SOUTH EAST SCOTLAND CANCER NETWORK PROSPECTIVE CANCER AUDIT

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1 SOUTH EAST SCOTLAND CANCER NETWORK PROSPECTIVE CANCER AUDIT BREAST CANCER 2013 COMPARATIVE AUDIT REPORT Mr Glyn Neades Chair Breast Group and Consultant Surgeon, NHS Fife Mr Matthew Barber, Consultant Surgeon, NHS Mr John Rainey, Consultant Surgeon, NHS Borders Miss Maria Bews-Hair, Consultant Surgeon, NHS Dumfries & Galloway Christine Dodds Senior Cancer Audit Facilitator, NHS Laura Allan, Cancer Audit Facilitator, NHS Dumfries & Galloway Martin Keith, Cancer Improvement, NHS Dumfries & Galloway Maggie McHardy, Cancer Audit Facilitator, NHS Fife Alistair Meikle, Cancer Audit Facilitator, NHS Borders Report no: SA B01/15 Audit Office, c/o Department of Clinical Oncology, Hospital, Crewe Road, Edinburgh, EH4 2XU T: W:

2 BREAST CANCER 2013 COMPARATIVE AUDIT REPORT Patients diagnosed 1 January December 2013 Contents DOCUMENT HISTORY...3 BREAST CANCER 2013 COMPARATIVE AUDIT REPORT...4 Comment by Chair of the Breast Group...4 ACTION POINTS...5 Action Points carried forward from 2012 audit report...6 SUMMARY OF QUALITY PERFORMANCE INDICATORS...7 INTRODUCTION AND METHODS...9 Dataset and Definitions...9 Audit Processes...10 Lead Clinicians and Audit Personnel...10 DATA QUALITY...10 ESTIMATE OF CASE ASCERTAINMENT...10 Clinical Sign-off...11 DIAGNOSIS AND STAGING...12 QPI 1 Non-Operative Diagnosis...12 QPI 2 Pre-Operative Assessment of Axilla (i)...13 QPI 2 Pre-Operative Assessment of Axilla (ii)...14 SURGERY...15 QPI 3 - Conservation Rate...15 QPI 4 - Surgical Margins...16 QPI 5 Immediate reconstruction rate...17 QPI 6 - Negative Axillary Clearance Rate...18 QPI 7 - Minimising Hospital Stay - 23 Hour Surgery*...19 PATHOLOGY...20 QPI 8 - HER2 Status for Decision Making...20 ONCOLOGY...22 QPI 9 - Radiotherapy for Breast Conservation...22 Time to adjuvant Radiotherapy...23 QPI 10 - Adjuvant Chemotherapy...24 Time to adjuvant chemotherapy...26 QPI 11 - Anti-HER2 Positive Therapy...27 Appendix 1 Age at Diagnosis...29 Appendix 2 - Gender...29 Appendix 3 Summary by Key Categories...30 Appendix 4 Overall Workload NHS...34 Appendix 5 Glossary...35 Breast Cancer 2013 Comparative Audit Report 2 Version 4.0 SA B01/15

3 DOCUMENT HISTORY Version Circulation Date Comments Version 1 Lead clinicians 09/10/14 Version 2 Breast Group Action points and 14/11/14 comments agreed Version 3 Breast Group 27/11/2014 Breast Cancer 2013 Comparative Audit Report 3 Version 4.0 SA B01/15

4 BREAST CANCER 2013 COMPARATIVE AUDIT REPORT Comment by Chair of the Breast Group I am pleased to present in this report the 2 nd year of Breast Cancer audit QPI results for the Breast Cancer network. In keeping with the overall aim of, i.e. to promote the highest standards of cancer care and equity of access across the region, I am confident that this report indicates a continuing commitment to providing the highest quality of care for all patients diagnosed with breast cancer in South East Scotland. This is the second year of Breast Cancer QPI reporting. QPIs have provided us with an updated framework against which to measure our performance and compare services not only across the region but also across Scotland. These results will be shared Scotland-wide at the next National meeting of Breast Cancer networks in February At last year s National meeting several areas of concern with the QPI documentation were highlighted. I am pleased that many of these concerns have been remedied in time for the current analysis to be carried out, but within our region we have ongoing concern that some QPIs (e.g. use of adjuvant chemotherapy) may not be set at an appropriate target for achievement. It will be interesting to review the outcomes of other regions for this measure. Others (e.g. Anti-her2 Positive Therapy) are being achieved at a very high level and perhaps do not pose sufficient challenge. It is interesting to note however that wide the use of 23 hour stay is consistently high. Within the current process, the QPIs will be due for review after 3 years of reporting. We are of course reliant on our very committed audit staff for the provision of the excellent, high quality data (as evidenced in the QA results within this report) on which we base this report, allowing us to identify areas of concern at the earliest opportunity. It is particularly worthy of note that in all cases, where there is an indication that individual patient treatments have fallen short of the required standard set out in the QPIs, that the clinical situation has been reviewed. This represents considerable additional time spent by audit staff and clinicians, again indicating a very high level of commitment to ensuring that data is accurate, and we have confidence in the quality of our clinical decision making. As a result of this retrospective examination I am reassured that our patients receive the highest quality of care. There is however an outstanding action from our previous report regarding the accessibility to ultrasound and the provision of a one stop service at St. John s Hospital in West. I believe this is moving forward and I hope we can soon look forward to reporting that equity of care is available at the St. John s clinic. Finally, sincere thanks are due to our audit colleagues for all their hard work particularly in the face of the challenges presented by the QPI s and the associated teething problems these have presented. Mr Glyn Neades, December 2014 Chair, Breast Group Breast Cancer 2013 Comparative Audit Report 4 Version 4.0 SA B01/15

