Health care delivery for head-and-neck cancer patients in Alberta: a practice guideline

Practice Guideline

Health care delivery for head-and-neck cancer patients in Alberta: a practice guideline


J.R. Harris , MD MHA * , H. Lau , MD , B.V. Surgeoner , MSc , N. Chua , MD § , W. Dobrovolsky , BSc DDS, J.C. Dort , MD # , E. Kalaydjian , BSc DDS ** , M. Nesbitt * , R.A. Scrimger , MD †† , H. Seikaly , MD * , D. Skarsgard , MD , M.A. Webster , MD ‡‡ , Members of the Alberta Provincial Head and Neck Tumour Team

*Department of Surgery, Division of Otolaryngology–Head and Neck Surgery, University of Alberta, Edmonton, AB.
Department of Oncology, Division of Radiation Oncology, University of Calgary, Calgary, AB.
Guideline Utilization Resource Unit, CancerControl Alberta, Alberta Health Services, Calgary, AB.
§Department of Oncology, University of Alberta, Edmonton, AB.
Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB.
# Department of Surgery, Division of Otolaryngology–Head and Neck Surgery, University of Calgary, Calgary, AB.
** Department of Surgery, Section of Dentistry and Oral Health, Alberta Health Services, Calgary, AB.
†† Department of Oncology, Division of Radiation Oncology, University of Alberta, Edmonton, AB.
‡‡ Department of Oncology, University of Calgary, Calgary, AB.


doi: http://dx.doi.org/10.3747/co.21.1980


ABSTRACT

Background

The treatment of head-and-neck cancer is complex and requires the involvement of various health care professionals with a wide range of expertise. We describe the process of developing a practice guideline with recommendations about the organization and delivery of health care services for head-and-neck cancer patients in Alberta.

Methods

Outcomes of interest included composition of the health care team, qualification requirements for team members, cancer centre and team member volumes, infrastructure needs, and wait times. A search for existing practice guidelines and a systematic review of the literature addressing the organization and delivery of health care services for head-and-neck cancer patients were conducted. The search included the Standards and Guidelines Evidence ( sage ) directory of cancer guidelines and PubMed.

Results

One practice guideline was identified for adaptation. Three additional practice guidelines provided supplementary evidence to inform guideline recommendations. Members of the Alberta Provincial Head and Neck Tumour Team (consisting of various health professionals from across the province) provided expert feedback on the adapted recommendations through an online and in-person review process. Selected experts in head-and-neck cancer from outside the province participated in an external online review.

SUMMARY

The recommendations outlined in this practice guideline are based on existing guidelines that have been modified to fit the Alberta context. Although specific to Alberta, the recommendations lend credence to similar published guidelines and could be considered for use by groups lacking the resources of appointed guideline panels. The recommendations are meant to be a guide rather than a fixed protocol. The implementation of this practice guideline will depend on many factors, including but not limited to availability of trained personnel, adequate funding of infrastructure, and collaboration with other associations of health care professionals in the province.

KEYWORDS: Head-and-neck cancer , health care delivery , practice guideline

1.  BACKGROUND

The treatment of head-and-neck cancer is complex. Significant expertise is required from a range of health care professionals because of the involvement of anatomically diverse structures (soft tissue, bone, skin, and a variety of glands and organs) and because of the vital functions affected by both the cancer and the treatment (breathing, chewing, swallowing, and speech).

Canadian Cancer Statistics 2012 does not report current statistics on the number of reported head-and-neck cancer cases overall. However, statistics concerning the two most frequently diagnosed types of head-and-neck cancer are reported: oral cancer is the most common, with 4000 new cases having been expected in 2012; laryngeal cancer is the next most common, with 1050 expected new cases. Approximately 1540 deaths were expected in 2012 from those two most commonly reported head-and-neck cancers (1150 oral and 390 laryngeal cancer deaths)1.

Several organizations have recognized the need for guidance about the organization and delivery of health care services for patients with head-and-neck cancer. In Canada, Cancer Care Ontario’s Program in Evidence-Based Care published relevant recommendations in 20092. Its recommendations are largely an adaptation of the 2004 recommendations from the then U.K. National Institute for Clinical Excellence (now the National Institute for Health and Care Excellence), which are outlined in the document Improving Outcomes in Head and Neck Cancers. In that document, an extensive synthesis of the literature was translated into specific practice-oriented recommendations3.

