Audit Report - West of Scotland Cancer Network · 2020. 2. 20. · Final - Skin Cancer MCN Audit...

The content of this report is © copyright WoSCAN unless otherwise stated.

1

Audit Report

Cutaneous Melanoma Quality Performance Indicators

Clinical Audit Data: 1

st July 2018 to 30

th June 2019

Mr Roger Currie MCN Clinical Lead Heather Wotherspoon MCN Manager Aishah Hanif Information Analyst

West of Scotland Cancer Network Skin Cancer Managed Clinical Network

West of Scotland Cancer Network Final - Skin Cancer MCN Audit Report v1.0 20/02/2020

2

Table of Contents

EXECUTIVE SUMMARY 3

1. INTRODUCTION 9

2. BACKGROUND 10

2.1 NATIONAL CONTEXT 10

2.2 WEST OF SCOTLAND CONTEXT 10

3. METHODOLOGY 13

4. RESULTS AND ACTION REQUIRED 14

4.1 DATA QUALITY 14

4.2 PERFORMANCE AGAINST QUALITY PERFORMANCE INDICATORS (QPIS) 15

QPI 1: EXCISION BIOPSY 16

QPI 2: PATHOLOGY REPORTING 20

QPI 3: MULTI-DISCIPLINARY TEAM MEETING (MDT) 23

QPI 4: CLINICAL EXAMINATION OF DRAINING LYMPH NODE BASINS 26

QPI 5: SENTINEL NODE BIOPSY PATHOLOGY 29

QPI 6: WIDE LOCAL EXCISIONS 31

QPI 7: TIME TO WIDE LOCAL EXCISION 34

QPI 8: BRAF STATUS 38

QPI 9: IMAGING FOR PATIENTS WITH ADVANCED MELANOMA 40

QPI 10: SYSTEMIC THERAPY 43

QPI 12: SURGICAL MARGINS 45

QPI 13: CLINICAL TRIALS 48

5. CONCLUSIONS 50

ACKNOWLEDGEMENT 52

ABBREVIATIONS 53

REFERENCES 54

APPENDIX I: NHS BOARD ACTION PLANS 55


3

Executive Summary

Introduction This report presents an assessment of the performance of West of Scotland (WoS) Skin Cancer Services using clinical audit data relating to patients diagnosed with cutaneous melanoma in the twelve months between 1st July 2018 and 30th June 2019. In order to ensure the success of the Cancer QPIs in driving quality improvement in cancer care, QPIs will continue to be assessed for clinical effectiveness and relevance. The initial formal review of cutaneous melanoma QPIs took place in 2018. With five years of reporting now complete, a second cycle of review will commence in December 2020. This clinically led review aims to identify potential refinements to the current QPIs and involves key clinicians from each of the Regional Cancer Networks. The review will focus on any significant changes to the QPIs that are required due to changes in evidence or clinical practice.

Background Skin Cancer services are organised around seven multi-disciplinary teams (MDTs) serving 2.5 million people4 in four NHS Boards across the WoS. The cutaneous melanoma MDTs are located in Ayrshire and Arran, Clyde, South Glasgow, North Glasgow, Forth Valley and Lanarkshire. The regional skin MDT (RMDT) is located at the Beatson West of Scotland Cancer Centre. It receives referrals from all units in the WoS; it discusses all stage III or IV cutaneous melanomas and very high risk squamous cell carcinomas, requiring either medical or radiation oncology input. Malignant melanoma was the sixth most common cancer in Scotland in 2017 with 1,229 new cases in this year6. In the ten years from 2007 to 2017, the incidence of malignant melanoma of the skin has increased by 6.0% in all persons6. This reflects an increase in incidence of 17.9% in males and a reduction of 5.9% in females6. This increase is, in the main, attributed to increased exposure to sunlight, both natural and artificial, with the trend in increased sun bed use and more people tending to holiday abroad5, 7. Whilst the incidence of malignant melanoma is increasing, survival from the disease is also improving with an increase in the five-year age-standardised relative survival for malignant melanoma from 77.9% in 1987-91 to 89.8% in 2007-11 in males, and 92.4% to 96.4% in females for the same period6. In the WoS, a total of 619 new cases of cutaneous melanoma were recorded through audit between 1st July 2018 and 30th June 2019. As the largest WoS Board, approximately 51% of all new cases of cutaneous melanoma were diagnosed in NHS Greater Glasgow and Clyde (NHSGGC) which is in line with population estimates for this Board. Of the 619 new cases of cutaneous melanoma, 51% of patients were female and 49% male. Incidence of cutaneous melanoma was higher in males for the 5-year age groups between 55-64 and 70-84, whereas the incidence was higher in females in all other age groups.

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 web-based database. Data relating to patients diagnosed between 1st July 2018 and 30th June 2019 was downloaded from eCASE at 2200 hrs on 23rd October 2019. Cancer audit is a dynamic process with patient data continually being revised and updated as more information becomes available. This


4

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 by the West of Scotland Cancer Network (WoSCAN) Information Team on behalf of the WoS NHS Boards 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.

Results The overall case ascertainment for cutaneous melanoma in WoS is high at 103.7%, which indicates excellent data capture through audit.

A summary of the Cutaneous Melanoma QPIs (QPI 1 to 13) for Year 5 (2018/19) clinical audit data is presented below, with a more detailed analysis of the results set out in the main report. Data are analysed by location of diagnosis or treatment, and illustrate NHS Board performance against each target and overall regional performance for each performance indicator. Results are presented graphically and the accompanying tabular format also highlights any missing data and its’ possible effect on any of the measured outcomes. Where the number of cases meeting the denominator criteria for any indicator is between one and four, the percentage calculation has not been shown on any associated charts or tables. This is to avoid any unwarranted variation associated with small numbers and to minimise the risk of disclosure. Any charts or tables impacted by this restricted data are denoted with a dash (-). An asterisk (*) is used to specify a denominator of zero and to distinguish between this and a 0% performance. Any commentary provided by NHS Boards relating to the impacted indicators will however be included as a record of continuous improvement. Specific NHS Board actions have been identified to address issues highlighted through data analysis.


5

Summary of QPI Results

Colour Key Symbol Key

Above QPI target ^

Small numbers in some Boards - percentage comparisons over a single year should be viewed with caution Below QPI target

Summary of the QPI results for clinical audit data. A dash (-) denotes restricted data where the denominator is less than 5. An asterisk (*) denotes data where the denominator is zero.

Quality Performance Indicator (QPI) Performance by NHS Board

QPI target Year AA FV GGC LAN WoS

QPI 1 (i): Proportion of patients with cutaneous melanoma who have their

diagnostic biopsy carried out by a skin cancer clinician. - Diagnostic excision biopsy as their initial procedure

90%

2016/17 NA NA NA NA NA

2017/18 98.7% 98.8% 100.0% 99.1% 99.4%

2018/19 97.2% 100.0% 99.6% 98.3% 99.0%

^QPI 1 (ii): Proportion of patients with cutaneous melanoma who have their

diagnostic biopsy carried out by a skin cancer clinician. - Diagnostic partial biopsy as their initial procedure

90%



2018/19 80.0% 100.0% 100.0% 100.0% 98.9%

QPI 2: Proportion of patients with cutaneous melanoma who undergo diagnostic

excision biopsy where the surgical pathology report contains a full set of data items (as defined by the current Royal College of Pathologists dataset).

90%



2018/19 94.4% 100.0% 98.4% 96.9% 97.6%

QPI 3: Proportion of patients with cutaneous melanoma who are discussed at a

MDT meeting before definitive treatment. 95%

2016/17 94.8% 87.5% 88.2% 91.5% 89.7%

2017/18 95.1% 89.9% 87.0% 93.4% 89.9%

2018/19 87.8% 95.6% 90.2% 95.4% 91.7%

QPI 4: Proportion of patients with cutaneous melanoma undergoing clinical

examination of relevant draining lymph node basins as part of clinical staging. 95%

2016/17 88.3% 83.6% 76.0% 91.5% 81.8%

2017/18 55.4% 68.9% 86.1% 94.2% 80.8%

2018/19 95.1% 71.8% 89.2% 97.4% 90.0%

^QPI 5: Proportion of patients with cutaneous melanoma who undergo SNB

where the SNB report contains a full set of data items (as defined by the current Royal College of Pathologists dataset).

