National Cancer Quality Steering Group minutes: March 2022

Attendees and apologies

Present

• James Mander, Regional Lead Cancer Clinician, SCAN (Chair) 
• Lesley Aitken, Senior Reviewer, Healthcare Improvement Scotland (HIS) 
• Matthew Barber, Consultant Breast Surgeon, NHS Lothian
• Jen Doherty, Project Co-ordinator, National Cancer Quality Programme
• Josephine Elliot, Programme Manager, HIS
• Hilary Glen, Consultant Medical Oncologist, NHSGGC
• Rob Jones, Consultant Medical Oncologist, NHSGGC
• Gregor McNie, Team Lead, Cancer Policy, Scottish Government
• Noelle O’Rourke, National Lead for the Scottish Cancer Network
• Lorraine Stirling, Project Officer, National Cancer Quality Programme
• Iain Tait, Consultant Surgeon and Clinical Director, NCA
• Seamus Teahan, Regional Lead Cancer Clinician, WoSCAN (Chair)
• Catherine Thomson, Service Manager (Population Health), Public Health Scotland (PHS)

Apologies

• Bobby Alikhani, Regional Manager (Cancer), SCAN
• Hugh Brown, National Primary Care Group, NHS Ayrshire and Arran
• Seona Carnegie, Policy Manager, Cancer Policy Team, Scottish Government
• Lynsey Cleland, Interim Depute Director, HIS
• Richmond Davies, Head of Service, PHS
• Asa Dahle-Smith, Medical Oncologist, NCA
• Kevin Freeman-Ferguson, Head of Service Review, Healthcare Improvement Scotland
• Angela Jesudason, Paediatric Oncologist and Clinical Lead for the MSN CYPC Teenagers & Young Adults
• David Morrison, Director, Scottish Cancer Registry
• Bryan McKellar, Interim Regional Manager (Cancer), NCA
• Hamish McRitchie, Clinical Lead Scottish Clinical Imaging Network
• Peter Sandiford, Deputy National Clinical Lead, Cancer QPI Review Group, Healthcare Improvement Scotland
• Nadeem Siddiqui, National Clinical Lead, Cancer QPI Review Group, Healthcare Improvement Scotland
• Mark Strachan, Consultant in Diabetes and Endocrinology, SCAN
• Carolyn Sunners, Senior Policy Manager, Scottish Government
• Stuart Thomas, Consultant Pathologist and Lead Clinician, Scottish Pathology Network
• Evelyn Thomson, Regional Manager (Cancer), WoSCAN
• Nkem Umez-eronini, Regional Clinical Lead, Urological Cancers, WoSCAN
• Joris Van Der Horst, Consultant Respiratory Physician, NHSGGC
• Simon Watson, Medical Director, Healthcare Improvement Scotland
• Joseph Woollcott, Health Influencing Senior Officer, Prostate Cancer UK

In attendance

• Lorna Bruce, Audit Manager, SCAN
• Kevin Burton, Consultant Gynae Oncologist and Clinical Lead, WoSCAN
• Carol Marshall, Audit Manager, WoSCAN
• Graham Macdonald, Consultant Clinical Oncologist, NCA
• Alan Nicholson, Project Manager, National Services Scotland, NSS
• Alison Rowell, Quality and Service Improvement Manager, WoSCAN
• C J Shukla, Consultant Urologist, SCAN

Items and actions

Welcome, apologies and declarations of interest

JM welcomed the group and those in attendance. Also welcomed was Josephine Elliot, Programme Manager at HIS who has replaced Tiffany Bonnar. 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 13 December 2021 (paper 1) and approved as an accurate record.

Matters arising

Ovarian cancer – feedback from NCA on survival analysis action plan

IT provided an overview of the NCA Executive Summary and actions identified in the ovarian cancer action plan that is due to be published along with the full progress report on 5th April 2022. IT advised that there has been a very comprehensive programme in the north looking at the discrepancy in ovarian cancer outcomes which has involved input from Medical Directors, Chief Executives, a separate review body and an independent chair along with clinicians across the NCA.

