Audit Report Report of the 2012 Clinical Audit Data

Transcription

1 Urological Cancer Managed Clinical Network Audit Report Report of the 2012 Clinical Audit Data Mr Seamus Teahan MCN Clinical Lead Tom Kane MCN Manager Sandie Ker Information Officer

2 Urological Cancer Audit Report Addendum Contents Amendment Record This report has been issued and amended as follows: Revision Page 31/32 Description Figure 13 has been amended to show corrected 2012 figures for NHS Greater Glasgow and Clyde, NHS Lanarkshire and WoS total in the proportion of patients with clinical metastases stage recorded. NHSGGC has been corrected from 74.6% to 94.9%, NHS Lanarkshire from 98.0% to 99.6% and WoS total from 84.9% to 97.2%. Clinical metastases stage recorded has been amended in Figure 14 to reflect the above changes. Revision Date: 9 th April 2014 Final Published Urological Cancer MCN Audit Report v1.1 09/04/2014 2

3 CONTENTS LIST OF TABLES 4 LIST OF FIGURES 4 EXECUTIVE SUMMARY 5 1. INTRODUCTION BACKGROUND NATIONAL CONTEXT WEST OF SCOTLAND CONTEXT METHODOLOGY RESULTS AND ACTION REQUIRED DATA QUALITY PERFORMANCE AGAINST AGREED QUALITY MEASURES AND QPIS RENAL CANCER QUALITY PERFORMANCE INDICATORS PROSTATE CANCER BLADDER CANCER TESTICULAR CANCER RENAL PELVIS AND URETER CANCERS CONCLUSIONS 42 ACKNOWLEDGEMENT 43 ABBREVIATIONS 44 REFERENCES 45 APPENDIX: NHS BOARD ACTION PLANS 47 Final Published Urological Cancer MCN Audit Report v1.1 09/04/2014 3

4 List of Tables Table 1: Proportion of patients discussed by an MDT in 2012 by NHS Board of diagnosis...11 Table 2: Relative age-standardised survival for urological cancers in Scotland showing percentage change from to Table 3: Number of patients diagnosed with urological cancer in 2012 by tumour type and location of diagnosis...12 Table 4: Age distribution of urological cancers for patients diagnosed in WoS in Table 5: Case ascertainment for 2012 cancer audit data by tumour type and NHS Board of diagnosis...14 Table 6: Number and proportion of patients diagnosed with renal cancer in 2012 by location of diagnosis...16 Table 7: Number of patients who died within 30 days of Cryotherapy, RFA, SACT or Surgery by NHS Board...26 Table 8: Number of radical prostatectomies performed per surgeon in List of Figures Figure 1: Proportion of patients in West of Scotland discussed by an MDT in 2011 and 2012 by tumour type...11 Figure 2: Case ascertainment for 2012 audit data by NHS Board of diagnosis for prostate, renal and bladder cancer...14 Figure 3: Proportion of all urological cancer patients with TNM recorded by location of diagnosis, 2011 and Figure 4: Proportion of patients with RCC diagnosed in 2012 that underwent pre-treatment cross-sectional imaging of the chest, abdomen and pelvis (QPI 1)...18 Figure 5: Proportion of patients with RCC diagnosed in 2012 (where surgery is not the primary treatment) who have a histological diagnosis before treatment, via biopsy (QPI 2)...20 Figure 6: Proportion of patients diagnosed in 2012 whose RCC is staged prior to treatment using the TNM staging system (QPI 3)...22 Figure 7: Proportion of patients diagnosed in 2012 whose RCC is histopathologically graded using the Fuhrman grading system (QPI 4)...23 Figure 8: Proportion of patients diagnosed in 2012 with non-metastatic RCC, not suitable for nephron sparing surgery, treated by radical nephrectomy (QPI 5)...24 Figure 9: Proportion of patients diagnosed in 2012 with T1a RCC who received nephron sparing surgery (QPI 6)...25 Figure 10: Proportion of patients diagnosed in WoS who died within 30 days of treatment by treatment type (QPI 7)...26 Figure 11: Proportion of prostate cancer patients with TNM recorded by year and location of diagnosis...28 Figure 12: Proportion of patients diagnosed in 2011 and 2012 with involved margins following radical prostatectomy...30 Figure 13: Proportion of patients diagnosed between 2010 and 2012 with a clinical metastases stage recorded...31 Figure 14: Proportion of patients diagnosed 2012 with clinical metastases stage recorded and percentage of these patients who received hormone therapy as first treatment...32 Figure 15: Proportion of bladder cancer patients with clinical TNM recorded by location of diagnosis, Figure 16: Proportion of T2-T4 TCC patients having neo-adjuvant chemotherapy by location of diagnosis...34 Figure 17: Proportion of T2-T4a bladder cancer patients having RC by location of diagnosis, Figure 18: Proportion of RC patients diagnosed between 2010 and 2012 having LND by location of diagnosis...36 Figure 19: Proportion of bladder cancer patients with clinical metastases stage recorded, diagnosed Figure 20: Proportion of metastatic bladder cancer patients diagnosed in 2012 undergoing palliative chemotherapy...37 Figure 21: Number of bladder cancer patients receiving systemic chemotherapy who died within 30 days...38 Figure 22: Number of patients diagnosed with testicular cancer between 2010 and 2012 receiving chemotherapy...39 Figure 23: Proportion of testicular cancer patients diagnosed in 2011 and 2012 with sufficient information to calculate a clinical disease stage...40 Figure 24: Proportion of RPU cancer patients with TNM recorded by location of diagnosis, 2010 to Final Published Urological Cancer MCN Audit Report v1.1 09/04/2014 4

5 Executive Summary Introduction This report contains an assessment of the performance of West of Scotland (WoS) urological cancer services using clinical audit data relating to patients diagnosed in Data have been collected for all urological cancers however data analysed and included within this report relate to cancers of the prostate, bladder, kidney, renal pelvis/ ureter (RPU) and testes. The National Cancer Quality Steering Group, under the auspices of the Scottish Cancer Taskforce, is currently taking forward the development of national Quality Performance Indicators (QPIs) for all cancers. This will enable future national comparative reporting and help drive continuous improvement for patients. QPIs have been finalised for renal and prostate cancers and were implemented for all patients diagnosed from 1 st January 2012 and 1 st July 2012 respectively. Renal cancer QPIs are outlined within this report for the first time as a complete year of renal QPI data is available for Twelve months of prostate QPI data will be reported separately in June 2014, and only selected measures for prostate cancer are detailed within this report. Development of bladder cancer QPIs is now complete and will be implemented for patients diagnosed on or after 1 st April Testicular cancer QPI development is also underway and implementation is scheduled for 1 st October At the beginning of 2011, the (WoSCAN) initiated a process which would agree regional quality of care and outcome measures for specific tumour networks, primarily those which would not feature immediately in the QPI development schedule. A core review group developed key outcome measures (KOMs) for bladder cancer patients and data has been analysed against these measures since 2010, allowing three years of comparative data to be presented within this report. Background Prostate cancer is the most commonly diagnosed malignancy in Scottish men and the fourth most commonly diagnosed cancer in Scotland after lung, breast and colorectal cancers 8. Cancers of the kidney and of the renal pelvis together rank as the ninth most common cancer type in Scotland 8. The incidence of prostate, renal, testes and bladder cancers are predicted to increase significantly by Relative survival from renal, ureteric, prostate and testicular cancers is increasing 11. Survival from prostate cancer has significantly improved 8,11 however it remains the second most common cause of cancer related death in Scottish men 8. Invasive bladder cancer is the seventh commonest cause of death from cancer in males in Scotland and is the tenth most common cause of death from cancer in females 8. Four NHS Boards across the WoS serve the 2.4 million population 7. From this population, around 2500 urological cancers are diagnosed each year. The configuration of the Multidisciplinary Teams (MDTs) in the region is set out below. MDT Ayrshire & Arran (AA) Greater Glasgow and Clyde (GGC) Forth Valley (FV) Lanarkshire (Lan) Constituent Hospitals Crosshouse Hospital, Ayr Hospital Gartnavel General Hospital, Glasgow Royal Infirmary, Inverclyde Royal Hospital, Royal Alexandra Hospital, Southern General, Vale of Leven, Victoria Infirmary, Western Infirmary Forth Valley Royal Hospital Wishaw General Hospital, Monklands District General, Hairmyres Final Published Urological Cancer MCN Audit Report v1.1 09/04/2014 5

