Upper Gastro-intestinal Cancer Managed Clinical Network Audit Report Upper GI Cancer Quality Performance Indicators Report of the 216 Clinical Audit Data Mr Matthew Forshaw MCN Clinical Lead Tracey Cole MCN Manager Julie McMahon Information Officer
CONTENTS EXECUTIVE SUMMARY 3 1. INTRODUCTION 13 2. BACKGROUND 13 2.1 NATIONAL CONTEXT 14 2.2 WEST OF SCOTLAND CONTEXT 15 3. METHODOLOGY 16 4. RESULTS AND RECOMMENDED ACTIONS 17 4.1 DATA QUALITY 17 4.2 PERFORMANCE AGAINST QUALITY PERFORMANCE INDICATORS 18 5. CONCLUSIONS 45 6. ACKNOWLEDGEMENTS 46 7. ABBREVIATIONS 47 8. REFERENCES 48 Final Published Upper Gastro-intestinal Cancer MCN Audit Report v1. 23/1/217 2
EXECUTIVE SUMMARY Introduction This report presents an assessment of the performance of West of Scotland Upper Gastro-intestinal (GI) Cancer Services relating to patients diagnosed in the region in 216 who have oesophageal and gastric (stomach) cancers. Twelve months of data were measured against v3. of the Upper GI Cancer Quality Performance Indicators (QPIs) which were implemented for patients diagnosed on or after 1 January 216. This was the fourth consecutive year of analysis following the initial Healthcare Improvement Scotland (HIS) publication of Upper GI cancer QPIs in 212. This was part of a programme of work led by the National Cancer Quality Steering Group (NCQSG) to develop national measures in the form of QPIs for all cancer types, in collaboration with the three Regional Cancer Networks and Information Services Division (ISD). Data definitions and measurability criteria to accompany the Upper GI Cancer QPIs are available from the ISD website 2. In order to ensure the success of the National Cancer QPIs in driving quality improvement in cancer care across NHS Scotland, a process of formal review was carried out after Year 3 of comparative reporting with tumour-specific Regional Clinical Leads undertaking a key role in determining the extent of the review required for each tumour type. The revised Upper GI Cancer QPIs 1 were published in March 217 and, as stated above, are valid for patients diagnosed on or after 1 January 216. Annual comparisons have been made where indicators remain comparable following this formal review. Any new QPIs which were developed requiring new data items will be reported in Year 5 once data becomes available for these new measures. Future reports will continue to compare clinical audit data in successive years to illustrate trends. Background The incidence rates of both oesophageal cancer and gastric cancer have decreased significantly over the last decade 3,4,5. Overall cancer mortality rates for oesophageal and gastric cancer patients in Scotland have decreased 3, most significantly for gastric cancer, with survival increasing over the last ten years 4. Upper GI cancer services are organised around MDTs serving 2.46 million people in four NHS Boards across the West of Scotland (WoS). There were 658 new cases of Upper GI cancer diagnosed in total in the West of Scotland (WoS) in 216: 452 oesophageal and 26 gastric. Services to manage these patients are configured as four local MDTs and their constituent hospital units are as follows: MDT Ayrshire & Arran (AA) Greater Glasgow and Clyde (GGC) Forth Valley (FV) Lanarkshire (Lan) Constituent Hospital(s) Crosshouse Hospital, Ayr Hospital Royal Alexandra Hospital, Inverclyde Royal Hospital, Vale of Leven, Western Infirmary/Gartnavel General Hospital, Glasgow Royal Infirmary, Southern General Hospital, Victoria Infirmary Forth Valley Royal Hospital Wishaw General Hospital, Monklands District General, Hairmyres Final Published Upper Gastro-intestinal Cancer MCN Audit Report v1. 23/1/217 3
Methodology The clinical audit data presented in this report were collected by clinical audit staff in each NHS Board in accordance with an agreed dataset and definitions. The data were entered locally into the electronic Cancer Audit Support Environment (ecase): a secure centralised web-based database. Data relating to patients diagnosed between 1 st January 216 and 31 st December 216 were downloaded from ecase on 5 th July 217. 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. Results The data are measured against ISD QPI measurability criteria and the results are summarised below as the overall result for WoSCAN and the range across NHS Boards in relation to the QPI targets. Figures are expressed in percentages and separately for oesophageal and gastric cancers where appropriate. Final Published Upper Gastro-intestinal Cancer MCN Audit Report v1. 23/1/217 4
Performance Summary Report OESOPHAGEAL CANCER Quality Performance Indicator (QPI) QPI 1: Endoscopy Proportion of patients with oesophageal cancer who have a histological diagnosis made within 6 weeks of initial endoscopy and biopsy. QPI 3: MDT Meeting Proportion of patients with oesophageal cancer who are discussed at MDT meeting before definitive treatment. Performance by Board QPI target AA FV GGC Lan WoS 89.8% < 97.1% > 91.2% > 95.1% > 92.9% > 95% 44 49 67 69 28 228 97 12 416 448 94.% > 94.2% < 94.7% > 96.9% > 95.% > 95% 47 5 65 69 215 227 94 97 421 443 QPI 4(i): Staging and Treatment Intent Proportion of patients with oesophageal cancer who have (i) TNM stage recorded at MDT meeting prior to treatment. QPI 4(ii): Staging and Treatment Intent Proportion of patients with oesophageal cancer who have (ii) treatment intent recorded at MDT meeting prior to treatment. QPI 5: Nutritional Assessment Proportion of patients with oesophageal cancer who are referred to a dietitian within 4 weeks of diagnosis (v2.7). QPI 6: Appropriate Selection of Surgical Patients Proportion of patients with oesophageal cancer who receive neo-adjuvant chemotherapy who then go on to have surgical resection (v2.7). QPI 7 (a) : 3 day Mortality Following Surgery - Proportion of patients with oesophageal cancer who die within 3 days of surgical resection. QPI 7 (b) : 9 day Mortality Following Surgery - Proportion of patients with oesophageal cancer who die within 9 days of surgical resection. 9% 95% 85% 8% < 5% < 7.5% 1% > 97.1% < 88.3% > 99.% > 93.4% > 51 51 67 69 23 23 11 12 422 452 1% = 98.6% < 91.3% > 97.1% > 94.7% > 51 51 68 69 21 23 99 12 428 452 6.8% < 66.2% > 64.8% < 54.9% < 62.3% < 31 51 45 68 149 23 56 12 281 451 1% = 66.7% < 81.8% < 77.8% > 78.3% > 3 3 1 15 27 33 7 9 47 6.% = NA 6.5% <.% > 4.8% < 4 3 46 12 3 62.% = NA 11.6% < 8.3% > 1.2% < 4 5 43 1 12 6 59 Final Published Upper Gastro-intestinal Cancer MCN Audit Report v1. 23/1/217 5
OESOPHAGEAL CANCER Quality Performance Indicator (QPI) Performance by Board QPI target AA FV GGC Lan WoS QPI 8 : Lymph Node Yield Proportion of patients with oesophageal cancer who undergo curative surgical resection where 15 lymph nodes are resected and pathologically examined. QPI 9 : Length of Hospital Stay Following Surgery Proportion of patients undergoing surgical resection for oesophageal cancer who are discharged within 14 days of surgical procedure. QPI 1(i) : Resection Margins Proportion of patients with oesophageal cancer who undergo surgical resection in which surgical margin is clear of tumour, i.e. negative surgical margin (i) circumferential QPI 1(ii) : Resection Margins Proportion of patients with oesophageal cancer who undergo surgical resection in which surgical margin is clear of tumour, i.e. negative surgical margin (ii) longitudinal QPI 11: Curative Treatment Rates Proportion of patients with oesophageal cancer who undergo curative treatment (v2.7). QPI 12 (i): 3-day Mortality Following Oncological Treatment Proportion of patients with oesophageal cancer who die within 3 days of curative oncological treatment (v2.7). (a) Chemoradiotherapy QPI 12 (i): 9-day Mortality Following Oncological Treatment Proportion of patients with oesophageal cancer who die within 9 days of curative oncological treatment (v2.7). (a) Chemoradiotherapy 9% 6% 7% 9% 35% < 1% For info only (v3. target < 7.5%) 75.% NA 76.1% 83.3% 77.4% 3 4 35 46 1 12 48 62 4.% NA 49.% 15.4% 41.8% 2 5 24 49 2 13 28 67 5.% > NA 77.8% < 41.7% < 68.9% < 2 4 35 45 5 12 42 61 1% = NA 95.7% < 1% = 96.8% < 4 4 45 47 12 12 61 63 24.% > 34.4% > 29.1% < 2.4% < 27.3% = 12 5 21 61 67 23 2 98 12 439 12.5% <.% =.% >.% = 2.6% < 1 8 7 19 5 1 39 12.5%.%.%.% 3.1% 1 8 4 15 5 1 32 Final Published Upper Gastro-intestinal Cancer MCN Audit Report v1. 23/1/217 6
OESOPHAGEAL CANCER Quality Performance Indicator (QPI) Performance by Board QPI target AA FV GGC Lan WoS QPI 12 (i): 3-day Mortality Following Oncological Treatment Proportion of patients with oesophageal cancer who die within 3 days of curative oncological treatment (v2.7). (b) Peri-operative chemotherapy QPI 12 (i): 9-day Mortality Following Oncological Treatment Proportion of patients with oesophageal cancer who die within 9 days of curative oncological treatment (v2.7). (b) Peri-operative chemotherapy QPI 12 (ii): 3-day Mortality Following Oncological Treatment Proportion of patients with oesophageal cancer who die within 3 days of palliative oncological treatment (v2.7). (c) Chemotherapy < 1% For info only (v3. target < 7.5%) < 2%.% = 7.1% <.% >.% = 1.4% > 7 1 14 35 16 1 72 *3-day mortality was not recorded for 5 cases in NHSGGC (14.3%) and 2 cases in NHS Lanarkshire (12.5%). Therefore NR for numerator in WoS is 9.7% 14.3% 15.4% 9.1%.% 9.% 1 7 2 13 3 33 14 6 67 *9-day mortality was not recorded for 5 cases in NHSGGC (15.2%) and 2 cases in NHS Lanarkshire (14.3%). Therefore NR for numerator in WoS is 1.4% 8.3% <.% > 2.4% > 4.3% > 3.4% > 1 12 12 1 42 1 23 3 89 GASTRIC CANCER Quality Performance Indicator (QPI) Performance by Board QPI target AA FV GGC Lan WoS QPI 1: Endoscopy Proportion of patients with gastric cancer who have a histological diagnosis made within 6 weeks of initial endoscopy and biopsy. QPI 3: MDT Meeting Proportion of patients with gastric cancer who are discussed at MDT meeting before definitive treatment. QPI 4(i): Staging and Treatment Intent Proportion of patients with gastric cancer who have (i) TNM stage recorded at MDT meeting prior to treatment. 95% 95% 9% 94.9% > 1% > 85.6% > 91.7% > 89.8% > 37 39 17 17 89 14 33 36 176 196 94.9% < 94.7% < 96.2% > 97.2% > 96.% > 37 39 18 19 12 16 35 36 192 2 1% = 1% = 9.8% > 1% > 95.1% > 4 4 19 19 99 19 37 37 195 25 Final Published Upper Gastro-intestinal Cancer MCN Audit Report v1. 23/1/217 7
