Audit Report Report of the 2011 Clinical Audit Data

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1 Lung Cancer Managed Clinical Network Audit Report Report of the 2011 Clinical Audit Data Dr Richard Jones Consultant Clinical Oncologist MCN Clinical Lead Kevin Campbell MCN Manager Julie McMahon Information Officer

2 CONTENTS EXECUTIVE SUMMARY 3 1. INTRODUCTION 6 2. BACKGROUND NATIONAL CONTEXT WEST OF SCOTLAND CONTEXT 7 3. METHODOLOGY 9 4. RESULTS AND ACTION REQUIRED DATA QUALITY RESULTS CONCLUSIONS 32 ACKNOWLEDGEMENT 33 ABBREVIATIONS 34 REFERENCES 36 APPENDIX: NHS BOARD ACTION PLANS 2

3 Executive Summary Introduction This report presents an assessment of performance of West of Scotland Lung Cancer Services measured against NHS Quality Improvement Scotland (QIS) Clinical Standards for the management of lung cancer, using clinical audit from the period January December Where appropriate, 2011 clinical audit data has been presented alongside data from 2009 and 2010 to allow year-on-year comparison. The (WoSCAN) Lung Cancer Managed Clinical Network (MCN) has been in existence for almost a decade. The Lung Cancer MCN continues to support the delivery and development of the service for approximately 2300 new lung cancer patients each year across seven Multidisciplinary Team Meetings (MDTM). The Network continues to benefit from enthusiastic engagement of a range of healthcare professionals and managers across the West of Scotland (WoS). The Scottish Cancer Taskforce Quality Subgroup is currently taking forward the development of national Quality Performance Indicators (QPIs) for all cancers. Work is near completion to develop QPIs for lung cancer. This will enable national comparative reporting and will help to drive continuous improvement for patients. Background The incidence rate of lung cancer in females continues to rise with a 17% increase over the last decade whereas in males the long term decline in incidence has continued with a significant fall of incidence of 15% over the same time period (1). Overall cancer mortality rates for male lung cancer patients in Scotland have decreased however the mortality rate for females is increasing (1). Despite more patients having the opportunity for anti-cancer therapy beyond initial treatment, lung cancer patients continue to have one of the lowest survival rates of any cancer, often due to advanced stage at presentation and are less amenable to treatment. Data shows that for patients diagnosed between year relative survival was 27.2% in males and 30.4% in females (2). 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 and 31 st December 2011 was downloaded from ecase on 22 nd August 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. 3

4 Results The data were used to assess performance against fifteen core Standards from the NHS QIS Standards for the management of lung cancer. Values represent the range and overall West of Scotland result expressed as a percentage. 1. A minimum of 75% of all lung cancer patients have their diagnosis confirmed by histology/cytology (72.9 [ ]%) 2. TNM stage is recorded for a minimum of 90% of cases at the time of diagnosis (Lung cancer) (91.3 [ ]%) 3. TNM stage is recorded for a minimum of 90% of cases at the time of diagnosis (Mesothelioma) (55.1 [ ]%) 4. WHO Performance Status is recorded for a minimum of 90% of cases at the time of diagnosis (92.6 [ ]%) 5. All patients with a diagnosis of lung cancer are discussed by a Multidisciplinary Team (94.6 [ ]%) 6. All patients with a diagnosis of lung cancer are seen by a Clinical Nurse Specialist (82.0 [ ]%) 7. The percentage of patients receiving anti cancer treatment for lung cancer (includes radiotherapy, chemotherapy, chemoradiotherapy, surgery and other therapies including endobronchial treatment) (61.1 [ ]%) 8. Less than 10% of patients that undergo surgery are resected by wedge or segmentectomy (10.2 [ ]%) 9. The 30 day mortality rate following final lung cancer surgery specific to the procedure performed (0.7 [ ]%) 10. A minimum of 60% of those limited disease SCLC patients receiving chemotherapy also receive consolidation radiotherapy to the chest (31.8 [ ]%) 11. A minimum of 60% of those limited disease SCLC patients receiving chemotherapy subsequently receiving prophylactic cranial irradiation (PCI) (28.4 [ ]%) 12. The 30-day mortality rate following final curative radiotherapy. (2.2 [ ]%) 13. The 30-day mortality rate following final palliative radiotherapy. (18.1 [ ]%) 14. A minimum of 60% of SCLC patients receive chemotherapy (75.3 [ ]%) 15. A minimum of 20% of NSCLC patients receive chemotherapy (30.8 [ ]%) 4

