-
The content of this report is © copyright WoSCAN unless
otherwise stated.
Audit Report Cervical Cancer Quality Performance Indicators
Endometrial Cancer Quality Performance Indicators
Clinical Audit Data: 01 October 2017 to 30 September 2018
Kevin Burton Consultant Gynaecological Oncologist MCN Clinical
Lead Kevin Campbell MCN Manager Julie McMahon Information
Officer
West of Scotland Cancer Network Gynaecological Cancer Managed
Clinical Network
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West of Scotland Cancer Network Final Published Endometrial
& Cervical Cancer QPI Audit Report V1.0 26/08/2019
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CONTENTS
EXECUTIVE SUMMARY 3
1. INTRODUCTION 8
2. BACKGROUND 8
2.1. NATIONAL CONTEXT 8
3. METHODOLOGY 9
4. RESULTS AND ACTION REQUIRED 10
4.1 PERFORMANCE AGAINST QUALITY PERFORMANCE INDICATORS (QPIS)
10
4.2. ENDOMETRIAL CANCER – QUALITY PERFORMANCE INDICATORS 11
4.3. CERVICAL CANCER – QUALITY PERFORMANCE INDICATORS 23
5. CONCLUSIONS 36
ACKNOWLEDGEMENT 38
ABBREVIATIONS 39
REFERENCES 40
APPENDIX 1: ACTION / IMPROVEMENT PLANS 42
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Executive Summary
Introduction This report contains an assessment of the
performance of West of Scotland (WoS) gynaecology cancer services
using clinical audit data relating to patients diagnosed between 1
October 2017 and 30 September 2018. Twelve months of data were
measured against the Endometrial and Cervical Cancer QPIs for the
fourth consecutive year. Previous years' results are presented
within this audit report for QPIs where results have remained
comparable. In order to ensure the success of the National Cancer
QPIs in driving quality improvement in cancer care across NHS
Scotland, a process of formal review was carried out after Year 3
of comparative reporting with tumour-specific Regional Clinical
Leads undertaking a key role in determining the extent of the
review required for each tumour type. The revised Endometrial and
Cervical Cancer QPIs1 were published in December 2018 and, as
stated above, are valid for patients diagnosed on or after 01
October 2017. Background Treatment and care for gynaecological
cancer patients is delivered by a single regional
multi-disciplinary team (MDT). This is facilitated by
video-conferencing technology and a bespoke IT system, which is
operationally dependant on close collaboration of professionals
from a range of clinical specialities across the region to provide
well planned and coordinated delivery of treatment and care.
Complex gynaecological malignancy often requires a multi-modality
approach and surgery remains a key component of effective curative
management. Methodology The clinical audit data presented in this
report was collected by clinical audit staff in each NHS Board in
accordance with an agreed dataset and definitions. The data was
entered locally into the electronic Cancer Audit Support
Environment (eCASE): a secure centralised web-based database. Data
relating to patients diagnosed between 1 October 2017 and 30
September 2018 was downloaded from eCASE on 10 April 2019. Analysis
was performed centrally by the West of Scotland Cancer Network
(WoSCAN) Information Team.
Results Results for each QPI are shown in detail in the main
report and illustrate Board performance against targets and overall
WoS performance for each quality indicator. Results are presented
graphically and the accompanying tabular format also highlights any
missing data and its possible effect on any of the measured
outcomes. The following summary of results shows the WoS and
individual units’ percentage performance against each QPI
target.
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West of Scotland Cancer Network Final Published Endometrial
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Endometrial/Cervical Cancer Performance Summary Report
QPI Target WoS A&A FV Lan Glasgow
North Glasgow
South Clyde
QPI 1 - Radiological Staging. Patients with endometrial cancer
should have their stage of disease assessed by magnetic resonance
imaging (MRI) and/or computed tomography (CT) prior to definitive
treatment.
90% 98.3%
>
96.4%
<
94.1%
>
97.1%
>
100%
>
100%
=
100%
=
169 172 27 28 16 17 33 34 37 37 20 20 36 36
QPI 2 - Multidisciplinary Team Meeting (MDT). Patients with
endometrial cancer should be discussed by a multidisciplinary team
(MDT) prior to definitive treatment.
95% 72.0%
<
64.2%
<
61.8%
<
59.6%
<
96.6%
<
92.6%
<
63.3%
<
208 289 34 53 21 34 34 57 56 58 25 27 38 60
QPI 3 - Total Hysterectomy and Bilateral Salpingo-Oophorectomy.
Patients with endometrial cancer should undergo total hysterectomy
(TH) and bilateral salpingo-oophorectomy (BSO).
85% 88.6%
<
81.1%
<
85.0%
<
91.2%
>
94.7%
>
78.6%
<
93.8%
<
265 299 43 53 34 40 52 57 54 57 22 28 60 64
QPI 4 - Laparoscopic Surgery (Hosp. of Surgery) Patients with
endometrial cancer undergoing definitive surgery should undergo
laparoscopic surgery, where clinically appropriate.
70% 75.7%
>
85.0%
>
92.9%
>
94.9%
>
69.3%
>
76.7%
>
54.9%
>
209 276 34 40 26 28 37 39 61 88 23 30 28 51
Above Target Result
Below Target Result
> Indicates increase on previous years figure
< Indicates decrease from previous years figure
= Indicates no change from previous year
Indicates no comparable measure from previous year
Endometrial QPIs Performance by Board
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QPI Target WoS A&A FV Lan NG SG Clyde
*QPI 5 - Adjuvant Vaginal Brachytherapy. Patients with
intermediate risk (stage IB, grade 1 or 2; or stage IA, grade 3
endometrioid or mucinous) endometrial cancer should be considered
for adjuvant radiotherapy.
90% 92.6%
>
92.3%
<
100%
=
83.3%
<
100%
>
88.9%
<
91.7%
>
50 54 12 13 6 6 5 6 8 8 8 9 11 12
*QPI 6 – SACT/Hormone Therapy. Patients with stage IV
endometrial cancer should have SACT or hormone therapy.
75% 55.6%
>
- - - 66.7%
>
- -
10 18 - - - - - - 4 6 - - - -
QPI 7 – 30 Day Mortality Following Surgery. 30 day mortality
following surgery for endometrial patients.
100%
>
85.7%
<
116 125 26 27 14 16 30 33 27 28 7 7 12 14
QPI 2 - Positron Emission Tomography/Computed Tomography
(PET/CT). Patients with cervical cancer, for whom primary
definitive surgery is not appropriate, should undergo positron
emission tomography - computed tomography imaging (PET/CT).
95% 98.5%
>
100%
=
100%
=
100%
>
100%
=
- 80.0%
<
67 68 17 17 9 9 21 21 12 12 - - 4 5
QPI 3 - Multidisciplinary Team Meeting (MDT). Patients with
cervical cancer should be discussed by a multidisciplinary team
(MDT) prior to definitive treatment.
95% 99.2%
>
100%
=
100%
=
100%
>
100%
=
100%
=
92.9%
>
123 124 27 27 16 16 31 31 30 30 6 6 13 14
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QPI Target WoS A&A FV Lan NG SG Clyde
*QPI 4 - Radical Hysterectomy. Patients with stage IB1 cervical
cancer should undergo radical hysterectomy.
85% 75.0%
<
66.7%
<
- - 75.0%
<
n/a 60.0%
=
21 28 4 6 - - - - 9 12 0 0 3 5
*QPI 5 - Surgical Margins. (Hosp. of Surgery) Patients with
surgically treated cervical cancer should have clear resection
margins.
95% 94.3%
<
- - - 97.4%
<
- 85.7%
>
50 53 - - - - - - 38 39 - - 6 7
*QPI 6 - 56 Day Treatment Time for Radical Radiotherapy.
Treatment time for patients with cervical cancer undergoing radical
radiotherapy should be no more that 56 days.
90% 97.4%
<
94.7%
<
100%
=
100%
=
100%
=
- 88.9%
<
76 78 18 19 9 9 23 23 14 14 - - 8 9
*QPI 7 – Chemoradiation. Patients with cervical cancer
undergoing radical radiotherapy should receive concurrent
platinum-based chemotherapy.