The Alberta Provincial Head and Neck Tumour Team includes these tumours types in its mandate: head-and-neck mucosal tumours, salivary gland cancers, tumours extending to the skull base from the head and neck (craniofacial cancers and sinus cancers, among others), major non-melanoma skin cancers (requiring free flap reconstruction, neck dissection, and radiation), and invasive or complex thyroid tumours (requiring laryngectomy, pharyngectomy, or tracheal resection).

Because of the relative rarity of these cancers and the complexity of their management, it is critical to establish guidelines for the allocation of health care resources and for the formation of the multidisciplinary team or teams that are required to care for these patients. The purpose of the present practice guideline is to outline recommendations for the organization and delivery of health care services for head-and-neck cancer patients in Alberta. This document was created to define a set of foundational principles for the systems within which future treatment guidelines for tumour sub-sites (for example, the oral cavity, oropharynx, and so on) can be applied. The specific questions that guided the literature search and development of the practice recommendations were these:

  • What does the health care team treating head-and-neck cancer patients look like?

  • What are the minimum qualifications required by core team members?

  • What are the minimum cancer centre and team member volumes that optimize clinical outcomes?

  • What are the unique infrastructure requirements for team members?

  • What are the acceptable wait times from referral to initiation of curative treatment for head-and-neck cancer patients?

The recommendations outlined in this guideline apply to adults more than 18 years of age with head-and-neck cancer. Different principles might apply to pediatric patients.

2.  METHODS

2.1  Literature Search

A knowledge management specialist from Cancer-Control Alberta and the Guideline Utilization Resource Unit of Alberta Health Services conducted the literature search and synthesis of the evidence. The systematic search was conducted using the sage (Standards and Guidelines Evidence) directory of cancer guidelines, the PubMed electronic database, and reference lists of included publications for the period 2000 to March 2012. In addition, the Web sites of prominent national and international cancer guideline developers—including the American Society of Clinical Oncology, Cancer Care Ontario, the European Society for Medical Oncology, the U.K. National Institute for Health and Clinical Excellence, the U.S. National Comprehensive Cancer Network, the New Zealand Guidelines Group, and the Scottish Intercollegiate Guidelines Network—were also searched. The search used “head and neck neoplasm” and “organization and delivery” as separate or combined terms.

2.2  Synthesis of Evidence

Practice guidelines, systematic reviews, and epidemiologic studies were included for review if they were published in English; considered adult patients with head-and-neck cancer; and reported on members of the treatment team, qualification requirements for team members, cancer centre and team member volumes, infrastructure requirements, and wait times from referral to start of treatment.

Evidence tables are used to present information from relevant publications. The full guideline, including evidence tables, can be found on the Alberta Health Services Web site (http://www.albertahealthservices.ca/hp/if-hp-cancer-guide-hn001-organization.pdf).

2.3  Development of Recommendations

The executive of the Alberta Provincial Head and Neck Tumour Team individually reviewed the results of the literature search as presented in the evidence tables. Based on its review, and in an effort to be efficient by making use of existing guidelines, the executive team decided to adapt Cancer Care Ontario’s organizational recommendations published in its guideline, The Management of Head and Neck Cancer in Ontario. At a face-to-face meeting in April 2012, members of the executive once again reviewed the recommendations and made edits to reflect the Alberta context. All recommendations had 100% consensus.

2.4  Internal and External Review

Draft recommendations were sent electronically to more than 100 health care professionals from relevant health care disciplines within the province, including oncology, surgery, dentistry, pathology, nursing, and allied health. The role of oral and maxillofacial surgery in major head-and-neck cancer care has been poorly defined and a subject of controversy across North America. Thus, oral and maxillofacial surgeons were specifically identified and engaged in guideline discussions to help create mutually agreeable definitions and guidelines. A link to an anonymous online survey was included to collect demographic information, level of agreement, and comments on the recommendations from the reviewers. The response rate was 30%.

Based on survey results, the guideline was revised by members of the executive and sent to three expert reviewers outside the province for further review. Comments provided by the external reviewers were minor and general in nature (for example, “Good work by the group. My comments are quite minor and intended to prompt consideration, nothing else”). Thus, the guideline, with minor changes, was published on the Alberta Health Services Web site.