5 Conclusions and Action Required It is encouraging that most units are meeting the NHS QIS Standards; results presented in this report demonstrate that patients with lung cancer in the WoS continue to receive an equitable and consistent standard of care regardless of geographical location. Improvements in data capture and quality have been observed in recent years which has facilitated meaningful analysis to help inform MCN activities. This progress is welcomed however it is also recognised that there is still room for further improvement. Much of the analysis is focussed on process rather than outcome, however it is anticipated that this will be addressed by the development and implementation of QPIs. The MCN will actively progress regional actions identified in this report and NHS Boards are asked to develop local Action/Improvement Plans in response to the findings presented in the report. Progress against these plans will be monitored by the MCN Advisory Board and reported to the Regional Cancer Advisory Group (RCAG) annually by Board Lead Cancer Clinicians and MCN Clinical Leads, as part of the regional audit governance process to enable RCAG to review and monitor regional improvement. This process is intended to deliver incremental and sustainable improvements in the quality of patient care. Action required: Ayrshire, North Glasgow and South Glasgow should explore the reason for the decrease in histological/cytological diagnosis to establish if this is due to clinical factors or a change in practice. All MDTs should establish robust processes to ensure that all lung cancer patients are discussed by the MDT to ensure that there is an agreed management plan, even in cases where active symptom control is more appropriate. Lanarkshire and North Glasgow should establish robust processes to ensure capture of TNM data either by documentation in case notes and/ or at MDT meetings. Emphasis must be given to the requirement of clinicians to do so to allow audit data capture and facilitate measurement of QPIs. North Glasgow should ensure that patient performance status is discussed and documented at the MDT meeting. Continued promotion of liaison and co-operation between clinical nurse specialists and audit staff is required across the region to ensure improved availability of data. Radiotherapy downloads from the Beatson West of Scotland Cancer Centre (BWoSCC) must be fully utilised by all NHS Boards to ensure continued improvement in data capture. TNM 7 is the standard staging system method which should be used for mesothelioma patients diagnosed from 1 st January All lung cancer MDTs should review their data collection methodology for capturing TNM stage in mesothelioma patients. A summary of actions for each NHS Board has been included within the Action Plan templates in the Appendices at the rear of the document. Completed Action Plans should be returned to WoSCAN within two months of publication of this report. 5

6 1. Introduction This report presents results of the annual assessment of service performance against NHS Quality Improvement Scotland (QIS) Standards of West of Scotland (WoS) lung cancer services, using the clinical audit data relating to patients diagnosed in the region in These audit data underpin much of the regional development and service improvement work of the Managed Clinical Network (MCN) and regular reporting of activity and performance is a fundamental requirement of an MCN to assure the quality of care delivered across the region. The lung cancer MCN continues to support and develop the clinical service for approximately 2,300 new lung cancer patients each year. Management of this patient group relies heavily on close collaboration between the respiratory physicians, oncologists, surgeons, pathologists, radiologists, palliative care and clinical nurse specialists (CNSs). The MCN continues to benefit from enthusiastic engagement from a range of healthcare professionals and managers across the WoS. The Scottish Cancer Taskforce Quality Subgroup is currently taking forward the development of National Quality Performance Indicators (QPIs) for all cancers. OPIs for Lung cancer are due to be implemented in April This will enable future national comparative reporting and help to drive continuous improvement for patients. 2. Background Lung cancer patients usually present to a chest physician, although a significant subgroup are referred by other clinicians, e.g. care of the elderly, and increasingly there is cross referral to lung cancer Multidisciplinary Team (MDT) meetings as awareness of other services within hospitals increases. There are seven lung cancer MDTs which operate around eight outpatient clinics serving 2.4 million people across four NHS Boards - NHS Ayrshire & Arran, NHS Forth Valley, NHS Greater Glasgow and Clyde, and NHS Lanarkshire - from this population approximately 2300 patients are diagnosed with lung cancer per annum. Surgical services are provided centrally at the Golden Jubilee National Hospital (GJNH). Table 1 lists the MDTs by NHS Board area, and includes the analysis group based on location of diagnosis, which has been used to present results throughout the report. Table 1: Lung Cancer MDT Configuration in the WoS MDT Analysis Group NHS Board Area (location of diagnosis) Crosshouse & Ayr Ayrshire & Arran (AA) NHS Ayrshire & Arran Forth Valley Royal Hospital Forth Valley (FV) NHS Forth Valley Pan Lanarkshire Lanarkshire (LS) NHS Lanarkshire Clyde Clyde (Clyde) North East Glasgow West Glasgow South Glasgow North Glasgow (NG) South Glasgow (SG) NHS Greater Glasgow and Clyde 6

7 2.1 National Context Lung cancer continues to be the most common cancer (16% of all cancers) in Scotland, with approximately 4800 new cases diagnosed each year. Nationally lung cancer accounts for 18% of male cancer patients and 15% of female cancer patients. Lung cancer incidence rates in females continue to rise with a 17% increase over the last ten years; in contrast the long term decline in incidence of male lung cancer has continued with a significant fall in incidence of 15% over the same time period. The lifetime risk of developing lung cancer is estimated to be 1 in 13 for males and 1 in 16 for females (1). Overall cancer mortality rates have decreased in Scotland by 15% in males and 7% in females over the last 10 years, however the mortality rate for females with lung cancer has increased by 11%; decreasing by 21% for males (1) Despite more patients having the opportunity for anti-cancer therapy beyond initial treatment, lung cancer patients continue to have one of the lowest survival rates of any cancer, often due to advanced stage of disease at presentation. Data shows that for patients diagnosed between year relative survival was 27.2% in males and 30.4% in females, 5 year relative survival drops to 7.3% and 8.8% for males and females respectively (2). Earlier detection of lung cancer could lead to improved outcomes in patients and increasing awareness of symptoms and promotion of earlier detection is currently being explored as part of the Scottish Government Detect Cancer Early programme (3). 2.2 West of Scotland Context Across Scotland 24% of the adult population continue to use tobacco products. In some of the most deprived areas in WoSCAN up to 50% of the adult population use tobacco products (4). It is also recognised that there is a substantial level of co-morbidities in lung cancer patients in the WoS, which contributes to poor survival and may restrict treatment options. Industrial exposure is a known cause of mesothelioma and this is particularly true in the WoS where ship building was a strong industry. 7

