Northern Ireland Pancreatic Cancer audit: measuring the quality of care for patients diagnosed 2019-2020

Executive Summary and Key RecommendationsThis Pancreatic Cancer Audit assesses the diagnosis, treatment, care and support of patients diagnosed with pancreatic cancer in Northern Ireland by comparing with previous audits and national and professional guidelines and identifying where improvements can be made. 540 patients diagnosed during 2019-2020 were investigated, including patients with malignant neuroendocrine tumours (NET) and adenocarcinomas. Where appropriate patients with malignantNETs were excluded from analysis as these are rare malignancies with very different treatment pathways and survival outcomes.Key findings:• 86% rise in confirmed pancreatic cancer cases between 2001 and 2020 (152 in 2001 and 283 in 2020).• The majority of patients (94%) were symptomatic at diagnosis.• The most common route to diagnosis was via emergency admission. Patients diagnosed electively were more likely to have localised stage I-III disease.• The majority of pancreatic cancer patients present with distant stage IV disease. Diagnosing pancreatic cancer at an earlier stage has a major impact on prognosis, with 1 year survival of 52% for stage I compared to only 6% for stage IV patients.• Almost all patients (99%) were discussed at MDT before starting treatment.• A quarter of patients had suspected liver metastasis at diagnosis.• 4 out of 5 patients had a palliative treatment plan. This varied by histological type - the majority of adenocarcinoma NOS patients were treated with palliative intent (83%) while the majority with a malignant neuroendocrine tumour (NETs) were treated with curative intent (56%).• Curative patients receiving neoadjuvant treatment and surgery had the longest median wait time from referral to treatment of 72-79 days.• Before the COVID-19 pandemic, pancreatic surgery was centralised at a single site at MIH, Belfast. After onset of the pandemic in 2020 surgery was spread across three BHSCT sites, namely MIH, RVH and BCH.• Median inpatient stay was 11 days. Patients without post-op complications had a median stay of 10 days while those with post operative complications had a median stay of 15 days.• 36% of curative patients who underwent neoadjuvant treatment have their planned surgery after three cycles.• An average of 87 patients received oncology treatment in 2019 and 2020, withapproximately an additional 45 patients being referred to oncology each year but not receiving treatment.• The two main categories of referral for palliative patients were to specialist Hospital and Community Palliative Care Teams (PCTs) (66%) and District Nursing (62.4%)- District nurses perform a large volume of community palliative care work. Approximately 1/5 of patients were referred to social services.• Enrolment in clinical trials was low at 0.9%.Key Recommendations:• Pancreatic cancer services should be appropriately funded to manage increasing patient numbers.• Primary prevention and health promotion campaigns, including reducing obesity, smoking and increasing physical activity, should be continued and developed.• Early diagnosis is key. Health agencies and wider stakeholders (e.g. PHA, DOH) to increase awareness of pancreatic cancer symptoms among the public and GPs to improve earlier diagnosis.• Use of a measure such as the Clinical Frailty Score may support more equitable treatment access across age groups.• HPB team to work with radiology and gastroenterology to ensure more timely access to PET-CT and EUS, which. will aid quicker referral to 1st treatment and help achieve 62-day targets.• HPB and radiology teams to ensure timely access to MRI and laparoscopy for patients with suspected liver metastasis as per NICE Guidance.• Clinicians to assess the impact of prehabilitation on post-surgical outcomes and inpatient stay.• HPB clinical cancer team to facilitate and encourage better access to clinical trials for pancreatic cancer patients.• Personalised and holistic care should be provided and supported for all pancreatic cancer patients