National Oesophago-Gastric Cancer Audit. Third Annual Report-Patient Summary
National Oesophago-Gastric Cancer Audit
Third Annual Report: Patient summary
The National Oesophago-Gastric Cancer Audit began in October 2006 with the aim of assessing the quality of care received by patients with oesophago-gastric (O-G) cancer in England and Wales. The Audit focused on patients diagnosed between 1 October 2007 and 30 June 2009.
Patient information was submitted to the Audit from:
- 152 (99 per cent) of the 154 NHS acute trusts in England that provide O-G cancer services
- all 13 Welsh NHS acute trusts.
English NHS trusts submitted clinical information for 16,264 patients. Welsh NHS trusts submitted clinical information for 1,015 patients.
In 2001, the Department of Health published guidance on improving outcomes for O-G Cancer patients. It recommended that curative surgical services were centralised into specialist cancer centres and that clinicians from different specialities, hospitals and professional backgrounds should work together as a coordinated multi-disciplinary team. A process of re-organisation care followed, and surgery for this type of cancer is now centralised to 43 large hospitals.
The risk of developing oesophago-gastric cancer increases with age, and it is also more common in men. Of the patients in the audit, two-thirds of the patients were male. The average age at diagnosis was 73 years. Only 1 in 10 were under 55 years.
Over the last 20 years, there has been a change in the pattern of oesophago-gastric cancer in England and Wales. The incidence of gastric (stomach) cancer has been falling, while the incidence of oesophageal cancer has increased. The most common form of stomach cancer is adenocarcinoma. Adenocarcinoma tumours also arise in the lower oesophagus and at the junction of the stomach, and form one of the common types of oesophageal cancer. The other distinctive form of oesophageal tumour is squamous cell.
In the Audit, 9,090 patients (52%) had a tumour in the lower third of the oesophagus or at the junction of the oesophagus and stomach. Another 5,307 (31%) had a stomach tumour.
The most effective treatment for individual patients is determined by how large the tumour has grown and whether that cancer has spread to other parts of the body. This is described as the stage of the disease, and is classified using the TNM system. This captures: the size and spread of the tumour (T), whether cancer cells have spread to lymph nodes (N), and whether the cancer has spread to another part of the body (M).
Metastases (M) are deposits of cancer that occur when the cancer has spread from the place in which it started to other parts of the body. These are commonly called secondary cancers. Disease in which this has occurred is known as metastatic disease.
Current guidelines recommend that all patients have a computed tomography (CT) scan of the chest and abdomen to determine the presence or absence of metastatic disease. However, a CT-scan may be of little clinical value amongst patients too frail to have a surgery to remove a tumour. Among the 17,279 patients, 15,393 (89 per cent) were reported as having a CT-scan as part of their staging investigations. Among patients who were potential candidates for surgical care, 95 per cent of patients underwent a CT-scan. This suggests that patients who would be suitable for curative care are having this key investigation. More recently, Positron Emission Tomography (PET)/CT-scans have been shown to improve the staging accuracy and have become more frequently used as resources have become available.
The combination of CT and Endoscopic Ultrasound (EUS) has been shown to have high levels of accuracy for staging oesophageal and junctional tumours. EUS is a medical procedure in which a probe is inserted into the oesophagus and then uses ultrasound to obtain images of the tumour. EUS is recommended to estimate the size of the tumour if a patient is sufficiently fit to undergo curative treatment and there is no evidence of widespread or metastatic disease on the CT scan.
90 per cent of patients with a tumour of the oesophagus or gastro-oesophageal junction (oesophageal and junctional tumours) were recorded as having an EUS investigation or were allocated a T-stage prior to treatment. Accurate T-staging is difficult without performing an EUS, and this suggests higher levels of compliance with recommended staging practice.
Patients without metastatic disease are candidates for treatment with curative intent. In the Audit, 36 per cent of patients had a curative treatment plan. Surgery (with or without chemotherapy) was planned for over 80 per cent of patients with the exception of those with squamous cell carcinoma of the oesophagus. For patients with squamous cell carcinoma, 58 per cent had surgery (alone or with chemotherapy) as their planned treatment, while 38 per cent had definitive chemo-radiotherapy or radiotherapy.
Clinical trials have demonstrated improved survival when chemotherapy is combined with surgery for patients with larger tumours, particularly for oesophageal and junctional tumours. Services seem to have responded to this evidence, with 80% of patients having treatment plans that combine surgery and chemotherapy. The proportion of patients with stomach cancers planned to have combined therapy is much lower.
Among patients who had planned palliative care, the most common treatment was palliative chemotherapy or radiotherapy. The purpose of palliative care is to prevent or treat as early as possible the symptoms of the disease, side effects caused by treatment of the disease, and psychological, social and spiritual problems related to the disease. For patients with an oesophageal or junctional tumour, 53 per cent of patients were considered for either palliative chemotherapy or radiotherapy. The proportion for patients with stomach cancer was 37 per cent. There was some variation across the Cancer Networks in the use of palliative oncology, with the proportion of palliative patients intended to receive palliative chemo- or radiotherapy ranging from 34 to 54 per cent.
