Radiotherapy in England in 2007: Modelled Demand and Audited Activity

Assessing a Suitable Radiotherapy Utilisation Benchmark for Older Patients With Head and Neck Cancer

AIMS

To (i) determine the actual radiotherapy utilization (RTU) stratified by age, (ii) develop an age- and co-morbidity adjusted optimal RTU model and (iii) examine the tolerance and toxicity of treatment of older patients with head and neck cancer.

MATERIALS AND METHODS

A retrospective cohort study based on New South Wales Cancer Registry records (2010-2014) linked to radiotherapy data (2010-2015) and admitted patient data (2008-2015) for patients diagnosed with head and neck cancer. We calculated the actual RTU, defined as the proportion of patients who received at least one course of radiotherapy within a year of diagnosis, by age group, including patients aged 80+ years. We also calculated the age and comorbidity-adjusted optimal RTU. For treatment tolerance, the radiotherapy dose for each age group and the completion rate for a seven week 70 Gray (Gy) course of curative intent radiotherapy were computed. The number of emergency department (ED) presentations were used as a surrogate measure of acute treatment toxicity for patients receiving 70 Gy.

RESULTS

Of the 5966 patients diagnosed with head and neck cancer, 814 (13.6%) were aged 80+ years. For all age groups, the actual RTU was less than the optimal RTU. The age- and comorbidity-adjusted optimal RTU for patients aged 80+ was 52% (95% CI: 51%-53%), and the actual RTU was 40% (95% CI: 37%-44%). Only 4.4% of patients aged 80+ received 70 Gy, and the completion rate for a 70 Gy course of radiotherapy for these patients was 92%. The ED presentation rate was similar for all age groups.

CONCLUSION

The actual RTU was less in the 80+ years patients and across all age groups. Fewer patients in the 80+ group received curative intent schedules compared to the actual RTU rate for younger age groups, despite similar rates of completion of curative intent radiotherapy and acute toxicity.

Learning healthcare systems and rapid learning in radiation oncology: Where are we and where are we going?

Learning health systems and rapid-learning are well developed at the conceptual level. The promise of rapidly generating and applying evidence where conventional clinical trials would not usually be practical is attractive in principle. The connectivity of modern digital healthcare information systems and the increasing volumes of data accrued through patients' care pathways offer an ideal platform for the concepts. This is particularly true in radiotherapy where modern treatment planning and image guidance offers a precise digital record of the treatment planned and delivered. The vision is of real-world data, accrued by patients during their routine care, being used to drive programmes of continuous clinical improvement as part of standard practice. This vision, however, is not yet a reality in radiotherapy departments. In this article we review the literature to explore why this is not the case, identify barriers to its implementation, and suggest how wider clinical application might be achieved.

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.

Comparison of Methods for Measuring Radiotherapy Utilisation

AIMS

Evidence-based estimates of appropriate rates of radiotherapy utilisation are usually stated as the proportion of cancer patients who should receive radiotherapy at least once in their lifetime. However, the prolonged follow-up required to measure the lifetime radiotherapy rate limits its value in monitoring access to radiotherapy in routine practice. The objectives of this study were to evaluate shorter-term methods for measuring radiotherapy utilisation and to determine how well they predict the lifetime radiotherapy rate.

MATERIALS AND METHODS

The Ontario Cancer Registry provided records of all cases of cancer diagnosed in Ontario between 1984 and 2015. Records of all radiotherapy delivered by Ontario cancer centres were linked to individual cases in the Ontario Cancer Registry. Patients were followed forward for 20 years to determine the relationship between short-term and long-term rates of use of radiotherapy. Radiotherapy utilisation was also estimated by comparing total radiotherapy workload with cancer incidence; these measures were compared with observed long-term radiotherapy rates.

