SOUTH EAST SCOTLAND CANCER NETWORK (SCAN) PROSPECTIVE CANCER AUDIT

Transcription

1 SOUTH EAST SCOTLAND CANCER NETWORK (SCAN) PROSPECTIVE CANCER AUDIT BREAST CANCER 2016 COMPARATIVE AUDIT REPORT Mr Glyn Neades Chair SCAN Breast Group and Consultant Surgeon, NHS Fife & NHS Lothian Mr Ahmed Mustafa, Consultant Surgeon, NHS Borders Miss Maria Bews-Hair, Consultant Surgeon, NHS Dumfries & Galloway Mr Matthew Barber, Consultant Surgeon, NHS Lothian Mr Oliver Young, Consultant Surgeon, NHS Lothian Christine Dodds SCAN Senior Cancer Audit Facilitator, NHS Lothian Laura Allan, Cancer Audit Facilitator, NHS Dumfries & Galloway Angela Gillie, Cancer Audit Facilitator, NHS Fife Alistair Johnston, Cancer Audit Facilitator, NHS Borders Report no: SA B08/17 SCAN Audit office, c/o Dept Clinical Oncology, Western General Hospital, Crewe Road, Edinburgh EH4 2XU T: W:

2 Contents Introduction by the Chair of the Scan Breast Group... 4 Action Points Action Points Breast Cancer Quality Performance Indicators Results Summary Dataset And Definitions... 8 Data Quality Estimate Of Case Ascertainment Case Ascertainment Methodology Quality Assurance Clinical Sign-Off QPI Results QPI 1 - Multidisciplinary Team Meeting QPI 2 Non-Operative Diagnosis QPI 3 Pre-Operative Assessment Of Axilla (I) QPI 3 Pre-Operative Assessment Of Axilla (II) QPI 4 - Conservation Rate QPI 5 - Surgical Margins QPI 6 Immediate Reconstruction Rate QPI 8 - Minimising Hospital Stay - Day Case Surgery QPI 9 - Her2 Status For Decision Making QPI 10 - Radiotherapy For Breast Conservation QPI 11 - Adjuvant Chemotherapy QPI 13 Re-Excision Rates QPI 14 - Referral For Genetics Testing (I) QPI 14 - Referral For Genetics Testing (II) QPI Day Mortality Following Chemotherapy Clinical Trial Access QPI Appendix 2 - Gender Appendix 3 Summary By Key Categories Appendix 4 - SCAN: New Breast Cancer Totals By Year Of Diagnosis Appendix 5 Overall Workload NHS Lothian Overall Workload NHS Fife Overall Workload NHS Borders Overall Workload NHS Dumfries & Galloway Appendix 5 Glossary SCAN Comparative Breast Cancer QPI Report 2016 Report Index: SA B08/17 2

3 DOCUMENT HISTORY Version Circulation Date Comments Version 1 Lead clinicians 03/10/2017 Draft results & outliers circulated Version 2 SCAN Breast Group Lead clinicians 27/10/2016 Action points and comments agreed Version 3 SCAN Breast Group 21/11/2017 For final comment. Lead Clinician s commentary added. Version 4 SCAN Group SCAN Governance Framework SCAN Action Plan Board Leads 11/12/2017 Potentially disclosive data removed for publishing to website Version 4W Published to the SCAN website 05/03/2018 SCAN Comparative Breast Cancer QPI Report 2016 Report Index: SA B08/17 3

4 INTRODUCTION BY THE CHAIR OF THE SCAN BREAST GROUP 2016 represents the 2 nd year of this 3 year cycle of QPI reporting. As always I am grateful to clinical and audit colleagues for their exhaustive efforts in not only collecting the data but also providing full details of instances where QPI targets have not been met. I am pleased that in reviewing these results no Action Points have been identified and this report offers reassurance that, in the areas examined, all units are performing well. Where targets have not been met it should be borne in mind that this is frequently due to individual patients electing not to pursue certain offered treatments, which is of course always their prerogative. Where overall numbers in the denominators are small, this inevitably impacts on the percentage achieved. Challenges remain, however, and staffing is an ongoing problem in several areas. The current modified QPIs were first reviewed at last year s annual Audit meeting and some concerns regarding appropriate target levels and the dataset and data definitions were raised. Further issues have arisen in recent months; further discussion will be required at a National level to consider these. Since the first meeting in Glasgow Royal Infirmary in 2006, the 3 Scottish Breast Cancer networks have met annually to compare their audit data in a spirit of openness. We have all benefited and enjoyed the resulting discussions which are so important in maintaining the standards of QPIs that are measured. Currently there are no plans to hold the National Audit meeting in February but it is hoped that we can still have a meeting later in 2018 rather than wait a further year until Glyn Neades, Chair, SCAN Breast Group SCAN Comparative Breast Cancer QPI Report 2016 Report Index: SA B08/17 4

5 ACTION POINTS 2016 None identified ACTION POINTS 2015 QPI Action required Person responsible for action Date for update Progress with status from Health Boards: 1 - Action fully implemented, 2 - Action agreed not yet implemented, 3 - No action taken) 9 Her2 for Decision Making Investigate possible benefits of change to Her2 & FISH testing process for D&G: transfer from Glasgow to Edinburgh laboratories Dr. Jeremy Thomas 01/06/ Completed SCAN Comparative Breast Cancer QPI Report 2016 Report Index: SA B08/17 5

