SCAN Audit Office, c/o Department of Clinical Oncology, Western General Hospital, Crewe Road, Edinburgh, EH4 2XU T: 0131 537 2266 W: www.scan.scot.nhs.uk [email protected]SOUTH EAST SCOTLAND CANCER NETWORK PROSPECTIVE CANCER AUDIT HEPATOPANCREATOBILIARY CANCER 2015 COMPARATIVE AUDIT REPORT Miss Anya Adair SCAN HPB Cancer Clinician Dr Annabel Howell, Lead Cancer Clinician, NHS Borders Mr Jeyakumar Apollos, Locum Consultant Surgeon, NHS Dumfries & Galloway Mr Peter Driscoll, Consultant Surgeon, NHS Fife Dr Lucy Wall, Consultant Oncologist, Edinburgh Cancer Centre Joanne Smith SCAN HPB Cancer Audit Facilitator Maureen Lamb, Cancer Audit Facilitator, Fife Lynn Smith, Cancer Audit Facilitator, Borders Martin Keith, Senior Cancer Information Officer, NHS Dumfries & Galloway Report number: SA UGI01/17w
Transcript
SCAN Audit Office, c/o Department of Clinical Oncology, Western General Hospital, Crewe Road, Edinburgh, EH4 2XU T: 0131 537 2266 W: www.scan.scot.nhs.uk [email protected]
SOUTH EAST SCOTLAND CANCER NETWORK PROSPECTIVE CANCER AUDIT
HEPATOPANCREATOBILIARY CANCER 2015 COMPARATIVE AUDIT REPORT Miss Anya Adair SCAN HPB Cancer Clinician Dr Annabel Howell, Lead Cancer Clinician, NHS Borders Mr Jeyakumar Apollos, Locum Consultant Surgeon, NHS Dumfries & Galloway Mr Peter Driscoll, Consultant Surgeon, NHS Fife Dr Lucy Wall, Consultant Oncologist, Edinburgh Cancer Centre Joanne Smith SCAN HPB Cancer Audit Facilitator Maureen Lamb, Cancer Audit Facilitator, Fife Lynn Smith, Cancer Audit Facilitator, Borders Martin Keith, Senior Cancer Information Officer, NHS Dumfries & Galloway Report number: SA UGI01/17w
SCAN HepatoPancreatoBiliary Cancer 2015 Comparative Audit Report 2
HEPATOPANCREATOBILIARY CANCER 2015 COMPARATIVE AUDI T REPORT
Patients diagnosed 1 January 2015 – 31 December 2015
Contents DOCUMENT HISTORY ............................................................................................................ 3 COMMENT BY DEPUTY CHAIR OF THE SCAN UPPER GI GROUP ...................................... 4 Action Points 2014 .................................................................................................................... 5 Action Points 2015 .................................................................................................................... 7 INTRODUCTION AND METHODS ........................................................................................... 9 ESTIMATE OF CASE ASCERTAINMENT .............................................................................. 10 HEPATOPANCREATICOBILIARY CANCER QPIs ................................................................. 12
QPI 2 – Diagnosis and Staging of HCC ............................................................................... 14 QPI 3 – Referral to Scottish Liver Transplant Unit ............................................................... 16 QPI 4 – Palliative Treatment for HCC .................................................................................. 18 QPI 5(i) – 30 Day Mortality Following Definitive Treatment .................................................. 20 QPI 5(ii) – 90 Day Mortality Following Definitive Treatment ................................................. 22
HEPATOPANCREATICOBILIARY CANCER QPIs (EXCLUDING HCC) ................................. 23 QPI 6 – Radiological Diagnosis of Pancreatic, Duodenal or Biliary Tract Cancers ............... 23 QPI 7 – Pathological Diagnosis of Pancreatic, Duodenal or Biliary Tract Cancer ................ 25 QPI 8 – Systemic Therapy for Pancreatic Cancer ............................................................... 27 QPI 9 – Resection Rate for Pancreatic, Duodenal or Biliary Tract Cancer ........................... 29 QPI 10 – Lymph Node Yield for Pancreaticoduodenectomy ................................................ 30 QPI 11 – 30 and 90 Day Mortality after Treatment with Curative Intent ............................... 32 QPI 12(i) – Volume of Cases per Centre ............................................................................. 33 QPI 12(ii) – Volume of Cases per Surgeon .......................................................................... 34
EPIDEMIOLOGY .................................................................................................................... 39 Number of Cases Based on Site of Origin of Tumour .......................................................... 39 Breakdown of Site of Origin of Tumour ................................................................................ 39 Age and Gender Distribution ............................................................................................... 40
APPENDICES ......................................................................................................................... 41 Appendix I – Glossary ......................................................................................................... 41
SCAN HepatoPancreatoBiliary Cancer 2015 Comparative Audit Report 3
DOCUMENT HISTORY
Version Circulation Date Comments
Version 1 SCAN Upper GI Group 19th August 2016
Version 2 SCAN Upper GI Group meeting 26th August 2016
Comments and actions identified. Lead clinician’s commentary added.
Version 3
Final report circulated to the Health Board Clinical Governance Groups
19/09/2016 Assessed for disclosive data
Version 3W
Added to SCAN website February 2017
SCAN HepatoPancreatoBiliary Cancer 2015 Comparative Audit Report 4
HEPATOPANCREATOBILIARY CANCER 2015 COMPARATIVE AUDI T REPORT
COMMENT BY DEPUTY CHAIR OF THE SCAN UPPER GI GROUP The Hepatobiliary service in South East continues to see a rise in the number of patients being
referred to the unit. With this increase comes mounting pressures on our services specifically
Endoscopic Ultrasound. The EUS team is working extremely hard to address this and have
introduced pathway to facilitate timely referral for urgent EUS and are attempting to increase
the number of sessions/endoscopists providing this service. SCAN’s support in the expansion of
this service would be greatly appreciated.
There was a significant improvement seen in reaching the QPI targets from 2013 to 2014.
Developments could still be made in some areas and we are addressing this,
for example introduction of an updated referral form for primary hepatocellular carcinoma has
been introduced to improve capture of relevant data fields.
We continue to actively participate in the Scottish HepatoPancreatoBiliary Cancer Network. The
last SHPBN educational network meeting was held here in Edinburgh in Nov 2015. We
participated in the national morbidity and mortality meeting held in Aberdeen and have
contributed to updates of National cancer protocols and involvement in National clinical trials.
