Skin Cancer Pathway Board Constitution 2015

Transcription

1 Skin Cancer Pathway Board Constitution 2015 _Web manchestercancer.org _ _Phone Date f Date for Review: 2017_

2 Contents Measure number Measure title Page 14-1C-101j Network Configuration of MDTs C-102j Network Configuration of Skin Cancer Services in the 7 Community 14-1C-103j Agreed Network Distribution of Clinics for 5 Immunocompromised Patients with Skin Cancer 14-1C-104j Network Group Membership C-105j Network Group Meetings C-106j Work Programme and Annual Report Work Plan & Annual Report 14-1C-107j Designated Hospital Practitioners for Mohs Surgery C-108j Training Policy for Model 2 Community Practitioners with 8 Named Trainers / Assessors 14-1C-109j Clinical Guidelines C-110j Chemotherapy Treatment Algorithms C-111j Patient Pathways for Primary Care/ Community Services 15,17 and MDTs 14-1C-112j Patient Pathways Between MDTs C-113j Patient Pathways for Supranetwork MDTs/Services C-114j Patient Pathways Shared with Other MDTs C-115j Patient Experience Annual report 14-1C-116j Clinical Outcomes Indicators and Audits Annual report 14-1C-117j Clinical Governance Arrangements for Community 8 Practitioners 14-1C-118j Discussion of Clinical Trials Annual report Appendix 1 Patient pathway 19 2

3 1. INTRODUCTION Cancer services in Greater Manchester and East Cheshire changed in 2013/14. The Greater Manchester and Cheshire Cancer Network ceased to exist in March 2013 when cancer networks nationally were amalgamated into strategic clinical networks as part of the NHS reorganisation. In Greater Manchester this coincided with the creation of Manchester Cancer, an integrated cancer system for Greater Manchester and East Cheshire. Twenty Manchester Cancer Pathway Clinical Directors were appointed in late 2013 and took up their roles on 1st January These clinical leaders have formed Pathway Boards, multi-professional clinical groups from across the region. Most Pathway Boards began meeting in spring For the purposes of the National Cancer Peer Review Programme, Manchester Cancer Pathway Boards are taken to be the network group for the relevant tumour type or cancer area. 2. CONFIGURATION 2.1. MDT configuration (14-1C-101j) Local skin cancer teams and contact points Each local skin MDT is the only skin MDT in the host hospital is named as a component of its locality Local skin cancer MDT Lead Clinician / Facilities and Catchment CCGs in catchment teams contact point services population full diagnostic Bolton Dr Corinna Mendonca service for skin conditions Bolton 288,341 East Cheshire Dr Tim Kingston full diagnostic Central & Eastern service for skin Cheshire (E) conditions 203,504 Mid Cheshire Dr Christina Wong full diagnostic Central & Eastern service for skin Cheshire (C) conditions 267,273 full diagnostic Salford 233,966 Salford Dr Rebecca Brooke service for skin Bury 194,675 conditions 60% Manchester (N) 103,963 Mohs Surgery 70% HMR 149,260 Stockport Dr John Newsham full diagnostic service for skin Stockport 298,505 conditions South Manchester* Dr Gavin Wong full diagnostic Manchester (S) 162,603 3

4 Central Manchester* Tameside Wigan Dr Farzana Nyemuddin Dr L Gardner Dr Elizabeth Stewart service for skin conditions full diagnostic service for skin conditions full diagnostic service for skin conditions full diagnostic service for skin conditions Manchester (C) Trafford Tameside & Glossop Oldham 40% Manchester (N) 30% HMR Ashton, Leigh and Wigan 206, , , ,544 69,309 63, ,766 TOTAL 3,269,066 The local skin services at South Manchester and Central Manchester have formed a joint MDT for discussion of patients. The MDT lead clinician is Dr Gavin Wong, Consultant Dermatologist at South Manchester. The named local skin teams will carry out the diagnostic process and surgical treatment for symptomatic patients from their own catchment, referring patients the Specialist Skin MDT for discussion of treatment, or to Christie Hospital for radiotherapy, and for chemotherapy if unable to provide locally Specialist skin team (incorporating the Melanoma MDT) The specialist skin MDT, incorporating the melanoma MDT is the only skin MDT in the host hospital is named as a component of its locality functions as the local skin MDT for its own local secondary referral population has a catchment population of >3million is the only MMDT in the network and takes all referrals for malignant melanoma for level 5 care from the catchment population takes all referrals of malignant melanoma for level 4 care from local catchment population Specialist skin cancer/melanoma team SMDT Lead Clinician Facilities and services Referring MDTs Catchment population Salford Dr Vindy Ghura full diagnostic service for skin conditions Mohs Surgery Bolton, East Cheshire, Mid Cheshire, Salford, Stockport, South Manchester / Trafford / Central Manchester Tameside, Wigan 3,269,066 NB: Patients from Wigan Local Skin MDT are referred to the Specialist Skin MDT and plastic surgeons at Whiston Hospital, St Helens & Knowsley NHS Trust. 4