6 Breast cancer Quality Performance Indicators Results Summary QPI 1 MDT discussion before definitive treatment 95 QPI 2 Non-operative diagnosis 95 QPI 3 Pre-operative assessment of the axilla (i) Ultrasound scan of the axilla 95 (ii) Biopsy if suspicious USS scan QPI 4 Conservation surgery 90 QPI 5 Surgical margins <5 QPI 6 Immediate reconstruction 25 QPI 8 Day case surgery Target% Borders D&G Fife Lothian SCAN 85 By HB surgery 60 By HB residence 60 QPI 9 Her2 status for decision making 80 QPI 10 Radiotherapy for conservation 95 QPI 11 Adjuvant chemotherapy 85 QPI 13 Re-excision rates <20 QPI 14 Referral for genetics testing (i) Patients under (ii) Patients under 40 (triple negative) 90 N 71 N 86 N 169 N 842 N % 94.5% 95.5% 96.0% D 72 D 91 D 177 D 877 D 1217 N 70 N 89 N 165 N 857 N % 97.8% 96.5% 98.3% D 72 D 91 D 171 D 872 D 1206 N 55 N 76 N 132 N 675 N % 98.7% 98.5% 99.3% D 55 D 77 D 134 D 680 D 946 N 21 N 22 N 56 N 166 N % 100% 98.2% 98.2% D 21 D 22 D 57 D 169 D 269 N 15 N 15 N 28 N 298 N % 88.2% 100% 98.7% D 17 D 17 D 28 D 302 D 364 N 0 N 0 N 0 N 15 N 15 0% 0% 0% 2.6% D 30 D 53 D 90 D 580 D 808 N 7 N 4 N 12 N 51 N % 16.7% 22.6% 38.6% D 30 D 24 D 53 D 132 D 239 N 24 N 46 N 88 N 544 N % 75.4% 71.0% 77.4% D 34 D 61 D 124 D 703 D 922 N 50 N 50 N 194 N 394 N % 48.5% 64.7% 76.8% D 64 D 103 D 300 D 513 D 980 N 60 N 70 N 137 N 701 N % 78.7% 83.5% 91.4% D 64 D 89 D 164 D 767 D 1084 N 23 N 44 N 75 N 521 N % 89.8% 92.6% 95.2% D 27 D 49 D 81 D 547 D 704 N 10 N 12 N 31 N 78 N % 80.0% 91.2% 82.1% D 16 D 15 D 34 D 95 D 160 N 9 N 8 N 31 N 139 N % 10.1% 21.2% 18.8% D 63 D 79 D 146 D 740 D 1028 N 0 N 0 N 1 N 1 N 2 N/A N/A 100% 100% D 0 D 0 D 1 D 1 D 2 N 0 N 0 N 1 N 7 N 8 N/A N/A 100% 100% D 0 D 0 D 1 D 7 D % 97.9% 99.2% 98.5% 97.8% 1.9% 31.0% 76.1% 70.2% 89.3% 94.2% 81.9% 18.2% 100% 100% SCAN Comparative Breast Cancer QPI Report 2016 Report Index: SA B08/17 6

7 QPI day mortality following chemotherapy Clinical trials QPI Neoadjuvant <1 Adjuvant <1 Palliative <5 Interventional 7.5 Translational 15 Target% Borders D&G Fife Lothian SCAN N 0 N 0 N 0 N 1 N 1 0% 0% 0% 1.3% D 7 D 15 D 27 D 80 D 129 N 0 N 0 N 0 N 0 N 0 0% 0% 0% 0% D 14 D 21 D 44 D 135 D 214 N 0 N 0 N 0 N 2 N 2 0% 0% 0% 18.2% D 1 D 3 D 2 D 11 D 17 N 3 N 2 N 7 N 86 N % 1.7% 3.3% 10.0% D 81 D 120 D 211 D 858 D 1270 N 1 N 0 N 20 N 277 N % 0% 9.5% 32.3% D 81 D 120 D 211 D 858 D % 0% 11.8% 8.0% 24.2% Numerator % performance Denominator Target met Not met SCAN Comparative Breast Cancer QPI Report 2016 Report Index: SA B08/17 7

8 INTRODUCTION & METHODS Cohort This report covers patients newly diagnosed with Breast cancer in SCAN between 01/01/2016 and 31/12/2016. The results contained within this report are 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 (SCAN) 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 were reviewed during Changes are reflected in the 2016 data which is presented in this report. 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 SCAN Comparative Breast Cancer QPI Report 2016 Report Index: SA B08/17 8

