clin-audi-supp-prog-oeso-gast-2014-key-find

Report
National
Oesophago–Gastric Cancer
Audit
Key Findings from 2014 Annual Report
and Progress Report
Georgina Chadwick
Clinical Research Fellow
High Grade Dysplasia (HGD) of the
Oesophagus

465 cases submitted to audit
◦ Diagnosed between 1st April 2012 & 31st March 2013.

Source of referral
◦ 52.9% Symptomatic
◦ 39.4% Barrett’s surveillance
◦ 7.7% Unknown.

79.4% Diagnosis confirmed by 2nd pathologist.

86.0% cases had treatment planned at MDT.
Treatment Plan for HGD

Planned treatment
All HGD
submissions
(n=465)
EMR
(39.6%)

Surveillance
(29.7%)
RFA
(14.4%)
Curative
surgery
(5.6%)
Other
(10.7%)
1/3 patients currently managed surveillance alone

This goes against BSG recommendations.
‘For HGD and Barrett’s-related adenocarcinoma confined to
the mucosa, endoscopic therapy is preferred over oesophagectomy
or endoscopic surveillance.’
Fitzgerald RC et al. British Society of Gastroenterology guidelines on the diagnosis and
management of Barrett's oesophagus. Gut. 2014;63(1):7-42.
Recommendations for HGD


Confirm all diagnoses of HGD with 2nd pathologist.
Discuss all patients with HGD at a specialist MDT for
oesophagogastric cancer.
◦ This team should include an interventional endoscopist, upper
GI cancer surgeon, radiologist and a GI pathologist.


Consider all patients with HGD for active treatment.
Refer patients to a specialist centre where local
expertise is not available.
Oesophago-gastric (OG) Cancer

Audit prospectively collected data on:
◦ Patients diagnosed with invasive epithelial OG cancer
◦ Diagnosed in NHS hospital in England or Wales
◦ Aged over 18 at diagnosis.

22,832 cases submitted
◦ Patients diagnosed: 1st April 2012 & 31st March 2013
◦ 78.6% case ascertainment.
Treatment Plan for OG cancer



Proportion treated with
curative intent increased to
37.3% vs 2010 Report.
For squamous cell cancers - Use of
definitive chemoradiotherapy
increased (31% to 39%).
For early cancers (T0/1,N0,M0) –
Increased use of endoscopic
resection.
Surgery

Overall 5,396 surgical records were submitted
◦ 95.0% Curative intent
◦ 4.3% Palliative intent and 0.7% Unknown.

Curative surgery
◦ 2,986 Oeosphagectomies
◦ 1,807 Gastrectomies
◦ Increase in proportion of minimally invasive (MI)
operations
 Oesophagectomies: 41.5% MI or Hybrid
 Gastrectomies: 15.9% MI.
Surgery with adjunct oncology

BSG guidelines
◦ Oesophageal cancer - Preoperative chemoradiation improves longterm survival over surgery alone
◦ Gastric cancer - Perioperative combination chemotherapy conveys a
significant survival benefit and is a standard of care.
Proportion of
patients with
locally advanced
disease managed
surgically who
received additional
oncological
therapy.

Allum W, Blazeby J, Griffin S, Cunningham D, Jankowski J, Wong R. Guidelines for
the management of oesophageal and gastric cancer. Gut. 2011;60(11):1449-72.
Surgical Outcomes
30-Day mortality
90-Day mortality

Oesophagectomy (%)
Gastrectomy (%)
2010
3.8
5.7
2010
4.5
6.9
2014
2.4
4.4
2014
2.3
4.5
Fall in both 30 and 90 day mortality post curative
oesophagectomy and gastrectomy.
Surgical Outcomes

Funnel plots looking at mortality for all Trusts
performing curative surgery for OG cancer,
demonstrate no significant variation across trusts
after adjusting for known confounders.
Surgical complications

Reported for English patients only.

Oesophagectomy
◦ 1 in 3 suffered any complication
 Most frequently respiratory affecting 17.7%
◦ Statistically significant rise in proportion suffering
respiratory or gastric complication after oesophagectomy
vs 2010 Audit Report.
Surgical Complications

Reported for English patients only.

Oesophagectomy
◦ 1 in 3 suffered any complication
 Most frequently respiratory affecting 17.7%
◦ Statistically significant rise in proportion suffering
respiratory or gastric complication after oesophagectomy vs
2010 Audit Report
◦ Variation in key complication rates by surgical approach.
Oesophagectomy
Open
Hybrid
MI
Overall
Any Complication 34.5%
36.3%
33.9%
33.0%
Anastomotic Leak 6.7%
7.1%
11.7%*
7.1%
Respiratory
complication
20.1%
14.1%
17.1%**
18.1%
* Statistically significant increased risk of leak with MI surgery compared to open.
** Rise since 2010, statistically significant and needs investigation.
Surgical Complications

Gastrectomy
◦ 1 in 5 suffered any complication
 Most frequently unplanned return to theatre affecting 8.1%
◦ No significant change in complication rates since the 2010
Audit Report
◦ Variation in key complication rates by surgical approach.
Gastrectomy
Open
MI
Overall
Any Complication
19.6%
16.5%
19.0%
Unplanned return
to theatre
7.7%
10.6%
8.1%
Resection Margins



Aim of surgery is to achieve tumour free resection margins.
Proportion of patients who had had an oesophagectomy
who had positive longitudinal resection margin has fallen
from 6.4% in 2010 to 3.7% in the 2014 Report.
BUT 9.1% of patients having a gastrectomy have an
incomplete resection.
Oesophagectomy
n
Positive long. (prox
dist resection margin
Positive circ. Margin
or 98
685
Gastrectomy
Total
Overall n
%
Overall n
%
Overall
%
3.7%
144
9.1%
242
5.7%
27.7%
113
10.5%
798
22.5%
Definitive Oncology – RTDS Link

For first time radiotherapy dataset linked to NOGCA
◦ 90.6% (n=2516) of RTDS Records linked successfully.

Radiotherapy treatment regimen, aligned with RCR
recommendations for:
◦ 59.7% patients treated with definitive chemoradiotherapy for
oesophageal cancer
◦ 46.4% patients treated with curative radiotherapy alone.

RTDS dataset will allow further exploration of use of
radiotherapy in future.
OG cancer in elderly


58.9% OG cancers diagnosed in patients aged 70yrs
or over.
Treatment:
◦ Nationally no difference in proportion managed with curative
intent according to age, after risk adjustment
◦ At local level, there was significant variation in proportion of
elderly patients managed with curative intent.
Early Cancers



Only 5.4% OG cancers diagnosed at early stage
(T0/1,N0,M0).
Lower oesophageal/GOJ tumours, and
oesophageal squamous cell cancers less likely to
be diagnosed early.
Across strategic clinical networks significant
variation in proportion of cancers diagnosed
early.
Recommendations for OG cancers


Monitor complications rates associated with
minimally invasive vs open surgery locally.
Monitor quality of surgery
◦ Completeness of surgical resection
◦ Complication rates and length of stay post-op.


Monitor dosing regimens used for definitive
radiotherapy for OG cancer.
At a local level audit
◦ Proportion of patients aged over 70 managed with
curative intent
◦ Proportion of cancer diagnosed early.

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