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Audit Report Colorectal Cancer Quality Performance Indicators Clinical Audit Data: 1st April 2018 and 31st March 2019

Dr Janet Graham MCN Deputy Clinical Lead Kevin Campbell MCN Manager Aishah Hanif Information Analyst

West of Scotland Cancer Network Colorectal Cancer Managed Clinical Network

West of Scotland Cancer Network Final Published Colorectal Cancer MCN Audit Report v1.0 31/01/2020

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CONTENTS

EXECUTIVE SUMMARY 3

1. INTRODUCTION 10

2. BACKGROUND 11

2.1 NATIONAL CONTEXT 11

2.2 WEST OF SCOTLAND CONTEXT 12

3. METHODOLOGY 14

4. RESULTS AND ACTION REQUIRED 15

4.1 DATA QUALITY 15

4.2 PERFORMANCE AGAINST QUALITY PERFORMANCE INDICATORS (QPIS) 16

QPI 1: RADIOLOGICAL DIAGNOSIS AND STAGING 17

QPI 2: PRE-OPERATIVE IMAGING OF THE COLON 21

QPI 3: MULTI-DISCIPLINARY TEAM (MDT) MEETING 23

QPI 4: STOMA CARE 25

QPI 5: LYMPH NODE YIELD 27

QPI 6: NEO-ADJUVANT THERAPY 29

QPI 7: SURGICAL MARGINS 31

QPI 8: RE-OPERATION RATES 35

QPI 9: ANASTOMOTIC DEHISCENCE 37

QPI 10: 30 AND 90 DAY MORTALITY FOLLOWING SURGICAL RESECTION 40

QPI 11: ADJUVANT CHEMOTHERAPY 45

QPI 12: 30 AND 90 DAY MORTALITY FOLLOWING CHEMOTHERAPY OR RADIOTHERAPY 48

QPI 13: CLINICAL TRIALS ACCESS 53

5. CONCLUSIONS 55

ABBREVIATIONS 57

REFERENCES 58

APPENDIX I: NHS BOARD ACTION PLANS 59


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Executive Summary

Introduction This report presents an assessment of performance of West of Scotland (WoS) Colorectal Cancer services relating to patients diagnosed in the twelve months between 1st April 2018 and 31st March 2019. This is the sixth consecutive year of Quality Performance Indicator (QPI) reporting against the measures which were first implemented for patients diagnosed from 1st April 2013. In order to ensure the success of the Cancer QPIs in driving quality improvement in cancer care, QPIs will continue to be assessed for clinical effectiveness and relevance. The initial formal review of colorectal cancer QPIs took place in 2016. With 6 years of reporting now complete, a 2nd cycle of review commenced in January 2020. This clinically led review aims to identify potential refinements to the current QPIs and involves key clinicians from each of the Regional Cancer Networks. The review will focus on any significant changes to the QPIs that are required due to changes in evidence or clinical practice.

Background Colorectal cancer services are organised around MDTs serving 2.5 million people2 in four NHS Boards across the West of Scotland. From this WoS population, each year around 1,700 patients are newly diagnosed with colorectal cancer (five year average from Cancer Registry). Table 1 details the six MDTs and their constituent hospital units following configuration during the 2017/18 services. Table 1: Summary of colorectal cancer MDTs and constituent hospital units in the West of Scotland.

MDT Constituent Hospital(s)

Ayrshire (AA) Crosshouse Hospital, Ayr Hospital

Clyde Royal Alexandra Hospital, Inverclyde Royal Hospital, Vale of Leven

North Glasgow (NG) Glasgow Royal Infirmary, Stobhill Hospital

South Glasgow (SG) Queen Elizabeth University Hospital, New Victoria Hospital, Gartnavel General Hospital

Forth Valley (FV) Forth Valley Royal Hospital

Lanarkshire (LAN) Hairmyres Hospital, Wishaw General Hospital, Monklands Hospital

Colorectal cancer is the third most common cancer, in both males and females, in Scotland with around 3,800 new diagnoses nationally each year4. From 2007 to 2017, the incidence of colorectal cancer decreased by 18.6%4. Despite this, actual numbers are predicted to increase by a quarter over the coming decade due to the aging population5. Overall cancer mortality rates show that colorectal cancer is the second most common cause of cancer deaths. From 2008 to 2018, mortality rates relating to colorectal cancer in Scotland have decreased by 10.8% in males and 3.1% in females4. Latest figures from ISD show a considerable improvement in survival for colorectal cancer with 60.4% of patients diagnosed between 2007 and 2011 surviving at least five years after diagnosis, compared to a 38% five year survival for those diagnosed between 1983 and 19874.


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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 between 1st April 2018 and 31st March 2019 was downloaded from eCASE at 2200 hrs on 2nd October 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 by the WoSCAN Information Team on behalf of the MCN 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.

Results The overall case ascertainment for colorectal cancer in WoS is 96.1% which indicates excellent data capture through audit. A summary of the Colorectal Cancer Quality Performance Indicators (QPIs 1 to 13) for the Year 6 (2018/19) clinical audit data is presented below, with a more detailed analysis of the results set out in the main report. Data are analysed by location of diagnosis or treatment, and illustrate NHS Board performance against each target and overall regional performance for each performance indicator. As patients within NHS Greater Glasgow and Clyde are managed by different MDTs, the GGC figures are presented by the following to reflect this: North Glasgow; South Glasgow and Clyde. Results are presented graphically and the accompanying tabular format also highlights any missing data and its’ possible effect on any of the measured outcomes. 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 restricted data are denoted with a dash (-). An asterisk (*) is used to specify a denominator of zero and to distinguish between this and a 0% performance. Any commentary provided by NHS Boards relating to the impacted indicators will however be included as a record of continuous improvement. Specific NHS Board actions have been identified to address issues highlighted through data analysis.


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Summary of QPI Results Colour Key Symbol Key

Above QPI target † Analysed by Board/hospital of surgery

Below QPI target ^ Small numbers in some Boards - percentage comparisons over a single year should be viewed with caution

Summary of the QPI results for clinical audit data. A dash (-) denotes restricted data where the denominator is less than 5. An asterisk (*) denotes data where the denominator is zero.

Quality Performance Indicator (QPI)

Performance by NHS Board

QPI target

Year AA FV NG SG Clyde GGC LAN WoS

QPI 1(i): Proportion of patients with colon cancer who undergo

CT chest, abdomen and pelvis before definitive treatment. 95%

2016/17 99.0% 98.7% 96.3% 98.1% 96.7% 97.1% 99.2% 98.1%

2017/18 99.0% 98.7% 100.0% 97.7% 95.5% 97.6% 98.4% 98.2%

2018/19 98.1% 97.4% 94.5% 95.6% 97.8% 95.9% 95.2% 96.3%

QPI 1(ii): Proportion of patients with rectal cancer who

undergo CT chest, abdomen and pelvis plus MRI pelvis before definitive treatment.

95%

2016/17 98.0% 100.0% 100.0% 100.0% 97.3% 99.2% 100.0% 99.2%

2017/18 100.0% 88.2% 97.2% 95.0% 96.2% 96.1% 98.2% 96.0%

2018/19 100.0% 100.0% 97.7% 98.0% 100.0% 98.5% 100.0% 99.2%

QPI 2: Proportion of patients with colorectal cancer who

undergo surgical resection who have the whole colon visualised by colonoscopy or CT colonography pre-operatively, unless the non visualised segment of the colon is removed.

95%

2016/17 91.3% 92.3% 94.8% 96.6% 94.4% 95.4% 91.4% 93.4%

2017/18 97.9% 97.8% 96.9% 100.0% 96.4% 98.0% 93.7% 97.1%

2018/19 95.6% 95.9% 95.5% 100.0% 98.1% 98.2% 94.7% 96.9%

QPI 3: Proportion of patients with colorectal cancer who are

discussed at MDT meeting before definitive treatment. 95%

2016/17 97.5% 96.8% 96.1% 94.6% 82.8% 91.4% 96.2% 94.1%

2017/18 98.9% 95.4% 97.5% 97.8% 93.2% 96.2% 96.2% 96.5%

2018/19 95.9% 98.1% 95.1% 97.6% 98.5% 97.2% 95.1% 96.7%

† QPI 4: Proportion of patients with colorectal cancer who

undergo elective surgical resection which involves stoma creation who are seen and have their stoma site marked pre-operatively by a nurse with expertise in stoma care.

95%

2016/17 100.0% 96.2% 94.6% 100.0% 100.0% 98.6% 94.6% 97.8%

2017/18 97.5% 96.3% 100.0% 98.0% 96.4% 98.0% 93.2% 96.7%

2018/19 97.3% 100.0% 98.3% 100.0% 100.0% 99.4% 96.7% 98.8%

† QPI 5: Proportion of patients with colorectal cancer who

undergo surgical resection where ≥ 12 lymph nodes are pathologically examined.

90%

2016/17 90.1% 92.8% 91.4% 93.5% 94.4% 93.2% 82.4% 90.4%

2017/18 96.0% 96.9% 91.5% 88.5% 89.3% 89.6% 87.6% 91.2%

2018/19 97.1% 95.7% 92.1% 95.6% 94.8% 94.3% 93.8% 94.8%

QPI 6: Proportion of patients with locally advanced rectal

cancer with threatened or involved circumferential resection margin (CRM) on pre-operative MRI who receive neo-adjuvant therapy designed to facilitate a margin-negative resection.

90%

2016/17 95.7% 100.0% 100.0% 100.0% 100.0% 100.0% 95.5% 97.9%

2017/18 71.4% 85.7% 100.0% 100.0% 91.7% 96.6% 92.6% 91.5%

2018/19 75.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 97.0%


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QPI target


† QPI 7(i): Proportion of patients with rectal cancer who

undergo surgical resection in which the circumferential margin is clear of tumour (neo-adjuvant short course radiotherapy).

95%

2016/17 95.0% 100.0% 100.0% 96.2% 95.5% 96.8% 90.5% 96.0%

2017/18 88.9% 85.7% 100.0% 100.0% 100.0% 100.0% 93.8% 94.4%

2018/19 96.4% 94.7% 100.0% 92.3% 89.5% 94.7% 100.0% 95.9% †

QPI 7(ii): Proportion of patients with rectal cancer who

undergo surgical resection in which the circumferential margin is clear of tumour (neo-adjuvant chemotherapy, long course radiotherapy, long course chemoradiotherapy or short course radiotherapy with long course intent).

