S E SCOTLAND CANCER NETWORK REPORT ON PROSPECTIVE AUDIT OF LYMPHOMA PATIENTS BORDERS, FIFE, AND LOTHIAN DIAGNOSED IN 2009

Transcription

1 SE Scotland Cancer Network SCAN AUDIT S E SCOTLAND CANCER NETWORK REPORT ON PROSPECTIVE AUDIT OF LYMPHOMA PATIENTS BORDERS, FIFE, AND LOTHIAN DIAGNOSED IN 2009 Dr John M Davies SCAN and NHS Lothian Dr Kerri L Davidson NHS Fife Dr John Tucker NHS Borders Report prepared by: Christine Maguire SCAN Cancer Audit Facilitator (Lothian & Borders) Kathy Burton Cancer Audit Manager (Fife) SCAN Audit Office, c/o Department of Clinical Oncology, Western General Hospital, Crewe Road, Edinburgh EH4 2XU T: W: F: Alison.Allen@luht.scot.nhs.uk South East Scotland Cancer Network (SCAN) Working regionally to improve cancer services

2 CONTENTS Document History 3 1 Introduction and Methods 4 2 Comment by Dr John Davies, SCAN Chair 6 3 Action Points 7 4 Patient Numbers in Audit and Case Ascertainment 4.1 Summary of Numbers by Main Disease Categories Comparison of Numbers in Audit Breakdown of Other Lymphomas 11 5 Multidisciplinary Management of Patients 5.1 Patients discussed at MDM Timing of Treatment in Relation to MDM MDM Decision to Treat Compared with Actual Treatment Given HIV and Hepatitis Testing Performance Status 19 6 Timings 6.1 Time from Referral to Diagnosis Time from Biopsy to MDM Discussion 22 7 Overall Survival and Outcomes 7.1 Overall Survival: All Lymphoma Overall Survival: DLBCL Complete Remission by Stage: DLBCL 24 8 Cause of Death 24 Glossary 25 2

3 DOCUMENT HISTORY Version Circulation Date Comments 1.1 SCAN Group 10/11/2010 For sense-checking. Agreed at SCAN Group meeting to fix sub-group meeting to discuss draft. Meeting fixed for 03/12/2010 postponed because of bad weather. Earliest reschedule date was February 1.2 Sub-group 21/02/2011 Report reviewed at meeting attended by Dr Davies, Dr Davidson, Christine Maguire, Kathy Burton, Alison Allen Apologies from Dr Tucker. Amendments suggested including addition of information on time from biopsy to MDM. 2.1 SCAN Group 18/03/2011 Version 2.1 with amendments and comments circulated with final deadline for comments /03/2011 Final Signed off Report SA H 04/11 Website Version SA H 04/11 W Clinical Governance Groups and RCPG Report reviewed for disclosive material to assess the risk of communication of personally identifiable information about a data subject 04/04/ /06/2011 Following assessment for disclosive material, some changes made to Table Table Table

4 1 INTRODUCTION AND METHODS COHORT This report provides a selection of the data recorded on patients diagnosed with lymphoma in Borders, Fife, and Lothian Health Board areas in the calendar year Management and audit of patients in Dumfries & Galloway is through the West of Scotland Cancer Network DATASET Data has been collected in line with the nationally-agreed dataset and definitions for lymphomas published by ISD 1 July 2005, as amended for all haematological malignancies from 1 January Registrations for all types started in Lothian from AUDIT PROCESS Data is captured onto an Access database. Patients are identified mainly through registration at the weekly regional Multidisciplinary Team Meeting (MDM). Additional data is captured at the same time as part of the MDM process. Remaining data is completed by re-entry from the clinical record (casenotes and electronic systems). Checks are made against pathology lists, bone marrow lists, and General Register Office (death certificate) data. LEAD CLINICIANS AND AUDIT PERSONNEL Lead clinicians with responsibility for signing off the report are: Lothian and SCAN: Dr John Davies, Consultant Haematologist Fife: Dr Kerri Davidson, Consultant Haematologist Borders: Dr John Tucker, Consultant Haematologist Data capture for Lothian and Borders was by Christine Maguire, SCAN Cancer Audit Facilitator. Data capture for Fife was by Kathy Burton, Fife Cancer Audit Manager. Assistance in database matters, data querying and reporting is provided by Alison Allen and other members of the SCAN Audit Team. DATA QUALITY Estimate of Case Ascertainment The first table in this report provides information on the number of patients included in the audit compared with the number expected based on comparison with a 5-year average from the Scottish Cancer Registry. This comparison suggests comprehensive coverage of patients newly-diagnosed with lymphoma in the three health board areas it covers. Results have been reviewed and checked locally by Lymphoma Lead Clinicians. Accuracy of Data Recording Data is recorded on the MDM/audit database to allow for discussion of each patient at the weekly multidisciplinary meeting. A summary is printed off following the meeting and signed off as correct by a clinician, for incorporating into the patient clinical record. SCAN participates in external Quality Assurance (QA) of data by the Information Services Division of National Services Scotland (ISD). No formal QA of lymphoma data has yet been undertaken. A number of database validations are in place. 4

