West of Scotland Cancer Network Urological Cancer Managed Clinical Network Audit Report Testicular Cancer Quality Performance Indicators Clinical Audit Data: 01 October 2015 to 30 September 2016 Mr Gren Oades MCN Clinical Lead Tom Kane MCN Manager Lorraine Stirling Project Officer
CONTENTS EXECUTIVE SUMMARY 3 1. INTRODUCTION 9 2. BACKGROUND 9 2.1 NATIONAL CONTEXT 10 2.2 WEST OF SCOTLAND CONTEXT 10 3. METHODOLOGY 11 4. RESULTS AND ACTION REQUIRED 12 4.1 DATA QUALITY 12 4.2 PERFORMANCE AGAINST QUALITY PERFORMANCE INDICATORS (QPIS) 13 QPI 1: RADIOLOGICAL STAGING 14 QPI 2: PRE-OPERATIVE ASSESSMENT 15 QPI 3: PRIMARY ORCHIDECTOMY 16 QPI 4: MULTIDISCIPLINARY TEAM MEETING (MDT) 18 QPI 5: PATHOLOGY REPORTING 20 QPI 6: ADJUVANT TREATMENT OF STAGE I SEMINOMA WITH CARBOPLATIN 21 QPI 7: SERUM TUMOUR MARKERS 22 QPI 8: SYSTEMIC THERAPY 23 QPI 9: COMPUTED TOMOGRAPHY SCANNING FOR SURVEILLANCE PATIENTS 25 QPI 10: 30-DAY MORTALITY 26 5. CONCLUSIONS 27 ACKNOWLEDGEMENT 29 ABBREVIATIONS 30 REFERENCES 31 APPENDIX: NHS BOARD ACTION PLANS 32 West of Scotland Cancer Network 2
Executive Summary Introduction This report contains an assessment of the performance of West of Scotland (WoS) urological cancer services using clinical audit data relating to patients diagnosed with testicular cancer in the twelve months between 01 October 2015 and 30 September 2016. Data are collected for all urological cancers, however data analysed and included within this report relates to cancer of the testis only and results are measured against the Testicular Cancer Quality Performance Indicators 1 (QPIs) which were implemented for patients diagnosed on or after 01 October 2014. The National Cancer Quality Steering Group (NCQSG) completed a programme of work to develop national QPIs for all cancer types to enable national comparative reporting and drive continuous improvement for patients in 2014. In collaboration with the three Regional Cancer Networks and Information Services Division (ISD) the Testicular Cancer QPIs were published by Healthcare Improvement Scotland (HIS) in October 2014. Data definitions and measurability criteria to accompany the Testicular Cancer QPIs are available from the ISD website 2. Twelve months of data were measured against the Testicular Cancer QPIs for the second consecutive year, and Year 1 and Year 2 results are presented within this audit report for QPIs where results have remained comparable. Following reporting of Year 1 data a process of baseline review was undertaken to ensure QPIs were fit for purpose and truly driving quality improvement in patient care. Future reports will continue to compare clinical audit data in successive years to further illustrate trends. Background Testicular cancer is rare and is the 16th most commonly diagnosed malignancy in Scottish men with a relative frequency of around 1.4% of all cancers 3. There has been a slight increase in the incidence of testicular cancer in the past ten years from 2004 to 2014 of 0.7% 3. Testicular cancer has the highest survival rates of all cancer types and survival has improved in the 20 years to 2011 4. Mortality rates for testicular cancer have fallen by 19.7% in the past ten years from 2005 to 2015 3. Major advances in the treatment of testicular cancer have contributed towards these improved survival and mortality rates. Four NHS Boards across the WoS serve the 2.48 million population 5. From this population, 100 new cases of testicular cancer were diagnosed between 01 October 2015 and 30 September 2016. The configuration of the Multidisciplinary Teams (MDTs) in the region is set out below. MDT Constituent Hospitals Ayrshire & Arran (AA) Crosshouse Hospital, Ayr Hospital Greater Glasgow and Clyde (GGC) (i) Gartnavel General Hospital, Glasgow Royal Infirmary, Queen Elizabeth University Hospital, Vale of Leven (ii) Royal Alexandra Hospital, Inverclyde Royal Hospital Forth Valley (FV) Lanarkshire (Lan) Forth Valley Royal Hospital Monklands District General, Wishaw General Hospital, Hairmyres Hospital West of Scotland Cancer Network 3
Methodology The clinical audit data presented in this report was collected by clinical audit staff in each NHS Board in accordance with an agreed dataset and definitions. The data was entered locally into the electronic Cancer Audit Support Environment (ecase): a secure centralised web-based database. Data relating to patients diagnosed between 01 October 2015 and 30 September 2016 was downloaded from ecase on 01 February 2017. Analysis was performed centrally by the West of Scotland Cancer Network (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 NHS 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 Case ascertainment is an estimate of the proportion of expected patients identified through audit. Case ascertainment for testicular cancer is excellent across WoS at 104.2% which indicates the majority of cases have been captured by audit and therefore results presented within this report should provide an accurate reflection of performance. It should be noted that the predicted incidence of all cancer types is based on historic numbers of cases diagnosed and therefore some variation in case ascertainment is expected, especially when overall numbers are small. Results for each QPI are shown in detail in the main report and illustrate Board performance against targets and overall WoS performance for each performance indicator. Results are presented graphically and the accompanying tabular format also highlights any missing data and its possible effect on any of the measured outcomes. 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 (-). For the second consecutive year, the QPI target was met for QPIs 5, (pathology reporting) 10 (i) and 10 (iii) (30 day mortality) by all four NHS Boards. Overall WoS performance also exceeded the QPI target for QPIs 4, 9 and 10(ii); however targets were only met by three of the four NHS Boards in each case. Targets for QPIs 1 (radiological staging), 3 (orchidectomy), 6 (adjuvant treatment) and 8 (systemic therapy) remained challenging in Year 2, as in Year 1, and overall improvement in WoS performance was only demonstrated for QPI 6. This may, in part, be due to the time lag between data analysis and implementation of Board actions; however NHS Boards should review previous actions implemented locally for QPIs 1, 3, 6 and 8 to assess whether these have been effective or require continuation. The summary of results overpage shows the WoS percentage performance against each QPI target and performance by NHS Board. West of Scotland Cancer Network 4
