Colorectal Cancer Quality Performance Indicators

Transcription

1 Publication Report Colorectal Cancer Quality Performance Indicators Patients diagnosed between April 2013 and March 2016 Publication date 27th June 2017 An Official Statistics Publication for Scotland

2 Contents Contents... 2 Introduction... 3 Foreword from Colorectal Cancer Clinical Leads... 6 Results and Commentary... 9 Case Ascertainment...9 Overall Performance Summary Quality Performance Indicators Clinical Trials Survival Analysis List of Tables...56 Contact...57 Further Information...57 Rate this publication...57 A1 Background Information A2 Colorectal Cancer QPIs A3 Colorectal Cancer Clinical Trials A4 Publication Metadata (including revisions details) A5 Early Access details (including Pre-Release Access) A6 ISD and Official Statistics

3 Introduction The cancer strategy Beating Cancer: Ambition and Action published in March 2016 builds on the commitment made in the Better Cancer Care plan to 'develop a work programme which will define how we will take forward quality indicators for cancer services' by further supporting a culture of continuous quality improvement in cancer care across NHSScotland. The new cancer strategy states a commitment to improving data collection to advance the quality and delivery of care for cancer patients. To achieve this, the Scottish Cancer Taskforce established the National Cancer Quality Steering Group (NCQSG), which includes responsibility for: The development of small sets (approximately indicators) of tumour specific national quality performance indicators (QPIs) as a proxy measure of quality care. Overseeing the implementation of the national governance framework that underpins the reporting of performance against these national QPIs. The QPIs have been developed collaboratively with the three Regional Cancer Networks: North of Scotland Cancer Network (NOSCAN), South East Scotland Cancer Network (SCAN), West of Scotland Cancer Network (WoSCAN), Information Services Division (ISD), and Healthcare Improvement Scotland. The QPIs are published on the Healthcare Improvement Scotland website. These indicators, used to drive quality improvement in cancer care across NHSScotland are kept under regular review; NHS Boards will be required to report against QPIs as part of a mandatory national cancer quality programme. ISD support NHS Boards in improving the quality of local data collection and reporting through the production of data validation specifications, and measurability criteria for QPIs. The current data sets are outlined on the Cancer Audit website. A rolling programme of reporting is planned across many tumour sites. National reports will include comparative reporting of performance against QPIs at NHS Board level across NHS Scotland, trend analysis and survival analysis (where applicable). This approach will help overcome existing issues relating to the reporting of small volumes in any one year. This report assesses performance against 12 Colorectal Cancer QPIs using clinical audit and SMR01 data relating to patients diagnosed with colorectal cancer for the period from April 2013 to March An initial report on the first year of data collection (April 2013 to March 2014) was previously published in June 2015 and the commentary included in that report may still be applicable when interpreting this report. 3

4 Data collection and analysis Colorectal cancer QPI data for patients diagnosed between April 2013 and March 2016 were collected by NHS Boards, supported by the regional cancer networks, and then analysed against the Colorectal cancer measurability document. Aggregated analysed data were then submitted to ISD via a data collection template for collation to allow comparisons at NHS Board level. To support the national reporting of QPIs and to provide context in their interpretation, an analysis of colorectal cancer survival was undertaken. A cohort of patients diagnosed with colorectal cancer during 2010 to 2012, and registered on the Scottish Cancer Registry, was used and linked to deaths data (up to December 2015) to provide 3 years of follow up for all patients (and up to 5 years of follow up for some). Data quality and completeness Small numbers: Where the number of cases meeting the denominator criteria for any indicator is between one and four, the percentage calculation has not been shown on any associated charts or tables. This is to avoid any unwarranted variation associated with small numbers and to minimise the risk of disclosure. Any charts or tables impacted by this are denoted with a dash (-). However, any commentary provided by NHS Boards relating to the impacted indicators will be included as a record of continuous improvement. Quality Assurance: The data quality team at ISD assessed a random sample of approximately 10% of Colorectal QPI records across mainland NHS Boards, with a date of diagnosis in year ending March The overall accuracy of recording of the sampled dataset was very high at 98.7% nationally. The accuracy of recording of individual data items ranged from 92% to 100% at Scotland level (excluding Island NHS Boards). The Data Quality team are working with Cancer networks to follow up findings from the assessment, clarify ambiguities in data definitions and further improve the quality of Colorectal QPI data. QPI8 Reoperation Rates: A detailed review of the measurability criteria for this QPI, and regional assessment of results over the last three years concluded that the use of SMR01 data for this measure did not provide robust comparable results. Therefore no national reoperation rates will be published at this time. Following formal review of the colorectal cancer QPIs a decision was taken to use clinical audit data, rather than SMR01 data for future assessment of performance in relation to this QPI. Patients diagnosed in 2017/18 will be reported regionally by the networks in 2019 and nationally in

5 Baseline Review: Following baseline review and year 1 publication of colorectal cancer QPIs data, some changes were made to measurability in order that the QPIs appropriately measured what they were intended to. These were positive changes and led to more focussed analysis in year 2. However, the alterations to measurability meant that year 1 and year 2 results were not directly comparable for some QPIs. Formal Review: In order to ensure the success of the National Cancer QPIs in driving quality improvement in cancer care across NHS Scotland it is critical that the QPIs continue to be clinically relevant and focus on areas which will result in improvements to the quality of patient care. It was proposed that a formal review of all QPIs should take place following 3 years national comparative reporting, with tumour specific Regional Clinical Leads undertaking a key role in determining the need and extent of the review required. For colorectal cancer, this review has already taken place; revised colorectal cancer QPIs for implementation from year 4 onwards will be published later in 2017, following public consultation. Any proposed changes to the QPIs as a result of this review will be noted in this report. 5

6 Foreword from Colorectal Cancer Clinical Leads The three Regional Cancer Networks (North of Scotland Cancer Network (NOSCAN), South East Scotland Cancer Network (SCAN), and West of Scotland Cancer Network (WOSCAN)) aim to promote the highest standards of cancer care and equity of access to cancer services across Scotland. The development and introduction of national Quality Performance Indicators (QPI) across Scotland represents a major step forward for patients with Colorectal Cancer. The QPIs have been developed by clinical staff across the three Regional Cancer Networks in collaboration with Information Services Division, Healthcare Improvement Scotland, Scottish Cancer Coalition and the Scottish Government. The measures that have been developed maintain a clear focus on patient outcomes to allow the identification of action points where QPIs have not been achieved, and to identify areas of high quality care that should continue and be shared across NHS Boards. Only by collecting accurate and relevant audit data can we identify areas for future development to improve services and patient outcomes, and reflect on whether the QPIs themselves are robust and continue to be clinically relevant. This first report of a cumulative three year data is an impressive piece of work based on data for patients diagnosed with Colorectal Cancer in Scotland between , of which 2606 were diagnosed in NOSCAN, 2771 in SCAN and 4740 in WOSCAN. Key Recommendations / Key Points to Note Overall performance against the 12 Colorectal Cancer QPIs was generally good across all NHS Boards; however, no individual NHS Board met all 12 QPI targets. This suggests that the target levels for the QPIs are challenging and that there are areas for improvement. QPI 1 Radiological Imaging and Staging i) Colon cancer: It is recognised that some patients are clearly on a palliative care trajectory at presentation and for this reason patients undergoing supportive care only were excluded from measurement following year 1 analysis. ii) Rectal cancer: This is an important QPI for assessing quality of overall care and system functionality. Patients in whom there were contraindications to MRI were excluded from measurement at baseline review following year one analysis. Over the 3 year period this QPI has remained challenging, but reassuringly there has been progressive improvement which is encouraging. SCAN and WOSCAN have achieved this target over the last 2 years consistently, with NOSCAN very close to the target. QPI 2 Pre-operative Imaging of the Colon Although some resource constraints were noted, it was agreed that though a challenging QPI, nonetheless it was one that all Boards should be aspiring to meet. 6

