THE 2017 BI-NATIONAL COLORECTAL CANCER AUDIT REPORT

Transcription

1 THE 217 BI-NATIONAL COLORECTAL CANCER AUDIT REPORT

2 THIS PUBLICATION WAS PRODUCED ON BEHALF OF THE BI-NATIONAL COLORECTAL CANCER AUDIT (BCCA). SUGGESTED CITATION: Professor Alexander Heriot, Professor Cameron Platell, Associate Professor Chris Byrne, Professor Pierre Chapuis, Mr Mark Doudle, Associate Professor Paul McMurrick, Dr Elizabeth Murphy, Mr Mark Thompson-Fawcett, Ms Angela Brennan, Professor Chris Reid, Ms Michaela O Regan, Ms Julie Wood, Mrs Kerri Buczynskyj. The Bi-National Colorectal Cancer Audit Report 217, May 217, pages 58. ANY ENQUIRES REGARDING THIS PUBLICATION SHOULD BE DIRECTED TO: BCCA Project Manager Suite 6, 9 Church Street Hawthorn VIC 3122 Phone: bcca@cssanz.org Website: The contents of this report may not be published or used without permission.

3 CONTENTS Acknowledgements...4 Foreword...5 Executive Summary...6 What is BCCA...8 Where are we now?...9 BCCA Governance...1 Data Access...11 Research...12 BCCA Methodology...13 Data Handling...14 Data Submission...15 List of Figures...19 List of Tables...2 Patient Characteristics...21 FOBT and Bowel Screening Programmes...24 Surgical Care...27 Overall Colorectal Cancer Care Length of Hospital Stay Operative Approach Colon Cancer Rectal Cancer Adjuvant Therapy Future Directions...54 BCCA Participation...55 BCCA Personnel...56 Glossary...57 References...58 THE BI-NATIONAL COLORECTAL CANCER AUDIT REPORT 217 3

4 ACKNOWLEDGEMENTS BCCA is funded by a combination of sources including in-kind donations from the Colorectal Surgical Society of Australia and New Zealand (CSSANZ), the Royal Australasian College of Surgeons (RACS) Colon and Rectal Surgery Section and annual subscription fees paid by surgeons. Education and reporting initiatives are supported by Medtronic (previously under Covidien). We also acknowledge funding from Johnson & Johnson and the RACS Research, Audit and Academic Surgery Division who supported BCCA in initial years. Expert advice was provided and analyses completed by Michael Esler and Arul Earnest from the Registry Sciences Unit, Department of Epidemiology and Preventive Medicine, Monash University. Development and ongoing database support is provided by the Clinical Data Management Systems (CDMS) team, esolutions, Monash University. This report would not have been possible without the efforts of surgeons, site managers and other relevant staff who have contributed data to BCCA. The management committee (BCCA Operations Committee) is also gratefully acknowledged and details of personnel can be found on page 56. BCCA is appreciative of support from CSSANZ General Manager, Liz Neilson, and the CSSANZ for their ongoing support. 4 THE BI-NATIONAL COLORECTAL CANCER AUDIT REPORT 217

5 FOREWORD Colorectal cancer remains one of the most common causes of cancer death in the western world and continues to be a significant healthcare problem. There has been an increased focus globally on the importance of quality of care and the increasing desire for transparency of outcomes. In this current climate, the importance of quality registries as a vehicle to allow benchmarking of patient outcomes is increasing. The Bi-National Colorectal Cancer Audit reports patient outcomes of patients with colorectal cancer across Australia and New Zealand between 27 and 216. The audit reports on over 17,7 patients and provides a snapshot of the quality of care of the various components of the patient journey. The audit provides an ideal tool to allow patients, surgeons and healthcare professionals a transparent view on the quality of care delivered to colorectal cancer patients across Australia and New Zealand from the institutions who contribute to BCCA. For example, the evolution of the approach to resection of rectal cancer has changed between 215 and 216 with an increase in open resections, a decrease in laparoscopic resections and an increase in alternative minimally invasive approaches including robotic and tatme, perhaps in the light of the Z651 and the ALaCaRT study. This report highlights the importance of quality registries as a tool to influence the provision of healthcare on a binational basis. The authors and participants are to be congratulated on their efforts in producing both this report and contributing to BCCA. Dr. Patricia Roberts President, American Society of Colon and Rectal Surgeons, Chair of Surgery, Lahey Hospital and Medical Center, Professor of Surgery, Tufts University School of Medicine THE BI-NATIONAL COLORECTAL CANCER AUDIT REPORT 217 5