6 Methodology The clinical audit data presented in this report was collected by clinical audit staff in each NHS Board in accordance with an agreed dataset and definitions. The data was entered locally into the electronic Cancer Audit Support Environment (ecase): a secure centralised web-based database. Data relating to patients diagnosed between 1 st January 2012 and 31 st December 2012 was downloaded from ecase on 11 th December Analysis was performed centrally by the WoSCAN Information Team and the timescales agreed took into account the patient pathway to ensure that a complete treatment record was available for each case. Initial results of the analysis were provided to local Boards to check for inaccuracies or obvious gaps before final analysis was carried out. Final results were disseminated for NHS Board verification in line with the regional audit governance process, to ensure that the data was an accurate representation of service in each area. Results The quality of urological cancer audit data has improved considerably in many respects in recent years. CEL 06 (2012) mandates all NHS Boards in Scotland to report on specified quality performance indicators (QPIs) on an annual basis. The QPIs will allow comparative assessment of outcomes regionally and nationally with respect to these predefined standards. Valid comparisons will only be possible however if data capture is complete and accurate and, though significant progress has been made in the region, further improvement is required if individual boards are to meet their obligations. Case ascertainment is an estimate of the proportion of expected patients that have been identified through audit. The predicted incidence of each cancer is based on historic numbers of cases diagnosed and therefore some variation in case ascertainment is expected. This normal variation is most appreciable in less common cancers as small fluctuations in the numbers of cases detected will have a greater impact on the incidence of that cancer relative to previous years. Larger or unexpected variance in case ascertainment may merit closer interrogation. The accurate recording of clinical staging data is a prerequisite to the measurement of many of the QPIs. If these data are incomplete it will not be possible to submit a valid report on these patients as required, and boards may be cited if these shortcomings are not addressed. The overall capture of TNM data in 2012 has shown improvement in all NHS Boards since Approximately 93% of patients diagnosed with a urological cancer had TNM data recorded in 2012 and this must improve further. As TNM data completeness has been poor historically, direct comparisons between 2012 and 2011 data are difficult where outcome measures rely on staging information to select eligible patients. For testicular and renal pelvis and ureter (RPU) cancers, numbers are low in some areas and this must be considered when comparing performance across the region. Results of a number of outcome measures are presented in the report in each tumour-specific section. Values in the results summary over page represent the WoS overall figure and range by Boards, expressed as a percentage unless otherwise stated. Final Published Urological Cancer MCN Audit Report v1.1 09/04/2014 6

7 Renal Cancer QPIs Target WoS Range QPI 1: Radiological diagnosis prior to first treatment for patients 100% 88.9% % diagnosed with renal cell carcinoma QPI 2: Histological diagnosis for non-surgical patients prior to first 100% 80.5% % a treatment QPI 3: Recording of clinical stage using TNM staging system 100% 94.9% % QPI 4: Histological (Fuhrman) Grading for clear cell carcinomas 95% 99.4% % undergoing resection QPI 5: Surgical treatment for patients with non-metastatic disease 100% 98.4% % a QPI 6: Nephron sparing surgery for patients with T1a renal cancer 40% 54.3% % a QPI 7: Prostate Cancer Thirty day surgical mortality; a) Cryotherapy b) Radio-frequency ablation (RFA) c) Systemic anti-cancer treatment (SACT) d) Surgery < 5% < 5% < 5% < 5% 0.0% 0.0% 5.6% 0.9% NA a NA a % a % I. Recording of clinical staging using TNM: 94.2% [ %] II. Volume of prostatectomy surgeries per surgeon performed in 2012: 1-34 [Total 124] III. Surgical margin involvement of pt2 patients undergoing radical prostatectomy: 21.4% [ %] a IV. Hormone therapy as first treatment for metastatic patients: 98.4% [ %] Bladder Cancer (KOMs) I. Recording of clinical staging using TNM: 89.4% [ %] II. Grade of tumour recorded for transitional cell carcinomas (TCCs) having transurethral resection of bladder tumour (TURBT): 99.3% [ %] III. Neo-adjuvant chemotherapy prior to radical therapy: 46.2% [ %] IV. Radical cystectomy for localised muscle-invasive cancers: 20.4% [ %] V. Lymph node dissection for radical cystectomy patients: 100% VI. Thirty day mortality for radical cystectomy patients: 0.0% VII. Palliative chemotherapy for metastatic patients: 18.8% [ %] a VIII. Thirty day mortality post-completion of systemic chemotherapy: 2.0% [ %] Testicular Cancer a I. Orchidectomy patients offered a prosthesis: 75.6% [ %] II. Chemotherapy treatment received: 71.3% [ %] III. Sufficient information recorded to calculate disease stage: 90.8% [ %] Renal Pelvis & Ureter Cancers (RPU) a I. Recording of clinical stage using TNM: 89.0% [ %] II. Thirty day mortality following nephroureterectomy: 0.0% a Note that small numbers may apply to some NHS Boards therefore proportions should be considered within the context of the total numbers detailed within the main report. Final Published Urological Cancer MCN Audit Report v1.1 09/04/2014 7

8 Conclusions and Action Required Significant improvements in the recording of TNM data in 2012 has facilitated accurate analysis of Renal Cancer QPI audit data and provided a baseline against which performance in future years can be compared. Areas for service improvement have been identified relating to diagnostics, specifically with regard to radiological diagnosis and histological diagnosis prior to non-surgical treatment. Generally, comparisons between audit data across different years for prostate, bladder, testicular and RPU cancer should be made with caution due to historically poor capture of TNM data. Improvement in 2012 data completeness is encouraging especially with the move towards QPI reporting for all cancer types. Actions where further improvement could be made are outlined within the report and areas where service provision requires improvement have also been identified. Each unit was asked to complete a Performance Summary Report and document areas for improvement where performance was below the regional result. The MCN will actively take forward regional actions identified and NHS Boards are asked to develop local Action/Improvement Plans in response to the findings presented in the report. Action required: Renal cancer NHSGGC and NHS Forth Valley to review diagnostic pathways to ensure that patients with renal cell carcinoma receive clinically appropriate radiological diagnosis. NHSGGC to review cases that do not have a histological diagnosis to ascertain if there is clear clinical reason for biopsy not being undertaken and act on findings, where appropriate. NHSGGC should establish whether missing staging information for renal cancer patients is a data recording issue or result of MDT processes. Prostate cancer NHSGGC and NHS Lanarkshire must ensure local processes are in place to support necessary improvement in the capture of clinical TNM staging information for all prostate cancer patients. NHS Lanarkshire should initiate a review of cases where margins were involved and take appropriate action against findings. Bladder cancer NHSGGC must ensure local processes are in place to support necessary improvement in the capture of clinical TNM staging information for all bladder cancer patients. Testicular cancer NHSGGC and NHS Ayrshire & Arran should review local processes to ensure that all testicular cancer patients undergoing orchidectomy are offered a prosthesis and the patient response is documented. Urological Cancer MCN should continue to monitor variance in chemotherapy rates across Boards to ensure compliance with WoSCAN CMG for Testicular Cancer. NHS Ayrshire & Arran, Forth Valley and Lanarkshire should review processes for the documentation of TNM data and serum tumour markers to further improve the proportion of testicular cancer patients with disease stage calculated. RPU cancer NHSGGC should review processes for the documentation of TNM data to further improve the proportion of patients diagnosed with RPU cancer who have disease stage calculated. Final Published Urological Cancer MCN Audit Report v1.1 09/04/2014 8

9 A summary of actions for each NHS Board has been included within the Action Plan templates in the Appendix. Completed Action Plans should be returned to WoSCAN within two months of publication of this report. Progress against these plans will be monitored by the MCN Advisory Board and any service or clinical issue which the Advisory Board considers not to have been adequately addressed will be escalated to the NHS Board Territorial Lead Cancer Clinician and Regional Lead Cancer Clinician. Additionally, progress will be reported to the Regional Cancer Advisory Group (RCAG) annually by NHS Board Territorial Lead Cancer Clinicians and MCN Clinical Leads, as part of the regional audit governance process to enable RCAG to review and monitor regional improvement. Final Published Urological Cancer MCN Audit Report v1.1 09/04/2014 9

10 1. Introduction This report contains an assessment of the performance of West of Scotland (WoS) urological cancer services using clinical audit data relating to patients diagnosed in Regular reporting of activity and performance is a fundamental requirement of a Managed Clinical Network (MCN) to assure the quality of care delivered across the region. Data have been collected for all urological cancers however data analysed and included within this report relates to cancers of the prostate, bladder, kidney, renal pelvis/ ureter (RPU) and testes. The National Cancer Quality Steering Group, under the auspices of the Scottish Cancer Taskforce, is currently taking forward the development of national Quality Performance Indicators (QPIs) for all cancers which will enable future national comparative reporting and help to drive continuous improvement for patients. Renal cancer was the first cancer to go through the QPI development process and QPIs were implemented for patients diagnosed from 1 st January Renal cancer QPI data for 2012 are included within this report. QPIs have also been implemented for prostate cancer patients diagnosed from 1 st July and twelve months of QPI data will be reported in June Only selected measures for patients diagnosed with prostate cancer in 2012 are therefore detailed within this report. These were previously part of a larger set of measurement criteria which were agreed by key clinical colleagues to align with upcoming prostate QPIs where approximate measurement was possible from the existing dataset. Development of bladder cancer QPIs is now complete and will be implemented for patients diagnosed from 1 st April Testicular cancer QPI development is also underway and implementation is scheduled for 1 st October Documentation relating to the QPIs is available on the Healthcare Improvement Scotland (HIS) website 1,2,3 and national minimum core datasets aligned to measurement of the indicators are available on the Information Services Division (ISD) website 4,5,6. At the beginning of 2011, the (WoSCAN) initiated a process which would agree regional quality of care and outcome measures for specific tumour networks, primarily those which did not feature immediately in the QPI development schedule. A core review group developed key outcome measures (KOMs) for bladder cancer patients and data has been analysed against these measures since 2010, allowing three years of data to be presented within this report. Final Published Urological Cancer MCN Audit Report v1.1 09/04/