5 ACTION POINTS QPI Action required Person responsible for action Date for update Progress QPI 2 One-Stop clinic St. John s Matthew Barber 01/04/2015 Challenges in appointing to breast radiology post to cover this service, but Jan 2015 is the expected delivery date. QPI 8 Her2 for decision making. Improved MDM documentation is required. All MDMs to ensure Her2 results are documented before or during meetings and these documents are to be made routinely available for audit purposes. Logistics for transporting tissue samples to laboratories is to be reviewed. All MDM chairs tbc 01/04/2015 QPI 10 Patients having adjuvant chemotherapy clinicians to refine current criteria for offering discussion of adjuvant chemotherapy where benefit is calculated to be low. Angela Bowman 01/04/2015 QPI 11 Anti-Her2 positive therapy (chemo & non-chemo patients). WGH clinicians to consider the implications for HER2 positive patients when refining treatment criteria for adjuvant chemotherapy (see above) Angela Bowman 01/04/2015 Breast Cancer 2013 Comparative Audit Report 5 Version 4.0 SA B01/15

6 Action Points carried forward from 2012 audit report QPI Action required Person responsible for action Date for update Progress 2 Preoperative assessment of the axilla St. John s Hospital one-stop clinic: update on progress for Group Not achieved. This Action Point to be carried forward All QPIs Review all QPI documentation post national networks meeting Glyn Neades Wilma Jack Christine Dodds Meeting to discuss documentation: 10/01/14. Draft notes from National Networks Meeting highlighted problem areas with QPI documentation which have resulted in difficulty in agreeing Action Points. Breast Cancer 2013 Comparative Audit Report 6 Version 4.0 SA B01/15

7 SUMMARY OF QUALITY PERFORMANCE INDICATORS QPI 1 Non-operative diagnosis Patients with breast cancer should have a non-operative histological diagnosis QPI 2 Pre-operative assessment of the axilla Target Borders D&G Fife % % % % % % (i) ultrasound examination of the axilla to be performed (ii) where ultrasound findings of the axilla are suspicious, biopsy to be performed QPI 3 Conservation rate Proportion of patients with small tumours having breast conservation rather than mastectomy QPI 4 Surgical margins Proportion of patients where final radial excision margins are <1mm < QPI 5 Immediate reconstruction rate Proportion of mastectomy patients having an immediate reconstruction > QPI 6 Negative axillary clearance rate Proportion of patients undergoing axillary clearance where no pathological evidence of nodal metastases is found QPI 7 Minimising Hospital Stay 23 Hour Surgery Patients should have the opportunity for 23 hour surgery (a maximum of 1 overnight stay following surgery) wherever possible QPI 8 Her2 Status for Decision Making < Her2 Status should be available to inform treatment decision making Breast Cancer 2013 Comparative Audit Report 7 Version 4.0

8 Target Borders D&G Fife QPI 9 Radiotherapy for Breast Conservation After wide local excision patients with breast cancer should receive radiotherapy QPI 10 Adjuvant chemotherapy Proportion of patients (aged 50 70) receiving adjuvant chemotherapy post surgery QPI 11 Anti-Her2 positive therapy Proportion of patients (aged 50 70) with Her2 positive breast cancer >10mm or node positive, who receive anti-her2 positive therapy % % % % % % Achieved Failed Comment: It should be noted that Borders Health Board has a significantly smaller cohort of patients that the other Health Boards in. The effect of small numbers has greater impact on their results and less significance can be attached to any failure to meet the QPI targets. Numbers of patients whose data has resulted in Borders failing the QPIs: QPI 2(ii): 3 patients; QPI 3: 2 patients; QPI 6: 1 patient; QPI 9: 2 patients and QPI 10: 1 patient. Breast Cancer 2013 Comparative Audit Report 8 Version 4.0

9 INTRODUCTION AND METHODS Cohort This report covers patients diagnosed with Breast cancer from The results contained within this report have been presented by NHS board of Staging and first treatment. Dataset and Definitions This report presents the performance of NHS Boards within the South East Scotland Cancer Network () against Quality Performance Indicators (QPIs) developed by the Scottish Government in collaboration with the three Regional Cancer Networks in Scotland, Information Services Division (ISD), and Healthcare Improvement Scotland. The stated intention is that QPIs should be responsive to changes in clinical practice and emerging evidence, and in keeping with the overarching aim of the cancer quality work programme, they should focus attention on areas most important in terms of improving survival and patient experience whilst reducing variance and ensuring safe, effective and person-centred cancer care. Following a period of development, public engagement and finalisation, each set of QPIs is published by Healthcare Improvement Scotland 1. Accompanying datasets and measurability criteria for QPIs are published on the ISD website 2. NHS boards are required to report against QPIs as part of a mandatory, publicly reported, programme at a national level. Breast Cancer QPIs were implemented from 01/01/2012, results were first reported in November 2012, and they will be due for review after the third year of reporting i.e. during 2015/2016. The standard QPI format is shown below: QPI Title: Description: Rationale and Evidence: Specifications: Target: Short title of Quality Performance Indicator (for use in reports etc.) Full and clear description of the Quality Performance Indicator. Description of the evidence base and rationale which underpins this indicator. Numerator: Denominator: Exclusions: Not recorded for numerator: Not recorded for exclusion: Not recorded for denominator: Of all the patients included in the denominator those who meet the criteria set out in the indicator. All patients to be included in the measurement of this indicator. Patients who should be excluded from measurement of this indicator. Include in the denominator for measurement against the target. Present as not recorded only if the patient cannot otherwise be identified as having met/not met the target. Include in the denominator for measurement against the target unless there is other definitive evidence that the record should be excluded. Present as not recorded only where the record cannot otherwise be definitively identified as an inclusion/exclusion for this standard. Exclude from the denominator for measurement against the target. Present as not recorded only where the patient cannot otherwise be definitively identified as an inclusion/exclusion for this standard. Statement of the level of performance to be achieved. 1 QPI documents are available at 2 Datasets and measurability documents are available at Breast Cancer 2013 Comparative Audit Report 9