70% 89.7%
>
84.2%
<
100%
>
87.0%
<
100%
>
- 88.9%
>
70 78 16 19 9 9 20 23 14 14 - - 8 9
**Small numbers in some Boards - percentage comparisons over a
single year should be viewed with caution. ‘-‘ Data not shown due
to small numbers (denominator less than 5).
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West of Scotland Cancer Network Final Published Endometrial
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Conclusions and Action Required The development of national QPIs
for endometrial and cervical cancer has helped drive continuous
quality improvement in the care of patients with endometrial or
cervical cancer whilst ensuring that activity at NHS
Board/treatment centre level is focussed on those areas that are
most important in terms of improving survival and patient outcomes.
West of Scotland NHS Boards have now completed the fourth year of
data collection for cervical and endometrial cancer QPIs. The
results presented in this report demonstrate that patients with
cervical and endometrial cancer continue to receive a consistently
high standard of care. Case ascertainment and data capture is of a
high standard enabling robust assessment of performance against
QPIs, comparison of performance across the country, and the
identification of outliers. Where QPI targets were not met, NHS
Boards have scrutinised cases further and provided detailed
clinical feedback. In the main this indicates valid clinical
reasons, or that in some cases patient choice or co-morbidities
have influenced clinical management. The MCN will actively progress
regional actions identified, NHS Boards are asked to develop local
Improvement Plans in response to the findings presented in the
report, and detailed within the appropriate NHS Board Action Plan
templates in Appendix 1. Actions: Endometrial Cancer QPI 2: MDT
Discussion Prior to Definitive Treatment
The MCN will initiate discussions around the appropriateness of
including Grade I endometrial patients within the QPI measurement
and will review the current MCN guideline to establish if any
changes are required.
QPI 3: Total Hysterectomy and Bilateral
Salpingo-Oophorectomy
NHS Ayrshire & Arran should review all cases not meeting the
QPI target and provide detailed clinical reasons to the MCN.
QPI 6: SACT/Hormone Therapy
NHSGGC should review the cases not meeting the target and
provide detailed clinical reasons for those advanced stage
endometrial cancer patients not receiving SACT.
A summary of actions for each NHS Board has been included within
the Action Plan templates in the Appendix. Completed Action Plans
should be returned to WoSCAN within two months of publication of
this report.
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1. Introduction This report contains an assessment of the
performance of West of Scotland (WoS) gynaecology cancer services
using clinical audit data relating to patients diagnosed between 1
October 2017 and 30 September 2018. Data analysed and included
within this report relate to cervical and endometrial cancers.
Regular reporting of activity and performance is a fundamental
requirement of a Managed Clinical Network (MCN) to assure the
quality of care delivered across the region. Results are measured
against the Endometrial and Cervical Cancer Quality Performance
Indicators (QPIs). Data definitions and measurability criteria to
accompany cancer QPIs are available from the ISD website2. Twelve
months of data were measured against the endometrial and cervical
cancer QPIs for the fourth consecutive year, and previous years'
results are presented within this audit report for QPIs where
results have remained comparable. Future reports will continue to
compare clinical audit data in successive years to further
illustrate trend analysis. In order to ensure the success of the
National Cancer QPIs in driving quality improvement in cancer care
across NHS Scotland, a process of formal review was carried out
after Year 3 of comparative reporting with tumour-specific Regional
Clinical Leads undertaking a key role in determining the extent of
the review required for each tumour type. The revised Endometrial
and Cervical cancer QPIs1 were published in December 2018 and, as
stated above, are valid for patients diagnosed on or after 01
October 2017. Any new QPIs which were developed requiring new data
items will be reported in Year 5 once data becomes available for
these new measures.
2. Background
Treatment and care for gynaecological cancer patients is
delivered by a single regional multi-disciplinary team (MDT). This
is facilitated by video-conferencing technology and a bespoke IT
system, which is operationally dependant on close collaboration of
professionals from a range of clinical specialities across the
region to provide well planned and coordinated delivery of
treatment and care. Complex gynaecological malignancy often
requires a multi-modality approach and surgery remains a key
component of effective curative management. 2.1. National Context
Endometrial cancer is the most common gynaecological cancer and the
fourth most common cancer in women in Scotland with approximately
800 new cases diagnosed annually. The incidence of endometrial
cancer has risen significantly by 24% over the last ten years
(2007-2017)3. This undoubtedly reflects increasing levels of
obesity4 and also an increasingly ageing population. Recently
published data highlights that the number of new cases of
endometrial cancer is predicted to increase by 55% between
2008-2012 and 2023-20275.
One-year and 5-year relative survival rates for endometrial
cancer for females diagnosed between 2007 and 2011 are 92.9% and
83.2% respectively3. Endometrial cancer is the 9th most common
death in females from cancer in Scotland with overall mortality
rates increasing by 59.1% from 2007 to 20174. Cervical cancer is
noted as being the twelfth most common cancer in women with
approximately 275 cases diagnosed each year3. The incidence of
cervical cancer has increased by 4.7% over the last ten years3.
Overall mortality rates have decreased by 6.2% over the past 10
years from 2007 to 2017 and 1-year and 5-year relative survival is
noted as being 87.5% and 73% respectively3. Recently published
figures indicate that the number of new cases of cervical cancer is
predicted to increase by 39.6% between 2008-2012 and 2023-20275.
Many cervical cancers are detected early due to the well
established screening programme introduced in 1988. The Human
Papilloma Virus (HPV) vaccine is designed to protect against
certain high risk types of HPV that are responsible for
approximately 70% of cervical cancer cases. The
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vaccination programme started in Scotland on 1st September 2008
and aims to protect females by routinely immunising them at 12-13
years of age, through a school based programme. Progression from
HPV infection to cervical cancer can take many years, therefore
surveillance to monitor the impact of the vaccination programme
will be a long term undertaking.
3. Methodology
The clinical audit data presented in this report was collected
by clinical audit staff in each NHS Board in accordance with an
agreed dataset and definitions. The data was recorded manually and
entered locally into the electronic Cancer Audit Support
Environment (eCASE): a secure centralised web-based database. Data
relating to patients diagnosed with endometrial or cervical cancer
between 1 October 2017 and 30 September 2018 was downloaded from
eCASE at 2200 hrs on 10 April 2019. Cancer audit is a dynamic
process with patient data continually being revised and updated as
more information becomes available. This means that apparently
comparable reports for the same time period and cancer site may
produce slightly different figures if extracted at different times.
Analysis was performed centrally for the region by the WoSCAN
Information Team and the timescales agreed took into account the
patient pathway to ensure that a complete treatment record was
available for each case. Initial results of the analysis were
provided to local Boards to check for inaccuracies, inconsistencies
or obvious gaps and a subsequent download taken upon which final
analysis was carried out. The final data analysis was disseminated
for NHS Board verification in line with the regional audit
governance process to ensure that the data was an accurate
representation of service in each area.
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4. Results and Action Required
4.1 Performance against Quality Performance Indicators (QPIs)
Results of the analysis of endometrial and cervical QPIs are set
out in the following section. Graphs and charts have been provided
where this aids interpretation and, where appropriate, numbers have
also been included to provide context. Where possible, results for
patients diagnosed in previous years have been presented alongside
the previous years’ results to illustrate trends. Data (both
graphically and in tabular format) are presented by location of
diagnosis or treatment, with some criteria given as an overall WoS
representation. Specific regional and NHS Board actions have been
identified to address issues highlighted through the data analysis.
Where the number of cases meeting the denominator criteria for any
indicator is between one and four, the percentage calculation has
not been shown on any associated charts or tables. This is to avoid
any unwarranted variation associated with small numbers and to
minimise the risk of disclosure. Any charts or tables impacted by
this are denoted with a dash (-). Any commentary provided by NHS
Boards relating to the impacted indicators will however be included
as a record of continuous improvement.
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4.2. Endometrial Cancer – Quality Performance Indicators
Introduction Quality Performance Indicators (QPIs) were implemented
for patients diagnosed with endometrial cancer on or after 1st
October 2014 and Endometrial Cancer QPIs1 are reported here for the
fourth consecutive year. There were 331 new diagnoses of
endometrial cancer captured by audit in the WoS in Year 4.