5 Patients may be referred to Mr Nick Telfer, Mr Vindy Ghura, Mr Vishal Madan, Mohs Surgeons at Salford Royal Hospital NHS Foundation Trust Distribution of clinics for immunocompromised patients (14-1C-103j) The following localities will staff and run clinics for immunocompromised patients with skin cancer: Salford Royal Foundation Trust Central Manchester University Hospital Trust University Hospital of South Manchester The localities mentioned above all host renal / cardiac transplants. Liver transplant recipients are also seen in these clinics Mohs surgery practitioners (14-1C-107j) Patients may be referred to Mr Nick Telfer, Mr Vindy Ghura, Mr Vishal Madan, Mohs Surgeons at Salford Royal Hospital NHS Foundation Trust. The above named surgeons accept referrals from Greater Manchester, Lancashire and South Cumbria Community services Policy for skin cancer services in the community The provision of treatment for skin cancer over the network, if carried out for NHS patients in the community setting, should be drawn only from the following 4 service models only: 1. The service provided under the DES/LES contracting system, under the governance of the CCG 2. Service Model 1: Group 3 GPwSIs trained and competent according to DH Guidance and Competencies for the Provision of Services using GPs with special interests: Dermatology and Skin Surgery 2011, under the governance of the PCT 3. Service Model 2: Registered healthcare professionals, either medically qualified practitioners, registered nurses or surgical care practitioners, all of whom are subject to the constraints given in the rest of this model, under the governance of the acute trust associated with a named skin cancer MDT 4. Service Model 3: Hospital medical specialists, consultant core members of skin cancer MDTs practicing in the community, under the governance of the acute trust via the MDT arrangements 5

6 Model DES / LES Governance Arrangements CCG Governance, according to DES / LES framework Scope of Practice GPs acting within DES / LES NHS statutory framework under minor surgery Excision (or curettage) only of BCCs on the DES/LES list, diagnosed by the practitioners themselves, either de novo of following referral for both diagnosis and management from other practitioners Practitioners acting according to the DES / LES service model should not knowingly excise supposed neoplastic skin lesions of any higher risk than BCCs on the DES / LES list Model 1 Model 2 CCG Governance, according to the DH GPwSI guidance Under Acute Trust Governance, associated with named skin cancer MDT Group 3 GPwSIs (dermatology & skin surgery) or GPwSIs in Skin Lesions Excision (or curettage) only of BCCs on the Model 1 list, diagnosed by the practitioners themselves, either de novo of following referral for both diagnosis and management from other practitioners Practitioners acting according to the DES / LES service model should not knowingly excise supposed neoplastic skin lesions of any higher risk than BCCs on the Model 1 list Medically qualified practitioners, registered nurses or surgical care practitioners, subject to constraints in this model Excision or curettage (as directed by referrers) of any skin cancers (other than procedures listed as hospital only measure?????) but with the provision that they have been previously diagnosed by and have a treatment plan agreed by legitimate referrers Model 3 Under Acute Trust Governance Consultant Core MDT members practicing in the community Boundaries of an MDTs clinical practice outside the hospital setting are not explicitly specified in the measures, but are constrained by: The need for formal case discussion by the MDT for cases at level 4 and above The requirements for certain procedures to all be performed in the same hospital for the whole of an MDTs practice CCGs are free not to commission any community skin cancer service but to rely instead on MDTs working in the hospital setting (Model 4 under acute trust governance) 6

