Optimal Radiotherapy Utilization Rate Research Articles

129: Development of an Optimal Radiotherapy Utilisation Rate for Older Patients with Head and Neck Cancer

129: Development of an Optimal Radiotherapy Utilisation Rate for Older Patients with Head and Neck Cancer

Development of an age- and comorbidity- adjusted optimal radiotherapy utilisation rate for lung, rectal, prostate and cervical cancers

IntroductionOptimal radiotherapy utilisation (RTU) modelling estimates the proportion of people with cancer who would benefit from radiotherapy. Assessment of comorbidities is an important component of the assessment of suitability for radiotherapy in addition to chronological age and life expectancy. Comorbidities have not been considered in previous optimal RTU models. We aimed to develop an age- and comorbidity- adjusted optimal RTU model for patients with lung, rectal, prostate, and cervical cancer, and compare them to actual RTU rates, with a particular focus on those aged 80+ years, MethodsNew South Wales (NSW) Cancer Registry data (2010–2014) linked to radiotherapy data (2010–2015) and hospitalisation data (2008–2015) were used to determine the number of patients diagnosed with lung, rectal, prostate and cervical cancer. The Cancer Specific C3 ‘all sites’ comorbidity index was calculated from hospital diagnosis data for each patient to determine suitability for radiotherapy. The index was then incorporated into a tumour site-specific decision tree model. The actual RTU was also calculated using the linked datasets. Results14,696 patients were diagnosed with non-small cell lung cancer (NSCLC), 1839 with small cell lung cancer (SCLC), 5551 with rectal cancer, 30,935 with prostate cancer and 1216 with cervical cancer in New South Wales from 2010-2014. The proportion of patients aged 80+ years at cancer diagnosis was 25% (3603 patients), 15% (279 patients), 17% (943 patients), 12% (3745 patients), and 7% (88 patients) respectively.The age- and comorbidity- adjusted optimal RTU rates for patients aged 80+ years using the C3 index were 49% (NSCLC), 49% (SCLC), 43% (rectal), 51% (prostate) and 40% (cervical). The corresponding actual RTU rates for patients aged 80+ years were 25%, 32%, 27%, 16%, and 56%. ConclusionEven after adjusting for age and comorbidities, the actual radiotherapy utilisation rates were lower than optimal radiotherapy utilisation rates in patients aged 80+ years except for patients with cervical cancer. This warrants further assessment and research into reasons and solutions.

SIOG2022-0007 - Development of an Age- and Comorbidity- Adjusted Optimal Radiotherapy Utilisation Rate for Patients with Lung Cancer

SIOG2022-0007 - Development of an Age- and Comorbidity- Adjusted Optimal Radiotherapy Utilisation Rate for Patients with Lung Cancer

Development of an age- and comorbidity adjusted- optimal radiotherapy utilisation rate for women with breast cancer

IntroductionOptimal radiotherapy utilisation (RTU) modelling estimates the proportion of people with cancer who would benefit from radiotherapy. Older adults with cancer may have comorbidities that can impact physiological reserve and affect radiotherapy recommendations. These have not been considered in previous models. We aimed to develop an age- and comorbidity-adjusted optimal RTU model for breast cancer. MethodsNew South Wales (NSW) Cancer Registry data (2010–2014) linked to radiotherapy data (2010–2015) and hospitalisation data (2008–2015) was used to determine the number of women diagnosed with invasive breast cancer in four pre-specified age groups. The Charlson Comorbidity Index (CCI), Cancer-Specific C3 ‘all sites’ index and the Hospital Frailty Risk Score (HFRS) were derived for each woman from diagnostic codes in hospital records. Women were deemed unfit, and thus unsuitable candidates for radiotherapy, if the comorbidity indices were as follows: CCI ≥2; C3 score ≥ 3; and HFRS ≥5. The proportions of women suitable for radiotherapy in each age group were then incorporated into a breast cancer decision tree model. The actual RTU was also calculated using the linked datasets. Results23,601 women were diagnosed with breast cancer in NSW from 2010 to 2014 and 2526 were aged 80+ years. The overall comorbidity adjusted- RTU for women of all ages was 85·9% (CCI), 83·7% (C3) and 81·9% (HFRS). The optimal comorbidity adjusted- RTU for women aged 80+ was 76·1% (CCI), 70·1% (C3) and 61·8% (HFRS). The actual RTU for women aged 80+ years was 24.7%. ConclusionThe vast majority of older Australian women with breast cancer are fit for radiotherapy. The overall optimal RTU is only slightly reduced when adjusted for age and comorbidities and was similar using each of the three indices examined. Our data suggest radiotherapy is markedly underutilised for older women with breast cancer.

