Network Activity and Clinical Audit Report

Transcription

1 Managed Clinical Network for Haemato-oncology Network Activity and Clinical Audit Report June 2010 Dr Pam McKay Lead Clinician Heather Wotherspoon Network Manager

2 Table of Contents ACKNOWLEDGEMENTS... 4 EXECUTIVE SUMMARY INTRODUCTION BACKGROUND TO THE MANAGEMENT OF HAEMATOLOGICAL MALIGNANCIES IN THE WEST OF SCOTLAND ACTIVITY OF THE NETWORK IN 2009/ CLINICAL MANAGEMENT GUIDELINES (CMGS) WEST OF SCOTLAND CANCER NETWORK (WOSCAN) CHEMOTHERAPY PROTOCOLS MULTI-DISCIPLINARY TEAM (MDT) MEETINGS CLINICAL AUDIT LIVING WITH CANCER EDUCATION EVENT CLINICAL AUDIT METHODOLOGY REGISTRATION OF ALL HAEMATOLOGICAL MALIGNANCIES: LYMPHOMA BASE DATA COLLECTION CLINICAL AUDIT RESULTS REGISTRATION OF ALL HAEMATOLOGICAL MALIGNANCIES ANALYSIS OF LYMPHOMA CASES DEMOGRAPHICS PATHOLOGY AND CLINICAL STAGE PLANNED TREATMENT OF HODGKIN LYMPHOMA (HL) PLANNED TREATMENT OF DIFFUSE LARGE B CELL LYMPHOMA (DLBCL) PLANNED TREATMENT OF FOLLICULAR LYMPHOMA SURVIVAL OF LYMPHOMA PATIENTS CONCLUSION, RECOMMENDATIONS AND NETWORK PRIORITIES 2010/ REFERENCES GLOSSARY OF TERMS AND ACRONYMS

3 Index to Tables and Figures Table No Table Title Page 1 Case ascertainment for non-hodgkin Lymphoma, Hodgkin lymphoma and acute leukaemia (2007 & 2008) Blood cancer registration by health board area (2007) Blood cancer registration by health board area (2008) Treatment choice for Hodgkin lymphoma (2007 & 2008) Chemotherapy treatment for Hodgkin lymphoma (2007 & 2008) Treatment choice for DLBCL (2007 & 2008) 21 7 Chemotherapy treatment for DLBCL (2007 & 2008) Treatment choice for follicular lymphoma (2007 & 2008) Chemotherapy treatment for follicular lymphoma (2007 & 2008) Comparison of 2 year survival figures for 2005 & 2006 with 2004 cohort Overall 2 year survival for lymphoma patients (2005 & 2006) Cause-specific 2 year survival for lymphoma patients (2005 & 2006). 27 Figure No Figure Title Page 1 Blood cancer registration in West of Scotland ( ) Distribution of Hodgkin lymphoma (left) and non-hodgkin lymphoma (right) by age in the West of Scotland 16 3 Distribution of Hodgkin lymphoma (left) and non-hodgkin lymphoma (right) by age in the United Kingdom Hodgkin lymphoma by subtype (2007 & 2008) Hodgkin lymphoma by clinical stage (2007 & 2008) 18 6 Non-Hodgkin lymphoma by subtype (2007 & 2008) 18 7 Diffuse large B cell lymphoma by clinical stage (2007 & 2008) Follicular lymphoma by clinical stage (2007 & 2008)

4 Acknowledgements This report has been prepared using clinical audit data collected by the Network audit staff on behalf of the Health Boards in Ayrshire and Arran, Forth Valley, Greater Glasgow and Clyde and Dumfries and Galloway in addition to clinical audit data provided by Lanarkshire Health Board. Sincere thanks to our Clinical Effectiveness colleagues throughout the region for supporting the Network staff. We would also like to thank the pathologists, clinicians and nursing staff who continue to register their cases with the network. Executive Summary This is the second report of the West of Scotland Haemato-oncology Managed Clinical Network (MCN). There are three main sections to this report; Network Activity, Clinical Audit and Network Objectives for 2010/2011. Network Activity: Key areas of development to note: Guidelines and Protocols: Clinical Management Guidelines (CMGs) are now available for the majority of haematological malignancies. Twenty-six regional chemotherapy protocols for the most commonly used regimens in haemato-oncology have now been developed. Multi-disciplinary Team (MDT) Meetings The Regional Lymphoma MDT meeting now includes patients with all haematological diagnoses. An audit evaluating the new Regional MDT process and participation at the Regional MDT meeting has been reported. Failure to refer to the Regional MDT meeting was a significant problem and participation at the meeting varied significantly throughout the region with only 5 of 12 sites participating in more than 50% of the meetings. In response to this, the MCN have reiterated the correct process to all clinicians and will repeat the audit in one year s time. Territorial Board Leads are aware of both issues and have been sent a full report with recommendations. A Regional Cutaneous Lymphoma MDT meeting was established in September

5 Clinical Audit Methodology for haemato-oncology clinical audit data collection has been reviewed and revised in collaboration with local NHS Boards to ensure that a robust and sustainable model of data collection is in place. Analyses is reported based on registration data for all haematological malignancies (excluding paediatric cases) diagnosed between 1 January 2007 and 31 December 2008, base clinical data for all lymphoma cases diagnosed during this period and survival analysis for lymphoma cases diagnosed between 1 January 2005 and 31 December 2006 (section 5). Patient Information A Guide to Fertility and Cancer Treatment in Haemato-Oncology Patients, has been produced and circulated throughout the Network. Neutropenic sepsis cards and immunocompromised patient cards were produced in April Moving Forward courses at the Beatson West of Scotland Cancer Centre (WOSCC) have been available to haemato-oncology patients throughout the West of Scotland since February Education Our first education event, Lymphoma Current Issues, took place in October Clinical Audit: Key findings: High level of case ascertainment for lymphoma and acute leukaemia across the region. Need to improve registration of haematological conditions not diagnosed by tissue biopsy. Network will review method of case capture and issue guidance to clinicians. Choice of initial treatment modality for Hodgkin Lymphoma across the Network is in concordance with the CMG. Good compliance with the CMG recommendations for choice of chemotherapy regimen in Hodgkin lymphoma. Choice of initial treatment modality for diffuse large B cell lymphoma across the Network complies with CMG recommendations and the figures from 2007 and 2008 demonstrate a more consistent chemotherapy practice across the region compared with the cohort reported previously (1). The proportion of patients with follicular lymphoma who initially enter a period of watchful waiting is similar to published data (2) and the current figures demonstrate a 5

