National Cancer Quality Steering Group action note: December 2021

Attendees and apologies

Present

• Seamus Teahan, Regional Lead Cancer Clinician, WoSCAN (Chair), ST
• Matthew Barber, Consultant Breast Surgeon, NHS Lothian, MB
• Jen Doherty, Project Co-ordinator, National Cancer Quality Programme, JD
• Hilary Glen, Consultant Medical Oncologist, NHSGGC HG
• Rob Jones, Consultant Medical Oncologist, NHSGGC RJ
• James Mander, Regional Lead Cancer Clinician, SCAN (Chair), JM
• Bryan McKellar, Interim Regional Manager (Cancer), NCA, BMcK
• Gregor McNie, Team Lead, Cancer Policy, Scottish Government, GMcN
• David Morrison, Director, Scottish Cancer Registry, DM
• Noelle O’Rourke, National Lead for the Scottish Cancer Network, NO’R
• Peter Sandiford, Deputy National Clinical Lead, Cancer QPI Review Group, Healthcare Improvement Scotland, PS
• Lorraine Stirling, Project Officer, National Cancer Quality Programme, LS
• Iain Tait, Consultant Surgeon and Clinical Director, NCA, IT
• Catherine Thomson, Service Manager (Population Health), Public Health Scotland, 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, LA
• Bobby Alikhani, Regional Manager (Cancer), SCAN, BA
• Tiffany Bonnar, Programme Manager, HIS, TB
• Hugh Brown, National Primary Care Group, NHS Ayrshire and Arran, HB
• Seona Carnegie, Policy Manager, Cancer Policy Team, Scottish Government, SC
• Lynsey Cleland, Interim Depute Director, HIS, LC
• Richmond Davies, Head of Service, PHS, RD
• Asa Dahle-Smith, Medical Oncologist, NCA, ADS
• 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
• Hamish McRitchie, Clinical Lead Scottish Clinical Imaging Network, HMcR
• Nadeem Siddiqui, National Clinical Lead, Cancer QPI Review Group, Healthcare Improvement Scotland, NS
• Stuart Thomas, Consultant Pathologist and Lead Clinician, Scottish Pathology Network, STH
• Evelyn Thomson, Regional Manager (Cancer), WoSCAN, ET
• Nkem Umez-eronini, Regional Clinical Lead, Urological Cancers, WoSCAN, NUE
• Simon Watson, Medical Director, Healthcare Improvement Scotland, SW

In attendance

• Lorna Bruce, Audit Manager, SCAN, LB
• Garry Hecht, Information Analyst, PHS, GH
• Tom Godfrey, Information Analyst, PHS TG
• Param Mariappan, Regional Lead, Urological Cancers, SCAN, PM
• Andrew Martindale, Regional Lead, Urological Cancers, NCA, AM
• Alison Rowell, Quality and Service Improvement Manager, WoSCAN, AR
• Carolyn Sunners, Senior Health Policy Advisor, Scottish Government, CS

Items and actions

Welcome, apologies and declarations of interest

ST welcomed the group and those in attendance. Also welcomed were new members Joseph Woollcott who has replaced Gerard McMahon as coalition member from Prostate Cancer UK. Richmond Davies has also joined the group replacing Elaine Strange as Head of Service at PHS and will be in attendance at a future meeting.

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 14 September 2021 paper 1) and approved as an accurate record.

Matters arising

Ovarian Cancer – Feedback from NCA on survival analysis action plan

BMcK presented to the group the current position in relation to the actions identified on the ovarian cancer action plan. Malcolm Metcalf, Associate Medical Director in NHS Grampian has been appointed lead of the action plan group which meets every six weeks.

A number of actions have been completed to date i.e. adoption of SCAN surgery guidelines and updates to NCA Clinical Management Guidelines; further investigations into staging differences with Radiology presenting difficult cases; and the establishment of a Regional MDT with improved communication and attendance from the three centres.

There has also been funding secured for a regional pathway coordinator (due to start in January 2022 and for an additional two surgical posts to bring the complement to four (advertised in January 2022). Following this the next steps are introducing a rehabilitation programme for surgical patients to look at optimal outcomes along with PROMs for tracking and managing patients after surgery.

BMCK advised that the key work which is ongoing will be compiled in a clinical summary report for publication which will complement the survival data and show the improvements that have been made. ST stated that it is good to see significant progress being made noting the national difficulty in recruiting gynaecology surgeons. An update on this position is required along with further progress on the improvements at the next NCQSG meeting.

