COLORECTAL CANCER COMPARATIVE AUDIT REPORT SOUTH EAST SCOTLAND CANCER NETWORK PROSPECTIVE CANCER AUDIT. Mr B.J. Mander SCAN Group Chair

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1 SOUTH EAST SCOTLAND CANCER NETWORK PROSPECTIVE CANCER AUDIT COLORECTAL CANCER COMPARATIVE AUDIT REPORT Mr B.J. Mander SCAN Group Chair Mr K Pal, NHS Borders Mr S Whitelaw, NHS Dumfries & Galloway Mr S Yalamarthi, NHS Fife Mr R G Wilson, NHS Lothian Dr H Philips, Clinical Oncologist, NHS Lothian Sarah Buchan SCAN Colorectal Cancer Audit Facilitator Lynn Smith, Cancer Audit Facilitator, NHS Borders Martin Keith, Senior Cancer Information Officer, NHS Dumfries & Galloway Maureen Lamb, Cancer Audit Facilitator, NHS Fife Report No: SA CO1/15 SCAN Audit Office, c/o Department of Clinical Oncology, Western General Hospital, Crewe Road, Edinburgh, EH4 2XU T: W: lorna.bruce@luht.scot.nhs.uk

2 COLORECTAL CANCER 2013 COMPARATIVE AUDIT REPORT Patients diagnosed 1 April March 2014 CONTENTS Document History... 4 Comment by Chair of the SCAN Colorectal Group... 5 ACTION POINTS... 6 Summary of Quality Performance Indicators... 7 Introduction and Methods... 9 Data Quality Actions for Improvement DIAGNOSIS AND STAGING QPI 1: Radiological Diagnosis and Staging (i) QPI 1: Radiological Diagnosis and Staging (ii) SURGICAL OUTCOMES QPI 4: Lymph Node Yield QPI 5: Neoadjuvant Radiotherapy QPI 6: Surgical Margins (i) QPI 6: Surgical Margins (ii) QPI 7: Re-operation Rates QPI 8: Anastomotic Dehiscence (i) QPI 8: Anastomotic Dehiscence (ii) QPI 8: Anastomotic Dehiscence (iii) ONCOLOGICAL TREATMENT OUTCOMES QPI 10: Adjuvant chemotherapy QPI 10: Adjuvant chemotherapy KEY CATEGORIES Glossary

3 DOCUMENT HISTORY Version Circulation Date Comments Version 1 Lead Clinicians 10/11/2014 Version 2 Version 3 4

4 Comment by Chair of the SCAN Colorectal Group This report provides comprehensive data on the management of colorectal cancer in the South East of Scotland from April 2014 March Once again the SCAN Audit Team and Sarah Buchan in particular, have worked extremely hard to produce data of such quality. This has been facilitated by local data collection teams. SCAN Colorectal Data has been submitted to the UK and Ireland Large Bowel Cancer Audit allowing for direct comparisons with the whole of the British Isles ( SCAN data holds up extremely well in comparison to other UK areas in terms of surgical outcomes. During 2013 in SCAN 957 patients were diagnosed with colorectal cancer. This represents an almost identical number of cancers as treated the previous year an approximately a 6% decrease on 2010 which may represent the plateau of increased incidence predicted by the introduction of bowel screening. Nonetheless we are managing over 20% more colorectal cancers in the region than we were in Of the 957 patients 758 (80%) underwent surgery, which was performed with curative intent in 90% of cases. 16% of the patients who had surgery were treated as emergencies. Despite the substantial increase in workload the exceptional standard of surgical care across the region has been maintained. Perioperative mortality for all patients undergoing elective surgery was 0.5% (which compares favourably with the UK audit average 30 day mortality rate of 3.7%. Complications caused by anastomotic dehiscence (leakage at the site of the surgical join) are very low (2.5% for colonic anastomosis, 4.5% for rectal anastomosis, and 1.1% for patients undergoing anastomosis following total mesorectal excision). They fall well within the required national NHSQIS standards of 5%, 10% and 20% respectively and are the lowest level we have ever recorded in the region. We have seen a steady rise in the percentage of cases treated laparoscopically within SCAN and within a relatively brief period of time we have got the % of patients within the region treated laparoscopically up to over 33% which is the UK average. 73 patients were treated with minimally invasive endoluminal techniques involving either endoscopic resection or Transanal Endoscopic Microsurgery (TEMS). This year has also seen us submitting data to the newly established Colorectal Quality Performance Indicators. The group and the audit staff has worked with great enthusiasm to ensure that the data submitted was of the highest quality. The QPIs have highlighted a number of areas that the group need to focus on in the next year which will be addressed by specific actions. These include; Ensuring that all patients considered to have upper rectal or rectosigmoid tumours get staged with an MRI scan and a CT scan. Increasing the number of patients whose colon is completely imaged before elective surgery Ensuring all patients at risk of a stoma meet with a stoma nurse preoperatively Ongoing education is an important component of the SCAN Colorectal Groups Role. In 2015 we intend to hold and educational event dealing with the management of low rectal cancer Mr B.J. Mander Chair SCAN Colorectal Group Jan 15 5

