Gynaecological Cancer Managed Clinical Network Audit Report Report of the Clinical Audit Data Nick Reed Consultant Clinical Oncologist MCN Clinical Lead (Joint) Nadeem Siddiqui Consultant Gynaecological Oncologist MCN Clinical Lead (Joint) Kevin Campbell MCN Manager Julie McMahon Information Officer
CONTENTS EXECUTIVE SUMMARY 3 1. INTRODUCTION 7 2. BACKGROUND 7 2.1 NATIONAL CONTEXT 7 2.2 WEST OF SCOTLAND CONTEXT 9 3. METHODOLOGY 9 4. RESULTS AND ACTION REQUIRED 4.1 DATA QUALITY 4.2 PERFORMANCE AGAINST AGREED QUALITY MEASURES ACKNOWLEDGEMENT 29 ABBREVIATIONS REFERENCES 31 2
Executive Summary Introduction This report presents analysis results for the assessment of activity and performance of the West of Scotland Gynaecological Cancer Services in respect of the management of endometrial, ovarian and cervical cancer, based on data captured for new cases diagnosed in. NHS Quality Improvement Scotland (QIS) Clinical Standards have been used to measure performance in the management of ovarian cancer and key clinical outcome measures were developed regionally to measure performance in the management of endometrial cancer. Cervical cancer data has been analysed for the first time this year to enable a baseline of activity to be established and inform the development of outcome focussed measures for future analysis. The Quality Subgroup of the Scottish Cancer Taskforce is currently taking forward the development of national Quality Performance Indicators (QPIs) for all cancers. The development of QPIs for ovarian cancer commenced in February 12 and the development process for cervical and endometrial cancer is scheduled to commence towards the end of 12. This will enable future national comparative reporting and will help to drive continuous improvement for patients. Background Gynaecological cancers account for 11.5% of all cancers affecting woman in Scotland with approximately 17 new cases of gynaecological cancer diagnosed annually. 1 Incidence in ovarian cancer over the last ten years has decreased by % and endometrial cancer incidence has risen significantly by 31% over the same time period. 2 Since the introduction of the Scottish Cervical Screening programme incidence of cervical cancer has been declining, however in the past few years the incidence rate has begun to increase. This may be due to a slight decrease in the uptake of the cervical smear test. The Human Papilloma Virus (HPV) vaccine is designed to protect against the two types of HPV that can cause % of cervical cancer cases. The vaccination programme started in Scotland during 8 and aims to protect females by routinely immunising them at 12-13 years of age. By 11 uptake rates for females in S2 in school year /11 were 91.8% for the first dose, 9.2% for the second dose and 81.% for the third dose. 3 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. Poor survival in ovarian cancer compared with endometrial and cervical cancer is due to patients presenting at an advanced stage. Endometrial cancers tend to present at an earlier stage where the onset of post menopausal vaginal bleeding triggers an urgent referral from primary care for investigation. Similarly, cervical cancers are also detected early due to the well established screening programme. A total of 756 newly diagnosed gynaecological malignancies were recorded by audit teams within the West of Scotland () during. This included 279 new cases of ovarian cancer, 4 cases of endometrial cancer and 173 cases of cervical cancer. The Gynaecology Managed Clinical Network (MCN) continues to support and develop the clinical service for these patients and at present gynaecological cancer services are organised around a single regional multi-disciplinary team (MDT). The Network continues to benefit from enthusiastic engagement of a range of healthcare professionals and managers across the. Methodology Audit staff in each Health Board are responsible for collecting data on patients diagnosed in their area and entering that data on the electronic Cancer Audit Support Environment (ecase). The data is extracted from ecase and analysed centrally by the (CAN) 3
Information Team. Data relating to patients diagnosed in was downloaded from e-case in late 11 to ensure that full treatment data was available. Initial results of the analysis were provided to Boards to check for inaccuracies, inconsistencies or obvious gaps and a subsequent download taken upon which final analysis was carried out. The results of final data analysis were disseminated for Health Board verification in line with the Regional Information Governance Framework to ensure that the data is an accurate representation of service in each area. The analysis of performance against agreed quality measures was undertaken to enable full comparison of performance and volume of activity across the region. Although the current cervical cancer dataset collected has some limitations, it is anticipated that data quality and completeness will improve and this will facilitate outcome focussed measurement in future analysis. Results Ovarian Cancer Performance was assessed against thirteen core NHS QIS Standards for the management of ovarian cancer. Values represent the result and the range expressed as a percentage. QIS 2a.1- CA125 assessment and abdominal and pelvic ultrasound are undertaken once ovarian cancer is suspected or an ovarian pelvic mass is identified. (96.6 [92.3-.]