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Clinical Standards Indicators in South East Coast

DRAFT Report 6. Cancer: Part 1

Document Purpose To identify any significant quality issues in the clinical care of cancer

patients that can be revealed from existing routine data.

Title Clinical Standards Indicators in South East Coast.

Report 6. Cancer: Part 1

Contributors:

Sadhana Bose, Consultant in Public Health Medicine, SEPHO

Isobel Perry, Public Health Intelligence Analyst, SEPHO

Andrew Hughes, Principal Analyst, SEPHO

Jo Watson, Principal Analyst, SEPHO

Jinan Ridha, Public Health Intelligence Analyst, SEPHO

Vivian Mak, Information Team Leader, Thames Cancer Registry

Rebecca Owen, Performance and Planning Analyst, Quality

Observatory, South East Coast SHA

Monica Roche, Director, Oxford Cancer Intelligence Unit

Alison Hill, Director, SEPHO

Publication Date October 2009

Description One in a series of reports on clinical quality of specific diseases and

conditions undertaken by SEPHO on behalf of South East Coast SHA.

Contact details South East Public Health Observatory

4150 Chancellor Court

Oxford Business Park South

Oxford OX4 2GX

Tel: 01865 334714

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CONTENTS

1. EXECUTIVE SUMMARY ........................................................................................3

2. PURPOSE OF THIS REPORT.................................................................................8

3. INTRODUCTION AND BACKGROUND ..................................................................8

4. THE BURDEN OF CANCER ..................................................................................11

5. LUNG CANCER ...................................................................................................15

6. BREAST CANCER................................................................................................23

7. COLORECTAL CANCER .......................................................................................32

APPENDIX 1 ...........................................................................................................43

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1. Executive summary

This is the sixth in a series of reports on clinical quality in South East Coast. It contains an

analysis of some key measures of the quality of care for patients with the three most

common cancers: lung, breast and colorectal cancer. It includes analyses of the Quality

and Outcomes Framework (QOF) data from primary care, Cancer Waiting Times (CWT)

data, Hospital Episodes Statistics (HES), cancer registry data, screening data and national

audit data. The report uses the latest available data from each source.

This report provides baseline data for a new indicator set. Primary Care Trusts (PCTs)

which are outliers will need to understand whether the data are an accurate reflection of

current activity and outcomes and whether the situation is improving, deteriorating or

staying the same. Further investigation of the quality of care of patients with cancer may

be warranted to determine whether there is a significant problem in the quality of the

care they commission.

Primary care

Comparison of cancer prevalence figures in South East Coast SHA using the Quality and

Outcomes Framework (QOF) for 2006/07 and 2007/08 and using the Registry data for

2006/07, shows a significant increase in cancer prevalence across South East Coast SHA

for all PCTs.

The QOF prevalence figures for 2007/08 (Fig 1) reported 52,996 patients with cancer in

the South East Coast SHA area. The prevalence rate in the PCTs varied, from 0.9% in

Medway to 1.4% in East Sussex Downs & Weald. West Sussex, Hastings & Rother and

East Sussex Downs & Weald PCTs prevalence rates were all significantly higher than

South East Coast SHA average.

In order to facilitate appropriate management of cancer patients in the primary care

setting, practices are required to maintain a register of cancer patients and to review

newly diagnosed cancer patients within six months of receiving confirmation of the

diagnosis. In 2007/08, 96% of practices in South East Coast SHA achieved maximum

points for cancer monitoring. At 99%, Surrey PCT performed significantly better than the

England and South East Coast averages. At 88%, Medway PCT performed significantly

worse than the South East Coast and England averages.

The percentage of patients excepted from cancer monitoring is higher for South East

Coast compared to the national average. East Sussex Downs & Weald PCT had a

significantly lower percentage of exceptions compared to the national and South East

Coast average. Brighton and Hove City PCT and West Sussex PCT have a significantly

higher percentage of exceptions compared to England.

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Lung cancer

Medway PCT had a significantly higher percentage of cancer referrals referred urgently

compared to the South East average, while Brighton & Hove City, West Sussex, and

Surrey PCTs had significantly lower referral rates than the South East Coast average.

37.2% of urgent referrals were confirmed as cancer. Medway and Surrey PCTs have a

high proportion of unknown referrals.

It is estimated that 20-30% of patients with non-small cell lung cancer (NSCLC) may be

eligible for radical surgery. The average resection rate from the National Lung Cancer

Audit was 9.0%. The South East Coast SHA surgical resection rate was 8.6 per 100

registrations. The resection rate for West Kent PCT at 12.1 per 100 registrations, was

significantly higher than the South East Coast SHA rate.

Both South East Coast SHA and England have seen significant increases in survival rates

at 1 year; South East Coast SHA has seen the percentage surviving to 1 year increase from

22.6% (1998-2000) to 27.6% (2004-2006). The South East Coast survival rate is similar to

the national rate for cases diagnosed between 2004 and 2006. Eastern & Coastal Kent

PCT had a significantly lower survival rate than the national average for 2004-2006 cases.

All but one of the South East Coast Trusts (East Sussex Hospitals NHS Trust) had low

levels of participation in the 2007 national lung cancer audit.

Breast cancer

The South East Coast SHA average referral rate in 2007/08 was 666 per 100,000. Eastern

& Coastal Kent and Hastings & Rother PCTs had a significantly higher percentage of

cancer referrals referred urgently compared to the South East Coast average. Brighton

& Hove PCT had a significantly lower percentage. Surrey and West Sussex PCTs had a

high proportion of cancer cases where the referral type was unknown. This data quality

issue should be addressed with providers.

Breast screening coverage rates of over 70% need to be achieved if the benefits of

screening are to be realised at population level. The 2007/08 South East Coast SHA breast

screening coverage was 76.7%, which is above the national standard of 70% and similar to

the England average of 76%. Medway, Hastings & Rother, Eastern & Coastal Kent and

West Kent PCTs achieved coverage rates significantly above the South East Coast

average; at 63.7%, Brighton & Hove City PCT coverage is significantly below the national

target.

Both South East Coast SHA and England have seen significant improvement in five year

survival rates between1994-1996 and 2000-2002; South East Coast SHA has seen the

percentage surviving to 5 years increase significantly from 74.9% to 83.4% i.e. for cases

diagnosed between 2000 and 2002, 83.4% survived to five years.

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The National Mastectomy and Breast Reconstruction Audit is funded by the Healthcare

Commission and designed as a four year project. Ten South East Coast Trusts

participated in the organisational audit.

Colorectal cancer

Eastern & Coastal Kent PCT had a significantly higher percentage of cancer referrals

referred urgently compared to the South East Coast average rate, and Brighton & Hove

City PCT had a significantly lower percentage. For some PCTs (Surrey and West

Sussex), a high proportion of cancer cases had an unknown referral type. This data

quality issue should be addressed with providers.