5 Clinical Sign-off Data from reports prepared for individual hospitals is signed off as accurate following review between the lead clinicians from each service and the audit staff. Once collated into a draft comparative report it is reviewed by a group of clinicians, before final sign-off is agreed. REPORTING AND ANALYSIS At present there are no nationally-agreed standards for haematological malignancies. The report presents descriptive data on both clinical process and outcomes of patients diagnosed in 2009 together with measurement of two clinical guidelines published by the UK National Institute for Clinical Excellence (NICE). Christine Maguire, SCAN Cancer Audit Facilitator Kathy Burton, Fife Cancer Audit Manager February

6 2 LYMPHOMA AUDIT REPORT 2009: OVERALL COMMENT BY SCAN LEAD CLINICIAN: DR JOHN DAVIES This report presents comparative data on Borders, Fife, and Lothian patients diagnosed with Lymphoma in the calendar year Patients are referred for discussion of treatment options to the Regional Multidisciplinary Team Meetings held weekly via teleconference. Lymphoma patients in Dumfries & Galloway are treated, and their records audited, through West of Scotland Cancer Network. At present there are no nationally-agreed standards for the care of Lymphoma patients, and we look forward to contributing to the forthcoming Quality Performance Indicator (QPI) for Lymphoma which will be developed through the programme supervised by the National Cancer Quality Steering Group. Progress on actions from our report on the 2008 cohort of patients, and Action Points from this report are set out below. This is the second year where we are able to show results on outcome of treatment. This is a major quality indicator and we intend to develop this part of the report more extensively in The ability to collect data on follow-up reflects the excellent input we receive from our audit staff. They are an invaluable resource which we must maintain. We plan in 2011 as part of the audit initiative of the Scottish Haematology Society to compare results in more detail with our colleagues elsewhere in Scotland. The results as they stand indicate that the care provided in Borders, Fife, and Lothian provides outcomes which compare well nationally and internationally. March

7 3 ACTION POINTS New action points The table below shows action points identified in review of this report 2009 Report Section Possible area for improvement Proposed Action Which clinical standard will this meet? 4.4 Improve quality of reporting of survival and complete remission results 5.5 Continue to improve recording of Performance Status Aim for >95% Present survival and complete remission data using Kaplan-Meier charts Ongoing vigilance required in ensuring information provided when patient discussed at MDM No specific national standards at present but disease-free survival is the acid test of quality of patient care Forthcoming Scottish national Quality Performance Indicators (QPIs) are likely to contain standards relating to Outcomes of treatment. No specific standard but required as vital component of risk stratification 7

8 Review of actions identified in 2008 The Table below shows the action points identified in the previous report for patients diagnosed in 2008, and indicates progress with action Report Section 2008 Report: Report Report 3.5 Possible area for improvement Increase percentage of patients treated after, rather than before, MDM Increase percentage of patients treated <4 weeks from diagnosis to treatment Improve recording of Performance Status Proposed Action following 2008 Report Audit actual versus planned delivery of treatment for report in 2009 Comparative Report Review use of NICE standard in light of new Scottish Government cancer waits target of 31 days Decision to treat to first treatment which may be more appropriate More vigilance required in ensuring information provided when patient discussed at MDM Which clinical standard will this meet? NICE Guidance on Improving Outcomes in Haematological Cancers 1A p29 NICE Guidance on Improving Outcomes in Haematological Cancers 1D p31 No specific standard but required as vital component of risk stratification Progress An additional sample audit was undertaken and showed that there were no changes in treatment decisions for 24 patients treated prior to the MDM 01/01/ /03/2009. Most patients treated before MDM will be those who can be treated according to standard protocols. A balance has to be struck between too-early referral to the MDM (when full results may not be available) and potential for delay in treatment. From 2010 results may show the effects of the introduction of a more detailed, and lengthier, cytogenetic profiling (MYC) ensuring more accurate diagnosis of Diffuse Large B Cell Lymphoma (DLBCL.) Results show further improvement in recording of Performance Status as a result of vigilance at MDM now 87.2% across SCAN. Should aim for 95%. 8

