37
The Challenges of Delivering World Class Radiotherapy Cambridge Computa:onal Radiotherapy Symposium 2015 Adrian Crellin
The Challenges of Delivering World Class Radiotherapy
Cambridge Computa:onal Radiotherapy Symposium
2015
Adrian Crellin
1985 and all that………..
What can currently cure cancer?
Radiotherapy 40%
Chemotherapy 11%
Surgery 49%
Radiotherapy
Chemotherapy
Surgery
Professor Sir Mike Richards, NCRI 2011
DH Cancer Reform Strategy 2007 – Aim -‐ ‘World Class Radiotherapy’
22%
18%
5% Surgery
Chemotherapy
Radiotherapy
RT = £335M
High resolu:on IGRT Mul:leaf collimator
First Linac
Computerized 3D CT treatment planning
1960 1970 1980 1990 2000 2010
IMRT dose-painting
Standard collimator
Cerrobend blocks
Shaped electron fields
Image Fusion
Stereotac:c Radiotherapy
Par:cle Therapy
The Evolution of Radiation Therapy Drive to increase conformal delivery to irregular tumour targets And reduce toxicity
Courtesy of Gillies McKenna
A Challenge?
Adap:ve RT
Hypofrac:ona:on
SABR
MRI Linacs
Protons
SRS
Brachytherapy
Trials Trials Trials
IndividualisaEon
IMRT/IGRT
Data & Coding
Varia:on
QA
Linac Replacement
Evidence Base
Combina:on with drugs
Novel Molecular RT PET
Biology
• 31 Day Targets
• Capacity
• IMRT Rates
• RIF
• SABR, Trials and CtE
• QIPP
✔ • Huge success
• Compliance across service • Modernisa:on of process
• Massive tribute to efforts workforce and service providers
• No resource
Some Recent Issues
• 31 Day Targets
• Capacity
• IMRT Rates
• RIF
• SABR, Trials and CtE
• QIPP
? • 14 Day Target Category 1
• 21 Day Target Category 2
• JCCO Guidelines 1993
• 31 Day Targets
• Capacity
• IMRT Rates
• RIF
• SABR, Trials and CtE
• QIPP
• Some gaps filled new Linacs and Centres
• Extended Hours • 7 Day Working
• Revised Access Rates 41%
• Plateau of Ac:vity
• 31 Day Targets
• Capacity
• IMRT Rates
• RIF
• SABR, Trials and CtE
• QIPP
• Radiotherapy Innova:on Fund 2012/13
• £23M
• Socware Licences / Training / Image Guidance
• Targeted Help and Mentoring
• 31 Day Targets
• Capacity
• IMRT Rates
• RIF
• SABR, Trials and CtE
• QIPP
• At least 50% should have IMRT -‐ evidence of gain – RCR/SCoR/IPEM
• Breast 40% inverse planned
• No upper limit – ‘May be departmentally advantageous’
Money
• Infla:onary impact of coding system – Perverse Incen:ves
• Is best prac:ce and what many centres are already doing
• Much of the revenue is already in system – Single specialty providers – 30% trust overheads – £2M out of £7M income unaccounted for
• 31 Day Targets
• Capacity
• IMRT Rates
• RIF • RIF 2??
• SABR, Trials and CtE
• QIPP
• Low price mechanism in place – not worked
• Huge Scale – Linacs 120 in 3 years – Upgrades remaining – Cone Beam – TPS and Licences
• PAC Report
• Cancer Taskforce and NHSE Na:onal Priority
• Workforce to Implement – Oncologists – Radiographers – Physicists
Equipment and …………
Varia:on – Quality Standards
• IMRT Rates
• Implementa:on of evidence based best prac:ce
• Ac:vity levels ‘rarer’ cancers
• QIPP • Breast 15 Frac:ons
– Centres and Clinicians • Single Frac:on Bone Mets
• Prostate CHHiP??? • Coupling with é IGRT standards
Varia:on – Quality Standards • IMRT Rates
• MRI Brachytherapy
• Implementa:on of evidence based best prac:ce
• Ac:vity levels – Rarer cancers – Surgical competency – 20 – Outlining varia:on – Teams
3/12 figures
Data
Basic Data CollecEon • RTDS
• Shic from NatCanSat to PHE April 2016
• Essen:al to Strategic Service Planning and management
• Align to Other Na:onal datasets
• Link to Outcomes
ModernisaEon • Linkage across provider centres
• Func:onal ‘Networks’ over 4-‐5 M popula:on
• Central Planning – Remote delivery – Satellites
• Team working QA standards outlining
– RTTQA Trials and CtE – Reference Benchmark Libraries and
Training – COAST / FALCON / RTTQA
Workflow Op:misa:on
Opportunity or Necessity?
