MCN Audit Report - woscan.scot.nhs.uk · Audit Report Report of the 2011 ... Dr Girish Gupta MCN...

Audit Report Report of the 2011 Clinical Audit Data

Dr Girish Gupta MCN Clinical Lead Tom Kane MCN Manager Jennifer Keatings Information Officer

West of Scotland Cancer Network Skin Cancer Managed Clinical Network

West of Scotland Cancer Network Final - Published Skin Cancer MCN Audit Report 9/10/2012 2

CONTENTS

EXECUTIVE SUMMARY 3

1. INTRODUCTION 6

2. BACKGROUND 7

2.1 NATIONAL CONTEXT 7

2.2 WEST OF SCOTLAND CONTEXT 8

3. METHODOLOGY 11

4. RESULTS AND ACTION REQUIRED 12

4.1 DATA QUALITY 12

4.2 PERFORMANCE AGAINST KEY OUTCOME MEASURES 14

CONCLUSIONS 25

ACKNOWLEDGEMENTS 26

ABBREVIATIONS 27

REFERENCES 28

APPENDIX: NHS BOARD ACTION PLANS I


Executive Summary

Introduction The purpose of this report is to present an assessment of performance of Malignant Melanoma Skin Cancer Services relating to patients diagnosed in the region in 2011. Data are reported against Key Outcome Measures (KOMs) developed regionally by a core review group and agreed by the Managed Clinical Network (MCN). The Quality Subgroup of the Scottish Cancer Taskforce is currently taking forward the development of national Quality Performance Indicators (QPIs) for all cancers. This will enable future national comparative reporting and will help to drive continuous improvement for patients. At the beginning of 2011, the West of Scotland Cancer Network (WoSCAN) initiated a process to optimise the use of available resources which would agree regional quality of care and outcome measures for those tumour networks which do not feature in the 2011 QPI development schedule and do not already have agreed NHS Quality Improvement Scotland (NHS QIS) Clinical Standards. This work was aimed at focussing regional analysis on key clinical outcome measures as an interim measure prior to the introduction of QPIs. Additionally, it was anticipated that this process would support more targeted data collection and ensure more efficient use of audit resource. Background The trend in incidence of cancer in Scotland is an increasing one generally however the incidence rate of malignant melanoma of the skin has increased by approximately 66% in males and 60% in females over the last decade. While the incidence of malignant melanoma is increasing significantly, the survival from the disease is also improving with increases in the five year survival from 64% to 85% in males, and 82% to 92% in females. Overall cancer mortality rates in Scotland have decreased in the last ten years however mortality rates for malignant melanoma have considerably increased especially in males with a 40% increase and 28% increase in females 1. Four NHS Boards across the West of Scotland (WoS) serve the 2.4 million population. In 2011, 538 cases of malignant melanoma were reported through audit as diagnosed in the WoS. The Multidisciplinary Team (MDT) configuration for services in the region is given below: MDT Constituent Hospital(s) Ayrshire & Arran Crosshouse Hospital, Ayr Hospital Clyde Royal Alexandra Hospital, Inverclyde Royal Hospital, Vale of Leven South Glasgow Southern General Hospital, Glasgow Royal Infirmary West Glasgow Western Infirmary Forth Valley Stirling Royal Infirmary, Falkirk & District Royal Hospital Lanarkshire Wishaw General Hospital, Monklands District General, Hairmyres Methodology The clinical audit data presented in this report were collected by clinical audit staff in each NHS Board in accordance with an agreed dataset and definitions. Data were entered locally into the electronic Cancer Audit Support Environment (eCASE): a secure centralised web-based database. Data relating to patients diagnosed between 1st January and 31st December 2011 were downloaded from eCASE on 25th July 2012.


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. Initial results of the analysis were provided to local Boards to check for inaccuracies or obvious gaps before final analysis was carried out. Final 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. Results Overall case ascertainment for WoSCAN is high however there is some fluctuation between areas. This in some part may be due to the difficulty in calculating case ascertainment using previous years’ figures when the incidence of melanoma is generally increasing and yearly fluctuations occur in some NHS Boards. Lanarkshire has notably lower ascertainment than the other areas which is worthy of further investigation. Data quality is mainly good however pathological tumour stage is poorly recorded in Ayrshire & Arran despite almost complete data completion in 2010. Subsequently the result of one of the outcome measures is affected as it relies on the pathological tumour stage. This is an area requiring improvement as much meaningful interpretation is based on the availability of the tumour stage data. Furthermore, it is anticipated that stage data will be required for the assessment of performance against QPIs. The outcome measure around the appropriateness of surgical excision margins is affected for Ayrshire & Arran by the incompleteness of the tumour stage. Although the completeness of excision margin data was generally good, some improvement is still required in Greater Glasgow and Clyde and in Lanarkshire. Further progress is required in data quality and completeness to facilitate a robust assessment of the performance of Malignant Melanoma Skin Cancer Services in WoSCAN. Data are measured against agreed criteria including six KOMs developed by the Managed Clinical Network (MCN). Below is a summary of results; figures are expressed in percentages and represent the combined WoS figure and the range across locations of diagnosis.