GASTRIC CANCER Quality Performance Indicator (QPI) Performance by Board QPI target AA FV GGC Lan WoS QPI 4(ii): Staging and Treatment Intent Proportion of patients with gastric cancer who have (ii) treatment intent recorded at MDT meeting prior to treatment. 95% 1% = 94.7% < 91.7% > 97.3% > 94.6% > 4 4 18 19 1 19 36 37 194 25 QPI 5: Nutritional Assessment Proportion of patients with gastric cancer who are referred to a dietitian within 4 weeks of diagnosis (v2.7). QPI 6: Appropriate Selection of Surgical Patients Proportion of patients with gastric cancer who receive neo-adjuvant chemotherapy who then go on to have surgical resection (v2.7). QPI 7 (a) : 3 day Mortality Following Surgery - Proportion of patients with gastric cancer who die within 3 days of surgical resection. QPI 7 (b) : 9 day Mortality Following Surgery - Proportion of patients with gastric cancer who die within 9 days of surgical resection. QPI 8 : Lymph Node Yield Proportion of patients with gastric cancer who undergo curative surgical resection where 15 lymph nodes are resected and pathologically examined. QPI 9 : Length of Hospital Stay Following Surgery Proportion of patients undergoing surgical resection for gastric cancer who are discharged within 14 days of surgical procedure. QPI 1(ii) : Resection Margins Proportion of patients with gastric cancer who undergo surgical resection in which surgical margin is clear of tumour, i.e. negative surgical margin (ii) longitudinal 85% 8% < 5% < 7.5% 8% 6% 9% 57.5% < 52.6% < 55.% < 48.6% < 54.1% < 23 4 1 19 6 19 18 37 111 25 1% > 4.% < 72.7% < 75.% < 73.1% < 6 6 2 5 8 11 3 4 19 26.% = NA 5.% <.% > 3.1% < 8 1 2 4 1 32.% = NA 6.3% <.% > 3.6% > 8 1 16 4 1 28 1% = NA 66.7% <.% < 71.4% < 8 8 12 18 2 2 28 1% NA 53.8% 5.% 59.1% 3 3 7 13 3 6 13 22 1% = NA 95.2% = 1% = 96.9% < 8 2 21 3 3 31 32 Final Published Upper Gastro-intestinal Cancer MCN Audit Report v1. 23/1/217 8
GASTRIC CANCER Quality Performance Indicator (QPI) Performance by Board QPI target AA FV GGC Lan WoS QPI 11: Curative Treatment Rates Proportion of patients with gastric cancer who undergo curative treatment (v2.7). QPI 12 (i): 3-day Mortality Following Oncological Treatment Proportion of patients with gastric cancer who die within 3 days of curative oncological treatment (v2.7). (a) Chemoradiotherapy QPI 12 (i): 9-day Mortality Following Oncological Treatment Proportion of patients with gastric cancer who die within 9 days of curative oncological treatment (v2.7). (a) Chemoradiotherapy QPI 12 (i): 3-day Mortality Following Oncological Treatment Proportion of patients with gastric cancer who die within 3 days of curative oncological treatment (v2.7). (b) Peri-operative chemotherapy QPI 12 (i): 9-day Mortality Following Oncological Treatment Proportion of patients with gastric cancer who die within 9 days of curative oncological treatment (v2.7). (b) Peri-operative chemotherapy QPI 12 (ii): 3-day Mortality Following Oncological Treatment Proportion of patients with gastric cancer who die within 3 days of palliative oncological treatment (v2.7). (c) Chemotherapy 35% < 1% For info only (v3. target < 7.5%) < 1% For info only (v3. target < 7.5%) < 2% 2.5% < 23.5% > 18.3% < 11.1% < 17.9% < 8 39 4 17 2 19 4 36 36 21 NA NA NA NA NA NA NA NA NA NA.% =.% =.% >.% =.% > 5 4 16 8 33 *3-day mortality was not recorded for 2 cases in NHSGGC (12.5%). Therefore NR for numerator in WoS is 6.1%.%.% 7.1%.% 3.4% 5 4 1 14 6 1 29 *9-day mortality was not recorded for 1 case in NHSGGC (7.1%). Therefore NR for numerator in WoS is 3.4% 33.3% <.% = 3.7% > 14.3% < 9.8% > 2 6 1 1 27 1 7 4 41 *3-day mortality was not recorded for 2 cases in NHSGGC (7.4%) Therefore NR for numerator in WoS is 4.9% Final Published Upper Gastro-intestinal Cancer MCN Audit Report v1. 23/1/217 9
Clinical Trials QPI Oesophageal and gastric cancers Upper GI Cancers Quality Performance Indicator (QPI) Performance by Board QPI target AA FV GGC Lan WoS QPI 14: Clinical Trial Access INTERVENTIONAL Proportion of patients with upper GI cancer who are enrolled in an interventional clinical trial. 7.5% 3.8% >.% = 4.5% > 2.7% > 3.5% > 4 16 8 17 381 4 15 25 717 QPI 14: Clinical Trial Access TRANSLATIONAL Proportion of patients with upper GI cancer who are enrolled in translational research. 15% 1.9% < 6.3% < 2.1% <.% < 2.1% < 2 16 5 8 8 381 15 15 717 Final Published Upper Gastro-intestinal Cancer MCN Audit Report v1. 23/1/217 1
Conclusions and Action Required Cancer audit has underpinned much of the regional development and service improvement work of the MCN and the regular reporting of activity and performance have been fundamental in assuring the quality of care delivered across the region. Following the development of QPIs, this has now become an established national programme to drive continuous improvement and ensure equity of care for patients across Scotland. West of Scotland Boards continued commitment to the improvement of the quality and completeness of audit data has supported the National Cancer Quality Programme in the formative years, and will be required throughout the formal review process with the addition of new QPIs. This commitment from Boards has provided accurate data for the reporting of performance against the Upper GI Cancer QPIs from which yearly comparisons in service provision across WoS Boards can be made. The Upper GI Cancer MCN is encouraged by the results presented in this report which demonstrate that patients with oesophageal and gastric cancer in the WoS continue to receive a consistently high standard of care. Case ascertainment and data capture is of a high standard enabling robust assessment of performance against QPIs. 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. Additionally, NHS Boards have indicated where positive action has already been taken at a local level to address any issues highlighted through the QPI data analysis. It is anticipated that these positive changes will result in improved performance going forward. Notable action taken in response to analysis results includes: QPI 1 NHS Lanarkshire disseminated protocols relating to the number of adequate biopsies and optimal reporting in upper GI malignancy to all NHSL endoscopy units. Similarly, NHS Ayrshire and Arran is working with endoscopy units and pathology to improve performance against this measure. QPI 5 NHS Forth Valley will continue to work with the dietitian to ensure appropriate nutritional assessment. The Board will ensure that MUST score is documented for all patients from 217 to allow future analysis of the revised QPI. QPI 7 Fitness threshold for major surgery has been readdressed in NHSGGC, and a High Risk clinic instituted to assess the most co-morbid cases, in response to mortality rates following surgical resection. QPI 8 NHS Lanarkshire will endeavour to carry out UGI cancer surgery in a single centre within Lanarkshire to improve performance in relation to lymph node yield. QPI 9 NHS GGC have initiated a review of SMR1 data to investigate potential discrepancies in recording of discharge dates. NHS Lanarkshire will review ERAS protocols and will work to discharge patients sooner where appropriate. NHS Boards are encouraged to continue with this proactive approach of reviewing data and addressing issues as necessary, in order to work towards increasingly advanced performance against targets, and demonstration of overall improvement in quality of the care and service provided to patients. The MCN Advisory Board will actively monitor progress against changes implemented by NHS Boards, and any service issue the Advisory Board considers not to have been adequately addressed, Final Published Upper Gastro-intestinal Cancer MCN Audit Report v1. 23/1/217 11
will be escalated to the appropriate NHS Board Lead Cancer Clinician and the Regional Lead Cancer Clinician. In addition, progress will be reported annually to the Regional Cancer Advisory Group (RCAG) by NHS Board 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 6 (212). Final Published Upper Gastro-intestinal Cancer MCN Audit Report v1. 23/1/217 12
