management of vulval cancer services in south west england jenny weeks j verne l hirschowitz, v...
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Management of Vulval Cancer Services in South West England
Jenny WeeksJ Verne L Hirschowitz, V Udaysanker, AD Falconer on behalf
SWCIS Gynaecology Tumour Panel
September 2004
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4 Cancer Networks
Peninsula
3 Counties
ASWCS
Dorset
SWIS Gynaecology Tumour Panel
Multidisciplinary membership
3
Background
• Calman Hine Report 1995• Improving Outcomes Guidance
Gynaecological Cancer 1999• SWCIS Regional Standards & Guidelines
(Royal College Pathologists/ Obstetricians & Gynaecologists)
-> improvement in care and outcomes ?
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Aim of the Audit
• Monitor treatment against standards
• Have outcomes improved?
UKCCR 2004
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Standards
• Managed by gynaecologist with special interest in oncology (Regional/IOG)
• Minimum dataset recorded (IOG) eg• Histological Type• Grade• ASA
• Groin nodes taken if Stage >IA (Regional)• Skin - clear margins from tumour ≥ 8mm
(Regional)
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Method
• All new diagnoses squamous carcinoma of vulva (1997 to 2002)
• Data collected by gynaecology specialist nurses, gynaecologists, oncologists & audit departments
• Supplementary data from SWCIS information systems
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Results
• 1997 – 2002: 435 cases squamous cell carcinoma (18 verrucous subtype)
• Surgery 80% radiotherapy 9%
• Stage I 33%
Stage II 28%
Stage III 16%
Stage IV 6%
not stated 16%0%
5%
10%
15%
20%
25%
30%
35%
I II III IV not stated
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Age & Stage at diagnosis
0
20
40
60
80
100
120
140
160
20s 30s 40s 50s 60s 70s 80s 90s
Decade
pat
ien
t
Stage I
Stage II
Stage III
Stage IV
not stated
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% Surgery by ‘gynaecologist with oncology interests’
0%
20%
40%
60%
80%
100%
1997 1998 1999 2000 2001 2002
op
era
tio
ns
10
% Recorded (Min Data Set)
• Cohort ASA Stage Grade
97 - 98 90% 87% 91%
99 – 00 77% 80% 88%
01 - 02 78% 83% 92%
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Width Tumour-free margins
Ops/Cons
0%
10%
20%
30%
40%
50%
60%
97- 98 99 - 00 01 - 02
op
erat
ion
s
≥8mm
≤8mm
not stated
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% operations ≥ 8mm margin by Consultant ‘activity level’
0%
10%
20%
30%
40%
50%
60%
70%
97- 98 99 - 00 01 - 02
< 5
5 to 9
≥ 10
Ops/Cons
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Nodes Taken (≥ Stage IB)
Ops/Cons
0%
10%
20%
30%
40%
50%
60%
70%
97- 98 99 - 00 01 - 02
pati
en
ts yes
no
nk
Nodes taken
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1997 to 2000Kaplan-Meier survival estimates, by age category
Ops/Cons
0.00
0.25
0.50
0.75
1.00
0 1 2 3Years since treatment
<70years >70 and <80years>80 years
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1997 to 2000 Survivor functions, by stage adjusted for age
Ops/Cons
0.00
0.25
0.50
0.75
1.00
0 1 2 3Years since treatment
Stage I Stage IIStage III Stage IVnot stated
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1997 to 2000 Survivor functions, by Treatment Year
adjusted for age
•
0.0
00
.25
0.5
00
.75
1.0
0
0 1 2 3Years since treatment
1997 19981999 2000
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Conclusion
• Centralisation of surgery has occurred
• Improvements in practice - not yet
• Improvements in outcome
– too soon to say?
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Thank you