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Audit Report Cervical Cancer Quality Performance Indicators

Endometrial Cancer Quality Performance Indicators

Clinical Audit Data: 01 October 2017 to 30 September 2018

Kevin Burton Consultant Gynaecological Oncologist MCN Clinical Lead Kevin Campbell MCN Manager Julie McMahon Information Officer

West of Scotland Cancer Network Gynaecological Cancer Managed Clinical Network

West of Scotland Cancer Network Final Published Endometrial & Cervical Cancer QPI Audit Report V1.0 26/08/2019

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CONTENTS

EXECUTIVE SUMMARY 3

1. INTRODUCTION 8

2. BACKGROUND 8

2.1. NATIONAL CONTEXT 8

3. METHODOLOGY 9

4. RESULTS AND ACTION REQUIRED 10

4.1 PERFORMANCE AGAINST QUALITY PERFORMANCE INDICATORS (QPIS) 10

4.2. ENDOMETRIAL CANCER – QUALITY PERFORMANCE INDICATORS 11

4.3. CERVICAL CANCER – QUALITY PERFORMANCE INDICATORS 23

5. CONCLUSIONS 36

ACKNOWLEDGEMENT 38

ABBREVIATIONS 39

REFERENCES 40

APPENDIX 1: ACTION / IMPROVEMENT PLANS 42


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Executive Summary

Introduction This report contains an assessment of the performance of West of Scotland (WoS) gynaecology cancer services using clinical audit data relating to patients diagnosed between 1 October 2017 and 30 September 2018. Twelve months of data were measured against the Endometrial and Cervical Cancer QPIs for the fourth consecutive year. Previous years' results are presented within this audit report for QPIs where results have remained comparable. In order to ensure the success of the National Cancer QPIs in driving quality improvement in cancer care across NHS Scotland, a process of formal review was carried out after Year 3 of comparative reporting with tumour-specific Regional Clinical Leads undertaking a key role in determining the extent of the review required for each tumour type. The revised Endometrial and Cervical Cancer QPIs1 were published in December 2018 and, as stated above, are valid for patients diagnosed on or after 01 October 2017. Background Treatment and care for gynaecological cancer patients is delivered by a single regional multi-disciplinary team (MDT). This is facilitated by video-conferencing technology and a bespoke IT system, which is operationally dependant on close collaboration of professionals from a range of clinical specialities across the region to provide well planned and coordinated delivery of treatment and care. Complex gynaecological malignancy often requires a multi-modality approach and surgery remains a key component of effective curative management. 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 entered locally into the electronic Cancer Audit Support Environment (eCASE): a secure centralised web-based database. Data relating to patients diagnosed between 1 October 2017 and 30 September 2018 was downloaded from eCASE on 10 April 2019. Analysis was performed centrally by the West of Scotland Cancer Network (WoSCAN) Information Team.

Results Results for each QPI are shown in detail in the main report and illustrate Board performance against targets and overall WoS performance for each quality 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. The following summary of results shows the WoS and individual units’ percentage performance against each QPI target.


Endometrial/Cervical Cancer Performance Summary Report

QPI Target WoS A&A FV Lan Glasgow

North Glasgow

South Clyde

QPI 1 - Radiological Staging. Patients with endometrial cancer should have their stage of disease assessed by magnetic resonance imaging (MRI) and/or computed tomography (CT) prior to definitive treatment.

90% 98.3%

>

96.4%

<

94.1%

>

97.1%

>

100%

>

100%

=

100%

=

169 172 27 28 16 17 33 34 37 37 20 20 36 36

QPI 2 - Multidisciplinary Team Meeting (MDT). Patients with endometrial cancer should be discussed by a multidisciplinary team (MDT) prior to definitive treatment.

95% 72.0%

<

64.2%

<

61.8%

<

59.6%

<

96.6%

<

92.6%

<

63.3%

<

208 289 34 53 21 34 34 57 56 58 25 27 38 60

QPI 3 - Total Hysterectomy and Bilateral Salpingo-Oophorectomy. Patients with endometrial cancer should undergo total hysterectomy (TH) and bilateral salpingo-oophorectomy (BSO).

85% 88.6%

<

81.1%

<

85.0%

<

91.2%

>

94.7%

>

78.6%

<

93.8%

<

265 299 43 53 34 40 52 57 54 57 22 28 60 64

QPI 4 - Laparoscopic Surgery (Hosp. of Surgery) Patients with endometrial cancer undergoing definitive surgery should undergo laparoscopic surgery, where clinically appropriate.

70% 75.7%

>

85.0%

>

92.9%

>

94.9%

>

69.3%

>

76.7%

>

54.9%

>

209 276 34 40 26 28 37 39 61 88 23 30 28 51

Above Target Result

Below Target Result

> Indicates increase on previous years figure

< Indicates decrease from previous years figure

= Indicates no change from previous year

Indicates no comparable measure from previous year

Endometrial QPIs Performance by Board


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QPI Target WoS A&A FV Lan NG SG Clyde

*QPI 5 - Adjuvant Vaginal Brachytherapy. Patients with intermediate risk (stage IB, grade 1 or 2; or stage IA, grade 3 endometrioid or mucinous) endometrial cancer should be considered for adjuvant radiotherapy.

90% 92.6%

>

92.3%

<

100%

=

83.3%

<

100%

>

88.9%

<

91.7%

>

50 54 12 13 6 6 5 6 8 8 8 9 11 12

*QPI 6 – SACT/Hormone Therapy. Patients with stage IV endometrial cancer should have SACT or hormone therapy.

75% 55.6%

>

- - - 66.7%

>

- -

10 18 - - - - - - 4 6 - - - -

QPI 7 – 30 Day Mortality Following Surgery. 30 day mortality following surgery for endometrial patients.

100%

>

85.7%

<

116 125 26 27 14 16 30 33 27 28 7 7 12 14

QPI 2 - Positron Emission Tomography/Computed Tomography (PET/CT). Patients with cervical cancer, for whom primary definitive surgery is not appropriate, should undergo positron emission tomography - computed tomography imaging (PET/CT).

95% 98.5%

>

100%

=

100%

=

100%

>

100%

=

- 80.0%

<

67 68 17 17 9 9 21 21 12 12 - - 4 5

QPI 3 - Multidisciplinary Team Meeting (MDT). Patients with cervical cancer should be discussed by a multidisciplinary team (MDT) prior to definitive treatment.

95% 99.2%

>

100%

=

100%

=

100%

>

100%

=

100%

=

92.9%

>

123 124 27 27 16 16 31 31 30 30 6 6 13 14


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QPI Target WoS A&A FV Lan NG SG Clyde

*QPI 4 - Radical Hysterectomy. Patients with stage IB1 cervical cancer should undergo radical hysterectomy.

85% 75.0%

<

66.7%

<

- - 75.0%

<

n/a 60.0%

=

21 28 4 6 - - - - 9 12 0 0 3 5

*QPI 5 - Surgical Margins. (Hosp. of Surgery) Patients with surgically treated cervical cancer should have clear resection margins.

