External Assurance of Performance against Cancer Quality Performance Indicators

Transcription

1 External Assurance of against Cancer Quality Indicators Lung Cancer August 2017 National Review

2 Healthcare Improvement Scotland is committed to equality. We have assessed the review process for likely impact on equality protected characteristics as defined by age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex, and sexual orientation (Equality Act 2010). You can request a copy of the equality impact assessment report from the Healthcare Improvement Scotland Equality and Diversity Advisor on or contactpublicinvolvement.his@nhs.net Healthcare Improvement Scotland 2017 First published August 2017 This document is licensed under the Creative Commons Attribution-Noncommercial- NoDerivatives 4.0 International Licence. This allows for the copy and redistribution of this document as long as Healthcare Improvement Scotland is fully acknowledged and given credit. The material must not be remixed, transformed or built upon in any way. To view a copy of this licence, visit 2

3 Contents Introduction 4 Background 4 What are quality performance indicators? 5 Format of quality performance indicators 5 Review process 6 Summary of findings 7 Areas of strength 7 Areas for improvement 7 Our findings 9 Appendix 1 National and regional recommendations 23 Appendix 2a Regional cancer networks 25 Appendix 2b Surgical centres in Scotland 26 Appendix 3 Review group membership 27 Appendix 4 Glossary of terms 28 3

4 Introduction Background In March 2012, the Scottish Government implemented the National Cancer Quality Programme. As part of the programme, Healthcare Improvement Scotland was tasked with providing assurance that NHS boards are meeting, or are working to meet, national cancer quality performance indicators (QPIs). Healthcare Improvement Scotland will undertake a review of the QPI data every three years for each specific tumour type. While NHS boards are accountable for achieving the QPI targets, they are supported by their regional cancer networks. The hospitals that comprise each region are listed in Appendix 2a. Within the three regions, only three of these hospitals provide surgical services for lung cancer patients in Scotland and are listed in Appendix 2b. There are three regional cancer networks which facilitate communication and partnership working across their regions in order to promote high standards of cancer care which meets the needs of cancer patients. The networks are the North of Scotland Cancer Network (NOSCAN), the South of Scotland Cancer Network (SCAN) and the West of Scotland Cancer Network (WoSCAN). The networks also support clinical audit and regional planning of cancer services. Each regional cancer network has a key steering group, known as the Regional Cancer Advisory Group (RCAG), or a Regional Cancer Advisory Forum in the case of NSCAN, which is responsible for supporting their constituent NHS boards in reviewing QPI data, undertaking the Healthcare Improvement Scotland QPI reviews and supporting the implementation of any required actions 1 2. All RCAGs, on behalf of their constituent NHS boards, submit data to the national review as well as supporting evidence, which provides the clinical context. This information helps the review group to understand how each NHS board is performing. The data and evidence are then analysed and compiled by Healthcare Improvement Scotland staff for consideration by the review group. Following the review, Healthcare Improvement Scotland writes to the NHS boards and RCAGs highlighting areas of good practice and variations and makes recommendations. Where required, NHS boards are asked to submit improvement action plans, with support from their RCAG, for any issues that the review group has identified. Members of the review group review and monitor these plans. This approach adds value to, and builds on, the existing governance work undertaken by the NHS boards and RCAGs. Regional cancer networks collate and consider the QPI data on an annual basis, monitoring the progress of NHS boards and units through the use of action plans. This annual process is supplemented by the Healthcare Improvement Scotland national review which gives an independent view of performance. Information Services Division (ISD), of NHS National Services Scotland, also publishes a three-year data report for the tumour-specific QPIs. This report includes collation of analysed performance data, trend and survival analysis and is used during the Healthcare Improvement Scotland review. The most recent ISD report on the lung QPIs is available on the ISD website: Indicators/Publications/ / Lung-QPI-Report.pdf. 1 For the purposes of the report, the term RCAG will be used throughout the remainder of the report when referring to any of the key steering groups of the regional cancer networks. 2 HDL(2001)54 4

5 What are quality performance indicators? QPIs are small sets of outcome-focused, evidence-based indicators which relate to key points in the tumour-specific cancer patient pathway deemed by an expert group to be critical in providing good quality care. Currently, there are 18 specific tumour type sets of indicators. These QPIs have been developed collaboratively by expert groups of clinicians drawn from the three regional cancer networks, ISD and Healthcare Improvement Scotland. The overarching aim is to ensure that activity at NHS board level is focused on the most important areas in terms of improving survival and patient experience, whilst reducing variance and ensuring safe, effective and person-centred cancer care. Some NHS boards, for example island NHS boards, may be treating small numbers of patients. When represented as a percentage, these small numbers can significantly distort the result and can make the target difficult to meet. Minor fluctuations in these patient numbers can have a significant impact on whether the NHS board meets the QPI target. This highlights the limited reliability that can be placed on these small numbers and is not an indication of a poor quality service. Where this is the case, it has been highlighted in the appropriate sections of the report. In addition, to preserve patient confidentiality, patient groups of less than four are described as small patient numbers throughout this report. Patient experience and clinical trial access QPIs that are applicable to the management of all tumour types are also in place. Measurement and reporting of the patient experience QPIs on a consistent national basis is still at an early stage. The QPIs can be found on the Healthcare Improvement Scotland website: ( mme_resources/cancer_qpis.aspx). Format of quality performance indicators QPIs are designed to be clear and measurable, based on sound clinical evidence whilst also taking into account other recognised standards and guidelines. Each QPI has a short title as well as a fuller description which explains exactly what the indicator is measuring. This is followed by a brief overview of the evidence base and rationale which explains why the development of this indicator was important. The measurability specifications are then detailed, highlighting how the indicator will actually be measured in practice to allow for comparison across NHSScotland. Finally a target is indicated, dictating the level which each unit should be aiming to achieve against each indicator. The National Cancer Quality Steering Group, which is a subgroup of the Scottish Cancer Taskforce, works with the clinical community to revise the QPIs as necessary when further evidence or data become available. This ensures that the chosen target levels are the most appropriate and help to support continuous quality improvement. Where QPIs have been revised or added during the three-year reporting period covered in this report, this has been highlighted in the relevant sections. 5

