MCN Audit Report - West of Scotland Cancer Network...West of Scotland Cancer Network Final Published Ovarian Cancer QPI Audit Report v1.0 01/11/2019 Conclusions and Action Required

The content of this report is © copyright WoSCAN unless otherwise stated.

Audit Report Ovarian Cancer Quality Performance Indicators

Clinical Audit Data:

01 October 2017 to 30 September 2018

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

West of Scotland Cancer Network Gynaecological Cancer Managed Clinical Network

West of Scotland Cancer Network Final Published Ovarian Cancer QPI Audit Report v1.0 01/11/2019

2

CONTENTS

EXECUTIVE SUMMARY 3

1. INTRODUCTION 9

2. BACKGROUND 9

2.1 NATIONAL CONTEXT 9

2.2 WEST OF SCOTLAND CONTEXT 10

2.4 FIGO STAGE 10

3. METHODOLOGY 12

4. RESULTS AND ACTION REQUIRED 12

4.1 DATA QUALITY 12

4.2 PERFORMANCE AGAINST QUALITY PERFORMANCE INDICATORS (QPIS) 13

ACKNOWLEDGEMENT 32

ABBREVIATIONS 33

REFERENCES 34

APPENDIX 1: ACTION / IMPROVEMENT PLANS 36


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Executive Summary

Introduction This report contains an assessment of the performance of West of Scotland (WoS) gynaecology services using clinical audit data relating to patients diagnosed with ovarian cancer in the twelve months between 1st October 2017 and 30th September 2018. Twelve months of data were measured against v3.0 of the Ovarian Cancer Quality Performance Indicators (QPIs) which were implemented for patients diagnosed on or after 01 October 2016. This was the fifth consecutive year of analysis following the initial Healthcare Improvement Scotland (HIS) publication of Ovarian Cancer QPIs in 2013. 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 Ovarian Cancer QPIs1 were published in May 2018 and, as stated above, are valid for patients diagnosed on or after 01 October 2016. Background The effective management of these patients relies on well co-ordinated delivery of treatment and care, requiring close collaboration of professionals from a range of specialties. 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 03 July 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 performance 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.


Ovarian Performance Summary Report

Ovarian Cancer Performance by Board

QPI Target WoS A&A FV LS NG SG Clyde

QPI 2 - Extent of disease assessed by Computed Tomography (CT) or Magnetic Resonance Imaging (MRI) prior to treatment. Proportion of patients with epithelial ovarian cancer having a CT scan or MRI of the abdomen and pelvis performed to exclude the presence of metastatic disease prior to starting treatment.

95% 99.5%

>

100%

=

100%

=

100%

>

100%

>

100%

=

97.1%

<

203 204 45 45 21 21 34 34 31 31 39 39 33 34

QPI 3 - Treatment planned and reviewed at a multi-disciplinary team meeting. Proportion of patients with epithelial ovarian cancer who are discussed at a MDT meeting before definitive treatment.

95% 95.3%

>

88.1%

<

100%

>

90.6%

>

100%

>

97.3%

=

100%

>

183 192 37 42 20 20 29 32 29 29 36 37 32 32

QPI 4 - Patients with early stage disease have an adequate staging operation. (HOSPITAL of SURGERY) Proportion of patients with early stage epithelial ovarian cancer (FIGO Stage 1) undergoing primary surgery for ovarian cancer, having their stage of disease adequately assessed, (TAH, BSO, Omentectomy and washings), to determine suitability for adjuvant therapies.

90% 90.9%

>

-

-

-

96.5%

>

-

66.7%

<

40 44 - - - - - - 28 29 - - 4 6

QPI 6 Histopathology reports are complete and support clinical decision making. (HOSPITAL of SURGERY) Proportion of patients with epithelial ovarian cancer undergoing pelvic clearance surgery having a complete pathology report as defined by the Royal College of Pathologists.

90% 93.0%

>

83.3%

<

-

-

92.9%

-

-

107 115 5 6 - - - - 91 98 - - - -

QPI 7 – Histological diagnosis prior to starting chemotherapy. Proportion of patients with epithelial ovarian cancer having a histological diagnosis obtained by percutaneous image-guided biopsy or laparoscopy prior to starting chemotherapy.

80% 87.2%

>

93.8%

<

88.9%

<

100%

>

90.0%

>

94.4%

<

60.0%

=

68 78 15 16 8 9 10 10 9 10 17 18 9 15

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


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QPI Target WoS A&A FV LS NG SG Clyde

QPI 9: First-line Chemotherapy Proportion of epithelial ovarian cancer patients who receive platinum-based chemotherapy, either in combination or as a single agent.

90% 75.1%

<

67.5%

<

63.2%

<

74.1%

<

80.8%

<

75.8%

<

89.3%

>

130 173 27 40 12 19 20 27 21 26 25 33 25 28

QPI 10(i) - Surgery for Advanced Disease. Proportion of patients with advanced epithelial ovarian cancer (FIGO Stage 2 or higher) undergoing surgery.

60% 62.6%

>

86.4%

<

42.1%

<

77.3%

>

66.7%

<

50.0%

=

59.1%

<

87 139 19 22 8 19 17 22 12 18 18 36 13 22

QPI 10(ii) - Surgery for Advanced Disease. (HOSPITAL of SURGERY) Proportion of patients with advanced epithelial ovarian cancer (FIGO Stage 2 or higher) undergoing surgery where no residual disease is achieved.

50% 76.5 %

>

-

n/a -

79.2%

>

-

n/a

62 81 - - 0 0 - - 61 77 - - 0 0

QPI 10(iii) - Surgery for Advanced Disease. (HOSPITAL of SURGERY) Proportion of patients with advanced epithelial ovarian cancer (FIGO Stage 2 or higher) undergoing delayed primary surgery after chemotherapy where no residual disease is achieved.