6 EXECUTIVE SUMMARY The Bi-National Colorectal Cancer Audit currently contains information on 17,7 patients with colorectal cancer across Australia and New Zealand that has been collected over the period 27 to 216. This includes almost 2,5 patients from 216. This represents approximately 15% of all new colorectal cancer patients that would have presented over this period. The majority of patients are over 5 years old with the 7-79 year age group being the most common age group at presentation. Over a third of patients are American Society of Anaesthesiologists (ASA) Classification 3 or greater, representing significant existing co-morbidities, and increasing the potential of postoperative complications. Approximately one third of the tumours (31%) are in the rectum, and over 55% of tumours are in the sigmoid colon or beyond, which is consistent with the distribution reported in the literature 1. The proportion of patients presenting with metastatic disease is 12%. The proportion of patients diagnosed following Faecal Occult Blood Test (FOBT) remains fairly steady however this has increased to 13% in 216. It will be interesting to see if this proportion progressively increases over the next few years as a result of the staged expansion of the National Bowel Cancer Screening Program (NBCSP) in Australia and the National Bowel Screening Programme (NBSP) in New Zealand. There does appear to be a stage shift in patients diagnosed through the screening programmes with a higher proportion of Stage I patients in people who participate in screening programmes. Overall hospital mortality for patients with colorectal cancer remains steady over time at less than 2%. The risk-adjusted mortality demonstrates a spectrum across hospitals. Mortality for emergency cases remains substantially greater than that of elective cases; however this has gradually reduced over the last decade. Whilst 88% of colorectal cancer cases are elective, 7% present as urgent cases, and 5% present as emergencies. Return to theatre may be utilised as a quality marker of hospital care. There is a spectrum of rates across the hospitals, with a mean of 5.6%. The mean adjusted complication rate is 23.9% and there are no hospitals with a significantly increased rate. Length of stay (LOS) is an important outcome of surgical care. It is interesting to note that the LOS has been fairly static since 27, stubbornly remaining with a mean LOS of approximately 8.5 days and a median of seven days, which is comparable to that reported in the UK 1. LOS increases as the tumours move from colon to rectum, with minor differences between right and left sided tumours. LOS increases with age which is expected but may be important when resourcing for the future with the increasing age of the population that are likely to require surgery. Urgency of admission remains an important factor with respect to LOS compared to an elective operation, being increased by one day for an urgent operation, and two days for an emergency operation. The adoption of a minimally invasive approach as compared to an open approach has progressively increased over time. In 27 fewer than 3% of colorectal resections were undertaken with a minimally invasive approach, increasing to 62% in 216. The nature of the minimally invasive approach has also changed over time, with alternative techniques such as robotic surgery or transanal Total Mesorectal Excision (tatme) being introduced into practice. The application of a minimally invasive approach is more common in colonic cases than in rectal, with 5% of colonic cases and 41% of rectal cases undertaken minimally invasively. The most common operation undertaken was for colon cancer and in 216 the proportion of operations undertaken laparoscopically was just over 6%. The rate of complications was 19.9%, with a couple of units having a slightly higher complication rate. The mean number of lymph nodes removed was 18.2, and this has increased slightly over time since THE BI-NATIONAL COLORECTAL CANCER AUDIT REPORT 217

7 Management of rectal cancer is frequently more complex than colon cancer. The proportion of rectal cancer cases discussed at a Multidisciplinary Team Meeting (MDT) has increased from 51% in 215 to 68% in 216. Magnetic Resonance Imaging (MRI) application for preoperative staging has increased from 3% in 27 to 74% in 216. Pelvic MRI would now be considered standard of care for rectal cancer staging for all tumours other than very early stage cancers. Just over half the patients with rectal cancer have received neoadjuvant therapy, the majority receiving long course chemoradiotherapy. The end stoma rate was 23.5% with either an abdominoperineal resection in 2% or a Hartmann s procedure in the remaining cases. There is a spectrum of frequency for this rate across units, with a reduction in frequency in units with greater numbers of cases reported. The surgical approach to rectal cancer resection continues to evolve. The proportion of rectal cancers resected with open resection is 41% in 216 which is an increase from 215. There is a decrease in the proportion of laparoscopic resections, however an increase in the number of hybrid procedures and the number of alternative minimally invasive approaches such as tatme. This may be a reflection of potential concern that a laparoscopic approach may not be optimal in a proportion of rectal cancers following the publication of the North-American Z651 2 trial and the Australasian ALaCaRT rectal cancer trial 3. Circumferential resection margin (CRM) is an important marker of quality of surgery and the rate of CRM involvement reported is 7% and has slowly reduced since 27, plateauing over the last three years. The surgical complication rate is 31.1%. It is usual for the complication rate for rectal cancer surgery to be higher than that of colonic surgery, as a result of the challenges of operating in the pelvis. There is a spectrum in complication rates across the different hospitals, however the overall anastomotic leak rate of 4% would generally be considered commendably low 4. Adjuvant therapy with chemotherapy is an important component of the management of patients with colorectal cancer. The utilisation of adjuvant therapy is high across Stage III patients of all ages, only reducing in patients aged over 9 years. The uptake is lower is Stage II disease as would be expected, however it is higher in patients under 3 years, reducing proportionately with increasing age. The BCCA provides a perspective of the quality of colorectal cancer surgery across Australia and New Zealand. Participation is increasing however it is currently at a level that it is likely that the data is skewed, representing a proportion of units rather than the two countries as a whole. The focus on quality of healthcare, as demonstrated by adverse outcomes such as the events in Bacchus Marsh in Victoria and the subsequent Duckett report 5 on improving quality in healthcare, means that the importance of quality registries such as BCCA is heightened. The ability to benchmark risk-adjusted outcomes for colorectal cancer patients is essential to help improve care for this patient group. THE BI-NATIONAL COLORECTAL CANCER AUDIT REPORT 217 7

8 WHAT IS BCCA The Bi-National Colorectal Cancer Audit (BCCA) is a surgical audit applicable to all surgeons who perform colorectal cancer surgery. It is a surgeon driven project led by a group of surgeons who are committed to excellence in the prevention, diagnosis and treatment of patients with colorectal cancer. The BCCA aims to create a large integrated dataset to be used for quality improvement and future research. Audit is a requirement of registration for surgeons in Australia and New Zealand and BCCA is a recognised audit for this purpose by the Royal Australasian College of Surgeons (RACS). BCCA data is recorded per surgeon per site, and information is collected about patient diagnosis, treatment and surgical outcomes. The database is secure and accessible via any Internet browser. Surgeons can run live deidentified summary reports at any time, comparing their outcomes to their site and to the whole database. Surgeons also have access to their own raw identifiable data at any time at the click of a button after logging into the secure system. BCCA is a Clinical Quality Registry (CQR), which aims to improve the safety or quality of health care provided to patients by collecting key clinical information from individual healthcare encounters which enable risk-adjusted outcomes to be used to drive quality improvement 6. CQRs can provide the most suitable and accurate method of providing monitoring and benchmark data and, where applicable, offer the greatest potential to improve health care performance across institutions and providers. By creating a large integrated dataset BCCA will be able to assist with setting benchmarks in colorectal surgery in Australia and New Zealand and thereafter the identification of outliers. All surgeons practicing in Australia and New Zealand are required to participate in peer-reviewed surgical audit as part of their registration 7 ; and by participating in a larger audit such as BCCA surgeons can compare their data to a larger pool of data thus making their audit more effective and meaningful. BCCA makes effective auditing accessible to all relevant surgeons throughout Australia and New Zealand who have appropriate approvals in place and access to the Internet. 8 THE BI-NATIONAL COLORECTAL CANCER AUDIT REPORT 217

