Gynaecological cancers are a diverse group of cancers arising from the female reproductive tract, encompassing malignancies of the uterus (including endometrium), ovary, fallopian tube, cervix, vagina and vulva, alongside tumours of variable malignant behaviour such as borderline ovarian tumours and persistent gestational trophoblastic neoplasia.[[1]] 10% of all cancer cases in New Zealand are gynaecological, the most common of which is endometrial, followed by ovarian and cervical. They also constitute 10% of all cancer deaths among New Zealand women.[[1]] There are inequitable outcomes between ethnicities, with Māori and Pacific Island patients having higher incidences of and mortality from endometrial and cervical cancers compared to non-Māori/non-Pacific Island.[[1]]

The Ministry of Health Standards of Service Provision for Gynaecological Cancer Patients introduced in 2012 aim to ensure that all elements of gynaecological cancer care are provided in an efficient, sustainable and equitable fashion.[[1]] These standards align with the national Faster Cancer Treatment (FCT) targets.[[2]]

Table 1: National FCT targets, gynaecological tumour standards/good practice points.

Gynaecological cancer services are regionally organised. In Northland District Health Board (DHB), all cases of suspected or confirmed gynaecological cancer are discussed at the Auckland multidisciplinary meeting (MDM), a tertiary level gynaecology-oncology service. The location of treatment is determined by the MDM depending on the complexity of disease and type of treatment required. Patients requiring radiotherapy or surgical treatment by gynaecology-oncology subspecialists receive treatment in Auckland, and others receive treatment in Northland. The above targets provide auditable standards to ensure consistency across centres.[[1]] However, there is still the potential for inequitable access between different DHBs.

Between June 2014 and June 2015, an audit evaluating Northland DHB’s performance regarding these standards identified significant delays across all elements in the assessment and management of patients with gynaecological cancers.[[3]] A repeat audit between January and December 2016 demonstrated an overall improvement, but it also showed that Northland DHB was still falling short of the Ministry of Health targets. Inequities in service provision between Māori and non-Māori patients were also identified.[[4]]

This repeat audit aims to:

1. Assess how Northland DHB is performing with regards to the targets defined in the Standards of Service Provision for Gynaecological Cancer Patients and the FCT targets.
2. Ascertain whether there has been an improvement in service provision following initiatives implemented since the previous audit period.
3. Identify where delays are occurring along the cancer care pathway.
4. Assess equity of service provision between ethnicities, namely Māori and non-Māori.

Methods

The study population for this audit consisted of all patients with gynaecological cancer referred by Northland DHB to the Auckland gynaecology-oncology MDM between 1 January 2018 and 31 December 2020. Patients were identified from MDM meeting minutes held by the gynaecology and colposcopy outpatients clinical nurse specialist. 295 patients were identified, of which 109 were excluded for the following reasons: MDM referral outside of timeframe, recurrent disease, benign histology, non-gynaecological cancer, MDM referral from private practitioners/external DHBs, treatment completed outside the region, or patient declining further investigation/treatment. For the remaining 186 patients, data were collected from electronic documents (discharge summaries, clinic letters, operation notes, MDM summary documents, radiology/histology requests and reports) stored in the electronic collection system Concerto, as well as from physical patient notes and email correspondence. Information regarding patient age, ethnicity, cancer type, referral source and triage category were also collected from the same electronic sources. Patient ethnicities were then prioritised as per the Ministry of Health Ethnicity Data Protocols for the purposes of statistical analysis.[[5]] The data were then collated in a Microsoft Excel spreadsheet and simple statistics were performed to calculate the percentage of patients who met each target, as well as the minimum, mean and maximum waiting times.

The datapoints for this audit were defined using the same definitions as the original audit (Table 2),[[3]] derived from the standards and good practice points from the Standards of Service Provision for Gynaecological Cancer Patients and national FCT targets (Table 1).[[1,2]]

Table 2: Audit datapoints and target timeframe with their respective standard of service provision.