Distribution by location of diagnosis is shown below in Figure 1.
Figure 1: Number and proportion of patients diagnosed with
endometrial cancer by location of diagnosis.
AA FV Lan GGC WoS
Year 1_2014/15 75 35 75 146 331
Year 2_2015/16 69 51 79 158 357
Year 3_2016/17 68 54 62 162 346
Year 4_2017/18 55 41 64 171 331
0
20
40
60
80
100
120
140
160
180
Ayrshire & Arran Forth Valley Lanarkshire GGC
Num
ber o
f Cas
es
Location of Diagnosis
2014/15 2015/16 2016/17 2017/18
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Endometrial FIGO Stage Distribution The distribution of
endometrial cancer by FIGO stage is presented in Figure 2, which
illustrates that 76% of patients presented with early stage (I, II)
disease and 16.3% of patients presented with advanced stage disease
(III,IV). However, it should be noted that full surgical staging is
not currently undertaken in all endometrial cancers. To date this
has been a decision taken by the Network to balance morbidity with
benefits. There are forthcoming trials which may affect this
current Network position. Once the trials have been published then
further discussions will take place to ensure ongoing management
can take latest evidence into account. Figure 2: Distribution of
endometrial cancer by FIGO stage.
FIGO Stage IA IB II IIIA IIIB IIIC IVA IVB NR NA
n 166 65 21 13 4 17 13 7 16 9
Figure 2 also highlights that 7.5% of patients had FIGO stage
coded as ‘not recorded’ or ‘not applicable’. FIGO stage should be
recorded for all patients and not only those who undergo surgery.
The availability of staging data is critical for survival analysis
and for accurate measurement of OPIs.
IA, 50.2%
IB, 19.6%
II, 6.3%
IIIA, 3.9
IIIB, 1.2%
IIIC, 5.1%
IVA, 3.9%
IVB, 2.1% NA, 2.7% NR, 4.8%
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QPI 1: Radiological Staging It is necessary to fully image the
pelvis and abdomen prior to starting first treatment in order to
establish the extent of disease and minimise unnecessary or
inappropriate treatment1. The target for this QPI is set at 90%
with the tolerance level designed to account for situations where
patients require urgent treatment before imaging has been performed
or where endometrial cancer is an incidental finding at
hysterectomy. It also allows for those patients who are deemed
unfit for investigation1. Figure 3: Proportion of patients with
endometrial cancer who have an MRI and/or CT scan of the abdomen
and pelvis performed prior to definitive treatment.
Performance (%) Numerator Denominator Not recorded
numerator Not recorded
numerator (%) Not recorded exclusions
Not recorded exclusions (%)
Not recorded denominator
AA 96.4% 27 28 0 0.0% 0 0.0% 0
FV 94.1% 16 17 0 0.0% 0 0.0% 0
Lan 97.1% 33 34 0 0.0% 5 14.7% 0
NG 100% 37 37 0 0.0% 0 0.0% 0 SG 100% 20 20 0 0.0% 0 0.0% 0
Clyde 100% 36 36 0 0.0% 0 0.0% 0 WoS 98.3% 169 172 0 0.0% 5 2.9%
0 Following discussion at formal review it was agreed that QPI 1
should be updated to focus on MRI/CT before definitive treatment
rather than first treatment.
0
10
20
30
40
50
60
70
80
90
100
Ayrshire & Arran
Forth Valley Lanarkshire North Glasgow South Glasgow Clyde
WoS
Pe
rfo
rman
ce (%
)
Location of Diagnosis
2014/15 2015/16 2016/17 2017/18
Title: Patients with endometrial cancer should have their stage
of disease assessed by MRI and/or CT prior to definitive
treatment.
Numerator: Number of patients with endometrial cancer having a
MRI and/or CT scan of the abdomen and pelvis carried out prior to
definitive treatment.
Denominator: All patients with endometrial cancer. Exclusions:
Patients with Grade 1 endometrioid or mucinous carcinoma on
pre-operative biopsy.
Patients with atypical hyperplasia on pre-operative biopsy.
Target: 90%
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Across WoS, 98.3% of patients diagnosed with endometrial cancer
had a CT scan or MRI of the abdomen and pelvis carried out prior to
definitive treatment in Year 4; 8.3 percentage points above the 90%
QPI target. All six WoS units exceeded the target with performance
ranging from 94.1% in NHS Forth Valley to 100% in the three NHSGGC
units. This is the fourth consecutive year that the target has been
met in the WoS.
QPI 2: Multidisciplinary Team Meeting (MDT) Evidence suggests
that patients with cancer managed by a multidisciplinary team have
a better outcome. There is also evidence that the multidisciplinary
management of patients increases their overall satisfaction with
their care1. Figure 4: Proportion of patients with endometrial
cancer who are discussed at a MDT meeting before definitive
treatment.
Performance (%) Numerator Denominator Not recorded
numerator Not recorded
numerator (%) Not recorded exclusions
Not recorded exclusions (%)
Not recorded denominator
AA 64.2% 34 53 0 0.0% 1 1.9% 0
FV 61.8% 21 34 0 0.0% 0 0.0% 0
Lan 59.6% 34 57 0 0.0% 0 0.0% 0
NG 96.6% 56 58 0 0.0% 0 0.0% 0 SG 92.6% 25 27 0 0.0% 0 0.0%
0
Clyde 63.3% 38 60 0 0.0% 0 0.0% 0 WoS 72.0% 208 289 0 0.0% 1
0.3% 0
0
10
20
30
40
50
60
70
80
90
100
Ayrshire &
Arran
Forth Valley Lanarkshire North Glasgow South Glasgow Clyde
WoS
Pe
rfo
rman
ce (%
)
Location of Diagnosis
2014/15 2015/16 2016/17 2017/18
Title: Patients with endometrial cancer should be discussed by a
multidisciplinary team prior to definitive treatment.
Numerator: Number of patients with endometrial cancer discussed
at MDT prior to definitive
treatment. Denominator: All patients with endometrial cancer.
Exclusions: Patients with atypical hyperplasia on pre-operative
biopsy.
Patients who died before first treatment. Target: 95%
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Previous definitions excluded those cases with Grade I
endometrioid or mucinous carcinoma on pre-operative biopsy. During
formal review it was agreed that the exclusions should be removed.
This change meant that all G1 endometrial cancers were to be
discussed at the MDT. As highlighted by Figure 4 this change has
resulted in a reduction in performance in all units with the
overall WoS performance falling from 95.8% in Year 3 to 72.0% in
Year 4. Only North Glasgow achieved the 95% QPI target achieving
96.6%. Performance in the other units ranged from 59.6% in NHS
Lanarkshire to 92.6% in South Glasgow. Results for cases not
meeting the QPI have been analysed further and patients with Grade
I endometrioid or mucinous carcinoma on pre-operative biopsy who
were previously excluded, account for 77 of the 81 cases not
meeting the QPI. All 77 cases were managed according to Network
Guidelines whereby all G1 cancers are recommended to proceed with
routine clinical management with total laparoscopic hysterectomy
and bilateral salpingo-oppherectomy unless there are features which
need to be discussed at the MDT. There are changes being made in
the MDT whereby certain cases will be presented for ratification of
decisions rather than requiring a full discussion. The MCN is
currently using QPI data to gather evidence to move forward with a
protocolised pathway for some MDT related decisions. In the
meantime cases will be discussed at the MDT adding to the workload
of the weekly MDT Action Required:
The MCN will initiate discussions around the appropriateness of
including Grade I endometrioid or mucinous carcinoma patients
within the QPI measurement and will review the current MCN
guideline to establish if any changes are required.
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QPI 3: Total Hysterectomy and Bilateral Salpingo-Oophorectomy
Total Hysterectomy and Bilateral Salpingo-Oopherectomy for
endometrial cancer is associated with best long term survival
(compared to primary radiotherapy or hormonal treatment)1. The
target for this QPI is 85% with the tolerance designed to account
for patients having fertility conserving treatment and those
patients who are not fit for surgical intervention1. Figure 5:
Proportion of patients with endometrial cancer who undergo total
hysterectomy/bilateral salpingo-oopherectomy.
