NICE issues guidance to improve healthcare services for skin cancers

  The National Institute for Health and Clinical Excellence (NICE) and the National Collaborating Centre for Cancer (NCCC) have issued guidance for the NHS in England and Wales on how healthcare services should be provided for adults, children and young people with skin tumours, including melanoma.  The guidance, which is the seventh in the Institute’s series on cancer services, provides advice to those who develop and deliver cancer services on the planning, commissioning and configuration of those services.

Skin cancers are, for the most part, curable, but the fact that their incidence has increased so rapidly has placed particular pressures on the services responsible for managing and treating people with these cancers. This guidance, which is based on a service model involving cancer networks as the vehicle for delivery of the NHS Cancer Plan, recommends that these networks should establish multidisciplinary teams for the provision of skin cancer care which for the first time brings community services into the system. This will ensure that the care provided to patients is tailored appropriately to the level of risk that their condition poses, and that NHS resources are used in the most effective way.

There are many types of skin cancer but the three most common (basal cell carcinoma [BCC] – a slow developing cancer of the epidermis that usually occurs on the face); squamous cell carcinoma [SCC] – a cancer of the outermost layer of skin cells; and malignant melanoma [MM]) account for more than 95% of all skin cancers. There are many other types of skin cancer that occur less commonly – such as skin lymphomas and skin sarcomas – and the NICE guidance also provides information about the treatment and care that people with these rarer cancers should be offered. Treatments for precancerous lesions and skin cancers are usually relatively simple, involving the removal or destruction of the lesion. However, some patients require extensive, longer-term treatment which may involve specialist care and treatment in hospital.

Key recommendations in the guidance include:

• Cancer networks should establish two levels of multidisciplinary teams – local hospital skin cancer multidisciplinary teams (LSMDTs) and specialist skin cancer multidisciplinary teams (SSMDTs). All health professionals who knowingly treat patients with any type of skin cancer should be members of one of these teams, whether they work in the community or in the hospital setting.
• People with precancerous skin lesions may be treated entirely by their GP or referred for diagnosis, treatment and follow-up to doctors working in the community who are members of the LSMDT/SSMDT. If there is any doubt about the diagnosis, people with precancerous lesions should be referred directly to their local hospital skin cancer specialist – normally a dermatologist, who is a member of the LSMDT/SSMDT.
• Patients with low-risk BCCs should be diagnosed, treated and followed-up by doctors – either a GP with a special interest (GPwSI), working in the community as part of the LSMDT/SSMDT, or a local hospital skin cancer specialist, normally a dermatologist, who is a member of the LSMDT/SSMDT and to whom they have been directly referred. Where there is doubt about the lesion being low or high grade, the patient should be referred directly to the LSMDT/SSMDT.
• All patients with a suspicious pigmented skin lesion, with a skin lesion that may be a high-risk BCC, a SCC or a MM, a rare tumour, or where the diagnosis is uncertain, should be referred to a doctor trained in the specialist diagnosis of skin malignancy, normally a dermatologist, who is a member of either an LSMDT or an SSMDT.

The incidence of all types of skin cancer has more than doubled over the past decade, as a result of social changes including increased UV light exposure from both sun and artificial sources. Skin cancers now constitute the most common group of cancers in the UK with approximately 60,000 registered cases in England and Wales each year, representing 20% of all cancer registrations. However, because of differing practices for registering skin cancers across England and Wales, it is unlikely that this figure represents an accurate picture of new cases each year - one estimate suggests that the true incidence of BCC and SCC could be as high as 125,000 new cases each year.

Dr Julia Verne, Consultant in Public Health Medicine and Chair of the Guideline Development Group, said: “The numbers of new cases of skin cancer diagnosed continue to rise year on year. It is important that wherever people are diagnosed and treated that they have access to the same high quality standard of care from trained professionals. This guidance should ensure improved standards of care for skin cancer patients across England and Wales and that the development of these services is patient focused.

Dr Dafydd Roberts, Consultant Dermatologist and Lead Clinician on the Guideline Development Group, said: “We believe that patients with skin cancer will benefit from the sort of teamworking described in this guidance, with doctors from primary care and different specialists from secondary care working closely together to ensure that each individual patient receives the optimum care for their condition.”

Mr James Smallwood, Consultant Surgeon and member of the Guideline Development Group, said: “The NICE Guidance for skin tumours has recognised the importance of including all skin cancers in a governance framework that recognises the importance of primary care but also the need for specialist multidisciplinary review of the serious cancers.”

Gillian Godsell, Skin Cancer Clinical Nurse Specialist and member of the Guideline Development Group, said: “This guidance will mean that all health professionals seeing patients with skin cancer will be part of a specialist skin cancer team. This will ensure that all those with suspected or confirmed skin cancer are seen by the right person, in the right place at the right time, thus reducing the so called "post-code lottery.”

Professor Julia Newton-Bishop, Consultant Dermatologist and member of the Guideline Development Group, said: “This guidance is intended to help the NHS move towards better, more cohesive care for skin cancer patients. The incidence of melanoma continues to increase in the UK and it is therefore important that our approaches to management are more streamlined. The prognosis of patients with melanoma is improved by early and prompt treatment and this guidance is directed towards promoting this.”