Since the guideline was first published in August 2012, it has been reviewed by the Alberta Provincial Head and Neck Tumour Team at its annual meeting in October 2012, and it was revised in November 2012, January 2013, April 2013, and May 2013. The guideline now has a scheduled annual review.

3.  RECOMMENDATIONS

The following recommendations are adapted from The Management of Head and Neck Cancer in Ontario: Section 1. Organizational and Clinical Practice Guideline Recommendations 2.

3.1  Question 1: Health Care Team

What does the health care team treating head-and-neck cancer patients look like?

Recommendation:

The health care team will include a core team, a primary care physician, and an extended team. The core team is responsible for assessment, planning, treatment, management, rehabilitation, and survivorship of the patient. The primary care physician (family physician or general practitioner) is not involved in the daily treatment of a head-and-neck cancer patient, but plays an important role in post-treatment supportive care and is responsible for the ongoing overall health of a head-and-neck cancer patient2. The extended team is responsible for supporting the core team to facilitate treatment, planning, management, survivorship, and rehabilitation as needed. All members of the extended team should have training or experience in managing head-and-neck cancer patients. Table i lists the core and extended care team members. Despite delineation of the team members in the next subsection, the complex care that head-and-neck cancer patients require, together with shortages of health care professionals and increasing health care costs, means that health care professionals must be able to work in collaborative practice models to ensure consistent and reliable care.

TABLE I   Core and extended care team members

 

3.2  Question 2: Qualifications

What are the minimum qualifications required by the core team members?

Recommendation:

Credentialing processes pose an inherent risk of excluding highly qualified health care professionals or of implicitly monopolizing care. Some flexibility should be used in the application of specific qualification requirements that assess the competence of health care professionals. Based on the Alberta experience, Table ii, which lists the qualification requirements for each core team member managing patients with head-and-neck cancer, is an excellent starting point for assessing the competency of team members. The qualifications were adapted from Cancer Care Ontario2 and in some instances have been modified and expanded to reflect the practice experience in Alberta.

TABLE II   Minimum qualifications required to care for head-and-neck cancer patients

 

3.3  Question 3: Volumes

What are the minimum cancer centre and team member volumes that optimize clinical outcomes?

Recommendation:

In general, the initial phases of care and the ongoing care of all head-and-neck cancer patients should be concentrated at a high-volume centre with adequate support and expertise to provide the level of interdisciplinary care required for such complex patients. Although the development of centres of excellence is strongly encouraged, innovative collaborations between high-volume and low-volume centres or regions should be expanded and defined to maintain the high quality of care being provided to head-and-neck cancer patients after the initial management phases2. The development of small-volume non-multidisciplinary treatment programs for patients with head-and-neck cancer is strongly discouraged2.

Some population-based studies show a favourable association between volume and outcome, with improved perioperative and long-term survival for procedures performed at high-volume hospitals613. Similarly, lower surgical mortality has been reported for patients treated by high-volume surgeons, which could account for a large proportion of the effect of hospital outcome on surgical mortality14. However, the adoption of volume standards as a surrogate for quality is controversial, and more research is needed to determine the range of cancer care for which a volume–outcome relationship exists. Volumes notwithstanding, if the practice environment is to promote quality improvement, it should foster ongoing development of health care professionals through formal education, mentorship, and peer support.

Currently, no Alberta data are available to directly inform minimum volume thresholds for surgeons and medical and radiation oncologists to ensure high-quality care. Thus, the Alberta Provincial Head and Neck Tumour Team, like Cancer Care Ontario, endorses the volumes recommended by the U.K. National Institute for Health and Care Excellence3. In addition, no data or practice guidelines from Alberta or elsewhere are available to directly inform minimum volumes for specialized oncology nurses, advanced-practice nurses, advanced speech-language pathologists, registered dietitians, and social workers. In some cases, minimum recommended volumes and full-time equivalents have been modified and expanded by the Alberta Provincial Head and Neck Tumour Team to reflect knowledge from practice experience in Alberta (Tables iii and iv ). The minimum recommended volumes and full-time equivalents are both presented as estimates only and can be predicted to change over time as further research becomes available.

TABLE III   Minimum recommended volumes required to care for head-and-neck cancer patients

 

TABLE IV  Minimum recommended full time equivalents ( fte s) to care for head-and-neck cancer patients

 

3.4  Question 4: Infrastructure

What are the unique infrastructure requirements of the team members?