6 Review process Lung cancer is the most common cancer overall in Scotland for both sexes combined, representing 16% of all cancers. In 2015, 4,997 people were diagnosed with lung cancer in Scotland 3. Lung cancer services are available throughout Scotland. These services are arranged around units, with a number of units in each region providing care to their local population. The NHS boards and units responsible for the delivery of lung cancer services, and the regional cancer networks considered in the review, are detailed in Appendix 2a. Before the review, the review group was given lung cancer QPI data which covered a reporting period of Our review group (see Appendix 3) considered regional data as well as NHS board level data. These data provided the foundation of the Healthcare Improvement Scotland review. In order for the review group to fully understand these data, regional cancer networks were invited to submit an evidence pack of supporting information. This included: a position statement from each region and cancer network action plans for improvement, and clinical commentary for each QPI to provide the context for the data. Clinical and management representatives from each region were invited to attend the review. This was to make sure that each region was able to respond directly to questions raised about the provision of services in their area as well as allowing them to share practice and discuss the outcomes of the QPIs. The clinicians who attended the review were lung cancer clinical network leads, or deputies, who have knowledge of the services provided by all units in their areas. The review group considered each of the QPIs individually, looking at NHS board level data. This provided the review group with a sense of performance within a region for the reporting period. Through the process of the review, a picture of the performance against the QPIs developed. This has enabled the review group to make a number of national and regional recommendations, these are detailed in Appendix Incidence-Report.pdf 6

7 Summary of findings Areas of strength The review group concluded that regional cancer networks and NHS boards are using QPI data to make improvements to lung cancer services. There was evidence that NHS boards and their cancer networks are reviewing data and taking steps locally to address issues and improve compliance with the QPIs. These actions support compliance with the QPI targets and improvements to services for cancer patients. The three cancer regions consistently met or exceeded the targets set for QPI 3 (Bronchoscopy) and QPI 8 (Radiotherapy in inoperable lung cancer) in QPI 2 (Pathological diagnosis), QPI 4 (PET CT in patients being treated with curative intent), QPI 6 (Surgical resection in non-small cell lung cancer), QPI 9 (Chemoradiotherapy in locally advanced non-small cell lung cancer) and QPI 12 (Chemotherapy in small cell lung cancer) was also met by the majority of NHS boards in In relation to QPI 2 (Pathological diagnosis), NHS Fife and NHS Ayrshire & Arran implemented improvements to ensure sufficient tissue samples are available for epidermal growth factor receptor (EGFR) testing. As a result, both NHS boards achieved the relevant target in NHS Lothian undertook a review to identify why the target was not achieved for QPI 7 (Lymph node assessment) during 2013/14 and 2014/15. Following the review, standard surgical protocols were implemented and this has resulted in the NHS board exceeding the target in A WoSCAN multidisciplinary education event was held in September 2016 to raise awareness of the oncology data required for a number of QPIs. NHS Greater Glasgow and Clyde has also undertaken improvement work to support compliance with QPI 11 (Systemic anti-cancer therapy in non-small cell lung cancer) in the future. Areas for improvement The review group made a number of recommendations, but the most notable areas for improvement were in relation to the following areas: QPI 1: Multi-Disciplinary Team Meeting (MDT) The review group recommends that NOSCAN and SCAN investigate the reasons why lung cancer patients are not discussed at the MDT prior to definitive treatment, and implement any required actions. Within NOSCAN, only NHS Tayside achieved the target in Within the other NHS boards in the North region, it was reported that some patients may be under the care of another specialty and are not referred to the lung cancer MDT, or are referred but after treatment is initiated. It was also noted that patients may not want to travel for diagnosis and treatment, therefore no referral is made. Similar issues were identified in NHS Dumfries & Galloway, where it was noted that the target may not have been achieved because the patient s treatment was initiated elsewhere prior to discussion at the lung cancer MDT. 7

8 QPI 5: Investigation of mediastinal malignancy The review group recommends that the lung cancer QPI review group identifies a more robust measure of diagnosis of lung cancer that has spread to the mediastinum. It was reported that there are clinical complexities around the diagnosis of mediastinal malignancy which are not reflected in the QPI, and as a result there have been inconsistencies in interpretation of the QPI. The QPI has, therefore, been archived to allow further exploration of a suitable alternative measure. Due to the issues identified with this QPI, the review group was unable to draw any firm conclusions around performance against this QPI. As a result, the review group made a recommendation that the lung cancer QPI review group identifies a more robust measure of diagnosis of mediastinal malignancy. QPI 6: Surgical resection in non-small cell lung cancer The review group recommends that NOSCAN develops improvement action plans following on from the data sharing exercise between all three cancer networks to address the low resection rates in NOSCAN. These action plans should be submitted to Healthcare Improvement Scotland. A number of actions have been undertaken within NOSCAN to try and understand why the majority of the NHS boards in the region are not meeting the target for part one of the QPI. A review of past cases has also been carried out to identify whether decisions were clinically appropriate. It was noted that these actions did not identify any explanation. All three cancer regions have now agreed to share data in order to assist identify and resolve the issues faced by NOSCAN with lower than expected resection rates. QPI 7: Lymph node assessment The review group recommends that surgical and pathology processes for lymph node assessment be standardised across all three surgical centres. Assessment of lymph nodes helps to guide prognosis and further treatment for lung cancer patients. Only five NHS boards met the QPI target in Where the target was not achieved, it was reported that this was due to a number of factors, including inadequate samples being obtained, samples not being correctly labelled and incomplete data recording. In order to improve performance, SCAN has implemented surgical protocols which include standards for sampling and labelling. In addition, a template has been developed to support accurate recording of the required pathology data. WoSCAN is undertaking a similar exercise to improve reporting of lymph node assessment across the region. The review group noted that there should be a standard approach to how samples are obtained, reported and audited across the three regional cancer networks. 8

