Endometrial CancerCPGON Audit

Background• Formulating standard management

pathways• Assessing compliance with existing

pathways• Understanding areas of similarity and

areas of variation

Specific Questions• Endometrial cancer 2011-2013 inclusive• Caseload and waiting times• Tumour grade: how it affects management and

outcome• Move toward laparoscopic surgery• Imaging• Survival• Trial recruitment

Data collection• Access Database with specific forms• Sent to 5 hospitals: Taunton, Exeter, Yeovil,

Torbay, NDDH• Returns received from all except NDDH• Data presented reflect data entered• Significant influence of missing data (esp on

Grade data)

Data analysis

• Taunton/Yeovil and Exeter/Torbay analysed separately

• Exeter data include NDDH cases who had hysterectomy in Exeter, but diagnostic data are missing

Cases: Exeter/Torbay/NDDHHysterectomy?

Source site No Yes Total

Exeter 15 212 227

NDDH 7 43 50

Other 2 2

Plymouth 1 1

Private 3 3

Torbay 15 104 119

Grand Total 38 364 402

Cases: Taunton/YeovilHysterectomy?

Source site No Yes Total

Exeter 1 1

Other 3 3

Private 3 3

Taunton 17 117 134

Yeovil 4 90 94

Grand Total 21 214 235

Where hysterectomies done

• Counts of cases by location of surgery and according to site of diagnosis

Exeter

Torbay

Taunton (from

Yeovil)

0 20 40 60 80 100 120 140 160 180 200

182

115

62

49

37

24

Hysterectomies 2011-2013

Waits for Hysterectomy• Reported as mean in days• Includes some long waits. Very long

waits (>100d) excluded if biopsy field blank

• Assumed to be cases where cancer not suspected or known

Taunton

NDDH

Torbay

Taunton(fromYeovil)

Exeter(fromTorbay)

Exeter

Yeovil

0 5 10 15 20 25 30 35 40 45

27

28

32

33

39

40

40

Wait (d)

Taunton Exeter Yeovil Torbay0

10

20

30

40

50

60

70

80

90

71

56

33

0

67

55

71

6

8376 75

56

% Laparoscopic

201120122013

Laparoscopic• Continues to rise• Need clarity on what the expected

figure should be• Exeter and Taunton consensus is that

transverse laparotomy is very rarely indicated

Taunton Exeter Yeovil Torbay0

10

20

30

40

50

60

70

80

90

100

1318

42

100

1421

29

94

2 4

17

44

%Transverse laparotomy

201120122013

Influence of Tumour Grade• Several issues:

–What grade should trigger referral to centre

– Proportion of cases undergraded and therefore underinvestigated and under-referred

– Does biopsy grade predict need for adjuvant therapy?

Current Practice

• Yeovil/Taunton: – G2 and 3 referred to Centre– G2 called HG (according to data submitted)– G2 and G3 have cross sectional imaging

• Exeter/Torbay/NDDH:– G3 only referred to centre– G2 called LG– Only G3 have cross-sectional imaging

Grade analysis• Problem of missing data: each case

needs two grade data fields entered to contribute (biopsy and final)

• How to calculate upward grade shift• Decision to use denominator of grades

able to shift (ie exclude G3)

Exeter Torbay Taunton Yeovil0

10

20

30

40

50

60

70

80

90

70

8076 78

% Cases where Grade did NOT change at hysterectomy

Exeter Torbay Taunton Yeovil0

2

4

6

8

10

12

14

1211

5

7

% Of G1/2 shifted to G3 at hys-terectomy

Exeter Torbay Taunton Yeovil0

10

20

30

40

50

60

70

80

90

100

% Cases imaged

G1G2G3

Exeter Torbay Taunton Yeovil0

2

4

6

8

10

12

14

16

18

% Final G3 not imaged

TY/G1 TY/G2 TY/G3 ET/G1 ET/G2 ET/G30%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

107 52

26

101 119

102

0 2

8

4 430

DeadAlive

Survival by Grade

Survival• Kaplan Meier for Exeter/Torbay/NDDH

cases• Highly significant G3 worse than G1

and G2, which were the same• Regret no similar plot for

Taunton/Yeovil

Adjuvant Radiotherapy• Again a missing data issue• How does biopsy grade predict

likelihood of adjuvant radiotherapy after hysterectomy?

• Hyperplasia = cases where biopsy showed hyperplasia but hysterectomy revealed cancer

Hyperplasia G1 G2 G30%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

40 51 42

29

6 11 6

19

8 12 1432

Adjuvant Treatment Exeter/Torbay

EBRTBrachyNone

Hyperplasia G1 G2 G30%

10%20%30%40%

50%60%70%80%90%

100%

20 49

14

3

310

10

8

3 1011

14

Adjuvant treatment Taunton/Yeovil

EBRTBrachyNone

Grade conclusions• Survival data clear that G1 and 2 are

separate from G3• However, in Yeovil, G2 referral means:– Quicker operation– Accurately selects cases who need

adjuvant treatment

188

75

43

3713 Stage in Exeter/Torbay

n=402

IA IB IIIII IV

IA IB II III IV Unknown0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

178 70 40

24

6

31

10 5 3

13

8

15

Survival by FIGO stage Exeter/Torbay

DeadAlive

Clear c

ell

Endo

metrioi

dMMMT

Sarco

maSe

rous

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

100%

10252

5 738

214

4 411

DeadAlive

Survival by Morphology

Exeter Torbay Taunton Yeovil0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

11 017 8

216 119117 86

Trial Recruitment

NoYes

Exeter Torbay Taunton Yeovil0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

25 9 17 8

202 110 117 86

Chemotherapy

NoYes

Conclusions• Variation within the Network (Grade triage)• Guidelines will need to reflect this, or

practice change• Patients do well and results in keeping with

published literature• We can do good audits together!!