Gynaecological Cancer Managed Clinical Network Audit Report Ovarian Cancer Quality Performance Indicators Cervical Cancer Quality Performance Indicators Endometrial Cancer Quality Performance Indicators Clinical Audit Data: 01 October 15 to 30 September 16 Kevin Burton Consultant Gynaecological Oncologist MCN Clinical Lead Kevin Campbell MCN Manager Julie McMahon Information Officer
CONTENTS EXECUTIVE SUMMARY 3 1. INTRODUCTION 11 2. BACKGROUND 11 3. METHODOLOGY 12 4. RESULTS AND ACTION REQUIRED 13 4.1 PERFORMANCE AGAINST QUALITY PERFORMANCE INDICATORS (QPIS) 13 4.2. OVARIAN CANCER QUALITY PERFORMANCE INDICATORS 14 4.3. ENDOMETRIAL CANCER QUALITY PERFORMANCE INDICATORS 35 4.4. CERVICAL CANCER QUALITY PERFORMANCE INDICATORS 45 5. CONCLUSIONS 54 ACKNOWLEDGEMENT 56 ABBREVIATIONS 57 REFERENCES 58 APPENDIX 1: ACTION / IMPROVEMENT PLANS 59 2
Executive Summary Introduction This report contains an assessment of the performance of West of Scotland (WoS) gynaecology cancer services using clinical audit data relating to patients diagnosed between 1 October 15 and 30 September 16. Data analysed and included within this report relate to ovarian, cervical and endometrial cancers. 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. Results are measured against the Ovarian, Endometrial and Cervical Cancer Quality Performance Indicators (QPIs). 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 14. In collaboration with the three Regional Cancer Networks and Information Services Division (ISD) the Ovarian Cancer QPIs were published by Healthcare Improvement Scotland (HIS) in August 13 1 and Endometrial and Cervical Cancer QPIs were published in October 14 1. Data definitions and measurability criteria to accompany cancer QPIs are available from the ISD website 2. Twelve months of data were measured against the Ovarian Cancer QPIs for the third consecutive year, and previous years results are presented within this audit report for QPIs where results have remained comparable. For endometrial and cervical cancer this is the second year of reporting QPI data, Year 1 and Year 2 results are therefore presented within this audit report. Future reports will continue to compare clinical audit data in successive years to further illustrate trend analysis. Background The effective management of these patients relies on well co-ordinated delivery of treatment and care, requiring close collaboration of professionals from a range of specialties. Treatment and care for gynaecological cancer patients is delivered by a single regional multi-disciplinary team (MDT).This is facilitated by video-conferencing technology and a bespoke IT system, which is operationally dependant on close collaboration of professionals from a range of clinical specialities across the region to provide well planned and coordinated delivery of treatment and care. Complex gynaecological malignancy often requires a multi-modality approach and surgery remains a key component of effective curative management. 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 endometrial and cervical patients diagnosed between 1 October 15 and 30 September 16 was downloaded from ecase on 12 April 17 with data for ovarian patients downloaded on the 28 th June 17. 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. 3
Results 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. The following summary of results shows the WoS and individual units percentage performance against each QPI target. 4
Ovarian Performance Summary Report Ovarian Cancer Performance by Board QPI Target WoS A&A FV LS NG SG Clyde *QPI 1: Risk of Malignancy Index recorded in the patients notes. Proportion of patients with Stage 1 epithelial ovarian cancer having RMI assessed and recorded in their notes prior to any definitive surgical intervention. QPI 2 - Extent of disease assessed by Computed Tomography (CT) or Magnetic Resonance Imaging (MRI) prior to treatment. Proportion of patients with epithelial ovarian cancer having a CT scan or MRI of the abdomen and pelvis performed to exclude the presence of metastatic disease prior to starting definitive treatment. QPI 3 - Treatment planned and reviewed at a multidisciplinary team meeting. Proportion of patients with epithelial ovarian cancer who are discussed at a MDT meeting before definitive treatment. *QPI 4.1 - Patients with early stage disease have an adequate staging operation. Proportion of patients with early stage epithelial ovarian cancer (FIGO Stage 1) undergoing primary surgery for ovarian cancer, having their stage of disease adequately assessed, (TAH, BSO, Omentectomy and washings), to determine suitability for adjuvant therapies. QPI 4.2 - Patients with early stage disease have an adequate staging operation. Proportion of patients with early stage epithelial ovarian cancer (FIGO Stage 1) undergoing primary surgery for ovarian cancer operated on by a specialist gynaecological oncologist., having their stage of disease adequately assessed, (TAH, BSO, Omentectomy and washings), to determine suitability for adjuvant therapies. - Data not shown due to small numbers 90% 48.1% 0.0% - 50.0% 80.0% 60.0% - 13 27 0 7 - - 3 6 4 5 3 5 - - 90% 97.8% 100% 100% 93.8% 97.8% 100% 96.4% = = = 224 229 41 41 24 24 45 48 45 46 42 42 27 28 95% 92.6% 97.6% 100% 91.8% 88.9% 90.0% 90.0% 212 229 41 24 24 45 49 45 36 27 30 95% 78.6% 83.3% n/a 60.0% = 87.5% - - 33 42 5 6 0 0 3 5 21 24 - - - - 95% 87.5% n/a n/a n/a 87.5% n/a n/a 21 24 0 0 0 0 0 0 21 24 0 0 0 0
Ovarian Cancer QPI Target WoS A&A FV LS NG SG Clyde *QPI 5.1 - No macroscopic residual disease following surgery for advanced disease. Proportion of patients with advanced epithelial ovarian cancer (FIGO Stage 2 or higher) who have no macroscopic residual disease following surgery. *QPI 5.2 - No macroscopic residual disease following surgery for advanced disease. Proportion of patients with advanced epithelial ovarian cancer (FIGO Stage 2 or higher) who have 1cm residual disease following surgery. *QPI 6 Histopathology reports are complete and support clinical decision making. Proportion of patients with epithelial ovarian cancer undergoing pelvic clearance having a complete pathology report as defined by the Royal College of Pathologists. *QPI 7.1 Histo/cytological diagnosis prior to starting neo-adjuvant chemotherapy. Proportion of patients with epithelial ovarian cancer having a histo/cytological diagnosis prior to starting neo-adjuvant chemotherapy. *QPI 7.2 Histo/cytological diagnosis prior to starting neo-adjuvant chemotherapy. Proportion of patients with epithelial ovarian cancer having a histo/cytological diagnosis prior to starting neo-adjuvant chemotherapy and the proportion of these with histological confirmation obtained by percutaneous image-guided biopsy or laparoscopy. *QPI 8.1 - Delayed primary surgery Proportion of patients with advanced epithelial ovarian cancer (FIGO Stage 3c, 4a or 4b) having delayed primary surgery following neo-adjuvant chemotherapy. 30% 62.3% - n/a - 60.0% - - 33 53 - - 0 0 - - 27 45 - - - - 60% 71.7% - n/a - 71.1% - - 38 53 - - 0 0 - - 32 45 - - - - 90% 65.0% 100% n/a 100% 62.2% - 33.3% = 76 117 6 6 0 0 5 5 61 98 - - 2 6 100% 100% 100% 100% 100% 100% = = = = = 100% 100% = = 58 58 11 11 11 11 11 11 12 12 7 7 6 6 80% 91.9% 85.7% 100% 91.7% 91.7% 85.7% 100% 57 62 12 14 11 11 11 12 11 12 6 7 6 6 75% 81.6% 75.0% 77.8% 72.7% 80.0% 100% 100% = 49 6 8 7 9 8 11 8 10 6 6 5 5 - Data not shown due to small numbers 6
QPI Target WoS A&A FV LS NG SG Clyde *QPI 8.2- Delayed primary surgery Proportion of patients with advanced epithelial ovarian cancer (FIGO Stage 3c, 4a or 4b) having delayed primary surgery following neo-adjuvant chemotherapy and where optimal cytoreduction is achieved. QPI 9: First-line Chemotherapy Proportion of epithelial ovarian cancer patients who receive platinum-based chemotherapy, either in combination or as a single agent. 65% 72.5% 50.0% 71.4% 87.5% 62.5% 66.7% 100% = 29 3 6 5 7 7 8 5 8 4 6 5 5 90% 85.0% 83.3% 90.9% 81.0% 81.6% 87.8% 88.9% 175 6 30 36 22 34 42 31 38 36 41 24 27 *Small numbers in some Boards - percentage comparisons over a single year should be viewed with caution. QPI Target WoS A&A FV LS GGC Clinical Trials Access Proportion of patients with ovarian cancer who are enrolled in an interventional clinical trial. 7.5% 16.4%.0% 9.5% 25.0% 7.5% 33 1 7 35 2 21 10 8 106 Clinical Trials Access Proportion of patients with ovarian cancer who are enrolled in translational research. 15% 5.0% 0.0% 0.0% 12.5% 4.7% 10 1 0 35 0 21 5 8 106 The denominator for Clinical Trials Access QPI uses 5-year cancer registry average (11 15). Analysis also uses board of residence 7
Endometrial Performance Summary Report QPI Target WoS A&A FV Lan QPI 1 - Radiological Staging. Patients with endometrial cancer should have their stage of disease assessed by magnetic resonance imaging (MRI) and/or computed tomography (CT) prior to first treatment. 90% 91.2% 76.9% 96.2% 87.0% North 97.4% South 96.6% Clyde 93.1% 177 194 26 25 26 46 37 38 28 29 27 29 QPI 2 - Multidisciplinary Team Meeting (MDT). Patients with endometrial cancer should be discussed by a multidisciplinary team (MDT) prior to definitive treatment. 95% 90.6% 65.4% 92.3% 93.5% 97.4% 92.9% 96.4% = 174 192 17 26 24 26 43 46 37 38 26 28 27 28 QPI 3 - Total Hysterectomy and Bilateral Salpingo- Oophorectomy. Patients with endometrial cancer should undergo total hysterectomy (TH) and bilateral salpingo-oophorectomy (BSO). 80% 88.7% 91.0% 83.7% 92.9% 90.6% 75.6% 93.2% 282 318 61 67 36 43 65 70 48 53 31 41 41 44 QPI 4 - Laparoscopic Surgery (Hosp. of Surgery) Patients with endometrial cancer undergoing definitive surgery should undergo laparoscopic surgery, where clinically appropriate. 70% 58.1% 70.2% 86.1% 92.6%.0% 29.2% = 25.7% 175 301 57 31 36 50 54 38 95 7 24 9 35 *QPI 5 - Adjuvant Vaginal Brachytherapy. Patients with intermediate risk (stage IB, grade 1 or 2; or stage IA, grade 3 endometrioid or mucinous) endometrial cancer should be considered for adjuvant vaginal brachytherapy. 90% 77.2% 66.7% 57.1% 76.9% 88.9% = - 91.7% 44 57 10 15 4 7 10 13 8 9 - - 11 12 *QPI 6 Chemotherapy. Patients with stage IV endometrial cancer should have chemotherapy. 75% 69.6% - 100% 50.0% = 60.0% - - 16 23 - - 5 5 3 6 3 5 - - - - - Data not shown due to small numbers 8
