ESGO Quality Indicators for Surgical Management of Cervical Cancer: An Audit of Compliance of a Tertiary Care Center

Abstract

Monica Thiagarajan

Objective This article assesses the compliance of surgical management of carcinoma cervix, to the quality indicators for treatment put forth by the European Society of Gynaeacological Oncology (ESGO), at a tertiary care center.

Methods This is a retrospective analysis and audit of data collected from electronic medical records of patients with carcinoma cervix who underwent surgical management in the department of gynecologic oncology from June 1, 2017 to May 31, 2020.

Results Compliance to all 15 quality indicators under 5 categories was assessed. The first two structural indicators were met. The mean number of parametrectomies was 24 and all were operated by a specialist. With regard to targets addressing overall management, only 46% cases were preoperatively planned in multidisciplinary team meetings and 74% met the target of required preop investigations. There was deficiency in recording pertinent intraoperative details and postoperative pathological information. On assessing the quality of surgical care, there were no postoperative urological fistula, but 18% had involved surgical margins, 16% were upstaged postsurgery, and 15% had recurrence within 2 years. All were counseled about fertility-sparing technique when relevant but only 7% had undergone lymph node staging as per recommendations and 51% had received adjuvant chemoradiation.

Conclusion This audit revealed that the department did not meet the ESGO quality standards published in 2020. The department has implemented structural and procedural changes to meet these standards and a plan to continuously assess compliance to the same.

 

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Keywords

cervical cancer - clinical audits - compliance - quality measures - radical hysterectomy

Introduction

Cervical cancer is the fourth most common malignancy globally and is characterized by geographic variation in incidence and mortality rates, secondary to inequalities in vaccination and screening rates and availability of health care services.[1] In India, there were 123,907 new cases and 77,348 deaths in 2020 which contributed to 1/5th of the global burden of new cases and deaths.[2] Surgery is the primary mode of management for early International Federation of Gynecology and Obstetrics (FIGO) 2018 stage IA1, IA2, IB1, 1B2, and select IB3 and IIA1 disease.[3] The 5-year survival rate for stage I disease is as high as 92%. Favorable survival rates in early-stage operable disease is an outcome measure of tailored, quality radical surgery.[4]

The quality of oncologic surgery impacts oncologic outcome of cancer survivors. The European Society of Gynaecologic Oncology (ESGO) has developed a set of 15 quality indicators which have been categorized as structural, process, and outcome indicators with measurability and target specifications.[5] It has been suggested that the indicators be used as a reference guideline for self-assessment, to develop quality assurance programs based on preset standard of care in the surgical management of carcinoma cervix.

Periodic clinical audit using predefined, realistic standard quality measures is a quality improvement exercise to improve patient outcomes; if identified deficiencies are addressed. The objective of this audit was to assess the compliance of an ESGO-accredited gynecologic oncology center in India, to the ESGO quality indicators for surgical management of carcinoma cervix.

 

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Materials and Methods

Electronic medical records of 82 patients with operable carcinoma cervix who underwent surgical management in the department of gynecologic oncology in a tertiary care center in South India, during the period June 1, 2017 to May 31, 2020 were retrieved and retrospectively analyzed to assess compliance to the ESGO quality indicators.

ESGO quality indicators: ESGO has put forth 15 indicators under 5 categories. The first set of quality indicators (QI, 1–2) is related to surgical volume and training. The second set (QI, 3–5) of indicators pertains to overall management which includes the number of ongoing clinical trials at the mentioned center, pretreatment discussion at multidisciplinary meetings, and adequacy of preoperative evaluation. The third set of quality indicators (QI, 6–8) concerns relevant and structural reporting of surgical and pathological information and postoperative complications. The fourth set of indicators (QI, 9–12) addresses surgical quality in terms of postoperative urological fistula rate, tumor-free margin status, postoperative stage shift of T1b disease, and 2-year recurrence rates of surgically managed pT1b1N0 disease. The final set (13–15) of indicators refers to conformance to standards of care concerning intraoperative lymph nodal assessment, counseling for fertility-sparing treatment when relevant, and postoperative adjuvant radiation rate.