8 Age and Gender Distribution There were 2465 new diagnoses of cancer recorded by the Lung MCN in the WoS during 2011 and of these 2387 were lung cancers and 78 mesothelioma cases. Of the lung cancer diagnoses 1226 (51%) diagnosed were male and 1161 (49%) female. Lung cancer continues to be more prevalent in patients aged 60 years and over with 86% of the total cases in 2011 occurring in patients within this group. Figure 1: Age & Gender Distribution of Lung Cancer Cases in the WoS Male Female Number of Cases < >85 Age Group Stage at Diagnosis Staging is the assessment of the extent of disease and is performed for prognostic and therapeutic purposes. Figure 2: Stage at Diagnosis of Lung Cancer Patients NR, 8.6% Inapplicable, 0.3% IA, 8.2% IB, 5.6% IIA, 2.9% IIB, 3.0% IIIA, 13.4% IV, 47.2% IIIB, 10.7% Figure 2 shows the presenting stage distribution of all lung cancer patients; 71.3% of patients in the WoS presented with advanced disease, stage III or IV. The national Detect Cancer Early Programme is promoting increased awareness of symptoms to increase early detection of lung cancer with the aim of improving outcomes for patients. (3) 8

9 3. 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 web- based database. Data relating to patients diagnosed between 1 st January and 31 st December 2011 was downloaded from ecase at 2200 hrs on 22 nd August 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 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 NHS 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. 9

10 4. Results and Action Required 4.1 Data Quality Case ascertainment is a measure of data quality derived from comparing the number of new patients captured by the audit with the numbers recorded by the National Cancer Registry; as a proportion of the average number accrued over the most recently available 5 year period. Cancer Registry information is available some time after the year of interest as collection and verification of data is time intensive; it is for this reason that audit data cannot be compared directly to Cancer Registry data for the same year. Figure 3 illustrates case ascertainment across west of Scotland NHS Boards. Cancer Registry data used to calculate case ascertainment for the 2011 cohort is the average of 2006 to 2010 (extracted in June 2012) and these figures are displayed in the accompanying data table. Figure 3: WoS Lung Cancer Case Ascertainment Percentage AA FV LS NG SG Clyde WoS Analysis Group Ayrshire & Arran Forth Valley Lanarkshire North Glasgow South Glasgow Clyde WoSCAN Cases from Audit Cancer Registration Cases The chart in Figure 3 shows increased case ascertainment on previous years, demonstrating improved data capture. Forth Valley s case ascertainment is recorded as 77% and is consistent with previous years. A problem with coding of patients to the Cancer Registry was discovered in the Forth Valley area and it is anticipated that once rectified will lead to an increase in case ascertainment figures for the NHS Board. 10

11 4.2 Results Distribution of lung cancer cases in the WoS There were 2387 new diagnoses of lung cancer in the WoS during The number diagnosed in each analysis group is presented in Figure 4. Figure 4: Distribution of Lung Cancer Cases in the WoS (2183 WoS cases) 2010(2196 WoS cases) 2011(2387 WoS cases) 600 Number of Cases AA FV LS NG SG Clyde Analysis Group Ayrshire & Arran Forth Valley Lanarkshire North Glasgow South Glasgow Clyde WoSCAN N

12 Of the lung cancer diagnoses around 16% were small cell lung cancers (SCLC) and 56% were non small cell lung cancers (NSCLC). The remaining 28% of cases of lung cancer recorded were made up of classifications shown in Figure 5. Figure 5: Types of Lung Cancer in the WoS Clinically Diagnosed, 27.4% NSCLC, 55.5% Carcinoid, 0.4% Other, 0.9% SCLC, 15.7% 12

13 QIS Standard 2a.1: A minimum of 75% of all lung cancer patients have their diagnosis confirmed by histology/cytology Histological diagnosis is important to determine the optimal treatment approach. Figure 6: Percentage of Cases with Histological/Cytological Diagnosis Percentage of Cases AA FV LS NG SG Clyde WoS Analysis Group Ayrshire & Arran Forth Valley Lanarkshire North Glasgow South Glasgow Clyde WoSCAN N D Figure 6 indicates that with the exception of Forth Valley, the numbers of patients histologically diagnosed has decreased in Some variation year-on-year can be expected and factors and clinical features such as age, stage and comorbidities of those presenting with lung cancer will influence this. Action Required: Ayrshire, North Glasgow and South Glasgow should explore the reason for the decrease in histological/cytological diagnosis to establish if this is due to clinical factors or a change in practice. 13