Cervical Performance Summary Report Cervical Cancer Performance by Board QPI Target WoS A&A FV Lan NG SG Clyde QPI 1 - Radiological Staging. Patients with cervical cancer should have their stage of disease assessed by magnetic resonance imaging (MRI) prior to first treatment. QPI 2 - Positron Emission Tomography/Computed Tomography (PET/CT). Patients with cervical cancer, for whom primary definitive surgery is not appropriate, should undergo positron emission tomography - computed tomography imaging (PET/CT). QPI 3 - Multidisciplinary Team Meeting (MDT). Patients with cervical cancer should be discussed by a multidisciplinary team (MDT) prior to definitive treatment. 95% 94.1% 100% 93.3% 88.5% 95.5% 90.9% 100% 95 101 16 16 14 15 23 26 21 22 10 11 11 11 95% 95.8% 100% 100% 100% 83.3% - 85.7% 46 48 8 8 9 9 15 15 5 6 - - 6 7 95% 97.1% 100% 100% 96.6% 95.2% 90.9% 100% = = = 101 104 15 15 17 17 28 29 21 10 11 11 11 *QPI 4 - Radical Hysterectomy. Patients with stage IB1 cervical cancer should undergo radical hysterectomy. *QPI 5 - Surgical Margins. (Hosp. of Surgery) Patients with surgically treated cervical cancer should have clear resection margins. *QPI 6-56 Day Treatment Time for Radical Radiotherapy. Treatment time for patients with cervical cancer undergoing radical radiotherapy should be no more that 56 days. *QPI 7 Chemoradiation. Patients with cervical cancer undergoing radical radiotherapy should receive concurrent platinum-based chemotherapy. - Data not shown due to small numbers 85% 66.7% 100% = - 62.5% 50.0% - - 18 27 5 5 - - 5 8 3 6 - - - - 95% 97.5% - - - 100% - - 39 - - - - - - 30 30 - - - - 90% 98.2% 100% 100% 100% 100% - 100% = = = = 56 57 9 9 11 11 17 17 8 8 - - 8 8 70% 86.4% 100% 81.8% 83.3% 75.0% - 87.5% = 51 59 10 10 9 11 15 18 6 8 - - 7 8 9
Conclusions and Action Required Cancer audit has underpinned much of the regional development and service improvement work of the MCN and the regular reporting of activity and performance have been fundamental in assuring the quality of care delivered across the region. Following the development of QPIs, this has now become an established national programme to drive continuous improvement and ensure equity of care for patients across Scotland. West of Scotland Boards continued commitment to the improvement of the quality and completeness of audit data has supported the National Cancer Quality Programme in the formative years, and will be required throughout the formal review process with the addition of new QPIs. This commitment from Boards has provided accurate data for the reporting of performance against the Gynaecological Cancer QPIs from which yearly comparisons in service provision across WoS Boards can be made. The results presented within this report illustrate that some of the QPI targets set have been challenging for NHS Boards to achieve and there remains room for further service improvement. It is however encouraging that ovarian QPI targets relating to CT or MRI prior to treatment, and histological/cytological diagnosis prior to starting neo-adjuvant chemotherapy were all consistently achieved. In cervical cancer, 56 day treatment time for radical radiotherapy and chemoradiation treatment were achieved across the WoS. Where QPI targets were not met NHS Boards have provided detailed commentary. In the main these indicate valid clinical reasons or that, in some cases, patient choice or co-morbidities have influenced patient management. 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 the Appendix. Actions: Ovarian Cancer: QPI 3 Multidisciplinary Team Meeting NHSGGC to review current processes to ensure that those patients requiring discussion are presented timeously to the regional MDT. This will be further reinforced through the regional MDT review work currently being undertaken by the MCN. QPI 5 No macroscopic residual disease following surgery for advanced disease Whilst the target for this QPI measure is being met there is a recognition that further improvement is desirable. To achieve this will require increased joint surgical team working with colleagues from other specialities. Endometrial cancer: QPI 3: Total Hysterectomy and Bilateral Salpingo-Oophorectomy & QPI 4: Laparoscopic Surgery Smaller surgical teams are to be developed to manage endometrial cancers. This will improve consistency of assessment and provision of surgical techniques to address the potential for variation in approach. 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.
1. Introduction This report contains an assessment of the performance of West of Scotland (WoS) gynaecology cancer services using clinical audit data relating to patients diagnosed between 1 October 15 and 30 September 16. Data analysed and included within this report relate to ovarian, cervical and endometrial cancers. 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. Results are measured against the Ovarian, Endometrial and Cervical Cancer Quality Performance Indicators (QPIs). 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 14. In collaboration with the three Regional Cancer Networks and Information Services Division (ISD) the Ovarian Cancer QPIs were published by Healthcare Improvement Scotland (HIS) in August 13 1 and Endometrial and Cervical Cancer QPIs were published in October 14 1. Data definitions and measurability criteria to accompany cancer QPIs are available from the ISD website 2. Twelve months of data were measured against the Ovarian Cancer QPIs for the third consecutive year, and previous years' results are presented within this audit report for QPIs where results have remained comparable. For endometrial and cervical cancer this is the second year of reporting QPI data, Year 1 and Year 2 results are therefore presented within this audit report. Future reports will continue to compare clinical audit data in successive years to further illustrate trend analysis. In order to ensure the success of the National Cancer QPIs in driving quality improvement in cancer care across NHS Scotland, a process of formal review of ovarian cancer QPIs was carried out after Year 3 of comparative reporting with tumour-specific Regional Clinical Leads undertaking a key role in determining the extent of the review required for each tumour type. The revised Ovarian Cancer QPIs 1 are due to be published in 18. 2. Background The effective management of these patients relies on well co-ordinated delivery of treatment and care, requiring close collaboration of professionals from a range of specialties. Treatment and care for gynaecological cancer patients is delivered by a single regional multi-disciplinary team (MDT).This is facilitated by video-conferencing technology and a bespoke IT system, which is operationally dependant on close collaboration of professionals from a range of clinical specialities across the region to provide well planned and coordinated delivery of treatment and care. Complex gynaecological malignancy often requires a multi-modality approach and surgery remains a key component of effective curative management. 2.1. National Context Endometrial cancer is the most common gynaecological cancer and the fourth most common cancer in women in Scotland with approximately 760 new cases diagnosed annually. The incidence of endometrial cancer has risen significantly by 32% over the last ten years 3. This undoubtedly reflects increasing levels of obesity 4 and also an increasingly ageing population. Recently published data highlights that the number of new cases of endometrial cancer is predicted to increase by 55% between 08-12 and 23-27 5. One-year and 5-year relative survival rates for endometrial cancer for females diagnosed between 07 and 11 are 92.9% and 83.2% respectively 3. Endometrial cancer is the 10 th most common death in females from cancer in Scotland with overall mortality rates increasing by 67.5% from 05 to 15 4. Cervical cancer is noted as being the tenth most common cancer in women with approximately 380 cases diagnosed each year 3. The incidence of cervical cancer has increased by 22% over the last ten 11
years 3. Overall mortality rates have decreased by 14% over the past 10 years from 05 to 15 and 1-year and 5-year relative survival is noted as being 87.5% and 73% respectively 3. Recently published figures indicate that the number of new cases of cervical cancer is predicted to increase by 39.6% between 08-12 and 23-27 5. Many cervical cancers are detected early due to the well established screening programme introduced in 1988. 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 08 and aims to protect females by routinely immunising them at 12-13 years of age, through a school based 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. Ovarian cancer is the sixth most commonly diagnosed malignancy in Scottish women with a relative frequency of around 3.5% of all female cancers 3. There has been an overall decrease in the incidence of ovarian cancer in the past ten years of 13%. Latest ISD figures show a fall in mortality in ovarian cancer patients of 14.2% over the last 10 year period, with corresponding improvements in 5 year survival; approximately 46% of patients are now surviving at least five years after diagnosis, compared to around 31% of those diagnosed between 1983-1987 3. 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 with endometrial or cervical cancer between 1 October 15 and 30 September 16 was downloaded from ecase at 20 hrs on 12 April 17. Data for ovarian patients was downloaded at 20 hrs on the 28 th June. 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 WoSCAN Information Team and the timescales agreed took into account the patient pathway to ensure that a complete treatment record was available for each case. Initial results of the analysis were provided to local Boards to check for inaccuracies, inconsistencies or obvious gaps and a subsequent download taken upon which final analysis was carried out. The final data analysis was disseminated for NHS Board verification in line with the regional audit governance process to ensure that the data was an accurate representation of service in each area. 12
4. Results and Action Required 4.1 Performance against Quality Performance Indicators (QPIs) Results of the analysis of ovarian cancer QPIs are set out in the following section with results of analysis for endometrial and cervical QPIs in subsequent sections. Graphs and charts have been provided where this aids interpretation and, where appropriate, numbers have also been included to provide context. Where possible, results for patients diagnosed in previous years have been presented alongside the previous years results to illustrate trends. Data (both graphically and in tabular format) are presented by location of diagnosis or treatment, with some criteria given as an overall WoS representation. Specific regional and 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. 13