11 2. Background Four NHS Boards across the WoS serve the 2.4 million population 7. From this population, around 2500 urological cancers are diagnosed each year. Management of urological cancers is dependent on the particular urological malignancy however all cancers will be discussed and managed through Multi-Disciplinary Teams (MDTs). The configuration of MDTs in the region is set out below. MDT Ayrshire & Arran (AA) Greater Glasgow and Clyde (GGC) Forth Valley (FV) Lanarkshire (Lan) Constituent Hospitals Crosshouse Hospital, Ayr Hospital Gartnavel General Hospital, Glasgow Royal Infirmary, Inverclyde Royal Hospital, Royal Alexandra Hospital, Southern General, Vale of Leven, Victoria Infirmary, Western Infirmary Forth Valley Royal Hospital Wishaw General Hospital, Monklands District General, Hairmyres All patients diagnosed with urological cancer should be discussed at an MDT meeting and each MDT convenes on a weekly basis. The proportion of patients diagnosed with each cancer type that were discussed by an MDT is shown in Table 1 by location of diagnosis. NHSGGC does not currently discuss low risk bladder cancer patients at MDT. These patients are defined as stage 0a, noninvasive papillary carcinoma (TaN0M0), and are commenced on standard treatment as per protocol. This accounts for the low proportion of bladder cancer patients discussed at MDT in NHSGGC as 60 of the 64 patients who were not discussed were recorded as stage 0a. Work is currently underway to set up an MDT in NHSGGC for patients diagnosed with penile cancer in the WoS. Table 1: Proportion of patients discussed by an MDT in 2012 by NHS Board of diagnosis Prostate 100.0% 92.4% 97.3% 93.0% 94.3% Renal 94.3% 89.8% 97.6% 98.9% 93.3% Bladder* 100.0% 82.5% 100.0% 100.0% 91.2% Testicular 100.0% 96.1% 85.7% 100.0% 96.6% Renal Pelvis & Ureter (RPU) 100.0% 100.0% 100.0% 100.0% 100.0% Figure 1: Proportion of patients in West of Scotland discussed by an MDT in 2011 and 2012 by tumour type Proportion of patients (%) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Prostate Renal Bladder Testicular RPU Site of origin of tumour Final Published Urological Cancer MCN Audit Report v1.1 09/04/

12 2.1 National Context Prostate cancer is the most common cancer in males with over 2800 cases diagnosed in Scotland per annum 8. Furthermore, it is ranked as the fourth most commonly diagnosed cancer of all cancers in male and female patients in Scotland after lung, breast and colorectal cancers. The incidence of prostate cancer has increased by 2.0% in the last ten years 8 and this in part is thought to be related to the increased use of PSA (Prostate Specific Antigen) testing 9. Cancers of the kidney and renal pelvis together rank as the ninth most common cancer type in Scotland 8. Prostate, renal, testes and bladder cancers are all predicted to increase significantly in incidence by Relative survival from renal (and renal pelvis), prostate and testicular cancers is increasing 11. Table 2 details the percentage change in 1 and 5 year relative survival by cancer type for patients diagnosed to Although relative survival from bladder cancer looks to be decreasing, this is due to coding changes for invasive and non-invasive bladder cancers during the observed period. Table 2: Relative age-standardised survival for urological cancers in Scotland showing percentage change from to Relative survival (%) at 1 year at 5 years M F M F Bladder (invasive only) Renal (including renal pelvis) Prostate Testis Survival from prostate cancer has significantly improved in the last ten years 8,11 ; however it remains the second most common cause of cancer related death in Scottish men 8. Invasive bladder cancer is the seventh commonest cause of death from cancer in males in Scotland and is the tenth most common cause of death from cancer in females West of Scotland Context A total of 2519 cases of urological cancer were recorded through audit as diagnosed in the West of Scotland in 2012 and the number of patients diagnosed with each malignancy is presented in Table 3. Prostate cancer is the most commonly diagnosed urological cancer and accounts for 47.5% of all urological cancer diagnoses in the West of Scotland in Table 3: Number of patients diagnosed with urological cancer in 2012 by tumour type and location of diagnosis Prostate Renal Bladder* Testicular Renal Pelvis & Ureter (RPU) Penile Total *Includes non-invasive cancer Data relating to penile cancers have not been analysed by the MCN due to the small numbers involved, however figures are included in Table 3 for information. Final Published Urological Cancer MCN Audit Report v1.1 09/04/

13 The majority of patients diagnosed with urological cancer are in the older age groups and median ages for each cancer type range from 64 to 75 years (Table 4). The exception is testicular cancer which is more common in younger men. As illustrated in Table 4, the mean age for patients diagnosed with testicular cancer in 2012 was 40 and the median age was 37 years. Table 4: Age distribution of urological cancers for patients diagnosed in WoS in 2012 Bladder Renal RPU Prostate Testicular Penile Male Female Male Female Male Female Male Male Male Minimum Maximum Mean Median Mode Total no Methodology The clinical audit data presented in this report was collected by clinical audit staff in each NHS Board in accordance with an agreed dataset and definitions. The data was recorded manually and entered locally into the electronic Cancer Audit Support Environment (ecase): a secure centralised webbased database. Data relating to patients diagnosed between 1 st January 2012 and 31 st December 2012 was downloaded from ecase at 2200 hrs on 11 th December Cancer audit is a dynamic process with patient data continually being revised and updated as more information becomes available. This means that apparently comparable reports for the same time period and cancer site may produce slightly different figures if extracted at different times. Analysis was performed centrally for the region by the WoSCAN Information Team and the timescales agreed took into account the patient pathway to ensure that a complete treatment record was available for each case. Initial results of the analysis were provided to local Boards to check for inaccuracies, inconsistencies or obvious gaps and a subsequent download taken upon which final analysis was carried out. The final data analysis was disseminated for NHS Board verification in line with the regional audit governance process to ensure that the data was an accurate representation of service in each area. 4. Results and Action Required 4.1 Data Quality Audit data quality can be assessed in the first instance by estimating the proportion of expected patients that have been identified through audit. Case ascertainment is calculated as the number of new cases identified by the audit as a proportion of the number of cases reported by the National Cancer Registry (provided by Information Services Division, National Services Scotland), by NHS Board of diagnosis. Cancer Registry figures used were extracted from ACaDMe (Acute Cancer Deaths and Mental Health), a system provided by Information Services Division (ISD). Cancer Registry figures are an average of the previous three/five years figures (as available) to take account of annual fluctuations in incidence within NHS Boards. Case ascertainment across WoS Boards for the 2012 audit data is detailed in Table 5. Bladder cancer figures cannot be extracted via the ACaDMe system as the non-invasive bladder cancers cannot be identified and included, hence previous information supplied by ISD has been utilised. There is variation in case ascertainment between Boards and across tumour types which is illustrated in Figure 2. For urological cancers with lower numbers, such as testicular and RPU cancers, the variation will largely be due to the small numbers involved and therefore these cancer types have not been Final Published Urological Cancer MCN Audit Report v1.1 09/04/

