Audit Report Breast Cancer Quality Performance Indicators

West of Scotland Cancer Network

Breast Cancer Managed Clinical Network

Clinical Audit Data: 01 January 2014 to 31 December 2014

Ms Iona Reid MCN Clinical Lead

Tom Kane MCN Manager

Julie McMahon Information Officer

CONTENTS

EXECUTIVE SUMMARY 3 1. INTRODUCTION 10 2. BACKGROUND 10

2.2 WEST OF SCOTLAND CONTEXT 12 3. METHODOLOGY 12 4. RESULTS AND ACTION REQUIRED 13

4.1 DATA QUALITY 13

4.2 PERFORMANCE AGAINST QUALITY PERFORMANCE INDICATORS (QPI S) 13 ACKNOWLEDGEMENT 36 ABBREVIATIONS 37 REFERENCES 38

APPENDIX II – ACTION PLAN TEMPLATE 37 Executive Summary

Introduction This report presents an assessment of performance of West of Scotland (WoS) Breast Cancer services relating to patients diagnosed in the twelve months between 1 January 2014 and 31 December 2014. Results are measured against the Breast Cancer Quality Performance Indicators (QPIs) which were implemented for patients diagnosed on or after 1 January 2012.

In 2010, the Scottish Cancer Taskforce established the National Cancer Quality Steering Group (NCQSG) to take forward the development of national QPIs for all cancer types to enable national comparative reporting and drive continuous improvement for patients. In collaboration with the three Regional Cancer Networks and Information Services Division (ISD) the first QPIs were published by Healthcare Improvement Scotland (HIS) in January 2012 and implementation for all cancer types was completed in autumn 2014. Data definitions and measurability criteria to accompany the breast cancer QPIs are available from the ISD website (1).

This is the third year of reporting breast cancer QPI data therefore results for patients diagnosed in 2014 have been presented alongside the previous years’ results to allow year on year comparison and illustrate trends.

In order to ensure success of the National Cancer QPIs in driving quality improvement in cancer care across NHS Scotland it is critical that QPIs continue to be clinically relevant and focus on areas which will result in improvements to the quality of patient care. As part of the national process it was agreed that indicators would be formally reviewed following the availability of 3 years of comparative reporting. This clinically led review aims to identify potential refinements to the current QPIs and involves key clinicians from each of the Regional Cancer Networks. The review of breast cancer QPIs began in December 2015 and the output of the review will be communicated in due course.

Background The trend in incidence of cancer in Scotland is generally an increasing one. Over the last decade the incidence rate of breast cancer has increased by 9%. Breast cancer is the most common cancer in women in Scotland with a frequency of 29% of all female cancers. While the incidence of breast cancer is increasing, significant improvements have been achieved in long term survival with around 88% of women surviving 5 years based upon current Information Services Division(ISD) data (2).

Four NHS Boards across the WoS serve the 2.5 million population. From this population around approximately 2300 new cases of breast cancer are diagnosed each year. WoS breast cancer services are organised around eight Multidisciplinary Teams (MDTs) with each MDT convening on a weekly basis.

Methodology The clinical audit data presented in this report was collected by clinical audit staff in each NHS Board in accordance with an agreed dataset and definitions. The data was entered locally into the electronic Cancer Audit Support Environment (eCASE): a secure centralised web-based database. Data relating to patients diagnosed between 1 January 2014 and 31 December 2014 was downloaded from eCASE on 26 August 2015.

Analysis was performed centrally by the WoSCAN Information Team and the timescales agreed took into account the patient pathway to ensure that a complete treatment record was available for each case. Results were disseminated for NHS Board verification in line with the regional audit governance process, to ensure that the data was an accurate representation of service in each area.

West of Scotland Cancer Network Final - Published Breast Cancer MCN Audit Report v1 08/02/2016 3 Results Results for each QPI are shown in detail in the main report and illustrate Board performance against each target and overall WoS performance for each performance indicator. Results are presented graphically and the accompanying tabular format also highlights any missing data and its possible effect on any of the measured outcomes. Additional narrative and clinical commentary is also provided in the main report to explain some of the apparent variances in performance.

The summary of results shows the WoS percentage performance against each QPI target and the range in performance by NHS Board. As patients within NHS Greater Glasgow and Clyde are managed by different MDTs, the NHSGGC figures are also shown broken down by analysis group – North East Glasgow, West Glasgow, South Glasgow and Clyde.

Summary of QPI Results Colour Key Above or equal to QPI target Below QPI target Symbol Key > Indicates improvement on previous year’s performance < Indicates decrease from previous year’s performance = Indicates no change from previous year Indicates no comparable measure to previous year BREAST Performance by Board Quality Performance Indicator QPI WoS AA FV LS NE West SG Clyde (QPI) target 96.9% 98.0% 97.4% 97.7% 94.5% 97.3% 94.3% 99.1% QPI 1: Multi-Disciplinary Team Meeting (MDT) Proportion of patients with breast 95% cancer who are discussed at MDT 2249 2320 389 397 276 292 357 367 276 292 357 367 333 353 328 331 meeting before definitive treatment.

QPI 2: Non operative Diagnosis . 96.3% 95.2% 98.5% 96.9% 97.2% 98.1% 92.4% 97.0% Proportion of patients with invasive or = > > > > > < < in-situ breast cancer who have a non- 95% operative diagnosis (core biopsy / 2244 2330 379 398 282 290 361 368 282 290 361 368 328 355 320 330 large volume biopsy). QPI 3.1: Patients with breast cancer 98.3% 99.7% 98.7% 98.6% 96.5% 96.6% 98.8% 99.2% should have pre-operative assessment of the axilla. = = > > < < < > Proportion of patients with invasive 95% 1732 1762 289 290 150 152 291 295 219 227 284 294 244 247 255 257 breast cancer who undergo assessment of the axilla by ultrasound before surgery. QPI 3.2: Patients with breast cancer 97.7% 100% 96.9% 97.7% 100% 94.7% 100% 95.8% should have pre-operative assessment of the axilla. > > < > > < > > Proportion of patients with invasive 390 399 50 50 63 65 85 87 50 50 54 57 42 42 46 48 breast cancer with suspicious 85% morphology reported on ultrasound who undergo a FNA/core biopsy of the axilla before surgery. QPI 4: Patients with small breast 88.6% 86.4% 82.0% 85.4% 92.0% 91.0% 88.1% 93.0% cancers should undergo breast conservation whenever < < < > > < > < appropriate*. 656 740 133 154 41 50 70 82 69 75 132 145 118 134 93 100 Proportion of surgically treated patients 85% with breast cancer less than 20mm whole tumour size on histology who achieve breast conservation. BREAST Performance by Board Quality Performance Indicator QPI WoS AA FV LS NE West SG Clyde (QPI) target QPI 5: Breast cancers which are 1.2% 0.0% 5.5% 1.8% 1.5% 1.9% 0.5% 0.5% surgically treated should be adequately excised. > < > > > > > < Proportion of surgically treated patients <5% 15 1203 0 213 4 73 3 169 2 136 4 207 1 209 1 196 with breast cancer (invasive or ductal carcinoma in situ) with final radial excision margins of less than 1mm. QPI 6: Patients undergoing 28.9% 32.7% 24.1% 32.4% 18.9% 28.3% 33.8% 31.3% mastectomy for breast cancer should have access to immediate < < > < < < > < breast reconstruction. >10% Proportion of patients who undergo immediate breast reconstruction at the 207 717 35 107 20 83 48 148 20 106 32 113 27 80 25 80 time of mastectomy for breast cancer. QPI 7: Over treatment of the axilla 1.5% 0.0% 2.8% 1.6% 3.8% 0.0% 0.0% 0.0% should be minimised. Proportion of patients with breast < = > < < = < < cancer undergoing axillary clearance <10% 4 263 0 17 1 36 1 62 2 53 0 47 0 25 0 23 with no pathological evidence of nodal metastatic disease*. QPI 8: Patients should have the 92.6% 91.6% 100% 94.2% 92.2% 94.2% 95.8% 84.6% opportunity for “23 hour” surgery (a maximum of 1 overnight stay > > > > < > > > following surgery) wherever 1330 1437 239 261 102 102 229 243 142 154 211 224 204 213 203 240 appropriate. Proportion of patients undergoing wide 80% excision and/or an axillary sampling procedure for breast cancer with a maximum of 1 night hospital stay following their procedure. QPI 9: HER2 status should be 54.8% 90.2% 6.0% 21.3% 71.7% 57.5% 72.7% 46.9% available to inform treatment decision making. > < > > > > > > Proportion of patients with invasive breast 90% 1159 2115 322 357 11 183 77 362 195 272 192 334 218 300 144 307 cancer for whom the HER2 status, as defined by ImmunoHistoChemistry (IHC), is known at the initial multidisciplinary team

