National Oesophago-Gastric Cancer Audit Research Articles

Diagnosis and treatment for gastro-oesophageal cancer in England and Wales: analysis of the National Oesophago-Gastric Cancer Audit (NOGCA) database 2012-2020.

The National Oesophago-Gastric Cancer Audit (NOGCA) captures patient data from diagnosis to end of primary treatment for all patients with oesophagogastric (OG) cancer in England and Wales. This study assessed changes in patient characteristics, treatments received, and outcomes for OG cancer surgery for the period 2012-2020, and examined which factors may have led to changes in clinical outcomes over this time. Patients diagnosed with OG cancer between April 2012 and March 2020 were included. Descriptive statistics were used to summarize patient demographics, disease site, type, and stage, patterns of care, and outcomes over time. The treatment variables of unit case volume, surgical approach, and neoadjuvant therapy were included. Regression models were used to examine associations between surgical outcomes (duration of stay and mortality), and patient and treatment variables. In total, 83 393 patients diagnosed with OG cancer during the study period were included. Patient demographics and cancer stage at diagnosis showed little change over time. Altogether, 17 650 patients underwent surgery as part of radical treatment. These patients had increasingly more advanced cancers, and a greater likelihood of pre-existing comorbidity in more recent years. Significant decreases in mortality rates and duration of stay were noted, along with improvements in oncological outcomes (nodal yields and margin positivity rates). Following adjustment for patient and treatment variables, increasing audit year and trust volume were associated, respectively, with improved postoperative outcomes: lower 30-day mortality (odds ratio (OR) 0.93 (95 per cent c.i. 0.88 to 0.98) and OR 0.99 (95 per cent c.i. 0.99-0.99)) and lower 90-day mortality (OR 0.94 (95 per cent c.i. 0.91 to 0.98) and OR 0.99 (95 per cent c.i. 0.99-0.99)), and a reduction in duration of postoperative stay (incidence rate ratio (IRR) 0.98 (95 per cent c.i. 0.97 to 0.98) and IRR 0.99 (95 per cent c.i. 0.99 to 0.99)). Outcomes of OG cancer surgery have improved over time, despite little evidence of improvements in early diagnosis. The underlying drivers for improvements in outcome are multifactorial.

OGC P12 Maintaining high volume oesophagagogastric resections during the COVID-19 pandemic: a single centres experience utilising the independent sector

Abstract Background With many resources redirected to care for the those affected by the COVID-19 pandemic, the NHS faced unprecedented pressure to maintain oesophagogastric (OG) cancer resectional services. Our institution along with many tertiary units across the country were faced with limited access to essential critical care beds. The implementation of emergency contracts between the NHS and the independent sector (IS) allowed our unit to maintain a high volume resectional service by utilising the resources of a local private hospital with HDU/ ITU provision. We began operating within the IS shortly after the first UK lockdown in March 2020, and continued through till February 2022. During this period, we continued operating at our tertiary unit (TU) albeit at a reduced capacity. This study aimed to evaluate the surgical outcomes of patients undergoing major OG resectional surgery between the two sites. Methods This retrospective study included all patients who underwent major OG resectional surgery (including GIST) from March 2020-February 2022. Operation type and site were identified using OPCS-4 clinical codes and combined with National OG Cancer Audit (NOGCA) data to compare basic patient demographics, length of stay, complication rates, COVID infection rates and 90-day mortality. Descriptive and statistical analysis between the two operating sites was performed. Results A total of 204 major OG resections were undertaken, 44% (89) at our TU;57 oesophagectomies and 32 gastrectomies, with 56% (115) at a local IS hospital;86 oesophagectomies and 29 gastrectomies. Additionally, 13 (6.4%) open and close procedures were performed across both sites. Median patient age was similar, 69 (45–86) years at our TU v. 68 (38–85) years at the IS site. A higher proportion of ASA 3 patients (46%) were operated on at our TU. No difference in median length of stay was observed; TU= 8 (1–93) days v. IS =9 (3–69) days, this included all patients who were repatriated to the TU. Higher complication rates seemed to occur in patients operated at the IS site v. the TU though these did not reach statistical significance; 18 (15.7%) patients suffered an anastomotic leak v. 9 (10.1%) respectively (p= 0.246). 21 (18.3%) v. 13 (14.6%) patients suffered a major respiratory (p=0.487) and 4 (3.5%) v. 1 (1.1%) a major cardiac (p=0.281) complication. There were no cases of COVID infection within 30 days of primary procedure at the IS site, with 2 cases within the TU cohort. Our 90-day mortality rates were similar (IS= 4.54% v. TU=5.32%), p=0.661. Conclusions Our study demonstrates that resection of patients with OG cancer is feasible in an independent sector hospital if supported by critical care. It allowed a high-volume tertiary unit to continue offering potentially curative surgery to patients whose treatment options would have otherwise been limited to oncological therapy only. Long term survival data compared to non-resecting trusts is required to determine whether this approach was superior. When considering future pandemic planning, we have demonstrated the value of this model in maintaining major OG resectional services.