Number of Cases 4.2. Ovarian Cancer Quality Performance Indicators Introduction Quality Performance Indicators (QPIs) were implemented for patients diagnosed with ovarian cancer on or after 1 st October 13 and Ovarian Cancer QPIs 1 are reported here for the third consecutive year. There were 236 new diagnoses of ovarian cancer captured by audit in the WoS in Year 3. Distribution by location of diagnosis is shown below in Figure 1. Figure 1: Number of patients diagnosed with ovarian cancer by location of diagnosis 1 13/14 14/15 15/16 100 80 60 0 Ayrshire & Arran Forth Valley Lanarkshire GGC Location of Diagnosis AA FV Lan GGC WoS Year 1_13/14 35 24 29 116 4 Year 2_14/15 45 56 114 235 Year 3_15/16 41 25 50 1 236 14
Performance (%) QPI 1 - Risk of Malignancy Index recorded in the patient notes Risk of Malignancy Index (RMI) score is derived from a measure of serum CA125, ultrasound imaging and menopausal status and is used to inform the MDT decision regarding the need for specialist surgical intervention. A score greater than or equal to 0 should initiate computed tomography (CT) scan of the pelvis and abdomen and referral to the specialist gynaecological oncology MDT for decision on treatment plan 1. QPI 1 states that 90% of patients with FIGO stage 1 epithelial ovarian cancer undergoing definitive surgical intervention should have RMI assessed and recorded in their notes prior to any definitive surgical intervention. The tolerance within this represents the small number of patients diagnosed by post-operative histology. QPI Title: Numerator: Patients with stage 1 epithelial ovarian cancer should have RMI assessed and recorded in their notes prior to any definitive surgical intervention. Number of patients with FIGO Stage 1 epithelial ovarian cancer having RMI score recorded in their notes prior to any definitive surgical intervention. Denominator: All patients with FIGO Stage 1 epithelial ovarian cancer undergoing definitive surgical intervention. Exclusions: Patients presenting to surgery as an emergency. Patients who do not undergo ultrasound. Target: 90% Due to the small numbers meeting the denominator criteria in each year of analysis individual year results cannot be presented therefore Figure 2 shows aggregated three year results. Figure 2: Proportion of patients with Stage 1 epithelial ovarian cancer having RMI assessed and recorded in their notes prior to any definitive surgical intervention (aggregated 3 year result) 100 90 80 70 13/16 60 50 30 10 0 Ayrshire & Arran Forth Valley Lanarkshire North South Clyde Wos Location of Diagnosis 15
Aggregated 3 year results (13-16) QPI 1 Performance (%) Numerator Denominator numerator exclusions denominator Past % Performance 13/14 14/15 15/16 AA 4.5% 1 22 0 0 3 0.0% 11.1% 0.0% FV 100.0% 8 8 0 0 0 100% - - Lan 50.0% 7 14 0 0 0-33.3% 50.0% NG.0% 12 30 0 0 2 37.5% 22.2% 80.0% SG 33.3% 3 9 0 0 0 - - 60.0% Clyde.0% 3 15 0 0 1 12.5% - - WoS 34.7% 34 98 0 0 6 35.0% 22.6% 48.1% Of the 98 patients with stage 1 disease, 34 had their RMI assessed and recorded in their notes prior to surgical intervention. This has resulted in a WoS performance of 34.7% against the 90% QPI target. Only NHS Forth Valley met the 90% target with a performance of 100%. Performance was considerably lower in the other units however it should be noted that despite 3 year aggregated results numbers are still low across all sites which will have a greater effect on percentage values. Feedback received from NHS Boards stated that the majority of patients are having CT rather than ultrasound carried out pre diagnosis and therefore it is not possible to calculate the RMI. It was also noted that the exact RMI score is not recorded but is noted on the MDT outcomes sheet as being greater than 0 or less than 0 which the audit staff cannot enter on ecase. The quality component being assessed by this QPI was to ensure that all relevant cases were being discussed at an MDT with a CT scan available to ensure appropriate management decision were being made. Following review of the cases NHS Boards were confident that despite not recording the exact RMI, the CT scans were being organised and reviewed at an MDT, meeting the intended objective of the QPI. Following discussion at the formal review meeting it was proposed that QPI 1 should be archived due to it no longer being deemed beneficial in improving quality of care. Due to a change in clinical practice many patients now undergo CT and RMI cannot be calculated for these patients. 16
Performance (%) QPI 2 - Extent of disease assessed by CT or MRI prior to treatment. For women diagnosed with ovarian cancer it is necessary to fully image the pelvis and abdomen prior to starting any definitive treatment in order to establish the extent of disease and minimise unnecessary treatment. The target for this QPI is set at 90%. The tolerance allowed by the target reflects the fact that CA125 assessment and ultrasound scan does not always raise suspicion of cancer 1. QPI Title: Numerator: Patients with epithelial ovarian cancer should have their stage of disease assessed by CT or MRI prior to treatment. Number of patients with epithelial ovarian cancer having a CT scan or MRI of the abdomen and pelvis carried out prior to starting treatment. Denominator: All patients with epithelial ovarian cancer. Exclusions: Patients who decline to undergo investigation. Patients presenting for surgery as an emergency. Target: 90% Figure 3: Proportion of patients with epithelial ovarian cancer having a CT scan or MRI of the abdomen and pelvis performed to exclude the presence of metastatic disease prior to starting definitive treatment. 100 90 13/14 14/15 15/16 80 70 60 50 30 10 0 Ayrshire & Arran Forth Valley Lanarkshire North South Clyde WoS Location of Diagnosis Performance (%) Numerator Denominator numerator numerator (%) exclusions exclusions (%) denominator AA 100.0% 41 41 0 0.0% 0 0.0% 0 FV 100.0% 24 24 0 0.0% 0 0.0% 0 Lan 93.8% 45 48 0 0.0% 0 0.0% 0 NG 97.8% 45 46 0 0.0% 0 0.0% 0 SG 100.0% 42 42 0 0.0% 0 0.0% 0 Clyde 96.4% 27 28 0 0.0% 0 0.0% 0 WoS 97.8% 224 229 0 0.0% 0 0.0% 0 As highlighted in Figure 3 all individual units achieved the target of 90% in Year 3. Overall, 97.8% of patients diagnosed in the WoS had their stage of disease assessed by CT or MRI prior to treatment. Results over the three years are also noted as being consistently high. At the formal review meeting it was proposed that the target for QPI 2 should be raised to 95%. 17
Performance (%) QPI 3 - Treatment planned and reviewed at a multi-disciplinary team meeting Effective MDT working is considered integral to provision of high quality ovarian cancer care, facilitating a cohesive treatment-planning function and ensuring treatment and care provision is individualised to patient needs. QPI 3 states that 95% of patients should be discussed at the MDT prior to definitive treatment. The tolerance allows for patients who need treatment urgently 1. QPI Title: Numerator: Patients with epithelial ovarian cancer should be discussed by a MDT prior to definitive treatment. Number of patients with epithelial ovarian cancer discussed at the MDT before definitive treatment. Denominator: All patients with epithelial ovarian cancer Exclusions: Patients who died before first treatment. Target: 95% Figure 4: Proportion of patients with epithelial ovarian cancer who are discussed at a MDT meeting before definitive treatment. 100 13/14 14/15 15/16 90 80 70 60 50 30 10 0 Ayrshire & Arran Forth Valley Lanarkshire North Location of Diagnosis South Clyde WoS Performance (%) Numerator Denominator numerator numerator (%) exclusions exclusions (%) denominator AA 97.6% 41 0 0.0% 0 0.0% 0 FV 100.0% 24 24 0 0.0% 0 0.0% 0 Lan 91.8% 45 49 0 0.0% 0 0.0% 0 NG 88.9% 45 0 0.0% 0 0.0% 0 SG 90.0% 36 0 0.0% 0 0.0% 0 Clyde 90.0% 27 30 0 0.0% 0 0.0% 0 WoS 92.6% 212 229 0 0.0% 0 0.0% 0 Overall the WoS achieved 92.6% against the 95% target, failing to achieve the QPI for the third consecutive year. NHS Forth Valley and NHS Ayrshire & Arran exceeded the 95% target with performance of 100% and 97.6% respectively. Although NHS Lanarkshire and Clyde did show improved performance between Year 2 and Year 3, performance was still under the 95% target. North and South have both seen a decrease in patients discussed at MDT prior to 18
definitive treatment between Year 2 and Year 3, North falling from 95.2% to 88.9% and South from 100% to 90%. NHS Lanarkshire reviewed all cases not meeting the QPI. Two of the four patients who did not meet this QPI were not suspected of having cancer prior to definitive treatment and so were not discussed at MDT. One of the patients was diagnosed under the medics and was felt unfit for invasive investigations or systemic treatment, and the final patient was for BSC and discussed at MDT after decision was made. NHSGGC commented that all cases had been reviewed. Reasons given for not meeting the target were that cancer was not suspected pre-op, patients receiving emergency treatment and it was noted that five cases that should have been discussed were not. NHSGGC stated that further education was needed to ensure all patients requiring discussion are presented to the MDT. Action Required: NHSGGC to review current processes to ensure that those patients requiring discussion are presented timeously to the regional MDT. This will be further reinforced through the regional MDT review work currently being undertaken by the MCN. Location of Surgery QPIs four to six are reported by location of surgery rather than by location of diagnosis. Surgical management of ovarian cancer is provided by gynaecological oncologists working in the regional specialist surgical centre in Royal Infirmary (represented by North on charts). Some patients with an RMI of less than 0, i.e. cancer is not suspected pre-operatively, may receive surgery in their local hospital but are subsequently diagnosed with epithelial ovarian cancer when post operative pathology is available. Please note that the number of operations carried out in local hospitals is small therefore comparisons of percentages should be made with caution. 19