1. All malignant melanomas should be referred urgently (53.2 [42.0-75.6]%).

2. Patients with malignant melanoma should not receive excision in Primary Care (1.3 [0-3.9]%).

3. Patients with malignant melanoma should generally1 not receive biopsy before surgical treatment (12.8 [6.8-20.0]%).

4. Breslow thickness or Clark level (if Breslow cannot be measured) should be recorded for all malignant melanoma patients (98.5 [97.2-100]%).

5. Pathological staging should be used to stage all malignant melanoma patients (88.6 [46.8-100]%).

6. Surgical wide excision margins should be appropriate to stage of tumour in line with SIGN guidelines, as set out in page 23 of the main report (66.9 [30.3-86.2]%).

Conclusions and Action Required Collection of data on malignant melanoma diagnoses began in 2006 and since that time there has been significant improvement in data quality. With data quality improving and the introduction of

1 Examples of exceptions are large lesions or lesions at difficult sites


KOMs, the MCN is moving towards robust performance assessment where audit data can highlight clinical/service issues and lead to improvement and service change. The outcome measures analysed go some way to allowing assessment of service quality however there are still some data quality issues which require further improvement to enable robust and meaningful results. 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. Progress against these plans will be monitored by the MCN Advisory Board and reported to the Regional Cancer Advisory Group (RCAG) annually by Board Lead Cancer Clinicians and MCN Clinical Leads, as part of the regional audit governance process to enable RCAG to review and monitor regional improvement. Action required: Service Improvement

• All NHS Boards to discuss referral issues with dermatologists and primary care cancer leads and identify means to increase numbers of appropriate urgent referrals.

• MCN to advocate inclusion of melanoma in the national Detect Cancer Early Programme. This in turn may yield greater results in promoting appropriate referrals than reliance on education events.

• NHS Greater Glasgow and Clyde, NHS Forth Valley and NHS Lanarkshire should review cases where excisions have been performed in Primary Care to establish reasons for the occurrences and promote referral into secondary care.

• NHS Greater Glasgow and Clyde should review the cases where biopsy was performed prior to surgical treatment to assess whether practice has been appropriate. Additionally, the Board should review clinical practice to ensure that further increases are not observed, unless clinically relevant.

• NHS Ayrshire & Arran should feed back the results of their review of biopsies prior to surgical treatment to the MCN Advisory Board and assess if further action is required.

• NHS Forth Valley and NHS Lanarkshire have increased proportions biopsied between 2010 and 2011 and should review these cases to assess if biopsies have been carried out appropriately.

Data Quality Improvement • NHS Lanarkshire should review their case ascertainment by utilising the Acute Cancer Deaths

and Mental Health information system (ACaDMe) to compare identified melanoma patients with Cancer Registry. The Board should also review the process for notification of cases from pathology department(s).

• NHS Ayrshire & Arran should review audit collection processes to identify reasons for the decline in data completeness of pathological tumour stage and ensure availability of these data in future.

• NHS Greater Glasgow and Clyde and NHS Lanarkshire should review audit data collection processes to ensure complete and accurate data capture for surgical excision margins.

A summary of actions for each NHS Board has been included within the Action Plan templates in Appendices I – VI. Completed Action Plans should be returned to WoSCAN within two months of publication of this report.


1. Introduction The purpose of this report is to present an assessment of performance of Malignant Melanoma Skin Cancer Services relating to patients diagnosed in the region in 2011. These audit data underpin much of the regional development/service improvement work of the Managed Clinical Network (MCN) and regular reporting of activity and performance is a fundamental requirement of an MCN to assure the quality of care delivered across the region. The Quality Subgroup of the Scottish Cancer Taskforce is currently taking forward the development of national Quality Performance Indicators (QPIs) for all cancers. This will enable future national comparative reporting and will help to drive continuous improvement for patients. As part of this process, a programme was outlined for the sequence and timescales of each of the tumour sites to be involved. Skin cancer is scheduled later in the programme and currently this disease group does not have NHS Quality Improvement Scotland (NHS QIS) Clinical Standards to report against. At the beginning of 2011, the West of Scotland Cancer Network (WoSCAN) initiated a process to optimise the use of available resources regionally and locally which would assure regional quality of care and have agreement on outcome measures for specific tumour networks. This work was aimed at focussing regional analysis on key clinical outcome measures whilst also aiming to support more targeted data collection and ensure more efficient use of audit resource. Additionally, it was anticipated that this early preparatory work would help inform the development of national QPIs and in time help expedite the national process for these networks. A core review group was established to carry out the initial process of drafting key outcome measures (KOMs). Regional measurability for the KOMs was then determined before disseminating documentation for wider consultation and regional agreement. KOMs have now been analysed and reported against for 2010 and 2011 clinical audit data.


2. Background Four NHS Boards across the West of Scotland (WoS) serve the 2.4 million population where over 500 cases of malignant melanoma are diagnosed each year. The MDT configuration is shown below: MDT Constituent Hospital(s) Ayrshire & Arran Crosshouse Hospital, Ayr Hospital Clyde Royal Alexandra Hospital, Inverclyde Royal Hospital, Vale of Leven South Glasgow Southern General Hospital, Glasgow Royal Infirmary West Glasgow Western Infirmary Forth Valley Stirling Royal Infirmary, Falkirk & District Royal Hospital Lanarkshire Wishaw General Hospital, Monklands District General, Hairmyres Patients are referred from their general practitioner to the dermatology department with a pigmented lesion for assessment. At clinic the lesion is assessed and patients with a benign mole are generally discharged. Patients with a possible melanoma have urgent surgery (excision) to remove the lesion. Tissue taken from the excision is sent to pathology for confirmation of a malignant melanoma diagnosis. Confirmed malignant melanoma patients are discussed at the next local skin cancer Multidisciplinary Team (MDT) meeting which takes place on a weekly to fortnightly basis. Unlike most other cancer types, patients are generally discussed at MDTs after they have completed their primary treatment. Generally patients will go on to have a wide excision at a later stage to reduce the risk of local recurrence.

