Faster Cancer Treatment pathway in gynaecological malignancy: a repeat clinical audit
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Gynaecological cancers are a diverse group of cancers arising from the female reproductive system, including ovary, fallopian tube, uterus, cervix, vagina and vulva. In New Zealand, gynaecological cancers make up 10% of all cancer cases and contribute to 10% of all cancer deaths.1 Of these, endometrial cancer is the most common type of gynaecological cancer in New Zealand, however ovarian cancer is responsible for the most gynaecological cancer deaths.1
The services for assessment and management of women with gynaecological cancers have developed regionally rather than being centrally organised, which raises an important question of whether there is consistent care across New Zealand. In an effort to ensure consistent care provision, the Ministry of Health has developed the ‘Faster Cancer Treatment’ (FCT) pathway, which aims to support district health boards (DHB) in achieving timely service provision for patients with suspected or confirmed malignancy.2
The two key targets which have been identified from this initiative are:
- Treatment should begin within 31 days of decision to treat with women with a confirmed diagnosis of gynaecological cancer
- Women referred with a high suspicion of gynaecological cancer receive their first cancer treatment within 62 days of the referral being made.3
The national baseline performance for all cancer patients receiving their first treatment within 62 days was reported as 65% in 2014, with a target of >85% by July 2016 and >95% by July 2017.2,3 Standards of service provision have been developed in order to achieve these targets along with other good practice points, which have been developed using existing evidence-based standards, clinical guidelines, patient pathways and expert opinion to ensure all elements in cancer care are provided in an efficient and sustainable manner.1
In the context of Northland DHB, all suspected or confirmed gynaecological cancer cases are discussed with specialists at Auckland (a tertiary level gynaecological treatment centre) for a management plan at a weekly gynaecological oncology multidisciplinary meeting. A large proportion of these patients then go on to have their treatment in Auckland, for example, patients requiring radiotherapy or surgery by gynaecology oncology specialists. While this current system promotes standard care across different DHBs, it has the potential to compromise the timeliness of care provision. It is therefore crucial that all elements of cancer care are provided within the timeframe outlined in the standards, in order to ensure all patients receive their treatment in a timely manner.
An audit evaluating Northland DHB’s performance against these national targets between June 2014 and June 2015 identified significant delays in assessment and treatment of gynaecological cancers.3 This study is a repeat clinical audit to review whether there has been an improvement in meeting the specific timeframes set out by the tumour standards and FCT targets.
Aims
The aims of this audit are as follows:
- To obtain data from clinical records of patients with gynaecological cancers to investigate whether their cancer pathway timeline complies with the targets defined in the Standards of Service Provision for Gynaecological Cancers and Faster Cancer Treatment pathway
- To review whether there has been an improvement in cancer care provision in Northland DHB following the changes that have been implemented since the previous audit.
Methods
The study population for this audit consisted of patients residing in the Northland DHB catchment areas who were discussed at the Auckland Gynaecology Oncology MDM between 1 January 2016 and 31 December 2016. These patients were identified by consulting the MDM patient list held by the Gynaecology and Colposcopy outpatients Clinical Nurse Specialist. A total of 76 patients were identified from this list, of which 30 were excluded from analysis due to the following reasons: non-malignant pathology on final histology; recurrence of previously treated cancer; cancer of non-gynaecological origin.
For the remaining 46 patients, information regarding their cancer treatment pathway was obtained from clinical notes and electronic patient record system (Concerto), by looking up their discharge summaries, clinic letters, operation notes, MDM reports, radiology and histology reports. Data collected from these sources were then collated on an Excel spreadsheet and statistical analysis performed to calculate the percentage of patients who met the standard for each datapoint, as well as the minimum, mean and maximum time for the datapoint to be achieved. These values were then compared directly with those from the previous audit for analysis.
The standards and the FCT targets set by the Ministry of Health remain the same as for the previous audit period (Table 1).4
Table 1: Faster cancer targets, gynaecological tumour standards and good practice point.
Therefore, datapoints used for this current audit have been imported directly from the previous audit (Table 2),4 allowing direct comparison with the previous audit.
Table 2: Audit datapoints and target timeframe with respective original standards of service provision for gynaecological cancer patients.4
Results
Demographics
There were 46 patients who were discussed at the Gynaecology Oncology MDM between January 2016 and December 2016 who had a new diagnosis of gynaecological cancer confirmed on their final histology. The average age of our patients was 60 years old, with the oldest patient being 83 and the youngest 25. Of the 46 patients, 27 were New Zealand European (58.7%), 13 New Zealand Māori (28.3%), four other European (8.7%) and two Pacific Islander (4.3%).
Cancer types
The most common type of cancer was endometrial cancer, closely followed by ovarian and cervical.
Figure 1: Final histological cancer type.
FCT targets
Datapoints 5 (first treatment within 31 days of decision to treat) and 6 (first treatment within 62 days of referral being made) relate directly to the national FCT targets.
Figure 2: Datapoint 5—Percentage of patients receiving treatment within 31 days of treatment decision.
Overall, datapoint 5 was met in 85% of cases with a mean time of 21 days (0–64 days) between decision to treat and first treatment. This is a marked improvement from the previous audit, where the target was met in 73% of patients with a mean time of 28.5 days (0–161 days). When this was broken down to where first treatment took place, 71% of patients receiving their first treatment in Northland met the target, while 96% of patients receiving their first treatment in Auckland met the target. The average wait time was 23 days for Northland and 20 days for Auckland.
Datapoint 6 was only met in 45% of patients with an average wait time of 83.6 days from referral to first treatment (0–310 days). This again showed an improvement from the previous audit, where the target was met in 39% of patients with an average wait time of 98.5 days (5–525 days). Subgroup analysis showed that the target was met in 35% of patients receiving treatment in Northland and 52% of those receiving treatment in Auckland. The average wait time was 89.4 days and 79.2 days respectively.
Figure 3: Datapoint 6—percentage of patients having first treatment within 62 days of initial referral.
Six patients were excluded from analysis as their cancer pathway did not reflect the DHB’s performance in meeting the target for the following reasons: two patients were seen and investigated by private specialists and referred to MDM for management; three patients had been followed up in colposcopy clinic for a number of years with high grade smears before they developed cancer; one patient had been seen and discharged from gynaecology clinic and re-referred self to clinic with recurrence of symptoms.
Table 3: Percentage of patients who met datapoints 5–6 (correlating to FCT targets) and mean, minimum and maximum waiting times.
FCT targets by ethnicity
Subgroup analysis by ethnicity showed Māori patients were less likely to meet FCT targets compared to their non-Māori counterparts.
Datapoint 5 was achieved in 76.9% of Māori patients compared with 87.9% in non-Māori. The average wait time was similar between the two groups.
Table 4: Māori and non-Māori patients having treatment within 31 days of decision to treat.
Figure 4: Māori and non-Māori patients having treatment within 62 days of GP referral.
Datapoint 6 was achieved in 27.3% of Māori patients compared with 51.7% in non-Māori. There was a significant discrepancy in wait time between referral and first treatment in Māori and non-Māori, with Māori on average waiting 38.5 days longer than non-Māori.
Table 5: Māori and non-Māori patients having treatment within 62 days of GP referral.
Figure 5: Māori and non-Māori patients having treatment within 31 days of decision to treat.
