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Audit Report Cervical Cancer Quality Performance Indicators

Endometrial Cancer Quality Performance Indicators

Clinical Audit Data: 01 October 2016 to 30 September 2017

Kevin Burton Consultant Gynaecological Oncologist MCN Clinical Lead Kevin Campbell MCN Manager Julie McMahon Information Officer

West of Scotland Cancer Network Gynaecological Cancer Managed Clinical Network

West of Scotland Cancer Network Final Published Endometrial & Cervical Cancer QPI Audit Report V1.0 23/08/2018

2

CONTENTS

EXECUTIVE SUMMARY 3

1. INTRODUCTION 7

2. BACKGROUND 7

3. METHODOLOGY 8

4. RESULTS AND ACTION REQUIRED 9

4.1 PERFORMANCE AGAINST QUALITY PERFORMANCE INDICATORS (QPIS) 9

4.2. ENDOMETRIAL CANCER – QUALITY PERFORMANCE INDICATORS 10

4.3. CERVICAL CANCER – QUALITY PERFORMANCE INDICATORS 19

5. CONCLUSIONS 29

ACKNOWLEDGEMENT 30

ABBREVIATIONS 31

REFERENCES 32

APPENDIX 1: ACTION / IMPROVEMENT PLANS 34


3

Executive Summary

Introduction This report contains an assessment of the performance of West of Scotland (WoS) gynaecology cancer services using clinical audit data relating to patients diagnosed between 1 October 2016 and 30 September 2017. Twelve months of data were measured against the Endometrial and Cervical Cancer QPIs for the third consecutive year. Previous years' results are presented within this audit report for QPIs where results have remained comparable. In order to ensure success of the National Cancer QPIs in driving quality improvement in cancer care across NHS Scotland it is critical that QPIs continue to be clinically relevant and focus on areas which will result in improvements to the quality of patient care. As part of the national process it was agreed that indicators would be formally reviewed following the availability of 3 years of comparative reporting. This clinically led review aims to identify potential refinements to the current QPIs and involves key clinicians from each of the Regional Cancer Networks. The review of endometrial and cervical cancer QPIs began in June 2018 and the output of the review will be communicated in due course. Background Treatment and care for gynaecological cancer patients is delivered by a single regional multi-disciplinary team (MDT). This is facilitated by video-conferencing technology and a bespoke IT system, which is operationally dependant on close collaboration of professionals from a range of clinical specialities across the region to provide well planned and coordinated delivery of treatment and care. Complex gynaecological malignancy often requires a multi-modality approach and surgery remains a key component of effective curative management. 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 1 October 2016 and 30 September 2017 was downloaded from eCASE on 11 April 2018. Analysis was performed centrally by the West of Scotland Cancer Network (WoSCAN) Information Team.

Results Results for each QPI are shown in detail in the main report and illustrate Board performance against targets and overall WoS performance for each quality 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. The following summary of results shows the WoS and individual units’ percentage performance against each QPI target.


Endometrial Performance Summary Report

Endometrial Performance by Board

QPI Target WoS A&A FV Lan Glasgow

North Glasgow

South Clyde

QPI 1 - Radiological Staging. Patients with endometrial cancer should have their stage of disease assessed by magnetic resonance imaging (MRI) and/or computed tomography (CT) prior to first treatment.

90% 95.4%

>

97.4%

>

90.0%

<

93.5%

>

93.8%

<

100%

>

100%

>

187 196 37 38 27 30 29 31 45 48 23 23 26 26

QPI 2 - Multidisciplinary Team Meeting (MDT). Patients with endometrial cancer should be discussed by a multidisciplinary team (MDT) prior to definitive treatment.

95% 95.8%

>

97.3%

>

89.3%

<

93.3%

=

97.9%

>

95.7%

>

100%

>

183 191 36 37 25 28 28 30 46 47 22 23 26 26

QPI 3 - Total Hysterectomy and Bilateral Salpingo-Oophorectomy. Patients with endometrial cancer should undergo total hysterectomy (TH) and bilateral salpingo-oophorectomy (BSO).

80% 91.6%

>

88.1%

<

87.8%

>

89.5%

<

92.8%

>

97.1%

>

97.8%

>

295 322 59 67 43 49 51 57 64 69 34 35 44 45

QPI 4 - Laparoscopic Surgery (Hosp. of Surgery) Patients with endometrial cancer undergoing definitive surgery should undergo laparoscopic surgery, where clinically appropriate.

70% 63.5%

>

75.0%

>

90.3%

>

89.1%

<

50.5%

>

41.9%

>

48.7%

>

193 304 39 52 28 31 41 46 53 105 13 31 19 39

*QPI 5 - Adjuvant Vaginal Brachytherapy. Patients with intermediate risk (stage IB, grade 1 or 2; or stage IA, grade 3 endometrioid or mucinous) endometrial cancer should be considered for adjuvant vaginal brachytherapy.

90% 89.8%

>

100%

>

100%

>

90.9%

>

88.9%

=

- 40.0%

<

44 49 11 11 9 9 10 11 8 9 - - 2 5

*QPI 6 – Chemotherapy. Patients with stage IV endometrial cancer should have chemotherapy.

75% 38.9%

<

- - - - - -

7 18 - - - - - - - - - - - -

‘-‘ Data not shown due to small numbers (denominator less than 5).


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Cervical Performance Summary Report

Cervical Cancer Performance by Board

QPI Target WoS A&A FV Lan NG SG Clyde

QPI 1 - Radiological Staging. Patients with cervical cancer should have their stage of disease assessed by magnetic resonance imaging (MRI) prior to first treatment.

95% 97.8%

>

100%

=

100%

>

100%

>

95.0%

<

80.0%

<

100%

=

91 93 11 11 17 17 29 29 19 20 4 5 11 11

QPI 2 - Positron Emission Tomography/Computed Tomography (PET/CT). Patients with cervical cancer, for whom primary definitive surgery is not appropriate, should undergo positron emission tomography - computed tomography imaging (PET/CT).

