lymphoma 2018 - 2019 comparative audit report

This report has been checked for disclosure of potentially sensitive information.

SCAN Audit Office, c/o Department of Clinical Oncology, Western General Hospital, Crewe Road, Edinburgh EH4 2XU T: 0131 537 2266 W: www.scan.scot.nhs.uk [email protected]

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SOUTH EAST SCOTLAND CANCER NETWORK (SCAN) PROSPECTIVE CANCER AUDIT

Lymphoma 2018 - 2019 COMPARATIVE AUDIT REPORT Dr Fiona M Scott, NHS Lothian Dr Kerri Davidson,NHS Fife Dr Jenny Buxton,NHS Borders Valerie Findlay SCAN Lymphoma Audit Facilitator Alison Robertson, Cancer Audit Facilitator NHS Fife

W_SA H05/21

mailto:[email protected]


W_SA H05/20 SCAN Comparative Lymphoma QPI Report 2018-19

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CONTENTS

Chair Summary ........................................................................................................................ 3 Action Points from 2018-19 ...................................................................................................... 4 Action Points from 2017-18 ................................................................................................... 4 Lymphoma QPI Attainment Summary 2018-19 ........................................................................ 5 Introduction and Methods ......................................................................................................... 7 Audit Process ........................................................................................................................... 8 Estimate of Case Ascertainment .............................................................................................. 9 Quality Assurance ............................................................................................................... 10 Clinical Sign-Off ..................................................................................................................... 10 Actions for Improvement ..................................................................................................... 10 QPI 1i Radiological Staging.................................................................................................... 11 QPI 1ii Radiological Staging ................................................................................................... 12 QPI 1iii) Radiological Staging ................................................................................................. 13 QPI 2 Treatment Response.................................................................................................... 15 QPI 3i Positron Emission Tomography (PET CT) Staging ...................................................... 17 QPI 3ii Positron Emission Tomography (PET CT) Staging ..................................................... 18 QPI 3iii Positron Emission Tomography (PET CT) Staging .................................................... 19 QPI 4i Cytogenetic Testing..................................................................................................... 21 QPI 4ii Cytogenetic Testing .................................................................................................... 22 QPI 5 Lymphoma MDT .......................................................................................................... 24 QPI 6 Treatment for follicular Lymphoma and Diffuse Large B Cell Lymphoma ..................... 26 QPI 10 Primary Cutaneous Lymphoma .................................................................................. 27 QPI 11 Hepatitis and HIV Status ............................................................................................ 28 QPI 12i) Treatment Response in Hodgkin Lymphoma ............................................................ 29 QPI 13 Maintenance Therapy for Follicular Lymphoma .......................................................... 31 QPI 14 Clinical Trial and Research Study Access .................................................................. 32 % Age Distribution Graph 2018-19 ......................................................................................... 34 % Age Distribution for SCAN 2014-19 .................................................................................... 34 Summary of all Lymphomas 2018-19 ..................................................................................... 35 Document history

Version Circulation Date Comments

Version 1 SCAN Haematology Lead clinicians

01/05/2020 15/05/2020

Version 2 SCAN Lead clinician and sign off group

13/05/2020 04/06/2020

Version 3 SCAN Haematology Group 11/06/2020 22/06/2020

Final Version SCAN Group SCAN Governance Framework SCAN Action Plan Board Leads

30/06/2020 NA

Web Version Published to SCAN Website



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Chair Summary

The SCAN Haematology group continued to work to improve the quality of care of patients with Haematological malignancies during 2019. Four of eleven individual QPIs were achieved within SCAN. The main challenge for the SCAN Haematology group remains access to and timing of radiological investigations and finalsied imaging reports.In addition national difficulites with robust provision of the necessary isotope required to support PET evaluation resulted in unpredictable and avoidvable delays in PET assessment. Delays in access to finalsied radiology reports is an ongoing issue but this did not delay delivery of chemotherapy. Improved understanding of the molecular complexity of Diffuse Large B cell Lymphoma has enabled better delineation of DLBCL which has been incorporated into the updated WHO Classification of Haematological malignancies. This updated WHO disease tree includes a number of Lymphoma subtypes where MYC analysis is not considered essential. The new WHO classification has been adopted locally and has led to a reduction in the number of biopsies in which MYC testing has been evaluated. In Lothian over 90% of the MYC test results are available within 3 weeks of treatment initiation but work is required on test turn around times in Fife as only 45% of cases have results avialable within 3 weeks of initation of treatment. A minorty of patients within SCAN are not reviewed by the regional Haematology MDT within 8 weeks of diagnosis. This is due in part to the varibale clinical presentations of Lymphoma and complex diagnostic pathways. In addition there are a number of cases where lymphoma was diagnosed postmortem. Failure to meet QPI 13 highlights the need for a review QPI measurability criteria, at present these criteria make no allowance for cases where the patient has died before maintenance could be initiated.

Recruitment into Lymphoma trials remains an issue, this is due in part to the current lack of national first line trials for Diffuse large B cell Lymphoma or Hodgkin Lymphoma. Additional nursing and pharmacy resources have been identified for St John’s Hopsital which is hoped will improve clinical trials access for West Lothian patients in the future. Pressure on staffing levels at the Borders General Hospital mean that realistically trials recruitment in the Borders will be very restricted for sometime. A new Consultant post with a remit to improve access to innovative trials and cellular therapies has been established within Lothian which it is hoped will increase trials portfolio in the next few years. Continued increase in clinical workload and affordability of new therapeutic approaches including cellular therapies remaim pressures across all units. Priorities for 2020 include review of clinical management guidelines and organisational format of the weekly regional MDT.

Fiona Scott SCAN Haematology Lead Clinician

June 2020



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Action Points from 2018-19

QPI Action required Person

Responsible Date

QPI5 Review measurability to exclude patients with primary cutaneous MZL ISD- Formal

Review

November 2020 (delayed due to

COVID pandemic)

Action Points from 2017-18

QPI Action required Person Responsible Progress

1i Propose at Lymphoma QPI formal review in November 2020 that “durable remission” is added as a treatment intent option.

