Radiotherapy Dose Fractionation, Access and Waiting Times in the Countries of the UK in 2005

Interventions to reduce the time to diagnosis of brain tumours

BACKGROUND

Brain tumours are recognised as one of the most difficult cancers to diagnose because presenting symptoms, such as headache, cognitive symptoms, and seizures, may be more commonly attributable to other, more benign conditions. Interventions to reduce the time to diagnosis of brain tumours include national awareness initiatives, expedited pathways, and protocols to diagnose brain tumours, based on a person's presenting symptoms and signs; and interventions to reduce waiting times for brain imaging pathways. If such interventions reduce the time to diagnosis, it may make it less likely that people experience clinical deterioration, and different treatment options may be available.

OBJECTIVES

To systematically evaluate evidence on the effectiveness of interventions that may influence: symptomatic participants to present early (shortening the patient interval), thresholds for primary care referral (shortening the primary care interval), and time to imaging diagnosis (shortening the secondary care interval and diagnostic interval). To produce a brief economic commentary, summarising the economic evaluations relevant to these interventions.

SEARCH METHODS

For evidence on effectiveness, we searched CENTRAL, MEDLINE, and Embase from January 2000 to January 2020; Clinicaltrials.gov to May 2020, and conference proceedings from 2014 to 2018. For economic evidence, we searched the UK National Health Services Economic Evaluation Database from 2000 to December 2014.

SELECTION CRITERIA

We planned to include studies evaluating any active intervention that may influence the diagnostic pathway, e.g. clinical guidelines, direct access imaging, public health campaigns, educational initiatives, and other interventions that might lead to early identification of primary brain tumours. We planned to include randomised and non-randomised comparative studies. Included studies would include people of any age, with a presentation that might suggest a brain tumour.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed titles identified by the search strategy, and the full texts of potentially eligible studies. We resolved discrepancies through discussion or, if required, by consulting another review author.

MAIN RESULTS

We did not identify any studies for inclusion in this review. We excluded 115 studies. The main reason for exclusion of potentially eligible intervention studies was their study design, due to a lack of control groups. We found no economic evidence to inform a brief economic commentary on this topic.

AUTHORS' CONCLUSIONS

In this version of the review, we did not identify any studies that met the review inclusion criteria for either effectiveness or cost-effectiveness. Therefore, there is no evidence from good quality studies on the best strategies to reduce the time to diagnosis of brain tumours, despite the prioritisation of research on early diagnosis by the James Lind Alliance in 2015. This review highlights the need for research in this area.

Accurate method for evaluating the duration of the entire radiotherapy process

BACKGROUND AND PURPOSE

Along with the increasing demand for high-quality radiotherapy and the growing number of high-precision radiotherapy devices, precise radiotherapy workflow management and accurate time evaluation of the entire radiotherapy process are crucial to providing appropriate, timely treatment for cancer patients. This study therefore aimed to establish an accurate, reliable method for evaluating the duration of the radiotherapy process, from beginning to end, based on real-time measurement data. These data are vital for improving the quality and efficiency of radiotherapy delivery.

MATERIALS AND METHODS

Altogether, 17 620 cancer patients' radiotherapy experiences were measured in real time in our radiation oncology department. The process was divided into five sequential core modules, with the start and stop times of each module automatically recorded using MOSAIQ software, an automated radiotherapy management system. The duration for each module and the total duration of the entire process were then automatically calculated and qualitatively analyzed.

RESULTS

The analysis showed significant treatment-time differences depending on the tumor site, which provided a practical reference for improvement of previous treatment modules and appointments management. In all, >60% of the cancer patients' total treatment time could be shortened.

CONCLUSIONS

We established a reliable method for evaluating the overall duration of radiotherapy protocols. The results pointed out a clear pathway by which we could improve future radiotherapy workflow management and appointment systems.

