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Variable and fixed costs in NHS radiotherapy; consequences for increasing hypo fractionation. Radiother Oncol 2021; 166:180-188. [PMID: 34890735 DOI: 10.1016/j.radonc.2021.11.035] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 11/19/2021] [Accepted: 11/30/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND/PURPOSE The increased use of hypofractionated radiotherapy changes department activity. While expected to be cost-effective, departments' fixed costs may impede savings. Understanding radiotherapy's cost-drivers, to what extent these are fixed and consequences of reducing activity can help to inform reimbursement strategies. MATERIAL/METHODS We estimate the cost of radiotherapy provision, using time-driven activity-based costing, for five bone metastases treatment strategies, in a large NHS provider. We compare these estimations to reimbursement tariff and assess their breakdown by cost types: fixed (buildings), semi-fixed (staff, linear accelerators) and variable (materials) costs. Sensitivity analyses assess the cost-drivers and impact of reducing departmental activity on the costs of remaining treatments, with varying disinvestment assumptions. RESULTS The estimated radiotherapy cost for bone metastases ranges from 430.95€ (single fraction) to 4240.76€ (45 Gy in 25#). Provider costs align closely with NHS reimbursement, except for the stereotactic ablative body radiotherapy (SABR) strategy (tariff exceeding by 15.3%). Semi-fixed staff costs account for 28.1-39.7% and fixed/semi-fixed equipment/space costs 38.5-54.8% of provider costs. Departmental activity is the biggest cost-driver; reduction in activity increasing cost, predominantly in fractionated treatments. Decommissioning linear accelerators ameliorates this, although can only be realised at equipment capacity thresholds. CONCLUSION Hypofractionation is less burdensome to patients and long-term offers a cost-efficient mechanism to treat an increasing number of patients within existing capacity. As a large majority of treatment costs are fixed/semi-fixed, disinvestment is complex, within the life expectancy of a linac, imbalances between demand and capacity will result in higher treatment costs. With a per-fraction reimbursement, this may disincentivise delivery of hypofractionated treatments.
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2
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Lee SF, Luk H, Wong A, Ng CK, Wong FCS, Luque-Fernandez MA. Prediction model for short-term mortality after palliative radiotherapy for patients having advanced cancer: a cohort study from routine electronic medical data. Sci Rep 2020; 10:5779. [PMID: 32238885 PMCID: PMC7113237 DOI: 10.1038/s41598-020-62826-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 03/11/2020] [Indexed: 12/18/2022] Open
Abstract
We developed a predictive score system for 30-day mortality after palliative radiotherapy by using predictors from routine electronic medical record. Patients with metastatic cancer receiving first course palliative radiotherapy from 1 July, 2007 to 31 December, 2017 were identified. 30-day mortality odds ratios and probabilities of the death predictive score were obtained using multivariable logistic regression model. Overall, 5,795 patients participated. Median follow-up was 39.6 months (range, 24.5-69.3) for all surviving patients. 5,290 patients died over a median 110 days, of whom 995 (17.2%) died within 30 days of radiotherapy commencement. The most important mortality predictors were primary lung cancer (odds ratio: 1.73, 95% confidence interval: 1.47-2.04) and log peripheral blood neutrophil lymphocyte ratio (odds ratio: 1.71, 95% confidence interval: 1.52-1.92). The developed predictive scoring system had 10 predictor variables and 20 points. The cross-validated area under curve was 0.81 (95% confidence interval: 0.79-0.82). The calibration suggested a reasonably good fit for the model (likelihood-ratio statistic: 2.81, P = 0.094), providing an accurate prediction for almost all 30-day mortality probabilities. The predictive scoring system accurately predicted 30-day mortality among patients with stage IV cancer. Oncologists may use this to tailor palliative therapy for patients.
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Affiliation(s)
- Shing Fung Lee
- Department of Clinical Oncology, Tuen Mun Hospital, New Territories West Cluster, Hospital Authority, Hong Kong, Hong Kong
| | - Hollis Luk
- Department of Clinical Oncology, Tuen Mun Hospital, New Territories West Cluster, Hospital Authority, Hong Kong, Hong Kong
| | - Aray Wong
- Department of Clinical Oncology, Tuen Mun Hospital, New Territories West Cluster, Hospital Authority, Hong Kong, Hong Kong
| | - Chuk Kwan Ng
- Department of Clinical Oncology, Tuen Mun Hospital, New Territories West Cluster, Hospital Authority, Hong Kong, Hong Kong
| | - Frank Chi Sing Wong
- Department of Clinical Oncology, Tuen Mun Hospital, New Territories West Cluster, Hospital Authority, Hong Kong, Hong Kong
| | - Miguel Angel Luque-Fernandez
- Department of Non-Communicable Disease and Cancer Epidemiology, Institute de Investigacion Biosanitaria de Granada (ibs.GRANADA), University of Granada, Granada, Spain. .,Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK.