West of Scotland Cancer Network Final - Published Breast Cancer MCN Audit Report v1 08/02/2016 6 BREAST Performance by Board Quality Performance Indicator QPI WoS AA FV LS NE West SG Clyde (QPI) target (MDT) meeting to decide first treatment.

BREAST Performance by Board Quality Performance Indicator QPI WoS AA FV LS NE West SG Clyde (QPI) target QPI 10: After wide local excision 95.5% 96.7% 100% 85.4% 100% 97.8% 96.0% 95.2% patients with breast cancer should receive radiotherapy. < < > < > < < = Proportion of patients with breast 95% 1004 1051 178 184 69 69 129 151 126 126 175 179 167 174 160 168 cancer who receive radiotherapy to the breast after conservation for invasive cancer. QPI 11: Patients with higher risk 64.6% 52.8% 54.8% 70.8% 74.4% 51.0% 75.7% 75.6% breast cancer should receive chemotherapy post operatively. < < < < < < < > Proportion of patients between 50 and 195 302 28 53 17 31 34 48 32 43 25 49 28 37 31 41 70 years of age at diagnosis with 85% surgically proven node positive or at least G3 >20mm breast cancer who receive adjuvant chemotherapy. QPI 12: Patients with HER2 positive 86.0% 69.2% 100% 71.4% 100% 80.0% 94.4% 100% intermediate or high risk breast cancer should receive anti-HER2 < < > < > < < = positive therapy. 74 86 9 13 11 11 10 14 8 8 12 15 17 18 7 7 Proportion of patients with breast cancer (who are between 50 and 70 90% years of age at diagnosis) with HER2 positive cancer greater than 10 mm or node-positive who receive anti-HER2 positive therapy.

West of Scotland Cancer Network Final - Published Breast Cancer MCN Audit Report v1 08/02/2016 7 Conclusions and Action Required

Cancer audit has underpinned much of the regional development and service improvement work of the MCN and the regular reporting of activity and performance have been fundamental in assuring the quality of care delivered across the region. With the development of Quality Performance Indicators, this has now become a national programme to drive continuous improvement and ensure equity of care for patients across Scotland.

The Breast Cancer MCN is encouraged by the continued support and commitment of Network members to deliver a high quality service to breast cancer patients across the WoS. The results presented in this report demonstrate that patients with breast cancer receive a consistent and improving standard of care across all geographical locations. Case ascertainment and data capture is of a high standard enabling robust assessment of performance against QPIs.

The results presented within this report illustrate that some of the QPI targets set have been challenging for NHS Boards to achieve and there remains room for further service improvement, however it is encouraging that targets relating to MDT discussion, pre-operative assessment of the axilla, minimising over treatment of the axilla, immediate breast reconstruction and minimising hospital stay were consistently met by all boards in 2014.

Additionally, comparison with 2012 and 2013 data has highlighted a number of areas where NHS Board performance has improved in 2014 for example 97.7% of patients undergoing FNA/core biopsy of the axilla in 2014 compared to 72.4% in 2012. The 23 hour surgery rate where patients have the opportunity for a maximum of one over night stay following surgery has risen to 92.6% in 2014 compared to 84.9% in 2012. However targets for QPIs relating to HER2 status and adjuvant chemotherapy have remained challenging for all units to achieve over the 3 years of analysis.

Where targets have not been met NHS Boards have provided detailed comment indicating valid clinical reasons or in some cases patient choice or co-morbidities have influenced patient management. One action has been identified for NHS GGC in relation to QPI 2 (non operative diagnosis) where a more detailed case note review is required for cases in South Glasgow not meeting the target and an action for all boards to provide clarity on local data recording for QPI 9 (HER2 status for decision making) has been identified. Additionally a regional action relating to potential variation in breast reconstruction rates has been identified.

Each Board was asked to complete a Performance Summary Report and document areas for improvement where performance was below the QPI target.

The MCN will actively take forward regional actions identified and NHS Boards are asked to develop local Action/Improvement Plans in response to the findings presented in the report.

Action Required: • NHSGGC to review cases in South Glasgow not meeting QPI 2 and provide further detail on those cases. • Breast Cancer MCN to review variation in breast reconstruction rates across the region to establish if there is an identifiable reason for this. • All boards to clarify if HER2 status is known and being documented at the pre-treatment MDT rather than initial MDT as per data definition changes.

Completed Action Plans should be returned to WoSCAN within two months of publication of this report.

West of Scotland Cancer Network Final - Published Breast Cancer MCN Audit Report v1 08/02/2016 8

Progress against these plans will be monitored by the MCN Advisory Board and any service or clinical issue which the Advisory Board considers not to have been adequately addressed will be escalated to the NHS Board Territorial Lead Cancer Clinician and Regional Lead Cancer Clinician.

Additionally, progress will be reported annually to the Regional Cancer Advisory Group (RCAG) by NHS Board Territorial Lead Cancer Clinicians and MCN Clinical Leads, and nationally on a three-yearly basis to Healthcare Improvement Scotland as part of the governance processes set out in CEL 06 (2012).

West of Scotland Cancer Network Final - Published Breast Cancer MCN Audit Report v1 08/02/2016 9 1. Introduction

This report contains an assessment of the performance of West of Scotland (WoS) breast cancer services using clinical audit data relating to patients diagnosed with breast cancer in the twelve months between 01 January 2014 and 31 December 2014. Regular reporting of activity and performance is a fundamental requirement of a Managed Clinical Network (MCN) to assure the quality of care delivered across the region. Results are measured against the Breast Cancer Quality Performance Indicators (QPIs) which were introduced for patients diagnosed on or after 1 January 2012.

In 2010, the Scottish Cancer Taskforce established the National Cancer Quality Steering Group (NCQSG) to take forward the development of national QPIs for all cancer types to enable national comparative reporting and drive continuous improvement for patients. In collaboration with the three Regional Cancer Networks and Information Services Division (ISD), the first QPIs were published by Healthcare Improvement Scotland (HIS) in January 2012 and implementation for all cancer types was completed in autumn 2014. CEL 06 (2012) mandates all NHS Boards in Scotland to report on QPIs on an annual basis. Data definitions and measurability criteria to accompany the Breast Cancer QPIs are available from the ISD website (1).

2. Background

The Breast Managed Clinical Network (MCN) was established in 2002 as a means of delivering equitable high quality clinical care to all breast cancer patients across four NHS Boards; Ayrshire & Arran, Forth Valley, Greater Glasgow and Clyde and Lanarkshire covering a population of 2.5 million.