9 AUDIT PROCESS Data was analysed by the audit facilitators in each NHS board according to the measurability document provided by ISD. SCAN data was collated by Christine Dodds, SCAN Senior Audit Facilitator for Breast cancer. Data capture is focused around the weekly multidisciplinary meetings ensuring that data covering patient referral, investigations and diagnosis is being picked up through routine process. Oncology data is obtained largely from electronic systems including downloads from ARIA (within the radiotherapy department) and ChemoCare for chemotherapy data. However, processes vary between the 5 separate hospitals providing a Breast service in SCAN. Recent years have seen less reliance on the need to access case notes for data collection. Lothian has now ceased routine use of case notes, however, the process remains dependent on audit staff for capture and entry of most of the data, and for quality checks. 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. In Lothian, TRAK has integrated the audit data fields with a purpose designed MDM module. 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 Lothian there are two: St. Johns (St J) in Livingston, West Lothian, and the Western General Hospital (WGH) in Edinburgh. Each of the five 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 SCAN region. Collecting complete audit data for these patients remains a challenge. Lead Clinicians and Audit Personnel SCAN Region Hospital Lead Clinician Audit Support NHS Borders Borders General Hospital Mr Ahmed Mustafa Alistair Johnston NHS Dumfries & Galloway NHS Fife SCAN & NHS Lothian Dumfries & Galloway Royal Infirmary Queen Margaret Hospital St Johns Hospital Western General Hospital Ms Maria Bews-Hair Mr Glyn Neades Mr Matthew Barber Mr Oliver Young Laura Allan Angela Gillie Christine Dodds SCAN Comparative Breast Cancer QPI Report 2016 Report Index: SA B08/17 9

10 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: 2011 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. Numbers recorded in audit: patients diagnosed 01/01/2016 to 31/12/2016 Borders D&G Fife Lothian SCAN Breast cancer Estimate of case ascertainment: calculated using the average of five years Cancer Registry data ( ) by Region of Residence. Cancer Registry totals - all breast cancer referrals (Screen detected and symptomatic) HB HB HB HB Year of diagnosis: diagnosis: diagnosis: diagnosis: diagnosis: Borders Dumfries & Fife Lothian SCAN Galloway Total yr average SCAN SCAN (% 5 yr 88.7% % 96.5% Case ascertainment methodology Detailed case listings were received from the Cancer Registry for the years , for all residents of the SCAN region. From this list, duplicate records were removed (e.g. patients with bilateral disease or multiple tumours) e.g data: Patients diagnosed and treated privately were removed (22) Patients with duplicate/bilateral records were removed (32) Patients with duplicate/multifocal records were removed (20) Patients confirmed as never seen by the Breast service were removed (8) These were entered into the table above, by year of diagnosis, and by the most probable HB of audit. A high proportion of new patients are diagnosed through the South East Scotland Breast Screening Centre with impalpable tumours requiring specialist equipment for investigations. SCAN Comparative Breast Cancer QPI Report 2016 Report Index: SA B08/17 10

11 These patients are frequently referred to the Edinburgh Breast Unit for staging rather than their local specialist unit. There is added complexity in that a high proportion of Fife residents are staged and treated in Tayside (83 in 2015), and a sizeable number of patients resident in Forth Valley are staged and treated in Lothian (59 in 2016). Theses, and other, cross border flows make regional case ascertainment calculations problematic, at best.. The overall estimate of case ascertainment for SCAN is regarded as more reliable than the individual figure for each Board. 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 Lothian Scotland Accuracy of data recording 97.9% 98.1% 98.9% 98.2% 98.8% (NHS Lothian s score was decreased because of the practice of recording radiotherapy boosts in the field RADSITE5 instead of RADSITE2 or RADSITE3. Their choice of field makes analysis easier and does not impact on data quality). Clinical Sign-off This report compares data from reports prepared for individual hospitals and signed off as accurate following review by the lead clinicians from each service. The collated SCAN results are reviewed jointly by the lead clinicians, to assess variances and provide comments on results: Individual health board results were reviewed and signed-off locally. Collated results were presented and discussed by lead clinicians at Edinburgh Breast Unit on 3 rd November 2017 We hope to circulate the final draft of this SCAN regional comparative report to members of the SCAN Breast Group during November 2017 for final comments. Actions for improvement After final sign off, the process stipulates that this report should be sent to Clinical Governance groups with action plans for completion at Health Board level, if appropriate. The report is uploaded to the SCAN website, together with action plans (where applicable), once it has been fully signed off and checked for any potentially disclosive material. SCAN Comparative Breast Cancer QPI Report 2016 Report Index: SA B08/17 11

12 QPI RESULTS QPI 1: Multidisciplinary Team Meeting Proportion of patients discussed at MDM before definitive treatment Target = 95% Numerator = Number of patients with breast cancer discussed at the MDM before definitive treatment Denominator = All patients with breast cancer Exclusions = Patients who died before first treatment Target 95% Borders D&G Fife St Johns WGH Lothian SCAN 2016 cohort Ineligible for this QPI Numerator Not recorded Denominator Exclusions Denominator % Performance 98.6% 94.5% 95.5% 100.0% 95.4% 96.0% 96.0% Comment D&G: The QPI was not met showing a shortfall of 0.5%. All 5 cases have been reviewed and reasons documented for treatment before MDT discussion as follows: 2 patients were commenced hormone therapy at the initial clinic, one of these was already on hormone treatment for a previous cancer. 1 started hormone therapy while an inpatient having previously declined any intervention, including biopsy. 1 patient was admitted as an emergency and a mastectomy was performed by a non-breast specialist surgeon. For 1 patient there was no reason recorded and treatment was commenced by a surgeon who has since left DGRI. No action has been identified. Historical Summary SCAN Comparative Breast Cancer QPI Report 2016 Report Index: SA B08/17 12