5 ACTION POINTS QPI Action required Person Responsible for action Date for update Progress QPI 1 (i) Change in practice at Radiology for emergency patients who are not undergoing CT chest preoperatively. SCAN Colorectal Lead Clinicians QPI 1 (ii) Ensure all patients upper rectal or rectosigmoid tumours undergo a pre-operative MRI, along with CT scan of chest, abdomen and pelvis. SCAN Colorectal Lead Clinicians QPI 2 Recommend all elective patients, who are unable to have colonoscopy, should have CT colonoscopy pre-operatively. SCAN Colorectal Lead Clinicians QPI 4 Ensure all patients at risk of a stoma meet a Stoma Nurse preoperatively. Colorectal Lead Clinicians in Lothian and Dumfries & Galloway QPI 5 The CRM (circumferential resection margin) should be recorded in all pre-operative imaging. SCAN Colorectal Lead Clinicians 6

6 Summary of Quality Performance Indicators: QPI 1 Radiological Diagnosis and Staging i) Patients with colon cancer who undergo CT chest, abdomen and pelvis before definitive treatment Target Borders D&G Fife Lothian SCAN % % % % % % ii) Patients with rectal cancer undergoing definitive treatment (chemoradiotherapy or surgical resection) who undergo CT chest, abdomen and pelvis and MRI pelvis before definitive treatment QPI 2 Pre-Operative Imaging of the Colon Patients with colorectal cancer undergoing surgical resection should have the whole colon visualised pre-operatively. QPI 3 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. QPI 4 Lymph Node Yield In patients undergoing resection for colorectal cancer the number of lymph nodes examined should be maximised. QPI 5 Neoadjuvant Radiotherapy Patients with locally advanced rectal cancer should receive neo-adjuvant chemoradiotherapy designed to facilitate a margin-negative resection Achieved Failed 7

7 QPI 6 Surgical Margins Rectal cancers undergoing surgical resection should be adequately excised (i) Primary surgery, or surgery following neo-adjuvant short course radiotherapy (ii) Surgery following neo-adjuvant long course radiotherapy or chemoradiotherapy QPI 7 Re-operation Rates For patients undergoing surgery for colorectal cancer re-operation should be minimised Target Borders D&G Fife Lothian SCAN % % % % % % < < Elective Index Procedure < Emergency Index Procedure < QPI 8 Anastomotic Dehiscence For patients undergoing surgical resection for colorectal cancer anastomotic dehiscence should be minimised. (i) Colonic anastomosis < (ii) Rectal anastomosis < (iii) Anterior resection with total mesorectal < excision QPI 9 30 day Mortality following Surgical Resection Mortality after surgical resection for colorectal cancer Elective Procedure < Emergency Procedure < QPI 10 Adjuvant Chemotherapy Patients with Dukes C and high risk Dukes B colorectal cancer should be considered for adjuvant chemotherapy. High Risk Dukes B Dukes C QPI day Mortality following Chemotherapy or Radiotherapy Mortality after chemotherapy or radiotherapy with curative intent for colorectal cancer < Achieved Failed 8

8 Introduction and Methods Cohort and Personnel This report is the eleventh to present comparative data on patients newly diagnosed with colorectal cancer in South East Scotland Cancer Network (SCAN) at the following hospitals: Borders General Hospital (NHS Borders), Dumfries and Galloway Royal Infirmary (NHS Dumfries & Galloway), Victoria Hospital, Kirkcaldy (NHS Fife), St John's Hospital at Howden, Livingston, and Western General Hospital, Edinburgh (NHS Lothian). The report covers data on patients newly-diagnosed in the twelve months from 1 April 2013 to 31 March Lead Clinicians and staff involved in audit were as follows Borders General Hospital (BGH) Mr K Pal Lynn Smith Dumfries & Galloway Royal Infirmary (DGRI) Mr S Whitelaw Martin Keith Victoria Hospital (Fife) Mr S Yalamarthi Maureen Lamb Western General Hospital, Edinburgh (WGH) Mr BJ Mander Sarah Buchan SCAN Mr BJ Mander Sarah Buchan Audit Processes and data recording Collection of the nationally-agreed core minimum dataset continues in all hospitals in South East Scotland. Data capture is focused round the process for the weekly multidisciplinary meetings i.e. ensuring that data covering patient referral, investigation, and diagnosis is being picked up through the routine process. Surgical and Oncology data is obtained either from the clinical records (electronic systems and case notes) or by download from the Department of Clinical Oncology database within the Edinburgh Cancer Centre (ECC) The process remains dependent on audit staff for capture and entry of data, and for data quality checking 3.4 Data was recorded on a local MS Access database in Lothian. In Borders, Fife and Dumfries & Galloway data was collected using E-case. 9

9 Dataset and Definitions The QPIs have been developed collaboratively with the three Regional Cancer Networks, Information Services Division (ISD), and Healthcare Improvement Scotland. QPIs will be kept under regular review and be responsive to changes in clinical practice and emerging evidence. The overarching aim of the cancer quality work programme is to ensure that activity at NHS board level is focussed on areas most important in terms of improving survival and patient experience whilst reducing variance and ensuring safe, effective and person-centred cancer care. Following a period of development, public engagement and finalisation, each set of QPIs is published by Healthcare Improvement Scotland 1. Accompanying datasets and measurability criteria for QPIs are published on the ISD website 2. NHS boards are required to report against QPIs as part of a mandatory, publicly reported, programme at a national level. The QPI dataset for Colorectal was implemented from 01/04/2013, and this is the first publication of QPI results for colorectal cancer within SCAN. The standard QPI format is shown below: QPI Title: Description: Rationale and Evidence: Specifications: Target: Short title of Quality Performance Indicator (for use in reports etc.) Full and clear description of the Quality Performance Indicator. Description of the evidence base and rationale which underpins this indicator. Numerator: Denominator: Of all the patients included in the denominator those who meet the criteria set out in the indicator. All patients to be included in the measurement of this indicator. Patients who should be excluded from measurement of this Exclusions: indicator. Include in the denominator for measurement against the Not recorded for target. Present as not recorded only if the patient cannot numerator: otherwise be identified as having met/not met the target. Include in the denominator for measurement against the target unless there is other definitive evidence that the record should Not recorded for be excluded. Present as not recorded only where the record exclusion: cannot otherwise be definitively identified as an inclusion/exclusion for this standard. Exclude from the denominator for measurement against the Not recorded for target. Present as not recorded only where the patient cannot denominator: otherwise be definitively identified as an inclusion/exclusion for this standard. Statement of the level of performance to be achieved. 1 QPI documents are available at 2 Datasets and measurability documents are available at 10