Proportion of Cases QPI 4 (i) - Patients with early stage disease have an adequate staging operation Surgery is considered the initial treatment of choice for women with early stage epithelial ovarian cancer. Patients suspected of having ovarian cancer should be operated on by a gynaecological oncologist; this has been shown to improve survival for women with ovarian cancer. Some women do present with symptoms requiring surgery but with no specific clinical features to indicate cancer and are therefore operated on/managed by a general gynaecologist; the cancer diagnosis is only made based on post-operative histopathological assessment (specification (i) accounts for this specific situation) 1. QPI Title: Numerator: Patients undergoing surgery for early stage epithelial ovarian cancer (FIGO Stage 1) have an adequate staging operation which includes Total Abdominal Hysterectomy (TAH), Bilateral Salpingo-Oophorectomy (BSO), omentectomy and washings. Number of early stage (FIGO Stage 1) epithelial ovarian cancer patients having primary surgery involving TAH, BSO, omentectomy and washings. Denominator: All early stage (FIGO Stage 1) epithelial ovarian cancer patients undergoing primary surgery. Exclusions: Patients having fertility conserving surgery. Patients with risk of malignancy index 0. Patients presenting for emergency surgery Target: 95% Due to the small numbers meeting the denominator criteria in each year of analysis individual year results cannot be presented therefore Figure 5 shows aggregated three year results. Figure 5: Proportion of early stage (FIGO Stage 1) epithelial ovarian cancer patients having primary surgery involving TAH, BSO, omentectomy and washing (aggregated 3 year result). 100 90 13/14-15/16 80 70 60 50 30 10 0 Ayrshire & Arran Forth Valley Lanarkshire North South Clyde WoS Location of Surgery
Aggregated 3 year results (13-16) QPI 4(i) Performance (%) Numerator Denominator - Data not shown due to small numbers numerator exclusions denominator Past % Performance 13/14 14/15 15/16 AA 88.2% 15 17 0 16 0 100% 85.1% 83.3% FV - - - 0 0 0 - - - Lan 63.6% 7 11 0 2 0-60.0% 60.0% NG 91.3% 63 69 0 34 3 92.3% 94.7% 87.5% SG 33.3% 2 6 0 4 1 - - - Clyde 63.6% 7 11 0 8 0 - - - WoS 82.6% 95 115 0 64 4 86.8% 82.9% 78.6% It should be noted that despite the 3 year aggregated results numbers are still low across all sites which will have a greater effect on percentage values. Overall in the WoS 82.6% of patients with early stage epithelial ovarian cancer underwent primary surgery involving TAH, BSO, omentectomy and washings. This falls short of the target of 95% for this measure. There was a high proportion of not-recorded values for the exclusion criteria and it is possible that some of these patients should have been excluded from the denominator. Data fields which were not recorded for exclusion relate to the recording of RMI. Other reasons provided for cases not meeting the target are where malignancy was not suspected pre-operatively. NHS Ayrshire & Arran reviewed cases and provided detailed clinical commentary on why cases did not meet the target. NHS Lanarkshire reviewed all cases not meeting this QPI target. Reasons provided were that cases not meeting the QPI were an incidental finding of ovarian cancer following surgery for other conditions. In all cases a second operation to complete the staging surgery was carried out. NHSGGC commented that the majority of cases not meeting the QPI relate to cases where preoperative malignancy not suspected. It is reassuring that detailed case review has confirmed that in cases where cancer was not suspected pre-operatively a second operation to complete staging and allow appropriate management decisions was undertaken. Following discussion at the formal review it was proposed that the exclusion of patients with RMI 0 should be removed. 21
Performance (%) QPI 4 (ii) - Patients with early stage disease have an adequate staging operation QPI Title: Numerator: Patients undergoing surgery for early stage epithelial ovarian cancer (FIGO Stage 1) have an adequate staging operation which includes Total Abdominal Hysterectomy (TAH), Bilateral Salpingo-Oophorectomy (BSO), omentectomy and washings. Number of early stage (FIGO Stage 1) epithelial ovarian cancer patients having primary surgery involving TAH, BSO, omentectomy and washings. Denominator: All early stage (FIGO Stage 1) epithelial ovarian cancer patients operated on by a gynaecological oncologist. Exclusions: Patients having fertility conserving surgery. Patients with risk of malignancy index 0. Patients presenting for emergency surgery Target: 95% QPI 4 (ii) applies to early stage epithelial ovarian cancer patients operated on by a gynaecological oncologist. All gynaecological oncologists operate from the specialist centre based at Royal Infirmary. Figure 6: Proportion of early stage (FIGO Stage 1) epithelial ovarian cancer patients operated on by a gynaecological oncologist having primary surgery involving TAH, BSO, omentectomy and washings. 100 13/14 14/15 15/16 90 80 70 60 50 30 10 0 Gynaecological Oncologist Operating Consultant General Gynaecologist Gynaecological Oncologist General Gynaecologist 13/14 24/26 (92.3%) 9/12 (75%) 14/15 18/19 (94.7%) 11/16 (68.8%) 15/16 21/24 (87.5%) 12/18 (66.7%) Figure 6 displays the proportion of patients being operated on by a gynaecological oncologist and those being operated on by a general gynaecologist. Results show that 87.5% of patients operated on by a gynaecological oncologist had an adequate staging operation with 21 of 24 cases meeting the QPI criteria. 66.7% of patients operated on by a general gynaecologist were noted as having an adequate staging operation with 12 out of 18 cases meeting the criteria. During formal review it was proposed that QPI 4(ii) should be archived. 22
Performance (%) QPI 5(i) - No macroscopic residual disease following surgery for advanced disease QPI 5(i) measures the proportion of patients with advanced epithelial ovarian cancer who have no macroscopic residual disease following surgery. The objective of performing surgery on women with epithelial ovarian cancer is complete resection of all macroscopic disease although this is not always possible in patients with advanced disease because of widespread involvement of peritoneal surfaces, bowel mesentery and serosa of bowel 1. The tolerances allowed by the target reflect this. QPI Title: Numerator: Surgery, as first definitive treatment, for patients with advanced epithelial ovarian cancer (FIGO Stage 2 or higher) should achieve no macroscopic residual disease. Number of patients with advanced epithelial ovarian cancer (FIGO Stage 2 or higher) with no macroscopic residual disease following surgery. Denominator: All patients with advanced epithelial ovarian cancer (FIGO Stage 2 or higher) undergoing surgery. Exclusions: Patients with FIGO stage 4 disease. Target: 30% Figure 7: Proportion of patients with advanced epithelial ovarian cancer (FIGO Stage 2 or higher) with no macroscopic residual disease following surgery. 14/15 15/16 100 90 80 70 60 50 30 10 0 Ayrshire & Arran Forth Valley Lanarkshire North South Clyde WoS Performance (%) Numerator Denominator Location of Surgery numerator numerator (%) exclusions exclusions (%) denominator AA* - - - 0 0.0% 0 0.0% 0 FV* - - - 0 0.0% 0 0.0% 0 Lan* - - - 0 0.0% 0 0.0% 0 NG 60.0% 27 45 1 2.2% 0 0.0% 2 SG* - - - 0 0.0% 0 0.0% 0 Clyde* - - - 0 0.0% 0 0.0% 0 WoS 62.3% 33 53 2 3.8% 0 0.0% 4 - Data not shown due to small numbers 23
Performance (%) Figure 7 illustrates the proportion of patients with advanced epithelial ovarian cancer with no macroscopic residual disease following surgery. Figures have been removed from the data table due to the small numbers involved for all units other than North. The regional specialist surgical centre (North ) achieved 60.0% which successfully met the 30% QPI target for the second consecutive year. It was decided at formal review that the target for QPI 5(i) should be raised to 60% and patients with FIGO stage 4B only should be excluded. Action Required: Whilst the target for this QPI measure is being met there is a recognition that further improvement is desirable. To achieve this will require increased joint surgical team working with colleagues from other specialities. QPI 5(ii) - No macroscopic residual disease following surgery for advanced disease QPI 5(ii) measures the proportion of patients with advanced epithelial ovarian cancer who have residual disease 1cm following surgery. Although the objective of surgery is to resect all visible disease as stated in QPI 5(i), on occasions where this is not possible the objective should be to achieve optimal cytoreduction, with macroscopic disease 1cm 1. QPI Title: Numerator: Surgery, as first definitive treatment, for patients with advanced epithelial ovarian cancer (FIGO Stage 2 or higher) should achieve no macroscopic residual disease. Number of patients with advanced epithelial ovarian cancer (FIGO Stage 2 or higher) undergoing surgery with macroscopic residual disease 1cm. Denominator: All patients with advanced epithelial ovarian cancer (FIGO Stage 2 or higher) undergoing surgery. Exclusions: Patients with FIGO stage 4 disease. Target: 60% Figure 8: Proportion of patients with advanced epithelial ovarian cancer (FIGO Stage 2 or higher) undergoing surgery with macroscopic residual disease 1cm. 100 90 14/15 15/16 80 70 60 50 30 10 0 Ayrshire & Arran Forth Valley Lanarkshire North Location of Surgery South Clyde WoS 24