14 QIS Standard 4a.2: TNM stage is recorded for a minimum of 90% of cases at the time of diagnosis Staging is the assessment of the extent of disease and is performed for prognostic and therapeutic purposes. TNM 7 (5) was implemented on 1 st January 2010 and is the current standard practice for staging all lung cancers. Figure 7: Recording of TNM Stage in Lung Cancer Percentage of Cases AA FV LS NG SG Clyde WoS Analysis Group Ayrshire & Arran Forth Valley Lanarkshire North Glasgow South Glasgow Clyde WoSCAN N D Figure 7 presents an assessment of staging data completeness across the WoS. Analysis of stage was based on stage at diagnosis (pre-treatment). Results show improvements in most units from 2010 to 2011; only North Glasgow shows a marginally lower result meaning that together with Lanarkshire, fails to meet the prescribed target. Action Required: Lanarkshire and North Glasgow should establish robust processes to ensure capture of TNM data either by documentation in case notes and/ or at MDT meetings. Emphasis must be given to the requirement of clinicians to do so to allow audit data capture and facilitate measurement of QPIs. 14

15 QIS Standard 4a.3: WHO Performance Status is recorded for a minimum of 90% of cases at the time of diagnosis Performance status (PS) is defined according to the internationally agreed World Health Organization (WHO) scale. PS at the time of decisions about treatment is a powerful prognostic indicator in lung cancer and is of particular importance in determining suitability of patients for chemotherapy or radical radiotherapy. Figure 8: Recording of WHO Performance Status in Lung Cancer Patients Percentage of Cases AA FV LS NG SG Clyde WoS Analysis Group Ayrshire & Arran Forth Valley Lanarkshire North Glasgow South Glasgow Clyde WoSCAN N D As illustrated in Figure 8, all MDTs with the exception of North Glasgow are meeting the 90% target. The Clyde figure has again shown improvement from previous year s figures. This improvement is encouraging and demonstrates potential to change processes at a local level to improve the quality of data for PS. Action Required: North Glasgow should ensure that patient performance status is discussed and documented at the MDT meeting. 15

16 Multidisciplinary Team Discussion NHS QIS Standard 1a.4 specifies that all patients with a diagnosis of lung cancer should be discussed by the MDT (within 4 weeks of referral). MDT working is now established as an important mechanism for ensuring that patients receive the most appropriate investigation and treatment. National guidance states that all patients should have a treatment plan discussed at a MDT meeting. Figure 9: Lung Cancer Patients Discussed by MDT Percentage of Cases AA FV LS NG SG Clyde WoS Analysis Group Ayrshire & Arran Forth Valley Lanarkshire North Glasgow South Glasgow Clyde WoSCAN N D The overall percentage of patients discussed by MDT during 2011 was 94.6%. It is particularly encouraging that in Forth Valley all patients were discussed at the MDT and in all other units the proportion of patients discussed is at or above 90%. NHS QIS Standard 1a.4 specifies that all patients with a diagnosis of lung cancer should be discussed by the MDT (within 4 weeks of referral). While the above data addresses whether a patient is discussed, it does not include information on timescales. Action Required: All MDTs should establish robust processes to ensure that all lung cancer patients are discussed by the MDT to ensure that there is an agreed management plan, even in cases where active symptom control is more appropriate. 16

17 Access to a Clinical Nurse Specialist with expertise in Lung Cancer Figure 10: Lung Cancer Patients Having Access to a CNS Percentage of Cases AA FV LS NG SG Clyde WoS Analysis Group Ayrshire & Arran Forth Valley Lanarkshire North Glasgow South Glasgow Clyde WoSCAN N * D *Subsequent to final data submission NHS Lanarkshire identified a further 74 patients who had been seen by a CNS, therefore the true proportion of patients seen by a CNS in Lanarkshire is 93% which is higher than the figure shown in Figure 10. Access to a Clinical Nurse Specialist (CNS) with expertise in lung cancer is a fundamental component of patient care although it would appear that not all patients are seen by this service. Figure 10 illustrates that 82% of patients were seen by a CNS in This is a slight decrease from the previous year where 88.8% patients were seen. Data on whether a patient has seen a nurse specialist is not routinely recorded in case notes and requires co-ordination between nurses and audit staff to ensure efficient data capture. It is also recognised that there is an unmet need for CNS cover in lung cancer MDTs. This should continue to be monitored to aid development of any future case for increased staffing. Action Required: Continued promotion of liaison and co-operation between clinical nurse specialists and audit staff is required across the region to ensure improved availability of data. 17

18 Anti-cancer Treatment In general, the treatment choices for lung cancer patients include surgery, chemotherapy, radiotherapy, palliative care and active monitoring, but often these individual treatment modalities are combined. Although not a Scottish standard, the proportion of patients receiving anti-cancer treatment is being used as a proxy quality measure by the National Lung Cancer Audit (NLCA). The NLCA produce an annual report which provides a full comparative analysis of data in respect of England and Wales. The three Scottish networks (North of Scotland Cancer Network [NOSCAN], South East Scotland Cancer Network [SCAN] and WoSCAN) contribute an agreed limited dataset to this report which demonstrates favourable comparison with other areas of the UK (6). Figure 11: Percentage of Lung Cancer Patients Receiving Anti-Cancer Treatment Patient Died before Treatment, 6.2% Patient Refused Treatment, 1.4% Anti Cancer Treatment, 61.1% No Active Cancer Treatment, 31.3% Analysis of treatment provision shows that 61% of patients in WoS underwent active cancer treatment, a slight decrease from 2010 (65%). NLCA recommends that active anti-cancer treatment rates below the England and Wales average of 60% should be reviewed (6). Anti-cancer treatment rates for WoSCAN overall are therefore in line with the recommended level set by UK NLCA. 18