Radiotherapy underutilisation and its impact on local control and survival in New South Wales, Australia

Background and purposeThis study aimed to identify the actual radiotherapy utilisation rate (A-RUR) in New South Wales (NSW) Australia for 2009–2011 and compare that to the published evidence-based optimal radiotherapy utilisation rate (O-RUR) and to previously reported A-RUR in NSW in 2004–2006. It also aimed to estimate the effect of underutilisation on 5-year local control (LC) and overall survival (OS) and identify factors that predict for underutilisation. Materials and methodsAll cases of registered cancer diagnosed in NSW between 2009 and 2011 were identified from the NSW Central Cancer Registry and linked with data from all radiotherapy departments. The A-RUR was calculated and compared with O-RURs for all cancers. The difference for each indication was used to estimate 5-year OS and LC shortfall. Univariate and multivariate analyses were performed to identify factors that correlated with reduced radiotherapy utilisation. Results110,645 cancer cases were identified. 25% received radiotherapy within one year of diagnosis compared to an estimated optimal rate of 45%. This has marginally improved from previously reported rate of 22% in NSW in 2004–2006. We estimated that 5-year OS and LC were compromised in 1162 and 5062 patients respectively. Factors that predicted for underuse of radiotherapy were older age, male gender, lower socioeconomic status, increasing distance to nearest radiotherapy centre and localised disease. ConclusionThe identified deficit in radiotherapy use has a significant negative impact on patient outcomes. Strategies to overcome such shortfalls need to be developed to improve radiotherapy use and patient outcomes.

What is the optimal radiotherapy utilization rate for lung cancer?-a systematic review.

Lung cancer is a major cause of morbidity and mortality globally. Although radiotherapy (RT) may be beneficial in the radical and/or palliative management of many lung cancer patients, it is underutilized worldwide. Population-level development of RT resources requires estimates of optimal radiotherapy utilization rates (ORUR) and actual radiotherapy utilization rate (ARUR). A systematic review of PubMed database for English-language articles from January 2009 to January 2019 was performed. Keywords included utilization, underutilization, demand, epidemiologic, benchmark, RT and cancer. Data abstracted included: study population, diagnosis, stage, year of diagnosis, timing of RT, intent of RT, ARUR, and ORUR. Eligible studies provided ARUR or ORUR for lung cancer, small cell lung cancer (SCLC), or non-small cell lung cancer (NSCLC). Included ARUR were based on at least 1,000 patients who were diagnosed or treated in 2009 or later. Included ORUR were based on evidence review or ARUR in 2009 or later. The initial search strategy yielded 1,627 unique abstracts. After review, 105 articles were determined appropriate for full-text review. From these, a final set of 21 articles met all inclusion criteria. In eight papers, ORUR was estimated. Estimated lifetime ORUR ranged from 61% to 82%. Methods for estimation included the evidence-based guideline model, Malthus model, and criterion-based benchmarking (CBB) model. The majority of estimates (6/8) used the evidence-based guideline model. Fifteen papers provided ARUR on lung cancer, inclusive of SCLC and NSCLC. ARUR within 9 months to 1 year of diagnosis ranged from 39% to 46%. Lifetime ARUR was an estimated 52% in Ontario, Canada. Palliative intent ARUR ranged from 12% in Central Poland to 46% in Ontario, Canada. RT is underutilized for lung cancer globally, and there is wide geographical variation in the level of underutilization.

