Review of Upper GI Cancer Quality Performance Indicators Consultation

Patients with oesophageal or gastric cancer should undergo endoscopy and biopsy to reach a diagnosis of cancer.

Proportion of patients with oesophageal or gastric cancer who have a histological diagnosis made within 6 weeks of initial endoscopy and biopsy.

For diagnosis of oesophageal or gastric cancer the use of endoscopy is recommended ².

A tissue diagnosis in cases of suspected oesophageal and gastric cancer requires adequate sampling of the suspicious lesion. Multiple biopsies should be obtained and the number of biopsies examined should always be reported. Repeat endoscopy and biopsy to obtain a diagnosis should be minimised ².

This QPI utilises a 6 week timeframe from initial endoscopy and biopsy to histological diagnosis. This has been deemed most appropriate by the QPI Review Group to account for clinical situations where the suspicion of malignancy is high however biopsy is not possible at the initial endoscopy procedure due to reasons such as anticoagulant use or gastric outlet obstruction.

Numerator:

Number of patients with oesophageal or gastric cancer who undergo endoscopy who have a histological diagnosis made within 6 weeks of initial endoscopy and biopsy ^[a] .

Denominator:

All patients with oesophageal or gastric cancer who undergo endoscopy.

Exclusions:

• No exclusions

95%

The tolerance within this target is designed to account for factors of patient choice.

Patients should be discussed by a multidisciplinary team prior to definitive treatment.

Proportion of patients with oesophageal or gastric cancer who are discussed at MDT meeting before definitive treatment.

Evidence suggests that patients with cancer managed by a multi-disciplinary team have a better outcome. There is also evidence that the multidisciplinary management of patients increases their overall satisfaction with their care ³.

Discussion prior to definitive treatment decisions being made provides reassurance that patients are being managed appropriately.

Numerator:

Number of patients with oesophageal or gastric cancer discussed at the MDT before definitive treatment.

Denominator:

All patients with oesophageal or gastric cancer.

Exclusions:

• Patients who died before first treatment.

95%

The tolerance within this target accounts for situations where patients require treatment urgently.

Patients with oesophageal or gastric cancer should be staged using the TNM ^[b] staging system and have statement of treatment intent recorded prior to treatment commencing.

Proportion of patients with oesophageal or gastric cancer who have TNM stage and treatment intent recorded at MDT meeting prior to treatment.

Please note: The specifications of this QPI are separated to ensure clear measurement of patients who have the following recorded at MDT meeting prior to treatment:

(i) TNM stage; and

(ii) Treatment Intent

It is important to discuss and consider treatment intent as patients with incurable disease treated as radical will be poorly served.

Patients with gastric or oesophageal cancer should undergo careful staging to assess the extent of disease and inform treatment decision making ². This may involve multiple investigations.

Clinical staging should follow the principles of TNM classification ⁴; this aids the determination of prognosis and choice of therapy. A statement regarding clinical stage and treatment intent should be recorded at the MDT. For patients presenting with metastatic disease it is not always possible or appropriate to determine T and N stage. Within the QPI T _xN _xM ₁ ^[c] is therefore accepted as complete staging in this situation.

Numerator:

Number of patients with oesophageal or gastric cancer who have TNM stage recorded at MDT meeting prior to treatment.

Denominator:

All patients with oesophageal or gastric cancer.

Exclusions:

• No exclusions

90%

The tolerance within this target accounts for situations where patients are not fit enough to undergo investigations and/or treatment; however, in these cases an attempt at TNM staging should be undertaken based on the information available. It also accounts for those patients who die before MDT meeting.

Numerator:

Number of patients with oesophageal or gastric cancer who have treatment intent recorded at MDT meeting prior to treatment.

Denominator:

All patients with oesophageal or gastric cancer.

Exclusions:

• No exclusions

95%

The tolerance within this target accounts for those patients who die before MDT meeting.

Patients with oesophageal or gastric cancer should be appropriately assessed by a dietitian to optimise nutritional status.

Proportion of patients with oesophageal or gastric cancer who undergo nutritional screening and are seen by a dietitian where appropriate before first treatment.

Please note: The specifications of this QPI have been separated to ensure clear measurement of patients who:

(i) Undergo nutritional screening with the Malnutrition Universal Screening Tool ( MUST) before first treatment; and

(ii) Are high risk of malnutrition ( MUST Score of 2 or more) and are seen by a dietitian before first treatment.

All patients with oesophageal or gastric cancer should be screened using a validated nutritional screening tool to assess nutritional risk. Those at risk of nutritional problems should have access to a state registered dietitian to provide appropriate advice ².

Poor nutritional status is a risk factor for poor tolerance of treatment whether curative or palliative and can impact greatly on quality of life ^5,6.