9 Our findings During the review process, an overlap in data collected for the third year of reporting was noted by the review group. This was due to the requirement to align the collection of lung cancer data to UK reporting timelines. Previously, NHS boards submitted lung cancer QPI data to ISD for the period 1 April to 31 March (known as financial year). This was changed from 2015 and NHS boards now collect data in calendar year format (January to December). This has resulted in a double count of data for the three-month period between 1 January 2015 and 31 March Through the course of the review meeting, members of the review group voiced a concern about the absence of a QPI to measure and set targets for best supportive care for lung cancer patients. It was noted that there was strong support from representatives within the cancer regions for the development of a best supportive care QPI as a welcome addition to the current suite of lung cancer QPIs to further improve cancer services to this group of patients. Recommendation: The review group recommends that the lung cancer QPI review group considers the development of a QPI to reflect the care that those patients designated for best supportive care, either at diagnosis or after treatment, should expect to receive. The remainder of this section will now focus on the review group s findings against each of the lung cancer QPIs. QPI 1: Multi-Disciplinary Team (MDT) Meeting Patients should be discussed by a multidisciplinary team prior to definitive treatment. The target for this QPI is 95%. This QPI was introduced to the suite of lung cancer QPIs in November This QPI applies to cases diagnosed from 1 April Due to the recent addition of this QPI, only two years of data (2014/15 and 2015) were available to the review group for consideration. 2014/ NOSCAN 91% 92% SCAN 95% 95% WoSCAN 95% 96% in 2015 Six NHS boards did not meet the target. These were NHS Grampian (93%), NHS Highland (85%), NHS Orkney (89%), NHS Shetland (90%), NHS Western Isles (91%) and NHS Dumfries & Galloway (85%). 9

10 Findings For those NHS boards that did not achieve the target, several reasons were reported. These included patients being treated by another specialty and not referred to the MDT, or referred after treatment was initiated. Some patients also required emergency treatment and so it was deemed clinically appropriate to proceed with treatment rather than wait for an MDT discussion. It was also noted that patients may not want to travel for treatment, particularly those from island NHS boards, therefore no referral was made to the lung cancer MDT. The island NHS boards have identified actions to raise awareness of the importance of referring lung cancer patients to the MDT. These are at various stages of implementation. The review group concluded that the relevant NHS boards should undertake a review of those lung cancer patients that did not get referred to the MDT to identify why this was the case and any remedial actions required. It would also be useful to revise the QPI to ensure that, where patients choose not to travel for treatment, they are excluded from the QPI. Recommendation The review group recommends that NHS Grampian, NHS Highland, NHS Orkney, NHS Shetland, NHS Western Isles and NHS Dumfries & Galloway investigate and consider the reasons why lung cancer patients were not discussed at the MDT prior to definitive treatment during the reporting period, and implement any required actions for improvement. 10

11 QPI 2: Pathological diagnosis Where possible patients should have a pathological diagnosis of lung cancer. This QPI measures three distinct elements: (1) Patients with lung cancer who have a pathological diagnosis; (The target for part one is 75%.) (2) Patients with a pathological diagnosis of non-small cell lung cancer (NSCLC) who have tumour sub-type identified; and (The target for part two is 80%.) (3) Patients with a pathological diagnosis of NSCLC who have analysis or predictive markers undertaken. (The target for part three is 75%.) This QPI was updated in February This revised version of the QPI relates to cases diagnosed from 1 April NOSCAN SCAN WoSCAN in / / (1) 88% (2) 85% (3) 63% (1) 84% (2) 84% (3) 59% (1) 86% (2) 85% (3) 65% (1) 90% (2) 90% (3) 85% (1) 90% (2) 90% (3) 80% (1) 86% (2) 90% (3) 79% (1) 86% (2) 87% (3) 80% (1) 80% (2) 91% (3) 80% (1) 86% (2) 90% (3) 86% All NHS boards consistently met part one and part three of the QPI in All NHS boards, with the exception of NHS Orkney, met part two of the target for Findings On review of the QPI data, NHS Fife identified that for a small number of patients, epidermal growth factor receptor (EGFR) testing could not be carried out due to insufficient tissue samples. Pathologists are now encouraged to review samples in order to ensure sufficient samples, of the correct quality, are obtained. NHS Ayrshire & Arran identified a similar issue and put in place measures to address this issue. As a result, both NHS boards achieved part three of the target in

