MCN Audit Report - woscan.scot.nhs.uk · Final Published Upper Gastro-intestinal Cancer MCN Audit...

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Audit Report

Upper GI Cancer Quality Performance Indicators

Report of the 2018 Clinical Audit Data

Mr Andrew Macdonald MCN Clinical Lead Tracey Cole MCN Manager Julie McMahon Information Officer

West of Scotland Cancer Network Upper Gastro-intestinal Cancer Managed Clinical Network

West of Scotland Cancer Network Final Published Upper Gastro-intestinal Cancer MCN Audit Report v1.0 26/11/2019 2

CONTENTS

EXECUTIVE SUMMARY 3

1. INTRODUCTION 12

2. BACKGROUND 12

2.1 NATIONAL CONTEXT 13

2.2 WEST OF SCOTLAND CONTEXT 14

3. METHODOLOGY 18

4. RESULTS 19

4.1 DATA QUALITY 19

4.2 PERFORMANCE AGAINST QUALITY PERFORMANCE INDICATORS 20

5. CONCLUSIONS 50

6. ACKNOWLEDGEMENTS 52

7. ABBREVIATIONS 53

8. REFERENCES 54

APPENDIX 1: NHS BOARD ACTION PLANS 56


EXECUTIVE SUMMARY

Introduction This report presents an assessment of performance of West of Scotland Upper Gastro-intestinal (GI) Cancer Services relating to patients diagnosed in the region between 01 January 2018 and 31 December 2018. Data was measured against v3.0 of the Upper GI Cancer Quality Performance Indicators (QPIs)1. This was the sixth consecutive year of analysis following the initial Healthcare Improvement Scotland (HIS) publication of Upper GI cancer QPIs in 2012.

Background There were 600 new cases of Upper GI cancer diagnosed in total in the West of Scotland (WoS) in 2018 (449 oesophageal, 151 gastric). Analysis of the data contained within this report is based on the NHS Board responsible for treatment. Outcome measures regarding the quality of surgical services have been analysed based on the NHS Board where surgery was performed. Quality assurance and continuous service improvement will be supported by regular assessment of service performance against the nationally defined QPI criteria. Methodology The clinical audit data presented in this report were collected by clinical audit staff in each NHS Board in accordance with an agreed dataset and definitions. Data were recorded manually and entered locally into the electronic Cancer Audit Support Environment (eCASE): a secure centralised web-based database. Data relating to patients diagnosed between 01 January 2018 and 31 December 2018 were downloaded from eCASE at 2200 hrs on 03 July 2019. 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 their data were an accurate representation of service in each area. Results The data are measured against ISD QPI measurability criteria and the results are summarised below as the overall result for WoSCAN and the range across NHS Boards in relation to the QPI targets. Figures are expressed in percentages and separately for oesophageal and gastric cancers where appropriate.


Performance Summary Report

OESOPHAGEAL CANCER Quality Performance Indicator (QPI)

Performance by Board

QPI target AA FV GGC Lan WoS

QPI 1: Endoscopy – Proportion of patients with oesophageal cancer who have a histological diagnosis made within 6 weeks of initial endoscopy and biopsy.

95% 91.9% > 92.5% < 92.6% < 91.1% < 92.2% <

57 62 49 53 214 231 82 90 402 436

QPI 3: MDT Meeting – Proportion of patients with oesophageal cancer who are discussed at MDT meeting before definitive treatment.

95% 89.3% < 94.8% < 95.3% < 85.7% < 92.4% <

50 56 55 58 221 232 78 91 404 437

QPI 4(i): Staging and Treatment Intent – Proportion of patients with oesophageal cancer who have (i) TNM stage recorded at MDT meeting prior to treatment.

90% 91.9% < 96.6% < 90.2% < 57.6% < 84.6% <

57 62 57 59 212 235 53 92 379 448

QPI 4(ii): Staging and Treatment Intent – Proportion of patients with oesophageal cancer who have (ii) treatment intent recorded at MDT meeting prior to treatment.

95% 96.8% < 96.6% < 90.6% > 98.9% > 94.0% >

60 62 57 59 213 235 91 92 421 448

QPI 5(i): Nutritional Assessment – Proportion of patients with oesophageal cancer who undergo nutritional screening with the MUST before first treatment.

95% 79.0% > 59.3% < 83.8% > 90.2% > 81.3% >

49 62 35 59 197 235 83 92 364 448

QPI 5(ii): Nutritional Assessment – Proportion of patients with oesophageal cancer at high risk of malnutrition (MUST score of 2 or more).

90% 100.0% = 100.0% = 91.9% < 100.0% = 95.6% <

23 23 20 20 91 99 39 39 173 181

QPI 6: Appropriate Selection of Surgical Patients – Proportion of patients with oesophageal cancer who receive neo-adjuvant chemotherapy or chemoradiotherapy who then go on to have surgical resection.

80%

50.0% < 80.0% > 58.8% < 55.6% < 61.0% >

3 6 8 10 20 34 5 9 36 59

QPI 7 (a)†: 30 day Mortality Following Surgery -

Proportion of patients with oesophageal cancer who die within 30 days of surgical resection.

< 5% - NA 0.0% = 0.0% = 0.0% =

- - 0 0 0 34 0 8 0 45





QPI 7 (b)†: 90 day Mortality Following Surgery -

Proportion of patients with oesophageal cancer who die within 90 days of surgical resection.

< 7.5% - NA 0.0% = 0.0% = 0.0% =

- - 0 0 0 28 0 6 0 36

QPI 8†: Lymph Node Yield – Proportion of patients with

oesophageal cancer who undergo surgical resection where ≥15 lymph nodes are resected and pathologically examined.

90%

- NA 81.6% > 87.5% > 83.7% >

- - 0 0 31 38 7 8 41 49

QPI 9†: Length of Hospital Stay Following Surgery –

Proportion of patients undergoing surgical resection for oesophageal cancer who are discharged within 14 days of surgical procedure.

60%

- NA 65.8% > 62.5% > 66.0% >

- - 0 0 25 38 5 8 33 50

QPI 10(i)†: Resection Margins – Proportion of patients

with oesophageal cancer who undergo surgical resection in which surgical margin is clear of tumour, i.e. negative surgical margin (i) circumferential

70%

- NA 68.4% < 62.5% > 67.3% >

- - 0 0 26 38 5 8 33 49

QPI 10(ii)†: Resection Margins – Proportion of patients

with oesophageal cancer who undergo surgical resection in which surgical margin is clear of tumour, i.e. negative surgical margin (ii) longitudinal

90%

- NA 97.4% < 100.0% = 98.0% <

- - 0 0 37 38 8 8 48 49

QPI 11: Curative Treatment Rates – Proportion of patients with oesophageal cancer who undergo curative treatment.

35% 16.4% < 23.7% < 22.1% < 21.7% > 21.5% <

10 61 14 59 52 235 20 92 96 447

QPI 12 (i): 30-day Mortality Following Oncological Treatment – Proportion of patients with oesophageal cancer who die within 30 days of curative oncological treatment. (a) Chemoradiotherapy

<5%

- 0.0% = 0.0% > 25.0% < 9.1% <

- - 0 5 0 7 2 8 2 22





QPI 12 (i): 90-day Mortality Following Oncological Treatment – Proportion of patients with oesophageal cancer who die within 90 days of curative oncological treatment. (a) Chemoradiotherapy

<7.5% - 0.0% = 16.7% < 28.6% < 15.8% <

- - 0 5 1 6 2 7 3 19

QPI 12 (i): 30-day Mortality Following Oncological Treatment – Proportion of patients with oesophageal cancer who die within 30 days of curative oncological treatment. (b) Peri-operative chemotherapy

<5%

0.0% = 0.0% > 0.0% = 6.7% < 1.6% <

0 5 0 6 0 37 1 15 1 63

QPI 12 (i): 90-day Mortality Following Oncological Treatment – Proportion of patients with oesophageal cancer who die within 90 days of curative oncological treatment. (b) Peri-operative chemotherapy

<7.5% 20.0% < 0.0% > 2.9% < 7.1% > 5.0% <

1 5 0 6 1 35 1 14 3 60

QPI 12 (ii): 30-day Mortality Following Oncological Treatment – Proportion of patients with oesophageal cancer who die within 30 days of palliative oncological treatment. (c) Chemotherapy

<5%

18.2% < 0.0% = 8.3% < 3.8% > 7.4% <

2 11 0 9 4 48 1 26 7 94

GASTRIC CANCER Quality Performance Indicator (QPI)



QPI 1: Endoscopy – Proportion of patients with gastric cancer who have a histological diagnosis made within 6 weeks of initial endoscopy and biopsy.

95%

84.0% < 94.4% < 84.8% > 97.3% > 89.0% >

21 25 17 18 56 66 36 37 130 146

QPI 3: MDT Meeting – Proportion of patients with gastric cancer who are discussed at MDT meeting before definitive treatment.

95%

100.0% > 88.2% < 92.3% > 87.5% < 91.7% >

23 23 15 17 60 65 35 40 133 145

QPI 4(i): Staging and Treatment Intent – Proportion of patients with gastric cancer who have (i) TNM stage recorded at MDT meeting prior to treatment.

90%

96.2% < 88.9% < 89.6% > 47.5% < 79.5% <

25 26 16 18 60 67 19 40 120 151





QPI 4(ii): Staging and Treatment Intent – Proportion of patients with gastric cancer who have (ii) treatment intent recorded at MDT meeting prior to treatment.

95%

100.0% > 100.0% > 97.0% > 95.0% > 97.4% >

26 26 18 18 65 67 38 40 147 151

QPI 5(i): Nutritional Assessment – Proportion of patients with gastric cancer who undergo nutritional screening with the MUST before first treatment.

95%

61.5% > 38.9% < 83.6% < 85.0% > 74.8% >

16 26 7 18 56 67 34 40 113 151

QPI 5(ii): Nutritional Assessment – Proportion of patients with gastric cancer at high risk of malnutrition (MUST score of 2 or more).

