Cancer National Specialist Advisory Group. WALES BOWEL CANCER AUDIT REPORT FOR PATIENTS DIAGNOSED APRIL 2009-MARCH 2010 and AUGUST 2010-JULY 2011

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1 WALES BOWEL CANCER AUDIT REPORT FOR PATIENTS DIAGNOSED APRIL 2009-MARCH 2010 and AUGUST 2010-JULY 2011 Published 2013

2 FOREWORD I am delighted to introduce the Wales Bowel Cancer Audit Report. This document includes data on over 4000 patients treated by the 13 Multidisciplinary teams (MDTs) in Wales. It is gratifying that the quality of data captured has continued to improve, making the exercise useful and meaningful. As the Cancer National Specialist Advisory Group (NSAG) colorectal quality indicators have been met by MDTs in all but a few cases, we will look at introducing new indicators in time for the next audit that will focus in on the clinical priorities for colorectal cancer services in NHS Wales and complement the findings of the UK National Bowel Cancer Audit. The 30 day mortality rate after surgery has continued to fall. However, emergency surgery is still required in 20% of operated patients in Wales and is associated with a far higher risk of post-operative death. Over 20% of patients presented with metastatic disease. It is hoped that the Bowel Cancer Screening Programme will alter these figures in the next few years. There has been a general increase in the use of laparoscopic surgery, whilst there is still room for improvement in the uptake rates in some units, the figures are encouraging and are testament to the formalised laparoscopic training and mentorship that has been supported by the Welsh Government (WG) and provided at the Welsh Institute for Minimal Access Therapy in recent years. The audit shows variation in the management of rectal cancer across Wales. Specifically, there are differences in the use of radiotherapy, the rates of permanent colostomy and complete surgical removal. The Colorectal Cancer (NSAG) will be considering these issues with a view to supporting a multidisciplinary training programme similar to the Department of Health s Low Rectal Cancer National Development Programme (LOREC). I am extremely grateful to the MDT co-ordinators and their clinical teams for the quality of their data returns and also Linda Roberts, Rebecca Thomas, Julie Howe for expert data analysis that has been guided by our clinical audit leads, Martyn Evans and Gethin Williams. Finally, I must thank Louise Carrington and Jane Hanson of the Cancer NSAG Core Team for their efforts in coordinating and editing the final report. Mark Davies (Chair Cancer NSAG Colorectal Group) 2

3 Acknowledgments This audit report was prepared on behalf of the Cancer National Specialist Advisory Group (NSAG) Colorectal subgroup by: Martyn Evans, Consultant Colorectal Surgeon, Singleton and Morriston Hospital, Swansea, Abertawe Bro Morgannwg University Health Board (ABMUHB) Gethin Williams, Consultant Colorectal Surgeon, Royal Gwent Hospital, Newport, Aneurin Bevan Health Board (ABHB) Rebecca Thomas, Senior Statistician, Welsh Cancer Intelligence and Surveillance Unit (WCISU) Julie Howe, Statistical Analyst, WCISU Linda Roberts, Canisc Information Specialist for Colorectal Cancer, Cancer Information Framework (CIF) Louise Carrington, Programme Coordinator, Cancer NSAG Core Team. Advice and comments were gratefully received from: Hayley Heard, Head of Bowel Cancer Screening Programme, Public Health Wales Andrew Maw, Consultant Colorectal Surgeon, Betsi Cadwaladr University Health Board (BCUHB), Lead for Colorectal Cancer North Wales Jane Hanson, Head of the Cancer NSAG Core Team Mark Davies, Consultant Surgeon, ABMUHB, Chair of the Colorectal subgroup of the Cancer NSAG Jared Torkington, Consultant Colorectal Surgeon, Cardiff and Vale LHB (C&VUHB), and Lead of Welsh Laparoscopic Colorectal Training Scheme Jeff Stamatakis, Retired consultant General Surgeon, former clinical audit lead for colorectal cancer (Wales) and former chair of the National Bowel Cancer Audit Project (NBOCAP). Thanks should also go to all MDTs, including data and administration staff, without whose work this report would not have been possible. Contacts Queries concerning this report should be directed in the first instance to the Cancer NSAG Core team at 3

4 Contents FOREWORD... 2 Acknowledgments... 3 Contacts... 3 Executive summary... 5 Recommendations... 7 Introduction Data collection Data presentation Risk adjusted mortality logistic regression Funnel plots Data quality Case ascertainment Completeness of key fields Number and distribution of newly diagnosed bowel cancers Procedures used in the surgical treatment of bowel cancer Operation and resection rates Stage of disease at presentation Surgical urgency of operated patients Co-morbidity day mortality following surgery for bowel cancer Use of laparoscopic surgery in Wales Length of stay Rectal cancer Use of radiotherapy Circumferential margin involvement APER rates Clinical outcomes Lymph node harvest Extra-mural vascular invasion National Specialist Advisory Group Clinical Indicators Bowel screening Screening demographics Surgical treatment Stage at presentation of screen detected cancers Laparoscopic surgery for screen-detected cancers Post operative mortality for screen detected cancers APPENDIX 1: Data set used in NBOCAP/WBCA