50% 70.6%

>

n/a n/a n/a 70.6%

>

n/a n/a

24 34 0 0 0 0 0 0 24 34 0 0 0 0

QPI 11 - BRCA1 and BRCA2 sequencing in epithelial ovarian cancer. Proportion of patients with epithelial ovarian cancer who undergo genetic testing.

90% 58.6% 45.0% 31.6% 67.9% 70.4% 82.1% 45.5%

109 186 18 40 6 19 19 28 19 27 32 39 15 33

QPI 12(i) - 30 Day Mortality –Surgery. (HOSPITAL of SURGERY) Proportion of patients with epithelial ovarian cancer who die within 30 days of surgery.

<5% 0.7% 0.0% - 0.0% 0.9% 0.0% 0.0%

1 141 0 6 - - 0 7 1 116 0 5 0 6

QPI 12(ii) - 30 Day Mortality – Primary/Palliative Chemotherapy. Proportion of patients with epithelial ovarian cancer who die within 30 days primary palliative chemotherapy.

<5% 6.3% 0.0% 10.0% 9.1% 11.1% 5.3% 5.9%

5 80 0 14 1 10 1 11 1 9 1 19 1 17

QPI 12(iii) - 30 Day Mortality –Adjuvant Chemotherapy. Proportion of patients with epithelial ovarian cancer who die within 30 days primary palliative chemotherapy.

<5% 1.4% 5.9% - 0.0% 0.0% 0.0% 0.0%

1 69 1 17 - - 0 17 0 14 0 8 0 10

‘- ‘Data not shown due to small numbers


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QPI Target WoS A&A FV LS GGC

Clinical Trials Access‡ – Proportion of patients diagnosed

with ovarian cancer who are consented* for a clinical trial / research study.

15% 49.8% 36.2% 30.3% 75.0% 49.0%

146 293 17 47 10 33 42 56 77 157

Clinical Trials Access‡ – Proportion of patients diagnosed

with ovarian cancer who entered a clinical trial / research study.

44.0% 36.2% 30.3% 66.1% 41.4%

129 293 17 47 10 33 37 56 65 157

‡ The denominator for Clinical Trials Access QPI uses 5-year cancer registry average (2013 – 2017) and also uses board of residence.


Conclusions and Action Required 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 Ovarian 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 extent of disease assessed by CT/MRI prior to treatment, histological diagnosis prior to starting chemotherapy and surgery for advanced disease were met by the majority of Boards. Additionally, comparison with previous years’ data has highlighted a number of areas where NHS Board performance has improved, for example discussion at Multidisciplinary Team (MDT) meeting and patients with early stage disease having an adequate staging operation. The results for QPI 12 also indicate good performance in relation to 30 day mortality rates following surgical treatment. 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. Results for QPI 9 indicate a reduction in patients receiving platinum-based first line chemotherapy, regionally. NHS Boards have reviewed the relevant patient notes and have indicated that the majority of patients were too advanced in their disease process to receive chemotherapy or not fit enough for treatment. Recent survival analysis highlighted a need for closer scrutiny of this group to identity if there are any issues with late presentation and diagnosis or if they represent an aging population. It is also worth noting that recent European guidelines have highlighted patient groups where the margin of benefit for chemotherapy may not be advantageous for the patient and this may have impact treatment decisions and resulting performance. QPI 11 is a new indicator and a working group has been set up to improve ascertainment and adherence in this QPI with year on year improvements expected as this new process is embedded. 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.

There are a number of actions required as a consequence of this assessment of performance against the agreed criteria.


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Actions: Case Ascertainment

MCN to work with ISD/cancer registry to investigate the reasons for WoS low case ascertainment figures.

FIGO Stage

NHS Ayrshire & Arran and NHS Lanarkshire to establish robust processes for capturing stage information for all patients.

QPI 9: First-line Chemotherapy

Analysis is ongoing into this cohort to establish the reasons for not meeting this target and to determine if any changes need to be made to achieve this QPI. BWoSCC to feedback reasons to the MCN.

QPI 10: Surgery for Advanced Disease

MCN to provide an update on patient and MDT factors impacting upon this QPI result, to RCAG and the National Cancer Quality Steering Group once the detailed audit of non surgical patients is complete.

QPI 11:-BRCA1 and BRCA2 Sequencing in Epithelial Ovarian Cancer

All boards should review referral pathways and identify ways in which performance against this measure can be further improved. A working group has been established to look into the process in more detail.

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 presents an assessment of performance of West of Scotland (WoS) Gynaecology Services relating to patients diagnosed with ovarian cancer in the region between 01 October 2017 and 30 September 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 Ovarian Cancer Quality Performance Indicators (QPIs) which were implemented for patients diagnosed on or after 01 October 2016. This was the fifth consecutive year of analysis following the initial Healthcare Improvement Scotland (HIS) publication of Ovarian Cancer QPIs in 2013. 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 Ovarian Cancer QPIs1 were published in May 2018 and, as stated above, are valid for patients diagnosed on or after 01 October 2016. Annual comparisons have been made where indicators remain comparable following this formal review. Future reports will continue to compare clinical audit data in successive years to illustrate trends.

2. Background The effective management of these patients relies on well co-ordinated delivery of treatment and care, requiring close collaboration of professionals from a range of specialties. 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. The standard treatments for ovarian cancer in Scotland are:

Primary surgery followed by adjuvant chemotherapy.

Primary chemotherapy followed by delayed primary surgery.

Primary chemotherapy. 2.1 National Context Ovarian cancer is the sixth most commonly diagnosed malignancy in Scottish women with a relative frequency of around 3.7% of all female cancers3. There has been an overall decrease in the incidence of ovarian cancer in the past ten years of 15%.

Latest ISD figures show a fall in mortality in ovarian cancer patients of 16% over the last 10 year period, with corresponding improvements in 5 year survival; approximately 46% of patients are now surviving at least five years after diagnosis, compared to around 31% of those diagnosed between 1983-19873.


