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Patel H, Drinkwater K, Stewart A. National Survey of Current Follow-up Protocols for Patients Treated for Endometrial Cancer in the UK. Clin Oncol (R Coll Radiol) 2024; 36:e146-e153. [PMID: 38548582 DOI: 10.1016/j.clon.2024.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 12/12/2023] [Accepted: 03/08/2024] [Indexed: 05/06/2024]
Abstract
AIMS The aim of this study was to establish a baseline of national practice for follow-up after treatment for endometrial cancer in the UK. MATERIALS AND METHODS An online cross-sectional survey was developed and distributed through the Royal College of Radiologists via an email link to the audit leads of radiotherapy centres in the UK. The survey was conducted from November 2021 to 5 January 2022. The main themes assessed in the survey were the form, frequency and duration of follow-up practices. RESULTS There were a total of 43/61 (70%) complete responses. 93% of centres had a standard follow-up protocol and 7% who did not have a follow-up protocol discharged patients after the post-operative review. Five centres (13%) used molecular profiling to inform follow-up practices. Patient-initiated follow-up was mainly used in the cohort of patients who had surgery alone with no adjuvant treatment (68%, (19/28)). In the cohort who had face-to-face follow-up, the majority had pelvic examinations as part of their review and total follow-up for five years. 93% of respondents are interested in a national follow-up protocol. CONCLUSION Our data shows that there is national variation in practise with regard to follow-up of women treated for endometrial cancer. Many of the follow-up practises are based on conventional follow-up regimens and these may fail to address the more holistic needs of cancer survivors. Recent publication of updated guidance from the British Gynaecological Cancer Society may help standardise practise and provide a more relevant approach to follow-up for women treated for endometrial cancer.
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Affiliation(s)
- H Patel
- St Luke's Cancer Centre, Royal Surrey County Hospital, Guildford, UK.
| | | | - A Stewart
- St Luke's Cancer Centre, Royal Surrey County Hospital, Guildford, UK; University of Surrey, Guildford, UK
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2
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McAleese J, Drinkwater K. Service Improvements and Workload Increases: Royal College of Radiologists (RCR) Re-Audit of Curative Intent Radiotherapy for Non-Small Cell Lung Cancer (NSCLC). Clin Oncol (R Coll Radiol) 2024; 36:e128-e136. [PMID: 38616447 DOI: 10.1016/j.clon.2024.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 02/13/2024] [Accepted: 03/13/2024] [Indexed: 04/16/2024]
Abstract
AIMS The Royal College of Radiologists (RCR) audit of radical radiotherapy (RR) for patients with non-small cell lung cancer (NSCLC) in 2013 concluded that there was under-treatment compared to international comparators and marked variability between cancer networks. Elderly patients were less likely to receive guideline recommended treatments. Access to technological developments was low. Various national and local interventions have since taken place. This study aims to re-assess national practice. MATERIALS AND METHODS Radiotherapy departments completed one questionnaire for each patient started on RR for 4 weeks in January 2023. RESULTS Ninety-three percent of centres returned data on 295 patients. RR has increased 70% since 2013 but patients on average wait 20% longer to start treatment (p = 0.02). Staging investigations were often outside a desirable timeframe (79% of PET/CT scans). Advanced planning techniques are used more frequently: 4-dimensional planning increased from 33% to 90% (P < 0.001), cone beam imaging from 67% to 97% (p < 0.001) and colleague led peer review increased from 41% to 73% (P < 0.001). CONCLUSION There have been significant improvements in care. There has been a considerable increase in clinical oncology workload with evidence of stress on the system that requires additional resourcing.
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Affiliation(s)
- J McAleese
- Northern Ireland Cancer Centre, Belfast, United Kingdom; Queens University, Belfast, United Kingdom; Royal College of Radiologists, United Kingdom
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3
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Baird P, Drinkwater K, Forrest J, Stewart AJ. The Royal College of Radiologists National Vulvar Cancer Audit. Clin Oncol (R Coll Radiol) 2024:S0936-6555(24)00138-9. [PMID: 38658266 DOI: 10.1016/j.clon.2024.03.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 03/14/2024] [Accepted: 03/26/2024] [Indexed: 04/26/2024]
Abstract
AIMS This audit examined UK vulvar cancer practice from March 2018 to January 2019 and compared it to standards from national and international recommendations. Follow-up data collection in 2020 examined patient outcomes and toxicity. MATERIALS AND METHODS Audit standards were based on Royal College of Radiologists (RCR) guidance and published literature. A web-based questionnaire was sent to the audit leads at all cancer centres in the UK. Prospective data collection included patient demographics, tumour characteristics, radiotherapy indications, dosimetry, timelines, and follow-up data. The audit targets were 95% compliance with the RCR dose/fractionation schemes in definitive and adjuvant patients, 40% use of intensity modulated radiotherapy (IMRT), 100% of radical patients treated as category 1, and 95% use of gap compensation for category 1 patients. RESULTS 34/54 UK radiotherapy centres (63%) completed data entry for 152 patients. 23 out of 34 (68%) centres submitted follow-up data for 94 patients. One indicator exceeded the audit target: 98% of radical patients received IMRT. The indicators of RCR dose/fractionation compliance for adjuvant/definitive radiotherapy were achieved by 80%/43% for the primary, 80%/86% for elective lymph nodes, and 21%/21% for pathological lymph nodes. The use of concomitant chemotherapy with radical radiotherapy in suitable patients was achieved by 71%. Other indicators demonstrated that 78% were treated as category 1 and 27% used gap compensation. Acute toxicity was mostly related to skin, gastrointestinal, and genitourinary sites. Grade 3 and Grade 4 toxicities were seen at acceptable rates within the radical and adjuvant groups. Late toxicity was mostly grade 0. CONCLUSION This audit provides a comprehensive picture of UK practice. IMRT is widely used in the UK, and treatment-related toxicity is moderate. The dose fractionation was very heterogeneous. The designation of vulvar cancer as category 1 was not regularly followed for radical/adjuvant patients, and there was minimal gap compensation during treatment.
