Survey of the Availability and Use of Advanced Radiotherapy Technology in the UK

doi:10.1016/j.clon.2010.06.014

Clinical Oncology

Volume 22, Issue 8, October 2010, Pages 636-642

https://doi.org/10.1016/j.clon.2010.06.014 Get rights and content

Abstract

Aims

To determine the availability of intensity-modulated radiotherapy (IMRT) treatment in the UK and to assess the magnitude of the shortfall in terms of patient treatments. In addition, the availability of image-guided radiotherapy (IGRT) was also reviewed.

Materials and methods

A survey was carried out between July and September 2008 of the use of advanced technology in radiotherapy.

Results

In total, 50 centres responded out of the 58 National Health Service centres canvassed, representing about 89% of patients treated in the UK. Forty-six centres had at least two machines capable of IMRT and 26 centres had at least one machine capable of IGRT. Thirty-two centres were carrying out forward-planned IMRT and 18 centres were carrying out the more complex inverse-planned IMRT. In all, 38 centres (76% of respondents) were offering either forward- or inverse-planned IMRT to some of their patients. All the centres with IGRT capability were using IGRT for at least some of their patients. Respondents were asked to list the total number of radical and palliative patients being treated according to the treatment site. Forty-two per cent of respondents took the option to list the total number of radical and palliative patients only. Based on these data, 10.7% of radical patients are currently being given forward-planned IMRT, mainly for breast cancer (18.6% of such patients) and 2.2% of radical patients are being given inverse-planned IMRT, mainly for prostate (7.5% of such patients) and head and neck cancer (6.7% of such patients). Whereas at present only 18 centres are able to treat with inverse-planned IMRT, 45 centres expected to be able to do so by 2010. Respondents were asked to estimate the percentage of patients who should be given IMRT for each site and this was used to estimate the shortfall in IMRT provision.

Conclusions

Based on the consensus of opinion, 32% of radically treated patients should receive inverse-planned IMRT and 22% forward-planned IMRT, making a total of 55%. In fact, 2% receive inverse-planned IMRT and 11% the less complex forward-planned IMRT. Thus, with an estimated 75 948 radical treatments being carried out with megavoltage radiotherapy, the professional opinion is that 41 421 of patients would benefit from treatment with IMRT. In fact, only 9775 were so treated in 2008; a shortfall of 32 497 patients treated instead with conventional radiotherapy.

Introduction

Recent press concern about the lack of availability of intensity-modulated radiotherapy (IMRT) treatments led the Royal College of Radiologists together with the Institute of Physics and Engineering in Medicine, the Society and College of Radiographers, the National Cancer Research Institute and the Academic Clinical Oncology and Radiobiology Research Network to set up a Radiotherapy Development Board. Their analysis of the benefits of IMRT [1] is published elsewhere in this issue. A survey carried out in 2007 [2] showed that under half of the centres in the UK were using IMRT either forward- or inverse-planned. However, the extent of the shortfall of provision of IMRT in terms of patient numbers was not clear from this survey. It was therefore decided to carry out a second survey 12 months later, both to see whether the number of centres offering IMRT had increased and to assess the magnitude of the shortfall in terms of patient treatments. In addition, the availability of image-guided radiotherapy (IGRT) was also reviewed.

Section snippets

Materials and Methods

A questionnaire was developed, which was sent to all centres in the UK. Forty-five National Health Service (NHS) centres in England, two NHS centres in Scotland, two NHS centres in Wales and the only centre in Northern Ireland responded. Two of the private centres responded, but neither of them gave sufficient details to allow them to be formally included in the analysis. Using data from the National Cancer Services Analysis Team (NATCANSAT) for numbers of courses per centre it was possible to

Equipment

Of 245 linear accelerators recorded in the study, 219 were equipped to carry out IMRT and of these 44 were equipped to carry out IGRT. Seventy-four per cent of centres had linear accelerators from only one manufacturer. Every centre had at least one linear accelerator equipped with the hardware and software to carry out IMRT, although four centres had only one such linear accelerator and might reasonably decide that without a back-up machine it was inappropriate to embark on an IMRT programme.

Discussion

This survey represents the state of development of IMRT and IGRT facilities in the UK in September 2008. Figure 1b shows that the amount of inverse-planned IMRT being offered to patients falls significantly short of what clinicians feel should be offered. The fact that the number of centres offering the less labour intensive forward-planned approach is greater, indicates that this is not due to a lack of desire on the part of the staff involved, but as indicated in Table 6, is largely due to

References (4)

S. Jefferies et al.
Results of a national survey of radiotherapy planning and delivery in the UK in 2007
Clin Oncol (R Coll Radiol)
(2009)
Staffurth J. A review of the clinical evidence for intensity-modulated radiotherapy. Clin Oncol (R Coll Radiol)...

There are more references available in the full text version of this article.