Performance (%) Numerator Denominator numerator numerator (%) exclusions exclusions (%) denominator AA* - - - 0 0.0% 0 0.0% 0 FV* - - - 0 0.0% 0 0.0% 0 Lan* - - - 0 0.0% 0 0.0% 0 NG 71.1% 32 45 1 2.2% 0 0.0% 2 SG* - - - 0 0.0% 0 0.0% 0 Clyde* - - - 0 0.0% 0 0.0% 0 WoS 71.7% 38 53 2 3.8% 0 0.0% 4 - Data not shown due to small numbers The overall figure in the WoS for patients with advanced epithelial ovarian cancer undergoing surgery with macroscopic residual disease of less 1cm was 71.7% which meets the 60% QPI target. The specialist centre (North ) achieved 71.1% which meets the target but is 12.2 percentage points below Year 2 performance. During formal review it was proposed that QPI 5(ii) should be archived. QPI 6 - Histopathology reports are complete and support clinical decision-making Histopathological reporting provides prognostic indicators which inform treatment planning for women diagnosed with epithelial ovarian cancer. The use of datasets improves the completeness of data in pathology reports and the Royal College of Pathologists has agreed a minimum data set for reporting ovarian cancer 1. The target for this QPI has been set at 90% and the tolerance within the target is designed to account for situations where it is not possible to report all components of the dataset due to poor quality of specimen. QPI Title: Numerator: Histopathology reports relating to pelvic clearance surgery for patients with epithelial ovarian cancer contain all necessary information to inform treatment decision making. Number of patients with epithelial ovarian cancer undergoing definitive cytoreductive surgery who have a complete pathology report that contains all data items as defined by the Royal College of Pathologists. Denominator: All patients with epithelial ovarian cancer undergoing definitive cytoreductive surgery. Exclusions: No Exclusions. Target: 90% Due to the small numbers meeting the denominator criteria in each year of analysis individual year results cannot be presented therefore Figure 9 shows aggregated three year results. 25
Performance (%) Figure 9: Proportion of patients with epithelial ovarian cancer undergoing pelvic clearance surgery having a complete pathology report as defined by the Royal College of Pathologists 100 90 80 70 13/16 60 50 30 10 0 Ayrshire & Arran Forth Valley Lanarkshire North Location of Surgery South Clyde WoS Aggregated 3 year results (13-16) QPI 4(i) Performance (%) Numerator Denominator numerator exclusions denominator Past % Performance 13/14 14/15 15/16 AA 100% 21 21 0 0 0 100% 100% 100% FV* 100% 5 5 0 0 0 - - n/a Lan 91.7% 11 12 0 0 0 - - 100% NG 77.2% 0 259 0 0 0 93.0% 78.7% 62.2% SG 83.3% 5 6 0 0 0 - - - Clyde 90.0% 9 10 0 0 0-80.0% 33.3% WoS 78.9% 251 317 0 0 0 93.1% 81.6% 65.0% Figure 9 shows aggregated three year results for QPI 6 however there is still wide variance in the number of cases across boards which will have a greater effect on percentage comparisons. Over three years 78.9% of patients with epithelial ovarian cancer who underwent definitive cytoreductive surgery had a complete pathology record. This falls short of the 90% target for this measure. All units with the exception of North and South achieved the QPI target. The overall WoS result for each analysis year also shows a decline in performance from 93.1% in Year 1 to 65% in Year 3; a drop of 28.1 percentage points and 25 percentage points below the target. NHSGGC commented that whilst reviewing cases not meeting the QPI it became apparent that most relate to those having delayed surgery i.e. surgery after chemotherapy. In these cases the stage will already have been determined by imaging and pre-chemotherapy biopsy. Washings will not be carried out routinely as this will add to the pathology workload for no additional value with respect to the patients care. It is recommended that these cases need to be excluded from this measure or the definition of adequate procedures for staging be redefined for surgery after chemotherapy. Following discussion at the formal review it was decided to update the notes for users within the dataset to state that washings are not required for delayed primary surgery. 26
Performance (%) QPI 7(i) - Histo/cytological diagnosis prior to starting neo-adjuvant chemotherapy Before commencing neo-adjuvant cytotoxic chemotherapy, women with suspected advanced ovarian cancer should have their diagnosis confirmed by histology or by cytology if histology is not appropriate 1. QPI Title: Numerator: Patients with epithelial ovarian cancer should have a histo/cytological diagnosis of their cancer prior to starting neo-adjuvant chemotherapy. Number of patients having histo/cytological diagnosis of epithelial ovarian cancer recorded prior to starting chemotherapy. Denominator: All patients with epithelial ovarian cancer undergoing neo-adjuvant chemotherapy. Exclusions: Patients for whom paracentesis, image-guided biopsy or laparoscopy is considered not suitable. Target: 100% Figure 10: Proportion of patients with epithelial ovarian cancer having a histo/cytological diagnosis prior to starting neo-adjuvant chemotherapy. 100 90 80 13/14 14/15 14/16 70 60 50 30 10 0 Ayrshire & Arran Forth Valley Lanarkshire North South Clyde Wos Location of Diagnosis Performance (%) Numerator Denominator numerator numerator (%) exclusions exclusions (%) denominator AA 100.0% 11 11 0 0.0% 0 0.0% 0 FV 100.0% 11 11 0 0.0% 0 0.0% 0 Lan 100.0% 11 11 0 0.0% 0 0.0% 0 NG 100.0% 12 12 0 0.0% 0 0.0% 0 SG 100.0% 7 7 0 0.0% 0 0.0% 0 Clyde 100.0% 6 6 0 0.0% 0 0.0% 0 WoS 100.0% 58 58 0 0.0% 0 0.0% 0 As highlighted in Figure 10 all patients in the WoS with epithelial ovarian cancer had a histological/cytological diagnosis recorded prior to starting neo-adjuvant chemotherapy for the third consecutive year. During formal review it was proposed that QPI 7(i) should be archived and the focus should now solely be on a diagnosis of ovarian cancer confirmed by histology. 27
Performance (%). QPI 7(ii) - Histological diagnosis prior to starting neo-adjuvant chemotherapy QPI 7(ii) looks at proportion of patients who have a histological diagnosis prior to starting neoadjuvant chemotherapy. The target for this QPI is set at 80%. The tolerance for this level reflects that not all patients are suitable for histological confirmation of disease, e.g. where no targetable lesion identified on imaging and patient unsuitable for general anaesthetic/laparoscopy 1. QPI Title: Numerator: Patients with epithelial ovarian cancer should have a histo/cytological diagnosis of their cancer prior to starting neo-adjuvant chemotherapy. Number of patients who have a diagnosis of epithelial ovarian cancer confirmed by histology prior to starting chemotherapy. Denominator: All patients with epithelial ovarian cancer having histo/cytological diagnosis recorded prior to starting neo-adjuvant chemotherapy. Exclusions: No Exclusions Target: 80% Figure 11: Proportion of patients with epithelial ovarian cancer having a histological diagnosis prior to starting neo-adjuvant chemotherapy. 100 90 80 13/14 14/15 15/16 70 60 50 30 10 0 Ayrshire & Arran Forth Valley Lanarkshire North South Clyde WoS Location of Diagnosis Performance (%) Numerator Denominator numerator numerator (%) exclusions exclusions (%) denominator AA 85.7% 12 14 0 0.0% 0 0.0% 0 FV 100.0% 11 11 0 0.0% 0 0.0% 0 Lan 91.7% 11 12 0 0.0% 0 0.0% 0 NG 91.7% 11 12 0 0.0% 0 0.0% 0 SG 85.7% 6 7 0 0.0% 0 0.0% 0 Clyde 100.0% 6 6 0 0.0% 0 0.0% 0 WoS 91.9% 57 62 0 0.0% 0 0.0% 0 Figure 11 indicates that 91.9% of patients in the WoS had a diagnosis of epithelial ovarian cancer confirmed by histology prior to starting neo-adjuvant chemotherapy, which exceeds the 80% target. This is an improvement on Year 1 results where only 63.5% of patients met the target. 28
Performance (%) All units met the target In Year 3 with NHS Ayrshire & Arran, NHS Forth Valley, North and Clyde showing a year on year improvement. It should however be noted that numbers are still low across all sites which will have an effect on percentage values. This target has been a good example of how a QPI can drive improvement in practice. QPI 8(i) - Delayed primary surgery QPI 8 looks at the proportion of women with advanced epithelial ovarian cancer having neo-adjuvant chemotherapy. Neo-adjuvant chemotherapy followed by surgery is a reasonable alternative to primary debulking surgery in stage 3c and 4 disease. The target set for this QPI is 75% with a 25% tolerance level to reflect variance in individual patient response to chemotherapy, treatment associated morbidities and impact of these on individual patient fitness for surgery 1. QPI Title: Delayed primary surgery, after neo-adjuvant chemotherapy for advanced epithelial ovarian cancer (FIGO Stage 3c or 4). Numerator: Number of patients with advanced epithelial ovarian cancer (FIGO Stage 3c or 4) undergoing delayed primary surgery after neo-adjuvant chemotherapy. Denominator: All patients with advanced epithelial ovarian cancer (FIGO Stage 3c or 4) having neoadjuvant chemotherapy. Exclusions: No exclusions. Target: 75% Figure 12: Proportion of patients with advanced epithelial ovarian cancer (FIGO Stage 3c, 4a or 4b) having delayed primary surgery following neo-adjuvant chemotherapy. 100 90 80 70 60 50 30 10 0 13/14 14/15 15/16 Analysis Year 13/14 14/15 15/16 Result 31/39 (79.5%) 44/53 (83%) /49 (81.6%) Please note that all delayed primary surgery is provided by gynaecological oncologists working in the regional specialist surgical centre. 29
Proportion of Cases The 75% target for QPI 8(i) was exceeded for the third consecutive year for patients diagnosed with advanced epithelial ovarian cancer in WoS, with 81.6% of patients undergoing delayed primary surgery after neo-adjuvant chemotherapy. QPI 8(ii) - Delayed primary surgery Improved patient outcomes are observed in patients with no visible residual disease following surgical resection. The objective of performing surgery is complete resection of all macroscopic disease, whether before chemotherapy or after neo-adjuvant chemotherapy. QPI 8(ii) states that 65% of women with advanced epithelial ovarian cancer undergoing delayed primary surgery after neoadjuvant chemotherapy should achieve optimal cytoreduction 1. QPI Title: Delayed primary surgery, after neo-adjuvant chemotherapy for advanced epithelial ovarian cancer (FIGO Stage 3c or 4), should achieve optimal cytoreduction (1cm). Numerator: Number of patients with advanced epithelial ovarian cancer (FIGO Stage 3c or 4) undergoing delayed primary surgery with residual disease 1cm. Denominator: All patients with advanced epithelial ovarian cancer (FIGO Stage 3c or 4) undergoing delayed primary surgery after neo-adjuvant chemotherapy. Exclusions: No exclusions. Target: 65% Figure 13: Proportion of patients with advanced epithelial ovarian cancer (FIGO Stage 3c, 4a or 4b) having delayed primary surgery following neo-adjuvant chemotherapy and where optimal cytoreduction is achieved. 100 90 80 70 60 50 30 10 0 13/14 14/15 15/16 13/14 14/15 15/16 Result 29/31 (93.5%) 34/44 (77.3%) 29/ (72.5%) Results show that 72.5% of patients with advanced epithelial ovarian cancer had residual disease of 1cm following delayed primary surgery in Year 3, which meets the 65% target. 30
