Management of Vulval Cancer Services in South West England

Jenny WeeksJ Verne L Hirschowitz, V Udaysanker, AD Falconer on behalf

SWCIS Gynaecology Tumour Panel

September 2004

2

4 Cancer Networks

Peninsula

3 Counties

ASWCS

Dorset

SWIS Gynaecology Tumour Panel

Multidisciplinary membership

3

Background

• Calman Hine Report 1995• Improving Outcomes Guidance

Gynaecological Cancer 1999• SWCIS Regional Standards & Guidelines

(Royal College Pathologists/ Obstetricians & Gynaecologists)

-> improvement in care and outcomes ?

4

Aim of the Audit

• Monitor treatment against standards

• Have outcomes improved?

UKCCR 2004

5

Standards

• Managed by gynaecologist with special interest in oncology (Regional/IOG)

• Minimum dataset recorded (IOG) eg• Histological Type• Grade• ASA

• Groin nodes taken if Stage >IA (Regional)• Skin - clear margins from tumour ≥ 8mm

(Regional)

6

Method

• All new diagnoses squamous carcinoma of vulva (1997 to 2002)

• Data collected by gynaecology specialist nurses, gynaecologists, oncologists & audit departments

• Supplementary data from SWCIS information systems

7

Results

• 1997 – 2002: 435 cases squamous cell carcinoma (18 verrucous subtype)

• Surgery 80% radiotherapy 9%

• Stage I 33%

Stage II 28%

Stage III 16%

Stage IV 6%

not stated 16%0%

5%

10%

15%

20%

25%

30%

35%

I II III IV not stated

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Age & Stage at diagnosis

0

20

40

60

80

100

120

140

160

20s 30s 40s 50s 60s 70s 80s 90s

Decade

pat

ien

t

Stage I

Stage II

Stage III

Stage IV

not stated

9

% Surgery by ‘gynaecologist with oncology interests’

0%

20%

40%

60%

80%

100%

1997 1998 1999 2000 2001 2002

op

era

tio

ns

10

% Recorded (Min Data Set)

• Cohort ASA Stage Grade

97 - 98 90% 87% 91%

99 – 00 77% 80% 88%

01 - 02 78% 83% 92%

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Width Tumour-free margins

Ops/Cons

0%

10%

20%

30%

40%

50%

60%

97- 98 99 - 00 01 - 02

op

erat

ion

s

≥8mm

≤8mm

not stated

12

% operations ≥ 8mm margin by Consultant ‘activity level’

0%

10%

20%

30%

40%

50%

60%

70%

97- 98 99 - 00 01 - 02

< 5

5 to 9

≥ 10

Ops/Cons

13

Nodes Taken (≥ Stage IB)

Ops/Cons

0%

10%

20%

30%

40%

50%

60%

70%

97- 98 99 - 00 01 - 02

pati

en

ts yes

no

nk

Nodes taken

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1997 to 2000Kaplan-Meier survival estimates, by age category

Ops/Cons

0.00

0.25

0.50

0.75

1.00

0 1 2 3Years since treatment

<70years >70 and <80years>80 years

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1997 to 2000 Survivor functions, by stage adjusted for age

Ops/Cons

0.00

0.25

0.50

0.75

1.00

0 1 2 3Years since treatment

Stage I Stage IIStage III Stage IVnot stated

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1997 to 2000 Survivor functions, by Treatment Year

adjusted for age

•

0.0

00

.25

0.5

00

.75

1.0

0

0 1 2 3Years since treatment

1997 19981999 2000

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Conclusion

• Centralisation of surgery has occurred

• Improvements in practice - not yet

• Improvements in outcome

– too soon to say?

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Thank you