SCC at “Tricky Sites” AuditAudit and quality control study of squamous cell carcinoma excised from scalp, nose, dorsum of hand with narrow deep margin (<1mm), and SCC with perineural or lymphovascular

involvement with <1mm any margin clearance at all body sites

Dr Joanna Fawcett Dr Jonathan Wordsworth

Dr David de Berker

At skin cancer MDT a group of lesions with narrow margins (<1mm) of excision cause debate:◦ Limited subcutaneous tissue of the:

Elderly scalp Dorsum of the nose Dorsum of the hand

◦ Perineural or lymphovascular involvement

Background

At skin cancer MDT a group of lesions with narrow margins (<1mm) of excision cause debate:◦ Limited subcut. Tissue of the:

Elderly scalp Dorsum of the nose Dorsum of the hand

◦ Perineural or lymphovascular involvement

Patients diagnosed Jan 2009-2010

Background

1. Qualifying tumours will have a management plan arising from the MDT (NICE IOG Guidance 2006)

2. There is evidence in the clinical notes that the MDT management plan was discussed/communicated with the patient or other responsible person

(NICE IOG Guidance 2006)

3. A follow up plan was determined by the MDT (NICE IOG Guidance 2006)

4. The follow up plan was within SSG guideline (SSG management of SSC guideline)

5. There is evidence in the clinical notes that the MDT follow up plan was undertaken(NICE IOG Guidance 2006)

6. The outcome at 5 years post treatment will be documented in the hospital record(Provisional)

Standards (target 100%)

Trusts involved in audit◦ UHBristol◦ NBT◦ RUH (results pending)◦ Taunton◦ Gloucester◦ Yeovil

also◦ Royal Devon and Exeter◦ North Devon and Barnstaple

Casenote review

Total number of patients:101

Sample

Average age: 81 Age range: 41-97

Results: Epidemiology

7%5%

10%

37%

41%

Percentage of patients with co-morbidites

Dementia Warfarin ImmunesuppressionPacemaker Other No comorbidities

76%

24%

Sex distributionMale Female

Results

46%

22%

11%

16%

6%

Location of SCCs

Scalp Back of hand or foot

Nose Other head and neck

Other body

1. Qualifying tumours will have a management plan arising from the MDT (NICE IOG Guidance 2006)

2. There is evidence in the clinical notes that the MDT management plan was discussed/communicated with the patient or other responsible person

(NICE IOG Guidance 2006)

3. A follow up plan was determined by the MDT (NICE IOG Guidance 2006)

4. The follow up plan was within SSG guideline (SSG management of SSC guideline)

5. There is evidence in the clinical notes that the MDT follow up plan was undertaken(NICE IOG Guidance 2006)

6. The outcome at 5 years post treatment will be documented in the hospital record(Provisional)

Standards (target 100%)

Results: Standard 1

98%

2%

“Qualifying tumours will have a management plan arising from the MDT “

(NICE IOG Guidance 2006)Yes No

Results: Standard 2

13%

23%

65%

“There is evidence in the clinical notes that the MDT management plan was discussed/communicated with the patient or other re-

sponsible person” (NICE IOG Guidance 2006)

No evidence Letter to patient Appointment with patient Other

Results: Standard 3

61%

34%

5%

“A follow up plan was determined by the MDT” (NICE IOG Guidance 2006)

Yes No No information

Results – Analysis by site

Results: Standard 4

46%

26%

27%

“The follow up plan was within SSG guideline” (SSG management of SSC guideline)

Yes No No information

Results: Standard 5

62%

38%

“There is evidence in the clinical notes that the MDT follow up plan was undertaken”

(NICE IOG Guidance 2006)

Yes No

Results: Standard 6

36%

51%

13%

“The outcome at 5 years post treatment will be documented in the hospital record”(Provisional guidance)

Yes No No information

1. Qualifying tumours will have a management plan arising from the MDT 98%(NICE IOG Guidance 2006)

2. There is evidence in the clinical notes that the MDT management plan was discussed/communicated with the patient or other responsible person 88%

(NICE IOG Guidance 2006)

3. A follow up plan was determined by the MDT 61%(NICE IOG Guidance 2006)

4. The follow up plan was within SSG guideline 46%(SSG management of SSC guideline)

5. There is evidence in the clinical notes that the MDT follow up plan was undertaken62%

(NICE IOG Guidance 2006)

6. The outcome at 5 years post treatment will be documented in the hospital record36%

(Provisional)

Standards (target 100%)

Results: OutcomesOutcome at 5 years

11%

70%

19%

Outcome at 5 yearsRecurrence No recurrence No information

Results: Outcomes

Nose Back of hand or foot Scalp Other head and neck Other body0.00

10.00

20.00

30.00

40.00

50.00

60.00

70.00

80.00

90.00

Recurrence of SCC by location

Perc

enta

ge o

f SCC

s

3

0 0

18

4 9

30

72

12

2

0

3 3

∎ Recurrence

∎ No recurrence

∎ No information8

Results: Histological features

Results – Analysis by site

Results: Management decisions

Results – Analysis by site∎ Offered monitoring

∎ Offered excision

∎ Offered radiotherapy

1. Qualifying tumours will have a management plan arising from the MDT 98%(NICE IOG Guidance 2006)

2. There is evidence in the clinical notes that the MDT management plan was discussed/communicated with the patient or other responsible person 88%

(NICE IOG Guidance 2006)

3. A follow up plan was determined by the MDT 61%(NICE IOG Guidance 2006)

4. The follow up plan was within SSG guideline 46%(SSG management of SSC guideline)

5. There is evidence in the clinical notes that the MDT follow up plan was undertaken62%

(NICE IOG Guidance 2006)

6. The outcome at 5 years post treatment will be documented in the hospital record36%

(Provisional)

Standards (target 100%)

Approximately 11% recurrence rate

All recurrences from scalp or head and neck

? Relevance of peripheral margins

Conclusions

Action plan

David de Berker Jonathan

Wordsworth Julia Griffith Sally Hawkins Jessica Painter Trudy Gale Helen Dunderdale

Chris Bower Noel Au-Yeung Mihaela Savu Karen Davies Rachel Wachsmuth Amrit Darvay Anita Takwale Penny Williams Jill Adams

Thanks to…