Bowel Cancer Quality Performance Indicators: Descriptions
Bowel Cancer Quality Performance Indicators: Descriptions2019Citation: Ministry of Health. 2019. Bowel Cancer Quality Performance Indicators: Descriptions. Wellington: Ministry of Health.Published in February 2019 by the Ministry of HealthPO Box 5013, Wellington 6140, New?ZealandISBN 978-1-98-856853-9 (online)HP 7039This document is available at t.nzThis work is licensed under the Creative Commons Attribution 4.0 International licence. In essence, you are free to: share ie, copy and redistribute the material in any medium or format; adapt ie, remix, transform and build upon the material. You must give appropriate credit, provide a link to the licence and indicate if changes were made.Contents TOC \o "1-2" \h \z 1Introduction PAGEREF _Toc2255208 \h 1Background PAGEREF _Toc2255209 \h 1Purpose PAGEREF _Toc2255210 \h 1Development process PAGEREF _Toc2255211 \h 2Glossary of terms PAGEREF _Toc2255212 \h 62Bowel cancer quality performance indicators PAGEREF _Toc2255213 \h 81Route to diagnosis PAGEREF _Toc2255214 \h 102Timeliness of treatment PAGEREF _Toc2255215 \h 113Stage at diagnosis PAGEREF _Toc2255216 \h 124Multidisciplinary discussion PAGEREF _Toc2255217 \h 135Length of stay after surgery PAGEREF _Toc2255218 \h 146Clinical trial participation PAGEREF _Toc2255219 \h 157Treatment survival PAGEREF _Toc2255220 \h 168Overall survival PAGEREF _Toc2255221 \h 179Structured pathology reporting PAGEREF _Toc2255222 \h 1810Lymph-node yield PAGEREF _Toc2255223 \h 1911Mismatch repair (MMR)/ microsatellite instability (MSI) testing PAGEREF _Toc2255224 \h 2012Circumferential resection margin (CRM) PAGEREF _Toc2255225 \h 2113Integrity of mesorectum PAGEREF _Toc2255226 \h 2214Rectal magnetic resonance imaging (MRI) reporting PAGEREF _Toc2255227 \h 2315Tumour localisation PAGEREF _Toc2255228 \h 2416Radiotherapy PAGEREF _Toc2255229 \h 2517Adjuvant chemotherapy PAGEREF _Toc2255230 \h 2618Metastatic colorectal cancer chemotherapy PAGEREF _Toc2255231 \h 2719Emergency surgery PAGEREF _Toc2255232 \h 2820Unplanned return to theatre PAGEREF _Toc2255233 \h 2921Stoma-free survival PAGEREF _Toc2255234 \h 30Appendix 1: Working group members 2018 PAGEREF _Toc2255235 \h 31Appendix 2: Initial assessment of availability of national data for calculating indicators PAGEREF _Toc2255236 \h 32Appendix 3: Stratifying?variables PAGEREF _Toc2255237 \h 35Abbreviations PAGEREF _Toc2255238 \h 36References PAGEREF _Toc2255239 \h 37IntroductionBackgroundThe Cancer Services team within the Ministry of Health and the National Bowel Cancer Working Group (NBCWG) have worked together to identify a set of quality performance indicators (QPIs) for bowel cancer.The indicators were selected to measure performance and drive quality improvement in bowel cancer diagnosis and treatment services across district health boards (DHBs) in New Zealand.The QPIs that appear in this document are part of a project to establish ongoing quality improvement for cancer care in New Zealand. Addressing variation in the quality of cancer services is essential to delivering improvements in quality of care. This is best achieved if there is consensus, and a set of clear indicators for what good cancer care looks like.The Ministry selected bowel cancer for the first tumour-specific indicators, to align with the rollout of the National Bowel Screening Programme. It is currently developing sets of indicators for other cancers and tumour types.PurposeThe ultimate aim of the project was to develop a framework for quality improvement whereby DHBs regularly review recent data, and act upon their findings accordingly.The QPIs that appear in this document will ensure that activity is focused on the areas that are most important in terms of improving survival and individual care experience, while reducing variation and supporting the most effective and efficient delivery of care.Development processThe Ministry of Health and the NBCWG were committed to ensuring that they developed these indicators in an open, transparent and timely way. The diagram below outlines the development process ( REF _Ref1115248 \h Figure 1).Figure SEQ Figure \* ARABIC 1: Overview of the process to select clinical quality performance indicators for bowel cancer careThe bowel cancer quality indicator group was first convened in September 2017, chaired by Dr Christopher Jackson (medical oncologist and deputy chair of the NBCWG). Membership of this group included clinical representatives from the NBCWG, consumers and other clinicians with expertise in developing QPIs. Appendix?1 lists members of the working groups.Selecting the indicatorsWe selected an initial long list of indicators following a literature review and environment scan. We considered this long list during a workshop with clinicians, consumers and other cancer care professionals, with a view to selecting a final set of indicators.We selected final QPIs based on the following criteria:Overall importance – does the indicator address an area of clinical importance that would significantly impact on the quality and outcome of care delivered?Evidence basis – is the indicator based on high-quality clinical evidence? Is there evidence of known equity gaps (eg, age or presence of co-morbidities) and opportunities for Māori health gain?Measurability – is the indicator measurable (ie, are there explicit requirements for data measurement, and are the required data items accessible and available for collection)?Following the initial workshop, members of the bowel cancer quality indicator group developed descriptions for the indicators.We provided clinicians and other cancer experts in New Zealand an opportunity to review the bowel tumour-specific QPIs in November 2017.We incorporated their feedback into the final set of indicators.Format of the quality performance indicatorsThe QPIs are designed to be clear and measurable, based on sound clinical evidence while also taking into account other recognised standards and guidelines.Each QPI has a title that can be used in reports, as well as a more detailed description that explains exactly what the indicator is measuring.This is followed by a brief overview of the rationale and evidence, which explains why we considered this indicator to be important.The measurability specifications are then set out; these highlight how we will measure the indicator in practice, to allow for comparison across New Zealand.We have tried to minimise exclusions, to simplify measurement and reporting.It is very difficult to accurately measure patient choice, co-morbidities and patient fitness; we note that this should be considered in interpreting variability between DHBs. Where there are other factors that might influence variability between DHBs, we have noted this.Measuring and reporting on the indicatorsAppendix 2 contains a summary of the initial assessment of data available in existing national data collections to measure each proposed indicator.Where national data was available for a specific indicator, we used this to develop and report on the indicator.Despite the initial assessment, we found that the specific data needed for indicators was not always available in the Ministry of Health’s national collections. To address this, in some instances, we made changes to the indicator specifications to fit with the available data (eg, we did not limit radiotherapy indicators to non-metastatic disease). In other cases, we decided the data and/or methods were not of sufficient quality to proceed with publishing the indicator (eg, in the case of unplanned return to theatre). We have added a statement in the notes section for each indicator to indicate where data could be reported in 2019.As part of the project, we identified areas where data improvement is required (cancer group stage and grade of cancer are two examples). Our clinical advisory groups and other data experts within the Ministry of Health are already working to implement the identified improvements.Participants at the initial workshop requested that the published indicators be stratified by the variables shown in Appendix 3.The first report on bowel cancer QPIs, Bowel Cancer Quality Improvement Report 2019, can be found on the Ministry of Health’s website: t.nz.Bowel cancer definitionsFor the purposes of the QPIs, we considered a person to be diagnosed with primary bowel cancer when that person was first entered on the New Zealand Cancer Registry with a diagnosis of cancer of the colon, rectosigmoid junction or rectum. The term ‘bowel’ is interchangeable with the term ‘colorectal’.Rectal cancer is defined as a cancer with its lower margin less than 15?cm above the anal verge as measured on sagittal magnetic resonance imaging (MRI).We exclude people diagnosed with appendiceal cancer, neuroendocrine tumours, gastrointestinal stromal tumours, lymphomas, squamous cell carcinomas and melanomas from all QPIs, as the presentation and management of these rare cancers is different from other colorectal tumours.Sources of national data for indicatorsThis document refers to the following national data sources.Mortality Collection – classifies the underlying cause of death for all deaths registered in New ZealandNew Zealand Cancer Registry (NZCR) – a population-based register of all primary malignant diseases diagnosed in New Zealand, excluding squamous and basal cell skin cancersNational Minimum Dataset (NMDS) – a collection of public and private hospital discharge information, including coded clinical data for inpatients and day patientsNational Non-Admitted Patients Collection (NNPAC) – includes event-based purchase units that relate to medical and surgical outpatient events and emergency department eventsNational Screening Database – national repository for information relating to bowel and other publicly funded screeningPharmaceutical Collection (PHARMS) – a data warehouse that supports the