Document Control (DC1)...collaboration with the three Regional Cancer Networks and Information Services Division (ISD) the first QPIs were published by Healthcare Improvement Scotland

West of Scotland Cancer Network Lung Cancer Managed Clinical Network

Audit Report Lung Quality Performance Indicators

Clinical Audit Data:

01 April 2014 to 31 March 2015

Mr John McPhelim Lead Nurse - Lung Cancer MCN Clinical Lead Tracey Cole MCN Manager Julie McMahon Information Officer

West of Scotland Cancer Network Final - Published Lung Cancer MCN Audit Report v1.0 09.11.2015

CONTENTS

EXECUTIVE SUMMARY 3

1. INTRODUCTION 11

2. BACKGROUND 11

2.1 NATIONAL CONTEXT 12

2.2 WEST OF SCOTLAND CONTEXT 12

3. METHODOLOGY 12

4. RESULTS AND ACTION REQUIRED 13

4.1 DATA QUALITY 13

4.2 PERFORMANCE AGAINST QUALITY PERFORMANCE INDICATORS (QPIS) 14

West of Scotland Cancer Network Final - Published Lung Cancer MCN Audit Report v1.0 09.11.2015 3

Executive Summary

Introduction This report presents an assessment of performance of West of Scotland (WoS) Lung Cancer services relating to patients diagnosed in the twelve months between 01 April 2014 and 31 March 2015. Results are measured against the Lung Cancer Quality Performance Indicators (QPIs) which were implemented for patients diagnosed on or after 01 April 2013. In 2010, the Scottish Cancer Taskforce established the National Cancer Quality Steering Group (NCQSG) to take forward the development of national QPIs for all cancer types to enable national comparative reporting and drive continuous improvement for patients. In collaboration with the three Regional Cancer Networks and Information Services Division (ISD) the first QPIs were published by Healthcare Improvement Scotland (HIS) in January 2012 and implementation for all cancer types was completed in autumn 2014. Data definitions and measurability criteria to accompany the lung cancer QPIs are available from the ISD website (1). Twelve months of data were measured against the Lung Cancer QPIs for the second consecutive year, and Year 1 and Year 2 results are presented within this audit report for QPIs where results have remained comparable and measurability is unchanged. Future reports will continue to compare clinical audit data in successive years to further illustrate trend analysis. Background The trend in incidence of cancer in Scotland is an increasing one generally; however the incidence rate of lung cancer in females has increased by 13% over the last decade. In males the long term decline in incidence has continued with a significant fall of 15% over the same time period(2). Overall cancer mortality rates for male lung cancer patients in Scotland have decreased however the mortality rate for females is increasing (2). Despite more patients having the opportunity for anti-cancer therapy beyond initial treatment, lung cancer patients continue to have one of the lowest survival rates of any cancer, often attributed to advanced stage at presentation which makes patients less amenable to treatment. Data shows that for patients diagnosed between 2007-2011 1 year relative survival was 30% in males and 33% in females(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 entered locally into the electronic Cancer Audit Support Environment (eCASE): a secure centralised web-based database. Data relating to patients diagnosed between 01 April 2014 and 31 March 2015 was downloaded from eCASE on 11 August 2015. Analysis was performed centrally by the West of Scotland Cancer Network (WoSCAN) Information Team 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 or obvious gaps before final analysis was carried out. Final results were 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 Results for each QPI are shown in detail in the main report and illustrate Board performance against each target and overall WoS performance for each performance indicator. Results are presented graphically and the accompanying tabular format also highlights any missing data and its possible effect on any of the measured outcomes. Additional narrative and clinical commentary is also provided in the main report to explain some of the apparent variances in performance. The summary of results shows the WoS percentage performance against each QPI target and the range in performance by NHS Board. As patients within NHS Greater Glasgow and Clyde are managed by 3 MDTs, the NHSGGC figures are also shown broken down by analysis group - north Glasgow, South Glasgow and Clyde. Summary of QPI Results Colour Key

Above or equal to QPI target

Below QPI target

Symbol Key > Indicates improvement on previous year’s performance

< Indicates decrease from previous year’s performance

= Indicates no change from previous year

Indicates no comparable measure to previous year

Lung Cancer Performance by Board

QPI Target WoS A&A FV LS NG SG Clyde GGC

QPI 1: Discussion at MDT Proportion of patients with lung cancer who are discussed at MDT meeting before definitive treatment.

95% 95.1% 93.5%

N:333 D:356

95.5% 95.2% 96.9% 95.8% 92.6%

N:388

D:419

95.3%

QPI 2.1: Pathological Diagnosis. Proportion of patients who have a pathological diagnosis of lung cancer.

75% 86.2%

=

88.6%

>

91.2%

>

91.5%

>

82.6%

<

82.8%

>

84.2%

<

83.0%

<

QPI 2.2: Pathological Diagnosis. Proportion of patients with a pathological diagnosis of non small cell lung cancer (NSCLC) who have tumour subtype identified.

80% 89.7%

>

91.2%

<

87.5%

>

90.0%

>

89.4%

>

90.1%

>

89.7%

>

89.7%

>




QPI 2.3: Pathological Diagnosis. Proportion of patients with a pathological diagnosis of adenocarcinoma NSCLC who have analysis of predictive markers undertaken.

75% 78.8%

>

67.6%

N:48 D:71

<

81.6%

>

77.9%

>

78.2%

>

94.0%

>

79.4%

>

82.5%

>

QPI 3: Bronchoscopy. Proportion of patients with lung cancer who have undergone bronchoscopy where CT thorax was performed prior to bronchoscopy.

95% 97.5%

>

99.1%

>

98.1%

<

95.6%

>

99.1%

>

100.0%

>

94.1%

N:222 D:236

>

97.7%

>

QPI 4: PET CT in patients being treated with curative intent. Proportion of patients with NSCLC who are being treated with curative intent (radical radiotherapy, radical chemoradiotherapy or surgical resection) who undergo PET CT prior to start of treatment.

95% 97.4%

>

100.0%

>

100.0%

>

98.4%

<

95.8%

<

94.5%

<

99.0%

<

96.2%

<

QPI 5: Investigation of mediastinal malignancy. Proportion of patients with NSCLC undergoing treatment with curative intent who have positive mediastinal/supraclavicular fossa (SCF) nodes (N2/N3) on PET CT scan who undergo node sampling.

80% 64.2%

N:77 D:120

>

53.8%

N:7 D:13

>

100.0%

>

54.8%

N:17 D:31

>

93.8%

>

53.8%

N:14 D:26

<

61.5%

N:16 D:26

>

66.2%

N:45 D:68

>

QPI 6.1: Surgical Resection in NSCLC. Proportion of patients who undergo surgical resection for NSCLC.

17% 24.2%

<

21.5%

>

29.2%

>

24.6%

<

27.3%

<

21.6%

<

20.9%

=

24.0%

<

QPI 6.2: Surgical Resection in NSCLC. Proportion of patients with stage I-II NSCLC who undergo surgical resection.

50% 66.7%

<

76.4%

>

75.0%

>

68.8%

<

65.2%

<

59.1%

<

60.4%

<

62.3%

<

QPI 7: Lymph node assessment. Proportion of patients with NSCLC undergoing surgery who have adequate sampling of lymph nodes (at least 1 node from at least 3 N” stations) performed at time of surgical resection or at previous mediastinoscopy.

80% 73.0% 89.4% 83.8% 46.8% 71.1% 80.0% 78.8% 83.4%

QPI 8: Radiotherapy in inoperable lung cancer. Proportion of patients with lung cancer not undergoing surgery who receive radical radiotherapy(54Gy or greater) ± chemotherapy.

15% 33.8%

>

26.2%

>

27.8%

>

37.5%

>

32.2%

>

46.5%

>

27.9%

>

35.0%

>



QPI 9: Chemoradiotherapy in locally advanced non small cell lung cancer. Proportion of patients with NSCLC not undergoing surgery who receive radical radiotherapy, to 54Gy or greater, and concurrent or sequential chemotherapy.

50% 56.4%

>

100.0%

>

100.0%

>

31.3%

N:5 D:16

>

58.3%

>

66.7%

>

54.5%

>

59.4%

>

QPI 10: Chemoradiotherapy in limited stage small cell lung cancer. Proportion of patients with limited stage (stage I – IIIB)* SCLC treated with radical intent who receive both platinum-based chemotherapy, and radiotherapy to 40Gy or greater.

70% 42.2%

N:27 D:64

>

75.0%

>

37.5%

N:3 D:8

>

33.3%

N:4 D:12

>

40.0%

N:6 D:15

>

50.0%

N:5 D:10

>

40.0%

N:6 D:15

<

42.5%

N:17 D:40

>

QPI 11.1: Systemic anti cancer therapy in non small lung cancer. Proportion of patients with NSCLC who receive systemic anti cancer therapy.

