Cancer Audit Research Flashcards
Outcomes of colorectal cancer resection in patients with inflammatory bowel disease: a national population-based analysis in England and Wales
Angela J. Kuryba,Abigail E. Vallance,Jemma M. Boyle,Michael S. Braun,Helen A. Blake,Jan van der Meulen,Nicola S. Fearnhead,Kate Walker
Aim
The aim was to compare early postoperative outcomes and 2-year cancer-specific mortality following colorectal cancer (CRC) resection in patients with and without inflammatory bowel disease (IBD) in England and Wales.
Method
Records for patients in the National Bowel Cancer Audit who had major CRC resection between April 2014 and December 2017 were linked to routinely collected hospital level administrative datasets and chemotherapy and radiotherapy datasets. Multivariable regression models were used to compare outcomes with adjustment for patient and tumour characteristics.
Results
In all, 63 365 patients were included. 1285 (2.0%) had an IBD diagnosis: 839 (65.3%) ulcerative colitis, 435 (33.9%) Crohn’s disease and 11 (0.9%) were indeterminate. IBD patients were younger, had more advanced cancer staging and a higher proportion of right-sided tumours. They also had a higher proportion of emergency resection, total/subtotal colectomy, open surgery and stoma formation at resection, with longer hospital admissions and higher rates of unplanned readmission and reoperation. Fewer rectal cancer patients with IBD received neoadjuvant radiotherapy (24.8% vs. 36.0%, P = 0.005) whilst similar proportions of Stage III colon cancer patients received adjuvant chemotherapy. Ninety-day postoperative mortality was similar, but unadjusted 2-year cancer-specific mortality was significantly higher in patients with IBD (subdistribution hazard ratio 1.35, 95% CI 1.18–1.55). Risk adjustment for patient and tumour factors reduced this association (adjusted subdistribution hazard ratio 1.22, 95% CI 1.05–1.43).
Conclusion
Patients with IBD and CRC are a distinct patient group who develop CRC at a younger age and undergo more radical surgery. They have worse cancer survival, with the difference in prognosis appearing after the early postoperative period.
IBD and bowel cancer
Stat analysis
Statistical analysis
The statistical significance of differences in patient characteristics between IBD and non-IBD patients was assessed using the χ2 test. Logistic regression was used to estimate relative differences in the odds of short-term postoperative outcomes (30-day unplanned readmission, 30-day unplanned reoperation, 90-day mortality and length of hospital stay >14 days) according to IBD diagnosis. Fine and Gray competing risks proportional hazards models were used to evaluate the impact of IBD on cancer-specific mortality with death from other causes considered a competing event and with follow-up considered to be censored at 2 years or 31 December 2019, whichever was earliest [30]. Cancer-specific mortality was defined as death from any cause within 90 days of surgery or death with bowel cancer or cancer of an unspecified site as the underlying cause in the 91 days to 2 years after surgery (Appendix S1). Robust standard errors were used in all models to account for clustering of outcomes within the NHS organization reporting surgery.
The following risk factors were included in the logistic regression and competing risk models: gender, age (in years, modelled as age and age2), IMD quintile, Charlson comorbidity score (0, 1, ≥2), ECOG performance status, tumour site, admission type, ASA score, TNM stage and the interaction between age and distant metastases (also modelled in years as age and age2).
Missing values for the risk factors were imputed with multiple imputation using chained equations, creating 10 imputed datasets, and Rubin’s rules were used to combine the model estimates across the datasets [31]. The imputation model included all risk factors and outcomes used in the analyses, including time to death/censoring. STATA® version 15.1 (StataCorp) was used for all analyses.
