Urological Cancers Managed Clinical Network Activity Report July 2012 June 2013 Mr Seamus Teahan Consultant Urologist MCN Clinical Lead Tom Kane MCN Manager 1
CONTENTS EXECUTIVE SUMMARY 3 1. INTRODUCTION 5 2. MCN WORKPLAN AND ACTIVITIES (REPORTING PERIOD 07/2012 TO 06/2013) 5 2.1 CORE OBJECTIVES 5 2.2 INDIVIDUAL MCN OBJECTIVES 6 2.3 OTHER MCN ACTIVITIES 6 3. QUALITY ASSURANCE / SERVICE DEVELOPMENT AND IMPROVEMENT 7 4. KEY PRIORITY AREAS FOR THE MCN IN THE NEXT 12 MONTHS 9 5. CONCLUSION 10 ACKNOWLEDGEMENT 11 2
Executive Summary Introduction The purpose of this document is to report the Urological Cancers Managed Clinical Network (MCN) activities in respect of: Performance against agreed objectives; Outcomes achieved; and Challenges encountered and actions taken to remedy defined issues. This activity report covers July 2012 to June 2013. It also reports on key audit findings and resultant actions from the 2011 clinical audit, as well as looking forward from July 2013 to June 2014. MCN Objectives The urological cancers MCN has made progress and delivered a number of key objectives which include: Implementation of Regional Follow Up Consensus Guidelines: following MCN wide engagement, the future model for follow up in prostate cancer patients was presented to and ratified by the Regional Cancer Clinical Leads Group and the Regional Cancer Advisory Group in December 2012. Implementation has been assessed across the partner Boards and planning for implementation of the guidelines is being discussed at a local level; Clinical Management Guideline (CMG) Review: The review process for the Castrate Refractory Prostate Cancer CMG has been completed in line with the agreed governance framework; Enhanced Recovery After Surgery (ERAS): There has been discussion amongst the steering group members on potential opportunities to apply enhanced recovery techniques. It is recognised that the benefit is with pre-operative/pre-intervention optimisation of patients and managing patient/carer expectations with good communication; Quality Performance Indicator (QPI) Development: MCN members have been well represented in this national programme. Following publication of the Prostate cancer QPIs in July 2012 the Steering Group undertook an exercise to benchmark performance of how close the MCN is to the specified quality measures. The Steering Group noted that the Prostate cancer QPIs would be challenging to achieve and will drive up quality as they are implemented. MCN members are continuing to work on the bladder QPIs; and Regional Clinical Audit: The 2011 clinical audit data report published in April 2013 is available on the (WoSCAN) website and the action plans are monitored on a regular basis by the Steering Group. Key Priority Areas for the MCN in the next 12 months The MCN work plan has been developed with an emphasis on identifying outcomes that improve the quality of patient care and overall efficiency. Below are the objectives to be progressed in the coming year: Support delivery of the regional clinical audit work programme for 2013/14, ensuring the regional governance process is adhered to; Support delivery of the national cancer QPI development programme; Develop exemplar ERAS pathways for the pre-surgical management of urological cancer patients across the West of Scotland; Develop a regional service map for urological cancers service provision, detailing the points of service delivery and the connections between them; 3
Take forward regionally the national programme Transforming Care After Treatment; Coordinate the review of urological cancers CMGs; Prepare for developments in prostatic surgery, following the publication of the Healthcare Improvement Scotland Evidence note in May 2013; and Complete the development of an outline business case to formalise the establishment of a regional penile cancer service. 4
1. Introduction The Urological Cancers MCN was established in 2003 as a means of delivering equitable high quality clinical care to all Urological cancer patients across the NHS Boards that comprise the West of Scotland (WoS) region: Ayrshire & Arran, Forth Valley, Greater Glasgow and Clyde and Lanarkshire. The 2011 WoSCAN audit data showed the following distribution of cancers: 50.6% Prostate cancer patients (1228) 28.8% Bladder cancer patients (699) 14.5% Renal cancer patients (353) 1.9% Renal/Pelvis/Ureter (47) 4.2% Testicular cancer patients (101) 1.4% Penile cancer patients (35) Greater Glasgow has the highest concentration of patients and when combined with Clyde figures provides services for 1239 (50.3%) of all urological cancers in the WoS. A number of patients come from other health boards into Glasgow for treatment e.g. prostate cryotherapy. The purpose of this document is to report the MCN activities in respect of: Performance against agreed objectives; Outcomes achieved; Challenges encountered and actions taken to remedy defined issues; and Update on progress of actions identified from the Audit Report. MCN Governance The Steering Group meets three times per annum with representation from each of the NHS Boards and all relevent specialities involved in the management of urological cancers. The Steering Group also benefits from active patient representation. The Steering Group is consulted between meetings as required by the lead and manager. Mr Seamus Teahan, Consultant Urologist, NHS Forth Valley continues in the clinical lead role. Dr Rob Jones, Senior Lecturer and Honorary Consultant Medical Oncologist at the Beatson West of Scotland Cancer Centre is the deputy lead. The input of all members of the MCN has been invaluable in supporting the delivery of the MCN work plan during 2012/13. 