The rate of emergency inpatient admissions to hospitals in South East Coast SHA, at

21.20 per 100,000 population was lower than the rate for England. None of the PCTs had

significantly higher rates than either the South East Coast or England averages. Eastern

& Coastal and East Sussex Downs & Weald PCTs had significantly lower rates.

South East Coast SHA three year survival rates for colorectal cancer have significantly

improved between 1996-1998 and 2002-2004, with 56% of those diagnosed in 2002-2004

surviving for three years. The South East Coast survival rate was, however, significantly

lower than the national rate of 58.1%. Brighton & Hove City, Eastern & Coastal Kent,

Hastings & Rother and West Kent PCTs show significantly lower survival rates compared

to the national average.

All South East Coast Trusts should be contributing to the national audit. However, only

one South East Coast Trust (Royal West Sussex NHS Trust) met the 80% standard for

both data completeness and data quality. Nine Trusts (Ashford & St Peters, Dartford &

Gravesham, East Kent, East Sussex, Frimley Park, Maidstone & Tunbridge Wells,

Medway, Royal Surrey County and Surrey & Sussex hospitals) did not participate in the

2006 audit.

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2. Purpose of this report

This report is an analysis of a small number of key measures of clinical quality in health

services for patients with lung, breast and colorectal cancers. It has been commissioned

by the South East Coast SHA to ensure that there are no serious problems with clinical

services that could and should have been identified from routine data sources. It uses

data that is readily available at PCT level.

The scope of the report is necessarily limited by the availability of routine data, much of

which (e.g. QOF monitoring data) relates to process rather than outcome. Performance

on many of these indicators is above the national average across much of the SHA but

further improvement in service user experience and outcomes are still possible and

necessary. By looking at variation between PCTs, this report highlights some areas for

further investigation. In order to improve user experiences, service outcomes and to

enhance quality of local services, it is recommended that commissioners use this report

alongside other local, regional and national reports describing commissioning and

delivery of cancer services.

3. Introduction and Background

3.1 Introduction

A set of reports have been commissioned from the South East Public Health Observatory

on the quality of health care in the South East Coast PCTs for a number of common

conditions. Results of the reports may identify potential quality issues in PCTs which

could require further discussion and investigation with individual PCTs.

The following reports have been/ are being prepared:

• Diabetes

• Cerebrovascular Disease (stroke and transient ischaemic attack)

• Cardiovascular Disease (coronary heart disease and heart failure)

• Mental Health

• Chronic Obstructive Pulmonary Disease (chronic bronchitis and emphysema)

• Cancers: Report 1 (lung, breast, colorectal)

• Cancers: Report 2 (gynaecological, upper gastrointestinal, urological)

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3.2 Local context

This report only covers the PCTs and Acute Trusts within South East Coast SHA. It does

not reflect cancer network boundaries as the four cancer networks that cover South East

Coast SHA area are not co-terminous with the SHA boundaries.

• Kent and Medway Cancer Network covers Eastern & Coastal, Medway and West

Kent PCTs and the Acute Trusts within these areas (Dartford & Gravesham, East

Kent, Maidstone & Tunbridge Wells, The Medway and Queen Victoria Hospital).

• Sussex Cancer Network covers Brighton & Hove City PCT, East Sussex Downs &

Weald PCT, Hastings & Rother PCT and West Sussex PCT (46%) and the Acute

Trusts within these areas (Brighton & Sussex University, East Sussex and

Worthing & Southlands).

• Central South Coast Cancer Network covers West Sussex PCT (28%) and the

Acute Trust within this area (Royal West Sussex). This network also covers

Hampshire and Isle of Wight PCTs, both of which come in the South Central SHA

area.

• Surrey West Sussex Hampshire Cancer Network covers Surrey and West Sussex

(26%) and the Acute Trusts within these areas (Ashford & St Peter's, Frimley Park,

Royal Surrey County and Surrey & Sussex Healthcare).

It is of interest to note that, between them, three cancer networks cover West Sussex

PCT.

3.3 Data sources

The data for this report have been drawn from:

1. Quality and Outcomes Framework (QOF), which is based on GP records (latest

year available: 2007-08)

2. Hospital Episodes Statistics (HES) which are based on admissions to hospital.

(latest year available: 2007/08, though readmissions are based on 2006/07), NHS

Health & Social Care Information Centre, 2008

3. Cancer Waiting Times (CWT) data are taken from the National Cancer Waiting

Times System (latest year available: 2007/08), extracted and supplied by South

East Coast SHA

4. Cancer prevalence data was supplied by Thames Cancer Registry

5. Cancer Survival data was obtained from the National Cancer Information Service

6. Screening data was obtained from the Health and Social Care Information

Centre.

7. National Audit data are based on submissions from Hospital Trusts to the

National Clinical Audit Support Programme (NCASP) which is part of The

Information Centre for Health and Social Care. For this report, the audit reports

were accessed through the Information Centre website

(http://www.ic.nhs.uk/statistics-and-data-collections/audits-and-

performance/national-clinical-audits)

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Any consideration of the QOF data needs to consider the impact of the number of

patients who have been excluded from the measure. Appendix 1 explains the criteria

agreed for exception reporting. The proportion excluded by PCTs were analysed in order to

understand any apparent variations (Figure 3). There is concern over the variability in the

numbers excluded by practices with some national evidence that patients from less

favourable socio economic groups are more likely to be excluded.

The graphs in this report use 95% confidence intervals (CIs). These indicate the level of

uncertainty about each value on the graph. Longer/wider intervals mean more

uncertainty. When a confidence interval does not overlap with the SHA or national CIs it

is reasonably certain that the value is truly different. The SHA and national CIs are not

presented on the charts but have been reviewed. Comments about a difference being

significant are only included if the PCT CIs do not overlap with the national or SHA CIs.

In this report, cancer incidence refers to the number of new cancer cases arising in a

specified period of time. Cancer prevalence refers to the number of people who have

previously received a diagnosis of cancer and who are still alive at a given time point.

Some of these patients will have been cured and others will not. Therefore prevalence

reflects both the incidence of cancer and its associated survival pattern.

4. The burden of Cancer

4.1 Prevalence of cancer

Figure 1 compares the estimated prevalence of cancer from GP practice registers using

QOF (2006/07 and 2007/08 data) and cancer registration data (2006/07).

The statistics are not age standardised. An equivalent prevalence derived from cancer

registration data was undertaken based on the numbers of patients diagnosed with

cancer between April 2003 and December 2006 who were alive at the end of Dec 2006 in

the SE Coast SHA. The data have been stratified by PCT area of residence and sex. Please

note that patients diagnosed with more than one tumour during this period are only

counted once.