OGC P24 The effect of the pandemic on the number of examined lymph nodes following major oesophophagogastric resection

Abstract Background Lymph node yield following oesophagogastric (OG) cancer resection remains a valuable prognosticator of overall patient survival. It is also a quality indicator of histopathological assessment and a surrogate marker of surgical technique. The Royal College of Pathologists’ state a minimum lymph node yield of 15 per specimen should obtained in 100% of cases where a radical OG resection has been undertaken. It is well known that the COVID-19 pandemic placed immense strain on NHS services. This study aimed to evaluate its effect on lymph node yield reporting following major OG resection in a large volume tertiary unit. Methods Retrospective National OG Cancer Audit (NOGCA) metrics were collected. Histological data including total lymph node yield and positive node status were extracted from patient records. Patient data was categorised into two study periods; pre-pandemic (March 2018-Feb 2020) and pandemic (March 2020- Feb 2022) following the first UK national lockdown. Comparative analysis between the two study periods was performed and for lymph node yield >15 per specimen a X2 statistic calculated. Results In the pre COVID period a total of 280 (excluding GIST) resections were performed, 75% (210) oesophagectomies v. 25% (70) gastrectomies. The median age was 69 (range 25–90, males= 189 v. females =91). In the post pandemic period a total of 188 resections were performed, 72% (135) oesophagectomies v. 28% (53) gastrectomies. The median age was 69 (38–87, males = 142 v. female= 46). Lymph node yield was available for 275 resections in pre-pandemic study period, with a median nodal yield of 20 (5–61). In the pandemic study period lymph node yield data was available for 180 patients, median 19.5 (0–69). The minimum nodal yield (>15) was obtained in 80.7% of resection specimens pre-pandemic v. 68.9% in the pandemic study period (p= 0.00382). Conclusions Our study demonstrates a higher rate of inadequate nodes examined in the post pandemic study period. Despite staffing pressures, efforts should be made to improve number of nodes examined to provide robust prognostic data.

P-OGC15 Impact of postoperative systemic treatment on survival for oesophageal adenocarcinoma after preoperative chemotherapy and oesophagectomy

Abstract Background Perioperative chemotherapy is widely used in the treatment of oesophageal cancer with substantial survival benefit over surgery alone. However, the postoperative part of these regimens is given in less than half of cases, reflecting uncertainty about its benefit. This study estimates the effect of postoperative chemotherapy after surgery for oesophageal cancer using a large population-based dataset and modern statistical methods. Methods Patients with oesophageal adenocarcinoma diagnosed between 2012 and 2018 and underwent preoperative chemotherapy followed by surgery, were identified from a national level audit in England and Wales (National Oesophagogastric Cancer Audit). Postoperative therapy was defined as the receipt of at least one cycle of systemic chemotherapy within 90 days of surgery. The comparative effectiveness of postoperative chemotherapy compared to observation was estimated using inverse propensity treatment weighting (IPTW). Results The study included 2,814 patients, in whom postoperative therapy was given to 1,054 (37.5%). Patients who received postoperative therapy were younger, with a lower ASA grade and were less likely to have surgical complications of any type, including anastomotic leak (all p < 0.001). Tumour characteristics were similar in both groups. Weighted median survival times for patients having no treatment or postoperative chemotherapy were 45.4 months and 57.5 months respectively. There was a life expectancy difference at five years of 2.9 months in favour of postoperative chemotherapy (95%CI 1.1–4.8 months, p < 0.001) with a Hazard Ratio of 0.80 (95%CI 0.70-0.91, p < 0.001). Conclusions Among patients with oesophageal adenocarcinoma treated with preoperative chemotherapy and surgery, improved overall survival was observed in those patients who received postoperative chemotherapy. Minimising surgical complications and improving patient fitness could increase the use of postoperative chemotherapy, leading to better outcomes for patients with oesophageal adenocarcinoma.