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Affiliation(s)
- P Baird
- Belfast Health and Social Care Trust, Belfast, UK
| | | | - J Forrest
- Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - A J Stewart
- St Luke's Cancer Centre, Royal Surrey County Hospital, Guildford, UK; University of Surrey, Guildford, UK.
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Jia Y, Szewczyk-Bieda M, Greenhalgh R, Drinkwater K. Preventing post-contrast acute kidney injury and hypersensitivity reactions: UK national audit. Clin Radiol 2023; 78:e898-e907. [PMID: 37612224 DOI: 10.1016/j.crad.2023.07.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 07/06/2023] [Accepted: 07/23/2023] [Indexed: 08/25/2023]
Abstract
AIM To audit UK radiology departmental protocols related to the prevention of Iodine-based contrast media (ICM) adverse drug reactions (ADRs) and to assess their compliance with the Royal College of Radiologists (RCR) endorsed Royal Australian and New Zealand College of Radiologists' 2018 Iodinated Contrast Guidelines. MATERIALS AND METHODS Questionnaires were sent to all UK acute National Health Service (NHS) providers treating adult patients with an audit lead registered with the RCR (162 providers encompassing 211 hospital radiology departments). The questionnaire included three main sections: renal function screening, renal protection regimens, and hypersensitivity reactions prevention and follow-up. Data collection was conducted between April and July 2022. RESULTS Sixty-one per cent (129/211) of departments responded, representing 67% of eligible providers. An independent imaging services provider supplied one additional set of data (n=130 overall). Of the responding departments, for post-contrast acute kidney injury (PC-AKI), 41% and 56% had the recommended risk assessment for inpatients and outpatients, respectively. Renal function testing was often over-utilised, and their results were applied improperly. Sixty-eight per cent of departments used the advised threshold for considering renal protection. For hypersensitivity reactions, 9% of departments had the correct risk assessment. Thirty-six per cent of departments had the correct risk mitigation protocol for identified high-risk patients. The documentation and follow-up for hypersensitivity reactions were similarly inadequate. CONCLUSION Local protocols on preventing ICM ADRs were largely non-compliant with RCR guidelines. Departments need to update their protocols in line with current evidence to avoid iatrogenic morbidity or unnecessary tests and over-precaution.
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Affiliation(s)
- Y Jia
- Department of Medicine, Imperial College London, London, UK.
| | - M Szewczyk-Bieda
- Department of Clinical Radiology, Ninewells Hospital, NHS Tayside, Dundee, UK
| | - R Greenhalgh
- Department of Radiology, London North West University Healthcare NHS Trust, London, UK
| | - K Drinkwater
- Directorate of Education and Professional Practice, The Royal College of Radiologists, London, UK
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McAleese J, Tumelty K, Baluch S, Powell C, Drinkwater K. Assessment of the Implementation of Lung Cancer Consensus Statements From the Royal College of Radiologists in 2021; Progress and Barriers. Clin Oncol (R Coll Radiol) 2022; 34:e463-e471. [PMID: 36109283 DOI: 10.1016/j.clon.2022.07.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Revised: 07/02/2022] [Accepted: 07/22/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Lung cancer outcomes in the UK are worse than those in many similar countries. The RCR developed a series of 43 consensus statements (CS) to facilitate improvements in care for patients treated with radiotherapy. METHODS We asked all 61 UK radiotherapy centres to self-assess the implementation of the CS and to describe their departmental key strengths and weaknesses in September 2021. RESULTS 87% of centres returned their assessments. Whilst developmental activity was seen in most areas for most centres, 24 of the statements were felt to be difficult to implement within the next 2 years by at least one centre. The most frequently reported strengths were in the implementation of SABR (stereotactic body radiotherapy), concurrent chemoradiation for non-small cell lung cancer and technological aspects of treatment planning. The most frequently described departmental weaknesses were in pre-habilitation, timeliness of PET/CT scans and prophylaxis for Pneumocystis jiroveci Pneumonia (PJP). Barriers to implementation were often due to insufficient resource, a requirement for organisations to work together, and a perceived lack of evidence base. Strengths were often attributed to good team working, a local champion and being an early adopter. CONCLUSIONS This work confirms the commitment of lung cancer radiotherapy teams across the UK to improve outcomes for their patients. Most of the statements have been implemented at least partially. Themes have been identified to aid further progress, one of which is a requirement for significant investment.
