National Oesophago–Gastric Cancer Audit 2015

This slide set is designed to Summarise the main audit findings for presentation at local MDT meetings Help you to audit your local trust practice against other Trusts in your SCN and against National figures where appropriate. We have designed the slides so that you can enter your data from the Annexes of the Annual Report in the appropriate space.

High Grade Dysplasia (HGD) of the Oesophagus Since April 2012, the NOGCA has been collecting data on patients with HGD of the oesophagus The audit aims to monitor current practice against national guidelines The key BSG recommendations are: Diagnosis should be confirmed by a second GI pathologist Patients should be discussed at a specialist MDT Endoscopic treatment preferred over surgery or surveillance EMRs should be performed in high volume centre Fitzgerald RC et al. British Society of Gastroenterology guidelines on the diagnosis and management of Barrett's oesophagus. Gut. 2014;63(1):7-42.  

National figures for HGD 930 cases submitted to NOGCA Diagnosed between 1st April 2012 and 31st March 2014 Source of referral 51.1% Symptomatic 40.4% Barrett’s surveillance 8.5% Unknown 82.8% Diagnosis confirmed by 2nd pathologist 87.3% Cases discussed at specialist MDT

National figures for HGD Currently, 35.8% of cases referred on to specialist hospital for treatment Number of cases treated is low at many hospitals Majority treated <5 cases over 2 years Only 7 treated ≥30 cases over 2 years

Treatment Plan for HGD BSG recommendation: Endoscopic treatment preferred over surgery or surveillance Proportion managed by surveillance associated with Age at diagnosis 12.6% <60 yrs compared to 43.2% ≥80 yrs (p<0.001) Hospital where treated Low-volume hospital 33.1% vs high-volume hospital 14.9% (p<0.001)

Treatment Plan for HGD Proportion managed by surveillance varied by SCN

Local HGD Data submissions XXX cases of HGD submitted to NOGCA between 1st April 2012 and 31st March 2014 Completeness of HGD records submitted. Including the use of ‘unknown’ for mandatory variables. Variable type Variable Name Local Trust Mandatory (% with ‘not known’ or ‘NA’ recorded Source of referral (%) xxx Diagnosis confirmed by a second pathologist Non-Mandatory (% complete) Length of circumferential Barrett’s Treatment agreed at MDT Complete this slide using data from Annex 5 of 2015 Annual Report, p58. NB Trusts who submitted data on less than 10 cases of HGD are not included in this Annex.

Management of HGD in local SCN National SCN Cases recorded 930 xx Diagnosis % Diagnosis confirmed by 2nd pathologist 82.8% Management % Discussed at MDT 83.7% % Active Management 83.8% Complete this slide using data from Annex 6 of 2015 AR, p59.

Key National Findings for HGD Good adherence to recommendation that diagnosis confirmed by second pathologist and cases discussed at MDT. But HIGH proportion of cases still managed by surveillance alone NHS Trusts and Health Boards should consider referral of patients with HGD to a specialist centre for treatment where local expertise not available. Add slide for any key local findings

Oesophago-gastric (OG) Cancer Audit prospectively collected data on: Patients diagnosed with invasive epithelial OG cancer Diagnosed in NHS hospitals in England or Wales Aged over 18 at diagnosis Data submitted of 22,301 patients Diagnosed between 1st April 2012 & 31st March 2014 Estimated case ascertainment = 80%

Local OG cancer Data Submissions National Local Trust OG cancer Cases recorded 22,301 xx % case ascertainment 79.8% Complete this slide using data from Annex 3 of 2015 AR, p52. NB Trusts who submitted data on less than 10 cases of HGD are not included in this Annex.

Completeness of surgical records It is important that key variables are submitted NOGCA reviewed the completeness of surgical records submitted to the audit. Including the use of ‘unknown’ for mandatory variables. Local Trust Number of surgical cases Xxx Surgical intent recorded (%) Complications recorded (%) Death in hospital recorded (%) Matched pathology record (%) xxx Complete this slide using data from Annex 4 of 2015 AR, p56. NB Trusts who submitted data on less than 10 cases of HGD are not included in this Annex.