The main items identified in the report are:

• excluding patients who die within 6 months from the analysis results in no difference in survival outcomes across Scotland for patients with ovarian cancer; this accounts for patients that present with late stage disease, co-morbities, performance status or age related issues and do not undergo aggressive treatment
• staging in ovarian cancer is different across the 5 cancer sites in NCA

A number of actions have been identified and progressed resulting in:

• a single weekly regional MDT for ovarian cancer across Scotland facilitated through the MS Teams platform
• funds that have been secured from the Scottish Government to appoint a MDT Coordinator
• a meeting with all cancer centres to standardise staging ovarian cancer scheduled in early April and
• a fourth gynae-oncologist that has been appointed to Grampian to increase capacity

It was also noted that in some centres patients are presenting very late through the emergency route that will require some public messaging and awareness, as well as GP training. IT added that PHS are undertaking further survival analysis on a later cohort of patients (2019-2020 data with follow-up to 2021). The earlier analysis (3 publications) that has previously been undertaken are being published along with publication of the NCA report.

KB noted that clinicians have responded to the report and are in agreement that the decision making in the early part of the cancer pathway is critical to outcomes. Essentially more resource and theatre capacity is required across Scotland in order to offer patients a reasonable surgical intervention timeframe. JM advised that the NCQSG would report these issues to the National Cancer Recovery Group (NCRG) while welcoming these improvements that have been instituted in NCA and acknowledging concerns around surgical capacity to treat ovarian cancer patients throughout Scotland.

Governance review of national groups

JM advised that the clinical leads are currently engaged in updating the current NCQSG membership as part of the transition to the National Cancer Quality Improvement Programme Board (NCQIPB) and have requested that interested clinicians within the regions put their name forward for consideration.

GMcN updated that as part of this transition, HIS would become a vital partner in some of the improvement activity. A draft terms of agreement letter is currently with the co-chairs for agreement before being forwarded to HIS. Subject to agreement by HIS this will inform the new NCQIPB Terms of Reference and aid membership discussions.

Recurrence data

MB advised that following the recent breast cancer QPI formal review meeting, the topic of breast cancer recurrence was raised and how this might be incorporated nationally into the wider quality programme. A meeting is scheduled to take place on 25th April with Scottish Government colleagues and key stakeholders to further explore the potential way forward with data capture and reporting.

MB stated that the pilot project in SCAN for breast cancer recurrence has been ongoing for a number of years and was presented at the national breast cancer education meeting on 18th March. This was well received with the clinical community keen to move this work forward however, they recognised issues with audit capacity.

CT sought clarity around how this relates to the national UK audit on secondary breast cancer which PHS have been approached. It was noted that this is a ‘one time’ audit which may not be as useful and has yet to be defined in terms of scope and detail. CT requested to be involved in the recurrence meeting in April which was agreed by ST.

NO’R highlighted that the QPI cancer audit is structured at present around the initial diagnostic pathway and first treatment along with survival analysis. The Scottish Cancer Network is looking at clinical management pathways throughout the overall cancer journey, however there is no formal process within the audit to capture the whole pathway. NO’R agreed that this is important but acknowledged that this is complicated and has vast resource implications. ST agreed, and at the meeting on 25th April it is hoped that there will be consensus around a process that can also be applied to other tumour groups going forward.

Governance

National testicular cancer QPI report (2017-2020 – paper 2)

GMacD and CJS presented to the group on behalf of the three regions an overview of the testicular cancer QPI results that were published by PHS on 14th December 2021. A number of QPIs have met the targets both at a regional and national level, with the last year of data including performance during 6 months of the COVID pandemic. testicular cancer QPIs are currently undergoing second cycle of formal review.