The effects of a lean transition on process times, patients and employees

Purpose Treatment delays must be avoided, especially in oncology, to assure sustainable high-quality health care and increase the odds of survival. The purpose of this paper is to hypothesize that waiting times would decrease and patients and employees would benefit, when specific lean interventions are incorporated in an organizational improvement approach. Design/methodology/approach In 2013, 15 lean interventions were initiated to improve flow in a single radiotherapy institute. Process/waiting times, patient satisfaction, safety, employee satisfaction, and absenteeism were evaluated using a mixed methods methodology (2010-2014). Data from databases, surveys, and interviews were analyzed by time series analysis, χ², multi-level regression, and t-tests. Findings Median waiting/process times improved from 20.2 days in 2012 to 16.3 days in 2014 ( p<0.001). The percentage of palliative patients for which waiting times had exceeded Dutch national norms (ten days) improved from 35 (six months in 2012: pre-intervention) to 16 percent (six months in 2013-2014: post-intervention; p<0.01), and the percentage exceeding national objectives (seven days) from 22 to 17 percent ( p=0.44). For curative patients, exceeding of norms (28 days) improved from 17 (2012) to 8 percent (2013-2014: p=0.05), and for the objectives (21 days) from 18 to 10 percent ( p<0.01). Reported safety incidents decreased 47 percent from 2009 to 2014, whereas safety culture, awareness, and intention to solve problems improved. Employee satisfaction improved slightly, and absenteeism decreased from 4.6 (2010) to 2.7 percent (2014; p<0.001). Originality/value Combining specific lean interventions with an organizational improvement approach improved waiting times, patient safety, employee satisfaction, and absenteeism on the short term. Continuing evaluation of effects should study the improvements sustainability.

Assessment of performance indicators of a radiotherapy department using an electronic medical record system

AIM

To retrospectively assess the performance indicators of our radiotherapy department and their temporal trends, using a commercially available electronic-medical-record (EMR) system.

BACKGROUND

A recent trend in healthcare quality is to define and evaluate performance indicators of the service provided.

MATERIALS AND METHODS

Patient and external-beam-radiotherapy-treatments data were retrieved using the Mosaiq EMR system from 1-January-2012 till 31-December-2015. Annual performance indicators were evaluated as: productivity (number of new cases/year and diagnosis distribution); complexity (ratio of Volumetric-Modulated-Arc-Therapy (VMAT) courses, average number of imaging procedures/patient); and quality (average, median and 90th percentile waiting times from admission to first treatment). The temporal trends of all performance indicators were assessed by linear regression.

RESULTS

Productivity: the number of new cases/year increased with an average rate of 4%. Diagnosis distribution showed that breast is the main pathology treated, followed by gastro-intestinal and head-and-neck. Complexity: the ratio of VMAT courses increased from 13% to 35%, with an average rate of 7% per year. The average number of imaging procedures/patient increased from 8 to 11. Quality: the waiting times from admission to treatment remained stable over time (R² ≤ 0.1), with average, median and 90th percentile values around 20, 15, and 31 days, respectively.

CONCLUSIONS

An EMR system can be used to: monitor the performance indicators of a radiotherapy department, identify workflow processes needing attention and improvement, estimate future demands of resources. Temporal analysis of our data showed an increasing trend in productivity and complexity paired with constant waiting times.

What is access to radiation therapy? A conceptual framework and review of influencing factors

OBJECTIVES

Optimal radiation therapy (RT) utilisation rates (RURs) have been defined for various cancer indications through extensive work in Australia and overseas. These benchmarks remain unrealised. The gap between optimal RUR and actual RUR has been attributed to inadequacies in 'RT access'. We aimed to develop a conceptual framework for the consideration of 'RT access' by examining the literature for existing constructs and translating it to the context of RT services. We further aimed to use this framework to identify and examine factors influencing 'RT access'.

METHODS

Existing models of health care access were reviewed and used to develop a multi-dimensional conceptual framework for 'RT access'. A review of the literature was then conducted to identify factors reported to affect RT access and utilisation. The electronic databases searched, the host platform and date range of the databases searched were Ovid MEDLINE, 1946 to October 2014 and PsycINFO via OvidSP,1806 to October 2014.

RESULTS

The framework developed demonstrates that 'RT access' encompasses opportunity for RT as well as the translation of this opportunity to RT utilisation. Opportunity for RT includes availability, affordability, adequacy (quality) and acceptability of RT services. Several factors at the consumer, referrer and RT service levels affect the translation of this opportunity for RT to actual RT utilisation.