management of pharmaceutical subsidies, and contains claim and payment information from pharmacists for subsidised dispensingsRadiation Oncology Collection (ROC) – a collection of radiation oncology treatment data, including both public and private providers.More information on these data sources can be found on the Ministry of Health’s website: t.nz.Glossary of termsTermDescriptionCommon indicatorIndicator of quality of diagnosis and treatment (ie, service provision) applied to more than one tumour group. Common indicators will be used for comparability and consistency across all tumour groups (eg, proportion of people who participate in a clinical trial). They will be considered for each tumour group, but can be defined differently for each group.Descriptive measureA measure that conveys the health sector capacity for providing high-quality care and service (eg, the number of people with bowel cancer who have surgery).Major resection Surgery can be a simple, safe method to cure people with solid tumours when the tumour is confined to the anatomic site of origin. Resection of the primary cancer involves definitive surgical treatment, encompassing a sufficient margin of normal tissue with the goal of curing the disease with surgery alone. When selecting a definitive surgical treatment careful consideration of the likelihood of local cure needs to be balanced against the impact of surgical morbidity on the person’s quality of life.Structured reportsStructured reports are reports (e.g. pathology) that contain structured data. Structured data are a collection of discrete values within a report, each with its own specification. A report containing structured data can be easily mined by computers for storing, sorting, and analysing the individual data elements.Synoptic reportsSynoptic reports are summary reports that are standardised in their format, content, and terminology and appear structured to the human eye. They may or may not contain structured data, and many combine structured inputs and narrative text.TNM group stageFor many purposes it is useful to combine TNM system categories into groups. Tumours localised to the organ of origin are generally staged as I or II depending on the extent, locally extensive spread, to regional nodes are staged as III, and those with distant metastasis staged as stage IV. The Union for International Cancer Control (UICC) uses the term Stage to define the anatomical extent of disease. The American Joint Committee on Cancer (AJCC) uses the term Prognostic Stage Group which may also include additional prognostic factors in addition to anatomical extent of disease.TNM systemThe TNM system is a global standard used to record the anatomical extent of disease. TNM was developed and is maintained by the UICC. It is also used by the AJCC and the International Federation of Gynecology and Obstetrics (FIGO).In the TNM system, each cancer is assigned a letter or number to describe the tumour, node, and metastases. T stands for the original (primary) tumour. N stands for nodes (indicates whether the cancer has spread to the nearby lymph nodes). M stands for metastasis.It is very important to note that the criteria used in the TNM system have varied over time, sometimes fairly substantially, according to the different editions that AJCC and UICC have released. For this reason, the name and edition of the staging system must be recorded alongside TNM values.Tumour-specific indicatorAn indicator of quality of diagnosis and treatment (ie, service provision) unique to a tumour group because of the treatment regimen.Bowel cancer quality performance indicatorsThe table below lists each indicator, with a hyperlink to the detailed descriptions for each indicator on the following pages.IDIndicator titleIndicator descriptionIndicator type1Route to diagnosisProportion of people with colorectal cancer who are diagnosed following a referral to a clinic, screening or presentation to an emergency department (with or without surgery)Common2Timeliness of treatmentTime from first histological diagnosis to first definitive treatmentCommon3Stage at diagnosisProportion of people with colorectal cancer by stage of diagnosisCommon4Multidisciplinary discussionProportion of people with colorectal cancer discussed at a multidisciplinary meeting (MDM)Common5Length of stay after surgeryMedian length of stay following surgery for colorectal cancerDescriptive6Clinical trial participationProportion of people with colorectal cancer in a clinical trialCommon7Treatment survivalProportion of people with colorectal cancer who died within 30 or 90 days of treatment (surgery, chemotherapy, radiotherapy)Common8Overall survivalOverall survival for people with colorectal cancer at 1, 3, 5 and 10 years from diagnosis by stage Common9Structured pathology reportingProportion of people with colorectal cancer who undergo surgical resection whose histology is reported in a structured formatCommon10Lymph-node yieldProportion of people with colorectal cancer who undergo surgical resection where ≥12?lymph nodes are pathologically examinedBowel-specific11Mismatch repair (MMR)/microsatellite instability (MSI) testingProportion of people with colorectal cancer who have been tested for MMR status on initial diagnosisBowel-specific12Circumferential resection margin (CRM)a)Proportion of people with rectal cancer undergoing surgery with reported CRMb)Proportion of reported CRMs with a positive margin (less than or equal to 1?mm – R1) Bowel-specific13Integrity of mesorectuma)Proportion of people with rectal cancer where mesorectal intactness/grade is documentedb)Proportion of each mesorectal grade/degree of intactness for rectal cancersBowel-specific14Rectal magnetic resonance imaging (MRI) reportingProportion of people with rectal cancer who receive an MRI that is synoptically reportedBowel-specific15Tumour localisationProportion of people with rectal cancer for whom distal tumour margin (tumour height) to anal verge distance is specified on the MRI reportBowel-specific16RadiotherapyProportion of people with non-metastatic rectal cancer who receive:a)no radiotherapy (ie, surgery alone)b)pre-operative short-course radiotherapy (SCRT)c)pre-operative long-course radiotherapy (LCRT)Bowel-specific17Adjuvant chemotherapya)Proportion of people with stage III colon cancer who receive adjuvant chemotherapyb)Proportion of people with stage III colon cancer who receive adjuvant chemotherapy within eight weeksBowel-specific18Metastatic colorectal cancer chemotherapyProportion of people with metastatic colorectal cancer receiving chemotherapyBowel-specific19Emergency surgeryProportion of people with colorectal cancer undergoing major resection who have emergency surgeryBowel-specific20Unplanned return to theatreProportion of people with an unplanned return to theatre within 30 days of surgery for colorectal cancerBowel-specific21Stoma-free survivalProportion of people with rectal cancer with stoma-free survival at 18 months after major resectionBowel-specificRoute to diagnosisIndicator descriptionProportion of people with bowel cancer who are diagnosed following a referral to a clinic, screening or presentation to an emergency department (with or without surgery).Rationale and evidencePeople who are diagnosed with early-stage bowel cancer and receive treatment early have a 90?percent chance of long-term survival.For this reason, bowel screening every two years can help save lives.Bowel screening can also detect polyps. Most polyps can be easily removed, reducing the risk that bowel cancer will develop.People referred from screening services tend to have earlier cancers, and are more likely to be treated with curative intent than people diagnosed via other referral means.Equity/Māori health gainThe PIPER study found that Māori people were more likely to be diagnosed following presentation to an emergency department (45%) than Pacific peoples (35%) and non-Māori/non-Pacific peoples (30%). PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TaGFycGxlczwvQXV0aG9yPjxZZWFyPjIwMTg8L1llYXI+
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ADDIN EN.CITE.DATA (Grothey et al 2004 ; Sharples et al 2018).These differences were reduced after controlling for demographic characteristics and disease variables such as stage and grade at diagnosis, but Māori people (particularly rural Māori) and those living in areas with the highest socioeconomic deprivation were still more likely to be diagnosed following an emergency department presentation.SpecificationsNumerator a)Number of people with colorectal cancer whose diagnosis followed an elective presentation.Numerator b)Number of people with colorectal cancer whose diagnosis is based on screening, defined as regular examination, such as faecal occult blood test or colonoscopy in asymptomatic people.Numerator c)Number of people with colorectal cancer whose diagnosis followed an emergency presentation.DenominatorNumber of people diagnosed with colorectal cancer.ExclusionsPeople diagnosed with colorectal cancer at death.Data sourcesNZCR, national screening database, NMDS.NotesThis indicator can be reported in 2019.Timeliness of treatmentIndicator descriptionTime from first histological diagnosis to first definitive treatment.Rationale and evidenceTimely high-quality care delivers the best outcomes for people diagnosed with bowel cancer.Timely treatment following diagnosis of cancer contributes to a better patient experience by reducing anxiety and uncertainty and minimising the risk of deterioration prior to treatment.Previous studies have identified ethnic inequalities in timely access to treatment; ensuring timely treatment for all will likely reduce equity gaps.Equity/Māori health gainA previous study found that Māori were more likely to experience treatment delays. ADDIN EN.CITE <EndNote><Cite><Author>Hill</Author><Year>2010</Year><RecNum>8</RecNum><DisplayText>(Hill et al 2010b)</DisplayText><record><rec-number>8</rec-number><foreign-keys><key app="EN" db-id="ezt95dfawvtw0kezr9npa0wivxfze9902pwz">8</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Hill, S.