35% 37.2%

=

43.7%

=

44.0%

>

49.3%

>

29.2%

N:71 D:243

<

35.0%

>

27.0%

N:50

D:185

<

30.1%

N:176 D:585

<

QPI 11.2: Systemic anti cancer therapy in non small lung cancer. Proportion of patients with stage IIIB and IV NSCLC who receive doublet chemotherapy including platinum as their first line regimen.

60% 57.3%

N:217 D:379

=

65.2%

>

60.0%

<

75.3%

>

44.7%

N:38 D:85

>

55.6%

N:30 D:54

<

40.7%

N:22 D:54

<

46.6%

N:90 D:193

<

QPI 12.1 Chemotherapy in small cell lung cancer. Proportion of patients with SCLC who receive first line chemotherapy ± radiotherapy.

70% 81.6%

>

92.9%

>

85.2%

>

77.8%

>

81.0%

>

81.5%

>

76.1%

>

79.9%

>

QPI 12.2 Chemotherapy in small cell lung cancer. Proportion of patients with SCLC not undergoing treatment with curative intent who receive palliative chemotherapy.

50% 76.3% 84.4% 81.8% 74.2% 77.8% 80.9% 62.5% 74.7%



QPI 13: 30 day mortality (surgery). Proportion of patients with lung cancer who die within 30 days of active treatment for lung cancer.

<5% 0.8%

<

0.0%

=

0.0%

<

0.0%

<

2.8%

<

0.0%

=

0.0%

=

1.4%

<

QPI 13: 90 day mortality (surgery). Proportion of patients with lung cancer who die within 90 days of active treatment for lung cancer.

<5% 3.2% 2.2% 2.2% 1.3% 4.0% 9.8%

N:5 D:51

0.0% 4.4%

QPI 13: 30 day mortality (radical radiotherapy). Proportion of patients with lung cancer who die within 30 days of active treatment for lung cancer.

<5% 0.7%

<

3.7%

>

0.0%

=

1.8%

>

0.0%

<

0.0%

<

0.0%

<

0.0%

<

QPI 13: 90 day mortality (radical radiotherapy). Proportion of patients with lung cancer who die within 90 days of active treatment for lung cancer.

<5% 4.4% 12.5%

N:3 D:24

0.0% 9.6%

N:5 D:52

3.2% 1.7% 0.0% 1.9%



QPI 13: 30 day mortality (adjuvant chemotherapy). Proportion of patients with lung cancer who die within 30 days of active treatment for lung cancer.

<5% 0.0%

<

0.0%

=

0.0%

<

0.0%

=

0.0%

<

0.0%

=

0.0%

<

0.0%

=

QPI 13: 90 day mortality (adjuvant chemotherapy). Proportion of patients with lung cancer who die within 90 days of active treatment for lung cancer.

<5% 7.4%

N:4 D:54

0.0% 0.0% 7.1%

N:1 D:14

18.2%

N:2 D:11

9.1%

N:1 D:11

0.0% 9.1%

N:3 D:33

QPI 13: 30 day mortality (chemoradiotherapy). Proportion of patients with lung cancer who die within 30 days of active treatment for lung cancer.

<5% 1.7%

>

0.0%

=

0.0%

=

0.0%

=

5.4%

N:2 D:37

0.0%

=

0.0%

=

2.6%

>

QPI 13: 90 day mortality (chemoradiotherapy). Proportion of patients with lung cancer who die within 90 days of active treatment for lung cancer.

<5% 8.6%

N:9 D:105

0.0% 14.3%

N:1 D:7

14.3%

N:2 D:14

11.4%

N:4 D:35

9.5%

N:2 D:21

0.0% 8.3%

N:6 D:72

QPI 13: 30 day mortality (palliative chemotherapy). Proportion of patients with lung cancer who die within 30 days of active treatment for lung cancer.

<10% 16.5%

N:87 D:527

>

18.4%

N:16 D:87

<

15.7%

N:8 D:51

>

14.2%

N:18 D:127

<

23.4%

N:25 D:107

>

13.3%

N:12 D:90

<

12.3%

N:8 D:65

<

17.2%

N; 45 D:262

>

QPI 13: 30 day mortality (biological therapy). Proportion of patients with lung cancer who die within 30 days of active treatment for lung cancer.

<10% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%


Conclusions and Action Required Cancer audit has underpinned much of the regional development and service improvement work of the Managed Clinical Network (MCN) and the regular reporting of activity and performance have been fundamental in assuring the quality of care delivered across the region. With the development of QPIs, this has now become a national programme to drive continuous improvement and ensure equity of care for patients across Scotland. West of Scotland Boards’ commitment in the past few years to the continuous improvement of the quality and completeness of audit data has supported the transition to national reporting. The improvements have provided accurate baseline data for the majority of measures for the first two years of Lung Cancer QPI analysis. QPIs relating to pathological diagnosis, Positron Emission Tomography (PET) Computerised Tomography (CT) in patients being treated with curative intent, surgical resection, radiotherapy in inoperable lung cancer and chemotherapy in Small Cell Lung Cancer (SCLC) were consistently met by all boards, and furthermore improvement was evident from the previous year in a number of additional areas. However targets for QPIs relating to mediastinal malignancy, chemotherapy in limited stage SCLC and systemic anti cancer therapy in Non Small Cell Lung Cancer (NSCLC) remain challenging for units to achieve. Some variance in performance is evident across the region however where targets have not been met NHS Boards have provided detailed comments indicating valid clinical reasons or in some cases patient choice or co-morbidities have influenced patient management. All actions are summarised overpage and are outlined in the main report under the relevant section. Each Board was asked to complete a Performance Summary Report and document areas for improvement where performance was below the QPI target. 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. Action Required:

QPI 7: – Lymph Node Assessment

NHS Lanarkshire to review cases and provide further detail on cases not meeting the QPI.

QPI 9: – Chemoradiotherapy in locally advanced NSCLC

NHS Lanarkshire to work with Oncology to ensure that all relevant radiotherapy data is captured to ensure accurate measurement of this QPI.

QPI 10: Chemoradiotherapy in limited stage SCLC.

NHS Forth Valley, NHS Lanarkshire and NHSGGC to work with Oncology to ensure that all relevant radiotherapy data is captured to ensure accurate measurement of this QPI.

QPI 11 (i): Systemic anti cancer therapy in NSCLC

NHSGGC to review cases and provide further detail on North Glasgow and Clyde cases not meeting the QPI.

QPI 11 (ii): Patients with stage IIIB and IV NSCLC should receive doublet chemotherapy including platinum as their first line therapy.

NHSGGC to review cases and provide further detail on cases not meeting the QPI.


QPI 13: 30 day mortality (palliative chemotherapy) and 90 day mortality (chemoradiotherapy).

NHSGGC to review cases and provide further detail on cases not meeting the 90 day mortality (chemoradiotherapy) and 30 day mortality (palliative chemotherapy) QPIs.

A summary of actions for each NHS Board has been included within the Action Plan templates in Appendix 1 where appropriate. 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. 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).


1. Introduction This report contains an assessment of the performance of West of Scotland (WoS) lung cancer services using clinical audit data relating to patients diagnosed with lung cancer in the twelve months between 01 April 2014 and 31 March 2015. Regular reporting of activity and performance is a fundamental requirement of a Managed Clinical Network (MCN) to assure the quality of care delivered across the region. Results are measured against the Lung Cancer Quality Performance Indicators (QPIs) which were introduced for patients diagnosed on or after 01 October 2013. In 2010, the Scottish Cancer Taskforce established the National Cancer Quality Steering Group (NCQSG) to take forward the development of national QPIs for all cancer types to enable national comparative reporting and drive continuous improvement for patients. In collaboration with the three Regional Cancer Networks and Information Services Division (ISD), the first QPIs were published by Healthcare Improvement Scotland (HIS) in January 2012 and implementation for all cancer types was completed in autumn 2014. CEL 06 (2012) mandates all NHS Boards in Scotland to report on QPIs on an annual basis. Data definitions and measurability criteria to accompany the Lung Cancer QPIs are available from the ISD website(1).