2.1 National Context The overall incidence of cancer in Scotland has increased in the last decade although there has been a decrease for some cancers1. Malignant melanoma of the skin however, has increased significantly over the last decade, by approximately 66% in males and 60% in females.1 Malignant melanoma is the 6th most common cancer in Scotland (7th in males and 5th in females) with almost 1200 cases diagnosed per annum.1 Predictions are for more than a 70% increase in the incidence of malignant melanoma in Scotland in the two decades up to 2020.2 The incidence of malignant melanoma is increasing significantly however the survival from the disease is also improving with increases in the five year survival for malignant melanoma: 64% to 85% in males, and 82% to 92% in females.1 Overall cancer mortality rates in Scotland have decreased by 15% in males and 7% in females1 in the last ten years however mortality rates for malignant melanoma have considerably increased especially in males with a 40% increase and 28% increase in females.3 Unlike many other cancers, malignant melanoma occurs most commonly in younger people. More than a quarter of cases in Scotland are in people under the age of 50 and more than half are under 65 years of age3 and there is a similar trend in the UK-wide data.4 In the UK as a whole it has been shown that there is a link between age and mortality with mortality rates being the highest in older men and women. Between 2008 and 2010 in the UK an average of 5% of deaths due to malignant melanoma were in the age group 15-39 years and an average of 62% of deaths were in those aged over 64 years of age.4


2.2 West of Scotland Context In the west of Scotland 538 cases of malignant melanoma were reported through audit as diagnosed in 2011. In line with the trend in Scotland and the UK, more than half of malignant melanomas in the west of Scotland occur in people under 65 years of age (54%). Note that cases collected through audit do not include patients under the age of 16 years. Figure 1 illustrates the numbers diagnosed in WoS by age for males and females. Figure 1: Number of patients diagnosed in WoSCAN in 2011 by age and gender

*Patients under 16 years of age are not included in the audit The incidence of malignant melanoma continues to increase and in the west of Scotland incidence rose from 318 in 2000 to 559 in 20103 with a steady increase each year. The clinical site of melanomas diagnosed in the West of Scotland in 2011 is presented in Figure 2 by gender. The gender difference is apparent with 42% of males having a melanoma located on the trunk compared with only 25% of females. Conversely, males have only 18% of melanomas located on the legs whereas this figure is much greater for females at 31%. Males have slightly more melanomas of the head and neck and females slightly more located on the arm. The distribution of cases by SIMD (Scottish Index of Multiple Deprivation) category is shown in Figure 3 for each area of diagnosis. For most locations, around 40% of patients are in the two most affluent groups and Forth Valley particularly has more than 50% of melanoma patients in the two most affluent categories.

0 – 19* 20 - 34 35 - 44 45 - 54 55 - 64 65 - 74 ≥ 75 Total Male 1 15 19 46 54 54 78 267 Female 1 31 43 38 43 50 65 271


Figure 2: Clinical site of malignant melanoma diagnosed in WoS (2011 audit data) by gender

Figure 3: SIMD category by location of diagnosis

Figure 4 indicates that superficial spreading melanoma is by far the largest type of melanoma found in WoS patients with almost two thirds of patients having this type of melanoma in 2011. This is consistent with the 2010 data. Lentigo maligna melanoma is the next most common type of melanoma after superficial spreading (15% and 16% of patients in 2010 and 2011 respectively). These melanomas develop from very slow growing pigmented areas of skin called lentigo maligna. The lentigo maligna (also known as an ‘in-situ’ lesion) is flat and grows outwards in the surface layers of the skin. It may gradually enlarge over several years and may change shape. If it becomes a lentigo maligna melanoma, it starts to invade


into the deeper layers of the skin and may form lumps (nodules). Once this happens it is described as invasive melanoma. Only invasive melanomas are collected and reported upon through the audit and consequently lentigo maligna (in-situ lesions) are not included in this report. The third most common type of melanoma is nodular melanoma (11% and 14% of patients in WoS in 2010 and 2011 respectively). This type of melanoma tends to develop quickly and begins to invade, deeper into the skin, quite rapidly if it is not removed. There is often a raised area on the skin surface with this type of melanoma. Due to the rate of growth, thickness and local invasion this is one of the most aggressive melanomas and has a higher chance of spreading to other areas (metastasise). Figure 4: Histogenic type of tumours diagnosed in WoS in 2011


3. Methodology The clinical audit data presented in this report were collected by clinical audit staff in each NHS Board in accordance with an agreed dataset and definitions. Data were 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 1st January and 31st December 2011 were downloaded from eCASE at 2200 hrs on 25th July 2012. 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 different figures if extracted at different times. 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. Initial results of the analysis were provided to local Boards to check for inaccuracies, inconsistencies or obvious gaps and a subsequent download taken upon which final analysis was carried out. The final data analysis was disseminated for NHS Board verification in line with the regional audit governance process to ensure that their data were an accurate representation of service in each area.


