OVARIAN CANCER ANNUAL REPORT

Transcription

1 ITEM 6.2 South East Scotland Cancer Network OVARIAN CANCER ANNUAL REPORT Data collected: 1 ST JANUARY TO 31 ST DECEMBER 2011 Dr K S Fegan Consultant Gynaecological Oncologist Victoria Hospital Kirkcaldy Jackie Stevenson Cancer Audit Facilitator Victoria Hospital Kirkcaldy Jackie Stevenson Cancer Audit Page of 31 Review Date- June 2013

2 1. FOREWORD 2. LEAD CLINICIAN COMMENTS 3. SUMMARY 4. RESULTS CONTENTS Cancer Registry & Case Ascertainment Data Summary Age at diagnosis Age by stage at diagnosis Referral process - referral to first seeing a gynaecologist 1 st seen by Gynaecologist to diagnosis Diagnosis to 1 st treatment Better Cancer Care Patient being informed requires surgery to laparotomy Date decision to treat to non surgical treatment Clinical presentation & investigations Laparotomy to chemo Clinical Trials Surgical treatment - Operating Clinician Surgical treatment continued: FIGO stage by operating clinician, type of list, hospital of operation Pre-op preparation, incision, washings & ascities Cytoreductive surgery, residual disease, size of residual disease Final FIGO stage by residual disease, FIGO stage for all surgical Final FIGO stage for surgical, histology, MDM discussion Chemotherapy: types, administering hospital, post chemo surgery / debulking surgery Survival Data Executive Summary Report Summary to the acute division Clinical Governance Committee Appendix Action Plan update Appendix Action Plan / recommendations Jackie Stevenson Cancer Audit Page of 31 Review Date- June 2013

3 1. FOREWORD Fife Acute Hospitals Ovarian Cancer Audit This report relates to diagnosed with primary ovarian cancer between 1 st January 2011 and 31 st December 2011 at Forth Park Hospital, Victoria Hospital and Queen Margaret Hospital. The aim of this report is to provide a full analysis of diagnosed within 2011 and also show trends and changes in performance within Fife over previous years. Issues and Difficulties Audit process Patients are identified for this report using a variety of methods which include: Multi-Disciplinary Team meetings Tracking of all new referrals from Business Objects Gynaecological Consultants Gynaecological Nurse Specialist Pathology reports Cytology reports GRO (death) data Collection of audit data is dependent on the completion of forms by Consultants and audit staff filling in any gaps. The collection of treatment data is mainly dependent on this information being included in correspondence from the Western General and Ninewells Hospitals. This data is also collected through contact between Cancer Audit Facilitators based at these hospitals. In order to make this report more compact graphs have been produced in accordance with the clinical standards but full statistics are available if required and can be obtained from Jackie Stevenson, Cancer Audit Facilitator, Victoria Hospital, extension Datasets and Definitions The Minimum Core Data Set developed by the Scottish Cancer Therapy Network under the direction of the Scottish Programme for Clinical Effectiveness in Reproductive Health continues to be collected. Definitions (as revised) were published by SCTN in September As a consequence of the guidance issued by the Scottish Executive Health Department (SEDH) on 13 April 2005 and the development of the core cancer standards through the National Clinical Dataset Development Programme (NCDDP), waiting times fields have been amended to include recommendations made. Additional changes have been made as a result of discussion with site-specific waiting time groups and were implemented for new diagnosed from 1 July Better Cancer Care An Action Plan was launched on 27 October Central to this is the development of a comprehensive programme of work to assure the quality of care delivered. Two key and complimentary strands of this work are assuring compliance with national clinical standards and guidelines through robust clinical governance and delivery of 2 new cancer targets which are reported on a monthly basis. Full details are on page 14. Measures, Analysis and Reporting Data has been analysed in line with national standards: Clinical Standards Board for Scotland (now QIS) and Our National Health. Jackie Stevenson Cancer Audit Page of 31 Review Date- June 2013