9 2008 Report 4.4 Investigate causespecific survival in patients with Follicular Lymphoma Because of small numbers requires longer-term aggregation of results review aggregated results to assess No specific standard relating to Haematological Malignancies The clinical records of 3 deceased patients identified in the 2008 report were reviewed and it was concluded that all three deaths were unavoidable with two certainly not related to Follicular Lymphoma or its treatment. 9

10 4 PATIENT NUMBERS IN AUDIT AND CASE ASCERTAINMENT 2009 Table 4.1 Summary of numbers by main disease categories Borders Fife Lothian SCAN Diffuse Large B-Cell Lymphoma Follicular Hodgkin Lymphoma Other Lymphomas ALL LYMPHOMAS TOTALS Annual Average patient numbers* Percentage estimated Case Ascertainment 115% 84% 109% 103% *Source: Scottish Cancer Registry Comment: Completeness of coverage of the population of patients to be included in the audit is estimated with reference to an annual average based on Scottish Cancer Registry figures for the five years Higher case ascertainment provides greater confidence in the reliability of results reported. Where numbers are small, however, results in any one year can be affected by a random variation in the numbers of patients presenting with disease. Table 4.2 Comparison of Numbers in Audit 2006, 2007, 2008 and 2009 Diffuse Large B-Cell Follicular Hodgkin Lymphoma Other Lymphomas TOTAL BORDERS FIFE LOTHIAN SCAN

11 Table 4.3 Breakdown of Other Lymphomas 2009 Borders Fife Lothian SCAN Lymphocytic Lymphoplasmacytic Burkitt s Lymphoma Mantle Cell Mediastinal (Thymic) Large B Cell Lymphoma Nodal Marginal Zone/Extranodal Marginal Zone Splenic Marginal Zone Anaplastic Large Cell Angioimmunoblastic Peripheral T Cell Lymphoma Unclassifiable Extranodal NK/T Cell +/- Enteropathy Post Transplant LPD Primary Cutaneous Anaplastic Large Cell Lymphoma Enteropathy-type T-cell Lymphoma Lymphomatoid Granulomatosis Primary Effusion Lymphoma Total

12 5 MULTIDISCIPLINARY MANAGEMENT OF PATIENTS 5.1 Patients discussed at Multidisciplinary Team Meeting (MDM) Table 5.1 Patients Discussed at MDM All types of Lymphoma 2009 BGH Fife Lothian SCAN Yes No Missing Data TOTALS The 2008 Scottish Core Cancer Standards included the requirement that all patients are managed by a multidisciplinary process. This is based on regular review of patients through routine Multidisciplinary Team Meetings which function in line with national guidance. Lothian, Fife, and Borders patients are managed through the weekly regional Haematology MDM at which pathology and radiology and other results are discussed and treatment options are proposed. 5.2 Timing of treatment in relation to discussion at MDM Table Treatment Started at MDM All types Lymphomas All SCAN SCAN 2006 SCAN 2007 SCAN 2008 SCAN 2009 Treatment before/same day as MDM Treatment after MDM Missing data N/A (not MDMd) TOTALS NICE Guidance on Improving Outcomes in Haematological Cancers 1A p29 recommends that, with limited exceptions, treatment should not precede discussion at the MDM. Following results for previous years, an additional sample audit was undertaken 01/01/ /03/2009 to assess actual versus planned treatment (see Tables below). This showed that there were no changes in treatment decisions for 24 patients treated prior to the MDM. Most patients treated before MDM will be those who can be treated according to standard protocols. A balance has to be struck between too-early referral to the MDM (when full results may not be available) and potential for delay in treatment. From 2010 results may show the effects of the introduction of a more detailed, and lengthier, cytogenetic profiling (MYC) ensuring more accurate diagnosis of DLBCL. 12