QOF prevalence figures are based on patients with a diagnosis of cancer, excluding non-

melanotic skin cancers, for 2006/07 from 1 April 2003 to 31st March 2007, and for 2007/08

from 1 April 2003 to 31st March 2008.

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Figure 1 Prevalence of cancer by Primary Care Trusts in South East Coast SHA

area

0.0

0.2

0.4

0.6

0.8

1.0

1.2

1.4

1.6

South East

Coast SHA

Brighton and

Hove City

East Sussex

Downs & Weald

Eastern &

Coastal Kent

Hasting &

Rother

Medway Surrey West Kent West Sussex

Primary Care Trust

Pe

rcen

t

Cancer Registry 2006 QOF 2006/07 QOF 2007/08

Source: Quality and Outcomes Framework 2006/07 and 2007/08 and Thames Cancer Registry 2006/07.

Comment:

Though the criteria used to register details of patients are different for the two datasets

(QOF and Cancer Registry), 2006/07 prevalence rates are similar across South East Coast

except for Eastern & Coastal Kent PCT, Hastings & Rother PCT, Medway PCT and West

Kent PCT.

However, comparing 2007/08 Quality and Outcomes Framework (QOF) data with QOF

data for 2006/07 and Registry data for 2006/07, shows a significant increase in cancer

prevalence figures for 2007/08 across South East Coast SHA for all PCTs.

The QOF prevalence figures for 2007/08 reported 52,996 patients with cancer in the

South East Coast SHA area. The prevalence rate in the PCTs varied, from 0.9% in

Medway to 1.4% in East Sussex Downs & Weald. West Sussex, Hastings & Rother and

East Sussex Downs & Weald PCTs prevalence rates were all significantly higher than the

prevalence for South East Coast SHA.

4.2 Primary Care: quality of monitoring indicators (QOF)

This indicator is derived from information within GP records that measure the quality of

the monitoring of patients with cancer. It is a composite of information about the

registration and review of people with cancer and is calculated as the percentage of

practices which achieve the target score for both measures (the threshold for achieving

maximum points for a GP practices).

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Figure 2 Percentage of practices achieving maximum points for Cancer

monitoring by Primary Care Trust in South East Coast SHA area,

2007/08 (with 95% confidence intervals)

95.5 96.1 95.1 98.0 87.9 99.0 96.1 96.275

80

85

90

95

100

Brighton and Hove

City

East Sussex Downs

& Weald

Eastern & Coastal

Kent

Hasting & Rother Medway Surrey West Kent West Sussex

Primary Care Trust

Pe

rce

nt

Percent South East Coast SHA average England average

Source: Quality and Outcomes Framework 2007/08

Cancer monitoring is based on two of the QOF indicators:

Cancer Indicator 1 The practice can produce a register of all cancer patients defined as a

‘register of patients with a diagnosis of cancer excluding non-melanoma skin cancers

from 1 April 2003’.

Cancer indicator 3 The percentage of patients with cancer, diagnosed within the last 18

months who have a patient review recorded as occurring at 6 months after the practice

has received confirmation of the diagnosis.

Comment:

Across South East Coast SHA in 2007/08, 96% of practices achieved the maximum points

for cancer monitoring (Figure 2). This is similar to the England average. At 99%, Surrey

PCT performed significantly better than the England and South East Coast averages. At

88%, Medway PCT performed significantly worse than the South East Coast and England

averages.

Practices should report the number of exceptions for each indicator set and individual

indicator. Exception codes have been added to systems by suppliers. Practices will not be

expected to report why individual patients were exception-reported. However, Practices

may be called on to justify why they have excepted patients from the quality framework

and this should be identifiable in the clinical record.

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Figure 3 Percentage of patients excepted from cancer monitoring target by PCT

in South East Coast SHA area, 2007/08 (with 95% confidence intervals)

5.7 2.4 4.0 3.9 2.9 4.3 3.6 5.20

1

2

3

4

5

6

7

8

9

Brighton and Hove

City Teaching

East Sussex Downs

& Weald

Eastern & Coastal

Kent

Hasting & Rother Medway Surrey West Kent West Sussex

Primary Care Trust

Perc

en

tPercent South East Coast SHA average England average

Source: Quality and Outcomes Framework 2007/08

Comment:

The South East Coast SHA average percentage of patients excepted from cancer

monitoring is higher than the national average (Figure 3). East Sussex Downs & Weald

PCT had a significantly lower percentage of exceptions to the national and South East

Coast average. Brighton and Hove City PCT and West Sussex PCT have a significantly

higher percentage of exceptions compared to England.

5. Lung Cancer

Deaths from cancers of the lung, bowel, breast and prostate together account for 47% of

all cancer deaths. Lung cancer is the most common cause of cancer death in the UK,

accounting for more than 1 in 5 cancer deaths1. Smoking causes 84% of deaths from lung

cancer, and 83% of deaths from chronic obstructive lung disease, including bronchitis2

. The disease burden of lung cancer is significant with over 33,000 deaths per annum in

England and Wales. There are two main types of lung cancer, small-cell lung cancer

(SCLC) and non-small cell lung cancer (NSCLC). The outcomes for lung cancer patients in

the UK are poor in comparison to many other countries and vary widely across the

country3. Treatments for the two types are very different and therefore accurate

histological diagnosis is essential. Surgery is the main curative treatment for NSCLC and

1 http://info.cancerresearchuk.org/cancerstats/mortality/cancerdeaths/

2 Callum C. The UK smoking epidemic: deaths in 1995. London: Health Education Authority, 1998.

3 National Lung Cancer Audit Key findings about the quality of care for people with Lung Cancer in England

and Wales. Report for the audit period 2006. The Information Centre, National Lung Cancer Audit.

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is generally accepted as the treatment of choice for early stage patients provided they

are medically fit. SCLC tends to progress rapidly, with about two-thirds of patients

presenting with extensive disease. It is a systemic condition so surgery is rarely an option

and chemotherapy is usually the treatment of choice.

5.1 Primary Care: Cancer Waiting Times (CWT)

The table shows the rates of referrals for lung cancer split by referral type and whether

the referral was confirmed as cancer.