TESTICULAR Quality Performance Indicators 1. Radiological Staging Proportion of patients who undergo CT scanning of the chest, abdomen and pelvis within 3 weeks of orchidectomy. 2. Pre-operative Assessment Proportion of patients who undergo preoperative assessment of the testicle which includes (i) STMs and (ii) testicular ultrasound. 3. Primary Orchidectomy Proportion of patients who undergo primary orchidectomy within 2 weeks of ultrasonographic diagnosis. 4. Multidisciplinary Team Meeting Patients should be discussed at MDT to agree a definitive management plan post orchidectomy with staging and pathology. 5. Pathology Reporting Proportion of patients undergoing orchidectomy where the pathology report contains full information (as per RCoP dataset). 6. Adjuvant Treatment of Stage I Seminoma with Carboplatin Proportion of patients with stage I seminoma receiving adjuvant single-dose carboplatin within 8 weeks of orchidectomy. Performance by NHS Board QPI target AA FV GGC LAN WoS 88.9% < 71.4% > 91.3% < 84.2% > 86.6% < 95% 16 18 10 14 42 46 16 19 84 97 100% = 64.3% < 97.8% > 100% = 93.8% < 95% 18 18 9 14 45 46 19 19 91 97 94.4% > 14.3% < 37.5% > 55.6% < 48.0% < 95% 17 18 2 14 18 48 10 18 47 98 100% = 100% = 100% > 94.7% < 99.0% > 95% 18 18 14 14 48 48 18 19 98 99 100% = 100% = 97.9% > 100% = 99.0% > 90% 18 18 14 14 47 48 19 19 98 99 85.7% < 50.0% > 78.9% > - 71.1% > 95% 6 7 4 8 15 19 - - 27 38 7. Serum Tumour Markers Proportion of patients with metastatic testicular cancer who undergo STMs 2 weeks before starting chemotherapy. 8. Systemic Therapy Proportion of patients with metastatic testicular cancer who undergo SACT within 3 weeks of an MDT decision to treat with SACT. 9. CT Scanning for Surveillance Patients Proportion of patients with stage I testicular NSGCT (or mixed) under surveillance who undergo at least three CT scans of the abdomen +/- chest and pelvis within 14 months of diagnosis. (Note: Year 1 data reported). 98% 95% 85% - - 92.3% < 75.0% < 88.5% < - - - - 12 13 6 8 23 26 - - 76.9% > 62.5% < 72.0% < - - - - 10 13 5 8 18 25 - - 100% - 91.7% - - - - 5 5 - - 11 12 West of Scotland Cancer Network 5
TESTICULAR Quality Performance Indicators Performance by NHS Board QPI target AA FV GGC LAN WoS 10. 30-day Mortality Proportion of patients who die within 30 days of treatment for testicular cancer. (Hospital of surgery) 10.a Orchidectomy 10. 30-day Mortality Proportion of patients who die within 30 days of treatment for testicular cancer. 10.b Chemotherapy 10. 30-day Mortality Proportion of patients who die within 30 days of treatment for testicular cancer. 10.c Radiotherapy < 5% < 5% < 5% 0.0% = 0.0% = 0.0% = 0.0% = 0.0% = 0 18 0 14 0 50 0 18 0 100 0.0% = 0.0% = 0.0% = 13.3% < 2.6% < 0 14 0 11 0 37 2 15 2 77 - - NA NA - - - - - 0 0 0 0 - - Meets/exceeds QPI target Does not meet QPI target (-) dash denotes a denominator of less than 5. Figures have been removed to ensure confidentiality. West of Scotland Cancer Network 6
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. With the development of Quality Performance Indicators, this has now become a national programme to drive continuous improvement and ensure equity of care for patients across Scotland. West of Scotland Boards commitment in the past few years to the continuous improvement of the quality and completeness of audit data has supported this transition to national reporting. The improvements have provided accurate baseline data for the first two years of reporting against Testicular Cancer QPIs from which yearly comparisons in the service provision across WoS Boards can be made. Data completeness is particularly high for Testicular Cancer QPIs with the 12 reported QPIs/sub-QPIs having all relevant data fields completed. Percentage case ascertainment has also improved significantly in Year 2 (p-value < 0.05), thus increasing the accuracy of the results reported. Overall WoS results from the second year of Testicular Cancer QPI analysis demonstrate that 6 of the 12 reported QPIs/sub-QPIs met or exceeded the QPI target. It is evident however that NHS Boards have found some QPI targets challenging to meet. The audit report has identified actions relating to service provision especially with regard to timescales within the patient pathway. As in Year 1 of data analysis, the time from ultrasound diagnosis to orchidectomy and the time from orchidectomy to CT scanning require improvement in order to meet QPI targets in Year 3. All actions are summarised overpage and are outlined in the main report under the relevant section. NHS Boards are asked to develop local Action/Improvement Plans in response to the findings presented in the report. Action required: QPI 1 Radiological Staging NHS Lanarkshire, Forth Valley and Ayrshire & Arran should monitor results locally to ensure actions implemented to improve time to post-orchidectomy CT scan have been effective. NHSGGC to review cases not meeting QPI and report on any actions taken through the MCN. QPI 2 Preoperative assessment NHS Forth Valley should monitor patients who do not receive a LDH marker as part of their preoperative assessment to ensure previously noted issues have been resolved. QPI 3 Primary orchidectomy NHS Forth Valley should review current practice and take action to ensure patients are undergoing orchidectomy within 14 days of ultrasound diagnosis. NHS Lanarkshire should review the direct referral policy previously implemented and monitor results locally to ensure patients are undergoing orchidectomy within 14 days of ultrasound diagnosis. NHSGGC should review cases where the time from ultrasound diagnosis to surgery exceeds 14 days to identify any delays and take appropriate action. West of Scotland Cancer Network 7
