Brain and central nervous system cancer: clinical quality performance indicators - engagement document

6. Quality Performance Indicators for Brain/CNS Cancer

QPI 1: Documentation of Performance Status

QPI Title: Patients with newly-diagnosed brain/central nervous system (CNS) cancer should have a world health organisation (WHO) performance status documented at time of multi-disciplinary team (MDT) discussion.

Description: Proportion of newly-diagnosed patients with brain/CNS cancer who have a documented WHO performance status at the time of multi-disciplinary team (MDT) discussion.

Rationale and Evidence: Performance status is an important prognostic indicator in patients with brain/CNS cancer. Accurate communication of performance status is vital in guiding complex management decisions, including recruitment into clinical trials².

In patients referred from other sites, who have not yet met a member of the neuro-oncology MDT, an estimated performance status should be given, based on the available information from the referring site.

For ease of measurability within this QPI, it is specifically the WHO performance status that is used. It is recognised that other tools exist and more complex decision making may be undertaken in order to inform treatment options for patients.

Specification:

Numerator: Number of newly-diagnosed patients with brain/CNS cancer discussed at MDT meeting with a documented WHO performance status at the time of MDT discussion.

Denominator: All newly-diagnosed patients with brain/CNS cancer discussed at MDT meeting.

Exclusions: No exclusions.

Target: 95%

The tolerance within this target is designed to account for situations where there is insufficient information available from the referring site to estimate the WHO performance status.

Please note:The MDT Chair should try to ensure that a valid performance status is documented on MDT outcome.

Revision(s): No change to QPI or measurement

QPI 2: Multi-disciplinary Team Meeting

QPI Title: Patients with brain/CNS cancer should be discussed by a multidisciplinary (MDT) team prior to any surgical procedure^[1].

Description: Proportion of patients with brain/CNS cancer who are discussed at MDT meeting before surgery.

Rationale and Evidence: 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 care³.

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

In the majority of cases, patients with Brain / CNS Cancer will undergo surgery (biopsy or resection) as their initial intervention prior to any further treatment. The measurement of this QPI will therefore focus on discussion of patients at this initial point within the clinical pathway.

Specification:

Numerator: Number of patients with brain/CNS cancer discussed at the MDT before surgery.

Denominator: All patients with brain/CNS cancer undergoing surgery.

Exclusions: Patients who died before first treatment.

Target: 90%

The tolerance within this target is designed to account for situations where patients require treatment urgently.

Revision(s): No change to QPI or measurement

QPI 3: Molecular Analysis

QPI Title: Patients with biopsied or resected gliomas should have molecular analysis performed on the tumour tissue within 28 days of surgery to inform diagnosis and treatment decision making.

Description: Proportion of patients with biopsied or resected gliomas who undergo relevant molecular analysis^[2] of tumour tissue within 28 days of surgery.

Please note: This QPI measures 3 distinct elements:

(i): Patients with IDH-wildtype diffuse astrocytic gliomas lacking microvascular proliferation and necrosis who have EGFR gene amplification testing, chromosome 7 and 10 copy number analysis, and TERT gene promotor mutation testing; and

(ii): Patients with IDH-mutant and ATRX-wildtype diffuse gliomas who have 1p/19q co-deletion status confirmed; and

(iii): Patients with IDH-mutant astrocytomas who have testing for homozygous deletion of CDKN2A/B.

Rationale and Evidence: Identifying genetic alterations in brain tumours is crucial for accurate diagnosis and informing subsequent clinical management.

To identify tumours associated with the most aggressive behaviour, there is strong evidence to support EGFR testing, chromosome 7 and 10 copy number analysis, and TERT gene promotor mutation testing. Whole chromosome 7 gain together with whole chromosome 10 loss, EGFR amplification or TERT promoter mutation are strong markers in identifying IDH-wildtype diffuse astrocytic gliomas with grade 4 clinical behaviour^4,5.

It is also recommended that CDKN2A/B homozygous deletion testing should be performed on IDH-mutant astrocytomas. CDKN2A/B deletion has been shown to be an adverse prognostic factor in these specific tumour types⁴.

Combined loss of 1p/19q in gliomas is associated with a more favourable response to therapy (chemotherapy or radiotherapy) and is associated with considerably better prognosis when compared to tumours with intact 1p/19q. As such, where indicated, 1p/19q analysis should be carried out to help determine treatment and provide information on predicted tumour response to therapy and prognosis^2,6,7.

The group have added a 28 day timeframe to allow for initial IDH testing and ensure that the molecular analysis is undertaken and reported before treatment takes place.

Specification (i):

Numerator: Number of patients with IDH Wildtype diffuse astrocytic gliomas lacking microvascular proliferation and necrosis who have EGFR gene amplification testing, chromosome 7 and 10 copy number analysis, and TERT gene promotor mutation testing within 28 days of surgery.