13 Table Treatment Started at MDM All types Lymphomas BGH BGH 2006 BGH 2007 BGH 2008 BGH 2009 Treatment before/same day as MDM Treatment after MDM Missing data N/A (not MDMd) TOTALS Table Treatment Started at MDM All types of Lymphomas Fife Fife 2006 Fife 2007 Fife 2008 Fife 2009 Treatment before/same day as MDM Treatment after MDM Missing data N/A (not MDMd) TOTALS Table Treatment Started at MDM - All types Lymphomas Lothian Lothian 2006 Lothian 2007 Lothian 2008 Lothian 2009 Treatment before/same day as MDM Treatment after MDM Missing data N/A (not MDMd) TOTALS

14 5.3 MDM Decision to Treat compared with Actual Treatment Given As an action point following reporting on results for 2008, it was agreed to carry out a sample audit to assess actual versus planned treatment. Data was recorded for patients diagnosed 01/01/ /03/2009. Results are shown below. This showed that there were no changes in treatment decisions for 24 patients treated prior to the MDM. See 5.2 (above) for comment. Table MDM Decision to Treat compared with Actual Treatment Given 01/01/ /03/2009 Treated Treated Treated All SCAN prior to on day after MDM of MDM MDM Total No. Receiving Treatment suggested at MDM No. Receiving Treatment other than suggested at MDM Treated prior to MDM but regimen agreed at MDM Total treated Table MDM Decision to Treat compared with Actual Treatment Given 01/01/ /03/2009 BGH Treated prior to MDM Treated on day of MDM Treated after MDM Total No. Receiving Treatment suggested at MDM No. Receiving Treatment other than suggested at MDM Treated prior to MDM but regimen agreed at MDM Total treated Table MDM Decision to Treat compared with Actual Treatment Given 01/01/ /03/2009 Fife Treated prior to MDM Treated on day of MDM Treated after MDM Total No. Receiving Treatment suggested at MDM No. Receiving Treatment other than suggested at MDM Treated prior to MDM but regimen agreed at MDM Total treated Note: 3 Fife patients died before treatment 14

15 Table MDM Decision to Treat compared with Actual Treatment Given 01/01/ /03/2009 Lothian Treated prior to MDM Treated on day of MDM Treated after MDM Total No. Receiving Treatment suggested at MDM No. Receiving Treatment other than suggested at MDM Treated prior to MDM but regimen agreed at MDM Total treated

16 5.4 HIV and Hepatitis Testing HIV Testing: Results show an increasing proportion of patients are being tested for HIV. This is becoming the standard clinical practice since approximately 80% of the population is theoretically at risk in S E Scotland. It has however not yet been adopted as opt out rather than opt in and further discussion will be required before this approach can be fully implemented. HIV testing is of increasing importance as outcomes for patients who are found to be HIV positive and co- treated with HAART and appropriate treatment for their Lymphoma now approach those of HIV negative populations. Table HIV TESTING - All Lymphomas - Comparison All SCAN HIV TEST PERFORMED: All SCAN n % Done Not requested/done Total A very small proportion of patients tested had a positive result. To avoid potential disclosure of sensitive information the data has been removed from the report. 16

17 Table HIV TESTING - All Lymphomas - Comparison by SCAN Health Board Area HIV TEST PERFORMED: BGH Done Not requested/done Total HIV TEST PERFORMED: Fife Done N/a Not requested/done N/a Total N/a HIV TEST PERFORMED: Lothian Done Not requested/done Total A very small proportion of patients tested had a positive result. To avoid potential disclosure of sensitive information the data has been removed from the report. 17

18 5.4.2 Hepatitis B Surface, Hepatitis B Core, and Hepatitis C Testing All health boards now routinely test patients for Hepatitis B and C, and in particular all patients being treated with Rituximab should be tested. It is expected that 2010 results will show a continued increase in the proportion of patients being tested. These tests did not start routinely in all parts of SCAN until mid Table Hepatitis B Surface, Hepatitis B Core, and Hepatitis C Testing HEPATITIS B SURFACE TEST PERFORMED 2009 BGH Fife Lothian SCAN Done Not requested/done Total HEPATITIS B CORE TEST PERFORMED 2009 BGH Fife Lothian SCAN Done Not requested/done Total HEPATITIS C TEST PERFORMED 2009 BGH Fife Lothian SCAN Done Not requested/done Total A very small proportion of patients tested had a positive result. To avoid potential disclosure of sensitive information the data has been removed from the report. 18

