Search

Abstract: Aims: This paper compares the predictions of radiotherapy demand for England from the Malthus model with those from the earlier National Radiotherapy Advisory Group (NRAG) model, from the international literature and also with observed radiotherapy usage in England as a whole as recorded in the English radiotherapy dataset (RTDS). Materials and methods: We reviewed the evidence base for radiotherapy for each type and stage of cancer using national and international guidelines, meta-analyses, systematic reviews and key clinical trials. Twenty-two decision trees were constructed and radiotherapy demand was calculated using English cancer incidence data for 2007, 2008 and 2009, accurate to the Primary Care Trust (PCT) level (population 91 500–1 282 384). The stage at presentation was obtained from English cancer registry data. In predictive mode, the model can take account of changes in cancer incidence as the population grows and ages. Results: The Malthus model indicates reduced indications for radiotherapy, principally for lung cancer and rarer tumours. Our estimate of the proportion of patients who should receive radiotherapy at some stage of their illness is 40.6%. This is lower than previous estimates of about 50%. Nevertheless, the overall estimate of demand in terms of attendances is similar for the NRAG and Malthus models. The latter models that 48 827 attendances should have been delivered per million population in 2011. National data from RTDS show 32 071 attendances per million in 2011. A 50% increase in activity would be required to match estimated demand. This underprovision extends across all cancers and represents reduced access and the use of dose fractionation at odds with international norms of evidence-based practice. By 2016, demand is predicted to grow to about 55 206 attendances per million and by 2020 to 60 057. Discussion: Services have increased their activity by 14% between 2006 and 2011, but estimated demand has increased by 11%. Access remains low and English radiotherapy dose fractionation still does not comply with international evidence-based practice. [Copyright &y& Elsevier]

Abstract: Aims: Modelling of demand has indicated substantial underprovision of radiotherapy in England. We have used national audit data to understand the differences between theory and practice. Materials and methods: We used a web-based tool to collect data on all National Health Service patients in England starting a course of radiotherapy in the week commencing 24 September 2007. We also collected information on cancer site, so that patients could be triaged into the 22 categories used by the National Radiotherapy Advisory Group (NRAG). Results: In England, excluding skin cancer other than melanoma, 2114 patients were prescribed 27 420 fractions during that week. Comparison of the audit data with the NRAG model showed that the shortfall in provision was a mixture of a lack of access (67%) and reduced fractionation (33%). The largest contributions to the overall gap were seen in the treatment of cancers of the breast (6%) (modelled at 15 fractions), head and neck (10%), lung (28%) and prostate (14%), together accounting for 58% of the difference. Others (including sarcoma and unknown primary) accounted for 19% of the difference. Limited access to radiotherapy for patients with stomach and pancreatic cancer contributed 10% and reduced fractionation for oesophageal cancer accounted for 6% of the overall gap. Fewer patients than expected were treated for rectal cancer, but they received 25 fraction regimens rather than short-course preoperative treatment. Patients with leukaemia and cancers of the brain, colon, corpus uteri and ovary received radiotherapy more often than expected, but because they are relatively rare none of these had an overall impact exceeding 1.2% of the gap in provision. Conclusions: This audit confirms the underprovision of radiotherapy in England and shows that it is largely accounted for by low access rates of 37% rather than the 50% accepted in the literature. In consequence we estimate that 33 881 patients (13.9%) of the 243 748 patients diagnosed with cancer in England during 2006/2007 did not receive the radiotherapy we would have expected. Some of this gap in provision may be accounted for by differences in stage and performance status, which limit treatment options, for example in lung cancer. The NRAG model should be updated to take account of new data from this and other national audits, to ensure that it describes the stage and performance status of English patients and is sensitive to the range of professional opinion about treatment options. This will be essential for long-term planning as cancer incidence increases over the next decade, but it does not weaken the conclusion that there is a substantial current shortfall to be addressed immediately to improve timely access to treatment and thus the outcomes of therapy. As more resource becomes available, it should be possible to consider changing dose fractionation to comply with evidence-based practice and national guidelines from the National Institute for Health and Clinical Excellence and other bodies without disadvantaging patients by increasing waiting times. [Copyright &y& Elsevier]

