Scottish Audit of Head and Neck Cancers. A Prospective Audit

Transcription

1 Scottish Audit of Head and Neck Cancers Steering Group Scottish Audit of Head and Neck Cancers A Prospective Audit Report Edited by David Loeb and Tracey Rapson Statistical Analysis by Tracey Rapson, ISD Scotland Disclaimer : The views expressed are those of the authors. Project funded by the Clinical Resource and Audit Group, Scottish Executive Health Department, through the Scottish Cancer Therapy Network. EDINBURGH 2004

2 Information Services, NHS National Services Scotland 2004 Brief extracts from this publication may be reproduced provided the source is fully acknowledged. Proposals for reproduction of large extracts should be addressed to: Cancer Information Programme Epidemiology and Statistics Group (ESG) Information Services (ISD) NHS National Services Scotland Gyle Square 1 South Gyle Crescent Edinburgh EH12 9EB Internet edition (click on Information; see under Publications) Designed and typeset in Edinburgh by David Loeb at Information Services, NHS National Services Scotland. ii

3 Contents Acknowledgements...iv Foreword... v Executive Summary... vii 1 Introduction by Gerry Robertson Methodology by Gerry Robertson Susan Harvey, and Tracey Rapson Epidemiology by Gerry Robertson, David Soutar, and David Hole Risk Factors by Gerry Robertson, David Soutar, and David Hole Presenting Signs and Symptoms by Gerry Robertson and Tracey Rapson Waiting Times by Susan Harvey and Gerry Robertson Diagnosis and Staging by Neil Corrigan and Andrew Carton Pathology by Kathryn McLaren and Torquil MacLeod Treatment 9a Surgery by Kenneth MacKenzie b Reconstructive Services by J Devine, Gerry Robertson, and David Soutar c Radiotherapy and Brachytherapy by David Hurman and Gerry Robertson d Chemotherapy by Dr Janet Ironside Supportive Care by Mary Wells Survival by Tracey Rapson Appendices 1 National Steering Group Committee Contributing hospitals Data collection proformas Results of multivariate survival analysis Surgical procedures for each stage; by subsite iii

4 Acknowledgements This project would not have been possible without the willingness of clinicians throughout Scotland involved in the care of patients with Head and Neck Cancers to have their work audited. Their enthusiasm and encouragement to raise standards is evident in the attendance at meetings and in the additional work undertaken completing data collection forms on top of heavy workloads. We are indebted to them. Thanks go to the staff of the hospital records departments who facilitated data access. The following changes of name have occurred since this report was written: the Common Services Agency for NHSScotland is now known as NHS National Services Scotland Information and Statistics Division is now known as Information Services; it continues to use the acronym ISD. It is part of NHS National Services Scotland Scottish Cancer Intelligence Unit is now part of the Epidemiology and Statistics Group (ESG) at ISD iv

5 Foreword The Scottish audit of head and neck cancers has involved a considerable amount of effort on the part of those involved in the diagnosis and treatment of these cancers. Careful collection and analysis of data has been essential to the production of this report, and all who have participated in this process should feel highly satisfied with the excellent outcome of their work. The report raises a number of issues. Five-year survival from these cancers has not improved significantly over the past two or three decades, although survival at one year for some of the cancers is indeed better. This improvement is almost certainly due to better supportive care during treatment. The report once again confirms the importance of smoking, high alcohol consumption and socio-economic deprivation as powerful risk factors for these cancers, and the audit underlines the importance of tackling these issues as an important way to prevent them arising in many of the sites in the head and neck. Any time an audit of cancer treatment across several centres is undertaken it is almost inevitable that variations in clinical practice will be identified. This audit is no exception. There are clearly differences across Scotland in how patients are investigated, how pathologists assess the spread of the tumour and how surgeons, clinical oncologists and medical oncologists treat the patients. There are a range of radiotherapy schedules in use, and the clinicians themselves have concluded that there is a need to agree protocols and policies so that patients with similar cancers and risk factors across Scotland might all receive treatment which gives them the best possible chance of a cure. The variation in approach to treatment is matched by variations in how patients symptoms are assessed for supportive care. Many patients do not have assessments of pain, nutritional status or the need for speech therapy. Head and Neck Cancers is an extremely complex range of conditions for which multi-disciplinary care has long been recognised as being essential to provide good survival and good quality of life. The authors of this report have concluded that too much information is unrecorded and hence a fragmented approach to care is likely. The incidence of head and neck cancers is increasing and we need urgently to do more, not only to prevent them occurring but also to ensure that they are treated effectively. This audit is an excellent starting point for a Scotland-wide effort aimed at achieving better control of this cancer in the years to come. Clinicians across Scotland need to be supported in their attempts to agree common protocols based on best available evidence of outcome and they need support in further peer-reviewed audits to ensure that all patients in Scotland have access to the best available treatment. Harry Burns Director of Public Health Greater Glasgow NHS Board January 2004 v

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7 Executive Summary Methodology A multidisciplinary National Steering Group Committee under the Chairmanship of in conjunction with the Clinical Resource Audit Group (CRAG) of the Scottish Executive Health Department was set up to oversee the project and met regularly. The aim of this 3 year project was to review the referral, investigation, treatment, and follow-up of patients with head and neck cancers within Scotland, and to audit the findings in terms of outcome. The project was a prospective population-based audit of all head and neck cancers in Scotland from 1 September 1999 to 31 August 2001 with a minimum of one year followup on each patient. The majority of the data were collected by the data managers. QA of 10% of all data collection forms was assessed by a member of SCTN staff and found to be excellent. 77 % of expected cases of head and neck cancer-based on SMR6 cancer registration figures (ISD Scotland) were registered in the audit. Epidemiology Approximately 1000 new cases are identified in Scotland each year.the majority of cancers (87%) are squamous cell carcinomas (SCC). Adenocarcinomas are mainly found in salivary glands. 31% of tumours arise in the laryngeal region, 25% in the oral cavity, 20% the oropharynx, and 6% in the hypopharynx. Male to female ratio is 2.45:1. 60% of patients are in the age group. 197 patients in the under 50 year age group have been identified. These patients have tumours arising more commonly in the oral and oropharynx region than in the larynx and hypopharynx. 70% of patients are in two of the WHO performance status categories normal activity or restricted strenuous activity. WHO performance status may not be the best index to assess how patients may benefit from radical therapy. There is no recorded change in survival between 1970 and vii