Other standards of cancer care service provision
The following results relate to the standards provided in the Standards of Provision for Gynaecological Cancer Patients in New Zealand.
Datapoint 1 required that patients have their first specialist appointment within 14 days of referral to gynaecology service from their general practitioner or other hospital specialty. This was achieved in 85% of patients with an average wait time of 12 days between referral and first specialist appointment, with the minimum being 0 days and maximum being 84 days. The previous audit had shown the target being met in only 65% of cases albeit a slightly shorter average time of 10.5 days (0–60 days).
Figure 6: Percentage of patients meeting the criteria for datapoints 1/2a/2b/2c.
Datapoint 2 necessitated that patients are offered radiological investigations within two weeks of request being made. This was analysed for each type of radiologic investigation, namely ultrasound (2a), CT (2b) and MRI (2c). For ultrasound, it took an average of 13.4 days for patients to have their scan, with the target of two weeks being met in 72% of patients. The range of wait times was 0–65 days. Datapoint 2a had been better achieved in the previous audit period, with the target being met in 81% of cases with an average wait time of 9.5 days (0–101 days). CT scans took on average 5.0 days, with the wait time ranging between 0 and 14 days. All of the patients needing CT had their scans within 14 days of request, which is an improvement from 89% in the previous audit with the average wait time of 6.5 days (0–26 days). MRI scans were performed on average 11.2 days from the request date, with minimum wait time of three days and maximum of 20 days. The target was met in 75% of cases. This is comparable to the previous audit period, when the target was met in 73% cases with an average wait time of 10.6 days (0–23 days).
Analysis for datapoint 3 was divided into two parts. Datapoint 3a required release of histology report confirming malignancy within two weeks of decision to biopsy for tissue diagnosis. Two patients were excluded from analysis as they were investigated in the private system and hence did not reflect DHB performance. Of the 44 patients included in the analysis, the target was achieved in 41% of our patients. On average this took 35.4 days with a minimum wait time of two days and maximum of 253 days. The target had been achieved in 35% of cases in the previous audit, with an average wait time of 31.5 days (0–140 days). As expected, the delay between decision for biopsy and actual biopsy taking place was most noticeable in patients who required an operative procedure for tissue diagnosis; in this group of patients, the target of 14 days was only met in 12% with an average wait time of 46.3 days, compared with 79% meeting the target with an average wait time of 22.5 days in patients who did not require an operative procedure for tissue diagnosis.
Datapoint 3b required provisional or final pathology reports to be communicated to the lead clinician within 10 working days of the specimen being taken, as set by the standards for service provision. This was achieved in 82% of patients with an average wait time of 8.1 days (2–22 days). This again shows an improvement from the previous audit where the target was met in 70% with an average wait time of 8.9 days (0–29 days).
Datapoint 4a related to the first MDM discussion taking place within 14 days of referral from Northland DHB. 84.4% of patients met the target with the average wait time of 9.8 days, ranging between 0–23 days. This standard had been better performed in the previous audit period, where 93% of patients met the target with an average wait time of 9.5 days (5–27 days).
Figure 7: Percentage of patients meeting the criteria for datapoints 3a/3b/4a/4b.
Datapoint 4b required that treatment decision is made within 14 days of MDM referral being made. This was the worst performing area of this audit, with only 31.6% of patients meeting this target with an average wait time of 19.3 days (7–46 days). Again, this standard had been better achieved in the previous audit, with the target being met in 59% of patients with an average wait time of 22.3 days (5–162 days).
Table 6: Percentage of patients who met datapoints 1–4 and mean, minimum and maximum waiting times.
Discussion
Timely provision of cancer treatment requires every step in cancer care pathway to be carried out in a structured and coordinated manner, which necessitated the development of National Standards of Service Provision for Gynaecological Cancers.5 While this provides a useful framework and timeline for individual steps in cancer care, including referral to first specialist appointment, performance of various investigations, MDM discussion, treatment decision and commencement of treatment, it is evident that achieving the ultimate FCT target of 62 days from GP referral to first treatment remains a challenge in management of patients with gynaecological cancers, as reflected in our audit outcome of only 45% of patients achieving this target.
As most patients do meet the other FCT target of receiving their first treatment within 31 days of decision to treat, it can be inferred that, for most patients, the delay occurs in the assessment and investigations leading up to decision to treat. The delay seems to be most marked in standard 3a—time from decision for histology to histology report being produced; less than half of our patients met the target of 14 days, but more importantly, the average wait time was 35 days, which is more than double the recommended timeframe. Unsurprisingly, the wait time was a lot longer in patients requiring an operative procedure for histology compared with those who did not. This reflects an inadequacy of our current healthcare system in providing theatre resources for management of our cancer patients in a timely manner, which is not limited to gynaecological cancers or to New Zealand healthcare setting; it has been identified in large studies that scarcity of access to surgery for management of cancer is a global phenomenon, with huge implications on disease burden globally.6
Challenges in timely provision of operative procedures had already been identified in the previous audit, which led to the implementation of an extra elective gynaecology operating list per week, which allows up to four extra operations to be carried out per week. Our patients with high suspicion of cancer requiring an operative procedure for histological confirmation have priority to go on this list, which is likely to improve our outcome for datapoint 3a. One of the downsides of such implementation would be the inevitable lost theatre time for other departments, which may or may not have an impact on service provision for patients with non-gynaecological cancers. In addition to the extra surgical list, a number of elective surgical slots are now reserved for patients on the FCT pathway, while other non-FCT patients are on standby in case these slots are not filled by FCT patients. This allows further flexibility in prioritisation and timely provision of limited theatre time and resources for patients on the FCT pathway. Unfortunately, both of these changes have only been implemented since the end of our current audit period and our audit outcome does not reflect the effect of these changes.
One of the best performing areas of our audit was standard 2, which requires radiological investigations to be carried out within 14 days of request being made. This was consistently well performed in the previous and current audit periods, with the exception of ultrasound, which had been better performed in the previous audit. In an effort to improve this, a dedicated ultrasound assessment of endometrial thickness is now offered on the day of first specialist appointment for patients with post-menopausal bleeding, which is one of the symptoms of endometrial cancer. It is hoped that this will not only reduce the waiting time for ultrasound for these patients (standard 2a), but also allow improved distribution of limited theatre resources by excluding patients who do not require an operative procedure for histology.
Multidisciplinary meetings have now become the standard of care for various cancer types as they have been shown to improve patient outcome.7,8,9 Unfortunately, our audit shows that this may be one of the rate limiting steps in commencing treatment for our patients on the FCT pathway. The average wait time between MDM referral and first MDM discussion was 9.8 days, despite MDM discussion taking place on a weekly basis; for most patients, this was due to the initial referral being incomplete and lacking necessary radiological and histological investigations to facilitate MDM discussion. Second part of this standard, requiring treatment decision to be made within 14 days of MDM referral, posed a greater challenge, as shown by less than a third of our patients meeting the target; most of our patients required multiple MDM discussions before treatment recommendation could be made, and this again was due to the inadequacy of investigations provided in the initial referral, which became available over multiple MDM’s. This shows that inability to perform investigations in a timely manner has major downstream effects in patients’ cancer journey with a potential to cause further delay in commencing treatment.