9 WHERE ARE WE NOW? Since the last report there have been some exciting developments for BCCA. Some of the highlights include: release of data for projects under the new data access policy; in 216 four research projects were approved and data released for analyses. Specific details of these projects can be found on page 12. development of a data import feature; by mapping data to a BCCA data template (in Excel) users will be able to upload their data directly into the online system. This will enable surgeons and hospitals that run equivalent databases to participate in BCCA without having to duplicate data entry efforts. This feature is now in the testing phase and will be live later in 217. development of a new quality assurance framework; a key component of BCCA is its utility as a quality assurance tool, this includes using the data to set relevant benchmarks and use these benchmarks to identify outliers. A Clinical Quality Policy has been developed and it is envisioned this will be in place later in 217. strategies to continue increasing participation; in order to set effective benchmarks it is important that the data submitted is representative of current practice, therefore increasing participation across Australia and New Zealand continues to be a priority. BCCA management committees continue to engage with other stakeholders to promote BCCA participation. THE BI-NATIONAL COLORECTAL CANCER AUDIT REPORT 217 9

10 BCCA GOVERNANCE The BCCA governance model complies with the National Operating Principles for Clinical Quality Registries as set out by the Australian Commission on Safety and Quality in Health Care 8. The registry is overseen by the BCCA Steering Committee in coordination with the BCCA Operations Committee. Employment and financial management remains under the auspices of the Colorectal Surgical Society of Australia and New Zealand (CSSANZ) Council. Day to day management of the database is achieved by a Project Manager who reports to the Operations Committee monthly. The Steering Committee is comprised of various stakeholders including clinicians, funders, consumers and other relevant specialists. The Steering Committee is responsible for oversight of BCCA activities, including that of the Operations Committee, providing ongoing review of objectives and effectiveness in meeting these and approving any new policies to address issues of clinical interest that may arise. The membership is as follows: Chair Mr Andrew Hunter One member of the CSSANZ Council Mr James Keck One member of the RACS Colon and Rectal Surgery Section Executive Mr Ian Faragher One representative recommended by the General Surgeons Australia (GSA) Council Mr Trevor Collinson The Operations Committee is responsible for the day to day management of BCCA, developing quality measures and forming relevant sub-committees to address data access, research and quality issues. The membership is as follows: Chair Professor Alexander Heriot (Victoria) Representatives of the Department of Epidemiology & Preventive Medicine, Monash University (DEPM) Professor Christopher Reid Ms Angela Brennan A representative of the CRC Audit (the extended dataset) Associate Professor Paul McMurrick (Victoria) Surgeons who regularly undertake surgery for colorectal cancer providing a broad geographic binational representation; Associate Professor Chris Byrne (New South Wales) Professor Pierre Chapuis (New South Wales) Dr Mark Doudle (Queensland) Dr Elizabeth Murphy (South Australia) Professor Cameron Platell (Western Australia) Associate Professor Mark Thompson-Fawcett (New Zealand) Other co-opted members as required; currently none. Sub-committees will be formed under the Operations Committee to address data access, research and quality. One representative recommended by the New Zealand Association of General Surgeons (NZAGS) Mr Grant Coulter A clinician with an interest in colorectal cancer Professor John Zalcberg One consumer representative Mr John Stubbs Chair of the BCCA Operations Committee Professor Alexander Heriot 1 THE BI-NATIONAL COLORECTAL CANCER AUDIT REPORT 217

11 DATA ACCESS BCCA s primary functions are: Facilitate clinical audit/s to improve patient safety; Create a large dataset of surgical information whereby it will be possible to stratify the data and establish benchmarks; Monitor surgical performance by peer review; and Provide feedback to surgeons in the form of summary statistics and individual reports regarding their performance. These functions are managed by the BCCA Operations Committee, in particular a Clinical Quality Committee. This Committee is responsible for establishing clinical audit systems, developing and maintaining a riskstratification model utilising BCCA data to facilitate benchmarks, implementing peer review processes and providing feedback. Feedback to surgeons in the form of summary statistics and individual reports regarding their performance is in-built to the online BCCA system and surgeons can access this resource at any time. The primary functions which are projects seen as core business of BCCA (risk-stratification, benchmarking) will not be approved as research projects for units wishing to access BCCA data. BCCA s secondary functions include: Facilitate research and research projects; and Advance knowledge and understanding of the optimum treatment for colorectal cancer to help ensure best practice. DATA ACCESS FOR RESEARCH BCCA encourages the use of BCCA data for the purpose of research. If you are a clinician or researcher who contributes data to BCCA or affiliated with a group who contributes to BCCA, we encourage you to utilise the information in the dataset. The BCCA Steering and Operations committees support opportunities for research in the area of colorectal cancer surgery performance, procedures, treatment and outcomes. BCCA supports the International Committee of Medical Journal Editors (ICMJE) recommendations for authorship 9. Participation in BCCA is not an assurance of authorship on any research project or paper, rather authors should have: i. contributed substantially to the conception and design of the study, the acquisition of data, or the analysis and interpretation; ii. drafted or provided critical revision of the article; and iii. provided final approval of the version to publish. BCCA should be acknowledged in any presentation or publication resulting from included data extracted from BCCA data. BCCA promotes opportunities for research and aims to engage BCCA users to be active in the utilisation of BCCA data. Deidentified BCCA data is available to users and those affiliated to users for research purposes. Consultants who agree to make their deidentified data accessible to others for research will also be able to access other users deidentified data. Data is deidentified by patient, surgeon and site. Consultants who do not want their deidentified data included for others to access for research will not be able to access other consultants deidentified data for their own research. Applications are reviewed on a case by case basis by the Research Committee and they provide recommendations to the BCCA Operations Committee for approval. They may request further information, seek evidence of appropriate ethical approvals, co-opt specialist members for advice or provide other feedback. Each researcher or unit may submit one research application for data access at a time (unless a special case can be made for a change to this policy). Once that project is complete, additional submissions may be made. It is expected that a research project will be completed within six months. Beyond this time, approval for projects will be withdrawn and data will be available to other units for the specified project. Evidence of completion and a summary report of research will be required for submission to the BCCA committees for their review. A unit must not go outside the scope of their original proposal; if a unit conducts research outside the scope of the original approval that unit will be denied access to data for three years. Any abstracts or papers produced must be submitted to the Research Committee for approval prior to presentation or publication. THE BI-NATIONAL COLORECTAL CANCER AUDIT REPORT

