Audit Report Report of the 2012 Clinical Audit Data

Gynaecological Cancer Managed Clinical Network Audit Report Report of the 2012 Clinical Audit Data Nadeem Siddiqui Consultant Gynaecological Oncologist MCN Clinical Lead Kevin Campbell MCN Manager Julie McMahon Information Officer

CONTENTS EXECUTIVE SUMMARY 3 1. INTRODUCTION 6 2. BACKGROUND 6 2.1 NATIONAL CONTEXT 6 2.2 WEST OF SCOTLAND CONTEXT 8 3. METHODOLOGY 8 4. RESULTS AND ACTION REQUIRED 8 4.1 DATA QUALITY 9 4.2 PERFORMANCE AGAINST QIS STANDARDS 10 5. CONCLUSIONS 26 ACKNOWLEDGEMENT 27 ABBREVIATIONS 28 REFERENCES 29 APPENDIX: NHS BOARD ACTION PLANS 30 Final Published Gynaecological Cancer MCN Audit Report v1.0 27/02/2014 2

Executive Summary Introduction This report presents results for the assessment of activity and performance of the West of Scotland Gynaecological Cancer Services in respect of the management of endometrial, ovarian and cervical cancer, utilising clinical audit data captured for new cases diagnosed in 2012. NHS Quality Improvement Scotland (QIS) Clinical Standards have been used to measure performance in the management of ovarian cancer and key clinical outcome measures (KOMs), developed regionally, are used to assess performance in the management of endometrial cancer. Cervical cancer data has been analysed to baseline activity and inform development of cervical cancer Quality Performance Indicators (QPIs). Under the auspices of the Scottish Cancer Taskforce, the National Cancer Quality Steering Group is currently taking forward the development of national Quality Performance Indicators (QPIs) for all cancers. This programme of work will enable national comparative reporting and will help to drive continuous improvement for patients. QPIs were implemented for patients diagnosed with ovarian cancer from 1st October 2013. Development of endometrial and cervical cancer QPIs commenced in August 2013, with indicators scheduled for implementation in October 2014. Background Gynaecological cancers account for 10% of all cancers affecting woman in Scotland with approximately 1700 new cases of gynaecological cancer diagnosed annually (1). Incidence in ovarian cancer over the last ten years has decreased by 10% and endometrial cancer incidence has risen significantly by 28.5% over the same time period (2). Since the introduction of the Scottish Cervical Screening Programme incidence of cervical cancer has been declining, however in the past few years the incidence rate has begun to increase (+11.6%) (2). This may be due to a slight decrease in the uptake of the cervical smear test (-2.2% since 2008) (3). The Human Papilloma Virus (HPV) vaccine is designed to protect against certain high risk types of HPV that are responsible for approximately 75% of cervical cancer cases (4). The vaccination programme started in Scotland during 2008 and aims to protect females by routinely immunising them at 12-13 years of age. By 2011 uptake rates for females in S2 in school year 2011/12 were 93.1% for the first dose, 91.7% for the second dose and 82.8% for the third dose. One year on, the uptake rates for S2 females have increased to 94.2% for one dose, 93.4% for two doses and 91.4% for all three doses (4). Progression from HPV infection to cervical cancer can take many years; therefore surveillance to monitor the impact of the vaccination programme will be a long term undertaking. A total of 774 newly diagnosed gynaecological malignancies were recorded by audit teams within the West of Scotland (WoS) during 2012. This included 286 new cases of ovarian cancer, 314 cases of endometrial cancer and 174 cases of cervical cancer. The Gynaecology Managed Clinical Network (MCN) continues to support and develop the clinical service for these patients and at present gynaecological cancer services are organised around a single regional multi-disciplinary team (MDT) meeting. The Network continues to benefit from enthusiastic engagement of a range of healthcare professionals and managers across the WoS. Final Published Gynaecological Cancer MCN Audit Report v1.0 27/02/2014 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 2012 and 31 st December 2012 were downloaded from ecase on 4 th December 2013. Analysis was performed by the (WoSCAN) Information Team and the timescales agreed took into account the patient pathway to try to ensure that a complete treatment record was available for each case. Initial results of the analysis were provided to local Boards to address 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 Ovarian Cancer Performance was assessed against eleven core NHS QIS Standards for the management of ovarian cancer. Values represent the WoS result and the range expressed as a percentage. QIS 2a.1: CA125 assessment and abdominal and pelvic ultrasound are undertaken once ovarian cancer is suspected or an ovarian pelvic mass is identified. (98.2% [93.8-100]%) QIS 3a.3: There is a weekly MDT meeting at which all new patients with raised Risk of Malignancy Index (RMI) and imaging showing a complex mass or extra ovarian disease are reviewed and discussed. (99.2[97.4-100]%) QIS 3a.4: All patients confirmed to have ovarian cancer after surgery are discussed at the MDT meeting post-operatively. (99.5 [99.2-100]%) QIS 5a.1: Preparation for surgery includes chest X-ray or CT scan, DVT prophylaxis and antibiotic prophylaxis. (98.9 [91.3-100]%), (98.9 [98.4-100]%), (98.9 [98.4-100]% ) QIS 6c.2: Washings are taken or ascitic fluid sent for cytology examination. (90.8 [0.0-100]%) QIS 6c.3: Optimal cytoreductive surgery is attempted and includes a hysterectomy and bilateral salpingo-oophorectomy. (87.1 [50.0-100]%) QIS 6c.4: Infracolic omentectomy is performed. (96.0 [83.3-100]%) QIS 6c.5: A record of residual disease is made in the operation notes. (100.0 [100]%) QIS 6c.7: FIGO surgical stage is recorded in the operation notes. (96.2 [91.7-100]%) QIS 6c.8: Final FIGO surgical pathological stage is recorded in the clinical notes. (97.8[91.7-100]%) QIS 8a.3: Histological type, sub-type (where appropriate) and grade of disease are recorded. (97.8[95.7-100]%) Endometrial Cancer Analysis of endometrial cancer data was assessed using five key outcome measures developed and agreed by the MCN. Results of the analysis are detailed below; the values represent the WoS figure and the range expressed as a percentage. KOM 1: Discussion by the MDT. (99.7 [96.8-100]%) KOM 2: Patients should have peritoneal washings sent for analysis. (98.1 [90.7-100.0]%) KOM 3: Patients should have surgical management completed by minimal access technique (laparascopic). (22.7 [3.7-55.5]%) KOM 4: Type 2 cases should have lymphadenectomy in order to determine appropriate adjuvant therapies. (56.5%) Final Published Gynaecological Cancer MCN Audit Report v1.0 27/02/2014 4