Inequities in health outcome between Māori and non-Māori have consistently been shown in the literature and this was also reflected in our audit outcomes. The difference was most marked in standard 3a (decision for histology–histology report <14 days), where it took on average 53.1 days for Māori patients to have their cancer diagnosis on histology from the decision to take histology, compared with 28.0 days for non-Māori. Further analysis revealed there were three outliers where the wait time was longer than 100 days; two of these were Māori patients, each taking 146 and 253 days for histological diagnosis of malignancy on repeat samples after initially non-malignant histology and one non-Māori patient, who had histological confirmation of malignancy 225 days after decision for histology, again due to initial samples showing non-malignant pathology. When these three outliers were eliminated, the average wait time was comparable between Māori and non-Māori, at 26.5 days and 22.2 days respectively.
It was disappointing to see such a marked discrepancy in percentage of patients achieving FCT targets depending on the location of treatment. Ideally, once treatment recommendation has been made by the MDM, patients should receive treatment in a timely fashion, regardless of where treatment takes place. Delay in starting first treatment in Northland likely reflects the current strain on resource availability for providing cancer treatment by Northland DHB. It is anticipated that the aforementioned extra operating list per week and flexibility in scheduling surgical lists will help reduce wait time for cancer operations, with subsequent improvement in meeting FCT targets.
This audit does have limitations which should be addressed prior to performance of subsequent audits. One of the main limitations of this audit was that there was a very short interval of six months between the end of primary audit period and the start of repeat audit period, allowing only a limited timeframe for the new implementations to take effect. Secondly, due to the small number of patients being included in our audit, cancer-specific analysis could not be performed. An audit with a bigger number of patients over a longer period of time may enable this to be done, which in turn may help identify specific areas for improvement for management of each cancer type.
Conclusion
This one-year follow-up audit has demonstrated an overall improvement in meeting FCT targets and Standards of Service Provision in Northland patients with gynaecological cancers compared with the previous audit period. However, it is evident that there is still a significant delay in patients’ cancer journey from referral to first treatment in Northland, as reflected by low rates of FCT targets being met. The biggest contributor to this delay appears to be a major shortage in theatre resources for both diagnosis and treatment of cancer, closely followed by limited availability of radiological investigations. A number of strategies have been implemented to address these areas in the FCT pathway where delay seems to be most pronounced, and a follow-up audit will be valuable in evaluating the effect of these new implementations.
Summary
Abstract
Aim
This clinical audit aimed to review the Faster Cancer Tract pathway in Northland patients with gynaecological cancers to evaluate whether there has been an improvement since the previous audit in 2014-2015.
Method
There were 46 patients who were discussed at the gynaecological oncology multidisciplinary meeting between January 2016 and December 2016 with confirmed gynaecological malignancy. Information regarding the time taken for various investigations, referrals, decisions and treatment to be completed for each patient was obtained from clinical records and compared against the Ministry of Health faster cancer treatment targets, standards of service provision and data from the previous audit.
Results
Overall, 85% of patients met the target of having their first treatment within 31 days of a decision being made for treatment. 45% of patients met the target of having their first treatment within 62 days of initial referral for suspected cancer. This reflects an overall improvement in service provision from the previous audit period, which showed targets being met in 73% and 39% of cases respectively.
Conclusion
There has been an overall improvement in cancer care service provision for Northland patients since the previous audit, however it still falls short of the national FCT targets.
Author Information
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
- Standards of Service Provision for Gynaecological Cancer Patients in New Zealand Provisional. Wellington: NZ Ministry of Health; 2013.
- Simpson A. Faster Cancer Treatment: Implementing the 62 day faster cancer treatment health target. Wellington. NZ Ministry of Health; 20159. Faster cancer treatment indicators: Business rules and data definitions. NZ Ministry of Health cancer services; 2014.
- Faster Cancer Treatment: Measuring and Monitoring faster cancer treatment. Wellington: NZ Ministry of Health; 2015.
- Askew C, Gangji A. Gynaecological cancer pathway for faster cancer treatment: a clinical audit. NZ Med J. 2016 Oct 28; 129(1444):79–89.
- Ministry of Health. National Tumour Standards. 2016. Retrieved from http://www.health.govt.nz/our-work/diseases-and-conditions/cancer-programme/faster-cancer-treatment-programme/national-tumour-standards
- Sullivan R, et al. Global cancer surgery: delivering safe, affordable, and timely cancer surgery. Lancet Oncol. 2015 Sep; 16(11):1193–224. doi: 10.1016/S1470-2045(15)00223-5.
- Lee B, et al. Efficacy of the multidisciplinary tumor board conference in gynecologic oncology. Medicine (Baltimore). 2017 Dec.
- Woo Y, et al. Centralisation of services for gynaecological cancer. Cochrane Database Syst Rev. 2012; 1(3).
- Cohen P, et al. The Multi-disciplinary Tumour Conference in Gynaecologic Oncology – Does it alter management? Int J Gynecol Cancer. 2009; 19:1470–1472.
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Faster Cancer Treatment pathway in gynaecological malignancy: a repeat clinical audit
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Gynaecological cancers are a diverse group of cancers arising from the female reproductive system, including ovary, fallopian tube, uterus, cervix, vagina and vulva. In New Zealand, gynaecological cancers make up 10% of all cancer cases and contribute to 10% of all cancer deaths.1 Of these, endometrial cancer is the most common type of gynaecological cancer in New Zealand, however ovarian cancer is responsible for the most gynaecological cancer deaths.1
The services for assessment and management of women with gynaecological cancers have developed regionally rather than being centrally organised, which raises an important question of whether there is consistent care across New Zealand. In an effort to ensure consistent care provision, the Ministry of Health has developed the ‘Faster Cancer Treatment’ (FCT) pathway, which aims to support district health boards (DHB) in achieving timely service provision for patients with suspected or confirmed malignancy.2
The two key targets which have been identified from this initiative are:
- Treatment should begin within 31 days of decision to treat with women with a confirmed diagnosis of gynaecological cancer
- Women referred with a high suspicion of gynaecological cancer receive their first cancer treatment within 62 days of the referral being made.3
The national baseline performance for all cancer patients receiving their first treatment within 62 days was reported as 65% in 2014, with a target of >85% by July 2016 and >95% by July 2017.2,3 Standards of service provision have been developed in order to achieve these targets along with other good practice points, which have been developed using existing evidence-based standards, clinical guidelines, patient pathways and expert opinion to ensure all elements in cancer care are provided in an efficient and sustainable manner.1
In the context of Northland DHB, all suspected or confirmed gynaecological cancer cases are discussed with specialists at Auckland (a tertiary level gynaecological treatment centre) for a management plan at a weekly gynaecological oncology multidisciplinary meeting. A large proportion of these patients then go on to have their treatment in Auckland, for example, patients requiring radiotherapy or surgery by gynaecology oncology specialists. While this current system promotes standard care across different DHBs, it has the potential to compromise the timeliness of care provision. It is therefore crucial that all elements of cancer care are provided within the timeframe outlined in the standards, in order to ensure all patients receive their treatment in a timely manner.
An audit evaluating Northland DHB’s performance against these national targets between June 2014 and June 2015 identified significant delays in assessment and treatment of gynaecological cancers.3 This study is a repeat clinical audit to review whether there has been an improvement in meeting the specific timeframes set out by the tumour standards and FCT targets.
