How Well Do We Look After Men with Prostate Cancer?

Quality Corner

Fundamentally, we all want to provide the highest quality care for the patients we manage with radiation therapy (RT). How can we know we do this?

The new Australian and New Zealand Prostate Cancer Outcomes Registry (PCOR-ANZ) radiation oncology clinical quality indicator (CQI) reports are a good start for radiation oncologists and RT units looking after men with prostate cancer.

The initial two biannual PCOR reports have been released in a ‘slow roll-out’ fashion across Australia and NZ, and these twice-yearly reports will—in the fullness of time—go to all participating RT units and clinicians treating significant numbers of men with prostate cancer, to provide feedback on the patterns of presentation and care for the men they look after, and their outcomes; as well as providing comparison with deidentified peers from their jurisdiction.

Also, the reports for radiation oncologists and for RT units provide summary statistics on the origin and referral pathways for the patients managed with RT in the context of pathways for all the prostate cancer diagnoses in the states.

PCOR has been providing surgical quality reports on a biannual basis since 2016, and the RO reports were based on this experience. The QIs for prostate RO care were selected from the published literature and a survey, and then honed using a ‘Delphi process’ involving radiation oncologists David Pryor, Marketa Skala, Andrew Kneebone, Peppe Sasso, Hany Elsaleh, and Jeremy Millar. The reports were then developed in a co-design process working with data-scientists at Monash, to create the PDF reports generated by R Markdown from the data outputs from PCOR.

The RO clinical quality indicator reports are intended as individualised reports to ROs (indexed on the RO, irrespective of the facility site) and to RO sites (indexed on the facility site, irrespective of the RO). They thus provide two perspectives of the same large dataset. They are intended as part of a quality-improvement loop, and to be an ongoing ‘conversation’ between clinicians/facilities and PCOR to encourage improvements in the registry, the reports, and the care.

As well as the overall statistics, the secured and confidential reports also detail names of men who report back to PCOR that they have very poor qualityof-life symptom outcomes, so sites and clinicians can be made aware of these (if they don’t know).

PCOR hopes they will be interesting and informative to recipients and might provoke quality-improvement efforts similar to those seen by surgeons with the surgical reports.

The reports are almost 30 pages long, and provide statistics and figures conveying descriptive statistics on the men looked after, and comparative and longitudinal information on the seven quality indicators based on process and outcome measures.

These bespoke, personalised quality reports are enabled by the RANZCR-endorsed Movember-funded PCORANZ. PCOR is also endorsed by COSA, USANZ, MOGA, CCA, and Cancer Australia. The Australian Commission on Safety and Quality in Health Care (ACSQHC) has listed PCOR-ANZ as a nationally prioritised clinical quality registry. The PCOR-ANZ is a federated quality registry, operating in accordance with the operational and governance principles incorporated in the ACSQHC ‘Framework for Australian clinical quality registries’ across all jurisdictions in Australia and New Zealand except (so far) West Australia, on a population-incidencediagnosis and opt-off consent basis.

Men are registered by a PCOR instance in each jurisdiction, and all combine and consolidate a common dataset in the PCOR-ANZ registry administered at Monash University in Melbourne with almost 75,000 men registered in PCOR-ANZ (from 2015) and in preexisting associated South Australian and Victorian registries. PCOR is particularly remarkable because it also collects, among other outcome datapoints, patient-reported outcomes measures (PROMs), directly from the patient, and using a standardised, validated, reliable, widely-employed prostate quality-oflife survey instrument. Two hundred and fifty sites participate, about evenly spread public and private; 382 clinicians participate (341 urologists, 23 radiation oncologists, and 18 medical oncologists); and PCOR distributes well over 1,000 individualised reports a year, on a biannual basis, via the jurisdictional PCORs.

Radiation oncologists make up a significant group of people in the PCORANZ leadership groups, for example Farhan Syed, Marketa Skala, Wee Loon Ong, Jeremy Millar, David Pryor, Saad Maqsood, and Doug Iupati. At a state level many more are involved. The leadership groups contain diverse group from many clinical, geographic and academic backgrounds; the Chair of the ANZ Governance Group is Professor Frank Frizzel, an academic colorectal surgeon and Editor-in-Chief of the New Zealand Medical Journal.

PCOR has a wide range of activities apart from CQI reports, and collects and contains a wealth of data; PCOR encourages ROs with project and research ideas to partner with PCOR to make best use of the resource. The RO reports are a ‘first draft’ and PCOR expects and hopes to have feedback to allow improvements both in the data quality and in the report style and format. In turn PCOR hopes that these reports will stimulate and enable local quality improvement efforts in the RO management of men with prostate cancer.

In the broader radiation oncology quality effort, this type of clinical quality registry will become increasingly fundamental in cancer health care as part of the digital information framework promoted by the new Australian National Cancer plan. Already the College is in a process of endorsing another registry, the binational colorectal cancer registry, and other cancer registries have been prioritised by the government: breast, lymphoma, and lung. We will start to see more of these, as well as reports for these, and ROs might be wise to get involved and become familiar with them to ensure that the registry and reports are fit-for-purpose as cancer care quality registries by recognising the important role RT plays in the care of patients with cancers. This is the mechanism by which we can get closest to knowing about the quality of care we provide.

Prof Jeremy Millar Chair | Quality Improvement Committee