Anya Adair August 2016
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Action Points 2014
QPI Action Required Lead Progress at Board Level
QPI 1
All boards to review cases where patients were not discussed at an MDT meeting. Some of the cases in Fife were admitted as an emergency and received treatment to alleviate symptoms prior to referral to the MDT meeting. Other boards to review cases to assess if any were emergency cases, the target of 95% is supposed to allow for cases such as this but the tolerance may be too low to account for the numbers being admitted as emergencies.
Anya Adair Annabel Howell Peter Driscoll Jeyakumar Apollos
Borders: On review 2 were palliative care only and 2 were not fit for treatment D&G: Mr Apollos has informed clinical colleagues of the need to register all patients with a suspected UGI malignancy with the MDT. There is some concern locally that patients requiring immediate clinical interventions or palliative care who do not have further treatment are considered to have failed this QPI if they receive this input before the next available MDT. Fife: Regarding the three gallbladders showing adenocarcinoma, all malignancies of the gallbladder will now be copied to Mr Peter Driscoll irrespective of the primary hospital consultant. Lothian: Cases reviewed, most had either emergency treatment to alleviate symptoms or had a decision made for supportive care only prior to MDT discussion.
QPI 2
All boards to review cases where data is not recorded to assess if the same data is consistently missing. Lothian to review MDT referral forms again to see if further amendments can be made to this.
Anya Adair Annabel Howell Peter Driscoll Jeyakumar Apollos
Child-Pugh calculator is now on TRAK which makes completion of this QPI easier. There are still many gaps in the necessary data required. We need to request all relevant information be provided before patients are discussed at the MDT
QPI 3 Borders to review cases where information is not recorded to ensure patients who should be included in the denominator are being included.
Annabel Howell
All three patients would not have been referred for transplant as they all had metastatic disease
QPI 4
Improved recording of Childs Pugh score would improve the quality of results for this QPI as many are ‘not recorded for exclusions’ due to this missing information. All boards should review patients who did not receive curative treatment and did not undergo TACE or SACT.
Anya Adair Annabel Howell Peter Driscoll Jeyakumar Apollos
Borders: The patients did not receive curative treatment due to advanced disease and co-morbidities Fife: Patients who failed this QPI were reviewed. All were discussed at the HPB MDT. All such patients have their management decisions made in Lothian. Lothian: The cases were reviewed and found to be valid clinical reasons in all but 1 case which was not documented.
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QPI Action Required Lead Progress at Board Level
QPI 6
This QPI was amended in 2014 following the Baseline Review Meeting, the amendment removed the requirement for patients to have had contrast enhanced imaging. However the understanding of some who attended the meeting was that the wording would be changed to CT Chest and Abdomen +/- Pelvis. All cases with incomplete imaging will be reviewed to ensure that this was appropriate.
Anya Adair Annabel Howell Peter Driscoll Jeyakumar Apollos
Borders: Erroneous data was provided at time of report. One patient recorded as not complete, actually was. The table should have read numerator 5 and denominator 5, 100%. Lothian: 5/12 Lothian patients had no pelvic imaging..
QPI 9 Resection data for previous 3-5 years to be reviewed Anya Adair
Resection rates have below the QPI target year the last few years. Below target resection rates have also been seen previously in WOSCAN. We will discuss at the HPB Network meeting whether this QPI is a realistic target.
QPI 10 Discussion with Lothian Pathology team regarding this QPI Anya Adair Lothian Pathology Team
Currently there are 2 pathologist reporting pancreatic resections and there may be a 3rd joining. This groups of pathologists are planning to discuss the findings. Currently a pathology trainee is conducting an audit reviewing the last 20 resections including the yield and reporting of lymph nodes present. The pathology team question whether the target is not realistic and report that the Royal College of Pathologists stipulate an average for cancer resections should be achieved.
QPI 12
3 surgeons did not meet the minimum number of 4 resections per year, data from the last 3 years will be reviewed locally to assess the average numbers of resections being carried out as numbers will fluctuate year on year.
Anya Adair Averaging over a 4 year period the 6 of the 7 surgeons in Edinburgh have performed 4 or more resections per year
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Action Points 2015
QPI Action required Person responsible for action Date for update
QPI 1 Supportive care cases in Fife to be reviewed Peter Driscoll 16/11/2016
QPI 2
Design a crib sheet for the MDM chair to remind of the points that require documentation for dictation. Ensure that all referral forms are filled in and patents are not discussed with inadequate information.
Anya Adair 16/11/2016
QPI 10 Cases to be reviewed to ascertain actual numbers of lymph nodes. Median and mean numbers of lymph nodes to be calculated.
Anya Adair 16/11/2016
QPI 12 Review data for individual surgeons over the 3 years Anya Adair 16/11/2016
Clinical Trials QPI
Potential new interventional trial protocols to be circulated for consideration in SCAN.
Anya Adair 16/11/2016
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QPI 12i. Volume of Cases/centre. Pancreatic resections for pancreatic cancer performed by each centre in a given year
11 Pancreatic resections only carried out in Lothian 16 28 41 16 28 41
QPI 12ii. Volume of Cases/Surgeon. Pancreatic resections for pancreatic cancer performed by each surgeon in a given year
4 2013: 4/7 surgeons did not meet the minimum target 2014: 3/8 surgeons did not meet the minimum target 2015: 2/9 surgeons did not meet the minimum target
Clinical Trials Access QPI
Patients with HPB cancers (including HCC) enrolled in an Interventional clinical trial
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INTRODUCTION AND METHODS Cohort This report covers patients diagnosed with a HepatioPancreaticoBiliary cancer from 01.01.2015 – 31.12.2015. The results contained within this report have been presented by NHS board of diagnosis, where the QPI relates to treatment outcomes the results have also been presented by hospital of treatment. Dataset and Definitions The QPIs have been developed collaboratively with the three Regional Cancer Networks, Information Services Division (ISD), and Healthcare Improvement Scotland. QPIs will be kept under regular review and be responsive to changes in clinical practice and emerging evidence. The overarching aim of the cancer quality work programme is to ensure that activity at NHS board level is focussed on areas most important in terms of improving survival and patient experience whilst reducing variance and ensuring safe, effective and person-centred cancer care. Following a period of development, public engagement and finalisation, each set of QPIs is published by Healthcare Improvement Scotland1. Accompanying datasets and measurability criteria for QPIs are published on the ISD website2. NHS boards are required to report against QPIs as part of a mandatory, publicly reported, programme at a national level. The QPI dataset for HepatioPancreaticoBiliary Cancer was implemented from 01/01/2013, and this is the third year of QPI reporting for HPB and the second SCAN regional QPI report to be published for HPB cancer. The standard QPI format is shown below: QPI Title: Short title of Quality Performance Indicator (for use in reports etc.)