10 Audit Processes Data was analysed by the audit facilitators in each NHS board according to the measurability document provided by ISD. data was collated by Christine Dodds, Senior Audit Facilitator for Breast cancer. Patients were identified through registration at weekly multidisciplinary team meetings, including patients referred from the Scottish Breast Screening Programme. Data capture was largely dependent on review of various hospitals electronic records systems. Data was recorded in ecase for Borders, Dumfries & Galloway and Fife. data was recorded in a Clinical Management System (CIM). It should be noted that Borders, Dumfries & Galloway and Fife Health Boards each have one hospital providing a specialist service for the diagnosis and treatment of Breast cancer, whereas in there are 2: St. Johns (St J) and the Hospital (WGH). Each of the 5 hospitals provides surgery and chemotherapy but radiotherapy is provided centrally in Edinburgh Cancer Centre. Patients living closer to either Carlisle or Dundee may opt to have oncology treatment out with the region. Collecting complete audit data for these patients remains a challenge. Lead Clinicians and Audit Personnel Region Hospital Lead Clinician Audit Support NHS Borders Borders Hospital Mr John Rainey Alistair Meikle NHS Dumfries & Galloway NHS Fife & NHS Dumfries & Galloway Royal Infirmary Queen Margaret Hospital St Johns Hospital Hospital Ms Maria Bews-Hair Mr Glyn Neades Mr Matthew Barber Martin Keith & Laura Allan Maggie McHardy Christine Dodds DATA QUALITY ESTIMATE OF CASE ASCERTAINMENT An estimate of case ascertainment (the percentage of the population with Breast cancer recorded in the audit) is made by comparison with the Scottish Cancer Registry five year average data: 2008 to High levels of case ascertainment provide confidence in the completeness of the audit recording and contribute to the reliability of results presented. Levels greater than 100% may be attributable to an increase in incidence. Allowance should be made when reviewing results where numbers are small and variation may be due to chance. Cancer Registry (by Hospital of Diagnosis) average 2013 % / Can Reg % NB: differences between Cancer Registry data and audit data should be noted: the Cancer Registry counts bilateral cases twice whereas the audit records these once only; multiple independent primaries are also counted separately by the Cancer Registry, but not by audit. Breast Cancer 2013 Comparative Audit Report 10

11 Quality Assurance All hospitals in the region participate in a Quality Assurance (QA) programme provided by the National Services Scotland Information Services Division (ISD). QA of the Breast cancer data was carried out in 2013 and accuracy results are shown below: Borders D&G Fife 97.9% 98.1% 98.9% 98.2% Clinical Sign-off To ensure the quality of the data and results presented, the process was as follows: Individual health board results were reviewed and signed-off locally. Collated results were presented and discussed by lead clinicians on 9 th October 2014 and at the Breast Group Meeting on 14th th November The final draft of the regional report was circulated to members of the Breast Group on 27/11/2014 for final comments. Data was submitted to ISD on 07/11/2014 for upload to the Dashboard and for inclusion in the Breast Cancer National report.. Breast Cancer 2013 Comparative Audit Report 11

12 DIAGNOSIS AND STAGING QPI 1 Non-Operative Diagnosis Patients with breast cancer should have a non-operative histological diagnosis Target = 95% Numerator = Number of patients with a non-operative diagnosis of breast cancer (core biopsy/large volume biopsy). Denominator = All patients with invasive or in-situ breast cancer. Exclusions = All breast cancer patients with lobular carcinoma in situ (LCIS) QPI 1 - Nonoperative diagnosis Borders D&G Fife St Johns 2013 cohort Ineligible for this QPI Target 95% Numerator Not recorded for the numerator 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% Denominator % Performance 98.6% 96.1% 99.0% 98.1% 98.2% 98.1% 98.1% Exclusions Denominator Comment: All hospitals have met this target. At a previous national meeting (Nov 2013), clinicians commented that they would find it useful to view these results split by invasive & non-invasive, as follows: QPI 1 - Nonoperative diagnosis OUTLIERS Borders D&G Fife St Johns Invasive Non-invasive Historical Summary QPI 1 - Nonoperative diagnosis Total Borders D&G Fife St Johns 2013 Performance 98.6% 96.1% 99.0% 98.1% 98.2% 98.1% 98.1% 2012 Performance 100.0% 98.1% 97.3% 97.8% 97.6% 97.7% 97.8% Breast Cancer 2013 Comparative Audit Report 12

13 QPI 2 Pre-Operative Assessment of Axilla (i) Ultrasound assessment of the axilla Target = 95% Numerator = Number of patients with invasive breast cancer who undergo assessment of the axilla by ultrasound before surgery. Denominator = All patients with invasive breast cancer undergoing surgery. Exclusions = No exclusions. QPI 2 - Pre- Operative assessment of the axilla - ultrasound Borders D&G Fife St Johns 2013 cohort Ineligible for this QPI Target 95% Numerator Not recorded for the numerator 0.0% 0.0% 0.0% 1.2% 0.0% 0.1% 0.1% Denominator % Performance 98.0% 98.7% 99.3% 91.4% 98.5% 97.7% 98.0% Exclusions Denominator Comment: St Johns has failed to meet this target because it does not yet have a One-Stop Clinic. This is the 4 th annual comparative report in which this issue has been documented as an Action Point. There have been difficulties in appointing to the radiology post associated with this service. This issue therefore remains an Action Point although the delivery date is expected to be January Historical Summary QPI 2 - Pre-Operative assessment of the axilla - ultrasound Borders D&G Fife St Johns 2013 Performance 98.0% 98.7% 99.3% 91.4% 98.5% 97.7% 98.0% 2012 Performance 97.9% 98.8% 100.0% 100.0% 97.2% 97.5% 98.0% Breast Cancer 2013 Comparative Audit Report 13