7 Configuration of community skin cancer services (14-1C-102j) The current configuration is as follows: CCG Model Location of Community Facilities MDT / Trust MDT Type Catchment Population Ashton, Model 4 No cases of skin cancer managed or treated in Wigan Local 315,766 Wigan & Leigh the community. All referred to local MDT. Bolton Model 4 No cases of skin cancer managed or treated in Bolton Local 288,341 the community. All referred to local MDT. Salford Model 4 No cases of skin cancer managed or treated in Salford Local & 233,966 the community. All referred to local MDT. Specialist Bury Model 4 Patients seen locally in Bury (Fairfield Hospital) by Salford dermatologist Salford Local & Specialist 194,675 Heywood, Middleton & Rochdale Model 4 70% of 2WW patients are seen in Bury (Fairfield Hospital) by Salford dermatologists. 30% of 2WW patients are seen in Oldham (Royal Oldham Hospital) by Tameside dermatologists Non-2WW patients seen by Dermatology CATS clinics at: Phoenix Centre, Heywood Durnford Med Centre, Middleton Ashworth Street Surgery, Rochdale Oldham Model 4 Patients seen locally in Oldham by Tameside dermatologists. (Royal Oldham Hospital) Any patients seen in primary care / ICATS will be referred to Tameside MDT. Tameside & Glossop Model 4 No cases of skin cancer managed or treated in the community. All referred to local MDT GPs involved in minor surgery required to attend MDT. Salford or Tameside Local 213,229 Tameside Local 238,544 Tameside Local 240,079 Stockport Model 2 GpwSIs Employed by Stockport FT Stockport Local 298,505 Manchester North Model 4 Central Model 4 South Model 2 60% of patients are seen in Bury by Salford dermatologists (Fairfield Hospital) 40% of patients are seen in Oldham by Tameside dermatologists (Royal Oldham Hospital) No cases of skin cancer managed or treated in the community. All referred to local MDT. Salford or Tameside Trafford / Central Manchester / South Manchester Central Manchester / South Manchester East Cheshire Local 173, ,690 GpwSIs Employed by UHSM 162,603 Trafford Model 4 No community service Suspected cancers referred to Central Manchester and University Hospital South Manchester Central & Eastern DES/LES and GpwSI feeding into East Cheshire or Mid Cheshire MDT Local 232,619 Local 203,504 7

8 Cheshire Model 1 Suspected cancers referred to East Cheshire or Mid Cheshire NHS Trust Mid Cheshire Local 267,273 3,269, Governance arrangements for community practitioners (14-1C-117j) Group 3 and skin lesion GPwSIs, and Model 2 practitioners practising in the network should each be associated with a named LSMDT or SSMDT Community skin cancer practitioners should have their practice included in the network audit The MDT lead clinicians should monitor the attendance of any GPwSIs associated with their MDT, at four MDT meetings a year and an annual community practitioners educational Network meeting Group 3 GPwSIs / Model 2 CCG Associated LSMDT LSMDT lead clinician practitioner None at present Manchester (South) UHSM / Central Manchester Dr Gavin Wong / Trafford None at present Stockport Stockport Dr John Newsham The Pathway Board will hold at least one educational meeting per year to which community skin cancer practitioners are invited, and which includes: A presentation of network skin cancer audit results. The audit and the presentation should include a topic involving BCCs, of relevance to practitioners treating them in the community and a breakdown of individual practitioner performance A four hour CPD session on skin lesion recognition including diagnosis and management of low risk BCCs Training policy for model 2 community practitioners (14-1C-108j) The training policy for the network for Model 2 community practitioners includes: Unless they fulfill the exemption conditions (as described in measure 11-1C-113j) practitioners should be trained and assessed in an agreed selection of the skin surgery curriculum and competencies as set out in guidance for the accreditation of General Practitioners with a special interest in dermatology (GPwSIs) and General Practitioners performing skin surgery 2011 The Skin NSSG will, if required in the future, after consultation with MDTs, agree named trainers / assessors of competence for the network for the 8

