Lymphoma clinical quality performance indicators review: consultation

Patients with lymphoma should be evaluated with appropriate imaging to detect the extent of disease and guide treatment decision making.

Proportion of patients with lymphoma undergoing treatment with curative intent who undergo Computed Tomography ( CT) scanning of the chest, abdomen and pelvis or PET CT scanning prior to treatment, within 2 weeks of radiology request, and where the report is available within 3 weeks of radiology request.

Please note: The specifications of this QPI are separated to ensure clear measurement of the following:

(i) Patients with lymphoma undergoing treatment with curative intent who are evaluated with appropriate imaging;

(ii) Patients with lymphoma undergoing treatment with curative intent who are evaluated with appropriate imaging within 2 weeks of radiology request; and

(iii) Patients with lymphoma undergoing treatment with curative intent who are evaluated with appropriate imaging where the report is available within 3 weeks of radiology request.

Accurate staging is important to ensure appropriate treatment is delivered and futile interventions avoided.

CT is recommended as the initial imaging investigation for all patients with lymphoma to detect extent of disease and guide treatment decision making. This should include CT of the chest, abdomen and pelvis. CT neck should also be undertaken where clinically appropriate. Intravenous contrast should be utilised unless contraindicated ².

Numerator:

Number of patients with lymphoma undergoing treatment with curative intent who undergo CT of chest, abdomen and pelvis or PET CT scanning prior to treatment.

Denominator:

All patients with lymphoma undergoing treatment with curative intent.

Exclusions

• Patients who refuse investigation.
• Patients with primary cutaneous lymphoma.

Numerator:

Number of patients with lymphoma undergoing treatment with curative intent who undergo CT of chest, abdomen and pelvis or PET CT scanning prior to treatment and within 2 weeks of radiology request.

Denominator:

All patients with lymphoma undergoing treatment with curative intent who undergo CT of chest, abdomen and pelvis or PET CT scanning prior to treatment.

Exclusions

• None.

Numerator:

Number of patients with lymphoma undergoing treatment with curative intent who undergo CT of chest, abdomen and pelvis or PET CT scanning prior to treatment where the report is available within 3 weeks of radiology request.

Denominator:

All patients with lymphoma undergoing treatment with curative intent who undergo CT of chest, abdomen and pelvis or PET CT scanning prior to treatment.

Exclusions

• None.

Specification (i): 95%

The tolerance within this target is designed to account for patients with B-cell lymphoproliferative disorders that do not necessarily require extensive imaging.

Specifications (ii) and (iii): 90%

The tolerance within this target is designed to account for situations where imaging may be delayed due to factors of patient fitness or patient choice.

Target for specification (i) increased to 95%.

Denominator for specification (ii) and (iii) changed to focus on those who have undergone CT/ PET CT prior to treatment. Removed exclusions from (ii) and (iii) as no longer required due to denominator change.

Specification (iii) added - Patients undergoing CT/ PET CT scanning prior to treatment with report available within 3 weeks of radiology request.

Patients with Diffuse Large B Cell Lymphoma ( DLBCL) who are treated with curative intent should have their response to treatment evaluated with appropriate imaging.

Proportion of patients with DLBCL who are undergoing chemotherapy treatment with curative intent, who have their response to treatment evaluated with Computed Tomography ( CT) scan of the chest, abdomen and pelvis or PET CT scan.

CT scanning is recommended as the most appropriate method of response assessment following chemotherapy for DLBCL ² as treatment response may not be clinically obvious.

Evidence suggests that mid-treatment evaluation is best practice, unless there is a good clinical response to treatment ². Measurement of this is however not specifically included within this QPI.

Numerator:

Number of patients with DLBCL who are undergoing chemotherapy treatment with curative intent who undergo CT of chest, abdomen and pelvis or PET CT at end of chemotherapy treatment*.

Denominator:

All patients with DLBCL who are undergoing chemotherapy treatment with curative intent.

Exclusions

• Patients who died during treatment.

90%

The tolerance within this target is designed to account for the fact that some patients will have a good clinical response to chemotherapy and will therefore not require an end of treatment scan. It also accounts for those patients who may not complete chemotherapy treatment due to factors of fitness.

No change to QPI.