95% 94.4%

<

100%

=

100%

=

87.5%

<

100%

>

- 85.7%

=

51 54 8 8 9 9 14 16 12 12 - - 7 8

QPI 3 - Multidisciplinary Team Meeting (MDT). Patients with cervical cancer should be discussed by a multidisciplinary team (MDT) prior to definitive treatment.

95% 98.0%

>

100%

=

100%

=

96.7%

>

100%

>

100%

>

91.7%

<

97 99 12 12 17 17 29 30 22 22 6 6 11 12

*QPI 4 - Radical Hysterectomy. Patients with stage IB1 cervical cancer should undergo radical hysterectomy.

85% 83.3%

>

- - 81.8%

>

85.7%

>

-

60.0%

<

25 30 - - - - 9 11 6 7 - - 3 5

*QPI 5 - Surgical Margins. (Hosp. of Surgery) Patients with surgically treated cervical cancer should have clear resection margins.

95% 97.6%

=

n/a - 87.5%

>

100%

=

- n/a

40 41 0 0 - - 7 8 29 29 - - 0 0

*QPI 6 - 56 Day Treatment Time for Radical Radiotherapy. Treatment time for patients with cervical cancer undergoing radical radiotherapy should be no more that 56 days.

90% 100%

=

100%

=

100%

=

100%

=

100%

=

- 100%

=

61 61 8 8 10 10 18 18 13 13 - - 11 11

*QPI 7 – Chemoradiation. Patients with cervical cancer undergoing radical radiotherapy should receive concurrent platinum-based chemotherapy.

70% 85.2%

<

100%

=

70.0%

<

88.9%

>

92.3%

>

- 72.7%

<

52 61 8 8 7 10 16 18 12 13 - - 8 11

‘-‘ Data not shown due to small numbers (denominator less than 5).


Conclusions and Action Required 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. Following the development of QPIs, this has now become an established national programme to drive continuous improvement and ensure equity of care for patients across Scotland.

Overall results from the third year of endometrial and cervical cancer QPI reporting are encouraging; case ascertainment and data capture is of a high standard. In endometrial cancer, targets relating to radiological staging and total hysterectomy and bilateral salpingo-oopherectomy were met by all boards. For cervical cancer targets relating to Multidisciplinary Team (MDT) discussion, 56 day treatment time for radical radiotherapy and chemoradiation were consistently met by all units. However, some of the QPI targets set have been challenging for NHS Boards to achieve. There remains room for further service improvement around a number of areas, including: laproscopic surgery for endometrial cancer patients and chemotherapy for stage IV endometrial cancer patients. Where QPI targets were not met, the majority of NHS Boards have provided detailed commentary. In the main these indicate valid clinical reasons or that, in some cases, patient choice or co-morbidities have influenced patient management. NHS Boards are encouraged to continue with this proactive approach of reviewing data and addressing issues as necessary, in order to work towards increasingly advanced performance against targets, and demonstration of overall improvement in quality of the care and service provided to patients. The MCN will actively progress regional actions identified, NHS Boards are asked to develop local Improvement Plans in response to the findings presented in the report, and detailed within the appropriate NHS Board Action Plan templates in Appendix 1. Actions: Endometrial QPI 4 – Laparoscopic Surgery

NHSGGC to determine resource and training requirements for laparoscopic surgery and feedback to the MCN.

Cervical QPI 4 – Radical Hysterectomy

NHSGGC to provide detailed feedback on the outcome of the ongoing review. 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.


7

1. Introduction This report contains an assessment of the performance of West of Scotland (WoS) gynaecology cancer services using clinical audit data relating to patients diagnosed between 1 October 2016 and 30 September 2017. Data analysed and included within this report relate to cervical and endometrial cancers. 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 Endometrial and Cervical Cancer Quality Performance Indicators (QPIs). Data definitions and measurability criteria to accompany cancer QPIs are available from the ISD website2. Twelve months of data were measured against the endometrial and cervical cancer QPIs for the third consecutive year, and previous years' results are presented within this audit report for QPIs where results have remained comparable. Future reports will continue to compare clinical audit data in successive years to further illustrate trend analysis. In order to ensure success of the National Cancer QPIs in driving quality improvement in cancer care across NHS Scotland it is critical that QPIs continue to be clinically relevant and focus on areas which will result in improvements to the quality of patient care. As part of the national process it was agreed that indicators would be formally reviewed following the availability of 3 years of comparative reporting. This clinically led review aims to identify potential refinements to the current QPIs and involves key clinicians from each of the Regional Cancer Networks. The review of endometrial and cervical cancer QPIs began in June 2018 and the output of the review will be communicated in due course.

2. Background

Treatment and care for gynaecological cancer patients is delivered by a single regional multi-disciplinary team (MDT). This is facilitated by video-conferencing technology and a bespoke IT system, which is operationally dependant on close collaboration of professionals from a range of clinical specialities across the region to provide well planned and coordinated delivery of treatment and care. Complex gynaecological malignancy often requires a multi-modality approach and surgery remains a key component of effective curative management. 2.1. National Context Endometrial cancer is the most common gynaecological cancer and the fourth most common cancer in women in Scotland with approximately 780 new cases diagnosed annually. The incidence of endometrial cancer has risen significantly by 33% over the last ten years3. This undoubtedly reflects increasing levels of obesity4 and also an increasingly ageing population. Recently published data highlights that the number of new cases of endometrial cancer is predicted to increase by 55% between 2008-2012 and 2023-20275.

One-year and 5-year relative survival rates for endometrial cancer for females diagnosed between 2007 and 2011 are 92.9% and 83.2% respectively3. Endometrial cancer is the 10th most common death in females from cancer in Scotland with overall mortality rates increasing by 70.9% from 2006 to 20164. Cervical cancer is noted as being the eleventh most common cancer in women with approximately 340 cases diagnosed each year3. The incidence of cervical cancer has increased by 19% over the last ten years3. Overall mortality rates have decreased by 2.1% over the past 10 years from 2006 to 2016 and 1-year and 5-year relative survival is noted as being 87.5% and 73% respectively3. Recently published figures indicate that the number of new cases of cervical cancer is predicted to increase by 39.6% between 2008-2012 and 2023-20275.