%) QIS 3a.3- There is a weekly MDT meeting at which all new patients with raised RMI and imaging showing a complex mass or extra ovarian disease are reviewed and discussed. (98.6[95.2-.]%) QIS 3a.4- All patients confirmed to have ovarian cancer after surgery are discussed at the MDT meeting post-operatively. (98.9 [97.6-.]%) QIS 5a.1- Preparation for surgery includes chest X-ray or CT scan, DVT prophylaxis and antibiotic prophylaxis. (93.1 [8.-98.8]%), (85.7 [76.2-.]%), (85.7 [76.2-.]% ) QIS 6c.1- A vertical incision is made. (75.6 [56.3-.]%) QIS 6c.2- Washings are taken or ascitic fluid sent for cytology examination. (88.1 [.-.]%) QIS 6c.3- Optimal cytoreductive surgery is attempted and includes a hysterectomy and bilateral salpingo-oophorectomy. (92.7 [86.3-.]%) QIS 6c.4- Infracolic omentectomy is performed. (94.8 [62.5-.]%) QIS 6c.5- A record of residual disease is made in the operation notes. (93.1 [8.-.]%) QIS 6c.7- FIGO surgical stage is recorded in the operation notes. (88. [78.6-.]%) QIS 6c.8- Final FIGO surgical pathological stage is recorded in the clinical notes. (96.6[9.-.]%) QIS 8a.3- Histological type, sub-type (where appropriate) and grade of disease are recorded. (97.7[9.-.]%) QIS 8a.5- Fluid cytology is reported with the main resection specimen. (88.1 [.-.]%) Endometrial Cancer Analysis of endometrial cancer data was assessed using six key outcome measures developed and agreed by the MCN. Results of the analysis are detailed below; the values represent the figure and the range expressed as a percentage. KOM 1: Discussion by the MDT. (99.3 [97.9-.]%) KOM 2: Patients should have peritoneal washings sent for analysis. (96.9 [94.9-.]%) KOM 3: Patients should have surgical management completed by minimal access techniques (laparascopic). (11.2 [.-28.2]%) KOM 4: Type 2 cases should have lymphadenectomy in order to determine appropriate adjuvant therapies. (. [.-72.2]%) KOM 5: Number of patients entering a surgical clinical trial. (No surgical clinical trials available) 4
KOM 6: Intermediate and high risk patients should be offered adjuvant therapy. (65.1 [.-.]%) Cervical Cancer Cervical cancer data was analysed for the first time this year, to enable the assessment of quality and completeness of data whilst establishing a baseline of service activity. Results of the analysis are detailed below. Values represent the figure and the range expressed as a percentage where appropriate. 1: Discussion by the MDT. ( 99.4 [96.2-.]% ) 2: Mode of First Treatment. (Surgery 37%, Chemoradiotherapy 25.4%, Chemotherapy.2%) 3: Proportion of patients Undergoing Surgery. ( 39.9 [28.6-54.5]% ) Conclusions and Action Required The results outlined in this report demonstrate that patients with gynaecological cancer in the continue to receive a high standard of care and we are encouraged by the continued support and commitment of Network members to deliver a high quality service. Collection of data on gynaecological cancers began in 1999 (ovarian cancer) and 1 (endometrial cancer) and in that time there has been significant improvement in data quality. With data quality improving and the introduction of key outcome measures, the MCN is moving towards robust performance assessment where audit data can highlight clinical/service issues and lead to improvement and service change. Regional and Health Board specific actions pertaining to service and data quality issues are detailed below. Each Health Board is responsible for taking action on the recommendations of the report locally and is required to assess their performance in the context of the as a whole, identifying areas for improvement and investigating potential reasons for any variation in performance. Health Boards are asked to develop local Action/Improvement Plans in response to the findings presented in the report. Progress against these plans will be monitored by the MCN Advisory Board and reported to the Regional Cancer Advisory Group (RCAG) annually to enable them to review and monitor regional improvement. Action required: Service Improvement Ovarian Cancer Recognising that the number of occasions where the required level of compliance is not achieved is very small, Health Boards are directed to address the following: The specialist surgical team in should review the 2 cases identified as not having been presented to the MDT to establish the reasons for this. Local lead clinicians, together with audit staff, should review case notes for those instances where compliance with Standard 5a.1 relating to pre-operative investigations is not met, to ensure appropriate surgical preparation procedures have been followed. All Health Boards with the exception of NHS Lanarkshire should review those cases which were not sent for cytological examination, to confirm appropriate consideration for adjuvant therapy. 5