Patients with Classical Hodgkin Lymphoma ( CHL) should be evaluated with PET CT scanning to detect the extent of disease and guide treatment decision making.

Proportion of patients with Classical Hodgkin Lymphoma undergoing treatment with curative intent who undergo PET CT scan prior to first treatment, within 2 weeks of radiology request, and where the report is available within 3 weeks of radiology request.

Please note: The specifications of this QPI are separated to ensure clear measurement of the following:

(i) Patients with Classical Hodgkin Lymphoma undergoing treatment with curative intent who undergo PET CT scan prior to first treatment;

(ii) Patients with Classical Hodgkin Lymphoma undergoing treatment with curative intent who undergo PET CT scan prior to first treatment and within 2 weeks of radiology request; and

(iii) Patients with Classical Hodgkin Lymphoma undergoing treatment with curative intent who undergo PET CT scan prior to first treatment where the report is available within 3 weeks of radiology request.

Accurate staging is important to ensure appropriate treatment is delivered and futile interventions avoided.

All newly diagnosed patients with CHL being considered for curative therapy should have a baseline PET CT scan ³.

A whole body PET CT scan is recommended for the diagnosis of CHL to assess the extent of disease and therefore identify the most appropriate treatment option ⁴.

Numerator:

Number of patients with CHL undergoing treatment with curative intent who undergo PET CT prior to treatment.

Denominator:

All patients with CHL undergoing treatment with curative intent.

Exclusions

• Patients who refuse investigation.

Numerator:

Number of patients with CHL undergoing treatment with curative intent who undergo PET CT prior to treatment and within 2 weeks of radiology request.

Denominator:

All patients with CHL undergoing treatment with curative intent who undergo PET CT prior to treatment.

Exclusions

• None.

Numerator:

Number of patients with CHL undergoing treatment with curative intent who undergo PET CT prior to treatment where the report is available within 3 weeks of radiology request.

Denominator:

All patients with CHL undergoing treatment with curative intent who undergo PET CT prior to treatment.

Exclusions:

• None.

95%

The tolerance within this target is designed to account for situations where patients are not fit enough to undergo all investigations prior to commencing treatment.

Denominator for specifications (ii) and (iii) changed to focus on those who have undergone PET CT prior to treatment. Removed exclusions from (ii) and (iii) as no longer required due to denominator change.

Specification (iii) added to QPI for patients with Classical Hodgkin Lymphoma ( CHL) undergoing PET CT prior to treatment where the report is available within 3 weeks of radiology request.

Patients with Burkitt Lymphoma and Diffuse Large B-Cell Lymphoma ( DLBCL) should have MYC ^◘ testing as part of diagnostic process, to identify those who may require central nervous system ( CNS) prophylaxis and alternative treatment.

Proportion of patients with Burkitt Lymphoma and DLBCL undergoing treatment with curative intent who have MYC testing as part of the diagnostic process.

Please note: The specifications of this QPI are separated to ensure clear measurement of the following:

(i) Patients with Burkitt Lymphoma and DLBCL undergoing chemotherapy treatment with curative intent who have MYC results reported prior to first treatment; and

(ii) Patients with Burkitt Lymphoma and DLBCL undergoing chemotherapy treatment with curative intent who have MYC results reported within 3 weeks of commencing treatment.

Classical cytogenetic or Fluorescence in Situ Hybridization ( FISH) analysis is essential for the diagnosis of Burkitt lymphoma ⁵.

Rearrangements of MYC in DLBCL are a strong prognostic factor and will guide treatment options and provide important information to help inform patients and carers about the nature of the disease and prognosis ⁷.

Deregulation of MYC in DLBCL, as occurs in translocations involving the long arm of chromosome 8, is highly associated with aggressive disease and a poor prognosis. Detection of such a translocation by FISH is an important prognostic factor and will often lead to a change in management ⁷.

Cases approaching 100% ki67 and with deregulation of p53 (p53+ p21-) need to be investigated for MYC rearrangements to exclude Burkitt lymphoma ⁶. Rearrangements of MYC, particularly in association with t(14;18) remain a strong prognostic factor in DLBCL ⁷.

Numerator:

Number of patients with Burkitt Lymphoma and DLBCL undergoing chemotherapy treatment with curative intent who have MYC results reported prior to treatment.