CONCLUSION

'Access' is a term that is widely used in the context of health service related research, planning and political discussions. It is a multi-faceted concept with many descriptions. We propose a conceptual framework for the consideration of 'RT access' so that factors affecting RT access and utilisation may be identified and examined. Understanding these factors, and quantifying them where possible, will allow objective evaluation of their impact on RT utilisation and guide implementation of strategies to modify their effects.

On-going improvement and persistent differences in the survival for patients with colon and rectum cancer across Europe 1999-2007 - Results from the EUROCARE-5 study

BACKGROUND

Previous population-based studies revealed major variation in survival for patients with colorectal cancer (CRC) in Europe by age and between different countries and regions, but also a sustained improvement in survival for patients with CRC in recent years. This EUROCARE-5 paper aims to update available knowledge from previous studies and to provide the latest survival estimates for CRC patients from Europe.

METHODS

The study analysed data of patients diagnosed with CRC from population-based cancer registries diagnosed in 29 European countries. Estimates of 1-year and 5-year relative survival (RS) were derived for patients diagnosed in 2000-2007 by European region, country and age at diagnosis. Additionally to these cohort estimates, time trends in 5-year RS were obtained for the calendar periods 1999-2001 and 2005-2007, using the period analysis methodology.

RESULTS

European average 5-year RS for patients diagnosed with colon and rectum cancer was 57% and 56%, respectively. The analyses showed persistent differences in cancer survival across Europe with lowest survival for CRC patients observed in Eastern Europe. The analyses further showed a strong gradient in age-specific survival. Even though the study revealed sustained improvement in patient survival between 1999-2001 and 2005-2007 (absolute increase of 4 and 6 percentage points for colon and rectum, respectively), the differences in the survival for CRC patients observed at the beginning of the millennium persisted over time.

CONCLUSION

Although survival for CRC patients in Europe improved markedly in the study period, significant geographic variations and a strong age gradient still persisted. Enhanced access to effective diagnostic procedures and treatment options might be the keys to reducing the existing disparities in the survival of CRC patients across Europe.

Health Resource Utilization Associated with Skeletal-Related Events in Patients with Advanced Prostate Cancer: A European Subgroup Analysis from an Observational, Multinational Study

This study aimed to increase the understanding of health resource utilization (HRU) associated with skeletal-related events (SREs) occurring in patients with bone metastases secondary to advanced prostate cancer. A total of 120 patients from Germany, Italy, Spain and the United Kingdom were enrolled in this observational study. They had bone metastases secondary to prostate cancer and had experienced at least one SRE in the 97 days before giving informed consent. HRU data were collected retrospectively for 97 days before enrolment and prospectively for up to 18–21 months. HRU, including the number and duration of inpatient hospitalizations, number of outpatient and emergency department visits and procedures, was independently attributed by investigators to an SRE. Of the 222 SREs included in this analysis, 26% were associated with inpatient stays and the mean duration per SRE was 21.4 days (standard deviation (SD) 17.8 days). Overall, 174 SREs (78%) required an outpatient visit and the mean number of visits per SRE was 4.6 (SD 4.6). All SREs are associated with substantial HRU. Preventing SREs in patients with advanced prostate cancer and bone metastases may help to reduce the burden to both patients and European healthcare systems.

Health resource utilization associated with skeletal-related events in patients with advanced breast cancer: results from a prospective, multinational observational study

