National OesophagoGastric Cancer Audit

Key Findings from 2014 Annual Report and Progress Report

Georgina ChadwickClinical Research Fellow

465 cases submitted to auditDiagnosed between 1st April 2012 & 31st March 2013.

Source of referral 52.9% Symptomatic39.4% Barretts surveillance7.7% Unknown.79.4% Diagnosis confirmed by 2nd pathologist.86.0% cases had treatment planned at MDT.High Grade Dysplasia (HGD) of the Oesophagus

Treatment Plan for HGDPlanned treatment 1/3 patients currently managed surveillance aloneThis goes against BSG recommendations.

For HGD and Barretts-related adenocarcinoma confined tothe mucosa, endoscopic therapy is preferred over oesophagectomyor endoscopic surveillance.Fitzgerald RC et al. British Society of Gastroenterology guidelines on the diagnosis and management of Barrett's oesophagus. Gut. 2014;63(1):7-42.

Confirm all diagnoses of HGD with 2nd pathologist.Discuss all patients with HGD at a specialist MDT for oesophagogastric cancer.This team should include an interventional endoscopist, upper GI cancer surgeon, radiologist and a GI pathologist.Consider all patients with HGD for active treatment.Refer patients to a specialist centre where local expertise is not available.

Recommendations for HGD

Audit prospectively collected data on:Patients diagnosed with invasive epithelial OG cancerDiagnosed in NHS hospital in England or WalesAged over 18 at diagnosis.

22,832 cases submitted Patients diagnosed: 1st April 2012 & 31st March 201378.6% case ascertainment.

Oesophago-gastric (OG) Cancer

Proportion treated with curative intent increased to 37.3% vs 2010 Report.

For squamous cell cancers - Use of definitive chemoradiotherapy increased (31% to 39%).For early cancers (T0/1,N0,M0) Increased use of endoscopic resection.

Treatment Plan for OG cancer

Overall 5,396 surgical records were submitted95.0% Curative intent4.3% Palliative intent and 0.7% Unknown.

Curative surgery2,986 Oeosphagectomies1,807 Gastrectomies

Increase in proportion of minimally invasive (MI) operationsOesophagectomies: 41.5% MI or HybridGastrectomies: 15.9% MI.

Surgery

BSG guidelines Oesophageal cancer - Preoperative chemoradiation improves long-term survival over surgery aloneGastric cancer - Perioperative combination chemotherapy conveys a significant survival benefit and is a standard of care.Surgery with adjunct oncologyAllum W, Blazeby J, Griffin S, Cunningham D, Jankowski J, Wong R. Guidelines for the management of oesophageal and gastric cancer. Gut. 2011;60(11):1449-72.Proportion of patients with locally advanced disease managed surgically who received additional oncological therapy.

Chart1

20.3275.484.19

27.5569.812.64

36.859.453.78

35.4358.276.3

23.1374.632.24

16.4380.283.29

45.648.85.6

39.5953.986.43

66.3831.91.72

28.0657.5514.39

31.1163.864.82

14.0977.278.64

30.7753.8515.38

13.5181.085.41

Surgery alone

Chemotherapy and surgery

Chemoradiotherapy and surgery

SCN

% Patients

Sheet1

Surgery aloneChemotherapy and surgeryChemoradiotherapy and surgery

CN0120.3275.484.19

CN0227.5569.812.64

CN0336.859.453.78

CN0435.4358.276.3

CN0523.1374.632.24

CN0616.4380.283.29

CN0745.648.85.6

CN0839.5953.986.43

CN0966.3831.91.72

CN1028.0657.5514.39

CN1131.1163.864.82

CN1214.0977.278.64

North Wales30.7753.8515.38

South Wales13.5181.085.41

Sheet1

Surgery alone

Chemotherapy and surgery

Chemoradiotherapy and surgery

SCN

% Patients

Sheet2

Sheet3

Fall in both 30 and 90 day mortality post curative oesophagectomy and gastrectomy.Surgical Outcomes

Oesophagectomy (%)Gastrectomy (%)201020142010201430-Day mortality3.82.44.52.390-Day mortality5.74.46.94.5

Funnel plots looking at mortality for all Trusts performing curative surgery for OG cancer, demonstrate no significant variation across trusts after adjusting for known confounders.Surgical Outcomes

Reported for English patients only.