Table 1 Lung cancer referrals – sensitivity (proportion of cancers referred as

urgent) and specificity (proportion of urgent referrals with cancer) by

PCT 2007/08

Colour coding - Urgent referral cancer

Significantly better than South East Coast SHA

average

Not significantly different to South East Coast SHA

average

Significantly worse than South East Coast SHA

average

Lung

% of cancer cases

urgently referred

% of urgent referrals

with cancer

% cancer cases with

unknown referral

Brighton and Hove City 20.3 9.9 0.0

East Sussex Downs and Weald 48.7 32.3 3.7

Eastern and Coastal Kent 51.6 43.3 7.9

Hastings and Rother 33.6 44.2 1.8

Medway 57.1 48.9 35.1

Surrey 37.8 33.5 22.4

West Kent 49.9 37.1 19.8

West Sussex 45.7 39.6 12.6

South East Coast SHA 45.7 37.2 14.8 Source: Cancer Waiting Times 2007/08

Comment:

Medway PCT had a significantly higher percentage of cancer referrals referred urgently

compared to the South East Coast average while Brighton & Hove City, Hastings &

Rother, and Surrey PCTs, had a significantly percentage than the South East Coast

average.

For some PCTs (Medway and Surrey), a high proportion of cancer cases had an unknown

referral type. This data quality issue should be addressed with providers.

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5.2 Lung cancers treated surgically

It is estimated that 20-30% of patients with non-small cell lung cancer (NSCLC) may be

eligible for radical surgery. In England, surgical resection rates have been much lower,

with a rate of only 9% reported in the 2006 national lung cancer audit report. Five-year

survival rates for early stage patients treated with radical surgery are over 60% and can

be as high as 80% for very early squamous cell carcinomas.

Figure 4 shows the number of surgical resections for lung cancer (taken from HES) per

100 new cases of lung cancer recorded on the cancer register. The chart includes

pneumonectomy and lobectomy procedures (HRG D02). The statistics are not age

standardised.

Figure 4 Lung cancer surgical resection rate (2006/07 and 2007/08) per

registration of non small cell lung cancer 2006/07 by Primary Care Trust

in South East Coast SHA area

5.9 11.0 7.2 7.2 9.2 8.6 12.1 7.10

2

4

6

8

10

12

14

16

Brighton and Hove

Teaching

East Sussex Downs

& Weald

Eastern & Coastal

Kent

Hastings & Rother Medway Teaching Surrey West Kent West Sussex

Primary Care Trust

Rate

per

100

case

s

Rate per 100 cases South East Coast SHA average

Source: Hospital Episode Statistics 2006/07 and 2007/08 and data from Thames Cancer Registry 2006/07

Comment:

The South East Coast SHA surgical resection rate was 8.6 per 100 registrations. The

average resection rate from the National Lung Cancer Audit was 9.0%. West Kent PCT

rate is significantly higher than the SHA rate with 12.1 resections per 100 registrations.

5.3 Lung cancer one year survival rates

Lung cancer has one of the lowest survival outcomes of any cancer because over two-

thirds of patients are diagnosed at a late stage when curative treatment is not possible.

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Earlier diagnosis and referral to specialist teams would make a significant difference to

survival rates. Many lung cancer patients are elderly, with other illnesses making them

unfit for radical treatment, but new surgical techniques may enable more patients with

complex medical problems to benefit from surgery.

In England and Wales the latest figures show around 27% of all lung cancer patients alive

one year after diagnosis falling to only 7% at five years.

Relative survival is the survival probability adjusted for causes of death other than the

specific cancer in question. It is calculated as the ratio of the observed survival to the

expected survival, where expected survival is based on the overall population mortality

rates. Figure 5 shows the trend in one year relative survival rates for people with lung

cancer diagnosed in 1998-2000, 2001-2003 and 2004-2006 by PCT, South East Coast SHA

and England. Figure 6 shows the variation in one year relative survival rates for cases

diagnosed in the time period 2004-2006.

Figure 5 Lung cancer one year relative survival rates by Primary Care Trust in

South East Coast SHA area, cases diagnosed in the periods 1998-2000,

2001-2003, 2004-2006

0

5

10

15

20

25

30

35

40

England* South East

Coast SHA

Brighton and

Hove City

Eastern and

Coastal Kent

East Sussex

Downs and

Weald

Hastings and

Rother


Primary Care Trust

% S

urv

iva

l

1998-2000 2001-2003 2004-2006

Source: The National Cancer Information Service

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Figure 6 Lung cancer one year relative survival rates by Primary Care Trust in

South East Coast SHA area, cases diagnosed in 2004-2006

23.3 24.3 30.1 23.1 23.8 31.2 31.5 26.90

5

10

15

20

25

30

35

40

Brighton and

Hove City

Eastern and

Coastal Kent

East Sussex

Downs and Weald

Hastings and

Rother


Primary Care Trust

% S

urv

ival

% Survival South East SHA average England average


Comment:

Both South East Coast SHA and England have seen significant increases in survival rates

at 1 year between 1998-2000 and 2004-2006; South East Coast SHA has seen the

percentage surviving to 1 year increase from 22.6% to 27.6%. The South East Coast

survival rate is similar to the national rate for cases diagnosed between 2004 and 2006.

Eastern & Coastal Kent PCT had a significantly lower survival rate than the national

average for 2004-2006 cases.

5.4 Participation in National Lung Cancer Audit (LUCADA)

The National Lung Cancer Audit (LUCADA) collects information on referral, diagnosis,

treatment and outcome for people diagnosed with lung cancer or mesothelioma. The aim

of the audit is to describe the range of treatments utilised for lung cancer patients and

explore regional variations in treatments and outcomes. Using data that has been risk-

adjusted for case mix, the audit would have the potential to explain some of the wide

variations found in outcome.

Case ascertainment is the number of cases recorded by Trust first seen compared to the

expected number of cases for 2007.

Table 2 is based on findings reported in the Third Annual Report of the LUCADA and

covers patients first seen in 2007. The overall number of cases submitted to the audit has

grown from approximately 10,000 from England alone in 2005 to more than 26,000

patients from England, Wales and Scotland for the year in question, representing

approximately 75 per cent of the expected number of cases. By the end of June 2008, all

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networks in England, Wales and Scotland were contributing to the audit and only one

trust (in England) had never contributed.

The information on expected number has been obtained from the Cancer Registries,

averaged over the 3 years 2000–2002 and agreed independently by the LUCADA with

each Cancer Network. Trusts are not expected to achieve 100 per cent with perhaps 85-

90 per cent being a realistic expectation. Trusts that have exceeded 100 per cent or

performed poorly may have had service reorganisations that have altered the distribution

of workload since the baseline was undertaken. As this analysis is by place first seen,

work undertaken by tertiary centres may be under-reported.

Table 2 2007 Lung cancer case ascertainment by Hospital Trust

85% and above

Below 85%

Trust name Number of cases

Percentage of

expected

Royal Surrey County Hospital NHS Trust 54 49.5

Ashford and St Peter's Hospitals NHS Trust 43 27

Frimley Park Hospital NHS Foundation Trust 18 15.5

Surrey and Sussex Healthcare NHS Trust 127 81.4

Worthing and Southlands Hospitals 108 77.1

East Sussex Hospitals NHS Trust 221 96.5

Brighton and Sussex University Hospitals 132 52.6

Dartford and Gravesham NHS Trust 87 71.9

Medway NHS Foundation Trust 20 9.8

Maidstone and Tunbridge Wells NHS Trust 171 84.2

East Kent Hospitals NHS Trust 231 61.8

Royal West Sussex NHS Trust 121 112

South Downs Health NHS Trust Not known Source: National Lung Cancer Audit. Report for the audit period 2007.The NHS Information Centre, 2007.

