National Cancer Quality Steering Group minutes: December 2022

Attendees and apologies

Present

• James Mander, Regional Lead Cancer Clinician, SCAN (Chair) - JM
• Seamus Teahan, Regional Lead Cancer Clinician, WoSCAN (Chair) - ST
• Jen Doherty, Project Co-ordinator, National Cancer Quality Programme - JD
• Kevin Freeman-Ferguson, Head of Service Review, Healthcare Improvement Scotland - KFF
• Hilary Glen, Consultant Medical Oncologist, NHSGGC - HG
• Bryan McKellar, Regional Manager (Cancer), NCA - BMcK
• Gregor McNie, Team Lead, Cancer Policy, Scottish Government - GMcN
• Matthew Barber, Consultant Breast Surgeon, NHS Lothian - MB
• Rafael Moleron, Consultant Clinical Oncologist, NCA - RM
• David Morrison, Director, Scottish Cancer Registry - DM
• Nicola McCloskey-Sellar, Regional Manager (Cancer), SCAN - NMS
• Noelle O’Rourke, National Lead for the Scottish Cancer Network - NO’R
• Lorna Porteous, GP and Clinical Lead Scottish Primary Care Cancer Group - LP
• Lorraine Stirling, Project Officer, National Cancer Quality Programme - LS
• Caroline Lauder, Senior Policy Manager, Scottish Government - CL
• Eve Thomson, Policy Advisor, Scottish Government - ETh
• Iain Tait, Consultant Surgeon and Clinical Director, NCA - IT
• Catherine Thomson, Service Manager (Population Health), Public Health Scotland (PHS) - CT
• Joris Van Der Horst, Consultant Respiratory Physician, NHSGGC - JVDH
• Joseph Woollcott, Health Influencing Senior Officer, Prostate Cancer UK - JW

Apologies

• Lesley Aitken, Senior Reviewer, Healthcare Improvement Scotland (HIS) - LA
• Lynsey Cleland, Interim Depute Director, HIS - LC
• Richmond Davies, Head of Service, PHS - RD
• Josephine Elliot, Programme Manager, HIS - JE
• Peter Hall, Consultant Medical Oncologist, SCAN - PH
• Angela Jesudason, Paediatric Oncologist and Clinical Lead for the MSN CYPC Teenagers and Young Adults- AJ
• Hamish McRitchie, Clinical Lead Scottish Clinical Imaging Network - HMcR
• Douglas Rigg, GP and Deputy Clinical Lead Scottish Primary Care Cancer Group - DG
• 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
• Evelyn Thomson, Regional Manager (Cancer), WoSCAN - ET
• Simon Watson, Medical Director, Healthcare Improvement Scotland - SW

In attendance

• Matthew Forshaw, Consultant Upper GI Surgeon, WoSCAN - MF
• Garry Hecht, Principal Information Analyst, PHS - GH
• Pauilius Leniauskas, Information Analyst, PHS - PL
• Andrew Martindale, Urological Cancers Clinical Lead, NCA - AM
• Melanie MacKean, Lung Cancer Clinical Lead, SCAN - MMK
• Alan McNeill, Urological Cancers Clinical Lead, SCAN - AMcN
• Angus Morton, Information Analyst, PHS - AMO
• Alison Rowell, Quality and Service Improvement Manager, WoSCAN - AR
• Clare Taylor, Senior Information Analyst, PHS - CFT
• Nkem Umez-Eronini, Urological Cancers Clinical Lead, WoSCAN - NUE

Items and actions

Welcome, apologies and declarations of interest

JM welcomed the group. A note of apologies are listed above.

No declarations of interest were noted.

Action notes and minutes from the previous meeting (paper 1)

The group considered the previous action note held on 12 September 2022 (paper 1) and approved as an accurate record.

Matters arising

Ovarian cancer – feedback from NCA on survival analysis action plan

BMcK advised that the ovarian cancer group continue to meet every six weeks to monitor progress against the action plan. Further analysis has been undertaken on the latest QPI data which shows the pathway timescales in NCA are comparable across Scotland and better for patients undergoing surgery and neo-adjuvant chemotherapy. The national staging guideline has been agreed and is progressing through the three regional cancer networks for formal sign-off. There is a joint SCAN/NCA advanced ovarian cancer MDT meeting where the learning is being adopted by the region.