1. Introduction This report presents an assessment of performance of West of Scotland Upper Gastro-intestinal (GI) Cancer Services relating to patients diagnosed in the region between 1 January 216 and 31 December 216. These audit data underpin much of the regional development/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. Twelve months of data were measured against v3. of the Upper GI Cancer Quality Performance Indicators (QPIs) which were implemented for patients diagnosed on or after 1 January 216. This was the fourth consecutive year of analysis following the initial Healthcare Improvement Scotland (HIS) publication of Upper GI cancer QPIs in 212. This was part of a programme of work led by the National Cancer Quality Steering Group (NCQSG) to develop national measures in the form of QPIs for all cancer types, in collaboration with the three Regional Cancer Networks and Information Services Division (ISD). In order to ensure the success of the National Cancer QPIs in driving quality improvement in cancer care across NHS Scotland, a process of formal review was carried out after Year 3 of comparative reporting with tumour-specific Regional Clinical Leads undertaking a key role in determining the extent of the review required for each tumour type. The revised Upper GI Cancer QPIs 1 were published in March 217 and, as stated above, are valid for patients diagnosed on or after 1 January 216. Annual comparisons have been made where indicators remain comparable following this formal review. Any new QPIs which were developed requiring new data items will be reported in Year 5 once data becomes available for these new measures. Future reports will continue to compare clinical audit data in successive years to illustrate trends. 2. Background Four NHS Boards across the WoS serve the 2.46 million population 6. There were 658 new cases of Upper GI cancer diagnosed in total in the West of Scotland (WoS) in 216: 452 oesophageal cases and 26 gastric, accounting for 5% and 33% respectively of the overall national diagnoses. The configuration of the Multidisciplinary Teams (MDTs) who manage and treat these patients across the region is set out below. MDT Ayrshire & Arran (AA) Greater Glasgow and Clyde (GGC) Forth Valley (FV) Lanarkshire (Lan) Constituent Hospital(s) Crosshouse Hospital, Ayr Hospital Royal Alexandra Hospital, Inverclyde Royal Hospital, Vale of Leven, Gartnavel General Hospital, Glasgow Royal Infirmary, Queen Elizabeth University Hospital (formerly Southern General), Victoria Infirmary Forth Valley Royal Hospital Wishaw General Hospital, Monklands District General, Hairmyres Patients from Forth Valley requiring major upper GI resection have their surgery in Glasgow Royal Infirmary. The Forth Valley surgeons are responsible for the local diagnosis, staging and follow up and are involved with the surgical resection in Glasgow. Analysis of the data contained within this report is based on the NHS Board responsible for treatment. Outcome measures regarding the quality of surgical services have been analysed based on the NHS Board where surgery was performed. Quality assurance and continuous service improvement will be supported by regular assessment of service performance against the nationally defined QPI criteria. Final Published Upper Gastro-intestinal Cancer MCN Audit Report v1. 23/1/217 13
2.1 National context Oesophageal cancer is the ninth most common cancer in Scotland with 92 cancers diagnosed nationally in 215 1. There has been a decrease in the incidence of oesophageal cancer over the ten years from 25 to 215 of 3.4% 1. As with oesophageal cancers, gastric (stomach) cancer is more common in males where it is the twelfth most common cancer in men in Scotland and the fifteenth most common cancer in women in Scotland in 215 3. The incidence of gastric cancer in Scotland has fallen significantly over the last ten years with a 33.6% decrease in males 3 and 25.7% in females 3. There were 61 cases of gastric cancer diagnosed in Scotland in 215. Overall cancer mortality rates have decreased by 14.% in males and 6% in females in the last ten years 1. The mortality rate for gastric cancer has seen the most significant decrease of any cancer type in both males and females, showing a 36.4% and 25.4% decrease in mortality rates respectively. The mortality rate for oesophageal cancer has seen significant decreases in both males and females by 8.1% and 13.2% respectively 1. However oesophageal cancer still remains the fourth most common cause of death from cancer in males and the sixth most common cause of death from cancer in females. Survival for oesophageal and gastric cancers is low compared to other cancers however relative 1- year and 5-year survival is increasing 6.Table 1 shows the percentage change in 1-year and 5-year survival rates for patients diagnosed in 1987-1991 compared to those diagnosed in 27-211. Table 1: Relative age-standardised survival for oesophageal and gastric cancers in Scotland at 1 year and 5 years showing percentage change from 1987-1991 to 27-211 5 Relative survival at 1 year (%) Relative survival at 5 years (%) 27-211 % change 27-211 % change Oesophageal cancer Gastric cancer Male 41.8% + 17.7% 12.1% + 6.5% Female 37.7% + 11.8% 12.7% + 4.6% Male 41.9% + 15.9% 15.4% + 5.3% Female 4.3% + 14.4% 2.5% + 9.3% Final Published Upper Gastro-intestinal Cancer MCN Audit Report v1. 23/1/217 14
2.2 West of Scotland context In 216 there were 658 new cases of oesophagogastric cancer that were identified through audit as having been managed in the West of Scotland. The number managed through each MDT/NHS Board is presented in Figure 1 and broken down by the site of origin of the tumour. Figure 1: Number of patients diagnosed in 216 with oesophageal or gastric cancer by NHS Board of diagnosis. Oesophageal Gastric 25 Number of Diagnoses 2 15 1 5 AA FV GGC LS NHS Board AA FV GGC Lan WoS Oesophageal cancer 51 69 23 12 452 Gastric cancer 4 19 11 37 26 Total 91 88 34 139 658 Oesophagogastric cancers are more common in men than women, the disease is more common in older age groups with 57% of cases occurring in individuals 7 years old and over. Figure 2: Number of patients diagnosed in 216 with oesophageal or gastric cancer in WoS within each age group. Male Female Oesophageal Male Female Gastric 7 3 6 25 5 2 4 3 2 15 1 1 5 <45 45-49 5-54 55-59 6-64 65-69 7-74 75-79 8-84 85+ <45 45-49 5-54 55-59 6-64 65-69 7-74 75-79 8-84 85+ Oesophageal Gastric <45 45-49 5-54 55-59 6-64 65-69 7-74 75-79 8-84 85+ All ages Male 3 8 17 3 39 51 49 52 29 27 315 Female 1 7 4 6 22 18 15 22 26 16 137 Male 6 1 9 7 1 12 29 27 23 7 131 Female 1 1 8 7 4 4 8 7 2 15 75 Final Published Upper Gastro-intestinal Cancer MCN Audit Report v1. 23/1/217 15
Figure 3: Clinical stage at diagnosis for patients diagnosed with oesophageal or gastric cancer in WoS in 216. Oesophageal Gastric Stage IV, 43.1% Not Recorded, 3.5% Stage IV, 43.1% Not Recorded, 2.4% Stage III, 22.8% Stage II, 13.9% Other, 9.5% Stage I, 1.6% Not assessable, 6% Stage III, 22.8% Stage II, 13.9% 7.7% Stage I, 9.7% Not assessable 5.3% Stage group T Stage N Stage M Stage Stage group T Stage N Stage M Stage Stage IA T1 N M Stage IA T1 N M Stage IB T2 N M T2 N M Stage IB Stage IIA T3 N M T1 N1 M T4a N M T3 N M Stage IIIA T3 N1 M Stage IIA T2 N1 M T1, T2 N2 M T1 N2 M Stage IIIB T3 N2 M T4a N M T4a N1, N2 M T3 N1 M Stage IIB Stage IIIC T4b Any N M T2 N2 M Any T N3 M T1 N3 M Stage IV Any T Any N M1 T4a N1 M Stage IIIA T3 N2 M T2 N3 M T4b N, N1 M Stage IIIB T4a N2 M T3 N3 M Stage IIIC T4a N3 M T4b N2, N3 M Stage IV Any T Any N M1 The audit dataset includes the Tumour, Nodal and Metastases (TNM) stage at diagnosis, which can be used to calculate an overall disease stage for each patient. This is done according to the TNM Classification of Malignant Tumours (7 th Edition) 7 and the tables in Figure 3 detail how stage is calculated from TNM for oesophageal and gastric cancers respectively. As it is not always specified whether T4 stage is T4a or T4b, stage groups are shown as Stage I, II, III or IV only as further breakdown by stage category is not always possible. 3. Methodology The clinical audit data presented in this report were collected by clinical audit staff in each NHS Board in accordance with an agreed dataset and definitions. Data were recorded manually and entered locally into the electronic Cancer Audit Support Environment (ecase): a secure centralised web-based database. Data relating to patients diagnosed between 1 January 216 and 31 December 216 were downloaded from ecase at 22 hrs on 5 July 217. 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. 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 their data were an accurate representation of service in each area. Final Published Upper Gastro-intestinal Cancer MCN Audit Report v1. 23/1/217 16
4. Results and recommended actions 4.1 Data quality Audit data quality 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 by the audit as a proportion of the number of cases reported by the National Cancer Registry (provided by ISD, National Services Scotland). Cancer Registry figures used were extracted from ACaDMe (Acute Cancer Deaths and Mental Health) on 13 June 217 via the standard reports available and are an average of the previous 5 years figures to take account of annual fluctuations in incidence within NHS Boards. The overall case ascertainment in WoSCAN is 91.8% which indicates good data capture for 216 and overall WoS results should therefore be an accurate reflection of performance in the region. Figure 3 illustrates estimated case ascertainment across the WoS NHS Boards and varies from 85.8% in NHS Ayrshire & Arran to 11% in Forth Valley. Case ascertainment figures are provided for guidance and are not an exact measurement as it is not possible to compare directly with the same cohort. Figure 4: Estimated case ascertainment by Board for patients diagnosed with oesophagogastric cancers in 216. 12 1 Case Ascertainment % 8 6 4 2 AA FV GGC LS WoS NHS Board AA FV GGC Lan WoS Cases from 216 audit 91 88 34 139 658 ISD Cases (211-215 average) 16 8 381 15 717 % Case ascertainment 85.8% 11% 89.2% 92.7% 91.8% Final Published Upper Gastro-intestinal Cancer MCN Audit Report v1. 23/1/217 17