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2.2 West of Scotland Context

There were 209 new diagnoses of ovarian cancer captured by audit in the WoS in Year 5. Distribution by location of diagnosis is shown below in Figure 1. Figure 1: Number of patients diagnosed with ovarian cancer by location of diagnosis

AA FV Lan GGC WoS

Year 1_2013/14 35 24 29 116 204

Year 2_2014/15 45 20 56 114 235

Year 3_2015/16 41 25 50 120 236

Year 4_2016/17 34 34 41 116 225

Year 5_2017/18 47 21 36 105 209

2.4 FIGO Stage Stage of disease is an important prognostic factor and knowledge of the stage distribution allows the MCN to understand implications of current and future management of patients with ovarian cancer. Furthermore, it facilitates greater understanding of disease progression and outcomes through survival analyses therefore it is important that this information is available and recorded accurately. Figure 3: Distribution of FIGO stage for epithelial ovarian cancer patients.

0

20

40

60

80

100

120

Ayrshire & Arran Forth Valley Lanarkshire GGC

Nu

mb

er

of

Cas

es

Location of Diagnosis

2013/14 2014/15 2015/2016 2016/2017 2017/18


11

FIGO Stage 1 1c 2 3 4 4a 4b NR NA

n 26 22 11 88 20 9 11 8 14

Figure 2 illustrates that 66.5% of patients in the WoS presented with advanced stage disease (FIGO 2 or above). Figure 2 also highlights that stage of disease was not adequately recorded for 11% of patients and further efforts are needed to improve capture of staging data. 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. Six of the eight not recorded values were attributed to NHS Lanarkshire. NHS Ayrshire & Arran were noted to have 12 cases where FIGO was recorded as not applicable. Action required.


FIGO 1a, 12.4%

FIGO 1c, 10.5%

FIGO 2, 5.3%

FIGO 3, 42.1%

FIGO 4, 9.6%

FIGO 4a, 4.3%

FIGO 4B, 5.3%

NR, 3.8%

NA, 6.7%

FIGO Stage


12

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 ovarian cancer between 1 October 2017 and 30 September 2018 was 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 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.

4. Results and Action Required 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 as the number of new cases identified by the audit as a proportion of the number of cases reported by the National Cancer Registry (provided by Information Services Division, National Services Scotland). Cancer Registry figures were extracted from ACaDMe (Acute Cancer Deaths and Mental Health), a system provided by Information Services Division (ISD). Cancer Registry figures are an average of the previous five years’ figures to take account of annual fluctuations in incidence within NHS Boards. Table 1 presents the case ascertainment for each NHS Board and for WoSCAN as a whole. Table 1: Case Ascertainment by NHS Board for patients diagnosed with ovarian cancer October 17 to September 18

With regards to the lower than expected case ascertainment, NHS GGC carried out a comparison with ISD cancer registry data to identify reasons for the differences observed. The Board reported that the vast majority of cases included in cancer registry figures which were not included within the QPI audit were non malignant, borderline cases and also some cases where the patient was highly suspicious of ovarian cancer but died before histology. Therefore there does not appear to be any issue with identification of relevant cases for audit by this board. The MCN will facilitate similar comparisons for the remaining WoS Boards. Action Required:-


Health Board of

diagnosis

Cases from

audit 2017-

2018

Cancer

registration

cases (2013 -

2017)

Case

ascertainment

Ayrshire & Arran 47 47 100.0%

Forth Valley 21 33 63.6%

Lanarkshire 36 56 66.1%

GGC 105 157 66.9%

Total 209 293 71.7%


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4.2 Performance against Quality Performance Indicators (QPIs) Results for each QPI are shown in detail in the main report and illustrate Board performance against each target and overall WoS performance for each performance 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. 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. QPI 1: Risk of Malignancy Index (RMI) During formal review it was agreed that due to a change in practice with many patients now undergoing CT scan rather than ultrasound, RMI could not be calculated therefore QPI 1 should be archived. QPI 2 - Extent of disease assessed by CT or MRI prior to treatment. For women diagnosed with ovarian cancer it is necessary to fully image the pelvis and abdomen prior to starting any definitive treatment in order to establish the extent of disease and minimise unnecessary treatment. The target for this QPI is set at 95%. The tolerance allowed by the target reflects the fact that CA125 assessment and ultrasound scan does not always raise suspicion of cancer1.

QPI Title: Patients with epithelial ovarian cancer should have their stage of disease assessed by CT or MRI prior to treatment.

Numerator: Number of patients with epithelial ovarian cancer having a CT scan or MRI of the abdomen

and pelvis carried out prior to starting treatment. Denominator: All patients with epithelial ovarian cancer. Exclusions: Patients who decline to undergo investigation.

Patients presenting for surgery as an emergency. Target: 95%


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Figure 4: Proportion of patients with epithelial ovarian cancer having a CT scan or MRI of the abdomen and pelvis performed prior to starting definitive treatment.

Performance (%) Numerator Denominator Not recorded

numerator Not recorded

numerator (%) Not recorded exclusions

Not recorded exclusions (%)

Not recorded denominator

AA 100% 45 45 0 0.0% 0 0.0% 0

FV 100% 21 21 0 0.0% 0 0.0% 0

Lan 100% 34 34 0 0.0% 0 0.0% 0

NG 100% 31 31 0 0.0% 0 0.0% 0

SG 100% 39 39 0 0.0% 0 0.0% 0

Clyde 97.1% 33 34 0 0.0% 0 0.0% 0

WoS 99.5% 203 204 0 0.0% 0 0.0% 0

Overall in the WoS, 99.5% of patients with epithelial ovarian cancer had a CT scan or MRI of the abdomen and pelvis carried out prior to starting treatment, successfully achieving the 95% target. All units achieved the QPI target and performance over the five years is noted as being consistently high as demonstrated in Figure 4.