2. Background Lung cancer patients usually present to a chest physician, although a significant subgroup are referred by other clinicians, e.g. care of the elderly, and increasingly there is cross referral to lung cancer Multidisciplinary Team (MDT) meetings. There are seven lung cancer MDTs which operate around eight outpatient clinics serving 2.4 million people across four NHS Boards - NHS Ayrshire & Arran, NHS Forth Valley, NHS Greater Glasgow and Clyde (NHSGGC), and NHS Lanarkshire. Surgical services are provided centrally at the Golden Jubilee National Hospital (GJNH). Table 1 lists the MDTs by NHS Board area, and includes the analysis group based on location of diagnosis, which has been used to present results throughout the report. Table 1: Lung Cancer MDT Configuration in the WoS

MDT Analysis Group (location of diagnosis)

NHS Board Area

Crosshouse & Ayr Ayrshire & Arran (AA) NHS Ayrshire & Arran

Forth Valley Royal Hospital Forth Valley (FV) NHS Forth Valley

Pan Lanarkshire Lanarkshire (LS) NHS Lanarkshire

Clyde Clyde (Clyde)

North East Glasgow

West Glasgow North Glasgow (NG)

South Glasgow South Glasgow (SG)

NHS Greater Glasgow and Clyde


2.1 National Context Lung cancer continues to be the most common cancer (17% of all cancers) in Scotland, with approximately 5000 new cases diagnosed each year(2). Nationally lung cancer accounts for 17% of male cancer patients and 16% of female cancer patients(2). Lung cancer incidence rates in females continue to rise with a 13% increase over the last ten years; in contrast the long term decline in incidence of male lung cancer has continued with a significant fall in incidence of 15% over the same time period(1). The lifetime risk of developing lung cancer is estimated to be 1 in 12 for males and 1 in 13 for females (2). Overall cancer mortality rates have decreased in Scotland by 15% in males and 6% in females over the last 10 years, however the mortality rate for females with lung cancer has increased by 7%; decreasing by 21% for males(2)

Despite more patients having the opportunity for anti-cancer therapy beyond initial treatment, lung cancer patients continue to have one of the lowest survival rates of any cancer, often attributed to advanced stage of disease at presentation. Data shows that for patients diagnosed between 2007 – 2011 1 year relative survival was 30% in males and 33% in females, 5 year relative survival drops to 8.8% and 10.9% for males and females respectively (3). Earlier detection of lung cancer could lead to improved outcomes in patients. The Scottish Government launched the Detect Cancer Early programme for lung cancer in November 2013 to increase awareness of symptoms and help detect cancer earlier and improve survival rates(4).

2.2 West of Scotland Context Across Scotland 23% of the adult population continue to use tobacco products(5). In some of the most deprived areas in WoSCAN up to 40% of the adult population use tobacco products(5). It is also recognised that there can be/are a substantial level of co-morbidities in lung cancer patients in the WoS, which contributes to poor survival and may restrict treatment options. Age and Gender Distribution There were 2,718 new diagnoses of cancer recorded by the Lung MCN in the WoS during the reporting period and of these, 2,631 were lung cancers and 87 mesothelioma cases. Of the lung cancer diagnoses 1,288 (49%) diagnosed were male and 1,343 (51%) female. Lung cancer continues to be more prevalent in patients aged 60 years and over with 88% of the total cases occurring in patients within this group.

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 with lung cancer between 01 April 2014 and 31 March 2015 was downloaded from eCASE at 2200 hrs on 5 August 2015. 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 for the region by the WoSCAN Information Team 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.

4. Results and Action Required

4.1 Data Quality

Quality of audit data can be assessed in the first instance by estimating the proportion of expected patients that have been identified through audit. Case ascertainment is calculated by the number of patients identified as diagnosed in a NHS Board through audit as a percentage of the incidence of cancer diagnosed in that NHS Board from Cancer Registry. Cancer Registry information is available some time after the year of interest as collection and verification of data is time intensive. For this reason, audit data cannot be compared directly to Cancer Registry data for the same year. The number of patients diagnosed each year will naturally vary. Cancer Registry figures used were extracted from Cancer Registry Scotland, a system provided by Information Services Division (ISD) via the standard reports available. Cancer Registry figures are an average of 2009 to 2013 figures to take account of annual fluctuations in incidence within NHS Boards. Figure 1: Case Ascertainment by NHS Board for patients diagnosed with lung cancer, 01 April 14 to 31 March 15.

0

10

20

30

40

50

60

70

80

90

100

110

Ayrshire & Arran Forth Valley Lanarkshire GGC WoSCAN

Percentage

of cases

Analysis Group



4.2 Performance against Quality Performance Indicators (QPIs) Results of the analysis of Lung Cancer Quality Performance Indicators (QPIs 1 to 13) are set out in the following sections. Graphs and charts have been provided where this aids interpretation and, where appropriate, numbers have also been included to provide context. Data (both graphically and in tabular format) are presented by location of diagnosis or treatment, with some criteria given as an overall West of Scotland representation. Specific regional and NHS Board actions have been identified to address issues highlighted through the data analysis.

QPI 1: Multi-Disciplinary (MDT) Meeting Effective MDT working is considered integral to provision of high quality lung cancer care, facilitating a cohesive treatment-planning function and ensuring treatment and care provision is individualised to patient needs. QPI 1 states that 95% of patients should be discussed at the MDT prior to definitive treatment. The tolerance allows for patients who need treatment urgently. Title: Patients with newly diagnosed lung cancer should be discussed by a MDT prior to

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

treatment. Denominator: All patients with diagnosed lung cancer. Exclusions: Patients who died before first treatment. Target: 95% or above Figure 2: The proportion of patients discussed at MDT prior to definitive treatment.

0

10

20

30

40

50

60

70

80

90

100

Ayrshire &

Arran

Forth Valley Lanarkshire North Glasgow South Glasgow Clyde WoSCAN

Percentage of cases

Analysis Group

Performance (%) Numerator Denominator Not recorded

numerator Not recorded

numerator (%) Not recorded

exclusions Not recorded

exclusions (%) Not recorded denominator

AA 93.5 333 356 0 0.0% 0 0.0% 0

FV 95.5 232 243 1 0.4% 0 0.0% 0

LS 95.2 440 462 3 4.1% 0 0.0% 0

NG 96.9 588 607 3 0.5% 2 0.3% 0

SG 95.8 386 403 3 0.7% 3 0.7% 0

Clyde 92.6 388 419 0 0.0% 0 0.0% 0

WoS 95.1% 2367 2490 10 0.4% 5 0.2% 0

As highlighted in Figure 2 NHS Ayrshire & Arran and Clyde did not meet the 95% target. Overall in the WoS, the proportion of patients discussed at MDT was 95.1%.

Feedback received from NHS Ayrshire & Arran stated that case note review identified only one patient who refused further investigations and was offered supportive care only, this patient was not discussed at MDT before or after starting treatment. A total of 11 cases required urgent treatment which was started before MDT review, and the remaining cases were not suitable for active treatment, they were therefore offered best supportive care and discussed at MDT after decision to treat was made.

NHSGGC commented that the cases in Clyde not meeting the target were from medical wards and not referred to the respiratory team. A reminder has been issued that all patients must be discussed at MDT.


QPI 2 (i), (ii) and (iii): Pathological Diagnosis A definitive diagnosis is valuable in helping inform patients and carers about the nature of the disease, the likely prognosis and treatment choice. Appropriate treatment of lung cancer depends on accurate diagnosis and distinction between histological types of lung cancer. Adequate tissue sampling should be undertaken, ensuring appropriate balance of risk to patients, to allow for pathological diagnosis including tumour sub-typing and analysis of predictive markers. Newer drug treatments for Non Small Cell Lung Cancer (NSCLC) work best if they are targeted on the basis of histological sub-type and/or predictive markers. These markers predict whether targeted treatments are likely to be effective and include, for example, epidermal growth factor receptor (EGFR) mutations. QPI 2 is split into 3 sub-groups the first group looks at all patients with lung cancer who have a pathological diagnosis. The target for this QPI is set at 75% and the tolerance within the target is designed to take account of the fact that it is not always appropriate, safe or possible to obtain a histological or cytological diagnosis due to the performance status of the patient or advanced nature of the disease. Title: (i): Patients with lung cancer who have a pathological diagnosis. Numerator: Number of patients with lung cancer who have a pathological diagnosis (including

following surgical resection). Denominator: All patients with lung cancer. Exclusions: Patients who refuse investigations or surgical resection.

Patients receiving supportive care. Target: 75% or above Figure 3: The proportion of patients who have a pathological diagnosis of lung cancer.