What Is the Optimal Radiotherapy Utilization Rate for Lung Cancer? a Systematic Review

Population-level planning for radiotherapy services requires estimates for optimal radiotherapy utilization rates (RTU) and epidemiological data on incidence and stage of each cancer type. Lung cancer is a common indication for palliative radiotherapy (RT), and is increasingly treated using RT for curative intent. This project aimed to review the literature to determine actual and estimated optimal RTU for non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC). A systematic review of PubMed/MEDLINE database for articles from January 2009 to January 2019 was performed. A search strategy was performed using keywords related to the terms utilization, underutilization, demand, epidemiologic, benchmark, radiotherapy and cancer. Abstracts were reviewed independently by two investigators, with discrepancies settled by consensus. Data abstracted included: cancer registry used, diagnosis, stage, time of diagnosis, time of RT, intent of RT, treatment sites, radiotherapy utilization rates, estimated optimal utilization rates, and methods used for estimating optimal rate. Included studies provided RTU or estimated optimal RTU for patients with lung cancer, SCLC, or NSCLC, based on cancer registry data from 2009 or later, with greater than 1000 patients. The initial search strategy yielded 1627 unique abstracts. After review, 94 articles were determined appropriate for a full-text review. From these, a final set of 17 articles met all inclusion criteria. Thirteen papers provided data on lung cancer, inclusive of SCLC and NSCLC. RTU within 9 months to 1 year of diagnosis ranged from 39% to 46%. Lifetime RTU ranged from less than 25% in Poland to an estimated 52% in Canada. Palliative intent RTU ranged from 12% in Poland to 46% in Canada. In 8 papers, optimal RTU was estimated using the evidence-based guideline model, Malthus model, or criterion-based benchmarking (CBB) model. The majority (n=6) of estimates used the evidence-based guideline model. Estimated lifetime RTU ranged from 61% with the Malthus model to 82% with the evidence-based guideline model. Three papers presented data specific to SCLC. RTU increased overall for stage 1 SCLC from 2009 to 2013. SBRT use increased from 3% to 6%, and conventional fractionation external beam RT use decreased from 34% to 30%. Optimal RTU for SCLC was 59% using the evidence-based guideline method. There is wide geographical variation in RTU for lung cancer. RTU for SCLC and NSCLC increased between 2009 and 2019. Optimal RTU for lung cancer ranged from 61% to 82%, and was higher than all observed RTU.

Estimating radiotherapy demands in South East Asia countries in 2025 and 2035 using evidence-based optimal radiotherapy fractions.

As about 50% of cancer patients may require radiotherapy, the demand of radiotherapy as the main treatment to treat cancer is likely to rise due to rising cancer incidence. This study aims to quantify the radiotherapy demand in countries in Southeast Asia (SEA) in 2025 and 2035 using evidence-based optimal radiotherapy fractions. SEA country-specific cancer incidence by tumor site for 2015, 2025 and 2035 was extracted from the GLOBOCAN database. We utilized the optimal radiotherapy utilization rate model by Wong etal. (2016) to calculate the optimal number of fractions for all tumor sites in each SEA country. The available machines (LINAC & Co-60) were extracted from the IAEA's Directory of Radiotherapy Centres (DIRAC) from which the number of available fractions was calculated. The incidence of cancers in SEA countries are expected to be 1.1 mil cases (2025) and 1.4 mil (2035) compared to 0.9 mil (2015). The number of radiotherapy fractions needed in 2025 and 2035 are 11.1 and 14.1 mil, respectively, compared to 7.6 mil in 2015. In 2015, the radiotherapy fulfillment rate (RFR; required fractions/available fractions) varied between countries with Brunei, Singapore and Malaysia are highest (RFR>1.0 - available fractions>required fractions), whereas Cambodia, Indonesia, Laos, Myanmar, Philippines, Timor-Leste and Vietnam have RFR<0.5. RFR is correlated to GDP per capita (ρ=0.73, P=0.01). To allow RFR ≥1 in 2025 and 2035, another 866 and 1177 machines are required, respectively. The number are lower if longer running hours are implemented. With the optimal number of radiotherapy fractions, estimation for number of machines required can be obtained which will guide acquisition of machines in SEA countries. RFR is low with access varied based on the economic status.