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Affiliation(s)
- J McAleese
- Northern Ireland Cancer Centre, Belfast, UK
| | - K Tumelty
- Northern Ireland Cancer Centre, Belfast, UK.
| | - S Baluch
- Queen Alexandra Hospital, Portsmouth, UK
| | - C Powell
- Velindre Cancer Centre, Cardiff, UK
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6
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Locke I, Drinkwater K. Implementation of Royal College of Radiologists Consensus Statements and National Institute for Health and Care Excellence Guidance: Breast Radiotherapy Practice in the UK. Clin Oncol (R Coll Radiol) 2021; 33:419-426. [PMID: 33597107 DOI: 10.1016/j.clon.2021.01.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 01/13/2021] [Accepted: 01/28/2021] [Indexed: 10/22/2022]
Abstract
AIMS Breast radiotherapy practice, driven by large randomised controls trials, is increasingly being risk adapted to the biology and stage of the cancer. The aim of this audit was to measure current breast radiotherapy practice in the UK against quality standards from the 2016 Royal College of Radiologists (RCR) consensus statements and the 2018 updated National Institute for Health and Care Excellence (NICE) guidelines. These guidelines include new recommendations for partial breast irradiation for women at lower risk of recurrence and internal mammary chain radiotherapy for those at higher risk. MATERIALS AND METHODS Radiotherapy departments completed a questionnaire for all patients starting adjuvant radiotherapy for early breast cancer in a 2-week period mid-2019. RESULTS Eighty-one per cent of centres returned data on 958 patients, including 18 bilateral cancers. Of 976 breast cancers, 23.9% were treated with mastectomy. The dose fractionation schedule for adjuvant radiotherapy was 40 Gy in 15 fractions in 95.7% of cases. Of the 743 cases treated with breast conservation, 29.9% received an additional tumour bed boost. The boost was given sequentially in 91.9% of cases and with eight different dose fractionation schedules. Of 494 left-sided breast cancer cases, 54% (n = 267) received radiotherapy in deep inspiratory breath hold. All centres except one had a deep inspiratory breath hold technique available. Only 12% of patients who met the RCR criteria for partial breast irradiation received it. Overall, 14.7% and 9.9% of patients meeting the RCR and NICE criteria for internal mammary chain radiotherapy, respectively, received it. CONCLUSIONS Despite established consensus statements and NICE guidelines there persists variation in breast radiotherapy practice in the UK. The results of practice-changing trials showing the benefit of cardiac-sparing radiotherapy techniques, partial breast radiotherapy and internal mammary nodal radiotherapy have not been fully implemented. This audit highlights areas for targeted quality improvement and future consensus statements.
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Affiliation(s)
- I Locke
- Royal Marsden NHS Foundation Trust, Sutton, Surrey, UK.
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7
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Callaway M, Greenhalgh R, Harden S, Elford J, Drinkwater K, Vanburen T, Ramsden W. Accelerated implementation of remote reporting during the COVID-19 pandemic. Clin Radiol 2021; 76:443-446. [PMID: 33745705 PMCID: PMC7846206 DOI: 10.1016/j.crad.2021.01.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 01/18/2021] [Indexed: 10/26/2022]
Abstract
AIM To assess, via a survey of UK radiological departments, if the COVID-19 pandemic led to a change in radiological reporting undertaken in a home environment with appropriate IT support. MATERIALS AND METHODS All imaging departments in the UK were contacted and asked about the provision of home reporting and IT support before and after the first wave of the pandemic. RESULTS One hundred and thirty-seven of the 217 departments contacted replied, producing a response rate of 61%. There was a 147% increase in the provision of remote access viewing and reporting platforms during the pandemic. Although 578 consultants had access to a viewing platform pre-pandemic, this had increased to 1,431 during the course of the first wave. CONCLUSION This survey represents work undertaken by UK NHS Trusts in co-ordinating and providing increased home-reporting facilities to UK radiologists during the first wave of this global pandemic. The impact of these facilities has been shown to allow more than just the provision of reporting of both elective and emergency imaging and provides additional flexibility in how UK radiologists can help support and provide services. This is a good start, but there are potential problems that now need to be overcome.
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Affiliation(s)
- M Callaway
- The Royal College of Radiologists, 63, Lincolns Inns Fields, London, UK.
| | - R Greenhalgh
- The Royal College of Radiologists, 63, Lincolns Inns Fields, London, UK
| | - S Harden
- The Royal College of Radiologists, 63, Lincolns Inns Fields, London, UK
| | - J Elford
- The Royal College of Radiologists, 63, Lincolns Inns Fields, London, UK
| | - K Drinkwater
- The Royal College of Radiologists, 63, Lincolns Inns Fields, London, UK
| | - T Vanburen
- The Royal College of Radiologists, 63, Lincolns Inns Fields, London, UK
| | - W Ramsden
- The Royal College of Radiologists, 63, Lincolns Inns Fields, London, UK
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Varughese M, Treece S, Drinkwater K, Williams M. Failing to Close the Gap between Evidence and Clinical Practice in Radical Bladder Cancer Radiotherapy: A Critical Unmet Need. Clin Oncol (R Coll Radiol) 2021; 33:340-341. [PMID: 33495067 DOI: 10.1016/j.clon.2021.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 01/06/2021] [Indexed: 11/30/2022]
Affiliation(s)
| | - S Treece
- North West Anglia NHS Foundation Trust, Huntingdon, UK
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9
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Callaway M, Harden S, Ramsden W, Beavon M, Drinkwater K, Vanburen T, Rubin C, Beale A. A national UK audit for diagnostic accuracy of preoperative CT chest in emergency and elective surgery during COVID-19 pandemic. Clin Radiol 2020; 75:705-708. [PMID: 32600651 PMCID: PMC7311900 DOI: 10.1016/j.crad.2020.06.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 06/19/2020] [Indexed: 01/07/2023]
Abstract
AIM To report on a snap audit of all departments in the UK as to the value of preoperative thoracic imaging, preferably computed tomography (CT), of patients undergoing any surgery to assess for changes consistent with COVID-19 preoperatively. MATERIALS AND METHODS All Imaging departments in the UK were contacted and asked to record the number of preoperative CT examinations performed in patients being considered for both emergency and elective surgical intervention over a 5-day period in May 2020. RESULTS Forty-seven percent of departments replied with data provided on >820 patients. Nineteen percent of additional preoperative CT was in patients undergoing elective intervention and 81% in patients presenting with surgical abdominal pain. There was a high rate of false positives in patients who tested negative for COVID-19, producing a sensitivity for thoracic CT of 68.4%. CONCLUSION This UK-wide audit demonstrates that a large number of additional thoracic imaging examinations over a 5-day period were performed with a low sensitivity for the identification of COVID-19 in this preoperative group of patients. Given these findings, it is difficult to justify this additional examination in this group of patients.