95% 94.3%

<

- - - 97.4%

<

- 85.7%

>

50 53 - - - - - - 38 39 - - 6 7

*QPI 6 - 56 Day Treatment Time for Radical Radiotherapy. Treatment time for patients with cervical cancer undergoing radical radiotherapy should be no more that 56 days.

90% 97.4%

<

94.7%

<

100%

=

100%

=

100%

=

- 88.9%

<

76 78 18 19 9 9 23 23 14 14 - - 8 9

*QPI 7 – Chemoradiation. Patients with cervical cancer undergoing radical radiotherapy should receive concurrent platinum-based chemotherapy.

70% 89.7%

>

84.2%

<

100%

>

87.0%

<

100%

>

- 88.9%

>

70 78 16 19 9 9 20 23 14 14 - - 8 9

**Small numbers in some Boards - percentage comparisons over a single year should be viewed with caution. ‘-‘ Data not shown due to small numbers (denominator less than 5).


Conclusions and Action Required The development of national QPIs for endometrial and cervical cancer has helped drive continuous quality improvement in the care of patients with endometrial or cervical cancer whilst ensuring that activity at NHS Board/treatment centre level is focussed on those areas that are most important in terms of improving survival and patient outcomes. West of Scotland NHS Boards have now completed the fourth year of data collection for cervical and endometrial cancer QPIs. The results presented in this report demonstrate that patients with cervical and endometrial cancer continue to receive a consistently high standard of care. Case ascertainment and data capture is of a high standard enabling robust assessment of performance against QPIs, comparison of performance across the country, and the identification of outliers. Where QPI targets were not met, NHS Boards have scrutinised cases further and provided detailed clinical feedback. In the main this indicates valid clinical reasons, or that in some cases patient choice or co-morbidities have influenced clinical management. The MCN will actively progress regional actions identified, NHS Boards are asked to develop local Improvement Plans in response to the findings presented in the report, and detailed within the appropriate NHS Board Action Plan templates in Appendix 1. Actions: Endometrial Cancer QPI 2: MDT Discussion Prior to Definitive Treatment

The MCN will initiate discussions around the appropriateness of including Grade I endometrial patients within the QPI measurement and will review the current MCN guideline to establish if any changes are required.

QPI 3: Total Hysterectomy and Bilateral Salpingo-Oophorectomy

NHS Ayrshire & Arran should review all cases not meeting the QPI target and provide detailed clinical reasons to the MCN.

QPI 6: SACT/Hormone Therapy

NHSGGC should review the cases not meeting the target and provide detailed clinical reasons for those advanced stage endometrial cancer patients not receiving SACT.

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


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1. Introduction This report contains an assessment of the performance of West of Scotland (WoS) gynaecology cancer services using clinical audit data relating to patients diagnosed between 1 October 2017 and 30 September 2018. Data analysed and included within this report relate to cervical and endometrial cancers. Regular reporting of activity and performance is a fundamental requirement of a Managed Clinical Network (MCN) to assure the quality of care delivered across the region. Results are measured against the Endometrial and Cervical Cancer Quality Performance Indicators (QPIs). Data definitions and measurability criteria to accompany cancer QPIs are available from the ISD website2. Twelve months of data were measured against the endometrial and cervical cancer QPIs for the fourth consecutive year, and previous years' results are presented within this audit report for QPIs where results have remained comparable. Future reports will continue to compare clinical audit data in successive years to further illustrate trend analysis. In order to ensure the success of the National Cancer QPIs in driving quality improvement in cancer care across NHS Scotland, a process of formal review was carried out after Year 3 of comparative reporting with tumour-specific Regional Clinical Leads undertaking a key role in determining the extent of the review required for each tumour type. The revised Endometrial and Cervical cancer QPIs1 were published in December 2018 and, as stated above, are valid for patients diagnosed on or after 01 October 2017. Any new QPIs which were developed requiring new data items will be reported in Year 5 once data becomes available for these new measures.

2. Background

Treatment and care for gynaecological cancer patients is delivered by a single regional multi-disciplinary team (MDT). This is facilitated by video-conferencing technology and a bespoke IT system, which is operationally dependant on close collaboration of professionals from a range of clinical specialities across the region to provide well planned and coordinated delivery of treatment and care. Complex gynaecological malignancy often requires a multi-modality approach and surgery remains a key component of effective curative management. 2.1. National Context Endometrial cancer is the most common gynaecological cancer and the fourth most common cancer in women in Scotland with approximately 800 new cases diagnosed annually. The incidence of endometrial cancer has risen significantly by 24% over the last ten years (2007-2017)3. This undoubtedly reflects increasing levels of obesity4 and also an increasingly ageing population. Recently published data highlights that the number of new cases of endometrial cancer is predicted to increase by 55% between 2008-2012 and 2023-20275.

One-year and 5-year relative survival rates for endometrial cancer for females diagnosed between 2007 and 2011 are 92.9% and 83.2% respectively3. Endometrial cancer is the 9th most common death in females from cancer in Scotland with overall mortality rates increasing by 59.1% from 2007 to 20174. Cervical cancer is noted as being the twelfth most common cancer in women with approximately 275 cases diagnosed each year3. The incidence of cervical cancer has increased by 4.7% over the last ten years3. Overall mortality rates have decreased by 6.2% over the past 10 years from 2007 to 2017 and 1-year and 5-year relative survival is noted as being 87.5% and 73% respectively3. Recently published figures indicate that the number of new cases of cervical cancer is predicted to increase by 39.6% between 2008-2012 and 2023-20275. Many cervical cancers are detected early due to the well established screening programme introduced in 1988. The Human Papilloma Virus (HPV) vaccine is designed to protect against certain high risk types of HPV that are responsible for approximately 70% of cervical cancer cases. The


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vaccination programme started in Scotland on 1st September 2008 and aims to protect females by routinely immunising them at 12-13 years of age, through a school based programme. Progression from HPV infection to cervical cancer can take many years, therefore surveillance to monitor the impact of the vaccination programme will be a long term undertaking.

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 with endometrial or cervical cancer between 1 October 2017 and 30 September 2018 was downloaded from eCASE at 2200 hrs on 10 April 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 for the region by the WoSCAN Information Team 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.


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4. Results and Action Required

4.1 Performance against Quality Performance Indicators (QPIs) Results of the analysis of endometrial and cervical QPIs are set out in the following section. Graphs and charts have been provided where this aids interpretation and, where appropriate, numbers have also been included to provide context. Where possible, results for patients diagnosed in previous years have been presented alongside the previous years’ results to illustrate trends. Data (both graphically and in tabular format) are presented by location of diagnosis or treatment, with some criteria given as an overall WoS representation. Specific regional and NHS Board actions have been identified to address issues highlighted through the data 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 are denoted with a dash (-). Any commentary provided by NHS Boards relating to the impacted indicators will however be included as a record of continuous improvement.