</author><author>Sarfati, D.</author><author>Blakely, T.</author><author>Robson, B.</author><author>Purdie, G.</author><author>Dennett, E.</author><author>Cormack, D.</author><author>Dew, K.</author><author>Ayanian, J. Z.</author><author>Kawachi, I.</author></authors></contributors><auth-address>Global Public Health Unit, University of Edinburgh, Edinburgh, United Kingdom. s.e.hill@ed.ac.uk</auth-address><titles><title>Ethnicity and management of colon cancer in New Zealand: do indigenous patients get a worse deal?</title><secondary-title>Cancer</secondary-title><alt-title>Cancer</alt-title></titles><periodical><full-title>Cancer</full-title><abbr-1>Cancer</abbr-1></periodical><alt-periodical><full-title>Cancer</full-title><abbr-1>Cancer</abbr-1></alt-periodical><pages>3205-14</pages><volume>116</volume><number>13</number><edition>2010/06/22</edition><keywords><keyword>Chemotherapy, Adjuvant</keyword><keyword>Colonic Neoplasms/ ethnology/ therapy</keyword><keyword>Ethnic Groups</keyword><keyword>Female</keyword><keyword>Health Services, Indigenous</keyword><keyword>Healthcare Disparities</keyword><keyword>Humans</keyword><keyword>Lymph Node Excision</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>New Zealand</keyword><keyword>Quality of Health Care</keyword></keywords><dates><year>2010</year><pub-dates><date>Jul 01</date></pub-dates></dates><isbn>0008-543X (Print)
0008-543X (Linking)</isbn><accession-num>20564634</accession-num><urls></urls><electronic-resource-num>10.1002/cncr.25127</electronic-resource-num><remote-database-provider>NLM</remote-database-provider><language>eng</language></record></Cite></EndNote>(Hill et al 2010b).SpecificationsNumeratorTime from first histological diagnosis to date of first treatment.DenominatorPeople having treatment for colorectal cancer.ExclusionsNone.Data sourcesNZCR, NMDS, ROC, PHARMS.NotesThis indicator was investigated in 2018.The histology date currently available on the NZCR is most often the date of definitive histology following surgery, rather than the earlier biopsy date (eg, when diagnosis was first made).This indicator cannot be reported in 2019.Stage at diagnosisIndicator descriptionProportion of people with colorectal cancer by stage at diagnosis.Rationale and evidenceStage at diagnosis is the most important determinant of prognosis.People who are diagnosed when their cancer is at an early stage have significantly improved survival outcomes ADDIN EN.CITE <EndNote><Cite><Author>McPhail</Author><Year>2015</Year><RecNum>49</RecNum><DisplayText>(McPhail et al 2015)</DisplayText><record><rec-number>49</rec-number><foreign-keys><key app="EN" db-id="ezt95dfawvtw0kezr9npa0wivxfze9902pwz">49</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>McPhail, S.</author><author>Johnson, S.</author><author>Greenberg, D.</author><author>Peake, M.</author><author>Rous, B.</author></authors></contributors><titles><title>Stage at diagnosis and early mortality from cancer in England</title><secondary-title>British Journal Of Cancer</secondary-title></titles><periodical><full-title>British Journal Of Cancer</full-title></periodical><pages>S108</pages><volume>112</volume><dates><year>2015</year><pub-dates><date>03/03/online</date></pub-dates></dates><publisher>The Author(s)</publisher><work-type>Full Paper</work-type><urls><related-urls><url>;(McPhail et al 2015).Stage is also a critical element in determining appropriate treatment.Equity/Māori health gainThe PIPER study found that Māori and Pacific people had higher proportions of metastatic (late-stage) colorectal disease at diagnosis than non-Māori, non-Pacific people PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TaGFycGxlczwvQXV0aG9yPjxZZWFyPjIwMTg8L1llYXI+
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ADDIN EN.CITE.DATA (Hill et al 2010a).The PIPER study did not identify significant differences in people reviewed at a colorectal multidisciplinary meetings by ethnic group or socioeconomic deprivation ADDIN EN.CITE <EndNote><Cite><Author>Jackson</Author><Year>2015</Year><RecNum>20</RecNum><DisplayText>(Jackson et al 2015)</DisplayText><record><rec-number>20</rec-number><foreign-keys><key app="EN" db-id="ezt95dfawvtw0kezr9npa0wivxfze9902pwz">20</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>Jackson, C</author><author>Sharples, K</author><author>Firth, M</author><author>Hinder, V</author><author>Jeffery, M</author><author>Keating, J</author><author>Secker, A</author><author>Derrett, S</author><author>Atmore, S</author><author>Bramley, D</author><author>De Groot, C</author><author>Stevens, W</author><author>Sarfati, D</author><author>Brown, C</author><author>Hill, A, </author><author>Reid, P</author><author>Lawrenson, R</author><author>Findlay, M</author></authors></contributors><titles><title>The PIPER Project - An Internal Examination of Colorectal Cancer Management in New Zealand</title></titles><number>18 February 2019</number><dates><year>2015</year></dates><urls><related-urls><url>(HRC%2011_764%20FINDLAY).pdf </url></related-urls></urls></record></Cite></EndNote>(Jackson et al 2015).SpecificationsNumeratorNumber of people with colorectal cancer discussed at an MDM.DenominatorNumber of people with colorectal cancer.ExclusionsNone.Data sourcesNZCR, MDM databases, NMDS.NotesThis indicator will initially measure the number of people who were discussed at an MDM. Over time, more criteria will be added (eg, people discussed at an MDM prior to treatment).No national data collection records whether a person’s treatment has been discussed at a colorectal cancer MDM.This indicator cannot be reported in 2019.Length of stay after surgeryIndicator descriptionMedian length of stay following surgery for colorectal cancer.Rationale and evidenceSurgery is the cornerstone of treatment for many cancers. There have been major developments in surgery for colorectal cancer over the past decade, which have included greater surgical specialisation and wider use of laparoscopic procedures. Hospital length of stay following surgery is an indicator of health service efficiency.In some health care settings, there have been initiatives aimed at reducing length of stay after cancer surgery; for example, through enhanced recovery programmes. These types of initiatives may confer advantages for patients, including faster recovery and fewer complications. One of the key concerns of attempts to reduce length of stay, however, is that it may compromise patient safety and lead to increased readmissions.Equity/Māori health gainThe PIPER study did not identify significant differences in length of stay by ethnic group or socioeconomic deprivation ADDIN EN.CITE <EndNote><Cite><Author>Jackson</Author><Year>2015</Year><RecNum>20</RecNum><DisplayText>(Jackson et al 2015)</DisplayText><record><rec-number>20</rec-number><foreign-keys><key app="EN" db-id="ezt95dfawvtw0kezr9npa0wivxfze9902pwz">20</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>Jackson, C</author><author>Sharples, K</author><author>Firth, M</author><author>Hinder, V</author><author>Jeffery, M</author><author>Keating, J</author><author>Secker, A</author><author>Derrett, S</author><author>Atmore, S</author><author>Bramley, D</author><author>De Groot, C</author><author>Stevens, W</author><author>Sarfati, D</author><author>Brown, C</author><author>Hill, A, </author><author>Reid, P</author><author>Lawrenson, R</author><author>Findlay, M</author></authors></contributors><titles><title>The PIPER Project - An Internal Examination of Colorectal Cancer Management in New Zealand</title></titles><number>18 February 2019</number><dates><year>2015</year></dates><urls><related-urls><url>(HRC%2011_764%20FINDLAY).pdf </url></related-urls></urls></record></Cite></EndNote>(Jackson et al 2015).SpecificationsNumeratorMedian length of stay following surgery.DenominatorPeople undergoing definitive surgery for colorectal cancer.ExclusionsNone.Data sourcesNZCR, NMDS.NotesThe results for this indicator should be presented by type of cancer (colorectal, colon and rectal).This is a descriptive indicator; it can be reported alongside other surgical indicators for information and context in 2019.Clinical trial participationIndicator descriptionProportion of people with colorectal cancer in a clinical trial.Rationale and evidenceProgress in preventing, diagnosing and treating cancer predominantly comes from scientific research, including the testing of new, potentially more effective medications and procedures through clinical trials. People who participate in these trials gain access to the very latest advances in cancer care developed by cancer specialists.Equity/Māori health gainNo data was available.SpecificationsNumeratorNumber of people with colorectal cancer treated on a clinical trial at any time after diagnosis.DenominatorNumber of people diagnosed with colorectal cancer.ExclusionsNone.Data sourcesClinical notes.NotesThere is no national data collection on people enrolled in clinical trials for colorectal cancer.This indicator cannot be reported in 2019.Treatment survivalIndicator descriptionProportion of people with colorectal cancer who died within 30 or 90 days of treatment (surgery, chemotherapy, radiotherapy).Rationale and evidenceTreatment-related mortality is a marker of the quality and safety of the whole service provided by the multidisciplinary team (MDT).Service providers (DHBs, clinicians, MDTs) should regularly assess outcomes of treatment, including treatment-related morbidity and mortality.Patients with poor performance status, who are therefore at a greater risk of treatment-related morbidity and mortality, are increasingly being considered for radical interventions. These interventions may be curative, but their impact needs to be