Audit Report Endometrial & Cervical Cancer Quality Performance Indicators

Transcription

1 Gynaecological Cancer Managed Clinical Network Audit Report Endometrial & Cervical Cancer Quality Performance Indicators Clinical Audit Data: 01 October 2014 to 30 September 2015 Nadeem Siddiqui Consultant Gynaecological Oncologist MCN Clinical Lead Kevin Campbell MCN Manager Julie McMahon Information Officer

2 CONTENTS EXECUTIVE SUMMARY 3 1. INTRODUCTION 8 2. BACKGROUND NATIONAL CONTEXT WEST OF SCOTLAND CONTEXT 9 3. METHODOLOGY RESULTS AND ACTION REQUIRED DATA QUALITY PERFORMANCE AGAINST QUALITY PERFORMANCE INDICATORS (QPIS) ENDOMETRIAL CANCER CERVICAL CANCER CONCLUSIONS 27 ACKNOWLEDGEMENT 28 ABBREVIATIONS 29 REFERENCES 30 Final Published - Endometrial and Cervical Cancer MCN Audit Report v1.0 04/07/2016 2

3 Executive Summary Introduction This report presents an assessment of performance of West of Scotland (WoS) Endometrial and Cervical Cancer services relating to patients diagnosed in the twelve months between 1 October 2014 and 30 September Results are measured against the Endometrial and Cervical Cancer Quality Performance Indicators (QPIs) which were implemented for patients diagnosed on or after 1 October The National Cancer Quality Steering Group (NCQSG) completed a programme of work to develop national QPIs for all cancer types to enable national comparative reporting and drive continuous improvement for patients in In collaboration with the three Regional Cancer Networks and Information Services Division (ISD) the Endometrial and Cervical Cancer QPIs were published by Healthcare Improvement Scotland (HIS) in October Data definitions and measurability criteria to accompany the QPIs are available from the ISD website 2. Twelve months of data are measured against the Endometrial & Cervical Cancer QPIs and presented within this audit report. There are no annual comparisons as this is the first year of analysis since implementation of the QPI dataset. Future reports will compare clinical audit data in successive years to illustrate trend analysis. Background The effective management of these patients relies on well co-ordinated delivery of treatment and care, requiring close collaboration of professionals from a range of specialties. Treatment and care for gynaecological cancer patients is delivered by a single regional multi-disciplinary team (MDT).This is facilitated by video-conferencing technology and a bespoke IT system, which is operationally dependant on close collaboration of professionals from a range of clinical specialities across the region to provide well planned and coordinated delivery of treatment and care. Complex gynaecological malignancy often requires a multi-modality approach and surgery remains a key component of effective curative management. Gynaecological oncologists working in the regional specialist surgical centre in Glasgow Royal Infirmary (GRI) provide centralised radical surgical treatment for cervical cancers for the WoS. Gynaecologists located in NHS Boards in the West of Scotland (WoS) provide local surgical management of endometrial cancers. Methodology The clinical audit data presented in this report was collected by clinical audit staff in each NHS Board in accordance with an agreed dataset and definitions. The data was entered locally into the electronic Cancer Audit Support Environment (ecase): a secure centralised web-based database. Data relating to patients diagnosed between 1 October 2014 and 30 September 2015 was downloaded from ecase on 29 th April Analysis was performed centrally by the (WoSCAN) Information Team and the timescales agreed took into account the patient pathway to ensure that a complete treatment record was available for each case. Initial results of the analysis were provided to local Boards to check for inaccuracies or obvious gaps before final analysis was carried out. Final results were disseminated for NHS Board verification in line with the regional audit governance process, to ensure that the data was an accurate representation of service in each area. Final Published - Endometrial and Cervical Cancer MCN Audit Report v1.0 04/07/2016 3

4 Results Case ascertainment for endometrial and cervical cancers is high across WoS at 101.5% and 112% respectively indicating an excellent level of data capture, however it should be noted that the predicted incidence of all cancer types is based on historic numbers of cases diagnosed and therefore some variation in case ascertainment is expected. Results for each QPI are shown in detail in the main report and illustrate Board performance against each target and overall WoS performance for each performance indicator. Results are presented graphically and the accompanying tabular format also highlights any missing data and its possible effect on any of the measured outcomes. The following summary of results shows the WoS percentage performance against each QPI target and the range in performance by NHS Board. Final Published - Endometrial and Cervical Cancer MCN Audit Report v1.0 04/07/2016 4

5 Performance Summary Report Endometrial Cancer Meets/exceeds QPI target Does not meet QPI target QPI Target WoS A&A FV Lan GGC QPI 1 - Radiological Staging Patients with endometrial cancer should have their stage of disease assessed by magnetic resonance imaging (MRI) and/or computed tomography (CT) prior to first treatment. 90% 92.0% 92.3% 81.8% 100% 91.7% QPI 2 - Multidisciplinary Team Meeting (MDT) Patients with endometrial cancer should be discussed by a multidisciplinary team (MDT) prior to definitive treatment. 95% 92.0% 82.1% 90.9% 100% 94.0% QPI 3 - Total Hysterectomy and Bilateral Salpingo-Oophorectomy Patients with endometrial cancer should undergo total hysterectomy (TH) and bilateral salpingo-oophorectomy (BSO). 80% 87.9% 77.8% 81.5% 92.2% 92.2% QPI 4 - Laparoscopic Surgery (Board of Surgery) Patients with endometrial cancer undergoing definitive surgery should undergo laparoscopic surgery, where clinically appropriate. 50% 57.4% 78.3% 62.5% 81.8% 41.1% QPI 5 - Adjuvant Vaginal Brachytherapy Patients with intermediate risk (stage IB, grade 1 or 2; or stage IA, grade 3 endometrioid or mucinous) endometrial cancer should be considered for adjuvant vaginal brachytherapy. 90% 85.7% 87.5% % 81.8% QPI 6 Chemotherapy Patients with stage IV endometrial cancer should have chemotherapy. 75% 57.7% 71.4% 50.0% % Data not shown due to small numbers Final Published - Endometrial and Cervical Cancer MCN Audit Report v1.0 04/07/2016 5