4 2. Lead Clinician Comments The incidence of ovarian cancer varies from year to year because of relatively small numbers, but is essentially unchanged. During 2011, consistent with previous years, very few women under 40 years of age were diagnosed with ovarian cancer and 68% were diagnosed at over 60 years of age. However 74% of over 60 years of age presented with late stage disease (77% for 2010). The median time to being seen by a gynaecologist has reduced considerably to 12 days from 21 in 2010 but this figure is in keeping with previous years although the range has varied. The source of referrals is consistent with last year but there is a slight decrease in the number of GP urgent suspicious referrals, 91% compared to 94% in The number of referred to Gynaecology by their GP has increased marginally on However GP referrals to Gastroenterology have increased by 5% whilst General Surgery referrals have reduced by 8%. The median number of days from seeing a gynaecologist to diagnosis continues to fall but the range has increased although there were justifiable reasons for the 3 with the prolonged waits. All eligible women (by the new waiting time definitions) were treated within 62 days of referral or 31 days of diagnosis, whether this treatment was surgical or non-surgical. All women received chemotherapy within the required 8 weeks postoperatively. 42% of women had primary surgery as 1st treatment with 32% having neo-adjuvant chemo followed by delayed primary surgery (52% and 38% for 2010 respectively). The number of receiving hormone therapy as1st treatment has increased by 13%. This is a result of women presenting with late stage disease and co-morbidities preventing chemotherapy being the appropriate 1 st treatment. The median number of days for surgery within the recommended 14 days remains the same as last year although the range has increased with appropriate reasons documented for the 3 with the prolonged waits. 1 patient had surgery performed by a general gynaecologist but this was an incidental finding and explains why no chest imaging was performed. 1 patient had surgery performed by a special interest gynaecologist for suspected endometrial cancer. Again this accounts for no chest imaging being done, pfannenstiel incision being used and no omentectomy performed. 1 patient had a laparotomy but was found to have unresectable disease and had chemotherapy as 1 st treatment. Out of the 8 who had neo-adjuvant chemo as 1 st treatment 2 were unsuitable for delayed primary surgery with the remaining 6 receiving surgery performed by the appropriate gynaecological surgeon. 5 of the delayed primary surgeries were performed in Fife and one in Edinburgh. For both primary surgery and delayed primary surgery, where applicable, washings were sampled and the size of residual disease recorded with the exception of 1 delayed primary surgery patient who was operated on in Edinburgh. 100% of women had Ca125 measured and were discussed at MDM in Edinburgh or Tayside. Unfortunately neither of the Fife consultants who managed the within this report are available to comment on the report findings. I am therefore providing this commentary in my capacity as the new Gynae Cancer Lead although I do not know these and was not involved in their care / management. Dr K S Fegan Gynae Cancer Lead NHS Fife Jackie Stevenson Cancer Audit Page of 31 Review Date- June 2013

5 3. Data Summary Sheet Ca125 (pre op) USS/CT Chest X-ray / CT chest Tested 28 Done 28 Done 26 Not tested 0 Not done 0 Not done 2 Total Mode of diagnosis Primary Surgery Washings / Ascites (surgical ) Definitve Gynaecological Surgery 13 gynaecological laparotomy 13 Sampled 12 Presumptive 4 No surgery 15 Not Sampled 1 Post Mortem 0 Not recorded 0 Biopsy 11 Total Vertical Incision Type of list Hysterectomy Midline 6 Elective 11 Total / sub total 7 Paramedian 6 Emergency 2 No hysterectomy 1 Pfannentiel 1 No surgery 15 Fertility preserving surgery 1 No surgery 15 Not recorded 0 No surgery 15 Not recorded 0 Total Oophorectomy Omentectomy Resdiual Disease Unilateral 4 Done 8 None 9 Bilateral 8 Omental Biopsy 4 Yes, <1cm 0 Ovarian biopsy (intention to treat) 1 Not performed 1 Yes, 1-5 cm 2 Not performed 0 No surgery 15 Yes, > 5cm 2 No surgery 15 No surgery 15 Not recorded 0 Total Clinical FIGO stage Final FIGO Stage First treatment 1A 4 1A 4 Gynaecological Surgery 12* 1B 1 1B 1 Declined treament 1 1C 1 1C 0 Chemotherapy 9 2A 0 2A 0 Died before treatment 1 2B 0 2B 0 No active treatment 0 2C 2 2C 2 Hormones 5 3A 2 3A 2 3B 0 3B 1 3C 3 3C Not recorded 0 Not recorded 0 No surgery 15 Inapplicable 1 Total * 1 patient was found to have unresectable disease at laparotomy so went on to have chemotherapy as 1 st treatment. Jackie Stevenson Cancer Audit Page of 31 Review Date- June 2013