All Health Boards with the exception of Forth Valley should review cases where an infracolic omentectomy has not been performed to establish the reasons for this and confirm appropriate selection for this procedure., Forth Valley, Lanarkshire and North should review cases where no record of residual disease is recorded to establish if this is a data recording or capture issue, and inform the development of robust data collection processes. North and Forth Valley should review cases where final surgical FIGO is not recorded to establish if this is a data recording or capture issue, and inform the development of robust data collection processes., Forth Valley and North should review cases where histopathology data has not been recorded to explore the reasons for this. Endometrial Cancer Clyde and North should review the 2 cases identified as not having been presented to the MDT to establish the reasons for this. All Health Boards with the exception of NHS Forth Valley should review those cases in which peritoneal washings were not sent for analysis, to confirm appropriate consideration for cytological assessment. Data Quality Improvement Boards should review local processes to ensure that all components of pre-operative investigations are identified and recorded appropriately in the e-case system to facilitate more accurate assessment against Ovarian Cancer Standard 5a.1. Radiotherapy downloads from the Beatson West of Scotland Cancer Centre (BCC) must be fully utilised by all Health Boards to ensure continued improvement in data capture for adjuvant therapies, particularly in relation to endometrial cancer. MCN to review and revise the cervical cancer data collection proforma and provide further guidance to audit staff in relation to the recording of surgical procedures on ecase. 6
1. Introduction This report presents analysis results for the assessment of performance of Gynaecological Cancer Services relating to patients diagnosed in the region in. The audit data presented within the report underpin much of the regional development and service improvement work of the Managed Clinical Network (MCN) and regular reporting of activity and performance is a fundamental requirement of an MCN to assure the quality of care delivered across the region. NHS Quality Improvement Scotland (QIS) Clinical Standards have been used to measure performance in the management of ovarian cancer. Key clinical outcome measures were developed regionally to measure performance in the management of endometrial cancer. Cervical cancer data has been analysed for the first time this year to enable a baseline of activity to be established and inform the development of outcome focussed measures for future analysis. The Quality Subgroup of the Scottish Cancer Taskforce is currently taking forward the development of national Quality Performance Indicators (QPIs) for all cancers. This will enable future national comparative reporting and will help to drive continuous improvement for patients. The development of Ovarian QPIs is currently underway with endometrial and cervical cancer scheduled later in the programme. 2. Background Surgical management of ovarian and endometrial cancer is provided by gynaecological oncologists working in the regional specialist surgical centre in Royal Infirmary (GRI) and by gynaecologists located in Health Boards in the West of Scotland (). The majority of those gynaecologists have a special interest in gynaecological oncology. Surgical treatment for cervical and vulva cancers is centralised at GRI. Gynaecological cancer services are organised around a single regional multi-disciplinary team (MDT) meeting weekly; surgical, oncology and nursing staff in the specialist surgical centre and Beatson West of Scotland Cancer Centre (BCC), supported by radiology and pathology staff with a special interest in gynaecological malignancies, link with local Health Board leads and clinical nurse specialists, pathologists and radiologists in planning and reviewing the management of patients. This weekly forum is supported by video-conferencing. Quality assurance and continuous service improvement is supported by regular assessment of service performance against recognised NHS QIS Clinical Standards for ovarian cancer for provision of treatment and care. 2.1 National Context Gynaecological cancers account for 11.5% of all cancers affecting woman in Scotland, with approximately 17 new cases of gynaecological cancers diagnosed annually. Endometrial cancer is the most common gynaecological cancer and the fifth most common cancer in women in Scotland with approximately 6 new cases diagnosed annually. Ovarian cancer has approximately 6 new cases diagnosed annually and cervical cancer 3 cases. 1 Incidence in ovarian cancer over the last ten years has decreased by %. Endometrial cancer incidence however has risen significantly by 31% over the same time period. This undoubtedly reflects increasing levels of obesity and also longstanding changes in fertility. 2 Since the introduction of the Scottish Cervical Screening programme incidence of cervical cancer has been declining, however in the past few years the incidence rate has begun to increase. This may be due to a slight decrease in the uptake of the cervical smear test. The Human Papilloma Virus (HPV) 7