12 QPI 3: Bronchoscopy Patients with lung cancer who are undergoing bronchoscopy for purposes of diagnosis and staging should have a CT thorax prior to bronchoscopy. Proportion of patients with lung cancer who have undergone bronchoscopy where CT thorax was performed prior to bronchoscopy. The target for this QPI is 95%. 2013/ / NOSCAN 93% 96% 98% SCAN 99% 98% 99% WoSCAN 96% 98% 99% in 2015 Findings All NHS boards within the three cancer regions consistently met the target in It was noted that this QPI is being archived as part of the revision of the lung cancer QPIs. However, data will still be collected to allow NHS boards to continue to consider performance. QPI 4: PET CT in patients being treated with curative intent Patients with lung cancer who are being treated with curative intent should have a PET CT Scan (Positron Emission Tomography-Computed Tomography) prior to treatment. Proportion of patients with NSCLC who are being treated with curative treatment (radical radiotherapy, radical chemoradiotherapy or surgical resection) who undergo PET CT prior to start of treatment. The target for this QPI is 95%. 2013/ / NOSCAN 97% 99% 97% SCAN 99% 99% 97% WoSCAN 97% 97% 98% All NHS boards within all three cancer regions consistently met the target 12

13 in 2015 during 2015 with the exception of NHS Borders (92%). Findings NHS Borders did not meet the target in 2015 due to a very small number of patients who did not have a full PET CT scan prior to treatment. The NHS board clearly identified the reasons for this and the review group was satisfied that appropriate clinical decisions were made. QPI 5: Investigation of mediastinal malignancy Patients with NSCLC with a possibility of mediastinal malignancy demonstrated on PET CT should undergo node sampling to confirm mediastinal malignancy. Proportion of patients with NSCLC undergoing treatment with curative intent who have positive mediastinal/supraclavicular fossa (SCF) nodes on PET CT scan who undergo node sampling. The target for this QPI is 80%. This QPI was amended in February 2015 to include patients undergoing treatment with curative intent. Previously, this QPI stated, patients with a NSCLC who have positive mediastinal/supraclavicular fossa (SCF) nodes on PET CT scan who undergo node sampling. This revised version of the QPI relates to cases diagnosed from 1 April This QPI was amended in February 2015 to try and better reflect the clinical complexities associated with the diagnosis of mediastinal malignancy. However, issues with inconsistent interpretation of the QPI remained and the National Cancer Quality Steering Group made the decision to archive the QPI to allow further consideration of a suitable alternative measure for diagnosis of malignancy. The review group, therefore, was unable to draw any conclusions around the quality of service across all three regional cancer networks. The review group recommends that the lung cancer QPI review group identifies a more robust measure of diagnosis of lung cancer that has spread to the mediastinum. 13

14 QPI 6: Surgical resection in non-small cell lung cancer Patients with NSCLC should undergo surgical resection. Proportion of patients who undergo surgical resection for NSCLC. Please note: This QPI measures two distinct elements: (1) Patients with NSCLC who undergo surgical resection; and (The target for part one is 17%.) (2) Patients with stage I II NSCLC who undergo surgical resection. (The target for part two is 50%.) NOSCAN SCAN WoSCAN in / / (1) 17% (2) 60% (1) 26% (2) 79% (1) 25% (2) 69% (1) 15% (2) 57% (1) 24% (2) 65% (1) 24% (2) 67% (1) 15% (2) 53% (1) 23% (2) 65% (1) 27% (2) 72% All NHS boards within SCAN and WoSCAN consistently met both targets during NHS Grampian (15%) and NHS Highland (12%) did not meet the target for part one of the QPI in NHS Tayside did not meet the targets for both elements of the QPI in 2015, achieving 12% and 46% respectively. Findings A number of actions have been undertaken within NOSCAN to try and understand why the majority of the NHS boards in the region are not meeting the target for part one of the QPI. This included a review of past cases to identify whether decisions were clinically appropriate and attendance of some NOSCAN clinicians at a WoSCAN multi-disciplinary team meeting. It was noted that these actions did not identify any explanation. All three cancer regions have now agreed to share data in order to assist identify and resolve the issues faced by NOSCAN with lower than expected resection rates. The review group noted the efforts made by NOSCAN to identify why the relevant NHS boards are not achieving the targets for surgical resection. The review group also welcomed the plans for data to be shared across all three regional cancer networks. Recommendation The review group recommends that NOSCAN develops improvement action plans following on from the data sharing 14

15 exercise between all three cancer networks to address the low resection rates in NOSCAN. These action plans should be submitted to Healthcare Improvement Scotland. QPI 7: Lymph node assessment In patients with NSCLC undergoing surgery, adequate assessment of lymph nodes should be made. Proportion of patients with NSCLC undergoing surgery who have adequate sampling of lymph nodes (at least 1 node from at least 3 N2 stations) performed at time of surgical resection or at previous mediastinoscopy. The target for this QPI is 80%. This QPI was updated in February 2015 with the following amendments: The requirement that the assessment of lymph nodes having to take place at the time of surgical procedure has been removed. Numerator now states, at least 1 node from at least 3 N2 stations. Previously the QPI required 6 or more lymph nodes, at least 3 nodes from N1 stations and 3 nodes from N2 stations. This revised version of the QPI relates to cases diagnosed from 1 April Due to the amendment of the QPI, the review group was only able to consider comparable data for 2014/15 and It should be noted that only three hospitals in Scotland provide surgical services for lung cancer patients and are listed in Appendix 2b. The performance table below is shown by hospital of surgery and not by the regional cancer network. 2014/ Aberdeen Royal Infirmary Royal Infirmary of Edinburgh 56% 60% 78% 83% Golden Jubilee 74% 77% in 2015 During 2015, only the Royal Infirmary of Edinburgh met the target. The Golden Jubilee Hospital narrowly missed the target achieving 77%. Findings Where the target was not achieved, it was reported that this was due to a number of factors, including inadequate samples being obtained, samples not being correctly labelled and incomplete data recording. In order to improve performance, SCAN has implemented surgical protocols which include standards for sampling and labelling. In addition, a template has been 15