Aims
The aims of this audit are as follows:
- To obtain data from clinical records of patients with gynaecological cancers to investigate whether their cancer pathway timeline complies with the targets defined in the Standards of Service Provision for Gynaecological Cancers and Faster Cancer Treatment pathway
- To review whether there has been an improvement in cancer care provision in Northland DHB following the changes that have been implemented since the previous audit.
Methods
The study population for this audit consisted of patients residing in the Northland DHB catchment areas who were discussed at the Auckland Gynaecology Oncology MDM between 1 January 2016 and 31 December 2016. These patients were identified by consulting the MDM patient list held by the Gynaecology and Colposcopy outpatients Clinical Nurse Specialist. A total of 76 patients were identified from this list, of which 30 were excluded from analysis due to the following reasons: non-malignant pathology on final histology; recurrence of previously treated cancer; cancer of non-gynaecological origin.
For the remaining 46 patients, information regarding their cancer treatment pathway was obtained from clinical notes and electronic patient record system (Concerto), by looking up their discharge summaries, clinic letters, operation notes, MDM reports, radiology and histology reports. Data collected from these sources were then collated on an Excel spreadsheet and statistical analysis performed to calculate the percentage of patients who met the standard for each datapoint, as well as the minimum, mean and maximum time for the datapoint to be achieved. These values were then compared directly with those from the previous audit for analysis.
The standards and the FCT targets set by the Ministry of Health remain the same as for the previous audit period (Table 1).4
Table 1: Faster cancer targets, gynaecological tumour standards and good practice point.
Therefore, datapoints used for this current audit have been imported directly from the previous audit (Table 2),4 allowing direct comparison with the previous audit.
Table 2: Audit datapoints and target timeframe with respective original standards of service provision for gynaecological cancer patients.4
Results
Demographics
There were 46 patients who were discussed at the Gynaecology Oncology MDM between January 2016 and December 2016 who had a new diagnosis of gynaecological cancer confirmed on their final histology. The average age of our patients was 60 years old, with the oldest patient being 83 and the youngest 25. Of the 46 patients, 27 were New Zealand European (58.7%), 13 New Zealand Māori (28.3%), four other European (8.7%) and two Pacific Islander (4.3%).
Cancer types
The most common type of cancer was endometrial cancer, closely followed by ovarian and cervical.
Figure 1: Final histological cancer type.
FCT targets
Datapoints 5 (first treatment within 31 days of decision to treat) and 6 (first treatment within 62 days of referral being made) relate directly to the national FCT targets.
Figure 2: Datapoint 5—Percentage of patients receiving treatment within 31 days of treatment decision.
Overall, datapoint 5 was met in 85% of cases with a mean time of 21 days (0–64 days) between decision to treat and first treatment. This is a marked improvement from the previous audit, where the target was met in 73% of patients with a mean time of 28.5 days (0–161 days). When this was broken down to where first treatment took place, 71% of patients receiving their first treatment in Northland met the target, while 96% of patients receiving their first treatment in Auckland met the target. The average wait time was 23 days for Northland and 20 days for Auckland.
Datapoint 6 was only met in 45% of patients with an average wait time of 83.6 days from referral to first treatment (0–310 days). This again showed an improvement from the previous audit, where the target was met in 39% of patients with an average wait time of 98.5 days (5–525 days). Subgroup analysis showed that the target was met in 35% of patients receiving treatment in Northland and 52% of those receiving treatment in Auckland. The average wait time was 89.4 days and 79.2 days respectively.
Figure 3: Datapoint 6—percentage of patients having first treatment within 62 days of initial referral.
Six patients were excluded from analysis as their cancer pathway did not reflect the DHB’s performance in meeting the target for the following reasons: two patients were seen and investigated by private specialists and referred to MDM for management; three patients had been followed up in colposcopy clinic for a number of years with high grade smears before they developed cancer; one patient had been seen and discharged from gynaecology clinic and re-referred self to clinic with recurrence of symptoms.
Table 3: Percentage of patients who met datapoints 5–6 (correlating to FCT targets) and mean, minimum and maximum waiting times.
FCT targets by ethnicity
Subgroup analysis by ethnicity showed Māori patients were less likely to meet FCT targets compared to their non-Māori counterparts.
Datapoint 5 was achieved in 76.9% of Māori patients compared with 87.9% in non-Māori. The average wait time was similar between the two groups.
Table 4: Māori and non-Māori patients having treatment within 31 days of decision to treat.
Figure 4: Māori and non-Māori patients having treatment within 62 days of GP referral.
Datapoint 6 was achieved in 27.3% of Māori patients compared with 51.7% in non-Māori. There was a significant discrepancy in wait time between referral and first treatment in Māori and non-Māori, with Māori on average waiting 38.5 days longer than non-Māori.
Table 5: Māori and non-Māori patients having treatment within 62 days of GP referral.
Figure 5: Māori and non-Māori patients having treatment within 31 days of decision to treat.
Other standards of cancer care service provision
The following results relate to the standards provided in the Standards of Provision for Gynaecological Cancer Patients in New Zealand.
Datapoint 1 required that patients have their first specialist appointment within 14 days of referral to gynaecology service from their general practitioner or other hospital specialty. This was achieved in 85% of patients with an average wait time of 12 days between referral and first specialist appointment, with the minimum being 0 days and maximum being 84 days. The previous audit had shown the target being met in only 65% of cases albeit a slightly shorter average time of 10.5 days (0–60 days).
Figure 6: Percentage of patients meeting the criteria for datapoints 1/2a/2b/2c.
Datapoint 2 necessitated that patients are offered radiological investigations within two weeks of request being made. This was analysed for each type of radiologic investigation, namely ultrasound (2a), CT (2b) and MRI (2c). For ultrasound, it took an average of 13.4 days for patients to have their scan, with the target of two weeks being met in 72% of patients. The range of wait times was 0–65 days. Datapoint 2a had been better achieved in the previous audit period, with the target being met in 81% of cases with an average wait time of 9.5 days (0–101 days). CT scans took on average 5.0 days, with the wait time ranging between 0 and 14 days. All of the patients needing CT had their scans within 14 days of request, which is an improvement from 89% in the previous audit with the average wait time of 6.5 days (0–26 days). MRI scans were performed on average 11.2 days from the request date, with minimum wait time of three days and maximum of 20 days. The target was met in 75% of cases. This is comparable to the previous audit period, when the target was met in 73% cases with an average wait time of 10.6 days (0–23 days).
Analysis for datapoint 3 was divided into two parts. Datapoint 3a required release of histology report confirming malignancy within two weeks of decision to biopsy for tissue diagnosis. Two patients were excluded from analysis as they were investigated in the private system and hence did not reflect DHB performance. Of the 44 patients included in the analysis, the target was achieved in 41% of our patients. On average this took 35.4 days with a minimum wait time of two days and maximum of 253 days. The target had been achieved in 35% of cases in the previous audit, with an average wait time of 31.5 days (0–140 days). As expected, the delay between decision for biopsy and actual biopsy taking place was most noticeable in patients who required an operative procedure for tissue diagnosis; in this group of patients, the target of 14 days was only met in 12% with an average wait time of 46.3 days, compared with 79% meeting the target with an average wait time of 22.5 days in patients who did not require an operative procedure for tissue diagnosis.