90%



2018/19 80.0% 100.0% 100.0% 100.0% 98.1%

QPI 6: Proportion of patients with cutaneous melanoma who undergo a wide

local excision, following diagnostic excision or partial biopsy. 95%


2017/18 95.1% 87.4% 92.1% 95.0% 92.4%

2018/19 88.0% 94.0% 93.3% 95.1% 93.2%

QPI 7(i): Proportion of patients with cutaneous melanoma who undergo their

wide local excision within 84 days of their diagnostic biopsy. - Diagnostic excision biopsy and wide local excision within 84 days

95%

2016/17 66.7% 50.0% 77.1% 40.4% 64.3%

2017/18 59.2% 74.1% 84.3% 61.7% 73.9%

2018/19 41.4% 74.1% 78.8% 75.6% 72.2%


6

Quality Performance Indicator (QPI) Performance by NHS Board

QPI target Year AA FV GGC LAN WoS

^QPI 7(ii): Proportion of patients with cutaneous melanoma who undergo wide

local excision within 84 days of their diagnostic biopsy. - Diagnostic partial biopsy and wide local excision within 84 days

95%

2016/17 100.0% 62.5% 80.5% 46.2% 75.0%

2017/18 50.0% 28.6% 76.6% 33.3% 62.5%

2018/19 80.0% 45.5% 90.9% 45.0% 74.7%

^QPI 8: Proportion of patients with unresectable stage III or IV cutaneous

melanoma who have their BRAF status checked. 75%

2016/17 - * 100.0% - 100.0%

2017/18 * - 100.0% - 100.0%

2018/19 * * - 100.0% 100.0%

^QPI 9: Proportion of patients with stage IIC and above cutaneous melanoma

who undergo computed tomography (CT) or positron emission tomography (PET) CT within 35 days of diagnosis.

95%

2016/17

2017/18 6.3% 50.0% 42.9% 17.6% 33.3%

2018/19 13.6% 7.7% 34.6% 23.1% 21.8%

^QPI 10: Proportion of patients with unresectable stage III and IV cutaneous

melanoma undergoing SACT. 60%

2016/17 - * 83.3% - 66.7%

2017/18 * - 70.0% - 80.0%

2018/19 * * - 85.7% 77.8%

QPI 12: Proportion of patients with cutaneous melanoma where complete

excision is undertaken with documented clinical margins of 2mm prior to definitive treatment (wide local excision).

85%



2018/19 15.9% 4.8% 43.8% 60.3% 40.0%


7

Conclusions Cancer audit data underpins much of the development and service improvement work of the MCN and regular reporting of activity and performance is a fundamental requirement of an MCN to assure the quality of care delivered. The Skin Cancer MCN remains committed to improve the quality and completeness of clinical audit data to ensure continued robust performance assessment and the identification of areas for service improvement. The Skin Cancer MCN is encouraged by the results presented in this report which demonstrate that patients with cutaneous melanoma in the WoS continue to receive a consistently high standard of care. 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, specifically around documentation in relation to examination of lymph node basins, time to wide local excision, time to CT/PET CT and surgical margins. However it is encouraging that targets relating to diagnostic excision biopsy and BRAF status were consistently met by all Boards in Year 5. Some variance in performance does exist across the regions and, as per the agreed Regional governance process, each NHS Board was asked to complete a Performance Summary Report, providing a documented response where performance was below the QPI target. NHS Boards have provided detailed comments indicating valid clinical reasons or that, in some cases, patient choice or co-morbidities have influenced patient management. Data recording issues have been highlighted in relation to QPI 4 (Clinical Examination of Draining Lymph Node Basins), QPI 5 (Sentinel Node Biopsy Pathology) and QPI 12 (Surgical Margins) whilst resource issues have impacted on performance against QPI 7 (Time to Wide Local Excision). Concerns around the measurability of QPI 9 (Imaging for Patients with Advanced Melanoma) and QPI 12 have also been raised. Remaining actions are summarised below and outlined in the main report under the relevant section. The MCN will actively take forward regional actions identified and NHS Boards are asked to develop local Action/Improvement Plans in response to the findings presented in the report. A summary of actions for each NHS Board has been included within the Action Plan templates in Appendix I. Action Required: QPI 4: Clinical Examination of Draining Lymph Node Basins

NHS Forth Valley and NHSGGC to implement a template letter to ensure clinical examination of draining lymph node basins is consistently documented in patient notes.

QPI 5: Sentinel Node Biopsy Pathology

NHS Ayrshire and Arran to reinforce to pathology team the importance of recording all items on RCPath proforma.

QPI 7: Time to Wide Local Excision

NHS Ayrshire and Arran and NHSGGC to feedback to the MCN on the outcome of the audits performed on patients failing to meet the criteria for QPI 7(i). Any learning from these should be shared with WoS Boards to facilitate co-ordinated regional action to address sources of delay.

MCN to propose a change in measurability at Formal Review to exclude patients who did not have a wide local excision and those who refuse surgery.


8

QPI 9: Imaging for Patients with Advanced Melanoma

MCN to further examine the regional data to identify sources of delay and develop an action plan for improvement, if appropriate, or identify necessary measurability changes to feed in to the formal review process.

QPI 12: Surgical Margins

All Boards to ensure consistent and accurate documentation of margins for skin tumours.

MCN to submit measurability concerns for consideration as part of the Formal Review process.

MCN to analyse regional data, excluding those patients who did not have an excision biopsy. Completed Action Plans should be returned to WoSCAN within two months of publication of this report. Progress against these plans will be monitored by the MCN Advisory Board and any service or clinical issue which the Advisory Board considers not to have been adequately addressed will be escalated to the NHS Board Territorial Lead Cancer Clinician and Regional Lead Cancer Clinician. Additionally, progress will be reported annually to the Regional Cancer Advisory Group (RCAG) by NHS Board Territorial Lead Cancer Clinicians and MCN Clinical Leads, and nationally on a three-yearly basis to Healthcare Improvement Scotland as part of the governance processes set out in CEL 06 (2012).


9

1. Introduction

This report contains an assessment of the performance of West of Scotland (WoS) Skin Cancer Services using clinical audit data relating to patients diagnosed with cutaneous melanoma in the twelve months between 1st July 2018 and 30th June 2019. These audit data underpin much of the regional development/service improvement work of the Managed Clinical Network (MCN) and regular reporting of activity and performance is a fundamental requirement of an MCN to assure the quality of care delivered across the region. Twelve months of data were measured against the Cutaneous Melanoma Quality Performance Indicators (QPIs) for the fifth consecutive year following the initial Healthcare Improvement Scotland (HIS) publication of cutaneous melanoma QPIs in 2014. The three most recent years of results (Year 3-5) are presented within this audit report for QPIs where results have remained comparable. In order to ensure the success of the Cancer QPIs in driving quality improvement in cancer care, QPIs will continue to be assessed for clinical effectiveness and relevance. The initial formal review of cutaneous melanoma QPIs took place in 2018. With five years of reporting now complete, a second cycle of review will commence in December 2020. This clinically led review aims to identify potential refinements to the current QPIs and involves key clinicians from each of the Regional Cancer Networks. The review will focus on any significant changes to the QPIs that are required due to changes in evidence or clinical practice.


10

2. Background

Four NHS Boards serve the 2.5 million population of the WoS4. In Year 5, 619 cases of cutaneous melanoma were reported through audit as diagnosed in the WoS. The multi-disciplinary team (MDT) configuration for services in the region is detailed below. Table 1: Cutaneous melanoma multi-disciplinary teams and constituent hospital units in the West of Scotland.

MDT Constituent Hospital(s)

Ayrshire & Arran Crosshouse Hospital, Ayr Hospital

Clyde Royal Alexandra Hospital, Inverclyde Royal Hospital, Vale of Leven

South Glasgow Queen Elizabeth University Hospital, New Victoria Hospital, West Glasgow Ambulatory Care Hospital

North Glasgow Glasgow Royal Infirmary, Stobhill Hospital

Forth Valley Forth Valley Royal Hospital

Lanarkshire Wishaw General Hospital, Monklands District General,

Beatson West of Scotland Cancer Centre (Regional MDT)

Take referrals from all units in the West of Scotland

The regional skin MDT is co-ordinated from the Beatson West of Scotland Cancer Centre (BWoSCC). It receives referrals from all units in the WoS; it discusses all stage III or IV cutaneous melanomas and high risk squamous cell carcinomas.

2.1 National Context The overall number of cancers diagnosed in Scotland has increased over the last 10 years although incidence of some cancers is decreasing5. In the ten years from 2007 to 2017, the incidence of malignant melanoma of the skin has increased by 6.0% in all persons6. This reflects an increase incidence of 17.9% in males and a reduction of 5.9% in females6. Overall, malignant melanoma was the sixth most common cancer in Scotland in 2017 with 1,229 new cases diagnosed in this year6. This increase is, in the main, attributed to increased exposure to sunlight, both natural and artificial, with the trend in increased sun bed use and more people tending to holiday abroad5, 7. Whilst the incidence of malignant melanoma is increasing, survival from the disease is also improving with an increase in the five-year age-standardised relative survival for malignant melanoma from 77.9% in 1987-91 to 89.8% in 2007-11 in males, and 92.4% to 96.4% in females for the same period6.