vaccine is designed to protect against the two types of HPV that can cause % of cervical cancer cases. The vaccination programme started in Scotland on 1 September 8 and aims to protect females by routinely immunising them at 12-13 years of age, through a school-based programme. In addition, the majority of NHS Boards started a catch up programme in January 9 offering immunisation to older females in the catch up cohort who have left school. By mid-august 11 uptake rates for females in S2 in school year /11 were 91.8% for the first dose, 9.2% for the second dose and 81.% for the third dose. 3 Table 1 shows the 1, 3 and 5 year relative survival for ovarian, endometrial and cervical cancers. 1 Table 1: Relative Survival Cancer Site 1 Year (%) 3 Year (%) 5 Year (%) Ovarian 71.1 51.2 43.2 Endometrial 93.1 85.9 84. Cervix 85.9 73.6.1 (Patients diagnosed 3-7) Poor survival in ovarian cancer compared with endometrial and cervical cancer is due to patients presenting at an advanced stage. Percentage survival is better for endometrial cancers as they have a tendency to present at an earlier stage. Most cases of endometrial cancer occur in postmenopausal women where the onset of post menopausal vaginal bleeding triggers an urgent referral from primary care for investigation. Many cervical cancers are also detected early due to the well established screening 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. 8
2.2 West of Scotland Context A total of 279 new cases of ovarian cancer, 4 cases of endometrial cancer and 173 cases of cervical cancer were diagnosed in the during. The numbers presented in Figure 1 are split by location of diagnosis and site of origin of tumour. Figure 1: Distribution of gynaecological malignancies in the West of Scotland Ovarian Endometrial Cervical Number of Patients Forth Valley Lanarkshire Clyde North Location of Diagnosis Forth Valley Lanarkshire Clyde North Ovarian 55 26 49 43 54 52 279 Endometrial 62 34 66 47 56 39 4 Cervical 27 21 42 23 38 22 173 The age distribution of women diagnosed with a gynaecological cancer in the is consistent with Scottish and UK figures with 93% of endometrial cancers and 79% of ovarian cancers diagnosed in women aged years and over. Cervical cancer affects a younger population with 64% of those diagnosed aged years or under. 3. Methodology Prospective audit of gynaecological cancer is long established in the. The MCN introduced a programme of data collection across the region in 1999 using a standardised data set to capture details of the management of all patients with a new diagnosis of ovarian cancer. Audit of endometrial cancer was similarly introduced in 1 and cervical in 5. Although differing processes of audit are in place across the region a standardised data set is collected. An extract of the required data items for each new diagnosis of ovarian, endometrial and cervical cancer () was generated to facilitate assessment of activity and performance. Ovarian data were assessed against NHS QIS Standards; endometrial data were assessed using a number of key outcome measures agreed by the MCN. Limitations of the cervical cancer data set restricted analysis to a baseline of activity and assessment of data completeness. 9
The data collection cycle is over a 12 month period from 1 st January to 31 st December each year, with analysis of the data approximately eight months following this to take account of the patient pathway and ensure that full treatment data is available. The data contained within this report was downloaded from the electronic Cancer Audit Support Environment (ecase) at 22: hrs on th November 11. 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 different figures if extracted at different times. The data is collected locally by audit staff and entered into ecase. Analysis is performed centrally by the (CAN) Information Team and provisional audit reports are issued to each Board to allow for missing data or errors to be rectified before a final download is taken. Final reports are then issued to each Board and results verified by the clinical lead in line with the Regional Information Governance Framework, to ensure that the data is an accurate representation of service in each area. Results are presented in graphical form and accompanied by a narrative highlighting relevant aspects of data collection, data quality and service performance. 4. Results and Action Required 4.1 Data Quality The case ascertainment comparison with Scottish Cancer Registration data (SMR6) detailed in Table 2 reflects the long established gynaecological cancer audit in the. Although numbers of new cases presenting will vary from year to year, assessment against a 5-year average of cancer registry data (5-9) gives a good indication of consistent performance of the audit process and indicates excellent data capture of patients diagnosed with gynaecological cancer in. Table 2: Case Ascertainment Cancer Site Cases from Audit Cancer Registry Average* Estimated Case Ascertainment Ovarian 279 274 1.8% Endometrial 4 2 116.9% Cervix 173 153 113.1% * The number of patients diagnosed each year will naturally vary therefore some Boards may report case ascertainment above % and others below. Case ascertainment is intended to be an indication rather than an exact measure. 4.2 Performance Against Agreed Quality Measures Results for each of the outcomes assessed are presented in graphical format with the underlying data also in tabular form. Data for and the results from the previous year (9) are included where applicable to enable comparative analysis. The data is presented as a combination of bar charts and pie charts with the majority of results displayed as a percentage of the overall number of cases. Results are accompanied by a narrative highlighting relevant aspects of data collection, data quality and service performance.