9 Model 2 practitioners training. They will be either core dermatology or surgical members of each local skin MDT Named Trainer / Assessor MDT Professional Status Dr Gavin Wong UHSM / Central Manchester / Consultant Dermatologist Trafford Dr John Newsham Stockport Consultant Dermatologist 2.5. Manchester Cancer Manchester Cancer covers a population of over 3 million served by the following organisations: Bolton NHS Foundation Trust Central Manchester University Hospitals NHS Foundation Trust East Cheshire NHS Trust Pennine Acute Hospitals NHS Trust (Bury, North Manchester, Oldham, Rochdale) Salford Royal NHS Foundation Trust Stockport NHS Foundation Trust Tameside Hospital NHS Foundation Trust The Christie NHS Foundation Trust University Hospital of South Manchester NHS Foundation Trust Wrightington, Wigan and Leigh NHS Foundation Trust The Christie Hospital is the tertiary referral centre for the region. Radiotherapy is delivered at Christie Hospital and the satellite radiotherapy units based at Royal Oldham Hospital and Salford Royal. Some chemotherapy and clinical trials will continue to be delivered from Christie Hospital, although local chemotherapy is currently available at: Wigan Bolton Oldham East Cheshire Mid Cheshire 2.6. Pathway Board Terms of Reference (14-1C-105j) The Skin Cancer Pathway Board is a multi-professional group chaired by Dr John Lear, a Consultant Dermatologist from Central Manchester University Hospitals NHS Foundation Trust. These are the Board s Terms of Reference. 9

10 These terms of reference were agreed in 2014 with Mr David Shackley, Medical Director of Manchester Cancer, on behalf of the Manchester Cancer Provider Board. The terms of reference will be subject to future review The Pathway Board The Skin Cancer Pathway Board is a cancer care specific board with responsibility to improve cancer outcomes and patient experience for local people across Greater Manchester and areas of Cheshire (a catchment population of 3.2 million). This area is synonymous with the old Greater Manchester and Cheshire Cancer Network area. The Pathway Board is led by a Pathway Clinical Director and is formed of a multidisciplinary team of clinicians and other staff from all of hospital trusts that are involved in the delivery of skin cancer care in Greater Manchester. The Pathway Board also has membership and active participation from primary care and patients representatives. The Skin Cancer Pathway Board reports into and is ultimately governed and held to account by the Manchester Cancer Provider Board Manchester Cancer Provider Board The Manchester Cancer Provider Board is responsible for the service and clinical delivery arm of Manchester Cancer, Greater Manchester s integrated cancer system. Manchester Cancer has two other arms: research and education (see appendix for the structure of Manchester Cancer). The Provider Board is independently chaired and consists of the Chief Executive Officers of the ten acute hospital trusts in the Greater Manchester area: Bolton NHS Foundation Trust Central Manchester University Hospitals NHS Foundation Trust East Cheshire NHS Trust Pennine Acute NHS Trust Salford Royal NHS Foundation Trust Stockport NHS Foundation Trust Tameside Hospital NHS Foundation Trust The Christie NHS Foundation Trust University Hospital of South Manchester NHS Foundation Trust; Wrightington, Wigan and Leigh NHS Foundation Trust; The Provider Board regularly invites representatives of commissioners, the Strategic Clinical Network, and Manchester Cancer to its meetings Purpose of the Pathway Board 10

11 The purpose of the Pathway Board is to improve cancer care for patients on the Greater Manchester skin cancer pathway. Specifically, the Pathway Board aims to save more lives, put patients at the centre of care, and improve patient experience. The Board will represent the interests of local people with cancer, respecting their wider needs and concerns. It is the primary source of clinical opinion on this pathway for the Manchester Cancer Provider Board and Greater Manchester s cancer commissioners. The Pathway Board will gain a robust understanding of the key opportunities to improve outcomes and experience by gathering and reviewing intelligence about the skin cancer pathway. It will ensure that objectives are set, with a supporting work programme that drives improvements in clinical care and patient experience. The Pathway Board will also promote equality of access, choice and quality of care for all patients within Greater Manchester, irrespective of their individual circumstances. The Board will also work with cancer commissioners to provide expert opinion on the design of any commissioning pathways, metrics and specifications Role of the Pathway Board The role of the Skin Cancer Pathway Board is to: Represent the Manchester Cancer professional and patient community for skin cancer. Identify specific opportunities for improving outcomes and patient experience and convert these into agreed objectives and a prioritised programme of work. Gain approval from Greater Manchester s cancer commissioners and the Manchester Cancer Provider Board for the programme of work and provide regular reporting on progress. Design and implement new services for patients where these progress the objectives of commissioners and Manchester Cancer, can be resourced, and have been shown to provide improvements in outcomes that matter to patients. Ensure that diagnosis and treatment guidelines are agreed and followed by all teams in provider trusts, and are annually reviewed. Ensure that all providers working within the pathway collect the pathway dataset measures to a high standard of data quality and that this data is shared transparently amongst the Pathway Board and beyond. Promote and develop research and innovation in the pathway, and have agreed objectives in this area. Monitor performance and improvements in outcomes and patient experience via a pathway scorecard, understanding variation to identify areas for action. 11

