Changes in the use of radiotherapy in Ontario 1984–1995

doi:10.1016/S0360-3016(99)00010-3

International Journal of Radiation OncologyBiologyPhysics

Volume 44, Issue 2, May 1999, Pages 355-362

https://doi.org/10.1016/S0360-3016(99)00010-3 Get rights and content

Abstract

Purpose: To describe changes in the use of radiotherapy in the management of cancer in Ontario between January 1, 1984 and December 31, 1995.

Methods: A retrospective review of prospectively gathered electronic records of all radiotherapy for cancer at nine provincial cancer treatment centres.

Results: Over the 12 years of the study, the incidence of cancer increased by 33%. The number of curative and adjuvant courses per incident case increased by 39.3% and the number of palliative courses per incident case decreased by 15.8%. The mean number of fractions per curative and adjuvant course increased by 13%, and the mean number of fractions per palliative course decreased by 22%. The number of curative fractions per incident case increased by 63%, and the number of palliative fractions per incident case decreased by 32%. The increase in curative workload was mainly due to an increase in the incidence of prostate cancer, to an increase in the number of courses per incident case in breast and prostate cancer, and to an increase in the number of fractions per curative course in every disease group. The decrease in palliative workload was due to a decrease in the number of courses per incident case in most disease groups, and to a decrease in the number of fractions per course in most disease groups.

Conclusions: In Ontario, between 1984 and 1995, there was a large shift in workload from palliative radiotherapy to curative radiotherapy. Potential causes for this phenomenon are discussed.

Introduction

In the Canadian province of Ontario, all radiotherapy is provided by a network of provincial cancer centres that are funded by the provincial government and operated by two statutory agencies, Cancer Care Ontario (CCO), and the Ontario Cancer Institute/Princess Margaret Hospital (OCI/PMH) (1). There are no private radiotherapy facilities in the province, and the provincial network is, therefore, the monopoly provider of care for the province’s population of 11,000,000 people. The system was designed to provide equitable access to high quality radiotherapy for all residents of the province while containing costs (2). The cancer centres are generally large, and this has permitted the development of strong teams of oncologists, technologists and physicists (3). The system is efficient, in that there is no unnecessary duplication of expensive facilities (3).

Unfortunately, Ontario’s centralized radiotherapy system proved unable to meet an increase in the demand for radiotherapy in the 1980s, and long waiting lists developed at many of the provincial radiotherapy centres (4). It remains unclear what precipitated Ontario’s waiting list “crisis,” but it appears that the system was caught by surprise by an increase in referrals precipitated by new indications for radiotherapy, combined with an increase in incidence of cancer (4). This situation was not unique to Ontario, and many other Canadian provinces experienced similar problems over the same period (5).

It has been suggested that waiting lists may function as an implicit form of rationing in publicly funded health-care systems (6), and there is some evidence that radiotherapy waiting lists did affect decisions about the use of radiotherapy in Ontario in the 1980s (7). It is known that the proportion of incident cases of lung cancer, head and neck cancer, and the gynecological malignancies that received radiotherapy as part of their initial treatment decreased significantly between 1984 and 1990 (7). There has also been great concern that waiting lists may have reduced the use of radiotherapy for palliation, although there is only anecdotal evidence to support this. The purpose of this study was to describe changes in the use of radiotherapy in the management of cancer in Ontario during and after the period of severe resource limitations in the late 1980s, with particular emphasis on the use of radiotherapy in palliation.

Section snippets

Radiotherapy records

All radiotherapy in Ontario is provided by eight CCO regional cancer centres and the Princess Margaret Hospital (PMH) in Toronto. Since the early 1980s, each of these centres has kept a computerized summary of every course of radiotherapy in a standard format (8). The summary includes: date of start of radiotherapy; region irradiated; type of treatment; intent of treatment; total dose; number of fractions; and overall treatment time. All centres provided us with their records of all courses of

Results

Figure 1 shows that, throughout the study period, the rate of increase in the number of treatment machines in operation in the province exceeded the rate of increase in the incidence of cancer. The number of megavoltage machines increased by 80%, from 30 machines in 1984 to 54 in 1995, and the incidence of cancer increased by 33%, from 33,013 in 1984 to 43,907 in 1995. As a result, the number of incident cases per megavoltage machines decreased by 26%, from 1100 in 1984 to 813 in 1995.

Discussion

This study has a number of limitations. First, we have described only the technical component of radiotherapy workload without measuring any of the nontechnical aspects of patient care that absorb much of the time and energy of radiation oncologists in Ontario (12). Second, our measures of technical activity are fairly crude; they do not take account of variations in the complexity of radiotherapy plans or provide any indication of the quality of the treatment. However, our simple approach

Acknowledgements

This work was supported by grants from the National Cancer Institute of Canada, and Cancer Care Ontario (W. J. Mackillop). Patti Groome is a career scientist of the Ministry of Health of Ontario. We thank Eric Holowaty, Nelson Chong, and Darlene Dale for providing data from the Ontario Cancer Registry. The authors gratefully acknowledge the support of Ontario’s radiation oncologists whose records made this study possible. We thank the following heads of radiation oncology, medical physicists,

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Clinical InvestigationsChanges in the use of radiotherapy in Ontario 1984–1995

Abstract

Introduction

Section snippets

Radiotherapy records

Results

Discussion

Acknowledgements

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Radiother Oncol

J Clin Epidemiol

Historical origins of current problems in cancer control

CMAJ

Containing Ontario’s hospital costs under universal insurance in the 1980sWhat was the record?

CMAJ

Does a centralized radiotherapy system provide adequate access to care?

J Clin Oncol

Clinical Investigations
Changes in the use of radiotherapy in Ontario 1984–1995