Quality statement 3 (developmental): Sentinel lymph node biopsy

Developmental quality statements set out an emergent area of cutting-edge service delivery or technology currently found in a minority of providers and indicating outstanding performance. They will need specific, significant changes to be put in place, such as redesign of services or new equipment.

Quality statement

People with early stage oral cavity cancer who do not need cervical access as part of surgical management are offered sentinel lymph node biopsy as an alternative to elective neck dissection.

Rationale

Sentinel lymph node biopsy for early stage oral cavity cancer can mean that elective neck dissection is avoided in those people who do not need it. This means a quicker recovery time, less time in hospital and avoiding the significant morbidity (neuropathic pain and reduced shoulder movement) associated with elective neck dissection.

Quality measures

Structure

a) Evidence of local arrangements and written clinical protocols to ensure that people with early stage oral cavity cancer who do not need cervical access as part of surgical management are offered sentinel lymph node biopsy as an alternative to elective neck dissection.

Data source: Local data collection and HANA (Head and Neck Cancer National Audit), Saving Faces.

Process

Proportion of people with early stage oral cavity cancer who do not need cervical access as part of surgical management who have sentinel lymph node biopsy as an alternative to elective neck dissection.

Numerator – the number in the denominator who do not need cervical access as part of surgical management who have sentinel lymph node biopsy as an alternative to elective neck dissection.

Denominator – the number of people with early stage oral cavity cancer.

Data source: Local data collection and HANA (Head and Neck Cancer National Audit), Saving Faces.

Outcome

a) Surgery-related morbidity for people with early stage oral cavity cancer.

Data source: Local data collection.

b) Length of hospital stay for people with early stage oral cavity cancer.

Data source: Local data collection.

What the quality statement means for different audiences

Service providers (head and neck cancer secondary and tertiary care services) have systems in place for people with early stage oral cavity cancer who do not need cervical access as part of surgical management to have sentinel lymph node biopsy as an alternative to elective neck dissection.

Healthcare professionals (members of head and neck cancer multidisciplinary teams) offer sentinel lymph node biopsy as an alternative to elective neck dissection to people with early stage oral cavity cancer who do not need cervical access as part of surgical management.

Commissioners (NHS England) ensure that they commission services which provide sentinel lymph node biopsy as an alternative to elective neck dissection for people with early stage oral cavity cancer who do not need cervical access as part of surgical management.

People with early stage mouth cancer have a minor diagnostic procedure to remove the main lymph gland linked to the cancer unless they need more extensive surgery at the same time. This will show whether the cancer has spread and if more surgery is needed.

Source guidance

Cancer of the upper aerodigestive tract: assessment and management in people aged 16 and over (2016) NICE guideline NG36, recommendation 1.3.5

Definitions of terms used in this quality statement

Early stage oral cavity cancer

Cancer of the mouth which is staged as T1-T2, N-0, meaning that the size of the cancer is still relatively small and no lymph nodes contain cancer cells.

[Adapted from NICE's guideline on cancer of the upper aerodigestive tract, information for the public]

Cervical access

This is surgical access into the neck, for example, to carry out free flap reconstruction.

[Adapted from NICE's guideline on cancer of the upper aerodigestive tract, recommendation 1.3.5 and expert opinion]

Sentinel lymph node biopsy

This is a diagnostic procedure which involves surgical removal of the first lymph node or group of nodes (the sentinel node) which drain directly from the primary cancer site. This is a minor surgical procedure which requires an overnight stay in hospital and has no significant morbidity attached to it.

[Adapted from NICE's guideline on cancer of the upper aerodigestive tract, full guideline glossary, appendix E]

Elective neck dissection

This is the planned removal of cervical lymph nodes in the neck. It is a significant surgical procedure requiring a stay in hospital of approximately 5 nights and has potentially significant morbidity risks such as neuropathic pain and reduced shoulder movement.

[Adapted from NICE's guideline on cancer of the upper aerodigestive tract, full guideline glossary, appendix E and expert opinion]

Equality and diversity considerations

Sentinel lymph node biopsy is a relatively new procedure for assessing early stage oral cavity cancer. It is not widely available and so people with early stage oral cavity cancer may need to travel a significant distance to undergo the procedure. People needing this procedure should be offered it irrespective of the distance they need to travel and should be supported to make the journey if necessary.