QPI 6 Adjuvant treatment with carboplatin NHSGGC to review cases that did not meet the QPI criteria and feedback results to the MCN. All NHS Boards should monitor results locally to ensure actions previously put in place have been effective, and identify alternative action where appropriate. QPI 8 Systemic therapy NHS Lanarkshire and NHSGGC should review cases to determine any potential issues in meeting the QPI criteria for QPI 8 and take appropriate action. A summary of actions for each NHS Board has been included within the Action Plan templates in the Appendix. Completed Action Plans should be returned to WoSCAN within two months of publication of this report. Progress against these plans will be monitored by the MCN Steering Group and any service or clinical issue which the Steering Group considers not to have been adequately addressed will be escalated to the NHS Board Territorial Lead Cancer Clinician and Regional Lead Cancer Clinician. Additionally, progress will be reported annually to the Regional Cancer Advisory Group (RCAG) by NHS Board Territorial Lead Cancer Clinicians and MCN Clinical Leads, and nationally on a threeyearly basis to Healthcare Improvement Scotland as part of the governance processes set out in CEL 06 (2012). West of Scotland Cancer Network 8
1. Introduction This report contains an assessment of the performance of West of Scotland (WoS) urological cancer services using clinical audit data relating to patients diagnosed with testicular cancer in the twelve months between 01 October 2015 and 30 September 2016. Regular reporting of activity and performance is a fundamental requirement of a Managed Clinical Network (MCN) to assure the quality of care delivered across the region. Data are collected for all urological cancers, however data analysed and included within this report relates to cancer of the testis. Results are measured against the Testicular Cancer Quality Performance Indicators 1 (QPIs) which were introduced for patients diagnosed on or after 01 October 2014. The National Cancer Quality Steering Group (NCQSG) completed a programme of work to develop national QPIs for all cancer types to enable national comparative reporting and drive continuous improvement for patients in 2014. In collaboration with the three Regional Cancer Networks and Information Services Division (ISD) the Testicular Cancer QPIs were published by Healthcare Improvement Scotland (HIS) in October 2014. Data definitions and measurability criteria to accompany the testicular cancer QPIs are available from the ISD website 2. Twelve months of data were measured against the Testicular Cancer QPIs for the second consecutive year, and Year 1 and Year 2 results are presented within this audit report for QPIs where results have remained comparable. Following reporting of Year 1 data a process of baseline review was undertaken to ensure QPIs were fit for purpose and truly driving quality improvement in patient care. Future reports will continue to compare clinical audit data in successive years to further illustrate trends. 2. Background Four NHS Boards across the WoS serve the 2.47 million population 5. There were 100 patients diagnosed with testicular cancer in the WoS between 01 October 2015 and 30 September 2016 showing a 45% increase in the number of cases captured by audit from the previous year. However, it should be noted that case ascertainment was low in Year 1 at 71.9% and this increase is more likely to reflect improved capture of cases rather than increasing incidence of testicular cancer. The configuration of the Multidisciplinary Teams (MDTs) in the region is set out below and each MDT convenes on a weekly basis. MDT Constituent Hospitals Ayrshire & Arran (AA) Crosshouse Hospital, Ayr Hospital Greater Glasgow and Clyde (GGC) (i) Gartnavel General Hospital, Glasgow Royal Infirmary, Queen Elizabeth University Hospital, Vale of Leven (ii) Royal Alexandra Hospital, Inverclyde Royal Hospital Forth Valley (FV) Lanarkshire (Lan) Forth Valley Royal Hospital Monklands District General, Wishaw General Hospital, Hairmyres Hospital West of Scotland Cancer Network 9
2.1 National Context Testicular cancer is the 16th most common cancer in males with approximately 200 cases diagnosed in Scotland each year between 2010 and 2014 6. The incidence of testicular cancer has increased slightly in the past ten years from 2004 to 2014 by 0.7% 3. Relative survival for testicular cancer is increasing 4 and testicular cancer has the highest survival rates compared to any other cancer type with a 1-year relative survival of 99.4% and a 5-year relative survival of 98.7% 3 (2007-2011). Table 1 shows the percentage change in 1-year and 5-year agestandardised survival rates for patients diagnosed with testicular cancer in 1983-1987 compared to those diagnosed in 2007-2011 4. Survival rates are age-standardised to allow fair comparison over time. Major advances in surgical, chemotherapy and radiotherapy treatments for testicular cancer have contributed to the high survival rates observed 4,7. Mortality rates have decreased by 19.7% in the last ten years from 2005 to 2015 3. Table 1: Relative age-standardised survival for testicular cancer in Scotland at 1 year and 5 years showing percentage change from 1983-1987 to 2007-2011 Relative survival at 1 year (%) Relative survival at 5 years (%) 2007-2011 % change 2007-2011 % change Testicular Cancer 99.4 % + 9.9 % 98.7 % + 15.1 % 2.2 West of Scotland Context A total of 100 cases of testicular cancer were recorded through audit as diagnosed in the West of Scotland between 01 October 2015 and 30 September 2016. The number and percentage of patients diagnosed within each NHS Board is presented in Figure 1. As the largest WoS Board, 49.0% of all new cases of testicular cancer were diagnosed in NHS Greater Glasgow and Clyde (NHSGGC) which is slightly higher than population estimates for this Board (46.4% of WoS population, 2015 mid-year estimates 5 ). Figure 1: Number of patients diagnosed with testicular cancer within each WoS NHS Board, Year 1 and Year 2. 50 Year 1 Year 2 Number of new diagnoses 45 40 35 30 25 20 15 10 5 0 AA FV GGC LAN NHS Board West of Scotland Cancer Network 10