8

Many cervical cancers are detected early due to the well established screening programme introduced in 1988. The Human Papilloma Virus (HPV) vaccine is designed to protect against certain high risk types of HPV that are responsible for approximately 70% of cervical cancer cases. The vaccination programme started in Scotland on 1st September 2008 and aims to protect females by routinely immunising them at 12-13 years of age, through a school based programme. Progression from HPV infection to cervical cancer can take many years, therefore surveillance to monitor the impact of the vaccination programme will be a long term undertaking.

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 endometrial or cervical cancer between 1 October 2016 and 30 September 2017 was downloaded from eCASE at 2200 hrs on 11 April 2018. 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.


9

4. Results and Action Required

4.1 Performance against Quality Performance Indicators (QPIs) Results of the analysis of endometrial and cervical QPIs are set out in the following section. Graphs and charts have been provided where this aids interpretation and, where appropriate, numbers have also been included to provide context. Where possible, results for patients diagnosed in previous years have been presented alongside the previous years’ results to illustrate trends. Data (both graphically and in tabular format) are presented by location of diagnosis or treatment, with some criteria given as an overall WoS representation. Specific regional and NHS Board actions have been identified to address issues highlighted through the data analysis. Where the number of cases meeting the denominator criteria for any indicator is between one and four, the percentage calculation has not been shown on any associated charts or tables. This is to avoid any unwarranted variation associated with small numbers and to minimise the risk of disclosure. Any charts or tables impacted by this are denoted with a dash (-). Any commentary provided by NHS Boards relating to the impacted indicators will however be included as a record of continuous improvement.


10

4.2. Endometrial Cancer – Quality Performance Indicators Introduction Quality Performance Indicators (QPIs) were implemented for patients diagnosed with endometrial cancer on or after 1st October 2014 and Endometrial Cancer QPIs1 are reported here for the third consecutive year. There were 346 new diagnoses of endometrial cancer captured by audit in the WoS in Year 3. Distribution by location of diagnosis is shown below in Figure 1. Figure 1: Number and proportion of patients diagnosed with endometrial cancer by location of diagnosis.

AA FV Lan GGC WoS

Year 1_2014/15 75 35 75 146 331

Year 2_2015/16 69 51 79 158 357

Year 3_2016/17 68 54 62 162 346

QPI 1: Radiological Staging It is necessary to fully image the pelvis and abdomen prior to starting first treatment in order to establish the extent of disease and minimise unnecessary or inappropriate treatment1. The target for this QPI is set at 90% with the tolerance level designed to account for situations where patients require urgent treatment before imaging has been performed or where endometrial cancer is an incidental finding at hysterectomy.

0

20

40

60

80

100

120

140

160

180

Ayrshire & Arran Forth Valley Lanarkshire GGC

Num

ber o

f Cas

es

Location of Diagnosis

2014/15 2015/16 2016/17

Title: Patients with endometrial cancer should have their stage of disease assessed by MRI and/or CT prior to first treatment.

Numerator: Number of patients with endometrial cancer having a MRI and/or CT scan of the abdomen and pelvis carried out prior to first treatment.

Denominator: All patients with endometrial cancer. Exclusions: Patients with Grade 1 endometrioid or mucinous carcinoma on pre-operative biopsy.

Patients with atypical hyperplasia on pre-operative biopsy. Target: 90%


11

Figure 2: Proportion of patients with endometrial cancer who have an MRI and/or CT scan of the abdomen and pelvis performed prior to first treatment.

Performance (%) Numerator Denominator Not recorded

numerator Not recorded

numerator (%) Not recorded exclusions

Not recorded exclusions (%)

Not recorded denominator

AA 97.4% 37 38 0 0.0% 0 0.0% 0

FV 90.0% 27 30 0 0.0% 0 0.0% 0

Lan 93.5% 29 31 0 0.0% 1 3.2% 0

NG 93.8% 45 48 0 0.0% 0 0.0% 0

SG 100.0% 23 23 0 0.0% 0 0.0% 0

Clyde 100.0% 26 26 0 0.0% 0 0.0% 0

WoS 95.4% 187 196 0 0.0% 1 0.5% 0

In the WoS, 95.4% of patients with endometrial cancer had a MRI and/or CT scan of the abdomen and pelvis carried out prior to first treatment, which exceeds the 90% QPI target. All units achieved the target with performance ranging from 90% in NHS Forth Valley to 100% in South Glasgow and Clyde. QPI 2: Multidisciplinary Team Meeting (MDT) Evidence suggests that patients with cancer managed by a multidisciplinary team have a better outcome. There is also evidence that the multidisciplinary management of patients increases their overall satisfaction with their care1.

0

10

20

30

40

50

60

70

80

90

100

Ayrshire & Arran

Forth Valley Lanarkshire North Glasgow

South Glasgow

Clyde WoS

Pe

rfo

rman

ce (%

)


2014/15 2015/16 2016/17

Title: Patients with endometrial cancer should be discussed by a multidisciplinary team prior to definitive treatment.

Numerator: Number of patients with endometrial cancer discussed at MDT prior to definitive

treatment. Denominator: All patients with endometrial cancer. Exclusions: Patients with Grade 1 endometrioid or mucinous carcinoma on pre-operative biopsy.

Patients with atypical hyperplasia on pre-operative biopsy. Patients who died before first treatment.

Target: 95%


12

Figure 3: Proportion of patients with endometrial cancer who are discussed at a MDT meeting before definitive treatment.






AA 97.3% 36 37 0 0.0% 0 0.0% 0

FV 89.3% 25 28 0 0.0% 0 0.0% 0

Lan 93.3% 28 30 0 0.0% 1 3.3% 0

NG 97.9% 46 47 0 0.0% 0 0.0% 0

SG 95.7% 22 23 0 0.0% 0 0.0% 0

Clyde 100.0% 26 26 0 0.0% 0 0.0% 0

WoS 95.8% 183 191 0 0.0% 1 0.5% 0

Overall, 183 of the 191 patients diagnosed with endometrial cancer in WoS were discussed at MDT prior to definitive treatment, resulting in a performance of 95.8% against the 95% QPI target. Improved performance of 5.2 percentage points from the previous year is also noted. The target was exceeded in four of the six Boards with NHS Lanarkshire performing slightly under target at 93.3%. NHS Forth Valley and NHS Lanarkshire reviewed all cases not meeting the QPI and reasons such as emergency admission, incidental findings post operatively, severe reaction to general anaesthetic and technical difficulties were cited as reasons for no MDT discussion prior to treatment.

