Consensus standards for the process of cancer care: a modified expert panel method applied to head and neck cancer. South and West Expert Tumour Panel for Head and Neck Cancer

Smoking influences the immunological architecture of the human larynx

Little is known about the effects of demographic and lifestyle factors on laryngeal mucosal immunology. Pinch biopsies of laryngeal mucosa were studied from 63 patients without laryngeal disease. Areas of positive staining for HLA-DR, HLA-DQ, HLA-DP, CD45, CD45RA, CD45RO, CD4, CD8, and CD79 were calculated. Patients were stratified according to gender and smoking status. Analysis of covariance showed current cigarette smokers had increased numbers of CD4+ T cells and there was an association between older age and greater CD4+ T cell numbers in both epithelium and lamina propria. Older age and female gender were associated with decreased lamina propria CD4+ CD45RO+ T cells and an increase in CD4+ CD45RO- T cells. T cell populations in the larynx may therefore be influenced by smoking, age and gender. We hypothesize that smoking induces changes in normal immunological function of the larynx, which may contribute to the etiology of inflammatory disease and cancer.

Effect of process standards on survival of patients with head and neck cancer in the south and west of England

The aim of the study was to compare standards for the process of care and 2-year survival between two cohorts of patients with head and neck cancer in the south and west of England. A total of 566 and 727 patients presented in 1996–97 and 1999–2000, respectively. The median number of cases treated per surgeon was 4 (1997, range 1–26) and 4 (2000, 1–23) and per radiotherapist was 10 (1–51) and 19 (1–70). For all ‘nontemporal’ standards, the overall standard increased, without reaching minimum high targets, while most ‘waiting times’ increased. Overall 2-year survival was 64.1% in 1997 and 65.1% in 2000. There was no difference in survival between networks (range 56–68, 1997, log-rank test 4.1, P=0.4; 62–69, 2000, log-rank test 1.26, P=0.69). Patients assessed by a multidisciplinary clinic exhibited improved survival (1997: P=0.1; 2000: hazard ratio 0.7, P=0.02), as did those with a pretreatment chest X-ray (hazard ratio 0.7, P=0.03). Despite an increased incidence, standards for the process of care for patients with head and neck cancer improved between 1996 and 2000, while waiting times increased and 2-year survival rates remained unaltered. Two out of five networks demonstrated centralisation of services between audits. Being seen in a multidisciplinary clinic correlated strongly with patient survival.

Providing cancer services to remote and rural areas: consensus study

There is controversy about how cancer care should be provided to patients in remote and rural areas. The aim of this project was to measure consensus among health professionals who treat rural patients with cancer about priorities for cancer care. A modified Delphi process was used. Of 78 health professionals in Grampian, 62 responded (79%). Of 49 items suggested, there was agreement on 26 (53%), encompassing fast access to diagnosis, high-quality specialist treatment, and well-coordinated delivery of care with good and fast communication and effective team working between all health professionals involved. Specialist oncology nurses in local hospitals were considered a priority along with good facilities, accommodation, and transport for patients. There was no agreement on the best location for chemotherapy (local or central). The only large difference of opinion between participants based in primary and secondary care concerned chemotherapy provision at local community hospitals (primary care was in favour, hospital practitioners against, P&<0.001). In making their decisions, participants took problems of access into account, but were also concerned with quality of care and feasibility in the current health service. Our findings show that more evidence is needed regarding the balance of risks and benefits of local chemotherapy provision. Overall, however, there is agreement on many principles for cancer care that could be translated into practice.

Eliciting views of patients with head and neck cancer and carers on professionally derived standards for care

OBJECTIVES

To examine views of patients and carers on the process of care for people with head and neck cancer; to assess whether focus groups are useful in this setting; to compare priorities and standards identified with those published by healthcare professionals; and to incorporate the expressed views into existing national standards.

DESIGN

Multicentre study of nine regional focus groups.

SETTING

Area covered by two regional health authorities.

PARTICIPANTS

40 patients who had had head and neck cancer and 18 carers.

MAIN OUTCOME MEASURES

Views of individuals and groups on standards. Applicability of the method for patients whose appearance and ability to communicate was altered and for recently bereaved carers. Ease of incorporation of views into national and regional standards.

RESULTS

Patients and carers participated in discussions on all the principal questions. Opinions were expressed on waiting times, information available to patients, coordination of care, and crisis management. Professionally derived standards were substantially improved by the incorporation of the views of patients and carers. There were no technical problems in carrying out this study on patients with communication difficulties or altered appearance nor with recently bereaved carers. Occasionally, participants said that the meetings were therapeutic.

CONCLUSIONS

Professionally facilitated and analysed focus groups are effective in assessing views of patients with cancer and carers on professionally derived standards for care and can be applied in settings traditionally viewed as difficult. Views expressed by patients and carers are powerful motivators for change in the delivery of cancer care.

Provision and quality assurance for head and neck cancer care

In 1998, the British Association of Head and Neck Oncologists (BAHNO) published a report entitled 'Provision and quality assurance for head and neck cancer care in the United Kingdom. A nationally co-ordinated multidisciplinary approach'. This document considered, amongst other issues, operational policies for patient care. We audited three aspects of the care of 73 patients with head and neck cancer from initial referral to definitive treatment against standards set out in this report.Fifty-nine patients (81%) were seen within two weeks of initial referral, the maximum interval proposed by the BAHNO report. In 41 patients (56%), the diagnosis was confirmed and their treatment plan determined within the further two-week period suggested in the report. Of the 25 patients who required adjuvant radiotherapy, only 11 (44%) began treatment within six weeks of their surgical phase; this represented the greatest variance from the BAHNO recommendations. These findings highlight the need for units active in the treatment of specific diseases to audit their activity against available minimum standards in an attempt to improve the quality of patient care.

Performance and standards for the process of head and neck cancer care: South and West audit of head and neck cancer 1996-1997 (SWAHN I). South and West Regional Cancer Organisation Tumour Panel for Head and Neck Cancer

Evidence suggests wide variation in cancer care between different hospitals in the UK. To establish bench-marking data, we designed a prospective, 1 year regional study comparing key performance measures with established standards for the 28 hospital Trusts in the South and West of England involved in head and neck cancer care. 566 sequential patients with a newly-diagnosed head and neck cancer were included. Numbers referred and treated per hospital Trust were 1-58 and 1-65 respectively. 59% of patients received a pretreatment chest X-ray (standard 95%). 45% of patients were seen in a multidisciplinary clinic pretreatment (standard 95%), and this was proportional to the frequency of clinics held (P<0.0001). Median number of cases treated per surgeon was 4 (1-26), and by radiotherapist was 10 (1-51). Times between parts of the process of oral cancer care were closer to the standards than those for laryngeal cancer. Two patients were entered into a clinical trial. One had a quality-of-life score. Thus, in 1996-1997, in the South and West of England, there were major discrepancies between actual performance and established standards in many fundamental aspects of head and neck cancer care. Re-audit is essential to determine if the implementation of the Calman-Hine report has resulted in improvements.