Performance (%) This is a slight decrease on Year 1 results where 93.5% met the target; a decrease of 21 percentage points and 4.8 percentage points below Year 2 results. However it should also be noted that numbers in this group are small which can affect overall percentage figures. QPI 9 - First-line Chemotherapy First line chemotherapy treatment of epithelial ovarian cancer should include a platinum agent, either in combination or as a single agent. Carboplatin is the platinum drug of choice in both single and combination therapy and paclitaxel is recommended in combination where the potential benefits justify the toxicity of the therapy. The tolerance allowed by the target recognises that there are a small number of patients who are not fit enough to undergo chemotherapy. QPI Title: Numerator: Chemotherapy treatment of epithelial ovarian cancer should include a platinum agent. Number of epithelial ovarian cancer patients who receive chemotherapy treatment involving either paclitaxel in combination with a platinum-based compound or carboplatin only. Denominator: All epithelial ovarian cancer patients. Exclusions: Patients with low-grade serous disease. Patients with FIGO stage 1a or 1b, low grade (G1) disease. Patients with Stage 1a clear cell tumours. Patients who decline chemotherapy treatment. Target: 90% Figure 14: Proportion of epithelial ovarian cancer patients who receive platinum-based chemotherapy, either in combination or as a single agent. 100 13/14 14/15 15/16 90 80 70 60 50 30 10 0 Ayrshire & Arran Forth Valley Lanarkshire North South Clyde WoS Location of Diagnosis 31
Performance (%) Numerator Denominator numerator numerator (%) exclusions exclusions (%) denominator AA 83.3% 30 36 0 0.0% 0 0.0% 2 FV 90.9% 22 0 0.0% 0 0.0% 0 Lan 81.0% 34 42 0 0.0% 6 11.5% 0 NG 81.6% 31 38 0 0.0% 0 0.0% 1 SG 87.8% 36 41 0 0.0% 1 2.9% 3 Clyde 88.9% 24 27 0 0.0% 1 3.1% 2 WoS 85.0% 175 6 0 0.0% 8 3.7% 8 The 90% target for QPI 9 was not achieved for patients diagnosed with epithelial ovarian cancer in WoS for the third consecutive year. WoS performance has however shown improved performance each year from 78.3% for patients diagnosed in Year 1 to 85.0% for patients diagnosed in Year 3. NHS Forth Valley met the target for QPI 9 with 90.9% of patients with epithelial ovarian cancer receiving chemotherapy which included a platinum agent. Clyde and South were only slightly below the QPI target with a performance of 88.9% and 87.8% respectively. The decision to prescribe chemotherapy is made by gynaecological oncology team at the Beatson West of Scotland Cancer Centre. NHS Ayrshire & Arran commented that cases who did not meet the target were reviewed and reasons included patients who had supportive care only, patients who received hormone therapy and patients died before treatment. NHS Lanarkshire achieved 81% against the 90% target. All cases not meeting have been reviewed and reasons provided include five cases who were for best supportive care therefore chemotherapy was not appropriate, patient refusal and patients who died before treatment commenced. NHSGGC stated that the majority of cases who did not meet the QPI were either not suitable for chemotherapy or opted not to undergo treatment. It was proposed at formal review that patients with stage 1a endometrioid tumours and patients with low grade mucinous tumours should be excluded from QPI 9. 32
Clinical Trial Access QPI Clinical trials are necessary to demonstrate the efficacy of new therapies and other interventions. Furthermore, evidence suggests improved patient outcomes from participation in clinical trials 1. Data definitions and measurability criteria to accompany the Clinical Trial QPI are available from the HIS website 1. The clinical trials QPI is measured utilising SCRN data and ISD incidence data, as is the methodology currently utilised by the Chief Scientist Office (CSO) and NCRI. Utilising SCRN data allows for comparison with CSO published data and ensures capture of all clinical trials recruitment, not solely first line treatment trials, as contained in the clinical audit data. Given that a significant proportion of clinical trials are for relapsed disease this is felt to be particularly important in driving quality improvement. This methodology utilises incidence as a proxy for all patients with cancer. This may slightly over, or underestimate, performance levels, however this is an established approach currently utilised by NHS Scotland 1. The following definitions are used to distinguish between interventional clinical trials and translational research: Interventional Clinical Trial: A clinical study in which participants are assigned to receive one or more interventions (or no intervention) so that researchers can evaluate the effects of the interventions on biomedical or health-related outcomes. The assignments are determined by the study protocol. Participants may receive diagnostic, therapeutic, or other types of interventions. Translational Research: Translational research transforms scientific discoveries arising from laboratory, clinical, or population studies into clinical applications to reduce cancer incidence, morbidity, and mortality. QPI Title: Numerator: All patients should be considered for participation in available clinical trials wherever eligible. Number of patients with epithelial ovarian cancer enrolled in an interventional clinical trial or translational research. Denominator: All patients with epithelial ovarian cancer. Exclusions: No exclusions. Target: Interventional 7.5% Translational 15% 33
Performance (%) Figure 15 below details the number of patients recruited into relevant clinical trials in 14 and 15. Figure 15: Proportion of epithelial ovarian cancer patients enrolled in an interventional clinical trial or translational research. 50 14 15 16 45 35 30 25 15 10 5 0 Interventional Analysis Group Translational The target is to enrol a minimum of 7.5% of patients into interventional clinical trials. Overall in the WoS this target was achieved with 11% (n=33) in 16 entered into an interventional clinical trial. With regards to translational research the QPI target was set at 15%, with the WoS achieving 3.3% (n=10) is below the 15% target and shows a decline in performance from the previous years. Table 1: List of clinical trials carried out at Beatson West of Scotland Cancer Centre (BWoSCC) in 16 and the number of patients with ovarian cancer recruited into each clinical trial per year. Trial Type Interventional Translational Project Title Recruited 16 ICON8 and ICON8B - ICON8 Trial Programme 6 AbbVie M13-694 (GOG3005) 3 NiCCC Trial (BIBF11) 5 TRIOC 2 Clovis CO-338-010 2 LOGS 4 CO-338-014 (ARIEL3) 1 OCTOPUS 2 ColoAd1-01 (OCTAVE) 3 CheckMate-032 1 HIPROC 2 D081KC00001 (MEDIOLA) Advanced Solid Tumours 1 BMS 986148 in solid tumors 1 BriTROC1 - Sample collection study in recurrent HGSOC 9 DNA Methylation 1 43 34
Number of Cases 4.3. Endometrial Cancer Quality Performance Indicators Introduction Quality Performance Indicators (QPIs) were implemented for patients diagnosed with endometrial cancer on or after 1 st October 14 and Endometrial Cancer QPIs 1 are reported here for the second consecutive year. There were 357 new diagnoses of endometrial cancer captured by audit in the WoS in Year 2. Distribution by location of diagnosis is shown below in Figure 15. Figure 25: Number and proportion of patients diagnosed with ovarian cancer by location of diagnosis. 160 1 1 100 80 60 14/15 15/16 0 Ayrshire & Arran Forth Valley Lanarkshire GGC Location of Diagnosis AA FV Lan GGC WoS Year 1_14/15 75 35 75 146 331 Year 2_15/16 69 51 79 158 357 35
Performance (%) QPI 1: Radiological Staging It is necessary to fully image the pelvis and abdomen prior to starting first treatment in order to establish the extent of disease and minimise unnecessary or inappropriate treatment 1. The target for this QPI is set at 90% with the tolerance level designed to account for situations where patients require urgent treatment before imaging has been performed or where endometrial cancer is an incidental finding at hysterectomy. Title: Numerator: Patients with endometrial cancer should have their stage of disease assessed by MRI and/or CT prior to first treatment. Number of patients with endometrial cancer having a MRI and/or CT scan of the abdomen and pelvis carried out prior to first treatment. Denominator: All patients with endometrial cancer. Exclusions: Patients with Grade 1 endometrioid or mucinous carcinoma on pre-operative biopsy. Patients with atypical hyperplasia on pre-operative biopsy. Target: 90% Figure 17: Proportion of patients with endometrial cancer who have an MRI and/or CT scan of the abdomen and pelvis performed prior to first treatment. 100 90 80 14/15 15/16 70 60 50 30 10 0 Ayrshire & Arran Forth Valley Lanarkshire North South Clyde WoS Location of Diagnosis Performance (%) Numerator Denominator numerator numerator (%) exclusions exclusions (%) denominator AA 76.9% 26 0 0.0% 0 0.0% 0 FV 96.2% 25 26 0 0.0% 0 0.0% 0 Lan 87.0% 46 0 0.0% 0 0.0% 0 NG 97.4% 37 38 1 2.6% 0 0.0% 0 SG 96.6% 28 29 1 3.4% 0 0.0% 0 Clyde 93.1% 27 29 1 3.4% 0 0.0% 0 WoS 91.2% 177 194 3 1.5% 0 0.0% 0 Overall in the WoS 91.2% of patients with endometrial cancer had a MRI and/or CT scan of the abdomen and pelvis carried out prior to first treatment, achieving the 90% target. Only NHS Ayrshire & Arran and NHS Lanarkshire did not achieve the QPI with performance of 76.9% and 87% respectively. 36
