Endometrial CancerCPGON Audit
Background• Formulating standard management
pathways• Assessing compliance with existing
pathways• Understanding areas of similarity and
areas of variation
Specific Questions• Endometrial cancer 2011-2013 inclusive• Caseload and waiting times• Tumour grade: how it affects management and
outcome• Move toward laparoscopic surgery• Imaging• Survival• Trial recruitment
Data collection• Access Database with specific forms• Sent to 5 hospitals: Taunton, Exeter, Yeovil,
Torbay, NDDH• Returns received from all except NDDH• Data presented reflect data entered• Significant influence of missing data (esp on
Grade data)
Data analysis
• Taunton/Yeovil and Exeter/Torbay analysed separately
• Exeter data include NDDH cases who had hysterectomy in Exeter, but diagnostic data are missing
Cases: Exeter/Torbay/NDDHHysterectomy?
Source site No Yes Total
Exeter 15 212 227
NDDH 7 43 50
Other 2 2
Plymouth 1 1
Private 3 3
Torbay 15 104 119
Grand Total 38 364 402
Cases: Taunton/YeovilHysterectomy?
Source site No Yes Total
Exeter 1 1
Other 3 3
Private 3 3
Taunton 17 117 134
Yeovil 4 90 94
Grand Total 21 214 235
Where hysterectomies done
• Counts of cases by location of surgery and according to site of diagnosis
Exeter
Torbay
Taunton (from
Yeovil)
0 20 40 60 80 100 120 140 160 180 200
182
115
62
49
37
24
Hysterectomies 2011-2013
Waits for Hysterectomy• Reported as mean in days• Includes some long waits. Very long
waits (>100d) excluded if biopsy field blank
• Assumed to be cases where cancer not suspected or known
Taunton
NDDH
Torbay
Taunton(fromYeovil)
Exeter(fromTorbay)
Exeter
Yeovil
0 5 10 15 20 25 30 35 40 45
27
28
32
33
39
40
40
Wait (d)
Taunton Exeter Yeovil Torbay0
10
20
30
40
50
60
70
80
90
71
56
33
0
67
55
71
6
8376 75
56
% Laparoscopic
201120122013
Laparoscopic• Continues to rise• Need clarity on what the expected
figure should be• Exeter and Taunton consensus is that
transverse laparotomy is very rarely indicated
Taunton Exeter Yeovil Torbay0
10
20
30
40
50
60
70
80
90
100
1318
42
100
1421
29
94
2 4
17
44
%Transverse laparotomy
201120122013
Influence of Tumour Grade• Several issues:
–What grade should trigger referral to centre
– Proportion of cases undergraded and therefore underinvestigated and under-referred
– Does biopsy grade predict need for adjuvant therapy?
Current Practice
• Yeovil/Taunton: – G2 and 3 referred to Centre– G2 called HG (according to data submitted)– G2 and G3 have cross sectional imaging
• Exeter/Torbay/NDDH:– G3 only referred to centre– G2 called LG– Only G3 have cross-sectional imaging
Grade analysis• Problem of missing data: each case
needs two grade data fields entered to contribute (biopsy and final)
• How to calculate upward grade shift• Decision to use denominator of grades
able to shift (ie exclude G3)
Exeter Torbay Taunton Yeovil0
10
20
30
40
50
60
70
80
90
70
8076 78
% Cases where Grade did NOT change at hysterectomy
Exeter Torbay Taunton Yeovil0
2
4
6
8
10
12
14
1211
5
7
% Of G1/2 shifted to G3 at hys-terectomy
Exeter Torbay Taunton Yeovil0
10
20
30
40
50
60
70
80
90
100
% Cases imaged
G1G2G3
Exeter Torbay Taunton Yeovil0
2
4
6
8
10
12
14
16
18
% Final G3 not imaged
TY/G1 TY/G2 TY/G3 ET/G1 ET/G2 ET/G30%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
107 52
26
101 119
102
0 2
8
4 430
DeadAlive
Survival by Grade
Survival• Kaplan Meier for Exeter/Torbay/NDDH
cases• Highly significant G3 worse than G1
and G2, which were the same• Regret no similar plot for
Taunton/Yeovil
Adjuvant Radiotherapy• Again a missing data issue• How does biopsy grade predict
likelihood of adjuvant radiotherapy after hysterectomy?
• Hyperplasia = cases where biopsy showed hyperplasia but hysterectomy revealed cancer
Hyperplasia G1 G2 G30%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
40 51 42
29
6 11 6
19
8 12 1432
Adjuvant Treatment Exeter/Torbay
EBRTBrachyNone
Hyperplasia G1 G2 G30%
10%20%30%40%
50%60%70%80%90%
100%
20 49
14
3
310
10
8
3 1011
14
Adjuvant treatment Taunton/Yeovil
EBRTBrachyNone
Grade conclusions• Survival data clear that G1 and 2 are
separate from G3• However, in Yeovil, G2 referral means:– Quicker operation– Accurately selects cases who need
adjuvant treatment
188
75
43
3713 Stage in Exeter/Torbay
n=402
IA IB IIIII IV
IA IB II III IV Unknown0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
178 70 40
24
6
31
10 5 3
13
8
15
Survival by FIGO stage Exeter/Torbay
DeadAlive
Clear c
ell
Endo
metrioi
dMMMT
Sarco
maSe
rous
0%10%20%30%40%50%60%70%80%90%
100%
10252
5 738
214
4 411
DeadAlive
Survival by Morphology
Exeter Torbay Taunton Yeovil0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
11 017 8
216 119117 86
Trial Recruitment
NoYes
Exeter Torbay Taunton Yeovil0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
25 9 17 8
202 110 117 86
Chemotherapy
NoYes
Conclusions• Variation within the Network (Grade triage)• Guidelines will need to reflect this, or
practice change• Patients do well and results in keeping with
published literature• We can do good audits together!!