13 QPI 2 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) St Western Target 95% Borders D&G Fife Johns General Lothian SCAN 2016 cohort Ineligible for this QPI Numerator Not recorded Denominator Exclusions Denominator % Performance 97.2% 97.8% 96.5% 100.0% 98.0% 98.3% 97.9% Comment All Health Boards met this target. All outlier cases have been examined in detail and largely relate to patients diagnosed by excision biopsy. No action has been identified. Historical Summary SCAN Comparative Breast Cancer QPI Report 2016 Report Index: SA B08/17 13

14 QPI 3 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. Western Target 95% Borders D&G Fife St Johns General Lothian SCAN 2016 cohort Ineligible for this QPI Numerator Not recorded Denominator Exclusions Denominator % Performance 100.0% 98.7% 98.5% 100.0% 99.2% 99.3% 99.2% Comment All Health Boards have met this target. Historical Summary SCAN Comparative Breast Cancer QPI Report 2016 Report Index: SA B08/17 14

15 QPI 3 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. St Western Target 85% Borders D&G Fife Johns General Lothian SCAN 2016 cohort Ineligible for this QPI Numerator Not recorded Denominator Exclusions Comments Denominator % Performance 100.0% 100.0% 98.2% 91.3% 99.3% 98.2% 98.5% All Health Boards met this target Historical Summary SCAN Comparative Breast Cancer QPI Report 2016 Report Index: SA B08/17 15

16 SURGERY QPI 4 - Conservation Rate Proportion of patients with small tumours having 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. Western Target 90% Borders D&G Fife St Johns General Lothian SCAN 2016 cohort Ineligible for this QPI Numerator Not recorded Denominator Exclusions Denominator % Performance 88.2% 88.2% 100.0% 100.0% 98.6% 98.7% 97.8% Comments All outliers have been reviewed in detail and in virtually all cases patient choice is the reason for Mastectomy being carried out rather than conservation surgery. It is noted that patients in Borders and Dumfries frequently preferred to avoid daily travel for radiotherapy which would have been necessary if they had opted for conservation surgery. One case was explained by technical difficulties. Historical summary SCAN Comparative Breast Cancer QPI Report 2016 Report Index: SA B08/17 16

17 QPI 5 - 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 Western Target < 5% Borders D&G Fife St Johns General Lothian SCAN 2016 cohort Ineligible for this QPI Numerator Not recorded Denominator Exclusions Denominator % Performance 0.0% 0.0% 0.0% 0.0% 2.6% 2.4% 1.9% Comments All Health Boards have met this target. Historical summary Max SCAN Comparative Breast Cancer QPI Report 2016 Report Index: SA B08/17 17

18 QPI 6 Immediate reconstruction rate Proportion of mastectomy patients having an immediate reconstruction Target 25% 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 Target 25% Borders D&G Fife St Johns Western General Lothian SCAN 2016 cohort Ineligible for this QPI Numerator Not recorded Denominator Exclusions Denominator % Performance 23.3% 16.7% 22.6% 27.3% 42.4% 38.6% 31.0% Comments In 2016 the target increased from >10% to 25%. SCAN Comparative Breast Cancer QPI Report 2016 Report Index: SA B08/17 18

19 Historical summary. SCAN Comparative Breast Cancer QPI Report 2016 Report Index: SA B08/17 19

20 QPI 8 - Minimising Hospital Stay - Day Case Surgery - Based on SMR01 Data and Provided to Boards by ISD Patients should have the opportunity for day case surgery (no overnight stay following surgery) wherever possible. Target = 60% Numerator = Number of patients with breast cancer undergoing wide excision and/or axillary sampling procedure (sentinel node biopsy or node sample ( 4 nodes), discharged on same day as 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. By HB of surgery: Day surgery only - without overnight hospital stay Borders D&G Fife Western General St Johns Lothian SCAN Numerator % 70.6% 75.4% 71.0% 75.8% 94.8% 77.4% 76.1% Denominator By HB of Residence: Day surgery only - without overnight Borders D&G Fife Lothian SCAN hospital stay Numerator % 78.1% 48.5% 64.7% 76.8% 70.2% Denominator Comment This QPI has been measured according to the new specification published in July A proportion of D&G patients have surgical treatment in Glasgow and these patients are more likely to require an overnight stay rather than endure a lengthy journey by road on the day of surgery. SCAN Comparative Breast Cancer QPI Report 2016 Report Index: SA B08/17 20

21 Historical summary It is not possible to show the previous years performance in a comparative chart due to changes in the measurability specification. QPI 8 - Max Hospital Stay Borde Western D&G Fife St Johns of 1 Night rs General Lothian SCAN 2016 day case surgery: 70.6% 75.4% 71.0% 94.8% 75.8% 77.4% 76.1% 2015: no overnight stay: 2015 Performance 65.8% 77.1% 67.3% 93.2% 75.8% 76.7% 75.4% 2013 & 2014: maximum 1 overnight stay 2014 Performance 81.6% 88.0% 96.1% 93.1% 92.9% 93.0% 93.04% 2013 Performance 92.3% 97.9% 97.1% 93.8% 93.1% 93.7% 94.4% SCAN Comparative Breast Cancer QPI Report 2016 Report Index: SA B08/17 21