7 It is also felt appropriate to exclude patients clearly undergoing palliative surgery (such as stoma formation alone) and therefore this will be taken into consideration in future reporting of this QPI. None of the three regions met the 95% target for this QPI. However, over the 3-year period the trend is upwards towards the target. This QPI continues to be challenging and NHS Boards should explore the reasons for not achieving the target. QPI 4 Stoma Care Documentation issues were noted in some Boards (e.g. NHS Grampian), where for some patients the date of stoma site marking was not recorded. The potential difficulties of providing this required level of service in rural areas (due to the limited pools of specialist staff expertise) has previously been highlighted. It has been suggested that this could be overcome by ensuring that non-stoma therapists are trained and mentored appropriately. Over the 3 year period improvement is evident in SCAN and WOSCAN with the target achieved in both regions in year three. Performance in NOSCAN is variable over the three years, however the issues associated with geography, as noted above should be factored in. QPI 5 - Lymph Node Yield Performance against this QPI has shown progressive improvement over the 3 years and all regions met the target consistently over the last 2 years. QPI 6 - Neoadjuvant Radiotherapy This has been a difficult QPI to achieve nationally, which is largely due to lower performance in NOSCAN. Further work should be carried out to identify reasons for this variance. QPI 9 Anastomotic dehiscence Overall, the anastomotic leak rates have been low with the exception of NOSCAN during the last year for rectal cancers, where the target was narrowly missed. QPI 10 and QPI and 90 Day Mortality Following Surgery, Chemotherapy or Radiotherapy Mortality remains the single end point around which there can be little debate and following correction for age/deprivation and co-morbidity can be the best indicator of both quality of systems of care and the potential for unwarranted variation. In view of the positive benefits that have been evidenced from other health care systems around its ability to improve patient outcomes, there has been agreement to the inclusion of 90 day mortality, which has been used for the latter 2 years. 7

8 Across the 3 regions we have been able to maintain good results, with mortality following elective and emergency surgical procedures being below the target figures of <5% and <15%. Similarly at a national level mortality rates following adjuvant chemotherapy, chemoradiotherapy and radiotherapy were below the <2% target. QPI 11 Adjuvant chemotherapy It has been noted that given the limited evidence from the literature there is no current timeline following surgery within which chemotherapy should be considered adjuvant. However, there is a strong intuitive belief that the effect of adjuvant treatment given earlier is likely to be most beneficial. The target was achieved nationally for patients with Dukes C and Dukes B colorectal cancer. Some variance was noted in relation to patients with Dukes B colorectal cancer, however NHS Boards noted that small numbers had impacted upon results. It is encouraging that improvement is evident across the three years for a number of QPIs. However results presented within this report demonstrate that there remains room for further service improvement, particularly in relation to pre-operative imaging of the colon, stoma care and neoadjuvant radiotherapy. Where variance has been noted or targets not achieved, NHS Boards should develop action plans for improvement. A significant amount of data has been collated and analysed for this report and the information and audit teams across NHS Scotland are to be congratulated. We would like to thank those teams involved for their hard work. Without their considerable efforts this level of progress would not be possible. Mr Mike Walker Mr Paul Horgan Mr Satheesh Yalamarthi CRC MCN Clinical Lead CRC MCN Clinical Lead CRC MCN Clinical Lead NOSCAN WoSCAN SCAN 8

9 Results and Commentary Case Ascertainment Case ascertainment is a measure of data quality and is calculated by comparing the number of new patients captured by the cancer audit with a five year average of the numbers recorded on the cancer registry. A five year average is used for registry data as the information is not available until sometime after the year under examination. This is due to data collection and verification processes. As the number of cases will vary each year, it is possible for case ascertainment to be over or under 100%. Therefore, the figures presented should be seen as an indication only. The average case ascertainment across Scotland in the year to March 2016 was 93.2% which is consistent with the previous 2 years: Estimated Case Ascertainment (%) Grampian Highland Orkney Shetland Tayside Western Isles NOSCAN Borders Dumfries & Galloway Fife Lothian SCAN Ayrshire & Arran Forth Valley Greater Lanarkshire WoSCAN Scotland Glasgow & Clyde NOSCAN SCAN WoSCAN Scotland 2013/ / /16 No. of Audit Records Diagnosed in 2015/16 Average No. of Cancer Registrations: No. of Audit Records Diagnosed in 2014/15 Average No. of Cancer Registrations: No. of Audit Records Diagnosed in 2013/14 Average No. of Cancer Registrations: Estimated Case Ascertainment % Estimated Case Ascertainment % Estimated Case Ascertainment % NOSCAN Grampian Highland Orkney Shetland Tayside Western Isles SCAN Borders Dumfries & Galloway Fife Lothian WoSCAN Ayrshire & Arran Forth Valley Greater Glasgow & Clyde Lanarkshire Scotland

10 Overall Performance Summary The tables below summarise the overall performance across the country for each QPI. NOSCAN: 10

11 SCAN: 11

12 WoSCAN: Clinical Trials Summary Table by Scottish Cancer Research Network (SCRN) Target not met Met or exceeded target - Data not shown due to small numbers * No data matching QPI criteria By Board of Surgery 12

13 Quality Performance Indicators The following section includes a detailed summary of each of the twelve colorectal cancer QPIs outlining the variation at NHS Board level. Charts are colour coded by reporting year or by network if reporting a single year. Where performance at either level is shown to fall below the target, commentary from the relevant NHS Board is included to provide context to the variation. Information in this report is shown by the Health Board of diagnosis with the exception of QPIs 4,5,7,9 and 10 which are shown by the Health Board of surgery. Further information at hospital level is available from the data tables, where applicable. QPI 1(i): Radiological Diagnosis and Staging (Colon) - Patients with colorectal cancer should be evaluated with appropriate imaging to detect extent of disease and guide treatment decision making. Accurate staging is necessary to detect metastatic disease, guide treatment and avoid inappropriate surgery. Numerator: Number of patients with colon cancer who undergo CT chest, abdomen and pelvis before definitive treatment. Denominator: All patients with colon cancer. Exclusions: Patients who refuse investigation. Patients who undergo emergency surgery Patients undergoing supportive care only Target: 95% At the baseline review following review of year 1 data, it was agreed to amend the definition of this indicator to exclude patients receiving supportive care as imaging is not appropriate in these cases. Therefore, any apparent improvement in this measure from year 1 onwards may be as a direct result of this change. Of the 1,570 patients diagnosed with colon cancer in Scotland during 2015/16, 97% (1,520) of patients received a CT of the chest, abdomen and pelvis to determine the extent of the disease prior to treatment. This exceeds the 95% target - only NHS Grampian, NHS Highland, NHS Shetland (small numbers), NHS Tayside and NHS Dumfries & Galloway missed the target. It was a similar pattern in year 2 where overall 96% of patients in Scotland met the target. Only NHS Grampian and NHS Tayside did not meet target in either of the reporting years. 13

