1. National Oesophago–Gastric Cancer Audit 2015

2.  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.

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

5.  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 National figures for HGD

6. 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)

7. Proportion managed by surveillance varied by SCN Treatment Plan for HGD

8. Variable typeVariable NameLocal Trust Mandatory (% with ‘not known’ or ‘NA’ recorded Source of referral (%)xxx Diagnosis confirmed by a second pathologist xxx Non-Mandatory (% complete) Length of circumferential Barrett’sxxx Treatment agreed at MDTxxx Local HGD Data submissions  XXX cases of HGD submitted to NOGCA between 1 st April 2012 and 31 st March 2014  Completeness of HGD records submitted. ◦Including the use of ‘unknown’ for mandatory variables.

9. NationalSCN Cases recorded930xx Diagnosis % Diagnosis confirmed by 2 nd pathologist 82.8%xx Management % Discussed at MDT83.7%xx % Active Management83.8%xx Management of HGD in local SCN

10.  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. Key National Findings for HGD

11.  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 1 st April 2012 & 31 st March 2014 ◦Estimated case ascertainment = 80% Oesophago-gastric (OG) Cancer

12. NationalLocal Trust OG cancer Cases recorded22,301xx % case ascertainment79.8%xx Local OG cancer Data Submissions 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.

13. Local Trust Number of surgical casesXxx Surgical intent recorded (%)Xxx Complications recorded (%)Xxx Death in hospital recorded (%)Xxx Matched pathology record (%)xxx 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.

14. Local Trust T-stage recorded (%)Xxx N-stage recorded (%)Xxx M-stage recorded (%)xxx 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.

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

16.  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) Surgery

17.  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 Oesophagectomy (%)Gastrectomy (%) 2010201520102015 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

18. Surgical Outcomes NationalLocal Trust Curative surgery volume4,951xx Mortality rate 30-dayxx 90-dayxx Complication ratexx

19.  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. Oesophageal SCCs

20. Significant variation across SCNs in choice of curative treatment for SCCs (surgery vs definitive oncology) Mid/Lower Oesophageal SCCs

21.  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. Definitive Oncology

22.  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. Palliative Treatment for OG cancer

23.  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 Home1,31010.9 Home4,11034.3 Hospice2,22318.5 Hospital4,15034.6 Other 208 1.7

24. 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.

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