19 Surgery in Lung Cancer The number of patients with lung cancers receiving surgical treatment has remained largely unchanged over the last few years. Of all patients managed in WoSCAN and diagnosed in 2011, 12.5% (275/2207) underwent a surgical procedure; this compares to 12% of patients diagnosed in 2010 and 11.9% diagnosed in Surgical rates across the region ranged from 9.7% in South Glasgow to 16.9% in Lanarkshire. Patients who refused surgical treatment or died before first treatment have not been included in these calculations. Surgical Procedure NHS QIS standard 5b.4: Less than 10% of patients that undergo surgery are resected by wedge or segmentectomy Figure 12 shows the proportion of each type of surgical procedure used in the surgical management of lung cancer patients. Figure 12: Surgical Resection Procedure for Lung Cancer Patients Other, 0.8% Not Recorded, 0.7% Wedge or Segmentectomy, 10.2% Pneumonectomy, 9.5% Lobectomy, 78.9% 19

20 Treatment of NSCLC patients Surgery is the most effective curative option in NSCLC, however surgery may not be feasible for all patients due to an advanced stage of disease at presentation and/or co-morbidities. In lung cancer patients for whom surgery is not considered an appropriate treatment modality radical radiotherapy is often the alternative treatment choice. Figure 13 shows the proportion of NSCLC patients in each analysis group undergoing surgery. Figure 13: Proportion of NSCLC Patients Receiving Surgery Percentage of Cases AA FV LS NG SG Clyde Analysis Group Ayrshire & Arran Forth Valley Lanarkshire North Glasgow South Glasgow Clyde WoSCAN N D

21 Radiotherapy Treatment in NSCLC Table 2: Radiotherapy Treatment in NSCLC Patients Ayrshire & Arran 50.6% Forth Valley 50.5% Lanarkshire 31.6% North Glasgow 55.5% South Glasgow 50.0% Clyde 49.5% West of Scotland 47.6% Table 2 shows the proportion of NSCLC patients receiving radiotherapy. In WoS 47.6% of NSCLC received radiotherapy. There was some variation amongst units ranging from 31.6% in Lanarkshire to 55.5% in North Glasgow. The lower percentage of patients receiving radiotherapy in Lanarkshire could be explained by the fact that the higher proportion (nearly 29%) of NSCLC patients underwent surgery in this NHS Board area. In some areas the increased use of chemotherapy as first line treatment in NSCLC patients may have contributed to reducing the administration of radiotherapy. Action Required: Radiotherapy downloads from the Beatson West of Scotland Cancer Centre (BWoSCC) must be fully utilised by all NHS Boards to ensure continued improvement in data capture. 21

22 QIS Standard 5d.1: A minimum of 20% of NSCLC patients receive chemotherapy Figure 14: Proportion of NSCLC patients receiving chemotherapy Percentage of Cases AA Clyde FV LS NG SG WoS Analysis Group Ayrshire & Arran Forth Valley Lanarkshire North Glasgow South Glasgow Clyde WoSCAN N D Figure 14 illustrates that an average of 31% of NSCLC patients in the WoS received chemotherapy as part of their management. All units met the standard of 20% although the proportion of patients receiving chemotherapy in Forth Valley has decreased from 40.7% in 2010 to 21.6% in

23 Treatment of SCLC QIS Standard 5d.1: A minimum of 60% of SCLC patients receive chemotherapy. Chemotherapy remains the standard primary treatment for SCLC and its effectiveness is well documented. Figure 15: Proportion of SCLC patients receiving chemotherapy Percentage of Cases AA FV LS NG SG Clyde WoS Ayrshire & Arran Forth Valley Lanarkshire North Glasgow South Glasgow Clyde WoSCAN N D Figure 15 indicates that all units in the WoS are meeting the 60% target. 23