Description: Full and clear description of the Quality Performance Indicator.
Rationale and Evidence:
Description of the evidence base and rationale which underpins this indicator.
Specifications:
Numerator: Of all the patients included in the denominator those who meet the criteria set out in the indicator.
Denominator: All patients to be included in the measurement of this indicator.
Exclusions: Patients who should be excluded from measurement of this indicator.
Not recorded for numerator:
Include in the denominator for measurement against the target. Present as not recorded only if the patient cannot otherwise be identified as having met/not met the target.
Not recorded for exclusion:
Include in the denominator for measurement against the target unless there is other definitive evidence that the record should be excluded. Present as not recorded only where the record cannot otherwise be definitively identified as an inclusion/exclusion for this standard.
Not recorded for denominator:
Exclude from the denominator for measurement against the target. Present as not recorded only where the patient cannot otherwise be definitively identified as an inclusion/exclusion for this standard.
Target: Statement of the level of performance to be achieved.
1 QPI documents are available at www.healthcareimprovementscotland.org 2 Datasets and measurability documents are available at www.isdscotland.org
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Audit Processes Data was analysed by the audit facilitators in each NHS board according to the measurability document provided by ISD. SCAN data was collated by Joanne Smith, SCAN Audit Facilitator for HPB cancer. Patients were mainly identified through registration at weekly multidisciplinary meetings, and through checks made against pathology listings and GRO death listings. Data capture was dependent on casenote audit and review of various hospitals electronic records systems. Data was recorded in eCase for Borders, Dumfries & Galloway and Fife, Lothian data was recorded in TRAK. Lead Clinicians and Audit Personnel
SCAN Region Hospital Lead Clinician Audit Support
NHS Borders Borders General Hospital Dr Annabel Howell Lynn Smith
NHS Dumfries & Galloway
Dumfries & Galloway Royal Infirmary
Mr Jeyakumar Apollos
Martin Keith
NHS Fife Queen Margaret Hospital Victoria Hospital Mr Peter Driscoll Maureen Lamb
SCAN & NHS Lothian
Royal Infirmary Edinburgh Western General Hospital Miss Anya Adair Joanne Smith
Edinburgh Cancer Centre Oncologist: Dr Lucy Wall
Data Quality Quality Assurance All hospitals in mainland Scotland participate in a Quality Assurance (QA) programme provided by the National Services Scotland Information Services Division (ISD). QA of the HPB QPI data is due to be carried out in September 2016. Clinical Sign-off To ensure the quality of the data and the results presented, the process was as follows:
• Individual health board results were reviewed and signed-off locally. • Data was submitted to WoSCAN on 10th August for inclusion in the National report • Collated results were presented and discussed at the Upper GI SCAN Group Meeting
on 26th August 2016 • The final draft of the regional report was circulated to members of the SCAN Upper GI
Group on • Collated results for all health boards in Scotland were presented at the HPB National
MCN Meeting on 11th November 2016
ESTIMATE OF CASE ASCERTAINMENT Estimated Case Ascertainment An estimate of case ascertainment (the percentage of the population with HepatoPancreaticoBiliary cancer recorded in the audit) is made by comparison with the Scottish Cancer Registry five-year average data from 2010 to 2014. High levels of case ascertainment provide confidence in the completeness of the audit recording and contribute to the reliability of results presented. Levels greater than 100% may be attributable to an increase in incidence. Allowance should be made when reviewing results where numbers are small and variation may be due to chance.
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Number of cases recorded in audit Patients diagnosed 01.01.2015 – 31.12.2015
Borders D&G Fife Lothian SCAN Tumour Site n % n % n % n % n %
Total HPB Cancers 28 100% 50 100% 87 100% 236 100% 401 100% Estimate of case ascertainment Calculated using the average of the most recent available five years of Cancer Registry Data
Borders D&G Fife Lothian SCAN
Number of cases from audit 28 50 87 236 373 Cases from Cancer Registry (2010-2014) 30 43 91 249 383
Case Ascertainment 93.3 114.0 95.6 94.8 97.4 Source: Scottish Cancer Registry, ISD. Data extracted from ACaDMe: 15.07.2016 Note: Case ascertainment is reported by board of diagnosis and has been estimated using a denominator based on the latest (2010-2014) five-year annual average available from the Scottish Cancer Registry. Death certificate only cases have been excluded. Cases that have been diagnosed in the private sector but received any treatment in NHS hospitals have been included.
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HEPATOPANCREATICOBILIARY CANCER QPIs
QPI 1 – Multi-Disciplinary Team Meeting (MDT)
Target = 95% Numerator = Number of patients with HPB cancer discussed at the MDT meeting before definitive treatment
Denominator = All patients with HPB cancer
Exclusions = Patients who died prior to first treatment
Target 95% Borders D&G Fife Lothian SCAN
2015 Cohort 28 50 87 238 403
Ineligible for this QPI 0 1 4 6 11 Numerator 28 45 67 204 344
Not recorded for numerator 0 0 0 0 0
Denominator 28 49 83 232 392 Not recorded for exclusions 0 0 0 0 0
Not recorded for denominator 0 0 0 0 0
% Performance 100.0 91.8 80.7 87.9 87.8 D&G: The target was not met showing a shortfall of 3.2% (4 cases). 2 patients were for supportive care and not discussed at MDT. One patient was an incidental finding and not discussed at MDT, One patient was seen by palliative care 1 day prior to MDT, One patient was for supportive care after radiology examination and was not discussed at MDT. Fife: The target was not met showing a shortfall of 14.3% (16 cases). 9 patients were for supportive care (stents placed) prior to MDT and 5 patients were referred to palliative care due to advanced disease and were not discussed at MDT. 2 patients declined treatment. 4 patients died before first treatment and have been excluded from the calculations. Lothian: The target was not met showing a shortfall of 7.1% (28 cases). 14 had the decision made as an in-patient for supportive care only, 4 were incidental findings, 4 had stent placed prior to MDT, 4 had surgery prior to MDT and 2 declined further investigations. 6 patients died prior to treatment and have been excluded from the calculations.