6 This report indicates that it is possible to collect comprehensive, meaningful outcome data for common lymphoma subtypes for the West of Scotland region. These patients are treated in dedicated Haematology units in 17 different hospitals across the region. Data is collected on patients of all ages (excluding paediatric cases) with varied means of presentation and with a variety of coexistent medical problems which can influence the potential for delivery of treatment. Our outcome data for Hodgkin lymphoma, follicular lymphoma and diffuse large B cell lymphoma (accounting for 73% of all lymphoma registrations) is extremely reassuring when all the above factors are recognised. Network Objectives for 2010/2011: Key Network Objectives for 2010/2011 include MDTs, lymphoma follow-up, blood cancer diagnostics, Teenage Cancer Trust Unit and clinical audit MDTs: Regional: Ensure regional MDT recommendations are adhered to throughout 2010/2011 Local: Undertake a review of MDT practice across the region; identify gaps/areas for improvement; develop action plans to address any deficiencies identified Lymphoma follow-up: Undertake a review of literature/ best practice regarding lymphoma follow-up practices; review current follow-up practices across the region and compare with literature; identify areas for change; develop action plans to optimise efficiency and effectiveness. Blood Cancer Diagnostics: Establish an integrated diagnostic reporting system for liquid haematological malignancies in the West of Scotland: Develop diagnostic pathways for liquid haematological malignancies Explore options for implementing IT system to coordinate diagnostic tests/results Teenage Cancer Trust (TCT) Unit: Optimise use of regional TCT facilities for the management of haematological cancers in adolescents and young adults across WOSCAN. 6

7 Clinical Audit: Complete implementation of agreed model for effective collection, analysis and reporting of haemato-oncology data. Transfer collection and entry of acute leukaemia base data to GG&C audit department Draft list of key clinical issues in lymphoma for Quality Performance Indicator (QPI) development Review acute leukaemia and lymphoma follow-up datasets with a view to reducing data fields 7

8 1. Introduction This is the second report of the West of Scotland Haemato-oncology MCN. The previous report, issued May 2009, detailed the progress of the Network since its formation in August 2002 and presented clinical audit data on lymphoma cases diagnosed between 1 January 2004 and 31 December 2006 in addition to survival data on the 2004 cohort. This current report reviews the activity of the Network over the last year. reports the analysis of registration data on all haematological malignancies (excluding paediatric cases) diagnosed between 1 January 2007 and 31 December 2008, base clinical data on all lymphoma cases diagnosed during this period and survival analysis for lymphoma patients diagnosed between 1 January 2005 and 31 December highlights the key Network objectives for 2010/ Background to the Management of Haematological Malignancies in the West of Scotland The West of Scotland Haemato-oncology MCN includes 5 Health Board areas; Greater Glasgow & Clyde, Ayrshire & Arran, Lanarkshire, Forth Valley and Dumfries & Galloway and covers a population of 2.6 million. Membership includes 46 consultant haemato-oncologists, 2 clinical oncologists and a number of pathologists across multiple sites in addition to other professional groups involved in the multi-disciplinary care of patients with blood cancer (haematological cancer). Blood cancer encompasses a number of different haematological malignancies lymphoma, acute leukaemia, chronic leukaemia, multiple myeloma and other plasma cell dyscrasias, myeloproliferative disorders and myelodysplastic syndromes. Non-Hodgkin lymphoma (NHL), the leukaemias and multiple myeloma are in the 20 most commonly diagnosed cancers in the UK in 2006 (3). In Scotland, NHL was the 7 th most frequently diagnosed malignancy in 2007 with 472 males and 470 females registered (4). Hodgkin lymphoma (HL) and leukaemia are among the most common cancers diagnosed in teenagers and young adults (15-24 years) in Scotland and the UK (3). The incidence of some types of haematological malignancies e.g. NHL, myeloma, chronic lymphocytic leukaemia (CLL) is rising, partly due to the fact that these cancers are more 8

