Urological Cancers Managed Clinical Network Activity Report April 2011- June 2012 Mr Seamus Teahan Consultant Urologist MCN Clinical Lead Tom Kane MCN Manager
CONTENTS EXECUTIVE SUMMARY 3 1. INTRODUCTION 5 2. BACKGROUND 6 3. MCN OBJECTIVES FOR 2011/12 6 3.1 MULTI-DISCIPLINARY TEAM WORKING 6 3.2 REGIONAL FOLLOW UP GUIDELINE DEVELOPMENT 7 3.3 DEVELOPMENT OF CLINICAL MANAGEMENT GUIDELINES (CMGS) 8 3.4 FURTHER MCN ACTIVITY 8 4. CLINICAL AUDIT 9 5. KEY PRIORITY AREAS FOR THE MCN IN 2012-13 10 6. CONCLUSION 11 ACKNOWLEDGEMENT 12 ABBREVIATIONS 13 REFERENCES 14 2
Executive Summary Introduction The purpose of this document is to report the urological cancers Managed Clinical Network (MCN) activities in respect of: Performance against agreed objectives; Outcomes achieved; and Challenges encountered and actions taken to remedy defined issues. MCN Objectives for 2011/12 The urological cancers MCN has made progress and delivered a number of key objectives which include: Multi-disciplinary Team Working The regional priority is to ensure all cancer patients are efficiently managed by a multidisciplinary team (MDT). Working closely with each of the MDT chairs the MCN reviewed the operational processes of the MDT. Regional Follow Up Guideline Development The network utilised the existing low volume of evidence to develop guidelines for renal and bladder cancers which have been approved by the Regional Cancer Clinical Leads Group (RCCLG) and the Regional Cancer Advisory Group (RCAG). The regional consensus guidelines (RCG) and the high level impact assessments (IA) have been sent to the local boards to undertake a detailed impact assessment prior to implementation. The work on prostate cancer is ongoing, with a joint short life working group from the Primary Care Network. Clinical Management Guidelines (CMG) The MCN has reviewed the testicular CMG and created a new CMG for patients with penile cancer. This will ensure equity of care for these patients across the region. Regional Clinical Audit The 2010 clinical audit report was published in May 2012. An action plan was agreed and is currently being progressed through appropriate governance structures. Quality Performance Indicators (QPIs) for renal and prostate cancer have been completed nationally and published. Clinical Audit The 2010 report of clinical audit data demonstrate that urological cancer services in the West of Scotland (WoS) continue to provide a high quality service. Key actions identified by the quality assurance process of auditing the 2010 clinical data include: Service Improvement Prostate Cancer: All Health Boards should assess any implications for the future provision of services in their local area with respect to the volume of radical prostatectomy indicator defined. Renal Cancer: All Health Boards should review local protocols relating to the management of non-surgical renal cancer patients to ensure histological confirmation of diagnosis is obtained prior to any non-surgical treatment; and 3
All Health Boards should review local protocols to ensure all eligible non-metastatic patients receive radical nephrectomy. Bladder Cancer: All Health Boards should review local protocols to ensure all eligible patients receive neoadjuvant chemotherapy prior to radical therapy where appropriate, in line with West of Scotland Cancer Network (WoSCAN) Clinical Management Guidelines; and All Health Boards should review protocol for the management of radical cystectomy patients to determine whether lymph node dissection is carried out appropriately. Testicular Cancer: All Health Boards should review protocols for management of patients undergoing orchidectomy to establish ways to increase the proportion of patients that are offered a prosthesis. Data Quality Improvement All Health Boards must ensure local processes are in place for clinical Tumour, Nodes Metastases (TNM) staging information to be recorded by clinical staff and available for collection by audit staff; All Health Boards should review processes for obtaining TNM data from pathology to identify ways of improving the completeness of these data; and All Health Boards should establish whether there are issues with the documentation of testicular cancer patients offered a prosthesis following orchidectomy as this may be a contributory factor to the low proportions observed in the last two years data. Key Priority Areas for the MCN in 2012-13 Each MCN develops their own workplan, in consultation with members and in response to the outcome of the leads and managers workshop in February 2012. The emphasis is on identifying outcomes that improve the quality of patient care and overall efficiency. Below are the objectives for the coming year: Support the review of Urological Cancer Clinical Management Guidelines (CMGs); Complete development of evidenced based guidelines for the follow up of prostate cancer patients in the WoS; Assess potential for application of enhanced recovery (ER) techniques and practices in the management of cancer; Support delivery of the national cancer quality performance indicator development programme; Support delivery of the regional clinical audit work programme for 2012-13; and Develop a regional service map for urological cancers service provision, detailing the points of service delivery and the connections between them. The 2012-13 work plan has been finalised and published. 4