14 included in Figure 2. Case ascertainment figures are provided for guidance and are not an exact measurement as it is not possible to compare directly with the same cohort. Case ascertainment for NHS Forth Valley is low for prostate cancer in 2012 at 68.1%. This is not thought to be due to poor audit capture however, and may be due to historically higher case numbers being recorded in Forth Valley comparative to population size. Generally, the overall increased incidence in prostate cancer is thought in part to be a reflection of increased detection through use of the prostate-specific antigen (PSA) test; however variations in the use of PSA testing make it difficult to interpret geographical variations in incidence 9. This could account for NHS Forth Valley having had previously higher incidence compared to other WoS Boards and is a possible explanation for the lower than predicted case ascertainment in 2012 if this reflects a transitory plateau in new diagnoses. Figure 2: Case ascertainment for 2012 audit data by NHS Board of diagnosis for prostate, renal and bladder cancer average Case ascertainment (%) 130% 120% 110% 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Prostate Renal Bladder Site of origin of tumour Table 5: Case ascertainment for 2012 cancer audit data by tumour type and NHS Board of diagnosis Prostate 93.3% 100.2% 68.1% 93.8% 93.5% Renal 106.0% 98.1% 93.2% 125.0% 103.7% Bladder* 99.2% 97.6% 93.9% 104.9% 98.8% Testicular 92.9% 106.3% 50.0% 53.3% 82.1% Renal Pelvis & Ureter (RPU) 90.0% 143.3% 166.7% 130.0% 125.0% * cancer registration data Urological cancer audit data quality has improved considerably since 2010, especially with regards to the recording of disease stage. Although staging data is included in the urological cancer pre-qpi dataset 12, prior to 2010 stage data had only been analysed for bladder cancer. As measurement against many of the forthcoming QPIs relies on staging data being complete, 2010 and 2011 staging data was analysed and presented in last year s audit report and revealed that significant improvement would be required in order to produce meaningful analyses against the QPIs, the reporting of which will be mandatory practice for NHS Boards as set out in CEL 06 (2012). Staging information has been analysed again for 2012 data for prostate, renal, bladder, testicular and RPU cancers and is presented under the relevant section for each cancer type. The audit data includes the Tumour, Nodal and Metastases (TNM) stage at diagnosis which is recorded according to the TNM Classification of Malignant Tumours (Sixth Edition) 13. Figure 3 shows the collated results for all urological cancer patients in 2011 and 2012 by NHS Board of diagnosis and gives an indication Final Published Urological Cancer MCN Audit Report v1.1 09/04/

15 where data completeness may still need to be addressed locally. Actions required by Boards in relation to TNM data completeness are detailed under each section by cancer type. Overall, TNM staging across WoS has improved from 64.2% in 2011 to 92.6% in Figure 3: Proportion of all urological cancer patients with TNM recorded by location of diagnosis, 2011 and Proportion of patients (%) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% NHS Board of diagnosis TNM completed Total no. patients TNM complete (%) 70.1% 99.8% 69.4% 88.7% 97.2% 98.1% 24.6% 93.9% 64.2% 92.6% Where stage of disease is required to assess a patients eligibility to be measured against an indicator or measure, then the patient will not be included if this information is not recorded. This leads to underestimation of patient numbers and affects reliability of results if measures are not calculated based on all eligible patients. For this reason, caution should be given when making comparisons between data from different years, and reference to TNM completion will be highlighted throughout the report where this will limit the interpretation of results. 4.2 Performance Against Agreed Quality Measures and QPIs Results of analysis of Renal Cancer Quality Performance Indicators (QPIs) are set out in the following section. Results of analysis for prostate, bladder, testicular and RPU cancers are set out against selected performance criteria in subsequent sections. Graphs and charts have been provided where this aids interpretation and, where appropriate, numbers have also been included to provide context. Results are presented in sections by tumour type. Data (both graphically and in tabular format) is presented by location of diagnosis with some criteria given as an overall West of Scotland (WoS) representation. Specific Regional and NHS Board actions have been identified to address issues highlighted through the data analysis. Final Published Urological Cancer MCN Audit Report v1.1 09/04/

16 4.2.1 Renal Cancer Quality Performance Indicators Introduction Quality Performance Indicators (QPIs) were implemented for patients diagnosed with renal cancer from 1 st January The Scottish Cancer Taskforce has taken forward the development of national tumour-specific QPIs for all cancers which will facilitate improved national comparative reporting and drive continuous improvement for patients. Reporting against QPIs is a mandatory requirement for NHSScotland Boards as set out in CEL 06 (2012). Although eight renal cancer QPIs are published (v1.1, 2 nd April 2012) and were implemented on 1 st January 2012, only QPIs 1 to 7 are detailed within this report as measurement against QPI 8 requires a twelve-month time lapse from date of diagnosis, therefore this indicator will be reported for patients diagnosed in 2012 in next year s audit report. This will ensure all eligible patients are captured in the analysis against this QPI. A QPI relating to the proportion of patients discussed at a Multi-Disciplinary Team meeting (MDT) has recently been developed and will be added to future renal QPI publications as the development process progresses. QPI reporting is a dynamic process; indicators and target levels will be kept under regular review and be responsive to changes in clinical practice and emerging evidence 1. Renal Cell Carcinomas (RCC) account for approximately 90% of all renal cancers 14, the most common subtype of which are clear cell. Rarer types of renal cancer include Transitional Cell Carcinomas (TCC) which respond to treatment which is more similar to that of bladder cancer and therefore these tumour types will be included in the development of QPIs for bladder cancer 1. The Renal Cancer QPI development group therefore agreed to focus QPI development on Renal Cell Carcinoma (RCC) 1 and the terms RCC and renal cancer are used interchangeably throughout this report. Background There were 390 new diagnoses of renal cancer captured by audit in the West of Scotland (WoS) in This represents 15.5% of all new WoS urological cancer diagnoses in 2012, and distribution by location of diagnosis is shown below in Table 6. Table 6: Number and proportion of patients diagnosed with renal cancer in 2012 by location of diagnosis Number of new cases Proportion of WoS Total (%) 13.6% 52.8% 10.5% 23.1% Renal cancer is more common in the male population with 54.9% of cases diagnosed in males in The median age at diagnosis was 68 years in both males and females. Relative survival from renal cancer is increasing 11 however the incidence of renal cancer is predicted to rise significantly by Data Quality Audit data quality can be assessed in the first instance by estimating the proportion of expected patients that have been identified through audit. Case ascertainment for renal cancer across the WoS showed an excellent level of data capture at 103.7% in The range between NHS Boards was 93.2% to 125.0% and this is likely to reflect yearly fluctuations in the number of new diagnoses, especially within the smaller Boards. Final Published Urological Cancer MCN Audit Report v1.1 09/04/

17 The 2011 audit report aimed to highlight areas where issues of data quality might impact the validity of the QPIs which would apply to patients diagnosed from 1 st January TNM staging was identified as one of the key areas where improvement would be essential in order for robust measurement of a number of QPIs, and indeed QPI 3 measures this directly for the whole cohort. This has proven to be a successful strategy in that 94.9% of patients diagnosed in 2012 have a TNM stage recorded prior to treatment compared to only 56.3% of patients in Resultantly, measurement against QPIs in 2012 which rely on TNM staging will be more accurate and will enable comparison with future analysis providing this level of data capture is maintained, or indeed improved upon. NHSGGC achieved 90.8% against this target and have commented that they will strive to record TNM data for 100% of future patients. Although outcome measures were reported in last year s audit report using the pre-qpi dataset that were designed to approximate the upcoming QPIs, 2012 data has not been reported against 2011 data and comparative yearly analysis will recommence from the time of QPI implementation. Final Published Urological Cancer MCN Audit Report v1.1 09/04/

18 QPI 1: Radiological diagnosis prior to first treatment Although pathological assessment is required for definitive diagnosis of renal cell carcinoma, radiology is an accurate diagnostic tool in almost all cases of renal cancer and is the first line of investigation. Patients with renal cell carcinoma should undergo CT with contrast to assess the extent of local and distant metastatic disease 15 prior to first treatment. The QPI measures the number of patients who undergo pre-treatment cross-sectional imaging of the chest, abdomen and pelvis with contrast, and the results are presented by Board of diagnosis in Figure 4. Numerator: Denominator: Number of patients receiving active treatment with a diagnosis of RCC who undergo crosssectional imaging (CT) of the chest, abdomen and pelvis (with contrast) before first treatment. All patients receiving active treatment (partial or radical nephrectomy, cryotherapy, radio frequency ablation or systemic therapy) with a diagnosis of RCC. Exclusions: Patients who refuse treatment. Patients who underwent cross sectional imaging (CT) without intra venous (IV) contrast. Patients who died before first treatment. Target: 100% Figure 4: Proportion of patients with RCC diagnosed in 2012 that underwent pre-treatment cross-sectional imaging of the chest, abdomen and pelvis (QPI 1) Proportion of patients (%) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% QPI target (100%) NHS Board of diagnosis Radiological diagnosis Total no. of patients In 2012, only NHS Ayrshire and Arran has achieved the 100% target set by this QPI. The QPI specifically measures those patients who have received a CT chest, abdomen and pelvis (CT CAP). It is likely that a number of patients have had only a CT chest and abdomen performed as staging investigations, however these patients are deemed to have not met the criteria for this QPI. As increasing numbers of patients are diagnosed following scans performed for other reasons a dedicated renal CT examination may be requested to complete the diagnostic work-up and further scanning of the pelvis may not be deemed clinically necessary. This indicator very closely aligns with QPI 3 Clinical Staging by TNM whereby complete staging can only be achieved in patients who have undergone a full diagnostic work-up. It is highlighted by QPI 3 Final Published Urological Cancer MCN Audit Report v1.1 09/04/