4. Results and Action Required

4.1 Data Quality Quality of audit data can be assessed in the first instance by estimating the proportion of expected patients that have been identified through audit. Case ascertainment is calculated by the number of patients identified as diagnosed in a NHS Board through audit as a percentage of the incidence of cancer diagnosed in that NHS Board from Cancer Registry. Cancer Registry information is available some time after the year of interest as collection and verification of data is time intensive; it is for this reason that audit data cannot be compared directly to Cancer Registry data for the same year. The trend in incidence of malignant melanoma has been an increasing one generally and this presents some difficulty in the assessment of case ascertainment. Cancer Registry figures used were extracted from ACaDMe (Acute Cancer Deaths and Mental Health), a system provided by Information Services Division (ISD), on 27th June 2012 via the standard reports available. Cancer Registry figures are an average of 2008 to 2010 figures to take account of annual fluctuations in incidence within NHS Boards. Figure 5 presents the case ascertainment for each NHS Board and for WoSCAN as a whole. Figure 5: Case ascertainment of 2011 data by location of diagnosis.

Lanarkshire has a notably lower case ascertainment than the other NHS Boards. Reasons should be explored for this variance. Cases of malignant melanoma are mostly picked up through the reporting of pathology following surgical removal of the lesion. High case ascertainment would be expected as a result as almost all patients will undergo a surgical procedure. Action required:

NHS Lanarkshire should review their case ascertainment by utilising ACaDMe to compare identified melanoma patients with Cancer Registry. The Board should also review the process for notification of cases from pathology department(s).

AA GG&C FV Lan WoSCAN Cases from audit 81 314 45 98 538 Cases from Cancer Registry (2008-2010) 77 313 43 118 551 Case ascertainment 105.2% 100.3% 104.7% 83.1% 97.6%


KOM 5 states that all patients should have a pathological tumour stage5 (pT stage) recorded. Results of this outcome measure are very good with the exception of Ayrshire & Arran where more than half of excisions had no pathological tumour stage recorded. This is a significant deterioration from 2010 results where more than 98% had a pT stage recorded. Subsequently KOM 6 was affected as this relied on the pathological tumour stage to measure suitability of surgical margins for the tumour stage. In 2010 the results of KOM5 were very poor in Greater Glasgow and Clyde however there has been a considerable improvement with completion of pT stage now greater than 95%. For Greater Glasgow and Clyde and Lanarkshire, KOM 6 results are affected by the incompleteness of the surgical excision margin for patients undergoing wide excision. In Greater Glasgow and Clyde more than 10% of patients did not have a surgical excision margin recorded. There was a similar proportion of patients with surgical excision margins not recorded in Lanarkshire where there was additionally one patient with margins recorded as inapplicable. Forth Valley data have improved significantly, as 2010 data included many patients with margins recorded as inapplicable. Following action by the Board, surgical excision margin data for 2011 are well completed. There is still some room for improvement in data quality if KOM 6 is to provide robust results for all NHS Boards. Action required:

NHS Greater Glasgow and Clyde and NHS Lanarkshire should review audit data collection processes to ensure complete and accurate data capture for surgical excision margins.


4.2 Performance Against Key Outcome Measures Results of analysis of selected performance criteria are set out in the following section. Graphs and charts have been provided where this aids interpretation and where appropriate, figures are also included to provide context. Results are presented by location of diagnosis with some criteria given as an overall WoSCAN representation. Specific Regional and NHS Board actions have been recommended to address issues highlighted through the data analysis. 4.2.1. KOM 1: All malignant melanomas should be referred urgently Scottish Intercollegiate Guidelines Network (SIGN) National guidelines for cutaneous melanoma state that “GPs should refer urgently all patients in whom melanoma is a strong possibility rather than carry out a biopsy in primary care”.6(p9) Earlier referral results in earlier treatment which may have an impact on thickness of melanoma and thus lead to improved survival. Figure 6 illustrates that all NHS Boards are far from reaching the SIGN indicated level of 100% of patients referred urgently. Almost no change is evident between 2010 and 2011 with an overall figure of around half of malignant melanoma patients in the WoS referred urgently. Forth Valley and Lanarkshire have higher proportions (greater than 70% referred urgently) than the other areas. Figure 6: Proportion of patients referred urgently in 2010 and 2011 by location of diagnosis

2 Subsequent to final data submission, NHS Ayrshire & Arran identified that 10 of the patients recorded as routine had been miscoded and should have been coded as urgent. The true proportion of urgent referrals is actually higher (63%) than shown in Figure 6.