19 5.5 Performance Status The recording of Performance Status continues to improve but the aim should be to record this for more than 95% of all patients in all parts of SCAN. Performance Status is a vital component of risk stratification in both low grade and high grade Non-Hodgkins Lymphoma and is essential for proper interpretation of outcome data. Table Summary of Performance Status Results All SCAN Performance Status Normal activity Symptoms but ambulatory Up & about >50% Confined to bed or chair >50% Completely disabled Not recorded/missing Data Total Performance Status at Diagnosis by Age Group 2009 SCAN <60 (n=101) (n=111) >75 (n=69) Total (n=281) Normal activity Symptoms but ambulatory Up & about >50% Confined to bed or chair >50% Completely disabled Not recorded/missing Data Borders <60 (n=7) (n=14) >75 (n=10) Total (n=31) Normal activity Symptoms but ambulatory Up & about >50% Confined to bed or chair >50% Completely disabled Not recorded/missing Data

20 5.5.2 Performance Status at Diagnosis by Age Group 2009 cont d Fife <60 (n=20) (n=25) >75 (n=18) Total (n=63) Normal activity Symptoms but ambulatory Up & about >50% Confined to bed or chair >50% Completely disabled Not recorded/missing Data Lothian <60 (n=74) (n=72) >75 (n=41) Total (n=187) Normal activity Symptoms but ambulatory Up & about >50% Confined to bed or chair >50% Completely disabled Not recorded/missing Data

21 6 TIMINGS ALL LYMPHOMAS 6.1 Patients numbers in these tables are based on those submitted to the Scottish Government to measure their waiting times targets for For the waiting times returns some patients were excluded from the analysis on the grounds of co-morbidities, patientinduced delay, for clinical reasons, or because they died before treatment. These results do not distinguish between patients referred urgently and those referred routinely. New cancer targets were introduced in and in future reports it is hoped to show results obtained through the Cancer Tracking processes now in place in SCAN health boards. Table Time from Referral to Diagnosis BGH Fife Lothian SCAN 31 days >31 days TOTALS Range Patients may be attending or referred to hospital for investigation or treatment of an unrelated condition and Lymphoma is diagnosed (Incidental Finding). In these instances date of diagnosis will be before referral to Haematology resulting in minus figures. Table 6.1.2: Time from Diagnosis to 1 st Treatment 2009 and comparison tables for Time from Diagnosis to 1 st Treatment BGH Fife Lothian SCAN <31 days >31 days TOTALS Range Time from Diagnosis to 1 st Treatment BGH Fife Lothian SCAN <31 days >31 days TOTALS Range

22 Time from Diagnosis to 1 st Treatment BGH Fife Lothian SCAN <31 days >31 days TOTALS Range Time from Diagnosis to 1 st Treatment BGH Fife Lothian SCAN <31 days >31 days TOTALS Range Patient may be awaiting confirmatory biopsy but blood results, CT scans etc. may be highly suggestive of underlying malignancy, or patient may be frail and anaemic, and therefore commenced on supportive therapy prior to diagnostic biopsy thus causing minus figures. Table 6.2 Time from Biopsy to MDM discussion 2009 BGH Fife Lothian SCAN Not MDM'd days days days days >31 days Totals Range >31 days Note: data in this table is based on all patients without exclusions on grounds of comorbidities, patient-induced delay, for clinical reasons, or because they died before treatment. The current Scottish Government target of decision to treat to first treatment within 31 days is well met within SCAN. However there remain some delays leading to that point in the pathway. Nearly 25% are waiting more than 31 days from biopsy to MDM discussion and further work needs to be done to improve this. 22

23 7 OVERALL SURVIVAL AND OUTCOMES 7.1 All Lymphomas: Overall Survival Recording of survival data started from 2008 so that full-year cohorts can not be reported until sufficient time has elapsed. This records death from any cause cancer may not have been primary cause of death. These figures for survival at 12 months from date of diagnosis compare well with national and international comparators. Table Overall Survival at ONE YEAR: All Lymphomas Patients diagnosed 01/01/ / FULL YEAR BGH Fife Lothian SCAN Status at Date Last Seen Alive but <350 days at DLS Alive at DLS 350 days Dead Not recorded Total *DLS = Date Last Seen 7.2 Diffuse Large B Cell Lymphoma (DLBCL): Overall Survival Table Overall Survival at ONE YEAR: DLBCL Patients diagnosed 01/01/ / FULL YEAR BGH Fife Lothian SCAN Status at Date Last Seen Alive but <350 days at DLS Alive at DLS 350 days Dead Not recorded Total Recording of survival data started from 2008 so that full-year cohorts can not be reported until sufficient time has elapsed 23