24 NHS QIS Standard 5c.5 A minimum of 60% of those limited (LD) SCLC patients receiving chemotherapy also receive consolidation radiotherapy to the chest NHS QIS Standard 5c.7 A minimum of 60% of those limited (LD) SCLC patients receiving chemotherapy susequently receive prophylactic cranial irradiation (PCI) These are two important measures of quality as SCLC is a radiosensitive disease. When radiotherapy is given as part of initial treatment it has the potential to increase disease control in irradiated sites. As relapse can often be limited to the chest or brain, there is the potential for consolidation radiotherapy to the chest, or PCI to improve survival in these patients. However, in the WoS, radiotherapy information on the whole is poorly recorded. As noted in previous years reports this is particularly true for patients who go on to receive radiotherapy after receiving chemotherapy. In the past extraction of multimodality treatment information was not straightforward and after initial data capture there was not always re-interrogation of the data. Since the end of 2010 the Information Team at the BWoSCC have been providing boards with regular downloads in respect of patients from their area who have received radiotherapy. This in turn had led to better data capture by the local audit teams and improved reporting of 2010 audit data as illustrated in Table 3, however results for 2011 show that the proportion of patients receiving consolidation radiotherapy to the chest has reduced for all boards. The overall WoS figure has dropped from 55.6% to 31.8%. It should be noted that the numbers of patients included in this standard are very small but this does not fully explain the drop in proportion of patients meeting the standard. Table 3: SCLC Patients Receiving Consolidation Radiotherapy Analysis Group Ayrshire & Arran 16.7% 62.5% 58.3% Forth Valley 10.0% 62.5% 25.0% Lanarkshire 26.3% 34.8% 15.8% North Glasgow 55.6% 64.0% 42.3% South Glasgow 62.5% 55.6% 12.5% Clyde 33.3% 85.7% 36.4% WoS 40.2% 55.6% 31.8% A system has recently been established in Forth Valley where by the oncologist will send copies of all oncology letters to the audit facilitator with the aim of improving oncology data recording. Feedback from the Clyde MDT indicated that there is some oncology concern over the set target and that lack of perceived benefit has affected numbers being put forward for radiotherapy. Action Required Radiotherapy downloads from BWoSCC must be fully utilised by all NHS Boards to ensure continued improvement in data capture. 24

25 QIS Standard 5c.7: A minimum of 60% of those limited (LD) SCLC patients receiving chemotherapy subsequently receive prophylactic cranial irradiation (PCI) Table 4: SCLC Patients Receiving PCI Analysis Group Ayrshire & Arran 0.0% 0.0% 66.7% Forth Valley 0.0% 0.0% 0.0% Lanarkshire 42.1% 17.4% 0.0% North Glasgow 58.3% 76.0% 46.2% South Glasgow 43.8% 66.7% 18.8% Clyde 11.1% 42.9% 18.2% WoS 36.3% 39.5% 28.4% Table 4 shows variation in the delivery of PCI across units in the WoS. Again it should be noted that the numbers included in this standard are small. Ayrshire & Arran is the only NHS Board noted as improving on previous year s figures. As with the previous standard, further investigation of the results should be undertaken to establish the reason for the drop in proportion of patients receiving PCI in A comparison of MCN audit data and BWoSCC data is currently been undertaken by the MCN to establish if all PCI patients have been captured in the audit. Action Required: Radiotherapy downloads from BWoSCC must be fully utilised by all NHS Boards to ensure continued improvement in data capture. 25

26 30 Day Mortality in Lung Cancer Patients Following Treatment Surgical Mortality Table 5 shows the 30 day mortality rate following surgery for lung cancer. Table 5: Surgical 30 day mortality rate Health Board No of surgical Patients Number dying within 30 days of final surgery Percentage (%) Ayrshire & Arran Clyde Forth Valley Lanarkshire North Glasgow South Glasgow WoS Radiotherapy with Curative Intent 30 Day Mortality Radiotherapy 30 day mortality rate is calculated as death within 30 days of the date of completion of radiotherapy. Table 6 shows the 30 day mortality rate following final curative radiotherapy for lung cancer. Table 6: 30 day mortality rate following final curative radiotherapy Health Board No of Radiotherapy Patients Number dying within 30 days of final radiotherapy Percentage (%) Ayrshire & Arran Clyde Forth Valley Lanarkshire North Glasgow South Glasgow WoS

27 Chemotherapy Mortality Chemotherapy 30 day mortality rate is calculated as death within 30 days of final chemotherapy administration. Table 7: 30 day mortality rate following final chemotherapy Health Board No of Chemotherapy Patients Number dying within 30 days of final chemotherapy Percentage (%) Ayrshire & Arran Clyde Forth Valley Lanarkshire North Glasgow South Glasgow WoS

28 Mesothelioma In 2011 there were 78 recorded cases of Mesothelioma in the WoS. Figure 16 shows the distribution of mesothelioma cases across analysis groups within the WoS. Figure 16: Distribution of Mesothelioma Cases in the WoS (105 WoS cases) 2011(78 WoS cases) 25 Number of Cases AA FV LS NG SG Clyde Analysis Group Ayrshire & Arran Forth Valley Lanarkshire North Glasgow South Glasgow Clyde WoSCAN N

29 Recording of TNM Stage Figure 17 indicates the data completeness of mesothelioma staging data across the WoS. TNM 7 (5) is the standard staging method used for mesothelioma patients. Analysis of stage was based on stage at diagnosis (pre-treatment). Figure 17: Recording of TNM Stage of Mesothelioma Cases Percentage of Cases AA FV LS NG SG Clyde WoS Analysis Group Ayrshire & Arran Forth Valley Lanarkshire North Glasgow South Glasgow Clyde WoSCAN N D Figure 17 indicates that data completeness is improving in all units with the exception of South Glasgow who have decreased slightly from It should be noted that due to the small numbers involved the omission of data for just one patient has an impact on the data appearance. It is important that the change to using TNM for Mesothelioma is highlighted to each MDT to ensure improved data capture. Action Required: TNM 7 is the standard staging system method which should be used for mesothelioma patients diagnosed from 1 st January All lung cancer MDTs should review their data collection methodology for capturing TNM stage in mesothelioma patients. 29