Performance (%) NHS Ayrshire & Arran reviewed cases and commented that 6 patients had MRI of the pelvis only. They added that MRI is no longer carried out and all patients are having CT imaging. NHS Lanarkshire also reviewed cases and data entry errors were noted. Lanarkshire would have achieved 93% which meets the QPI target. Once corrected NHS QPI 2: Multidisciplinary Team Meeting (MDT) Evidence suggests that patients with cancer managed by a multidisciplinary team have a better outcome. There is also evidence that the multidisciplinary management of patients increases their overall satisfaction with their care 1. Title: Numerator: Patients with endometrial cancer should be discussed by a multidisciplinary team prior to definitive treatment. Number of patients with endometrial cancer discussed at MDT prior to definitive treatment. Denominator: All patients with endometrial cancer. Exclusions: Patients with Grade 1 endometrioid or mucinous carcinoma on pre-operative biopsy. Patients with atypical hyperplasia on pre-operative biopsy. Patients who died before first treatment. Target: 95% Figure 18: Proportion of patients with endometrial cancer who are discussed at a MDT meeting before definitive treatment. 100 14/15 15/16 90 80 70 60 50 30 10 0 Ayrshire & Arran Performance (%) Numerator Denominator Forth Valley Lanarkshire North Location of Diagnosis numerator South numerator (%) exclusions exclusions (%) denominator AA 65.4% 17 26 0 0.0% 0 0.0% 0 FV 92.3% 24 26 0 0.0% 0 0.0% 3 Lan 93.5% 43 46 0 0.0% 0 0.0% 0 NG 97.4% 37 38 0 0.0% 0 0.0% 0 SG 92.9% 26 28 0 0.0% 0 0.0% 0 Clyde 96.4% 27 28 0 0.0% 0 0.0% 0 WoS 90.6% 174 192 0 0.0% 0 0.0% 3 Following baseline review it was agreed that patients who died before treatment should be excluded from this QPI. Data contained within Figure 18 for Year 1 has not been amended to exclude these cases. Clyde WoS 37
Overall WoS results show that 90.6% of patients diagnosed with endometrial cancer were discussed at MDT prior to definitive treatment which is below the 95% QPI target. North and Clyde achieved the target with performances of 97.4% and 96.4% respectively. NHS Ayrshire & Arran achieved 65.4% against the 95% target. This showed a 16.7 percentage point decrease on the previous years performance. NHS Ayrshire & Arran reviewed all cases not meeting the QPI and reasons provided included cases where cancer was not identified on biopsy and cases where imaging confirmed no extra uterine disease who were then discussed post surgery. NHS Forth Valley achieved 92.3%, however this represented two cases not meeting the QPI criteria. Reasons provided stated that in both cases after reviewing imaging, the opportunity for prompt surgery was undertaken before MDT discussion could take place. NHS Lanarkshire reviewed the three cases not meeting the QPI and reported that two cases should have been excluded from the denominator but due to incorrect coding were included. Once coding was corrected the Lanarkshire results would have been 97.7% which would meet the 95% QPI target. South were marginally below the 95% target with a performance of 92.9%. This equates to two cases which were reviewed, and reasons provided were that cancer was detected as an incidental finding and diagnosis not being possible due to an inability to obtain a pre-operative biopsy. 38
Performance (%) QPI 3: Total Hysterectomy and Bilateral Salpingo-Oophorectomy Total Hysterectomy/Bilateral Salpingo-Oopherectomy for endometrial cancer is associated with best long term survival (compared to primary radiotherapy or hormonal treatment) 1. The target for this QPI is 80% with the tolerance designed to account for patients having fertility conserving treatment patients who are not fit for surgical intervention. Title: Numerator: Patients with endometrial cancer should undergo total hysterectomy/bilateral salpingooopherectomy. Number of patients with endometrial cancer who undergo total hysterectomy/bilateral salpingo-oopherectomy. Denominator: All patients with endometrial cancer. Exclusions: Patients with FIGO Stage IV. Patients who decline surgical treatment. Patients having neo-adjuvant chemotherapy. Target: 80% Figure 19: Proportion of patients with endometrial cancer who undergo total hysterectomy/bilateral salpingo-oopherectomy. 14/15 15/16 100 90 80 70 60 50 30 10 0 Ayrshire & Arran Performance (%) Numerator Denominator Forth Valley Lanarkshire North Location of Diagnosis numerator South numerator (%) exclusions exclusions (%) denominator AA 91.0% 61 67 0 0.0% 0 0.0% 0 FV 83.7% 36 43 0 0.0% 0 0.0% 0 Lan 92.9% 65 70 0 0.0% 0 0.0% 0 NG 90.6% 48 53 0 0.0% 0 0.0% 0 SG 75.6% 31 41 0 0.0% 0 0.0% 0 Clyde 93.2% 41 44 0 0.0% 0 0.0% 0 WoS 88.7% 282 318 0 0.0% 0 0.0% 0 Overall 282 of the 318 patients diagnosed with endometrial cancer in the WoS underwent total hysterectomy/bilateral salpingo-oopherectomy, resulting in a performance of 88.7% against the 80% target. All units met the target with the exception of South who achieved 75.6%. NHSGGC reviewed all cases in South not meeting the target and patient fitness was cited as the most common reason for patients not undergoing total hysterectomy/bilateral salpingooopherectomy. NHSGGC commented that smaller surgical teams are to be developed to manage Clyde WoS 39
Performance (%) endometrial cancers. This will improve consistency of assessment and provision of surgical techniques to ensure that any potential for variation in surgical approach is minimised. Action Required: Smaller surgical teams are to be developed to manage endometrial cancers. This will improve consistency of assessment and provision of surgical techniques to address the potential for variation in approach. QPI 4: Laparoscopic Surgery Laparoscopic surgery, by appropriately trained surgeons, is recommended for patients with endometrial cancer as it has been found to be feasible and surgically safe with reduced post-operative complications and length of stay 1. The target for this QPI is set at 70% which reflects the fact that some patients may not be clinically suitable for laparoscopic surgery. Title: Numerator: Patients with endometrial cancer undergoing definitive surgery should undergo laparoscopic surgery, where clinically appropriate. Number of patients with endometrial cancer undergoing definitive surgery who undergo laparoscopic surgery. Denominator: All patients with endometrial cancer undergoing definitive surgery. Exclusions: No exclusions. Target: 70% Figure : Proportion of patients with endometrial cancer undergoing definitive surgery who undergo laparoscopic surgery. 100 14/15 15/16 90 80 70 60 50 30 10 0 Ayrshire & Arran Performance (%) Numerator Denominator Forth Valley Lanarkshire North Location of Surgery numerator South numerator (%) exclusions exclusions (%) denominator AA 70.2% 57 0 0.0% 0 0.0% 0 FV 86.1% 31 36 0 0.0% 0 0.0% 0 Lan 92.6% 50 54 0 0.0% 0 0.0% 0 NG.0% 38 95 0 0.0% 0 0.0% 0 SG 28.2% 7 24 0 0.0% 0 0.0% 0 Clyde 25.7% 9 35 0 0.0% 0 0.0% 0 WoS 58.1% 175 301 0 0.0% 0 0.0% 0 Clyde WoS
Following baseline review the target for QPI 4 was changed from 50% to 70%. Of the 301 patients diagnosed in WoS with endometrial cancer undergoing surgery, 175 patients are recorded as undergoing laparoscopic surgery resulting in a WoS performance of 58.1% against the 70% QPI target. NHS Ayrshire & Arran, NHS Forth Valley and NHS Lanarkshire all exceeded the target with performance of 70.2%, 86.1% and 92.6% respectively. North, South and Clyde did not meet the QPI target. NHSGGC commented that before the inception of this QPI the percentage cases were low for laproscopic surgery. Since the introduction of this QPI we have seen the percentage of cases increase, showing this to be an effective QPI in addressing a quality measure. Smaller surgical teams are to be developed in NHSGGC to manage endometrial cancers and it is anticipated that the percentage of cases undergoing laproscopic surgery will increase.. 41
Performance (%) QPI 5: Adjuvant Vaginal Brachytherapy For stage IB grade 1-2 brachytherapy has been shown to improve local control rates without the toxicity associated with external beam radiotherapy 1. Title: Numerator: Patients with stage IB, grade 1 or 2, or stage IA, grade 3 endometrioid or mucinous endometrial cancer should be considered for adjuvant vaginal brachytherapy. All patients with stage IB, grade 1 or 2, or stage IA, grade 3 endometrioid or mucinous endometrial cancer receiving vaginal vault brachytherapy. Denominator: All patients with stage IB, grade 1 or 2, or stage IA, grade 3 endometrioid or mucinous endometrial cancer. Exclusions: Patients who decline brachytherapy. Target: 90% Figure 21: Proportion of patients with stage IB, grade 1 or 2, or stage IA, grade 3 endometrioid or mucinous endometrial cancer having adjuvant vaginal brachytherapy. 100 14/15 15/16 90 80 70 60 50 30 10 0 Ayrshire & Arran Performance (%) Numerator Denominator Forth Valley Lanarkshire North Location of Diagnosis numerator South numerator (%) exclusions exclusions (%) denominator AA 66.7% 10 15 0 0.0% 0 0.0% 0 FV 57.1% 4 7 0 0.0% 0 0.0% 0 Lan 76.9% 10 13 0 0.0% 0 0.0% 0 NG 88.9% 8 9 0 0.0% 0 0.0% 0 SG - - - 0 0.0% 0 0.0% 0 Clyde 91.7% 11 12 0 0.0% 0 0.0% 0 WoS 77.2% 44 57 0 0.0% 0 0.0% 0 - Data not shown due to small numbers It should be noted that numbers of patients are low and therefore comparisons between sites should be made with caution. Results are restricted for South due to small numbers. Overall in the WoS 44 out of 54 cases received vaginal vault brachytherapy which equates to 77.2%. NHS Ayrshire & Arran reviewed the five cases not meeting the QPI and reported that in all cases radical radiotherapy was given. 42 Clyde WoS
NHS Forth Valley achieved 57.1% against the 90% target; however this represents 3 cases not meeting the QPI criteria. NHS Forth Valley reported that the decision to receive adjuvant brachytherapy is made at the MDT and NHS Forth Valley does not have further opportunity to influence this decision. NHS Lanarkshire reported that all 3 cases were reviewed and all cases were seen by an oncologist and treated with adjuvant radiotherapy. NHSGGC commented that only two cases were noted as not meeting the QPI and in both cases it was due to the treatment not being clinically appropriate. 43
Performance (%) QPI 6: Chemotherapy Platinum chemotherapy can improve progression free survival in patients with stage IV endometrial cancer. The use of chemotherapy should be considered for patients with stage IV disease or those with stage III disease plus residual disease at the completion of surgery 1. Title: Numerator: Patients with stage IV endometrial cancer should have chemotherapy. All patients with stage IV endometrial cancer receiving chemotherapy. Denominator: All patients with stage IV endometrial cancer. Exclusions: Patients who refuse chemotherapy. Target: 75% Figure 22: Proportion of patients with stage IV endometrial receiving chemotherapy. WoS 100 90 80 70 60 50 30 10 0 Year 1 Year 2 Performance (%) Numerator Denominator numerator numerator (%) exclusions exclusions (%) denominator 14/15 57.7% 15 26 0 0.0% 0 0.0% 0 15/16 63.3% 16 23 0 0.0% 0 0.0% 0 Following baseline review patients who refuse chemotherapy were excluded from this measure. Due to the very small numbers contained within this QPI data can only be reported by region. Overall in the WoS, 63.3% of patients with stage IV endometrial cancer received chemotherapy which is a slight improvement on the previous years results. However numbers are still small and comparisons should be made with caution. All boards reviewed cases not meeting the QPI target and reasons provided included patients not fit for chemotherapy due to their performance status and age, and cases where hormone therapy was considered to be more appropriate. 44