RESULTS

The rate of use of radiotherapy within 1 year of diagnosis (RT_1y) was strongly predictive of the rate of use of radiotherapy after 20 years (RT_20y); for each annual cohort of cases between 1984 and 1995, RT_20y was approximately equal to 1.3 × RT_1y. The number of cases treated for the first time with radiotherapy in a specified period, divided by the number of new cases diagnosed in the same period, was about equal to the proportion of cases treated with radiotherapy within 20 years of diagnosis (RT_20y).

CONCLUSIONS

The lifetime rate of use of radiotherapy may be predicted quite accurately from the rate observed within 1 year of diagnosis, or from the ratio of new cases treated to cancer incidence in a specified period. Either of these measures may therefore be used to audit radiotherapy utilisation against the existing evidence-based targets.

Mathematical Modelling for Patient Selection in Proton Therapy

Proton beam therapy (PBT) is still relatively new in cancer treatment and the clinical evidence base is relatively sparse. Mathematical modelling offers assistance when selecting patients for PBT and predicting the demand for service. Discrete event simulation, normal tissue complication probability, quality-adjusted life-years and Markov Chain models are all mathematical and statistical modelling techniques currently used but none is dominant. As new evidence and outcome data become available from PBT, comprehensive models will emerge that are less dependent on the specific technologies of radiotherapy planning and delivery.

Estimation of the optimal utilisation rates of radical prostatectomy, external beam radiotherapy and brachytherapy in the treatment of prostate cancer by a review of clinical practice guidelines

BACKGROUND AND PURPOSE

We aimed to construct an evidence-based model of optimal treatment utilisation for prostate cancer, incorporating all local treatment modalities: radical prostatectomy (RP), external beam radiotherapy (EBRT), and brachytherapy (BT); and then to compare this optimal model with actual practice.

MATERIALS AND METHODS

Evidence-based guidelines were used to construct a prostate cancer treatment decision-tree. The proportion of patients who fulfilled treatment criteria was drawn from the epidemiological literature. These data were combined to calculate the overall proportion of patients that should optimally have RP, EBRT and/or BT at least once during the course of their disease. The model was peer reviewed and tested by sensitivity analyses and compared with actual practice.

RESULTS

Optimal utilisation rates, at some point during the disease course, were: RP, 24% (range 15-30%); EBRT, 58% (range 54-64%); BT, 9.6% (range 6.0-17.9%); and any RT, 60% (range 56-66%). Many patients had indications for more than one of these treatments, and at least one of these treatments was indicated in 76% of patients. The model was sensitive to patient preference estimates. Optimal rates were achievable in some health care jurisdictions.

CONCLUSIONS

Modelling optimal utilisation of all local treatment options for a particular cancer is possible. These optimal prostate cancer treatment rates can be used as a planning and quality assurance tool, providing an evidence-based benchmark against which can be measured patterns of practice.

The German and Belgian accreditation models for diabetic foot services

The International Working Group on the Diabetic Foot recommends that auditing should be part of the organization of diabetic foot care, the efforts required for data collection and analysis being balanced by the expected benefits. In Germany legislature demands measures of quality management for in- and out-patient facilities, and, in 2003, the Germany Working Group on the Diabetic Foot defined and developed a certification procedure for diabetic foot centres to be recognized as 'specialized'. This includes a description of management facilities, treatment procedures and outcomes, as well as the organization of mutual auditing visits between the centres. Outcome data is collected at baseline and 6 months on 30 consecutive patients. By 2014 almost 24,000 cases had been collected and analysed. Since 2005 Belgian multidisciplinary diabetic foot clinics could apply for recognition by health authorities. For continued recognition diabetic foot clinics need to treat at least 52 patients with a new foot problem (Wagner 2 or more or active Charcot foot) per annum. Baseline and 6-month outcome data of these patients are included in an audit-feedback initiative. Although originally fully independent of each other, the common goal of these two initiatives is quality improvement of national diabetic foot care, and hence exchanges between systems has commenced. In future, the German and Belgian accreditation models might serve as templates for comparable initiatives in other countries. Just recently the International Working Group on the Diabetic Foot initiated a working group for further discussion of accreditation and auditing models (International Working Group on the Diabetic Foot AB(B)A Working Group).