6 Cervical Cancer QPI Target WoS A&A FV Lan GGC QPI 1 - Radiological Staging Patients with cervical cancer should have their stage of disease assessed by magnetic resonance imaging (MRI) prior to first treatment. QPI 2 - Positron Emission Tomography/Computed Tomography (PET/CT) Patients with cervical cancer, for whom primary definitive surgery is not appropriate, should undergo positron emission tomography - computed tomography imaging (PET/CT). QPI 3 - Multidisciplinary Team Meeting (MDT) Patients with cervical cancer should be discussed by a multidisciplinary team (MDT) prior to definitive treatment. QPI 4 - Radical Hysterectomy Patients with stage IB1 cervical cancer should undergo radical hysterectomy. QPI 5 - Surgical Margins.(Board of Surgery) Patients with surgically treated cervical cancer should have clear resection margins. QPI 6-56 Day Treatment Time for Radical Radiotherapy Treatment time for patients with cervical cancer undergoing radical radiotherapy should be no more that 56 days. QPI 7 Chemoradiation Patients with cervical cancer undergoing radical radiotherapy should receive concurrent platinum-based chemotherapy. 95% 81.9% 95.0% 86.7% 66.7% 87.9% % 86.3% 76.9% 80.0% 83.9% 92.7% % 97.1% 100% 100% 100% 93.2% % 87.2% 100% % 81.3% % 94.2% % 93.3% % 98.9% 100% 100% 100% 97.6% % 91.6% 100% 100% 83.9% 92.7% Data not shown due to small numbers Final Published - Endometrial and Cervical Cancer MCN Audit Report v1.0 04/07/2016 6

7 Conclusions and Action Required Cancer audit underpins much of the development and service improvement work of Managed Clinical Networks and the regular reporting of activity and performance are fundamental in assuring the quality of care delivered across the region. The development and implementation of Endometrial and Cervical Cancer QPIs will help drive continuous quality improvement in patient care whilst ensuring that activity is focussed on those areas that are most important in terms of improving survival patient outcomes, quality of care and patient experience. In addition, the introduction of QPIs and the associated governance structure will facilitate regular monitoring and reporting of data to promote equitable care across the country. These results illustrate that some of the QPI targets set have been challenging for NHS Boards to achieve and there remains room for further service improvement in a number of areas, specifically MDT discussion for endometrial cases, chemotherapy in stage IV endometrial cases and also radiological staging and PET/CT in cervical cancer cases. It is however encouraging that targets relating to radical hysterectomy, treatment time for radical radiotherapy and patients with cervical cancer undergoing chemoradiation were met by all Boards in 2014/15. Where QPI targets were not met NHS Boards have provided detailed commentary. In the main these indicate valid clinical reasons or that, in some cases, patient choice or co-morbidities have influenced patient management. NHS Boards are asked to develop local Action/Improvement Plans in response to the findings presented in this report. Progress against these plans will be monitored by the MCN Advisory Board and reported to the Regional Cancer Advisory Group (RCAG) annually by the Board Lead Cancer Clinicians and Managed Clinical Network (MCN) Clinical Leads, as part of the regional audit governance process to enable RCAG to review and monitor regional improvement. Action Required NHS Ayrshire & Arran, Forth Valley and GGC to ensure patients with endometrial cancer are discussed at MDT prior to definitive treatment. South Glasgow and Clyde should review all endometrial cancer cases where laparoscopic hysterectomy was not undertaken to identify the reasons for this management approach and feedback to the MCN, noting action to be taken, where necessary. NHSGGC to review all cervical cancer cases which were not discussed at MDT prior to definitive treatment and feedback to MCN. Completed Action Plans should be returned to WoSCAN within two months of publication of this report. Progress against these plans will be monitored by the MCN Advisory Board and any service or clinical issue which the Advisory Board considers not to have been adequately addressed will be escalated to the NHS Board Territorial Lead Cancer Clinician and Regional Lead Cancer Clinician. Additionally, progress will be reported annually to the Regional Cancer Advisory Group (RCAG) by NHS Board Territorial Lead Cancer Clinicians and MCN Clinical Leads, and nationally on a three-yearly basis to Healthcare Improvement Scotland as part of the governance processes set out in CEL 06 (2012). Final Published - Endometrial and Cervical Cancer MCN Audit Report v1.0 04/07/2016 7

