1. Oesophago–Gastric Cancer Audit
National
Oesophago–Gastric Cancer
Audit
Key Findings from 2014 Annual Report and Progress Report
Hi I am Georgina Chadwick, I am gastroenterology SpR currently doing an OOPE at the RCS working as a research fellow on the NOGCA. I would like to briefly go through some of the new area considered in the 2014 Annual Report which is due to be published at the beginning of November.
Georgina Chadwick
Clinical Research Fellow

2. High Grade Dysplasia (HGD) of the Oesophagus
465 cases submitted to audit
Diagnosed between 1st April 2012 & 31st March 2013.
Source of referral
52.9% Symptomatic
39.4% Barrett’s surveillance
7.7% Unknown.
79.4% Diagnosis confirmed by 2nd pathologist.
86.0% cases had treatment planned at MDT.

3. Treatment Plan for HGD Planned treatment
1/3 patients currently managed surveillance alone
This goes against BSG recommendations.
‘For HGD and Barrett’s-related adenocarcinoma confined to
the mucosa, endoscopic therapy is preferred over oesophagectomy
or endoscopic surveillance.’
Fitzgerald RC et al. British Society of Gastroenterology guidelines on the diagnosis and management of Barrett's oesophagus. Gut. 2014;63(1):7-42.  

4. Recommendations for HGD
Confirm all diagnoses of HGD with 2nd pathologist.
Discuss all patients with HGD at a specialist MDT for oesophagogastric cancer.
This team should include an interventional endoscopist, upper GI cancer surgeon, radiologist and a GI pathologist.
Consider all patients with HGD for active treatment.
Refer patients to a specialist centre where local expertise is not available.

5. Oesophago-gastric (OG) Cancer
Audit prospectively collected data on:
Patients diagnosed with invasive epithelial OG cancer
Diagnosed in NHS hospital in England or Wales
Aged over 18 at diagnosis.
22,832 cases submitted
Patients diagnosed: 1st April 2012 & 31st March 2013
78.6% case ascertainment.

6. Treatment Plan for OG cancer
Proportion treated with curative intent increased to 37.3% vs 2010 Report.
For squamous cell cancers - Use of definitive chemoradiotherapy increased (31% to 39%).
For early cancers (T0/1,N0,M0) – Increased use of endoscopic resection.

7. Surgery Overall 5,396 surgical records were submitted Curative surgery
95.0% Curative intent
4.3% Palliative intent and 0.7% Unknown.
Curative surgery
2,986 Oeosphagectomies
1,807 Gastrectomies
Increase in proportion of minimally invasive (MI) operations
Oesophagectomies: 41.5% MI or Hybrid
Gastrectomies: 15.9% MI.

8. Surgery with adjunct oncology
BSG guidelines
Oesophageal cancer - Preoperative chemoradiation improves long- term survival over surgery alone
Gastric cancer - Perioperative combination chemotherapy conveys a significant survival benefit and is a standard of care.
Proportion of patients with locally advanced disease managed surgically who received additional oncological therapy.
Allum W, Blazeby J, Griffin S, Cunningham D, Jankowski J, Wong R. Guidelines for the management of oesophageal and gastric cancer. Gut. 2011;60(11):

9. Surgical Outcomes
Oesophagectomy (%)
Gastrectomy (%)
2010
2014
30-Day mortality
3.8
2.4
4.5
2.3
90-Day mortality
5.7
4.4
6.9
Fall in both 30 and 90 day mortality post curative oesophagectomy and gastrectomy.

10. Surgical Outcomes
Funnel plots looking at mortality for all Trusts performing curative surgery for OG cancer, demonstrate no significant variation across trusts after adjusting for known confounders.

11. Surgical complications
Reported for English patients only.
Oesophagectomy
1 in 3 suffered any complication
Most frequently respiratory affecting 17.7%
Statistically significant rise in proportion suffering respiratory or gastric complication after oesophagectomy vs 2010 Audit Report.

12. Surgical Complications
Reported for English patients only.
Oesophagectomy
1 in 3 suffered any complication
Most frequently respiratory affecting 17.7%
Statistically significant rise in proportion suffering respiratory or gastric complication after oesophagectomy vs Audit Report
Variation in key complication rates by surgical approach.
Oesophagectomy
Open
Hybrid MI
Overall
Any Complication
34.5%
36.3%
33.9%
33.0%
Anastomotic Leak
6.7%
7.1%
11.7%*
Respiratory complication
18.1%
20.1%
14.1%
17.1%**
* Statistically significant increased risk of leak with MI surgery compared to open.
** Rise since 2010, statistically significant and needs investigation.

13. Surgical Complications
Gastrectomy
1 in 5 suffered any complication
Most frequently unplanned return to theatre affecting 8.1%
No significant change in complication rates since the Audit Report
Variation in key complication rates by surgical approach.
Gastrectomy
Open MI
Overall
Any Complication
19.6%
16.5%
19.0%
Unplanned return to theatre
7.7%
10.6%
8.1%

14. Resection Margins
Aim of surgery is to achieve tumour free resection margins.
Proportion of patients who had had an oesophagectomy who had positive longitudinal resection margin has fallen from 6.4% in 2010 to 3.7% in the 2014 Report.
BUT 9.1% of patients having a gastrectomy have an incomplete resection.
Oesophagectomy
Gastrectomy
Total n
Overall %
Positive long. (prox or dist resection margin 98
3.7%
144
9.1%
242
5.7%
Positive circ. Margin
685
27.7%
113
10.5%
798
22.5%

15. Definitive Oncology – RTDS Link
For first time radiotherapy dataset linked to NOGCA
90.6% (n=2516) of RTDS Records linked successfully.
Radiotherapy treatment regimen, aligned with RCR recommendations for:
59.7% patients treated with definitive chemoradiotherapy for oesophageal cancer
46.4% patients treated with curative radiotherapy alone.
RTDS dataset will allow further exploration of use of radiotherapy in future.

16. OG cancer in elderly
58.9% OG cancers diagnosed in patients aged 70yrs or over.
Treatment:
Nationally no difference in proportion managed with curative intent according to age, after risk adjustment
At local level, there was significant variation in proportion of elderly patients managed with curative intent.

17. Early Cancers
Only 5.4% OG cancers diagnosed at early stage (T0/1,N0,M0).
Lower oesophageal/GOJ tumours, and oesophageal squamous cell cancers less likely to be diagnosed early.
Across strategic clinical networks significant variation in proportion of cancers diagnosed early.

18. Recommendations for OG cancers
Monitor complications rates associated with minimally invasive vs open surgery locally.
Monitor quality of surgery
Completeness of surgical resection
Complication rates and length of stay post-op.
Monitor dosing regimens used for definitive radiotherapy for OG cancer.
At a local level audit
Proportion of patients aged over 70 managed with curative intent
Proportion of cancer diagnosed early.