19 performance that both NHS Forth Valley and NHS Greater Glasgow and Clyde, who achieved performance levels below the WoSCAN average for QPI 1, have appropriately staged the majority of their patients using TNM classification before first treatment (97.6% and 90.8% respectively), which in turn requires these patients to have had a radiological diagnosis. There were 4 patients within NHSGGC that did not have sufficient data recorded to determine exclusion against the above measure and therefore it is possible they should have been excluded from the denominator. The potential impact on performance for NHSGGC as a result, is that performance has been decreased by a maximum of 2.8%. All other Boards had 100% of data recorded. Action required: NHSGGC and NHS Forth Valley to review diagnostic pathways to ensure that patients receive clinically appropriate radiological diagnosis. Final Published Urological Cancer MCN Audit Report v1.1 09/04/

20 QPI 2: Histological diagnosis prior to treatment It is important to confirm a diagnosis of renal cell carcinoma (RCC) prior to any minimally invasive therapies such as radiofrequency ablation (RFA), cryotherapy or systemic anti-cancer therapy (SACT) to avoid treatment of non-malignant lesions. Additionally if SACT is being considered it must be known that there is a definitive diagnosis of RCC as other types of renal cancer may not respond to these treatments 1. Numerator: Denominator: Number of patients with RCC for whom surgery is not the first treatment who have a histological diagnosis (confirmed by biopsy) before first treatment. All patients with RCC for whom surgery is not the first treatment. Exclusions: Patients who refuse treatment Patients receiving supportive care only (not for active treatment) Patients receiving active surveillance Patients who died before treatment Histology not assessable Target: 100% Figure 5 refers to those patients for whom surgery was not the first treatment recorded. The proportion of patients having a histological diagnosis prior to treatment is described by location of diagnosis. Patients who refused treatment, those who died before first treatment, patients who received supportive care only and patients for whom it was decided to watch and wait have not been included, nor have patients for whom the pathologist deemed the histology not assessable. Figure 5: Proportion of patients with RCC diagnosed in 2012 (where surgery is not the primary treatment) who have a histological diagnosis before treatment, via biopsy (QPI 2) Proportion of patients (%) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% QPI target (100%) NHS Board of diagnosis Histological diagnosis Total no. of patients The numbers of patients in the above analysis, detailed in the data table accompanying Figure 5, are low, especially for the smaller Boards, and this has a considerable effect on proportions. NHS Lanarkshire has reviewed cases and, of the 2 patients who did not meet the target in NHS Lanarkshire, 1 patient had emergency radiotherapy to metastases prior to surgery and 1 patient had palliative radiotherapy. Final Published Urological Cancer MCN Audit Report v1.1 09/04/

21 NHSGGC has commented that in some cases there is minimal clinical benefit and possible risk involved in taking a biopsy prior to treatment, and the 6 cases not meeting the target in NHSGGC will be reviewed to establish whether this was the case for these individual patients. It is evident from the low numbers included in the above analysis that the 100% target may be difficult for Boards to achieve year on year as smaller numbers are more susceptible to large fluctuations in percentages. Overall, 80.5% of patients met the target in WoS in It should also be noted that, further to ISD dataset review at 12 months post implementation, the measurability of this QPI has been changed to ensure accuracy, therefore figures for following years analyses may differ. Action required: NHSGGC to review cases that do not have a histological diagnosis to ascertain if there is clear clinical reason for biopsy not being undertaken and act on findings, where appropriate. Final Published Urological Cancer MCN Audit Report v1.1 09/04/

22 QPI 3: Clinical Staging by TNM Patients with RCC should be staged using the TNM staging system. It is important that patients are staged clinically to aid treatment decisions. It is vital that data is recorded for the ct, cn and cm stage as all three data fields are required to enable stage of disease at presentation to be determined. This will also facilitate analysis of additional performance indicators which are based on disease stage. Numerator: Denominator: Exclusions: None Target: 100% Number of patients diagnosed with RCC who were clinically staged using TNM staging system before first treatment. All patients diagnosed with RCC Figure 6: Proportion of patients diagnosed in 2012 whose RCC is staged prior to treatment using the TNM staging system (QPI 3) Proportion of patients (%) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% QPI target (100%) NHS Board of diagnosis Clinically staged (TNM) Total no. of patients NHS Ayrshire & Arran and Lanarkshire have both achieved the QPI target of 100%. Only one patient was not clinically staged in Forth Valley, resulting in 97.6% of patients meeting the criteria against the 100% target. NHSGGC has commented that there has been significant improvement in the recording of TNM data (63.9% in 2011 to 90.8% in 2012) and that they will strive to record TNM data for all future patients. A review of all cases which did not meet the target revealed that 13 of these 19 patients were discussed at MDT therefore it would be beneficial to establish whether this was a data recording issue, or whether TNM data was not available at the time of MDT discussion. Staging data is generally very good across the WoS in 2012 at 94.9% and improvement in NHSGGC will greatly influence the overall WoS result for As staging information underpins many of the QPIs for renal cancer it is also essential that Boards which have achieved the QPI target of 100% maintain this excellent performance going forward. Action required: NHSGGC should establish whether missing staging information for renal cancer patients is a data recording issue or result of MDT processes. Final Published Urological Cancer MCN Audit Report v1.1 09/04/

23 QPI 4: Histological (Fuhrman) Grading for clear cell carcinomas undergoing resection Fuhrman grade can be used to determine prognosis and treatment 1. In 2012, 176 of 177 patients diagnosed with clear cell renal carcinoma who underwent surgical resection were histologically graded using the Fuhrman grading system, equating to 99.4%. All NHS Boards have achieved the QPI target of greater than or equal to 95%, demonstrating excellent performance against this indicator. Numerator: Denominator: Exclusions: None Target: 95% Number of patients with histological diagnosis of RCC on a surgical resection specimen whose clear cell RCC is graded using the Fuhrman grading system. All patients with clear cell RCC who undergo surgical resection Figure 7: Proportion of patients diagnosed in 2012 whose RCC is histopathologically graded using the Fuhrman grading system (QPI 4) Proportion of patients (%) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% QPI target ( 95.0%) NHS Board of diagnosis Histopathological grade (Fuhrman) Total no. of patients Final Published Urological Cancer MCN Audit Report v1.1 09/04/

24 QPI 5: Surgical treatment for patients with non-metastatic disease In patients with non-metastatic renal cancer (T1-3N0M0), radical nephrectomy (RN) is the standard treatment choice for patients who are not suitable for minimally invasive procedures 1. Patients who refuse treatment or who are eligible for a more suitable treatment are not included in the denominator and this accounts for the 100% target against this Quality Performance Indicator. Numerator: Denominator: Number of patients with T1-3N0M0 RCC without evidence of metastatic disease at diagnosis who undergo radical nephrectomy (either by open or laparoscopic procedure). All patients with T1-3N0M0 RCC without evidence of metastatic disease at diagnosis Exclusions: Patients who refuse treatment Patients who undergo nephron sparing treatment (partial nephrectomy, cryotherapy or RFA) Patients receiving supporting care only (not for active treatment) Patients receiving active surveillance (no active treatment) Patients who died before first treatment Target: 100% As with many of the outcome measures, QPI 5 is reliant on the completeness of clinical TNM staging information for accurate measurement. Three of the four WoS Boards have excellent completeness of TNM data for renal cancer patients, and therefore results illustrated in Figure 8 provide accurate analysis for patients diagnosed in NHS Ayrshire & Arran, Forth Valley and Lanarkshire. There were 3 patients in NHSGGC that did not have sufficient information recorded to determine inclusion in the denominator for this measure and therefore the figures below may underestimate the number of eligible patients in NHSGGC by up to 4.6%. Figure 8: Proportion of patients diagnosed in 2012 with non-metastatic RCC, not suitable for nephron sparing surgery, treated by radical nephrectomy (QPI 5) Proportion of patients (%) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% QPI target (100%) NHS Board of diagnosis Radical nephrectomy Total no. of patients NHS Forth Valley and Lanarkshire did not achieve the 100% target, achieving 88.9% and 97.2% respectively, resulting in an overall WoS result of 98.4%. Although this falls short of the 100% target, it should be noted that in both Boards this equates to one patient and small numbers also influence proportions in NHS Forth Valley. Although the QPI excludes patients who died before first treatment, the patient who did not meet the criteria in NHS Lanarkshire had radiotherapy as first treatment but subsequently died before surgical treatment. Final Published Urological Cancer MCN Audit Report v1.1 09/04/