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4.2. Endometrial Cancer – Quality Performance Indicators Introduction Quality Performance Indicators (QPIs) were implemented for patients diagnosed with endometrial cancer on or after 1st October 2014 and Endometrial Cancer QPIs1 are reported here for the fourth consecutive year. There were 331 new diagnoses of endometrial cancer captured by audit in the WoS in Year 4. Distribution by location of diagnosis is shown below in Figure 1. Figure 1: Number and proportion of patients diagnosed with endometrial cancer by location of diagnosis.

AA FV Lan GGC WoS

Year 1_2014/15 75 35 75 146 331

Year 2_2015/16 69 51 79 158 357

Year 3_2016/17 68 54 62 162 346

Year 4_2017/18 55 41 64 171 331

0

20

40

60

80

100

120

140

160

180

Ayrshire & Arran Forth Valley Lanarkshire GGC

Num

ber o

f Cas

es

Location of Diagnosis

2014/15 2015/16 2016/17 2017/18


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Endometrial FIGO Stage Distribution The distribution of endometrial cancer by FIGO stage is presented in Figure 2, which illustrates that 76% of patients presented with early stage (I, II) disease and 16.3% of patients presented with advanced stage disease (III,IV). However, it should be noted that full surgical staging is not currently undertaken in all endometrial cancers. To date this has been a decision taken by the Network to balance morbidity with benefits. There are forthcoming trials which may affect this current Network position. Once the trials have been published then further discussions will take place to ensure ongoing management can take latest evidence into account. Figure 2: Distribution of endometrial cancer by FIGO stage.

FIGO Stage IA IB II IIIA IIIB IIIC IVA IVB NR NA

n 166 65 21 13 4 17 13 7 16 9

Figure 2 also highlights that 7.5% of patients had FIGO stage coded as ‘not recorded’ or ‘not applicable’. FIGO stage should be recorded for all patients and not only those who undergo surgery. The availability of staging data is critical for survival analysis and for accurate measurement of OPIs.

IA, 50.2%

IB, 19.6%

II, 6.3%

IIIA, 3.9

IIIB, 1.2%

IIIC, 5.1%

IVA, 3.9%

IVB, 2.1% NA, 2.7% NR, 4.8%


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QPI 1: Radiological Staging It is necessary to fully image the pelvis and abdomen prior to starting first treatment in order to establish the extent of disease and minimise unnecessary or inappropriate treatment1. The target for this QPI is set at 90% with the tolerance level designed to account for situations where patients require urgent treatment before imaging has been performed or where endometrial cancer is an incidental finding at hysterectomy. It also allows for those patients who are deemed unfit for investigation1. Figure 3: Proportion of patients with endometrial cancer who have an MRI and/or CT scan of the abdomen and pelvis performed prior to definitive treatment.

Performance (%) Numerator Denominator Not recorded

numerator Not recorded

numerator (%) Not recorded exclusions

Not recorded exclusions (%)

Not recorded denominator

AA 96.4% 27 28 0 0.0% 0 0.0% 0

FV 94.1% 16 17 0 0.0% 0 0.0% 0

Lan 97.1% 33 34 0 0.0% 5 14.7% 0

NG 100% 37 37 0 0.0% 0 0.0% 0 SG 100% 20 20 0 0.0% 0 0.0% 0

Clyde 100% 36 36 0 0.0% 0 0.0% 0 WoS 98.3% 169 172 0 0.0% 5 2.9% 0 Following discussion at formal review it was agreed that QPI 1 should be updated to focus on MRI/CT before definitive treatment rather than first treatment.

0

10

20

30

40

50

60

70

80

90

100

Ayrshire & Arran

Forth Valley Lanarkshire North Glasgow South Glasgow Clyde WoS

Pe

rfo

rman

ce (%

)


2014/15 2015/16 2016/17 2017/18

Title: Patients with endometrial cancer should have their stage of disease assessed by MRI and/or CT prior to definitive treatment.

Numerator: Number of patients with endometrial cancer having a MRI and/or CT scan of the abdomen and pelvis carried out prior to definitive treatment.

Denominator: All patients with endometrial cancer. Exclusions: Patients with Grade 1 endometrioid or mucinous carcinoma on pre-operative biopsy.

Patients with atypical hyperplasia on pre-operative biopsy. Target: 90%


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Across WoS, 98.3% of patients diagnosed with endometrial cancer had a CT scan or MRI of the abdomen and pelvis carried out prior to definitive treatment in Year 4; 8.3 percentage points above the 90% QPI target. All six WoS units exceeded the target with performance ranging from 94.1% in NHS Forth Valley to 100% in the three NHSGGC units. This is the fourth consecutive year that the target has been met in the WoS.

QPI 2: Multidisciplinary Team Meeting (MDT) Evidence suggests that patients with cancer managed by a multidisciplinary team have a better outcome. There is also evidence that the multidisciplinary management of patients increases their overall satisfaction with their care1. Figure 4: Proportion of patients with endometrial cancer who are discussed at a MDT meeting before definitive treatment.






AA 64.2% 34 53 0 0.0% 1 1.9% 0

FV 61.8% 21 34 0 0.0% 0 0.0% 0

Lan 59.6% 34 57 0 0.0% 0 0.0% 0

NG 96.6% 56 58 0 0.0% 0 0.0% 0 SG 92.6% 25 27 0 0.0% 0 0.0% 0

Clyde 63.3% 38 60 0 0.0% 0 0.0% 0 WoS 72.0% 208 289 0 0.0% 1 0.3% 0

0

10

20

30

40

50

60

70

80

90

100

Ayrshire &

Arran


Pe

rfo

rman

ce (%

)


2014/15 2015/16 2016/17 2017/18

Title: Patients with endometrial cancer should be discussed by a multidisciplinary team prior to definitive treatment.

Numerator: Number of patients with endometrial cancer discussed at MDT prior to definitive

treatment. Denominator: All patients with endometrial cancer. Exclusions: Patients with atypical hyperplasia on pre-operative biopsy.

Patients who died before first treatment. Target: 95%


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Previous definitions excluded those cases with Grade I endometrioid or mucinous carcinoma on pre-operative biopsy. During formal review it was agreed that the exclusions should be removed. This change meant that all G1 endometrial cancers were to be discussed at the MDT. As highlighted by Figure 4 this change has resulted in a reduction in performance in all units with the overall WoS performance falling from 95.8% in Year 3 to 72.0% in Year 4. Only North Glasgow achieved the 95% QPI target achieving 96.6%. Performance in the other units ranged from 59.6% in NHS Lanarkshire to 92.6% in South Glasgow. Results for cases not meeting the QPI have been analysed further and patients with Grade I endometrioid or mucinous carcinoma on pre-operative biopsy who were previously excluded, account for 77 of the 81 cases not meeting the QPI. All 77 cases were managed according to Network Guidelines whereby all G1 cancers are recommended to proceed with routine clinical management with total laparoscopic hysterectomy and bilateral salpingo-oppherectomy unless there are features which need to be discussed at the MDT. There are changes being made in the MDT whereby certain cases will be presented for ratification of decisions rather than requiring a full discussion. The MCN is currently using QPI data to gather evidence to move forward with a protocolised pathway for some MDT related decisions. In the meantime cases will be discussed at the MDT adding to the workload of the weekly MDT Action Required:

The MCN will initiate discussions around the appropriateness of including Grade I endometrioid or mucinous carcinoma patients within the QPI measurement and will review the current MCN guideline to establish if any changes are required.