16 developed to support accurate recording of the required pathology data. WoSCAN has undertaken a similar exercise to improve reporting of lymph node assessment across the region. The review group noted that there should be a standard approach to how samples are obtained, reported and audited across all three surgical centres. Recommendation The review group recommends that surgical and pathology processes for lymph node assessment be standardised across all three surgical centres. QPI 8: Radiotherapy in inoperable lung cancer Patients with inoperable lung cancer should receive radiotherapy and chemotherapy. Proportion of patients with lung cancer not undergoing surgery who receive radiotherapy with curative intent (54Gy or greater) and chemotherapy. The target for this QPI is 15%. This QPI was amended in February 2015 to include an additional exclusion within the specification. Patients with stage IV (M1a or M1b) disease. This revised version of the QPI relates to cases diagnosed from 1 April Due to the amendment of the QPI, the review group was only able to consider comparable data for 2014/15 and / NOSCAN 34% 33% SCAN 49% 47% WoSCAN 34% 37% in 2015 All NHS boards met the target during Findings This QPI target will be increased to 35% for future reporting years. Representatives from NOSCAN noted that radiotherapy resources within NHS Grampian are limited and a planned increase to the target will cause challenges for this NHS board going forward. Other regions reported that they will take account of the increased target for this QPI and will build this into forward plans for radiotherapy delivery. 16

17 QPI 9: Chemoradiotherapy in locally advanced non-small cell lung cancer Patients with inoperable locally advanced NSCLC should receive potentially curative radiotherapy and concurrent or sequential chemotherapy. Proportion of patients with NSCLC not undergoing surgery who receive radical radiotherapy, to 54Gy or greater, and concurrent or sequential chemotherapy. The target for this QPI is 50%. This QPI was amended in February 2015 which resulted in one exclusion being removed from the specification. This exclusion is, patients receiving stereotactic radiotherapy. This revised version of the QPI relates to cases diagnosed from 1 April Due to the amendment of the QPI, the review group was only able to consider comparable data for 2014/15 and / NOSCAN 68% 73% SCAN 70% 83% WoSCAN 56% 61% in 2015 All NHS boards, except NHS Ayrshire & Arran (40%), met the target in Findings NHS Ayrshire & Arran did not meet the target due to small patient numbers. The review group was assured that these patients were reviewed and that clinically appropriate decisions had been made. 17

18 QPI 10: Chemoradiotherapy in limited stage small cell lung cancer Patients with limited stage small cell lung cancer (SCLC) should receive platinumbased chemotherapy and (concurrent or sequential) radiotherapy. Proportion of patients with limited stage (stage I IIIB) SCLC treated with radical intent who receive both platinum-based chemotherapy, and radiotherapy to 40Gy or greater. The target for this QPI is 70% 2013/ / NOSCAN 44% 70% 59% SCAN 62% 75% 73% WoSCAN 27% 42% 68% in 2015 During 2015, six NHS boards did not meet the target. These were NHS Grampian (60%), NHS Highland (57%), NHS Tayside (50%), NHS Dumfries and Galloway (33%), NHS Forth Valley (50%) and NHS Greater Glasgow and Clyde (62%). Findings Representatives from all three regional cancer networks provided assurance that appropriate clinical decisions were made for those patients who did not receive platinum-based chemotherapy and radiotherapy. It was further noted that this QPI only applies to a very small number of patients within some NHS boards, which makes it difficult to draw any clear conclusions from the data. 18

19 QPI 11: Systemic anti-cancer therapy in non-small cell lung cancer Patients with inoperable non-small cell lung cancer (NSCLC) should receive systemic anti-cancer therapy, where appropriate. Proportion of patients with NSCLC not undergoing surgery who receive platinumbased chemotherapy. Please note: This QPI measures two distinct elements: (1) Patients with NSCLC who receive systemic anti-cancer therapy; and (The target for part one is 35%.) (2) Patients with stage IIIB and IV NSCLC receive doublet chemotherapy including platinum as their first line regimen. (The target for part two is 60%.) NOSCAN SCAN WoSCAN in / / (1) 41% (1) 46% (1) 44% (2) 57% (2) 73% (2) 67% (1) 39% (1) 37% (1) 37% (2) 50% (2) 61% (2) 67% (1) 37% (1) 37% (1) 35% (2) 58% (2) 57% (2) 53% During 2015, four NHS boards did not meet part one of the target. These were NHS Grampian (34%), NHS Shetland (25%), NHS Fife (30%) and NHS Greater Glasgow and Clyde (27%). In the same audit year, NHS Grampian (54%), NHS Fife (57%) and NHS Greater Glasgow and Clyde (41%) did not meet part two of the target. Findings Representatives from NOSCAN and SCAN reported that where the targets were not met, this was generally as a result of patients choosing not to have the treatment, co-morbidity issues or poor performance status. The review group was assured that appropriate clinical decisions were made for those patients who did not receive systemic anti-cancer therapy. Improvement work is under way in NHS Greater Glasgow and Clyde to assist with future compliance with this QPI. A review of patients who 19