Patients with breast cancer and bone metastases often experience skeletal complications (skeletal-related events [SREs]: pathologic fracture, radiation to bone, surgery to bone or spinal cord compression). Prospective data on the health resource burden of SREs are needed for planning healthcare requirements and estimating the value of new treatments, but limited data are available. This prospective, observational study collected health resource utilization (HRU) data independently attributed to SREs by investigators. Eligible patients had bone metastases secondary to breast cancer, life expectancy ≥6 months, Eastern Cooperative Oncology Group (ECOG) performance status ≤2, and at least one SRE in the 97 days before enrollment. Data, collected retrospectively for 97 days before enrollment and prospectively for 18–21 months, included number and duration of inpatient stays, outpatient visits, emergency room visits and procedures. Altogether, 223 patients were enrolled from Germany, Italy, Spain and the UK. Of the 457 SREs, 118 (25.8%) were associated with inpatient stays. The mean duration of stay was 19.5 (standard deviation [SD] 19.2) days per SRE (based on 117 SREs). Surgery to bone and spinal cord compression were the SREs most likely to require inpatient stays (77.8% and 57.9% of SREs, respectively), while radiation to bone was the least likely (9.7%). Spinal cord compression required the longest inpatient stay per event (34.2 [SD 30.2] days) and radiation to bone the shortest (14.3 [SD 10.2] days). Overall, 342 SREs (74.8%) required an outpatient visit, with radiation to bone the most likely (85.7%), and surgery to bone the least likely (42.6%). Radiation to bone was also associated with the greatest number of outpatient visits per event (6.8 [SD 6.7] visits). All SREs were associated with substantial HRU therefore, preventing SREs in patients with breast cancer may reduce the burden imposed on healthcare systems.

Health resource utilisation associated with skeletal-related events in European patients with lung cancer: Α subgroup analysis from a prospective multinational study

Bone complications or skeletal-related events (SREs), typically defined as radiation to bone, pathological fractures, surgery to bone and spinal cord compression, occur frequently in patients with bone metastases. As the survival of patients with advanced lung cancer improves, preventing SREs is becoming increasingly clinically relevant. The aim of this analysis was to assess the impact of SREs on health resource utilisation (HRU) in European lung cancer patients with bone metastasis. This multinational, observational study included patients who had at least one SRE in the 97 days prior to enrolment, a life expectancy of ≥6 months and an Eastern Cooperative Oncology Group performance status of 0-2. Data on HRU were retrospectively collected for up to 97 days prior to enrolment with a planned prospective follow-up for up to 18-21 months. The HRU measures included the number and length of inpatient hospitalisations and the number of outpatient visits and procedures. The investigators determined whether each HRU was attributable to a SRE. In total, 135 patients with lung cancer, enrolled at centres in Germany, Italy, Spain and the United Kingdom, contributed 214 SREs to this analysis. The median length [quartile (Q)1, Q3] of follow-up ranged from 1.5 (0.7, 3.3) to 5.6 (2.0, 8.2) months across the countries. Overall, 41% of the SREs required an inpatient stay, with a median (Q1, Q3) duration of 19.0 (6.0, 28.0) days. Spinal cord compression and surgery to bone were the SRE types most frequently requiring inpatient stays. Radiation to bone was associated with the largest number of outpatient visits and procedures. All the SREs resulting from bone metastases in patients with lung cancer contribute considerably to HRU and efforts to minimise the incidence of bone complications in these patients through appropriate treatments may help reduce this burden.

Are probiotics more efficacious than placebo at preventing radiotherapy-induced diarrhoea in adults with cancer

Background

Patients with cancer undergoing radiotherapy often develop diarrhoea, causing distress and hindering treatment. As probiotics have favourable effects on the gut flora, they are potentially good candidates in the prevention of radiotherapy-induced diarrhoea (RID).

Purpose

The outcome of interest of this systematic review was the efficacy of probiotics in preventing RID.

Materials and methods

Medline and Embase databases were systematically searched. Four randomised controlled trials (RCTs) were finally selected.

Results

Three RCTs showed beneficial results, which were statistically significant. One RCT showed non-beneficial results, which were not statistically significant. The quality of the studies was mixed, and serious limitations were found.

Conclusion

While the indications are towards a benefit of the use of probiotics in preventing RID, more robust evidence is required in the form of well-designed RCTs.

Reduced dose radiotherapy for local control in non-Hodgkin lymphoma: a randomised phase III trial

PURPOSE

This multicentre, prospective, randomised-controlled trial compared efficacy and toxicity of differing radiotherapy doses in non-Hodgkin lymphoma (NHL).

PATIENTS AND METHODS

Patients with any histological subtype of NHL, requiring radiotherapy for local disease control, whether radical, consolidative or palliative, were included. Three hundred and sixty one sites of indolent NHL (predominantly follicular NHL and marginal zone lymphoma) were randomised to receive 40-45Gy in 20-23 fractions or 24Gy in 12 fractions. Six hundred and forty sites of aggressive NHL (predominantly diffuse large B cell lymphoma as part of combined-modality therapy) were randomised to receive 40-45Gy in 20-23 fractions or 30Gy in 15 fractions. Patients with all stages of disease, having first-line and subsequent therapies were included; first presentations of early-stage disease predominated.

