Radiotherapy Utilization Rates Research Articles

The effect of travel distance on radiotherapy utilization in NSW and ACT

BackgroundIt has been estimated that half of all cancer patients should receive radiotherapy during the course of the disease. Actual Radiotherapy Utilization (RTU) rates are usually lower than the optimal rates. MethodsData were collected from all radiotherapy departments (RTD) in New South Wales (NSW) and the Australian Capital Territory (ACT) for the period 2004–06 and were linked to Central Cancer Registries. Geographic Information System (GIS) software was used to calculate road distance between patient residence and the closest RTD. Patients were excluded from the study if their nearest RTD was outside NSW. ResultsThe overall RTU rate was 26%. The RTU rates decreased with increasing travel distance from patient residence to the nearest RTD (p<0.0001). Multivariate logistic regression shows that male gender, younger age and shorter travel distance were significantly associated with receiving radiotherapy. Patients were 10% less likely to receive radiotherapy for each additional 100km distance from the nearest RTD (p<0.001). ConclusionsThere was a statistically significant reduction in radiotherapy access with longer road distance between patient residence and radiotherapy department.

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.

Radiotherapy utilization in BRAF mutation-tested metastatic melanoma in the targeted therapy era.

Tumor BRAF mutation testing is routine for all patients with metastatic melanoma (MM) owing to the availability of agents targeting this intracellular pathway. To test whether there is a difference in radiotherapy (RT) utilization according to BRAF mutation status, we performed a retrospective review of RT utilization in a contemporary cohort undergoing BRAF mutation testing. Clinical records of MM patients undergoing BRAF mutation testing between April 2010 and August 2012 were reviewed. Overall survival (OS) was calculated using Kaplan-Meier methods. Differences between BRAF status were calculated using chi-square tests for categorical variables, median tests for continuous variables and Cox proportional hazards models to compare OS. Up to 158 patients were identified but 17 were excluded due to inadequate clinical data. Of the remaining 141 patients, 69 (49%) tested BRAF mutant (BRAF-m), median age 47 years (range 21-79) with median follow-up of 16.8 months (IQR11.3-25.2). Seventy-two (51%) tested BRAF wild type (BRAF-w), median age 62 years (range 25-84) with median follow-up of 27.1 months (IQR12.5-57.4). Overall, RT utilization was similar: 68% in BRAF-m and 69% in BRAF-w. Mean number of treatment courses was 1.70 for BRAF-m and 2.36 for BRAF-w (Pearson chi-square 3.92, P = 0.05). Up to 51% of BRAF-m and 56% of BRAF-w required ≧2 RT courses. Forty-six percent BRAF-m compared with 29% BRAF-w received brain RT (P = 0.04). Median OS was 17.7 months (IQR7.6-35.5) in BRAF-m and 19 months (IQR7.8-35.1) in BRAF-w (P = 0.99). High RT utilization rates were observed irrespective of BRAF mutation status. Significantly more BRAF-w patients received RT but more BRAF-m patients received brain RT.

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.

Improving radiotherapy utilization rates in Ontario.

48 Background: Radiotherapy (RT) utilization is the proportion of patients (Pts) with a new diagnosis of carcinoma that receives at least one course of RT during the duration of their illness (MacKillop et al). In Ontario, the benchmark for utilization is 42%, and the target rate for Cancer Care Ontario (CCO) is 48%. However in 2005/06 Ontario’s utilization rate was only 35%. This shortfall implies that a significant number of Pts in Ontario were not receiving the best possible treatment. Methods: CCO has developed Capital Investments Strategies to take into account a growing population, an increased incidence of cancer (2.7% per annum), and changing demographics. The most recent (2012) has developed a plan for a gradual improvement in utilization at a rate of 0.5% per annum. With support from the Ministry of Health and Long-Term Care (MOHLTC), the amount of RT Units (RTUs) available increased from 77 (2005/06) to 103 (2013/14). In addition, the MOHLTC supported training programs for provincial Medical Physicists and Radiation Therapists to ensure effective staffing for increased RTUs. Results: Due to investments in RTUs and training, the number of Pts treated in Ontario has risen over 38% from 26,448 in 2005/06 to 36,613 in 2012/13. As a result, provincial utilization rates have risen from 35.1% in 2004/05 to 38.8% in 2012/13, closer to provincial targets. Notable improvements have been seen in centres such as The Carlo Fidani Peel Regional Cancer Centre, where the total number of RT Pts treated increased from 623 (2005/06) to 2532 (2012/13). Similar improvements are seen in other Local Health Integration Networks where comparable investments have been made. These improvements have been attained at the same time as provincial RT wait times have significantly improved from 80.2% (Jan 2010) to 91.6% (Dec 2012) of Pts seen within targets, exceeding provincial targets of 87%. Conclusions: The increase in RT utilization rates provincially demonstrates the success of developing a comprehensive capital investment strategy and coupling it with increased investments in human resource planning. The increased utilization rate has outpaced the increasing cancer incidence and demonstrates the success of these strategies, providing better access to care for cancer Pts in Ontario.