14 120.0 QPI 1(i): Radiological Diagnosis and Staging by Health Board of Diagnosis % Grampian Highland Orkney Shetland Tayside Western Isles NOSCAN Borders Dumfries & Galloway Fife Lothian SCAN Ayrshire & Arran Forth Valley Greater Lanarkshire WoSCAN Scotland Glasgow & Clyde NOSCAN SCAN WoSCAN Scotland 2013/ / /16 Target 2015/16 Past % Performance NHS Board/Region % Performance Numerator Denominator Numerator Exclusion Denominator 2013/ /15 Grampian Highland Orkney Shetland Tayside Western Isles NOSCAN Borders Dumfries & Galloway Fife Lothian SCAN Ayrshire & Arran Forth Valley Greater Glasgow & Clyde Lanarkshire WoSCAN Scotland Source: Cancer audit - Data not shown due to small numbers * No data matching QPI criteria NHS Grampian stated that some of the patients not meeting target in 2015/16 were either too frail for chemotherapy or had other metastatic disease so it was felt clinically unnecessary to arrange a further scan. Similarly in NHS Highland it was felt that for the patients not meeting target who had advanced disease and/or receiving palliative treatment, a CT prior to treatment would not have influenced treatment and may have introduced delays. In NHS Tayside, it was stated that there is now increased awareness regarding the timeous requisition of the chest CT as part of the staging process to improve performance for this indicator. At the formal review it was agreed to add further exclusions to the definition of this indicator. For future reporting, patients undergoing palliative treatment (chemotherapy, radiotherapy or surgery) and patients who die before first treatment will be excluded. Given these have been cited above as a factor in not meeting target for some NHS Boards then it is expected that results should continue to improve in year 4. 14

15 QPI 1(ii): Radiological Diagnosis and Staging (Rectal) - Patients with colorectal cancer should be evaluated with appropriate imaging to detect extent of disease and guide treatment decision making. Accurate staging is necessary to detect metastatic disease, guide treatment and avoid inappropriate surgery. Numerator: All patients with rectal cancer undergoing definitive treatment (chemoradiotherapy or surgical resection) who undergo CT chest, abdomen and pelvis and MRI pelvis before definitive treatment. Denominator: All patients with rectal cancer undergoing definitive treatment (chemoradiotherapy or surgical resection). Exclusions: Patients who refuse investigation. Patients who undergo emergency surgery Patients with a contraindication to MRI Target: 95% At the baseline review following review of year 1 data, it was agreed to amend the definition of this indicator to exclude patients with a contraindication to MRI. Therefore, any apparent improvement in this measure from year 1 onwards may be as a direct result of this change. Of the 577 patients diagnosed with rectal cancer in Scotland during 2015/16, 95% (547) of patients received a CT of the chest, abdomen and pelvis to determine the extent of the disease prior to treatment. This represents an increase from 92% in the previous year. NHS Grampian, NHS Highland, NHS Dumfries & Galloway, NHS Lothian and NHS Ayrshire & Arran did not meet target in 2015/16 but, generally, there is an improving trend in these Boards QPI 1(ii): Radiological Diagnosis and Staging by Health Board of Diagnosis % Grampian Highland Orkney Shetland Tayside Western Isles NOSCAN Borders Dumfries & Galloway Fife Lothian SCAN Ayrshire & Arran Forth Valley Greater Lanarkshire WoSCAN Scotland Glasgow & Clyde NOSCAN SCAN WoSCAN Scotland 2013/ / /16 Target 15

16 2015/16 Past % Performance NHS Board/Region % Performance Numerator Denominator Numerator Exclusion Denominator 2013/ /15 Grampian Highland Orkney Shetland Tayside Western Isles NOSCAN Borders Dumfries & Galloway Fife Lothian SCAN Ayrshire & Arran Forth Valley Greater Glasgow & Clyde Lanarkshire WoSCAN Scotland Source: Cancer audit - Data not shown due to small numbers * No data matching QPI criteria NHS Grampian, NHS Ayrshire & Arran and NHS Highland reported that some of the patients not meeting this target did not have an MRI scan as the site of tumour origin was only confirmed as rectal by surgical pathology rather than as sigmoid colon as originally thought. At the formal review it was agreed to add further exclusions to the definition of this indicator. For future reporting, patients undergoing Transanal Endoscopic Microsurgery (TEM) or Transanal Resection of Tumour (TART), patients who undergo palliative treatment (chemotherapy, radiotherapy or surgery) and patients who die before first treatment will be excluded. 16

17 QPI 2: Pre-Operative Imaging of the Colon - Patients with colorectal cancer undergoing surgical resection should have the whole colon visualised preoperatively. The whole colon is visualised preoperatively to avoid missing synchronous tumours and to remove synchronous adenomas. Numerator: Number of patients who undergo elective surgical resection for colorectal cancer who have the whole colon visualised by colonoscopy or CT colonography before surgery, unless the non visualised segment of the colon has been removed. Denominator: All patients who undergo elective surgical resection for colorectal cancer. Exclusions: No exclusions. Target: 95% There has been steady improvement in this indicator across the three years for most NHS Boards, although overall in Scotland it was still below target in 2015/16 at 91%. In 2015/16, five NHS Boards met the target compared with only 3 in 2013/14. During the baseline review it was recognized that this QPI describes the recommended gold standard of care for this group of patients so there is still further improvement to be made QPI 2: Pre-Operative Imaging of the Colon by Health Board of Diagnosis % Grampian Highland Orkney Shetland Tayside Western Isles NOSCAN Borders Dumfries & Galloway Fife Lothian SCAN Ayrshire & Arran Forth Valley Greater Lanarkshire WoSCAN Scotland Glasgow & Clyde NOSCAN SCAN WoSCAN Scotland 2013/ / /16 Target 17

18 2015/16 Past % Performance NHS Board/Region % Performance Numerator Denominator Numerator Exclusion Denominator 2013/ /15 Grampian Highland Orkney Shetland Tayside Western Isles NOSCAN Borders Dumfries & Galloway Fife Lothian SCAN Ayrshire & Arran Forth Valley Greater Glasgow & Clyde Lanarkshire WoSCAN Scotland Source: Cancer audit - Data not shown due to small numbers * No data matching QPI criteria Several NHS Boards (NHS Grampian, NHS Ayrshire & Arran, NHS Forth Valley and NHS Lanarkshire) commented that many of the patients not meeting this QPI had incomplete colonic imaging for a variety of clinical reasons. For example, patients requiring urgent surgery, patients refusing colonoscopy and patients with strictures preventing the scope from passing. During the reporting period, NHS Forth Valley did not have access to a CT colonography machine which may account for some of the patients not meeting target. This is now available and it is, therefore, expected that results may improve in future reporting. At the formal review, minor changes were proposed to the definition of this QPI: description to include the word elective for clarity and the addition of exclusions for patients undergoing palliative surgery and patients who have incomplete bowel imaging due to obstructing tumour. 18

19 QPI 3: Multi Disciplinary Team (MDT) Meeting - Patients should be discussed by a multidisciplinary team prior to definitive treatment. Evidence suggests that patients with cancer managed by a multi-disciplinary team have a better outcome. Numerator: Number of patients with colorectal cancer discussed at the MDT before definitive treatment. Denominator: All patients with colorectal cancer Exclusions: Patients who died before first treatment. Patients undergoing emergency surgery Patients undergoing treatment with endoscopic polypectomy only Target: 95% This QPI was only introduced for colorectal cancer in year 2. In Scotland in 2015/16, the percentage of patients discussed at MDT prior to definitive treatment was below target at 92%. Only NHS Shetland, NHS Fife, NHS Lothian and NHS Forth Valley met the target in each of the 2 reporting years QPI 3: Multi-Disciplinary Team (MDT) Meeting by Health Board of Diagnosis % Grampian Highland Orkney Shetland Tayside Western Isles NOSCAN Borders Dumfries & Galloway Fife Lothian SCAN Ayrshire & Arran Forth Valley Greater Lanarkshire WoSCAN Scotland Glasgow & Clyde NOSCAN SCAN WoSCAN Scotland 2013/ / /16 Target 19