Recommendation:

Table v describes the unique infrastructure requirements agreed upon by members of the Alberta Provincial Head and Neck Tumour Team.

TABLE V  Unique infrastructure requirementsa

 

3.5  Question 5: Wait Times

What are the acceptable wait times from referral to initiation of curative treatment for head-and-neck cancer patients?

Recommendation:

Table vi describes the wait times to care that members of the Alberta Provincial Head and Neck Tumour Team have agreed are acceptable and are consistent with Cancer Care Ontario recommendations.

TABLE VI   Wait times to care

 

4.  SUMMARY

The recommendations outlined in this practice guideline are based on existing guidelines that have been modified to fit the Alberta context. Although specific to Alberta, the recommendations lend credence to similar published guidelines and could be considered for use by groups lacking the resources of appointed guideline panels. The recommendations are meant to be a guide rather than a fixed protocol. The implementation of this practice guideline will depend on many factors, including, but not limited to, availability of trained personnel, adequate funding of infrastructure, and collaboration with other associations of health care professionals in the province.

5.  REVIEW AND UPDATE

Practice guidelines developed by the Alberta Provincial Head and Neck Tumour Team are reviewed on an annual basis—or earlier, if critical new evidence or contextual information is brought to the attention of executive members of the team.

6.  ACKNOWLEDGMENTS

The authors thank the members of the Alberta Provincial Head and Neck Tumour Team for their input into the development of this practice guideline and Dr. Neil Hagen, Executive Director, Provincial Tumour Programs, CancerControl Alberta for supporting the Provincial Head and Neck Tumour Team in the development of this guideline. The Guideline Utilization Resource Unit, CancerControl Alberta and Alberta Health Service, is acknowledged for funding and administrative support. In addition, thanks are extended to the three external reviewers: Dr. George Browman, BC Cancer Agency; Dr. Martin Corsten, University of Ottawa; and Dr. John Kim, University of Toronto.

7.  CONFLICT OF INTEREST DISCLOSURES

The authors have no financial conflicts of interest to declare.

8. REFERENCES

1. Canadian Cancer Society’s Steering Committee on Cancer Statistics. Canadian Cancer Statistics 2012. Toronto, ON: Canadian Cancer Society; 2012. [Available online at: http://www.cancer.ca/~/media/cancer.ca/CW/cancer%20information/cancer%20101/Canadian%20cancer%20statistics/Canadian-Cancer-Statistics-2012---English.pdf; cited April 3, 2013]

2. Gilbert R, Devries–Aboud M, Winquist E, Waldron J, McQuestion M on behalf of the Head and Neck Disease Site Group. The Management of Head and Neck Cancer in Ontario. Evidence-Based Series 5-3. Toronto, ON: Cancer Care Ontario; 2009. [Available online at: https://www.cancercare.on.ca/common/pages/UserFile.aspx?fileId=58592; cited March 9, 2012]

3. United Kingdom, National Institute for Clinical Excellence (nice). Guidance on Cancer Services. Improving Outcomes in Head and Neck Cancers: The Manual. London, U.K.: nice; 2004. [Available online at: http://www.nice.org.uk/nicemedia/live/10897/28851/28851.pdf; cited March 9, 2012]

4. Scottish Intercollegiate Guidelines Network (sign). Diagnosis and Management of Head and Neck Cancer: A National Clinical Guideline. Edinburgh, U.K.: sign; 2006. [Available online at: http://www.sign.ac.uk/pdf/sign90.pdf; cited March 14, 2012]

5. National Comprehensive Cancer Network (nccn). NCCN Clinical Practice Guidelines in Oncology: Head and Neck Cancers. Ver. 2.2011. Fort Washington, PA: nccn; 2011. [Current version available online at: http://www.nccn.com/files/cancer-guidelines/breast/index.html (free registration required); cited August 10, 2012]

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Correspondence to: Jeffrey R. Harris, Otolaryngology–Head and Neck Surgery, and Head and Neck Oncology, University of Alberta, 1E4.29 WC Mackenzie Centre, 8440 112th Street, Edmonton, Alberta T6G 2A1. E-mail: jeffrey.harris@albertahealthservices.ca

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Current Oncology , VOLUME 21 , NUMBER 5 , October 2014








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ISSN: 1198-0052 (Print) ISSN: 1718-7729 (Online)