0

10

20

30

40

50

60

70

80

90

100

Ayrshire & Arran

Forth Valley Lanarkshire North Glasgow

South Glasgow Clyde WoS

Prop

orti

on o

f Cas

es


2013/14 2014/15 2015/16 2016/17 2017/18


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QPI 3 - Treatment planned and reviewed at a multi-disciplinary team meeting Effective MDT working is considered integral to provision of high quality ovarian cancer care, facilitating a cohesive treatment-planning function and ensuring treatment and care provision is individualised to patient needs. QPI 3 states that 95% of patients should be discussed at the MDT prior to definitive treatment. The tolerance allows for patients who need treatment urgently1. Figure 5: Proportion of patients with epithelial ovarian cancer who are discussed at a MDT meeting before definitive treatment.






AA 88.1% 37 42 0 0.0% 0 0.0% 0

FV 100% 20 20 0 0.0% 0 0.0% 0

Lan 90.6% 29 32 0 0.0% 0 0.0% 0

NG 100% 29 29 0 0.0% 0 0.0% 0

SG 97.3% 36 37 0 0.0% 0 0.0% 0

Clyde 100% 32 32 0 0.0% 0 0.0% 0

WoS 95.3% 183 192 0 0.0% 0 0.0% 0

WoS performance was 95.3% against the 95% QPI target with 183 of 192 patients diagnosed with epithelial ovarian cancer being discussed at MDT meeting before definitive treatment. Four of the six units achieved the target with only NHS Ayrshire & Arran and NHS Lanarkshire below target with performance of 88.1% and 90.6% respectively.

0

10

20

30

40

50

60

70

80

90

100

Ayrshire & Arran

Forth Valley Lanarkshire North Glasgow South Glasgow Clyde WoS

Prop

orti

on o

f Cas

es


2013/14 2014/15 2015/16 2016/17 2017/18

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

Numerator: Number of patients with epithelial ovarian cancer discussed at the MDT before definitive

treatment. Denominator: All patients with epithelial ovarian cancer Exclusions: Patients who died before first treatment. Target: 95%


16

NHS Ayrshire & Arran commented that five patients did not meet target and following review of documentation the main reasons identified were; cases where cancer was not suspected pre-operatively, patients receiving emergency treatment and patient did not attend outpatients appointment. NHS Lanarkshire commented that the three cases failing to meet this QPI target have been reviewed and treated appropriately. Reasons provided included cases that had an RMI of less than 200, and patients receiving treatment as an emergency. Location of Surgery QPIs 4, 6, 10(ii) and 10(iii) are reported by location of surgery rather than by location of diagnosis. Surgical management of ovarian cancer is provided by gynaecological oncologists working in the regional specialist surgical centre in Glasgow Royal Infirmary (represented by North Glasgow on charts). Some patients with an RMI of less than 200, i.e. cancer is not suspected pre-operatively, may receive surgery in their local hospital but are subsequently diagnosed with epithelial ovarian cancer when post operative pathology is available. In Year 5 137 patients (65.6%) underwent surgery. Hospital of surgery is noted below.

109 cases in regional specialist centre (GRI)

14 cases in NHSGGC (not specialist surgical centre)

7 cases in NHS Lanarkshire

1 cases in NHS Forth Valley

6 cases in NHS Ayrshire & Arran

Please note that the number of operations carried out in local hospitals is small therefore comparisons of percentages should be made with caution.

During formal review it was agreed that QPIs 5 and 8 would be archived and a new QPI (QPI 10) would be developed that covers all aspects of surgery for advanced disease.


17

QPI 4 - Patients with early stage disease have an adequate staging operation Surgery is considered the initial treatment of choice for women with early stage epithelial ovarian cancer and will typically include TAH, BSO and omentectomy and may also involve assessment by palpation, visualisation and/or biopsy as indicated, of peritoneal surfaces, appendix and bowel mesentery and sampling of pelvic and para-aortic lymph nodes1. Figure 6: Proportion of early stage (FIGO Stage 1) epithelial ovarian cancer patients having primary surgery involving TAH, BSO, omentectomy and washings.






2013/14 86.8% 33 38 0 0.0% 26 68.4% 1

2014/15 82.9% 29 35 0 0.0% 24 68.6% 0

2015/16 78.6% 33 42 0 0.0% 14 33.3% 4

2016/17 85.0% 34 40 0 0.0% 0 0.0% 0

2017/18 90.9% 40 44 0 0.0% 0 0.0% 0

0

10

20

30

40

50

60

70

80

90

100

2013/2014 2014/2015 2015/2016 2016/2017 2017/18

Pe

rfo

rman

ce (%

)

Year of Diagnosis

WoS

QPI Title: Patients undergoing surgery for early stage epithelial ovarian cancer (FIGO Stage 1) have an adequate staging operation which includes Total Abdominal Hysterectomy (TAH), Bilateral Salpingo-Oophorectomy (BSO), omentectomy and washings.

