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The National Prostate Cancer Audit — Introducing a New Generation of Cancer Audit

Published:November 07, 2013DOI:https://doi.org/10.1016/j.clon.2013.10.006
      Health service providers and healthcare professionals are expected to assure the quality of their services and safe-guard high standards of care. Successive UK governments have claimed that it is their ambition to provide a health service that achieves ‘world-class healthcare outcomes’ []. The current government has translated this into three priorities for the National Health Service (NHS): (a) empower local clinicians to deliver better outcomes, (b) provide information to patients that will help them to make choices and (c) create greater accountability to all those who use the NHS [
      • National Commissioning Board
      ]. Although there is ongoing political debate about how we can create an ‘NHS which achieves results that are amongst the best in the world’, it is evident that national clinical audits have an important role to play [
      • Black N.
      Time for a new approach to assessing the quality of hospitals in England.
      ].
      In this editorial, we describe the National Prostate Cancer Audit (NPCA) as an example of a new generation of national audits of cancer services in England and Wales (http://www.npca.org.uk). The audit is part of the National Clinical Audit and Patient Outcomes Programme, which also includes four additional cancer audits focusing on head and neck oncology, lung cancer, oesophago-gastric cancer and bowel cancer [
      • Healthcare Quality Improvement Partnership (HQIP)
      National clinical audit projects managed and commissioned by HQIP: programme list 2013/14.
      ].
      Current political initiatives have moved away from measuring process targets in the NHS towards a ‘relentless focus on clinical outcomes’, which should be measured and reported in the public domain to encourage quality improvements []. The current NHS outcomes framework presents a series of indicators covering five outcome domains designed to provide a balanced coverage of NHS activity [].
      For cancer services, new indicators will measure overall 1 and 5 year survival for all cancers (including childhood cancers), as well as specific 1 and 5 year survival for breast, lung and bowel cancer combined []. However, quality itself is a multidimensional concept that reflects many different aspects of the healthcare system, including safety, effectiveness and patient experience, as well as issues related to equity [
      • Institute of Medicine (US)
      Crossing the quality chasm: a new health system for the 21st century.
      ]. Therefore, the scope of national clinical audits should extend beyond the provision of outcome data alone.

      National Prostate Cancer Audit

      The NPCA has been commissioned on behalf of NHS England. It started on 1 April 2013 and will continue for at least 5 years. It aims to collect information on the stage of newly diagnosed patients and their subsequent treatment choices. It will provide detail on early complications, longer term survival and quality of life. The audit also focuses on areas of controversy, such as the management of patients with low-risk disease (‘are we over-treating patients potentially best managed by active surveillance?’) as well as the availability and provision of multimodality therapy for patients with advanced disease (‘are we under-treating patients with locally advanced or high-risk disease?’).
      The NPCA follows an ambitious time schedule and aims to deliver outputs relevant to clinical practice early in the course of the audit, thereby enhancing the ‘buy-in’ and participation of local staff. It has four main components. First, an organisational survey will determine the current infrastructure of prostate cancer services in England and Wales, including the availability of high dose rate and low dose rate brachytherapy, intensity-modulated radiotherapy and robotic surgery.
      Second, an analysis of pre-existing data sources, including radiotherapy and chemotherapy datasets, routine hospital episode statistics, national cancer registry records and mortality records from the Office for National Statistics, will provide baseline data on current practice and outcomes.
      Third, a prospective audit of all newly diagnosed prostate cancer patients in England and Wales will investigate patient demographics, routes to diagnosis, tumour characteristics, diagnostic and staging investigations, treatment choices and patient outcomes. A particular focus will be adherence to national guidelines [
      • National Institute for Health and Care Excellence
      Prostate cancer diagnosis and treatment – NICE clinical guideline 58.
      ].
      Fourth, the audit will collect patient-reported outcomes and experience measures (PROMs and PREMs). Patients who receive radical treatment will be sent a questionnaire 12 months after their initial diagnosis. This will be the first time that a national clinical audit of cancer services will systematically measure the functional impact of radical therapies on patients' lives.
      The organisational survey and analysis of existing data will be carried out in the audit's first year. The collection of data on newly diagnosed men will start from April 2014 and it is intended that PROMs and PREMs data will be collected 1 year after diagnosis (from April 2015).
      A guiding principle for the prostate cancer audit's design, which truly makes it the first of a new generation of national audits of cancer services, is that the burden of data collection on staff and patients will be kept to a minimum. Data will therefore be collected by capturing the dataset that is routinely collected by the multidisciplinary teams through the newly established National Cancer Registration Service in England [
      • Public Health England
      The National Cancer Registration System.
      ]. In its initial year, the audit will try to ‘harmonise’ these multidisciplinary team datasets and consider inclusion of additional data items.
      The National Cancer Registration Service in England will also collect imaging records, pathology results, radiotherapy and chemotherapy data, and information about survival from the Office for National Statistics. The audit will also incorporate the recently implemented Cancer Outcomes and Services Dataset, which replaces the National Cancer Dataset as the new national standard for reporting cancer in the NHS in England [
      • Public Health England
      Cancer Outcomes and Services Dataset (COSD).
      ]. The potential of this national registration system is vast and it will certainly change how national clinical audits of cancer services will be carried out in the future. Data on patients diagnosed in Wales will be provided by NHS Wales from the Welsh Cancer Information System [
      • Wales N.H.S.
      Cancer Network Information System Cymru.
      ].
      There are many challenges in ensuring that a high-quality national audit dataset is being collected. The harmonisation of the datasets may require multidisciplinary teams to collect data items that are not routinely available at present. For example, the collection of long-term toxicity data may be limited in the audit's initial period. On the other hand, it is envisaged that by necessitating routine collection of these data items, their completeness will greatly improve in the long run.

