British Association of Head and Neck Oncologists (BAHNO) standards 2020

1Liverpool Head & Neck Centre, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK 2The Royal Marsden Hospital, London, UK 3Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK 4Portsmouth Hospitals, Portsmouth, UK 5University College London Hospitals NHS Foundation Trust, London, UK 6Manchester Academic Health Sciences Centre (MAHSC), University of Manchester, Manchester, UK 7University Hospitals Bristol & Weston NHS Foundation Trust, Bristol, UK 8Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK 9Oxford University NHS Foundation Trust, Oxford, UK 10The Royal Marsden NHS Foundation Trust, London, UK 11Freeman Hospital, Newcastle Upon Tyne, UK 12Department of Speech, Voice and Swallowing, The Royal Marsden NHS Foundation Trust, London, UK 13Barts Health NHS Trust, London, UK 14Greater Glasgow & Clyde Health Board, Royal Alexandra Hospital and Queen Elizabeth University Hospital, Glasgow, UK 15Guy’s & St Thomas’ NHS Foundation Trust/King’s College London, London, UK 16London North West University Healthcare NHS Trust, London, UK 17Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK

Whilst there are elements of these Standards that might similarly be applicable to units/trusts providing management of sarcomas and/or lymphoproliferative diseases, these tumour types were not specifically considered within the remit of these BAHNO Standards. ALL individuals should be seen by a specialist head and neck nurse/clinical nurse specialist (eg Macmillan nurses in the UK) whose contact details should be made available to the patient at the earliest opportunity.

| Co-ordination of services
ALL centres should have a list of consultants who are designated to provide head and neck cancer care.

| Referral to specialist head and neck cancer services
Referrals should adhere to national and local guidelines. Referrals using the UK "Two-week wait (2WW)" pathway should have sufficient detail to allow for triage into the most appropriate clinic.
Referrals should contain sufficiently detailed information such that pre-referral investigations can be completed if necessary. There should be a secure image transfer system so any accessible lesions (inc. oral cavity) can be assessed. There should be an agreed pathway for a senior clinician to downgrade 2WW referrals if considered benign.
Referral outside the urgent pathway, particularly by routine mail, should be discouraged. However, where unavoidable, the same information is required.
The referral system should be sufficiently robust to support referral from both general medical and dental practitioners.
Referrals should be sent to appropriate specialties: • Hoarseness to ear, nose and throat surgery (ENT) • Oral ulcers/lesions to oral and maxillofacial surgery (OMFS) There should be an awareness and consideration of the national guidance regarding the urgent cancer diagnostic services.

| Information technology
ALL host trusts should provide funding for hardware, software, annual licenses and updates to maintain the services detailed in these Standards.
ALL trusts should also provide adequate administrative support to collect and enter data into regional and national cancer registries.
ALL units to have a named and dedicated IT co-ordinator.
ALL trusts should have strategic plans to introduce IT and pathway solutions capable of continually optimising head and neck cancer pathways (diagnostic and therapeutic).

| Patient information
3.4.1 | Documentation of information provided to individuals and carers following a "significant (bad) news" consultation All individuals should be made aware of their diagnosis unless they make an express wish to the contrary. The subsequent depth of detail provided should be tailored to the individual's requests but must be sufficient to allow the making of informed decisions.

| Information about treatment
Patients should be provided with consistent information and support at diagnosis in line with the NICE service guidance on improving outcomes in head and neck cancer and recommendations of the National Peer Review Programme. Where appropriate, this should include details of disease aetiology (eg information about Human papillomavirus (HPV) to individuals with HPV-associated oropharyngeal squamous cell carcinoma).
Information and support should be tailored to the individual's needs (including the benefits and side effects of treatment, psychosocial and long-term functional issues).
Details of available peer-support services should be made available to patients for all standard treatment pathways-this may be in variable formats (eg written leaflets, brail and electronic) and languages.

| Outpatient facilities
ALL units to have appropriate equipment such that clinical images can be taken and used and shared for disease monitoring and MDT discussion.
It is desirable to have access to narrow band imaging. ALL outpatients should have video screens to support provision of nasendoscopy and rigid endoscopy of the nasal cavity.
There should be facilities for photo-documentation with digital storage.
The following should be available in the head and neck outpatient setting: • A microscope available for aural examinations • Facilities for dental assessments, minor oral surgery (biopsy and dental extractions) and dental radiology, the latter to include the minimum of a dental panoramic tomogram (DPT) but where possible to include access to intra-oral radiographs • Appropriate personal protective equipment (PPE) available as recommended by national guidelines.