0

10

20

30

40

50

60

70

80

90

100

Ayrshire &

Arran


Percentage

of cases

Analysis Group

Year 1 Year 2






AA 88.6 233 263 0 0.0% 0 0.0% 0

FV 91.2 155 170 0 0.0% 0 0.0% 0

LS 91.5 345 377 0 0.0% 0 0.0% 0

NG 82.6 431 522 0 0.0% 2 0.4% 0

SG 82.8 255 308 0 0.0% 3 1.0% 0

Clyde 84.2 240 285 0 0.0% 1 0.4% 0

WoS 86.2% 1659 1925 0 0.0% 6 0.3% 0


Figure 3 illustrates that of the 1925 patients included within the denominator criteria, 1659 had a pathological diagnosis. This equates to a rate of 86.2% which is above the target rate of 75% for this indicator. All NHS Boards managed to achieve this target. The second part of the QPI looks at those patients diagnosed with a pathological diagnosis of NSCLC who have a tumour subtype identified. The target is set at 80% with the tolerance level designed to account for situations where there is insufficient tissue to perform additional testing. Title: (ii): Patients with a pathological diagnosis of non small cell lung cancer (NSCLC) who

have tumour subtype identified Numerator: Number of patients with a pathological diagnosis of NSCLC who have a tumour

subtype identified. Denominator: All patients with a pathological diagnosis of NSCLC. Exclusions: No exclusions Target: 80% or above Figure 4: The proportion of patients with a pathological diagnosis of NSCLC who have tumour subtype identified.

0

10

20

30

40

50

60

70

80

90

100

Ayrshire & Arran

Forth Valley Lanarkshire North Glasgow

South Glasgow

Clyde WoSCAN

Percentage

of cases

Analysis Group

Year 1 Year 2






AA 91.2 208 228 0 0.0% 0 0.0% 0

FV 87.5 126 144 0 0.0% 0 0.0% 0

LS 90.0 278 309 0 0.0% 0 0.0% 0

NG 89.4 344 385 0 0.0% 0 0.0% 0

SG 90.1 200 222 0 0.0% 0 0.0% 0

Clyde 89.7 227 253 0 0.0% 0 0.0% 0

WoS 89.7% 1383 1541 0 0.0% 0 0.0% 0

NSCLC was diagnosed in 1541 patients in the WoS during the analysis period. 89.7% of these patients had their tumour subtype identified. As can be seen in Figure 4 all NHS Boards have met the 80% target for QPI 3.


Following baseline review discussion it was agreed that patients with a diagnosis of ‘Other Specified NSCLC’ should be added to the numerator criteria. This change was implemented for Year 2 analysis and resulted in an extra 31(2%) cases meeting the QPI standard. Data contained within Figure 3 for Year 1 has not been amended to include the extra cases.

The third subgroup states that 75% of stage 3b and 4 adenocarcinoma NSCLCs should have analysis of predictive markers undertaken. The tolerance level within this target is designed to account for situations where there is insufficient tissue to perform predictive marker analysis. Furthermore, predictive marker analysis may not be appropriate if patients are not suitable for further treatment. Following discussion at the Lung Cancer QPI Baseline Review, it was agreed that in order to ensure this QPI is measuring the most appropriate cohort of patients QPI 2(iii) should be changed from including all stage IIIB or IV NSCLC to measure only patients with stage IIIB or IV adenocarcinoma NSCLC. Title: (iii): Patients with a pathological diagnosis of stage IIIB or IV adenocarcinoma NSCLC

who have analysis of predictive markers undertaken. Numerator: Number of patients with a pathological diagnosis of stage IIIB or IV adenocarcinoma

NSCLC who have analysis of predictive markers undertaken. Denominator: All patients with a pathological diagnosis of stage IIIB or IV adenocarcinoma NSCLC. Exclusions: Patients with performance status 4. Target: 75% or above

Figure 5: The proportion of patients with a pathological diagnosis of adenocarcinoma NSCLC who have analysis of predictive markers undertaken.

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South Glasgow

Clyde WoSCAN

Percentage

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Analysis Group






AA 67.6 48 71 0 0.0% 0 0.0% 4

FV 81.6 31 38 0 0.0% 0 0.0% 0

LS 77.9 53 68 0 0.0% 3 4.4% 3

NG 78.2 68 87 0 0.0% 0 0.0% 12

SG 94.0 47 50 0 0.0% 2 4.0% 8

Clyde 79.4 50 63 0 0.0% 6 9.5% 0

WoS 78.8% 297 377 0 0.0% 11 2.9% 27

Five of the six units exceeded the 75% target set resulting in an overall WoS performance of 78.8%. Published results in the Year 1 lung cancer QPI audit report are not directly comparable to Year 2 results due to changes in the measurement and have therefore not been shown in Figure 5.



NHS Ayrshire & Arran achieved 67.6% against the 75% target. Comments received from the Board stated that review of patients not meeting the QPI identified 6 patients who had insufficient tissue for EGFR analysis. They added that since August 2014 patients with adenocarcinoma diagnosed locally routinely have EGFR analysis if there is sufficient tissue for this test. This should show an improvement in this measurement for the next annual report.

QPI 3: Bronchoscopy Patients with suspected lung cancer should have timely and appropriate investigations carried out to confirm a diagnosis of lung cancer. The sequence of investigations varies according to a variety of factors including clinical and radiological information, patient fitness, treatment intention and patient choice. Computerised Tomography (CT) thorax should be performed before an intended bronchoscopy to avoid unnecessary bronchoscopy and to guide how the procedure is conducted. Title: Patients with lung cancer who are undergoing bronchoscopy for purposes of

diagnosis and staging should have a CT thorax prior to bronchoscopy. Numerator: Number of patients with lung cancer undergoing bronchoscopy where CT thorax was

performed prior to bronchoscopy. Denominator: All patients with lung cancer undergoing bronchoscopy. Exclusions: No exclusions Target: 95% or above

Figure 6: The proportion of patients with lung cancer who have undergone CT prior to bronchoscopy.

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Percentage

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Analysis Group

Year 1 Year 2

Performance

(%) Numerato

r Denominat

or

Not recorded

numerator

Not recorded numerator

(%) Not recorded exclusions

Not recorded exclusions

(%) Not recorded denominator

AA 99.1 107 108 0 0.0% 0 0.0% 0

FV 98.1 105 107 0 0.0% 0 0.0% 0

LS 95.6 195 204 0 0.0% 0 0.0% 0

NG 99.1 313 316 0 0.0% 0 0.0% 0

SG 100.0 200 200 0 0.0% 0 0.0% 0

Clyde 94.1 222 236 0 0.0% 0 0.0% 0

WoS 97.5% 1142 1171 0 0.0% 0 0.0% 0

As is illustrated in Figure 6 a CT scan (thorax) was performed prior to bronchoscopy in 97.5% of patients diagnosed with lung cancer in the reporting period. All units in the WoS managed to meet the target with the exception of Clyde who fell just short of the 95% target with 94.1%. Following discussion at the baseline review meeting it was noted that in the year one analysis patients who had a CT scan carried out on the same day as bronchoscopy were being recorded as not meeting the standard. This has been amended for year two analysis so that these cases are now included within the meeting category. There were 10 patients noted in Year 1 as having CT carried out on the same day as bronchoscopy, re-running the analysis for this cohort would change the WoS Year 1 result from 95.5% to 96.2%.


Feedback received from NHSGGC on Clyde cases not meeting the target stated that access to CT before clinic appointment is often an issue at the Royal Alexandra Hospital/Vale of Leven Hospital and there is no current provision of protected CT slots. CTs are requested at the time of vetting but may be delayed by the need for recent urea and electrolytes (U&Es) blood results before contrast CT can be performed. This issue has been escalated to relevant directors and a reminder has recently been sent out to GPs to arrange bloods for U&Es when referring patients for urgent suspected lung cancer. QPI 4: PET CT in patients being treated with curative intent Accurate staging is important to ensure appropriate treatment is delivered to patients with lung cancer. All patients being considered for radical treatment with curative intent should have a Positron Emission Tomography (PET) CT scan completed and reported by the multidisciplinary team before treatment. The target for this QPI has been set at 95% and the tolerance within the target is designed to account for the fact that some patients will refuse to undergo PET CT. In addition, in patients with small peripheral tumours (T1N0 disease) PET CT may not always be clinically appropriate. Title: Patients with lung cancer who are being treated with curative intent should have a

PET CT Scan (Positron Emission Tomography – Computed Tomography) prior to treatment.

Numerator: Number of patients with NSCLC who are being treated with curative intent (radical

radiotherapy, chemoradiotherapy or surgical resection) who undergo PET CT prior to start of treatment.

Denominator: All patients with NSCLC who are being treated with curative intent (radical

radiotherapy, chemoradiotherapy or surgical resection). Exclusions: No exclusions Target: 95% or above

Figure 7: The proportion of patients with NSCLC treated with curative intent who undergo PET CT prior to treatment.