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QPI 3: Total Hysterectomy and Bilateral Salpingo-Oophorectomy Total Hysterectomy and Bilateral Salpingo-Oopherectomy for endometrial cancer is associated with best long term survival (compared to primary radiotherapy or hormonal treatment)1. The target for this QPI is 85% with the tolerance designed to account for patients having fertility conserving treatment and those patients who are not fit for surgical intervention1. Figure 5: Proportion of patients with endometrial cancer who undergo total hysterectomy/bilateral salpingo-oopherectomy.






AA 81.1% 43 53 0 0.0% 0 0.0% 0

FV 85.0% 34 40 0 0.0% 1 2.5% 0

Lan 91.2% 52 57 0 0.0% 2 3.5% 0

NG 94.7% 54 57 0 0.0% 1 1.8% 0 SG 78.6% 22 28 0 0.0% 3 10.7% 0

Clyde 93.8% 60 64 0 0.0% 2 3.1% 0 WoS 88.6% 265 299 0 0.0% 9 3.0% 0 Following discussion at formal review it was agreed that the target for QPI 7 should be raised from 80% to 85%.

0

10

20

30

40

50

60

70

80

90

100

Ayrshire &

Arran


Pe

rfo

rman

ce (%

)


2014/15 2015/16 2016/17 2017/18

Title: Patients with endometrial cancer should undergo total hysterectomy and bilateral salpingo-oopherectomy.

Numerator: Number of patients with endometrial cancer who undergo total hysterectomy/bilateral

salpingo-oopherectomy. Denominator: All patients with endometrial cancer. Exclusions: Patients with FIGO Stage IV.

Patients who decline surgical treatment. Patients having neo-adjuvant chemotherapy.

Target: 85%


17

Of the 299 patients diagnosed with endometrial cancer, 265 underwent total hysterectomy and bilateral salpingo-oopherectomy. Four of the six units have exceeded the 85% target resulting in an overall performance of 88.6% across the WoS NHS Ayrshire did not meet the 85% target with 10 cases not undergoing total hysterectomy and bilateral salpingo-oopherectomy (81.1%). NHS Ayrshire & Arran provided commentary on 3 of the 10 cases not meeting the target. Reasons provided included patient with multiple co-morbidities and not fit for surgery, patient died pre treatment and patient moved and was referred to appropriate NHS Health board for treatment. NHSGGC commented that all cases not meeting the QPI were reviewed and there was a consistent finding that all cases were unfit for surgery. NHSGGC added that the gynaecological oncology network is pursuing a pre-habilitation programme of work to improve patient fitness for intervention. This group will also look into the possibility of objective measures of frailty to allow consistent decision making in gynaecological cancer cases with respect to fitness. The initial work is being piloted in Clyde but there is an aspiration to extend this work across the Network. Action Required:



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QPI 4: Laparoscopic Surgery Laparoscopic surgery, by appropriately trained surgeons, is recommended for patients with endometrial cancer as it has been found to be feasible and surgically safe with reduced post-operative complications and length of stay1. The target for this QPI is set at 70% which reflects the fact that some patients may not be clinically suitable for laparoscopic surgery. Figure 6: Proportion of patients with endometrial cancer undergoing definitive surgery who undergo laparoscopic surgery.






AA 85.0% 34 40 0 0.0% 0 0.0% 0

FV 92.9% 26 28 0 0.0% 0 0.0% 0

Lan 94.9% 37 39 0 0.0% 0 0.0% 0

NG 69.3% 61 88 0 0.0% 0 0.0% 0 SG 76.7% 23 30 0 0.0% 0 0.0% 0

Clyde 54.9% 28 51 0 0.0% 0 0.0% 0 WoS 75.7% 209 276 0 0.0% 0 0.0% 0 Laparoscopic hysterectomy results in a shorter hospital stay, reduction in wound infections and other complications and better overall patient experience. Laparoscopic surgery is a developing area of clinical practice and variation in the use of laparoscopic hysterectomy across the region reflects both training and local resource availability. Figure 6 indicates that laparoscopic surgery is available in all units and that that the numbers of patients being operated on laparoscopically in the WoS is increasing year on year from 57.4% in Year 1 to 75.7% in Year 4.

0

10

20

30

40

50

60

70

80

90

100

Ayrshire & Arran

Forth Valley Lanarkshire North Glasgow

South Glasgow

Clyde WoS

Pe

rfo

rman

ce (%

)

Location of Surgery

2014/15 2015/16 2016/17 2017/18

Title: Patients with endometrial cancer undergoing definitive surgery should undergo laparoscopic surgery, where clinically appropriate.

Numerator: Number of patients with endometrial cancer undergoing definitive surgery who

undergo laparoscopic surgery. Denominator: All patients with endometrial cancer undergoing definitive surgery. Exclusions: No exclusions. Target: 70%


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Clyde achieved 54.9% against the 70% QPI target however did demonstrate a significant improvement on Year 1 performance of 3.3%. NHSGGC commented that this represents a continued improvement in this QPI and further improvement is anticipated. There were many cases where a laparoscopic approach does not appear to have been offered or considered on case review. There were also a number of cases where a laparoscopic approach was not thought to be feasible. In North Glasgow due to the tertiary referral of complex cases with co-existing lymph node or ovarian disease then not met cases generally fell into this group. During the timeframe of this QPI changes were instituted that should lead to further improvements – there has been work scheduling put in place to align clinical cases with surgeons with laparoscopic skills meaning that more patients will be offered minimal access surgery and more cases will be deemed feasible. Future development of tertiary referral skills to offer laparoscopic para-aortic node dissection is part of the central team skill development plan.


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QPI 5: Adjuvant Radiotherapy For stage IB grade 1-2 brachytherapy has been shown to improve local control rates without the toxicity associated with external beam radiotherapy. Other types of radiotherapy such as adjuvant EBRT (External Beam Radiation Therapy) is also recommended to decrease pelvic recurrence in high-intermediate risk patients with LVSI (lymphovascular space invasion) positive tumours where no surgical nodal staging has been performed1. Figure 7: Proportion of patients with stage IB, grade 1 or 2, or stage IA, grade 3 endometrioid or mucinous endometrial cancer having adjuvant radiotherapy.






