Equity of Access to Proton Beam Therapy in England: A National NHS analysis

Abstract

Policies to improve population health have often focused on equitable access to health services. While new technologies have an enormous potential in improving health outcomes, they may not always be equally accessible across diverse geographical areas and socio-economic backgrounds. Between 2008 and 2018, 1352 patients with eligible indications for Proton Beam Therapy (PBT) were treated overseas within the NHS Proton Overseas Programme (POP) and 947 patients have been treated at the Christie since the National NHS PBT service started in December 2018. The 8 most common PBT cancer indications cover more than 80% of the referrals and referral rates depend on several factors. Aim of this study is to evaluate equity of access to PBT throughout the country and how this has changed since the national PBT service inception. Incidence data were available for 7/8 of the most common PBT cancer indications. These data were provided by the National Disease Registration Service (NDRS) by diagnosis, age group and by the 7 NHS regions in England. The incidence data referred to the time period 2013-2019. The first national NHS PBT center started accepting referrals in October 2018, therefore this time period was split in pre-NHS PBT (1/1/13-30/9/18) and post-NHS PBT (1/10/18-31/12/19). Demographics and clinical characteristics of patients referred for PBT were extracted from the national NHS PBT registry for matching clinical diagnoses and time period. The ratio between the referred (observed) and newly diagnosed (expected) patients is the Proton Utilization Proportion (PUP), which tracks the proportion of eligible patients using the technology. For the 7 common PBT indications examined, the total number of newly diagnosed patients was 2134 in the pre-NHS PBT period and 461 in the post-NHS PBT period. The (accepted) referrals were 587 and 300 in the pre-and post-NHS PBT period, respectively. An increase in the PUP between the pre-NHS PBT and the post-NHS PBT is noted for any diagnostic category, age group and NHS region. The most noticeable increase is noticed for Medulloblastoma, which became a commissioned indication for PBT only in 2016.The PUP in England increased post-NHS PBT by 137% overall. Of note, post-NHS PBT, 99% of the patients aged 0-15 with these 7 common indications for PBT were referred and treated with PBT. Promoting equality of access to cutting-edge radiotherapy technologies is at the heart of NHS England's values. Throughout the development of the policies and processes related to PBT access in the UK, the NHS has given regard to the need to reduce geographical variation which may contribute to health inequalities. The PUP has increased since the opening of a National PBT service in England, which uses a central web-based Proton Referral Pathway managed by a National Proton Office. Further analysis will follow to examine whether socio-economic or geographical barriers exist within each region.