9 common with increasing age. The most striking rise is seen in NHL where the UK incidence increased by > 40% over the 20 year period from (5). The majority of haematological malignancies are treated locally. Tertiary referral is required for autologous and allogeneic stem cell transplantation and may be required for treatment of less common conditions e.g. acute lymphoblastic leukaemia (ALL) or for administration of highly intensive chemotherapy regimens. A six bedded Teenage Cancer Trust (TCT) Unit opened in the Beatson WOSCC in May Dr Nick Heaney was appointed in January 2010 as Consultant with an interest in Adolescents and Young Adults with Haematological Malignancies. This is a regionally funded appointment providing a regional service and is the first post of its kind in the UK. Consistency in practice can be achieved across the region by use of MCN approved CMGs, the use of regional chemotherapy protocols and discussion of all patients at MDT meetings. These were key areas of Network activity in 2009 and compliance with CMGs is reported in the Clinical Audit section of this report (page 13). 3. Activity of the Network in 2009/2010 The Haemato-oncology MCN has made considerable progress over the last year, moving forward a number of areas highlighted in Better Cancer Care, An Action Plan (6). 3.1 Clinical Management Guidelines (CMGs) West of Scotland CMGs for the management of patients with lymphoma have been available for many years, both regional (produced by the West of Scotland Lymphoma Group) and national (Scottish Consensus Papers produced by lymphoma leads in North, East and West of Scotland). The first MCN CMGs for lymphoma (Hodgkin Lymphoma, Diffuse Large B cell Lymphoma and Follicular Lymphoma) were produced in 2007 and updated in In addition, CMGs are now available for myeloproliferative disorders (chronic myeloid leukaemia, polycythaemia rubra vera, essential thrombocythaemia) and chronic lymphocytic leukaemia. CMGs for acute lymphoblastic leukaemia, acute myeloid leukaemia, myeloma, myelodysplasia and Waldenstrom s macroglobulinaemia are awaiting final approval by the Regional Prescribing Advisory Subgroup and Area Drugs and Therapeutics Committees. This represents a significant achievement, with CMGs now available for the majority of haematological malignancies. The Clinical Audit section reports compliance with the CMG recommendations for Hodgkin Lymphoma (HL), Diffuse Large B cell Lymphoma (DLBCL) and Follicular Lymphoma and allows us to assess consistency of practice across the region. 9

10 3.2 West of Scotland Cancer Network (WOSCAN) Chemotherapy Protocols Twenty-six regional protocols for the most commonly used regimens in haemato-oncology have now been developed and distributed throughout the network. Move to regional consistency will be facilitated when a chemotherapy electronic prescribing and administration system (CEPAS) is implemented across the region. This will enable the replacement of a paper based chemotherapy prescribing system to a uniform protocol driven electronic one that is accessible across WOSCAN. 3.3 Multi-disciplinary Team (MDT) Meetings The format of the Regional Lymphoma MDT meeting was changed in November The meeting was restricted to all new lymphoma patients not managed according to CMGs and problem lymphoma, CLL and myeloma cases. In March 2009, a further change was made to include patients with all haematological diagnoses and the previously separate monthly leukaemia MDT meeting was disbanded. These changes were made to allow discussion of more complex cases of all haematological malignancies across the region. A Regional Cutaneous Lymphoma MDT meeting was established in September 2009 to consolidate expertise in this rare condition and to facilitate clinico-pathological correlation. An audit was carried out to evaluate the first 6 months of the new Regional MDT process. Only 5 of 11 sites managed to follow the correct process for more than 50% of their cases. Failure to refer to the Regional MDT was a significant problem. In response to this, the MCN have reiterated the correct process to all clinicians and made them aware of a planned reaudit in one year s time. Participation at the Regional MDT meeting was also evaluated over a one year period (November 2008 to October 2009). This revealed a wide variation throughout the region with only 5 of 12 sites participating in more than 50% of the meetings. Four sites only linked into the meeting when presenting cases. Territorial Board Leads are aware of these issues which were highlighted at the Regional Cancer Advisory Group (RCAG) meeting in December 2009 and have been sent a full report with recommendations. 10

11 3.4 Clinical Audit The methodology for haemato-oncology clinical audit data collection has recently been reviewed and revised in collaboration with local NHS Boards. This change has been driven by a number of factors but predominantly by the need to ensure that a robust and sustainable model of data collection is in place, which is not reliant on non-recurring funding. To help ensure complete data collection, local audit resource has now been identified in NHS Ayrshire and Arran, NHS Greater Glasgow and Clyde, NHS Lanarkshire and NHS Forth Valley to supplement the part-time resource available within the Regional Cancer Network. Local audit staff in most Board areas now collect both waiting times and base data for lymphoma and acute leukaemia while regional Network staff collect follow-up data for these conditions in addition to chronic myeloid leukaemia (CML) base data. The benefit of this approach is that it ensures that local audit staff and management are fully sighted on current local issues and have local control of their data. At present, no local resource has been identified in NHS Dumfries and Galloway. Discussions are currently ongoing at local health board level. 3.5 Living with Cancer Patient Information 1. A regional audit of information given to patients with haematological malignancies was carried out. Two main areas requiring further work were identified: Poor recording of information given to patients - a summary sheet has now been produced and distributed throughout the region via the Nursing Network. This will facilitate consistency in approach to information given to patients across the region. Inconsistent information on fertility - a booklet, A Guide to Fertility and Cancer Treatment in Haemato-Oncology Patients, has been produced in conjunction with Dr Helen Lyall, Assisted Conception Unit, Glasgow Royal Infirmary. The booklet was circulated through the Nursing Network in January Neutropenic sepsis cards and immunocompromised patient cards were produced in April These wallet sized cards were produced to provide further information to medical staff who may not be familiar with these conditions and provide relevant contact details. The cards also provide the patient with a useful reminder of symptoms requiring medical attention. 11

12 Moving Forward Moving Forward courses at the Beatson WOSCC have been available to haematooncology patients throughout the West of Scotland since February The aim is to run 4 to 5 courses per year. These are self-help courses which cover a number of areas relating to the physical, emotional, practical and financial needs of the patient and their carers. The importance of this support is highlighted in Better Cancer Care, An Action Plan (6) which refers to survivorship and the support required from healthcare workers in both the statutory and voluntary sector to empower patients to move forward following their diagnosis and treatment of cancer. 3.6 Education Event Our first education event, Lymphoma Current Issues, took place on 28 October The meeting included presentations from colleagues from a variety of disciplines including radiology, pathology, ENT and gynaecology emphasising the importance of networking. This was very well attended and the feedback was excellent. 4. Clinical Audit Methodology 4.1 Registration of all Haematological Malignancies: Lymphomas are registered via the individual pathologists throughout WOSCAN Acute leukaemias and other lymphoproliferative disorders are registered from flow cytometry reports sent to the Network from laboratories at Crosshouse and Gartnavel General Hospital. MDS, MPD and plasma cell dyscrasias are registered by clinicians 4.2 Lymphoma Base Data Collection Lymphoma audit data for this report was collected by the Network staff with local support from clinical audit facilitators in Lanarkshire and Ayrshire and Arran. Data collection from all 5 Health Boards (Ayrshire and Arran, Dumfries and Galloway, Forth Valley, Greater Glasgow & Clyde and Lanarkshire) was in line with the nationally agreed minimum dataset for lymphoma. Data was primarily gathered from case notes with electronic systems and MDT meeting reports used to fill any gaps. The collected data was entered onto a centralised MS Access database. The data has been verified, analysed and reported in line with the agreed Network Information Governance processes. The majority of the data are presented on a West of Scotland basis. However, where numbers allow, the analysis has been presented by Health Board subgroups. 12

