National Oesophago-Gastric Cancer Audit update

Project Overview

Clinical AuditsAUGIS members are encouraged to take part in local audit projects. In the past 10 years the AUGIS Council has also initiated national audit projects for members in order to help with benchmarking requirements and to improve their own practice. The first national audit report was published in 2002 and several audits have been completed in the intervening years.

The aim of the National Oesophago-Gastric Cancer Audit is to examine the overall quality of care for oesophago-gastric cancer in the UK.  In particular it is looking at:

  • The patterns of treatment and what determines them
  • Compliance with key process standards, such as the use of staging investigations
  • The outcomes of surgery and other treatment, including peri-operative mortality, lymph node yields and resection margin status

It is funded by the Healthcare Quality Improvement Program (HQIP) and is a collaboration between 4 organisations:

  • AUGIS
  • British Society of Gastroenterology
  • National Clinical Audit Support Program (NCASP) of the Information Centre for Health and Social Care (IC)
  • Clinical Effectiveness Unit of the Royal College of Surgeons of England / London School of Hygiene and Tropical Medicine (CEU)

The main component of the project is a prospective study which includes all patients diagnosed with invasive epithelial cancer of the oesophagus, gastro-oesophageal junction or stomach in England and Wales between 1st October 2007 and 30th June 2009.

It also includes a study of the organisation of O-G cancer services, an investigation of patients’ quality of life and an analysis of existing databases (such as the Hospital Episodes Statistics (HES) database).

Third Annual Report

The Third and Final Annual Report was published on 3rd November 2010. It describes the care received by over 17,000 patients with oesophago-gastric cancer in England and Wales. This included 3,803 curative surgical resections.

Highlights of the report include:

  • Reporting of endoscopic ultrasound for staging was variable across Cancer Networks, and there remains uncertainty about whether EUS is being under-utilised among patients having curative surgery.
  • The 30-day postoperative mortality rate for oesophagectomy and gastrectomy was 3.8 per cent (95 per cent CI 3.1 to 4.7) and 4.5 per cent (95 per cent CI 3.4 to 5.7), respectively. Around 1 in 10 oesophagectomy patients and 1 in 12 gastrectomy patients had an unplanned return to theatre during their hospital stay
  • Peri-operative outcomes for open and minimally-invasive resections were similar. For oesphagectomy, there was a statistically significant difference in the rate of anastomotic leak (7.4 per cent for open and 10.5 per cent for minimally invasive procedures) but this did not translate into worse 30-day or 90-day mortality, rate of reoperation, or other complications (cardiac, respiratory, wound infection, etc). For gastrectomy, there were no statistically significant differences in complication rates between the open and minimally invasive approaches.
  • Selected postoperative outcomes were calculated for individual NHS trusts to support local benchmarking. The risk-adjusted complication rates for all NHS trusts were within the expected range.

The full report can be downloaded here: PDF NHS IC OGC Audit 2010 interactive

Previous reports

First Annual Report

The First Annual Report was published in June 2008 and contained the results of the work performed in the Audit’s first year, principally the results of the organisational survey and the initial analysis of the joint Hospital Episode Statistics – Cancer Registry database.

Among the interesting findings are:

  • 11 cancer networks had still not completed the centralisation process
  • Only 53% of surgical centres have the recommended minimum 3 surgeons
  • O-G cancer has the 2nd worst provision of clinical nurse specialists, behind only pancreatic cancer
  • 1 year survival rose from 30% in 1998 to 37% in 2005
  • The use of neoadjuvant chemotherapy in oesophageal cancer rose from 8% in 1998 to 48% in 2005

More detail from the organisational survey has since been published in the peer-reviewed journal BMC Health Services Research. The full text of this article is available free online from: http://www.biomedcentral.com/1472-6963/9/204

The full report can be downloaded here: PDF Document First Annual Report June 2008


2nd Annual Report

The 2nd Report was published in September 2009 and consisted of initial results from the prospective study, with data on over 11,500 patients and 2000 surgical resections. This represents a surgical case ascertainment of 73% which is very encouraging for the first year of an audit. Although it concentrated on the diagnostic and referral process, it also contained some figures on short-term outcomes.

Highlights of the report include:

  • Although the median age of patients was 72, 10% of patients were aged 55 or under and 1% were under 40.
  • The 30-day mortality rate for oesophagectomy and gastrectomy was 3.2 per cent (95% CI 2.3 to 4.5) and 4.2 per cent (95% CI 2.9 to 6.0), respectively and the in-hospital mortality was 5.0% (95% CI 3.8 to 6.4) and 6.9% (95% CI 5.2 to 9.0).
  • Minimally invasive oesophagectomy patients had fewer respiratory complications than those having surgery by the open route. There were no other significant differences between the two approaches in terms of peri-operative mortality, complications, length of stay or lymph node yield
  • 95% of oesophagectomies and 72% of gastrectomies yielded the minimum number of lymph nodes required for TNM histopathological staging.
  • 80% of patients with stage II or III adenocarcinoma of the oesophagus or GOJ were planned to undergo neoadjuvant chemotherapy. However, for stomach cancer patients, the proportion was only 55 per cent.

The full report can be downloaded here: PDF Document Second Annual Report September 2009

Future

The future shape of this Audit is still uncertain. The newly formed National Cancer Intelligence Network (NCIN) is working on how much quality data can be gathered using existing capture systems and this work will inform how much extra data will need to be collected to monitor treatment outcomes. It is certain however that some form of clinical data collection will be required.

Monitoring surgical outcomes is something that is essential for improving care and one which we cannot avoid even if we should wish to. Please continue to enter your treatment data for eligible patients in order to ensure that the process is as beneficial as possible and that we as clinicians are able to continue to lead the process. Thank you to everyone for all their hard work.

It has taken a lot of hard work from people all over the country to make the first national audit a success but we now have meaningful information that can be used to improve our practice and patient care. This is a long process and one in which we are still only at the beginning.

A new national audit started in June 2011 and is collecting data on patients diagnosed from April 1, 2011

PDF - Download the New Audit Update

Contacts

If you have any questions about the Audit, please do not hesitate to contact either Richard Hardwick (Lead clinician and consultant surgeon in Cambridge; richard.hardwick@addenbrookes.nhs.uk ) or Tom Palser (Research Fellow; tpalser@rcseng.ac.uk )

 


2009 NOGCA report