Numerator: Number of early stage (FIGO Stage 1) epithelial ovarian cancer patients having primary

surgery involving TAH, BSO, omentectomy and washings. Denominator: All early stage (FIGO Stage 1) epithelial ovarian cancer patients undergoing primary

surgery. Exclusions: Patients having fertility conserving surgery. Patients presenting for emergency surgery Target: 90%


18

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. Of the 44 patients with early stage epithelial ovarian cancer patients who underwent primary surgery, 40 had an adequate staging operation involving TAH, BSO, omentectomy and washings, resulting in a performance of 90.9% against the 90% QPI target. At unit level the majority of cases were operated on in North Glasgow who achieved 96.4% against the 90% target with 27 of 28 patients having an adequate staging operation. NHSGGC had three cases that didn’t meet the QPI. Feedback from NHSGGC stated that two patients had risk reducing BSO which diagnosed their ovarian cancers. Both were then discussed at the MDT and had recommendation of completion surgery. This was achieved in one patient. The other patient had a concurrent breast cancer and due to the presence of liver metastasis it was not appropriate to complete her surgical staging. NHS Lanarkshire commented that the one case failing to meet this QPI target has been reviewed and appropriately treated. In previous years the high number of not recorded cases for the exclusion criteria was attributed to RMI score not being complete, following formal review discussion patients with RMI <200 were no longer excluded from QPI 4. The target was also lowered from 95% to 90% given the removal of the exclusion criteria. QPI 6 - Histopathology reports are complete and support clinical decision-making Histopathological reporting provides prognostic indicators which inform treatment planning for women diagnosed with epithelial ovarian cancer. The use of datasets improves the completeness of data in pathology reports and the Royal College of Pathologists has agreed a minimum data set for reporting ovarian cancer1. The target for this QPI has been set at 90% and the tolerance within the target is designed to account for situations where it is not possible to report all components of the dataset due to poor quality of specimen.

QPI Title: Histopathology reports relating to pelvic clearance surgery for patients with epithelial ovarian cancer contain all necessary information to inform treatment decision making.

Numerator: Number of patients with epithelial ovarian cancer undergoing definitive cytoreductive

surgery who have a complete pathology report that contains all data items as defined by the Royal College of Pathologists.

Denominator: All patients with epithelial ovarian cancer undergoing definitive cytoreductive surgery. Exclusions: No Exclusions. Target: 90%


19

Figure 7: Proportion of patients with epithelial ovarian cancer undergoing pelvic clearance surgery having a complete pathology report as defined by the Royal College of Pathologists






2013/14 93.1% 95 102 0 0.0% 0 0.0% 0

2014/15 81.6% 80 98 0 0.0% 0 0.0% 0

2015/16 65.0% 76 117 0 0.0% 0 0.0% 0

2016/17 86.2% 94 109 0 0.0% 0 0.0% 0

2017/18 93.0% 107 115 0 0.0% 0 0.0% 0

Due to the majority of operations taking place in the centre (North Glasgow) the numbers for other individual units are low therefore Figure 7 shows WoS yearly results. Overall in the WoS in Year 4, 93.0% of patients with epithelial ovarian cancer undergoing definitive cytoreductive surgery had a complete pathology report which successfully meets the 90% QPI target. NHS Ayrshire & Arran commented that the one case not meeting the QPI had been reviewed and pathology was reported initially as borderline malignancy. NHSGGC achieved the QPI target and provided commentary on the seven cases that did not have a complete pathology report. A small number of pathology reports were incomplete as there was no FIGO stage. However it may not be always possible / appropriate to include a FIGO stage such as in post chemotherapy cases or when intraoperative findings may alter FIGO stage.

0

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2013/2014 2014/2015 2015/2016 2016/2017 2017/18

Pe

rfo

rman

ce (%

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WoS


20

QPI 7 - Histological diagnosis prior to starting chemotherapy QPI 7 looks at the proportion of patients who have a histological diagnosis prior to starting chemotherapy. The target for this QPI is set at 80%. The tolerance for this level reflects that not all patients are suitable for histological confirmation of disease, e.g. where no targetable lesion is identified on imaging and the patient unsuitable for general anaesthetic/laparoscopy1. Figure 8: Proportion of patients with epithelial ovarian cancer having a histological diagnosis prior to starting chemotherapy.






AA 93.8% 15 16 0 0.0% 0 0.0% 0

FV 88.9% 8 9 0 0.0% 0 0.0% 0

Lan 100% 10 10 0 0.0% 0 0.0% 0

NG 90.0% 9 10 0 0.0% 0 0.0% 0

SG 94.4% 17 18 0 0.0% 0 0.0% 0

Clyde 60.0% 9 15 0 0.0% 0 0.0% 0

WoS 87.2% 68 78 0 0.0% 0 0.0% 0

Of the 78 patients with epithelial ovarian cancer undergoing chemotherapy, 68 had a histological diagnosis prior to starting chemotherapy. This equates to a WoS performance of 87.2% against the

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2013/14 2014/15 2015/16 2016/17 2017/18

QPI Title: Patients with epithelial ovarian cancer should have a histological diagnosis of their cancer prior to starting chemotherapy.

Numerator: Number of patients who have a diagnosis of epithelial ovarian cancer confirmed by

histology prior to starting chemotherapy. Denominator: All patients with epithelial ovarian cancer undergoing chemotherapy. Exclusions: No Exclusions Target: 80%


21

80% QPI target. Only Clyde did not achieve the target performance ranging from 100% in NHS Lanarkshire to 60% in Clyde. NHSGGC commented that overall in NHSGGC this QPI was met. The six cases in Clyde were reviewed and feedback stated that historically within the Clyde sector patients were treated on cytology alone however practice has changed and this is no longer the case. NHSGGC will continue to monitor this change in practice. QPI 9 - First-line Chemotherapy First line chemotherapy treatment of epithelial ovarian cancer should include a platinum agent, either in combination or as a single agent. Carboplatin is the platinum drug of choice in both single and combination therapy and paclitaxel is recommended in combination where the potential benefits justify the toxicity of the therapy1. The tolerance allowed by the target recognises that there are a small number of patients who are not fit enough to undergo chemotherapy. Figure 9: Proportion of epithelial ovarian cancer patients who receive platinum-based chemotherapy, either in combination or as a single agent.

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QPI Title: Chemotherapy treatment of epithelial ovarian cancer should include a platinum agent. Numerator: Number of epithelial ovarian cancer patients who receive chemotherapy treatment

involving either paclitaxel in combination with a platinum-based compound or carboplatin only.

Denominator: All epithelial ovarian cancer patients. Exclusions: Patients with low-grade serous disease.