AA Clyde GG FV Lan WoSCAN 2010 2011 2010 2011 2010 2011 2010 2011 2010 2011 2010 2011

Urgent 31 412 43 41 105 100 35 34 80 70 294 286 Soon 10 0 0 0 1 0 1 0 0 0 12 0 Routine 10 28 36 24 63 79 6 5 19 18 134 154 Not Recorded 3 0 0 0 0 0 1 0 0 2 4 2 Inapplicable 11 12 10 11 72 59 3 6 14 8 110 96 Total 65 81 89 76 241 238 46 45 113 98 554 538


Following final data analysis it was highlighted that in assessing this outcome measure, all patients with malignant melanoma have been included. There will be however, a proportion of patients that due to their mode of referral would have no urgency assigned to the referral, for example; patients referred from a review clinic or from private healthcare. If these patients were excluded from the total patients, the proportion of this total referred urgently would be a more accurate assessment. The numbers referred through these methods are low so the effect on the proportions would not be large and ultimately, the outcome is the same i.e. that the proportion of patients not referred urgently is still too high. This outcome measure will be amended next year nevertheless, until then it is important that the urgent referral rate is addressed across the region. Previous attempts have been made to address the low rates of urgent referrals across the region by holding educational events however as these events have made little visible impact it was decided to discontinue these from 2012 and explore alternative action. NHS Ayrshire & Arran has implemented a number of initiatives with the aim of increasing the proportion of patients referred urgently. This includes a skin referral pro-forma for GPs and a quarterly report to each practice containing an analysis of urgent cancer referral rates and details of cancers diagnosed to enable practices to review any cancers presenting through Emergency Departments or referred as routine. Action required:

a. All NHS Boards to discuss referral issues with dermatologists and primary care cancer leads and identify means to increase numbers of appropriate urgent referrals.

b. MCN to advocate inclusion of melanoma in the national Detect Cancer Early Programme. This in turn may yield greater results in promoting appropriate referrals than reliance on education events.


4.2.2. KOM 2: Patients with malignant melanoma should not receive excision in Primary Care Where melanoma is suspected, excisions should not be performed in primary care.6,7 Patients with suspected melanoma should be referred urgently for assessment. Figure 7 indicates that several NHS Boards are performing excisions in Primary Care. The outcome measure agreed states that no patients should be biopsied in Primary Care. Following analysis of 2010 data, it was highlighted that practice must be examined to identify reasons for this and work done to effect a change to this practice. All Boards with the exception of Ayrshire & Arran have failed to improve, instead having greater proportions receiving biopsy in Primary Care, although these numbers are small. The overall trend across WoSCAN is that less biopsies were performed in primary care in 2011 than in 2010. Figure 7: Proportion of patients receiving biopsy in Primary Care in 2010 and 2011 by location of diagnosis

NHS Ayrshire & Arran have two GPs with special interest (GPwSI) performing excisions in Primary Care who form part of the local dermatology service; these were responsible for biopsies performed in 2010. Following an action outlined in the Report of 2010 Clinical Audit Data, NHS Ayrshire & Arran has drawn up a protocol for the operation of GPwSI within the skin cancer service in the Board area. Action required:

NHS Greater Glasgow and Clyde, NHS Forth Valley and NHS Lanarkshire should review cases where excisions have been performed in Primary Care to establish reasons for the occurrences and promote referral into secondary care.


Biopsy in PC 9 0 2 3 0 2 0 1 1 1 12 7 No Biopsy in PC 56 81 87 73 241 236 46 44 112 97 542 531 Total 65 81 89 76 241 238 46 45 113 98 554 538


4.2.3. KOM 3: Patients with malignant melanoma should generally not receive biopsy before surgical treatment Biopsies should generally not be performed where a melanoma is suspected6,7 as there is a risk of inadequate sampling. There are however exclusions to this such as large lesions or lesions at difficult sites (for example lesions of ears or subungual lesions of the hand or toe nails). Other than these exclusions, there will be a small number of cases, likely around 10% where a biopsy is indicated prior to excision. Figure 8 displays an increase in the proportion of patients who had a biopsy prior to surgical treatment between 2010 and 2011 for all NHS Boards. NHS Ayrshire & Arran and NHS Greater Glasgow and Clyde had higher proportions than the other Boards in 2010 and this was highlighted as an action point in the previous report. With a marked increase in the proportion of biopsies in 2011, these Boards in particular should review practice to determine reasons for high and increasing proportions of biopsies prior to surgical treatment. Ayrshire & Arran has initiated a review of the 2011 biopsies to identify whether these have been carried out appropriately. Although NHS Forth Valley and NHS Lanarkshire have lower proportions than the other Boards which may be within reasonable limits, these Boards must monitor practice to ensure further increases do not become evident. Figure 8: Proportion of patients who had a biopsy prior to surgical treatment in 2010 and 2011

Action required:

a. NHS Greater Glasgow and Clyde should review the cases where biopsy was performed prior to surgical treatment to assess whether practice has been appropriate. Additionally, the Board should review clinical practice to ensure that further increases are not observed.

b. NHS Ayrshire & Arran should feed back the results of their review of biopsies prior to surgical treatment to the MCN Advisory Board and assess if further action is required.


Biopsy prior to surgical treatment 8 16 8 11 31 30 2 3 7 8 56 68

Total 64 80 89 75 236 234 44 44 112 97 545 530


c. NHS Forth Valley and NHS Lanarkshire have increased proportions biopsied between 2010 and 2011 and should review these cases to assess if biopsies have been carried out appropriately and ensure there are no further increases.