85%

2016/17 90.0% 77.8% 100.0% 95.8% 82.4% 92.5% 95.0% 91.2%

2017/18 90.9% 88.9% 96.2% 95.0% 95.7% 95.7% 90.9% 93.7%

2018/19 100.0% 87.5% 78.9% 93.8% 100.0% 88.9% 84.6% 88.7%

† QPI 8: Proportion of patients who undergo surgical resection

for colorectal cancer who return to theatre to deal with complications related to the index procedure (within 30 days of surgery).

<10%

2016/17

2017/18 7.3% 6.7% 6.4% 5.5% 10.1% 7.3% 5.4% 6.8%

2018/19 3.1% 7.4% 7.4% 3.9% 4.0% 5.0% 4.6% 4.9%

† QPI 9(i): Proportion of patients who undergo colonic

anastomosis with anastomotic leak as a post-operative complication.

< 5%

2016/17 5.2% 3.9% 3.4% 0.0% 1.4% 1.4% 4.4% 2.9%

2017/18 0.0% 3.6% 3.4% 1.2% 6.9% 3.6% 2.2% 2.7%

2018/19 2.4% 2.4% 2.0% 0.0% 0.0% 0.5% 2.8% 1.5%

† QPI 9(ii): Proportion of patients who undergo rectal

anastamosis with anastomotic leak as a post-operative complication.

< 10%

2016/17 3.6% 8.6% 0.0% 10.4% 0.0% 4.2% 5.0% 4.8%

2017/18 7.1% 5.7% 1.8% 5.9% 8.1% 5.4% 12.5% 6.8%

2018/19 4.5% 5.3% 1.5% 1.4% 7.7% 2.8% 8.8% 4.4%

† QPI 10(i): Proportion of patients with colorectal cancer who

die within 30 days of elective surgical resection. < 3%

2016/17 1.6% 2.9% 1.0% 2.6% 1.6% 1.8% 2.0% 2.0%

2017/18 2.4% 3.0% 0.0% 0.0% 3.1% 1.0% 0.7% 1.4%

2018/19 0.7% 0.0% 0.7% 1.1% 0.9% 0.9% 0.0% 0.6%

† QPI 10(i): Proportion of patients with colorectal cancer who

die within 90 days of elective surgical resection. < 4%

2016/17 1.7% 2.9% 2.0% 2.6% 2.5% 2.4% 4.1% 2.7%

2017/18 3.3% 4.0% 0.9% 2.1% 3.3% 2.2% 2.8% 2.7%

2018/19 2.3% 1.1% 1.5% 2.3% 0.9% 1.7% 0.7% 1.5%

† QPI 10(ii): Proportion of patients with colorectal cancer who

die within 30 days of emergency surgical resection. < 15%

2016/17 12.5% 12.5% 10.5% 6.7% 13.3% 10.1% 2.8% 9.0%

2017/18 3.6% 5.3% 9.1% 6.9% 11.1% 9.0% 2.6% 6.1%

2018/19 8.0% 0.0% 7.1% 4.5% 12.1% 8.7% 0.0% 5.5%

† QPI 10(ii): Proportion of patients with colorectal cancer who

die within 90 days of emergency surgical resection. < 20%

2016/17 12.5% 12.5% 15.8% 10.0% 20.7% 15.4% 2.8% 11.7%

2017/18 3.6% 5.3% 9.1% 10.3% 14.8% 11.5% 5.3% 8.0%

2018/19 12.0% 6.3% 7.1% 4.5% 18.2% 11.6% 2.9% 9.0%


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QPI target


QPI 11(i): Proportion of patients between 50 and 74 years of

age at diagnosis with Dukes C colorectal cancer who receive adjuvant chemotherapy.

70%

2016/17

2017/18

2018/19 81.0% 84.6% 100.0% 96.4% 78.9% 92.3% 94.3% 90.3%

^QPI 11(ii): Proportion of patients between 50 and 74 years of

age at diagnosis with high risk Dukes B colorectal cancer who receive adjuvant chemotherapy.

50%

2016/17

2017/18

2018/19 73.3% 88.9% 66.7% 76.2% 69.2% 72.5% 72.7% 74.7%

QPI 12a: Proportion of patients with colorectal cancer who die

within 30 days of neo-adjuvant chemoradiotherapy treatment with curative intent.

< 1%

2016/17 2.9% 0.0% 5.9% 0.0% 0.0% 1.5% 2.3% 1.9%

2017/18 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

2018/19 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 3.8% 0.9%

QPI 12a: Proportion of patients with colorectal cancer who die

within 90 days of neo-adjuvant chemoradiotherapy treatment with curative intent.

< 1%

2016/17 6.3% 6.7% 6.3% 0.0% 0.0% 1.5% 2.3% 3.2%

2017/18 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

2018/19 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 4.0% 0.9%

QPI 12b: Proportion of patients with colorectal cancer who die

within 30 days of adjuvant chemotherapy treatment with curative intent.

< 1%

2016/17 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

2017/18 0.0% 0.0% 0.0% 1.9% 2.8% 1.6% 1.4% 1.2%

2018/19 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 1.8% 0.4%

QPI 12b: Proportion of patients with colorectal cancer who die

within 90 days of adjuvant chemotherapy treatment with curative intent.

< 1%

2016/17 3.0% 0.0% 0.0% 0.0% 0.0% 0.0% 1.8% 1.0%

2017/18 0.0% 0.0% 0.0% 2.1% 3.2% 1.8% 1.6% 1.4%

2018/19 2.6% 0.0% 0.0% 1.8% 0.0% 0.8% 4.3% 1.7%

^QPI 12c: Proportion of patients with colorectal cancer who

die within 30 days of radiotherapy treatment with curative intent.

< 1%

2016/17 - - 0.0% - - 0.0% - 0.0%

2017/18 - - 0.0% - 0.0% 0.0% - 0.0%

2018/19 - - - 0.0% - 0.0% - 0.0%

^QPI 12c: Proportion of patients with colorectal cancer who

die within 90 days of radiotherapy treatment with curative intent.

< 1%

2016/17 - - 0.0% - - 0.0% - 0.0%

2017/18 - - 14.3% - 14.3% 11.1% - 7.7%

2018/19 - - - 0.0% - 0.0% - 0.0%

^QPI 12d: Proportion of patients with colorectal cancer who die within 30 days of palliative chemotherapy.

<10%

2016/17 11.8% 21.1% 10.5% 25.0% 13.6% 16.9% 13.3% 16.0%

2017/18 0.0% 30.8% 8.3% 11.5% 0.0% 7.0% 10.7% 8.6%

2018/19 0.0% 5.6% 7.7% 3.7% 9.1% 6.5% 18.9% 8.5%


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Conclusions Cancer audit data underpins much of the development and service improvement work of the MCN and regular reporting of activity and performance is a fundamental requirement of an MCN to assure the quality of care delivered. The Colorectal Cancer MCN remains committed to improve the quality and completeness of clinical audit data to ensure continued robust performance assessment and the identification of areas for service improvement. The Colorectal Cancer MCN is encouraged by the results presented in this report which demonstrate that patients with colorectal cancer in the WoS continue to receive a consistently high standard of care. The results illustrate that some of the QPI targets set have been challenging for NHS Boards to achieve and there remains room for further service improvement around a number of areas. It is however encouraging that the targets relating to MDT discussion, stoma care, lymph node yield, re-operation rates, anastomotic dehiscence, mortality rates following surgical resection, and adjuvant chemotherapy were met by all Boards in Year 6 (2018/19). Some variance in performance does exist across the regions and, as per the agreed Regional governance process, each NHS Board was asked to complete a Performance Summary Report, providing a documented response where performance was below the QPI target. NHS Boards provided detailed comments indicating valid clinical reasons, or in some cases patient choice or co-morbidities, have influenced patient management. Remaining actions are summarised below and outlined in the main report under the relevant section. The MCN will actively take forward regional actions identified and NHS Boards are asked to develop local Action/Improvement Plans in response to the findings presented in the report. A summary of actions for each NHS Board has been included within the Action Plan templates in Appendix I. Action Required: QPI 9: Anastomotic Dehiscence

NHS Lanarkshire to review cases failing QPI 9(ii) and provide feedback to the MCN. QPI 10: 30 and 90 Day Mortality Following Surgical Resection

All Boards to review cases failing QPI 10(ii) and provide feedback to the MCN. QPI 12: 30 and 90 Day Mortality Following Chemotherapy or Radiotherapy

NHS Lanarkshire to provide feedback to the MCN on the outcome of the case series review of QPI 12d at the M&M meeting for all seven patients.

QPI 13: Clinical Trials Access

MCN to continue to promote recruitment of patients into Trials, as appropriate, and to raise awareness of trials across the wider MCN membership, as opportunities allow.

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.


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Additionally, progress will be reported annually to the Regional Cancer Advisory Group (RCAG) by NHS Board Territorial Lead Cancer Clinicians and MCN Clinical Leads, and nationally on a three-yearly basis to Healthcare Improvement Scotland as part of the governance processes set out in CEL 06 (2012).


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1. Introduction This report presents an assessment of performance of West of Scotland (WoS) Colorectal Cancer services relating to patients diagnosed in the twelve months between 1 April 2018 and 31 March 2019. Results are measured against the Colorectal Cancer Quality Performance Indicators (QPIs) which were implemented for patients diagnosed on or after 01 April 2013. The National Cancer Quality Steering Group (NCQSG) completed a programme of work to develop national QPIs for all cancer types to enable national comparative reporting and drive continuous improvement for patients in 2014. In collaboration with the three Regional Cancer Networks and Information Services Division (ISD) the Colorectal Cancer QPIs were published by Healthcare Improvement Scotland (HIS) in December 20121. Data definitions and measurability criteria to accompany the colorectal cancer QPIs are available from the ISD website2. Twelve months of data were measured against the Colorectal Cancer QPIs for the sixth consecutive year. Following reporting of Year 1 data (2013/14), a process of baseline review was undertaken to ensure QPIs were fit for purpose and truly driving quality improvement in patient care. This review process resulted in measurability changes to some QPIs. Formal review of the Colorectal Cancer QPIs commenced in 2016, with the revised QPIs published in April 2017. Some QPIs have undergone major changes after formal review and so the data for 2018/19 may not be comparable with data from previous years. Other QPIs have undergone minor changes where data is still comparable. QPI changes will be detailed in the performance section of each QPI. Future reports will continue to compare clinical audit data in successive years where it is clear and possible to do so, to further illustrate trends.