8 1. Introduction This report presents an assessment of performance of West of Scotland (WoS) Endometrial and Cervical Cancer services relating to patients diagnosed in the twelve months between 1 October 2014 and 30 September Results are measured against the Endometrial and Cervical Cancer Quality Performance Indicators (QPIs) which were implemented for patients diagnosed on or after 1 October The National Cancer Quality Steering Group (NCQSG) completed a programme of work to develop national QPIs for all cancer types to enable national comparative reporting and drive continuous improvement for patients in In collaboration with the three Regional Cancer Networks and Information Services Division (ISD) the Endometrial and Cervical Cancer QPIs were published by Healthcare Improvement Scotland (HIS) in October Data definitions and measurability criteria to accompany the cervix and endometrial cancer QPIs are available from the ISD website 2. Twelve months of data are measured against the Endometrial & Cervical Cancer QPIs and presented within this audit report. There are no annual comparisons as this is the first year of analysis since implementation of the QPI dataset. Future reports will compare clinical audit data in successive years to illustrate trend analysis. 2. Background The effective management of these patients relies on well co-ordinated delivery of treatment and care, requiring close collaboration of professionals from a range of specialties. Treatment and care for gynaecological cancer patients is delivered by a single regional multi-disciplinary team (MDT).This is facilitated by video-conferencing technology and a bespoke IT system, which is operationally dependant on close collaboration of professionals from a range of clinical specialities across the region to provide well planned and coordinated delivery of treatment and care. Complex gynaecological malignancy often requires a multi-modality approach and surgery remains a key component of effective curative management. Gynaecological oncologists working in the regional specialist surgical centre in Glasgow Royal Infirmary (GRI) provide centralised radical surgical treatment for cervical cancers for the WoS. Gynaecologists located in NHS Boards in the West of Scotland (WoS) provide local surgical management of endometrial cancers National Context Endometrial cancer is the most common gynaecological cancer and the fourth most common cancer in women in Scotland with approximately 760 new cases diagnosed annually. The incidence of endometrial cancer has risen significantly by 32% over the last ten years 3. This undoubtedly reflects increasing levels of obesity 4 and also an increasingly ageing population. Recently published data highlights that the number of new cases of endometrial cancer is predicted to increase by 55% between and One-year and 5-year relative survival rates for endometrial cancer for females diagnosed between 2007 and 2011 are 92.9% and 83.2% respectively 3. Endometrial cancer is the 12 th most common death from cancer in Scotland with overall mortality rates increasing by 49.4% from 2004 to Cervical cancer is noted as being the tenth most common cancer in women with 385 cases diagnosed each year 3. The incidence of cervical cancer has increased by 18% over the last ten years 3. Overall mortality rates have decreased by 18.6% over the past 10 years from 2004 to 2014 and 1-year and 5-year relative survival is noted as being 87.5% and 73% respectively 3. Final Published - Endometrial and Cervical Cancer MCN Audit Report v1.0 04/07/2016 8

9 Number of Cases Recently published figures indicate that the number of new cases of cervical cancer is predicted to increase by 39.6% between and Many cervical cancers are detected early due to the well established screening programme introduced in The Human Papilloma Virus (HPV) vaccine is designed to protect against certain high risk types of HPV that are responsible for approximately 70% of cervical cancer cases. The vaccination programme started in Scotland on 1st September 2008 and aims to protect females by routinely immunising them at years of age, through a school based programme. Progression from HPV infection to cervical cancer can take many years, therefore surveillance to monitor the impact of the vaccination programme will be a long term undertaking. 2.2 West of Scotland Context A total of 331 cases of endometrial cancer and 187 cases of cervical cancer were recorded through audit as diagnosed in the WoS between 01 October 2014 and 30 September The numbers presented in Figure 1 are split by location of diagnosis and site of origin of tumour. Figure 1: Number of patients diagnosed with endometrial or cervical cancer by location of diagnosis. Endometrial Cervical Ayrshire & Arran Forth Valley Lanarkshire GGC Ayrshire & Arran Location of Diagnosis Forth Valley Lanarkshire GGC WoS Endometrial Cervical Final Published - Endometrial and Cervical Cancer MCN Audit Report v1.0 04/07/2016 9

10 Number of Cases Figure 2 illustrates the distribution of endometrial and cervical cancer cases by age. The median age of cervical cancer patients was 43.5 years and 66 years for endometrial cancer patients. Figure 2: Number of patients diagnosed with endometrial and cervical cancer in WoS within each age group Oct 14 to Sept 15. Endometrial Cervical >=85 Age at Diagnosis Final Published - Endometrial and Cervical Cancer MCN Audit Report v1.0 04/07/

11 3. Methodology The clinical audit data presented in this report was collected by clinical audit staff in each NHS Board in accordance with an agreed dataset and definitions. The data was recorded manually and entered locally into the electronic Cancer Audit Support Environment (ecase): a secure centralised web-based database. Data relating to patients diagnosed with endometrial or cervical between 1 October 2014 and 30 September 2015 was downloaded from ecase at 2200 hrs on 29 April Cancer audit is a dynamic process with patient data continually being revised and updated as more information becomes available. This means that apparently comparable reports for the same time period and cancer site may produce slightly different figures if extracted at different times. Analysis was performed centrally for the region by the WoSCAN Information Team and the timescales agreed took into account the patient pathway to ensure that a complete treatment record was available for each case. Initial results of the analysis were provided to local Boards to check for inaccuracies, inconsistencies or obvious gaps and a subsequent download taken upon which final analysis was carried out. The final data analysis was disseminated for NHS Board verification in line with the regional audit governance process to ensure that the data was an accurate representation of service in each area. 4. Results and Action Required 4.1 Data Quality Quality of audit data can be assessed in the first instance by estimating the proportion of expected patients that have been identified through audit. Case ascertainment is calculated by the number of patients identified as diagnosed in a NHS Board through audit as a percentage of the incidence of cancer diagnosed in that NHS Board from Cancer Registry. Cancer Registry information is available some time after the year of interest as collection and verification of data is time intensive. For this reason, audit data cannot be compared directly to Cancer Registry data for the same year. The number of patients diagnosed each year will naturally vary. Cancer Registry figures used were extracted from Cancer Registry Scotland, a system provided ISD via the standard reports available. Cancer Registry figures are an average of 2008 to 2012 figures to take account of annual fluctuations in incidence within NHS Boards. Table 1 presents the case ascertainment for each NHS Board and for WoSCAN as a whole. Table 2: Case ascertainment by NHS Board for patients diagnosed with endometrial or cervical cancer, 01/10/2014 to 30/09/2015 Endometrial Cancer Health Board of Diagnosis Ayrshire & Arran (01/10/ /09/2015) Audit Cancer Registry ( ) Case Ascertainment % Forth Valley % Cervical Cancer Health Board of Diagnosis Ayrshire & Arran (01/10/ /09/2015) Audit Cancer Registry ( ) Case Ascertainment % Forth Valley % Lanarkshire % GGC % WoS % Lanarkshire % GGC % WoS % Final Published - Endometrial and Cervical Cancer MCN Audit Report v1.0 04/07/