Performance (%) Numerator Denominator Not recorded
numerator Not recorded
numerator (%) Not recorded exclusions
Not recorded exclusions (%)
Not recorded denominator
AA 81.1% 43 53 0 0.0% 0 0.0% 0
FV 85.0% 34 40 0 0.0% 1 2.5% 0
Lan 91.2% 52 57 0 0.0% 2 3.5% 0
NG 94.7% 54 57 0 0.0% 1 1.8% 0 SG 78.6% 22 28 0 0.0% 3 10.7%
0
Clyde 93.8% 60 64 0 0.0% 2 3.1% 0 WoS 88.6% 265 299 0 0.0% 9
3.0% 0 Following discussion at formal review it was agreed that the
target for QPI 7 should be raised from 80% to 85%.
0
10
20
30
40
50
60
70
80
90
100
Ayrshire &
Arran
Forth Valley Lanarkshire North Glasgow South Glasgow Clyde
WoS
Pe
rfo
rman
ce (%
)
Location of Diagnosis
2014/15 2015/16 2016/17 2017/18
Title: Patients with endometrial cancer should undergo total
hysterectomy and bilateral salpingo-oopherectomy.
Numerator: Number of patients with endometrial cancer who
undergo total hysterectomy/bilateral
salpingo-oopherectomy. Denominator: All patients with
endometrial cancer. Exclusions: Patients with FIGO Stage IV.
Patients who decline surgical treatment. Patients having
neo-adjuvant chemotherapy.
Target: 85%
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Of the 299 patients diagnosed with endometrial cancer, 265
underwent total hysterectomy and bilateral salpingo-oopherectomy.
Four of the six units have exceeded the 85% target resulting in an
overall performance of 88.6% across the WoS NHS Ayrshire did not
meet the 85% target with 10 cases not undergoing total hysterectomy
and bilateral salpingo-oopherectomy (81.1%). NHS Ayrshire &
Arran provided commentary on 3 of the 10 cases not meeting the
target. Reasons provided included patient with multiple
co-morbidities and not fit for surgery, patient died pre treatment
and patient moved and was referred to appropriate NHS Health board
for treatment. NHSGGC commented that all cases not meeting the QPI
were reviewed and there was a consistent finding that all cases
were unfit for surgery. NHSGGC added that the gynaecological
oncology network is pursuing a pre-habilitation programme of work
to improve patient fitness for intervention. This group will also
look into the possibility of objective measures of frailty to allow
consistent decision making in gynaecological cancer cases with
respect to fitness. The initial work is being piloted in Clyde but
there is an aspiration to extend this work across the Network.
Action Required:
NHS Ayrshire & Arran should review all cases not meeting the
QPI target and provide detailed clinical reasons to the MCN.
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QPI 4: Laparoscopic Surgery Laparoscopic surgery, by
appropriately trained surgeons, is recommended for patients with
endometrial cancer as it has been found to be feasible and
surgically safe with reduced post-operative complications and
length of stay1. The target for this QPI is set at 70% which
reflects the fact that some patients may not be clinically suitable
for laparoscopic surgery. Figure 6: Proportion of patients with
endometrial cancer undergoing definitive surgery who undergo
laparoscopic surgery.
Performance (%) Numerator Denominator Not recorded
numerator Not recorded
numerator (%) Not recorded exclusions
Not recorded exclusions (%)
Not recorded denominator
AA 85.0% 34 40 0 0.0% 0 0.0% 0
FV 92.9% 26 28 0 0.0% 0 0.0% 0
Lan 94.9% 37 39 0 0.0% 0 0.0% 0
NG 69.3% 61 88 0 0.0% 0 0.0% 0 SG 76.7% 23 30 0 0.0% 0 0.0%
0
Clyde 54.9% 28 51 0 0.0% 0 0.0% 0 WoS 75.7% 209 276 0 0.0% 0
0.0% 0 Laparoscopic hysterectomy results in a shorter hospital
stay, reduction in wound infections and other complications and
better overall patient experience. Laparoscopic surgery is a
developing area of clinical practice and variation in the use of
laparoscopic hysterectomy across the region reflects both training
and local resource availability. Figure 6 indicates that
laparoscopic surgery is available in all units and that that the
numbers of patients being operated on laparoscopically in the WoS
is increasing year on year from 57.4% in Year 1 to 75.7% in Year
4.
0
10
20
30
40
50
60
70
80
90
100
Ayrshire & Arran
Forth Valley Lanarkshire North Glasgow
South Glasgow
Clyde WoS
Pe
rfo
rman
ce (%
)
Location of Surgery
2014/15 2015/16 2016/17 2017/18
Title: Patients with endometrial cancer undergoing definitive
surgery should undergo laparoscopic surgery, where clinically
appropriate.
Numerator: Number of patients with endometrial cancer undergoing
definitive surgery who
undergo laparoscopic surgery. Denominator: All patients with
endometrial cancer undergoing definitive surgery. Exclusions: No
exclusions. Target: 70%
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Clyde achieved 54.9% against the 70% QPI target however did
demonstrate a significant improvement on Year 1 performance of
3.3%. NHSGGC commented that this represents a continued improvement
in this QPI and further improvement is anticipated. There were many
cases where a laparoscopic approach does not appear to have been
offered or considered on case review. There were also a number of
cases where a laparoscopic approach was not thought to be feasible.
In North Glasgow due to the tertiary referral of complex cases with
co-existing lymph node or ovarian disease then not met cases
generally fell into this group. During the timeframe of this QPI
changes were instituted that should lead to further improvements –
there has been work scheduling put in place to align clinical cases
with surgeons with laparoscopic skills meaning that more patients
will be offered minimal access surgery and more cases will be
deemed feasible. Future development of tertiary referral skills to
offer laparoscopic para-aortic node dissection is part of the
central team skill development plan.
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QPI 5: Adjuvant Radiotherapy For stage IB grade 1-2
brachytherapy has been shown to improve local control rates without
the toxicity associated with external beam radiotherapy. Other
types of radiotherapy such as adjuvant EBRT (External Beam
Radiation Therapy) is also recommended to decrease pelvic
recurrence in high-intermediate risk patients with LVSI
(lymphovascular space invasion) positive tumours where no surgical
nodal staging has been performed1. Figure 7: Proportion of patients
with stage IB, grade 1 or 2, or stage IA, grade 3 endometrioid or
mucinous endometrial cancer having adjuvant radiotherapy.
Performance (%) Numerator Denominator Not recorded
numerator Not recorded
numerator (%) Not recorded exclusions
Not recorded exclusions (%)
Not recorded denominator
AA 92.3% 12 13 0 0.0% 0 0.0% 0
FV 100% 6 6 0 0.0% 0 0.0% 0
Lan 83.3% 5 6 0 0.0% 0 0.0% 3
NG 100% 8 8 0 0.0% 0 0.0% 0 SG 88.9% 8 9 0 0.0% 0 0.0% 0
Clyde 91.7% 11 12 0 0.0% 0 0.0% 0 WoS 92.6% 50 54 0 0.0% 0 0.0%
3 - Data not shown due to small numbers
0
10
20
30
40
50
60
70
80
90
100
Ayrshire & Arran
Forth Valley Lanarkshire North Glasgow
South Glasgow
Clyde WoS
Pe
rfo
rman
ce (%
)
Location of Diagnosis
2014/15 2015/16 2016/17 2017/18
Title: Patients with stage IB, grade 1 or 2, or stage IA, grade
3 endometrioid or mucinous endometrial cancer should be considered
for adjuvant radiotherapy.