20 2015/16 Past % Performance NHS Board/Region % Performance Numerator Denominator Numerator Exclusion Denominator 2013/ /15 Grampian * 91.6 Highland * 91.8 Orkney * 83.3 Shetland * Tayside * 88.7 Western Isles * 87.5 NOSCAN * 90.5 Borders * Dumfries & Galloway * 93.2 Fife * 97.2 Lothian * 98.3 SCAN * 97.5 Ayrshire & Arran * 69.8 Forth Valley * 98.5 Greater Glasgow & Clyde * 82.8 Lanarkshire * 97.7 WoSCAN * 85.4 Scotland * 89.6 Those Health Boards which did not meet target in year 2 or 3 cited a number of clinical reasons as contributing factors in their performance. In particular, patients receiving palliative treatment, patients with benign pathology until resection or patients receiving best supportive care were given as clinically appropriate reasons why these cases were not discussed prior to MDT. NHS Highland also stated that the majority of patients not meeting this QPI were from Argyll and Bute and, therefore, the process for discussing these patients at the MDT will be reviewed. The tolerance statement within this QPI will be updated following formal review to account for patients where the decision to manage by best supportive care is made prior to MDT discussion to allow for the confirmation of that decision at MDT. 20

21 QPI 4: Stoma Care - Patients with colorectal cancer who require a stoma are assessed and have their stoma site marked pre-operatively by a nurse with expertise in stoma care. Access to a nurse with expertise in stoma care increases patient satisfaction and optimal independent functioning. Furthermore, there is significant evidence to suggest that patients not marked preoperatively can have significant problems with their stoma post operatively and this can affect their recovery and rehabilitation. Numerator: Number of patients with colorectal cancer who undergo elective surgical resection which involves stoma creation who are seen by and have their stoma site marked preoperatively by a nurse with expertise in stoma care. Denominator: All patients with colorectal cancer who undergo elective surgical resection which involves stoma creation. Exclusions: Patients who refuse to be seen by a nurse with expertise in stoma care. Target: 95% In NHS Borders all colorectal cancer patients undergoing surgical resection involving stoma creation were seen pre-operatively by a stoma nurse in each of the three reporting years. NHS Dumfries & Galloway, NHS Fife and NHS Forth Valley also achieved 100% in year 3. At a national level, 94% of patients in 2015/16 benefitted from seeing a stoma nurse prior to surgery up from 90% in year 1; indicating an improving trend. Further information on this indicator is available at hospital level in the data tables QPI 4: Stoma Care by Health Board of Surgery % Grampian Highland Orkney Shetland Tayside Western Isles NOSCAN Borders Dumfries & Galloway Fife Lothian SCAN Ayrshire & Arran Forth Valley Greater Lanarkshire WoSCAN Scotland Glasgow & Clyde NOSCAN SCAN WoSCAN Scotland 2013/ / /16 Target 21

22 2015/16 Past % Performance NHS Board/Region % Performance Numerator Denominator Numerator Exclusion Denominator 2013/ /15 Grampian Highland Orkney * * * * * Shetland Tayside Western Isles * * NOSCAN Borders Dumfries & Galloway Fife Lothian SCAN Ayrshire & Arran Forth Valley Greater Glasgow & Clyde Lanarkshire WoSCAN Scotland Source: Cancer audit - Data not shown due to small numbers * No data matching QPI criteria NHS Grampian stated that a data recording issue contributed to missing target in 2015/16 as for some patients the date of stoma site marking was not recorded. Additionally, in some cases, a stoma was performed during surgery that was not anticipated and other patients had more urgent surgery than scheduled. NHS Highland, NHS Tayside and NHS Western Isles also stated that some patients had unplanned stomas formed or had urgent surgery. At the formal review, it was agreed to leave this indicator unchanged. 22

23 QPI 5: Lymph Node Yield - For patients undergoing resection for colorectal cancer the number of lymph nodes examined should be maximised. Maximising the number of lymph nodes resected and analysed enables reliable staging which influences treatment decision making. Numerator: Number of patients with colorectal cancer who undergo curative surgical resection where 12 lymph nodes are pathologically examined. Denominator: All patients with colorectal cancer who undergo curative surgical resection (with or without neoadjuvant short course radiotherapy). Exclusions: Patients with rectal cancer who undergo long course neo-adjuvant chemo radiotherapy or radiotherapy. Patients who undergo transanal endoscopic microsurgery or transanal resection of tumour. Target: 80% For Scotland overall, 89% of patients undergoing surgical resection in 2015/16 had the required number of lymph nodes pathologically examined. This is the third consecutive year that the target has been met at a national level. At NHS Board level all Boards achieved target in 2015/16 with the exception of those impacted by small numbers. Further information on this indicator is available at hospital level in the data tables QPI 5: Lymph Node Yield by Health Board of Surgery % Grampian Highland Orkney Shetland Tayside Western Isles NOSCAN Borders Dumfries & Galloway Fife Lothian SCAN Ayrshire & Arran Forth Valley Greater Lanarkshire WoSCAN Scotland Glasgow & Clyde NOSCAN SCAN WoSCAN Scotland 2013/ / /16 Target 23

24 2015/16 Past % Performance NHS Board/Region % Performance Numerator Denominator Numerator Exclusion Denominator 2013/ /15 Grampian Highland Orkney Shetland Tayside Western Isles NOSCAN Borders Dumfries & Galloway Fife Lothian SCAN Ayrshire & Arran Forth Valley Greater Glasgow & Clyde Lanarkshire WoSCAN Scotland Source: Cancer audit - Data not shown due to small numbers * No data matching QPI criteria NHS Grampian noted that there are a high number of cases classed as not recorded for denominator in each of the 3 years as the operation intent is not recorded by the MDT. Therefore, although the target is met, this does not give a true representation. Given the consistently high performance in this indicator, it was agreed at the formal review to increase the target from 80% to 90% for future reporting. 24

25 QPI 6: Neoadjuvant Radiotherapy - Patients with locally advanced rectal cancer should receive neoadjuvant chemoradiotherapy designed to facilitate a margin-negative resection. Patients with rectal tumours that involve or threaten the mesorectal fascia on preoperative imaging may benefit from preoperative radiotherapy. Numerator: Number of patients with rectal cancer with a threatened or involved CRM on preoperative MRI undergoing surgery who receive long course neoadjuvant chemoradiotherapy. Denominator: All patients with rectal cancer with a threatened or involved CRM on preoperative MRI undergoing surgery. Exclusions: Patients who refused radiotherapy. Patients in whom radiotherapy is contraindicated. Patients who presented as an emergency for surgery. Target: 90% In each of the 3 reporting years the target was missed at a national level. This is largely due, in particular, to the performance in NOSCAN in which only 56% met the target in 2015/16 compared to 87% in SCAN and 96% in WoSCAN QPI 6: Neo-adjuvant Radiotherapy by Health Board of Diagnosis % Grampian Highland Orkney Shetland Tayside Western Isles NOSCAN Borders Dumfries & Galloway Fife Lothian SCAN Ayrshire & Arran Forth Valley Greater Lanarkshire WoSCAN Scotland Glasgow & Clyde NOSCAN SCAN WoSCAN Scotland 2013/ / /16 Target 25

