Scottish Ovarian Cancer Forum (SOCF): A Feasibility Pilot

Project Title: Scottish Ovarian Cancer Forum (SOCF): A Feasibility Pilot

Project Lead & Pilot location: Dr Mary Cairns – Aberdeen Royal Infirmary – NHS Grampian

Inequality Criteria: Age and location

Objective Criteria: Improve survival rates & reducing inequalities

Scottish Ovarian Cancer Forum (SOCF): A Feasibility Pilot

Full Case Study (10 minute read)

Outline:

The project established a multi-centre, collaborative, real-time, educational multidisciplinary forum for women with advanced ovarian cancer (Stage 3/4) being considered for surgery (upfront or interval). Surgery is key to ovarian cancer treatment, with survival linked to residual disease extent post-surgery.

However, there are substantial regional variations across the UK concerning the proportion of patients undergoing surgery and the amount of residual disease afterwards. The Scottish Ovarian Cancer Quality Performance Indicators (QPIs), implemented in 2013, annually track this, focusing on Stage 2-4 ovarian cancer women undergoing surgery.

Surgery for advanced ovarian cancer in the North Cancer Alliance (NCA) has been centralised in Aberdeen since 2015, covering six health boards across a vast geographical area.

Despite this, the NCA consistently fails to meet QPI 10 targets requiring 65% of women with Stage 2 or higher ovarian cancer to have surgery. As a result, 70% of advanced stage NCA patients were not undergoing surgery. This is significantly higher compared to 47% in the West of Scotland Cancer Network (WOSCAN) and 34% in South East Scotland Cancer Network (SCAN). This translates into poorer survival rates for NCA patients.

There is ongoing debate about factors contributing to this disparity, such as geographical challenges and late disease presentation in rural patients. To address this issue, the NCA has initiated several efforts to increase surgical rates, including clinical nurse specialist provision expansion, multidisciplinary surgical team enhancement, robust High Dependency Unit (HDU) provision, a regional ovarian Multidisciplinary Team (MDT), and planned consultant and theatre expansion. Recent data (2019-20) indicate these efforts are improving surgical rates which are now at 55%.

Project design planning and implementation:

The project was initiated in response to published survival data in 2018, aiming to facilitate shared learning between Scottish cancer networks and provide governance around the MDT surgical decision making within NCA. The project's objectives were to debate and evaluate surgical decision-making practices and thus increase surgical rates for advanced ovarian cancer. The focus of the weekly meeting was to review cross sectional imaging and assess the feasibility of surgical resection. A key measure of the project's success was the proportion of patients for whom a decision for surgery was made.

Project Planning (April-June 2022):

The first three months were dedicated to project planning. The project had a 'mock' meeting on June 15th and officially went 'live' on June 22nd, with weekly meetings thereafter.

Team Composition:

The project team comprised Mary Cairns, Catherine Lamberton (CNS), Nidal Ghaoui Dit Ebef (Consultant Gynaecological Oncologist, NHS Lothian), Elsa Armstrong (data manager), the regional NCA coordinator, and administrative support in all four centres (Dundee, Inverness, Aberdeen, and Edinburgh).

Administrative Challenges:

The project encountered administrative difficulties, including the departure of the regional NCA coordinator six weeks into the project and different IT systems across the four NHS boards. Coordination across these sites was a challenging task until a new regional coordinator took over in September 2022.

Radiology Input:

There were problems obtaining radiology input, causing a delay in discussing cases from the Lothian region until August 3rd. Due to radiology constraints and time, patient numbers had to be capped, and the idea of radiologists presenting cases from other centres was not realised.

Data Sharing Issues:

Early in the planning stages, Caldicott approval was obtained, but there was a delay in obtaining the DPIA agreement with Lothian, causing a slight delay in discussing Lothian cases. Initial issues with different referral documentation submitted from different Boards were quickly addressed.

Standardisation & Streamlining:

With the new Regional NCA coordinator, coming into post, the referral process and outcome recording were streamlined. All boards agreed to use the same referral form, and a standard outcome form was recorded live at the meeting to be uploaded to the patient record later.