Ovarian Cancer A total of 279 ovarian cancers were diagnosed in the between 1 st December. January and 31 st QIS Standard 2a.1 - CA125 assessment and abdominal and pelvic ultrasound are undertaken once ovarian cancer is suspected or an ovarian pelvic mass is identified. Figure 2: CA125/abdominal and pelvic ultrasound are undertaken 9 9 8 Forth Valley Lanarkshire Clyde North Analysis Group Forth Valley Lanarkshire Clyde North 9 9 9 9 9 9 9 N 34 29 24 35 43 38 35 47 35 44 194 2 D 31 36 29 26 35 45 31 38 37 47 38 46 1 238 Risk of Malignancy Index (RMI), a recognised predictor of ovarian cancer, is calculated using an algorithm based on the CA125 marker in conjunction with results of the pelvic ultrasound and menopausal status. An RMI > 2 (approximately 8% positive predictor) initiates further investigation and subsequent presentation to the regional MDT review meeting. The results presented in Figure 2 illustrate that RMI assessment is now routinely used when suspicion is raised. On the relatively few occasions where it appears this assessment was not undertaken it is likely that CT imaging had already been carried out and cancer already predicted. 11
QIS Standard 3a.3 - There is a weekly MDT meeting at which all new patients with raised RMI and imaging showing a complex mass or extra ovarian disease are reviewed and discussed. Figure 3: Proportion of patients discussed at MDT Pre-op Post Op 9 8 Forth Valley Lanarkshire Clyde North Analysis Group Forth Valley Lanarkshire Clyde North Pre- Op Post Op Pre- Op Post Op Pre- Op Post Op Pre- Op Post Op Pre- Op Post Op Pre- Op Post Op Pre- Op Post Op N 32 26 42 38 45 82 42 14 219 172 D 32 26 21 44 38 45 84 42 14 222 174 MDT review meetings have been repeatedly endorsed in cancer services as the principal mechanism for ensuring that all relevant specialities contribute to and participate in decisions about the clinical management of patients. Effective MDT working is considered integral to provision of high-quality 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; effective communication. Gynaecological cancer services in the have been organised around a single regional MDT for a decade. This is facilitated by video-conferencing, enabling specialists and key staff in District General Hospitals (DGHs) to plan and review individual patient treatment and care in an interactive forum. Post-operative MDT review is critical to determining individual patient suitability for adjuvant treatment. The outcome of surgery and subsequent pathology is normally presented to the MDT in all cases, even where confirmed as borderline malignancy, or patient choice is to have no further treatment. Figure 3 demonstrates good performance across the region with only 2 patients in North not discussed at MDT. 12
Action Required: The specialist surgical team in should review the 2 cases identified as not having been presented to the MDT to establish the reasons for this. QIS Standard 5a.1 Preparation for surgery includes chest X-ray or CT scan, DVT prophylaxis and antibiotic prophylaxis. Figure 4: Pre-operative preparations 9 8 CT/Xray DVT Prophylaxis Antibiotic Prophylaxis Forth Valley Lanarkshire Clyde North Chest X-ray or Computerised Tomography (CT) scan, Deep Vein Thrombosis (DVT) prophylaxis and antibiotic prophylaxis are core components of routine pre-operative preparation. It is the considered view of the MCN that these results are inaccurate and that identification or availability of information in patient notes is the underlying reason for this apparent poor performance. Action Required: Local lead clinicians, together with audit staff, should review case notes for those instances where compliance with this Standard is not met, to ensure appropriate surgical preparation procedures have been followed. Boards should review local processes to ensure that all components of pre-operative investigations are identified and recorded appropriately in the e-case system to facilitate more accurate assessment against this Standard. 13
QIS Standard 6c.2 - Washings are taken or ascitic fluid sent for cytology examination. Figure 5: Washings are taken and sent for cytological examination 9 9 8 Ayrshire Forth Valley Lanarkshire Clyde North Location of Surgery Forth Valley Lanarkshire Clyde North 9 9 9 9 9 9 9 N 6 7 11 6 11 16 18 13 52 68 13 9 111 119 D 9 8 13 12 16 16 58 76 13 9 125 135 Ascites or pelvic washings are analysed for evidence of tumour spread outwith the ovaries and throughout the pelvic cavity. This is a determinant in consideration for adjuvant therapy. It can be seen from Figure 5 that there is variation across the region with and Lanarkshire sending % of washings for cytological examination and Forth Valley only sending % of samples. It is acknowledged that variation in practice exists as some Health Boards may only send early stage disease cases for cytological examination to determine whether adjuvant chemotherapy is required whilst other Boards routinely send all samples. Action Required: All Health Boards with the exception of NHS Lanarkshire should review those cases which were not sent for cytological examination, to confirm appropriate consideration for adjuvant therapy. 14