26 2015/16 Past % Performance NHS Board/Region % Performance Numerator Denominator Numerator Exclusion Denominator 2013/ /15 Grampian Highland Orkney * * * * * Shetland * Tayside Western Isles * NOSCAN Borders Dumfries & Galloway Fife Lothian SCAN Ayrshire & Arran Forth Valley Greater Glasgow & Clyde Lanarkshire WoSCAN Scotland Source: Cancer audit - Data not shown due to small numbers * No data matching QPI criteria Due to the concerns raised at the baseline review regarding the interpretation and clarity of the definitions (see Year 1 Report); changes were proposed at the formal review discussion to address this. It was agreed to amend this QPI to include other methods of neo-adjuvant therapy long course chemoradiotherapy, long course radiotherapy, short course radiotherapy with long course intent (delay to surgery) and neo-adjuvant chemotherapy. Several NHS Boards (NHS Grampian, NHS Highland, and SCAN) had stated that several patients not meeting this QPI had received short-course radiotherapy; therefore the proposed changes should result in an improved performance in this indicator. 26

27 QPI 7(i): Surgical Margins - Rectal cancers undergoing surgical resection should be adequately excised. For patients who receive primary surgery, or surgery following neo-adjuvant short course radiotherapy. The circumferential margin is an independent risk factor for the development of distant metastases and mortality. It is recognised that local recurrence of rectal cancer can be accurately predicted by pathological assessment of circumferential margin involvement in these tumours. Numerator: Number of patients with rectal cancer who undergo elective primary surgical resection or surgical resection following short course neoadjuvant radiotherapy in which the circumferential margin is clear of tumour. Denominator: All patients with rectal cancer who undergo elective primary surgical resection or surgical resection following short course neo-adjuvant radiotherapy. Exclusions: Patients who undergo transanal endoscopic microsurgery or transanal resection of tumour. Target: 95% At the baseline review, it was agreed that the emphasis of this QPI should be changed to re-enforce a more positive message such that the goal should be to achieve >95% of patients with a surgical margin free of tumour. This change was implemented from year 2 onwards. At regional level in 2015/16, only NOSCAN was lower than 95% which contributed to Scotland narrowly missing the target with 94% of patients with a clear surgical margin. Due to the smaller cohort sizes of patients meeting the criteria for this QPI, there is wide variation at NHS Board level. Further information on this indicator is available at hospital level in the data tables QPI 7(i): Surgical Margins by Health Board of Surgery % Grampian Highland Orkney Shetland Tayside Western Isles NOSCAN Borders Dumfries & Galloway Fife Lothian SCAN Ayrshire & Arran Forth Valley Greater Lanarkshire WoSCAN Scotland Glasgow & Clyde NOSCAN SCAN WoSCAN Scotland 2013/ / /16 Target 27

28 2015/16 Past % Performance NHS Board/Region % Performance Numerator Denominator Numerator Exclusion Denominator 2013/ /15 Grampian Highland Orkney * * * * * Shetland Tayside Western Isles * * * * * NOSCAN Borders Dumfries & Galloway Fife Lothian SCAN Ayrshire & Arran Forth Valley Greater Glasgow & Clyde Lanarkshire WoSCAN Scotland Source: Cancer audit - Data not shown due to small numbers * No data matching QPI criteria NHS Forth Valley commented that due to the small numbers involved in 2015/16 it would not be advisable to make any changes to current practice based on these figures. A review of all 3 years data shows that NHS Forth Valley is above target (97%) for the full reporting period. All resections not meeting target for this QPI were reviewed in NHS Grampian, NHS Highland, NHS Shetland and NHS Ayrshire & Arran and valid reasons were noted. SCAN commented that all resections are reviewed at the MDT as a learning opportunity. 28

29 QPI 7(ii): Surgical Margins - Rectal cancers undergoing surgical resection should be adequately excised. For patients who receive surgery following neo-adjuvant long course radiotherapy or chemo radiotherapy. The circumferential margin is an independent risk factor for the development of distant metastases and mortality. It is recognised that local recurrence of rectal cancer can be accurately predicted by pathological assessment of circumferential margin involvement in these tumours. Numerator: Number of patients with rectal cancer who undergo elective surgical resection following neoadjuvant long course radiotherapy or chemoradiotherapy in the circumferential margin is clear of tumour. Denominator: All patients with rectal cancer who undergo elective surgical resection following neo-adjuvant long course radiotherapy or chemoradiotherapy. Exclusions: Patients who undergo transanal endoscopic microsurgery or transanal resection of tumour. Target: 85% At the baseline review, it was agreed that the emphasis of this QPI should be changed to re-enforce a more positive message such that the goal should be to achieve >95% of patients with a surgical margin free of tumour. This change was implemented from year 2 onwards. Again, small numbers may be impacting performance of this QPI. At a regional level all networks met the target in year 3 with Scotland overall at 93% of patients with clear surgical margin. Further information on this indicator is available at hospital level in the data tables QPI 7(ii): Surgical Margins by Health Board of Surgery % Grampian Highland Orkney Shetland Tayside Western Isles NOSCAN Borders Dumfries & Galloway Fife Lothian SCAN Ayrshire & Arran Forth Valley Greater Lanarkshire WoSCAN Scotland Glasgow & Clyde NOSCAN SCAN WoSCAN Scotland 2013/ / /16 Target 29

30 2015/16 Past % Performance NHS Board/Region % Performance Numerator Denominator Numerator Exclusion Denominator 2013/ /15 Grampian Highland Orkney * * * * * Shetland * * * - * Tayside Western Isles * * * * * NOSCAN Borders Dumfries & Galloway * Fife Lothian SCAN Ayrshire & Arran Forth Valley Greater Glasgow & Clyde Lanarkshire WoSCAN Scotland Source: Cancer audit - Data not shown due to small numbers * No data matching QPI criteria At the formal review it was agreed to include other methods of neo-adjuvant therapy in the definition as per QPI6. This will be in place for future reporting of this QPI. 30

31 QPI 8: Re-operation Rates - For patients undergoing surgery for colorectal cancer, re-operation should be minimised. It is important to minimise morbidity and mortality related to the treatment of colorectal cancer. Re-operation rates may offer a sensitive and relevant marker of surgical quality. Numerator: Number of patients with colorectal cancer who undergo surgical resection who return to theatre following initial surgical procedure (within 30 days of surgery) to deal with complications related to the index procedure. Denominator: All patients with colorectal cancer who undergo surgical resection. Exclusions: No exclusions Targets: <10% (Elective surgical resection) <15% (Emergency surgical resection) A detailed review of the measurability criteria for this QPI, and regional assessment of results over the last three years concluded that the use of SMR01 data for this measure did not provide robust comparable results. Therefore no national reoperation rates will be published at this time. Following formal review of the colorectal cancer QPIs a decision was taken to use clinical audit data, rather than SMR01 data for future assessment of performance in relation to this QPI. Patients diagnosed in 2017/18 will be reported regionally by the networks in 2019 and nationally in

32 QPI 9(i): Anastomotic Dehiscence - For patients who undergo surgical resection for colorectal cancer anastomotic dehiscence should be minimised. For patients receiving colonic anastomosis. Anastomotic dehiscence is a major cause of morbidity and a measure of the quality of surgical care. Anastomotic leakage is an important and potentially fatal complication of colorectal cancer surgery, and measures to minimise it should be taken. Numerator: Number of patients with colorectal cancer who undergo a surgical procedure involving anastomosis of the colon having anastomotic leak requiring intervention (radiological or surgical). Denominator: All patients with colorectal cancer who undergo a surgical procedure involving anastomosis of the colon. Exclusions: No exclusions Target: <5% In each of the 3 reporting years, fewer than 5% of the colorectal cancer patients in Scotland meeting the criteria for this QPI developed an anastomotic leak. In 2015/16, all NHS Boards achieved the 5% target with the exception of NHS Highland and NHS Dumfries & Galloway. Further information on this indicator is available at hospital level in the data tables. 9.0 QPI 9(i): Anastomotic Dehiscence by Health Board of Surgery <5% Grampian Highland Orkney Shetland Tayside Western Isles NOSCAN Borders Dumfries & Galloway Fife Lothian SCAN Ayrshire & Forth Valley Greater Lanarkshire WoSCAN Scotland Arran Glasgow & Clyde NOSCAN SCAN WoSCAN Scotland 2013/ / /16 Target 32