Radiotherapy in the Barwon South Western Region: A rural perspective

Cancer-related mortality rates are higher in rural areas compared with urban regions. Whether there are corresponding geographical variations in radiotherapy utilisation rates (RURs) is the subject of this study. RURs for the regional centre of Geelong and rural areas of the Barwon South Western Region were calculated using a population-based database (2009). Lower RURs were observed for rural patients compared with the Geelong region for prostate cancer (15.7% vs 25.8%, P = 0.02), rectal cancer (32.8% vs 44.7%, P = 0.11), lymphoma (9.4% vs 26.2%, P = 0.05), and all cancers overall (25.6% vs 28.9%, P = 0.06). This lower rate was significant in men (rural, 19.9%; Geelong, 28.3%; P = 0.00) but not in women (rural, 33.6%; Geelong, 29.7%; P = 0.88). Time from diagnosis to radiotherapy was not significantly different for patients from the two regions. Tumour staging within the rural and Geelong regions was not significantly different for the major tumour streams of rectal, prostate and lung cancer (P = 0.61, P = 0.79, P = 0.43, respectively). A higher proportion of tumours were unstaged or unstageable in the rural region for lung (44% vs 18%, P < 0.01) and prostate (73% vs 57%, P < 0.01) cancer. Lower RURs were observed in our rural region. Differences found within tumour streams and in men suggest a complexity of relationships that will require further study.

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 comparison of surgical and radiotherapy breast cancer therapy utilization in Canada (British Columbia), Scotland (Dundee), and Australia (Western Australia) with models of “optimal” therapy

BackgroundDifferent jurisdictions report different breast cancer treatment rates. Evidence-based utilization models may be specific to derived populations. We compared predicted optimal with actual radiotherapy utilization in British Columbia, Canada; Dundee, Scotland; and Perth, Western Australia. DesignData were analyzed for differences in demography, tumor, and treatment. Epidemiological data were fitted to published Australian optimal radiotherapy utilization trees and region-specific optimal treatment rates were calculated. Optimal and actual surgery/radiotherapy rates from 2 population-based and 1 institution-based registries were compared for patients diagnosed with breast cancer between 2000 and 2004, and 2002 for British Columbia. ResultsMastectomy rates differed between British Columbia (40%), Western Australia (44%), and Dundee (47%, p<0.01). Radiotherapy rates differed between British Columbia (60%), Western Australia (52%), and Dundee (49%, p<0.01). Actual radiotherapy utilization rates were lower than optimal estimates.Region-specific optimal utilization rates at diagnosis varied from 57% to 71% for radiotherapy and 62% to 64% when taking into account patient preference. Variation was attributed to local differences in demography and tumor stage. ConclusionsActual treatment rates varied, and were associated with patterns of care and guideline differences. Actual radiotherapy rates were lower than optimal rates. Differences between optimal and actual utilization may be due to access shortfalls, and patient preference.

Bladder Preservation for Localized Muscle-Invasive Bladder Cancer: The Survival Impact of Local Utilization Rates of Definitive Radiotherapy