14 QPI 2 Pre-Operative Assessment of Axilla (ii) Biopsy of the Axilla where ultrasound reveals suspicion of spread to nodes Target = 85% Numerator = Number of patients with invasive breast cancer with suspicious morphology on ultrasound who undergo an FNA/core biopsy Denominator = All patients with invasive breast cancer undergoing surgery with suspicious morphology reported on ultrasound. Exclusions = No exclusions. QPI 2 - Preoperative Assessment of the axilla - biopsy Borders D&G Fife St Johns 2013 cohort Ineligible for this QPI Target 85% Numerator Not recorded for the numerator 0.0% 0.0% 0.0% 0.0% 0.8% 0.6% 0.3% Denominator % Performance 83.3% 100.0% 97.4% 100.0% 98.4% 98.7% 97.6% Exclusions Denominator Comments: Comment removed for web report due to small numbers. Historical Summary QPI 2 - Preoperative Assessment of the axilla - biopsy Borders D&G Fife St Johns 2013 Performance 83.3% 100.0% 97.4% 100.0% 98.4% 98.7% 97.6% 2012 Performance 100.0% 89.3% 100.0% 62.5% 99.4% 96.0% 96.0% Breast Cancer 2013 Comparative Audit Report 14

15 SURGERY QPI 3 - Conservation Rate Proportion of patients with small tumours having breast conservation surgery rather than mastectomy Target = 85% Numerator = Number of surgically treated patients with breast cancer less than 20mm whole tumour size on histology (invasive plus in situ disease) treated by breast conservation surgery. Denominator = All surgically treated patients with breast cancer less than 20mm whole tumour size on histology (invasive plus in situ disease). Exclusions = All patients with multifocal breast cancer; all patients with breast cancer who have received neoadjuvant systemic therapy for 6 weeks (hormonal therapy or chemotherapy); all male patients. QPI 3 - Borders D&G Fife St Johns Conservation Rate 2013 cohort Ineligible for this QPI Target 85% Numerator Not recorded for the numerator 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% Denominator % Performance 83.3% 92.0% 92.5% 100.0% 99.3% 99.3% 97.6% Exclusions Denominator Comments: Comment removed for web report due to small numbers. Historical summary QPI 3 - Conservation Rate Borders D&G Fife St Johns 2013 Performance 83.3% 92.0% 92.5% 100.0% 99.3% 99.3% 97.6% 2012 Performance 100.0% 89.7% 86.8% 100.0% 96.4% 96.5% 95.0% Breast Cancer 2013 Comparative Audit Report 15

16 QPI 4 - Surgical Margins Proportion of patients where final radial excision margins are <1mm Target < 5% Numerator = Number of patients with breast cancer (invasive or ductal carcinoma in situ) having breast conservation surgery with final radial (i.e. superior, inferior, medial or lateral) excision margins less than 1mm (on pathology report). Denominator = All patients with breast (invasive or ductal carcinoma in situ) cancer having breast conservation surgery. Exclusions = LCIS alone QPI 4 - Surgical Borders D&G Fife St Johns Margins 2013 cohort Ineligible for this QPI Target < 5% Numerator Not recorded for the numerator 0.0% 0.0% 0.0% 0.0% 0.2% 0.2% 0.1% Denominator % Performance 0.0% 0.0% 1.1% 0.0% 1.6% 1.5% 1.3% Exclusions Denominator Comments: All hospitals have met this target Historical summary QPI 4 - Surgical Margins Borders D&G Fife St Johns 2013 Performance 0.0% 0.0% 1.1% 0.0% 1.6% 1.5% 1.3% 2012 Performance 8.3% 0.0% 2.3% 2.0% 1.7% 1.7% 1.8% Breast Cancer 2013 Comparative Audit Report 16

17 QPI 5 Immediate reconstruction rate Proportion of mastectomy patients having an immediate reconstruction Target > 10% Numerator = Number of patients with breast cancer undergoing immediate breast reconstruction at the time of mastectomy Denominator = All patients with breast cancer undergoing mastectomy. Exclusions = All patients with M1 disease and males QPI 5 - Immediate reconstruction rate Borders D&G Fife St Johns 2013 cohort Ineligible for this QPI Target >10% Numerator Not recorded for the numerator 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% Denominator % Performance 40.9% 10.0% 37.5% 13.5% 32.8% 28.2% 29.2% Exclusions Denominator Comments: D&G have increased their percentage since last year, although numbers overall are very small. Most of their Screening patients proceed to Glasgow for surgery (including immediate reconstruction, if appropriate) Historical summary. QPI 5 - Immediate reconstruction rate Borders D&G Fife St Johns 2013 Performance 40.9% 10.0% 37.5% 13.5% 32.8% 28.2% 29.2% 2012 Performance 30.4% 4.8% 15.8% 27.3% 34.9% 33.9% 27.6% Breast Cancer 2013 Comparative Audit Report 17

18 QPI 6 - Negative Axillary Clearance Rate Proportion of patients undergoing axillary clearance where no pathological evidence of nodal metastases is found Target = <10% Numerator = Number of patients with breast cancer undergoing surgical axillary clearance found to have no nodal metastasis (including nodes taken at any previous sampling procedure). Denominator = All patients with breast cancer undergoing surgical axillary clearance. Exclusions = All patients with breast cancer who have received neoadjuvant systemic therapy for 6 weeks (hormonal therapy or chemotherapy). QPI 6 - Negative axillary clearance rate Borders D&G Fife St Johns 2013 cohort Ineligible for this QPI Target < 10% Numerator Not recorded for the numerator 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% Denominator % Performance 10.0% 0.0% 0.0% 5.3% 0.0% 1.5% 1.8% Exclusions Denominator Comments: Comment removed for web report due to small numbers. Historical summary QPI 6 - Negative axillary clearance rate Borders D&G Fife St Johns 2013 Performance 10.0% 0.0% 0.0% 5.3% 0.0% 1.5% 1.8% 2012 Performance 18.8% 4.5% 8.0% 0.0% 0.0% 0.0% 4.3% Breast Cancer 2013 Comparative Audit Report 18