Information on 2,200 oesophagectomies (operations to remove part of the oesophagus) and 1,412 gastrectomies (operations to remove part or all of the stomach) were submitted to the Audit.
The 30-day postoperative mortality rate for oesophagectomy and gastrectomy was 3.8 per cent and 4.5 per cent, respectively. This is approximately half the rate compared to 10 years ago.
Both types of operation may be performed using minimally invasive (MI) techniques, which is sometimes known as keyhole surgery. These techniques involve the use of laparoscopic instruments under the guidance of a camera inserted through several small (1-2cm) incisions rather than using a large incision characteristic of an open surgical approach. By reducing the injury associated with an open approach, MI operations are thought to reduce patient morbidity.
The use of minimally-invasive surgery is still in an early phase of adoption. Postoperative outcomes were similar for open and minimally-invasive procedures. For oesophagectomy, there was statistically significant difference in the rates of anastomotic leak (7.4 per cent for open and 10.5 per cent for minimally invasive procedures) but this did not translate into worse 30-day or 90-day mortality, rate of reoperation, or other complications (cardiac, respiratory, wound infection, etc). For patients undergoing gastrectomy, there were no statistically significant differences in complication rates between the open and minimally invasive approaches.
The Union Internacional Contra la Cancrum, UICC, staging system recommended that the minimum number of lymph nodes required for pathological staging after surgery are 6 for oesophageal cancer and 15 for gastric cancer. 96 per cent of oesophagectomies and 75 per cent of gastrectomies met these standards. Clinical guidelines also recommend monitoring whether the removed tissue from curative operations is free of tumour at its edges (margins). Longitudinal resection margins were positive for 6.4 per cent of oesophagectomies and 8.9 per cent of gastrectomies. The Audit has provided the first national figures for these pathology outcomes.
The audit received information on 3,995 patients who have palliative oncological care. Chemotherapy was the most common course of treatment, with 2,450 patients receiving this treatment. There were 1,171 courses of palliative radiotherapy and 374 courses of palliative chemo-radiotherapy.
Patients undergoing palliative chemotherapy were younger on average than patients undergoing palliative radiotherapy, with an average age of 65 years for palliative chemotherapy compared to 76 years for palliative radiotherapy. The average age of patients undergoing palliative chemo-radiotherapy was 66 years.
Palliative radiotherapy was well tolerated by the 1,171 patients recorded with this treatment, with 92 per cent completing their prescribed course. Only 53 per cent of the 2,450 patients receiving palliative chemotherapy completed the prescribed course. 16 per cent of these patients suffered acute chemotherapy toxicity and a further 10 per cent of patients chose to stop.
Endoscopic palliative therapies are treatments that aim to relieve symptoms, such as vomiting or swallowing difficulties. These therapies include stents, laser therapy and brachytherapy. A stent is a small tube that is inserted into the area of narrowing that then expands and relieves the blockage. Laser therapy is a technique that uses a laser to destroy the surface of the tumour and thereby relieve any blockage. Brachytherapy is a palliative treatment that involves inserting radioactive beads into the tumour; the radiation from these beads then slowly shrinks the tumour over time.
The most common endoscopic palliative therapy was a stent insertion, and made up 84 per cent of the 2,882 reported therapies. Other types of procedure (such as laser therapy) and brachytherapy were concentrated in particular Cancer networks. This may reflect incomplete data submission but it may also reflect variation in the availability of endoscopic palliative therapies.
For patients who had a stent inserted, the stent was placed successfully in 98 per cent of cases.
- 1. O-G cancer services should ensure that all patients who are candidates for curative treatment undergo a CT-scan plus an EUS (if oesophageal / upper junctional tumour) or a staging laparoscopy (if gastric / lower junctional tumour) and should improve the monitoring of their use.
- 2. All patients should be discussed with the specialist multidisciplinary team to reduce the observed variation in the proportion of patients selected for palliative oncology.
- 3. Surgeons should monitor their pathology outcomes in order to (1) ensure an adequate lymph node yield is obtained in every patient, and (2) to maintain low rates of positive longitudinal margins.
- 4. Minimally invasive surgery should continue to be introduced cautiously following the guidance published by the Association of Upper Gastro-Intestinal Surgeons.
- 5. Cancer Networks should improve access to brachytherapy.
- 6. Clinicians should use the data on inpatient complications to inform patients about risks of different curative and palliative treatments.
- 7. Multidisciplinary teams at NHS trusts should review the outcomes of their own patients and compare them with the national outcomes described in this report. Results of peer-comparisons should be incorporated into Cancer Network annual work plans.
National Oesophago-Gastric Cancer Audit. An audit of the care received by patients with Oesophago-Gastric Cancer in England and Wales. Third Annual Report. Leeds: The information Centre, 2011.