P-OGC30 High volume oesophagogastric resection in a small private hospital during COVID 19, April 2020- April 2021

BackgroundLike other hospitals at the peak of the pandemic, our institution had limited elective critical care capacity. This study summarises the outcomes of patients undergoing oesophagogastric (OG) resection at our institution, treated as the result of the emergency national contract between the NHS and the independent sector hospitals.MethodsPatients undergoing OG resection at our institution between April 2020 and April 2021 were included. Patients were managed through the multidisciplinary team and were treated according to standard ERAS pathways, involving critical care input. National OG Cancer Audit (NOGCA) metrics were collected and compared to pre-COVID data. Results81 patients underwent oesophagogastric resection in the private sector (60 oesophagectomies). Median length of stay was 9 days (9 pre-COVID). This included 21 patients who were repatriated to our main centre for ongoing management. 30-day mortality was 3.7% (1.8% pre-COVID), 90-day mortality 6.7% (4.2% pre-COVID). This included one patient who contracted COVID following discharge. 9 patients suffered an anastomotic leak, equating to a leak rate of 11% (7% pre-COVID). 22 resections were performed at our main centre (110-140 OG resection pre-COVID)ConclusionsIt is likely the private institution in this study represented one of the busiest oesophagogastric centres in the UK during COVID-19. A large cohort of patients underwent potentially curative surgery as a result of the emergency contract, who would have otherwise been placed on prolonged or palliative chemotherapy. 30 and 90-day mortality and anastomotic leak rates were higher than pre-pandemic levels, reinforcing the value of centralised tertiary OG resection services.

321 RANDOM SURVIVAL FOREST FOR PERSONALISED PROGNOSTICATION AFTER ESOPHAGECTOMY

Abstract For patients with esophageal cancer, producing accurate prediction models for long-term survival after esophagectomy has proved challenging. We investigated whether Random Survival Forests (RSF), a machine learning method, could produce an accurate prognostic model for overall survival after esophagectomy. Methods The study used data from the 'National Oesophago-Gastric Cancer Audit' (NOGCA) and included patients diagnosed with esophageal adenocarcinoma or squamous cell carcinoma between 2012 and 2018 in England and Wales and who underwent a curative esophagectomy with adequate lymphadenectomy (15 lymph nodes) and survived to discharge (n = 6838). Missing data was handled using multiple imputation. 15 variables were selected for inclusion using Random Forest variable importance and used to train the final model. The same variables with non-linearity transformations were used to develop a traditional Cox regression model for comparison. Results Median survival was 50 months. The final RSF model had good discrimination on internal validation with a C-index of 0.7627 (0.7625–0.7629), exceeding the cox model 0.7539 (0.7541–0.7537). At 3 years post-surgery, overall survival was 56.2%. The RSF yielded a mean predicted survival of 59.3% (IQR 33.3–87.1%) with good calibration (Figure 1) compared to 57.4% (38.4%–79.8%) for the cox model. The most influential variables were lymph node involvement and pT/ypT stage, however other variables including neoadjuvant treatment completion and surgical complications were also important. Decision curve analysis was undertaken which also showed an increased net benefit with the RSF model. Conclusion A Random Forest survival model provided better performance in predicting survival after curative esophagectomy. This will allow more personalised predictions to be delivered clinicians and patients. An online web app is provided at https://uoscancer.shinyapps.io/NOGCA/

O14: RANDOM FOREST MODELS FOR PREDICTING SURVIVAL AFTER OESOPHAGECTOMY

Abstract Introduction For patients with oesophageal cancer, producing accurate prediction models for survival after oesophagectomy has proved challenging. We investigated whether Random Survival Forests (RSF), a novel machine learning method, could produce an accurate prognostic model for overall survival after oesophagectomy. Method The study used data from the National Oesophago-Gastric Cancer Audit and included patients diagnosed with oesophageal adenocarcinoma or squamous cell carcinoma between 2012 and 2018 in England and Wales and who underwent a curative oesophagectomy with adequate lymphadenectomy (15 LN) and survived to discharge (n=6198). Missing data was handled using multiple imputation and the data was split into training and validation cohorts. 13 variables were selected for inclusion using Random Forest variable importance and used to train the final model. The same variables were used to develop a traditional Cox regression model. Result Median survival was 53 months in both cohorts. The final RSF model had good discrimination in the validation cohort with a C-index of 0.757(0.755-0.759), exceeding the Cox model; 0.748(0.746-0.750). At 3 years post-surgery, overall survival was 56.2%. The RSF yielded a mean predicted survival of 55.8%(IQR 29.5%-81.7%) compared to 55.4%(40.0%-77.7%) for the Cox model. The most important variables were lymph node involvement and pT/ypT stage, however other variables including neoadjuvant treatment completion and surgical complications were also found to be important. Conculsion A Random Forest survival model provided better performance in predicting survival after curative oesophagectomy. This will allow more personalised predictions to be delivered clinicians and patients. Take-home message Random Forest survival models can accurately predict post-operative prognosis after oesophagectomy.