| Examination under anaesthesia
There should be facility for ALL individuals to undergo examination under anaesthesia (EUA) where the clinician deems it necessary to make robust therapeutic decisions. A DPT is required as a minimum for all patients prior to undergoing a dental assessment. This assessment should be supported by intra-oral radiographs where necessary.

| Fine-needle aspiration
Provide fine-needle aspiration cytology/core biopsy analysis for ALL individuals with a neck lump that is suspected of being cancer of the upper aerodigestive tract. This should be performed by a specialist radiologist, pathologist or clinician. The biopsy laterality and biopsy site must be documented in ALL instances.
Aim to perform ALL fine-needle aspiration cytology or core sampling under ultrasound guidance. ALL ultrasound-guided fine-needle aspiration cytology should be subject to rapid on-site evolution/assessment (ROSE/ROSA).

| External pathology
In ALL units, capacity should be available to review biopsy specimens of cancer diagnosed in primary or secondary care. Where this deemed necessary, it should be by a specialist head and neck pathologist within the tertiary care setting. Surgical margins must be discussed for ALL patients within the MDT and documentation made of the significance and recommendation for acting on close or involved margins.

| Reporting
ALL surgically resected cases should include all core data set items for head and neck cancer histopathology reporting. There should be at least one named pathologist per centre participating in the national external quality assurance scheme.
ALL incisional biopsies and core biopsies for suspected cancer should be reported within 7 calendar days (confirming or excluding diagnosis of malignancy as a minimum).
Reporting of definitive resection specimens should be reported within 10 calendar days where decalcification is not required.
ALL squamous cell carcinomas of the oropharynx should be tested to determine HPV status.
ALL centres should have access to: • Diagnostic and predictive molecular testing • Histological frozen section facilities for intra-operative diagnosis where units offer surgical treatment.

| Timetabling
ALL individuals should be staged weekly in each unit undertaking head and neck cancer treatment using the current staging (TNM8 at time of publication).
The structure of the multidisciplinary team (MDT) must allow capability for membership of the MDT to participate virtually (eg teleconference/video conference).

| Staffing
It is recommended that, as a minimum, the MDT should consist of the following professionals with specialist interest in head and neck cancer:

| MDT clinic configuration
Facility should be available for both a head and neck surgeon and a head and neck oncologist to undertake joint consultations (particularly where treatment equipoise exists or where support of combined treatment planning is necessary).

| Individual patient discussion
ALL individuals with a new or recurrent head and neck cancer diagnosis should be discussed by an MDT prior to treatment; this discussion should be documented in MDT outcomes.
Where treatment needs to be expedited (prior to or following MDT discussion) there should be an agreed pathway so as to not delay treatment. MDT discussion should still occur and be recorded.

| Treatment planning pathway
The agreed treatment pathway should ideally be formulated at the first MDT for ALL patients.
That agreement must either prescribe definitive treatment OR outline necessary investigations leading to final treatment plan.
The aim of treatment (curative/palliative) should be documented in MDT outcomes for ALL individuals being discussed within that MDT.
In ALL cases, the recommended treatment plan should be communicated to the individual and carers verbally, to the GP in writing.

| Nursing staff
The nurse in charge on each shift should have a specialist qualification in a related discipline and a minimum of 5 years of experience.
Two other nurses on the staff should have, or be preparing for, a specialist qualification in related disciplines.
Nursing staff (including health care assistants) should have competencies associated with altered airway management and major haemorrhage in the head and neck setting.
Nurses should be informed and aware of ongoing clinical research projects, audits and clinical trials.

| Head and neck care
Higher advice at experienced specialist registrar AND consultant level to be available 24 hours a day, every day.

| Other staffing
Named speech and language therapist, dietitian/nutritional nurse specialist, physiotherapist, pharmacist, dental hygienist, psychologist and social worker.
ALL individuals should: • Have access to dedicated inpatient dietetic, physiotherapy, occupational therapy and speech and language/swallowing therapy, clinical nurse specialist. Further detail of their broader roles is provided below. This applies equally to people recovering from surgery and to those admitted with treatment-related toxicities.
Multidisciplinary assessment in line with pre-habilitation and enhanced recovery protocols is to be encouraged in ALL units and for ALL individuals.

| Patient admission
Patients should be provided with proposed treatment dates within national targets/guidelines in ALL cases.
Arrangements should be available for pre-operative assessment prior to admission in ALL units delivering surgical treatment for head and neck cancer.
Comprehensive multidisciplinary discharge planning should be instigated at admission. This might include feeding arrangements, airway/tracheostomy care and mouth care.