The Breast MCN continues to support and develop the clinical service for approximately 2300 breast cancer patients per annum. The effective management of these patients throughout the region relies on coordinated delivery of treatment and care that requires close collaboration of professions from a range of specialties. WoS breast cancer services are organised around eight Multidisciplinary Teams (MDTs). The configuration of the MDTs in the region is set out below.

Table 1: WoS MDT Configuration MDT Constituent Hospital Ayrshire Crosshouse Hospital Forth Valley Forth Valley Royal Hospital Lanarkshire Monklands District General Lanarkshire Wishaw General Hospital Greater Glasgow & North East Stobhill Hospital Greater Glasgow South New Victoria Infirmary Greater Glasgow West Western Infirmary Greater Glasgow & Clyde Royal Alexandra Hospital ,Inverclyde Royal Hospital

West of Scotland Cancer Network Final - Published Breast Cancer MCN Audit Report v1 08/02/2016 10 All patients diagnosed with breast cancer should be discussed at an MDT meeting and each MDT convenes on a weekly basis. A QPI to measure the proportion of patients with breast cancer discussed at MDT has been developed and was implemented for all patients diagnosed on or after 1 July 2014.

2.1 National Context

Breast cancer is the most common cancer in women in Scotland with approximately 4700 new cases diagnosed annually. The incidence rate of breast cancer continues to rise with a 9% increase over the last decade. This may be attributed to the higher prevalence of known risk factors among the female population such as long standing changes in fertility, increasing levels of post-menopausal obesity and increases in alcohol consumption. Breast cancer in men is very rare, accounting for less than 1% of all cancers in Scotland (2) .

In spite of the increase in incidence of breast cancer, mortality rates from breast cancer have decreased by 19% over the last 10 years (2) . Significant improvements have been achieved in long term survival with around 88% of women surviving 5 years based upon current Information Services Division (ISD) data (3) . Early detection of breast cancer through a national screening programme, improvements in diagnosis and staging of breast cancer and improved treatment interventions are all likely factors in survival.

West of Scotland Cancer Network Final - Published Breast Cancer MCN Audit Report v1 08/02/2016 11 2.2 West of Scotland Context

A total of 2344 cases of breast cancer were recorded through audit as diagnosed in the WoS between 1 January 2014 and 31 December 2014. The number of patients diagnosed within each unit is presented in Figure 1. As the largest WoS Board, 58% of all new cases of breast cancer were diagnosed in NHS Greater Glasgow and Clyde (NHSGGC) which is in line with population estimates for this board.

Figure 1: Number of patients diagnosed with breast cancer by unit of diagnosis, January 2014 to December 2014

2012 2013 2014

500

450

400

350

300

250

200

Number of Cases of Number 150

100

0 Ayrshire & Forth Valley Lanarkshire N&E Glasgow West Glasgow South Glasgow Clyde Arran Analysis Group

3. Methodology

The clinical audit data presented in this report was collected by clinical audit staff in each NHS Board in accordance with an agreed dataset and definitions. The data was recorded manually and entered locally into the electronic Cancer Audit Support Environment (eCASE): a secure centralised web-based database. Data relating to patients diagnosed between 1 January 2014 and 31 December 2014 was downloaded from eCASE at 2200 hrs on 26 August 2015.

Analysis was performed centrally for the region by the WoSCAN Information Team and the timescales agreed took into account the patient pathway to ensure that a complete treatment record was available for each case. Data analysis reports were disseminated for NHS Board verification in line with the regional audit governance process to ensure that the data was an accurate representation of service in each area.

Cancer audit is a dynamic process with patient data continually being revised and updated as more information becomes available. This means that apparently comparable reports for the same time period and cancer site may produce slightly different figures if extracted at different times.

West of Scotland Cancer Network Final - Published Breast Cancer MCN Audit Report v1 08/02/2016 12 4. Results and Action Required

4.1 Data Quality

Case ascertainment is a measure of data quality and is calculated by comparing the number of new patients captured by the cancer audit with a five year average of the numbers recorded on the cancer registry. A five year average is used for registry data as the information is not available until sometime after the year under examination. This is due to data collection & verification processes. As the number of cases will vary each year, it is possible for case ascertainment to be over or under 100%. Therefore, the figures presented should be seen as an indication only.

Overall case ascertainment for WoS is high at 98.5% which indicates excellent data capture through audit. Case ascertainment figures however are provided for guidance and are not an exact measurement as it is not possible to compare directly with the same cohort. Case ascertainment for each Board across WoS is illustrated in Figure 2. There is variation in percentage case ascertainment across the Boards ranging from 91.7% to 123.6%. It should also be noted that cases diagnosed at the Glasgow Screening Centre are attributed to NHS Greater Glasgow & Clyde cancer registration figures. This may make NHSGGC case ascertainment figures lower than expected and non NHSGGC figures higher than expected.

Figure 2: Case Ascertainment by NHS Board for patients diagnosed with breast cancer January 14 to December 14

2012 2013 2014 140 130 120 110 100 90 80 70 60 50 40

Percentage of Cases(%) of Percentage 30 20 10 0 Ayrshire & Arran Forth Valley Lanarkshire GGC WoS

NHS Board

4.2 Performance against Quality Performance Indicators (QPIs)

The following section includes a detailed summary of each of the twelve breast cancer QPIs outlining the variation at individual unit level. Graphs and charts have been provided where this aids interpretation and, where appropriate, numbers have also been included to provide context.

Where performance is shown to fall below the target, commentary from the relevant NHS Board is included to provide context to the variation. Specific NHS Board actions have been identified to address issues highlighted through the data analysis.

West of Scotland Cancer Network Final - Published Breast Cancer MCN Audit Report v1 08/02/2016 13

QPI 1: Multi-Disciplinary Team Meeting Effective MDT working is considered integral to provision of high quality breast cancer care, facilitating a cohesive treatment-planning function and ensuring treatment and care provision is individualised to patient needs. QPI 1 states that 95% of patients should be discussed at the MDT prior to definitive treatment. The tolerance allows for situations where cancer is not suspected pre-operatively or where patients receive endocrine treatment prior to MDT meeting.

QPI Title: Number of patients with breast cancer who are discussed at MDT meeting before definitive treatment.

Numerator: Number of patients with breast cancer discussed at the MDT before definitive treatment.

Denominator: All patients with breast cancer.

Exclusions: Patients who died before treatment.

Target: 95% or above

Figure 3: The proportion of patients with breast cancer who are discussed by the MDT prior to definitive treatment. 2014 100

% Performance % 30

0 Ayrshire & Forth Monklands Wishaw Hairmyres N&E West South Clyde WoSCAN Arran Valley Glasgow Glasgow Glasgow Analysis Group Not recorded Not recorded Not recorded Not recorded Not recorded 201 4 Performance (%) Numerator Denominator numerator numerator (%) exclusions exclusions (%) denominator AA 98.0 389 397 0 0.0% 0 0.0% 0 FV 97.4 188 193 0 0.0% 0 0.0% 0 ML 94.2 65 69 0 0.0% 0 0.0% 0 WS 98.3 178 181 0 0.0% 0 0.0% 0 HM 98.5 135 137 0 0.0% 0 0.0% 0 N&E G 94.5 276 292 0 0.0% 0 0.0% 0 WG 97.3 357 367 0 0.0% 0 0.0% 0 SG 94.3 333 353 1 0.3 % 0 0.0% 0 Clyde 99.1 328 331 0 0. 0% 0 0.0% 0 WoS 96.9 % 2249 232 0 1 0.0 % 0 0.0% 0

This was the first year of analysing the MDT QPI. As highlighted in Figure 3 the proportion of patients discussed at an MDT meeting in the WoS is high with 96.9% of cases discussed however Monklands, North & East Glasgow and South Glasgow just missed the 95% target. West of Scotland Cancer Network Final - Published Breast Cancer MCN Audit Report v1 08/02/2016 14

All boards reviewed cases not discussed prior to definitive treatment and provided reasons for this. In many cases patients were appropriately started on hormone therapy before MDT, or other clinical reasons were provided. In NHS GGC a number of patients were discussed at a screening MDT pre operatively, rather than the unit MDT.