5 APPENDIX 2: NCEPOD operative urgency classification APPENDIX 3: American Society of Anesthesiology Grading System APPENDIX 4: Odds ratios for 30 day mortality following surgery calculated from the WBCA risk adjustment model APPENDIX 5: DATA APPENDIX 6: REFERENCES Executive summary This is the 6 th audit report of colorectal cancer in Wales. It is based on clinical information from patients diagnosed during 2 periods: 1 st April st March 2010 and 1 st August st July Only those treated by MDTs in Welsh Health Boards are included. Audit data on this cohort of patients is also submitted to the NHS Information Centre for inclusion in the National Bowel Cancer Audit Program (NBOCAP). Where possible we have benchmarked against the NBOCAP report (published December 2012). Data quality link to section The data quality has improved dramatically since the first Welsh audit in Case ascertainment is currently 100%. Data completeness of the five variables used in the calculation of risk adjusted postoperative mortality is at 100% for age, urgency of surgery, operation type; 81% for Dukes stage and 96% for ASA grade. Central validation of data revealed errors with stage and postoperative death reports. These were corrected prior to carrying out statistical analysis. Clinical profile of colorectal cancer in Wales link to section Just over 2000 people were diagnosed with colorectal cancer in each audit year. In 2009/10, 77% of colon cancer patients and 67% of rectal cancer patients underwent a resection. In 2010/11 the figures were 75% for colonic resections and 56% for rectal cancer resections. Over 20% of patients present with metastatic disease. Emergency surgery represented one-fifth of all operations for colorectal cancer. 5

6 Mortality rate link to section The overall 30 day mortality rate following surgery has fallen to its lowest level since the first report ten years ago. Non-adjusted 30 day mortality following elective colorectal surgery in both audit years was 3%. For emergency surgery the mortality rates were higher (16% in 2009/10 and 11% in 2010/11). For the first time this report provides a calculation for riskadjusted mortality results for individual hospitals based on 3 years of consecutive data. Lymph nodes link to section Lymph node yield is held as a quality indicator for surgery and pathological assessment. The number of lymph nodes examined in patients having major resection surgery has remained static over the last three years. Over 60% of patient specimens achieve the national standard agreed for accurate staging by reporting on 12 or more lymph nodes. Laparoscopic surgery & length of stay link to section The proportion of elective/scheduled laparoscopic operations performed has increased to 46% in the audit period 2010/11. There is wide inter-unit variation, with implication that some suitable patients in Wales are not being considered for laparoscopic surgery, contrary to best practice guidelines (NICE TA105 1 ). The all Wales median length of stay for all elective colorectal surgery was 8 days in 2009/10 and 7 days in 2010/11. Many surgical teams in Wales have adopted enhanced recovery protocols for their patients. In 2010/11 patients having laparoscopic surgery had a median length of stay of 6 days. Bowel screening link to section The audit results clearly confirm the benefits of bowel screening with a significant increase in early curative stage diagnosis. The uptake has been 55% of the invited population over the audit period. There were 203 screen detected cancers in 2009/10 (10.1% of total cancers diagnosed). There were 241 screen detected cancers in 2010/11 (11.9% of total cancers diagnosed). 6

7 In 2010/11, 7% of screen detected cancers were stage Dukes D, as opposed to 24% in patients presenting with symptoms. 66% of screen detected cancers in 2010/11 were stage Dukes A or B against 27% in symptomatic patients. Rectal cancer link to section Nearly 600 cases of rectal cancer were diagnosed in 2010/11 representing 29% of all bowel cancers diagnosed in Wales. There is a wide variation in the use of preoperative short and long course radiotherapy. Overall circumferential margin involvement for the 2 audit periods for elective/scheduled rectal cancer cases was 5.8% with a rate of 3% for anterior resections and 11% for Abdomino-Perineal Excision of Rectum (APER). For the first time, this audit publishes Circumferential Margin Involvement (CMI) results for individual hospitals based on 3 consecutive years data. APER rate for elective resected rectal cases was 34% in 2009/10 and 28% in 2010/11. Recommendations It is recommended that LHBs consider the following actions: 1. Maintain the continual improvement on data collection through: a. The lead clinician and other MDT members ensuring accurate and complete data recording for their patients. b. Appropriate provision for coding and administration staff to support the clinical MDT staff. 2. MDTs use this audit report as a basis for an annual review of their practice and performance as benchmarked against other Welsh MDTs, and the UK-wide NBOCAP, with each MDT holding an annual meeting to review their performance. 3. Prompted by the high postoperative mortality of emergency patients, MDTs to review their practice to optimise their management of emergency patients (e.g. prompt 7

8 access to emergency theatres and critical care services, availability of colonic stenting). 4. In line with current NICE guidelines, MDTs ensure that suitable patients are either offered the choice of laparoscopic surgery or referred to surgeons/units that can offer this if necessary. MDTs audit their laparoscopic results. 5. MDTs benchmark their performance with respect to other MDTs using three year data on both postoperative mortality and circumferential margin involvement. Outliers should perform in-house audit of their service to examine the reasons for their results. 6. Move towards a national consensus on the role and application of radiotherapy for rectal cancer, where currently a wide variation in use is reported. There is no centrally funded MDT training in low rectal cancer management Welsh MDTs currently; all Wales training and education should be considered. The Cancer NSAG will: 7. Identify new clinical indicators for future audits in recognition of the audit results that most of the NSAG clinical indicators of best practice in the management of bowel cancer, agreed in 2008, are being exceeded by most MDTs. 8. Broaden the scope of the audit to cover more multidisciplinary data, to include: a. Analysis of the outcomes of patients with rectal cancer who appear to have a complete response and therefore do not initially undergo surgical resection ( wait and watch ). b. Analysis of stoma reversals and CMI rates for rectal cancers operated on as emergencies. c. Permanent stoma rates and complications d. Dukes A polyp cancers e. Complications from operations including the need to return to theatre for further surgery 9. Support LHBs by providing feedback via PowerPoint to individual MDTs. 8