Inclusion Criteria

Patients with invasive carcinoma cervix with FIGO 2009 clinical stages IIA1 or less who underwent primary surgical management during the study period were included.

 

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Statistical Analysis

The data were analyzed using IBM SPSS Statistics for Windows, version 22 (IBM Corp., Armonk, New York, United States). Continuous variables are presented as mean or median and categorical variables are presented as percentages.

 

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Results

Compliance to Indicators Related to Surgical Volume and Training (QI, 1–2)

Over the 3 years, 82 patients underwent primary surgical management for carcinoma cervix, with a mean number of 24 (range: 21–29) parametrectomies performed per year. This met the minimum target but was short of the optimal target of 30. During this period, 122 patients with cervical cancer underwent surgeries for diagnostic indications such as examination under anesthesia and therapeutic indications ([Table 1]) which included radical hysterectomy following neoadjuvant chemotherapy, exenteration, besides palliative surgeries. All patients were operated either by a certified gynecologic oncologist or a trainee being supervised by a certified gynecologic oncologist, achieving the prerequisite target.

Table 1 Surgical procedures performed (n = 122)

Surgery performed	Number (n = 122)
Primary surgery for carcinoma cervix	82
Pelvic exenteration for recurrent carcinoma cervix	5
Post-NACT radical hysterectomy	4
Post-RT hysterectomy for residual disease	4
Cone biopsy	11
Examination under anesthesia ± biopsy	3
Pyometra drainage	3
Palliative procedures for recurrence (ileostomy, pyometra washout, biopsy for recurrence detection)	9
Resuturing for wound dehiscence following primary surgery	1

Abbreviations: NACT, neoadjuvant chemotherapy; RT, radiation therapy.

 

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Compliance to Indicators Related to Overall Management (QI, 3–5)

The center was involved in four clinical trials during the study period. However, as against the prerequisite mandatory preop discussion of every patient at multidisciplinary team (MDT) meetings, only 46% of our patients were discussed ([Table 2]). Preoperative investigations before surgery according to the ESGO-the European Society for Radiotherapy and Oncology-the European Society of Pathology (ESGO-ESTRO-ESP) guidelines include pelvic examination, preoperative biopsy, magnetic resonance imaging (MRI), and extended investigations in case of suspicious nodal involvement.[6] Though 74% patients had undergone all the essential investigations, the target of 100% was not met.

Table 2 ESGO quality indicators

Quality indicators	Target	Achieved
No of radical procedures done per year	15	24
Surgeries performed or supervised by gynecologic oncologist	100%	100%
No. of clinical trials being conducted	> 1	4
Treatment discussed at MDT	100%	46% (37/82)
Complete preoperative workup	100%	74% (61/82)
Optimal surgical report	100%	7% (6/82)
Optimal pathological report	≥ 90%	49% (40/82)
Structured reporting of postoperative morbidity	≥ 90%	78% (64/82)
Urological fistula rate within 30 postoperative days	≤ 3%	0
Clear surgical margins	≥ 97%	82% (67/82)
T-upstaged T1b disease	< 10%	16% (9/55)
Recurrence of T1b1 disease	< 10%	15% (6/39)
Standard lymph node staging	≥ 98%	7% (6/82)
Fertility sparing treatment	100%	100%
Received adjuvant treatment	< 15%	51% (20/39)

Abbreviations: ESGO, European Society of Gynaeacological Oncology; MDT, multidisciplinary team.

 

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Compliance to Indicators Related to Surgical, Pathological, and Postoperative Complication Reporting (QI, 6–8)

The next set of indicators was related to recording pertinent information. The ESGO-ESTRO-ESP have set recommendations to record key elements in surgical and pathological reports and structured recording of postoperative complications. Only 7% of patient's surgical reports ([Table 3]) and 49% of the pathological reports met the ESGO standards ([Table 4]). As per the specifications, 78% had structured reporting of complications.