24 7.3 COMPLETE REMISSION: Diffuse Large B Cell Lymphoma (DLBCL): Recording of survival data started from 2008 so that full-year cohorts can not be reported for all patients until sufficient time has elapsed. Table ONE-YEAR outcomes for Patients diagnosed January December 2008 Complete Remission for DLBCL at Date Last Seen 350 days Patients diagnosed 01/01/ /12/2008 FULL YEAR BGH Fife Lothian SCAN Total Number DLBCL Total Number DLBCL in CR These results show comparable outcomes to published national and international data on similar patient cohorts. 8 CAUSE OF DEATH: All Lymphomas Table 8.1 Patients Diagnosed 01/01/ /06/2009 BGH Fife Lothian SCAN Cause of Death Progressive Disease Treatment Related Unrelated Not Recorded TOTAL This data is very encouraging in terms of treatment related toxicity but also identifies the need to identify more effective anti-lymphoma regimes. 24

25 GLOSSARY Audit BGH Cancer Case ascertainment Clinical Governance CR Dataset DLBCL DLS Fife GRO Records HAART Hepatitis B Surface Hepatitis B Core Hepatitis C HIV The measuring and evaluation of care against best practice with a view to improving current practice and care delivery. Borders General Hospital The name given to a group of diseases that can occur in any organ of the body, and in blood, and which involve abnormal uncontrolled growth of cells. Number of cases recorded as a proportion of those expected using the average of the most recent available five years reported in the Scottish Cancer Registry Ensures that patients receive the highest quality of care possible, putting each patient at the centre of his or her care. This is achieved by making certain that those providing services work in an environment that supports them and places the safety and quality of care at the top of the organisation's agenda. Complete Remission - All symptoms and signs of disease are gone, although cancer cells may remain in the body. The patient does not feel any of the former symptoms and doctors cannot find clinical signs of the tumour A list of required and specific information relating to a single disease Diffuse Large B Cell Lymphoma Date Last Seen Queen Margaret Hospital, Dunfermline and Victoria Hospital, Kirkcaldy General Register Office Records provide official government information on births, marriages and deaths Highly Active Anti-Retroviral Therapy (HAART) consists of 3 or more highly potent anti-hiv drugs, commonly reverse transcriptase inhibitors and protease inhibitors Hepatitis B surface antigen (HBsAg) is a protein antigen produced by HBV (Hepatitis B Virus). This antigen is the earliest indicator of acute hepatitis B and frequently identifies infected people before symptoms appear. In some people (particularly those infected as children or those with a weak immune system, such as those with AIDS), chronic infection with HBV occurs Anti-hepatitis B core antigen (anti-hbc) is an antibody to the hepatitis B core antigen. The core antigen is found on virus particles but disappears early in the course of infection. This antibody is produced during and after an acute HBV (Hepatitis B Virus) infection and is usually found in chronic HBV carriers as well as those who have cleared the virus, and usually persists for life Hepatitis C is an infection of the liver caused by the hepatitis C virus Human immunodeficiency virus (HIV) attacks the body's immune system. A healthy immune system provides a natural defence against disease and infection. If the immune system is damaged by HIV, it increases the risk of developing a serious infection or disease, such as cancer. 25

26 Multidisciplinary team Meeting (MDM) NR Outcome Performance Status Quality assurance (QA) SCAN SJH Stage QMH VHK WGH A multiprofessional group of people from different disciplines (both healthcare and non-healthcare) who work together to provide care for patients with a particular condition. Within the South East Scotland Cancer Network (SCAN) a weekly Haematological cancer regional multidisciplinary team meeting is held at the Western General Hospital, Edinburgh with video links to BGH, SJH, QMH, VHK where patients from the Lothian (including West Lothian), Borders and Fife areas are discussed. Not Recorded A measure of the effects, beneficial or adverse, which a person experiences as a result of the care, treatments or services they have received. An overall assessment of the functional/physical performance of the patient When a sample of data is compared with the data definitions South East Scotland Cancer Network St John s Hospital, Livingston The extent to which cancer has spread from its original site to other parts of the body. Usually denoted by a number from Stage 1 (least severe) to Stage 4 (more advanced). Queen Margaret Hospital, Dunfermline Victoria Hospital, Kirkcaldy Western General Hospital, Edinburgh 26