West of Scotland Cancer Network Lung Cancer Managed Clinical Network Audit Report Report of the 2010 Clinical Audit Data Dr Richard Jones Consultant Clinical Oncologist MCN Clinical Lead Tracey Cole MCN Manager Julie McMahon WoSCAN Information Officer Final Published Lung Cancer Managed Clinical Network Audit Report v1.0 8 th November 2011 1
CONTENTS EXECUTIVE SUMMARY 3 1. INTRODUCTION 6 2. BACKGROUND 6 2.1 NATIONAL CONTEXT 6 2.2 WEST OF SCOTLAND CONTEXT 7 2.3 AGE DISTRIBUTION 7 2.4 LUNG CANCER CASE ASCERTAINMENT BY HEALTH BOARD OF DIAGNOSIS 8 2.5 DEPRIVATION CATEGORY 9 2.6 STAGE AT DIAGNOSIS 9 3. METHODOLOGY 10 4. RESULTS AND RECOMMENDED ACTIONS 10 4.1 DATA QUALITY 10 4.2 PERFORMANCE AGAINST AGREED QUALITY MEASURES 10 4.3 RESULTS 10 5. CONCLUSIONS 28 5.1 REQUIRED ACTIONS IDENTIFIED 28 ACKNOWLEDGEMENT 29 ABBREVIATIONS 30 REFERENCES 31 Final Published Lung Cancer Managed Clinical Network Audit Report v1.0 8 th November 2011 2
Executive Summary Introduction This report assesses performance against NHS Quality Improvement Scotland (QIS) Standards of West of Scotland (WoS) lung cancer services, using the clinical audit data from the period January December 2010. It provides relevant audit data and an overview of activity, and sets out actions that require to be taken by Boards. The West of Scotland Cancer Network (WoSCAN) Lung Cancer Managed Clinical Network (MCN) has been in existence for almost a decade. The Lung Cancer MCN continues to support the delivery and development of the service for approximately 2,100 new lung cancer patients each year across 7 Multidisciplinary Team Meetings (MDTM), and 11 clinics. The Network continues to benefit from enthusiastic engagement of a range of healthcare professionals and managers across the WoS. Background Lung cancer continues to be the most common cancer in Scotland, with approximately 19% of male cancer patients and 16% of female cancer patients affected. The incidence in females continues to rise with a 10% increase over the last 10 years; whereas in males incidence has decreased by around 20% over the same time period. Despite more patients having the opportunity for anti-cancer therapy beyond initial treatment, lung cancer patients continue to have one of the lowest survival rates of any cancer, often due to advanced stage at presentation. Data shows that for patients diagnosed between 2003 2007 1 year relative survival was 27.2% in males and 30.4% in females, with 5 year relative survival dropping to 7.3% and 8.8% respectively. Earlier detection of lung cancer would lead to improved outcomes in patients and increasing awareness of symptoms and promotion of earlier detection is currently being explored as part of a national programme by the Scottish Government. Approximately 4900 new cases are diagnosed per annum in Scotland; the majority of these cases are diagnosed, treated and managed within the 4 NHS Boards in the WoSCAN area NHS Ayrshire and Arran, NHS Forth Valley, NHS Greater Glasgow and Clyde, and NHS Lanarkshire. Methodology Audit of lung cancer is long established in the WoS, Audit staff in each WoS Health Board are responsible for collecting data on patients diagnosed by their service and entering that data on ecase (electronic cancer audit support environment). The data is extracted from ecase and analysed centrally by the WoSCAN Information Team using SQL Server Reporting Services (SSRS). Analysis of the 2010 data, against the pre-determined NHS QIS Standards, was undertaken to show the performance of each NHS Board individually, and also produce a collated report which allows for full comparison of performance and volume of activity across the Boards. As approximately 60% of the WoS new diagnoses are managed in the NHS Greater Glasgow and Clyde area, analysis is broken down and presented in the following geographical groups Clyde, North Glasgow and South Glasgow. Mesothelioma patients were included in the data analysis for the first time in 2010. Mesothelioma is a separate disease as it arises from the pleura rather than the lung. Mesothelioma patients are considered by the Lung Cancer MCN as they generally present via lung cancer MDTs. Gaps currently exist in the information available, although with the increased awareness this report will bring the Lung Cancer MCN are confident that, as with lung cancer data, there will be continued improvement in the data capture and reporting in respect of mesothelioma patients. In 2010 105 new diagnosis of mesothelioma was recorded in the WoS. Final Published Lung Cancer Managed Clinical Network Audit Report v1.0 8 th November 2011 3
Results The data measures 15 core Standards from the NHS QIS Standards for the management of lung cancer. Values represent the WoS average figure and range across the Boards expressed as a percentage. 1. A minimum of 75% of all lung cancer patients have their diagnosis confirmed by histology/cytology ( 80 [74.5-86.9]% ) 2. TNM stage is recorded for a minimum of 90% of cases at the time of diagnosis (Lung cancer) (89.6 [79.5-93.2]%) 3. TNM stage is recorded for a minimum of 90% of cases at the time of diagnosis (Mesothelioma) (29.5 [0.0-100]%) 4. WHO Performance Status is recorded for a minimum of 90% of cases at the time of diagnosis (90.9 [84.9-99.0]% ). 5. All patients with a diagnosis of lung cancer are discussed by a Multidisciplinary Team (94.2 [90.2-98.5]% ). 6. All patients with a diagnosis of lung cancer are seen by a Clinical Nurse Specialist (88.6 [77.4-94.4]%). 7. The percentage of patients receiving anti cancer treatment for lung cancer (includes radiotherapy, chemotherapy, chemoradiotherapy, surgery and other therapies including endobronchial treatment) (63.5 [57.0-68.3]%). 