Testicular Cancer AA FV GGC LAN N % N % N % N % WoS Total Year 1 14 20.3% 8 11.6% 37 53.6% 10 14.5% 69 Year 2 18 18.0% 14 14.0% 49 49.0% 19 19.0% 100 The majority of men diagnosed with testicular cancer are in the younger age groups with more than half of all new diagnoses occurring in males under 40 years old. The median age at diagnosis is 35 years. Figure 2 illustrates the distribution of the number of new diagnoses within each 5-year age group for the WoS. Figure 2: Number of patients diagnosed with testicular cancer in WoS within each age group, Oct 15 to Sept 16. 24 Number of new diagnoses 22 20 18 16 14 12 10 8 6 4 2 0 NHS Board Age group 16-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75+ No. of cases 1 7 19 20 19 12 6 6 1 3 3 2 1 35.0 Median age 3. Methodology The clinical audit data presented in this report was collected by clinical audit staff in each NHS Board in accordance with an agreed dataset and definitions. The data was recorded manually and entered locally into the electronic Cancer Audit Support Environment (ecase): a secure centralised webbased database. Data relating to patients diagnosed between 01 October 2015 and 30 September 2016 was downloaded from ecase at 2200 hrs on 01 February 2017. 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 slightly different figures if extracted at different times. Analysis was performed centrally for the region by the West of Scotland Cancer Network (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 NHS 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 the data was an accurate representation of service in each area. West of Scotland Cancer Network 11
4. Results and Action Required 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 as the number of new cases identified by the audit as a proportion of the number of cases reported by the National Cancer Registry (provided by Information Services Division, National Services Scotland). Cancer Registry figures were extracted from ACaDMe (Acute Cancer Deaths and Mental Health), a system provided by Information Services Division (ISD). Cancer Registry figures are an average of the previous five years figures to take account of annual fluctuations in incidence within NHS Boards. The overall case ascertainment in WoSCAN is 104.2% which indicates excellent data capture for Year 2 data analysis. This is an increase from 71.9% in Year 1 which is likely to indicate an improvement in the number of cases being captured through audit, rather than an increase in incidence. Given the small numbers of patients diagnosed with testicular cancer during the 12-month period, there is fluctuation in case ascertainment which is reflected in the Board figures below. Case ascertainment figures however are provided for guidance and are not an exact measurement as it is not possible to compare directly with the same cohort. Lower or higher figures can also indicate changes in incidence of a particular cancer type within a Board or region over time. Case ascertainment for each WoS Board is illustrated in Figure 3. Figure 3: Case ascertainment by NHS Board for patients diagnosed with testicular cancer, Oct 15 to Sept 16. 160% 140% Case ascertainment (%) 120% 100% 80% 60% 40% 20% 0% AA FV GGC LAN WoS NHS Board of diagnosis AA FV GGC Lan WoS Cases from audit 18 14 49 19 100 ISD Cases (2010-2014 average) 14 9 54 19 96 % Case ascertainment 128.6% 155.6% 90.7% 100.0% 104.2% For each of the 10 reported Testicular Cancer QPIs, all the relevant data items had values recorded (i.e. for numerator, denominator or exclusions) and therefore the information presented within this report is likely to be of high accuracy. West of Scotland Cancer Network 12
4.2 Performance against Quality Performance Indicators (QPIs) Results of the analysis of Testicular Cancer Quality Performance Indicators (QPIs 1 10) 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. Where possible, and with consideration given to any changes after Baseline Review, results for patients diagnosed in Year 2 have been presented alongside the previous year s 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. Specific NHS Board actions have been identified to address issues highlighted through the data 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. West of Scotland Cancer Network 13
QPI 1: Radiological Staging Patients with testicular cancer should be evaluated with appropriate imaging to detect the extent of disease and guide treatment decision making. Timely imaging is important to ensure treatment decision making can occur as soon as possible 1. Unnecessary delays can have an impact on prognostic groups and hence survival rates. Computed Tomography (CT) scanning is an essential part of the staging of all germ cell tumours 1. Description: Numerator: Proportion of patients with testicular cancer who undergo Computed Tomography (CT) scanning, ideally contrast-enhanced CT, of the chest, abdomen and pelvis within 3 weeks of orchidectomy. Number of patients with testicular cancer undergoing CT scanning of the chest, abdomen and pelvis within 3 weeks of orchidectomy. Denominator: All patients with testicular cancer. Exclusions: Patients undergoing chemotherapy prior to orchidectomy. Target: 95% Figure 4: The proportion of patients with testicular cancer who undergo CT scanning of the chest, abdomen and pelvis within three weeks of orchidectomy. 100% 90% QPI Target Year 1 Year 2 Proportion of Patients (%) 80% 70% 60% 50% 40% 30% 20% 10% 0% AA FV GGC LAN WoS NHS Board of Diagnosis QPI 1 Performance (%) Numerator Denominator numerator numerator (%) exclusions exclusions (%) denominator AA 88.9% 16 18 0 0.0% 0 0.0% 0 FV 71.4% 10 14 0 0.0% 0 0.0% 0 GGC 91.3% 42 46 0 0.0% 0 0.0% 0 LAN 84.2% 16 19 0 0.0% 0 0.0% 0 WoS 86.6% 84 97 0 0.0% 0 0.0% 0 Of the 97 patients diagnosed with testicular cancer who did not have chemotherapy prior to orchidectomy, 84 patients underwent CT scanning within 3 weeks of orchidectomy resulting in a WoS West of Scotland Cancer Network 14