12 4.2 Performance against Quality Performance Indicators (QPIs) Results of the analysis of endometrial cancer QPIs 1 to 6 and cervical cancer QPIs 1 to 7 are set out in the following sections. Graphs and charts have been provided where this aids interpretation and, where appropriate, numbers have also been included to provide context. Data (both graphically and in tabular format) are presented by location of diagnosis or treatment, with some criteria given as an overall WoS representation. Specific regional and NHS Board actions have been identified to address issues highlighted through the data analysis. Where the number of cases meeting the denominator criteria for any indicator is between one and four, the percentage calculation has not been shown on any associated charts or tables. This is to avoid any unwarranted variation associated with small numbers and to minimise the risk of disclosure. Any charts or tables impacted by this are denoted with a dash (-). Any commentary provided by NHS Boards relating to the impacted indicators will however be included as a record of continuous improvement. Final Published - Endometrial and Cervical Cancer MCN Audit Report v1.0 04/07/

13 Number of Cases 4.3 Endometrial Cancer QPI 1: Radiological Staging It is necessary to fully image the pelvis and abdomen prior to starting first treatment in order to establish the extent of disease and minimise unnecessary or inappropriate treatment 1. The target for this QPI is set at 90% with the tolerance level designed to account for situations where patients require urgent treatment before imaging has been performed or where endometrial cancer is an incidental finding at hysterectomy. Title: Numerator: Patients with endometrial cancer should have their stage of disease assessed by MRI and/or CT prior to first treatment. Number of patients with endometrial cancer having a MRI and/or CT scan of the abdomen and pelvis carried out prior to first treatment. Denominator: All patients with endometrial cancer. Exclusions: Patients with Grade 1 endometrioid or mucinous carcinoma on pre-operative biopsy. Patients with atypical hyperplasia on pre-operative biopsy. Target: 90% Figure 2: Proportion of patients with endometrial cancer who have an MRI and/or CT scan of the abdomen and pelvis performed prior to first treatment Ayrshire & Arran Forth Valley Lanarkshire GGC WoS Performance (%) Numerator Denominator Location of Diagnosis numerator numerator (%) exclusions exclusions (%) Final Published - Endometrial and Cervical Cancer MCN Audit Report v1.0 04/07/ denominator AA % 0 0.0% 0 FV % % 0 Lan % 0 0.0% 0 GGC % 1 1.2% 0 WoS % 4 2.3% 0 Figure 2 illustrates that three of the four boards achieved the 90% target resulting in an overall WoS performance of 92%. Only NHS Forth Valley did not meet the 90% target with performance of 81.8%. NHS Forth Valley reported that the clinical lead reviewed all cases and valid clinical reasons were given for three cases. The one remaining case was not suitable for nodal surgery therefore an MRI was not performed. Pre operative CT assessment should however have been

14 Number of Cases undertaken to exclude any obvious extra uterine disease. NHS Forth Valley have noted that in future they will arrange CT imaging in cases where MRI is not possible or deemed unnecessary. QPI 2: Multidisciplinary Team Meeting (MDT) Evidence suggests that patients with cancer managed by a multidisciplinary team have a better outcome. There is also evidence that the multidisciplinary management of patients increases their overall satisfaction with their care 1. Title: Numerator: Patients with endometrial cancer should be discussed by a multidisciplinary team prior to definitive treatment. Number of patients with endometrial cancer discussed at MDT prior to definitive treatment. Denominator: All patients with endometrial cancer. Exclusions: Patients with Grade 1 endometrioid or mucinous carcinoma on pre-operative biopsy. Patients with atypical hyperplasia on pre-operative biopsy. Target: 95% Figure 3: Proportion of patients with endometrial cancer who are discussed at a MDT meeting before definitive treatment Ayrshire & Arran Forth Valley Lanarkshire GGC WoS Performance (%) Numerator Denominator Location of Diagnosis numerator numerator (%) exclusions exclusions (%) denominator AA % 0 0.0% 0 FV % % 0 Lan % 0 0.0% 0 GGC % 1 1.2% 0 WoS % 4 2.3% 0 Figure 3 illustrates that the 95% target for MDT discussion was not achieved in WoS with only 92.0% of patients being discussed at the MDT prior to definitive treatment. Only NHS Lanarkshire met the target. NHS Ayrshire & Arran, Forth Valley and GGC reviewed the cases which did not meet the QPI target and identifying found that the majority of cases were incidental findings post-operatively, or patients died before treatment could commence or were unfit for treatment. Final Published - Endometrial and Cervical Cancer MCN Audit Report v1.0 04/07/