Methods: • Retrospective review of all radiotherapy treatment episodes
• Jan 2004-April 2011 (42,792 episodes) • Electronic patient record.
• Linked to the National Cancer Registration Service for diagnosis, death and socioeconomic status.
• Palliative intent identified based on documented intent and fractionation.
• Treatments delivered with the same start date amalgamated into a single episode.
• Exclusions e.g. non-melanomatous skin cancer, haematological malignancies.
• Total of 14, 972 palliative episodes analysed.
Survival following palliative radiotherapy by primary diagnosis:
0.00
0.25
0.50
0.75
1.00
Surv
ival p
roba
bility
374 315 254 216 183Bladder414 366 314 282 243Oesophagus631 561 495 438 379Colorectal1232 1148 1059 971 891Prostate1378 1290 1208 1128 1057Breast3070 2595 2151 1756 1450Lung
Number at risk
0 30 60 90 120Survival (days)
Lung Breast
Prostate Colorectal
Oesophagus Bladder
30 day mortality following palliative radiotherapy to bone by fractionation:
Fractionation n (%) 30 day mortality (%)
1 4863 76.8 15.3 2-4 145 2.3 13.1 5 1117 17.6 11.2 6-9 9 0.001 0.0 ≥10 200 3.2 3.0 Overall 6334 100 14.1
15.3
13.1 11.2
3
0
2
4
6
8
10
12
14
16
18
1 2-4 5 ≥10
30 d
ay m
orta
lity
(%)
Fractionation
Yesterday -‐ Paper referral pathway (2010)
STAR
T
Referral from Oncologist
Booking form to Secretary / Admin
Booking form to Booking Office
Add new DxCheck against PPM
Affiliate to primary Dx on MSQ
Clerk sorts booking forms into
priority order
Query PAS LinkAdd Dx onto MSQ as primary
Book notes to pull appointment
Book according to guidelines
Booking Form +/- letter to Helper in
booking office
Letter produced on MSQ
Clerk phones patient to tell pre-
treatment appointment
Book Treatment A/C to guidelines
Helper books transport If
neededBooking form to
tray in office
Booking form taken to MD room
by helper
Booking form filed in lever archHelper sends
letter in post
Are patients on MSQ
Booking Form to CWT Monitor
CWT monitor indicates Target date on booking
form
DAY 0 - 4 DAY 4 - 5
DAY 5 - 6 DAY 4 - 5
DAY 6 - 7
No
Yes
Tomorrow – Electronic referral & pre-‐treatment pathwayRe
ferral & Pre Treatmen
t Process
Patient registered in MOSAIQ via ESI interface
Completion Booking QCL – IQ script triggers Sim QCL
Completion of Planning QCL – IQ script triggers Physics QCL
Completion of Sim QCL – IQ script triggers Planning QCL
Oncologist adds a diagnosis and clinical protocol – triggering a
small electronic form (assessment) -‐ Oncologist
completes form Booking clerks completes booking & helper books transport
if needed
Clerk phones patient with pre-‐treatment appointments
Completion of Physics QCL – IQ script triggers Radiographer
Data Prep QCL
Radiographer Data Prep
Tomorrow!
Importance of Radiotherapy QA
Ensures: Treatment complies with na:onally accepted standards
Adherence to the trial protocol
Minimises varia:ons across recrui:ng sites
Outcomes reflect differences in randomised schedules NOT departures from protocol
Peters L J et al. JCO 2010;28:2996-‐3001 Cri9cal Impact of Radiotherapy Protocol Compliance and Quality in the Treatment of Advanced Head and Neck Cancer: Results From TROG 02.02
‘Even more striking was the correla:on between the number of pa:ents entered and the probability of receiving unsa:sfactory radiotherapy: in centers enrolling fewer than five pa:ents, 29.8% had a predicted major adverse impact compared with 5.4% in centers Enrolling 20 pa:ents.’