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Comment: In most cases the patients were for supportive care or had stents inserted due to jaundice. These patients are often discussed with the duty HPB consultant in Edinburgh rather than delaying till MDM discussion. Action: Fife supportive care patients to be reviewed.
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QPI 1 - Multi-Disciplinary Team MeetingHPB Cancer 2015
Not discussed at MDT
Discussed at MDT
QPI Target 95%
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HEPATOCELLULAR CARCINOMA QPIs
QPI 2 – Diagnosis and Staging of HCC
Target = 90%
Numerator = Number of patients with HCC undergoing either CT or MRI with full information recorded3
Denominator = All patients with HCC
Exclusions = No exclusions
Target 90% Borders D&G Fife Lothian SCAN
2015 Cohort 2 7 25 58 92
Ineligible for this QPI 0 0 0 0 0 Numerator 2 0 0 16 18
Not recorded for numerator 0 0 0 0 0
Denominator 2 7 25 58 92 Not recorded for exclusions 0 0 0 0 0
Not recorded for denominator 0 0 0 0 0
% Performance 100.0 0.0 0.0 27.6 19.6 D&G: The target was not met in all 7 cases. Various data items were not documented, most frequently, vascular invasion and final M stage. Fife: The target was not met in all 25 cases. Various data items were not documented, most frequently Childs Pugh score and final M stage. Lothian: The target was not met showing a shortfall of 62.4% (42 cases). 16 of those had incomplete imaging. Childs Pugh, M stage and listing criteria were poorly documented.
3 Full information includes: Number of liver lesions, size of largest liver lesion, presence or absence of vascular invasion, presence of extra hepatic metastases, presence or absence of chronic liver disease, cause of chronic liver disease, Childs Pugh score and Alpha-Fetoprotein Quantification.
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Comment: We have poorer data capture results this year than 2014. We are not recording specifically presence/absence of extrahepatic mets, total bilirubin, encephalopathy and acities, which contribute to the Childs Pugh score This is in part due to the MDM chair not documenting each point and part due to referral forms being incompletely filled in by the referring clinicians Action: Design a crib sheet for the MDM chair to remind of the points that require documentation for dictation. We have recently adopted a common referral form used between SCAN and WoSCAN which we hope will improve this, but need to ensure that all referral forms are filled in and patents are not discussed with inadequate information.
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QPI 2 - Diagnosis and Staging of HCCHCC 2015
Incomplete staging
Complete staging
QPI Target 90%
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QPI 3 – Referral to Scottish Liver Transplant Unit
Target = 90%
Numerator = Number of patients with HCC meeting the UK listing criteria that are referred to SLTU
Denominator = All patients with HCC meeting the UK listing criteria4
Exclusions = Patients who refuse treatment, patients with Alpha-Fetoprotein >1000iu/L, patients with evidence of vascular invasion, patients with extra hepatic disease
Target 90% Borders D&G Fife Lothian SCAN
2015 Cohort 2 7 25 58 92
Ineligible for this QPI 2 4 24 32 62 Numerator 0 3 1 26 30
Not recorded for numerator 0 0 0 0 0
Denominator 0 3 1 26 30 Not recorded for exclusions 0 3 0 15 18
Not recorded for denominator 0 1 0 9 10
% Performance N/A 100.0 100.0 100.0 100.0 The target was met in all Boards, however there were some issues with not recorded data. D&G: In 1 case the size of lesion was not recorded on CT so was not included in the denominator, the size on USS was at least 11cm so the patient would not have been suitable for transplant referral. Fife: 14 patients were excluded, 10 had AFPs over 1000, 6 did not meet the UK listing criteria, 3 had vascular invasion and 1 declined treatment. Lothian: 24 patients were excluded and 8 did not meet the UK listing criteria. Cases with missing criteria for exclusion and denominator, have been included in the calculations as other available data indicates they should be included
4 Current UK listing criteria are: single tumour <5cm diameter; up to 5 tumours all <3cm; single tumour 5-7cm which shows no significant progression over 6 months
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Comment: This QPI was met across the Boards. Patients with AFP greater than 1000 may be down-staged, so should still be referred to the Scottish Liver Transplant Unit. This QPI therefore requires revision at the forthcoming formal review.
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QPI 3 - Referral to Scottish Liver Transplant UnitHCC 2015
Not referred to SLTU
Referred to SLTU
QPI Target 90%
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QPI 4 – Palliative Treatment for HCC
Target = 40%
Numerator = Number of patients with HCC not undergoing treatment with curative intent who receive TACE or approved SACT
Denominator = All patients with HCC not undergoing treatment with curative intent (liver transplantation, resection or ablation)
Exclusions = Patients with decompensated chronic liver disease (Childs Pugh Grade C) and patients who refuse treatment
Target 40% Borders D&G Fife Lothian SCAN
2015 Cohort 2 7 25 58 92
Ineligible for this QPI 0 4 4 22 30 Numerator 2 2 3 18 25
Not recorded for numerator 0 0 0 0 0
Denominator 2 3 21 36 62 Not recorded for exclusions 0 2 0 13 15
Not recorded for denominator 0 0 0 0 0
% Performance 100.0 66.7 14.3 50.0 40.3 Fife: The target was not met showing a shortfall of 25.7% (18 cases). 16 patients were for supportive care and 2 patients had valid clinical reasons for not undergoing treatment. Lothian: The target was met in Lothian but there were some issues with not recorded data. 13 with missing exclusion criteria had no Childs Pugh score recorded these have still been included in the calculations. 22 patients were ineligible. 8 are exclusions due to Childs Pugh score or refusing treatment and 14 had curative treatments. Of the 18 not undergoing TACE or SACT, 17 were for supportive care only and 1 died prior to treatment.
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Comment: More accurate recording of the Childs Pugh score may improve results. All patients were treated appropriately and no further action has been identified.