90%

100.0% > 100.0% = 90.9% > 100.0% = 95.7% >

9 9 6 6 20 22 10 10 45 47

QPI 6: Appropriate Selection of Surgical Patients – Proportion of patients with gastric cancer who receive neo-adjuvant chemotherapy or chemoradiotherapy who then go on to have surgical resection.

80%

- - 66.7% < - 76.9% >

- - - - 6 9 - - 10 13

QPI 7 (a)†: 30 day Mortality Following Surgery -

Proportion of patients with gastric cancer who die within 30 days of surgical resection.

<5%

- NA 0.0% = - 0.0% =

- - 0 0 0 14 - - 0 18

QPI 7 (b)†: 90 day Mortality Following Surgery -

Proportion of patients with gastric cancer who die within 90 days of surgical resection.

<7.5%

- NA 7.7% < - 6.3% <

- - 0 0 1 13 - - 1 16

QPI 8†: Lymph Node Yield – Proportion of patients with

gastric cancer who undergo curative surgical resection where ≥15 lymph nodes are resected and pathologically examined.

80%

- NA 50.0% < - 64.3% <

- - 0 0 5 10 - - 9 14





QPI 9†: Length of Hospital Stay Following Surgery –

Proportion of patients undergoing surgical resection for gastric cancer who are discharged within 14 days of surgical procedure.

60%

- NA 73.3% < - 60.0% <

- - 0 0 11 15 - - 12 20

QPI 10(ii)†: Resection Margins – Proportion of patients

with gastric cancer who undergo surgical resection in which surgical margin is clear of tumour, i.e. negative surgical margin (ii) longitudinal

90%

- NA 92.9% = - 94.4% <

- - 0 0 13 14 - - 17 18

QPI 11: Curative Treatment Rates – Proportion of patients with gastric cancer who undergo curative treatment.

35%

12.0% > 11.1% > 22.4% > 7.5% < 15.3% >

3 25 2 18 15 67 3 40 23 150

QPI 12 (i): 30-day Mortality Following Oncological Treatment – Proportion of patients with gastric cancer who die within 30 days of curative oncological treatment. (a) Chemoradiotherapy

<5%

NA NA NA NA NA

0 0 0 0 0 0 0 0 0 0

QPI 12 (i): 90-day Mortality Following Oncological Treatment – Proportion of patients with gastric cancer who die within 90 days of curative oncological treatment. (a) Chemoradiotherapy

<7.5%

NA NA NA NA NA

0 0 0 0 0 0 0 0 0 0

QPI 12 (i): 30-day Mortality Following Oncological Treatment – Proportion of patients with gastric cancer who die within 30 days of curative oncological treatment. (b) Peri-operative chemotherapy

<5%

- - 0.0% = - 0.0% =

- - - - 0 11 - - 0 17

QPI 12 (i): 90-day Mortality Following Oncological Treatment – Proportion of patients with gastric cancer who die within 90 days of curative oncological treatment. (b) Peri-operative chemotherapy

<7.5% - - 0.0% = - 0.0% =

- - - - 0 10 - - 0 15





QPI 12 (ii): 30-day Mortality Following Oncological Treatment – Proportion of patients with gastric cancer who die within 30 days of palliative oncological treatment.

(c) Chemotherapy

<5%

- - 10.0% < 0.0% > 3.6% >

- - - - 1 10 0 12 1 28

QPI 13: HER2 Status – Proportion of patients with metastatic gastric or gastro-oesophageal junction adenocarcinoma undergoing first line palliative chemotherapy as their initial treatment for whom the HER2 status is reported prior to commencing treatment.

90%

- - 68.8% < 25.0% < 56.7% <

- - - - 11 16 2 8 17 30

‘-‘ Data not shown due to small numbers (denominator less than 5)

Clinical Trials QPI – Oesophageal and gastric cancers

Upper GI CANCER Quality Performance Indicator (QPI)



QPI 14: Clinical Trials Access – Proportion of patients diagnosed with upper GI cancer who are consented for inclusion in a clinical trial/research study.

15%

0.9% < 1.1% < 3.1% < 0.6% < 2.0% <

1 106 1 90 12 393 1 156 15 744


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. With the development of QPIs, this has now become a national programme to drive continuous improvement and ensure equity of care for patients across Scotland.

West of Scotland Boards’ continued commitment to the improvement of the quality and completeness of audit data has supported the National Cancer Quality Programme in the formative years, and will be required throughout the formal review process. This commitment from Boards has provided accurate data for the reporting of performance against the Upper GI Cancer QPIs from which yearly comparisons in service provision across WoS Boards can be made. The results presented within this report illustrate that some of the QPI targets set have been challenging for NHS Boards to achieve and there remains room for further service improvement, however it is encouraging that targets relating to treatment intent (gastric), nutritional assessment for patients at high risk of malnutrition, surgical mortality, length of hospital stay following resection and longitudinal resection margins were met by all NHS Boards. 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. Actions required: QPI 1 – Endoscopy

NHSGGC to report back the findings of the audit of oesophageal cases not meeting the QPI to the MCN.

QPI 4i – Staging and Treatment Intent

NHS Lan to ensure that TNM is recorded for all oesophageal and gastric patients at MDT prior to treatment commencing.

QPI 4ii - Staging and Treatment Intent

The MCN should initiate discussion with regards to the measurement of this QPI as part of the formal review process.

QPI 6 – Appropriate Selection of Surgical Patients

NHSGGC should report the results of the detailed review of patients not meeting the QPI back to the MCN.

QPI 8 – Lymph Node Yield

MCN Lead to engage with the formal review process regards revision of this indicator.

QPI 9 – Length of Hospital Stay

Results of this local length of stay analysis in NHS Lan should be fed back to the MCN. The MCN will request that consideration is given to the inclusion of a date of discharge field within the QPI dataset, to allow the QPI to be more accurately measured using audit rather than SMR01 data.


QPI 10 - Resection Margins

Given comments returned the MCN will request that this QPI is discussed as part of the national formal review in November 2019.

QPI 13 – HER 2 Status

MCN to explore the HER2 reporting process in more detail with NHS Boards to establish the source of delays and identify any remedial action required.

Completed Action Plans should be returned to WoSCAN within two months of publication of this report.

The MCN Advisory Board will actively monitor progress against changes implemented by NHS Boards, and any service issue the Advisory Board considers not to have been adequately addressed, will be escalated to the appropriate NHS Board Lead Cancer Clinician and the Regional Lead Cancer Clinician. In addition, progress will be reported annually to the Regional Cancer Advisory Group (RCAG) by NHS Board 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).


1. Introduction

This report presents an assessment of performance of West of Scotland (WoS) Upper Gastro-intestinal (GI) Cancer Services relating to patients diagnosed in the region between 01 January 2018 and 31 December 2018. These audit data underpin much of the regional development/service improvement work of the Managed Clinical Network (MCN) and regular reporting of activity and performance is a fundamental requirement of an MCN to assure the quality of care delivered across the region. Twelve months of data were measured against v3.0 of the Upper GI Cancer Quality Performance Indicators (QPIs) which were implemented for patients diagnosed on or after 01 January 2016. This was the sixth consecutive year of analysis following the initial Healthcare Improvement Scotland (HIS) publication of Upper GI Cancer QPIs in 2012. In order to ensure success of the National Cancer QPIs in driving quality improvement in cancer care across NHS Scotland it is critical that QPIs continue to be clinically relevant and focus on areas which will result in improvements to the quality of patient care. As part of the national process it was agreed that indicators would be formally reviewed following 3 years of national comparative reporting, this took place in 2015. With 6 years of reporting now complete, a further cycle of review will now commence. This clinically led review aims to identify potential refinements to the current QPIs and involves key clinicians from each of the Regional Cancer Networks. It is anticipated that this will be a more focussed review given the changes that have been made to the indicators to date. The review will focus on any significant changes to the QPIs that are required due to changes in evidence or clinical practice, as well as an opportunity to make adjustments to new indicators developed at the initial formal review.

2. Background

Four NHS Boards across the WoS serve the 2.5 million population. There were 600 new cases of Upper GI cancer diagnosed in total in the West of Scotland (WoS) in 2018 (449 oesophageal, 151 gastric). The configuration of the Multidisciplinary Teams (MDTs) who manage and treat these patients across the region is set out below.

MDT Constituent Hospital(s) Ayrshire & Arran (AA) Crosshouse Hospital, Ayr Hospital Greater Glasgow and Clyde (GGC)

Royal Alexandra Hospital, Inverclyde Royal Hospital, Vale of Leven, Gartnavel General Hospital, Glasgow Royal Infirmary, Queen Elizabeth University Hospital, Victoria Infirmary

Forth Valley (FV) Forth Valley Royal Hospital Lanarkshire (Lan) Wishaw General Hospital, Monklands District General, Hairmyres

Patients from Forth Valley requiring major upper GI resection have their surgery in Glasgow Royal Infirmary. The Forth Valley surgeons are responsible for the local diagnosis, staging and follow up and are involved with the surgical resection in Glasgow. Analysis of the data contained within this report is based on the NHS Board responsible for treatment. Outcome measures regarding the quality of surgical services have been analysed based on the NHS Board where surgery was performed. Quality assurance and continuous service improvement will be supported by regular assessment of service performance against the nationally defined QPI criteria.


2.1 National context

Oesophageal cancer is the ninth most common cancer in Scotland with 972 cases diagnosed nationally in 20172. There has been a decrease in the incidence of oesophageal cancer from 2007 to 2017 of 3.5%2. Oesophageal cancer is more common in males with just over two thirds of cases occurring nationally in males in 2017 (ratio of 2:1). Gastric cancer is the thirteenth most common cancer in Scotland with 614 cases diagnosed nationally in 20173. The incidence of gastric cancer in Scotland has fallen significantly, with a 35.9% decrease in males and a 28.6% decrease in females between 2007 and 2017. As with oesophageal cancer, the ratio of male:female cases is approximately 2:1.