30 Performance Status Recording Figure 18: Recording of WHO Performance Status in Mesothelioma Cases Percentage of Cases AA FV LS NG SG Clyde WoS Health Board Ayrshire & Arran Forth Valley Lanarkshire North Glasgow South Glasgow Clyde WoSCAN N D Figure 18 indicates that the recording of Performance Status is improving in most units. The Lanarkshire figure however has decreased from 86.7% in 2010 to 64.3% in 2011 and North Glasgow from 93.1% to 78.6%. South Glasgow and Forth Valley both have performance status recorded for all patients. 30

31 Treatment for Mesothelioma Patients Anti Cancer Treatment Figure 19 shows the active treatment rate in mesothelioma patients in the WoS. Figure 19: Percentage of Mesothelioma cancer patients receiving anti-cancer treatment (surgery, chemotherapy, radiotherapy, palliative care, active monitoring) Patient Died, 9% Anti Cancer Treatment, 32.1% No Active Cancer Treatment, 59% The distribution of first treatment in mesothelioma patients across the region is shown in Figure 20. Figure 20: First Treatment for Mesothelioma Patients Other Mode of First Treatment Died before Rx Watch Wait Supp Care Chemo Endobronchial Radio Surgery Percentage of Patients There is currently no nationally agreed appropriate level of intervention over and above active symptom control for mesothelioma patients. The information detailed in Figure 20 is intended as a baseline for future years. 31

32 5. Conclusions The results presented in this report show that most units are meeting the NHS QIS Standards. This once again demonstrates that patients with lung cancer in the West of Scotland continue to receive a consistent standard of care. There are a number of actions required as a consequence of this assessment of performance against the agreed criteria, several of which relate to a continued commitment to data quality improvement. 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. A summary of actions for each NHS Board has been included within the Action Plan templates in the Appendices at the rear of the document. 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 reported to the Regional Cancer Advisory Group (RCAG) annually by Board Lead Cancer Clinicians and MCN Clinical Leads, as part of the regional governance process to enable RCAG to review and monitor regional improvement. 32

33 Acknowledgement This report has been prepared using clinical audit data provided by the following NHS Boards in the WoSCAN area: NHS Ayrshire & Arran NHS Forth Valley NHS Greater Glasgow and Clyde NHS Lanarkshire We would like to thank all members and active participants in the cancer network for their continued support of the MCN, and the many hospitals that are committed to making the audit succeed. We also acknowledge the efforts of the clinical effectiveness staff, nurses, and other service users for their work in ensuring the data are available to enable analysis to take place each year. Without their considerable efforts this level of progress would not be possible. 33

34 Abbreviations BWoSCC Beatson West of Scotland Cancer Centre CMG Clinical Management Guidelines CNS Clinical Nurse Specialist ecase Electronic Cancer Audit Support Environment GJNH Golden Jubilee National Hospital ISD Information Services Division MCN Managed Clinical Network MDT Multidisciplinary Team MDTM Multidisciplinary Team Meeting NCRI National Cancer Research Institute NHS GGC NHS Greater Glasgow and Clyde NHS QIS NHS Quality Improvement Scotland NICE National Institute for Clinical Excellence NLCA National Lung Cancer Audit NOSCAN North of Scotland Cancer Network NSCLC Non Small Cell Lung Cancer PCI Prophylactic Cranial Irradiation PS Performance Status PET Positron Emission Tomography QPIs Quality Performance Indicators 34

35 RCAG Regional Cancer Advisory Group SCAN South East Scotland Cancer Network SCRN Scottish Cancer Research Network SCLC Small Cell Lung Cancer WHO World Health Organisation WoS West of Scotland WoSCAN 35

36 References List of references and useful websites for further information 1. Cancer-Incidence-report.pdf? /Cancer_in_Scotland_summary_m.pdf 3. Detect Cancer Early Programme Draft National Implementation Plan, Scottish Government Health Directorates, June Tackling Tobacco within NHS Greater Glasgow and Clyde, Board Paper 11/46 5. TNM Classification of Malignant Tumours, 7 th Edition, UICC

37 Appendix: NHS Board Action Plans A summary of actions for each NHS Board has been included within the following Action Plan templates. Completed Action Plans should be returned to WoSCAN within two months of publication of this report.

38 Appendix I Action / Improvement Plan Health Board: NHS Ayrshire & Arran KEY (Status) Action Plan Lead: 1 Action fully implemented Date: 2 Action agreed but not yet implemented 3 No action taken (please state reason) No Action Required Health Board Action Taken Action 1. Ayrshire, North Glasgow and South Glasgow should explore the reason for the decrease in histological/cytological diagnosis to establish if this is due to clinical factors or a change in practice. Detail specific actions that will be taken by the NHS Board. Timescales Start End Insert date Insert date Lead Progress/Action Status Status (see key) Insert name of responsible lead for each specific action. Provide detail of action in progress, change in practices, problems encountered or reasons why no action taken. Insert No. from key above 2. All MDTs should establish robust processes to ensure that all lung cancer patients are discussed by the MDT to ensure that there is an agreed management plan, even in cases where active symptom control is more appropriate.