Denominator: All patients with IDH Wildtype diffuse astrocytic gliomas lacking microvascular proliferation and necrosis undergoing surgery

Exclusions:

• No exclusions.

Specification (ii):

Numerator: Number of patients with IDH-mutant and ATRX-wildtype diffuse gliomas who have 1p/19q co-deletion status confirmed within 28 days of surgery.

Denominator: All patients with IDH-mutant and ATRX-wildtype diffuse gliomas undergoing surgery.

Exclusions:

• No exclusions.

Specification (iii):

Numerator: Number of patients with IDH-mutant astrocytomas who have testing for homozygous deletion of CDKN2A/B within 28 days of surgery.

Denominator: All patients with IDH-mutant astrocytomas undergoing surgery.

Exclusions:

• No exclusions.

Target: Specifications (i), (ii) and (iii) 90%

The tolerance within this target level is designed to account for cases in which there is insufficient viable tissue for molecular analysis.

Revision(s):

• QPI has been amended to reflect advances in molecular testing and tumour diagnostics.
• Clinical cohorts and tests have been revised. Comprises of 3 separate specifications.

QPI 4: Neuropathological Diagnosis

Revision(s):

• This QPI has been archived – the QPI target has been consistently met across all regions over the previous 3 years. This is considered standard practice across Scotland.

QPI 6: Maximal Surgical Resection

QPI Title: Where considered consistent with a safe outcome, patients should undergo maximal surgical resection of malignant gliomas^[3] with the use of surgical techniques^[4] to aid the extent of resection.

Description: Proportion of patients with malignant glioma (with enhancing component on pre-operative imaging) who undergo surgical resection where >=90%^[5] reduction in tumour volume is achieved and one or more surgical techniques have been used to aid the extent of resection.

Please Note: the specifications of this QPI are separated to ensure clear measurement of patients with malignant glioma (with enhancing component on pre-operative imaging) who undergo surgical resection:

(i) Where >=90% reduction in tumour volume is achieved; and

(ii) Where >=90% reduction in tumour volume is achieved and one or more surgical technique has been used to aid the extent of resection.

Rationale and Evidence: The extent of surgical resection is an independent prognostic factor in Grade III and Grade IV malignant gliomas. Maximal safe surgical resection (>=90%) prolongs time to tumour recurrence⁸ and is associated with prolonged survival⁹. Maximum safe surgical resection is recommended by several published guidelines¹⁰.

Evidence has shown that the use of 5-ALA guided resection is more likely to result in complete or near-complete removal of the tumour and therefore improve progression free survival^11,12.

Intraoperative MRI or intraoperative ultrasound are other techniques which should be considered to help achieve surgical resection, and awake craniotomy to preserve neurological function¹².

Please refer to all footnotes for further information around the measurement of this QPI.

QPI 6: Maximal Surgical Resection (continued)

Specification (i):

Numerator: Number of patients with malignant glioma (with enhancing component on pre-operative imaging) undergoing surgical resection where >=90% reduction in tumour volume is achieved.

Denominator: All patients with malignant glioma (with enhancing component on pre-operative imaging) undergoing surgical resection.

Exclusions:

• Patients undergoing biopsy only.

Target: 40%

Specification (ii)

Numerator: Number of patients with malignant glioma (with enhancing component on pre-operative imaging) who undergo surgical resection where >=90% reduction in tumour volume is achieved and one or more surgical techniques have been used to aid the extent of resection.

Denominator: All patients with malignant glioma (with enhancing component on pre-operative imaging) who undergo surgical resection where >=90% reduction in tumour volume is achieved.

Exclusions:

• Patients undergoing biopsy only.

Target: 50%

Please note: Additional information on the total number of patients with high grade glioma who undergo surgical resection/partial debulking will be reported alongside this QPI. This information will be reviewed to identify whether there is variation in practice between these surgical management options for patients across the regions.

Revision(s):

• Current QPI is now Specification (i) – no change
• Specification (ii) added to capture the use of one or more techniques to aid the extent of resection.
• Additional information to be reported alongside this QPI on the total number of high grade glioma patients undergoing surgical resection / partial debulking.

QPI 7: Early Post-Operative Imaging

QPI Title: Patients with malignant gliomae (with enhancing component on pre-operative imaging) undergoing surgical resection should be subject to early post-operative imaging.

Description: Proportion of patients with malignant glioma (with enhancing component on pre-operative imaging), who receive early post operative imaging with Magnetic Resonance Imaging (MRI) within 3 days (72hrs) of surgical resection.

Rationale and Evidence:

Post operative imaging:

(i) provides a measurement of surgical performance;

(ii) helps to determine if further treatment is required;

(iii) helps determine what further treatment might be appropriate;

(iv) estimates residual tumour to help target radiotherapy when needed; and

(v) helps to assess prognosis

Imaging should be carried out within 72hrs to enable reliable assessment of the extent of the resection^13-17. MRI is the preferred imaging method for patients with glioma.

