colorectal cancer 2016 – 2017 quality performance ... colorectal cancer... · mr manimaran mr...

SCAN Audit Office, c/o Department of Clinical Oncology, Western General Hospital, Crewe Road, Edinburgh EH4 2XU T: 0131 537 2266 W: www.scan.scot.nhs.uk [email protected]

SOUTH EAST SCOTLAND CANCER NETWORK PROSPECTIVE CANCER AUDIT

COLORECTAL CANCER 2016 – 2017 Quality Performance Indicators (QPI) Comparative Report Mr S Yalamarthi, NHS Fife, Lead Colorectal Cancer Clinician, SCAN Group Chair Mr K Pal, NHS Borders Mr S Whitelaw, NHS Dumfries & Galloway Mr N Manimaran, NHS Fife Mr D Speake, NHS Lothian Mr R G Wilson, NHS Lothian Dr H Philips, Clinical Oncologist, NHS Lothian Sarah Buchan SCAN Colorectal Cancer Audit Facilitator Lynn Smith, Cancer Audit Facilitator, NHS Borders Laura Halliday, Cancer Audit Facilitator, NHS Dumfries & Galloway Martin Keith, Cancer Improvement, NHS Dumfries & Galloway Maureen Lamb, Cancer Audit Facilitator, NHS Fife SA C01/18_W

2 SCAN Colorectal Cancer 2016-17 Comparative Audit Report

COLORECTAL CANCER 2016-17 COMPARATIVE AUDIT REPORT

Patients diagnosed 1 April 2016 – 31 March 2017

Contents DOCUMENT HISTORY ............................................................................................................. 3

Comment by Chair of the SCAN Colorectal Group .................................................................... 4

ACTION POINTS ....................................................................................................................... 6

Key ............................................................................................................................................ 9

Introduction and Methods ........................................................................................................ 10

Data Quality........................................................................................................................................... 12

Estimate for case ascertainment ........................................................................................................... 13

Actions for Improvement ....................................................................................................................... 13

DIAGNOSIS AND STAGING ................................................................................................... 14

QPI 1: Radiological Diagnosis and Staging (i) ......................................................................... 14

QPI 1: Radiological Diagnosis and Staging (ii) ......................................................................... 16

QPI 2: Pre-Operative Imaging of the Colon .............................................................................. 18

QPI 3: Multi-Disciplinary Team (MDT) Meeting ........................................................................ 20

QPI 4: Stoma Care .................................................................................................................. 22

SURGICAL OUTCOMES ......................................................................................................... 24

QPI 5: Lymph Node Yield ........................................................................................................ 24

QPI 6: Neo-adjuvant Therapy .................................................................................................. 26

QPI 7: Surgical Margins (i) ....................................................................................................... 28

QPI 7: Surgical Margins (ii) ...................................................................................................... 30

QPI 8: Re-operation Rates....................................................................................................... 32

QPI 9: Anastomotic Dehiscence (ii) ......................................................................................... 36

QPI 10 (i): 30 Day Mortality Following Surgical Resection ....................................................... 38

QPI 10 (i): 30 Day Mortality Following Surgical Resection ....................................................... 40

QPI 10 (ii): 90 Day Mortality Following Surgical Resection....................................................... 42

QPI 10 (ii): 90 Day Mortality Following Surgical Resection....................................................... 44

ONCOLOGICAL TREATMENT OUTCOMES .......................................................................... 46

QPI 11: Adjuvant chemotherapy in Patients with High Risk Dukes B ....................................... 46

QPI 11: Adjuvant chemotherapy in Patients with Dukes C colorectal cancer ........................... 48

QPI 12 (i): 30 Day Mortality Following Chemotherapy or Radiotherapy ................................... 50

QPI 12 (i): 90 Day Mortality Following Chemotherapy or Radiotherapy ................................... 51

QPI 12 (ii): 30 Day Mortality Following Chemotherapy or Radiotherapy ................................... 52

Clinical Trials ........................................................................................................................... 53

Key Categories ........................................................................................................................ 55

Summary of Quality Performance Indicators: ........................................................................... 62

Glossary .................................................................................................................................. 63


DOCUMENT HISTORY

Version Circulation Date Comments

Version 1 Lead Clinicians’ Sign off Group 02/11/2017 Circulated in advance of the Leads

meeting

Version 1.2 Lead Clinicians’ Sign off Group 09/11/2017

D&G figures updated. Minor changes to Fife figures. Low case ascertainment investigated and 7 additional patients added following update of Cancer Registry queries.

Version 2.4

SCAN Lead Clinician for commentary

08/12/2017 Commentary received 15/01/2018 and added to Version 4 of the report.

Version 3 SCAN Colorectal Group Members 18/12/2017 Final comments from SCAN Group

requested – None received.

Final Report SA C01/18

Clinical Governance Groups

16/01/2018

SA C01/18

Final report added to the SCAN website

Report assessed for disclosure and prepared for website


Comment by Chair of the SCAN Colorectal Group

This report provides comprehensive data on the management of colorectal cancer in the South East of Scotland from 1st April 2016 – 31st March 2017. The SCAN Audit Team have worked extremely hard to produce data of consistently high quality. This has been facilitated by the local data collection teams, who have again delivered with high quality data in a timely manner. This year some changes were made to the CRC QPI Attainment Summary sheet, with inclusion of Numerator and Denominator numbers. This is a useful and helpful amendment. SCAN data holds up extremely well in comparison to other UK areas in terms of Colorectal Cancer outcomes. During 2016-17 across SCAN, 891 patients were diagnosed with colorectal cancer and the numbers are relatively similar for the last 2 years. Since the introduction of the bowel screening programme 7 years ago, there has been a reduction of nearly 15% in cancers. Radiological staging investigations have consistently improved over the years and this is the first time we achieved the required target for rectal cancers. Pre-operative colonic imaging still requires some work and has been a difficult target to meet over the years. Reasons for the failure to meet this target need further analysis.. Nearly 80% (711 patients) of patients underwent surgical treatment with a high curative resection rate of 90%, this figure being higher for rectal cancers (92%). Nearly 22% of patients underwent emergency surgery, which has been consistent over the years. Surgical outcomes in terms of low positive resection margins (2.4%), anastomotic leak rates (2.7% for colonic; 4.2% for rectal surgery) and re-operations (2.4% for elective surgery; 4.2% for emergency surgery) are excellent outcomes, demonstrating the high degree of surgical care offered across the network. The target for lymph node yield of >12 nodes was increased from 80% to 90% this year and we have fallen short of this target. Over the last 4 years we have consistently been between 85-90%. Further analysis of the node numbers in those with negative nodes were analysed and 83.7% had >12 nodes, reassuring us about the quality of resections and adequate sampling by pathologists. Despite the busy workload, exceptional standard of surgical care across the region has been maintained, demonstrated by low 30-day day mortality rates after elective and emergency surgery of 1.5% and 5.3% respectively. 90-day mortality rates for all patients undergoing elective surgery were 1.9% and 8.3% for emergency patients which compares favourably with UK wide averages of 2.2% and 10.5% (National Large Bowel Cancer Audit 2015). Over the last few years we have seen a steady and increasing use of laparoscopic surgery for colorectal cancers. This year nearly 60% of all the resections were done by laparoscopic means. Transanal Endoscopic Microsurgery (TEMS) continued to be used for a small select group of patients. Adjuvant chemotherapy, as in previous years, has been delivered by a highly professional team of oncologists to High Risk Dukes B and C patients, achieving the targets with very low mortality figures. Though we have recruited adequate numbers into translational research, there is room for improvement to recruit more patients into interventional studies. As a SCAN wide target, there are plans to look at this more closely and have a wider strategy for entry into clinical trials


The introduction of QPIs has progressively improved the outcomes in some areas, but there are still some areas to work on, which will be challenging. I believe that through continued effort by the entire team, these should be achievable, thereby delivering patient care to the best possible standards. Mr S Yalamarthi Chair SCAN Colorectal Group January 18


ACTION POINTS Colorectal QPI Action Plans 2016-2017 QPI Action Required Lead Date for update

1 (i) Monitor D&G results Mr Whitelaw Dec 2018

2 D&G, Fife and Lothian to ensure appropriate pre-operative imaging of colon is performed and ensure CT of the colon is performed if endoscopic imaging is incomplete.

Mr Whitelaw Mr Manimaran Mr Speake

Next SCAN Group Meeting 2/2/2018

4 Action is required to ensure patients are seen and marked appropriately by Stoma Nurses in Lothian. Mr Speake Next SCAN Group Meeting 2/2/2018

5 Performance has remained at 85-89% over the past 4 years, continued monitoring is required. Ensure local pathology leads know that the target has increased to 90%.

Mr Whitelaw Mr Manimaran Mr Speake Dr Fineron


7 (i) This QPI was met but SCAN will carry out a separate audit of cases with positive margins from the 2016-17 cohort, which will be documented in the 2017-18 report

Mr Yalamarthi Dec 2018

Clinical Trial QPI

As Surgical Services require infrastructure to recruit to clinical trials, a strategic plan is required in order to meet this QPI.

Mr Speak Mr Cruickshank Dr Philips


General

The TNM staging system is moving to TNM 8 from January 2018. This will create some difficulties with data collection as Dukes staging is now technically obsolete. Our audit team are already addressing this issue and for a period of time all pathology results will be reported both with TNM 5 and TNM 8 to ensure that the data capture is not affected. This will also allow the new system to embed into the clinical practice.

Mr Whitelaw Mr Pal Mr Manimaran Mr Speake

Dec 2018

Action Points from 2015-16

No. Action Required Progress/Action Status Status

QPI 2

Dumfries, Fife and Lothian to disseminate requirement for appropriate pre-operative imaging of colon and need for CT Colon if endoscopic imaging is

D&G: Following discussion NHS D&G does not have the CT capacity to increase the number of CT Colons beyond current level. Therefore all patients diagnosed by flexible sigmoidoscopy will receive completion colonoscopy and patients with incomplete colonoscopies will receive CT Colon. The newly appointed MDT Co-ordinator will highlight patients who have not had complete bowel visualisation and has made changes to the MDT database to identify patients who require further bowel visualisation. Colonoscopies are now being done in Stranraer although reporting capacity has not increased Fife : Following the last 2 years, this QPI was reviewed and steps were taken to ensure that CT colon is appropriately requested in situations of incomplete colonoscopies. This has enabled better checks under these circumstances and increased the number of CT colons requested, guided by the clinical picture of the patients

2 1


No. Action Required Progress/Action Status Status

incomplete. Lothian: Cancer MDM Co-Coordinator has been asked to remind all endoscopists to order CT colon not plain CT in all patients where colonoscopy incomplete Discussion at the SCAN group on 5/7/17 suggests that this is happening now.