6 Data Summary Sheet (cont) Cellular Differentiation Histopathological type Grade I 1 Epitheliel borderline 6 Grade II 0 Ep ca - serous 16 Grade III 19 Ep ca - mucinous 1 Borderline 6 Ep ca - endometroid 0 Anaplastic 0 Ep ca - clear cell 1 Ascitic Fluid only 2 Ep ca - undiff 0 No histological sample 0 Ep ca - mixed 1 Not recorded 0 Ep ca - unspecified 2 Sertoli leydig sex cord 1 Other 0 Fluid - type unknown 0 No histological sample 0 Total Jackie Stevenson Cancer Audit Page of 31 Review Date- June 2013

7 4. RESULTS NHS Fife Cancer Registry The 2010 Cancer Registry figure, as published by ISD, is 42 with the mean figure for the period 1997 to 2010 being 37. Year Registration Figure MEAN 37 Fife audit case ascertainment Reporting Period Patients 2002/ / / / MEAN 35 Please note that Cancer Registry statistics are based on cancer incidence dates (first presentation) but Fife audit case ascertainment figures are based on date of diagnosis of primary ovarian cancer. Jackie Stevenson Cancer Audit Page of 31 Review Date- June 2013

8 There were 28 diagnosed with ovarian cancer between 01/01/2011 and 31/12/2011 Age of at diagnosis, N=28 Cumulative no of % pts < > The youngest patient was 25 years old and the eldest was 88 years old Graph1: Age of Patient at Diagnosis % of % % Cumulative 0.0 < >80 Age Mean = 65 Median = 67 Range = days Report period Mean Median Range Jackie Stevenson Cancer Audit Page of 31 Review Date- June 2013

9 Graph 2: Age by cancer stage number of a 1b 1c 2a 2b 2c 3a 3b 3c 4 not staged stage < >80 Jackie Stevenson Cancer Audit Page of 31 Review Date- June 2013

10 1. Referral process 2005 commitment: 100% of all will receive treatment within two months (62 days) of GP referral. For who have an incidental finding of ovarian cancer, the referral date used is the date first seen by a Gynaecologist which may not be the first hospital clinician seen. These were diagnosed with ovarian cancer whilst being investigated / treated for the following reasons, N=5: suspected recurrence of a previous colorectal cancer (2 ) endometrial cancer severe endometriosis urinary incontinence 2 Patients were not seen by a Gynaecologist: 1 patient was diagnosed by General Medicine, referred directly to Gynae MDM and seen by Oncology. 1 patient was being treated for another cancer, was discussed regularly at Gynae MDM but was never seen by a gynaecologist and sadly died before treatment for ovarian cancer. Time from initial referral to date first seen by Gynaecologist : N=26 who saw a Gynaecologist, including the 5 who had an incidental finding of ovarian cancer Graph 3: Time from initial referral to first seeing a Gynaecologist % % Total % Cumulative Total No of days Median = 12 days Range = 0 to 48 days Report period Median Range Jackie Stevenson Cancer Audit Page of 31 Review Date- June 2013