Oesophagectomy1 in 3 suffered any complicationMost frequently respiratory affecting 17.7%Statistically significant rise in proportion suffering respiratory or gastric complication after oesophagectomy vs 2010 Audit Report.Surgical complications

Surgical ComplicationsReported for English patients only. Oesophagectomy1 in 3 suffered any complicationMost frequently respiratory affecting 17.7%Statistically significant rise in proportion suffering respiratory or gastric complication after oesophagectomy vs 2010 Audit Report Variation in key complication rates by surgical approach.* Statistically significant increased risk of leak with MI surgery compared to open. ** Rise since 2010, statistically significant and needs investigation.

OesophagectomyOpenHybridMIOverallAny Complication34.5%36.3%33.9%33.0%Anastomotic Leak6.7%7.1%11.7%*7.1%Respiratory complication18.1%20.1%14.1%17.1%**

Surgical ComplicationsGastrectomy1 in 5 suffered any complicationMost frequently unplanned return to theatre affecting 8.1%No significant change in complication rates since the 2010 Audit ReportVariation in key complication rates by surgical approach.

GastrectomyOpenMIOverallAny Complication19.6%16.5%19.0%Unplanned return to theatre7.7%10.6%8.1%

Resection MarginsAim of surgery is to achieve tumour free resection margins.Proportion of patients who had had an oesophagectomy who had positive longitudinal resection margin has fallen from 6.4% in 2010 to 3.7% in the 2014 Report.BUT 9.1% of patients having a gastrectomy have an incomplete resection.

OesophagectomyGastrectomyTotalnOverall %nOverall %nOverall %Positive long. (prox or dist resection margin983.7%1449.1%2425.7%Positive circ. Margin68527.7%11310.5%79822.5%

For first time radiotherapy dataset linked to NOGCA 90.6% (n=2516) of RTDS Records linked successfully.Radiotherapy treatment regimen, aligned with RCR recommendations for:59.7% patients treated with definitive chemoradiotherapy for oesophageal cancer46.4% patients treated with curative radiotherapy alone.

RTDS dataset will allow further exploration of use of radiotherapy in future.

Definitive Oncology RTDS Link

58.9% OG cancers diagnosed in patients aged 70yrs or over.Treatment: Nationally no difference in proportion managed with curative intent according to age, after risk adjustmentAt local level, there was significant variation in proportion of elderly patients managed with curative intent. OG cancer in elderly