Patients who are suitable for radical treatment, e.g. surgery, and who are malnourished benefit from nutrition support prior to treatment and all patients who have surgery benefit from early post-operative enteral feeding. Both can reduce complications such as sepsis, poor wound healing and reduce length of stay ⁷.

Numerator:

Number of patients with oesophageal or gastric cancer who undergo nutritional screening with the MUST before first treatment.

Denominator:

All patients with oesophageal or gastric cancer.

Exclusions:

• No exclusions.

95%

The tolerance within this target accounts for those patients with very advanced disease who may not be fit for treatment, and for factors of patient choice.

Numerator:

Number of patients with oesophageal or gastric cancer at high risk of malnutrition ( MUST score of 2 or more) who are seen by a dietitian before first treatment.

Denominator:

All patients with oesophageal or gastric cancer at high risk of malnutrition ( MUST score of 2 or more).

Exclusions:

• No exclusions.

85%

The tolerance within this target accounts for situations where patients require treatment urgently as well as factors of patient choice.

Patients with oesophageal or gastric cancer whose treatment plan is neoadjuvant chemotherapy or chemoradiotherapy followed by surgery should progress to surgery following completion of this treatment.

Proportion of patients with oesophageal or gastric cancer who receive neo-adjuvant chemotherapy or chemoradiotherapy who then go on to have surgical resection.

Patients with oesophageal or gastric cancer who are suitable for surgical resection should be offered neoadjuvant chemotherapy treatment ^2,8,9. Neoadjuvant chemotherapy or chemoradiotherapy prior to surgery provides a survival benefit for patients with oesophageal or gastric cancer ^10,11.

It is optimal management that patients who undergo neoadjuvant chemotherapy or chemoradiotherapy proceed to resectional (curative) surgery; various reasons may affect this including initial under-staging of disease.

Numerator:

Number of patients with oesophageal or gastric cancer who receive neo-adjuvant chemotherapy or chemoradiotherapy who then undergo surgical resection.

Denominator:

All patients with oesophageal or gastric cancer who receive neo-adjuvant chemotherapy or chemoradiotherapy.

Exclusions:

• No exclusions

80%

The tolerance within this target accounts for the fact that some patients' disease may progress despite neo-adjuvant chemotherapy or chemoradiotherapy, and for factors of patient choice.

30 and 90 day mortality following surgical resection for oesophageal or gastric cancer.

Proportion of patients with oesophageal or gastric cancer who die within 30 or 90 days of surgical resection for oesophageal or gastric cancer.

Treatment related mortality is a marker of the quality and safety of the whole service provided by the Multi Disciplinary Team ( MDT) ¹².

Treatment should only be undertaken in individuals that may benefit from treatment, that is, disease specific treatments should not be undertaken in futile situations. This QPI is intended to ensure treatment is given appropriately.

Numerator:

Number of patients with oesophageal or gastric cancer who undergo surgical resection who die within 30/90 days of treatment.

Denominator:

All patients with oesophageal or gastric cancer who undergo surgical resection.

Exclusions:

• No exclusions

30 day - <5%

90 day - <7.5%

For patients with oesophageal or gastric cancer undergoing curative resection the number of lymph nodes examined should be maximised.

Proportion of patients with oesophageal or gastric cancer who undergo surgical resection where ≥15 lymph nodes are resected and pathologically examined.

Maximising the number of lymph nodes resected and analysed enables reliable staging which influences treatment decision making.

Evidence recommends that at least 15 lymph nodes are resected and examined by a pathologist ^9,13.

Numerator:

Number of patients with oesophageal or gastric cancer who undergo surgical resection where ≥15 lymph nodes are resected and pathologically examined.

Denominator:

All patients with oesophageal or gastric cancer who undergo surgical resection.

Exclusions:

• No exclusions

Gastric cancer - 80%

Oesophageal cancer - 90%

The tolerance within this target accounts for situations where patients are not fit enough to undergo extensive lymphadenectomy and for situations where surgical resection is performed for palliation.

Length of hospital stay following surgery for oesophageal or gastric cancer should be as short as possible.

Proportion of patients undergoing surgical resection for oesophageal or gastric cancer who are discharged within 21 days of surgical procedure.

Length of hospital stay acts as a surrogate measure for the quality of surgery and post-operative care for patients undergoing surgical resection for oesophagogastric cancer.

This QPI is intended as a surrogate marker to address various issues of quality care including surgery, post-operative complications and access to community services.

Numerator:

Number of patients undergoing surgical resection for oesophageal or gastric cancer who are discharged within 21 days of surgical procedure.

Denominator:

All patients undergoing surgical resection for oesophageal or gastric cancer.

Exclusions

• No exclusions

80%

The tolerance within this target is designed to account for situations where it is not safe or practical for patients to go home within 21 days of surgery.