12 RESEARCH The BCCA Data Access Policy was released at the beginning of 216, this has allowed researchers to access and utilise useful clinical information to answer their own research questions. In addition to the approved research projects where data has been released last year saw the BCCA Operations Committee publish two papers. PUBLICATIONS: Hunter, R.A., Moore, J., BCCA Operations Committee (216). Evolution of the Bi-National Colorectal Cancer Audit: history, governance and future directions. ANZ Journal of Surgery, 86(6) pp Patrick Ely Teloken, P.E., Spilsbury, K., Platell, C., BCCA Operations Committee (216). Analysis of mortality in colorectal surgery in the Bi-National Colorectal Cancer Audit. ANZ Journal of Surgery, 86(6) pp APPROVED RESEARCH PROJECTS: 1. What s the best technique for comparing hospital performance on return to theatre data? Funnel plots? Risk-adjustment? Multilevel regression analyses? Investigator: Professor Cameron Platell, St John of God Subiaco Status: Complete, in preparation for publication. Variability in 3-day return to theatre rates is an important quality indicator for monitoring surgical performance. The aim of this study was to provide the Bi-National Colorectal Cancer Audit (BCCA) with a predictive model of return to theatre that accommodates for very different hospital and patient risk profiles. 2. Validation of the ACPGBI risk prediction model for 3-day mortality after surgery for colorectal cancer does it apply in Australia? Investigator: Associate Prof Paul McMurrick, Cabrini Institute Status: In progress. The project will be used to derive a risk stratification formula from all data from participating BCCA sites. This will allow for a comparison of outcomes from various clinical centres, and to also make statistical allowance for the differences in the underlying risk of their patient population, allowing meaningful comparison of results, with a view to ensure the safety of patient care. 3. Factors affecting CRM positivity in rectal cancer resection and the impact on management Investigator: Mr Satish Warrier, Peter MacCallum Cancer Centre Status: Complete, accepted for podium presentation at the 217 American Society of Colon and Rectal Surgeons (ASCRS) Annual Scientific and Tripartite Meeting and manuscript submitted for publication. The aim of this project was to assess the quality of rectal cancer resection across Australasia and identify factors that may influence Circumferential Resection Margin (CRM) positivity. In particular, the difference in socioeconomic status; public versus private hospitals; rural versus urban hospitals; and the level of training received at the time of surgery (registrar-in-training, fellow-in-training or consultants). The conclusion of this project has reaffirmed the quality of surgery was not influenced by any of these factors and a high standard of care is being delivered to all patients irrespective of location or socioeconomic status. 4. Predicting pathological complete response and associated survival outcome in rectal cancer project Investigators: Mr Joseph Kong, Peter MacCallum Cancer Centre Status: Approved. The primary aim of this project is to identify the clinical and pathological variables that can influence the rate of pathological complete response after neoadjuvant chemoradiotherapy in locally advanced rectal cancer. The secondary outcome is to assess the influence of tumour regression grade in predicting survival outcomes. This project is part of the investigators PhD thesis and will be used as a starting point in identifying novel biomarkers to predict response to neoadjuvant chemoradiotherapy in patients diagnosed with locally advanced rectal cancer. For further information about these projects please contact the investigators. 12 THE BI-NATIONAL COLORECTAL CANCER AUDIT REPORT 217

13 BCCA METHODOLOGY From 27 to December 213 BCCA data was collected via paper forms with the majority of these sent for entry at the RACS Research, Audit and Academic Surgery Division. Other sites have stored these forms locally on an equivalent database. In December 213, the online BCCA database was launched and as sites attain amendments to their ethical approvals to allow utilisation of this new model they have migrated to the online system. All sites must have appropriate approvals in place to participate. This varies from region to region, and it includes but is not limited to Ethics Committee approval, Research Governance approval, Public Health Act approval (QLD only) and specific hospital level approvals. See page 55 BCCA Participation for more information regarding the process per region. Patients are informed by their surgeons or treating team of the surgeon s participation in BCCA and are given the opportunity to opt-out of having their data included in the database. The online database was developed by, and is maintained by Clinical Data Management Systems (CDMS) and the School of Public Health and Preventive Medicine (SPHPM) at Monash University. The database is accessible via any Internet browser. Surgeons, site-managers or support staff can enter data directly into the database after logging in via a secure encrypted page. The online system has inbuilt processes to ensure data completeness and data integrity. Data can be saved and further details added later, data will only be accepted in approved formats ensuring there are no inconsistencies in reporting, and incomplete cases remain on the home page after login as a reminder to complete them. Surgeons and sites can only see identifiable data that they have submitted but can run anonymised summary reports comparing themselves to the whole database getting live feedback regarding their performance. In 216 an automatic data feed was implemented linking the CRC Audit to BCCA, this allows participants of CRC Audit (the extended dataset) to automatically participate in BCCA (the minimum dataset). This automatic data feed reduces the amount of data handling required ensuring data integrity. The CRC Audit currently covers select sites within the Monash Partners network. THE BI-NATIONAL COLORECTAL CANCER AUDIT REPORT