2.2 West of Scotland Context In the WoS, a total of 619 new cases of cutaneous melanoma were recorded through audit between 1st July 2018 and 30th June 2019. The number of patients diagnosed within each NHS Board is presented in Figure 1. As the largest WoS Board, approximately 51% of all new cases of cutaneous melanoma were diagnosed in NHS Greater Glasgow and Clyde (NHSGGC) which is in line with population estimates for this Board. Figure 2 illustrates the number of new cases in Year 5 by 5-year age group and sex. Of the 619 new cases of cutaneous melanoma, 51% of patients were female and 49% male. Incidence of cutaneous melanoma was higher in males for those aged between 55-64 and 70-84, whereas the incidence was higher in females in all other age groups.


11

Figure 1: Number of new cases diagnosed with cutaneous melanoma in the West of Scotland, by NHS Board of diagnosis, from Year 1 (2014/15) to Year 5 (2018/19).

Figure 2: Number of new cases diagnosed with cutaneous melanoma in the West of Scotland between 1

st July 2018

and 30th

June 2019 by 5-year age group and sex.

0

100

200

300

400

500

600

700

Year 1 Year 2 Year 3 Year 4 Year 5

96 80 77 86 82

5543

7390

71

315406

326 294315

119

129

129 121151

Nu

mb

er o

f n

ew

ca

se

s

Year of analysis

AA FV GGC LAN

01

2

10

8

15

27

35 35

27

41

46

42

15

8

5

14

1617

20

33

30

3231

33

31

2223

0

5

10

15

20

25

30

35

40

45

50

<25 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+

Nu

mb

er o

f n

ew

ca

se

s

5-year age group

Male Female


12

The clinical site of melanomas diagnosed in the WoS in Year 5 is presented by sex in Figure 3. The gender difference can be seen with males more likely to have melanomas located on the head & neck and trunk, whereas females are more likely to have melanomas located on the upper and lower limbs.

Figure 3: Proportion of new cases diagnosed with cutaneous melanoma in the West of Scotland between 1

st July

2018 and 30th

June 2019 by sex for each clinical site of tumour. The data labels represent the corresponding number of new cases diagnosed.

84

130

50

1

30

3

4

2

42

68

70

3

111

11

8

2

Head & Neck

Trunk

Arm

Hand & Palm

Leg

Foot & Sole

Metastatic disease only

Other

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Clin

ica

l sit

e o

f tu

mo

ur

Proportion of new cases (%)

Male Female


13

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 web-based database. Data relating to patients diagnosed between 1st July 2018 and 30th June 2019 with cutaneous melanoma was downloaded from eCASE at 2200 hrs on 23rd October 2019. 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 by the West of Scotland Cancer Network (WoSCAN) Information Team on behalf of WoS NHS Boards 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.


14

4. Results and Action Required

4.1 Data Quality Audit data quality can be assessed in the first instance by estimating the proportion of expected patients that have been identified through audit. Case ascertainment is calculated as the number of new cases identified by the audit as a proportion of the number of cases reported by the National Cancer Registry (provided by ISD, National Services Scotland), by NHS Board of diagnosis. Cancer Registry figures were extracted from ACaDMe (Acute Cancer Deaths and Mental Health), a system provided by ISD. Cancer Registry figures are an average of the previous five years’ figures to take account of annual fluctuations in incidence within NHS Boards. As the number of cases will vary each year, it is possible for case ascertainment to be over or under 100%. Therefore, the figures presented should be seen as an indication only. The overall case ascertainment for cutaneous melanoma in WoS is high at 103.7%, which indicates excellent data capture through audit. Case ascertainment figures however are provided for guidance and are not an exact measurement as it is not possible to compare directly with the same cohort. Table 2 details the case ascertainment for the four Boards within the WoS. This level of data capture aids the interpretation of analysis based on cancer audit data, as more complete data will return more reliable results. Table 2: Case ascertainment by Board of diagnosis, given as a proportion of average number of new cases from Cancer Registry data between 2013 and 2017, for patients diagnosed with cutaneous melanoma in Year 5 (2018/19).

AA FV GGC LAN WoS

New cases from audit data from Jul 2018 – Jun 2019

82 71 315 151 619

New cases from Cancer Registry data (2013-17)

87 66 315 129 597

% Case ascertainment 94.3% 107.6% 100.0% 117.1% 103.7%


15

4.2 Performance against Quality Performance Indicators (QPIs) Results of the analysis of Cutaneous Melanoma QPI (QPIs 1 to 13) are set out in the following sections. Data are presented by location of diagnosis or treatment, and illustrate NHS Board or performance against each target and overall regional performance for each performance indicator. Results are presented graphically and the accompanying tables also highlight any missing data and its possible effect on any of the measured outcomes for the current year of 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 restricted data are denoted with a dash (-). An asterisk (*) is used to specify a denominator of zero and to distinguish between this and a 0% performance. Any commentary provided by NHS Boards relating to the impacted indicators will however be included as a record of continuous improvement. Specific regional and NHS Board actions have been identified to address issues highlighted through the data analysis.


16

QPI 1: Excision Biopsy Description:

Proportion of patients with cutaneous melanoma who have their initial diagnostic biopsy carried out by a skin cancer clinician*.

Numerator: (i) Number of patients with cutaneous melanoma undergoing diagnostic excision biopsy as their initial procedure who had this carried out by a skin cancer clinician*.

(ii) Number of patients with cutaneous melanoma undergoing diagnostic partial biopsy as their initial procedure who had this carried out by a skin cancer clinician*.

Denominator: (i) All patients with cutaneous melanoma undergoing diagnostic excision biopsy as

their initial procedure. (ii) All patients with cutaneous melanoma undergoing diagnostic partial biopsy as

their initial procedure.

Exclusions: No exclusions.

Target: 90%

*Please note: a skin cancer clinician can be defined as a:

Dermatologist;

Plastic Surgeon;

Oral and Maxillofacial Surgeon, or

A locally designated clinician with a special interest in skin cancer, who is also a member (or under the supervision of a member) of the melanoma MDT.

The initial biopsy is important for both diagnosis and pathological staging. Evidence has shown an excision biopsy to be the most appropriate procedure as it allows accurate evaluation of tumour thickness and other prognostic factors1. If melanoma is suspected, an excision biopsy should be carried out to ensure the melanoma is completely removed, except in rare circumstances where an incision or shave biopsy may be a more appropriate initial procedure due to location or size of lesion. Patients suspected of having melanoma should be referred to secondary care to have their excision biopsy carried out by someone with specialist experience in melanoma1. At formal review it was decided to split the QPI into two parts. Part (i) looks at patients undergoing excision biopsy as their initial procedure while part (ii) looks at patients undergoing partial biopsy as their initial procedure. Due to the changes to the QPI, Year 4-5 results are presented for Part (i) with only Year 5 results presented for Part (ii). For Year 5, a more detailed breakdown of the data is shown in the accompanying tables.


17

QPI 1(i)

Description:

Proportion of patients with cutaneous melanoma who have

their initial diagnostic biopsy carried out by a skin cancer

clinician*.

Numerator:

Number of patients with cutaneous melanoma undergoing diagnostic excision biopsy as their

initial procedure who had this carried out by a skin cancer

clinician*.

Denominator:

All patients with cutaneous melanoma undergoing diagnostic

excision biopsy as their initial procedure.

Exclusions:

No exclusions.

Target: 90%

Figure 4: Summary of QPI 1(i) results, illustrating the proportion of patients with cutaneous melanoma undergoing diagnostic excision biopsy as their initial procedure who had this carried out by a skin cancer clinician*, by NHS Board of diagnosis from Year 4 (2017/18) to Year 5 (2018/19). The red line represents the QPI target of 90%. Table 3: Details of QPI 1(i) results by NHS Board of diagnosis for Year 5 (2018/19).

QPI 1(i) Target: 90%

AA FV GGC LAN WoS

% Performance (Y5) 97.2% 100.0% 99.6% 98.3% 99.0%

Numerator 69 58 244 119 490

Denominator 71 58 245 121 495

NR numerator 0 0 0 0 0

NR exclusions 0 0 0 0 0

NR denominator 0 0 0 0 0

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

AA FV GGC LAN WoS

Pro

po

rtio

n o

f p

ati

en

ts (%

)

NHS Board of diagnosis

Year 4 Year 5


18

QPI 1(ii)

Description:

Proportion of patients with cutaneous melanoma who have

their initial diagnostic biopsy carried out by a skin cancer

clinician*.

Numerator:

Number of patients with cutaneous melanoma undergoing diagnostic partial biopsy as their

initial procedure who had this carried out by a skin cancer

clinician*.

Denominator:


partial biopsy as their initial procedure.

Exclusions:

No exclusions.