The standards forming datapoints 1 and 6 specify “women referred urgently with a high suspicion of cancer.” However, not all patients with gynaecological cancer are deemed to be “high suspicion” at initial triage. Therefore, the outcomes for these two datapoints were only calculated for those who had their outpatient referral triaged as “urgent with a high suspicion of cancer” or were seen as inpatients. There were also patients triaged as urgent for reasons other than cancer, semi-urgent and routine, and their triage status documented accordingly. These patients were not initially tracked by the FCT pathway until after their FSA. There is no national target for time from referral to FSA for those deemed to require an urgent (non-cancer) or semi-urgent out-patient review. Northland aims to see urgent, non-cancer referrals within 10 working days, semi-urgent within four weeks and routine within four months. To assess the waiting times for radiological investigations across all imaging modalities, datapoints 2a, 2b and 2c were combined to create datapoint 2. Datapoints 3a and 4b were defined in the benchmark audit after discussion with local clinicians as an extrapolation of good practice point 3.3 and standard 12 respectively,[[1]] and were thus reproduced compare the current performance with previous audit periods.[[3]] For datapoints 4b, 5 and 6, the date of decision to treat was the date this decision was discussed with the patient and their whānau following the final MDM plan, in line with the FCT definitions.[[3]]

Results

Patient demographics

Over the three-year period, there were 186 patients with a confirmed diagnosis of new gynaecological cancer. The average age at diagnosis was 61.7 (22–88). Of these 186 patients, 92 were New Zealand European (49.5%), 73 Māori (39.2%), 14 other European (7.5%), two other Asian (1.1%), two Chinese (1.1%), one South East Asian (0.5%), one Fijian (0.5%) and one European not further defined (0.5%). This equates to 113 non-Māori (60.8%) and 73 Māori (39.2%).

Referral and triage information

The majority of referrals came from general practice (68.8%), with the remaining referred by the emergency department (10.2%), other inpatient (14%) or outpatient (5.4%) specialties or from the private sector (1.6%). 59.7% of patients were triaged as urgent with a high-suspicion of cancer, 2.2% as urgent, 11.3% as semi-urgent (11.3%) and 4.3% as routine. 21% of patients were seen as inpatients.

Cancer type

The most common cancer type was endometrial, followed by cervical and malignant ovarian. For 186 patients, there were a total of 189 cancer diagnoses, with three patients having both endometrial and ovarian primaries. The category “other” encompasses gestational trophoblastic disease, other cancers of the Mullerian tract, or where the primary cancer type was not completely determined, most commonly labelled as “primary peritoneal vs tubo-ovarian.” Of interest, the most common cancer types among Māori patients were the most prevalent gynaecological cancers (endometrial, cervical, ovarian), with fewer patients being affected by more rare cancer types (Table 3).

Table 3: Final histological cancer diagnosis (stratified by Māori vs non-Māori).

Standard of service provision

Figure 1: Percentage of patients meeting the target for each datapoint compared to previous audit periods, in reference to the 90% target set by the Ministry of Health.

Datapoint 1 stipulates that women deemed to be “high suspicion of gynaecological cancer” have their first specialist assessment (FSA) within 14 days of referral.[[1]] This target was met for 90.7% of patients, an improvement on 85.4%[[4]] and 65%[[3]] in previous audits. The waiting times were shorter, with a mean time from referral to FSA of 6.7 days (0–33), compared to 12.0 days[[4]] and 10.5 days.[[3]]

Figure 2: Mean wait times for each datapoint compared to previous audit periods.