2. MCN Workplan and Activities (reporting period 07/2012 to 06/2013) 2.1 Core Objectives Implementation of Regional Follow Up Consensus Guidelines Following MCN wide engagement, the future model for prostate cancer follow up was presented to and ratified by the Regional Cancer Clinical Leads Group (RCCLG) and the Regional Cancer Advisory Group (RCAG) in December 2012. The Follow Up Regional Consensus Guidelines was formally issued to the partner Boards for detailed impact assessment and planning for implementation. No barriers to implementation have been identified and in support of implementation, follow up is discussed at Steering Group meetings with members indicating that the guideline is being discussed at a local level. 5
Enhanced Recovery After Surgery (ERAS) There has been discussion amongst the Steering Group members on potential opportunities to apply ERAS techniques. It is recognised that the benefit is with pre-operative/pre-intervention optimisation of patients and managing patient/carer expectations with good communication. It has been agreed that the MCN will develop specific ERAS pathways for prostate, bladder and kidney cancer patients. This will carry forward into the work plan for 2013/14. Regional Clinical Audit Programme A key area of work for the MCN was to effectively utilise audit findings to inform and drive service improvement. The 2011 audit report and progress with action plans are being discussed on a regular basis at the Steering Group. This process is intended to deliver incremental and sustainable improvements in the quality of patient care. National Quality Performance Indicator Development Programme (QPI) The MCN was involved in supporting the development of national QPI for prostate cancer which were published in July 2012. The MCN Steering Group reviewed the prostate QPIs noting the potential implications. The QPIs were also discussed at the annual education event where the audit data presented was based on the QPIs. MCN members are also currently involved in developing QPIs for bladder and also testicular cancers. 2.2 Individual MCN Objectives Review of Clinical Management Guidelines (CMGs) CMGs ensure the safe and equitable management of patients across the West of Scotland Cancer Network (WoSCAN) area whilst optimising the effectiveness of treatment and care. The review of the castrate refractory prostate cancer CMG has been led by Dr Jones and has been completed. Ongoing review of other urological cancer CMGs will continue into the workplan for 2013/14 2.3 Other MCN Activities Education An educational event was held in Glasgow in March 2013. The event was well attended by a variety of professions from the MCN. The 2011 MCN clinical audit data was presented, with a particular emphasis on prostate and renal cancers, due to the availability of the QPIs. The meeting benefited from external speakers, including the National Clinical Lead for ERAS in NHS England and a Professor of Clinical Oncology from the University of Birmingham. Topics presented and discussed included: Enhanced Recovery After Surgery; Contemporary Management of Muscle Invasive Bladder Cancer: an Oncologist s Perspective; Audit (1) Prostate Cancer; and Audit (2) Renal Cancer. Data Sharing Request The MCN has had a request from a member to undertake a defined audit, which would require sharing data currently held by the MCN. Specifically a request was made for the MCN to provide information for an examination of trends in reporting prostate cancer in the West of Scotland in 2010 and 2011, in order that comparison could be made with 2008 data and with pathology data from pathology departments. This request was discussed and approved by MCN members representing the partner Boards. The information provided will highlight examples of good practice as well as any 6
variation and allow network members to share good practice or take steps to minimise variation as required. Active Surveillance (AS) The MCN was asked to support a piece of work ongoing (By colleagues in Glasgow Royal Infirmary and the University of Glasgow) that will make comparison between current practice amongst clinicians using AS compared with recommendations from the National Institute of Health and Clinical Excellence (NICE) in England. The group will come back to the Steering Group in due course to advise of the outcome, which will afford the opportunity for the MCN to take a view on current practice and also on the potential to create a definition of AS that can be used by clinicians across the WoS. Gonadorelin Analogues for Advanced Prostate Cancer Following the completion of a review of the options for treatment in order to standardise therapy the MCN has monitored the implementation, noting that local Health Boards are progressively moving patients to the gonadorelin analogue of choice. Penile Cancer The MCN gained support from RCAG to formalise a regional penile cancer service. Having previously developed a CMG for penile cancer, the MCN has now developed a referral pathway for the partner Boards to send patients into Glasgow. The MCN is currently finalising an outline business case to support the formalising of a regional service model for the surgical management of penile cancer. 