Completeness of Pathology records Staging data is key data for risk adjusting cases when monitoring surgical outcomes Audit assessed the proportion of cases with complete pathological TNM stage. Local Trust T-stage recorded (%) Xxx N-stage recorded (%) M-stage recorded (%) xxx Complete this slide using data from Annex 4 of 2015 AR, p56. NB Trusts who submitted data on less than 10 cases of HGD are not included in this Annex.

Treatment Plan for OG cancer Overall proportion of patients treated with curative intent was 38.1%

Surgery A total of 4,951 curative surgical records were submitted 3,036 Oeosphagectomies 1,701 Gastrectomies Increased use of multimodal therapy (e.g. neoadjuvant chemotherapy) since 2010 Increase in proportion of minimally invasive (MI) operations. Oesophagectomies: 41% MI or Hybrid (30% in 2010) Gastrectomies: 14% MI (13% in 2010)

Surgical Outcomes   Oesophagectomy (%) Gastrectomy (%) 2010 2015 30-Day mortality 3.8 2.2 4.5 2.3 90-Day mortality 5.7 4.3 6.9 4.2 Complication rate 29.8 36.9 19.4 23.7 Fall in both 30 and 90 day postoperative for curative oesophagectomy and gastrectomy. Overall complication rates remain high Increased rate since 2010 probably reflects better reporting of complications to the NOGCA

Surgical Outcomes National Local Trust Curative surgery volume 4,951 xx Mortality rate 30-day 90-day Complication rate On this slide you can compare your trusts mortality to national figures and highlight your own trust on the graph

Oesophageal SCCs Curative treatment options Upper oesophageal SCCs: Definitive oncology preferred Mid/lower oesophageal: Definitive oncology or surgery may be considered. Current management in England and Wales 67% upper oesophageal lesions received definitive oncology Mid/ Lower oesophageal more even split: 46% definitive oncology and 54% surgery.

Mid/Lower Oesophageal SCCs Significant variation across SCNs in choice of curative treatment for SCCs (surgery vs definitive oncology) On this slide you can highlight choice of tx in your SCN

Definitive Oncology English radiotherapy data (RTDS) linked to NOGCA for patients diagnosed April 2012 to March 2013 Treatment regimen aligned with Royal College of Radiologists recommendations for: 65% patients treated with definitive chemoradiotherapy for oesophageal cancer. 49% patients treated with definitive radiotherapy alone for oesophageal cancer. RTDS dataset will allow further exploration of use of radiotherapy in future.

Palliative Treatment for OG cancer Two thirds of patients managed palliatively Palliative oncology most common treatment Completion of palliative chemo is low (54.9%) Endoscopic / radiological stent insertion used to treat dysphagia in many patients Combining data from Audit and HES suggests 3,357 patients with oesophageal cancer had a stent inserted BUT only 59.5% of patients who had stent insertion recorded in HES had record submitted to audit.

Place of Death The Audit investigated place of death among patients with a palliative treatment intent. Proportion of patients dying in hospital significantly higher in patients living in most deprived areas compared to least deprived (39% vs 30%). Place of Death Number of patients % Care Home 1,310 10.9 Home 4,110 34.3 Hospice 2,223 18.5 Hospital 4,150 34.6 Other 208 1.7

Recommendations for OG cancers NHS trusts should closely monitoring the complication rates among curative surgical patients All patients with oesophageal SCCs being considered for curative therapy should be discussed with a surgeon and oncologist Completion rates for palliative chemotherapy remain low, and patients need to be assessed carefully before starting treatment Trusts need to review their policies for ensuring patients who have a palliative stent inserted have this data submitted to the audit.

Contact Details For any queries please contact: Dr Georgina Chadwick Clinical Research Fellow The National Oesophago-Gastric Cancer Audit E-Mail: gchadwick@rcseng.ac.uk