22 PATHOLOGY QPI 9 - HER2 Status for Decision Making Her2 Status should be available to inform treatment decision making Revised target = 80% Numerator = Number of patients with invasive breast cancer for whom the HER2 status is known at initial MDT meeting to decide first treatment. Denominator = All patients with invasive breast cancer. Exclusions = none Western Target 80% Borders D&G Fife St Johns General Lothian SCAN 2016 cohort Ineligible for QPI Numerator Not recorded Denominator Exclusions Denominator % Performance 93.8% 78.7% 83.5% 92.4% 91.2% 91.4% 89.3% SCAN Comparative Breast Cancer QPI Report 2016 Report Index: SA B08/17 22

23 Comment D&G: Her2 testing was previously carried out in Glasgow, whereas the other Health Boards used laboratory services in Edinburgh. During 2016 D&G transferred its testing arrangements to Edinburgh, with improved results. The cases taking >14 days for a Her2 status result were largely those which required a FISH test. Historical summary The chart below does not show performance pre-2015 due to changes in the QPI specification QPI 9 - HER2 status availability Target 90% Borders D&G Fife St Johns Western General Lothian SCAN 2014 Performance 55.7% 43.0% 63.7% 63.8% 73.2% 72.0% 66.8% 2013 Performance 29.4% 12.5% 40.4% 47.5% 72.5% 69.4% 57.6% 2012 Performance 38.2% 6.9% 17.4% 37.9% 63.5% 60.6% 47.5% SCAN Comparative Breast Cancer QPI Report 2016 Report Index: SA B08/17 23

24 ONCOLOGY QPI 10 - 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. Western Target 95% Borders D&G Fife St Johns General Lothian SCAN 2016 cohort Ineligible for this QPI Numerator Not recorded Denominator Exclusions Denominator % Performance 85.2% 89.8% 92.6% 100.0% 94.7% 95.2% 94.2% Comment D&G: The target was not met with a shortfall of 5.2%. D&G patients have the added difficulty of the need to travel considerable distances for treatment, mainly to Edinburgh. 2 declined for this reason. There were valid clinical reasons why the other patients did not have radiotherapy. Borders: The target was not met with a shortfall of 9.8%. All 4 patients declined radiotherapy. Fife: The target was not met with a shortfall of 2.4% (6 cases). 2 patients declined radiotherapy; 3 had valid clinical reasons and in 1 case the reason was not documented. Lothian: The target was not met, with a shortfall of 0.8%. All cases have been checked in detail. Reasons for not having adjuvant radiotherapy are as follows: Of the 26 patients who did not receive radiotherapy 11 declined radiotherapy treatment; 8 were not fit enough for radiotherapy itself and several of these had had surgery under local anaesthetic. 2 patients could not have radiotherapy as they had received radiotherapy for other cancers, 2 patients were deemed low risk and after discussion did not receive radiotherapy. In 1 patient radiotherapy was not technically possible; 1 patient died before radiotherapy and 1 patient was found to have metastatic disease. SCAN Comparative Breast Cancer QPI Report 2016 Report Index: SA B08/17 24

25 Historical summary SCAN Comparative Breast Cancer QPI Report 2016 Report Index: SA B08/17 25

26 QPI 11 - Adjuvant Chemotherapy This QPI has proved problematic in previous years. Clinicians have not had confidence in the nationally specified analysis method and subsequent results. This QPI was revised during 2016 and is now dependent on collection of a PREDICT score. PREDICT is an online prognostication and treatment benefit tool designed to help clinicians and patients make informed decisions about treatment following breast cancer surgery. The survival estimates, presented both with and without adjuvant therapy (hormone therapy, chemotherapy and trastuzumab), are provided for 5 and 10 years following surgery. 3 Numerator = number of patients with invasive breast cancer who have a >=5% overall survival benefit of chemotherapy treatment predicted at 10 years, who undergo adjuvant chemotherapy Denominator = All patients with invasive breast cancer who have a >=5% overall survival benefit of chemotherapy treatment predicted at 10 years 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. Target = 85% St Western Target 85% Borders D&G Fife Johns General Lothian SCAN 2016 cohort Ineligible for QPI Numerator Not recorded Denominator Exclusions Denominator % Performance 62.5% 80.0% 91.2% 80.8% 82.6% 82.1% 81.9% 3 SCAN Comparative Breast Cancer QPI Report 2016 Report Index: SA B08/17 26

27 Comment A PREDICT score has proved difficult to generate and record at the MDM. Therefore an algorithm was developed in SCAN to produce the score retrospectively, allowing us to include all patients with a score of 5% or more in the denominator. We have subsequently examined the details of all patients not having adjuvant chemotherapy and reasons were found to be either due to the patient declining treatment or having co morbidities which precluded treatment. The data definitions allow not applicable to be recorded for the PREDICT score but there is no guidance on when this would be appropriate. It is considered likely that there will be different interpretations applied across Scotland therefore comparison of these results is likely to be adversely affected. QPI 11 - Patients having adjuvant chemotherapy Borders D&G Fife St Johns Western General Lothian SCAN 2016 Performance 62.5% 80.0% 91.2% 80.8% 82.6% 82.1% 81.9 QPI revised between 2015 & Performance % 85.7% 93.8% 62.1% 67.0% 70.5% 2014 Performance 70.0% 73.3% 76.2% 88.9% 59.5% 64.9% 67.8% 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% SCAN Comparative Breast Cancer QPI Report 2016 Report Index: SA B08/17 27