Abstract: Aims: Modelling of demand has shown substantial underprovision of radiotherapy in the UK. We used national audit data to study geographical differences in radiotherapy waiting times, access and dose fractionation across the four countries of the UK and between English strategic health authorities. Materials and methods: We used a web-based tool to collect data on diagnosis, dose fractionation and waiting times on all National Health Service patients in the UK starting a course of radiotherapy in the week commencing 24 September 2007. Cancer incidence for the four countries of the UK and for England by primary care trust was used to model demand for radiotherapy aggregated by country and by strategic health authority. Results: Across the UK, excluding skin cancer, 2504 patients were prescribed 33 454 fractions in the audit week. Waits for radical radiotherapy exceeded the recommended 4 week maximum for 31% of patients (range 0–62%). Fractions per million per year ranged from 17 678 to 36 426 and radical fractions per incident cancer ranged from 3.0 to 6.7. Patients who were treated received similar treatment in terms of fractions per radical course of radiotherapy (18.2–23.0). Access rates ranged from 25.2 to 48.8%, nearing the modelled optimum of 50.7% in three regions. Fractions per million prescribed as a first course of treatment varied from 43.9 to 90.3% of modelled demand. The percentage of patients failing to meet the 4 week Joint Council for Clinical Oncology target for radical radiotherapy rose as activity rates increased (r =0.834), indicating a mismatch of demand and capacity. In England, a comparison between strategic health authorities showed that increasing deprivation was correlated with lower rates of access to radiotherapy (r =−0.820). Conclusions: There are substantial differences across the UK in the radiotherapy provided to patients and its timeliness. Radiotherapy capacity does not reflect regional variations in cancer incidence across the UK (3618–5800 cases per million per year). In addition, deprivation is a major unrecognised influence on radiotherapy access rates. In regions with higher levels of deprivation, fewer patients with cancer receive radiotherapy and the proportion treated radically is lower. This probably reflects late presentation with advanced disease, poor performance status and co-morbid illness. To provide an equitable, evidence-based service, the needs of the local population should be assessed using demand modelling based on local cancer incidence. Ideally this should include data on deprivation, performance status and stage at presentation. The results should be compared with local radiotherapy activity data to understand waits, access and dose fractionation in order to plan adequate provision for the future. The development of a mandatory radiotherapy data set in England will facilitate this, but to assist change it is essential that the results are analysed and fed back to clinicians and commissioners. [Copyright &y& Elsevier]

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 (1.33×1.37=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. [Copyright &y& Elsevier]

Abstract: Aims: To document UK practice in radiotherapy fractionation. Methods: All radiotherapy centres in the UK participated in a 1-week audit from 29 September 2003. Fractionation data were collected for all patients starting external beam radiotherapy. This included 2498 patients who were prescribed 32 547 fractions. Results: For the radical treatment of non-skin malignancy (n =708), the prescribed dose ranged from a single fraction of 8Gy for total-body irradiation to 75Gy in 43 fractions for prostate cancer. Postoperative treatment for breast cancer was dominated by three regimens: 40Gy in 15 fractions; 45Gy in 20 fractions; and 50Gy in 25 fractions. Palliative treatment was given in a single fraction to 393 patients (36%) with doses of up to 15Gy. Three hundred and ninety patients (36%) received four to seven fractions delivering 20–25Gy. Only 89 patients (8%) received more than 10 fractions with palliative intent but used 29% of such fractions. In the treatment of bone metastases, the most common prescriptions were 8–10Gy in a single fraction and 20Gy in five fractions. Conclusion: UK radiotherapy practice has become more uniform and moved closer to practice in North America and Europe over the past 15 years. For radical radiotherapy, 54% of prescriptions were for a fraction size of 1.8–2.0Gy but the distribution was bi-modal and 20% of patients were prescribed fraction sizes of 2.7–3.0Gy. Evidence-based practice now supports hypo-fractionated palliative treatment favouring single fractions for bone metastases and one or two fractions for many patients with advanced lung cancer. Two fractions are advised for some patients with brain metastasis. If these guidelines had been applied uniformly, then the number of treatments prescribed for palliation could have fallen by 36% from 5197 to 3313. This would have represented a 6% reduction in the overall radiotherapy workload. Not all patients are suitable for such hypo-fractionated treatments, but this is an area in which resource use can be improved. In the postoperative management of breast cancer, a change in practice to use 15 fractions uniformly would reduce overall radiotherapy workload by 4%. By contrast, a change to 25 fractions would increase overall workload by 7%. [Copyright &y& Elsevier]