14 DATA HANDLING In February 217, the data entered to the online BCCA system up until surgery date 31 December 216 was extracted for analyses. This data was combined with the data from the St John of God (SJOG) Colorectal Cancer Database. These two datasets are merged for the purposes of this report. In 217, it is anticipated that the SJOG Colorectal Cancer Database will be able to utilise the BCCA data import system. Throughout the report analyses were undertaken where complete data was available, cases with missing information were excluded per question. Where deemed relevant, sections include details about how many Treatment Episodes (TE) or patients were included in the analysis. Funnel plots are used throughout the report; they are a visual representation of how many outliers there are; they identify those who are performing better or worse than the average. The funnel plot curves represent two standard deviations (95% control limits) and three standard deviations (99.8% control limits) from the mean, those above and below these lines are considered outliers. In the preparation of funnel plots all units of less than 1 patients were included in a single group (patients in all, labelled group ZZ), including this group, there were 79 units analysed. For the 79 units the median number of patients was 11, mean 236, with a range from 12 patients to a maximum of 1,596 patients. The majority of the funnel plots present unadjusted crude rate or mean while others (where noted) are risk-adjusted. Risk-adjustment takes into account differences in risk-factors; it enables adjustment for confounding variables. Risk-adjusted figures in the current report take different variables into account and these are noted under each graph. Some of the variables adjusted for include ASA grade, age, urgency of surgery, complications and position of tumour. Outliers are represented as coloured dots in the plots. It is possible some of the outliers may be due to confounders which are not measured. Length of hospital stay (LOS) data was capped at 3 days; this represents 97% of all data submitted. Higher stays were not included in the LOS analyses due to potential data entry errors with the range up to 1,111 LOS reported. This approach was also applied to the Lymph Node data, with the highest figure being capped at 4 as this represents 98% of all data submitted. Before this exclusion criterion was applied the maximum Lymph Nodes collected reported was 189. Box and whisker plots are presented throughout the report. The box borders identify the first quartile (a number for which 25% of the data is less than that number), the median, and third quartile (a number for which 75% of the data is less than that number). The mean is highlighted in the centre. The interquartile range (IQR) is the difference between the first and third quartile. The whiskers illustrate the lowest measurement still within 1.5 times the IQR of the first quartile, and the highest measurement still within 1.5 times the IQR of the third quartile (often called the Tukey boxplot ) THE BI-NATIONAL COLORECTAL CANCER AUDIT REPORT 217

15 DATA COMPLETION There is a spectrum of data completeness over time and on review of 29 key data elements we observe that data completion has improved over time. We believe the online system (launched in February 21 for CRC Audit and in December 213 for BCCA) has facilitated improved data completeness as evidenced in Figure 1. Due to the nature of data being updated retrospectively we once again see a dip in data completion for the most recent period. FIGURE 1. PERCENTAGE DATA COMPLETION OVER TIME FOR 29 KEY BCCA ITEMS 9 88 PERCENTAGE OF DATA ENTERED YEAR DATA SUBMISSION Data submission has steadily increased since 27. It is understood that some surgeons and sites were still finalising their 216 data at the time of data extraction therefore the overall 216 number is expected to increase further. FIGURE 2. TOTAL TREATMENT EPISODES SUBMITTED TO BCCA OVER TIME NUMBER OF TREATMENT EPISODES 18, 16, 14, 12, 1, 8, 6, 4, 2, 17,724 15,36 12,865 1,494 8,99 7,273 5,272 3,372 1, YEAR THE BI-NATIONAL COLORECTAL CANCER AUDIT REPORT

16 TABLE 1. HOSPITALS PARTICIPATING IN BCCA State Hospital Collecting data Before 215 In 215 In 216 ACT Calvary ACT ACT Canberra Hospital NZ Christchurch Hospital NZ Grace Hospital NZ Hawkes Bay Regional Hospital NZ Mercy Ascot Hospital NZ Middlemore Hospital NZ North Shore Hospital NZ Ormiston Hospital NZ Royston Hospital NZ Southern Cross Christchurch NZ Southern Cross New Plymouth NZ Southern Cross North Harbour NZ St George s Hospital NZ Taranaki Base Hospital NZ Tauranga Hospital NZ Wanganui Hospital NZ Wellington Regional Hospital NSW Baringa Private Hospital NSW Belmont District Hospital NSW Calvary Riverina NSW Coffs Harbour Health Campus NSW Concord Repatriation General Hospital NSW Gosford Private Hospital NSW Gosford Public Hospital NSW John Hunter Hospital NSW Kareena Private Hospital NSW Lake Macquarie Private Hospital NSW Lingard Private Hospital NSW Maitland Hospital NSW Mater Sydney NSW Nepean Hospital NSW Newcastle Private Hospital NSW North Shore Private Hospital NSW Norwest Private Hospital NSW POW Private Hospital NSW POW Public Hospital NSW Royal North Shore Hospital NSW Royal Prince Alfred Hospital NSW Ryde Hospital 16 THE BI-NATIONAL COLORECTAL CANCER AUDIT REPORT 217

17 TABLE 1. HOSPITALS PARTICIPATING IN BCCA (CONTINUED) State Hospital Collecting data Before 215 In 215 In 216 NSW St George Hospital NSW Sydney Adventist Hospital NSW The Tweed Hospital NSW Wagga Wagga Base Hospital NSW Westmead Public Hospital NSW Wollongong Hospital QLD Allamanda Private Hospital QLD Cairns Base Hospital QLD Gold Coast University Hospital QLD Ipswich Hospital QLD John Flynn Private Hospital QLD Nambour General Hospital QLD Pindara Private Hospital QLD Princess Alexandra Hospital QLD QEII Jubilee Hospital QLD St Andrew s Ipswich Private QLD St Andrew s War Memorial QLD Sunnybank Private Hospital QLD The Sunshine Coast Private Hospital QLD Townsville Hospital SA Ashford Hospital SA Calvary North Adelaide SA Calvary Wakefield SA Flinders Medical Centre SA Flinders Private Hospital SA Lyell McEwin Hospital SA Modbury Hospital SA Port Lincoln Hospital SA Repatriation General Hospital SA Royal Adelaide Hospital SA St Andrew s Hospital SA The Queen Elizabeth Hospital SA Western Community Hospital TAS Calvary Lenah Valley TAS Hobart Private Hospital TAS Launceston General Hospital TAS North West Regional Hospital TAS St Vincent s Hospital Tasmania VIC Austin Hospital THE BI-NATIONAL COLORECTAL CANCER AUDIT REPORT