15 Number of Cases At the baseline review of endometrial cancer QPIs, the appropriateness of excluding patients who die before treatment within the measurement of this indicator will be discussed. Action required: NHS Ayrshire & Arran, Forth Valley and GGC to ensure patients with endometrial cancer are discussed at MDT prior to definitive treatment. QPI 3: Total Hysterectomy and Bilateral Salpingo-Oophorectomy Total Hysterectomy/Bilateral Salpingo-Oopherectomy for endometrial cancer is associated with best long term survival (compared to primary radiotherapy or hormonal treatment) 1. The target for this QPI is 80% with the tolerance designed to account for patients having fertility conserving treatment patients who are not fit for surgical intervention. Title: Numerator: Patients with endometrial cancer should undergo total hysterectomy/bilateral salpingooopherectomy. Number of patients with endometrial cancer who undergo total hysterectomy/bilateral salpingo-oopherectomy. Denominator: All patients with endometrial cancer. Exclusions: Patients with FIGO Stage IV. Patients who decline surgical treatment. Patients having neo-adjuvant chemotherapy. Target: 80% Figure 4: Proportion of patients with endometrial cancer who undergo total hysterectomy/bilateral salpingooopherectomy Ayrshire & Arran Forth Valley Lanarkshire GGC WoS Performance (%) Numerator Denominator Location of Diagnosis numerator numerator (%) exclusions exclusions (%) denominator AA % 1 0.4% 0 FV % 1 0.4% 0 Lan % 0 0.0% 0 GGC % 0 0.0% 0 WoS % 2 0.8% 0 All boards in the WoS met the target with the exception of NHS Ayrshire & Arran who fell just short of the 80% target with 77.8%. The overall WoS performance was 87.9%. Final Published - Endometrial and Cervical Cancer MCN Audit Report v1.0 04/07/

16 Number of Cases NHS Ayrshire & Arran has reviewed cases which did not meet the QPI and commented that there were appropriate clinical reasons for this. In the majority of the cases not meeting the QPI patients were not fit for surgery. QPI 4: Laparoscopic Surgery Laparoscopic surgery, by appropriately trained surgeons, is recommended for patients with endometrial cancer as it has been found to be feasible and surgically safe with reduced postoperative complications and length of stay 1. The target for this QPI is set at 50% which reflects the fact that some patients may not be clinically suitable for laparoscopic surgery. Title: Numerator: Patients with endometrial cancer undergoing definitive surgery should undergo laparoscopic surgery, where clinically appropriate. Number of patients with endometrial cancer undergoing definitive surgery who undergo laparoscopic surgery. Denominator: All patients with endometrial cancer undergoing definitive surgery. Exclusions: No exclusions. Target: 50% Figure 5: Proportion of patients with endometrial cancer undergoing definitive surgery who undergo laparoscopic surgery Ayrshire & Arran Forth Valley Lanarkshire North Glasgow South Glasgow Clyde WoS Location of Surgery Performance (%) Numerator Denominator numerator numerator (%) exclusions exclusions (%) denominator AA % 0 0.0% 0 FV % 0 0.0% 0 Lan % 0 0.0% 0 NG % 0 0.0% 0 SG % 0 0.0% 0 Clyde % 0 0.0% 0 WoS % 0 0.0% 0 Of the 263 patients diagnosed in WoS with endometrial cancer undergoing surgery, 151 patients are recorded as undergoing laparoscopic surgery resulting in a WoS performance of 57.4% against the 50% QPI target. Only South Glasgow and Clyde failed to meet the QPI target with a performance of 29.2% and 3.3% respectively. Final Published - Endometrial and Cervical Cancer MCN Audit Report v1.0 04/07/

17 Number of Cases Action required: South Glasgow and Clyde should review all cases where laparoscopic hysterectomy was not undertaken to identify the reasons for this management approach and feedback to the MCN, noting action to be taken, where necessary. QPI 5: Adjuvant Vaginal Brachytherapy For stage IB grade 1-2 brachytherapy has been shown to improve local control rates without the toxicity associated with external beam radiotherapy 1. Title: Numerator: Patients with stage IB, grade 1 or 2, or stage IA, grade 3 endometrioid or mucinous endometrial cancer should be considered for adjuvant vaginal brachytherapy. All patients with stage IB, grade 1 or 2, or stage IA, grade 3 endometrioid or mucinous endometrial cancer receiving vaginal vault brachytherapy. Denominator: All patients with stage IB, grade 1 or 2, or stage IA, grade 3 endometrioid or mucinous endometrial cancer. Exclusions: Patients who decline brachytherapy. Target: 90% Figure 6: Proportion of patients with stage IB, grade 1 or 2, or stage IA, grade 3 endometrioid or mucinous endometrial cancer having adjuvant vaginal brachytherapy Ayrshire & Arran Forth Valley Lanarkshire GGC WoS Performance (%) Numerator Denominator numerator numerator (%) exclusions exclusions (%) denominator AA % 0 0.0% 0 FV % 0 0.0% 0 Lan % 0 0.0% 0 GGC % 0 0.0% 0 WoS % 0 0.0% 0 - Data not shown due to small numbers Location of Diagnosis It should be noted that numbers of patients, are low and therefore comparisons between Boards should be made with caution. NHS Ayrshire and Arran and NHSGGC did not meet the QPI target, however this equated to only one or two cases in each Board. Overall in the WoS 36 out of 42 cases received vaginal vault brachytherapy. NHS Ayrshire & Arran and GGC have reviewed all cases not meeting the QPI noting that these patients received external beam radiotherapy rather than brachytherapy. Final Published - Endometrial and Cervical Cancer MCN Audit Report v1.0 04/07/