Numerator: All patients with stage IB, grade 1 or 2, or stage
IA, grade 3 endometrioid or mucinous
endometrial cancer receiving adjuvant radiotherapy. Denominator:
All patients with stage IB, grade 1 or 2, or stage IA, grade 3
endometrioid or mucinous
endometrial cancer. Exclusions: Patients who decline
brachytherapy or radiotherapy. Target: 90%
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Following formal review it was agreed that due to a change in
practice for patients with intermediate risk endometrial cancer
with some patients now getting EBRT (external beam radiation
therapy) rather than vaginal brachytherapy. Therefore, the QPI was
updated to include all forms of radiotherapy. It should be noted
that numbers of patients are low and therefore comparisons between
units should be made with caution. Overall, 50 of the 54 patients
with stage IB, grade 1 or 2, or stage IA, grade 3 endometrioid or
mucinous endometrial cancer received adjuvant radiotherapy,
resulting in a performance of 92.6% against the 90% QPI target. NHS
Lanarkshire and South Glasgow did not meet the QPI target, however
this equated to only one or two cases in each Board. QPI 6:
Systemic Anti-Cancer Treatment/Hormone Therapy Hormonal therapy and
chemotherapy play an important role in the management of advanced
endometrial cancer. Platinum chemotherapy can improve progression
free survival in patients with stage IV endometrial cancer. The use
of chemotherapy should be considered for patients with stage IV
disease or those with stage III disease plus residual disease at
the completion of surgery. Hormonal therapy is indicated for
patients with advanced endometrial cancer and endometriod
histology1. Figure 8: Proportion of patients with stage IV
endometrial cancer receiving SACT or hormone therapy.
Performance
(%) Numerator Denominator Not recorded
numerator Not recorded
numerator (%) Not recorded exclusions
Not recorded exclusions (%)
Not recorded denominator
2014/15 57.7% 15 26 0 0.0% 0 0.0% 0
2015/16 63.3% 16 23 0 0.0% 0 0.0% 0 2016/17 38.9% 7 18 0 0.0% 0
0.0% 5
2017/18 55.6% 10 18 0 0.0% 0 0.0% 14
0
10
20
30
40
50
60
70
80
90
100
2014/15 2015/16 2016/17 2017/18
Pe
rfo
rman
ce (%
)
WoS
Title: Patients with stage IV endometrial cancer should have
SACT or Hormone Therapy. Numerator: All patients with stage IV
endometrial cancer receiving SACT or Hormone Therapy. Denominator:
All patients with stage IV endometrial cancer. Exclusions: Patients
who refuse any SACT or hormone therapy. Target: 75%
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At formal review it was raised that this QPI focuses on a small
number of potentially very sick women with advanced disease. It was
agreed to change the wording of the QPI from chemotherapy to
Systemic Anti-Cancer Therapy (SACT). This will then account for
patients who receive hormone therapy. Due to the small numbers
meeting the denominator criteria in each year of analysis
individual unit results cannot be presented therefore Figure 8
shows overall WoS results. Of the 18 patients with stage IV
endometrial cancer, 10 patients are recorded as having received
SACT or hormone therapy resulting in a WoS performance of 55.6%
against the 75% QPI target. NHSGGC reviewed all cases not meeting
the QPI target and commented that a small number of cases were
affected by this QPI and a small number of cases not met will have
a disproportionate effect on the result. Action required:
NHS GGC has been asked to review the six cases not meeting the
target and provide detailed clinical reasons for those advanced
stage endometrial cancer patients not receiving SACT.
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4.3. Cervical Cancer – Quality Performance Indicators
Introduction Quality Performance Indicators (QPIs) were implemented
for patients diagnosed with cervical cancer on or after 1st October
2014 and Cervical Cancer QPIs1 are reported here for the fourth
consecutive year. There were 148 new diagnoses of cervical cancer
captured by audit in the WoS in Year 4. Distribution by location of
diagnosis is shown below in Figure 9. Figure 9: Number and
proportion of patients diagnosed with cervical cancer by location
of diagnosis.
AA FV Lan GGC WoS
Year 1_2014/15 23 24 57 83 187
Year 2_2015/16 20 23 33 69 145
Year 3_2016/17 14 25 40 69 148
Year 4_2017/18 29 24 34 68 155
Figure 10 illustrates the age distribution of patients diagnosed
with cervical cancer in the WoS for patients in Year 4. The median
age was 43 years.
0
10
20
30
40
50
60
70
80
90
Ayrshire & Arran Forth Valley Lanarkshire GGC
Nu
mb
er
of
Cas
es
Location of Diagnosis
2014/15 2015/16 2016/17 2017/18
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Figure 10: Age of patients diagnosed with cervical cancer.
Cervical FIGO Stage Distribution The distribution of cervical
cancer by FIGO stage is presented in Figure 11, which illustrates
that 75.6% of patients presented with early stage (I, II) disease
and 10.3% of patients presented with advanced stage disease
(III,IV). Figure 11: Distribution of cervical cancer by FIGO
stage.
FIGO Stage IA IB IIA IIB IIIA IIIB IVA IVB NR NA
n 32 41 2 43 2 4 7 3 6 16
Figure 11 also highlights that for 10.3% of patients FIGO stage
was recorded as either not applicable or not recorded. FIGO stage
should be recorded for all patients, as mentioned previously the
availability of staging data is critical for survival analysis and
for accurate measurement of OPIs.
0
5
10
15
20
25
30
25-29 30-34 35-39 40-44 45-49 50-54 55-60 60-64 65-69 70-74
75-79 80-84 85+
2017/18 9 26 19 21 20 13 11 10 8 6 8 4 1
Nu
mb
er
of C
ases
IA, 20.5%
IB, 26.3%
IIA, 1.3%
IIB, 27.6%
IIIA, 1.3%
IIIB, 2.6%
IVA, 4.5%
IVB, 1.9%
NA, 10.3%NR, 3.8%
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QPI 1: Radiological Staging It is necessary to fully image the
pelvis prior to definitive treatment in order to establish the
extent of disease and minimise unnecessary or inappropriate
treatment1. Figure 12: Proportion of patients with cervical cancer
who have an MRI of the pelvis performed prior to first
treatment.
Performance (%) Numerator Denominator Not recorded
numerator Not recorded
numerator (%) Not recorded exclusions
Not recorded exclusions (%)
Not recorded denominator
AA 96.3% 26 27 0 0.0% 0 0.0% 0
FV 87.5% 14 16 0 0.0% 0 0.0% 0
Lan 90.9% 30 33 0 0.0% 0 0.0% 0
NG 96.4% 27 28 0 0.0% 0 0.0% 0 SG 100% 7 7 0 0.0% 0 0.0% 0
Clyde 85.7% 12 14 0 0.0% 0 0.0% 0 WoS 92.8% 116 125 0 0.0% 0
0.0% 0 Following discussion at formal review it was agreed that
patients treated by LLETZ only would no longer be excluded from QPI
1.
0
10
20
30
40
50
60
70
80
90
100
Ayrshire & Arran
Forth Valley Lanarkshire North Glasgow South Glasgow Clyde
WoS
Pe
rfo
rman
ce (%
)
Location of Diagnosis
2014/15 2015/16 2016/17 2017/18
Title: Patients with cervical cancer should have their stage of
disease assessed by MRI prior to definitive treatment.
Numerator: All patients with cervical cancer having MRI of the
pelvis carried out prior to definitive
treatment. Denominator: All patients with cervical cancer.
Exclusions: Patients with histopathological FIGO stage 1A1 disease.
Patients unable to undergo MRI due to contraindications. Patients
with histopathological FIGO stage IVB disease. Patients who refuse
MRI investigation. Target: 95%
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The 95% target for QPI 1 was not achieved for patients diagnosed
with cervical cancer in WoS in Year 5. Of the 125 patients, 116 had
a MRI of the pelvis performed prior to first treatment. WoS
performance decreased from 97.8% in Year 3 to 92.8% in Year 4; a
decrease of 5 percentage points. NHS Forth Valley commented that
both patients which breach the QPI have been clinically reviewed.
One patient had stage 4 disease demonstrated on CT and MRI was not
felt to be required. The second patient was reviewed and discussed
at MDT and MRI was also not deemed to be required. NHS Lanarkshire
achieved 90.9% against the 95% QPI target. All cases not meeting
the QPI were reviewed and feedback reasons provided included; MDT
recommended a PET CT scan rather than MRI, one case was initially
thought to be endometrial cancer and the final case was initially
staged as 1A. NHSGGC commented that the Clyde cases not meeting
were a mix of genuine not met cases and incidental clinical
findings. Staff have been reminded of the network imaging
guidelines in cancer diagnoses.