NB: This table has retained the hospital names used within the LUCADA 2007 report to enable comparison with the report.

Comment:

All but one of the South East Coast Trusts (East Sussex Hospitals NHS Trust) had low

levels of participation in the 2007 national lung cancer audit.

Deadline for submission of data for patient first seen in 2008 was 30th June 2009. Data

that was not uploaded in time to be processed for this cut off will not be included in the

next LUCADA Annual Report.

5.5 Issues for consideration by commissioners of lung cancer services:

• How does the overall lung cancer referral rate in your PCT compare to the national

and SHA averages? If the overall rate is higher or lower, is this explained by any

difference in the incidence rate?

• What about the sensitivity (the proportion of cancers that came through the

urgent referral route) and specificity (the proportion of urgent referrals that turn

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out to have cancer) of referrals? Are there clear guidelines for GPs on what should

constitute an urgent referral and are these usually followed?

• How does the lung cancer surgical resection rate compare to national and SHA

averages? Are all patients who might benefit from surgery identified and

discussed at a specialist MDT meeting?

• How do the lung cancer 1 year survival rates compare with the national and SHA

averages? What information is available to help explain any differences (see next

point about participation in LUCADA)?

• Are all acute trusts providing services for patients with lung cancer participating in

LUCADA? As an integral part of participation in the audit, trusts should discuss

the national audit results with their local teams and develop action plans to

improve the quality of care. Local action plans have the potential to convert local

audit data into important changes in practice and thereby close the audit loop.

The implementation of this is the remit of the hospitals, trusts and networks

concerned.

6. Breast Cancer

Breast cancer is the most common cancer in women. Breast cancer incidence rates have

increased by more than 50% over the last twenty-five years. Breast cancer survival rates

have also been improving for more than twenty years. Breast cancer survival rate is

better when the cancer is diagnosed earlier. Around 9 out of 10 women diagnosed with

early stage breast cancer survive beyond five years. This drops to around 1 out of 10

women diagnosed with advanced cancer1.

Many breast cancers are detected by mammography before any symptoms are noticed.

Other signs include breast lumps, change in size or shape of the breast, dimpling of

breast skin, nipple inversion or rash around the nipple.

Currently the National Breast Screening Programme covers women aged 50 to 70, but

over the next few years the age range will be extended to include both younger (47-49

years) and older (71 to 73 years) women. Surgery and radiotherapy are used to control

local disease, and systemic treatments (chemotherapy and /or hormonal therapy) to

combat frank or occult metastatic disease. Systemic treatments may also be

administered as a primary treatment to reduce the size of the tumour prior to surgery.

Nearly all patients, whatever the stage of their disease, have some form of surgery.


The table shows the rates of referrals for breast cancer split by referral type and whether

the referral was confirmed as cancer.

of 31

Table 3 Breast cancer referral – sensitivity (proportion of cancers referred as

urgent) and specificity (proportion of urgent referrals with cancer) by

Primary Care Trust in South East Coast SHA area, 2007/08

Colour coding - Referral cancer

Significantly better than South East Coast SHA average

Not significantly different to South East Coast SHA average

Significantly worse than South East Coast SHA average

Breast

% of cancer

cases urgently

referred

% of urgent

referrals with

cancer

% cancer cases

with unknown

referral





Medway 43.8 12.2 1.2

Surrey 49.3 14.7 17.3

West Kent 49.0 17.3 8.0

West Sussex 46.7 16.8 16.2


Comment:

Eastern & Coastal Kent and Hastings & Rother PCTs had a significantly higher percentage

of cancer referrals referred urgently compared to the South East Coast average. Brighton

& Hove PCT had a significantly lower percentage.

Surrey and West Sussex PCTs had a high proportion of cancer cases where the referral

type was unknown. This data quality issue should be addressed with providers.

6.2 Breast screening coverage

Breast screening coverage rates of over 70% need to be achieved if the benefits of

screening are to be realised at population level.

Figure 7 shows the breast screening population coverage for women aged 53 – 70 yrs by

PCT; the National Standard is 70%. The coverage is the number of women screened in

the last three years as a percentage of the eligible target population.

of 31

Figure 7 NHS Breast Screening Programme: coverage of women aged 53-70 by

Primary Care Trust in South East Coast SHA area, as at 31 March 2008

63.7 72.1 78.7 78.8 80.7 76.9 78.9 76.60

10

20

30

40

50

60

70

80

90

Brighton and

Hove City

East Sussex

Downs and

Weald

Eastern and

Coastal Kent

Hastings and

Rother


Primary Care Trust

Perc

en

tag

eEngland average South East Coast SHA average National Target

Source: KC63 Copyright ©2009, The Health and Social Care Information Centre. All rights reserved.

Comment:

The South East Coast SHA breast screening coverage rate in 2007/08 was 76.7%, which is

above the national standard of 70% and similar to the England average of 76%. Medway,

Hastings & Rother, Eastern & Coastal Kent and West Kent PCTs achieved coverage rates

significantly above the South East Coast average; at 63.7%, Brighton & Hove City PCT

coverage is significantly below the national target.

6.3 Breast cancer five year survival rates

Figure 8 shows five year survival rates for females with breast cancer diagnosed in 1994-

1996, 1997-1999 and 2000-2002 by PCT, South East Coast SHA and England.

Figure 9 shows the variation in five year survival rates for cases diagnosed in the latest

time period 2000-2002. Relative survival is the survival probability adjusted for causes of

death other than the specific cancer in question. It is calculated as the ratio of the

observed survival to the expected survival, where expected survival is based on the

overall population mortality rates.

of 31

Figure 8 Female breast cancer 5 year relative survival rates by Primary Care

Trust in South East Coast SHA area cases diagnosed in 1994-1996,

1997-1999, 2000-2002

0

10

20

30

40

50

60

70

80

90

100

England South East

Coast

Brighton and

Hove City

Eastern and

Coastal Kent

East Sussex

Downs and

Weald

Hastings and

Rother


Primary Care Trust

% S

urv

ival

1994-1996 1997-1999 2000-2002


Figure 9 Female breast cancer 5 year relative survival rates by Primary Care

Trust in South East Coast SHA area, cases diagnosed in 2000-2002

82.1 81.9 82.9 77.8 80.4 86.5 82.9 83.70

10

20

30

40

50

60

70

80

90

100

Brighton and Hove

City

Eastern and

Coastal Kent

East Sussex Downs

and Weald

Hastings and

Rother


Primary Care Trust

% S

urv

iva

l

% Survival England average South East Coast SHA average


Comment:

of 31

Both South East Coast SHA and England have seen significant improvement in five year

survival rates between 1994-1996 and 2000-2002; South East Coast SHA has seen the

percentage surviving to 5 years increase from 74.9% to 83.4%.