      National Clinical Audits: A Source of Real-life Data

      Research studies, especially experimental studies using randomisation, are designed to have a strong ‘internal validity’ (i.e. they are designed to minimise the possibility of bias). As a result, the settings in which they take place and the patients they include often differ from ‘real-life practice’ [
      • Garrison Jr., L.P.
      • Neumann P.J.
      • Erickson P.
      • Marshall D.
      • Mullins C.D.
      Using real-world data for coverage and payment decisions: the ISPOR Real-World Data Task Force report.
      ]. National clinical audits offer a rich source of real-life data as they are designed to be relevant to a particular group of patients in a particular clinical setting. As a consequence, these audits have many complementary advantages (Figure 1).
      Figure thumbnail gr1
      Fig 1Advantages of real-life data (adapted from
      [
      • Garrison Jr., L.P.
      • Neumann P.J.
      • Erickson P.
      • Marshall D.
      • Mullins C.D.
      Using real-world data for coverage and payment decisions: the ISPOR Real-World Data Task Force report.
      ]
      ).
      Apart from providing an opportunity to assess the generalisability and applicability of the results of experimental studies, data from national clinical audits can be used to determine how services can be best organised and delivered. Variation in access to cancer services is a serious concern and audit data can answer questions such as ‘why do patients with similar health problems receive different treatment?’.
      An enhanced understanding of factors that contribute to practice variation will be the first step towards designing better services. This is illustrated by a recent review of the National Radiotherapy Dataset. This review showed variation in the number of radiotherapy attendances in England, with higher rates of activity in smaller and non-teaching radiotherapy centres [
      • Hoskin P.
      • Forbes H.
      • Ball C.
      • Riley D.
      • Cooper T.
      Variations in radiotherapy delivery in England—evidence from the National Radiotherapy Dataset.
      ]. Possible explanations for this trend are the closer proximity of small centres to the patient population, thus improving access, and the choice of other treatment modalities from surgical services and medical oncology that may be offered at larger teaching hospitals. Another example is a review of radiotherapy demand and activity in England that highlighted current underprovision of radiotherapy across all cancer sites [
      • Round C.
      • Williams M.
      • Mee T.
      • et al.
      Radiotherapy demand and activity in England 2006–2020.
      ]. Reduced access to radiation treatment and non-conformity to accepted evidence-based fractionation schedules were identified as explanatory factors.
      An investigation of immediate breast reconstruction after mastectomy for breast cancer is an example of a study addressing determinants of practice variation [
      • Jeevan R.
      • Cromwell D.
      • Browne J.
      • et al.
      Regional variation in use of immediate breast reconstruction after mastectomy for breast cancer in England.
      ]. This study, which was part of the National Mastectomy and Breast Reconstruction Audit [
      • Royal College of Surgeons of England – Clinical Effectiveness Unit
      ], showed considerable regional variation in the use of immediate reconstruction between English cancer networks, highlighting how patient choice can be influenced by the availability of services within an area. The audit also found that post-mastectomy radiotherapy use differed across networks, which may partly explain the observed variation in immediate breast reconstruction.
      Similarly, audit data can also be used to investigate determinants of variations in outcomes (‘why do patients who receive similar treatments experience different outcomes?’). An example is a study of the impact of the ‘route-to-diagnosis’ on the survival of patients with oesophago-gastric cancer [
      • Palser T.R.
      • Cromwell D.A.
      • Hardwick R.H.
      • Riley S.A.
      • Greenaway K.
      • van der Meulen J.H.
      Impact of route to diagnosis on treatment intent and 1-year survival in patients diagnosed with oesophagogastric cancer in England: a prospective cohort study.
      ]. This study, which was part of the National Oesophago-gastric Cancer Audit [
      • Royal College of Surgeons of England – Clinical Effectiveness Unit
      ], found that outcomes are considerably worse if patients are diagnosed after an emergency admission to hospital, resulting in the key recommendation that NHS providers develop strategies to reduce emergency admissions within their local cancer network.
      A final example of the research potential of national clinical audit data comes from the National Bowel Cancer Audit [
      • The Association of Coloproctology of Great Britain and Ireland (ACPGBI)
      ]. It found that 90 day mortality after bowel cancer surgery has decreased from 6.4% in 2008 to 4.5% in 2012. This drop in mortality coincides with substantial changes in patient selection and postoperative care by multidisciplinary teams involved in the initial management of bowel cancer patients. However, interpreting the causality of these relationships requires some caution.

      Conclusions

      The NPCA, which starts collecting data in 2014 on newly diagnosed patients, has great potential to contribute to improvements in prostate cancer services in England and Wales. It will compare practice against national guidelines and address concerns about over-diagnosis and over-treatment of men with low-risk disease and under-treatment of men with locally advanced or high-risk disease. It will also compare outcomes among NHS providers. Many of these outcomes will be reported by the patients themselves. At the same time, the audit will generate a wealth of ‘real-life’ [
      • Garrison Jr., L.P.
      • Neumann P.J.
      • Erickson P.
      • Marshall D.
      • Mullins C.D.
      Using real-world data for coverage and payment decisions: the ISPOR Real-World Data Task Force report.
      ] data that will provide unprecedented opportunities to study questions about how the treatment of men with prostate cancer can be further improved.

      Conflict of Interest

      The authors are members of the Project Team of the National Prostate Cancer Audit, which investigates the care that men with prostate cancer receive in England and Wales (www.npca.org.uk/). This audit is funded by the Healthcare Quality Improvement Partnership (www.hqip.org.uk/) on behalf of NHS England and NHS Wales.

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