11 Referral process continued a) All referrals N = 28, split by route by which they were referred for investigation of signs or symptoms that lead to a diagnosis of cancer. 10.7% Source of referral - all referrals 3.6% GP referral letters 17.9% 42.9% GP admissions to hospital Incidental Finding Review Other 25.0% 91% of GP referral letters (to any specialty) were referred as urgent suspicious. (2010 = 94.1%) b) The following chart demonstrates the various specialties to which the have been referred by their GP, n=12. GP referrals split by specialty 8.3% 8.3% 16.7% 66.7% Gynaecology General Medicine General Surgery Gastroenterology c) The following chart demonstrates the various specialties to which the have been referred direct to hospital as an emergency by their GP, n=7. GP admissions by Specialty 28.6% General Medicine General Surgery 71.4% Jackie Stevenson Cancer Audit Page of 31 Review Date- June 2013

12 Time from date first seen by Gynaecologist to diagnosis Excludes 1 patient who died before treatment 1 patient who declined all active treatment and had Best Supportive Care 1 patient not seen by a gynaecologist (referred direct to MDM by General Surgeon) N=25, all who saw a Gynaecologist, including 4 who were diagnosed before being seen by a gynaecologist. Graph 4: Time from date first seen by a Gynaecologist to diagnosis % % Total % Cumulative Total 0.0 < >56 number of days Median = 8 days Range = -33 to 92 days Report period Median Range to to to 96 Summary of diagnosed before seeing a gynecologist, N=4.-33 days thought to have recurrence of colorectal cancer, biopsy confirmed incidental finding of ovarian cancer and referred to gynaecologist 26 days later -17 days admitted to General Surgery referred to gynae, biospy performed and MDM discussed prior to being seen by gynaecologist -7 days referred to Physicians imaging performed and ascites tapped prior to referral and being seen by gyanecologist. -3 days admitted to Physicians imaging performed and pleural fluid tapped prior to referral and being seen by gyanecologist. Summary of longest waits, N=3 92 days anaesthetic assessment required and referred for investigation of increased CEA. 62 days lesion behind kidney referred for investigation by Urologists and discussion at Urology MDM. 58 days initially managed conservatively but due to increase in size of cysts listed for surgery, moderate RMI. Jackie Stevenson Cancer Audit Page of 31 Review Date- June 2013

13 Time from diagnosis to first treatment Excludes 1 patient who died before treatment 1 patient who declined all treatment - Best Supportive Care. N=26 Graph 5: Diagnosis to 1 st treatment % total % Total % Cumulative Total days Graph 6: 1 st treatment type 50.0 % % 0.0 Primary surgery Neo-adjuvant Chemo Hormones Primary chemo Best supportive care Died before treatment Treatment type Jackie Stevenson Cancer Audit Page of 31 Review Date- June 2013

14 Better Cancer Care An Action Plan was launched on 27 October 2008 and 2 new cancer waiting times targets were introduced: Target 1 62-day target to treatment for all referred urgently with a suspicion of cancer. These are subject to both the 62 day target (i.e. referral to 1 st treatment) and 31 day target (i.e. date decision to treat to 1 st treatment). Target 2 31-day target from decision to treat to first treatment for all diagnosed with cancer irrespective of their route of referral. Date decision to treat to 1 st treatment separate cohort of from 62 day pathway. Graph 7: 62 day pathway, N=16 (all met the target) day target (DTT to 1st tx) 62 day target (ref to 1st tx) % % Total 62 day tgt % Total 31 day tgt >62 No of days Graph 8: 31 day pathway, N=12 (all met the target) % % Total 31 day tgt % Cumulative total 31 day tgt no of days Jackie Stevenson Cancer Audit Page of 31 Review Date- June 2013