KOM 5: Number of patients entering a surgical clinical trial. (No surgical clinical trials available) Cervical Cancer Cervical cancer data was analysed to enable the assessment of quality and completeness of data whilst establishing a baseline of service activity. Results of the analysis are detailed below. Values represent the WoS figure and the range expressed as a percentage where appropriate. 1: Discussion by the MDT. (100 [100.0]% ) 2: Mode of first treatment. (Surgery 46.0%, Chemoradiotherapy 33.9%, Chemotherapy 5.7%) 3: Proportion of patients undergoing surgery. (50.6 [33.3-65.3]% ) Conclusions and Action Required The results presented in this report once again demonstrate gynaecological cancer treatment and care in the WoS is generally compliant with recognised best practice. Collection of data on gynaecological cancers began in 1999 (ovarian cancer) and 2001 (endometrial cancer) and in that time there has been significant improvement in data quality. Progress made in recent years is welcomed and it is also recognised that we must build on these achievements and continue to improve the quality of the gynaecological cancer service provided in the West of Scotland. It is anticipated that the implementation of gynaecological cancer QPIs will improve future national comparative reporting by focussing data collection and measurement on the key areas which affect quality of care for patients and help to drive continuous improvement. NHS Boards are asked to develop local Action/Improvement Plans in response to the findings presented in this report. Progress against these plans will be monitored by the MCN Advisory Board and reported to the Regional Cancer Advisory Group (RCAG) annually by the Board Lead Cancer Clinicians and Managed Clinical Network (MCN) Clinical Leads, as part of the regional audit governance process to enable RCAG to review and monitor regional improvement. Action Required A summary of actions for each NHS Board has been included within the Action Plan templates in Appendix 1. Completed Action Plans should be returned to WoSCAN within two months of publication of this report. NHS Boards should take steps to ensure that staging data is complete for all patients diagnosed with gynaecological cancer, not only those patients undergoing surgical treatment. Final Published Gynaecological Cancer MCN Audit Report v1.0 27/02/2014 5

1. Introduction This report presents an assessment of performance of West of Scotland Gynaecological Cancer Services relating to patients diagnosed in the region in 2012. Where available, 2012 clinical audit data has been presented alongside data from previous years to allow year-on-year comparison. 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. NHS Quality Improvement Scotland (QIS) Clinical Standards have been used to measure performance in the management of ovarian cancer. Key clinical outcome measures were developed regionally to measure performance in the management of endometrial cancer. Cervical cancer data has been analysed to enable a baseline of activity to be established and to help inform the development of future cervical cancer Quality Performance Indicators (QPIs). Under the auspices of the Scottish Cancer Taskforce, the National Cancer Quality Steering Group is currently taking forward the development of national Quality Performance Indicators (QPIs) for all cancers. This programme of work will enable national comparative reporting and will help to drive continuous improvement for patients. Ovarian cancer QPIs were implemented for patients diagnosed with ovarian cancer from 1st October 2013 onwards. Development of endometrial and cervical cancer QPIs commenced in August 2013, with indicators scheduled for implementation in October 2014. 2. Background Surgical management of ovarian and endometrial cancer is provided by gynaecological oncologists working in the regional specialist surgical centre in Royal Infirmary (GRI) and by gynaecologists located in NHS Boards in the West of Scotland (WoS). Radical surgical treatment for cervical and vulva cancers for the WoS is also centralised at GRI. Gynaecological cancer services are organised around a single regional weekly multi-disciplinary team (MDT) meeting. Surgical, oncology and nursing staff in the specialist surgical centre and Beatson West of Scotland Cancer Centre (BWoSCC), supported by radiology and pathology staff with a special interest in gynaecological malignancies, link with local NHS Board leads and clinical nurse specialists, pathologists and radiologists to plan and review the management of patients. This weekly forum is supported by video-conferencing. 2.1 National Context Gynaecological cancers account for 10% of all cancers affecting woman in Scotland, with approximately 1700 new cases of gynaecological cancers diagnosed annually. Endometrial cancer is the most common gynaecological cancer and the fourth most common cancer in women in Scotland with approximately 640 new cases diagnosed annually. Ovarian cancer has approximately 580 new cases diagnosed annually and cervical cancer 313 cases (1). Incidence in ovarian cancer over the last ten years has decreased by 10%, however the incidence of endometrial cancer has risen significantly by 28.5% over the same time period. This undoubtedly reflects increasing levels of obesity and also longstanding changes in fertility, both of which increase a woman's risk of developing endometrial cancer (2). Since the introduction of the Scottish Cervical Screening Programme incidence of cervical cancer has been declining, however the incidence rate has risen by +11.6% in the past few years (2). This may be due to a slight decrease in the uptake of the cervical smear test (-2.2% since 2008) (3). The Human Papilloma Virus (HPV) vaccine is designed to protect against certain high risk types of HPV that are responsible for approximately 70% of cervical cancer cases. The vaccination programme started in Scotland on 1st September 2008 and aims to protect females by routinely immunising them at 12-13 years of age, through a school based programme. In addition, the majority of NHS Boards started a Final Published Gynaecological Cancer MCN Audit Report v1.0 27/02/2014 6

catch up programme in January 2009 offering immunisation to older females in the catch up cohort who have left school. By 2011 uptake rates for females in S2 in school year 2011/12 were 93.1% for the first dose, 91.7% for the second dose and 82.8% for the third dose. One year on, the uptake rates for S2 females have increased to 94.2% for one dose, 93.4% for two doses and 91.4% for all three doses (4). Table 1 shows the 1, 3 and 5 year relative survival for ovarian, endometrial and cervical cancers. Table 1: Relative survival for ovarian, endometrial and cervical cancers (1) Cancer Site 1 Year (%) 3 Year (%) 5 Year (%) Ovarian 71.1 51.2 43.2 Endometrial 93.1 85.9 84.0 Cervix 85.9 73.6 70.1 Poor survival in ovarian cancer compared with endometrial and cervical cancer is due to patients presenting at an advanced stage (5). Relative survival is better for endometrial cancers as they have a tendency to present at an earlier stage. Most cases of endometrial cancer occur in postmenopausal women where the onset of post menopausal vaginal bleeding triggers an urgent referral from primary care for investigation. Many cervical cancers are also detected early due to the well established screening programme. Progression from HPV infection to cervical cancer can take many years, therefore surveillance to monitor the impact of the vaccination programme will be a long term undertaking. Final Published Gynaecological Cancer MCN Audit Report v1.0 27/02/2014 7

2.2 West of Scotland Context A total of 286 new cases of ovarian cancer, 314 cases of endometrial cancer and 174 cases of cervical cancer were diagnosed in the WoS during 2012. The numbers presented in Figure 1 are split by location of diagnosis and site of origin of tumour. Figure 1: Distribution of gynaecological malignancies in the West of Scotland 90 80 70 Ovarian Endometrial Cervical Number of Patients 60 50 40 30 20 10 0 Ayrshire & Arran Forth Valley Lanarkshire Clyde North South Location of Diagnosis Ayrshire & Arran Forth Valley Lanarkshire Clyde North South Ovarian 56 18 48 38 88 38 286 Endometrial 72 31 55 55 60 41 314 Cervical 21 18 41 23 49 22 174 WoS 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 2012 and 31 st December 2012 were downloaded from ecase on 4 th December 2013. 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. Final Published Gynaecological Cancer MCN Audit Report v1.0 27/02/2014 8

4. Results and Action Required 4.1 Data Quality Quality of audit data 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 as diagnosed in an NHS Board through audit as a percentage of the incidence of cancer diagnosed in that NHS Board from Cancer Registry. Cancer Registry information is available some time after the year of interest as collection and verification of data is time intensive; it is for this reason that audit data cannot be compared directly to Cancer Registry data for the same year. Cancer Registry figures used were extracted from ACaDMe (Acute Cancer Deaths and Mental Health), a system provided by Information Services Division (ISD), on 4 th December 2013 via the standard reports available. Cancer Registry figures are an average of 2007 to 2011 figures to take account of annual fluctuations in incidence within NHS Boards. Figures include patients diagnosed in the private sector but who received treatment in the NHS and exclude death certificate only registrations. Table 2 illustrates estimated case ascertainment across the West of Scotland NHS Boards for 2012 audit data. Table 2: Case ascertainment Cancer Site Cases from Audit Cancer Registry Average* Estimated Case Ascertainment Ovarian 286 315 90.8% Endometrial 314 288 109.0% Cervix 174 155 112.2% Stage of disease is an important prognostic factor which informs treatment decisions and outcomes. Analysis of QIS Standard 6c.8 shows that stage of disease for ovarian surgical patients is routinely collected with 97.8% of patients noted as having stage recorded. Whilst it is acknowledged that the majority of ovarian cases undergo surgical treatment, stage should also be recorded for patients who do not. Data from patients diagnosed in 2012 shows that stage was not recorded for the 100 patients who did not undergo surgery. The availability of staging data is critical for accurate measurement of the new national OPIs, as exampled in QPI 1 where stage of disease determines the population denominator. Action Required: NHS Boards should take steps to ensure that staging data is complete for all patients diagnosed with gynaecological cancer, not only those patients undergoing surgical treatment. Final Published Gynaecological Cancer MCN Audit Report v1.0 27/02/2014 9

4.2 Performance Against QIS Standards Results for each of the outcomes assessed are presented in graphical format with the underlying data also in tabular form. Data for 2012 and the results from the previous years (2010 & 2011) are included where applicable to enable comparative analysis. The data is presented as a combination of bar charts and pie charts with the majority of results displayed as a percentage of the overall number of cases. Results are accompanied by narrative highlighting relevant aspects of data collection, data quality and service performance. Ovarian Cancer A total of 286 ovarian cancers were diagnosed in the WoS between 1 st January and 31 st December 2012. QIS Standard 2a.1 - CA125 assessment and abdominal and pelvic ultrasound are undertaken once ovarian cancer is suspected or an ovarian pelvic mass is identified. Figure 2: QIS Standard 2a.1 CA125 Assessment 2010 2011 2012 100 90 80 % compliance 70 60 50 40 30 20 10 0 Ayrshire & Arran Forth Valley Lanarkshire Clyde North South WoS Analysis Group Ayrshire & Arran Forth Valley Lanarkshire Clyde North South WoSCAN 10 11 12 10 11 12 10 11 12 10 11 12 10 11 12 10 11 12 10 11 12 N 34 34 48 24 15 15 43 42 44 38 52 38 47 82 87 44 25 37 230 250 269 D 36 34 51 26 15 16 45 42 44 38 52 38 47 82 87 46 25 38 238 250 274 Risk of Malignancy Index (RMI), a recognised predictor of ovarian cancer, is calculated using an algorithm based on the CA125 marker in conjunction with results of the pelvic ultrasound and menopausal status. An RMI > 200 (approximately 80% positive predictor) initiates further investigation and subsequent presentation to the regional gynaecological oncology MDT review meeting. Final Published Gynaecological Cancer MCN Audit Report v1.0 27/02/2014 10

