Frequency
Invasive Cervical Cancer Audit V. Mistry, S. Rajkumar, G. Lane, G. Majeed Guy’s and St Thomas’ NHS Founda8on Trust, London, UK Graph 2
Results
The NHS Cervical Screening Programme (NHSCSP) in England provides screening to approximately 14 million women. Due to its success, cervical cancer is regarded as a preventable disease, and the development of invasive cancer considered an adverse event requiring inves8ga8on. Since April 2007, the NHSCSP has conducted an annual na8onwide audit using data from regional Quality Assurance Reference Centres (QARCs). This acts as a quality control tool by highligh8ng deficiencies in the screening process and providing informa8on to healthcare professionals in order to guide improvement. Furthermore, as part of the Duty of Candour, it is a requirement that all cervical cancer pa8ents are offered the findings of a review into their screening history. Unfortunately, this na8onwide audit does not present the data at a local NHS Trust level; as such, it is difficult for individual units to obtain applicable learning points.
1) 20 pa8ents were diagnosed with invasive cervical carcinoma, with 18 (90%) being of the squamous subtype (graph 1). 2) 9 pa8ents (45%) were diagnosed via the NHSCSP; 8 of these had an Interna8onal Federa8on of Gynecology and Obstetrics (FIGO) stage ≤1B. The remaining 11 pa8ents were diagnosed following presenta8on with symptoms; only 2 had a FIGO stage ≤1B (table 1 and graph 2). 3) NHSCSP compliance was: 20% complete, 40% incomplete and 40% never had a smear (graph 3). FIGO stage ≥3B at diagnosis was only seen in those with incomplete or no screening history. Possible reasons for screening non-‐compliance can be seen in table 2. 4) All pa8ents were discussed at a mul8disciplinary mee8ng (MDM) and all recommended treatments were appropriate for disease stage. 5) Mortality rate was 10%. Characteris8cs of those that died can be seen in table 3. 6) Disclosure lelers were offered to 17 pa8ents (85%). 3 accepted a review of their NHSCSP screening history, and of these, 2 had cytological undercall at some point during their screening. Graph 1
3B
8
3A 6
2B
4
2A
2
1B1 1A1 Screen detected
Graph 3
Pathway
Opportunis8c symptoms
Screening compliance vs FIGO stage at diagnosis
9
4B
8
4A
7
20 18 16 14 12 10 8 6 4 2 0
3B
6
3A
5 4
2B
3
2A
2
1B1
1
1A1
0
Methods Table 1
4A
0
Cervical carcinoma histology
Squamous
Retrospec8ve study of all pa8ents diagnosed with invasive cervical carcinoma at Guy’s and St Thomas’ NHS Founda8on Trust (London, England) between 1st January to 31st December 2014. Informa8on was sought from pa8ents’ medical notes, the Trust’s Electronic Pa8ent Record (EPR) soWware and the Na8onal Health Authority Informa8on System (NHAIS) via the ‘Open Exeter’ database. Data were collected onto bespoke proformas and analysed using MicrosoW Excel for Mac 2011 (Redmond, USA).
4B
10
Frequency
To conduct an equivalent NHSCSP audit of invasive cervical cancer in pa8ents at a single gynaecological-‐oncology Ter8ary Referral Centre in central London. The specific objec8ves were to determine: 1) Incidence of invasive cervical cancer 2) Factors contribu8ng to cervical cancer development 3) Standards of management once diagnosis is established 4) Cervical cancer mortality rate 5) If cervical cancer pa8ents were offered the findings of a review into their screening history
Frequency
Aims
Pathway of diagnosis vs FIGO stage at diagnosis
12
Frequency
Introduc>on
Histological type
Symptoms at presenta>on
Irregular vaginal bleeding
Complete
Adenocarcinoma
Incomplete
Never
Compliance
Frequency 4
Table 2 Possible reasons for non-‐compliance
(not mutually exclusive)
Frequency
Non-‐UK na8onal
4
Civil partnership
2
Psychiatric comorbidity
2
Post-‐menopausal bleeding
2
Post-‐coital bleeding
2
Abdominal pain
2
Drug use
1
Intermenstrual bleeding
1
Nursing home resident
1
Table 3 Characteris>cs of pa>ents that died
Results
Age
>65 years
FIGO stage at diagnosis
4A & 4B
Pathway of diagnosis
Symptoms
Cervical screening history
Never
Management
Pallia8ve
Conclusions Pa8ents with a less advanced stage of cervical cancer at diagnosis tend to be those who are asymptoma8c, screen-‐detected and who have complete compliance with the NHSCSP; this highlights that the NHS Cervical Screening Programme works. Despite this, only 1 in 5 women adhered to the recommended screening intervals; however there appear to be characteris8cs in common to those with poor compliance. Pa8ents’ acceptance of a review of their screening history is low; although upon disclosure of the review, it was shown that cytological undercall does occur. Even though the mortality rate appears high, we are unable to interpret this due to the small number of pa8ents included in this audit.
Recommenda>ons 1) Target pa8ents with poor compliance and those with characteris8cs that may pre-‐dispose them to incomplete screening 2) Ensure standards within cytology, colposcopy and histology to reduce undercall and subsequent inappropriate ac8on 3) The results of the NHSCSP screening history review should be more accessible in order to aid data collec8on for audits at a local level 4) Re-‐audit in 1 year (2015 cohort)
Acknowledgements The authors would like to thank the following members of the mul8disciplinary team, without whom the above audit would not have occurred: Mr Ali Kubba, Mr Rahul Nath, Mr Gautam Mehra, Helen Eageling and Marian DeVries.