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QPI 4 - Palliative Treatment for HCCHCC 2015
Patients not undergoing curative or palliative treatment
Patients undergoing SACT
Patients undergoing TACE
QPI Target 40%
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QPI 5(i) – 30 Day Mortality Following Definitive Tr eatment
Target = <10%
Numerator = Number of patients with HCC undergoing disease specific treatment (liver transplant, resection, ablation, TACE or SACT) who die within 30 days of definitive treatment
Denominator = All patients with HCC undergoing disease specific treatment (liver transplant, resection, ablation, TACE or SACT)
Ineligible for this QPI 1 5 22 39 67 Numerator 0 0 0 0 0
Not recorded for numerator 0 0 0 0 0
Denominator 1 2 3 19 25 Not recorded for exclusions 0 0 0 0 0
Not recorded for denominator 0 0 0 0 0
% Performance 0.0 0.0 0.0 0.0 0.0
Systemic Anti Cancer Therapy (SACT) Target <10% Borders D&G Fife Lothian SCAN
2015 Cohort 2 7 25 58 92
Ineligible for this QPI 1 6 25 54 86 Numerator 0 0 0 0 0
Not recorded for numerator 0 0 0 0 0
Denominator 1 1 0 4 6 Not recorded for exclusions 0 0 0 0 0
Not recorded for denominator 0 0 0 0 0
% Performance 0.0 0.0 N/A 0.0 0.0
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QPI 5(ii) – 90 Day Mortality Following Definitive T reatment
Target = <10%
Numerator = Number of patients with HCC undergoing disease specific treatment (liver transplant, resection or ablation) who die within 90 days of definitive treatment
Denominator = All patients with HCC undergoing disease specific treatment (liver transplant, resection or ablation)
Ineligible for this QPI 2 4 25 53 84 Numerator 0 0 0 0 0
Not recorded for numerator 0 0 0 0 0
Denominator 0 3 0 5 8 Not recorded for exclusions 0 0 0 0 0
Not recorded for denominator 0 0 0 0 0
% Performance N/A 0.0 N/A 0.0 0.0
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HEPATOPANCREATICOBILIARY CANCER QPIs (EXCLUDING HCC )
QPI 6 – Radiological Diagnosis of Pancreatic, Duode nal or Biliary Tract Cancers
Target = 80%
Numerator = Number of patients with pancreatic, duodenal or biliary tract cancer who undergo CT of the chest, abdomen and pelvis
Denominator = All patients with pancreatic, duodenal or biliary tract cancer
Exclusions = Patients receiving supportive care only
Target 80% Borders D&G Fife Lothian SCAN
2015 Cohort 26 37 45 154 262
Ineligible for this QPI 11 26 29 88 154 Numerator 13 10 13 49 85
Not recorded for numerator 0 0 0 0 0
Denominator 15 11 16 66 108 Not recorded for exclusions 0 0 0 0 0
Not recorded for denominator 0 0 0 0 0
% Performance 86.7 90.9 81.3 74.2 78.7 Lothian: The target was not met showing a shortfall of 5.8% (17 cases). 15 of those had incomplete imaging and 2 patients had no imaging for valid clinical reasons.
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Comment: Although Lothian did not meet this QPI it is noted that pelvic imaging is not required in patients that have already been shown to be metastatic on chest or abdominal imaging, and no action is indicated. This QPI requires to be revised at the forthcoming formal review.
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QPI 6 - Radiological Diagnosis of Pancreatic, Duoden al or Biliary Tract Cancers
HPB Cancer 2015
Incomplete imaging
Complete CT Chest/Abdomen/Pelvis
QPI Target 80%
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QPI 7 – Pathological Diagnosis of Pancreatic, Duode nal or Biliary Tract Cancer
Target = 50%
Numerator = Number of patients with pancreatic, duodenal or distal biliary tract cancer undergoing non-surgical treatment who have a histological or cytological diagnosis (e.g. brush cytology, endoscopic or image guided biopsy)
Denominator = All patients with pancreatic, duodenal or distal biliary tract cancer undergoing non-surgical treatment
Exclusions = No exclusions
Target 50% Borders D&G Fife Lothian SCAN
2015 Cohort 26 37 45 154 262
Ineligible for this QPI 19 32 37 143 231 Numerator 7 5 5 9 26
Not recorded for numerator 0 0 0 0 0
Denominator 7 5 8 11 31 Not recorded for exclusions 0 0 0 0 0
Not recorded for denominator 0 0 0 0 0
% Performance 100.0 100.0 62.5 81.8 83.9 The target was met by all Boards Note: Fife: 3 patients received palliative chemotherapy but did not have cytological or histological diagnosis Lothian: Ineligible includes those having surgery or supportive care only. 2 patients had a clinical diagnoses only
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Comment: This QPI was met by all Health Boards and no action is required.
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QPI 7 - Pathological Diagnosis of Pancreatic, Duoden al or Biliary Tract Cancers
HPB Cancer 2015
Patients undergoing non-surgical treatment with no histological or cytological diagnosis
Patients undergoing non-surgical treatment who have a histological or cytological diagnosis
QPI Target 50%
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QPI 8 – Systemic Therapy for Pancreatic Cancer
Target = 50%
Numerator = Number of patients undergoing pancreatic cancer resection who receive adjuvant chemotherapy
Denominator = All patients undergoing resection for pancreatic cancer
Exclusions = Patients who die post-operatively (within 60 days of surgery) and patients who refuse chemotherapy
Systemic Therapy for Pancreatic Cancer – Board of D iagnosis Target 50% Borders D&G Fife Lothian SCAN
2015 Cohort 26 37 45 154 262
Ineligible for this QPI 24 34 42 144 244 Numerator 2 3 3 8 16
Not recorded for numerator 0 0 0 0 0
Denominator 2 3 3 10 18 Not recorded for exclusions 0 0 0 0 0
Not recorded for denominator 0 0 0 0 0
% Performance 100.0 100.0 100.0 80.0 88.9 The target was met by all Boards Note: Lothian: 2 patients were not fit to undergo adjuvant chemotherapy.
0%
20%
40%
60%
80%
100%
Borders D&G Fife Lothian SCAN
% P
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Health Board
QPI 8 - Systemic Therapy for Pancreatic CancerHPB Cancer 2015
Patients undergoing pancreatic resection who do not receive adjuvant chemotherapy
Patients undergoing pancreatic resection who receive adjuvant chemotherapy
QPI Target 50%
SCAN HepatoPancreatoBiliary Cancer 2015 Comparative Audit Report 28
Systemic Therapy for Pancreatic Cancer – Hospital o f Treatment Target 50% BGH DRI VHK WGH SCAN
2015 Cohort 26 37 45 154 262
Ineligible for this QPI 24 34 42 144 244 Numerator 2 3 3 8 16
Not recorded for numerator 0 0 0 0 0
Denominator 2 3 3 10 18 Not recorded for exclusions 0 0 0 0 0
Not recorded for denominator 0 0 0 0 0
% Performance 100.0 100.0 100.0 80.0 88.9
Comment: This QPI was met by all Health Boards and no action is required.