0

10

20

30

40

50

60

70

80

90

100

Ayrshire & Arran


South Glasgow

Clyde WoS

Pe

rfo

rman

ce (%

)


2014/15 2015/16 2016/17


13

QPI 3: Total Hysterectomy and Bilateral Salpingo-Oophorectomy Total Hysterectomy/Bilateral Salpingo-Oopherectomy for endometrial cancer is associated with best long term survival (compared to primary radiotherapy or hormonal treatment)1. The target for this QPI is 80% with the tolerance designed to account for patients having fertility conserving treatment patients who are not fit for surgical intervention. Figure 4: Proportion of patients with endometrial cancer who undergo total hysterectomy/bilateral salpingo-oopherectomy.






AA 88.1% 59 67 0 0.0% 0 0.0% 1

FV 87.8% 43 49 0 0.0% 0 0.0% 0

Lan 89.5% 51 57 1 1.8% 0 0.0% 2

NG 92.8% 64 69 0 0.0% 0 0.0% 2

SG 97.1% 34 35 0 0.0% 0 0.0% 0

Clyde 97.8% 44 45 0 0.0% 0 0.0% 0

WoS 91.6% 295 322 1 0.3% 0 0.0% 5

Overall in the WoS 91.6% of patients had a histological or cytological diagnosis prior to treatment, achieving the 80% target for the third consecutive year. Performance ranged from 88.1% in NHS Ayrhire & Arran to 97.8% in Clyde.

0

10

20

30

40

50

60

70

80

90

100

Ayrshire & Arran


South Glasgow

Clyde WoS

Pe

rfo

rman

ce (%

)


2014/15 2015/16 2016/17

Title: Patients with endometrial cancer should undergo total hysterectomy/bilateral salpingo-oopherectomy.

Numerator: Number of patients with endometrial cancer who undergo total hysterectomy/bilateral

salpingo-oopherectomy. Denominator: All patients with endometrial cancer. Exclusions: Patients with FIGO Stage IV.

Patients who decline surgical treatment. Patients having neo-adjuvant chemotherapy.

Target: 80%


14

Following last years report NHSGGC commented that smaller surgical teams were to be developed to manage endometrial cancers. It was hoped that this would improve consistency of assessment and provision of surgical techniques to ensure that any variation in surgical approach is minimised. Year 3 results highlight that all NHSGGC units showed improved performance from Year 2 results with South Glasgow rising from 75.6% in Year 2 to 97.1% in Year 3. QPI 4: Laparoscopic Surgery Laparoscopic surgery, by appropriately trained surgeons, is recommended for patients with endometrial cancer as it has been found to be feasible and surgically safe with reduced post-operative complications and length of stay1. The target for this QPI is set at 70% which reflects the fact that some patients may not be clinically suitable for laparoscopic surgery. Figure 5: Proportion of patients with endometrial cancer undergoing definitive surgery who undergo laparoscopic surgery.






AA 75.0% 39 52 0 0.0% 0 0.0% 0

FV 90.3% 28 31 0 0.0% 0 0.0% 0

Lan 89.1% 41 46 0 0.0% 0 0.0% 0

NG 50.5% 53 105 0 0.0% 0 0.0% 0

SG 41.9% 13 31 0 0.0% 0 0.0% 0

Clyde 48.7% 19 39 0 0.0% 0 0.0% 0

WoS 63.5% 193 304 0 0.0% 0 0.0% 0

0

10

20

30

40

50

60

70

80

90

100

Ayrshire & Arran


South Glasgow

Clyde WoS

Pe

rfo

rman

ce (%

)

Location of Surgery

2014/15 2015/16 2016/17

Title: Patients with endometrial cancer undergoing definitive surgery should undergo laparoscopic surgery, where clinically appropriate.

Numerator: Number of patients with endometrial cancer undergoing definitive surgery who

undergo laparoscopic surgery. Denominator: All patients with endometrial cancer undergoing definitive surgery. Exclusions: No exclusions. Target: 70%


15

Of the 304 patients diagnosed in the WoS with endometrial cancer undergoing surgery, 193 are recorded as undergoing laproscopic surgery, resulting in a WoS performance of 63.5% against the 70% QPI target. Three of the six units achieved the target with performance ranging from 41.9% in South Glasgow to 90.3% in NHS Forth Valley. Five of the six units also showed improvement from the Year 2 results. Smaller surgical teams have been developed in NHSGGC to manage endometrial cancers and it is anticipated that the numbers of cases undergoing laproscopic surgery in NHSGGC will continue to increase. Action required:-



16

QPI 5: Adjuvant Vaginal Brachytherapy For stage IB grade 1-2 brachytherapy has been shown to improve local control rates without the toxicity associated with external beam radiotherapy1. Figure 6: Proportion of patients with stage IB, grade 1 or 2, or stage IA, grade 3 endometrioid or mucinous endometrial cancer having adjuvant vaginal brachytherapy.






AA 100.0% 11 11 0 0.0% 0 0.0% 0

FV 100.0% 9 9 0 0.0% 0 0.0% 0

Lan 90.9% 10 11 0 0.0% 0 0.0% 1

NG 88.9% 8 9 0 0.0% 0 0.0% 0

SG - - - 0 0.0% 0 0.0% 0

Clyde 40.0% 2 5 0 0.0% 0 0.0% 0

WoS 89.8% 44 49 0 0.0% 0 0.0% 1 - Data not shown due to small numbers

The numbers of patients included within this QPI are low and this can have a considerable effect on proportions, therefore comparisons between sites should be made with caution. Overall in the WoS 44 out of 49 cases received vaginal vault brachytherapy which equates to 89.8%.