Lorna Bruce November

2020

4 Review WHO codes at Formal Review Cancer Quality Program

Coordinator Nov 2020

4 Action is required in Fife to ensure that MYC testing is carried out within the 3 week timescale in all suitable patients

Dr K Davidson Sept 2019



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Lymphoma QPI Attainment Summary 2018-19 Target % Borders Fife Lothian SCAN

QPI 1 Proportion of patients treated with curative intent who have CT of chest, abdomen & pelvis or PET/CT

Prior to treatment 95 N 22

100% N 51

98.1% N 114

96.6% N 187

97.4% D 22 D 52 D 118 D 192

Within 2 weeks of request 90 N 20

90.9% N 43

84.3% N 96

84.2% N 159

85.0% D 22 D 51 D 114 D 187

Reported within 3 weeks of request 90 N 22

100% N 46

90.2% N 101

88.6% N 169

90.4% D 22 D 51 D 114 D 187

QPI 2 Proportion of patients with DLBCL treated with curative intent given end of treatment CT/PET

90 N 6

100% N 10

66.7% N 47

94.0% N 62

88.7% D 6 D 15 D 50 D 70

QPI 3 Proportion of patients with Classical Hodgkin Lymphoma treated with curative intent that undergo PET CT scan.

Prior to treatment 95 N NA

NA N 7

87.5% N 21

95.5% N 28

93.3% D NA D 8 D 22 D 30

Within 2 weeks of request 95 N NA

NA N 4

57.1% N 12

57.1% N 16

57.1% D NA D 7 D 21 D 28

Reported within 3 weeks of request 95 N NA

NA N 6

85.7% N 18

85.7% N 24

85.7% D NA D 7 D 21 D 28

QPI 4 Proportion of patients with Burkitt Lymphoma and DLBCL treated with curative intent who have MYC testing as part of the diagnostic process

Before treatment 60 N 10

90.9% N 1

5.0% N 36

57.1% N 47

50.0% D 11 D 20 D 63 D 94

Within 3 weeks of treatment 85 N 11

100% N 9

45.0% N 58

92.1% N 78

83.0% D 11 D 20 D 63 D 94

QPI 5 Proportion of patients reviewed by MDT within 8 weeks of diagnosis.

90 N 32

94.1% N 67

85.9% N 143

87.2% N 242

87.7% D 34 D 78 D 164 D 276

QPI 6 Proportion of patients with FL or DLBCL treated with chemotherapy and anti B cell monoclonal antibody therapy

95 N 13

100% N 26

100% N 68

100% N 107

100% D 13 D 26 D 68 D 107

QPI 10 Patients with primary cutaneous lymphoma discussed at a specialist MDT meeting

95 N NA

N 1

100% N 2

100% N 3

100% D NA D 1 D 2 D 3

QPI 11 Patients with lymphoma undergoing SACT who have hepatitis B,C and HIV status checked prior to treatment

95 N 21

100% N 47

100% N 116

96.7% N 184

97.9% D 21 D 47 D 120 D 188

QPI 12 Proportion of patients with advanced HL treated with ABVD who have treatment evaluated with a PET CT

After 2 cycles 80 N NA

NA N 5

83.3% N 11

100% N 16

94.1% D NA D 6 D 11 D 17

Reported within 3 days 80 N NA

NA N 2

40.0% N 7

63.6% N 9

56.3% D NA D 5 D 11 D 16



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Lymphoma QPI Attainment Summary 2018-19 Target % Borders Fife Lothian SCAN

QPI 13 Proportion of patients with FL treated with R-chemotherapy who have R maintenance therapy.

90 N 3

100% N 6

100% N 6

75.0% N 15

88.2% D 3 D 6 D 8 D 17

QPI 14 Proportion of patients with lymphoma who are consented for a clinical trial/research study

15 N 1

2.9% N 0

0% N 8

4.3% N 9

3.0% D 34 D 75 D 187 D 296



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Introduction and Methods

Cohort This report covers patients newly diagnosed with Lymphoma in Borders, Fife, and Lothian Health Board areas between 1st October 2018 and 30th September 2019. Management and audit of patients with Lymphoma in Dumfries & Galloway is via the West of Scotland Cancer Network. The results contained within this report have been presented by NHS board of diagnosis.

Dataset and Definitions The QPIs have been developed collaboratively with the three Regional Cancer Networks, Information Services Division (ISD), and Healthcare Improvement Scotland. QPIs will be kept under regular review and be responsive to changes in clinical practice and emerging evidence. The overarching aim of the cancer quality work programme is to ensure that activity at NHS board level is focused on areas most important in terms of improving survival and patient experience whilst reducing variance and ensuring safe, effective and person-centred cancer care. Following a period of development, public engagement and finalisation, each set of QPIs is published by Healthcare Improvement Scotland1.

Accompanying datasets and measurability criteria for QPIs are published on the ISD website2. NHS boards are required to report against QPIs as part of a mandatory, publicly reported, programme at a national level.

The QPI dataset for Lymphoma was implemented from 01/10/2013. The dataset underwent a formal review and was revised in December 2017. This is the 6th publication of QPI results for Lymphoma within SCAN and the 3rd with the revised dataset.

The following QPIs have been updated:

QPI 1 – Radiological Staging

QPI 3 – Positron Emission Tomography (PET CT) Staging

QPI 4 – Cytogenetic Testing

QPI 5 – Lymphoma MDT

QPI 6 – Treatment for Follicular Lymphoma and Diffuse Large B-Cell Lymphoma

QPI 11 – Hepatitis and HIV Status

The following QPIs have been archived

QPI 7 - Treatment of Grade 3b Follicular Lymphoma

QPI 8 - Treatment for Stage 1a Diffuse Large B Cell Lymphoma

QPI 9 - Treatment for Classical Hodgkin Lymphoma

The following new QPIs were reported for the first time in 2017-18.

