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West of Scotland Cancer Network Haemato-oncology

Managed Clinical Network

Audit Report

Report of the 2010 Clinical Audit Data

Dr Pam McKay Consultant Haematologist MCN Clinical Lead Heather Wotherspoon MCN Manager Julie McMahon Information Officer

West of Scotland Cancer Network Final – Published Haemato-oncology MCN Audit Report 29/03/2012

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EXECUTIVE SUMMARY 3

1. INTRODUCTION 6

2. BACKGROUND 6

2.1 NATIONAL CONTEXT 6

2.2 WEST OF SCOTLAND CONTEXT 7

3. METHODOLOGY 10

4. RESULTS AND ACTION REQUIRED 10

4.1 DATA QUALITY 10

4.2 PERFORMANCE AGAINST KEY OUTCOME MEASURES 11

4.3 RESULTS 11

5. CONCLUSIONS 29

ACKNOWLEDGEMENT 30

REFERENCES 31

ABBREVIATIONS 32


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Executive Summary Introduction The West of Scotland Cancer Network (WoSCAN) Haemato-oncology Managed Clinical Network (MCN) was formed in August 2002. The Haemato-oncology MCN includes five Health Board areas; Greater Glasgow and Clyde, Ayrshire & Arran, Lanarkshire, Forth Valley and Dumfries & Galloway and covers a population of 2.6 million. Membership includes 46 consultant haemato-oncologists, 3 clinical oncologists and a number of pathologists with a special interest in lymphoma in addition to other professional groups involved in the multi-disciplinary care of patients with blood cancer (haematological cancer). This report covers the period January – December 2010. It provides relevant audit data and an overview of activity, and sets out actions that require to be taken by Boards. The Haemato-oncology MCN do not have Healthcare Improvement Scotland standards against which to report performance. The Scottish Cancer Taskforce Quality Subgroup is taking forward the development of national Quality Performance Indicators (QPIs) for all cancers. In due course, QPIs for haematological cancers, beginning with lymphoma, will be developed. This will enable the Network to assure the quality of care provided and to drive continuous improvement. In the interim, compliance with regional Clinical Management Guidelines (CMGs) for Hodgkin lymphoma (HL) , diffuse large B cell lymphoma (DLBCL) and follicular lymphoma has been assessed and Key Outcome Measures (KOMs) for lymphoma and acute leukaemia have been developed regionally to enable more focussed analysis of the 2010 data. Background Blood cancer encompasses a number of different haematological malignancies – lymphoma, acute leukaemia, chronic leukaemia, multiple myeloma and other plasma cell dyscrasias, myeloproliferative disorders and myelodysplastic syndromes. In 2010, 1045 newly diagnosed haematological malignancies were recorded by audit teams within the West of Scotland (WoS). This included 480 new cases of lymphoma and 108 cases of acute leukaemia. The Haemato-oncology MCN continues to support and develop the clinical service for these patients and at present there are seven local Multi-disciplinary Teams (MDTs) held across the region. The Network continues to benefit from enthusiastic engagement of a range of healthcare professionals and managers across the WoS. Methodology Audit staff in each WoS Health Board are responsible for collecting data on patients diagnosed in their area and entering that data on eCASE (electronic cancer audit support environment). The data is extracted from eCASE and analysed centrally by the WoSCAN Information Team. Analysis of the 2010 data against pre-determined outcome measures was undertaken to show the performance of each NHS Board and also produce a collated report which allows for full comparison of performance and volume of activity across the region. Results In addition to basic demographics and CMG compliance, the measures analysed were revised this year and analysis of performance against eight defined KOMs was carried out. Results of the analysis are detailed below; the values represent the WoS figure and the range expressed as a percentage.


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Lymphoma KOM 1: Patients with newly diagnosed Hodgkin lymphoma should have staging Positron Emission Tomography/Computerised Tomography (PET/CT) scan performed. ( 66.2 [37.5-87.0]% ) KOM 2: All patients with a new diagnosis of lymphoma should have pathology reviewed by a member of the regional Lymphoma Pathology Review Group (no audit data available for 2010). KOM 3: Patients aged 16-24 years diagnosed with lymphoma should be discussed at the Regional Haemato-oncology MDT meeting (no audit data available for 2010). KOM 4: Proportion of patients with lymphoma entered into clinical trials. ( 4.4 [0.0-10.9]% ) Acute Leukaemia KOM 5: Proportion of patients with acute leukaemia who have cytogenetics performed at diagnosis. ( 68.5 [50.0-100.0]% ) KOM 6: Proportion of patients with acute leukaemia who have immunophenotyping performed at diagnosis. ( 84.3 [33.3-100.0]% ) KOM 7: All patients diagnosed with acute myeloid leukaemia (AML) <60 years, should receive first treatment within five days of diagnosis. ( 58.1 [0.0-80.0]% ) KOM 8: Proportion of patients with acute leukaemia entered into clinical trials. ( 37.7 [0.0-51.7]% ) Conclusion and Action Required We are encouraged by the continued support and commitment of Network members to deliver a high quality service to haemato-oncology patients across the WoS. In particular, we are pleased to note the progress made in establishing well structured weekly local MDTs across all sites/Health Boards to complement the function of the Regional Haemato-oncology MDT. It is anticipated that this will lead to an improvement in case ascertainment and quality of data recording which will be evident in future reports. The report does however raise a number of issues in relation to patient treatment and data recording, which should be examined further. Each Health Board is responsible for taking action on the recommendations of the report locally and is required to assess their performance in the context of the WoS as a whole, identifying areas for improvement and investigating potential reasons for any variation in performance. Action Required: Service Improvement

All Health Boards to encourage sites to open trials where recruitment is likely to be high e.g. 1st line therapy for DLBCL and HL.

All Health Boards to encourage referral into the Beatson West of Scotland Cancer Centre (BWoSCC) for trials open for patients with less common conditions, relapsed patients and commercial studies.


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Haemato-oncology MCN to continue to highlight the need for integrated reporting of test results and the development of an IT system for improving blood cancer diagnostics in the WoS to enable full assessment of performance against KOMs 5 and 6 in future analysis.

Forth Valley to explore reasons for a lower proportion of patients having immunophenotyping performed at diagnosis to establish if this is a data collection issue or variation in practice.

All Health Boards to review and comment on acute leukaemia clinical trial participation figures. CMG Compliance

All Health Boards to review and comment on cases where staging PET/CT was not performed in patients with newly diagnosed HL.

