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e13454 Objectives: We evaluated the quality of care for patients with squamous cell carcinoma (SCC) of the oral cavity, oropharynx, hypopharynx or larynx in Belgium. Methods: Data of the Belgian Cancer Registry were coupled with health insurance data and hospital discharge data. Quality of care and the association with hospital volume were evaluated based on six quality indicators. Results: Half of the patients were treated with primary radiotherapy, with or without systemic therapy (49.7%) and 38.1% with surgery, with or without (neo)adjuvant therapy. Single-modality treatment was provided to 78.1% of early-disease patients. Of the patients with cN0 disease, 56.4% underwent neck dissection. Postoperative radiotherapy was completed timely in 48.5% of patients. Concomitant chemotherapy was administered to 58.2% of patients

81-91 Abstract Objectives: The study investigated the association between hospital volume and observed survival of patients with a head and neck squamous cell carcinoma (HNSCC). Methods: Overall, 9245 patients diagnosed with HNSCC between 2009 and 2014, were identified in the population-based Belgian Cancer Registry. This database was coupled with other databases providing information on diagnostic and therapeutic procedures, vital status, and comorbidities. The overall and relative survival probabilities were estimated using the Kaplan-Meier and the Ederer II methods, respectively. The relation between hospital volume and observed survival since diagnosis was then assessed using Cox proportional hazard models adjusted for potential confounders.

11 pp. Aims: The study assessed the quality of diagnosis and staging offered to patients with a head and neck squamous cell carcinoma (HNSCC) and the variability across Belgian hospitals. Methods: In total, 9,245 patients diagnosed with HNSCC between 2009 and 2014, were identified in the population-based Belgian Cancer Registry (BCR). The BCR data were coupled with other databases providing information on diagnostic and therapeutic procedures reimbursed by the compulsory health insurance, vital status data, and comorbidities. The use of diagnosis and staging procedures was assessed by four quality indicators (QI) (i.e., use of dedicated head and neck imaging studies, use of PET-CT, TNM reporting and interval between diagnosis and start of treatment), for which a target was defined before the analysis. The association between the binary QIs and observed survival was assessed using Cox proportional hazard models adjusted for potential confounders. Results: Overall, 82.5% of patients received staging by MRI and/or CT of the head and neck region before the start of treatment. In 47.6% of stage III-IV patients eligible for treatment with curative intent, a whole-body FDG-PET(/CT) was performed. The proportion of patients whose cTNM and pTNM stage was reported to the BCR was 80.5 and 78.4%, respectively. The median interval from diagnosis to first treatment with curative intent was 32 days (IQR: 19-46). For none of these QIs the pre-set targets were reached and a substantial variability between centers was observed for all quality indicators. No binary QI was significantly associated with observed survival. Conclusions: The four quality indicators related to diagnosis and staging in HNSCC all showed substantial room for improvement. For none of them the pre-set targets were met at the national level and the variability between centers was substantial. Each Belgian hospital received an individual feedback report in order to stimulate reflection and quality improvement processes.