QPI 1iii - Radiological Staging QPI 3iii - Positron Emission Tomography (PET CT) Staging

QPI 12 - Treatment Response in Hodgkin Lymphoma

QPI 13 - Maintenance Therapy for Follicular Lymphoma

1 QPI documents are available at www.healthcareimprovementscotland.org 2 Datasets and measurability documents are available at www.isdscotland.org

http://www.healthcareimprovementscotland.org/

http://www.isdscotland.org/



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The standard QPI format is shown below: QPI Title: Short title of Quality Performance Indicator (for use in reports etc.)

Description: Full and clear description of the Quality Performance Indicator.

Rationale and Evidence:

Description of the evidence base and rationale which underpins this indicator.

Specifications:

Numerator: Of all the patients included in the denominator those who meet the criteria set out in the indicator.

Denominator: All patients to be included in the measurement of this indicator.

Exclusions: Patients who should be excluded from measurement of this indicator.

Not recorded for numerator:

Include in the denominator for measurement against the target. Present as not recorded only if the patient cannot otherwise be identified as having met/not met the target.

Not recorded for exclusion:

Include in the denominator for measurement against the target unless there is other definitive evidence that the record should be excluded. Present as not recorded only where the record cannot otherwise be definitively identified as an inclusion/exclusion for this standard.

Not recorded for denominator:

Exclude from the denominator for measurement against the target. Present as not recorded only where the patient cannot otherwise be definitively identified as an inclusion/exclusion for this standard.

Target: Statement of the level of performance to be achieved.

Audit Process

Data was analysed by the audit facilitators in each NHS board according to the measurability document provided by ISD. Lothian and Borders data was collated by Valerie Findlay, SCAN Audit Facilitator for Haematology, Fife data was collected by Alison Robertson, Audit Facilitator for Fife.

Data capture is focused round the process for the weekly multidisciplinary meetings ensuring that data covering patient referral, investigation and diagnosis is being picked up through the routine process.

Oncology data is obtained either from the clinical records (electronic systems and case notes) or by downloads from Aria and from the Department of Clinical Oncology database within the Edinburgh Cancer Centre (ECC).

Each of the 3 health boards provides chemotherapy data but radiotherapy is provided centrally in Edinburgh Cancer Centre. Patients living closer to either Carlisle or Dundee may opt to have oncology treatment out with the SCAN region. Collecting complete audit data for these patients remains a challenge. The process remains dependent on audit staff for capture and entry of data, and for data quality checking Data was recorded on TRAK in Lothian and Borders. Fife data was collected using E-case..



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Lead Clinicians and Audit Personnel SCAN Region Hospital Lead Clinician Audit Support

NHS Borders Borders General Hospital Dr J Buxton Valerie Findlay

NHS Fife Queen Margaret Hospital/Victoria Hospital

Dr K. Davidson Alison Robertson

SCAN & NHS Lothian

St Johns Hospital Western General Hospital

Dr F.M. Scott Valerie Findlay

Data Quality

Estimate of Case Ascertainment

An estimate of case ascertainment (the percentage of the population with Lymphoma recorded in the audit) is made by comparison with the Scottish Cancer Registry five year average data from 2014 to 2018. High levels of case ascertainment provide confidence in the completeness of the audit recording and contribute to the reliability of results presented. Levels greater than 100% may be attributable to an increase in incidence. Allowance should be made when reviewing results where numbers are small and variation may be due to chance. Number of cases recorded in audit: patients diagnosed 01/10/2018 to 30/09/2019

Borders Fife Lothian SCAN

HL 1 10 22 33

DLBCL 11 25 76 112

FL 8 13 25 46

Other Lymphomas 15 31 49 95

Total 35 79 172 286

Estimate of case ascertainment: calculated using the average of the most recent available five years of Cancer Registry data (2014-2018) from ACaDMe Comparative datamart (April 2020)


HL - Cases from Audit 1 10 22 33

HL- Cancer Registry 5 yr average 3 10 33 45

% Case Ascertainment 33.3% 100% 66.7% 73.3%


NHL - Cases from Audit 34 69 150 253

NHL- Cancer Registry 5 yr average 32 65 154 250

% Case Ascertainment 106.3% 106.2% 97.4% 101.2%

DLBCL – Diffuse Large B Cell Lymphoma; FL – Follicular Lymphoma; HL – Hodgkin Lymphoma; NHL – Non Hodgkin Lymphoma



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Quality Assurance

All hospitals in the region participate in a Quality Assurance (QA) programme provided by the National Services Scotland Information Services Division (ISD). QA of Lothian and Borders Lymphoma data was carried out in 2015 and compared well with accuracy in the other Scottish Health Boards.

Clinical Sign-Off

This report compares data from reports prepared for individual hospitals and signed off as accurate following review by the lead clinicians from each service. The collated SCAN results are reviewed jointly by the lead clinicians, to assess variances and provide comments on results:

Individual health board results were reviewed and signed-off locally.

Draft report circulated 01/05/2020, prior to Regional sign off meeting delayed due to the Covid19 lockdown.

Collated results were presented and discussed at the Haematology SCAN Leads Meeting on 13/05//2020.

Final report circulated to SCAN Haematology Group and Clinical Governance Groups on dd/mm/2020.