Forth Valley to review and comment on reason for Cyclophosphamide, Doxorubicin, Vincristine, Prednisolone (CHOP) chemotherapy regimen only in 33% of cases with DLBCL.

Clyde to review and comment on reason for omitting Rituximab with first course in 28% of cases with DLBCL.

Lanarkshire to provide further information on why 25% of cases with DLBCL received alternative (i.e. non-CHOP) chemotherapy with Rituximab.

South Glasgow to provide further information on regimen (other – Rituximab) used in 24% of cases with DLBCL.

Forth Valley to review and comment on figures for CHOP +/- Rituximab (R) as first line treatment for follicular lymphoma.

Data Quality Improvement

Registration of lymphoproliferative disorders requires to be improved across the region. Data collection process to be reviewed by all Health Boards.

Forth Valley to review their data collection methodology for registering all types of haematological malignancy.

Method of recording/documenting clinical stage to be reviewed, particularly in South Glasgow, Forth Valley and Clyde to ensure robust data collection processes are in place.


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1. Introduction The West of Scotland Cancer Network (WoSCAN) Haemato-oncology Managed Clinical Network (MCN) was formed in August 2002. The Haemato-oncology MCN includes five Health Board areas; Greater Glasgow and Clyde, Ayrshire & Arran, Lanarkshire, Forth Valley and Dumfries & Galloway and covers a population of 2.6 million. Membership includes 46 consultant haemato-oncologists, 3 clinical oncologists and a number of pathologists with a special interest in lymphoma in addition to other professional groups involved in the multi-disciplinary care of patients with blood cancer (haematological cancer). This report covers the period January 2010 – December 2010, providing relevant audit data, an overview of activity, and information on future areas to be addressed. It contains results for the assessment of performance of West of Scotland (WoS) haemato-oncology cancer services measured against pre-determined clinical outcome measures as agreed by members of the Haemato-oncology MCN. Compliance with regional Clinical Management Guidelines (CMGs) for Hodgkin lymphoma (HL), diffuse large B cell lymphoma (DLBCL) and follicular lymphoma is also reported.

2. Background

Blood cancer encompasses a number of different haematological malignancies – lymphoma, acute leukaemia, chronic leukaemia, multiple myeloma and other plasma cell dyscrasias, myeloproliferative disorders and myelodysplastic syndromes. During 2010 a total of 1045 new haematological malignancies were diagnosed in WoS, the majority of which were treated locally. Tertiary referral is required for autologous and allogeneic stem cell transplantation and may be required for treatment of less common conditions e.g. acute lymphoblastic leukaemia (ALL) or for administration of highly intensive chemotherapy regimens. There is a regional service for adolescents and young adults with haematological malignancies with Teenage Cancer Trust (TCT) in-patient beds and facilities located in the Beatson West of Scotland Cancer Centre (BWoSCC).

2.1 National Context

Non-Hodgkin lymphoma (NHL), the leukaemias and multiple myeloma are in the twenty most commonly diagnosed cancers in the UK in 2008.1 In Scotland, NHL was the seventh most frequently diagnosed malignancy in both males and females with 498 cases registered for each sex.2 HL and leukaemia are among the most common cancers diagnosed in teenagers and young adults (15-24 years) in Scotland and the UK.1 Information Services Division (ISD) Scotland figures from 2008 demonstrate that lymphomas accounted for 22.1% of all cancers diagnosed in teenagers and young adults.3 The incidence of some types of haematological malignancies e.g. NHL, myeloma, chronic lymphocytic leukaemia (CLL) is rising, partly because these cancers are more common with increasing age. The most striking rise is seen in NHL where the UK incidence increased by over 40% over the 20 year period from 1987-2006.4

2.2 West of Scotland Context

The total number of new haematological malignancies registered per annum in the WoS remains fairly static. The number of cases registered in 2010 by disease group is illustrated in Figure 1. Figure 1: Distribution of haematological malignancies in the West of Scotland

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Disease Group Table 1 details the number of cases diagnosed in the WoS by disease group and analysis group. A total of 1045 blood cancers were registered in 2010 compared with 1115 in 2009 (figures from NHS Dumfries & Galloway excluded). Lymphomas continue to account for over 40% of the total registrations each year. The most notable difference from the 2009 cohort is the total number of lymphoproliferative disorders (LPD) registered in WoS, falling from 176 cases to 91 cases. In 2010 there was a slight decrease in the number of LPDs registered in Ayrshire & Arran and South Glasgow whereas the other Health Boards demonstrated a significant fall in the number of cases registered. This may be in part due to changing practice where cell markers are not recommended if lymphocyte count is less than 6 x 109/l, resulting in a lower number of confirmed very early stage, borderline lymphocytosis LPDs.


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Table 1: Disease group distribution in the West of Scotland

Ayrshire & Arran

Clyde Forth Valley Lanarkshire North Glasgow

South Glasgow

WoS

2009 2010 2009 2010 2009 2010 2009 2010 2009 2010 2009 2010 2009 2010

Lymphoma 72 70 69 80 65 46 99 96 124 110 65 78 494 480

Acute Leukaemia 12 14 15 5 18 12 25 30 29 33 6 14 105 108

Chronic Myeloid Leukaemia

3 3 1 2 0 4 3 1 8 6 2 3 17 19

Plasma Cell Dyscrasias

33 44 35 24 18 2 47 36 38 45 23 34 194 185

LymphoproliferativeDisorders

21 18 27 13 20 2 46 20 36 19 26 19 176 91

MyelodysplasticSyndrome

10 22 7 9 5 3 13 21 6 16 11 18 52 89

MyeloproliferativeDisease

19 22 7 9 10 6 11 8 21 13 9 15 77 73

N= 170 193 161 142 136 75 244 212 262 242 142 181 1115 1045

Previous reports have highlighted the need to review methods of capturing cases not diagnosed by tissue biopsy in order to improve registration5 and Table 1 illustrates an increase in the number of blood cancers registered in Ayrshire & Arran and South Glasgow in 2010. In Ayrshire & Arran, this has been primarily due to an increase in the number of plasma cell dyscrasias (PCD) and myelodysplastic syndromes (MDS) registered. In South Glasgow there has been a general increase in all types of blood cancer registration, excluding LPDs which have fallen slightly. Although some of these changes may be due to a fluctuation in incidence, some are more likely to be due to improved registration. The introduction of a weekly Multi-disciplinary Team (MDT) meeting at both sites for the discussion of all haematological malignancies is likely to have contributed to these positive findings. In Forth Valley, the number of blood cancers registered has decreased significantly, falling from 136 cases in 2009 to 75 cases in 2010. In particular, registration of LPDs and PCDs appear incomplete. This is an unexpected finding given that Forth Valley have a well established and structured local MDT at which all haematological malignancies are discussed. Action Required:

Registration of LPDs requires to be improved across the region. Data collection process to be reviewed by all Health Boards.