10 Data Quality Clinical Sign-Off: This report compares data from reports prepared for individual hospitals and signed off as accurate following review by the lead clinicians from each service. Additionally, the collated SCAN results are reviewed jointly by the lead clinicians, including the lead Oncologist, to assess variances and provide comments on results. External QA: SCAN Audit participates in external quality assurance (QA) of data by ISD Scotland, (i.e. when a sample of data is compared with the data definitions). There has not been an external QA of the whole Colorectal Dataset since A QA of the QPI colorectal dataset is scheduled to take place in February Estimated Case Ascertainment: Case ascertainment has been estimated using Scottish Cancer Registration data for comparison purposes. Tables on case ascertainment and five year averages are contained in the next section. Most patients are identified through weekly multidisciplinary meetings. The following sources are used to check for missing patients: 1. Pathology records 2. GRO Death lists 3. Dept of Clinical Oncology retrospective database 4. Clinical Nurse Specialist database 11

11 ESTIMATE OF CASE ASCERTAINMENT Estimated Case Ascertainment An estimate of case ascertainment (the percentage of the population with colorectal cancer recorded in the audit) is made by comparison with the Scottish Cancer Registry five year average data from 2008 to High levels of case ascertainment provide confidence in the completeness of the audit recording and contribute to the reliability of results presented. Levels greater than 100% may be attributable to an increase in incidence. Allowance should be made when reviewing results where numbers are small and variation may be due to chance. Number of cases recorded in audit: patients diagnosed to Borders D&G Fife Lothian SCAN Colon cancer Rectal cancer Total Estimate of case ascertainment: calculated using the average of the most recent available five years of Cancer Registry Data Borders D&G Fife Lothian SCAN Cases from Audit Cancer Registry 5 Year Average Case Ascertainment % Actions for Improvement After final sign off, the process is for the report to be sent to the Clinical Governance groups within the four health boards and to the Regional Cancer Planning Group. Action plans and progress with plans will be highlighted to the groups. The report will be placed on the SCAN website once it has been fully signed-off and checked for any disclosive material. Sarah Buchan SCAN Audit Facilitator Source: Scottish Cancer Registry, ISD. Data extracted from ACaDMe Note: Case ascertainment is reported by board of diagnosis and has been estimated using a denominator based on the latest ( ) five-year annual average available from the Scottish Cancer Registry. Death certificate only cases have been excluded. Cases that have been diagnosed in the private sector but received any treatment in NHS hospitals have been included. 12

12 DIAGNOSIS AND STAGING QPI 1: Radiological Diagnosis and Staging (i) Target = 95% Numerator = Number of patients with colon cancer who undergo CT chest, abdomen and pelvis before definitive treatment. Denominator = All patients with colon cancer Exclusions = (a) Patients who refuse investigations (b) Patients who undergo emergency surgeryª Patients with colon cancer who undergo staging investigations Borders D&G Fife Lothian SCAN before definitive treatment N N N N N Cohort Ineligible for this QPI Target 95% Numerator Not Recorded for the Numerator Denominator Not Recorded for Exclusion Not Recorded for Denominator % Performance 94.9% 87.1% 92.8% 95.3% 93.3% FIFE: 9 patients incomplete - CT abdo/pelvis only; 5 of these patients had CT Chest post-op: 3 were too frail and hence valid reason for not performed; 2 not performed and no clear reasons as to why this was not performed. (1 patient lost to post op follow up) QPI 1 (i) Colon Cancer - Pre-op Staging % Patients Patients undergoing pre-op staging investigations QPI Target 20 0 Borders D&G Fife Lothian Scan Health Board Comment: SCAN as a whole is just falling short of the target. In D&G, high grade dysplasia diagnoses are not currently discussed at their MDM. This will change and should raise their target above 95%. In Lothian, some patients are not having CT chest before surgery. It may be there needs to be a change in practice for emergency patients. 13

13 QPI 1: Radiological Diagnosis and Staging (ii) Target = 95% 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 = (a) Patients who refuse investigations (b) Patients who undergo emergency surgeryª Patients with rectal cancer undergoing staging Borders D&G Fife Lothian SCAN investigations before definitive treatment N N N N N Cohort Ineligible for this QPI Target 95% Numerator Not Recorded for Numerator Denominator Not Recorded for Exclusions Not Recorded for Denominator % Recorded 100.0% 58.3% 76.5% 98.8% 86.9% FIFE: 11 patients incomplete - all tumours rectosigmoid but at surgery were upper/mid rectal cancer, hence no MRI performed. One patient was a polyp cancer at the rectosigmoid. LOTHIAN: One patient had rectosigmoid cancer with metastases. QPI 1(ii) Rectal Cancer - Pre-op Staging % Patients Patients undergoing pre-op staging investigations QPI Target 20 0 Borders D&G Fife Lothian SCAN Health Board Comment: If there is doubt regarding site of tumour, a pre-op MRI should be performed. This will be discussed and developed with local Radiology Departments across the Boards. ª Emergency surgical resection is defined as surgical resection which occurs within 72 hours of emergency admission to hospital 14