25 QPI 6: Nephron sparing surgery Nephron sparing surgery (NSS) is appropriate surgical treatment for patients with early stage disease (T1aN0M0) and clinical trials have indicated comparable long-term survival with radical treatment 15,16. The advantages of NSS are improved renal function and lesser chance of post-operative cardiovascular complications 1. It is however recognised that some patients may opt to have laparoscopic radical nephrectomy, rather than open nephron sparing surgery, due to the shorter recovery time and the decreased risk of post-operative complications. The QPI therefore has a target to reflect patient choice and requires that 40% of T1a patients undergo nephron sparing surgery. Numerator: Denominator: Number of patients with a T1aN0M0 RCC undergoing NSS (laparoscopic partial nephrectomy or open procedure partial nephrectomy). All patients with T1aN0M0 RCC Exclusions: Patients who refuse treatment Patients who undergo nephron sparing treatment (partial nephrectomy, cryotherapy or RFA) Patients receiving supporting care only (not for active treatment) Patients receiving active surveillance (no active treatment) Patients who died before first treatment Target: 40% Figure 9 illustrates that all Boards have achieved this target in 2012 and, on average, 54.3% of patients diagnosed with early stage disease across the WoS have undergone NSS. Figure 9: Proportion of patients diagnosed in 2012 with T1a RCC who received nephron sparing surgery (QPI 6) Proportion of patients (%) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% QPI target ( 40.0%) Error bars NHS Board of diagnosis Nephron sparing surgery Total no. of patients Although the QPI target was met by all boards in 2012 there is potential for significant variation year on year on the reported rates of nephron surgery due to the relatively small numbers of eligible cases. Final Published Urological Cancer MCN Audit Report v1.1 09/04/

26 QPI 7: Thirty-day mortality Thirty-day mortality following treatment is shown in Figure 10 for all patients diagnosed in WoS by treatment type, against the evidence-based target of less than 5%. The treatment types included in analysis are cryotherapy, radiofrequency ablation (RFA), systemic anti-cancer treatment (SACT) and surgery. Table 7 also illustrates this information in more detail at Board level. Numerator: Denominator: Number of patients who undergo minimally invasive (Cryotherapy, RFA or SACT) or operative treatment as first treatment for RCC who die within 30 days of first treatment. All patients who undergo minimally invasive (Cryotherapy, RFA or SACT) or operative treatment as first treatment for RCC. Exclusions: Patients who undergo emergency surgery (nephrectomy). Target: < 5% Figure 10: Proportion of patients diagnosed in WoS who died within 30 days of treatment by treatment type (QPI 7) Proportion of patients (%) 10% 9% 8% 7% 6% 5% 4% 3% 2% 1% 0% QPI target (< 5.0%) Cryotherapy RFA SACT Surgery Type of treatment Table 7: Number of patients who died within 30 days of Cryotherapy, RFA, SACT or Surgery by NHS Board a) Cryotherapy b) RFA c) SACT d) Surgery AA GGC FV Lan AA GGC FV Lan AA GGC FV Lan AA GGC FV Lan N D Numerator (N) = Number of patients who died within 30 days of treatment; Denominator (D) = Total number of patients The target was achieved across the WoS for all treatment types with the exception of SACT. Of the 18 patients treated with SACT, 1 patient died within 30 days of treatment which equates to a 5.6% mortality rate for WoS. This case was one of two patients receiving systemic anticancer treatment in Lanarkshire in NHS Lanarkshire has reported that the patient died from non cancer-related issues. This highlights the importance of remaining vigilant when interpreting these results and demonstrates the effect small numbers can have, resulting in large percentage fluctuations. Of the 213 patients diagnosed in WoS in 2012 that received surgery as first treatment, there were 2 post-surgical deaths which occurred within 30 days. This equates to a WoS surgical mortality rate of 0.9% in 2012 which is lower than the 2011 rate of 1.5% and below the QPI target of less than 5.0%. Both deaths occurred in NHS Lanarkshire resulting in a 3.7% post-surgical mortality rate in this Board and, though this is below the QPI target of less than 5.0%, NHS Lanarkshire will be asked to review both cases and report back to the MCN on the completion of the review. Final Published Urological Cancer MCN Audit Report v1.1 09/04/

27 QPI 8: Systemic therapy for advanced/ metastatic disease Patients with advanced and/or metastatic renal cell carcinoma (RCC) should receive systemic therapy between diagnosis and death 1 (pg.15). To ensure accurate reporting of this QPI, i.e. that all patients are included where a year has elapsed since their diagnosis, patients diagnosed in the twelve months from 1 st January 2012 to 31 st December 2012 will be reported in the 2013 audit report. Numerator: Denominator: Number of patients with RCC which is advanced and / or metastatic at time of diagnosis where at least 12 months have elapsed since diagnosis, irrespective of whether or not they have died, who receive first treatment with SACT, within 12 months of diagnosis. All patients with RCC which is advanced and / or metastatic at time of diagnosis where at least 12 months have elapsed since diagnosis irrespective of whether or not they have died. Exclusions: Patients with a performance status of 2, 3 or 4 at time of diagnosis Patients who refused systemic treatment Patients enrolled in a clinical trial Target: 70% Conclusions Overall WoS NHS Board performance against the Renal Cancer Quality Performance Indicators is good, with NHS Ayrshire & Arran meeting 100% of targets for the above indicators. Four of the renal QPIs have a target of 100%, the extremely challenging nature of which should be recognised. Some areas for improvement have however been highlighted, notably that the recording of TNM data remains of primary importance to enable the inclusion of all eligible patients in the analysis and this has been achieved on the whole, unless where otherwise stated. There has been considerable improvement in data recording and capture since 2011 which has enabled accurate reporting against the majority of Renal Cancer Quality Performance Indicators for 2012 audit data. Actions relating to service provision have been identified, NHS Boards are asked to develop local Action/Improvement Plans in response to the findings presented in the report. The Urological Cancer MCN will actively monitor progress against all actions and escalate any areas of concern through the Regional Cancer Advisory Group. Final Published Urological Cancer MCN Audit Report v1.1 09/04/

28 4.2.2 Prostate Cancer Clinical staging using TNM As aforementioned, it is important that patients are staged clinically to aid treatment decisions and it is vital that data is recorded indicating the TNM stage so that it can be used to measure against other quality indicators. Determining at what stage of disease patients are presenting will also establish whether disease stage at presentation is improving for patients diagnosed with cancer. Figure 11 presents the proportion of prostate cancer patients that had complete T, N and M information recorded for 2011 and All NHS Boards have demonstrated improvement since 2011, with the exception of Forth Valley which decreased slightly from 100% to 97.3%. NHS Lanarkshire has made excellent improvement on TNM recording since 2011; however it remains the only NHS Board with less than 90% of patients with complete TNM data recorded in Although not directly measured as an upcoming prostate QPI, TNM staging will be required to measure against three of the published QPIs for prostate cancer 2 and therefore it is essential that this data is complete to ensure all appropriate patients are included in the analysis. Figure 11: Proportion of prostate cancer patients with TNM recorded by year and location of diagnosis Proportion of patients (%) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% NHS Board of diagnosis TNM completed Total no. patients Action required: NHSGGC and NHS Lanarkshire must ensure local processes are in place to support necessary improvement in the capture of clinical TNM staging information for all prostate cancer patients. Final Published Urological Cancer MCN Audit Report v1.1 09/04/

29 Volume of prostatectomy surgeries per surgeon Radical prostatectomy should be performed by surgeons who regularly perform the procedure as higher volume is associated with better post operative outcomes 2. The surgical volume of prostatectomy procedures presented is the number of procedures carried out by each surgeon in 2012 on patients diagnosed in WoS, irrespective of the date of diagnosis, which may have been prior to Table 8 details the number of procedures performed by each surgeon in 2012 by the location of surgery. There were 124 radical prostatectomies performed in 2012, compared to 121 in 2011 and 145 in Table 8: Number of radical prostatectomies performed per surgeon in 2012 Board of Surgery AA GGC FV Lan Lothian WoS Surgeon A B C D E F G H J K Total No. performed There are several caveats to the results presented in Table 8. These audit data include only those patients diagnosed in the NHS and individual surgeons may perform further operations in the private sector. Surgeons J and K are based in NHS Lothian therefore this number refers exclusively to patients diagnosed in the WoS and operated on in Surgeons C and D operated together in 3 cases however the operations are only counted against one surgeon according to the pre-qpi dataset. The upcoming QPI measures will permit credit to be attributed to each surgeon in these cases and resultantly credits for surgeons C and D would be 16 and 20 respectively. A surgical volume QPI has been developed for prostate cancer however rather than collecting the information through clinical audit for reporting of this indicator, data will be obtained through the Scottish Morbidity Records (SMR01) system. This will maximise the use of data which are already collected and remove the need for any duplication of data collection. The target for the QPI is 12 radical prostatectomies per surgeon in a single year period. Although the data presented in Table 8 is not directly comparable, it should give NHS Boards some useful information for planning and impact assessment purposes. Surgeon 5 performed a cystoprostatectomy and these operations will not be included when measuring performance against the surgical volume QPI. Final Published Urological Cancer MCN Audit Report v1.1 09/04/