Cancer audits can investigate:
- Compare the patient and disease characteristics
- Operative and oncological management
- Outcomes up to 2 years after operation/treatment (e.g. a major resection for CRC) in patients with and without a risk factor (e.g. IBD)
English Hospital Episode Statistics (HES) or the Patient Episode Data for Wales (PEDW) are…
Administrative hospital datasets that include records of all inpatient hospital admissions covered by the National Health Service (NHS) in that nation
Cancer audits link…
Cancer registry data and hospital admission/ adminstrative data
Range of data sources
- Cancer registries (e.g. National Bowel Cancer Audit): Age, gender, Eastern Cooperative Oncology Group (ECOG) performance status, referral source, surgical urgency (elective/emergency), American Society of Anesthesiologists (ASA) score, pathological staging (TNM), cancer site, and the Index of Multiple Deprivation (IMD).
- Administrative hospital datasets (HES/PEDW): The presence of comorbid conditions, length of hospital stay, unplanned readmission, and unplanned reoperation after CRC resection.
- Office for National Statistics (ONS): Mortality data - Date and underlying cause of death were obtained from ONS data.
- Other cancer databases (Systemic Anti-Cancer Therapy (SACT) Database and the National Radiotherapy Dataset (RTDS))
Disadvantage of routinely collected data
Inflammatory bowel disease patients were identified from ICD-10 codes in the HES/PEDW databases; however, the duration, severity and extent of IBD was not known, nor the degree of active inflammation or the endoscopic surveillance that the patient had undergone. In addition, no medication data are included within the HES/PEDW databases; therefore the preoperative use of immunosuppressant and biological medications, and its impact upon postoperative outcomes, could not be determined.
Change in the Use of Fractionation in Radiotherapy Used for Early Breast Cancer at the Start of the COVID-19 Pandemic: A Population-Based Cohort Study of Older Women in England and Wales
M.R. Gannon
D. Dodwell
K. Miller
K. Horgan
K. Clements
J. Medina
I. Kunkler
D.A. Cromwell
Aims:
Adjuvant radiotherapy is recommended for most patients with early breast cancer (EBC) receiving breast-conserving surgery and those at moderate/high risk of recurrence treated by mastectomy. During the first wave of COVID-19 in England and Wales, there was rapid dissemination of randomised controlled trial-based evidence showing non-inferiority for five-fraction ultra-hypofractionated radiotherapy (HFRT) regimens compared with standard moderate-HFRT, with guidance recommending the use of five-fraction HFRT for eligible patients. We evaluated the uptake of this recommendation in clinical practice as part of the National Audit of Breast Cancer in Older Patients (NABCOP).
Materials and methods:
Women aged ≥50 years who underwent surgery for EBC from January 2019 to July 2020 were identified from the Rapid Cancer Registration Dataset for England and from Wales Cancer Network data. Radiotherapy details were from linked national Radiotherapy Datasets. Multivariate mixed-effects logistic regression models were used to assess characteristics influential in the use of ultra-HFRT.
Results:
Among 35 561 women having surgery for EBC, 71% received postoperative radiotherapy. Receipt of 26 Gy in five fractions (26Gy5F) increased from <1% in February 2020 to 70% in April 2020. Regional variation in the use of 26Gy5F during April to July 2020 was similar by age, ranging from 49 to 87% among women aged ≥70 years. Use of 26Gy5F was characterised by no known nodal involvement, no comorbidities and initial breast-conserving surgery. Of those patients receiving radiotherapy to the breast/chest wall, 85% had 26Gy5F; 23% had 26Gy5F if radiotherapy included regional nodes. Among 5139 women receiving postoperative radiotherapy from April to July 2020, nodal involvement, overall stage, type of surgery, time from diagnosis to start of radiotherapy were independently associated with fractionation choice.
Conclusions:
There was a striking increase in the use of 26Gy5F dose fractionation regimens for EBC, among women aged ≥50 years, within a month of guidance published at the start of the COVID-19 pandemic in England and Wales.