Figure 2 illustrates the proportion of ovarian cancer patients undergoing RMI assessment. Patients where cancer was not suspected pre-operatively have not been included in the denominator detailed in the data table. The graph illustrates a decrease in the proportion of patients undergoing RMI assessment in the last year. Important to note that QPI 1, implemented on 1 st October 2013, states that 90% of patients with stage one epithelial ovarian cancer should have RMI assessed and recorded in their notes prior to definitive surgical intervention. NHS Ayrshire & Arran, NHS Forth Valley and South have all seen a decrease from 2011 to 2012 in the number of patients undergoing RMI assessment. Review of cases by NHS Ayrshire & Arran confirmed that 2 cases were incidental findings and operated on by general surgeons, which should have been excluded, and one case where MRI was carried out pre-operatively rather than ultrasound. The South case also underwent MRI scanning pre-operatively. Discussed at MDT QIS Standard 3a.3 - There is a weekly MDT meeting at which all new patients with raised RMI and imaging showing a complex mass or extra ovarian disease are reviewed and discussed. NHS QIS Standard 3a.3 specifies that all patients with raised RMI and imaging showing a complex mass or extra ovarian disease should be discussed by the MDT (within 4 weeks of referral). The data below addresses whether a patient is discussed, it does not however include information on timescales. Figure 3: Proportion of patients discussed at MDT Pre-op Post Op 100 90 80 % compliance 70 60 50 40 30 20 10 0 Ayrshire & Arran Forth Valley Lanarkshire Clyde North South WoS Analysis Group Ayrshire & Arran Forth Valley Lanarkshire Clyde North South WoS Pre- Op Post Op Pre- Op Post Op Pre- Op Post Op Pre- Op Post Op Pre- Op Post Op Pre- Op Post Op Pre- Op Post Op N 46 23 15 3 37 13 33 10 82 124 38 12 251 185 D 47 23 15 3 38 13 33 10 82 125 38 12 253 186 Final Published Gynaecological Cancer MCN Audit Report v1.0 27/02/2014 11

Effective MDT working is considered integral to provision of high-quality cancer care; facilitating a cohesive treatment planning function and ensuring treatment and care provision is individualised to patient needs. MDT working also supports many of the key requirements of good quality service delivery: adherence to evidence-based guidelines and protocols; recruitment to clinical trials; timely, appropriate and equitable access to the full range of specialist services; audit of activity and clinical practice; professional education; effective communication. Post-operative MDT review is critical to determining individual patient suitability for adjuvant treatment. The outcome of surgery and subsequent pathology is normally presented to the MDT in all cases, even where confirmed as borderline malignancy, or patient choice is to have no further treatment. Overall in WoS, the proportion of patients discussed at an MDT meeting pre and post operatively has remained fairly static from 2010 to 2012. Of all patients in WoSCAN diagnosed in 2012, 99.2% of patients were discussed pre-operatively and 99.4% were discussed post operatively. QIS Standard 5a.1 Preparation for surgery includes chest X-ray or CT scan, DVT prophylaxis and antibiotic prophylaxis. Figure 4: Pre-operative preparations 100 90 80 70 CT/Xray DVT Prophylaxis Antibiotic Prophylaxis % compliance 60 50 40 30 20 10 0 Ayrshire & Arran Forth Valley Lanarkshire Clyde North South WoS Ayrshire & Arran Forth Valley Lanarkshire Clyde North South WoSCAN CT DVT Antb iotic CT DVT Antb iotic CT DVT Antb iotic CT DVT Antb iotic CT DVT Antb iotic CT DVT Antb iotic CT DVT Antb iotic N 21 23 23 3 3 3 13 13 13 10 10 10 125 123 123 12 12 12 184 184 184 D 23 23 23 3 3 3 13 13 13 10 10 10 125 125 125 12 12 12 186 186 186 Chest X-ray or Computerised Tomography (CT) scan, Deep Vein Thrombosis (DVT) prophylaxis and antibiotic prophylaxis are core components of routine pre-operative preparation. The number of patients receiving pre-operative preparations has remained largely unchanged over the last few years. 98.9% of patients diagnosed in 2012 received a pre-operative chest x-ray/ct scan, DVT prophylaxis and antibiotic prophylaxis. Final Published Gynaecological Cancer MCN Audit Report v1.0 27/02/2014 12