9 10. Work with WG and NBOCAP to explore sharing of analysis of Welsh data submissions to allow the WCBA to focus on unique analysis pertinent to Welsh outcomes and patients. 11. Annually update the colorectal cancer section of the Cancer Delivery Plan s Technical report with key information to support improving outcomes. 9

10 Introduction This document reports a two year audit of patients diagnosed and treated by the 13 colorectal MDTs between 1 st April 2009 and 31 st March 2010 and between 1 st August 2010 and 31 st July There has been an adjustment in the start month of the audit year between the two years reported within this report to allow the WBCA to align itself with NBOCAP which previously altered the start date of its audit to August in The Cancer NSAG supported a report encompassing two years to bring the WBCA in alignment with the NBOCAP report 2 (published December 2012). Data collection The information source for the WBCA report is Canisc (Cancer Network Information System Cymru) which is the Wales clinical cancer record/database. The collection of data in Canisc by cancer MDTs has been mandated by WG since The audit was limited to those patients diagnosed with a colorectal cancer (see appendix 1) during the dates specified above. A file consisting of the data items in NBOCAP (appendix 1) was extracted from Canisc in July A validation process identified duplicate entries and incompatible and out of range values (described in the relevant sections of the report). In addition, the data file was cross-linked with data held by the Bowel Screening Wales (BSW) Programme to identify all patients diagnosed by the Screening Programme. Those patients who either died within 30 days of surgery or before discharge from hospital should be recorded in Canisc and therefore reported to the audit. However, experience from previous WBCA 4, 5 and NBOCAP audits 6 have shown that there can be under-reporting of this extremely important outcome by individual MDTs. As in the previous two WBCA reports, the Canisc data file has been cross-linked with a copy of the Office for National Statistics (ONS) death file held by WCISU to ensure all patients dying within 30 days of surgery were identified. The audit methodology at this stage is unable to differentiate between patients who are being primarily managed for their diagnosis of colorectal cancer and those who are being primarily managed for another diagnosis but also have colorectal cancer e.g. a patient with 10

11 primary lung cancer who also has a colorectal primary. The audit group considers that this would relate to a very minor number of cases within the audit as a whole, but on a patient level treatment may incorrectly appear sub-optimal. In terms of the outcome measures presented here, this would largely be limited to the percentage of patients surgically treated. Throughout the report there are defined rules that govern the way that results are reported. the term operation is used for all procedures excluding stent insertion and endoscopic polypectomy. a resection involves removal of the primary disease, either endoscopically or surgically, therefore from the data items procedure list (appendix 1) the following procedures are not recorded as resections: o Examination under Anaesthesia only (EUA) o Stoma ileostomy and colostomy only o Laparotomy only o Laparoscopy only o Stent procedures o Some other procedures in which there are no histopathology results recorded to suggest a resection has taken place. The final cleaned file was analysed using two software packages, IBM SPSS i STATA ii and the results were compared to ensure accuracy. and Data presentation Results are attributed to the MDT responsible for providing patient care. In a small number of cases a patient will have been diagnosed in one MDT and had surgery performed in another MDT, in these cases the results have been attributed to the MDT that performed the surgery. Results have been reported by MDT, rather than LHB, because some LHBs have more than one colorectal MDT. Analysis in this way allows more relevant interpretation of the audit results and facilitates local review of outcomes and process of care. i ii IBM SPSS StatisticsMac v20, is the registered trademark of IBM Corporation, USA STATA is the registered trademark of STATACORP, L.P. Texas, USA, 11

12 In some figures the abbreviations in table 1 have been used for MDTs due to space constraints. Table 1: Abbreviations used for MDTs MDT Bronglais General Hospital Cardiff & Vale Nevill Hall Hospital Prince Charles Hospital Princess of Wales and Neath Port Talbot Hospitals Royal Glamorgan Hospital Royal Gwent Hospital Swansea Hospitals (Moriston/Singleton) West Wales General and Prince Philip Hospitals Withybush General Hospital Ysbyty Glan Clwyd Ysbyty Gwynedd Ysbyty Maelor Wrexham Abbreviation Bronglais/BR Cardiff/CAR NHH PCH POW & NPT RGLH RGH Swansea/SWA WGH & PPH Withybush/WB YGC YG YMH The report has been prepared in two principal sections. The first reports on the care of all patients in Wales with a new diagnosis of colorectal cancer (CRC) in the audit periods. The second focuses on only the care of patients diagnosed through the BSW Programme. This report is the first to include data from a whole audit year that includes screen-detected patients. The results are presented either as tables with numerical values or bar charts (some with error bars representing the 95% confidence interval). Risk adjusted mortality logistic regression Risk adjusted mortality rates were calculated using logistic regression. Logistic regression analysis is a method used for predicting an outcome (usually a binary variable yes(1)/no(0)) based on one or more predictor variables. It is possible to test whether a predictor variable is statistically significant in affecting the outcome of interest when other predictor variables are taken into account. The probabilities describing the possible outcome as a function of explanatory variables are modelled using a logistic function. 12