19 QPI 7 - Minimising Hospital Stay - 23 Hour Surgery* * - Based on SMR01 Data and Provided to Boards by ISD Patients should have the opportunity for 23 hour surgery (a maximum of 1 overnight stay following surgery) wherever possible. Target = 80% Numerator = Number of patients with breast cancer undergoing wide excision and/or axillary sampling procedure (sentinel node biopsy or node sample ( 4 nodes) with a maximum hospital stay of 1 night following their procedure. Denominator = All patients with breast cancer undergoing wide excision and/or axillary sampling procedure (sentinel node biopsy or node sample ( 4 nodes). Exclusions = All patients with breast cancer undergoing partial breast reconstruction. Max Hospital Stay of 1 Night Borders D&G Fife St Johns Numerator % Performance 92.3% 97.9% 97.1% 93.8% 93.1% 93.7% 94.4% Denominator Comments: All hospitals have met this target but outliers have been checked. These are predominantly explained by patient co morbidities, particularly issues associated with blood thinning, or where patients have limited support at home. Historical summary Previous data not available Breast Cancer 2013 Comparative Audit Report 19

20 PATHOLOGY QPI 8 - HER2 Status for Decision Making Her2 Status should be available to inform treatment decision making Target = 90% Numerator = Number of patients with invasive breast cancer for whom the HER2 status (as defined by IHC) is known at initial MDT meeting to decide first treatment. Denominator = All patients with invasive breast cancer. Exclusions = none (NB: QPI measurability document does not allow exclusion of patients staged as Tis. See 2 nd table for ISD compliant results) Table 1 excludes all Tis patients QPI 8 - HER2 status known at initial MDT Borders D&G Fife St Johns 2013 cohort Ineligible for this QPI Target 90% Numerator Not recorded for the numerator 0.0% 6.3% 0.0% 0.0% 0.0% 0.0% 0.5% Denominator % Performance 29.9% 12.6% 40.4% 49.5% 75.0% 71.8% 59.1% Exclusions Denominator Table 2 - no exclusions (as per Measurability document) QPI 8 - HER2 status known at initial MDT Borders D&G Fife St Johns 2013 cohort Ineligible for this QPI Target 90% Numerator Not recorded for the numerator 0.0% 6.3% 0.0% 0.0% 0.0% 0.0% 0.5% Denominator % Performance 29.4% 12.5% 39.6% 47.5% 72.5% 69.4% 57.4% Exclusions Denominator Breast Cancer 2013 Comparative Audit Report 20

21 Comment: The measurability of this QPI stipulates that cases where the Her2 test is deferred until excision should be included in the denominator, (as well as patients staged as clinical Tis but with invasion at surgery). The overall number is not large e.g. WGH: 21 cases Substantial checking of the data has been carried out in and Borders. These checks revealed some instances where results were available on the pathology database but at the time of the MDM there was a lack of documentation to indicate that the result had been discussed at the meeting. It remains debateable whether or not we should regard the result as available if it has not been expressly stated, or documented in the MDM records before or during the meeting. The figures in both tables above show the number of patients with Her2 results documented at the meeting, as well as those with a result available on the relevant system (e.g. APEX) at the time. Action Point: All Health Boards must improve MDM documentation to ensure that the Her2 result is recorded before or during the meeting. This record must be available for audit purposes after each MDM. QPI 8 - HER2 status known at initial MDT Borders D&G Fife St Johns 2013 Performance 29.9% 12.6% 40.4% 49.5% 75.0% 71.8% 59.1% 2012 Performance 38.2% 6.9% 17.4% 37.9% 63.5% 60.6% 47.5% Breast Cancer 2013 Comparative Audit Report 21

22 ONCOLOGY QPI 9 - Radiotherapy for Breast Conservation After wide local excision patients with breast cancer should receive radiotherapy. Target = 95% Numerator = Number of patients with invasive breast cancer having conservation surgery receiving radiotherapy to the breast. Denominator = All patients with invasive breast cancer having conservation surgery. Exclusions = All patients with breast cancer taking part in clinical trials of radiotherapy treatment; all patients with M1 disease. QPI 9 - Radiotherapy for breast conservation Borders D&G Fife St Johns 2013 cohort Ineligible for this QPI Target 95% Numerator Not recorded for the numerator 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% Denominator % Performance 91.3% 92.9% 95.2% 100.0% 97.3% 97.5% 96.7% Exclusions Denominator Comments: Comments removed for web report due to small numbers. Historical summary QPI 9 - Radiotherapy for breast conservation Borders D&G Fife St Johns 2013 Performance 91.3% 92.9% 95.2% 100.0% 97.3% 97.5% 96.7% 2012 Performance 88.0% 94.7% 96.2% 93.5% 94.3% 94.2% 94.2% Breast Cancer 2013 Comparative Audit Report 22