8. The percentage of lung cancer patients treated with curative intent (26.6 [24.5-28.2]%). 9. The 30 day mortality rate following final lung cancer surgery specific to the procedure performed (2.6 [0.0-6.7]% ) 10. A minimum of 35% of NSCLC patients should receive palliative radiotherapy (22.9 [13.9-34.4]%) 11. A minimum of 60% of those limited disease SCLC patients receiving chemotherapy also receive consolidation radiotherapy to the chest (55.6 [34.8-85.7]%). 12. A minimum of 60% of those limited disease SCLC patients receiving chemotherapy subsequently receiving prophylactic cranial irradiation (PCI) (39.5 [0.0-76.0]%). 13. The 30-day mortality rate following final radiotherapy. (10.6 [3.1-17.5]%). 14. A minimum of 60% of SCLC patients receive chemotherapy (65.6 [50.0-72.3]% ). 15. A minimum of 20% of NSCLC patients receive chemotherapy (32.0 [28.6-40.7]%). Conclusions and Recommended Actions The Lung Cancer MCN are encouraged that most units are meeting the NHS QIS Standards, with results presented in this report demonstrating that patients with lung cancer in the WoS continue to receive a consistent standard of care, despite geographical location. Although the results are indicative of good quality service across the region, each MDT is responsible for taking action on the recommendations of the report locally. MDTs are required to assess their performance against the nationally defined criteria in the context of the WoS as a whole, identifying areas for improvement and investigating potential reasons for variation in performance. Final Published Lung Cancer Managed Clinical Network Audit Report v1.0 8 th November 2011 4
Key Actions Required: All Boards to ensure that all mesothelioma data is well recorded. Clyde to ensure more robust Performance Status recording at MDT meetings. All MDT meetings should discuss all patients. Method of recording/documenting patients access to a CNS to be reviewed. Retrospective audit required in respect of limited disease SCLC patients receiving PCI following chemotherapy in NHS Ayrshire and Arran, NHS Forth Valley, and NHS Lanarkshire. Radiotherapy treatment intent should be documented in order to fully report on NHS QIS Standard 5c.13. Uniform practice to be agreed on and adopted in respect of chemotherapy end date recording. Encourage a closer relationship between audit support teams and the MDT/clinical team, building on the good progress made in year through closer working relationships. Final Published Lung Cancer Managed Clinical Network Audit Report v1.0 8 th November 2011 5
1. Introduction This report assesses performance against NHS Quality Improvement Scotland (QIS) Standards of West of Scotland (WoS) lung cancer services, using the clinical audit data from the period January December 2010. It provides relevant audit data and an overview of activity, and sets out actions that require to be taken by Boards. The West of Scotland Cancer Network (WoSCAN) Lung Cancer Managed Clinical Network (MCN) has been in existence for almost a decade. The Lung Cancer MCN continues to support the delivery and development of the service for approximately 2,100 new lung cancer patients each year across 7 Multidisciplinary Teams (MDTs). The Network continues to benefit from enthusiastic engagement of a range of healthcare professionals and managers across the WoS. 2. Background Lung cancer patients usually present to a chest physician, although a significant subgroup are referred by other clinicians, e.g. care of the elderly, and increasingly there is cross referral to lung cancer MDT meetings as awareness of other services within hospitals increases. As detailed above there are 7 lung cancer MDTs which operate around 11 outpatient clinics serving 2.4 million people across 4 health boards - NHS Ayrshire & Arran, NHS Forth Valley, NHS Greater Glasgow and Clyde, and NHS Lanarkshire - from this population approximately 2,100 patients are diagnosed with lung cancer per annum. Surgical services are provided centrally at the Golden Jubilee National Hospital (GJNH). Table 1 lists the MDTs by health board area, and includes the analysis group based on location of diagnosis, which has been used to present results throughout the report. Table 1: Lung Cancer MDT Configuration in the WoS MDT Analysis Group NHS Board Area (location of diagnosis) Crosshouse & Ayr Ayrshire & Arran (AA) NHS Ayrshire and Arran Forth Valley Royal Hospital Forth Valley (FV) NHS Forth Valley Pan Lanarkshire Lanarkshire (LS) NHS Lanarkshire Clyde Clyde (Clyde) North East Glasgow West Glasgow South Glasgow North Glasgow (NG) South Glasgow (SG) NHS Greater Glasgow and Clyde 2.1 National Context Lung cancer continues to be the most common cancer (17% of all cancers) in Scotland, with approximately 4900 new cases diagnosed each year (1). Nationally lung cancer affects about 19% of male cancer patients and 16% of female cancer patients. Incidence in females continues to rise with approximately a 10% increase over the last 10 years; whereas in males incidence has decreased by around 20% over the same time period. The lifetime risk of developing lung cancer is estimated to be 1 in 13 for males and 1 in 16 for females. Despite more patients having the opportunity for anti-cancer therapy beyond initial treatment, lung cancer patients continue to have one of the lowest survival rates of any cancer, often due to advanced Final Published Lung Cancer Managed Clinical Network Audit Report v1.0 8 th November 2011 6