Variation in histopathological assessment and association with surgical quality indicators following oesophagectomy.

Histopathological outcomes, such as lymph node yield and margin positivity, are used to benchmark and assess surgical centre quality, and are reported annually by the National Oesophago-Gastric Cancer Audit (NOGCA) in England and Wales. The variation in pathological specimen assessment and how this affects these outcomes is not known. A survey of practice was circulated to all tertiary oesophagogastric cancer centres across England and Wales. Questions captured demographic data, and information on how specimens were prepared and analysed. National performance data were retrieved from the NOGCA. Survey results were compared for tertiles of lymph node yield, and circumferential and longitudinal margins. Survey responses were received from 32 of 37 units (86 per cent response rate), accounting for 93.1 per cent of the total oesophagectomy volume in England and Wales. Only 5 of 32 units met or exceeded current guidelines on specimen preparation according to the Royal College of Pathologists guidelines. There was wide variation in how centres defined positive (R1) margins, and how margins and lymph nodes were assessed. Centres with the highest nodal yield were more likely to use systematic fat blocking, and to re-examine specimens when the initial load was low. Systematic blocking of lesser curve fat resulted in significantly higher rates of patients with at least 15 lymph nodes examined (91.4 versus 86.5 per cent; P = 0.027). Preparation and histopathological assessment of specimens varies significantly across institutions. This challenges the validity of currently used surgical quality metrics for oesophageal and other tumours.

Routine use of feeding jejunostomy in oesophageal cancer resections: results of a survey in England.

Nutrition and post-operative feeding in oesophageal cancer resections for enhanced recovery remain a controversial subject. Feeding jejunostomy tubes (FJT) have been used post-operatively to address the subject but evidence to support its routine use is contentious. There is currently no data on FJT use in England for oesophageal cancer resections. Knowledge regarding current FJT usage, and rationale for its use may provide a snapshot of the trend and current standing on FJT use by resectional units in England. A standardised survey was sent electronically to all oesophageal resectional units in the United Kingdom (UK) between October 2016 and January 2018. In summary, the questionnaire probes into current FJT use, rationale for its usage, consideration of cessation of its use, and rationale of cessation of its use for units not using FJT. The resectional units were identified using the National Oesophago-Gastric Cancer Audit (NOGCA) progress report 2016 and 1 selected resectional unit from Northern Ireland, Scotland, and Wales, respectively. Performance data of those units were collected from the 2017 NOGCA report. Out of 40units that were eligible, 32 (80.0%) centres responded. The responses show a heterogeneity of FJT use across the resectional centres. Most centres (56.3%) still place FJT routinely with 2 of 18 (11.1%) were considering stopping its routine use. FJT was considered a mandatory adjunct to chemotherapy in 3 (9.4%) centres. FJT was not routinely used in 9 (28.1%) of centres with 5 of 9 (55.6%) reported previous complications and 4 of 9 (44.4%) cited using other forms of nutrition supplementation as factors for discontinuing FJT use. There were 5 (15.6%) centres with divided practice among its consultants. Of those 2 of 5 (40.0%) were considering stopping FJT use, and hence, a total of 4 of 23 (17.4%) of units are now considering stopping routine FJT use. In conclusion, the wider practice of FJT use in the UK remains heterogenous. More research regarding the optimal post-operative feeding regimen needs to be undertaken.

FA06.03: THE EFFECT OF LYMPH NODE HARVEST UPON MORTALITY FROM OESOPHAGECTOMY FOR OESOPHAGEAL ADENOCARCINOMA: NATIONAL POPULATION-BASED COHORT STUDY

Abstract Background In an era of increased utilisation of multimodality treatment for oesophageal adenocarcinoma the role of radical lymphadenectomy remains controversial. The objectives of this population-based cohort study were to evaluate the influence of lymph node harvest upon short- and long-term mortality following oesophagectomy for oesophageal adenocarcinoma, with subset analysis of patients receiving neoadjuvant therapy. Methods The UK National Oesophago-Gastric Cancer Audit (NOGCA) was used to identify suitable patients operated on between 1st April 2012 and 31st March 2016. Logistic regression of confounders was used to generate predicted mortality probabilities for utilisation in Risk-Adjusted Cumulative Sum (RA-CUSUM) analysis to identify the lymph node harvest change-points associated with changes in one-, two- and three-year mortality. Results Within the three-year study period, 3883 patients were included of these 2192 patients (56%) received neoadjuvant chemotherapy. For all patients there were non-significant change-points in 1-, 2-, and 3-year mortality at 19, 27 and 19 lymph nodes respectively. For patients receiving neoadjuvant therapy change-point analysis did show statistically significant reductions in 2-year mortality (44.9% before to 39.2% after 19 lymph nodes; P = 0.017) and 3-year mortality (55.0% before to 47.4% after 20 lymph nodes; P = 0.035). 30-day and 90-day mortality and anastomotic leak were not significantly by lymph node harvest of greater than 19 lymph nodes. Conclusion The results of this national population-based cohort study suggest that at least 20 lymph nodes should be harvested during oesophagectomy given the prognostic importance in oesophageal adenocarcinoma, and the benefits to improve pathological staging of the patient and appropriately allocate adjuvant therapy. Disclosure All authors have declared no conflicts of interest.