The Benefits of Providing External Beam Radiotherapy in Low- and Middle-income Countries

More than half of all cancer diagnoses worldwide occur in low- and middle-income countries (LMICs) and the incidence is projected to rise substantially within the next 20 years. Radiotherapy is a vital, cost-effective treatment for cancer; yet there is currently a huge deficit in radiotherapy services within these countries. The aim of this study was to estimate the potential outcome benefits if external beam radiotherapy was provided to all patients requiring such treatment in LMICs, according to the current evidence-based guidelines. Projected estimates of these benefits were calculated to 2035, obtained by applying the previously published Collaboration for Cancer Outcomes, Research and Evaluation (CCORE) demand and outcome benefit estimates to cancer incidence and projection data from the GLOBOCAN 2012 data. The estimated optimal radiotherapy utilisation rate for all LMICs was 50%. There were about 4.0 million cancer patients in LMICs who required radiotherapy in 2012. This number is projected to increase by 78% by 2035, a far steeper increase than the 38% increase expected in high-income countries. National radiotherapy benefits varied widely, and were influenced by case mix. The 5 year population local control and survival benefits for all LMICs, if radiotherapy was delivered according to guidelines, were estimated to be 9.6% and 4.4%, respectively, compared with no radiotherapy use. This equates to about 1.3 million patients who would derive a local control benefit in 2035, whereas over 615 000 patients would derive a survival benefit if the demand for radiotherapy in LMICs was met. The potential outcome benefits were found to be higher in LMICs. These results further highlight the urgent need to reduce the gap between the supply of, and demand for, radiotherapy in LMICs. We must attempt to address this ‘silent crisis’ as a matter of priority and the approach must consider the complex societal challenges unique to LMICs.

Optimal radiotherapy utilisation rate in developing countries: An IAEA study

Optimal radiotherapy utilisation rate (RTU) is the proportion of all cancer cases that should receive radiotherapy. Optimal RTU was estimated for 9 Middle Income Countries as part of a larger IAEA project to better understand RTU and stage distribution.

OC-0192: Optimal radiotherapy utilization rate in developing countries: an IAEA study

OC-0192: Optimal radiotherapy utilization rate in developing countries: an IAEA study

Evidence-based Estimates of the Demand for Radiotherapy

There are different methods that may be used to estimate the future demand for radiotherapy services in a population ranging from expert opinion through to complex modelling techniques. This manuscript describes the use of evidence-based treatment guidelines to determine indications for radiotherapy. It also uses epidemiological data to estimate the proportion of the population who have attributes that suggest a benefit from radiotherapy in order to calculate the overall proportion of a population of new cases of cancer who appropriately could be recommended to undergo radiotherapy. Evidence-based methods are transparent and adaptable to different populations but require extensive information about the indications for radiotherapy and the proportion of cancer cases with those indications in the population.In 2003 this method produced an estimate that 52.4% of patients with a registered cancer-type had an indication for radiotherapy. The model was updated in 2012 because of changes in cancer incidence, stage distributions and indications for radiotherapy. The new estimate of the optimal radiotherapy utilisation rate was 48.3%. The decrease was due to changes in the relative frequency of cancer types and some changes in indications for radiotherapy. Actual rates of radiotherapy utilisation in most populations still fall well below this benchmark.

Estimating the demand for radiotherapy from the evidence: A review of changes from 2003 to 2012

Background and PurposeIn 2003 we estimated that 52.3% of new cases of cancer in Australia had an indication for external beam radiotherapy at least once at some time during the course of their illness. This update reviews the contemporary evidence to define the optimal proportion of new cancers that would benefit from radiotherapy as part of their treatment and estimates the changes to the optimal radiotherapy utilisation rate from 2003 to 2012. Materials and MethodsNational and international guidelines were reviewed for external beam radiotherapy indications in the management of cancers. Epidemiological data on the proportion of new cases of cancer with each indication for radiotherapy were identified. Indications and epidemiological data were merged to develop an optimal radiotherapy utilisation tree. Univariate and Monte Carlo simulations were used in sensitivity analysis. ResultsThe overall optimal radiotherapy utilisation rate (external beam radiotherapy) for all registered cancers in Australia changed from 52.3% in 2003 to 48.3% in 2012. Overall 8.9% of all cancer patients in Australia have at least one indication for concurrent chemo-radiotherapy during the course of their illness. ConclusionsThe reduction in the radiotherapy utilisation rate was due to changes in epidemiological data, changes to radiotherapy indications and refinements of the model structure.

A decade of investment in radiotherapy in New South Wales: Why does the gap between optimal and actual persist?