4.2 Performance against Quality Performance Indicators Results of the analysis of Upper GI Cancer QPIs 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. Each QPI displays first the performance in oesophageal cancer and then the same for gastric cancer. Where possible, and with consideration given to any changes after formal review, results for patients diagnosed in Year 4 have been presented alongside the previous years results to illustrate trends. Data (both graphically and in tabular format) are presented by location of diagnosis or location of treatment with some criteria given as an overall West of Scotland representation. Boards have already reviewed cases where targets have not been met, and the detailed clinical commentary provided by Boards is noted beside each measure along with details of any specific changes that have already been implemented to address issues highlighted through the 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. An asterisk (*) is applied to indicate a denominator of zero and to distinguish between this and a % performance. Final Published Upper Gastro-intestinal Cancer MCN Audit Report v1. 23/1/217 18
QPI 1: Biopsy Procedure For diagnosis of oesophageal and gastric cancer the use of endoscopy is recommended 1. The tolerance within the 95% target is designed to account for factors of patient choice. QPI 1: Numerator: Denominator: Exclusions: Patients with oesophageal or gastric cancer should undergo endoscopy and biopsy to reach a diagnosis of cancer. Number of patients with oesophageal or gastric cancer who undergo endoscopy who have a histological diagnosis made within 6 weeks of initial endoscopy and biopsy. All patients with oesophageal or gastric cancer who undergo endoscopy. No exclusions. Target: 95% QPI 1 was updated following discussion at the formal review meeting. It was agreed to focus on achieving the diagnosis in a timelier manner. Therefore the QPI was changed from looking at the number of patients who had a histological diagnosis made following initial endoscopy and biopsy to those patients who have a histological diagnosis within six weeks of initial endoscopy and biopsy. The QPI target was also raised from 9% to 95%. Due to these changes it has not been possible to compare the results with previous years data. Figure 5: The proportion of patients with oesophageal cancer who underwent endoscopy that had a histological diagnosis made within 6 weeks of initial endoscopy and biopsy. Performance (%) 1 9 8 7 6 5 4 3 2 1 Oesophageal 216 AA FV GGC LAN WoS NHS Board QPI 1 Performance (%) Numerator Denominator numerator numerator (%) exclusions exclusions (%) denominator AA 89.8% 44 49.%.% FV 97.1% 67 69.%.% GGC 91.2% 28 228.%.% Lan 95.1% 97 12.%.% WoS 92.9% 416 448.%.% The 95% was not achieved in the WoS in 216. Of the 448 oesophageal patients who underwent endoscopy, 416 had a histological diagnosis within 6 weeks of initial endoscopy and biopsy. NHS Forth Valley and NHS Lanarkshire both exceeded the target with performance of 97.1% and 95.1% respectively. Final Published Upper Gastro-intestinal Cancer MCN Audit Report v1. 23/1/217 19
Both NHS Ayrshire & Arran and NHSGGC reviewed all cases not meeting this QPI. Reasons for this included inability to obtain biopsy on first endoscopy, no evidence of malignancy on first pathology review, cases suspicious but not definitive for malignancy, and patient not attending for the appointment. Figure 6: The proportion of patients with gastric cancer who underwent endoscopy that had a histological diagnosis made within 6 weeks of initial endoscopy and biopsy. Performance (%) 1 9 8 7 6 5 4 3 2 1 Gastric 216 AA FV GGC NHS Board LAN WoS QPI 1 Performance (%) Numerator Denominator numerator numerator (%) exclusions exclusions (%) denominator AA 94.9% 37 39.%.% FV 1.% 17 17.%.% GGC 85.6% 89 14.%.% Lan 91.7% 33 36.%.% WoS 89.8% 176 196.%.% Overall WoS results show that 89.8 % of patients with gastric cancer had a histological diagnosis within 6 weeks of initial endoscopy and biopsy which is below the new 95% target. NHS Forth Valley and NHS Ayrshire & Arran achieved the QPI target. NHS Lanarkshire reviewed the 3 cases not meeting the QPI criteria and valid clinical reasons were provided. NHS Lanarkshire also commented that protocols on number of adequate biopsies and ideal reporting in UGI malignancy have previously been disseminated to all NHSL endoscopy units. NHSGGC achieved 85.6% against the 95% target. NHSGGC commented that all cases had been reviewed, as with oesophageal cases, and the main reasons identified for not meeting the QPI target were again inability to obtain biopsy on first endoscopy, cases suspicious but not definitive for malignancy and no evidence of malignancy on first pathology review. QPI 2: Radiological Staging During formal review it was agreed that as this QPI was consistently achieved and embedded in practice it should be archived. Final Published Upper Gastro-intestinal Cancer MCN Audit Report v1. 23/1/217 2
QPI 3: MDT Discussion Evidence suggests that patients with cancer managed by a multi-disciplinary team achieve better outcomes. There is also evidence that the multidisciplinary management of patients increases their overall satisfaction with their care 1. Discussion prior to definitive treatment decisions being made provides reassurance that patients are being managed appropriately 1. The tolerance within this QPI accounts for situations where patients require surgery or other intervention urgently. QPI 3: Numerator: Denominator: Exclusions: Patients should be discussed by a multidisciplinary team prior to definitive treatment. Number of patients with oesophageal or gastric cancer discussed at the MDT before definitive treatment. All patients with oesophageal and gastric cancer. Patients who died before first treatment. Target: 95% Figure 7: The proportion of patients with oesophageal cancer who were discussed at the MDT meeting before definitive treatment. Performance (%) 1 9 8 7 6 5 4 3 2 1 Oesophageal 214 215 216 AA FV GGC LAN WoS NHS Board QPI 3 Performance (%) Numerator Denominator numerator numerator (%) exclusions exclusions (%) denominator AA 94.% 47 5.%.% FV 94.2% 65 69.%.% GGC 94.7% 215 227 1.4%.% Lan 96.9% 94 97.%.% WoS 95.% 421 443 1.2%.% Of the 443 patients across the region with oesophageal cancer who were measured against this QPI, 421 were discussed at MDT prior to definitive treatment. This equates to 95% and successfully meets the QPI target. Figure 8 also shows an improving trend in the WoS across the years. NHS Lanarkshire achieved the target with a performance of 96.9% and a 13.4 percentage point improvement on the previous years results. NHS Ayrshire & Arran noted improvement from the previous year and were only one percentage point below the target. Reasons provided for cases not meeting the target include patients who had stent insertion or surgery performed as an emergency, prior to MDT discussion. Final Published Upper Gastro-intestinal Cancer MCN Audit Report v1. 23/1/217 21
NHS FV narrowly missed the QPI target with 94.2%. All cases were reviewed and reasons provided included patients having stent inserted on admission prior to MDT discussion, refusal of further investigations, and dying before treatment. NHSGGC reviewed the 12 cases not meeting the QPI and reasons provided included the requirement for treatment urgently, patients dying before MDT discussion, and a case where MDT discussion was prior to treatment but the date unknown due to the discussion taking place out with Scotland. Had this case been included then NHSGGC would have exceeded the target of this QPI. Figure 8: The proportion of patients with gastric cancer who were discussed at the MDT meeting before definitive treatment. Gastric 214 215 216 1 9 8 7 6 5 4 3 2 1 AA FV GGC LAN WoS NHS Board Performance (%) QPI 3 Performance (%) Numerator Denominator numerator numerator (%) exclusions exclusions (%) denominator AA 94.9% 37 39.%.% FV 94.7% 18 19.%.% GGC 96.2% 12 16.%.% Lan 97.2% 35 36.%.% WoS 96.% 192 2.%.% Overall 192 of the 2 patients diagnosed with gastric cancer in the WoS were discussed at the MDT prior to definitive treatment, resulting in a performance of 96.% against the 95% QPI target. All four Boards achieved the target with both NHS Lanarkshire and NHSGGC noting improvements on the previous years results. Final Published Upper Gastro-intestinal Cancer MCN Audit Report v1. 23/1/217 22