PS01.215: SUPERIOR MEDIASTINAL LYMPHADENECTOMY IN TOTALLY MINIMALLY INVASIVE OESOPHAGECTOMY FOR CANCER: CLINICAL AND ONCOLOGICAL OUTCOMES

Abstract Background Minimally invasive oesophagectomy (MIO) is a challenging procedure associated with high rate of complications and mortality. The exact benefits of superior mediastinal lymphadenectomy (SML) have long been debated with no clear evidence pertaining to better outcomes for patients. With this study we aim to compare the short-term outcomes of MIOs that also underwent SML against the UK national average. Methods Thirty-nine consecutive patients underwent totally MIO under a surgical team from September 2016 to December 2017. SML included left and right paratracheal nodes (including the paratracheal retrocaval compartment) as well as the nodes along the left and right recurrent laryngeal nerves throughout their mediastinal course. Eligible patients had to have undergone SML during either a 3-stage or a 2-stage MIO. Comparisons of the following outcomes were made against the data released by the UK National Oesophago-Gastric Cancer Audit (NOGCA) 2017; anastomotic leak rate, chyle leak rate, 30-day mortality, 90-day mortality, length of stay (LOS), cardiac complications, respiratory complications, wound infection, unplanned surgery. Results Seven patients were identified as eligible according to the criteria. 30- and 90- day mortality was reduced in the participant group compared to national average (0% vs 1.9% and 0% vs 3.3% respectively). Wound infection and cardiac complications were also reduced in the participant group (0% vs 5.3% and 0% vs 2.8% respectively). There were no anastomotic or chyle leaks noted (vs National 3.8% and 6.3% respectively), but conversely rate of respiratory complications was considerably higher in our group (42.8% vs 16.9%). There was 1 right recurrent laryngeal nerve palsy noted. Median LOS was longer in the sample group (16 vs 12 days), with no reoperations (0 vs 10.2%). Median total lymph node count was 45 (IQR, 37–68), with median SML count being 8 (IQR, 5–22). Conclusion The small sample size is immediately recognised as a limiting and influencing factor in the results of this study. However MIOs with SML may provide some, although not comprehensive, benefit in oncological outcomes without adding any further significant morbidity. Larger studies are needed to assess the role SML can play in improving patient outcomes. Disclosure All authors have declared no conflicts of interest.

Volume-outcome revisited: The effect of hospital and surgeon volumes on multiple outcome measures in oesophago-gastric cancer surgery.

BackgroundMost studies showing a volume outcome effect in resection surgery for oesophago-gastric cancer were conducted before the centralisation of clinical services. This study evaluated the relation between hospital- and surgeon volume and different risk-adjusted outcomes after oesophago-gastric (OG) cancer surgery in England between 2011 and 2013.MethodsIn data from the National Oesophago-Gastric Cancer Audit from the UK, multivariable random-effects logistic regression models were used to quantify the effect of surgeon and hospital volume on three outcomes: 30-day and 90-day mortality and anastomotic leakage. The models included patient risk factors to adjust for differences in case-mix among hospitals and surgeons. The between-cluster heterogeneity was estimated with the median odds ratio (MOR).ResultsThe study included patients treated at 42 hospitals and 329 surgeons. The median (interquartile range) of the annual hospital and surgeon volumes were 110 patients (82 to 137) and 13 patients (8 to 19), respectively. The overall rates for 30-day and 90-day mortality were 2.3% and 4.4% respectively, and the anastomotic leakage was 6.3%. Higher hospital volume was associated with lower 30-day mortality (OR: 0.94; 95% CI: 0.91–0.98) and lower anastomotic leakage rates (OR: 0.96; 95% CI: 0.93–0.98) but not 90-day mortality. Higher surgeon volume was only associated with lower anastomotic leakage rates (OR: 0.81; 95% CI: 0.72–0.92). Hospital volume explained a part of the between-hospital variation in 30-day mortality whereas surgeon volume explained part of the between-hospital variation in anastomotic leakage.ConclusionsIn the setting of centralized O-G cancer surgery in England, we could still observe an effect of volume on short-term outcomes. However, the effect is inconsistent, depending on the type of outcome measure under consideration, and much smaller than in previous studies. Efforts to centralise O-G cancer services further should carefully address the effects of both hospital and surgeon volume on the range of outcome measures that are relevant to patients.