28 QPI 13 Re-excision Rates Numerator = number of patients with breast cancer (invasive or in situ) having breast conservation surgery who undergo re-excision or mastectomy following initial breast surgery Denominator = all patients with breast cancer (invasive or in situ) having conservation surgery as their initial or only breast surgery Exclusions = LCIS only St Western Target <20% Borders D&G Fife Johns General Lothian SCAN 2016 cohort Ineligible for QPI Numerator Not recorded Denominator Exclusions Denominator % Performance 14.3% 10.1% 21.2% 20.3% 18.6% 18.8% 18.2% Comment This QPI was introduced in 2016, therefore there is no historic data for comparison. St. Johns - Matthew Barber agrees that re-excision rates are higher than is desirable. This tendency was also shown in recently reviewed Breast Screening data. He has already implemented change to his personal practice by taking routine additional cavity shaves and is hopeful that this will improve figures. No further action is identified. SCAN Comparative Breast Cancer QPI Report 2016 Report Index: SA B08/17 28

29 QPI 14: Referral for Genetics Testing (i) Target: 90% Numerator = Number of patients with breast cancer who are aged under 30 years at diagnosis referred to a specialist clinic for genetic testing Denominator = Number of patients with breast cancer who are aged under 30 years at diagnosis Exclusions = none Western Target 90% Borders D&G Fife St Johns General Lothian SCAN 2016 cohort Ineligible for QPI Numerator Not recorded Denominator Exclusions Denominator % Performance 100.0% 100.0% 100.0% 100.0% Comment This QPI was introduced in 2016, therefore there is no historic data for comparison. Borders, Dumfries and St Johns had no patients in this age group. SCAN Comparative Breast Cancer QPI Report 2016 Report Index: SA B08/17 29

30 QPI 14: Referral for Genetics Testing (ii) Target: 90% Numerator = Number of patients with triple negative breast cancer who are aged under 40 years at diagnosis referred to a specialist clinic for genetic testing Denominator = Number of patients with triple negative breast cancer who are aged under 40 years at diagnosis Exclusions = none Western Target 90% Borders D&G Fife St Johns General Lothian SCAN 2016 cohort Ineligible for QPI Numerator Not recorded Denominator Exclusions Denominator % Performance 100.0% 100.0% 100.0% 100.0% 100.0% Comment Borders and Dumfries had no patients in this category. SCAN Comparative Breast Cancer QPI Report 2016 Report Index: SA B08/17 30

31 QPI 15: 30 day Mortality following Chemotherapy Numerator =Number of patients who undergo chemotherapy that die within 30 days of treatment (i) Neoadjuvant (ii) Adjuvant (iii) Palliative Denominator = All patients with breast cancer undergoing chemotherapy (i) Neoadjuvant (ii) Adjuvant (iii) Palliative Target = <1% (neoadjuvant & adjuvant treatment) Target = <5% (palliative treatment) (i) Neoadjuvant chemotherapy (ii) Adjuvant Target <1% Borders D&G Fife St Johns Western General Lothian SCAN 2016 cohort Ineligible for QPI Numerator Not recorded Denominator Exclusions Denominator % Performance 0.0% 0.0% 0.0% 0.0% 1.4% 1.3% 0.8% Western Target <1% Borders D&G Fife St Johns General Lothian SCAN 2016 cohort Ineligible for QPI Numerator Not recorded Denominator Exclusions Denominator % Performance 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% SCAN Comparative Breast Cancer QPI Report 2016 Report Index: SA B08/17 31

32 (iii) Palliative Comment Western Target <5% Borders D&G Fife St Johns General Lothian SCAN 2016 cohort Ineligible for QPI Numerator Not recorded Denominator Exclusions Denominator % Performance 0.0% 0.0% 0.0% 0.0% 28.6% 18.2% 11.8% This QPI was introduced in 2016, therefore there is no historic data for comparison. Small numbers are an issue affecting the overall percentages achieved for this QPI. Details of the 3 Lothian patients have been reviewed. NB: The denominator for this QPI is confined to those patients who newly present with breast cancer which is found to be metastatic at the time of diagnosis. It does not represent the larger group of patients who require palliative chemotherapy for disease diagnosed in previous years. SCAN Comparative Breast Cancer QPI Report 2016 Report Index: SA B08/17 32