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Affiliation(s)
- M Callaway
- The Royal College of Radiologists, 63, Lincolns Inns Fields, London, UK.
| | - S Harden
- The Royal College of Radiologists, 63, Lincolns Inns Fields, London, UK
| | - W Ramsden
- The Royal College of Radiologists, 63, Lincolns Inns Fields, London, UK
| | - M Beavon
- The Royal College of Radiologists, 63, Lincolns Inns Fields, London, UK
| | - K Drinkwater
- The Royal College of Radiologists, 63, Lincolns Inns Fields, London, UK
| | - T Vanburen
- The Royal College of Radiologists, 63, Lincolns Inns Fields, London, UK
| | - C Rubin
- The Royal College of Radiologists, 63, Lincolns Inns Fields, London, UK
| | - A Beale
- The Royal College of Radiologists, 63, Lincolns Inns Fields, London, UK
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Gilbert A, Drinkwater K, McParland L, Adams R, Glynne-Jones R, Harrison M, Hawkins MA, Sebag-Montefiore D, Gilbert DC, Muirhead R. UK national cohort of anal cancer treated with intensity-modulated radiotherapy: One-year oncological and patient-reported outcomes. Eur J Cancer 2020; 128:7-16. [PMID: 32109852 DOI: 10.1016/j.ejca.2019.12.022] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 12/13/2019] [Accepted: 12/26/2019] [Indexed: 01/22/2023]
Abstract
BACKGROUND Concurrent chemoradiotherapy is the standard treatment for anal cancer. Following national UK implementation of intensity-modulated radiotherapy (IMRT), this prospective, national cohort evaluates the one-year oncological outcomes and patient-reported toxicity outcomes (PRO) after treatment. MATERIALS AND METHODS A national cohort of UK cancer centers implementing IMRT was carried out between February to July 2015. Cancer centers provided data on oncological outcomes, including survival, and disease and colostomy status at one-year. EORTC-QLQ core (C30) and colorectal (CR29) questionnaires were completed at baseline and one-year followup. The PRO scores at baseline and one year were compared. RESULTS 40 UK Cancer Centers returned data with a total of 187 patients included in the analysis. 92% received mitomycin with 5-fluorouracil or capecitabine. One-year overall survival was 94%; 84% were disease-free and 86% colostomy-free at one-year followup. At one year, PRO results found significant improvements in buttock pain, blood and mucus in stools, pain, constipation, appetite loss, and health anxiety compared to baseline. No significant deteriorations were reported in diarrhea, bowel frequency, and flatulence. Urinary symptom scores were low at one year. Moderate impotence symptoms at baseline remained at one year, and a moderate deterioration in dyspareunia reported. CONCLUSIONS With national anal cancer IMRT implementation, at this early pre-defined time point, one-year oncological outcomes were reassuring and resulted in good disease-related symptom control. one-year symptomatic complications following CRT for anal cancer using IMRT techniques appear to be relatively mild. These PRO results provide a basis to benchmark future studies.
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Affiliation(s)
- A Gilbert
- University of Leeds, Leeds Cancer Centre, St. James's University Hospital, Leeds, UK.