West of Scotland Cancer Network Final - Published Breast Cancer MCN Audit Report v1 08/02/2016 15 QPI 2: Non Operative Diagnosis: Diagnosis of patients non-operatively allows them, where possible to have only one definitive procedure. However, it may not always be technically possible to undertake a biopsy and patient choice may also be a factor. QPI Title: Number of patients with invasive or in-situ breast cancer who have a non operative diagnosis.

Numerator: Number of patients with a non-operative diagnosis of breast cancer (core biopsy / large volume biopsy).

Denominator: All patients with invasive or in-situ breast cancer.

Exclusions: All breast cancer patients with lobular carcinoma in situ (LCIS).

Target: 95% or above

Figure 4: The proportion of patients with a non-operative diagnosis of breast cancer (core biopsy/large volume biopsy) 2012 2013 2014 100

% Performance % 30

0 Ayrshire & Forth Monklands Wishaw Hairmyres N&E West South Clyde WoSCAN Arran Valley Glasgow Glasgow Glasgow Analysis Group Not recorded Not recorded Not recorded Not recorded Not recorded 201 4 Performance (%) Numerator Denominator numerator numerator (%) exclusions exclusions (%) denominator AA 95.2 379 398 1 0. 3% 0 0.0% 0 FV 98.5 194 197 0 0.0% 0 0.0% 0 ML 95.7 66 69 0 0.0% 0 0.0% 0 WS 98.4 179 182 0 0.0% 0 0.0% 0 HM 95.7 135 141 1 0.7 % 0 0.0% 0 N&E G 97.2 282 290 0 0.0% 0 0.0% 0 WG 98.1 361 368 0 0.0% 0 0.0% 0 SG 92.4 328 355 8 2.3% 0 0.0% 0 Clyde 97.0 320 330 0 0.0% 0 0.0% 0 WoS 96.3 % 2244 2330 10 0.4 % 0 0.0% 0

Of the 2,330 invasive or in-situ breast cancer patients diagnosed in the WoS in 2014, 2,244 were given a non operative diagnosis, which equates to a rate of 96.3% which is above the target rate of 95%. Performance appears to be sustained across the three years, 2012 to 2014 as demonstrated in Figure 4. Only one unit – South Glasgow – fell short of the target set for the QPI, with a non-operative diagnosis rate of 92.4%. .

West of Scotland Cancer Network Final - Published Breast Cancer MCN Audit Report v1 08/02/2016 16 Action: NHSGGC to review cases in South Glasgow and provide further detail on cases not meeting the QPI.

QPI 3: Pre-Operative Assessment of the Axilla QPI 3 is split into two sub-groups. The first group looks at all patients with invasive breast cancer who undergo ultrasound assessment of the axilla. A pre-operative diagnosis of nodal disease enables definitive treatment of axilla at the time of initial breast surgery. The target for this QPI is set at 95%. The tolerance within this target accounts for the fact that some patients may refuse investigation and/or treatment. QPI Title: Patients with breast cancer should have pre-operative assessment of the axilla.

Numerator: Number of patients with invasive breast cancer who undergo assessment of the axilla by ultrasound before surgery.

Denominator: All patients with invasive breast cancer undergoing surgery.

Exclusions: No exclusions.

Target: 95% or above

Figure 5: The proportion of patients with invasive breast cancer who undergo assessment of the axilla by ultrasound before surgery. 2012 2013 2014 100

% Performance % 40

0 Ayrshire & Forth Monklands Wishaw Hairmyres N&E West South Clyde WoSCAN Arran Valley Glasgow Glasgow Glasgow Analysis Group

Performance Not recorded Not recorded Not recorded Not recorded Not recorded 2014 (%) Numerator Denominator numerator numerator (%) exclusions exclusions (%) denominator AA 99.7 289 290 0 0.0% 0 0.0% 1 FV 98.7 150 152 0 0.0% 0 0.0% 0 ML 100.0 49 49 0 0.0% 0 0.0% 0 WS 98.6 137 139 0 0.0% 0 0.0% 0 HM 98.1 105 107 0 0.0% 0 0.0% 1 N&E G 96.5 219 227 0 0.0% 0 0.0% 0 WG 96.6 284 294 0 0. 0% 0 0.0% 0 SG 98.8 244 247 0 0. 0% 0 0.0% 8 Clyde 99.2 255 257 0 0.0% 0 0.0% 0 WoS 98.3% 1732 1762 0 0.0% 0 0.0% 10

West of Scotland Cancer Network Final - Published Breast Cancer MCN Audit Report v1 08/02/2016 17 As highlighted in Figure 5 all individual units achieved the target of 95%. Overall 98.3% of patients diagnosed in 2014 received a pre-operative ultrasound assessment. Results over the three years are also noted as being consistently high.

The second part of the QPI measures the number of patients with invasive breast cancer with suspicious morphology reported on ultrasounds that undergo a FNA/core biopsy of the axilla before surgery. The target is set at 85% with the tolerance level taking into account that FNA/core biopsy of the axilla is not always technically possible. QPI Title: Patients with breast cancer whose pre-operative ultrasound assessment of the axilla found suspicious morphology should undergo FNA/core biopsy.

Numerator: Number of patients with invasive breast cancer with suspicious morphology on ultrasound who undergo an FNA/core biopsy.

Denominator: All patients with invasive breast cancer undergoing surgery with suspicious morphology reported on ultrasound.

Exclusions: No exclusions.

Target: 85% or above

Figure 6: The proportion of patients with invasive breast cancer with suspicious morphology on ultrasound who undergo an FNA/core biopsy. 2012 2013 2014 100

% Performance % 30

0 Ayrshire & Forth Monklands Wishaw Hairmyres N&E West South Clyde WoSCAN Arran Valley Glasgow Glasgow Glasgow Analysis Group

Performance Not recorded Not recorded Not recorded Not recorded Not recorded 2014 (%) Numerator Denominator numerator numerator (%) exclusions exclusions (%) denominator AA 100.0 50 50 0 0.0% 0 0.0% 0 FV 96.9 63 65 0 0.0% 0 0.0% 0 ML 100.0 8 8 0 0.0 % 0 0.0% 0 WS 96.0 48 50 0 0.0 % 0 0.0% 0 HM 100.0 29 29 0 0.0% 0 0.0% 0 N&E G 100 50 50 0 0.0% 0 0.0% 0 WG 94.7 54 57 0 0.0% 0 0.0% 0 SG 100.0 42 42 0 0.0% 0 0.0% 0 Clyde 95.8 46 48 0 0.0% 0 0.0% 0 WoS 97.7 % 390 399 0 0.0 % 0 0.0% 0 West of Scotland Cancer Network Final - Published Breast Cancer MCN Audit Report v1 08/02/2016 18

Figure 6 demonstrates that 2014 results are excellent across all boards. 399 breast cancer patients were found to have morphologically suspicious nodes after ultrasound assessment of the axilla. Of these 390 (97.7%) underwent FNA/core biopsy meaning that the target rate of 85% was achieved. WoS performance has also improved year on year rising from 72.4% in 2012 to 97.7% in 2014. In 2014 an action was raised for NHSGGC to provide an action plan for improvement for Clyde who had failed to meet the target for two consecutive years. As can be seen in Figure 6 data for Clyde shows a significant improvement going from 58.1% in 2012 to 95.8% in 2014.

