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The case for sentinel node biopsy

The less invasive way to diagnose and treat head and neck cancers 

A less invasive procedure to diagnose and treat head and neck cancers is proving beneficial for patients


Picture: Alamy

In early 2014, when working at Guy’s and St Thomas’ NHS Foundation Trust, I saw first-hand the benefits of using sentinel node biopsy (SNB) – a less invasive treatment for diagnosing and treating head and neck cancers.

What is sentinel node biopsy?

SNB is an alternative, and significantly less invasive, treatment for diagnosing and treating head and neck cancers. A fluorescent camera locates the nodes in the neck that could contain migrating cancer cells, so that these can be targeted and removed.

This saves more than 70% of patients with early disease from having a neck dissection. It spares vital glands and helps patients get back to a normal life more quickly, compared with traditional neck dissection techniques.

SNB has been endorsed by the National Institute for Health and Care Excellence.

I was fortunate enough to work alongside consultant oral and maxillofacial head and neck surgeon Mark McGurk, founder of the Head and Neck Cancer Foundation (HNCF) and pioneer of SNB.

Aesthetics

SNB surgery is a better option for patients than neck dissections due to the reduced aesthetic impact and the relatively low levels of trauma for the patient. However, many nurses, surgeons and patients are unaware of its benefits or its effects on aftercare because it is not yet routinely practised.

With a traditional neck dissection, many patients find the sight of a neck wound overwhelming when they see themselves post surgery. It can be mortifying to see yourself in this way and people are not prepared for what they see.

Many patients, particularly women, also express concerns about healing time and what the surgical line will look like after healing as it is such an exposed area of the body. A lot of women wear scarves to hide what they believe is unsightly scarring, especially as it can be swollen, red and tender. Patients can never be fully prepared for what they see, especially as every case is unique.

Change of appearance

Hospitals aren’t always focused on minimising changes in appearance after an operation and patients can often catch glimpses of themselves and any visible differences when they see their reflection. In the past, I have had patients (particularly younger people) ask for the mirrors to be covered up in the toilets before they go in so they don’t have to look at themselves.

It can be a difficult process to get a patient to even look at or touch their wound to clean it when I teach them how to care for their wound before they are discharged.

In contrast, patients who have had SNB are often pleasantly surprised and comment on how small the incision on their neck is. They have a better range of movement and are able to eat and drink easily. It requires very little physical support from a nurse as there is not much post-op wound care.

Neck dissection patients tend to have limited mobility due to the size of the wound, swelling and tightness due to post-op inflammation. This causes difficulty when rotating their neck or moving around independently at times, particularly in older or less mobile people. With these neck dissection cases, I help to assist the healing process by mobilising and washing the patient.

Reduced length of hospital stay

Neck dissection patients can face much longer stays in hospitals compared with an SNB patient. It is not at all rare for a person who has had SNB in the morning to return home in 24-48 hours, thereby reducing the length of an inpatient stay.

SNB also has a different impact on aftercare compared with the traditional procedure. The healing process for a neck dissection is lengthy and patients are at a higher risk of infection due to the exposed wound and the potential for developing haematomas. Therefore, this patient group requires more invasive and frequent nursing input and monitoring.

Nurses need to check for oedema and redness as signs of complications post-surgery. On discharge, district nurses and follow-up visits are necessary for the removal of stitches and clips seven to ten days after surgery, during which time the patient is exposed to increased infection and wound dehiscence.

With SNB, less surveillance is required, reducing pressure on nurses as the patient acuity level is very low. There is little risk of nerve damage and resulting secondary surgery such as artificial airways, as with a neck dissection. The patient has no heavily exposed wounds, just an incision site that needs monitoring for signs of swelling, bleeding or infection. Patients can usually eat and drink immediately after surgery and are able to fully rotate their head and neck.

Less painful

SNB patients ask for less analgesia and they only require light pain relief such as paracetamol, ibuprofen or low doses of codeine. In comparison, patients who have a neck dissection have undergone a lot more trauma and experience much higher levels of pain, especially immediately afterwards and during the first few days after surgery so they tend to ask for strong painkillers such as opioids.

My experience of SNB and the skills I had acquired meant that when I moved to University College London Hospitals NHS Foundation Trust, I was able to educate and instruct patients and nurses on the healing and treatment process.

As more surgeons practice SNB, it will significantly reduce patient acuity levels in head and neck cancers, reduce the length of stay in hospitals, and reduce the psychological and physiological effects associated with such forms of invasive surgery.

60-second interview with Vicki Thomas

What does your job involve and what are your main responsibilities?

My job as a clinical practice facilitator involves teaching and maintaining skills for new and existing head and neck staff. This includes orientation to the unit, understanding head and neck nursing, tracheostomy and stoma care, and improving practice to reduce infections. As well as working on the ward, I am also required to deal with staffing, HR, complaints, assisting with Care Quality Commission compliance and dealing with members of the multidisciplinary team to help with the safe discharge  of patients with complex care needs.

What do you most enjoy about your job?

The role is challenging and the client group is specific. I enjoy working as an integral part of a team. Seeing patients regain their confidence and getting back home as quickly and safely as possible is rewarding.

What achievement makes you most proud?

I am most proud of my volunteering work and having had the opportunity to work abroad in Ethiopia as a head and neck nurse. I am honoured to have had the opportunity to work with a unique team of dedicated professionals. I never thought it would be possible to do such amazing, worthwhile nursing.

What are your hopes for your career?

I hope to be in a position where I can bridge preoperative care and expectations with the harsh reality of what head and neck cancer surgery involves. It is such a life-changing surgery due to the disfigurement it can bring. I would like to be part of a programme that helps to rehabilitate head and neck cancer patients and provides support for their families.

What do you find most challenging about your role?

Finding a method of communicating that works well for the patient and myself in a diverse city such as London. This makes the role of a head and neck clinical practice facilitator even more challenging.


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Vicki Thomas is a head and neck clinical practice facilitator and deputy sister at Univesity College London Hospitals NHS Foundation Trust

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