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Lymphoma Age and Gender Distribution Figure 2 illustrates the distribution of HL and NHL by age and gender. The median age of HL patients was 51 years. In NHL, the median age was 67 years, with 70.8% of patients aged 60 years or over. HL continues to be more common in males (57.4%) than females (42.6%) where as NHL occurs with equal frequency in males (50%) and females (50%). Figure 2: Distribution of Hodgkin lymphoma (left) and non-Hodgkin lymphoma (right) by age and sex in the West of Scotland

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Acute Leukaemia Age and Gender Distribution Figure 3 illustrates the distribution of acute myeloid leukaemia (AML) and acute lymphoblastic leukaemia (ALL) by age. The median age of AML patients was 64 years, with 66.3% of patients aged 60 years or over. The median age of ALL patients was 55 years, with 29.4% aged under 30 years, 17.6% aged 30-60 years and 52.9% of patients aged over 60 years. Figure 3: Distribution of AML (left) and ALL (right) by age in the West of Scotland


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AML continues to be more common in males (57.3%) than females (42.7%). This 1.3 fold excess of AML in the male population reinforces the findings from earlier cohorts (2005-2009).5 A similar pattern is noted for ALL with 76.5% occurrence in males and 23.5% in females.

3. Methodology

Within WoSCAN, haemato-oncology data is collected in the five NHS Boards by Clinical Effectiveness Facilitators (CEFs). Data collection is defined by a pre-determined dataset required to assess performance against agreed Key Outcome Measures (KOMs). Previous audit reports have included data from NHS Dumfries & Galloway however, in 2010 responsibility for the collection of audit data was transferred to local Boards and currently Dumfries & Galloway have no audit resource to support this. The 2010 report therefore contains data from only four NHS Boards. The data collection cycle is over a 12 month period from 1st January to 31st December each year, with analysis of the data approximately eight months following this to take account of the patient pathway and ensure that full treatment data is available. The data is collected locally by CEFs and entered into the electronic Cancer Audit Support Environment (eCASE) system. Analysis is performed centrally by the WoSCAN Information Team and provisional audit reports are issued to each Board to allow for missing data or errors to be rectified before a final download is taken. Final reports are then issued to each Board and results are verified by the clinical lead for that area.

4. Results and Action Required

4.1 Data Quality

Capturing data on the total incident population (or as near as possible to that total) in each organisation is central to the validity of the audit findings. Assessment of population completeness by each Health Board is calculated by comparing the number of new cases identified by audit against the five year average (2004-2008) of cancer registry incidence data. Table 2 indicates the case ascertainment by disease type. Table 2: Case ascertainment

N Expected number of cases

Case Ascertainment (%)

Non-Hodgkin lymphoma (NHL)

400 413 96.8

Hodgkin lymphoma (HL)

68 73 93.1

Acute Leukaemia (AML/ALL)

106 95 111.5

* The number of patients diagnosed each year will naturally vary therefore some Boards may report case ascertainment above 100% and others below. Case ascertainment is intended to be an indication rather than an exact measure. Good case ascertainment is a quality marker of the audit process and the figures in Table 2 are reassuring and provide confidence that the results are representative of the relevant population for the year reported. The high case ascertainment figure for acute leukaemia is likely to be attributable to an increased number of cases being captured through the audit process in recent years rather than a true increase in the number of cases diagnosed.


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4.2 Performance Against Key Outcome Measures

Results for each of the KOMs assessed are presented in graphical format with the underlying data in tabular form where applicable. The data is presented as a combination of bar charts and pie charts. The majority of the results in the charts are displayed as a percentage of the overall number of cases.

4.3 Results

Analysis of Lymphoma Cases 480 lymphomas were diagnosed between 1 January 2010 and 31 December 2010:

68 HL (14.1%) 400 NHL (83%) 10 Primary Cutaneous NHL (2.1%) 2 Not recorded (0.4%)

Pathological Subtypes of Hodgkin Lymphoma Figure 4 illustrates the pathological subtypes of HL. Nodular sclerosing HL accounted for almost half the cases (48.5%) of HL in 2010. The percentage of nodular lymphocyte predominant Hodgkin lymphomas (10.3%) continues to be higher than published data.6 Figure 4: Hodgkin lymphoma by pathological subtype

Classical Hodgkin Lymphoma,

22.1% (n=15)Lymphocyte-

depleted Classical Hodgkin Lymphoma, 2.9%

(n=2)

Lymphocyte-rich Classical HL, 1.5%

(n=1)

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Lymphoma, 14.7% (n=10)

Nodular Lymphocyte Predominant

Hodgkin Lymphoma, 10.3%, (n=7)

Nodular sclerosis classical

HL, 48.5% (n=33)


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Clinical Stage of Hodgkin Lymphoma The distribution of HL by clinical stage is presented in Figure 5, which illustrates that 47% of patients presented with early stage (I or II) disease and 35% of patients presented with advanced stage disease (III or IV). The proportion of cases with stage not recorded (NR) has increased from 6.7% in 2009 to 17.6%. This coincides with the transfer of responsibility for audit data collection to local Health Boards. Figure 5: Hodgkin lymphoma by clinical stage

Stage I, 11.8% (n=8)

Stage 2, 35.3%(n=24)

Stage 3, 19.1%(n=13)

Stage 4, 16.2%(n=11)

NR, 17.6%(n=12)

Planned Treatment of Hodgkin Lymphoma

CMG for HL recommends radiotherapy alone for: Low bulk, stage 1A lymphocyte predominant Hodgkin Lymphoma Clinical stage 1A HL (mass < 5cm), PET scan confirming localised disease and unfit for

chemotherapy The treatment given to newly diagnosed HL patients in 2010 is detailed in Table 3, which shows a similar picture to the 2009 data with the majority of HL patients receiving chemotherapy, and less than 10% of patients receiving radiotherapy alone. The ‘Other’ treatment category includes supportive care, watchful waiting and died before starting treatment.