18 TABLE 1. HOSPITALS PARTICIPATING IN BCCA (CONTINUED) State Hospital Collecting data Before 215 In 215 In 216 VIC Alfred Hospital VIC Ballarat Base Hospital VIC Cabrini Hospital VIC Dandenong Hospital VIC Epworth Eastern Hospital VIC Epworth Geelong Hospital VIC Epworth Richmond Hospital VIC Frankston Hospital VIC Peter MacCallum Cancer Centre VIC St John of God Ballarat Hospital VIC St John of God Geelong Hospital VIC The Avenue Hospital VIC The Royal Melbourne Hospital VIC The Northern Hospital VIC Western Hospitals WA Hollywood Private Hospital WA Osborne Park WA St John of God Murdoch WA St John of God Subiaco 18 THE BI-NATIONAL COLORECTAL CANCER AUDIT REPORT 217

19 LIST OF FIGURES Figure Title Page No. Figure 1. Percentage Data Completion over Time for 29 Key BCCA Items 15 Figure 2. Total Treatment Episodes Submitted to BCCA over Time 15 Figure 3. Age Distribution of Patients 22 Figure 4. Diagram of Primary Tumour Site, Count and Percentage 22 Figure 5. Age Distribution of Patients Diagnosed Following FOBT 25 Figure 6. Site of Tumour of Patients Diagnosed through a National Screening Programme Compared to All BCCA data 25 Figure 7. Stage of Cancer of Patients Diagnosed via a National Screening Programme Compared to All BCCA data 26 Figure 8. Hospital Mortality over Time 29 Figure 9. Post-surgical Inpatient Mortality by Hospital (unadjusted) 3 Figure 1. Risk-adjusted Post-surgical Inpatient Mortality by Hospital 3 Figure 11. Urgency of Admission and Inpatient Mortality Rate over Time 31 Figure 12. Return to Theatre Rate by Hospital (unadjusted) 32 Figure 13. Risk-adjusted Return to Theatre Rate by Hospital 32 Figure 14. Risk-adjusted Surgical Complications for all BCCA Treatment Episodes 33 Figure 15. Length of Hospital Stay by Hospital (unadjusted) 34 Figure 16. Risk-adjusted Length of Hospital Stay by Hospital 35 Figure 17. Length of Stay and Tumour Site 35 Figure 18. Length of Stay and Tumour Position 36 Figure 19. Length of Stay and Age 36 Figure 2. Length of Stay over Time 37 Figure 21. Length of Stay and Urgency of Admission 38 Figure 22. Summarised Operative Approach over Time 39 Figure 23. Detailed Operative Approach over Time 39 Figure 24. Detailed Operative Approach and Tumour Position 4 Figure 25. Summarised Operative Approach and Length of Stay 4 Figure 26. Operative Approach over Time for Colon Cancer 41 Figure 27. Relative Frequency of Surgical Complications for Colon Cancer 42 Figure 28. Tumour Stage for Colon Cancer 44 Figure 29. Mean Number of Lymph nodes (LN) Examined in Resected Specimen by Hospital 44 Figure 3. Lymph Nodes Examined in Resected Specimen for Colon Cancers over Time 45 Figure 31. Proportion of Patients with Rectal Cancer Undergoing MRI Scan as Part of Preoperative Staging over Time 47 Figure 32. Neoadjuvant Therapy Use for Rectal Cancer and Type of Therapy 47 Figure 33. Detailed Operative Approach over Time for Rectal Cancer 48 Figure 34. Permanent End Stoma Rate by Hospital for Rectal Cancer Patients 45 Figure 35. Circumferential Margin Involvement over Time in Rectal Cancer 5 Figure 36. Patients with Positive Margins and whether they Received Neoadjuvant Therapy over Time 51 Figure 37. Surgical Complications in Rectal Cancer by Hospital 52 Figure 38. Percentage of Stage II and Stage III Patients who Received Chemotherapy 53 THE BI-NATIONAL COLORECTAL CANCER AUDIT REPORT

20 LIST OF TABLES Table Title Page No. Table 1. Hospitals Participating in BCCA 16 Table 2. Patient Characteristics 21 Table 3. American Society of Anaesthesiologists (ASA) Classification for All Treatment Episodes 21 Table 4. Cancer Stage for All Treatment Episodes 23 Table 5. Number of Patients with Tumour Diagnosed Following FOBT over Time 24 Table 6. Primary Surgical Procedure for all BCCA Treatment Episodes 27 Table 7. Hospital Mortality over Time 28 Table 8. Urgency of Admission over Time 29 Table 9. Urgency of Admission and Inpatient Mortality 31 Table 1. Length of Stay and Tumour Position 36 Table 11. Length of Stay and Age 36 Table 12. Length of Stay over Time 37 Table 13. Length of Stay and Urgency of Admission 38 Table 14. Summarised Operative Approach and Length of Stay 4 Table 15. Primary Procedure for Patients with Colon Cancer 41 Table 16. Summary of Surgical and Medical Complications for Patients Undergoing Colon Cancer Surgery 43 Table 17. Tumour Stage for Colon Cancer 44 Table 18. Summary of Lymph Nodes Examined in Resected Specimen over Time 45 Table 19. Proportion of Rectal Cancer Cases Discussed at MDT 46 Table 2. Use of Neoadjuvant Therapy for Rectal Cancer 47 Table 21. Primary Procedure for Patients with Rectal Cancer 48 Table 22. Circumferential Margin Involvement over Time 49 Table 23. Use of Neoadjuvant Therapy and Margin Involvement 5 Table 24. Surgical and Medical Complications of Patients Undergoing Surgery for Rectal Cancer 51 Table 25. Percentage of Stage II and III Cancer Patients Receiving Chemotherapy 53 2 THE BI-NATIONAL COLORECTAL CANCER AUDIT REPORT 217