RESULTS

There was no difference in overall response rate (ORR) between standard and lower-dose arms. In the indolent group, ORR was 93% and 92%, respectively, (p=0.72); in the aggressive group, ORR was 91% in both arms (p=0.87). With a median follow-up of 5.6years, there was no significant difference detected in the rate of within-radiation field progression (HR=1.09, 95%CI=0.76-1.56, p=0.64 in the indolent group; HR=0.98, 95%CI=0.68-1.4, p=0.89 in the aggressive group). There was also no significant difference detected in the progression free or overall survival. There was a trend for reduced toxicities in the low-dose arms; only the reduction in reported erythema reached significance.

CONCLUSION

In a large, randomised trial, there was no loss of efficacy associated with radiotherapy doses of 24Gy in indolent NHL and 30Gy in aggressive NHL, compared with previous standard doses of 40-45Gy.

Evidence against the proposition that "UK cancer survival statistics are misleading": simulation study with National Cancer Registry data

OBJECTIVES

To simulate each of two hypothesised errors in the National Cancer Registry (recording of the date of recurrence of cancer, instead of the date of diagnosis, for registrations initiated from a death certificate; long term survivors who are never notified to the registry), to estimate their possible effect on relative survival, and to establish whether lower survival in the UK might be due to one or both of these errors.

DESIGN

Simulation study.

SETTING

National Cancer Registry of England and Wales. Population Patients diagnosed as having breast (women), lung, or colorectal cancer during 1995-2007 in England and Wales, with follow-up to 31 December 2007.

MAIN OUTCOME MEASURE

Mean absolute percentage change in one year and five year relative survival associated with each simulated error.

RESULTS

To explain the differences in one year survival after breast cancer between England and Sweden, under the first hypothesis, date of diagnosis would have to have been incorrectly recorded by an average of more than a year for more than 70% of women known to be dead. Alternatively, under the second hypothesis, failure to register even 40% of long term survivors would explain less than half the difference in one year survival. Results were similar for lung and colorectal cancers.

CONCLUSIONS

Even implausibly extreme levels of the hypothesised errors in the cancer registry data could not explain the international differences in survival observed between the UK and other European countries.

The risks to healthy tissues from the use of existing and emerging techniques for radiation therapy

As radical radiotherapy treatments become more effective, more and more cancer patients are becoming cured of their disease and surviving for decades. Damage to exposed healthy tissues that becomes manifest in the medium-to-long-term is becoming a more significant factor in the choice of individual treatment plans and treatment modality. However, currently there are no reliable objective methods for predicting in an individual patient the occurrence of normal tissue complications, or second cancers caused by radiation. This is especially needed as new competing techniques and modalities become available, such as IMRT, protons, carbon ions, etc., all advancing the ability to focus the radiation dose on the target while sparing normal tissue. ALLEGRO is a Euratom-funded project that is currently investigating the current state of knowledge, and attempting to define the priority research areas. Preliminary considerations of the problems to be solved and research priorities are presented.

Training needs of radiographers for implementing Tomotherapy in NHS practice

Background: Addenbrooke’s was awarded Department of Health funding for Tomotherapy in 2006, to evaluate the functionality and application of the image guidance element of Tomotherapy. No Tomotherapy unit had been implemented into a National Health Service (NHS) working environment before, so there was no model to follow. An education and training program needed to be created to ensure accurate and efficient delivery of radiotherapy using Tomotherapy.

Method: The educational needs of radiographers had to be derived from first principles. An assessment of Tomotherapy treatment delivery process was made, identifying the tasks within the process and then the skills and knowledge required to achieve each task. The process was derived from site visits to non-NHS centres using Tomotherapy, nationally and internationally. This was supplemented by educational courses for specific aspects of Tomotherapy Intensity Modulated Radiotherapy (IMRT) and Image Guided Radiotherapy (IGRT).