Datapoint 3b required provisional or final pathology reports to be communicated to the lead clinician within 10 working days of the specimen being taken, as set by the standards for service provision. This was achieved in 82% of patients with an average wait time of 8.1 days (2–22 days). This again shows an improvement from the previous audit where the target was met in 70% with an average wait time of 8.9 days (0–29 days).
Datapoint 4a related to the first MDM discussion taking place within 14 days of referral from Northland DHB. 84.4% of patients met the target with the average wait time of 9.8 days, ranging between 0–23 days. This standard had been better performed in the previous audit period, where 93% of patients met the target with an average wait time of 9.5 days (5–27 days).
Figure 7: Percentage of patients meeting the criteria for datapoints 3a/3b/4a/4b.
Datapoint 4b required that treatment decision is made within 14 days of MDM referral being made. This was the worst performing area of this audit, with only 31.6% of patients meeting this target with an average wait time of 19.3 days (7–46 days). Again, this standard had been better achieved in the previous audit, with the target being met in 59% of patients with an average wait time of 22.3 days (5–162 days).
Table 6: Percentage of patients who met datapoints 1–4 and mean, minimum and maximum waiting times.
Discussion
Timely provision of cancer treatment requires every step in cancer care pathway to be carried out in a structured and coordinated manner, which necessitated the development of National Standards of Service Provision for Gynaecological Cancers.5 While this provides a useful framework and timeline for individual steps in cancer care, including referral to first specialist appointment, performance of various investigations, MDM discussion, treatment decision and commencement of treatment, it is evident that achieving the ultimate FCT target of 62 days from GP referral to first treatment remains a challenge in management of patients with gynaecological cancers, as reflected in our audit outcome of only 45% of patients achieving this target.
As most patients do meet the other FCT target of receiving their first treatment within 31 days of decision to treat, it can be inferred that, for most patients, the delay occurs in the assessment and investigations leading up to decision to treat. The delay seems to be most marked in standard 3a—time from decision for histology to histology report being produced; less than half of our patients met the target of 14 days, but more importantly, the average wait time was 35 days, which is more than double the recommended timeframe. Unsurprisingly, the wait time was a lot longer in patients requiring an operative procedure for histology compared with those who did not. This reflects an inadequacy of our current healthcare system in providing theatre resources for management of our cancer patients in a timely manner, which is not limited to gynaecological cancers or to New Zealand healthcare setting; it has been identified in large studies that scarcity of access to surgery for management of cancer is a global phenomenon, with huge implications on disease burden globally.6
Challenges in timely provision of operative procedures had already been identified in the previous audit, which led to the implementation of an extra elective gynaecology operating list per week, which allows up to four extra operations to be carried out per week. Our patients with high suspicion of cancer requiring an operative procedure for histological confirmation have priority to go on this list, which is likely to improve our outcome for datapoint 3a. One of the downsides of such implementation would be the inevitable lost theatre time for other departments, which may or may not have an impact on service provision for patients with non-gynaecological cancers. In addition to the extra surgical list, a number of elective surgical slots are now reserved for patients on the FCT pathway, while other non-FCT patients are on standby in case these slots are not filled by FCT patients. This allows further flexibility in prioritisation and timely provision of limited theatre time and resources for patients on the FCT pathway. Unfortunately, both of these changes have only been implemented since the end of our current audit period and our audit outcome does not reflect the effect of these changes.
One of the best performing areas of our audit was standard 2, which requires radiological investigations to be carried out within 14 days of request being made. This was consistently well performed in the previous and current audit periods, with the exception of ultrasound, which had been better performed in the previous audit. In an effort to improve this, a dedicated ultrasound assessment of endometrial thickness is now offered on the day of first specialist appointment for patients with post-menopausal bleeding, which is one of the symptoms of endometrial cancer. It is hoped that this will not only reduce the waiting time for ultrasound for these patients (standard 2a), but also allow improved distribution of limited theatre resources by excluding patients who do not require an operative procedure for histology.
Multidisciplinary meetings have now become the standard of care for various cancer types as they have been shown to improve patient outcome.7,8,9 Unfortunately, our audit shows that this may be one of the rate limiting steps in commencing treatment for our patients on the FCT pathway. The average wait time between MDM referral and first MDM discussion was 9.8 days, despite MDM discussion taking place on a weekly basis; for most patients, this was due to the initial referral being incomplete and lacking necessary radiological and histological investigations to facilitate MDM discussion. Second part of this standard, requiring treatment decision to be made within 14 days of MDM referral, posed a greater challenge, as shown by less than a third of our patients meeting the target; most of our patients required multiple MDM discussions before treatment recommendation could be made, and this again was due to the inadequacy of investigations provided in the initial referral, which became available over multiple MDM’s. This shows that inability to perform investigations in a timely manner has major downstream effects in patients’ cancer journey with a potential to cause further delay in commencing treatment.
Inequities in health outcome between Māori and non-Māori have consistently been shown in the literature and this was also reflected in our audit outcomes. The difference was most marked in standard 3a (decision for histology–histology report <14 days), where it took on average 53.1 days for Māori patients to have their cancer diagnosis on histology from the decision to take histology, compared with 28.0 days for non-Māori. Further analysis revealed there were three outliers where the wait time was longer than 100 days; two of these were Māori patients, each taking 146 and 253 days for histological diagnosis of malignancy on repeat samples after initially non-malignant histology and one non-Māori patient, who had histological confirmation of malignancy 225 days after decision for histology, again due to initial samples showing non-malignant pathology. When these three outliers were eliminated, the average wait time was comparable between Māori and non-Māori, at 26.5 days and 22.2 days respectively.
It was disappointing to see such a marked discrepancy in percentage of patients achieving FCT targets depending on the location of treatment. Ideally, once treatment recommendation has been made by the MDM, patients should receive treatment in a timely fashion, regardless of where treatment takes place. Delay in starting first treatment in Northland likely reflects the current strain on resource availability for providing cancer treatment by Northland DHB. It is anticipated that the aforementioned extra operating list per week and flexibility in scheduling surgical lists will help reduce wait time for cancer operations, with subsequent improvement in meeting FCT targets.
This audit does have limitations which should be addressed prior to performance of subsequent audits. One of the main limitations of this audit was that there was a very short interval of six months between the end of primary audit period and the start of repeat audit period, allowing only a limited timeframe for the new implementations to take effect. Secondly, due to the small number of patients being included in our audit, cancer-specific analysis could not be performed. An audit with a bigger number of patients over a longer period of time may enable this to be done, which in turn may help identify specific areas for improvement for management of each cancer type.
Conclusion
This one-year follow-up audit has demonstrated an overall improvement in meeting FCT targets and Standards of Service Provision in Northland patients with gynaecological cancers compared with the previous audit period. However, it is evident that there is still a significant delay in patients’ cancer journey from referral to first treatment in Northland, as reflected by low rates of FCT targets being met. The biggest contributor to this delay appears to be a major shortage in theatre resources for both diagnosis and treatment of cancer, closely followed by limited availability of radiological investigations. A number of strategies have been implemented to address these areas in the FCT pathway where delay seems to be most pronounced, and a follow-up audit will be valuable in evaluating the effect of these new implementations.
Summary
Abstract
Aim
This clinical audit aimed to review the Faster Cancer Tract pathway in Northland patients with gynaecological cancers to evaluate whether there has been an improvement since the previous audit in 2014-2015.
