Audit on outcome of patients with oesophageal cancer following oesophagectomy

This audit evaluates the positive margin rates and survival of patients undergoing oesophagectomy.

Neo-adjuvant chemotherapy followed by oesophagectomy is the standard of care for oesophageal cancer in the UK [1]. However, prognosis is poor, especially for patients with positive margins [1]. This audit evaluates the survival and positive margin rates of a centre against published clinical trials outcomes and the National Oesophago-gastric Cancer Audit 2013.

The standard: 

• R0 at the circumferential resection (CRM) and longitudinal margins should be achieved in >73% and >96% of patients respectively [2]

• Perioperative in-hospital mortality should be <2.9% [2]

• 1 and 2 years overall survival (OS) of:

   - all patients should be >73% and >50% respectively [1]

   - R1 patients should be >51% and >27% respectively [3]

Target: 

Targets as above.

Indicators: 

• Survival rate of all patients and patients with positive margins

• Perioperative mortality

• Recurrence rate

• Pattern of recurrence

Data items to be collected: 

Demographics:

   • Total number of patients

   • Age of patients

   • Sex of patients

   • Clinical stage of disease

   • Pathological stage of disease

Chemotherapy treatment details:

   • Number of patients receiving neo-adjuvant chemotherapy

   • Type of chemotherapy regimen

   • Number of patients who did not receive neo-adjuvant chemotherapy

Outcome:

   • Adjuvant treatment received

   • Pattern of recurrence

   • Date of recurrence based on imaging or pathology

   • Status at last assessment – alive free of disease, alive with disease, died free of disease, died of disease

Suggested number: 

All patients operated over at least 12 months period.

• Identify reasons for target not being met.

For example:

   - High proportion of patients with advanced disease

   - Low correlation between clinical and pathological staging

   - Low proportion of patients undergoing neo-adjuvant chemotherapy

   - Low number of surgeries performed at centre

• Re-audit once issue identified and change implemented

• Personnel: audit lead

• Collaboration with surgeons and radiologists to collect clinical and pathological stage of disease based on pre-operative and follow-up investigations (CT scan, EUS, PET-CT) and surgery

• Access to MDT proforma

1. Ronellenfitsch U, Schwarzbach M, Hofheinz R, et al. Preoperative chemo(radio)therapy versus primary surgery for gastroesophageal adenocarcinoma: systematic review with meta-analysis combining individual patient and aggregate data. Eur J Cancer 2013; 49(15): 3149-58. doi:10.1016/j.ejca.2013.05.029; 10.1016/j.ejca.2013.05.029.

2. Chadwick G, Groene O, Cromwell D, Hardwick R, Riley S, Crosby T, Greenaway K. National Oesophago-gastric Cancer Audit - 2013, Annual report. 2013; Available at: http://www.hscic.gov.uk/catalogue/PUB11093/clin-audi-supp-prog-oeso-gast-2013-rep.pdf. Accessed January 26, 2013.

3. Allum WH, Stenning SP, Bancewicz J, Clark PI, Langley RE. Long-term results of a randomized trial of surgery with or without preoperative chemotherapy in esophageal cancer. J Clin Oncol 2009; 27(30): 5062-7. doi:10.1200/JCO.2009.22.2083; 10.1200/JCO.2009.22.2083.

S. Teoh, N Warner, S Mukherjee