Communication Challenges:

Changes in personnel at different boards presented challenges in information access. Communication could have been improved to ensure all parties were aware of their responsibilities and requirements.

Data and Measures:

Qualitative Data:

Participant Interviews were carried out over Teams with CNS Catherine Lamberton from 19/01/23 to the 27/01/23. Members of the Scottish Ovarian Cancer Forum from Gynae Oncology, Medical Oncology, General surgery, Radiology and CNS team members were asked the following questions and their responses are given below. The aim of the interviews was to understand from an individual's perspective what was working well so far, what the challenges have been and what would be needed to sustain and embed this approach.

Key takeaways:

What worked well:

• The utilisation of Teams as a platform for the meetings, providing administrative support and timely distribution of lists.
• The radiology input was commended for its quality, providing valuable perspectives on surgical feasibility.
• The leadership of Dr. Cairns and Dr. Ghaoui was lauded, as were the contributions from the different specialties in Edinburgh.
• Participants generally felt they had ample time for meaningful discussions leading to better patient management decisions.
• The level of participation and respect for differing opinions within the team was also highly appreciated.

What did not work well:

• The timing of the meetings presented significant challenges, especially for those whose shifts started after the meetings or those who had conflicting childcare responsibilities.
• There was a struggle to provide time for the radiology team to prepare for meetings.
• The clarity about who was reporting which cases was sometimes lacking, leading to duplication of work and time wasted in preparations.
• The initial stages of the project posed significant challenges in coordination.
• There was a sentiment of reduced engagement from certain departments like radiology departments in Raigmore and Tayside.

What would be needed to sustain and embed the project:

• Maintaining the current level of administrative support is crucial.
• It is essential to ensure ongoing funding and dedicated time for the radiology team, given their pivotal role in the process.
• Streamlining discussions to avoid duplication of work is important.
• It would be beneficial to clearly outline which regions are preparing which cases.
• There is a need to adapt the timing of the meetings to fit better with the team's other responsibilities.
• Finally, the presence of all stakeholders at meetings is seen as essential for the project's ongoing success.

Results:

Patient Data presented at each meeting included;

Patient Data:

Comprehensive patient data was presented, including age, performance status, comorbidities, drug and social history, histology, CT results at diagnosis and subsequent stages, chemotherapy data, and recent CA125 levels.

Outcome Sheet Data:

Key data recorded included the stage of the disease at presentation, decisions about upfront surgery or neoadjuvant chemotherapy, and stratified decisions considering whether surgery was possible due to patient or disease factors.

Follow-Up Data:

Follow-up data collected included the treatment actually carried out (either surgical or chemotherapy), with detailed descriptions of surgical outcomes and chemotherapy courses. It was noted that some follow-up data was still outstanding due to the patient pathway at the time of the report.

Protocol:

The protocol involved discussing all patients with Stage 3 and 4 ovarian cancer at the time of diagnosis, after three cycles of chemotherapy, or after six cycles if surgery hadn't been performed.

Adjustments were made due to radiology and meeting times. Exceptions were made for patients with contraindications to surgery, such as extreme age or recent thrombo-embolic event. Complex cases with ovarian cancer recurrence were also discussed, even if outside the standard protocol, to assist in decision making.

Performance Status (PS):

It was noted that performance status, an important piece of clinical information for patient decision making, was often not recorded. Despite reminders to clinicians and administrative staff, this issue persisted resulting in incomplete data. This identified a significant area for improvement.

Impact & results - successes

Between June 2022 and February 2023, 122 discussions took place in the Multidisciplinary Team (MDT) concerning 88 women with an average age of 68 years. The majority (82 out of 88) were newly diagnosed, with most (80 out of 82) having stage III/IV ovarian cancer. The remaining 6 cases were recurrences.

The women were grouped into three categories:

• newly diagnosed (55)
• undergoing neoadjuvant chemotherapy (NACT, 27)
• recurrent cases considering surgery (6)

In the first group, 18 were selected for primary surgery, 33 for NACT, and 4 received supportive care.

Of the eighteen selected for primary surgery, 3 died before treatment.

