Colorectal Liver Metastases questionnaire results Ewen Harrison Consultant HPB Surgeon Royal Infirmary Edinburgh Professor of Surgery and Data Science Director Centre Medical Informatics, University of Edinburgh
Colorectal Liver Metastases questionnaire results
Ewen Harrison Consultant HPB Surgeon
Royal Infirmary Edinburgh Professor of Surgery and Data Science Director Centre Medical Informatics,
University of Edinburgh
Colorectal cancer
• 3rd most common cancer men and women in Scotland (2017, NSD).
• >50% develop liver metastases.
• Liver resection the treatment of choice.
• Resection provides a potential curative treatment – 5-year survival 40-60%.
Overall Pathology: Edinburgh data
Pre-op aetiology
2018 Malignant
Final pathology
Open or Laparoscopic
Liver resection morbidity & mortality
Colorectal liver metastases: The ‘lost’ patients
• No reliable information on number with CRLM and management.
• No outcome measures
• No standardisation of care
• Likely variation in practice and outcomes for this group of patients
SHPBN Education event Jan 2019
• Colorectal colleagues participated
– surgeons, oncologists, radiologists and CNS.
• Excellent participation and break out session to discuss how to move forward with the formation of a colorectal Liver metastases Collaborative under the SHPBN umbrella.
CRCLM Collaborative
Consensus
• We need to ensure that there is both equitable and consistent referral of colorectal liver metastases patients into HPB MDTs and that once reviewed there is standardized treatment and outcomes for these patients across HPB units in Scotland.
ACTION 1. PROSPECTIVE 3-MONTH SNAPSHOT AUDIT ACROSS COLORECTAL MDTS
What number of patients with CRLMs are being discussed in Colorectal MDTs and are they being discussed with HPB teams?
3- Month prospective snapshot audit across CR MDTs
• Aim: To determine the number of patients with colorectal liver metastases (CRLM) being discussed and referred to hepatobiliary (HPB) services.
• Methods: The questionnaire was sent to each colorectal MDT across 14 health boards
1st March- 31st May 2019
12 colorectal MDTs across the three
networks contributed
Health boards / hospitals who contributed
• 93 MDT meetings took place over which a total of 169 new colorectal liver metastases were discussed:
119 Synchronous
50 metachronous
• Median 2 New CRLM discussed per MDT meeting(including synchronous and metachronous)
• HPB surgeon was not present at the meeting: 86.9%
• Total number referred to the HPB MDT: 26.6% (45/169)
Number of patients referred to an HPB MDT from each
hospital: Clear Geographical variation
Main reason for not referring to HPB MDT: Lesion was felt to be not operable 31.9%
ACTION 2. CONSIDER QUALITY PERFORMANCE INDICATORS (QPIS) FOR CRLMS
Currently there are no Quality Performance Indicators for this group of patients that are lost between the colorectal and HPB data collection.
Consider QPIs in both the Colorectal and HPB data sets
Multidisciplinary Short Life Working Group
Propose the introduction of two QPIs: 1. Colorectal data set 2. HPB data set
QPI in the Colorectal Data set
“All patients will a new diagnosis of colorectal liver metastases should be referred to an HPB MDT”
Consider an appropriate target, exclusions and inclusions e.g.
• Target 95%
• Inclusions: All patients with colorectal liver metastases
• Exclusions:
Primary CRC not resectable
Comorbidity precludes surgery
Extra hepatic metastases (excluding pulmonary)
Patient choice
Introduction of this QPI would be in keeping with the NICE guidelines in England: NICE Colorectal guidance CG131 1.3.2 If the CT scan shows metastatic disease only in the liver and the patient has no contraindication to further treatment a specialist hepatobiliary MDT should decide if further imaging to confirm surgery is suitable for the patient – or potentially suitable after further treatment – is needed (2011)
Essential to Include both Synchronous & Metachronous CRLM
• Tracking synchronous metastases more
straightforward • Metachronous requires more thought as
currently recurrence is not included in QPIs. • Discussion with David Morrison, Director of
Cancer Registry who is leading on National work with regards to recurrence data – supportive of including the metachronous lesions and
did not feel this would pose a significant problem.
The Audit Identifies
1. The workload for data managers is realistic and should not impact on data collectors and analysis greatly
2. Currently decision on operability of liver metastases is being made in the absence of an HPB surgeon.
3. Geographical variation in the number of CRLM referred to an HPB MDT
Summary (1) • CRLM patients are a lost group of patients in
Scotland
• Current outcomes for CRC in UK are lower than other countries
• Numbers of patients in Scotland going forward to liver resection is lower than in other countries.
Summary (2) • We need to standardise care pathways
across the country and collect data on this group of patients.
• Introduction of QPIs across Colorectal and HPB can positively impact on care
• Supported by
MCNs: WoSCAN, NoSCAN & SCAN
Health Improvement Scotland
NSD