6.4 Participation in National Mastectomy and Breast Reconstruction Audit

The National Mastectomy and Breast Reconstruction Audit is funded by the Healthcare

Commission and designed as a four year project. The audit collects information on all

women (aged 16 and over) who undergo mastectomy and/or breast reconstruction

between 1 January and 30 September 2008 in both the NHS and Independent sector. The

first annual report from this audit was published in 2008 and presented the first year’s

work on the project including a pre-audit qualitative study, Hospital Episode Statistics

(HES) analysis and organisational audit. The results of the clinical data collection and

patient reported outcomes study will be reported in subsequent reports.

The aim of the audit is to describe provision of and access to breast reconstruction in

England and Wales. Evaluate current clinical practice in mastectomy and breast

reconstruction and measure outcomes following mastectomy with or without

reconstruction and assess the quality of information provided to women undergoing

mastectomy and their satisfaction with the reconstructive choices made.

To enable this, three additional pieces of work were performed in 2007 to investigate

those aspects not easily addressed through prospective data collection:

• a qualitative study of interviews with 30 stakeholders

• an organisational survey of 144 NHS Trusts (93 per cent response rate) and 43

private hospitals (88 per cent response rate)

• a retrospective analysis of the Hospital Episode Statistics (HES) dataset between

1997-2006

Submission of data is one of the indicators in the Healthcare Commission's Annual Health

Check.

of 31

Table 4 Participation in National Mastectomy and Breast Reconstruction

Audit by Trust

Hospital name

Organisational

audit

Prospective

audit

ASHFORD AND ST PETER'S HOSPITALS NHS TRUST Y

BRIGHTON AND SUSSEX UNIVERSITY HOSPITALS Y

DARTFORD AND GRAVESHAM NHS TRUST Y

EAST KENT HOSPITALS NHS TRUST

EAST SUSSEX HOSPITALS NHS TRUST Y

FRIMLEY PARK HOSPITAL NHS FOUNDATION TRUST Y

MAIDSTONE AND TUNBRIDGE WELLS NHS TRUST Y

MEDWAY NHS Foundation Trust

ROYAL SURREY COUNTY HOSPITAL NHS TRUST Y

ROYAL WEST SUSSEX NHS TRUST Y

SOUTH DOWNS HEALTH NHS TRUST

SURREY AND SUSSEX HEALTHCARE NHS TRUST Y

WORTHING AND SOUTHLANDS HOSPITALS Y

Source: First Annual Report of the National Mastectomy and Breast Reconstruction Audit 2008, The NHS Information Centre, 2008.

Comment:

Ten South East Coast Trusts participated in the organisational audit.

Prospective clinical data will be reported at national level and by NHS Trust and

independent hospitals in the second Annual Report which will be available in Autumn

2009. The 2nd report will also describe patterns of care and outcomes using a linked

Hospital Episode Statistics and Cancer Registry database provided by the UK Association

of Cancer Registries. Data from the three and eighteen month questionnaires is expected

to be reported in the Audit’s third (2010) and fourth (2011) Annual Reports.

6.5 Future breast cancer indicator

Access to sentinel node biopsy

NICE recommends that for all patients undergoing primary surgical treatment for

invasive breast cancer, axillary staging should be by minimal surgery rather than node

clearance. If pre-operative evaluation of the axilla shows no evidence of metastases,

sentinel lymph node biopsy (SLNB) is the preferred option. SLNB should be performed

using the dual technique with isotope and blue dye.

The ALMANAC trial and other studies have shown that sentinel node biopsy does not

lead to higher local recurrence rates and gives fewer long term problems than lymph

node sampling or clearance. The chance of arm swelling, arm and shoulder weakness

and arm and shoulder numbness are much lower after sentinel lymph node biopsy.

of 31

A preliminary analysis of 2006/7 HES data compared to cancer registry data showed

incomplete recording of sentinel node procedures. Further work will be undertaken on

2007/8 HES data, with the intention of using sentinel node biopsy rates as an indicator in

future reports.

6.6 Issues for consideration by commissioners of breast cancer services

• How does the overall referral rate in your PCT compare to the national and SHA

averages? If the overall rate is higher or lower, is this explained by any differences

in the incidence rate?





• How does the breast screening coverage rate compare to national and SHA

averages? Are low coverage figures explained by low uptake or slippage on the

screening round interval or a combination of both?

• How does the breast cancer 5 year survival rate compare with the national and

SHA averages? How can any differences be explained?

• Are all local acute trusts providing services for patients with breast cancer

participating in the National Mastectomy and Breast Reconstruction audit? As an

integral part of participation in the audit, trusts should discuss the national audit

results with their local teams and develop action plans to improve the quality of

care. Local action plans have the potential to convert local audit data into

important changes in practice and thereby close the audit loop. The

implementation of this is the remit of the hospitals, trusts and networks

concerned.

7. Colorectal Cancer

Colorectal (bowel) cancer incidence rates have remained relatively stable for over a

decade. Around half of people diagnosed with bowel cancer survive for at least five years

after diagnosis. Research suggests that over 80% of bowel cancer patients will survive for

more than five years if diagnosed at the earliest stage. The NHS Bowel Screening

Programme began in England in 2006 and is currently being rolled out across the country.

There could be up to 20,000 fewer deaths from bowel cancer over the next 20 years if

even 60% of those eligible took up the invitation for bowel screening.

The presenting features of colon cancer are often non-specific, such as weight loss and

anaemia due to occult blood loss. Rectal and distal colon cancers, on the other hand,

usually present with bleeding and/or altered bowel habits, symptoms that overlap with

less serious but more common conditions. A fifth of patients may present with acute

bowel obstruction or peritonitis due to bowel perforation.

of 31

Colorectal cancer can often be treated successfully, particularly if the cancer is diagnosed

and treated early. Surgery to remove the tumour is the main treatment used, with around

80% of patients undergoing surgery. Radiotherapy or chemotherapy is also given to

some patients.


The table shows the rates of referrals for lower gastrointestinal cancer split by referral

type and whether the referral was confirmed as cancer. The majority of these cancers are

colorectal.