Table 3 Components of complete surgical report (n = 82)

Components of complete surgical report	Achieved
Surgical approach	100% (82)
Type of LN staging	100% (82)
Technique of sentinel lymph node detection	Not applicable
Localization of sentinel lymph node	Not applicable
Level of pelvic lymphadenectomy	98% (81/82)
Type of parametrial resection	11% (9/82)
Type of adnexal procedure	95% (78/82)
Duration of surgery	84% (69/82)
Blood loss	92% (75/82)
Intraop complication - type/grade/management	94% (77/82)

Abbreviation: LN, lymph node.

Table 4 Components of complete pathologic report (n = 82)

Components of complete pathologic report	Achieved
Description of the specimen	100% (82)
Macroscopic description of specimen	100% (82)
Macroscopic tumor site	85% (70/82)
Tumor dimensions	79% (65/82)
Histological tumor type and grade	97% (80/82)
Lymphovascular space involvement	96% (79/82)
Coexisting pathology	100% (82)
Distance of uninvolved cervical stroma	100% (82)
Margin status	83% (68/82)
Lymph node (LN) status, including sentinel lymph node	100% (82)
Pathologically confirmed distant metastases	99% (81/82)
Provisional pathological staging	83% (68/82)
The results of any frozen section specimen evaluation	100% (82)

 

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Compliance to Indicators Related to Quality of Surgical Procedures (QI, 9–12)

Regarding indicators addressing quality of surgical procedures, there were no urological fistulas during this period. As against the desired target of ≥ 97% who have disease-free vaginal and parametrial margins postoperatively, 67/82 (82%) had clear margins, 5 patients had involvement of margin by invasive malignancy, and there was no comment about margin status in 10 patients. Proportion of patients with stage T1b disease who were upstaged based on tumor extent after surgery was 16%, as against the target of 10%. Recurrence rate at 2 years in patients with stage TIb1 disease without nodal involvement was 15% (6/39) in contrast to the advised target of < 10%. Four of the six recurrences were treated with radiation, one received palliative chemotherapy, and one opted for no treatment.

 

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Compliance to Indicators Related to Standard of Care (QI, 13–15)

The final three indicators assess the compliance of management with standard of surgical care. Only 7% of our patients had undergone lymph node staging according to the ESGO-ESTRO-ESP guidelines as against the needed target of ≥ 98%. All eligible patients for fertility-sparing surgery were counseled. Approximately 50% of patients with pT1b1N0 disease received adjuvant radiation (target: < 15%) ([Table 4]).

 

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Discussion

In India, cervical cancer contributed to 9.4% of the total cancer patients in 2020 and is one of the leading causes of cancer-related deaths in the country.[7] This is typical in the absence of an organized screening and vaccination program.

Gynecologic oncology subspeciality training began a few decades later in India compared with the west. Our department began as a unit of gynecology, specializing in the treatment of gynecologic cancer in 2011, which later transitioned into a department of gynecologic oncology in 2016 in a tertiary referral center in southern India. Around 150 cases of cervical cancer per year are seen in the outpatient department and around 500 patients were seen over during this study period, of whom 82 underwent surgery for early disease. Subspeciality training has been shown to be effective to impact treatment decisions and improve survival outcomes of women with ovarian, endometrial, and cervical cancer.[8] [9] [10] This audit was performed to assess our compliance to set standards as an exercise for self-improvement. A total of 5 out of 15 quality indicators were met by the center ([Fig. 1]).

Fig. 1 Compliance to European Society of Gynaeacological Oncology (ESGO) quality indicators.

Compliance to Indicators Related to Surgical Volume and Training (QI, 1–2)

Most patients present with advanced disease to our department in a tertiary referral center, due to lack of organized, national screening programs and hence the optimum target of ≥ 30 was not met. Data from other regional referral centers in India report only 11.4% present with early, operable carcinoma cervix.[4] As an academic training center, we fulfilled the minimum criteria regarding case volume, training, and research activities. All cases were performed or supervised by trained gynecologic oncologists.

