An audit of the management of uterine malignancy within the West Midlands
This paper is published on behalf of the West Midlands Gynaecological Oncology Group, whose members are listed on page 555.
Correspondence: Mr C. W. E. Redman, Academic Unit, Maternity Building, North Staffordshire Hospital, Stoke-on-Trent ST4 6QG, UK.
Objective To audit the management of uterine malignancy.
Design Retrospective casenote analysis.
Setting Cancer units/centres within the West Midlands.
Sample The last 10 cases managed by each hospital in 1997.
Results Ninety-six cases of uterine malignancy from ten hospitals were analysed. Only six hospitals were able to provide a complete data set. Eighty-eight cases (92%) presented with abnormal, usually postmenopausal, vaginal bleeding. Over 90% of the cases were primary endometrial carcinomas. Of the 15 standards audited, 11 were met by at least one hospital. No hospital met all the standards, although every hospital was able to meet at least one. Standards concerned with initial referral and diagnostic intervals were universally failed. Outpatient diagnosis was made in only 30%. The availability of Rapid Access Clinics neither promoted outpatient diagnosis nor sped up diagnosis. Once the diagnosis had been made, surgery was usually performed within six weeks.
Conclusions This audit has provided valuable baseline data for future activity. Serious attention must be given to improvement in clinical cancer data collection. Referral pathways for women with suspected uterine cancer, and endometrial cancer in particular, need improvement. It is recommended that the current standards remain unaltered, and after the West Midlands Gynaecological Oncology Group had the opportunity to consider and implement the necessary changes, the audit be repeated.
All cancer patients should have access to a uniformly high standard of care1. In order to promote this, providers have been urged to develop guidelines and audit their performance. To foster these goals, the West Midlands Gynaecological Oncology Group was formed, comprising gynaecologists, pathologists, oncologists and specialist nurses from all 16 cancer units and centres in the region. Clinical guidelines for each of the gynaecological cancer sites were completed and accepted by the group as a whole by the beginning of 1998 after almost 12 months of active and open discussion. Standards were derived from these guidelines in order to audit quality of care. This report describes the baseline audit on the management of uterine malignancy.
In April 1998 the lead clinician from each of the gynaecological cancer centres was assigned the task of collecting data from the last 10 cases of uterine malignancy diagnosed in their hospital during 1997, using a standard proforma. A reminder letter was sent out in July 1998 and forms returned by 31 August 1998 were analysed. Wherever possible, missing data items were sought after.
Each hospital was asked to provide details of its cancer team in terms of lead and support gynaecological surgeon, oncologist, pathologist and gynaecological oncology nurse. In three hospitals a ‘formal’ cancer team was only formed during or after the audit period but for the purpose of this audit, the referral pattern was assessed on whether or not patients were referred to clinicians who subsequently became members of the cancer team.
A list of 19 standards had been identified, which primarily dealt with the patient pathway, in terms of timing, referral pattern and management. The primary referral interval was defined as the interval between the date on the referral letter and first clinic visit (if patients presented as an emergency then the primary interval was 0). All the standards required a performance of greater than 80%.
The data from the completed proformata were transcribed onto a Macintosh microcomputer and analysed using Abacus Concepts, Statview 4–01 (Abacus Concepts, Inc, Berkeley, California, USA, 1992). Categorical data was analysed using the χ2 test.
Ten out of the 16 gynaecological cancer teams within the West Midlands participated in the audit, contributing 96 cases with adequate data. Two of the noncontributors were cancer centres (Table 1). Only four of the participating hospitals had a designated Rapid Access Clinic but virtually (90%) all had a specialist gynaecological oncology nurse.
Table 1. Contributing gynaecological cancer teams. Values are given as n. WM = West Midlands; GO nurse = gynaecological oncology nurse specialist
Only six hospitals provided adequate data on 10 cases. Four hospitals provided data on only nine cases as one unit had only managed nine uterine malignancies that year, while in the other three, only nine clinical records could be traced.
The mean age at presentation was 64 years (range 37–85). Eighty-eight women (92%) presented with abnormal vaginal bleeding (postmenopausal bleeding = 81; perimenopausal bleeding = 6; irregular bleeding on hormone replacement therapy = 1). Of the remaining eight cases, two women presented with an abnormal asymptomatic cervical smear and six presented with either with a suspected pelvic mass and/or ascites.
The disease characteristics of the 96 cases are summarised in Table 2. Over 90% of the cases were primary endometrial carcinomas. There were five malignancies of mesenchymal origin; three mixed Müllerian tumours (Stages I, II and unknown), a Stage I leiomyosarcoma found incidentally at hysterectomy for suspected fibroids and a Stage IV high-grade endometrial stromal sarcoma.
