National Cancer Quality Steering Group action note: March 2021

Attendees and apologies

Present

• James Mander, Regional Lead Cancer Clinician, SCAN (chair) (JM)
• Lesley Aitken, Senior Reviewer, Healthcare Improvement Scotland (LA)
• Bobby Alikhani, Regional Manager (Cancer), SCAN (BA)
• Matthew Barber, Consultant Breast Surgeon, NHS Lothian (MB)
• Seona Carnegie, Policy Manager, Cancer Policy Team, Scottish Government (SC)
• Jen Doherty, Project Co-ordinator, National Cancer Quality Programme (JD)
• Hilary Glen, Consultant Medical Oncologist, NHSGGC (HG)
• David Morrison, Director, Scottish Cancer Registry (DM)
• Gerard McMahon, Cancer Coalition, Prostate Cancer UK (GMcM)
• Gregor McNie, Team Lead, Cancer Policy, Scottish Government (GMcN)
• Peter Sandiford, Deputy National Clinical Lead, Cancer QPI Review Group, Healthcare Improvement Scotland (PS)
• Nadeem Siddiqui, National Clinical Lead, Cancer QPI Review Group, Healthcare Improvement Scotland (NS)
• Lorraine Stirling, Project Officer, National Cancer Quality Programme (LS)
• Elaine Strange, Head of Service, Public Health Scotland (ES)
• Seamus Teahan, Regional Lead Cancer Clinician, WoSCAN (Chair) (ST)
• Catherine Thomson, Service Manager (Population Health), Public Health Scotland (CT)
• Evelyn Thomson, Regional Manager (Cancer), WoSCAN (ET)
• Joris Van Der Horst, Consultant Respiratory Physician, NHSGGC (JVDH)
• Simon Watson, Medical Director, Healthcare Improvement Scotland (SW)

Apologies

• Hugh Brown, National Primary Care Group, NHS Ayrshire and Arran (HB)

• Lorraine Cowie, Regional Manager, Interim (Cancer), NCA (LC)

• Asa Dahle-Smith, Medical Oncologist, NCA (ADS)

• David Dodds, Chief of Medicine for Regional Services, NHSGGC (DD)

• Kevin Freeman-Ferguson, Head of Service Review, Healthcare Improvement Scotland (KFF)

• Angela Jesudason, Paediatric Oncologist and Clinical Lead for the MSN CYPC Teenagers & Young Adults (AJ)

• Rob Jones, Consultant Medical Oncologist, NHSGGC (RJ)

• Hamish McRitchie, Clinical Lead Scottish Clinical Imaging Network (HMcR)

• Iain Tait, Consultant Surgeon and Clinical Director, NCA (IT)

• Stuart Thomas, Consultant Pathologist and Lead Clinician, Scottish Pathology Network (STH)

In attendance:

• Lorna Bruce, Audit Manager, SCAN (LB)
• Kevin Burton, Gynaecological Cancer MCN Clinical Lead, WoSCAN (KB)
• Mary Cairns, Consultant Gynaecological Oncologist, NCA (MC)
• David Cameron, Clinical Director, SCRN (DC)
• Charlie Gourley, Honorary Consultant In Medical Oncology, SCAN (CG)
• Aileen Keel, Director, Innovative Healthcare Delivery Programme (AK)
• Bryan McKellar, Programme Coordinator, NCA (BMcK)

Items and actions

Welcome, apologies and declarations of interest

(a) JM welcomed the group and introductions were made. A note of apologies are listed above. No declarations of interest were noted.

Action notes and minutes from the previous meeting – paper 1

a) The group considered the previous action note held on 21st December 2020 (Paper 1) and approved as an accurate record.

Matters arising

Ovarian cancer – feedback from NCA following preliminary survival analysis

JM advised that the Chairs of the NCQSG had received a response from NCA on behalf of Grant Archibald, Chief Executive of NHS Tayside outlining a 20 point ovarian cancer survival analysis action plan. This was discussed by the Medical Directors on 3rd March, however the Chairs have been asked not to share with the group as it has still to be shared with the wider clinical team.