Cited by (62)

International survey; current practice in On-line adaptive radiotherapy (ART) delivered using Magnetic Resonance Image (MRI) guidance
2020, Technical Innovations and Patient Support in Radiation Oncology
The uptake of new technologies has varied internationally and there have often been barriers to implementation. On-line adaptive radiotherapy (ART) promises to improve patient outcome. This survey focuses on the implementation phase of delivering ART and professional roles and responsibilities currently involved in the workflow and changes which may be expected in the future.
A 38 question survey included aspects on current practice; professional responsibilities; benefits and barriers; and decision making and responsibilities. For the purposes of the questionnaire and paper, ART was considered where tumour and /or organs at risk were contoured and re-planning was performed on-line. The questionnaire was electronically distributed via radiotherapy networks.
Nineteen international responses were received. Europe (n = 11), United States of America (n = 4); Canada (n = 2), Australia (n = 1) and Hong Kong (n = 1). The majority of centres started using ART in either 2018 (n = 7) or 2019 (n = 6). Four centres started treating with ART between 2015 and 2017, and the first was in 2014. Centres initially treated prostate and oligometastases patients, expanding to treat prostate, oligometastases, pancreas and rectum. The majority of centres were working in conventional roles, however moving towards radiographers taking more responsibility in contouring organs at risk (OAR), target and dosimetry. The three most important criteria chosen by medical doctors to determine if ART should be used were overall gross anatomy changes of target and OAR, target not covered by planning target volume (PTV) and OAR close to the high dose area. There was no clear consensus on the minimum improvement in dose to target or reduction in dose to OAR to warrant adaption.
On-line ART has been implemented successfully internationally. Initial practice maintains conventional professional roles and responsibilities, however there is trend to changing roles for the future. There is little consensus regarding the triggers of adaption.
Forward- and Inverse-Planned Intensity-Modulated Radiotherapy in the CHHiP Trial: A Comparison of Dosimetry and Normal Tissue Toxicity
2019, Clinical Oncology
Citation Excerpt :
There is a clear relationship between increasing radiation dose and improved clinical outcome (biochemical progression-free survival) [4]. Intensity-modulated radiotherapy (IMRT) has proven to be a powerful technique in terms of its dosimetric benefits for complex treatment sites and has become widely adopted for the treatment of prostate cancer [5–8]. CHHiP (Conventional or Hypofractionated High-dose Intensity Modulated Radiotherapy In Prostate Cancer; CRUK/06/016) was a randomised phase III trial in men with localised prostate cancer.
The CHHiP (Conventional or Hypofractionated High-dose Intensity Modulated Radiotherapy In Prostate Cancer; CRUK/06/016) trial investigated hypofractionated radiotherapy for localised prostate cancer. Forward- (FP) or inverse-planned (IP) intensity-modulated techniques were permitted. Dose–volume histogram and toxicity data were compared to explore the effects of planning method.
In total, 337 participants with intermediate-risk disease and prospectively collected toxicity data were included. Patients were matched on prostate and rectum/bladder volumes and on radiotherapy dose for toxicity comparisons. The primary outcome was grade 2 or higher Radiation Therapy Oncology Group (RTOG) bowel or bladder toxicity at 2 years.
IP patients had smaller volumes of rectum irradiated to 50–70 Gy (P < 0.001); FP patients had smaller volumes of bladder irradiated to 74 Gy (P = 0.001). Acute grade 2 + bowel toxicity was worse with FP (27/53 [52%]; 11/53 [21%] IP; P = 0.0002); with no significant differences in acute urinary toxicity. At 2 years, RTOG grade 2 + bowel toxicity rates were FP 0/53 and IP 2/53 and RTOG grade 2 + bladder rates were FP 0/54 and IP 1/57.
Significant differences were found between dose–volume histograms from FP and IP methods. IP may result in small reductions in acute bowel toxicity but both techniques were associated with low rates of late radiotherapy side-effects.
Modalities and techniques used for stereotactic radiotherapy, intensity-modulated radiotherapy, and image-guided radiotherapy: A 2018 survey by the Japan Society of Medical Physics
2019, Physica Medica
Over the last several decades, there have been great advances in radiotherapy with the development of new technologies and modalities, and radiotherapy trends have changed rapidly. To comprehend the current state of radiotherapy in Japan, the QA/QC 2016–2017 Committee of the Japan Society of Medical Physics set up an intensity-modulated radiotherapy/image-guided radiotherapy (IMRT/IGRT) working group and performed a Web-based survey to show the current status of radiotherapy in Japan. The Web-based questionnaire, developed using Google Forms, contained 42 items: 7 on stereotactic radiotherapy implementation, 4 on IMRT, 24 on IGRT, and 7 on respiratory motion management. The survey was conducted from 17 January to 9 March of 2018; in total, 335 institutions provided data. The results show that volumetric modulated arc therapy was used at a level comparable to that of static gantry IMRT. For IGRT, machine-integrated computed tomography (CT), including kilovoltage or megavoltage cone-beam CT and megavoltage CT, was used at many institutions in conjunction with target-based image registration. For respiratory motion management, breath holding was the most commonly used technique. Our hope is that multi-institutional surveys such as this one will be conducted periodically to elucidate the current status of radiotherapy and emerging developments in this field. If our questionnaire was distributed worldwide, in the same format, then global trends in radiotherapy could be better understood.