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Analysis Group

Year 1 Year 2






AA 100.0 72 72 0 0.0% 0 0.0% 0

FV 100.0 53 53 0 0.0% 0 0.0% 0

LS 98.4 121 123 2 1.6% 0 0.0% 0

NG 95.8 159 166 0 0.0% 0 0.0% 3

SG 94.5 104 110 0 0.0% 0 0.0% 1

Clyde 99.0 95 96 0 0.0% 0 0.0% 0

WoS 97.4% 604 620 2 0.3% 0 0.0% 4


All six units have met the 95% target for QPI 4 resulting in an overall performance of 97.4% for WoS. QPI 5: Investigation of mediastinal malignancy Mediastinal nodes which are PET CT positive should be further evaluated by mediastinal node sampling, unless patients have metastatic disease. PET CT positive mediastinal nodes may be positive due to reactive changes rather than cancer. Sampling these nodes to determine if they are definitely positive for malignancy will ensure that patients suitable for radical treatment are treated appropriately. The target for this QPI is set at 80% with the tolerance designed to account for incidences where mediastinal node sampling would be inappropriate to the management of the patient, specifically in patients in whom there is a high probability of metastatic disease (for example bulky disease). Title: Patients with NSCLC with a possibility of mediastinal malignancy demonstrated on

PET CT should undergo node sampling to confirm mediastinal malignancy. Numerator: Number of patients with NSCLC undergoing treatment with curative intent who have a

PET CT scan that shows positive mediastinal/SCF nodes (N2/N3) that have nodes sampled.

Denominator: All patients with NSCLC undergoing treatment with curative intent who have a PET

CT scan that shows positive mediastinal/SCF nodes (N2/N3). Exclusions: Patients who refuse treatment. Patients with stage IV (M1a or M1b) disease. Target: 80% or above

Figure 8: The proportion of patients with NSCLC treated with curative intent who undergo PET CT that shows positive mediastinal/SCF nodes that have nodes sampled.

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Analysis Group






AA 53.8 7 13 0 0.0% 0 0.0% 0

FV 100.0 8 8 0 0.0% 0 0.0% 0

LS 54.8 17 31 0 0.0% 0 0.0% 0

NG 93.8 15 16 0 0.0% 2 12.5% 1

SG 53.8 14 26 0 0.0% 0 0.0% 0

Clyde 64.5 16 26 0 0.0% 0 0.0% 0

WoS 64.2% 77 120 0 0.0% 2 1.7% 0



Only Year 2 performance is illustrated in Figure 8 as results are not directly comparable to the previously published Year 1 performance (59.5%) due to a change in the measurability. The change was implemented following baseline review discussion whereby it was agreed that the denominator for this QPI should be changed to limit it to only patients who receive curative/radical treatment, as opposed to excluding patients based on performance status. This will ensure this QPI is measuring the most appropriate cohort of patients. NHS Forth Valley and North Glasgow have both met the 80% target. NHS Ayrshire & Arran, NHS Lanarkshire, South Glasgow and Clyde did not meet the target, achieving 53.8%, 54.8%, 53.8% and 64.5% respectively, resulting in an overall WoS performance of 64.2% against the 80% target. NHS Ayrshire & Arran commented that review of the cases not meeting the QPI identified that: 3 patients had curative surgery which did not require node sampling prior to surgery; 1 patient refused surgery; 1 patient had liver metastases; and the remaining case was not appropriate for surgery following MDT review. NHSGGC reviewed all cases in Clyde not meeting the QPI in detail and provided clinical reasons why the cases did not meet the target. They also commented that they feel the guideline fails to account for patients receiving radical radiotherapy, who may not need nodal sampling if immediately adjacent to primary tumour. In South Glasgow an audit of mediastinal staging will be carried out and findings will be advised. The lead clinician in NHS Lanarkshire reviewed all cases that did not meet the target. It was stated that treatment decisions would have been the same regardless of whether the nodes were sampled.

QPI 6: Surgical resection in NSCLC All patients should be considered for surgical treatment appropriate to their stage of disease. For patients with NSCLC who are suitable for treatment with curative intent surgical resection by lobectomy is the superior treatment option. Surgery is the treatment which offers best chance of cure to patients with localised NSCLC. Title: Patients with non small cell lung cancer (NSCLC) should undergo surgical resection Numerator: Number of patients with NSCLC who undergo surgical resection. Denominator: All patients with NSCLC. Exclusions: All patients who refuse surgery. All patients who die before surgery. Target: 17% or above.

Figure 9: The proportion of patients with NSCLC who undergo surgical resection.

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Analysis Group

Year 1 Year 2






AA 21.5 49 228 0 0.0% 0 0.0% 0

FV 29.2 42 144 0 0.0% 0 0.0% 0

LS 24.6 76 309 0 0.0% 0 0.0% 0

NG 27.3 105 384 0 0.0% 0 0.0% 0

SG 21.6 48 222 0 0.0% 0 0.0% 0

Clyde 20.9 53 253 0 0.0% 0 0.0% 0

WoS 24.2% 373 1540 0 0.0% 0 0.0% 0

As illustrated in Figure 9 all six units met the target of 17% or above for the second consecutive year. Overall, in the WoS 24.2% of patients with NSCLC received surgical resection with curative intent.


Patients with stage I and II NSCLC are more likely to be suitable for surgical resection; therefore specification (ii) has been developed to ensure this indicator focuses on the patients most appropriate for surgical resection. Title: Patients with non small cell lung cancer (NSCLC) should undergo surgical resection ( ii): Patients with stage I – II NSCLC who undergo surgical resection. Numerator: Number of patients with stage I-II (T1aN0 - T2bN1 or T3N0) NSCLC who undergo

surgical resection. Denominator: All patients with stage I-II (T1aN0 - T2bN1 or T3N0) NSCLC. Exclusions: All patients who refuse surgery. All patients who die before surgery. Target: 50% or above

Figure 10: The proportion of patients with stage I-II NSCLC who undergo surgical resection.

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Year 1 Year 2






AA 76.4 42 55 0 0.0% 0 0.0% 2

FV 75.0 30 40 0 0.0% 0 0.0% 0

LS 68.8 53 77 0 0.0% 0 0.0% 2

NG 65.2 73 112 0 0.0% 0 0.0% 15

SG 59.1 39 66 0 0.0% 0 0.0% 5

Clyde 60.4 32 53 0 0.0% 0 0.0% 1

WoS 66.7% 269 403 0 0.0% 0 0.0% 25

Figure 10 indicates that all six units met the 50% target resulting in an overall Wos result of 66.7%. This is a slight decrease on year one results where 69.4% of patients with stage I – II NSCLC underwent surgical resection. The 25 not-recorded values for the denominator are attributed to TNM Classification fields recorded as ‘99 – not recorded’. The importance of TNM recording to be reiterated to all Boards.


QPI 7: Lymph node assessment Adequate assessment of lymph nodes for accurate staging will help guide prognosis and further treatment management. Title: In patients with NSCLC undergoing surgery adequate assessment of lymph nodes

should be made. Numerator: Number of patients with NSCLC undergoing surgical resection by lobectomy or

pneumonectomy that have at least 1 node from at least 3 N2 stations sampled at time of resection or at previous mediastinoscopy.

Denominator: All patients with NSCLC undergoing surgical resection by lobectomy or

pneumonectomy. Exclusions: No exclusions. Target: 80%

Figure 11: The proportion of patients with NSCLC undergoing surgical resection by lobectomy or pneumonectomy that have at least 1 node from at least 3 N2 stations sampled.

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Percentage

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Analysis Group






AA 94.6 351 371 0 0.0% 0 0.0% 0

FV 97.8 268 349 0 0.0% 0 0.0% 0

LS 91.9 56 56 0 0.0% 0 0.0% 0

NG 96.9 285 294 0 0.0% 0 0.0% 0

SG 97.0 293 302 4 1.3% 0 0.0% 0

Clyde 98.6 341 346 2 0.6% 0 0.0% 0

WoS 96.6% 2207 2285 11 1.1% 0 0.0% 0

Measurement of QPI 7 changed from Year 1 to Year 2 with the addition of a new data field within the Lung dataset to allow accurate measurement of lymph node assessment. The change was agreed at baseline review to ensure the QPI measured what it intended to measure, following feedback from relevant thoracic surgeons.

Feedback received from NHSGGC provided valid clinical reasons for the Clyde patients not meeting the target. It was also stated that a local audit at The Golden Jubilee National Hospital (GJNH) has highlighted this issue and it is anticipated that this will improve next year with greater awareness.


Action Required:

NHS Lanarkshire to review cases and provide further detail on cases not meeting the QPI.