SCAN HepatoPancreatoBiliary Cancer 2015 Comparative Audit Report 29
QPI 9 – Resection Rate for Pancreatic, Duodenal or Biliary Tract Cancer
Target = 15%
Numerator = Number of patients with pancreatic, duodenal or distal biliary tract cancer who undergo resection
Denominator = All patients with pancreatic, duodenal or distal biliary tract cancer
Exclusions = No exclusions
Target 15% Borders D&G Fife Lothian SCAN
2015 Cohort 26 37 45 154 262
Ineligible for this QPI 1 5 3 23 32 Numerator 2 3 5 18 28
Not recorded for numerator 0 0 0 0 0
Denominator 25 32 42 131 230 Not recorded for exclusions 0 0 0 0 0
Not recorded for denominator 0 0 0 0 0
% Performance 8.0 9.4 11.9 13.7 12.2 Note this QPI does not include resections for tumour sites C23x and C240A
Comment: Figures show a slight improvement from 2014, but the resection rates will differ between cancer sites, e.g., pancreatic resection rates will be lower than duodenal. This QPI requires revision at the forthcoming formal review. It may be useful to incorporate resection rates into survival analyses performed by ISD.
0%
20%
40%
60%
80%
100%
Borders D&G Fife Lothian SCAN
% P
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Health Board
QPI 9 - Resection Rate for Pancreatic, Duodenal or B iliary Tract Cancer
HPB Cancer 2015
Patients with pancreatic, duodenal or distal biliary tract cancer who do not undergo resection
Patients with pancreatic, duodenal or distal biliary tract cancer who undergo resection
QPI Target 15%
SCAN HepatoPancreatoBiliary Cancer 2015 Comparative Audit Report 30
QPI 10 – Lymph Node Yield for Pancreaticoduodenecto my
Target = 100%
Numerator = Number of patients with pancreatic cancer who undergo pancreaticoduodenectomy where ≥15 lymph nodes are resected and pathologically examined Denominator = All patients with pancreatic cancer who undergo pancreaticoduodenectomy
Exclusions = No exclusions
Target 100% Borders D&G Fife Lothian SCAN
2015 Cohort 26 37 45 154 262
Ineligible for this QPI 24 35 40 139 238 Numerator 1 2 2 8 13
Not recorded for numerator 0 0 0 0 0
Denominator 2 2 5 15 24 Not recorded for exclusions 0 0 0 0 0
Not recorded for denominator 0 0 0 0 0
% Performance 50.0 100.0 40.0 53.3 54.2 Borders: The target was not met showing a shortfall of 50 % (1 case). Fife: The target was not met showing a shortfall of 60 % (3 cases). Lothian: The target was not met showing a shortfall of 46.7 % (3 cases).
0%
20%
40%
60%
80%
100%
Borders D&G Fife Lothian SCAN
% P
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Health Board
QPI 10 - Lymph Node Yield for Pancreatic CancerHPB Cancer 2015
Patients who undergo pancreaticoduodenectomy where <15 lymph nodes are resected
Patients who undergo pancreaticoduodenectomy where ≥15 lymph nodes are resected
QPI Target 100%
SCAN HepatoPancreatoBiliary Cancer 2015 Comparative Audit Report 31
Lymph Node Yield – Hospital of Surgery Target 100% RIE SCAN
Numerator 21 21
Not recorded for numerator 0 0
Denominator 36 36 Not recorded for exclusions 0 0
Not recorded for denominator 0 0
% Performance 58.3 58.3 Note: 8 additional resections recorded for RIE are patients who were diagnosed outwith the SCAN region. Comment: The Royal College of Pathologists dataset for carcinoma of the pancreas stipulates an average of 15 for cancer resections should be achieved as a marker of quality of pathology dissection, rather than a minimum (required by this QPI). This QPI requires revision at the forthcoming formal review. Action: Cases to be reviewed to ascertain actual numbers of lymph nodes. Median and mean numbers of lymph nodes to be calculated.
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QPI 11 – 30 and 90 Day Mortality after Treatment wi th Curative Intent Target = <5% Numerator = Number of patients with pancreatic, duodenal or distal biliary tract cancer undergoing surgical resection who die within 30 days Denominator = All patients with pancreatic, duodenal or distal biliary tract cancer undergoing surgical resection Exclusions = No exclusions 30 Day mortality following treatment with curative intent By Board of treatment Target <5% Lothian
2015 Cohort 262
Ineligible for this QPI 234
Numerator 0
Not recorded for numerator 0
Denominator 42
Not recorded for exclusions 0
Not recorded for denominator 0
% Performance 0.0
90 Day mortality following treatment with curative intent By Board of treatment Target <5% Lothian
2015 Cohort 262
Ineligible for this QPI 234
Numerator 1
Not recorded for numerator 0
Denominator 42
Not recorded for exclusions 0
Not recorded for denominator 0
% Performance 2.4 This minimum target was achieved in SCAN. One patient died 78 days post-op and had known hepatic mets at time of resection and had a palliative resection performed as an emergency.
When calculating this QPI, only the procedure code is used and an additional data item for curative or palliative should be added in order to ensure that only curative operations are included in this measure nationally.