1

QPI 3

Dumfries to look at their practice to determine if changes need to be made

D&G: MDT Co-ordinator appointed who will work with the Cancer Tracking team to ensure all new cancers known to the tracking team are listed for MDT. Those patients who are for palliative treatment should also be included for discussion at the MDT. This will hopefully improve performance in this QPI and will need continued monitoring. Non-surgical colleagues will be advised to refer patients to the colorectal services even if their cancers are picked up incidentally and do not require any intervention.

2

QPI 5

Lothian to feedback information to Pathology regarding reduction in lymph node yield year on year

Complete 1

QPI 7

All Boards to review all positive resection margins at MDM as a learning opportunity

Borders: Complete D&G: Discussion will be held within the MDT and a documented action if required stored within MDT system. Fife: All positive resection margins are discussed at Colorectal MDT and this will continue in the future Lothian: Ongoing, Michael Duff will progress this now. There are plans to look at the Positive margins across SCAN to identify learning points and find ways forward. Each individual unit will collect specific data (to be finalised) and this will be collectively looked at.

1 2 1 2

QPI 9 (i)

Dumfries to look at their practice to determine if there are any available learning or changes in practice that need to be made

D&G: Case reviewed during QPI analysis with S Whitelaw. 2/3 patients were treated as emergencies by non colorectal surgeons and 1/3 by a colorectal surgeon. No obvious learning was identified however it is apparent that this will only be of clinical benefit if reviewed at time of surgery/ anastomotic leak. This will be managed going forward as per QPI 7This Action is now complete

1


CRC QPI Attainment Summary 2016-17 Target% Borders D&G Fife Lothian SCAN

1. Radiological Staging & Diagnosis Colon 95

N 32 100%

N 36 92.3%

N 88 100%

N 195 99.0% N 352 98.6%

D 32 D 39 D 88 D 197 D 357

Rectum 95 N 15

100% N 14

87.5% N 38

100% N 98 96.1% N 165

96.5% D 15 D 16 D 38 D 102 D 171

2. Pre-operative imaging of the Colon 95 N 46

95.8% N 47

85.5% N 113

93.4% N 235 92.5% N 441

92.3% D 48 D 55 D 121 D 254 D 478

3. MDT before definitive treatment 95 N 71

92.2% N 78

96.3% N 169

95.5% N 269 95.1% N 587

95.0% D 77 D 81 D 177 D 283 D 618

4. Stoma Care: stoma site marked pre-operatively 95 N 14

100% N 23

85.2% N 27

100% N 75 93.8% N 139

93.9% D 14 D 27 D 27 D 80 D 148

5. Lymph Node Yield: surgical resection where ≥12 lymph nodes

90 N 41

87.2% N 60

100% N 108

83.1% N 218 86.2% N 427

87.3% D 47 D 60 D 130 D 252 D 489

6. Neo-adjuvant Radiotherapy (rectal) 90 N 2

100% N 3

100% N 10

83.3% N 20 100% N 35

94.6% D 2 D 3 D 12 D 20 D 37

7. Surgical Margins

Primary surgery or surgery after short course XRT

95 N 13

100% N 13

100% N 31

96.9% N 66 97.1% N 123

97.6% D 13 D 13 D 32 D 68 D 126

After neo-adjuvant chemo, long course chemoradiotherapy, long course radiotherapy or short course radiotherapy with long course intent

85 N 2

100% N 3

100% N 10

90.9% N 24

100% N 39

97.5% D 2 D 3 D 11 D 24 D 40

8. Re-operation Rates

Elective <10 N 1

2.1% N 1

1.6% N 3

2.4% N 7 2.7% N 12

2.4% D 47 D 62 D 127 D 258 D 494

Emergency <15 N 0

0% N 1

5.9% N 1

3.6% N 4

4.5% N 6

4.2% D 10 D 17 D 28 D 88 D 143

9. Anastomotic Dehiscence

Colon <5 N 0

0% N 2

6.1% N 2

3.0% N 3

2.3% N 7

2.7% D 26 D 33 D 66 D 130 D 255

Rectum incl. TME <10 N 0

0% N 0

0.0% N 1

2.0% N 8

6.3% N 9

4.2% D 21 D 14 D 51 D 128 D 214

TME <20 N

- N

- N

- N

- N

- D

D

D

D

D

10i). 30 day mortality following surgical resection

Elective <3 N 0

0% N 1

1.7% N 4

3.1% N 2

0.8% N 7

1.5% D 44 D 58 D 127 D 253 D 482

Emergency <15 N 2

16.7% N 1

8.3% N 2

7.1% N 2

2.5% N 7

5.3% D 12 D 12 D 28 D 81 D 133


CRC QPI Attainment Summary 2016-17 Target% Borders D&G Fife Lothian SCAN

10ii) 90 day mortality following surgical resection

Elective <4 N 0

0.0% N 1

1.7% N 5

4.0% N 3

1.2% N 9

1.9% D 44 D 58 D 127 D 253 D 482

Emergency <20 N 3

25.0% N 1

8.3% N 2

7.4% N 5

6.2% N 11

8.3% D 12 D 12 D 27 D 81 D 132

11. Adjuvant Chemotherapy HR Dukes B 50

N 2 66.7%

N 1 50.0%

N 3 50%

N 14 51.9%

N 20 52.6%

D 3 D 2 D 6 D 27 D 38

Dukes C 70 N 8

72.7% N 10

71.4% N 26

86.7% N 48

82.8% N 92

81.4% D 11 D 14 D 30 D 58 D 113

12i) 30 day Mortality after Curative Oncological Treatment

All oncology treatment <1 N -

N - N -

N - N -

D

D

D

D

D

Neo-adjuvant <1 N 0

0% N 0

0% N 0

0% N 0

0% N 0

0% D 1 D 2 D 9 D 24 D 36

Radiotherapy <1 N 0

0% N 0

0% N 0

0% N 1

3.4% N 1

1.9% D 4 D 8 D 12 D 29 D 53

Adjuvant Chemotherapy <1 N 0

0% N 0

0% N 0

0% N 0

0% N 0

0% D 17 D 14 D 44 D 87 D 162

12i) 90 day Mortality after Curative Oncological Treatment

All oncology treatment <1 N

- N

- N

- N

- N

- D

D

D

D

D

Neo-adjuvant <1 N 0

0% N 0

0% N 0

0% N 0

0% N 0

0% D 1 D 2 D 8 D 24 D 35

Radiotherapy <1 N 0

0% N 0

0% N 0

0% N 1

3.4% N 1

2.0% D 4 D 5 D 12 D 29 D 50

Adjuvant Chemotherapy <1 N 0

0% N 0

0% N 0

0% N 0

0% N 0

0% D 14 D 11 D 45 D 87 D 157

12ii). 30 day Mortality after Palliative Chemotherapy <10 N 0

0% N 1

8.3% N 1

5.9% N 6 14.0% N 8

10.4% D 5 D 12 D 17 D 43 D 77

QPI Clinical Trials NB: N: patients enrolled in Trials and held on SCRN database D: 5 year average Cancer Registry patients

Interventional 7.5 N 1

1.1% N 1

0.8% N 5

2.3% N 17

3.0% N 27

2.6% D 95 D 130 D 220 D 576 D 1021

Translational 15 N 31

32.6% N 42

32.3% N 60

27.3% N 46

8.0% N 184

18.0% D 95 D 130 D 220 D 576 D 1021

Key

Numerator (N) % Performance Denominator (D)


Introduction and Methods Cohort and Personnel This report is the twelfth to present comparative data on patients newly diagnosed with colorectal cancer in South East Scotland Cancer Network (SCAN) at the following hospitals: Borders General Hospital (NHS Borders), Dumfries and Galloway Royal Infirmary (NHS Dumfries & Galloway), Victoria Hospital, Kirkcaldy (NHS Fife), and Western General Hospital, Edinburgh (NHS Lothian). The report covers data on patients newly-diagnosed in the twelve months from 1 April 2016 to 31 March 2017. Lead Clinicians and staff involved in audit were as follows

SCAN Region Hospital Lead Clinician Audit Support

NHS Borders Borders General Hospital Mr Karol Pal Lynn Smith

NHS Dumfries & Galloway

Dumfries & Galloway Royal Infirmary

Mr Stuart Whitelaw Laura Halliday Martin Keith

NHS Fife Victoria Hospital Mr Natarajan Manimaran Maureen Lamb

SCAN & NHS Lothian

Western General Hospital Mr Doug Speake Sarah Buchan

Audit Processes and data recording Data was analysed by the audit facilitators in each NHS Board according to the measurability document provided by ISD. SCAN data was collated by Sarah Buchan, SCAN Audit Facilitator for Colorectal cancer. Data capture is focused round the process for the weekly multidisciplinary meetings i.e. ensuring that data covering patient referral, investigation, and diagnosis is being picked up through the routine process. Surgical and Oncology data is obtained either from the clinical records (electronic systems and case notes) or by download from the Department of Clinical Oncology database within the Edinburgh Cancer Centre (ECC). Each of the 5 hospitals provides surgery and chemotherapy but radiotherapy is provided centrally in Edinburgh Cancer Centre. Patients living closer to either Carlisle or Dundee may opt to have treatment outwith the SCAN region. All QPIs will be analysed and presented by Hospital of Diagnosis for data verification/sign off purposes with additional reports by Hospital of Surgery as appropriate. The process remains dependent on audit staff for capture and entry of data, and for data quality checking In Borders, Fife and Dumfries & Galloway data was collected using E-case. Data was recorded on TRAK in Lothian.


Dataset and Definitions The QPIs have been developed collaboratively with the three Regional Cancer Networks, Information Services Division (ISD), and Healthcare Improvement Scotland. QPIs will be kept under regular review and be responsive to changes in clinical practice and emerging evidence. The overarching aim of the cancer quality work programme is to ensure that activity at NHS board level is focussed on areas most important in terms of improving survival and patient experience whilst reducing variance and ensuring safe, effective and person-centred cancer care. Following a period of development, public engagement and finalisation, each set of QPIs is published by Healthcare Improvement Scotland1. Accompanying datasets and measurability criteria for QPIs are published on the ISD website2. NHS boards are required to report against QPIs as part of a mandatory, publicly reported, programme at a national level. The QPI dataset for Colorectal was implemented from 01/04/2013. Following year 3 results the Colorectal QPIs were subject to a formal review and revised documents for data collection were published in August 2017. This is the fourth publication of QPI results for colorectal cancer within SCAN and some of the revisions will not be implemented till year 5, depending on whether new data items were required or not. The standard QPI format is shown below: QPI Title: Short title of Quality Performance Indicator (for use in reports etc.)