Overall cancer mortality rates have decreased by 12% in males and 7.5% in females in the last ten years4. The mortality rate for gastric cancer has seen the most significant decrease of any cancer type in both males and females, showing a 32.8% and 31.5% decrease in mortality rates respectively3. The mortality rate for oesophageal cancer has seen significant decreases in both males and females by 9% and 14.9% respectively2. However oesophageal cancer still remains the fourth most common cause of death from cancer in males and the sixth most common cause of death from cancer in females. Survival for oesophageal and gastric cancers is low compared to other cancers however relative 1-year and 5-year survival is increasing5.Table 1 shows the percentage change in 1-year and 5-year survival rates for patients diagnosed in 1987-1991 compared to those diagnosed in 2007-2011. Table 1: Relative age-standardised survival for oesophageal and gastric cancers in Scotland at 1 year and 5 years showing percentage change from 1987-1991 to 2007-2011

2

Relative survival at 1 year (%) Relative survival at 5 years (%)

2007-2011 % change 2007-2011 % change

Oesophageal cancer Male 41.8% + 17.7% 12.1% + 6.5%

Female 37.7% + 11.8% 12.7% + 4.6%

Gastric cancer Male 41.9% + 15.9% 15.4% + 5.3%

Female 40.3% + 14.4% 20.5% + 9.3%


2.2 West of Scotland context In 2018 there were 600 new cases of oesophagogastric cancer that were identified through audit as having been managed in the West of Scotland. The number managed through each MDT/NHS Board is presented in Figure 1 and broken down by the site of origin of the tumour. Figure 1: Number of patients diagnosed in 2018 with oesophageal or gastric cancer by NHS Board of diagnosis.

AA FV GGC Lan WoS

Oesophageal cancer 62 59 236 92 449

Gastric cancer 26 18 67 40 151

Total 88 77 303 132 600

Figure 2 illustrates the distribution of oesophageal cancer cases by age group and gender. As with previous years data, the occurrence of oesophageal cancer is higher in males (68.2% of cases) than in females (31.8% of cases).

Figure 2: Number of patients diagnosed in 2018 with oesophageal cancer in WoS within each age group.

<45 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+ All ages

Oesophageal Male 6 11 13 30 40 43 67 41 33 22 306

Female 1 2 4 17 9 15 20 28 22 25 143

0

50

100

150

200

250

Ayrshire & Arran Forth Valley Greater Glasgow and Clyde Lanarkshire

No

. of

Dia

gno

ses

NHS Board

Oesophageal cancer Gastric cancer

0

10

20

30

40

50

60

70

80

Under 45 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+

No.

of P

atie

nts

Age Range

Oesophageal

Male Female


Figure 3 illustrates the distribution of gastric cancer cases by age group and gender. As with previous years data, the occurrence of gastric cancer is higher in males (66.2% of cases) than in females (33.8% of cases).

Figure 3: Number of patients diagnosed in 2018 with gastric cancer in WoS within each age group.

<45 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+ All ages

Gastric Male 1 2 4 3 11 12 11 15 17 24 100

Female 2 0 3 3 2 3 5 6 16 11 51

Stage at Diagnosis Staging is the assessment of the extent of disease and is performed for prognostic and therapeutic purposes. TNM 8 staging was used to stage all Upper GI cancers during 2018.

Morphology n %

Oesophageal - Adenocarcinoma 287 47.8

Oesophageal - Squamous 124 20.7

Gastric - Adenocarcinoma 134 22.3

Other (not assessable, NOS, Not applicable etc) 55 9.2

Total 600 100.0

Oesophageal - Adenocarcinoma Oesophageal - Squamous

Stage n % Stage n %

I 3 1.0 I 3 2.4

IIA 0 0.0 II 22 17.7

IIB 23 8.0 III 18 14.5

III 73 25.4 IVA 19 15.3

IVA 29 10.1 IVB 43 34.7

IVB 122 42.5 Not Recorded 15 12.1

Not Recorded 24 8.4 Not Applicable 4 3.2

Not Applicable 7 2.4 Total 124

Not able to group using TNM 8 6 2.1

Total 287

0

5

10

15

20

25

30

Under 45 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+

No.

of P

atie

nts

Age Range

Gastric

Male Female


The 6 cases that were unable to be grouped using the TNM8 staging classification were all recorded as T4 when the TNM8 stage grouping looks for T4a or T4b. This meant that the cases could be in either the stage III category or stage IVA category.

Gastric - Adenocarcinoma

Stage n %

I 15 11.2

IIA 2 1.5

IIB 14 10.4

III 10 7.5

IV 66 49.3

Not Recorded 13 9.7

Not Applicable 6 4.5

Not able to group using TNM 8 8 6.0

Total 134

The 8 cases that were unable to be grouped using the TNM8 staging classification were all recorded as T4 when the TNM8 stage grouping looks for T4a or T4b. This meant that three of the cases could be in either the stage IIB category or stage IVA category and 5 cases could be categorized in the stage III group or stage IVA group. Overall there were 130 cases coded as T4 but due to using Nstage and Mstage values 117 were able to be categorized in the correct stage group. Site of Tumour Figure 4 displays the breakdown by site of tumour for oesophageal cancer and illustrates that 47.9% of oesophageal cancers in Year 6 occurred in the lower third oesophagus. Figure 4: Site of origin of oesophageal tumours.

Cervical Oesophagus, 0.4% (n=2)

Upper Third Oesophagus, 6.2% (n=28)

Middle Third Oesophagus, 16%

(n= 72)

Lower Third Oesophagus, 47.9%

(n=215)

Overlapping Lesion of Oesophagus,

6% (n=27)

Oesophagus NOS, 3.6% (n=16)

Cardia NOS,19.8% (n= 89)

Site of Tumour (Oesophageal)


Figure 5 displays the breakdown by site of tumour for gastric cancer. Figure 5: Site of origin of gastric tumours.

Performance Status by Board Performance status (PS) is usually defined according to the five-point internationally agreed World Health Organization (WHO) scale. PS is not only an independent prognostic indicator but is an important determinant of treatment modality. For example, PS 4 patients are seldom treated with aggressive, radical treatments. Table 3: WHO performance status definitions

Grade Explanation of activity

0 Fully active, able to carry on all pre-disease performance without restriction.

1 Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work.

2 Ambulatory and capable of all self care but unable to carry out any work activities. Up and about more than 50% of waking hours.

3 Capable of only limited self care, confined to bed or chair more than 50% of waking hours.

4 Completely disabled. Cannot carry on any self care. Totally confined to bed or chair.

PS is not only an independent prognostic indicator but is an important determinant of treatment modality. For example, PS 4 patients are seldom treated with aggressive, radical treatments.

Fundus of Stomach, 6% (n=9)

Body of Stomach, 17.2% (n=26)

Gastric Antrum, 11.9% (n=18)

Pylorus, 15.2% (n=23)Lesser Curvature of

Stomach, 8.6% (n=13)

Greater Curvature of Stomach, 4% (n=6)

Overlapping Lesion of Stomach, 7.3% (n=11)

Stomach NOS, 29.8% (n=45)

Site of Tumour (Gastric)


Figure 6: Performance status of patients diagnosed with UGI cancer in 2018.

3. Methodology

The clinical audit data presented in this report were collected by clinical audit staff in each NHS Board in accordance with an agreed dataset and definitions. Data were recorded manually and entered locally into the electronic Cancer Audit Support Environment (eCASE): a secure centralised web-based database. Data relating to patients diagnosed between 01 January 2018 and 31 December 2018 were downloaded from eCASE at 2200 hrs on 03 July 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 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 their data were an accurate representation of service in each area.

PS-0, 26.8%

PS-1, 33.3%

PS-2, 16.3%

PS-3, 9.5

PS-4, 1.5%

NR, 12.5%

Performance Status

Hospital of Diagnosis

Ayrshire & Arran Forth Valley Lanarkshire Clyde North Glasgow South Glasgow Total

Performance Status n % n % n % n % n % n % n %

0 12 13.6% 30 39.0% 29 22.0% 26 28.6% 30 35.7% 34 26.6% 161 26.8%

1 45 51.1% 21 27.3% 31 23.5% 34 37.4% 24 28.6% 45 35.2% 200 33.3%

2 20 22.7% 9 11.7% 7 5.3% 18 19.8% 19 22.6% 25 19.5% 98 16.3%

3 8 9.1% 11 14.3% 10 7.6% 7 7.7% 7 8.3% 14 10.9% 57 9.5%

4 2 2.3% 4 5.2% 0 0.0% 2 2.2% 0 0.0% 1 0.8% 9 1.5%

Not Recorded 1 1.1% 2 2.6% 55 41.7% 4 4.4% 4 4.8% 9 7.0% 75 12.5%

Total 88 77 132 91 84 128 600


4. Results

4.1 Data quality

Audit data quality can be assessed in the first instance by estimating the proportion of expected patients that have been identified through audit. Case ascertainment is calculated by the number of patients identified by the audit as a proportion of the number of cases reported by the National Cancer Registry (provided by ISD, National Services Scotland). Cancer Registry figures used were extracted from ACaDMe (Acute Cancer Deaths and Mental Health) on 13 June 2018 via the standard reports available and are an average of the previous 5 years’ figures to take account of annual fluctuations in incidence within NHS Boards. The overall case ascertainment in WoSCAN is 80.6% which indicates good data capture for 2018 and overall WoS results should therefore be an accurate reflection of performance in the region. Figure 7 illustrates estimated case ascertainment across the WoS NHS Boards and varies from 77.1% in NHS Greater Glasgow & Clyde (NHSGGC) to 85.6% in NHS Forth Valley (NHS FV). This result represents a notable drop in case ascertainment in NHSGGC compared to previous years. This was reviewed and checked by NHSGGC who confirmed that all relevant cases had been captured for the QPI audit, and that this represented fluctuations in the number of cases presenting with the disease, rather than any data discrepancy. This reinforces the message that case ascertainment figures should be used for guidance rather than being viewed as an exact measure of data capture.

Figure 7: Estimated case ascertainment by Board for patients diagnosed with oesophagogastric cancers in 2018.