SCAN HepatoPancreatoBiliary Cancer 2015 Comparative Audit Report 33
QPI 12(i) – Volume of Cases per Centre
Target = Minimum of 11 procedures per centre in a given year
Number of pancreatic resections for pancreatic cancer performed by each centre in a given year
QPI 12a: Volume of Cases per Centre
HOSPITAL OF
SURGERY NHS BOARD OF DIAGNOSIS
RIE Borders D&G Fife Lothian SCAN Lanarkshire Forth Valley GG&C WoSCAN J55.1 Total Pancreatectomy and excision of surrounding tissue
n 1 0 0 0 0 0 1 0 0 1
J56.1 Pancreaticoduodenectomy and excision of surrounding tissue
n 0 0 0 0 0 0 0 0 0 0
J56.2 Pancreaticoduodenectomy and resection of antrum of stomach
n 36 2 2 5 15 24 1 10 1 36
J57.3 Left Pancreatectomy n 4 0 1 0 3 4 0 0 0 4
J57.9 Unspecified other partial excision of pancreas
n 0 0 0 0 0 0 0 0 0 0
Total number of pancreatic resections n 41 2 3 5 18 28 2 10 1 41
SCAN HepatoPancreatoBiliary Cancer 2015 Comparative Audit Report 34
QPI 12(ii) – Volume of Cases per Surgeon
Target = Minimum 4 procedures per surgeon in a given year
Number of pancreatic resections for pancreatic cancer performed by each surgeon in a given year
QPI 11b: Volume of Cases per Surgeon OPERATING SURGEON
Surgeon
1 Surgeon
2 Surgeon
3 Surgeon
4 Surgeon
5 Surgeon
6 Surgeon
7 Surgeon
8 Surgeon
9 J55.1 Total Pancreatectomy and excision of surrounding tissue n
0 0 0 0 0 1 0 0 0
J56.1 Pancreaticoduodenectomy and excision of surrounding tissue n
0 0 0 0 0 0 0 0 0
J56.2 Pancreaticoduodenectomy and resection of antrum of stomach n
4 5 6 4 9 5 2 5 0
J57.3 Left Pancreatectomy n
1 0 0 1 0 1 1 0 1
J57.9 Unspecified other partial excision of pancreas n
0 0 0 0 0 0 0 0 0
Total number of pancreatic resections n
5 5 6 5 9 7 3 5 1
NB: 5 procedures listed above were carried out as joint procedures and are therefore recorded in the figures for both surgeons involved. Comment: Over 3 years this QPI has been met. Action: Review data for individual surgeons over the 3 years.
SCAN HepatoPancreatoBiliary Cancer 2015 Comparative Audit Report 35
CLINICAL TRIALS
Clinical Trials Access
Target = 7.5% Interventional Trials/ 15% Translational Research
Numerator = Number of patients with HPB cancers (including HCC) enrolled in a clinical trial
Denominator = All patients with HPB cancers (including HCC)
Exclusions = No exclusions
Note: The clinical trials QPI will be measured utilising South East SCRN data and Cancer Registry data (5 year average of case ascertainment)
Clinical Trials - Interventional TrialsHPB Cancer 2015
Patients not enrolled in an interventional clinical trial
Patients enrolled in an interventional clinical trial
QPI Target 7.5%
SCAN HepatoPancreatoBiliary Cancer 2015 Comparative Audit Report 36
Interventional Trials in 2015 Numbers recruited
ESPAC-4 3
SORAMIC 3
TACE2 1
TOFFEE 1
Action : Potential new interventional trial protocols are being circulated for consideration in SCAN.
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KEY CATEGORIES
Treatment Types Number of patients undergoing each type of treatment by tumour site Site of Tumour Surgery n Non-surgical Treatment n Other n
HCC [C22.0]
Orthotopic transplantation of liver 8 Ablation 8 Supportive Care only 40 Right Hepatectomy 3 TACE (pre-surgery) 5 Patient refused treatment 2 Left Hepatectomy 0 TACE (no surgery) 21 Patient died before treatment 2 Resection of segment of liver 3 Chemotherapy 1 Not recorded 0 Wedge excision of liver 0 Biological Therapy 5 Extended right hemihepatectomy 0 Extended left hemihepatectomy 0 Other specified partial excision of liver 0
Surgery n Non-surgical Treatment n Other n Total Pancreatectomy 0 Adjuvant Chemotherapy 16 Supportive Care only 114 Pancreaticoduodenectomy and excision of surrounding tissue (PPPD) 0 Neo-adjuvant Chemotherapy 0 Patient refused treatment 11 Pancreaticoduodenectomy and resection of antrum of stomach (Whipples) 14 Palliative Chemotherapy 36 Patient died before treatment 4 Distal Pancreatectomy 3 Chemoradiotherapy 0 Not recorded 0 Pancreatectomy 1 Biological Therapy 0 Watchful waiting 1 Bypass of duodenum by anastomosis of stomach to jejunum 1 Endoscopic Treatment 1 Billiary bypass 0 Double bypass/gastroenterostomy 10
Surgery n Non-surgical Treatment n Other n Total Cholecystectomy 7 Adjuvant Chemotherapy 5 Supportive Care only 37 Subtotal Cholecystectomy 0 Neo-adjuvant Chemotherapy 0 Patient refused treatment 4 Partial excision of bile duct 0 Palliative Chemotherapy 5 Patient died before treatment 2
SCAN HepatoPancreatoBiliary Cancer 2015 Comparative Audit Report 38
Pancreaticoduodenectomy and excision of surrounding tissue (PPPD) 0 Chemoradiotherapy 0 Not recorded 0 Pancreaticoduodenectomy and resection of antrum of stomach (Whipples) 8 Biological Therapy 0 Excision of ampulla of Vater 0 Endoscopic Treatment 0 Double bypass/gastroenterostomy 3 Orthotopic transplantation of liver 1
Duodenum [C17.0]
Surgery n Non-surgical Treatment n Other n Partial excision of Duodenum 0 Adjuvant Chemotherapy 1 Supportive Care only 3 Excision of lesion of Duodenum 0 Neo-adjuvant Chemotherapy 0 Patient refused treatment 0 Bypass of duodenum 0 Palliative Chemotherapy 1 Patient died before treatment 0 Pancreaticoduodenectomy and excision of surrounding tissue (PPPD) 0 Chemoradiotherapy 0 Not recorded 0 Pancreaticoduodenectomy and resection of antrum of stomach (Whipples) 2 Biological Therapy 0 Double bypass/gastroenterostomy 0 Endoscopic Treatment 0
Intrahepatic Bile Duct
[C22.1]
Surgery n Non-surgical Treatment n Other n Right Hepatectomy 0 Adjuvant Chemotherapy 0 Supportive Care only 30 Left Hepatectomy 0 Neo-adjuvant Chemotherapy 0 Patient refused treatment 5 Resection of segment of liver 0 Palliative Chemotherapy 13 Patient died before treatment 2 Wedge excision of liver 0 Chemoradiotherapy 0 Not recorded 0 Extended right hemihepatectomy 0 Biological Therapy 0 Extended left hemihepatectomy 0 Endoscopic Treatment 0 Other specified partial excision of liver 0 Partial excision of bile duct 0
Hepaticojejunostomy 1
SCAN HepatoPancreatoBiliary Cancer 2015 Comparative Audit Report 39
EPIDEMIOLOGY
Number of Cases Based on Site of Origin of Tumour
Borders D&G Fife Lothian SCAN Tumour Site n % n % n % n % n %
Min 44 57 50 41 44 51 21 47 Max 83 88 95 91 91 91 95 97
Mean 71.1 77.4 73.2 71.8 71 72 69 75 Median 76 78 76 70.5 72 71 70 76
SCAN HepatoPancreatoBiliary Cancer 2015 Comparative Audit Report 41
APPENDICES
Appendix I – Glossary Ablative therapies See Radiofrequency Ablation Active treatment Treatment which is intended to improve the cancer and/or alleviate symptoms, as opposed to supportive care. Adjuvant Chemotherapy The use of chemotherapy, after initial treatment by surgery to reduce the risk of recurrence of the cancer. Adjuvant therapy/ treatment Additional cancer treatment given after the primary treatment to lower the risk that the cancer will come back. Adjuvant therapy may include chemotherapy, radiation therapy, hormone therapy, targeted therapy or biological therapy. AFP (Alpha-fetoprotein) A protein normally produced by a foetus. AFP levels are usually undetectable in the blood of healthy adult men or women (who are not pregnant). An elevated level of AFP suggests the presence of either a primary liver cancer or germ cell tumour. Audit The measuring and evaluation of care against best practice with a view to improving current practice and care delivery. Biliary tract The organs and ducts that make and store bile (a fluid made by the liver that helps digest fat), and release it into the small intestine. The biliary tract includes the gallbladder and bile ducts inside and outside the liver. Also called biliary system. Biopsy Removal of a sample of tissue from the body to assist in diagnosis of a disease.