This study examines the management and outcomes of muscle-invasive bladder cancer in the United States. Patients with muscle-invasive bladder cancer diagnosed between 1988 and 2006 were identified in the Surveillance, Epidemiology, and End Results (SEER) database. Patients were classified according to three mutually exclusive treatment categories based on the primary initial treatment: no local management, radiotherapy, or surgery. Overall survival was assessed with Kaplan-Meier analysis and Cox models based on multiple factors including treatment utilization patterns. The study population consisted of 26,851 patients. Age, sex, race, tumor grade, histology, and geographic location were associated with differences in treatment (all p < 0.01). Patients receiving definitive radiotherapy tended to be older and have less differentiated tumors than patients undergoing surgery (RT, median age 78 years old and 90.6% grade 3/4 tumors; surgery, median age 71 years old and 77.1% grade 3/4 tumors). No large shifts in treatment were seen over time, with most patients managed with surgical resection (86.3% for overall study population). Significant survival differences were observed according to initial treatment: median survival, 14 months with no definitive local treatment; 17 months with radiotherapy; and 43 months for surgery. On multivariate analysis, differences in local utilization rates of definitive radiotherapy did not demonstrate a significant effect on overall survival (hazard ratio, 1.002; 95% confidence interval, 0.999-1.005). Multiple factors influence the initial treatment strategy for muscle-invasive bladder cancer, but definitive radiotherapy continues to be used infrequently. Although patients who undergo surgery fare better, a multivariable model that accounted for patient and tumor characteristics found no survival detriment to the utilization of definitive radiotherapy. These results support continued research into bladder preservation strategies and suggest that definitive radiotherapy represents a viable initial treatment strategy for those who wish to attempt to preserve their native bladder.

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.

Radiotherapy in rectal cancer: development, adequacy and radiotherapy utilisation rate. A comparative analysis with the most frequent tumour sites

Radiotherapy is a basic weapon in the local treatment of multiple solid tumors. The radiotherapy activity has been evaluated in our centre during the past eleven years. The study focused on rectal cancer. This is a descriptive study of all radiotherapy procedures performed between January 1998 and December 2008. It quantifies the workload of each pathology treated, the rate of irradiation and its adequacy with optimal rates of irradiation according to the best available scientific evidence. We quantified 9,622 external radiotherapy procedures of which 6,009 were associated with the five pathologies that involved the highest workloads. Of these, 905 were performed in rectal cancer. The workloads due to cancers of the breast, prostate, lung, gynaecological pathologies and rectal cancers were 23.2%, 11.8%, 11.6%, 6.3% and 9.3% respectively. The real "radiotherapy utilisation rates" of these pathologies were 62%, 20.2%, 34.3%, 21% and 64% respectively, while the "rates of adequacy" were 74.7%, 33.6%, 45.1%, 60% and 104.8%. The "radiotherapy utilisation rate" for rectal cancer was equivalent to the estimated optimum rate as defined on the basis of reference groups. The therapy utilised developed chronologically in parallel with the available scientific evidence. The radiotherapy utilisation rates for breast and prostate cancer gradually increased, with a tendency to reach optimal rates. Radiotherapy as a treatment for lung cancer was underutilised. In global terms, the rate of utilisation of radiation therapy was low, although it displayed a tendency to increase.

Patterns of care for cervical cancer in Auckland, New Zealand, 2003–2007

The purpose of this review is to document current patterns of care for the International Federation of Gynecology and Obstetrics (FIGO) stage IB1 to IVA cervical cancer in a New Zealand cancer centre. This is a retrospective review of women with newly diagnosed FIGO Stage IB1-IVA cervical cancer in the Auckland/Northland regions between 2003 and 2007. Two hundred seven patients were identified. Fifty-three percent were stage IB, 24% stage II, 19% stage III and 3% stage IVA. Factors associated with stage ≥ IIB were age >50, lack of participation in cervical screening and public first specialist assessment. Ninety percent (90/100) of stage IB1 patients and 73% (8/11) of stage IB2 patients were treated with primary surgery. Thirty-eight percent of surgically treated stage IB1 and 100% of surgically treated stage IB2 tumours had indications for adjuvant radiotherapy. Radiotherapy utilisation rates were: stage IB 49% (IB1 44%, IB2 91%); stage II 93%; stage III 90%; and stage IVA 71%. Brachytherapy utilisation rate (BTU) for stages IIB to IVA was 64% overall and 75% in definitively treated patients. Seventy-five percent of patients treated with definitive radiotherapy received concurrent cisplatin chemotherapy. Both radiotherapy and brachytherapy utilization rates were below optimal and are being addressed. No formal surgical or chemotherapy utilisation estimates exist for comparison; however, the use of concurrent cisplatin chemotherapy was similar to other groups. A high rate of adjuvant (chemo)radiotherapy was noted in surgically treated Stage IB patients, suggesting a need for an increased consideration of primary chemoradiotherapy in these patients to avoid the unnecessary toxicity of trimodality therapy. Future outcome analysis is planned.

