Peer Review: Cancer Sub-site: Gynaecology Health Board/Region: All-Wales Cycle: Second Date of review: February 2018
This report describes the findings and themes observed by clinical review panels during the second round of gynaecological cancer peer review in Wales 2018. SERVICE DESCRIPTION STRUCTURE AND FUNCTION OF THE SERVICE brief overview There are many different types and primary sites for gynaecological cancer. The main four (4) sub sites include endometrial, vulval, ovarian and cervical cancers. Low grade endometrial cancer is diagnosed and managed within local cancer units in all Health Boards though by designated cancer specific consultants. Intermediate/High grade endometrial, vulval, ovarian and cervical cancers should all be managed by the appropriate regional service, for which there are three services in Wales. These regional teams are based around Cardiff, Gwynedd and Swansea. There were recognised improvements all-round for gynaecological cancer services with the functions of local and regional teams with strong clinical leadership and a collaborative community of practice. Health Boards should recognise the good progress made in achieving their action plans of the 2015 review; and Clinical Nurse Specialist (CNS) numbers have increased, which improved the access to a key worker and implementation of Holistic Needs Assessments (HNAs). DIAGNOSTIC PATHWAY brief summary The majority of teams had or are working towards an Urgent Suspected Cancer (USC) pathway that includes Post-Menopausal Bleed (PMB) and pelvic mass. In these circumstances general practice has direct access to tests such as ultrasound for pelvic masses, and where endometrial thickness greater than 4mm and is regarded as abnormal, transvaginal scanning, endometrial sampling and hysteroscopy may also be available in a one stop clinic or as the next step in the pathway. There may also be requests for magnetic resonance imaging (MRI) and chest x-ray to follow. Some providers use the Myosure tissue removal system within the hysteroscopy clinic, however there is not yet a unified approached within Wales. The approach of diagnosing vulval cancers is to biopsy in an outpatient setting and refer to the designated oncology centre requesting further scans as appropriate. A number of standard diagnostic tests are routinely used in the diagnosing of ovarian cancers that include, but are not limited to: Full blood count (FBC), liver and renal function tests, tumour makers, chest x-ray and computed tomography (CT). A screening programme is available for cervical cancer patients with evidence of variation of uptake around Wales. In the event sarcomas are diagnosed along the gynaecological cancer pathway, teams consult or refer to the sarcoma MDT in South Wales and in North Wales the team consults or refers to NHS England providers in Manchester/Owestry, as sarcoma services are commissioned by Welsh Health Specialist Services Committee (WHSSC). There is a challenge to increase the capacity but also to streamline the diagnostic pathway for gynaecological cancer patients. This will be embraced through the implementation of a Single Suspected Cancer Pathway (SCP), although most Health Boards do not meet the Urgent Suspected Cancer (USC) target. The review saw variation across teams as to how the diagnostic pathway is delivered locally, such as the use of one stop clinics, referral to designated clinics or by referral to 06 March 2018 1
general gynaecology clinics. Included in the variation was the use of the Myosure system. The hysteroscopic intrauterine procedure used by trained gynaecologists to resect and remove tissue including submucous myomas, endometrial polyps, and retained products of conception. STAGING Whilst many cancers are staged using the TNM Classification of Malignant Tumours, gynaecological cancers are staged using the FIGO staging systems, which are determined by the International Federation of Gynaecology and Obstetrics. The review in 2015 saw that staging was not always recorded; the review of 2018 had seen improvement in recording of stage and further improvement can be made. As an example it is assumed that the significant improvement of pathology service in Betsi Cadwaladr University Health Board has had a positive impact on the recording of cancer stage, but not all Health Boards are in the same position. SURGERY Surgeons who are part of a gynaecological multidisciplinary team (MDT) in cancer units operate on low grade endometrial cancer patients. Intermediate/high grade endometrial, vulval, ovarian and cervical cancer patients (if eligible) are operated on within the three regional MDTs in Wales. There is variation within the delivery of surgical services in the number of surgeons and the availability of laparoscopic surgery in the cancer units. Depending in some instances on the surgeon operating and/or the unit operating. There was a feeling that surgery should be delivered laparoscopically wherever possible to enable improved outcome measures for patients that fits within prudent healthcare. Where sarcomas are diagnosed in north Wales there was concern over the timeliness of surgery when referred to NHS England. CANCER NURSING Health Boards made improvements in cancer nursing numbers with some gaps remaining. The consequence of this was variation in HNAs being carried out, shared with other health care practitioners and primary care. HNAs are not routinely carried out and communicated; therefore, the data is unavailable to gain knowledge about the services needs of patients. SURVIVORSHIP The availability of allied health professional (AHP) services varies across Health Boards and Velindre NHS Trust, but there are examples of successful use of third sector providers in some settings. This is specifically in relation to occupational therapy, dietetics, lymphoedema, psychological support, physiotherapy and women s health in general. There is very limited prehabilitation undertaken and very limited rehabilitation services. There is a very good example of a late-effects service developed through Velindre Cancer Centre but is limited in the Health Boards. 06 March 2018 2
ONCOLOGY There is limited cross-cover of oncology, but in general there is availability of oncology via the tertiary MDTs. Treatment times to post-operation radiotherapy is poor and variable introduction of IMRT. There was significant variation in the collection and assessment of 30 day mortality data for chemotherapy with limited clear data available and an inability to benchmark across services. RESEARCH Most research activity related to observational studies not interventional studies. There was a general inability to recruit to a large UK study (ICON8) due to the unavailability of the chemotherapy drug known as Avastin (Bevacizumab) which is used in the standard arm of the study. GENERAL Very little was known by the service of Patient Reported Outcome Measures (PROMS) and Patient Reported Experience Measures (PREMS). There was a lack of knowledge and understanding of the Teenage and Young Adults (TYA) service available in south Wales. The North Wales access is well-established and provided by English services. The information used for this review related to 2016. There was a lack of development and information leadership working nationally to improve information for gynaecological cancers. This impacts the ability of the gynaecological cancer site group and teams to conduct validation and audit. GOVERNANCE There are very good working relations and pathway development in south where patients cross borders, but there was a lack of written agreements on the ownership of patients and who delivered their corresponding services along the patient pathway. The same could be said for sarcoma patients in North Wales where WHSSC are the commissioners of the service. 06 March 2018 3
USC REFERRALS Gynaecology USC Referrals treated within 62 days 10 9 8 7 6 5 4 3 2 1 2015 2018 NUSC REFERRALS Gynaecology Non-USC treated within 31 days 10 98% 96% 94% 92% 9 88% 86% 84% 82% 8 2015 2018 06 March 2018 4
CONVERSION RATE 2018 Conversation rate for gynae cancer 12% 1 8% 6% 4% 2% DETECTION RATE 2018 Detection rate for gynae cancer 6 5 4 3 2 1 06 March 2018 5
STAGE RECORDED Stage recorded as percentage 10 8 6 4 2 2015 2018 RADIOTHERAPY WITHIN 28 DAYS 2018 Percentage of patients starting definitie radiotherapy within 28 days of decision to Treat date 10 9 8 7 6 5 4 3 2 1 06 March 2018 6
PATIENTS RECORDED TO HAVE RECEIVED AN MRI (CERVIX & ENDOMETRIAL) Percentage of patients recorded as receiving an MRI for staging of cervix and endometrial cancer 10 9 8 7 6 5 4 3 2 1 2015 - Cervix 2015 - Endometrial 2018 - Cervix 2018 - Endometrial PATIENTS RECORDED AS SEEN BY A CLINICAL NURSE SPECIALIST 10 8 6 4 2 Percentage of patients seen by the Gynaecological Clinical Nurse Specialist 2015 2018 06 March 2018 7