Coding of Barrett’s oesophagus with high-grade dysplasia in national administrative databases: a population-based cohort study

ObjectivesThe International Classification of Diseases 10th Revision (ICD-10) system used in the English hospital administrative database (Hospital Episode Statistics (HES)) does not contain a specific code for oesophageal high-grade dysplasia...

Quantitative Shotgun Proteomics Unveils Candidate Novel Esophageal Adenocarcinoma (EAC)-specific Proteins

Esophageal cancer is the eighth most common cancer worldwide and the majority of patients have systemic disease at presentation. Esophageal adenocarcinoma (OAC), the predominant subtype in western countries, is largely resistant to current chemotherapy regimens. Selective markers are needed to enhance clinical staging and to allow targeted therapies yet there are minimal proteomic data on this cancer type. After histological review, lysates from OAC and matched normal esophageal and gastric samples from seven patients were subjected to LC MS/MS after tandem mass tag labeling and OFFGEL fractionation. Patient matched samples of OAC, normal esophagus, normal stomach, lymph node metastases and uninvolved lymph nodes were used from an additional 115 patients for verification of expression by immunohistochemistry (IHC).Over six thousand proteins were identified and quantified across samples. Quantitative reproducibility was excellent between technical replicates and a moderate correlation was seen across samples with the same histology. The quantitative accuracy was verified across the dynamic range for seven proteins by immunohistochemistry (IHC) on the originating tissues. Multiple novel tumor-specific candidates are proposed and EPCAM was verified by IHC.This shotgun proteomic study of OAC used a comparative quantitative approach to reveal proteins highly expressed in specific tissue types. Novel tumor-specific proteins are proposed and EPCAM was demonstrated to be specifically overexpressed in primary tumors and lymph node metastases compared with surrounding normal tissues. This candidate and others proposed in this study could be developed as tumor-specific targets for novel clinical staging and therapeutic approaches.

Evaluating the care received by patients with oesophago-gastric (OG) cancer: the richer picture provided by linked datasets

ABSTRACTObjectivesThe national oesophago-gastric cancer audit evaluates the care given to patients with OG cancer diagnosed in England and Wales, identifying areas for local services to improve and so achieve better patient outcomes. While the audit follows a standard approach by collecting a core dataset, it extends this by linking to other national databases in order to (1) reduce the burden of data collection, (2) add data that could not otherwise be obtained, (3) verify the quality of audit data. This presentation will provide an overview of the modern approach to national clinical audits and introduce anticipated future developments.
 ApproachThe data collected by hospitals and submitted to the audit is expanded by linkage to radiotherapy data (RTDS), date of death from the Office for National Statistics and administrative hospital admission data (HES). The linked data enables the Audit to: (1) examine whether radiotherapy regimens used in definitive oncology comply with guideline recommendations, using dosage information drawn from RTDS; (2) publish comparative short-term survival figures for NHS trusts and surgeons using ONS date of death; and (3) assess the quality of data submitted from hospitals by comparing coded procedural information in HES and the audit dataset.
 ResultsThe analysis of the linked data has led to several important audit findings, namely: (1) Access to RTDS data confirmed reasonable compliance with official guidelines on recommended radiotherapy dosing schedules. (2) Linked mortality data has provided robust and credible estimates of surgical outcomes and is a critical output to NHS trusts and surgeons, as well as the wider public. Our analysis has highlighted a gradual decline in post-operative mortality. (3) Linkage of audit and HES data identified gaps in the recording of endoscopic stenting, with many procedures not being submitted by participating trusts. These diverse results underline the usefulness of linked data in revealing a more complete picture of the care received by OG cancer patients.
 ConclusionLinked data has become integral for the successful implementation of a national clinical audit, supplementing the core dataset with information that would otherwise be unavailable or difficult and costly to collect. Linkage enhances the audit’s ability to assess health services’ compliance with professional standards and to give service providers the opportunity to benchmark their performance. Future developments are expected to expand on this by including primary care service use before diagnosis.