Governance review of national groups

GMcN advised that transition of this group to a National Cancer Quality Improvement Programme Board (NCQIPB) includes redefining the role of HIS and further clarification in terms of governance/escalation. This has been laid out in draft format following discussion with the Chairs and will be forwarded to Simon Watson at HIS in due course for feedback. This will then define the new Terms of Reference and CEL for the group.

ST advised that the new group’s membership will also be updated with the inclusion of equitable representation across the regions. The Chairs agreed that there is a requirement for additional clinicians in SCAN/NCA with an interest in cancer quality. IT added that he would discuss membership with colleagues in NCA. Current membership to be circulated to Regional Lead Clinicians.

Governance – national cervical and endometrial cancer PHS report

A response to the following actions highlighted at the previous meeting has been received by Clinical Leads within the regions:

• cervical cancer (QPI 7: chemoradiation) – regional variation noted in SCAN. Cameron Martin has reviewed all cases that do not meet the QPI and all patients were managed appropriately with no clinical concerns highlighted
• Endometrial Cancer (QPI 5: Adjuvant Radiotherapy) – in NHS Tayside results were lower than the other Boards. Ann-Maree Kennedy advised that patients declining radiotherapy/brachytherapy should have been excluded from the QPI which was not done. The 2 patients (6/8) that were not referred to oncology had either significant psychiatric or medical co-morbidities and were therefore not suitable for treatment

Recurrence data – paper 2

An exercise was carried out to seek views from tumour specific regional clinical leads on the collection and reporting of recurrence data. Paper 2 outlines a summary of responses received with regards to specific areas of interest, numbers involved, various approaches and any work undertaken to date.

Both MB and PM in SCAN highlighted the pilot projects for breast and bladder cancer that have been ongoing to collect this data over the previous years. MB highlighted the challenges and complexity involved e.g. defining recurrence; smaller units with small numbers; resource involved with larger numbers and ensuring that all areas are capturing the same data. It was noted that SCAN and also NHS Highland have participated and MB is of the view that a QPI could be developed.

The group were unanimous in the opinion that recurrence data is important to collect in terms of measuring cancer outcomes. IT suggested it would be a sensible approach to pilot collecting this data with one of the more aggressive cancers where data would be available quicker as opposed to other cancers where the impact will not be seen for a number of years.

HG noted that prostate cancer data is collected in NHS England which captures the whole patient journey, however this has required extensive dedicated funding.

CT stated that QPI data is too slow and this may be an opportunity for Boards to think about reviewing their processes for data collection and sign-off to be more efficient. For example, the diagnostic part of the pathway could be looked at before the treatment is complete. This would allow for PHS to extract and analyse signed-off data from eCASE quicker.

In conclusion, it was agreed to focus on breast and lung cancers in the first instance as a pilot. ST suggested that YVDH and MB discuss with their colleagues and bring a proposal to the next meeting for further discussion onhow feasible it is to collect and what may be required in terms of resource.

Application of QPI process in private sector

QPI data collection and reporting in the private sector was raised at the previous meeting. LA/NS agreed to further discuss at a higher level with colleagues in HIS. A response has been received from HIS that outlines their previous position in that they do not look at independent healthcare services which offer cancer treatment as part of the regulatory process. Regulation is undertaken at service level to ensure appropriate governance is in place for the safety of patients, and HIS do not routinely undertake inspections of specific departments or specialties.

Governance

National bladder cancer QPI report (2017-2020 – paper 3)

PM presented to the group on behalf of the three regions an overview of the Bladder Cancer QPI results that were published by PHS on 2nd November 2021. It was noted that the Bladder Cancer QPIs are currently undergoing second cycle of formal review.

A number of QPIs have met the targets both at regional and national level. PM emphasised the collaboration across Scotland in relation to collecting quality data and the global interest in the QPI work. PM added that bladder cancer is a very highly recurrent cancer with at least 70% of the recurrences occurring in the first three years.