20 did not receive systemic anti-cancer therapy is planned to provide further detail on those cases not meeting the QPI targets. In addition, a WoSCAN education event was held in September 2016, to ensure staff are aware of the data that should be recorded and reported for this QPI. This QPI is expected to be revised in the future to take account of the increased use of biological therapy which will result in a change to the treatment approach for relevant patients. QPI 12: Chemotherapy in small cell lung cancer Patients with small cell lung cancer (SCLC) should receive chemotherapy. Proportion of patients with SCLC who receive first line chemotherapy and radiotherapy. Please note: This QPI measures two distinct elements: (1) All patients with SCLC; and (The target for part one is 70%.) (2) All patients with SCLC not undergoing treatment with curative intent (The target for part two is 50%.) This QPI was amended in February 2015 to measure two distinct elements as outlined above (1 and 2). In addition this QPI was previously specified to measure patients who receive chemotherapy with palliative intent alone. This revised version of the QPI relates to cases diagnosed from 1 April Due to the amendment of the QPI, the review group was only able to consider comparable data for 2014/15 and NOSCAN SCAN WoSCAN in / (1) 78% (1) 77% (2) 73% (2) 71% (1) 77% (1) 71% (2) 72% (2) 65% (1) 82% (1) 83% (2) 76% (2) 78% During 2015, all NHS boards met both parts of the QPI with the exception of NHS Fife. Findings In 2015, NHS Fife achieved 59% for part one of the target and 48% for part two of the target.the review group recognised the challenges in 20

21 meeting this QPI as the treatment can be demanding and performance status will dictate the patient s ability to withstand treatment. However, it was also noted that NHS Fife has experienced delays between diagnosis and treatment starting. NHS Fife advised the review group that work is currently under way to investigate this issue further. QPI 13: Mortality following treatment for lung cancer 30 and 90 day mortality following treatment for lung cancer. Proportion of patients with lung cancer who die within 30 or 90 days of active treatment for lung cancer. Please note: This QPI measures two distinct elements: (1) Surgery, Radical Radiotherapy, Adjuvant Chemotherapy, Radical Chemoradiotherapy and Palliative Chemotherapy; and (The target for part one is <5%.) (2) Biological Therapy (excluded from 90 day mortality) (The target for part two is <10%.) This QPI was amended in February 2015 to include 90 day mortality. In addition, the QPI was split to measure mortality for patients receiving specific treatments at both 30 and 90 days. This is outlined above (1 and 2). Cause of death data was not available to assist the review group in its interpretation of mortality data. This was particularly evident for biological therapy due to the nature of prescribing. The patient is prescribed biological therapy in tablet form as an outpatient which they take at home. Therefore, in some cases, the cause of death cannot be ascertained because patients may become too unwell to continue the biological treatment due to tumour progression. It was also noted that this specific target within the QPI is measured from the start date of treatment which also poses issues with interpretation of data. The review group also noted the known risks associated with the delivery of palliative chemotherapy when tumour progression is likely. Although palliative chemotherapy is delivered to improve symptoms rather than increase lifespan, patients should be kept under review to determine cause of death, so that disease progression and treatment-related causes can be separately identified where possible. It is also important to note that for a significant number of NHS boards, the mortality data reflects small patient numbers. When represented as a percentage, small numbers can significantly distort the result and does not necessarily reflect a poor service. For example, an island NHS board may only have two patients with lung cancer receiving active treatment. If one of these patients dies within 30 days, it is impossible for the NHS board to meet the QPI targets. 21

22 As a result, the review group was unable to draw any meaningful conclusions on treatment related mortality across all three regional cancer networks. However, it was noted that it is important that all NHS boards ensure that mortality reviews are carried out to identify if any changes to practice are required. Recommendation When QPI 13 is scheduled for review, incorporation of cause of death data and mortality reviews should be considered. QPI for Clinical Trials Access All patients should be considered for participation in available clinical trials, wherever eligible. Proportion of patients with lung cancer who are enrolled in an interventional clinical trial or translational research. This QPI states that all patients should be considered for participation in available clinical trials, wherever eligible. The target for participation in interventional trials is 7.5%, and for translational research it is 15%. Data was only provided at regional level in NOSCAN. More detailed information will be provided in the future when patients postcode information is available to enable analysis by NHS board of residence. SCAN and WoSCAN provided an analysis of clinical trials data at an NHS board level as part of their evidence submission Interventional Translational NOSCAN 0.4% 5.9% SCAN 0.7% 1.8% WoSCAN 1.9% 0.4% in 2014/15 None of the NHS boards achieved the targets in Findings As previously indicated in Healthcare Improvement Scotland reports on tumour-specific cancer QPIs, the review group heard that these are very challenging targets. Admission to clinical trials continues to be problematic for all NHS boards due to the rigorous selection criteria. Representatives noted that it may, therefore, be more useful for the QPI to focus on the number of patients screened for clinical trials rather than the number recruited into the trial. Work is under way to review the clinical trials QPI (for all tumour groups), and future reporting will measure the proportion of patients screened for trials and will combine both interventional and translational trials. 22