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Cases from 2018 audit 88 77 303 132 600

ISD Cases (2013-2017 average) 106 90 393 156 744

% Case ascertainment 83.0% 85.6% 77.1% 84.6% 80.6%

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4.2 Performance against Quality Performance Indicators

Results of the analysis of Upper GI Cancer QPIs are set out in the following sections. Graphs and charts have been provided where this aids interpretation and, where appropriate, numbers have also been included to provide context. Each QPI displays first the performance in oesophageal cancer and then the same for gastric cancer. Where possible, and with consideration given to any changes after formal review, results for patients diagnosed in Year 6 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 location of treatment with some criteria given as an overall West of Scotland representation. Boards have already reviewed cases where targets have not been met, and the detailed clinical commentary provided by Boards is noted beside each measure along with details of any specific changes that have already been implemented to address issues highlighted through the 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. An asterisk (*) is applied to indicate a denominator of zero and to distinguish between this and a 0% performance.


QPI 1: Biopsy Procedure For diagnosis of oesophageal and gastric cancer the use of endoscopy is recommended. A tissue diagnosis in cases of suspected oesophageal and gastric cancer requires adequate sampling of the suspicious lesion. Multiple biopsies should be obtained and the number of biopsies examined should always be reported1. The tolerance within the 95% target is designed to account for factors of patient choice.

QPI 1: Patients with oesophageal or gastric cancer should undergo endoscopy and biopsy to reach a diagnosis of cancer.

Numerator: Number of patients with oesophageal or gastric cancer who undergo endoscopy who have a histological diagnosis made within 6 weeks of initial endoscopy and biopsy.

Denominator: All patients with oesophageal or gastric cancer who undergo endoscopy.

Exclusions: No exclusions.

Target: 95%

Figure 8: The proportion of patients with oesophageal cancer who underwent endoscopy that had a histological diagnosis made within 6 weeks of initial endoscopy and biopsy.

QPI 1 Performance (%) Numerator Denominator Not recorded

numerator Not recorded exclusions

Not recorded denominator

AA 91.9% 57 62 0 0 0

FV 92.5% 49 53 0 0 0

GGC 92.6% 214 231 0 0 0

Lan 91.1% 82 90 0 0 0

WoS 92.2% 402 436 0 0 0

The 95% was not achieved in the WoS in 2018. Of the 436 oesophageal patients who underwent endoscopy, 402 had a histological diagnosis within 6 weeks of initial endoscopy and biopsy resulting in a WoS performance of 92.2%. No NHS board achieved the target however performance was above 90% in all boards ranging from 91.1% in NHS Lanarkshire (NHS Lan) to 92.6% in NHSGGC. NHS Ayrshire & Arran (NHSAA) have reviewed cases not meeting the target and provided feedback. Reasons provided for patients not meeting the target include: diagnosis made clinically and therefore pathology not pursued; biopsy indicative of dysplastic pathology or “suspicion of malignancy”.

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NHS FV stated that all patients that breached the QPI target have been reviewed and it was shown that they were all dealt with clinically appropriately. NHSGGC reported that most of the cases not meeting the QPI were due to sampling error rather than a missed cancer at initial scope. NHSGGC stated that they should ensure that an appropriate number of biopsies are performed at the initial biopsy, and would undergo an audit of cases not meeting the QPI. NHS Lan reviewed the 8 cases who did not meet the target - 6 had a histological diagnosis made more than 6 weeks following initial endoscopy, and 2 did not have a histological diagnosis. NHS Lan advised that all patients were appropriately treated with the appropriate number of biopsies taken (minimum 6 per site) in each case. The Board will emphasise the importance of urgent pathology in suspicious lesions/nodules and the need for urgent repeat endoscopy if there is negative pathology. Additionally the Board will continue with the ongoing audit of urgent waiting times for endoscopy and protocols on the number of adequate biopsies, and ideal reporting in UGI malignancy will continue to be reinforced to all NHS Lan endoscopy units. Action Required:-


Figure 9: The proportion of patients with gastric cancer who underwent endoscopy that had a histological diagnosis made within 6 weeks of initial endoscopy and biopsy.




AA 84.0% 21 25 0 0 0

FV 94.4% 17 18 0 0 0

GGC 84.8% 56 66 0 0 0

Lan 97.3% 36 37 0 0 0

WoS 89.0% 130 146 0 0 0

Overall WoS results show that 89.0% of patients with gastric cancer had a histological diagnosis within 6 weeks of initial endoscopy and biopsy which is below the 95% target. NHS Lan were the only board to achieve the QPI target with a performance of 97.3%. NHSAA achieved 84% against the 95% target. The four cases not meeting the QPI were reviewed. In three cases the biopsy was indicative of dysplastic pathology or “suspicion of

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malignancy”, and the remaining case did not have a biopsy due to anticoagulation therapy and an international normalized ratio (INR) result of 3.4. NHSFV just missed the target with a performance of 94.4%. The one case not meeting was reviewed and it was shown that they were dealt with clinically appropriately. The majority of cases in NHSGGC not meeting the QPI were again noted as being due to sampling error rather than a missed cancer at initial scope. As mentioned above, NHSGGC stated that they will ensure that an appropriate number of biopsies are performed at initial biopsy and that an audit of cases not meeting the QPI will be carried out. The MCN have recognised a quality improvement opportunity and have developed a poster for display in all endoscopy rooms across the region which reinforces the importance of optimising the opportunity of a successful biopsy at initial procedure, and advises on the procedure to be adopted should this not be possible. QPI 3: MDT Discussion

Evidence suggests that patients with cancer managed by a multi-disciplinary team achieve better outcomes. There is also evidence that the multidisciplinary management of patients increases their overall satisfaction with their care1. Discussion prior to definitive treatment decisions being made provides reassurance that patients are being managed appropriately1. The tolerance within this QPI accounts for situations where patients require surgery or other intervention urgently.

QPI 3: Patients should be discussed by a multidisciplinary team prior to definitive treatment.

Numerator: Number of patients with oesophageal or gastric cancer discussed at the MDT before definitive treatment.

Denominator: All patients with oesophageal and gastric cancer.

Exclusions: Patients who died before first treatment.

Target: 95%

Figure 10: The proportion of patients with oesophageal cancer who were discussed at the MDT meeting before definitive treatment.

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AA 89.3% 50 56 0 0 0

FV 94.8% 55 58 0 0 0

GGC 95.3% 221 232 0 0 0

Lan 85.7% 78 91 0 0 0

WoS 92.4% 404 437 0 0 0

Of the 437 patients across the region with oesophageal cancer who were measured against this QPI, 404 were discussed at MDT prior to definitive treatment. This equates to 92.4% against the 95% QPI target. NHS Board Performance ranged from 85.7% in NHS Lan to 95.3% in NHSGGC. NHSAA reported that all patients not meeting the QPI were treated symptomatically and appropriately. Reasons for the six cases not meeting included patients having stents, laser therapy, palliative radiotherapy or dilatation prior to MDT. NHSFV commented that patients which breached the target have been clinically reviewed. For two cases the MDT was post first treatment and in the remaining case the MDT was after date of death. NHS Lan reported that all cases have been reviewed and were treated appropriately. Of the 13 cases not meeting the QPI, 12 were treated endoscopically before being discussed at MDT, and the remaining patient died before discussion. NHSL will reaffirm to the MDT the importance of patients being discussed at the MDT meeting prior to treatment where possible. Figure 11: The proportion of patients with gastric cancer who were discussed at the MDT meeting before definitive treatment.




AA 100% 23 23 0 0 0

FV 88.2% 15 17 0 0 0

GGC 92.3% 60 65 0 0 0

Lan 87.5% 35 40 0 0 0

WoS 91.7% 133 145 0 0 0

Of the 145 patients with gastric cancer, 133 were recorded as having been discussed at the MDT prior to definitive treatment, resulting in a WoS performance of 91.7%, which is below the 95% QPI target. NHSAA was the only Board to meet the 95% target with a performance of 100.0%.

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NHSFV, NHSGGC and NHS Lan did not meet the QPI target with performance of 88.2%, 92.3% and 87.5% respectively. Boards have reviewed cases not meeting the target and provided feedback. A number of patients received treatment, e.g. stenting prior to MDT which was clinically appropriate in the situation. Other reasons included emergency surgery and patients dying prior to MDT discussion. NHSL highlighted that there have been discussions to advocate for early stenting of patients who have complete dysphagia and are not suitable for curative treatment, rather than waiting for MDT discussion. The MCN acknowledges that the QPI target is challenging due to the legitimate clinical reasons for commencing treatment before MDT, however it is agreed that those cases not meeting the target should continue to be reviewed as part of the annual QPI reporting process, to ensure that patients are being appropriately managed. QPI 4: Staging and Treatment Intent Patients with gastric or oesophageal cancer should undergo careful staging to assess the extent of disease and inform treatment decision making1. Clinical staging should follow the principles of TNM classification; this aids the determination of prognosis and choice of therapy. A statement regarding clinical stage and treatment intent should be recorded at the MDT meeting using version 8 of the classification. For patients presenting with metastatic disease it is not always possible or appropriate to determine T and N stage. Within the QPI TxNxM1 is therefore accepted as complete staging in this situation1. Following formal review the specifications of this QPI were separated to ensure clear measurement of patients who have the following recorded at MDT meeting prior to treatment : (i) TNM stage; and (ii) Treatment Intent

QPI 4(i): Patients with oesophageal or gastric cancer should be staged using the TNM staging system and have this recorded at MDT prior to treatment commencing.

Numerator: Number of patients with oesophageal or gastric cancer who have TNM stage recorded at MDT prior to treatment.



Target: 90%

Figure 12: The proportion of patients with oesophageal cancer who had TNM stage recorded at MDT prior to treatment.