Patients with FIGO stage 1a or 1b, low grade (G1) disease. Patients with Stage 1a clear cell tumours. Patients who decline chemotherapy treatment. Patients with Stage 1a Grade 2 endometrioid tumours. Patients with low grade mucinous tumours.

Target: 90%


22






AA 67.5% 27 40 0 0.0% 0 0.0% 0

FV 63.2% 12 19 0 0.0% 1 5.3% 0

Lan 74.1% 20 27 0 0.0% 6 22.2% 0

NG 80.8% 21 26 0 0.0% 0 0.0% 0

SG 75.8% 25 33 0 0.0% 0 0.0% 0

Clyde 89.3% 25 28 0 0.0% 0 0.0% 0

WoS 75.1% 130 173 0 0.0% 7 4.0% 0

The 90% target for QPI 9 was not achieved for patients diagnosed with epithelial ovarian cancer in WoS for the fifth consecutive year. Of 173 patients diagnosed, 130 had chemotherapy treatment which included a platinum agent. WoS performance decreased from 86.3% in Year 4 to 75.1% in Year 5; a decrease of 11.2 percentage points and 14.9 percentage points below the QPI target. The decision to prescribe chemotherapy is made by gynaecological oncology team at the Beatson West of Scotland Cancer Centre. At NHS Board level, no unit achieved the QPI target with performance ranging from 63.2% in NHS Forth Valley to 89.3% in Clyde. Clyde were also the only unit to demonstrate improved performance from the previous year. NHS Ayrshire & Arran commented that all cases not meeting the QPI were reviewed. Reasons for not meeting the QPI were patient fitness for treatment either due to co-morbidities or disease, patients’ choice for no active treatment, clinical decision not to give chemotherapy and patient entered clinical trial. NHS Lanarkshire stated that all cases not meeting this QPI target have been reviewed. Reasons provided included patients that died before treatment (which is not excluded from this measure), patients not fit for chemotherapy and one patient that received carboplatin only as part of a clinical trial. NHSGGC commented that this QPI was not met by the three units in NHSGGC. Three patients were diagnosed with G2 Stage 1A mucinous ovarian cancer. Practice has recently changed and the Medical Oncologists do not offer adjuvant chemotherapy to these patients. The remainder were unfit / declined treatment. NHSGGC will continue to monitor this especially the fitness of patients for treatment and consider why this should be different from other areas. Action required:-



23

QPI 10 – Surgery for Advanced Disease Evidence shows that most women with ovarian cancer present with advanced disease. Surgery along with chemotherapy remains the optimal treatment for women with advanced ovarian cancer1. Figure 10: Proportion of patients with advanced epithelial ovarian cancer (FIGO Stage 2 or higher) undergoing surgery.






AA 86.4% 19 22 0 0.0% 0 0.0% 0

FV 42.1% 8 19 0 0.0% 0 0.0% 1

Lan 77.3% 17 22 0 0.0% 0 0.0% 6

NG 66.7% 12 18 0 0.0% 0 0.0% 1

SG 50.0% 18 36 0 0.0% 0 0.0% 0

Clyde 59.1% 13 22 0 0.0% 0 0.0% 0

WoS 62.6% 87 139 0 0.0% 0 0.0% 8

Overall in the WoS, 62.6% of patients with advanced epithelial ovarian cancer underwent either primary or delayed surgery which meets the 60% QPI target for the second year. Three of the six units met the target with performance ranging from 86.4% in NHS Ayrshire & Arran to 42.1% in NHS Forth Valley.

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ArranForth Valley Lanarkshire North

GlasgowSouth Glasgow Clyde WoS

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2016/17 2017/18

QPI 10(i): Patients with advanced epithelial ovarian cancer (FIGO Stage 2 or higher) should undergo primary or delayed surgery and should achieve no macroscopic residual disease.

Numerator: Number of patients with advanced epithelial ovarian cancer (FIGO Stage 2 or higher)

undergoing surgery (primary or delayed). Denominator: All patients with advanced epithelial ovarian cancer (FIGO Stage 2 or higher) Exclusions: No Exclusions Target: 60%


24

NHS Lanarkshire has exceeded this QPI target however the five cases not meeting have been reviewed. One patient died before treatment, one would have required significant de-bulking and the other three patients presented with advanced metastatic disease and therefore not suitable for surgery. NHSGGC commented that all patients not meeting the QPI were reviewed at the MDT. The majority were not fit for surgery, declined treatment or died prior to being considered for surgery. GGC will continue to monitor this for recurrent themes. NHS Forth Valley stated all patients which breach the target were clinically reviewed and the decision to treat was taken at MDT and carried out in Glasgow. Examining the patient denominator numbers for each board it would appear that a lower proportion of patients from FV are being put forward for surgery. It should be noted however that this is a regional service, and decisions regarding suitability for surgery are made at the regional MDT. The MCN is keen to further understand the patient or MDT factors which may be impacting upon this decision making process, and work is already underway at BWoSCC as part of the national survival analysis action plan, to audit this cohort to determine why more patients are not proceeding to surgery. QPI 10 (ii) looks at those patients with advanced epithelial cancer who underwent primary surgery where no residual disease is achieved. Due to the majority of operations taking place in the centre (60/76) the numbers for other individual units are low therefore individual Board results cannot be presented. WoS performance against this QPI was 76.5% (62 out of 81 cases) against the 50% QPI target. The third part of the QPI looks at those patients with advanced epithelial ovarian cancer who underwent delayed primary surgery after chemotherapy. Thirty four patients underwent delayed primary surgery with 24 achieving no residual disease; this equates to 70.6% and meets the 50% QPI target. All cases were operated on at the centre (North Glasgow). Action required:-



25

QPI 11: BRCA1 and BRCA2 Sequencing in Epithelial Ovarian Cancer. Genetic testing should be performed in patients with ovarian cancer where the combined risk of BRCA1 and BRCA2 mutation is ≥10%. All women with non-mucinous ovarian cancer should be offered BRCA1 and BRCA2 mutation testing. Access to genetic testing is very difficult to measure accurately therefore uptake is utilised within this QPI as a proxy for access. Although it will not provide an absolute measure of patient access to genetic testing it will give an indication across NHS Boards and highlight any areas of variance which can then be further examined. Figure 10: Proportion of patients with advanced epithelial ovarian cancer (FIGO Stage 2 or higher) undergoing surgery.