QIS Standard 6c.3 - Optimal cytoreductive surgery is attempted and includes a hysterectomy and bilateral salpingo-oophorectomy. Figure 6: Optimal cytoreductive surgery is attempted 9 8 9 Ayrshire Forth Valley Lanarkshire Clyde North Location of Surgery Forth Valley Lanarkshire Clyde North 9 9 9 9 9 9 9 N 11 4 5 6 11 11 46 44 12 8 89 89 D 11 11 4 5 7 15 11 51 12 8 99 96 Removal of cancer is the primary objective of surgery; the intention when planning treatment is to achieve optimal cytoreduction (no macroscopic residual disease in pelvic cavity). On occasion however, disease may be so extensive that this is simply not achievable and not in the best interests of the patient. Results presented in Figure 6 show that for 7 patients (7%) across the, optimal cytoreductive surgery was not achieved. 15
QIS Standard 6c.4 - Infracolic omentectomy is performed. Figure 7: Infracolic omentectomy is performed 9 9 8 Ayrshire Forth Valley Lanarkshire Clyde North Location of Surgery Forth Valley Lanarkshire Clyde North 9 9 9 9 9 9 9 N 7 5 15 19 15 53 74 13 8 112 127 D 9 8 13 12 16 16 58 76 13 8 125 134 The results presented in Figure 7 show some variation in activity across the region. This standard targets the patient group suspected of cancer pre-operatively therefore it is unclear why this apparent variation in practice exists though one reason may be that infracolic omentectomy is not feasible in very advanced disease. Action Required: All Health Boards with the exception of Forth Valley should review cases where an infracolic omentectomy has not been performed to establish the reasons for this and confirm appropriate selection for this procedure. 16
QIS Standard 6c.5 - A record of residual disease is made in the operation notes. Figure 8: A record of residual disease is made in the operation notes 9 9 8 Ayrshire Forth Valley Lanarkshire Clyde North Location of Surgery Forth Valley Lanarkshire Clyde North 9 9 9 9 9 9 9 N 24 25 15 8 14 19 26 64 77 24 14 167 163 D 26 27 15 16 32 84 24 14 183 175 Residual disease following surgery is a key prognostic indicator; macroscopic residual disease is indicative of a less favourable overall outcome. It is also important that this information is available to the MDT post surgery for consideration of adjuvant therapy. Figure 8 shows some variance across the region with and Clyde having residual disease recorded in operation notes in % of cases while, Forth Valley, Lanarkshire and North range from 8% to 95% of cases recorded. Action Required:, Forth Valley, Lanarkshire and North should review cases where no record of residual disease is recorded to establish if this is a data recording or capture issue, and inform the development of robust data collection processes. 17
QIS Standard 6c.8 Final FIGO surgical pathological stage is recorded in notes. Figure 9: Final FIGO surgical stage is recorded 9 9 8 Ayrshire Forth Valley Lanarkshire Clyde North Location of Surgery Forth Valley Lanarkshire Clyde North 9 9 9 9 9 9 9 N 26 27 14 9 15 32 55 79 16 14 158 169 D 26 27 15 16 32 84 24 14 183 175 Final stage of disease is a critical determinant in considering adjuvant therapies. Final stage should be agreed with the MDT, based on all available information. Figure 9 shows that 5 cases in North and 1 case in Forth Valley did not have final surgical International Federation of Gynaecology and Obstetrics (FIGO) stage recorded. All other Health Boards had % of FIGO stage recorded. Action Required: North and Forth Valley should review cases where final surgical FIGO is not recorded to establish if this is a data recording or capture issue and inform the development of robust data collection processes. 18
QIS Standard 8a.3 Histological type, sub-type (where appropriate) and grade of disease are recorded. Figure : Histological type, sub-type (where appropriate) and grade of disease are recorded 9 8 9 Ayrshire Forth Valley Lanarkshire Clyde North Location of Surgery Forth Valley Lanarkshire Clyde North 9 9 9 9 9 9 9 N 26 25 15 9 16 32 68 83 24 14 181 171 D 26 27 15 16 32 84 24 14 183 175 A complete histopathology report of the surgical resection is necessary in order to establish what options are appropriate for further treatment modalities. Figure shows that 4 patients in the did not have a complete histopathology report recorded. Action Required:, Forth Valley and North should review cases where histopathology data has not been recorded to explore the reasons for this. 19
Endometrial Cancer A total of 4 endometrial cancers were diagnosed in the between 1 st January and 31 st December. KOM 1: Discussion by the MDT All cases should be discussed at the MDT meeting in order that consideration can be given to the appropriate application of all available treatment modalities. (Grade 1 cases are not routinely discussed at pre-op MDT) Figure 11: Proportion of patients discussed at MDT 9 8 9 Ayrshire Forth Valley Lanarkshire Clyde North Location of Diagnosis Forth Valley Lanarkshire Clyde North 9 9 9 9 9 9 9 N 49 62 34 47 64 52 46 47 55 38 39 263 D 49 62 34 48 64 52 47 48 56 38 39 265 2 2 patients who died before first treatment were excluded from this outcome measure. MDT review is important in ensuring that all patients are considered for adjuvant therapy, where appropriate. This forum also provides the route to specialist surgical intervention for those women requiring lymph node sampling. Only 2 patients are identified as not having been presented to the MDT. Action Required: Clyde and North should review the 2 cases identified as not having been presented to the MDT to establish the reasons for this.