West of Scotland Cancer Network Final - Published Breast Cancer MCN Audit Report v1 08/02/2016 19 QPI 4: Conservation Rate Breast conservation is appropriate for small breast cancers; randomised trials have shown no difference in survival for tumours treated by conservation surgery followed by radiotherapy to mastectomy. The target for this QPI is set at 85% and the tolerance level takes into account that breast conservation may not always be an appropriate treatment option for a variety of reasons, primarily patient choice. QPI Title: Patients with small breast cancers should undergo breast conservation whenever appropriate.

Numerator: Number of surgically treated patients with breast cancer less than 20mm whole tumour size on histology (invasive plus in situ disease) treated by breast conservation surgery.

Denominator: All surgically treated patients with breast cancer less than 20mm whole tumour size on histology (invasive plus in situ disease).

Exclusions: All patients with multifocal breast cancer. All patients with breast cancer who have received neoadjuvant systemic therapy for ≥6 weeks (hormonal therapy or chemotherapy).

Target: 85% or above

Figure 7: The proportion of surgically treated patients with breast cancer less than 20mm whole tumour size on histology treated by breast conservation surgery. 2012 2013 2014 100

40 % Performance % 30

0 Ayrshire & Forth Monklands Wishaw Hairmyres N&E West South Clyde WoSCAN Arran Valley Glasgow Glasgow Glasgow Analysis Group Not recorded Not recorded Not recorded Not recorded Not recorded 2013 Performance (%) Numerator Denominator numerator numerator (%) exclusions exclusions (%) denominator AA 86.4 133 154 0 0.0% 0 0.0% 0 FV 82.0 41 50 0 0.0% 0 0.0% 0 ML 94.1 16 17 0 0.0% 0 0.0% 0 WS 82.1 32 39 0 0.0% 0 0.0% 0 HM 84.6 22 26 0 0.0 % 0 0.0% 0 N&E G 92.0 69 75 0 0.0% 0 0.0% 0 WG 91.0 132 145 0 0.0% 0 0.0% 0 SG 88.1 118 134 0 0.0% 0 0.0% 0 Clyde 93.0 93 100 0 0.0% 0 0.0% 0 WoS 88.6% 656 740 0 0.0% 0 0.0% 0

Figure 7 illustrates that the proportion of patients with small breast cancers being treated with conservation surgery in the WoS has remained largely unchanged since 2012, from 89.0% to

West of Scotland Cancer Network Final - Published Breast Cancer MCN Audit Report v1 08/02/2016 20 88.6% in 2014. Seven of the nine units met the 85% target with only NHS Forth Valley and Wishaw not meeting the target achieving 82.0% and 82.1% respectively.

NHS Forth Valley commented that a review of all cases which did not meet standard was conducted and eight of the nine cases were noted as being due to patient choice, with the patient either choosing to have a mastectomy or refusing conservation surgery.

NHS Lanarkshire reviewed all cases not meeting the standard and reported that five of the seven cases were again due to patient choice and valid clinical reasons were noted for the remaining two cases.

West of Scotland Cancer Network Final - Published Breast Cancer MCN Audit Report v1 08/02/2016 21 QPI 5: Surgical Margins There is an increased risk of local recurrence if radial surgical excision margins are less than 1mm after breast cancer surgery. QPI Title: Breast cancers which are surgically treated should be adequately excised.

Numerator: Number of patients with breast cancer (invasive or ductal carcinoma in situ) having breast conservation surgery with final radial (i.e. superior, inferior, medial or lateral) excision margins less than 1mm (on pathology report).

Denominator: All patients with breast (invasive or ductal carcinoma in situ) cancer having breast conservation surgery.

Exclusions: LCIS alone.

Target: Less than 5%

Figure 8: The proportion of patients with breast cancer having conservation surgery with final radial excision margins less than 1mm. 2012 2013 2014

4 % Performance %

0 Ayrshire & Forth Monklands Wishaw Hairmyres N&E West South Clyde WoSCAN Arran Valley Glasgow Glasgow Glasgow Analysis Group

Not recorded Not recorded Not recorded Not recorded Not recorded 2014 Performance (%) Numerator Denominator numerator numerator (%) exclusions exclusions (%) denominator AA 0.0 0 213 0 0.0% 0 0.0% 0 FV 5.5 4 73 0 0.0% 0 0.0% 0 ML 2.9 1 35 0 0.0% 0 0.0% 0 WS 1.4 1 72 0 0.0 % 0 0.0% 0 HM 1.6 1 62 0 0.0% 0 0.0% 1 N&E G 1.5 2 136 0 0.0% 0 0.0% 0 WG 1.9 4 207 0 0.0% 0 0.0% 0 SG 0.5 1 209 0 0.0 % 0 0.0% 8 Clyde 0. 5 1 196 0 0. 0% 0 0.0% 0 WoS 1.2% 15 1203 0 0.0% 0 0.0% 9

Although NHS Forth Valley were just over the 5% target in 2014, all units have consistently achieved high levels of compliance with this important quality measure year on year; overall regional performance in the WoS in 2014 was noted as 1.2%.

Feedback received from NHS Forth Valley stated that a review of patients who did not meet the standard was conducted. No further tissue could be taken for three of the four patients. For the West of Scotland Cancer Network Final - Published Breast Cancer MCN Audit Report v1 08/02/2016 22 remaining patient (Intermediate grade DCIS 0.5 from margin) discussion was held at MDT and with the patient and it was decided that no further surgery would be carried out. .

QPI 6: Immediate Reconstruction Rate Evidence suggests that breast reconstruction is not associated with an increase in the rate of local recurrence, nor does it affect the ability to detect recurrence and it can yield psychological benefit. Access to immediate breast reconstruction is difficult to measure therefore uptake is used as a proxy. Although it will not provide an absolute measure of patient access to this procedure it will give an indication of access across NHS Boards and highlight any areas of variance which can then be further examined.

The tolerance within this target accounts for the fact that patient choice is a key factor in the number of patients who undergo immediate breast reconstruction at the time of mastectomy. QPI Title: Patients undergoing mastectomy for breast cancer should have access to immediate breast reconstruction.

Numerator: Number of patients with breast cancer undergoing immediate breast reconstruction at the time of mastectomy.

Denominator: All patients with breast cancer undergoing mastectomy.

Exclusions: All patients with M1 disease.

Target: Greater than 10%

Figure 9: The proportion of patients with breast cancer undergoing immediate breast reconstruction at the time of mastectomy. 2012 2013 2014 50

20 % Performance %

0 Ayrshire & Forth Monklands Wishaw Hairmyres N&E West South Clyde WoSCAN Arran Valley Glasgow Glasgow Glasgow Analysis Group Not recorded Not recorded Not recorded Not recorded Not recorded 2014 Performance (%) Numerator Denominator numerator numerator (%) exclusions exclusions (%) denominator AA 32.7 35 107 0 0.0% 0 0.0% 1 FV 24.1 20 83 0 0.0% 0 0.0% 0 ML 15.8 3 19 0 0.0% 0 0.0% 0 WS 46.2 36 78 0 0.0% 0 0.0% 0 HM 17.6 9 51 0 0.0% 0 0.0% 1 N&E G 18.9 20 106 0 0.0% 0 0.0% 0 WG 28.3 32 113 0 0.0% 0 0.0% 0 SG 33.8 27 80 0 0.0 % 0 0.0% 7 Clyde 31.3 25 80 0 0.0% 0 0.0% 0 WoS 28.9 % 207 717 0 0.0 % 0 0.0 % 9 West of Scotland Cancer Network Final - Published Breast Cancer MCN Audit Report v1 08/02/2016 23

The number of patients with breast cancer undergoing immediate reconstruction at time of mastectomy in the WoS has remained fairly static over the last few years. Of all patients diagnosed in 2014, 28.9% underwent immediate breast reconstruction; this compares to 29.1% (218/750) of patients diagnosed in 2013 and 26.6% (202/760) in 2012. Figure 9 also demonstrates that for all three years all nine units achieved the QPI target.