0

10

20

30

40

50

60

70

80

90

100

Ayrshire & Arran


South Glasgow

Clyde WoS

Perf

orm

ance

(%)


2014/15 2015/16 2016/17

Title: Patients with stage IB, grade 1 or 2, or stage IA, grade 3 endometrioid or mucinous endometrial cancer should be considered for adjuvant vaginal brachytherapy.

Numerator: All patients with stage IB, grade 1 or 2, or stage IA, grade 3 endometrioid or mucinous

endometrial cancer receiving vaginal vault brachytherapy. Denominator: All patients with stage IB, grade 1 or 2, or stage IA, grade 3 endometrioid or mucinous

endometrial cancer. Exclusions: Patients who decline brachytherapy. Target: 90%


17

NHSGGC commented that the four cases not meeting the target have been reviewed and practice has changed since the QPI was introduced, vaginal brachytherapy is no longer offered to grade 2 cancers. During formal review discussions it was acknowledged that there has been a change in practice for patients with intermediate risk endometrial cancer and that some patients now get EBRT (external beam radiation therapy) rather than vaginal brachytherapy. It has been proposed by the formal review group that the QPI be updated to include all forms of radiotherapy. QPI 6: Chemotherapy Platinum chemotherapy can improve progression free survival in patients with stage IV endometrial cancer. The use of chemotherapy should be considered for patients with stage IV disease or those with stage III disease plus residual disease at the completion of surgery1. Figure 7: Proportion of patients with stage IV endometrial cancer receiving chemotherapy.

Performance

(%) Numerator Denominator Not recorded





2014/15 57.7% 15 26 0 0.0% 0 0.0% 0

2015/16 63.3% 16 23 0 0.0% 0 0.0% 0

2016/17 38.9% 7 18 0 0.0% 0 0.0% 5

Of the 18 patients with stage IV endometrial cancer, 7 received chemotherapy resulting in a WoS performance of 38.9% against the 75% QPI target. This is a decrease on the previous years’ performance of 57.7% in Year 1 and 63.3 in Year 2.

All boards reviewed cases not meeting the QPI and submitted valid clinical reasons which included cases where patients were unfit for chemotherapy, patients who declined treatment and patients that died before treatment.

0

10

20

30

40

50

60

70

80

90

100

2014/15 2015/16 2016/17

Per

form

ance

(%)

WoS

Title: Patients with stage IV endometrial cancer should have chemotherapy. Numerator: All patients with stage IV endometrial cancer receiving chemotherapy. Denominator: All patients with stage IV endometrial cancer. Exclusions: Patients who refuse chemotherapy. Target: 75%


18

At formal review it was raised that this QPI focuses on a small number of potentially very sick women with advanced disease. It was agreed to change the wording of the QPI from chemotherapy to Systemic Anti-Cancer Therapy (SACT). This will then account for patients who receive hormone therapy.


19

4.3. Cervical Cancer – Quality Performance Indicators Introduction Quality Performance Indicators (QPIs) were implemented for patients diagnosed with cervical cancer on or after 1st October 2014 and Cervical Cancer QPIs1 are reported here for the third consecutive year. There were 148 new diagnoses of cervical cancer captured by audit in the WoS in Year 3. Distribution by location of diagnosis is shown below in Figure 8. Figure 8: Number and proportion of patients diagnosed with cervical cancer by location of diagnosis.

AA FV Lan GGC WoS

Year 1_2014/15 23 24 57 83 187

Year 2_2015/16 20 23 33 69 145

Year 3_2016/17 14 25 40 69 148

Figure 9 illustrates the age distribution of patients diagnosed with cervical cancer in the WoS for patients in Year 3. The median age was 43 years. Figure 9: Age of patients diagnosed with cervical cancer.

0

10

20

30

40

50

60

70

80

90

Ayrshire & Arran Forth Valley Lanarkshire GGC

Num

ber o

f Cas

es


2014/15 2015/16 2016/17

0

5

10

15

20

25

20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-60 60-64 65-69 70-74 75-79 80-84 85+

Year 3 4 12 22 22 22 15 18 8 9 7 3 3 3 0

Nu

mb

er

of C

ases


20

QPI 1: Radiological Staging It is necessary to fully image the pelvis prior to definitive treatment in order to establish the extent of disease and minimise unnecessary or inappropriate treatment1. Figure 10: Proportion of patients with cervical cancer who have an MRI of the pelvis performed prior to first treatment.






AA 100.0% 11 11 0 0.0% 0 0.0% 0

FV 100.0% 17 17 0 0.0% 0 0.0% 0

Lan 100.0% 29 29 0 0.0% 0 0.0% 0

NG 95.0% 19 20 0 0.0% 0 0.0% 0

SG 80.0% 4 5 0 0.0% 0 0.0% 0

Clyde 100.0% 11 11 0 0.0% 0 0.0% 0

WoS 97.8% 91 93 0 0.0% 0 0.0% 0

Of the 93 patients diagnosed with cervical cancer across WoS in Year 3, 91 patients had a MRI of the pelvis carried out prior to treatment. This resulted in a WoS performance of 97.8% against the 95% target for QPI 1. Results have also shown a year on year improvement. All units met the target with the exception of South Glasgow who achieved 80%, however this represented one case. NHSGGC reviewed the case not meeting the target and a valid clinical reason was submitted.

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South Glasgow

Clyde WoS

Pe

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2014/15 2015/16 2016/17

Title: Patients with cervical cancer should have their stage of disease assessed by MRI prior to definitive treatment.

Numerator: All patients with cervical cancer having MRI of the pelvis carried out prior to definitive

treatment. Denominator: All patients with cervical cancer. Exclusions: Patients with histopathological FIGO stage 1A1 disease. Patients treated by LLETZ only. Patients unable to undergo MRI due to contraindications. Patients with histopathological FIGO stage IVB disease. Patients who refuse MRI investigation. Target: 95%


21

QPI 2: Positron Emission Tomography/Computed Tomography (PET/CT) Patients not suitable for surgery and being considered for radical radiotherapy (+/- concurrent chemotherapy) are recommended to undergo PET/CT because of the significant risk of extra pelvic disease which if detected will change patient management1. Figure 11: Proportion of patients with cervical cancer, for whom primary definitive treatment is radical radiotherapy, who have PET/CT imaging.