AA 45.0% 18 40 0 0.0% 0 0.0% 0

FV 31.6% 6 19 0 0.0% 0 0.0% 1

Lan 67.9% 19 28 0 0.0% 1 3.6% 6

NG 70.4% 19 27 0 0.0% 0 0.0% 1

SG 82.1% 32 39 0 0.0% 0 0.0% 0

Clyde 45.5% 15 33 0 0.0% 0 0.0% 0

WoS 58.6% 109 186 0 0.0% 1 0.5% 8

QPI 11 was introduced following formal review, however due to new data items being required for measurement, this is the first year of reporting.

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South Glasgow

Clyde WoS

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Year 5

QPI Title: Patients with ovarian cancer should have access to genetic testing. Numerator: Number of patients with epithelial ovarian cancer who undergo genetic testing. Denominator: All patients with epithelial ovarian cancer. Exclusions: Patients with low grade serous disease.

Patients with mucinous tumours. Target: 90%


26

Overall in the WoS 58.6% of patients with epithelial ovarian cancer underwent genetic testing resulting in a WoS performance of 58.6%, against the 90% target. No unit met the QPI with performance ranging from 31.6% in NHS Forth Valley to 82.1% in South Glasgow. NHS Ayrshire and Arran commented that 22 patients failed to meet target. Following review of documentation: 1 case was BRCA1/2 (wild type) reported January 2019, 1 patient borderline tumour diagnosis, 3 patients diagnosed with stage 1 disease and the remaining patients died shortly after diagnosis or wide spread metastatic disease was noted on initial diagnosis. NHS Lanarkshire stated that The 9 cases that failed to meet this QPI target have been reviewed. Five patients died before treatment and one declined investigations which are not excluded from the measure. Two patients were for BSC only therefore no testing. The other patient should have met the QPI however this was not documented on clinical portal. This would show 71.4% compliance for NHSL. NHS GGC commented that this is a new QPI and there is ongoing work with Medical Oncologists and Genetics to improve referral pathways for testing. Action required:-


QPI 12 – 30 Day Mortality after Treatment for Ovarian Cancer Treatment related mortality is a marker of the quality and safety of the whole service provided by the Multi Disciplinary Team (MDT). Table 2: Proportion of patients with epithelial ovarian cancer who undergo surgery that die within 30 days of treatment.

QPI Title: 30 day mortality following treatment for ovarian cancer. Numerator: Number of patients with epithelial ovarian cancer who die within 30 days of treatment. Denominator: All patients with epithelial ovarian cancer who undergo treatment. .

a) Surgery b) Primary/Palliative Chemotherapy c) Adjuvant chemotherapy

Exclusions: No exclusions. Target: <5%


27

Table 2 indicates that there was 1 death within 30 days of surgery in patients diagnosed with epithelial ovarian cancer. This represents 0.7% of patients receiving surgery across the WoS and is within the QPI target of less than 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.

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 will be 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.

30 day Surgical MortalityTarget <5%

Board of Surgery % n

Ayrshire & Arran 0.0% 0/6

Forth Valley -

Lanarkshire 0.0% 0/7

North Glasgow (centre) 0.9% 1/113

North Glasgow (Stobhill) - -

South Glasgow 0.0% 0/5

Clyde 0.0% 0/6

WoS 0.7% 1/141

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

Numerator: Number of patients diagnosed with ovarian cancer consented for a clinical trial/research

study. Denominator: All patients with diagnosed with ovarian cancer.. Exclusions: No exclusions. Target: 15%


28

Figure 11: Proportion of patients diagnosed with ovarian cancer who are consented for a clinical trial / research study in 2017.

Consented - QPI Target 15%

N D %

AA 17 47 36.2%

FV 10 33 30.3%

Lan 42 56 75.0%

GGC 77 157 49.0%

WoS Total 146 293 49.8%

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.

Overall for patients in WoS diagnosed with ovarian cancer, 146 patients consented for a clinical trial/research study resulting in a WoS performance of 49.8% against the 15% target. Feedback from clinicians at the Beatson West of Scotland Cancer Centre indicted that although performance is good, there have been delays in opening some trials due to contract and other issues out with local control. For example, the PRIMA trial opened and was closed within two months which affected the ability to recruit. The delays indicated above have affected the opening of ICON 9, which will be a major recruiting study in first line treatment. A broad portfolio of trials has been maintained, however it should be highlighted that the time required by the principle investigator for the administration of trials has increased significantly in recent years as has the time required at each patient consultation. This combined with a move towards trials in more defined groups (eg molecular markers or specific lines of therapy) means that the number of patients recruited to each trial is smaller.

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Ayrshire & Arran Forth Valley Lanarkshire GGC WoS

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Board of Residence

2017 Cases 2018 Cases


29

Table 5: List of clinical trials and the number of patients with ovarian cancer consented to each clinical trial in 2018. (N.B. All recruits noted below were resident within WoS).