15 CSBS 9. Essential criteria: 10 Working day maximum between a patient being informed she requires primary surgery and date of surgery Agreed 14 day maximum wait between decision to perform laparotomy and day of procedure Date of decision to treat to date of surgery. 13 eligible, including 1 patient who had a primary laparotomy but the disease was unresectable so she had neo-adjuvant chemo as 1 st treatment: 14 did not have a laparotomy (7 had neo-adjuvant chemo, 1 patient had primary chemo, 1 patient declined treatment / BSC, 5 had hormones. 1 patient died before treatment N=13 all Patients seen by a Gynaecologist and had a primary laparotomy. Graph 9: Time from decision to treat by Gynaecologist to primary laparotomy, n= % % Total % Cumulative Total >56 number of days Median = 13 days Range = 0 to 92 days Report period Median Range to to to 96 Summary of longest wait: 92 days anaesthetic assessment required and referred for investigation of increased CEA. 62 days lesion behind kidney referred for investigation by Urologists and discussion at Urology MDM. 58 days initially managed conservatively but due to increase in size of cysts listed for surgery, moderate RMI. Jackie Stevenson Cancer Audit Page of 31 Review Date- June 2013

16 Date of decision to treat by gynaecologist or oncologist to non surgical first treatment First treatment includes chemotherapy, neo-adjuvant chemotherapy, best supportive care, hormones. 13 eligible 13 had a primary laparotomy as intended 1 st first treatment (including 1 unresectable). 1 patient died before treatment 1 patient declined all treatment / BSC. Graph 10: Time from decision to treat by Gynaecologist to Non-surgical primary treatment, n= % % Total % Cumulative Total number of days Median = 3 days Range = 0 to 13 days Jackie Stevenson Cancer Audit Page of 31 Review Date- June 2013

17 Clinical presentation of Clinical Presentation % of total Discharge Menstrual irregularity PCB PMB Abnormal cytology Abdominal swelling Abdominal pain GI upset Urinary symptom Weight loss DVT Other* Other* dyspnoea (shortness of breath) fatigue Jackie Stevenson Cancer Audit Page of 31 Review Date- June 2013

18 Investigations The following investigations should be organised as a minimum: (a) CA 125 level for all. (b) Abdominal and pelvic ultrasound and/or CT scan and chest imaging for all (excluding Borderline pt1a tumours). Ca125 (all tumour types) N % Performed Not Performed 0 0 Not Recorded 0 0 Total N = all tumours (excl Borderline pt1 tumours) % N = all Borderline pt1 tumours % Chest Imaging Performed Not Performed 1* 4.3 1** 20 Not Recorded Total * incidental finding, thought to be severe endometriosis ** moderate MRI N=all tumours (excl Borderline pt1 tumours) % N = all Borderline pt1 tumours % Imaging - US/CT/MRI Performed Not Performed Not Recorded Total Jackie Stevenson Cancer Audit Page of 31 Review Date- June 2013

19 Treatment Chemotherapy (Waiting Times) SIGN 75 Guideline 5.2: Chemotherapy should be started no later than eight weeks after primary surgery. Waiting time from date of primary surgery to start of chemotherapy 1 patient died before treatment 1 patient had Best Supportive Care 5 had hormones as 1 st treatment 7 had neo-adjuvant chemotherapy 8 had surgery but no chemotherapy N=6, Patients who had primary surgery followed by chemotherapy, including the patient who had unresectable disease at laparotomy. Graph 11: Time from primary surgery to Chemotherapy, n= % % Total % Cumulative Total no of days Median = 41 days Range = 23 to 50 days Report period Median Range to to to 105 Jackie Stevenson Cancer Audit Page of 31 Review Date- June 2013

20 Percentage of Patients entering clinical trials must be recorded N = 14 ( who had Chemotherapy) No participated in clinical trials of 1 st line therapy. Jackie Stevenson Cancer Audit Page of 31 Review Date- June 2013