30 Surgical margin involvement of pt2 patients undergoing radical prostatectomy Prostate cancers that are organ confined and treated with radical prostatectomy should be free from margin involvement post-surgery. Positive surgical margin (PSM) is an independent prognostic factor in adversely impacting biochemical recurrence free (PSA failure) period and progression free survival 2 (pg.11). As this outcome measure relates specifically to patients with organ confined disease i.e. pt2 patients, it is necessary for pathological stage information to be recorded, for patients to be included. Figure 12: Proportion of patients diagnosed in 2011 and 2012 with involved margins following radical prostatectomy Proportion of patients (%) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% NHS Board of diagnosis b Margins involved Margins not involved Not recorded Total patients This outcome measure is based on a QPI and the target set for this QPI is that less than 25% of patients should have involved surgical margins following radical prostatectomy. All Boards have improved on 2011 performance which has resulted in an overall improvement in the West of Scotland from 24.7% of patients in 2011 to 21.4% of patients in 2012 having involved surgical margins. All Boards with the exception of NHS Lanarkshire have achieved the proposed QPI target in 2012 which gives a good indication that this target is achievable for the prostate QPI report in June NHS Lanarkshire has shown improvement since 2011; however 28.6% of pt2 patients undergoing radical prostatectomy had involved surgical margins in Action required: NHS Lanarkshire should initiate a review of cases where margins were involved and take appropriate action against findings. b Figures reported in 2011 Audit Report for NHS Forth Valley showed 4/10 patients with involved margins. Errors in data capture identified by NHS FV showed that 5 eligible pt2 patients had not been included in the analysis and the revised figures were reported as 4/15 patients having involved surgical margins in Final Published Urological Cancer MCN Audit Report v1.1 09/04/

31 Hormone therapy as first treatment for metastatic patients This measure is based upon a QPI which measures the proportion of patients having immediate hormone therapy for metastatic disease 2. With the QPI in mind and using the existing dataset, the MCN agreed to a measure which calculates the proportion of patients having primary hormone therapy (HT) or hormone therapy as first treatment for metastatic disease (TanyNanyM1). Patients entered into a clinical trial or patients refusing HT, or any treatment, were excluded. For patients to be selected for this measure, it must be known whether the patient has presented with metastatic disease. Figure 13 illustrates the completeness of the metastases (M) stage for all patients diagnosed in 2010, 2011 and All Boards have made significant improvement in data capture since 2010 with NHS Ayrshire & Arran and Forth Valley capturing 100% of data in Figure 13: Proportion of patients diagnosed between 2010 and 2012 with a clinical metastases stage recorded Proportion of patients (%) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% A&A GGC FV Lan WoS NHS Board of diagnosis As there are no two years where data completeness is consistent across the four Boards and results are therefore not comparative, Figure 14 instead displays the proportion of patients with clinical metastases recorded in 2012 alongside the proportion of metastatic patients who received hormone therapy as first treatment in 2012 to indicate reliability of the results. Information in the accompanying table shows the number of metastatic patients receiving hormone therapy in 2011 and 2012; however comparisons between years should be made with caution. Final Published Urological Cancer MCN Audit Report v1.1 09/04/

32 Figure 14: Proportion of patients diagnosed in 2012 with clinical metastases stage recorded and percentage of metastatic patients who received hormone therapy as first treatment Clinical metastases stage recorded Hormone therapy as first treatment Proportion of patients (%) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% NHS Board of diagnosis HT as first treatment No HT Not recorded Total patients Final Published Urological Cancer MCN Audit Report v1.1 09/04/

33 4.2.3 Bladder Cancer KOM1: Clinical TNM Staging of bladder cancer determines treatment options and is directly proportional to clinical outcome 17. All bladder cancer patients should therefore be staged according to the TNM classification. Figure 15: Proportion of bladder cancer patients with clinical TNM recorded by location of diagnosis, Proportion of patients (%) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% NHS Board of diagnosis N D Numerator (N) = Number of patients with clinical TNM recorded; Denominator (D) = Total number of patients With the exception of NHS Forth Valley, TNM data has been historically poorly recorded across WoSCAN. Improvement from 2011 data capture is evident in all NHS Boards in 2012, with three of the four Boards achieving 100% of patients with TNM data recorded. Further improvement is required in NHSGGC to capture stage data, to enable accurate assessment of performance against this measure. Action required: NHSGGC must ensure local processes are in place to support necessary improvement in the capture of clinical TNM staging information for all bladder cancer patients. KOM2: Grade of tumour Grading of bladder cancer relates to treatment and is directly proportional to clinical outcome. Grade of tumour should be recorded for all patients with transitional cell carcinoma (TCC) having a transurethral resection of bladder tumour (TURBT). There were 545 patients identified across WoSCAN with transitional cell carcinoma who had a TURBT. Of these, only 4 patients did not have grade of tumour recorded (0.7%). This is a similar result to 2011 and as there is little room for improvement, this suggests that this is not an area where further work needs to be focussed. NHS Boards should strive to maintain excellent performance in this area. Final Published Urological Cancer MCN Audit Report v1.1 09/04/

34 KOM3: Neo-adjuvant chemotherapy prior to radical therapy There is strong evidence to support the use of neo-adjuvant chemotherapy for patients with T2-T4 transitional cell carcinoma (TCC) of the bladder prior to radical therapy 18. Additionally there is a survival advantage of 5% at five years regardless of local therapy given 18. The agreed outcome measure states that neo-adjuvant chemotherapy should be offered to suitable patients prior to definitive radical therapy for patients with T2-T4 transitional cell carcinoma of the bladder. Definitive radical therapy is considered to be primary radical radiotherapy, cystectomy or chemoradiotherapy. This is in line with the WoSCAN Regional Clinical Management Guideline (CMG) v3 for Muscle Invasive Early Bladder Cancer (re-issued December 2012) 19. Figure 16: Proportion of T2-T4 TCC patients having neo-adjuvant chemotherapy by location of diagnosis Proportion of patients (%) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% NHS Board of diagnosis Neo-adj chemo No neo-adj chemo Not recorded Total Poorly recorded historical TNM data is described earlier in the report and the results of this outcome measure are limited as the number of patients included will be underestimated in 2010 and However, amongst those patients known to have T2-T4 TCCs, the proportion receiving neo-adjuvant chemotherapy is less than 50% across the West of Scotland in each year, as illustrated in Figure 16. Only taking into account those results with TNM data recorded for over 95% of patients (bold type), the proportion of patients having neo-adjuvant chemotherapy varies from a minimum of 20.0% to a maximum of 66.6%. NHS Forth Valley is the only NHS Board with comparable data over three years and yearly fluctuation is evident with a minimum of 37.5% in 2011 and a maximum of 66.7% in 2012 having neo-adjuvant chemotherapy. The small numbers in Forth Valley should be taken into consideration when making comparisons however. There have been historical issues with capture of oncology information, however access has now been granted to the ChemoCare prescribing system for NHS Boards outwith GGC and it is anticipated that this will help improve access to chemotherapy information. Final Published Urological Cancer MCN Audit Report v1.1 09/04/

35 Evidence indicates that neo-adjuvant chemotherapy is not indicated in patients with a performance status of 2 or greater 20. Performance status is not recorded for bladder cancer patients in the current dataset therefore these patients could not be excluded. A proportion of patients with abnormal renal function will not be candidates for neo-adjuvant therapy 20 however it is not possible to identify these patients from the audit dataset. These limitations should be considered when reviewing results and may explain the variation seen across NHS Boards. KOM4: Radical cystectomy for localised muscle-invasive cancers Radical cystectomy (RC) is the standard treatment for localised muscle-invasive (T2-T4aNanyM0) bladder cancers 20. Figure 17 presents the proportions of T2-T4a patients having radical cystectomy (this includes cystoprostatectomy). Figure 17: Proportion of T2-T4a bladder cancer patients having RC by location of diagnosis, Proportion of patients (%) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% NHS Board of diagnosis Had RC Total Poor recording of TNM is described earlier in the report and therefore the results of this outcome measure are limited, especially in 2010 and 2011, as the number of patients included will be underestimated. Of the patients identified, most areas have low proportions receiving radical cystectomy, albeit low numbers are involved in several NHS Boards. Again, looking only at figures where over 95% of patients had TNM recorded (bold type), the proportion of patients undergoing a radical cystectomy ranges between 14.3% and 25.0% of patients diagnosed with localised muscleinvasive bladder cancer. Improvements in the capture of TNM data is required to enable full assessment of performance against this measure. Final Published Urological Cancer MCN Audit Report v1.1 09/04/