34 p. ill., KEY MESSAGES. 1 -- SHORT REPORT. 3 -- 1. BACKGROUND 7 -- 1.1. QUALITY IMPROVEMENT INITIATIVES IN ONCOLOGY. 7 -- 1.2. HEAD AND NECK CANCER, A HETEROGENEOUS GROUP OF MALIGNANCIES AFFECTING VARIOUS SITES WITH DIFFERING PROGNOSES. 7 -- 1.3. SCOPE 7 -- 1.4. WHAT THIS STUDY AIMS AT AND DOES NOT AIM AT 7 -- 2. DATA AND METHODS. 8 -- 2.1. THE DATABASE - A LINKAGE BETWEEN THE BELGIAN CANCER REGISTRY AND ADMINISTRATIVE DATABASES. 8 -- 2.2. THE PATIENTS - DIAGNOSED IN 2009-2014, WITH EXCLUSION OF PATIENTS WITH MULTIPLE AND RECURRENT TUMOURS 9 -- 2.3. ASSIGNMENT OF PATIENTS TO A CENTRE OF DIAGNOSIS, A CENTRE OF MAIN TREATMENT AND A CENTRE OF FIRST TREATMENT 9 -- 2.4. CASE-MIX ADJUSTMENT 9 -- 2.5. IDENTIFICATION AND SELECTION OF POSSIBLE QUALITY INDICATORS 9 -- 2.6. VALIDATION STUDY AND SUBSEQUENT DATA CHECKS. 10 -- 2.7. STATISTICAL ANALYSES 10 -- 3. QUALITY OF CARE FOR PATIENTS WITH HEAD AND NECK SQUAMOUS CELL CARCINOMA 11 -- 3.1. A COHORT OF 9 245 HNSCC PATIENTS DIAGNOSED IN 2009-2014 11 -- 3.2. MAIN THERAPEUTIC PROCEDURES: RADIOTHERAPY AND SURGERY 13 -- 3.3. LARGE DISPERSION OF CARE IN BELGIUM. 13 -- 3.4. RESULTS FOR 12 QUALITY INDICATORS 14 -- 3.4.1. Diagnosis and staging 15 -- 3.4.2. Treatment 18 -- 3.4.3. Safety of care – 30-day mortality after treatment with curative intent 20 -- 3.4.4. Survival after the diagnosis of HNSCC 22 -- 3.5. ASSOCIATION BETWEEN HOSPITAL VOLUME AND SURVIVAL 22 -- 4. STRENGTHS AND LIMITATIONS 24 -- 5. CONCLUSIONS AND PERSPECTIVES FOR THE FUTURE 26 -- RECOMMENDATIONS 28 -- REFERENCES 31

28 p. ill., In België nemen het Federaal Kenniscentrum voor de Gezondheidszorg (KCE), het Kankerregister en het College voor Oncologie al een aantal jaren initiatieven om de zorgkwaliteit voor kankerpatiënten te verbeteren. Deze keer werd de zorg voor mensen met hoofd- en halskanker onder de loep genomen. Het KCE stelde samen met klinische experten een set van kwaliteitsindicatoren en te behalen doelstellingen op, en evalueerde aan de hand daarvan de zorg die in de Belgische ziekenhuizen wordt aangeboden. Opnieuw stelde het KCE vast dat de kans op overleving significant groter is in ziekenhuizen die jaarlijks meer dan 20 patiënten met hoofd- en halskanker verzorgen. In België halen 23 ziekenhuizen (of minder dan één vierde van de ziekenhuizen) deze drempel. Het KCE beveelt daarom aan om de zorg voor deze patiënten te centraliseren in ziekenhuizen met de nodige expertise, zoals dit onlangs ook gebeurde voor slokdarm- en pancreaskankerchirurgie. Op het moment van deze publicatie ontvangt elk betrokken ziekenhuis een feedbackrapport van het Kankerregister met daarin zijn resultaten en situering t.o.v. de andere ziekenhuizen (benchmarking), zodat verbetertrajecten kunnen opgestart