4.2.4. KOM 4: Breslow thickness or Clark level (if Breslow cannot be measured) should be recorded for all malignant melanoma patients There is a strong association between tumour thickness and prognosis. Breslow thickness is the single most important prognostic variable in primary cutaneous melanoma.6 Where Breslow thickness is less than 1mm, Clark level should be recorded. Clark level is a measure of the depth of invasion of melanoma into the skin layers. Almost all patients (who did not have metastatic disease) had a Breslow thickness or Clark level recorded; 99% across WoSCAN and ranging from 97% to 100% across the region. 4.2.4.1 Breslow thickness by gender Figure 9: Breslow thickness by gender for all patients diagnosed in WoS in 2011

There is not a particularly pronounced gender difference in the Breslow thickness with similar proportions in each category.


4.2.4.2 Breslow thickness by Scottish Index of Multiple Deprivation (SIMD) The Scottish Index of Multiple Deprivation (SIMD) has seven domains (income, employment, education, housing, health, crime, and geographical access) at datazone level, which have been combined into an overall index to pick out area concentrations of multiple deprivation. Figure 10 demonstrates a link between Breslow thickness and deprivation with those in the most deprived areas having higher proportions of thicker melanomas. The proportion of thinner melanomas increases with deprivation score with the proportion of patients with a Breslow less than 1mm at 44% in the most deprived areas compared to 62% in the least deprived areas. This suggests that those in the most affluent areas may be more likely to have less advanced disease perhaps due to earlier detection. Figure 10: Breslow thickness by SIMD for all patients diagnosed in WoS in 2011


4.2.5. KOM 5: Pathological staging should be used to stage all malignant melanoma patients Pathological staging helps to determine prognosis, choice of treatment and appropriate follow up of the patient. Pathological tumour stage is well recorded for patients in the WoS with the exception of NHS Ayrshire and Arran where a significant deterioration in data completeness is apparent from 2010 to 2011. Figure 11 illustrates that Ayrshire dropped from almost 100% data completeness in 2010 to less than 50% in 2011. Problems had previously been identified in Greater Glasgow where a number of pathologists were not including the tumour stage in their reports. This has now been addressed by the Board and has resulted in a considerable improvement in data completeness in 2011. Figure 11: Proportion of patients with pathological tumour stage recorded by location of diagnosis in 2010 and 2011

A breakdown of the tumour stage recorded for all patients is given in Figure 12. The majority of patients fall into (early) pT1 stage which carries the best prognosis for invasive melanoma. Patients with pT1a stage can now be discharged after one year of follow-up.7 Figure 12: Breakdown of pT stage for patients diagnosed in WoS in 2011


pT recorded 63 37 73 70 113 216 44 43 109 94 402 460 Total 64 79 89 72 234 229 44 43 111 96 542 519


Action required:

NHS Ayrshire & Arran should review audit collection processes to identify reasons for the decline in data completeness of pathological tumour stage and ensure availability of this data in future.


4.2.6. KOM 6: Surgical wide excision margins should be appropriate to stage of tumour in line with SIGN guidelines This outcome measure is based on SIGN guidelines and states that for wide excisions, the surgical excision margin should be appropriate to the tumour stage of the patient.6(p16) Table 1 displays the recommended surgical excision margin for each tumour stage according to SIGN guidelines. Table 1: SIGN guidelines for surgical excision margins in cutaneous melanoma Pathological tumour stage Recommended surgical excision margin pT1 (melanoma 0 to 1 mm thickness) 1 cm pT2 (melanoma 1 to 2 mm thickness) 1 to 2 cm pT3 (melanoma 2 to 4 mm thickness) 2 cm pT4 (melanoma > 4 mm thickness) 2 cm Although it was agreed that this was an important issue and should be the subject of an outcome measure, the current data collected does not allow exact measurement of the surgical excision margins. The data for surgical margins currently collected is a categorical data item where the options do not allow for an exact match to the SIGN recommendation. After discussion it was agreed that the options available were close enough to give an indication if these guidelines were being adhered to. Table 2 indicates how the audit data item maps to the information in the SIGN guidelines. Table 2: Mapping of WoSCAN audit data to surgical excision margins from SIGN guidelines

In the 2010 Audit Report it was highlighted as a regional action to consider a change to the dataset to collect surgical excision margins appropriate to those set out in the SIGN guidelines. The data on surgical excision margins complies with ISD National Data Definitions published in 2005 and revised earlier in 2012. The MCN will not make a change to the dataset at this time, as alignment with the National Definitions is preferable and will allow for national comparative reporting. The results of the outcome measure are presented in Figure 13 for patients diagnosed in 2010 and 2011. As pathological tumour stage was poorly recorded in Ayrshire & Arran in 2011, this affected the measurement of this outcome measure for this period. Poor staging data in 2010 meant that only Lanarkshire could be assessed against the outcome measure. Stage data is well recorded for 2011 apart from Ayrshire & Arran and therefore the outcome measure can be assessed for the other NHS Boards. In Greater Glasgow and Clyde more than 10% of patients did not have a surgical excision margin recorded. There was a similar proportion of patients with surgical excision margins not recorded in Lanarkshire where there was additionally one patient with margins recorded as inapplicable. These Boards will have to do some further work to ensure all surgical excision margins are recorded. Figure 13 illustrates the improvement in data quality between 2010 and 2011 (with the exception of Ayrshire & Arran). Compliance in Greater Glasgow and Clyde and Lanarkshire was reasonably high in 2011 however Forth Valley had only around a third of cases compliant with the SIGN guidelines. Of the 54 cases in the WoS in 2011 that did not comply with the SIGN guidelines for surgical excision margins, more than 75% (41 cases) had a surgical excision margin less than the recommended distance. In Forth Valley, 43% (10/23) of cases that did not comply with the SIGN guidelines had surgical excision margins that were greater than those indicated by the SIGN guidelines so although they did not comply, the prognosis of the patient should not be affected.