Change in the Use of Fractionation in Radiotherapy Used for Early Breast Cancer at the Start of the COVID-19 Pandemic: A Population-Based Cohort Study of Older Women in England and Wales
Statistical analysis
The percentage of women who received radiotherapy, and of these the percentage who received five-fraction hypofractionated radiotherapy (HFRT), was calculated for the overall cohort and within patient subgroups. These were used to investigate the use of radiotherapy over time and the change to 26Gy5F in 2020. Patients were grouped by week or month based on the date of surgery. The statistical significance of differences between group percentages was assessed using a chi-squared test. Regional variation was examined graphically using the 10 Government Office Regions covering England and Wales.
A multilevel mixed-effects logistic regression model was developed to evaluate the relationship between receipt of five-fraction radiotherapy and associated factors, and was fitted in women who started radiotherapy between April and July 2020. The model included age at diagnosis, patient fitness, number of comorbidities, overall stage, nodal involvement, type of surgery and time since diagnosis. A model fitted only to Welsh patients examined the relationship with the same variables (except overall stage) with the addition of tumour stage, ER/PR/HER2 status and invasive grade. Categories of ‘unknown’ were created where data items had missing, unintelligible or conflicting information.
A multilevel model was used to account for the clustering of patients within geographical regions (Cancer Alliances for England and Wales) **due to the relatively low levels of activity at NHS organisations. Each geographical region was fitted as a random intercept, which allowed for the average use of five-fraction radiotherapy to vary between regions.
All data preparation and statistical analyses were conducted using Stata version 17.0.
National Bowel Cancer Audit
The National Bowel Cancer Audit (NBCA) is a national clinical audit commissioned and funded by the Health Quality Inmprovement Partnership (HQIP). It has been reporting nationally since 2002 and is run by the Clinical Effectiveness Unit in partnership with the Association of Coloproctologists of Great Britain and Ireland, and the Clinical Audit Support Unit of the Health and Social Care Information Centre. Its aim is to evaluate the quality of care received by patients with bowel cancer in England and Wales.
Since 2015 the scope of the Audit has been broadened:
* Wider to explore management and outcomes across
all patients with colorectal cancer, not just those
undergoing surgery
* Earlier in the patient pathway to how and where
patients were diagnosed, and their stage at diagnosis
* Later in the patient pathway to longer-term outcomes
and treatments, and care at the end of life.
Quality improvement
NBOCA Quality Improvement Plan
The aim of the NBOCA QI Plan is to involve all members of the multidisciplinary team managing patients with colorectal cancer, covering all areas of the pathway, from diagnosis and peri-operative care, to adjuvant and neoadjuvant oncological mangement, stage IV disease and end of life care.
NBOCA will be responsible for providing trusts/hospitals/MDTs with relevant metrics across the patient pathway.
Quality improvement plan:
* Areas of concern highlighted in 2020 annual report
* Improvement goals e.g. improving patient experience, improving cancer outcomes
QI Objective is divided into the parts of the patient pathway (e.g. diagnosis, perioperative care, oncological management, stage IV disease, end of life care). For each patient pathway, there are relevant metrics with national and local QI targets.
On methodological development, that ensures
performance indicators used by the Audit are clinically
relevant and methodologically robust. We also
undertake work to strengthen our analytical approaches
(to handling missing and erroneous data, data linkage
errors, differences in case mix) as well as for detecting
units with outlying (worse than expected) performance.
What the audit measures?
The NBOCA collects data on items which have been
identified and generally accepted as good measures of
clinical care. It compares regional variation in outcomes
between English cancer alliances and Wales as a nation.
It also compares local variation between English NHS
trusts or hospitals, and Welsh MDTs. A summary of
performance indicators measured in patients with bowel
cancer is available via the hyperlink.
The majority of data items are collected by NHS trusts
and hospitals in England as part of the Cancer Outcomes
and Services Dataset (COSD). Risk-adjusted outcomes
reported this year include: 90-day post-operative
mortality, 30-day unplanned readmission rate, two-year
mortality, 30-day unplanned return to theatre and
18-month unclosed diverting ileostomy rate for anterior
resections.