balanced against people’s overall prognosis.Equity/Māori health gainThe PIPER study found that people who resided in more socially deprived areas had a higher 90-day mortality after surgery ADDIN EN.CITE <EndNote><Cite><Author>Jackson</Author><Year>2015</Year><RecNum>20</RecNum><DisplayText>(Jackson et al 2015)</DisplayText><record><rec-number>20</rec-number><foreign-keys><key app="EN" db-id="ezt95dfawvtw0kezr9npa0wivxfze9902pwz">20</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>Jackson, C</author><author>Sharples, K</author><author>Firth, M</author><author>Hinder, V</author><author>Jeffery, M</author><author>Keating, J</author><author>Secker, A</author><author>Derrett, S</author><author>Atmore, S</author><author>Bramley, D</author><author>De Groot, C</author><author>Stevens, W</author><author>Sarfati, D</author><author>Brown, C</author><author>Hill, A, </author><author>Reid, P</author><author>Lawrenson, R</author><author>Findlay, M</author></authors></contributors><titles><title>The PIPER Project - An Internal Examination of Colorectal Cancer Management in New Zealand</title></titles><number>18 February 2019</number><dates><year>2015</year></dates><urls><related-urls><url>(HRC%2011_764%20FINDLAY).pdf </url></related-urls></urls></record></Cite></EndNote>(Jackson et al 2015). There was not a statistically significant difference in 90-day mortality after surgery between Māori and non-Māori/non-Pacific people.SpecificationsNumerator a)Number of people with colorectal cancer who undergo emergency or elective surgical resection who die within 30 or 90 days of surgery.Denominator a)Number of people with colorectal cancer who undergo emergency or elective surgical resection.Numerator b)Number of people with colorectal cancer who undergo neoadjuvant chemoradiotherapy, radiotherapy or adjuvant chemotherapy with curative intent who die within 30 or 90 days of treatment.Denominator b)Number of people with colorectal cancer who undergo neo-adjuvant chemoradiotherapy, radiotherapy or adjuvant chemotherapy with curative intent.ExclusionsNone.Data sources NZCR, NMDS, Mortality Collection, PHARMS, ROC.NotesThis indicator will be reported by treatment modality (ie, chemotherapy, radiotherapy and surgery).Both 30-day and 90-day mortality after surgery (elective and emergency) were reported in 2019.Overall survivalIndicator descriptionOverall survival for people with colorectal cancer at 1, 3, 5 and 10 years from diagnosis by stage.Rationale and evidenceOverall survival is universally recognised as being unambiguous and unbiased, with a defined end point of paramount clinical relevance.Survival provides evidence that the treatment provided has extended the life of people diagnosed with cancer.Equity/Māori health gainThe PIPER study found that five-year overall survival for people diagnosed with colorectal cancer was lower for Māori (42%) than it was for non-Māori/non-Pacific people (51%). 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ADDIN EN.CITE.DATA (Sluijter et al 2016).Equity/Māori health gainNo data was available.SpecificationsNumeratorNumber of people with colorectal cancer who undergo curative surgical resection whose histology is reported in a structured format.DenominatorNumber of people with colorectal cancer who undergo curative surgical resection (with or without neo-adjuvant therapy).ExclusionsPeople with rectal cancer who undergo neoadjuvant therapy.People who undergo transanal endoscopic microsurgery or transanal resection of tumour.Data sourcesNZCR, pathology reports, NMDS.NotesVarying evidence exists regarding the most appropriate target level; this may need redefining in the future, to take account of new evidence or as further data becomes available.The data required for this indicator is not recorded in the NZCR; therefore, this indicator cannot be reported in 2019.Lymph-node yieldIndicator descriptionProportion of people with colorectal cancer who undergo surgical resection where ≥12 lymph nodes are pathologically examined.Rationale and evidenceMaximising the number of lymph nodes resected and analysed enables reliable staging, which influences treatment decision-making ADDIN EN.CITE <EndNote><Cite><Author>RCPA</Author><Year>2016</Year><RecNum>27</RecNum><DisplayText>(RCPA 2016)</DisplayText><record><rec-number>27</rec-number><foreign-keys><key app="EN" db-id="ezt95dfawvtw0kezr9npa0wivxfze9902pwz">27</key></foreign-keys><ref-type name="Standard">58</ref-type><contributors><authors><author>RCPA</author></authors></contributors><titles><title>Colorectal Cancer Structured Reporting Protocol </title></titles><dates><year>2016</year></dates><publisher>Royal College of Pathologists of Australasia</publisher><urls><related-urls><url>;(RCPA 2016).Equity/Māori health gainA previous study showed that, in general, Māori had less lymph nodes removed than non-Māori ADDIN EN.CITE <EndNote><Cite><Author>Hill</Author><Year>2010</Year><RecNum>8</RecNum><DisplayText>(Hill et al 2010b)</DisplayText><record><rec-number>8</rec-number><foreign-keys><key app="EN" db-id="ezt95dfawvtw0kezr9npa0wivxfze9902pwz">8</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Hill, S.</author><author>Sarfati, D.</author><author>Blakely, T.</author><author>Robson, B.</author><author>Purdie, G.</author><author>Dennett, E.</author><author>Cormack, D.</author><author>Dew, K.</author><author>Ayanian, J. Z.</author><author>Kawachi, I.</author></authors></contributors><auth-address>Global Public Health Unit, University of Edinburgh, Edinburgh, United Kingdom. s.e.hill@ed.ac.uk</auth-address><titles><title>Ethnicity and management of colon cancer in New Zealand: do indigenous patients get a worse deal?</title><secondary-title>Cancer</secondary-title><alt-title>Cancer</alt-title></titles><periodical><full-title>Cancer</full-title><abbr-1>Cancer</abbr-1></periodical><alt-periodical><full-title>Cancer</full-title><abbr-1>Cancer</abbr-1></alt-periodical><pages>3205-14</pages><volume>116</volume><number>13</number><edition>2010/06/22</edition><keywords><keyword>Chemotherapy, Adjuvant</keyword><keyword>Colonic Neoplasms/ ethnology/ therapy</keyword><keyword>Ethnic Groups</keyword><keyword>Female</keyword><keyword>Health Services, Indigenous</keyword><keyword>Healthcare Disparities</keyword><keyword>Humans</keyword><keyword>Lymph Node Excision</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>New Zealand</keyword><keyword>Quality of Health Care</keyword></keywords><dates><year>2010</year><pub-dates><date>Jul 01</date></pub-dates></dates><isbn>0008-543X (Print)
0008-543X (Linking)</isbn><accession-num>20564634</accession-num><urls></urls><electronic-resource-num>10.1002/cncr.25127</electronic-resource-num><remote-database-provider>NLM</remote-database-provider><language>eng</language></record></Cite></EndNote>(Hill et al 2010b).SpecificationsNumeratorNumber of people with colorectal cancer who undergo surgical resection where ≥12 lymph nodes are pathologically examined.DenominatorNumber of people with colorectal cancer who undergo surgical resection (with or without neo-adjuvant short course radiotherapy).ExclusionsPeople with rectal cancer who undergo long-course neo-adjuvant chemo radiotherapy or radiotherapy.Data sourcesNZCR, pathology reports, NMDS.NotesBetter documentation of neoadjuvant therapy is needed on the clinical request form. Without this information it is not possible to exclude people undergoing long-course radiotherapy from the data.Pathology reports do not always record whether a person had a curative resection.Indicator results should be presented for rectal and colon cancer separately.Varying evidence exists regarding the most appropriate target level for this indicator; this may need redefining in the future, to take account of new evidence or as further data becomes available.The data required for this indicator is recorded on the NZCR for colon cancer but not for rectal cancer. Due to pre-operative radiotherapy treatment, rectal cancer surgery often occurs more than four months after diagnosis (the period for which the NZCR records these details).This indicator can only be reported for people with colon cancer in 2019.Mismatch repair (MMR)/ microsatellite instability (MSI) testingIndicator descriptionProportion of people with colorectal cancer who have been tested for MMR status on initial diagnosis.Rationale and evidenceTesting for DNA MMR status by immunohistochemistry (IHC) or by MSI can be performed on tumours to determine if the cancer occurred because of Lynch syndrome. This is important, as it has implications not only for the management of the initial tumour but also subsequent screening of the individual affected and their family members. In addition, there is increasing evidence that MMR status may predict response to chemotherapy in all people with colorectal cancer, not just those with Lynch syndrome ADDIN EN.CITE <EndNote><Cite><Author>Ministry of Health</Author><Year>2018</Year><RecNum>28</RecNum><DisplayText>(Ministry of Health 2018 ; RCPA 2016)</DisplayText><record><rec-number>28</rec-number><foreign-keys><key app="EN" db-id="ezt95dfawvtw0kezr9npa0wivxfze9902pwz">28</key></foreign-keys><ref-type name="Standard">58</ref-type><contributors><authors><author>Ministry of Health,</author></authors></contributors><titles><title>Molecular Testing of Colorectal Cancers in New Zealand: Minimum standards for molecular testing of newly diagnosed colorectal cancers</title></titles><dates><year>2018</year></dates><pub-location>Wellington</pub-location><publisher>Ministry of Health</publisher><urls><related-urls><url> February 2019</access-date></record></Cite><Cite><Author>RCPA</Author><Year>2016</Year><RecNum>27</RecNum><record><rec-number>27</rec-number><foreign-keys><key app="EN" db-id="ezt95dfawvtw0kezr9npa0wivxfze9902pwz">27</key></foreign-keys><ref-type name="Standard">58</ref-type><contributors><authors><author>RCPA</author></authors></contributors><titles><title>Colorectal