20th – 22nd June 2016
Results
The NHS Cervical Screening Programme (NHSCSP) in England provides screening to approximately 14 million women. Due to its success, cervical cancer is regarded as a preventable disease, and the development of invasive cancer considered an adverse event requiring inves8ga8on. Since April 2007, the NHSCSP has conducted an annual na8onwide audit using data from regional Quality Assurance Reference Centres (QARCs). This acts as a quality control tool by highligh8ng deficiencies in the screening process and providing informa8on to healthcare professionals in order to guide improvement. Furthermore, as part of the Duty of Candour, it is a requirement that all cervical cancer pa8ents are offered the findings of a review into their screening history. Unfortunately, this na8onwide audit does not present the data at a local NHS Trust level; as such, it is difficult for individual units to obtain applicable learning points.
1) 20 pa8ents were diagnosed with invasive cervical carcinoma, with 18 (90%) being of the squamous subtype (graph 1). 2) 9 pa8ents (45%) were diagnosed via the NHSCSP; 8 of these had an Interna8onal Federa8on of Gynecology and Obstetrics (FIGO) stage ≤1B. The remaining 11 pa8ents were diagnosed following presenta8on with symptoms; only 2 had a FIGO stage ≤1B (table 1 and graph 2). 3) NHSCSP compliance was: 20% complete, 40% incomplete and 40% never had a smear (graph 3). FIGO stage ≥3B at diagnosis was only seen in those with incomplete or no screening history. Possible reasons for screening non-‐compliance can be seen in table 2. 4) All pa8ents were discussed at a mul8disciplinary mee8ng (MDM) and all recommended treatments were appropriate for disease stage. 5) Mortality rate was 10%. Characteris8cs of those that died can be seen in table 3. 6) Disclosure lelers were offered to 17 pa8ents (85%). 3 accepted a review of their NHSCSP screening history, and of these, 2 had cytological undercall at some point during their screening. Graph 1
3B
8
3A 6
2B
4
2A
2
1B1 1A1 Screen detected
Graph 3
Pathway
Opportunis8c symptoms
Screening compliance vs FIGO stage at diagnosis
9
4B
8
4A
7
20 18 16 14 12 10 8 6 4 2 0
3B
6
3A
5 4
2B
3
2A
2
1B1
1
1A1
0
Methods Table 1
4A
0
Cervical carcinoma histology
Squamous
Retrospec8ve study of all pa8ents diagnosed with invasive cervical carcinoma at Guy’s and St Thomas’ NHS Founda8on Trust (London, England) between 1st January to 31st December 2014. Informa8on was sought from pa8ents’ medical notes, the Trust’s Electronic Pa8ent Record (EPR) soWware and the Na8onal Health Authority Informa8on System (NHAIS) via the ‘Open Exeter’ database. Data were collected onto bespoke proformas and analysed using MicrosoW Excel for Mac 2011 (Redmond, USA).
4B
10
Frequency
To conduct an equivalent NHSCSP audit of invasive cervical cancer in pa8ents at a single gynaecological-‐oncology Ter8ary Referral Centre in central London. The specific objec8ves were to determine: 1) Incidence of invasive cervical cancer 2) Factors contribu8ng to cervical cancer development 3) Standards of management once diagnosis is established 4) Cervical cancer mortality rate 5) If cervical cancer pa8ents were offered the findings of a review into their screening history
Frequency
Aims
Pathway of diagnosis vs FIGO stage at diagnosis
12
Frequency
Introduc>on
Histological type
Symptoms at presenta>on
Irregular vaginal bleeding
Complete
Adenocarcinoma
Incomplete
Never
Compliance
Frequency 4
Table 2 Possible reasons for non-‐compliance
(not mutually exclusive)
Frequency
Non-‐UK na8onal
4
Civil partnership
2
Psychiatric comorbidity
2
Post-‐menopausal bleeding
2
Post-‐coital bleeding
2
Abdominal pain
2
Drug use
1
Intermenstrual bleeding
1
Nursing home resident
1
Table 3 Characteris>cs of pa>ents that died
Results
Age
>65 years
FIGO stage at diagnosis
4A & 4B
Pathway of diagnosis
Symptoms
Cervical screening history
Never
Management
Pallia8ve
Conclusions Pa8ents with a less advanced stage of cervical cancer at diagnosis tend to be those who are asymptoma8c, screen-‐detected and who have complete compliance with the NHSCSP; this highlights that the NHS Cervical Screening Programme works. Despite this, only 1 in 5 women adhered to the recommended screening intervals; however there appear to be characteris8cs in common to those with poor compliance. Pa8ents’ acceptance of a review of their screening history is low; although upon disclosure of the review, it was shown that cytological undercall does occur. Even though the mortality rate appears high, we are unable to interpret this due to the small number of pa8ents included in this audit.
Recommenda>ons 1) Target pa8ents with poor compliance and those with characteris8cs that may pre-‐dispose them to incomplete screening 2) Ensure standards within cytology, colposcopy and histology to reduce undercall and subsequent inappropriate ac8on 3) The results of the NHSCSP screening history review should be more accessible in order to aid data collec8on for audits at a local level 4) Re-‐audit in 1 year (2015 cohort)
Acknowledgements The authors would like to thank the following members of the mul8disciplinary team, without whom the above audit would not have occurred: Mr Ali Kubba, Mr Rahul Nath, Mr Gautam Mehra, Helen Eageling and Marian DeVries.
20th – 22nd June 2016