23 Time to adjuvant Radiotherapy (additional report item requested by Breast Group) The previous NHS QIS standard required a start date within 42 days of final surgery or final chemotherapy. Essential standard: 70% Desirable: 85% Patients treated with adjuvant radiotherapy fall into 2 distinct groups, and results are shown separately below for each one: Adjuvant radiotherapy only (no adjuvant chemotherapy) Time to Radiotherapy (next after surgery) Borders D&G Fife St Johns Numerator Not recorded Denominator % Performance 34.8% 32.4% 46.5% 33.3% 45.1% 44.1% 44.0% Range (days) Median (day) Adjuvant radiotherapy after adjuvant chemotherapy Time to Radiotherapy (after adjuvant chemo) Borders D&G Fife St Johns Numerator Not recorded Denominator % Performance 81.8% 94.4% 82.1% 95.7% 86.7% 88.3% 86.5% Range (days) Median (day) Comments It is clear from these results that patients having radiotherapy after adjuvant chemotherapy are starting treatment in a timely manner. In fact and Dumfries & Galloway meet the previous desirable standard set by Health Improvement Scotland. The challenge clearly lies with those patients having adjuvant radiotherapy immediately after surgery (i.e. no adjuvant chemotherapy). The process requires adequate wound healing before treatment planning can be undertaken and radiotherapy machine slots booked. A project is currently underway in to review radiotherapy booking for breast cancer patients and it is hoped that the time delay can be improved upon. St. Johns: the patient pathway has been examined again in minute detail. The overall time taken is dependent on several different specialties, all with an important role to play, and which cannot be influenced by clinical oncology. The conclusion reached is that patients must be seen to discuss radiotherapy within 7 days of the post operative MDM, and a maximum of 7 days after that to the radiotherapy planning appointment. Currently the time from planning to starting radiotherapy is 14 days. Ensuring these time limits are adhered to represents a considerable demand particularly as so many different specialists are involved at each stage. Breast Cancer 2013 Comparative Audit Report 23

24 QPI 10 - Adjuvant Chemotherapy Proportion of patients (aged 50 70) receiving adjuvant chemotherapy post surgery Target = 85% Numerator = Number of patients between 50 and 70 years of age at diagnosis with surgically proven node positive or at least G3 >20mm breast cancer who receive adjuvant chemotherapy. Denominator = All patients between 50 and 70 years of age at diagnosis with surgically proven node positive, or at least G3 and >20mm breast cancer. Exclusions = All patients with breast cancer taking part in trials of chemotherapy treatment. All patients with breast cancer who have had neo-adjuvant chemotherapy; all patients with M1 disease. QPI 10 - Patients having adjuvant chemotherapy Borders D&G Fife St Johns 2013 cohort Ineligible for this QPI Target 85% Numerator Not recorded for the numerator 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% Denominator % Performance 80.0% 81.8% 94.4% 77.8% 64.5% 67.0% 72.7% Exclusions Denominator Comments: Borders: Comment removed for web report due to small numbers. D&G: Comment removed for web report due to small numbers. Fife: Comment removed for web report due to small numbers. St. Johns: Comment removed for web report due to small numbers. Hospital: Because more than half of the patients treated at the Hospital are diagnosed through the screening system, there is a high incidence of small grade 1 and 2 cancers in our case mix. There is evidence to show that the screen detected cancers have a better prognosis than symptomatic cancers, when all other risk factors are taken into consideration. Of the patients who could have been considered for chemotherapy under QPI standards but who did not receive chemotherapy, the vast majority had small grade 1 or 2 cancers that were strongly ER positive and HER2 negative with one involved node; six had grade 3 cancers (two were unfit for treatment and three declined) and one of these was a HER2 positive cancer (in a patient who was not fit for any chemotherapy). Adjuvant online was used to calculate the additional survival benefit over and above endocrine therapy if the patients were also given 2nd generation chemotherapy. It is not routine practice here to offer chemotherapy if the benefit is less than 3%, and we usually discuss this option neutrally at between 3 and 5%. 14 patients had a predicted additional survival benefit of < 3%, and most of these were not offered chemotherapy as the benefit was felt to be too low to offset the potential toxicities and risk of death. Breast Cancer 2013 Comparative Audit Report 24

25 Of the 17 with 3% or more predicted benefit, 3 were not fit enough because of serious co morbidities, 12 were offered chemotherapy but refused as they felt it was not worth the toxicity for the modest improvement in survival, one patient with a grade 3 cancer and 1 positive node was not offered chemotherapy at age 70 for a survival benefit of 5%. 1 patient was not offered chemotherapy after it was judged that the benefit would be minimal. In all, 13/76 WGH patients declined chemotherapy after discussion (17%) and the MDM members felt the risks of treatment were not justified in another 11 (15%). It was impossible for the WGH to meet the target as too many patients declined chemotherapy, which reflects the open nature of the discussion and informed consent process. We argue that the standard for this QPI is too high for a unit with a high proportion of screen detected cancers and does not take into account the very low benefit that chemotherapy offers to patients with small, low grade cancers. It also fails to allow for patients who decline treatment after a full discussion of the risks and benefits. Angela Bowman, Consultant Medical Oncologist David Cameron, Consultant Medical Oncologist Larry Hayward, Consultant Medical Oncologist Historical summary QPI 10 - Patients having adjuvant chemotherapy Borders D&G Fife St Johns 2013 Performance 80.0% 81.8% 94.4% 77.8% 64.5% 67.0% 72.7% 2012 Performance 88.9% 61.5% 72.7% 80.0% 61.1% 62.9% 65.8% Breast Cancer 2013 Comparative Audit Report 25