QPI 4: Staging and Treatment Intent Patients with gastric or oesophageal cancer should undergo careful staging to assess the extent of disease and inform treatment decision making 1. Clinical staging should follow the principles of TNM classification; this aids the determination of prognosis and choice of therapy. A statement regarding clinical stage and treatment intent should be recorded at the MDT meeting. For patients presenting with metastatic disease it is not always possible or appropriate to determine T and N stage. Within the QPI TxNxM1 is therefore accepted as complete staging in this situation 1. Following formal review the specifications of this QPI were separated to ensure clear measurement of patients who have the following recorded at MDT meeting prior to treatment:-(i) TNM stage; and (ii) Treatment Intent QPI 4(i): Numerator: Denominator: Exclusions: Patients with oesophageal or gastric cancer should be staged using the TNM staging system and have this recorded at MDT prior to treatment commencing. Number of patients with oesophageal or gastric cancer who have TNM stage recorded at MDT prior to treatment. All patients with oesophageal and gastric cancer. No exclusions. Target: 9% Figure 9: The proportion of patients with oesophageal cancer who had TNM stage recorded at MDT prior to treatment. Oesophageal 216 Performance (%) 1 9 8 7 6 5 4 3 2 1 AA FV GGC LAN WoS NHS Board QPI 4(i) Performance (%) Numerator Denominator numerator numerator (%) exclusions exclusions (%) denominator AA 1.% 51 51.%.% FV 97.1% 67 69.%.% GGC 88.3% 23 23.%.% Lan 99.% 11 12.%.% WoS 93.4% 422 452.%.% Overall, 422 of the 452 patients diagnosed with oesophageal cancer in the WoS had TNM staging recorded at MDT meeting, resulting in a performance of 93.4% against the 9% target. NHS Ayrshire Final Published Upper Gastro-intestinal Cancer MCN Audit Report v1. 23/1/217 23
& Arran, NHS Forth Valley and NHS Lanarkshire all achieved the QPI target with performances of 1%, 97.1% and 99% respectively, NHSGGC just fell short of the target with 88.3%. NHSGGC carried out a review of the 27 cases and reasons for not meeting the target include no pre-treatment MDT for TNM to be recorded, cases not staged by MDT due to performance status/fitness for treatment, malignancy being an incidental finding at surgery, and cases where the full TNM was not recorded. NHSGGC will strive to ensure that the full TNM is recorded in all cases. Figure 1: The proportion of patients with gastric cancer who had TNM stage recorded at MDT prior to treatment. Gastric 216 Performance (%) 1 9 8 7 6 5 4 3 2 1 AA FV GGC LAN WoS NHS Board QPI 4(i) Performance (%) Numerator Denominator numerator numerator (%) exclusions exclusions (%) denominator AA 1.% 4 4.%.% FV 1.% 19 19.%.% GGC 9.8% 99 19.%.% Lan 1.% 37 37.%.% WoS 95.1% 195 25.%.% Overall performance across the WoS is 95.1% with 195 of 25 gastric patients having TNM stage recorded at MDT meeting prior to treatment. All Boards exceeded the 9% QPI target with NHS Ayrshire & Arran, NHS Forth Valley and NHS Lanarkshire all achieving 1% and NHSGGC achieving 9.8%. Final Published Upper Gastro-intestinal Cancer MCN Audit Report v1. 23/1/217 24
QPI 4(ii): Numerator: Denominator: Exclusions: Target: 95% Patients with oesophageal or gastric cancer should have treatment intent recorded at MDT prior to treatment commencing. Number of patients with oesophageal or gastric cancer who treatment intent recorded at MDT prior to treatment. All patients with oesophageal and gastric cancer. No exclusions. Figure 11: The proportion of patients with oesophageal cancer who have treatment intent recorded at MDT prior to treatment. Oesophageal 216 Performance (%) 1 9 8 7 6 5 4 3 2 1 AA FV GGC LAN WoS NHS Board QPI 4(ii) Performance (%) Numerator Denominator numerator numerator (%) exclusions exclusions (%) denominator AA 1.% 51 51.%.% FV 98.6% 68 69.%.% GGC 91.3% 21 23.%.% Lan 97.1% 99 12.%.% WoS 94.7% 428 452.%.% In the WoS, 94.7% of oesophageal patients had treatment intent recorded at MDT prior to treatment. Only NHSGGC did not achieve the 95% QPI target. Reasons for not meeting the target were provided by NHSGGC and include, cases where intent unknown at MDT as clinical assessment required post MDT prior to final treatment decision, cases where there was no MDT discussion for intent to be recorded, and cases where patients died before MDT. NHSGGC will strive to ensure that treatment intent is recorded in all cases in the future. Final Published Upper Gastro-intestinal Cancer MCN Audit Report v1. 23/1/217 25
Figure 12: The proportion of patients with gastric cancer who have treatment intent recorded at MDT prior to treatment. Gastric 216 Performance (%) 1 9 8 7 6 5 4 3 2 1 AA FV GGC LAN WoS NHS Board QPI 4(ii) Performance (%) Numerator Denominator numerator numerator (%) exclusions exclusions (%) denominator AA 1.% 4 4.%.% FV 94.7% 18 19.%.% GGC 91.7% 1 19.%.% Lan 97.3% 36 37.%.% WoS 94.6% 194 25.%.% For patients diagnosed with gastric cancer, overall WoS performance was 94.6%, with 194 of 25 patients having treatment intent recorded at MDT prior to treatment. NHSGGC commented that, as with oesophageal cases, reasons for not meeting the QPI were, no MDT discussion for intent to be recorded, and intent unknown at MDT as clinical assessment required post MDT prior to treatment decision. NHSGGC will strive to ensure treatment intent is recorded in all cases in the future. QPI 5: Nutritional Assessment It is required that all patients with oesophageal or gastric cancer should be screened using a validated screening tool to assess nutritional risk. Those at risk of nutritional problems should have access to a state registered dietitian to provide appropriate advice 1. As it is difficult to accurately capture data around the nutritional status of patients prior to commencing treatment for various reasons, during years 1 to 4 of reporting the absolute number of patients referred to the dietetics service prior to treatment is being utilised as a proxy measure. Work had already been underway nationally as it had been identified at the time of year 1 reporting that the focus of this QPI required to be changed. Therefore at the formal review the 4 week timescale was removed, and the revised QPI now stipulates that nutritional screening must take place before first treatment. Additionally the indicator will be split into 2 parts to measure: the number of patients who undergo screening with the Malnutrition Universal Screening Tool (MUST) before treatment; and of those who undergo screening and have a high risk of malnutrition identified the proportion then seen by a dietitian. However due to MUST score being a new field and requiring to be inserted into the dataset, performance against the revised QPI will not be reported until next year. Final Published Upper Gastro-intestinal Cancer MCN Audit Report v1. 23/1/217 26
QPI 5: Numerator: Denominator: Exclusions: Patients with oesophageal or gastric cancer should be referred for dietetic assessment where there are concerns about their nutritional status prior to commencing treatment. Number of patients with oesophageal or gastric cancer referred to a dietitian within 4 weeks of diagnosis. All patients with oesophageal and gastric cancer. No exclusions. Target: 85% Figure 13: The proportion of patients with oesophageal cancer who were referred to a dietitian within 4 weeks of diagnosis. 1 9 8 7 6 5 4 3 2 1 Performance (%) Oesophageal 214 215 216 AA FV GGC LAN WoS NHS Board QPI 5 Performance (%) Numerator Denominator numerator numerator (%) exclusions exclusions (%) denominator AA 6.8% 31 51.%.% FV 66.2% 45 68.%.% GGC 64.8% 149 23 1.4%.% Lan 54.9% 56 12 1 1.%.% WoS 62.3% 281 451 2.4%.% The 85% target was not achieved in WoS for patients diagnosed with oesophageal cancer in 216, with 281 of 451 patients being referred to dietetics within 4 weeks of diagnosis (62.3%) None of the four WoS NHS Boards met the target with performance ranging from 54.9% in NHS Lanarkshire to 66.2% in NHS Forth Valley. Comments were provided by all four NHS Boards for patients not meeting the target. Reasons include patients declining referral to dietitian, referral of all patients not appropriate, and patients being referred outside of the 4 week window. It is anticipated that changes made to this indicator at the time of formal review will produce more informative data results. Final Published Upper Gastro-intestinal Cancer MCN Audit Report v1. 23/1/217 27
Figure 14: The proportion of patients with gastric cancer who were referred to a dietitian within 4 weeks of diagnosis. Performance (%) 1 9 8 7 6 5 4 3 2 1 Gastric 214 215 216 AA FV GGC LAN WoS NHS Board QPI 5 Performance (%) Numerator Denominator numerator numerator (%) exclusions exclusions (%) denominator AA 57.5% 23 4.%.% FV 52.6% 1 19.%.% GGC 55.% 6 19.%.% Lan 48.6% 18 37.%.% WoS 54.1% 111 25.%.% As with oesophageal cases the 85% target was not achieved with 111 of 25 patients being referred to dietetics within 4 weeks of diagnosis (54.1%). None of the four NHS Boards achieved the OPI target. All 4 WoS NHS Boards reviewed cases not meeting the QPI, and reiterated that referral of all patients is not appropriate, a number of patients decline referral to the dietetic service, and others are referred outside of the 4 week window. It is anticipated that changes made to this indicator at the time of formal review will produce more meaningful data results in both groups of patients. QPI 6: Appropriate Selection of Surgical Patients Patients with oesophageal or gastric cancer who are suitable for surgical resection should be offered treatment with neoadjuvant chemotherapy. It is considered optimal management for patients who undergo neoadjuvant chemotherapy proceed to resectional (curative) surgery; however, various reasons affect this including initial under-staging of disease 1. At the formal review meeting it was agreed that it was appropriate to include patients receiving neoadjuvant chemoradiotherapy within this indicator also. However due to new codes being required in the dataset to measure this, performance against the revised QPI will not be available for reporting until next year. Year 4 analysis is therefore reported below against the original criteria. Final Published Upper Gastro-intestinal Cancer MCN Audit Report v1. 23/1/217 28