QPI 8: Radiotherapy in inoperable lung cancer. Radiotherapy is an important treatment option as it has a proven survival benefit for patients with lung cancer. The target for this QPI is set at 15% with the tolerance level designed to account for the fact that due to co-morbidities and age not all patients will be suitable for radiotherapy. In addition, patients may not have disease that can be encompassed within a radical radiotherapy field without excess toxicity. Title: Patients with inoperable lung cancer should receive radiotherapy ± chemotherapy. Numerator: Number of patients with lung cancer not undergoing surgery who received radical

radiotherapy (≥54Gy) ± chemotherapy. Denominator: All patients with lung cancer not undergoing surgery Exclusions: Patients with SCLC Patients who refuse radiotherapy. Patients who die prior to treatment. Patients with stage IV (M1a or M1b) disease. Target: 15%

Figure 12: The proportion of patients with lung cancer not undergoing surgery who received radical radiotherapy ± chemotherapy.

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Percentage

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Analysis Group






AA 26.2 33 126 0 0.0% 17 13.5% 0

FV 27.8 20 72 0 0.0% 1 1.4% 0

LS 37.5 66 176 0 0.0% 12 6.8% 0

NG 32.2 77 239 5 2.1% 29 12.1% 0

SG 46.5 79 170 1 0.6% 4 2.4% 0

Clyde 27.9 50 179 0 0.0% 13 0.0% 1

WoS 33.8% 325 962 6 0.6% 76 7.9% 1



All 6 units achieved the QPI target of 15%. Overall 33.8% of patients in the WoS with inoperable lung cancer received radical radiotherapy ± chemotherapy. Only Year 2 performance is illustrated in Figure 12 as results are not directly comparable to the previously published Year 1 performance (12.9%) due to a change in the measurability. The change was implemented following baseline review discussion whereby it was agreed that patients with stage 4 disease should be excluded from the denominator. It was also agreed that due to a data capture issue relating to the recording of radiotherapy dose that the Radiotherapy Type data field would be used to identify patients receiving radical radiotherapy rather than using radiotherapy dose. All units were noted as having cases with insufficient data recorded to establish exclusion from the QPI, the majority of which related to missing data for TNM data. The importance of accurate TNM recording should be reiterated to all Boards.

QPI 9: Chemoradiotherapy in locally advanced NSCLC Patients with stage III NSCLC who are not suitable for surgery should receive chemoradiotherapy, as this has a proven survival benefit. Potential benefit of survival does, however, have to be balanced with the risk of additional toxicities from this treatment. Title: Patients with inoperable locally advanced NSCLC should receive potentially curative

radiotherapy and concurrent or sequential chemotherapy. Numerator: All patients with stage IIIa NSCLC with performance status 0-1 not undergoing

surgery who receive chemoradiotherapy (radical radiotherapy ≥54Gy and concurrent or sequential chemotherapy).

Denominator: All patients with stage IIIa NSCLC with performance status 0-1 not undergoing

surgery who receive radical radiotherapy ≥54Gy. Exclusions: Patients who refuse treatment. Patients who die prior to treatment. Patients receiving Continuous Hyperfractionated Radiotherapy. Target: 50%

Figure 13: The proportion of patients with stage IIIa NSCLC with PS 0-1 not undergoing surgery who receive chemoradiotherapy.

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Percentage

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Analysis Group






AA 100.0 5 5 0 0.0% 0 0.0% 0

FV 100.0 2 2 0 0.0% 0 0.0% 0

LS 31.3 5 16 0 0.0% 1 12.5% 0

NG 58.3 7 12 0 0.0% 6 50.0% 2

SG 66.7 6 9 0 0.0% 1 11.1% 1

Clyde 54.5 6 11 0 0.0% 0 0.0% 0

WoS 56.4% 31 55 0 0.0% 11 20.0% 3

All units with the exception of NHS Lanarkshire achieved the 50% target, however due to the small numbers any comparison of percentages should be treated with caution. Figures for Year 2 are again not directly comparable to the previous year due to measurability changes. Radiotherapy Type was used to identify patients in Year 2 receiving radical radiotherapy rather than using radiotherapy dose.



Feedback received from NHS Lanarkshire stated that they had limited access to radiotherapy data and that the Clinical Quality Department would work with oncology and the MCN around better access to the data needed for accurate recording. However it is important to note that all boards now have access to the same data extract report from the ARIA radiotherapy system, and supplementary information can also be obtained from clinical notes/patient administration systems. As a result of discussions at the 2014 regional education event, it was agreed that a standard letter detailing oncological treatments received by patients should be developed. This consistency in recording both systemic anti cancer therapy and radiotherapy would aid data collection. This is currently in development by the MCN.

Action Required:

NHS Lanarkshire to work with Oncology to ensure that all relevant radiotherapy data is captured to ensure accurate measurement of this QPI.

QPI 10: Chemoradiotherapy in limited stage SCLC Patients with limited stage disease Small Cell Lung Cancer (SCLC) should receive concurrent chemoradiotherapy, as this is proven to improve survival. Combination treatment is dependent on patient fitness levels and any potential survival benefit should be balanced with the risk of additional toxicities of this treatment. Title: Patients with limited stage SCLC should receive platinum based chemotherapy and

(concurrent or sequential) radiotherapy. Numerator: All patients with stage I-IIIB SCLC with PS 0-1 who receive chemoradiotherapy Denominator: All patients with stage I-IIIB SCLC with PS 0-1. Exclusions: Patients who refuse treatment. Patients who die prior to treatment. Patients who undergo surgical resection. Target: 70%

Figure 14: The proportion of patients with limited stage SCLC receiving platinum based chemotherapy and radiotherapy.

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Analysis Group






AA 75.0 3 4 0 0.0% 0 0.0% 0

FV 37.5 3 8 0 0.0% 0 0.0% 1

LS 33.3 4 12 0 0.0% 0 0.0% 1

NG 40.0 6 15 0 0.0% 0 0.0% 0

SG 50.0 5 10 0 0.0% 0 0.0% 0

Clyde 40.0 6 15 0 0.0% 0 0.0% 0

WoS 42.2% 27 64 0 0.0% 0 0.0% 2

As illustrated in Figure 14 only NHS Ayrshire & Arran met the 70% target set for this QPI. It is clear that this was a challenging target to achieve and this is reflected in the WoS result where only 42% of patients with limited stage SCLC received chemoradiotherapy. It should however be noted that numbers of patients in the above analysis, detailed in the data table accompanying Figure 14, are low, especially for the smaller WoS Boards, and this has a considerable effect on proportions therefore comparisons should be made with caution. As with the previous QPI the measurability was changed to use the Radiotherapy Type field in Year 2 data rather than radiotherapy dose and therefore the data is not comparable to Year 1 results. West of Scotland Cancer Network Final - Published Lung Cancer MCN Audit Report v1.0 09.11.2015 31


NHS Lanarkshire commented that they have limited access to radiotherapy data. However, again it should be noted that all Boards have access to the same ARIA data extract. NHS Forth Valley stated that they have small numbers which has a major impact on their percentages but that it was an improvement on last year’s results where they achieved 14.3%. NHSGGC commented that Clyde were currently in the process of reviewing all cases not meeting the standard. It was also noted that meetings are to take place with the management team to re-discuss ways of restructuring the oncology service in Clyde. South Glasgow commented that there was some concern that the documentation regarding radiotherapy may be poorly recorded in notes and a review was in progress. Again it should be noted that all Boards now have access to a data extract report from the ARIA radiotherapy system, and supplementary information can also be obtained from clinical notes/patient administration systems.

Action Required:

NHS Forth Valley, NHS Lanarkshire and NHSGGC to work with oncology to ensure that all relevant radiotherapy data is captured to ensure accurate measurement of this QPI.

QPI 11 (i): Systemic anti cancer therapy in NSCLC Systemic anti cancer therapy should be offered to all patients with NSCLC and good performance status, to improve survival, disease control and quality of life.

Title: Patients with inoperable NSCLC should receive systemic anti cancer therapy where

appropriate. Numerator: All patients with NSCLC not undergoing surgery who receive systemic anti cancer

therapy. Denominator: All patients with NSCLC not undergoing surgery. Exclusions: Patients who refuse chemotherapy. Patients who die prior to treatment. Patients who are participating in clinical trials. Target: 35%

Figure 15: The proportion of patients with NSCLC not undergoing surgery who receive systemic anti cancer therapy.