26 Time to adjuvant chemotherapy (additional report item requested by Breast Group) The previous NHS QIS standard required a start date within 42 days of final surgery Essential: 80% Desirable: 95% Time to Adjuvant Chemotherapy Borders D&G Fife St Johns Numerator Not recorded Denominator % Performance 91.7% 90.9% 88.4% 87.9% 73.5% 77.0% 81.6% Range (days) Median (day) Comment: WGH: all outliers have been checked in detail, and reasons for delay are as follows: service reason 9 (35%). 4 patients were referred in a timely fashion but waiting times were not met by ward 1 and no other reason was evident. The other 5 were outside NHS control as they received treatment outside (Borders 1, Forth Valley 3, outside UK 1). Median time to treatment for service delays in was 44 days (range 43-57) and other locations 56 days (51-57). medical reasons 10 (37%): 2 had unforeseen cardiac problems requiring cardiology assessment, tests and revised chemotherapy; 8 had wound infections or wound breakdown. patient choice 8 (19%): these delays were for holidays, social events and indecision about treatment. Only 4 delays were avoidable by the Hospital. This would have brought our compliance significantly closer to the previous waiting times standard of 80%. Angela Bowman, Consultant Medical Oncologist St Johns: 4 patients had clinical reasons for the delays. These were mainly due to wound healing problems or seroma. Breast Cancer 2013 Comparative Audit Report 26

27 QPI 11 - Anti-HER2 Positive Therapy Proportion of patients (aged 50 70) with Her2 positive breast cancer >10mm or node positive, who receive anti-her2 positive therapy. Target = 90% Numerator = Number of patients with breast cancer who are between 50 and 70 years of age at diagnosis with HER2 positive (by 3+ on IHC &/or FISH +ve) tumours >10mm (or 10mm and node positive) who receive adjuvant anti-her2 positive therapy. Denominator = All patients with breast cancer who are between 50 and 70 years of age at diagnosis with HER2 positive (by 3+ on IHC &/or FISH +ve) tumours >10mm (or 10mm and node positive), and were treated with chemotherapy* *previous analysis (2012) did not include reference to treatment by chemotherapy Exclusions = patients with M1 disease QPI 11 - Anti- Her2 positive therapy Borders D&G Fife St Johns 2013 cohort Ineligible for this QPI Target 90% Numerator Not recorded for the numerator 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% Denominator % Performance 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Exclusions Denominator Comments: Results improved very significantly following changes to the specification of the denominator after requests made at the national meeting in November However, a decision was later made at a national level to revert to the previous specification of this QPI i.e. the reference in the denominator to chemotherapy treatment was removed. See result below: QPI 11 - Anti-Her2 positive therapy (chemo & non-chemo patients) Borders D&G Fife St Johns 2013 cohort Ineligible for this QPI Target 90% Numerator Not recorded for the numerator 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% Denominator % Performance 100.0% 100.0% 100.0% 100.0% 70.6% 77.3% 87.2% Exclusions Denominator Breast Cancer 2013 Comparative Audit Report 27

28 WGH: 5 patients did not have herceptin. 1 declined chemotherapy and therefore did not proceed to herceptin; 2 were unfit for treatment, 2 had relatively low risk tumours: 15 mm grade 1 & G2 respectively. Historical summary QPI 11 - Anti-Her2 positive therapy (chemo & non-chemo patients) Borders D&G Fife St Johns 2013 Performance 100.0% 100.0% 100.0% 100.0% 70.6% 77.3% 87.2% 2012 Performance 100.0% 83.3% 85.7% 100.0% 83.3% 87.9% 88.0% Breast Cancer 2013 Comparative Audit Report 28

29 Appendix 1 Age at Diagnosis Age at Diagnosis WGH St.Johns Fife Borders D&G n <45 % n % n % n % n % n % n % n % n % n % n Total % Age at diagnosis - % 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% WGH St.Johns Fife Borders D&G Age bands <50 Appendix 2 - Gender Borders Dumfries Fife WGH St Johns Gender % % % % % % Female % % % % % % Male 0 0% 0 0% % 4 0.5% 0 0% 5 0.4% Total % % % % % % Breast Cancer 2013 Comparative Audit Report 29

30 Appendix 3 Summary by Key Categories Borders Dumfries Fife WGH St Johns Referral % % % % % % GP referral % % % % % % Breast Screening 1 1.4% 4 3.9% % % % % Incidental/Secondary care 4 5.7% % % % 8 7.5% % Review patients 1 1.4% 6 5.8% % % 3 2.8% % Genetics Clinic 0 0.0% 0 0.0% 3 1.6% 0 0.0% 1 0.9% 4 0.3% Ref from private healthcare 0 0.0% 0 0.0% 0 0.0% 3 0.4% 1 0.9% 4 0.3% Other 0 0.0% 1 1.0% 1 0.5% 3 0.4% 0 0.0% 5 0.4% Not recorded 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% Total % % % % % % T Stage T % 0 0.0% 1 0.5% 0 0.0% 0 0.0% 1 0.1% T % 8 7.8% % % % % T % % % % % % T % 3 2.9% 7 3.6% % % % T % 7 6.8% % % % % Tis (DCIS) 3 4.3% 0 0.0% % % 7 6.6% % Tx (not assessable) 0 0.0% 2 1.9% 1 0.5% 1 0.1% 1 0.9% 5 0.4% T9 (not recorded) 0 0.0% % 0 0.0% 0 0.0% 0 0.0% % Total % % % % % % N Stage N % % % % % % N % % % % % % N % 0 0.0% 3 1.6% 7 0.9% 0 0.0% % N % 0 0.0% 2 1.0% 8 1.0% 2 1.9% % NX 0 0.0% 1 1.0% 0 0.0% 9 1.2% 8 7.5% % N9 (not recorded) 2 2.9% % 0 0.0% 0 0.0% 0 0.0% % Total % % % % % % Breast Cancer 2013 Comparative Audit Report 30