Actions for Improvement

After final sign off, the process is for the report to be sent to the Clinical Governance groups with action plans for completion at Health Board level. The report is placed on the SCAN website with completed action plans once it has been fully signed-off and checked for any disclosive material



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QPI 1i Radiological Staging Target 95%

Proportion of patients treated with curative intent who undergo Computed Tomography (CT) scanning of the chest, abdomen and pelvis or PET CT scanning prior to treatment and within 2 weeks of radiology request

Numerator = Number of patients with lymphoma undergoing treatment with curative intent who undergo CT of chest, abdomen and pelvis or PET CT scanning prior to treatment Denominator = All patients with lymphoma undergoing treatment with curative intent Exclusions = patients who refuse investigation, patients with primary cutaneous lymphoma

Target 95% Borders Fife Lothian SCAN

2018-19 cohort 35 79 172 286

Ineligible for this QPI 13 27 54 94

Numerator i 22 51 114 187

Not recorded for the numerator 0 0 0 0

Denominator 22 52 118 192

Not recorded for exclusions 0 0 0 0

Not recorded for denominator 0 0 0 0

% Performance 100% 98.1% 96.6% 97.4%

Comments Fife: The target was met Borders: The target was met Lothian: The target was met

BGH Fife Lothian SCAN

Year 2016-17 96.0% 95.2% 96.4% 96.0%

Year 2017-18 100.0% 98.1% 94.7% 96.0%

Year 2018-19 100.0% 98.1% 96.6% 97.4%

% Target 95.0% 95.0% 95.0% 95.0%

0%

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50%

60%

70%

80%

90%

100%

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QPI 1i Radiological StagingLymphoma 2016-19



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QPI 1ii Radiological Staging Target 90%

Numerator = Number of patients with lymphoma undergoing treatment with curative intent who undergo CT of chest, abdomen and pelvis or PET CT scanning prior to treatment and within 2 weeks of radiology request.

Denominator = All patients with lymphoma undergoing treatment with curative intent who undergo CT of chest, abdomen and pelvis or PET CT scanning prior to treatment. Exclusions = patients who refuse investigation, patients with primary cutaneous lymphoma


2018-19 cohort 35 79 172 286


Numerator ii 20 43 96 159


Denominator ii 22 51 114 187



% Performance 90.9% 84.3% 84.2% 85.0%

QPI 1ii) Analysis counting radiology working days only

QPI 1ii Target% Borders Fife Lothian SCAN

14 working days 90 N 22

100% N 48

94.1% N 105

92.1% N 175

93.6% D 22 D 51 D 114 D 187

Comments

Borders: The target was met

Fife: The target was not met showing a shortfall of 5.7% (8 cases). 2 patients cancelled their given appointments, 4 patients were within 14 working days, 1 request was not marked urgent, and 1 had CT performed at request of another service prior to haematology referral. Lothian: The target was not met showing a shortfall of 5.8% (18 cases). The range for those not meeting target was 15 to 159 days.10 scans were performed in less than 14 working days from request. The longest wait for a scan requested by the Haematology team was 43 days; this however was due to the fact that the patient was unable to attend initial scan date due to surgery. In another two cases, scans were undertaken 28 days post request however both were routine referrals re investigation of anaemia and the scan abnormalities were incidental findings. 1 patient waited 26 days, this was a request initiated by the breast team over the Christmas/New Year period. The remaining 3 patients waited less than 22 days from referral to scan date. In one case, there was an apparent 159 day delay, this however is misleading and reflects the inflexibility of the QPI process. The imaging in question was requested by another team as a planned 6 monthly radiological review of a non-haematological malignancy. The patient then presented 5 months later with a new clinical Haematological malignancy and the timing of the ‘elective ‘ follow-up scan from the other team was such that the Haematology team did not need to request further imaging. The QPI process however dictates that the date of request is taken from the time that the routine imaging request was made even though there was no evidence of a haematological malignancy at that time point.



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QPI 1iii) Radiological Staging Target 90%

Numerator = Number of patients with lymphoma undergoing treatment with curative intent who undergo CT of chest, abdomen and pelvis or PET CT scanning prior to treatment where the report is available within 3 weeks of radiology request. Denominator = All patients with lymphoma undergoing treatment with curative intent who undergo CT of chest abdomen and pelvis or PET CT scanning prior to treatment (no exclusions).


2018-19 cohort 35 79 172 286


Numerator ii 22 46 101 169





% Performance 100% 90.2% 88.6% 90.4%

QPI 1iii) Analysis counting radiology working days only

QPI 1iii Target% Borders Fife Lothian SCAN

21 working days 90 N 22

100% N 49

96.1% N 109

95.6% N 180

96.2% D 22 D 51 D 114 D 187


Year 2016-17 91.7% 76.7% 76.6% 78.5%

Year 2017-18 95.8% 84.3% 80.4% 83.0%

Year 2018-19 90.9% 84.3% 84.2% 85.0%

%Target 90% 90% 90% 90%

0%

10%

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40%

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100%%

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QPI 1ii Radiological StagingLymphoma 2016-19



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Comment Borders: The target was met

Fife: The target was met

Lothian: The target was not met showing a shortfall of 1.4% (13 cases) where the time to report ranged from 22-160 days post request. 8 reports were available within 21 working days of request. The 5 longest waits were as described for part ii. Again the data is confounded by the inclusion of 160 day ‘delay’ derived from a scan requested well in advance for another disorder before there was an established Haematological malignancy. Lothian would have met the 90% target if this case is excluded from the data analysis.


Year 2017-18 91.7% 98.0% 91.6% 93.1%

Year 2018-19 100.0% 90.2% 88.6% 90.4%

%Target 90% 90% 90% 90%

0%

10%

20%

30%

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60%

70%

80%

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100%

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QPI 1iii Radiological StagingLymphoma 2017-19



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QPI 2 Treatment Response Target 90%

Proportion of patients with DLBCL who are undergoing chemotherapy treatment with curative intent, who have their response to treatment evaluated with Computed Tomography (CT) scan of the chest, abdomen and pelvis or PET CT scan.