Description: Full and clear description of the Quality Performance Indicator.

Rationale and Evidence:

Description of the evidence base and rationale which underpins this indicator.

Specifications:

Numerator: Of all the patients included in the denominator those who meet the criteria set out in the indicator.

Denominator: All patients to be included in the measurement of this indicator.

Exclusions: Patients who should be excluded from measurement of this indicator.

Not recorded for numerator:

Include in the denominator for measurement against the target. Present as not recorded only if the patient cannot otherwise be identified as having met/not met the target.

Not recorded for exclusion:

Include in the denominator for measurement against the target unless there is other definitive evidence that the record should be excluded. Present as not recorded only where the record cannot otherwise be definitively identified as an inclusion/exclusion for this standard.

Not recorded for denominator:

Exclude from the denominator for measurement against the target. Present as not recorded only where the patient cannot otherwise be definitively identified as an inclusion/exclusion for this standard.

Target: Statement of the level of performance to be achieved.

1 QPI documents are available at www.healthcareimprovementscotland.org 2 Datasets and measurability documents are available at www.isdscotland.org


Data Quality

Clinical Sign-Off: This report compares data from reports prepared for individual hospitals and signed off as accurate following review by the lead clinicians from each service. Additionally, the collated SCAN results are reviewed jointly by the lead clinicians, including the lead Oncologist, to assess variances and provide comments on results. External QA: SCAN Audit participates in external quality assurance (QA) of data by ISD Scotland, (i.e. when a sample of data is compared with the data definitions). A QA of the QPI colorectal dataset took place in February 2015 and overall accuracy percentage results are shown below:

Estimated Case Ascertainment: Case ascertainment has been estimated using Scottish Cancer Registration data 2011-2015 for comparison purposes. Tables on case ascertainment and five year averages are contained in the next section. Most patients are identified through weekly multidisciplinary meetings. The following sources are used to check for additional patients: 1. Pathology records 2. GRO Death lists 3. Dept of Clinical Oncology retrospective database 4. Clinical Nurse Specialist database 5. ACaDMe (Acute, Cancer, Deaths and Mental Health); a data mart part of NHS National

Services Scotland.

Borders D&G Fife Lothian Scotland

Accuracy of data recording (%) 99.4 99.4 98.3 97.0 99.0


ESTIMATE OF CASE ASCERTAINMENT

Estimated Case Ascertainment An estimate of case ascertainment (the percentage of the population with colorectal cancer recorded in the audit) is made by comparison with the Scottish Cancer Registry five year average data from 2011 to 2015. High levels of case ascertainment provide confidence in the completeness of the audit recording and contribute to the reliability of results presented. Levels greater than 100% may be attributable to an increase in incidence. Allowance should be made when reviewing results where numbers are small and variation may be due to chance. Number of cases recorded in audit: patients diagnosed 01.04.2016 to 31.03.2017

Borders D&G Fife Lothian SCAN Colon cancer 67 66 152 329 614 Rectal cancer 29 37 64 147 277 Total 96 103 216 476 891

Estimate of case ascertainment: calculated using the average of the most recent available five years of Cancer Registry Data Borders D&G Fife Lothian SCAN Cases from Audit 96 103 216 476 891

Cancer Registry 5 Year Average 95 130 220 576 1021 Case Ascertainment % 101.1% 79.2% 98.2% 82.6% 87.3%

Actions for Improvement After final sign off, the process is for the report to be sent to the Clinical Governance groups within the four health boards and to the Regional Cancer Planning Group. Action plans and progress with plans will be highlighted to the groups. The report will be placed on the SCAN website once it has been fully signed-off and checked for any disclosive material. Sarah Buchan SCAN Audit Facilitator ___________________________________________________________________________ Source: Scottish Cancer Registry, ISD. Data extracted from ACaDMe on 13/11/2017. Note: Case ascertainment is reported by board of diagnosis and has been estimated using a denominator based on the latest (2011-2015) five-year annual average available from the Scottish Cancer Registry. Death certificate only cases have been excluded. Cases that have been diagnosed in the private sector but received any treatment in NHS hospitals have been included.


DIAGNOSIS AND STAGING

QPI 1: Radiological Diagnosis and Staging (i) Target = 95%

Numerator = Number of patients with colon cancer who undergo CT chest, abdomen and pelvis before definitive treatment.

Denominator = All patients with colon cancer

Exclusions = (a) Patients who refuse investigations (b) Patients who undergo emergency surgery (c) Patients undergoing supportive care only (d) Patients who undergo palliative treatment (chemotherapy, radiotherapy or surgery) (e) Patients who die before first treatment

Target 95% Borders D&G Fife Lothian SCAN 2016-2017 Cohort 96 103 216 476 891 Ineligible for this QPI 63 64 128 279 534

Numerator 33 36 88 195 352 Not Recorded for the Numerator 0 0 0 0 0 Denominator 33 39 88 197 357 Not Recorded for Exclusion 0 0 0 0 0 Not Recorded for Denominator 0 0 0 0 0 % Performance 100.0% 92.3% 100.0% 99.0% 98.6%

Comments where the QPI was not met: D&G: The target was not met showing a shortfall of 2.7% (3 cases). All 3 were diagnosed by CT colon and did not have full chest imaging completed. Changes to the MDM process were made in February 2017 to highlight patients who have not had CT chest pre-operatively, so this figure should improve for the next round of reporting.

Action: Monitor D&G results next year, no further action identified


Following formal review after year 3, QPI 1 (i) was updated. The inclusion of appendiceal cancers was removed from the dataset and additional exclusions were added; (d) Patients who undergo palliative treatment (chemotherapy, radiotherapy or surgery) (e) Patients who die before first treatment. Below are QPI 1 (i) figures from the first 3 years of QPI collection.


QPI 1: Radiological Diagnosis and Staging (ii) Target = 95%

Numerator = All patients with rectal cancer undergoing definitive treatment (chemoradiotherapy or surgical resection) who undergo CT chest, abdomen and pelvis and MRI pelvis before definitive treatment.

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

Exclusions = (a) Patients who refuse investigations (b) Patients who undergo emergency surgery3 (c) Patients with a contraindication to MRI (d) Patients who undergo Transanal Endoscopic Microsurgery (TEM) (e) Patients who undergo Transanal Resection of Tumour (TART) (f) Patients who undergo palliative treatment (chemotherapy, radiotherapy or surgery) (g) Patients who died before first treatment

Target 95% Borders D&G Fife Lothian SCAN 2016-17 Cohort 96 103 216 476 891 Ineligible for this QPI 81 87 178 374 720 Numerator 15 14 38 98 165 Not Recorded for Numerator 0 0 0 0 0 Denominator 15 16 38 102 171

Not Recorded for Exclusions 0 0 0 0 0 Not Recorded for Denominator 0 2 0 0 2 % Recorded 100.0% 87.5% 100.0% 96.1% 96.5%

Comments where the QPI was not met D&G: The target was not met showing a shortfall of 7.5% (2 cases). 1 was felt to be endoscopically sigmoid, but resectional pathology confirmed rectal. 1 patient declined investigation then subsequently agreed and no documented reason was found as to why an MRI was not performed. Action: No action identified. Following formal review after year 3, QPI 1 (ii) was updated. Additional exclusions were added; (d) Patients who undergo Transanal Endoscopic Microsurgery (TEM) (e) Patients who undergo Transanal Resection of Tumour (TART) (f) Patients who undergo palliative treatment (chemotherapy, radiotherapy or surgery) (g) Patients who died before first treatment. Below are the QPI 1 (ii) figures comparing the four years of data collected.

3 Emergency surgical resection is defined by the Consultant in Charge of the patient’s care


QPI 2: Pre-Operative Imaging of the Colon Target = 95%

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 colon has been removed.

Denominator = All patients who undergo elective surgical resection for colorectal cancer

Exclusions = No exclusions


Numerator 46 47 113 235 441 Not Recorded for the Numerator 0 0 0 1 1 Denominator 48 55 121 254 478

Not Recorded for Exclusions 0 0 0 0 0 Not Recorded for the Denominator 0 0 0 0 0 % Percentage 95.8% 85.5% 93.4% 92.5% 92.3%

Comments where the QPI was not met

D&G: The target was not met showing a shortfall of 9.5% (8 cases). 5 had flexible sigmoidoscopy only; 2 had incomplete colonoscopies; 1 had a large tumour visualised on CT chest, abdomen and pelvis and proceeded to surgery post MDT.

Fife: The target was not met showing a shortfall of 1.6% (8 cases). 6 had flexible sigmoidoscopy only; 1 scope was limited by pain and 1 scope was limited by looping. All patients discussed at MDT.

Lothian: The target was not met showing a shortfall of 2.5% (19 cases). 10 were limited by tumour. 8 colonoscopies were not performed due to various different reasons. 1 declined investigation.

Action: Again, action is required in D&G, Fife and Lothian.


Following formal review after year 3 QPI 2 was updated: The inclusion of appendiceal cancers was removed from the dataset. A new value was added to the field Large Bowel Imaging in the Colorectal Data Definitions, “Incomplete due to obstructing tumour”. This value has been added for patients diagnosed from year 5 (01/04/2017 to 31/03/2018). Below are QPI 2 figures from the first 3 years of QPI collection.


QPI 3: Multi-Disciplinary Team (MDT) Meeting Target = 95%

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.


Numerator 71 78 169 264 582 Not Recorded for Numerator 0 0 0 0 0 Denominator 77 81 177 278 613

Not Recorded for Exclusions 0 0 0 0 0 Not Recorded for Denominator 0 0 0 0 0 % Recorded 92.2% 96.3% 95.5% 95.0% 94.9%


Borders: The target was not met showing a shortfall of 3.8% (6 cases). 2 were not referred to the Colorectal Team. 2 died but were not discussed at MDM at all. 1 was given palliative treatment before the MDM discussion, it was agreed the outcome would not have changed. 1 was diagnosed incidentally and not for further treatment.

Action: No action is identified.


Following formal review after year 3 QPI 3 was updated: The inclusion of appendiceal cancers was removed from the dataset. Multi-Disciplinary Team (MDT) Meeting information was not collected in year 1 of the QPI implementation. Figures for years 2 and 3 are below.