KOM 2: Patients should have peritoneal washings sent for analysis. Figure 12: Proportion of peritoneal washings sent for analysis 9 8 Ayrshire Forth Valley Lanarkshire Clyde North Location of Surgery Forth Valley Lanarkshire Clyde North N 39 27 46 37 74 27 2 D 27 47 38 78 28 258 Peritoneal washings are analysed for evidence of tumour spread. This is a determinant in consideration of adjuvant therapy. Figure 12 illustrates that all Boards in the are routinely sending peritoneal washings for analysis. With regards to the 8 cases where samples were not sent for analysis it may be that there is clear evidence of disease beyond the primary site and cytological assessment is deemed unnecessary. Action Required: All Health Boards with the exception of NHS Forth Valley should review those cases in which peritoneal washings were not sent for analysis, to confirm appropriate consideration for cytological assessment. 21
KOM 3: Patients should have surgical management completed by minimal access (laparoscopic) techniques. Figure 13: Proportion of patients undergoing laparoscopic surgery Ayrshire Forth Valley Lanarkshire Clyde North Location of Surgery Forth Valley Lanarkshire Clyde North N 11 9 2 6 28 D 39 24 46 38 76 27 2 Laparoscopic assisted vaginal hysterectomy (LAVH) is less invasive facilitating shorter hospital stay, reduction in wound infections and other complications and better overall patient experience. Laparoscopic surgery is a developing area of clinical practice and variation in the use of LAVH across the region reflects both training and local resource availability. carried out laparoscopic surgery on 28.2% of their surgery patients, however Forth Valley and performed no laparoscopic surgery. 22
KOM 4: Type 2 cases should have lymphadenectomy in order to determine appropriate adjuvant therapies. Figure 14: Proportion of Type 2 cases undergoing lymphadenectomy 8 Ayrshire Forth Valley Lanarkshire Clyde North Location of Surgery All Grade 3, clear cell, serous papillary and carcinosarcoma cases should receive staging lymphadenectomy where appropriate, to differentiate between those patients requiring only radiotherapy and those who additionally require chemotherapy. A total of 5 (28%) patients did not receive a staging lymphadenectomy, however, it is recognised that this procedure may not be appropriate for all patients and factors such as obesity and/or frailty of patient should be considered. In accordance with recognised best practice all patients requiring lymphadenectomies undergo surgery at the specialist centre, as illustrated in Figure 14. 23
KOM6: Intermediate & high risk patients receiving adjuvant therapy. All intermediate (Grade 2, 1B) & high risk (all others not intermediate and not in exclusions clause) post surgical patients should be offered adjuvant therapy. Figure 15: Proportion of intermediate and high risk patients receiving adjuvant therapy Adjuvant Therapy No Oncology Treat NR 9 8 Ayrshire Forth Valley Lanarkshire Clyde North Location of Surgery Forth Valley Lanarkshire Clyde North Adjuvant Therapy 4 17 14 35 12 82 No Record of Adjuvant Therapy 4 2 13 4 33 Not Recorded 11 11 Total 14 15 17 16 48 16 126 Figure 15 shows wide variation between locations in the. Forth Valley have no patients recorded as having adjuvant therapy whereas Lanarkshire have % of appropriate patients receiving adjuvant treatment. This may be indicative of an oncology data capture issue in Forth Valley. In mid-11 a monthly download of radiotherapy data to each Health Board was implemented from the BCC according to an agreed minimum dataset. An initial download of all retrospective data were made available to assist with completion of audit data with subsequent monthly downloads of current information. Action Required: Radiotherapy downloads from BCC must be fully utilised by all Health Boards to ensure continued improvement in data capture. 24
Cervical Cancer A total of 173 cervical cancers were diagnosed in the between 1 st January and 31 st December. Cervical cancer data has been analysed for the first time this year to enable a baseline of activity to be established and inform the development of outcome focussed measures for future analysis. This initial analysis identified a number of discrepancies between the data collection proformas being used to gather cervical cancer data and the available data options on ecase. In addition, the limited options available to record FIGO stage for cervical cancer patients prohibited measurement of a number of outcome measures which were reliant upon detailed staging information. Inconsistency in the recording of surgical procedures was also apparent across the region. The FIGO staging options on ecase have since been amended and the MCN will endeavour to provide further guidance in relation to the collection and recording of cervical cancer data to enable more outcome focussed analysis going forward. Action required: MCN to review and revise the cervical cancer data collection proforma and provide further guidance to audit staff in relation to the recording of surgical procedures on ecase. All patients should be discussed by the MDT. Figure 16: Proportion of patients discussed at MDT 9 8 Ayrshire Forth Valley Lanarkshire Clyde North Analysis Group Forth Valley Lanarkshire Clyde North N 25 21 42 22 37 22 169 D 26 21 42 22 37 22 1 *3 patients were excluded as they died before treatment. As noted earlier MDT working is considered integral to provision of high-quality cancer care. Figure 16 shows that only one cervical cancer patient from was not discussed at MDT. 25