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3
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Affiliation(s)
- Katie Spencer
- Leeds Institute of Cancer and Pathology, University of Leeds, Leeds LS2 9NL, UK
| | - Rhona Parrish
- Garforth Medical Centre, Garforth, Leeds LS25 1HB, UK
| | - Rachael Barton
- Queen's Centre for Oncology and Haematology, Castle Hill Hospital, Cottingham HU16 5JQ, UK
| | - Ann Henry
- Leeds Institute of Cancer and Pathology, University of Leeds, Leeds LS2 9NL, UK
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Clarke S, Faivre-Finn C, Woolf DK. Current Practice of Whole Brain Radiotherapy in Metastatic Non-small Cell Lung Cancer. Clin Oncol (R Coll Radiol) 2018; 30:e40. [PMID: 29449056 DOI: 10.1016/j.clon.2018.01.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 01/29/2018] [Indexed: 11/16/2022]
Affiliation(s)
- S Clarke
- The University of Manchester, Manchester, UK; The Christie NHS Foundation Trust, Manchester, UK
| | - C Faivre-Finn
- The University of Manchester, Manchester, UK; The Christie NHS Foundation Trust, Manchester, UK
| | - D K Woolf
- The University of Manchester, Manchester, UK; The Christie NHS Foundation Trust, Manchester, UK.
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Donnelly TD, Woolf DK, Farrar NG. Management of metastatic bone disease in the appendicular skeleton. ACTA ACUST UNITED AC 2018. [DOI: 10.1302/2048-0105.71.360580] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- T. D. Donnelly
- Specialty Registrar, Trauma and Orthopaedics, Mid-Cheshire Hospitals NHS Foundation Trust, Crewe, UK
| | - D. K. Woolf
- Consultant Clinical Oncologist, The Christie NHS Foundation Trust, Manchester, UK and The University of Manchester, Manchester, UK
| | - N. G. Farrar
- Consultant Orthopaedics Surgeon, Mid-Cheshire Hospitals NHS Foundation Trust, Crewe, UK
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6
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Price J, Wolfe T, Shawcroft E, Sundar S. Single-fraction Radiotherapy Should be the Standard of Care for Palliation of Cancer Symptoms in Patients with Limited Life Expectancy. Clin Oncol (R Coll Radiol) 2017. [DOI: 10.1016/j.clon.2017.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Woolf DK, Slotman BJ, Faivre-Finn C. The Current Role of Radiotherapy in the Treatment of Small Cell Lung Cancer. Clin Oncol (R Coll Radiol) 2016; 28:712-719. [PMID: 27522475 DOI: 10.1016/j.clon.2016.07.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 07/09/2016] [Accepted: 07/15/2016] [Indexed: 10/21/2022]
Abstract
Radiotherapy has been shown to play a key role in the management of small cell lung cancer. There are well-established data in the literature for the use of concurrent chemoradiotherapy for stage I-III disease, although key questions remain over the timing of radiation, the optimal dose/fractionation and particularly once versus twice daily treatment, the use of elective nodal irradiation and drug combinations. Data for the use of thoracic radiation in stage IV disease, after chemotherapy, have recently become available and are leading to a change in practice. Prophylactic cranial irradiation has been shown to be of use in both stage I-III and stage IV disease, although uncertainties surround its use in the elderly population and the use of brain imaging before treatment. This overview will address the current available evidence and focus on areas for future research.
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Affiliation(s)
- D K Woolf
- The Christie Hospital NHS Foundation Trust, Manchester, UK.