Cancer Structured Reporting Protocol </title></titles><dates><year>2016</year></dates><publisher>Royal College of Pathologists of Australasia</publisher><urls><related-urls><url>;(Ministry of Health 2018 ; RCPA 2016).Equity/Māori health gainNo data was available.SpecificationsNumeratorNumber of people with colorectal cancer who were tested for MMR status on initial diagnosis.DenominatorNumber of people with colorectal cancer who have a tissue diagnosis.ExclusionsNone.Data sourcesNZCR, pathology reports, NMDS.NotesThe current standard refers to IHC for MMR testing but not MSI ADDIN EN.CITE <EndNote><Cite><Author>National Bowel Cancer Tumour Standards Working Group</Author><Year>2013</Year><RecNum>25</RecNum><DisplayText>(National Bowel Cancer Tumour Standards Working Group 2013)</DisplayText><record><rec-number>25</rec-number><foreign-keys><key app="EN" db-id="ezt95dfawvtw0kezr9npa0wivxfze9902pwz">25</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>National Bowel Cancer Tumour Standards Working Group,</author></authors></contributors><titles><title>Standards of Service Provision for Bowel Cancer Patients in New Zealand – Provisional</title></titles><number>18 February 2019</number><dates><year>2013</year></dates><pub-location>Wellington</pub-location><publisher>Ministry of Health</publisher><urls><related-urls><url>;(National Bowel Cancer Tumour Standards Working Group 2013). The target level for testing will be determined after initial analysis of data.The data required for this indicator was not recorded on the NZCR therefor this indicator cannot be reported in 2019.Circumferential resection margin (CRM)Indicator descriptiona)Proportion of people with rectal cancer undergoing surgery with reported CRM.b)Proportion of reported CRMs with a positive margin (less than or equal to 1?mm – R1).Rationale and evidenceInvolvement of the CRM is associated with increased local recurrence, metastatic disease and reduced overall survival ADDIN EN.CITE <EndNote><Cite><Author>Bernstein</Author><Year>2009</Year><RecNum>11</RecNum><DisplayText>(Bernstein et al 2009)</DisplayText><record><rec-number>11</rec-number><foreign-keys><key app="EN" db-id="ezt95dfawvtw0kezr9npa0wivxfze9902pwz">11</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Bernstein, T. E.</author><author>Endreseth, B. H.</author><author>Romundstad, P.</author><author>Wibe, A.</author></authors></contributors><auth-address>Department of Surgery, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway. tor.bernstein@stolav.no</auth-address><titles><title>Circumferential resection margin as a prognostic factor in rectal cancer</title><secondary-title>Br J Surg</secondary-title><alt-title>The British journal of surgery</alt-title></titles><periodical><full-title>Br J Surg</full-title><abbr-1>The British journal of surgery</abbr-1></periodical><alt-periodical><full-title>Br J Surg</full-title><abbr-1>The British journal of surgery</abbr-1></alt-periodical><pages>1348-57</pages><volume>96</volume><number>11</number><edition>2009/10/23</edition><keywords><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Kaplan-Meier Estimate</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Neoplasm Metastasis</keyword><keyword>Neoplasm Recurrence, Local/mortality</keyword><keyword>Rectal Neoplasms/mortality/ surgery</keyword><keyword>Rectum/ surgery</keyword><keyword>Risk Factors</keyword><keyword>Treatment Outcome</keyword></keywords><dates><year>2009</year><pub-dates><date>Nov</date></pub-dates></dates><isbn>1365-2168 (Electronic)
0007-1323 (Linking)</isbn><accession-num>19847867</accession-num><urls></urls><electronic-resource-num>10.1002/bjs.6739</electronic-resource-num><remote-database-provider>NLM</remote-database-provider><language>eng</language></record></Cite></EndNote>(Bernstein et al 2009).Equity/Māori health gainNo data was available.SpecificationsNumeratorNumber of people with rectal cancer who undergo surgical resection where the CRM is reported.Number of people with rectal cancer who undergo surgical resection where the CRM is reported as positive.DenominatorNumber of people with rectal cancer who undergo surgical resection (with or without neo-adjuvant therapy).Number of people with rectal cancer who undergo surgical resection where the CRM was reported.ExclusionsPeople who undergo transanal endoscopic microsurgery or transanal resection of tumour.Data sourcesNZCR, pathology reports, NMDS.NotesA positive CRM is defined as 1?mm, but the current New Zealand standard states < 2?mm PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5OYXRpb25hbCBCb3dlbCBDYW5jZXIgVHVtb3VyIFN0YW5k
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ADDIN EN.CITE.DATA (Glynne-Jones et al 2017).Tumour localisation is vital for operative planning, and should be detailed in all synoptic reports.A standard synoptic template ensures a comprehensive report, including all relevant data items ADDIN EN.CITE <EndNote><Cite><Author>RANZCR</Author><RecNum>63</RecNum><DisplayText>(RANZCR)</DisplayText><record><rec-number>63</rec-number><foreign-keys><key app="EN" db-id="ezt95dfawvtw0kezr9npa0wivxfze9902pwz">63</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>RANZCR</author></authors></contributors><titles><title>NZ Branch guidelines for synoptic reporting of rectal MRI. Recommended synoptic report template and associated minimum dataset</title></titles><number>18 February 2019</number><dates></dates><publisher>RANZCR</publisher><urls><related-urls><url>;(RANZCR).Equity/Māori health gainNo data was available.SpecificationsNumeratorNumber of people with rectal cancer who receive an MRI that is synoptically reported.DenominatorNumber of people with rectal cancer.ExclusionsNone.Data sourcesNZCR, DHB RIS/PACS databases, radiology reports, NMDS.NotesFor some people, a curative/radical treatment approach is clearly not appropriate (eg, extreme age, severe comorbidities or widespread metastatic disease may prohibit it).There is no national collection for radiology data; therefore, this indicator was not reported in 2019.Tumour localisationIndicator descriptionProportion of people with rectal cancer for whom distal tumour margin (tumour height) to anal verge distance is specified on the MRI report.Rationale and evidenceLocalisation of rectal tumours is important for planning surgery, adjuvant therapy and audit.There is no consensus on the best way to localise rectal tumours; several methods are used.It is likely that MRI is the most pragmatic and reproducible method of tumour localisation. Tumour localisation is included as a core data item for synoptic reporting of rectal MRI PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5LZWxsZXI8L0F1dGhvcj48WWVhcj4yMDE0PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Keller et al 2014).Equity/Māori health gainNo data was available.SpecificationsNumeratorNumber of people with rectal cancer for whom distal tumour margin (tumour height) to anal verge distance is specified on the rectal MRI report.DenominatorNumber of people with rectal cancer.ExclusionsNone.Data sourcesNZCR, DHB RIS/PACS databases, radiology reports.NotesThis indicator could be based on endoscopy or rigid sigmoidoscopy, but it is generally agreed that MRI is best practice, especially with low rectal cancer.A paper from 2016 presents a series of MRI-defined low rectal cancers from Oxford. Grading is from the LOREC group in the United Kingdom PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5LdXN0ZXJzPC9BdXRob3I+PFllYXI+MjAxNjwvWWVhcj48
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ADDIN EN.CITE.DATA (Kusters et al 2016).There is no national collection of radiology data; therefore, this indicator was not reported in 2019.RadiotherapyIndicator descriptionProportion of people with non-metastatic rectal cancer who receive:a)no radiotherapy (ie, surgery alone)b)pre-operative short-course radiotherapy (SCRT)c)pre-operative long-course radiotherapy (LCRT).Rationale and evidenceAdjuvant (pre- or post-operative) radiotherapy reduces the risk of pelvic recurrence of rectal cancer, but results in morbidity, so appropriate patient selection for this treatment is important ADDIN EN.CITE <EndNote><Cite><Author>NICE</Author><Year>November 2011</Year><RecNum>29</RecNum><DisplayText>(NICE November 2011)</DisplayText><record><rec-number>29</rec-number><foreign-keys><key app="EN" db-id="ezt95dfawvtw0kezr9npa0wivxfze9902pwz">29</key></foreign-keys><ref-type name="Standard">58</ref-type><contributors><authors><author>NICE</author></authors></contributors><titles><title>Colorectal cancer: diagnosis and management</title></titles><dates><year>November 2011</year></dates><publisher>National Institute for Health and Care Excellence</publisher><urls><related-urls><url>;(NICE November 2011).Pre-operative radiotherapy results in fewer long-term side effects than post-operative radiotherapy PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TYXVlcjwvQXV0aG9yPjxZZWFyPjIwMTI8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (Sauer et al 2012).The current New Zealand guidelines for the management of early colorectal cancer recommend either pre-operative SCRT or pre-operative long-course chemoradiation for people with rectal cancer who are at risk of local recurrence ADDIN EN.CITE <EndNote><Cite><Author>NZGG</Author><Year>2011</Year><RecNum>30</RecNum><DisplayText>(NZGG 2011)</DisplayText><record><rec-number>30</rec-number><foreign-keys><key app="EN" db-id="ezt95dfawvtw0kezr9npa0wivxfze9902pwz">30</key></foreign-keys><ref-type name="Standard">58</ref-type><contributors><authors><author>NZGG</author></authors></contributors><titles><title>Management of Early Colorectal Cancer – Evidence-based Best Practice Guidelines</title></titles><dates><year>2011</year></dates><pub-location>Wellington</pub-location><publisher>New Zealand Guidelines Group</publisher><urls></urls></record></Cite></EndNote>(NZGG 2011). Pre-operative long-course