Target: 90%

Figure 5: Summary of QPI 1(ii) results, illustrating the proportion of patients with cutaneous melanoma undergoing diagnostic partial biopsy as their initial procedure who had this carried out by a skin cancer clinician*, by NHS Board of diagnosis for Year 5 (2018/19). The red line represents the QPI target of 90%. Table 4: Details of QPI 1(ii) results by NHS Board of diagnosis for Year 5 (2018/19).

QPI 1(ii) Target: 90%

AA FV GGC LAN WoS

% Performance (Y5) 80.0% 100.0% 100.0% 100.0% 98.9%

Numerator 4 11 55 20 90

Denominator 5 11 55 20 91




0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

AA FV GGC LAN WoS

Pro

po

rtio

n o

f p

ati

en

ts (%

)


Year 5


19

Results: For Part (i), the QPI target of 90% has been met by all four NHS Boards over the last two years. The overall regional performance for the WoS was 99.0%, which indicates a slight decrease on the previous year’s result. For Part (ii), NHS Forth Valley, NHSGGC and NHS Lanarkshire met the target of 90%. NHS Ayrshire and Arran failed to meet the QPI with 80%, although small numbers are noted within the Board. The WoS performance was 98.9%. The NHS Ayrshire and Arran case was reviewed by a Consultant Oral and Maxillofacial Surgeon and Cancer Manager and detailed feedback was provided. The case will be discussed at a Directorate meeting to ensure any learning points are actioned.


20

QPI 2: Pathology Reporting Description:

Proportion of patients with cutaneous melanoma who undergo diagnostic excision biopsy where the surgical pathology report contains a full set of data items (as defined by the current Royal College of Pathologists dataset).

Numerator: Number of patients with cutaneous melanoma undergoing diagnostic excision biopsy where the surgical pathology report contains a full set of data items (as defined by the current Royal College of Pathologists dataset).

Denominator: All patients with cutaneous melanoma undergoing diagnostic excision biopsy.


Target: 90%

To allow treatment planning to take place for patients diagnosed with cutaneous melanoma, prognostic information from the primary excision biopsy is needed. The use of datasets ‘improves the completeness’ of data in pathology reports1. Following Baseline Review it was agreed that the field SNOMED would be removed from the list of information required for pathology reports to be considered complete. At formal review it was agreed to remove macroscopic features as a requirement for the histopathology report to be complete. Due to the changes to the QPI measurement, results are presented for Year 5 only. A more detailed breakdown of the data is shown in the accompanying table. Results: The QPI target of 90% was met by all four NHS Boards. The performance for the WoS was 97.6%


21

QPI 2

Description:

Proportion of patients with cutaneous melanoma who

undergo diagnostic excision biopsy where the surgical

pathology report contains a full set of data items.

Numerator:

Number of patients with cutaneous melanoma undergoing diagnostic excision biopsy where

the surgical pathology report contains a full set of data items (as defined by the current Royal College of Pathologists dataset).

Denominator:


excision biopsy.

Exclusions:

No exclusions.

Target: 90%

Figure 6: Summary of QPI 2 results, illustrating the proportion of patients with cutaneous melanoma undergoing diagnostic excision biopsy where the surgical pathology report contains a full set of data items (as defined by the current Royal College of Pathologists dataset), by NHS Board of diagnosis for Year 5 (2018/19). The red line represents the QPI target of 90%.

Table 5: Details of QPI 2 results by NHS Board of diagnosis for Year 5 (2018/19).

QPI 2 Target: 90%

AA FV GGC LAN WoS

% Performance (Y5) 94.4% 100.0% 98.4% 96.9% 97.6%

Numerator 67 60 243 127 497

Denominator 71 60 247 131 509




0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

AA FV GGC LAN WoS

Pro

po

rtio

n o

f p

ati

en

ts (%

)


Year 5


22


23

QPI 3: Multi-Disciplinary Team Meeting (MDT) Description:

Proportion of patients with cutaneous melanoma who are discussed at MDT meeting before definitive treatment.

Numerator: Number of patients with cutaneous melanoma discussed at the MDT before definitive treatment (wide local excision, chemotherapy/SACT, supportive care and radiotherapy).

Denominator: All patients with cutaneous melanoma.

Exclusions: Patients who died before first treatment.

Target: 95%

Evidence suggests that patients with cancer managed by a multi-disciplinary team have a better outcome. There is also evidence that the multi-disciplinary management of patients increases their overall satisfaction with their care. Discussion prior to definitive treatment decisions provides reassurances that patients are being managed appropriately1. A summary of the QPI results are presented for the three most recent years of audit data (Year 3 to Year 5). For Year 5, a more detailed breakdown of the data is shown in the accompanying table.


24

QPI 3

Description:

Proportion of patients with cutaneous melanoma who are

discussed at MDT meeting before definitive treatment.

Numerator:

Number of patients with cutaneous melanoma discussed

at the MDT before definitive treatment (wide local excision,

chemotherapy/ SACT, supportive care and radiotherapy).

Denominator:

All patients with cutaneous melanoma.

Exclusions:

Patients who died before first treatment.

Target: 95%

Figure 7: Summary of QPI 3 results, illustrating the proportion of patients with cutaneous melanoma discussed at the MDT before definitive treatment (wide local excision, chemotherapy/ SACT, supportive care and radiotherapy), by NHS Board of diagnosis from Year 3 (2016/17) to Year 5 (2018/19). The red line represents the QPI target of 95%. Table 6: Details of QPI 3 results by NHS Board of diagnosis for Year 5 (2018/19).

QPI 3 Target: 95%

AA FV GGC LAN WoS

% Performance (Y5) 87.8% 95.6% 90.2% 95.4% 91.7%

Numerator 72 65 284 144 565

Denominator 82 68 315 151 616




0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

AA FV GGC LAN WoS

Pro

po

rtio

n o

f p

ati

en

ts (%

)


Year 3 Year 4 Year 5


25

Results: NHS Forth Valley and NHS Lanarkshire met the target of 95%, whilst NHS Ayrshire and Arran and NHSGGC failed to meet the target. The overall WoS performance was short of the target with 91.7%. Boards have reviewed cases not meeting the QPI criteria and provided the following feedback. NHS Ayrshire and Arran stated that due to MDT meetings taking place fortnightly, these stage IA patients have undergone a wide local excision prior to MDT discussion to avoid any considerable delay in treatment. NHSGGC highlighted that cases failing to meet the QPI criteria were due to the efficient treatment of standard cases that have been managed by protocol or decision not to follow protocol for valid medical reasons. The Board confirmed that all invasive melanomas are reviewed (discussed) at the MDT, with limited discussion of uncomplicated IA cases. The Board will stress the importance of MDT review prior to treatment for IB cases and above.


26

QPI 4: Clinical Examination of Draining Lymph Node Basins Description:

Proportion of patients with cutaneous melanoma undergoing clinical examination of relevant draining lymph node basins as part of clinical staging.

Numerator: Number of patients with cutaneous melanoma who undergo clinical examination of relevant draining lymph node basins as part of clinical staging.

Denominator: All patients with cutaneous melanoma.


Target: 95%

Scottish Intercollegiate Guidelines Network reports the examination of regional lymph node basin as an important aspect of the clinical evaluation of patients with cutaneous melanoma as the presence of nodal metastasis is an important predictor of outcome and prognosis1. A summary of the QPI results are presented for the three most recent years of audit data (Year 3 to Year 5). For Year 5, a more detailed breakdown of the data is shown in the accompanying table.


27

QPI 4

Description:

Proportion of patients with cutaneous melanoma undergoing

clinical examination of relevant draining lymph node basins as

part of clinical staging.

Numerator:

Number of patients with cutaneous melanoma who

undergo clinical examination of relevant draining lymph node

basins as part of clinical staging.

Denominator:

All patients with cutaneous melanoma.

Exclusions:

No exclusions.

Target: 95%

Figure 8: Summary of QPI 4 results, illustrating the proportion of patients with cutaneous melanoma who undergo clinical examination of relevant draining lymph node basins as part of clinical staging, by NHS Board of diagnosis from Year 3 (2016/17) to Year 5 (2018/19). The red line represents the QPI target of 95%. Table 7: Details of QPI 4 results by NHS Board of diagnosis for Year 5 (2018/19).

QPI 4 Target: 95%

AA FV GGC LAN WoS

% Performance (Y5) 95.1% 71.8% 89.2% 97.4% 90.0%

Numerator 78 51 281 147 557

Denominator 82 71 315 151 619




0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

AA FV GGC LAN WoS

Pro

po

rtio

n o

f p

ati

en

ts (%

)




28

Results: NHS Ayrshire and NHS Lanarkshire met the 95% target, with NHS Forth Valley and NHSGGC falling short. NHS Forth Valley had 18 cases classified as “Not recorded numerator”, which indicates that these patients did not have an exact date recorded for examination of lymph node basins. The overall performance for the WoS increased from 80.8% to 90.0%. Boards have reviewed cases not meeting the QPI criteria. Both, NHS Forth Valley and NHSGGC highlighted that the failure to record the clinical examination within the patients’ notes was the sole reason for their performance. The Boards stated that they will ensure the details are recorded within the clinical notes, with NHSGGC proposing to implement a template letter to capture the data.