| | | | - L McParland
- Leeds Clinical Trials Research Unit, Worsley Building, University of Leeds, Leeds, UK
| | - R Adams
- Cardiff University - Centre for Trials Research and Velindre Cancer Centre, Cardiff, UK
| | - R Glynne-Jones
- Mount Vernon Centre for Cancer Treatment, Mount Vernon Hospital, Rickmansworth Road, Northwood, UK
| | - M Harrison
- Mount Vernon Centre for Cancer Treatment, Mount Vernon Hospital, Rickmansworth Road, Northwood, UK
| | - M A Hawkins
- CRUK MRC Oxford Institute for Radiation Oncology, University of Oxford, Oxford, UK
| | - D Sebag-Montefiore
- University of Leeds, Leeds Cancer Centre, St. James's University Hospital, Leeds, UK
| | - D C Gilbert
- Sussex Cancer Centre, Royal Sussex County Hospital, Eastern Road, Brighton, UK
| | - R Muirhead
- Oxford University Hospitals NHS Trust, Department of Oncology, Churchill Hospital, Oxford, UK
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Sinnott JD, Mortimer R, Smith J, Skelton E, Drinkwater K, Lipscomb D, Howlett DC. The effect of routine radiological reporting of thyroid incidentalomas on rates of thyroid needle biopsy, thyroid surgery and detection of thyroid malignancy. Clin Endocrinol (Oxf) 2017; 87:825-831. [PMID: 28718944 DOI: 10.1111/cen.13424] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Revised: 06/25/2017] [Accepted: 07/13/2017] [Indexed: 11/27/2022]
Abstract
OBJECTIVE This study looked at the effect of a changing radiology reporting policy to routinely review the thyroid gland where visible and report on any thyroid lesion, recommending further investigation as appropriate. CONTEXT Incidentaloma is a term used to describe a lesion found on imaging unrelated to the clinical issue under investigation. There is variability in the radiological reporting of thyroid incidentalomas and conflicting recommendations as to how these lesions should be managed. DESIGN Data were collected retrospectively during a two-year period, including 12 months before and 12 months after the change in reporting policy and categorized according to whether the lesion under investigation was a thyroid incidentaloma or a symptomatic thyroid lesion. PATIENTS All patients undergoing ultrasound-guided fine-needle aspiration cytology or core biopsy were included. MEASUREMENTS The effects of the change in policy were analysed including rates of needle biopsy, rates of malignancy and subsequent surgical intervention. RESULTS There was a 122% increase in thyroid incidentalomas undergoing needle biopsy, the majority of these were detected on computed tomography. The number of malignancies increased from 1 to 4 from year 1 to year 2. All patients were >35 years old. One patient had a positron emission tomography (PET)-detected cancer, two of four of the non-PET-detected malignancies were <1.5 cm. CONCLUSION This study posits that routine radiological reporting of thyroid incidentalomas, with further investigation when clinically appropriate, is warranted. The results suggest that lesion size and CT characteristics are not reliable criteria to triage patients for investigation/biopsy.
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Affiliation(s)
- J D Sinnott
- Department of ENT, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - R Mortimer
- Department of Accident and Emergency, Eastbourne District General Hospital, Eastbourne, UK
| | - J Smith
- Department of Oral and Maxillofacial Surgery, Eastbourne District General Hospital, Eastbourne, UK
| | - E Skelton
- Department of Radiology, Eastbourne District General Hospital, Eastbourne, UK
| | - K Drinkwater
- Audit Officer, Royal College of Radiologists, London, UK
| | - D Lipscomb
- Department of Endocrinology, Eastbourne District General Hospital, Eastbourne, UK
| | - D C Howlett
- Department of Radiology, Eastbourne District General Hospital, Eastbourne, UK
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12
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McAleese J, Baluch S, Drinkwater K, Bassett P, Hanna GG. The Elderly are Less Likely to Receive Recommended Radical Radiotherapy for Non-small Cell Lung Cancer. Clin Oncol (R Coll Radiol) 2017; 29:593-600. [PMID: 28735769 DOI: 10.1016/j.clon.2017.06.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2017] [Revised: 06/12/2017] [Accepted: 06/15/2017] [Indexed: 12/25/2022]
Affiliation(s)
- J McAleese
- Northern Ireland Cancer Centre, Belfast City Hospital, Belfast, UK.
| | - S Baluch
- Queen Alexandra Hospital, Cosham, Portsmouth, UK
| | | | - P Bassett
- Royal College of Radiologists, London, UK
| | - G G Hanna
- Northern Ireland Cancer Centre, Belfast City Hospital, Belfast, UK; Centre for Cancer Research and Cell Biology, Queen's University of Belfast, Belfast, UK
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13
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Howlett DC, Drinkwater K, Frost C, Higginson A, Ball C, Maskell G. Re: The accuracy of emergency abdominal CT in adult patients who present with non-traumatic abdominal pain: results of a UK national audit. A reply. Clin Radiol 2017. [PMID: 28648250 DOI: 10.1016/j.crad.2017.05.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
| | | | - C Frost
- London School of Hygiene and Tropical Medicine, London, UK
| | | | - C Ball
- Queen Alexandra Hospital, Portsmouth, UK
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14
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Muirhead R, Drinkwater K, O'Cathail SM, Adams R, Glynne-Jones R, Harrison M, Hawkins MA, Sebag-Montefiore D, Gilbert DC. Initial Results from the Royal College of Radiologists' UK National Audit of Anal Cancer Radiotherapy 2015. Clin Oncol (R Coll Radiol) 2017; 29:188-197. [PMID: 27810119 PMCID: PMC5304408 DOI: 10.1016/j.clon.2016.10.005] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 08/08/2016] [Accepted: 08/15/2016] [Indexed: 11/22/2022]
Abstract
AIMS UK guidance was recently developed for the treatment of anal cancer using intensity-modulated radiotherapy (IMRT). We audited the current use of radiotherapy in UK cancer centres for the treatment of anal cancer against such guidance. We describe the acute toxicity of IMRT in comparison with patient population in the audit treated with two-phase conformal radiotherapy and the previous published data from two-phase conformal radiotherapy, in the UK ACT2 trial. MATERIALS AND METHODS A Royal College of Radiologists' prospective national audit of patients treated with radiotherapy in UK cancer centres was carried out over a 6 month period between February and July 2015. RESULTS Two hundred and forty-two cases were received from 40/56 cancer centres (71%). In total, 231 (95%) underwent full dose radiotherapy with prophylactic nodal irradiation. Of these, 180 (78%) received IMRT or equivalent, 52 (22%) two-phase conformal (ACT2) technique. The number of interruptions in radiotherapy treatment in the ACT2 trial was 15%. Interruptions were noted in 7% (95% confidence interval 0-14%) of courses receiving two-phase conformal and 4% (95% confidence interval 1-7%) of those receiving IMRT. The percentage of patients completing the planned radiotherapy dose, irrelevant of gaps, was 90% (95% confidence interval 82-98%) and 96% (95% confidence interval 93-99%), in two-phase conformal and IMRT respectively. The toxicity reported in the ACT2 trial, in patients receiving two-phase conformal in the audit and in patients receiving IMRT in the audit was: any toxic effect 71%, 54%, 48%, non-haematological 62%, 49%, 40% and haematological 26%, 13%, 18%, respectively. CONCLUSIONS IMRT implementation for anal cancer is well underway in the UK with most patients receiving IMRT delivery, although its usage is not yet universal. This audit confirms that IMRT results in reduced acute toxicity and minimised treatment interruptions in comparison with previous two-phase conformal techniques.