| | - B J Slotman
- VU University Medical Center, Amsterdam, The Netherlands
| | - C Faivre-Finn
- The Christie Hospital NHS Foundation Trust, Manchester, UK; The University of Manchester, Manchester Academic Health Science Centre, Institute of Cancer Sciences, Manchester Cancer Research Centre (MCRC), Manchester, UK
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Stavas MJ, Arneson KO, Ning MS, Attia AA, Phillips SE, Perkins SM, Shinohara ET. The Refusal of Palliative Radiation in Metastatic Non-Small Cell Lung Cancer and Its Prognostic Implications. J Pain Symptom Manage 2015; 49:1081-1087.e4. [PMID: 25596010 DOI: 10.1016/j.jpainsymman.2014.11.298] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Revised: 11/15/2014] [Accepted: 11/23/2014] [Indexed: 12/25/2022]
Abstract
CONTEXT Patients with metastatic non-small cell lung cancer (NSCLC) have limited survival. Population studies have evaluated the impact of radiation refusal in the curative setting; however, no data exist concerning the prognostic impact of radiation refusal in the palliative care setting. OBJECTIVES To investigate the patterns of radiation refusal in newly diagnosed patients with metastatic NSCLC. METHODS Patients with Stage IV NSCLC diagnosed between 1988 and 2010 were identified in the Surveillance, Epidemiology, and End Results database. Univariate and multivariate analyses were used to identify predictors for refusal of radiation and the impact of radiation and refusal on survival in the palliative setting. RESULTS A total of 285,641 patients were initially included in the analysis. Palliative radiation was recommended in 42% and refused by 3.1% of patients. Refusal rates remained consistent across included years of study. On multivariate analysis, older, nonblack/nonwhite, unmarried females were more likely to refuse radiation (P < 0.001 in all cases). Median survival for patients refusing radiation was three months vs. five months for those receiving radiation and two months for those whom radiation was not recommended. CONCLUSION Patients with metastatic NSCLC who refuse recommended palliative radiation have a poor survival. Radiation refusal or the recommendation against treatment can serve as a trigger for integrating palliative care services sooner and contributes greatly to prognostic awareness. Further investigation into this survival difference and the factors behind refusal are warranted.
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Affiliation(s)
- Mark J Stavas
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
| | - Kyle O Arneson
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Matthew S Ning
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Albert A Attia
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sharon E Phillips
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Stephanie M Perkins
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Eric T Shinohara
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Spencer K, Morris E, Dugdale E, Newsham A, Sebag-Montefiore D, Turner R, Hall G, Crellin A. 30 day mortality in adult palliative radiotherapy--A retrospective population based study of 14,972 treatment episodes. Radiother Oncol 2015; 115:264-71. [PMID: 25861831 PMCID: PMC4504022 DOI: 10.1016/j.radonc.2015.03.023] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Revised: 03/23/2015] [Accepted: 03/23/2015] [Indexed: 11/25/2022]
Abstract
Background: 30-day mortality (30DM) has been suggested as a clinical indicator of the avoidance of harm in palliative radiotherapy within the NHS, but no large-scale population-based studies exist. This large retrospective cohort study aims to investigate the factors that influence 30DM following palliative radiotherapy and consider its value as a clinical indicator. Methods: All radiotherapy episodes delivered in a large UK cancer centre between January 2004 and April 2011 were analysed. Patterns of palliative radiotherapy, 30DM and the variables affecting 30DM were assessed. The impact of these variables was assessed using logistic regression. Results: 14,972 palliative episodes were analysed. 6334 (42.3%) treatments were delivered to bone metastases, 2356 (15 7%) to the chest for lung cancer and 915 (5.7%) to the brain. Median treatment time was 1 day (IQR 1–7). Overall 30DM was 12.3%. Factors having a significant impact upon 30DM were sex, primary diagnosis, treatment site and fractionation schedule (p < 0.01). Conclusion: This is the first large-scale description of 30-day mortality for unselected adult palliative radiotherapy treatments. The observed differences in early mortality by fractionation support the use of this measure in assessing clinical decision making in palliative radiotherapy and require further study in other centres and health care systems.
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Affiliation(s)
- Katie Spencer
- St James's Institute of Oncology, Leeds Cancer Centre, St James's University Teaching Hospital, United Kingdom; Section of Clinical Oncology, Institute of Cancer and Pathology, University of Leeds, St James's University Teaching Hospital, United Kingdom.