Actions:



29

QPI 5: Sentinel Node Biopsy Pathology Description:

Proportion of patients with cutaneous melanoma who undergo SNB where the SNB report contains a full set of data items (as defined by the current Royal College of Pathologists dataset).

Numerator: Number of patients with cutaneous melanoma undergoing SNB, where the SNB report contains a full set of data items (as defined by the current Royal College of Pathologists dataset).

Denominator: All patients with cutaneous melanoma undergoing SNB.


Target: 90%

Evidence suggest Sentinal Node Biopsy (SNB) reports should be carried out in a standardised way so that findings between centres are comparable. The importance of meticulous diagnosis and reporting has been outlined by Royal College of Pathologists; histological parameters play a major role in defining patient treatment1. At formal review, it was agreed to remove the requirement for macroscopic features to be recorded in order for the lymph node report to be complete. Due to the changes to the QPI measurement, results are presented for Year 5 only. A more detailed breakdown of the data is shown in the accompanying table.

Results: For QPI 5, NHS Forth Valley, NHSGGC and NHS Lanarkshire met the target of 90%. NHS Ayrshire and Arran failed to meet the QPI with 80%, although small numbers are noted within the Board. The WoS performance was 98.1%. NHS Ayrshire and Arran reviewed the cases and stated that although the pathology reports were well documented and comprehensive, staging detail was not included resulting in patients failing to meet the QPI target. The Board will reinforce to the pathology team the importance of recording all data items on the RCPath proforma. Actions:



30

QPI 5

Description:


undergo SNB where the SNB report contains a full set of data

items.

Numerator:

Number of patients with cutaneous melanoma undergoing

SNB, where the SNB report contains a full set of data items (as defined by the current Royal College of Pathologists dataset).

Denominator:

All patients with cutaneous melanoma undergoing SNB.

Exclusions:

No exclusions.

Target: 90%

Figure 9: Summary of QPI 5 results, illustrating the proportion of patients with cutaneous melanoma undergoing SNB, where the SNB report contains a full set of data items (as defined by the current Royal College of Pathologists dataset), by NHS Board of diagnosis for Year 5 (2018/19). The red line represents the QPI target of 90%. Table 8: Details of QPI 5 results by NHS Board of diagnosis for Year 5 (2018/19).

QPI 5 Target: 90%

AA FV GGC LAN WoS

% Performance (Y5) 80.0% 100.0% 100.0% 100.0% 98.1%

Numerator 8 29 38 31 106





0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

AA FV GGC LAN WoS

Pro

po

rtio

n o

f p

ati

en

ts (%

)


Year 5


31

QPI 6: Wide Local Excisions Description:

Proportion of patients with cutaneous melanoma who undergo a wide local excision, following diagnostic excision or partial biopsy.

Numerator: Number of patients with cutaneous melanoma undergoing diagnostic excision or partial biopsy who undergo a wide local excision.

Denominator: All patients with cutaneous melanoma undergoing diagnostic excision or partial biopsy.

Exclusions: Patients who died before treatment.

Target: 95%

Surgical excision is an effective cure for primary cutaneous melanoma. The lesion is initially removed for histological diagnosis and assessment of tumour depth. A further excision is carried out to minimise the risk of local recurrence. Studies have shown the importance of removing the tumour and a margin of healthy skin1. The standard treatment for primary cutaneous melanoma is wide local excision of the skin and subcutaneous tissues around the melanoma. Treatment for melanoma aims to achieve histological free margins with low likelihood of local recurrence or persistent disease1. The appropriate surgical margin is determined by the thickness of the lesion. A variety of evidence exists determining the most clinically appropriate surgical margin. The Melanoma QPI Development Group felt ensuring a wide local excision took place was a good indicator of quality, with the decision of appropriate surgical margin being left to MDT/Clinical judgement1. Following formal review, it was agreed to combine the two parts of the QPI into a single specification analysing patients who have undergone either diagnostic excision biopsy or partial biopsy. Due to changes to the QPI measurement, results are presented for the two most recent years of audit data (Year 4 to Year 5). For Year 5, a more detailed breakdown of the data is shown in the accompanying table.


32

QPI 6

Description:


undergo a wide local excision, following diagnostic excision or

partial biopsy.

Numerator:

Number of patients with cutaneous melanoma undergoing

diagnostic excision or partial biopsy who undergo a wide local

excision.

Denominator:


excision or partial biopsy.

Exclusions:

Patients who died before treatment.

Target: 95%

Figure 10: Summary of QPI 6 results, illustrating the proportion of patients with cutaneous melanoma undergoing diagnostic excision or partial biopsy who undergo a wide local excision, by NHS Board of diagnosis from Year 4 (2017/18) to Year 5 (2018/19). The red line represents the QPI target of 95%. Table 9: Details of QPI 6 results by NHS Board of diagnosis for Year 5 (2018/19).

QPI 6 Target: 95%

AA FV GGC LAN WoS

% Performance (Y5) 88.0% 94.0% 93.3% 95.1% 93.2%

Numerator 66 63 280 136 545

Denominator 75 67 300 143 585




0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

AA FV GGC LAN WoS

Pro

po

rtio

n o

f p

ati

en

ts (%

)


Year 4 Year 5


33

Results: NHS Lanarkshire was the only Board to meet the 95% target. NHS Forth Valley and NHSGGC were slightly short of the target with 94.0% and 93.3% respectively. However, whilst NHS Ayrshire and Arran met the target last year, this year the Board’s performance fell below the target with 88.0%. The overall performance for the WoS was 93.2%. Boards have reviewed cases not meeting the QPI criteria and provided the following feedback. In NHS Ayrshire and Arran, valid clinical reasons were given for patients failing to meet the QPI criteria including patient death, patient refusal of further treatment, advanced disease and graft failure at the site of first surgery. Following the review, the Board flagged data errors in the case of 2 patients where a wide local excision was performed and documented within the clinical notes; however this data was not recorded on the eCASE database. Going forward, the Board will ensure accurate data entry to reflect the details in patients’ notes. NHS Forth Valley stated that patients failing to meet the QPI criteria did not receive a wide local excision; however their treatment was clinically appropriate. NHSGGC also highlighted valid clinical reasons for not meeting the QPI target. These included patients with stage IV disease not requiring further local treatment but going on to receive systemic therapy, and delays to further treatment due to patient co-morbidities.


34

QPI 7: Time to Wide Local Excision Description:

Proportion of patients with cutaneous melanoma who undergo their wide local excision within 84 days of their diagnostic biopsy.

Numerator: (i) Number of patients with cutaneous melanoma who undergo their wide local excision within 84 days of their diagnostic excision biopsy.

(ii) Number of patients with cutaneous melanoma who undergo their wide local excision within 84 days of their partial biopsy.

Denominator: (i) All patients with cutaneous melanoma undergoing diagnostic excision biopsy.

(ii) All patients with cutaneous melanoma undergoing partial biopsy.

Exclusions: (i) Patients who have also undergone partial biopsy. (ii) No exclusions.

Target: 95%

It is important that patients with cutaneous melanoma undergo surgical excision as soon as possible. There is no clear consensus from clinical literature on the most appropriate timeframe for wide local excision however studies have found that delays in receiving definitive treatment can have an unfavourable impact within a number of cancer types. The Cutaneous Melanoma QPI Development Group has therefore agreed that 84 days is the most appropriate timeframe based on clinical consensus and current best practice1. The QPI is split into two parts. Part (i) looks at patients undergoing their wide local excision within 84 days of their diagnostic excision biopsy, while part (ii) looks at patients undergoing their wide local excision within 84 days of their diagnostic partial biopsy. A summary of the QPI results, for both parts, are presented for the three most recent years of audit data (Year 3 to Year 5). For Year 5, a more detailed breakdown of the data is shown in the corresponding accompanying table.


35

QPI 7(i)

Description:


undergo their wide local excision within 84 days of their diagnostic

biopsy.

Numerator:


undergo their wide local excision within 84 days of their diagnostic

excision biopsy.

Denominator:


excision biopsy.

Exclusions:

Patients who have also undergone partial biopsy.

Target: 95%

Figure 11: Summary of QPI 7(i) results, illustrating the proportion of patients with cutaneous melanoma who undergo their wide local excision within 84 days of their diagnostic excision biopsy, by NHS Board of diagnosis from Year 3 (2016/17) to Year 5 (2018/19). The red line represents the QPI target of 95%. Table 10: Details of QPI 7(i) results by NHS Board of diagnosis for Year 5 (2018/19).

QPI 7(i) Target: 95%

AA FV GGC LAN WoS

% Performance (Y5) 41.4% 74.1% 78.8% 75.6% 72.2%

Numerator 29 43 193 93 358

Denominator 70 58 245 123 496




0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

AA FV GGC LAN WoS

Pro

po

rtio

n o

f p

ati

en

ts (%

)




36

QPI 7(ii)

Description:


undergo their wide local excision within 84 days of their partial

biopsy.

Numerator:


undergo their wide local excision within 84 days of their partial

biopsy.

Denominator:

All patients with cutaneous melanoma undergoing partial

biopsy.

Exclusions:

No exclusions.

Target: 95%

Figure 12: Summary of QPI 7(ii) results, illustrating the proportion of patients with cutaneous melanoma who undergo their wide local excision within 84 days of their partial biopsy, by NHS Board of diagnosis from Year 3 (2016/17) to Year 5 (2018/19). The red line represents the QPI target of 95%. Table 11: Details of QPI 7(ii) results by NHS Board of diagnosis for Year 5 (2018/19).

QPI 7(ii) Target: 95%

AA FV GGC LAN WoS

% Performance (Y5) 80.0% 45.5% 90.9% 45.0% 74.7%

Numerator 4 5 50 9 68





0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

AA FV GGC LAN WoS

Pro

po

rtio

n o

f p

ati

en

ts (%

)




37

Results: For Part (i), no Board in the WoS met the 95% target. Only NHS Lanarkshire showed improvement on the previous year’s performance, with the NHS Forth Valley performance remaining consistent. The overall performance for the WoS was 72.2%, indicating a decrease on the previous year’s performance of 73.9%. Feedback from Boards highlighted capacity issues, service pressures, metastatic disease and patient choice as factors for not meeting the target. NHS Lanarkshire noted that the increased rate of SNB in response to the changes in available systemic therapy has affected performance against this QPI, as the treatment requires additional treatment time to be available. The Board propose to add the 84-day target to the formstream MDT page to ensure wide local excision is performed within the specified timeframe. NHS Aryshire and Arran are currently performing a full review of the cases failing to meet the QPI criteria to identify any common themes arising during the patient pathway. NHSGGC identified delays within plastic surgery which will be further explored through a local audit of referral processes and clinical capacity. For Part (ii), no Boards in the WoS met the 95% target. However, all Boards showed improvement on the previous year’s target. The overall performance for the WoS was 74.7%, indicating an increase on the previous year’s performance of 62.5%. Feedback from Boards highlighted metastatic disease, patient frailty and patient choice as factors for not meeting the target. As previously mentioned, NHS Lanarkshire highlighted the increased rate of SNB as a contributing factor to the Board’s performance, since this requires additional theatre time to be available. The Board propose to add the 84-day target to the formstream MDT page to ensure wide local excision is performed within the specified timeframe.

Actions:




38

QPI 8: BRAF Status Description:

Proportion of patients with unresectable stage III or IV cutaneous melanoma who have their BRAF status checked.

Numerator: Number of patients with unresectable stage III or IV cutaneous melanoma who have their BRAF status checked.

Denominator: All patients with unresectable stage III or IV cutaneous melanoma.


Target: 75%

Patients with unresectable stage IIIC and IV melanoma should undergo a B-RAF status check to assess suitability for vemurafenib (BRAF inhibitor). Many patients with stage IIIC disease will not have undergone surgery, making pathological staging impossible. The Cutaneous Melanoma QPI Development Group therefore agreed to measure all stage III patients within this QPI1. A summary of the QPI results are presented for the three most recent years of audit data (Year 3 to Year 5), with a more detailed breakdown of the data shown in the accompanying table. Due to small numbers, the data is presented at a regional level. Results: The 75% target has been consistently met over the three years. The performance for the WoS has been 100.0% for the last three consecutive years.


39

QPI 8

Description:

Proportion of patients with unresectable stage III or IV

cutaneous melanoma who have their BRAF status checked.

Numerator:

Number of patients with unresectable stage III or IV

cutaneous melanoma who have their BRAF status checked.

Denominator:

All patients with unresectable stage III or IV cutaneous

melanoma.

Exclusions:

No exclusions.

Target: 75%

Figure 13: Summary of QPI 8 results, illustrating the proportion of patients with unresectable stage III or IV cutaneous melanoma who have their BRAF status checked, for the West of Scotland from Year 3 (2016/17) to Year 5 (2018/19). The red line represents the QPI target of 75%. Table 12: Details of QPI 8 results for the West of Scotland from Year 3 (2016/17) to Year 5 (2018/19).

QPI 8 Target: 75%

WoS


% Performance 100.0% 100.0% 100.0%

Numerator 9 16 9

Denominator 9 16 9

NR numerator 0 0 0

NR exclusions 0 0 0

NR denominator 6 5 9

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Pro

po

rtio

n o

f p

ati

en

ts (%

)

Year of analysis

WoS


40

QPI 9: Imaging for Patients with Advanced Melanoma Description:

Proportion of patients with stage IIC and above cutaneous melanoma who undergo computed tomography (CT) or positron emission tomography (PET) CT within 35 days of diagnosis.

Numerator: Number of patients with stage IIC and above cutaneous melanoma who undergo computed tomography (CT) or positron emission tomography (PET) CT within 35 days of diagnosis.

Denominator: All patients with stage IIC and above cutaneous melanoma.


Target: 95%

Guidelines recommend that patients with stage IIC and above disease should be offered initial staging imaging. Patients with high grade cutaneous melanoma should undergo imaging of the head, chest, abdomen and pelvis to exclude metastases. It has been reported that patients with low grade disease do not benefit from imaging due to a high incidence of false positives. To ensure alignment with current clinical practice, stage has been utilised to stratify patients for inclusion within this QPI over grading1. At formal review it was agreed to include patients with stage IIC disease and above instead of just patients with stage III and IV disease. A condition was also added to ensure that patients receive a CT or PET CT within 35 days of diagnosis rather than prior to completion lymphadenectomy. Due to changes to the QPI measurement, results are presented for the two most recent years of audit data (Year 4 to Year 5). For Year 5, a more detailed breakdown of the data is shown in the accompanying table.


41

QPI 9

Description:

Proportion of patients with stage IIC and above cutaneous melanoma who undergo

computed tomography (CT) or positron emission tomography

(PET) CT within 35 days of diagnosis.

Numerator:

Number of patients with stage IIC and above cutaneous melanoma

who undergo computed tomography (CT) or positron

emission tomography (PET) CT within 35 days of diagnosis.

Denominator:

All patients with stage IIC and above cutaneous melanoma.

Exclusions:

No exclusions.

Target: 95%

Figure 14: Summary of QPI 9 results, illustrating the proportion of patients with stage IIC and above cutaneous melanoma who undergo computed tomography (CT) or positron emission tomography (PET) CT within 35 days of diagnosis, by NHS Board of diagnosis from Year 4 (2017/18) to Year 5 (2018/19). The red line represents the QPI target of 95%. Table 13: Details of QPI 9 results by NHS Board of diagnosis for Year 5 (2018/19).

QPI 9 Target: 95%

AA FV GGC LAN WoS

% Performance (Y5) 13.6% 7.7% 34.6% 23.1% 21.8%

Numerator 3 1 9 6 19





0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

AA FV GGC LAN WoS

Pro

po

rtio

n o

f p

ati

en

ts (%

)


Year 4 Year 5


42

Results: None of the Boards met the 95% target. The best performing Board was NHSGGC with 34.6%. It was anticipated that the performance would improve following last year’s audit, as this would allow the revised practice of scanning within 35 days of diagnosis to be fully implemented within all Boards. However, the overall performance for the WoS was 21.8%, indicating a decrease on last year’s performance of 33.3%. All NHS Boards reviewed cases and provided detailed feedback. All Boards acknowledged that further work is required to examine pathways however some preliminary work to identify reasons for the 95% target not being met has identified potential issues in the measurement of this QPI. The start point for calculating this QPI is date of diagnosis, which is the date the biopsy was taken. However, there will not be a confirmed diagnosis until the pathology is reported. Therefore the results of the QPI may be reflecting delays in pathology reporting, rather than imaging delays. Further work is required to understand the true sources of delay which are impacting upon performance against this indicator. Actions:



43

QPI 10: Systemic Therapy Description:

Proportion of patients with unresectable stage III or IV cutaneous melanoma undergoing Systemic Anti Cancer Therapy (SACT).

Numerator: Number of patients with unresectable stage III or IV cutaneous melanoma who undergo SACT.