In order to ensure the success of the Cancer QPIs in driving quality improvement in cancer care, QPIs will continue to be assessed for clinical effectiveness and relevance.


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2. Background Colorectal cancer services are organised around MDTs serving 2.5 million people2 in four NHS Boards across the West of Scotland. From this WoS population, each year around 1,700 patients are newly diagnosed with colorectal cancer (five year average from Cancer Registry). Table 2 details the six MDTs and their constituent hospital units following configuration during the 2017/18 services. Table 2: Summary of colorectal cancer MDTs and constituent hospital units in the West of Scotland.

MDT Constituent Hospital(s)

Ayrshire (AA) Crosshouse Hospital, Ayr Hospital

Clyde Royal Alexandra Hospital, Inverclyde Royal Hospital, Vale of Leven

North Glasgow (NG) Glasgow Royal Infirmary, Stobhill Hospital

South Glasgow (SG) Queen Elizabeth University Hospital, New Victoria Hospital, Gartnavel General Hospital

Forth Valley (FV) Forth Valley Royal Hospital

Lanarkshire (LAN) Hairmyres Hospital, Wishaw General Hospital, Monklands Hospital

2.1 National Context Colorectal cancer is the third most common cancer, in both males and females, in Scotland with around 3,800 new diagnoses nationally each year4. From 2007 to 2017, the incidence of colorectal cancer decreased by 18.6%4. Despite this, actual numbers are predicted to increase by a quarter over the coming decade due to the aging population5. The lifetime risk of developing colorectal cancer is currently estimated at 1 in 16 for males and 1 in 21 for females. Modifiable risk factors include diet, physical exercise and smoking6. Overall cancer mortality rates show that colorectal cancer is the second most common cause of cancer deaths. From 2008 to 2018, mortality rates relating to colorectal cancer in Scotland have decreased by 10.8% in males and 3.1% in females4. Latest figures from ISD show a considerable improvement in survival for colorectal cancer with 60.4% of patients diagnosed between 2007 and 2011 surviving at least five years after diagnosis, compared to a 38% five year survival for those diagnosed between 1983 and 19874. Early diagnosis of colorectal cancer is very important in maximising options for treatment and

increasing the likelihood of cure7.The Scottish Bowel Screening Programme was introduced to

increase early detection of cancer and therefore lead to further improvements in survival8.The programme is designed to facilitate the early detection and cure of asymptomatic cancers as well as reduce the overall incidence of colorectal cancer through the removal of precancerous polyps.


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2.2 West of Scotland Context A total of 1,587 cases of colorectal cancer were diagnosed and identified by audit in the WoS between the 1st April 2018 and 31st March 2019. The number of patients diagnosed within each NHS Board is presented in Figure 1. As the largest WoS Board, 49.5% of all new cases of colorectal cancer were diagnosed in NHS Greater Glasgow and Clyde (GGC) which is in line with population estimates for this board.

Figure 1: Number of new cases diagnosed with colorectal cancer by NHS Board of diagnosis between 1

st April 2018

and 31st

March 2019.

Colorectal cancer occurs most frequently later in life. Figure 2 illustrates the number of new cases in Year 6 by 5-year age group and sex. There are approximately 5 males diagnosed for every 4 females and the incidence of colorectal cancer is higher in males in most age groups. As women live longer than men, the total number of cases diagnosed in women aged 85 years or more is greater than for males.

0

200

400

600

800

1000

1200

1400

1600

1800

AA FV GGC LAN WoS

261202

785

339

1587

Nu

mb

er o

f n

ew

ca

se

s (n

)

NHS Board of diagnosis


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Figure 2: Number of new cases diagnosed with colorectal cancer in the West of Scotland between 1

st April 2018 and

31st

March 2019 by 5-year age group and sex.

0

20

40

60

80

100

120

140

160

<45 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+

2023

37

76

107

149

138

129

110

57

25 23

5853

58

100

116

104109

95

Nu

mb

er o

f n

ew

ca

se

s (n

)

5-year age group

Male Female


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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 between 1st April 2018 and 31st March 2019 was downloaded from eCASE at 2200 hrs on 2nd October 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 by the WoSCAN Information Team on behalf of the MCN and the timescales agreed took into account the patient pathway to ensure that a complete treatment record was available for each case. Initial results of the analysis were provided to local Boards to check for inaccuracies, inconsistencies or obvious gaps and a subsequent download taken upon which final analysis was carried out. The final data analysis was disseminated for NHS Board verification in line with the regional audit governance process to ensure that the data was an accurate representation of service in each area.


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4. Results and Action Required

4.1 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 ISD, National Services Scotland), by NHS Board of diagnosis. Cancer Registry figures were extracted from ACaDMe (Acute Cancer Deaths and Mental Health), a system provided by ISD. Cancer Registry figures are an average of the previous five years’ figures to take account of annual fluctuations in incidence within NHS Boards. As the number of cases will vary each year, it is possible for case ascertainment to be over or under 100%. Therefore, the figures presented should be seen as an indication only. The overall case ascertainment for WoS is high at 96.1%, which indicates excellent data capture through audit. Case ascertainment figures however are provided for guidance and are not an exact measurement as it is not possible to compare directly with the same cohort. Table 3 details the case ascertainment for the four Boards within the WoS. This level of data capture aids the interpretation of analysis based on cancer audit data, as more complete data will return more reliable results. Table 3: Case ascertainment by Board of diagnosis, given as a proportion of average number of new cases from Cancer Registry data between 2013 and 2017, for patients diagnosed in Year 6 (2018/19).

AA FV GGC LAN WoS

New cases from audit data from Apr 2018 – Mar 2019

261 202 785 339 1587

New cases from Cancer Registry data (2013-17)

269 190 838 355 1652

% Case ascertainment 97.0% 106.3% 93.7% 95.5% 96.1%


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4.2 Performance against Quality Performance Indicators (QPIs) Results of the analysis of Colorectal Cancer Quality Performance Indicators (QPIs 1 to 13) are set out in the following sections. Data are presented by location of diagnosis or surgery, and illustrate NHS Board or performance against each target and overall regional performance for each performance indicator. Results are presented graphically and the accompanying tables also highlight any missing data and its possible effect on any of the measured outcomes for the current year of 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 restricted data are denoted with a dash (-). An asterisk (*) is used to specify a denominator of zero and to distinguish between this and a 0% performance. Any commentary provided by NHS Boards relating to the impacted indicators will however be included as a record of continuous improvement. Specific regional and NHS Board actions have been identified to address issues highlighted through the data analysis.


17

QPI 1: Radiological Diagnosis and Staging QPI 1:

Patients with colorectal cancer should be evaluated with appropriate imaging to detect extent of disease and guide treatment decision making.

Numerator: (i) Number of patients with colon cancer who undergo CT chest, abdomen and pelvis before definitive treatment.

(ii) All patients with rectal cancer undergoing definitive treatment who undergo CT chest, abdomen and pelvis and MRI pelvis before definitive treatment.

Denominator: (i) All patients with colon cancer.

(ii) All patients with rectal cancer undergoing definitive treatment (chemoradiotherapy or surgical resection).

Exclusions: (i) Patients who refuse investigation, patients who undergo emergency surgery, patients

undergoing supportive care only, patients who undergo palliative treatment (chemotherapy, radiotherapy or surgery) and patients who died before first treatment.

(ii) Patients who refuse investigation, patients who undergo emergency surgery, patients with a contraindication to MRI, patients who undergo Transanal Endoscopic Microsurgery (TEM), patients who undergo Transanal Resection of Tumour (TART), patients who undergo palliative treatment (chemotherapy, radiotherapy or surgery) and patients who died before treatment.

Target: 95%

Accurate staging is necessary to detect metastatic disease, guide treatment and avoid inappropriate surgery. All patients with colorectal cancer should be staged by contrast enhanced CT of the chest, abdomen and pelvis, to estimate the stage of disease, unless the use of intravenous iodinated contrast is contraindicated. MRI of the rectum is recommended for local staging of patients with rectal cancer. To reflect this, QPI 1 is split into two sub-groups. The first sub-group looks at all patients with colon cancer who undergo CT chest abdomen and pelvis before definitive treatment, and a summary of these results for the three most recent years of audit data (Year 4 to Year 6) is presented in Figure 3. For Year 6, a more detailed breakdown of the data by NHS Board of diagnosis is shown in Table 4. The second part of the QPI looks at those patients diagnosed with rectal cancer undergoing definitive treatment (chemoradiotherapy or surgical resection) who undergo CT of the chest abdomen and pelvis and MRI pelvis prior to their definitive treatment. A summary of these results, by NHS Board of diagnosis, is presented in Figure 4 with a more detailed breakdown of Year 6 data shown in Table 5.


18

QPI 1(i)

Figure 3: Summary of QPI 1(i) results, illustrating the proportion of patients with colon cancer who undergo CT chest, abdomen and pelvis before definitive treatment, by NHS Board of diagnosis from Year 4 (2016/17) to Year 6 (2018/19). The red line represents the QPI target of 95%.

Table 4: Details of QPI 1(i) results by NHS Board of diagnosis for Year 6 (2018/19).

QPI 1(i) Target: 95%

AA FV NG SG Clyde GGC LAN WoS

Performance (%) 98.1% 97.4% 94.5% 95.6% 97.8% 95.9% 95.2% 96.3%

Numerator 102 75 86 131 90 307 120 604

Denominator 104 77 91 137 92 320 126 627

NR numerator 0 0 0 0 0 0 0 0

NR exclusions 0 1 0 1 0 1 5 7

NR denominator 0 0 0 0 0 0 0 0

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19

QPI 1(ii)

Figure 4: Summary of QPI 1(ii) results, illustrating the proportion of patients with rectal cancer undergoing definitive treatment who undergo CT chest, abdomen and pelvis and MRI pelvis before definitive treatment, by NHS Board of diagnosis from Year 4 (2016/17) to Year 6 (2018/19). The red line represents the QPI target of 95%.