Table 2. Disease characteristics. Values are given as n
The standards chosen and the results of their audit are summarised in Table 3. Four standards dealing with patients who did not present with abnormal vaginal bleeding are not presented as the numbers involved are too small for meaningful comment. These standards were:
Table 3. Percentage of cases meeting audit standard (the target for each standard was 80%). Values in bold = standard achieved. PMB = postmenopausal bleeding; GCT = gynaecological cancer team; GO = gynaecological oncology.
|A. Primary referral|| || || || || || || || || || || |
| 1. PMB/discharge should be referred to the GCT||48||88||100||44||71||60||40||44||37||56||2|
| 2. PMB/discharge should be seen within 2 weeks||33||50||50||22||43||50||50||11||50||22||0|
|B. First visit|| || || || || || || || || || || |
| 1. Diagnosis within 2 weeks of first visit*||29||44||37||60||30||70||30||50||20||44||0|
| 2. Patients informed of diagnosis within 2 weeks*||24||22||37||30||10||70||20||20||10||10||0|
|C. Second visit|| || || || || || || || || || || |
| 1. Should be within 2 weeks of first visit||26||22||30||30||20||70||20||20||10||22||0|
| 2. Patient should be seen by GCT||49||88||60||50||80||70||40||50||40||56||1|
| 3. Patient should be introduced to GO nurse||22||88||100||0||40||0||10||0||10||0||2|
|D. Surgery|| || || || || || || || || || || |
| 1. Should be within 8 weeks of first visit*||72||67||43||89||55||89||44||78||77||78||2|
| 2. Should be within 6 weeks of second visit||87||100||71||100||67||100||100||89||89||89||7|
| 3. Should be performed by the GCT||60||88||86||44||100||70||40||78||20||56||3|
|E. Primary radiotherapy|| || || || || || || || || || || |
| 1. See radiotherapist within 2 weeks of referral||56||100||71||60||43||75||100||67||50||0||2|
| 2. Should commence within 6 weeks of referral||58||50||86||100||71||100||87||83||33||44||4|
|F. Management|| || || || || || || || || || || |
| 1. Referred to the GCT prior to treatment||63||88||87||50||100||70||40||70||60||56||3|
| 2. Discussed at a multidisciplinary meeting||40||88||12||100||100||0||0||80||10||0||3|
| 3. Histological diagnosis by GCT pathologist||52||100||37||50||60||50||40||50||20||77||1|
|Time to ‘recruit’ sample (months)**|| ||7||12+||4||7||7||12||4||12+||7|| |
|Total no. of standards met|| ||9||5||4||3||3||4||1||1||1|| |
- 1> 90% of women with smears suggestive of endometrial cancer should be referred to the gynaecological cancer team.
- 2> 90% of women with smears suggestive of endometrial cancer should be seen with two weeks.
- 3> 90% of women aged > 45 years with abnormal perimenopausal bleeding should be seen with six weeks.
- 4> 90% of women with abnormal bleeding on hormone replacement therapy should be seen within six weeks.
Standards B1, B2 and D1 relate only to women presenting with postmenopausal bleeding (n= 81).
Of the 15 standards audited, 11 were met by at least one hospital. No hospital met all the standards, although every hospital was able to meet at least one standard. There was no association between workload and number of standards met. No hospital met the necessary standards concerned with initial referral interval and time to diagnosis. On the other hand once the diagnosis had been made, surgery was performed within the required six weeks from the second visit in 80% of cases.
Approximately half of the 81 women who presented with postmenopausal bleeding were seen within two weeks. Overall, the mean primary referral interval was 3.4 weeks (range 0–12). Eleven women were admitted as emergencies either directly to the ward or via the Accident and Emergency Department. Table 4 summarises how and where the diagnosis was made. In only 24 (30%) was the diagnosis made by outpatient endometrial sampling (plus hysteroscopy on a single occasion). In the four hospitals with a Rapid Access Clinic, only half (17/35) of the women with postmenopausal bleeding processed them. Even then, 12 of the 17 (71%) women seen in a Rapid Access Clinic subsequently underwent inpatient endometrial assessment. The provision of a Rapid Access Clinic did not increase the proportion of women seen within 14 days of referral (χ2= 0.52; P= 0.8) or promote increased outpatient diagnosis (χ2= 0.45; P= 0.5).
Table 4. Association between mode of diagnosis and provision of a Rapid Access Clinic for women presenting with postmenopausal bleeding. Values are given as n. OP = outpatient; IP = inpatient.
|OP end sample||4||4||15||23|
This relatively simple exercise has been valuable and a number of lessons have been learnt. Although the required information should have been easy to collect data were received from only 10 of the 16 (62%) constituent members of the group and, even then, only six units were able to find all the notes. All members reported problems in obtaining the clinical information as much of the simple data required for this audit was not being routinely collected. No support was received from any of the hospitals' clinical audit or informatics departments. The importance of clinical audit in cancer units and centres is stressed in the Calman-Hine report but the current deficiencies in data collection and handling, coupled with insufficient audit facilities significantly limits its potential. Despite the shortcomings in the execution of this audit, it has highlighted the deficiency in the routine collection of gynaecological cancer data, which has been found by others2. The West Midlands Gynaecological Oncology Group is devising a prospective minimum clinical and pathological dataset to enable prospective and adequate data collection.