Feedback from NHS Ayrshire & Arran following local case note review indicated valid clinical reasons for those patients who did not undergo a pre-operative CT scan. Review of cases in North indicated both cases were incorrectly coded and did in fact receive DVT and Antibiotic prophylaxis. QIS Standard 6c.2 - Washings are taken or ascitic fluid sent for cytology examination. Ascites or pelvic washings are analysed for evidence of tumour spread outwith the ovaries and throughout the pelvic cavity. This is a determinant in consideration for adjuvant therapy. Figure 5 indicates the proportion of patients having washings sent for cytological examination in each NHS Board from 2010 to 2012, illustrating that the number of patients having washings sent for analysis has varied over the years. It should be noted that numbers are small in some of the NHS Boards; therefore % comparisons over a single year should be viewed with caution Figure 5: Washings are taken and sent for cytological examination 100 90 80 70 2010 2011 2012 % compliance 60 50 40 30 20 10 0 Ayrshire Forth Valley Lanarkshire Clyde North South WoS Analysis Group Ayrshire & Arran Forth Valley Lanarkshire Clyde North South WoSCAN 10 11 12 10 11 12 10 11 12 10 11 12 10 11 12 10 11 12 10 11 12 N 7 7 14 6 4 0 16 11 9 13 18 9 68 99 114 9 9 12 119 148 158 D 8 9 18 10 4 1 16 11 9 16 19 10 76 103 124 9 9 12 135 155 174 NHS Ayrshire & Arran undertook a review of all cases not meeting the standard. Three cases were noted to be incidental findings and were operated on by general surgeons, therefore should have been excluded. One additional patient had incomplete surgery. NHSGGC reported that 6 advanced cases having surgery after neo-adjuvant chemotherapy did not have washings taken but this did not impact on their post-operative treatment or prognosis. Final Published Gynaecological Cancer MCN Audit Report v1.0 27/02/2014 13

QIS Standard 6c.3 - Optimal cytoreductive surgery is attempted and includes a hysterectomy and bilateral salpingo-oophorectomy. Removal of cancer is the primary objective of surgery; the intention when planning treatment is to achieve optimal cytoreduction (no macroscopic residual disease in pelvis and abdomen). On occasion however, disease may be so extensive that this is simply not achievable and not in the best interests of the patient. Figure 6: Optimal cytoreductive surgery is attempted 100 90 80 70 2010 2011 2012 % compliance 60 50 40 30 20 10 0 Ayrshire Forth Valley Lanarkshire Clyde North South WoS Analysis Group Ayrshire & Arran Forth Valley Lanarkshire Clyde North South WoSCAN 10 11 12 10 11 12 10 11 12 10 11 12 10 11 12 10 11 12 10 11 12 N 11 6 7 5 1 1 10 3 3 11 5 1 44 48 66 8 5 3 89 68 81 D 11 7 8 5 1 2 10 3 5 11 7 2 51 57 73 8 5 3 96 80 93 Figure 6 illustrates the proportion of patients who underwent optimal cytoreductive surgery in each year from 2010 to 2012. The small number of operations which take place annually within five of the six NHS Boards can result in high proportions therefore any comparison of proportions should be treated with caution. The small numbers involved for all NHS Boards other than NHSGGC can be seen in the accompanying data table to Figure 6. Feedback from Boards stated that despite radiology confirming tumour is operable it is not always possible to achieve optimal cytoreduction at surgery. Final Published Gynaecological Cancer MCN Audit Report v1.0 27/02/2014 14

QIS Standard 6c.4 - Infracolic omentectomy is performed. Figure 7: Infracolic omentectomy is performed 2010 2011 2012 100 90 80 70 % compliance 60 50 40 30 20 10 0 Ayrshire Forth Valley Lanarkshire Clyde North South WoS Analysis Group Ayrshire & Arran Forth Valley Lanarkshire Clyde North South WoSCAN 10 11 12 10 11 12 10 11 12 10 11 12 10 11 12 10 11 12 10 11 12 N 5 8 15 10 4 1 15 10 9 15 19 10 74 101 121 8 8 11 127 150 167 D 8 9 18 10 4 1 16 11 9 16 19 10 76 103 124 8 9 12 134 155 174 Figure 7 indicates that seven patients did not receive infracolic omentectomy in the WoS. One reason for this may be that infracolic omentectomy is not feasible in very advanced disease. Review of cases in NHS Ayrshire & Arran not meeting the standard again highlighted that three cases were noted to be incidental findings and were operated on by general surgeons, therefore should have been excluded from the denominator. NHSGGC reported that for three cases in North omentectomy was not possible due to very advanced disease, one case in South did not undergo omentectomy. It is important to note that QPI 4 specifies that 95% of patients undergoing surgery for early stage epithelial ovarian cancer have an adequate staging operation which includes Total Abdominal Hysterectomy (TAH), Bilateral Salpingo-Oophorectomy (BSO), omentectomy and washings. The tolerance within this target accounts for patients having fertility conserving surgery, patients with a RMI <200 and patients presenting for emergency surgery. The WoS figures from QIS Standards 6c.2, 6c.3 and 6c.4 show that this target is achievable though there is a risk that NHS Boards operating on smaller numbers are more susceptible to fluctuations in results. Final Published Gynaecological Cancer MCN Audit Report v1.0 27/02/2014 15

QIS Standard 6c.5 - A record of residual disease is made in the operation notes. Figure 8: A record of residual disease is made in the operation notes 2010 2011 2012 100 90 80 70 % compliance 60 50 40 30 20 10 0 Ayrshire Forth Valley Lanarkshire Clyde North South WoS Analysis Group Ayrshire & Arran Forth Valley Lanarkshire Clyde North South WoSCAN 10 11 12 10 11 12 10 11 12 10 11 12 10 11 12 10 11 12 10 11 12 N 25 21 23 8 7 3 19 16 13 20 22 10 77 100 125 14 10 12 163 176 186 D 27 21 23 10 7 3 20 18 13 20 22 10 84 104 125 14 10 12 175 182 186 Figure 8 illustrates that 2012 results show improvement in the recording/documentation of residual disease with the number patients having information recorded in relation to this data item rising from 93.1% in 2010 to 100% in 2012. Residual disease following surgery is a key prognostic indicator; macroscopic residual disease is indicative of a less favourable overall outcome. It is also important that this information is available to the MDT post surgery for consideration of adjuvant therapy. QPI 5 No macroscopic residual disease following surgery for advanced disease specifies that for patients with advanced epithelial ovarian cancer (FIGO Stage 2 or higher) undergoing surgery, as first definitive treatment, surgical resection should achieve no macroscopic residual disease. Thus, the focus of measurement clearly addresses the outcome of surgical resection rather than the recording of surgical information. Final Published Gynaecological Cancer MCN Audit Report v1.0 27/02/2014 16