 

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Compliance to Indicators Related to Overall Management (QI, 3–5)

Cervical cancer case burden and mortality afflicts the low- and middle-income countries and with this consideration, the revised staging by FIGO does not mandate but encourages preoperative usage of MRI,[11] due to its inherent soft tissue resolution and multiplanar capability. However, despite cost constraints, there has been greater usage of MRI over the years by the department,[12] in preoperative evaluation . However, patients with clinical impression of stage IA1, post-cone, and those with severe financial limitation did not undergo a preoperative MRI in this study. Preoperative MDT discussion with the involvement of multiple concerned specialities allows comprehensive discussion and implementation of best, individualized therapeutic strategy along with adherence to clinical guidelines. During this period, only 46% of the patients were preoperatively discussed in MDT and after the results of the audit, preoperative MDT discussion has been made mandatory in the department.

 

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Compliance to Indicators Related Surgical, Pathological, and Postoperative Complication Reporting (QI, 6–8)

Structured operative reports allow clear, scientific documentation of operative procedures which capture and allow easy interpretation of discrete data elements. Similarly, synoptic pathological reports allow concise recording of essential parameters, compliance with standardized diagnostic criteria and terminology, and permit easy storage and retrieval of information. Surgical and pathological reports are key components of patient risk stratification and treatment plan decision. ESGO has laid requirements for key elements to be incorporated in surgical and pathological reports.[6] In the absence of a reporting template, both surgical and pathological reports were deficient. Assessment of the existing surgical reports revealed deficiency in recording the type of parametrectomy ([Table 1]). Pathological reports were deficient in reporting tumor dimension, tumor location, margin status, and provisional pathological staging ([Table 3]). Similarly, in the absence of any followed classification system of documenting complications, complications were described in the electronic records of these patients but were not graded.

 

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Compliance to Indicators Related to Quality of Surgical Procedures (QI, 9–12)

The indicators describing the quality of surgical procedures were not achieved. The use of MRI and multidisciplinary discussion help in proper patient selection, achieving clear vaginal and parametrial margin status, and thereby decreasing the chance of postoperative upstaging of tumors and morbidity associated with dual-modality treatment. Clear surgical margins are an obligate requirement for optimal oncological outcome. In our audit, 16% were upstaged following surgery.

The practice of intraoperative frozen section of pelvic lymph nodes and sentinel lymph node assessment is not followed in our center and hence the target regarding lymph node staging was not met.

 

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Compliance to Indicators Related to Standard of Care (QI, 13–15)

Twenty of 39 patients (51%) with pT1bN0 received adjuvant therapy. The overall adjuvant treatment rate was 37.8% (31/82). Four patients among the 11 with high-risk factors received adjuvant treatment for nodal involvement while 7 had vaginal or parametrial involvement.

This high adjuvant rate among pT1bN0 is primarily due to selection of larger tumors and subsequent postoperative radiation for intermediate risk factors. This audit's revelation of high adjuvant radiation and high recurrence rate despite high adjuvant treatment rate has been of concern. Efforts have been made to evaluate the cause and rectify the increased rate of adjuvant treatment.

 

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Results in the Context of Published Literature

Much progress has been made in cancer surgery secondary to subspecialization with a focus on site-specific surgeon education and training in appropriate decision making. Quality of cancer surgery and care is paramount to patient outcome and this has been studied and highlighted since the start of the century.[13] The quality of surgery done has a role in local control and survival. The aim of the surgery should be to remove the tumor completely, with tumor-free margins which prevent local recurrence.

Surgical management of early cervical cancer with tumor-free margins has been associated with more than 90% disease-free survival.[14] To achieve the desired surgical outcome, there should be a feedback system based on evidence-based standards by which the performance of a surgical team is continually assessed. Clinical audits and quality improvement projects with set clinical standards help identify deficiencies and help improve patient care. To measure quality of surgery and cancer care, professional bodies have proposed quality indicators which need to be examined, validated, and incorporated into quality assurance programs.