3. Quality Assurance / Service Development and Improvement The primary function of the MCN is to facilitate continuous clinical service improvement, supporting delivery of high-quality, equitable, treatment and care to patients with urological cancers in the WoS. The MCN prospective clinical audit programme underpins much of the regional service development and improvement work of the MCN and supports quality assurance (QA) by providing the means for regular assessment and reporting against recognised and agreed measures of service performance and quality. The annual regional quality assurance of service provision utilises regionally agreed Outcome Measures. The latest report of audit data is based on 2428 new diagnoses of urological cancers presenting in 2011, set against results obtained from the previous report. The MCN QA process requires local multi-disciplinary teams to critically review and verify their own results before being collated to provide a regional comparative report of performance against agreed measures and variance between MDTs. The report of the 2011 clinical audit data was published in April 2013 and can be found in the WoSCAN internet site. Regional Audit and Governance Process In accordance with agreed governance procedures, partner Boards were asked to produce Action/Improvement Plans, in response to audit findings, to take forward recommendations set out in the Audit Report; the expectation thereafter is that these actions will be progressed and monitored via local governance structures. Plans are expected to be submitted to the Regional Information Manager within two months of publication of the report. An Action/Improvement Plan template is provided to ensure consistency and standardisation across the region. The MCN Manager/Clinical Lead have been reviewing the Board Action Plans to identify priorities for co-ordinated regional action and these, along with progress against specific Board actions are monitored throughout the year by the Steering Group under the standing MCN Work Plan agenda item. 7
Action Plan Progression Recommended actions on the basis of the key findings of the audit report were directed to partner Boards requesting that local plans are developed to address areas of deficiency identified. All NHS Boards have produced Action/Improvement plans and outlined below is a high level summary of progress. Service Improvement Prostate: Forth Valley and Lanarkshire have reviewed radical prostatectomy cases with margin involvement. Forth Valley concluded that they will ensure all cases are recorded accurately. Lanarkshire carried out further analysis. In 3 cases where margins were involved the PSA was <0.2. It was concluded that service change was not required to meet the indicator. Ayrshire & Arran review the patients prospectively. All of their patients following radical prostatectomy pathway are discussed at Multi-Disciplinary Team Meetings (MDTs) and positive margin involvement is noted and assessed in the MDT outcome sheet. Renal: All NHS Boards have reviewed local protocols relating to the management of non-surgical renal cancer patients to ensure histological confirmation of diagnosis is obtained prior to any non-surgical treatment. All NHS Boards have reviewed local protocols to ensure all suitable non metastatic patients are considered for radical nephrectomy. Lanarkshire has added TNM staging to the MDT. electronic page to ensure better data capture. Ayrshire & Arran discuss at the MDT. Bladder: All NHS Boards have reviewed local protocols to ensure all eligible bladder cancer patients receive neo-adjuvant chemotherapy where appropriate, in line with the WoSCAN Clinical Management Guideline. NHS Forth Valley advises that access to Chemocare will improve the documentation of chemotherapy audit data. Lanarkshire are investigating the possibility of including this in the electronic MDT page. Ayrshire & Arran discuss this at the MDT. All NHS Boards have reviewed local protocols for the management of radical cystectomy patients to determine whether lymph node dissection can be optimised. Forth Valley is looking to improve documentation. Lanarkshire concluded that their data collection is poor and are currently looking to improve this. The bladder audit form in Lanarkshire will include a lymph node dissection data item. Ayrshire & Arran note the need to ensure that this is documented and will discuss developing a proforma. Testicular: All Health Board have reviewed protocols for management of patients undergoing orchidectomy to establish ways to increase the proportion of patients that are offered prosthesis. Forth Valley indicated that they will ensure that the patient leaflets available will be fully utilised. Ayrshire & Arran are discussing developing a proforma to facilitate consistent reporting. Ayrshire & Arran were asked to monitor chemotherapy rates for testicular cancer patients and ensure all cases are referred to oncology in accordance with the WoSCAN CMG. All of their new patients are discussed at the MDT and referred onwards appropriately in line with the WoSCAN CMG. 8