33 Clinical Trial Access QPI Proportion of patients with Breast cancer who are enrolled in an interventional clinical trial or translational research. Target: Interventional clinical trials 7.5% Translational research 15% These target levels have been agreed based on current National Cancer Research Institute (NCRI) data. Numerator 1 = Number of patients with Breast cancer enrolled in an interventional clinical trial. Numerator 2 = Number of patients with Breast cancer enrolled in translational research. Denominator = All patients with breast cancer: Average 5 year ( ) incidence by Health Board of residence (Cancer Registry data). Other HB Interventional Target 7.5% Borders D&G Fife Lothian postcode SCAN Numerator Denominator % Performance 3.7% 1.7% 3.3% 10.0% 8.0% Other HB Translational Target 15% Borders D&G Fife Lothian* postcode SCAN Numerator Denominator % Performance 1.2% 0.0% 9.5% 32.3% 24.2% Numbers Interventional Trials in 2016 recruited Add-Aspirin 26 CANC FAST-Forward 9 FURVA 15 Heart Function During Breast Cancer Treatment 3 IBIS 3: POLaR (Feasibility) 1 MAMMO NCRN FINESSE - lucitanib in ER+ metastatic BrCa 1 NCRN / BravO niraparib vs physician's choice in HER2- BRCA BrCa 1 NCRN Enzalutamide with Trastuzumab in HER2+ AR+ MBCa 3 Olympia / MA.36 3 POSNOC 3 UNIRAD 11 WO29522 (Impassion-130) 2 Total 101 SCAN Comparative Breast Cancer QPI Report 2016 Report Index: SA B08/17 33

34 Numbers Translational Trials in 2016 recruited AURORA 13 Breast collection 156 Cardiac Troponin I Study 58 Circulating Free DNA Study 35 EORTC10085 (observational) 3 Evaluation of the prognostic role of ctdna in metastatic breast cancer patients 10 ROSCO 8 The NEO Study 24 Total 307 Comment No comparison is made with previous years because the earlier data had a large proportion of missing post-codes resulting in a significant number of trials patients not being assigned to the appropriate Health Board. SCAN Comparative Breast Cancer QPI Report 2016 Report Index: SA B08/17 34

35 APPENDIX 1 AGE AT DIAGNOSIS Age Borders D&G Fife St.Johns WGH Lothian SCAN <45 n % 13.9% 6.5% 12.2% 15.3% 6.7% 7.8% 8.7% n % 8.3% 15.2% 8.9% 15.3% 5.7% 6.9% 7.9% n % 12.5% 10.9% 11.7% 7.2% 18.4% 17.0% 15.5% n % 11.1% 9.8% 7.8% 11.7% 12.1% 12.0% 11.2% n % 6.9% 15.2% 6.1% 7.2% 13.4% 12.6% 11.5% n % 12.5% 13.0% 15.0% 11.7% 16.6% 16.0% 15.4% n % 11.1% 12.0% 10.6% 9.9% 9.6% 9.6% 10.0% n % 6.9% 7.6% 11.7% 6.3% 7.7% 7.5% 8.1% n % 13.9% 6.5% 9.4% 9.0% 4.2% 4.8% 6.1% 85+ n % 2.8% 3.3% 6.7% 6.3% 5.7% 5.8% 5.5% Total n % APPENDIX 2 - GENDER Borders Dumfries Fife WGH St Johns SCAN Gender % % % % % % Female 71 99% % % % % % Male 1 1% 0 0% 0 0% 2 0% 0 0% 3 0.2% Total % % % % % % SCAN Comparative Breast Cancer QPI Report 2016 Report Index: SA B08/17 35

36 APPENDIX 3 SUMMARY BY KEY CATEGORIES Borders Dumfries Fife WGH St Johns SCAN Referral % % % % % % GP referral % % % % % % Breast Screening 6 8.3% % % % 5 4.5% % Incidental/Secondary care 3 4.2% 5 5.4% % % 8 7.2% % Review patients 6 8.3% 2 2.2% 7 3.9% % 4 3.6% % Genetics Clinic 0 0.0% 0 0.0% 1 0.6% 1 0.1% 2 1.8% 4 0.3% Ref from private healthcare 0 0.0% 0 0.0% 0 0.0% 2 0.3% 0 0.0% 2 0.2% Other 0 0.0% 0 0.0% 0 0.0% 3 0.4% 1 0.9% 4 0.3% 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% 0 0.0% 1 0.1% 0 0.0% 3 0.2% T % % % % % % T % % % % % % T % 7 7.6% % % 4 3.6% % T % 6 6.5% % % % % Tis (DCIS) 6 8.3% 2 2.2% % % 6 5.4% % Tx (not assessable) 0 0.0% 1 1.1% 0 0.0% 2 0.3% 0 0.0% 3 0.2% T9 (not recorded) 0 0.0% 3 3.3% 2 1.1% 1 0.1% 0 0.0% 6 0.5% Total % % % % % % N Stage N % % % % % % N % % % % % % N % 1 1.1% 4 2.2% 3 0.4% 0 0.0% % N % 1 1.1% 2 1.1% 6 0.8% 0 0.0% 9 0.7% NX 1 1.4% 3 3.3% 3 1.7% 3 0.4% 0 0.0% % N9 (not recorded) 0 0.0% 3 3.3% 2 1.1% 2 0.3% 0 0.0% 7 0.6% Total % % % % % % M Stage M % % % % % % M % % % % 7 6.3% % M9 (not recorded) 2 2.8% 3 3.3% 5 2.8% % 1 0.9% % Total % % % % % % SCAN Comparative Breast Cancer QPI Report 2016 Report Index: SA B08/17 36