Figure 9 shows that Wishaw General appears to have a higher rate for breast reconstruction than other WoS units and this would be worthy of further more detailed comparison across the region.

Action: Breast Cancer MCN to review variation in breast reconstruction rates across the region to establish if there is an identifiable reason for this.

QPI 7: Negative Axillary Clearance Rate Surgical axillary clearance is associated with increased arm morbidity compared with other surgical staging procedures and should therefore not be utilised unless there is evidence of nodal metastatic disease. QPI Title: Over treatment of the axilla should be minimised.

Numerator: Number of patients with breast cancer undergoing surgical axillary clearance found to have no nodal metastasis (including nodes taken at any previous sampling procedure).

Denominator: All patients with breast cancer undergoing surgical axillary clearance.

Exclusions: All patients with breast cancer who have received neoadjuvant systemic therapy for ≥6 weeks (hormonal therapy or chemotherapy).

Target: Less than 10%

Figure10: The proportion of patients with breast cancer undergoing surgical axillary clearance found to have no nodal metastasis. 2012 2013 2014 25

10 % Performance %

0 Ayrshire & Forth Monklands Wishaw Hairmyres N&E West South Clyde WoSCAN Arran Valley Glasgow Glasgow Glasgow Analysis Group Not recorded Not recorded Not recorded Not recorded Not recorded 201 4 Performance (%) Numerator Denominator numerator numerator (%) exclusions exclusions (%) denominator AA 0.0 0 17 0 0.0% 0 0.0% 0 FV 2.8 1 36 0 0.0% 0 0.0% 0 ML 8.3 1 12 0 0.0% 0 0.0% 0 West of Scotland Cancer Network Final - Published Breast Cancer MCN Audit Report v1 08/02/2016 24 WS 0.0 0 23 0 0.0% 0 0.0% 0 HM 0.0 0 27 0 0.0% 0 0.0% 0 N&E G 3.8 2 53 0 0.0% 0 0.0% 0 WG 0.0 0 47 0 0.0% 0 0.0% 0 SG 0.0 0 25 0 0.0 % 0 0.0% 0 Clyde 0.0 0 23 0 0.0% 0 0.0% 0 WoS 1.5% 4 263 0 0.0% 0 0.0% 0

All units have achieved the less than 10% target in 2014. Figure 10 illustrates improvements are apparent in the majority of units over the three years but particularly for Hairmyres where in 2012 19% of breast cancer patients undergoing surgical axillary clearance were found to have no nodal metastasis compared to 0% in 2014.

QPI 8: Minimising Hospital Stay – “23 Hour” Surgery It is safe to perform wide excision and axillary staging as a short stay procedure in the majority of patients and clinical quality has been shown to be improved utilising this model, resulting in better patient outcomes. Benefits of short stay include reduction in readmissions, reduction in complications, improved patient mobility and enhanced recovery.

However, it is not always appropriate for all patients due to social circumstances, co-morbidities and/or geographical residence. QPI Title: Patients should have the opportunity for a maximum of 1 overnight stay following surgery wherever appropriate.

Numerator: Number of patients with breast cancer undergoing wide excision and/or axillary sampling procedure (sentinel node biopsy or node sample ( ≥4 nodes) with a maximum hospital stay of 1 night following their procedure.

Denominator: All patients with breast cancer undergoing wide excision and/or axillary sampling procedure (sentinel node biopsy or node sample ( ≥4 nodes)).

Exclusions: All patients with breast cancer undergoing partial breast reconstruction.

Target: 80% or above

Figure11: The proportion of patients with breast cancer undergoing wide excision and/or axillary sampling procedure with a maximum hospital stay of 1 night following their procedure. 2012 2013 2014 100

40 % Performance % 30

0 Ayrshire & Arran Forth Valley Lanarkshire GGC WoSCAN NHS Board West of Scotland Cancer Network Final - Published Breast Cancer MCN Audit Report v1 08/02/2016 25 Not recorded Not recorded Not recorded Not recorded Not recorded 201 4 Performance (%) Numerator Denominator numerator numerator (%) exclusions exclusions (%) denominator AA 91.6% 239 261 0 0.0% 0 0.0% 0 FV 100.0% 102 102 0 0.0% 0 0.0% 0 LS 94.2% 229 243 0 0.0% 0 0.0% 0 GGC 91.4 % 760 831 0 0.0 % 0 0.0% 0 WoS 92.6 % 1330 1437 0 0.0 % 0 0.0 % 0

ISD has provided information from The General/Acute Inpatient and Day Case dataset (SMR01) to calculate the number of 23 hour surgeries being carried out by each NHS Board.

Overall in the WoS in 2014 there were 1330 operations conducted as a short stay procedure out of a possible 1437. This equates to 92.6% which meets the 80% target. Further breakdown by surgical unit indicates that all individual units met the 80% QPI target. Figure 11 also demonstrates all boards have consistently achieved high levels of compliance with this important quality measure year on year. NHS Forth Valley are noted as achieving 100% compliance in 2014.

QPI 9: HER2 Status for Decision Making HER2 status has a significant impact on survival and therefore has a significant influence on decisions regarding neoadjuvant and adjuvant treatment. However, it is not always possible to undertake ImmunoHistoChemistry (IHC) on a core biopsy e.g. due to tumour size. The target for this QPI is set at 90% with the tolerance designed to account for the fact that it is not always possible to undertake IHC on a core biopsy.

QPI Title: HER2 status should be available to inform treatment decision making.

Numerator: Number of patients with invasive breast cancer for whom the HER2 status (as defined by IHC) is known at pre-treatment MDT meeting to decide first treatment.

Denominator: All patients with invasive breast cancer.

Exclusions: No exclusions.

Target: 90% or above

Figure12: The proportion of patients with invasive breast cancer for whom the HER2 status is known at initial MDT.

West of Scotland Cancer Network Final - Published Breast Cancer MCN Audit Report v1 08/02/2016 26 2012 2013 2014 100

% Performance % 40

0 Ayrshire & Forth Monklands Wishaw Hairmyres N&E West South Clyde WoSCAN Arran Valley Glasgow Glasgow Glasgow Analysis Group Not recorded Not recorded Not recorded Not recorded Not recorded 201 4 Performance (%) Numerator Denominator numerator numerator (%) exclusions exclusions (%) denominator AA 90.2 322 357 0 0.0% 0 0. 0% 0 FV 6.0 11 183 0 0.0% 0 0.0% 0 ML 33.3 21 63 0 0.0% 0 0.0% 0 WS 17.1 29 170 0 0.0% 0 0.0% 0 HM 20.9 27 129 0 0.0% 0 0.0% 0 N&E G 71.7 195 272 0 0.0% 0 0.0% 0 WG 57.5 192 334 0 0. 0% 0 0.0% 0 SG 72.7 218 300 0 0.0% 0 0.0% 0 Clyde 46.9 144 307 0 0. 0% 0 0.0% 0 WoS 54.8% 1159 2115 0 0.0% 0 0.0% 0

All units with the exception of one failed to meet the target over the three years of reporting. Having HER2 available at initial MDT has shown to be one of the more challenging QPIs. In many areas testing is not performed on site and samples are sent in batches inevitably delaying testing which results in the HER2 not being available at the initial MDT. For 2014 data the measurability specification of this QPI was revised to measure whether a patient’s HER2 status is available to inform treatment decision making. As can be seen in Figure 12 despite only one unit meeting the target all remaining units have shown improvement from the previous years.

Feedback from NHS Forth Valley indicated that patients are generally diagnosed one week and discussed at MDT the next week. The patient’s HER2 status is known for the patients but not before their first MDT meeting.

