Colorectal Liver Metastases questionnaire results

Ewen Harrison Consultant HPB Surgeon

Royal Infirmary Edinburgh Professor of Surgery and Data Science Director Centre Medical Informatics,

University of Edinburgh

Colorectal cancer

• 3rd most common cancer men and women in Scotland (2017, NSD).

• >50% develop liver metastases.

• Liver resection the treatment of choice.

• Resection provides a potential curative treatment – 5-year survival 40-60%.

Overall Pathology: Edinburgh data

Pre-op aetiology

2018 Malignant

Final pathology

Open or Laparoscopic

Liver resection morbidity & mortality

Colorectal liver metastases: The ‘lost’ patients

• No reliable information on number with CRLM and management.

• No outcome measures

• No standardisation of care

• Likely variation in practice and outcomes for this group of patients

SHPBN Education event Jan 2019

• Colorectal colleagues participated

– surgeons, oncologists, radiologists and CNS.

• Excellent participation and break out session to discuss how to move forward with the formation of a colorectal Liver metastases Collaborative under the SHPBN umbrella.

CRCLM Collaborative

Consensus

• We need to ensure that there is both equitable and consistent referral of colorectal liver metastases patients into HPB MDTs and that once reviewed there is standardized treatment and outcomes for these patients across HPB units in Scotland.

ACTION 1. PROSPECTIVE 3-MONTH SNAPSHOT AUDIT ACROSS COLORECTAL MDTS

What number of patients with CRLMs are being discussed in Colorectal MDTs and are they being discussed with HPB teams?

3- Month prospective snapshot audit across CR MDTs

• Aim: To determine the number of patients with colorectal liver metastases (CRLM) being discussed and referred to hepatobiliary (HPB) services.

• Methods: The questionnaire was sent to each colorectal MDT across 14 health boards

1st March- 31st May 2019

12 colorectal MDTs across the three

networks contributed

Health boards / hospitals who contributed

• 93 MDT meetings took place over which a total of 169 new colorectal liver metastases were discussed:

119 Synchronous

50 metachronous

• Median 2 New CRLM discussed per MDT meeting(including synchronous and metachronous)

• HPB surgeon was not present at the meeting: 86.9%

• Total number referred to the HPB MDT: 26.6% (45/169)

Number of patients referred to an HPB MDT from each

hospital: Clear Geographical variation

Main reason for not referring to HPB MDT: Lesion was felt to be not operable 31.9%

ACTION 2. CONSIDER QUALITY PERFORMANCE INDICATORS (QPIS) FOR CRLMS

Currently there are no Quality Performance Indicators for this group of patients that are lost between the colorectal and HPB data collection.

Consider QPIs in both the Colorectal and HPB data sets

Multidisciplinary Short Life Working Group

Propose the introduction of two QPIs: 1. Colorectal data set 2. HPB data set

QPI in the Colorectal Data set

“All patients will a new diagnosis of colorectal liver metastases should be referred to an HPB MDT”

Consider an appropriate target, exclusions and inclusions e.g.

• Target 95%

• Inclusions: All patients with colorectal liver metastases

• Exclusions:

Primary CRC not resectable

Comorbidity precludes surgery

Extra hepatic metastases (excluding pulmonary)

Patient choice

Introduction of this QPI would be in keeping with the NICE guidelines in England: NICE Colorectal guidance CG131 1.3.2 If the CT scan shows metastatic disease only in the liver and the patient has no contraindication to further treatment a specialist hepatobiliary MDT should decide if further imaging to confirm surgery is suitable for the patient – or potentially suitable after further treatment – is needed (2011)

Essential to Include both Synchronous & Metachronous CRLM

• Tracking synchronous metastases more

straightforward • Metachronous requires more thought as

currently recurrence is not included in QPIs. • Discussion with David Morrison, Director of

Cancer Registry who is leading on National work with regards to recurrence data – supportive of including the metachronous lesions and

did not feel this would pose a significant problem.

The Audit Identifies

1. The workload for data managers is realistic and should not impact on data collectors and analysis greatly

2. Currently decision on operability of liver metastases is being made in the absence of an HPB surgeon.

3. Geographical variation in the number of CRLM referred to an HPB MDT

Summary (1) • CRLM patients are a lost group of patients in

Scotland

• Current outcomes for CRC in UK are lower than other countries

• Numbers of patients in Scotland going forward to liver resection is lower than in other countries.

Summary (2) • We need to standardise care pathways

across the country and collect data on this group of patients.

• Introduction of QPIs across Colorectal and HPB can positively impact on care

• Supported by

MCNs: WoSCAN, NoSCAN & SCAN

Health Improvement Scotland

NSD