stage at presentation. Data shows that for patients diagnosed between 2003 2007 1 year relative survival was 27.2% in males and 30.4% in females, 5 year relative survival drops to 7.3% and 8.8% respectively (2). Earlier detection of lung cancer would lead to improved outcomes in patients and increasing awareness of symptoms and promotion of earlier detection is currently being explored as part of a national programme by the Scottish Government (3). 2.2 West of Scotland Context Currently across Scotland 24% of the adult population use tobacco products. In the WoS smoking is a well-known contributory factor to lung cancer. In some of the most deprived areas in WoSCAN up to 50% of the adult population use tobacco products (4). It is also recognised that there is a substantial level of co-morbidities in lung cancer patients in the WoS, which contributes to poor survival and may restrict treatment options. Industrial exposure is a known cause of mesothelioma. This is particularly true in the WoS where ship building was a strong industry. 2.3 Age Distribution The occurrence of lung cancer is slightly higher in males (51%) than in females (49%). Figure 1 illustrates the distribution of lung cancer cases by age group. Lung cancer continues to be more prevalent in patients of 60 and over with 86% of the total cases in 2010 occurring in patients within this age group. A large sub group of lung cancer diagnosis (797 patients) are aged 75 years and above. Patients within this category can provide significant management challenges, again due to co-morbidities, and it is recognised that older patients may tolerate aggressive treatments less well. Figure 1: Age distribution of lung cancer patients Percentage of Cases Age Group Final Published Lung Cancer Managed Clinical Network Audit Report v1.0 8 th November 2011 7
2.4 Lung Cancer Case Ascertainment by Health Board of Diagnosis Capturing data on the total incident population (or as near as possible to that total) in each organisation is central to the validity of the audit findings. Assessment of population completeness by each health board is calculated by comparing the number of new cases identified by the audit against the 5 year average (2005-2009) of cancer registry incidence data. Table 2 indicates the case ascertainment by health board. Table 2: Case Ascertainment for Lung Cancer Analysis Group Cases from audit Cancer Registry Average Estimated Case Ascertainment (%) Ayrshire & Arran 290 333 87.1 Clyde 318 366 86.9 Forth Valley 191 243 78.6 Lanarkshire 435 508 85.6 North Glasgow 617 675 91.4 South Glasgow 345 425 81.2 WoS 2196 2550 86.1 A lung cancer case ascertainment of 86% provides confidence that the results shown are representative of the relevant population for the year reported. In Forth Valley however, case ascertainment remains below the regional average. This was true for previous years also. To address this issue, Forth Valley audit data has been compared to cancer registry data to determine patients not captured by audit. A problem with coding of patients was discovered in the Forth Valley area when further investigation was carried out locally. Addressing this issue has led to a 5% increase in case ascertainment between the 2009 and 2010 data. Table 3: Case Ascertainment for Mesothelioma Analysis Group Cases from audit Cancer Registry Average Estimated Case Ascertainment (%) Ayrshire & Arran 15 10 150.0 Clyde 26 22 118.2 Forth Valley 5 9 55.6 Lanarkshire 15 20 75.0 North Glasgow 29 30 96.7 South Glasgow 15 19 78.9 WoS 105 110 95.5 In respect of mesothelioma case ascertainment it was noted in table 3 that both Ayrshire and Arran and Clyde had a figure of over 100%. Generally this can be attributed to small numbers and general year on year fluctuation in incidence. Final Published Lung Cancer Managed Clinical Network Audit Report v1.0 8 th November 2011 8
2.5 Deprivation Category Figure 2: Cases by Deprivation Category Number of Cases Deprivation Health BoardCategory As seen in previous years lung cancer incidence continues to be higher in moderate-high deprivation areas. 2.6 Stage at Diagnosis Staging is the assessment of the extent of disease and is performed for prognostic and therapeutic purposes. Figure 3: 3: Stage at at diagnosis of of lung cancer patients NR, 10.4% Inapplicable, 0.5% IA, 7.6% IB, 5.2% IIA, 3.5% IIB, 4.0% IIIA, 11.7% IV, 45.2% IIIB, 11.7% Analysis of stage in lung cancer patients was based on stage at diagnosis (pre-treatment). Figure 3 shows the stage distribution of all lung cancer patients. More than 68.7% of patients in the WoS presented with advanced stage disease (III or IV), there is a need to look at methods of improvement in early detection, this will be supported by the national Detect Cancer Early Programme (3). Final Published Lung Cancer Managed Clinical Network Audit Report v1.0 8 th November 2011 9
3. Methodology Within WoSCAN lung cancer data is collected in the 4 NHS Boards by Clinical Effectiveness Facilitators (CEFs). Data collection is defined by a pre-determined set of values that are required to assess performance against the NHS QIS Standards for Lung Cancer 2008 (5). The data collection cycle is over the 12 month period from 1 st January to 31 st December, with analysis on the data approximately 6 months following this. The data is recorded manually and entered locally into the electronic Cancer Audit Support Environment (ecase) system. When the data entry on ecase is completed, analysis is then performed centrally by the WoSCAN Information Team using SQL Server Reporting Services (SRSS). SRSS is a recent introduction in the analysis of data in the WoS, analyses in previous years on lung cancer data were carried out using Microsoft Access. Mesothelioma patients were included in the data analysis for the first time in 2010, there were 105 diagnoses across the WoS. As may be expected with first time analysis some gaps exist in the information available. With the increased awareness this report will bring to members of the network, the Lung Cancer MCN are confident that, as with lung cancer data, there will be continued improvement in the data capture and reporting in respect of mesothelioma patients, and in subsequent reports comparative data will be presented. 