The Victorian Colorectal Cancer Advisory Group was formed after the Colorectal Cancer 2018 Summit to ensure that findings and conclusions of this repeat summit were acted upon. Members of the group present progress of local investigations into summit-identified variations at meetings, in order that learnings are shared and opportunities for further collaboration found.
Discussion following the Colorectal 2018 Summit resulted in a local working party of engaged clinicians leading development of rectal cancer treatment guidelines, advocacy for a 100% MDM discussion rate, and the development of regional Rectal MRI request and reporting templates. These issues are learnings from the summit reflecting regional relevance. Much impetus for this work was generated from a Grampians Integrated Cancer Services-sponsored dinner to ‘place on the table’ the above issues for collegiate conversations.
The formation of the Victorian Colorectal Advisory Group has enabled the conclusions of the second colorectal summit to be further investigated. Variations observed have been explored and remedies instituted. Deficiencies in treatment planning based on inaccurate imaging have been addressed. The group plans to continue to monitor these issues and audit the measures adopted to improve them. In addition, the group will:
monitor the implementation of synoptic MRI reports for rectal cancer through monitoring of practice change and patient outcomes.
provide input and expertise, and guide data analysis for A/Prof Paul Mitchell's project, ‘Emergency presentations of patients with colorectal cancer: Investigation of events leading to presentation as an emergency.'
advise the ICS on strategies to improve quality of CRC MDMs.
Data from the Colorectal 2018 Summit showed a significantly lower proportion of +12 lymph nodes taken for patients with colon cancer (stages II, III) who had surgery within the HRICS region (excluding Albury) when compared to the state average:
This was considered significant due to summit data demonstrating patients with colon cancer with less than 12 nodes examined have a 14% increased risk of death:
It was recognised that summit data was from 2015, and that all other HRICS data from this period was on target. The variation was presented to the clinical reference group in the region for consultation. Suggested causes for the variation included pathology reporting, clinician practice, and presumed stage IV at surgery. Challenges in data collection for the HRICS region were acknowledged to be a complicating factor for local analysis (cross-border issues). Data from 2011 to 2018 captures up to the border of the Murray River.
Local investigation after the summit showed there was pathology under-reporting in one of the centres in the HRICS area, which was addressed in 2018. The number of lymph nodes examined did not reflect in survival figures. It was emphasised to MDM surgeons to always check how many lymph nodes are harvested.
When investigating node harvest by surgeon in the specific area, there was a greater number of specimens sent to Melbourne for analysis than sent locally for the same surgeons.
Prior to investigation, node harvest was identified as important due to being a possible marker for excellence in surgery in the region. Since investigation, it has now been identified as significant for pathology in the region. Local pathology staff were educated on and assisted with further evaluation of lymph nodes and reporting, including implementation of synoptic reporting. The colorectal advisory group suggested re-auditing using the Victorian Cancer Registry and DHHS SCIP data.
Department of Health and Human Services SCIP data for 2017 was reviewed and no variation for lymph node resection was found in HRICS. In the future there will be provision of the optimal care pathway and indicator information to local clinicians. Additionally, feedback to pathology and re-auditing will be undertaken.
Update Mon 30 Sep 2019
Prof Peter Gibbs
Data presented at the Colorectal 2018 Summit showed 55% of colon cancer patients who had surgery within WCMICS hospitals are achieving timely adjuvant intravenous chemotherapy (within 56 days of surgery):
As part of post-summit local action, WCMICS investigated further. Summit data was for 2011–2015, so recent data was sourced from the Statewide Cancer Indicator Platform (SCIP). This more up-to-date data showed a steady improvement since 2011, with WCMICS the highest performing high-volume Integrated Cancer Service in 2017:
Reasons for improvement may be the WCMICS-funded redesign project at Western Health, which reduced the median time from referral to treatment from 18 days to 10 days. The Peter MacCallum Cancer Centre also underwent process redesign after relocating campus to Parkville and absorbing The Royal Melbourne Hospital activity. However, these improvements are unlikely to fully explain the difference between these data sets and further consideration of the data may be recommended. Clinical trials provide a different funding model and it is possible that with a greater number of patients participating there may have been a positive impact on timeliness to treatment. The action plan for WCMICS is to continue to monitor this indicator using SCIP.
