist, pathologist, oncologist, clinical nurse specialist, and relevant allied health professionals, to review investigation results with a pathway navigator [10] 
• An oncologist with an interest in head and neck cancer, and a radiologist with an established head and neck interest should be present at the full MDT. The capacity required to deliver these core roles should be reflected in job plans. National guidance on How to Maximise Effectiveness of MDT Meetings is available. Locally agreed, clear criteria for referral to specialist MDT can also support with efficient pathway management [10]
• It is unlikely that all necessary management decisions will be made at a single MDT. Some cancer patients require more than one MDT discussion before final diagnosis and treatment options are reached. This can consist of a diagnostic planning meeting or mini-MDT between radiologist, oncologist, referring surgeon, and pathologist at days 10–16. Some small cancers may only require one discussion [10] 
• MDTs could consider direct referral from pathologists and radiologists, ensuring that a robust process is implemented to ensure the patient’s diagnosis is communicated before receiving any subsequent appointments [10]
• PET–CT service specifications set out the standards of care expected from organisations funded by NHS England to provide specialised care, including the expected timings for the provider to ‘appoint an examination date, perform the examination, complete the diagnostic report, and return the diagnostic report and images to the referring clinician within 7 business days, or as specified by the contract’ [11]
• PET–CT is indicated for diagnosis of occult primary tumour with metastatic squamous cell carcinoma neck nodes, T4 cancer of the hypopharynx or nasopharynx, or N3 cancer of the upper aerodigestive tract. PET–CT should be carried out and reported within 10 calendar days, and by day 25, to allow preparation for pre-arranged outpatient clinic and treatment planning discussion by day 28 [11]

Holistic Needs

• Personalised care and support planning should be based upon the patient and clinician(s) completing a holistic needs assessment, usually soon after diagnosis [12]
• The holistic needs assessment ensures conversations focus on what matters to the patient, considering wider health, wellbeing, practical issues, and support, in addition to clinical needs and fitness. This enables shared decision making regarding treatment and care options [12]