worden. KERN BOODSCHAPPEN 2 -- SYNTHESE 4 -- 1. ACHTERGROND 7 -- 1.1. INITIATIEVEN VOOR KWALITEITSVERBETERING IN DE ONCOLOGIE 7 -- 1.2. KENMERKEN VAN HOOFD- EN HALSKANKER 8 -- 1.3. DOELSTELLING VAN DEZE STUDIE 8 -- 2. HOE GINGEN WE TE WERK? 9 -- 2.1. EEN KOPPELING TUSSEN DE GEGEVENS VAN HET KANKERREGISTER EN ANDERE ADMINISTRATIEVE DATABANKEN 9 -- 2.2. NAUWE SAMENWERKING MET KLINISCHE EXPERTEN 9 -- 2.3. MEER DAN 9 000 PATIËNTEN BESTUDEERD, GEDIAGNOSTICEERD IN 2009-2014 9 -- 2.4. REKENING HOUDEN MET PATIËNT- EN TUMORKENMERKEN 10 -- 2.5. IDENTIFICATIE EN SELECTIE VAN KWALITEITSINDICATOREN 10 -- 2.6. VALIDATIE EN STATISTISCHE ANALYSES 10 -- 2.7. KANTTEKENING: ADMINISTRATIEVE DATA VRAGEN EEN VOORZICHTIGE INTERPRETATIE 10 -- 3. KWALITEIT VAN ZORG VOOR PATIËNTEN MET HOOFD-EN HALSKANKER 11 -- 3.1. ANALYSE VAN DE GEGEVENS VAN MEER DAN 9 000 PATIËNTEN 11 -- 3.2. VOORAL RADIOTHERAPIE EN CHIRURGIE 11 -- 3.3. GROTE ZORGSPREIDING 11 -- 3.4. RESULTATEN VOOR 12 KWALITEITSINDICATOREN 12 -- 3.4.1. Diagnose en stadiëring van de tumor 14 -- 3.4.2. Behandeling 16 -- 3.4.3. Mortaliteit op 30 dagen na een curatieve behandeling 17 -- 3.4.4. Overleving na de diagnose 17 -- 3.5. VERBAND TUSSEN OVERLEVING EN ERVARING VAN ZORGTEAM 17 -- 3.6. WAT WE (NOG) NIET WETEN…. 19 -- 3.7. ONVOLDOENDE RAPPORTERING AAN HET KANKERREGISTER 20 -- 4. CONCLUSIE 21 -- AANBEVELINGEN 22 -- REFERENTIES 25

313 p. ill., TABLE OF CONTENTS.1 -- LIST OF FIGURES 5 -- LIST OF TABLES.8 -- LIST OF ABBREVIATIONS .19 --  SCIENTIFIC REPORT 22 -- 1 INTRODUCTION.22 -- 1.1 HEAD AND NECK CANCER IN BELGIUM22 -- 1.2 DISPERSION OF CARE IN BELGIUM 23 -- 1.3 MEASURING QUALITY 24 -- 2 OBJECTIVES, SCOPE & TERMINOLOGY .25 -- 2.1 WHAT THIS STUDY AIMS AT AND DOES NOT AIM AT .25 -- 2.2 PRECEDING STEPS 26 -- 2.3 SCOPE.26 -- 2.4 TARGET AUDIENCE 26 -- 2.5 TERMINOLOGY 26 -- 3 METHODOLOGY27 -- 3.1 STEP 1: IDENTIFICATION OF THE TARGET POPULATION: DATA SELECTION AND LINKAGE OF DATABASES.27 -- 3.1.1 Selection of the study population in the Belgian Cancer Registry database .27 -- 3.1.2 Linkage with health insurance data.29 -- 3.1.3 Linkage with hospital discharge data.30 -- 3.1.4 Vital status30 -- 3.2 STEP 2: IDENTIFICATION AND SELECTION OF POSSIBLE QUALITY INDICATORS .30 -- 3.2.1 Identification of possible quality indicators 30 -- 3.2.2 Selection process and results 31 -- 3.2.3 Measurability of selected quality indicators 32 -- 3.2.4 Final selection of quality indicators to be fully elaborated32 -- 3.3 STEP 3: OPERATIONALIZATION OF INDICATORS 34 -- 3.3.1 Technical fiches 34 -- 3.3.2 Defining diagnostic and therapeutic procedures based on health insurance data.34 -- 3.3.3 Defining the treatment scheme of the patient 38 -- 3.3.4 Statistical analyses 38 -- 3.3.5 Case-mix adjustment .41 -- 3.4 STEP 4: ASSIGNMENT OF EACH PATIENT TO ONE CENTRE.45 -- 3.5 STEP 5: VALIDATION OF DIAGNOSTIC AND THERAPEUTIC DATA .46 -- 3.5.1 Introduction and methodology 46 -- 3.5.2 Validation of the algorithm to assign patients to one treatment hospital .47 -- 3.5.3 Validation of patient and tumour characteristics and of diagnostic and therapeutic procedures as identified in the health insurance data linked to cancer registry data .48 -- 3.6 STEP 6: MEASUREMENT OF QUALITY INDICATORS, AT NATIONAL LEVEL AND BY CENTRE.50 -- 3.7 STEP 7: INTERPRETATION OF RESULTS.50 -- 4 CHARACTERISTICS OF THE STUDY SAMPLE .50 -- 4.1 BASELINE DEMOGRAPHICS AND TUMOUR CHARACTERISTICS 50 -- 4.1.1 Patient characteristics 50 -- 4.1.2 Tumour characteristics 51 -- 4.2 MAIN DIAGNOSTIC AND STAGING PROCEDURES.52 -- 4.3 MAIN THERAPEUTIC PROCEDURES 53 -- 4.4 TIME TRENDS FOR MAIN DIAGNOSTIC, STAGING AND THERAPEUTIC PROCEDURES 56 -- 5 INDICATOR RESULTS 56 -- 5.1 QUALITY OF DIAGNOSIS AND STAGING IN SQUAMOUS CELL CARCINOMA OF THE HEAD AND NECK.56 -- 5.1.1 Timeliness of start of first treatment with curative intent (DS-1) 56 -- 5.1.2 MRI and/or contrast-enhanced CT of the primary site and draining lymph nodes before treatment (DS-2) 58 -- 5.1.3 T, N and M staging in new cases of SCC of the head and neck (DS-3) 60 -- 5.1.4 FDG-PET(/CT) before treatment (DS-4) 62 -- 5.2 QUALITY OF TREATMENT IN SQUAMOUS CELL CARCINOMA OF THE HEAD AND NECK 64 -- 5.2.1 Single modality treatment in stage I-II (T-1) 64 -- 5.2.2 Total laryngectomy in T4a laryngeal cancer (SX-1) 66 -- 5.2.3 Timeliness postoperative radiotherapy (RT-1) 67 -- 5.2.4 Primary chemoradiotherapy for locally-advanced non-metastatic disease (RT-2).69 -- 5.2.5 Neck imaging after primary (chemo)radiotherapy (LN-1) 71 -- 5.2.6 Elective neck dissection in cN0M0 squamous cell carcinoma of the head and neck (LN-2).72 -- 5.3 SAFETY OF CARE.74 -- 5.3.1 Post-treatment mortality (G-1) 74 -- 5.4 OBSERVED AND RELATIVE SURVIVAL .78 -- 5.4.1 The 1, 2 and 5-year observed and relative survival after a diagnosis of SCC of the head and neck (G-2) 78 -- 5.5 ASSOCIATION BETWEEN HOSPITAL VOLUME AND OUTCOME (V-1) 83 -- 5.5.1 Introduction .83 -- 5.5.2 Methods 83 -- 5.5.3 Results 84 -- 5.5.4 Discussion 89 -- 6 STRENGTHS AND LIMITATIONS 92 -- 7 CONCLUSIONS AND PERSPECTIVES FOR THE FUTURE.95 -- RECOMMENDATIONS 96 -- APPENDICES 99 -- APPENDIX 1. RARECARE DEFINITION HEAD AND NECK SQUAMOUS CELL CARCINOMA .99 -- APPENDIX 2. IDENTIFICATION AND SELECTION OF QUALITY INDICATORS 100 -- APPENDIX 3. BILLING CODES 115 -- APPENDIX 4. CASE MIX ADJUSTMENT 144 -- APPENDIX 5. VALIDATION 145 -- APPENDIX 6. DESCRIPTIVE DATA.164 -- APPENDIX 7. QUALITY INDICATORS 188 -- REFERENCES 304

