Quality indicators
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The registry's specific quality indicators
Currently, none of the registry's quality indicators have the status of national quality indicators. The Cancer Registry of Norway and the Gynecological Cancer Registry's advisory board collaborate with the Norwegian Directorate of Health, to give a selection of the professional community's quality indicators national status.
The quality indicators are largely based on national and European recommendations/guidelines. The advisory board evaluates the indicators every year and, if necessary, adjusts in accordance with the latest knowledge.
Quality indicators for ovarian cancer:
The indicator target for the use of CT thorax/abdomen/pelvis and/or MRI of the pelvis in the investigation of ovarian cancer is achieved at the national level in 2023, with a rate of 97.3 %. However, the indicator target for conducting MDT meetings during the investigation of ovarian cancer is not met at the national level in 2023, with 79.4 % of patients.
The proportion of patients who undergo surgery varies depending on where they live. Nationally, 70.5 % of patients are operated on. The extremes in this report are Helse Midt-Norge, where 67.8 % of patients were operated on in 2023, compared to 73.4 % of patients in Helse Vest. This varies somewhat from year to year, but the trend is that the variation is decreasing. The results also show variation within the health regions based on where the patient lives.
Nationally, 87.7 % of surgeries were performed at one of the country's hospitals with specialized competence in 2023. This is a slight increase from previous years. Centralization is recommended to ensure the quality of treatment and is also considered more cost-effective.
An important indicator of good surgery is the absence of residual tumor. The indicator target for the absence of residual tumor after surgery for advanced ovarian cancer is set at a minimum of 65 %. In 2023, 79.9 % of the patient group in Norway had no residual tumor after surgery. This proportion has remained consistently high in recent years. This may reflect good surgical practice but also that hospitals have become better at selecting patients for surgery.
This is the second annual report where medicinal treatment is included. The results suggest somewhat different practices among health regions in the use of chemotherapy at stage I. At stages II-IV, we see less variation between regions. New this year is the examination of the time from surgery to the start of chemotherapy, as well as the use of chemotherapy in the last period before death. The new figures suggest some variation between health regions. This development will be monitored.
The mortality rate 60 days after surgery over the past three years is now 0.7 %, well within the register's indicator target of a maximum of 3 %. Postoperative mortality one year after surgery for the same three-year period was 6.5 %. The results show some variation between hospitals, but less so than seen in previous annual reports. The overall mortality one year after diagnosis over the past three years was 18.3 % at the national level. The variation between health regions was from 16.8 % to 24.3 %.
The 5-year relative survival rate for ovarian cancer has steadily increased over the past 40 years from 30.9 % in 1980 to 50.3 % in 2023. The variation between health regions in 2023 ranged from 47.6 % to 51.4 %.
Quality indicators for cervical cancer:
In the examination of the disease, the National treatment guidelines recommend a CT scan of the lungs and abdomen, and an MRI of the abdomen/pelvis. The use of pelvic MRI in the examination is one of the registry’s quality indicators. The indicator target of a minimum of 90 % of patients was achieved for the first time in 2023. The use of PET before radiotherapy is among the register’s quality indicators. This year, it was defined as an indicator target that 95 % of patients undergoing radiotherapy should receive a PET scan. None of the health regions achieved this target in 2023. The majority of patients (68.0 %) were diagnosed with squamous cell carcinoma, while 24.2 % had adenocarcinoma.
Nationally, 49.1 % of patients undergo surgery, either with conization or hysterectomy (removal of the uterus). 45.3 % of patients have received radiotherapy. The results show considerable variation in the proportion of patients undergoing hysterectomy among the health regions. The proportion of patients completing radiotherapy within 50 days is a new quality indicator this year. The indicator target of a minimum of 95 % of radiotherapy patients is achieved at the national level in 2023.
The 5-year relative survival rate for cervical cancer has steadily increased over the past 40 years. The national average for 5-year survival is now 82.7 %, with regional variation ranging from 78.9 % to 82.7 %.