Mode of First Treatment Figure 17: Mode of First Treatment Endoscopic, 3.5% Supportive Care, 2.3% Patient Refused, Patient Died, 1.2% 1.7% Not recorded,.6% Chemoradiotherapy, 25.4% Surgery, 37% Chemotherapy,.2% Radiotherapy, 8.1% Figure 17 shows the distribution of treatment performed for cervical cancers. The most common treatment types were surgery (37%), chemotherapy (.2%), and chemoradiotherapy (25.4%). 26
Proportion of Patients Undergoing Surgery by Location of Diagnosis Figure 18: Proportion of patients undergoing surgery Surgery No Surgery 9 8 Ayrshire Forth Valley Lanarkshire Clyde North Analysis Group Forth Valley Lanarkshire Clyde North N 6 15 11 15 12 69 D 27 21 42 23 38 22 173 Surgery is a proxy measure of stage at presentation, as patients who present late usually require surgical intervention. Figure 18 shows that in Forth Valley 28.6% of patients had surgery, which would suggest that patients presented earlier compared to (54.5%) and Clyde (47.8%) where the surgical activity would suggest the patients presented later. Surgical treatment of cervical cancer could involve local excision of the tumour by Loop Electrosurgical Excision Procedure/ Large Loop Excision of the Transformation Zone (LEEP/LLETZ) or hysterectomy and this could be a radical hysterectomy with pelvic lymph node dissection or a simple hysterectomy +/- pelvic lymph node dissection. A total of 23 patients from the cohort received a radical hysterectomy in the specialist centre and 2 patients received a simple hysterectomy. 27
5. Conclusions The results presented in this report demonstrate the continued support and commitment of Network members to deliver a high quality service to gynaecological patients across the. Cancer audit data underpins much of the regional development and service improvement work of the MCN and regular reporting of activity and performance is a fundamental requirement of an MCN to assure the quality of care delivered across the region. Collection of gynaecological cancer data began in 1999 (ovarian cancer) and 1 (endometrial cancer) and in that time there has been significant improvement in data quality. With data quality improving and the introduction of regional outcome measures for endometrial cancer, the MCN continues to improve the performance assessment and quality assurance process, and increasingly audit data can highlight clinical/service issues and lead to service change. The outcome measures analysed go some way to allowing assessment of service quality however there are still some data quality issues which have impeded meaningful interpretation of results. There are a number of actions required in response to this assessment of performance, several of which relate to a continued commitment to data quality improvement. Most significantly, improvement is required in the recording of cervical cancer data. Clinicians, audit staff and the MCN must work together to improve the capture of these data if we are to make further progress in assessing quality of service. Additional actions relating to service provision were identified particularly in relation to notable variance in relation to cytological examination to enable appropriate consideration for adjuvant therapy and the use of laparoscopic surgery across the region. Health Boards should examine their performance in the context of the overall results for the West of Scotland and in particular, Boards are asked to develop local Action/ Improvement Plans in response to the audit findings detailed within 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 Board Clinical Leads and MCN Lead Clinicians as part of the regional governance process, to enable RCAG to review and monitor regional improvement. 28
Acknowledgement This report has been prepared using clinical audit data provided by the following Health Boards in the CAN area: NHS NHS Forth Valley NHS Greater and Clyde NHS Lanarkshire We would like to thank all members and active participants in the cancer network for their continued support of the MCN, and the many hospitals that are committed to making the audit succeed. We also acknowledge the efforts of the clinical effectiveness staff, nurses, and other service users for their work in ensuring the data are available to enable analysis to take place each year. Without their considerable efforts this level of progress would not be possible. 29
Abbreviations BCC CT DGHs DVT ecase FIGO GRI LEEP LAVH MCN MDT QPI RMI CAN Beatson West of Scotland Cancer Centre Computerised Tomography District General Hospitals Deep Vein Thrombosis Electronic Cancer Audit Support Environment Federation of Gynacological Oncologists Royal Infirmary Loop Electrosurgical Excision Procedure Laparoscopic assisted vaginal hysterectomy Managed Clinical Network Multi-disciplinary Team Quality Performance Indicator Risk of Malignancy Index West of Scotland
References 1. http://www.isdscotland.org/health-topics/cancer/cancer-statistics/female-genital-organ/ 2. http://www.isdscotland.org/health-topics/cancer/publications/12-4-24/12-4-24- Cancer-Incidence-report.pdf 3. http://www.isdscotland.org/health-topics/child-health/publications/11-9-22/11-9-22- ImmunisationHPV-Summary.pdf?25388735533 31