AA 92.3% 12 13 0 0.0% 0 0.0% 0

FV 100% 6 6 0 0.0% 0 0.0% 0

Lan 83.3% 5 6 0 0.0% 0 0.0% 3

NG 100% 8 8 0 0.0% 0 0.0% 0 SG 88.9% 8 9 0 0.0% 0 0.0% 0

Clyde 91.7% 11 12 0 0.0% 0 0.0% 0 WoS 92.6% 50 54 0 0.0% 0 0.0% 3 - Data not shown due to small numbers

0

10

20

30

40

50

60

70

80

90

100

Ayrshire & Arran

Forth Valley Lanarkshire North Glasgow

South Glasgow

Clyde WoS

Pe

rfo

rman

ce (%

)


2014/15 2015/16 2016/17 2017/18

Title: Patients with stage IB, grade 1 or 2, or stage IA, grade 3 endometrioid or mucinous endometrial cancer should be considered for adjuvant radiotherapy.

Numerator: All patients with stage IB, grade 1 or 2, or stage IA, grade 3 endometrioid or mucinous

endometrial cancer receiving adjuvant radiotherapy. Denominator: All patients with stage IB, grade 1 or 2, or stage IA, grade 3 endometrioid or mucinous

endometrial cancer. Exclusions: Patients who decline brachytherapy or radiotherapy. Target: 90%


21

Following formal review it was agreed that due to a change in practice for patients with intermediate risk endometrial cancer with some patients now getting EBRT (external beam radiation therapy) rather than vaginal brachytherapy. Therefore, the QPI was updated to include all forms of radiotherapy. It should be noted that numbers of patients are low and therefore comparisons between units should be made with caution. Overall, 50 of the 54 patients with stage IB, grade 1 or 2, or stage IA, grade 3 endometrioid or mucinous endometrial cancer received adjuvant radiotherapy, resulting in a performance of 92.6% against the 90% QPI target. NHS Lanarkshire and South Glasgow did not meet the QPI target, however this equated to only one or two cases in each Board. QPI 6: Systemic Anti-Cancer Treatment/Hormone Therapy Hormonal therapy and chemotherapy play an important role in the management of advanced endometrial cancer. Platinum chemotherapy can improve progression free survival in patients with stage IV endometrial cancer. The use of chemotherapy should be considered for patients with stage IV disease or those with stage III disease plus residual disease at the completion of surgery. Hormonal therapy is indicated for patients with advanced endometrial cancer and endometriod histology1. Figure 8: Proportion of patients with stage IV endometrial cancer receiving SACT or hormone therapy.

Performance

(%) Numerator Denominator Not recorded





2014/15 57.7% 15 26 0 0.0% 0 0.0% 0

2015/16 63.3% 16 23 0 0.0% 0 0.0% 0 2016/17 38.9% 7 18 0 0.0% 0 0.0% 5

2017/18 55.6% 10 18 0 0.0% 0 0.0% 14

0

10

20

30

40

50

60

70

80

90

100

2014/15 2015/16 2016/17 2017/18

Pe

rfo

rman

ce (%

)

WoS

Title: Patients with stage IV endometrial cancer should have SACT or Hormone Therapy. Numerator: All patients with stage IV endometrial cancer receiving SACT or Hormone Therapy. Denominator: All patients with stage IV endometrial cancer. Exclusions: Patients who refuse any SACT or hormone therapy. Target: 75%


22

At formal review it was raised that this QPI focuses on a small number of potentially very sick women with advanced disease. It was agreed to change the wording of the QPI from chemotherapy to Systemic Anti-Cancer Therapy (SACT). This will then account for patients who receive hormone therapy. Due to the small numbers meeting the denominator criteria in each year of analysis individual unit results cannot be presented therefore Figure 8 shows overall WoS results. Of the 18 patients with stage IV endometrial cancer, 10 patients are recorded as having received SACT or hormone therapy resulting in a WoS performance of 55.6% against the 75% QPI target. NHSGGC reviewed all cases not meeting the QPI target and commented that a small number of cases were affected by this QPI and a small number of cases not met will have a disproportionate effect on the result. Action required:

NHS GGC has been asked to review the six cases not meeting the target and provide detailed clinical reasons for those advanced stage endometrial cancer patients not receiving SACT.


23

4.3. Cervical Cancer – Quality Performance Indicators Introduction Quality Performance Indicators (QPIs) were implemented for patients diagnosed with cervical cancer on or after 1st October 2014 and Cervical Cancer QPIs1 are reported here for the fourth consecutive year. There were 148 new diagnoses of cervical cancer captured by audit in the WoS in Year 4. Distribution by location of diagnosis is shown below in Figure 9. Figure 9: Number and proportion of patients diagnosed with cervical cancer by location of diagnosis.

AA FV Lan GGC WoS

Year 1_2014/15 23 24 57 83 187

Year 2_2015/16 20 23 33 69 145

Year 3_2016/17 14 25 40 69 148

Year 4_2017/18 29 24 34 68 155

Figure 10 illustrates the age distribution of patients diagnosed with cervical cancer in the WoS for patients in Year 4. The median age was 43 years.

0

10

20

30

40

50

60

70

80

90

Ayrshire & Arran Forth Valley Lanarkshire GGC

Nu

mb

er

of

Cas

es


2014/15 2015/16 2016/17 2017/18


24

Figure 10: Age of patients diagnosed with cervical cancer.

Cervical FIGO Stage Distribution The distribution of cervical cancer by FIGO stage is presented in Figure 11, which illustrates that 75.6% of patients presented with early stage (I, II) disease and 10.3% of patients presented with advanced stage disease (III,IV). Figure 11: Distribution of cervical cancer by FIGO stage.

FIGO Stage IA IB IIA IIB IIIA IIIB IVA IVB NR NA

n 32 41 2 43 2 4 7 3 6 16

Figure 11 also highlights that for 10.3% of patients FIGO stage was recorded as either not applicable or not recorded. FIGO stage should be recorded for all patients, as mentioned previously the availability of staging data is critical for survival analysis and for accurate measurement of OPIs.

0

5

10

15

20

25

30

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

2017/18 9 26 19 21 20 13 11 10 8 6 8 4 1

Nu

mb

er

of C

ases

IA, 20.5%

IB, 26.3%

IIA, 1.3%

IIB, 27.6%

IIIA, 1.3%

IIIB, 2.6%

IVA, 4.5%

IVB, 1.9%

NA, 10.3%NR, 3.8%


25

QPI 1: Radiological Staging It is necessary to fully image the pelvis prior to definitive treatment in order to establish the extent of disease and minimise unnecessary or inappropriate treatment1. Figure 12: Proportion of patients with cervical cancer who have an MRI of the pelvis performed prior to first treatment.






AA 96.3% 26 27 0 0.0% 0 0.0% 0

FV 87.5% 14 16 0 0.0% 0 0.0% 0

Lan 90.9% 30 33 0 0.0% 0 0.0% 0

NG 96.4% 27 28 0 0.0% 0 0.0% 0 SG 100% 7 7 0 0.0% 0 0.0% 0

Clyde 85.7% 12 14 0 0.0% 0 0.0% 0 WoS 92.8% 116 125 0 0.0% 0 0.0% 0 Following discussion at formal review it was agreed that patients treated by LLETZ only would no longer be excluded from QPI 1.