12 Escalate any clinical concerns through provider trusts. Highlight any key issues that cannot be resolved within the Pathway Board itself to the Medical Director of Manchester Cancer for assistance. Ensure that decisions, work programmes, and scorecards involve clearly demonstrable patient participation. Share best practices with other Pathway Boards within Manchester Cancer. Contribute to cross-cutting initiatives (e.g. work streams in living with and beyond cancer and early diagnosis). Discuss opportunities for improved education and training related to the pathway and implement new educational initiatives. Develop an annual report of outcomes and patient experience, including an overview of progress, difficulties, peer review data and all relevant key documentation. This report will be published in July of each year and will be the key document for circulation to the Provider Board. A template for this report is available so that all Pathway Boards complete the report in a similar manner Membership principles All member organisations of Manchester Cancer will have at least one representative on the Pathway Board unless they do not wish to be represented. Provider trusts not part of Manchester Cancer can be represented on the Pathway Board if they have links to the Greater Manchester skin cancer pathway. All specialties and professions involved in the delivery of the pathway will be represented. The Board will have at least one patient or carer representative within its membership One professional member of the Pathway Board will act as a Patient Advocate, offering support to the patient and carer representative(s). The Board will have named leads for: Pathology Radiology Surgery Teenagers and young adults Specialist nursing Living with and beyond cancer ( survivorship ) Research 12

13 Data collection (clinical outcomes/experience and research input). It is possible for an individual to hold more than one of these posts. The Pathway Clinical Director is responsible for their fair appointment and holding them to account. These named leads will link with wider Manchester Cancer Boards for these areas where they exist. All members will be expected to attend regular meetings of the Pathway Board to ensure consistency of discussions and decision-making (meeting dates for the whole year will be set annually to allow members to make arrangements for their attendance). A register of attendance will be kept: members should aim to attend at least 5 of the 6 meetings annually and an individual s membership of the Pathway Board will be reviewed in the event of frequent non-attendance. Each member will have a named deputy who will attend on the rare occasions that the member of the Board cannot Frequency of meetings The Skin Cancer Pathway Board will meet every two-three months Quorum Quorum will be the Pathway Clinical Director plus five members of the Pathway Board or their named deputies Communication and engagement Accurate representative minutes will be taken at all meetings and these will be circulated and then validated at the next meeting of the Board. All minutes, circulated papers and associated data outputs will be archived and stored by the Pathway Clinical Director and relevant Pathway Manager. The Pathway Board will design, organise and host at least one open meeting per year for the wider clinical community and local people. This meeting or meetings will include: An annual engagement event to account for its progress against its work programme objectives and to obtain input and feedback from the local professional community An annual educational event for wider pathway professionals and interested others to allow new developments and learning to be disseminated across the system 13

14 Representatives from all sections of the Manchester Cancer professional body will be invited to these events, as well as patient and public representatives and voluntary sector partners. An annual report will be created and circulated to the Medical Director of the Manchester Cancer Provider Board by 31 st July of each calendar year. The agendas, minutes and work programmes of the Pathway Board, as well as copies of papers from educational and engagement events, will be made available to all in an open and transparent manner through the Manchester Cancer website once this has been developed Administrative support Administrative support will be provided by the relevant Pathway Manager with the support of the Manchester Cancer core team. Over the course of a year, an average of one day per week administrative support will be provided Pathway Board membership (14-1C-104j) Andrew Sykes Consultant Clinical Oncologist Christie Chris Duff Consultant Plastic Surgeon UHSM Corinna Mendonca Consultant Dermatologist Bolton David Mowatt Consultant Plastic Surgeon SRFT Deemesh Oudit Consultant Plastic Surgeon Christie Elaine Hodkinson Divisional Manager SRFT Elizabeth Stewart Consultant Dermatologist WWL Gavin Wong Consultant Dermatologist UHSM John Newsham Consultant Dermatologist Stockport Julie Colins Clinical Nurse Specialist UHSM Katie Bailey Dermatology CNS Tameside Loma Gardner Consultant Dermatologist Tameside Louisa Motta Consultant Dermato-Pathologist SRFT Neil Cutler Patient Representative - Nick Telfer Consultant Dermatologist / Mohs Lead SRFT Paul Lorigan Consultant Medical Oncologist Christie Rebecca Brooke Consultant Dermatologist SRFT Sue Taylor Skin Cancer Nurse Specialist WWL Tim Woolford Consultant ENT Surgeon CMFT Timothy Kingston Consultant Dermatologist East Cheshire Vindy Ghura Consultant Dermatologist SRFT Vishal Madan Consultant Dermatologist SRFT 14