Method
There were 46 patients who were discussed at the gynaecological oncology multidisciplinary meeting between January 2016 and December 2016 with confirmed gynaecological malignancy. Information regarding the time taken for various investigations, referrals, decisions and treatment to be completed for each patient was obtained from clinical records and compared against the Ministry of Health faster cancer treatment targets, standards of service provision and data from the previous audit.
Results
Overall, 85% of patients met the target of having their first treatment within 31 days of a decision being made for treatment. 45% of patients met the target of having their first treatment within 62 days of initial referral for suspected cancer. This reflects an overall improvement in service provision from the previous audit period, which showed targets being met in 73% and 39% of cases respectively.
Conclusion
There has been an overall improvement in cancer care service provision for Northland patients since the previous audit, however it still falls short of the national FCT targets.
Author Information
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
- Standards of Service Provision for Gynaecological Cancer Patients in New Zealand Provisional. Wellington: NZ Ministry of Health; 2013.
- Simpson A. Faster Cancer Treatment: Implementing the 62 day faster cancer treatment health target. Wellington. NZ Ministry of Health; 20159. Faster cancer treatment indicators: Business rules and data definitions. NZ Ministry of Health cancer services; 2014.
- Faster Cancer Treatment: Measuring and Monitoring faster cancer treatment. Wellington: NZ Ministry of Health; 2015.
- Askew C, Gangji A. Gynaecological cancer pathway for faster cancer treatment: a clinical audit. NZ Med J. 2016 Oct 28; 129(1444):79–89.
- Ministry of Health. National Tumour Standards. 2016. Retrieved from http://www.health.govt.nz/our-work/diseases-and-conditions/cancer-programme/faster-cancer-treatment-programme/national-tumour-standards
- Sullivan R, et al. Global cancer surgery: delivering safe, affordable, and timely cancer surgery. Lancet Oncol. 2015 Sep; 16(11):1193–224. doi: 10.1016/S1470-2045(15)00223-5.
- Lee B, et al. Efficacy of the multidisciplinary tumor board conference in gynecologic oncology. Medicine (Baltimore). 2017 Dec.
- Woo Y, et al. Centralisation of services for gynaecological cancer. Cochrane Database Syst Rev. 2012; 1(3).
- Cohen P, et al. The Multi-disciplinary Tumour Conference in Gynaecologic Oncology – Does it alter management? Int J Gynecol Cancer. 2009; 19:1470–1472.
For the PDF of this article,
contact nzmj@nzma.org.nz
Faster Cancer Treatment pathway in gynaecological malignancy: a repeat clinical audit
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Gynaecological cancers are a diverse group of cancers arising from the female reproductive system, including ovary, fallopian tube, uterus, cervix, vagina and vulva. In New Zealand, gynaecological cancers make up 10% of all cancer cases and contribute to 10% of all cancer deaths.1 Of these, endometrial cancer is the most common type of gynaecological cancer in New Zealand, however ovarian cancer is responsible for the most gynaecological cancer deaths.1
The services for assessment and management of women with gynaecological cancers have developed regionally rather than being centrally organised, which raises an important question of whether there is consistent care across New Zealand. In an effort to ensure consistent care provision, the Ministry of Health has developed the ‘Faster Cancer Treatment’ (FCT) pathway, which aims to support district health boards (DHB) in achieving timely service provision for patients with suspected or confirmed malignancy.2
The two key targets which have been identified from this initiative are:
- Treatment should begin within 31 days of decision to treat with women with a confirmed diagnosis of gynaecological cancer
- Women referred with a high suspicion of gynaecological cancer receive their first cancer treatment within 62 days of the referral being made.3
The national baseline performance for all cancer patients receiving their first treatment within 62 days was reported as 65% in 2014, with a target of >85% by July 2016 and >95% by July 2017.2,3 Standards of service provision have been developed in order to achieve these targets along with other good practice points, which have been developed using existing evidence-based standards, clinical guidelines, patient pathways and expert opinion to ensure all elements in cancer care are provided in an efficient and sustainable manner.1
In the context of Northland DHB, all suspected or confirmed gynaecological cancer cases are discussed with specialists at Auckland (a tertiary level gynaecological treatment centre) for a management plan at a weekly gynaecological oncology multidisciplinary meeting. A large proportion of these patients then go on to have their treatment in Auckland, for example, patients requiring radiotherapy or surgery by gynaecology oncology specialists. While this current system promotes standard care across different DHBs, it has the potential to compromise the timeliness of care provision. It is therefore crucial that all elements of cancer care are provided within the timeframe outlined in the standards, in order to ensure all patients receive their treatment in a timely manner.
An audit evaluating Northland DHB’s performance against these national targets between June 2014 and June 2015 identified significant delays in assessment and treatment of gynaecological cancers.3 This study is a repeat clinical audit to review whether there has been an improvement in meeting the specific timeframes set out by the tumour standards and FCT targets.
Aims
The aims of this audit are as follows:
- To obtain data from clinical records of patients with gynaecological cancers to investigate whether their cancer pathway timeline complies with the targets defined in the Standards of Service Provision for Gynaecological Cancers and Faster Cancer Treatment pathway
- To review whether there has been an improvement in cancer care provision in Northland DHB following the changes that have been implemented since the previous audit.
Methods
The study population for this audit consisted of patients residing in the Northland DHB catchment areas who were discussed at the Auckland Gynaecology Oncology MDM between 1 January 2016 and 31 December 2016. These patients were identified by consulting the MDM patient list held by the Gynaecology and Colposcopy outpatients Clinical Nurse Specialist. A total of 76 patients were identified from this list, of which 30 were excluded from analysis due to the following reasons: non-malignant pathology on final histology; recurrence of previously treated cancer; cancer of non-gynaecological origin.
For the remaining 46 patients, information regarding their cancer treatment pathway was obtained from clinical notes and electronic patient record system (Concerto), by looking up their discharge summaries, clinic letters, operation notes, MDM reports, radiology and histology reports. Data collected from these sources were then collated on an Excel spreadsheet and statistical analysis performed to calculate the percentage of patients who met the standard for each datapoint, as well as the minimum, mean and maximum time for the datapoint to be achieved. These values were then compared directly with those from the previous audit for analysis.
The standards and the FCT targets set by the Ministry of Health remain the same as for the previous audit period (Table 1).4
Table 1: Faster cancer targets, gynaecological tumour standards and good practice point.
Therefore, datapoints used for this current audit have been imported directly from the previous audit (Table 2),4 allowing direct comparison with the previous audit.
Table 2: Audit datapoints and target timeframe with respective original standards of service provision for gynaecological cancer patients.4
Results
Demographics
There were 46 patients who were discussed at the Gynaecology Oncology MDM between January 2016 and December 2016 who had a new diagnosis of gynaecological cancer confirmed on their final histology. The average age of our patients was 60 years old, with the oldest patient being 83 and the youngest 25. Of the 46 patients, 27 were New Zealand European (58.7%), 13 New Zealand Māori (28.3%), four other European (8.7%) and two Pacific Islander (4.3%).
Cancer types
The most common type of cancer was endometrial cancer, closely followed by ovarian and cervical.
Figure 1: Final histological cancer type.
FCT targets
Datapoints 5 (first treatment within 31 days of decision to treat) and 6 (first treatment within 62 days of referral being made) relate directly to the national FCT targets.
Figure 2: Datapoint 5—Percentage of patients receiving treatment within 31 days of treatment decision.