BMcK added that the regional co-ordinator is now in post and has been helping to support auditing of the current MDT and revising the constitution. Next step includes looking at survival analysis for the 2018-2020 cohort of patients with supporting clinical commentary. A focus for NCA is on the higher proportion of stage IV patients and to encourage earlier presentation.

BMcK advised in relation to surgical capacity, the fourth remaining gynaecological oncology post is still outstanding and that the skill mix is currently being looked at to see if this can be filled (no applicants previously).

Recurrance data

ST advised that the Breast Cancer QPIs have recently undergone public engagement where a significant volume of responses have been received. In terms of the recurrence QPI there has been various feedback in support of the QPI, as well as others noting the difficulties with measurement and concerns around the resource required to collect the data.

JD stated that there has been a large number of comments from patients received via the Breast Cancer Now charity which relate to their particular treatment and experience. Work is ongoing to filter out those comments which do not relate to QPIs prior to the finalisation meeting taking place on 16th January 2023. A statement will be formulated in response to patient experience comments to ensure these can be directed appropriately.

ST stated that going forward a template will be developed to handle such comments that are out with the QPI process. It will also be made clearer within the engagement process, what is expected in terms of feedback.

Information governance approahc for the national analysis of QPI data

JD advised that the QPI data governance sub-group membership has now been identified which comprises clinical representatives and audit/information managers from each region along with colleagues from PHS. James Mansell, Consultant Breast Surgeon in the West has agreed to chair the group and dates will be sought for the initial meeting in January 2023. It is hoped the initial meetings will enable agreement of the process and following this data requests can be progressed via email.

The order of the agenda changed at this point.

Governance review of national cancer groups

Transition to National Cancer Quality Improvement Programme Board (NCQIPB)

ST advised that a meeting is due to take place on 17 January 2023 with colleagues from HIS, Scottish Cancer Network and Scottish Government to discuss the transition of the NCQSG to a National Cancer Quality Improvement Programme Board (NCQIPB). An update will be available at the next NCQSG meeting in March 2023 - Healthcare Improvement Scotland/Chairs NCQSG / Scottish Government

Assurance of national performance

Cancer quality performace indicatior review process 2022 update

KFF provided an update on the reviews undertaken to date and confirmed that the melanoma report was published on 10 November 2022. HIS have approached the Scottish Cancer Coalition and melanoma charity MASScot for patient/carer feedback. JM queried the statement at the end of the melanoma report around the actions that will be reviewed after a year. KFF confirmed at this point HIS will engage with the regions/boards around the action plans that have been developed and the progress around identified improvements.

The cervical and endometrial cancer QPI report has been sent to the regions for factual accuracy. Estimated time for publication is late January 2023. The acute leukaemia QPI report is currently in the process of being finalised before being sent to the regions in the new year for factual accuracy. The head and neck cancer report will follow thereafter.

KFF advised that the current QPI programme within HIS has been paused and further discussions will take place around external quality assurance following the transition of the NCQSG to a NCQIPB.

Governance

National prostate cancer QPI report (2018-2021 – paper 2)

The three regional urological cancer lead clinicians presented to the group an overview of the prostate cancer QPI performance due to be published by PHS on 13 December 2022. The third cycle of formal review for prostate cancer QPIs is currently ongoing.

A number of QPIs were discussed. Some main points are highlighted below:

• QPI 5: Surgical Margins (20%). Challenging QPI for WoSCAN with current results at 23%. It was noted there has been a reduction in surgeons from four to three along with a focus on nerve sparing procedures which aim to preserve functional outcome. NHSGGC are recruiting patients into a trial which aims to minimise positive margins while performing nerve sparing surgery. Team discussions are also underway looking at the impact on patients. AMcN advised that the QPI focuses on a specific cohort of pT2 patients who undergo radical prostatectomy which should not affect the margin rate. AMcN stated that there would be benefit in having QA meetings with larger groups rather than boards discussing within their own areas with a small number of surgeons. ST agreed with comments and noted that formal feedback is awaited from the Chief of Medicine
• QPI 6: Volume of Cases per Surgeon (minimum 50 procedures per surgeon in a one year period). PHS advised that this QPI is not visible on the dashboard due to the way in which data is presented by each of the regions. There is a link available within the published PHS report to these results. AMcN stressed the importance of high volume for good outcomes and noted that the REDCap Database which is currently under development will have a common dataset for all surgeons in Scotland going forward. BMcK stated that NCA are aware of the issues of low volume surgery and ‘Getting it Right for the North’ has a focus on how to best deliver surgery and the robotics programme. It was noted that there is often a desire for patients’ receiving treatment in local hospitals and the impact this has on quality. It is likely that this is an issue that HIS would focus on during review when this occurs. Post meeting note: Results for QPI 6 (target of minimum 50 procedures annually): West 2/3 surgeons met (1 surgeon undertook 45 procedures), SCAN 2 surgeons met, NCA 2/5 surgeons met (three surgeons undertook 30, 33 and 2 procedures), Agreed that Chairs would alert National Cancer Recovery Group around concerns about low volume prostate activity and the impact of an increased robotic programme - James Mander / Seamus Teahan
• QPI 7: Hormone Therapy and Docetaxel Chemotherapy. The 40% target has not been met by any of the NHS boards over the three years. Evidence and clinical practice has changed to allow further treatment regimens to be included which will improve outcomes for patients. This will form part of the revisions at the ongoing formal review.
• QPI 8: Post-Surgical Incontinence. This QPI has been successfully implemented in SCAN due to the recording of functional outcomes via the REDCap electronic system hosted by PHS. An email containing links will be sent to the patient pre-op and at three and 12 month intervals post-op. The QPI is being updated to include patients undergoing all radical treatments and measure all functional outcomes rather than solely concentrate on incontinence. Work is underway to transfer this system onto a PHS server to enable all regions to access for use. It was suggested in future this could also be used for radiotherapy toxicity outcomes.
• QPI 11: Management of Active Surveillance. The 95% target has not been met over the previous two years, mainly due to patients having MRI scans just before the 12-18 month timeframe. Timing has been adjusted slightly during formal review. AMcN stated that there are no concerns around the quality of active surveillance
• QPI 14: Diagnostic Pre-biopsy MRI with PI-RADS/Likert Grading. QPI performance is significantly lower in SCAN compared with the other regions. AM stated that cross-regional discussion would be useful to see what measures have been taken within NCA and WoSCAN to achieve consistent reporting. JM added that this has been discussed at the SCAN Regional Planning Group resulting in Medical Directors writing to radiologists asking for this to be actioned
• QPI 15: Low Burden Metastatic Disease. Initially results were low in WoSCAN for recording burden of disease however this has improved since including in the annual teaching programme. It was noted that patients not getting radiotherapy were appropriate, however if the West remains consistently lower then it requires further investigation to see if any other factors are involved

Areas of concern not covered by QPIs include the single surgeon issue from a NCA perspective, and theatre capacity within SCAN impacting on waiting times. The main focus from WoSCAN is improving surgical margin rates. HG added that delivery of systemic therapy remain a big issue across all regions, particularly with new drugs being approved by SMC. JM advised that David Cameron (Clinical Director, Scottish Cancer Research Network) updated the NCRG on this situation regarding the delivery of SACT across the country and the need for urgent discussion of new drugs.

JM thanked the Regional Clinical Leads for their contribution and ongoing clinical engagement.

National cancer quality programme – highlight report (paper 5)

Highlight report

JD spoke to paper 5 which outlines progress on a number of key areas within the Quality Programme. In terms of the QPI Formal Reviews, the only item for attention is the breast cancer QPI engagement comments already discussed under matters arising. All other tumour types are progressing as per the report.

Cancer QPI dashboard (public version) – additional paper 8

GH spoke to paper 8 regarding concerns raised at the previous meeting around potential disclosure issues when creating a public facing dashboard. The group felt that numbers less than five in the audit should be suppressed to protect confidentiality, particularly in smaller boards within NCA.

An example was shown (Cervical Cancer QPI 4 – Radical Hysterectomy) which has a number of exclusions resulting in small numbers across all regions. GH stressed the number of different factors involved in the QPI criteria and exclusions which would make it difficult to identify one particular patient. It was also noted that if you apply the same logic to large denominators where only one patient does not meet, potentially that could also be identifiable. If all results are suppressed, the utility of the dashboard becomes questionable.

JM highlighted that boards may wish to be involved in decisions as there could be legal implications if a patient become identifiable. BMcK agreed that ultimately this is health board data and he requires the opportunity to discuss within NCA prior to a decision being reached.

ST highlighted that where there are such small numbers there may also be a question around the usefulness of the QPI. It was also noted that networks need to check their reports as not all have numbers suppressed to date.