Numerator = Number of patients with DLBCL who are undergoing chemotherapy treatment with curative intent who undergo CT of chest, abdomen and pelvis at end of chemotherapy treatment. Denominator = All patients with DLBCL who are undergoing chemotherapy treatment with curative intent. Exclusions= Patients who died during treatment, primary DLBCL CNS, unfit for curative treatment


2018-19 cohort 35 79 172 286


Numerator 6 10 47 63

Not recorded for numerator 0 1 0 1




% Performance 100% 66.7% 94.0% 88.7%

Comments

BGH: The target was met

Fife: The target was not met showing a shortfall of 25.7% (5 cases) 3 patients were within 7 days of target, 1 patient was PET negative post chemotherapy therefore no need to repeat following consolidation radiotherapy. 1 patient was still undergoing treatment at time of reporting

Lothian: The target was met



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2016-17 80.0% 78.3% 89.9% 85.4%

2017-18 90.0% 89.5% 83.9% 85.9%

2018-19 100.0% 66.7% 94.0% 88.7%

% Target 90% 90% 90% 90%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% P

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Lymphoma 2016-19



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QPI 3i Positron Emission Tomography (PET CT) Staging Target 95%

Proportion of patients with Classical Hodgkin Lymphoma (CHL) undergoing treatment with curative intent who undergo PET CT scan prior to first treatment and within 2 weeks of radiology request

Numerator: Number of patients with CHL undergoing treatment with curative intent that undergo PET CT prior to treatment Denominator: All patients with CHL undergoing treatment with curative intent (no exclusions)


2018-19 cohort 35 79 172 286


Numerator i NA 7 21 28

Not recorded for numerator NA 0 0 0

Denominator NA 8 22 30

Not recorded for exclusions NA 0 0 0

Not recorded for denominator NA 0 0 0

% Performance NA 87.5% 95.5% 93.3%

Comment

BGH: There were no eligible patients in this cohort.

Fife: The target was not met showing a shortfall of 7.5% (1 case). The patient was an inpatient and too unwell to have a PET scan.

Lothian: The target was met.


2016-17 100.0% 90.0% 82.6% 87.2%

2017-18 100.0% 100.0% 83.3% 88.9%

2018-19 0.0% 87.5% 95.5% 93.3%

Target 95% 95% 95% 95% 95%

0%

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QPI 3i PETCT StagingLymphoma 2016-19



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QPI 3ii Positron Emission Tomography (PET CT) Staging Target 95%

Numerator: Number of patients with CHL undergoing treatment with curative intent who undergo PET CT prior to treatment and within 2 weeks of radiology request

Denominator: All patients with CHL undergoing treatment with curative intent who undergo PET CT prior to treatment. Exclusions: Patients who refuse investigation, unfit for curative treatment


2018-19 cohort 35 79 172 286


Numerator ii NA 4 12 16





% Performance NA 57.1% 57.1% 57.1%

QPI 3ii Analysis counting radiology working days only

QPI 3ii Target% Borders Fife Lothian SCAN

14 working days 95 N NA

NA N 6

85.7% N 18

85.7% N 24

85.7% D NA D 7 D 21 D 28

Comments


Fife: The target was not met showing a shortfall of 37.9% (3 cases). 1 had scan delayed to allow time for fertility preservation and 2 were scanned within 18 days of request.

Lothian: The target was not met showing a shortfall 37.9% (9 cases). The range for those not meeting target was 15 -20 days. 6 were scanned within 14 working days of request and 2 within 15 working days. 2 patients had scan delayed to allow time for fertility preservation which cannot be done post PET scan. 4 patients could not have PET scan on planned dates due to Scotland wide isotope failure. The remaining 2 cases were scanned within 12 working days.



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QPI 3iii Positron Emission Tomography (PET CT) Staging Target 95%

Numerator = Number of patients with CHL undergoing treatment with curative intent who undergo PET CT prior to first treatment where the report is available within 3 weeks of request.

Denominator = All patients with CHL undergoing treatment with curative intent who undergo PET CT prior to treatment.


2018-19 cohort 35 79 172 286


Numerator iii NA 6 18 24





% Performance NA 85.7% 85.7% 85.7%

QPI 3iii Analysis counting radiology working days only

QPI 3iii Target% Borders Fife Lothian SCAN

21 working days 95 N NA

NA N 6

85.7% N 20

95.2% N 26

92.9% D NA D 7 D 21 D 28


2016-17 83.3% 88.9% 78.9% 82.4%

2017-18 100% 92.3% 72.0% 80.0%

2018-19 0.0% 57.1% 57.1% 57.1%

Target 95% 95% 95% 95% 95%

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tsQPI 3ii PETCT Staging

Lymphoma 2016-19



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Comments


Fife: The target was not met showing a shortfall of 9.3% (1 case) delayed due to fertility preservation as for part 3ii above.

Lothian: The target was not met showing a shortfall 9.3% (2 cases), which waited 24 and 27 days from request to report. Both cases not meeting target were reported within 19 and 20 working days respectively. One patient had scan delayed to allow for fertility preservation, one patient had scan delayed due to technical difficulties with PET isotope as outlined in QPI 3ii above.


2017-18 100% 100% 88.0% 92.5%

2018-19 0.0% 85.7% 85.7% 85.7%

% Target 95% 95% 95% 95%

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Health Board

QPI 3 iii PETCT StagingLymphoma 2017-19



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QPI 4i Cytogenetic Testing Target = 60%

Proportion of patients with Burkitt Lymphoma and DLBCL undergoing treatment with curative intent who have MYC testing as part of diagnostic process and prior to treatment.

Numerator = Number of patients with Burkitt lymphoma and DLBCL undergoing treatment with curative intent who have MYC results reported prior to treatment. Denominator : All patients with Burkitt lymphoma and DLBCL undergoing treatment with curative intent (no exclusions) Target 60% Borders Fife Lothian SCAN

2018-19 cohort 35 79 172 286







% Performance 90.9% 20.0% 57.1% 53.2%

Comments Borders: The target was met

Fife: The target was not met showing a shortfall of 40%(16 cases) 3 patients were >70yrs and did not have MYC test as would not alter management, 2 patients were not tested the reason is unclear.11 patients were tested but results reported after starting SACT.