Short Title TOTAL

A Phase I trial of CCT245737 in patients with advanced cancer 8

AZD1775 Food Effects 1

FAK-PD1 v1 1

GENOMIC MEDICINE COLLABORATION (AZ, SGP, SMS-IC): HIGH-GRADE SEROUS OVARIAN CANCER PROJECT 97

HORIZONS: Understanding the impact of cancer diagnosis and treatment 8

ICON8 and ICON8B - ICON8 Trial Programme 5

MEDIOLA/D081KC00001 5

MROC: MR in Ovarian Cancer 4

NCRN - 2789 OCTAVE - ColoAd1 in platinum-resistant epithelial ovarian ca 1

NiCCC Trial (BIBF1120) 2

OCTOVA 2

PRIMA 2

PROCLAIM CX-2009 in adults with metastatic/advanced solid tumour 2

Study of NUC-1031 in Patients with Platinum-Resistant Ovarian Cancer 4

CANC 5110 3

OReO 1

Total 146


30

Conclusions and Action Required 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 Ovarian 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 extent of disease assessed by CT/MRI prior to treatment, histological diagnosis prior to starting chemotherapy and surgery for advanced disease were met by the majority of Boards. Additionally, comparison with previous years’ data has highlighted a number of areas where NHS Board performance has improved, for example discussion at Multidisciplinary Team (MDT) meeting and patients with early stage disease having an adequate staging operation. The results for QPI 12 also indicate good performance in relation to 30 day mortality rates following surgical treatment. 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. Results for QPI 9 indicate a reduction in patients receiving platinum-based first line chemotherapy, regionally. NHS Boards have reviewed the relevant patient notes and have indicated that the majority of patients were too advanced in their disease process to receive chemotherapy or not fit enough for treatment. Recent survival analysis highlighted a need for closer scrutiny of this group to identity if there are any issues with late presentation and diagnosis or if they represent an aging population. It is also worth noting that recent European guidelines have highlighted patient groups where the margin of benefit for chemotherapy may not be advantageous for the patient and this may have impact treatment decisions and resulting performance. QPI 11 is a new indicator and a working group has been set up to improve ascertainment and adherence in this QPI with year on year improvements expected as this new process is embedded. 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.

There are a number of actions required as a consequence of this assessment of performance against the agreed criteria.


31

Actions: Case Ascertainment


FIGO Stage


QPI 9: First-line Chemotherapy


QPI 10: Surgery for Advanced Disease


QPI 11:-BRCA1 and BRCA2 Sequencing in Epithelial Ovarian Cancer


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).


32

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.


33

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


34

References

1. Healthcare Improvement Scotland. Ovarian Cancer Quality Performance Indicators, August 2013 [Accessed on: 14th August 2015] Available at: http://www.healthcareimprovementscotland.org/our_work/cancer_care_improvement/cancer_qpis/quality_performance_indicators.aspx

2. Information Services Division. Cancer in Scotland, June 2004 (updated April 2015) [Accessed

on: 14th August 2015]. Available at: http://www.isdscotland.org/Health-Topics/Cancer/Cancer-Statistics/

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

cancers. [Accessed on: 16th August 2015]. Available at: http://www.isdscotland.org/Health-Topics/Cancer/Cancer-Statistics/Female-Genital-Organ/

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

[Accessed on: 5th May 2015] 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.aspx

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

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-estimates

http://www.scotpho.org.uk/population-dynamics/population-estimates-and-projections/data/nhs-board-population-estimates


35

Copyright

The content of this report is © copyright WoSCAN unless otherwise stated.

Organisations may copy, quote, publish and broadcast material from this report without payment and without approval

provided they observe the conditions below. Other users may copy or download material for private research and

study without payment and without approval provided they observe the conditions below.

The conditions of the waiver of copyright are that users observe the following conditions:

Quote the source as the West of Scotland Cancer Network (WoSCAN).

Do not use the material in a misleading context or in a derogatory manner.

Where possible, send us the URL.

The following material may not be copied and is excluded from the waiver:

The West of Scotland Cancer Network logo.

Any photographs.

Any other use of copyright material belonging to the West of Scotland Cancer Network requires the formal permission

of the Network.


Appendix 1: Action / Improvement Plans

WoSCAN Action / Improvement Plan – Ovarian Cancer

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

Start End

Ensure actions mirror those detailed in Audit Report.

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

Insert date

Insert date

Insert name of responsible lead for each action.

Insert No. from key above

1. Case Ascertainment MCN to work with ISD/cancer registry to investigate the reasons for WoS low case ascertainment figures.

2. QPI 9: First-line Chemotherapy Analysis is ongoing into this cohort to establish the reasons for not meeting this target and to determine if any changes need to be made to achieve this QPI. BWoSCC to feedback reasons to the MCN.

QPI 10: Surgery for Advanced Disease MCN to provide an update on patient and MDT factors impacting upon this QPI result, to RCAG and the National Cancer Quality Steering Group once the detailed audit of non surgical patients is complete.

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)


37

NHS Ayrshire & Arran Action / Improvement Plan – Ovarian Cancer


Start End



Insert date

Insert date



1. FIGO Stage NHS Ayrshire & Arran to establish robust processes for capturing stage information for all patients.

2. QPI 11:-BRCA1 and BRCA2 Sequencing in Epithelial Ovarian Cancer All boards should review referral pathways and identify ways in which performance against this measure can be further improved.

NHS Board: NHS Ayrshire & Arran KEY (Status)





38

NHS Forth Valley Action / Improvement Plan – Ovarian Cancer


Start End



Insert date

Insert date




NHS Board: NHS Forth Valley KEY (Status)





39

NHS Lanarkshire Action / Improvement Plan – Ovarian Cancer


Start End



Insert date

Insert date



1. FIGO Stage NHS Lanarkshire to establish robust processes for capturing stage information for all patients.


NHS Board: NHS Lanarkshire KEY (Status)





40

NHSGGC Action / Improvement Plan – Ovarian Cancer


Start End



Insert date

Insert date




NHS Board: NHSGGC KEY (Status)




Documents

MCN Audit Report - West of Scotland Cancer Network...West of Scotland Cancer Network Final Published Ovarian Cancer QPI Audit Report v1.0 01/11/2019 Conclusions and Action Required