4. Results and Recommended Actions 4.1 Data Quality All hospitals in the region participate in the Quality Assurance programme provided by the National Services Scotland Information & Statistics Division (ISD), although this is not analysed every year. The most recent quality assurance examination of data (patients diagnosed in 2008) against national data definitions showed accuracy rates of 90-96% across WoSCAN, the national average was 96%. The recent introduction in WoS of analysis using SRSS will enable the local CEFs to run minianalyses on their local data throughout the data cycle. This will support quality improvement whereby the CEFs and local Board Clinical Leads can quality assure their data in a timely manner and not wait until the full annual download is presented to them. 4.2 Performance Against Agreed Quality Measures Results for each of the NHS QIS Standards assessed are presented in graphical format with the underlying data also in tabular form. Data for 2010 and the results from the previous year (2009) are given to enable comparative analysis. The data is presented as a combination of bar charts, pie charts and line graphs. The majority of the results in the charts are displayed as a percentage of the overall number of cases. 4.3 Results There were 2301 new diagnoses recorded by the lung cancer MCN in the WoS during 2010, of these 2196 were lung cancers and 105 mesothelioma. Of the lung cancer diagnoses around 16% were small cell lung cancers (SCLC) and 63% were non small cell lung cancers (NSCLC). The other 21% of cases of lung cancer recorded were made up of classifications shown in figure 6. Final Published Lung Cancer Managed Clinical Network Audit Report v1.0 8 th November 2011 10
Figure 4 shows the distribution of lung cancer cases across Boards within the WoS and table 4 shows the distribution of mesothelioma cases. Figure 5 shows the breakdown of cancer type and figure 6 shows the variation in types of lung cancer. Figure 4: Distribution of Lung Cancer Cases (2170 WoS cases) (2196 WoS cases) Number of Cases Analysis Health Board Group AA Clyde FV LS NG SG WoS 2009 2010 2009 2010 2009 2010 2009 2010 2009 2010 2009 2010 2009 2010 N (lung) 288 290 318 318 174 191 415 435 632 617 343 345 2170 2196 Table 4: Distribution of Mesothelioma Cases AA Clyde FV LS NG SG WoS N 15 26 5 15 29 15 105 Figure 5: Distribution of Cancer Types in WoS Carcinoid, 0.6% Not Recorded, Clinically 0.3% Diagnosed, 19.1% Mesothelioma, 4.6% Clinically Diagnosed, 20% Carcinoid, 0.7% Other, 2.5% Figure 6: Distribution of Lung Cancer Types Not Recorded, 0.4% Other, 2.4% SCLC, 16.4% NSCLC, 56.5% SCLC, 17.2% NSCLC, 59.2% Final Published Lung Cancer Managed Clinical Network Audit Report v1.0 8 th November 2011 11
Mode of Diagnosis Dependant on clinical and other factors, a histological or cytological diagnosis is not always possible, or indeed beneficial to the patient, due to the invasive nature of investigation. A minimum of 75% of all lung cancer patients have their diagnosis confirmed by histology/cytology Figure 7: Histological/Cytological Diagnosis Percentage of Cases Health Analysis Board Group AA Clyde FV LS NG SG WoS 2009 2010 2009 2010 2009 2010 2009 2010 2009 2010 2009 2010 2009 2010 N 245 232 259 251 121 141 367 377 497 487 258 261 1747 1749 D 288 290 318 318 174 191 415 435 632 617 343 345 2170 2196 The data shows an overall histological and/or cytological confirmation rate of nearly 80% in the region. As seen from Figure 5 Lanarkshire has the highest confirmation rate at 86.7% and Forth Valley the lowest at 73.8%. As detailed above histological diagnosis is not always possible or beneficial dependant on the patient population and comorbidities. Final Published Lung Cancer Managed Clinical Network Audit Report v1.0 8 th November 2011 12
Staging Staging is the assessment of the extent of disease and is performed for prognostic and therapeutic purposes. TNM 7 (6) was implemented on 1 st January 2010 and is the current standard practice for staging all lung cancer and mesothelioma patients. TNM stage is recorded for a minimum of 90% of cases at the time of diagnosis Figure 8: Recording of TNM Stage Percentage of Cases Health Analysis Board Group AA Clyde FV LS NG SG WoS Lung Meso Lung Meso Lung Meso Lung Meso Lung Meso Lung Meso Lung Meso N 270 9 296 6 178 1 346 0 557 0 319 15 1966 31 D 290 15 318 26 191 5 435 15 617 29 345 15 2196 105 Comparison with 2009 data was not possible for this standard as in previous years TNM Stage was only reported for NSCLC. In 2010 all cases were staged using the TNM 7 staging classification including Mesothelioma. Figure 8 indicates the data completeness of staging data across the WoS. Analysis of stage was based on stage at diagnosis (pre-treatment). The results demonstrate that Lanarkshire had the lowest percentage in recording of lung cancer stage with 79.5% recorded. All other health boards met the target of 90% in recording TNM for lung cancer. With regards to staging of Mesothelioma only South Glasgow had TNM stage recorded for all patients, other teams varied with Lanarkshire and North Glasgow not having recorded stage for any mesothelioma patients. Action Required: TNM 7 is the standard staging method which should be used for mesothelioma patients diagnosed from 1 st January 2011. All lung cancer MDTs to review their data collection methodology for capturing TNM stage in mesothelioma patients. Final Published Lung Cancer Managed Clinical Network Audit Report v1.0 8 th November 2011 13