Table 5 Lower gastrointestinal cancer referrals – sensitivity (proportion of

cancers referred as urgent) and specificity (proportion of urgent

referrals with cancer) by Primary Care Trust in South East Coast SHA

area, 2007/08

Colour coding – Urgent referral cancer: Colour coding - Referral cancer

Significantly better than South East Coast SHA average

Not significantly different to South East Coast SHA average

Significantly worse than South East Coast SHA average

% of cancer cases

urgently referred

% of urgent

referrals with

cancer

% cancer cases

with unknown

referral





Medway 42.2 9.9 1.9

Surrey 48.0 11.1 22.0

West Kent 43.8 12.6 4.3

West Sussex 39.9 11.9 13.4


Comment:

Eastern & Coastal Kent PCT had a significantly higher percentage of cancer referrals

referred urgently compared to the South East Coast average rate, and Brighton & Hove

PCT had a significantly lower percentage.

For some PCTs (Surrey and West Sussex), a high proportion of cancer cases had an

unknown referral type. This data quality issue should be addressed with providers.

7.2 Colorectal cancer emergency inpatient admissions

Nationally about a fifth of patients who undergo surgery for colorectal cancer are

admitted as emergencies. Evidence has shown that the mortality rate in this group was

four times higher than among those who underwent elective surgery (21.7% for

of 31

emergency/urgent surgery, versus 5.5% for scheduled/elective procedures). Patients who

present as emergencies are likely to have experienced symptoms for about three weeks;

in up to a quarter of cases, symptoms may have been present for three months before

admission. Comparisons between parts of Europe show that higher emergency

admission rates and poorer survival rates are both typical of places where colon cancer is

diagnosed at a later stage.

Figure 10 Colorectal cancer emergency inpatient hospital admissions by Primary

Care Trust in South East Coast SHA area, 2007/08

24.0 14.7 13.6 22.6 25.4 17.9 15.8 16.60

5

10

15

20

25

30

35

Brighton and

Hove City

Teaching

East Sussex

Downs and

Weald

Eastern and

Coastal Kent

Hastings and

Rother


Primary Care Trust

Ag

e S

tan

dard

ise

d r

ate

pe

r 10

0,0

00

South East Coast SHA England average

Source: Hospital Episode Statistics, NHS Health & Social Care Information Centre

Comment:

The rate of emergency inpatient admissions to hospital in South East Coast SHA, at 21.2

per 100,000 population was higher than the rate for England. None of the PCTs had a

significantly higher rate than either South East Coast or England average. Eastern &

Coastal PCT and East Sussex Downs & Weald PCT had significantly lower rates.

7.3 Rectal cancer surgical procedures

There are several different surgical approaches to surgical treatment of rectal cancer, the

most common of which used to be Abdomino Perineal Excision (APE). This involves the

removal of the anal sphincter and necessitates the permanent use of a colostomy bag.

APE is unavoidable in some patients but evidence suggests that it should not now be the

treatment of choice for most patients as other procedures such as Anterior Resection

(AR) which avoid the need for a permanent colostomy are preferable. APE is also

associated with higher rates of recurrence and poorer survival than anterior resection.

The Department of Health has published guidance, encouraging surgeons, wherever

possible, to use alternative methods and adopt AR, rather than APE. Research published

of 31

recently by the Northern and Yorkshire Cancer Registry and Information Service

(NYCRIS) suggested a wide variation in practice across England.

The NYCRIS analysis used a linked cancer registry-HES file. This chart updates the

NYCRIS analysis using unlinked HES data for 2007/08. A further update will be planned

when a new cancer registry-HES linked file is available in 2009. Figure 11 shows the

proportion of surgical procedures by Trust, categorised as abdominoperineal excision

(APE), anterior resection (AR), Hartmanns procedures and other.

Figure 11 Proportion of rectal cancer surgical procedures by category and

Hospital Trust in South East Coast SHA area, 2007/08

0

10

20

30

40

50

60

70

80

90

100

Royal Surrey

County

Hospital

Frimley Park

Hospital

Dartford

and

Gravesham

Medway

Foundation

Worthing

and

Southlands

Hospitals

Royal West

Sussex

Ashford and

St Peter's

Hospitals

Surrey and

Sussex

Healthcare

East Kent

Hospitals

Maidstone

and

Tunbridge

Wells

East Sussex

Hospitals

Brighton

and Sussex

University

Hospitals

Primary Care Trust

Pe

rce

nta

ge

APE AR Hartmann's Other

Source: Hospital Episode Statistics, NHS Health & Social Care Information Centre

Comment:

Trusts across South East Coast SHA show wide variation. Five Acute Trusts currently have

the highest proportion of APEs recorded (East Sussex Hospital, East Kent Hospital,

Brighton & Sussex University Hospitals, Worthing & Southlands Hospitals and Royal West

Sussex Hospital).

There may be problems with the quality of the coding of surgical procedures on HES in

some Trusts. There may also be differences in case mix which cannot be allowed for in

the above analysis. One of the aims of the National Bowel Cancer Audit (see section 7.5)

is to publish risk adjusted abdominoperineal excision rates by Trust.

7.4 Colorectal cancer three year survival rates

Figure 12 shows three year survival rates for people with colorectal cancer diagnosed in

1996-1998, 1999-2001 and 2002-2004 by PCT, South East Coast SHA and England.

of 31

Figure 13 shows the variation in three year survival rates for cases diagnosed in the latest

time period 2004-2006. Relative survival is the survival probability adjusted for causes of

death other than the specific cancer in question. It is calculated as the ratio of the

observed survival to the expected survival, where expected survival is based on the

overall population mortality rates.

Figure 12 Colorectal cancer 3 year relative survival rates by Primary Care Trust in

South East Coast SHA area, cases diagnosed in the periods 1996-1998,

1999-2001 and 2002-2004

0

10

20

30

40

50

60

70

England South East

Coast

Brighton and

Hove City

Eastern and

Coastal Kent

East Sussex

Downs and

Weald

Hastings and

Rother


Primary Care Trust

% S

urv

ival

1996-1998 1999-2001 2002-2004


Figure 13 Colorectal cancer 3 year relative survival rates by Primary Care Trust in

South East Coast SHA area, cases diagnosed in 2002-2004

51.1 51.6 49.8 57.8 57.7 52.8 60.359.90

10

20

30

40

50

60

70

Brighton and

Hove City

Eastern and

Coastal Kent

East Sussex

Downs and

Weald

Hastings and

Rother


Primary Care Trust

% S

urv

ived

England average South East Coast SHA average


of 31

Comment:

South East Coast SHA three year survival rates for colorectal cancer have significantly

improved between 1996-1998 and 2002-2004, improving to 56% surviving for three

years. The 2002-2004 three year survival rate for South East Coast is significantly lower

than the national rate of 58%. Brighton & Hove, Eastern & Coastal Kent, Hastings &

Rother and West Kent PCTs had significantly lower survival rates compared to the

national average for 2002-2004.