performance of 86.6% against the 95% QPI target. Overall performance in the WoS was 2.5 percentage points below performance in Year 1 (89.1%). The 95% target for QPI 1 was not achieved by any of the WoS Boards for patients undergoing CT scanning within 3 weeks of orchidectomy in Year 2. Performance ranged from 71.4% in NHS Forth Valley to 91.3% in NHSGGC. Within NHS Lanarkshire, 3 patients did not meet the QPI criteria due to having CT scanning outwith the 21-day timeframe. In NHS Forth Valley, 4 out of 14 did not meet the QPI criteria. NHS Forth Valley reported that 4 patients underwent CT scanning within 4 weeks of orchidectomy. The clinical team have discussed this delay and have suggested booking the scan on the day of surgery or at the post-operative MDT meeting. Within NHS Ayrshire & Arran, 2 of 18 patients did not meet the QPI criteria. Comments received stated that this was due to capacity issues of which management are aware. Action Required: NHS Lanarkshire, Forth Valley and Ayrshire & Arran should monitor results locally to ensure actions implemented to improve time to post-orchidectomy CT scan have been effective. NHSGGC to review cases not meeting QPI and report on any actions taken through the MCN. QPI 2: Pre-operative Assessment Patients with testicular cancer should have pre-operative assessment of the testicle and Serum Tumour Markers (STMs). In most instances, the diagnosis of testicular tumours is established with a carefully performed physical examination and scrotal ultrasound 1. When conducting preoperative assessments, evidence has demonstrated the importance of investigating STM concentrations and conducting a testicular ultrasound. Serum determination of tumour markers before and after orchidectomy allow for staging and prognosis to be determined 1. Description: Numerator: Denominator: Proportion of patients with testicular cancer who undergo preoperative assessment of the testicle which, at a minimum, includes: (i) STMs*, and (ii) testicular ultrasound. Number of patients with testicular cancer undergoing orchidectomy, who undergo a preoperative assessment of the testicle which, at a minimum, includes: (i) STMs*, and (ii) testicular ultrasound. All patients with testicular cancer undergoing orchidectomy. Exclusions: Patients who refuse to undergo assessment. Patients undergoing chemotherapy prior to orchidectomy. Target: 95% * AFP Alpha-fetoprotein, HCG Human chorionic gonadotropin, LDH Lactate dehydrogenase West of Scotland Cancer Network 15
Figure 5: The proportion of patients with testicular cancer who underwent preoperative assessment of the testicle (STMs and testicular ultrasound). 100% 90% QPI Target Year 1 Year 2 Proportion of Patients (%) 80% 70% 60% 50% 40% 30% 20% 10% 0% AA FV GGC LAN WoS NHS Board of Diagnosis QPI 2 Performance (%) Numerator Denominator numerator numerator (%) exclusions exclusions (%) denominator AA 100% 18 18 0 0.0% 0 0.0% 0 FV 64.3% 9 14 0 0.0% 0 0.0% 0 GGC 97.8% 45 46 0 0.0% 0 0.0% 0 LAN 100% 19 19 0 0.0% 0 0.0% 0 WoS 93.8% 91 97 0 0.0% 0 0.0% 0 Of the 97 patients that were diagnosed with testicular cancer that underwent orchidectomy in Year 2 (minus exclusions), 91 patients underwent a preoperative assessment of the testicle which included Serum Tumour Markers (STMs) and testicular ultrasound. This resulted in a WoS performance of 93.8% against the 95% QPI target. NHS Ayrshire & Arran, NHS Lanarkshire and NHSGGC met the target for QPI 2 for the second consecutive year. NHS Forth Valley commented that 5 patients did not have their lactate dehydrogenase (LDH) marker taken as part of their preoperative assessment and advised that this was a change in hospital systems. This issue has now been raised and highlighted. This resulted in a decrease in performance for NHS Forth Valley of 35.7 percentage points from Year 1 performance. Action Required: NHS Forth Valley should monitor patients who do not receive a LDH marker as part of their preoperative assessment to ensure previously noted issues have been resolved. QPI 3: Primary Orchidectomy Patients with testicular cancer should have primary orchidectomy within 2 weeks of ultrasonographic diagnosis. Orchidectomy is the primary therapeutic intervention for patients who have early-stage testicular cancer. The overall aim of primary orchidectomy is to remove the tumour and minimise local recurrence and abnormal lymphatic spread 1. To ensure pathological information is obtained and future West of Scotland Cancer Network 16
treatment decision making can be made, it is important that orchidectomy is carried out as quickly as possible from diagnosis 1. Description: Proportion of patients with testicular cancer who undergo primary orchidectomy within 2 weeks of ultrasonographic diagnosis. Numerator: Denominator: Number of patients with testicular cancer undergoing orchidectomy within 2 weeks of ultrasonographic diagnosis. All patients with testicular cancer undergoing orchidectomy. Exclusions: Patients undergoing chemotherapy prior to orchidectomy. Target: 95% Figure 6: The proportion of patients with testicular cancer who underwent primary orchidectomy within two weeks of ultrasonographic diagnosis. 100% 90% QPI Target Year 1 Year 2 Proportion of Patients (%) 80% 70% 60% 50% 40% 30% 20% 10% 0% AA FV GGC LAN WoS NHS Board of Diagnosis QPI 3 Performance (%) Numerator Denominator numerator numerator (%) exclusions exclusions (%) denominator AA 94.4% 17 18 0 0.0% 0 0.0% 0 FV 14.3% 2 14 0 0.0% 0 0.0% 0 GGC 37.5% 18 48 0 0.0% 0 0.0% 0 LAN 55.6% 10 18 0 0.0% 0 0.0% 0 WoS 48.0% 47 98 0 0.0% 0 0.0% 0 Of the 98 patients diagnosed with testicular cancer undergoing orchidectomy (minus exclusions), 47 patients underwent surgery within two weeks of ultrasound diagnosis. This resulted in an overall WoS performance of 48.0% against the 95% QPI target for Year 2 and a decrease of 4.3 percentage points from the previous year. None of the four NHS Boards met the 95% target and performance varied significantly between Boards ranging from 14.3% in NHS Forth Valley to 94.4% in NHS Ayrshire & Arran. NHS Ayrshire & Arran has noted that 1 patient did not meet the QPI due to capacity issues of which management are aware. West of Scotland Cancer Network 17