QPI 4: Stoma Care – Hospital of Surgery Target = 95%

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. Lothian

Target 95% BGH DGRI VHK RIE WGH SCAN Numerator 14 23 27 0 75 139 Not Recorded for Numerator 0 0 0 0 1 1 Denominator 14 27 27 0 80 148 Not Recorded for Exclusions 0 0 0 0 0 0 Not Recorded for Denominator 0 4 0 0 0 4 % Recorded 100.0% 85.2% 100.0% n/a 93.8% 93.9%

Cases operated on outwith Board of Diagnosis: Lothian: operated on 1 case each from BGH, D&G, Fife & 3 cases from WoSCAN region. Fife also sent 1 case to Tayside & 1 to Forth Valley. Comments where the QPI was not met: D&G: The target was not met showing a shortfall of 9.8% (4 cases) 2 were not listed for stoma creation on theatre lists as anastomosis was planned at time of surgery therefore not known to Stoma Nurses. 1 listed as +/- ileostomy was not sited. Patient very nervous about Stoma and although risk explained it was decided not to site this patient. 1 not sited, no documented reason why this was not done but was not known to Stoma Nurse pre-operatively. Lothian: The target was not met with a shortfall of 1.2% (5 cases). 2 were seen the day after surgery, 2 were seen before discharge, 1 was not reviewed by the Stoma Service.

Action: The volume of patients makes this QPI difficult to achieve. Action is required to ensure patients are seen and marked appropriately by Stoma Nurses.


Following formal review after year 3 QPI 3 was updated: The inclusion of appendiceal cancers was removed from the dataset. Below are the QPI 4 figures from the first 3 years of QPI collection.


SURGICAL OUTCOMES

QPI 5: Lymph Node Yield – Hospital of Surgery Target = 90%

Numerator = Number of patients with colorectal cancer who undergo curative surgical resection where > 12 lymph nodes are pathologically examined. Total number of lymph nodes examined microscopically after final surgery is more than or equal to 12.

Denominator = All patients with colorectal cancer who undergo curative surgical resection (with or without neoadjuvant short course radiotherapy).

Exclusions = Patient with rectal cancer who undergo long course neo-adjuvant chemoradiotherapy or radiotherapy. Patients who undergo transanal endoscopic microsurgery or transanal resection of tumour. Lothian

Target 90% BGH DGRI VHK RIE WGH SCAN Numerator 41 60 108 5 213 427 Not Recorded for the Numerator 0 0 0 0 0 0 Denominator 47 60 130 5 247 489 Not Recorded for Exclusions 0 0 0 0 14 14 Not Recorded for Denominator 0 0 0 0 0 0 % Percentage 87.2% 100.0% 83.1% 100.0% 86.2% 87.3%

Cases operated on outwith Board of Diagnosis: Borders sent 1 case to Lothian and 1 to Tayside; Fife sent 1 to Forth Valley; Lothian operated on 1 case from Borders and 3 from WoSCAN region. Comments where this QPI was not met: Borders: There was a shortfall of 2.8% (6 cases). Fife: There was a shortfall of 6.9% (22 cases). Lothian: There was a shortfall of 3.5% (34 cases).

Action: Performance has remained at 85-89% over the last 4 years, continued monitoring is required.


Following discussion at the Colorectal QPI National Meeting in February 2015, it was agreed it would be useful to consider looking at lymph node yield from node negative patients. This table shows the number of nodes examined for patients with Node negative (N0) disease. Lymph Node Yield in Node Negative Patients

LN BGH D&G Fife Lothian SCAN <12 6 0 27 31 64

12 to 19 23 6 68 79 176 20 to 29 5 23 42 49 119

>30 1 8 6 18 33 Total 35 37 143 177 392

It is noted that the QPI target has increased from 80% to 90% following the 3-year formal review. The target was continuously met in previous years by all Boards, but each Board is aware of the new target and will strive to meet this. It is noted in the HIS Colorectal QPI paper (http://www.healthcareimprovementscotland.org/his/idoc.ashx?docid=f399d719-8597-48f6-999a-1e248d5ab6aa&version=-1) that varying evidence exists regarding the most appropriate target level therefore this may need redefined in the future, to take account of new evidence or as further data becomes available. Below are QPI 5 figures from the first 3 years of QPI collection.


QPI 6: Neo-adjuvant Therapy Target= 90%

Numerator = Number of patients with rectal cancer with a threatened or involved CRM on preoperative MRI undergoing surgery who receive long course neo-adjuvant therapy. Denominator = All patients with rectal cancer with a threatened or involved CRM on preoperative MRI undergoing surgery.

Exclusions = Patients who refuse neo-adjuvant. Patients in whom neo-adjuvant therapy is contraindicated. Patients who presented as an emergency for surgery

Target 90% Borders D&G Fife Lothian SCAN 2016-17 Cohort 96 103 216 476 891 Ineligible for the QPI 94 99 204 456 853

Numerator 2 3 10 20 35 Not Recorded for the Numerator 0 0 0 0 0 Denominator 2 3 12 20 37

Not Recorded for Exclusions 0 0 0 0 0 Not Recorded for Denominator 0 8 0 0 8 % Percentage 100.0% 100.0% 83.3% 100.0% 94.6%


Fife: The target was not met showing a shortfall of 16.3% (2 cases). One had short course radiotherapy and one didn't have any pre-op treatment, due to liver metastases being found the decision was made to go straight to surgery.

Action: All patients were treated appropriately and no action is required. Following formal review after year 3, QPI 6 was updated. The inclusion of appendiceal cancers was removed from the dataset. The next page has QPI 6 figures comparing the four years of data collected.


QPI 7: Surgical Margins (i) – Hospital of Surgery Target = 95%

Numerator = Number of patients with rectal cancer who undergo elective primary surgical resection or surgical resection following short course neoadjuvant radiotherapy in which tumour is present at the circumferential margin.

Denominator = All patients with rectal cancer who undergo elective primary surgical resection or surgical resection following short course neoadjuvant radiotherapy.

Exclusions = Patients who undergo transanal endoscopic microsurgery or transanal resection of tumour. Lothian

Target 95% BGH DGRI VHK RIE WGH SCAN Numerator 13 13 31 0 66 123 Not Recorded for the Numerator 0 0 0 0 0 0 Denominator 13 13 32 0 68 126 Not Recorded for Exclusions 0 0 0 0 0 0 Not Recorded for Denominator 0 0 0 0 0 0 % Percentage 100.0% 100.0% 96.9% 0.0% 97.1% 97.6%

Cases operated on outwith Board of Diagnosis: Borders sent 1 case to Tayside; Fife sent 1 case to Forth Valley. All Boards met this QPI Action: This is a good result, however we strive to avoid positive margins, so SCAN will carry out a separate audit of cases with positive margins in 2016-17 data which will be included in next years report. Following formal review after year 3, QPI 7 (i) was not updated. The next page has QPI 7 (i) figures comparing the four years of data collected


QPI 7: Surgical Margins (ii) – Hospital of Surgery Target = 85%

Numerator = Number of patients with rectal cancer who undergo elective surgical resection following neo-adjuvant long course radiotherapy or chemoradiotherapy in which tumour is not present at the circumferential margin.

Denominator = All patients with rectal cancer who undergo elective surgical resection following neo-adjuvant long course radiotherapy or chemoradiotherapy

Exclusions = Patients who undergo transanal endoscopic microsurgery or transanal resection of tumour.

Lothian Target 85% BGH DGRI VHK RIE WGH SCAN

Numerator 2 3 10 0 24 39

Not Recorded for the Numerator 0 0 0 0 0 0

Denominator 2 3 11 0 24 40 Not Recorded for Exclusions 0 0 0 0 0 0

Not Recorded for Denominator 0 1 0 0 0 1

% Percentage 100.0% 100.0% 90.9% 0.0% 100.0% 97.5% Cases operated on outwith Board of Diagnosis: D&G sent 1 case to Lothian, Fife sent 1 case to Lothian and 1 to Tayside; Lothian operated on 1 case from D&G, 1 case from Fife and 1 case from WoSCAN All Boards met this QPI Action: No action required. Following formal review after year 3, QPI 7 (ii) was not updated. The next page has QPI 7 (ii) figures comparing the four years of data collected.


QPI 8: Re-operation Rates - Hospital of Surgery

Target = <10% (elective surgical resection) <15% (emergency surgical resection)

Numerator = Number of patients with colorectal cancer who undergo surgical resection who return to theatre following initial surgical 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. Lothian

Elective - Target <10% BGH DGRI VHK RIE WGH SCAN Numerator 1 1 3 0 7 12 Not Recorded for the Numerator 0 0 0 0 0 0 Denominator 57 62 127 0 258 504 Not Recorded for Exclusions 0 0 0 0 0 0 Not Recorded for Denominator 0 0 0 0 0 0 % Percentage 1.8% 1.6% 2.4% 0.0% 4.3% 2.4%

Cases operated on outwith Board of Diagnosis: Lothian operated on 1 case from BGH and 1 case from Fife.


Lothian Emergency - Target <15% BGH DGRI VHK RIE WGH SCAN

Numerator 0 1 1 0 4 6 Not Recorded for the Numerator 0 0 0 0 0 0 Denominator 10 17 28 4 84 143 Not Recorded for Exclusions 0 0 0 0 0 0 Not Recorded for Denominator 0 0 0 0 0 0 % Percentage 0.0% 5.9% 3.6% 0.0% 4.8% 4.2%

Following formal review it has been agreed that ISD will no longer provide the figures for QPI 8 from SMR01 returns. It will now be collected locally by audit staff in each Board. It should be noted however, that in Borders, Fife and Lothian we have been collecting and reporting on this QPI from information collected locally since 2013.


QPI 9: Anastomotic Dehiscence (i) – Hospital of Surgery Target = <5%

Numerator = Number of patients with colorectal cancer who undergo a surgical procedure involving anastomosis of the colon; or rectum; or patients with rectal cancer who undergo anterior resection and TME; having anastomotic leak requiring intervention (radiological or surgical).

Denominator =.All patients with colorectal cancer who undergo a surgical procedure involving anastomosis of the colon.

Exclusions = No exclusions. Lothian

Target <5% BGH DGRI VHK RIE WGH SCAN Numerator 0 2 2 0 3 7 Not Recorded for the Numerator 0 0 0 0 1 1 Denominator 26 33 66 2 128 255 Not Recorded for Exclusions 0 0 0 0 0 0 Not Recorded for Denominator 0 1 0 0 0 1 % Percentage 0.0% 6.1% 3.0% 0.0% 2.3% 2.7%

Cases that were operated on outwith Board of Diagnosis: 3 cases from Borders were operated on in Lothian Comments where QPI not met D&G: The target was not met showing a shortfall of 1.1% (2 cases). Both were reviewed by the MDT (different surgeons) and no specific learning was identified.