Performance Status Performance status (PS) is usually defined according to the five point internationally agreed World Health Organization (WHO) scale. PS at the time of decisions about treatment is a powerful prognostic indicator in lung cancer and is of particular importance in determining suitability of patients for chemotherapy or radical radiotherapy. WHO Performance Status is recorded for a minimum of 90% of cases at the time of diagnosis Figure 9: Recording of WHO Performance Status Percentage of Cases Health Analysis Board Group AA Clyde FV LS NG SG WoS 2009 2010 2009 2010 2009 2010 2009 2010 2009 2010 2009 2010 2009 2010 N 268 270 185 273 174 189 381 406 569 536 333 327 1910 2001 D 288 290 318 318 174 191 415 435 632 617 343 345 2170 2196 Figure 9 shows that Clyde and North Glasgow are below the standard for Lung Cancer, although the Clyde figure has improved substantially, by almost 28%, between the 2009 and 2010 analyses. Indeed across the region the recording of PS data in 2010 has improved to 91% from 88% in 2009. Action Required: Clyde should ensure that PS is discussed and documented at the MDT meeting. Final Published Lung Cancer Managed Clinical Network Audit Report v1.0 8 th November 2011 14
Breakdown of WHO Performance Status (PS) Figure 10: WHO Performance Status Distribution Across the WoS Percentage of Cases Performance Status Performance Status Figure 10 indicates the distribution of PS status for all lung cancers. The results indicate a wide spread of PS, but despite the finding that most patients tumours are discovered at an advanced stage, only a small proportion (18%) have poor PS recorded. Final Published Lung Cancer Managed Clinical Network Audit Report v1.0 8 th November 2011 15
Multidisciplinary Team (MDT) In addition to staging and performance status information being recorded, another key quality measure is whether or not the patient was discussed by the MDT. MDT working is now established as an important mechanism for ensuring that patients receive the most appropriate investigation and treatment. National guidance states that all patients should have a treatment plan discussed at a MDT meeting. All patients with a diagnosis of lung cancer are discussed by a Multidisciplinary Team Figure 11: Patients discussed by MDT Percentage of Cases Health Board Analysis Group AA Clyde FV LS NG SG WoS 2009 2010 2009 2010 2009 2010 2009 2010 2009 2010 2009 2010 2009 2010 N 286 285 292 292 174 188 408 415 588 555 323 336 2071 2071 D 288 290 318 318 174 191 415 435 632 617 343 345 2170 2196 Figure 11 shows that the overall percentage of patients discussed by the MDT during 2010 was 94.3%. NHS QIS Standard 1a.4 specifies that all patients with a diagnosis of lung cancer should be discussed by the MDT (within 4 weeks of referral). While the above data addresses whether a patient is discussed, it does not include information on timescales. Action Required: All MDTs to discuss all patients to ensure that there is an agreed management plan, even in cases where active symptom control is more appropriate. Final Published Lung Cancer Managed Clinical Network Audit Report v1.0 8 th November 2011 16
Clinical Nurse Specialist Patients have access to a Clinical Nurse Specialist (CNS) with expertise in lung cancer. Figure 12: Lung cancer patients having access to CNS Percentage of Cases Health Board Analysis Group AA Clyde FV LS NG SG WoS 2010 2010 2010 2010 2010 2010 2010 N 224 275 179 411 541 320 1950 D 290 318 191 435 617 345 2196 Figure 13: Mesothelioma patients having access to CNS Percentage of Cases 100 90 80 70 60 50 40 30 20 10 0 AA Clyde FV LS NG SG WoS Health Board Analysis Group Ayrshire Clyde FV Lanarkshire NG SG WoS 2010 2010 2010 2010 2010 2010 2010 N 12 23 5 14 22 13 89 D 15 26 5 15 29 15 105 Final Published Lung Cancer Managed Clinical Network Audit Report v1.0 8 th November 2011 17
Access to a Clinical Nurse Specialist (CNS) with expertise in lung cancer (Figure 12) is an important aspect of patient care. This was analysed for the first time using the 2010 data, and although it would appear from these results that not all patients are offered this service, incomplete documentation accounts, at least in part, for the failure of some units to meet this target. This may also reflect a need to realign the audit process to ensure adequate data capture in the future. It is recognised that there is an unmet need for CNS cover in lung cancer MDTs. This should continue to be monitored to aid development of any future case for increasing staffing. Action Required: All MDTs review how access to a CNS is documented and ensure that local audit teams are aware of the process and where to obtain the information. For patients not seen by CNS the reason for this should be documented. Treatment In general, the treatment choices for lung cancer patients include surgery, chemotherapy, radiotherapy, palliative care and active monitoring, but these individual treatment modalities are often combined. Although the proportion of patients receiving anti-cancer treatment is not a Scottish standard, it is being used as a quality measure by the National Lung Cancer Audit (NLCA). The NLCA produce an annual report which provides a full comparative analysis of data in respect of England and Wales. The 3 Scottish networks (North of Scotland Cancer Network [NOSCAN], South East Scotland Cancer Network [SCAN] and WoSCAN) contribute an agreed limited dataset to this report which demonstrates favourable comparison with other areas of the UK. Results are not yet available for comparison with 2010 data, however, the previous years WoSCAN data (patients diagnosed in 2009) is shown in the 2010 NLCA report (7). The percentage of all patients diagnosed with lung cancer receiving anti-cancer treatment is recorded (Lung Cancer Patients). Figure 14: Percentage of lung cancer patients receiving anti-cancer treatment (surgery, chemotherapy, radiotherapy, palliative care, active monitoring) Percentage of Cases Analysis Health Board Group Final Published Lung Cancer Managed Clinical Network Audit Report v1.0 8 th November 2011 18