1. Introduction The (WoSCAN) area covers Ayrshire and Arran (AA), Forth Valley (FV), Lanarkshire (LAN) and Greater Glasgow and Clyde (GGC) Health Boards. There is one Multidisciplinary Team (MDT) meeting in each board, with GGC having two; pan Glasgow based in the Beatson West of Scotland Cancer Centre (BWoSCC) and one based in the Royal Alexandra Hospital (RAH) in Paisley. The 2010 WoSCAN audit data showed the following distribution of cancers: 49.2% Prostate cancer patients (1144) 29.6% Bladder cancer patients (687) 14.6% Renal cancer patients (339) 3% Renal/Pelvis/Ureter (70) 3.6% Testicular cancer patients (83) Greater Glasgow has the highest concentration of patients and when combined with Clyde figures provides services for 1126 (48.4%) of all urological cancers in the WoSCAN area. A number of patients come from other health boards into Glasgow for treatment e.g. prostate cryotherapy. The comparisons between WoSCAN and the other cancer networks i.e. North of Scotland (NOSCAN) and the South East (SCAN) indicate that WoSCAN has approximately 45% of all new urological cancers in Scotland, which is in line with the population distribution. It is predicted in a number of national documents 1, 2 that the numbers of urological cancers will grow over the next decade. Prostate, Bladder and Testicular cancers are predicted to grow in excess of the average of 3.7% for all cancers i.e. 4.8%, 9.8% and 4% respectively. The purpose of this document is to report the urological cancers Managed Clinical Network (MCN) activities in respect of: Performance against agreed objectives; Outcomes achieved; and Challenges encountered and actions taken to remedy defined issues. Looking forward There are a number of key areas that are likely to have an impact across the health boards: Enhanced Recovery After Surgery (ERAS) This is a core objective for all of the MCNs. In the context of urological cancers, the MCN will consider the potential for the use of ERAS for all open procedures e.g. Radical Nephrectomy, Prostatectomy, Cystectomy, Retroperitoneal Node Dissection and major reconstruction procedures. The adoption of ERAS could lead to patients returning to normality more quickly and a reduction in the length of stay for patients in hospital. Volume of Prostate Surgery performed As part of the MCN s ongoing work following the publication of the Quality Performance Indicators (QPIs), the MCN will review the volume of radical prostatectomies performed by each surgeon, to ensure that the minimum 12 procedures per surgeon in a 1 year period is being attained. 5
MCN Governance Mr Khaver Qureshi indicated his decision to resign from the role of Clinical Lead in early 2012 due to his appointment as Clinical Director for Urology, Greater Glasgow and Clyde. Dr J. Martin Russell also indicated that it would be an appropriate time for him to stand down as deputy lead of the MCN. The steering group members indicated their appreciation of the work carried out by Mr Qureshi and Dr Russell. Mr Seamus Teahan, Consultant Urologist, NHS Forth Valley was successfully appointed to the role of clinical lead, with the support of management within NHS Forth Valley. Dr Rob Jones, Senior Lecturer and Honorary Consultant Medical Oncologist has agreed to take on the role of deputy lead. The steering group membership has been refreshed to ensure engagement with all the relevant clinical specialities and across the 4 partner Boards. The input of all members of the MCN has been invaluable in supporting the delivery of the MCN work plan during 2011/12. 2. Background Prostate cancer is the most common cancer in males with over 2800 cases diagnosed in Scotland per annum. Furthermore, it is ranked as the fourth most commonly diagnosed cancer of all cancers in all patients in Scotland after lung, breast and colorectal cancers. The incidence of prostate cancer has increased by 15% in the last ten years.3 Cancers of the kidney and of the renal pelvis together rank as the ninth most common cancer type in Scotland. 3 Prostate, renal, testes and bladder cancers are all predicted to increase significantly in incidence in the two decades to 2020. 3 Relative survival from renal (and renal pelvis), prostate and testicular cancers is increasing 3.Survival from prostate cancer has significantly improved 3, 4 however it remains the second most common cause of cancer related death in Scottish men. 3 Invasive bladder cancer is the seventh commonest cause of death from cancer in males in Scotland and is the ninth most common cause of death from cancer in females 3. As there are a number of cancers within urology, the reasons for the increasing incidence are varied. It is acknowledged that cigarette smoking is detrimental to health and there is a correlation between smoking and bladder cancer; chemicals in the workplace have also been associated with bladder cancer. Smoking is also implicated in renal cancer, as well as obesity and genetic pre disposition. Testicular cancer is comparatively rare. The risk factors are largely unknown but are thought to include familial history i.e. increased risk if a brother has testicular cancer and also if one of the testicles is undescended. Family history and diet have been implicated. Prostate cancer is more common in black and mixed race men than white or Asian men. The major risk factor for prostate cancer is increasing age. 3. MCN Objectives for 2011/12 The MCN work plan was created and agreed via a process of consultation between MCN members, clinical lead and manager. This work plan is also aligned to the national quality strategy and forms part of the overall WoSCAN consolidated regional work plan. Progress throughout the year has been steady and achievements outlined below. 3.1 Multi-disciplinary Team Working The cancer core standards indicate that all patients should be discussed at and managed by a multidisciplinary process 5. Effective MDT working is considered integral to provision of high-quality 6