Lothian: The target was not met showing a shortfall of 2.9%(27 cases) 3 patients did not have a MYC test requested 2 of which had morphology where a MYC test would not alter management.24 had MYC test after starting treatment – see part ii



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QPI 4ii Cytogenetic Testing Target 85% Numerator: Number of patients with Burkitt Lymphoma and DLBCL undergoing chemotherapy treatment with curative intent who have MYC results reported within 3 weeks of commencing treatment. Denominator: All patients with Burkitt Lymphoma and DLBCL undergoing chemotherapy treatment with curative intent.


2018-19 cohort 35 79 172 286







% Performance 100% 60.0% 92.1% 86.2%

Comments Borders: The target was met

Fife: The target was not met showing a shortfall of 25% (8 cases) 3 patients were over 70yrs (as for 4i), 2 did not have MYC test (as for 4i), 3 had MYC test reported within 24-28 days of starting SACT.

Lothian: The target was met Action: A new policy was adopted in Fife in Sept 2019 to improve MYC test turnaround. This should be reflected by an improvement in 2019-20..


2016-17 83.3% 33.3% 82.0% 67.4%

2017-18 63.6% 45.0% 59.7% 57.3%

2018-19 90.9% 20.0% 57.1% 53.2%

%Target 60% 60% 60% 60%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% P

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tsQPI 4i Cytogenetic Testing

Lymphoma 2016-19



23


2016-17 100% 55.6% 92.0% 82.0%

2017-18 100% 60.0% 90.3% 85.4%

2018-19 100.0% 60.0% 92.1% 86.2%

%Target 85% 85% 85% 85%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% p

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tsQPI 4ii Cytogenetic Testing

Lymphoma 2016-19



24

QPI 5 Lymphoma MDT Target 90%

Proportion of patients with lymphoma who are discussed at MDT meeting within 8 weeks of diagnosis.

Numerator - Number of patients with lymphoma discussed at the MDT within 8 weeks of diagnosis Denominator - All patients with Lymphoma Exclusions: Patients who died before first treatment and patients with primary cutaneous lymphoma.


2018-19 cohort 35 79 172 286


Numerator 32 67 143 242





% Performance 94.1% 85.9% 87.2% 87.7%

Comments Borders: The target was met Fife: The target was not met showing a shortfall of 4.1% (11 cases). 2 patients had previous MGUS which progressed to Lymphoma, both received appropriate chemotherapy. 9 patients missed the target by less than 14 days mainly due to complicated referral pathways via other specialities. Lothian: The target was not met with a shortfall of 2.8% (21 cases) The range for those missing target is 58 -134 days. 15 were less than 56 working days from referral to MDM. One patient was not reviewed at the Haematology MDM but was reviewed at the specialist skin lymphoma MDM. Their inclusion in this QPI is due to the absence of an appropriate morphology code. Two patients had delayed workup as a result of previous surgery by another service, 2 were referrals from other services, one was a difficult diagnosis. Action: Review QPI measurability at next Formal Review (Nov 2020). Consider excluding patients with primary cutaneous marginal zone lymphoma who are reviewed by the skin lymphoma MDT.



25


2016-17 97.4% 86.5% 88.6% 89.2%

2017-18 100.0% 60.0% 90.3% 85.4%

2018-19 94.1% 85.9% 87.2% 87.7%

%Target 90% 90% 90% 90%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% P

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tsQPI 5 MDT

Lymphoma 2017-19



26

QPI 6 Treatment for follicular Lymphoma and Diffuse Large B Cell Lymphoma Target 95%

Proportion of patients with follicular lymphoma and DLBCL undergoing treatment with chemotherapy who receive Rituximab

Numerator: Proportion of patients with FL and DLBCL who receive chemotherapy in combination with anti-B cell monoclonal antibody therapy Denominator: All patients with FL and DLBCL who receive chemotherapy Exclusions: patients who refuse chemotherapy, enrolled in clinical trials.


2018-19 cohort 135 79 172 286







% Performance 100% 100% 100% 100%

Comments The QPI was met by all Health Boards

.


2016-17 100% 100% 100% 100%

2017-18 100% 100% 100% 100%

2018-19 100.0% 100.0% 100.0% 100.0%

Target 95% 95% 95% 95% 95%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% P

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QPI 6 Treatment of FL and DLBCLLymphoma 2016-19



27

QPI 10 Primary Cutaneous Lymphoma Target 95%

Proportion of patients with primary cutaneous lymphoma who are discussed at a specialist MDT meeting which includes representation from pathology, dermatology, oncology ± haemato-oncology.

Numerator = Proportion of patients with primary cutaneous lymphoma who are discussed at a specialist MDT meeting. Denominator = All patients with primary cutaneous lymphoma Exclusions = No exclusions


2018-19 cohort 35 79 172 286


Numerator NA 1 2 3





% Performance NA 100% 100% 100%

Comments Borders: There were no eligible patients in this cohort. Fife: The target was met Lothian: The target was met March 2019 saw the introduction of a specific skin lymphoma MDM with associated admin support. This is a work in progress and ultimately aims to have outcomes recorded and viewed on TRAK.



28

QPI 11 Hepatitis and HIV Status Target 95%

Proportion of patients with lymphoma undergoing SACT based treatment who have hepatitis B, hepatitis C and HIV status checked prior to treatment

Numerator = Number of patients with lymphoma undergoing SACT who have hepatitis B, C and HIV status checked prior to treatment. Denominator = All patients with lymphoma undergoing SACT treatment (no exclusions).


2018-19 cohort 35 79 172 286


Numerator 21 47 116 184





% Performance 100% 100% 96.7% 97.9%

Comment

The QPI was met in all Health Boards


2016-17 100.0% 87.5% 98.8% 94.9%

2017-18 95.8% 92.2% 96.6% 95.5%

2018-19 100.0% 100.0% 96.7% 97.9%

% Target 95% 95% 95% 95%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% P

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QPI 11 Hepatitis and HIV status Lymphoma 2016-19



29

QPI 12i) Treatment Response in Hodgkin Lymphoma Target 80%

Numerator: Number of patients with advanced HL (stage2B and above) who receive ABVD chemotherapy treatment that undergo PET CT scan after 2 cycles of chemotherapy.