0

10

20

30

40

50

60

70

80

90

100

Ayrshire & Arran


Pe

rfo

rman

ce (%

)


2014/15 2015/16 2016/17 2017/18

Title: Patients with cervical cancer should have their stage of disease assessed by MRI prior to definitive treatment.

Numerator: All patients with cervical cancer having MRI of the pelvis carried out prior to definitive

treatment. Denominator: All patients with cervical cancer. Exclusions: Patients with histopathological FIGO stage 1A1 disease. Patients unable to undergo MRI due to contraindications. Patients with histopathological FIGO stage IVB disease. Patients who refuse MRI investigation. Target: 95%


26

The 95% target for QPI 1 was not achieved for patients diagnosed with cervical cancer in WoS in Year 5. Of the 125 patients, 116 had a MRI of the pelvis performed prior to first treatment. WoS performance decreased from 97.8% in Year 3 to 92.8% in Year 4; a decrease of 5 percentage points. NHS Forth Valley commented that both patients which breach the QPI have been clinically reviewed. One patient had stage 4 disease demonstrated on CT and MRI was not felt to be required. The second patient was reviewed and discussed at MDT and MRI was also not deemed to be required. NHS Lanarkshire achieved 90.9% against the 95% QPI target. All cases not meeting the QPI were reviewed and feedback reasons provided included; MDT recommended a PET CT scan rather than MRI, one case was initially thought to be endometrial cancer and the final case was initially staged as 1A. NHSGGC commented that the Clyde cases not meeting were a mix of genuine not met cases and incidental clinical findings. Staff have been reminded of the network imaging guidelines in cancer diagnoses.


27

QPI 2: Positron Emission Tomography/Computed Tomography (PET/CT) Patients not suitable for surgery and being considered for radical radiotherapy (+/- concurrent chemotherapy) are recommended to undergo PET/CT because of the significant risk of extra pelvic disease which if detected will change patient management1. Figure 13: Proportion of patients with cervical cancer, for whom primary definitive treatment is radical radiotherapy, who have PET/CT imaging.






AA 100% 17 17 0 0.0% 0 0.0% 0

FV 100% 9 9 0 0.0% 0 0.0% 0

Lan 100% 21 21 0 0.0% 0 0.0% 0

NG 100% 12 12 0 0.0% 0 0.0% 0 SG - - - 0 0.0% 0 0.0% 0


Following discussion at formal review it was agreed that patients who declined PET/CT should be excluded. Due to a new data item required to exclude these patients the revised data can’t be reported until Year 5.

0

10

20

30

40

50

60

70

80

90

100

Ayrshire & Arran


Pe

rfo

rman

ce (%

)


2014/15 2015/16 2016/17 2017/18

Title: Patients with cervical cancer for whom primary definitive surgery is not appropriate, should undergo PET/CT.

Numerator: All patients with cervical cancer undergoing primary radical radiotherapy who have

PET/CT imaging prior to starting treatment. Denominator: All patients with cervical cancer undergoing primary radical radiotherapy. Exclusions: No exclusions. Target: 95%


28

Across WoS, 98.5% of patients diagnosed with cervical cancer who received primary radical radiotherapy had PET/CT imaging prior to starting treatment. This exceeds the 95% QPI target by 5.7 percentage points and shows a slightly improved performance from 2013 to 2014. Five of the six units met the 95% QPI target however it should be noted that numbers are low and this can have a greater effect on proportions. Comparison across years should also be made with caution. Figures for South Glasgow have been restricted due to having a denominator of less than 5. QPI 3: Multidisciplinary Team Meeting (MDT) Evidence suggests that patients with cancer managed by a multi-disciplinary team have a better outcome. There is also evidence that the multidisciplinary management of patients increases their overall satisfaction with their care1. Figure 14: Proportion of patients with cervical cancer who are discussed at a MDT meeting before definitive treatment.






AA 100% 27 27 0 0.0% 2 7.4% 0

FV 100% 16 16 0 0.0% 0 0.0% 0

Lan 100% 31 31 0 0.0% 2 6.5% 0

NG 100% 30 30 0 0.0% 0 0.0% 0 SG 100% 6 6 0 0.0% 0 0.0% 0

Clyde 92.9% 13 14 0 0.0% 0 0.0% 0 WoS 99.2% 123 124 0 0.0% 4 3.2% 0

0

10

20

30

40

50

60

70

80

90

100

Ayrshire &

Arran


Pe

rfo

rman

ce (%

)


2014/15 2015/16 2016/17 2017/18

Title: Patients with cervical cancer should be discussed by a MDT prior to definitive treatment.

Numerator: All patients with cervical cancer discussed at the MDT before definitive treatment. Denominator: All patients with cervical cancer. Exclusions: Patients with histopathological FIGO stage 1A1 disease. Patients who died before treatment. Target: 95%


29

Of the 124 patients diagnosed with cervical cancer, 123 were discussed ay MDT prior to definitive treatment, resulting in a WoS performance of 99.2% against the 95% QPI target. Clyde did not meet the target with performance of 92.9%, however it should be noted that, due to small numbers, this represents one case which was an incidental finding. QPI 4: Radical Hysterectomy Radical surgery is recommended for FIGO stage IB1 disease if there are no contraindications to surgery. Patients with tumours


30

units achieved the target with performance ranging from 60% in Clyde to 100% in NHS Forth Valley and NHS Lanarkshire. However, caution should be given to percentage comparisons across different units as this may represent a very small number of cases. NHSGGC reviewed all cases not meeting the QPI target and commented that larger tumours within the 1b1 category are not offered a radical hysterectomy to avoid multimodality therapy and this was the case for North Glasgow. The Clyde cases were incidental findings and appropriately managed. QPI 5: Surgical Margins The quality of radical surgery for cervical cancer has an important influence on local control of the tumour and ultimately survival. Therefore, it is important to optimise and ensure the quality of surgical care for cervical cancer patients1. QPI 5 is analysed by location of surgery rather than location of diagnosis. Figure 16: Proportion of patients with cervical cancer who have surgical margins clear of tumour following hysterectomy.

Performance

(%) Numerator Denominator Not recorded





2014/15 94.2% 49 52 1 1.9% 0 0.0% 0

2015/16 97.5% 39 40 1 2.5% 0 0.0% 0

2016/17 97.6% 40 41 0 0.0% 0 0.0% 0

2017/18 94.3% 50 53 0 0.0% 0 0.0% 0

0

10

20

30

40

50

60

70

80

90

100

2014/15 2015/16 2016/17 2017/18

Pe

rfo

rman

ce (%

)

WoS

Title: Patients with surgically treated cervical cancer should have clear resection Numerator: All patients with cervical cancer who undergo surgery where surgical margins are clear

of tumour. Denominator: All patients with cervical cancer who undergo surgery. Exclusions: Patients who decline surgery. Patients who undergo fertility conserving treatment.