18 Number of Cases QPI 6: Chemotherapy Platinum chemotherapy can improve progression free survival in patients with stage IV endometrial cancer. The use of chemotherapy should be considered for patients with stage IV disease or those with stage III disease plus residual disease at the completion of surgery 1. Title: Numerator: Patients with stage IV endometrial cancer should have chemotherapy. All patients with stage IV endometrial cancer receiving chemotherapy. Denominator: All patients with stage IV endometrial cancer. Exclusions: No exclusions. Target: 75% Figure 6: Proportion of patients with stage IV endometrial receiving chemotherapy Ayrshire & Arran Forth Valley Lanarkshire GGC WoS Performance (%) Numerator Denominator numerator numerator (%) exclusions exclusions (%) denominator AA % 0 0.0% 2 FV % 0 0.0% 1 Lan % 0 0.0% 0 GGC % 0 0.0% 0 WoS % 0 0.0% 3 - Data not shown due to small numbers Location of Diagnosis Small numbers mean that any comparison of results should be treated with caution. The overall figure in the WoS for patients with stage 4 endometrial cancer receiving chemotherapy was 57.7%, against the 75% target. NHS Ayrshire & Arran, NHS Forth Valley, NHS Lanarkshire and NHSGGC reviewed all cases not meeting the QPI and valid clinical reasons were noted for those who did not receive chemotherapy, in the main fitness for chemotherapy treatment. Final Published - Endometrial and Cervical Cancer MCN Audit Report v1.0 04/07/

19 Number of Cases 4.4 Cervical Cancer QPI 1: Radiological Staging It is necessary to fully image the pelvis prior to definitive treatment in order to establish the extent of disease and minimise unnecessary or inappropriate treatment 1. Title: Numerator: Patients with cervical cancer should have their stage of disease assessed by MRI prior to first treatment. All patients with cervical cancer having MRI of the pelvis carried out prior to first treatment. Denominator: All patients with cervical cancer. Exclusions: Patients with histopathological FIGO stage 1A1 disease. Patients treated by LLETZ only. Patients unable to undergo MRI due to contraindications. Target: 95% Figure 7: Proportion of patients with cervical cancer who have an MRI of the pelvis performed prior to first treatment Ayrshire & Arran Forth Valley Lanarkshire GGC WoS Performance (%) Numerator Denominator Location of Diagnosis numerator numerator (%) exclusions exclusions (%) denominator AA % 0 0.0% 0 FV % 0 0.0% 0 Lan % 0 0.0% 0 GGC % 0 0.0% 0 WoS % 0 0.0% 0 Of the 138 patients diagnosed with cervical cancer, 113 underwent MRI of the pelvis prior to first treatment. This has resulted in a WoS performance of 81.9% against the 95% QPI target. Only NHS Ayrshire & Arran met the 95% target. Results were variable in the other boards ranging from 66.7% in NHS Lanarkshire to 87.9% in NHSGGC. NHS Forth Valley, Lanarkshire and GGC have reviewed cases not meeting the QPI noting that this was after first treatment, other reasons include: patient choice and incidental findings of cancer post surgery. In the absence of a clinical suspicion of cancer, LLETZ biopsy prior to MRI Final Published - Endometrial and Cervical Cancer MCN Audit Report v1.0 04/07/

20 Number of Cases is appropriate. The measurement of this QPI will be considered at baseline review to identify if provision could be made to account for these cases in future analysis. QPI 2: Positron Emission Tomography/Computed Tomography (PET/CT) Patients not suitable for surgery and being considered for radical radiotherapy (+/- concurrent chemotherapy) are recommended to undergo PET/CT because of the significant risk of extra pelvic disease which if detected will change patient management 1. Title: Numerator: Patients with cervical cancer for whom primary definitive surgery is not appropriate, should undergo PET/CT. All patients with cervical cancer undergoing primary radical radiotherapy who have PET/CT imaging prior to starting treatment. Denominator: All patients with cervical cancer undergoing primary radical radiotherapy. Exclusions: No exclusions. Target: 95% Figure 8: Proportion of patients with cervical cancer, for whom primary definitive treatment is radical radiotherapy, who have PET/CT imaging Ayrshire & Arran Forth Valley Lanarkshire GGC WoS Performance (%) Numerator Denominator Location of Diagnosis numerator numerator (%) exclusions exclusions (%) Final Published - Endometrial and Cervical Cancer MCN Audit Report v1.0 04/07/ denominator AA % 0 0.0% 0 FV % 0 0.0% 0 Lan % 0 0.0% 0 GGC % 0 0.0% 0 WoS % 0 0.0% 0 Of the 95 patients with cervical cancer undergoing primary radical radiotherapy, 85 received PET/CT imaging prior to starting treatment. This equates to a WoS performance of 86.3% against the 95% QPI target for this measure. No boards achieved the 95% target, however, it should be noted that numbers in some units are low and results could therefore be susceptible to annual fluctuation. NHS Ayrshire & Arran and Lanarkshire notes that following cases review those patients not meeting the target received adjuvant chemoradiotherapy following surgery rather than as primary treatment. Discussion nationally has identified there is a data recording and

21 Number of Cases measurement issue regarding patients receiving adjuvant chemoradiotherapy which will be discussed and rectified at baseline review. NHS Forth Valley noted that the decision to undergo PET/CT has historically always been made at MDT discussion, in the cases which did not meet the target these patients were discussed at MDT where PET/CT was not deemed necessary. QPI 3: Multidisciplinary Team Meeting (MDT) Evidence suggests that patients with cancer managed by a multi-disciplinary team have a better outcome. There is also evidence that the multidisciplinary management of patients increases their overall satisfaction with their care 1. Title: Numerator: Patients with cervical cancer should be discussed by a MDT prior to definitive treatment. All patients with cervical cancer discussed at the MDT before definitive treatment. Denominator: All patients with cervical cancer. Exclusions: Patients with histopathological FIGO stage 1A1 disease. Patients treated by LLETZ only. Target: 95% Figure 9: Proportion of patients with cervical cancer who are discussed at a MDT meeting before definitive treatment Ayrshire & Arran Forth Valley Lanarkshire GGC WoS Performance (%) Numerator Denominator Location of Diagnosis numerator numerator (%) exclusions exclusions (%) denominator AA % 0 0.0% 0 FV % 0 0.0% 0 Lan % 0 0.0% 0 GGC % 0 0.0% 0 WoS % 0 0.0% 0 The 95% target for MDT discussion was achieved in WoS with 97.1% of patients being discussed at the MDT before definitive treatment. As indicated by Figure 9 three of the 4 boards successfully met the QPI target with only NHSGGC not meeting the 95% target by a small margin of 1.8 percentage points. Final Published - Endometrial and Cervical Cancer MCN Audit Report v1.0 04/07/