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QPI 4(i) Performance (%) Numerator Denominator Not recorded



AA 91.9% 57 62 0 0 0

FV 96.6% 57 59 0 0 0

GGC 90.2% 212 235 0 0 0

Lan 57.6% 53 92 0 0 0

WoS 84.6% 379 448 0 0 0

The 90% target for QPI 3 was not achieved for patients diagnosed with oesophageal cancer in WoS in 2018, of 448 oesophageal patients 379 had TNM stage data recorded at MDT prior to treatment. Three of the four Boards achieved the 90% QPI target, however overall WoS performance decreased from 93.1% in 2017 to 84.6% in 2018; a decrease of 8.5 percentage points and 5.4 percentage points below the QPI target. NHS Lan achieved 57.6% against the 90% target. This represents a 32.7 percentage-point decrease on 2017 performance for the Board. NHS Lan confirmed that all cases not meeting the QPI target have been reviewed. In all cases the information was available at the time of the pre-treatment MDT to ensure full discussion and decision about treatment could be made. This has therefore been highlighted as a data recording issue rather than a clinical one, and the MDT has been reminded of the importance of recording the TNM at the pre-treatment MDT meeting. It is anticipated that the introduction of a new electronic MDT system, which is currently under development in NHS Lan, should help to improve this and this will be monitored through local QPI reporting. Radiologists have also agreed to add an addendum to the radiology report after the MDT discussion to ensure radiological staging of patients is documented.

Figure 13: The proportion of patients with gastric cancer who had TNM stage recorded at MDT prior to treatment.




AA 96.2% 25 26 0 0 0

FV 88.9% 16 18 0 0 0

GGC 89.6% 60 67 0 0 0

Lan 47.5% 19 40 0 0 0

WoS 79.5% 120 151 0 0 0

Overall, 120 of the 151 patients diagnosed with gastric cancer in WoS had TNM staging recorded at MDT meeting prior to treatment, resulting in a performance of 79.5% against the 90% QPI target. NHS Board performance ranged from 47.5% in NHS Lan to 96.2% in NHSAA.

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NHSFV did not meet the QPI target achieving 88.9%. This however, represented only 2 of 18 cases not meeting the QPI criteria. NHSFV stated that small numbers have a huge impact on this QPI and one cases makes the difference between meeting and not meeting this target.

NHS Lan achieved 47.5% against the 95% target a reduction of 50.2 percentage points on 2017 performance. As previously mentioned above, this has been highlighted as a local data recording issue rather than a clinical one. Action Required:-


QPI 4(ii): Patients with oesophageal or gastric cancer should have treatment intent recorded at MDT prior to treatment commencing.

Numerator: Number of patients with oesophageal or gastric cancer who treatment intent recorded at MDT prior to treatment.



Target: 95%

Figure 14: The proportion of patients with oesophageal cancer who have treatment intent recorded at MDT prior to treatment.

QPI 4(ii) Performance (%) Numerator Denominator Not recorded



AA 96.8% 60 62 0 0 0

FV 96.6% 57 59 0 0 0

GGC 90.6% 213 235 0 0 0

Lan 98.9% 91 92 0 0 0

WoS 94.0% 421 448 0 0 0

Of the 448 patients diagnosed with oesophageal cancer, 421 had treatment intent recorded at MDT prior to treatment. This equates to a WoS performance of 94% against the 95% QPI target. NHSAA, NHS FV and NHS Lan all met the QPI target, achieving 96.8%, 96.6% and 98.9% respectively. NHSGGC achieved 90.6% against the 95% target. All cases were reviewed and feedback stated that recording of TNM and treatment intent has improved substantially in recent years. Several of

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the cases not meeting the QPI were noted to have died before MDT discussion. NHSGGC believes that these patients should be excluded from the measurement of the QPI. Action Required:-


Figure 15: The proportion of patients with gastric cancer who have treatment intent recorded at MDT prior to treatment.




AA 100% 26 26 0 0 0

FV 100% 18 18 0 0 0

GGC 97.0% 65 67 0 0 0

Lan 95.0% 38 40 0 0 0

WoS 97.4% 147 151 0 0 0

Overall performance across the WoS is 97.1% with 147 of 151 gastric patients having treatment intent recorded at MDT meeting prior to treatment. All Boards met the 95 QPI target with performance ranging from 95% in NHS Lan to 100% in NHSAA and NHSFV.

QPI 5: Nutritional Assessment All patients with oesophageal or gastric cancer should be screened using a validated screening tool to assess nutritional risk. Those at risk of nutritional problems should have access to a state registered dietitian to provide appropriate advice1. Poor nutritional status is a risk factor for poor tolerance of treatment and can impact greatly on quality of life. Appropriate nutritional support can help reduce complications such as sepsis, poor wound healing and reduce length of stay1. At formal review, this QPI was split into two parts. Part (i) measures patients screened using the Malnutrition Universal Screening Tool (MUST). Part (ii) measures high risk patients referred to a dietician.

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QPI 5(i): Patients with oesophageal or gastric cancer should be appropriately assessed by a dietitian to optimise nutritional status.

Numerator: Number of patients with oesophageal or gastric cancer who undergo nutritional screening with the MUST before first treatment.



Target: 95%

Figure 16: The proportion of patients with oesophageal cancer who undergo nutritional screening with the MUST before treatment.




AA 79.0% 49 62 0 0 0

FV 59.3% 35 59 0 0 0

GGC 83.8% 197 235 0 0 0

Lan 90.2% 83 92 0 0 0

WoS 81.3% 364 448 0 0 0

The 95% target for QPI 5 was not achieved for the second consecutive year. In the WoS 81.3% of oesophageal patients underwent nutritional screening prior to first treatment. No board met the target however it should be noted that overall performance is much improved across the region in respect of nutritional assessment with the 2-part measure, with the most noticeable improvement in NHS Lan with performance of 90.2% against the target in 2018 compared to 26% in 2017. NHSAA commented that 7 patients who did not meet the QPI did have referrals but this was after first treatment, with 6 patients not being referred to the dietician as there was no clinical need for this. NHSFV achieved 59.3% against the 95% target and commented that not all patients require to be seen prior to first treatment. NHSFV will continue to work closely with the dietician to ensure continued improvement in performance against this measure however the Board noted that this is an unfunded service with limited availability within the service. NHSGGC achieved 83.8% and stated that this represented a significant improvement on previous years where patients with oesophageal cancer were not seen by the dietetic service. The

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introduction of the MUST screening tool is relatively recent and it is anticipated that there will be continued improvement on uptake of this. The importance of this will be emphasised to the CNS team. When the MUST score is high, over 90% of patients are being seen by the dietetic service. The MCN acknowledges that all patients with OG cancer would benefit and should have access to specialist dietetic services, however this will require resource. In the meantime efforts are focussed on targeting resources to individual patients with the greatest need. NHS Lan showed significant improvement on the previous year’s result of 26%. The 9 cases not meeting the QPI target were reviewed and in 5 of the cases the MUST score was recorded but this was not prior to first treatment. Figure 17: The proportion of patients with gastric cancer who undergo nutritional screening with the MUST before treatment.




AA 61.5% 16 26 0 0 0

FV 38.9% 7 18 0 0 0

GGC 83.6% 56 67 0 0 0

Lan 85.0% 34 40 0 0 0

WoS 74.8% 113 151 0 0 0

Across the WoS 74.8% of patients diagnosed with gastric cancer underwent nutrition screening prior to first treatment. No Board achieved the QPI with performance ranging from 38.9% in NHSFV to 85% in NHS Lanarkshire. Similar to oesophageal results significant improvement is noted in NHS Lanarkshire.

Feedback from boards reflects the comments made previously for patients with oesophageal cancer.

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QPI 5(ii): Patients with oesophageal or gastric cancer should be appropriately assessed by a dietitian to optimise nutritional status.

Numerator: Number of patients with oesophageal or gastric cancer at high risk of malnutrition (MUST score of 2 or more) who are referred to a dietitian.

Denominator: All patients with oesophageal and gastric cancer at high risk of malnutrition (MUST score of 2 or more).


Target: 90%

Figure 18: The proportion of patients with oesophageal cancer at high risk of malnutrition who are referred to a dietician.




AA 100% 23 23 0 0 4

FV 100% 20 20 0 0 0

GGC 91.9% 91 99 0 0 0

Lan 100% 39 39 0 0 1

WoS 95.6% 173 181 0 0 5

Overall in the WoS of the 181 patients with oesophageal cancer at high risk of malnutrition (MUST score of 2 or more) , 173 were referred to a dietician, which equates to 95.6% achieving the 90% QPI target for the second consecutive year. All Boards achieved the QPI target of 90%.

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Figure 19: The proportion of patients with gastric cancer at high risk of malnutrition who are referred to a dietitian.




AA 100% 9 9 0 0 1

FV 100% 6 6 0 0 0

GGC 90.9% 20 22 0 0 0

Lan 100% 10 10 0 0 1

WoS 95.7% 45 47 0 0 2 - Denominator is less than 5; percentages should be viewed with caution.

Across WoS, 95.7% of patients with gastric cancer at high risk of malnutrition were referred to a dietician, which successfully meets the 90% QPI target for the second consecutive year. All Boards achieved the QPI target.

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QPI 6: Appropriate Selection of Surgical Patients Patients with oesophageal or gastric cancer who are suitable for surgical resection should be offered treatment with neoadjuvant chemotherapy or chemoradiotherapy. Neoadjuvant chemotherapy or chemoradiotherapy prior to surgery provides a survival benefit for patients with oesophageal and gastric cancer. These patients should proceed to curative resectional surgery; however a number of reasons may affect this e.g. initial understaging of disease1.

QPI 6: Patients with oesophageal or gastric cancer whose treatment plan is neoadjuvant chemotherapy or chemoradiotherapy followed by surgery should progress to surgery following completion of this treatment.

Numerator: Number of patients with oesophageal or gastric cancer who receive neoadjuvant chemotherapy or chemoradiotherapy who then undergo surgical resection.

Denominator: All patients with oesophageal or gastric cancer who receive neoadjuvant chemotherapy or chemoradiotherapy.


Target: 80%

Figure 20: The proportion of patients with oesophageal cancer who received neoadjuvant chemotherapy or chemoradiotherapy who then underwent surgical resection.




AA 50.0% 3 6 0 0 0

FV 80.0% 8 10 0 0 0

GGC 58.8% 20 34 0 0 1

Lan 55.6% 5 9 1 0 0

WoS 61.0% 36 59 1 0 1

Across WoS, 61.0% of patients diagnosed with oesophageal cancer who received neo-adjuvant chemotherapy or chemoradiotherapy went on to have surgical resection in 2018. Performance across the four NHS Boards ranged from 50% in NHSAA to 80% in NHSFV, with only NHSFV achieving the 80% target set by QPI 6. It should be noted that numbers are low in three of the four NHS Boards and this can have a greater effect on proportions. Comparison across years should also be made with caution.