QIS Standard 6c.8 Final FIGO surgical pathological stage is recorded in notes. Stage of disease is an important prognostic factor and knowledge of the stage distribution allows the MCN to understand implications on current and future management of patients with ovarian cancer. Furthermore, it facilitates understanding of the disease through survival analyses therefore it is important that this information is available and recorded accurately. Figure 9: Final FIGO surgical stage is recorded 100 90 80 70 2010 2011 2012 % compliance 60 50 40 30 20 10 0 Ayrshire Forth Valley Lanarkshire Clyde North South WoS Analysis Group Ayrshire & Arran Forth Valley Lanarkshire Clyde North South WoSCAN 10 11 12 10 11 12 10 11 12 10 11 12 10 11 12 10 11 12 10 11 12 N 27 21 23 9 7 3 20 18 12 20 22 10 79 99 123 14 10 11 169 177 182 D 27 21 23 10 7 3 20 18 13 20 22 10 84 104 125 14 10 12 175 182 186 Overall in WoS, the proportion of patients with final FIGO stage recorded in notes has remained fairly static from 2010 to 2012. Of all patients in WoSCAN diagnosed in 2012, 97.8% of patients had stage recorded. Only South and Lanarkshire have seen a slight decrease from the previous year s figures. QIS Standard 6c.8 shows that stage of disease for ovarian surgical patients is routinely collected. Whilst it is acknowledged that the majority of ovarian cases undergo surgical treatment, stage should also be recorded for patients who do not. Data shows that stage was not recorded for any non surgical patients. The availability of staging data is critical for accurate measurement of the new national OPIs. Final Published Gynaecological Cancer MCN Audit Report v1.0 27/02/2014 17

Figure 10: Distribution of Final FIGO stage for ovarian cancer patients undergoing surgery. NR, 2.7% Inapplicable, 1.6% Early Stage, 31.2% Advanced Stage, 64.5% Figure 10 illustrates that 65.4% of patients undergoing surgery for ovarian cancer had advanced disease. These results are consistent with previous year s figures. QIS Standard 8a.3 Histological type, sub-type (where appropriate) and grade of disease are recorded. Figure 11: Histological type, sub-type (where appropriate) and grade of disease are recorded 100 90 80 70 2010 2011 2012 % compliance 60 50 40 30 20 10 0 Ayrshire Forth Valley Lanarkshire Clyde North South WoS Analysis Group Final Published Gynaecological Cancer MCN Audit Report v1.0 27/02/2014 18

Ayrshire & Arran Forth Valley Lanarkshire Clyde North South WoSCAN 10 11 12 10 11 12 10 11 12 10 11 12 10 11 12 10 11 12 10 11 12 N 25 21 22 9 6 3 20 18 13 20 22 10 83 103 122 14 10 12 171 180 182 D 27 21 23 10 7 3 20 18 13 20 22 10 84 104 125 14 10 12 175 182 186 A complete histopathology report of the surgical resection is necessary in order to establish what options are appropriate for further treatment modalities. As seen in Figure 11 four cases (one in NHS Ayrshire & Arran and three in North ) did not have a complete histopathological report recorded. QPI 6 specifies that 90% of patients should have a complete histopathology report to support clinical decision making. The 10% tolerance within this target reflects situations where it is not possible to report all components of the data set due to poor quality of surgical specimens. Final Published Gynaecological Cancer MCN Audit Report v1.0 27/02/2014 19

Endometrial Cancer A total of 314 endometrial cancers were diagnosed in the WoS between 1 st December 2012. January and 31 st KOM 1: Discussion by the MDT All cases should be discussed at the MDT meeting in order that consideration can be given to the appropriate application of all available treatment modalities. (Grade 1 cases are not routinely discussed at pre-op MDT) Figure 12: Proportion of patients discussed at MDT 100 90 80 70 2010 2011 2012 % compliance 60 50 40 30 20 10 0 Ayrshire Forth Valley Lanarkshire Clyde North South WoS Analysis Group Ayrshire & Arran Forth Valley Lanarkshire Clyde North South WoSCAN 10 11 12 10 11 12 10 11 12 10 11 12 10 11 12 10 11 12 10 11 12 N 62 52 71 34 36 30 64 64 53 46 47 55 55 58 60 39 56 41 300 313 310 D 62 52 71 34 36 31 64 64 53 47 47 55 56 58 60 39 56 41 302 313 311 MDT review is important in ensuring that all patients are considered for adjuvant therapy, where appropriate. This forum also provides the route to specialist surgical intervention for those women requiring lymph node sampling. Overall in the WoS the proportion of patients discussed at MDT has remained fairly static from 2010 to 2012. Of all patients in WoSCAN diagnosed in 2012, 99.7% were discussed. Figure 12 indicates that only one patient was not discussed by the MDT in 2012. Feedback from Forth Valley stated that they will continue to highlight the importance of discussing patients at MDT. Final Published Gynaecological Cancer MCN Audit Report v1.0 27/02/2014 20

KOM 2: Patients should have peritoneal washings sent for analysis. Figure 13: Proportion of peritoneal washings sent for analysis 2010 2011 2012 100 90 80 70 % compliance 60 50 40 30 20 10 0 Ayrshire Forth Valley Lanarkshire Clyde North South WoS Analysis Group Ayrshire & Arran Forth Valley Lanarkshire Clyde North South WoSCAN 10 11 12 10 11 12 10 11 12 10 11 12 10 11 12 10 11 12 10 11 12 N 39 34 39 27 29 20 46 38 43 37 31 39 74 98 86 27 30 27 250 260 254 D 40 35 43 27 31 20 47 42 43 38 34 40 78 99 86 28 33 27 258 274 259 Peritoneal washings are analysed for evidence of tumour spread. This is a determinant in consideration of adjuvant therapy. Figure 13 illustrates that all Boards in the WoS are routinely sending peritoneal washings for analysis. With regards to the 4 cases in NHS Ayrshire & Arran valid clinical reasons were given for the samples which were not sent. Final Published Gynaecological Cancer MCN Audit Report v1.0 27/02/2014 21