The Expert Advisory Group on Cancer1 were particularly concerned that all patients have ‘access to a uniformly high standard of care’. This audit indicates that there are wide variations as evidenced by the number of standards met. Quality of care, as defined by the standards used in this audit, was independent of workload or whether the hospital was a cancer centre or unit. The standards were predominately concerned with the patient pathway and were empirical. They were determined by consensus of the group as a whole as representing a minimum standard for care. Referral intervals and response times were, in part, based on the standards from the NHS Cervical Cancer Screening Programme. While every hospital was able to met at least one of the audited standards, there were four standards, dealing with initial referral and diagnosis, that no hospital met. This might indicate that the standards were either wrong or unrealistic. Following discussion of the West Midlands Gynaecological Oncology Group it was decided that the standard (A2) requiring that ‘more than 90% of women with postmenopausal bleeding should be seen with two weeks of referral’ should remain unchanged as 33% of patients were seen within the required interval, indicating that the standard is feasible. Every effort should be made to ensure that delays in referral be minimised by improved communications between the general practitioners and hospitals. Although the clinical importance of postmenopausal bleeding is well recognised, less than half of these patients were referred to one of the cancer team gynaecologists. Simple measures, such as clearly defined referral pathways and use of the telephone should help. Some will advocate the need for increased resources to meet these standards; however, part of the problem stems from the fact that many cancer teams have a general gynaecology commitment that necessarily compromises their ability to see higher priority cases while suspected and even confirmed malignancy continues to be managed outside the cancer team. There is, therefore, an argument for a redistribution of caseload before more resources, if any are available, are thrown into the pot.
The other three standards not achieved by any hospital were concerned with the interval between the first and second visit, when ideally the diagnosis is known and communicated to the patient. The main limiting factor is the time needed to process the histological report although this was achieved in a quarter of cases. Therefore, it is recommended that this standard also remains unchanged.
Only 30% of women presenting with postmenopausal bleeding received outpatient endometrial sampling which is lower than reported in the North West Region3. The inevitable delays and risks resultant from inpatient investigation are unnecessary when effective outpatient diagnosis is possible4 and every effort should be made to establish the diagnosis at the initial visit. Introducing Rapid Access Clinics for ‘one-stop’ diagnosis may help, although in this audit they did not appear to do so. The data would suggest that these clinics were not being used properly as most women attending them still underwent inpatient assessment. While there was a wide variation in initial referral and diagnosis, the time to treatment was more uniform once the diagnosis was established. The interval from the second visit to surgery was less than six weeks in all but two hospitals and overall 87% underwent surgery within the specified time. Consequently initial referral and diagnostic intervals offer the greatest scope for improvement.
Women with postmenopausal bleeding continue to be referred to gynaecologists outside the cancer team. Although this audit indicates that once the diagnosis of uterine malignancy is made referral to the cancer team can occur, only 60% of operations for uterine malignancy were performed by the cancer team. There is still a commonly held belief that uterine cancer management is simply a question of surgery and sometimes radiotherapy. However, patients managed outside the multidisciplinary approach of the cancer team are being denied the advantages that such an approach can bring. Prior to treatment only 40% of cases were formally discussed at a multidisciplinary case conference. Six of the nine hospitals did convene regular multidisciplinary case conferences but it was not standard practise to discuss every case, as recommended in the guidelines. This is an area for debate. With the advent of the ASTEC study it could be argued that every case should be formally discussed to document entry into this study, as recruitment could, of itself, act as a marker of quality of care.
The West Midlands Gynaecological Oncology Group guidelines recognise the importance of the gynaecological oncology nurse, who can co-ordinate every aspect of the patient's care, liaising with colleagues within and outside the hospital, as well as acting as the patient's guide through the treatment pathway. Only one unit lacked a gynaecological oncology nurse, so it was disappointing that in only five hospitals was she present in the clinic when the diagnosis was given, as this is an especially important time. Only two hospitals reached the necessary standard but this, in part, may have been a failure in documentation rather than in practise.
This audit exercise has provided valuable baseline data for future activity. All the hospitals in the West Midland Gynaecological Oncology Group have received cancer unit/centre recognition partly because of their stated commitment to working within the group's guidelines. This study emphasises the difference between intention and actual practise. It is recommended that the current standards remain unaltered, and after the West Midlands Gynaecological Oncology Group have had the opportunity to consider and implement the necessary changes, the audit be repeated. Apart from these clinical considerations serious attention must be given to improvement in clinical cancer data collection.
West Midlands Gynaecological Oncology Group members: Dr C. B. Finn, Mr A. C. Head, Professor D. M. Luesley, Mr G. J. Lewis, Mr D. J. Murphy, Miss J. Meggy, Dr S. Oates, Mr M. D. Pickerell, Mr A. D. G. Roberts. The West Midlands Gynaecological Oncology Group wishes to thank all those involved in the collection of the audit data.