PWE-075 Changing Patterns of Management and Outcomes for Early Oesophageal Adenocarcinomas in England and Wales

Introduction Currently only 1 in 20 oesophageal adenocarcinomas are diagnosed at early stage.1 Where patients are diagnosed at an early stage, studies have suggested that up to 90% of patients managed with curative surgical intent survive 5 years.2 In this study we investigated the changing patterns of management for oesophageal adenocarcinomas in England and Wales, and associated patient outcomes. Methods This study uses data collected for the National Oesophago Gastric Cancer Audit (NOGCA), and compares patients diagnosed in the year following 1st April 2008 (Group 1), with those diagnosed five years later in 2013 (Group 2). The study was limited to patients diagnosed with early stage (T0/1, N0, M0) oesophageal adenocarcinoma. Outcomes considered included proportion of patients managed with curative intent, curative treatment modality and patient outcomes at 1 year. Results A similar number of patients were diagnosed with early stage cancer over both time frames, Group 1 (n = 202) and Group 2 (n = 193). The proportion of patients managed with curative intent increased over the five years from 77.4% to 83.4% (chi-square test, p = 0.13). However the proportion of patients aged ≥75 years managed with curative intent increased significantly between 2008 and 2013, from 48% to 67% (p = 0.02). These increases are likely to reflect changes in curative treatment modalities. Over the last five years, there has been a significant increase in the proportion of patients managed with less invasive curative treatment modalities, with the proportion being managed endoscopically increasing from 18% to 34%, while there was a corresponding decrease in the proportion managed surgically from 76% to 61% (p = 0.007). Patients diagnosed with early cancer in 2013 who were managed with curative intent were significantly more likely to survive 1 year than those who had been diagnosed in 2008 (98% vs 93%, p = 0.05). Conclusion Outcomes for patients diagnosed with early oesophageal adenocarcinomas have improved over the last five years. Over the same period, the proportion of patients managed with less invasive endoscopic treatment modalities has increased significantly. However, it should be noted that a sizeable minority of patients are still being managed with palliative intent. The NOGCA will continue to monitor the management of this group of patients in future. References 1 Chadwick G, et al. Management and survival of patients with early stage oesophageal adenocarcinomas in England: a population-based cohort study. British Journal of Surgery. 2 Wani S, et al. Comparison of endoscopic therapies and surgical resection in patients with early esophageal cancer: a population-based study. Gastrointest Endosc. 2014;79(2):224–32.e1. Disclosure of Interest None Declared

PWE-140 Relationship Between Social Deprivation and The Care Pathway of Osoephago-Gastric (OG) Cancer Patients

Introduction Incidence and mortality of all cancers combined in England are higher in individuals living within the most deprived areas compared to those from the least deprived. The government recognises that overall performance can be improved for people living in deprived areas. We analysed the effect of deprivation on the care pathway of patients with OG cancer. Methods This study used data collected by the National Oesophago-Gastric Cancer audit (NOGCA) between April 2012 and March 2014 to evaluate the effect of social deprivation on the route of referral into secondary care and treatment options. Social deprivation was measured using the English Index of Multiple Deprivation, with patients allocated to quintiles based on the deprivation score for their area of residence. Quintile 1 represents the least deprived group and quintile 5 the most deprived. Analysis was performed using multivariable logistic regression. Results 16,635 patients were included in the study with a mean age of 70.4 years and 69.2% males. The proportion of patients who were diagnosed after an emergency admission was 11.4% in the least deprived group and 16.4% in the most deprived group. An increase in a quintile of deprivation was associated with an 18% increase in risk of an emergency admission after adjusting for risk factors (age at diagnosis, sex, pre-treatment TNM stage, co-morbidities, site of tumour, and performance status), odds ratio (CI) 1.18 (1.1,13) p = 0.001. With every increase in the quintile of deprivation, there was a 8% decrease in likelihood of having curative surgery, odds ratio (CI) 0.92 (0.90,0.96) p Conclusion The treatment pathway of patients with OG cancer differs among patients living in different areas of social deprivation, with most deprived patients being more likely to be diagnosed after an emergency admission and less likely to have curative surgery. The reasons for the variation needs to be investigated to improve overall outcomes. Disclosure of Interest None Declared

PTH-139 Is There Nationwide Variation in the Proportion of Palliative Oesophago-Gastric Cancer Patients Dying in Hospital?

