Thyroid cancer - clinical quality performance indicators: engagement document

4. Quality Performance Indicators for Thyroid Cancer

QPI 1 - Multi-Disciplinary Team (MDT) Meeting

QPI Title:

Patients with thyroid cancer should be discussed by a multidisciplinary team to determine a treatment management plan.

Description:

Proportion of patients with thyroid cancer who are discussed at a MDT meeting.

Rationale and Evidence:

Evidence suggests that patients with cancer managed by a multi-disciplinary team (MDT) have a better outcome. There is also evidence that multidisciplinary management increases overall patient satisfaction with care provided, and has the potential to improve quality of life and survival.

Discussion of treatment plans by a MDT provides reassurance that patients are being managed appropriately. Many cases of thyroid cancer are only confirmed after surgery (e.g. after thyroidectomy for a benign thyroid condition or where cytology is indeterminate) In these instances, a diagnostic lobectomy or thyroidectomy may be confirmed as the definitive treatment. It is therefore appropriate for these cases to be discussed post-treatment.

Specification:

• Numerator:
  • Number of patients with thyroid cancer discussed at a MDT meeting.
• Denominator:
  • All patients with thyroid cancer.
• Exclusions:
  • Patients who died before first treatment.
• Target:
  • 95%

QPI 2 - Molecular Testing in Differentiated Thyroid Cancer

QPI Title:

Patients with differentiated thyroid cancer should undergo molecular testing to allow for appropriate treatment planning.

Description:

Proportion of patients with differentiated thyroid cancer measuring >=10mm in size who undergo molecular testing as part of the diagnostic process.

Rationale and Evidence:

The use of molecular markers in differentiated thyroid cancer is valuable in determining risk stratification at diagnosis, may potentially influence treatment intensification, and can aid the selection of specific targeted therapies in the context of advanced radioiodine refractory disease.

For example, BRAF, TERT and combined BRAF/TERT mutations in papillary thyroid cancers are associated with increasing risk of recurrence and are incorporated in the ATA risk classification system.

Specifications:

• Numerator:
  • Number of patients with differentiated thyroid cancer measuring >=10mm in size who undergo molecular testing.
• Denominator:
  • All patients with differentiated thyroid cancer measuring >=10mm in size.
• Exclusions:
  • No exclusions.
• Target:
  • 95%

The tolerance level within this target is designed to account for situations where there is insufficient tissue for molecular testing.

QPI 3 - Volume of Cases per Surgeon

QPI Title:

Thyroid surgery should be performed by surgeons who perform the procedures routinely.

Description:

Number of thyroid operations performed by a surgeon over a 1 year period.

Rationale and Evidence:

Thyroid cancer should be operated on by high volume surgeons in order to reduce morbidity and increase favourable oncological results.

The literature demonstrates that there is a correlating relationship between volume and outcome in terms of complications for thyroid surgery.

A number of studies have shown the effect of high surgical volume of thyroidectomy on the reduced incidence of recurrent laryngeal nerve (RLN) injury and post-operative hypocalcaemia, as well as shorter length of hospital stay.

Specifications:

Number of thyroid operations performed by each surgeon in a given year.

• Exclusions:
  • No exclusions
• Target:
  • Minimum 20 procedures per surgeon in a 1 year period.

This is a minimum target level and is designed to ensure that all surgeons performing thyroid surgery perform a minimum of 20 procedures per year.

Please Note: Varying evidence exists regarding the most appropriate target level for surgical case volume. In order to ensure that the target level takes account of level 1 evidence and will drive continuous quality improvement as intended this performance indicator must be kept under regular review.

It is recommended that where two consultants operate together on the same patient the case should be counted under the Lead Surgeon.

Please note:

SMR01 data will be utilised to support reporting and monitoring of this QPI rather than clinical audit. This will maximise the use of data which are already collected and remove the need for any duplication of data collection. Standard reports are in place with direct access for each Board to run these reports to ensure nationally consistent analysis and reporting.

QPI 4 - Time to Completion Surgery

QPI Title:

Patients with thyroid cancer who are required to undergo completion thyroidectomy should do so within 3 months of initial lobectomy.

Description:

Proportion of patients with thyroid cancer who undergo completion thyroidectomy within 3 months of initial lobectomy.

Rationale and Evidence:

Completion thyroidectomy allows surgeons to remove any residual thyroid tissue safely at a later date, which is often required following review of pathological findings.

Although there is no definitive evidence on the exact timing, clinical opinion states that an optimal time could be 3 months. This will facilitate timely adjuvant radioiodine remnant ablation treatment whilst also reducing complications which may occur with early surgery.