NHS Lanarkshire noted that w ith central lab testing the board is required to send the sample to Glasgow and it takes around two weeks for results to become available. All patients have their initial MDT discussion after one week with the results of their path. Unless the board moves to local IHC for HER2, it will not be possible to meet the target. The feasibility of carrying out HER2 testing locally within Lanarkshire is being investigated.

NHSGGC commented that the majority of patients have initial MDT discussion within a week of core biopsy (as little as 2 days later). HER2 2+ results requiring FISH will not be back and routine HER2 is usually not available within 48hrs. However formal Her2 status is available at

West of Scotland Cancer Network Final - Published Breast Cancer MCN Audit Report v1 08/02/2016 27 MDT discussion when adjuvant treatment plans are made or final decision about neo-adjuvant treatment is made.

Action Required: All boards to clarify if HER2 status is known and being documented at the pre-treatment MDT rather than initial MDT as per data definition changes.

West of Scotland Cancer Network Final - Published Breast Cancer MCN Audit Report v1 08/02/2016 28 QPI 10: Radiotherapy for Breast Conservation Trials have demonstrated a significant reduction in local recurrence with the use of radiotherapy after breast conservation. Patient choice and fitness for treatment will have an effect on uptake. QPI Title: After wide local excision patients with breast cancer should receive radiotherapy

Numerator: Number of patients with invasive breast cancer having conservation surgery receiving radiotherapy to the breast.

Denominator: All patients with invasive breast cancer having conservation surgery.

Exclusions: All patients with breast cancer taking part in clinical trials of radiotherapy treatment. All patients with M1 disease.

Target: 95% or above

Figure13: The proportion of patients with invasive breast cancer having conservation surgery receiving radiotherapy to the breast. 2012 2013 2014 100

40 % Performance % 30

0 Ayrshire & Forth Monklands Wishaw Hairmyres N&E West South Clyde WoSCAN Arran Valley Glasgow Glasgow Glasgow Analysis Group Not recorded Not recorded Not recorded Not recorded Not recorded 2014 Performance (%) Numerator Denominator numerator numerator (%) exclusions exclusions (%) denominator AA 96.7 178 184 2 1.1% 1 0.5% 0 FV 100 69 69 0 0.0% 0 0.0% 0 ML 76.7 23 30 0 0.0% 0 0.0% 0 WS 87.5 56 64 0 0.0% 0 0.0% 0 HM 87.7 50 57 0 0.0% 0 0.0% 1 N&E G 100.0 126 12 6 0 0. 0% 0 0.0% 0 WG 97.8 175 179 0 0. 0% 0 0.0% 0 SG 96.0 167 174 0 0.0 % 0 0.0% 7 Clyde 95.2 160 168 0 0.0% 0 0.0% 0 WoS 95.5% 1004 1051 2 0.2% 1 0.5% 8

In 2014 in the WoS 95.5% of breast cancer patients who underwent conservation surgery received radiotherapy to the breast. This figure is consistent with 2012 and 2013 results. At unit level six of the nine units met the 95% QPI target. Performance for Monklands, Wishaw, and Hairmyres who did not achieve the target is 76.7%, 87.5% and 87.7% respectively. Wishaw demonstrated an improvement from 2013 performance however both Monklands and Hairmyres have shown decreases in performance from 2013.

West of Scotland Cancer Network Final - Published Breast Cancer MCN Audit Report v1 08/02/2016 29 NHS Lanarkshire reviewed all cases not meeting the QPI target. Reasons given as to why patients did not receive radiotherapy were noted to be due to co-morbidities, patient refusal and MDT decision not to give radiotherapy.

QPI 11: Adjuvant Chemotherapy Clinical trials have demonstrated that adjuvant drug treatments substantially reduce 5-year recurrence rates and 15-year mortality rates. However, it may not always be undertaken due to factors such as patient choice, co-morbidities and fitness for treatment. QPI Title: Patients with higher risk breast cancer should receive chemotherapy post operatively.

Numerator: Number of patients between 50 and 70 years of age at diagnosis with surgically proven node positive or at least G3 >20mm breast cancer who receive adjuvant chemotherapy.

Denominator: All patients between 50 and 70 years of age at diagnosis with surgically proven node positive or at least G3 >20mm breast cancer.

Exclusions: All patients with breast cancer taking part in trials of chemotherapy treatment. All patients with breast cancer who have had neo-adjuvant chemotherapy. All patients with M1 disease.

Target: 85% or above

Figure14: The proportion of patients between 50 and 70 years of age at diagnosis with surgically proven node positive or at least G3 >20mm breast cancer who receive adjuvant chemotherapy. 2012 2013 2014 100

% Performance % 30

0 Ayrshire & Forth Valley Monklands Wishaw Hairmyres N&E West South Clyde WoSCAN Arran Glasgow Glasgow Glasgow Analysis Group

Not recorded Not recorded Not recorded Not recorded Not recorded 2014 Performance (%) Numerator Denominator numerator numerator (%) exclusions exclusions (%) denominator AA 52.8 28 53 0 0.0% 0 0.0% 0 FV 54.8 17 31 0 0.0% 0 0.0% 0 ML 75.0 6 8 0 0.0% 0 0.0% 0 WS 68.2 15 22 0 0.0% 0 0.0% 0 HM 72.2 13 18 0 0.0 % 0 0.0% 0 N&E G 74.4 32 43 0 0.0% 0 0.0% 0 WG 51.0 25 49 0 0.0% 0 0.0% 0 SG 75.7 28 37 0 0.0% 0 0.0% 3 Clyde 75.6 31 41 0 0.0% 0 0.0% 0 WoS 64.6 % 195 302 0 0.0 % 0 0.0 % 3 West of Scotland Cancer Network Final - Published Breast Cancer MCN Audit Report v1 08/02/2016 30

Figure 14 highlights that no units met the 85% QPI target in 2014. It was also noted that whilst improvements were apparent for the majority of units between 2012 and 2013, only one unit (Clyde) sustained this improvement in 2014. Overall in the WoS 64.6% of patients with higher risk breast cancer received chemotherapy post operatively. This is a slight decrease on 2013 results of 71.7%.

NHS Ayrshire & Arran commented that 25 cases did not meet this QPI. Six cases refused treatment, in ten cases it was felt that chemotherapy would have little benefit and was therefore not given and in nine cases there was pre existing medical conditions which made them unsuitable for chemotherapy.

Forth Valley reviewed all cases which did not meet this standard. Nine patients refused chemotherapy and four patients were unable to have chemotherapy due to clinical reasons. NHS Lanarkshire also reviewed all cases not meeting this QPI and reasons given for patients not receiving adjuvant chemotherapy were patient refusal, co-morbidities and MDT decision not to give chemotherapy.

NHSGGC stated that all patients are discussed at MDTs and assessment is made of the benefit of adjuvant chemotherapy versus risk. Patients not offered chemotherapy are considered unfit or to have minimal benefit and after discussion decline chemotherapy.

West of Scotland Cancer Network Final - Published Breast Cancer MCN Audit Report v1 08/02/2016 31 QPI 12: Anti-HER2 Positive Therapy Women with intermediate or high risk-disease who are HER2 positive show benefit when they receive trastuzumab in addition to chemotherapy. However, uptake will be influenced by factors such as patient choice, co-morbidities and fitness for treatment. QPI Title: Patients with HER2 positive intermediate or high risk breast cancer should receive anti- HER2 positive therapy.

Numerator: Number of patients with breast cancer who are between 50 and 70 years of age at diagnosis with HER2 positive (by 3+ on IHC &/or FISH +ve) tumours >10mm (or ≤10mm and node positive) who receive adjuvant anti-HER2 positive therapy.