Action: These figures are very good. Small number variation in regional boards induces large percentage changes. No action is identified.


Following formal review after year 3, QPI 9 (i) was updated. The inclusion of appendiceal cancers was removed from the dataset. Below are the QPI 9 (i) figures from the first 3 years of QPI collection.


QPI 9: Anastomotic Dehiscence (ii) – Hospital of Surgery Target = <10%

Numerator = Number of patients with colorectal cancer who undergo a surgical procedure involving anastomosis of the colon; or rectum; or patients with rectal cancer who undergo anterior resection and TME; having anastomotic leak requiring intervention (radiological or surgical).

Denominator = All patients with colorectal cancer who undergo a surgical procedure involving anastomosis of the rectum (including anterior resection with TME)

Exclusions = None. Lothian

Target <10% BGH DGRI VHK RIE WGH SCAN Numerator 0 0 1 0 8 9




% Percentage 0.0% 0.0% 2.0% 0.0% 6.3% 4.2%

Cases that were operated on outwith Board of Diagnosis: 1 case from Borders was operated on in Tayside; 1 case from WoSCAN was operated on in Lothian This QPI was met by all Boards.

Action: No action required.


Following formal review after year 3, QPI 9 (ii) was updated. The inclusion of appendiceal cancers was removed from the dataset. Below are the QPI 9 (ii) figures from the first 3 years of QPI collection.


QPI 10 (i): 30 Day Mortality Following Surgical Res ection – Hospital of Surgery

Target = Elective surgical resection <3% Emergency surgical resection <15%

Numerator = Number of patients with colorectal cancer who undergo emergency or elective surgical resection who die within 30 days of surgery.

Denominator = All patients with colorectal cancer who undergo emergency or elective surgical resection.

Exclusions = No exclusions

Elective Surgery

Lothian Target <3% BGH DGRI VHK RIE WGH SCAN

Numerator 0 1 4 0 2 7 Not Recorded for the Numerator 0 0 0 0 0 0 Denominator 44 58 127 0 253 482 Not Recorded for Exclusions 0 0 0 0 0 0 Not Recorded for Denominator 0 0 0 0 0 0 % Percentage 0.0% 1.7% 3.1% 0.0% 0.8% 1.5%

Cases operated on outwith Board of Diagnosis: Borders sent 2 cases to Lothian, 1 case to Tayside; D&G sent 1 case to Lothian, Fife sent 1 case to Tayside, 1 case to Forth Valley; Lothian operated on 2 cases from Borders, 1 case from D&G, 1 case from Fife and 3 cases from WoSCAN. Comments where the QPI was not met: Fife : The target was not met with a shortfall of 0.1% (4 cases) 25 days - multi-organ failure; 10 days - pulmonary oedema/heart failure; 5 days - aspiration pneumonia; 11 days - pulmonary embolism.

Action: No action identified.


Following formal review after year 3, QPI 10 (i) was updated. The target was changed from <5% to <3%. The inclusion of appendiceal cancers was removed from the dataset. Below are the QPI 10 (i) figures from the first 3 years of QPI collection.


QPI 10 (i): 30 Day Mortality Following Surgical Res ection – Hospital of Surgery

Emergency Surgery Lothian

Target <15% BGH DGRI VHK RIE WGH SCAN

Numerator 2 1 2 0 2 7




% Percentage 16.7% 8.3% 7.1% 0.0% 2.6% 5.3%

Cases operated on outwith Board of Diagnosis: 1 case from Borders operated on in Lothian. Comments where the QPI was not met: Borders: The target was not met with a shortfall of 1.7% (2 cases). 1 died 1 day post operative from intractable hypotension, 1 died 3 days post operatively from sepsis and multi-organ failure which did not respond to treatment.

Action: Small numbers produce large percentage changes and no action has been identified.


QPI 10 (ii): 90 Day Mortality Following Surgical Re section

Target = Elective surgical resection <4% Emergency surgical resection <15% Numerator = Number of patients with colorectal cancer who undergo emergency or elective surgical resection who die within 90 days of surgery. Denominator = All patients with colorectal cancer who undergo emergency or elective surgical resection. Exclusions = No exclusions Elective Surgery Lothian

Target <4% BGH DGRI VHK RIE WGH SCAN Numerator (elective surgery) 0 1 5 0 3 9 Not Recorded for the Numerator 0 0 0 0 0 0 Denominator 44 58 127 0 253 482 Not Recorded for Exclusions 0 0 0 0 0 0 Not Recorded for Denominator 0 0 0 0 0 0 % Percentage 0.0% 1.7% 3.9% 0.0% 1.2% 1.9%

Cases operated on outwith Board of Diagnosis: Borders sent 2 cases to Lothian, 1 case to Tayside; D&G sent 1 case to Lothian, Fife sent 1 case to Tayside, 1 case to Forth Valley; Lothian operated on 2 cases from Borders, 1 case from D&G, 1 case from Fife and 3 cases from WoSCAN. This QPI was met in all Boards.


Following formal review after year 3, QPI 10 (ii) was updated. The target was changed from <5% to <4%. The inclusion of appendiceal cancers was removed from the dataset. Below are the QPI 10 (ii) figures from the first 3 years of QPI collection.


QPI 10 (ii): 90 Day Mortality Following Surgical Re section – Hospital of Surgery

Emergency Surgery

Lothian Target <20% BGH DGRI VHK RIE WGH SCAN

Numerator (emergency surgery) 3 1 2 0 5 11




% Percentage 25.0% 8.3% 7.4% 0.0% 6.6% 8.3% Cases operated on outwith Board of Diagnosis: 1 case from Borders operated on in Lothian. Comments where this QPI was not met: Borders: The target was not met showing a shortfall of 5% (3 cases). 1 patient under the care of the palliative team with extensive distant metastases died from progression. 1 elderly patient did not improve postoperatively and the decision was made to limit further therapeutic interventions. 1 patient presented with perforated cancer and stercoral peritonitis and progressed to multiorgan failure. The high postoperative death rate is rather unfortunate as we are dealing with very small numbers.

Action: Small numbers produce large percentage changes and no action has been identified.


ONCOLOGICAL TREATMENT OUTCOMES

QPI 11: Adjuvant chemotherapy in Patients with High Risk Dukes B Target = 50%

Numerator = 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 = All patients between 50 and 74 years of age at diagnosis with high risk Dukes B colorectal cancer who undergo surgical resection.

Exclusions = No exclusions.

Target 50% Borders D&G Fife Lothian SCAN 2016-17 Cohort 96 103 246 476 921 Ineligible for the QPI 93 101 240 449 883

Numerator - High Risk Dukes B 2 1 3 14 20 Not Recorded for the Numerator 0 0 0 0 0 Denominator 3 2 6 27 38

Not Recorded for Exclusions 0 0 0 0 0 Not Recorded for Denominator 0 1 0 0 1 % Percentage 66.7% 50.0% 50.0% 51.9% 52.6% High risk Dukes B colorectal cancer is defined as patients with (pT4a or pT4b disease) with/ without extramural venous invasion, or pT3 pN0 M0 with extramural venous invasion

This QPI was met by all Boards


Following formal review after year 3, QPI 11 was updated. The inclusion of appendiceal cancers was removed from the dataset. In addition the definition of high risk Dukes B was changed to all patients with (pT4a or pT4b disease) with/without extramural vascular invasion or pT3 N0 M0 with extramural vascular invasion. Below are the QPI 11 figures from the first 3 years of QPI collection.

Action : No action identified.


QPI 11: Adjuvant chemotherapy in Patients with Duke s C colorectal cancer

Target = 70%

Numerator = 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.

Denominator = All patients between 50 and 74 years of age at diagnosis with Dukes C, colorectal cancer who undergo surgical resection.

Exclusions = No exclusions. Target: 70% Borders D&G Fife Lothian SCAN

2016-17 Cohort 96 103 216 476 891 Ineligible for the QPI 85 89 186 418 778 Numerator - Dukes C 8 10 26 48 92 Not Recorded for the Numerator 0 0 0 0 0 Denominator 11 14 30 58 113


All Boards met this QPI


Following formal review after year 3, QPI 11 was updated. The inclusion of appendiceal cancers was removed from the dataset. Below are the QPI 11 figures from the first 3 years of QPI collection.

Action: No action identified.


QPI 12 (i): 30 Day Mortality Following Chemotherapy or Radiotherapy Target = <1%

Numerator = Number of patients with colorectal cancer who undergo neo-adjuvant chemoradiotherapy, radiotherapy or adjuvant chemotherapy with curative intent who die within 30 days of treatment.

Denominator = All patients with colorectal cancer who undergo neo-adjuvant chemoradiotherapy, radiotherapy or adjuvant chemotherapy with curative intent.


30 day mortality after neo-adjuvant chemoradiothera py with curative intent Target <1% Borders D&G Fife Lothian SCAN

Numerator 0 0 0 0 0 Not Recorded for the Numerator 0 0 0 0 0

Denominator 1 2 9 24 36

Not Recorded for Exclusions 0 0 0 0 0 Not Recorded for Denominator 0 0 0 0 0

% Percentage 0.0% 0.0% 0.0% 0.0% 0.0% 30 day mortality after radiotherapy with curative i ntent

Target <1% Borders D&G Fife Lothian SCAN Numerator 0 0 0 1 1 Not Recorded for the Numerator 0 0 0 0 0 Denominator 4 8 12 29 53


30 day mortality after adjuvant chemotherapy with c urative intent

Target <1% Borders D&G Fife Lothian SCAN Numerator 0 0 0 0 0 Not Recorded for the Numerator 5 0 0 0 5

Denominator 16 14 44 87 161

Not Recorded for Exclusions 0 0 0 0 0 Not Recorded for Denominator 0 0 0 0 0

% Percentage 0.0% 0.0% 0.0% 0.0% 0.0%

Note: A small number in the cohort gives rise to large percentage changes Comments where the QPI was not met: Lothian: The target was not met with a shortfall of 2.4% (1 case). This patient died 21 days post radiotherapy multi-organ failure. Following formal review after year 3, QPI 12 (i) was updated. The inclusion of appendiceal cancers was removed from the dataset. The target was also changed from <2% to <1%.


QPI 12 (i): 90 Day Mortality Following Chemotherapy or Radiotherapy Target = <1%

Numerator = Number of patients with colorectal cancer who undergo neo-adjuvant chemoradiotherapy, radiotherapy or adjuvant chemotherapy with curative intent who die within 90 days of treatment.

Denominator = All patients with colorectal cancer who undergo neo-adjuvant chemoradiotherapy, radiotherapy or adjuvant chemotherapy with curative intent.