13 In contrast to the more established Networks e.g. Breast and Colorectal, the Haematooncology MCN do not currently have nationally agreed Quality Performance Indicators (QPIs) against which to report performance. Regional CMGs for HL, DLBCL and follicular lymphoma have been developed and have been used by the MCN to evaluate compliance as reported in the results section. The Scottish Cancer Taskforce Quality Subgroup is taking forward the development of national QPIs for all cancers. In due course, QPIs for haematological cancers, beginning with lymphoma, will be developed. This will enable the network to assure the quality of care provided and to drive continuous improvement. 5. Clinical Audit Results The following analyses is based on registration data for all haematological malignancies (excluding paediatric cases which are registered through the Children and Teenagers Scottish Cancer Network (CATSCAN)) diagnosed between 1 January 2007 and 31 December 2008, base clinical data on all lymphoma cases diagnosed during this period and survival analysis for lymphoma patients diagnosed between 1 January 2005 and 31 December Registration of all Haematological Malignancies 1185 and 1125 blood cancers were registered in 2007 and 2008 respectively with lymphoma accounting for almost half the number of cases. A total of 418 and 453 cases of NHL (including primary cutaneous NHL) were recorded in 2007 and In both years, 73 cases of HL were registered. A total of 94 and 109 cases of acute leukaemia (AML/ALL) were recorded in 2007 and 2008 respectively. Case ascertainment was calculated by comparing the number of new cases of NHL, HL and acute leukaemia identified by the audit process to the expected number of NHL, HL and acute leukaemia in patients 15 years based on average incidence figures for 2003 to 2007 (7) (Table 1). Table 1: Case ascertainment for non-hodgkin lymphoma, Hodgkin lymphoma and acute leukaemia (2007 & 2008) Non-Hodgkin lymphoma (NHL) Hodgkin lymphoma (HL) Acute leukaemia (AML/ALL) N Expected number of cases Case ascertainment (%) N Expected number of cases Case ascertainment (%)

14 Good case ascertainment is a quality marker of the audit process and the figures in Table 1 are very reassuring. With reference to lymphoma, it is likely that the percentage is over 100 due to the fact that the number of lymphoma cases diagnosed has been on the increase in recent years. In contrast, the high case ascertainment figure for acute leukaemia is not attributable to an increase in the number of cases diagnosed but is due to the fact that more cases were registered through audit than in cancer registration. Figure 1 illustrates how the registrations for 2007 and 2008 compare with those from the first three years of the Network. Over the five year period, the number of lymphomas has risen, the number of acute leukaemias has been relatively stable whereas the numbers of myelodysplastic syndrome (MDS), myeloproliferative disorders (MPD), other lymphoproliferative disorders (OLD) and plasma cell dyscrasias (PCD) have fallen. It would appear that this is more likely due to a fall in the number of cases of MDS, MPD, OLD and PCD being registered with the Network rather than a real decrease in the number of new cases diagnosed. The decrease in the number of PCDs may reflect a move away from recording Monoclonal Gammopathy of Uncertain Significance (MGUS). Figure 1: Blood cancer registration in West of Scotland ( ) 14

15 The number of cases by disease type and health board area is illustrated in Tables 2 and 3. Table 2: Blood cancer registration by health board area (2007) Disease Type Ayrshire & Arran Argyll & Clyde Forth Valley Lanark shire Greater Glasgow Dumfries & Galloway Private or Not recorded AL Lymph MDS MPD OLD PCD Total N= Table 3: Blood cancer registration by health board area (2008) Disease Type Ayrshire & Arran Argyll & Clyde Forth Valley Lanark shire Greater Glasgow Dumfries & Galloway Private or Not recorded AL Lymph MDS MPD OLD PCD Total N= Comments: There is good case ascertainment with regard to HL, NHL, AML/ALL. The commitment of the pathologists within the Network is central to achieving the high level of case ascertainment for lymphoma. With data collection now devolved to individual health boards, it is important that this high level of case ascertainment is maintained in order to be able to assess the care provided to patients in the region. Need to improve registration of conditions not diagnosed by tissue biopsy. Review method of case capture e.g. bone marrow reports. 15

16 5.2 Analysis of Lymphoma Cases 1033 lymphomas were diagnosed between 1 January 2007 and 31 December 2008: 146 HL (14%) 830 NHL (81%) 41 primary cutaneous NHL (4%) 16 other (not recorded, mastocytosis, histiocyte and dendritic cell neoplasm) (1%) Demographics HL is more common in males (61%) than females (39%) whereas NHL occurs with almost equal frequency between males (51%) and females (49%). Figure 2 illustrates the distribution of HL and NHL by age group. The graph for HL shows a bimodal distribution, with peaks at years and years. NHL continues to be primarily a disease of the elderly with 70% of cases > 60 years. Figure 2: Distribution of Hodgkin lymphoma (left) and non-hodgkin lymphoma (right) by age in the West of Scotland Note: HL graph does not include the age categories 0-4, 5-9 and as there were no cases in these categories. NHL graph does not include the age categories 0-4 and 5-9 as there were no cases in these categories. Comparison of West of Scotland data with UK figures (includes England, Wales, Scotland and N. Ireland) for 2006 obtained from Cancer Research UK (8) show a similar picture with a bimodal age distribution in HL and an increase in NHL with advancing age. UK data also demonstrates that HL is more common in males for most age groups. However, in contrast to the very similar sex distribution seen in NHL cases in the West of Scotland, the UK figures illustrate that the disease is more common in males for all age groups with the exception of those cases age 80+years (Figure 3). 16