15 3. PATHWAYS AND GUIDELINES 3.1. Clinical guidelines (14-1C-109j) Manchester Cancer Pathway Boards have been in place since spring 2014 and are going through the process of reviewing the clinical guidelines and patient pathways inherited from the old cancer network groups. Where they exist, updated guidelines and pathways have been posted to the relevant pages of the Manchester Cancer website Where guidelines and pathways are yet to be reviewed and updated then the legacy documents from the cancer network continue to be current. Where they exist, these legacy documents have also been posted to the relevant pages of the Manchester Cancer website The combined skin cancer legacy clinical guideline can be found at Chemotherapy algorithms (14-1C-110j) All chemotherapy algorithms can be accessed via the intranet of The Christie NHS Foundation Trust. These are live documents: Search for: Policies & Guidelines Sub-category 1: Chemotherapy protocols 3.3. Primary care referral guidelines (14-1C-111j) Actinic keratoses and precancerous lesions may be dealt with by any GP (level 1 care) GPs should refer suspected cases of skin cancer requiring treatment, including BCCs, to the contact point of the relevant named MDTs in the network configuration (as described in measure 11-1A-204j. For cases of low risk BCC there is the option of referral to the contact point of a relevant GP based service Contact points for relevant community services are shown below Guidance for GPs on clinically identifying BCCs in shown below It is inevitable that SCCs and other tumours outside the remit of GPs will be excised accidentally by them, when diagnosis is not clinically apparent. The guidelines are 15

16 Ashton, Wigan & Leigh underpinned by an assumption that GPs will not knowingly treat patients beyond their remit CCG Model Community Facilities Contact Point MDT Model 4 No cases of skin cancer managed or treated in the community. All referred to local MDT. Bolton Model 4 No cases of skin cancer managed or treated in the community. All referred to local MDT. Salford Model 4 No cases of skin cancer managed or treated in the community. All referred to local MDT. Bury Model 4 Patients seen locally in Bury by Salford dermatologist Heywood, Model 4 70% of patients are seen in Bury by Salford Middleton & dermatologists. Rochdale 30% of patients are seen in Oldham by Tameside dermatologists Oldham Model 4 Patients seen locally in Oldham by Tameside dermatologists. Any patients seen in primary care / ICATS will be referred to Tameside MDT. Tameside & Glossop Model 4 GPs involved in minor surgery required to attend MDT. Awaiting NICE guidance to finalise governance for low risk BCCs Wigan Bolton Salford Salford Salford or Tameside Tameside Tameside Stockport Model 2 GpwSIs Employed by Stockport FT Stockport Manchester North Model 4 Central Model 4 South Model 2 60% of patients are seen in Bury by Salford dermatologists. 40% of patients are seen in Oldham by Tameside dermatologists No cases of skin cancer managed or treated in the community. All referred to local MDT. GpwSIs Employed by UHSM Trafford Model 4 No community service Suspected cancers referred to Central Manchester and University Hospital South Manchester Central & Eastern Cheshire DES/LES and Model 1 GpwSI feeding into East Cheshire or Mid Cheshire MDT Suspected cancers referred to East Cheshire or Mid Cheshire NHS Trust Tracey Wright, Cancer Commissioning Manager Salford or Tameside Central Manchester / South Manchester Central Manchester / South Manchester East Cheshire Mid Cheshire Guidance for GPs on clinically identifying potential high risk BCCs (level 2 care) Clinical features of BCCs at high risk of recurrence (any of these): 16