Denominator: All patients with advanced Hodgkin Lymphoma (stage 2B and above) who receive ABVD chemotherapy treatment (no exclusions).


2018-19 cohort 35 79 172 286


Numerator NA 5 11 16





% Performance NA 83.3% 100% 94.1%

Comment: The QPI was met in all Health Boards


2017-18 0.0% 44.4% 81.3% 65.4%

2018-19 0.0% 83.3% 100.0% 94.1%

% Target 80.0% 80.0% 80.0% 80.0%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% P

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QPI 12 Treatment Response in HLLymphoma 2017-19



30

QPI 12ii) Treatment Response in Hodgkin Lymphoma Target 80%

Numerator Number of patients with advanced Hodgkin Lymphoma (stage 2B and above) who receive ABVD chemotherapy treatment that undergo PET CT scan after 2 cycles of chemotherapy where the report is available within 3 days.

Denominator All patients with advanced Hodgkin Lymphoma (stage 2B and above) who receive ABVD chemotherapy treatment that undergo PET CT scan after 2 cycles of chemotherapy (no exclusions).


2018-19 cohort 35 79 172 286


Numerator NA 2 7 9





% Performance NA 40.0% 63.6% 56.3%

Comments: Borders: There were no eligible patients in this cohort Fife: The target was not met showing a shortfall of 40% (3 cases). All scans were reported within 6 days. Lothian : The target was not met with a shortfall of 16.4% (4 cases). The longest report time was 9 days, 2 were reported within 5 days and 1 reported within 4 days. There are very small patient numbers involved in this QPI.


2017-18 0.0% 100.0% 30.8% 47.1%

2018-19 0.0% 40.0% 63.6% 56.3%

% Target 80.0% 80.0% 80.0% 80.0%

0%

10%

20%

30%

40%

50%

60%

70%

80%

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%p

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QPI 12ii Treatment Response in HLLymphoma 2017-19



31

QPI 13 Maintenance Therapy for Follicular Lymphoma Target 90%

Numerator: Number of patients with follicular lymphoma who undergo treatment with R-Chemotherapy who receive maintenance treatment with anti B cell monoclonal antibody therapy.

Denominator: All patients with follicular lymphoma who undergo treatment with R-Chemotherapy Exclusions: Patients enrolled in clinical trials.


2018-19 cohort 35 79 172 286


Numerator 3 6 6 15





% Performance 100% 100% 75.0% 88.2%

Comments Borders: The target was met Fife: The target was met

Lothian: The target was not met with a shortfall of 15% (2 cases) 1 patient died before maintenance, 1 patient had treatment postponed due to COVID 19.


2017-18 100.0% 100.0% 75.0% 84.2%

2018-19 100.0% 100.0% 75.0% 88.2%

% Target 90% 90% 90% 90%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% P

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QPI 13 Maintenance Therapy for FLLymphoma 2017-19



32

QPI 14 Clinical Trial and Research Study Access Target =15%

Proportion of patients with lymphoma who are consented for a clinical trial/research study. Numerator Number of patients diagnosed with lymphoma consented for a clinical trial/research study. Denominator All patients diagnosed with Lymphoma, average 5 year incidence from Cancer Registry (2014 – 2018)


Numerator 1 0 8 9


% Performance 2.9% 0% 4.3% 3.0%

Trial data from 2019 SCRN download

Clinical Trial/research studies 2019 Borders Fife Lothian SCAN

Cardiac Care 0 0 6 6

ENRICH 0 0 1 1

Cell Free DNA 0 0 1 1

Horizon -Understanding the impact of cancer diagnosis and treatment

1 0 0 1

There are currently no first line treatment trials for the main lymphoma subgroups.



33

Age Distribution


16-19 years 0 1 1 2

20-24 0 0 8 8

25-29 0 1 5 6

30-34 0 1 6 7

35-39 1 1 3 5

40-44 1 3 7 11

45-49 0 4 6 10

50-54 1 4 11 16

55-59 2 10 14 26

60-64 2 9 20 31

65-69 4 10 18 32

70-74 5 14 20 39

75-79 7 9 26 42

80-84 7 6 14 27

>85 5 6 13 24

Total 35 79 172 286

% Age Distribution


16-19 years 0.0% 1.3% 0.6% 0.7%

20-24 0.0% 0.0% 4.7% 2.8%

25-29 0.0% 1.3% 2.9% 2.1%

30-34 0.0% 1.3% 3.5% 2.4%

35-39 2.9% 1.3% 1.7% 1.7%

40-44 2.9% 3.8% 4.1% 3.8%

45-49 0.0% 5.1% 3.5% 3.5%

50-54 2.9% 5.1% 6.4% 5.6%

55-59 5.7% 12.7% 8.1% 9.1%

60-64 5.7% 11.4% 11.6% 10.8%

65-69 11.4% 12.7% 10.5% 11.2%

70-74 14.3% 17.7% 11.6% 13.6%

75-79 20.0% 11.4% 15.1% 14.7%

80-84 20.0% 7.6% 8.1% 9.4%

>85 14.3% 7.6% 7.6% 8.4%

SCAN % Age Distribution 2014-19

2014-15 2015-16 2016-17 2017-18 2018-19

<50 years 2.5 18.5 13.2 18.2 17.1

50-59 years 10.5 11.6 16.5 14.0 14.7

60-69 years 23.1 25.3 22.1 26.7 22.0

70-79 years 33.8 21.9 30.0 26.0 28.3

80 + years 15.7 22.6 18.2 15.0 17.8



34

% Age Distribution Graph 2018-19

% Age Distribution for SCAN 2014-19

0 1.3% 0.6% 0.7%0 1.3% 7.6% 4.9%2.9% 2.5%5.2%

4.2%2.9%

8.9%

7.6%7.3%

8.6%

17.7%14.5%

14.7%17.1%

24.1% 22.1%22.0%

34.3%

29.1% 26.7% 28.3%

34.3%

15.2% 15.7% 17.8%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


% p

ati

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ts

Health Board

% Age DistributionLymphoma 2018-19

>80yrs

70-79yrs

60-69yrs

50-59yrs

40-49yrs

30-39yrs

20-29yrs

16-19yrs

2.5%

18.5%13.2%

18.2% 17.1%10.5%

11.6%16.5%

14.0% 14.7%23.1%

25.3% 22.1%26.7%

22.0%

33.8%21.9% 30.0%

26.0%28.3%

15.7% 22.6% 18.2% 15.0% 17.8%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2014-15 2015-16 2016-17 2017-18 2018-19