Direct costs of radiotherapy for rectal cancer: a microcosting study

Background

Radiotherapy provides significant benefits in terms of reducing risk of local recurrence and death from rectal cancer. Despite this, up-to-date cost estimates for radiotherapy are lacking, potentially inhibiting policy and decision-making. Our objective was to generate an up-to-date estimate of the cost of traditional radiotherapy for rectal cancer and model the impact of a range of potential efficiency improvements.

Methods

Microcosting methods were used to estimate total direct radiotherapy costs for long- (assumed at 45-50 Gy in 25 daily fractions over a 5 week period) and short-courses (assumed at 25 Gy in 5 daily fractions over a one week period). Following interviews and on-site visits to radiotherapy departments in two designated cancer centers, a radiotherapy care pathway for a typical rectal cancer patient was developed. Total direct costs were derived by applying fixed and variable unit costs to resource use within each care phase. Costs included labor, capital, consumables and overheads. Sensitivity analyses were performed.

Results

Radiotherapy treatment was estimated to cost between €2,080 (5-fraction course) and €3,609 (25-fraction course) for an average patient in 2012. Costs were highest in the treatment planning phase for the short-course (€1,217; 58% of total costs), but highest in the radiation treatment phase for the long-course (€1,974: 60% of total costs). By simultaneously varying treatment time, capacity utilization rates and linear accelerator staff numbers, the base cost fell by 20% for 5-fractions: (€1,660) and 35% for 25-fractions: (€2,354).

Conclusions

Traditional radiotherapy for rectal cancer is relatively inexpensive. Moreover, significant savings may be achievable through service organization and provision changes. These results suggest that a strong economic argument can be made for expanding the use of radiotherapy in rectal cancer treatment.

Investigation of radiosensitivity gene signatures in cancer cell lines

Intrinsic radiosensitivity is an important factor underlying radiotherapy response, but there is no method for its routine assessment in human tumours. Gene signatures are currently being derived and some were previously generated by expression profiling the NCI-60 cell line panel. It was hypothesised that focusing on more homogeneous tumour types would be a better approach. Two cell line cohorts were used derived from cervix [n = 16] and head and neck [n = 11] cancers. Radiosensitivity was measured as surviving fraction following irradiation with 2 Gy (SF2) by clonogenic assay. Differential gene expression between radiosensitive and radioresistant cell lines (SF2 median) was investigated using Affymetrix GeneChip Exon 1.0ST (cervix) or U133A Plus2 (head and neck) arrays. There were differences within cell line cohorts relating to tissue of origin reflected by expression of the stratified epithelial marker p63. Of 138 genes identified as being associated with SF2, only 2 (1.4%) were congruent between the cervix and head and neck carcinoma cell lines (MGST1 and TFPI), and these did not partition the published NCI-60 cell lines based on SF2. There was variable success in applying three published radiosensitivity signatures to our cohorts. One gene signature, originally trained on the NCI-60 cell lines, did partially separate sensitive and resistant cell lines in all three cell line datasets. The findings do not confirm our hypothesis but suggest that a common transcriptional signature can reflect the radiosensitivity of tumours of heterogeneous origins.

Retreatment with radiotherapy for symptomatic bone, brain or visceral metastases

BACKGROUND

The need for reirradiation in the metastatic disease appears when other modalities of treatment lose their efficacy. The aim of reirradiation in the metastatic disease is mainly palliative to control a particular symptom. However, this theoretical benefit must be confronted against the risk of an undesirable toxicity.

MATERIALS AND METHODS

Experience with reirradiation for symptomatic bone, brain or visceral metastases are reviewed. Twenty-two patients were found to have a second palliative radiotherapy on the same location. Locatión of metastases were visceral in 5 (23 %) patients, brain in 4 (18 %) patients, spine in 1 (4.5 %) patient and bone metastasis other than spine in 12 (54.5 %) patients. Median dose delivered in the first treatment was 30 Gy (range 20-30 Gy) and 20 Gy for the second treatment (range 6-32.4 Gy).