KOM 3: Patients should have surgical management completed by minimal access (laparoscopic) techniques. Figure 14: Proportion of patients undergoing laparoscopic surgery 2010 2011 2012 50 40 % compliance 30 20 10 0 Ayrshire Forth Valley Lanarkshire Clyde North South WoS Location of Surgery Ayrshire & Arran Forth Valley Lanarkshire Clyde North South WoSCAN 10 11 12 10 11 12 10 11 12 10 11 12 10 11 12 10 11 12 10 11 12 N 11 9 9 0 10 11 9 11 14 2 0 7 6 20 16 0 1 1 28 51 58 D 39 35 42 24 29 20 46 42 42 38 34 39 76 98 85 27 33 27 250 271 255 Laparoscopic assisted vaginal hysterectomy (LAVH) is less invasive facilitating a shorter hospital stay, reduction in wound infections and other complications and better overall patient experience. Laparoscopic surgery is a developing area of clinical practice and variation in the use of LAVH across the region reflects both training and local resource availability. Figure 14 indicates that laparoscopic surgery is available in all units and that that the numbers of patients being operated on laparoscopically in the WoS is increasing year on year from 11.2% in 2010 to 22.7% in 2012. Final Published Gynaecological Cancer MCN Audit Report v1.0 27/02/2014 22

KOM 4: Type 2 cases should have lymphadenectomy in order to determine appropriate adjuvant therapies. In accordance with recognised best practice all WoS patients requiring lymphadenectomies undergo surgery at the specialist centre, as illustrated in Figure 15. Figure 15: Proportion of Type 2 cases undergoing lymphadenectomy in specialist centre (NG) 90 80 70 60 % compliance 50 40 30 20 10 0 2010 2011 2012 Year of Surgery All clear cell, serous papillary and carcinosarcoma cases should receive staging lymphadenectomy where appropriate to determine suitability of future treatment options. Patients with negative nodes are not routinely offered external beam pelvic radiotherapy. A total of 35 clear cell, serous papillary and carcinosarcoma patients were referred to the specialist centre in 2012 for lymphadenectomy. 26 of these underwent lymphadenectomy whereas in 9 cases it was felt to be inappropriate due to peritoneal and omental disease being present (advanced stage disease). Final Published Gynaecological Cancer MCN Audit Report v1.0 27/02/2014 23

Cervical Cancer A total of 174 cervical cancers were diagnosed in the WoS between 1 st January and 31 st December 2012. Cervical cancer data has been analysed to enable a baseline of activity to be established and to help inform the development of future QPIs. 1: All patients should be discussed by the MDT. Figure 16: Proportion of patients discussed at MDT 100 90 80 70 2010 2011 2012 % compliance 60 50 40 30 20 10 0 Ayrshire Forth Valley Lanarkshire Clyde North South WoS Analysis Group Ayrshire & Arran Forth Valley Lanarkshire Clyde North South WoSCAN 10 11 12 10 11 12 10 11 12 10 11 12 10 11 12 10 11 12 10 11 12 N 25 24 21 21 12 18 42 28 39 22 18 21 37 34 48 22 13 22 169 129 169 D 26 24 21 21 13 18 42 28 39 22 19 21 37 34 48 22 13 22 170 131 169 As noted earlier MDT working is considered integral to provision of high quality cancer care. Figure 16 illustrates the proportion of patients discussed at MDT in each year from 2010 to 2012. It is clear that all NHS Boards are meeting this target. Final Published Gynaecological Cancer MCN Audit Report v1.0 27/02/2014 24

2: Mode of First Treatment Figure 17: Mode of First Treatment Supportive Care, 4% Patient Refused, 1.1% Patient Died, 2.3% Chemoradiotherapy 33.9% Surgery, 46% Chemotherapy, 5.7% Radiotherapy, 5.7% Figure 17 shows the distribution of treatment performed for cervical cancers. The most common treatment types were surgery (46.0%) and chemoradiotherapy (33.9%). Final Published Gynaecological Cancer MCN Audit Report v1.0 27/02/2014 25

Conclusions The results presented in this report demonstrate the continued support and commitment of Network members to deliver a high quality service to gynaecological patients across the WoS. Cancer audit data underpins much of the regional development and service improvement work of the MCN and regular reporting of activity and performance is a fundamental requirement of an MCN to assure the quality of care delivered across the region. It has been an aim of the Gynaecological Cancer MCN to improve quality and completeness of clinical audit data to ensure that robust performance assessment can take place. Improvements have been observed in recent years and in several areas significant improvements have led to meaningful and useful data available to the MCN. Progress made in recent years is welcomed and it is also recognised that we must build on these achievements and continue to improve the quality of gynaecological service provided in the West of Scotland. National clinical QPIs for ovarian cancers, which are evidence based, outcome focussed and measurable have now been implemented. QPIs for endometrial and cervical cancers are due to be implemented in October 2014. The intention of these indicators is to enable continuous improvement and drive service change, where appropriate, by focussing on areas of key clinical importance which actually make a difference to patient outcome and experience. The audit dataset has been aligned directly to the measurement of the QPIs, resulting in more focussed data collection. The MCN will actively take forward regional actions identified and NHS Boards are asked to develop local Action/Improvement Plans in response to the findings presented in the report. A summary of actions for each NHS Board has been included within the Action Plan templates in Appendix 1. 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 Advisory Board and reported to RCAG annually by Board Lead Cancer Clinicians and MCN Clinical Leads, as part of the regional governance process to enable RCAG to review and monitor regional improvement. Final Published Gynaecological Cancer MCN Audit Report v1.0 27/02/2014 26