21 PATIENT CHARACTERISTICS Information on over 17,7 patients with colorectal cancer across Australia and New Zealand has been collected over the period from 27 to 216, with almost 2,5 patients added in 216. While this is a substantial number of patients, it only represents around 15% of the new colorectal cancer patients that would have presented over this period across Australia and New Zealand. It is likely however that the patient demographics are reflective of the colorectal cancer population over the period of time as a whole. The majority of the patients are over 5 years with 7-79 years being the most common age group at presentation. There are still however a number of patients presenting below 5 years of age and it is important that there is awareness that colorectal cancer can occur in younger patients, though at a lower frequency. The distribution of the American Society of Anaesthesiologists (ASA) classification gives an indication of the overall fitness of patients at the time of surgery. Over a third of patients are ASA 3 or greater, representing significant existing co-morbidities, and increasing the potential of postoperative complications. Approximately one third of tumours (31%) are in the rectum, and over 55% of tumours are in the sigmoid colon or beyond, which is consistent with the distribution reported in the literature. The proportion of patients presenting with metastatic disease is 12%, which is lower than is often reported, and may represent some skewing of the data. This will be interesting to assess in future years. TABLE 2. PATIENT CHARACTERISTICS Age Range Age Mean (±SD) 69 (±12.9) Age Median 7 Female: Male 1:1.2 TABLE 3. AMERICAN SOCIETY OF ANAESTHESIOLOGISTS (ASA) CLASSIFICATION FOR ALL TREATMENT EPISODES Count Percent ASA 1 2, % ASA 2 8, % ASA 3 5, % ASA % ASA % TOTAL 17,68 1% * ASA is a system for assessing the fitness of patients before surgery where 1 represents a healthy person and 5 represents someone who is not expected to survive without surgery. THE BI-NATIONAL COLORECTAL CANCER AUDIT REPORT

22 FIGURE 3. AGE DISTRIBUTION OF PATIENTS 5, 4,5 4, NUMBER OF PATIENTS 3,5 3, 2,5 2, 1,5 1, 5 < AGE GROUP FIGURE 4. DIAGRAM OF PRIMARY TUMOUR SITE, COUNT AND PERCENTAGE* Transverse Colon 1,486 (8.3%) Splenic Flexure 535 (3.%) Hepatic Flexure 877 (4.9%) Ascending Colon 2,215 (12.4%) Descending Colon 551 (3.1%) Rectosigmoid 1,69 (6.%) Caecum 2,15 (12.1 %) Sigmoid Colon 3,391 (19.%) Rectum Upper Third 759 (4.3%) * Unknown 53 (.3 %) Rectum Middle Third 2,19 (11.3%) Rectum Lower Third 2,712 (15.2%) *n=17,827 treatment episodes 22 THE BI-NATIONAL COLORECTAL CANCER AUDIT REPORT 217

23 TABLE 4. CANCER STAGE FOR ALL TREATMENT EPISODES Count (%) Colon Rectum TOTAL Stage 538 (4%) 48 (8%) 946 (5%) Stage 1 2,57 (21%) 1,768 (33%) 4,275 (24%) Stage 2 4,85 (33%) 1,17 (22%) 5,255 (3%) Stage 3 3,461 (28%) 1,412 (26%) 4,873 (27%) Stage 4 1,563 (13%) 55 (1%) 2,113 (12%) Stage X 43 (%) 73 (1%) 116 (1%) TOTAL 12,197 (1) 5,381 (1) 17,578 (1%) * The AJCC staging system is a classification system developed by the American Joint Committee on Cancer for describing the extent of disease progression in cancer patients. It utilises the TNM scoring system to calculate an overall stage value, where T is Tumour size, N is Lymph Nodes affected, and M is Metastases. THE BI-NATIONAL COLORECTAL CANCER AUDIT REPORT

24 FOBT DIAGNOSIS AND BOWEL SCREENING PROGRAMMES Whilst the majority of colorectal cancers present due to symptoms, a proportion are identified as a result of screening programmes. The National Bowel Cancer Screening Program (NBCSP) was initiated in Australia in 27 following a successful pilot programme. It utilises an immunological faecal occult blood test (FOBT) to identify occult lower gastrointestinal bleeding and patients with positive tests are offered a colonoscopy via their general practitioner. In 216 men and women turning 5, 55, 6, 64, 65, 7, 72 and 74 were invited to participate, this age spread is due to increase in 217. In New Zealand, a pilot screening programme is being undertaken in the Waitemata District Health Board (WDHB) area, which started in October 211 and will continue through to December 217. It has covered men and women aged 5 to 74 from the WDHB. A subset of patients from the WDHB are submitted to the BCCA and hence the data presented below includes patients from bowel cancer screening programmes in both Australia and New Zealand. In 217 the New Zealand National Bowel Screening Programme (NBSP) will begin its rollout across New Zealand DHBs starting with Hutt Valley and Wairarapa in addition to maintaining Waitemata, it will offer bowel screening every two years to eligible people aged 6 to 74 years. The proportion of patients diagnosed following FOBT remains fairly steady however this has increased to 13% in 216. It will be interesting to see if this proportion progressively increases over the next few years as a result of the staged expansion of the programme. The age distribution of patients identified is consistent with the age distribution of the screening programme as would be expected. The distribution of tumour site is similar to the overall distribution of patients which is not surprising as screening is aimed at identifying asymptomatic patients and hence the distribution is likely to be identical to the overall colorectal cancer population. It is encouraging however that there does appear to be a stage shift in patients diagnosed through the NBCSP with a higher proportion of Stage I patients. This should increase the likelihood of curative treatment in these patients. TABLE 5. NUMBER OF PATIENTS WITH TUMOUR DIAGNOSED FOLLOWING FOBT OVER TIME TOTAL Diagnosed following FOBT 11% 13% 11% 1% 9% 8% 11% 12% 11% 13% 1% Not Diagnosed following FOBT 89% 87% 89% 9% 91% 92% 89% 88% 89% 87% 9% Count 645 1,116 1,385 1,783 1,827 1,521 1,588 2,37 2,51 2,132 18, THE BI-NATIONAL COLORECTAL CANCER AUDIT REPORT 217