NHS Forth Valley has commented that delay in the 10 cases that did not meet the QPI criteria was due to GP referral to ultrasound scan, thus causing delay to orchidectomy. NHS Forth Valley advised that when they measured the time between the patient s first outpatient appointment and orchidectomy all patients were seen within 2 weeks and the Board commented that they will continue with current practice. For the remaining 2 cases delay was due to referral via an alternative pathway and factors of patient choice. NHS Lanarkshire had 8 cases not meeting this QPI due to a delay in time to orchidectomy. NHS Lanarkshire reported that 8 patients waited over 14 days (ranging from 15 24 days), one case of which was due to patient choice and another due to delayed sonography reporting. Actions Required: NHS Forth Valley should review current practice and take action to ensure patients are undergoing orchidectomy within 14 days of ultrasound diagnosis. NHS Lanarkshire should review the direct referral policy previously implemented and monitor results locally to ensure patients are undergoing orchidectomy within 14 days of ultrasound diagnosis. NHSGGC should review cases where the time from ultrasound diagnosis to surgery exceeds 14 days to identify any delays and take appropriate action. Further analysis of WoS figures has shown that the median number of days from date of ultrasound to orchidectomy is 15.0 days for the current cohort of patients. Table 2 shows the median and mean number of days to surgery for patients in Year 1 and Year 2 who (i) met the QPI criteria, (ii) did not meet the QPI criteria and (iii) all patients. Table 2: The median and mean number of days from date of ultrasound diagnosis to date of surgery for patients with testicular cancer who underwent primary orchidectomy in Year 1 and Year 2. QPI MET QPI NOT MET ALL PATIENTS Year 1 Year 2 Year 1 Year 2 Year 1 Year 2 No. of patients 34 47 30 51 64 98 Median (days) 8.0 7.0 26.0 20.5 12.5 15.0 Mean (days) 7.2 5.9 27.7 26.0 16.5 16.3 As previously stated in last year s report, there was discussion at the National Urology Meeting and the Baseline Review meeting in April 2016 regarding the variable performance across Boards for QPI 3. Issues identified which could be contributing to delayed surgery included patient fitness for orchidectomy, patient availability or the requirement for presurgical semen storage. It was also felt that competing pressure with surgical list organisation was a factor. At the Testicular QPI Baseline Review meeting it was agreed that the target should remain at 95% to drive service improvement as it was considered important that patients should be treated within two weeks of diagnosis. QPI 4: Multidisciplinary Team Meeting (MDT) Patients with testicular cancer should be discussed by a multidisciplinary team to agree a definitive management plan post orchidectomy with staging and pathology. Orchidectomy can be used as a diagnostic tool as well as definitive treatment for patients with testicular cancer 1. It is important to have the information that is gained from this procedure available at the MDT meeting to ensure a fully informed decision, including tumour type, prognosis and risk factors, can be made on the best management plan for the patient 1. West of Scotland Cancer Network 18
Description: Numerator: Denominator: Proportion of patients with testicular cancer who are discussed at an MDT meeting to agree a definitive management plan post orchidectomy. Number of patients with testicular cancer undergoing orchidectomy who are discussed at the MDT to agree a definitive management plan post orchidectomy. All patients with testicular cancer undergoing orchidectomy. Exclusions: None Target: 95% Figure 7: The proportion of patients with testicular cancer who were discussed at an MDT meeting to agree a definitive management plan post orchidectomy. 100% 90% QPI Target Year 1 Year 2 Proportion of Patients (%) 80% 70% 60% 50% 40% 30% 20% 10% 0% AA FV GGC LAN WoS NHS Board of Diagnosis QPI 4 Performance (%) Numerator Denominator numerator numerator (%) exclusions exclusions (%) denominator AA 100% 18 18 0 0.0% 0 0.0% 0 FV 100% 14 14 0 0.0% 0 0.0% 0 GGC 100% 48 48 0 0.0% 0 0.0% 0 LAN 94.7% 18 19 0 0.0% 0 0.0% 0 WoS 99.0% 98 99 0 0.0% 0 0.0% 0 Of the 99 patients that were diagnosed with testicular cancer that underwent orchidectomy in Year 2, 98 patients were discussed by a multidisciplinary team to agree a definitive management plan post orchidectomy with staging and pathology. This resulted in a WoS performance of 99.0% against the 95% QPI target. Overall performance was high in the West of Scotland with three out of the four Boards meeting the target for QPI 4 with NHS Ayrshire & Arran, NHS Forth Valley and NHSGGC each achieving 100%. NHS Lanarkshire reported that only one case was not discussed by a multidisciplinary team. Due to unique circumstances in this case, the patient followed a different pathway and was referred directly to Glasgow for treatment. West of Scotland Cancer Network 19