23 Appendix 1 National and regional recommendations Recommendations The review group found that there were a number of recommendations for the lung cancer community within NHSScotland. Some of the recommendations made during the review were particular to specific NHS boards and regional cancer networks. The responsible regional lung cancer network leads should consider these recommendations within their local clinical community. Some of the recommendations relate to the national clinical group who developed the cancer QPIs and the associated targets. The national QPI group should consider the points raised by the review group and consider any specific feedback provided by the regional cancer network leads. The context for the recommendations listed below is detailed in the report. Our findings The review group recommends: The review group recommends that the lung cancer QPI review group be asked to develop a QPI reflecting the care that those patients designated for best supportive care, either at diagnosis or after treatment, should expect to receive. QPI 1: Multi-Disciplinary Team (MDT) Meeting The review group recommends: The review group recommends that NHS Grampian, NHS Highland, NHS Orkney, NHS Shetland, NHS Western Isles and NHS Dumfries & Galloway investigate and considers the reasons why lung cancer patients were not discussed at the MDT prior to definitive treatment during the reporting period, and implement any required actions for improvement. QPI 5: Investigation of mediastinal malignancy The review group recommends: The review group recommends that the lung cancer QPI review group identifies a more robust measure of diagnosis of lung cancer that has spread to the mediastinum. QPI 6: Surgical resection in non-small cell lung cancer The review group recommends: The review group recommends that NOSCAN develop improvement action plans following on from the data sharing exercise between all three cancer networks to address the low resection rates in NOSCAN. These action plans should be submitted to Healthcare Improvement Scotland. QPI 7: Lymph node assessment The review group recommends: The review group recommends that surgical and pathology processes for lymph 23

24 node assessment be standardised across all three surgical centres. QPI 13: Mortality following treatment for lung cancer The review group recommends: When QPI 13 is scheduled for review, incorporation of cause of death data and mortality reviews should be considered. 24

25 Appendix 2a Regional cancer networks Where an NHS board has more than one hospital delivering cancer care, these have been listed below the NHS board. North of Scotland Cancer Network (NOSCAN) NHS Grampian Aberdeen Royal Infirmary Dr Gray s Hospital NHS Shetland Gilbert Bain Hospital NHS Orkney Balfour Hospital NHS Highland Belford Hospital Broadford Hospital Caithness Hospital Mid Argyll Community Hospital and Integrated Care Centre (ICC) Lorn & Islands Hospital Raigmore Hospital NHS Tayside Ninewells Hospital Perth Royal Infirmary NHS Western Isles Western Isles Hospital South East Scotland Cancer Network (SCAN) NHS Borders Borders General Hospital NHS Fife Queen Margaret Hospital Victoria Hospital NHS Dumfries & Galloway Dumfries & Galloway Royal Infirmary Galloway Community Hospital NHS Lothian St John s Hospital Western General Hospital West of Scotland Cancer Network (WoSCAN) NHS Ayrshire & Arran Ayr Hospital Crosshouse Hospital NHS Greater Glasgow and Clyde Beatson West of Scotland Cancer Centre Inverclyde Royal Hospital New Victoria Hospital Queen Elizabeth Hospital Royal Alexandria Hospital Stobhill Hospital Vale of Leven Hospital NHS Forth Valley Forth Valley Royal Hospital NHS Lanarkshire Hairmyres Hospital Monklands Hospital Wishaw General Hospital 25

26 Appendix 2b Surgical centres in Scotland North of Scotland Cancer Network (NOSCAN) NHS Grampian Aberdeen Royal Infirmary South East Scotland Cancer Network (SCAN) NHS Lothian Edinburgh Royal Infirmary West of Scotland Cancer Network (WoSCAN) NHS Greater Glasgow and Clyde Golden Jubilee 26

27 Appendix 3 Review group membership Review group Dr Mike Cornbleet, Chair Ms Belinda Henshaw, Senior Programme Manager Mrs Sue Lovatt, Programme Manager Mrs Stephanie Macmillan, Project Officer Mrs Stella Macpherson, Public Partner Mr Howard McNulty, Public Partner Ms Linda Richmond, Administrative Officer Dr Nadeem Siddiqui, Clinical Advisor Regional representatives South East Scotland Cancer Network Lorna Bruce, Audit Manager Jan McClean, Director of Regional Planning Colin Selby, Clinical Lead North of Scotland Cancer Network Jaime Lyon, MCN Manager Hardy Remmen, Clinical Lead Christine Urquhart, Cancer Audit & Information Manager West of Scotland Cancer Network Tracey Cole, Lung Cancer MCN Manager Carol Marshall, Information Manager National Services Scotland John Connor, Principle Information Analyst John McPhelim, Clinical Lead Evelyn Thomson, Regional Manager 27

28 Appendix 4 Glossary of terms adenocarcinoma adjuvant therapy biopsy carcinoma chemoradiotherapy chemotherapy clinical trials combined modality co-morbidities computerised tomography (ct) core biopsy curative intent cytological diagnosis epidermal growth factor receptor (EGFR) excision Cancer that begins in cells that line certain internal organs and that have gland-like (secretory) properties. Treatment given in addition to other treatment, for example chemotherapy or radiotherapy given as well as surgery. Removal of tissue to be looked at under a microscope. The medical term for cancer. Treatment that combines chemotherapy with radiotherapy. Treatment aimed at destroying cancer cells using anti-cancer drugs, which are also called cytotoxic drugs. A type of research study that tests how well new medical approaches or medicines work. These studies test new methods of screening, prevention, diagnosis, or treatment of a disease. Intergrated use of two or more different treatments (surgery, chemotherapy, radiotherapy) to combat the cancer. One or more additional disorders (or diseases) occurring at the same time as a primary disease or disorder. An X-ray imaging technique, which allows detailed investigation of the internal organ of the body. Biopsy using a hollow needle to take a sample(s) of tissue for analysis under a microscope. Treatment which is given with the aim of curing the cancer. The study of the structure and function of cells under the microscope, and of their abnormalities. The process of identifying a disease, such as cancer, from its signs and symptoms. The protein found on the surface of cells and to which epidermal growth factor binds, causing the cells to divide. It is found at abnormally high levels on the surface of cancer cells. Surgical removal. 28

