## National Bowel Cancer Audit

# Annual Report 2017 Version 2

This 2017 Annual Report contains data from the 2016/2017 reporting period which covers patients in England and Wales with a date of diagnosis from 1 April 2015 to 31 March 2016.

The report was prepared by the Project Team:
Jemma Boyle Michael Braun Elizabeth Eaves Jim Hill Angela Kuryba Alison Roe Abigail Vallance Jan Van der Meulen Kate Walker With support from NHS Digital:
Claire Meace Rose Napper Arthur Yelland Prepared in partnership with:
The Association of Coloproctology of Great Britain and Ireland (ACPGBI) is the professional body that represents UK colorectal surgeons. ACPGBI assisted in the clinical interpretation of the data presented in the 2017 Annual Report.

The Royal College of Surgeons of England (RCS) is an independent professional body committed to enabling surgeons to achieve and maintain the highest standards of surgical practice and patient care. The project team based in the Clinical Effectiveness Unit (CEU) at the RCS carried out the analysis of the data for the 2017 Annual Report.

NHS Digital is the trading name for the Health and Social Care Information Centre (HSCIC). They provide 'Information and Technology for better health and care'. The Clinical Audit and Registries Management Service of NHS Digital manages a number of national clinical audits in the areas of cancer, diabetes and heart disease. It manages the audit on behalf of the RCS.

The Healthcare Quality Improvement Partnership (HQIP) is led by a consortium of the Academy of Medical Royal Colleges, the Royal College of Nursing and National Voices. It aims is to promote quality improvement, and in particular to increase the impact that clinical audit has on healthcare quality in England and Wales. HQIP holds the contract to manage and develop the National Clinical Audit Programme, comprising more than 30 clinical audits that cover care provided to people with a wide range of medical, surgical and mental health conditions. The programme is funded by NHS England, the Welsh Government and, with some individual audits, also funded by the Health Department of the Scottish Government, DHSSPS Northern Ireland and the Channel Islands. www.hqip.org.uk/national-programmes With review by the Clinical Advisory Group:
Austin Acheson Deborah Alsina Robert Arnott Richard Beable Judith Brodie Jo Church Martyn Evans Nicola Fearnhead Stephen Fenwick Paul Finan Sarah Galbraith Sasha Hewitt Asha Kaur Gerald Langman Jose Lourtie Charles Maxwell-Armstrong Andy McMeeking Andrew Murphy Kate Roggan Baljit Singh Dale Vimalachandran Sarah Walker Lisa Wilde

National
Bowel
Cancer
Audit
Annual
Report
2017

Version 2

An audit of the care received by people with Bowel Cancer in England and Wales 2017 Annual Report

## Contents

| Acknowledgements	                                                                                                  |   5 |
|--------------------------------------------------------------------------------------------------|-----|
| Foreword                                                                                         |   6 |
| 1. Executive summary                                                                             |   7 |
| Audit background                                                                                 |   7 |
| Audit aims                                                                                       |   7 |
| Audit values                                                                                     |   7 |
| What the audit measures                                                                          |   7 |
| Clinical Outcome Publication                                                                     |   7 |
| Key findings and recommendations                                                                 |   8 |
| Chapter 3 - Care pathways                                                                        |   8 |
| Chapter 4 - Surgical care                                                                        |   9 |
| Chapter 5 - Survival                                                                             |   9 |
| Chapter 6 - Rectal cancer                                                                        |   9 |
| NBOCA news for 2017                                                                              |  10 |
| 2. Methods                                                                                       |  11 |
| Methods - NBOCA 2017                                                                             |  11 |
| 2.1 Data collection                                                                              |  11 |
| 2.2 Data linkage                                                                                 |  12 |
| 2.3 Data processing - Type 2 objections                                                          |  13 |
| 2.4 Case ascertainment                                                                           |  13 |
| 2.5 Data completeness                                                                            |  14 |
| 2.6 Handling missing data                                                                        |  15 |
| 2.7 Definition of outcomes derived from HES/PEDW                                                 |  15 |
| 2.8 Definition of Surgical Urgency                                                               |  15 |
| 2.9 Statistical Analysis                                                                         |  16 |
| 3. Care pathways                                                                                 |  18 |
| Care pathways - NBOCA 2017                                                                       |  18 |
| 3.1 Where are patients diagnosed with bowel cancer presenting?                                   |  18 |
| 3.2 How are patients treated following diagnosis?                                                |  22 |
| 3.3 How often was adjuvant chemotherapy used in patients with stage III colon and rectal cancer? |  26 |
| Recommendations - Care pathways                                                                  |  27 |
| 4. Surgical care                                                                                 |  28 |
| 4.1 How many patients die within 90-days of major surgery?                                       |  28 |
| 4.2 How long do patients stay in hospital after major bowel cancer resection?                    |  32 |
| 4.3 How many patients have an unplanned readmission within 30-days                               | 34  |
| of discharge from hospital after major bowel cancer surgery?                                     |     |
| 4.4 How many patients have laparoscopic surgery?                                                 |  37 |
| 4.5 How many patients have more than twelve lymph nodes examined?                                |  38 |
| Recommendations - Surgical care                                                                  |  39 |
| 5. Survival                                                                                      |  40 |
| 5.1 What is the two-year survival of patients with bowel cancer?                                 |  40 |
| Recommendations - Survival                                                                       |  44 |
| 6. Rectal Cancer                                                                                 |  45 |
| 6.1 How are patients with rectal cancer treated?                                                 |  45 |
| 6.2 How are stomas used in rectal cancer surgery and how often are 'temporary' stomas reversed?  |  49 |
| Recommendations - Rectal cancer                                                                  |  51 |

## 7. Bowel Cancer Management - Trust By Trust 52

Appendices
Appendix 1 - Potential outlier responses	
78

## Acknowledgements

The National Bowel Cancer Audit (NBOCA), commissioned by the Healthcare Quality Improvement Partnership (HQIP), has been developed by the Association of Coloproctology of Great Britain and Ireland (ACPGBI) and is managed by the Clinical Audit and Registries Management Service within NHS Digital on behalf of the Clinical Effectiveness Unit (CEU) of the Royal College of Surgeons of England (RCS). The data for Wales has been supplied by the Cancer Information System Cymru (CaNISC). The analyses and writing for this report were carried out by the Clinical Effectiveness Unit of the Royal College of Surgeons of England with support from NHS Digital and Jim Hill and Michael Braun from the ACPGBI.

The Project Team and Board would like to thank the clinical and non-clinical staff at all National Health Service (NHS) trusts and Welsh Health Boards who collected and submitted data to the audit for their hard work, support and leadership. 

## The National Bowel Cancer Audit Project Team Consists Of:

Jemma Boyle CEU
Michael Braun NBOCA Clinical Co-lead Elizabeth Eaves 	
NHS Digital Jim Hill NBOCA Clinical Lead Angela Kuryba 	
CEU
Alison Roe NHS Digital Abigail Vallance 	
CEU
Jan Van der Meulen CEU
Kate Walker 	
CEU

## The National Bowel Cancer Audit Project Board Consists Of:

- Chair
- Neil Mortensen	
RCS Council Member
- Members
- Michael Braun	
NBOCA Clinical Co-lead
- Jo Church	
ACPGBI Patient Representative
- Martyn Evans	
Representative for Wales
- Nicola Fearnhead	
Chair of CAG/ACPGBI 

	
Council Member
- Paul Finan	
NCIN SSCRG Representative
- Alison Roe	
NBOCA Project Manager
- Jim Hill	
NBOCA Clinical Lead
- Sasha Hewitt	
Associate Director for Quality 

	
& Development, HQIP
- Sarah Walker	
Project Manager, HQIP
- Jan Van der Meulen	
NBOCA Methodologist
- Kate Walker	
NBOCA Methodologist

## The National Bowel Cancer Audit Clinical Advisory Group (Cag) Consists Of:

- Chair
- Nicola Fearnhead	
ACPGBI
- Members
- Austin Acheson	
ACPGBI Research & Audit

	
Committee Representative
- Deborah Alsina	
Bowel Cancer UK Representative
- Robert Arnott	
Patient Representative (ACPGBI)
- Richard Beable	
Radiology Representative

	
(ACPGBI)
- Judith Brodie	
Beating Bowel Cancer

	
Representative
- Jo Church	
Patient Representative (ACPGBI)
- Martyn Evans	
Representative for Wales
- Stephen Fenwick	
HPB representative (AUGIS)
- Paul Finan	
NCIN SSCRG Representative
- Sarah Galbraith	
Palliative Care Medicine

	
Representative
- Asha Kaur	
Bowel Cancer UK Representative
- Gerald Langman	
Histopathology Representative 

	
(ACPGBI)
- Jose Lourtie	
National Emergency Laparotomy

	
Audit (NELA) Representative
- Charles Maxwell-	
ACPGBI Multidisciplinary

Armstrong	
Clinical Committee Chair
- Andy McMeeking	
Transforming Cancer Services

	
Team for London
- Sasha Hewitt	
Healthcare Quality Improvement

	
Partnership (HQIP)
- Sarah Walker	
Healthcare Quality Improvement

	
Partnership (HQIP)
- Andrew Murphy	
Public Health England
- Kate Roggan	
Nursing Team Representative
- Baljit Singh	
ACPGBI Research & Audit

	
Committee Representative
- Dale Vimalachandran	
ACPGBI Research & Audit

	
Committee Representative
- Lisa Wilde	
Bowel Cancer UK Representative

## Foreword

This eighth annual report from the National Bowel Cancer Audit is the most up to date information from England and Wales regarding the care and outcomes of bowel cancer patients. The report reflects an enormous amount of hard work in collecting, analysing and interpreting a mass of data and I am extremely grateful to all those individuals involved - trusts, Welsh health boards, NHS Digital and the Clinical Effectiveness Unit at the Royal College of Surgeons of England. It is clear that outcomes from colorectal cancer are improving. Data obtained by Cancer Research UK has shown that bowel cancer mortality rates have decreased by 42% in the UK since the early 1970s. Over the last decade in the UK (between 2003-2005 and 2012-2014), bowel cancer age-standardised mortality rates have decreased by 12% overall, with a similar decrease in males (15%) and females (11%). This year's audit report also contains some encouraging trends; mortality rates following both elective and emergency surgery are falling and there are increased numbers of operations being performed laparoscopically. It is positive to see that almost one quarter of eligible patients were diagnosed through the Bowel Cancer Screening Programme. However, diagnoses via screening services vary considerably across the country and work to promote the NHS Bowel Cancer Screening Programme needs to continue. The audit has continued to widen its scope and now links to the Systemic Anti-Cancer Therapy (SACT) dataset. This is in the early stages of analysis but has enabled more accurate information regarding the use of chemotherapy to be presented.

Complete and accurate data remain the key requirement to describe processes and outcomes of care for all patients with bowel cancer. The clinical ownership and oversight of the data submitted by each trust is crucial. It remains our responsibility to provide accurate and up to date information to those diagnosed and undergoing treatment for bowel cancer. The value of the annual report remains dependent on the quality of data submitted by the contributing multidisciplinary teams. To improve accessibility of the 2017 Annual Report to patients, an individual patient report has again been produced. The report summarises the key results in a patient-friendly format.

The National Bowel Cancer Audit is now embedded as part of the National Clinical Audit and Patient Outcome Programme (NCAPOP). This enables further work to be done to fully describe the quality of care and outcomes for patients with bowel cancer in England and Wales.

## 1. Executive Summary Audit Background

Bowel cancer is a major cause of illness, disability and death in the United Kingdom (UK). The National Bowel Cancer Audit (NBOCA) describes and compares the care and outcomes of patients diagnosed with bowel cancer in England and Wales. The audit is now well established and has collected data in its professional form since 2005. The NBOCA is commissioned by the Healthcare Quality Improvement Partnership (HQIP) and funded by NHS England and Welsh Government. The audit is carried out by the Clinical Effectiveness Unit (CEU) of the Royal College of Surgeons of England in partnership with the Association of Coloproctology of Great Britain and Ireland (ACPGBI), and NHS Digital. The 2017 Annual Report is the eighth report produced by the above collaborative and includes data on over 30,000 patients diagnosed with bowel cancer between 1 April 2015 and 31 March 2016. The overall case ascertainment for England and Wales was 95%. The key audience of the Annual Report and the Patient Report include those who deliver care to bowel cancer patients, commission bowel cancer services and patients. 

## Audit Aims

The aim of the audit is to measure the quality of care and outcomes of patients with bowel cancer in England and Wales.

## Audit Values

Our values define what is important in the way we deliver the National Bowel Cancer Audit. In carrying out our work, we aim to:

- Produce accurate and reliable information for clinicians, 
patients, hospital staff and the public by ensuring that the data we collect is as complete and accurate as possible and by ensuring the information is produced using appropriate statistical methods.
- Deliver the National Bowel Cancer Audit in a way that 
supports bowel cancer services to improve the quality of the care delivered to patients.
- Ensure the confidentiality of patient information supplied 
by hospitals is protected.

## What The Audit Measures

The NBOCA collects data on items which have been identified and generally accepted as measures of good care. It compares the variation in these between Cancer Alliances and trusts/hospital sites. A summary of the performance indicators measured in patients with bowel cancer is available at https://www.nboca.org.uk/resources/ performance-indicators-description/ The majority of data items are collected by NHS trusts in England as part of the Cancer Outcomes and Services Dataset (COSD). Riskadjusted outcomes reported include: 90-day post-operative mortality, 30-day unplanned readmission rate, two-year mortality for patients having major resection and 18-month stoma rate.

## Clinical Outcome Publication

The NBOCA publishes data at individual surgeon level and trust level for English NHS trusts. This information is available on the ACPGBI, NHS Choices and MyNHS websites as part of the Clinical Outcomes Publication (COP) programme. The COP programme represents an ambitious endeavour aimed to improve transparency around clinical outcomes. The total number of cases and the 90-day post-operative mortality rate, for patients undergoing elective/scheduled major surgery following a diagnosis of bowel cancer between 1 April 2010 and 31 March 2016, are currently reported at both surgeon and trust level. Additional trust/hospital level outcomes will be reported for all patients with bowel cancer (emergency and elective) treated in the corresponding audit period. The reporting schedule is shown in Table 1.1. 

| COP Reporting Year                                             | Additional Trust Outcomes                     |
|----------------------------------------------------------------|-----------------------------------------------|
| 2016                                                           |                                               |
| Rate of major resection                                        | Crude rates with no outlier reporting         |
| Case ascertainment                                             | Including patients who do not undergo surgery |
| 2017                                                           |                                               |
| 30 day unplanned readmission                                   | Outlier reporting; risk-adjusted              |
| Percentage length of stay >5 days                              | Risk-adjusted                                 |
| 2018                                                           |                                               |
| Positive circumferential rectal resection margin rates         |                                               |
| Proportion of colonic resections with >12 lymph nodes reported |                                               |
| 2019                                                           |                                               |
| Unplanned rates of return to theatre                           | Outlier reporting; risk-adjusted              |
| These results will be available at                             | http://www.acpgbi.org.uk/surgeon-outcomes/    |

## Key Findings And Recommendations Chapter 3 - Care Pathways

- 9% of all patients with bowel cancer and 23% of 
patients aged 60-74 years and therefore eligible were diagnosed via the Bowel Cancer Screening Programme These patients were more likely to be treated with curative intent than patients diagnosed via other means. Diagnoses via screening services varied from 16% to 29% across Cancer Alliances.

- 75% of all patients diagnosed with bowel cancer 
were treated with curative intent 

93% of these patients underwent a major resection and 7% underwent endoscopic or minimally invasive local excision. 

- 25% of patients were treated with palliative intent

18% of these patients underwent a major resection of the bowel cancer primary. A further 14% of patients underwent a palliative surgical procedure or stent.
- There are large differences in the administration 
of adjuvant (post-surgical) chemotherapy between geographical regions The use of adjuvant chemotherapy in patients with stage III disease ranged from 41% to 68% across Cancer Alliances.

## Recommendations

3(a). Healthcare professionals must continue to promote bowel cancer screening and address the significant geographical variation in the uptake of screening 3(b). More evidence is required to determine the role of surgery of the primary tumour with few or absent symptoms in patients with synchronous unresectable metastases of colorectal cancer. Results from the several randomised controlled trials currently underway will be invaluable in this regard. 3(c). The geographical disparity in the use of adjuvant chemotherapy needs to be explored further.

- 90-day mortality after major resection has 
continued to fall and was 3.2% for 2015/16 

The change was seen in both elective patients and those undergoing emergency surgery. In patients having urgent or emergency surgery it decreased from 13.9% in 2011/12 to 10.3% in 2015/16.

- Median length of stay following major bowel 
cancer resection is unchanged at 7 days in elective patients and 11 days in emergency patients 

Over a third of patients undergoing an emergency major resection remain in hospital for more than 2 weeks postoperatively.
- The use of laparoscopic surgery for colorectal 
cancer resection continues to grow with 54% of major resections completed laparoscopically this audit period Patients with advanced cancer, high ASA (American Society of Anesthesiologists) grade and advanced age were also more likely to have an open resection. Around a quarter of patients undergoing urgent or emergency resection had this performed laparoscopically.

## - 83% Of Patients Have More Than 12 Lymph Nodes

examined The observed proportion of major resections with more than 12 lymph nodes examined varied considerably by trust, from 37% to 98%. This does not take into account variation in patient and tumour characteristics.

## Recommendations

4(a). Bowel cancer care teams should be congratulated for achieving a continued reduction in postoperative mortality which has taken place without any reduction in resection rates. There should be a continued effort in the delivery of high quality care with a view to further improvements in outcomes.

## Chapter 5 - Survival

- Two-year survival rates for all patients diagnosed 
with bowel cancer have remained stable at 67% since 2011

Whilst the two-year survival in those undergoing major resection has remained relatively stable at 82% in 2011/12 and 83% in 2013/14, the two-year survival in patients who do not undergo tumour excision has decreased from 35% in 2011/12 to 29% in 2013/14.

- There remains significantly more variation in twoyear survival by trust/multidisciplinary team (MDT) than would be expected by chance alone

## Recommendations

5(a). Action is required nationally to reduce risk exposures, support healthy behaviours and mitigate the effects of socioeconomic deprivation in an attempt to reduce regional variation in cancer survival.

## Chapter 6 - Rectal Cancer

- 52% of rectal cancer patients underwent major 
resection and 7% underwent a local excision.

Just 5% of rectal cancer patients are managed with a stoma alone.
- 38% of rectal cancer patients undergoing major 
resection received neo-adjuvant (pre-surgical) treatment.

The use of neo-adjuvant treatment ranged widely between Cancer Alliances, from 23% to 58% of patients. This varied within both the use of long course radiotherapy (18-43%) and short-course radiotherapy (0-29%). 

- 83% of rectal cancer patients had a stoma formed 
at the time of surgical resection.

Half of rectal cancer patients undergoing major resection had a stoma at 18 months. There was substantial variation in rates across trusts/sites with 18% of trusts/ sites having an adjusted rate above 60% and 9% of trusts/sites having an adjusted rate below 40%.

## Recommendations

6(a). The presence of a stoma is well recognised to decrease quality of life. Priority should be given to actively managing patients with a defunctioning stoma following anterior resection and planning early closure whenever possible. 6(b). Better understanding of the regional difference in the use of pre-operative treatment for rectal cancer patients is required.

## Nboca News For 2017 Chemotherapy Dataset

The audit now links to the Systemic Anti-Cancer Therapy (SACT) dataset. This is in the early stages of analysis but has enabled more accurate information regarding the use of chemotherapy to be presented, identifying a larger number of patients receiving chemotherapy than was collected in the audit dataset. 

## Website

The NBOCA now has its own dedicated website. Users can access individual trust results, annual reports and short reports, as well as information regarding data entry and contact details. The website can be accessed at https://www.nboca.org.uk/. 

## Patient Reported Outcome Measures

NHS England's National Cancer PROMs Programme of the National Survivorship Initiative collected patient reported outcome measures (PROMs) for bowel cancer patients in a one-off study in 2013. This report can be accessed at https://www.england.nhs.uk/wp-content/uploads/2015/03/ colorectal-cancer-proms-report-140314.pdf. The PROMs data have been linked to the National Bowel Cancer Audit (NBOCA) dataset in order to carry out a study to assess the feasibility of reporting PROMs as part of a national audit of bowel cancer patients. The feasibility was assessed according to i) the characteristics of responders versus non-responders ii) the representativeness of the responders at different points along their pathway from diagnosis, iii) regional variation in responses, and iv) the validity of the measures in comparison to NBOCA clinical measures expected to impact upon patient experience. The NBOCA PROMs feasibility report can be accessed at https://www.nboca.org.uk/reports.

## Supplementary Short Reports

The NBOCA published a short report in July 2017 investigating optimal timing between radiotherapy and surgery in rectal cancer patients: https://www.nboca.org.uk/reports/short-report-1-2017/ The results of this are summarised on page 47. A further report was published in October 2017 on cancer specific mortality (https://www.nboca.org.uk/reports/ short-report-2-2017/). In 2018 the audit will publish two further supplementary reports on chemotherapy and end of life care.

## Patient Episode Database For Wales

The audit now links to Patient Episode Database for Wales (PEDW). The database contains all inpatient and day case activity undertaken in NHS Wales plus data on Welsh residents treated in English trusts. This allows more accurate information to be presented for Welsh patients. See http://www.infoandstats.wales.nhs.uk/page. cfm?orgid=869&pid=40977 for more information.

## Organisational Audit

The results of the organisational audit of NHS sites in England and Wales treating bowel cancer patients has been updated for this year. This details the facilities available at each trust/MDT and can be accessed at https://www.nboca. org.uk/reports/organisational-survey-results-2017/. The services available at each trust are also listed under each trust within the Trust Results section of the website which can be accessed at https://www.nboca.org.uk/trust-results/. 

## Reporting According To Cancer Alliance

Regional results across England, previously reported according to Strategic Clinical Network are now reported according to 19 Cancer Alliances in England and the Wales Cancer Alliance. Cancer Alliances have been introduced to bring together local senior clinical and managerial leaders representing the whole cancer patient pathway across a specific geography. See https://www.england.nhs.uk/ cancer/strategy/alliance-guidance/ and http://www. walescanceralliance.org/ for more information.

## Twitter

We now have a twitter page. Follow @NBOCA_CEU for regular updates.

## 2. Methods Methods - Nboca 2017

- All data for patients diagnosed with colorectal 
cancer from 1 April 2013 was submitted via NHS Digital's Clinical Audit Platform (CAP). Data is col­ lected at the trust level in England and centrally from the Cancer Network Information System Cymru (CaNISC) system in Wales. Only patients with a new primary diagnosis of bowel cancer are included. 

- Historic data submitted via the Open Exeter 
system has been uploaded into the CAP system. 
- Case ascertainment is calculated for English 
Cancer Alliances and trusts, using Hospital Episode Statistics (HES) data to estimate the denominators and for Wales and Welsh MDTs using Patient Episode Data Wales (PEDW).
- The Audit dataset is linked to HES data at the 
patient level to obtain further information on patient care and follow-up for patients treated in England and PEDW for patients treated in Wales. 
- Funnel plots are used to compare the following 
four outcomes: 90-day mortality after major resection; 30-day emergency readmission after major resection; two-year mortality after major resection and 18-month stoma rate after ma­ jor resection for rectal cancer. Comparisons are made between Cancer Alliances and between trusts/sites. All outcomes are adjusted for patient case-mix.

- Potential outliers on these four risk-adjusted 
outcomes are reported back to trusts/hospital sites in advance of the report being published in order that the results can be validated.

## 2.1 Data Collection

All but one of the eligible NHS trusts/hospital sites in England and Health Boards in Wales submitted data to the audit for inclusion in the 2017 Annual Report. The focus of this report is patients in England and Wales submitted to the audit who were diagnosed between 1 April 2015 and 31 March 2016. Data is also available from the previous four audits and comparisons are made across years for certain outcomes. Since March 2014, patient data has been collected via NHS Digital's Clinical Audit Platform (CAP) system. This can be accessed at http://content.digital.nhs.uk/ clinicalauditplatform. This allows only one treatment record to be listed per patient and patients identified as being submitted to the audit in a previous year are excluded from subsequent audits. The dataset has been redesigned to contain fewer items, some of which are mandatory, which has succeeded in improving data completeness across all patients, not just those having surgery. For example, pre-treatment staging is now complete in 73% of patients compared to 40% in 2011/12. Performance status and curative intent were not collected until 2013 and these are now complete in 83% and 89% of patients respectively. All participating trusts in England individually submitted their data for this annual report to this system. The Welsh data was submitted centrally from CaNISC. Historic audit data from Open Exeter was transferred to the CAP system and is available for review and editing if required. Further information about Open Exeter and the data transfer are available in Section 1.1 of the 2015 supportive document, found at https://www.nboca.org.uk/ reports/annual-report-2015/

## 2.2 Data Linkage A) Hes/Pedw

Audit data linked to HES/PEDW data allows the possibility of exploiting HES/PEDW data for items not available in the audit. In particular HES/PEDW is useful for analysing certain patient outcomes including emergency readmissions and stoma provision. The mode of admission (elective or emergency) is recorded in HES/PEDW, as is the number of co-morbidities, which is defined according to the Charlson co-morbidity score. Patients treated at hospitals in England were linked to HES records using their NHS numbers, date of birth, sex and postcode. 95% of patients undergoing major surgery at English trusts in the audit could be linked to HES; the equivalent for Welsh patients and PEDW was 91%. Estimates for 30-day unplanned readmissions or 18-month stoma rates exclude those patients not linked to HES/PEDW. Risk-adjusted mortality estimates for patients not linked to HES/PEDW relied on imputed data for comorbidities and mode of admission. See Section 2.6 for more details of the imputation methods.

## B) Office For National Statistics

Linking audit data to mortality data from the Office for National Statistics (ONS) allows the audit to analyse patient mortality across England and Wales without increasing the data entry burden for sites. In addition to date of death, the audit has access to place and cause of death and plans to produce reports using this information in the near future. Linkage to ONS is performed using patient NHS number, date of birth, sex and postcode.

## C) Radiotherapy Dataset

The National Radiotherapy Dataset (RTDS) contains information about radiotherapy treatment received by patients in England, such as primary cancer site, curative intent, dose, number of attendances, first appointment date, and reason for treatment. Patients treated at hospitals in England were linked to RTDS records using their NHS numbers, date of birth, sex and postcode. In general, treatment episodes were grouped into long course, short course or other based on the number of attendances; however, an additional small number of records with a prescribed radiation dose between 44-46 Gy were classified as long course. The audit date of surgery was used to distinguish between radiotherapy only, pre-operative and post-operative (not used in this report) treatment. RTDS data was used as the basis of the first definitive non-surgical treatment; if no RTDS data was available for a patient this information was updated from SACT data (see 2.2 d) below) and then finally from the audit pre-operative treatment variable (capturing audit-only radiotherapy and chemotherapy patients).

For the last three months of the audit reporting period (January to March 2016) the linkage to RTDS is poorer, therefore the results using RTDS for rectal cancer patients are presented for patients diagnosed between January and December 2015. This is due to timing of treatment in relation to diagnosis i.e. patients diagnosed in the last 3 months of the audit year were unlikely to have received their radiotherapy in time to be recorded in the extract of RTDS linked to the audit. RTDS data is not available for Welsh patients unless they received the radiotherapy in England. Therefore the pre-operative treatment variable recorded in audit data is presented for Welsh patients. 

## D) Systemic Anti-Cancer Therapy

The Systemic Anti-Cancer Therapy (SACT) dataset contains information about chemotherapy treatment received by patients in England, such as primary cancer site, chemotherapy type, planned and actual number of treatments, dose, route of administration and reasons for stopping or reducing treatment. Patients treated at hospitals in England were linked to SACT records using their NHS numbers, date of birth, sex and postcode. Regimen start dates were compared to the audit dates of diagnosis and surgery to determine whether chemotherapy was given alone, prior to surgery or after surgery. Similarly to RTDS data, the SACT dataset is not available for Welsh patients. Therefore audit data on pre-operative and post-operative chemotherapy are presented for Welsh patients.

## 2.3 Data Processing - Type 2 Objections

Patients in England who do not want their personal confidential information to be shared outside of NHS Digital, for purposes other than for their direct care, can register a type 2 opt-out with their GP practice. The audit could not receive HES or ONS data for patients who have registered a type 2 opt-out so their records could not be linked. Table 2.1 shows the number of records that could be linked to HES/ONS over the past five years.

HES/ONS linkage by audit year
|                                     | 2011-12    | 2012-13   | 2013-14    | 2014-15   | 2015-16   |
|-------------------------------------|------------|-----------|------------|-----------|-----------|
|                                     |            |           |            |           |           |
| Total                               | Not linked | Total     | Not linked |           |           |
| N (%)                               |            |           |            |           |           |
| All patients                        |            |           |            |           |           |
| 30,354                              | 581 (1.9)  | 31,398    | 636 (2.0)  | 30,713    | 766 (2.5) |
| Patients undergoing Major Resection |            |           |            |           |           |
| 19,319                              | 458 (2.4)  | 20,074    | 488 (2.4)  | 19,687    | 542 (2.8) |

## 2.4 Case Ascertainment

Case ascertainment is expressed as a ratio of the number of bowel cancer patients reported to the audit compared to the total number of patients admitted for the first time to the participating units with a date of diagnosis of bowel cancer within the audit period, according to Hospital Episode Statistics (HES) data for patients diagnosed in England and Patient Episode Database for Wales (PEDW) for patients diagnosed in Wales. These are administrative databases containing records of all admissions to NHS trusts and were used to estimate the denominator of this proportion. Patients who requested a type 2 opt-out did not have HES data and therefore the denominator for England is an under-estimate and consequently, case ascertainment is over-estimated. Because of the variation in rates of type 2 opt-outs by region, this will affect regional and trust/site estimates differently. 

Case ascertainment by year
 
2011-12
2012-13
2013-14
2014-15
2015-16
Patients identified in HES/PEDW
33,640
32,849
31,796
31,979
32,335
Patients identified in audit
30,354
31,397
30,712
31,075
30,710
% case ascertainment
90
96
97
97
95

According to NHS Digital, across England as a whole the proportion of patients who have requested type 2 opt-out was 2.3% in June 2017, with variation by region. The proportion of audit patients who have opted out has increased over the last five years. More information about Type 2 opt-out is available from http://content.digital.nhs.uk/article/7092/Information-ontype-2-opt-outs

| Total   | Not linked   | Total   | Not linked   |
|---------|--------------|---------|--------------|
| N (%)   | N (%)        | N (%)   | N (%)        |

In HES/PEDW, a patient was considered to be diagnosed with primary bowel cancer when admitted to hospital for the first time with a diagnosis of bowel cancer (C18, C19 or C20 according to the International Classification of Diseases 10th Revision) in the first diagnosis field. It was assumed to be a first bowel cancer admission if no previous bowel cancer diagnosis could be identified in any of the diagnostic fields since 1 April 2010. Case ascertainment by year is given in Table 2.2. Overall case ascertainment is 95% this year for England and Wales as a whole. Case ascertainment at Cancer Alliance/Wales and trust/site level is given in Table 7.1.

## 2.5 Data Completeness

Data completeness is defined as the proportion of patients with complete data items on all seven of the variables: age, sex, ASA grade, pathological TNM stage (tumour, node, metastasis staging) and site of cancer, as these audit variables are used for risk adjustment. Mode of admission and number of co-morbidities are also used in the risk adjustment model but as these variables are collected from HES data they are not included in the assessment of data completeness. Data completeness is only assessed in patients who underwent major surgery, because only in these patients could all seven data items be expected to be complete.

Where pathological M-stage is submitted as 'not assessed' (Mx) or 'not recorded' (M9) it is updated from pre-operative tumour staging where recorded as M0 or M1. Dukes' staging is no longer in the audit dataset and therefore can no longer be used to update missing values of M-stage. For the purposes of the audit, the following recorded tumour stages are considered to be missing data: Tx, T9, Nx, N9, Mx, M9. 

Percentage of patients undergoing major surgery with complete data on the 7 items from the audit used in risk adjustment, by audit year
|                                           | 2011-12   | 2012-13   | 2013-14   | 2014-15   | 2015-16   |
|-------------------------------------------|-----------|-----------|-----------|-----------|-----------|
|                                           |           |           |           |           |           |
| N                                         | %         | N         | %         | N         | %         |
| Total patients undergoing major resection |           |           |           |           |           |
| 19,319                                    |           | 20,074    |           | 19,687    |           |
| Complete data on 7 key items              |           |           |           |           |           |
| 16,087                                    | 83.3      | 17,825    | 88.8      | 15,751    | 80.0      |
| Data completeness if TNM M-stage recorded |           |           |           |           |           |
| 17,587                                    | 91.0      | 18,826    | 93.8      | 18,084    | 91.9      |

Data completeness reports have been sent to each NHS trust both to provide feedback on the data submitted and to point to areas for improvement. The removal of Duke's staging from the dataset and subsequent change in handling of pathological M-stage data led to a significant drop in overall data completeness in 2013/14 (Table 2.3). Data completeness by Cancer Alliance/trust/MDT is shown in Table 7.1.

## 2.6 Handling Missing Data

Multiple imputation using chained equations was used to fill in any missing risk factor information for the four adjusted outcomes reported at trust and Cancer Alliance level. This method uses a patient's other risk-factors to predict their missing information, whilst taking into account the uncertainty due to their missing information. In addition to the variables in the risk adjustment model, and the outcomes, the following variables were included in the imputation model: surgical urgency, mode of admission according to the audit, surgical procedure, number of lymph nodes extracted, number of positive lymph nodes extracted, Index of Multiple Deprivation (national ranking of residential area measuring it's relative deprivation across seven domains), length of hospital stay, and days from diagnosis to surgery. Amongst patients undergoing major surgery, 5.8 per cent were missing ASA grade, 8.5 per cent were missing TNM T-stage, 8.7 per cent were missing TNM N-stage and 14.3 per cent were missing TNM M-stage. Mode of admission and Charlson comorbidity score came from HES/PEDW and were missing in patients who were not linked to HES/ PEDW. Virtually all patients had complete data on sex, age, and site of cancer.

## 2.7 Definition Of Outcomes Derived From Hes/Pedw

Length of hospital stay was calculated for patients undergoing major surgery and was defined as the number of days between either discharge or death and the date of surgical procedure as recorded in HES/PEDW. 

Emergency readmission within 30-days of surgery was derived for patients undergoing major surgery, and was defined as an emergency admission to any hospital for any cause within 30-days of surgery. Emergency admissions include: admission via Accident and Emergency, general practitioner, bed bureau, or consultant outpatient clinic. 18-month stoma rate was estimated for rectal cancer patients undergoing major surgery. Patients undergoing an abdomino-perineal excision of the rectum (APER) (operation to remove the entire rectum and anal canal) or Hartmann's procedure (operation to remove area of bowel on left hand side with part of rectum, leaving a colostomy) according to the audit were assumed to have had a stoma at the time of their primary procedure. This was classified as permanent in patients having an APER. 

HES/PEDW data was used to capture whether anterior resection (AR) (operation to remove all of part of the rectum) patients received a stoma and the type of stoma that was created. In patients having an AR or Hartmann's procedure, information on subsequent stoma reversal was also obtained from HES/PEDW. A procedure code for reversal of ileostomy or colostomy within 18 months of surgery was assumed to mean that the patient had their stoma reversed. To make comparisons between Cancer Alliances and between trusts/hospitals, 18-month stoma rates for all resectional surgery (APER, Hartmann's and anterior resection) were adjusted for case-mix using the same risk factors as for 90-day mortality (except cancer site). Data were pooled over three years to ensure sufficient numbers of operations per trusts to make comparisons. 

It is only the 2014 and 2017 Annual Report which have no overlap in the data reported.

## 2.8 Definition Of Surgical Urgency

The audit uses the pre-2004 National Confidential Enquiry into Patient Outcomes and Death (NCEPOD) classification of surgical urgency (below): Elective: Operation at a time to suit both patient and surgeon e.g. after an elective admission. Scheduled: An early operation (usually within three weeks) but not immediately life-saving. This category often includes patients treated on cancer pathways with targets. Urgent: As soon as possible after resuscitation and usually within 24 hours.

Emergency: Immediate and life-saving operation, resuscitation simultaneous with surgical treatment. Operation usually within two hours. 

## 2.9 Statistical Analysis

Most results reported in this audit report are descriptive. The results of categorical data items are reported as percentages (%). The denominator of these proportions is in most cases the number of patients for whom the value of the data item was not missing. Results are typically grouped by Cancer Alliances and/or trust/hospital/MDT. England's 13 Cancer Alliances were used in the analyses, and compared to Wales as a whole. The results for Wales are reported according to where the multidisciplinary team who discussed the patients' management were located, rather than by trust/hospital.

## Funnel Plots

Funnel plots are used to make comparisons between cancer alliances or between trusts/hospitals on the following outcomes: 90-day mortality after major surgery; 30-day emergency readmission after major surgery; two-year mortality after major surgery; and 18-month stoma rates for rectal cancer patients undergoing major surgery. The rate for each Cancer Alliance or for each trust or hospital is plotted against the total number of patients used to estimate the rate. The 'target' is specified as the average rate across all Cancer Alliances/trusts/hospitals. The funnel limits depend on the target rate and the number of patients included in the estimate; rate estimates have greater uncertainty when estimated from fewer patients. Results fall outside the inner limits if they are statistically significantly different from the target at a 0.05 level, and outside the outer limits if they are statistically significantly different from the target at a 0.002 level. The inner funnel limit is the threshold for an "alert" and the outer funnel level is the threshold for an "alarm". This implies that 95 per cent of the trusts or hospitals are expected to be within the inner funnel limits and 99.8 per cent within the outer funnel limits, if they are all performing according to the target. 

If all trusts/hospitals in this report had the same underlying rate for a particular outcome, four would be expected to lie above and four below the inner limits, and 0.2 above and 0.2 below the outer limits by chance alone. Cancer Alliances, trusts or hospitals with results outside the outer (99.8%) funnel limit are considered as potential outliers and have been contacted according to the recommended HQIP procedure. 

## Adjusted Outcomes

A previously peer-reviewed model for risk adjustment of post-operative mortality in bowel cancer patients was used. Multivariable logistic regression was carried out to estimate risk-adjusted 90-day post-operative mortality, 30-day emergency readmission, and 18-month stoma rates for rectal cancer patients undergoing major surgery. A Poisson model was fitted to estimate risk-adjusted two-year mortality after major surgery. Unlike the 90-day mortality, 30-day emergency readmission rate and 18-month stoma rate, the two-year mortality rate takes into account the length of time each patient was followed up for. The observed two-year mortality is the number of patients who died within two years divided by the sum of the amount of time each patient is followed for. For example, in two trusts/hospitals with the same proportion of patients dying within two years, the trust in which patients die earlier will have a higher two-year mortality rate. 

Multivariable Regression Model Variables
Patient Characteristics
Age (modelled as age plus age-squared) Sex
Morbidity and Presentation
ASA grade; 
Charlson co-morbidity score (according to HES). Mode of admission (according to HES) 
Cancer
T-stage (pathological), N-stage (pathological), M-stage (pathological), Site of tumour

An interaction between age and distant metastases was also included in the models to allow age to have a different effect in patients with and without metastases. Once patients have metastatic disease the effect of age is found to be far less important than in patients without metastases. The model for two-year survival additionally included interactions between epoch (0-3 months after surgery vs. 3-24 months after surgery) and all of the risk factors. This allows risk factors to have a different effect shortly after surgery and in the longer term. For example, the effect of ASA grade is much larger peri-operatively than in the longer-term, whilst cancer stage has a much larger impact on longer-term than short-term mortality. The model for 18-month stoma rate did not include cancer site as it was for rectal cancer patients only. Patients with missing date of surgery were excluded, and multiple imputation was used to fill in any missing information on the risk factors. The following trusts were excluded from the listed analysis because overall data completeness was less than 20% or ASA grade and/or TNM 
stage was missing in more than 80% patients included in the analysis:

## 90-Day Mortality:

- Frimley Health NHS Foundation Trust - 

Frimley Park Hospital
- Mid Essex Hospital Services NHS Trust - The Queen Elizabeth Hospital, King's Lynn, 

NHS Foundation Trust

- University Hospitals of North Midlands NHS Trust - 

Royal Stoke University Hospital

## 30-Day Emergency Readmission:

- East and North Hertfordshire NHS Trust - Frimley Health NHS Foundation Trust - 

Frimley Park Hospital
- Mid Essex Hospital Services NHS Trust - The Queen Elizabeth Hospital, King's Lynn, 

NHS Foundation Trust
- University Hospitals of North Midlands NHS Trust - 

Royal Stoke University Hospital
- University Hospitals Birmingham NHS Foundation Trust

## Two-Year Survival:

- Bradford Teaching Hospitals NHS Foundation Trust - Colchester Hospital University NHS Foundation Trust - Luton and Dunstable University Hospital 

NHS Foundation Trust
- University Hospitals of North Midlands NHS Trust - 

Royal Stoke University Hospital
The individual trusts and the CQC have been made aware of this. This is the third consecutive year that The Queen Elizabeth Hospital, King's Lynn, NHS Foundation Trust has been excluded from 90 day mortality and 30 day emergency readmission (previously 90 day readmission) analyses.

Walsall Healthcare NHS Trust did not submit any data. The adjusted outcomes were estimated using indirect standardisation. The observed number of events for a trust or hospital was divided by the number expected on the basis of the multivariable regression model. The adjusted rate was then estimated by multiplying this ratio by the average rate in all patients included in the analysis. All statistical analyses were performed using Stata version 14.1.

## 3. Care Pathways Care Pathways - Nboca 2017

- 55% of patients were diagnosed with bowel 
cancer following GP referral and around 9% of patients were diagnosed through The National Bowel Cancer Screening Programme. 
- Almost one quarter of patients aged 60-74, 
and therefore eligible, were diagnosed via screening. There is wide geographical variation in the proportion of patients diagnosed through screening in those of eligible age.
- Treatment with curative intent varied depending 
on mode of presentation. Only 53% of patients presenting as an emergency were treated with curative intent compared to 71% of patients diagnosed following GP referral and 90% of patients diagnosed through screening.
- 37% of patients did not undergo major resection. 
The reasons behind this have been subdivided in to four categories: too little cancer (4%), too much cancer (12%), too frail (5%) or unknown/ other reason (16%). 

## 3.1 Where Are Patients Diagnosed With Bowel Cancer Presenting? Referral Source

The majority of patients (55%) were diagnosed with bowel cancer following a GP referral, as shown in Table 3.1. The proportion of patients diagnosed following a referral from screening services has been unchanged for the last three years, at just under 10%. Patients diagnosed following an emergency admission had more advanced disease, poorer performance status and were comparatively older than patients diagnosed from GP or screening services. Only half of these patients had curative treatment intent, compared to 70% and 90% in those diagnosed via GP and screening services respectively. 

Description of the 30,710 patients diagnosed with bowel cancer between 1 April 2015 and 31 March 2016, by Referral Source
|                                  |                        |        |        | Emergency Admission   | GP Referral   | Screening Referral   | Other/ Not Known   |
|----------------------------------|------------------------|--------|--------|-----------------------|---------------|----------------------|--------------------|
| Number                           | %                      | Number | %      | Number                | %             | Number               | %                  |
| Total no. patients               | 6,057                  |        | 16,707 |                       | 2,970         |                      | 4,976              |
| Sex                              | Male                   |        |        |                       |               |                      |                    |
| 3,214                            | 53.1                   | 9,330  | 55.9   | 1,938                 | 65.3          | 2,826                | 56.8               |
| Female                           |                        |        |        |                       |               |                      |                    |
| 2,843                            | 46.9                   | 7,375  | 44.1   | 1,031                 | 34.7          | 2,149                | 43.2               |
| Missing (% of total)             |                        |        |        |                       |               |                      |                    |
| 0                                | 0.0                    | 2      | 0.0    | 1                     | 0.0           | 1                    | 0.0                |
| Age-group                        | <50 yrs                |        |        |                       |               |                      |                    |
| 527                              | 8.7                    | 869    | 5.2    | 2                     | 0.1           | 402                  | 8.1                |
| 50-64 yrs                        |                        |        |        |                       |               |                      |                    |
| 1,093                            | 18.0                   | 3,659  | 21.9   | 957                   | 32.2          | 1,056                | 21.2               |
| 65-74 yrs                        |                        |        |        |                       |               |                      |                    |
| 1,365                            | 22.5                   | 4,344  | 26.0   | 1,905                 | 64.1          | 1,374                | 27.6               |
| 75-84 yrs                        |                        |        |        |                       |               |                      |                    |
| 1,858                            | 30.7                   | 5,693  | 34.1   | 102                   | 3.4           | 1,544                | 31.0               |
| 85+ yrs                          |                        |        |        |                       |               |                      |                    |
| 1,214                            | 20.0                   | 2,142  | 12.8   | 4                     | 0.1           | 600                  | 12.1               |
| Cancer site                      | Caecum/ascending colon |        |        |                       |               |                      |                    |
| 2,128                            | 35.1                   | 4,277  | 25.6   | 500                   | 16.8          | 1,501                | 30.2               |
| Hepatic flexure                  |                        |        |        |                       |               |                      |                    |
| 296                              | 4.9                    | 624    | 3.7    | 103                   | 3.5           | 190                  | 3.8                |
| Transverse colon                 |                        |        |        |                       |               |                      |                    |
| 491                              | 8.1                    | 975    | 5.8    | 166                   | 5.6           | 354                  | 7.1                |
| Splenic flexure/descending colon |                        |        |        |                       |               |                      |                    |
| 578                              | 9.5                    | 797    | 4.8    | 162                   | 5.5           | 288                  | 5.8                |
| Sigmoid colon                    |                        |        |        |                       |               |                      |                    |
| 1,497                            | 24.7                   | 3,480  | 20.8   | 962                   | 32.4          | 1,082                | 21.7               |
| Rectosigmoid                     |                        |        |        |                       |               |                      |                    |
| 259                              | 4.3                    | 989    | 5.9    | 174                   | 5.9           | 246                  | 4.9                |
| Rectal                           |                        |        |        |                       |               |                      |                    |
| 808                              | 13.3                   | 5,565  | 33.3   | 903                   | 30.4          | 1,315                | 26.4               |
| T1                               |                        |        |        |                       |               |                      |                    |
| 112                              | 1.8                    | 653    | 3.9    | 357                   | 12.0          | 379                  | 7.6                |
| Pre-treatment                    |                        |        |        |                       |               |                      |                    |
| TNM T-stage                      |                        |        |        |                       |               |                      |                    |
| T2                               |                        |        |        |                       |               |                      |                    |
| 460                              | 7.6                    | 2,746  | 16.4   | 785                   | 26.4          | 882                  | 17.7               |
| T3                               |                        |        |        |                       |               |                      |                    |
| 2,019                            | 33.3                   | 7,635  | 45.7   | 1,114                 | 37.5          | 1,906                | 38.3               |
| T4                               |                        |        |        |                       |               |                      |                    |
| 1,779                            | 29.4                   | 2,930  | 17.5   | 141                   | 4.7           | 726                  | 14.6               |
| Tx                               |                        |        |        |                       |               |                      |                    |
| 555                              | 9.2                    | 1,129  | 6.8    | 286                   | 9.6           | 484                  | 9.7                |
| T9                               |                        |        |        |                       |               |                      |                    |
| 1,132                            | 18.7                   | 1,614  | 9.7    | 287                   | 9.7           | 599                  | 12.0               |
| N0                               |                        |        |        |                       |               |                      |                    |
| 1,912                            | 31.6                   | 6,492  | 38.9   | 1,607                 | 54.1          | 2,205                | 44.3               |
| Pre-treatment                    |                        |        |        |                       |               |                      |                    |
| TNM N-stage                      |                        |        |        |                       |               |                      |                    |
| N1                               |                        |        |        |                       |               |                      |                    |
| 1,523                            | 25.1                   | 4,965  | 29.7   | 731                   | 24.6          | 1,249                | 25.1               |
| N2                               |                        |        |        |                       |               |                      |                    |
| 1,007                            | 16.6                   | 2,830  | 16.9   | 228                   | 7.7           | 597                  | 12.0               |
| Nx                               |                        |        |        |                       |               |                      |                    |
| 473                              | 7.8                    | 795    | 4.8    | 114                   | 3.8           | 316                  | 6.4                |
| N9                               |                        |        |        |                       |               |                      |                    |
| 1,142                            | 18.9                   | 1,624  | 9.7    | 290                   | 9.8           | 609                  | 12.2               |
| M0                               |                        |        |        |                       |               |                      |                    |
| 3,171                            | 52.4                   | 11,355 | 68.0   | 2,338                 | 78.7          | 3,358                | 67.5               |
| Pre-treatment                    |                        |        |        |                       |               |                      |                    |
| TNM M-stage                      |                        |        |        |                       |               |                      |                    |
| M1                               |                        |        |        |                       |               |                      |                    |
| 1,637                            | 27.0                   | 3,080  | 18.4   | 198                   | 6.7           | 765                  | 15.4               |
| Mx                               |                        |        |        |                       |               |                      |                    |
| 416                              | 6.9                    | 1,031  | 6.2    | 173                   | 5.8           | 353                  | 7.1                |
| M9                               |                        |        |        |                       |               |                      |                    |
| 833                              | 13.8                   | 1,241  | 7.4    | 261                   | 8.8           | 500                  | 10.0               |
| Normal activity                  |                        |        |        |                       |               |                      |                    |
| 1,412                            | 29.0                   | 6,410  | 45.1   | 1,631                 | 66.2          | 1,790                | 43.6               |
| Performance                      |                        |        |        |                       |               |                      |                    |
| Status                           |                        |        |        |                       |               |                      |                    |
| Walk & light work                |                        |        |        |                       |               |                      |                    |
| 1,475                            | 30.3                   | 4,562  | 32.1   | 664                   | 26.9          | 1,366                | 33.3               |
| Walk & all self care: up >50%    |                        |        |        |                       |               |                      |                    |
| 991                              | 20.4                   | 2,144  | 15.1   | 144                   | 5.8           | 626                  | 15.2               |
| Ltd self care: confined >50%     |                        |        |        |                       |               |                      |                    |
| 787                              | 16.2                   | 953    | 6.7    | 19                    | 0.8           | 289                  | 7.0                |
| Completely disabled              |                        |        |        |                       |               |                      |                    |
| 200                              | 4.1                    | 132    | 0.9    | 6                     | 0.2           | 35                   | 0.9                |
| Missing (% of total)             |                        |        |        |                       |               |                      |                    |
| 1,192                            | 19.7                   | 2,506  | 15.0   | 506                   | 17.0          | 870                  | 17.5               |
| Care Plan Intent                 | Curative               |        |        |                       |               |                      |                    |
| 3,183                            | 52.6                   | 11,867 | 71.0   | 2,672                 | 90.0          | 3,632                | 73.0               |
| Non Curative                     |                        |        |        |                       |               |                      |                    |
| 1,881                            | 31.1                   | 3,127  | 18.7   | 124                   | 4.2           | 764                  | 15.4               |
| No Cancer Treatment              |                        |        |        |                       |               |                      |                    |
| 506                              | 8.4                    | 845    | 5.1    | 58                    | 2.0           | 284                  | 5.7                |
| Not Known                        |                        |        |        |                       |               |                      |                    |
| 487                              | 8.0                    | 868    | 5.2    | 116                   | 3.9           | 296                  | 5.9                |
| ASA grade*                       | 1                      |        |        |                       |               |                      |                    |
| 435                              | 12.1                   | 1,503  | 13.5   | 434                   | 18.2          | 467                  | 14.0               |
| 2                                |                        |        |        |                       |               |                      |                    |
| 1,596                            | 44.4                   | 6,184  | 55.6   | 1,558                 | 65.2          | 1,835                | 54.9               |
| 3                                |                        |        |        |                       |               |                      |                    |
| 1,277                            | 35.5                   | 3,206  | 28.8   | 375                   | 15.7          | 961                  | 28.8               |
| 4 or 5                           |                        |        |        |                       |               |                      |                    |
| 286                              | 8.0                    | 233    | 2.1    | 21                    | 0.9           | 79                   | 2.4                |
| Missing/Not Known (% of total)   |                        |        |        |                       |               |                      |                    |
| 2,463                            | 40.7                   | 5,581  | 33.4   | 582                   | 19.6          | 1,634                | 32.8               |
| Surgical Treatment               | Major Resection        |        |        |                       |               |                      |                    |
| 3,290                            | 54.3                   | 10,585 | 63.4   | 2,274                 | 76.6          | 3,082                | 61.9               |
| Local Excision                   |                        |        |        |                       |               |                      |                    |
| 47                               | 0.8                    | 589    | 3.5    | 304                   | 10.2          | 326                  | 6.6                |
| Stoma                            |                        |        |        |                       |               |                      |                    |
| 242                              | 4.0                    | 515    | 3.1    | 9                     | 0.3           | 88                   | 1.8                |
| Stent                            |                        |        |        |                       |               |                      |                    |
| 89                               | 1.5                    | 158    | 0.9    | 6                     | 0.2           | 28                   | 0.6                |
| Other                            |                        |        |        |                       |               |                      |                    |
| 318                              | 5.3                    | 329    | 2.0    | 50                    | 1.7           | 132                  | 2.7                |
| None Reported                    |                        |        |        |                       |               |                      |                    |
| 2,071                            | 34.2                   | 4,531  | 27.1   | 327                   | 11.0          | 1,320                | 26.5               |

* ASA grade only required if patient undergoes surgical treatment

## Diagnosis From Screening

The proportion of patients at screen eligible age (60-74 years) diagnosed following a referral from screening services is 23%. Patients referred from screening services tended to have earlier cancers and were more likely to be treated with curative intent than patients diagnosed via other referral means. 

## Geographical Variation In Screening Diagnoses In Eligible Patients

Figure 3.1 demonstrates wide variation in screening diagnoses amongst patients aged 60-74 years, and therefore eligible for screening. This ranged from 16% in Cheshire and Merseyside to 29% in East Midlands. 

## Invited Commentary From Dr Suzanne Wright, Head Of Implementation And Training, The Nhs Bowel Cancer Screening Programme

The 2017 Annual Report from the National Bowel Cancer Audit finds that around 9% of colorectal cancer patients are diagnosed through screening services in England and around 12% in Wales. This proportion is higher (23%) when only patients of eligible age are considered. The NBOCA results clearly show the advantages of participating in screening, with these patients being diagnosed with less advanced bowel cancers, and being more likely to be treated with curative intent. The Bowel Cancer Screening Programme commenced in 2006 in England and 2008 in Wales, inviting men and women (aged 60-69 years) to take part in a faecal occult blood testing programme. In 2010 the programme extended the screening age range to include people up to 74 years old. For the year 2015-2016 there were 4.3 million people invited to take part in the Bowel Cancer Screening Programme, with 56% of those invited participating.

Although participation compares well with most other guaiac-based faecal occult blood test (gFOBt) programmes; it is the lowest participation of the 3 English cancer screening programmes. There are marked differences in the male, deprived and previous non-responders populations each showing lower participation rates. Within Wales, 284 400 patients were invited to participate in the 2015-2016 period, with a 54% uptake. In 2014 the Bowel Cancer Screening Programme commissioned a pilot to evaluate the move to a new faecal immunochemical test (FIT). The results of this pilot demonstrated markedly improved participation rates particularly in men and previous non-respondents due to better usability. As a result, FIT will be introduced in England in spring/summer 2018 and rolled out in Wales in early 2019. In addition, a one-off test called bowel scope screening is being introduced in England which involves telescopic examination of the bowel and will be offered to men and women aged 55. We hope to see the positive impact of the introduction of the FIT, as well as bowel scope screening, reflected in future NBOCA Annual Reports. 

## 3.2 How Are Patients Treated Following Diagnosis? Care Pathways

76% of patients diagnosed with bowel cancer who have a care plan intent recorded were treated with curative intent (Table 3.2). Surgical removal of a locally confined cancer remains the most certain modality of cure but patient suitability and disease characteristics have a profound influence on treatment. Patient characteristics according to care pathway are shown in Table 3.2. Treatment intent appeared to change at the extremes of age. 60% of patients under the age of 50 years were treated with curative intent, 70% of patients between the ages of 50 and 74, 62% of patients 75 to 84 years and 37% of those over the age of 85 years. This most likely relates to more advanced disease in younger patients and the increased fragility of very elderly patients in whom further active treatment may not be in their best interests. Similarly, performance status was a clear discriminator of treatment. 85% of patients treated with curative intent were performance status 1 or 2, compared to 45% of those treated with non-curative intent A significant proportion of patients (37%) did not undergo major resection. These patients are subdivided into three broad categories:

## Too Little Cancer (Stage I):

- Those undergoing a local resection or polypectomy OR
- Those with rectal cancer and pre-treatment M0 
undergoing long course radiotherapy with curative monitoring intent (to represent those with complete response) 

## Too Much Cancer (Stage Iv):

- No excision and reason for no treatment included 
advanced stage cancer OR
- No excision and non-curative intent and metastatic 
disease

## Too Frail:

- Not in 'too much cancer' group AND: - No excision and reason for no treatment includes 
significant comorbidity OR
- No excision and performance status 3 or 4
There remains a substantial group of patients (16%) whom it was not possible to classify. More complete information is required on the data items: reason for no treatment, performance status, care plan intent and pre-treatment M-stage to reduce this proportion.

Description of the 30,710 patients diagnosed with bowel cancer between 1 April 2015 and 31 March 2016, by NBOCA Treatment Pathway
|                           |                        |                 | Curative   | Non Curative/No Treatment   | Unknown    |
|---------------------------|------------------------|-----------------|------------|-----------------------------|------------|
| Major Resection           | Too little             | Major Resection | Too much   | Too frail                   | Other*     |
| N                         | %                      | N               | %          | N                           | %          |
| Total patients            | 18,086                 |                 | 1,332      |                             | 1,148      |
| Gender                    | Male                   |                 |            |                             |            |
| 10,168                    | 56.2                   | 823             | 61.8       | 624                         | 54.4       |
| Female                    |                        |                 |            |                             |            |
| 7,916                     | 43.8                   | 508             | 38.2       | 524                         | 45.6       |
| Missing (% of total)      |                        |                 |            |                             |            |
| 2                         | 0.0                    | 1               | 0.1        | 0                           | 0.0        |
| Age                       | <50                    |                 |            |                             |            |
| 1,018                     | 5.6                    | 62              | 4.7        | 89                          | 7.8        |
| 50-64                     |                        |                 |            |                             |            |
| 4,439                     | 24.5                   | 331             | 24.8       | 267                         | 23.3       |
| 65-74                     |                        |                 |            |                             |            |
| 5,899                     | 32.6                   | 483             | 36.3       | 314                         | 27.4       |
| 75-84                     |                        |                 |            |                             |            |
| 5,380                     | 29.7                   | 353             | 26.5       | 344                         | 30.0       |
| 85+                       |                        |                 |            |                             |            |
| 1,350                     | 7.5                    | 103             | 7.7        | 134                         | 11.7       |
| Cancer site               | Caecum/ascending colon |                 |            |                             |            |
| 5,357                     | 29.6                   | 41              | 3.1        | 434                         | 37.8       |
| Hepatic flexure           |                        |                 |            |                             |            |
| 786                       | 4.3                    | 7               | 0.5        | 56                          | 4.9        |
| Transverse colon          |                        |                 |            |                             |            |
| 1,307                     | 7.2                    | 22              | 1.7        | 70                          | 6.1        |
| 1,153                     | 6.4                    | 41              | 3.1        | 77                          | 6.7        |
| Splenic flexure/          |                        |                 |            |                             |            |
| descending colon          |                        |                 |            |                             |            |
| Sigmoid colon             |                        |                 |            |                             |            |
| 4,168                     | 23.0                   | 478             | 35.9       | 304                         | 26.5       |
| Rectosigmoid              |                        |                 |            |                             |            |
| 975                       | 5.4                    | 66              | 5.0        | 53                          | 4.6        |
| Rectal                    |                        |                 |            |                             |            |
| 4,340                     | 24.0                   | 677             | 50.8       | 154                         | 13.4       |
| T1                        |                        |                 |            |                             |            |
| 740                       | 4.1                    | 523             | 39.3       | 12                          | 1.0        |
| Pre-treatment             |                        |                 |            |                             |            |
| TNM T-stage               |                        |                 |            |                             |            |
| T2                        |                        |                 |            |                             |            |
| 3,680                     | 20.3                   | 191             | 14.3       | 74                          | 6.4        |
| T3                        |                        |                 |            |                             |            |
| 8,494                     | 47.0                   | 70              | 5.3        | 399                         | 34.8       |
| T4                        |                        |                 |            |                             |            |
| 2,642                     | 14.6                   | 21              | 1.6        | 435                         | 37.9       |
| Tx                        |                        |                 |            |                             |            |
| 1,130                     | 6.2                    | 267             | 20.0       | 73                          | 6.4        |
| T9                        |                        |                 |            |                             |            |
| 1,400                     | 7.7                    | 260             | 19.5       | 155                         | 13.5       |
| N0                        |                        |                 |            |                             |            |
| 8,381                     | 46.3                   | 855             | 64.2       | 266                         | 23.2       |
| Pre-treatment             |                        |                 |            |                             |            |
| TNM N-stage               |                        |                 |            |                             |            |
| N1                        |                        |                 |            |                             |            |
| 5,318                     | 29.4                   | 69              | 5.2        | 351                         | 30.6       |
| N2                        |                        |                 |            |                             |            |
| 2,325                     | 12.9                   | 26              | 2.0        | 302                         | 26.3       |
| Nx                        |                        |                 |            |                             |            |
| 644                       | 3.6                    | 120             | 9.0        | 74                          | 6.4        |
| N9                        |                        |                 |            |                             |            |
| 1,418                     | 7.8                    | 262             | 19.7       | 155                         | 13.5       |
| M0                        |                        |                 |            |                             |            |
| 14,753                    | 81.6                   | 960             | 72.1       | 392                         | 34.1       |
| Pre-treatment             |                        |                 |            |                             |            |
| TNM M-stage               |                        |                 |            |                             |            |
| M1                        |                        |                 |            |                             |            |
| 1,013                     | 5.6                    | 13              | 1.0        | 573                         | 49.9       |
| Mx                        |                        |                 |            |                             |            |
| 1,259                     | 7.0                    | 117             | 8.8        | 73                          | 6.4        |
| M9                        |                        |                 |            |                             |            |
| 1,061                     | 5.9                    | 242             | 18.2       | 110                         | 9.6        |
| Normal activity           |                        |                 |            |                             |            |
| 7,965                     | 51.6                   | 599             | 56.4       | 324                         | 34.1       |
| Performance               |                        |                 |            |                             |            |
| Status                    |                        |                 |            |                             |            |
| Walk & light work         |                        |                 |            |                             |            |
| 5,148                     | 33.4                   | 305             | 28.7       | 352                         | 37.1       |
| 1,839                     | 11.9                   | 118             | 11.1       | 170                         | 17.9       |
| Walk & all self care:up   |                        |                 |            |                             |            |
| >50%                      |                        |                 |            |                             |            |
| 433                       | 2.8                    | 38              | 3.6        | 84                          | 8.9        |
| Ltd self care: confined   |                        |                 |            |                             |            |
| >50%                      |                        |                 |            |                             |            |
| Completely disabled       |                        |                 |            |                             |            |
| 41                        | 0.3                    | 2               | 0.2        | 19                          | 2.0        |
| Not recorded (% of total) |                        |                 |            |                             |            |
| 2,660                     | 14.7                   | 270             | 20.3       | 199                         | 17.3       |
pathway or 
unknown 
treatment intent
Description of the 30,710 patients diagnosed with bowel cancer between 1 April 2015 and 31 March 2016, by NBOCA Treatment Pathway
|                           |            |                 | Curative   | Non Curative/No Treatment   | Unknown    |
|---------------------------|------------|-----------------|------------|-----------------------------|------------|
| Major Resection           | Too little | Major Resection | Too much   | Too frail                   | Other*     |
| N                         | %          | N               | %          | N                           | %          |
| Missing pathology record† |            |                 |            |                             |            |
| 1,376                     | 7.6        | 346             | 26.0       | 108                         | 9.4        |
| T0                        |            |                 |            |                             |            |
| 245                       | 1.5        | 17              | 1.7        | 9                           | 0.9        |
| Final pathology           |            |                 |            |                             |            |
| T-stage                   |            |                 |            |                             |            |
| T1                        |            |                 |            |                             |            |
| 1,113                     | 6.7        | 680             | 69.0       | 19                          | 1.8        |
| T2                        |            |                 |            |                             |            |
| 2,679                     | 16.0       | 97              | 9.8        | 68                          | 6.5        |
| T3                        |            |                 |            |                             |            |
| 8,695                     | 52.0       | 27              | 2.7        | 327                         | 31.4       |
| T4                        |            |                 |            |                             |            |
| 3,836                     | 23.0       | 4               | 0.4        | 601                         | 57.8       |
| Tx                        |            |                 |            |                             |            |
| 23                        | 0.1        | 33              | 3.3        | 2                           | 0.2        |
| T9                        |            |                 |            |                             |            |
| 119                       | 0.7        | 128             | 13.0       | 14                          | 1.3        |
| N0                        |            |                 |            |                             |            |
| 9,867                     | 59.0       | 490             | 49.7       | 323                         | 31.1       |
| Final pathology           |            |                 |            |                             |            |
| N-stage                   |            |                 |            |                             |            |
| N1                        |            |                 |            |                             |            |
| 4,237                     | 25.4       | 21              | 2.1        | 277                         | 26.6       |
| N2                        |            |                 |            |                             |            |
| 2,443                     | 14.6       | 3               | 0.3        | 419                         | 40.3       |
| Nx                        |            |                 |            |                             |            |
| 30                        | 0.2        | 226             | 22.9       | 7                           | 0.7        |
| N9                        |            |                 |            |                             |            |
| 133                       | 0.8        | 246             | 24.9       | 14                          | 1.3        |
| M0                        |            |                 |            |                             |            |
| 14,610                    | 87.4       | 841             | 85.3       | 479                         | 46.1       |
| Final pathology           |            |                 |            |                             |            |
| M-stage                   |            |                 |            |                             |            |
| M1                        |            |                 |            |                             |            |
| 937                       | 5.6        | 7               | 0.7        | 483                         | 46.4       |
| Mx                        |            |                 |            |                             |            |
| 1,075                     | 6.4        | 64              | 6.5        | 64                          | 6.2        |
| M9                        |            |                 |            |                             |            |
| 88                        | 0.5        | 74              | 7.5        | 14                          | 1.3        |

 *Other includes pathways with small numbers of cases,for example, the 307 patients who are recorded as declining treatment. In addition, there are patients with data inconsistencies, such as Curative Care Plan Intent but no recorded treatment. † For Major resection and Too little pathways this data should be recorded. For Too much, Too frail and Not known/ Other pathways this data would not be expected unless patient had surgery

## Curative Intent

93% of patients treated with curative intent underwent a major resection (Table 3.3). Linkage to SACT data shows that around 34% patients received post-operative chemotherapy. The use of radiotherapy in the rectal cancer patients included in this group is further explored in Chapter 6. 

## Non-Curative Intent

18% of patients treated with non-curative intent underwent a major resection of primary tumour, of whom 60% subsequently underwent chemotherapy. Nearly half of these procedures were performed on an urgent or emergency basis (compared to 14% of major resection procedures performed in patients treated with curative intent). A further 14% of patients treated with non-curative intent underwent a palliative surgical procedure (stoma formation or stent) (Table 3.3). 

pathway or 
unknown 
treatment intent

Of patients who did not undergo a major resection, 30% of those with advanced disease underwent chemotherapy, and almost no patients deemed too frail for major resection received chemotherapy. 

## Unknown/Other

There were over 5,000 patients who do not readily fit into one of the pathways described above. These patients appear to be a varied cohort and their characteristics are not directly comparable to those patients in any particular pathway. 

Description of management of the 30,710 patients diagnosed with bowel cancer between 1 April 2015 and 31 March 2016, by NBOCA treatment pathway
| Curative                      | Non Curative/No Treatment   | Unknown    |
|-------------------------------|-----------------------------|------------|
| Major                         | Too little                  | Major      |
| Resection                     |                             |            |
| N                             | %                           | N          |
| Total patients                | 18,086                      | 1,331      |
| Planned treatment†            | Surgery                     |            |
| 16,632                        | 92.0                        | 1,177      |
| Radiotherapy                  |                             |            |
| 1,208                         | 6.7                         | 58         |
| Chemotherapy                  |                             |            |
| 2,111                         | 11.7                        | 46         |
| Specialist Palliative Care    |                             |            |
| 11                            | 0.1                         | 8          |
| Brachytherapy                 |                             |            |
| 9                             | 0.0                         | 2          |
| None                          |                             |            |
| 422                           | 2.3                         | 104        |
| Reason for no treatment       | Patient declined            |            |
| 2                             | 0.0                         | 5          |
| Unfit: co-morbidity           |                             |            |
| 4                             | 0.0                         | 4          |
| Unfit: advanced disease       |                             |            |
| 6                             | 0.0                         | 39         |
| Multiple                      |                             |            |
| 0                             | 0.0                         | 0          |
| NK                            |                             |            |
| 319                           | 1.8                         | 47         |
| Missing                       |                             |            |
| 17,755                        | 98.2                        | 1,236      |
| Active monitoring intent      | Curative                    |            |
| 2,368                         | 13.1                        | 183        |
| Palliative                    |                             |            |
| 51                            | 0.3                         | 8          |
| 243                           | 1.3                         | 25         |
| Unknown or uncertain          |                             |            |
| future intent                 |                             |            |
| None                          |                             |            |
| 10,530                        | 58.2                        | 810        |
| Missing                       |                             |            |
| 4,894                         | 27.1                        | 305        |
| Long Course RT                |                             |            |
| 1,066                         | 5.9                         | 59         |
| First definitive non-surgical |                             |            |
| treatment                     |                             |            |
| Short Course RT               |                             |            |
| 388                           | 2.1                         | 24         |
| Other/Brachy                  |                             |            |
| 10                            | 0.1                         | 2          |
| Chemotherapy                  |                             |            |
| 780                           | 4.3                         | 2          |
| None Recorded                 |                             |            |
| 15,842                        | 87.6                        | 1,244      |
| Surgical Urgency              | Elective/Scheduled          |            |
| 2,571                         | 14.2                        | 49         |
| Emergency/Urgent              |                             |            |
| 15,487                        | 85.8                        | 1,210      |
| Missing (% of total)          |                             |            |
| 28                            | 0.2                         | 72         |
| Type of Surgery               | Major Resection             |            |
| 18,086                        | 100.0                       | 0          |
| Local Excision                |                             |            |
| 0                             | 0.0                         | 1,292      |
| Stoma                         |                             |            |
| 0                             | 0.0                         | 5          |
| Stent                         |                             |            |
| 0                             | 0.0                         | 0          |
| Other                         |                             |            |
| 0                             | 0.0                         | 1          |
| None recorded                 |                             |            |
| 0                             | 0.0                         | 33         |
| Palliative                    |                             |            |
| 373                           | 2.1                         | 28         |
| Treatment Aim following       |                             |            |
| surgery                       |                             |            |
| Curative                      |                             |            |
| 17,277                        | 95.5                        | 1,185      |
| Uncertain                     |                             |            |
| 436                           | 2.4                         | 85         |
| Missing                       |                             |            |
| 0                             | 0.0                         | 33         |
| Post-operative Destination    | Standard ward               |            |
| 6,201                         | 54.5                        | 627        |
| High Care Area                |                             |            |
| 1,474                         | 13.0                        | 21         |
| HDU Level 2                   |                             |            |
| 2,554                         | 22.4                        | 14         |
| ITU Level 3                   |                             |            |
| 1,153                         | 10.1                        | 1          |
| Missing (% of total)          |                             |            |
| 6,704                         | 37.1                        | 668        |
| Yes                           |                             |            |
| 6,201                         | 34.3                        | 87         |
| Post-operative                |                             |            |
| Chemotherapy                  |                             |            |
| No                            |                             |            |
| 11,885                        | 65.7                        | 1,211      |
| N/A                           |                             |            |
| 0                             | 0.00                        | 33         |

* Other includes pathways with small numbers of cases,for example, the 307 patients who are recorded as declining treatment. In addition, there are patients with data inconsistencies, such as Curative Care Plan Intent but no recorded treatment. † Patients can have more than one planned treatment recorded therefore the percentage total may be greater than 100

pathway or 
unknown 
treatment 
intent
Too much
Too frail
Other*
Resection

## Geographical Variation In Care Pathways

As shown in Figure 3.2 the proportion of patients undergoing curative major resection ranged from 55%- 66%. Some of this variability still present may represent differences in data completeness. 

## 3.3 How Often Was Adjuvant Chemotherapy Used In Patients With Stage Iii Colon And Rectal Cancer?

National Institute for Health and Care Excellence (NICE) guidance recommends that systemic chemotherapy should be offered post-operatively to all patients with stage III colorectal cancer who are fit enough to tolerate it. This is the first year data has been available for the administration of adjuvant chemotherapy via linkage with the SACT database. This has enabled more accurate information regarding the use of chemotherapy to be presented. One year of data is currently available and therefore assessment of trends in chemotherapy use over time has not been possible. Out of the 3,765 patients identified from the audit as undergoing major resection with stage III colonic or rectal cancer (N1 or N2 disease on post-operative staging), 1,987 (53%) underwent adjuvant treatment with chemotherapy within 3 months of major resection. An additional 155 (4%) patients commenced chemotherapy 3-6 months from major resection. Patients receiving chemotherapy tended to be performance status 0/1 and be ASA grade 1/2. Patients also tended to be younger with 30% of patients over the age of 75 years old receiving chemotherapy compared to 72% of patients under the age of 75 years. There was no major difference in administration of chemotherapy based on tumour site or surgical urgency.

## Geographical Variation In Adjuvant Treatment

The use of adjuvant chemotherapy in patients with stage III disease ranged from 41% in Humber, Coast and Vale to 68% in North Central and East London, as displayed in Figure 3.3. Wales is not presented because the Systemic Anti-Cancer Therapy dataset is not available for patients.

## Recommendations - Care Pathways:

3(a). Healthcare professionals must continue to promote bowel cancer screening and address the significant geographical variation in the uptake of screening. 3(b). More evidence is required to determine the role of major resection of asymptomatic primary colorectal tumours in the context of synchronous inoperable metastatic disease. Results from the several randomised controlled trials currently underway will be invaluable in this regard. 3(c). The geographical disparity in the use of adjuvant chemotherapy needs to be explored further.

The audit has shown considerable national variation in the administration of post-operative chemotherapy. Possible explanations for this variation include age and co-morbidity. If there is significant variation in the use of adjuvant chemotherapy after correcting for these factors that would be very clinically significant. We know the use of adjuvant chemotherapy is associated with an improved chance of cure so optimising its use could result in improved outcomes.

## 4. Surgical Care Surgical Care - Nboca 2017

- Overall 90-day mortality after major surgery has steadily reduced over five years from 4.7% in 2011/12 to 3.2% in 
2015/16.
- 90-day mortality following elective or scheduled surgery for bowel cancer was 1.9% in contrast to 10.3% in 
patients who had surgery on an urgent or emergency basis.
- The median length of hospital stay following elective major surgery is 7 days and following emergency major 
surgery is 11 days.
- Overall, one in ten patients had an emergency readmission within 30-days of major resection. - The proportion of major resections performed laparoscopically is increasing year on year with no increase in the 
rate of conversion to open.
- 83% of patients undergoing major resection have more than 12 lymph nodes examined.

## 4.1 How Many Patients Die Within 90-Days Of Major Surgery? 90-Day Post-Operative Mortality Over Time

Over the past five years the proportion of patients undergoing major resection has remained relatively constant, while unadjusted post-operative mortality has decreased (Table 4.1). In 2015/16 3.2% patients died within 90-days of major resection. 

Patients undergoing major surgery and chance of death after major surgery, by audit year
 
2011-12
2012-13
2013-14
2014-15
2015-16
 
Number
%
Number
%
Number
%
Number
%
Number
%
Total patients 
30,354
 
31,398
 
30,713
 
31,076
 
30,710
 
Undergoing major resection
19,319
63.6
20,067
63.9
19,686
64.1
19,575
63.0
19,231
62.6
891
4.7
933
4.8
758
4.0
716
3.8
593
3.2
Dead at 90 days after surgery, out of those undergoing major resection Missing mortality
459
 2.4 
490
 2.4 
548
 2.8 
619
 3.2 
896
 4.6 

## Variation In 90-Day Post-Operative Mortality Between Care Providers

The variation in 90-day post-operative mortality across Cancer Alliances is shown in Figure 4.1. When making comparisons between Cancer Alliances and between trusts/ hospitals, 90-day mortality was adjusted for the 9 risk factors listed on page 17. After risk adjustment there were two Cancer Alliances outside the inner limits. Funnel plots for 90-day post-operative mortality by trust/ hospital, both observed and risk-adjusted, are presented in Figure 4.2. This year there are three trusts outside the outer limits for 90-day mortality. This is more than would be expected by chance.

## 90-Day Post-Operative Mortality According To Operative Urgency

21% of patients were diagnosed with bowel cancer following an emergency admission (Table 4.2). This varied according to trust/hospital site and less than 10% of major resections were classified as urgent/emergency in 25 trusts and over 20% were classified as urgent/emergency in 35 trusts (Table 7.3).

Emergency admissions in England & Wales from HES/PEDW, by audit year
|                      | 2011-12   | 2012-13   | 2013-14   | 2014-15   | 2015-16   |
|----------------------|-----------|-----------|-----------|-----------|-----------|
| Total patients       |           |           |           |           |           |
| 30,354               |           | 31,406    |           | 30,726    |           |
| Emergency admission  |           |           |           |           |           |
| 5,606                | 20.8      | 5,898     | 21.2      | 5,744     | 21.3      |
| Elective admission   |           |           |           |           |           |
| 21,313               | 79.2      | 21,874    | 78.8      | 21,182    | 78.7      |
| Missing (% of total) |           |           |           |           |           |
| 3,435                | 11.3      | 3,634     | 11.6      | 3,800     | 12.4      |

The 90-day mortality following elective or scheduled surgery for bowel cancer was 1.8% (Table 4.3). Postoperative mortality has decreased over the last four years in both elective patients and emergency patients. In those undergoing elective or scheduled surgery 90-day mortality has dropped form 2.9% in 2011/12 to 1.9% in 2015/16, 

Mortality in patients who had major surgery by surgical urgency
|                                           |      |            |      |            | 2011-12   | 2012-13    | 2013-14   | 2014-15    | 2015-16   |
|-------------------------------------------|------|------------|------|------------|-----------|------------|-----------|------------|-----------|
| Number                                    | %    | Number     | %    | Number     | %         | Number     | %         | Number     | %         |
| Total patients undergoing major resection |      |            |      |            |           |            |           |            |           |
| 19,319                                    |      | 20,067     |      | 19,686     |           | 19,575     |           | 19,231     |           |
| Overall 90-day mortality*                 |      |            |      |            |           |            |           |            |           |
| 891/18,861                                | 4.7  | 933/19,578 | 4.8  | 757/19,139 | 4.0       | 716/18,958 | 3.8       | 591/18,338 | 3.2       |
| Elective                                  |      |            |      |            |           |            |           |            |           |
| 354/12,321                                | 2.9  | 362/12,645 | 2.9  | 277/12,471 | 2.2       | 250/12,224 | 2.0       | 210/11,383 | 1.8       |
| Scheduled                                 |      |            |      |            |           |            |           |            |           |
| 104/3,360                                 | 3.1  | 121/3,814  | 3.2  | 91/3,595   | 2.5       | 86/3,678   | 2.3       | 74/3,938   | 1.9       |
| 90-day mortality                          |      |            |      |            |           |            |           |            |           |
| by urgency of                             |      |            |      |            |           |            |           |            |           |
| operation                                 |      |            |      |            |           |            |           |            |           |
| Urgent                                    |      |            |      |            |           |            |           |            |           |
| 150/1,291                                 | 11.6 | 169/1,300  | 13.0 | 132/1,254  | 10.5      | 110/1,218  | 9.0       | 89/1,157   | 7.7       |
| Emergency                                 |      |            |      |            |           |            |           |            |           |
| 262/1,681                                 | 15.6 | 277/1,698  | 16.3 | 254/1,788  | 14.2      | 268/1,807  | 14.8      | 218/1,828  | 11.9      |
| Missing urgency of operation              |      |            |      |            |           |            |           |            |           |
| 21/208                                    | 10.1 | 4/121      | 3.3  | 3/31       | 9.7       | 2/31       | 6.5       | 0/32       | 0.0       |

*some patients are missing mortality data due to Type 2 objections (section 2.3), others due to ONS date of death occurring prior to the reported date of surgery or a valid date of surgery could not be transferred to CAP from Open Exeter.

and in those undergoing urgent or emergency surgery, 13.9% in 2014/15 to 10.3% in 2015/16. The National Emergency Laparotomy Audit (NELA) has also reported a decrease in postoperative mortality amongst all patients undergoing emergency laparotomy, a large proportion of whom are bowel cancer patients. 

## Invited Commentary From Dr Dave Murray, Clinical Lead, National Emergency Laparotomy Audit

For some years now, there has been concern over the number of patients with bowel cancer who require surgery as an urgent or emergency procedure. This latest NBOCA report shows that 90-day mortality has fallen from 12.5% in 2014-15 to 10.3% in 2015-16. This reduction in mortality reflects a similar drop seen in the National Emergency Laparotomy Audit (NELA), with 30-day mortality for all patients undergoing emergency laparotomy falling to 10.6% in the latest NELA report 
(covering December 2015 to November 2016), compared to 11.8% when NELA commenced three years ago. A key aspect of the published standards against which NELA audits is that emergency laparotomy is timepressured high risk surgery, and as such warrants appropriate resource, such as consultant delivered care and access to critical care beds. These resources are more often than not automatically provided for patients undergoing elective surgery with lower mortality rates (elective cancer surgery is a good example). However, NELA has demonstrated improvement in some of these areas; risk assessment before surgery has improved from 56% to 71% of patients, and consultant presence in theatre has improved from 70% to 79% of patients. However, there is still some way to go, especially in areas dependent on sufficient hospital "infrastructure" to meet standards; the proportion of the most urgent patients arriving in theatre within two hours has remained around 75% since NELA commenced. 

Similarly, the proportion of high-risk patients admitted directly to critical care after surgery has also remained around 75%. 

## 4.2 How Long Do Patients Stay In Hospital After Major Bowel Cancer Resection? Trends In Length Of Stay Over Time

Median length of stay following major resection was 7 days, which is unchanged over the last 5 years. Median length of stay varied according to patient age (7 days in patients less than 75 years old and 10 days in patients 85 years or older) and operative urgency (7 days in elective major resection and 11 days in emergency major resection). Over one third of patients undergoing emergency major resection remained in hospital more than 2 weeks following major resection, compared to 15% of elective patients. 

In theory, all patients requiring an emergency laparotomy for bowel cancer should be included in both NELA and NBOCA, which provides a valuable opportunity for linkage between the two Audits. There are some disparities between the both Audits' findings, which may in part be due to differences between the respective datasets. Unlike NBOCA, NELA does not record pathological diagnosis. Despite NELA's >80% case ascertainment rate, only 1,735 patients had "colorectal cancer" as an operative finding, significantly fewer than the 2,985 patients in NBOCA who had urgent/ emergency surgery. 25% of cases were completed laparoscopically in NBOCA, but 12% in NELA. At a methodological level, linkage will allow us to assess data quality and make judgements on the robustness of conclusions drawn. Patients undergoing emergency laparotomy for bowel cancer will fall into three groups: 1) those with known cancer who return to theatre for an emergency laparotomy following an elective resection, 2) those with known cancer whose emergency laparotomy pre-empts their elective treatment, 3) those with unknown cancer where the diagnosis of cancer is made during their admission for the emergency laparotomy. The pathways of care for each of these groups will be different, and outcomes may also vary. Linkage will provide a richer source of information from which to better understand the quality of care received by patients undergoing emergency surgery for bowel cancer. Whilst it may not be possible to shift all patients from an emergency to elective procedure, a greater understanding of the factors that impact emergency outcomes, coupled with improvements in those areas, should produce a continued fall in mortality.

## Geographical Variation In Length Of Stay

There was substantial variation between Cancer Alliances in length of stay following both elective and emergency major resection, as shown in Figure 4.3. Amongst elective patients geographical variation was mainly seen in the proportion of patients staying less than 7 days, while in emergency patients there was variation across all time periods. 

## 4.3 How Many Patients Have An Unplanned Readmission Within 30-Days Of Discharge From Hospital After Major Bowel Cancer Surgery?

Trends in emergency readmissions within 30-days Overall, 10% of patients had an emergency readmission within 30-days of surgery. This has remained stable over the last five years.

Emergency hospital readmission rate within 30-days of surgery for patients undergoing major resection in England and Wales, by audit year
|                                           |        |        |        |        | 2011-12   | 2012-13   | 2013-14   | 2014-15   | 2015-16   |
|-------------------------------------------|--------|--------|--------|--------|-----------|-----------|-----------|-----------|-----------|
| Number                                    | %      | Number | %      | Number | %         | Number    | %         | Number    | %         |
| Total patients undergoing major resection | 19,319 |        | 20,074 |        | 19,687    |           | 19,575    |           | 19,232    |
| Yes                                       | 1,869  | 10.5   | 1,878  | 10.1   | 1,859     | 10.3      | 1,822     | 10.1      | 1,675     |
| Emergency readmission                     |        |        |        |        |           |           |           |           |           |
| within 30 days                            |        |        |        |        |           |           |           |           |           |
| No                                        | 15,981 | 89.5   | 16,680 | 89.9   | 16,236    | 89.7      | 16,161    | 89.9      | 15,048    |
| Missing (% of total)                      | 1,469  | 7.6    | 1,516  | 7.6    | 1,592     | 8.1       | 1,592     | 8.1       | 2,509     |

## Geographical Variation In 30-Day Emergency Readmission

As shown in Figure 4.4 and 4.5, no Cancer Alliances or trust/hospital fell outside the outer limits for observed or adjusted readmission rate. 

As seen in Figure 4.5, seven trusts fell above the inner limit on adjusted readmission rate. This is no more than would be expected by chance alone. 

## 4.4 How Many Patients Have Laparoscopic Surgery?

The audit subdivides surgical access into three categories:

- open resection - laparoscopic converted to open resection - completed laparoscopic resection

## Trends In The Use Of Laparoscopic Surgery

As shown in Figure 4.6, the proportion of major resections performed laparoscopically has continued to increase and for the second year more than half of major resections were completed laparoscopically. There was no rebound increase in unplanned conversion (currently 8%).

The use of laparoscopic surgery according to cancer site was highest in patients with rectal cancer (68% started laparoscopically) and caecal cancer (64% started laparoscopically) and was lowest in patients with cancer of the splenic flexure/descending colon (49% started laparoscopically). Patients with advanced cancer, high ASA grade and advanced age were also more likely to have an open resection. Around a quarter of patients undergoing urgent or emergency resection had this performed laparoscopically. The rate of conversion in these cases was low at 4%. 

## Geographical Variation In Laparoscopic Surgery

The proportion of patients with laparoscopic completed resections ranged from 32% to 72% across Cancer Alliances as shown in Figure 4.7. Rates of unplanned conversion to open ranged from 4% to 12%. The use of laparoscopic surgery also varied widely between hospitals/ MDTs (Table 7.3).

## 4.5 How Many Patients Have More Than Twelve Lymph Nodes Examined?

From 2018 the proportion of patients undergoing major resection who have more than 12 lymph nodes examined will be reported according to trust/MDT. This year 83% of patients had more than 12 lymph nodes examined. 

## Geographical Variation In Lymph Node Yield

As shown in Figure 4.8, the proportion of patients undergoing major resection with more than 12 lymph nodes examined varied considerably by trust, from 37% to 98%. These should be interpreted with caution because they are not adjusted for differences in case-mix between trusts, such as the use of neoadjuvant radiotherapy, which may impact upon the lymph node yield. 

## Recommendations - Surgical Care

4(a). Bowel cancer care teams should be congratulated for achieving a continued reduction in postoperative mortality which has taken place without any reduction in resection rates. There should be a continued effort in the delivery of high quality care with a view to further improvements in outcomes.

## 5. Survival Survival - Nboca 2017

- Two-year survival rates for all patients diagnosed 
with bowel cancer has remained stable at 67%.
- Two-year survival rates in patients undergoing 
major resection has remained relatively stable at 82% in 2012/13 and 83% in 2013/14 
- Two-year survival in patients who do not undergo 
tumour excision has decreased from 35% in 2011/12 to 29% in 2013/14.
- No Cancer Alliance/nation fell above the outer limit 
for adjusted two-year mortality amongst patients undergoing a major resection.

Two-year survival over time for all patients diagnosed between 1 April 2011 and 31 March 2014
 
2011-12
2012-13
2013-14
All patients 
30,024
 
31,056
 
30,310
 
Died within 24 months of diagnosis
Yes
9,826
33.4
10,231
33.7
9,859
33.4
No
19,553
66.6
20,145
66.3
19,627
66.6
Missing (% of total)
645
 2.1 
680
 2.2 
824
 2.7 
Underwent Major Resection
19,194
63.9
19,927
64.2
19,550
64.5
Died within 24 months of diagnosis
Yes
3,455
18.5
3,420
17.6
3,155
16.6
No
15,243
81.5
15,992
82.4
15,814
83.4
Missing (% of total)
496
 1.7 
515
 1.7 
581
 1.9 
Underwent Local Excision 
1,098
3.7
1,417
4.6
1,283
4.2
Died within 24 months of diagnosis
Yes
104
9.7
107
7.8
106
8.5
No
972
90.3
1,269
92.2
1,137
91.5
Missing (% of total)
22 
 0.1 
41 
 0.1 
40
 0.1 
No Excision of Tumour 
9,732
32.4
9,712
31.3
9,477
31.3
Died within 24 months of diagnosis
Yes
6,267
65.2
6,704
69.9
6,598
71.1
No
3,338
34.8
2,884
30.1
2,676
28.9
Missing (% of total)
127
 0.4 
124
 0.4 
203
 0.7 

## 5.1 What Is The Two-Year Survival Of Patients With Bowel Cancer? Trends In Two-Year Survival Over Time

Two-year survival rates for all patients diagnosed with bowel cancer have remained stable at around 67% since 2011/12. Two-year survival rates in patients undergoing major resection has slightly increased to 83% (Table 5.1). Twoyear survival in patients who do not undergo tumour excision has decreased from 35% in 2011/12 to 29% in 2013/14. The reasons behind this are not clear, particularly as the proportion of patients who do not undergo primary tumour resection has remained unchanged and some newer chemotherapy treatments have become more widely funded. Patients who do not undergo resection are often very frail with comorbidities, and with an ageing population the frailty of patients who are not resected may have increased over time. 

| N   | %   | N   | %   | N   | %   |
|-----|-----|-----|-----|-----|-----|

## Geographical Variation In Two-Year Survival In All Patients

Variation in two-year mortality is likely to reflect, at least in part, differences in the quality of surgery, patient characteristics and provision of neo-adjuvant and adjuvant chemotherapy and radiotherapy. Due to the proportion of missing pre-treatment staging data on patients who do not undergo major resection, the estimates are not adjusted for differences in patient case-mix. There was a large variation in two-year patient survival according to Cancer Alliance/nation as shown in Figure 5.2. This variation is more than would be expected by chance alone, with one Cancer Alliance falling above and three falling below the outer limits. Some of the regional variation in two-year mortality may reflect the marked health inequalities known to exist between the least deprived and most deprived areas. A further important factor to take into account is the cause of death. As a proportion of deaths at two years will likely be secondary to diseases other than bowel cancer, data on cause of death may help to understand some of the regional variation in all-cause mortality. The audit has recently received cause of death data, results surrounding which will form part of a short report in the future.

## Geographical Variation In Two-Year Survival In Patients Undergoing Major Resection

Figures 5.3 and 5.4 show observed and adjusted two-year mortality amongst patients undergoing a major resection by Cancer Alliance and by trust/MDT. No Cancer Alliances fell above the outer limits. Two Cancer Alliances fell below the outer limits. Although there remains significantly more variation by trust/MDT than would be expected by chance alone, the number of trusts above the inner limits this year reduced from 20 to 13. This year, four trust/MDTs fell above the outer limits, two of which have previously been an outlier for two-year mortality (when only non-overlapping time periods are considered). A further 9 trusts/hospitals fell above the inner limits. 

## Recommendations - Survival

5(a). Action is required nationally to reduce risk exposures, support healthy behaviours and mitigate the effects of socioeconomic deprivation in an attempt to reduce regional variation in cancer survival.

## 6. Rectal Cancer Rectal Cancer - Nboca 2017

- 52% of rectal cancer patients underwent major 
resection and 7% underwent a local excision. Just 5% of rectal cancer patients are managed with a stoma alone.
- 38% of rectal cancer patients undergoing major 
resection received neo-adjuvant treatment.
- The use of neo-adjuvant treatment ranged widely 
between Cancer Alliances from 23% to 58% of patients.
- 83% of rectal cancer patients had a stoma formed 
at the time of surgical resection.
- 50% of rectal cancer patients undergoing major 
resection had a stoma at 18 months. There was substantial variation in rates across trusts/sites.

Management of rectal cancer patients, by audit year
|                         |       |       |       |       | 2011-12   | 2012-13   | 2013-14   | 2014-15   | 2015-16   |
|-------------------------|-------|-------|-------|-------|-----------|-----------|-----------|-----------|-----------|
| N                       | %     | N     | %     | N     | %         | N         | %         | N         | %         |
| Total                   | 8,933 |       | 9,196 |       | 9,058     |           | 9,127     |           | 8,592     |
| Major resection         |       |       |       |       |           |           |           |           |           |
| 4,871                   | 54.5  | 4,995 | 54.3  | 5,062 | 55.9      | 4,955     | 54.3      | 4,474     | 52.1      |
| Local excision          |       |       |       |       |           |           |           |           |           |
| 511                     | 5.7   | 687   | 7.5   | 643   | 7.1       | 615       | 6.7       | 613       | 7.1       |
| Non-resectional surgery |       |       |       |       |           |           |           |           |           |
| 876                     | 9.8   | 816   | 8.9   | 667   | 7.4       | 685       | 7.5       | 621       | 7.2       |
| No Surgery              |       |       |       |       |           |           |           |           |           |
| 2,675                   | 29.9  | 2,698 | 29.3  | 2,686 | 29.7      | 2,872     | 31.5      | 2,884     | 33.6      |

## Use Of Radiotherapy

Of all rectal cancer patients undergoing a major resection, 38% received pre-operative treatment. 26% patients received long-course radiotherapy and 8% patients received short-course radiotherapy. Patient characteristics according to pre-surgical treatment type are shown in Table 6.2. Patients receiving long-course radiotherapy tended to be younger and have less comorbidities than those receiving short-course radiotherapy or no neo-adjuvant treatment and, as would be expected, a greater proportion had a higher T-stage and nodal involvement. 

## 6.1 How Are Patients With Rectal Cancer Treated? Trends Over Time

Surgical resection of the rectum remains the foremost intervention for the treatment of rectal cancer, with 52% of rectal cancer patients undergoing major resection (Table 6.1). 7% of patients undergo local excision of rectal cancer. The proportion of patients undergoing no procedure (either resectional or non-resectional), increased slightly this year from 32% in 2014/15 to 34% in 2015/16. This may be due to an increase in the number of patients with a complete pathological response to chemoradiotherapy (CRT) and therefore not undergoing resection. Of the 4,164 patients who did not undergo major resection, 15% underwent a local excision, 10% stoma, 4% 'other' surgery (such as stenting) and 71% no procedure. For the first time this year we are able to show the time from completing radiotherapy to surgery whereas in previous years only the time from diagnosis to surgery has been available. This is helpful in interpreting the data. In particular we find that 76% of patients have surgery within 14 days of completing short-course radiotherapy. The findings of a short report investigating the timing between long-course radiotherapy and surgery is detailed in the box overleaf. 

Patient characteristics by treatment type, for 4,622 rectal cancer patients diagnosed between 1 January 2015 and 31 December 2015 who underwent a major resection
No preop treatment 
Long-course RT 

Short-course RT 
Other treatment 

recorded
pre-surgery
pre-surgery
pre-surgery *
Number
%
Number
%
Number
%
Number
%
Total rectal cancer patients
2,817
 
1,231
 
386
 
188
 
Sex
Male
1,811
64.3
788
64.0
253
65.5
122
64.9
Female
1,006
35.7
443
36.0
133
34.5
66
35.1
Age-group
<50 yrs
152
5.4
136
11.0
20
5.2
24
12.8
50-64 yrs
838
29.7
458
37.2
106
27.5
75
39.9
65-74 yrs
981
34.8
398
32.3
146
37.8
65
34.6
75-84 yrs
715
25.4
232
18.8
102
26.4
23
12.2
85+ yrs
131
4.7
7
0.6
12
3.1
1
0.5
Pre-treatment TNM T-stage
T1
167
5.9
4
0.3
6
1.6
1
0.5
T2
1,056
37.5
127
10.3
86
22.3
30
16.0
T3
1,240
44.0
860
69.9
257
66.6
110
58.5
T4
149
5.3
201
16.3
22
5.7
37
19.7
TX
88
3.1
5
0.4
4
1.0
2
1.1
T9
117
4.2
34
2.8
11
2.8
8
4.3
Pre-treatment TNM N-stage
N0
1,631
57.9
254
20.6
141
36.5
58
30.9
N1
774
27.5
492
40.0
146
37.8
67
35.6
N2
219
7.8
433
35.2
78
20.2
52
27.7
Nx
60
2.1
14
1.1
9
2.3
2
1.1
N9
133
4.7
38
3.1
12
3.1
9
4.8
Pre-treatment TNM M-stage
M0
2,314
82.1
1,042
84.6
312
80.8
108
57.4
M1
121
4.3
67
5.4
23
6.0
60
31.9
Mx
222
7.9
78
6.3
41
10.6
9
4.8
M9
160
5.7
44
3.6
10
2.6
11
5.9
Time to surgery from final RT
Within 7 days
 
 
0
0.0
195
61.3
 
 
8-14 days
 
 
2
0.2
48
15.1
 
 
3-8 weeks
 
 
34
3.1
22
6.9
 
 
9-12 weeks
 
 
375
33.8
16
5.0
 
 
13-16 weeks
 
 
409
36.8
21
6.6
 
 
17-20 weeks
 
 
155
14.0
6
1.9
 
 
21+ weeks
 
 
135
12.2
10
3.1
 
 
Missing (% of total)
 
 
121
 9.8 
68
 17.6 
 
 
Mode of admission (from HES)
Elective
2,463
95.3
1,091
96.2
344
97.7
166
96.0
Emergency
122
4.7
43
3.8
8
2.3
7
4.0
Missing (% of total)
232
 8.2 
97 
 7.9 
34
 8.8 
15
 8.0 
Comorbidities (from HES)
0
1,569
60.7
723
63.7
201
57.1
115
66.5
1
749
29.0
311
27.4
110
31.3
45
26.0
2+
268
10.4
101
8.9
41
11.6
13
7.5
Missing (% of total)
231
 8.2 
96 
 7.8 
34 
 8.8 
15
 8.0 

* Chemotherapy, brachytherapy or radiotherapy that cannot be classified into our definitions of long/short-course

## Nboca Short Report 2017 The Optimal Timing Between Long-Course Radiotherapy And Surgery In Rectal Cancer Patients

A short report investigating the impact of time to surgery after long-course radiotherapy on circumferential margin status, tumour downstaging, rate of complete response, 18-month stoma presence and 24 month mortality in patients with rectal cancer has been published. This included 4,164 patients with rectal cancer who finished long-course radiotherapy 28-182 days before undergoing surgery.

## Key Findings:

- Median time from CRT to surgery was approximately 12 weeks (85 days (IQR 71-100 days)) - <10% of patients had surgery within 8 weeks of finishing radiotherapy
- Patients who waited longer tended to be older and less healthy (more co-morbidities and higher ASA grade) - Patients who waited longer were more likely to have a stoma 18 months after surgery and:
°
° were more likely to have a surgical procedure leading to a permanent stoma (44% at 4-10 weeks vs 60% at 
14-26 weeks)
°
° were less likely to have a stoma reversed after an anterior resection (72% at 4-10 weeks vs 60% at 14-26 
weeks)
- The lowest rate of positive circumferential margins occurred between 4-14 weeks - The highest rates of complete response and downstaging occurred between 10-14 weeks - There was no evidence that time to surgery had an effect on mortality at 24 months after starting CRT (p=0.46)
In conclusion the median time to surgery within our cohort is longer than that previously reported. The best tumour response appears to occur between 10-14 weeks. A longer delay to surgery is associated with an increased risk of having a stoma 18 months after surgery.

The full report can be accessed at https://www.nboca.org.uk/reports/short-report-1-2017/ 

## Geographical Variation In The Use Of Neoadjuvant Radiotherapy

The use of neo-adjuvant treatment according to Cancer Alliance is presented in Figure 6.1. The use of neo-adjuvant treatment ranged from 23% of patients in Somerset, Wiltshire, Avon and Gloucestershire to 58% of patients in West Yorkshire. This varied within both the use of long course radiotherapy (18-43%) and short-course radiotherapy (0-29%). RTDS was only linked to English data and therefore the reported use of radiotherapy in Wales is from audit data alone, which could contribute to the observed differences between Cancer Alliances in England and Wales. 

## 6.2 How Are Stomas Used In Rectal Cancer Surgery And How Often Are 'Temporary' Stomas Reversed? Formation Of Stoma And Stoma Reversal

From 2012-2015, 84% of rectal cancer patients had a stoma formed at the time of surgical resection (Table 6.3). In addition to all patients undergoing APER and Hartmann's, around 77% of anterior resections were covered by a stoma. Overall, 52% of rectal cancer patients undergoing major resection had a stoma at 18 months. Within 18 months 65% of patients with a stoma following anterior resection had undergone stoma reversal. 

Description of stoma types by procedure for 14,204 rectal cancer patients linked to HES/PEDW having a major resection between 1 April 2012 and 31 March 2015, by procedure
AR
APER
Hartmann's
Other
Number
%
Number
%
Number
%
Number
%
Total rectal cancer patients undergoing major resection
8,946
 
3,667
 
1,230
 
361
 
Any stoma
No
2,032
22.7
0
0.0
0
0.0
256
70.9
Yes
6,914
77.3
3,667
100.0
1,230
100.0
105
29.1
Stoma at 18 months, ignoring deaths
No
6,515
72.8
0
0.0
89
7.2
276
76.5
Yes
2,431
27.2
3,667
100.0
1,141
92.8
85
23.5

## Geographical Variation In 18-Month Stoma Rates

There was considerable variation in adjusted 18-month stoma rates between Cancer Alliances, with three falling above the outer limits. There were also three alliances below the outer limits (Figure 6.2). The variation by trust/hospital site was also large, with six falling above the outer limits, of which one was also an outlier in 2014, and eight falling below the outer limits. A further 16 trusts/MDTs fell above the inner limits (Figure 6.3). This analysis of stoma at 18 months includes all surgical resections for rectal cancer (abdominoperineal excision of the rectum, Hartmann's and anterior resection). Therefore variation is likely to reflect differences in practice with respect to patient selection for permanent stoma, use of adjuvant chemotherapy and local service prioritisation of stoma closure.

## Recommendations - Rectal Cancer

6(a). The presence of a stoma is well recognised to decrease quality of life. Priority should be given to actively managing patients with a defunctioning stoma following anterior resection and planning early closure whenever possible. 6(b). Better understanding of the regional difference in the use of pre-operative treatment for rectal cancer patients is required.

## 7. Bowel Cancer Management - Trust By Trust

Key
Audit year ●	 >80% case ascertainment or data completeness ■	 50-80% case ascertainment or data completeness ▲	 <50% case ascertainment or data completeness
Please note grades were assigned to case ascertainment and data completeness before the figures were rounded to whole numbers.

The Royal Marsden, Clatterbridge Centre for Oncology NHS Foundation trust and The Christie Hospital NHS Foundation trust are tertiary cancer centres that mainly provide oncological treatment for bowel cancer patients. The Royal Marsden and The Christie Hospital NHS Foundation trust have been excluded from Case Ascertainment in this table. Clatterbridge Centre for Oncology NHS Foundation trust has been excluded from all data in this table

Case ascertainment and data completeness according to trust/hospital site
| Cancer Alliance/Trust Name                                         | No. cases reported    | No. cases         | Case          | Patients with    |
|--------------------------------------------------------------------|-----------------------|-------------------|---------------|------------------|
| to the Audit                                                       | identified in         | ascertainment     | complete pre- |                  |
| HES/PEDW                                                           | %                     | treatment staging |               |                  |
| (%)*                                                               |                       |                   |               |                  |
| Overall                                                            | 30,710                | 32,335            | 95            |                  |
| -                                                                  |                       |                   |               |                  |
| 76                                                                 |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 83                                                                 |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 19,231                                                             | 81                    |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 12                                                                 | 53                    | 27                | 3             | 6                |
| North East and Cumbria                                             | 1,785                 | 1,865             | 96            |                  |
| -                                                                  |                       |                   |               |                  |
| 76                                                                 |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 83                                                                 |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 1,155                                                              | 91                    |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 11                                                                 | 51                    | 32                | 3             | 3                |
| City Hospitals Sunderland NHS Foundation Trust                     | 167                   | 187               | 89            |                  |
| -                                                                  |                       |                   |               |                  |
| 71                                                                 |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 100                                                                |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 92                                                                 | 67                    |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 13                                                                 | 55                    | 27                | 4             | 0                |
| County Durham and Darlington NHS Foundation Trust                  | 296                   | 288               | 103           |                  |
| -                                                                  |                       |                   |               |                  |
| 69                                                                 |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 96                                                                 |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 153                                                                | 99                    |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 8                                                                  | 59                    | 29                | 2             | 1                |
| Gateshead Health NHS Foundation Trust                              | 161                   | 157               | 103           |                  |
| -                                                                  |                       |                   |               |                  |
| 53                                                                 |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 19                                                                 |                       |                   |               |                  |
| ▲                                                                  |                       |                   |               |                  |
| 98                                                                 | 90                    |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 14                                                                 | 50                    | 31                | 5             | 0                |
| North Cumbria University Hospitals NHS Trust                       | 118                   | 169               | 70            |                  |
| -                                                                  |                       |                   |               |                  |
| 84                                                                 |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 51                                                                 |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 84                                                                 | 62                    |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 0                                                                  | 55                    | 42                | 1             | 2                |
| North Tees and Hartlepool NHS Foundation Trust                     | 228                   | 221               | 103           |                  |
| -                                                                  |                       |                   |               |                  |
| 86                                                                 |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 94                                                                 |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 140                                                                | 94                    |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 14                                                                 | 50                    | 29                | 2             | 5                |
| Northumbria Healthcare NHS Foundation Trust                        | 280                   | 284               | 99            |                  |
| -                                                                  |                       |                   |               |                  |
| 83                                                                 |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 84                                                                 |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 171                                                                | 99                    |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 16                                                                 | 50                    | 30                | 2             | 1                |
| South Tees Hospitals NHS Foundation Trust                          | 239                   | 230               | 104           |                  |
| -                                                                  |                       |                   |               |                  |
| 38                                                                 |                       |                   |               |                  |
| ▲                                                                  |                       |                   |               |                  |
| 81                                                                 |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 181                                                                | 88                    |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 17                                                                 | 46                    | 24                | 2             | 10               |
| South Tyneside NHS Foundation Trust                                | 93                    | 105               | 89            |                  |
| -                                                                  |                       |                   |               |                  |
| 90                                                                 |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 100                                                                |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 69                                                                 | 100                   |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 3                                                                  | 45                    | 45                | 7             | 0                |
| The Newcastle Upon Tyne Hospitals NHS Foundation Trust             | 203                   | 224               | 91            |                  |
| -                                                                  |                       |                   |               |                  |
| 90                                                                 |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 98                                                                 |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 167                                                                | 99                    |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 7                                                                  | 51                    | 38                | 4             | 0                |
| Lancashire and South Cumbria                                       | 913                   | 921               | 99            |                  |
| -                                                                  |                       |                   |               |                  |
| 88                                                                 |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 89                                                                 |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 509                                                                | 89                    |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 17                                                                 | 48                    | 27                | 2             | 6                |
| Blackpool Teaching Hospitals NHS Foundation Trust                  | 237                   | 209               | 113           |                  |
| -                                                                  |                       |                   |               |                  |
| 93                                                                 |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 97                                                                 |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 104                                                                | 83                    |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 11                                                                 | 65                    | 15                | 1             | 8                |
| East Lancashire Hospitals NHS Trust                                | 221                   | 226               | 98            |                  |
| -                                                                  |                       |                   |               |                  |
| 88                                                                 |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 99                                                                 |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 149                                                                | 99                    |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 19                                                                 | 53                    | 25                | 2             | 1                |
| Lancashire Teaching Hospitals NHS Foundation Trust                 | 211                   | 268               | 79            |                  |
| -                                                                  |                       |                   |               |                  |
| 91                                                                 |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 100                                                                |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 104                                                                | 86                    |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 14                                                                 | 44                    | 26                | 1             | 14               |
| University Hospitals of Morecambe Bay NHS Foundation Trust         | 244                   | 218               | 112           |                  |
| -                                                                  |                       |                   |               |                  |
| 74                                                                 |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 61                                                                 |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 152                                                                | 84                    |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 20                                                                 | 34                    | 38                | 3             | 5                |
| Greater Manchester                                                 | 1,468                 | 1,478             | 99            |                  |
| -                                                                  |                       |                   |               |                  |
| 62                                                                 |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 88                                                                 |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 906                                                                | 94                    |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 13                                                                 | 52                    | 30                | 3             | 2                |
| Bolton NHS Foundation Trust                                        | 210                   | 198               | 106           |                  |
| -                                                                  |                       |                   |               |                  |
| 95                                                                 |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 100                                                                |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 130                                                                | 93                    |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 5                                                                  | 49                    | 36                | 4             | 6                |
| Central Manchester University Hospitals NHS Foundation Trust       | 180                   | 145               | 124           |                  |
| -                                                                  |                       |                   |               |                  |
| 74                                                                 |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 98                                                                 |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 115                                                                | 99                    |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 36                                                                 | 45                    | 15                | 3             | 1                |
| Pennine Acute Hospitals NHS Trust                                  | 361                   | 327               | 110           |                  |
| -                                                                  |                       |                   |               |                  |
| 80                                                                 |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 87                                                                 |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 187                                                                | 91                    |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 8                                                                  | 58                    | 27                | 5             | 2                |
| Salford Royal NHS Foundation Trust                                 | 116                   | 113               | 103           |                  |
| -                                                                  |                       |                   |               |                  |
| 71                                                                 |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 88                                                                 |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 63                                                                 | 89                    |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 14                                                                 | 56                    | 25                | 5             | 0                |
| Stockport NHS Foundation Trust                                     | 181                   | 184               | 98            |                  |
| -                                                                  |                       |                   |               |                  |
| 90                                                                 |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 80                                                                 |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 112                                                                | 97                    |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 9                                                                  | 60                    | 29                | 2             | 0                |
| Tameside and Glossop Integrated Care NHS Foundation Trust          | 127                   | 127               | 100           |                  |
| -                                                                  |                       |                   |               |                  |
| 79                                                                 |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 91                                                                 |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 78                                                                 | 96                    |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 10                                                                 | 41                    | 45                | 3             | 1                |
| The Christie NHS Foundation Trust                                  | ~                     | ~                 | ~             | ~                |
| -                                                                  |                       |                   |               |                  |
| 17                                                                 | 64                    | 17                | 2             | 0                |
| University Hospital of South Manchester NHS Foundation Trust       | 123                   | 141               | 87            |                  |
| -                                                                  |                       |                   |               |                  |
| 66                                                                 |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 55                                                                 |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 87                                                                 | 95                    |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 13                                                                 | 45                    | 40                | 1             | 1                |
| Wrightington, Wigan and Leigh NHS Foundation Trust                 | 158                   | 141               | 112           |                  |
| -                                                                  |                       |                   |               |                  |
| 85                                                                 |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 92                                                                 |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 75                                                                 | 85                    |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 8                                                                  | 49                    | 39                | 4             | 0                |
| West Yorkshire                                                     | 1,364                 | 1,333             | 102           |                  |
| -                                                                  |                       |                   |               |                  |
| 83                                                                 |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 64                                                                 |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 865                                                                | 62                    |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 25                                                                 | 40                    | 22                | 2             | 11               |
| Airedale NHS Foundation Trust                                      | 140                   | 130               | 108           |                  |
| -                                                                  |                       |                   |               |                  |
| 99                                                                 |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 100                                                                |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 98                                                                 | 96                    |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 72                                                                 | 21                    | 2                 | 0             | 4                |
| Bradford Teaching Hospitals NHS Foundation Trust                   | 153                   | 156               | 98            |                  |
| -                                                                  |                       |                   |               |                  |
| 96                                                                 |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 89                                                                 |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 106                                                                | 82                    |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 15                                                                 | 45                    | 25                | 2             | 13               |
| Calderdale and Huddersfield NHS Foundation Trust                   | 271                   | 237               | 114           |                  |
| -                                                                  |                       |                   |               |                  |
| 27                                                                 |                       |                   |               |                  |
| ▲                                                                  |                       |                   |               |                  |
| 24                                                                 |                       |                   |               |                  |
| ▲                                                                  |                       |                   |               |                  |
| 144                                                                | 24                    |                   |               |                  |
| ▲                                                                  |                       |                   |               |                  |
| 15                                                                 | 52                    | 25                | 2             | 6                |
| Harrogate and District NHS Foundation Trust                        | 171                   | 131               | 131           |                  |
| -                                                                  |                       |                   |               |                  |
| 67                                                                 |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 88                                                                 |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 95                                                                 | 95                    |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 12                                                                 | 56                    | 26                | 3             | 3                |
| Leeds Teaching Hospitals NHS Trust                                 | 348                   | 396               | 88            |                  |
| -                                                                  |                       |                   |               |                  |
| 56                                                                 |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 39                                                                 |                       |                   |               |                  |
| ▲                                                                  |                       |                   |               |                  |
| 250                                                                | 55                    |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 14                                                                 | 44                    | 35                | 4             | 3                |
| Mid Yorkshire Hospitals NHS Trust                                  | 281                   | 283               | 99            |                  |
| -                                                                  |                       |                   |               |                  |
| 66                                                                 |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 89                                                                 |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 172                                                                | 56                    |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 34                                                                 | 24                    | 6                 | 2             | 34               |
| Humber, Coast and Vale                                             | 852                   | 842               | 101           |                  |
| -                                                                  |                       |                   |               |                  |
| 75                                                                 |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 93                                                                 |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 566                                                                | 64                    |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 10                                                                 | 32                    | 27                | 2             | 30               |
| Hull and East Yorkshire Hospitals NHS Trust                        | 282                   | 282               | 100           |                  |
| -                                                                  |                       |                   |               |                  |
| 74                                                                 |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 93                                                                 |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 173                                                                | 25                    |                   |               |                  |
| ▲                                                                  |                       |                   |               |                  |
| 12                                                                 | 14                    | 10                | 0             | 64               |
| Northern Lincolnshire and Goole NHS Foundation Trust               | 244                   | 238               | 103           |                  |
| -                                                                  |                       |                   |               |                  |
| 77                                                                 |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 94                                                                 |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 183                                                                | 63                    |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 4                                                                  | 31                    | 30                | 3             | 32               |
| York Teaching Hospital NHS Foundation Trust - The York Hospital    | 213                   | 226               | 94            |                  |
| -                                                                  |                       |                   |               |                  |
| 71                                                                 |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 92                                                                 |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 139                                                                | 99                    |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 19                                                                 | 55                    | 26                | 0             | 0                |
| York Teaching Hospital NHS Foundation Trust - Scarborough Hospital | 113                   | 96                | 118           |                  |
| -                                                                  |                       |                   |               |                  |
| 80                                                                 |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 92                                                                 |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 71                                                                 | 99                    |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 1                                                                  | 30                    | 61                | 8             | 0                |
| South Yorkshire, Bassetlaw, North Derbyshire and Hardwick          | 1,039                 | 1,040             | 100           |                  |
| -                                                                  |                       |                   |               |                  |
| 82                                                                 |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 74                                                                 |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 630                                                                | 91                    |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 15                                                                 | 56                    | 25                | 2             | 2                |
| Barnsley Hospital NHS Foundation Trust                             | 130                   | 124               | 105           |                  |
| -                                                                  |                       |                   |               |                  |
| 69                                                                 |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 96                                                                 |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 74                                                                 | 86                    |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 18                                                                 | 58                    | 11                | 3             | 11               |
| Chesterfield Royal Hospital NHS Foundation Trust                   | 199                   | 194               | 103           |                  |
| -                                                                  |                       |                   |               |                  |
| 77                                                                 |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 76                                                                 |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 111                                                                | 94                    |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 19                                                                 | 55                    | 23                | 1             | 3                |
| Doncaster and Bassetlaw Hospitals NHS Foundation Trust             | 252                   | 251               | 100           |                  |
| -                                                                  |                       |                   |               |                  |
| 48                                                                 |                       |                   |               |                  |
| ▲                                                                  |                       |                   |               |                  |
| 15                                                                 |                       |                   |               |                  |
| ▲                                                                  |                       |                   |               |                  |
| 158                                                                | 82                    |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 20                                                                 | 53                    | 25                | 3             | 0                |
| Sheffield Teaching Hospitals NHS Foundation Trust                  | 319                   | 338               | 94            |                  |
| -                                                                  |                       |                   |               |                  |
| 85                                                                 |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 100                                                                |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 207                                                                | 94                    |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 11                                                                 | 59                    | 28                | 2             | 0                |
| The Rotherham NHS Foundation Trust                                 | 139                   | 133               | 105           |                  |
| -                                                                  |                       |                   |               |                  |
| 87                                                                 |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 97                                                                 |                       |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 80                                                                 | 100                   |                   |               |                  |
| -                                                                  |                       |                   |               |                  |
| 10                                                                 | 55                    | 31                | 4             | 0                |
| Patients with    | No. cases having    | Data completeness    | Patients having    | Patients having    | Patients having    | Patients having    | Patients having    |
|------------------|---------------------|----------------------|--------------------|--------------------|--------------------|--------------------|--------------------|
| recorded         | major surgery       | for patients         | major surgery      | major surgery      | major surgery      | major surgery      | major surgery with |
| performance      | according to the    | having major         | recorded as ASA 1  | recorded as ASA 2  | recorded as ASA 3  | recorded as ASA    | no ASA recorded    |
| status           | Audit               | surgery              | (%)                | (%)                | (%)                | 4/5                | (%)                |
| (%)              | %                   | (%)                  |                    |                    |                    |                    |                    |
Case ascertainment and data completeness according to trust/hospital site
| Cancer Alliance/Trust Name                                                         | No. cases reported    | No. cases         | Case          | Patients with    |
|------------------------------------------------------------------------------------|-----------------------|-------------------|---------------|------------------|
| to the Audit                                                                       | identified in         | ascertainment     | complete pre- |                  |
| HES/PEDW                                                                           | %                     | treatment staging |               |                  |
| (%)*                                                                               |                       |                   |               |                  |
| Cheshire and Merseyside                                                            | 1,602                 | 1,560             | 103           |                  |
| -                                                                                  |                       |                   |               |                  |
| 72                                                                                 |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 95                                                                                 |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 1,006                                                                              | 76                    |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 9                                                                                  | 57                    | 26                | 3             | 4                |
| Aintree University Hospital NHS Foundation Trust                                   | 220                   | 207               | 106           |                  |
| -                                                                                  |                       |                   |               |                  |
| 87                                                                                 |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 91                                                                                 |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 118                                                                                | 75                    |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 11                                                                                 | 59                    | 25                | 2             | 3                |
| Countess of Chester Hospital NHS Foundation Trust                                  | 137                   | 157               | 87            |                  |
| -                                                                                  |                       |                   |               |                  |
| 90                                                                                 |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 100                                                                                |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 102                                                                                | 92                    |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 8                                                                                  | 89                    | 1                 | 2             | 0                |
| East Cheshire NHS Trust                                                            | 132                   | 128               | 103           |                  |
| -                                                                                  |                       |                   |               |                  |
| 96                                                                                 |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 100                                                                                |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 88                                                                                 | 66                    |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 11                                                                                 | 44                    | 40                | 5             | 0                |
| Mid Cheshire Hospitals NHS Foundation Trust                                        | 180                   | 161               | 112           |                  |
| -                                                                                  |                       |                   |               |                  |
| 87                                                                                 |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 100                                                                                |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 93                                                                                 | 94                    |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 4                                                                                  | 73                    | 23                | 0             | 0                |
| Royal Liverpool and Broadgreen University Hospitals NHS Trust                      | 215                   | 207               | 104           |                  |
| -                                                                                  |                       |                   |               |                  |
| 87                                                                                 |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 97                                                                                 |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 134                                                                                | 85                    |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 13                                                                                 | 60                    | 23                | 4             | 0                |
| Southport and Ormskirk Hospital NHS Trust                                          | 133                   | 117               | 114           |                  |
| -                                                                                  |                       |                   |               |                  |
| 81                                                                                 |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 79                                                                                 |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 89                                                                                 | 31                    |                   |               |                  |
| ▲                                                                                  |                       |                   |               |                  |
| 7                                                                                  | 53                    | 33                | 3             | 4                |
| St Helens and Knowsley Hospital Services NHS Trust                                 | 199                   | 194               | 103           |                  |
| -                                                                                  |                       |                   |               |                  |
| 94                                                                                 |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 99                                                                                 |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 135                                                                                | 93                    |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 7                                                                                  | 49                    | 39                | 4             | 1                |
| Warrington and Halton Hospitals NHS Foundation Trust                               | 134                   | 165               | 81            |                  |
| -                                                                                  |                       |                   |               |                  |
| 75                                                                                 |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 83                                                                                 |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 92                                                                                 | 30                    |                   |               |                  |
| ▲                                                                                  |                       |                   |               |                  |
| 5                                                                                  | 40                    | 12                | 11            | 32               |
| Wirral University Teaching Hospital NHS Foundation Trust                           | 251                   | 210               | 120           |                  |
| -                                                                                  |                       |                   |               |                  |
| 92                                                                                 |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 100                                                                                |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 155                                                                                | 94                    |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 12                                                                                 | 51                    | 37                | 1             | 0                |
| Wales                                                                              | 1,911                 | 1,606             | 119           |                  |
| -                                                                                  |                       |                   |               |                  |
| 73                                                                                 |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 74                                                                                 |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 1,214                                                                              | 91                    |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 10                                                                                 | 53                    | 32                | 4             | 1                |
| Bronglais MDT                                                                      | 57                    | 39                | 146           |                  |
| -                                                                                  |                       |                   |               |                  |
| 63                                                                                 |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 81                                                                                 |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 11                                                                                 | 27                    |                   |               |                  |
| ▲                                                                                  |                       |                   |               |                  |
| 9                                                                                  | 36                    | 18                | 18            | 18               |
| Cardiff MDT                                                                        | 218                   | 166               | 131           |                  |
| -                                                                                  |                       |                   |               |                  |
| 73                                                                                 |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 6                                                                                  | 6                     | 120               | 72            |                  |
| -                                                                                  |                       |                   |               |                  |
| 9                                                                                  | 57                    | 28                | 0             | 6                |
| Nevill Hall Hospital MDT                                                           | 110                   | 79                | 139           |                  |
| -                                                                                  |                       |                   |               |                  |
| 79                                                                                 |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 98                                                                                 |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 68                                                                                 | 87                    |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 4                                                                                  | 50                    | 41                | 3             | 1                |
| Prince Charles Hospital MDT                                                        | 100                   | 83                | 120           |                  |
| -                                                                                  |                       |                   |               |                  |
| 96                                                                                 |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 100                                                                                |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 68                                                                                 | 99                    |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 0                                                                                  | 41                    | 51                | 7             | 0                |
| Princess of Wales MDT                                                              | 137                   | 127               | 108           |                  |
| -                                                                                  |                       |                   |               |                  |
| 93                                                                                 |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 98                                                                                 |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 77                                                                                 | 99                    |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 13                                                                                 | 65                    | 19                | 3             | 0                |
| Royal Glamorgan Hospital MDT                                                       | 131                   | 109               | 120           |                  |
| -                                                                                  |                       |                   |               |                  |
| 92                                                                                 |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 98                                                                                 |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 78                                                                                 | 96                    |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 8                                                                                  | 51                    | 33                | 8             | 0                |
| Royal Gwent Hospital MDT                                                           | 230                   | 139               | 165           |                  |
| -                                                                                  |                       |                   |               |                  |
| 86                                                                                 |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 83                                                                                 |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 147                                                                                | 99                    |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 22                                                                                 | 52                    | 24                | 2             | 0                |
| Swansea MDT                                                                        | 199                   | 178               | 112           |                  |
| -                                                                                  |                       |                   |               |                  |
| 94                                                                                 |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 26                                                                                 |                       |                   |               |                  |
| ▲                                                                                  |                       |                   |               |                  |
| 156                                                                                | 96                    |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 12                                                                                 | 56                    | 28                | 4             | 0                |
| West Wales General and Prince Phillip MDT                                          | 164                   | 163               | 101           |                  |
| -                                                                                  |                       |                   |               |                  |
| 83                                                                                 |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 85                                                                                 |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 103                                                                                | 84                    |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 7                                                                                  | 62                    | 25                | 4             | 2                |
| Withybush General MDT                                                              | 91                    | 85                | 107           |                  |
| -                                                                                  |                       |                   |               |                  |
| 81                                                                                 |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 99                                                                                 |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 70                                                                                 | 84                    |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 10                                                                                 | 51                    | 33                | 6             | 0                |
| Ysbwyty Glan Clwydd MDT                                                            | 152                   | 150               | 101           |                  |
| -                                                                                  |                       |                   |               |                  |
| 79                                                                                 |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 100                                                                                |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 103                                                                                | 92                    |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 6                                                                                  | 50                    | 37                | 5             | 2                |
| Ysbwyty Gwynedd MDT                                                                | 153                   | 135               | 113           |                  |
| -                                                                                  |                       |                   |               |                  |
| 73                                                                                 |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 100                                                                                |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 110                                                                                | 95                    |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 2                                                                                  | 49                    | 45                | 3             | 2                |
| Ysbwyty Maelor MDT                                                                 | 168                   | 153               | 110           |                  |
| -                                                                                  |                       |                   |               |                  |
| 86                                                                                 |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 67                                                                                 |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 103                                                                                | 98                    |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 11                                                                                 | 52                    | 35                | 2             | 0                |
| West Midlands                                                                      | 2,954                 | 3,331             | 89            |                  |
| -                                                                                  |                       |                   |               |                  |
| 76                                                                                 |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 77                                                                                 |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 1,956                                                                              | 67                    |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 10                                                                                 | 52                    | 27                | 2             | 9                |
| Burton Hospitals NHS Foundation Trust                                              | 158                   | 158               | 100           |                  |
| -                                                                                  |                       |                   |               |                  |
| 97                                                                                 |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 99                                                                                 |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 109                                                                                | 98                    |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 9                                                                                  | 52                    | 34                | 5             | 0                |
| George Eliot Hospital NHS Trust                                                    | 108                   | 113               | 96            |                  |
| -                                                                                  |                       |                   |               |                  |
| 95                                                                                 |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 100                                                                                |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 74                                                                                 | 100                   |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 1                                                                                  | 53                    | 46                | 0             | 0                |
| Heart of England NHS Foundation Trust                                              | 438                   | 407               | 108           |                  |
| -                                                                                  |                       |                   |               |                  |
| 80                                                                                 |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 100                                                                                |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 275                                                                                | 95                    |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 12                                                                                 | 60                    | 24                | 3             | 0                |
| Sandwell and West Birmingham Hospitals NHS Trust                                   | 225                   | 199               | 113           |                  |
| -                                                                                  |                       |                   |               |                  |
| 47                                                                                 |                       |                   |               |                  |
| ▲                                                                                  |                       |                   |               |                  |
| 17                                                                                 |                       |                   |               |                  |
| ▲                                                                                  |                       |                   |               |                  |
| 141                                                                                | 47                    |                   |               |                  |
| ▲                                                                                  |                       |                   |               |                  |
| 10                                                                                 | 52                    | 28                | 3             | 7                |
| Shrewsbury and Telford Hospital NHS Trust                                          | 305                   | 332               | 92            |                  |
| -                                                                                  |                       |                   |               |                  |
| 65                                                                                 |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 100                                                                                |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 186                                                                                | 47                    |                   |               |                  |
| ▲                                                                                  |                       |                   |               |                  |
| 10                                                                                 | 41                    | 27                | 2             | 19               |
| South Warwickshire NHS Foundation Trust                                            | 143                   | 153               | 93            |                  |
| -                                                                                  |                       |                   |               |                  |
| 64                                                                                 |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 3                                                                                  |                       |                   |               |                  |
| ▲                                                                                  |                       |                   |               |                  |
| 104                                                                                | 92                    |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 8                                                                                  | 51                    | 37                | 1             | 4                |
| The Dudley Group NHS Foundation Trust                                              | 192                   | 225               | 85            |                  |
| -                                                                                  |                       |                   |               |                  |
| 83                                                                                 |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 84                                                                                 |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 158                                                                                | 64                    |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 8                                                                                  | 42                    | 34                | 1             | 15               |
| The Royal Wolverhampton NHS Trust                                                  | 244                   | 276               | 88            |                  |
| -                                                                                  |                       |                   |               |                  |
| 85                                                                                 |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 85                                                                                 |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 166                                                                                | 84                    |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 8                                                                                  | 55                    | 28                | 2             | 6                |
| University Hospitals Birmingham NHS Foundation Trust                               | 78                    | 217               | 36            |                  |
| ▲                                                                                  |                       |                   |               |                  |
| 78                                                                                 |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 37                                                                                 |                       |                   |               |                  |
| ▲                                                                                  |                       |                   |               |                  |
| 50                                                                                 | 0                     | 0                 | 14            | 52               |
| University Hospitals Coventry and Warwickshire NHS Trust                           | 202                   | 235               | 86            |                  |
| -                                                                                  |                       |                   |               |                  |
| 27                                                                                 |                       |                   |               |                  |
| ▲                                                                                  |                       |                   |               |                  |
| 70                                                                                 |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 121                                                                                | 66                    |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 7                                                                                  | 55                    | 31                | 2             | 5                |
| University Hospitals of North Midlands NHS Trust - County Hospital                 | 71                    | †                 | 84            |                  |
| -                                                                                  |                       |                   |               |                  |
| 92                                                                                 |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 93                                                                                 |                       |                   |               |                  |
| -                                                                                  | ▲                     |                   |               |                  |
| ▲                                                                                  |                       |                   |               |                  |
| ▲                                                                                  |                       |                   |               |                  |
| ▲                                                                                  | ▲                     |                   |               |                  |
| ▲                                                                                  |                       |                   |               |                  |
| ▲                                                                                  |                       |                   |               |                  |
| ▲                                                                                  |                       |                   |               |                  |
| ▲                                                                                  |                       |                   |               |                  |
| ▲                                                                                  |                       |                   |               |                  |
| ▲                                                                                  |                       |                   |               |                  |
| ▲                                                                                  |                       |                   |               |                  |
| ▲                                                                                  |                       |                   |               |                  |
| ▲                                                                                  |                       |                   |               |                  |
| University Hospitals of North Midlands NHS Trust - Royal Stoke University Hospital | 260                   | †                 | 84            |                  |
| -                                                                                  |                       |                   |               |                  |
| 88                                                                                 |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 92                                                                                 |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 238                                                                                | 8                     |                   |               |                  |
| ▲                                                                                  |                       |                   |               |                  |
| 11                                                                                 | 43                    | 19                | 2             | 25               |
| Walsall Healthcare NHS Trust                                                       | -                     | 143               | -             | -                |
| Worcestershire Acute Hospitals NHS Trust                                           | 400                   | 359               | 111           |                  |
| -                                                                                  |                       |                   |               |                  |
| 93                                                                                 |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 66                                                                                 |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 250                                                                                | 92                    |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 10                                                                                 | 63                    | 25                | 2             | 0                |
| Wye Valley NHS Trust                                                               | 130                   | 122               | 107           |                  |
| -                                                                                  |                       |                   |               |                  |
| 71                                                                                 |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 88                                                                                 |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 82                                                                                 | 66                    |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 10                                                                                 | 48                    | 22                | 0             | 21               |
| East Midlands                                                                      | 2,005                 | 2,085             | 96            |                  |
| -                                                                                  |                       |                   |               |                  |
| 86                                                                                 |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 68                                                                                 |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 1,253                                                                              | 85                    |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 11                                                                                 | 56                    | 28                | 3             | 2                |
| Derby Teaching Hospitals NHS Foundation Trust                                      | 282                   | 282               | 100           |                  |
| -                                                                                  |                       |                   |               |                  |
| 59                                                                                 |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 96                                                                                 |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 175                                                                                | 92                    |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 15                                                                                 | 57                    | 25                | 3             | 1                |
| Kettering General Hospital NHS Foundation Trust                                    | 186                   | 207               | 90            |                  |
| -                                                                                  |                       |                   |               |                  |
| 65                                                                                 |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 100                                                                                |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 142                                                                                | 88                    |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 38                                                                                 | 41                    | 20                | 1             | 0                |
| Northampton General Hospital NHS Trust                                             | 158                   | 211               | 75            |                  |
| -                                                                                  |                       |                   |               |                  |
| 54                                                                                 |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 83                                                                                 |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 101                                                                                | 65                    |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 8                                                                                  | 44                    | 33                | 4             | 12               |
| Nottingham University Hospitals NHS Trust                                          | 390                   | 362               | 108           |                  |
| -                                                                                  |                       |                   |               |                  |
| 90                                                                                 |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 99                                                                                 |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 201                                                                                | 100                   |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 4                                                                                  | 66                    | 26                | 4             | 0                |
| Sherwood Forest Hospitals NHS Foundation Trust                                     | 210                   | 200               | 105           |                  |
| -                                                                                  |                       |                   |               |                  |
| 20                                                                                 |                       |                   |               |                  |
| ▲                                                                                  |                       |                   |               |                  |
| 16                                                                                 |                       |                   |               |                  |
| ▲                                                                                  |                       |                   |               |                  |
| 122                                                                                | 50                    |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 11                                                                                 | 61                    | 24                | 0             | 5                |
| University Hospitals of Leicester NHS Trust                                        | 491                   | 479               | 103           |                  |
| -                                                                                  |                       |                   |               |                  |
| 74                                                                                 |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 24                                                                                 |                       |                   |               |                  |
| ▲                                                                                  |                       |                   |               |                  |
| 322                                                                                | 100                   |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 4                                                                                  | 56                    | 35                | 4             | 0                |
| United Lincolnshire Hospitals NHS Trust - Lincoln and Grantham                     | 176                   | 235               | 75            |                  |
| -                                                                                  |                       |                   |               |                  |
| 33                                                                                 |                       |                   |               |                  |
| ▲                                                                                  |                       |                   |               |                  |
| 72                                                                                 |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 104                                                                                | 80                    |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 13                                                                                 | 63                    | 20                | 0             | 5                |
| United Lincolnshire Hospitals NHS Trust - Pilgrim Hospital Boston                  | 112                   | 109               | 103           |                  |
| -                                                                                  |                       |                   |               |                  |
| 35                                                                                 |                       |                   |               |                  |
| ▲                                                                                  |                       |                   |               |                  |
| 91                                                                                 |                       |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 86                                                                                 | 60                    |                   |               |                  |
| -                                                                                  |                       |                   |               |                  |
| 2                                                                                  | 57                    | 38                | 2             | 0                |
| Patients with    | No. cases having    | Data completeness    | Patients having    | Patients having    | Patients having    | Patients having    | Patients having    |
|------------------|---------------------|----------------------|--------------------|--------------------|--------------------|--------------------|--------------------|
| recorded         | major surgery       | for patients         | major surgery      | major surgery      | major surgery      | major surgery      | major surgery with |
| performance      | according to the    | having major         | recorded as ASA 1  | recorded as ASA 2  | recorded as ASA 3  | recorded as ASA    | no ASA recorded    |
| status           | Audit               | surgery              | (%)                | (%)                | (%)                | 4/5                | (%)                |
| (%)              | %                   | (%)                  |                    |                    |                    |                    |                    |
Case ascertainment and data completeness according to trust/hospital site
| Cancer Alliance/Trust Name                                                          | No. cases reported    | No. cases         | Case          |   Patients with  |
|-------------------------------------------------------------------------------------|-----------------------|-------------------|---------------|------------------|
| to the Audit                                                                        | identified in         | ascertainment     | complete pre- |                  |
| HES/PEDW                                                                            | %                     | treatment staging |               |                  |
| (%)*                                                                                |                       |                   |               |                  |
| East of England                                                                     | 3,629                 | 3,608             | 101           |                  |
| -                                                                                   |                       |                   |               |                  |
| 81                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 86                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 2,094                                                                               | 74                    |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 9                                                                                   | 52                    | 30                | 3             |                7 |
| Basildon and Thurrock University Hospitals NHS Foundation Trust                     | 260                   | 223               | 117           |                  |
| -                                                                                   |                       |                   |               |                  |
| 69                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 91                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 104                                                                                 | 93                    |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 10                                                                                  | 60                    | 24                | 4             |                3 |
| Bedford Hospital NHS Trust                                                          | 159                   | 148               | 107           |                  |
| -                                                                                   |                       |                   |               |                  |
| 30                                                                                  |                       |                   |               |                  |
| ▲                                                                                   |                       |                   |               |                  |
| 100                                                                                 |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 81                                                                                  | 73                    |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 12                                                                                  | 57                    | 19                | 0             |               12 |
| Cambridge University Hospitals NHS Foundation Trust                                 | 278                   | 327               | 85            |                  |
| -                                                                                   |                       |                   |               |                  |
| 65                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 100                                                                                 |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 216                                                                                 | 98                    |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 5                                                                                   | 60                    | 31                | 4             |                0 |
| Colchester Hospital University NHS Foundation Trust                                 | 272                   | 240               | 113           |                  |
| -                                                                                   |                       |                   |               |                  |
| 74                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 84                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 131                                                                                 | 79                    |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 13                                                                                  | 58                    | 28                | 1             |                0 |
| East and North Hertfordshire NHS Trust                                              | 254                   | 240               | 106           |                  |
| -                                                                                   |                       |                   |               |                  |
| 11                                                                                  |                       |                   |               |                  |
| ▲                                                                                   |                       |                   |               |                  |
| 1                                                                                   |                       |                   |               |                  |
| ▲                                                                                   |                       |                   |               |                  |
| 87                                                                                  | 2                     |                   |               |                  |
| ▲                                                                                   |                       |                   |               |                  |
| 16                                                                                  | 60                    | 23                | 0             |                1 |
| Hinchingbrooke Health Care NHS Trust                                                | 127                   | 99                | 128           |                  |
| -                                                                                   |                       |                   |               |                  |
| 77                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 96                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 70                                                                                  | 83                    |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 6                                                                                   | 57                    | 27                | 4             |                6 |
| Ipswich Hospital NHS Trust                                                          | 237                   | 238               | 100           |                  |
| -                                                                                   |                       |                   |               |                  |
| 78                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 97                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 143                                                                                 | 48                    |                   |               |                  |
| ▲                                                                                   |                       |                   |               |                  |
| 6                                                                                   | 28                    | 16                | 0             |               50 |
| James Paget University Hospitals NHS Foundation Trust                               | 139                   | 130               | 107           |                  |
| -                                                                                   |                       |                   |               |                  |
| 83                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 98                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 87                                                                                  | 87                    |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 8                                                                                   | 37                    | 53                | 2             |                0 |
| Luton and Dunstable University Hospital NHS Foundation Trust                        | 144                   | 138               | 104           |                  |
| -                                                                                   |                       |                   |               |                  |
| 84                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 98                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 92                                                                                  | 83                    |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 14                                                                                  | 57                    | 22                | 4             |                3 |
| Mid Essex Hospital Services NHS Trust                                               | 186                   | 179               | 104           |                  |
| -                                                                                   |                       |                   |               |                  |
| 63                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 100                                                                                 |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 113                                                                                 | 4                     |                   |               |                  |
| ▲                                                                                   |                       |                   |               |                  |
| 8                                                                                   | 35                    | 35                | 3             |               19 |
| Milton Keynes University Hospital NHS Foundation Trust                              | 128                   | 154               | 83            |                  |
| -                                                                                   |                       |                   |               |                  |
| 66                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 92                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 91                                                                                  | 73                    |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 18                                                                                  | 45                    | 32                | 2             |                3 |
| Norfolk and Norwich University Hospitals NHS Foundation Trust                       | 458                   | 419               | 109           |                  |
| -                                                                                   |                       |                   |               |                  |
| 57                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 100                                                                                 |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 253                                                                                 | 95                    |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 8                                                                                   | 57                    | 30                | 1             |                4 |
| Peterborough and Stamford Hospitals NHS Foundation Trust                            | 210                   | 213               | 99            |                  |
| -                                                                                   |                       |                   |               |                  |
| 49                                                                                  |                       |                   |               |                  |
| ▲                                                                                   |                       |                   |               |                  |
| 100                                                                                 |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 148                                                                                 | 88                    |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 9                                                                                   | 47                    | 34                | 8             |                1 |
| Southend University Hospital NHS Foundation Trust                                   | 160                   | 165               | 97            |                  |
| -                                                                                   |                       |                   |               |                  |
| 18                                                                                  |                       |                   |               |                  |
| ▲                                                                                   |                       |                   |               |                  |
| 56                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 106                                                                                 | 96                    |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 7                                                                                   | 66                    | 23                | 2             |                3 |
| The Princess Alexandra Hospital NHS Trust                                           | 105                   | 151               | 70            |                  |
| -                                                                                   |                       |                   |               |                  |
| 98                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 34                                                                                  |                       |                   |               |                  |
| ▲                                                                                   |                       |                   |               |                  |
| 44                                                                                  | 66                    |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 7                                                                                   | 41                    | 39                | 2             |               11 |
| The Queen Elizabeth Hospital, King's Lynn, NHS Foundation Trust                     | 111                   | 158               | 70            |                  |
| -                                                                                   |                       |                   |               |                  |
| 45                                                                                  |                       |                   |               |                  |
| ▲                                                                                   |                       |                   |               |                  |
| 97                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 80                                                                                  | 3                     |                   |               |                  |
| ▲                                                                                   |                       |                   |               |                  |
| 0                                                                                   | 35                    | 60                | 4             |                1 |
| West Hertfordshire Hospitals NHS Trust                                              | 242                   | 218               | 111           |                  |
| -                                                                                   |                       |                   |               |                  |
| 85                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 100                                                                                 |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 140                                                                                 | 81                    |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 9                                                                                   | 51                    | 33                | 4             |                2 |
| West Suffolk NHS Foundation Trust                                                   | 159                   | 168               | 95            |                  |
| -                                                                                   |                       |                   |               |                  |
| 40                                                                                  |                       |                   |               |                  |
| ▲                                                                                   |                       |                   |               |                  |
| 99                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 108                                                                                 | 94                    |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 2                                                                                   | 60                    | 33                | 5             |                0 |
| Peninsula                                                                           |                       |                   |               |                  |
| 1,186                                                                               | 1,161                 | 102               |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 61                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 75                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 747                                                                                 | 94                    |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 16                                                                                  | 55                    | 25                | 3             |                2 |
| Northern Devon Healthcare NHS Trust                                                 | 143                   | 136               | 105           |                  |
| -                                                                                   |                       |                   |               |                  |
| 76                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 100                                                                                 |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 84                                                                                  | 96                    |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 7                                                                                   | 62                    | 29                | 2             |                0 |
| Plymouth Hospitals NHS Trust                                                        | 217                   | 285               | 76            |                  |
| -                                                                                   |                       |                   |               |                  |
| 83                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 70                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 178                                                                                 | 89                    |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 11                                                                                  | 50                    | 30                | 2             |                7 |
| Royal Cornwall Hospitals NHS Trust                                                  | 308                   | 289               | 107           |                  |
| -                                                                                   |                       |                   |               |                  |
| 85                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 72                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 194                                                                                 | 97                    |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 20                                                                                  | 48                    | 25                | 6             |                1 |
| Royal Devon and Exeter NHS Foundation Trust                                         | 309                   | 275               | 112           |                  |
| -                                                                                   |                       |                   |               |                  |
| 90                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 100                                                                                 |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 192                                                                                 | 100                   |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 15                                                                                  | 62                    | 22                | 2             |                0 |
| Torbay and South Devon NHS Foundation Trust                                         | 209                   | 176               | 119           |                  |
| -                                                                                   |                       |                   |               |                  |
| 88                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 32                                                                                  |                       |                   |               |                  |
| ▲                                                                                   |                       |                   |               |                  |
| 99                                                                                  | 81                    |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 24                                                                                  | 56                    | 18                | 2             |                0 |
| Somerset, Wiltshire, Avon and Gloucestershire                                       | 1,696                 | 1,674             | 101           |                  |
| -                                                                                   |                       |                   |               |                  |
| 60                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 94                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 1,011                                                                               | 89                    |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 10                                                                                  | 55                    | 28                | 2             |                4 |
| Gloucestershire Hospitals NHS Foundation Trust                                      | 438                   | 433               | 101           |                  |
| -                                                                                   |                       |                   |               |                  |
| 70                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 88                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 280                                                                                 | 83                    |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 11                                                                                  | 57                    | 30                | 2             |                0 |
| North Bristol NHS Trust                                                             | 264                   | 234               | 113           |                  |
| -                                                                                   |                       |                   |               |                  |
| 97                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 100                                                                                 |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 155                                                                                 | 100                   |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 9                                                                                   | 53                    | 37                | 1             |                0 |
| Royal United Hospitals Bath NHS Foundation Trust                                    | 231                   | 263               | 88            |                  |
| -                                                                                   |                       |                   |               |                  |
| 95                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 82                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 180                                                                                 | 97                    |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 10                                                                                  | 53                    | 31                | 4             |                2 |
| Salisbury NHS Foundation Trust                                                      | 176                   | 157               | 112           |                  |
| -                                                                                   |                       |                   |               |                  |
| 89                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 94                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 80                                                                                  | 85                    |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 11                                                                                  | 65                    | 20                | 0             |                4 |
| Taunton and Somerset NHS Foundation Trust                                           | 183                   | 184               | 99            |                  |
| -                                                                                   |                       |                   |               |                  |
| 61                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 99                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 97                                                                                  | 67                    |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 6                                                                                   | 47                    | 21                | 0             |               26 |
| University Hospitals Bristol NHS Foundation Trust                                   | 218                   | 199               | 110           |                  |
| -                                                                                   |                       |                   |               |                  |
| 86                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 99                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 111                                                                                 | 100                   |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 15                                                                                  | 62                    | 21                | 2             |                0 |
| Weston Area Health NHS Trust                                                        | 96                    | 99                | 97            |                  |
| -                                                                                   |                       |                   |               |                  |
| 98                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 99                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 63                                                                                  | 100                   |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 8                                                                                   | 52                    | 35                | 5             |                0 |
| Yeovil District Hospital NHS Foundation Trust                                       | 90                    | 105               | 86            |                  |
| -                                                                                   |                       |                   |               |                  |
| 76                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 99                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 45                                                                                  | 67                    |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 11                                                                                  | 44                    | 24                | 0             |               20 |
| Wessex                                                                              | 1,633                 | 1,540             | 106           |                  |
| -                                                                                   |                       |                   |               |                  |
| 83                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 82                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 991                                                                                 | 92                    |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 10                                                                                  | 59                    | 25                | 2             |                4 |
| Dorset County Hospital NHS Foundation Trust                                         | 133                   | 133               | 100           |                  |
| -                                                                                   |                       |                   |               |                  |
| 89                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 100                                                                                 |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 91                                                                                  | 82                    |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 15                                                                                  | 43                    | 35                | 0             |                7 |
| Hampshire Hospitals NHS Foundation Trust - Basingstoke and North Hampshire Hospital | 113                   | 183               | 62            |                  |
| -                                                                                   |                       |                   |               |                  |
| 84                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 100                                                                                 |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 79                                                                                  | 99                    |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 4                                                                                   | 78                    | 16                | 0             |                1 |
| Hampshire Hospitals NHS Foundation Trust - Royal Hampshire County Hospital          | 149                   | 148               | 101           |                  |
| -                                                                                   |                       |                   |               |                  |
| 100                                                                                 |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 100                                                                                 |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 102                                                                                 | 95                    |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 13                                                                                  | 57                    | 28                | 2             |                0 |
| Isle of Wight NHS Trust                                                             | 116                   | 95                | 122           |                  |
| -                                                                                   |                       |                   |               |                  |
| 70                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 83                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 69                                                                                  | 88                    |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 13                                                                                  | 58                    | 26                | 3             |                0 |
| Poole Hospital NHS Foundation Trust                                                 | 179                   | 173               | 103           |                  |
| -                                                                                   |                       |                   |               |                  |
| 79                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 94                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 96                                                                                  | 97                    |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 11                                                                                  | 56                    | 29                | 3             |                0 |
| Portsmouth Hospitals NHS Trust                                                      | 371                   | 319               | 116           |                  |
| -                                                                                   |                       |                   |               |                  |
| 62                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 30                                                                                  |                       |                   |               |                  |
| ▲                                                                                   |                       |                   |               |                  |
| 208                                                                                 | 89                    |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 7                                                                                   | 61                    | 25                | 1             |                6 |
| The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust               | 247                   | 207               | 119           |                  |
| -                                                                                   |                       |                   |               |                  |
| 99                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 100                                                                                 |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 143                                                                                 | 95                    |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 8                                                                                   | 59                    | 30                | 3             |                0 |
| University Hospital Southampton NHS Foundation Trust                                | 325                   | 282               | 115           |                  |
| -                                                                                   |                       |                   |               |                  |
| 99                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 99                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 203                                                                                 | 90                    |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 11                                                                                  | 62                    | 16                | 1             |               10 |
| Thames Valley                                                                       | 1,015                 | 1,054             | 96            |                  |
| -                                                                                   |                       |                   |               |                  |
| 82                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 93                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 679                                                                                 | 93                    |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 16                                                                                  | 54                    | 24                | 3             |                3 |
| Buckinghamshire Healthcare NHS Trust                                                | 240                   | 220               | 109           |                  |
| -                                                                                   |                       |                   |               |                  |
| 97                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 100                                                                                 |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 157                                                                                 | 99                    |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 25                                                                                  | 52                    | 21                | 2             |                0 |
| Great Western Hospitals NHS Foundation Trust                                        | 201                   | 218               | 92            |                  |
| -                                                                                   |                       |                   |               |                  |
| 68                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 76                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 142                                                                                 | 82                    |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 8                                                                                   | 44                    | 34                | 3             |               12 |
| Oxford University Hospitals NHS Foundation Trust                                    | 321                   | 348               | 92            |                  |
| -                                                                                   |                       |                   |               |                  |
| 74                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 95                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 209                                                                                 | 91                    |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 22                                                                                  | 56                    | 19                | 2             |                0 |
| Royal Berkshire NHS Foundation Trust                                                | 253                   | 268               | 94            |                  |
| -                                                                                   |                       |                   |               |                  |
| 91                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 98                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 171                                                                                 | 99                    |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 9                                                                                   | 61                    | 27                | 4             |                0 |
| Surrey and Sussex                                                                   | 1,631                 | 1,791             | 91            |                  |
| -                                                                                   |                       |                   |               |                  |
| 85                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 88                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 1,132                                                                               | 69                    |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 10                                                                                  | 61                    | 20                | 4             |                5 |
| Ashford and St Peter's Hospitals NHS Foundation Trust                               | 86                    | 151               | 57            |                  |
| -                                                                                   |                       |                   |               |                  |
| 94                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 100                                                                                 |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 71                                                                                  | 79                    |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 17                                                                                  | 48                    | 32                | 3             |                0 |
| Brighton and Sussex University Hospitals NHS Trust                                  | 239                   | 195               | 123           |                  |
| -                                                                                   |                       |                   |               |                  |
| 54                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 95                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 165                                                                                 | 47                    |                   |               |                  |
| ▲                                                                                   |                       |                   |               |                  |
| 4                                                                                   | 91                    | 4                 | 1             |                1 |
| East Sussex Healthcare NHS Trust                                                    | 255                   | 290               | 88            |                  |
| -                                                                                   |                       |                   |               |                  |
| 31                                                                                  |                       |                   |               |                  |
| ▲                                                                                   |                       |                   |               |                  |
| 30                                                                                  |                       |                   |               |                  |
| ▲                                                                                   |                       |                   |               |                  |
| 167                                                                                 | 63                    |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 11                                                                                  | 63                    | 16                | 2             |                9 |
| Frimley Health NHS Foundation Trust - Frimley Park Hospital                         | 133                   | 225               | 59            |                  |
| -                                                                                   |                       |                   |               |                  |
| 78                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 98                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 125                                                                                 | 2                     |                   |               |                  |
| ▲                                                                                   |                       |                   |               |                  |
| 10                                                                                  | 61                    | 24                | 2             |                2 |
| Frimley Health NHS Foundation Trust - Heatherwood and Wexham Park Hospitals         | 216                   | 189               | 114           |                  |
| -                                                                                   |                       |                   |               |                  |
| 94                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 100                                                                                 |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 101                                                                                 | 89                    |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 24                                                                                  | 55                    | 18                | 2             |                1 |
| Royal Surrey County Hospital NHS Foundation Trust                                   | 152                   | 161               | 94            |                  |
| -                                                                                   |                       |                   |               |                  |
| 97                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 99                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 83                                                                                  | 55                    |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 10                                                                                  | 42                    | 8                 | 0             |               40 |
| Surrey and Sussex Healthcare NHS Trust                                              | 162                   | 217               | 75            |                  |
| -                                                                                   |                       |                   |               |                  |
| 98                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 99                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 162                                                                                 | 100                   |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 6                                                                                   | 62                    | 26                | 6             |                0 |
| Western Sussex Hospitals NHS Foundation Trust - St Richard's Hospital               | 193                   | 185               | 104           |                  |
| -                                                                                   |                       |                   |               |                  |
| 73                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 100                                                                                 |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 145                                                                                 | 97                    |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 5                                                                                   | 54                    | 30                | 9             |                2 |
| Western Sussex Hospitals NHS Foundation Trust - Worthing Hospital                   | 195                   | 178               | 110           |                  |
| -                                                                                   |                       |                   |               |                  |
| 78                                                                                  |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 100                                                                                 |                       |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 113                                                                                 | 95                    |                   |               |                  |
| -                                                                                   |                       |                   |               |                  |
| 14                                                                                  | 46                    | 29                | 5             |                5 |
| Patients with    | No. cases having    | Data completeness    | Patients having    | Patients having    | Patients having    | Patients having    | Patients having    |
|------------------|---------------------|----------------------|--------------------|--------------------|--------------------|--------------------|--------------------|
| recorded         | major surgery       | for patients         | major surgery      | major surgery      | major surgery      | major surgery      | major surgery with |
| performance      | according to the    | having major         | recorded as ASA 1  | recorded as ASA 2  | recorded as ASA 3  | recorded as ASA    | no ASA recorded    |
| status           | Audit               | surgery              | (%)                | (%)                | (%)                | 4/5                | (%)                |
| (%)              | %                   | (%)                  |                    |                    |                    |                    |                    |
Case ascertainment and data completeness according to trust/hospital site
| Cancer Alliance/Trust Name                                                        | No. cases reported    | No. cases         | Case          | Patients with    |
|-----------------------------------------------------------------------------------|-----------------------|-------------------|---------------|------------------|
| to the Audit                                                                      | identified in         | ascertainment     | complete pre- |                  |
| HES/PEDW                                                                          | %                     | treatment staging |               |                  |
| (%)*                                                                              |                       |                   |               |                  |
| Kent and Medway                                                                   | 1,029                 | 1,057             | 97            |                  |
| -                                                                                 |                       |                   |               |                  |
| 73                                                                                |                       |                   |               |                  |
| -                                                                                 |                       |                   |               |                  |
| 87                                                                                |                       |                   |               |                  |
| -                                                                                 |                       |                   |               |                  |
| 652                                                                               | 84                    |                   |               |                  |
| -                                                                                 |                       |                   |               |                  |
| 12                                                                                | 54                    | 25                | 2             | 7                |
| Dartford and Gravesham NHS Trust                                                  | 145                   | 167               | 87            |                  |
| -                                                                                 |                       |                   |               |                  |
| 90                                                                                |                       |                   |               |                  |
| -                                                                                 |                       |                   |               |                  |
| 100                                                                               |                       |                   |               |                  |
| -                                                                                 |                       |                   |               |                  |
| 99                                                                                | 100                   |                   |               |                  |
| -                                                                                 |                       |                   |               |                  |
| 8                                                                                 | 73                    | 18                | 1             | 0                |
| East Kent Hospitals University NHS Foundation Trust                               | 429                   | 431               | 100           |                  |
| -                                                                                 |                       |                   |               |                  |
| 82                                                                                |                       |                   |               |                  |
| -                                                                                 |                       |                   |               |                  |
| 87                                                                                |                       |                   |               |                  |
| -                                                                                 |                       |                   |               |                  |
| 272                                                                               | 87                    |                   |               |                  |
| -                                                                                 |                       |                   |               |                  |
| 12                                                                                | 54                    | 32                | 3             | 0                |
| Maidstone and Tunbridge Wells NHS Trust                                           | 292                   | 286               | 102           |                  |
| -                                                                                 |                       |                   |               |                  |
| 85                                                                                |                       |                   |               |                  |
| -                                                                                 |                       |                   |               |                  |
| 79                                                                                |                       |                   |               |                  |
| -                                                                                 |                       |                   |               |                  |
| 184                                                                               | 73                    |                   |               |                  |
| -                                                                                 |                       |                   |               |                  |
| 10                                                                                | 38                    | 26                | 3             | 24               |
| Medway NHS Foundation Trust                                                       | 163                   | 173               | 94            |                  |
| -                                                                                 |                       |                   |               |                  |
| 77                                                                                |                       |                   |               |                  |
| -                                                                                 |                       |                   |               |                  |
| 89                                                                                |                       |                   |               |                  |
| -                                                                                 |                       |                   |               |                  |
| 97                                                                                | 78                    |                   |               |                  |
| -                                                                                 |                       |                   |               |                  |
| 19                                                                                | 66                    | 13                | 1             | 1                |
| West London                                                                       | 1,270                 | 1,846             | 69            |                  |
| -                                                                                 |                       |                   |               |                  |
| 82                                                                                |                       |                   |               |                  |
| -                                                                                 |                       |                   |               |                  |
| 97                                                                                |                       |                   |               |                  |
| -                                                                                 |                       |                   |               |                  |
| 792                                                                               | 75                    |                   |               |                  |
| -                                                                                 |                       |                   |               |                  |
| 13                                                                                | 50                    | 24                | 3             | 10               |
| Chelsea and Westminster Hospital NHS Foundation Trust                             | 154                   | 160               | 96            |                  |
| -                                                                                 |                       |                   |               |                  |
| 88                                                                                |                       |                   |               |                  |
| -                                                                                 |                       |                   |               |                  |
| 100                                                                               |                       |                   |               |                  |
| -                                                                                 |                       |                   |               |                  |
| 97                                                                                | 84                    |                   |               |                  |
| -                                                                                 |                       |                   |               |                  |
| 16                                                                                | 59                    | 22                | 3             | 0                |
| Croydon Health Services NHS Trust                                                 | 108                   | 117               | 92            |                  |
| -                                                                                 |                       |                   |               |                  |
| 95                                                                                |                       |                   |               |                  |
| -                                                                                 |                       |                   |               |                  |
| 100                                                                               |                       |                   |               |                  |
| -                                                                                 |                       |                   |               |                  |
| 52                                                                                | 96                    |                   |               |                  |
| -                                                                                 |                       |                   |               |                  |
| 4                                                                                 | 60                    | 37                | 0             | 0                |
| Epsom and St Helier University Hospitals NHS Trust                                | 199                   | 202               | 99            |                  |
| -                                                                                 |                       |                   |               |                  |
| 82                                                                                |                       |                   |               |                  |
| -                                                                                 |                       |                   |               |                  |
| 99                                                                                |                       |                   |               |                  |
| -                                                                                 |                       |                   |               |                  |
| 84                                                                                | 21                    |                   |               |                  |
| ▲                                                                                 |                       |                   |               |                  |
| 4                                                                                 | 15                    | 4                 | 0             | 77               |
| Imperial College Healthcare NHS Trust                                             | 213                   | 233               | 91            |                  |
| -                                                                                 |                       |                   |               |                  |
| 90                                                                                |                       |                   |               |                  |
| -                                                                                 |                       |                   |               |                  |
| 100                                                                               |                       |                   |               |                  |
| -                                                                                 |                       |                   |               |                  |
| 133                                                                               | 97                    |                   |               |                  |
| -                                                                                 |                       |                   |               |                  |
| 10                                                                                | 48                    | 36                | 6             | 0                |
| Kingston Hospital NHS Foundation Trust                                            | 158                   | 163               | 97            |                  |
| -                                                                                 |                       |                   |               |                  |
| 82                                                                                |                       |                   |               |                  |
| -                                                                                 |                       |                   |               |                  |
| 93                                                                                |                       |                   |               |                  |
| -                                                                                 |                       |                   |               |                  |
| 99                                                                                | 91                    |                   |               |                  |
| -                                                                                 |                       |                   |               |                  |
| 14                                                                                | 57                    | 23                | 6             | 0                |
| London North West Hospitals NHS Trust                                             | 226                   | 286               | 79            |                  |
| -                                                                                 |                       |                   |               |                  |
| 73                                                                                |                       |                   |               |                  |
| -                                                                                 |                       |                   |               |                  |
| 97                                                                                |                       |                   |               |                  |
| -                                                                                 |                       |                   |               |                  |
| 137                                                                               | 61                    |                   |               |                  |
| -                                                                                 |                       |                   |               |                  |
| 24                                                                                | 50                    | 16                | 1             | 9                |
| St George's University Hospitals NHS Foundation Trust                             | 99                    | 173               | 57            |                  |
| -                                                                                 |                       |                   |               |                  |
| 74                                                                                |                       |                   |               |                  |
| -                                                                                 |                       |                   |               |                  |
| 94                                                                                |                       |                   |               |                  |
| -                                                                                 |                       |                   |               |                  |
| 81                                                                                | 94                    |                   |               |                  |
| -                                                                                 |                       |                   |               |                  |
| 22                                                                                | 53                    | 20                | 5             | 0                |
| The Hillingdon Hospitals NHS Foundation Trust                                     | 95                    | 93                | 102           |                  |
| -                                                                                 |                       |                   |               |                  |
| 72                                                                                |                       |                   |               |                  |
| -                                                                                 |                       |                   |               |                  |
| 86                                                                                |                       |                   |               |                  |
| -                                                                                 |                       |                   |               |                  |
| 66                                                                                | 44                    |                   |               |                  |
| ▲                                                                                 |                       |                   |               |                  |
| 8                                                                                 | 59                    | 33                | 0             | 0                |
| The Royal Marsden NHS Foundation Trust                                            | ~                     | ~                 | ~             | ~                |
| -                                                                                 |                       |                   |               |                  |
| 5                                                                                 | 58                    | 30                | 0             | 7                |
| South East London                                                                 | 550                   | 732               | 75            |                  |
| -                                                                                 |                       |                   |               |                  |
| 86                                                                                |                       |                   |               |                  |
| -                                                                                 |                       |                   |               |                  |
| 80                                                                                |                       |                   |               |                  |
| -                                                                                 |                       |                   |               |                  |
| 377                                                                               | 80                    |                   |               |                  |
| -                                                                                 |                       |                   |               |                  |
| 14                                                                                | 53                    | 21                | 2             | 9                |
| Guy's and St Thomas' NHS Foundation Trust                                         | 112                   | 195               | 57            |                  |
| -                                                                                 |                       |                   |               |                  |
| 31                                                                                |                       |                   |               |                  |
| ▲                                                                                 |                       |                   |               |                  |
| 12                                                                                |                       |                   |               |                  |
| ▲                                                                                 |                       |                   |               |                  |
| 93                                                                                | 29                    |                   |               |                  |
| ▲                                                                                 |                       |                   |               |                  |
| 6                                                                                 | 39                    | 20                | 1             | 33               |
| King's College Hospital NHS Foundation Trust - King's College Hospital            | 94                    | 126               | 75            |                  |
| -                                                                                 |                       |                   |               |                  |
| 86                                                                                |                       |                   |               |                  |
| -                                                                                 |                       |                   |               |                  |
| 100                                                                               |                       |                   |               |                  |
| -                                                                                 |                       |                   |               |                  |
| 80                                                                                | 95                    |                   |               |                  |
| -                                                                                 |                       |                   |               |                  |
| 20                                                                                | 58                    | 19                | 0             | 4                |
| King's College Hospital NHS Foundation Trust - Princess Royal University Hospital | 102                   | 172               | 59            |                  |
| -                                                                                 |                       |                   |               |                  |
| 83                                                                                |                       |                   |               |                  |
| -                                                                                 |                       |                   |               |                  |
| 95                                                                                |                       |                   |               |                  |
| -                                                                                 |                       |                   |               |                  |
| 61                                                                                | 93                    |                   |               |                  |
| -                                                                                 |                       |                   |               |                  |
| 21                                                                                | 44                    | 30                | 3             | 2                |
| Lewisham and Greenwich NHS Trust                                                  | 242                   | 239               | 101           |                  |
| -                                                                                 |                       |                   |               |                  |
| 90                                                                                |                       |                   |               |                  |
| -                                                                                 |                       |                   |               |                  |
| 98                                                                                |                       |                   |               |                  |
| -                                                                                 |                       |                   |               |                  |
| 143                                                                               | 100                   |                   |               |                  |
| -                                                                                 |                       |                   |               |                  |
| 13                                                                                | 64                    | 20                | 3             | 0                |
| North Central and East London                                                     | 1,071                 | 1,242             | 86            |                  |
| -                                                                                 |                       |                   |               |                  |
| 84                                                                                |                       |                   |               |                  |
| -                                                                                 |                       |                   |               |                  |
| 100                                                                               |                       |                   |               |                  |
| -                                                                                 |                       |                   |               |                  |
| 672                                                                               | 82                    |                   |               |                  |
| -                                                                                 |                       |                   |               |                  |
| 21                                                                                | 52                    | 22                | 2             | 4                |
| Barking, Havering and Redbridge University Hospitals NHS Trust                    | 277                   | 267               | 104           |                  |
| -                                                                                 |                       |                   |               |                  |
| 73                                                                                |                       |                   |               |                  |
| -                                                                                 |                       |                   |               |                  |
| 100                                                                               |                       |                   |               |                  |
| -                                                                                 |                       |                   |               |                  |
| 152                                                                               | 64                    |                   |               |                  |
| -                                                                                 |                       |                   |               |                  |
| 14                                                                                | 47                    | 25                | 4             | 10               |
| Barts Health NHS Trust                                                            | 133                   | 302               | 44            |                  |
| ▲                                                                                 |                       |                   |               |                  |
| 96                                                                                |                       |                   |               |                  |
| -                                                                                 |                       |                   |               |                  |
| 100                                                                               |                       |                   |               |                  |
| -                                                                                 |                       |                   |               |                  |
| 94                                                                                | 73                    |                   |               |                  |
| -                                                                                 |                       |                   |               |                  |
| 17                                                                                | 52                    | 24                | 2             | 4                |
| Homerton University Hospital NHS Foundation Trust                                 | 89                    | 92                | 97            |                  |
| -                                                                                 |                       |                   |               |                  |
| 96                                                                                |                       |                   |               |                  |
| -                                                                                 |                       |                   |               |                  |
| 100                                                                               |                       |                   |               |                  |
| -                                                                                 |                       |                   |               |                  |
| 56                                                                                | 95                    |                   |               |                  |
| -                                                                                 |                       |                   |               |                  |
| 7                                                                                 | 54                    | 30                | 4             | 5                |
| North Middlesex University Hospital NHS Trust                                     | 69                    | 89                | 78            |                  |
| -                                                                                 |                       |                   |               |                  |
| 59                                                                                |                       |                   |               |                  |
| -                                                                                 |                       |                   |               |                  |
| 100                                                                               |                       |                   |               |                  |
| -                                                                                 |                       |                   |               |                  |
| 46                                                                                | 70                    |                   |               |                  |
| -                                                                                 |                       |                   |               |                  |
| 33                                                                                | 52                    | 15                | 0             | 0                |
| Royal Free London NHS Foundation Trust                                            | 290                   | 275               | 105           |                  |
| -                                                                                 |                       |                   |               |                  |
| 97                                                                                |                       |                   |               |                  |
| -                                                                                 |                       |                   |               |                  |
| 100                                                                               |                       |                   |               |                  |
| -                                                                                 |                       |                   |               |                  |
| 182                                                                               | 96                    |                   |               |                  |
| -                                                                                 |                       |                   |               |                  |
| 15                                                                                | 57                    | 25                | 2             | 1                |
| Whittington Health NHS Trust                                                      | 74                    | 74                | 100           |                  |
| -                                                                                 |                       |                   |               |                  |
| 46                                                                                |                       |                   |               |                  |
| ▲                                                                                 |                       |                   |               |                  |
| 100                                                                               |                       |                   |               |                  |
| -                                                                                 |                       |                   |               |                  |
| 56                                                                                | 88                    |                   |               |                  |
| -                                                                                 |                       |                   |               |                  |
| 48                                                                                | 48                    | 4                 | 0             | 0                |
| University College London Hospitals NHS Foundation Trust                          | 139                   | 143               | 97            |                  |
| -                                                                                 |                       |                   |               |                  |
| 85                                                                                |                       |                   |               |                  |
| -                                                                                 |                       |                   |               |                  |
| 99                                                                                |                       |                   |               |                  |
| -                                                                                 |                       |                   |               |                  |
| 86                                                                                | 88                    |                   |               |                  |
| -                                                                                 |                       |                   |               |                  |
| 36                                                                                | 49                    | 15                | 0             | 0                |

- No cases submitted ▲ Too few cases to report (<10) † Combined case ascertainment for Trust. Denominator 392

| Patients with    | No. cases having    | Data completeness    | Patients having    | Patients having    | Patients having    | Patients having    | Patients having    |
|------------------|---------------------|----------------------|--------------------|--------------------|--------------------|--------------------|--------------------|
| recorded         | major surgery       | for patients         | major surgery      | major surgery      | major surgery      | major surgery      | major surgery with |
| performance      | according to the    | having major         | recorded as ASA 1  | recorded as ASA 2  | recorded as ASA 3  | recorded as ASA    | no ASA recorded    |
| status           | Audit               | surgery              | (%)                | (%)                | (%)                | 4/5                | (%)                |
| (%)              | %                   | (%)                  |                    |                    |                    |                    |                    |

The Royal Marsden, The Christie Hospital and The Clatterbridge Cancer Centre NHS Foundation Trusts are tertiary cancer centres that mainly provide oncological treatment for bowel cancer patients therefore have been excluded from Treatment Pathways, but included in Cancer Alliance totals.

Management of all patients reported to the audit according to trust/hospital site
| Diagnosing Cancer Alliance/Trust Name                              | Number of    |
|--------------------------------------------------------------------|--------------|
| patients                                                           |              |
| reported                                                           |              |
| to the                                                             |              |
| audit                                                              |              |
| Overall                                                            | 30,710       |
| North East and Cumbria                                             | 1,785        |
| City Hospitals Sunderland NHS Foundation Trust                     | 167          |
| County Durham and Darlington NHS Foundation Trust                  | 296          |
| Gateshead Health NHS Foundation Trust                              | 161          |
| North Cumbria University Hospitals NHS Trust                       | 118          |
| North Tees and Hartlepool NHS Foundation Trust                     | 228          |
| Northumbria Healthcare NHS Foundation Trust                        | 280          |
| South Tees Hospitals NHS Foundation Trust                          | 239          |
| South Tyneside NHS Foundation Trust                                | 93           |
| The Newcastle Upon Tyne Hospitals NHS Foundation Trust             | 203          |
| Lancashire and South Cumbria                                       | 913          |
| Blackpool Teaching Hospitals NHS Foundation Trust                  | 237          |
| East Lancashire Hospitals NHS Trust                                | 221          |
| Lancashire Teaching Hospitals NHS Foundation Trust                 | 211          |
| University Hospitals of Morecambe Bay NHS Foundation Trust         | 244          |
| Greater Manchester                                                 | 1,468        |
| Bolton NHS Foundation Trust                                        | 210          |
| Central Manchester University Hospitals NHS Foundation Trust       | 180          |
| Pennine Acute Hospitals NHS Trust                                  | 361          |
| Salford Royal NHS Foundation Trust                                 | 116          |
| Stockport NHS Foundation Trust                                     | 181          |
| Tameside and Glossop Integrated Care NHS Foundation Trust          | 127          |
| University Hospital of South Manchester NHS Foundation Trust       | 123          |
| Wrightington, Wigan and Leigh NHS Foundation Trust                 | 158          |
| West Yorkshire                                                     | 1,364        |
| Airedale NHS Foundation Trust                                      | 140          |
| Bradford Teaching Hospitals NHS Foundation Trust                   | 153          |
| Calderdale and Huddersfield NHS Foundation Trust                   | 271          |
| Harrogate and District NHS Foundation Trust                        | 171          |
| Leeds Teaching Hospitals NHS Trust                                 | 348          |
| Mid Yorkshire Hospitals NHS Trust                                  | 281          |
| Humber, Coast and Vale                                             | 852          |
| Hull and East Yorkshire Hospitals NHS Trust                        | 282          |
| Northern Lincolnshire and Goole NHS Foundation Trust               | 244          |
| York Teaching Hospital NHS Foundation Trust - The York Hospital    | 213          |
| York Teaching Hospital NHS Foundation Trust - Scarborough Hospital | 113          |
| South Yorkshire, Bassetlaw, North Derbyshire and Hardwick          | 1,039        |
| Barnsley Hospital NHS Foundation Trust                             | 130          |
| Chesterfield Royal Hospital NHS Foundation Trust                   | 199          |
| Doncaster and Bassetlaw Hospitals NHS Foundation Trust             | 252          |
| Sheffield Teaching Hospitals NHS Foundation Trust                  | 319          |
| The Rotherham NHS Foundation Trust                                 | 139          |
| Cheshire and Merseyside                                            | 1,602        |
| Aintree University Hospital NHS Foundation Trust                   | 220          |
| Countess of Chester Hospital NHS Foundation Trust                  | 137          |
| East Cheshire NHS Trust                                            | 132          |
| Mid Cheshire Hospitals NHS Foundation Trust                        | 180          |
| Royal Liverpool and Broadgreen University Hospitals NHS Trust      | 215          |
| Southport and Ormskirk Hospital NHS Trust                          | 133          |
| St Helens and Knowsley Hospital Services NHS Trust                 | 199          |
| Warrington and Halton Hospitals NHS Foundation Trust               | 134          |
| Wirral University Teaching Hospital NHS Foundation Trust           | 251          |
| Seen by    | Curative    | Too Little    | Non-      | Too Much/    | Not       |
|------------|-------------|---------------|-----------|--------------|-----------|
| clinical   | Major       | Treatment     | Curative  | Too Frail    | Known/    |
| nurse      | Resection   | Pathway       | Major     | Treatment    | Other     |
| specialist | Treatment   | (%)           | Resection | Pathways     | Treatment |
| (%)        | Pathway     | Treatment     | (%)       | Pathway      |           |
| (%)        | Pathway     | (%)           |           |              |           |
| (%)        |             |               |           |              |           |
Management of all patients reported to the audit according to trust/hospital site
| Diagnosing Cancer Alliance/Trust Name                              | Number of    |
|--------------------------------------------------------------------|--------------|
| patients                                                           |              |
| reported                                                           |              |
| to the                                                             |              |
| audit                                                              |              |
| Wales                                                              | 1,911        |
| Bronglais MDT                                                      | 57           |
| Cardiff MDT                                                        | 218          |
| Nevill Hall Hospital MDT                                           | 110          |
| Prince Charles Hospital MDT                                        | 100          |
| Princess of Wales MDT                                              | 137          |
| Royal Glamorgan Hospital MDT                                       | 131          |
| Royal Gwent Hospital MDT                                           | 230          |
| Swansea MDT                                                        | 199          |
| West Wales General and Prince Phillip MDT                          | 164          |
| Withybush General MDT                                              | 91           |
| Ysbwyty Glan Clwydd MDT                                            | 152          |
| Ysbwyty Gwynedd MDT                                                | 153          |
| Ysbwyty Maelor MDT                                                 | 168          |
| West Midlands                                                      | 2,954        |
| Burton Hospitals NHS Foundation Trust                              | 158          |
| George Eliot Hospital NHS Trust                                    | 108          |
| Heart of England NHS Foundation Trust                              | 438          |
| Sandwell and West Birmingham Hospitals NHS Trust                   | 225          |
| Shrewsbury and Telford Hospital NHS Trust                          | 305          |
| South Warwickshire NHS Foundation Trust                            | 143          |
| The Dudley Group NHS Foundation Trust                              | 192          |
| The Royal Wolverhampton NHS Trust                                  | 244          |
| University Hospitals Birmingham NHS Foundation Trust               | 78           |
| University Hospitals Coventry and Warwickshire NHS Trust           | 202          |
| University Hospitals of North Midlands NHS Trust - County Hospital | 71           |
| University Hospitals of North Midlands NHS Trust -                 |              |
| Royal Stoke University Hospital                                    |              |
| 260                                                                | 100          |
| Walsall Healthcare NHS Trust                                       | -            |
| Worcestershire Acute Hospitals NHS Trust                           | 400          |
| Wye Valley NHS Trust                                               | 130          |
| East Midlands                                                      | 2,005        |
| Derby Teaching Hospitals NHS Foundation Trust                      | 282          |
| Kettering General Hospital NHS Foundation Trust                    | 186          |
| Northampton General Hospital NHS Trust                             | 158          |
| Nottingham University Hospitals NHS Trust                          | 390          |
| Sherwood Forest Hospitals NHS Foundation Trust                     | 210          |
| University Hospitals of Leicester NHS Trust                        | 491          |
| United Lincolnshire Hospitals NHS Trust - Lincoln and Grantham     | 176          |
| United Lincolnshire Hospitals NHS Trust - Pilgrim Hospital Boston  | 112          |
| East of England                                                    | 3,629        |
| Basildon and Thurrock University Hospitals NHS Foundation Trust    | 260          |
| Bedford Hospital NHS Trust                                         | 159          |
| Cambridge University Hospitals NHS Foundation Trust                | 278          |
| Colchester Hospital University NHS Foundation Trust                | 272          |
| East and North Hertfordshire NHS Trust                             | 254          |
| Hinchingbrooke Health Care NHS Trust                               | 127          |
| Ipswich Hospital NHS Trust                                         | 237          |
| James Paget University Hospitals NHS Foundation Trust              | 139          |
| Luton and Dunstable University Hospital NHS Foundation Trust       | 144          |
| Mid Essex Hospital Services NHS Trust                              | 186          |
| Milton Keynes University Hospital NHS Foundation Trust             | 128          |
| Norfolk and Norwich University Hospitals NHS Foundation Trust      | 458          |
| Peterborough and Stamford Hospitals NHS Foundation Trust           | 210          |
| Southend University Hospital NHS Foundation Trust                  | 160          |
| The Princess Alexandra Hospital NHS Trust                          | 105          |
| The Queen Elizabeth Hospital, King's Lynn, NHS Foundation Trust    | 111          |
| West Hertfordshire Hospitals NHS Trust                             | 242          |
| West Suffolk NHS Foundation Trust                                  | 159          |
| Seen by    | Curative    | Too Little    | Non-      | Too Much/    | Not       |
|------------|-------------|---------------|-----------|--------------|-----------|
| clinical   | Major       | Treatment     | Curative  | Too Frail    | Known/    |
| nurse      | Resection   | Pathway       | Major     | Treatment    | Other     |
| specialist | Treatment   | (%)           | Resection | Pathways     | Treatment |
| (%)        | Pathway     | Treatment     | (%)       | Pathway      |           |
| (%)        | Pathway     | (%)           |           |              |           |
| (%)        |             |               |           |              |           |
Management of all patients reported to the audit according to trust/hospital site
| Diagnosing Cancer Alliance/Trust Name                                 | Number of    |
|-----------------------------------------------------------------------|--------------|
| patients                                                              |              |
| reported                                                              |              |
| to the                                                                |              |
| audit                                                                 |              |
| Peninsula                                                             | 1,186        |
| Northern Devon Healthcare NHS Trust                                   | 143          |
| Plymouth Hospitals NHS Trust                                          | 217          |
| Royal Cornwall Hospitals NHS Trust                                    | 308          |
| Royal Devon and Exeter NHS Foundation Trust                           | 309          |
| Torbay and South Devon NHS Foundation Trust                           | 209          |
| Somerset, Wiltshire, Avon and Gloucestershire                         | 1,696        |
| Gloucestershire Hospitals NHS Foundation Trust                        | 438          |
| North Bristol NHS Trust                                               | 264          |
| Royal United Hospitals Bath NHS Foundation Trust                      | 231          |
| Salisbury NHS Foundation Trust                                        | 176          |
| Taunton and Somerset NHS Foundation Trust                             | 183          |
| University Hospitals Bristol NHS Foundation Trust                     | 218          |
| Weston Area Health NHS Trust                                          | 96           |
| Yeovil District Hospital NHS Foundation Trust                         | 90           |
| Wessex                                                                | 1,633        |
| Dorset County Hospital NHS Foundation Trust                           | 133          |
| Hampshire Hospitals NHS Foundation Trust -                            |              |
| Basingstoke and North Hampshire Hospital                              |              |
| 113                                                                   | 95           |
| Hampshire Hospitals NHS Foundation Trust -                            |              |
| Royal Hampshire County Hospital                                       |              |
| 149                                                                   | 95           |
| Isle of Wight NHS Trust                                               | 116          |
| Poole Hospital NHS Foundation Trust                                   | 179          |
| Portsmouth Hospitals NHS Trust                                        | 371          |
| The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust | 247          |
| University Hospital Southampton NHS Foundation Trust                  | 325          |
| Thames Valley                                                         | 1,015        |
| Buckinghamshire Healthcare NHS Trust                                  | 240          |
| Great Western Hospitals NHS Foundation Trust                          | 201          |
| Oxford University Hospitals NHS Foundation Trust                      | 321          |
| Royal Berkshire NHS Foundation Trust                                  | 253          |
| Surrey and Sussex                                                     | 1,631        |
| Ashford and St Peter's Hospitals NHS Foundation Trust                 | 86           |
| Brighton and Sussex University Hospitals NHS Trust                    | 239          |
| East Sussex Healthcare NHS Trust                                      | 255          |
| Frimley Health NHS Foundation Trust - Frimley Park Hospital           | 133          |
| Frimley Health NHS Foundation Trust -                                 |              |
| Heatherwood and Wexham Park Hospitals                                 |              |
| 216                                                                   | 10           |
| Royal Surrey County Hospital NHS Foundation Trust                     | 152          |
| Surrey and Sussex Healthcare NHS Trust                                | 162          |
| Western Sussex Hospitals NHS Foundation Trust - St Richard's Hospital | 193          |
| Western Sussex Hospitals NHS Foundation Trust - Worthing Hospital     | 195          |
| Kent and Medway                                                       | 1,029        |
| Dartford and Gravesham NHS Trust                                      | 145          |
| East Kent Hospitals University NHS Foundation Trust                   | 429          |
| Maidstone and Tunbridge Wells NHS Trust                               | 292          |
| Medway NHS Foundation Trust                                           | 163          |
| West London                                                           | 1,270        |
| Chelsea and Westminster Hospital NHS Foundation Trust                 | 154          |
| Croydon Health Services NHS Trust                                     | 108          |
| Epsom and St Helier University Hospitals NHS Trust                    | 199          |
| Imperial College Healthcare NHS Trust                                 | 213          |
| Kingston Hospital NHS Foundation Trust                                | 158          |
| London North West Hospitals NHS Trust                                 | 226          |
| St George's University Hospitals NHS Foundation Trust                 | 99           |
| The Hillingdon Hospitals NHS Foundation Trust                         | 95           |
| Seen by    | Curative    | Too Little    | Non-      | Too Much/    | Not       |
|------------|-------------|---------------|-----------|--------------|-----------|
| clinical   | Major       | Treatment     | Curative  | Too Frail    | Known/    |
| nurse      | Resection   | Pathway       | Major     | Treatment    | Other     |
| specialist | Treatment   | (%)           | Resection | Pathways     | Treatment |
| (%)        | Pathway     | Treatment     | (%)       | Pathway      |           |
| (%)        | Pathway     | (%)           |           |              |           |
| (%)        |             |               |           |              |           |
Management of all patients reported to the audit according to trust/hospital site
| Diagnosing Cancer Alliance/Trust Name                                  | Number of    |
|------------------------------------------------------------------------|--------------|
| patients                                                               |              |
| reported                                                               |              |
| to the                                                                 |              |
| audit                                                                  |              |
| South East London                                                      | 550          |
| Guy's and St Thomas' NHS Foundation Trust                              | 112          |
| King's College Hospital NHS Foundation Trust - King's College Hospital | 94           |
| King's College Hospital NHS Foundation Trust -                         |              |
| Princess Royal University Hospital                                     |              |
| 102                                                                    | 97           |
| Lewisham and Greenwich NHS Trust                                       | 242          |
| North Central and East London                                          | 1,071        |
| Barking, Havering and Redbridge University Hospitals NHS Trust         | 277          |
| Barts Health NHS Trust                                                 | 133          |
| Homerton University Hospital NHS Foundation Trust                      | 89           |
| North Middlesex University Hospital NHS Trust                          | 69           |
| Royal Free London NHS Foundation Trust                                 | 290          |
| Whittington Health NHS Trust                                           | 74           |
| University College London Hospitals NHS Foundation Trust               | 139          |
| - No cases submitted                                                   |              |
| Seen by    | Curative    | Too Little    | Non-      | Too Much/    | Not       |
|------------|-------------|---------------|-----------|--------------|-----------|
| clinical   | Major       | Treatment     | Curative  | Too Frail    | Known/    |
| nurse      | Resection   | Pathway       | Major     | Treatment    | Other     |
| specialist | Treatment   | (%)           | Resection | Pathways     | Treatment |
| (%)        | Pathway     | Treatment     | (%)       | Pathway      |           |
| (%)        | Pathway     | (%)           |           |              |           |
| (%)        |             |               |           |              |           |
Management of patients who had major surgery according to trust/hospital site Diagnosing Cancer Alliance /Trust Name
No. patients 
Patients 
having major 
with distant 
surgery
metastases 
at time of 
surgery (%)
Overall
19,295
9
16
18
92
84
63
15,949
69
North East and Cumbria
1,159
9
18
18
96
86
77
1,018
64
City Hospitals Sunderland NHS Foundation Trust
92
19
16
16
73
83
92
85
71
County Durham and Darlington NHS Foundation Trust
153
5
18
16
100
84
71
143
67
Gateshead Health NHS Foundation Trust
98
14
18
18
100
84
86
96
67
North Cumbria University Hospitals NHS Trust
84
8
21
15
79
79
75
37
80
North Tees and Hartlepool NHS Foundation Trust
140
12
16
18
99
87
91
123
60
Northumbria Healthcare NHS Foundation Trust
171
5
13
16
100
82
55
155
57
South Tees Hospitals NHS Foundation Trust
185
9
16
20.5
98
89
76
162
59
South Tyneside NHS Foundation Trust
69
10
19
16
100
86
86
66
60
The Newcastle Upon Tyne Hospitals NHS Foundation Trust
167
5
22
21
99
93
81
151
67
Lancashire and South Cumbria
510
6
14
15
96
69
56
468
79
Blackpool Teaching Hospitals NHS Foundation Trust
104
4
10
14
92
62
70
97
71
East Lancashire Hospitals NHS Trust
150
10
17
18
100
89
29
134
91
Lancashire Teaching Hospitals NHS Foundation Trust
104
3
13
10
100
37
71
100
77
University Hospitals of Morecambe Bay NHS Foundation Trust
152
5
13
16
91
78
64
137
75
Greater Manchester
911
9
18
16
97
77
49
775
76
Bolton NHS Foundation Trust
130
6
24
12
98
55
20
118
86
Central Manchester University Hospitals NHS Foundation Trust
115
10
25
15
100
79
30
83
82
Pennine Acute Hospitals NHS Trust
187
8
19
20
95
90
59
165
71
Salford Royal NHS Foundation Trust
63
5
11
14
100
73
65
58
80
Stockport NHS Foundation Trust
112
10
18
16
100
82
39
109
87
Tameside and Glossop Integrated Care NHS Foundation Trust
78
8
9
17.5
100
81
73
67
75
The Christie NHS Foundation Trust
64
26
0
15
97
67
28
33
84
University Hospital of South Manchester NHS Foundation Trust
87
7
23
20
100
89
71
79
72
Wrightington, Wigan and Leigh NHS Foundation Trust
75
3
19
13
88
68
72
63
39
West Yorkshire
871
12
11
19
97
84
72
788
76
Airedale NHS Foundation Trust
99
8
7
29
100
98
82
86
71
Bradford Teaching Hospitals NHS Foundation Trust
106
6
0
19
90
91
91
95
79
Calderdale and Huddersfield NHS Foundation Trust
144
28
7
18
96
84
49
130
88
Harrogate and District NHS Foundation Trust
95
10
15
17
100
83
82
91
67
Leeds Teaching Hospitals NHS Trust
255
16
16
18
100
78
78
226
72
Mid Yorkshire Hospitals NHS Trust
172
10
13
17
97
82
57
160
78
| Major surgery    | Median      | Proportion    | Laparoscopic    | No. patients    | Risk-adjusted    |
|------------------|-------------|---------------|-----------------|-----------------|------------------|
| carried out      | number of   |               |                 |                 |                  |
| Proportion       |             |               |                 |                 |                  |
| of patients      | surgery     | included in   | length of stay  | cases           |                  |
| ≥                |             |               |                 |                 |                  |
| 12               |             |               |                 |                 |                  |
| as urgent or     | lymph nodes | with recorded | nodes           | attempted       | risk-adjusted    |
| emergency        | excised     | number of     | (%)             | (%)             | length of stay   |
| (%)              | lymph nodes |               |                 |                 |                  |
| (%)              |             |               |                 |                 |                  |
Table 7.3 continued Management of patients who had major surgery according to trust/hospital site Diagnosing Cancer Alliance / Trust Name
No. patients 
Patients 
having major 
with distant 
surgery
metastases 
at time of 
surgery (%)
Humber, Coast and Vale
570
8
10
18
93
81
38
500
80
Hull and East Yorkshire Hospitals NHS Trust
174
10
13
17
78
80
32
149
86
Northern Lincolnshire and Goole NHS Foundation Trust
186
10
5
19
98
82
44
160
88
York Teaching Hospital NHS Foundation Trust - The York Hospital
139
2
12
19
99
81
36
126
73
York Teaching Hospital NHS Foundation Trust - Scarborough Hospital
71
11
11
17
100
82
45
65
63
South Yorkshire, Bassetlaw, North Derbyshire and Hardwick
634
10
13
17
98
84
53
574
75
Barnsley Hospital NHS Foundation Trust
75
15
19
15
100
71
12
69
94
Chesterfield Royal Hospital NHS Foundation Trust
111
17
9
16
100
82
41
105
78
Doncaster and Bassetlaw Hospitals NHS Foundation Trust
158
8
15
15
96
91
87
136
60
Sheffield Teaching Hospitals NHS Foundation Trust
210
8
11
28
96
95
42
190
78
The Rotherham NHS Foundation Trust
80
6
18
12.5
100
56
71
74
72
Cheshire and Merseyside
1,008
9
17
17
81
87
55
865
76
Aintree University Hospital NHS Foundation Trust
118
8
13
18
77
93
50
100
74
Countess of Chester Hospital NHS Foundation Trust
102
17
18
18
93
84
30
92
66
East Cheshire NHS Trust
88
2
18
15
67
86
61
79
79
Mid Cheshire Hospitals NHS Foundation Trust
93
3
19
14.5
95
73
62
81
79
Royal Liverpool and Broadgreen University Hospitals NHS Trust
135
8
10
18.5
87
96
37
109
80
Southport and Ormskirk Hospital NHS Trust
89
3
25
18
37
94
76
71
80
St Helens and Knowsley Hospital Services NHS Trust
135
12
20
19
96
90
59
124
67
Warrington and Halton Hospitals NHS Foundation Trust
93
9
24
16
60
88
46
85
77
Wirral University Teaching Hospital NHS Foundation Trust
155
9
12
16.5
98
76
71
124
82
Wales
1,218
14
20
16
100
78
46
979
71
Bronglais MDT
11
25
80
16
100
82
27
7
82
Cardiff MDT
120
15
20
16
100
79
72
90
61
Nevill Hall Hospital MDT
68
13
19
16
100
79
32
58
75
Prince Charles Hospital MDT
68
9
15
14.5
100
76
84
58
55
Princess of Wales MDT
77
8
9
17
100
82
32
68
67
Royal Glamorgan Hospital MDT
78
13
17
15
100
73
51
64
79
Royal Gwent Hospital MDT
147
14
23
17
100
82
46
117
80
Swansea MDT
158
18
23
17
100
84
31
130
72
West Wales General and Prince Phillip MDT
103
17
24
15
100
72
51
86
79
Withybush General MDT
70
6
14
15
100
73
59
65
77
Ysbwyty Glan Clwydd MDT
103
22
30
19
100
83
34
83
59
Ysbwyty Gwynedd MDT
110
14
14
16
100
75
31
63
86
Ysbwyty Maelor MDT
105
8
18
17
100
73
53
90
58
|              |              | Major surgery    | Median        |
|--------------|--------------|------------------|---------------|
| Proportion   | Laparoscopic | No. patients     | Risk-adjusted |
| carried out  | number of    |                  |               |
| Proportion   |              |                  |               |
| of patients  |              |                  |               |
| surgery      | included in  | length of stay   | cases         |
| ≥            |              |                  |               |
| 12           |              |                  |               |
| as urgent or | lymph nodes  | with recorded    |               |
| nodes        | attempted    | risk-adjusted    | >5 days       |
| emergency    | excised      | number of        |               |
| (%)          | (%)          | length of stay   | (%)           |
| (%)          |              |                  |               |
| lymph nodes  |              |                  |               |
| (%)          |              |                  |               |
Table 7.3 continued Management of patients who had major surgery according to trust/hospital site Diagnosing Cancer Alliance / Trust Name
No. patients 
Patients 
having major 
with distant 
surgery
metastases 
at time of 
surgery (%)
West Midlands
1,959
11
18
21
80
92
65
1,443
67
Burton Hospitals NHS Foundation Trust
109
19
16
16
99
78
63
93
60
George Eliot Hospital NHS Trust
74
12
15
22.5
100
95
68
67
68
Heart of England NHS Foundation Trust
275
7
23
35
97
97
68
217
69
Sandwell and West Birmingham Hospitals NHS Trust
141
3
18
26
60
96
53
117
64
Shrewsbury and Telford Hospital NHS Trust
187
11
19
17
82
89
39
168
60
South Warwickshire NHS Foundation Trust
104
14
23
15
99
75
72
90
63
The Dudley Group NHS Foundation Trust
159
16
14
19
91
86
63
133
70
The Royal Wolverhampton NHS Trust
166
16
16
18
98
93
48
152
86
University Hospitals Birmingham NHS Foundation Trust
50
0
29
9
2
98
60
† 
† 
University Hospitals Coventry and Warwickshire NHS Trust
121
11
16
24
99
95
63
114
75
University Hospitals of North Midlands NHS Trust - County Hospital
▲
▲
▲
▲
▲
▲
▲
▲
▲
University Hospitals of North Midlands NHS Trust - Royal Stoke University Hospital
239
21
18
18
11
98
82
† 
† 
Walsall Healthcare NHS Trust
•
•
•
•
•
•
•
•
•
Worcestershire Acute Hospitals NHS Trust
250
9
18
27.5
94
96
83
222
58
Wye Valley NHS Trust
82
6
1
17
99
87
76
68
68
East Midlands
1,256
10
18
17
99
78
57
1,097
66
Derby Teaching Hospitals NHS Foundation Trust
175
7
14
21
100
90
50
154
69
Kettering General Hospital NHS Foundation Trust
142
8
37
20
98
88
73
127
61
Northampton General Hospital NHS Trust
102
5
15
15
91
75
69
91
63
Nottingham University Hospitals NHS Trust
201
7
22
15
100
70
76
176
56
Sherwood Forest Hospitals NHS Foundation Trust
122
10
11
20
100
87
43
115
76
University Hospitals of Leicester NHS Trust
324
12
15
13
100
62
44
299
71
United Lincolnshire Hospitals NHS Trust - Lincoln and Grantham
104
17
16
20.5
98
86
38
70
79
United Lincolnshire Hospitals NHS Trust - Pilgrim Hospital Boston
86
17
14
21
99
94
76
65
48
|              |              | Major surgery    | Median        |
|--------------|--------------|------------------|---------------|
| Proportion   | Laparoscopic | No. patients     | Risk-adjusted |
| carried out  | number of    |                  |               |
| Proportion   |              |                  |               |
| of patients  |              |                  |               |
| surgery      | included in  | length of stay   | cases         |
| ≥            |              |                  |               |
| 12           |              |                  |               |
| as urgent or | lymph nodes  | with recorded    |               |
| nodes        | attempted    | risk-adjusted    | >5 days       |
| emergency    | excised      | number of        |               |
| (%)          | (%)          | length of stay   | (%)           |
| (%)          |              |                  |               |
| lymph nodes  |              |                  |               |
| (%)          |              |                  |               |
Table 7.3 continued Management of patients who had major surgery according to trust/hospital site Diagnosing Cancer Alliance / Trust Name
No. patients 
Patients 
having major 
with distant 
surgery
metastases 
at time of 
surgery (%)
East of England
2,104
8
17
17
84
85
64
1,563
67
Basildon and Thurrock University Hospitals NHS Foundation Trust
104
11
16
15
100
80
53
92
70
Bedford Hospital NHS Trust
83
9
15
17
84
84
48
21
91
Cambridge University Hospitals NHS Foundation Trust
216
16
20
17
100
93
50
199
72
Colchester Hospital University NHS Foundation Trust
131
8
24
16
91
72
90
120
51
East and North Hertfordshire NHS Trust
87
0
7
13
3
100
69
† 
† 
Hinchingbrooke Health Care NHS Trust
70
14
11
18.5
94
91
84
58
60
Ipswich Hospital NHS Trust
143
4
20
16
100
77
56
126
72
James Paget University Hospitals NHS Foundation Trust
88
9
18
16
100
68
85
76
62
Luton and Dunstable University Hospital NHS Foundation Trust
92
7
17
19
98
90
65
85
56
Mid Essex Hospital Services NHS Trust
115
0
14
14
3
99
87
† 
† 
Milton Keynes University Hospital NHS Foundation Trust
91
12
24
16
87
86
74
74
78
Norfolk and Norwich University Hospitals NHS Foundation Trust
255
3
4
16
100
76
47
234
72
Peterborough and Stamford Hospitals NHS Foundation Trust
149
5
23
16
98
81
60
142
62
Southend University Hospital NHS Foundation Trust
106
10
14
21
99
92
83
89
67
The Princess Alexandra Hospital NHS Trust
44
6
16
19
70
95
41
27
73
The Queen Elizabeth Hospital, King's Lynn, NHS Foundation Trust
81
0
23
12
4
99
35
† 
† 
West Hertfordshire Hospitals NHS Trust
141
8
18
19
100
81
72
120
74
West Suffolk NHS Foundation Trust
108
3
21
17
94
91
69
100
56
Peninsula
752
5
13
16
98
78
68
600
60
Northern Devon Healthcare NHS Trust
84
5
12
16
96
82
75
77
59
Plymouth Hospitals NHS Trust
179
4
12
18
99
88
47
101
68
Royal Cornwall Hospitals NHS Trust
197
5
9
17
99
85
86
174
46
Royal Devon and Exeter NHS Foundation Trust
193
8
18
14
100
63
67
166
63
Torbay and South Devon NHS Foundation Trust
99
2
17
14
92
70
62
82
71
Somerset, Wiltshire, Avon and Gloucestershire
1,014
7
15
20
97
89
71
856
59
Gloucestershire Hospitals NHS Foundation Trust
280
8
12
23
99
91
58
254
63
North Bristol NHS Trust
156
6
10
21
100
90
94
139
52
Royal United Hospitals Bath NHS Foundation Trust
180
4
17
23
98
94
78
138
60
Salisbury NHS Foundation Trust
81
8
27
17
93
85
83
74
43
Taunton and Somerset NHS Foundation Trust
97
2
29
15
93
87
78
61
43
University Hospitals Bristol NHS Foundation Trust
112
4
4
17.5
100
85
66
95
68
Weston Area Health NHS Trust
63
21
6
18
100
83
30
57
71
Yeovil District Hospital NHS Foundation Trust
45
8
31
18
84
87
73
38
71
|              |              | Major surgery    | Median        |
|--------------|--------------|------------------|---------------|
| Proportion   | Laparoscopic | No. patients     | Risk-adjusted |
| carried out  | number of    |                  |               |
| Proportion   |              |                  |               |
| of patients  |              |                  |               |
| surgery      | included in  | length of stay   | cases         |
| ≥            |              |                  |               |
| 12           |              |                  |               |
| as urgent or | lymph nodes  | with recorded    |               |
| nodes        | attempted    | risk-adjusted    | >5 days       |
| emergency    | excised      | number of        |               |
| (%)          | (%)          | length of stay   | (%)           |
| (%)          |              |                  |               |
| lymph nodes  |              |                  |               |
| (%)          |              |                  |               |
Table 7.3 continued Management of patients who had major surgery according to trust/hospital site Diagnosing Cancer Alliance / Trust Name
No. patients 
Patients 
having major 
with distant 
surgery
metastases 
at time of 
surgery (%)
Wessex
994
7
13
18
99
83
73
850
65
Dorset County Hospital NHS Foundation Trust
92
5
21
20
99
89
69
83
61
Hampshire Hospitals NHS Foundation Trust - Basingstoke and North Hampshire Hospital
79
3
10
15
100
72
80
71
76
Hampshire Hospitals NHS Foundation Trust - Royal Hampshire County Hospital
103
7
16
14.5
95
76
64
94
74
Isle of Wight NHS Trust
69
6
7
19
100
86
59
60
66
Poole Hospital NHS Foundation Trust
97
6
15
20
100
92
91
86
37
Portsmouth Hospitals NHS Trust
208
16
14
19
100
89
87
169
67
The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust
143
3
6
14
97
79
56
117
75
University Hospital Southampton NHS Foundation Trust
203
6
12
19
100
81
69
170
63
Thames Valley
683
7
17
20
100
92
69
576
68
Buckinghamshire Healthcare NHS Trust
157
10
18
22
99
92
72
124
61
Great Western Hospitals NHS Foundation Trust
143
5
17
19
99
89
32
134
86
Oxford University Hospitals NHS Foundation Trust
212
5
14
20
100
91
85
172
68
Royal Berkshire NHS Foundation Trust
171
8
19
18
100
94
79
146
57
Surrey and Sussex
1,135
5
18
18
84
89
71
861
69
Ashford and St Peter's Hospitals NHS Foundation Trust
71
15
21
15
87
85
73
63
74
Brighton and Sussex University Hospitals NHS Trust
168
5
31
18
86
85
93
118
64
East Sussex Healthcare NHS Trust
167
7
13
20
95
90
24
150
87
Frimley Health NHS Foundation Trust - Frimley Park Hospital
125
0
14
26.5
2
100
83
† 
† 
Frimley Health NHS Foundation Trust - Heatherwood and Wexham Park Hospitals
101
8
26
17.5
91
95
80
86
77
Royal Surrey County Hospital NHS Foundation Trust
83
5
18
23
93
89
96
71
27
Surrey and Sussex Healthcare NHS Trust
162
2
20
16
100
90
60
145
70
Western Sussex Hospitals NHS Foundation Trust - St Richard's Hospital
145
3
7
21
100
90
79
126
71
Western Sussex Hospitals NHS Foundation Trust - Worthing Hospital
113
3
17
15
100
75
77
102
62
Kent and Medway
654
7
21
18
93
91
67
577
69
Dartford and Gravesham NHS Trust
100
3
7
18
100
90
61
94
77
East Kent Hospitals University NHS Foundation Trust
272
10
26
18
88
90
76
243
60
Maidstone and Tunbridge Wells NHS Trust
184
5
19
18
94
92
51
154
81
Medway NHS Foundation Trust
98
8
27
19
99
93
77
86
61
|              |              | Major surgery    | Median        |
|--------------|--------------|------------------|---------------|
| Proportion   | Laparoscopic | No. patients     | Risk-adjusted |
| carried out  | number of    |                  |               |
| Proportion   |              |                  |               |
| of patients  |              |                  |               |
| surgery      | included in  | length of stay   | cases         |
| ≥            |              |                  |               |
| 12           |              |                  |               |
| as urgent or | lymph nodes  | with recorded    |               |
| nodes        | attempted    | risk-adjusted    | >5 days       |
| emergency    | excised      | number of        |               |
| (%)          | (%)          | length of stay   | (%)           |
| (%)          |              |                  |               |
| lymph nodes  |              |                  |               |
| (%)          |              |                  |               |
Table 7.3 continued Management of patients who had major surgery according to trust/hospital site Diagnosing Cancer Alliance / Trust Name
No. patients 
Patients 
having major 
with distant 
surgery
metastases 
at time of 
surgery (%)
West London
811
9
16
19
93
83
57
651
76
Chelsea and Westminster Hospital NHS Foundation Trust
97
21
27
21
93
89
60
80
74
Croydon Health Services NHS Trust
52
6
12
17
100
83
40
45
68
Epsom and St Helier University Hospitals NHS Trust
84
4
5
12
100
56
10
70
73
Imperial College Healthcare NHS Trust
134
2
10
23
97
89
84
110
72
Kingston Hospital NHS Foundation Trust
99
8
21
18
98
87
45
92
82
London North West Hospitals NHS Trust
153
7
13
27
92
97
80
117
73
St George's University Hospitals NHS Foundation Trust
82
12
40
16
95
76
52
59
74
The Hillingdon Hospitals NHS Foundation Trust
66
17
6
14
61
79
64
47
90
The Royal Marsden NHS Foundation Trust
44
13
0
17
100
68
23
31
98
South East London
379
6
12
18
100
86
62
329
65
Guy's and St Thomas' NHS Foundation Trust
95
18
12
18
100
82
55
81
73
King's College Hospital NHS Foundation Trust - King's College Hospital
80
8
11
19
100
91
78
66
76
King's College Hospital NHS Foundation Trust - Princess Royal University Hospital
143
3
18
19
100
88
58
126
65
Lewisham and Greenwich NHS Trust
61
3
2
15
98
79
63
56
41
North Central and East London
673
11
16
17
91
85
66
579
80
Barking, Havering and Redbridge University Hospitals NHS Trust
152
5
34
15
81
85
57
133
79
Barts Health NHS Trust
94
12
11
19
74
94
84
75
76
Homerton University Hospital NHS Foundation Trust
56
4
9
18.5
100
93
75
53
61
North Middlesex University Hospital NHS Trust
46
3
15
13
100
61
63
35
102
Royal Free London NHS Foundation Trust
182
14
13
16
97
80
67
155
80
Whittington Health NHS Trust
57
18
9
22
96
95
63
49
62
University College London Hospitals NHS Foundation Trust
86
18
9
19
99
87
57
79
101

▲ Too few cases to report (<10) - No cases submitted † Adjusted estimates not reported due to poor completeness of risk adjustment variables

|              |              | Major surgery    | Median        |
|--------------|--------------|------------------|---------------|
| Proportion   | Laparoscopic | No. patients     | Risk-adjusted |
| carried out  | number of    |                  |               |
| Proportion   |              |                  |               |
| of patients  |              |                  |               |
| surgery      | included in  | length of stay   | cases         |
| ≥            |              |                  |               |
| 12           |              |                  |               |
| as urgent or | lymph nodes  | with recorded    |               |
| nodes        | attempted    | risk-adjusted    | >5 days       |
| emergency    | excised      | number of        |               |
| (%)          | (%)          | length of stay   | (%)           |
| (%)          |              |                  |               |
| lymph nodes  |              |                  |               |
| (%)          |              |                  |               |
Outcomes of patients who had major surgery according to trust/hospital site (excludes those recorded as <18 years or ICD-10 code C18.1 (Malignant neoplasm of appendix)
| Cancer Alliance/Trust Name                                   | No. patients    |   Observed 90- |
|--------------------------------------------------------------|-----------------|----------------|
| having major                                                 | day mortality   |                |
| surgery                                                      | (%)             |                |
| Overall                                                      | 17,643          |            3.2 |
| North East and Cumbria                                       | 1,072           |            3.4 |
| City Hospitals Sunderland NHS Foundation Trust               | 87              |            3.4 |
| County Durham and Darlington NHS Foundation Trust            | 147             |            2   |
| Gateshead Health NHS Foundation Trust                        | 96              |            5.2 |
| North Cumbria University Hospitals NHS Trust                 | 38              |            0   |
| North Tees and Hartlepool NHS Foundation Trust               | 135             |            4.4 |
| Northumbria Healthcare NHS Foundation Trust                  | 163             |            4.3 |
| South Tees Hospitals NHS Foundation Trust                    | 175             |            2.9 |
| South Tyneside NHS Foundation Trust                          | 68              |            1.5 |
| The Newcastle Upon Tyne Hospitals NHS Foundation Trust       | 163             |            3.7 |
| Lancashire and South Cumbria                                 | 493             |            3.7 |
| Blackpool Teaching Hospitals NHS Foundation Trust            | 98              |            8.2 |
| East Lancashire Hospitals NHS Trust                          | 142             |            2.8 |
| Lancashire Teaching Hospitals NHS Foundation Trust           | 103             |            1.9 |
| University Hospitals of Morecambe Bay NHS Foundation Trust   | 150             |            2.7 |
| Greater Manchester                                           | 852             |            2.5 |
| Bolton NHS Foundation Trust                                  | 126             |            4   |
| Central Manchester University Hospitals NHS Foundation Trust | 102             |            2   |
| Pennine Acute Hospitals NHS Trust                            | 173             |            2.3 |
| Salford Royal NHS Foundation Trust                           | 60              |            1.7 |
| Stockport NHS Foundation Trust                               | 109             |            0.9 |
| Tameside and Glossop Integrated Care NHS Foundation Trust    | 68              |            1.5 |
| The Christie NHS Foundation Trust                            | 57              |            0   |
| University Hospital of South Manchester NHS Foundation Trust | 85              |            4.7 |
| Wrightington, Wigan and Leigh NHS Foundation Trust           | 72              |            4.2 |
| West Yorkshire                                               | 834             |            3.5 |
| Airedale NHS Foundation Trust                                | 92              |            4.3 |
| Bradford Teaching Hospitals NHS Foundation Trust             | 100             |            2   |
| Calderdale and Huddersfield NHS Foundation Trust             | 134             |            0.7 |
| Harrogate and District NHS Foundation Trust                  | 94              |            2.1 |
| Leeds Teaching Hospitals NHS Trust                           | 247             |            4   |
| Mid Yorkshire Hospitals NHS Trust                            | 167             |            6   |
| Adjusted 90-   | No. patients    | Observed    | Adjusted      | No. patients    | Observed       | Adjusted    |
|----------------|-----------------|-------------|---------------|-----------------|----------------|-------------|
| day mortality  | having major    | 30-day      | 30-day        | having major    | 2-year         | 2-year      |
| (%)            | surgery linked  | unplanned   | unplanned     | resection       |                | mortality   |
| to HES/PEDW    | readmission     | readmission | 1 Apr 13 - 31 | rate (% per     | (% per person- |             |
| rate           | rate            | Mar 14      | person-2-     | 2-years)        |                |             |
| (%)            | (%)             | years)      |               |                 |                |             |
Outcomes of patients who had major surgery according to trust/hospital site (excludes those recorded as <18 years or ICD-10 code C18.1 (Malignant neoplasm of appendix)
| Cancer Alliance/Trust Name                                         | No. patients    | Observed 90-   |
|--------------------------------------------------------------------|-----------------|----------------|
| having major                                                       | day mortality   |                |
| surgery                                                            | (%)             |                |
| Humber, Coast and Vale                                             | 542             | 5.2            |
| Hull and East Yorkshire Hospitals NHS Trust                        | 166             | 3.6            |
| Northern Lincolnshire and Goole NHS Foundation Trust               | 176             | 6.3            |
| York Teaching Hospital NHS Foundation Trust - The York Hospital    | 133             | 6.0            |
| York Teaching Hospital NHS Foundation Trust - Scarborough Hospital | 67              | 4.5            |
| ▲                                                                  | ▲               | ▲              |
| South Yorkshire, Bassetlaw, North Derbyshire and Hardwick          | 613             | 3.1            |
| Barnsley Hospital NHS Foundation Trust                             | 73              | 2.7            |
| Chesterfield Royal Hospital NHS Foundation Trust                   | 108             | 5.6            |
| Doncaster and Bassetlaw Hospitals NHS Foundation Trust             | 153             | 0.7            |
| Sheffield Teaching Hospitals NHS Foundation Trust                  | 201             | 3.0            |
| The Rotherham NHS Foundation Trust                                 | 78              | 5.1            |
| Cheshire and Merseyside                                            | 950             | 2.4            |
| Aintree University Hospital NHS Foundation Trust                   | 112             | 1.8            |
| Countess of Chester Hospital NHS Foundation Trust                  | 96              | 0.0            |
| East Cheshire NHS Trust                                            | 86              | 3.5            |
| Mid Cheshire Hospitals NHS Foundation Trust                        | 89              | 0.0            |
| Royal Liverpool and Broadgreen University Hospitals NHS Trust      | 128             | 0.8            |
| Southport and Ormskirk Hospital NHS Trust                          | 82              | 2.4            |
| St Helens and Knowsley Hospital Services NHS Trust                 | 132             | 5.3            |
| Warrington and Halton Hospitals NHS Foundation Trust               | 91              | 6.6            |
| Wirral University Teaching Hospital NHS Foundation Trust           | 134             | 1.5            |
| Wales                                                              | 1,208           | 4.9            |
| Bronglais MDT                                                      | 11              | 0.0            |
| ▲                                                                  | ▲               | ▲              |
| 24                                                                 | 36.8            | 28.4           |
| Cardiff MDT                                                        | 120             | 3.3            |
| Nevill Hall Hospital MDT                                           | 68              | 2.9            |
| Prince Charles Hospital MDT                                        | 68              | 7.4            |
| Princess of Wales MDT                                              | 77              | 3.9            |
| Royal Glamorgan Hospital MDT                                       | 77              | 5.2            |
| Royal Gwent Hospital MDT                                           | 146             | 2.1            |
| Swansea MDT                                                        | 154             | 6.5            |
| West Wales General and Prince Phillip MDT                          | 103             | 4.9            |
| Withybush General MDT                                              | 70              | 8.6            |
| Ysbwyty Glan Clwydd MDT                                            | 103             | 6.8            |
| Ysbwyty Gwynedd MDT                                                | 108             | 3.7            |
| Ysbwyty Maelor MDT                                                 | 103             | 5.8            |
| Adjusted 90-   | No. patients    | Observed    | Adjusted      | No. patients    | Observed       | Adjusted    |
|----------------|-----------------|-------------|---------------|-----------------|----------------|-------------|
| day mortality  | having major    | 30-day      | 30-day        | having major    | 2-year         | 2-year      |
| (%)            | surgery linked  | unplanned   | unplanned     | resection       |                | mortality   |
| to HES/PEDW    | readmission     | readmission | 1 Apr 13 - 31 | rate (% per     | (% per person- |             |
| rate           | rate            | Mar 14      | person-2-     | 2-years)        |                |             |
| (%)            | (%)             | years)      |               |                 |                |             |
Outcomes of patients who had major surgery according to trust/hospital site (excludes those recorded as <18 years or ICD-10 code C18.1 (Malignant neoplasm of appendix)
| Cancer Alliance/Trust Name                                                         | No. patients    | Observed 90-   |
|------------------------------------------------------------------------------------|-----------------|----------------|
| having major                                                                       | day mortality   |                |
| surgery                                                                            | (%)             |                |
| West Midlands                                                                      | 1,628           | 3.7            |
| Burton Hospitals NHS Foundation Trust                                              | 99              | 13.1           |
| George Eliot Hospital NHS Trust                                                    | 72              | 2.8            |
| Heart of England NHS Foundation Trust                                              | 268             | 3.7            |
| Sandwell and West Birmingham Hospitals NHS Trust                                   | 137             | 4.4            |
| Shrewsbury and Telford Hospital NHS Trust                                          | 178             | 2.2            |
| South Warwickshire NHS Foundation Trust                                            | 100             | 2.0            |
| The Dudley Group NHS Foundation Trust                                              | 151             | 2.0            |
| The Royal Wolverhampton NHS Trust                                                  | 166             | 1.8            |
| University Hospitals Birmingham NHS Foundation Trust                               | 17              | 0.0            |
| University Hospitals Coventry and Warwickshire NHS Trust                           | 119             | 3.4            |
| University Hospitals of North Midlands NHS Trust - County Hospital                 |                 |                |
| ▲                                                                                  | ▲               | ▲              |
| 68                                                                                 | 24.4            | 15.6           |
| University Hospitals of North Midlands NHS Trust - Royal Stoke University Hospital | 230             | 3.9            |
| Walsall Healthcare NHS Trust                                                       | -               | -              |
| Worcestershire Acute Hospitals NHS Trust                                           | 239             | 4.2            |
| Wye Valley NHS Trust                                                               | 80              | 3.8            |
| East Midlands                                                                      | 1,207           | 2.6            |
| Derby Teaching Hospitals NHS Foundation Trust                                      | 166             | 0.6            |
| Kettering General Hospital NHS Foundation Trust                                    | 136             | 2.2            |
| Northampton General Hospital NHS Trust                                             | 94              | 4.3            |
| Nottingham University Hospitals NHS Trust                                          | 195             | 2.6            |
| Sherwood Forest Hospitals NHS Foundation Trust                                     | 117             | 1.7            |
| University Hospitals of Leicester NHS Trust                                        | 317             | 2.8            |
| United Lincolnshire Hospitals NHS Trust - Lincoln and Grantham                     | 98              | 5.1            |
| United Lincolnshire Hospitals NHS Trust - Pilgrim Hospital Boston                  | 84              | 2.4            |
| Adjusted 90-   | No. patients    | Observed    | Adjusted      | No. patients    | Observed       | Adjusted    |
|----------------|-----------------|-------------|---------------|-----------------|----------------|-------------|
| day mortality  | having major    | 30-day      | 30-day        | having major    | 2-year         | 2-year      |
| (%)            | surgery linked  | unplanned   | unplanned     | resection       |                | mortality   |
| to HES/PEDW    | readmission     | readmission | 1 Apr 13 - 31 | rate (% per     | (% per person- |             |
| rate           | rate            | Mar 14      | person-2-     | 2-years)        |                |             |
| (%)            | (%)             | years)      |               |                 |                |             |
Outcomes of patients who had major surgery according to trust/hospital site (excludes those recorded as <18 years or ICD-10 code C18.1 (Malignant neoplasm of appendix)
| Cancer Alliance/Trust Name                                      | No. patients    |   Observed 90- |
|-----------------------------------------------------------------|-----------------|----------------|
| having major                                                    | day mortality   |                |
| surgery                                                         | (%)             |                |
| East of England                                                 | 1,751           |            2.9 |
| Basildon and Thurrock University Hospitals NHS Foundation Trust | 101             |            4   |
| Bedford Hospital NHS Trust                                      | 23              |            4.3 |
| Cambridge University Hospitals NHS Foundation Trust             | 209             |            1.4 |
| Colchester Hospital University NHS Foundation Trust             | 125             |            0.8 |
| East and North Hertfordshire NHS Trust                          | 86              |            0   |
| Hinchingbrooke Health Care NHS Trust                            | 66              |            3   |
| Ipswich Hospital NHS Trust                                      | 137             |            8   |
| James Paget University Hospitals NHS Foundation Trust           | 85              |            2.4 |
| Luton and Dunstable University Hospital NHS Foundation Trust    | 90              |            3.3 |
| Mid Essex Hospital Services NHS Trust                           | 107             |            1.9 |
| Milton Keynes University Hospital NHS Foundation Trust          | 81              |            4.9 |
| Norfolk and Norwich University Hospitals NHS Foundation Trust   | 244             |            1.6 |
| Peterborough and Stamford Hospitals NHS Foundation Trust        | 147             |            4.1 |
| Southend University Hospital NHS Foundation Trust               | 98              |            2   |
| The Princess Alexandra Hospital NHS Trust                       | 27              |            0   |
| The Queen Elizabeth Hospital, King's Lynn, NHS Foundation Trust | 77              |            2.6 |
| West Hertfordshire Hospitals NHS Trust                          | 127             |            2.4 |
| West Suffolk NHS Foundation Trust                               | 105             |            3.8 |
| Peninsula                                                       | 647             |            3.6 |
| Northern Devon Healthcare NHS Trust                             | 79              |            1.3 |
| Plymouth Hospitals NHS Trust                                    | 109             |            8.3 |
| Royal Cornwall Hospitals NHS Trust                              | 185             |            4.3 |
| Royal Devon and Exeter NHS Foundation Trust                     | 182             |            1.6 |
| Torbay and South Devon NHS Foundation Trust                     | 92              |            2.2 |
| Somerset, Wiltshire, Avon and Gloucestershire                   | 921             |            2   |
| Gloucestershire Hospitals NHS Foundation Trust                  | 272             |            1.8 |
| North Bristol NHS Trust                                         | 152             |            0   |
| Royal United Hospitals Bath NHS Foundation Trust                | 145             |            2.1 |
| Salisbury NHS Foundation Trust                                  | 77              |            2.6 |
| Taunton and Somerset NHS Foundation Trust                       | 67              |            1.5 |
| University Hospitals Bristol NHS Foundation Trust               | 105             |            1   |
| Weston Area Health NHS Trust                                    | 60              |            6.7 |
| Yeovil District Hospital NHS Foundation Trust                   | 43              |            4.7 |
| Adjusted 90-   | No. patients    | Observed    | Adjusted      | No. patients    | Observed       | Adjusted    |
|----------------|-----------------|-------------|---------------|-----------------|----------------|-------------|
| day mortality  | having major    | 30-day      | 30-day        | having major    | 2-year         | 2-year      |
| (%)            | surgery linked  | unplanned   | unplanned     | resection       |                | mortality   |
| to HES/PEDW    | readmission     | readmission | 1 Apr 13 - 31 | rate (% per     | (% per person- |             |
| rate           | rate            | Mar 14      | person-2-     | 2-years)        |                |             |
| (%)            | (%)             | years)      |               |                 |                |             |
Outcomes of patients who had major surgery according to trust/hospital site (excludes those recorded as <18 years or ICD-10 code C18.1 (Malignant neoplasm of appendix)
| Cancer Alliance/Trust Name                                                          | No. patients    |   Observed 90- |
|-------------------------------------------------------------------------------------|-----------------|----------------|
| having major                                                                        | day mortality   |                |
| surgery                                                                             | (%)             |                |
| Wessex                                                                              | 952             |            2.1 |
| Dorset County Hospital NHS Foundation Trust                                         | 88              |            1.1 |
| Hampshire Hospitals NHS Foundation Trust - Basingstoke and North Hampshire Hospital | 75              |            0   |
| Hampshire Hospitals NHS Foundation Trust - Royal Hampshire County Hospital          | 99              |            5.1 |
| Isle of Wight NHS Trust                                                             | 66              |            4.5 |
| Poole Hospital NHS Foundation Trust                                                 | 93              |            1.1 |
| Portsmouth Hospitals NHS Trust                                                      | 202             |            2.5 |
| The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust               | 131             |            1.5 |
| University Hospital Southampton NHS Foundation Trust                                | 198             |            1.5 |
| Thames Valley                                                                       |                 |                |
| 652                                                                                 | 2.0             |            2.2 |
| Buckinghamshire Healthcare NHS Trust                                                | 149             |            0.7 |
| Great Western Hospitals NHS Foundation Trust                                        | 139             |            4.3 |
| Oxford University Hospitals NHS Foundation Trust                                    | 198             |            2   |
| Royal Berkshire NHS Foundation Trust                                                | 166             |            1.2 |
| Surrey and Sussex                                                                   | 962             |            3.7 |
| Ashford and St Peter's Hospitals NHS Foundation Trust                               | 70              |            0   |
| Brighton and Sussex University Hospitals NHS Trust                                  | 158             |            7   |
| East Sussex Healthcare NHS Trust                                                    | 161             |            1.2 |
| Frimley Health NHS Foundation Trust - Frimley Park Hospital                         | 116             |            2.6 |
| Frimley Health NHS Foundation Trust - Heatherwood and Wexham Park Hospitals         | 95              |            4.2 |
| Royal Surrey County Hospital NHS Foundation Trust                                   | 78              |            2.6 |
| Surrey and Sussex Healthcare NHS Trust                                              | 154             |            4.5 |
| Western Sussex Hospitals NHS Foundation Trust - St Richard's Hospital               | 137             |            5.8 |
| Western Sussex Hospitals NHS Foundation Trust - Worthing Hospital                   | 109             |            1.8 |
| Kent and Medway                                                                     | 614             |            3.7 |
| Dartford and Gravesham NHS Trust                                                    | 97              |            4.1 |
| East Kent Hospitals University NHS Foundation Trust                                 | 256             |            4.7 |
| Maidstone and Tunbridge Wells NHS Trust                                             | 168             |            2.4 |
| Medway NHS Foundation Trust                                                         | 93              |            3.2 |
| Adjusted 90-   | No. patients    | Observed    | Adjusted      | No. patients    | Observed       | Adjusted    |
|----------------|-----------------|-------------|---------------|-----------------|----------------|-------------|
| day mortality  | having major    | 30-day      | 30-day        | having major    | 2-year         | 2-year      |
| (%)            | surgery linked  | unplanned   | unplanned     | resection       |                | mortality   |
| to HES/PEDW    | readmission     | readmission | 1 Apr 13 - 31 | rate (% per     | (% per person- |             |
| rate           | rate            | Mar 14      | person-2-     | 2-years)        |                |             |
| (%)            | (%)             | years)      |               |                 |                |             |
Outcomes of patients who had major surgery according to trust/hospital site (excludes those recorded as <18 years or ICD-10 code C18.1 (Malignant neoplasm of appendix)
| Cancer Alliance/Trust Name                                                        | No. patients    |   Observed 90- |
|-----------------------------------------------------------------------------------|-----------------|----------------|
| having major                                                                      | day mortality   |                |
| surgery                                                                           | (%)             |                |
| West London                                                                       | 729             |            4.1 |
| Chelsea and Westminster Hospital NHS Foundation Trust                             | 87              |            5.7 |
| Croydon Health Services NHS Trust                                                 | 50              |            2   |
| Epsom and St Helier University Hospitals NHS Trust                                | 83              |            6   |
| Imperial College Healthcare NHS Trust                                             | 122             |            3.3 |
| Kingston Hospital NHS Foundation Trust                                            | 97              |            5.2 |
| London North West Hospitals NHS Trust                                             | 130             |            3.8 |
| St George's University Hospitals NHS Foundation Trust                             | 67              |            6   |
| The Hillingdon Hospitals NHS Foundation Trust                                     | 53              |            1.9 |
| The Royal Marsden NHS Foundation Trust                                            | 40              |            0   |
| South East London                                                                 | 354             |            3.1 |
| Guy's and St Thomas' NHS Foundation Trust                                         | 88              |            2.3 |
| King's College Hospital NHS Foundation Trust - King's College Hospital            | 75              |            1.3 |
| King's College Hospital NHS Foundation Trust - Princess Royal University Hospital | 136             |            5.1 |
| Lewisham and Greenwich NHS Trust                                                  | 55              |            1.8 |
| North Central and East London                                                     | 638             |            3.4 |
| Barking, Havering and Redbridge University Hospitals NHS Trust                    | 144             |            6.9 |
| Barts Health NHS Trust                                                            | 85              |            0   |
| Homerton University Hospital NHS Foundation Trust                                 | 55              |            3.6 |
| North Middlesex University Hospital NHS Trust                                     | 43              |            9.3 |
| Royal Free London NHS Foundation Trust                                            | 172             |            2.3 |
| Whittington Health NHS Trust                                                      | 55              |            0   |
| University College London Hospitals NHS Foundation Trust                          | 84              |            2.4 |

† Adjusted estimates not reported because most patients missing pathological TNM staging (also not included in associated Network totals) †† Adjusted estimates not reported because most patients missing pathological M stage (also not included in associated Network totals) ††† Adjusted estimates not reported because most patients missing ASA grade (also not included in associated Network totals) ▲ Too few cases to report (<10) - No cases submitted

| Adjusted 90-   | No. patients    | Observed    | Adjusted      | No. patients    | Observed       | Adjusted    |
|----------------|-----------------|-------------|---------------|-----------------|----------------|-------------|
| day mortality  | having major    | 30-day      | 30-day        | having major    | 2-year         | 2-year      |
| (%)            | surgery linked  | unplanned   | unplanned     | resection       |                | mortality   |
| to HES/PEDW    | readmission     | readmission | 1 Apr 13 - 31 | rate (% per     | (% per person- |             |
| rate           | rate            | Mar 14      | person-2-     | 2-years)        |                |             |
| (%)            | (%)             | years)      |               |                 |                |             |
Results for patients with rectal cancer who had major surgery according to trust/hospital site
| Cancer Alliance/Trust Name                                   | Number of    |   Positive  |
|--------------------------------------------------------------|--------------|-------------|
| patients with                                                | margins      |             |
| rectal cancer                                                | reported     |             |
| undergoing                                                   | (%)          |             |
| major surgery                                                |              |             |
| Overall                                                      | 4,468        |           7 |
| North East and Cumbria                                       | 285          |           4 |
| City Hospitals Sunderland NHS Foundation Trust               | 17           |           0 |
| County Durham and Darlington NHS Foundation Trust            | 40           |           3 |
| Gateshead Health NHS Foundation Trust                        | 24           |           4 |
| North Cumbria University Hospitals NHS Trust                 | 12           |           0 |
| North Tees and Hartlepool NHS Foundation Trust               | 39           |           3 |
| Northumbria Healthcare NHS Foundation Trust                  | 41           |           2 |
| South Tees Hospitals NHS Foundation Trust                    | 48           |           2 |
| South Tyneside NHS Foundation Trust                          | 19           |          16 |
| The Newcastle Upon Tyne Hospitals NHS Foundation Trust       | 45           |           7 |
| Lancashire and South Cumbria                                 | 110          |           3 |
| Blackpool Teaching Hospitals NHS Foundation Trust            | 27           |           0 |
| East Lancashire Hospitals NHS Trust                          | 29           |           0 |
| Lancashire Teaching Hospitals NHS Foundation Trust           | 20           |          15 |
| University Hospitals of Morecambe Bay NHS Foundation Trust   | 34           |           0 |
| Greater Manchester                                           | 230          |           9 |
| Bolton NHS Foundation Trust                                  | 31           |          13 |
| Central Manchester University Hospitals NHS Foundation Trust | 31           |           6 |
| Pennine Acute Hospitals NHS Trust                            | 52           |          13 |
| Salford Royal NHS Foundation Trust                           | 15           |           0 |
| Stockport NHS Foundation Trust                               | 26           |           8 |
| Tameside and Glossop Integrated Care NHS Foundation Trust    | 20           |           5 |
| The Christie NHS Foundation Trust                            | 20           |          10 |
| University Hospital of South Manchester NHS Foundation Trust | 22           |           0 |
| Wrightington, Wigan and Leigh NHS Foundation Trust           | 13           |          15 |
| West Yorkshire                                               | 215          |          10 |
| Airedale NHS Foundation Trust                                | 25           |           4 |
| Bradford Teaching Hospitals NHS Foundation Trust             | 24           |           8 |
| Calderdale and Huddersfield NHS Foundation Trust             | 45           |           7 |
| Harrogate and District NHS Foundation Trust                  | 22           |          14 |
| Leeds Teaching Hospitals NHS Trust                           | 58           |          19 |
| Mid Yorkshire Hospitals NHS Trust                            | 41           |           5 |
| Records        | APER rate    | Number of     | Short or     | Adjusted    |
|----------------|--------------|---------------|--------------|-------------|
| missing status | (%)          | patients      | long-course  |             |
| Number of      |              |               |              |             |
| patients in    |              |               |              |             |
| Observed       |              |               |              |             |
| 18-month       | 18-month     |               |              |             |
| of margins     | diagnosed    | Pre-operative | HES 18-month | stoma rate  |
| (%)            | with rectal  | radiotherapy  | stoma        | using       |
| cancer Jan-    | (%)          | estimate      | HES/PEDW     | HES/PEDW    |
| Dec 2015       | (%)          | (%)           |              |             |
| undergoing     |              |               |              |             |
| major surgery  |              |               |              |             |
Results for patients with rectal cancer who had major surgery according to trust/hospital site
| Cancer Alliance/Trust Name                                         | Number of    | Positive    |
|--------------------------------------------------------------------|--------------|-------------|
| patients with                                                      | margins      |             |
| rectal cancer                                                      | reported     |             |
| undergoing                                                         | (%)          |             |
| major surgery                                                      |              |             |
| Humber, Coast and Vale                                             | 124          | 15          |
| Hull and East Yorkshire Hospitals NHS Trust                        | 31           | 55          |
| Northern Lincolnshire and Goole NHS Foundation Trust               | 41           | 0           |
| York Teaching Hospital NHS Foundation Trust - The York Hospital    | 37           | 0           |
| York Teaching Hospital NHS Foundation Trust - Scarborough Hospital | 15           | 13          |
| South Yorkshire, Bassetlaw, North Derbyshire and Hardwick          | 163          | 4           |
| Barnsley Hospital NHS Foundation Trust                             | 20           | 0           |
| Chesterfield Royal Hospital NHS Foundation Trust                   | 25           | 0           |
| Doncaster and Bassetlaw Hospitals NHS Foundation Trust             | 37           | 3           |
| Sheffield Teaching Hospitals NHS Foundation Trust                  | 56           | 5           |
| The Rotherham NHS Foundation Trust                                 | 25           | 12          |
| Cheshire and Merseyside                                            | 219          | 8           |
| Aintree University Hospital NHS Foundation Trust                   | 18           | 22          |
| Countess of Chester Hospital NHS Foundation Trust                  | 36           | 3           |
| East Cheshire NHS Trust                                            | 16           | 0           |
| Mid Cheshire Hospitals NHS Foundation Trust                        | 23           | 0           |
| Royal Liverpool and Broadgreen University Hospitals NHS Trust      | 33           | 0           |
| Southport and Ormskirk Hospital NHS Trust                          | 18           | 0           |
| St Helens and Knowsley Hospital Services NHS Trust                 | 32           | 25          |
| Warrington and Halton Hospitals NHS Foundation Trust               | 19           | 5           |
| Wirral University Teaching Hospital NHS Foundation Trust           | 24           | 17          |
| Wales                                                              | 273          | 4           |
| Bronglais MDT                                                      |              |             |
| ▲                                                                  |              |             |
| ▲                                                                  | ▲            | ▲           |
| 17                                                                 | 47           | 43          |
| Cardiff MDT                                                        | 31           | 0           |
| Nevill Hall Hospital MDT                                           | 12           | 8           |
| Prince Charles Hospital MDT                                        | 18           | 6           |
| Princess of Wales MDT                                              | 24           | 0           |
| Royal Glamorgan Hospital MDT                                       | 16           | 6           |
| Royal Gwent Hospital MDT                                           | 31           | 3           |
| Swansea MDT                                                        | 39           | 3           |
| West Wales General and Prince Phillip MDT                          | 19           | 5           |
| Withybush General MDT                                              | 15           | 7           |
| Ysbwyty Glan Clwydd MDT                                            | 24           | 8           |
| Ysbwyty Gwynedd MDT                                                | 19           | 5           |
| Ysbwyty Maelor MDT                                                 | 23           | 4           |
| Records        | APER rate    | Number of     | Short or     | Adjusted    |
|----------------|--------------|---------------|--------------|-------------|
| missing status | (%)          | patients      | long-course  |             |
| Number of      |              |               |              |             |
| patients in    |              |               |              |             |
| Observed       |              |               |              |             |
| 18-month       | 18-month     |               |              |             |
| of margins     | diagnosed    | Pre-operative | HES 18-month | stoma rate  |
| (%)            | with rectal  | radiotherapy  | stoma        | using       |
| cancer Jan-    | (%)          | estimate      | HES/PEDW     | HES/PEDW    |
| Dec 2015       | (%)          | (%)           |              |             |
| undergoing     |              |               |              |             |
| major surgery  |              |               |              |             |
Results for patients with rectal cancer who had major surgery according to trust/hospital site
| Cancer Alliance/Trust Name                                                         | Number of    | Positive    |
|------------------------------------------------------------------------------------|--------------|-------------|
| patients with                                                                      | margins      |             |
| rectal cancer                                                                      | reported     |             |
| undergoing                                                                         | (%)          |             |
| major surgery                                                                      |              |             |
| West Midlands                                                                      | 477          | 4           |
| Burton Hospitals NHS Foundation Trust                                              | 21           | 5           |
| George Eliot Hospital NHS Trust                                                    | 14           | 7           |
| Heart of England NHS Foundation Trust                                              | 80           | 1           |
| Sandwell and West Birmingham Hospitals NHS Trust                                   | 34           | 3           |
| Shrewsbury and Telford Hospital NHS Trust                                          | 37           | 3           |
| South Warwickshire NHS Foundation Trust                                            | 22           | 9           |
| The Dudley Group NHS Foundation Trust                                              | 46           | 2           |
| The Royal Wolverhampton NHS Trust                                                  | 48           | 0           |
| University Hospitals Birmingham NHS Foundation Trust                               | 15           | 0           |
| University Hospitals Coventry and Warwickshire NHS Trust                           | 24           | 4           |
| University Hospitals of North Midlands NHS Trust - County Hospital                 |              |             |
| ▲                                                                                  | ▲            | ▲           |
| 31                                                                                 | 77           | 75          |
| University Hospitals of North Midlands NHS Trust - Royal Stoke University Hospital | 53           | 0           |
| Walsall Healthcare NHS Trust                                                       |              |             |
| -                                                                                  | -            | -           |
| ▲                                                                                  | ▲            |             |
| 60                                                                                 | 43           | 41          |
| Worcestershire Acute Hospitals NHS Trust                                           | 58           | 7           |
| Wye Valley NHS Trust                                                               | 24           | 17          |
| East Midlands                                                                      | 331          | 7           |
| Derby Teaching Hospitals NHS Foundation Trust                                      | 49           | 14          |
| Kettering General Hospital NHS Foundation Trust                                    | 33           | 6           |
| Northampton General Hospital NHS Trust                                             | 29           | 3           |
| Nottingham University Hospitals NHS Trust                                          | 53           | 2           |
| Sherwood Forest Hospitals NHS Foundation Trust                                     | 27           | 4           |
| University Hospitals of Leicester NHS Trust                                        | 97           | 7           |
| United Lincolnshire Hospitals NHS Trust - Lincoln and Grantham                     | 21           | 10          |
| United Lincolnshire Hospitals NHS Trust - Pilgrim Hospital Boston                  | 22           | 9           |
| Records        | APER rate    | Number of     | Short or     | Adjusted    |
|----------------|--------------|---------------|--------------|-------------|
| missing status | (%)          | patients      | long-course  |             |
| Number of      |              |               |              |             |
| patients in    |              |               |              |             |
| Observed       |              |               |              |             |
| 18-month       | 18-month     |               |              |             |
| of margins     | diagnosed    | Pre-operative | HES 18-month | stoma rate  |
| (%)            | with rectal  | radiotherapy  | stoma        | using       |
| cancer Jan-    | (%)          | estimate      | HES/PEDW     | HES/PEDW    |
| Dec 2015       | (%)          | (%)           |              |             |
| undergoing     |              |               |              |             |
| major surgery  |              |               |              |             |
Results for patients with rectal cancer who had major surgery according to trust/hospital site
| Cancer Alliance/Trust Name                                      | Number of    | Positive    |
|-----------------------------------------------------------------|--------------|-------------|
| patients with                                                   | margins      |             |
| rectal cancer                                                   | reported     |             |
| undergoing                                                      | (%)          |             |
| major surgery                                                   |              |             |
| East of England                                                 | 468          | 5           |
| Basildon and Thurrock University Hospitals NHS Foundation Trust | 27           | 15          |
| Bedford Hospital NHS Trust                                      | 20           | 25          |
| Cambridge University Hospitals NHS Foundation Trust             | 54           | 2           |
| Colchester Hospital University NHS Foundation Trust             | 36           | 3           |
| East and North Hertfordshire NHS Trust                          | 15           | 0           |
| Hinchingbrooke Health Care NHS Trust                            | 14           | 0           |
| Ipswich Hospital NHS Trust                                      | 28           | 14          |
| James Paget University Hospitals NHS Foundation Trust           | 22           | 5           |
| Luton and Dunstable University Hospital NHS Foundation Trust    | 28           | 11          |
| Mid Essex Hospital Services NHS Trust                           | 17           | 0           |
| Milton Keynes University Hospital NHS Foundation Trust          | 27           | 4           |
| Norfolk and Norwich University Hospitals NHS Foundation Trust   | 68           | 4           |
| Peterborough and Stamford Hospitals NHS Foundation Trust        | 39           | 3           |
| Southend University Hospital NHS Foundation Trust               | 25           | 0           |
| The Princess Alexandra Hospital NHS Trust                       |              |             |
| ▲                                                               | ▲            | ▲           |
| 39                                                              | 41           | 39          |
| The Queen Elizabeth Hospital, King's Lynn, NHS Foundation Trust | 18           | 0           |
| West Hertfordshire Hospitals NHS Trust                          |              |             |
| ▲                                                               | ▲            | ▲           |
| 125                                                             | 44           | 43          |
| West Suffolk NHS Foundation Trust                               | 21           | 0           |
| Peninsula                                                       | 195          | 14          |
| Northern Devon Healthcare NHS Trust                             | 22           | 5           |
| Plymouth Hospitals NHS Trust                                    | 45           | 16          |
| Royal Cornwall Hospitals NHS Trust                              | 54           | 9           |
| Royal Devon and Exeter NHS Foundation Trust                     | 48           | 4           |
| Torbay and South Devon NHS Foundation Trust                     | 26           | 46          |
| Somerset, Wiltshire, Avon and Gloucestershire                   | 236          | 3           |
| Gloucestershire Hospitals NHS Foundation Trust                  | 75           | 4           |
| North Bristol NHS Trust                                         | 35           | 3           |
| Royal United Hospitals Bath NHS Foundation Trust                | 48           | 0           |
| Salisbury NHS Foundation Trust                                  | 18           | 0           |
| Taunton and Somerset NHS Foundation Trust                       | 17           | 0           |
| University Hospitals Bristol NHS Foundation Trust               | 24           | 4           |
| Weston Area Health NHS Trust                                    |              |             |
| ▲                                                               | ▲            | ▲           |
| 50                                                              | 66           | 62          |
| Yeovil District Hospital NHS Foundation Trust                   | 10           | 20          |
| Records        | APER rate    | Number of     | Short or     | Adjusted    |
|----------------|--------------|---------------|--------------|-------------|
| missing status | (%)          | patients      | long-course  |             |
| Number of      |              |               |              |             |
| patients in    |              |               |              |             |
| Observed       |              |               |              |             |
| 18-month       | 18-month     |               |              |             |
| of margins     | diagnosed    | Pre-operative | HES 18-month | stoma rate  |
| (%)            | with rectal  | radiotherapy  | stoma        | using       |
| cancer Jan-    | (%)          | estimate      | HES/PEDW     | HES/PEDW    |
| Dec 2015       | (%)          | (%)           |              |             |
| undergoing     |              |               |              |             |
| major surgery  |              |               |              |             |
Results for patients with rectal cancer who had major surgery according to trust/hospital site
| Cancer Alliance/Trust Name                                                          | Number of    | Positive    |
|-------------------------------------------------------------------------------------|--------------|-------------|
| patients with                                                                       | margins      |             |
| rectal cancer                                                                       | reported     |             |
| undergoing                                                                          | (%)          |             |
| major surgery                                                                       |              |             |
| Wessex                                                                              | 257          | 12          |
| Dorset County Hospital NHS Foundation Trust                                         | 23           | 0           |
| Hampshire Hospitals NHS Foundation Trust - Basingstoke and North Hampshire Hospital | 23           | 9           |
| Hampshire Hospitals NHS Foundation Trust - Royal Hampshire County Hospital          | 14           | 7           |
| Isle of Wight NHS Trust                                                             | 11           | 9           |
| Poole Hospital NHS Foundation Trust                                                 | 25           | 12          |
| Portsmouth Hospitals NHS Trust                                                      | 69           | 3           |
| The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust               | 31           | 23          |
| University Hospital Southampton NHS Foundation Trust                                | 61           | 26          |
| Thames Valley                                                                       | 146          | 11          |
| Buckinghamshire Healthcare NHS Trust                                                | 30           | 10          |
| Great Western Hospitals NHS Foundation Trust                                        | 37           | 22          |
| Oxford University Hospitals NHS Foundation Trust                                    | 50           | 6           |
| Royal Berkshire NHS Foundation Trust                                                | 29           | 7           |
| Surrey and Sussex                                                                   | 235          | 6           |
| Ashford and St Peter's Hospitals NHS Foundation Trust                               |              |             |
| ▲                                                                                   | ▲            | ▲           |
| 47                                                                                  | 49           | 50          |
| Brighton and Sussex University Hospitals NHS Trust                                  | 31           | 0           |
| East Sussex Healthcare NHS Trust                                                    | 47           | 0           |
| Frimley Health NHS Foundation Trust - Frimley Park Hospital                         | 34           | 0           |
| Frimley Health NHS Foundation Trust - Heatherwood and Wexham Park Hospitals         | 24           | 25          |
| Royal Surrey County Hospital NHS Foundation Trust                                   | 18           | 0           |
| Surrey and Sussex Healthcare NHS Trust                                              | 24           | 13          |
| Western Sussex Hospitals NHS Foundation Trust - St Richard's Hospital               | 33           | 6           |
| Western Sussex Hospitals NHS Foundation Trust - Worthing Hospital                   | 15           | 13          |
| Kent and Medway                                                                     | 140          | 8           |
| Dartford and Gravesham NHS Trust                                                    | 25           | 16          |
| East Kent Hospitals University NHS Foundation Trust                                 | 44           | 5           |
| Maidstone and Tunbridge Wells NHS Trust                                             | 47           | 9           |
| Medway NHS Foundation Trust                                                         | 24           | 4           |
| Records        | APER rate    | Number of     | Short or     | Adjusted    |
|----------------|--------------|---------------|--------------|-------------|
| missing status | (%)          | patients      | long-course  |             |
| Number of      |              |               |              |             |
| patients in    |              |               |              |             |
| Observed       |              |               |              |             |
| 18-month       | 18-month     |               |              |             |
| of margins     | diagnosed    | Pre-operative | HES 18-month | stoma rate  |
| (%)            | with rectal  | radiotherapy  | stoma        | using       |
| cancer Jan-    | (%)          | estimate      | HES/PEDW     | HES/PEDW    |
| Dec 2015       | (%)          | (%)           |              |             |
| undergoing     |              |               |              |             |
| major surgery  |              |               |              |             |
Results for patients with rectal cancer who had major surgery according to trust/hospital site
| Cancer Alliance/Trust Name                                                        | Number of    | Positive    |
|-----------------------------------------------------------------------------------|--------------|-------------|
| patients with                                                                     | margins      |             |
| rectal cancer                                                                     | reported     |             |
| undergoing                                                                        | (%)          |             |
| major surgery                                                                     |              |             |
| West London                                                                       | 180          | 7           |
| Chelsea and Westminster Hospital NHS Foundation Trust                             | 21           | 10          |
| Croydon Health Services NHS Trust                                                 |              |             |
| ▲                                                                                 | ▲            | ▲           |
| 50                                                                                | 38           | 39          |
| Epsom and St Helier University Hospitals NHS Trust                                | 11           | 18          |
| ▲                                                                                 | ▲            |             |
| 55                                                                                | 40           | 40          |
| Imperial College Healthcare NHS Trust                                             | 35           | 3           |
| Kingston Hospital NHS Foundation Trust                                            | 19           | 11          |
| London North West Hospitals NHS Trust                                             | 32           | 3           |
| St George's University Hospitals NHS Foundation Trust                             | 13           | 0           |
| The Hillingdon Hospitals NHS Foundation Trust                                     | 15           | 0           |
| The Royal Marsden NHS Foundation Trust                                            | 25           | 16          |
| South East London                                                                 | 77           | 10          |
| Guy's and St Thomas' NHS Foundation Trust                                         | 28           | 18          |
| King's College Hospital NHS Foundation Trust - King's College Hospital            | 11           | 9           |
| ▲                                                                                 | ▲            |             |
| 40                                                                                | 53           | 53          |
| King's College Hospital NHS Foundation Trust - Princess Royal University Hospital | 24           | 4           |
| Lewisham and Greenwich NHS Trust                                                  | 14           | 7           |
| ▲                                                                                 | ▲            |             |
| 47                                                                                | 49           | 48          |
| North Central and East London                                                     | 107          | 10          |
| Barking, Havering and Redbridge University Hospitals NHS Trust                    | 26           | 0           |
| Barts Health NHS Trust                                                            | 20           | 20          |
| Homerton University Hospital NHS Foundation Trust                                 |              |             |
| ▲                                                                                 | ▲            | ▲           |
| 33                                                                                | 58           | 55          |
| North Middlesex University Hospital NHS Trust                                     |              |             |
| ▲                                                                                 | ▲            | ▲           |
| 25                                                                                | 68           | 68          |
| Royal Free London NHS Foundation Trust                                            | 27           | 15          |
| Whittington Health NHS Trust                                                      | 11           | 9           |
| University College London Hospitals NHS Foundation Trust                          | 13           | 8           |
| ▲                                                                                 |              |             |
| Too few cases to report (<10)                                                     |              |             |
| Records        | APER rate    | Number of     | Short or     | Adjusted    |
|----------------|--------------|---------------|--------------|-------------|
| missing status | (%)          | patients      | long-course  |             |
| Number of      |              |               |              |             |
| patients in    |              |               |              |             |
| Observed       |              |               |              |             |
| 18-month       | 18-month     |               |              |             |
| of margins     | diagnosed    | Pre-operative | HES 18-month | stoma rate  |
| (%)            | with rectal  | radiotherapy  | stoma        | using       |
| cancer Jan-    | (%)          | estimate      | HES/PEDW     | HES/PEDW    |
| Dec 2015       | (%)          | (%)           |              |             |
| undergoing     |              |               |              |             |
| major surgery  |              |               |              |             |
24 Month Mortality NHS Trusts
Comment
Outlier 2016 Annual Report
The Hillingdon Hospitals NHS Foundation Trust
Thank you for your letter dated 1st August 2017 with regards to the National Bowel Cancer Audit and that The Hillingdon Hospital's NHS Foundation Trust was a potential outlier. We have reviewed the statistics that you kindly provided along with the letter. Unfortunately although we requested additional data the NBCA team were only able to provide limited information i.e. the NHS numbers of the patients who had died within 2 years. This meant it was difficult to assess if there were any gaps in data fields not included in the statistical information provided that may have affected the risk adjustment calculations. The Trust has undertaken a review of patients who underwent major surgical resections during the period in question (1st April 2013 to 31st March 2014). The findings are as follows: The Trust submitted data for 64 patients in total for this period and not 55 patients as stated in the NBCA statistics. A comparison was undertaken of the list provided by NBCA of patients who had died within 2yrs of surgery. - 
1x data error by THH - patient was incorrectly entered as a primary colorectal cancer but was a secondary cancer and therefore not eligible for inclusion.
- 
1x error by NBCA - patient did not have a major resection so should not have been included in the surgical mortality statistics. 
This leaves a total of 62 patients which is 7 more than the NBCA statistics and all 7 patients did not die within 2 years so would have had a marked effect on the denominator used to calculate the Trust's mortality figures. Of these 62 patients, 23 patients died within 2 years. The figures show an average of 308 days between date of surgery and the patient's death; this indicates that the trusts 30 and 90 day mortality figures are within the national average. of the 23 patients who died within 2 years, 22 were clinically reviewed and the key findings were: - 
All of the deaths were not directly related to surgical treatment, were expected and unavoidable with the exception of 2 cases. The Trust was already aware of these two cases and separate formal reviews were undertaken at the time. 
- 
The MDT decision agreed with the treatment undertaken in 100% of these cases. 
- 
A higher than average number of patients over the age of 85 underwent surgery [THH 12.73%, Nat. Ave 7.54%] 

- 
A higher than average number of patients with Metastases underwent surgery [THH 16.36%, Nat. Ave 9.03%] 
- 
A higher than average number of patients with a high ASA score underwent surgery [ASA=3 THH 34.55%, Nat. Ave 26.93%; ASA=4/5 THH 5.45%, Nat Ave 2.89%]
As the Trust is undertaking surgery on patients in a poorer state of health, older and with more metastases than the national average, we would expect to see a higher 2 year mortality rate than that of the national average. The 30 and 90 day mortality rates are within national average supporting the decision to offer surgical treatment, the MDT feels strongly that the patients informed choice, appropriate palliation and adjuvant treatment should not be influenced by estimated 'long term' mortality. The colorectal team has strong links with the local major oncology centre which offers trials for advanced stage malignancies. 

This is reflected in the fact that three of the patients who died had more than one primary malignancy. Finally it needs to be noted that mortality reviews have not identified any issues with the decision making or the way clinical care was delivered. The unit has taken steps to strengthen the validation of all data submitted to NBCA, HES and trust IT systems, and will continue to work with the NBCA which provides useful benchmarking and helps signpost to best practice and care as well as potential concerns. Finally, we have several awareness projects in conjunction with primary care to reduce the late presentation and advanced stage bowel cancer within local population.

Outlier 2015 Annual Report
24 Month Mortality NHS Trusts
Comment
Outlier 2016 Annual Report
King's College Hospital (Denmark Hill) 
Thank you for your letter of 1 August 2017 providing us with advance information of the National Bowel Cancer Audit (NBOCA) findings. The audit data identified King's College Hospital Denmark Hill (KCH DH) as having adjusted 2 year mortality of 40.2% after major resection, compared to England and Wales adjusted rate of 19.5%, and KCH DH's previous year when it was 25.4% and within expected range. KCH DH crude mortality was 26.25% (21/80). In response to your letter we immediately initiated an internal investigation and casenote review. NBOCA identified 21 deaths during 2013-14. One set of casenotes were not available and the remaining 20 cases were reviewed by consultant colorectal surgeons, with a final review undertaken by the Clinical Director for Cancer & End of Life Care and the Corporate Medical Director for Patient Outcomes. Our conclusions were:
1.	  Is there a quality of care issue? 
Case reviewers did not identify any quality of care issues in any of the cases assessed. There was not a high rate of procedure-related complications. 19/20 (95%) of deaths were classed as 'definitely not avoidable' and one as 'slight evidence of avoidability'; this was a case where a tumour perforation occurred.
2.	 Is there something about KCH casemix that influences adjusted mortality rates? 
Ninety percent of the patients in our cohort had stage 3 or 4 cancer (i.e. locally advanced or metastatic) at presentation; 50% had stage 4 disease, which is particularly associated with a lower survival (NHS England data show that 1-year survival for patients diagnosed with stage 4 disease is 40%). Death within 2 years of diagnosis was therefore not an unexpected outcome. KCH crude mortality at 2 years was 26.25% (21/80). The casenote review indicated that 12/20 (60%) of patients had a major comorbidity at the time of surgery. NBOCA identified 35% of patients as having one or more comorbidities. The population that King's serves is a young population with a high level of deprivation. Unlike other national mortality indicators (Summary Hospital-level Mortality Indicator and Hospital Summary Mortality Radio), the risk-adjustment model used by NBOCA does not take deprivation into account. 28% of KCH patients were over 75, compared to 38% nationally, but we know that in the effect of deprivation on health means that they are not necessarily lower-risk patients. The NBOCA model identifies younger patients as lower-risk.

## 3.	 Are There Data Quality Issues That Impact Upon The Result?

KCHFT was undergoing a major organisational change during the period of the collection of the data in this sample (1/4/2013 to 31/3/2014), with the acquisition of a new hospital site. Significant resource was therefore diverted to ensure that the site had processes in place to support the NBOCA submission. This may have had an adverse impact on the quality of data submitted at our Denmark Hill site, in particular the level of detail in relation to patients' comorbidities. As previously noted, our casenote review indicated that 12/20 (60%) of patients had a major comorbidity at the time of surgery but this is not reflected in the NBOCA data.

## Conclusion

Our investigation has not identified any quality of care issues in relation to patients having surgery for bowel cancer at King's College Hospital (Denmark Hill). We believe that our young, deprived population, coupled with very small numbers (20) and under-recording of comorbidities, may be affecting the statistical modelling and leading to the apparent high adjusted mortality rate. We are, however, always extremely keen to improve our service for our local population, where people often present late with advanced symptoms of bowel cancer. We intend to share the results of our review with our local Macmillan GPs and discuss with them actions that might be taken locally to raise public awareness and encourage earlier screening. No response provided

United Lincolnshire Hospitals NHS Trust - Pilgrim Hospital Boston 

Outlier 2015 Annual Report
24 Month Mortality NHS Trusts
Comment
Outlier 2016 Annual Report
Doncaster and Bassetlaw Hospitals NHS Foundation Trust 
I have had confirmation of how the analysis was conducted and had the data that the NBOCA used for adjusting our mortality rate as well as UK averages. Analysis was conducted on all major resections at DBH for colorectal cancer between 01/04/2013 and 31/03/2014 Cases were identified from NBOCAP Mortality data was taken from HES to identify deaths Mortality was expressed as Observed 2 year Mortality Rate calculated by the number of deaths occurring within 2 years divided by the sum of the follow-up for each patient up to maximum of 2 years. Therefore output is expressed as a function of the number of deaths and how soon deaths occurred. This rate was then adjusted by the following factors - all (I presume) from NBOCAP data apart from the last 2 which are from HES data based on our hospital coding output.

1.	 Age 2.	 ASA grade - This is from NBOCAP 3.	 T stage 4.	 N stage 5.	 M stage 6.	 Mode of admission (HES data)

7.	 Number of comorbidities (HES data)
I have down loaded our data from NBOCAP and personally reviewed the emergency admissions, which we have not scrutinised as much when previously reviewing our data. Between myself and the audit department we have checked the data entry for all elective/ acute admissions and there were some errors, but not many. I have sampled data from around 10% of patients for ASA and TN stage and this broadly appears correct. I have not been able to do the same for M status as this required more note trawling and I ran out of time. We have a large amount of missing data here. The audit department has reviewed all records for the elective entries and I have done the same for the emergency entries to identify our deaths. This is dependent on deaths being recorded on our PAS system, but I think this is reasonably accurate. I didn't find any patients who were still registered alive on our PAS who weren't still in recent follow-up. I have tabulated the findings from the NBOCAP team along with my own analysis from our data for comparison.
Variable
My Analysis
My Analysis
Notes
National Data
DBH Data
Number patients Number deaths within 2 years Unadjusted mortality
19.5
33.9
?
Adjusted mortality

/continues over

Outlier 2015 Annual Report
?
174
178
?
?
26 (14.6%)
?
21.2%
8-16%
Not quite sure how this was done, but can get figure anywhere close to theirs
24 Month Mortality NHS Trusts
Comment
Outlier 2016 Annual Report
Doncaster and Bassetlaw Hospitals NHS Foundation Trust 
Data for adjusting 65-74
31.86%
58 (33.33%)
60 (33.71%)
 75-84
29.63%
47 (27.01%)
49 (27.53%)
Age 0-64
30.94%
56 (32.18%)
55 (30.90%)
My data is in line with theirs and with national average
 84+
7.56%
13 (7.47%)
14 (7.87%)
 2
53.92%
106 (60.92%)
109 (61.24%)
 3
26.99%
40 (22.99%)
39 (21.91%)
 4/5
2.95%
0 (0%)
0
 miss
4.6%
0 (0%)
0
ASA 1
11.55%
28 (16.09%)
30 (16.85%)
My data and theirs were in agreement, but our ASAs are significantly lower than national average. 
1
6.38%
11 (6.32%)
11 (6.18%)
2
15.36%
51 (29.31%)
53 (29.78%)
3
48.81%
89 (51.56%)
91 (51.12%)
T stage 0
1.48%
0 (0%)
0
My data and theirs were in agreement, but our T4 is much lower than national average
4
24.22%
22 (12.64%)
21 (11.80%)
miss
3.76%
1 (0.57%)
2 (1.12%)
1
23.52%
46 (26.44%)
47 (26.40%)
2
15.53%
18 (10.34%)
21 (11.80%)
miss
3.97%
1 (0.57%)
2 (1.12%)
N- Stage 0
56.98%
109 (62.64%)
108 (60.67%)
My data and theirs were in agreement, but our N2 is a bit lower than national average
1
9.10%
8 (4.60%)
8 (4.49%)
miss
12.71%
21 (12.07%)
57 (32.02%)
M-Stage 0
78.19%
145 (83.33%)
113 (63.48%)
We have more missing data and I think our M stage may be higher - more in line with national average
Mode/ admission Elective
78.72%
151 (86.78%)
162 (91.01%)
Acute
15.5%
18 (10.34%)
16 (8.99%)
Number comorbidities 0
54.82%
94 (54.02%)
I don't have access to this data
1
27.53%
54 (31.03%)
2
11.96%
21 (12.07%)
miss
5.69%
5 (2.87%)

In comparison of data, I do not find that our mortality rate is as high as theirs, but I guess their HES data should be more accurate. Also I am not sure if they use a fudge factor in getting the unadjusted rate from the cumulative follow-up. Our significant adjustment upwards appears to be related to

- 
Lower ASA grade
- 
Lower T stage
- 
Slightly lower N2 stage
- 
Lower M stage
- 
Lower acute admissions rate
- 
Compared to the general population
I think that our ASA and T stage and N stage data is right, but I am not sure about the M stage and I think this required further evaluation. Our emergency data is probably right, but I have asked Julie to try and obtain the admission data from coding for these patients and this would be useful to compare. I have yet to go through the deaths and look at what caused them. Most seem to be related to tumour progression and these are almost always N+ve patients as expected. We did have an unusual series of early deaths unrelated to surgery - e.g. one patient had psychological issues and starved himself to death - but I am not sure if they definitely occurred in this period.

Outlier 2015 Annual Report
There is a degree of agreement between my data and theirs, but data is from different sources. Our acute rate is 
lower than national average Our data is in line with national average
90 Day Mortality NHS Trusts
Comment
Outlier 2016 Annual Report
Blackpool Teaching Hospitals NHS Foundation Trust 
Thank you for letting us know of the potential outlier on outcome measure for the year April 2015- March 2016, and also provided with the details of the eight deceased patients used in your calculation. We have carried out the detailed reviews of the cases notes of the deceased. We noted that two patients should never have been in your database for analysis as one patient had never had primary removal of bowel cancer due to frozen pelvis, and the other patient was carried out as an acute emergency for bowel obstruction and hence would have been excluded from your study. The analyses of the remaining review of cases noted that there were 4 postoperative deaths secondary to one anastomotic leak, one ischaemic left colon in arterio-pathic patient and 2 patients have cardiac related deaths (myocardial infarction and acute cardiac failure). Another case was due to development of pulmonary embolism in the community 35 days after primary surgery. These cases all have corner's post mortem. The final case was unrelated to surgery as patient developed community acquired pneumonia, and passed away at day 87 in hospital following admission under medical team. (Detailed review notes of the patients were attached herewith as word document for your ready reference including 
patients' comorbidity and ASA status). Therefore, mortality in out trust in this period following immediate surgery were due to development of recognised complications following surgery (with a case of mortality unrelated to surgery). Going back to the crude mortality for the year April 2015- March 2016, by removing the two inappropriate patients from the data, our year crude mortality should be 6.2 % but by adjusting the complexity and premorbid state of the patients, the percentage should be even lower. Going further by looking into the crude mortality over a 3 year period and 5 year period, our outcome mortality respectively are 2.7 % (7/258) and 2.7 % (12/441) which were in line with the national mortality figure. There were years in our trust without any perioperative mortality. Hence we feel that the 2015-2016 morality figure is likely to be a one off. Nowadays, our trust has a protocol in place (serious un-towards incidence) for every elective/ scheduled mortality to see whether any lessons can be learned.
Outlier 2015 Annual Report
90 Day Mortality NHS Trusts
Comment
Outlier 2016 Annual Report
Outlier Communication
York Teaching Hospital NHS Foundation Trust - The York Hospital 
Thank you for your letter received on 1st August 2017 advising us that our risk-adjusted 90 day mortality for patients undergoing resection of their bowel cancer in the period 2015/16 was in excess of the national average figure which indicates we are a significant outlier. This is scheduled to be published in December 2017 National Bowel Cancer Audit Report. We are, of course, very concerned by the possibility that our colorectal cancer service in 2015/16 was under-performing. We have undertaken a notes and audit review of all patients in this cohort to understand why the Trust is a significant outlier.

## Methodology:

Following identification of all the patients in the cohort who had died we examined all our data. This identified a further death not included in your report but also a further 6 cancer resections not identified either.
A retrospective case note review was completed by two surgeons. This also used a specific mortality review proforma (aligned to the Trust Mortality Review process). These proforma are filled in 1 week after any in-patient death during our General Surgery Safety and Quality meeting held weekly to discuss if the death was avoidable/unavoidable with the aim of understanding possible failures and improvements that can be made. This also included CPEX data that was available for all of the elective patients. This was then reviewed by the Governance lead for the surgical department for the Trust.

## Outcomes: Data Quality

The review of these historic cases identified significant areas of data weaknesses the quality of our data submission to the audit platform. For example our TNM coding was poor. Among the errors there were 33 T4 cancers rather than the 27 on the NBCA database and 74 T3 cancers vs 68 on NBCA. There were at least 10 patients with metastases at the time of resection rather than 3. This would affect the adjusted mortality.
Clinical Reviews of the deaths
- 
Median Age of patients reviewed was 84 years; (60 - 89)
- 
7/9 patients died in the post-operative period and two were late deaths after readmission under the general medical team.
- 
All post-operative deaths were discussed with the coroner and the responsible surgeon asked for post-mortems in a different trust for transparency in the four patients requiring post-mortems.
- 
5/9 Patients had respiratory failure (2 were due to aspiration and sudden arrest, 1 from PE's in a patient with known PE's and a prophylactic IVC filter in, and 2 due to 
pneumonia)
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2/9 patients had MOF secondary to anastamotic leaks that were operated on. The other two were recorded as Biliary sepsis and Lewy Body Dementia.
- 
2 post-operative deaths were recorded as 'potentially avoidable' with 1 being an aspiration pneumonitis querying the early oral nutrition used in enhanced recovery as one of the other deaths was also due to aspiration and cardiac arrest in another patient undergoing enhanced recovery. The other potentially avoidable death was in a patient who developed cholangitis post-operatively from new onset CBD stone related obstruction - this queried whether earlier ITU care would have benefited the patient.
- 
Examining the two anastamotic leaks both had inconclusive CT scans which could potentially have delayed the decision to surgery.

## Actions

The review of the two 'potentially avoidable' deaths led to changes in our enhanced recovery oral nutrition protocol, and feedback has been given to the intensivists. The mortality reviews have not identified any issues in the way clinical care was delivered. We will share this learning within our wider surgical/anaesthetic/nursing team. We now have a concerted perioperative team approach where the anaesthetists and surgeons perform postoperative ward rounds to ensure that any deviation from planned progression is picked up early. We have already begun to input valid data on staging and will strengthen the collaboration of the clinicians and the Clinical audit and coding teams to assure the validation of HES data with NBOCA data to improve the accuracy of future data submissions. 
Outlier 2015 Annual Report
90 Day Mortality NHS Trusts
Comment
Outlier 2016 Annual Report
Summary and future plan:
York Teaching Hospital NHS Foundation Trust - The York Hospital 
The Trust is confident that its outlier status will resolve. Having examined our data to be submitted for the 2018 report covering admissions from 2016-2017 we are reassured to a degree that there was only 5 identifiable 90 day deaths out of 167 resections (unadjusted mortality 3.0%), of which only 2 were elective curative resections. However, it must be stressed that this data hasn't undergone its second round of validation before submission to NBOCAP for the 2016-2017 round. Having performed this "deep dive" we feel that overall the outlier status is likely to be due to a combination of random variation and data quality issues however we are not relying on this assumption. The latest report outcomes have been discussed internally and brought to the attention of the Governance team managing patient safety. As a Trust we consider that the MDT review and resulting actions put in place are an appropriate way to address the outlier issue and any potential shortfall in our colorectal cancer service.
Brighton and Sussex University Hospitals NHS Trust
Further to your communication highlighting Brighton and Sussex University Hospitals as a National outlier for the 90 Day mortality following large bowel cancer resections, we have carried out an investigation on the data submitted to the NBOCAP team. After interrogating the three data sets on colorectal surgery available to us, for the period of 1/04/2015 and 31/03/2016, we were able to amend the mortality outcomes as follows: The total number of patients undergoing elective surgery was obtained from the Somerset database. This includes all patients diagnosed with colorectal cancer, irrespective of the treatment they received. The numbers undergoing elective and emergency surgery ware carefully validated against the departmental colorectal database, and the CEPOD database. The total number of patients undergoing elective surgery was 128. The total number of patients who died, as recorded by NBOCAP was 11. of these, 5 had undergone elective surgery, 5 emergency surgery, and one was outside the 90 day period. Taking into consideration the above figures, the overall 90 day mortality for all patients undergoing elective colorectal surgery is 3.9% (5/128). It would seem therefore that the significant discrepancy in the outcomes was due to the fact that 6 of the 11 deaths on the data communicated to NBOCAP were recorded as elective surgery, whereas in fact five patients had undergone emergency surgery and one patient died outside the 90 day period. On behalf of the colorectal service we would like to take this opportunity to apologise for the errors in our data submission which led to the NBOCAP conclusions on our 90 day mortality outcomes. We are committed as an organisation and the directorate team to ensure that the future data submissions are accurate and robust. We will be pleased to submit further clarifications or details if required.
Outlier 2015 Annual Report
18 Month Stoma Rates Strategic Clinical Networks
Comment
Outlier 2016 Annual Report
NHS Trusts West Wales General and Prince Phillip MDT
Thank you for your letter of 1 August 2017. The Heath Board NBOCAP audit has found that the adjusted 18 month stoma rate for West Wales and Prince Philip Hospital multidisciplinary team (MDT) was 86% compared to the national average in England of 52%. Thank you for the clarification of the data subset, the CEU contacted Mr Mathias, Consultant General and Colorectal Surgeon. I understand from the CEU's response that the data was obtained entirely using the PEDW software and not CANISC, which as you are aware is the system used throughout NHS Wales to input data. Mr Mathias has engaged in detailed discussions with relevant clinicians and the Health Board Medical Director and the Health Board is currently conducting an audit across all sites of the Health Board in order to scrutinise the 18 month stoma rate. The findings of this will be shared with you as soon as possible. The data from West Wales and Prince Philip Hospital MDT shows that the stoma rate is around 56% for elective resections. The data set from CANISC and the figures from 
April 2013 to March 2016 are attached [below]. We will be in a position to share further information with you on completion of the Health Board wide audit.

## Rectal Cancer Stoma Rates - Elective Curative Resections

Data includes:
1.	 All patients undering curative resection of the sigmoid/rectosigmoid/rectal

2.	 Only elective 3.	 Operated at WWG - excluded exenterations (ABM)

Formula for determining overall stoma rate at 18months 

- 
Overall permanent stoma rate for undergoing resectional surgery for rectal cancers =

APER + AR-H*/ APER + AR + AR-H * includes AR not reversed
AR
(AR-Not Reversed)
2013-2014
32
4
16
7
55
49
2014-2015
13
3
4
15
32
69
2015-2016
18
2
6
11
35
54
TOTAL
63
9
26
33
122
56
Outlier 2015 Annual Report
AR+H
APER
TOTAL 
%
18 Month Stoma Rates Strategic Clinical Networks
Comment
Outlier 2016 Annual Report
NHS Trusts The Christie NHS Foundation Trust 
I asked our senior colorectal surgeons to review the recent data and comment on why Christie patients have a higher than usual rate for a permanent stoma. Mr Wilson has responded with the following: The 80% figure seems correct but as last year, our data continues to show a significantly higher proportion of both rectal and colon cancers treated are T4 than that seen nationally (in the rectal cohort, 18 of 83 patients have stage T4 (21.7%). In the colonic cohort, 10 of 20 patients have stage T4 (50%)). Overall in our cohort, the T4 tumours represent 28/103 (27.2%). In the last NBOCAP report the reported rate of T4 rectal cancers was 7%. Last year we had exactly the same conversation with NBOCAP
, indicating that we are a 
tertiary referral centre with one of the largest multi-visceral resection practices in the UK. These procedures by definition will lead to permanent stomas in the majority (often with an associated urostomy as well!) This was accepted and is printed at the end of the final report. A recent audit of our last 101 total pelvic clearances for rectal cancer (locally advanced 
primaries and recurrent tumours) demonstrated an overall R0 resection rate of 75.2%. In the primary rectal cancer group the R0 resection rate was 78.6% and in the recurrent rectal cancer group the R0 resection rate was 58.2%. This cohort had a 30 day mortality of <1%, a grade 4 complication rate of 9%, a grade 3 complication rate of 3% and a grade 2 complication rate of 45% (NCI scoring). The primary rectal cancer group have an overall median survival of 49 months (55 months in the R0 group) and a 3 year overall survival of 67% (71% in the R0 group). In 2015 and 2016 combined, the Colorectal team at The Christie performed 1003 intermediate, major and major complex operations, with four 30- day mortalities (0.4%) and a combined NCI grade 3/grade 4 complication rate of 10.1%. This data should convince NBOCAP that our practice has complication rates and outcomes comparable with the best internationally published series (references 1 and 2).

1.	 Simillis C, Baird DL, Kontovounisios C, Pawa N, Brown G, Rasheed S, Tekkis PP
. 
A Systematic Review to Assess Resection Margin Status After Abdominoperineal Excision and Pelvic Exenteration for Rectal Cancer. Ann Surg. 2017 Feb;265(2):291- 299.
2.	 Quyn AJ, Austin KK, Young JM, Badgery-Parker T, Masya LM, Roberts R, Solomon MJ. 
Outcomes of pelvic exenteration for locally advanced primary rectal cancer: Overall survival and quality of life. Eur J Surg Oncol. 2016 Jun;42(6):823-8.

This time the report mentions that delays in stoma reversal may, in some centres, reflect a delay for adjuvant chemotherapy to be concluded but unfortunately does not recognise that it may also be a reflection of patient case mix, particularly when late stage and or recurrent and hence referred to a team who undertake more complex procedures. You kindly included this in the final report following our letter to you last year. As this will apply to our case mix, and therefore to audit results in the foreseeable future, we would appreciate some inclusion in the discussion that this is the reason among the patients receiving surgery in this tertiary cancer centre.
East Kent Hospitals University NHS 
Foundation Trust 
Thank you for your letter highlighting that the National Bowel Cancer Audit has found that East Kent Hospital University Foundation Trust has a significantly higher than expected rate of 18 month stoma rates after major resection. Discussion with surgeons and indeed results from the 2 previous year's audits suggest that the data are correct and are not due to random variation or data definitions and quality. There may be some differences in patient case-mix and that is being examined together with a search for other potential contributing factors. I would like to correct what I believe may be a typographical error in your letter of the 1st August because the letter goes on to say that "A local audit of these cases with a decision as to whether the deaths were expected/unexpected and avoidable/unavoidable might be appropriate. We have also been requested to share this information with the CQC as part of the new approach to proactively share all outlier data with our regulators.". Whilst East Kent Hospital University Foundation Trust may be an outlier in terms of higher than expected 18 month stoma rate I believe if anything, especially at the Margate site, our mortality is significantly less, as doubtless you will have seen from the data such as the National Emergency Laparotomy audit. I have requested our 2 colorectal surgical departments in Ashford and Margate to examine this higher 18 month stoma rate in detail in order to better understand the reasons behind this and this is work that will be completed in time for our first GIRFT General Surgery visit later this year.
Outlier 2015 Annual Report
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18 Month Stoma Rates Strategic Clinical Networks
Comment
Outlier 2016 Annual Report
NHS Trusts Nevill Hall Hospital MDT
We have looked at our data from CANISC that was submitted during the years audited and find that this is at variance with the outcome data provided by NBOCAP: When we analysed our data manually it showed that our crude and unadjusted per cent stoma rate for ALL Major cancer resections was exactly 50% and the stoma rate for ALL rectal cancers was also 50%. For the eighteen months between 1st October 2015 to the 31st March 2017, we had 98 major cases and 49 had no stomas whilst 49 had stomas = 50%. For rectal cancers, we would also like to point out that when it comes to decision making regarding whether to proceed with either a low anterior resection or an APER, such decision making always involves two Consultant Colorectal surgeons. Furthermore we would like to add that quality of life and patient choice are also taken into account in this decision making process and we are to understand that these parameters are not used in the data adjustment. There is therefore a discrepancy between our crude data and the adjusted outcome data and we cannot understand how the percentage figure goes up after adjustment instead of down. In the past we had problems with data transfer between the data we input into 
CANISC (which we validate every six months) and Cancer Services, with the main issue being in coding. At the meeting we had in December 2016 between the ACPGBI, NBOCAP and the Welsh MDT leads regarding the Welsh audit data, it was pointed out that there were problems with CANISC and with the interaction between PEDW and HES; indeed in the NBOCAP report (version 2) for 2016 it specifically states that there was no PEDW data for all Welsh MDT's for stomas following 'major rectal cancer surgery'. This could have been a factor in the audit but then it would have affected all the Welsh MDT's equally. We will continue to audit our data locally and ensure proper validation and would be grateful if you would include this statement in the publication of the Audit in December 2017.
Lancashire Teaching Hospitals NHS Foundation Trust 
Review of Outlier Status with Regard to 18 month stoma Rate in Rectal Surgery in 2017 NBOCAP Audit 
In this year's NBOCAP audit 90 patients have been identified as having had a stoma created as a result of a resection of a rectal carcinoma at Lancashire Teaching Hospitals NHS Foundation Trust. of these 64 were identified as still having a stoma 18 months after their cancer resection. As colorectal MDT lead for the trust I have reviewed the records of these patients with the regard to the reasons for stoma non-closure. The data provided by NBOCAP was generally accurate with 3 exceptions. One patient identified as a stoma non-closure had their loop ileostomy closed in the private sector within 18 months. One of the patients had a stoma formed in an emergency procedure to defunction a perforated advanced rectal cancer without a resection and hence lies out with the remit of this audit. Conversely one patient not identified as a non-closure had undergone AP resection with a permanent stoma. There were therefore 63 patients who had not had a stoma closure within the remit of the audit# of these 32 patients had undergone Abdomino-Perineal Resection (APR). APR is a major operation resulting in an irreversible stoma and should be regarded as a last resort where there is no oncologically sound and clinically sensible alternative. In this trust we strive to 
avoid APR where alternatives are available and have extensively pursued both local resection by TEM and rectal conservation with surveillance after complete response to radiotherapy. I have reviewed the records of the patients undergoing APR and am satisfied that in all cases, after consideration of the proximity of the tumour to the anus and the tumour staging, no reasonable alternative was available. Since the denominator in this audit does not include rectal cancers managed without a stoma, this figure does not represent the AP resection rate for the unit. In a further 6 patients a low Hartmann's procedure with permanent end colostomy was performed. Three of these cases were performed as palliative resections with a high risk of pelvic recurrence where an anastomosis was deemed ontologically inappropriate. In a 2 cases the patients had extensive co-morbidity and anastomosis was deemed unacceptably hazardous. In one case very dense post radiation fibrosis was found intraoperatively preventing formation of an anastomosis. This therefore leaves 25 cases where an anterior resection with a planned temporary defunctioning stoma was performed but the stoma was not closed within 18 months In 15 of these patients there as a subsequent decision not to close the stoma. In 3 of these cases patients had progressive metastatic disease requiring ongoing chemotherapy and in one there was a local tumour recurrence. In 4 cases it was agreed that the anaesthetic risk for further surgery was high due to comorbidity and patients decided against stoma closure. Two further patients opted not to have their stoma closured due to concerns about further surgery or post-operative function. In 4 cases stoma closer was prevented by an anastomotic leak. In one case the patient died in the post-operative period before stoma closure. In 10 cases the stoma was subsequently closed beyond 18 months. In three of these cases closure was delayed due to the presence of a small radiological leak on contrast enema but closure took place successfully shortly after 18 months. In three cases patients requested a delay before going ahead with stoma closure. In the remaining 4 cases a combination of prolonged chemotherapy and subsequent waiting list pressures led to closure shortly after the 18 months target.
Outlier 2015 Annual Report
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18 Month Stoma Rates Strategic Clinical Networks
Comment
Outlier 2016 Annual Report
NHS Trusts Leeds Teaching Hospitals NHS Trust
Thank you for the opportunity to scrutinise our data prior to publication of the NBOCAP audit. We are aware of our previous outlier status for 18 months stoma rates from a previous audit period and have analysed the reasons for that. We undertook a careful review of the new dataset you provided that has not been published before (Rectal cancers from April 2014-March 2015). The national analysis has calculated an adjusted stoma rate of 64% and an unadjusted rate of 67%. Our analysis undertaken by Mr Richard Baker - Clinical lead for colorectal surgery looked at 61 cases. of these 16 underwent an APER (26%), we are satisfied that these were appropriate; 15 tumours were within 2cm of the dentate line on histology and one was at 4cm. 5 of the cases were exenterations or recurrent cancers and a further 8 were tertiary referrals 
from other hospitals because of different complicating factors. All of these had a stoma. If these 13 tertiary referral cases are excluded from the analysis our 18 months stoma rate is 57%. The leak rate was 5% (n= 3) preventing reversal in 2 patients and delaying it in one (reversed at 26 months). We are conscious of a higher rate of Hartmann's procedures in this series compared to the published data from the 2016 NBOCAP audit (8% nationally versus 21%). Retrospectively, the decisions to do a Hartmann's either before surgery (due to co - morbidity, n=11) or intraoperatively (due to complicating factors, n=2) seem reasonable. This is something we will continue to monitor and try to improve.
Outlier 2015 Annual Report
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