Table 5: Details of QPI 1(ii) results by NHS Board of diagnosis for Year 6 (2018/19).

QPI 1(ii) Target: 95%


Performance (%) 100.0% 100.0% 97.7% 98.0% 100.0% 98.5% 100.0% 99.2%

Numerator 39 38 42 48 42 132 49 258

Denominator 39 38 43 49 42 134 49 260

NR numerator 0 0 0 0 0 0 0 0



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20

Results: For QPI 1(i), all Boards achieved the 95% target. The overall performance for the WoS was 96.3%. Within NHS Greater Glasgow and Clyde, North Glasgow was slightly short of the target at 94.5%. NHS Greater Glasgow and Clyde reviewed the cases not meeting the target and provided feedback. Within the Board, North Glasgow cited CT imaging following palliative stenting and no imaging performed as reasons for patients failing to meet the QPI criteria. In cases where no CT imaging was performed, this was due to patients either being managed palliatively without treatment or being treated for presumed benign lesions, where subsequent diagnosis was made on pathology. For QPI 1(ii), all Boards achieved the 95% target showing an improvement on the previous year’s performance.


21

QPI 2: Pre-Operative Imaging of the Colon QPI 2:

Patients with colorectal cancer undergoing elective surgical resection should have the whole colon visualised pre-operatively

Numerator:

Number of patients who undergo elective surgical resection for colorectal cancer who have the whole colon visualised by colonoscopy or CT colonography before surgery, unless the non visualised segment of the colon is to be removed.

Denominator: All patients who undergo elective surgical resection for colorectal cancer.

Exclusions: Patients who undergo palliative surgery. Patients who have incomplete bowel imaging due to obstructing tumour (added as exclusion at formal review; this is effective for Year 5 data onwards).

Target: 95%

Where colorectal cancer is suspected clinically, the whole of the large bowel should be examined to confirm a diagnosis of cancer. CT colonography can be used as a sensitive and safe alternative to colonoscopy. Following formal review, it was agreed to exclude patients undergoing palliative surgery and those with an incomplete scope due to obstructing or structuring tumours. Figure 5 presents a summary of the results for QPI 2 by NHS Board of diagnosis for the three most recent years of audit data (Year 4 to Year 6). For Year 6, a more detailed breakdown of the data is shown in Table 6. Results: NHS Ayrshire and Arran, NHS Forth Valley and NHS Greater Glasgow and Clyde met the 95% target; NHS Lanarkshire was marginally short of the target at 94.7%. The overall performance for the WoS was 96.9%. NHS Lanarkshire reviewed the cases not meeting the target and provided feedback. The Board highlighted that one case was incorrectly recorded, which has since been updated. Following this update to the audit data, NHS Lanarkshire meets the QPI target with a performance of 95.5%. Other reasons for patients failing to meet the QPI included: patients being unsuitable for the procedure due to co-morbidities and the need for urgent surgery following CT; extreme patient discomfort; technical difficulty; and a change to location of treatment.


22

QPI 2

Figure 5: Summary of QPI 2 results, illustrating the proportion of patients who undergo elective surgical resection for colorectal cancer who have the whole colon visualised by colonoscopy or CT colonography before surgery, unless the non visualised segment of the colon is to be removed, by NHS Board of diagnosis from Year 4 (2016/17) to Year 6 (2018/19). The red line represents the QPI target of 95%.

Table 6: Details of QPI 2 results by NHS Board of diagnosis for Year 6 (2018/19).

QPI 2 Target: 95%


Performance (%) 95.6% 95.9% 95.5% 100.0% 98.1% 98.2% 94.7% 96.9%

Numerator 109 93 106 170 105 381 126 709

Denominator 114 97 111 170 107 388 133 732

NR numerator 0 1 0 0 0 0 0 1



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23

QPI 3: Multi-Disciplinary Team (MDT) Meeting QPI 3:

Patients with newly diagnosed colorectal cancer should be discussed by a multi-disciplinary team prior to definitive treatment.

Numerator: Number of patients with colorectal cancer discussed at the MDT before definitive treatment.

Denominator: All patients with colorectal cancer.

Exclusions: Patients who died before first treatment, patients undergoing emergency surgery and patients undergoing treatment with endoscopic polypectomy only.

Target: 95%

Evidence suggests that patients with cancer managed by a multi-disciplinary team have a better outcome. There is also evidence that the multidisciplinary management of patients increases their overall satisfaction with their care. QPI 3 states that 95% of patients should be discussed at the MDT prior to definitive treatment. The tolerance accounts for situations where patients require treatment urgently. Figure 6 presents a summary of the results for QPI 3 by NHS Board of diagnosis for the three most recent years of audit data (Year 4 to Year 6). For Year 6, a more detailed breakdown of the data is shown in Table 7.

Results: All Boards met the 95% target. The overall WoS performance met the target with 96.7%.


24

QPI 3

Figure 6: Summary of QPI 3 results, illustrating the proportion of patients with colorectal cancer discussed at the MDT before definitive treatment, by NHS Board of diagnosis from Year 4 (2016/17) to Year 6 (2018/19). The red line represents the QPI target of 95%.


QPI 3 Target: 95%


Performance (%) 95.9% 98.1% 95.1% 97.6% 98.5% 97.2% 95.1% 96.7%

Numerator 209 158 175 288 194 657 254 1278

Denominator 218 161 184 295 197 676 267 1322

NR numerator 0 0 0 1 0 1 0 1



0%

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25

QPI 4: Stoma Care QPI 4:

Patients with colorectal cancer who require a stoma are assessed and have their stoma site marked pre-operatively by a nurse with expertise in stoma care.

Numerator: Number of patients with colorectal cancer who undergo elective surgical resection which

involves stoma creation who are seen by and have their stoma site marked preoperatively by a nurse with expertise in stoma care.

Denominator: All patients with colorectal cancer who undergo elective surgical resection which involves

stoma creation.

Exclusions: Patients who refuse to be seen by a nurse with expertise in stoma care.

Target: 95%

Access to a nurse with expertise in stoma care increases patient satisfaction and optimal independent functioning. Furthermore, there is significant evidence to suggest that patients not marked preoperatively can have significant problems with their stoma post operatively and this can affect their recovery and rehabilitation. Before surgery, all patients should be offered information about the likelihood of having a stoma, why it might be necessary, and how long it might be needed for. A trained stoma professional should give specific information on the care and management of stomas to all patients considering surgery that might result in a stoma. Figure 7 presents a summary of the results for QPI 4 by NHS Board of surgery for the three most recent years of audit data (Year 4 to Year 6). For Year 6, a more detailed breakdown of the data is shown in Table 8. Results: All Boards met the QPI target of 95%, showing an improvement following the previous year’s performance. The overall performance for the WoS was 98.8%.


26

QPI 4

Figure 7: Summary of QPI 4 results, illustrating the proportion of patients with colorectal cancer who undergo elective surgical resection which involves stoma creation who are seen by and have their stoma site marked preoperatively by a nurse with expertise in stoma care, by NHS Board of surgery from Year 4 (2016/17) to Year 6 (2018/19). The red line represents the QPI target of 95%.

Table 8: Details of QPI 4 results by NHS Board of surgery for Year 6 (2018/19).

QPI 4 Target: 95%


Performance (%) 97.3% 100.0% 98.3% 100.0% 100.0% 99.4% 96.7% 98.8%

Numerator 36 31 57 63 38 158 29 254

Denominator 37 31 58 63 38 159 30 257

NR numerator 0 0 0 0 0 0 0 0



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27

QPI 5: Lymph Node Yield QPI 5:

For patients undergoing resection for colorectal cancer the number of lymph nodes examined should be maximised.

Numerator: Number of patients with colorectal cancer who undergo curative surgical resection where ≥12

lymph nodes are pathologically examined.

Denominator: All patients with colorectal cancer who undergo curative surgical resection (with or without neo-

adjuvant short course radiotherapy).

Exclusions: Patients with rectal cancer who undergo long course neo-adjuvant chemoradiotherapy or

radiotherapy; patients who undergo transanal endoscopic microsurgery (TEM) or transanal resection of tumour (TART).

Target: 90%

Maximising the number of lymph nodes resected and analysed enables reliable staging which influences treatment decision making. Figure 8 presents a summary of the results for QPI 5 by NHS Board of surgery for the three most recent years of audit data (Year 4 to Year 6). For Year 6, a more detailed breakdown of the data is shown in Table 9. Results: All Boards met the QPI target of 90%, showing an improvement on the previous year’s performance. The overall performance for the WoS was 94.8%, compared to 91.2% in Year 5. NHS Lanarkshire has had issues with this QPI over the past few years. The Board highlighted that it would be useful to try to align this QPI with the Royal College of Pathologists guidelines. which are different and can cause a conflict in harvesting / reporting nodes.


28

QPI 5

Figure 8: Summary of QPI 5 results, illustrating the proportion of patients with colorectal cancer who undergo curative surgical resection where ≥12 lymph nodes are pathologically examined, by NHS Board of surgery from Year 4 (2016/17) to Year 6 (2018/19). The red line represents the QPI target of 90%.


QPI 5 Target: 90%


Performance (%) 97.1% 95.7% 92.1% 95.6% 94.8% 94.3% 93.8% 94.8%

Numerator 133 89 116 173 127 416 135 773

Denominator 137 93 126 181 134 441 144 815

NR numerator 0 0 0 0 1 1 0 1



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29

QPI 6: Neo-adjuvant Therapy QPI 6:

Patients with locally advanced rectal cancer should receive neo-adjuvant therapy designed to facilitate a margin-negative resection.

Numerator: Number of patients with rectal cancer with a threatened or involved CRM on preoperative MRI

undergoing surgery who receive neo-adjuvant therapy.

Denominator: All patients with rectal cancer with a threatened or involved CRM on preoperative MRI

undergoing surgery.

Exclusions: Patients who refused neo-adjuvant therapy, patients in whom neo-adjuvant therapy is

contraindicated and patients who presented as an emergency for surgery.