Denominator: All patients with breast cancer who are between 50 and 70 years of age at diagnosis with HER2 positive (by 3+ on IHC &/or FISH +ve) tumours >10mm (or ≤10mm and node positive).

Exclusions: No exclusions.

Target: 90% or above

Figure15: The proportion of patients with breast cancer (who are between 50 and 70 years of age at diagnosis) with HER2 positive cancer greater than 10 mm or node-positive who receive anti-HER2 positive therapy. 2012 2013 2014 100

40 % Performance % 30

0 Ayrshire & Forth Monklands Wishaw Hairmyres N&E West South Clyde WoSCAN Arran Valley Glasgow Glasgow Glasgow Analysis Group

Not recorded Not recorded Not recorded Not recorded Not recorded 201 4 Performance (%) Numerator Denominator numerator numerator (%) exclusions exclusions (%) denominator AA 69.2 9 13 0 0.0% 0 0.0% 0 FV 100 .0 11 11 0 0.0% 0 0.0% 0 ML 33.3 1 3 0 0.0% 0 0.0% 0 WS 75.0 6 8 0 0.0% 0 0.0% 0 HM 100.0 3 3 0 0.0% 0 0.0% 0 N&E G 100.0 8 8 0 0.0 % 0 0.0% 0 WG 80.0 12 15 0 0.0 % 0 0.0% 0 SG 94.4 17 18 0 0.0 % 0 0.0% 0 Clyde 100.0 7 7 0 0.0% 0 0.0% 0 WoS 86.0% 74 86 0 0.0% 0 0.0% 0

West of Scotland Cancer Network Final - Published Breast Cancer MCN Audit Report v1 08/02/2016 32 NHS Ayrshire and Arran stated that they had four cases which did not meet this QPI. Review of these cases confirmed that in two cases treatment was refused, one patient died before completion of chemotherapy and did not receive therapy. One patient developed myocarditis and therefore no herceptin was given. Cases not meeting this QPI in NHS Lanarkshire have been reviewed. Of the four cases not meeting the indicator, two patients refused chemotherapy and valid clinical reasons were given for the two remaining patients. NHSGGC commented that cases not offered herceptin were reviewed. These cases were considered unfit for chemotherapy plus herceptin. It should also be noted that numbers in this group are small.

West of Scotland Cancer Network Final - Published Breast Cancer MCN Audit Report v1 08/02/2016 33 5. Conclusions

Analysis of 2014 audit data and comparison with 2012 and 2013 data demonstrates a continual commitment to provide an equitable and consistent standard of care for breast cancer patients in the west of Scotland. The ongoing improvement in data quality over several years has enabled robust analysis of performance against QPIs for the third year. The QPIs included within the report are evidence based and outcome rather than process focussed and were developed by a multidisciplinary group. Cancer audit data underpins much of the development and service improvement work of the MCN and regular reporting of activity and performance is a fundamental requirement of an MCN to assure the quality of care delivered.

NHS Boards have carried out case note review and provided detailed clinical comment where targets have not been achieved or variance across the region has been highlighted. A number of board and regional actions have been noted below.

This is the third year of analysing the Breast QPI data and having achieved a significant improvement in compliance with several of the indicators, the MCN can now begin to interrogate the figures a little more closely and consider outliers from the norm in either direction. For example, for 2013 and again for 2014 Wishaw Hospital has a significantly higher rate for breast reconstruction than any other unit in the WoS, and it would be constructive to identify the reasons for this and compare to practice across the region. Additionally it is important that boards provide further supporting information where 'patient choice' has been documented as the reason for patients not receiving a specific treatment, or boards not achieving a QPI target. This would enable the MCN to further explore reasons for variance in patient treatment uptake across the region. The MCN will encourage boards to provide more specific information in response to future audit analysis, as there is no clear reason why patient choice should be significantly different across different boards within the WoS.

NHS Boards are asked to develop local Action/Improvement Plans in response to the findings presented in the report.

Action Required:

• NHSGGC to review cases in South Glasgow not meeting QPI 2 and provide further detail on those cases. • Breast Cancer MCN to review variation in breast reconstruction rates across the region to establish if there is an identifiable reason for this. • All boards to clarify if HER2 status is known and being documented at the pre-treatment MDT rather than initial MDT as per data definition changes. West of Scotland Cancer Network Final - Published Breast Cancer MCN Audit Report v1 08/02/2016 34

Completed Action Plans should be returned to WoSCAN within two months of publication of this report.

Additionally, progress will be reported annually to the Regional Cancer Advisory Group (RCAG), by NHS Board Territorial Lead Cancer Clinicians and MCN Clinical Leads, and nationally on a three-yearly basis to Healthcare Improvement Scotland as part of the governance processes set out in CEL 06 (2012).

West of Scotland Cancer Network Final - Published Breast Cancer MCN Audit Report v1 08/02/2016 35

Acknowledgement

This report has been prepared using clinical audit data provided by the following NHS Boards in the WoSCAN area:

NHS Ayrshire & Arran NHS Forth Valley NHS Greater Glasgow and Clyde NHS Lanarkshire

We would like to thank all members and active participants in the cancer network for their continued support of the MCN, and the many hospitals that are committed to making the audit succeed. We also acknowledge the efforts of the clinical effectiveness staff, nurses, and other service users for their work in ensuring the data are available to enable analysis to take place each year. Without their considerable efforts this level of progress would not be possible.

West of Scotland Cancer Network Final - Published Breast Cancer MCN Audit Report v1 08/02/2016 36 Abbreviations

BWoSCC Beatson West of Scotland Cancer Centre

DCIS Ductal Carcinoma InSitu

e-CASE Electronic Cancer Audit Support Environment

FNA Fine Needle Aspiration

HER2 Human Epidermal growth factor Receptor

HIS Healthcare Improvement Scotland

IHC ImmunoHistoChemistry

ISD Information Services Division

MCN Managed Clinical Network

MDT Multidisciplinary Team

NHSGGC NHS Greater Glasgow and Clyde

NCQSG National Cancer Quality Steering Group

QPI Quality Performance Indicators

WLE Wide Local Excision

WoS West of Scotland

WoSCAN West of Scotland Cancer Network

West of Scotland Cancer Network Final - Published Breast Cancer MCN Audit Report v1 08/02/2016 37 References

1. Information Services Division Cancer Audit (ISD) [Accessed on 06.01.2015] http://www.isdscotland.org/Health-Topics/Cancer/Cancer-Audit/

2. Cancer in Scotland (Oct 2014): Information Services Division, NHS National Services Scotland http://www.isdscotland.org/Health-Topics/Cancer/Publications/2014-10- 28/Cancer_in_Scotland_summary_m.pdf [Accessed on 06.01.2015]

3. Information Services Division Cancer Statistics http://www.isdscotland.org/Health-Topics/Cancer/Cancer-Statistics/Breast/

4. Healthcare Improvement Scotland [Accessed on 08.01.2015] http://www.isdscotland.org/Health-Topics/Cancer/Cancer-Statistics/Breast/

West of Scotland Cancer Network Final - Published Breast Cancer MCN Audit Report v1 08/02/2016 38

Appendix I

Action / Improvement Plan

Health Board: KEY (Status) Action Plan Lead: 1 Action fully implemented Date : 2 Action agreed but not yet implemented 3 No action taken (please state reason)

No Action Required Health Board Action Taken Timescales Lead Progress/Action Status Status Start End (see key) Ensure actions mirror those Detail specific actions that will Insert Insert Insert name Provide detail of action in progress, change Insert detailed in Audit Report. be taken by the NHS Board. date date of in practices, problems encountered or No. from responsible reasons why no action taken. key lead for each above specific action. 1.

2. 3.

West of Scotland Cancer Network Final - Published Breast Cancer MCN Audit Report v1 08/02/2016 Appendix