31 Borders Dumfries Fife WGH St Johns M Stage M % % % % % % M % 3 2.9% 9 4.7% % 9 8.5% % M9 (not recorded) % % 6 3.1% % 9 8.5% % Total % % % % % % Part of TNM "not recorded" % % 6 3.1% % 9 8.5% % Tumour Types % % % % % % DCIS % % % % % % LCIS 0 0.0% 0 0.0% 1 9.1% 2 3.0% 0 0.0% 3 2.3% Paget s Disease 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% Other non-invasive 0 0.0% 0 0.0% 1 9.1% 1 1.5% 0 0.0% 2 1.5% Non-invasive total 2 2.9% 7 6.8% % % 4 3.8% % Ductal carcinoma % % % % % % Lobular carcinoma 6 8.8% 8 8.3% % % % % Medullary carcinoma 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% Mucinous carcinoma 2 2.9% 2 2.1% 4 2.2% % 4 4.0% % Tubular carcinoma 2 2.9% 1 1.0% 1 0.6% % 4 4.0% % Mixed (invasive) 1 1.5% 0 0.0% 9 5.0% % 1 1.0% % Other invasive 1 1.5% 5 5.2% 1 0.6% % 4 4.0% % Invasive total % % % % % % Inapplicable (no histology) 0 0.0% 0 0.0% 2 1.0% 5 0.7% 1 0.9% 8 0.6% Not recorded 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% Total % % % % % % ER Status (Invasive tumours) High Positive (6-8) % % % % % % Low positive (3-5) 6 8.6% % 4 2.1% % % % Negative (0-2) % % % % % % Not assessable 0 0.0% 0 0.0% 2 1.0% 2 0.3% 0 0.0% 4 0.3% Not recorded 0 0.0% 0 0.0% 0 0.0% 0 0.0% 2 2.0% 2 0.2% Inapplicable 0 0.0% 0 0.0% 8 4.1% 0 0.0% 0 0.0% 8 0.7% Total % % % % % % Breast Cancer 2013 Comparative Audit Report 31

32 Borders Dumfries Fife WGH St Johns Her2 Status (Invasive tumours) Her2 positive % 9 9.4% % % % % Her2 negative % % % % % % Not recorded 0 0.0% 0 0.0% 2 1.0% 0 0.0% 0 0.0% 2 0.2% Not done / Inconclusive 0 0.0% 5 5.2% % 6 0.9% 2 2.0% % Not assessable 2 2.9% 1 1.0% 1 0.5% 3 0.4% 0 0.0% 7 0.6% Total % % % % % % First treatment Surgery % % % % % % Hormone therapy % % % % % % Chemotherapy % 8 7.8% % % % % Radiotherapy 0 0.0% 0 0.0% 2 1.0% 1 0.1% 0 0.0% 3 0.2% Other 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% No active treatment (Supportive care) 1 1.4% 3 2.9% 1 0.5% 1 0.1% 0 0.0% 6 0.5% Died before treatment 0 0.0% 0 0.0% 0 0.0% 1 0.1% 1 0.9% 2 0.2% Refused all treatment 0 0.0% 2 1.9% 1 0.5% 1 0.1% 0 0.0% 4 0.3% Total % % % % % % Surgery Localising/Excision biopsy 0 0.0% 2 1.9% 1 0.5% 3 0.4% 0 0.0% 6 0.5% Conservation surgery % % % % % % Mastectomy % % % % % % Mastectomy + immediate reconstruction % 3 2.9% % % 5 4.7% % Axillary surgery alone 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% Other 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% Refused treatment 0 0.0% 0 0.0% 2 1.0% 3 0.4% 2 1.9% 7 0.6% Not yet/pending 0 0.0% 0 0.0% 0 0.0% 1 0.1% 0 0.0% 1 0.1% Not applicable % % % % % % " " (histologically proven by core) (19 /19) 20/22 (33/35) 79/84 17/19 Not recorded 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% Total % % % % % % Breast Cancer 2013 Comparative Audit Report 32

33 Borders Dumfries Fife WGH St Johns Radiotherapy Primary radical 0 0.0% 3 2.9% 2 1.0% 1 0.1% 0 0.0% 6 0.5% Adjuvant % % % % % % Palliative 0 0.0% 1 1.0% 5 2.6% % 3 2.8% % Refused 2 2.9% 1 1.0% 3 1.6% 8 1.0% 1 0.9% % Inapplicable % % % % % % Not recorded 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% Not yet/pending 0 0.0% 0 0.0% 0 0.0% % 1 0.9% % Total % % % % % % Chemotherapy Adjuvant only % % % % % % Neoadjuvant % 9 8.7% % % % % Palliative 0 0.0% 0 0.0% 3 1.6% % 5 4.7% % Refused 3 4.3% 1 1.0% 4 2.1% % 2 1.9% % Inapplicable % % % % % % Not recorded 0 0.0% 1 1.0% 0 0.0% 0 0.0% 0 0.0% 1 0.1% Not yet/pending 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% Total % % % % % % Hormone therapy Neoadjuvant 4 5.7% 5 4.9% % % 8 7.5% % Peri-operative 2 2.9% 4 3.9% % % 5 4.7% % Primary % % % % % % Palliative 0 0.0% 0 0.0% 4 2.1% % 6 5.7% % Adjuvant (none pre-op) % % % % % % Inapplicable % % % % % % Not recorded 0 0.0% 2 1.9% 0 0.0% 3 0.4% 0 0.0% 5 0.4% Refused 1 1.4% 2 1.9% 0 0.0% 7 0.9% 1 0.9% % Not yet/pending 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% Total % % % % % % Breast Cancer 2013 Comparative Audit Report 33

34 Borders Dumfries Fife WGH St Johns Biological therapy (Her2 positive) Herceptin treatment % % % % % % No biological therapy % % % % 1 7.1% % No decision yet 0 0.0% 0 0.0% 0 0.0% 1 1.4% 0 0.0% 1 0.8% Not recorded 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% Total % % % % % % Appendix 4 Overall Workload NHS All new outpatient attendance activity for the years 2012 & Location Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Total WGH STJ Total Location Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Total WGH STJ Total Data source: NHS, Performance Management Team Breast Cancer 2013 Comparative Audit Report 34