Target: 90%

Patients with rectal tumours that involve or threaten the mesorectal fascia on preoperative imaging may benefit from preoperative radiotherapy. Patients with rectal cancer who require downstaging of the tumour because of encroachment on the mesorectal fascia should receive neo-adjuvant therapy, followed by surgery at an interval to allow cytoreduction. For patients with rectal cancer, MRI is utilised to assess the extent of disease prior to treatment. A statement regarding margin status is required within the MRI report to guide treatment. Following formal review, QPI 6 was amended to incorporate all forms of neo-adjuvant therapy. As a result, data is not comparable to previous years. Figure 9 presents a summary of the results for QPI 6 by NHS Board of diagnosis for the two most recent years of audit data (Year 5 and Year 6). For Year 6, a more detailed breakdown of the data is shown in Table 10. Results: NHS Forth Valley, NHS Greater Glasgow and Clyde and NHS Lanarkshire met the 90% target. NHS Ayrshire and Arran was short of the target with 75.0%. The overall performance for the WoS met the target with 97.0% and shows an improvement on the previous year’s performance. NHS Ayrshire and Arran reviewed all cases not meeting the QPI criteria and commented that all patients achieved R0 resection. Small numbers are noted for NHS Ayrshire and Arran.


30

QPI 6

Figure 9: Summary of QPI 6 results, illustrating the proportion of patients with rectal cancer with a threatened or involved CRM on preoperative MRI undergoing surgery who receive neo-adjuvant therapy, by NHS Board of diagnosis from Year 4 (2016/17) to Year 6 (2018/19). The red line represents the QPI target of 90%.


QPI 6 Target: 90%


Performance (%) 75.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 97.0%

Numerator 6 9 11 15 9 35 14 64

Denominator 8 9 11 15 9 35 14 66

NR numerator 0 0 0 0 0 0 0 0



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31

QPI 7: Surgical Margins QPI 7:

Rectal cancers undergoing surgical resection should be adequately excised.

Numerator: (i) Number of patients with rectal cancer who undergo elective primary surgical resection or immediate/early surgical resection following neo-adjuvant short course radiotherapy in which the circumferential margin is clear of tumour.

(ii) Number of patients with rectal cancer who undergo elective surgical resection following neo-adjuvant chemotherapy, long course radiotherapy, long course chemoradiotherapy or short course radiotherapy with long course intent in which the circumferential margin is clear of tumour.

Denominator: (i) All patients with rectal cancer who undergo elective primary surgical resection or

immediate/early surgical resection following neo-adjuvant short course radiotherapy. (ii) All patients with rectal cancer who undergo elective surgical resection following neo-

adjuvant chemotherapy, long course radiotherapy, long course chemoradiotherapy or short course radiotherapy with long course intent (delay to surgery).

Exclusions: (i) Patients who undergo transanal endoscopic microsurgery (TEM) or transanal resection of

tumour (TART). (ii) Patients who undergo transanal endoscopic microsurgery (TEM) or transanal resection of

tumour (TART).

Target:

(i) 95% (ii) 85%

The circumferential margin is an independent risk factor for the development of distant metastases and mortality. It is recognised that local recurrence of rectal cancer can be accurately predicted by pathological assessment of circumferential margin involvement in these tumours. QPI 7 is split into two sub-groups. The first sub-group looks at patients with rectal cancer who undergo elective primary surgical resection or surgical resection following short course neo-adjuvant radiotherapy. The target for this QPI is set at 95% and the tolerance within the target is designed to account for the fact that patients who undergo neo-adjuvant long course radiotherapy are already acknowledged to have a tumour threatening the circumferential margin therefore are more likely to have positive surgical margins. Following formal review, part (i) was updated to define immediate/early surgical resection as surgery performed less than 6 weeks after neo-adjuvant therapy. A summary of these results by NHS Board of surgery is presented in Figure 10, with a more detailed breakdown of Year 6 data shown in Table 11. The second part of the QPI looks at all patients with rectal cancer who undergo elective surgical resection following neo-adjuvant therapy. The target for this is set at 85%. Following formal review, part (ii) was updated to include other methods of neo-adjuvant therapy (as per QPI 6). Figure 11 presents a summary of the results by NHS Board of surgery for the three most recent years of audit data (Year 4 to Year 6). For Year 6, a more detailed breakdown of the data is shown in Table 12.


32

QPI 7(i)

Figure 10: Summary of QPI 7(i) results, illustrating the proportion of patients with rectal cancer who undergo elective primary surgical resection or immediate/early surgical resection following neo-adjuvant short course radiotherapy in which the circumferential margin is clear of tumour, by NHS Board of surgery from Year 4 (2016/17) to Year 6 (2018/19). The red line represents the QPI target of 95%.

Table 11: Details of QPI 7(i) results by NHS Board of surgery for Year 6 (2018/19).



Performance (%) 96.4% 94.7% 100.0% 92.3% 89.5% 94.7% 100.0% 95.9%

Numerator 27 18 30 24 17 71 23 139

Denominator 28 19 30 26 19 75 23 145

NR numerator 0 0 0 0 0 0 0 0



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QPI 7(ii)

Figure 11: Summary of QPI 7(ii) results, illustrating the proportion of patients with rectal cancer who undergo elective surgical resection following neo-adjuvant chemotherapy, long course radiotherapy, long course chemoradiotherapy or short course radiotherapy with long course intent in which the circumferential margin is clear of tumour, by NHS Board of surgery from Year 4 (2016/17) to Year 6 (2018/19). The red line represents the QPI target of 85%.

Table 12: Details of QPI 7(ii) results by NHS Board of surgery for Year 6 (2018/19).



Performance (%) 100.0% 87.5% 78.9% 93.8% 100.0% 88.9% 84.6% 88.7%

Numerator 5 7 15 15 10 40 11 63

Denominator 5 8 19 16 10 45 13 71

NR numerator 0 0 1 0 0 1 1 2



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Results: For QPI 7(i), NHS Ayrshire and Arran and NHS Lanarkshire met the 95% target. NHS Forth Valley and NHS Greater Glasgow and Clyde fell slightly short of the target with both Boards performing at 94.7%. Within NHS Greater Glasgow and Clyde, South Glasgow and Clyde failed to meet the target. The overall WoS performance was 95.9%. Boards have reviewed cases not meeting the QPI criteria and provided the following detailed feedback. NHS Forth Valley commented that the one case failing to meet the QPI was managed in a clinically appropriate manner. Within NHS Greater Glasgow and Clyde, South Glasgow and Clyde highlighted the presence of involved nodes close to the circumferential margin. The Board stated that on review of the data, the cases were managed in a clinically appropriate manner and there was no concern with regards to surgical practice. However, this QPI will be kept under close review. For QPi 7(ii), NHS Ayrshire and Arran, NHS Forth Valley and NHS Greater Glasgow met the 85% target. Within NHS Greater Glasgow and Clyde, North Glasgow failed to meet the QPI. NHS Lanarkshire was slightly short of the target with 84.6%. The overall WoS performance was 88.7%. Boards have reviewed cases not meeting the QPI criteria and provided the following detailed feedback. Within NHS Greater Glasgow and Clyde, North Glasgow noted that at the time of the analysis, the pathology report for one patient was outstanding. The audit data has since been updated to report margin free R0 resection, meaning this patient would be deemed as meeting the QPI criteria increasing the performance to 84.2%. For the remaining cases, the Board cited an R1 resection, exenterative surgery and significant local progression following the patient’s decision to delay surgery as reasons for not meeting the QPI. NHS Lanarkshire highlighted that at the time of the analysis the pathology report for one patient was outstanding. Following receipt of the pathology report, the audit data has been updated. This update means that the Board achieved 92.3% and meets the QPI. For the second case failing to meet the QPI, this was deemed to be a technically difficult surgical case. It was noted that there was no indication of this prior to treatment otherwise additional measures would have been taken.


35

QPI 8: Re-operation Rates QPI 8:

For patients undergoing surgery for colorectal cancer re-operation rates should be minimised.

Numerator: Number of patients with colorectal cancer who undergo surgical resection who return to theatre following initial procedure (within 30 days of surgery) to deal with complications related to the index procedure.

Denominator: All patients with colorectal cancer who undergo surgical resection.

Exclusions: No exclusions.

Target:

<10%

It is important to minimise morbidity and mortality related to the treatment of colorectal cancer. Re-operation rates may offer a sensitive and relevant marker of surgical quality1. Following formal review, it was decided to measure this QPI using audit data rather than SMR01 data which had been used previously. Year 5 is the first year for which there is sufficient data to present findings. As such, Figure 12 presents a summary of the results by NHS Board of surgery for the two most recent years of audit data (Year 5 and Year 6). For Year 6, a more detailed breakdown of the data is shown in Table 13. Results: All Boards were within the 10% target. The performance for the WoS region was 4.9%, compared to 6.8% in Year 5.


36

QPI 8

Figure 12: Summary of QPI 8 results, illustrating the proportion of patients with colorectal cancer who undergo surgical resection who return to theatre following initial procedure (within 30 days of surgery) to deal with complications related to the index procedure, by NHS Board of surgery from Year 5 (2017/18) to Year 6 (2018/19). The red line represents the QPI target of <10%.


QPI 8 Target: <10%


Performance (%) 3.1% 7.4% 7.4% 3.9% 4.0% 5.0% 4.6% 4.9%

Numerator 5 8 11 8 6 25 8 46

Denominator 160 108 149 203 150 502 173 943

NR numerator 0 1 1 1 0 2 1 4



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37

QPI 9: Anastomotic Dehiscence QPI 9:

For patients who undergo surgical resection for colorectal cancer anastomotic dehiscence should be minimised.

Numerator: (i) Number of patients with colorectal cancer who undergo a surgical procedure involving anastomosis of the colon having anastomotic leak requiring intervention (radiological or surgical).

(ii) Number of patients with colorectal cancer who undergo a surgical procedure involving anastomosis of the rectum (including anterior resection with total mesorectal excision (TME)) having anastomotic leak requiring intervention (radiological or surgical).

Denominator: (i) All patients with colorectal cancer who undergo a surgical procedure involving

anastomosis of the colon. (ii) All patients with rectal cancer who undergo a surgical procedure involving anastomosis of

the rectum (including anterior resection with TME).