It was noted that these documents should be transparent for shared learning purposes. ST raised the point that the action plan does not have any timelines attached which is important to see that any actions identified are being completed. This will be fed back to LC. ET raised the question around the timeframe for responding to such analysis, noting this has been a lengthy exercise with multiple analyses. There must be an end point agreed to move forward. The analysis is further discussed under item 5.
Lorraine Cowie

National upper GI cancer QPI report

JM sought an update on the action regarding a paper from NCA for Upper GI Cancer on low volume surgical services following approval by Medical Directors. BMcK advised that Medical Directors have met a few times since December and are moving towards a decision regarding all low volume surgery, rather than just specific to Upper GI cancer.

Governance

National ovarian cancer QPI report (2016-2019) – paper 2

KB presented to the group on behalf of the 3 regions an overview of the Ovarian Cancer QPI results that were published by PHS on 23rd February 2021. Overall performance is high across a number of QPIs with many targets being met on a regional/national level. Ovarian Cancer QPIs are currently undergoing the 2nd Cycle of Formal Review.
The following QPIs were noted for discussion:

QPI 3 (treatment planned and reviewed at MDT)

Regions have done well at discussing patients at MDTs. However, following some of the issues around survival analysis NCA felt that the definition of MDT should be further defined at formal review. WoSCAN and SCAN have one regional MDT as opposed to NCA where there are local MDTs in each of the 3 centres. Noted that there was a recent move in NCA to have a structured regional MDT where all patients are discussed from the 3 north cancer centres and the QPI has been changed to reflect this in the definition.

QPI 4 (patients with early stage disease have an early staging operation)

QPI target has been met in NCA and WoSCAN. KB and CG both advised that they did not have any feedback as to why the target has not been met in SCAN. This will be followed up. The Chairs will formally write to Cameron Martin the Clinical Lead for Ovarian Cancer in SCAN asking for a review of the patients in this QPI
James Mander / Seamus Teahan

QPI 9 (first line chemotherapy)

Performance is similar across the regions (80% - 82%) against the 90% target. Noted this is a difficult target to achieve due to patient frailty and also declining performance status from initial presentation to receiving chemotherapy. CG advised that it is clear internationally from studies that there is a percentage of patients that are just not fit enough for chemotherapy. 

QPI 10 (surgery for advanced diseased)

Again this QPI links closely with survival analysis. SCAN are consistently over the 60% target, WoSCAN just under and NCA performing lower for patients in 2018/19. Patients who undergo surgery have high rates of cytoreduction, however this may be due to patient selection. It was highlighted that this may change when there is an increase in the number of patients who undergo surgery including more complex cases.

MC discussed the survival analysis action plan for NCA noting that this is a revised version of a business case submitted in 2018 following the original survival data. Subsequent survival analysis has not shown any improvement in terms of offering surgery and advised that regional pathway co-ordination and other resources would be required to provide clinical and meaningful changes. Also noted lack of timelines for action points. 
AK stated that these differences in survival have been noted over a long period of time and have highlighted the requirement to re-visit escalation policies. The issues will also be raised during the next HIS review.
ST agreed adding that there is a need for a transparent way in which actions are identified and closed. This is an opportune time for the NCQSG when updating their Terms of Reference. 

QPI 12 (30 day mortality after first line treatment for ovarian cancer)

It was noted that there were no concerns over mortality and small numbers may skew figures in some Boards. 

QPI 13 (clinical trials)

High levels of recruitment to trials has been achieved across SCAN and WoSCAN. It was noted that time and resource to recruit as well as the geographical challenge in the north with 3 smaller centres has impacted on NCA results. NCA are looking at a regional collaborative model to allow better recruitment to trials, however highlighted the challenge with only one medical oncologist. CG stated that there may be an opportunity to take advantage of funding schemes to facilitate research. It was highlighted that both SCAN and WoSCAN have CRUK funded centres with academics who ultimately drive research. DC noted that a more geographic inclusive approach to trials is required and agreed to further discuss the position with ovarian cancer in the north to see how they can be supported.

No other issues were raised and JM thanked the Regional Clinical Leads for their contribution and ongoing clinical engagement.

Survival analysis

Ovarian cancer survival analysis update – paper 3

KB presented to the group an overview of the various iterations of ovarian cancer survival analysis that have been undertaken to date. Noted that although Scotland has made small improvements in terms of ovarian cancer outcomes, they are not doing as well as the rest of the UK.

Survival by network in the original analysis of 2013-16 cohort found significant differences across Scotland with the NCA having the poorest survival outcomes. The updated analysis (2016-18 cohort) with a more curtailed follow-up showed some separation but no significant differences between the 3 regions. 