Two variations were investigated by Gippsland Regional Integrated Cancer Services (GRICS) after the CRC2018 Summit. The first was the percentage of patients with colorectal cancer who were having surgery performed in an emergency admission. For the GRICS region, this rate was at 15% (2011-2015) with a statewide average of 14%.
It was identified that there are multiple reasons for delay to treatment resulting in emergency surgical admission within the GRICS region. A prospective study is being undertaken by Monash University medical students on the referral pathway; from symptoms to GP appointment, from GP appointment to diagnosis, and from diagnosis to treatment plan. The study aims to identify delays in the referral pathway.
Other ideas to reduce emergency admissions include direct access endoscopy, with a view to improving the diagnostic process. Two specific letters have been developed to achieve direct access; one for the primary care physician and another for gastroenterologists and surgeons when a patient is symptomatic. These letters are quickly triaged to expedite the referral process. Where GPs believe there is metastatic disease, they can now refer directly to medical oncology.
In addition, GRICS have developed service maps to enhance cancer referral pathways for clinicians and GPs. The colorectal service map provides access information for each Gippsland health service providing chemotherapy services. GRICS have run workshops for GPs and clinicians on the new colorectal referral pathway. The GRICS service map for colorectal cancer is now publicly available at <https://grics.com.au/health-professionals/referral-pathways/>.
GRICS investigated the time from referral to treatment. According to the colorectal OCP, adjuvant chemotherapy should commence within 8 weeks of surgery. There was a recognised delay to treatment for patients requiring adjuvant chemotherapy. To minimise this, a pro forma letter has been developed to expedite treatment. The letter was piloted at Gippsland Cancer Care Centre and auditing has shown a >90% success rate of the new triage booking form being effective on commencing treatment in a timely fashion.
The second variation investigated was timing of MDM treatment planning for rectal cancer. Summit data indicated approximately 50% of patient discussion at MDMs was not prospective (2015).
Further local investigation indicated 85% of rectal patients are discussed prospectively, with an agreed aim of all rectal patients to be discussed at local MDM prior to treatment within the GRICS region. As advised by specialists during discussion on this summit variation, a number of patients are referred to metropolitan ICS regions for surgery and are therefore included at metro MDMs. GRICS would like to improve, in conjunction with metro hospitals, communications regarding these referred patients in order to receive their metro MDM treatment plans.
GRICS have focused on quality improvement at their local MDMs to meet the cancer services performance indicator of communicating MDM-recommended treatment plans to GPs within seven days. Initial audit results showed an average of 26 days from MDM to to GP. A software upgrade was undertaken to enable an automated process for distribution of MDM treatment plans to GPs and to assist with tracking of this documentation. After the upgrade, treatment plan distribution reduced to an average of 13 days, and a subsequent audit showed an average of 12 days to send the treatment plans. Additionally, GRICS are also aiming to increase the inclusion of MDM treatment plans in patients’ central medical records to 80%.
Next steps will involve the re-auditing of newly diagnosed colorectal patients and the percentage who receive a prospective MDM discussion, and including staging information in treatment plans and summaries.
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Data presented at the Colorectal 2018 Summit showed a statistically significant lower survival rate for Loddon Mallee Integrated Cancer Service (LMICS) patients with Stage IV colon cancer at diagnosis:
Adjusted Hazard Ratio [95% CI]
Cox proportional hazard model risk-adjusted for age, sex, socio-economic status, year of diagnosis and VAED-derived Charlson Comorbidity Index
Data source: VCR and VAED 2011–2015
This variation was investigated by LMICS. Statewide linked survival data for LMICS residents with Stage IV colon cancer, broken down by ICS of treatment, was obtained from the Department of Health and Human Services. A medical record audit was conducted at the largest health service in LMICS of residents diagnosed with Stage IV colon cancer from 2011–2015 and 2016 (patients treated with surgery, chemotherapy or radiotherapy within one year of diagnosis).