The following QPIs were noted for discussion:

• QPI 2: Quality of TURBT – standardised documentation to improve compliance for this QPI has been developed and implemented in NHS Lothian on TrakCare. It is hoped this will be rolled out across Scotland over the next year which will further improve results
• QPI 3: Mitomycin C following TURBT – due to half of patients being low grade non-invasive cancers it is essential that this group receive a single shot of mitomycin. PM stated that long term follow up data has demonstrated that this significantly reduces five-year recurrence free survival
• QPI 4: Early Re-Transurethral Resection of Bladder Tumour (TURBT) – this is one of the most challenging QPIs due to the requirement for a re-resection within a 6 week timeframe. Importantly, it should be noted that the work within QPI 2 has improved the quality of the first resection and the need for repeat TURBT is becoming less and can be more selective. This is being addressed through formal review. Steps implemented going forward include increased capacity to perform re-resections in individual Health Boards and improving the efficiency of pathways. PM advised that they have received support from the NCRI for running a clinical trial to access the accuracy of MRI scanning
• QPI 9: Oncological Discussion – challenging QPI for regions to meet the 60% target. Although this is felt to be of no benefit to some patients who are not suitable for oncological treatment, oncology colleagues are keen to retain and maintain the 60% target
• QPI 10: Radical Radiotherapy with Chemotherapy – regions have consistently been unable to achieve the 50% target over the previous three years. It has been proposed at Formal Review that the definition should be changed from chemotherapy to SACT in order to highlight all relevant treatments
• QPI 11: 30 and 90 day Mortality – noted that performance is related to the numbers within each hospital and there are some centres that are still performing radical cystectomy below the recommended 20 per centre. ST advised that in the west there are ongoing discussions on how cystectomy services are provided and QPI results will change accordingly. IT added that the role of volume and outcome is important and the implementation of robotic platforms will highlight this further. It was noted that there are discussions ongoing within the regions how urology services are taken forward

JM posed the question around where the main areas of quality improvement are for Bladder Cancer. PM advised that where low grade patients are concerned, Mitomycin can make a huge difference. With high grade patients, late presentation is a concern with no QPI around early diagnosis. Improved surgical intervention and chemotherapy can make a difference.

In addition, RJ highlighted that all areas are under performing with regards to QPI 10 (radical radiotherapy with chemotherapy). The use of radiosensitisers were discussed, with RJ advising on another alternative therapy used in some English centres which should be tolerated for more patients. NOR advised that that this has been discussed as part of the new re-framed CMGs to list all treatments that are available. ST advised that there are constraints of what can be included in CMGs if treatments are not licenced. ST advised that he will raise this issue again with the relevant groups.

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

Ovarian cancer survival analysis - update

CT advised that PHS have undertaken ovarian cancer survival analysis that has been presented to the NCQSG for:

•  October 2013 – September 2016 followed up to December 2017
•  October 2016 – September 2018 followed up to December 2020

There is now further analysis from October 2013 – September 2016 followed up to March 2021 which has not been presented. Discussed if further analysis is required of the later two year cohort up until September 2021. Further discussion will take place with NCA outside this meeting to agree what further analysis is required. ST stressed that this analysis has been ongoing for a number of years and it is important for this to be closed off now.

Other tumour specific survival analysis

CT advised that PHS has continued work with the head and neck survival analysis and noted the concerns around completeness of older data for performance status, staging and treatment. This has now been checked with the networks.

Upper GI cancer is underway and going through final checks. With regards to lung and HPB cancer, PHS are meeting with the lead clinicians of both groups to agree the specification before a timescale is agreed.

CT highlighted that the extra resource within the team at PHS will enable survival analysis to be available more timely.

Publication of survival analysis – paper 4

CT spoke to paper 4 and outlined the proposal for PDF publications of the survival reports to be published that will ultimately be available in the public domain when regional/local governance has been agreed. This proposal has been written on the assumption that PHS will extract data will be taken directly from eCASE.

CT advised that the governance group at PHS advised that these reports are required to be badged as ‘experimental statistics’ as opposed to ‘official statistics’ as each of the reports are not replicated year on year. This will also allow for more flexibility around the reports and the reason for an experimental statistics publication will be noted in the front section. CT advised that comparison against annual survival data is an area that PHS are exploring/improving especially for tumour groups that have shorter survival.

The group acknowledged and supported this process stating that this works well for data that is reported regionally however, if data is reported at Board level there will be the need to include local Medical Directors/Board governance processes.

CT will forward a final proposal will be sent to the group following final amendments.

Population survival results

Tom Godfrey, Information Analyst at PHS presented to the group the findings of the general cancer population survival results. This included an overview of trends in net survival for 27 cancer site groupings.

Historically, PHS have published these reports every three years (with a five year cycle 1993-95 and 2013-97 with follow-up until 31st December 2018) with the most recent in January 2021 containing observed and net survival. The key points from the latest report suggests that one and five year survival is improving for many cancers. TG advised that PHS now have a better understanding of the methodology and are moving to annual reports with the next one available in

March 2022 which will focus on the pre-pandemic period.