AA 100.0% 8 8 0 0.0% 0 0.0% 0

FV 100.0% 9 9 0 0.0% 0 0.0% 0

Lan 87.5% 14 16 0 0.0% 0 0.0% 0

NG 100.0% 12 12 0 0.0% 0 0.0% 0

SG - - - 0 0.0% 0 0.0% 0

Clyde 87.5% 7 8 0 0.0% 0 0.0% 0


Overall in WoS, of the 54 patients diagnosed with cervical cancer undergoing radical radiotherapy in Year 3, 51 had PET/CT imaging prior to starting treatment, resulting in a performance of 94.4% which is marginally below the 95% target. NHS Lanarkshire and Clyde were below target with both achieving 87.5%. However, numbers are low and this can have a greater effect on proportions. All cases not meeting the target were reviewed and valid clinical reasons submitted.

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South Glasgow

Clyde WoS

Pe

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2014/15 2015/16 2016/17

Title: Patients with cervical cancer for whom primary definitive surgery is not appropriate, should undergo PET/CT.

Numerator: All patients with cervical cancer undergoing primary radical radiotherapy who have

PET/CT imaging prior to starting treatment. Denominator: All patients with cervical cancer undergoing primary radical radiotherapy. Exclusions: No exclusions. Target: 95%


22

QPI 3: Multidisciplinary Team Meeting (MDT) Evidence suggests that patients with cancer managed by a multi-disciplinary team have a better outcome. There is also evidence that the multidisciplinary management of patients increases their overall satisfaction with their care1. Figure 12: Proportion of patients with cervical cancer who are discussed at a MDT meeting before definitive treatment.






AA 100.0% 12 12 0 0.0% 1 8.3% 0

FV 100.0% 17 17 0 0.0% 0 0.0% 0

Lan 96.7% 29 30 0 0.0% 0 0.0% 0

NG 100.0% 22 22 0 0.0% 0 0.0% 0

SG 100.0% 6 6 0 0.0% 0 0.0% 0

Clyde 91.7% 11 12 0 0.0% 0 0.0% 0

WoS 98.0% 97 99 0 0.0% 1 1.0% 0

Of the 99 patients across the region with cervical cancer, 97 were discussed at the MDT prior to definitive treatment. This equates to 98% and successfully meets the 95% QPI target. All units exceeded the target with the exception of Clyde who achieved 91.7%, however this represents one case that was not discussed. The case was reviewed by NHSGGC and a valid clinical reason was given.

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South Glasgow

Clyde WoS

Pe

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Title: Patients with cervical cancer should be discussed by a MDT prior to definitive treatment.

Numerator: All patients with cervical cancer discussed at the MDT before definitive treatment. Denominator: All patients with cervical cancer. Exclusions: Patients with histopathological FIGO stage 1A1 disease. Patients treated by LLETZ only. Patients who died before treatment. Target: 95%


23

QPI 4: Radical Hysterectomy Radical surgery is recommended for FIGO stage IB1 disease if there are no contraindications to surgery. Patients with tumours <4 cm in diameter are less likely to have metastatic spread and benefit most from radical hysterectomy. In young women quality of life is less impaired after radical hysterectomy than following chemo-radiation therapy1. Figure 13: Proportion of patients with stage IB1 cervical cancer (as defined by radiology and/or histopathology) who undergo radical hysterectomy.

Performance






2014/15 87.2% 34 39 0 0.0% 0 0.0% 0

2015/16 66.7% 18 27 0 0.0% 0 0.0% 0

2016/17 83.3% 25 30 0 0.0% 0 0.0% 1

Due to the smaller numbers included within this QPI cumulative WoS results are presented in Figure 13. Overall in the WoS 83.3% of patients with FIGO stage IB1 cervical cancer underwent radical hysterectomy. Although this is marginally below the 85% QPI target, it does show a considerable improvement on Year 2 results when performance was 66.7%. Cases not meeting the QPI in NHS Lanarkshire & NHSGGC were reviewed and detailed clinical commentary was provided. Reasons included cases where the patient was not fit for surgery and cases that were an incidental finding at surgery. An issue was identified in Clyde that is being explored further, however there was no adverse effect to patients.

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2014/15 2015/16 2016/17

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WoS

Title: Patients with FIGO stage IB1 cervical cancer should undergo radical hysterectomy Numerator: All patients with FIGO stage IB1 cervical cancer who undergo radical hysterectomy. Denominator: All patients with FIGO stage IB1 cervical cancer. Exclusions: Patients who decline surgery. Patients who undergo fertility conserving treatment.

Patients who have neo-adjuvant chemotherapy. Patients enrolled into surgical trials.

Target: 85%


24

Action Required:

NHSGGC to provide detailed feedback on the outcome of the ongoing review. QPI 5: Surgical Margins The quality of radical surgery for cervical cancer has an important influence on local control of the tumour and ultimately survival. Therefore, it is important to optimise and ensure the quality of surgical care for cervical cancer patients1. QPI 5 is analysed by location of surgery rather than location of diagnosis. Figure 14: Proportion of patients with cervical cancer who have surgical margins clear of tumour following hysterectomy.

Performance






2014/15 94.2% 49 52 1 1.9% 0 0.0% 0

2015/16 97.5% 39 40 1 2.5% 0 0.0% 0

2016/17 97.6% 40 41 0 0.0% 0 0.0% 0

Again due to the small numbers of patients included within this QPI cumulative WoS results are presented in Figure 14. Of the 41 patients with cervical cancer undergoing surgery, 40 had surgical margins which were clear of tumour. This equates to 97.6% and meets the 95% QPI target for the second consecutive year. The one case not meeting the QPI was reviewed and detailed clinical commentary provided.