Chart1

3780.24867724870.040.04

5780.33737024220.040.04

6490.26810477660.030.03

7640.34816753930.030.03

9190.33297062020.030.03

9560.28765690380.030.03

9790.26455566910.030.03

11010.31335149860.030.03

12710.23367427220.020.02

12910.31603408210.030.03

13880.26152737750.020.02

14780.2983761840.020.02

2080.25961538460.060.06

4050.22716049380.040.04

TOTAL

% Curative Intent

SCN

% Managed with curative intent

Number of Patients

Elderly

Curative tx in over 70s

SCNCurativeTOTAL% Cure

CN0127595629%CN093780.2486772487

CN02345110131%CN045780.3373702422

CN034411,47830%CN116490.2681047766

CN0419557834%CN107640.3481675393

CN0530691933%CN059190.3329706202

CN062971,27123%CN019560.2876569038

CN073631,38826%CN129790.2645556691

CN084081,29132%CN0211010.3133514986

CN099437825%CN0612710.2336742722

CN1026676435%CN0812910.3160340821

CN1117464927%CN0713880.2615273775

CN1225997926%CN0314780.298376184

NORTH WALES5420826%NORTH WALES2080.2596153846

SOUTH WALES9240523%SOUTH WALES4050.2271604938

35691236529%

Data for chart

CI

SCNTOTAL% Curative IntentNegativePositive

CN0937825%0.040.04FIGURE 8.1

CN0457834%0.040.04

CN1164927%0.030.03

CN1076435%0.030.03

CN0591933%0.030.03

CN0195629%0.030.03

CN1297926%0.030.03

CN02110131%0.030.03

CN06127123%0.020.02MEAN AT 29%

CN08129132%0.030.03

CN07138826%0.020.02

CN03147830%0.020.02

NORTH WALES20826%0.060.06

SOUTH WALES40523%0.040.04

Elderly

0.040.04

0.040.04

0.030.03

0.030.03

0.030.03

0.030.03

0.030.03

0.030.03

0.020.02

0.030.03

0.020.02

0.020.02

0.060.06

0.040.04

TOTAL

% Curative Intent

SCN

% Managed with curative intent

Number of Patients

Sheet2

Sheet2

SCN

% Treated with definitive radiotherapy or chemoradiotherapy

Number of Patients

Sheet3

Only 5.4% OG cancers diagnosed at early stage (T0/1,N0,M0).Lower oesophageal/GOJ tumours, and oesophageal squamous cell cancers less likely to be diagnosed early. Across strategic clinical networks significant variation in proportion of cancers diagnosed early.Early Cancers

Chart1

4950.06868686870.020.02

6950.03309352520.010.01

8060.08188585610.020.02

8680.05529953920.010.01

8930.06718924970.020.02

12800.050.010.01

13010.03766333590.010.01

13510.04367135460.010.01

16830.02911467620.010.01

17640.07823129250.010.01

18620.05316863590.010.01

18730.05979711690.010.01

2220.06756756760.030.03

4400.02954545450.010.01

TOTAL

% Early Stage

SCN

% Proportion of cancers diagnosed at early stage

Number of Patients

Early

Diagnosed early

SCNDiagnosed EarlyTOTAL% Diagnosed EarlySCNTOTAL% Diagnosed Early

CN01641,2805%CN094957%

CN02991,8625%CN106953%

CN031381,7648%CN048068%

CN04668068%CN128686%

CN05491,3014%CN118937%

CN06491,6833%CN0112805%

CN07591,3514%CN0513014%

CN081121,8736%CN0713514%

CN09344957%CN0616833%

CN10236953%CN0317648%

CN11608937%CN0218625%

CN12488686%CN0818736%

NORTH WALES152227%NORTH WALES2227%

SOUTH WALES134403%SOUTH WALES4403%

829155335%

Data for chartFIGURE 9.1

CI

SCNTOTAL% Early StageNegativePositive

CN094957%0.020.02

CN106953%0.010.01

CN048068%0.020.02

CN128686%0.010.01

CN118937%0.020.02

CN0112805%0.010.01

CN0513014%0.010.01MEAN AT 5%

CN0713514%0.010.01

CN0616833%0.010.01

CN0317648%0.010.01

CN0218625%0.010.01

CN0818736%0.010.01

NORTH WALES2227%0.030.03

SOUTH WALES4403%0.010.01

Early

0.020.02

0.010.01

0.020.02

0.010.01

0.020.02

0.010.01

0.010.01

0.010.01

0.010.01

0.010.01

0.010.01

0.010.01

0.030.03

0.010.01

TOTAL

% Early Stage

SCN

% Proportion of cancers diagnosed at early stage

Number of Patients

Sheet2

Sheet2

SCN

% Treated with definitive radiotherapy or chemoradiotherapy

Number of Patients

Sheet3

Recommendations for OG cancersMonitor complications rates associated with minimally invasive vs open surgery locally. Monitor quality of surgeryCompleteness of surgical resectionComplication rates and length of stay post-op. Monitor dosing regimens used for definitive radiotherapy for OG cancer. At a local level audit Proportion of patients aged over 70 managed with curative intentProportion of cancer diagnosed early.

Hi I am Georgina Chadwick, I am gastroenterology SpR currently doing an OOPE at the RCS working as a research fellow on the NOGCA. I would like to briefly go through some of the new area considered in the 2014 Annual Report which is due to be published at the beginning of November.

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