13 For this analysis, the outcome was whether a patient had died within 30 days (inclusive) of surgery. The predictor variables analysed were sex, age, cancer site, ASA, Dukes stage, surgical urgency, surgical access and whether the surgery was a resection. The analysis was performed by the statistics unit at WCISU, using similar methods to those used to produce the Association of Coloproctology of Great Britain and Ireland (ACPGBI) Colorectal Cancer Risk adjusted mortality model 7, 8 (see appendix 4). The predictor variables found to be significant were age, ASA, Dukes stage, surgical urgency and surgical access. The analysis was repeated using only complete data (i.e. no missing values for any of the predictor variables) and results were similar to those using all data. Funnel plots The funnel plots in this report are designed to give an indication whether the outcome for a particular hospital is substantially different from the mean. The x axis shows the number of cases for that hospital, and the y axis the outcome under consideration. The dotted lines (see figure 10) show 95% (two standard deviations) confidence intervals and dashed lines show 99.7% (three standard deviations) confidence intervals. If a hospital were to lie outside the confidence limits then its outcome under study would be statistically significantly different from the mean and considered to be an outlier, with higher rates if above the upper dotted line and with lower rates if below the lower dotted line. Data quality This section addresses case ascertainment and completeness of key data fields, whether the audit has captured all patients with colorectal cancer who presented to secondary care in the relevant years and how complete was data for each of these patients, particularly for the key variables used to calculate risk for post-operative mortality. 13

14 Case ascertainment Case ascertainment was calculated by comparison with registrations held at WCISU. The WBCA and NBOCAP reports are based on cases diagnosed in the period, April to March, or August to July. Cancer Registries report by calendar year. The WCISU data in table 2 refers to cases registered 1 st January 31 st December 2009 and 1 st January 31 st December Case ascertainment is therefore indicative only, which explains the apparent contradiction of a case ascertainment of >100%. Table 2 demonstrates that the vast majority of patients expected to be treated for CRC in Wales have been reported to the WBCA. Table 2: Case ascertainment 2009/10 data 2010/11 data WBCA WCISU % WBCA WCISU % count count count count YG % % YGC % % YMH % % POW & NPT % % SWANSEA % % WWG & PPH % % WITHYBUSH % % BRONGLAIS % % NHH % % RGH % % CARDIFF % % RGLH % % PCH % % ALL WALES % % OTHER WELSH HOSPITAL ENGLISH HOSPITAL NULL HOSPITAL

15 Null hospital diagnoses, recorded at WCISU, are mainly Death Certificate Only (DCO) cases, where no other information is available for that case other than a death certificate stating a bowel cancer. WCISU records the diagnosing hospital, whether or not it has an MDT and as a result captures a number of cases diagnosed at smaller cottage hospitals (Other Welsh Hospitals in the table). Measured against WCISU records, case ascertainment for Wales as a whole (100%) and individual hospitals is excellent. Completeness of key fields Table 3 reports the completeness of the variables by MDT that are used to risk adjust for post-operative mortality following surgery. The results show an impressive increase in the quality of data submitted to the audits compared to previous years. It will never be possible to achieve 100% completeness for the field Dukes stage because it is impossible to assign a Dukes stage to patients who do not have a surgical resection and do not have radiological evidence of metastatic disease. This situation may arise in patients with surgically resectable disease who are too unfit for surgery and those patients treated by endoscopic excision alone. Table 3: Data quality by MDT for the variables used in the calculation of risk adjusted mortality a) 2009/10 MDT Age Stage ASA* Surgical urgency YG 100% 95% 79% 100% YGC 100% 100% 99% 100% YMH 100% 88% 93% 99% POW & NPT 100% 94% 99% 100% SWANSEA 100% 89% 93% 89% WWG & PPH 100% 85% 100% 100% WITHYBUSH 100% 88% 96% 100% BRONGLAIS 100% 100% 100% 100% NHH 100% 74% 89% 100% RGH 100% 88% 94% 100% CARDIFF 100% 96% 87% 98% RGLH 100% 96% 99% 99% PCH 100% 84% 100% 100% 15

16 ALL WALES 100% 90% 94% 98% b) 2010/11 MDT Age Stage ASA* Surgical urgency YG 100% 93% 85% 100% YGC 100% 93% 98% 100% YMH 100% 73% 98% 100% POW & NPT 100% 92% 100% 100% SWANSEA 100% 92% 99% 100% WWG & PPH 100% 90% 96% 99% WITHYBUSH 100% 99% 99% 100% BRONGLAIS 100% 96% 100% 100% NHH 100% 91% 95% 100% RGH 100% 90% 95% 100% CARDIFF 100% 96% 90% 100% RGLH 100% 96% 99% 100% PCH 100% 86% 100% 100% ALL WALES 100% 91% 96% 100% *ASA includes only patients having surgical procedures other than polypectomy or stent 16

17 Number and distribution of newly diagnosed bowel cancers During the audit period the thirteen MDTs treated 2019 patients with a new diagnosis of bowel cancer in 2009/10 and 2031 patients in 2010/11. The 2009/10 figure was an increase of 126 cases compared to the audit of 2008/9. The increase may be due to the introduction of population screening for colorectal cancer by Bowel Screening Wales (BSW). The age of patients diagnosed with bowel cancer in Wales in the audit periods is reported in table 4 below. Seventy three percent of patients with bowel cancer in Wales were over 65 years of age at diagnosis, a figure that is very similar to the 72% of patients over the age of 65 reported in NBOCAP 2 for Table 4: Age of patients diagnosed with bowel cancer in Wales Age group 2009/10 data 2010/11 data 2 yrs of data Colon Rectum Total Colon Rectum Total Colon Rectum no. no. no. no. no. no. % % Total % < % 0% 0% % 2% 1% % 8% 6% % 22% 19% % 33% 32% % 23% 29% % 12% 12% All ages % 100% 100% Whilst there is little change in the proportion of colon to rectal cancer since 2007/08, when compared with the Wales-Trent Audit of 1993 a proximal shift in disease presentation has occurred, with the proportion of cases that are rectal decreasing from 41.3% to less than 30% 4, 5, 9, 10, 11 (see table 5). The reasons for this are not fully understood but the phenomenon of a proximal shift in CRC incidence has previously been noted by others