36 KOM5: Lymph node dissection for radical cystectomy patients The European Association of Urologists (EAU) recommends, lymph node dissection should be an integral part of cystectomy, however the extent of the dissection has not been established 20. The proportion of radical cystectomy patients (for all stages of disease) having lymph node dissection (LND) is presented in Figure 18. Overall in WoSCAN, 100% of patients undergoing radical cystectomy had lymph nodes dissected in This is an improvement on 2010 and 2011 when 65% and 68% of RC patients had a LND respectively. Greater Glasgow and Clyde have achieved 100% in the last two years and all other Boards have seen an improvement to 100% in Figure 18: Proportion of RC patients diagnosed between 2010 and 2012 having LND by location of diagnosis Proportion of patients (%) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% NHS Board of diagnosis LN Dissection No LN Dissection Not recorded Total There are small numbers involved in many areas however 2012 has seen a more consistent approach across the West of Scotland compared to previous years. Data recording issues in NHS Lanarkshire have been addressed since 2011 with 100% of data now recorded. Bladder cancer QPIs published in February 2014 include a QPI relating to lymph node dissection, recommending a target number of 10 lymph nodes to be dissected for each patient 3. KOM6: Thirty day mortality for radical cystectomy patients There were no recorded deaths following radical cystectomy across the region in the 49 patients diagnosed in 2012 undergoing radical cystectomy. This indicates consistent regional performance with 0.0% mortality for radical cystectomy patients over the last three years. One patient did not have date of death recorded in NHS Ayrshire & Arran in 2012 however. Final Published Urological Cancer MCN Audit Report v1.1 09/04/

37 KOM7: Palliative chemotherapy for metastatic patients TNM staging information has improved across the West of Scotland from 2011 to 2012 with 89.6% of patients having a metastases (M) stage recorded in Due to very poorly recorded TNM staging information in 2010 and 2011 however, performance against this outcome cannot be accurately compared between years. Three NHS Boards had 100% of TNM data recorded in 2012 and the proportion of these patients undergoing palliative chemotherapy varies between 0.0% and 20.0% in these Boards. Very small numbers are involved here, as illustrated in Figure 20, and therefore it is not appropriate to make comparisons between Boards even with 100% of TNM data completeness. Figure 19: Proportion of bladder cancer patients with clinical metastases stage recorded, diagnosed Proportion of patients (%) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% NHS Board of diagnosis Figure 20: Proportion of metastatic bladder cancer patients diagnosed in 2012 undergoing palliative chemotherapy Proportion of patients (%) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% NHS Board of diagnosis Palliative chemotherapy Non-palliative chemotherapy No chemotherapy Total no. of patients Final Published Urological Cancer MCN Audit Report v1.1 09/04/

38 Further improvement in NHSGGC must be made in the capture of TNM data to allow robust assessment of the service provided to metastatic patients. It is anticipated that with the implementation of Quality Performance Indicators there will an increased focus on the need for clinical TNM that will drive the improvement of data capture. KOM8: Thirty day mortality post-completion of systemic chemotherapy A total of 51 patients diagnosed in 2012 received systemic chemotherapy in WoS and Figure 21 illustrates the distribution of these patients across the four NHS Boards. There was one death within thirty days of completion of systemic therapy and this occurred in NHS Lanarkshire. This equates to a 2.0% mortality rate for the West of Scotland for patients receiving systemic chemotherapy. Figure 21: Number of bladder cancer patients receiving systemic chemotherapy who died within 30 days Died within 30 days Alive at 30 days 30 Number of patients AA GGC FV Lan NHS Board of diagnosis Final Published Urological Cancer MCN Audit Report v1.1 09/04/

39 4.2.4 Testicular Cancer Surgical treatment Surgery is the standard treatment for testicular cancer and 94.3% of the 87 patients diagnosed with testicular cancer in 2012 were treated surgically, 98.8% of which were recorded as having an orchidectomy. This equates to 93.1% of all testicular patients in 2012 having had an orchidectomy and this is a decrease from 2011 figures when 100% of the 101 patients diagnosed underwent orchidectomy. NHS Ayrshire & Arran has however commented that one patient was incorrectly coded and 100% of their patients did in fact receive surgery. This would bring the overall WoS total to 94.3% of testicular cancer patients undergoing orchidectomy in All patients who undergo an orchidectomy should be offered a prosthesis 21. The option of having a prosthesis fitted was recorded as being discussed with 75.6% of patients diagnosed in 2012 undergoing orchidectomy. This is a slight improvement on last year when 74.3% of patients were recorded as having been offered a prosthesis. Previous years have shown 56% and 48% recorded as having been offered in 2009 and 2010 respectively. Although the trend here is encouraging, work is ongoing to ensure all men are offered a prosthesis and to ensure data capture adequately reflects local practice. Of the 62 patients offered a prosthesis, only 37.1% (23 patients) had a prosthesis inserted. NHS Lanarkshire was the only NHS Board to record that 100% of patients were offered a prosthesis and only 6.7% of patients accepted the offer. Action required: NHSGGC and NHS Ayrshire & Arran should review local processes to ensure that all testicular cancer patients undergoing orchidectomy are offered a prosthesis and the patient response is documented. Chemotherapy treatment Chemotherapy treatment was received by 71.3% of testicular cancer patients diagnosed in the WoS in This figure is based upon all testicular cancer patients with the exception of those patients who refused treatment. Figure 22 illustrates the small numbers of patients diagnosed with testicular cancer within individual NHS Boards and the numbers of these patients who received chemotherapy treatment in 2010, 2011 and Figure 22: Number of patients diagnosed with testicular cancer between 2010 and 2012 receiving chemotherapy 70 Chemotherapy No chemotherapy Not recorded Number of patients AA GGC FV Lan NHS Board of diagnosis by year Final Published Urological Cancer MCN Audit Report v1.1 09/04/

40 For 2010, 2011 and 2012, NHS Ayrshire & Arran have a lower proportion receiving chemotherapy than the other NHS Boards. Although the number of total patients is low, there are a similar number of patients diagnosed in NHS Forth Valley and NHS Lanarkshire and both areas have higher proportions receiving chemotherapy (71.4% and 75.0% respectively). NHS Ayrshire & Arran have commented that chemotherapy was not deemed necessary in the 6 patients who did not receive it in Application of chemotherapy for testicular cancer is dependent on a range of factors including age, disease stage and morphology of tumour as set out within WoSCAN Clinical Management Guidelines (CMG) for Testicular Cancer 22. Variance across the region should be monitored for compliance with the CMG. Action required: Urological Cancer MCN should continue to monitor variance in chemotherapy rates across Boards to ensure compliance with WoSCAN CMG for Testicular Cancer. Clinical stage of disease Staging of patients at diagnosis aids treatment decisions and can be an indicator of prognosis. To determine the stage of disease for testicular cancer, TNM information is required and additionally a serum (S) value based on a combination of three different serum tumour marker results: alphafetoprotein (AFP), human chorionic gonadotropin (HCG) and lactate dehydrogenase (LDH). Variation is apparent in the proportions of patients where sufficient TNM and S information was recorded to allow a stage of disease to be calculated. Improvements are evident in all four Boards with NHSGGC having sufficient information recorded to calculate disease stage for 100% of patients. Improvements are required across the other three Boards and processes to document this information should be reviewed. It should be noted however that in NHS Ayrshire & Arran and Forth Valley the deficit in each case relates to one patient having insufficient information recorded for staging. Figure 23: Proportion of testicular cancer patients diagnosed in 2011 and 2012 with sufficient information to calculate a clinical disease stage Proportion of patients (%) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% NHS Board of diagnosis Disease stage complete Total patients Action required: NHS Ayrshire & Arran, Forth Valley and Lanarkshire should review processes for the documentation of TNM data and serum tumour markers to further improve the proportion of testicular cancer patients with disease stage calculated. Final Published Urological Cancer MCN Audit Report v1.1 09/04/

41 4.2.5 Renal pelvis and Ureter Cancers Clinical TNM Staging of patients at diagnosis aids treatment decisions and can be an indicator of prognosis. Figure 24 indicates that there has been an overall improvement in the recording of TNM data for patients diagnosed with RPU cancer between 2010 and 2012 across the West of Scotland. Three of the four NHS Boards have achieved 100% of patients with TNM data recorded in 2012; however NHSGGC needs to build on improvements to increase data completeness further. Figure 24: Proportion of RPU cancer patients with TNM recorded by location of diagnosis, 2010 to Proportion of patients (%) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% NHS Board of diagnosis TNM recorded Total Action required: NHSGGC should review processes for the documentation of TNM data to further improve the proportion of patients diagnosed with RPU cancer who have disease stage calculated. Thirty day mortality following nephroureterectomy Of all 75 patients diagnosed in 2012 with RPU cancer, 34 underwent a nephroureterectomy procedure and none of these patients died within 30 days of surgery. Twenty-nine nephroureterectomies were performed in 2011 and again there were no deaths within 30 days of surgery. Of patients diagnosed in 2010, there was one death within 30 days of surgery from 43 nephroureterectomies, equating to a mortality rate of 2.3%. Final Published Urological Cancer MCN Audit Report v1.1 09/04/