Denominator: All patients with unresectable stage III or IV cutaneous melanoma.

Exclusions: Patients who died before treatment.

Target: 60%

As the majority of metastatic melanomas are not amenable to surgery, it is often found that systemic therapy is the best option. Systemic Anti Cancer Therapy (SACT) should be available for the management of patients with cutaneous melanoma where appropriate1. A summary of the QPI results are presented for the three most recent years of audit data (Year 3 to Year 5), with a more detailed breakdown of the data shown in the accompanying table. Due to small numbers, the data is presented at a regional level. Results: The 60.0% target has been met for 3 consecutive years. The overall performance for Year 5 is 77.8%, which demonstrates a slight decrease from the previous year.


44

QPI 10

Description:

Proportion of patients with unresectable stage III or IV

cutaneous melanoma undergoing Systemic Anti Cancer Therapy

(SACT).

Numerator:

Number of patients with unresectable stage III or IV cutaneous melanoma who

undergo SACT.

Denominator:

All patients with unresectable stage III or IV cutaneous

melanoma.

Exclusions:

Patients who died before treatment.

Target: 60%

Figure 15: Summary of QPI 10 results, illustrating the proportion of patients with unresectable stage III or IV cutaneous melanoma who undergo Systemic Anti Cancer Therapy, for the West of Scotland from Year 3 (2016/17) to Year 5 (2018/19). The red line represents the QPI target of 60%. Table 14: Details of QPI 10 results for the West of Scotland from Year 3 (2016/17) to Year 5 (2018/19).

QPI 10 Target: 60%

WoS


% Performance 66.7% 80.0% 77.8%

Numerator 6 12 7

Denominator 9 15 9

NR numerator 0 0 0

NR exclusions 0 2 0

NR denominator 6 5 9

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Pro

po

rtio

n o

f p

ati

en

ts (%

)

Year of analysis

WoS


45

QPI 12: Surgical Margins Description:

Proportion of patients with cutaneous melanoma where complete excision is undertaken with documented clinical margins of 2mm prior to definitive treatment (wide local excision).

Numerator: Number of patients with cutaneous melanoma where complete excision is undertaken with documented clinical margins of 2mm prior to wide local excision.

Denominator: All patients with cutaneous melanoma who undergo wide local excision.


Target: 85%

Accurate clinical and histological diagnosis is essential for the appropriate management of patients1. Suspicious lesions should be excised with narrow margins including subcutaneous fat1. Guidelines report that in order to carry out full histological evaluation and assessment of a suspected melanoma, the optimal specimen is a complete excision with a 2mm surround of normal skin and a cuff of fat1. This QPI was introduced following formal review and is therefore the first time it has been reported. As such the results are presented for Year 5 only. A more detailed breakdown of the data is shown in the accompanying table.


46

QPI 12

Description:

Proportion of patients with cutaneous melanoma where

complete excision is undertaken with documented clinical margins

of 2mm prior to definitive treatment (wide local excision).

Numerator:

Number of patients with cutaneous melanoma where

complete excision is undertaken with documented clinical margins

of 2mm prior to wide local excision.

Denominator:

All patients with cutaneous melanoma who undergo wide

local excision.

Exclusions:

No exclusions.

Target: 85%

Figure 16: Summary of QPI 12 results, illustrating the proportion of patients with cutaneous melanoma where complete excision is undertaken with documented clinical margins of 2mm prior to wide local excision, by NHS Board of diagnosis for Year 5 (2018/19). The red line represents the QPI target of 85%. Table 15: Details of QPI 12 results by NHS Board of diagnosis for Year 5 (2018/19).

QPI 12 Target: 85%

AA FV GGC LAN WoS

% Performance (Y5) 15.9% 4.8% 43.8% 60.3% 40.0%

Numerator 11 3 128 82 224

Denominator 69 63 292 136 560




0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

AA FV GGC LAN WoS

Pro

po

rtio

n o

f p

ati

en

ts (%

)


Year 5


47

Results: No Boards in the WoS met the QPI target of 85%. The best performing Board was NHS Lanarkshire with 60.3%. The overall performance for the WoS was 40.0%. Boards have reviewed cases not meeting the QPI and provided detailed feedback indicating a number of measurability issues with this QPI. For example, the QPI looks at the margin taken at the time of excision biopsy however the denominator incorrectly includes patients who did not have an excision biopsy. There is also some clinical debate around the requirement for a tolerance for the 2mm clinical margin. These points will be submitted to the Formal Review process for consideration. Additionally three out of the four Boards had a significant number of cases where the margin status was not documented. Due to the measurability and documentation issues, it is difficult to make an assessment of clinical practice based on this data. Actions:



MCN to analyse regional data, excluding those patients who did not have an excision biopsy.


48

QPI 13: Clinical Trials Description:

Proportion of patients diagnosed with cutaneous melanoma who are consented for a clinical trial/research study.

Numerator: Number of patients diagnosed with cutaneous melanoma consented for a clinical trial/research study.

Denominator: All patients diagnosed with cutaneous melanoma.


Target: 15%

Clinical trials are necessary to demonstrate the efficacy of new therapies and other interventions. Evidence suggests improved patient outcomes when hospitals are actively recruiting patients into clinical trials1. Clinicians are therefore encouraged to enter patients into well designed trials and to collect longer-term follow-up data. High accrual activity into clinical trials is used as a goal of an exemplary clinical research site1. The measurement of this QPI focuses on those patients who have consented in order to reflect the intent to join a clinical trial and demonstrate the commitment to recruit patients. Often patients can be prevented from enrolling within a trial due to stratification of studies and precise inclusion criteria identified during the screening process.

Table 16 presents a summary of the results by NHS Board of residence in 2018. The denominator for this QPI is identified by using a 5-year average of Scottish Cancer Registry data.

Table 16: Details of QPI 13, illustrating the proportion of patients consented for clinical trials for cutaneous melanoma, by NHS Board of residence in 2018. The denominator represents the 5 year average of ISD incidence data for cutaneous melanoma between 2013 and 2017.

QPI 13 Target: 15%

AA FV GGC LAN Outwith

WoS WoS

Performance % 1.1% 6.1% 3.2% 3.9% - 4.5%

Numerator 1 4 10 5 7 27

Denominator 87 66 315 129 - 597

The target is to consent a minimum of 15% of patients diagnosed with cutaneous melanoma for a clinical trial/research study. Overall in the WoS this was not achieved with 4.5% of patients in 2018 consented for a clinical trial/research study. A list of active melanoma clinical trials in 2018 is shown below.

An Open-Label Multicenter Phase 1 Study of E7386 in Subjects with Selected Advanced Neoplasms

CANC - 4974

CheckMate 401: CHECKpoint pathway and nivoluMAb clinical Trial Evaluation 401

Checkmate 915

IMCgp 100-201

IMCgp100-401

PIANO Study - PLX3397 cKIT in advanced acral and mucosal melanoma

SelPac

TRILOGY


49

The majority of patients diagnosed have early stage disease with no lymph node involvement and are managed in the surgical setting. Hence the number of patients that are eligible for systemic therapy trials is much smaller than the denominator. Although the team are pro-active in discussing clinical trials with patients, there is now a wider availability of more established treatments available to metastatic disease.


50

5. Conclusions

Cancer audit data underpins much of the development and service improvement work of the MCN and regular reporting of activity and performance is a fundamental requirement of an MCN to assure the quality of care delivered. The Skin Cancer MCN remains committed to improve the quality and completeness of clinical audit data to ensure continued robust performance assessment and the identification of areas for service improvement. The Skin Cancer MCN is encouraged by the results presented in this report which demonstrate that patients with cutaneous melanoma in the WoS continue to receive a consistently high standard of care. 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, specifically around documentation in relation to examination of lymph node basins, time to wide local excision, time to CT/PET CT and surgical margins. However it is encouraging that targets relating to diagnostic excision biopsy and BRAF status were consistently met by all Boards in Year 5. Some variance in performance does exist across the regions and, as per the agreed Regional governance process, each NHS Board was asked to complete a Performance Summary Report, providing a documented response where performance was below the QPI target. NHS Boards have provided detailed comments indicating valid clinical reasons or that, in some cases, patient choice or co-morbidities have influenced patient management. Data recording issues have been highlighted in relation to QPI 4 (Clinical Examination of Draining Lymph Node Basins), QPI 5 (Sentinel Node Biopsy Pathology) and QPI 12 (Surgical Margins) , whilst resource issues have impacted on performance against QPI 7 (Time to Wide Local Excision). Concerns around the measurability of QPI 9 (Imaging for Patients with Advanced Melanoma) and QPI 12 have also been raised. Remaining actions are summarised below and outlined in the main report under the relevant section. The MCN will actively take forward regional actions identified and NHS Boards are asked to develop local Action/Improvement Plans in response to the findings presented in the report. A summary of actions for each NHS Board has been included within the Action Plan templates in Appendix I. Action Required: QPI 4: Clinical Examination of Draining Lymph Node Basins


QPI 5: Sentinel Node Biopsy Pathology


QPI 7: Time to Wide Local Excision




51

QPI 9: Imaging for Patients with Advanced Melanoma


QPI 12: Surgical Margins



MCN to analyse regional data, excluding those patients who did not have an excision biopsy. Completed Action Plans should be returned to WoSCAN within two months of publication of this report. Progress against these plans will be monitored by the MCN Advisory Board and any service or clinical issue which the Advisory Board considers not to have been adequately addressed will be escalated to the NHS Board Territorial Lead Cancer Clinician and Regional Lead Cancer Clinician. Additionally, progress will be reported annually to the Regional Cancer Advisory Group (RCAG) by NHS Board Territorial Lead Cancer Clinicians and MCN Clinical Leads, and nationally on a three-yearly basis to Healthcare Improvement Scotland as part of the governance processes set out in CEL 06 (2012).