Results: The core skills and knowledge required were identified and an in-house educational programme created. Competencies for Tomotherapy delivery were assessed against image matching accuracy and speed. All radiographers were able to meet these standards so that Tomotherapy IGRT on the treatment unit required no input from clinical oncologists, making effective and efficient use of staff resources.

Conclusion: The educational and training needs of radiographer staff were identified and a Tomotherapy training program was devised to enable image registration to be radiographer driven.

Adjuvant regional irradiation after breast-conserving therapy for early stage breast cancer: a survey of canadian radiation oncologists

AIMS

To document the use of adjuvant regional irradiation after breast-conserving therapy for early stage breast cancer by Canadian radiation oncologists and to identify the factors influencing their clinical decisions.

MATERIALS AND METHODS

We conducted a survey to assess the above aims. In April 2008, a questionnaire was sent to 167 members of the Canadian and Quebec Associations of Radiation Oncologists with interest in breast cancer management. The answers were obtained through a dedicated website, which collected the raw data collected for analysis.

RESULTS

In total, 67 radiation oncologists completed the survey, corresponding to a 40% response rate. Most respondents were experienced and high-volume providers. We identified several areas of variation in the decision-making regarding regional lymph node irradiation after breast-conserving therapy. Regarding the decision to combine regional nodal irradiation with irradiation of the breast, the number of positive nodes after axillary dissection (1-3 vs > or =4) was a crucial determinant. For patients with between one and three positive nodes and a nodal ratio of 50%, most respondents added regional irradiation. Similarly, the same nodal ratio of 50% was the main factor for inclusion of the axillary nodal region in the radiation field. However, few radiation oncologists have chosen to include the internal mammary chain in their treatment plan. The number of positive lymph nodes, the nodal ratio, the number of lymph nodes removed and the presence of extracapsular extension were the primary self-reported factors that directed the decision to offer regional radiotherapy.

CONCLUSIONS

This survey showed that there is a wide variation of practices among radiation oncologists in Canada. These results support the need for treatment guidelines and provide guidance on which factors should be included in a decision-making algorithm.

Geographical variation in radiotherapy services across the UK in 2007 and the effect of deprivation

AIMS

Modelling of demand has shown substantial underprovision of radiotherapy in the UK. We used national audit data to study geographical differences in radiotherapy waiting times, access and dose fractionation across the four countries of the UK and between English strategic health authorities.

MATERIALS AND METHODS

We used a web-based tool to collect data on diagnosis, dose fractionation and waiting times on all National Health Service patients in the UK starting a course of radiotherapy in the week commencing 24 September 2007. Cancer incidence for the four countries of the UK and for England by primary care trust was used to model demand for radiotherapy aggregated by country and by strategic health authority.

RESULTS

Across the UK, excluding skin cancer, 2504 patients were prescribed 33 454 fractions in the audit week. Waits for radical radiotherapy exceeded the recommended 4 week maximum for 31% of patients (range 0-62%). Fractions per million per year ranged from 17 678 to 36 426 and radical fractions per incident cancer ranged from 3.0 to 6.7. Patients who were treated received similar treatment in terms of fractions per radical course of radiotherapy (18.2-23.0). Access rates ranged from 25.2 to 48.8%, nearing the modelled optimum of 50.7% in three regions. Fractions per million prescribed as a first course of treatment varied from 43.9 to 90.3% of modelled demand. The percentage of patients failing to meet the 4 week Joint Council for Clinical Oncology target for radical radiotherapy rose as activity rates increased (r=0.834), indicating a mismatch of demand and capacity. In England, a comparison between strategic health authorities showed that increasing deprivation was correlated with lower rates of access to radiotherapy (r=-0.820).

CONCLUSIONS

There are substantial differences across the UK in the radiotherapy provided to patients and its timeliness. Radiotherapy capacity does not reflect regional variations in cancer incidence across the UK (3618-5800 cases per million per year). In addition, deprivation is a major unrecognised influence on radiotherapy access rates. In regions with higher levels of deprivation, fewer patients with cancer receive radiotherapy and the proportion treated radically is lower. This probably reflects late presentation with advanced disease, poor performance status and co-morbid illness. To provide an equitable, evidence-based service, the needs of the local population should be assessed using demand modelling based on local cancer incidence. Ideally this should include data on deprivation, performance status and stage at presentation. The results should be compared with local radiotherapy activity data to understand waits, access and dose fractionation in order to plan adequate provision for the future. The development of a mandatory radiotherapy data set in England will facilitate this, but to assist change it is essential that the results are analysed and fed back to clinicians and commissioners.