After this time period, changes in the tumour resection bed confound estimation. Delaying assessment until these changes settle is inappropriate as regrowth of high-grade tumours can occur rapidly and also post operative treatments such as radiotherapy and chemotherapy are normally instituted rapidly which could further affect the images.

Specifications:

Numerator: Number of patients with malignant glioma (with enhancing component on pre-operative imaging), undergoing surgical resection who receive MRI within 3 days (72hrs) of surgical resection.

Denominator: All patients with malignant glioma (with enhancing component on pre-operative imaging), undergoing surgical resection.

Exclusions:

• Patients unable to undergo an MRI scan^[6] e.g.-
  • Pacemaker or other MRI incompatible implanted device.
  • Cerebral aneurysm clip.
  • Contraindication to intravenous contrast medium.
• Patients who refuse MRI.
• Patients undergoing biopsy only.

QPI 7: Early Post-Operative Imaging (continued)

Target: 90%

The tolerance within this target is designed to account for situations where patients are deemed unfit to attend for imaging within the stated timeframe.

Revision(s):

• No change to QPI

QPI 9: Access to Oncological Treatment

QPI Title: The maximum time between surgery and oncological treatment for patients with high grade glioma (world health organisation (WHO) grades III and IV) should be 6 weeks.

Description: Proportion of patients with high grade glioma (WHO grades III and IV) undergoing surgery who commence their oncological treatment (chemotherapy, radiotherapy, or chemoradiotherapy) within 6 weeks of surgery.

Rationale and Evidence: Evidence demonstrates a negative impact on patient outcome if adjuvant treatment is delayed. It has been reported that by delaying oncological treatment, the risk of death increased by 8.9% for each week from the date of first surgery¹⁸.

In addition, evidence shows that patients commencing radiotherapy within 6 weeks of the date of surgery had improved overall survival¹⁹.

Specifications:

Numerator: Number of patients with high grade glioma (WHO grades III and IV) who undergo oncological treatment (chemotherapy, radiotherapy, or chemoradiotherapy) who commence treatment within 6 weeks of surgery.

Denominator: All patients with high grade glioma (WHO grades III and IV) who undergo oncological treatment (chemotherapy, radiotherapy, or chemoradiotherapy) following surgery.

Exclusions:

• No exclusions.

Target: 90%

The tolerance within the target is designed to account for patients with post-operative complications and those situations where oncological treatment may be delayed due to patient choice.

Revision(s):

• No change to QPI

QPI 11: Seizure Management

QPI Title: Patients with brain/CNS cancer presenting with seizures at diagnosis should be seen by a neurologist and/or a named epilepsy specialist nurse (ESN).

Description: Proportion of patients with brain/CNS cancer presenting with seizures at diagnosis who are seen by a neurologist or a named ESN within four months of first MDT discussion.

Rationale and Evidence: Diagnosing epilepsy can be complex and it is crucial that specialists are involved early to avoid misdiagnosis²⁰.

The diagnosis of epilepsy is more accurate when made by a medical practitioner who specialises in epilepsy, resulting in better patient outcomes. Access to a specialist nurse with expertise in epilepsy management enhances the quality of life for patients and gives a more patient centred approach to care^21,22.

The QPI Formal Review Group agree that a timeframe of 4 months is appropriate for this intervention given the multiple appointments, treatments and abundance of information being provided during the earlier stages of diagnosis.

Specification:

Numerator: Number of patients presenting with seizures at diagnosis seen by a neurologist or a named ESN within four months of first MDT discussion.

Denominator:

All brain/CNS cancer patients presenting with seizures at diagnosis.

Exclusions:

• No exclusions

Target: 95%

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

Revision(s):

· Timeframe within QPI changed from four weeks to four months.

· The QPI Formal Review Group agree that four weeks is not a realistic timeframe and more importantly is not appropriate for the patient given the multiple appointments, treatments and wealth of information all being provided during the initial stages of diagnosis.

QPI 12: Key Worker

Revision(s):

• This QPI has been archived – performance is consistently low year on year largely due to documentation issues and is not driving improvement for patients.
• The key worker can change over time and measuring the quality of co-ordinated care throughout the pathway is better assessed using a qualitative approach.

QPI 13: 30 Day Mortality after Treatment for Brain/CNS Cancer

QPI Title: 30 day mortality following treatment for brain/CNS cancer.

Description: Proportion of patients with brain/CNS cancer who die within 30 days of treatment (surgery, radiotherapy or chemoradiotherapy) for brain / CNS cancer.

Rationale and Evidence: Treatment related mortality is a marker of the quality and safety of the whole service provided by the Multi Disciplinary Team (MDT)³.