Datapoint 2 stipulates that radiological investigations are to be completed within 14 days of receiving the request.[[1]] This target was met in 90.4% of cases across all imaging modalities, with a mean time of 7.8 days (0–76). The biggest improvement was seen for MRI scans (2c), with 95.1% of MRIs being performed within 14 days, compared to 75.0%[[4]] and 73%.[[3]] Wait times were shorter, with a mean time of 6.5 days (0–25) compared to 11.2 days[[4]] and 10.6 days.[[3]] The target was met for 82.3% of ultrasounds, with an average wait time of 6.7 days (0–33). Fewer CT scans were performed within target (91.9% compared to 100% in 2016), with slightly longer wait times, too (8.1 days compared to 5.0 days).[[4]]

Datapoint 3a stipulates that the time from decision to take histology to histology being reported should be 14 days or less.[[3]] This is comprised of two components: the time from decision to collect histology to histology collection, and the time from collection of histology to histology report (datapoint 3b). The target for datapoint 3a was met in 66.0% of cases, with a mean wait time of 8.9 days (0–29). This is an improvement compared 40.9%[[4]] and 35%[[3]] in previous audit periods. Stratifying by histology collection method, the longest wait times were for those who required an operation for histology collection, most notably hysteroscopy, with only 22.4% of patients requiring a hysteroscopy meeting the target, waiting a mean time of 28.6 days. However, the wait times were substantially shorter compared to 2014–2015, where the mean wait time for hysteroscopy was 52.0 days.[[3]] Shorter waiting times were seen across all histology collection methods.

Datapoint 3b stipulates that a provisional or final histology report should be communicated with the lead clinician within 10 working days.[[1]] This was met in 88.2% of cases, an improvement on 81.8%[[4]] and 70%[[3]] previously. The mean time for histology reporting was also shorter than previous periods at 5.7 working days.

Datapoint 4a stipulates that the first MDM discussion should occur within 14 days of the MDM referral (provided the referral criteria are met).[[1]] Given that the date of first MDM discussion and date of treatment decision may not be the same, datapoint 4b was created and stipulates that a treatment decision should be made and discussed with the patient within 14 days of MDM referral.[[3]] Datapoint 4a was met in 77.4% of cases, a smaller proportion compared to previous audit periods at 84.4%[[4]] and 93%.[[3]] The wait times for MDM discussion were longer, with a mean time of 12.1 days (2–49) compared to 9.82 days[[4]] and 9.5 days.[[3]] Datapoint 4b was the worst performing outcome in this audit, with only 43.3% meeting the target, though this is an improvement on 31.6% in last audit period.[[4]] The mean time from MDM referral to treatment decision was 20.5 days (0–109), similar to previous.[[3,4]]

Datapoint 5 stipulates that patients with confirmed gynaecological cancer should receive their first treatment within 31 days of treatment decision,[[1]] aligning with the 31-day FCT target.[[2]] This target was met by 89.2% of patients (an improvement on 85%[[4]] and 73%[[3]] previously), with a mean time of 22.3 days (0–151). Stratifying by treatment location, this target was met by 98.8% of those receiving treatment in Auckland, compared to 81.6% of those receiving treatment in Northland. There were statistically significant differences in wait times between treatment locations, with those receiving treatment in Auckland waiting an average of 9.4 days less than those receiving treatment Northland (Table 4).

Table 4: Datapoints 5 and 6 by treatment location.

Datapoint 6 stipulates that patients referred urgently with a high suspicion of cancer should receive their first treatment within 62 days of referral,[[1]] aligning with the 62-day FCT target. As of June 2017, this target should be met by 90% of patients.[[2]] This target was met by 66.9% of patients, with a mean time of 61.3 days (1–398), a significant improvement compared to previous periods at 45%[[4]] and 39%.[[3]] The target was met by 70.6% of those receiving treatment in Auckland, compared to 63.4% in Northland, with mean wait times of 57.3 days and 64.9 days respectively; however, the difference in wait times between treatment locations was not statistically significant (Table 4).

Results by ethnicity

There was a statistically significant difference in age at presentation of gynaecological cancers between Māori and non-Māori, with Māori presenting an average of 6.9 years younger for gynaecological cancers overall (Table 5). Stratifying by cancer subtype, there was also a statistically significant difference in the age at presentation for endometrial cancer, with Māori presenting an average of 7.1 years younger, at a mean age at presentation of 60.4 years old (95% CI 56.6–64.2), compared to 67.5 years old (95% CI 65.0–70.0) for non-Māori.