Specifications:

• Numerator:
  • Number of patients with thyroid cancer who undergo completion thyroidectomy within 3 months of initial lobectomy.
• Denominator:
  • All patients with thyroid cancer who undergo lobectomy as their initial surgery followed by completion thyroidectomy.
• Exclusions:
  • Patients who die within 3 months of initial lobectomy.
• Target:
  • 70%

The tolerance within this target is designed to account for situations where patients cannot undergo surgery within the proposed timeframe due to co-morbidities or factors of patient choice.

Please note:

Additional information on the time from first biopsy to first definitive surgery will be reported across NHS Boards alongside this QPI. This information will be reviewed to ensure there is no impact on the quality of care due to delays in patient pathways.

QPI 5 - Radioiodine Remnant Ablation (RRA) following Thyroidectomy for Differentiated Thyroid Cancer

QPI Title:

Patients with T4 and/or N1b or metastatic differentiated thyroid cancer should receive high dose Radioiodine Remnant Ablation (RRA), where clinically appropriate.

Description:

Proportion of patients with T4 and/or N1b or metastatic differentiated thyroid cancer who have undergone thyroidectomy and receive 3.7GBq RRA.

Rationale and Evidence:

RRA is an important tool in minimising recurrence following surgical resection of locally advanced / high risk DTC and subsequent radioiodine therapy may control distant disease in patients with metastatic involvement.

It is recommended that patients with high risk features such as T4 and/or N1b or M1 disease receive radioactive iodine with ablation activity of 3.7GBq.

The QPI Development Group agreed not to include aggressive subtypes (e.g. tall cell variant of papillary thyroid cancer) in the measurement of this QPI as there are other clinical factors that require consideration in order to determine the most appropriate treatment plan for this cohort of patients.

Specifications:

• Numerator:
  • Number of patients with T4 and/or N1b or metastatic differentiated thyroid cancer who have undergone thyroidectomy and receive 3.7GBq RRA.
• Denominator:
  • All patients with T4 and/or N1b or metastatic differentiated thyroid cancer who have undergone thyroidectomy.
• Exclusions:
  • Patients who decline RRA treatment.
  • Patients who die prior to RRA treatment.
• Target:
  • 90%

The tolerance within this target is to account for those patients with contraindications to RRA. In addition, it accounts for the fact that due to co-morbidities and fitness levels, not all patients will be suitable for RRA.

QPI 6 - Timing of Radioiodine Remnant Ablation (RRA) following Thyroidectomy for Differentiated Thyroid Cancer

QPI Title:

Patients with differentiated thyroid cancer who require high dose Radioiodine Remnant Ablation (RRA) should receive this therapy within 3 months of thyroidectomy.

Description:

Proportion of patients with differentiated thyroid cancer who undergo high dose (3.7GBq) RRA within 3 months of thyroidectomy.

Rationale and Evidence:

Radioiodine remnant ablation (RRA) is an important tool in minimising recurrence following thyroidectomy for differentiated thyroid cancer (DTC) and plays an integral role in risk stratification.

Although there are no definitive recommendations around optimal timing, there is evidence which suggests that delays in commencing radioactive iodine treatment for longer than 88 days is associated with risk of disease persistence and recurrence in N1 papillary thyroid cancer.

Furthermore, it has been shown that delayed initial radioactive iodine treatment (>=3 months post thyroidectomy) related to incomplete response in intermediate to high risk differentiated thyroid cancer.

Specifications:

• Numerator:
  • Number of patients with differentiated thyroid cancer who undergo high dose (3.7GBq) RRA within 3 months of thyroidectomy.
• Denominator:
  • All patients with differentiated thyroid cancer who undergo high dose (3.7GBq) RRA following thyroidectomy.
• Exclusions:
  • Patients who delay treatment due to pregnancy / breastfeeding.
• Target:
  • 70%

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

QPI 7 - Dynamic Risk Stratification (DRS) after Radioiodine Remnant Ablation (RRA) for Differentiated Thyroid cancer

QPI Title:

Patients with differentiated thyroid cancer who undergo Radioiodine Remnant Ablation (RRA) should have Dynamic Risk Stratification (DRS) performed following treatment.

Description

Proportion of patients with differentiated thyroid cancer who undergo RRA and have DRS performed within 12 months of completion of RRA.

Rationale and Evidence:

Dynamic Risk Stratification (DRS) using Thyroglobulin (Tg) and a neck ultrasound, nine to twelve months after Radioiodine Remnant Ablation (RRA), is now widely used following publication of the British Thyroid Association's 2014 guidelines and the NICE guideline 2022 (Thyroid cancer: assessment and management (NG230).