18 Table 5: Tumour site by MDT MDT 2009/2010 data 2010/2011 data Colon no. Rectum no. Total no. Colon no. Rectum no. Total no. YG YGC YMH POW & NPT SWANSEA WWG & PPH WITHYBUSH BRONGLAIS NHH RGH CARDIFF RGLH PCH ALL WALES Procedures used in the surgical treatment of bowel cancer Table 6 details the procedures performed to treat patients in the audit period. The names of the procedures are fixed by the NBOCAP data set definitions (appendix 1). The Office of Population Censuses and Surveys Classification of Surgical Operations (OPCS) codes reported in Canisc were mapped to the data set for the WBCA/NBOCAP. In a small number of cases the OPCS code did not easily fit the data set definitions, and the clinical audit leads agreed the best-fit by consensus. Cases that could not be mapped were recorded as other. 18

19 A particular difficulty with multi-visceral resection was encountered and these procedures were therefore recorded as other but included in analyses that examined outcomes in patients having their disease resected. The definitions of operation and resection used here have been described previously (see data presentation section). In table 6 procedures in which the primary tumour has been excised/resected have been shaded. Table 6: Primary procedure performed to treat patients with bowel cancer in Wales All Surgical Procedures 2009/10 data 2010/11 data Right hemicolectomy Extended right hemicolectomy Tranverse colectomy 5 3 Left hemicolectomy Sigmoid colectomy Total colectomy and ileorectal anastomosis Total excision of colon and rectum Total excision of colon and rectum and anastomosis 1 8 of ileum to anus and creation of a pouch Hartmann's procedure Anterior resection APER Transanal Resection of Tumour (TART) 14 9 Transanal Endoscopic Microsurgery (TEMS) 0 1 Polypectomy EUA only 2 1 Laparoscopy only 2 2 Laparotomy only 7 7 Stoma - colostomy only Stoma - ileostomy only Stent Other Total The number of anterior resections performed (390 for patients diagnosed in 2009/10 and 375 for those in 2010/11) appears high compared to the number of rectal cancers resected: 383 patients from the 2009/10 cohort and 332 from 2010/11. However, historically operations where any part of the rectum is removed, even a small, proximal section, are often recorded as anterior resection. A proportion of the anterior resections included in the 19

20 audit data will therefore relate to tumours with a primary site in the terminal portion of the colon (sigmoid or rectosigmoid), where a portion of the rectum was removed. Another prominent feature of table 6 is the small number of cases treated by Transanal Endoscopic Microsurgery (TEMS): only one procedure across the audit cohort. In the future, population screening may identify more patients suitable for local excision with this technique as part of their tailored treatment. Operation and resection rates The following charts (figure 1 and figure 2) report the proportion of patients diagnosed with either colon or rectal cancer that had an operation for their disease (this excludes patients treated by stent and endoscopic polypectomy). The charts show considerable inter-mdt variation in the use of surgery, with one or two MDTs operating on approximately 90% of all patients whilst in others this figure is around 65%. Previous WBCA reports have recorded similar variation. Whilst there is likely to be year on year variation, the data presented suggests that there are management differences between MDTs. Figure 1: Proportion of colon cancers being operated on by MDT and year 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% YG YGC YMH POW & NPT SWANSEA WWG & PPH MDT WITHYBUSH BRONGLAIS NHH RGH CARDIFF RGLH PCH ALL WALES 09/10 colon data 10/11 colon data 95% CI 20

21 Figure 2: Proportion of rectal cancers operated on by MDT and year 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% YG YGC YMH POW & NPT SWANSEA WWG & PPH MDT WITHYBUSH BRONGLAIS NHH RGH CARDIFF RGLH PCH ALL WALES 09/10 rectal data 10/11 rectal data 95% CI Figure 3 and figure 4 show the proportion of patients diagnosed with colon and rectal cancer respectively that had their primary tumour resected, by either surgical or endoscopic methods. It is extremely unlikely that a patient will be cured of CRC without surgical or endoscopic removal of their primary disease, except for a small proportion of rectal cancers that may have a complete clinicopathological response to radiotherapy. It is therefore concerning to note that only 56% of patients diagnosed with rectal cancer in Wales in 2010/11 had their primary tumour resected. The implication being that fewer than 6 out of 10 patients in Wales have potentially curative disease at diagnosis. These data have clear implications when comparing survival with other nations. The figure in Wales is similar to the 57% of patients with rectal cancer who had their disease resected in the 2012 NBOCAP report, which included patients treated UK wide over the same time period. The reasons why so many patients with rectal cancer do not have their disease resected is not fully understood. In the previous WBCA report 4 the rectal resection rate at the Royal Gwent Hospital was found to be less than 50%. This prompted an in-house study which found that the reasons for non-resection were multi-factorial but included 21