Exclusions = No exclusions. 90 day mortality after neo-adjuvant chemoradiothera py with curative intent



90 day mortality after radiotherapy with curative i ntent



90 day mortality after adjuvant chemotherapy with c urative intent



Note: A small number in the cohort gives rise to large percentage changes Comments where the QPI was not met: Lothian: The target was not met with a shortfall of 2.4% (1 case). This patient died 21 days post radiotherapy from multi-organ failure. Following formal review after year 3, QPI 12 (i) was updated. The inclusion of appendiceal cancers was removed from the dataset. The target was also changed from <2% to <1%.


QPI 12 (ii): 30 Day Mortality Following Chemotherap y or Radiotherapy Target = <10%

Numerator = Number of patients with colorectal cancer who undergo palliative chemotherapy who die within 30 days of treatment.

Denominator = All patients with colorectal cancer who undergo palliative chemotherapy.




Comments where this QPI was not met:

Lothian: There was a shortfall of 4% (6 cases). 4 had treatment stopped prior to death for progression/clinical deterioration; 2 were still on active treatment with no plan to stop at the time of death.

All deaths have been reviewed and patients were treated appropriately. No action has been identified.


CLINICAL TRIALS

Clinical Trials Access Interventional Target = 7.5% Translational Target = 15% Numerator = Number of patients with Colorectal cancer enrolled in an interventional/translational clinical trial. Denominator = All patients with Colorectal cancer Exclusions = No exclusions Note: The clinical trials QPI will be measured utilising SCRN data and Cancer Registry data (5 year average of case ascertainment 2010-2014)

Interventional Target 7.5% Borders D&G Fife Lothian

Missing

SCAN Postcode/

Outwith SCAN Numerator 1 1 5 17 3 27

Denominator 95 130 220 576 1021

% Performance 1.1% 0.8% 2.3% 3.0% 2.6%

Interventional Trials in 2016 Numbers recruited

Add-Aspirin 6 CANC - 4905 6 EPOCH 7 FOCUS 4 1 OZONE 1 TOFFEE 6

Translational Target 15% Borders D&G Fife Lothian

Missing

SCAN

Postcode/ Outwith

SCAN Numerator 31 42 60 46 5 184

Denominator 95 130 220 576 1021

% Performance 32.6% 32.3% 27.3% 8.0% 18.0%

Translational Trials in 2016 Numbers recruited

SOCCS3 184 Action: As surgical services require infrastructure to recruit to clinical trials a strategic plan is required in order to meet this QPI. Action D Speake.


Clinical Trial data was not collected until 2014/15 when only the SCAN total could be reported. From 2015/16 Board level data has been reported.


KEY CATEGORIES

Table 1: Rectal v Other Colorectal Patients, percen tage of patients undergoing Surgery

No of Patients

Diagnosed All patients who

had surgery

Number of patients diagnosed with rectal

cancer


cancer who had surgery

Borders 96 69 71.9% 29 30.2% 19 65.5% D&G 103 86 83.5% 37 35.9% 27 73.0% Fife 216 174 80.6% 64 29.6% 56 87.5% Lothian 476 382 80.3% 147 30.9% 121 82.3% SCAN 891 711 79.8% 277 31.1% 223 80.5%

Table 2: Rectal v Other Colorectal Patients

No of Patients

Diagnosed

All patients who had definitive

surgery


cancer


cancer who had definitive surgery

Borders 96 63 65.6% 29 30.2% 16 55.2% D&G 103 70 68.0% 37 35.9% 18 48.6% Fife 216 154 71.3% 64 29.6% 49 76.6% Lothian 476 335 70.4% 147 30.9% 107 72.8% SCAN 891 622 69.8% 277 31.1% 190 68.6%

Table 3: Emergency v Elective Surgery (Excluding non definitive surgery – Endoscopic Treatment/Stents/Defunctioning Stomas/Bypass Surgery)

All patients who had

definitive surgery Emergency Elective Inapplicable Missing Data

Borders 63 13 20.6% 50 79.4% 0 0.0% 0 0.0% D&G 70 12 17.1% 58 82.9% 0 0.0% 0 0.0% Fife 154 28 18.2% 126 81.8% 0 0.0% 0 0.0% Lothian 335 82 24.5% 253 75.5% 0 0.0% 0 0.0% SCAN 622 135 21.7% 487 78.3% 0 0.0% 0 0.0%


Table 4: Rectal Cancer Patients Emergency V Electiv e Surgery (Excluding non definitive surgery – Endoscopic Treatment/Stents/Defunctioning Stomas/Bypass Surgery)

All patients

diagnosed with rectal

cancer who had

definitive surgery Emergency Elective Not Recorded Missing Data


Table 5: Intent of Surgery (Excluding non definitive surgery – Endoscopic Treatment/Stents/Defunctioning Stomas/Bypass Surgery)

All Patients who had

Definitive Surgery Curative Palliative Not Recorded Missing Data

Borders 63 54 85.7% 8 12.7% 0 0.0% 0 0.0% D&G 70 64 91.4% 6 8.6% 0 0.0% 0 0.0% Fife 154 138 89.6% 16 10.4% 0 0.0% 0 0.0%

Lothian 335 292 87.2% 40 11.9% 3 0.9% 0 0.0%

SCAN 622 548 88.1% 70 11.3% 3 0.5% 0 0.0% Table 6: Intent of Surgery – Rectal Cancer N=All patients diagnosed with rectal cancer who had definitive surgery (Excluding non definitive surgery – Endoscopic Treatment/Stents/Defunctioning Stomas/Bypass Surgery)

All patients diagnosed with rectal

cancer who had

definitive surgery Curative Palliative Not Recorded Missing Data



Table 7: Gender N= All patients diagnosed

Total Patients Diagnosed Male Female Borders 96 51 53.1% 45 46.9% D&G 103 55 53.4% 48 46.6% Fife 216 116 53.7% 100 46.3% Lothian 476 254 53.4% 222 46.6% SCAN 891 476 53.4% 415 46.6%

Table 8: Age at Diagnosis N=All patients diagnosed

Age Borders D&G Fife Lothian SCAN <40 1 1.0% 0 0.0% 1 0.5% 10 2.1% 12 1.3%

40-49 3 3.1% 5 4.9% 7 3.2% 18 3.8% 33 3.7% 50-59 12 12.5% 9 8.7% 26 12.0% 59 12.4% 106 11.9% 60-69 26 27.1% 24 23.3% 50 23.1% 114 23.9% 214 24.0% 70-79 27 28.1% 33 32.0% 76 35.2% 152 31.9% 288 32.3% 80-89 22 22.9% 30 29.1% 47 21.8% 112 23.5% 211 23.7% 90+ 5 5.2% 2 1.9% 9 4.2% 11 2.3% 27 3.0%

Total 96 100.0% 103 100.0% 216 100.0% 476 100.0% 891 100.0% Table 9: Tumour Site N=All patients diagnosed Site of Tumour Borders D&G Fife Lothian SCAN Appendix 2 2.1% 1 1.0% 0 0.0% 1 0.2% 4 0.4% Ascending Colon 11 11.5% 9 8.7% 13 6.0% 51 10.7% 84 9.4% Caecum 12 12.5% 21 20.4% 45 20.8% 65 13.7% 143 16.0% Colon Unspec 0 0.0% 0 0.0% 1 0.5% 4 0.8% 5 0.6% Descending Colon 5 5.2% 2 1.9% 10 4.6% 20 4.2% 37 4.2% Hepatic Flexure 5 5.2% 3 2.9% 15 6.9% 20 4.2% 43 4.8% Rectum 29 30.2% 37 35.9% 64 29.6% 147 30.9% 277 31.1% Sigmoid Colon 21 21.9% 22 21.4% 49 22.7% 124 26.1% 216 24.2% Splenic Flexure 6 6.3% 2 1.9% 7 3.2% 13 2.7% 28 3.1% Transverse Colon 5 5.2% 6 5.8% 12 5.6% 31 6.5% 54 6.1% Overlapping Lesion 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% Not Recorded 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% Missing Data 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% Total 96 100.0% 103 100.0% 216 100.0% 476 100.0% 891 100.0%


Table 10: Dukes Stage N=All patients diagnosed Borders D&G Fife Lothian SCAN Dukes A 14 14.6% 14 13.6% 35 16.2% 58 12.2% 121 13.6% Dukes B 21 21.9% 28 27.2% 49 22.7% 111 23.3% 209 23.5% Dukes C1 18 18.8% 23 22.3% 53 24.5% 99 20.8% 193 21.7% Dukes C2 12 12.5% 2 1.9% 7 3.2% 12 2.5% 33 3.7% Dukes D (M1) 25 26.0% 21 20.4% 19 8.8% 51 10.7% 116 13.0% Inapplicable¹ 6 6.3% 15 14.6% 53 24.5% 144 30.3% 218 24.5% Not Recorded 0 0.0% 0 0.0% 0 0.0% 1 0.2% 1 0.1% Missing Data 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% Total 96 100.0% 103 100.0% 216 100.0% 476 100.0% 891 100.0%

*Numbers showing an inapplicable Dukes staging include patients who had no surgery or patients who had polypectomies, stents or defunctiong stomas for whom Duke's Stage would not be assessable. Table 11: Inapplicable Dukes Stage N= (Excluding non definitive surgery – Endoscopic Treatment/Stents/Defunctioning Stomas/Bypass Surgery) Borders D&G Fife Lothian SCAN

Endoscopic Mucosal Resections 0 0.0% 1 6.7% 1 1.9% 6 4.2% 8 3.7%

Appendicectomies 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% Non Definitive Surgery 3 50.0% 4 26.7% 10 18.9% 16 11.1% 33 15.1% No Residual Tumour 0 0.0% 0 0.0% 2 3.8% 2 1.4% 4 1.8% No Surgery Performed 3 50.0% 9 60.0% 39 73.6% 88 61.1% 139 63.8% Trans Endoscopic Micro Surgery 0 0.0% 0 0.0% 1 1.9% 11 7.6% 12 5.5% Other 0 0.0% 1 6.7% 0 0.0% 21 14.6% 22 10.1% Total 6 100.0% 15 100.0% 53 100.0% 144 100.0% 218 100.0%

Table 12: Clinical Stage IV N=All patients diagnosed presenting with Final M1 Stage of disease at presentation