22 Number of Cases Action required: NHSGGC to review all cases which were not discussed at MDT prior to definitive treatment and feedback to MCN. QPI 4: Radical Hysterectomy Radical surgery is recommended for FIGO stage IB1 disease if there are no contraindications to surgery. Patients with tumours <4 cm in diameter are less likely to have metastatic spread and benefit most from radical hysterectomy. In young women quality of life is less impaired after radical hysterectomy than following chemo-radiation therapy 1. Title: Numerator: Patients with FIGO stage IB1 cervical cancer should undergo radical hysterectomy All patients with FIGO stage IB1 cervical cancer who undergo radical hysterectomy. Denominator: All patients with FIGO stage IB1 cervical cancer. Exclusions: Patients who decline surgery. Patients who undergo fertility conserving treatment. Patients who have neo-adjuvant chemotherapy. Patients enrolled into surgical trials. Target: 70% Figure 10: Proportion of patients with stage IB1 cervical cancer (as defined by radiology and/or histopathology) who undergo radical hysterectomy Ayrshire & Arran Forth Valley Lanarkshire GGC WoS Performance (%) Numerator Denominator numerator numerator (%) exclusions exclusions (%) Final Published - Endometrial and Cervical Cancer MCN Audit Report v1.0 04/07/ denominator AA % 0 0.0% 0 FV % 0 0.0% 0 Lan % 0 0.0% 0 GGC % 0 0.0% 0 WoS % 0 0.0% 0 - Data not shown due to small numbers Location of Diagnosis Small numbers mean that any comparison of results should be treated with caution. Of the 39 patients with FIGO stage IB1 cervical cancer 34 underwent radical hysterectomy resulting in a WoS performance of 87.2%. As indicated by Figure 10 all units achieved the 70% QPI target, however it should be noted that numbers were low in NHS Forth Valley and figures have been removed due to the effect of small numbers on percentage values.

23 Number of Cases QPI 5: Surgical Margins The quality of radical surgery for cervical cancer has an important influence on local control of the tumour and ultimately survival. Therefore, it is important to optimise and ensure the quality of surgical care for cervical cancer patients 1. QPI 5 is analysed by location of surgery rather than location of diagnosis. Title: Numerator: Patients with surgically treated cervical cancer should have clear resection All patients with cervical cancer who undergo surgery where surgical margins are clear of tumour. Denominator: All patients with cervical cancer who undergo surgery. Exclusions: Patients who decline surgery. Patients who undergo fertility conserving treatment. Patients who have neo-adjuvant chemotherapy. Patients enrolled into surgical trials. Target: 95% Figure 11: Proportion of patients with cervical cancer who have surgical margins clear of tumour following hysterectomy Ayrshire & Arran Forth Valley Lanarkshire North Glasgow South Glasgow Clyde WoS Location of Surgery Performance (%) Numerator Denominator numerator numerator (%) exclusions exclusions (%) Final Published - Endometrial and Cervical Cancer MCN Audit Report v1.0 04/07/ denominator AA % 0 0.0% 0 FV % 0 0.0% 0 Lan % 0 0.0% 0 NG % 0 0.0% 0 SG % 0 0.0% 0 Clyde % 0 0.0% 0 WoS % 0 0.0% 0 - Data not shown due to small numbers Of the 52 patients diagnosed with cervical cancer undergoing surgery, 49 were noted as having surgical margins clear of tumour (94%). It should however be noted that due to low numbers figures for some units have been removed. Only South Glasgow did not meet the target however this equated to only one case which upon review margins were noted as being clear but which was not stated clearly on the pathology report summary.

24 Number of Cases QPI 6: 56 Day Treatment for Radical Radiotherapy Overall treatment time for locally advanced cervical cancer should be as short as possible. Radiotherapy for squamous carcinoma should be completed within 56 days 1. Title: Numerator: Treatment time for patients with cervical cancer undergoing radical radiotherapy should be no more than 56 days. All patients with cervical cancer undergoing radical radiotherapy (external beam or brachytherapy) whose overall treatment time, from start to the end of treatment, is not more than 56 days. Denominator: All patients with cervical cancer undergoing radical radiotherapy (external beam or brachytherapy). Exclusions: No exclusions. Target: 90% 05% Figure 11: Proportion of patients with cervical cancer undergoing radical radiotherapy whose overall treatment time, from the start to the end of treatment, is not more than 56 days Ayrshire & Arran Forth Valley Lanarkshire GGC WoS Performance (%) Numerator Denominator Location of Diagnosis numerator numerator (%) exclusions exclusions (%) denominator AA % 0 0.0% 0 FV % 0 0.0% 0 Lan % 0 0.0% 0 GGC % 0 0.0% 0 WoS % 0 0.0% 0 Figure 11 highlights that encouragingly all units met the 90% QPI target resulting in an overall WoS performance of 98.9%, with only 1 patient across the WoS completing radical radiotherapy in over 56 days (overall treatment time was 58 days). Final Published - Endometrial and Cervical Cancer MCN Audit Report v1.0 04/07/