There is a gap between optimal and actual radiotherapy utilization (RTU) rates in New South Wales (NSW). It is uncertain if this is because these investments have been insufficient to meet demand, or demand has been over-estimated. In this study we assess trends in infrastructure, staffing and productivity in NSW over the last 10 years. The NSW Radiotherapy Management Information System reports annually on activity including new patients, new courses, retreatments, attendances, radiotherapy fields and Area Health Service (AHS) of residence. Data are obtained from interstate radiotherapy departments that treat NSW residents. A census of equipment and staffing is reported. RTU was defined as the number of new cases in a year treated by radiotherapy divided by the number of new cases of cancer in that year. From 1999 to 2008, 115,941 NSW residents received at least one course of radiotherapy. During this time period there were 325,965 new diagnoses of cancer reported by the Central Cancer Registry. RTU was 38% in 1999 and in 2008. The number of linear accelerators increased from 34 to 42 between 1999 and 2008 but the number of accelerators per 1000 new cases of cancer remained static at 1.2. For AHSs, there was a significant relationship between more linear accelerators per 1000 patients and higher RTU (P = 0.0023). Radiotherapy utilization in NSW has remained at 38% for the period 1999 to 2008 because investment in new facilities only just kept pace with the increase in the number of new cases of cancer with an indication for radiotherapy. Some regional AHS have shown significant increases in RTU with new facilities.

What will be the radiotherapy machine capacity required for optimal delivery of radiotherapy in Scotland in 2015?

Aims Lack of radiotherapy capacity has been cited as a reason for poor cancer outcomes reported in the United Kingdom. This modelling study was conducted to ensure sufficient capacity in the future and to aid health service planning. Methods The predicted changes in the incidence of each cancer type to 2015 were calculated using the age–period–cohort technique. To develop the model the indications for radiotherapy now and in 2015 were established, as were the fractionation schedules for each clinical scenario. The optimal radiotherapy utilisation rates and required radiotherapy capacity were estimated for 2005 and for 2015. Results Cancer incidence is expected to rise by 18.9% by 2015. In Scotland, the estimated optimal radiotherapy utilisation rate during initial management is 44.2–47.9%. The model suggested that currently for optimal delivery, the capacity for 195,300–256,300 fractions is required. Due to predicted changes in the patient population, it is anticipated that requirements will increase to between 276,400 and 354,200 fractions per annum by 2015. Based on the current working practices, this is a 20–54% increase in current capacity, or from 5 to 6–7.6 machines per million head of population. Conclusions In order to meet the current and projected demand, a marked increase in the provision of radiotherapy machine capacity will be required in Scotland by 2015.

Patterns of Radiotherapy Re-Treatment in Patients with Lung Cancer: A Retrospective, Longitudinal Study

The optimal initial radiotherapy utilization rate for lung cancer is estimated to be 76% of all new cases. The actual re-treatment rate has not been defined. Re-treatment information can aid clinical decision making and resource planning. The aim of this study was to examine the indications for re-treatment in a population cohort and report the proportion of patients who receive more than one radiotherapy treatment for lung cancer throughout their lifetime. A retrospective longitudinal analysis of a cohort of patients with lung cancer treated with radiotherapy in the South Western Sydney Area Health Services (SWSAHS) in 1993 and 1996 was performed. The indication for and timing of all episodes of radiotherapy were recorded and analyzed using SPSS Data 3.5 software (SPSS, Inc., Chicago, IL). Of the 527 patients diagnosed with lung cancer in the study period, 279(53%) were treated at least once with radiotherapy. Initial radiotherapy was palliative for 79%, definitive for 14%, and adjuvant for 7%. The most common sites of initial radiotherapy were chest (79%), bone (10%), and brain (9%). Of the 279 patients, 73 (27%) received treatment with a second course of radiotherapy, 19 (7%) had a third radiotherapy episode, and 6 (2%) had a fourth. One patient had five radiotherapy episodes. Overall, there were 328 radiotherapy courses delivered to the 279 patients. The re-treatment rate for our cohort was 27%, exceeding other estimations of re-treatment. Common sites re-treated were chest and bone. Re-treatment was 17% of the initial linear accelerator treatment delivery work load for lung cancer.