Māori patients with cancer were less likely to be triaged as urgent with a high suspicion of cancer or to be seen as inpatients, and were more likely to be triaged as semi-urgent or routine compared to non-Māori (Table 6).

Table 5: Mean age at presentation for all gynaecological cancers for Māori and non-Māori.

Table 6: Percentage of Māori and Non-Māori for each triage category

Compared to non-Māori, Māori were less likely to have their CT scans performed within 14 days (datapoint 2b), have a treatment decision within 14 days of MDM referral (datapoint 4b), or receive their first treatment within 31 days of treatment decision (datapoint 55) and 62 days of initial referral (datapoint 6) (Figure 3).

Figure 3: Percentage meeting each datapoint target by ethnicity, in reference to the 90% target set by the Ministry of Health.

Figure 4: Mean wait times by ethnicity (with 95% confidence intervals).

Māori had longer wait times for most datapoints, though these differences were not statistically significant (Figure 4). The largest difference was for datapoint 3a, with Māori patients waiting on average 4.5 days longer compared to non-Māori; with similar wait times for datapoint 3b, this is due to a delay in collecting histology. Looking specifically at hysteroscopy, Māori waited almost twice as long from decision for hysteroscopy to hysteroscopy being performed compared to non-Māori (27.6 days compared to 15.0 days). Compared to the previous audit period, there has been an improvement in equity of service provision, with a higher proportion of both Māori and non-Māori met the 31- and 62-day targets (datapoints 5 and 6), alongside a reduction in wait times for both groups (Table 7).

Table 7: Datapoints 5 and 6 by ethnicity compared to 2016 audit period.

Discussion

The introduction of tumour-specific national standards as part of the Ministry of Health’s FCT programme have improved service delivery and clinical practice for all elements of cancer care.[[1]] However, while the standards provide a framework for the provision of cancer care, the overall target of 62 days from referral to first treatment is difficult to achieve, with only 66.9% of patients meeting this target. Although this is a substantial improvement compared to previous audit periods, it is still far from the 90% target set by the Ministry of Health and is only a marginal improvement on baseline performance established by the Ministry of Health in 2014 of 65%.[[3]] With 89.2% of patients receiving treatment with 31 days of decision to treat, most of the delays in cancer care occur during the investigation and discussion processes that lead to a treatment decision.

The best performing area in this audit was radiological investigations, with 90.4% of all imaging being performed within the 14-day target. The most notable improvement was in MRI, with 95.1% of MRI scans being performed within the target. This is a reflection of Northland DHB’s increased MRI capacity, with urgent MRI now being performed on Saturdays.

There are ongoing delays in obtaining histology, with 66.0% of patients having their histology reported within 14 days from decision to collect histology. This is largely confined to those requiring an operative procedure (most commonly hysteroscopy), a reflection of the inadequacy of theatre resources, preventing timely investigation and management for cancer patients across all specialties. The deficits identified in the benchmark audit led to the implementation of an additional weekly gynaecology operating list, for which patients with suspected or confirmed malignancy are prioritised. There has subsequently been substantial improvement in the proportion of patients meeting the 14-day target compared to this audit (66.0% vs 35%), with a decrease in average wait times from 31.5 days to 8.9 days. As it stands, hysteroscopies are almost always performed under general anaesthetic; implementation of outpatient hysteroscopies is being considered as a way of improving access, but this is yet to be implemented.