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Affiliation(s)
- R Muirhead
- CRUK MRC Oxford Institute for Radiation Oncology, University of Oxford, Oxford, UK.
| | | | - S M O'Cathail
- Oxford University Hospitals NHS Trust, Department of Oncology, Churchill Hospital, Oxford, UK
| | - R Adams
- Cardiff University Department of Cancer and Genetics and Velindre Hospital, Cardiff, UK
| | - R Glynne-Jones
- Mount Vernon Centre for Cancer Treatment, Mount Vernon Hospital, Northwood, UK
| | - M Harrison
- Mount Vernon Centre for Cancer Treatment, Mount Vernon Hospital, Northwood, UK
| | - M A Hawkins
- CRUK MRC Oxford Institute for Radiation Oncology, University of Oxford, Oxford, UK
| | - D Sebag-Montefiore
- University of Leeds, Cancer Research UK Leeds Centre, St. James's University Hospital, Leeds, UK
| | - D C Gilbert
- Sussex Cancer Centre, Royal Sussex County Hospital, Brighton, UK
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15
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McAleese J, Baluch S, Drinkwater K. 134: Marked variability in the access to curative radiotherapy for NSCLC in the UK. Lung Cancer 2017. [DOI: 10.1016/s0169-5002(17)30184-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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16
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Howlett DC, Drinkwater K, Frost C, Higginson A, Ball C, Maskell G. The accuracy of interpretation of emergency abdominal CT in adult patients who present with non-traumatic abdominal pain: results of a UK national audit. Clin Radiol 2016; 72:41-51. [PMID: 27927488 DOI: 10.1016/j.crad.2016.10.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 10/14/2016] [Accepted: 10/17/2016] [Indexed: 10/20/2022]
Abstract
AIM To evaluate major/minor discrepancy rates for provisional (initial) and addendum (supplementary senior review) emergency computed tomography (CT) reports in patients presenting with non-traumatic abdominal pain. MATERIALS AND METHODS Ethical approval for this type of study is not required in the UK. All radiology departments with an approved lead for audit registered with the Royal College of Radiologists were invited to participate in this retrospective audit. The first 50 consecutive patients (25 surgical, 25 non-surgical) who underwent emergency abdominal CT for non-traumatic abdominal pain in 2013 were included. Statistical analyses were performed to identify organisational and report/patient-related variables that might be associated with major discrepancy. RESULTS One hundred and nine (58%) of 188 departments supplied data to the study with a total of 4,931 patients (2,568 surgical, 2,363 non-surgical). The audit standard for provisional report major discrepancy was achieved for registrars (target <10%, achieved 4.6%), for on-site consultants (target <5%, achieved 3.1%) and consultant addendum (target <5%, achieved 2.9%). Off-site reporters failed to meet the standard target (<5%, achieved 8.7% overall and 12.7% in surgical patients). The standard for patients coming to harm was not met in the surgical group (target <1%, achieved 1.5%) and was narrowly missed overall (target <1%, achieved 1%). CONCLUSION This study should be used to provide impetus to improve aspects of out-of-hours CT reporting. Clear benefits of CT interpretation/review by on-site and more senior (consultant) radiologists have been demonstrated.
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Affiliation(s)
- D C Howlett
- Department of Radiology, Eastbourne Hospital, Eastbourne, UK
| | - K Drinkwater
- Department of Professional Practice, The Royal College of Radiologists, London, UK.