The analysis highlighted that patients who undergo either primary or delayed surgery have much better outcomes than those with no surgery. The number of patients not having surgery in NCA is lower than SCAN and WoSCAN, however it is felt that overall the number of patients undergoing surgery across all regions is not adequate. Stage distribution also differed across the regions with more stage IV cases recorded in NCA compared to the other regions. The differences across the regions in resource and recruitment in both surgical and oncology teams was also noted. On looking at the non-surgical cohort in WoSCAN (approx. 300 patients) it was found that disease factors contributed most in decision making around non-surgical treatment. 

It was commented that ovarian cancer would benefit from being included in the small volume cancers work focussing on equitable access to care and treatment across Scotland. AK agreed that this should be on their workplan.

PS noted that the analysis was not age standardised and there was no sub-group analysis by ethnicity or area of deprivation which is important for survival outcomes and inequalities. It was also noted that net survival analysis is generally considered to be more accurate than cause-specific survival. Although agreed this is a valid point, the current data is enough to highlight that there is an issue.

CT presented a few brief slides outlining key differences noted from the analysis and discussed difficulties with undertaking multi-variate analysis and net survival with this data. It was suggested that analysis could be re-ran including a further 12 months follow up or repeated with 2019 data (and the same follow up period). 

Further discussion ensued on differences in management approaches, MDT discussion of some patients, and further exploration of staging. Concerns were raised by the Clinical Leads and others that the issues around ovarian cancer management, the continued underachievement in some of the ovarian cancer QPIs, the ongoing potentially discrepancies in survival from ovarian cancer and the lack of transparent progress in the NCA to address these areas. JM advised that there is enough concerns voiced in the meeting to escalate these concerns to the National Cancer Recovery Group as a matter of urgency. The Chairs will alert the NCA Management Team of this escalation immediately after the meeting.
James Mander / Seamus Teahan

Other tumour-specific survival analysis

CT advised that the team at PHS are currently looking at a longer term follow-up of the original 2013-16 ovarian cancer survival analysis and have also began to split this up into individual years. At present the team are not planning on doing a combined analysis of both cohorts.
Work is continuing in validating and cleaning the data for head and neck and upper GI cancers. Both are around 85% complete and analysis is due to commence in the next few weeks for Head and Neck Cancer. When initial results are available these will be shared with the networks as per the agreed process.

Assurance of national performance 

Proposed options for the cancer quality performance indicator review process 2021/21 – paper 4

SW provided a comprehensive update on the proposed assurance review process as outlined in paper 4.

The revised process was developed after consulting with key stakeholders over the last few months. HIS will review the most recent data available on the dashboard for one tumour type and develop key lines of enquiry which will be specific and focussed. An indicative timetable has been developed noting potential risks. Although only the first few reviews are noted, this will be seen as a rolling programme. 

CT highlighted that dashboard updates are also required for publication of reports and national meetings therefore there is a need for a joint plan by the cancer networks, HIS and PHS to ensure appropriate timings for all requirements to be met. SW noted that their timetable was designed around available data therefore they would be keen to confirm dates. 

ET discussed some of the practicalities involved with regards to timelines. E.g. if the data is only recently available then clinicians will be in the process of scrutinising this and developing action plans. These will then need to be implemented before any improvement will be demonstrated. There needs to be clarity as to the added value of reviewing at this point.

AK agreed that there is an issue around ensuring the timelines are optimal for review and also a requirement to get the process of scrutiny correct in order to compare QPIs across the country in a meaningful way.

ET enquired around the next steps as Melanoma is scheduled to start soon. LA acknowledges this and will pick up this point with ET outside of this meeting to discuss.

QPI reporting

Review of clinical trials and research access QPI

DC advised that the focus for the last 12 months has been on COVID however is aware that tumour types are struggling to meet the Clinical Trials and Research Access QPI despite a lot of effort in terms of maintaining research activity.

Certain challenges are known and acknowledged e.g. many trials require additional sub-stratification of the cancer which then deems them unsuitable following the process of consent. As part of cancer recovery, a subgroup has been set up which will look at teasing out the barriers to accessing trials whether these be at hospital, regional or national level and what can be done to enhance access for patients wherever they live in Scotland. There is also a need to assess what is being measured and if this needs changed, as well as looking into a regional process for recruitment.