25 Number of Cases QPI 7: Chemoradiation Any patient with cervical cancer considered suitable for radical radiotherapy treatment should have concurrent chemoradiotherapy with a platinum based chemotherapy, if fit for treatment 1. Title: Numerator: Patients with cervical cancer undergoing radical radiotherapy should receive concurrent platinum-based chemotherapy. All patients with cervical cancer undergoing radical radiotherapy who receive concurrent chemotherapy. Denominator: All patients with cervical cancer who undergo radical radiotherapy. Exclusions: No exclusions. Target: 70% Figure 12: Proportion of patients with cervical cancer undergoing radical radiotherapy who receive concurrent chemotherapy Ayrshire & Arran Forth Valley Lanarkshire GGC WoS Performance (%) Numerator Denominator Location of Diagnosis numerator numerator (%) exclusions exclusions (%) denominator AA % 0 0.0% 0 FV % 0 0.0% 0 Lan % 0 0.0% 0 GGC % 0 0.0% 0 WoS % 0 0.0% 0 The target level was successfully met by all units resulting in an overall WoS performance of 91.6%. NHS Lanarkshire commented that fitness levels and patient choice accounted for those 5 cases which did not meet the target. Final Published - Endometrial and Cervical Cancer MCN Audit Report v1.0 04/07/

26 Clinical Trial Access QPI Clinical trials are necessary to demonstrate the efficacy of new therapies and other interventions. Furthermore, evidence suggests improved patient outcomes from participation in clinical trials 1. Data definitions and measurability criteria to accompany the Clinical Trial QPI are available from the HIS website 1. The clinical trials QPI is measured utilising SCRN data and ISD incidence data, as is the methodology currently utilised by the Chief Scientist Office (CSO) and NCRI. Utilising SCRN data allows for comparison with CSO published data and ensures capture of all clinical trials recruitment, not solely first line treatment trials, as contained in the clinical audit data. Given that a significant proportion of clinical trials are for relapsed disease this is felt to be particularly important in driving quality improvement. This methodology utilises incidence as a proxy for all patients with cancer. This may slightly over, or underestimate, performance levels, however this is an established approach currently utilised by NHS Scotland 1. The following definitions are used to distinguish between interventional clinical trials and translational research: Interventional Clinical Trial: A clinical study in which participants are assigned to receive one or more interventions (or no intervention) so that researchers can evaluate the effects of the interventions on biomedical or health-related outcomes. The assignments are determined by the study protocol. Participants may receive diagnostic, therapeutic, or other types of interventions. Translational Research: Translational research transforms scientific discoveries arising from laboratory, clinical, or population studies into clinical applications to reduce cancer incidence, morbidity, and mortality. QPI Title: Numerator: All patients should be considered for participation in available clinical trials wherever eligible. Number of patients with endometrial or cervical cancer enrolled in an interventional clinical trial or translational research. Denominator: All patients with endometrial or cervical cancer. Exclusions: No exclusions. Target: Interventional 7.5% Translational 15% Table 3 below details the number of patients with recruited into relevant clinical trials in 2014 and A number of the clinical trials which were recruiting patients in this period included cervix, endometrial and ovarian cancer patients it is therefore not possible to measure the QPI at this time. Final Published - Endometrial and Cervical Cancer MCN Audit Report v1.0 04/07/

27 Table 3: Number of patients who are enrolled in an interventional clinical trial or translational research Trial Name Tumour Type Trial Type ENGOT-EN2-DGCG- EORTC EORTC PARAGON INTERLACE NiCCC Trial (BIBF1120) A phase III Trial of postoperative chemotherapy or no further treatment for patients with node-negative stage I-II intermediate or high risk endometrial cancer. Phase III Randomized Study of Doxorubicin and Cisplatin With or Without Paclitaxel in Patients With Locally Advanced, Metastatic, and/or Relapsed Endometrial Cancer. Phase II study of aromatase inhibitors in women with potentially hormone responsive recurrent/metastatic gynaecological neoplasms A phase III multicentre trial of weekly induction chemotherapy followed by standard chemoradiation versus standard chemoradiation alone in patients with locally advanced cervical cancer A Randomised Phase II Study of Nintedanib (BIBF1120) Compared to Chemotherapy in Patients with Recurrent Clear Cell Carcinoma of the Ovary or Endometrium Endometrial Interventional 1 0 Endometrial Interventional 0 0 Cervical/Ovarian/ Endometrial Interventional 2 2 Cervical Interventional 0 5 Ovary/Endometrial Interventional 0 1 Total Recruited 3 8 Please note the NiCCC Trial included both patients with ovarian and endometrial cancer. 5. Conclusions Cancer audit underpins much of the development and service improvement work of Managed Clinical Networks and the regular reporting of activity and performance are fundamental in assuring the quality of care delivered across the region. The development and implementation of Endometrial and Cervical Cancer QPIs will help drive continuous quality improvement in patient care whilst ensuring that activity is focussed on those areas that are most important in terms of improving survival patient outcomes, quality of care and patient experience. In addition, the introduction of QPIs and the associated governance structure will facilitate regular monitoring and reporting of data to promote equitable care across the country. These results illustrate that some of the QPI targets set have been challenging for NHS Boards to achieve and there remains room for further service improvement in a number of areas, specifically MDT discussion for endometrial cases, chemotherapy in stage IV endometrial cases and also radiological staging and PET/CT in cervical cancer cases. It is however encouraging that targets relating to radical hysterectomy, treatment time for radical radiotherapy and patients with cervical cancer undergoing chemoradiation were met by all Boards in 2014/15. Where QPI targets were not met NHS Boards have provided detailed commentary. In the main these indicate valid clinical reasons or that, in some cases, patient choice or co-morbidities have influenced patient management. Action required: Endometrial Cancer: NHS Ayrshire & Arran, Forth Valley and GGC to ensure patients with endometrial cancer are discussed at MDT prior to definitive treatment. Final Published - Endometrial and Cervical Cancer MCN Audit Report v1.0 04/07/