| Staffing
The senior nurse should have a specialist qualification in a related discipline.
Staff should include one other nurse with or studying specialist qualification in a related discipline.
Theatre staff should have an adequate skill set to manage the full range of head and neck cancer patients. Specialist ongoing training in head and neck procedures should be available for all members of the theatre staff.

| Anaesthetics
There should be one or more named consultant anaesthetist(s) with advanced expertise in head and neck anaesthesia and complex airway management (inc. jet ventilation, awake fibre-optic intubation).
They should be responsible for directly or indirectly overseeing 100% of major head and neck operations. • Laser instrumentation (suitable for head and neck use).
• Two-headed operating microscope appropriate for microvascular surgery and associated microvascular instruments. This is not an exhaustive list, and other available equipment should include all materials, technologies and resources befitting of a service delivering high-quality care.  • Head and neck oncologist.

| Provision of techniques
Surgeons providing reconstruction for head and neck defects must have a specialist interest in head and neck surgery with prior training and experience.
The range of reconstructive options offered by reconstructive surgeons must be commensurate with the ablative defect and be deemed to be contemporary practice.
Where this is not available, units must be able to offer onward referral, or have documented referral pathways to specialist centres providing such services, ensuring ALL reconstructive options are available for ALL individuals.
ALL units providing this reconstructive service must have systems in place to achieve a timely AND safe return to theatre where necessary, ensuring the appropriate surgical skill mix is available at all times. Provision of a reconstructive service must be supported by a robust microvascular on-call service. ALL units should be prepared to present their outcomes following free flap reconstruction for external peer review.

| Quality
IMRT in ALL cases where critical sparing would not be achievable by 3D conformal radiotherapy planning.
Peer review ALL curative H&N radiotherapy contours before treatment begins.
There should be a minimum of two head and neck clinical oncologists in each unit to provide seamless continuity of service and optimise quality.

| Timing
ALL radical treatments should start within 17 days of the decision to treat with recording of clinically justifiable delays. This pathway should be audited regularly to enable redesign to facilitate improvement.
For radiotherapy delivered with palliative intent, treatment should commence within 14 days of the decision to treat.
All unplanned breaks must be managed according to RCR criteria.
Completion of adjuvant therapy should aim to be within 100 days of commencement of definitive therapy in ALL cases. Extension of this time frame should only be where patient-specific factors dictate this need.

| Regimens
ALL centres to have written protocols for different tumour sites and intents, either produced locally or using national guidelines. These should be reviewed and updated in the light of research trial evidence at least every two years.

| Chemotherapy, monoclonal antibodies and immunotherapy regimens
Evidence-based guidelines for the use of chemoradiotherapy and for palliative systemic therapies should be present in 100% of units.

| Compliance
Any deviation from national protocols needs to be documented and agreed within MDT structures.

| Holistic needs assessment
All patients should be offered a holistic needs assessment at diagnosis, post-treatment and as required thereafter-this allows healthcare professionals to understand needs and signpost to other services as appropriate.
Discharge planning, feeding/airway/community support, etc., should begin prior to admission.

| Dietitian
ALL units should have a named dietitian with at least 50% of time dedicated to head and neck cancer work with specialist knowledge in tube feeding and altered textured diets. ALL Individuals should be nutritionally screened using a validated tool. Those who are malnourished, or at risk of malnutrition, should be referred to the dietitian for early intervention and nutrition support.
ALL individuals who are undergoing treatment likely to significantly impact on their ability to meet their nutritional requirements should be seen by a specialist dietitian for pre-treatment counselling.
The following should be available in ALL units: • A baseline assessment should be conducted to assess nutritional status and discuss the need for nutritional support prior, during or after treatment including NG or gastrostomy (PEG or RIG) and/or including prophylactic placement • As appropriate, the findings of baseline assessments should be made available for discussion at the head and neck MDT to inform treatment planning • Access for ALL individuals to a dietitian as required, for example on-treatment radiotherapy clinics, in the post-operative setting and at outpatient facilities If patients are to be referred on to local services, dietitians and speech and language therapists should be available in a consultancy role to support providers in primary care. ALL patients undergoing ablative treatment that will alter oral and dental function (including risk of osteoradionecrosis) and/ or appearance should also be assessed for dental extractions prior to treatment. Pathways for dental treatment/extractions should be configured so as to avoid delays to definitive cancer treatment.

