1. Squamous cell carcinoma pathway update
University Hospitals Bristol NHS Foundation Trust
Dermatology Service
Dr Adam Bray
Consultant Dermatologist
MDT Lead

2. Problems to address: focussing on SCC:
Lack of FU capacity leading to delays in high risk skin cancer patient pathways
MDT meeting inefficient for all attendees
Meeting can be shortened by not discussing all SCC but risks poor staging/recording which may affect case selection for future trials and national data
Causes:
Increasing demand:
UK skin cancer rates doubling every 10 years
Ageing population
Centralisation of skin cancer treatment due to closing DGH units
Poor staging and risk stratification of new SCC cases at MDT
SCC forms much of demand but no standard national guidance for FU schedules (and guidance out of date)

3. Solution: Created new SCC protocols for MDT meeting
Algorithm constructed following recent:
Audit of 5yrs Bristol SCC recurrences (characteristics of tumours and presentation)
Review of literature and recent AJCC 8 staging changes
Risk stratification by MDT coordinator+CNS pre-meeting using agreed algorithm
Facilitates easy staging
Assigns each case into risk group (Very high, High, Low)
Uses available data to establish recurrence risk group from:
Established tumour risk factors from pathology report
Host immunity or genetic predisposition (from electronic surgical booking form)
Special patient needs (from electronic surgical booking form; e.g. unsuitable for group session)
Last 2 meetings would have saved about 1 patient year 1 of fu ie 3 appointments whilst increasing fu for highest risk from 2-3yrs and adding group sessions for all
Currently low risk group only but will be for all risk groups post face to face

4. Example section of SCC management algorithm

5. Pre-filled MDT outcomes
Enter standardised outcomes into SCR comments box pre-meeting based on risk group:
Procedure done and anatomical site
Tumour and host characteristics summary
Highlighting high risk factors
Clinical stage by AJCC8
Discussion required Y/N (If case is standard no discussion is required as management is determined by standard protocol)
How patient will receive results and timescale
Any further treatment to be offered based on narrow margins
Clinic FU schedule planned and duration
Group education session to be offered and timescale
Person to action any test ordering or additional communication
Name of Consultant responsible

6. Solution: Created new SCC protocols for MDT meeting
Outcomes for non-discussion cases checked by clinical staff pre-main meeting & published on MDT case list for all to review:
Minimises discussions in meeting
Discussion focussed on very high risk and positive or close margins
Identify patients with higher need for face-to-face results or 1:1
Improve staging and cancer registration
Group patient education sessions reduces FU appointments
See next slide
Last 2 meetings would have saved about 1 patient year 1 of fu ie 3 appointments whilst increasing fu for highest risk from 2-3yrs and adding group sessions for all
Currently low risk group only but will be for all risk groups post face to face

7. Group FU sessions Patient education for all patients
Groups of up to 20 patients
Standardised powerpoint presentation with recorded audio
Can be supervised by 1xCNS or even non-clinical staff with CNS at the end to take questions
Reduce number and duration of 1:1 FU appointments
Currently established for old low risk group then discharged
Feedback excellent
Next to roll out to higher risk groups before ongoing FU as well
Sessions cover:
Diagnosis
Sun-protection
Self-monitoring for tumour recurrence:
local
lymph nodes
Self-monitoring for new tumours:
Another SCC
BCC
Melanoma
What to do if something found

8. Proposed aims and rationale
Changes should achieve all stated aims:
Stratify risk more accurately
Improve MDT efficiency and data recording
Target FU on those most likely to benefit
Maximise patient self-management
Reduce burden on secondary care
Reduce or not increase burden on primary care
Unknown impact but probably no substantial change
Possibly modest increase in patients attending for new lesion referral who would have previously been under hospital FU
Possibly modest decrease in patients asking for lesion or self- monitoring advice from GP

9. Measuring impact Just introduced this week
So will be auditing the impact over next few months on:
Duration of MDT
Perceived quality of discussions and boredom levels
FU appts reduction
Errors not picked up in the meeting