Target volumes
• Trials • CtE • Early involvement of RTTQA in trials
design NaEonal protocols Vs IndividualisaEon of Care? Courtesy Liz Miles -‐ RTTQA
Quality and Complexity
• Breast è increasingly complex – IMRT – IORT – Breath Hold – Boosts – Nodes
• Colorectal Cancer -‐ Data on trials ac:ve centres and survival • Ovarian Cancer -‐ Survival advantage with second line in major
academic centres
• Decision Making and Teams
• Research and trials as a priority
SABR / SRS -‐ £21M • Rou:nely Commissioned
– Lung
• Trials – CORE – SARON – SPARC – Lung Tech – ABC-‐07
• CtE – Non CORE Oligomets – HCC – Re-‐treatment
• SRS -‐ Consulta:on
• Increased Access for cerebral mets
• Trials??
• Equipoise
Protons
• Entrance Beam always more Photons • No Exit Beam protons
• Most of the dose is outside the target – photons
• Most of dose is onside target protons
• IMRT redistributes dose from 3DCRT • PBT reduces integral dose
Jus:fica:on in Paediatric Radiotherapy
High cure rates Developing normal :ssues Vulnerable :ssues
Late side effects – Hormone system – Bone growth
Neuropsychological impact
Memory and IQ Access at younger age
• Second Malignancy – Up to 5 % currently – Reduce by factor of 2 –
10
Proton
IMRT
Jus:fica:on -‐ Adults
• Wider range cancers and indica:ons • higher doses to target volume • improved cure rates • Skull Base/Para-‐spinal/Paranasal Sinuses
• Reduced dose outside target volume • Reduced second malignancy • Younger adults – fer:lity • Reduced late effects • Individual situa:ons where otherwise treatment compromised
• Medias:nal Lymphoma/L Breast IMC/HPV Head and Neck Cancer/Gene:c sensi:vity/Anatomical varia:on
• Trials -‐ Lung / Prostate
• FBC + Equipment Procurement 2015
• Wider list than overseas Programme -‐ s:ll limited diagnoses
• Up to 1500 Cases per annum
• 2018 First pa:ents
• UK Based NHS Centres – UCLH – Chris:e
• Link to Oxford Centre for Research and CtE
• All pa:ents in Trials or Prospec:ve Evalua:on Protocols
NHS PBT Service in UK
The nature of evidence • Dose modelling
• Everyday tool in clinical practice
• Concept of proof - dose and physics
31 Darby SC, Ewertz M, Hall P EJM 2013; 368:987-98
32
Is this proof?
Merchant et al. IJROBP 90 (3) 2014
In Silico Evidence • Rare – ’they don’t understand us’
• Can’t do the outcomes work until have a proton facility
• Duty bound to collect outcomes and evaluate
• Make smarter arguments – Confirmatory studies
33
Protons - Uncertainties need addressing
• Evidence base arguments
• Fractionation • Addition of systemic agents
• Cost / Size • Range Uncertainty • Imaging • Movement
• RBE
• Published Outcomes
34
Chaudhary et al IJROBP 90 (1) 2014
It is NOT just a slot in for IMRT/IGRT
So …… • New Technologies
– Introduce with high QA – Adequate ac:vity – Affordability – Evidence Base
– Clinical Trials – Evalua:on all pa:ents – Beware commercially driven
influences
• Improve our arguments
• ‘Get the basics right’
• Integrated environment
• Understand Risk – Smaller margins – Hypofrac:ona:on – Cost
• Not everything will be done everywhere
• Partnership – Networks across larger popula:ons 4-‐5M
• Some pa:ents will travel for access/ quality
The opportunity
Adap:ve RT
Hypofrac:ona:on
SABR
MRI Linacs
Protons
SRS
Brachytherapy
Trials Trials Trials
IndividualisaEon
Data & Coding
QA
Evidence Base
Combina:on with drugs
Novel Molecular RT CT/PET/MRI
Biology
The Challenge
Deliver Higher Quality Care and Innova:ve Technologies
Modernisa:on and Reconfigura:on
Recognise Funding Constraints
Partnership working across Centres in Networks