QPI 5: Pathology Reporting Pathology reports for testicular cancer should contain full pathology information to inform patient management 1. To allow treatment planning to take place for patients diagnosed with testicular cancer, it is important that adequate subtyping and staging of testicular tumours is carried out to determine clinical management 1. This information will allow patients to make informed decisions about their care 1. Description: Numerator: Denominator: Exclusions: None Target: 90% Proportion of patients with testicular cancer undergoing orchidectomy where the pathology report contains tumour type and size, vascular invasion and rete stromal invasion (based upon the current Royal College of Pathologists dataset). Number of patients with testicular cancer undergoing orchidectomy where histological pathology report contains tumour type and size, vascular invasion and rete stromal invasion. All patients with testicular cancer undergoing orchidectomy. Figure 8: The proportion of patients with testicular cancer undergoing orchidectomy where the pathology report contains tumour type and size, vascular invasion and rete stromal invasion. Proportion of Patients (%) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% QPI Target Year 1 Year 2 0% AA FV GGC LAN WoS NHS Board of Diagnosis QPI 5 Performance (%) Numerator Denominator numerator numerator (%) exclusions exclusions (%) denominator AA 100% 18 18 0 0.0% 0 0.0% 0 FV 100% 14 14 0 0.0% 0 0.0% 0 GGC 97.9% 47 48 0 0.0% 0 0.0% 0 LAN 100% 19 19 0 0.0% 0 0.0% 0 WoS 99% 98 99 0 0.0% 0 0.0% 0 Of the 99 patients that were diagnosed with testicular cancer that underwent orchidectomy in Year 2, 98 patients pathology report contained information on tumour type and size, vascular invasion and rete stromal invasion (based upon the current Royal College of Pathologists dataset). This resulted in a WoS performance of 99.0% against the 90% QPI target. All four NHS Boards met the target for QPI West of Scotland Cancer Network 20
5 with NHS Ayrshire & Arran, NHS Forth Valley and NHS Lanarkshire each achieving 100% for the second consecutive year. It is extremely encouraging that over the past 2 years all WoS NHS Boards met the QPI target level of 90%. QPI 6: Adjuvant treatment of stage I seminoma with carboplatin Patients with stage I seminoma receiving adjuvant single dose carboplatin should have an AUC (Area Under the Curve) of 7mg/ml/min based on ethylene diamine tetra-acetic acid (EDTA) clearance 1. Evidence has shown that the administration of carboplatin can prevent metastatic relapse and contralateral cancer in patients with testicular cancer 1. Description: Numerator: Denominator: Proportion of patients with stage I seminoma receiving adjuvant single dose carboplatin AUC of 7mg/ml/min (AUC7), based on EDTA clearance within 8 weeks of orchidectomy. Number of patients with stage I seminoma receiving adjuvant single dose carboplatin AUC7, based on EDTA clearance within 8 weeks of orchidectomy. All patients with stage I seminoma undergoing adjuvant single dose carboplatin AUC7. Exclusions: Patients who are treated within a clinical trial. Target: 95% Figure 9: The proportion of patients with stage I seminoma receiving adjuvant single dose carboplatin AUC7 based on EDTA clearance, within 8 weeks of orchidectomy. 100% 90% QPI Target Year 1 Year 2 Proportion of Patients (%) 80% 70% 60% 50% 40% 30% 20% 10% 0% - - - AA FV GGC LAN WoS NHS Board of Diagnosis QPI 6 Performance (%) Numerator Denominator numerator numerator (%) exclusions exclusions (%) denominator AA 85.7% 6 7 0 0.0% 0 0.0% 0 FV 50.0% 4 8 0 0.0% 0 0.0% 0 GGC 78.9% 15 19 0 0.0% 0 0.0% 0 LAN - - - 0 0.0% 0 0.0% 0 WoS 71.1% 27 38 0 0.0% 0 0.0% 0 (-) Data is not shown where the denominator is less than 5. West of Scotland Cancer Network 21
Of the 38 patients with stage I seminoma receiving adjuvant single-dose carboplatin (AUC7), 27 patients received chemotherapy treatment within 8 weeks of orchidectomy. This resulted in a WoS performance of 71.1% against the 95% QPI target and an overall improvement of 7.9 percentage points on Year 1 performance. NHS Ayrshire & Arran achieved 85.7% against the 95% target with 6 of 7 cases meeting the QPI criteria. Board comment stated that the one case not meeting the QPI target was due to public holidays, and capacity issues of which management are aware. NHS Forth Valley achieved 50% against the 95% target with 4 of 8 cases meeting the QPI criteria. NHS Forth Valley reported that these 4 patients all started their treatment within 10 weeks of orchidectomy. Reasons for delay included referral for sperm banking, external pathology review and an administrative delay. NHSGGC achieved 78.9% against the 95% target with 15 of 19 cases meeting the QPI criteria. Comments have not yet been received by NHSGGC. NHS Lanarkshire had a denominator of less than 5 and therefore results are not shown above due to the effect small numbers have on percentages. Comments received from the Board indicated that all patients in Lanarkshire did receive adjuvant chemotherapy however 2 cases were not within the 56- day timeframe. NHS Lanarkshire have liaised with oncology colleagues and procedures are now in place to avoid any delay to adjuvant chemotherapy in the future. Action Required: NHSGGC to review cases that did not meet the QPI criteria and feedback results to the MCN. All NHS Boards should monitor results locally to ensure actions previously put in place have been effective, and identify alternative action where appropriate. QPI 7: Serum Tumour Markers Patients with metastatic testicular cancer should undergo Serum Tumour Markers (STMs) before starting chemotherapy to determine their correct International Germ Cell Cancer Collaborative Group (IGCCCG) prognostic grouping. Advanced testicular cancer studies have shown that it is beneficial to measure STMs pre-chemotherapy 1. The value of this is to allow for appropriate treatment planning for patients with elevated STMs. Monitoring of STMs can indicate whether the treatment is working or whether a more intensive course of treatment is needed 1. Description: Numerator: Denominator: Exclusions: None. Target: 98% Proportion of patients with metastatic testicular cancer who undergo STMs 2 weeks before starting chemotherapy. Number of patients with metastatic testicular cancer undergoing chemotherapy who have STMs checked 2 weeks before starting chemotherapy. All patients with metastatic testicular cancer undergoing chemotherapy. West of Scotland Cancer Network 22