Marion Stevenson-Rouse, patient cancer representative on the Guideline Development Group, said:” At present the service for patients with skin cancer is often fragmented and many patients are managed by healthcare professionals who do not have a special interest in skin cancer. The NICE guidance, by recommending that care should be consolidated into the hands of trained personnel working in approved teams and to agreed protocols should ensure that every patient receives appropriate treatment. This should result in better outcomes for patients. The early detection and prevention of skin cancer were not within the scope of this guidance. However, evidence suggests that in the long term the most effective way to reduce the impact of skin cancer on the population and the NHS will be through reduction of exposure to ultraviolet (UV) radiation, combined with increased awareness of the signs and symptoms of cancer.”

About this guidance

1. ‘Improving outcomes for people with skin tumours including melanoma (guidance on cancer services)’ can be found on the NICE website at www.nice.org.uk/csgstim

  2. Cancer service guidance supports the implementation of The NHS Cancer Plan for England , and the NHS Plan for Wales Improving Health in Wales . The service guidance programme was initiated in 1995 to follow on from the Calman-Hine Report, A Policy Framework for Commissioning Cancer Services. The focus of the cancer service guidance is to guide the commissioning of services and is therefore different from clinical practice guidelines. Health services in England and Wales have organisational arrangements in place for securing improvements in cancer services and those responsible for their operation should take this guidance into account when planning, commissioning and organising services for cancer patients. The recommendations in the guidance concentrate on aspects of services that are likely to have significant impact on health outcomes. Both the objectives and resource implications of implementing the recommendations are considered. This guidance can be used to identify gaps in local provision and to check the appropriateness of existing services.
 

New NICE guideline will help tackle the problem of malnutrition in the NHS 

The National Institute for Health and Clinical Excellence (NICE) and the National Collaborating Centre for Acute Care    have today (22 February 2006) launched a clinical guideline to help the NHS identify patients who are malnourished or  at risk of malnutrition. The guideline sets out the appropriate nutrition support that these people should                        receive.                                                                                                                                                               

The guideline recommends that                                                                                                                             

• All hospital inpatients on admission and all outpatients at their first clinic appointment should be screened        (weighed, measured and have Body Mass Index (BMI) calculated). Screening should be repeated weekly for      inpatients and when there is clinical concern for outpatients. People in care homes should be screened on        admission and when there is clinical concern.                                                                                              

• Nutrition support should be considered in people who are malnourished, as defined by a BMI of less than      18.5; unintentional weight loss greater than 10% within the last 3–6 months; or a BMI of less than 20 and          unintentional weight loss greater than 5% within the last 3–6 months.                                                            

• Nutrition support should be considered in people at risk of malnutrition, as defined by having eaten little or      nothing for more than 5 days and/or are likely to eat little or nothing for the next 5 days or longer; who are          unable to take in nutrients properly, and/or who have increased nutritional needs.                                            

• All acute hospital trusts should employ at least one specialist nutrition support nurse and establish a nutrition   steering committee.                                                                                                                                   

• All healthcare professionals who are directly involved in patient care should receive education and training,         relevant to their post, on the importance of providing adequate nutrition.                                                          

Andrea Sutcliffe , Deputy Chief Executive of NICE and Executive Lead for this guideline says: “ This guideline should help reassure patients and give confidence to their relatives and carers, that all at risk patients, no matter         where they live or what their underlying condition, will now be screened and if necessary offered appropriate nutritional  support. The recommendations to improve the organisation of care are also important, as they will go a long way to      ensuring that good nutrition, both in terms of hospital food and nutrition support is better organised and more               effectively delivered.   While some recommendations will increase costs for the health service in the short term, in the  long run the improvement in the quality of care for patients will mean health service resources are used more               effectively and savings will be achieved. ”                                                                                                               

Dr Mike Stroud of the Institute of Human Nutrition, University of Southampton and Chair of the Guideline     Development Group says: “Ensuring patients receive adequate nutrition is an essential part of basic patient care,      yet we know malnutrition is still a big problem for the NHS. The guideline contains one obvious and simple message -  Do not let your patients starve and when you offer them nutrition support, do so by the safest, simplest most effective route.’ By recommending a widespread programme of screening and nutrition support, this guidance is likely to make   a real difference and save lives.”                                                                                                                            

Joanna Prickett, Chief Dietitian, North Bristol NHS Trust and British Dietetic Association representative on    the Guideline Development Group says: “Malnutrition is very common. Within the population as a whole it affects   less than 5% however amongst hospital inpatients and those in care homes, as many as 40% could be suffering from  malnutrition. More than 10% of over 65’s in the general population are at medium or high risk of malnutrition and this    figure rises to as much as 60% amongst those in hospital.”                                                                                     

Professor Paul Little, Professor of Primary Care Research, University of Southampton and Royal College of  General Practitioners representative on the guideline development group says: “GP’s and others in primary     care see the vast majority of patients who are malnourished, but often do not think of malnutrition during clinical           management. Malnutrition is serious problem - the consequences include vulnerability to infection, delayed wound       healing, impaired function of heart and lungs, decreased muscle strength and depression.   This guideline will raise the profile of malnutrition and its management in primary care, and also highlight the need for more research.”                  

Carolyn Wheatley, Chair of Patients on Intravenous and Nasogastric Nutrition Therapy (PINNT) and Patient  Representative on the Guideline Development Group says: “ Choosing the most effective and safest route for      nutrition support is essential, yet current knowledge of nutrition support amongst most UK health professionals is        poor. The objective of these guidelines is to improve the practice of nutrition support by providing evidence and             information for all healthcare professionals, patients and their carers so that malnutrition, whether in hospital or in the   community, is recognized and treated by the best form of nutrition support at the appropriate time.”                            

                                                                                                                                                                                       (22/2/06)