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QPI 2: Positron Emission Tomography/Computed Tomography (PET/CT)
Patients not suitable for surgery and being considered for radical
radiotherapy (+/- concurrent chemotherapy) are recommended to
undergo PET/CT because of the significant risk of extra pelvic
disease which if detected will change patient management1. Figure
13: Proportion of patients with cervical cancer, for whom primary
definitive treatment is radical radiotherapy, who have PET/CT
imaging.
Performance (%) Numerator Denominator Not recorded
numerator Not recorded
numerator (%) Not recorded exclusions
Not recorded exclusions (%)
Not recorded denominator
AA 100% 17 17 0 0.0% 0 0.0% 0
FV 100% 9 9 0 0.0% 0 0.0% 0
Lan 100% 21 21 0 0.0% 0 0.0% 0
NG 100% 12 12 0 0.0% 0 0.0% 0 SG - - - 0 0.0% 0 0.0% 0
Clyde 80.0% 4 5 0 0.0% 0 0.0% 0 WoS 98.5% 67 68 0 0.0% 0 0.0% 0
- Data not shown due to small numbers
Following discussion at formal review it was agreed that
patients who declined PET/CT should be excluded. Due to a new data
item required to exclude these patients the revised data can’t be
reported until Year 5.
0
10
20
30
40
50
60
70
80
90
100
Ayrshire & Arran
Forth Valley Lanarkshire North Glasgow South Glasgow Clyde
WoS
Pe
rfo
rman
ce (%
)
Location of Diagnosis
2014/15 2015/16 2016/17 2017/18
Title: Patients with cervical cancer for whom primary definitive
surgery is not appropriate, should undergo PET/CT.
Numerator: All patients with cervical cancer undergoing primary
radical radiotherapy who have
PET/CT imaging prior to starting treatment. Denominator: All
patients with cervical cancer undergoing primary radical
radiotherapy. Exclusions: No exclusions. Target: 95%
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West of Scotland Cancer Network Final Published Endometrial
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Across WoS, 98.5% of patients diagnosed with cervical cancer who
received primary radical radiotherapy had PET/CT imaging prior to
starting treatment. This exceeds the 95% QPI target by 5.7
percentage points and shows a slightly improved performance from
2013 to 2014. Five of the six units met the 95% QPI target however
it should be noted that numbers are low and this can have a greater
effect on proportions. Comparison across years should also be made
with caution. Figures for South Glasgow have been restricted due to
having a denominator of less than 5. QPI 3: Multidisciplinary Team
Meeting (MDT) Evidence suggests that patients with cancer managed
by a multi-disciplinary team have a better outcome. There is also
evidence that the multidisciplinary management of patients
increases their overall satisfaction with their care1. Figure 14:
Proportion of patients with cervical cancer who are discussed at a
MDT meeting before definitive treatment.
Performance (%) Numerator Denominator Not recorded
numerator Not recorded
numerator (%) Not recorded exclusions
Not recorded exclusions (%)
Not recorded denominator
AA 100% 27 27 0 0.0% 2 7.4% 0
FV 100% 16 16 0 0.0% 0 0.0% 0
Lan 100% 31 31 0 0.0% 2 6.5% 0
NG 100% 30 30 0 0.0% 0 0.0% 0 SG 100% 6 6 0 0.0% 0 0.0% 0
Clyde 92.9% 13 14 0 0.0% 0 0.0% 0 WoS 99.2% 123 124 0 0.0% 4
3.2% 0
0
10
20
30
40
50
60
70
80
90
100
Ayrshire &
Arran
Forth Valley Lanarkshire North Glasgow South Glasgow Clyde
WoS
Pe
rfo
rman
ce (%
)
Location of Diagnosis
2014/15 2015/16 2016/17 2017/18
Title: Patients with cervical cancer should be discussed by a
MDT prior to definitive treatment.
Numerator: All patients with cervical cancer discussed at the
MDT before definitive treatment. Denominator: All patients with
cervical cancer. Exclusions: Patients with histopathological FIGO
stage 1A1 disease. Patients who died before treatment. Target:
95%
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Of the 124 patients diagnosed with cervical cancer, 123 were
discussed ay MDT prior to definitive treatment, resulting in a WoS
performance of 99.2% against the 95% QPI target. Clyde did not meet
the target with performance of 92.9%, however it should be noted
that, due to small numbers, this represents one case which was an
incidental finding. QPI 4: Radical Hysterectomy Radical surgery is
recommended for FIGO stage IB1 disease if there are no
contraindications to surgery. Patients with tumours
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units achieved the target with performance ranging from 60% in
Clyde to 100% in NHS Forth Valley and NHS Lanarkshire. However,
caution should be given to percentage comparisons across different
units as this may represent a very small number of cases. NHSGGC
reviewed all cases not meeting the QPI target and commented that
larger tumours within the 1b1 category are not offered a radical
hysterectomy to avoid multimodality therapy and this was the case
for North Glasgow. The Clyde cases were incidental findings and
appropriately managed. QPI 5: Surgical Margins The quality of
radical surgery for cervical cancer has an important influence on
local control of the tumour and ultimately survival. Therefore, it
is important to optimise and ensure the quality of surgical care
for cervical cancer patients1. QPI 5 is analysed by location of
surgery rather than location of diagnosis. Figure 16: Proportion of
patients with cervical cancer who have surgical margins clear of
tumour following hysterectomy.
Performance
(%) Numerator Denominator Not recorded
numerator Not recorded
numerator (%) Not recorded exclusions
Not recorded exclusions (%)
Not recorded denominator
2014/15 94.2% 49 52 1 1.9% 0 0.0% 0
2015/16 97.5% 39 40 1 2.5% 0 0.0% 0
2016/17 97.6% 40 41 0 0.0% 0 0.0% 0
2017/18 94.3% 50 53 0 0.0% 0 0.0% 0
0
10
20
30
40
50
60
70
80
90
100
2014/15 2015/16 2016/17 2017/18
Pe
rfo
rman
ce (%
)
WoS
Title: Patients with surgically treated cervical cancer should
have clear resection Numerator: All patients with cervical cancer
who undergo surgery where surgical margins are clear
of tumour. Denominator: All patients with cervical cancer who
undergo surgery. Exclusions: Patients who decline surgery. Patients
who undergo fertility conserving treatment.
Patients enrolled into surgical trials.
Target: 95%
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31
Due to the majority of operations taking place in the centre
(North Glasgow) the numbers for other individual units are low
therefore Figure 16 shows WoS yearly results. Overall in the WoS in
Year 4, 94.3% of patients with cervical cancer had surgical margins
clear of tumour following hysterectomy, which is marginally below
the 95% QPI target. NHSGGC commented that the cases not meeting the
target were reviewed and were incidental findings and appropriately
managed pre-operatively. QPI 6: 56 Day Treatment for Radical
Radiotherapy Overall treatment time for locally advanced cervical
cancer should be as short as possible. Radiotherapy for squamous
carcinoma should be completed within 56 days1. Figure 17:
Proportion of patients with cervical cancer undergoing radical
radiotherapy whose overall treatment time, from the start to the
end of treatment, is not more than 56 days.
0
10
20
30
40
50
60
70
80
90
100
Ayrshire &
Arran
Forth Valley Lanarkshire North Glasgow South Glasgow Clyde
WoS
Pe
rfo
rman
ce (%
)
Location of Diagnosis
Title: Treatment time for patients with cervical cancer
undergoing radical radiotherapy should be no more than 56 days.
Numerator: All patients with cervical cancer undergoing radical
radiotherapy (external beam or
brachytherapy) whose overall treatment time, from start to the
end of treatment, is not more than 56 days.
