SACT: What can we learn from Real World Data? Dr Rebecca Smittenaar Analytical Lead (Systemic Anti-Cancer Therapy) Public Health England

What will I cover? Brief introduction to the SACT database What our routine outputs are Cancer Drugs Fund Routine reports to Trusts Bespoke reports (CTYA, Dose Banding) Medicines Optimisation CQUIN 30 day mortality post SACT workbook Is Age a Barrier to Chemotherapy? 2

National Cancer Registration & Analysis Service Overview HEALTHCARE PROVIDERS 170 DATA SOURCES 12 LOCAL SYSTEM OTHER NATIONAL REPOSITORY NATIONAL AUDITS REGIONAL OFFICES 8 MULTI-DISCIPLINARY TEAMS 1,700+ LOCAL DATA SYSTEMS 500+ 3

Why are SACT data important? Improving patient care: 1. Patterns of service provision 2. Patient safety 3. Support evaluation of clinical effectiveness 4. Identify and address variation 4

What data do we collect in SACT? Patient Every item Hospital of data + in Consultant the dataset has been rigorously vetted by Cycle the NCIN clinical panel and the NHS Information Standards Board to make Drugs sure it is relevant. Tumour + Diagnosis Regimen Outcome 43 data items in total http://www.datadictionary.nhs.uk/data_dictionary/messages/clinical_data_sets/data_sets/systemic_anti-cancer_therapy_data_set_fr.asp 5

Cancer Drugs Fund 7

Completed Data Collections Drug Cancer Analysis Appraisal Pembrolizumab 1 st Line PD-L1 positive NSCLC Overall Survival Brentuximab Vedotin Hodgkin s Lymphoma Survey - % patient became eligible for stem cell transplant Data collection ends 4 th January Recommended Routine Commissioning Recommended Routine Commissioning Drug Cancer Analysis Appraisal Osimertinib EGFR and T790M mutation positive NSCLC Overall Survival 8

Where will you find these reports? https://cancerstats.ndrs.nhs.uk/welcome SACT@phe.gov.uk 9

Contents Routine reporting suite understanding and meeting user needs (trusts) Number of patients receiving treatment for each tumour group Information on number/proportions of regimens reported by treatment intent and tumour group and performance status Outcome summary data Drug and regimens administered by tumour group 10

CTYA Reports Contents Patient, tumour, regimen and administration count by month Regimen and drug level information Administration, by day and month Regimen, by trust 11

Allows trusts to monitor drug dose in comparison to National Dose Banding tables Designed to support efficient and effective service provision Inside Dose Banding Report Outside London, bendamustine, Dec 2017-Mar 2018 12

SACT - Medicines Optimisation CQUIN Key SACT targets were included in NHS England s MO CQUIN 2017-2018 These targets were designed to improve the quality and completeness of SACT data London trusts are running CQUIN 2018-2019 FY 13

Improving open access to SACT data Different Platform More rigorous Information Governance arrangements Other ways to access SACT data Office for Data Release Simulacrum NCRASenquiries@phe.gov.uk Project Proposal Process 14

http://www.thelancet.com/journals/lanonc/article/piis1470-2045(16)30383-7/abstract 16

30 day mortality post SACT crude rate Objective Set up a routine reporting feed to share 30 day mortality post SACT with NHS trusts Pilot overview Workbook circulation to Trusts and NHS England w/c 3 rd December 2018 Trusts informed whether they are at, above or below the national average Trusts able to request NHS numbers of affected patients from SACT helpdesk Trust invited to comment on their data and results Evaluation questionnaire sent to trusts Workbook into public domain with companion report including Trust comments beginning February 2019 17

Crude mortality rates, annual 2015 2016 Workbook Contents Cancer scope All cancers combined (excluding non-melanoma skin cancer) Breast AML Colon Lung (NSCLC, SCLC) Upper GI (Oesophago-gastric) CTYA (0-24years) Stratified by the following Age group (18+,18-49, 50-69,70+) Treatment intent (All intent, Curative, Palliative, Intent not assigned) Geography Trust Regional Cancer Alliance National 18

Workbook ABC ABC Trust ABC Trust ABC Trust 19

What can the data tell me? Crude rather than risk adjusted feed Management Information rather than a performance indicator Designed to support clinical case note review mortality and morbidity meetings No formal outlier process No target rate, but generally lower is better 20

All intents, All age groups 2015 2016 All cancers (exc. NMSC) 4.36% 4.44% AML 15.52% 15.33% Breast 1.77% 1.98% Colon 3.82% 3.41% CTYA 1.63% 2.02% SCLC 10.73% 9.07% NSCLC 7.36% 7.60% Upper GI-OG 5.05% 5.02% At a national level, only SCLC has decreased rates from 2015 to 2016 21

By Trust: All ages, all intents, mortality between 2015 and 2016 All cancers (exc. NMSC) 2 3 AML 0 1 Breast 0 0 Colon 0 0 CTYA 0 0 SCLC 0 1 NSCLC 0 1 Upper GI-OG 0 0 22

By 2030, UK estimates 1 suggest that 76% of cancer in men and just under 70% in women will occur over the age of 65 Managing older patients with cancer can pose significant challenges: physiology, comorbidities, polypharmacy social background 1 Mistry et al. Cancer incidence in the United Kingdom: projections to the year 2030. British Journal of Cancer. 2011; 105, 1795 1803. 24

There are challenging treatment decisions in the context of estimating life expectancy Older patients historically underrepresented in clinical trials 2 In some studies, fit elderly patients receive same relative benefit from SACT as their younger counterparts 3,4,5 1 Holmes CE, Muss HB. Diagnosis and treatment of breast cancer in the elderly. CA Cancer J Clin. 2003; 53:227-244. 2 Hutchins et al. Underrepresentation of patients 65 years of age or older in cancer-treatment trials. N Engl J Med 1999; 341:2061-2067. 3 Muss HB. Adjuvant chemotherapy in older and younger women With lymph node positive breast cancer. JAMA. 2005;293(9):1073-1081. 4 Hung A, Mullins CD. Relative effectiveness and safety of chemotherapy in elderly and nonelderly patients with stage III colon cancer: a systematic review. Oncologist. 2013;18(1):54-63. 5 Davidoff et al. Chemotherapy and survival benefit in elderly patients with advanced non-small-cell lung cancer. J Clin Oncol. 2010; 28(13):2191-7. 25

Key Questions Does age independently predict access to SACT? Is there variable prescribing of systemic therapy between trusts? 26

3 Cohorts of Patients NICE guidelines recommend SACT Breast cancer (stage II and III), following surgery (adjuvant SACT) Colon cancer (stage III), following surgery (adjuvant SACT) NSCLC, stage IIIB and IV, palliative SACT 27

Paper currently under review therefore results cannot be published here 28

With thanks to the ABC expert panel: Michael Wallington, Hanhua Liu, Nicolò Matteo Luca Battisti, Alistair Ring, Sarah Payne, Eva Morris, Martine Bomb, Jenny Seligmann, Rebecca Birch, Rebecca Smittenaar, Tania Kalsi, Lesley Mensah, Luke Hounsome, David Dodwell, Stuart Underhill, Peter Selby, Janine Mansi This work uses data provided by patents and collected by the NHS as part of their care and support 29

Any Questions? SACT@phe.gov.uk 30