QPI 6: Numerator: Denominator: Exclusions: Patients with oesophageal or gastric cancer whose treatment plan is neoadjuvant chemotherapy followed by surgery should progress to surgery following completion of chemotherapy portion of treatment plan. Number of patients with oesophageal or gastric cancer who receive neoadjuvant chemotherapy who then undergo surgical resection. All patients with oesophageal or gastric cancer who receive neoadjuvant chemotherapy. No exclusions. Target: 8% Figure 15: The proportion of patients with oesophageal cancer who received neoadjuvant chemotherapy who then underwent surgical resection. Oesophageal 214 215 216 1 9 8 7 6 5 4 3 2 1 AA FV GGC LAN WoS NHS Board Performance (%) QPI 6 Performance (%) Numerator Denominator numerator numerator (%) exclusions exclusions (%) denominator AA - - -.%.% FV 66.7% 1 15.%.% GGC 81.8% 27 33 1 3.%.% Lan 77.8% 7 9 1 11.1%.% WoS 78.3% 47 6 2 3.3%.% - Denominator is less than 5; percentages should be viewed with caution. Overall in the WoS, 78.3% of patients diagnosed with oesophageal cancer who received neo-adjuvant chemotherapy went on to have surgical resection. This is 1.7 percentage points below the 8% QPI target. Performance across the four NHS Boards ranged from 66.7% in NHS Forth Valley to 81.8% in NHSGGC. Results are restricted for NHS Ayrshire & Arran due to small numbers. Cases not meeting the QPI in NHS Forth Valley were reviewed and reasons provided were disease progression during the initial neoadjuvant treatment phase, patient refusal, concerns regarding fitness for surgery post neoadjuvant treatment. NHS Lanarkshire also reviewed the two cases not meeting the QPI and detailed clinical commentary was provided. Final Published Upper Gastro-intestinal Cancer MCN Audit Report v1. 23/1/217 29
Figure 16: The proportion of patients with gastric cancer who received neoadjuvant chemotherapy who then underwent surgical resection. Performance (%) 1 9 8 7 6 5 4 3 2 1 Gastric 214 215 216 AA FV GGC LAN WoS NHS Board QPI 6 Performance (%) Numerator Denominator numerator numerator (%) exclusions exclusions (%) denominator AA 1.% 6 6.%.% FV 4.% 2 5.%.% GGC 72.7% 8 11.%.% Lan - - -.%.% WoS 73.1% 19 26.%.% - Denominator is less than 5; percentages should be viewed with caution. Across the WoS 73.1% of gastric patients that received neo-adjuvant chemotherapy went on to receive surgical resection. This is 6.9 percentage points below the 8% QPI target. Only NHS Ayrshire & Arran exceeded the target achieving 1%. NHS Forth Valley achieved 4% against the target however due to small numbers this represented 3 cases not meeting the QPI criteria. Valid clinical reasons for not proceeding to surgery were given in each case. NHSGGC achieved 72.7% and commented that this represented 3 cases. Again, valid clinical reasons were provided. NHS Lanarkshire achieved 75% against the 8% target but data was restricted due to small numbers. Valid clinical reasons were provided for the one case not meeting the QPI criteria. As demonstrated in comments returned from NHS Boards, small numbers can have a greater effect on proportions. Therefore for both oesophageal and gastric cases, caution should be given to apparent changes in performance across multiple years, as this may be representative of very small numbers of cases. QPI 7: 3/9-day Mortality Following Surgery Treatment related mortality is a marker of the quality and safety of the whole service provided by the Multi Disciplinary Team (MDT). Treatment should only be undertaken in individuals that may benefit from treatment, that is, disease specific treatments should not be undertaken in futile situations 1. This QPI is intended to ensure treatment is given appropriately. Final Published Upper Gastro-intestinal Cancer MCN Audit Report v1. 23/1/217 3
QPI 7: Numerator: Denominator: Exclusions: Target: < 5% 3 and 9-day mortality following surgical resection for oesophageal or gastric cancer. Number of patients with oesophageal or gastric cancer who undergo surgical resection who die within 3 or 9 days of treatment. All patients with oesophageal or gastric cancer who undergo surgical resection. No exclusions. There were three deaths recorded following surgical resection for oesophageal cancer at 3 days post treatment in 216 resulting in a WoS performance of 4.8% which is below the QPI target of < 1%. NHSGGC recorded five deaths at 9 days post surgery resulting in a performance of 11.6% against the <7.5% target and NHS Lanarkshire recorded one death resulting in a performance of 8.3%. There was one death recorded in NHSGGC within 3 days of surgery for gastric cancer in 216 resulting in a mortality rate of 5.% which is below the <1% target. NHSGGC also recorded one death within 9 days of surgery in NHSGGC, resulting in a mortality rate of 6.3% which is below the <7.5% target. NHSGGC carried out a review of these cases and clinical detail was provided. In addition, the Board noted that the fitness threshold for major surgery has been readdressed and a High Risk clinic to assess the most co-morbid cases has been instituted. NHS Lanarkshire reviewed the single case and provided further detail to the MCN. The Board noted that cardio-pulmonary exercise testing (CPEX) and anaesthetic assessment remain part of the MDT approach to selecting appropriate surgical patients. Following discussion at the national Upper GI Cancer meeting in November 216 additional analysis was undertaken to establish whether having a time limit for collecting definitive treatment data had an effect on mortality rates, particularly at 9 days. The results of this additional analysis, carried out on data from the first 3 years of QPI reporting showed that this affected very small numbers of patients and had no impact on the overall results. QPI 8: Lymph Node Yield Maximising the number of lymph nodes resected and analysed enables reliable staging which influences treatment decision making. Evidence recommends that at least 15 lymph nodes are resected and examined by a pathologist 1. Initially when published this QPI measured lymph node yield in patients undergoing surgical resection for gastric cancer only. During the formal review process QPI 8 was updated to include measurement of lymph node yield in patients undergoing surgery for oesophageal cancer also. Therefore figure 17 offers no comparison against previous years performance. Final Published Upper Gastro-intestinal Cancer MCN Audit Report v1. 23/1/217 31
QPI 8: Numerator: Denominator: Exclusions: For patients with oesophageal or gastric cancer undergoing curative resection the number of lymph nodes examined should be maximised. Number of patients with oesophageal or gastric cancer who undergo curative surgical resection where 15 lymph nodes are resected and pathologically examined. All patients with oesophageal or gastric cancer who undergo curative surgical resection. No exclusions. Target: Oesophageal - 9% Gastric - 8% Figure 17: The proportion of patients with oesophageal cancer who underwent curative surgical resection where 15 lymph nodes were resected and pathologically examined. Oesophageal 216 Performance (%) 1 9 8 7 6 5 4 3 2 1 QPI 8 Performance (%) Numerator Denominator AA FV GGC LAN WoS NHS Board numerator numerator (%) exclusions exclusions (%) denominator AA - - -.%.% FV NA NA NA GGC 76.1% 35 46.%.% Lan 83.3% 1 12.%.% WoS 77.4% 48 62.%.% - Denominator is less than 5; percentages should be viewed with caution. Of the 62 oesophageal patients who underwent curative surgical resection 48 had 15 lymph nodes resected and pathologically examined. This equates to a rate of 77.4% which is below the target rate of 9%. Performance for NHSGGC and NHS Lanarkshire was 76.1% and 83.3% respectively. NHS Ayrshire & Arran had a denominator of less than five so data has been restricted however they achieved 75% against the 9% target. Detailed reasons were provided for the case not meeting the target. NHS Lanarkshire reviewed all cases that did not meet the target and provided detailed clinical reasons. NHS Lanarkshire also commented that pathological and surgical services will continue to work together to ensure that optimal lymph node retrieval is performed. NHSGGC also reviewed cases not meeting the QPI target and commented that pathological node issues have been previously addressed and no new reasons are evident. Final Published Upper Gastro-intestinal Cancer MCN Audit Report v1. 23/1/217 32