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Table 3: Treatment choice for Hodgkin lymphoma

2009 2010

N % N %

Chemotherapy 75 84.2 57 83.8

Radiotherapy Only 5 6.7 5 7.4

Other 8 9.0 6 8.8

Not Recorded 1 1.1 0 0.0

N = 89 68

Chemotherapy Treatment for Hodgkin Lymphoma

CMG for HL recommends ABVD chemotherapy as first line treatment in all patients except those who are elderly/frail or have a poor performance status where alternatives e.g. ChlVPP are indicated.

The type of chemotherapy administered to HL patients is detailed in Table 4. Treatment across the WoS continues to show good compliance with the CMG recommendation, with Adriamycin, Bleomycin, Vinblastine, Dacarbazine (ABVD) chemotherapy regimen administered in 86% of cases in 2010. This includes 2 cases where bleomycin was omitted. Table 4: Chemotherapy treatment for Hodgkin lymphoma

2009 2010

N % N %

ABVD 68 90.7 49 86.0

Other 7 9.3 4 7.0

Not Recorded 0 0.0 4 7.0

N = 75 57


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Pathological Subtypes of Non-Hodgkin Lymphoma The pathological subtypes of NHL are illustrated in Figure 6. DLBCL accounted for almost half the cases (46.8%), with follicular NHL and ‘Other’ accounting for 24.9% and 28.2% of the cases respectively. Again, this is a similar picture to that reported for the 2009 cohort.5 Figure 6: Non-Hodgkin lymphoma by pathological subtype

DLBCL, 46.8%(n=187)

Follicular, 24.9%

(n=100)

Other, 28.2%(n=113)

Clinical Stage of Diffuse Large B Cell Lymphoma The distribution of DLBCL by clinical stage is presented in Figure 7, which illustrates that 17.1% of patients presented with stage I disease and 48.6% of patients presented with stage II – IV disease. Stage was not recorded in 64 of the 187 patients (34.2%), which is significantly higher than the 18.9% figure reported in the previous cohort.5 Figure 7: Diffuse large B cell lymphoma by clinical stage

Stage 1, 17.1%(n=32)

Stage 2, 13.9%(n=26)

Stage 3, 16%

(n=30)Stage 4, 18.7%(n=35)

NR, 34.2%(n=64)


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Planned Treatment of Diffuse Large B Cell Lymphoma

CMG for DLBCL recommends chemotherapy as the initial treatment of choice.

Table 5 details the treatment given to newly diagnosed DLBCL patients in 2010 and shows that 82% of DLBCL patients received chemotherapy. Five patients (2.7%) received radiotherapy alone and only 1.6% of patients received surgery. Again, this is a similar picture to that reported for the 2009 cohort5 and shows compliance with the CMG. The ‘Other’ treatment category includes supportive care, watchful waiting, died before treatment and refusal of treatment. Table 5: Treatment choice for DLBCL

Ayrshire & Arran

Clyde Forth Valley

Lanarkshire North Glasgow

South Glasgow

WoS

N % N % N % N % N % N % N %

Chemotherapy 20 80.0 25 75.8 12 80.0 32 86.5 35 87.5 29 78.4 153 81.8

Radiotherapy 0 0.0 1 3.0 0 0.0 1 2.7 3 7.5 0 0.0 5 2.7

Surgery 0 0.0 1 3.0 0 0.0 1 2.7 0 0.0 1 2.7 3 1.6

Other 5 20.0 6 18.2 3 20.0 3 8.1 2 5.0 7 18.9 26 13.9

N = 25 33 15 37 40 37 187

Chemotherapy Treatment for Diffuse Large B Cell Lymphoma

DLBCL CMG recommendation* – chemotherapy regimen: R-CHOP as first line therapy R-CODOX-M/IVAC – consider if high IPI (3-5) in younger, fit patients** R-GCVP – consider if impaired ejection fraction or other co-morbidities in which

anthracyclines should be avoided** * as per DLBCL CMG v2 (January 2009) which has since been updated to v3 (December 2011) ** in context of current NCRI clinical trials

The type of chemotherapy administered is detailed in Table 6. Comparison with the 2009 cohort illustrates a significant increase in the percentage of patients being given Cyclophosphamide, Doxorubicin, Vincristine, Prednisolone (CHOP) chemotherapy regimen (1% to 8.5%) and a decrease in the number of patients receiving Rituximab, Cyclophosphamide, Doxorubicin, Vincristine, Prednisolone (R-CHOP) (86% to 68.6%). A high percentage of cases in Forth Valley and Clyde received CHOP alone. A number of unexpected findings which potentially demonstrate non-compliance with the CMG require clarification from Health Boards, and these have been detailed in the Action Required section below. Further enquiries in Clyde revealed that patients received CHOP cycle 1 followed by R-CHOP for subsequent cycles.


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Table 6: Chemotherapy treatment for DLBCL

Ayrshire & Arran

Clyde Forth Valley


South Glasgow

WoS

N % N % N % N % N % N % N %

RITUXIMAB ONLY

0 0.0 0 0.0 0 0.0 1 3.1 1 2.9 0 0.0 2 1.3

CHOP ONLY 1 5.0 7 28.0 4 33.3 0 0.0 0 0.0 1 3.4 13 8.5

R-CHOP 17 85.0 13 52.0 4 33.3 23 71.9 31 88.6 17 58.6 105 68.6

Other + Rituximab

1 5.0 0 0.0 0 0.0 8 25.0 2 5.7 2 6.9 13 8.5

Other -Rituximab

1 5.0 3 12.0 0 0.0 0 0.0 1 2.9 7 24.1 12 7.8

Not Recorded 0 0.0 2 8.0 4 33.3 0 0.0 0 0.0 2 6.9 8 5.2

N= 20 25 12 32 35 29 153

Action Required:

Forth Valley to review and comment on reason for CHOP only in 33% of cases. Clyde to review and comment on reason for omitting Rituximab with first course in 28% of

cases. Lanarkshire to provide further information on why 25% of cases received alternative (i.e. non-

CHOP) chemotherapy with Rituximab. South Glasgow to provide further information on regimen (other – Rituximab) used in 24% of

cases. Clinical Stage of Follicular Lymphoma Figure 8 illustrates the distribution of follicular lymphoma by clinical stage at presentation. As expected, a higher percentage of patients with follicular NHL presented with advanced stage (III or IV) disease (54%) in comparison to 24% who presented with stage I or II disease. Once again, there has been a significant rise in the number of cases with stage not recorded (22%). Figure 8: Follicular lymphoma by clinical stage