Figure 10: The proportion of patients with metastatic testicular cancer who undergo STMs 2 weeks before starting chemotherapy. 100% 90% QPI Target Year 1 Year 2 Proportion of Patients (%) 80% 70% 60% 50% 40% 30% 20% 10% 0% - - - - - AA FV GGC LAN WoS NHS Board of Diagnosis QPI 7 Performance (%) Numerator Denominator numerator numerator (%) exclusions exclusions (%) denominator AA - - - 0 0.0% 0 0.0% 0 FV - - - 0 0.0% 0 0.0% 0 GGC 92.3% 12 13 0 0.0% 0 0.0% 0 LAN 75.0% 6 8 0 0.0% 0 0.0% 0 WoS 88.5% 23 26 0 0.0% 0 0.0% 0 (-) Data is not shown where the denominator is less than 5. Of the 26 patients diagnosed with metastatic testicular cancer undergoing chemotherapy, 23 patients underwent Serum Tumour Markers (STMs) two weeks before starting chemotherapy, resulting in an overall WoS performance of 88.5% against the 98% target. Actual numbers are not shown for NHS Ayrshire & Arran and NHS Forth Valley as these Boards have a denominator of less than 5, and percentages will therefore be susceptible to large annual fluctuation. NHS Lanarkshire commented that the 2 cases not meeting QPI 7 had STMs tested 15 days and 22 days prior to starting chemotherapy. It should be noted however that numbers are small and this will have an effect on percentages. QPI 8: Systemic Therapy Patients with metastatic testicular cancer who are undergoing systemic therapy should receive Systemic Anti-Cancer Therapy (SACT) within 3 weeks of an MDT decision to treat with SACT. Evidence has demonstrated that delays in diagnosis and treatment can have a negative impact on the survival rates of patients 1. In certain types of testicular cancer this can have a bigger impact on prognosis and survival 1. West of Scotland Cancer Network 23
Description: Numerator: Denominator: Proportion of patients with metastatic testicular cancer who undergo SACT within 3 weeks of an MDT decision to treat with SACT. Number of patients with metastatic testicular cancer undergoing SACT within 3 weeks of an MDT decision to treat with SACT. All patients with metastatic testicular cancer undergoing SACT. Exclusions: Patients whose primary chemotherapy management is as part of a chemotherapy clinical trial. Target: 95% Figure 11: The proportion of patients with metastatic testicular cancer who undergo SACT within 3 weeks of an MDT decision to treat with SACT. 90% 80% QPI Target Year 1 Year 2 Proportion of Patients (%) 70% 60% 50% 40% 30% 20% 10% 0% - - - - - AA FV GGC LAN WoS NHS Board of Diagnosis QPI 8 Performance (%) Numerator Denominator numerator numerator (%) exclusions exclusions (%) denominator AA - - - 0 0.0% 0 0.0% 0 FV - - - 0 0.0% 0 0.0% 0 GGC 76.9% 10 13 0 0.0% 0 0.0% 0 LAN 62.5% 5 8 0 0.0% 0 0.0% 0 WoS 72.0% 18 25 0 0.0% 0 0.0% 0 (-) Data is not shown where the denominator is less than 5. Of the 25 patients diagnosed with metastatic testicular cancer undergoing SACT, 18 patients were started on therapy within 3 weeks of an MDT decision to treat with SACT. This resulted in an overall WoS performance of 72.0% against the 95% QPI target and shows a decrease of 11.3 percentage points from Year 1. NHS Ayrshire & Arran and NHS Forth Valley each had a denominator of less than 5 and therefore results are not shown above. NHSGGC achieved 76.9% against the 95% target with 10 of 13 patients meeting the QPI criteria, however small numbers should also be noted in this Board which may result in insubstantial year-on-year variation in percentage performance. NHS Ayrshire & Arran reported that they had one patient that did not achieve the QPI due to being a complex case requiring a further biopsy after MDT before proceeding with SACT. West of Scotland Cancer Network 24
NHS Lanarkshire achieved 62.5% with 5 of 8 patients meeting the QPI criteria and reported that 2 cases were not discussed in the MDT meeting in NHSGGC before starting chemotherapy and the remaining case waited 28 days. Action Required: NHS Lanarkshire and NHSGGC should review cases to determine any potential issues in meeting the QPI criteria for QPI 8 and take appropriate action. QPI 9: Computed Tomography Scanning for Surveillance Patients Patients with stage I testicular non-seminomatous (or mixed) germ cell tumour (NSGCT) under surveillance should undergo Computed Tomography (CT) scanning of the abdomen +/- chest and pelvis, as per clinical relevance. There are several ways to manage patients with stage I NSGCT; active surveillance is a standard approach to take 1. Evidence has shown that the results from surveillance are as favourable as those who undertake adjuvant therapy 1. Description: Numerator: Denominator: Proportion of patients with stage I testicular NSGCT (or mixed) under surveillance who undergo at least three CT scans of the abdomen +/- chest and pelvis within 14 months of diagnosis. Number of patients with stage I testicular NSGCT (or mixed) under surveillance who undergo at least three CT scans of the abdomen +/- chest and pelvis within 14 months of diagnosis. All patients with stage I testicular non-seminomatous (or mixed) germ cell tumour. Exclusions: Patients who have received adjuvant chemotherapy. Patients who are treated within a clinical trial. Target: 85% Table 3: The proportion of patients with stage I testicular NSGCT (or mixed) under surveillance who undergo at least three CT scans of the abdomen +/- chest and pelvis within 14 months of diagnosis. QPI 9 Performance (%) Numerator Denominator numerator numerator (%) exclusions exclusions (%) denominator AA - - - 0 0.0% 0 0.0% 0 FV - - - 0 0.0% 0 0.0% 0 GGC 100% 5 5 0 0.0% 0 0.0% 0 LAN - - - 0 0.0% 0 0.0% 0 WoS 91.7% 11 12 0 0.0% 0 0.0% 0 In order to ensure that a full 14-month period had elapsed, enabling accurate measurement, this QPI was reported for patients diagnosed between 01 October 2014 and 30 September 2015. Of the 12 patients with stage 1 testicular non-seminomatous (or mixed) germ cell tumour (NSGCT) under surveillance, 11 patients underwent Computed Tomography (CT) scanning of the abdomen or chest and pelvis within 14 months of diagnosis. This resulted in an overall WoS performance of 91.7% against the 85% QPI target. NHS Ayrshire & Arran, NHS Forth Valley and NHS Lanarkshire all had a denominator of less than 5 therefore results are not shown above. NHS Lanarkshire reported that one patient had a second CT scan 4 weeks over the 14 months timeframe from date of diagnosis. NHSGGC achieved 100% against the 85% target with all 5 of 5 patients meeting the QPI criteria. West of Scotland Cancer Network 25