Target:

(i) <5% (ii) <10%

Anastomotic dehiscence is a major cause of morbidity and a measure of the quality of surgical care. Anastomotic leakage is an important and potentially fatal complication of colorectal cancer surgery, and measures to minimise it should be taken. QPI 9 is split into two sub-groups. The first sub-group looks at patients with colorectal cancer who undergo a surgical procedure involving anastomosis of the colon having anastomotic leak requiring intervention (radiological or surgical). A summary of these results by NHS Board of surgery is presented in Figure 13, with a more detailed breakdown of Year 6 data shown in Table 14. The second part of the QPI looks at patients with colorectal cancer who undergo a surgical procedure involving anastomosis of the rectum (including: anterior resection with TME) having anastomotic leak requiring intervention (radiological or surgical). Figure 14 presents a summary of the results by NHS Board of surgery for the three most recent years of audit data (Year 4 to Year 6). For Year 6, a more detailed breakdown of the data is shown in Table 15. Results: For QPI 9(i), all Boards were within the 5% target. The overall performance for the WoS was 1.5% and shows continual year on year improvement. For QPI 9(ii), although all Boards were within the 10% target, showing an improvement on the previous year’s performance, some variance was observed between Boards, notably a performance of 8.8% in NHS Lanarkshire for 2018/19 and a performance of 12.5% in 2017/18. The overall performance for the WoS was 4.4%, compared to 6.8% in Year 5. Actions:

NHS Lanarkshire to review cases failing QPI 9(ii) and provide feedback to the MCN.


38

QPI 9(i)

Figure 13: Summary of QPI 9(i) results, illustrating the proportion of patients with colorectal cancer who undergo a surgical procedure involving anastomosis of the colon having anastomotic leak requiring intervention (radiological or surgical), by NHS Board of surgery from Year 4 (2016/17) to Year 6 (2018/19). The red line represents the QPI target of <5%.


QPI 9(i) Target: <5%


Performance (%) 2.4% 2.4% 2.0% 0.0% 0.0% 0.5% 2.8% 1.5%

Numerator 2 1 1 0 0 1 2 6

Denominator 82 41 51 91 76 218 71 412

NR numerator 0 0 0 0 0 0 0 0



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QPI 9(ii)

Figure 14: Summary of QPI 9(ii) results, illustrating the proportion of patients with colorectal cancer who undergo a surgical procedure involving anastomosis of the rectum (including anterior resection with total mesorectal excision (TME)) having anastomotic leak requiring intervention (radiological or surgical), by NHS Board of surgery from Year 4 (2016/17) to Year 6 (2018/19). The red line represents the QPI target of <10%.


QPI 9(ii) Target: <10%


Performance (%) 4.5% 5.3% 1.5% 1.4% 7.7% 2.8% 8.8% 4.4%

Numerator 2 2 1 1 3 5 5 14

Denominator 44 38 68 70 39 177 57 316

NR numerator 0 0 0 0 0 0 1 1



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40

QPI 10: 30 and 90 Day Mortality Following Surgical Resection QPI 10:

Mortality after surgical resection for colorectal cancer.

Numerator: (i) Number of patients with colorectal cancer who undergo elective surgical resection who

die within 30 or 90 days of surgery. (ii) Number of patients with colorectal cancer who undergo emergency surgical resection

who die within 30 or 90 days of surgery.

Denominator: (i) All patients with colorectal cancer who undergo elective surgical resection. (ii) All patients with colorectal cancer who undergo emergency surgical resection.


Target:

(i) Elective surgery:

30 day <3% 90 day <4%

(ii) Emergency surgery: 30 day <15% 90 day <20%

Treatment related mortality is a marker of the quality and safety of the whole service provided by the Multi Disciplinary Team (MDT). Outcomes of treatment, including treatment-related morbidity and mortality should be regularly assessed. The QPI target is split into two sub-groups. For part (i), the QPI concerns patients who undergo elective surgery. Following formal review, the 30 day elective target was changed from <5% to <3%. Additionally, a 90 day mortality target was added of <4%. A summary of the 30 day and 90 day mortality rates is presented in Figures 15 and 16 respectively, for the three most recent years of audit data (Year 4 to Year 6). For Year 6, a more detailed breakdown of the results is shown in Tables 16 for the 30 day mortality rates and Table 17 for the 90 day mortality rates. The second part looks at patients who undergo emergency surgical resection. Following formal review, a 90 day mortality target was added of <20%. A summary of the 30 day and 90 day mortality rates is presented in Figures 17 and 18 respectively, with a more detailed breakdown of the results shown in Tables 18 for the 30 day mortality rates and Table 19 for the 90 day mortality rates. Results: For QPI 10(i), all Boards met the <3% target for mortality within 30 days of elective surgical resection. The WoS performance was 0.6%, compared to 1.4% in Year 5. Similarly, all Boards met the <4% target for mortality within 90 days of elective surgery. The WoS performance was 1.5%, compared to 2.7% in Year 5. The regional mortality rates following elective surgical resection indicate the best overall performance for all years of analysis. For QPI 10(ii), all Boards met the <15% target for mortality within 30 days of emergency resection. The WoS performance was 5.5%, compared to 6.1% in Year 5. Likewise, all Boards met the <20% target for mortality within 90 days of emergency surgical resection. Performance within NHSGGC varied, with the Clyde sector achieving 18.2% against the <20% target which was higher than any other WoS unit. Actions:

All Boards to review cases failing QPI 10(ii) and provide feedback to the MCN.


41

QPI 10(i) – 30 Day

Figure 15: Summary of QPI 10(i) results, illustrating the proportion of patients with colorectal cancer who undergo elective surgical resection who die within 30 days of surgery, by NHS Board of surgery from Year 4 (2016/17) to Year 6 (2018/19). The red line represents the QPI target of <3%.


QPI 10(i) – 30 Day Target: <3%


Performance (%) 0.7% 0.0% 0.7% 1.1% 0.9% 0.9% 0.0% 0.6%

Numerator 1 0 1 2 1 4 0 5

Denominator 134 91 134 179 116 429 138 792

NR numerator 0 0 0 0 0 0 0 0



0%

1%

2%

3%

4%

5%

AA FV GGC LAN WoS

Pro

po

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)




42

QPI 10(i) – 90 Day

Figure 16: Summary of QPI 10(i) results, illustrating the proportion of patients with colorectal cancer who undergo elective surgical resection who die within 90 days of surgery, by NHS Board of surgery from Year 4 (2016/17) to Year 6 (2018/19). The red line represents the QPI target of <4%.




Performance (%) 2.3% 1.1% 1.5% 2.3% 0.9% 1.7% 0.7% 1.5%

Numerator 3 1 2 4 1 7 1 12

Denominator 133 90 132 174 112 418 135 776

NR numerator 0 0 0 0 0 0 0 0



0%

1%

2%

3%

4%

5%

AA FV GGC LAN WoS

Pro

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)




43

QPI 10(ii) – 30 Day

Figure 17: Summary of QPI 10(ii) results, illustrating the proportion of patients with colorectal cancer who undergo emergency surgical resection who die within 30 days of surgery, by NHS Board of surgery from Year 4 (2016/17) to Year 6 (2018/19). The red line represents the QPI target of <15%.


QPI 10(ii) – 30 Day Target: <15%


Performance (%) 8.0% 0.0% 7.1% 4.5% 12.1% 8.7% 0.0% 5.5%

Numerator 2 0 1 1 4 6 0 8

Denominator 25 16 14 22 33 69 35 145

NR numerator 0 0 0 0 0 0 0 0



0%

5%

10%

15%

20%

AA FV GGC LAN WoS

Pro

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)




44


Figure 18: Summary of QPI 10(ii) results, illustrating the proportion of patients with colorectal cancer who undergo emergency surgical resection who die within 90 days of surgery, by NHS Board of surgery from Year 4 (2016/17) to Year 6 (2018/19). The red line represents the QPI target of <20%.




Performance (%) 12.0% 6.3% 7.1% 4.5% 18.2% 11.6% 2.9% 9.0%

Numerator 3 1 1 1 6 8 1 13

Denominator 25 16 14 22 33 69 35 145

NR numerator 0 0 0 0 0 0 0 0



0%

5%

10%

15%

20%

25%

AA FV GGC LAN WoS

Pro

po

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f p

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ts (%

)




45

QPI 11: Adjuvant Chemotherapy QPI 11:

Patients with Dukes C and high risk Dukes B colorectal cancer should be considered for adjuvant chemotherapy.

Numerator: (i) Number of patients between 50 and 74 years of age at diagnosis with Dukes C colorectal cancer who undergo surgical resection who receive adjuvant chemotherapy.

(ii) Number of patients between 50 and 74 years of age at diagnosis with high risk Dukes B colorectal cancer who undergo surgical resection who receive adjuvant chemotherapy.

Denominator: (i) All patients between 50 and 74 years of age at diagnosis with Dukes C colorectal cancer

who undergo surgical resection. (ii) All patients between 50 and 74 years of age at diagnosis with high risk Dukes B colorectal

cancer who undergo surgical resection.

Exclusions: Patients who refuse chemotherapy; patients who undergo neo-adjuvant treatment.

Target:

(i) 70% (ii) 50%

All patients with Dukes C and high risk Dukes B colorectal cancer should be considered for adjuvant chemotherapy to reduce the risk of local and systemic recurrence. At formal review, it was decided to exclude patients undergoing neo-adjuvant therapy. Due to the difficulties associated with accurate measurement of co-morbidities and patient fitness these cannot be utilised as exclusions within this QPI. To ensure focussed measurement and a QPI examining expected outcomes the age range of 50-74 years has been selected. This represents the majority of patients and therefore provides a good proxy for access to adjuvant chemotherapy in the whole patient population. The QPI is split into two sub-groups. The first sub-group concerns patients with Dukes C colorectal who receive adjuvant chemotherapy while the second sub-group consider patients with high risk Dukes B colorectal cancer. Following formal review, it was decided to change the definition of high risk Dukes B to include T3 tumours with extramural venous invasion. Due to Dukes stage no longer being compatible with TNM8 staging, the results are not comparable with previous years. As such data is presented for Year 6 only. A summary of the results are presented in Figures 19 and 20, with a more detailed breakdown of the data shown in the corresponding tables (Tables 20 and 21), for QPI 11(i) and (ii) respectively. Results: All Boards met the QPI target of 70% and 50% for part (i) and (ii) respectively. The overall WoS performance for QPI 11(i) was 90.3%, whilst QPI 11(ii) was 74.7%.