Patients presenting

with Clinical Stage IV disease Borders D&G Fife Lothian SCAN

Metastatic Disease 25 26.0% 21 20.4% 50 23.1% 118 24.8% 214 24.0% No Metastatic Disease 65 67.7% 69 67.0% 162 75.0% 290 60.9% 586 65.8% Cannot Determine 6 6.3% 12 11.7% 4 1.9% 56 11.8% 78 8.8% Not Recorded 0 0.0% 1 1.0% 0 0.0% 10 2.1% 11 1.2% Missing Data 0 0.0% 0 0.0% 0 0.0% 2 0.4% 2 0.2% Total 96 100.0% 103 100.0% 216 100.0% 476 100.0% 891 100.0%


Table 13: Radiotherapy N = All patients diagnosed with rectal cancer who received Radiotherapy or Chemoradiotherapy

N Table 14: All patients receiving Chemotherapy N=All patient who receive Chemotherapy or Chemoradiotherapy

N Neoadjuvant

Chemotherapy Primary

Chemotherapy Palliative

Chemotherapy Adjuvant

Chemotherapy Not

Recorded Borders 26 1 3.8% 1 3.8% 6 23.1% 18 69.2% 0 0.0% D&G 35 3 8.6% 0 0.0% 15 42.9% 17 48.6% 0 0.0% Fife 70 8 11.4% 0 0.0% 17 24.3% 45 64.3% 0 0.0% Lothian 162 24 14.8% 0 0.0% 43 26.5% 91 56.2% 4 2.5% SCAN 293 36 12.3% 1 0.3% 81 27.6% 171 58.4% 4 1.4%

Table 15: Surgical Approach N=All colorectal cancer patients undergoing definitive surgery Borders D&G Fife Lothian SCAN Laparoscopic 28 29.2% 11 10.7% 104 48.1% 143 30.0% 286 32.1% Lap converted to Open 6 6.3% 4 3.9% 22 10.2% 29 6.1% 61 6.8% Open 29 30.2% 54 52.4% 27 12.5% 135 28.4% 245 27.5% Transanal Endoscopic Microsurgery 0 0.0% 1 1.0% 1 0.5% 11 2.3% 13 1.5% Transanal Resection of Tumour 0 0.0% 0 0.0% 0 0.0% 2 0.4% 2 0.2% Inapplicable 33 34.4% 33 32.0% 62 28.7% 141 29.6% 269 30.2% Not Recorded 0 0.0% 0 0.0% 0 0.0% 14 2.9% 14 1.6% Missing Data 0 0.0% 0 0.0% 0 0.0% 1 0.2% 1 0.1% Total 96 100.0% 103 100.0% 216 100.0% 476 100.0% 891 100.0%

Table 16: EMR and TEMS Resection N=All patients having endoscopic mode of first treatment (excluding colonic stents) Borders D&G Fife Lothian SCAN Endoscopic Mucosal Resections 3 3 10 6 22 EMR followed by definitive Surgery 0 0.0% 1 33.3% 4 40.0% 3 50.0% 8 36.4%

TEMS resection 0 1 1 11 13 TEMS followed by definitive surgery 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0%

Borders 9 1 11.1% 1 11.1% 1 11.1% 1 11.1% 1 11.1% 4 44.4% 0 0.0%D&G 12 5 41.7% 3 25.0% 1 8.3% 0 0.0% 0 0.0% 3 25.0% 0 0.0%Fife 23 9 39.1% 8 34.8% 3 13.0% 1 4.3% 0 0.0% 2 8.7% 0 0.0%Lothian 63 20 31.7% 24 38.1% 7 11.1% 1 1.6% 0 0.0% 8 12.7% 3 4.8%SCAN 107 35 32.7% 36 33.6% 12 11.2% 3 2.8% 1 0.9% 17 15.9% 3 2.8%

NNot

Recorded

Neoadjuvant Single

Therapy

Neoadjuvant Combined

TherapyAdjuvant

Postoperative Palliative

Neoadjuvant Long Course

RT onlyPrimary Radical


Table 17: Dukes Staging - Screened Patients v Non-S creened Patients N=All colorectal patients

Borders D&G Fife Lothian SCAN SCREENED PATIENTS Dukes A 7 7.3% 3 2.9% 13 6.0% 28 7.0% 51 5.7% Dukes B 2 2.1% 4 3.9% 9 4.2% 18 4.5% 33 3.7% Dukes C1 0 0.0% 5 4.9% 11 5.1% 15 3.8% 31 3.5% Dukes C2 1 1.0% 0 0.0% 1 0.5% 2 0.5% 4 0.4% Dukes D (M1) 0 0.0% 2 1.9% 2 0.9% 8 2.0% 12 1.3% Inapplicable 1 1.0% 0 0.0% 0 0.0% 3 0.8% 4 0.4% Not Recorded 0 0.0% 0 0.0% 0 0.0% 1 0.3% 1 0.1% Missing 0 0.0% 0 0.0% 0 0.0% 1 0.3% 1 0.1% Total - Screened 11 14 36 76 137

Dukes A 7 7.3% 11 10.7% 22 10.2% 42 10.5% 82 9.2% Dukes B 19 19.8% 24 23.3% 40 18.5% 93 23.3% 176 19.8% Dukes C1 18 18.8% 18 17.5% 43 19.9% 86 21.5% 165 18.5% Dukes C2 11 11.5% 2 1.9% 6 2.8% 10 2.5% 29 3.3% Dukes D 25 26.0% 19 18.4% 19 8.8% 104 26.0% 167 18.7% Inapplicable 5 5.2% 15 14.6% 50 23.1% 50 12.5% 120 13.5% Not Recorded 0 0.0% 0 0.0% 0 0.0% 14 3.5% 14 1.6% Missing 0 0.0% 0 0.0% 0 0.0% 1 0.3% 1 0.1% Total - Non-screened 85 89 180 400 754

TOTAL PATIENTS 96 100.0% 103 100.0% 216 100.0% 476 100.0% 891 100.0%


Table 18: Permanent Stoma rate is not more than 40% is patients with rectal tumours ( QIS Standard 8b1) In many cases it is not possible to tell if a stoma is permanent until a number of years have passed. For the purposes of this report, a stoma is defined as permanent only for those procedures (abdominoperineal resection and colostomy and panproctocolectomy and ileostomy) which the stoma was fashioned with the intention of being permanent.

N= All Rectal Cancer patients undergoing elective surgery excluding non-definitive surgery

Borders D&G Fife Lothian SCAN

All Rectal Cancer patients undergoing elective Surgery 16 19 46 98 179 Patients undergoing APER with Colostomy OR Panproctocolectomy with ileostomy - left with a permanent stoma 3 18.8% 4 21.1% 14 30.4% 17 17.3% 38 21.2

2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 SCAN 11.4 11.7 13.7 18.2 18.1 23.3 17.8 20 25.5 21.2


Summary of Quality Performance Indicators: CRC QPI Attainment Summary 2013 – 2015 Borders D&G Fife Lothian SCAN

Target % Yr1 Yr2 Yr3 Yr1 Yr2 Yr3 Yr1 Yr2 Yr3 Yr1 Yr2 Yr3 Yr1 Yr2 Yr3

Radiological Staging & Diagnosis Colon 95 94.9 100 100 87.1 97.1 91.3 92.8 95.3 98.1

95.3 98.4 98.8 93.3 97.6 97.9

Rectum 95 100 94.7 100 58.3 50.0 90.0 76.5 90.0 94.6 98.8 89.2 94.4 86.9 85.7 94.4

Pre-operative imaging of the Colon 95 96.6 95.7 92.3 77.1 80.0 81.4 86.6 80.9 85.2 86.5 92.5 91.8 86.4 88.0 88.9

MDT before definitive treatment 95 - 100 95.1 - 93.2 88.8 - 97.2 97.4 - 98.3 95.4 - 97.5 94.9

Stoma Care: stoma site marked pre-operatively 95 100 100 100 82.4 70.6 100 100 97.0 100 84.1 89.2 95.0 89.0 90.2 97.4

Lymph Node Yield: surgical resection where ≥12 lymph nodes 80 89.4 84.0 81.8 88.6 96.2 95.3 83.9 87.7 89.1 90.6 87.4 82.9 88.6 88.4 85.9

Neo-adjuvant Radiotherapy (rectal) 90 50.0 100 0 0 100 100 83.3 71.4 71.4 94.7 100 100 81.3 91.3 86.7

Surgical Margins Primary surgery or surgery following short course XRT 95 100 100 87.5 89.9 93.3 100 0 0 96.3 96.2 97.9 94.1 96.9 98.3 95.0

ollowing l l long course radiotherapy or chemoradiotherapy 85 100 100 100 100 100 100 60.0 83.3 100 88.2 100 93.8 85.7 95.5 96.6

Re-operation Rates Elective <10 1.7 0 0 6.1 8.0 2.1 2.7 2.3 6.7 4.3 2.0 3..0 3.7 2.6 3.6

Emergency <15 5.6 6.7 0 9.1 0 11.1 5.6 8.0 6.9 5.7 4.8 3.0 6.0 5.1 4.5

Anastomotic Dehiscence Colon <5 2.6 0 0 6.1 4.2 8.3 0 1.4 1.4 3.4 0.6 1.2 2.2 1.3 2.1

Rectum inc TME <10 - 4.0 0 - 5.9 4.8 - 2.0 6.0 - 1.4 4.3 - 2.2 4.3

TME <20 0 - - 0 - - 0 - - 1.9 - - 1.1 - -

30 day mortality following surgical resection

Elective <5 0 2.2 0 1.4 1.3 0 0.7 0 0.8 0.3 0.4 1.9 0.5 0.6 1.3

Emergency <15 16.7 6.7 0 15.4 0 0 11.1 7.4 13.8 3.3 4.1 4.4 8.3 4.8 5.5

90 day mortality following surgical resection

Elective n/a - 6.5 0 - 2.7 1.8 - 0 2.5 - 0.4 2.3 - 1.1 2.1

Emergency n/a - 6.7 0 - 11.1 5.9 - 7.4 13.8 - 9.5 8.9 - 8.8 9.0

Adjuvant Chemotherapy HR Dukes B 50 50.0 - 100 40.0 50.0 71.4 100 75.0 100 47.1 64.3 42.9 53.1 65.0 70.0

Dukes C 70 43.8 69.2 100 70.0 100 92.9 65.6 66.7 79.2 76.0 68.1 81.0 69.2 72.6 83.6

30 day Mortality after Curative Oncological Treatment

All oncology treatment <2 0 6.3 - 0 0 - 0 0 - 0 1.2 - 0 1.2 -

Neo-adjuvant Chemoradiotherapy

<2 - - 0 - - 0 - - 0 - - 0 - - 0

Radiotherapy <2 - - 0 - - 0 - - 0 - - 0 - - 0

Adjuvant Chemotherapy <2 - - 0 - - 0 - - 2.4 - - 0 - - 0.6

90 day Mortality after Curative Oncological Treatment

All oncology treatment <2 - 6.3 - - 0 - - 2.1 - - 1.2 - - 1.8 -

Neo-adjuvant Chemoradiotherapy

<2 - - 0 - - 0 - - 0 - - 0 - - 0

Radiotherapy <2 - - 0 - - 0 - - 0 - - 0 - - 0

Adjuvant Chemotherapy <2 - - 0 - - 5.0 - - 2.4 - - 0 - - 1.2

Clinical Trial QPI Interventional Clinical Trials

7.5 - - 0 - - 0 - - 0.4 - - 1.6 - 0.6 1.2

Translational Research Trials

15 - - 27.6 - - 11.3 - - 33.9 - - 15.9 - 22.8 22.6


GLOSSARY

Active treatment: Treatment which is intended to improve the cancer and/or alleviate symptoms, as opposed to supportive care. Adenocarcinoma: A malignant growth of glandular tissue. Adenoma: A benign (non malignant) tumour that develops from epithelial tissue.