Denominator: All patients with cervical cancer undergoing
radical radiotherapy (external beam or
brachytherapy). Exclusions: No exclusions. Target: 90% 05%
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West of Scotland Cancer Network Final Published Endometrial
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Performance (%) Numerator Denominator Not recorded
numerator Not recorded
numerator (%) Not recorded exclusions
Not recorded exclusions (%)
Not recorded denominator
AA 94.7% 18 19 0 0.0% 0 0.0% 0
FV 100% 9 9 0 0.0% 0 0.0% 0
Lan 100% 23 23 0 0.0% 0 0.0% 0
NG 100% 14 14 0 0.0% 0 0.0% 0 SG - - - 0 0.0% 0 0.0% 0
Clyde 88.9% 8 9 0 0.0% 0 0.0% 0 WoS 97.4% 76 78 0 0.0% 0 0.0% 0
- Data not shown due to small numbers
Five of the six units exceeded the 90% target set for QPI 7
resulting in an overall WoS performance of 97.4% in Year 4. Clyde
were just below target with 88.9%, however this represented one
case that had an overall treatment time of 58 days. QPI 7:
Chemoradiation Any patient with cervical cancer considered suitable
for radical radiotherapy treatment should have concurrent
chemoradiotherapy with a platinum based chemotherapy, if fit for
treatment1. Figure 18: Proportion of patients with cervical cancer
undergoing radical radiotherapy who receive concurrent
chemotherapy.
0
10
20
30
40
50
60
70
80
90
100
Ayrshire &
Arran
Forth Valley Lanarkshire North Glasgow South Glasgow Clyde
WoS
Perf
orm
ance
(%)
Location of Diagnosis
Title: Patients with cervical cancer undergoing radical
radiotherapy should receive concurrent platinum-based
chemotherapy.
Numerator: All patients with cervical cancer undergoing radical
radiotherapy who receive
concurrent chemotherapy. Denominator: All patients with cervical
cancer who undergo radical radiotherapy. Exclusions: No exclusions.
Target: 70%
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West of Scotland Cancer Network Final Published Endometrial
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Performance (%) Numerator Denominator Not recorded
numerator Not recorded
numerator (%) Not recorded exclusions
Not recorded exclusions (%)
Not recorded denominator
AA 84.2% 16 19 0 0.0% 0 0.0% 0
FV 100% 9 9 0 0.0% 0 0.0% 0
Lan 87.0% 20 23 0 0.0% 0 0.0% 0
NG 100% 14 14 0 0.0% 0 0.0% 0 SG - - - 0 0.0% 0 0.0% 0
Clyde 88.9% 8 9 0 0.0% 0 0.0% 0 WoS 89.7% 70 78 0 0.0% 0 0.0%
0
Performance across the WoS was 89.7% against the 70% target with
70 of 78 patients diagnosed with cervical cancer undergoing radical
radiotherapy receiving concurrent chemotherapy. All units met the
target with performance ranging from 75% in South Glasgow to 100%
in NHS Forth Valley and North Glasgow. Data is restricted for South
Glasgow due to small numbers. Clinical Trial Access Clinical trials
are necessary to demonstrate the efficacy of new therapies and
other interventions. Furthermore, evidence suggests improved
patient outcomes when hospitals are actively recruiting patients
into clinical trials1. Data definitions and measurability criteria
to accompany the Clinical Trial QPI are available from the HIS
website1. The clinical trials QPI is measured utilising Scottish
Cancer Research Network (SCRN) data and ISD incidence data, as is
the methodology currently utilised by the Chief Scientist Office
(CSO) and National Cancer Research Institute (NCRI). Utilising SCRN
data allows for comparison with CSO published data and ensures
capture of all clinical trials recruitment, not solely first line
treatment trials, as contained in the clinical audit data. Given
that a significant proportion of clinical trials are for relapsed
disease this is felt to be particularly important in driving
quality improvement. This methodology utilises incidence as a proxy
for all patients with cancer. This may slightly over, or
underestimate, performance levels, however this is an established
approach currently utilised by NHS Scotland1.
Following formal review the Clinical Trials Access QPI was
updated to measure the number of patients consented for
participation in a clinical trial rather than only those who are
enrolled. There are a number of patients who undergo screening but
do not proceed to enrolment for various reasons, e.g. they do not
have the mutation required for entry on to the trial.
QPI Title: All patients should be considered for participation
in available clinical trials/research studies wherever
eligible.
Numerator: Number of patients diagnosed with gynaecological
cancer consented for a clinical
trial/research study. Denominator: All patients with diagnosed
with a gynaecological cancer.. Exclusions: No exclusions. Target:
15%
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West of Scotland Cancer Network Final Published Endometrial
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Figure 19: Proportion of patients diagnosed with endometrial or
cervical who are consented* for a clinical trial / research study
in 2018.
Consented - QPI Target 15% Recruited
NHS Board of Residence N D % N D %
Ayrshire & Arran 4 86 4.7% 1 86 1.2%
Forth Valley 0 63 0.0% 0 63 0.0%
GGC 4 263 1.5% 4 263 1.5%
Lanarkshire 9 113 8.0% 3 113 2.7%
WoS 17 525 3.2% 8 525 1.5%
Overall for patients in WoS diagnosed with cervical or
endometrial cancer, 17 patients consented for a clinical
trial/research study resulting in a WoS performance of 3.2% against
the 15% target. The target was not met by any of the NHS Boards.
Comments received from clinicians stated that currently there is
only one open trial for cervical cancer which has been hard to
recruit to due to 2 factors; 1) Risk of hair loss and 2) Potential
of treatment time being almost doubled (chemoradiotherapy only is 7
weeks whereas neo-adjuvant chemotherapy plus chemoradiotherapy
would be 13 weeks). There was one endometrial trial which was very
restrictive because of the requirement for fresh biopsies,
recruitment was therefore poor.
0
2
4
6
8
10
12
14
16
18
20
A&A FV Lan GGC WoS
Pro
po
rtio
n o
f p
ati
en
ts (
%)
Analysis Group
Consented Entered
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35
Table 3: List of clinical trials and the number of patients with
endometrial, cervical or ovarian cancer consented/entered into each
clinical trial in 2018. (N.B. All recruits noted below were
resident within WoS).
Short Title Consented Entered
A Phase I trial of CCT245737
in patients with advanced
cancer 2 2
AZD1775 Continued Access 1 1
CANC - 4443 - Nivolumab in
Viral-positive Solid Tumors 1 1
First in Human,
DoseEscalating Study of
HuMaX®-TF-ADC in solid
Tumour 1 0
HORIZONS 7 2
INTERLACE 2 2
PROCLAIM CX-2009 in adults
with metastatic/advanced
solid tumours 1 0
SYD985.001 2 0Total 17 8
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5. Conclusions
Cancer audit has underpinned much of the regional development
and service improvement work of the MCN and the regular reporting
of activity and performance have been fundamental in assuring the
quality of care delivered across the region. Following the
development of QPIs, this has now become an established national
programme to drive continuous improvement and ensure equity of care
for patients across Scotland. During 2018, QPI definitions have
been reviewed nationally to provide an improved set of indicators,
some of which are reported in here.
Overall, results from the fourth year of Endometrial and
Cervical Cancer QPI reporting are encouraging; case ascertainment
and data capture is of a high standard overall and notable
improvements in performance have been demonstrated for a number of
QPIs. With regards to endometrial cancer, five of the seven QPI
target were achieved. QPIs 1 and 3 were consistently met at
regional level for four consecutive years and significant year on
year improvement was noted in relation to QPI 4 (laproscopic
surgery) with the 70% QPI target being achieved in Year 4 across
the WoS. A change in measurement at formal review of QPI 2 (MDT
Discussion) where patients with Grade I endometrioid or mucinous
carcinoma were no longer excluded saw performance decrease across
the majority of boards however all cases not achieving the target
were managed according to network guidelines. Discussions will be
initiated around the appropriateness of including these cases
within the QPI measurement and the current MCN guideline will be
reviewed to establish if any changes are required. In relation to
cervical cancer, overall WoS results demonstrate that the target
was met for 4 of the 7 reported QPIs for patients diagnosed in Year
4. Consistent performance over four years was noted for QPI 3
(discussion at MDT), QPI 6 (56 day treatment for radical
radiotherapy) and for QPI 7 (patients undergoing radical
radiotherapy who receive concurrent chemotherapy). Results for QPI
2 PET/CT imaging prior to starting radical radiotherapy have also
shown improvement over the four year period. Where QPI targets were
not met, NHS Boards have provided detailed comment. In the main
these indicate valid clinical reasons or that, in some cases,
patient choice or co-morbidities have influenced patient
management. Additionally, NHS Boards have indicated where positive
action has already been taken at a local level to address any
issues highlighted through the QPI data analysis. It is anticipated
that these positive changes will result in improved performance
going forward. NHS Boards are encouraged to continue with this
proactive approach of reviewing data and addressing issues as
necessary, in order to work towards increasingly advanced
performance against targets, and demonstration of overall
improvement in quality of the care and service provided to
patients. Action required: Endometrial Cancer QPI 2: MDT Discussion
Prior to Definitive Treatment
The MCN will initiate discussions around the appropriateness of
including Grade I endometrioid or mucinous carcinoma patients
within the QPI measurement and will review the current MCN
guideline to establish if any changes are required.