Denominator:

All patients with Burkitt Lymphoma and DLBCL undergoing chemotherapy treatment with curative intent.

Exclusions

• No exclusions.

Numerator:

Number of patients with Burkitt Lymphoma and DLBCL undergoing chemotherapy treatment with curative intent who have MYC results reported within 3 weeks of commencing treatment.

Denominator:

All patients with Burkitt Lymphoma and DLBCL undergoing chemotherapy treatment with curative intent.

Exclusions

• No exclusions.

Specification (i): 60%

Specification (ii): 85%

The tolerance within this target accounts for situations where there is no fresh tissue for cytogenetic analysis and there is insufficient tissue for FISH studies. Furthermore, MYC testing may not be appropriate if patients are not suitable for more intensive treatment, i.e. for factors of fitness or due to co-morbidities.

QPI separated into 2 parts - wording has been revised in specification (i) to specifically state chemotherapy treatment.

Specification (ii) added to focus on the availability of MYC results within 3 weeks of commencing treatment (chemotherapy) with more challenging target (85%).

Patients with lymphoma should be discussed by a multidisciplinary team following diagnosis.

Proportion of patients with lymphoma who are discussed at MDT meeting within 8 weeks of diagnosis.

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 ⁸.

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

Within this QPI an 8 week from diagnosis timeframe has been utilised as the QPI Group agreed that, due to the complex referral and diagnostic pathway for patients with lymphoma, this was the most appropriate time period in which patients should be discussed at MDT.

Numerator:

Number of patients with lymphoma discussed at the MDT within 8 weeks of diagnosis.

Denominator:

All patients with lymphoma.

Exclusions:

• Patients who died before first treatment.
• Patients with primary cutaneous lymphoma.

90%

The tolerance within this target is designed to account for situations where additional complex diagnostic testing requires to be undertaken.

QPI updated to measure patients with lymphoma who are discussed at MDT meeting within 8 weeks of diagnosis (increased from 6 weeks).

Target increased from 85% to 90%.

Patients with symptomatic advanced* follicular lymphoma and Diffuse Large B Cell Lymphoma ( DLBCL) should undergo treatment with anti-B cell monoclonal antibody therapy ^‡ in combination with chemotherapy.

Proportion of patients with follicular lymphoma and DLBCL undergoing treatment with chemotherapy who receive anti-B cell monoclonal antibody therapy.

Patients with symptomatic advanced stage follicular lymphoma and DLBCL should receive rituximab in combination with chemotherapy as this increases response to chemotherapy and provides a progression free, and overall, survival benefit ^2,9.

Rituximab in combination with chemotherapy is recommended for the treatment of patients with symptomatic advanced stage follicular lymphoma ^2,9.

Rituximab is recommended for use in NHSScotland by the Scottish Medicines Consortium. When added to a number of different chemotherapy regimens it produced statistically significant improvements in survival when compared with chemotherapy regimens alone ¹⁰.

* As it is difficult to accurately identify those patients with symptomatic advanced follicular lymphoma, the number of patients with follicular lymphoma undergoing chemotherapy is being utilised as a proxy measure for symptomatic advanced disease.

Numerator:

Number of patients with follicular lymphoma and DLBCL who receive chemotherapy in combination with anti-B cell monoclonal antibody therapy.

Denominator:

All patients with follicular lymphoma and DLBCL who receive chemotherapy.

Exclusions

• Patients who refuse chemotherapy.
• Patients enrolled in clinical trials.

95%

The tolerance within this target accounts for that fact that due to co-morbidities and fitness levels not all patients will require or be suitable for anti-B cell monoclonal antibody therapy.

QPI wording updated to remove reference to rituximab and replace with anti-B cell monoclonal antibody therapy.

Footnote added regarding current practice in relation to rituximab.

Patients with primary cutaneous lymphoma should be discussed at a specialist MDT meeting.

Proportion of patients with primary cutaneous lymphoma who are discussed at a specialist MDT meeting which includes representation from pathology, dermatology, oncology ± haemato-oncology.

A specialist MDT for patients with primary cutaneous lymphoma facilitates clinico-pathological correlation, which is very important in this group of conditions where treatment is multi-faceted. Furthermore it allows for consolidation of expertise in this rare condition which will help develop robust diagnosis and management.