21 4. Treatment (Surgical) All with a suspected diagnosis of Ovarian Cancer should be operated on only by a designated Gynaecological Surgeon or referred to a Gynaecological Oncologist. 1 patient died before treatment 14 did not have surgery N=13 all Patients who had a primary laparotomy (incl 1 patient found to have unresectable disease at laparotomy) 12/13 (92.3%) surgical were operated on by a designated gynaecological surgeon NACT who had delayed primary All laparotomy n=13 surgery n=6 Clinician type % % Sub-specialty trained Special Interest Gynaecologist 11* General Gynaecologist General Surgeon Total * Includes 4 joint procedures with General Surgeon Consultant Title No of operated on % No of operated on % Dr C Martin Sub Specialty Trained Gynaecologist Dr G Walker Sub Specialty Trained Gynaecologist Dr J Macnab Special Interest Gynaecologist Dr S Pinion Special Interest Gynaecologist Dr C McKinley General Gynaecologist Total Jackie Stevenson Cancer Audit Page of 31 Review Date- June 2013

22 For all surgical N=13 Surgical FIGO stage by operating Consultant Surgical Patients DPS stage Stage CM SP JM CMcK CM GW SP 1A 3 1 1B 1 1C 1 2A 2B 2C 2 3A 1 1 3B 3C Total NACT who had delayed All laparotomy n=13 primary surgery n=6 Type of list % % Emergency Elective Not recorded Hospital of operation % % Forth Park Hospital, Kirkcaldy Queen Margaret Hospital, Dunfermline Victoria Hospital, Kirkcaldy New Royal Infirmary, Edinburgh 1* *Transferred to RIE for surgery due to IVC compression. 2/8 neo-adjuvant chemo diagnosed in 2011 were not suitable for delayed primary surgery. 2/8 neo-adjuvant chemo diagnosed in 2011 had delayed primary surgery performed in 2012 at Victoria Hospital Jackie Stevenson Cancer Audit Page of 31 Review Date- June 2013

23 All considered suitable for surgery will have appropriate pre-operative preparation. Preparation to include; chest imaging, DVT prophylaxis and antibiotic prophylaxis n= 13 (Patients who had surgery, incl Borderline pt1 tumours) Pre-op preparation Received Not Received Not recorded % Number of % Number of % Chest imaging DVT Prophylaxis Antibiotic prohylaxis no chest imaging 1 patient thought to have endometriosis and 1 had a moderate RMI antibiotic prophylaxis not recorded no evidence found. All considered suitable for primary surgery will have an appropriate surgical procedure carried out A vertical incision should be made. NACT who had delayed All laparotomy n=13 primary surgery n=6 Incision % % Midline incision Paramedian incision Pfannenestiel / Low transverse 1* * This patient was thought to have endometrial cancer Washings should be taken or ascitic fluid sent for cytology N=13 (all Patients who had primary surgery) Washings & Ascites % of total % of Sampled Not Sampled 1* Inapplicable Not recorded Total * Unresectable disease at laparotomy Jackie Stevenson Cancer Audit Page of 31 Review Date- June 2013

24 Primary cytoreductive surgery should be attempted and include a total or subtotal hysterectomy and bilateral salpingo-oophorectomy. Including 1 patient found to have unresectable disease at laparotomy NACT who had delayed primary All laparotomy n=13 surgery n=6 Total/Subtotal Hysterectomy & Oophorectomy % of % of with uterus present pre op with no uterus present pre op received total hysterectomy received sub total hysterectomy Fertility preserving surgery (under 30 no hysterectomy) patient did not have a hysterectomy 1* with both ovaries pre op received bilateral salpingo-oophorectomy received unilateral salpingo-oophorectomy Ovarian biopsy only (intention to treat) did not received salpingo-oophorectomy with reason documented ** 16.7 Patients had omentectomy Patients had omental biopsy Patients did not have an omentectomy or biopsy performed 1* 7.7 1** 16.7 * No hysterectomy - unresectable. No omentectomy thought to be endometrial cancer **No omentectomy for NACT patient no omental tissue evident. No salpingo-oophorectomy no identifiable ovarian tissue. A record of residual disease should be made. NACT who had delayed N=13 (all who had primary surgery) primary surgery. N =6 Residual Disease % of Number of % of Patients had no residual disease Patients had residual disease did not have a record of their residual disease N=4 (all with residual disease) N=5 size of deposits % Number of % of < 1 cm cm > 5 cm not recorded Total Jackie Stevenson Cancer Audit Page of 31 Review Date- June 2013