Treatment for cervical cancer is centralized to ensure the quality of care and because it is considered more cost-effective.
Quality improvements
The Norwegian Gynecological Cancer Registry contains a number of data on assessment and treatment that are described in the National treatment guidelines for gynaecological cancer from the Norwegian Directorate of Health.
Clinical areas of improvement for ovarian cancer:
Preoperative Tests Before Neoadjuvant Treatment: Preoperative tests should ideally be conducted for everyone before starting treatment, but this is not fulfilled nationally. Given the small numbers, the reasons should be further investigated through a review of medical records.
Low Proportion of Completed MDT Meetings: The indicator target is not met at the national level in 2023. At the regional level, the target is only achieved by Helse Vest.
Low Proportion of Operated Patients: The indicator target for the proportion of operated patients is not met at the national level in 2023. Selection criteria and changes in diagnostics may play a role here and will be examined further in a planned national quality project.
Type of Surgery: Laparotomy is by far the most commonly used surgical treatment method for ovarian cancer (88 % of operations). When reviewing patients with stage I ovarian cancer, it should be discussed nationally whether (re-)staging can be done laparoscopically.
Variation in the Use of Lymph Node Resection: We see variation among the health regions at different stages. This should be further investigated, and the indication should be discussed nationally.
High Proportion of Stage I Patients with Surgery Only: A high proportion of patients with stage I receive only surgery without chemotherapy. It should be investigated whether this is due to morphology or different interpretations of the National treatment guidelines.
Variation in Medicinal Treatment at Stage I: Fewer patients are given chemotherapy after surgery at stage I in Helse Sør-Øst than in Helse Midt-Norge and Helse Vest. This likely reflects different practices and should be further investigated.
Variation in Time from Surgery to Start of Chemotherapy: We see variation between the health regions. Treatment should aim to start within 3 weeks according to the National treatment guidelines. The reasons for delayed start should be investigated further.
Variation in the Use of Chemotherapy in the Last Period Before Death: We see variation in the use of chemotherapy in the last 4 weeks before death between health institutions. This should be discussed and clarified in national meetings.
Variation in Postoperative Mortality and Total Mortality After One Year: Helse Nord has a slightly higher mortality rate after one year compared to other health regions. It should be investigated whether this is related to cancer or other causes.
Clinical preventive measures for cervical cancer
Use of PET Before Radiotherapy: The indicator target for the use of PET is not met nationally, and the results show variation in usage among the health regions in the country. The reasons need to be investigated further.
Variation in the Use of Concurrent Chemotherapy During Radiotherapy: The benefit of concurrent chemotherapy during radiotherapy is documented. The reasons for variation between health regions should be investigated further.
Variation in Total Mortality One Year After Diagnosis: Helse Nord has a slightly higher total mortality rate one year after diagnosis compared to the other health regions. It should be investigated whether this is related to cancer or other causes.
See analyses/figures and detailed information on initiated measures in the report (Norwegian only).
Measures for patient-oriented quality improvement
Based on the fact that over time differences have been seen in the proportion of ovarian cancer patients who undergo surgery between the health regions, the quality improvement project Indication for surgery was initiated in 2020. The project was completed in 2021. The analyses included all ovarian cancer patients with a diagnosis in the period 2016–2019. The project group consists of representatives from all health regions.
See results from the project (Norwegian only).
Proms:
In order to further strengthen the quality of health services, the Cancer Registry of Norway worked in 2019 and 2020 to plan and build infrastructure for collecting PROMs (patient-reported outcome and experience measures), including integration with ePROM, which is the national solution for collecting PROMs.
The Norwegian Gynecological Cancer Registry will start with the routine collection of PROMs/PREMs in 2023. In order to distinguish between common ailments in the population and ailments related to ovarian cancer, a random sample of people without ovarian cancer will also be invited to submit a questionnaire.
Read more about the population surveys (Norwegian only).