Outcome of T1N0M0 squamous cell carcinoma of the larynx treated with short-course radiotherapy to a total dose of 50 Gy in 16 fractions: the Birmingham experience

AIMS

To review the results of hypofractionated radiotherapy in T1N0M0 squamous cell carcinoma of the larynx.

MATERIALS AND METHODS

A series of 100 patients treated with radiotherapy between 1993 and 2001 was reviewed. The median age was 67 years. The median follow-up was 7 years (range 3-14 years). Radiotherapy was delivered to a total dose of 50 Gy in 16 fractions treating daily, 5 days a week over 21 days.

RESULTS

Locoregional control rates with radiotherapy alone were 92% at 2 years and 88% at 5 years. After salvage surgery, the ultimate locoregional control rate was 96%. The relapse-free survival rates at 2 and 5 years were 85 and 70%, respectively. The cause-specific survival rates at 2 and 5 years were 99 and 97%, respectively. Overall survival rates at 2 and 5 years were 91 and 76%, respectively. Second primary cancers occurred in 21% of patients, primarily in the lung.

CONCLUSIONS

Radiotherapy to a total dose of 50 Gy in 16 fractions for T1N0M0 squamous cell carcinoma of the larynx offers high locoregional control rates with voice preservation. These results from a hypofractionated radiotherapy schedule are comparable with other longer fractionation schedules and offer potential for optimising resource usage.

Managing workflow in treatment planning using standard spreadsheet software

Aims: Recent years have seen an expansion of UK radiotherapy treatment capacity with a drive to reduce radiotherapy waiting times. Consequently, the time available for planning patients is decreasing. In this context, management of treatment planning workflow in the Princess Royal Hospital is described and monthly planning times are presented from September 2003 onwards.

Materials and Methods: After patients are imaged, patient name, unit number and appointments are available to the planning spreadsheet via a link to the radiotherapy information system. The planning spreadsheet is in descending order of appointment date. Treatment planning staff select the first available task, taking account of individual competencies. At plan completion, the patient record is moved to the completed list.

Results: Since September 2003, patient numbers through treatment planning steadily increased from around 90 a month to about 130 currently. Planning times decreased from 11 to 7 workdays.

Conclusions: Workflow through treatment planning is indirectly managed and the approach allows for day-to-day staffing fluctuations and competency levels. There is instant information on planning status for all patients throughout the department, building up a record as part of the work process. Bottlenecks and staff training needs can be analysed by reviewing the historic patient workload.

Waiting times for systemic cancer therapy in the United Kingdom in 2006

This audit was conducted to measure waiting times for systemic cancer therapy across the United Kingdom. All patients, aged 16 years or older, commencing their first course of systemic therapy between 13 November and 19 November 2006 were eligible for inclusion. Data on 936 patients from 81 hospital sources were collected. Systemic therapy is largely given in compliance with national waiting time targets. In terms of the Joint Council for Clinical Oncology (JCCO) targets, 84% of patients commence treatment within 21 days and 98% of patients complied with the Department of Health target that treatment should follow within 31 days of the decision being agreed with the patient. Only 76% complied with the Department of Health 62-day target from GP referral to first definitive treatment. However, the date of urgent referral by the GP was not submitted for most patients in our survey, leaving a sample of only 84 out of 936 patients (9% of total) suitable for this analysis. There was only a 3- to 5-day difference between the waiting times for systemic therapy for patients categorised as urgent compared with routine. Locally agreed definitions had little impact on patients' priority for treatment. This audit has established a baseline measurement of waiting times for systemic therapy across the United Kingdom. The continuing introduction of novel therapies is likely to have a significant effect on the service and we recommend that service managers model the likely impact on resource requirements. In addition, urgent treatment should be clearly defined as that required within 24 h (maximum 48 h) to avoid the risk of clinical deterioration, particularly in patients with acute leukaemia, lymphoma or germ cell tumour.