| | - Eva Morris
- Cancer Epidemiology Group, Section of Epidemiology and Biostatistics, Institute of Cancer and Pathology, University of Leeds, St James's University Teaching Hospital, United Kingdom
| | - Emma Dugdale
- St James's Institute of Oncology, Leeds Cancer Centre, St James's University Teaching Hospital, United Kingdom; Section of Clinical Oncology, Institute of Cancer and Pathology, University of Leeds, St James's University Teaching Hospital, United Kingdom
| | - Alexander Newsham
- St James's Institute of Oncology, Leeds Cancer Centre, St James's University Teaching Hospital, United Kingdom; Section of Clinical Oncology, Institute of Cancer and Pathology, University of Leeds, St James's University Teaching Hospital, United Kingdom
| | - David Sebag-Montefiore
- St James's Institute of Oncology, Leeds Cancer Centre, St James's University Teaching Hospital, United Kingdom; Section of Clinical Oncology, Institute of Cancer and Pathology, University of Leeds, St James's University Teaching Hospital, United Kingdom
| | - Rob Turner
- St James's Institute of Oncology, Leeds Cancer Centre, St James's University Teaching Hospital, United Kingdom
| | - Geoff Hall
- St James's Institute of Oncology, Leeds Cancer Centre, St James's University Teaching Hospital, United Kingdom; Section of Clinical Oncology, Institute of Cancer and Pathology, University of Leeds, St James's University Teaching Hospital, United Kingdom
| | - Adrian Crellin
- St James's Institute of Oncology, Leeds Cancer Centre, St James's University Teaching Hospital, United Kingdom
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Westhoff PG, de Graeff A, Monninkhof EM, Bollen L, Dijkstra SP, van der Steen-Banasik EM, van Vulpen M, Leer JWH, Marijnen CA, van der Linden YM. An easy tool to predict survival in patients receiving radiation therapy for painful bone metastases. Int J Radiat Oncol Biol Phys 2014; 90:739-47. [PMID: 25260489 DOI: 10.1016/j.ijrobp.2014.07.051] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2014] [Revised: 07/23/2014] [Accepted: 07/31/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE Patients with bone metastases have a widely varying survival. A reliable estimation of survival is needed for appropriate treatment strategies. Our goal was to assess the value of simple prognostic factors, namely, patient and tumor characteristics, Karnofsky performance status (KPS), and patient-reported scores of pain and quality of life, to predict survival in patients with painful bone metastases. METHODS AND MATERIALS In the Dutch Bone Metastasis Study, 1157 patients were treated with radiation therapy for painful bone metastases. At randomization, physicians determined the KPS; patients rated general health on a visual analogue scale (VAS-gh), valuation of life on a verbal rating scale (VRS-vl) and pain intensity. To assess the predictive value of the variables, we used multivariate Cox proportional hazard analyses and C-statistics for discriminative value. Of the final model, calibration was assessed. External validation was performed on a dataset of 934 patients who were treated with radiation therapy for vertebral metastases. RESULTS Patients had mainly breast (39%), prostate (23%), or lung cancer (25%). After a maximum of 142 weeks' follow-up, 74% of patients had died. The best predictive model included sex, primary tumor, visceral metastases, KPS, VAS-gh, and VRS-vl (C-statistic = 0.72, 95% CI = 0.70-0.74). A reduced model, with only KPS and primary tumor, showed comparable discriminative capacity (C-statistic = 0.71, 95% CI = 0.69-0.72). External validation showed a C-statistic of 0.72 (95% CI = 0.70-0.73). Calibration of the derivation and the validation dataset showed underestimation of survival. CONCLUSION In predicting survival in patients with painful bone metastases, KPS combined with primary tumor was comparable to a more complex model. Considering the amount of variables in complex models and the additional burden on patients, the simple model is preferred for daily use. In addition, a risk table for survival is provided.
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Affiliation(s)
- Paulien G Westhoff
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Alexander de Graeff
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Evelyn M Monninkhof
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Laurens Bollen
- Department of Orthopedic Surgery, Leiden University Medical Center, The Netherlands
| | - Sander P Dijkstra
- Department of Orthopedic Surgery, Leiden University Medical Center, The Netherlands
| | | | - Marco van Vulpen
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jan Willem H Leer
- Department of Radiotherapy, University Medical Center Nijmegen, Nijmegen, The Netherlands
| | - Corrie A Marijnen
- Department of Clinical Oncology, Leiden University Medical Center, Leiden, The Netherlands
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Jeremic B, Vanderpuye V, Abdel-Wahab S, Gaye P, Kochbati L, Diwani M, Emwula P, Oro B, Lishimpi K, Kigula-Mugambe J, Dawotola D, Wondemagegnehu T, Nyongesa C, Oumar N, El-Omrani A, Shuman T, Langenhoven L, Fourie L. Patterns of Practice in Palliative Radiotherapy in Africa – Case Revisited. Clin Oncol (R Coll Radiol) 2014; 26:333-43. [DOI: 10.1016/j.clon.2014.03.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2014] [Revised: 02/14/2014] [Accepted: 03/11/2014] [Indexed: 12/25/2022]
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12
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Stavas M, Arneson K, Friedman J, Misra S. From Whole Brain to Hospice: Patterns of Care in Radiation Oncology. J Palliat Med 2014; 17:662-6. [DOI: 10.1089/jpm.2013.0549] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Affiliation(s)
- Mark Stavas
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kyle Arneson
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jeffrey Friedman
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sumathi Misra
- Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
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