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Year 1 Year 2






AA 43.7 73 167 0 0.0% 0 0.0% 0

FV 44.0 40 91 0 0.0% 0 0.0% 0

LS 49.3 101 205 0 0.0% 0 0.0% 0

NG 29.2 71 243 0 0.0% 2 0.8% 0

SG 35.0 55 157 1 0.6% 2 1.3% 0

Clyde 27.0 50 185 0 0.0% 5 2.7% 0

WoS 37.2% 390 1048 1 0.1% 9 0.9% 0

Four of the six units met the target for QPI 11(i); NHS AA, NHS FV, NHS Lanarkshire and South Glasgow resulting in an overall WoS result of 37.2%.

Action Required:

NHSGGC to review cases and provide further detail on North Glasgow and Clyde cases not meeting the QPI.


The second section of QPI 11 measures patients with stage IIIB and IV NSCLC receiving doublet chemotherapy including platinum as their first line regimen. Patients with stage III or IV NSCLC should be offered chemotherapy, dependent on fitness level, as this is proven to improve survival, provides palliation for symptoms caused by primary or metastatic tumour and improves quality of life. Title: Patients with stage IIIB or IV NSCLC should receive doublet chemotherapy including

platinum as their first line regimen. Numerator: All patients with stage IIIB or IV NSCLC with performance status 0-1 not undergoing

surgery who receive doublet chemotherapy including platinum as their first line regimen.

Denominator: All patients with stage IIIB or IV NSCLC with performance status 0-1 not undergoing

surgery. Exclusions: Patients who refuse chemotherapy. Patients who die prior to treatment. Patients who are participating in clinical trials. Target: 60%

Figure 16: The proportion of patients with stage IIIB or IV NSCLC with PS 0-1 not undergoing surgery who receive doublet chemotherapy including platinum as their first line regimen.

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Percentage of cases

Analysis Group

Year 1 Year 2






AA 65.2 45 69 0 0.0% 0 0.0% 11

FV 60.0 24 40 0 0.0% 0 0.0% 0

LS 75.3 58 77 0 0.0% 0 0.0% 11

NG 44.7 38 85 0 0.0% 0 0.8% 7

SG 55.6 30 54 0 0.0% 0 0.0% 12

Clyde 40.7 22 54 0 0.0% 0 0.0% 10

WoS 57.3% 217 379 0 0.1% 0 0.0% 51

North Glasgow, South Glasgow and Clyde did not meet the QPI target of 60%. NHS Ayrshire & Arran, NHS Lanarkshire and North Glasgow have all demonstrated an improvement from Year 1 performance; however as NHS Forth Valley, South Glasgow and Clyde have all shown small decreases in performance the overall WoS result is marginally lower than Year 1.


Action Required:

NHSGGC to review cases and provide further detail on cases not meeting the QPI. QPI 12 (i): Chemotherapy in SCLC Following discussion at the Lung Cancer QPI Baseline Review, it was agreed that QPI 12 should be divided into two subgroups for Year 2 analysis. Patients are now reported separately by (i) intermediate risk and (ii) high risk categories. Patients with SCLC should receive combination chemotherapy, dependent on fitness levels, as this has a proven survival benefit and provides palliation for symptoms caused by primary or metastatic tumour. Title: Patients SCLC should receive chemotherapy. Numerator: All patients with SCLC who receive first line chemotherapy ± radiotherapy. Denominator: All patients with SCLC. Exclusions: Patients who refuse chemotherapy. Patients who die prior to treatment. Patients who are participating in clinical trials. Target: 70% Figure 17: The proportion of patients with SCLC who receive first line chemotherapy ± radiotherapy.

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Forth Valley Lanarkshire North

Glasgow

South Glasgow Clyde WoSCAN

Percentage

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Analysis Group






AA 92.9 39 42 0 0.0% 0 0.0% 0

FV 85.2 23 27 0 0.0% 0 0.0% 0

LS 77.8 56 72 0 0.0% 0 0.0% 0

NG 81.0 64 79 0 0.0% 0 0.0% 0

SG 81.5 44 54 0 0.0% 0 0.0% 0

Clyde 76.1 35 46 0 0.0% 0 0.0% 0

WoS 81.6% 261 320 0 0.1% 0 0.0% 0

All boards achieved the 70% target set for QPI 12(i), resulting in an overall WoS performance of 81.6%. Year 1 performance reported in the previous Lung Cancer QPI Audit Report cannot be directly compared with Year 2 performance due to the subcategories implemented above and the consequent change in measurement.


Part two of QPI 12 looks at those patients with SCLC not undergoing treatment with curative intent and of them the number who received palliative chemotherapy. Title: Patients SCLC should receive chemotherapy. Numerator: All patients with SCLC not undergoing treatment with curative intent who receive

palliative chemotherapy. Denominator: All patients with SCLC not undergoing treatment with curative intent. Exclusions: Patients who refuse chemotherapy. Patients who die prior to treatment. Patients who are participating in clinical trials. Target: 50%

Figure 18: The proportion of patients with SCLC not undergoing treatment with curative intent who receive palliative chemotherapy.

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AA 84.4 27 32 0 0.0% 0 0.0% 0

FV 81.8 18 22 0 0.0% 0 0.0% 0

LS 74.2 46 62 0 0.0% 0 0.0% 0

NG 77.8 49 63 0 0.0% 0 0.0% 1

SG 80.9 38 47 0 0.0% 0 0.0% 0

Clyde 62.5 25 40 0 0.0% 0 0.0% 0

WoS 76.3% 203 266 0 0.0% 0 0.0% 1

As highlighted in Figure 18 all units achieved the 50% target set for QPI 12(ii).The overall WoS performance was noted as 76.3%. As with the previous QPI results from Year 1 could not be compared to Year 2 due to the changes in the measurement of this QPI.


QPI 13: 30 Day Mortality: 30 day mortality following treatment for lung cancer Thirty-day mortality following treatment is shown in Table 1 for all patients diagnosed in WoS by treatment type, against the evidence-based target of less than 5% (or <10% for palliative chemotherapy and biological therapy). The treatment types included in analysis are surgery, radical radiotherapy, adjuvant chemotherapy, chemoradiotherapy, palliative chemotherapy and biological therapy. Figure 19 also illustrates a more detailed breakdown of mortality following palliative chemotherapy. Title: 30 day Mortality following treatment for lung cancer. Numerator: All patients with lung cancer who receive active treatment who die within 30 days of

treatment. Denominator: All patients with lung cancer who receive active treatment. Exclusions: No exclusions. Target: <5% (or <10% for palliative chemotherapy and biological therapy) Table 1: The proportion of patients with lung cancer who receive active treatment who die within 30 days of treatment.

QPI Target WoS Result (Year 1)

WoS Result (Year 2)

Surgery <5 % 1.9% 0.8%

Radical Radiotherapy <5 % 1.9% 0.7%

Adjuvant Chemotherapy <5 % 3.4% 0.0%

Chemoradiotherapy <5% 0.0% 1.7%

Palliative Chemotherapy <10% 16.1% 16.5%

Biological Therapy <10% No cases 0.0%

The target was achieved at board and regional level for all treatment types in Year 2 with the exception of palliative chemotherapy. The mortality rate for patients receiving palliative chemotherapy is expected to be lower than 10% within 30 days. All units were unable to achieve this which impacted the WoS figure overall where almost 16.5% of patients died within 30 days of receiving palliative chemotherapy. Figure 19: The proportion of patients with lung cancer receiving palliative chemotherapy who die within 30 days of treatment.

0

10

20

30

40

50

Ayrshire & Arran


Percen

tage

of cases

Analysis Group







AA 18.4 16 87 0 0.0% 0 0.0% 0

FV 15.7 8 51 0 0.0% 0 0.0% 0

LS 14.2 18 127 5 3.9% 0 0.0% 0

NG 23.4 25 107 2 1.9% 0 0.0% 0

SG 13.3 12 90 6 6.7% 0 0.0% 1

Clyde 12.3 8 65 8 12.3% 0 0.0% 1

WoS 16.5% 87 527 21 4.0% 0 0.0% 2

Following review of their cases NHS Ayrshire & Arran reported that cause of death had been established as poor performance status and disease progression. Quarterly review meetings are held locally where all patient dying within 30 days of chemotherapy are discussed and actions taken forward. NHS Forth Valley advised they reviewed all 8 cases, 6 of which were SCLC cases which were more aggressive. It was also suggested that it may be more appropriate to further define this QPI by NSCLC and SCLC. This will be discussed nationally following Year 3 reporting. NHS Lanarkshire advised that cases will be reviewed by oncologists, and actively monitored at chemotherapy mortality meetings. It was agreed after Baseline Review that future reporting of mortality rates should include 90 day mortality rates for surgery, radical radiotherapy and chemoradiotherapy. Table 2 shows the 90 day mortality rate for the WoS for each treatment type. Title: 90 day Mortality following treatment for lung cancer. Numerator: All patients with lung cancer who receive active treatment who die within 90 days of

treatment. Denominator: All patients with lung cancer who receive active treatment. Exclusions: No exclusions. Target: <5% Table 2: The proportion of patients with lung cancer who receive active treatment who die within 90 days of treatment.