Figure 18: The proportion of patients with gastric cancer who underwent curative surgical resection where 15 lymph nodes were resected and pathologically examined. Performance (%) 1 9 8 7 6 5 4 3 2 1 Gastric 214 215 216 AA FV GGC LAN WoS QPI 8 Performance (%) Numerator Denominator NHS Board numerator numerator (%) exclusions exclusions (%) denominator AA 1.% 8 8.%.% FV NA NA NA GGC 66.7% 12 18.%.% Lan - - -.%.% WoS 71.4% 2 28.%.% - Denominator is less than 5; percentages should be viewed with caution. Overall in the WoS 71.4% of gastric patients who underwent curative surgical resection 15 had lymph nodes resected and pathologically examined. This is 8.6 percentage points below the 8% target. Only NHS Ayrshire & Arran met the target with a performance of 1% for the second consecutive year. NHS Lanarkshire had a denominator of less than five therefore data has been restricted. NHS Lanarkshire commented that all cases have been reviewed and detailed clinical commentary was provided for cases not meeting the QPI. Where possible it has been agreed that cases should be operated in a single centre in NHS Lanarkshire. NHSGGC stated that pathological node issues have been previously addressed and no new reasons pertain. For both oesophageal and gastric cases small numbers are a factor within this QPI and comparison of percentages should be viewed with caution. QPI 9: Length of Hospital Stay Following Surgery Length of hospital stay acts as a surrogate measure for the quality of surgery and post-operative care for patients undergoing surgical resection for oesophagogastric cancer 1. This QPI is intended as a surrogate marker to address various issues of quality care including surgery, post-operative complications, and access to community services. SMR1 data provided by ISD is utilised for measurement of QPI 9. Following discussion at the formal review meeting it was agreed to reduce the maximum length of stay within the criteria from 21 days to 14 days. Final Published Upper Gastro-intestinal Cancer MCN Audit Report v1. 23/1/217 33
QPI 9: Numerator: Denominator: Exclusions: Target: 6% Length of hospital stay following surgery for oesophageal or gastric cancer should be as short as possible. Number of patients undergoing surgical resection for oesophageal or gastric cancer who are discharged within 14 days of surgical procedure. All patients undergoing surgical resection for oesophageal or gastric cancer. No exclusions. Figure 19: The proportion of patients who underwent surgical resection for oesophageal cancer who were discharged within 14 days of surgical procedure. Performance (%) 1 9 8 7 6 5 4 3 2 1 QPI 9 Performance (%) Numerator Denominator Oesophageal 216 AA FV GGC LAN WoS NHS Board numerator numerator (%) exclusions exclusions (%) Final Published Upper Gastro-intestinal Cancer MCN Audit Report v1. 23/1/217 34 denominator AA 4.% 2 5.%.% FV NA.%.% GGC 49.% 24 49.%.% Lan 15.4% 2 13.%.% WoS 41.8% 28 67.%..% Of the 67 patients undergoing surgical resection for oesophageal cancer, 28 patients were discharged within 14 days of their surgical procedure. This resulted in a WoS performance of 41.8% against the 6% QPI target. None of the four NHS Boards met the target for this QPI and performance varied across the Boards from 15.4% in NHS Lanarkshire to 49.% in NHSGGC. NHS Ayrshire & Arran have reviewed all cases and provided detailed clinical reasons for cases not meeting the QPI criteria. NHS Lanarkshire commented that it is acknowledged that this is a surrogate of complications from oesophagectomy, however the current practice in NHS Lanarkshire is to send patients on pass to return for review on the ward, and for patients to learn home feeding for their feeding jejunostomy prior to formal discharge. Whilst this does not account for all cases it skews the data towards longer length of stay. NHS Lanarkshire plan to review Enhanced Recovery After Surgery (ERAS) protocols and work to discharge patients sooner where appropriate. NHSGGC commented that discharge times reflect the significant co-morbid nature of their cases. Whether instituting an ERAS policy will change this remains for future evaluation. After reviewing the cases failing to meet the QPI, the Board has concerns regarding the accuracy of some of the
discharge dates recorded on SMR1. This is under further investigation and review of SMR1 data will be undertaken Figure 2: The proportion of patients who underwent surgical resection for gastric cancer who were discharged within 14 days of surgical procedure. Performance (%) 1 QPI 9 Performance (%) Numerator Denominator 9 8 7 6 5 4 3 2 1 GASTRIC 216 AA FV GGC LAN WoS NHS Board numerator numerator (%) exclusions exclusions (%) Final Published Upper Gastro-intestinal Cancer MCN Audit Report v1. 23/1/217 35 denominator AA - - -.%.% FV NA.%.% GGC 53.8% 7 13.%.% Lan 5.% 3 6.%.% WoS 59.1% 13 22.%..% - Denominator is less than 5; percentages should be viewed with caution. Overall in the WoS 59.1% of gastric patients who underwent surgical resection were discharged within 14 days of their surgical procedure. This performance was just short of the 6% QPI target. NHSGGC achieved 53.8% and provided general comments as noted above for oesophageal cases. NHS Lanarkshire achieved 5% against the 6% target, however this represented 3 cases. NHS Lanarkshire commented that cases have been reviewed and reasons for not meeting the QPI include, emergency nature of procedure, borderline surgical suitability/high risk patient and development of post-operative complications. No single factor can be targeted however the Board will continue to aim to select suitable surgical candidates who are optimised nutritionally and are operated on in an early elective setting. Once again, in respect of both oesophageal and gastric cancers, the number of patients included within the denominator is low and can have a considerable effect on overall proportions, therefore percentages should be viewed with caution. QPI 1: Resection Margins Tumour involvement of surgical margins following excision is a negative prognostic factor; therefore surgeons should aim to ensure resection margins are clear of tumour 1. QPI 1 (i) previously incorporated circumferential and longitudinal margins. Following formal review it was agreed to measure clear circumferential margin only and the QPI has been updated accordingly. In this instance comparison with previous years results was able to be reported due to local analysis being undertaken for this measure. QPI 1 (ii) remains unchanged.
QPI 1 (i): Numerator: Denominator: Exclusions: Target: 7% Oesophageal cancers which are surgically resected should be adequately excised. Number of patients with oesophageal cancer who undergo surgical resection in which circumferential surgical margin is clear of tumour. All patients with oesophageal cancer who undergo surgical resection. No exclusions. Figure 21: The proportion of patients with oesophageal cancer who underwent surgical resection in which circumferential surgical margins were clear of tumour. Performance (%) QPI 1 i Performance (%) Numerator Denominator 9 8 7 6 5 4 3 2 1 Oesophageal 214 215 216 AA FV GGC LAN WoS NHS Board numerator numerator (%) exclusions exclusions (%) denominator AA - - -.%.% FV NA NA NA GGC 77.8% 35 45.%.% 1 Lan 41.7% 5 12.%.% 1 WoS 68.9% 42 61.%.% 2 - Denominator is less than 5; percentages should be viewed with caution. For patients diagnosed with oesophageal cancer the overall performance across the WoS is 68.9%, with 42 of 61 patients undergoing surgical resection having circumferential margins clear of tumour. This is just below the 7% target and shows a decreasing trend over the three years. However small numbers are included so caution should be given to changes in performance across different years as this may represent a very small number of cases. NHS Ayrshire & Arran met the target achieving 7% but data was restricted due to small numbers. NHSGGC achieved 77.8% against the 7% target with 35 out of 45 oesophageal patients who underwent surgical resection having clear circumferential margins. NHS Lanarkshire reviewed all cases not meeting the QPI criteria and detailed clinical reasons were provided. NHS Lanarkshire commented that due to the late presentation of disease and the desire to offer curative treatment where patients are fit, with no clear evidence of disease out with the resection field, this QPI remains difficult to achieve. Locally NHS Lanarkshire will continue to be critical when reviewing staging investigations to ensure under-staging does not occur. Final Published Upper Gastro-intestinal Cancer MCN Audit Report v1. 23/1/217 36
QPI 1 (ii): Numerator: Denominator: Exclusions: Target: 9% Oesophageal and gastric cancers which are surgically resected should be adequately excised. Number of patients with oesophageal or gastric cancer who undergo surgical resection in which longitudinal surgical margin is clear of tumour. All patients with oesophageal or gastric cancer who undergo surgical resection. No exclusions. Figure 22: The proportion of patients with oesophageal cancer who underwent surgical resection in which longitudinal surgical margin was clear of tumour. Final Published Upper Gastro-intestinal Cancer MCN Audit Report v1. 23/1/217 37
Oesophageal 214 215 216 Performance (%) 1 9 8 7 6 5 4 3 2 1 AA FV GGC LAN Wos NHS Board QPI 1 ii Performance (%) Numerator Denominator numerator numerator (%) exclusions exclusions (%) denominator AA - - -.%.% FV NA NA NA GGC 95.7% 45 47 1 2.1%.% 1 Lan 1.% 12 12.%.% 1 WoS 96.8% 61 63 1 1.6%.% 2 - Denominator is less than 5; percentages should be viewed with caution. Overall in the WoS of the 63 patients with oesophageal cancer undergoing surgical resection 61 had clear longitudinal margins, resulting in a performance of 96.8% which is above the 9% target. All NHS Boards exceeded the target with NHS Ayrshire & Arran and NHS Lanarkshire achieving 1%, however due to small numbers NHS Ayrshire & Arran data was restricted. Final Published Upper Gastro-intestinal Cancer MCN Audit Report v1. 23/1/217 38