Data sources
Eligible NHS trusts/hospitals/MDTs in England and
Health Boards in Wales submit data to the audit. To
generate the audit report the NBOCA records are linked
to multiple other datasets including Hospital Episode
Statistics Admitted Patient Care (HES-APC), Patient
Episode Database for Wales (PEDW), Office for National Statistics (ONS) mortality data, the Radiotherapy dataset (RTDS), the Systemic Anti-Cancer Therapy dataset (SACT), National Cancer Registry data (including Rapid Registration data), the National Emergency Laparotomy Audit (NELA) and Intensive Care National Audit and Research Centre (ICNARC) Case Mix Programme dataset. RTDS, SACT and National Cancer Registry data are currently only available for patients treated in England .
Severity of Dementia and Survival in Patients Diagnosed with Colorectal Cancer: A National Cohort Study in England and Wales
A.J.Kuryba∗†J.M.Boyle∗†J.van der Meulen∗†A.Aggarwal†‡K.Walker∗†1N.S.Fearnhead§1M.S.Braun||¶1
Aims
There is little evidence about the survival of patients with colorectal cancer (CRC) also diagnosed with dementia. We quantified dementia severity and estimated how it is associated with 2-year overall survival.
Materials and methods
Records of patients aged 65 years or older diagnosed with CRC in England and Wales were identified. A novel proxy for dementia severity combined dementia diagnosis in administrative hospital data with Eastern Cooperative Oncology Group performance status. Cox regression was used to estimate hazard ratios with and without risk adjustment.
Results
In total, 4033 of 105 250 CRC patients (3.8%) had dementia recorded. Two-year survival decreased with increasing dementia severity from 65.4% without dementia, 53.5% with mild dementia, 33.0% with moderate dementia to 16.5% with severe dementia (hazard ratio comparing severe with no dementia: 2.97; 95% confidence interval 2.79, 3.16). Risk adjustment for comorbidity and cancer stage reduced this association slightly (hazard ratio 2.52; 95% confidence interval 2.37, 2.68) and additional adjustment for treatment factors reduced it further (hazard ratio 1.60; 95% confidence interval 1.50, 1.70).
Conclusions
Survival of CRC patients varied strongly according to dementia severity, suggesting that a ‘one-size-fits-all’ policy for the care of CRC patients with dementia is not appropriate. Comprehensive assessment of cancer patients with dementia that considers dementia severity is essential in a shared decision-making process that ensures patients receive the most appropriate treatment for their individual needs and preferences.
Severity of Dementia and Survival in Patients Diagnosed with Colorectal Cancer: A National Cohort Study in England and Wales
Statistical analysis
Kaplan-Meier plots are presented for all-cause 2-year
survival according to dementia severity. Mortality data
were available up to 31 December 2018, with follow-up
censored after this date. The Log-rank test was used to
compare these survival estimates.
Multivariable Cox regression was used to obtain hazard
ratios that represent the relative differences in mortality
according to patient, tumour and treatment factors. Survival by dementia severity was sequentially adjusted for patient, tumour and health service factors, starting with a basic model including just age and sex. Patient factors were added to the model (number of comorbidities), followed by tumour factors (tumour site and pre-treatment staging added one at a time) and finally by treatment factors (emergency referral
and major resection added one at a time) to assess how much the risk-adjustment reduced the hazard ratios for the dementia severity categories, compared with patients with no dementia. All risk factors were included in the model either as categorical or as binary variables.
Three sensitivity analyses were carried out. The first was to check whether adding population quintiles of socioeconomic deprivation to the final model changed the results. The second was to assess the sensitivity of findings to assumptions about the relatively high proportion of missing performance status data, by restricting the cohort in the final model to National Health Service (NHS) hospital organisations with more than 70% complete performance status data. The third was to ensure that the results were not affected by variation in the proportion of missing staging information between the categories of dementia severity, by restricting the cohort in the final model to NHS hospital organisations with more than 70% complete pretreatment staging.
STATA version 15.1 (StataCorp, College Station, Texas, USA) was used for all analyses.
