Background to the audit
Radical radiotherapy practice in head and neck cancer was identified as a target for a national audit as there is published data on the effects of delays in treatment and gaps in therapy on survival, and published national guidelines on their management. We utilised a novel two-part online audit tool to rapidly collect data from Cancer Centres across the UK. The first part examined the centre's policies for managing gaps in therapy, the second collected data on 50 consecutive patients treated in that centre. Completed forms were returned electronically, allowing direct transfer into a central database. The audit was first presented at the British Cancer Research Meeting last July and amended and updated results were circulated to Trusts late in 2001.
Results
Fifty-five centres returned data on a total of 2553 patients. Treatment was completed within two days of target in 78 per cent of cases, although 55 per cent of patients had one or more treatment interruptions. The commonest causes of breaks in treatment were: public holidays (67 per cent), service days (47 per cent) and machine breakdown (14 per cent). Of patients whose treatment was interrupted, 56 per cent still completed therapy on time due to compensatory steps. Seven centres had no set policy for dealing with treatment interruptions. As the date "first seen" in the oncology head and neck clinic was recorded, an estimate of time to start treatment could be made. Average delay to starting RT was 40 days with only six centres having a mean time to commencement of treatment of less than 28 days. Around 15 per cent of patients waited more than two months from first visit to the radiotherapy clinic and the average wait was six weeks in 2000.
Much media interest in cancer therapy focuses on patients deprived of access to high cost drugs. Whilst drug therapy is important, there has been much less coverage of an issue that affects far more patients and that may be a significant cause of the poor cancer survival rates prevalent in the UK-radiotherapy. Recent newspaper reports have however highlighted longstanding deficiencies in the provision of radiotherapy for cancer in the UK.
The audit set out primarily to examine the management of gaps in therapy. Broadly the results of this part of the audit were encouraging with most cases (78 per cent) completing therapy within a few days of target. Nonetheless, despite the publication of guidelines, some departments did not have a set policy for managing gaps and the audit clearly shows most gaps are predictable in advance allowing planning for their compensation. There was also considerable variation between departments in their overall performance. Strengthened guidelines are being finalised by the college and will be issued shortly and the audit repeated.
The audit also gave an estimate of waiting times. This is a complex issue as illustrated in the figure and is the subject of a number of targets in the NHS Cancer Plan. The current target is for radiotherapy to commence within four weeks of the decision to treat - this may be either waiting time 1 or 2 in the figure. We measured waiting time 2 as generally a decision in principle which can be made at the first visit, although it may require a scan to finalise details of therapy.
More importantly, for the patient the clock started ticking from GP referral and this is acknowledged in future targets set in the Cancer Plan. The recently implemented two week maximum wait from GP to specialist (wait 3) is an important first step but is of no value if the patient then waits many weeks for further tests, scans or therapy. There are known to be long delays in many areas in access to imaging and, as shown in this audit, radiotherapy. Whilst some of the waits can be run in parallel (for instance, referrals to oncologists, requests for scans), some decisions critically depend on the results of tests being available (the final treatment decision depends on biopsy and scan results) so some "serial" waiting is inevitable. A more detailed waiting time audit is currently being planned by the college to identify the principle bottlenecks across the country and to ascertain whether the possible upward trend in mean waiting times seen in this audit is continuing. Given the range of waiting times measured by this audit, it is clear that some of the future Cancer Plan targets (waits 4 and 5 in the figure) will be hard to achieve without significant improvements in a number of key areas, including imaging and radiotherapy. It should also be pointed out that to wait two months from initial referral to treatment, currently largely unachievable, is not a target that feels very impressive sitting in the clinic dealing with patients - put yourself in the position of a patient knowing that this dreadful thing is growing inside them, may spread and become incurable, and that treatment will not commence for many weeks.
Can the situation be improved
A number of steps have been taken to try and shorten delay times. The Cancer Services Collaborative Scheme was established to try and streamline processes and reduce steps in the treatment pathway. This has undoubtedly had some success but some of the apparent progress has been misleading. For example waiting times for radiotherapy in our centre were reduced for patients fast tracked by quicker referral within collaborative projects, but only directly at the expense of other patients waiting longer, and our overall waiting times have risen since the collaborative project started. This highlights the need for a comprehensive audit, as carried out here rather than selective audits of subgroups.
Improved radiotherapy services will require continued investment on a number of fronts. A Linac expansion programme is already in place. In parallel steps are being taken to increase radiographer numbers both by increased recruitment and retention. New radiographer helper posts are being created to allow existing trained staff to focus on service delivery.
Paradoxically some of the present waiting time problems may have been created by the increased emphasis on quality of cancer services, which may be generating increased referrals to radiotherapy departments of patients previously under-treated (our own waiting times have risen in the last two years despite no change in capacity). This trend will need to be carefully monitored as, if true, it may derail the current planning assumptions. Sustained pressure for change backed by continued investment in equipment and manpower will need to be maintained if the targets in the Cancer Plan are to be met.
General Principles of Radiotherapy
Radiotherapy is the principal non-surgical cancer treatment and can be used as sole curative therapy (radical radiotherapy), palliative therapy or as an adjunct to another cancer therapy either before (neoadjuvant) or after (adjuvant). Radiotherapy is generally given as a series of daily treatments, termed fractions, as this reduces toxicity and increases efficacy. Radical treatments will generally last four-seven weeks (20-35 fractions). Shorter courses (typically 1-10 fractions) can be used for palliation on the pragmatic grounds that as little as one fraction can relieve symptoms (e.g. bone pain) for the patient's remaining life expectancy.
Radiotherapy Equipment
The majority of radiotherapy machines are linear accelerators ("Linacs") although some specialist work is carried out on lower energy machines or by direct insertion of radioactive material into the tumour (brachytherapy). A typical department will have around four Linacs per million population served (norms in Europe and North America are significantly higher at 5.5 per million). To illustrate, Birmingham currently has five linacs, with a sixth being installed and two more planned. We currently treat 5,500 new patients each year, administering 50,000 fractions split roughly 50:50 between radical and palliative therapy.
New Developments
Recent developments include the ability to deliver multiple beams shaped in three dimensions to reduce dose to organs outside the target volume for therapy (called conformal therapy). A further development on this, intensity modulated radiotherapy allows the alteration of beam shapes and direction during therapy and gives still better dose distributions. These newer techniques carry additional overheads in terms of both planning and delivery time, partly offset by improved software and hardware design. They do however deliver treatment with significantly fewer side effects and probably an improved chance of cure in some diseases (e.g. prostate cancer).