Introduction The DH ‘End of Life Care Strategy’ recommends that patients are treated in familiar surroundings and previous studies have suggested that 56–74% of people would prefer to die at home. 1 This study investigated whether there was nationwide variation in the proportion of palliative oesophago-gastric (OG) cancer patients dying in hospital. Methods We used data from the National Oesophago-Gastric Cancer Audit to identify patients diagnosed with OG cancer in England and Wales between 1/4/2011 and 31/3/2013. The study was limited to patients managed with palliative intent who died during follow up. Place of death was identified by linking the data to the ONS death register. The proportions of patients dying in hospital were derived for each strategic clinical networks (SCNs), and were adjusted for regional differences in age, sex, planned modality, and social deprivation. Results 22,285 patients were diagnosed with OG cancer, 13,187 were managed with palliative intent and 12,012 of these died during follow up. Overall, 34.6% of patients died in hospital, 34.3% died at home, 18.5% died in a hospice, 10.9% died in a care home and 1.7% died elsewhere. After adjustment, the proportion of patients dying in hospital across SCNs typically fell between 30% and 40% (see Figure 1). The value of 50.9% (95% CI 46.1–56.0%)) for South Wales was large, in comparison. Conclusion About one third of OG cancer patients treated palliatively die in hospital, and there was some variation between regions in England and Wales. This needs to be monitored at a local level, and investigated where rates are higher than expected. Differences between regions may reflect local access to hospice services and other social support. Reference 1 National Audit Office (2008). End of life care. http://www.nao.org.uk/report/end-of-life-care/ Disclosure of Interest None Declared

Management of Barrett’s high-grade dysplasia: initial results from a population-based national audit

Previous studies reported significant variation in the management of patients with Barrett's esophagus. However, these are based on self-reported clinical practice. The aim of this study was to examine the management of high-grade dysplasia in Barrett's esophagus in England by using patient-level data and to compare practice with guidelines. From April 2012 to March 2013, National Health Service (NHS) trusts in England prospectively collected data on patients newly diagnosed with high-grade dysplasia (HGD) of the esophagus as part of the National Oesophago-Gastric Cancer Audit. Data were collected on patient characteristics, diagnosis and endoscopic findings, treatment planning, and therapy. Between April 2012 and March 2013, NHS trusts reported 465 cases of HGD. Diagnosis was confirmed by a second pathologist in 79.4% of cases (270/340), and 86.0% (374/465) had their treatment planned at a multidisciplinary team meeting. A total of 290 patients (62.4%) were managed endoscopically (frequently with endoscopic resection or radiofrequency ablation), whereas 26 patients (5.6%) had esophagectomy. The proportion of patients managed by surveillance varied by age (P < .001), ranging from 19.5% in patients aged <65 years to 63.8% in patients aged ≥85 years. More patients received active treatment if their cases were discussed at a multidisciplinary meeting (73.5% vs 44.3%; P < .001) or managed at higher-volume trusts (87.8% vs 55.4%; P < .001). There was marked variation in the management of HGD across England, with a third of patients receiving no active treatment. Patients discussed at a specialist multidisciplinary meeting or managed in high-volume trusts were more likely to receive active treatment.

OC-076 Outcomes after curative treatment for oesophago-gastric cancer in the elderly: Abstract OC-076 Table 1

Introduction 60% of Oesophago-Gastric (OG) cancers are diagnosed in patients aged 70 or over. 1 The 2014 National Oesophago-Gastric cancer audit (NOGCA) report found that elderly patients were equally likely to be managed with curative intent (after adjusting for known confounders), but it is not clear whether their short term outcomes are comparable. In this study we investigated whether age was associated with outcomes after curative surgery. Method This study uses data collected for the NOGCA, focusing on patients diagnosed between 1 st April 2011 and 31 st March 2013 who had a curative resection before the 1 st January 2014. Outcomes considered were 90 day mortality and complication rates. Results were adjusted for known confounders: sex, TNM stage at diagnosis, performance status, comorbidities and ASA grade. Results Overall 13,334 patients aged 70 or over were diagnosed with OG cancer. 28.8% of these were managed with curative intent, such that 1,001 oesophagectomies and 1,039 gastrectomies were performed in patients aged 70 or over. Patients aged 70 or over undergoing a curative oesophagectomy had higher 90-day mortality and complication rates than younger patients, this difference was maintained after adjusting for known confounders (Table 1). For gastrectomies there was no significance in outcomes according to the age of patient. Conclusion Elderly patients undergoing an oesophagectomy had significantly worse outcomes compared to younger patients. Therefore efforts need to be made to reduce their higher risk to levels achieved by younger patients in future. Disclosure of interest None Declared. Reference Chadwick G, Taylor A, Groene O, et al . The National Oesophago-Gastric Cancer Audit. An audit of the care received by people with Oesophago-gastric cancer in England and Wales. 2014 Annual Report. In: HSCIC, ed., 20142014