33 2015/16 Past % Performance NHS Board/Region % Performance Numerator Denominator Numerator Exclusion Denominator 2013/ /15 Grampian Highland Orkney Shetland Tayside Western Isles * * * NOSCAN Borders Dumfries & Galloway Fife Lothian SCAN Ayrshire & Arran Forth Valley Greater Glasgow & Clyde Lanarkshire WoSCAN Scotland Source: Cancer audit - Data not shown due to small numbers * No data matching QPI criteria SCAN commented that since NHS Dumfries & Galloway have failed to meet target in 2 of the 3 reporting years a review will be undertaken to determine if there is any available learning or changes to practice that need to be made. At the formal review, it was agreed to leave this indicator unchanged. 33

34 QPI 9(ii): Anastomotic Dehiscence - For patients who undergo surgical resection for colorectal cancer anastomotic dehiscence should be minimised. For patients receiving rectal anastomosis. Anastomotic dehiscence is a major cause of morbidity and a measure of the quality of surgical care. Anastomotic leakage is an important and potentially fatal complication of colorectal cancer surgery, and measures to minimise it should be taken. Numerator: Number of patients with rectal cancer who undergo a surgical procedure involving anastomosis of the rectum (including anterior resection with TME) having anastomotic leak requiring intervention (radiological or surgical). Denominator: All patients with rectal cancer who undergo a surgical procedure involving anastomosis of the rectum. Exclusions: No exclusions Target: <10% At a national level, this QPI was comfortably achieved in each of the three years with approximately fewer than 5% of patients in this cohort developing an anastomotic leak. Only NHS Highland missed the target in 2015/16. In year 1, this indicator was reported in two separate specifications for patients with and without anterior resection with TME (total mesorectal excision). At the baseline review it was agreed to merge these together. For further information, please refer to the Year 1 Report. Further information on this indicator is available at hospital level in the data tables QPI 9(ii): Anastomotic Dehiscence by Health Board of Surgery <10% Grampian Highland Orkney Shetland Tayside Western Isles NOSCAN Borders Dumfries & Galloway Fife Lothian SCAN Ayrshire & Forth Valley Greater Lanarkshire WoSCAN Scotland Arran Glasgow & Clyde NOSCAN SCAN WoSCAN Scotland 2013/ / /16 Target 34

35 2015/16 Past % Performance NHS Board/Region % Performance Numerator Denominator Numerator Exclusion Denominator 2013/ /15 Grampian Highland Orkney * - Shetland Tayside Western Isles * * * * - NOSCAN Borders Dumfries & Galloway Fife Lothian SCAN Ayrshire & Arran Forth Valley Greater Glasgow & Clyde Lanarkshire WoSCAN Scotland Source: Cancer audit - Data not shown due to small numbers * No data matching QPI criteria NHS Highland recognises the disappointing result for this indicator in year 3 compared to the previous year. All patients who had an anastomotic leak in 2015/16 were high risk patients; therefore, consideration is being given to concentrating high risk patients into the care of a smaller number of surgeons. This will be considered as part of a wider review of the processes to reduce anastomotic leak. At the formal review, no further changes were proposed. 35

36 QPI 10: 30 and 90 Day Mortality Following Surgical Resection - Mortality after surgical resection for colorectal cancer. Treatment related mortality is a marker of the quality and safety of the whole service provided by the Multi Disciplinary Team (MDT). Outcomes of treatment, including treatment-related morbidity and mortality should be regularly assessed. Numerator: Number of patients with colorectal cancer who undergo emergency or elective surgical resection who die within 30 or 90 days of surgery. Denominator: All patients with colorectal cancer who undergo emergency or elective surgical resection. Exclusions: No exclusions Targets: <5% (Elective surgical resection 30 day mortality) <15% (Emergency surgical resection 30 day mortality) Elective Surgical Resection 30 Day Mortality In Scotland, in each of the 3 years, the mortality rate for colorectal cancer patients undergoing elective surgical resection was under 2% within 30 days of surgery. At NHS Board level, the mortality rates were all lower than 3% and below the stated target of 5% for elective surgery. 6.0 QPI 10(i): 30 Day Mortality Following Surgical Resection - Elective by Health Board of Surgery 5.0 <5% Grampian Highland Orkney Shetland Tayside Western Isles NOSCAN Borders Dumfries & Galloway Fife Lothian SCAN Ayrshire & Forth Valley Greater Lanarkshire WoSCAN Scotland Arran Glasgow & Clyde NOSCAN SCAN WoSCAN Scotland 2013/ / /16 Target 36

37 2015/16 Past % Performance NHS Board/Region % Performance Numerator Denominator Numerator Exclusion Denominator 2013/ /15 Grampian Highland Orkney Shetland Tayside Western Isles NOSCAN Borders Dumfries & Galloway Fife Lothian SCAN Ayrshire & Arran Forth Valley Greater Glasgow & Clyde Lanarkshire WoSCAN Scotland Source: Cancer audit - Data not shown due to small numbers * No data matching QPI criteria 90 Day Mortality 90 day mortality was added after the baseline review and it was agreed to review the data after 2 years before deciding on a target. For the 2 reporting years, the 90 day mortality rate in Scotland for elective surgery was less than 3% and all NHS Boards were under 7%. 7.0 QPI 10(ii): 90 Day Mortality Following Surgical Resection - Elective by Health Board of Surgery Grampian Highland Orkney Shetland Tayside Western Isles NOSCAN Borders Dumfries & Galloway Fife Lothian SCAN Ayrshire & Forth Valley Greater Lanarkshire WoSCAN Scotland Arran Glasgow & Clyde NOSCAN SCAN WoSCAN Scotland 2013/ / /16 37

38 2015/16 Past % Performance NHS Board/Region % Performance Numerator Denominator Numerator Exclusion Denominator 2013/ /15 Grampian * 2.9 Highland * 2.1 Orkney * - Shetland * 0.0 Tayside * 1.1 Western Isles * - NOSCAN * 2.0 Borders * 6.5 Dumfries & Galloway * 2.7 Fife * 0.0 Lothian * 0.4 SCAN * 1.1 Ayrshire & Arran * 4.1 Forth Valley * 3.6 Greater Glasgow & Clyde * 3.7 Lanarkshire * 3.4 WoSCAN * 3.7 Scotland * 2.5 Following the formal review it was agreed to adopt a target of <4% for 90 day mortality following elective surgical resection. This target will be in place for future reporting of this indicator. Emergency Surgical Resection 30 Day Mortality 9% of colorectal cancer patients receiving emergency surgical resection died within 30 days of surgery in 2015/16. This is consistent with the previous 2 years. All NHS Boards achieved target in 2015/16; an improvement over the previous 2 years QPI 10(i): 30 Day Mortality Following Surgical Resection - Emergency by Health Board of Surgery <15% Grampian Highland Orkney Shetland Tayside Western Isles NOSCAN Borders Dumfries & Galloway Fife Lothian SCAN Ayrshire & Forth Valley Greater Lanarkshire WoSCAN Scotland Arran Glasgow & Clyde NOSCAN SCAN WoSCAN Scotland 2013/ / /16 Target 38