Centralised MDMs are now the standard of care for gynaecological cancer as they have been shown to improve patient outcomes.[[6]] Unfortunately, this audit shows it is also one of the rate-limiting steps in initiating treatment, with fewer patients having their first MDM discussions within 14 days of referral, and waiting longer from MDM referral to MDM discussion compared to previous audits. Treatment decisions are often further delayed due to the need for multiple discussions and for additional investigations requested by the MDM. Once a decision is made, patients were able to access treatment within a reasonable timeframe, suggesting that the delays during the MDM process contribute the delays seen in the overall time from referral to gynaecological services to first treatment. Unfortunately, results pertaining to the MDM process may be inaccurate; MDM referrals are submitted via email correspondence between individual clinicians and are often submitted pending completion of investigations. There is no formal documentation of when referrals are sent or deemed complete, meaning that the date of MDM referral used for statistical analysis was often a best guess. We have suggested the date of referral be included in the MDM meeting minutes to improve the accuracy of future audits.

It is a shame to see ongoing inequities between patients depending on treatment location, with patients receiving treatment in Auckland having significantly shorter wait times once a treatment decision has been made and minimal improvement compared to previous audit periods. Patients living in Northland already face immense geographical barriers to accessing specialist services, with Northland DHB covering a land area of 13,286km[[2]] compared to Auckland’s 1,086km[[2]].[[7]] These barriers are compounded by socioeconomic status, with a high proportion of Northland people living in the most deprived quintile.[[8]] The inequities that exist are a reflection on the immense strain on surgical services in Northland, with small secondary-level services catering for a population of 193,170.[[7]] These differences are compounded by the comparatively larger operating capacity that the subspecialty gynaecology-oncology service has. In addition, patients deemed suitable for surgical treatment in Northland tend to have earlier stage and less aggressive disease, making treatment somewhat less time sensitive.

Māori and Pacific Island women have higher incidences of and mortality from gynaecological cancers and evidence shows that Māori women have poorer access to healthcare and worse survival rates.[[1]] Māori were over-represented in this audit, comprising 39.2% of patients with gynaecological cancer, compared to 35.8% of the Northland population.[[8]] Compared to non-Māori, Māori patients are waited longer for histology collection—particularly hysteroscopy—as well as for their first treatment, from both decision to treat (datapoint 5) and initial referral (datapoint 6). There has been an improvement in these two datapoints compared to the last audit period, but a difference remains. Of interest were the disparities in triage category: Māori patients with cancer were much more likely to be triaged as routine, with a relative risk of 4.6 (95% CI 1.0–22.4) compared to non-Māori. Triaging of referrals is currently performed by a designated senior medical officer (SMO) based on the clinical information provided by the referrer. For those with cancer, a triage category of semi-urgent or routine causes significant delays in time to FSA, with Northland DHB aiming to see patients within four weeks and four months of referral, respectively. This subsequently delays access to appropriate treatment. However, due to the wording of Standards of Service Provision for Gynaecological Cancer Patients, these delays are not reflected in the outcomes for datapoints 1 and 6, as these patients are not deemed to have a high suspicion of cancer at the initial referral. If we look at the mean time from referral to first treatment for all patients with a confirmed cancer diagnosis, it increases from 68.5 to 93.8 days for Māori, and from 57.3 to 69.0 days for non-Māori—a much larger disparity than the outcomes for datapoint 6 would suggest. One possible explanation for these disparities may be the younger age at diagnosis for Māori patients with gynaecological cancer, notably endometrial cancer occurring in premenopausal women. As a result of this audit, Northland DHB plans to take into consideration the fact that Māori women present younger with gynaecological cancer when triaging referrals, with the aim to address the delays in accessing appropriate treatment for these women.

This audit is one of the first to comment on equity of service provision for patients with gynaecological cancer between ethnicities, and although it demonstrates some statistically significant differences between Māori and non-Māori, the sample size was too small to definitively comment on the statistical significance of many of the potential inequities highlighted. An audit with a larger sample size over a longer period of time would be of use to further investigate these differences.

Supplementary material

Supplementary Table 1: Percentage of patients meeting each target and mean wait times for each datapoint compared to previous audits. View Supplementary Table 1.