Fourteen of the NACT recipients were subsequently excluded from surgical consideration due to co-morbidities (7), death (2), outcome unknown (3), chemotherapy stopped for best supportive care (2).

For the remaining nineteen, 17 proceeded with surgery and 2 had laparoscopic assessment and did not proceed. Therefore, out of the 55 patients, 32 did have surgery (either primary or interval) , making the actual surgery rate 56%. This is a notable increase from the previous 30% surgery rate

In the second group (undergoing NACT), a higher surgery rate of 81% was observed (22 out of 27). This should be interpreted carefully due to potential patient attrition prior to this point.

For recurrent cases, secondary debulking was decided for 66% (4 out of 6).

However, we lack exact figures for those who were not included in the discussions. With an estimated annual incidence of ovarian cancer at about 200 in the NCA, the 82 new diagnoses discussed over six months suggest that around 18% of the ovarian cancer population may have been overlooked.

Lessons learned – challenges and changes

Lessons Learned:

The project underscored the critical role of surgery in treating ovarian cancer and reinforced the need to consider all women with the condition for surgical intervention, either upfront or interval. It brought to light that nationally, and within NCA, around 50% of women undergo no surgery at all.

The project also highlighted challenges related to planning time, patient selection due to radiology time constraints, and administrative issues.

Strengths of Approach:

The project resulted in the creation of a practical forum for dealing with complex patient cases where decision-making could be particularly challenging. Despite the presence of written guidelines, this forum was proven extremely beneficial clinically, leading to a decision to maintain it, albeit with some revisions, for future use. Moreover, the project was successful in strengthening the working relationships between the two cancer networks.

Limitations

What would be done if undertaken again:

More time would be allocated for planning and addressing the constraints on radiology time to optimise patient selection.

Steps would be taken to address administrative issues that were encountered.

While the forum in its current form may not continue, the emphasis would remain on the importance of stratified surgical decision-making within a multidisciplinary surgical team.

Ongoing discussions between NHS Lothian and NHS Grampian suggest looking at how to best move forward while applying the insights gained from this project.

Conclusion:

The IMPROVE UK Project achieved its primary objectives, providing an educational forum that allowed clinicians to challenge and improve their decision-making processes for patients with advanced ovarian cancer.

The platform fostered stronger collaborations and working relationships among team members, which will potentially enhance future clinical work.

Furthermore, it successfully led to the standardisation of staging, which is expected to significantly aid in quality performance indicator measurements and survival data analysis going forward.

However, it is critical to acknowledge the persisting regional disparities, specifically in resources like manpower and theatre capacity, that pose challenges to the project. The project highlighted the essential role of radiology in these discussions, and thus, underscores the necessity for dedicated radiology input for its continuation.

Despite these challenges, the project shows great promise in paving the way for more collaborative work within Scotland and across the UK. It sets a precedent for future initiatives aimed at improving patient care in ovarian cancer and potentially other areas of oncology.

Project Outputs e.g. protocols, information for patients etc

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These outputs contributed to the effectiveness and evaluation of the project.

Outputs
• Scottish Ovarian Cancer Forum Operational Policy: An operational policy for the Scottish Ovarian Cancer Forum was established as part of the project's guidelines and standard operating procedures.
• SOCF Outcome Form: This form was utilised to document the outcomes of each meeting. It was subsequently uploaded into patient records to ensure continuity of care and clear communication among different teams.
• Surgical Guideline SOCF: A surgical guideline was developed and uploaded as a supporting document to assist in decision-making and standardising care for advanced stage ovarian cancer patients.
• National Radiology Consensus (draft): The project identified discrepancies in radiological staging across different regions, as highlighted in the Ovarian Cancer Survival Analysis (ISD 2018). This led to an urgent national meeting in September 2022, resulting in a draft of a national radiology consensus. The variation in radiological reporting versus the patient population sparked this initiative.
• National Radiology Staging Guideline: The project played a critical role in fostering a consensus on radiology staging guidelines. The document was agreed upon, endorsed, and adapted into clinical practice across all three cancer networks in Scotland. This standardised guideline can help reduce discrepancies and enhance care quality.