AA Clyde FV LS NG SG WoS 2009 2010 2009 2010 2009 2010 2009 2010 2009 2010 2009 2010 2009 2010 N 169 173 211 205 101 129 259 280 415 428 210 213 1365 1428 D 288 290 318 318 174 191 415 435 632 617 343 345 2170 2196 Figure 14 shows that the active treatment rates in WoS ranged from 59.6% in Ayrshire to 69.3% in North Glasgow. Treatment rates (all active treatment not just first treatment) have slowly but steadily increased year on year since the formation of the Network and comparable audit data collection and reporting. The percentage of all patients diagnosed with lung cancer receiving anti-cancer treatment is recorded (Mesothelioma Patients). Figure 15: Percentage of Mesothelioma cancer patients receiving anti-cancer treatment (surgery, chemotherapy, radiotherapy, palliative care, active monitoring) Percentage of Cases Health Board Analysis Group AA Clyde FV LS NG SG WoS 2010 2010 2010 2010 2010 2010 2010 N 2 7 2 7 13 3 34 D 15 26 5 15 29 15 105 Figure 15 shows the active treatment rates in mesothelioma patients in the WoS ranged from 13% in Ayrshire to 46.6% in Lanarkshire. This includes all active treatments administered. Final Published Lung Cancer Managed Clinical Network Audit Report v1.0 8 th November 2011 19
The distribution of first treatment in mesothelioma patients across the Region is show in figure 16. Figure 16: First Treatment for Mesothelioma patients Died before Rx Watch Wait Mode of First Treatment Other Pt Refused Supp Care Chemo Radio Surgery 0 5 10 15 20 25 30 35 40 45 50 Percentage of Patients There is currently no nationally agreed appropriate level of intervention over and above active symptom control for mesothelioma patients. The information detailed in figure 16 will serve as a baseline for future years. It is intended that this is then compared with other areas in the UK. Surgery Surgery is the most effective curative option in NSCLC. Historically resection rates in all sub types of lung cancer, not just NSCLC, in Scotland and the rest of the UK have been lower than in other parts of the world (17% in Europe and 21% in North America) (8). In the WoS during 2010 the resection rate was 11.8%. This may be due to advanced stage of patients at presentation and comorbidities which result in the patient being considered not feasible for surgery. There was very little variation in resection rates across the region, with rates ranging from 9.1% in Clyde to 16.1% in Lanarkshire. In lung cancer patients for whom surgery is not considered an appropriate mode of first treatment due to advanced stage and/or co-morbidities, radical radiotherapy is often the alternate treatment choice. Figure 17 displays the surgical resection rate for patients in the WoS. Figure 17: Surgical Resection Rate in All Lung Cancer Patients Percentage of Cases Analysis Health Board Group Final Published Lung Cancer Managed Clinical Network Audit Report v1.0 8 th November 2011 20
AA Clyde FV LS NG SG WoS 2009 2010 2009 2010 2009 2010 2009 2010 2009 2010 2009 2010 2009 2010 N 33 38 38 29 20 23 63 70 69 64 36 35 259 259 D 288 290 318 318 174 191 415 435 632 617 343 345 2170 2196 It is anticipated that with centralisation of thoracic surgery services in the WoS, at the GJNH since 2008, and finalisation of planned mergers in WoSCAN MDTs, access to surgical opinion at MDT meetings will be improved. Work continues in all teams to maximise the opportunities provided by these changes. Figure 18 displays the type of procedure undergone by lung cancer patients whom received surgical resection. Figure 18: Surgical Resection Procedure for Lung Cancer Patients Surgery in Mesothelioma Patients Table 5: Surgery in Mesothelioma Patients Analysis Group No of surgical Mesothelioma Patients Surgical Procedure Ayrshire & Arran 7 VATS Surgical Clyde 5 Pleurodesis Forth Valley 0 Lanarkshire 1 Not recorded North Glasgow 0 South Glasgow 3 WoS 16 Surgical Pleurodesis Final Published Lung Cancer Managed Clinical Network Audit Report v1.0 8 th November 2011 21
As displayed in figure 5, all surgical procedures for mesothelioma patients, some of which were diagnostic and others palliative, were recorded. There is a requirement for further discussion on the recording of surgical procedures for mesothelioma. Action Required: Data recording for mesothelioma patients receiving surgery requires to be improved across the region. Discussion will be held with members of the Lung Cancer MCN and local CEFs regards uniformity of recording of surgical procedures in mesothelioma patients. Treatment in NSCLC Patients Radiotherapy has an established role in the management of NSCLC patients and is well documented in its effectiveness in palliating thoracic symptoms. A minimum of 35% of NSCLC patients should receive palliative radiotherapy Figure 19: NSCLC patients receiving palliative radiotherapy Percentage of Cases Health Analysis BoardGroup AA Clyde FV LS NG SG WoS 2009 2010 2009 2010 2009 2010 2009 2010 2009 2010 2009 2010 2009 2010 N 43 27 70 38 21 21 75 39 130 124 52 49 391 298 D 185 162 208 182 86 113 296 280 376 360 210 204 1361 1301 As seen from figure 19 the essential standard of 35% is not met by any health board area in WoS, although North Glasgow achived 34.4%. The regional average of NSCLC patients receiving palliative radiotherapy is 22.9%. The reason for health boards not meeting the essential standard may be explained by the increasing numbers of NSCLC patients receiving chemotherapy, as shown in figure 20. Also, this may be an ongoing data availability and completeness issue rather than low radiotherapy administration. Final Published Lung Cancer Managed Clinical Network Audit Report v1.0 8 th November 2011 22