chemoradiation is recommended for people who have a low rectal cancer or a threatened CRM ADDIN EN.CITE <EndNote><Cite><Author>NICE</Author><Year>November 2011</Year><RecNum>29</RecNum><DisplayText>(NICE November 2011)</DisplayText><record><rec-number>29</rec-number><foreign-keys><key app="EN" db-id="ezt95dfawvtw0kezr9npa0wivxfze9902pwz">29</key></foreign-keys><ref-type name="Standard">58</ref-type><contributors><authors><author>NICE</author></authors></contributors><titles><title>Colorectal cancer: diagnosis and management</title></titles><dates><year>November 2011</year></dates><publisher>National Institute for Health and Care Excellence</publisher><urls><related-urls><url>;(NICE November 2011).Short-course radiotherapy is more convenient for patients, has fewer short-term side effects and uses fewer health resources PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CdWprbzwvQXV0aG9yPjxZZWFyPjIwMDQ8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (Bujko et al 2004).Equity/Māori health gainNo data was available.Specifications a)NumeratorNumber of people with non-metastatic rectal cancer who have not received pre-operative radiotherapy.DenominatorNumber of people with non-metastatic rectal cancer who have received definitive surgery.ExclusionsNone.Specifications b)NumeratorNumber of people with non-metastatic rectal cancer who have received short-course pre-operative radiotherapy.DenominatorNumber of people with non-metastatic rectal cancer who have received definitive surgery.ExclusionsNone.Specifications c)NumeratorNumber of people with non-metastatic rectal cancer who have received long-course pre-operative radiotherapy.DenominatorNumber of people with non-metastatic rectal cancer who have received definitive surgery.ExclusionsNone.Data sourcesNZCR, ROC, NMDS.NotesIdeally indicator 16c results will be presented by R0 and R1 rates, as all people with anticipated positive (R1) resection margins should receive long-course pre-operative radiotherapy.This indicator can only be reported in 2019 for all (non-metastatic and metastatic) rectal cancer patients, as TNM group stage is not available to identify people with metastatic disease on the NZCR.Adjuvant chemotherapyIndicator descriptiona)Proportion of people with stage III colon cancer who receive adjuvant chemotherapy.b)Proportion of people with stage III colon cancer who receive adjuvant chemotherapy within eight weeks.Rationale and evidenceAdjuvant chemotherapy in stage III colon cancer has been shown to significantly improve overall survival PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5BbmRyZTwvQXV0aG9yPjxZZWFyPjIwMTU8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (Andre et al 2015).The PIPER study found that 59?percent of people with stage III colon cancer received adjuvant chemotherapy.The evidence for adjuvant chemotherapy in rectal cancer is more contentious.People with high-risk stage II colon cancer derive benefit from adjuvant chemotherapy, although the risk–benefit ratio varies considerably between patients.Subgroups of people with stage III colon cancer benefit from the addition of oxaliplatin to fluoropyrimidine chemotherapy, although not all people derive benefit PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5BbmRyZTwvQXV0aG9yPjxZZWFyPjIwMTU8L1llYXI+PFJl
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ADDIN EN.CITE.DATA (Andre et al 2015).The recommended duration of adjuvant chemotherapy is currently under review.Time to commencement of chemotherapy has been shown to correlate with benefit; statistical modelling suggests that starting chemotherapy within four weeks of surgery is associated with greater predicted benefit ADDIN EN.CITE <EndNote><Cite><Author>Biagi</Author><Year>2011</Year><RecNum>10</RecNum><DisplayText>(Biagi et al 2011)</DisplayText><record><rec-number>10</rec-number><foreign-keys><key app="EN" db-id="ezt95dfawvtw0kezr9npa0wivxfze9902pwz">10</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Biagi, J. J.</author><author>Raphael, M. J.</author><author>Mackillop, W. J.</author><author>Kong, W.</author><author>King, W. D.</author><author>Booth, C. M.</author></authors></contributors><auth-address>Department of Oncology, Queen's University, Kingston, Ontario, Canada. jim.biagi@krcc.on.ca</auth-address><titles><title>Association between time to initiation of adjuvant chemotherapy and survival in colorectal cancer: a systematic review and meta-analysis</title><secondary-title>JAMA</secondary-title><alt-title>Jama</alt-title></titles><periodical><full-title>JAMA</full-title><abbr-1>Jama</abbr-1></periodical><alt-periodical><full-title>JAMA</full-title><abbr-1>Jama</abbr-1></alt-periodical><pages>2335-42</pages><volume>305</volume><number>22</number><edition>2011/06/07</edition><keywords><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Chemotherapy, Adjuvant</keyword><keyword>Colorectal Neoplasms/ drug therapy/surgery</keyword><keyword>Disease-Free Survival</keyword><keyword>Drug Administration Schedule</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Survival Analysis</keyword><keyword>Time Factors</keyword><keyword>Treatment Outcome</keyword></keywords><dates><year>2011</year><pub-dates><date>Jun 08</date></pub-dates></dates><isbn>1538-3598 (Electronic)
0098-7484 (Linking)</isbn><accession-num>21642686</accession-num><urls></urls><electronic-resource-num>10.1001/jama.2011.749</electronic-resource-num><remote-database-provider>NLM</remote-database-provider><language>eng</language></record></Cite></EndNote>(Biagi et al 2011). This modelling has not been verified in a randomised study.Equity/Māori health gainThe PIPER study found that utilisation of chemotherapy diminished with people’s age and increasing comorbidities ADDIN EN.CITE <EndNote><Cite><Author>Jackson</Author><Year>2015</Year><RecNum>20</RecNum><DisplayText>(Jackson et al 2015)</DisplayText><record><rec-number>20</rec-number><foreign-keys><key app="EN" db-id="ezt95dfawvtw0kezr9npa0wivxfze9902pwz">20</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>Jackson, C</author><author>Sharples, K</author><author>Firth, M</author><author>Hinder, V</author><author>Jeffery, M</author><author>Keating, J</author><author>Secker, A</author><author>Derrett, S</author><author>Atmore, S</author><author>Bramley, D</author><author>De Groot, C</author><author>Stevens, W</author><author>Sarfati, D</author><author>Brown, C</author><author>Hill, A, </author><author>Reid, P</author><author>Lawrenson, R</author><author>Findlay, M</author></authors></contributors><titles><title>The PIPER Project - An Internal Examination of Colorectal Cancer Management in New Zealand</title></titles><number>18 February 2019</number><dates><year>2015</year></dates><urls><related-urls><url>(HRC%2011_764%20FINDLAY).pdf </url></related-urls></urls></record></Cite></EndNote>(Jackson et al 2015).A previous study found that Māori were slightly less likely to receive adjuvant therapy compared to non-Māori, and were more likely to have a prolonged delay prior to commencement of chemotherapy ADDIN EN.CITE <EndNote><Cite><Author>Hill</Author><Year>2010</Year><RecNum>8</RecNum><DisplayText>(Hill et al 2010b)</DisplayText><record><rec-number>8</rec-number><foreign-keys><key app="EN" db-id="ezt95dfawvtw0kezr9npa0wivxfze9902pwz">8</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Hill, S.</author><author>Sarfati, D.</author><author>Blakely, T.</author><author>Robson, B.</author><author>Purdie, G.</author><author>Dennett, E.</author><author>Cormack, D.</author><author>Dew, K.</author><author>Ayanian, J. Z.</author><author>Kawachi, I.</author></authors></contributors><auth-address>Global Public Health Unit, University of Edinburgh, Edinburgh, United Kingdom. s.e.hill@ed.ac.uk</auth-address><titles><title>Ethnicity and management of colon cancer in New Zealand: do indigenous patients get a worse deal?</title><secondary-title>Cancer</secondary-title><alt-title>Cancer</alt-title></titles><periodical><full-title>Cancer</full-title><abbr-1>Cancer</abbr-1></periodical><alt-periodical><full-title>Cancer</full-title><abbr-1>Cancer</abbr-1></alt-periodical><pages>3205-14</pages><volume>116</volume><number>13</number><edition>2010/06/22</edition><keywords><keyword>Chemotherapy, Adjuvant</keyword><keyword>Colonic Neoplasms/ ethnology/ therapy</keyword><keyword>Ethnic Groups</keyword><keyword>Female</keyword><keyword>Health Services, Indigenous</keyword><keyword>Healthcare Disparities</keyword><keyword>Humans</keyword><keyword>Lymph Node Excision</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>New Zealand</keyword><keyword>Quality of Health Care</keyword></keywords><dates><year>2010</year><pub-dates><date>Jul 01</date></pub-dates></dates><isbn>0008-543X (Print)
0008-543X (Linking)</isbn><accession-num>20564634</accession-num><urls></urls><electronic-resource-num>10.1002/cncr.25127</electronic-resource-num><remote-database-provider>NLM</remote-database-provider><language>eng</language></record></Cite></EndNote>(Hill et al 2010b).SpecificationsNumeratorNumber of people with stage III colon cancer with resection of primary tumour who receive a single dose of chemotherapy (count prescription of oral chemotherapy as ‘received’).DenominatorNumber of people with stage III colon cancer (not rectal) who have undergone resection of the primary tumour and are alive at 12 weeks post-operatively.ExclusionsPeople with rectal cancer.People who die within 90 days of surgery.Data sourcesNZCR, pathology reports, NMDS, PHARMS, local chemotherapy databases.NotesThis is an important indicator in terms of equity.Limited chemotherapy prescribing data is available in the PHARMS dataset. This indicator is also dependent on TNM group stage. Data on TNM group stage to identify people with stage III colon cancer is not consistently available from the NZCR.This indicator cannot be reported in 2019.Metastatic colorectal cancer chemotherapyIndicator descriptionProportion of people with metastatic colorectal cancer receiving chemotherapy.Rationale and evidencePeople with stage IV colorectal cancer who have adequate ECOG performance status (ECOG grade 0–2) who are treated with fluoropyrimidine chemotherapy have improved duration of survival and improved quality of life, compared to those who receive supportive care alone PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5DdW5uaW5naGFtPC9BdXRob3I+PFllYXI+MTk5ODwvWWVh