Patients enrolled into surgical trials.

Target: 95%


31

Due to the majority of operations taking place in the centre (North Glasgow) the numbers for other individual units are low therefore Figure 16 shows WoS yearly results. Overall in the WoS in Year 4, 94.3% of patients with cervical cancer had surgical margins clear of tumour following hysterectomy, which is marginally below the 95% QPI target. NHSGGC commented that the cases not meeting the target were reviewed and were incidental findings and appropriately managed pre-operatively. QPI 6: 56 Day Treatment for Radical Radiotherapy Overall treatment time for locally advanced cervical cancer should be as short as possible. Radiotherapy for squamous carcinoma should be completed within 56 days1. Figure 17: Proportion of patients with cervical cancer undergoing radical radiotherapy whose overall treatment time, from the start to the end of treatment, is not more than 56 days.

0

10

20

30

40

50

60

70

80

90

100

Ayrshire &

Arran


Pe

rfo

rman

ce (%

)


Title: Treatment time for patients with cervical cancer undergoing radical radiotherapy should be no more than 56 days.

Numerator: All patients with cervical cancer undergoing radical radiotherapy (external beam or

brachytherapy) whose overall treatment time, from start to the end of treatment, is not more than 56 days.

Denominator: All patients with cervical cancer undergoing radical radiotherapy (external beam or

brachytherapy). Exclusions: No exclusions. Target: 90% 05%


32






AA 94.7% 18 19 0 0.0% 0 0.0% 0

FV 100% 9 9 0 0.0% 0 0.0% 0

Lan 100% 23 23 0 0.0% 0 0.0% 0

NG 100% 14 14 0 0.0% 0 0.0% 0 SG - - - 0 0.0% 0 0.0% 0


Five of the six units exceeded the 90% target set for QPI 7 resulting in an overall WoS performance of 97.4% in Year 4. Clyde were just below target with 88.9%, however this represented one case that had an overall treatment time of 58 days. QPI 7: Chemoradiation Any patient with cervical cancer considered suitable for radical radiotherapy treatment should have concurrent chemoradiotherapy with a platinum based chemotherapy, if fit for treatment1. Figure 18: Proportion of patients with cervical cancer undergoing radical radiotherapy who receive concurrent chemotherapy.

0

10

20

30

40

50

60

70

80

90

100

Ayrshire &

Arran


Perf

orm

ance

(%)


Title: Patients with cervical cancer undergoing radical radiotherapy should receive concurrent platinum-based chemotherapy.

Numerator: All patients with cervical cancer undergoing radical radiotherapy who receive

concurrent chemotherapy. Denominator: All patients with cervical cancer who undergo radical radiotherapy. Exclusions: No exclusions. Target: 70%


33






AA 84.2% 16 19 0 0.0% 0 0.0% 0

FV 100% 9 9 0 0.0% 0 0.0% 0

Lan 87.0% 20 23 0 0.0% 0 0.0% 0

NG 100% 14 14 0 0.0% 0 0.0% 0 SG - - - 0 0.0% 0 0.0% 0

Clyde 88.9% 8 9 0 0.0% 0 0.0% 0 WoS 89.7% 70 78 0 0.0% 0 0.0% 0

Performance across the WoS was 89.7% against the 70% target with 70 of 78 patients diagnosed with cervical cancer undergoing radical radiotherapy receiving concurrent chemotherapy. All units met the target with performance ranging from 75% in South Glasgow to 100% in NHS Forth Valley and North Glasgow. Data is restricted for South Glasgow due to small numbers. Clinical Trial Access Clinical trials are necessary to demonstrate the efficacy of new therapies and other interventions. Furthermore, evidence suggests improved patient outcomes when hospitals are actively recruiting patients into clinical trials1. Data definitions and measurability criteria to accompany the Clinical Trial QPI are available from the HIS website1. The clinical trials QPI is measured utilising Scottish Cancer Research Network (SCRN) data and ISD incidence data, as is the methodology currently utilised by the Chief Scientist Office (CSO) and National Cancer Research Institute (NCRI). Utilising SCRN data allows for comparison with CSO published data and ensures capture of all clinical trials recruitment, not solely first line treatment trials, as contained in the clinical audit data. Given that a significant proportion of clinical trials are for relapsed disease this is felt to be particularly important in driving quality improvement. This methodology utilises incidence as a proxy for all patients with cancer. This may slightly over, or underestimate, performance levels, however this is an established approach currently utilised by NHS Scotland1.

Following formal review the Clinical Trials Access QPI was updated to measure the number of patients consented for participation in a clinical trial rather than only those who are enrolled. There are a number of patients who undergo screening but do not proceed to enrolment for various reasons, e.g. they do not have the mutation required for entry on to the trial.

QPI Title: All patients should be considered for participation in available clinical trials/research studies wherever eligible.

Numerator: Number of patients diagnosed with gynaecological cancer consented for a clinical

trial/research study. Denominator: All patients with diagnosed with a gynaecological cancer.. Exclusions: No exclusions. Target: 15%


34

Figure 19: Proportion of patients diagnosed with endometrial or cervical who are consented* for a clinical trial / research study in 2018.

Consented - QPI Target 15% Recruited

NHS Board of Residence N D % N D %

Ayrshire & Arran 4 86 4.7% 1 86 1.2%

Forth Valley 0 63 0.0% 0 63 0.0%

GGC 4 263 1.5% 4 263 1.5%

Lanarkshire 9 113 8.0% 3 113 2.7%

WoS 17 525 3.2% 8 525 1.5%

Overall for patients in WoS diagnosed with cervical or endometrial cancer, 17 patients consented for a clinical trial/research study resulting in a WoS performance of 3.2% against the 15% target. The target was not met by any of the NHS Boards. Comments received from clinicians stated that currently there is only one open trial for cervical cancer which has been hard to recruit to due to 2 factors; 1) Risk of hair loss and 2) Potential of treatment time being almost doubled (chemoradiotherapy only is 7 weeks whereas neo-adjuvant chemotherapy plus chemoradiotherapy would be 13 weeks). There was one endometrial trial which was very restrictive because of the requirement for fresh biopsies, recruitment was therefore poor.

0

2

4

6

8

10

12

14

16

18

20

A&A FV Lan GGC WoS

Pro

po

rtio

n o

f p

ati

en

ts (

%)

Analysis Group

Consented Entered


35

Table 3: List of clinical trials and the number of patients with endometrial, cervical or ovarian cancer consented/entered into each clinical trial in 2018. (N.B. All recruits noted below were resident within WoS).