17 Site Size Circumstances Face, scalp, ears 2cm or more Immunocompromised patients Genetically pre-disposed patients (eg Gorlins syndrome) Previously treated lesion Flat lesion, hard thickened skin (appearance of morphoeic BCC) For the purpose of GP referral, low risk BCC is considered to be any BCC, other than those above. Distribution process The above guidance was circulated to all Skin Cancer MDT Clinical Leads, Acute Trust Cancer Managers and Primary care Trust Cancer Managers on 20 June Patient pathways 14-1C-111j See appendix 1 for the skin cancer pathway. For the teenage and young adult cancer pathways developed under the old Greater Manchester and Cheshire Cancer Network see Pathways between teams and for supranetwork MDTs/services (14-1C-112j; 14-1C-113j; 14-1C-114j) All the named local skin cancer MDTs (Bolton; East Cheshire; Mid Cheshire; Salford; Stockport; Tameside; Central Manchester/South Manchester/Trafford) will refer cases of the types of skin cancer needing care level 5 to: Specialist skin cancer MDT based at Salford Royal Foundation Trust Specialist T-cell Lymphoma MDT at Christie Hospital Supra-network sarcoma MDT at Christie Hospital Skin cancer cases needing care level 5 Cutaneous lymphoma Kaposi s Sarcoma Cutaneous sarcoma above superficial fascia Other rare skin cancers Specialist Team Specialist T-cell Lymphoma MDT at Christie Hospital Specialist Skin cancer MDT at Salford Royal Foundation NHS Trust Supra-network sarcoma MDT at Christie Hospital Specialist Skin cancer MDT at Salford Royal Foundation NHS Trust MDT Lead Clinician Dr Richard Cowan Dr John Lear Dr James Wylie Dr John Lear 17

18 Mycosis fungoides (including Sezary syndrome) Mycosis fungoides, stage IA, in addition to lymphomatoid papulosis can be discussed and managed by the Local Skin MDT (LSMDT). If the patient is not referred, the Supra-network T-cell lymphoma MDT (STLMDT) should still be notified so that the histological diagnosis can be confirmed, and that accurate figures of new diagnoses can be recorded. Mycosis fungoides stage IB and above, must be discussed at the local Skin Cancer MDT and referred to the STLMDT as follows: Referrals of Stage IB, IIA and III to be referred to: Dr. Eileen Parry at Salford Royal Hospital (NB; Prognosis of stage III is greater than IIB (ISCL / EORTC updated guidelines, Blood 2008). Stage III patients are considered for photopheresis, which is managed by Dr Parry at Salford. Patients are referred on to Dr Cowan at Christie Hospital if further systemic treatment is needed) Stage IIB and IV to be directed to: Dr. Richard Cowan at the Christie Hospital For mycosis fungoides stage IIB and over, treatment options will include Total Surface Electron Beam Therapy (TSEBT), extracorporeal photopheresis (ECP), Bexarotene, radiotherapy, chemotherapy (oral / intravenous) and clinical trials. TSEBT is performed at the Christie Hospital under Dr Cowan. Requests are made by/via the STLMDT. Photophoresis Cases of erythrodermic cutaneous T-cell lymphoma, stages III & Iva, are suitable for consideration of ECP. All referrals should come via the STLMDT from Salford or Christie, and should be discussed with the clinician in charge of the ECP facility. The named facility for extra corporeal photophoresis is: Manchester Blood Centre, Plymouth Grove, Manchester, M13 9LL. The clinician in charge is: Dr Deepak Sadani. 18

19 Appendix 1 Patient pathway Skin Cancer Pathway 62 day target for patients referred as suspected cancer Day 0 GP Referral By Day 14 First seen Outpatient Appointment: Dermatology Secondary Care Suspected Cancer Clinic Referral to Surgical Specialist (includes plastics, ENT, Maxilo-facial, opthal/oculoplastic and general surgery) Peri-ocular tumour patients should be referred directly to the oculoplastics team at MREH, or if BCC may be referred directly to Mohs Clinic at SRFT Discuss with Patient Biopsy May also be first treatment Minor Ops List By Day 31 Discuss with Patient Decision to Treat Biopsy (May also be first treatment) Minor Ops List Pathology By Day 31 Discuss with Patient Decision to Treat Referral to Surgical Specialists / Oncologists / Other Service Providers Treatment Options: - Surgery - Radiotherapy - Systemic Therapy Agree Treatment with Patient Other treatment without Biopsy Patients diagnosed with SCC in situ, BCC and noncancer patients are stepped off the 62 day pathway By Day 62 Dermatologist Appt for Excision By Day 62 First Definitive Treatment By Day 62 First Definitive Treatment 19