| | - C Frost
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - A Higginson
- Department of Radiology, Queen Alexandra Hospital, Portsmouth, UK
| | - C Ball
- Department of Radiology, Queen Alexandra Hospital, Portsmouth, UK
| | - G Maskell
- Department of Radiology, Royal Cornwall Hospital, Truro, UK
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17
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Halliday K, Drinkwater K, Howlett D. Evaluation of paediatric radiology services in hospitals in the UK. Clin Radiol 2016; 71:1263-1267. [DOI: 10.1016/j.crad.2016.05.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Revised: 03/24/2016] [Accepted: 05/20/2016] [Indexed: 12/28/2022]
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18
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Gilbert D, Drinkwater K, O'Cathail S, Adams R, Glynne-Jones R, Harrison M, Hawkins M, Sebag-Montefiore D, Muirhead R. Stepwise Multicenter Introduction of Intensity Modulated Radiation Therapy for Anal Cancer in the United Kingdom: From Consensus Guidance to Large-Scale Prospective Audit, Prior to Future Clinical Trials. Int J Radiat Oncol Biol Phys 2016. [DOI: 10.1016/j.ijrobp.2016.06.260] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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19
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McAleese J, Baluch S, Drinkwater K. The Quality of Curative-intent Radiotherapy for Non-small Cell Lung Cancer in the UK. Clin Oncol (R Coll Radiol) 2015; 27:498-504. [DOI: 10.1016/j.clon.2015.05.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Revised: 05/06/2015] [Accepted: 05/21/2015] [Indexed: 12/25/2022]
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20
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Stewart A, Drinkwater K, Parkinson N, Locke I. Findings of the Royal College of Radiologists (UK) National Audit of Prostate Cancer Brachytherapy. Int J Radiat Oncol Biol Phys 2014. [DOI: 10.1016/j.ijrobp.2014.05.1349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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21
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Remedios D, Drinkwater K, Warwick R. National audit of appropriate imaging. Clin Radiol 2014; 69:1039-44. [PMID: 25037149 DOI: 10.1016/j.crad.2014.05.109] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Revised: 05/20/2014] [Accepted: 05/27/2014] [Indexed: 10/25/2022]
Abstract
AIMS To audit the availability of imaging referral guidelines; vetting by radiologists of GP-initiated CT and MRI requests; and the achievement of appropriate imaging using retrospective assessment as a surrogate. MATERIALS AND METHODS A web-based questionnaire was distributed to imaging departments in the UK seeking awareness of guideline availability; the percentage of consecutive general practitioner (GP)-requested computed tomography (CT) and magnetic resonance imaging (MRI) investigations that showed evidence of vetting; and the percentage of procedures where retrospective assessment showed the investigation to be appropriate according to imaging referral guidelines. RESULTS Replies were received from 88 departments covering 1700 of 2700 (63%) consultant radiologists practising in the UK. Regarding the availability of guidelines, approximately a third of respondents were not aware of guidelines being available to all radiologists and radiographers. The 68% level of availability (58/88 departments) is well below the standard of 100%. In keeping with the target of 95%, vetting of CT requests was shown in 1815/1890 (96%) and MRI in 1181/1250 (95%). Appropriateness of CT examinations was shown in 1746/1870 (93%) and MRI in 1154/1215 (95%), well above the target of 90%. The most common reason for an inappropriate investigation for both MRI and CT was the inability to affect patient management. CONCLUSIONS Although awareness of referral guidelines availability was limited at 68%, well below the 100% standard, the meticulous vetting of requests (shown in 95-96%) with the amendment or return of inappropriate requests (9-12%) enables a high level of appropriate imaging (93-95%) for GP-requested CT and MRI, thus making the best use of clinical radiology.
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Affiliation(s)
- D Remedios
- Department of Clinical Radiology, Northwick Park Hospital, Harrow, HA1 3UJ, UK.
| | | | - R Warwick
- Department of Clinical Radiology, Buckinghamshire Healthcare NHS Trust, UK
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22
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McAleese J, Baluch S, Drinkwater K. 210 The first UK audit of curative-intent radiotherapy for non-small cell lung cancer; the need to assess quality and improve outcomes. Lung Cancer 2014. [DOI: 10.1016/s0169-5002(14)70210-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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23
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Saunders D, Ajaz M, Staples E, Butler C, Drinkwater K, Spooner D. Clinical Oncology Training in the UK: Results of a National Survey (2007). Clin Oncol (R Coll Radiol) 2009; 21:75-6. [DOI: 10.1016/j.clon.2008.10.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2008] [Accepted: 10/29/2008] [Indexed: 10/21/2022]
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24
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Barter S, Drinkwater K, Remedios D. National audit of provision of MRI services 2006/07. Clin Radiol 2008; 64:284-90. [PMID: 19185658 DOI: 10.1016/j.crad.2008.09.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2008] [Revised: 09/04/2008] [Accepted: 09/10/2008] [Indexed: 11/18/2022]
Abstract
In 2003 the Royal College of Radiologists Clinical Radiology Audit Sub-Committee began an audit process evaluating the standards of provision of magnetic resonance imaging (MRI) services. This was prompted by the publication of the 2002 Audit Commission Report, which had identified that lack of MRI provision was responsible for more than half of the total waiting times for diagnostic imaging investigations. The audit found that the time from request to report did not meet the standard for cancer staging examinations, but nationally, was within the target set for routine orthopaedic examinations. However, national mean waiting times were longer than recommended for both cancer and orthopaedic MRI. Since then, there has been massive investment in MRI capacity, both from installation of MRI systems in NHS Trusts, and in England, from outsourcing of routine MRI cases through the Department of Health contract with an independent provider. A re-audit in 2006/7 shows that there has been a significant improvement in waiting times for routine orthopaedic examinations, but the position with cancer staging examinations has deteriorated. Control chart methodology shows that underperformance is due to common cause variation, i.e., improvements need to be made to the overall process from receiving the request for MRI to the issue of the report. Follow-up with participating departments demonstrated there were some common themes for underperformance, and suggestions for improvement are made from departments with best performance.
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Affiliation(s)
- S Barter
- Royal College of Radiologists, London, UK.