7.5 Participation in the National Bowel Cancer Audit (NBOCAP)

The primary aims of the National Bowel Cancer Audit (NBOCAP) are to investigate

whether the care received by people with bowel cancer is consistent with national and

professional body guidelines and to identify areas where improvements can be made. In

England, data on participation in the audit is supplied to the Healthcare Commission and

used in the ‘Annual Health Check’. The NBOCAP is now commissioned by the Healthcare

Quality Improvement Partnership (HQIP) which took over responsibility for the National

Clinical Audit and Patients Outcomes Programme from the Healthcare Commission in

April 2008. The NBOCAP is run jointly by the NCASP, in the NHS Information Centre, and

the Association of Coloproctology of Great Britain and Ireland (ACPGBI).

Data from the NBOCAP can be used to measure performance against national standards,

set future guidance and monitor outcomes. As part of the NBOCAP, the NCASP has

produced a Local Action Plan (LAP) toolkit to help support Cancer Networks in

converting national audit data into changes in clinical practice and outcomes. This LAP

toolkit can be used to identify areas of data collection and clinical practice that may fall

below national standards and need improvement. LAPs will be linked to both Peer

Review and the Annual Health Check in the near future. There is also potential for using

the results in conjunction with the Clinical Negligence Scheme for Trusts (CNST).

The 2007 full audit report includes cases diagnosed from 31 March 2004 to 1 April 2006;

case ascertainment and data completeness has been based on the 2005-2006 data only.

Case ascertainment has been calculated using the Cancer Wait Times submission

numbers for England. Data completeness has been calculated by looking at the amount

of missing data from the five variables comprising the Association of Coloproctology’s

mortality model, which adjusts for case-mix, and expressing this as a percentage of

missing data. Case ascertainment and data quality for trusts has been divided into three

categories, using a ‘traffic light’ system.

of 31

Grade

Data completeness

Data quality

Good >80% completeness <20% missing

Fair 50-80% completeness 20-50% missing

Poor <50% completeness >50% missing

Table 6 Participation in NBOCAP 2005 and 2006, Case Ascertainment 2006 and

Quality of Data 2006 by Hospital Trust in South East Coast SHA area

Participation

Case

ascertainment

2006

Data

quality

2006

Trust Name 2005 2006

ASHFORD AND ST PETER'S HOSPITALS NHS

TRUST x x

BRIGHTON AND SUSSEX UNIVERSITY

HOSPITALS NHS TRUST x Y

DARTFORD AND GRAVESHAM NHS TRUST Y x

EAST KENT HOSPITALS NHS TRUST x x

EAST SUSSEX HOSPITALS NHS TRUST Y x

FRIMLEY PARK HOSPITAL NHS

FOUNDATION TRUST x x

MAIDSTONE AND TUNBRIDGE WELLS NHS

TRUST x x

MEDWAY NHS TRUST x x

ROYAL SURREY COUNTY HOSPITAL NHS

TRUST x x

ROYAL WEST SUSSEX NHS TRUST Y Y

SURREY AND SUSSEX HEALTHCARE NHS

TRUST x x

WORTHING AND SOUTHLANDS HOSPITALS

NHS TRUST Y Y

Source: The National Bowel Cancer Audit Project 2007 Full Annual Report, NHS Information Centre, 2008

Comment:

All South East Coast Trusts should be contributing to the national audit.

Only one South East Coast Trust (Royal West Sussex NHS Trust) met the 80% standard

for both data completeness and data quality. Nine Trusts (Ashford & St Peters, Dartford

& Gravesham, East Kent, East Sussex, Frimley Park, Maidstone & Tunbridge Wells,

Medway, Royal Surrey County and Surrey & Sussex hospitals) did not participate in the

2006 audit.

No full audit report was published for 2008 as there were issues around the analysis. Only

a Public and Executive Summary was published in February 2009 that does not include

Trust based data. The 2008 Public and Executive Summary can be accessed from the IC

website (www.ic.nhs.uk/webfiles/Services/NCASP/Cancer). The data on cases diagnosed

between August 2007 and July 2008 that would have been included in the 2008 Annual

Report has been included in the 2009 Annual Report which is due to be published in

October 2009.

of 31

7.6 Issues for consideration by commissioners of colorectal cancer services

• How does the overall colorectal cancer referral rate in your PCT compare to the

national and SHA averages? If the overall rate is higher or lower is this explained

by any differences in the incidence rate?





• How does the colorectal cancer emergency admission rate compare to national

and SHA averages? A higher emergency admission rate might indicate a higher

proportion of patients presenting with late stage cancer and the reasons for this

should be investigated.

• How does the acute trust abdomino-perineal excision (APE) rate for rectal cancer

compare to the national and SHA averages? If the rate is high, the reasons for this

should be investigated, including reviewing the quality of the coding of surgical

procedures on HES and the impact of case mix.

• How does the colorectal cancer 3 year survival rate compare with the national and

SHA averages? How can any differences be explained?

• Are all acute trusts providing services for patients with colorectal cancer

participating in the National Bowel Cancer Audit? As an integral part of

participation in the audit, trusts should discuss the national audit results with their

local teams and develop action plans to improve the quality of care. Local action

plans have the potential to convert local audit data into important changes in

practice and thereby close the audit loop. The implementation of this is the remit

of the hospitals, trusts and networks concerned.

of 31

Appendix 1

Exceptions permitted from the QOF reporting

The Quality and Outcomes Framework includes the concept of exception reporting. This has

been introduced to allow practices to pursue the quality improvement agenda and not be

penalised, where, for example, patients do not attend for review, or where a medication cannot

be prescribed due to a contraindication or side-effect.

The following criteria have been agreed for exception reporting:

A) Patients who have been recorded as refusing to attend review who have been invited on

at least three occasions during the preceding twelve months

B) Patients for whom it is not appropriate to review the chronic disease parameters due to

particular circumstances e.g. terminal illness, extreme frailty

C) Patients newly diagnosed within the practice or who have recently registered with the

practice, who should have measurements made within three months and delivery of

clinical standards within nine months e.g. blood pressure or cholesterol measurements

within target levels

D) Patients who are on maximum tolerated doses of medication whose levels remain sub-

optimal

E) Patients for whom prescribing a medication is not clinically appropriate e.g. those who

have an allergy, another contraindication or have experienced an adverse reaction

F) Where a patient has not tolerated medication

G) Where a patient does not agree to investigation or treatment (informed dissent), and this

has been recorded in their medical records

H) Where the patient has a supervening condition which makes treatment of their condition

inappropriate e.g. cholesterol reduction where the patient has liver disease

I) Where an investigative service or secondary care service is unavailable.

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