14 QPI 2: Pre-Operative Imaging of the Colon Target = 95% 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 nonvisualised segment of colon has been removed. Denominator = All patients who undergo elective surgical resection for colorectal cancer Exclusions = No exclusions Elective Colorectal Patients undergoing Surgical Resection have the whole colon visualised by colonoscopy/ct Borders D&G Fife Lothian SCAN colonography pre-operatively, unless the non-visualised segment has been removed N N N N N Cohort Ineligible for this QPI Target 95% Numerator Not Recorded for the Numerator Denominator Not Recorded for Exclusions Not Recorded for the Denominator % Percentage 96.6% 77.1% 86.6% 86.5% 86.4% FIFE: One patient went straight to surgery; 6 patients had flexible sigmoidoscopy rather than colonoscopy (Reasons for flexible sigmoidoscopy only: one patient had impending obstruction from rectal tumour and needed urgent defunctioning colostomy; 2 patients had a full colonoscopy within 6-18 months prior to diagnosis, one of which was under 6 monthly polyp surveillance and had transformation to cancer at the polyp site; One patient was too frail for major surgery/colonoscopy and had local excision; one patient was elderly following flexi sig went straight to surgery, no clear reasons for colonoscopy not being performed); 10 patients scopes were limited by tumour; 3 scopes were incomplete due to patient intolerance/looping. LOTHIAN: 35 patients had incomplete pre-visualisation of the whole bowel. 4 patients did not have pre-operative visualisation. QPI 2 Pre-op Visualisation of Colon % Patients Pre-op Staging of Colon QPI Target 20 0 Borders D&G Fife Lothian Health Board SCAN Comment: Patients who attend electively with strictures, who cannot have full colonoscopies, should be booked for CT colonoscopies. It is recognised that there needs to be a change in the pathway locally. 15

15 QPI 3: Stoma Care Target = 95% 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. Number of patients with colorectal cancer undergoing elective surgical resection which involves stoma creation are seen by and have their stoma site marked pre-operatively by Borders D&G Fife Lothian SCAN a Stoma Care Nurse N N N N N Cohort Ineligible for this QPI Target 95% Numerator Not Recorded for Numerator Denominator Not Recorded for Exclusions Not Recorded for Denominator % Recorded 100.0% 82.4% 100.0% 84.1% 89.0% QPI 3: Stoma Care % Patients Patients seen by Stoma Nurse Preoperatively QPI Target 20 0 Borders D&G Fife Lothian SCAN Health Board Comment: Since these results stoma booking arrangements have been changed in Dumfries & Galloway, along with including stoma skill in the proposed ERAS nurses job description. In Lothian, there were some unexpected stomas but work will continue with the Stoma Nurses to improve the service. 16

16 SURGICAL OUTCOMES QPI 4: Lymph Node Yield Target = 80% 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 = (a) Patients with rectal cancer who undergo long course neoadjuvant chemoradiotherapy or radiotherapy. (b) Patients who undergo transanal endoscopic microsurgery or transanal resection of tumour. Colorectal Cancer Patients undergoing curative surgical resection have > 12 lymph nodes Borders D&G Fife Lothian SCAN pathologically examined N N N N N Cohort Ineligible for this QPI Target 80% Numerator Not Recorded for the Numerator Denominator Not Recorded for Exclusions Not Recorded for Denominator % Percentage 89.4% 88.6% 83.9% 90.6% 88.6% QPI 4: Lymph Node Yield % Patients Number of Patients having > 12 Lymph Nodes removed QPI Target 20 0 Borders D&G Fife Lothian Health Board SCAN Comment: All Boards are achieving the 80% target for this QPI. 17

17 QPI 5: Neoadjuvant Radiotherapy Target= 90% Numerator = Number of patients with rectal cancer with a threatened or involved CRM on preoperative MRI undergoing surgery who receive long course neoadjuvant chemoradiotherapy¹. Denominator = All patients with rectal cancer with a threatened or involved CRM on preoperative MRI undergoing surgery. Exclusions = (a) Patients who refuse radiotherapy (b) Patients in whom radiotherapy is contraindicated (c) Patients who presented as an emergency for surgery Rectal Cancer Patients with threatened or involved CRM on pre-op MRI receive Borders D&G Fife Lothian SCAN long course neo-adjuvant chemoradiotherapy N N N N N Cohort Ineligible for the QPI Target 90% Numerator Not Recorded for the Numerator Denominator Not Recorded for Exclusions Not Recorded for Denominator % Percentage 50.0% 0.0% 83.3% 94.7% 91.3% FIFE - 3 patients who were not recorded for denominator did not have MRI performed. One patient had short course radiotherapy not long course chemoradiotherapy due to comorbidities. LOTHIAN: 1 patient had short course radiotherapy not long course chemoradiotherapy due to comorbidities. D&G - 11 patients did not have CRM recorded on MRI report, no other information available to determine if should be included in denominator QPI 5: Neoadjuvant Radiotherapy % Patients Rectal Patients undergoing neoadjuvant chemoradiotherapy QPI Target 20 0 Borders D&G Fife Lothian Health Board SCAN Comment: This was felt by SCAN to be a difficult QPI to achieve. The CRM needs to be recorded in all preoperative imaging. D&G radiology reports currently don t contain this information. Changes at MDM level will assist with data collection. 18