Number of Cases 4.4. Cervical Cancer Quality Performance Indicators Introduction Quality Performance Indicators (QPIs) were implemented for patients diagnosed with cervical cancer on or after 1 st October 14 and Cervical Cancer QPIs 1 are reported here for the second consecutive year. There were 145 new diagnoses of cervical cancer captured by audit in the WoS in Year 2. Distribution by location of diagnosis is shown below in Figure 23. 14/15 15/16 90 80 70 60 50 30 10 0 Ayrshire & Arran Forth Valley Lanarkshire GGC Location of Diagnosis AA FV Lan GGC WoS Year 1_14/15 23 24 57 83 187 Year 2_15/16 23 33 69 145 45
Performance (%) QPI 1: Radiological Staging It is necessary to fully image the pelvis prior to definitive treatment in order to establish the extent of disease and minimise unnecessary or inappropriate treatment 1. Title: Numerator: Patients with cervical cancer should have their stage of disease assessed by MRI prior to definitive treatment. All patients with cervical cancer having MRI of the pelvis carried out prior to definitive treatment. Denominator: All patients with cervical cancer. Exclusions: Patients with histopathological FIGO stage 1A1 disease. Patients treated by LLETZ only. Patients unable to undergo MRI due to contraindications. Patients with histopathological FIGO stage IVB disease. Patients who refuse MRI investigation. Target: 95% Figure 24: Proportion of patients with cervical cancer who have an MRI of the pelvis performed prior to first treatment. 100 14/15 15/16 90 80 70 60 50 30 10 0 Ayrshire & Arran Forth Valley Lanarkshire North South Clyde WoS Location of Diagnosis Performance (%) Numerator Denominator numerator numerator (%) exclusions exclusions (%) denominator AA 100% 16 16 0 0.0% 0 0.0% 0 FV 93.3% 14 15 0 0.0% 0 0.0% 0 Lan 88.5% 23 26 0 0.0% 0 0.0% 0 NG 95.5% 21 22 0 0.0% 0 0.0% 0 SG 90.9% 10 11 0 0.0% 0 0.0% 0 Clyde 100% 11 11 0 0.0% 0 0.0% 0 WoS 94.1% 95 101 0 0.0% 0 0.0% 0 Following baseline review QPI 1 was changed to look at the number of patients having MRI carried out prior to definitive treatment rather than first treatment. Two exclusions were added to the QPI criteria, patients with histopathological FIGO stage IVB disease and patients who refuse MRI investigation. The tolerance level was also updated to include cases where cancer was an incidental finding at surgery. 46
Across the WoS, 94.1% of patients diagnosed with cervical cancer had MRI of the pelvis carried out prior to definitive surgery. This was just marginally below the 95% QPI target. NHS Ayrshire & Arran, North and Clyde all met the target with performance of 100%, 95.5% and 100% respectively. The majority of sites showed improvement from the previous years results but this may be due to the change in measurability following baseline review. NHS Forth Valley, NHS Lanarkshire and South just fell below the 95% target. All cases were reviewed locally and in the majority of cases incidental finding at surgery was cited as the main reason cases did not meet the target. 47
Performance (%) QPI 2: Positron Emission Tomography/Computed Tomography (PET/CT) Patients not suitable for surgery and being considered for radical radiotherapy (+/- concurrent chemotherapy) are recommended to undergo PET/CT because of the significant risk of extra pelvic disease which if detected will change patient management 1. Title: Numerator: Patients with cervical cancer for whom primary definitive surgery is not appropriate, should undergo PET/CT. All patients with cervical cancer undergoing primary radical radiotherapy who have PET/CT imaging prior to starting treatment. Denominator: All patients with cervical cancer undergoing primary radical radiotherapy. Exclusions: No exclusions. Target: 95% Figure 25: Proportion of patients with cervical cancer, for whom primary definitive treatment is radical radiotherapy, who have PET/CT imaging. 14/15 15/16 100 90 80 70 60 50 30 10 0 Ayrshire & Arran Performance (%) Numerator Denominator Forth Valley Lanarkshire North Location of Diagnosis numerator South numerator (%) exclusions exclusions (%) denominator AA 100% 8 8 0 0.0% 0 0.0% 0 FV 100% 9 9 0 0.0% 0 0.0% 0 Lan 100% 15 15 0 0.0% 0 0.0% 0 NG 83.3% 5 6 0 0.0% 0 0.0% 0 SG - - - 0 0.0% 0 0.0% 0 Clyde 85.7% 6 7 0 0.0% 0 0.0% 0 WoS 95.8% 46 48 0 0.0% 0 0.0% 0 Overall in the WoS 46 out of 48 patients with cervical cancer who underwent primary radical radiotherapy received PET/CT imaging prior to treatment. This equates to a performance of 95.8% which meets the QPI target of 95%. NHS Ayrshire & Arran, NHS Forth Valley and NHS Lanarkshire all met the target and showed improved performance from Year 1 results, however numbers are low and this can have a greater effect on proportions. Comparison across years should also be made with caution. Clyde WoS 48
Performance (%) Cases which did not meet the target in North and Clyde were reviewed and valid clinical reasons provided. QPI 3: Multidisciplinary Team Meeting (MDT) Evidence suggests that patients with cancer managed by a multi-disciplinary team have a better outcome. There is also evidence that the multidisciplinary management of patients increases their overall satisfaction with their care 1. Title: Numerator: Patients with cervical cancer should be discussed by a MDT prior to definitive treatment. All patients with cervical cancer discussed at the MDT before definitive treatment. Denominator: All patients with cervical cancer. Exclusions: Patients with histopathological FIGO stage 1A1 disease. Patients treated by LLETZ only. Patients who died before treatment. Target: 95% Figure 26: Proportion of patients with cervical cancer who are discussed at a MDT meeting before definitive treatment. 100 90 80 70 60 50 30 10 0 Ayrshire & Arran Forth Valley Lanarkshire North South Clyde WoS Location of Diagnosis Performance (%) Numerator Denominator numerator numerator (%) exclusions exclusions (%) denominator AA 100% 15 15 0 0.0% 0 0.0% 0 FV 100% 17 17 0 0.0% 0 0.0% 0 Lan 96.6% 28 29 0 0.0% 0 0.0% 0 NG 95.2% 21 0 0.0% 0 0.0% 0 SG 90.9% 10 11 0 0.0% 0 0.0% 0 Clyde 100% 11 11 0 0.0% 0 0.0% 0 WoS 97.1% 101 104 0 0.0% 0 0.0% 0 Following discussion at baseline review patients who died before treatment are now excluded from this QPI. Overall in the WoS 97.1% of patients with cervical cancer were discussed at MDT prior to definitive treatment, which is above the 95% QPI target. All sites met the target with the exception of South 49
Performance (%) who achieved 90.9% however, this represents one patient not discussed prior to defintive treatment due to cancer being an incidental finding at surgery. QPI 4: Radical Hysterectomy Radical surgery is recommended for FIGO stage IB1 disease if there are no contraindications to surgery. Patients with tumours 4 cm in diameter are less likely to have metastatic spread and benefit most from radical hysterectomy. In young women quality of life is less impaired after radical hysterectomy than following chemo-radiation therapy 1. Title: Numerator: Patients with FIGO stage IB1 cervical cancer should undergo radical hysterectomy All patients with FIGO stage IB1 cervical cancer who undergo radical hysterectomy. Denominator: All patients with FIGO stage IB1 cervical cancer. Exclusions: Patients who decline surgery. Patients who undergo fertility conserving treatment. Patients who have neo-adjuvant chemotherapy. Patients enrolled into surgical trials. Target: 85% Figure 27: Proportion of patients with stage IB1 cervical cancer (as defined by radiology and/or histopathology) who undergo radical hysterectomy. 100 WoS 90 80 70 60 50 30 10 0 Year 1 Year 2 Performance (%) Numerator Denominator numerator numerator (%) exclusions exclusions (%) denominator Year 1 87.2% 34 39 0 0.0% 0 0.0% 0 Year 2 66.7% 18 27 0 0.0% 0 0.0% 0 Due to the smaller numbers of patients included within this QPI, there is wide variation at board level of patients meeting the QPI criteria. Therefore, cumulative WoS results are presented in Figure 27. Following baseline review it was agreed that the target for this QPI should be changed from 70% to 85%. Overall in the WoS 66.7% of patients with FIGO Stage IB1 cervical cancer underwent radical hysterectomy. This was below the new 85% target and.5 percentage points below the Year 1 result. Individual boards reviewed cases not meeting the QPI and detailed clinical commentary was provided. Reasons provided included patient fitness and incidental finding at surgery. 50
Performance (%) QPI 5: Surgical Margins The quality of radical surgery for cervical cancer has an important influence on local control of the tumour and ultimately survival. Therefore, it is important to optimise and ensure the quality of surgical care for cervical cancer patients 1. QPI 5 is analysed by location of surgery rather than location of diagnosis. Title: Numerator: Patients with surgically treated cervical cancer should have clear resection All patients with cervical cancer who undergo surgery where surgical margins are clear of tumour. Denominator: All patients with cervical cancer who undergo surgery. Exclusions: Patients who decline surgery. Patients who undergo fertility conserving treatment. Patients enrolled into surgical trials. Target: 95% Figure 28: Proportion of patients with cervical cancer who have surgical margins clear of tumour following hysterectomy. WoS 100 90 80 70 60 50 30 10 0 Year 1 Year 2 Performance (%) Numerator Denominator numerator numerator (%) exclusions exclusions (%) denominator Year 1 94.2% 49 52 1 1.9% 0 0.0% 0 Year 2 97.5% 39 1 2.5% 0 0.0% 0 Again due to the smaller numbers of patients included within this QPI cumulative WoS results are presented in Figure 28. The 95% target was achieved in the WoS for Year 2 with 97.5% of patients who underwent surgery having surgical margins clear of tumour. The one case not meeting the QPI target was reviewed and detailed clinical commentary was provided. 51