Measurement of quality indicators gives quick objective insight into the efficiency of an institution. Before the implementation of quality indicators into a quality improvement program, their measurability, reliability, and their potential for use need to be ascertained. Though several indicators have been put forth over the last two decades, their efficiency in improving quality needs to be validated. The quality indicators put forth by ESGO in 2020, focus on surgical management and have the advantage of being put forth by an apex body. It helps to objectively measure the quality of surgical care with realistic quality goals.

Since its introduction, ESGO quality indicators have been used for various purposes. Ponce et al used six outcome indicators to report oncologic and surgical outcomes following robotic radical hysterectomy in multiple centers in the Iberian Peninsula. Five out of the six outcome indicators were met with the exception of high adjuvant treatment rate (28%).[15]

The SUCCOR study reported a difference in oncologic outcomes following a retrospective analysis of patients operated by open and minimally invasive approach across various European centers.[16] A follow-up publication showed compliance to the ESGO quality indicator impacted oncologic outcome impact.[17]

A high-volume center in China reported compliance with the ESGO quality indicators. They had retrospectively assessed 5,952 patients who underwent surgery. The center had met most targets but identified targets which required improved compliance, namely, mandatory pretreatment discussion at multidisciplinary meetings, prerequisite preoperative workup (19.7% patients had incomplete workup), postoperative upstaging rate of T1b (14.7%), and an increased adjuvant rate which was 28.3%.[18] There have been no other reports from centers from developing countries which have reported compliance with the ESGO quality indicators.

Our center, situated in southern India, is culturally and socially different from established European centers. This audit has revealed deficiencies which need corrective practices to be implemented. Greater adoption of preoperative advanced imaging, mandatory preoperative MDT discussion, and structured surgical, postoperative complication, and pathological reporting have been introduced. There is a need for uptake of these quality indicators into a quality assurance program in all developing oncologic centers, to ensure uniformity in surgical practices which in turn will result in the desired oncologic outcome. Despite the need to measure up to quality indicators, these quality indicators need to be tailored for non-European lower middle-income countries where routine preoperative MRI scans, sentinel lymph node mapping, and intraoperative frozen section may not be possible.

 

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Strengths and Limitations of the Study

The strength of this study is that this is from a young gynecologic oncology department from a single institution, located in a developing country, which desires to improve patient care by critically analyzing itself. From the outcome of this study, it plans to reaudit itself after implementation of corrective measures. The limitations of this study is that during this retrospective audit, specific procedures considered essential for meeting the quality standards, such as sentinel node dissection, were not implemented during the study period and might be implemented only in research settings in the institution.

 

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Implications for Practice and Future Research

We have modified our surgical, pathological, and postoperative morbidity reporting according to the guidelines. We plan to analyze our compliance after implementing the above changes in clinical practice. While we need to be at par with western standards, we also need to develop culture-sensitive quality indicators as sentinel lymph node mapping in cervical cancer might not applicable in countries like India until they become part of a mandatory guideline.

 

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Conclusion

The department did not meet the published ESGO quality standards. Understanding that improvement in clinical and surgical practices improves patient outcomes, quality assurance programs should replace clinical audits to address deficits in clinical and surgical practices. The department endeavors to rectify the deficiencies revealed by the audit.

 

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Conflict of Interest

None declared.

Ethical Approval

This study was approved by the institutional study board (IRB Min No: 12591). Given the retrospective nature of the study, patient consent was waived.

Authors' Contributions

M.T. and V.T. conceived the study design. M.T., V.T., A.S., D.S.T., A.T., R.C., and A.P. were involved in data collection, analysis, interpretation, and conclusion. M.T. and V.T. prepared the manuscript which was reviewed and approved by all the coauthors. All authors have agreed to be responsible for the published research.

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Publication History

Received: 25 September 2023

Accepted: 02 July 2024

Article published online:
22 July 2024