SIGN recommended excision margin Audit data – surgical excision margin 1 cm 1-2 cm 1 to 2 cm 1-2 cm 2 cm 2-3 cm


KOM 6 is based on the SIGN Guidelines for Cutaneous Melanoma where it is advocated that a more conservative surgical approach should be used than in the past. It is therefore of some concern that there are a proportion of patients for whom the surgical excision margin is less than the conservative recommendation. The purpose of the guidance and therefore the outcome measure is to assess whether surgical margins are appropriate to stage. Wider margins than are deemed necessary by SIGN is not recommended practice however it would be assumed that narrower margins are also not recommended as this could affect the prognosis of the patient. Figure 13: Proportion of patients having wide excision who complied with SIGN guideline for surgical excision margin

Action required:

a. NHS Greater Glasgow and Clyde and NHS Lanarkshire should review audit data collection processes to ensure complete and accurate capture of surgical excision margins.

b. NHS Forth Valley should discuss and review surgical techniques to establish whether compliance with the SIGN guidelines can be improved.


Complied 38 17 50 48 24 117 1 10 82 75 195 267 Did not comply 2 3 13 4 14 23 9 23 12 1 50 54 Not Recorded 20 26 20 4 134 33 1 0 1 10 176 73 Inapplicable 0 4 0 0 5 0 29 0 0 1 34 5 Total 60 50 83 56 177 173 40 33 95 87 455 399


Conclusions Cancer audit data underpins much of the regional 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 across the region. Data collection of malignant melanoma diagnoses began in 2006 and since that time, there has been significant improvement in data quality. With data quality improving and the introduction of KOMs, the MCN is moving towards robust performance assessment where audit data can highlight clinical/service issues and lead to service change. The outcome measures analysed go some way to allowing assessment of service quality however there are still some data quality issues which require further improvement to enable fully robust and meaningful results. Further improvements in recording of stage of disease and surgical excision margin data are still required. Clinicians and audit staff must work together to improve the capture of these data if we are to make further progress in assessing quality of service. The incidence of malignant melanoma continues to rise and is it predicted that incidence will continue to increase until 2020. Around half of patients across the region present with thicker tumours (1mm or greater) which have a less favourable prognosis with much higher risk of metastasis. It is anticipated that the Scottish Government Detect Cancer Early Initiative will highlight the importance of presenting to a GP earlier and will impact on the numbers presenting with more advanced stages of disease. There are a number of actions required as a consequence of this assessment of performance against the agreed criteria, a small number of which relate to a continued commitment to data quality improvement. Additional actions relating to service provision were identified particularly in relation to biopsies prior to surgical treatment and compliance with SIGN guidelines regarding surgical excision margins. 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. A summary of actions for each NHS Board has been included within the Action Plan templates in Appendices I – VI. Completed Action Plans should be returned to WoSCAN within two months of publication of this report. Progress against these plans will be monitored by the MCN Advisory Board and reported to the Regional Cancer Advisory Group (RCAG) annually by Board Lead Cancer Clinicians and MCN Clinical Leads, as part of the regional governance process to enable RCAG to review and monitor regional improvement.


Acknowledgements This report has been prepared using clinical audit data provided by each of the NHS Boards in the WoSCAN area. We would like to thank colleagues in the clinical effectiveness departments throughout the West of Scotland for gathering, submitting and verifying these data. We would also like to thank the clinicians, nurses and others involved in the management of skin cancer in the West of Scotland for their contribution.


Abbreviations

AA Ayrshire & Arran

ACaDMe Acute Cancer Deaths and Mental Health (information system)

e-CASE Electronic Cancer Audit Support Environment

FV Forth Valley

GG&C Greater Glasgow and Clyde

GPwSI General Practitioner with Special Interest

ISD Information Services Division

KOM Key Outcome Measure

Lan Lanarkshire

MCN Managed Clinical Network

MDT Multidisciplinary Team

NHS QIS NHS Quality Improvement Scotland

pT Tumour Stage assessed from pathological sample (according to TNM staging system)

QPI Quality Performance Indicator

RCAG Regional Cancer Advisory Group

SIGN Scottish Intercollegiate Guidelines Network

SIMD Scottish Index of Multiple Deprivation

TNM Tumour, Nodes, Metastases (staging system)