22 metastatic disease in half of patients, locally advanced disease in 15% of patients and patient age / morbidity in a quarter of patients 13. Figure 3: Proportion of colon cancer cases being resected by MDT and year 0% 20% 40% 60% 80% 100% YG YGC YMH POW & NPT SWANSEA WWG & PPH MDT WITHYBUSH BRONGLAIS NHH RGH CARDIFF RGLH PCH ALL WALES 09/10 colon data 10/11 colon data 95% CI Figure 4: Proportion of rectal cancer cases being resected by MDT and year MDT 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% YG YGC YMH POW & NPT SWANSEA WWG & PPH WITHYBUSH BRONGLAIS NHH RGH CARDIFF RGLH PCH ALL WALES 09/10 rectal data 10/11 rectal data 95% CI 22

23 Stage of disease at presentation The Dukes system remains in common use for staging bowel cancer and the audit continues to use this. Although there is also the facility in Canisc to record Tumour Node Metastasis (TNM) stage, as developed by the International Union Against Cancer (UICC). The continued use of Dukes stage allows year on year comparison of stage. It is anticipated that future audit reports will present data on TNM and Dukes stage in parallel. The relevant data item in Canisc is modified Dukes staging. This is the final clinicopathological (CP) stage and takes into account clinical, radiological and histopathology information. The CP Dukes stage of operated patients by MDT is recorded in figure 5. It must be remembered that unless a patient has metastatic disease identified on radiological investigation, a patient can only be assigned a Dukes stage by removal of their cancer and histopathological analysis. Therefore, the small number of patients who are unfit or have locally advanced disease that precludes resection are unable to be assigned a Dukes stage and it is therefore expected that this data item will be missing from a small number of cases in figure 5. Accurate reporting of Dukes stage is essential as it is used to calculate the risk adjusted mortality of a unit. As with other variables used for the calculation of risk adjusted mortality, the reporting of Dukes stage has improved greatly compared to previous WBCA 4, 5 and current NBOCAP reports. Precise comparison with this year s NBOCAP data has not been possible because the NBOCAP report 2 has moved to reporting pathological stage using the UICC system, rather than Dukes stage. However, using the UICC system, pathological data is missing from between 35 and 50% of patients included in the NBOCAP audit this year, which results in uncertainty when interpreting results. Experience in previous years has identified that patients with CP Dukes stage D are frequently under reported. This is believed to be due to the pathologist s report on a resected specimen not taking into account the results of preoperative imaging. In this situation a patient with liver metastases may be assigned a Dukes stage of A to C by a pathologist not aware of the results of preoperative imaging. This stage may then erroneously be recorded in the CP Dukes stage. As in previous reports validation of the CP Dukes stage has been performed and any patient who has been recorded as having metastatic disease in the Liver CT result or the distant metastases data fields in whom the CP Dukes stage was not recorded as stage D has had the record amended. 23

24 Figure 5: Clinicopathological Dukes Stage of Operated Patients a) 2009/10 100% Proportion of cases 80% 60% 40% 20% 0% YG YGC YMH POW & NPT SWANSEA WWG & PPH WITHYBUSH BRONGLAIS NHH RGH CARDIFF RGLH PCH ALL WALES (blank) D C B A b) 2010/11 Proportion of cases 100% 80% 60% 40% 20% 0% YG YGC YMH POW & NPT SWANSEA WWG & PPH WITHYBUSH BRONGLAIS NHH RGH CARDIFF RGLH PCH ALL WALES (blank) D C B A

25 Figure 6 below details the proportion of patients by MDT who have metastatic disease (Dukes stage D) at presentation. These patients are presenting with a stage of disease which is unlikely to be curable and increases the risk of postoperative death. There is year on year variation between MDTs but the all Wales figure has been around 20% in the previous WBCA reports, unchanged since the Wales-Trent Bowel Cancer Audit of 1993 and similar to the results reported in the NBOCAP report in It is hoped that the introduction of population screening for bowel cancer in Wales will reduce this figure in future audits. Figure 6: Proportion of Dukes D stage by MDT and year for all colorectal cases 0% 10% 20% 30% 40% 50% YG YGC YMH POW & NPT SWANSEA WWG & PPH MDT WITHYBUSH BRONGLAIS NHH RGH CARDIFF RGLH PCH ALL WALES 2008/09 data 2009/10 data 2010/11 data

26 Surgical urgency of operated patients The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) categorisation is used to classify surgical urgency (see appendix 2). The completeness of surgical urgency reporting has seen year on year improvement since the start of the audit. In the audit year 2009/10 surgical urgency was complete in over 98% of patients operated upon (see appendix 5). This figure rose further in 2010/11 with only one case out of 1457 patients operated upon missing surgical urgency data. Table 7 below reports surgical urgency of patients operated on an urgent or emergency basis by MDT. Table 7: Number of urgent and emergency operations by MDT performed in the audit 09/10 data 10/11 data Immediate (Emergency) Urgent Immediate (Emergency) Urgent YG YGC YMH POW & NPT SWANSEA WWG & PPH WITHYBUSH BRONGLAIS NHH RGH CARDIFF RGLH PCH ALL WALES