5 Estimating the optimal radiotherapy utilization rate based on clinical guidelines and best available evidence and comparing it to current practice

5 Estimating the optimal radiotherapy utilization rate based on clinical guidelines and best available evidence and comparing it to current practice

Estimating the optimal radiotherapy utilization for carcinoma of the central nervous system, thyroid carcinoma, and carcinoma of unknown primary origin from evidence‐based clinical guidelines

In this one in a series of articles, the objective was to estimate the ideal proportion of patients with cancer who should receive radiotherapy at least once during the course of their illness based on the best available evidence. This estimate should be useful in planning for future radiotherapy facilities. Optimal rates of radiotherapy for patients with central nervous system (CNS) carcinoma, thyroid carcinoma, or carcinoma of unknown primary site (CUP) have not been studied previously. A systematic review of evidence-based treatment guidelines for the treatment of CNS carcinoma, CUP, and thyroid carcinoma was undertaken. An optimal radiotherapy utilization tree was constructed for each of these malignancies depicting the indications for radiotherapy at various stages of disease. The proportion of patients who had clinical attributes that indicated a possible benefit from radiotherapy was calculated by adding epidemiological data to the radiotherapy utilization tree. The optimal proportion of patients who should receive radiotherapy was then calculated using specialized decision-analysis software. Sensitivity analyses using univariate analysis and Monte Carlo simulations were performed. The optimal rates of radiotherapy utilization for carcinoma of the CNS, thyroid carcinoma, and CUP were 92%, 10%, and 61%, respectively. Comparison with actual rates of utilization in South Australia, Sweden, and the U.S. suggested an under-utilization of radiotherapy for CNS carcinoma and CUP. However, the actual rates of radiotherapy for thyroid carcinoma exceeded the optimal rate for some jurisdictions, although some data may have included radioactive iodine, which was not included in the current project. It was possible to estimate optimal radiotherapy utilization rates based on evidence. This methodology allowed a comparison of optimal rates with actual rates to identify areas in which improvements in the evidence-based use of radiotherapy can be made, and it may provide valuable data for future radiotherapy service planning.

Estimation of an optimal external beam radiotherapy utilization rate for head and neck carcinoma

Radiotherapy is used commonly in the treatment of patients with head and neck carcinoma. The benchmark radiotherapy utilization rates for head and neck carcinoma largely are unknown. The objective of the current study was to determine the optimal radiotherapy utilization rate for patients with head and neck carcinoma and to compare this optimal rate with actual utilization rates where actual utilization data were available. An optimal radiotherapy utilization tree was constructed that depicted all patients with head and neck carcinoma in whom radiotherapy was indicated according to evidence-based treatment guidelines. The proportions of patients with clinical attributes that indicated possible benefit from radiotherapy were obtained from epidemiological data and were inserted into the utilization tree. The optimal proportion of patients with carcinoma of the head and neck who should receive radiotherapy was calculated by merging the evidence-based recommendations with the epidemiological data in the tree. Optimal rates of radiotherapy utilization were compared with actual rates obtained from population-based studies. Radiotherapy was indicated at some point during their illness in 74% of all patients with head and neck carcinoma. By subsite, the optimal radiotherapy utilization rates were oral cavity, 74%; lip, 20%; larynx, 100%; oropharynx, 100%; salivary gland, 87%; hypopharynx, 100%; nasopharynx, 100%; paranasal sinuses, 100%; and unknown squamous cell carcinoma of the head and neck, 90%. All treatment recommendations were based on Level III or IV evidence. Assessment of actual radiotherapy utilization rates indicated an increased use of radiotherapy over time for head and neck carcinoma. However, there also were some decreases in the use of radiotherapy for some carcinoma subsites over the past 20 years, despite the lower actual rates compared with the optimal rates. The reasons for these reductions in use were not identified. The actual radiotherapy utilization rate for patients with head and neck carcinoma corresponded reasonably closely to the optimal rate for some populations but also identified some shortfalls for other patient groups. The results of this study provide a way of assessing shortfalls in radiotherapy.

O-120 Estimating an optimal radiotherapy utilisation rate for lung cancer based upon evidence-based treatment guidelines

O-120 Estimating an optimal radiotherapy utilisation rate for lung cancer based upon evidence-based treatment guidelines