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2014/15 2015/16 2016/17

Perf

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ance

(%)

WoS

Title: Patients with surgically treated cervical cancer should have clear resection Numerator: All patients with cervical cancer who undergo surgery where surgical margins are clear

of tumour. Denominator: All patients with cervical cancer who undergo surgery. Exclusions: Patients who decline surgery. Patients who undergo fertility conserving treatment.

Patients enrolled into surgical trials.

Target: 95%


25

QPI 6: 56 Day Treatment for Radical Radiotherapy Overall treatment time for locally advanced cervical cancer should be as short as possible. Radiotherapy for squamous carcinoma should be completed within 56 days1. Figure 15: Proportion of patients with cervical cancer undergoing radical radiotherapy whose overall treatment time, from the start to the end of treatment, is not more than 56 days.






AA 100.0% 8 8 0 0.0% 0 0.0% 0

FV 100.0% 10 10 0 0.0% 0 0.0% 0

Lan 100.0% 18 18 0 0.0% 0 0.0% 0

NG 100.0% 13 13 0 0.0% 0 0.0% 0

SG - - - 0 0.0% 0 0.0% 0

Clyde 100.0% 11 11 0 0.0% 0 0.0% 0


As demonstrated in Figure 15, all units achieved the QPI target with 100% of patients in the WoS with cervical cancer undergoing radical radiotherapy (external beam or brachytherapy) whose overall treatment time, from start to the end of treatment, was not more than 56 days. All Boards have consistently met the target over the last 3 years. Results are restricted for South Glasgow due to small numbers.

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South Glasgow

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Perf

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Title: Treatment time for patients with cervical cancer undergoing radical radiotherapy should be no more than 56 days.

Numerator: All patients with cervical cancer undergoing radical radiotherapy (external beam or

brachytherapy) whose overall treatment time, from start to the end of treatment, is not more than 56 days.

Denominator: All patients with cervical cancer undergoing radical radiotherapy (external beam or

brachytherapy). Exclusions: No exclusions. Target: 90% 05%


26

QPI 7: Chemoradiation Any patient with cervical cancer considered suitable for radical radiotherapy treatment should have concurrent chemoradiotherapy with a platinum based chemotherapy, if fit for treatment1. Figure 16: Proportion of patients with cervical cancer undergoing radical radiotherapy who receive concurrent chemotherapy.






AA 100.0% 8 8 0 0.0% 0 0.0% 0

FV 70.0% 7 10 0 0.0% 0 0.0% 0

Lan 88.9% 16 18 0 0.0% 0 0.0% 0

NG 92.3% 12 13 0 0.0% 0 0.0% 0

SG - - - 0 0.0% 0 0.0% 0

Clyde 72.7% 8 11 0 0.0% 0 0.0% 0

WoS 85.2% 52 61 0 0.0% 0 0.0% 0

Overall in the WoS 85.2% of patients with cervical cancer undergoing radical radiotherapy received concurrent chemotherapy, which meets the 70% QPI target. All units met the target for the third consecutive year. It should be noted that numbers are small and this can have a greater effect on proportions. South Glasgow results are restricted due to small numbers.

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Title: Patients with cervical cancer undergoing radical radiotherapy should receive concurrent platinum-based chemotherapy.

Numerator: All patients with cervical cancer undergoing radical radiotherapy who receive

concurrent chemotherapy. Denominator: All patients with cervical cancer who undergo radical radiotherapy. Exclusions: No exclusions. Target: 70%


27

Clinical Trial Access Clinical trials are necessary to demonstrate the efficacy of new therapies and other interventions. Furthermore, evidence suggests improved patient outcomes when hospitals are actively recruiting patients into clinical trials1. Data definitions and measurability criteria to accompany the Clinical Trial QPI are available from the HIS website1. The clinical trials QPI is measured utilising Scottish Cancer Research Network (SCRN) data and ISD incidence data, as is the methodology currently utilised by the Chief Scientist Office (CSO) and National Cancer Research Institute (NCRI). Utilising SCRN data allows for comparison with CSO published data and ensures capture of all clinical trials recruitment, not solely first line treatment trials, as contained in the clinical audit data. Given that a significant proportion of clinical trials are for relapsed disease this is felt to be particularly important in driving quality improvement. This methodology utilises incidence as a proxy for all patients with cancer. This may slightly over, or underestimate, performance levels, however this is an established approach currently utilised by NHS Scotland1.

A number of the clinical trials which were recruiting in this period included cervix, endometrial and ovarian cancer patients therefore the data could not be separated into separate endometrial and cervical clinical trials. Figure 17: Proportion of patients diagnosed with endometrial, cervical or ovarian cancer who are consented* for a clinical trial / research study in 2017.

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Analysis Group

Consented Entered

QPI Title: All patients should be considered for participation in available clinical trials/research studies wherever eligible.

Numerator: Number of patients diagnosed with gynaecological cancer consented for a clinical

trial/research study. Denominator: All patients with diagnosed with a gynaecological cancer.. Exclusions: No exclusions. Target: 15%


28

Consented - QPI Target 15% Entered Trial

N D % N D %

AA 8 133 6.0% 4 133 3.0%

FV 1 90 1.1% 1 90 1.1%

Lan 14 165 8.5% 13 165 7.9%

GGC 11 408 2.7% 13 408 3.2%

WoS Total 38 797 4.8% 31 797 3.9%

Following formal review the Clinical Trials Access QPI was updated to measure the number of patients consented for participation in a clinical trial rather than only those who are enrolled. There are a number of patients who undergo screening but do not proceed to enrolment for various reasons, e.g. they do not have the mutation required for entry on to the trial.

Overall for patients in WoS diagnosed with cervical, endometrial or ovarian cancer, 38 patients consented for a clinical trial/research study resulting in a WoS performance of 4.8% against the 15% target. The target was not met by any of the NHS Boards. Table 3: List of clinical trials and the number of patients with endometrial, cervical or ovarian cancer consented/entered into each clinical trial in 2017. (N.B. All recruits noted below were resident within WoS).