% p

atie

nts

Year of Diagnosis

% Age Distribution LymphomaSCAN 2014-19

80 + years

70-79 years

60-69 years

50-59 years

<50 years



35

Summary of all Lymphomas 2018-19

Breakdown of all Lymphomas by morphology Borders Fife Lothian SCAN

Angioimmunoblastic T cell 2 0 4 6

B-cell Lymphoma, Unclassifiable, with Features Indeterminate between Diffuse Large B-cell Lymphoma and Burkitt Lymphoma 0 0 2 2

Classical Hodgkin Lymphoma 0 3 20 23

Composite Hodgkin & Non Hodgkin Lymphoma 2 0 2

Diffuse Large B Cell Lymphoma 10 24 67 101

Burkitt’s Lymphoma 1 0 2 3

EBV Positive DLBCL of the Elderly 0 0 2 2

Extranodal Marginal Zone Lymphoma of MALT 1 2 4 7

Follicular Lymphoma 1 4 7 12

Follicular Lymphoma Grade 1 1 4 4 9

Follicular Lymphoma Grade 2 3 4 11 18

Follicular Lymphoma Grade 3A 3 1 1 5

Follicular Lymphoma Grade 3B 0 0 1 1

Large B cell Lymphoma arising in HHV8 associated Multicentric Castleman’s Disease 0 0 4 4

Lymphocyte Rich Classical Hodgkin Disease 1 0 0 1

Lymphoplasmacytic Lymphoma 4 11 8 23

Malignant Lymphoma NHL NOS 1 4 0 5

Malignant Lymphoma, Not Otherwise Specified 0 2 0 2

Mantle Cell 2 4 7 13

Mixed Cellularity Classical Hodgkin Lymphoma 0 4 1 5

Mycosis Fungoides 0 1 0 1

Nodular Lymphocyte Predominant Hodgkin Lymphoma 0 0 3 3

Nodal Marginal Zone 1 1 1 3

Nodular Sclerosis Classical Hodgkin Lymphoma 0 3 1 4

Peripheral T-Cell Lymphoma, Unspecified 1 0 10 11

Primary Mediastinal (Thymic) Large B-cell Lymphoma 0 1 1 2

Primary Cutaneous DLBCL, Leg type 0 0 1 1

Sezary Syndrome 0 0 1 1

Splenic B-cell Lymphoma/Leukaemia, Unclassifiable 0 0 2 2

Splenic B-Cell Marginal Zone Lymphoma 2 4 6 12

T-cell Histiocyte rich Large B cell Lymphoma 1 0 1 2

Total 35 79 172 286



36

Lymphoma QPI Attainment Summary table 2016-2018 BGH Fife Lothian SCAN

Target % Yr4 Yr5 Yr4 Yr5 Yr4 Yr5 Yr4 Yr5

QPI1 Radiological Staging

Prior to treatment 95 96.0% 100% 95.2% 98.1% 96.4% 94.7% 96.0% 96.0%

Within 2 wks of request 90 91.7% 91.7% 76.7% 84.3% 76.6% 80.4% 78.5% 83.0%

Reported within 3 wks 90 NA 91.7% NA 98.0% NA 91.6% NA 93.1%

QPI 2 Treatment Response 90 80.0% 91.7% 78.3% 89.5% 89.9% 83.9% 85.4% 85.9%

QPI 3 PET CT Staging for patients with HL treated with curative intent

Prior to treatment 95 100% 100% 90.0% 100% 82.6% 83.3% 87.2% 88.9%

Within 2wks of request 95 83.3% 100% 88.9% 92.3% 78.9% 72.0% 82.4% 80.0%

Reported within 3 wks 95 NA 100% NA 100% NA 88.0% NA 92.5%

QPI 4 Cytogenetic Testing

Before treatment 60 83.3% 63.6% 33.3% 45.0% 82.0% 59.7% 67.4% 57.3%

Within 3 wks of treatment

85 100% 100% 55.6% 60.0% 92.0% 90.3% 82.0% 85.4%

QPI 5 Reviewed by MDT 90 97.4% 100% 86.5% 88.9% 88.6% 87.9% 89.2% 89.5%

QPI 6 DLBCL and FL treated with anti B cell monoclonal antibody therapy

95 100% 100% 100% 100% 100% 100% 100% 100%

QPI 10 Primary Cutaneous Lymphoma reviewed by MDT

95 50.0% NA 100% 100% 100% 100% 85.7% 100%

QPI 11 Hepatitis and HIV status 95 100% 95.8% 87.5% 92.2% 98.8% 96.6% 94.9% 95.5%

QPI 12 Treatment response in HL

After 2 cycles 80 NA 0% NA 44.4% NA 81.3% NA 65.4%

Reported within 3 days 80 NA NA NA 100% NA 30.8% NA 47.1%

QPI13 Maintenance therapy for Follicular Lymphoma

90 NA 100% NA 100% NA 75.0% NA 84.2%

QPI14 Clinical trial and research study access 15 0% 0% 0% 1.3% 5.2% 26.3% 3.3% 16.9%

Target met Target not met No data available

Year 4 - 2016-17 Year 5 - 2017-18

lymphoma 2018 - 2019 comparative audit report

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