Image-guided, intensity-modulated radiation therapy in definitive radiotherapy for 1433 patients with cervical cancer
2018, Gynecologic Oncology
Citation Excerpt :
Intensity-modulated radiation therapy (IMRT) is one of the most important technical advances in radiation therapy in the past two decades. It has been proven to decrease treatment toxicity without compromising survival from various kinds of cancer and is widely used in cancer treatment [1,2], especially in head and neck carcinomas [3,4]. Cervical cancer is one of the most common cancers in women in developing countries.
Image guidance should be used for patients with cervical cancer treated with definitive intensity-modulated radiation therapy (IMRT). In this study, we provided a pattern of image guidance and verified it in a large population.
We retrospectively analyzed patients with stages IB1–IVA cervical cancer treated with IMRT combined with high-dose brachytherapy and concurrent chemotherapy in our institute from January 2005 to December 2015. A dose of 50.4 Gy in 28 fractions was prescribed to the planning target volume with fixed-field IMRT, volumetric modulated arc therapy, or helical tomotherapy. Daily megavoltage computed tomography (CT) or weekly cone-beam CT (CBCT)/CT-on-rail were used for image guidance. Considering tumor regression during treatment, a second CT simulation and IMRT planning after 20 fractions of IMRT was performed.
A total of 1433 patients were included in this study. Four hundred thirteen patients (28.8%) had regional lymph node metastases. A total of 1261 patients (88.0%) received concurrent chemotherapy. The median follow-up was 32.2 months (range, 1.9–124.9 months). The 3-year overall survival (OS), disease-free survival (DFS), and local control (LC) rates were 83.0%, 75.0%, and 87.4%, respectively. The 3-year DFS rates for patients with stages IB1, IB2, IIA, IIB, IIIA, IIIB, and IVA disease were 90.2%, 87.6%, 84.0%, 76.7%, 61.6%, 59.8%, and 25.9%. The incidence rates of grade 3 or greater chronic gastrointestinal and genitourinary toxicities were 2.3% and 1.3%.
This pattern of image guidance was rational for patients with cervical cancer treated with IMRT. The survival rates were high, and the toxicities were acceptable.
Omission of Breast Radiotherapy in Low-risk Luminal A Breast Cancer: Impact on Health Care Costs
2016, Clinical Oncology
The economic burden of cancer care is substantial, including steep increases in costs for breast cancer management. There is mounting evidence that women age ≥ 60 years with grade I/II T1N0 luminal A (ER/PR+, HER2– and Ki67 ≤ 13%) breast cancer have such low local recurrence rates that adjuvant breast radiotherapy might offer limited value. We aimed to determine the total savings to a publicly funded health care system should omission of radiotherapy become standard of care for these patients.
The number of women aged ≥ 60 years who received adjuvant radiotherapy for T1N0 ER+ HER2– breast cancer in Ontario was obtained from the provincial cancer agency. The cost of adjuvant breast radiotherapy was estimated through activity-based costing from a public payer perspective. The total saving was calculated by multiplying the estimated number of luminal A cases that received radiotherapy by the cost of radiotherapy minus Ki-67 testing.
In 2010, 748 women age ≥ 60 years underwent surgery for pT1N0 ER+ HER2– breast cancer; 539 (72%) underwent adjuvant radiotherapy, of whom 329 were estimated to be grade I/II luminal A subtype. The cost of adjuvant breast radiotherapy per case was estimated at $6135.85; the cost of Ki-67 at $114.71. This translated into an annual saving of about $2.0million if radiotherapy was omitted for all low-risk luminal A breast cancer patients in Ontario and $5.1million across Canada.
There will be significant savings to the health care system should omission of radiotherapy become standard practice for women with low-risk luminal A breast cancer.
Hypofractionated radiotherapy in prostate cancer
2015, The Lancet Oncology

View all citing articles on Scopus

¹: Radiotherapy Development Board: A. Barrett (University of East Anglia, representing the National Radiotherapy Action Group, UK), J. Barrett (Royal Berkshire Hospital, representing the Royal College of Radiologists [RCR], UK), C. Beardmore (representing the Society and College of Radiographers [SCoR], UK), S. Davies (North Middlesex University Hospital, London, UK), S. Hood (lay representative), R. Mackay (Christie NHS Foundation Trust, representing the Institute of Physics in Engineering and Medicine [IPEM], UK), P. Mayles (Clatterbridge Centre for Oncology, representing the National Cancer Research Institute [NCRI], UK), A. Poynter (Ipswich Hospital NHS Trust, representing the Academic Clinical Oncology and Radiobiology Research Network [ACORRN], UK), P. Price (University of Manchester, ACORRN, UK), D. Routsis (Addenbrooke’s Hospital, SCoR, UK), J. Staffurth (Cardiff University, NCRI, UK), S. Thomas (Addenbrooke’s Hospital, IPEM, UK), M. Williams (Addenbrooke’s Hospital, RCR, UK).

View full text

OverviewSurvey of the Availability and Use of Advanced Radiotherapy Technology in the UK