Figure 23: The proportion of patients with gastric cancer who underwent surgical resection in which longitudinal surgical margin was clear of tumour. Performance(%) 1 9 8 7 6 5 4 3 2 1 Gastric 214 215 216 AA FV GGC LAN WoS NHS Board QPI 1 ii Performance (%) Numerator Denominator numerator numerator (%) exclusions exclusions (%) denominator AA 1.% 8 8.%.% FV NA NA NA GGC 95.2% 2 21 1 4.8%.% 1 Lan - - -.%.% 1 WoS 96.9% 31 32 1 3.1%.% 2 - Denominator is less than 5; percentages should be viewed with caution. Across the WoS 96.9% of patients diagnosed with gastric cancer had clear longitudinal margins following surgical resection, exceeding the QPI target of 9%. All three NHS Boards exceeded the target with performance ranging from 95.2% in NHSGGC to 1% in NHS Lanarkshire and NHS Ayrshire & Arran. As with oesophageal cases, numbers are low in individual boards for gastric cases and therefore caution should be given to percentage comparisons. QPI 11: Curative Treatment Rates Curative treatment should be offered to as many patients as possible, as this is proven to have a survival benefit. Surgical resection of the tumour remains the mainstay of curative treatment for patients with oesophageal or gastric cancer 1. However in those patients with oesophageal cancer who have locally advanced disease, are unfit for surgery, or decline surgery, chemoradiotherapy should be considered. Radiotherapy alone is also an option in patients considered unsuitable for combination therapy but is rarely curative in oesophageal cancer. Final Published Upper Gastro-intestinal Cancer MCN Audit Report v1. 23/1/217 39
QPI 11: Numerator: Patients with oesophageal or gastric cancer should undergo curative treatment whenever possible. Number of patients with oesophageal or gastric cancer who undergo curative treatment. Neoadjuvant chemoradiotherapy or chemotherapy followed by surgery; Primary surgery; Radical chemoradiotherapy; and Endoscopic Mucosal Resection Denominator: All patients with oesophageal or gastric cancer. Exclusions: No exclusions. Target: 35% Figure 24: The proportion of patients with oesophageal cancer who underwent curative treatment. Performance (%) 1 9 8 7 6 5 4 3 2 1 QPI 11 Performance (%) Numerator Denominator Oesophageal 214 215 216 AA FV GGC LAN WoS NHS Board numerator numerator (%) exclusions exclusions (%) denominator AA 24.% 12 5.%.% FV 34.4% 21 61.%.% GGC 29.1% 67 23.%.% Lan 2.4% 2 98 1 1.%.% WoS 27.3% 12 318 1.2%.% Of the 318 patients diagnosed with oesophageal cancer, 12 underwent curative treatment, resulting in a WoS performance of 27.3% against the 35% target. None of the WoS NHS Boards achieved the QPI target, although NHS Forth Valley were only marginally below. WoS performance is largely unchanged across the three years. All Boards provided clinical commentary indicating that results were dependent upon stage and co-morbidity at presentation and also the advanced nature of presenting cases. As detailed in section 2.2 43% of oesophageal cancers were stage IV at presentation. Final Published Upper Gastro-intestinal Cancer MCN Audit Report v1. 23/1/217 4
Figure 25: The proportion of patients with gastric cancer who underwent curative treatment. Performance (%) 1 9 8 7 6 5 4 3 2 1 QPI 11 Performance (%) Numerator Denominator Gastric 214 215 216 AA FV GGC LAN WoS NHS Board numerator numerator (%) exclusions exclusions (%) denominator AA 2.5% 8 39.%.% FV 23.5% 4 17.%.% GGC 18.3% 2 19 1.9%.% Lan 11.1% 4 36.%.% WoS 17.9% 36 21 1.5%.% Overall performance across the WoS is 17.9%, with 36 of 21 gastric patients undergoing curative treatment. This is 17.1 percentage points below the 35% QPI target. None of the WoS NHS Boards achieved the target with performance ranging from 11.1% in NHS Lanarkshire to 23.5% in NHS Forth Valley. As with oesophageal cancer, issues such as stage, fitness, co-morbidities and advance disease at presentation were cited as reasons for patients not receiving curative treatment. Again, as detailed previously 43% of patients with gastric cancer presented with stage IV disease. Final Published Upper Gastro-intestinal Cancer MCN Audit Report v1. 23/1/217 41
QPI 12: 3-day mortality following oncological treatment Treatment related mortality is a marker of the quality and safety of the whole service provided by the Multi Disciplinary Team (MDT). Treatment should only be undertaken in individuals that may benefit from treatment, that is, disease specific treatments should not be undertaken in futile situations 1. This QPI is intended to ensure treatment is given appropriately. QPI 12 (i): Numerator: Denominator: Exclusions: Target: < 5% 3-day mortality following curative oncological treatment for oesophageal or gastric cancer: a) Chemoradiotherapy b) Perioperative Number of patients with oesophageal or gastric cancer who receive curative oncological treatment who die within 3 days of treatment. All patients with oesophageal or gastric cancer who receive curative oncological treatment. No exclusions. Due to changes made at formal review to the coding of Radiotherapy Course Type and Type of Systemic Anti Cancer Therapy, data cannot be reported against V3 measurability until next year. Therefore to ensure that there are no gaps in the data analysis V2.7 measurability has continued to be used to analyse QPI 12. Due to the small cohort of patients included within each mortality indicator, there is wide variance at NHS Board level. Therefore only network level results are reported below. QPI 12(i) a) Chemoradiotherapy Oesophageal and Gastric Cancer In respect of oesophageal cancer patients the WoS performance was 2.6%, which was one death within 3 days of chemoradiotherapy. None of the patients who were diagnosed with gastric cancer in 216 underwent curative treatment with chemoradiotherapy. QPI 12(i) b) Perioperative Chemotherapy Oesophageal and Gastric cancer In respect of oesophageal cancer patients the WoS performance was 1.4%, which was one death within 3 days of peri-operative chemotherapy. There were no deaths within 3 days of perioperative chemotherapy for patients diagnosed with gastric cancer in 216. QPI 12 (ii) Palliative Chemotherapy - Oesophageal Cancer QPI 12 (ii): Numerator: Denominator: Exclusions: Target: < 5% 3-day mortality following palliative oncological treatment for oesophageal or gastric cancer: Chemotherapy Number of patients with oesophageal or gastric cancer who receive palliative oncological treatment who die within 3 days of treatment. All patients with oesophageal or gastric cancer who receive palliative oncological treatment. No exclusions. There were 3 deaths within 3 days of palliative chemotherapy in patients diagnosed with oesophageal cancer within 216. This represents 3.4% of patients receiving palliative chemotherapy across the WoS and is within the QPI target. Final Published Upper Gastro-intestinal Cancer MCN Audit Report v1. 23/1/217 42
QPI 12 (ii) Palliative chemotherapy Gastric cancer There were 4 deaths within 3 days of palliative chemotherapy in patients diagnosed with gastric cancer within 216. This represents 9.8% of palliative chemotherapy patients across the WoS and is within the <2% target. The number of patients included within the denominator however is low (n=41) and this can have a considerable effect on proportions. QPI 14: Clinical Trials Access Clinical trials are necessary to demonstrate the efficacy of new therapies and other interventions. Evidence suggests improved patient outcomes from participation in clinical trials 1. Clinicians are therefore encouraged to enter patients into well-designed trials and to collect longer-term follow-up data. High accrual activity into clinical trials is used as a goal of an exemplary clinical research site 1. The clinical trials QPI is measured utilising Scottish Cancer Research Network (SCRN) data and ISD incidence data, as is the methodology currently utilised by the Chief Scientist Office (CSO) and the National Cancer Research Institute (NCRI). The principal benefit of this approach is that this data is already collected utilising a robust mechanism 1. QPI 14: Description: Numerator: Denominator: All patients should be considered for participation in available clinical trials, wherever eligible. Proportion of patients with Upper GI cancer who are enrolled in an interventional clinical trial or translational research. Number of patients with Upper GI cancer enrolled in an interventional clinical trial or translational research. All patients with Upper GI cancer. Exclusions: No exclusions Target: Interventional trials 7.5% Translational research 15% The QPI targets for clinical trials are 7.5% for interventional trials and 15% for translational trials. It should be noted that these targets are ambitious, especially with the move towards more targeted clinical trials. These trials are often genetically selective which target smaller populations of patients and therefore many of the cancer trials which are currently open to recruitment have very select eligibility criteria. Figure 26: Proportion of patients recruited into interventional or translational clinical trials for upper GI cancer by NHS Board of residence. Interventional Translational Performance (%) 2 18 16 14 12 1 8 6 4 2 AA FV GGC LAN WoS NHS Board Final Published Upper Gastro-intestinal Cancer MCN Audit Report v1. 23/1/217 43