Data Quality Improvement Greater Glasgow and Clyde now have TNM data recorded as standard at the MDT meeting for new cancer diagnosis. Ayrshire & Arran and Lanarkshire have reviewed their data quality for TNM staging. Lanarkshire will be developing an audit form and implement it for prostate and bladder cancers. They will also develop quality assurance reports to allow periodic assessment. Ayrshire & Arran note that their data quality has improved and that this information is gathered at the MDT. If for any reason TNM is not recorded, then it is discussed with the Clinical Nurse Specialist. All NHS Boards have reviewed processes for capture of pathological information to facilitate accurate measurement of surgical margin involvement for prostatectomies. Lanarkshire has re-affirmed the importance of completion of all data items on pathology forms with relevant staff. Ayrshire & Arran are in discussion with their audit facilitator to progress this. Ayrshire & Arran have reviewed audit processes for accurate recording of dates to ensure robust assessment of whether patients have a histological diagnosis of renal cancer prior to non-surgical treatment. All NHS Boards have reviewed data capture methods to ensure all surgical information for bladder cancer patients are obtained especially whether number of patients undergoing lymph node dissection is carried out to facilitate robust outcome measurement. Forth Valley will look to improve documentation. Lanarkshire will develop an audit form and implement it for prostate and bladder cases. Lanarkshire will also establish closer working between groups to make further improvements. Ayrshire & Arran are looking to develop a proforma to improve data capture. All NHS Boards have reviewed the position regarding the documentation of patients offered prosthesis to ensure accurate assessment can be made regarding the service provided to testicular cancer patients. Forth Valley plan to improve their documentation of the conversation held with patients regarding prosthesis. Lanarkshire are investigating the possibility of inclusion in an electronic MDT page. Ayrshire & Arran are looking to develop a proforma to improve data capture. All Health Boards have agreed the need to establish processes for the documentation of TNM data and serum tumour markers for testicular cancers to facilitate calculation of disease stage. Greater Glasgow and Clyde now record TNM data as standard at the MDT. Escalation Process Any service or clinical issue which the Steering Group considers not to have been adequately addressed will be escalated to the Regional Lead Cancer Clinician and relevant territorial NHS Board Cancer Clinical Lead by the MCN Clinical Lead. 4. Key Priority Areas for the MCN in the next 12 months The MCN work plan has been developed with an emphasis on identifying outcomes that improve the quality of patient care and overall efficiency. Below are the objectives to be progressed in the coming year: Support delivery of the regional clinical audit work programme for 2013/14, ensuring the regional governance process is adhered to; Support delivery of the national cancer QPI development programme; Develop exemplar ERAS pathways for prostate, bladder and kidney cancers for the surgical management of urological cancer patients, to support implementation of ERAS activities across the West of Scotland; 9
To develop a regional service map for urological cancers service provision, detailing the points of service delivery and the connections between them; Take forward regionally the national programme Transforming Care After Treatment (TCAT); Coordinate the review of CMGs; Prepare for developments in prostatic surgery following the publication of the Healthcare Improvement Scotland Evidence note in May 2013; and Complete development of outline business case to formalise establishment of a regional penile cancer service. 5. Conclusion The MCN has had a productive year and in order for the clinical lead and manager to perform their duties effectively, the support of the Steering Group is vital. The MCN has continued to work closely with local and regional clinical and management teams across the region. The work on prostate cancer follow up work has been highly significant and it is expected that it will have a major impact as it is implemented. The ongoing review of CMGs has helped to ensure that patients receive care based on the most up to date evidence. Looking ahead, the MCN welcomes the opportunity to work with colleagues nationally on the TCAT programme as well as working regionally on a number of agreed pieces of work to ensure that the quality of care provided for urological cancers patients increases. The MCN will prepare for developments in prostatic surgery following the publication of the Health Improvement Scotland evidence note in May 2013. 10
Acknowledgement This report represents the achievements and challenges progressed across the four NHS Boards of the : NHS Ayrshire & 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 Managed Clinical Network, without their efforts this level of progress would not be possible. 11