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: • Local Hospital Skin Cancer Multi-disciplinary Teams (LSMDT) • Specialist Skin Cancer Multi-disciplinary 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 Multi-disciplinary 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 pre-disposing 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

Guidance on Cancer Services