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All WoS Boards returned similar commentary and provided valid reason for patients not proceeding to surgery following neo-adjuvant chemotherapy. The reasons are common across the WoS and include:

coding of treatment at MDT under-staging of disease patient selection changes in performance status / disease progression toxicity of chemotherapy

metastatic or unresectable disease at time of surgery NHS Lan also advised whilst there is a desire to improve curative treatment rates it is likely that many borderline patients will be offered radical treatment, following a full and thorough consenting process. It is also understood that not all patients are suitable for radical treatment and quality of life and survival benefit will continue to be fully considered when selecting surgical patients NHS GGC advised that a detailed review of notes of the patients not meeting this target will be undertaken. Action Required:-


Figure 21: The proportion of patients with gastric cancer who received neoadjuvant chemotherapy or chemoradiotherapy who then underwent surgical resection.




2016 73.1% 0 0 0

2017 75.0% 0 0 0

2018 76.9% 10 13 0 0 0 -

Due to the small numbers meeting the denominator criteria in each year of analysis individual board results cannot be presented therefore Figure 6 shows WoS yearly results. Across the WoS 76.9% of gastric patients that received neo-adjuvant chemotherapy went on to receive surgical resection which is below the 80% QPI target. NHSGGC were the only board not to achieve the QPI target and commentary received from NHSGGC reflects the comments made previously for patients with oesophageal cancer.

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Small numbers can have a greater effect on proportions. Therefore for both oesophageal and gastric cases, caution should be given to apparent changes in performance across multiple years, as this may be representative of very small numbers of cases. QPI 7: 30/90-day Mortality Following Surgery Treatment related mortality is a marker of the quality and safety of the whole service provided by the Multi Disciplinary Team (MDT). Treatment should only be undertaken in individuals that may benefit from treatment, that is, disease specific treatments should not be undertaken in futile situations. This QPI is intended to ensure treatment is given appropriately1. At formal review the 30 day target was increased from 10% to 5%. The 90 day target was increased from 10% to 7.5%.

QPI 7: 30 and 90-day mortality following surgical resection for oesophageal or gastric cancer.

Numerator: Number of patients with oesophageal or gastric cancer who undergo surgical resection who die within 30 or 90 days of treatment.

Denominator: All patients with oesophageal or gastric cancer who undergo surgical resection.


Target: 30 day: < 5%

90 day: <7.5%

Within the WoS, there were no deaths at 30 days following surgical resection for oesophageal or gastric cancer for the second consecutive year. There were no deaths noted at 90 days following surgical resection for oesophageal cancer and one death within 90 days of gastrectomy. NHSGGC reviewed the one case and commented that this patient presented as an emergency with a perforated tumour where curative surgery is not possible. The mortality figures post resection remain very encouraging. The improving results for this QPI illustrate that the measures taken to improve patient selection for surgical resection and the introduction of a “high risk” clinic in NHSGGC have had a positive effect on patient outcome.


QPI 8: Lymph Node Yield Maximising the number of lymph nodes resected and analysed enables reliable staging which influences treatment decision making. Evidence recommends that at least 15 lymph nodes are resected and examined by a pathologist1. Initially when published this QPI measured lymph node yield in patients undergoing surgical resection for gastric cancer only. During the formal review process QPI 8 was updated to include measurement of lymph node yield in patients undergoing surgery for oesophageal cancer also. Therefore figure 19 only offers comparison against one previous year where data allows. The tolerance within the QPI target accounts for situations where patients are not fit enough to undergo extensive lymphadenectomy and for situations where surgical resection is performed for palliation1.

QPI 8: For patients with oesophageal or gastric cancer undergoing curative resection the number of lymph nodes examined should be maximised.

Numerator: Number of patients with oesophageal or gastric cancer who undergo surgical resection where ≥15 lymph nodes are resected and pathologically examined.



Target: Oesophageal - 90% Gastric - 80%

Figure 22: The proportion of patients with oesophageal cancer who underwent curative surgical resection where ≥15 lymph nodes were resected and pathologically examined.




2016 % 0 0 0

2017 % 0 0 0

2018 83.7% 41 49 0 0 0

Of the 49 oesophageal patients who underwent surgical resection 41 had ≥15 lymph nodes resected and pathologically examined. This equates to a rate of 83.7% which is below the target rate of 90%. Due to the small numbers in individual boards overall WoS figures are displayed.

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Although NHS Lan have failed to meet this QPI there has been an improvement on last year’s result of 50%. One patient failed to meet the QPI target and this case was reviewed. The dissection protocol was changed following the Upper GI National cancer network meeting in November 2018. Since this one case was reported (September 2018) NHS Lan now process all peri-oesophageal fat to ensure that no lymph node is left behind in the specimen. The pathology department will carry out an audit of resections to ascertain whether this has led to an improvement in lymph node yield, the results of which will be reported back to the MCN.

NHSGGC achieved 81.6% against this target. The Board noted that potential reasons for not achieving the QPI target are multi-factorial, however it was highlighted that survival analysis has suggested that long term survival following surgery is significantly higher in NHSGGC than the national average. The practice of upper GI surgeons is to adopt a radical D2 approach, also offering pragmatic D1 resections for elderly unfit patients, which may reduce the average lymph node count. Although the same D2 operation is undertaken in patients, the range of lymph node counts vary, this may be due to the effects of chemotherapy or the method of lymph node micro-dissection used by different pathologists. In this context, the Board has questioned the validity of this QPI, and this will be considered as part of the national formal review process in November 2019. Figure 23: The proportion of patients with gastric cancer who underwent curative surgical resection where ≥15 lymph nodes were resected and pathologically examined.




2016 0 0 0

2017 0 0 0

2018 64.3% 9 14 0 0 0

Of the 14 patients with gastric cancer undergoing surgical resection, 9 had ≥15 lymph nodes resected and pathologically examined. This resulted in a WoS performance of 64.3% against the 80% target. NHSAA and NHS Lan both met the target with both achieving 100%. NHSGGC achieved 50% and provided general comments as noted above for oesophageal cases. Once again, in respect of both oesophageal and gastric cancers, the number of patients included within the denominator is low and can have a considerable effect on overall proportions, therefore percentages should be viewed with caution. The MCN Advisory Board has discussed this QPI and is in agreement that revision of the measurement/reporting should be considered as part of formal review discussions.

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Action Required:-


QPI 9: Length of Hospital Stay Following Surgery Length of hospital stay acts as a surrogate measure for the quality of surgery and post-operative care for patients undergoing surgical resection for oesophagogastric cancer1. This QPI is intended as a surrogate marker to address various issues of quality care including surgery, post-operative complications, and access to community services. SMR01 data provided by ISD is utilised for measurement of QPI 9. Following discussion at the formal review meeting it was agreed to reduce the maximum length of stay within the criteria from 21 days to 14 days.

QPI 9: Length of hospital stay following surgery for oesophageal or gastric cancer should be as short as possible.

Numerator: Number of patients undergoing surgical resection for oesophageal or gastric cancer who are discharged within 14 days of surgical procedure.

Denominator: All patients undergoing surgical resection for oesophageal or gastric cancer.


Target: 60%

Figure 24: The proportion of patients who underwent surgical resection for oesophageal cancer who were discharged within 14 days of surgical procedure.




AA - - - 0 0 0

FV * * * 0 0 0

GGC 65.8% 25 38 0 0 0

Lan 62.5% 5 8 0 0 0

WoS 66.0% 33 50 0 0 0 - Denominator is less than 5; * denominator is zero; percentages should be viewed with caution.

Of the 50 patients undergoing surgical resection for oesophageal cancer, 33 patients were discharged within 14 days of their surgical procedure. This resulted in a WoS performance of 66.0% successfully meeting the 60% QPI target.

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Figure 25: The proportion of patients who underwent surgical resection for gastric cancer who were discharged within 14 days of surgical procedure.




2016 59.1% 13 22 0 0 0

2017 76.7% 23 30 0 0 0

2018 60.0% 12 20 0 0 0

Again due to the small numbers included within this QPI individual NHS boards results cannot be shown, overall WoS yearly results are displayed. Performance across the WoS was 60% against the 60% QPI target. NHSGGC achieved the QPI with 73.3% of gastric patients undergoing surgical resection being discharged within 14 days of surgical procedure. Following review of 2 cases not meeting the QPI target, NHS Ayrshire advised that 1 patient had to return to theatre and the other had an anastomotic leak. NHS Lan achieved 33.3% and commented that the SMR01 data analysed for this QPI is not a true reflection of patients treated in Lanarkshire. NHS Lan have conducted their own analysis into length of stay for 2017 data, highlighting a number of SMR01 data errors including incorrect operation dates and inclusion of Neuroendocrine tumours and insitu disease, which are excluded from the QPI audit. Action Required:-


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QPI 10: Resection Margins Tumour involvement of surgical resection margins following excision is a negative prognostic factor; therefore surgeons should aim to ensure resection margins are clear of tumour1. QPI 10 (i) previously incorporated circumferential and longitudinal margins. Following formal review it was agreed to measure clear circumferential margin only and the QPI has been updated accordingly. In this instance comparison with previous years’ results was able to be reported due to local analysis being undertaken for this measure. QPI 10 (ii) remains unchanged.

QPI 10 (i): Oesophageal cancers which are surgically resected should be adequately excised.

Numerator: Number of patients with oesophageal cancer who undergo surgical resection in which circumferential surgical margin is clear of tumour.

Denominator: All patients with oesophageal cancer who undergo surgical resection.


Target: 70%

Figure 26: The proportion of patients with oesophageal cancer who underwent surgical resection in which circumferential surgical margins were clear of tumour.