28 p. ill., Le Centre fédéral d’expertise des soins de santé (KCE), le Registre du cancer et le Collège d'oncologie mènent depuis plusieurs années un travail de fond pour améliorer la qualité des soins aux patients atteints de cancer. La dernière étude en date porte sur les cancers de la tête et du cou. Un ensemble d'indicateurs de qualité et d'objectifs à atteindre a été défini avec l’aide d’experts de terrain, et les soins délivrés dans les hôpitaux belges ont ensuite été évalués sur cette base. Une fois de plus, le KCE a constaté que les chances de survie sont significativement plus élevées dans les hôpitaux qui traitent, par an, plus de 20 patients atteints de ce type de cancers, un seuil que seuls 23 hôpitaux atteignent (soit moins d’un quart des hôpitaux de notre pays). Le KCE recommande donc de centraliser le traitement de ces cancers dans les hôpitaux disposant de l'expertise nécessaire, comme cela vient d’être décidé pour la chirurgie des cancers de l'œsophage et du pancréas. Simultanément à la publication de cette étude, chaque hôpital évalué recevra un rapport de feedback du Registre du cancer, contenant ses propres résultats pour les différents indicateurs et sa situation par rapport aux autres hôpitaux (benchmarking) afin d’adopter des mesures pour améliorer la qualité des soins. MESSAGES CLÉS 2 -- SYNTHÈSE 4 -- 1. CONTEXTE. 7 -- 1.1. INITIATIVES POUR L’AMÉLIORATION DE LA QUALITÉ DES SOINS EN ONCOLOGIE 7 -- 1.2. CARACÉTRISTIQUES DES CANCERS DE LA TÊTE ET DU COU. 8 -- 1.3. OBJECTIF DE CETTE ÉTUDE. 8 -- 2. COMMENT AVONS-NOUS PROCÉDÉ ? 9 -- 2.1. COUPLAGE ENTRE LES DONNÉES DU REGISTRE DU CANCER ET D’AUTRES BASES DE DONNÉES ADMINISTRATIVES 9 -- 2.2. COLLABORATION ÉTROITE AVEC DES EXPERTS CLINIQUES 9 -- 2.3. PLUS DE 9 000 PATIENTS INCLUS ENTRE 2009 ET 2014 9 -- 2.4. PRISE EN COMPTE DES CARACTÉRISTIQUES DU PATIENT ET DE LA TUMEUR 10 -- 2.5. IDENTIFICATION ET SÉLECTION DES INDICATEURS DE QUALITÉ 10 -- 2.6. VALIDATION ET ANALYSES STATISTIQUES 10 -- 2.7. AVERTISSEMENT : LES DONNÉES ADMINISTRATIVES NÉCESSITENT UNE INTERPRÉTATION PRUDENTE 10 -- 3. QUALITÉ DES SOINS AUX PATIENTS ATTEINTS D’UN CANCER DE LA TÊTE ET DU COU 11 -- 3.1. ANALYSE DES DONNÉES DE PLUS DE 9 000 PATIENTS 11 -- 3.2. TRAITEMENT PRINCIPAL : RADIOTHÉRAPIE OU CHIRURGIE 11 -- 3.3. GRANDE DISPERSION DES SOINS 12 -- 3.4. RÉSULTATS POUR 12 INDICATEURS DE QUALITÉ 12 -- 3.4.1. Diagnostic et stadification de la tumeur 15 -- 3.4.2. Traitement 16 -- 3.4.3. Mortalité à 30 jours après un traitement curatif 17 -- 3.4.4. Survie après le diagnostic 17 -- 3.5. LIEN ENTRE LA SURVIE ET L’EXPÉRIENCE DE L’ÉQUIPE SOIGNANTE. 18 -- 3.6. CE QUE NOUS NE SAVONS PAS (ENCORE)… 20 -- 3.7. DÉCLARATION INSUFFISANTE AU REGISTRE DU CANCER 20 -- 4. CONCLUSION 21 -- RECOMMANDATIONS 22 -- RÉFÉRENCES 25