Oesophageal and gastric cancers which are surgically resected should be adequately excised.

Proportion of patients with oesophageal or gastric cancer who undergo surgical resection in which surgical margin is clear of tumour, i.e. negative surgical margin.

Please note: The specifications of this QPI have been separated to ensure clear measurement of both:

(i) Oesophageal cancer patients who have a clear circumferential margin; and

(ii) Oesophageal and gastric cancer patients who have a clear longitudinal margin.

Tumour involvement of surgical resection margins is a negative prognostic factor; therefore surgery should aim to ensure resection margins are clear of tumour.

Oesophageal and gastric cancer resectional surgery should aim to ensure complete excision of the tumour, i.e. achieve an R0 resection, as this affects prognosis and long term patient outcome ^2,9.

Numerator:

Number of patients with oesophageal cancer who undergo surgical resection in which circumferential surgical margin is clear of tumour.

Denominator:

All patients with oesophageal cancer who undergo surgical resection.

Exclusions:

• No exclusions.

70%

Numerator:

Number of patients with oesophageal or gastric cancer who undergo surgical resection in which longitudinal surgical margin is clear of tumour.

Denominator:

All patients with oesophageal or gastric cancer who undergo surgical resection.

Exclusions:

• No exclusions.

90%

Patients with oesophageal or gastric cancer should undergo curative treatment whenever possible.

Proportion of patients with oesophageal or gastric cancer who undergo curative treatment, this includes:

• Neoadjuvant chemoradiotherapy or chemotherapy followed by surgery;
• Primary surgery;
• Radical chemoradiotherapy; and
• Endoscopic Mucosal Resection.

Curative treatment should be offered to as many patients as possible, as this is proven to have a survival benefit. The UK National Oseophago-Gastric Cancer Audit Report (2012) data demonstrate that around three-quarters of patients receiving treatment with curative intent survived at least 1 year from diagnosis. At two years, just over one-half of patients were still alive ¹⁴.

Surgical resection of the tumour remains the mainstay of curative treatment for patients with oesophageal or gastric cancer ¹⁴.

Chemoradiotherapy should be considered in patients with oesophageal cancer who have locally advanced disease, those unfit for surgery or those who decline surgery ².

Radiotherapy alone is an option in patients considered unsuitable for combination therapy but is rarely curative for oesophageal cancer ¹⁵.

Numerator:

Number of patients with oesophageal or gastric cancer who undergo curative treatment.

Denominator:

All patients with oesophageal or gastric cancer.

Exclusions:

• No exclusions

35%

The tolerance within this target takes into consideration patient choice, fitness and co-morbidities which preclude curative treatment.

It is intended as a composite measure of the entire diagnostic and staging pathway, but recognises that the majority of patients will have advanced disease at presentation.

30 and 90 day mortality following oncological treatment for oesophageal or gastric cancer.

Proportion of patients with oesophageal or gastric cancer who die within 30 or 90 days of oncological treatment ^[d] for oesophageal or gastric cancer.

Treatment related mortality is a marker of the quality and safety of the whole service provided by the Multi Disciplinary Team ( MDT) ¹².

Treatment should only be undertaken in individuals that may benefit from treatment, that is, disease specific treatments should not be undertaken in futile situations. This QPI is intended to ensure treatment is given appropriately.

Numerator:

Number of patients with oesophageal or gastric cancer who receive curative oncological treatment who die within 30 / 90 days of treatment.

Denominator:

All patients with oesophageal or gastric cancer who receive curative oncological treatment.

Exclusions:

• No exclusions

Please Note:

This indicator will be reported by treatment modality/intent as opposed to one single figure.

30 day - <5%

90 day - <7.5%

Numerator:

Number of patients with oesophageal or gastric cancer who receive palliative oncological treatment who die within 30 days of treatment.

Denominator:

All patients with oesophageal or gastric cancer who receive palliative oncological treatment.

Exclusions:

• No exclusions

Please Note:

This indicator will be reported by treatment modality/intent as opposed to one single figure.

<5%

All patients should be considered for participation in available clinical trials, wherever eligible.

Proportion of patients with Upper GI cancer who are enrolled in an interventional clinical trial or translational research.

Clinical trials are necessary to demonstrate the efficacy of new therapies and other interventions. Furthermore evidence suggests improved patient outcomes from participation in clinical trials ³.

Clinicians are therefore encouraged to enter patients into well-designed trials and to collect longer-term follow-up data.

High accrual activity into clinical trials is used as a goal of an exemplary clinical research site.

Numerator:

Number of patients with Upper GI cancer enrolled in an interventional clinical trial or translational research.

Denominator:

All patients with Upper GI cancer.

Exclusions:

• No exclusions

Interventional clinical trials - 7.5%

Translational research - 15%