The following QPIs were noted for discussion:

QPI 1: radiological staging. 95% target not met regionally over the previous three years (with the exception of SCAN in 2019/20) for patients undergoing a CT scan of the chest, abdomen and pelvis within 3 weeks of orchidectomy. GMacD advised that on looking further at the data in Grampian, many cases were due to patients defaulting on an offered scan date, or requesting a delay rather than a quality issue. CJS agreed, and noted that in Lothian they had liaised with the radiology leads to book CT slots pre-operatively which has improved the process. GMacD highlighted some concerns around doing staging pre operatively which may result in a small proportion of patients undergoing unwarranted radiation exposure.

QPI 3: primary orchidectomy – 95% target not met by all three regions over the previous years. This is a multi-step process from the ultrasound diagnosis through urology referral, pre-operative assessment and then on to surgery. Timeframe has been relaxed previously from two weeks to three weeks and noted a number of reasons/areas where delays can occur. Noted that patient choice can impact however there is also an issue with theatre capacity. Agreed the importance of not continuously relaxing the timeframe, and address the issues.

QPI 6: quality of adjuvant treatment and QPI 8: systemic therapy – performance in both QPIs impacted by small numbers in any one centre. The significant drop in performance for QPI 8 for patients undergoing SACT within three weeks of a MDT decision to treat is partly due to advanced disease requiring emergency treatment out with the required timeframe of MDT. Noted that COVID may also have contributed to delays.

QPI 9: imaging for surveillance patients – the QPI looks at having at least three images within 14 months of diagnosis. Again it is small numbers and performance is generally close to the 85% in the three regions. Reasons for not meeting the target are usually due to patients defaulting rather than clinical or system issues.

GMacD and CJS advised that there are no concerns around clinical care for testicular cancer patients, although going forward there is concern around the impact of losing the oncologist in Tayside as well as radiology resource and theatre capacity for achieving the QPI targets. GMcN advised that with regards to the immediate pressures in Tayside there has been a working group established and a package of support for the various services affected.

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

CT advised that PHS have translated ovarian cancer survival analysis reports that have been previously shared with this group into ‘experimental statistic’ reports. These will be made available on the PHS website along with a single clinical commentary that covers the three reports. Consensus going forward for similar tumour specific reports is to include the names of the clinical leads as authors within the clinical commentary.

Other tumour specific survival analysis

CT advised that the initial draft survival analysis for head and neck cancer data is complete and ready for discussion with the lead clinicians.

As discussed above under item 3(a) there is further ovarian cancer survival analysis for 2019-2020 data with follow-up to 2021 cohort to be carried out.

PHS have met with the lung cancer clinicians and a final specification should be finalised by the end of next week prior to a request for data from the networks. HPB Cancer has an agreed specification and data is now available which is currently being validated. Upper GI cancer is also underway and PHS are in the process of finalising the validations prior to the analysis.

CT added that a definite timescale for publication will be agreed after sharing the initial reports of the above analyses with the relevant clinicians.

Assurance of national performance

Assurance of national performance – HIS review process 2022 update

LA provided an update on behalf of HIS advising that the melanoma review is complete and the report is due to go through the HIS internal governance sign off process. Noted that this can cause delays. It will then be sent to the regional networks for factual accuracy before publication. The report includes reference to more recent data for comparison where relevant in order for the report to be as updated as possible. The findings will be discussed once the report is published.

The next tumour groups undergoing review are acute leukaemia and cervical and endometrial cancers. HIS carried out table-top reviews for these groups as there was no requirement for formal meetings and good progress is being made with writing the reports. Following these, the next tumour group to undergo review is head and neck cancer.

The feedback meeting with key stakeholders has been re-scheduled to 22 April 2022 where there will be an opportunity to provide feedback and streamline the process. JM/ST agreed that it would be difficult to review/comment on the process given the melanoma report will not be published by this date. Further discussion to take place around this out with the meeting.

QPI reporting

SACT 30-day mortality (paper 3 – not previously circulated)

CT advised that following agreement by the SACT Programme Board, chairs of the NCQSG and PHS the general consensus is that SACT 30-day mortality should be reported and monitored by the SACT data group rather than through the QPIs. A report will be presented to this group on an annual basis detailing 30-day mortality for all tumour groups highlighting any areas of concern.