52

Acknowledgement

This report has been prepared using clinical audit data provided by the following NHS Boards in the WoSCAN area: NHS Ayrshire & Arran NHS Forth Valley NHS Greater 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.


53

Abbreviations

AA NHS Ayrshire & Arran

ACaDMe Acute Cancer Deaths and Mental Health

eCASE Electronic Cancer Audit Support Environment

FV NHS Forth Valley

GGC NHS Greater Glasgow and Clyde

HIS Healthcare Improvement Scotland

ISD Information Services Division

LAN NHS Lanarkshire

MCN Managed Clinical Network

MDT(s) Multi-disciplinary Team(s)

NCQSG National Cancer Quality Steering Group

NHSGGC NHS Greater Glasgow and Clyde

QPI(s) Quality Performance Indicator(s)

R&D Research and Development

RCAG Regional Cancer Advisory Group

RCP Royal College of Pathologists

RMDT Regional Multi Disciplinary Meeting

SACT Systemic Anti-Cancer Therapy

SMR01 Scottish Morbidity Records

WLE Wide local excision

WoS West of Scotland

WoSCAN West of Scotland Cancer Network


54

References

1. Healthcare Improvement Scotland. Melanoma Quality Performance Indicators, v3.0; August

2018 [Accessed on: 2nd December 2019]. Available at: http://www.healthcareimprovementscotland.org/our_work/cancer_care_improvement/cancer_qpis/quality_performance_indicators.aspx

2. Information Services Division. National Data Definitions for the Minimum Core Data Set for

Melanoma. July 2019; Version 3.2 [Accessed on: 2nd December 2019]. Available at: https://www.isdscotland.org/Health-Topics/Cancer/Cancer-Audit/docs/Melanoma/Melanoma-QPI-Dataset-v3.2-Final.pdf

3. Information Services Division. Melanoma cancer, Measurability of Quality Performance Indicators. Version 3.1 [Accessed on: 2nd December 2019]. Available at: https://www.isdscotland.org/Health-Topics/Cancer/Cancer-Audit/docs/Melanoma/Melanoma-QPI-Measurability-v3.1-Final.pdf

4. ScotPHO, Public Health Information for Scotland. Mid 2018 Population Estimates Scotland.

[Accessed on: 2nd December 2019]. Available at: https://www.nrscotland.gov.uk/statistics-and-data/statistics/statistics-by-theme/population/population-estimates/mid-year-population-estimates/mid-2018

5. Information Services Division. Cancer in Scotland. April 2019. [Accessed on: 2nd December

2019] Available at: https://www.isdscotland.org/Health-Topics/Cancer/Publications/2019-04-30/2019-04-30-Cancer-Incidence-Report.pdf

6. Information Services Division, Cancer Statistics, Summary Statistics for Melanoma. [Accessed on: 2nd December 2019]. Available at: http://www.isdscotland.org/Health-Topics/Cancer/Cancer-Statistics/Skin/

7. Cancer Research UK Skin Cancer Mortality Statistics. [Accessed on: 2nd December 2019].

Available at: http://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/skin-cancer

http://www.healthcareimprovementscotland.org/our_work/cancer_care_improvement/cancer_qpis/quality_performance_indicators.aspx

http://www.healthcareimprovementscotland.org/our_work/cancer_care_improvement/cancer_qpis/quality_performance_indicators.aspx

https://www.isdscotland.org/Health-Topics/Cancer/Cancer-Audit/docs/Melanoma/Melanoma-QPI-Dataset-v3.2-Final.pdf

https://www.isdscotland.org/Health-Topics/Cancer/Cancer-Audit/docs/Melanoma/Melanoma-QPI-Dataset-v3.2-Final.pdf

https://www.isdscotland.org/Health-Topics/Cancer/Cancer-Audit/docs/Melanoma/Melanoma-QPI-Measurability-v3.1-Final.pdf

https://www.isdscotland.org/Health-Topics/Cancer/Cancer-Audit/docs/Melanoma/Melanoma-QPI-Measurability-v3.1-Final.pdf

https://www.nrscotland.gov.uk/statistics-and-data/statistics/statistics-by-theme/population/population-estimates/mid-year-population-estimates/mid-2018



https://www.isdscotland.org/Health-Topics/Cancer/Publications/2019-04-30/2019-04-30-Cancer-Incidence-Report.pdf

https://www.isdscotland.org/Health-Topics/Cancer/Publications/2019-04-30/2019-04-30-Cancer-Incidence-Report.pdf

http://www.isdscotland.org/Health-Topics/Cancer/Cancer-Statistics/Skin/

http://www.isdscotland.org/Health-Topics/Cancer/Cancer-Statistics/Skin/

http://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/skin-cancer

http://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/skin-cancer


55

Appendix I: NHS Board Action Plans

A summary of actions for each NHS Board has been included within the following Action Plan templates. Completed Action Plans should be returned to WoSCAN within two months of publication of this report.

Action / Improvement Plan

KEY (Status)

Area: NHS Ayrshire and Arran

1 Action fully implemented

Action Plan Lead: 2 Action agreed but not yet implemented

Date: 3 No action taken (please state reason)

QPI No.

Action Required Health Board Action Taken Timescales

Lead Progress/Action Status Status (see Key) Start End

Ensure actions mirror those detailed in Audit Report.

Detail specific actions that will be taken by the NHS Board.

Insert date

Insert date

Insert name of responsible lead for each specific action.

Provide detail of action in progress, change in practices, problems encountered or reasons why no action taken.

Insert No. from key above.

5


7

NHS Ayrshire and Arran to feedback to the MCN on the outcome of the audits performed on patients failing to meet the criteria for QPI 7(i). Any learning from these should be shared with WoS Boards to facilitate co-ordinated regional action to address sources of delay.

12 All Boards to ensure consistent and accurate documentation of margins for skin tumours.


56


KEY (Status)

Area: NHS Forth Valley




QPI No.





Insert date

Insert date




4

NHS Forth Valley to implement a template letter to ensure clinical examination of draining lymph node basins is consistently documented in patient notes.



57


KEY (Status)

Area: NHS Greater Glasgow and Clyde




QPI No.





Insert date

Insert date




4

NHSGGC to implement a template letter to ensure clinical examination of draining lymph node basins is consistently documented in patient notes.

7

NHSGGC to feedback to the MCN on the outcome of the audits performed on patients failing to meet the criteria for QPI 7(i). Any learning from these should be shared with WoS Boards to facilitate co-ordinated regional action to address sources of delay.



58


KEY (Status)

Area: NHS Lanarkshire




QPI No.





Insert date

Insert date






59


KEY (Status)

Area: Skin Cancer MCN




QPI No.





Insert date

Insert date




7


9


12 MCN to submit measurability concerns for consideration as part of the Formal Review process.

12 MCN to analyse regional data, excluding those patients who did not have an excision biopsy.


60

Copyright The content of this report is © copyright WoSCAN unless otherwise stated. Organisations may copy, quote, publish and broadcast material from this report without payment and without approval provided they observe the conditions below. Other users may copy or download material for private research and study without payment and without approval provided they observe the conditions below. The conditions of the waiver of copyright are that users observe the following conditions:

Quote the source as the West of Scotland Cancer Network (WoSCAN). Do not use the material in a misleading context or in a derogatory manner. Where possible, send us the URL.

The following material may not be copied and is excluded from the waiver:

The West of Scotland Cancer Network logo. Any photographs.

Any other use of copyright material belonging to the West of Scotland Cancer Network requires the formal permission of the Network.

Date post:	12-Oct-2020
Category:	Documents
Upload:	others
View:	1 times
Download:	0 times

Audit Report - West of Scotland Cancer Network · 2020. 2. 20. · Final - Skin Cancer MCN Audit...

Documents