39 No Action Required Health Board Action Taken 3. Radiotherapy downloads from the Beatson West of Scotland Cancer Centre (BWoSCC) must be fully utilised by all NHS Boards to ensure continued improvement in data capture. 4. TNM 7 is the standard staging system method which should be used for mesothelioma patients diagnosed from 1 st January All lung cancer MDTs should review their data collection methodology for capturing TNM stage in mesothelioma patients Timescales Start End Lead Progress/Action Status Status (see key)

40 Appendix II Action / Improvement Plan Health Board: NHS Forth Valley KEY (Status) Action Plan Lead: 1 Action fully implemented Date: 2 Action agreed but not yet implemented 3 No action taken (please state reason) No Action Required Health Board Action Taken 1. Action All MDTs should establish robust processes to ensure that all lung cancer patients are discussed by the MDT to ensure that there is an agreed management plan, even in cases where active symptom control is more appropriate. Detail specific actions that will be taken by the NHS Board. Timescales Start End Insert date Insert date Lead Progress/Action Status Status (see key) Insert name of responsible lead for each specific action. Provide detail of action in progress, change in practices, problems encountered or reasons why no action taken. Insert No. from key above 2. Radiotherapy downloads from the Beatson West of Scotland Cancer Centre (BWoSCC) must be fully utilised by all NHS Boards to ensure continued improvement in data capture.

41 No Action Required Health Board Action Taken 3. TNM 7 is the standard staging system method which should be used for mesothelioma patients diagnosed from 1 st January All lung cancer MDTs should review their data collection methodology for capturing TNM stage in mesothelioma patients Timescales Start End Lead Progress/Action Status Status (see key)

42 Appendix III Action / Improvement Plan Health Board: NHS Lanarkshire KEY (Status) Action Plan Lead: 1 Action fully implemented Date: 2 Action agreed but not yet implemented 3 No action taken (please state reason) No Action Required Health Board Action Taken 1. Action Lanarkshire and North Glasgow should establish robust processes to ensure capture of TNM data either by documentation in case notes and/ or at MDT meetings. Emphasis must be given to the requirement of clinicians to do so to allow audit data capture and facilitate measurement of QPIs. Detail specific actions that will be taken by the NHS Board. Timescales Start End Insert date Insert date Lead Progress/Action Status Status (see key) Insert name of responsible lead for each specific action. Provide detail of action in progress, change in practices, problems encountered or reasons why no action taken. Insert No. from key above 2. All MDTs should establish robust processes to ensure that all lung cancer patients are discussed by the MDT to ensure that there is an agreed management plan, even in cases where active symptom control is more appropriate.

43 No Action Required Health Board Action Taken 3. Radiotherapy downloads from the Beatson West of Scotland Cancer Centre (BWoSCC) must be fully utilised by all NHS Boards to ensure continued improvement in data capture. 4. TNM 7 is the standard staging system method which should be used for mesothelioma patients diagnosed from 1 st January All lung cancer MDTs should review their data collection methodology for capturing TNM stage in mesothelioma patients Timescales Start End Lead Progress/Action Status Status (see key)

44 Appendix IV Action / Improvement Plan Health Board: North Glasgow (NHS Greater Glasgow & Clyde) KEY (Status) Action Plan Lead: 1 Action fully implemented Date: 2 Action agreed but not yet implemented 3 No action taken (please state reason) No Action Required Health Board Action Taken Action Ayrshire, North Glasgow and South Glasgow should explore the reason for the decrease in histological/cytological diagnosis to establish if this is due to clinical factors or a change in practice. Lanarkshire and North Glasgow should establish robust processes to ensure capture of TNM data either by documentation in case notes and/ or at MDT meetings. Emphasis must be given to the requirement of clinicians to do so to allow audit data capture and facilitate measurement of QPIs. Detail specific actions that will be taken by the NHS Board. Timescales Start End Insert date Insert date Lead Progress/Action Status Status (see key) Insert name of responsible lead for each specific action. Provide detail of action in progress, change in practices, problems encountered or reasons why no action taken. Insert No. from key above

45 No Action Required Health Board Action Taken 3. North Glasgow should ensure that patient performance status is discussed and documented at the MDT meeting Timescales Start End Lead Progress/Action Status Status (see key) All MDTs should establish robust processes to ensure that all lung cancer patients are discussed by the MDT to ensure that there is an agreed management plan, even in cases where active symptom control is more appropriate. Radiotherapy downloads from the Beatson West of Scotland Cancer Centre (BWoSCC) must be fully utilised by all NHS Boards to ensure continued improvement in data capture. 6. TNM 7 is the standard staging system method which should be used for mesothelioma patients diagnosed from 1 st January All lung cancer MDTs should review their data collection methodology for capturing TNM stage in mesothelioma patients

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