urological cancer care; facilitating a cohesive treatment planning function and ensuring treatment and care provision is individualised to patient needs. MDT working also supports many of the key requirements of good quality service delivery: adherence to evidence-based guidelines and protocols; recruitment to clinical trials; timely, appropriate and equitable access to the full range of specialist services; audit of activity and clinical practice; professional education and effective communication. The report of Regional MDT Review undertaken in 2010/11 and published in July 2011 highlighted that MDT review meetings for urological cancers are well established, generally well structured and organised across the WoS. The main clinical specialities involved in the management of urological cancer are well represented at all MDT review meetings. Administrative groups are generally represented at MDT meetings providing a resource for audit, clerical and overall co-ordination functions. 3.2 Regional Follow up Guideline Development Over the next decade cancer incidence is predicted to rise, mainly due to an ageing population. This will place increasing demand on current services with more treatments being delivered and more people living with or beyond cancer, often with multiple co-morbidities. It is recognised that current models of service will not be sustainable. Increased capacity and different models for surveillance of recurrences, treatment toxicities and late effects of treatment will be required. Recognising this in 2010/11 Regional Cancer Advisory Group (RCAG) requested that all MCNs undertake a critical review of current follow up practice across West of Scotland (WoS) Boards and develop/agree regional guidelines for follow up for all cancers. The urological cancers MCN has taken two different approaches to developing regional consensus guidelines for the following urological cancers: Renal and Bladder Cancers: Mr Ross Clark, consultant urologist, NHS Ayrshire & Arran led on this work with Mr Qureshi. A detailed questionnaire was circulated and completed by a wide range of clinicians involved in urological cancers. The purpose of the questionnaire was to establish current follow up management in each Health Board in WoSCAN. A literature review was carried out in order to understand what the current view in research is in respect of follow up. Draft regional consensus guidelines (RCG) and impact assessment (IA) documents were developed utilising the information gathered, were then discussed by the urological cancers steering group and circulated to the wider membership for comment. The RCG and IA were approved by Regional Cancer Clinical Leads Group (RCCLG) and RCAG in October 2011 and February 2012 respectively. Boards are currently undertaking a detailed impact assessment on the implementation of the regionally agreed guideline. Progress will be kept under review by RCCLG and an update was provided to RCAG in April 2012. This work is well underway but will continue into next year s work plan for full implementation to be achieved. Prostate Cancer: It was agreed that it would be particularly important to involve colleagues from the primary care network at an early stage. The approach to this had been to form a joint short life working group between the two networks, co-chaired by Mr Steve Leung, ST7 urology, NHS GGC and Dr Rosalie Dunn, lead cancer GP, NHS Lanarkshire. A clear remit has been agreed and the expected outcome will be regional consensus guidelines agreed and implemented across WoS, which clearly defines: The rationale and purpose of any follow up that is required for each patient group; 7
The essential minimum components of follow up; Any specific interventions required, including the rationale for these; and The potential impact of any proposed changes to current practice. The joint working group plans to take draft RCG and IA documents to the RCCLG and RCAG meetings in October 2012 for approval. 3.3 Development of Clinical Management Guidelines (CMGs) The MCN continues to systematically review the CMGs to ensure that the quality of care provided continues to be based on the most up to date clinical evidence. CMG development is integral to the MDT process, allowing local MDT discussion of patients managed according to CMG. New CMGs for Testicular Cancer and Penile Cancer were developed in 2012 by collaboration between a range of clinical specialties caring for these patients. 3.4 Further MCN Activity In addition to the initial agreed work plan objectives other activities has been completed by the network during 2011-2012 and details of these are outlined below. Gonadorelin Analogues for Advanced Prostate Cancer Hormone treatment is used in the management of prostate cancer. The MCN was requested by pharmacy colleagues to review the current options for treatment with a view to standardising therapy and optimising costs. The MCN has also worked with colleagues in the primary care network on this topic as it has implications for prescribing out of hospital. The MCN has completed this work and the agreed documentation is being utilised within each of the health boards both primary and secondary care to standardise treatment. Timing of MRI scans post-positive TRUS-guided prostate biopsy The MCN received a request for clarity on this topic from the health boards and following review and consultation the MCN confirmed that the advice provided to members in 2008 on timings remains current and should continue to be used in clinical practice National Institute for Health and Clinical Excellence (NICE) The steering group reviewed the NICE Not to do list from colleagues in NHS England in respect of urological cancers. No changes to clinical practice were required in the WoSCAN area. Development of a CMG for Bladder cancer Members of the network indicated that on the basis of new evidence that it was needed to revise this CMG to take account of changes to adjuvant chemotherapy. Quality Performance Indicators (QPIs) The network has been involved in supporting the development of national QPIs for renal and prostate cancers which have been published. Education Event The MCN hosted an educational event in February 2012 and the topics covered in the programme included: Follow Up of Urological Cancers; 2010 Audit Data; 8