RESULTS

A good symptomatic response after first irradiation (complete response or disappearance of >50 % of symptoms) was reached in 21 (95.5 %) of the 22 patients analyzed. After second irradiation, 82 % (18 patients) achieved a good response, 3 (14 %) patients had a moderate response (relief of symptoms <50 %) whereas no response was observed in 1 (4 %) patient. Acute toxicity was limited to grade 1-2 proctitis in 2 and 3 patients after the first and second irradiation, respectively. No cases of late toxicity after the first or second irradiation were recorded.

CONCLUSION

A second treatment with palliative radiotherapy is feasible and well tolerated and offers the possibility of symptomatic relief in a high percentage of patients with symptomatic metastases.

Radiation therapy for cutaneous melanoma

Radiation therapy is used infrequently for cutaneous melanoma, despite research suggesting benefit in certain clinical scenarios. This review presents data forming the highest level of evidence supporting the use of radiation therapy. Retrospective and prospective studies demonstrate radiation therapy for primary tumors is associated with high control rates. Two randomized trials have found improvements in regional control with adjuvant radiotherapy to regional lymphatics. Retrospective and prospective studies demonstrate radiation therapy is associated with palliative response and metastatic tumor control. Optimal care of melanoma patients involves radiation therapy; awareness of this is incumbent of clinicians caring for patients with this disease.

The cancer burden in the United Kingdom in 2007 due to radiotherapy

The number of long-term cancer survivors in the general population of the UK is substantial and increasing rapidly. Many cancer survivors have been treated with radiotherapy but the likely number of radiotherapy-related second cancers has not previously been estimated. We used estimates of the numbers of cancer survivors in the UK at the beginning of 2007, in conjunction with estimates of the relative risk of a second primary cancer associated with previous radiotherapy from the United States Surveillance Epidemiology and End Results (SEER) programme, to estimate the numbers of incident cancers in the UK in 2007 that were associated with radiotherapy for a previous cancer and that may have been caused by it. We estimated that 1,346 cases of cancer, or about 0.45% of the 298,000 new cancers registered in the UK in 2007, were associated with radiotherapy for a previous cancer. The largest numbers of radiotherapy-related second cancers were lung cancer (23.7% of the total), oesophageal cancer (13.3%), and female breast cancer (10.6%); 54% of radiotherapy-related second cancers were in individuals aged 75 or over. The highest percentages of second cancers related to radiotherapy were among survivors of Hodgkin's disease and cancers of the oral cavity and pharynx and cervix uteri; over 15% of second cancers among these survivors were associated with radiotherapy for the first cancer. These calculations, which involve a number of assumptions and approximations, provide a reasonable, if conservative, estimate of the fraction of incident cancers in the UK that are attributable to past radiation therapy.

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.

Fewer fractions of adjuvant external beam radiotherapy for early breast cancer are safe and effective and can now be the standard of care. Why the UK's NICE accepts fewer fractions as the standard of care for adjuvant radiotherapy in early breast cancer

Fractionation regimes for individual tumour sites have varied greatly across the UK for many years. This has been particularly true for breast cancer which accounts for up to 40% of a radiotherapy department's work load. Over the last 30 years or so many UK oncology centres have coped with this large case load and a lack of megavoltage machines by reducing fractionation and routinely using internationally non standard regimes so that these regimes have themselves become one of the options for standard treatment. Nowadays, medicine is largely evidence based rather than historically relying more on clinical experience or intuition. Large studies particularly in the UK and Canada set out to address this question and have shown that fewer fractions are equivalent in terms of local recurrence, late tissue effects and cosmesis. Current studies are focusing on further hypofractionation and partial breast radiotherapy (see papers Yarnold (2010) Is it safe to push "hypofractionation" further?. The Breast (this issue). Lehman (2010) The less than whole breast radiotherapy approach. The Breast (this issue)).