8 Risk factors 83% of all patients, 81% of those developing oral cancers, and 93% of those developing laryngeal cancers, were current or previous smokers. Fewer females than males smoked. The majority of smokers were in the 45+ age group 38% admitted to being problem drinkers. (The audit questionnaire was not designed to identify binge drinkers.) There were more male problem drinkers than female ones. Deprivation appears to have a role in the development of laryngeal, oral and oropharyngeal carcinoma. More patients with stage 3 & 4 disease live in deprived areas 5 th quintile. Presenting signs and symptoms Presenting symptom Tumour site % of patients Hoarseness Larynx 82.0 Pain/discomfort Oral 40.0 Oropharynx 54.6 Larynx 25.6 Nasopharynx 41.2 Hypopharynx 46.3 Lump in neck Oropharynx 22.2 Dysphagia Oropharynx 25.0 Larynx 16.0 Ulceration Oral 52.9 Oropharynx 19.6 Waiting times Time from referral letter arriving at hospital to first clinic attendance median 14 days Time from being seen at hospital to diagnosis median 9 days Time from diagnosis to primary surgery median 32 days. Time from surgery to postoperative radiotherapy median 51 days. Time from diagnosis to radiotherapy if there is no indication for radical surgery median 63 days viii

9 Diagnosis and staging Computed tomography (CT) is most commonly used for locoregional staging Chest x-ray (CXR) is most commonly used for chest staging Increasing availability of magnetic resonance imaging (MRI) and interest in ultrasound are expected to have had an impact on the choice of imaging modalities employed Pathology Degree of differentiation of SCC varied according to site of tumour and regional location in Scotland. Pathologists tend not to comment on differentiation when they receive only a biopsy specimen. 30% of cases treated by radical surgery had a neck dissection. Incidence of neck dissections varied regionally, from 1 5.9% (Tayside) to 36.5% (Greater Glasgow). On average 63.8% of those having a neck dissection had lymph node involvement; range 48.3% (Forth Valley) 85.7% (Dumfries). 32.5% of patients having a neck dissection were found to have nodal involvement with extra capsular spread (ECS): highest incidence of ECS (42%) in those with oropharyngeal and hypopharyngeal cancer. On average, 10.7% of excision margins were close and 8.9% were involved. 40% of excision margins were not commented on. Surgery 1039 (54.4%) of patients registered in the audit had some form of surgery. 92.5% were treated with curative intent. The percentage of patients who received surgery varied significantly by health board of residence, indicating a possible difference in treatment strategies between health boards. Although known to be a prognostic factor, blood loss was poorly recorded. Reconstructive services The audit implies that Grampian, Orkney & Shetland, Highland & Western Isles, and Tayside do not offer a comprehensive surgical reconstructive service for patients with head and neck cancer. There is wide variation in the type of reconstruction relating to tumour T stage and therefore the extent of surgery. Ayrshire & Arran, Highland & Western Isles, and Lanark appear more likely to use free tissue transfer than other boards in treating T1 tumours. Further investigation into this state of affairs is required to establish if this is genuine and whether or not further centralisation is required for reconstructive services. ix

10 Radiotherapy and Brachytherapy Overall, 64% of Head and Neck Cancers patients in Scotland were referred for radiotherapy Radiotherapy is delivered at five centres in Scotland. It is delivered at Cumberland Infirmary for the 0.8% of cases who live close to the Scottish English border. One independent centre has now been closed. Radiotherapy is used as unimodality therapy for those with early disease and in combined therapy for those with advanced disease. 83% of patients in Scotland were treated by one of five radiotherapy treatment schedules: radical: 5400 cgy in 20 fractions (#) over 28 days; 6000 cgy in 25# over 35 days; 6600 cgy in 33# over 45 days post-op: 5000 cgy in 20# over 28 days ; 6000 cgy in 30# over 42 days. 65% of patients had at least one unscheduled, uncompensated interruption (gap) in their treatment schedule. 54% of gaps were due to machine servicing. Brachytherapy is used very occasionally, at one centre, to treat patients with advanced tongue tumours. Chemotherapy 13.7% of patients registered in the audit received chemotherapy. 83.6% were given it as part of combined modality treatment with radical intent. 16.4% of those receiving chemotherapy were given it with palliative intent. Platinum-containing regimens were used most frequently. The morbidity associated with chemoradiotherapy is significant but poorly documented and must be taken into consideration in the management plan for each individual patient. National protocols or guidelines are required. Survival Overall, the 12- and 18-month survival estimates for Head and Neck Cancers patients in Scotland were 78% and 71%, respectively. Survival varied between tumour sites and was highest for laryngeal cancer patients and lowest for patients with cancer of the hypopharynx and pyriform sinus. The major factors affecting survival were found to be age, WHO level of physical activity, pre-treatment aim of treatment, clinical stage, and type of treatment. Longer waiting times from referral to first clinic and first clinic to diagnosis were associated with higher survival. x