18 QPI 6: Surgical Margins (i) Target = <5% Numerator = Number of patients with rectal cancer who undergo elective primary surgical resection or surgical resection following short course neoadjuvant radiotherapy in which tumour is present at the circumferential margin. Denominator = All patients with rectal cancer who undergo elective primary surgical resection or surgical resection following short course neoadjuvant radiotherapy. Exclusions = Patients who undergo transanal endoscopic microsurgery or transanal resection of tumour. Rectal Cancer Patients who undergo elective primary surgical resection or surgical resection following short course neoadjuvant therapy Borders D&G Fife Lothian SCAN N N N N N Cohort Ineligible for the QPI Target <5% Numerator Not Recorded for the Numerator Denominator Not Recorded for Exclusions Not Recorded for Denominator % Percentage 0.0% 11.1% 0.0% 3.8% 3.1% LOTHIAN: 2 patients had positive CRM post surgery. 1 went straight to surgery as CRM predicted clear. 1 had neoadjuvant short course radiotherapy then surgery but acellular mucin in CRM margin. QPI 6 (i) - Surgical Margins 50 % Patients Primary surgery or surgery following neoadjuvant short course XRT with +CRM QPI Target <5% Borders D&G Fife Lothian SCAN Health Board Comment: Overall, SCAN is achieving the target for this QPI. 19

19 QPI 6: Surgical Margins (ii) Target = <15% Numerator = Number of patients with rectal cancer who undergo elective surgical resection following neo-adjuvant long course radiotherapy or chemoradiotherapy in which tumour is present at the circumferential margin. Denominator = All patients with rectal cancer who undergo elective surgical resection following neoadjuvant long course radiotherapy or chemoradiotherapy Exclusions = Patients who undergo transanal endoscopic microsurgery or transanal resection of tumour. All Rectal Cancer patients who undergo elective surgical resection following neoadjuvant long course radiotherapy or Borders D&G Fife Lothian SCAN chemoradiotherapy N N N N N Cohort Ineligible for the QPI Target <15% Numerator Not Recorded for the Numerator Denominator Not Recorded for Exclusions Not Recorded for Denominator % Percentage 0.0% 0.0% 40.0% 11.8% 14.3% FIFE: 2 patients had long course Chemoradiotherapy. Both had involved margins at surgery. Should also be noted that small numbers have an impact on percentage. LOTHIAN: 2 patients long course Chemoradiotherapy. 1 patient resected tumour within 0.1mm of resection margin. 1 patient resected tumour <1mm from resection margin. QPI 6 (ii) Surgical Margins % Patients Surgery following neoadjuvant long course XRT or ChemoXRT QPI Target <15% 0 Borders D&G Fife Lothian Health Board SCAN Comment: Although SCAN overall is achieving the target set, it should be noted that small figures have an impact on percentage. D&G patients who did not meet this target were given an MRI and discussed at MDM. 20

20 QPI 7: Re-operation Rates Target = <10% (elective surgical resection) <15% (emergency surgical resection) 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. All colorectal cancer patients undergoing surgical resection who return to theatre within 30 days of their index procedure for complications - Index procedure Borders D&G Fife Lothian SCAN Elective N N N N N Cohort Ineligible for the QPI Target <10-15% Numerator Not Recorded for the Numerator Denominator Not Recorded for Exclusions Not Recorded for Denominator % Percentage 1.7% 6.1% 2.7% 4.3% 3.7% All colorectal cancer patients undergoing surgical resection who return to theatre within 30 days of their index procedure for complications - Index procedure Emergency Borders D&G Fife Lothian SCAN N N N N N Cohort Ineligible for the QPI Target <10-15% Numerator Not Recorded for the Numerator Denominator Not Recorded for Exclusions Not Recorded for Denominator % Percentage 5.6% 9.1% 5.6% 5.7% 6.0% Comment: The QPI figures above have been generated by each Board, not ISD. Figures supplied by ISD were not felt to be an appropriate reflection of this QPI. 21

21 QPI 8: Anastomotic Dehiscence (i) Target = <5% 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. All patients with colorectal cancer who undergo a surgical procedure involving Borders D&G Fife Lothian SCAN anastomosis of the colon N N N N N Cohort Ineligible for the QPI Target <5% Numerator Not Recorded for the Numerator Denominator Not Recorded for Exclusions Not Recorded for Denominator % Percentage 2.6% 6.1% 0.0% 3.4% 2.5% LOTHIAN: 4 patients did not meet the target, 2 patients underwent elective surgery and 2 patients underwent emergency surgery. QPI 8 (i): Colonic Anastomosis % Patients All patients undergoing anastomosis of the colon QPI Target <5% Borders D&G Fife Lothian SCAN Health Board Comment: Overall, SCAN is achieving the target for this QPI. 22

22 QPI 8: Anastomotic Dehiscence (ii) Target = <10% Numerator = Number of patients with colorectal cancer who undergo a surgical procedure involving anastomosis of the rectum having anastomotic leak requiring intervention (radiological or surgical). Denominator = All patients with colorectal cancer who undergo a surgical procedure involving anastomosis of the rectum. Exclusions = Patients who undergo total mesorectal excision (TME). All patients with colorectal cancer who undergo a surgical procedure involving anastomosis of the rectum Borders D&G Fife Lothian SCAN N N N N N Cohort Ineligible for the QPI Target <10% Numerator Not Recorded for the Numerator Denominator Not Recorded for Exclusions Not Recorded for Denominator % Percentage 5.6% 4.0% 0.0% 5.7% 4.5% LOTHIAN: 5 patients who did not meet the target underwent elective surgery. QPI 8 (ii): Rectal Anastomosis % Patients All patients undergoing anastomosis of the rectum QPI Target <10% Borders D&G Fife Lothian SCAN Health Board Comment: All Boards are achieving the <10% target for this QPI. 23