25 Final FIGO stage by residual disease 13/28 (46.4%) had primary surgery 9/13 (69.2%) who had surgery did not have residual disease N=4 (laparotomy with residual disease) N=5 (NACT) Final FIGO Stage 1a 1b 1c 2a 2b pts with residual disease 2c 1 1 3a 3b Size of residual disease Number of pts with residual disease Size of residual disease < 1cm 1-5 cm > 5cm < 1cm 1-5 cm > 5cm Not recorded 3c Total Surgical (clinical) pathological stage to be recorded in case notes NACT who had delayed N=13 (all who had surgery) primary surgery. N =6 Surgical Figo Stage Number % Number % 1A B C A B C A B C Not recorded Jackie Stevenson Cancer Audit Page of 31 Review Date- June 2013

26 Final FIGO stage as documented by Multi Disciplinary Meeting (MDM) N= 28, all Final FIGO Stage Number % 1A B C A B C A B C Not recorded Inapplicable 1* 3.6 * Patient had a biopsy only and received Best Supportive Care at home. Essential criterion: Pathology - a standard minimum pathological report should be issued to include type, sub-type and ideally grade of disease. N=28 all with histology (incl. ascites, pleural fluid, biopsies, surgery) Type sub type recorded % Recorded % Not recorded 0 0.0% Total with histology % N=26 all with histology (incl. ascites, pleural fluid, biopsies, surgery) Grade of disease Fife % Recorded % Inapplicable (dysgerminoma or insufficient tissue) 0 0.0% Not recorded 2* 7.1% Total with histology % * Diagnosed by ascites only not graded Tumour histopathology should be undertaken or reviewed by a consultant Pathologist who specialises in Gynaecological Pathology 28/28 (100%) had their pathology discussed at a MDM 27 discussed at MDM in Western General Hospital, Lothian 1 patient discussed at MDM in Ninewells Hospital, Tayside Jackie Stevenson Cancer Audit Page of 31 Review Date- June 2013

27 5. Treatment (Chemotherapy) First line treatment should include a platinum compound. Excluding 1 patient died before treatment 1 patient refused all treatment / BSC 6 had a Borderline tumour. 6 had no chemo due to co-morbidities (1 x surgery only, 5 x hormone treatment) N=14 all eligible. All who received chemotherapy except with Borderline tumours / refused treatment / no histology 8 received neo-adjuvant chemo 1 patient received primary chemo 5 received adjuvant chemo Chemotherapy type % Platinum alone Platinum & Taxane Other Total Hospital where Chemotherapy is administered N=14 Patients receiving Chemotherapy Platinum only % of total Platinum & Taxane % of total Total % Hospital Edinburgh Cancer Centre (WGH) Ninewells Total Jackie Stevenson Cancer Audit Page of 31 Review Date- June 2013