QPI 10(i) Performance (%) Numerator Denominator

Not recorded numerator

Not recorded exclusions


AA - - - 0 0 0

FV * * * 0 0 0

GGC 68.4% 26 38 0 0 0

Lan 62.5% 5 8 0 0 0


For patients diagnosed with oesophageal cancer the overall performance across the WoS is 67.3%, with 33 of 49 patients undergoing surgical resection having circumferential margins clear of tumour. This is just below the 70% target and shows a slight improvement on last year’s result. Small numbers are included however, so caution should be given to changes in performance across different years as this may represent a very small number of cases. NHSGGC commented that microscopic circumferential resection margin is almost impossible to predict pre and intra-operatively and the definition is debatable internationally.

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NHS Lan stated that the 3 cases that did not meet the QPI target have been reviewed. This has raised a question regarding the CRM in 1 case. One case had an involved lymph node <1mm from CRM and so whilst the margin is not involved it is considered CRM positive margin due to pathology definitions. The target would have been met if not for this case. Unless the Board only offers surgery to T1N0 patients there remains a risk of patients having positive CRM. The Board will however strive to reduce this through appropriate staging and patient selection at MDT. Action Required:-


QPI 10 (ii): Oesophageal and gastric cancers which are surgically resected should be adequately excised.

Numerator: Number of patients with oesophageal or gastric cancer who undergo surgical resection in which longitudinal surgical margin is clear of tumour.



Target: 90%

Figure 27: The proportion of patients with oesophageal cancer who underwent surgical resection in which longitudinal surgical margin was clear of tumour.

QPI 10(ii) Performance (%) Numerator Denominator




AA - - - 0 0 0

FV * * * 0 0 0

GGC 97.4% 37 38 0 0 0

Lan 100% 8 8 0 0 0


Overall in the WoS of the 49 patients with oesophageal cancer undergoing surgical resection 48 had clear longitudinal margins, resulting in a performance of 98% against the 90% target. All NHS Boards exceeded the target with NHSAA and NHS Lan achieving 100%, however due to small numbers NHSAA data was restricted.

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Figure 28: The proportion of patients with gastric cancer who underwent surgical resection in which longitudinal surgical margin was clear of tumour.

QPI 10(ii) Performance (%) Numerator Denominator




2016 96.9% 31 32 1 0 2

2017 95.8% 23 24 0 0 0

2018 94.4% 17 18 0 0 0 - Denominator is less than 5; * denominator is zero; percentages should be viewed with caution.

Due to the small numbers in each NHS board overall WoS are displayed in Figure 28. Across the WoS 94.4% of patients diagnosed with gastric cancer had clear longitudinal margins following surgical resection, exceeding the QPI target of 90%. All three NHS Boards exceeded the target with performance ranging from 97.4% in NHSGGC to 100% in NHS Lan and NHSAA. It should be noted that NHS FV cases have surgery within NHSGGC.

As with oesophageal cases, numbers are low in individual boards for gastric cases and therefore caution should be given to percentage comparisons.

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QPI 11: Curative Treatment Rates Surgical resection of the tumour remains the mainstay of curative treatment for patients with oesophageal or gastric cancer1. However in those patients with oesophageal cancer who have locally advanced disease, are unfit for surgery, or decline surgery, chemoradiotherapy should be considered. Radiotherapy alone is also an option in patients considered unsuitable for combination therapy but is rarely curative for oesophageal cancer. The tolerance within the target takes account for patient choice, fitness and comorbidities which preclude curative treatment. It is recognised that the majority of patients will have advanced disease at presentation.

QPI 11: Patients with oesophageal or gastric cancer should undergo curative treatment whenever possible.

Numerator: Number of patients with oesophageal or gastric cancer who undergo curative treatment.

Neoadjuvant chemoradiotherapy or chemotherapy followed by surgery;

Primary surgery;

Radical chemoradiotherapy; and

Endoscopic Mucosal Resection

Denominator: All patients with oesophageal or gastric cancer.


Target: 35%

Figure 29: The proportion of patients with oesophageal cancer who underwent curative treatment.




AA 16.4% 10 61 0 0 0

FV 23.7% 14 59 0 0 0

GGC 22.1% 52 235 2 0 0

Lan 21.7% 20 92 1 0 0

WoS 21.5% 96 447 3 0 0

Of the 447 patients diagnosed with oesophageal cancer, 96 underwent curative treatment, resulting in a WoS performance of 21.5% against the 35% target. None of the WoS NHS Boards achieved the QPI target with performance ranging from 16.4% in NHSAA to 23.7 in NHSFV.

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All Boards provided clinical commentary indicating that results were dependent upon stage and co-morbidity at presentation and also the advanced nature of presenting cases. NHS Ayrshire and Arran commented that they continue to assess patients on an individual basis with thorough staging and potentially curable cases are discussed at the regional MDT. NHSFV stated that this is an aspirational target. All patients with potentially curable disease are discussed at the regional MDT. NHSGGC commented that the reasons for a low rate of curative treatment are not clear, however are consistent annually and across the country. The Board continues to treat disease aggressively using endoscopic treatment where appropriate. This rate compares poorly with the rest of the UK, according to the national OG audit but is consistent across Scotland. The case ascertainment of the Scottish data is higher than the rest of the UK and it is postulated that this spuriously elevates the treatment rate in the rest of the UK. Although NHS Lan failed to meet the QPI target, the result is an improvement on last year’s result of 17.7%. On review of cases not meeting the QPI it is noted that at the time of diagnosis 48% patients have metastatic disease; 14% have locally advanced or incurable disease; 3% patient died before MDT or refused treatment; and 8% were unfit for curative treatment. This demonstrates that 73% of patients are unsuitable for consideration of curative treatment at initial presentation and following staging investigations. As a result it remains that due to late presentation of disease and high levels of co-morbidity this QPI is unlikely to be met unless efforts are made to improve health and establish awareness campaigns aimed at encouraging patients to present early. Figure 30: The proportion of patients with gastric cancer who underwent curative treatment.




AA 12.0% 3 25 0 0 0

FV 11.1% 2 18 1 0 0

GGC 22.4% 15 67 0 0 0

Lan 7.5% 3 40 0 0 0

WoS 15.3% 23 150 1 0 0

Overall performance across the WoS is 15.3%, with 23 of 150 gastric patients undergoing curative treatment. This is 19.7 percentage points below the 35% QPI target. None of the WoS NHS

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Boards achieved the target with performance ranging from 7.5% in NHS Lan to 22.4% in NHS NHSGGC. Feedback from boards reflects the comments made previously for patients with oesophageal cancer, also the MCN recognise that the target for this QPI is aspirational for Scotland, but for gastric cancer is in line with performance in other areas of the UK. QPI 12: 30-day mortality following Oncological treatment Treatment related mortality is a marker of the quality and safety of the whole service provided by the Multi Disciplinary Team (MDT). Treatment should only be undertaken in individuals that may benefit from treatment. This QPI is intended to ensure treatment is given appropriately1.

QPI 12 (i): 30/90-day mortality following curative oncological treatment for oesophageal or gastric cancer:

a) Chemoradiotherapy b) Perioperative chemotherapy

(ii) 30-day mortality following palliative oncological treatment for oesophageal or gastric cancer:

c) Chemotherapy

Numerator (i): Number of patients with oesophageal or gastric cancer who receive curative oncological treatment who die within 30 days of treatment.

(ii) Number of patients with oesophageal or gastric cancer who receive palliative oncological treatment who die within 30 days of treatment.

Denominator (i): All patients with oesophageal or gastric cancer who receive curative oncological treatment.

(ii) All patients with oesophageal or gastric cancer who receive palliative oncological treatment.

Exclusions (i)+(ii): No exclusions.

Target (i): < 5% - 30 Day <7.5% - 90 Day

(ii) <5%

With regards to mortality following SACT, a decision has been taken nationally to move to a new generic QPI (30-day mortality for SACT) applicable across all tumour types. This new QPI will use CEPAS (Chemotherapy ePrescribing and Administration System) data to measure SACT mortality to ensure that the QPI focuses on the prevalent population rather than the incident population. The measurability for this QPI is still under development to ensure consistency across the country and it is anticipated that performance against this measure will be reported in the next audit cycle. In the meantime all deaths within 30 days of SACT will continue to be reviewed at a NHS Board level.


QPI 13: HER2 Status

HER2 is a negative prognostic factor affecting recurrence rates. Availability of HER2 status is important to inform treatment decision making. Delay in the availability of HER2 status result may lead to a delay in appropriate therapy and complicate the communication of a clear plan to the patient1.

QPI 13: HER2 status should be available to inform treatment decision making in patients with advanced gastric and gastro-oesophageal junction adenocarcinoma.

Description: Proportion of patients with metastatic gastric or gastro-oesophageal junction adenocarcinoma undergoing first line palliative chemotherapy as their initial treatment for whom the HER2 status is reported prior to commencing treatment.

Numerator: Number of patients with metastatic gastric or gastro-oesophageal junction adenocarcinoma undergoing first line palliative chemotherapy as their initial treatment for whom the HER2 status is reported prior to commencing treatment.

Denominator: All patients with metastatic gastric or gastro-oesophageal junction adenocarcinoma undergoing first line palliative chemotherapy as their initial treatment.

Exclusions: No exclusions

Target: 90%

Figure 31: The proportion of patients with gastric cancer who had HER2 status reported prior to starting treatment.




AA - - - 0 0 0

FV - - - 0 0 0

GGC 68.8% 11 16 0 0 6

Lan 25.0% 2 8 0 0 10

WoS 56.7% 17 30 0 0 16 - Denominator is less than 5; percentages should be viewed with caution.

Overall in the WoS of the 30 patients with metastatic gastric or gastro-oesophageal junction adenocarcinoma undergoing first line palliative chemotherapy as their initial treatment, 17 had HER2 status reported prior to commencing treatment, resulting in a performance of 56.7% against the 90% target. No individual board met the target with all showing a reduction in performance from the previous year, however numbers are low in individual boards and therefore caution should be given to percentage comparisons. Data has been restricted for NHSAA and NHSFV due to small numbers.