Acknowledgement This report has been prepared using clinical audit data provided by the following NHS Boards in the WoSCAN area: NHS Ayrshire & Arran NHS Forth Valley NHS Greater and Clyde NHS Lanarkshire We would like to thank all members and active participants in the cancer network for their continued support of the MCN, and the many hospitals that are committed to making the audit succeed. We also acknowledge the efforts of the clinical effectiveness staff, nurses, and other service users for their work in ensuring the data are available to enable analysis to take place each year. Without their considerable efforts this level of progress would not be possible. Final Published Gynaecological Cancer MCN Audit Report v1.0 27/02/2014 27

Abbreviations BWoSCC CT DGHs DVT ecase FIGO GRI HPV KOM LEEP LAVH MCN MDT QIS QPI RMI RCAG WoS WoSCAN Beatson West of Scotland Cancer Centre Computerised Tomography District General Hospitals Deep Vein Thrombosis Electronic Cancer Audit Support Environment Federation of Gynacological Oncologists Royal Infirmary Human Papilloma Virus Key Outcome Measures Loop Electrosurgical Excision Procedure Laparoscopic assisted vaginal hysterectomy Managed Clinical Network Multi-disciplinary Team Quality Improvement Scotland Quality Performance Indicator Risk of Malignancy Index Regional Cancer Advisory Group West of Scotland Final Published Gynaecological Cancer MCN Audit Report v1.0 27/02/2014 28

References 1. http://www.isdscotland.org/health-topics/cancer/cancer-statistics/female-genital-organ/ (accessed on 07/02/14) 2. http://www.isdscotland.org/health-topics/cancer/publications/2012-04-24/2012-04-24-cancer- Incidence-report.pdf (accessed on 07/02/14) 3. http://www.isdscotland.org/health-topics/cancer/cervical-screening/ (accessed on 07/02/14) 4. http://www.isdscotland.org/health-topics/child-health/publications/2012-09-25/2012-09-25- HPV-Uptake-Report.pdf (accessed on 07/02/14) 5. http://www.nice.org.uk/nicemedia/live/13464/54194/54194.pdf (accessed on 18/02/14) Final Published Gynaecological Cancer MCN Audit Report v1.0 27/02/2014 29

Appendix 1: NHS Board Action Plans A summary of actions for each NHS Board has been included within the Action Plan templates in Appendix 1. Completed Action Plans should be returned to WoSCAN within two months of publication of this report. Action / Improvement Plan Health Board: NHS Ayrshire & Arran KEY (Status) Action Plan Lead: 1 Action fully implemented Date: 2 Action agreed but not yet implemented 3 No action taken (please state reason) No Action Required Health Board Action Taken Timescales Lead Progress/Action Status Status Start End (see key) Action Detail specific actions that will be taken by the NHS Board. Insert date Insert date 1. NHS Boards should take steps to ensure that staging data is complete for all patients diagnosed with gynaecological cancer, not only those patients undergoing surgical treatment. Insert name of responsible lead for each specific action. Provide detail of action in progress, change in practices, problems encountered or reasons why no action taken. Insert No. from key above Final Published Gynaecological Cancer MCN Audit Report v1.0 27/02/2014 30

Action / Improvement Plan Health Board: NHS Forth Valley KEY (Status) Action Plan Lead: 1 Action fully implemented Date: 2 Action agreed but not yet implemented 3 No action taken (please state reason) No Action Required Health Board Action Taken Timescales Lead Progress/Action Status Status Start End (see key) Action Detail specific actions that will be taken by the NHS Board. Insert date Insert date 1. NHS Boards should take steps to ensure that staging data is complete for all patients diagnosed with gynaecological cancer, not only those patients undergoing surgical treatment. Insert name of responsible lead for each specific action. Provide detail of action in progress, change in practices, problems encountered or reasons why no action taken. Insert No. from key above Final Published Gynaecological Cancer MCN Audit Report v1.0 27/02/2014 31

Action / Improvement Plan Health Board: NHS Greater and Clyde (Clyde) KEY (Status) Action Plan Lead: 1 Action fully implemented Date: 2 Action agreed but not yet implemented 3 No action taken (please state reason) No Action Required Health Board Action Taken Timescales Lead Progress/Action Status Status Start End (see key) Action Detail specific actions that will be taken by the NHS Board. Insert date Insert date 1. NHS Boards should take steps to ensure that staging data is complete for all patients diagnosed with gynaecological cancer, not only those patients undergoing surgical treatment. Insert name of responsible lead for each specific action. Provide detail of action in progress, change in practices, problems encountered or reasons why no action taken. Insert No. from key above Final Published Gynaecological Cancer MCN Audit Report v1.0 27/02/2014 32

Action / Improvement Plan Health Board: NHS Greater and Clyde (Greater ) KEY (Status) Action Plan Lead: 1 Action fully implemented Date: 2 Action agreed but not yet implemented 3 No action taken (please state reason) No Action Required Health Board Action Taken Timescales Lead Progress/Action Status Status Start End (see key) Action Detail specific actions that will be taken by the NHS Board. Insert date Insert date 1. NHS Boards should take steps to ensure that staging data is complete for all patients diagnosed with gynaecological cancer, not only those patients undergoing surgical treatment. Insert name of responsible lead for each specific action. Provide detail of action in progress, change in practices, problems encountered or reasons why no action taken. Insert No. from key above Final Published Gynaecological Cancer MCN Audit Report v1.0 27/02/2014 33