37 Borders Dumfries Fife WGH St Johns SCAN Part of TNM not recorded 2 2.8% 5 5.4% 5 2.8% % 1 0.9% % Tumour Types % % % % % % DCIS % % % % % % LCIS 0 0.0% 0 0.0% 1 7.1% 9 8.9% 0 0.0% % Paget s Disease % 0 0.0% 1 7.1% 0 0.0% 0 0.0% 2 1.5% Other non-invasive 0 0.0% 0 0.0% 1 7.1% 3 3.0% 0 0.0% 4 3.0% Non-invasive total % 2 2.2% % % 6 5.4% % Ductal carcinoma % % % % % % Lobular carcinoma 5 7.8% % % % % % Medullary carcinoma 0 0.0% 0 0.0% 0 0.0% 1 0.1% 1 1.0% 2 0.2% Mucinous carcinoma 2 3.1% 1 1.1% 6 3.7% % 2 1.9% % Tubular carcinoma 0 0.0% 1 1.1% 0 0.0% % 0 0.0% % Mixed (invasive) 3 4.7% 4 4.5% 2 1.2% % 1 1.0% % Other invasive 3 4.7% 2 2.2% 1 0.6% % 3 2.9% % Occult, with +ve nodes 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% Invasive total % % % % % % Inapplicable (no histology) 0 0.0% 1 1.1% 2 1.1% 1 0.1% 0 0.0% 4 0.3% 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 9.7% 3 3.4% 7 4.3% % 5 4.8% % Negative (0-2) % % % % % % Not assessable 0 2.8% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 2 0.2% Not recorded 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% Inapplicable 0 0.0% 1 1.1% 1 0.6% 1 0.1% 0 0.0% 3 0.3% Total % % % % % % Her2 Status (Invasive tumours) Her2 positive % % % % % % Her2 negative % % % % % % Not recorded 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% Not done / Inconclusive 0 0.0% 0 0.0% 4 2.4% 7 1.0% 0 0.0% % Not assessable 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% Total % % % % % % SCAN Comparative Breast Cancer QPI Report 2016 Report Index: SA B08/17 37

38 Borders Dumfries Fife WGH St Johns SCAN First treatment Surgery % % % % % % Hormone therapy % % % % % % Chemotherapy % % % % % % Radiotherapy 0 0.0% 0 0.0% 3 1.7% 2 0.3% 1 0.9% 6 0.5% Biological therapy 0 0.0% 1 1.1% 0 0.0% 0 0.0% 0 0.0% 1 0.1% No active treatmentt (Supportive care) 0 0.0% 1 1.1% 1 0.6% 1 0.1% 0 0.0% 3 0.2% Died before treatment 0 0.0% 0 0.0% 1 0.6% 0 0.0% 0 0.0% 1 0.1% Refused all treatment 0 0.0% 0 0.0% 1 0.6% 1 0.1% 1 0.9% 3 0.2% Not recorded 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% Total % % % % % % Final Surgery Localising/Excision biopsy 0 0.0% 0 0.0% 0 0.0% 6 0.9% 0 0.0% 6 0.6% Conservation surgery % % % % % % Therapeutic mammoplasty 0 0.0% 0 0.0% 0 0.0% % 0 0.0% % Conservation Total % % % % % % Mastectomy % % % % % % Mastectomy + immediate reconstruction 6 9.5% 4 5.1% % % % % Mastectomy total % % % % % % Axillary surgery alone 0 0.0% 0 0.0% 0 0.0% 1 0.1% 0 0.0% 1 0.1% Other 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% Surgery total % % % % % % Refused treatment 0 0.0% 1 1.1% 0 0.0% 6 0.8% 5 4.5% % Not yet/pending 0 0.0% 0 0.0% 5 2.8% 3 0.4% 0 0.0% 8 0.7% Not applicable % % % % % % Not recorded 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% Total % % % % % % SCAN Comparative Breast Cancer QPI Report 2016 Report Index: SA B08/17 38

39 Borders Dumfries Fife WGH St Johns SCAN % % % % % % Radiotherapy Primary radical 0 0.0% 1 1.1% 0 0.0% 2 0.3% 0 0.0% 3 0.2% Adjuvant % % % % % % Palliative 5 6.9% 0 0.0% 5 2.8% % 2 1.8% % Refused 0 0.0% 5 5.4% 1 0.6% % 2 1.8% % 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% 7 3.9% 3 0.4% 0 0.0% % Total % % % % % % Chemotherapy (1 st course) Adjuvant % % % % % % Neoadjuvant 7 9.7% % % % 9 8.1% % Palliative 1 1.4% 3 3.3% 2 1.1% 7 0.9% 4 3.6% % Refused 2 2.8% % 6 3.3% % 5 4.5% % 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% 5 2.8% 3 0.4% 0 0.0% 8 0.7% Total % % % % % % Hormone therapy (1st course) Neoadjuvant 4 5.6% % % % 2 1.8% % Peri-operative 1 1.4% % 7 3.9% % 4 3.6% % Primary 4 5.6% 5 5.4% % % % % Palliative 4 5.6% 4 4.3% 3 1.7% % 6 5.4% % Adjuvant % % % % % % Inapplicable % % % % % % Not recorded 0 0.0% 0 0.0% 0 0.0% 2 0.3% 0 0.0% 2 0.2% Refused 1 1.4% 0 0.0% 1 0.6% 7 0.9% 1 0.9% % Not yet/pending 0 0.0% 0 0.0% 3 1.7% 1 0.1% 0 0.0% 4 0.3% Total % % % % % % SCAN Comparative Breast Cancer QPI Report 2016 Report Index: SA B08/17 39