DC advised that he does not necessarily think the QPI aids recruitment however it highlights where there are challenges and would be reluctant to remove this. Agreed that they do however need to reflect whether it is the correct QPI.

The subgroup will meet monthly and it is expected that barriers will be identified in approximately 2-3 months. Solutions are expected to take longer and progress will be fed back to this group in due course.

DM also stated that he would welcome any feedback on potential ways in which to improve the current measure.

SACT 30-day mortality

JD provided an update on progress with establishing QPI reports for SACT 30-day mortality using Chemocare data. Further work has now been progressed on the breast cancer reports by the regions with 4 out of 5 reports available and validated against the national platform. The treatment intent split now also seems to be fairly comparable across the regions. JD added that this is a time consuming process which will require to be done for all tumour types before the national system can be used to generate reports. There now also requires agreement on sign off of data, and whether timescales of reporting are manageable as renal cancer will also be due shortly, followed by prostate, upper GI and HPB cancers.

CT stated that one of the reasons this has taken so long is due to there being several different ways in which the reports can be ran. It was noted that PHE use a different methodology and there needs to be consensus as to the best methodology to use. 

In terms of patient cohorts it was agreed that it should be all patients undergoing SACT during a given time rather than just newly diagnosed patients which the QPI audit data captures. 

It was agreed that the National SACT Data Group should make a recommendation on the appropriate methodology to be used.
Catherine Thomson 

Information governance approach for the national analysis of QPI data 

CT provided an update on the information governance approach discussed at previous meetings and the associated Memorandum of Understanding (MoU) which is required.

A draft version of a single MoU covering all cancer datasets which includes separate appendices for each of the datasets and associated sign-off has been presented to the National Information Governance Leads meeting last week. This is utilising the terms of National Data Sharing Accord for sharing cancer data with PHS for the purposes of improving patient care. Taking this approach there is a requirement for the I.G. leads along with the support from the Caldicott Guardians in the Boards to sign-off this overarching MoU to allow data to flow in to PHS. Comment are due back from the I.G leads at the end of March 2021.

Following this the appendices will be finalised covering each of the datasets including QPIs, Cancer Registry, SACT, and Waiting Times data. These will also include extra detail that will outline the governance arrangements around publishing, processing and reporting.

QPI formal review process

QPI formal review 2nd cycle process update and delays to the schedule – paper 5

JD provided an update noting that paper 5 has been circulated which provides details of progress with the 2nd cycle of formal reviews along with information on some further delays that have been implemented due to Covid.

2nd cycle QPI formal reviews are progressing well with colorectal cancer being the only tumour group still outstanding prior to Covid. This has now undergone engagement, following which a delay to the finalisation meeting has been requested due to further Covid-related pressures in the north. 

In terms of other delays there has been a request for both sarcoma and testicular cancer to delay review for 12 months. It is proposed these may be slightly less than 12 months in order to align with available data from a further years reporting. In addition, the tumour types that were delayed most due to Covid. i.e. lung, upper GI and colorectal cancers are unlikely to undergo their 3rd cycle review at the appropriate time next year given there will be only one year of revised QPI reporting.

JD stated that the timetable is manageable over the next year, however this may become more challenging moving forward into the second half of cycle 3 in 2023. 

JM advised that the group are keen that there are no further delays assuming the conditions with the pandemic remain stable and advised that he is notified of any further requests.

NCQSG workplan 2019 – 2021 – paper 6

JD advised that the updated workplan was circulated for information with no further points to note. A revised and updated workplan is due to be developed in April 2021 which is timely with the review of the NCQSG Terms of Reference.

Risk and issues log – paper 7

(a) ET advised that the Risk and Issue Log was circulated for information.

AOCB

(a) Governance Review of national cancer groups
JM provided a brief update on the national cancer governance review which has recently been undertaken. As part of this review, there is a recommendation for the NCQSG to continue with a focus on governance, but also with an additional remit to drive improvement. As previously stated the Terms of Reference are to be discussed in more detail and further information shared with this group in due course.

DM enquired about the QPI data collected during Covid where patients management has been disrupted, and whether there should be additional things reported as well as the routine QPIs. ST stated that this will not be reported until around 12 months later when it is hoped there will be good progress being made with recovery. This demonstrates one of the challenges with QPI data collection and reporting.

Date of next meeting

Monday 21 June 2021, 10:00am to 1:00pm, via MS Teams