28 Ovarian Cancer Survival Data by FIGO Stage (excluding borderline tumours, who died before treatment or declined treatment) Diagnosed in 2006 Total number of % to 6 months % 0-12 months % 2yr %3yr %4yr Totals % Jackie Stevenson Cancer Audit Page of 31 Review Date- June 2013 %5yr Stage 1 & % % % % % % Stage 3 & % 53.80% 30.80% 15.40% 15.40% 15.40% No stage % 0.00% 0.00% 0.00% 0.00% 0.00% Total % 56.50% 43.50% 34.80% 34.80% 34.80% Diagnosed in 2007 Total number of % 6 months % 0-12 months % 2yr %3yr %4yr Stage % 83.30% 83.30% 83.30% 75.0% Stage % 71.40% 42.90% 7.10% 7.1% No stage % 36.40% 36.40% 9.10% 9.1% Totals % 64.90% 54.10% 32.40% 29.7% Diagnosed in 2008 Total number of % 6 months % 0-12 months % 2yr % 3 yr Stage % 71.40% 71.40% 71.43% Stage % 50.00% 27.80% 16.67% No stage % 20.00% 0.00% 0.00% Totals % 50.00% 33.30% 26.67% Diagnosed in 2009 Total number of % 6 months % 0-12 months % 2 year Stage % % % Stage % 60.00% 20.00% No stage % 50.00% 12.50% Totals % 63.60% 31.82% Diagnosed in 2010 Total number of % 6 months % 0-12 months Stage % 90.0% Stage % 58.8% No stage % 40.0% Totals % 65.6% Diagnosed in 2011 Total number of % 6 months Stage % Stage % No stage 0 0.0%

29 Ovarian Executive Summary Investigations Year 1 Year 2 Year 3 Year 4 Year 5 Year 6 Year 7 Year 8 Year 9 Year 10 Percentage with CA125 level recorded 88% 100% 97% 93% 100% 100% 95% 96% 93% 100% Percentage receiving either abdominal and pelvic ultrasound MRI or CT scan 91% 100% 100% 93% 97% 100% 100% 100% 100% 100% Treatment (Surgical) All with suspected diagnosis should be operated on by a designated Gynaecological Surgeon or referred to a Gynaecological Oncologist 100% 100% 97% 81% 97% 96% 88% 76% 100% 92% Preparation to include pre-treatment CXR (surgical ) 85% 82% 84% 88% 90% 96% 100% 100% 86% 85% Treatment (Chemotherapy) Percentage receiving platinum compound 100% 100% 100% 89% 95% 100% 89% 93% 100% 100% Waiting Times Percentage within 2 months of initial referral (2005 commitment) % 64% 85% 63% 73% 71% 75% 100% Percentage operated on within 10 days of decision to treat by Gynaecologist % 48% 46% 29% 36% 30% 44% 54% Percentage receiving Chemotherapy within 8 weeks of surgery % 82% 88% 94% 83% 82% 81% 100% Jackie Stevenson Cancer Audit Page of 31 Review Date- June 2013

30 Appendix ACTION PLAN no update available Key: Priority *** High ** Medium * Low Identified Challenge Priority Lead Responsibility Recommendation 1 Key Milestones Cost Comments Improve referral process for women with?ovarian cancer Improve awareness of ovarian mass/cancer as cause of abdominal swelling/gi symptoms amongst general practitioners Med Dr Pinion Time (SP) Consider implications of recent controversial NICE guideline. Draft Fife guideline prepared, for consultation with relevant specialties/gps Recommendation 2 Improve internal referral process for women referred initially to other specialties Recommendation 3 Med Dr Pinion Done (Depends on need for ethical approval) Time (SP/other staff) Paper Remind consultants/trainees of referral process? pilot a symptom questionnaire for women over 50 attending gastroenterology service Develop and implement guideline for investigation of ascites/paracentesis Med Dr Pinion August 11 Time (SP) Agreed in consultation with radiology/cancer leads /medicine/ surgery/ gastroenterology. On intranet. Jackie Stevenson Cancer Audit Page of 31 Review Date- June 2013

31 Current ovarian cancer patient pathway Patient diagnosis Biopsy Ca125 / cytology / scan Decision for therapy Follow up only Best supportive care Staging laparotomy Neoadjuvant chemotherapy Delayed primary surgery Palliative primary chemotherapy Adjuvant chemotherapy x6 Adjuvant chemotherapy x3 Jackie Stevenson Cancer Audit Page of 31 Review Date- June 2013