25 FIGURE 5. AGE DISTRIBUTION OF PATIENTS DIAGNOSED FOLLOWING FOBT* 7 6 NUMBER OF PATIENTS < AGE GROUP *n=1,752 patients FIGURE 6. SITE OF TUMOUR OF PATIENTS DIAGNOSED THROUGH A NATIONAL SCREENING PROGRAMME COMPARED TO OTHER BCCA DATA* 3. PERCENTAGE OF PATIENTS % Non-Screening Programme % Screening Programme Caecum Ascending colon Hepatic flexure 3.4 Transverse colon Splenic flexure Descending colon Sigmoid colon Rectosigmoid 4.2 Rectum upper third Rectum mid third Rectum lower third *n=683 screening patients and 17,234 other BCCA patients THE BI-NATIONAL COLORECTAL CANCER AUDIT REPORT

26 FIGURE 7. STAGE OF CANCER OF PATIENTS DIAGNOSED VIA A NATIONAL SCREENING PROGRAMME COMPARED TO OTHER BCCA DATA* 5 45 PERCENTAGE OF PATIENTS % Non-Screening Programme % Screening Programme Stage Stage I Stage II Stage III Stage IV Stage X CANCER STAGE *n=672 screening patients and 17,3 other BCCA patients 26 THE BI-NATIONAL COLORECTAL CANCER AUDIT REPORT 217

27 SURGICAL CARE Surgery is the primary treatment for the majority of patients with colorectal cancer. The range of operations required is a result of the variable site of origin of the tumour. The data is categorised into: overall colorectal cancer care, length of hospital stay, operative approach, and specifics related to colon cancer and to rectal cancer respectively. Subcategories are addressed separately and presented below. TABLE 6. PRIMARY SURGICAL PROCEDURE FOR ALL BCCA TREATMENT EPISODES Operation Count Percentage Right hemicolectomy 5,324 28% Extended right hemicolectomy 899 5% Left hemicolectomy 647 3% Sigmoid colectomy 141 1% Total colectomy 233 1% Subtotal colectomy 57 3% Proctocolectomy 157 1% High anterior resection (1.1-15) 3,258 17% Low anterior resection (6.1-1) 1,58 8% Ultra low anterior resection (-6) 2,55 14% APR 1,9 6% Hartmanns 629 3% Miscellaneous operation (eg. for complication) 37 % Colo-anal anastomosis 52 % Transverse colectomy 15 1% Local excision 161 1% TEMS/TAMIS 171 1% Laparotomy only 45 % Other 39 2% Non-operative (No Surgery) 689 4% TOTAL 18,773 1% THE BI-NATIONAL COLORECTAL CANCER AUDIT REPORT

28 OVERALL COLORECTAL CANCER CARE Overall hospital mortality for patients with colorectal cancer remains steady over time at less than 2%. It is recognised that urgency of hospital admission, namely elective, urgent, or emergency is a strong factor influencing hospital mortality and this is supported by the data presented below. Most (88%) of colorectal cancer cases are elective, 7% present as urgent cases, and 5% present as emergencies. Mortality for emergency cases remains substantially greater than that of elective cases, however this has gradually reduced over the last decade. This may be an anomaly however it could represent a progressive improvement in the ability to rescue with a progressive increase in focus on this area across hospitals. Assessing quality of care is challenging as it is multifactorial and there are a range of outcomes that can be considered. Hospital mortality is an important outcome and is encouragingly low at 1.3% overall. If the mortality is assessed across all the hospitals, there is a reduction in mortality with increase in number of cases undertaken. The mortality data can be riskadjusted for factors that influence mortality and factors that influence in-hospital mortality including age, ASA, urgency of admission, complications, location of tumour in the rectum, laparoscopic entry and surgical procedure. The risk-adjusted mortality is represented on a funnel plot and is consistent with the unadjusted data, demonstrating no outliers and hence no hospitals with significantly increased mortality. It is important to risk-adjust data as there is likely to be a variation in the spectrum of cases treated in different centres. Return to theatre may also be utilised as a quality marker of hospital care. There is a spectrum of rates across the hospitals, with a mean of 5.6%. The data can be risk-adjusted for age, ASA, urgency, complications, location of tumour rectum, laparoscopic entry and surgical procedure, raising the mean return to theatre rate to 6.1%. There are no hospitals with a significantly increased return to theatre rate. Overall complications are presented for all operative cases. Subgroup analysis for colonic and for rectal cases are presented later. A range of factors affect overall complication rate including tumour site, sex, age, ASA, urgency, laparoscopic entry and surgical procedure. The mean adjusted complication rate is 23.9%. TABLE 7. HOSPITAL MORTALITY OVER TIME TOTAL Treatment Episodes 58 1,274 1,514 1,898 1,998 1,626 1,566 2,34 2,456 2,276 17,528 Inpatients Deaths Inpatient Mortality Rate 2% 2% 2% 1% 2% 2% 1% 2% 1% 1% 1% 28 THE BI-NATIONAL COLORECTAL CANCER AUDIT REPORT 217