A minimum of 20% of NSCLC patients receive chemotherapy Figure 20: Chemotherapy in NSCLC patients Percentage of Cases Analysis Health Board Group AA Clyde FV LS NG SG WoS 2009 2010 2009 2010 2009 2010 2009 2010 2009 2010 2009 2010 2009 2010 N 64 49 59 59 28 46 89 94 92 103 68 65 400 416 D 185 162 208 182 86 113 296 280 376 360 210 204 1361 1301 Figure 20 illustrates that an average of 32% of NSCLC patients in the WoS received chemotherapy as part of their management. All boards in excelled in this standard. Final Published Lung Cancer Managed Clinical Network Audit Report v1.0 8 th November 2011 23
Treatment in SCLC Patients NHS QIS Standard 5c.5 A minimum of 60% of those limited (LD) SCLC patients receiving chemotherapy also receive consolidation radiotherapy to the chest NHS QIS Standard 5c.7 A minimum of 60% of those limited (LD) SCLC patients receiving chemotherapy susequently receive prophylactic cranial irradiation (PCI) These are two important measures of quality as SCLC is a radiosensitive disease. When radiotherapy is given as part of initial treatment it has the potential to increase disease control in irradiated sites. As relapse can often be limited to the chest or brain, there is the potential for consolidation radiotherapy to the chest, or prophylactic cranial irradiation to improve survival in these patients. However, in the WoS, radiotherapy information on the whole is poorly recorded. As noted in previous years reports this is particularly true for patients who go on to receive radiotherapy after receiving chemotherapy. In the past extraction of multimodality treatment information was not straightforward and after initial data capture there was not always re-interrogation of the data. In the past 12 months however, the Information Team at the Beatson West of Scotland Cancer Centre (BWoSCC) have begun to provide boards with regular downloads in respect of patients from their area who have received radiotherapy. This in turn has led to better data capture by the local audit teams and improved reporting as illustrated by tables 6 and 7. A minimum of 60% of those limited disease SCLC patients receiving chemotherapy also receive consolidation radiotherapy to the chest Table 6: Limited disease SCLC patients receiving chemotherapy who also received consolidation radiotherapy to the chest Analysis Group 2009 2010 Ayrshire & Arran 16.7% 62.5% Clyde 33.3% 85.7% Forth Valley 10.0% 62.5% Lanarkshire 26.3% 34.8% North Glasgow 55.6% 64.0% South Glasgow 62.5% 55.6% WoS 40.2% 55.6% Final Published Lung Cancer Managed Clinical Network Audit Report v1.0 8 th November 2011 24
A minimum of 60% of those limited disease SCLC patients receiving chemotherapy subsequently receiving prophylactic cranial irradiation (PCI) Table 7: Limited disease SCLC patients receiving chemotherapy who subsequently received prophylactic cranial irradiation (PCI) Analysis Group 2009 2010 Ayrshire & Arran 0.0% 0.0% Clyde 11.1% 42.9% Forth Valley 0.0% 0.0% Lanarkshire 42.1% 17.4% North Glasgow 58.3% 76.0% South Glasgow 43.8% 66.7% WoS 36.3% 39.5% With regards to the variation in results across the region it was noted that the radiotherapy information being issued by the BWoSCC does not contain information on PCI. This will be addressed for future reporting and analysis. Action Required: It is requested that Ayrshire and Arran, Forth Valley and Lanarkshire undertake a retrospective audit of those limited disease SCLC patients receiving chemotherapy which includes review of the BWoSCC case notes. Final Published Lung Cancer Managed Clinical Network Audit Report v1.0 8 th November 2011 25
Chemotherapy Chemotherapy remains the standard primary treatment for SCLC and its effectiveness is well documented. A minimum of 60% of SCLC patients receive chemotherapy Figure 21: Chemotherapy in SCLC patients Percentage of Cases 100 90 80 70 60 50 40 30 20 10 0 2009 2010 AA Clyde FV LS NG SG WoS Health Analysis Board Group AA Clyde FV LS NG SG WoS 2009 2010 2009 2010 2009 2010 2009 2010 2009 2010 2009 2010 2009 2010 N 36 28 26 38 18 17 46 55 79 76 34 34 239 248 D 55 56 46 61 30 27 61 79 110 108 45 47 347 378 In WoS, 65.6% of SCLC patients received chemotherapy as part of their treatment, as shown in figure 21. Only one Board area, Ayrshire and Arran, did not meet the essential standard - only 50% of SCLC patients received chemotherapy. Final Published Lung Cancer Managed Clinical Network Audit Report v1.0 8 th November 2011 26
30 Day Mortality in Lung Cancer Patients Following Treatment Surgical Mortality Table 8 shows the 30 day mortality rate following surgery for lung cancer. Table 8: Surgical 30 day mortality rate Health Board No of surgical Patients Number dying within 30 days of final surgery Percentage (%) Ayrshire & Arran 38 1 2.6% Clyde 29 1 3.4% Forth Valley 23 0 0.0% Lanarkshire 70 0 0.0% North Glasgow 64 2 3.1% South Glasgow 35 0 0.0% WoS 259 4 1.5% This is slightly lower than the national 30 day surgical mortality rate of 1.7%. Radiotherapy Mortality Radiotherapy 30 day mortality rate is calculated as death within 30 days of the date of completion of radiotherapy. Rates for the WoS are illustrated in table 9. Table 9: Radiotherapy 30 day mortality rate Health Board No of Radiotherapy Patients Number dying within 30 days of final radiotherapy Percentage (%) Ayrshire & Arran 115 11 9.6% Clyde 102 12 11.8% Forth Valley 65 5 7.7% Lanarkshire 126 3 2.3% North Glasgow 295 53 17.9% South Glasgow 137 7 5.1% WoS 840 91 10.8% NHS QIS Standard 5c.13 specifies that the 30 day mortality rate following final radiotherapy with curative intent is recorded and analysed. Treatment intent is not considered in analysis of this standard 30 day mortality following all radiotherapy is calculated. Action Required: For true reporting in line with the QIS Standard 5c.13 accurate recording of radical and palliative intent should be captured by all NHS Boards. Final Published Lung Cancer Managed Clinical Network Audit Report v1.0 8 th November 2011 27
