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.
All ICS and clinical leads are invited to contact the colorectal advisory group to present at group meetings on local work on data from the Colorectal 2018 Summit. Meetings share learnings and identify opportunities for collaboration in order to ensure findings and conclusions of the Colorectal 2018 Summit are investigated and acted upon. Please contact the VTS team on <NEMICSAdmin@austin.org.au>.
Data presented at the Colorectal 2018 Summit showed a statistically significant lower survival rate for 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.
Back to top
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:
- 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.
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:
- 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.
Conclusions from review and discussion are:
- 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.
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:
- 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.
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:
- 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.
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:
- Adjuvant capecitabine
- Significant comorbidities
- Advanced age
- Declined treatment
- Deceased shorty after surgery.
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:
- 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
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 cochair 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 cochair Dr Geoff Chong, NEMICS & GICS, spoke on clinician-led initiatives to investigate and improve variations: