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.