Chemotherapy Mortality Chemotherapy 30 day mortality rate is calculated as death within 30 days of final chemotherapy administration. Unfortunately this data is not available for 2010 as recording was not uniform enough to allow for accurate reporting. Action Required: Discussion will be held in a wide forum with members of the Lung Cancer MCN and CEFs regards the best way to accurately and uniformly record this information and ensure accurate end dates of chemotherapy are recorded. It is anticipated that this will be further facilitated by the introduction of the Chemotherapy Electronic Prescribing and Administration System (CEPAS). 5. Conclusions The Lung Cancer MCN are encouraged that most units are meeting the NHS QIS Standards. The results presented in this report once again demonstrate that patients with Lung cancer in the West of Scotland continue to receive a consistent standard of care. We are encouraged by the progress which has been made over the last year and the network will actively take forward the required actions in this report in conjunction with local NHS Boards. 5.1 Required Actions Identified All Boards to ensure that mesothelioma data is well recorded as this is now part of the standard reporting process, and will be subject to comparative reporting in the next report. Particular attention should be given to: o Ensuring that mesothelioma TNM stage is clearly documented in case notes and discussed at local MDT meetings to enable local audit staff to accurately record this data. o Recording of surgical procedure undertaken in mesothelioma patients. Uniformity of recording is required. Clyde to ensure a more robust PS recording system at MDT to ensure this information is documented. All MDTs to discuss all patients, even in cases where active symptom control is the management option, to ensure that there is an agreed management plan for all patients. Method of recording/documenting access to a CNS to be reviewed and local audit teams made aware of the process and where to obtain this information. Reasons for patients not seeing a CNS should be documented. Reporting of PCI in limited disease SCLC patients to be improved particularly in NHS Ayrshire and Arran, NHS Forth Valley and NHS Lanarkshire. It is recommended that a retrospective audit of local case notes and BWoSCC case notes is undertaken. Encourage a closer relationship between audit support teams and the MDT/clinical team, building on the good progress made in year through closer working relationships. Intent of radiotherapy treatment should be captured to enable accurate recording of performance against NHS QIS Standard 5c.13. Uniform practice should be adopted in respect of chemotherapy date recording, particularly in respect of end date of chemotherapy. This will be discussed in a Lung Cancer MCN wide forum with clinical staff and CEFs. Final Published Lung Cancer Managed Clinical Network Audit Report v1.0 8 th November 2011 28
Acknowledgement This report has been prepared using clinical audit data provided by the following Health Boards in the WoSCAN area: NHS Ayrshire and Arran NHS Forth Valley NHS Greater Glasgow 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 Lung Cancer Managed Clinical Network Audit Report v1.0 8 th November 2011 29
Abbreviations BWoSCC CEF CNS CEPAS ecase GJNH ISD MCN MDT MDTM NHS GGC NHS QIS NICE NLCA NOSCAN NSCLC PCI PS SCAN SCLC SIGN SSRS TNM WHO WoS WoSCAN Beatson West of Scotland Cancer Centre Clinical Effectiveness Facilitator Clinical Nurse Specialist Chemotherapy Electronic Prescribing and Administration System Electronic Cancer Audit Support Environment Golden Jubilee National Hospital Information Services Division Managed Clinical Network Multidisciplinary Team Multidisciplinary Team Meeting NHS Greater Glasgow and Clyde NHS Quality Improvement Scotland National Institute for Clinical Excellence National Lung Cancer Audit North of Scotland Cancer Network Non Small Cell Lung Cancer Prophylactic Cranial Irradiation Performance Status South East Scotland Cancer Network Small Cell Lung Cancer Scottish Intercollegiate Guidelines Network SQL Standard Reporting Service Tumour, Nodes, Metastases (staging system) World Health Organisation West of Scotland West of Scotland Cancer Network Final Published Lung Cancer Managed Clinical Network Audit Report v1.0 8 th November 2011 30
References 1. Better Cancer Care, An Action Plan, 2008 2. Trends in Cancer Survival in Scotland - 1983 2007, ISD, National Services Scotland, August 2010 3. Detect Cancer Early Programme Draft National Implementation Plan, Scottish Government Health Directorates, June 2011 4. Tackling Tobacco within NHS Greater Glasgow and Clyde, Board Paper 11/46 5. NHS QIS Standards for Lung Cancer 2008 5. TNM Classification of Malignant Tumours, 7 th Edition, UICC 6. The NHS Information Centre, National Lung Cancer Audit 2010 7. Management of Patients with Lung Cancer - SIGN Guideline 80, 2005 Final Published Lung Cancer Managed Clinical Network Audit Report v1.0 8 th November 2011 31