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Stage 1, 12%(n=12)

Stage 2, 12%(n=12)

Stage 3, 30%(n=30)

Stage 4, 24%(n=24)

NR, 22%(n=22)

Planned Treatment of Follicular Lymphoma

CMG for follicular NHL recommends: Stage 1, small volume disease – involved field radiotherapy Asymptomatic, low bulk, no marrow failure – watch & wait or NCRI trial of Rituximab

versus Watch and Wait (now closed) Symptomatic, bulk, marrow failure - chemotherapy

Table 7 details the treatment given to newly diagnosed follicular NHL cases. In 2010, there was a reduction in the number of patients receiving chemotherapy, 42% compared to 46% in 2009. In contrast, there has been an increase in the proportion of patients initially entering a period of watchful waiting, 42% compared to 39% in 2009. Ten patients (10%) received radiotherapy alone. The ‘Other’ category included supportive care, surgery and died before treatment. Although 42% of patients across the WoS entered an initial period of watchful waiting, there was marked variation between Health Boards ranging from 20% in South Glasgow to 58.8% in Clyde. Table 7: Treatment choice for follicular lymphoma

Ayrshire & Arran

Clyde Forth Valley


South Glasgow

WoS

N % N % N % N % N % N % N %

Chemotherapy 6 60.0 5 29.4 7 53.8 8 32.0 8 40.0 8 53.3 42 42.0

Radiotherapy 0 0.0 1 5.9 2 15.4 3 12.0 2 10.0 2 13.3 10 10.0

Watchful Wait 3 30.0 10 58.8 4 30.8 14 56.0 8 40.0 3 20.0 42 42.0

Other 1 10.0 1 5.9 0 0.0 0 0.0 2 10.0 2 13.3 6 6.0

N = 10 17 13 25 20 15 100

Chemotherapy Treatment for Follicular Lymphoma

Follicular lymphoma CMG recommendation* - chemotherapy regimen: R-CVP R-CHOP – consider if clinically aggressive or FLIPI ≥ 3 Chlorambucil + Dexamethasone +/- Rituximab – consider in frail patients * as per follicular NHL CMG v2 (Jan 2009) which has since been updated to v3 (Nov 2011)

The type of chemotherapy administered is detailed in Table 8. The percentage of patients prescribed Rituximab, Cyclophosphamide, Vincristine, Prednisolone (R-CVP) chemotherapy regimen has been relatively stable over the last 4 years, ranging from 58% in 2007 to 53% in 2009 and 2010. Comparison with the 2009 cohort demonstrates a decrease in the use of R-CHOP in this patient group, falling from 37% to 26% in 2010. This figure is more in keeping with results from the 2007 and 2008 cohort which reported figures of 24% and 30% respectively.


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Table 8: Chemotherapy treatment for follicular lymphoma

Ayrshire & Arran

Clyde Forth Valley


South Glasgow

WoS

N % N % N % N % N % N % N %

R-CVP 4 66.7 4 80.0 2 28.6 4 50.0 6 75.0 4 50.0 24 57.1

R-CHOP 2 33.3 0 0.0 2 28.6 3 37.5 1 12.5 3 37.5 11 26.2

CHOP Only 0 0.0 0 0.0 2 28.6 1 12.5 0 0.0 0 0.0 3 7.1

Other -Rituximab

0 0.0 1 20.0 0 0.0 0 0.0 1 12.5 0 0.0 2 4.8

NR 0 0.0 0 0.0 1 14.3 0 0.0 0 0.0 1 12.5 2 4.8

N= 6 5 7 8 8 8 42

The use of R-CHOP varies from 0% (Clyde) to 37.5% (Lanarkshire and South Glasgow) however numbers are small and should be interpreted with caution. CHOP +/-R is given as first line treatment to 57.2% of patients in Forth Valley, with half of the patients receiving CHOP alone. This is likely to be due to a data collection issue however further investigation is required locally to ensure practice complies with CMG recommendations. Action Required:

Forth Valley to review and comment on figures for CHOP +/- R as first line treatment.

Recording of Clinical Stage Assessment of clinical stage is performed for both prognostic and therapeutic purposes. Failure to accurately record clinical stage makes it difficult to determine compliance with CMGs. Table 9 shows the number of cases with clinical stage not recorded by disease type and analysis group. Table 9: Cases with clinical stage not recorded

Ayrshire & Arran

Clyde Forth Valley


South Glasgow

WoS

HL Stage Not Recorded

0/8 4/15 2/4 1/8 2/23 3/10 12/6817.6%

DLBCL Stage Not Recorded

7/25 19/33 9/15 2/37 2/40 25/37 64/18724.2%

Follicular Stage Not Recorded

0/10 5/17 4/13 0/25 6/20 7/15 22/10022%

Total Stage Not Recorded

7/4316.3%

28/6543.1%

15/3246.9%

3/704.3%

10/8312.0%

35/6256.4%

98/35527.6%

It is important to note that the number of lymphoma cases where stage has not been recorded has almost doubled from last year’s figure of 14.6% and is four times greater than the figure from the


18


19

2007/2008 cohort (6.0%).7 Of particular concern is the percentage of cases with stage not recorded in Clyde (43%), South Glasgow (56%) and Forth Valley (47%). The recording issue in South Glasgow and Clyde may be partly explained by the absence of a structured local MDT in 2010. In Forth Valley however, there is a well structured local weekly MDT at which a MDT template is completed which includes recording of clinical stage. This should therefore be explored further to facilitate the development of robust data collection processes. Recording of stage data in Lanarkshire was more complete with only 3 of the 70 cases having stage not recorded. Action Required:


KOM 1: Patients with newly diagnosed Hodgkin lymphoma should have staging PET/CT scan performed. The WoSCAN HL CMG (version 3, July 2009) recommends a staging PET/CT scan for all patients at diagnosis. This aims to refine staging (upstage/downstage) and provide a baseline for comparison if PET is performed in the future. The percentage of patients undergoing staging PET/CT scan is illustrated in Figure 9. There appears to be variation in practice across Health Boards ranging from 37.5% in Ayrshire & Arran to 87% in North Glasgow. Figure 9: Percentage of patients undergoing PET/CT Scan

0

10

20

30

40

50

60

70

80

90

100

Ayrshire & Arran

Clyde Forth Valley Lanarkshire North Glasgow South Glasgow WoS

Pe

rce

nta

ge

of

Pa

tie

nts

Analysis Group

Ayrshire & Arran

Clyde Forth Valley


South Glasgow

WoS

n % n % n % n % n % n % n %

N 3 37.5 10 66.7 2 50.0 4 50.0 20 87.0 6 60.0 45 66.2

D 8 15 4 8 23 10 68

Action Required

All Health Boards to review and comment on cases where staging PET/CT was not performed.