27 Figure 7: Proportion of operated cases that were classed as emergency/urgent in the management of colorectal cancer in Wales 2008/ / /11 0% 10% 20% 30% 40% 50% Proportion of operated on cases The rate of urgent/ emergency surgery has remained static at around 20% over recent audits periods (figure 7) and is similar to that reported in the Wales-Trent audit of 1993 and the 21% figure reported in the most recently published NBOCAP report 2. Urgent/emergency surgery to treat bowel cancer is associated with a far higher risk of peri-operative mortality than elective surgery. The crude mortality rate for urgent/emergency surgery was 16% in 2009/10 and 11% in 2010/11. The rates compare unfavourably with a rate of 3% for elective surgery in both 2009/10 and 2010/11. The rates of urgent/emergency surgery by MDT are presented in figure 8. It is concerning that the need for emergency surgery has not decreased. The reasons for this are poorly understood, and it is a challenging area in which to improve the results of bowel cancer care. It is hoped that as the BSW programme matures this figure will reduce. It is possible that NCEPOD categorisation is not being accurately recorded; two thirds of all unplanned operations were recorded as immediate (emergency), which according to NCEPOD classification would suggest that these patients would have gone to theatre within minutes of a decision to operate. In the surgical management of CRC it would be unusual for a patient to require such immediate surgery. To avoid confusion a simpler separation is to present surgery performed on either an elective/scheduled or emergency/urgent basis (figure 8). 27

28 Figure 8: Surgical urgency by MDT and year MDT 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 2009/ / / / / /11 POW & NPT 2009/ / / / / /11 Withybush 2009/ /11 MDT YG YG YGC YGC YMH YMH POW & NPT SWANSE A Swansea WWG & PPH WWG & PPH WITHYB USH Bronglais 2009/ /11 BRONGL AIS NHH NHH RGH RGH CARDIFF Cardiff RGLH RGLH PCH PCH 2009/ / / / / / / / / /11 All 2009/10 Wales 2010/11 ALL WALES Elective/scheduled Emergency/urgent 28

29 Co-morbidity Co-morbidity is recorded using American Society of Anaesthesiologists (ASA) grading (appendix 3). Whilst this is a subjective measure, it has previously been demonstrated to correlate well with the risk of post-operative death 8. Over the past few years there has been a steady improvement in the recording of ASA status, rising to 94% complete in and 96% complete on (table 3). Figure 9 reports the ASA score of operated patients. As in previous audits there are variations between MDTs. It is generally accepted that ASA scoring has a subjective component, as it relies on the anaesthetist s opinion about a patient s general health. Inter-unit differences may be a combination of different co-morbidity levels in the patients that a unit is treating and differences in ASA grading by anaesthetists between units. Figure 9: ASA score by MDT in operated colorectal cancer patients for the years 2009/10 and 2010/11 a) 2009/10 100% 90% 80% Proportion of cases 70% 60% 50% 40% 30% 20% 10% 0% POW WWG WITH ALL SWA BRON CARD All YG YGC YMH & SWA & YBUS WB BR NHH RGH CAR RGLH PCH WALE NSEA GLAIS IFF Wales NPT PPH H S Unknown &

30 b) 2010/11 100% 90% 80% Proportion of cases 70% 60% 50% 40% 30% 20% 10% 0% POW WWG WITH ALL SWA BRON CARD YG YGC YMH & SWA & YBUS WB All BR NHH RGH CAR RGLH PCH WALE NSEA GLAIS IFF Wales NPT PPH H S Unknown & day mortality following surgery for bowel cancer Non-adjusted 30 day mortality following elective colorectal surgery in both audit years across Wales was 3% (data not shown). Figure 10 represents the risk-adjusted 30 day mortality rate for both elective and emergency surgery throughout Welsh hospitals over the last three audit periods. The variables analysed on each patient were sex, age, cancer site, ASA, Dukes stage, surgical urgency, surgical access and whether the surgery was a resection. The impact that each factor made to the model is reported in appendix 4. Robust comparison of post-operative mortality needs to be risk-adjusted to ensure that the impact of differences between patients can be taken into account (e.g. age, comorbidity, stage of presentation, emergency surgery etc.). The results have been averaged from 3 continuous years data, which avoids drawing conclusions based on the variations that are recognised to occur yearon-year or anomalous periods. 30

31 The average 30 day risk-adjusted mortality from the last three years of data is 5.1%, ranging from 2.5% to 8.6% between hospitals. For comparison, the figure for England using Hospital Episode Statistics (HES) data from was 6.2% 14 and the unadjusted figure for Denmark was 9.9% 15. It is worth noting that in previous years NBOCAP has reported Wales as having a higher average observed post-operative mortality than England. However they have also demonstrated that lower case ascertainment leads to a decreased postoperative mortality estimate with the conclusion that observed rates in Wales better reflected the true mortality rate compared to English rates as a whole. Hospitals should use their own data to audit their results in comparison with others. Much of the variation in 30 day mortality is probably due to the timely diagnosis and management of emergency patients. Those with a high ASA score deserve particular attention from the surgical and critical care teams as a patient is over 12 times more likely to suffer from a postoperative death within 30 days of surgery with an ASA score of IV or V compared to a patient with an ASA score of 1. Social deprivation and lifestyle factors are not included in the risk adjustment model used by the WBCA. However, differences in deprivation have been shown to contribute to an excess risk of peri-operative mortality in more deprived patients undergoing surgery for CRC 16 and may be a contributory factor to the observed differences. Figure 10: Risk adjusted postoperative mortality (within 30 days) for patients having surgery (combined 3 years data for patients diagnosed April 2008-March 2010 and August 2010 to July 2011) Risk adjusted mortality rate (%) PCH RGLH NHH YMH BRONGLAIS WITHYBUSH POW & NPT CARDIFF WWG & PPH YG RGH YGC SWANSEA Cases Data Average 2SD limits 3SD limits 31