17 Figure 3: Distribution of Hodgkin lymphoma (left) and non-hodgkin lymphoma (right) by age in the United Kingdom Pathology and Clinical Stage Figure 4 illustrates the pathological subtypes of HL. Nodular sclerosing HL accounted for just over half the cases (56%). 8% of cases were Nodular Lymphocyte Predominant HL (NLPHL) which concurs with current figures in the literature (9). Figure 4: Hodgkin lymphoma by subtype (2007 & 2008) Lymphocyte Depleted Classical HL 1% Unclassifiable HL 2% Mixed Cellularity Classical HL 31% Nodular Sclerosis Classical HL 56% Lymphocyte Rich Classical HL 2% Nodular Lymphocyte Predominant HL 8% 49% of patients with HL presented with advanced stage disease (III or IV) with only 17% presenting with stage I disease (Figure 5). 17

18 Figure 5: Hodgkin lymphoma by clinical stage (2007 & 2008) Stage 1 17% Stage 2 32% NR 2% Stage 4 23% Stage 3 26% NR = not recorded Figure 6 illustrates the pathological subtypes of NHL. DLBCL accounted for almost half the cases (48%), with follicular NHL and other accounting for 23% and 29% of the cases respectively. Figure 6: Non-Hodgkin lymphoma by subtype (2007 & 2008) DLBCL 48% Other 29% Follicular lymphoma 23% 51% of patients with DLBCL presented with advanced stage disease (III or IV), with only 21% of patients having a single site of disease at presentation (Figure 7). 18

19 Figure 7: Diffuse large B cell lymphoma by clinical stage (2007 & 2008) NR 8% Stage 1 21% Stage 2 20% Stage 4 32% Stage 3 19% NR = not recorded As expected, a higher percentage of patients with follicular NHL presented with stage III or IV disease (58%) (Figure 8). Similar to DLBCL, 22% of patients with follicular NHL presented with stage I disease. Figure 8: Follicular lymphoma by clinical stage (2007 & 2008) NR 4% Stage 1 22% Stage 2 16% Stage 4 33% Stage 3 25% NR = not recorded 19

20 5.2.3 Planned Treatment of Hodgkin lymphoma (HL) Table 4 details the treatment given to newly diagnosed HL patients in 2007 and % of HL patients received chemotherapy. During the 2 year period, 8 patients received radiotherapy alone. Other treatment included supportive care, watchful waiting, surgery, died before treatment and withdrawal of immunosuppression. Table 4: Treatment choice for Hodgkin lymphoma (2007 & 2008) N % N % Chemotherapy Radiotherapy alone Other Not recorded N = The CMG for HL recommends radiotherapy alone for: Low bulk, stage 1A lymphocyte predominant Hodgkin Lymphoma (NLPHL) Clinical stage 1A HL (mass < 5cm), PET scan confirming localised disease and unfit for chemotherapy Review of the 8 cases receiving radiotherapy only showed that 4 patients were stage 1A NLPHL, 1 patient stage IIA NLPHL and 3 cases were elderly patients with stage 1A classical HL (2 nodular sclerosing HL, 1 mixed cellularity HL). Comment: Choice of initial treatment modality for HL cases across the Network therefore appears to be in concordance with the CMG. The type of chemotherapy administered is detailed in Table 5. The CMG for HL recommends ABVD chemotherapy as first line treatment in all patients except those who are elderly/frail or have a poor performance status where alternatives eg ChlVPP are suggested. Table 5: Chemotherapy treatment for Hodgkin lymphoma (2007 & 2008) Chemotherapy N % N % ABVD/AVD PVACE-BOP Other chemotherapy N =

21 Treatment across the West of Scotland is extremely consistent with ABVD/AVD administered in 88% and 93% of cases in 2007 and 2008 respectively. Four patients were treated with AVD alone during this 2 year period. Three patients were elderly with multiple co-morbidities and one patient had underlying respiratory problems. Aggressive upfront chemotherapy regimens e.g. PVACE-BOP are less commonly used, possibly reflecting the practice of early interim PET scanning to determine if therapy should be escalated. Ten patients received other types of chemotherapy (5 ChlVPP, 2 VEPEMB in SHIELD study (now closed), 1 VEPEMB, 1 BEACOPP (high Hasenclever score) and 1 DHAP (congenital cardiac disease)). Comments: There is good compliance with the CMG recommendations for choice of chemotherapy regimen in HL. Until there is good evidence demonstrating similar efficacies of AVD compared with ABVD (currently being addressed in NCRI RAPID and RATHL studies), ABVD remains standard first line treatment. There is good evidence to suggest interim PET predicts outcome (10, 11). However the benefits of escalation of treatment is not proven and is currently being addressed in NCRI RATHL Study (opened August 2008) Planned Treatment of Diffuse Large B Cell Lymphoma (DLBCL) The CMG for DLBCL recommends chemotherapy as the initial treatment of choice. Table 6 details the treatment given to newly diagnosed DLBCL patients in 2007 and Table 6: Treatment choice for DLBCL (2007 & 2008) N % N % Chemotherapy Radiotherapy alone Other Not recorded N = % and 87% of DLBCL patients received chemotherapy in 2007 and 2008 respectively. Only 4 patients received radiotherapy alone during the 2 year period; 2 of these patients were not fit for intensive chemotherapy; 1 patient had primary CNS lymphoma and was only fit for palliative radiotherapy; the reason for not administering chemotherapy in 1 patient is 21