Project Title Consented Entered

ICON8 and ICON8B - -

Interlace - -

BritROC1 13 13

OCTAVE - -

OvPsych2 - -

NiCCC Trial - -

Octopus 8 8

CANC 3795 - -

CANC 5110 - -

CANC 5651 - -

Nucana - -

Total 38 31 ‘-‘ Data not shown due to small numbers (denominator of less than 5).


29

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. Following the development of QPIs, this has now become an established national programme to drive continuous improvement and ensure equity of care for patients across Scotland.

Overall results from the third year of endometrial and cervical cancer QPI reporting are encouraging; case ascertainment and data capture is of a high standard. In endometrial cancer targets relating to radiological staging and total hysterectomy and bilateral salpingo-oopherectomy were met by all boards and for cervical cancer targets relating to, Multidisciplinary Team (MDT) discussion, 56 day treatment time for radical radiotherapy and chemoradiation were consistently met by all units. However, some of the QPI targets set have been challenging for NHS Boards to achieve. There remains room for further service improvement around a number of areas, including: laproscopic surgery for endometrial patients and chemotherapy for stage IV endometrial patients. Where QPI targets were not met, NHS Boards have provided detailed comment. In the main these indicate valid clinical reasons or that, in some cases, patient choice or co-morbidities have influenced patient management. Additionally, NHS Boards have indicated where positive action has already been taken at a local level to address any issues highlighted through the QPI data analysis. It is anticipated that these positive changes will result in improved performance going forward. NHS Boards are encouraged to continue with this proactive approach of reviewing data and addressing issues as necessary, in order to work towards increasingly advanced performance against targets, and demonstration of overall improvement in quality of the care and service provided to patients. The Gynae-oncology MCN will actively participate in the forthcoming endometrial and cervical cancer QPI formal review process, to ensure the continued clinical relevance of the quality measures.

Action required:

Endometrial QPI 4 – Laparoscopic Surgery


Cervical QPI 4 – Radical Hysterectomy

NHSGGC to provide detailed feedback on the outcome of the ongoing review. 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).


30

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.


31

Abbreviations

BWoSCC Beatson West of Scotland Cancer Centre

CT Computed Tomography

eCASE Electronic Cancer Audit Support Environment

FIGO Federation of Gynaecological Oncologists

GRI Glasgow Royal Infirmary

HIS Healthcare Improvement Scotland

ISD Information Services Division

MCN Managed Clinical Network

MDT Multidisciplinary Team

MRI Magnetic resonance imaging

NCQSG National Cancer Quality Steering Group

NHSGGC NHS Greater Glasgow and Clyde

PET Positron Emission Tomography

QPI Quality Performance Indicator

RCAG Regional Cancer Advisory Group

RMI Risk of Malignancy Index

TAH Total Abdominal Hysterectomy

WoS West of Scotland

WoSCAN West of Scotland Cancer Network


32

References

1. Healthcare Improvement Scotland. Cancer Quality Performance Indicators, [Accessed on: 22nd September 2018] Available at: http://www.healthcareimprovementscotland.org/our_work/cancer_care_improvement/cancer_qpis/quality_performance_indicators.aspx

2. Information Services Division. Head and Neck Cancer: Data Definitions, Measurability and Data Validations Accessed on: 22nd September 2018]. Available at: http://www.isdscotland.org/Health-Topics/Cancer/Cancer-Audit/

3. Information Services Division. Cancer in Scotland, June 2004 (updated April 2018) [Accessed

on: 22nd September 2018]. Available at: http://www.isdscotland.org/Health-Topics/Cancer/Cancer-Statistics/

4. Information Services Division, Cancer Statistics, Summary statistics for female genital organ

cancers. [Accessed on: 22nd September 2018]. Available at: http://www.isdscotland.org/Health-Topics/Cancer/Cancer-Statistics/Female-Genital-Organ/

5. ScotPHO, Public Health Information for Scotland. Population: estimates by NHS Board

[Accessed on: Accessed on: 22nd September 2018]] Available at: http://www.scotpho.org.uk/population-dynamics/population-estimates-and-projections/data/nhs-board-population-estimates

http://www.healthcareimprovementscotland.org/our_work/cancer_care_improvement/cancer_qpis/quality_performance_indicators.aspx

http://www.healthcareimprovementscotland.org/our_work/cancer_care_improvement/cancer_qpis/quality_performance_indicators.aspx

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

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

http://www.isdscotland.org/Health-Topics/Cancer/Cancer-Statistics/Female-Genital-Organ/

http://www.isdscotland.org/Health-Topics/Cancer/Cancer-Statistics/Female-Genital-Organ/

http://www.scotpho.org.uk/population-dynamics/population-estimates-and-projections/data/nhs-board-population-estimates

http://www.scotpho.org.uk/population-dynamics/population-estimates-and-projections/data/nhs-board-population-estimates


33

Copyright

The content of this report is © copyright WoSCAN unless otherwise stated.

Organisations may copy, quote, publish and broadcast material from this report without payment and without approval

provided they observe the conditions below. Other users may copy or download material for private research and

study without payment and without approval provided they observe the conditions below.

The conditions of the waiver of copyright are that users observe the following conditions:

Quote the source as the West of Scotland Cancer Network (WoSCAN).

Do not use the material in a misleading context or in a derogatory manner.

Where possible, send us the URL.

The following material may not be copied and is excluded from the waiver:

The West of Scotland Cancer Network logo.

Any photographs.

Any other use of copyright material belonging to the West of Scotland Cancer Network requires the formal permission

of the Network.


Appendix 1: Action / Improvement Plans

WoSCAN Action / Improvement Plan – Endometrial & Cervical Cancer

No Action Required NHS Board Action Taken Timescales Lead Status (see key)

Start End

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.

Insert date

Insert date

Insert name of responsible lead for each action.

Insert No. from key above

1. Endometrial QPI 4 – Laparoscopic Surgery NHSGGC to determine resource and training requirements for laparoscopic surgery and feedback to the MCN.

2. Cervical QPI 4 – Radical Hysterectomy NHSGGC to provide detailed feedback on the outcome of the ongoing review.

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)

west of scotland cancer network - mcn audit report...west of scotland cancer network final published...

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