20


21

KOM 2: All patients with a new diagnosis of lymphoma should have pathology reviewed by a member of the Regional Lymphoma Pathology Review Group. Improving Outcomes Guidance (NICE 2003) identified accurate diagnosis as being one of the most important aspects of lymphoma management.8 It is recognised that 10-15% of lymphoma cases are misdiagnosed, potentially resulting in inappropriate therapy. Specialist reporting in lymphoma is considered optimal delivery of service and has become the norm throughout the UK. It was recognised that central review in the WoS by a single lymphoma pathologist was unsustainable and an alternative model was introduced with the establishment of a designated consultant pathologist in the main hospitals throughout the WoS who would take responsibility for lymphoma reporting and would participate in the monthly Regional Lymphoma Pathology Review Group meeting. In 2010, there was a designated lymphoma pathologist in Glasgow Royal Infirmary (GRI) (covering North Glasgow), Southern General (covering South Glasgow), Crosshouse (covering Ayrshire and Arran) and Stirling (covering Forth Valley). Although there was no designated lymphoma pathologist in Lanarkshire or Clyde in 2010, all cases were seen by a lymphoma pathologist in GRI. Lymphoma CMGs state that all pathology should be reviewed by a member of the Regional Lymphoma Pathology Review Group. However, there is no data readily available to determine the percentage of cases which meet this recommendation. The only data available to provide some indication of review numbers comes from the lists of patients formally reviewed at the monthly meetings of the Regional Lymphoma Pathology Review Group. Of the 480 lymphoma cases diagnosed in 2010, 111 (23.1%) were discussed at the Regional Lymphoma Pathology Review Group meeting. It is acknowledged however, that this figure greatly underestimates the number of lymphoma cases reviewed by a member of the Regional Lymphoma Pathology Review Group. The majority of cases from North Glasgow, Lanarkshire and Clyde were reviewed internally by the two lymphoma pathologists based at GRI. Given the time constraints on the number of patients which can be reviewed at the monthly meeting, these cases were not routinely discussed at the Review Group meeting unless a wider expert opinion was sought. The majority of cases from South Glasgow, Ayrshire & Arran and Forth Valley were reported or reviewed by the local lymphoma pathologist. It would appear that the majority of cases across the region satisfy this KOM, although formal documentation to support this is not currently available.


22

KOM 3: Patients aged 16-24 years diagnosed with lymphoma should be discussed at the Regional Haemato-oncology MDT meeting. The teenage and young adult (TYA) group was singled out for discussion in the 2005 National Institute for Health and Clinical Excellence guidance “Improving outcomes in children and young people with cancer.” 9 This document was to serve as a benchmark for future planning and delivery of cancer services for children and young people in Scotland as stated in the National Delivery Plan for Scotland. One of its key recommendations was for all care to be delivered through an appropriately constituted MDT.

In August 2010, the Regional Cancer Advisory Group (RCAG) endorsed the proposal from the Haemato-oncology MCN that all TYA patients with a haematological malignancy should be discussed at the Regional Haemato-oncology MDT. In 2010, 14 patients aged 16-24 years were diagnosed with a haematological malignancy; 9 lymphomas, 4 acute leukaemias and 1 chronic myeloid leukaemia (CML). Only 1 patient was diagnosed after RCAG endorsement of the proposal in August and this patient was discussed at the regional MDT as recommended. One further patient diagnosed in July 2010 was presented at the regional MDT for discussion of the management plan. The 12 cases not discussed at the regional MDT were all diagnosed before August 2010. It is anticipated that analysis of performance against this outcome measure will produce more meaningful results for patients diagnosed during 2011, following full implementation of this recommendation.

KOM 4: Proportion of patients with lymphoma entered into clinical trials One of the Scottish Cancer Research Network’s initial targets was to double trial recruitment over a 3 year period from a baseline of 3.7% of cancer patients. By 2005/2006, recruitment rates had risen to 13.9%. Better Cancer Care, An Action Plan (2008) aimed to set new targets to support increased recruitment of patients to trials, to ensure recruitment continued to exceed 13.9%.10 Table 10 shows the number of patients entered into clinical trials across the region, ranging from 0% (Ayrshire & Arran and South Glasgow) to 10.9% (North Glasgow). However these figures should be interpreted with caution given the number of cases coded as not recorded/not applicable. Table 10: Lymphoma Clinical Trials

Ayrshire & Arran

Clyde Forth Valley


South Glasgow

WoS

N % N % N % N % N % N % N %

Entered Trial 0 0.0 2 2.5 1 2.2 6 6.2 12 10.9 0 0.0 21 4.4

No TrialAvailable

61 87.1 19 23.7 40 86.9 83 86.4 76 69.1 58 74.3 337 70.2

Other 0 0.0 3 3.8 4 8.7 2 2.1 4 3.6 0 0.0 13 2.7

Not Applicable 9 12.9 26 32.5 1 2.2 5 5.2 5 4.5 4 5.1 50 10.4

Not Recorded 0 0.0 30 37.5 0 0.0 0 0.0 13 11.8 16 20.5 59 12.3

N = 70 80 46 96 110 78 480

One of the challenges in trial participation is that most patients with haematological malignancies are treated locally. Given small number of patients involved and the intensive amount of work required in setting up a trial, very few clinical trials are opened. Action Required:

Health Boards to encourage all sites to open trials where recruitment is likely to be high e.g. 1st line therapy for DLBCL and HL.

Health Boards to encourage referral into BWoSCC for trials open for patients with less common conditions, relapsed patients and commercial studies.