46

QPI 11(i)

Figure 19: Summary of QPI 11(i) results, illustrating the proportion of patients between 50 and 74 years of age at diagnosis with Dukes C colorectal cancer who undergo surgical resection who receive adjuvant chemotherapy, by NHS Board of diagnosis for Year 6 (2018/19). The red line represents the QPI target of 70%.

Table 20: Details of QPI 11(i) results by NHS Board of diagnosis for Year 6 (2018/19).



Performance (%) 81.0% 84.6% 100.0% 96.4% 78.9% 92.3% 94.3% 90.3%

Numerator 17 11 18 27 15 60 33 121

Denominator 21 13 18 28 19 65 35 134

NR numerator 0 0 0 0 0 0 0 0



0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

AA FV GGC LAN WoS

Pro

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ts (%

)


Year 6


47

QPI 11(ii)

Figure 20: Summary of QPI 11(ii) results, illustrating the proportion of patients between 50 and 74 years of age at diagnosis with high risk Dukes B colorectal cancer who undergo surgical resection who receive adjuvant chemotherapy, by NHS Board of diagnosis for Year 6 (2018/19). The red line represents the QPI target of 50%.




Performance (%) 73.3% 88.9% 66.7% 76.2% 69.2% 72.5% 72.7% 74.7%

Numerator 11 8 4 16 9 29 8 56

Denominator 15 9 6 21 13 40 11 75

NR numerator 0 0 0 0 0 0 0 0



0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

AA FV GGC LAN WoS

Pro

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ts (%

)


Year 6


48

QPI 12: 30 and 90 Day Mortality Following Chemotherapy or Radiotherapy QPI 12:

Mortality after chemotherapy or radiotherapy for colorectal cancer.

Numerator: (i) Treatment with curative intent:-

(a) Number of patients with colorectal cancer who undergo neo-adjuvant chemoradiotherapy with curative intent who die within 30 or 90 days of treatment.

(b) Number of patients with colorectal cancer who undergo adjuvant chemotherapy with curative intent who die within 30 or 90 days of treatment.

(c) Number of patients with colorectal cancer who undergo radiotherapy with curative intent who die within 30 or 90 days of treatment.

(ii) Treatment with palliative intent:-

(d) Number of patients with colorectal cancer who undergo palliative chemotherapy who die within 30 days of treatment.

Denominator: (i) Treatment with curative intent:-

(a) All patients with colorectal cancer who undergo neo-adjuvant chemoradiotherapy

with curative intent. (b) All patients with colorectal cancer who undergo adjuvant chemotherapy with curative

intent. (c) All patients with colorectal cancer who undergo radiotherapy with curative intent.

(ii) Treatment with palliative intent:-

(d) All patients with colorectal cancer who undergo palliative chemotherapy.


Target:

(i) Curative: (a), (b) & (c) <1% (ii) Palliative: (d) <10%

Treatment related mortality is a marker of the quality and safety of the whole service provided by the Multi Disciplinary Team (MDT). Following formal review, the QPI was split into two key sub-groups. The first sub-group considers patients receiving treatment with curative intent including neo-adjuvant chemoradiotherapy, adjuvant chemotherapy, and radiotherapy. At formal review, the target for part (i) was changed from <2% to <1%. Due to small numbers, the mortality rates are presented by mode of treatment. A summary of the 30 and 90 day mortality rates are presented in Figures 21 and 22 respectively. For Year 6, additional data can be found in Table 22 for 30 day mortality rates and Table 23 for 90 day mortality rates. Part (ii) was added to capture patients receiving treatment with palliative intent, specifically palliative chemotherapy. The results of the 30 day mortality rates are summarised by NHS Board of diagnosis for the three most recent years of audit data (Year 4 to Year 6) in Figure 23. For Year 6, a more detailed breakdown of the data is shown in Table 24.


49

QPI 12(i) – 30 Day

Figure 21: Summary of QPI 12(i) results, illustrating the proportion of patients with colorectal cancer who undergo treatment with curative intent who die within 30 days of treatment, by mode of treatment from Year 4 (2016/17) to Year 6 (2018/19). The red line represents the QPI target of <1%.

Table 22: Details of QPI 12(i) results by mode of treatment for Year 6 (2018/19).


Neo-adjuvant chemoradiotherapy

Adjuvant chemotherapy

Radiotherapy Curative

intent

Performance (%) 0.9% 0.4% 0.0% 0.5%

Numerator 1 1 0 2

Denominator 115 267 15 397

NR numerator 1 27 1 29

NR exclusions 0 0 0 0

NR denominator 0 12 13 25

0%

1%

2%

3%

4%

5%


Adjuvant chemotherapy Radiotherapy Curative intent

Pro

po

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)

Mode of treatment



50

QPI 12(i) – 90 Day

Figure 22: Summary of QPI 12(i) results, illustrating the proportion of patients with colorectal cancer who undergo treatment with curative intent who die within 90 days of treatment, by mode of treatment from Year 4 (2016/17) to Year 6 (2018/19). The red line represents the QPI target of <1%.

Table 23: Details of QPI 12(i) results by mode of treatment for Year 6 (2018/19).



Adjuvant chemotherapy

Radiotherapy Curative

intent

Performance (%) 0.9% 1.7% 0.0% 1.4%

Numerator 1 4 0 5

Denominator 112 232 15 359

NR numerator 1 27 1 29

NR exclusions 0 0 0 0

NR denominator 0 12 13 25

0%

1%

2%

3%

4%

5%

6%

7%

8%


Adjuvant chemotherapy Radiotherapy Curative intent

Pro

po

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)

Mode of treatment



51


Figure 23: Summary of QPI 12(ii) results, illustrating the proportion of patients with colorectal cancer who undergo treatment with palliative intent who die within 30 days of treatment, by NHS Board of diagnosis from Year 4 (2016/17) to Year 6 (2018/19). The red line represents the QPI target of <10%.




Performance (%) 0.0% 5.6% 7.7% 3.7% 9.1% 6.5% 18.9% 8.5%

Numerator 0 1 1 1 2 4 7 12

Denominator 24 18 13 27 22 62 37 141

NR numerator 3 3 0 0 1 1 4 11



0%

5%

10%

15%

20%

25%

30%

35%

40%

AA FV GGC LAN WoS

Pro

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)




52

Results: For QPI 12(i), there were two patients in the WoS who died within 30 days of treatment with curative intent, resulting in a performance of 0.5% which was within the QPI target of 1%. By mode of treatment, there were no deaths following radiotherapy, one death following neo-adjuvant chemoradiotherapy and one death following adjuvant chemotherapy. All modes of treatment met the 30 day mortality QPI target of 1%. There were five patients in the WoS who died within 90 days of treatment with curative intent, resulting in a performance of 1.4% which was outwith the QPI target of 1%. By mode of treatment, there were no deaths following radiotherapy, one death following neo-adjuvant chemoradiotherapy and four deaths following adjuvant chemotherapy. The results showed that mortality rates following curative treatment with neo-adjuvant chemoradiotherapy or radiotherapy met the 90 day mortality QPI target of 1%, but adjuvant chemotherapy fell short with 1.7%. Boards have reviewed cases not meeting the 30 and 90 day mortality target following treatment with curative intent and provided the following feedback. NHS Ayrshire and Arran, NHS Greater Glasgow and Clyde and NHS Lanarkshire cited rapid disease progression, hospital acquired pneumonia, sepsis, dihydropyrimidine dehydrogenase (DPD) deficiency and drug toxicity as reasons for patients failing to meet the QPI criteria. NHS Greater Glasgow and Clyde highlighted the introduction of a pilot study to test patients for DPD deficiency prior to treatment. For QPI 12(ii), NHS Ayrshire and Arran, NHS Forth Valley and NHS Greater Glasgow and Clyde met the 90 day mortality QPI target of <10% following treatment with palliative intent. NHS Lanarkshire failed to meet the target with 18.9%. The overall WoS performance was 8.5%. Boards have reviewed cases not meeting the 30 day mortality target following treatment with palliative intent and provided the following feedback. NHS Lanarkshire stated that all patients failing to meet the QPI criteria were confirmed as having metastatic disease at diagnosis. The Board highlighted that a review of the cases would be conducted at an upcoming Mortality and Morbidity (M&M) MDT. Actions:

NHS Lanarkshire to provide feedback to the MCN on the outcome of the case series review at the M&M meeting for all seven patients.


53


QPI 13:

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

Description: Proportion of patients with colorectal cancer who are consented for a clinical trial/research study.

Numerator: Number of patients with colorectal cancer consented for a clinical trial/research study.

Denominator: All patients diagnosed with colorectal cancer.


Target: 15%

Clinical trials are necessary to demonstrate the efficacy of new therapies and other interventions. Evidence suggests improved patient outcomes from participation in clinical trials1.Clinicians are therefore encouraged to enter patients into well-designed trials and to collect longer-term follow-up data. High accrual activity into clinical trials is used as a goal of an exemplary clinical research site1. The clinical trials QPI is measured utilising Scottish Cancer Research Network (SCRN) data and ISD incidence data, as is the methodology currently utilised by the Chief Scientist Office (CSO) and the National Cancer Research Institute (NCRI). The principal benefit of this approach is that this data is already collected utilising a robust mechanism1.

Following 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.

Table 25 presents a summary of the results for QPI 13 by NHS Board of diagnosis in 2018. The denominator for this QPI is identified by using a 5-year average of Scottish Cancer Registry data.

Table 25: Details of QPI 13, illustrating the proportion of patients consented for clinical trials for colorectal cancer, by NHS Board of diagnosis in 2018. The denominator represents the 5 year average of ISD incidence data for all colorectal cancer in between 2013 and 2017.

QPI 13 Target: 15%

AA FV GGC LAN Outwith

WoS WoS

Performance % 6.3% 45.3% 2.9% 3.4% - 8.8%

Numerator 17 86 24 12 6 145

Denominator 269 190 838 355 - 1652

In the WoS there were 145 patients consented for clinical trials. NHS Forth Valley met the 15% target with a performance of 45.3%. All other Boards were short of the target. The performance for the WoS was 8.8%. Six patients did not have a Board of residence recorded.