22 unknown but the patient was elderly with stage 1 disease. Other treatment included supportive care, watchful waiting, surgery, died before treatment, withdrawal of immunosuppression and refusal of treatment. Comment: Choice of initial treatment modality for DLBCL across the Network appears to comply with the CMG. DLBCL CMG recommendation chemotherapy regimen: R-CHOP as first line therapy R-CODOX-M/IVAC consider if high IPI (3-5) in younger, fit patients* R-GCVP consider if impaired ejection fraction or other co-morbidities in which anthracyclines should be avoided* (* in context of current NCRI clinical trials) The type of chemotherapy administered is detailed in Table 7. Table 7: Chemotherapy treatment for DLBCL (2007 & 2008) Chemotherapy N % N % Rituximab alone CHOP R-CHOP R-CEOP Other chemotherapy + Rituximab Other chemotherapy - Rituximab N = % of patients in 2007 and 2008 received R-CHOP. Only 8 patients over the 2 year period were given CHOP alone. These patients were clinically unwell at the time of presentation and died soon after treatment was initiated. Comparison of these figures with the data previously presented (1) shows a clear increase in the use of R-CHOP since data collection began in In 2004, 56% of chemotherapy was R-CHOP rising to 78% in 2005 and 75% in There was a corresponding decrease in the use of CHOP (23% in 2004 falling to 3% and 5% in 2005 and 2006 respectively). Comment: The figures from 2007 and 2008 demonstrate a more consistent chemotherapy practice across the region in compliance with the CMG recommendations. 22

23 5.2.5 Planned Treatment of Follicular Lymphoma The CMG for follicular NHL recommends: Stage 1, small volume disease - involved field radiotherapy Asymptomatic, low bulk, no marrow failure - watch & wait or NCRI trial of Rituximab versus Watch and Wait (now closed) Symptomatic, bulk, marrow failure chemotherapy Table 8: Treatment choice for follicular lymphoma (2007 & 2008) N % N % Chemotherapy Watchful waiting Radiotherapy alone Other NR N = Table 8 details the treatment given to newly diagnosed follicular NHL cases in 2007 and In 2007 and 2008, 53% and 51% of patients received chemotherapy. Almost one third of patients entered a period of watchful waiting which is very similar to the figures from the cohort reported previously (1). 22 patients received radiotherapy alone during the 2 year period. Other treatment included supportive care, surgery, died before treatment, withdrawal of immunosuppression and refusal of treatment. Comment: The proportion of patients who initially enter a period of watchful waiting is similar to published data (1, 2). Follicular lymphoma CMG recommendation chemotherapy regimen: R-CVP R-CHOP - consider if clinically aggressive or FLIPI 3 Chlorambucil + Dexamethasone +/-Rituximab - consider in frail patients 23

24 Table 9: Chemotherapy treatment for follicular lymphoma (2007 & 2008) N % N % Rituximab alone R-CVP CVP R-CHOP Other chemotherapy - Rituximab N = Table 9 details the chemotherapy regimen used. Five of the 6 patients who had Rituximab alone were in the Watch and Wait Study. In 2007 and 2008, 58% and 56% of patients were prescribed R-CVP with only 2 patients over the 2 year period being given CVP alone. 24% and 30% of cases were prescribed R-CHOP upfront. Comment: The figures from 2007 and 2008 demonstrate a consistent chemotherapy practice across the region in compliance with the CMG recommendations. 5.3 Survival of Lymphoma Patients Cancer survival estimation is an important part of assessing the overall quality of cancer care in a region. This section presents lymphoma survival statistics, including two year overall (OS) and cause-specific survival (CSS) for patients diagnosed in 2005 and Generally, the death of a patient is taken as the end point in estimation of overall survival i.e. all deaths, including deaths from causes other than cancer, are considered in the calculation of overall survival. We used CSS to describe the deaths attributable to lymphoma. Deaths due to causes other than lymphoma are considered as simply termination of follow-up. The method of CSS can be applied only when reliably coded information on cause of death is available. Even when cause of death information is available it is often vague and difficult to determine whether or not cancer is the primary cause of death. For our analysis, the cause of death for lymphoma patients was obtained from the General Register Office (GRO) and validated by the Network staff with help from clinicians. 24

25 Two year OS for HL, DLBCL and follicular NHL was 79.3%, 53.5% and 85.7% respectively. As age is known to affect survival, we used the cut offs in the relevant prognostic scores ie 45 yrs for HL (Hasenclever score) and 60 yrs for DLBCL and follicular lymphoma (IPI and FLIPI prognostic indices respectively) (Table 10). Table 10: Comparison of 2 year survival figures for 2005 & 2006 with 2004 cohort Overall Cause-specific Hodgkin Overall 79.3% (83.2%) 88.9% (91.5%) <45 yrs 95.9% (94.6%) 97.1% (97.3%) p< yrs 59.5% (70.8%) 78.0% (84.9%) p<0.001 DLBCL Overall 53.5% (57.8%) 70.8% (76.8%) < 60 yrs 77.5% (72.3%) p < % (82.1%) 60 yrs 44.0% (53.1%) 64.5% (75.2%) p<0.001 Follicular Overall 85.7% (82.2%) 96.0% (92.7%) < 60 yrs 94.4% (96.8%) p = % 60 yrs 78.6% (74.7%) 95.3% (88.3%) p = NS NB: Survival figures from the 2004 patient cohort are noted in brackets Table 10 demonstrates that there is a highly significant difference in OS between the age groups for the 3 disease subtypes analysed. The current figures for the 2005/2006 cohort are similar to those obtained in 2004 with the exception of DLBCL patients 60 yrs and HL patients 45 yrs who fare less well in the more recent cohort. In HL, CSS and OS are similar in contrast to DLBCL where there is a ~ 17% difference. This is most likely to reflect the fact that HL is predominantly a disease of younger adults in contrast to DLBCL which increases in incidence with age (>70% of our patient population > 60 years) with patients more likely to have co-morbidities. In addition to age, survival data was analysed by sex, stage and deprivation category (Tables 11 and 12). 25