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ADDIN EN.CITE.DATA (Cunningham et al 1998).The addition of oxaliplatin and irinotecan to fluoropyrimidine chemotherapy improves overall survival in those with stage IV colorectal cancer PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Hcm90aGV5PC9BdXRob3I+PFllYXI+MjAwNDwvWWVhcj48
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ADDIN EN.CITE.DATA (Grothey et al 2004).Clinically meaningful and statistically significant improvements in overall survival have been seen in people with metastatic colorectal cancer, left-sided primary tumour and all people with RAS wild-type status who receive cetuximab or panitumumab PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CZW5zb248L0F1dGhvcj48WWVhcj4yMDE3PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA (Benson et al 2017). These agents are not presently funded in New Zealand.Modest improvements in overall survival have been seen with the use of bevacizumab, regorafinib, aflibercept and TAS 102. These agents are not presently funded in New Zealand.Equity/Māori health gainChemotherapy may be underutilised for people with bowel cancer who have comorbidities PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TYXJmYXRpPC9BdXRob3I+PFllYXI+MjAwOTwvWWVhcj48
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ADDIN EN.CITE.DATA (Sarfati et al 2009).The PIPER study found that there were no clear trends in the proportion of people receiving chemotherapy by ethnicity, although these analyses were unadjusted, and further potentially important information may be yet be discovered ADDIN EN.CITE <EndNote><Cite><Author>Jackson</Author><Year>2015</Year><RecNum>20</RecNum><DisplayText>(Jackson et al 2015)</DisplayText><record><rec-number>20</rec-number><foreign-keys><key app="EN" db-id="ezt95dfawvtw0kezr9npa0wivxfze9902pwz">20</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>Jackson, C</author><author>Sharples, K</author><author>Firth, M</author><author>Hinder, V</author><author>Jeffery, M</author><author>Keating, J</author><author>Secker, A</author><author>Derrett, S</author><author>Atmore, S</author><author>Bramley, D</author><author>De Groot, C</author><author>Stevens, W</author><author>Sarfati, D</author><author>Brown, C</author><author>Hill, A, </author><author>Reid, P</author><author>Lawrenson, R</author><author>Findlay, M</author></authors></contributors><titles><title>The PIPER Project - An Internal Examination of Colorectal Cancer Management in New Zealand</title></titles><number>18 February 2019</number><dates><year>2015</year></dates><urls><related-urls><url>(HRC%2011_764%20FINDLAY).pdf </url></related-urls></urls></record></Cite></EndNote>(Jackson et al 2015).SpecificationsNumeratorNumber of people with stage IV colorectal cancer who receive at least a single dose of chemotherapy (count prescription of oral chemotherapy as ‘received’).DenominatorNumber of people with stage IV colorectal cancer.Exclusions(Potentially) people who die within 30 days of diagnosis.Data sourcesNZCR, pathology reports, NMDS, PHARMS, local chemotherapy databases.NotesLimited chemotherapy prescribing data is available in the PHARMS dataset. This indicator is also dependent on the availability of data on TNM group stage to identify people with stage?IV cancer. Data on TNM group stage is not available from the NZCR therefore this indicator cannot be reported in 2019.Emergency surgeryIndicator descriptionProportion of people with colorectal cancer undergoing major resection who have emergency surgery.Rationale and evidencePeople having emergency major resection for colorectal cancer have increased mortality, morbidity and stoma formation. These people are also less likely to be treated with curative intent ADDIN EN.CITE <EndNote><Cite><Author>HQIP</Author><Year>2016</Year><RecNum>26</RecNum><DisplayText>(HQIP 2016)</DisplayText><record><rec-number>26</rec-number><foreign-keys><key app="EN" db-id="ezt95dfawvtw0kezr9npa0wivxfze9902pwz">26</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>HQIP</author></authors></contributors><titles><title>National Bowel Cancer Audit Annual Report </title></titles><number>18 February 2019</number><dates><year>2016</year></dates><publisher>Healthcare Quality Improvement Partnership Ltd</publisher><urls><related-urls><url>;(HQIP 2016).Equity/Māori health gainNo data was available.SpecificationsNumeratorNumber of people undergoing major resection for colorectal cancer following an emergency admission.DenominatorNumber of people having major colonic resection for colorectal cancer.ExclusionsPeople who undergo transanal endoscopic microsurgery, transanal resection of tumour or endoscopic resection.Data sourcesNZCR, NMDS.NotesThis indicator can be reported in 2019.Unplanned return to theatreIndicator descriptionProportion of people with an unplanned return to theatre within 30 days of surgery for colorectal cancer.Rationale and evidencePrevious studies have reported large variation in unplanned return to theatre rates ADDIN EN.CITE <EndNote><Cite><Author>Burns</Author><Year>2011</Year><RecNum>5</RecNum><DisplayText>(Burns et al 2011)</DisplayText><record><rec-number>5</rec-number><foreign-keys><key app="EN" db-id="ezt95dfawvtw0kezr9npa0wivxfze9902pwz">5</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Burns, Elaine M</author><author>Bottle, Alex</author><author>Aylin, Paul</author><author>Darzi, Ara</author><author>Nicholls, R John</author><author>Faiz, Omar</author></authors></contributors><titles><title>Variation in reoperation after colorectal surgery in England as an indicator of surgical performance: retrospective analysis of Hospital Episode Statistics</title><secondary-title>BMJ</secondary-title></titles><periodical><full-title>BMJ</full-title></periodical><pages>d4836</pages><volume>343</volume><dates><year>2011</year></dates><urls></urls><electronic-resource-num>10.1136/bmj.d4836</electronic-resource-num></record></Cite></EndNote>(Burns et al 2011).Unplanned return to theatre and other unplanned procedures are markers of serious post-operative complications ADDIN EN.CITE <EndNote><Cite><Author>Morris</Author><Year>2007</Year><RecNum>6</RecNum><DisplayText>(Morris et al 2007)</DisplayText><record><rec-number>6</rec-number><foreign-keys><key app="EN" db-id="ezt95dfawvtw0kezr9npa0wivxfze9902pwz">6</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Morris, Arden M.</author><author>Baldwin, Laura-Mae</author><author>Matthews, Barbara</author><author>Dominitz, Jason A.</author><author>Barlow, William E.</author><author>Dobie, Sharon A.</author><author>Billingsley, Kevin G.</author></authors></contributors><titles><title>Reoperation as a Quality Indicator in Colorectal Surgery: A Population-Based Analysis</title><secondary-title>Annals of Surgery</secondary-title></titles><periodical><full-title>Annals of Surgery</full-title></periodical><pages>73-79</pages><volume>245</volume><number>1</number><dates><year>2007</year></dates><isbn>0003-4932
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ADDIN EN.CITE.DATA (van Westreenen et al 2011).Equity/Māori health gainNo data was available.SpecificationsNumeratorNumber of people undergoing major resection for colorectal cancer with an unplanned return to theatre for an intra-abdominal procedure or wound complication within 30 days.DenominatorNumber of people undergoing major resection for colorectal cancer.ExclusionsPeople undergoing surgery for central line placement and closure of ileostomy.Data sourcesNZCR, NMDS.NotesThis indicator was developed in 2018, but local DHB auditing revealed inconsistencies between national and local results.This indicator cannot be reported in 2019.Stoma-free survivalIndicator descriptionProportion of people with rectal cancer with stoma-free survival at 18 months after major resection.Rationale and evidenceEffective MDT planning and surgical technique may lower the rate of permanent colostomy and ileostomy. There is variation in the rate of abdominoperineal resection (APER) for low rectal cancer, and an approximate 25?percent rate of permanent ileostomy following low anterior resection.The APER rate is simple to measure, but evidence supporting the APER rate as a quality marker is weak PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Kb3JnZW5zZW48L0F1dGhvcj48WWVhcj4yMDEzPC9ZZWFy