54

A list of active colorectal clinical trials in 2018 is shown below.

A Phase I trial of LY3143921 hydrate in solid tumours

A Phase I trial of oral CCT245737

A Phase Ib open label Study to assess NUC-3373 in patients with colorectal cancer

Add-Aspirin Trial

An Open-Label Multicenter Phase 1 Study of E7386 in Subjects with Selected Advanced Neoplasms

Aristotle

AZD1775 Food Effects

BEACON CRC Study

CAROSELL Colon and Rectal cancer Opdivo Safety and Efficacy with 101

CX-072 in patients with advanced/recurrent solid tumours or lymphomas

ECMC EXPLOR BIOMARKER

FOCUS-4: Molecular selection of therapy in colorectal cancer

JNJ-63723283

NCRN - 3131: EPOCH TheraSphere in Metastatic Colorectal Carcinoma of the Liver (TS102)

SOCCS3

The SCOTTY Study Although the WoS performance (8.8%) is higher than other gastrointestinal (GI) cancers, this is predominately due to excellent recruitment in NHS Forth Valley to the SOCCS3 biomarker study; however due to workforce challenges, this was not mirrored at other NHS Board sites. The ADD ASPIRIN trial recruits from four tumour groups including colorectal cancer but again, personnel resource issues have impacted on recruitment to this cohort of patients. FOCUS 4 is the current flagship trial in the 1st line setting, but recruitment to this trial across the UK has slowed in recent months. However, recruitment to early phase and more complex trials has been more successful with patients with BRAF mutant disease showing a willingness to travel to receive treatment at the Beatson West of Scotland Cancer Centre (BWoSCC). Lower GI radiotherapy trial recruitment has been affected by a couple of barriers, including delays in opening radiotherapy trials and lack of a centralised clinic for this group of patients. As previously indicated, recruiting and managing clinical trial patients at standard clinics is extremely time consuming and this may be contributing to lack of engagement from clinicians in identifying and recruiting patients. Actions:



55

5. Conclusions Cancer audit data underpins much of the development and service improvement work of the MCN and regular reporting of activity and performance is a fundamental requirement of an MCN to assure the quality of care delivered. The Colorectal Cancer MCN remains committed to improve the quality and completeness of clinical audit data to ensure continued robust performance assessment and the identification of areas for service improvement. The Colorectal Cancer MCN is encouraged by the results presented in this report which demonstrate that patients with colorectal cancer in the WoS continue to receive a consistently high standard of care. The results illustrate that some of the QPI targets set have been challenging for NHS Boards to achieve and there remains room for further service improvement around a number of areas. It is however encouraging that the targets relating to MDT discussion, stoma care, lymph node yield, re-operation rates, anastomotic dehiscence, mortality rates following surgical resection, and adjuvant chemotherapy were met by all Boards in Year 6 (2018/19). Some variance in performance does exist across the regions and, as per the agreed Regional governance process, each NHS Board was asked to complete a Performance Summary Report, providing a documented response where performance was below the QPI target. NHS Boards provided detailed comments indicating valid clinical reasons, or in some cases patient choice or co-morbidities, have influenced patient management. Remaining actions are summarised below and outlined in the main report under the relevant section. The MCN will actively take forward regional actions identified and NHS Boards are asked to develop local Action/Improvement Plans in response to the findings presented in the report. A summary of actions for each NHS Board has been included within the Action Plan templates in Appendix I. Action Required: QPI 9: Anastomotic Dehiscence

NHS Lanarkshire to review cases failing QPI 9(ii) and provide feedback to the MCN. QPI 10: 30 and 90 Day Mortality Following Surgical Resection

All Boards to review cases failing QPI 10(ii) and provide feedback to the MCN. QPI 12: 30 and 90 Day Mortality Following Chemotherapy or Radiotherapy

NHS Lanarkshire to provide feedback to the MCN on the outcome of the case series review of QPI 12d at the M&M meeting for all seven patients.



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.


56

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).


57

Abbreviations

AA Ayrshire & Arran

ACaDMe Acute Cancer Deaths and Mental Health

BWoSCC Beatson West of Scotland Cancer Centre

CNS Clinical Nurse Specialist

CRM Circumferential margin

DVT Deep Venous Thrombosis

DPD Dihydropyrimidine dehydrogenase

eCASE Electronic Cancer Audit Support Environment

FV Forth Valley

GGC Greater Glasgow and Clyde

GGH Gartnavel General Hospital

GRI Glasgow Royal Infirmary

ISD Information Services Division

LAN Lanarkshire

M&M Mortality and Morbidity

MCN Managed Clinical Network

MDT Multidisciplinary Team

NG North Glasgow

NICE National Institute for Health and Clinical Excellence

QEUH Queen Elizabeth University Hospital

QPI Quality Performance Indicator

RCAG Regional Cancer Advisory Group

SG South Glasgow

STOB Stobhill Hospital

TNM Tumour Node Metastases

VIC Victoria Infirmary

WIG Western Infirmary Glasgow

WoS West of Scotland

WoSCAN West of Scotland Cancer Network


58

References

1. Healthcare Improvement Scotland. Colorectal Cancer Quality Performance Indicators, December 2012 (updated May 2017 v3.0). [Accessed on: 12th November 2019]. Available at: http://www.healthcareimprovementscotland.org/our_work/cancer_care_improvement/cancer_qpis/quality_performance_indicators.aspx

2. ScotPHO, Public Health Information for Scotland. Mid-2018 Population Estimates Scotland.

[Accessed on: 12th November 2019] Available at: https://www.nrscotland.gov.uk/statistics-and-data/statistics/statistics-by-theme/population/population-estimates/mid-year-population-estimates/mid-2018

3. Information Services Division. Data Definitions for the National Minimum Core Data Set to

support the introduction of Colorectal Quality Performance Indicators v3.3 [Accessed on: 12th November 2019]. Available at: http://www.isdscotland.org/Health-Topics/Cancer/Cancer-Audit/

4. Information Services Division. Summary Statistics for Colorectal Cancer [Accessed on: 12th

November 2019]. Available at: http://www.isdscotland.scot.nhs.uk/Health-Topics/Cancer/Cancer-Statistics/Colorectal/

5. Information Services Division. Cancer Incidence Projections for Scotland 2013-2027. August

2015. [Accessed on: 12th November 2019]. Available at: http://www.isdscotland.scot.nhs.uk/Health-Topics/Cancer/Publications/2015-08-18/2015-08-18-Cancer-Incidence-Projections-Report.pdf

6. Information Services Division. Cancer in Scotland. April 2018. [Accessed on: 12th November

2019]. Available at: https://www.isdscotland.org/Health-Topics/Cancer/Publications/2019-04-30/Cancer_in_Scotland_summary_m.pdf

7. Scottish Government. Detect Cancer Early. August 2012. [Accessed on: 12th November 2019] Available at: http://www.scotland.gov.uk/About/Performance/scotPerforms/partnerstories/NHSScotlandperformance/DetectCancerEarly

8. NHS National Services Division. National Bowel Screening Programme. December 2013.

[Date accessed: 12th November 2019]. Available at: https://www.nhsinform.scot/healthy-living/screening/bowel/bowel-screening

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

https://www.nrscotland.gov.uk/statistics-and-data/statistics/statistics-by-theme/population/population-estimates/mid-year-population-estimates/mid-2018



http://www.isdscotland.org/Health-Topics/Cancer/Cancer-Audit/

http://www.isdscotland.scot.nhs.uk/Health-Topics/Cancer/Cancer-Statistics/Colorectal/

http://www.isdscotland.scot.nhs.uk/Health-Topics/Cancer/Cancer-Statistics/Colorectal/

http://www.isdscotland.scot.nhs.uk/Health-Topics/Cancer/Publications/2015-08-18/2015-08-18-Cancer-Incidence-Projections-Report.pdf

http://www.isdscotland.scot.nhs.uk/Health-Topics/Cancer/Publications/2015-08-18/2015-08-18-Cancer-Incidence-Projections-Report.pdf

https://www.isdscotland.org/Health-Topics/Cancer/Publications/2019-04-30/Cancer_in_Scotland_summary_m.pdf

https://www.isdscotland.org/Health-Topics/Cancer/Publications/2019-04-30/Cancer_in_Scotland_summary_m.pdf

http://www.scotland.gov.uk/About/Performance/scotPerforms/partnerstories/NHSScotlandperformance/DetectCancerEarly

http://www.scotland.gov.uk/About/Performance/scotPerforms/partnerstories/NHSScotlandperformance/DetectCancerEarly

https://www.nhsinform.scot/healthy-living/screening/bowel/bowel-screening

https://www.nhsinform.scot/healthy-living/screening/bowel/bowel-screening


59

Appendix I: NHS Board Action Plans

A summary of actions for each NHS Board has been included within the respective Action Plan templates below. Completed Action Plans should be returned to WoSCAN within two months of publication of this report.

Action / Improvement Plan

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

Start End

Ensure actions mirror those detailed in Audit Report.

Detail specific actions that will be taken by the NHS Board.

Insert date

Insert date

Insert name of responsible lead for each action.

Provide detail of action in progress, change in practices, problems encountered or reasons why no action taken.

Insert No. from key above

10(ii) All Boards to review cases failing QPI 10(ii) and provide feedback to the MCN.

NHS Board: NHS Ayrshire and Arran KEY (Status)

Action Plan Lead: 1 Action fully implemented

Date: 2 Action agreed but not yet implemented

3 No action taken (please state reason)


60



Start End



Insert date

Insert date





NHS Board: NHS Forth Valley KEY (Status)





61



Start End



Insert date

Insert date





NHS Board: NHS Greater Glasgow and Clyde KEY (Status)





62



Start End



Insert date

Insert date




9(ii) NHS Lanarkshire to review cases failing QPI 9(ii) and provide feedback

to the MCN.


12d NHS Lanarkshire to provide feedback to the MCN on the outcome of the case series review of QPI 12d at the M&M meeting for all seven patients.

NHS Board: NHS Lanarkshire KEY (Status)





63



Start End



Insert date

Insert date




13 MCN to continue to promote recruitment of patients into Trials, as appropriate, and to raise awareness of trials across the wider MCN membership, as opportunities allow.

NHS Board: Colorectal Cancer MCN KEY (Status)





64

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

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

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