Adjuvant therapy /treatment: Additional cancer treatment given after the primary treatment to lower the risk that the cancer will come back. Adjuvant therapy may include chemotherapy, radiation therapy, hormone therapy, targeted therapy, or biological therapy. Anastomosis: An artificial connection, created by surgery, between two tubular organs or parts, especially between two parts of the intestine. For example, a junction created by a surgeon between two pieces of bowel which have been cut to remove the intervening section. Anastomotic dehiscence/ leak: Bursting open or splitting of the surgical connection between two sections of intestine. Anterior resection: The procedure to remove a diseased section of rectum, and rejoining of the healthy tissue at either end of the diseased area. Anti-cancer therapy: Any treatment which is designed to kill cancer cells. Asymptomatic: Having no symptoms. You are considered asymptomatic if you:

· Have recovered from an illness or condition and no longer have symptoms

· Have an illness or condition (such as early stage high blood pressure or glaucoma) but do not have symptoms Audit: The measuring and evaulation of care against best practice with a view to improving current practice and care delivery.

Biopsy: Removal of a sample of tissue from the body to assist in diagnosis of a disease. Bowel: The long, tube-shaped organ in the abdomen that completes the process of digestion. The bowel has two parts, the small bowel and the large bowel.

Cancer: The name given to a group of diseases that can occur in any organ of the body, and in blood, and which involve abnormal uncontrolled growth of cells.

Cancer Centre: Cancer services are based in cancer centres. Such centres provide the entire spectrum of cancer care - both on-site and to associated cancer units. Cause-specific survival: A method of estimating net survival. Only deaths attributable to the cancer of diagnosis are counted as deaths, giving the probability of survival in the absence of other causes of death. Chemoradiotherapy: Treatment that combines chemotherapy with radiotherapy. Chemotherapy: The use of drugs that kill cancer cells, or prevent or slow their growth. Circumferential margins (CRM): Margins of tissue surrounding a rectal cancer after it has been removed. Clinical effectiveness: Measure of the extent to which a particular intervention works. Clinical Governance: Ensures that patients receive the highest quality of care possible, putting each patient at the centre of his or her care. This is achieved by making certain that those providing services work in an environment that supports them and places the safety and quality of care at the top of the organisation's agenda. Clinical Nurse Specialist (CNS): A nurse with specialist training in a particular type of cancer. Clinical trials: A type of research study that tests how well new medical approaches or medicines work. These studies test new methods of screening, prevention, diagnosis, or treatment of a disease.


Colon: Part of the bowel. Also called the large intestine or large bowel. This structure has five major divisions: caecum, ascending colon, transverse colon, descending colon and sigmoid colon. The colon is responsible for forming, storing and expelling waste matter into the rectum. Colonoscopy: Examination of the interior of the large bowel using a long, flexible, instrument (a colonoscope) inserted through the anus. A colonoscope is capable of reaching to the upper end of the large bowel (colon) and can be used to diagnose diseases of the large bowel. Colorectal Cancer: Cancer that develops in the colon (the longest part of the large intestine) and/or the rectum (the last several centimetres of the large intestine before the anus). Co-morbidity: The condition of having two or more diseases at the same time. Computed Tomography (CT): An X-ray imaging technique used in diagnosis that can reveal many soft tissue structures not shown by conventional radiography. A computer is used to assimilate multiple X-ray images into a two-dimensional and/or three-dimensional cross-sectional image. CT Colonography: Computed tomography of the abdomen and pelvis that focuses on the colon. Computed tomography is an x-ray

Contraindicated: A symptom or medical condition that makes a particular treatment or procedure inadvisable because a person is likely to have a bad reaction. Curative: Having properties which cure. Something which overcomes disease and promotes recovery. Dataset: A list of required and specific information relating to a single disease. Elective: Subject to the choice or decision of the patient or physician, applied to procedures that are advantageous to the patient, but not urgent. Emergency Surgery: Unscheduled surgery performed promptly and often for lifesaving purposes.

Extramural vascular invasion: The direct invasion of a blood vessel (usually a vein) by tumour. In rectal cancer, this can occur on a macroscopic level and be detected on staging MRI. It is a significant prognostic factor, being a predictor of haematogenous spread.

Fatal: Results in death. HIS Healthcare Improvement Scotland: From April 2011, Healthcare Improvement Scotland (HIS) brings together the roles of the former Clinical Standards Board of Scotland (CSBS) and NHS Quality Improvement Scotland (NHS QIS). This is a statutory body whose purpose is to support healthcare providers in Scotland to deliver high quality, evidence-based, safe, effective and person-centred care; and to scrutinise those services to provide public assurance about the quality and safety of that care. www.healthcareimprovementscotland.org High risk: High risk colorectal cancer is defined as patients with pT4 (see TNM) disease and extramural vascular invasion.

Independent risk factor: A substance or condition that increases an individual’s chances of getting a particular type of cancer. Index procedure: Initial or first surgical procedure performed. Interventional radiology: Refers to a range of techniques which rely on the use of radiological image guidance (X-ray fluoroscopy, ultrasound, computed tomography (CT) or magnetic resonance imaging (MRI) to precisely target therapy. Intravenous iodinated contrast: A substance administered intravenously (directly into bloodstream) to enhance the visibility of structures on imaging.

ISD: Information Services Divison. Health service activity, manpower and finance data are collected, validated, interpreted and distribuated by ISD. These data are received from NHS Boards and general practices. Website address: www.isdscotland.org

KRAS: A gene which is found in the human body. If this gene mutates cancer can form.


KRAS testing: A test to establish the type of KRAS gene mutation present in a colorectal cancer. Large bowel: Another name for the large intestine. Long course radiotherapy: A course of radiotherapy lasting up to 6 weeks. Lymph nodes: Small bean shaped structures located along the lymphatic system. Nodes filter bacteria or cancer cells that might travel through the lymphatic system.

Metastatic disease: Spread of cancer away from the primary site to somewhere else via the bloodstream or the lymphatic system. Metastatic disease can be local (close to the area where the cancer is) or distant (in another area of the body).

Morbidity: How much ill health a particular condition causes.

Mortality: Either (1) the condition of being subject to death; or (2) the death rate, which reflects the number of deaths per unit of population in any specific region, age group, disease or other classification, usually expressed as deaths per 1000, 10,000 or 100,000.

Magnetic Resonance Imaging (MRI): A procedure in which radio waves and a powerful magnet linked to a computer are used to create detailed pictures of areas inside the body. These pictures can show the difference between normal and diseased tissue.

Multi Disciplinary Team: The collective name for a group of clinicians from various medical and non-medical disciplines appropriate to the disease area. Multi Disciplinary Team Meeting (MDTM): A regular meeting where participants from various clinical disciplines appropriate to the disease meet to discuss and agree diagnosis and subsequent clinical management of patients. Neo-adjuvant Therapy: The use of chemothearpy and/or radiotherapy prior to surgery. The aim of neo-adjuvant therapy is to reduce the size of any cancerous tumour.

NoSCAN: North of Scotland Cancer Network.

Oncologist: A doctor who specialises in the treatment of cancer patients. A clinical oncologist, or radiotherapist, specialises in treating cancer with radiation or drugs, and a medical oncologist specialises in treating cancer with drugs.

Outcome: A measure of effects, beneficial or adverse, which a person experiences as a result of the care, treatments or services they have received. Palliative: Treatment which serves to alleviate symptoms due to the underlying cancer but is not expected to cure it.

Pathological: The study of disease processes with the aim of understanding their nature and causes. This is achieved by observing samples of fluid and tissues obtained from the living patient by various methods, or at post mortem.

Performance status: A measure of how well a patient is able to perform ordinary tasks and carry out daily activities. (PS WHO score of 0=asymptomatic, 4=bedridden). Polyp: A small finger-like growth arising from the skin or a mucus surface, usually attached by a stem. Post operative complication: A complication or problem experienced following a surgical procedure. Prognosis: An assessment of the expected future course and outcome of a person’s disease. Quality assurance (QA): When a sample of data is compared with the data definitions. Radical treatment: Treatment that aims to get to completely get rid of a cancer. Radiotherapy: The use of radiation, usually X-rays or gamma rays, to kill tumour cells. Rectal anastomosis: A surgical procedure where part of the colon or ano-rectum is removed and the remaining ends joined together.

Rectal Cancer: Cancer that forms in the tissues of the rectum (the last several centimetres of the large intestine closest to the anus). Rectum: The distal or lowest portion of the large intestine.


Recurrence: When new cancer cells are detected, at the site of original tumour or elsewhere in the body, following treatment. SCAN: South East Scotland Cancer Network. Short course radiotherapy: 5 treatments of radiotherapy given (as a course of therapy) over 1 week prior to surgery being performed. Staging: Process of describing to what degree cancer has spread from its original site to another part of the body. Staging involves clinical, radiological, surgical and pathological assessments. Stoma: An artificial opening of the bowel that has been brought to the abdominal surface. Surgery/Surgical Resection: Surgical removal of the tumour/lesion. Synchronous tumours: Two or more colorectal tumours presenting at the same time in the colon or rectum. Total mesorectal excision (TME): A procedure in which any tissue surrounding the rectum which may contain tumour cells is removed at the same time as the rectum. Transanal endoscopic microsurgery (TEM): An alternative to open or laparoscopic excision whereby small rectal lesions are surgically excised using a minimally invasive approach. Transanal resection of tumour (TART): Surgical procedure performed to remove a tumour in the rectum through the anus. WoSCAN: West of Scotland Cancer Network.

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