Outcomes of treatment, including treatment related morbidity and mortality should be regularly assessed.

Treatment should only be undertaken in individuals that may benefit from that treatment, that is, treatments should not be undertaken in futile situations. This QPI is intended to ensure treatment is given appropriately, and the outcome reported on and reviewed.

Please note: 30 Day Mortality for Systemic Anti-Cancer Therapy (SACT) is measured separately from the QPI process. National SACT data from CEPAS (Chemotherapy Electronic Prescribing and Administration System) is utilised to support reporting and monitoring of this measure rather than audit data. This methodology allows the whole population of patients with brain/CNS cancer undergoing SACT to be captured rather than those newly diagnosed within the audit.

Specifications:

Numerator: Number of patients with brain/CNS cancer who undergo treatment that die within 30 days of treatment.

Denominator: All patients with brain/CNS cancer who undergo treatment (surgery, radiotherapy or chemoradiotherapy).

Exclusions:

• No exclusions.

Please note: This indicator will be reported by treatment modality, i.e. surgery, radiotherapy, chemoradiotherapy as opposed to one single figure.

Target: <5%

Revision(s):

• Note added within the rationale to explain why 30 Day Mortality following SACT is not included within the QPI.
• No change to QPI measurement.

QPI 14: Clinical Trials and Research Study Access

Revision(s):

• This QPI has now been removed from the individual tumour specific QPI documents and will be replaced by trials activity measures reported via the Scottish Cancer Research Network.

QPI 15: 30 Day Mortality following Systemic Anti-Cancer Therapy (SACT)

Revision(s):

• This QPI has now been removed from the QPI process and is reported by Public Health Scotland using national SACT data which has been checked and validated across Scotland.

QPI 16: Access to Timely Surgery – NEW QPI

QPI Title: Patients with high grade glioma (WHO Grades III and IV) should undergo timely surgery.

Description: Proportion of patients with high grade glioma (WHO Grades III and IV) who undergo surgery within 14 days of MDT discussion.

Rationale and Evidence: Due to the fact that some patients may present with non-specific symptoms, it is important that once a radiological diagnosis has been established, timely treatment should commence.

Patients who may improve should be identified and undergo more urgent resection in order not to hinder Karnofsky Performance Scale (KPS) score improvement²³.

Evidence suggests that glioblastoma surgery should not be delayed for longer than a month from the initial diagnostic scan²⁴.

Specification:

Numerator: Number of patients with high grade glioma (WHO Grades III and IV) who undergo surgery within 14 days of MDT discussion.

Denominator: All patients with high grade glioma (WHO Grades III and IV) who undergo surgery (biopsy or resection).

Exclusions:

• No exclusions

Target: 75%

The tolerance within this target accounts for the fact that not all patients will be suitable for surgery within the optimal timeframe due to co-morbidities or factors of patient choice.

Revision(s):

• NEW QPI

QPI 17: Neuropsychological Assessment - NEW QPI

QPI Title: Patients with malignant glioma should have access to neuropsychology assessment during their treatment pathway.

Description:

Proportion of patients with malignant glioma undergoing surgical resection who are seen by a Clinical Neuropsychologist/Clinical Psychologist for assessment prior to and following surgery.

Please note: The specifications of this QPI are separated to ensure clear measurement of patients who are seen by a Clinical Neuropsychologist/Clinical Psychologist:

(i) Within 4 weeks prior to surgery; and

(ii) Within 4 weeks after surgery.

Rationale and Evidence: Neuropsychological assessment is a key component in the management of patients with brain tumours both pre and post-operatively^25,26,27. It is an important adjunct to identify cognitive symptoms and can be used to aid treatment planning²⁵.

Treatment options including surgical resection comes with a risk of cognitive impairment, therefore it is important to assess this both before and after surgery in order to understand the impact with regards to functional outcomes for patients^,26,27.

It has been suggested that cognitive assessment prior to surgery helps predict cognitive outcomes better than tumour topography or tumour volume²⁶.

Specification (i):

Numerator: Number of patients with malignant glioma undergoing surgical resection who are seen by a Clinical Neuropsychologist/Clinical Psychologist within 4 weeks prior to surgery.

Denominator: All patients with malignant glioma undergoing surgical resection.

Exclusions:

• Patients who decline assessment.
• Patients undergoing biopsy only

Specification (ii):

Numerator: Number of patients with malignant glioma undergoing surgical resection who are seen by a Clinical Neuropsychologist/Clinical Psychologist within 4 weeks after surgery.

Denominator: All patients with malignant glioma undergoing surgical resection.

Exclusions:

• Patients who decline assessment.
• Patients undergoing biopsy only.

Target: 80%

The tolerance within this target is designed to account for those patients with comorbidities, or very advanced disease who may not be fit for assessment.