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NHS AA and NHSFV commented that the patients who breached this target had HER2 testing carried out but was reported post treatment and that small numbers have a huge impact on this QPI. NHSGGC reported that of the 5 cases not meeting the numerator; 1 was not tested for HER2 status and 4 had HER2 status reported after the chemotherapy start date. As specimens are sent outwith NHSGGC for testing this will require further investigation. A review of the HER2 status requesting process from MDT is underway, to examine cases where HER2 status is reported post chemotherapy start date. NHS Lan commented that the 6 patients that did not meet the QPI target have been reviewed. In 3 cases HER2 status was reported after first treatment. In 2 cases HER2 was reported on the same day as first treatment commencing, and in 1 case there is no record of the HER2 status being checked. It has been agreed that HER 2 will be requested for all new gastric cancers at the time of 1st MDT discussion. This QPI will continue to be monitored through local reporting. It was highlighted to the MCN that specimens are sent to University College London for analysis and therefore work is required to establish the reasons for delays in receiving results. The MCN will explore this in more detail with NHS Boards to establish the source of the delay and identify any remedial action required. Action Required:-



QPI 14: Clinical Trials Access Clinical trials are necessary to demonstrate the efficacy of new therapies and other interventions. Evidence suggests improved patient outcomes when hospitals are actively recruiting patients into clinical trials. Clinicians are therefore encouraged to enter patients into well designed trials and to collect long term follow up data7. 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 the National Cancer Research Institute (NCRI). The principal benefit of this approach is that this data is already collected utilising a robust mechanism7.

QPI 14: All patients should be considered for participation in available clinical trials/research studies, wherever eligible.

Description: Proportion of patients diagnosed with Upper GI cancer who are consented for a clinical trial/research study.

Numerator: Number of patients diagnosed with Upper GI cancer consented for a clinical trial/research study.

Denominator: All patients diagnosed with Upper GI cancer.

Exclusions: No exclusions

Target: 15%

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.

The denominator for this QPI is identified by using a 5 year average of Scottish Cancer Registry data. Table 4: Proportion of patients consented and recruited to clinical trials for upper GI cancer by NHS Board of residence.

Board of Residence

N D % N D %

AA 1 106 0.94% 1 106 0.94%

FV 1 90 1.11% 1 90 1.11%

GGC 12 393 3.05% 10 393 2.54%

Lan 1 156 0.64% 0 156 0.00%

Outwith WoS - - - - - -

WoS Total 15 744 2.02% 12 744 1.61%

Consented – QPI Target 15% Recruited


Table 5: List of clinical trials carried out at Beatson West of Scotland Cancer Centre (BWoSCC) in 2017 and the number of patients with Upper GI cancer consented for each clinical trial.

Recruiting and managing clinical trial patients at standard clinics is extremely time consuming and this may be contributing to lack of engagement from clinicians in identifying and recruiting patients. The lead clinician in this tumour group has constructive ideas of how trial recruitment could be improved and this suggests that addressing how clinical trials are delivered in the BWoSCC would enable more patients to access clinical trials.

Consented

Short Title Total

A Phase I/IIa trial of BT1718 in patients

with advanced solid tumours 3

Add-Aspirin Trial 2

BALLAD 2

CX-072 in patients with

advanced/recurrent solid tumours or

lymphomas 1

RTL Advanced Study 6

SCOPE 2 1Total 15


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. With the development of QPIs, this has now become a national programme to drive continuous improvement and ensure equity of care for patients across Scotland.

West of Scotland Boards’ continued commitment to the improvement of the quality and completeness of audit data has supported the National Cancer Quality Programme in the formative years, and will be required throughout the formal review process. This commitment from Boards has provided accurate data for the reporting of performance against the Upper GI Cancer QPIs from which yearly comparisons in service provision across WoS Boards can be made. The results presented within this report illustrate that some of the QPI targets set have been challenging for NHS Boards to achieve and there remains room for further service improvement, however it is encouraging that targets relating to treatment intent (gastric), nutritional assessment for patients at high risk of malnutrition, surgical mortality, length of hospital stay following resection and longitudinal resection margins were met by all NHS Boards. 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. Actions required: QPI 1 – Endoscopy


QPI 4i – Staging and Treatment Intent


QPI 4ii - Staging and Treatment Intent


QPI 6 – Appropriate Selection of Surgical Patients


QPI 8 – Lymph Node Yield



QPI 9 – Length of Hospital Stay


QPI 10 - Resection Margins


QPI 13 – HER 2 Status


Completed Action Plans should be returned to WoSCAN within two months of publication of this report. The MCN Advisory Board will actively monitor progress against changes implemented by NHS Boards, and any service issue the Advisory Board considers not to have been adequately addressed, will be escalated to the appropriate NHS Board Lead Cancer Clinician and the Regional Lead Cancer Clinician. In addition, progress will be reported annually to the Regional Cancer Advisory Group (RCAG) by NHS Board 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).


6. Acknowledgements

This report has been prepared using clinical audit data provided by each of the NHS Boards in the WoSCAN area. We would like to thank colleagues in the clinical effectiveness departments throughout the West of Scotland for gathering, submitting and verifying these data. We would also like to thank the clinicians, nurses and others involved in the management of upper GI cancer in the West of Scotland for their contribution.


7. Abbreviations

AA / NHSAA

NHS Ayrshire & Arran

ACaDMe Acute Cancer Deaths and Mental Health (information system)

CNS Clinical Nurse Specialist

e-CASE Electronic Cancer Audit Support Environment

EUS Endoscopic Ultrasound

FV /

NHSFV

NHS Forth Valley

GGC / NHSGGC

NHS Greater Glasgow and Clyde

GI Gastro-intestinal

ISD Information Services Division (NHS National Services Scotland)

Lan /

NHS Lan

NHS Lanarkshire

MCN Managed Clinical Network

MDT Multidisciplinary Team

SACT Systemic anti-cancer therapy

QIS Quality Improvement Scotland

QPIs Quality Performance Indicators

RCAG Regional Cancer Advisory Group

TNM Tumour, Nodes, Metastases (staging system)

WoS West of Scotland

WoSCAN West of Scotland Cancer Network


8. References

1. Upper GI Cancer. Clinical Quality Performance Indicators. December 2012. Available

at: http://www.healthcareimprovementscotland.org/our_work/cancer_care_improvement/programme_resources/cancer_qpis.aspx [Accessed on: 25th September 2019]

2. ISD, NHS National Services Scotland. Summary Statistics for Oesophageal Cancer.

Available at: http://www.isdscotland.org/Health-Topics/Cancer/Cancer-Statistics/Oesophageal/ [Accessed on: 25th September 2019]

3. ISD, NHS National Services Scotland. Summary Statistics for Stomach Cancer.

Available at: http://www.isdscotland.org/Health-Topics/Cancer/Cancer-Statistics/Stomach/ [Accessed on: 25th September 2019]

4. Information Services Division. Cancer in Scotland. June 2004 [updated April 2018]

Available at: http://www.isdscotland.org/Health-Topics/Cancer/Publications/2018-04-24/Cancer_in_Scotland_summary_m.pdf [Accessed on: 25th September 2019]

5. ISD, NHS National Services Scotland. Trends in Cancer Survival in Scotland, 1983-2007. August 2010. Available at: http://www.isdscotland.org/Health-Topics/Cancer/Cancer-Statistics/Survival_summary_8307.pdf?1 [Accessed on: 25th September 2019]

6. UICC (Union for International Cancer Control). TNM Classification of Malignant

Tumours. 7th Edition. Wiley-Blackwell; 2009.

7. Clinical Trials Quality Performance Indicator. July 2014 (updated October 2017). Available at: http://www.healthcareimprovementscotland.org/our_work/cancer_care_improvement/programme_resources/cancer_qpis.aspx [Accessed on: 25th September 2019]

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


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

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

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

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

http://www.isdscotland.org/Health-Topics/Cancer/Publications/2018-04-24/Cancer_in_Scotland_summary_m.pdf

http://www.isdscotland.org/Health-Topics/Cancer/Publications/2018-04-24/Cancer_in_Scotland_summary_m.pdf

http://www.isdscotland.org/Health-Topics/Cancer/Cancer-Statistics/Survival_summary_8307.pdf?1

http://www.isdscotland.org/Health-Topics/Cancer/Cancer-Statistics/Survival_summary_8307.pdf?1




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: NHS Board Action Plans

A summary of actions for each NHS Board has been included within the Action Plan templates in Appendix 1. Completed Action Plans should be returned to WoSCAN within two months of publication of this report.

Upper Gastro-intestinal Cancer Action / Improvement Plan

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

Start End

Ensure actions mirror those detailed in Audit Report.

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

Insert date

Insert date

Insert name of responsible lead for each action.

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

Insert No. from key above

1. QPI 4ii - Staging and Treatment Intent The MCN should initiate discussion with regards to the measurement of this QPI as part of the formal review process.

2. QPI 8 – Lymph Node Yield MCN Lead to engage with the formal review process regards revision of this indicator.

3. QPI 9 – Length of Hospital Stay The MCN will request that consideration is given to the inclusion of a date of discharge field within the QPI dataset, to allow the

NHS Board: WoSCAN MCN KEY (Status)

Action Plan Lead: 1 Action fully implemented

Date: 2 Action agreed but not yet implemented

3 No action taken (please state reason)



Start End

QPI to be more accurately measured using audit rather than SMR01 data.

4. QPI 10 - Resection Margins Given comments returned the MCN will request that this QPI is discussed as part of the national formal review in November 2019.

5. QPI 13 – HER 2 Status MCN to explore the HER2 reporting process in more detail with NHS Boards to establish the source of delays and identify any remedial action required.




Start End



Insert date

Insert date




1. QPI 4i – Staging and Treatment Intent NHS Lan to ensure that TNM is recorded for all oesophageal and gastric patients at MDT prior to treatment commencing.

2. QPI 9 – Length of Hospital Stay Results of the local length of stay analysis in NHS Lan should be fed back to the MCN.

NHS Board: NHS Lanarkshire KEY (Status)







Start End



Insert date

Insert date




1. QPI 1 – Endoscopy NHSGGC to report back the findings of the audit of oesophageal cases not meeting the QPI to the MCN.

2. QPI 6 – Appropriate Selection of Surgical Patients NHSGGC should report the results of the detailed review of patients not meeting the QPI back to the MCN.

NHS Board: NHS Greater Glasgow and Clyde KEY (Status)




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