Brush Cytology Examination of cells obtained from a mucosal surface using a cytological brush Case ascertainment Number of cases recorded as a proportion of those expected using the average of the most recent available five years reported in the Scottish Cancer Registry. Case-mix Population of patients with different prognostic factors. Chemotherapy The use of drugs that kill cancer cells, or prevent or slow their growth. Childs Pugh Is used to assess the prognosis of chronic liver disease, mainly cirrhosis. Although it was originally used to predict mortality during surgery, it is now used to determine the prognosis, as well as the required strength of treatment and the necessity of liver transplantation. Chronic liver disease Chronic liver disease in the clinical context is a disease process of the liver that involves a process of progressive destruction and regeneration of the liver parenchyma leading to fibrosis and cirrhosis. Computerised Tomography (CT) An x-ray imaging technique, which allows detailed investigation of the internal organ of the body Curative treatment Treatment which is given with the aim of curing the cancer.
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Cytological The study of the structure and function of cells under the microscope, and of their abnormalities. Diagnosis The process of identifying a disease, such as cancer, from its signs and symptoms. Duodenal Refers to the duodenum, or the first part of the small intestine. Dysplastic nodules Abnormal development or growth of tissues, organs, or cells. Endoscopic Ultrasound (EUS) A procedure in which an endoscope is inserted into the body. A probe at the end of the endoscope is used to bounce high energy sound waves (ultrasound) off internal organs to make a picture. GRO Records General Register Office Records provide official government information on births, marriages and deaths. Hepatocellular Carcinoma (HCC) A type of adenocarcinoma and the most common type of liver tumour. Hepatopancreatobiliary (HPB) Cancer Cancer of the liver, pancreas, gallbladder and biliary tract. Histological/histopathological The study of the structure, composition and function of tissues under the microscope, and their abnormalities Lesion Tumour, mass, or other abnormality. Liver A large organ located in the upper abdomen. The liver cleanses the blood and aids in digestion by secreting bile.
Liver transplantation Liver transplantation is a surgery that removes a diseased liver and replaces it with a healthy donor liver. Lymph nodes Small bean shaped organs located along the lymphatic system. Nodes filter bacteria or cancer cells that might travel through the lymphatic system. Malignancy Cancerous. Malignant cells can invade and destroy the tissue from which they originate and can spread to other sites in the body. Metastatic Spread of cancer away from the primary site to somewhere else via the bloodstream or the lymphatic system. Mortality Either (1) the condition of being subject to death; or (2) the death rate, which reflects the number of deaths per unit of population in any specific region, age group, disease or other classification, usually expressed as deaths per 1000, 10,000 or 100,000. Multi-Disciplinary Team (MDT) A meeting which is held on a regular basis, which is made up of participants from various disciplines appropriate to the disease area, where diagnosis, management, and appropriate treatment of patients is discussed and decided. Orthotopic Refers to something that occurs in the normal or usual place in the body. It is often used to describe tissue or an organ that is transplanted into its normal place in the body. Palliative treatment Anything which serves to alleviate symptoms due to the underlying cancer but is not expected to cure it.
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Pancreas/Pancreatic A glandular organ located in the abdomen. It makes pancreatic juices, which contain enzymes that aid in digestion, and it produces several hormones, including insulin. The pancreas is surrounded by the stomach, intestines, and other organs. Pancreatitis Inflammation of the pancreas. Performance status A measure of how well a patient is able to perform ordinary tasks and carry out daily activities. Radio Frequency Ablation (RFA) A procedure that uses radio waves to heat and destroy abnormal cells. Scottish Liver Transplant Unit (SLTU) The Scottish Liver Transplantation Unit (SLTU) is funded to provide liver transplant services to the people of Scotland Staging Process of describing to what degree cancer has spread from its original site to another part of the body. Staging involves clinical, surgical and pathology assessments. Surgical resection Surgical removal of the tumour/lesion. Survival The percentage of people in a study or treatment group who are alive for a certain period of time after they were diagnosed with or treated for a disease, such as cancer. Systemic Anti Cancer Therapy (SACT) Treatment of cancer using drugs which induce a reduction in tumour cell population, for example cancer chemotherapy or hormone therapy.
Trans-arterial Chemoembolisation (TACE) Administration of chemotherapy directly to the liver tumour via a catheter. With this technique, the chemotherapy targets the tumour while sparing the patient many side effects of traditional chemotherapy that is given to the whole body Tumour size The size of a cancer measured by the amount of space taken up by the tumour. Whipple’s resection A type of surgery used to treat pancreatic cancer. The head of the pancreas, the duodenum, a portion of the stomach, and other nearby tissues are removed. Also called pancreaticoduodenectomy