39 2015/16 Past % Performance NHS Board/Region % Performance Numerator Denominator Numerator Exclusion Denominator 2013/ /15 Grampian Highland Orkney * * Shetland * * * - - Tayside Western Isles * * * - - NOSCAN Borders Dumfries & Galloway Fife Lothian SCAN Ayrshire & Arran Forth Valley Greater Glasgow & Clyde Lanarkshire WoSCAN Scotland Source: Cancer audit - Data not shown due to small numbers * No data matching QPI criteria 90 Day Mortality 90 day mortality was added after the baseline review and it was agreed to review the data after 2 years before deciding on a target. For the 2 reporting years, the 90 day mortality rate in Scotland for emergency surgery was less than 13%. At NHS Board level the mortality rates ranged from 0% to 19% across the 2 years QPI 10(ii): 90 Day Mortality Following Surgical Resection - Emergency by Health Board of Surgery Grampian Highland Orkney Shetland Tayside Western Isles NOSCAN Borders Dumfries & Galloway Fife Lothian SCAN Ayrshire & Forth Valley Greater Lanarkshire WoSCAN Scotland Arran Glasgow & Clyde NOSCAN SCAN WoSCAN Scotland 2013/ / /16 39

40 2015/16 Past % Performance NHS Board/Region % Performance Numerator Denominator Numerator Exclusion Denominator 2013/ /15 Grampian * 11.6 Highland * 10.0 Orkney * * Shetland * * * * - Tayside * 18.8 Western Isles * * * * - NOSCAN * 13.3 Borders * 6.7 Dumfries & Galloway * 11.1 Fife * 7.4 Lothian * 9.5 SCAN * 8.8 Ayrshire & Arran * 14.3 Forth Valley * 15.8 Greater Glasgow & Clyde * 12.2 Lanarkshire * 6.1 WoSCAN * 11.7 Scotland * 11.2 All patients with surgery related deaths are routinely discussed at local mortality and morbidity meetings where detailed clinical factors are discussed, and similarly any oncology related deaths are reviewed by cancer centres. Following the formal review it was agreed to adopt a target of <20% for 90 day mortality following emergency surgical resection. This target will be in place for future reporting of this indicator. Further information on this indicator is available at hospital level in the data tables. 40

41 QPI 11: Adjuvant Chemotherapy - Patients with Dukes C and high risk Dukes B colorectal cancer should be considered for adjuvant chemotherapy. All patients with Dukes C and high risk Dukes B colorectal cancer should be considered for adjuvant chemotherapy to reduce the risk of local and systemic recurrence. Due to the difficulties associated with accurate measurement of co-morbidities and patient fitness these cannot be utilised as exclusions within this QPI. To ensure focussed measurement and a QPI examining expected outcomes the age range of years has been selected. This represents the majority of patients and therefore provides a good proxy for access to adjuvant chemotherapy in the whole patient population. Numerator: Number of patients between 50 and 74 years of age at diagnosis with Dukes C, or high risk Dukes B, colorectal cancer who undergo surgical resection who receive adjuvant chemotherapy. Denominator: All patients between 50 and 74 years of age at diagnosis with Dukes C, or high risk Dukes B, colorectal cancer who undergo surgical resection. Exclusions: Patients who refuse chemotherapy Targets: 70% (Patients with Dukes C colorectal cancer) 50% (Patients with Dukes B colorectal cancer) Dukes C Colorectal Cancer Overall in Scotland 81% of patients in the years age group, who underwent surgical resection, received adjuvant chemotherapy in 2015/16. This is an increase from 71% in year 1. This improvement since year 1 is also evident at NHS Board level for the majority of Boards. At the baseline review post year 1, a new exclusion was added for patients who refuse chemotherapy which may have contributed to this improvement. 41

42 120.0 QPI 11: Adjuvant Chemotherapy - Dukes C by Health Board of Diagnosis % Grampian Highland Orkney Shetland Tayside Western Isles NOSCAN Borders Dumfries & Galloway Fife Lothian SCAN Ayrshire & Arran Forth Valley Greater Lanarkshire WoSCAN Scotland Glasgow & Clyde NOSCAN SCAN WoSCAN Scotland 2013/ / /16 Target 2015/16 Past % Performance NHS Board/Region % Performance Numerator Denominator Numerator Exclusion Denominator 2013/ /15 Grampian Highland Orkney * Shetland Tayside Western Isles * NOSCAN Borders Dumfries & Galloway Fife Lothian SCAN Ayrshire & Arran Forth Valley Greater Glasgow & Clyde Lanarkshire WoSCAN Scotland Source: Cancer audit - Data not shown due to small numbers * No data matching QPI criteria NHS Tayside reviewed all cases not meeting target in 2015/16 and concluded that patient co-morbidities contributed significantly to the decision making. In the majority of cases the decision to not proceed with adjuvant chemotherapy was made after discussion between the patient and oncologist. Both NHS Orkney and NHS Western Isles commented on the small numbers affecting their results. 42

43 Dukes B Colorectal Cancer There were fewer patients with Dukes B cancer in this age group, therefore some of the variation in performance of this QPI at NHS Board level may be driven by small numbers. At a national level, the target was achieved with 56% of Dukes B patients receiving adjuvant chemotherapy in 2015/16. The target was achieved nationally in each of the three reporting years QPI 11: Adjuvant Chemotherapy - High Risk Dukes B by Health Board of Diagnosis % Grampian Highland Orkney Shetland Tayside Western Isles NOSCAN Borders Dumfries & Galloway Fife Lothian SCAN Ayrshire & Arran Forth Valley Greater Lanarkshire WoSCAN Scotland Glasgow & Clyde NOSCAN SCAN WoSCAN Scotland 2013/ / /16 Target 2015/16 Past % Performance NHS Board/Region % Performance Numerator Denominator Numerator Exclusion Denominator 2013/ /15 Grampian Highland Orkney * * * * * Shetland * * * - * Tayside Western Isles * NOSCAN Borders * Dumfries & Galloway Fife Lothian SCAN Ayrshire & Arran Forth Valley Greater Glasgow & Clyde Lanarkshire WoSCAN Scotland Source: Cancer audit - Data not shown due to small numbers * No data matching QPI criteria Whilst acknowledging the impact of small numbers on these figures, several NHS Boards (NHS Grampian, NHS Tayside, NHS Ayrshire & Arran and NHS Forth Valley) reviewed the cases not meeting the target and provided valid clinical reasons including patient receiving palliative treatment, patient fitness and patient co-morbidities. At the formal review, it was agreed to amend the definition of Dukes B to include T3 tumours with extramural venous invasion. There will also be an exclusion added for patients undergoing neo-adjuvant treatment. These changes will be in place for future reporting of this QPI. 43

44 QPI 12: 30 or 90 Day Mortality Following Chemotherapy or Radiotherapy - Mortality after chemotherapy or radiotherapy with curative intent for colorectal cancer. Treatment related mortality is a marker of the quality and safety of the whole service provided by the Multi Disciplinary Team (MDT). Numerator: Number of patients with colorectal cancer who undergo neo-adjuvant chemoradiotherapy, radiotherapy or adjuvant chemotherapy with curative intent who die within 30 or 90 days of treatment. Denominator: All patients with colorectal cancer who undergo neo-adjuvant chemoradiotherapy, radiotherapy or adjuvant chemotherapy with curative intent. Exclusions: No exclusions. Target: <2% A). Adjuvant Chemotherapy 30 Day Mortality At a national level, the mortality rate 30 days after adjuvant chemotherapy was less than 1% in each of the three reporting years. Small numbers impacted the performance in a couple of NHS Boards, but generally the mortality rates were very low or zero for patients receiving this treatment type. 90 Day Mortality The reporting of 90 day mortality was added after the baseline review and, therefore, only 2 years of data are available. In each of the 2 years, the 90 day mortality rate following adjuvant chemotherapy was less than 1.5% for Scotland. B). Chemoradiotherapy 30 Day Mortality Across the 3 years in Scotland, there were 2 deaths within 30 days of receiving neoadjuvant chemoradiotherapy. 90 Day Mortality In each of the 2 years where 90 day mortality rates were recorded, less than 1.5% of patients receiving neoadjuvant chemoradiotherapy died within 90 days of receiving the treatment. 44