23 QPI 8: Anastomotic Dehiscence (iii) Target = <20% Numerator = Number of patients with rectal cancer who undergo anterior resection and TME having anastomotic leak requiring intervention (radiological or surgical). Denominator = All patients with rectal cancer who undergo anterior resection and TME. Exclusions = No exclusions All patient with rectal cancer who undergo surgical anterior resection and TME Borders D&G Fife Lothian SCAN N N N N N Cohort Ineligible for the QPI Target <20% Numerator Not Recorded for the Numerator Denominator Not Recorded for Exclusions Not Recorded for Denominator % Percentage 0.0% 0.0% 0.0% 1.9% 1.1% LOTHIAN: 1 patient who did not meet the target underwent elective surgery. QPI 8 (iii): Anterior Resection with TME % Patients Patients undergoing Anterior Resection with TME requiring intervention QPI Target <20% Borders D&G Fife Lothian SCAN Health Board Comment: All Boards are achieving the <20% target for this QPI. 24

24 QPI 9: 30 Day Mortality Following Surgical Resection Target = Elective surgical resection <5% Emergency surgical resection <15% Numerator = Number of patients with colorectal cancer who undergo emergency or elective surgical resection who die within 30 days of surgery. Denominator = All patients with colorectal cancer who undergo emergency or elective surgical resection. Exclusions = No exclusions Elective Surgery All patients with colorectal cancer who undergo elective surgical resection who die Borders D&G Fife Lothian SCAN within 30 days of surgery N N N N N Cohort Ineligible for this QPI Elective Surgery <5% Numerator (elective surgery) Not Recorded for the Numerator Denominator Not Recorded for Exclusions Not Recorded for Denominator % Percentage 0.0% 1.4% 0.7% 0.3% 0.5% FIFE: 3 patients died within 30 days of surgery: 2 Emergency; 1 Elective - this patient had a synchronous tumour (UGI cancer and also had a gastrectomy) QPI 9: 30 Day Mortality (Elective) % Patients Day mortality following elective surgery QPI Target <5% Borders D&G Fife Lothian SCAN Health Board 25

25 QPI 9: 30 Day Mortality Following Surgical Resection Emergency Surgery All patients with colorectal cancer who undergo emergency surgical resection who die within 30 days of Borders D&G Fife Lothian SCAN surgery N N N N N Cohort Ineligible for this QPI Emergency Surgery <15% Numerator (emergency surgery) Not Recorded for the Numerator Denominator Not Recorded for Exclusions Not Recorded for Denominator % Percentage 16.7% 15.4% 11.1% 3.3% 8.3% QPI 9: 30 Day Mortality (Emergency) % Patients Day Mortality following emergency surgery QPI Target <15% Borders D&G Fife Lothian Health Board SCAN Comment: SCAN is achieving the target set overall. 26

26 ONCOLOGICAL TREATMENT OUTCOMES QPI 10: Adjuvant chemotherapy Target = Patients with Dukes C colorectal cancer 70% cancer 50% Patients with high risk Dukes B colorectal 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 = No exclusions. High Risk Dukes B Borders D&G Fife Lothian SCAN N N N N N Cohort Ineligible for the QPI High Risk Dukes B - 50% Numerator - High Risk Dukes B Not Recorded for the Numerator Denominator Not Recorded for Exclusions Not Recorded for Denominator % Percentage 50.0% 40.0% 100.0% 47.1% 53.1% LOTHIAN: Dukes B High Risk patients declined treatment. 6 did not have adjuvant chemotherapy. QPI 10: Adjuvant Chemotherapy (High Risk Dukes B) 100 % Patients High Risk Dukes B receiving adjuvant chemotherapy QPI Target <50% Borders D&G Fife Lothian SCAN Health Board 27

27 QPI 10: Adjuvant chemotherapy Dukes C Borders D&G Fife Lothian SCAN N N N N N Cohort Ineligible for the QPI Target: Dukes C - 70% Numerator - Dukes C Not Recorded for the Numerator Denominator Not Recorded for Exclusions Not Recorded for Denominator % Percentage 43.8% 70.0% 65.6% 76.0% 69.2% LOTHIAN: Dukes C patients declined treatment. 3 didn t have chemo predominantly for post op complications. 1 post op stroke. 6 ischaemic heart disease and or cerebro vascular disease. 1 dementia. 1 advanced (incurable) ca prostate rendering adjuvant chemo inappropriate. 1 frailty due to Parkinson s. 2 respiratory comorbity (COPD and TB; brochiectasis and complicated diabetes). 1 toxicity from chemo component of downstaging chemoxrt. 1 learning difficulties and multiple other medical problems. FIFE: Dukes C patients - 1 Patient under surveillance re best time to start adjuvant chemotherapy: 2 had palliative chemo; 2 declined; 5 were unfit; 1 patient was due chemorads for synchronous UGI cancer. QPI 10: Adjuvant Chemotherapy (Dukes C) % Patients Dukes C receiving adjuvant chemotherapy QPI Target <70% Borders D&G Fife Lothian Health Board SCAN Comment: This QPI includes patients that decline chemotherapy which needs addressed at the baseline review. 28