The audit showed patients treated outside of LMICS appeared to have greater survival than those treated within LMICS. However, this was not statistically significant.
When data was further analysed by first treatment type (surgery or chemotherapy), patients who had surgery in another ICS had greater survival than those who had surgery in LMICS. It was noted that there may be a selection bias, with stronger surgical candidates possibly referred to metropolitan hospitals for surgery. Patients who had chemotherapy in LMICS appeared to have greater survival than those who had chemotherapy in another ICS. The results were not statistically significant for either treatment type of surgery or chemotherapy.
The audit also found that of patients diagnosed with Stage IV colon cancer and treated in LMICS, 72% received surgery and 25% received chemotherapy.
The results of this audit were presented at a multidisciplinary team meeting and surgery versus chemotherapy rates discussed.
Colon cancer indicators will be monitored through the Statewide Cancer Indicator Platform every six months. LMICS will flag significant variations for clinician discussion and auditing.
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Update Mon 27/03/2019
Mr David Deutscher
Data presented at the Colorectal 2018 Summit showed utilisation of neoadjuvant radiotherapy in rectal cancer patient treatment (stages I, II, III) was significantly less for patients who had surgery within Grampians Integrated Cancer Services (GICS) hospitals.
This data was discussed at the Ballarat Health Service (BHS) colorectal multidisciplinary meeting (MDM) and brought to the attention of the director of surgery. The director reviewed 44 consecutive ultra-low anterior resections from 2010 to 2018. The review provided an initial overview of the current service and any areas where the process might be improved. A common resection type for BHS was chosen to minimise differences caused by surgical technique.
The summit data raised the question of whether there was any indication of higher local recurrence rates, which might be predicted to occur from surgery-only treatment.
The review showed that of the 44 patients:
From 2010 to 2013, MDM discussion was documented by hand in notes on a proforma sheet. Notes contain limited information with no record of names and specialties of MDM members or decision makers. From 2014, information is typed but identification was still mostly absent.
MDM documentation almost entirely did not record consensus or otherwise. In two instances, MDM decision non-consensus was recorded.
Twenty-eight of the forty-four patients had preoperative MRI tumour assessment. For 26 patients, the formal report gave a TNM stage, and for two patients there was no formal staging. Circumferential Resection Margin was intermittently reported.
Pathological staging of the resection specimen was reviewed in the 13 MRI-staged patients who did not have neoadjuvant therapy. Eight patients were overstaged by MRI (RT would have been overtreatment). Three were understaged. Two were correctly staged and refused adjuvant therapy.
Twelve of the forty-four patients received neoadjuvant radiotherapy. Of these, eight were in remission (four without complication and four with complications) in their last recorded follow ups. Two were alive with known metastatic disease.
There was no local recurrence amongst the 44 patients in their last recorded follow ups.
General discussion on the topic with the head of cancer surgery at Peter Mac revealed the following issues:
Conclusions from review and discussion are:
Overall, the director of surgery felt there is little to be gained by measuring neoadjuvant radiotherapy uptake in a system that currently has immature basic investigation, MDM process and MDM documentation. Importantly, no local recurrence was demonstrated in this patient group size. Group size was large enough to suggest the internationally reported recurrence rate of up to 20% would be apparent if it were real.
Barwon South Western Region Integrated Cancer Service (BSWRICS–Geelong) identified two variations as a priority from the Colorectal 2018 Summit. These were:
These variations were investigated to ascertain whether the variations were a true reflection of patient treatment, and if so, whether the variations were unwarranted. This involved three pieces of work:
Findings of the comparative analysis confirmed that the utilisation of adjuvant chemotherapy (oral and intravenous) for stage III colon cancer patients does appear lower compared to other health services.