26 Table 11: Overall 2 year survival for lymphoma patients (2005 & 2006) Overall survival Lymphoma HL NHL DLBC Follicular Number of cases Survival % % Survival by sex Male Female % Survival by deprivation index Affluent Intermediate p = 0.8* p = 0.058* 84.4 p = 0.35* Deprived Not Known 71.4 No events No events % Survival by Stage I II III IV Not Known No events * p values for difference between affluent and deprived. 26

27 Table 12: Cause-specific 2 year survival for lymphoma patients (2005 & 2006) Cause-specific survival Lymphoma HL NHL DLBC Follicular Number of cases Survival % % Survival by sex Male Female % Survival by deprivation index Affluent No events Intermediate p = 0.71* p = 0.044* 96.4 p=0.182* Deprived Not Known 89.3 Only 2 cases 88.0 % Survival by Stage 6 cases no events No events I 87.8 All censored II No events III IV Not Known No events * p values for difference between affluent and deprived. Sex: There is no statistical difference in OS or CSS according to sex in any disease entity. Stage: Stage has been shown to affect prognosis in HL, DLBCL and follicular NHL. HL patients with stage IV disease fared significantly worse than those of stages I, II, III (2 year CSS 69.9% versus >94.6%, p=0.006). A similar picture was seen in DLBCL with stage IV patients having a 52.6% 2 year CSS versus >75.6% in those with stages I-III (p<0.001). However, stage IV disease did not confer a survival disadvantage in follicular NHL. Deprivation: There is a trend towards a positive impact of affluence on 2 year survival for DLBCL but no statistical significant difference in other lymphoma sub groups. Comparison of WOSCAN data with published data: Hodgkin Lymphoma: the 79.3% 2 year OS for HL patients in the WOSCAN cohort is similar to the 78% 5 year OS reported by Hasenclever et al (12) although the latter study did not include early stage good risk patients. 27

28 Follicular lymphoma: the WOSCAN figure of 85.7% 2 year OS for patients with follicular NHL (all ages) compares favourably with the figure of 83% 4 year OS for patients receiving R- CVP in the study reported by Marcus et al (13). Diffuse large B cell lymphoma: the figures for DLBCL, however, compare less favourably with the published seminal randomised trial data. The MinT study (14), a randomised trial of 6 cycles of CHOP versus R CHOP for patients years with good prognosis (ageadjusted IPI 0-1) DLBCL, reported a 3 year OS rate of 93% for patients receiving R-CHOP compared with the 77.5% 2 year OS reported in our audit (included all age-adjusted IPI groups)). The 2 year CSS of 84.3% in our audit is closer to the MinT study results. For patients 60 years of age the 44% 2 year OS in our population is considerably poorer than the 70% 2 year OS, for R CHOP treated patients, reported by Coiffier et al (15). The latter was a randomised trial of 8 cycles of CHOP versus R CHOP for patients aged years. Again, the CSS of 64.5% at 2 years in our audit, is closer to these published results. The inferior overall survival results in our audit most likely reflect the fact that DLBCL is an aggressive disease requiring urgent, intensive treatment with patient co morbidities having a significant impact on the ability to deliver or tolerate optimal treatment. The selected populations in the referenced published studies are likely to have improved outcomes as they will have largely excluded patients with concurrent medical problems and clearly will not include the small proportion of patients who die before starting treatment. Comments: This report indicates that it is possible to collect comprehensive, meaningful outcome data for common lymphoma subtypes for the West of Scotland region, which has a population approaching 2.6 million people. These patients have been treated in dedicated Haematology units in 17 different hospitals which serve this region. This patient population has been identified through lymphoma pathology registration and therefore includes patients of all ages, with varied means of presentation and with a variety of coexistent medical problems which can influence the potential for treatment delivery. Our outcome data for HL, follicular lymphoma and DLBCL (accounting for 73% of all lymphoma registrations) is extremely reassuring when all the above factors are recognised. 28

29 6. Conclusion, Recommendations and Network Priorities 2010/2011 This report has presented the activity of the Haemato-oncology network during the year 2009/2010 and reported the analysis of registration data on all haematological malignancies diagnosed between 1 January 2007 and 31 December 2008, base clinical data on all lymphoma cases diagnosed during this period and survival analysis for lymphoma patients diagnosed between 1 January 2005 and 31 December We are encouraged by the progress which has been made over the last year and the network will actively take forward a number of issues raised in this report in conjunction with local health boards. The workplan objectives for 2010/2011 will focus on the following key areas: MDTs: Regional: Ensure regional MDT recommendations are adhered to throughout 2010/2011 Local: Undertake a review of MDT practice across the region; identify gaps/areas for improvement; develop action plans to address any deficiencies identified Lymphoma follow-up: Undertake a review of literature/ best practice regarding lymphoma follow-up practices; review current follow-up practices across the region and compare with literature; identify areas for change; develop action plans to optimise efficiency and effectiveness. Blood Cancer Diagnostics: Establish an integrated diagnostic reporting system for liquid haematological malignancies in the West of Scotland: Develop diagnostic pathways for liquid haematological malignancies Explore options for implementing IT system to coordinate diagnostic tests/results Teenage Cancer Trust (TCT) Unit: Optimise use of regional TCT facilities for the management of haematological cancers in adolescents and young adults across WOSCAN. Clinical Audit: Complete implementation of agreed model for effective collection, analysis and reporting of haemato-oncology data. Transfer collection and entry of acute leukaemia base data to GG&C audit department Draft list of key clinical issues in lymphoma for Quality Performance Indicator (QPI) development Review acute leukaemia and lymphoma follow-up datasets with a view to reducing data fields 29