28 QPI 11: 30 Day Mortality Following Chemotherapy or Radiotherapy Target = <2% Numerator = Number of patients with colorectal cancer who undergo neo-adjuvant chemoradiotherapy, radiotherapy or adjuvant chemotherapy with curative intent who die within 30 days of treatment. Denominator = All patients with colorectal cancer who undergo neo-adjuvant chemoradiotherapy, radiotherapy or adjuvant chemotherapy with curative intent. Exclusions = No exclusions. All patients with colorectal cancer who undergo neoadjuvant chemotherapy, radiotherapy, or adjuvant chemotherapy with curative intent who die within 30 days of treatment Borders D&G Fife Lothian SCAN N N N N N Cohort Ineligible for the QPI Target <2% Numerator Not Recorded for the Numerator Denominator Not Recorded for Exclusions Not Recorded for Denominator % Percentage 0.0% 0.0% 0.0% 0.0% 0.0% Comment: Overall, SCAN is achieving the target for this QPI. 29

29 KEY CATEGORIES Table 1: Rectal v Other Colorectal Patients, percentage of patients undergoing Surgery No of Patients Diagnosed All patients who had surgery Number of patients diagnosed with rectal cancer Number of patients diagnosed with rectal cancer who had surgery Borders % % % D&G % % % Fife % % % Lothian % % % SCAN % % % Table 2: Rectal v Other Colorectal Patients No of Patients Diagnosed All patients who had definitive surgery Number of patients diagnosed with rectal cancer Number of patients diagnosed with rectal cancer who had definitive surgery Borders % % % D&G % % % Fife % % % Lothian % % % SCAN % % % Table 3: Emergency v Elective Surgery (Excluding non definitive surgery Endoscopic Treatment/Stents/Defunctioning Stomas/Bypass Surgery) All patients who had definitive surgery Emergency Elective Inapplicable Missing Data Borders % % 0 0.0% 0 0.0% D&G % % 0 0.0% 0 0.0% Fife % % 0 0.0% 0 0.0% Lothian % % 0 0.0% 0 0.0% SCAN % % 0 0.0% 0 0.0% 30

30 Table 4: Rectal Cancer Patients Emergency V Elective Surgery (Excluding non definitive surgery Endoscopic Treatment/Stents/Defunctioning Stomas/Bypass Surgery) All patients diagnosed with rectal cancer who had definitive surgery Emergency Elective Not Recorded Missing Data Borders % % 0 0.0% 0 0.0% D&G % % 0 0.0% 0 0.0% Fife % % 0 0.0% 0 0.0% Lothian % % 0 0.0% 0 0.0% SCAN % % 0 0.0% 0 0.0% Table 5: Intent of Surgery (Excluding non definitive surgery Endoscopic Treatment/Stents/Defunctioning Stomas/Bypass Surgery) All Patients who had Definitive Surgery Curative Palliative Not Recorded Missing Data Borders % 4 5.3% 0 0.0% 0 0.0% D&G % % 1 1.3% 0 0.0% Fife % % 0 0.0% 0 0.0% Lothian % % 0 0.0% 1 0.3% SCAN % % 1 0.1% 1 0.1% Table 6: Intent of Surgery N=All patients diagnosed with rectal cancer who had definitive surgery (Excluding non definitive surgery Endoscopic Treatment/Stents/Defunctioning Stomas/Bypass Surgery) All patients diagnosed with rectal cancer who had definitive surgery Curative Palliative Not Recorded Missing Data Borders % 0 0.0% 0 0.0% 0 0.0% D&G % 0 0.0% 0 0.0% 0 0.0% Fife % 4 8.0% 0 0.0% 0 0.0% Lothian % % 0 0.0% 0 0.0% SCAN % % 0 0.0% 0 0.0% 31

31 Table 7: Sex N= All patients diagnosed Total Patients Diagnosed Male Female Borders % % D&G % % Fife % % Lothian % % SCAN % % Table 8: Age at Diagnosis N=All patients diagnosed Borders D&G Fife Lothian SCAN < % 0 0.0% 3 1.4% 7 1.3% % % 5 4.2% 9 4.3% % % % % % % % % % % % % % % % % % % % % % % % 3 2.5% 8 3.8% % % Total % % % % % Table 9: Tumour Site N=All patients diagnosed Site of Tumour Borders % D&G % Fife % Lothian % SCAN % Appendix Ascending Colon Caecum Colon Unspecified Descending Colon Hepatic Flexure Rectum Sigmoid Colon Splenic Flexure Transverse Colon Overlapping Lesion Not Recorded Missing Data Total

32 Table 10: Dukes Stage N=All patients diagnosed Borders % D&G % Fife % Lothian % SCAN % Dukes A Dukes B Dukes C Dukes C Dukes D (M1) Inapplicable Not Recorded Missing Data Total Table 11: Inapplicable Dukes Stage (Excluding non definitive surgery Endoscopic Treatment/Stents/Defunctioning Stomas/Bypass Surgery) Borders % D&G % Fife % Lothian % SCAN % Endoscopic Mucosal Resections Appendicectomies Non Definitive Surgery No Residual Tumour No Surgery Performed Trans Endoscopic Micro Surgery Other Total Table 12: Clinical Stage IV N=All patients diagnosed presented with Final M1 Stage of disease at presentation Patients presenting with Clinical Stage IV disease Borders % D&G % Fife % Lothian % SCAN % Metastatic Disease No Metastatic Disease Cannot Determine Not Recorded Missing Data Total