Estimation of an Optimal Utilisation Rate for Palliative Radiotherapy in Newly Diagnosed Cancer Patients

Aims An optimal utilisation rate for palliative radiotherapy in newly diagnosed cancers will be useful in the planning and delivery of cancer services and has not been reported to date. The aim of this study was to estimate the proportion of new cases of cancer that should receive palliative radiotherapy as their first course of radiotherapy at some time during the course of their illness. Materials and methods A previously developed model depicting indications for radiotherapy was merged with Australian cancer epidemiological data and re-analysed to identify palliative or radical treatment end points. Palliative radiotherapy end points were further divided by treatment site. The optimal palliative radiotherapy utilisation rates were compared with actual radiotherapy utilisation data for newly diagnosed cancers. Results Fourteen per cent of all new cancer cases should optimally receive palliative radiotherapy as their first course of radiotherapy treatment. Comparisons with actual radiotherapy utilisation rates from New South Wales, Australia, show that for some common cancers, more newly diagnosed patients receive palliative radiotherapy as their first radiotherapy treatment than would be optimally recommended in this model. This suggests that many patients in New South Wales are not currently being referred for curative treatment. Conclusion Palliative radiotherapy is optimally recommended as the first course of radiotherapy in 14% of all newly diagnosed cancers.

Estimating the lifetime utilization rate of radiotherapy in cancer patients: The Multicohort Current Utilization Table (MCUT) method

Extensive research has been carried out to establish the appropriate proportion of cancer patients requiring radiotherapy at some point during their illness. However, it is difficult to compare the actual rates against the appropriate rate, because calculating the actual rates requires life-long follow up of cancer patients. We have developed a method, referred to as the Multicohort Current Utilization Table (MCUT) method, to estimate the predicted lifetime utilization rates based on current medical practice. We implemented the method in SAS as a macro, and validated it by comparing the predicted and the actual utilization rates of radiotherapy in lung, breast, and prostate cancer cases diagnosed in Ontario, Canada. The MCUT method could be used to predict lifetime utilization rate of any medical services.

Is rural radiation oncology practice quality as good as the big smoke? Results of the Australian radiotherapy single machine unit trial

Radiotherapy utilization rates in rural Australia are suboptimal, with one solution being the building of single machine units (SMUs). One concern raised with such an approach is the quality of care delivered in SMUs. The Australian and Victorian governments have established two SMUs in the state of Victoria, with each SMU operated as a satellite service of a major 'hub' site. We report on the planned evaluation of practice quality. Radiation oncologist (RO) clinical practice was externally audited using the Royal Australian and New Zealand College of Radiologists Peer Review Audit instrument. This tool splits RO clinical practice into documentation/quality assurance (QA) criteria and decision-making criteria. Over the four sites, 130 patients were randomly selected for audit. At hub sites, 79.6% of all criteria audited were adequate, compared with 84.4% of criteria audited at SMUs (P = 0.0002). This difference was largely because of better adherence to documentation/QA criteria at the SMU sites. RO decision-making and protocol adherence were routinely very high and consistent with other clinical practice audits. There were no significant differences between hubs and SMUs for adherence to decision-making criteria; however, the few potential deficiencies in patient care identified occurred only at the hub sites. In at least one of these cases, potential suboptimal management was as a direct result of inadequate documentation. This audit found that SMUs provide as high a standard of radiotherapeutic care as larger hub departments. The findings also emphasize the need for all departments to target clinical documentation.

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.

Utilization of radiotherapy for rectal cancer in Greater Western Sydney 1994–2001

AbstractBackground and purpose: Despite evidence for the efficacy of radiotherapy in stages II and III rectal cancer, utilization rates remain low. The aim of this study is to examine patient, provider and service factors affecting utilization of radiotherapy in rectal cancer patients.Materials and methods: Patients with a diagnosis of curable rectal cancer were identified from the colorectal tumor databases of three Sydney Area Health Services between 1994 and 2001. Data were collected on tumor characteristics such as site and stage, provider factors such as type of surgery and surgeon caseload, and patient factors including socioeconomic status and access to radiotherapy.Results: Thirty‐five percent of stage II and 57% of stage III rectal cancer patients received radiotherapy. Independent determinants of utilization were age less than 70 years (odds ratio, 2.96; 95% confidence interval, 1.75–5.03), high‐volume surgeons (OR, 1.95; 95% CI, 1.17–3.24), stage III disease (OR, 2.06; 95% CI, 1.25–3.41) and abdominoperineal resections (OR, 3.67; 95% CI, 1.94–6.94).Conclusion: Radiotherapy utilization rates remain low. Age, and being referred to a surgeon with a high caseload, has a greater impact on radiotherapy utilization than other provider, socioeconomic or service factors.

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