WoS West of Scotland

WoSCAN West of Scotland Cancer Network


References 1. Information Services Division. Cancer in Scotland. [Internet] June 2004 [updated April 2012; cited September 2012]. Available at: http://www.isdscotland.org/Health-Topics/Cancer/Publications/2012-04-24/Cancer_in_Scotland_summary_m.pdf 2. Information Services Division. Cancer In Scotland: Sustaining Change. [Internet] Scottish Executive; Nov 2004 [cited September 2012]. Available at: http://www.scotland.gov.uk/Resource/Doc/30859/0012657.pdf 3. Information Services Division. Cancer statistics for malignant melanoma of the skin [Internet] [cited September 2012] Available at: http://www.isdscotland.org/Health-Topics/Cancer/Cancer-Statistics/Skin/ 4. Cancer Research UK. [Internet] [Updated 3 August 2012; cited September 2012] Available at: http://info.cancerresearchuk.org/cancerstats/types/skin/mortality/ 5. UICC (Union for International Cancer Control). TNM Classification of Malignant Tumours. Sixth Edition. Wiley-Liss; 2002. 6. Scottish Intercollegiate Guidelines Network. Cutaneous melanoma: a national clinical guideline. July 2003. Can be accessed at: http://www.sign.ac.uk/pdf/sign72.pdf 7. Marsden JR, Newton-Bishop JA, Burrows L et al. Revised U.K. guidelines for the management of cutaneous melanoma 2010. Br J Dermatol. [Internet] 2010 August [cited 2012 September]; 163 (2):238-256. Available from: http://www.bad.org.uk/Portals/_Bad/Guidelines/Clinical%20Guidelines/Melanoma%20guidelines%202010.pdf

http://www.isdscotland.org/Health-Topics/Cancer/Publications/2012-04-24/Cancer_in_Scotland_summary_m.pdf

http://www.isdscotland.org/Health-Topics/Cancer/Publications/2012-04-24/Cancer_in_Scotland_summary_m.pdf

http://www.scotland.gov.uk/Resource/Doc/30859/0012657.pdf

http://www.isdscotland.org/Health-Topics/Cancer/Cancer-Statistics/Skin/

http://www.isdscotland.org/Health-Topics/Cancer/Cancer-Statistics/Skin/

http://info.cancerresearchuk.org/cancerstats/types/skin/mortality/

http://www.sign.ac.uk/pdf/sign72.pdf

http://www.bad.org.uk/Portals/_Bad/Guidelines/Clinical%20Guidelines/Melanoma%20guidelines%202010.pdf

http://www.bad.org.uk/Portals/_Bad/Guidelines/Clinical%20Guidelines/Melanoma%20guidelines%202010.pdf

Appendix: NHS Board Action Plans A summary of actions for each NHS Board has been included within the Action Plan templates in Appendices I – VI. Completed Action Plans should be returned to WoSCAN within two months of publication of this report

West of Scotland Cancer Network Final - Published Skin Cancer MCN Audit Report 9/10/2012 Appendix I

Action / Improvement Plan Health Board: NHS Ayrshire & Arran Action Plan Lead: Date:

KEY (Status) 1 Action fully implemented

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 (see Key) Start End

Ensure actions mirror those detailed in Audit Report.

Detail specific actions that will be taken by the NHS Board.

Insert date

Insert date

Insert name of responsible lead for each specific action.

Provide detail of action in progress, change in practices, problems encountered or reasons why no action taken.

Insert No. from key above.

1. All NHS Boards to discuss referral issues with dermatologists and primary care cancer leads and identify means to increase numbers of appropriate urgent referrals.

2. NHS Ayrshire & Arran should feed back the results of their review of biopsies prior to surgical treatment to the MCN Advisory Board and assess if further action is required.

3. NHS Ayrshire & Arran should review audit collection processes to identify reasons for the decline in data completeness of pathological tumour stage and ensure availability of these data in future.

West of Scotland Cancer Network Final - Published Skin Cancer MCN Audit Report 9/10/2012 Appendix II

Action / Improvement Plan Health Board: NHS Greater Glasgow and Clyde Action Plan Lead: Date:







Insert date

Insert date





2. NHS Greater Glasgow and Clyde should review cases where excisions have been performed in Primary Care to establish reasons for the occurrences and promote referral into secondary care.

3. NHS Greater Glasgow and Clyde should review the cases where biopsy was performed prior to surgical treatment to assess whether practice has been appropriate. Additionally, Board should review clinical practice to ensure that further increases are not observed, unless clinically relevant.

4. NHS Greater Glasgow and Clyde should review audit data collection processes to ensure complete and accurate capture of surgical excision margins.

West of Scotland Cancer Network Final - Published Skin Cancer MCN Audit Report 9/10/2012 Appendix III

Action / Improvement Plan Health Board: NHS Forth Valley Action Plan Lead: Date:







Insert date

Insert date





2. NHS Forth Valley should review cases where excisions have been performed in Primary Care to establish reasons for the occurrences and promote referral into secondary care.

3. NHS Forth Valley have increased proportions biopsied between 2010 and 2011 and should review these cases to assess if biopsies have been carried out appropriately.

West of Scotland Cancer Network Final - Published Skin Cancer MCN Audit Report 9/10/2012 Appendix IV

Action / Improvement Plan Health Board: NHS Lanarkshire Action Plan Lead: Date:







Insert date

Insert date





2. NHS Lanarkshire should review cases where excisions have been performed in Primary Care to establish reasons for the occurrences and promote referral into secondary care.

3. NHS Lanarkshire have increased proportions biopsied between 2010 and 2011 and should review these cases to assess if biopsies have been carried out appropriately.

4. NHS Lanarkshire should review their case ascertainment by utilising ACaDMe to compare identified melanoma patients with Cancer Registry. The Board should also review the process for notification of cases from pathology department(s).

West of Scotland Cancer Network Final - Published Skin Cancer MCN Audit Report 9/10/2012 Appendix V

5. NHS Lanarkshire should review audit data collection processes to ensure complete and accurate capture of surgical excision margins.

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