33 Table 14: All patients receiving Chemotherapy N=All patient who receive Chemotherapy or Chemoradiotherapy Neoadjuvant Single Therapy Neoadjuvant Combined Therapy Primary Adjuvant Not N Radical Postoperative Palliative Recorded Borders % % % 0 0.0% 0 0.0% 0 0.0% D&G % % 0 0.0% 0 0.0% % 0 0.0% Fife % % 0 0.0% 0 0.0% % 0 0.0% Lothian % % 2 3.1% 4 6.3% % 0 0.0% SCAN % % 4 4.1% 4 4.1% % 0 0.0% Lothian: 3 patients declined any oncology treatment. 4 patients declined adjuvant treatment.1patient contra-indicated for neoadjuvant treatment. 3 patients contra-indicated for adjuvant treatment. 2 patients died before treatment. Table 15: Surgical Approach N=All colorectal cancer patients undergoing surgery Borders % D&G % Fife % Lothian % SCAN % Laparoscopic % % % % % Laparoscopic converted to Open 3 2.9% 5 4.2% 7 3.3% % % Open % % % % % Inapplicable % % % % % Not Recorded 0 0.0% 0 0.0% 0 0.0% % % Missing Data 0 0.0% 0 0.0% 0 0.0% 2 0.4% 2 0.2% Total % % % % % Table 16: EMR and TEMS Resection N=All patients having endoscopic mode of first treatment (excluding colonic stents) Borders % D&G % Fife % Lothian % SCAN % Endoscopic Mucosal Resections EMR followed by definitive Surgery 0 0.0% % % % % TEMS resection TEMS followed by definitive surgery 0 0.0% 0 0.0% 0 0.0% % % 34

34 Table 17: Dukes Staging - Screened Patients v Non-Screened Patients N=All colorectal patients Borders % D&G % Fife % Lothian % SCAN % SCREENED PATIENTS Dukes A 0 0.0% 9 7.6% % % % Dukes B 5 4.8% 7 5.9% % % % Dukes C % 1 0.8% % % % Dukes C % 0 0.0% 2 1.0% 5 1.0% % Dukes D (M1) 0 0.0% 1 0.8% 2 1.0% 6 1.1% 9 0.9% Inapplicable 5 4.8% 0 0.0% 1 0.5% 0 0.0% 6 0.6% Not Recorded 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% Missing 0 0.0% 0 0.0% 0 0.0% 1 0.2% 1 0.1% Total - Screened NON-SCREENED PATIENTS Dukes A 7 6.7% % % % % Dukes B % % % % % Dukes C % % % % % Dukes C % 2 1.7% 7 3.3% % % Dukes D 2 1.9% % % % % Inapplicable % 5 4.2% % 0 0.0% % Not Recorded 0 0.0% % 0 0.0% 2 0.4% % Missing 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% Total - Nonscreened TOTAL PATIENTS % % % % % 35

35 Table 18: Permanent Stoma rate is not more than 40% is patients with rectal tumours (QIS Standard 8b1) In many cases it is not possible to tell if a stoma is permanent until a number of years have passed. For the purposes of this report, a stoma is defined as permanent only for those procedures (abdominoperineal resection and colostomy and panproctocolectomy and ileostomy) which the stoma was fashioned with the intention of being permanent. n=all Rectal Cancer patients undergoing elective surgery excluding non-definitive surgery All Rectal Cancer patients undergoing elective Surgery Patients undergoing APER with Colostomy OR Panproctocolectomy with ileostomy - left with a permanent stoma Borders % D&G % Fife % Lothian % SCAN % % % % % % SCAN % Rectal Cancer Patients with Permanent Stoma % Patients SCAN Target <40%

36 GLOSSARY (Edited Selection Based On NHS QIS Bowel Cancer Standards, Published 2008) Adenocarcinoma Adjuvant Therapy Anastomosis Anastomotic dehiscence Antibiotic prophylaxis Audit BGH Bowel Cancer Cancer centre Clinical Governance Clinical Nurse Specialist (CNS) Colon Colonic anastomosis A malignant growth of glandular tissue. The use of chemotherapy and/or radiotherapy in addition to surgery. The aim of adjuvant therapy is to destroy any cancer that has spread. An artificial connection, created by surgery, between two tubular organs or parts, especially between two parts of the intestine. For example, a junction created by a surgeon between two pieces of bowel which have been cut to remove the intervening section. Bursting open or splitting of the surgical connection between two sections of intestine The administration of antibiotics to reduce the risk of infection. The measuring and evaluation of care against best practice with a view to improving current practice and care delivery. Borders General Hospital A tube-like structure which runs from the stomach to the anus. It allows digestion of food and the discharge of waste products. The name given to a group of diseases that can occur in any organ of the body, and in blood, and which involve abnormal uncontrolled growth of cells. Cancer services are based in cancer centres. Such centres provide the entire spectrum of cancer care - both on-site and to associated cancer units. Ensures that patients receive the highest quality of care possible, putting each patient at the centre of his or her care. This is achieved by making certain that those providing services work in an environment that supports them and places the safety and quality of care at the top of the organisation's agenda. A clinical nurse specialist is a registered nursing professional who has acquired additional knowledge, skills and experience, together with a professionally and/or academically accredited post-registration qualification (if available) in a clinical speciality. They practice at an advanced level and may have sole responsibility for a care episode or defined client/group. Part of the bowel. Also called the large intestine or large bowel. This structure has five major divisions: caecum, ascending colon, transverse colon, descending colon, and sigmoid colon. The colon is responsible for forming, storing and expelling waste matter into the rectum. A procedure in which a part of the colon is removed and the two remaining ends are rejoined. 37