Short Title Consented Entered

A Phase I trial of CCT245737

in patients with advanced

cancer 2 2

AZD1775 Continued Access 1 1

CANC - 4443 - Nivolumab in

Viral-positive Solid Tumors 1 1

First in Human,

DoseEscalating Study of

HuMaX®-TF-ADC in solid

Tumour 1 0

HORIZONS 7 2

INTERLACE 2 2

PROCLAIM CX-2009 in adults

with metastatic/advanced

solid tumours 1 0

SYD985.001 2 0Total 17 8


36

5. Conclusions

Cancer audit has underpinned much of the regional development and service improvement work of the MCN and the regular reporting of activity and performance have been fundamental in assuring the quality of care delivered across the region. Following the development of QPIs, this has now become an established national programme to drive continuous improvement and ensure equity of care for patients across Scotland. During 2018, QPI definitions have been reviewed nationally to provide an improved set of indicators, some of which are reported in here.

Overall, results from the fourth year of Endometrial and Cervical Cancer QPI reporting are encouraging; case ascertainment and data capture is of a high standard overall and notable improvements in performance have been demonstrated for a number of QPIs. With regards to endometrial cancer, five of the seven QPI target were achieved. QPIs 1 and 3 were consistently met at regional level for four consecutive years and significant year on year improvement was noted in relation to QPI 4 (laproscopic surgery) with the 70% QPI target being achieved in Year 4 across the WoS. A change in measurement at formal review of QPI 2 (MDT Discussion) where patients with Grade I endometrioid or mucinous carcinoma were no longer excluded saw performance decrease across the majority of boards however all cases not achieving the target were managed according to network guidelines. Discussions will be initiated around the appropriateness of including these cases within the QPI measurement and the current MCN guideline will be reviewed to establish if any changes are required. In relation to cervical cancer, overall WoS results demonstrate that the target was met for 4 of the 7 reported QPIs for patients diagnosed in Year 4. Consistent performance over four years was noted for QPI 3 (discussion at MDT), QPI 6 (56 day treatment for radical radiotherapy) and for QPI 7 (patients undergoing radical radiotherapy who receive concurrent chemotherapy). Results for QPI 2 PET/CT imaging prior to starting radical radiotherapy have also shown improvement over the four year period. Where QPI targets were not met, NHS Boards have provided detailed comment. In the main these indicate valid clinical reasons or that, in some cases, patient choice or co-morbidities have influenced patient management. Additionally, NHS Boards have indicated where positive action has already been taken at a local level to address any issues highlighted through the QPI data analysis. It is anticipated that these positive changes will result in improved performance going forward. NHS Boards are encouraged to continue with this proactive approach of reviewing data and addressing issues as necessary, in order to work towards increasingly advanced performance against targets, and demonstration of overall improvement in quality of the care and service provided to patients. Action required: Endometrial Cancer QPI 2: MDT Discussion Prior to Definitive Treatment


QPI 3: Total Hysterectomy and Bilateral Salpingo-Oophorectomy



37

QPI 6: SACT/Hormone Therapy


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 the Appendix. 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).


38

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.


39

Abbreviations

BWoSCC Beatson West of Scotland Cancer Centre

BSO Bilateral Salpingo-Oophorectomy

CT Computed Tomography

eCASE Electronic Cancer Audit Support Environment

FIGO Federation of Gynaecological Oncologists

GRI Glasgow Royal Infirmary

HIS Healthcare Improvement Scotland

ISD Information Services Division

MCN Managed Clinical Network

MDT Multidisciplinary Team

MRI Magnetic resonance imaging

NCQSG National Cancer Quality Steering Group

NHSGGC NHS Greater Glasgow and Clyde

PET Positron Emission Tomography

QPI Quality Performance Indicator

RCAG Regional Cancer Advisory Group

RMI Risk of Malignancy Index

TAH Total Abdominal Hysterectomy

WoS West of Scotland

WoSCAN West of Scotland Cancer Network


40

References

1. Healthcare Improvement Scotland. Cancer Quality Performance Indicators, [Accessed on: 22nd September 2018] Available at: http://www.healthcareimprovementscotland.org/our_work/cancer_care_improvement/cancer_qpis/quality_performance_indicators.aspx

2. Information Services Division. Head and Neck Cancer: Data Definitions, Measurability and Data Validations Accessed on: 22nd September 2018]. Available at: http://www.isdscotland.org/Health-Topics/Cancer/Cancer-Audit/

3. Information Services Division. Cancer in Scotland, June 2004 (updated April 2018) [Accessed

on: 22nd September 2018]. Available at: http://www.isdscotland.org/Health-Topics/Cancer/Cancer-Statistics/

4. Information Services Division, Cancer Statistics, Summary statistics for female genital organ

cancers. [Accessed on: 22nd September 2018]. Available at: http://www.isdscotland.org/Health-Topics/Cancer/Cancer-Statistics/Female-Genital-Organ/

5. ScotPHO, Public Health Information for Scotland. Population: estimates by NHS Board

[Accessed on: Accessed on: 22nd September 2018]] Available at: http://www.scotpho.org.uk/population-dynamics/population-estimates-and-projections/data/nhs-board-population-estimates

http://www.healthcareimprovementscotland.org/our_work/cancer_care_improvement/cancer_qpis/quality_performance_indicators.aspxhttp://www.healthcareimprovementscotland.org/our_work/cancer_care_improvement/cancer_qpis/quality_performance_indicators.aspxhttp://www.isdscotland.org/Health-Topics/Cancer/Cancer-Audit/http://www.isdscotland.org/Health-Topics/Cancer/Cancer-Statistics/http://www.isdscotland.org/Health-Topics/Cancer/Cancer-Statistics/Female-Genital-Organ/http://www.isdscotland.org/Health-Topics/Cancer/Cancer-Statistics/Female-Genital-Organ/http://www.scotpho.org.uk/population-dynamics/population-estimates-and-projections/data/nhs-board-population-estimateshttp://www.scotpho.org.uk/population-dynamics/population-estimates-and-projections/data/nhs-board-population-estimates


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.


Appendix 1: Action / Improvement Plans

WoSCAN Action / Improvement Plan – Ovarian Cancer

No Action Required NHS Board Action Taken Timescales Lead Status (see key)

Start End

Ensure actions mirror those detailed in Audit Report.

Provide detailed outcome of clinical review, details of specific improvement action taken, or reasons why no action taken.

Insert date

Insert date

Insert name of responsible lead for each action.

Insert No. from key above

1. QPI 2: MDT Discussion Prior to Definitive Treatment (Endometrial Cancer)


NHS Board: WoSCAN KEY (Status)

Action Plan Lead: 1 Action fully implemented

Date: 2 Action agreed but not yet implemented

3 No action taken (please state reason)


43

NHS Ayrshire & Arran Action / Improvement Plan – Ovarian Cancer


Start End



Insert date

Insert date



1. QPI 3: Total Hysterectomy and Bilateral Salpingo-Oophorectomy (Endometrial Cancer)


NHS Board: NHS Ayrshire & Arran KEY (Status)





44

NHS Greater Glasgow and Clyde Action / Improvement Plan – Ovarian Cancer


Start End



Insert date

Insert date



1. QPI 6: SACT/Hormone Therapy (Endometrial Cancer)


NHS Board: NHSGGC KEY (Status)




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