45 C). Radiotherapy 30 Day Mortality There were 227 patients in Scotland who received radiotherapy as a curative treatment for colorectal cancer across the 3 reporting years and all were alive at the 30 day mark. 90 Day Mortality Over the 2 reporting years, only 1 patient died within 90 days of receiving this treatment. At the formal review, the target for 30 and 90 day mortality rates for these curative treatment types was reduced from <2% to <1%. An additional category looking at mortality rates for palliative chemotherapy will be added with a target of <10%. 45

46 Clinical Trials Access to Clinical Trials is a common issue for all cancer types; therefore, a generic QPI was developed to measure performance across the country. Further details on the development and definition of this QPI can be found here. Specifically for colorectal cancer, the QPI is defined as follows and Appendix A3 contains a list of colorectal cancer trials into which patients have been recruited in Scotland during the reporting period ending March Information is shown by each Scottish Cancer Research Network (SCRN). Clinical Trials Access: Proportion of patients with colorectal cancer who are enrolled in an interventional clinical trial or translational research. All patients should be considered for participation in available clinical trials, wherever eligible. Numerator: Number of patients with colorectal cancer enrolled in an interventional clinical trial or translational research. Denominator: All patients with colorectal cancer. Exclusions: No exclusions. Target: Interventional clinical trials 7.5% Translational research 15% The aspiration is to enrol a minimum of 7.5% of patients into Interventional Clinical Trials and 15% into Translational research. Interventional Trials 8.0% % of Colorectal Cancer Patients Enrolled in Interventional Clinical Trials 7.0% 6.0% 5.0% 4.0% 3.0% 2013/ / /16 Target 2.0% 1.0% 0.0% SCRN - North & East SCRN - South East SCRN - West 2013/ / /16 No of patients Av cancer No of patients Av cancer No of patients Av cancer Target %Enrolled Network enrolled registrations enrolled registrations %Enrolled enrolled registrations %Enrolled SCRN - North & East 7.5% % % % SCRN - South East 7.5% % % % SCRN - West 7.5% % % % 46

47 Translational Trials 45.0% % of Colorectal Cancer Patients Enrolled in Translational Clinical Trials 40.0% 35.0% 30.0% 25.0% 20.0% 15.0% 2013/ / /16 Target 10.0% 5.0% 0.0% SCRN - North & East SCRN - South East SCRN - West 2013/ / /16 No of patients Av cancer No of patients Av cancer No of patients Av cancer Target %Enrolled Network enrolled registrations enrolled registrations %Enrolled enrolled registrations %Enrolled SCRN - North & East 15% % % % SCRN - South East 15% % % % SCRN - West 15% % % % The QPI targets for clinical trials are 7.5% for interventional trials and 15% for translational trials. It should be noted that these targets are ambitious, particularly with the move towards more targeted trials. All cancer patients in Scotland are considered for potential participation in the open trials currently available. However, as with other cancer specific studies, consequent to the demise of larger general trials and the advent of genetically selective trials that only target small populations of patients, many of the cancer trials that are currently open to recruitment in Scotland have very select eligibility criteria. Consequently they will only be available to a small percentage of the total number of people who were diagnosed with cancer. The number of patients screened for clinical trials is often higher than the number recruited as not all patients will pass the screening stage, however the screening phase can involve a considerable amount of time and resource. Due to the increasing complexity of trials and time burden needed to run them effectively, and a lack of clinical and research support to run such further trials, it is not currently possible to open a greater number (and thereby to have a greater scope) of available trials in Scotland. Constraints imposed by the commercial trial sponsors also limit the number of trials it is possible to open in smaller cancer centres such as those in the NOSCAN region. However a large number of feasibility requests for trials are continually being reviewed by all consultants and if an expression of interest is submitted, the chances that the site will be selected for running the trial are high. 47

48 Survival Analysis To support the national reporting of QPIs and to provide context in their interpretation, an analysis of colorectal cancer survival was undertaken. A cohort of patients diagnosed with colorectal cancer during 2010 to 2012, and registered on the Scottish Cancer Registry, was used and linked to deaths data (up to December 2015) to provide 3 years of follow up for all patients (and up to 5 years of follow up for some). There follows a series of survival curves showing the variation in survival rates for this cohort of patients by the following key criteria: age and gender screen detected or not tumour site Dukes stage deprivation category (SIMD) regional cancer network Further details on this analysis, including patient characteristics, analysis criteria and additional survival curves are available in the data tables. 1a). Survival Rates by Age Group Males Total Patients Deaths 1-year Survival (%) 3-year Survival (%) 5-year Survival (%) No. % No. % % 50 2% % 134 5% ,253 21% % ,004 33% % ,698 28% % % %

49 1b). Survival Rates by Age Group - Females Total Patients Deaths 1-year Survival (%) 3-year Survival (%) 5-year Survival (%) No. % No. % % 46 2% % 120 5% % % ,388 28% % ,478 30% % % % Figures 1a and 1b show the survival rates at 1, 3 and 5 year intervals for males and females across a range of age groups. 49

50 2). Survival Rates by Screen Detected Status Total Patients Deaths 1-year Survival (%) 3-year Survival (%) 5-year Survival (%) No. % No. % Yes 1,889 17% 340 6% No 9,068 83% % Not Known 8 0% 6 0% Figure 2 shows that survival rates are significantly improved in patients whose cancer was detected through cancer screening programmes. 50

51 3). Survival Rates by Cancer Site Total Patients Deaths 1-year Survival (%) 3-year Survival (%) 5-year Survival (%) No. % No. % Proximal colon (C18.0-C18.4) 3,927 36% % Distal colon (C18.5-C18.7) 3,313 30% % Rectum (C20) 3,096 28% % Overlapping/Unspecified colon (C18.8-C18.9) 629 6% 429 8% Figure 3 shows the 5 year survival rates by the specific colorectal cancer site. It is clear that patients with colorectal cancer categorised as overlapping/unspecified colon have significantly lower survival rates, albeit based on a smaller cohort of patients. 51

52 4). Survival Rates by Dukes Stage Total Patients Deaths 1-year Survival (%) 3-year Survival (%) 5-year Survival (%) No. % No. % A - Tumour limited to muscularis propria (musc 1,967 18% 293 5% B - Tumour invades through muscularis propria 2,734 25% % C - Regional lymph nodes positive (apical node 2,574 23% % D - Distant metastases (e.g. liver) 2,064 19% % Not Known 1,626 15% % The survival rates by stage of cancer as classified by the Dukes staging system are shown in Figure 4. As expected, 5 year survival rates decrease significantly from stage A to D. 52

53 5). Survival Rates by Deprivation Category (SIMD) Total Patients Deaths 1-year Survival (%) 3-year Survival (%) 5-year Survival (%) No. % No. % 1 - Most deprived 2,174 20% % ,337 21% % ,142 20% % ,261 21% % Least deprived 2,051 19% % The impact of deprivation on cancer survival rates is shown in Figure 5. Survival rates decrease with increasing levels of deprivation. 53