QPI Target WoS Result (Year 2)

Surgery <5 % 3.2%

Radical Radiotherapy <5 % 4.4%

Chemoradiotherapy <5% 8.6%

Table 2 highlights that the WoS met the <5% target for surgical and radical radiotherapy 90 day mortality. There were 9 deaths recorded within 90 days of chemoradiotherapy treatment in the WoS during the reporting period resulting in a 8.6% (9/105) mortality rate. Both NHS Forth Valley and NHS Lanarkshire advised that non achievement of the 90 day chemoradiotherapy aspect of this QPI was due to the small numbers involved. West of Scotland Cancer Network Final - Published Lung Cancer MCN Audit Report v1.0 09.11.2015 38


For both 30 day mortality following palliative chemotherapy, and 90 day mortality following chemoradiotherapy in NHSGGC, the team in South Glasgow plan to review all cases. In North Glasgow it was reported that there was insufficient detail available for analysis and further discussion/review should take place at MDT to look at patient selection.

Action Required: NHSGGC to review cases and provide further detail on cases not meeting the 90 day

mortality (chemoradiotherapy) and 30 day mortality (palliative chemotherapy) QPIs.

5. Conclusions Cancer audit has underpinned much of the regional development and service improvement work of the MCN and the regular reporting of activity and performance have been fundamental in assuring the quality of care delivered across the region. With the development of QPIs, this has now become a national programme to drive continuous improvement and ensure equity of care for patients across Scotland. West of Scotland Boards’ commitment in the past few years to the continuous improvement of the quality and completeness of audit data has supported this transition to national reporting. The improvements have provided accurate baseline data for the first and second year of Lung Cancer QPIs from which yearly comparisons in the service provision across WoS Boards can be made. QPIs relating to pathological diagnosis, PET CT in patients being treated with curative intent, surgical resection, radiotherapy in inoperable lung cancer and chemotherapy in SCLC were consistently met by all boards, and furthermore improvement was evident from the previous year in a number of additional areas. However targets for QPIs relating to mediastinal malignancy, chemotherapy in limited stage SCLC and systemic anti cancer therapy in NSCLC remain challenging for units to achieve. Some variance in performance is evident across the region however where targets have not been met NHS Boards have provided detailed comments indicating valid clinical reasons or in some cases patient choice or co-morbidities have influenced patient management. There have been some results where the absence of accurate TNM recording has made the target unachievable, the importance of TNM recording is highlighted to all Boards. Work is currently ongoing within the MCN developing a regional MDT proforma which should assist this. 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 the Appendix. 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. 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).


Acknowledgement This report has been prepared using clinical audit data provided by the following NHS Boards in the WoSCAN area: NHS Ayrshire & Arran NHS Forth Valley NHS Greater Glasgow and Clyde NHS Lanarkshire

We would like to thank all members and active participants in the cancer network for their continued support of the MCN, and the many hospitals that are committed to making the audit succeed. We also acknowledge the efforts of the clinical effectiveness staff, nurses, and other service users for their work in ensuring the data are available to enable analysis to take place each year. Without their considerable efforts this level of progress would not be possible.


Abbreviations

CT Computed Tomography

eCASE Electronic Cancer Audit Support Environment

EGFR Epidermal Growth Factor Receptor

GJNH Golden Jubilee National Hospital

HIS Healthcare Improvement Scotland

ISD Information Services Division

MCN Managed Clinical Network

MDT Multidisciplinary Team

NCQSG National Cancer Quality Steering Group

NSCLC Non Small Cell Lung Cancer

PS Performance Status

PET Positron Emission Tomography

QPIs Quality Performance Indicators

RCAG Regional Cancer Advisory Group

SCLC Small Cell Lung Cancer

U&Es Urea and Electrolytes

WoS West of Scotland

WoSCAN West of Scotland Cancer Network


List of references and useful websites for further information

1. http://www.isdscotland.org/Health-Topics/Cancer/Cancer-Audit/ [Accessed on: 15th September 2015]

2. http://www.isdscotland.org/Health-Topics/Cancer/Publications/2015-04-28/Cancer_in_Scotland_summary_m.pdf [Accessed on: 15th September 2015]

3. http://www.isdscotland.org/Health-Topics/Cancer/Cancer-Statistics/Lung-Cancer-and-Mesothelioma/ [Accessed on: 15th September 2015]

4. http://www.gov.scot/Topics/Health/Services/Cancer/Detect-Cancer-Early [Accessed on: 15th September 2015

5. http://www.gov.scot/resource/0041/00417331.pdf [Accessed on: 15th September

2015

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

http://www.isdscotland.org/Health-Topics/Cancer/Publications/2015-04-28/Cancer_in_Scotland_summary_m.pdf

http://www.isdscotland.org/Health-Topics/Cancer/Publications/2015-04-28/Cancer_in_Scotland_summary_m.pdf

http://www.isdscotland.org/Health-Topics/Cancer/Cancer-Statistics/Lung-Cancer-and-Mesothelioma/

http://www.isdscotland.org/Health-Topics/Cancer/Cancer-Statistics/Lung-Cancer-and-Mesothelioma/

http://www.gov.scot/Topics/Health/Services/Cancer/Detect-Cancer-Early

http://www.gov.scot/resource/0041/00417331.pdf

NHS Lanarkshire Action / Improvement Plan – Lung Cancer (November 2015)

Timescales No Action Required NHS Board Action Taken Start End

Lead Status (see key)

Ensure actions mirror those detailed in Audit Report.

Provide detailed outcome of clinical review, details of specific improvement action taken, or reasons why no action taken.

Insertdate

Insert date

Insert name of responsible lead for each action.

Insert No. from key above

1.

QPI 7 - Lymph node assessment. NHS Lanarkshire to review cases and provide further detail on cases not meeting the QPI.

2. QPI 9 - Chemoradiotherapy in locally advanced NSCLC. NHS Lanarkshire to work with Oncology to ensure that all relevant radiotherapy data is captured to ensure accurate measurement of this QPI.

3. QPI 10 - Chemoradiotherapy in limited stage SCLC. NHS Lanarkshire to work with Oncology to ensure that all relevant radiotherapy data is captured to ensure accurate measurement of this QPI.

NHS Board: NHS Lanarkshire KEY (Status) Action Plan Lead: 1 Action fully implemented Date: 2 Action agreed but not yet implemented 3 No action taken (please state reason)

West of Scotland Cancer Network Final - Published Lung Cancer QPI Audit Report v1.0 09.11.2015

NHS Forth Valley Action / Improvement Plan – Lung Cancer (November 2015)

NHS Board: NHS Forth Valley KEY (Status) Action Plan Lead: 1 Action fully implemented Date: 2 Action agreed but not yet implemented 3 No action taken (please state reason)

Timescales No Action Required NHS Board Action Taken

Start End Lead Status

(see key)



Insertdate

Insert date



3. QPI 10 - Chemoradiotherapy in limited stage SCLC. NHS Forth Valley to work with Oncology to ensure that all relevant radiotherapy data is captured to ensure accurate measurement of this QPI.


NHSGGC Action / Improvement Plan – Lung Cancer (November 2015)





Insertdate

Insert date



3. QPI 10 - Chemoradiotherapy in limited stage SCLC. NHSGGC to work with Oncology to ensure that all relevant radiotherapy data is captured to ensure accurate measurement of this QPI.

4. QPI 11 (i) - Systemic anti cancer therapy in NSCLC. NHSGGC to review cases and provide further detail on North Glasgow and Clyde cases not meeting the QPI.

5. QPI 11 (ii)- Patients with stage IIIB and IV NSCLC should receive doublet chemotherapy including platinum as their first line therapy.

NHS Board: NHSGGC KEY (Status) Action Plan Lead: 1 Action fully implemented Date: 2 Action agreed but not yet implemented 3 No action taken (please state reason)





NHSGGC to review cases and provide further detail on cases not meeting the QPI.

6. QPI 13: 30 day mortality (palliative chemotherapy) and 90 day mortality (chemoradiotherapy). NHSGGC to review cases and provide further detail on cases not meeting the 30 day mortality (palliative chemotherapy) QPI and 90 day mortality (chemoradiotherapy) QPI.

Documents

Document Control (DC1)...collaboration with the three Regional Cancer Networks and Information Services Division (ISD) the first QPIs were published by Healthcare Improvement Scotland