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25
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Chalmers N, Jones K, Drinkwater K, Uberoi R, Tawn J. The UK nephrostomy audit. Can a voluntary registry produce robust performance data? Clin Radiol 2008; 63:888-94. [DOI: 10.1016/j.crad.2007.10.021] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2007] [Revised: 10/08/2007] [Accepted: 10/17/2007] [Indexed: 11/26/2022]
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26
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Williams MV, Summers ET, Drinkwater K, Barrett A. Radiotherapy Dose Fractionation, Access and Waiting Times in the Countries of the UK in 2005. Clin Oncol (R Coll Radiol) 2007; 19:273-86. [PMID: 17517327 DOI: 10.1016/j.clon.2007.03.011] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2007] [Accepted: 03/20/2007] [Indexed: 11/16/2022]
Abstract
AIMS The Royal College of Radiologists has published a review of the evidence base for radiotherapy dose fractionation. We modelled the implications of changes in practice on radiotherapy demand and compared it with current activity, access and waiting times across the countries of the UK. MATERIALS AND METHODS We collected data on diagnosis, dose fractionation and waiting times on all patients in the UK starting a course of radiotherapy in the week commencing 26 September 2005. Excluding skin cancer, 2610 patients were prescribed 34,194 fractions. RESULTS Radiotherapy access rates were 38% in England, 43% in Scotland and 37% in Wales. These are all lower than the 52% of cancer patients recommended by modelling. To increase access to the recommended level, a 33% increase in activity is required across the UK. For each of 13 cancer diagnoses, we modelled optimum fractionation and compared it with current practice. To deliver the dose fractionation with the best evidence base, a further increase in activity of 37% is required. To take account of both access and optimal fractionation, the two factors should be multiplied (1.33x1.37=1.82) giving an overall increase of 82% for the UK. This would require 53,741 fractions per million population annually. The exact value depends on the cancer incidence in each country, but should be compared with current activity of 28,040 in England, 39 584 in Scotland and 31,228 in Wales. Limited capacity is reflected in waiting times. The percentage of patients exceeding the maximum recommended wait of 28 days for radical or adjuvant postoperative radiotherapy was 55% in England, 44% in Scotland and 74% in Wales. CONCLUSIONS To secure adequate access to treatment and optimal dose fractionation, substantial increases in radiotherapy activity of 92% in England, 61% in Scotland and 97% in Wales are required. Achieving this will require a planned programme of investment in staff, training and equipment.
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Affiliation(s)
- M V Williams
- Royal College of Radiologists, 38 Portland Place, London W1B 1JQ, and Norfolk and Norwich University Hospital, Norwich, UK.
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27
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Canfell K, Gray W, Snijders P, Murray C, Tipper S, Drinkwater K, Beral V. Factors predicting successful DNA recovery from archival cervical smear samples. Cytopathology 2004; 15:276-82. [PMID: 15456416 DOI: 10.1111/j.1365-2303.2004.00164.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Polymerase chain reaction (PCR)-based DNA testing of archival cervical smear slides is a useful method of retrospectively establishing the presence of the human papillomavirus (HPV) in cervical cells. A cellular DNA recovery test is performed in parallel to HPV DNA testing to ensure that sufficient cells are present and purification of sample DNA has been successfully performed. Previous studies have not comprehensively assessed DNA recovery rates in slides older than 13 years. We undertook a study to determine the factors impacting DNA recovery in 436 UK slides dating from 11 to 33 years prior to testing. Overall, a low cellular DNA recovery success rate of 29% was obtained but a strong trend was observed with increasing recovery rates the older the slides (P < 0.001). Recovery rates increased from 22% in the most recent slides collected from 1988 to 1992, to 61% in the oldest slides, collected in 1970-72. It is likely that fixation compounds incorporating acetic acid, introduced in the UK through the 1980s, have compromised subsequent attempts at PCR amplification. These findings emphasize the importance of the original fixation method in the success of DNA recovery from archival smear samples.
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Affiliation(s)
- K Canfell
- Polartechnics, Sydney, NSW 2011, Australia.
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28
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Zwanenburg K, Bowen D, Bundy A, Frank K, Drinkwater K, O'Boyle R, Sameoto D, Sinclair M. 4 Decadal changes in the Scotian Shelf large marine ecosystem. ACTA ACUST UNITED AC 2002. [DOI: 10.1016/s1570-0461(02)80056-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
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29
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Abstract
In an investigation of catches of 17 commercial marine species of fish and shellfish from the Gulf of Maine, 10 showed statistically significant correlations with sea temperatures at St. Andrews, N.B., or Boothbay Harbour, Maine. Most fish records contained at least 40 yr of data. Descriptive equations are produced for four species based first on the correlation between catch and sea temperature and second on the correlation between catch and sea temperature allowing for fishing effort. Inclusion of fishing effort, not surprisingly, improved the correlations for all of the species so examined. The equations permitted the "prediction" of later parts of the records from earlier parts.Considering the fish species collectively, the Gulf of Maine system from 1940 to 1959 appeared to be in equilibrium with little fluctuation in the total commercial biomass. We interpret the large fluctuations in individual species abundance as resulting from a combination of fishing pressure and to a significant degree oceanic climate as represented by sea temperature. The small fluctuations in the total biomass displays the species variation, with their differing climatic "preferences," as well as possible predator (including man)–prey relationships. Environmentally imposed patterns underlie at least 50% of the fluctuations in catch of many species and the understanding of these fluctuations is basic to effective management.
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