Overall, datapoint 5 was met in 85% of cases with a mean time of 21 days (0–64 days) between decision to treat and first treatment. This is a marked improvement from the previous audit, where the target was met in 73% of patients with a mean time of 28.5 days (0–161 days). When this was broken down to where first treatment took place, 71% of patients receiving their first treatment in Northland met the target, while 96% of patients receiving their first treatment in Auckland met the target. The average wait time was 23 days for Northland and 20 days for Auckland.
Datapoint 6 was only met in 45% of patients with an average wait time of 83.6 days from referral to first treatment (0–310 days). This again showed an improvement from the previous audit, where the target was met in 39% of patients with an average wait time of 98.5 days (5–525 days). Subgroup analysis showed that the target was met in 35% of patients receiving treatment in Northland and 52% of those receiving treatment in Auckland. The average wait time was 89.4 days and 79.2 days respectively.
Figure 3: Datapoint 6—percentage of patients having first treatment within 62 days of initial referral.
Six patients were excluded from analysis as their cancer pathway did not reflect the DHB’s performance in meeting the target for the following reasons: two patients were seen and investigated by private specialists and referred to MDM for management; three patients had been followed up in colposcopy clinic for a number of years with high grade smears before they developed cancer; one patient had been seen and discharged from gynaecology clinic and re-referred self to clinic with recurrence of symptoms.
Table 3: Percentage of patients who met datapoints 5–6 (correlating to FCT targets) and mean, minimum and maximum waiting times.
FCT targets by ethnicity
Subgroup analysis by ethnicity showed Māori patients were less likely to meet FCT targets compared to their non-Māori counterparts.
Datapoint 5 was achieved in 76.9% of Māori patients compared with 87.9% in non-Māori. The average wait time was similar between the two groups.
Table 4: Māori and non-Māori patients having treatment within 31 days of decision to treat.
Figure 4: Māori and non-Māori patients having treatment within 62 days of GP referral.
Datapoint 6 was achieved in 27.3% of Māori patients compared with 51.7% in non-Māori. There was a significant discrepancy in wait time between referral and first treatment in Māori and non-Māori, with Māori on average waiting 38.5 days longer than non-Māori.
Table 5: Māori and non-Māori patients having treatment within 62 days of GP referral.
Figure 5: Māori and non-Māori patients having treatment within 31 days of decision to treat.
Other standards of cancer care service provision
The following results relate to the standards provided in the Standards of Provision for Gynaecological Cancer Patients in New Zealand.
Datapoint 1 required that patients have their first specialist appointment within 14 days of referral to gynaecology service from their general practitioner or other hospital specialty. This was achieved in 85% of patients with an average wait time of 12 days between referral and first specialist appointment, with the minimum being 0 days and maximum being 84 days. The previous audit had shown the target being met in only 65% of cases albeit a slightly shorter average time of 10.5 days (0–60 days).
Figure 6: Percentage of patients meeting the criteria for datapoints 1/2a/2b/2c.
Datapoint 2 necessitated that patients are offered radiological investigations within two weeks of request being made. This was analysed for each type of radiologic investigation, namely ultrasound (2a), CT (2b) and MRI (2c). For ultrasound, it took an average of 13.4 days for patients to have their scan, with the target of two weeks being met in 72% of patients. The range of wait times was 0–65 days. Datapoint 2a had been better achieved in the previous audit period, with the target being met in 81% of cases with an average wait time of 9.5 days (0–101 days). CT scans took on average 5.0 days, with the wait time ranging between 0 and 14 days. All of the patients needing CT had their scans within 14 days of request, which is an improvement from 89% in the previous audit with the average wait time of 6.5 days (0–26 days). MRI scans were performed on average 11.2 days from the request date, with minimum wait time of three days and maximum of 20 days. The target was met in 75% of cases. This is comparable to the previous audit period, when the target was met in 73% cases with an average wait time of 10.6 days (0–23 days).
Analysis for datapoint 3 was divided into two parts. Datapoint 3a required release of histology report confirming malignancy within two weeks of decision to biopsy for tissue diagnosis. Two patients were excluded from analysis as they were investigated in the private system and hence did not reflect DHB performance. Of the 44 patients included in the analysis, the target was achieved in 41% of our patients. On average this took 35.4 days with a minimum wait time of two days and maximum of 253 days. The target had been achieved in 35% of cases in the previous audit, with an average wait time of 31.5 days (0–140 days). As expected, the delay between decision for biopsy and actual biopsy taking place was most noticeable in patients who required an operative procedure for tissue diagnosis; in this group of patients, the target of 14 days was only met in 12% with an average wait time of 46.3 days, compared with 79% meeting the target with an average wait time of 22.5 days in patients who did not require an operative procedure for tissue diagnosis.
Datapoint 3b required provisional or final pathology reports to be communicated to the lead clinician within 10 working days of the specimen being taken, as set by the standards for service provision. This was achieved in 82% of patients with an average wait time of 8.1 days (2–22 days). This again shows an improvement from the previous audit where the target was met in 70% with an average wait time of 8.9 days (0–29 days).
Datapoint 4a related to the first MDM discussion taking place within 14 days of referral from Northland DHB. 84.4% of patients met the target with the average wait time of 9.8 days, ranging between 0–23 days. This standard had been better performed in the previous audit period, where 93% of patients met the target with an average wait time of 9.5 days (5–27 days).
Figure 7: Percentage of patients meeting the criteria for datapoints 3a/3b/4a/4b.
Datapoint 4b required that treatment decision is made within 14 days of MDM referral being made. This was the worst performing area of this audit, with only 31.6% of patients meeting this target with an average wait time of 19.3 days (7–46 days). Again, this standard had been better achieved in the previous audit, with the target being met in 59% of patients with an average wait time of 22.3 days (5–162 days).
Table 6: Percentage of patients who met datapoints 1–4 and mean, minimum and maximum waiting times.
Discussion
Timely provision of cancer treatment requires every step in cancer care pathway to be carried out in a structured and coordinated manner, which necessitated the development of National Standards of Service Provision for Gynaecological Cancers.5 While this provides a useful framework and timeline for individual steps in cancer care, including referral to first specialist appointment, performance of various investigations, MDM discussion, treatment decision and commencement of treatment, it is evident that achieving the ultimate FCT target of 62 days from GP referral to first treatment remains a challenge in management of patients with gynaecological cancers, as reflected in our audit outcome of only 45% of patients achieving this target.
As most patients do meet the other FCT target of receiving their first treatment within 31 days of decision to treat, it can be inferred that, for most patients, the delay occurs in the assessment and investigations leading up to decision to treat. The delay seems to be most marked in standard 3a—time from decision for histology to histology report being produced; less than half of our patients met the target of 14 days, but more importantly, the average wait time was 35 days, which is more than double the recommended timeframe. Unsurprisingly, the wait time was a lot longer in patients requiring an operative procedure for histology compared with those who did not. This reflects an inadequacy of our current healthcare system in providing theatre resources for management of our cancer patients in a timely manner, which is not limited to gynaecological cancers or to New Zealand healthcare setting; it has been identified in large studies that scarcity of access to surgery for management of cancer is a global phenomenon, with huge implications on disease burden globally.6
Challenges in timely provision of operative procedures had already been identified in the previous audit, which led to the implementation of an extra elective gynaecology operating list per week, which allows up to four extra operations to be carried out per week. Our patients with high suspicion of cancer requiring an operative procedure for histological confirmation have priority to go on this list, which is likely to improve our outcome for datapoint 3a. One of the downsides of such implementation would be the inevitable lost theatre time for other departments, which may or may not have an impact on service provision for patients with non-gynaecological cancers. In addition to the extra surgical list, a number of elective surgical slots are now reserved for patients on the FCT pathway, while other non-FCT patients are on standby in case these slots are not filled by FCT patients. This allows further flexibility in prioritisation and timely provision of limited theatre time and resources for patients on the FCT pathway. Unfortunately, both of these changes have only been implemented since the end of our current audit period and our audit outcome does not reflect the effect of these changes.