QPI 3: Total Hysterectomy and Bilateral
Salpingo-Oophorectomy
NHS Ayrshire & Arran should review all cases not meeting the
QPI target and provide detailed clinical reasons to the MCN.
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QPI 6: SACT/Hormone Therapy
NHSGGC should review the cases not meeting the target and
provide detailed clinical reasons for those advanced stage
endometrial cancer patients not receiving SACT.
The MCN will actively take forward regional actions identified
and NHS Boards are asked to develop local Action/Improvement Plans
in response to the findings presented in the report. A summary of
actions for each NHS Board has been included within the Action Plan
templates in the Appendix. Completed Action Plans should be
returned to WoSCAN within two months of publication of this report.
Progress against these plans will be monitored by the MCN Advisory
Board and any service or clinical issue which the Advisory Board
considers not to have been adequately addressed will be escalated
to the NHS Board Territorial Lead Cancer Clinician and Regional
Lead Cancer Clinician. Additionally, progress will be reported
annually to the Regional Cancer Advisory Group (RCAG), by NHS Board
Territorial Lead Cancer Clinicians and MCN Clinical Leads, and
nationally on a three-yearly basis to Healthcare Improvement
Scotland as part of the governance processes set out in CEL 06
(2012).
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Acknowledgement
This report has been prepared using clinical audit data provided
by the following NHS Boards in the WoSCAN area: NHS Ayrshire &
Arran NHS Forth Valley NHS Greater Glasgow and Clyde NHS
Lanarkshire
We would like to thank all members and active participants in
the cancer network for their continued support of the MCN, and the
many hospitals that are committed to making the audit succeed. We
also acknowledge the efforts of the clinical effectiveness staff,
nurses, and other service users for their work in ensuring the data
are available to enable analysis to take place each year. Without
their considerable efforts this level of progress would not be
possible.
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Abbreviations
BWoSCC Beatson West of Scotland Cancer Centre
BSO Bilateral Salpingo-Oophorectomy
CT Computed Tomography
eCASE Electronic Cancer Audit Support Environment
FIGO Federation of Gynaecological Oncologists
GRI Glasgow Royal Infirmary
HIS Healthcare Improvement Scotland
ISD Information Services Division
MCN Managed Clinical Network
MDT Multidisciplinary Team
MRI Magnetic resonance imaging
NCQSG National Cancer Quality Steering Group
NHSGGC NHS Greater Glasgow and Clyde
PET Positron Emission Tomography
QPI Quality Performance Indicator
RCAG Regional Cancer Advisory Group
RMI Risk of Malignancy Index
TAH Total Abdominal Hysterectomy
WoS West of Scotland
WoSCAN West of Scotland Cancer Network
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References
1. Healthcare Improvement Scotland. Cancer Quality Performance
Indicators, [Accessed on: 22nd September 2018] Available at:
http://www.healthcareimprovementscotland.org/our_work/cancer_care_improvement/cancer_qpis/quality_performance_indicators.aspx
2. Information Services Division. Head and Neck Cancer: Data
Definitions, Measurability and Data Validations Accessed on: 22nd
September 2018]. Available at:
http://www.isdscotland.org/Health-Topics/Cancer/Cancer-Audit/
3. Information Services Division. Cancer in Scotland, June 2004
(updated April 2018) [Accessed
on: 22nd September 2018]. Available at:
http://www.isdscotland.org/Health-Topics/Cancer/Cancer-Statistics/
4. Information Services Division, Cancer Statistics, Summary
statistics for female genital organ
cancers. [Accessed on: 22nd September 2018]. Available at:
http://www.isdscotland.org/Health-Topics/Cancer/Cancer-Statistics/Female-Genital-Organ/
5. ScotPHO, Public Health Information for Scotland. Population:
estimates by NHS Board
[Accessed on: Accessed on: 22nd September 2018]] Available at:
http://www.scotpho.org.uk/population-dynamics/population-estimates-and-projections/data/nhs-board-population-estimates
http://www.healthcareimprovementscotland.org/our_work/cancer_care_improvement/cancer_qpis/quality_performance_indicators.aspxhttp://www.healthcareimprovementscotland.org/our_work/cancer_care_improvement/cancer_qpis/quality_performance_indicators.aspxhttp://www.isdscotland.org/Health-Topics/Cancer/Cancer-Audit/http://www.isdscotland.org/Health-Topics/Cancer/Cancer-Statistics/http://www.isdscotland.org/Health-Topics/Cancer/Cancer-Statistics/Female-Genital-Organ/http://www.isdscotland.org/Health-Topics/Cancer/Cancer-Statistics/Female-Genital-Organ/http://www.scotpho.org.uk/population-dynamics/population-estimates-and-projections/data/nhs-board-population-estimateshttp://www.scotpho.org.uk/population-dynamics/population-estimates-and-projections/data/nhs-board-population-estimates
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West of Scotland Cancer Network Final Published Endometrial
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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.
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Any other use of copyright material belonging to the West of
Scotland Cancer Network requires the formal permission
of the Network.
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West of Scotland Cancer Network Final Published Endometrial
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Appendix 1: Action / Improvement Plans
WoSCAN Action / Improvement Plan – Ovarian Cancer
No Action Required NHS Board Action Taken Timescales Lead Status
(see key)
Start End
Ensure actions mirror those detailed in Audit Report.
Provide detailed outcome of clinical review, details of specific
improvement action taken, or reasons why no action taken.
Insert date
Insert date
Insert name of responsible lead for each action.
Insert No. from key above
1. QPI 2: MDT Discussion Prior to Definitive Treatment
(Endometrial Cancer)
The MCN will initiate discussions around the appropriateness of
including Grade I endometrioid or mucinous carcinoma patients
within the QPI measurement and will review the current MCN
guideline to establish if any changes are required.
NHS Board: WoSCAN KEY (Status)
Action Plan Lead: 1 Action fully implemented
Date: 2 Action agreed but not yet implemented
3 No action taken (please state reason)
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NHS Ayrshire & Arran Action / Improvement Plan – Ovarian
Cancer
No Action Required NHS Board Action Taken Timescales Lead Status
(see key)
Start End
Ensure actions mirror those detailed in Audit Report.
Provide detailed outcome of clinical review, details of specific
improvement action taken, or reasons why no action taken.
Insert date
Insert date
Insert name of responsible lead for each action.
Insert No. from key above
1. QPI 3: Total Hysterectomy and Bilateral Salpingo-Oophorectomy
(Endometrial Cancer)
NHS Ayrshire & Arran should review all cases not meeting the
QPI target and provide detailed clinical reasons to the MCN.
NHS Board: NHS Ayrshire & Arran KEY (Status)
Action Plan Lead: 1 Action fully implemented
Date: 2 Action agreed but not yet implemented
3 No action taken (please state reason)
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NHS Greater Glasgow and Clyde Action / Improvement Plan –
Ovarian Cancer
No Action Required NHS Board Action Taken Timescales Lead Status
(see key)
Start End
Ensure actions mirror those detailed in Audit Report.
Provide detailed outcome of clinical review, details of specific
improvement action taken, or reasons why no action taken.
Insert date
Insert date
Insert name of responsible lead for each action.
Insert No. from key above
1. QPI 6: SACT/Hormone Therapy (Endometrial Cancer)
NHSGGC should review the cases not meeting the target and
provide detailed clinical reasons for those advanced stage
endometrial cancer patients not receiving SACT.
NHS Board: NHSGGC KEY (Status)
Action Plan Lead: 1 Action fully implemented
Date: 2 Action agreed but not yet implemented
3 No action taken (please state reason)