For the clinical audit, it was found that patients not receiving adjuvant intravenous therapy had one or more of the following reasons documented:
The colorectal MDM audit data was analysed at an individual health service level, indicating some opportunities for improvement in increasing the percentage of documented prospective MDM treatment planning for rectal cancer patients. Follow-up is occurring with health services.
Colorectal multidisciplinary team members have been tasked with further investigating the utilisation and timeliness of adjuvant therapy (oral and intravenous) for stage III colon cancer patients.
Colorectal Cancer Summit 2018
Summit videos are below.
Read the progress on the 2014 Colorectal Cancer Summit outcomes, Optimal Care Pathway implementation efforts and colorectal cancer data (2011-2015) in our related documents below.
Make a difference to outcomes and the experience of care by contributing your expertise at Victorian Tumour Summits!
The clinical working party co-chaired by Mr Brian Hodgkins and Dr Geoff Chong was re-formed to oversee the Victorian Colorectal Cancer (CRC) Summit for 2018. Over 60 multidisciplinary colorectal cancer clinicians attended the 2nd CRC Summit in Melbourne on 16 March.
Discussion topics were:
Summits are usually filmed to provide ongoing resources for clinicians.
Professor Robert Thomas, Chair, Australia's Cancer Advisory Council, opened the summit:
Ms Kathryn Whitfield, Assistant Director of Cancer Strategy and Development at the Department of Health and Human Services, provided an update on progress since the 2014 Colorectal Summit:
Working party co-chair Mr Brian Hodgkins, Colorectal Surgeon, Monash Health, presented colorectal cancer data (2011-2015):
Dr Zee Wan Wong, Peninsula Health; Mr Brian Hodgkins, Monash Health; working party co-chair Dr Geoff Chong, NEMICS & GICS, spoke on clinician-led initiatives to investigate and improve variations:
- Two patients had preoperative MDM discussion documented.
- Sixteen had both pre- and postoperative discussion documented.
- Fifteen had postoperative discussion documented.
- Eleven had no MDM discussion documented.
- A lack of uptake of preoperative MRI staging. Uptake has risen 10% in the last 10 years, from 60% to 70%. Preoperative MRI staging is required by guidelines.
- A lack of rigorous MDM process. Gathering the right people at the right time, in order to discuss all cases adequately.
- A change in practice. The trend is away from neoadjuvant radiotherapy and guidelines are taking time to reflect this. In addition, the concern regarding local recurrence from surgery-only treatment comes from an outdated and unreliable historic study.
- The investigation of summit data showing significantly less use of neoadjuvant radiotherapy in GICS has shone a light on a low uptake of preoperative MRI scans and the need for standardisation of MRI reports.
- Work remains to be done to improve MDM presentation and documentation of rectal cancers in particular.
- Issues are relevant to other health providers statewide, as well as GICS hospitals.
- A lower proportion of patients receiving adjuvant chemotherapy intravenously within eight weeks of surgery for stage III colon cancer
- Over 50% of rectal cancer cases treated in the BSWRICS region having their documented multidisciplinary team meeting (MDM) discussion after their treatment.
- Comparative analysis using regional ECO Clinical Registry (01 Jan 2011–31 Dec 2015)
- Clinical audit of stage III colon cancer patients (01 Jan 2013–31 Dec 2015) who did not receive adjuvant intravenous chemotherapy
- Audit of rectal cancer patients (diagnosed between 01 Jan–31 Dec 2017) for evidence of a documented MDM treatment plan.
- Adjuvant capecitabine
- Significant comorbidities
- Advanced age
- Declined treatment
- Deceased shorty after surgery.
- How are we tracking with colorectal cancer multidisciplinary care in Victoria?
- The quality of colorectal cancer care in Victoria: review of data
- Developments in screening, colonoscopies and early diagnosis of colorectal cancer