Quality objectives for the Gynecological Cancer Registry
The register's specific quality objectives
Currently, none of the register's quality indicators have the status of national quality indicators. The Cancer Registry of Norway and the Gyn Cancer Registry of Norway's advisory council collaborate with the Norwegian Directorate of Health to give a selection of the professional community's quality indicators national status.
The quality indicators are largely based on national and European recommendations/guidelines. The Academic Council evaluates the indicators every year and, if necessary, adjusts in accordance with the latest knowledge.
Quality indicators for ovarian cancer:
The use of CT thorax/abdomen/pelvis and/or pelvic MRI in the assessment of ovarian cancer was introduced as a quali- tet indicator in last year's report. The 95% indicator target will be achieved at the national level in 2022 with a share of 97.2%. Last year, a quality indicator was also introduced for the implementation of an MDT meeting during the assessment of ovarian cancer. The indicator target was set for at least 95 % of all ovarian cancer patients. The target will not be achieved at the national level in 2022 with a share of 83.6%.
The proportion of patients who undergo surgery varies depending on where the patients live. In total in the country, 70.7 % of patients undergo surgery. In the Central Norway Regional Health Authority Norway, 75.0 % of the patients underwent surgery in 2022, compared with 67.8 % of the patients in the South-Eastern Norway Regional Health Authority. The results also show variation in the proportion who undergo surgery according to where the patient lives within the health regions.
The indicator goal for centralised treatment is that at least 80 % of operations should be performed at a hospital with special expertise in gynaecological oncology. At the national level, 84.5% of the operations were performed at one of the country's hospitals with specialist expertise in 2022. Centralisation is recommended to ensure the quality of treatment, as well as being considered more cost-effective.
Mortality 60 days after surgery over the past three years as a whole now stands at 0.6 %, which is well within the indicator target for the registry, which is set at a maximum of 3 %. Postoperative mortality one year after surgery for the same three-year period was 6.2 %.
The results show some variation between hospitals, but to a lesser extent than we have seen in previous annual reports. Total mortality one year after diagnosis in the last three years was 18.8 % at the national level. The variation between health regions was 16.8–21.3%.
The 5-year survival rate for ovarian cancer has increased steadily over the past 40 years from 31.1% in 1980 to 50.9% in 2022. The variation between health regions in 2022 was from 44.9% to 53.1%, which is slightly less variation than we saw in last year's report (43.8 to 55.5%).
Quality indicators for cervical cancer:
When assessing cervical cancer, the national guidelines recommend that CT of the lungs and abdomen and MRI of the abdomen/pelvis be performed. The use of pelvic MRI in assessment is one of the registry's quality indicators. The indicator target of at least 90% of patients will not be achieved in 2022.
The use of PET before radiotherapy is also among the quality indicators in the registry. No indicator target has been defined for this indicator, but the results show that there is some variation among the health regions in the use of PET before radiation. The majority, 67.9 %, of patients have been diagnosed with squamous cell carcinoma, while 22.4 % have adenocarcinoma.
In total in the country, 49.6 % of patients undergo surgery, either with conisation or hysterectomy (removal of the uterus). 45.9% of patients have received radiation therapy. The proportion receiving radiation therapy varies somewhat among the health regions. The results also show some variation in the proportion who are hysterectomised among the health regions.
5-year relative survival for cervical cancer has increased steadily over the past 40 years. The national average for 5-year survival now stands at 82.7%, with a range between regions from 78.1% to 84.8%.
The Quality Registry for Gynecological Cancer contains a number of data on assessment and treatment that are described in the National Action Programme with guidelines for gynaecological cancer from the Norwegian Directorate of Health.
It has been assessed whether the national guidelines in the action programme have been met, and areas have been identified that can be improved with regard to, inter alia, assessment (CT thorax) and areas where the guidelines are complied with, such as for centralisation of treatment. It is the hospitals that have a high degree of reporting that can use the results for quality work locally.
Clinical areas of improvement for ovarian cancer:
• None of the health regions achieve the target of a minimum 80% proportion of surgeries in 2022. What constitutes the optimal proportion of surgeries is a controversial topic in the academic communities nationally and internationally. The Academic Council will evaluate the quality indicator target before the next annual report.
• Western Norway Regional Health Authority does not achieve the indicator target for 5-year relative survival. In recent years, the health region has conducted severalmedical record reviews to shed light on factors that may explain their lower survival and based on this implemented several improvement measures. In recent annual reports, both hospitals in the Western Norway Regional Health Authority have shown an improvement in postoperative mortalityafter one year and for surgery to macroscopic tumour freedom. It is still too early to see any effect on 5-year relative survival from the improvement measures. Developments will be followed further.
• Total mortality one year after diagnosis says something about the quality of cancer treatment. It should be low in hospitals that have optimal treatment of patients. No indicator measure has been defined for total mortality after one year, but a relatively wide range in the results suggests that there is room for improvement.
• The indicator target for conducting an MDT meeting during assessment is set at 90 % of all patients. The target will not be achieved at the national level (83.6%) in 2022, and there is some variation in reported use of MDT meetings among health regions.
See more areas of improvement for ovarian cancer in the report (Norwegian only)
Clinical areas of improvement for cervical cancer:
• The indicator target for the use of pelvic MRI in cervical cancer assessment is set for 90 % of patients. The target is not met at the national level, which shows by 84.2% in 2022.
• The quality indicator for the use of PET before radiotherapy does not yet have a defined indicator target, but the results show that there is great variation among the health regions. This is a fairly new modality with low access with no requirement for use in the guidelines, so some variation is natural. We nevertheless include it among the improvement areas in order to follow developments extra in the future.
Measures for patient-oriented quality improvement
Based on the fact that over time differences have been seen in the proportion of ovarian cancer patients who undergo surgery between the health regions, the quality improvement project Indication for surgery was initiated in 2020. The project was completed in 2021. The analyses included all ovarian cancer patients with a diagnosis in the period 2016–2019. The project group consists of representatives from all health regions.
The absence and reduction of residual tumours is important for the patients' prognosis for ovarian cancer. In the previous annual reports, it has been highlighted that some of the hospitals with specialist expertise did not meet the indicator target for no residual tumour after surgery. As a result, both St. Olavs Hospital and Stavanger University Hospital have carried out medical record reviews of their patients for quality assurance in recent years.
Stavanger University Hospital introduced standardised surgical descriptions for reporting in 2021, and results show that the hospital has had an increase in the proportion with no residual tumour after surgery from 35 % in 2019 to 80 % in 2022.
In order to further strengthen the quality of health services, the Cancer Registry of Norway worked in 2019 and 2020 to plan and build infrastructure for collecting PROMs (patient-reported outcome and experience measures), including integration with ePROM, which is the national solution for collecting PROMs.
The National Quality Registry for Gynecological Cancer will start with the routine collection of PROMs/PREMs in 2023. In order to distinguish between common ailments in the population and ailments related to ovarian cancer, a random sample of people without ovarian cancer will also be invited to submit a questionnaire.