JM suggested this still requires further discussion, and feedback should be sought from individual boards via Regional Cancer Planning Groups around how the data is presented - Evelyn Thomson, Bryan McKellar, Nicola McCloskey-Sellar

Agreed governance process for publication of cancer QPI survival analysis reports – paper 6

CT advised that the governance process for the publication of cancer QPI survival analysis reports had been previously agreed by the three regional networks. However, there is now a requirement for a further amendment since analysis is being discussed with the group prior to publication on the PHS website. Agreed if the timing was appropriate this should be incorporated - Catherine Thomson

Lung cancer PHS survival analysis

1 January 2018 – 31 December 2019 with follow-up to 30th June 2022 (paper 3)

CT spoke through the lung cancer survival analysis (paper 3) that was presented at the recent Scottish Lung Cancer education event on 18th November 2022. The cancer types were broken down into 3 group’s i.e. non-small cell lung cancer (NSCLC), small cell lung cancer (SCLC) and clinical diagnosis.

It was noted that there was no significant survival difference between the networks for all three groups. It is however known that there are differences in deprivation, stage and clinical management across the networks therefore the Lung Cancer Leads feel that further analysis is required to look at this in more detail.

MMK stated that audit staff within SCAN have been proactive in checking other systems e.g. GRO data as alternative sources to identify more (potentially sicker) patients which may impact on survival. JD advised that this was raised at the recent NCQOG meeting with an action for Regional Audit Managers to identify any variation in case ascertainment processes with a view to producing a consensus going forward.

ST queried survival in Scotland compared to other parts of the UK and further afield. JVDH advised that the UK is behind Europe and lagging in the UK although there are improvements.

JM suggested there is a wider discussion required around MDT practices and decision making, standardisation of histology etc. NO advised caution when comparing between centres as there are so many factors involved and often it could be the same oncologist in different places with different treatments available.

In terms of further analysis, CT advised that PHS have several different survival analyses ongoing at the moment and it would be useful to have a discussion to determine priorities going forward. - Catherine Thomson

National oesophago-gastric cancer audit (NOGCA)

Upper GI Cancer collaboration with the national oesophago-gastric cancer audit (NOGCA) for England and Wales (paper 4)

MF presented to the group an overview of progress to date on a benchmarking collaboration with Scottish QPI data with the National Oesophago-Gastric Cancer Audit (NOGCA) for England and Wales. This involved input from the three regional Audit Managers and analysts along with the Clinical Effectiveness unit at the Royal College of Surgeons of England. MF advised that up to this point there has been no UK wide comparison. The NOGCA audit process differs as it involves prospective data collection which is very dependent on hospital staff submitting data.

As part of this collaborative a limited number of comparative measures were chosen to be analysed free of charge. The number of patients diagnosed over this time period in each of the three years is consistent across each of the countries, however Scotland demonstrates high case ascertainment levels in comparison. Scotland also showed a higher level of CT scan recording, and there was variation in TNM versions used between countries/networks.

MF discussed curative treatment rates which has not historically been met for oesophageal and gastric cancer. This benchmarking exercise has allowed for further analysis and adjusted data shows that Scotland has a similar curative treatment rate as England (better than Wales). Surgical outcomes were also discussed which show Scotland sitting in the middle between England and Wales. A lower positive margin rate is also seen which is re-assuring. It could be argued this has been driven by QPIs, however could also be differences in patient selection for surgery or higher rates of minimally invasive surgery in England which can make assessment of margins intraoperatively more difficult.

MF stated that this has been a valuable benchmarking exercise which has proven that there can be a valid comparison between the two audits, and it is hoped that there can be expansion of comparable measures in future. It was noted that there is still variation in treatment patterns between the three networks therefore there is still a need for further survival analysis. MF confirmed there was no cost involved in this audit and has been a long term aim of AUGIS (Association of Upper GI Surgeons of GB and Ireland) to engage in this type of work.

The Chairs thanked MF for attending the meeting today and for speaking through a very informative presentation.

Risk and issues log

The risk and issue log was circulated for information. JD advised that since the last meeting an additional risk (I.D 6) has been added for eCASE in terms of the functionality of the system due to the outdated technology. This has been reduced from high risk to medium as a technical refresh can be carried out which will provide temporary stability until a longer term solution can be costed and implemented.

Any other competent business

International cancer benchmarking program (ICBP) – oesophageal network event

An International Cancer Benchmarking Program event for oesophageal cancer will take place in January 2023. WoSCAN and NCA have put forward nominations, while SCAN have circulated the invite and interested colleagues will link directly.