The group agreed this is interesting work with NOR stating that it was encouraging to see an overall improvement in lung cancer survival. This is mainly driven by the wider use of systemic therapies and in relation to the increase in five year survival which indicates that radical treatments and increased surgical resection is making a difference.

The area of benchmarking this data was discussed against NHS England or other parts of Europe. TG advised that links to other registry publication are available within the report and communication with these groups has been ongoing in the hope of standardising the methodology.

DM advised that the Scottish Cancer Registry contributes to various other registries i.e. International Cancer Benchmarking Partnership, Concord Programme and the EUROCARE studies. It was suggested that as net survival is a description of the totality of every part of the patient pathway it is worthwhile drilling down each level to ascertain which element has contributed the most over time.

ST thanked TG for his informative presentation and noted that any further suggestions for future reports should be forwarded to PHS.

Assurance of national performance

Assurance of national performance – HIS review process 2021 update

PS provided an update on behalf of HIS advising that review meetings in WoSCAN and SCAN have taken place for Melanoma as the first tumour group to undergo the revised process. The review meeting in NCA is due to take place on 28th January 2022. Following this there will be an opportunity for managers/Boards to provide any feedback on this initial test review.

The next groups that HIS will focus on are acute leukaemia and cervical and endometrial cancers. There is a possibility that these two groups may not require formal meetings due to the extent of the key lines of enquiry. HIS will advise on this in due course.

There are capacity issues within the HIS CQPI team, however it was noted that this will not affect any of the planned reviews.

Scottish cancer registry

Proposed new molecular pathology and genetics information on the Scottish cancer registry

DM advised that the Scottish Cancer Registry is continually updating the Scottish Cancer Registry (SCR) which is influenced by WHO and European Cancer Registries. A list has been circulated to this group detailing the molecular pathology and genetics tests that are recorded within the QPIs.

Questions were posed as to whether this is the best list for SCR, and if so whether the QPI dataset would be a reliable source of pulling this data for inclusion in the SCR.

RJ stated that data on these tests may not be included within the QPI dataset on a long term basis e.g. if this becomes routinely carried out and the QPI is no longer relevant. ST noted that there is currently a national review of molecular testing being undertaken and it would be worthwhile contacting Sarah Ogilvie with regards to a complete list. It was concluded that the data would be better provided through laboratories rather than the QPI dataset.

QPI reporting

SACT 30-day mortality – paper 5

Paper 5 was updated and circulated to this group following discussions at the NCQOG in November on the process of reporting SACT 30-day Mortality. Concerns were raised due to the different SACT reports being generated resulting in different mortality figures which will lead to confusion.

ST acknowledged that it would be difficult to resolve today given the time required to ensure appropriate discussion. This will be deferred to the next meeting in March 2022 for ratification following further input at the next NCQOG. ST asked that this group consider the points raised in paper five and forward any comments or suggestions to CT.

Information governance approach for the national analysis of QPI data

CT provided an update on the information governance process stating that the associated Memorandum of Understanding (MoU) has now been signed off by the 14 territorial Boards plus the relevant special Health Boards.

PHS are now working on the individual appendices governing how data will be utilised from eCASE. CT stated that the survival publication process will be part of the appendix to determine how routine requests can be managed by PHS. Research requests and projects are not covered by the MoU.

CT advised that PHS have been working in parallel with the SACT group to develop the appendix and a Short Life Working Group has been set up to take this forward.

A further draft will be presented to the next NCQSG meeting in March for ratification.

QPI formal review process

QPI formal review second cycle progress update

 JD provided an update on the 2nd cycle of QPI formal reviews. These are still progressing with head and neck along with acute leukaemia reviews complete and melanoma at final approval stage.

Reviews for bladder cancer and cervical and endometrial cancers are currently underway. A further two tumour types have still to undergo second cycle review due to requested delays during the pandemic (sarcoma and testicular cancer). These will take place in January and March 2022.

The third cycle of QPI formal reviews have commenced which will overlap due to the timing. Initial meetings for breast and renal cancer are due in February 2022 followed by prostate cancer. Chairs have still to be appointed for both renal and prostate cancers.

JD advised that when the audit reporting schedules have been updated, a more formal timetable will be finalised for the remainder of the third round of reviews.

NCQSG workplan 2019 – 2021 (paper 6)

 JD advised that the workplan was circulated for information and most items have been covered throughout the agenda for this meeting.

Risk and issues log – (paper 7)

 JD advised that the Risk and Issue Log was circulated for information noting that there has been nothing new added since the last meeting.

AOCB

No other competent business was noted.

Date of next meeting

Monday 28 March 2022, 10:00 to 13:00.