The group agreed that it was important that this could still be discussed at network meetings and does not lose its visibility. Timelines around running the reports also need to be considered to ensure the data is as up to date as possible. CT re-iterated that at present the analysis can only look at curable/non curable due to the way in which the disease trees have been set up in the different instance of chemocare.

CT advised that the final SBAR paper will be updated by PHS and sent round this group in due course for feedback.

Scottish Thyroid Cancer Network (paper 4)

AN presented to the group an overview of the Scottish Thyroid Cancer Network (STCN) which is newly established in 2018 through Scottish Government funding and sits within the NSS Clinical Directorate. The STCN at present do not have any QPIs and it is now in a position that this is required as a key factor to meet many of its strategic objectives. The network has the necessary resource to permit a programme of national audit data collection and reporting through existing established MDTs where the data would be collected by a data analysis resource provided by Business Intelligence through NSD. The network is now asking this group to consider building this tumour type into the National Cancer Quality Programme along with the development of national QPIs.

NO’R advised that the STCN has undertaken excellent work to date completing audit across the country to agree protocols so that all regions are consistent but are conscious this is not audited or managed in the same way that other cancer types are as they do not have QPIs which are a priority for clinicians.

JD stated that there had been an initial discussion with ET, MS and AN around the request for QPIs and noted that there may be an opportunity towards the end of 2022 for this to be incorporated into the schedule.

The group had no objections specifically around this tumour type, however, it was highlighted that QPIs need to be measurable and that small numbers can often skew results resulting in misleading variation.

There was also concern raised around the potential requests from other low volume groups and agreed there is a requirement for a framework to agree criteria in order to become a national network and request QPIs. There was agreement that JM will feedback and discuss further with MS.

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 been agreed and signed off at the end of December 2021 by all 14 territorial boards and the relevant special health boards. This has allowed PHS to effectively be a data controller for QPI data in addition to health boards, and enable them to extract data from eCASE in future.

PHS is still in the process of drafting the appendix for the MoU to specifically outline information on data requests which are considered to be ‘routine analysis’. This is being run alongside the process for SACT data, and is making good progress. It is hoped that a paper will be available for the next meeting in June that Brian Murray, principal information development manager at PHS will present for discussion and agreement.

QPI formal review process

QPI formal review - second and third cycle progress update

JD provided an update. Reviews for bladder cancer and cervical and endometrial cancer QPIs are in the final stages. Sarcoma and testicular cancer QPI reviews which were delayed from 2021 are now underway. A further meeting date has yet to be secured for sarcoma following cancellation of the initial meeting in January due to clinical pressures. The testicular cancer review meeting is scheduled for 6th May 2022.

The third cycle of QPI formal reviews have now commenced with both breast cancer and renal cancer underway and progressing well.

Proposed schedule for third cycle formal review (paper 5)

JD spoke to paper 5 which outlines the schedule for the third round of QPI reviews in line with the audit reporting timetable following year 9 of reported QPI data. Due to a small number of tumour types being delayed or taking longer to complete during the pandemic there is now a requirement to amend this going forward.

Lung, upper GI and colorectal cancers were significantly delayed resulting in a number of QPIs that had new data items not being reported until 2022. Further review of these groups as per the original schedule was felt to be soon and a number of options were considered taking into account the distribution of workload across both the quality team and PHS/NSS.

The group agreed with the proposal to move the lung and colorectal cancer reviews from 2022 to 2024 at the end of cycle 3. This will allow for further data to be reported to inform the review. Upper GI cancer (which had minimal changes at the last review) will be retained for review in the schedule planned for 2022. 11. NCQSG Workplan 2019 – 2022 (paper 6) (a) JD advised that the updated workplan was circulated for information. In addition to the items covered within the agenda it was noted that work is progressing with the eCASE development work / new reporting environment for QPI data.

Risk and issues log (paper 7)

JD advised that the risk and issue log was circulated for information. Noted that issue 27 (HIS reporting) has been updated and issue 29 (delays to the Quality Programme due to COVID-19) has been closed.

Any other competent business

No other competent business was noted.