32 Use of laparoscopic surgery in Wales NICE have recommended laparoscopic surgery as an alternative to open surgery for the treatment of bowel cancer 1, providing that the patient and their disease are suitable for this approach and that appropriately trained surgeons are able to undertake the surgery. The benefit of a laparoscopic approach is that patients receive an equally effective cancer operation but have a more rapid recovery, with a shorter hospital stay. The current audit has found that a laparoscopic approach was associated with a reduction in hospital stay of three days. Recent consecutive audit periods show a progressive increase in the use of laparoscopic surgery for the treatment of bowel cancer across Wales, with the figure for elective surgery in 2010/11 standing at 46% (figure 11, excludes data on polyps, stents, EUA, TART and TEMS). This figure is higher than that reported in England, where for the similar 2010/11 period 34% of elective operations were performed laparoscopically. The increased uptake in Wales is testament to the Welsh laparoscopic colorectal training scheme that was introduced by WG in response to the NICE recommendation. There is debate amongst experts as to the appropriate percentage of patients that are able to have a laparoscopic approach but the wide inter-mdt variability in Wales suggests that there is scope for increased use. The uptake for elective bowel resection by MDT is shown in figure 11, which highlights this variation. The trend in most MDTs is for an increased use in the most recent audit period. This report does not include conversion rates for laparoscopic to open surgery, due to this data not having been routinely collected during the current audit periods. It is however, recognised that conversion rates are important to record in laparoscopic colorectal surgery. Therefore, the routinely collected data has been amended to include this and it will be reported in future audits. 32

33 Figure 11: Percentage of elective/scheduled cases performed laparoscopically by MDT (excludes polyps, stents, EUA, TART and TEMS) 100% 90% 80% 70% Proportion of cases 60% 50% 40% 30% 20% 10% 0% YG YGC YMH POW & NPT SWANSEA WWG & PPH WITHYBUSH BRONGLAIS NHH RGH CARDIFF RGLH PCH ALL WALES 2009/10 data 43% 47% 1% 24% 46% 4% 43% 0% 10% 41% 63% 14% 77% 36% 2010/11 data 81% 72% 16% 35% 40% 3% 72% 2% 22% 47% 68% 7% 91% 46%

34 Figure 12: Variation in known surgical access for elective major colon resections by year and resection type 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% AR APER Ext R Hemi Laparo tomy /Lapar AR APER Ext R Hemi Hartm ann's Hartmann's oscopy only laparotomy/ laparoscopy only Left Hemi Other Right Hemi SIgmoid colectomy L Hemi Other R Hemi Sigmoi d colecto my TC & IRA Restor ative Procto Colost omy only Colostomy only Ileostomy only Ileosto my only Procto colectomy TC & IRA Procto colecto my colecto my restorative protocolectomy Trans colecto my Trans colectomy TOTAL Total 2009/ / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / /11 Laparoscopic Open Figure 12 reports the use of laparoscopic surgery for the most frequently performed elective operations for bowel cancer (excludes polyps, stents, EUA, TART and TEMS). Over 50% of anterior resections and right hemicolectomies were performed laparoscopically in the 2010/11 audit period. Of the elective operations performed for tumours located in the rectum (figure 13), 35% were performed laparoscopically in 2009/10 and 40% in 2010/11.

35 Figure 13: Variation in known surgical access for elective major rectal resections by year and resection type 100% 90% 80% Proportion of cases 70% 60% 50% 40% 30% 20% 10% 0% Anterior resection APER Hartmann's procedure Other Anterior resection APER Hartmann's procedure 2009/10 data 2010/11 data Open Laparoscopic Other Length of stay Length of stay (LOS) is an outcome measure that is of interest to the patient, the surgeon and healthcare managers. It is calculated by measuring the interval in days between the date of operation and the date of death or discharge. The Wales median LOS is eight days, a reduction of one day compared to the WBCA audit of 2008/9. The median LOS in the current audit is the same as that reported in the UK wide NBOCAP report 2. An ongoing finding of the WBCA is that the LOS after surgery has reduced in each successive year and is now almost half the fifteen day median LOS reported in the Wales-Trent audit of The median LOS by MDT is reported in figure 14. Organisations may wish to examine the local reasons for the failure of LOS to fall further. 35

36 Figure 14: Overall median length of stay after surgery reported by MDT performing surgery (in days), surgical access and year Median LOS (days) YG YGC YMH POW & NPT SWANSEA WWG & PPH MDT WITHYBUSH BRONGLAIS NHH RGH CARDIFF RGLH PCH ALL WALES Open 2009/10 Laparoscopic 2009/10 Open 2010/11 Laparoscopic 2010/11 The overall reduction in LOS after surgery has been achieved through reductions in the LOS after elective surgery. LOS after urgent/emergency surgery has been 12 days in each of the three audits between 2008 and In the audit year 2010/11 (table 8) the median LOS after elective surgery has fallen to seven days. The widening difference between median LOS after elective and emergency surgery is likely to be due to both the increased use of laparoscopic surgery and the introduction of enhanced recovery after surgery programmes. 36

37 Table 8: Median LOS after surgery reported by MDT and surgical urgency 2009/10 data 2010/11 data Elective/ Scheduled Urgent/ Emergency Elective/ Scheduled Urgent/ Emergency YG YGC YMH POW & NPT SWANSEA WWG & PPH WITHYBUSH BRONGLAIS NHH RGH CARDIFF RGLH PCH ALL WALES Table 8 reports the median LOS after surgery according to surgical access. In the units performing higher volumes of laparoscopic surgery there is a marked decrease in LOS associated with the use of minimally invasive surgery. 37