23

Analysis of Acute Leukaemia Cases A total of 108 acute leukaemias were diagnosed between 1 January 2010 and 31 December 2010. Registration of Cases The numbers of AML and ALL cases (by disease type and analysis group) are illustrated below and summarised in Figure 10. The total number of AML cases per year in the WoS has remained very stable over the last three years, with 93 cases registered in 2010 compared to 92 and 91 cases registered in 2008 and 2009 respectively. There has also been little change in the number of ALL cases registered during this three year period with 13 cases registered in 2010 compared to 11 and 14 cases registered in 2008 and 2009 respectively. Cases from Dumfries & Galloway are not included. Figure 10: Registration of Acute Leukaemia Patients

0

5

10

15

20

25

30

35

Ayrshire & Arran


South Glasgow

Nu

mb

er

of

Pa

tie

nts

Analysis Group

AML ALL NOS NR

Ayrshire & Arran


South Glasgow

WoS

AML 13 3 9 27 29 12 93

ALL 1 2 2 2 4 2 13

NOS 0 0 1 0 0 0 1

NR 0 0 0 1 0 0 1

N= 14 5 12 30 33 14 108


24

Planned Treatment of AML Table 11 details the planned therapy for AML patients diagnosed in 2010. Figures for 2009 are included for reference. The results are very similar to the previous cohort with half the patients receiving intensive chemotherapy aimed at remission induction and almost one third of patients being given supportive care only. Table 11: Planned Treatment for AML Patients

Planned Therapy 2009 2010

N % N %

Intensive Chemotherapy 49 50.5% 48 51.6%

Low Dose PalliativeChemotherapy

9 9.3% 9 9.7%

Supportive Care Only 25 25.8% 29 31.2%

Other 8 8.2% 0 0.0

None 4 4.1% 2 2.2%

Not Recorded 2 2.1% 5 5.4%

Total 97 93

The planned therapy for ALL patients is shown in Table 12. There appears to be a fall in the number of cases being treated intensively in the current cohort. However, numbers are small and should be interpreted with caution. Furthermore, in the current cohort, 52.9% of patients were aged over 60 years which is considerably higher than the average figure for the 2005-2009 cohort of 33.8%. This is likely to explain any differences in treatment intensity. Table 12: Planned Therapy for ALL Patients

Planned Therapy 2009 2010

N % N %

Intensive Chemotherapy 12 80.0% 8 61.5%

Low Dose PalliativeChemotherapy

1 6.7% 1 7.7%

Supportive Care Only 2 13.3% 2 15.4%

None 0 0.0% 2 15.4%

Total 15 13


25

KOM 5: Proportion of patients with acute leukaemia who have cytogenetics performed at diagnosis. The diagnostic pathway is the single most important part of modern haematological cancer care. Cytogenetics seeks to find acquired chromosome changes (somatic cell mutations) as opposed to constitutional (hereditary) chromosome changes providing diagnostic and prognostic information. The proportion of patients with acute leukaemia who have cytogenetics performed at diagnosis is illustrated in Figure 11. There appears to be variation in practice across the region ranging from 50% in Forth Valley to 100% in Clyde*, with a WoS average of 68.5%. These figures are unexpected, and are likely to represent the difficulty in accessing the results in case notes and clinical systems. This highlights the need, already identified by the Haemato-oncology MCN, for the development of improved lab information systems. Figure 11: Cytogenetics performed at diagnosis

0

10

20

30

40

50

60

70

80

90

100

Ayrshire Clyde Forth Valley


South Glasgow

WoS

Pe

rce

nta

ge

of

Pa

tie

nts

Analysis Group

Ayrshire Clyde Forth Valley


South Glasgow

WoS

Performed 10 5 6 21 24 8 74

Not Performed

4 0 2 8 4 3 21

NR 0 0 4 1 5 3 13

N= 14 5 12 30 33 14 108

* Clyde cases fit for intensive therapy are managed in North Glasgow. Action Required:

Haemato-oncology MCN to continue to highlight the need for integrated reporting of test results and the development of an IT system for improving blood cancer diagnostics in the WoS.


26

KOM 6: Proportion of patients with acute leukaemia who have immunophenotyping performed at diagnosis. The diagnostic pathway is the single most important part of modern haematological cancer care. Immunophenotyping will increase the accuracy of diagnosis. Figure 12 illustrates the proportion of patients with acute leukaemia who have immunophenotyping performed at diagnosis. Once again there appears to be variation in practice across Health Boards ranging from 33.3% in Forth Valley to 100% in Clyde, with a WoS average of 84.3%. These figures are unlikely to be representative and true figures are thought to be higher. Again, information access and collation is likely to be a significant problem here which reinforces the need for an IT system for improving blood cancer diagnostics. Figure 12: Immunophenotyping performed at diagnosis

0

10

20

30

40

50

60

70

80

90

100

Ayrshire & Arran

Clyde Forth Valley


South Glasgow

WoS

Pe

rce

nta

ge

of

Pa

tie

nts

Analysis Group

Ayrshire & Arran

Clyde Forth Valley


South Glasgow

WoS

Performed 12 5 4 27 32 11 91

Not Performed

2 0 3 2 1 2 10

NR 0 0 5 1 0 1 7

N= 14 5 12 30 33 14 108

Action Required:



27

KOM 7: All patients diagnosed with AML, <60years, should receive first treatment within 5 days of diagnosis. The number of patients with AML aged under 60 years who received treatment within five days of diagnosis is shown in Figure 13. Further to the development of this KOM, a WoS audit (awaiting publication) has shown that there is no statistical difference in outcome between patients treated within 5 days of diagnosis and those treated >5 days. Figure 13: Treatment Within 5 days

Treat within 5 days of

diagnosis, 58.1%(n=18)

Treatment > 5 days from Diagnosis,

38.7% (n=12)

Not recorded, 3.2% (n=1)

KOM 8: Number of patients with acute leukaemia entered into clinical trials Table 13 details the number of patients with acute leukaemia entered into clinical trials. Clinical trial entry is good and well above the UK average for cancer in general. The reasons for significant local variation, however, should be explored. Table 13: Leukaemia Clinical Trials

Ayrshire & Arran

Clyde Forth Valley


South Glasgow

WoS

N % N % N % N % N % N % N %

Entered Trial 6 42.9 0 0.0 1 9.1 15 51.7 16 48.5 2 14.3 40 37.7

No TrialAvailable

1 7.1 0 0.0 3 27.3 3 10.3 3 9.1 0 0.0 10 9.4

Other 3 21.4 1 20.0 2 18.2 11 37.9 5 15.1 1 7.1 23 21.7

Not Applicable 4 28.6 0 0.0 0 0.0 0 0.0 3 9.1 4 28.6 11 10.4

Not Known 0 0.0 4 80.0 5 45.5 0 0.0 6 18.2 7 50.0 22 20.8

N = 14 5 11 29 33 14 106

Action Required:


28 All Boards to review and comment on trial participation figures.


29

5. Conclusions We are encouraged by the continued support and commitment of Network members to deliver a high quality service to haemato-oncology patients across the WoS. In particular, we are pleased to note the progress made in establishing well-structured weekly local MDTs across all sites/Health Boards to complement the function of the Regional Haemato-oncology MDT. It is anticipated that this will lead to an improvement in case ascertainment and quality of data recording in future reports. A number of actions have been identified through the audit data analysis, many of which relate to service provision, CMG compliance or a continued commitment to data quality improvement. Action Required: Service Improvement

All Health Boards to encourage sites to open trials where recruitment is likely to be high e.g. 1st line therapy for DLBCL and HL.