An Update on Prostate Cryotherapy Service and Translational Research in Urology in the West of Scotland; Current and Future Perspectives in Urological Radiotherapy; Urological Cancer Quality Performance Indicators an Update; and Epidemiology of Prostate Cancer in the West of Scotland. The event evaluated positively and will inform the planning process for the future events. 4. Clinical Audit MCN members are increasingly engaged in audit data collection and analysis, and this practice will continue in order to drive improvement for the future. The clinical audit data was collected by clinical audit staff in each Health Board and entered into Electronic Cancer Audit Support Environment (e- CASE), a secure centralised web-based database. The data was downloaded by the WoSCAN Information Team during the latter part of 2011 to take account of the patient pathway and ensure that full treatment audit data were available. Over the last few years, the Urological Cancer MCN has endeavoured to improve quality and completeness of clinical audit data to ensure that robust performance assessment can take place. Improvements in quality and completeness of data have allowed a growing number of urological cancers to be analysed and reported each year and this year, analyses of five tumour types are detailed in the report. This is in itself an improvement for the MCN. The report on the 2010 clinical audit data was published in May 2012 and can be found at the following link: WoSCAN Audit Report There are clear areas for improvement across all health boards and specific actions have been detailed below: Service Improvement Prostate Cancer: All Health Boards should assess any implications for the future provision of services in their local area with respect to the volume of radical prostatectomy indicator defined. Greater Glasgow should report their findings post completion of the review of radical prostatectomy patients with involved margins. Renal Cancer: All Health Boards should review local protocols relating to the management of non-surgical renal cancer patients to ensure histological confirmation of diagnosis is obtained prior to any non-surgical treatment. All Health Boards should review local protocols to ensure all eligible non-metastatic patients receive either radical or partial nephrectomy as indicated. Bladder Cancer: All Health Boards should review local protocols to ensure all eligible patients receive neoadjuvant chemotherapy prior to radical therapy where appropriate, in line with WoSCAN Clinical Management Guidelines. All Health Boards should review protocol for the management of radical cystectomy patients to determine whether lymph node dissection is carried out appropriately. 9
Testicular Cancer: All Health Boards should review protocols for management of patients undergoing orchidectomy to ensure testicular prosthesis insertion is discussed pre-operatively with all men. In addition protocols should be put in place to specifically record the number of patients who either accept of decline this offer. Ayrshire & Arran should review chemotherapy data capture and if required review cases to ensure all cases were appropriately assessed for referral to oncology. Data Quality Improvement All Health Boards must ensure local processes are in place for clinical Tumour, Nodes, Metastases (TNM) staging information to be recorded by clinical staff and available for collection by audit staff. All Health Boards should review processes for obtaining TNM data from pathology to identify ways of improving the completeness of these data. In addition to reviewing the process for obtaining pathological TNM data, NHS Lanarkshire should review the process for the capture of surgical margin involvement data. All Health Boards should establish whether there are issues with the documentation of testicular cancer patients offered a prosthesis following orchidectomy as this may be a contributory factor to the low proportions observed in the last two years data. The existing audit and clinical governance framework has been revised in line with the agreed governance and reporting process for national Quality Performance Indicators and involves the introduction, in quarter one 2012-13, of a Board specific Performance Summary Report which will ensure that any potential issues are highlighted to Boards at an early stage. Templates will also be provided to enable Boards to develop local Action/Improvement Plans in response to audit findings. MCN Managers and Clinical Leads will review Board Action Plans to identify priorities for co-ordinated regional action and these, along with progress against specific Board actions will be monitored by the MCN Advisory Board throughout the year. This process aims to systematically drive service improvement and development and improve outcomes for cancer patients. Board and MCN Clinical Leads will feedback details of action taken to RCAG on an annual basis to enable RCAG to review and monitor regional improvement and escalate issues to Health Board Chief Executives as appropriate. 