| Dental/prosthodontic care and rehabilitation
A suitably qualified practitioner should be available to preoperatively assess ALL patients who may require orbital, nasal and auricular prostheses. ALL Units should provide (or have a pathway to facilitate) implant-retained prostheses. The pre-treatment planning for ALL patients requiring extensive resections involving the tooth-baring tissues should involve a suitably trained restorative dentist.

| Physiotherapy
All centres should have pathways for physiotherapy following surgery.
Progressive resistance training for people with impaired shoulder function should be considered as soon as possible after neck dissection.

| Psychological care
Individuals receiving head and neck cancer care should have access to psychology services, in particular a psychologist with a defined head and neck interest (occupying 25% of job plan).
ALL permanent medical, nursing and allied health professional staff should be aware of written protocols and referral routes for psychological support.

| Addiction support and counselling
Smokers should be offered help to stop smoking in line with the NICE guideline on stop smoking interventions and services. ALL individuals and carers should be informed at the point of diagnosis that continuing to smoke will adversely affect outcomes including treatment-related side effects, risk of recurrence and the risk of second primary cancers.
All patients with alcohol dependency and/or drug misuse should be offered local support before treatment. Heavy-use alcohol and drug dependents may need to be hospitalised for several days presurgery to enable safe detox and withdrawal monitoring. For those recognised to be dying (last days of life), an individualised care plan should support care for ALL individuals.

| THYROID CANCER
The clinical management of thyroid cancer is not intended to be NICE guidance is expected to be released in April 2022.

| Principles
ALL patients with thyroid cancer, including those whose cancer is discovered after surgery for apparently benign disease, should be referred for discussion of the patient's management by a thyroid cancer MDT.
The management of thyroid cancer should be the responsibility of the specialist MDT, membership of which will normally be agreed by the regional cancer network and according to the Manual for Head and Neck Cancer services.
Patient-shared decisions are important for a significant number of patients, particularly in areas with no clear evidence base to direct management. This could apply equally to those with low-risk or advanced-stage disease. This may be based on patient views, concerns and willingness to undergo long-term follow-up. All members of the MDT should maintain thyroid-specific continuing professional development.
Patients will normally be seen by one or more members of the MDT; a combined clinic is recommended.

2 | Diagnosis
In many cases, investigation of a neck lump will have a common pathway both in UAT metastasis and in thyroid cancer.
The use of BTA U1-U5 or TIRADS1-5 ultrasound scoring/grading systems is recommended for assessing risk of malignancy and guiding the need for fine-needle aspiration cytology.
As with UAT cancers, fine-needle aspiration biopsy should be carried out by a suitably trained specialist, ideally with ultrasound guidance. This should be offered within a designated neck lump pathway-if possible as a "one-stop" process.
Thyroid cytology should be reported by a cytopathologist with experience in thyroid disease and with access to colleagues with additional experience for second opinions when appropriate. The cytology report should contain a descriptive section interpreting the findings, followed by the "Thy" numerical category as defined by the Royal College of Pathologists.

3 | Treatment
In the UK, thyroid surgery is carried out by many specialties (ear nose and throat surgery, endocrine surgery, oral and maxillofacial surgery, general surgery). ALL surgeons must have training and expertise in the management of thyroid cancer and be a core member of the multidisciplinary team (MDT) managing thyroid cancer.
It is expected that ALL surgeons involved in the care of patients with thyroid cancer submit their data to an approved audit, Information on ALL patients diagnosed and treated for thyroid cancer should be collected using approved local cancer network or national databases. Outcomes should be subject to regular audit.

| Clinical trials
There should be a named clinical lead and nurse practitioner for head and neck research.  c. ALL individuals to be seen by specialist head and neck dietitian at least once a week during radiotherapy treatment (>60gy) and as required for rehabilitation d. ALL individuals to be seen by specialist head and neck dietitian pre-treatment.

| Governance and clinical audit
• Head and neck nursing and holistic care a. ALL patients should see a CNS at the time of diagnosis.
b. ALL patients should be offered an holistic needs assessment at diagnosis, following treatment and at any other significant time during their cancer journey. c. ALL patients should have access to psychological support.
• Restorative dentistry a. ALL patients should receive a dental assessment (including DPT) prior to and after any treatment that impacts upon the oral cavity.
b. ALL dentate patients shall be prescribed high concentration fluoride unless otherwise contraindicated.
c. ALL patients should receive oral hygiene instruction by a suitably trained member of the dental team.
• Palliative care a. ALL expected inpatient deaths should be reviewed as to whether care in the last days of life was supported with an individualised care plan.