Numerator:

Number of patients with primary cutaneous lymphoma who are discussed at a specialist MDT meeting.

Denominator:

All patients with primary cutaneous lymphoma.

Exclusions

• No exclusions.

95%

No changes to QPI.

Virological testing for Human Immunodeficiency Virus ( HIV), hepatitis B and C should be undertaken for patients undergoing anti-B cell monoclonal antibody therapy ^§.

Proportion of patients with lymphoma undergoing anti-B cell monoclonal antibody therapy who have hepatitis B, hepatitis C and HIV status checked prior to treatment.

Clinical assessment and virological testing for HIV, hepatitis B and C should be undertaken for all patients as part of the diagnostic process and in all patients considered at risk of virus reactivation ^{2 4}.

All patients who are found to be hepatitis B should receive the appropriate anti-viral prophylaxis and those found to be HIV positive should receive appropriate anti-retroviral treatment before commencing treatment.

Numerator:

Number of patients with lymphoma undergoing anti-B cell monoclonal antibody therapy who have hepatitis B, C and HIV status checked prior to treatment.

Denominator:

All patients with lymphoma undergoing anti-B cell monoclonal antibody therapy.

Exclusions

• No exclusions.

95%

The tolerance within this target accounts for situations where patients undergo other treatments prior to anti-B cell monoclonal antibody therapy.

Target lowered from 100% to 95%.

QPI wording updated to remove reference to rituximab and replace with anti-B cell monoclonal antibody therapy.

Footnote added regarding current practice in relation to rituximab.

Patients with advanced Hodgkin Lymphoma who receive treatment with ABVD ^** chemotherapy should have early assessment of response by appropriate imaging.

Proportion of patients with advanced Hodgkin Lymphoma (stage 2B and above) who receive ABVD chemotherapy treatment, that have their treatment evaluated with PET CT scan after 2 cycles of chemotherapy.

PET CT demonstrates a higher level of accuracy compared with contrast CT scan and is therefore the most appropriate method of response assessment following chemotherapy in lymphoma patients ¹¹.

Interim PET CT is recommended for patients with advanced Hodgkin Lymphoma undergoing treatment with ABVD chemotherapy as this is an indicator of predicted treatment success when continuing treatment ^11,12.

Evidence suggests that the optimal timing for PET CT to be carried out is following 2 cycles of ABVD chemotherapy ¹¹.

Numerator:

Number of patients with advanced Hodgkin Lymphoma (stage 2B and above) who receive ABVD chemotherapy treatment that undergo PET CT scan after 2 ^{◘ ◘} cycles of chemotherapy.

Denominator:

All patients with advanced Hodgkin Lymphoma (stage 2B and above) who receive ABVD chemotherapy treatment.

Exclusions

• Patients who died during treatment.

80%

The tolerance within this target is designed to account for those patients who may not complete ABVD chemotherapy treatment due to factors of fitness. It also accounts for those patients where PET CT may not be appropriate as the result will not alter management due to co-morbidities or fitness.

NEW QPI

Patients with follicular lymphoma undergoing R-Chemotherapy ^{‡ ‡} should receive maintenance therapy with rituximab.

Proportion of patients with follicular lymphoma undergoing treatment with R-Chemotherapy who receive maintenance therapy with rituximab.

Maintenance treatment with rituximab can prolong the time until relapse and delay the need for more treatment ².

It is recommended that patients with follicular lymphoma responding to first line rituximab based chemotherapy should receive rituximab maintenance therapy as this has progression free survival benefits ^2,13 .

Numerator:

Number of patients with follicular lymphoma who undergo treatment with R-Chemotherapy who receive maintenance therapy with rituximab.

Denominator:

All patients with follicular lymphoma who undergo treatment with R-Chemotherapy.

Exclusions

• Patients who refuse chemotherapy.
• Patients enrolled in clinical trials.
• Patients who died before chemotherapy treatment.

90%

The tolerance within this target accounts for the fact that some patients will not respond to chemotherapy treatment and therefore not be appropriate for maintenance therapy with rituximab. Maintenance therapy may also not be suitable due to co-morbidities and fitness levels.

NEW QPI

This QPI which is applicable to all tumour sites is currently under review.

The revised Clinical Trial Access QPI will be included within the final Lymphoma QPI document.