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ADDIN EN.CITE.DATA (Jorgensen et al 2013).Stoma-free survival is an important outcome and quality-of-life measure.Equity/Māori health gainNo data was available.SpecificationsNumeratorNumber of people who are alive and stoma-free at 18 months after major resection.DenominatorNumber of people who undergo major resection for rectal cancer.ExclusionsPeople who undergo transanal endoscopic microsurgery, transanal resection of tumour or endoscopic resection of tumour.People who die within 18 months of surgery.Data sourcesNZCR, NMDS.NotesThis is a complex quality marker, due to confounding variables (it requires definition and accurate recording of low rectal cancer). This indicator has been selected instead of the APER rate, to avoid inadvertently promoting an increase in ultra-low anterior resection rates to meet a weak marker of quality.This indicator can be reported in 2019.Appendix 1: Working group members 2018The bowel cancer quality indicator group members were:Dr Christopher Jackson (chair), medical oncologist, Southern District Health BoardProfessor Ian Bissett (deputy chair), colorectal surgeon, Auckland District Health Board/University of AucklandMr Christopher Harmston, general and colorectal surgeon, Northland District Health BoardDr Sarah Derrett, consumer, Bowel Cancer New ZealandDr Joe Feltham, radiologist, Capital and Coast District Health BoardDr Nicole Kramer, pathologist, Auckland District Health BoardDr Iain Ward, radiation oncologist, Canterbury District Health BoardDr Janet Hayward, general practitioner, Nelson.The National Bowel Cancer Working Group members in 2018 were:Professor Ian Bissett (chair), colorectal surgeon, Auckland District Health Board/University of AucklandDr Christopher Jackson (deputy chair), medical oncologist, Southern District Health BoardMr Adrian Secker, general surgeon, Nelson Marlborough District Health BoardAnne Cleland, gastroenterology nurse, MidCentral District Health BoardMr David Vernon, general surgeon, Lakes District Health BoardDenise Robbins, consumer representativeDr Helen Moore, radiologist, Auckland District Health BoardDr Iain Ward, radiation oncologist, Canterbury District Health BoardDr Janet Hayward, general practitioner, NelsonDr Joe Feltham, radiologist, Capital and Coast District Health BoardDr John McMenamin, general practitioner, WhanganuiJudith Warren, cancer nurse, Waikato District Health BoardDr Marianne Lill, general surgeon, Whanganui District Health BoardDr Nicole Kramer, pathologist, Auckland District Health BoardDr Nina Scott (Ngāti Whatua), public health physician, WaikatoMr Ralph Van Dalen, colorectal surgeon, Waikato District Health BoardMr Siraj Rajaratnam, general and colorectal surgeon and endoscopist, Waitemata District Health BoardAssociate Professor Susan Parry, gastroenterologist, Auckland District Health BoardDr Teresa Chalmers-Watson, gastroenterologist and hepatologist, Canterbury District Health Board.Appendix 2: Initial assessment of availability of national data for calculating indicatorsQI noIndicator titleIndicator descriptionNational data available?Data requiredData sourceSite1TNM group stageSurgeryChemotherapyRadiotherapyDeathOtherNZCRPathology reportRadiology reportNMDSNNPAC/ ROCPHARMSMDMMortalityCR1Route to diagnosisProportion of people with cancer who are diagnosed following a referral to a clinic, screening or presentation to an emergency department (with or without surgery)Yes2Timeliness of treatment following diagnosisTime from first histological diagnosis to first definitive treatmentYes3Stage at diagnosisProportion of people with colorectal cancer by stage of diagnosisNox4Multidisciplinary discussionProportion of people with colorectal cancer discussed at a multidisciplinary meeting (MDM)Noxx6Clinical trial participationProportion of people with colorectal cancer in a clinical trialNoxx7Treatment survivalProportion of people with colorectal cancer who died within 30 or 90 days of treatment (surgery, chemotherapy, radiotherapy)Yes8Overall survivalOverall survival for people with colorectal cancer at 1, 3, 5 and 10 years from diagnosis by stageNox9Structured pathology reportingProportion of people with colorectal cancer who undergo surgical resection whose histology is reported in a structured formatNox10Lymph-node yieldProportion of people with colorectal cancer who undergo surgical resection where ≥12 lymph nodes are pathologically examinedYes11Mismatch repair (MMR)/microsatellite instability (MSI) testingProportion of people with colorectal cancer who have been tested for MMR status on initial diagnosisNox12aCircumferential margin (CRM)a)Proportion of people with rectal cancer undergoing surgery with reported CRMNox12bCircumferential margin (CRM)b)Proportion of reported CRMs with a positive margin (less than or equal to 1mm – R1)Nox13aIntegrity of mesorectuma)Proportion of people with rectal cancer where mesorectal intactness/grade is documentedNox13bIntegrity of mesorectumb)Proportion of each mesorectal grade/ degree of intactness for rectal cancersNox14Rectal MRI reportingProportion of people with rectal cancer who receive an MRI that is synoptically reportedNoxx15Tumour localisationProportion of people with rectal cancer for whom distal tumour margin (tumour height) to anal verge distance is specified on the MRI reportNoxx16RadiotherapyProportion of people with non-metastatic rectal cancer who receive:a)no radiotherapy (ie, surgery alone)b)pre-operative short-course radiotherapy (SCRT)c)pre-operative long-course radiotherapy (LCRT)Nox17Adjuvant chemotherapya)Proportion of people with stage III colon cancer who receive adjuvant chemotherapyb)Proportion of people with stage III colon cancer who receive adjuvant chemotherapy within eight weeksNox18Metastatic colorectal cancer chemotherapyProportion of people with metastatic colorectal cancer receiving chemotherapyNox19Emergency surgeryProportion of people with colorectal cancer undergoing major resection who have emergency surgeryYes20Unplanned return to theatreProportion of people with an unplanned return to theatre within 30 days of surgery for colorectal cancerYes21Stoma-free survivalProportion of people with rectal cancer with stoma-free survival at 18 months after major resectionYesDescriptive measures5Length of stay after surgeryMedian length of stay following surgery for colorectal cancerYes1C – colon, R – rectumAppendix 3: Stratifying?variablesIn addition to DHB and regional cancer network, the indicators will be stratified by the following variables where possible:agesexethnicity (Māori, Pacific, Asian, European/Other)socioeconomic 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ADDIN EN.CITE.DATA (Sarfati et al 2014a ; Sarfati et al 2014b).AbbreviationsAPERabdominoperineal resectionAJCCAmerican Joint Committee on CancerCRMcircumferential resection marginDHBdistrict health boardIHCimmunohistochemistryLCRTlong-course pre-operative radiotherapyMDMmultidisciplinary meetingMDTmultidisciplinary teamMMRmismatch repairMRImagnetic resonance imagingMSImicrosatellite instabilityNBCWGNational Bowel Cancer Working GroupNMDSNational Minimum DatasetNNPACNational Non-Admitted Patients CollectionNZCRNew Zealand Cancer RegistryPACSpicture archiving and communications systemsPHARMSPharmaceutical CollectionQPIquality performance indicatorRISradiology information system ROCRadiation Oncology CollectionSCRTpre-operative short-course radiotherapyTNMtumour, node, metastasesUICCUnion for International Cancer ControlReferences ADDIN EN.REFLIST Amin MB, Edge S, Greene F, et al, eds. 2017. 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Assessment of abdominoperineal resection rate as a surrogate marker of hospital quality in rectal cancer surgery. Br J Surg 100(12): 1655-63.Keller DS, Paspulati R, Kjellmo A, et al. 2014. MRI-defined height of rectal tumours. Br J Surg 101(2): 127-32.Kusters M, Slater A, Betts M, et al. 2016. The treatment of all MRI-defined low rectal cancers in a single expert centre over a 5-year period: is there room for improvement? Colorectal Dis 18(11): O397-O404.MacFarlane JK, Ryall RD, Heald RJ. 1993. Mesorectal excision for rectal cancer. Lancet 341(8843): 457-60.Maslekar S, Sharma A, Macdonald A, et al. 2007. Mesorectal grades predict recurrences after curative resection for rectal cancer. Dis Colon Rectum 50(2): 168-75.McPhail S, Johnson S, Greenberg D, et al. 2015. Stage at diagnosis and early mortality from cancer in England. British Journal Of Cancer 112: S108.Ministry of Health. 2018. Molecular Testing of Colorectal Cancers in New Zealand: Minimum standards for molecular testing of newly diagnosed colorectal cancers. Wellington: Ministry of Health.Morris AM, Baldwin L-M, Matthews B, et al. 2007. Reoperation as a Quality Indicator in Colorectal Surgery: A Population-Based Analysis. Annals of Surgery 245(1): 73-9.National Bowel Cancer Tumour Standards Working Group. 2013. Standards of Service Provision for Bowel Cancer Patients in New Zealand – Provisional. URL: (accessed 18 February 2019).NICE. November 2011. Colorectal cancer: diagnosis and management. National Institute for Health and Care Excellence.NZGG. 2011. Management of Early Colorectal Cancer – Evidence-based Best Practice Guidelines. Wellington: New Zealand Guidelines Group.RANZCR. NZ Branch guidelines for synoptic reporting of rectal MRI. Recommended synoptic report template and associated minimum dataset. URL: (accessed 18 February 2019).RCPA. 2016. Colorectal Cancer Structured Reporting Protocol Royal College of Pathologists of Australasia.Sarfati D, Gurney J, Stanley J, et al. 2014a. Development of a pharmacy-based comorbidity index for patients with cancer. Med Care 52(7): 586-93.Sarfati D, Gurney J, Stanley J, et al. 2014b. Cancer-specific administrative data-based comorbidity indices provided valid alternative to Charlson and National Cancer Institute Indices. J Clin Epidemiol 67(5): 586-95.Sarfati D, Hill S, Blakely T, et al. 2009. The effect of comorbidity on the use of adjuvant chemotherapy and survival from colon cancer: a retrospective cohort study. BMC Cancer 9: 116.Sauer R, Liersch T, Merkel S, et al. 2012. Preoperative versus postoperative chemoradiotherapy for locally advanced rectal cancer: results of the German CAO/ARO/AIO-94 randomized phase III trial after a median follow-up of 11 years. J Clin Oncol 30(16): 1926-33.Sharples KJ, Firth MJ, Hinder VA, et al. 2018. The New Zealand PIPER Project: colorectal cancer survival according to rurality, ethnicity and socioeconomic deprivation-results from a retrospective cohort study. N Z Med J 131(1476): 24-39.Sluijter CE, van Lonkhuijzen LR, van Slooten HJ, et al. 2016. The effects of implementing synoptic pathology reporting in cancer diagnosis: a systematic review. Virchows Arch 468(6): 639-49.van Westreenen HL, Ijpma FF, Wevers KP, et al. 2011. Reoperation after colorectal surgery is an independent predictor of the 1-year mortality rate. Dis Colon Rectum 54(11): 1438-42. ................
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