29 extensive stage disease fine needle aspiration (FNA) histological/histopathological hyperfractionated radiotherapy immunohistochemistry (IHC) Information Services Division (ISD) inoperable invasive cancer limited stage SCLC lobectomy lung cancer lymph nodes malignancy Cancer that has spread beyond the initial site of development and is not usually possible to cure by local measures alone. Using a fine needle and syringe to take a sample of cells for analysis under a microscope. The study of the structure, composition and function of tissues under the microscope, and their abnormalities. Radiotherapy treatment in which the total dose of radiation is divided into small doses and treatments are given more than once a day. Identification of specific proteins by staining tissues with antibodies A division of NHS National Services Scotland (NSS), part of NHSScotland. ISD provides health information, health intelligence, statistical services and advice that support the NHS in progressing quality improvement in health and care. Describes a condition too extensive to be treated by surgery. Has the potential to spread to other parts of the body. A staging classification for small cell lung cancer developed by the Veterans Administration Lung Study Group. Using the 7 th edition of the TNM staging system this broadly includes T1-4, N1-3, M0 disease. A surgical procedure that is used to take out a segment of the lung (called a lobe). There are two types of primary lung cancer: Small Cell Lung Cancer (SCLC) and Non-small Cell Lung Cancer (NSCLC) which behave and respond to treatment differently. Also known as lymph glands. Small ovalshaped structures found in clusters throughout the lymphatic system, for example under the arm (axilla). Cancerous. Malignant cells can invade and destroy nearby tissue and spread to other parts of the body. 29

30 mediastinal malignancy metastatic morbidity morphology mortality multi-disciplinary team (MDT) nodal metastatic disease node positive non-operative diagnosis non-small cell lung cancer (NSCLC) palliative treatment pathological performance status Cancerous growths that form in the area of the chest that separates the lungs. This area, called the mediastinum, is surrounded by the breastbone in front, the spine in back, and the lungs on each side. The mediastinum contains the heart, aorta, oesophagus, thymus and trachea. Spread of cancer away from the primary site to somewhere else via the bloodstream or the lymphatic system. How much ill health a particular condition causes. Microscopic appearance. Either (1) the condition of being subject to death; or (2) the death rate, which reflects the number of deaths per unit of population in any specific regions, age group, disease or other classification, usually expressed as deaths per 1000, or 10,000 or, 100,000 A team of clinicians from a variety of disciplines including nursing, oncology, surgery and pharmacy. See node positive Spread of cancer to nearby lymph nodes Diagnosis by core or large volume biopsy without removal of the tumour. The most common type of lung cancer representing between 70-80% of cases. There are three types of NSCLC: Squamous Cell Carcinoma, Adenocarcinoma and Large Cell Carcinoma. Anything which serves to alleviate symptoms due to the underlying cancer, but is not expected to cure it. The study of disease processes with the aim of understanding their nature and causes. This is achieved by observing samples of fluid and tissues obtained from the living patient by various methods, or at post-mortem examination. A measure of how well a patient is able to perform ordinary tasks and carry out daily activities (for example, WHO score of 0=asymptomatic, 4=bedridden). 30

31 peripheral tumour platinum-based chemotherapy pneumonectomy positron emission tomography / computed tomography (PET CT) predictive markers primary tumour prognosis quality performance indicator (QPI) radical treatment radiotherapy small cell lung cancer (SCLC) staging sterotactic radiotherapy surgery/surgical resection surgical margin An abnormal mass of tissue situated in subsegmental bronchi and is not usually visible on bronchoscopy. Chemotherapy drugs that contain derivatives of the metal platinum. An operation to remove an entire lung. A specialised imaging technique which demonstrates uptake of tracer in areas of high cell metabolism and can help differentiate between benign and malignant masses. It is most frequently used to help stage lung cancer by demonstrating or excluding distant metastases. A finding that can be used to help predict whether a person s cancer will respond to a specific treatment. May also describe something that increases a person s risk of developing a condition or disease. Original site of the cancer. The mass of tumour cells at the original site of abnormal tissue growth. An assessment of the expected future course and outcome of treatment. A proxy measure of quality care. Treatment which is given with the aim of destroying cancer cells to attain cure. The use of high energy X-rays to destroy cancer cells. A type of lung cancer in which the cells are small and round. SCLC is often fast growing and can spread quickly. Process of describing to what degree cancer has spread from its original site to another part of the body. Staging involves clinical, surgical and pathology assessments. See TNM classification. A type of external radiotherapy that uses special equipment to position the patient and precisely deliver radiation to a tumour. Surgical removal of the tumour/lesion. How close the cancer cells are to the edges of the whole area of tissue removed during surgery. 31

32 survival systemic anti-cancer therapy (SACT) thoracoscopy tissue TNM classification toxicity tumour unit well-differentiated The percentage of people in a study or treatment group who are alive for a certain period of time after they were diagnosed with or treated for a disease, such as cancer. Treatment of cancer using drugs which induce a reduction in tumour cell population, for example cancer chemotherapy or hormone therapy. Thoracoscopy is the insertion of an endoscope, a narrow diameter tube with a viewing mirror or camera attachment, through a very small incision (cut) in the chest wall. A group or layer of cells that work together to perform a specific function. TNM classification provides a system for staging the extent of cancer. T refers to the size of the primary tumour. N refers to the involvement of the lymph nodes. M refers to the presence of metastases or distant spread of the disease. The extent to which something is poisonous or harmful. An overgrowth of cells forming a lump; may be benign (not cancer) or cancer. Centre for delivering care. Cancer in which the cells are mature and look like cells in the tissue from when it arose. Differentiated cancers tend to be decidedly less aggressive than undifferentiated cancer composed of immature cells. 32

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