One of the best performing areas of our audit was standard 2, which requires radiological investigations to be carried out within 14 days of request being made. This was consistently well performed in the previous and current audit periods, with the exception of ultrasound, which had been better performed in the previous audit. In an effort to improve this, a dedicated ultrasound assessment of endometrial thickness is now offered on the day of first specialist appointment for patients with post-menopausal bleeding, which is one of the symptoms of endometrial cancer. It is hoped that this will not only reduce the waiting time for ultrasound for these patients (standard 2a), but also allow improved distribution of limited theatre resources by excluding patients who do not require an operative procedure for histology.
Multidisciplinary meetings have now become the standard of care for various cancer types as they have been shown to improve patient outcome.7,8,9 Unfortunately, our audit shows that this may be one of the rate limiting steps in commencing treatment for our patients on the FCT pathway. The average wait time between MDM referral and first MDM discussion was 9.8 days, despite MDM discussion taking place on a weekly basis; for most patients, this was due to the initial referral being incomplete and lacking necessary radiological and histological investigations to facilitate MDM discussion. Second part of this standard, requiring treatment decision to be made within 14 days of MDM referral, posed a greater challenge, as shown by less than a third of our patients meeting the target; most of our patients required multiple MDM discussions before treatment recommendation could be made, and this again was due to the inadequacy of investigations provided in the initial referral, which became available over multiple MDM’s. This shows that inability to perform investigations in a timely manner has major downstream effects in patients’ cancer journey with a potential to cause further delay in commencing treatment.
Inequities in health outcome between Māori and non-Māori have consistently been shown in the literature and this was also reflected in our audit outcomes. The difference was most marked in standard 3a (decision for histology–histology report <14 days), where it took on average 53.1 days for Māori patients to have their cancer diagnosis on histology from the decision to take histology, compared with 28.0 days for non-Māori. Further analysis revealed there were three outliers where the wait time was longer than 100 days; two of these were Māori patients, each taking 146 and 253 days for histological diagnosis of malignancy on repeat samples after initially non-malignant histology and one non-Māori patient, who had histological confirmation of malignancy 225 days after decision for histology, again due to initial samples showing non-malignant pathology. When these three outliers were eliminated, the average wait time was comparable between Māori and non-Māori, at 26.5 days and 22.2 days respectively.
It was disappointing to see such a marked discrepancy in percentage of patients achieving FCT targets depending on the location of treatment. Ideally, once treatment recommendation has been made by the MDM, patients should receive treatment in a timely fashion, regardless of where treatment takes place. Delay in starting first treatment in Northland likely reflects the current strain on resource availability for providing cancer treatment by Northland DHB. It is anticipated that the aforementioned extra operating list per week and flexibility in scheduling surgical lists will help reduce wait time for cancer operations, with subsequent improvement in meeting FCT targets.
This audit does have limitations which should be addressed prior to performance of subsequent audits. One of the main limitations of this audit was that there was a very short interval of six months between the end of primary audit period and the start of repeat audit period, allowing only a limited timeframe for the new implementations to take effect. Secondly, due to the small number of patients being included in our audit, cancer-specific analysis could not be performed. An audit with a bigger number of patients over a longer period of time may enable this to be done, which in turn may help identify specific areas for improvement for management of each cancer type.
Conclusion
This one-year follow-up audit has demonstrated an overall improvement in meeting FCT targets and Standards of Service Provision in Northland patients with gynaecological cancers compared with the previous audit period. However, it is evident that there is still a significant delay in patients’ cancer journey from referral to first treatment in Northland, as reflected by low rates of FCT targets being met. The biggest contributor to this delay appears to be a major shortage in theatre resources for both diagnosis and treatment of cancer, closely followed by limited availability of radiological investigations. A number of strategies have been implemented to address these areas in the FCT pathway where delay seems to be most pronounced, and a follow-up audit will be valuable in evaluating the effect of these new implementations.
Summary
Abstract
Aim
This clinical audit aimed to review the Faster Cancer Tract pathway in Northland patients with gynaecological cancers to evaluate whether there has been an improvement since the previous audit in 2014-2015.
Method
There were 46 patients who were discussed at the gynaecological oncology multidisciplinary meeting between January 2016 and December 2016 with confirmed gynaecological malignancy. Information regarding the time taken for various investigations, referrals, decisions and treatment to be completed for each patient was obtained from clinical records and compared against the Ministry of Health faster cancer treatment targets, standards of service provision and data from the previous audit.
Results
Overall, 85% of patients met the target of having their first treatment within 31 days of a decision being made for treatment. 45% of patients met the target of having their first treatment within 62 days of initial referral for suspected cancer. This reflects an overall improvement in service provision from the previous audit period, which showed targets being met in 73% and 39% of cases respectively.
Conclusion
There has been an overall improvement in cancer care service provision for Northland patients since the previous audit, however it still falls short of the national FCT targets.
Author Information
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
- Standards of Service Provision for Gynaecological Cancer Patients in New Zealand Provisional. Wellington: NZ Ministry of Health; 2013.
- Simpson A. Faster Cancer Treatment: Implementing the 62 day faster cancer treatment health target. Wellington. NZ Ministry of Health; 20159. Faster cancer treatment indicators: Business rules and data definitions. NZ Ministry of Health cancer services; 2014.
- Faster Cancer Treatment: Measuring and Monitoring faster cancer treatment. Wellington: NZ Ministry of Health; 2015.
- Askew C, Gangji A. Gynaecological cancer pathway for faster cancer treatment: a clinical audit. NZ Med J. 2016 Oct 28; 129(1444):79–89.
- Ministry of Health. National Tumour Standards. 2016. Retrieved from http://www.health.govt.nz/our-work/diseases-and-conditions/cancer-programme/faster-cancer-treatment-programme/national-tumour-standards
- Sullivan R, et al. Global cancer surgery: delivering safe, affordable, and timely cancer surgery. Lancet Oncol. 2015 Sep; 16(11):1193–224. doi: 10.1016/S1470-2045(15)00223-5.
- Lee B, et al. Efficacy of the multidisciplinary tumor board conference in gynecologic oncology. Medicine (Baltimore). 2017 Dec.
- Woo Y, et al. Centralisation of services for gynaecological cancer. Cochrane Database Syst Rev. 2012; 1(3).
- Cohen P, et al. The Multi-disciplinary Tumour Conference in Gynaecologic Oncology – Does it alter management? Int J Gynecol Cancer. 2009; 19:1470–1472.
Contact diana@nzma.org.nz
for the PDF of this article
Faster Cancer Treatment pathway in gynaecological malignancy: a repeat clinical audit
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