5. Key Priority Areas for the MCN in 2012-13 The MCN has now agreed its objectives for 2012-13 following participation at the annual regional planning workshop and through consultation with network members. A number of core objectives are going to be carried over from this year and will be priority areas in the work plan to be completed. Having completed the work to develop the regional consensus guideline for the follow up of renal and bladder cancers, the MCN will review implementation via the members. The MCN will also complete the work to develop regional consensus guidelines for prostate cancer; and Ensure progress is achieved against the audit report action plan. The MCN will take forward additional objectives: 10
Support the review of Urological Cancer Clinical Management Guidelines (CMGs). Updating the CMGs will ensure that the quality of care provided continues to be based on the most up to date clinical evidence; Assess potential for application of enhanced recovery (ER) techniques and practices in the management of cancer. ER pathways can deliver improvements in efficiency through reduced length of inpatient stay, reduction in high dependency and intensive care requirements and lower rates of post-operative complications and morbidity requiring re-admissions. Additionally overall patient experience is improved, indicating a better quality of care; Support delivery of the regional clinical audit work programme for 2012-13. Performance monitoring through regional comparative analysis is essential to ensure the safe and effective delivery of equitable care and drive continuous improvement of services across the region; Support delivery of the national cancer quality performance indicator development programme. National cancer QPIs will ensure that quality improvement activity is focussed on those areas that are most important in terms of improving survival and patient experience whilst reducing variance and ensuring safe, effective and person centred cancer care; and To develop a regional service map for urological cancers service provision, detailing the points of service delivery and the connections between them. Completion of this work will ensure equity of care for cancer patients in the West of Scotland by using information to improve quality and outcomes. A further update will be available when the MCN Clinical Lead and Manager attend RCAG in August to present the MCN s annual update report. 6. Conclusion This has been a transitional year with a change of lead and deputy lead. The MCN has had a productive year and in order for the clinical lead and manager to perform their duties effectively, the support of the steering group is vital. The regular visits by the manager to MDTs have also been helpful in increasing not only the profile of the MCN to the members but also in increasing engagement. Recognising the pressures on clinical time the MCN is looking at the most time efficient and effective way to engage and involve members in MCN activities to ensure essential clinical input to the ongoing improvement and development of cancer care in the WoS. The follow up work has been highly significant and it is expected that it will have a major impact as it is implemented. It is perceived that there will be the opportunity to reduce the amount of follow up carried out and to ensure that it is tailored to patient needs. The ongoing review of CMGs has helped to ensure that patients receive care based on the most up to date evidence. The review of Gonadorelin Analogues for Advanced Prostate Cancer proved to be a project which further enhanced collaboration between two networks and also pharmacy colleagues. Standardising to one specific Gonadorelin Analogue for the majority of patients in each of the health boards will aid in optimising resources. Going forward into 2012-13, whilst all of the work of the network is important, the following items may prove to be more challenging and are most likely to impact on clinical practice: Prostate Cancer Follow up Guideline implementation; 11
Enhanced Recovery After Surgery (ERAS); and Volume / Outcome analysis in prostate cancer surgery. The next activity report of the Urological Cancers MCN will be published by 31.07.13. Acknowledgement This report represents the achievements and challenges progressed across the 4 partner Health Boards of the : NHS Ayrshire & Arran NHS Forth Valley NHS Greater Glasgow and Clyde NHS Lanarkshire We would like to thank all members and active participants in the cancer network for their continued support of the Managed Clinical Network, without their efforts this level of progress would not be possible. 12
Abbreviations BWoSCC Beatson West of Scotland Cancer Centre CMG Clinical Management Guideline(s) ER Enhanced Recovery ERAS Enhanced Recovery After Surgery ISD Information Services Division MCN Managed Clinical Network MDT Multidisciplinary Team NHS AA NHS Ayrshire and Arran NHS FV NHS Forth Valley NHS GGC NHS Greater Glasgow and Clyde NHS LAN NHS Lanarkshire NICE National Institute for Health and Clinical Excellence NOSCAN North of Scotland Cancer Network QPIs Quality Performance Indicators RCAG Regional Cancer Advisory Group RCCLG Regional Cancer Clinical Leads Group TNM Tumour, Nodes, Metastases SCAN South East Scotland Cancer Network WoSCAN WoS West of Scotland 13
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