Endometrial Cancer CPGON Audit

Background Formulating standard management pathways Assessing compliance with existing pathways Understanding areas of similarity and areas of variation

Specific Questions Endometrial cancer inclusive Caseload and waiting times Tumour grade: how it affects management and outcome Move toward laparoscopic surgery Imaging Survival Trial recruitment

Data collection Access Database with specific forms Sent to 5 hospitals: Taunton, Exeter, Yeovil, Torbay, NDDH Returns received from all except NDDH Data presented reflect data entered Significant influence of missing data (esp on Grade data)

Data analysis Taunton/Yeovil and Exeter/Torbay analysed separately Exeter data include NDDH cases who had hysterectomy in Exeter, but diagnostic data are missing

Cases: Exeter/Torbay/NDDH Hysterectomy? Source siteNoYes Total Exeter NDDH74350 Other22 Plymouth11 Private33 Torbay Grand Total

Cases: Taunton/Yeovil Hysterectomy? Source siteNoYesTotal Exeter11 Other33 Private33 Taunton Yeovil49094 Grand Total

Where hysterectomies done Counts of cases by location of surgery and according to site of diagnosis

Waits for Hysterectomy Reported as mean in days Includes some long waits. Very long waits (>100d) excluded if biopsy field blank Assumed to be cases where cancer not suspected or known

Laparoscopic Continues to rise Need clarity on what the expected figure should be Exeter and Taunton consensus is that transverse laparotomy is very rarely indicated

Influence of Tumour Grade Several issues: – What grade should trigger referral to centre – Proportion of cases undergraded and therefore underinvestigated and under-referred – Does biopsy grade predict need for adjuvant therapy?

Current Practice Yeovil/Taunton: – G2 and 3 referred to Centre – G2 called HG (according to data submitted) – G2 and G3 have cross sectional imaging Exeter/Torbay/NDDH: – G3 only referred to centre – G2 called LG – Only G3 have cross-sectional imaging

Grade analysis Problem of missing data: each case needs two grade data fields entered to contribute (biopsy and final) How to calculate upward grade shift Decision to use denominator of grades able to shift (ie exclude G3)

Survival by Grade

Survival Kaplan Meier for Exeter/Torbay/NDDH cases Highly significant G3 worse than G1 and G2, which were the same Regret no similar plot for Taunton/Yeovil

Adjuvant Radiotherapy Again a missing data issue How does biopsy grade predict likelihood of adjuvant radiotherapy after hysterectomy? Hyperplasia = cases where biopsy showed hyperplasia but hysterectomy revealed cancer

Grade conclusions Survival data clear that G1 and 2 are separate from G3 However, in Yeovil, G2 referral means: – Quicker operation – Accurately selects cases who need adjuvant treatment

Survival by Morphology

Conclusions Variation within the Network (Grade triage) Guidelines will need to reflect this, or practice change Patients do well and results in keeping with published literature We can do good audits together!!