All Health Boards to encourage referral into the BWoSCC for trials open for patients with less common conditions, relapsed patients and commercial studies.

Haemato-oncology MCN to continue to highlight the need for integrated reporting of test results and the development of an IT system for improving blood cancer diagnostics in the WoS to enable full assessment of performance against KOMs 5 and 6 in future analysis.


All Health Boards to review and comment on acute leukaemia clinical trial participation figures. CMG Compliance

All Health Boards to review and comment on cases where staging PET/CT was not performed in patients with newly diagnosed HL.

Forth Valley to review and comment on reason for CHOP chemotherapy regimen only in 33% of cases with DLBCL.

Clyde to review and comment on reason for omitting Rituximab with first course in 28% of cases with DLBCL.

Lanarkshire to provide further information on why 25% of cases with DLBCL received alternative (i.e. non-CHOP) chemotherapy with Rituximab.

South Glasgow to provide further information on regimen (other – Rituximab) used in 24% of cases with DLBCL.

Forth Valley to review and comment on figures for CHOP +/- R as first line treatment for follicular lymphoma.

Data Quality Improvement

Registration of lymphoproliferative disorders requires to be improved across the region. Data collection process to be reviewed by all Health Boards.



The MCN will actively take forward regional actions identified and Health Boards are asked to develop local Action/Improvement Plans in response to the findings presented in the report. Progress against these plans will be monitored by the MCN Advisory Board and reported to RCAG annually by Board Clinical Leads and MCN Lead Clinicians, as part of the regional governance process to enable RCAG to review and monitor regional improvement.


30

Acknowledgement This report has been prepared using clinical audit data provided by the following Health 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 MCN for their continued support, 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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References 1. Cancer Research UK

http://info.cancerresearchuk.org/cancerstats/incidence/commoncancers/index.htm 2. Cancer in Scotland (October 2011): Information Services Division, NHS National Services

Scotland 3. Cancers in Teenagers and Young Adults in Scotland (1979-2008) (March 2011): Information

Services Division, NHS National Services Scotland 4. Cancer Research UK http://info.cancerresearchuk.org/cancerstats/types/nhl/incidence/index.htm#trends 5. Network Activity and Clinical Audit Report (November 2011); West of Scotland Cancer Network; Haemato-oncology Managed Clinical Network.

6. Swerdlow, S.H., Campo, E., Harris, N.L., Jaffe, E.S., Pileri, S.A., Stein, H., Thiele, J., Vardiman, J.W (Eds): World Health Organisation Classification of Tumours of Haematopoietic and Lymphoid Tissues, Fourth Edition. IARC Press: Lyon 2008. 7. Network Activity and Clinical Audit Report (June 2010); West of Scotland Cancer Network; Managed Clinical Network for Haemato-oncology. 8. National Institute for Health and Clinical Excellence (2003). Guidance on Cancer Services.

Improving Outcomes in Haematological Cancers. 9. National Institute for Health and Clinical Excellence (2005). Improving Outcomes in Children

and Young People with Cancer. 10. Better Cancer Care, An Action Plan. The Scottish Government, Edinburgh 2008.

http://info.cancerresearchuk.org/cancerstats/incidence/commoncancers/index.htm

http://www.isdscotland.org/Health-Topics/Cancer/Publications/2011-10-25/Cancer_in_Scotland_summary_m.pdf

http://www.isdscotland.scot.nhs.uk/Health-Topics/Cancer/Publications/2011-03-29/2011-03-29-TYACancer-Report.pdf?19845217467

http://info.cancerresearchuk.org/cancerstats/types/nhl/incidence/index.htm#trends

http://www.woscan.scot.nhs.uk/UserFiles/Haem-onc%20report_final.pdf


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Abbreviations

ABVD Chemotherapy regimen: Adriamycin, Bleomycin, Vinblastine, Dacarbazine ALL Acute Lymphoblastic Leukaemia AML Acute Myeloid Leukaemia BWoSCC Beatson West of Scotland Cancer Centre CEF Clinical Effectiveness Facilitator ChlVPP Chemotherapy regimen: Chlorambucil, Vinblastine, Procarbazine,

Prednisolone CHOP Chemotherapy regimen: Cyclophosphamide, Doxorubicin, Vincristine,

Prednisolone CLL Chronic Lymphocytic Leukaemia CMG Clinical Management Guideline CML Chronic Myeloid Leukaemia CT Computerised Tomography DLBCL Diffuse Large B cell Lymphoma eCASE Electronic Cancer Audit Support Environment GRI Glasgow Royal Infirmary HL Hodgkin Lymphoma ISD Information Services Division KOM Key Outcome Measure LPD Lymphoproliferative Disorders MCN Managed Clinical Network MDS Myelodysplastic Syndrome MDT Multi-disciplinary Team NHL Non-Hodgkin Lymphoma NICE National Institute for Health and Clinical Excellence NLPHL Nodular Lymphocyte Predominant Hodgkin Lymphoma PCD Plasma Cell Dyscrasias


33

PET Positron Emission Tomography QPI Quality Performance Indicator RCAG Regional Cancer Advisory Group R-CHOP Chemotherapy regimen: Rituximab, Cyclophosphamide, Doxorubicin,

Vincristine, Prednisolone R-CODOX-M/IVAC Chemotherapy regimen: Rituximab, Cyclophosphamide, vincristine,

doxorubicin, high-dose methotrexate / ifosfamide, etoposide and high-dose cytarabine

R-CVP Chemotherapy regimen: Rituximab, Cyclophosphamide, Vincristine,

Prednisolone R-GCVP Chemotherapy regimen: Rituximab, Gemcitabine, Cyclophosphamide,

Vincristine, Prednisolone TCT Teenage Cancer Trust TYA Teenage and Young Adult WoS West of Scotland WoSCAN West of Scotland Cancer Network

mcn audit report - woscan.scot.nhs.uk...information services division (isd) scotland figures from...

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