DRS has been proposed and validated for patients who have received total thyroidectomy and RAI ablation. This permits the patients to be risk stratified into the following three groups - Excellent Response; Indeterminate Response and Incomplete Response.

Subsequent aspects of management including level of TSH suppression, frequency of follow-up and discharge from secondary care would be determined by this risk stratification.

Specifications:

• Numerator:
  • Number of patients with differentiated thyroid cancer who undergo RRA and have DRS performed within 12 months of completion of RRA.
• Denominator:
  • All patients with differentiated thyroid cancer who undergo RRA.
• Exclusions:
  • Patients who die within 12 months of treatment.
• Target:
  • 90%

The tolerance within this target is to account for the fact that some patients may not be fit for any further treatment due to disease progression therefore scoring may not be appropriate.

QPI 8 - Histological Diagnosis: Core Biopsy

QPI Title:

Patients with anaplastic thyroid cancer should have access to timely image guided core biopsy.

Description:

Proportion of patients with anaplastic thyroid cancer who undergo image guided core biopsy within one week of initial clinic appointment.

Rationale and Evidence:

Anaplastic thyroid cancer is a highly aggressive disease and prognosis relates to rapid diagnosis and surgery.

Diagnostic management must be initiated quickly in order to improve the outcome for patients. Evidence shows that it may be possible to double the overall survival time with the use of fast tracked investigations and targeted therapies. Diagnostic confirmation requires urgent biopsy followed by immuno-histochemical and molecular analysis.

Specifications:

• Numerator:
  • Number of patients with anaplastic thyroid cancer who undergo image guided core biopsy within one week of initial clinic appointment.
• Denominator:
  • All patients with anaplastic thyroid cancer.
• Exclusions:
  • Patients who decline biopsy investigation.
• Target:
  • 90%

The tolerance within this target is designed to account for situations where cancer is not suspected pre-operatively, or where patients are deemed unfit for radical treatment.

QPI 9 - Radiological Staging: CT Scan

QPI Title:

Patients with anaplastic thyroid cancer should have access to timely CT scan for staging purposes.

Description:

Proportion of patients with anaplastic thyroid cancer who undergo staging CT scan, where the report is available within one week of initial clinic appointment.

Rationale and Evidence:

Anaplastic thyroid cancer is a highly aggressive disease and prognosis relates to rapid diagnosis and surgery.

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

Initial radiological staging should include CT neck, chest, abdomen and pelvis. It is critical that all initial staging procedures are expedited in order to avoid any delays to treatment.

Specifications:

• Numerator:
  • Number of patients with anaplastic thyroid cancer who undergo staging CT Scan, where the report is available within one week of initial clinic appointment.
• Denominator:
  • All patients with anaplastic thyroid cancer.
• Exclusions:
  • Patients who decline CT investigation.
• Target:
  • 90%

The tolerance within this target is designed to account for situations where cancer is not suspected pre-operatively, or where patients are deemed unfit for radical treatment.

QPI 10 - Turnaround Time of Molecular Testing in Anaplastic Thyroid Cancer

QPI Title:

Patients with anaplastic thyroid cancer should undergo molecular testing with timely results available to allow for appropriate treatment planning.

Description:

Proportion of patients with anaplastic thyroid cancer who undergo molecular testing with the genomics report available within 7 days of the sample arriving in the genomics laboratory.

Rationale and Evidence:

Anaplastic thyroid carcinoma is a rare and aggressive malignancy with a poor prognosis for patients. It accounts for 1-2 % of all thyroid cancers, but also the majority of deaths from thyroid cancer. This type of cancer has a number of oncogenic alterations which is associated with being more aggressive, and therefore more challenging to treat.

Tyrosine kinase inhibitors have recently been found to be effective in the treatment of anaplastic thyroid carcinoma in which BRAF mutations are present.

Due to the rapidly progressive nature of anaplastic thyroid cancer, the risk of airway compromise and also the likelihood of distant metastases, treatment needs to be started as quickly as possible.

Specifications:

• Numerator:
  • Number of patients with anaplastic thyroid cancer who undergo molecular testing with the genomics report available within 7 days of the sample arriving in the genomics laboratory.
• Denominator:
  • All patients with anaplastic thyroid cancer.
• Exclusions:
  • No exclusions.
• Target:
  • 90%

The tolerance level within this target is designed to account for situations where there is insufficient tissue for molecular testing, or for factors of patient choice.