30 References 1. The West of Scotland Adult Blood Cancer Managed Clinical Network Horning SJ, Rosenberg SA. The natural history of initially untreated low-grade non- Hodgkin s lymphoma. NEJM 1984;311: Cancer research UK 4. Cancer in Scotland (December 2009): Information Services Division, NHS National Services Scotland mmary_m.pdf&pcontentdispositiontype=inline 5. Cancer Research UK 6. The Scottish Government. Better Cancer Care, An Action Plan. Edinburgh: Scottish Government; October Scottish Cancer Registry, ISD. s.xls&pcontentdispositiontype=inline 8. Cancer Research UK 9. Jaffe ES, Harris NL, Stein H and Vardiman JW (Eds): World Health Organisation Classification of Tumours. Pathology and Genetics of Tumours of Haematopoietic and Lymphoid Tissues. IARC Press: Lyon Hutchings M et al. Prognostic value of interim FDG-PET after two of three cycles of chemotherapy in Hodgkin lymphoma. Ann Oncol 2005; 16 (7): Gallamini A et al. Early Interim 2-[18F]Fluoro-2-Deoxy-D-Glucose Positron Emission Tomography Is Prognostically Superior to International Prognostic Score in Advanced-Stage Hodgkin's Lymphoma: A Report From a Joint Italian-Danish Study. J Clin Oncol 2007; 25 (24): Hasenclever D, Diehl V. A prognostic score for advanced Hodgkin s disease. N Eng J Med 1998; 339 (21):

31 13. Marcus R et al. Phase III study of R-CVP compared with cyclophosphamide, vincristine, and prednisolone alone in patients with previously untreated advanced follicular lymphoma. J Clin Oncol 2008; 26(28): Pfreundschuh M et al. CHOP-like chemotherapy plus rituximab versus CHOP-like chemotherapy alone in young patients with good-prognosis diffuse large-b-cell lymphoma: a randomised controlled trial by the MabThera International (MInT) Group. Lancet Oncol 2006; 7: Coiffier B et al. CHOP chemotherapy plus rituximab compared with CHOP alone in elderly patients with diffuse large-b-cell lymphoma. N Eng J Med 2002; 346(4):

32 Glossary of Terms and Acronyms ABVD ALL AML AVD BEACOPP CATSCAN CEPAS ChIVPP CLL CMG CML CNS CSS DHAP DLBCL ENT FLIPI GRO HL IPI MCN MDS MDT MGUS MPD Chemotherapy regimen: Adriamycin, Bleomycin, Vinblastine, Dacarbazine Acute Lymphoblastic Leukaemia Acute Myeloid Leukaemia Chemotherapy regimen: Adriamycin, Vinblastine, Dacarbazine Chemotherapy regimen: Cyclophosphamide, Adriamycin, Etoposide, Procarbazine, Prednisone, Bleomycin, Vincristine Children and Teenagers Scottish Cancer Network Chemotherapy Electronic Prescribing and Administration System Chemotherapy regimen: Chlorambucil, Vinblastine, Procarbazine, Prednisolone Chronic Lymphocytic Leukaemia Clinical Management Guideline Chronic Myeloid Leukaemia Central Nervous System Cause-specific survival Chemotherapy regimen: Dexamethasone, Cisplatin, Cytarabine Diffuse Large B cell Lymphoma Ear, Nose and Throat Follicular Lymphoma International Prognostic Index General Register Office Hodgkin Lymphoma International Prognostic Index Managed Clinical Network Myelodysplastic Syndrome Multi-disciplinary Team Monoclonal Gammopathy of Uncertain Significance Myeloproliferative Disorders 32

33 NCRI RAPID Study NCRI RATHL Study NHL NLPHL OLD OS PCD PET PVACE-BOP QPI RCAG R-CHOP R-CODOX- M/IVAC R-CVP R-GCVP NCRI SHIELD study TCT VAPEC-B VEPEMB WOSCAN WOSCC National Clinical Research Institute study in early stage Hodgkin lymphoma National Clinical Research Institute study in advanced stage Hodgkin lymphoma Non-Hodgkin Lymphoma Nodular Lymphocyte Predominant Hodgkin Lymphoma Other Lymphoproliferative Disorders Overall survival Plasma Cell Dyscrasias Positron Emission Tomography Chemotherapy regimen: Vinblastine, Etoposide,Chlorambucil, Procarbazine, Doxorubicin, Vincristine, Bleomycin, Prednisolone Quality Performance Indicator Regional Cancer Advisory Group Chemotherapy regimen: Rituximab, Cyclophosphamide, Doxorubicin, Vincristine, Prednisolone Chemotherapy regimen: Rituximab, Cyclophosphamide, vincristine, doxorubicin, high-dose methotrexate / ifosfamide, etoposide and high-dose cytarabine Chemotherapy regimen: Rituximab, Cyclophosphamide, Vincristine, Prednisolone Chemotherapy regimen: Rituximab, Gemcitabine, Cyclophosphamide, Vincristine, Prednisolone National Clinical Research Institute study of Hodgkin lymphoma in the elderly Teenage Cancer Trust Chemotherapy regimen: Vincristine, Doxorubicin, Prednisolone, Etoposide, Cyclophoasphamide, Bleomycin Chemotherapy regimen: Vinblastine, Cyclophosphamide, Procarbazine, Etoposide, Mitoxantrone, Bleomycin West of Scotland Cancer Network West of Scotland Cancer Centre 33