Issues Knowledge – all patients who might benefit must see a Clinical Oncologist Access – how can we best get the patients to the technology Opportunity – to be treated by the best staff with the best technique available

Describing a Cutting Edge Radiotherapy Service Trish Fisher Clinical Director Specialised Cancer Services Simon Pledge Lead Clinician Radiation Services

The Vision The Sheffield Teaching Hospitals Corporate Strategy is entitled ‘Excellence as Standard’ and although Weston Park Hospital has a tradition of leading the field in Radiotherapy despite providing an efficient rapid service, recent operating conditions have stretched the service and resulted in a degree of stagnation. Our vision is to move back to the Premier Division of Radiotherapy Providers in the UK.

The Vision All patients who might benefit from radiotherapy should receive it All patients should receive their treatment promptly All patients should receive state of the art treatment if appropriate The patient experience should be optimal Involvement in cutting edge research

All patients who might benefit from radiotherapy should receive it The number of fractions delivered to the North Trent population are not at the NRAG recommended levels Current (as at Mar 2011) : 55,376 fractions NRAG Recommendations: 72,000 fractions

Lack of sufficient Clinical Oncology input into MDTs leading to Radiotherapy not being considered as an option Patients not always discussed again at the MDT for consideration of subsequent treatment e.g. to review post operative histology Radiotherapy not presented as a treatment option in the patients consultation with the clinician Travel time to Radiotherapy Treatment Centre is a deterring factor for the patient Potential Issues Access Levels

Lack of General appreciation of Radiotherapy in STH Anonymous eSurvey of STH Consultants n= approx 600 As of 10/6/11 78 responses 70% involved in Cancer care Excluding those who felt they didn’t need to over half did not feel they knew enough about radiotherapy to discuss the treatment with patients Over half thought an update/departmental visit would be useful Potential Issues Access Levels

Audit commenced to establish which MDTs are lacking sufficient Clinical Oncology input – qualified observers will then be focused on those MDTs NSSGs to review and, where necessary revise, protocols regarding re-discussion at the MDT after initial treatment with either surgery or chemotherapy – audit against those guidelines to ensure protocols are followed Encourage referral to Clinical Oncology for borderline / unenthusiastic patients – NSSGs to review referral protocols Survey patients treated in the peripheral units re travel times Next Steps Access Levels

All patients should receive their treatment promptly Cancer Waiting Time targets (62 day and 31 day subsequent treatments) should be achieved for all patients We continue to aspire to meet the RCR targets of 14 days for palliative treatment and 28 days for radical treatment

Lack of available operational Linac hours (based on current staff establishment within Radiotherapy) – one machine currently not fully staffed Increasing demand affects waiting times Late referral to a Clinical Oncologist due to sub optimal patient pathways Potential Issues Waiting Times

Work ongoing to devise a methodology which calculates available capacity within Radiotherapy at a point in time Waiting times monitoring information updated regularly Focused work on tightening referral pathways – review current patient pathways and set aspirational targets for significant points Next Steps Waiting Times

All patients should receive state of the art treatment if appropriate We are currently not in a position to provide technologically advanced forms of Radiotherapy where previously we’ve led the field in many areas of development

Under provision of Image Guided Radio Radiotherapy (IGRT) Under provision of Intensive Modulated Radiotherapy (IMRT) No provision of Stereotactic Body Radiotherapy (SBRT) Under provision of In Vivo Dosimetry Linacs do not have the required technological capability Potential Issues Technologies

IGRT development plan - prioritise tumour sites for extension of IGRT, including new technologies as they become available, e.g. on set kV imaging and seed implants IMRT development plan - determine groups of patients / tumour groups who could benefit most from IMRT SBRT development plan – business case in progress for lung cancer In Vivo Dosimetry development plans – identify groups of patients / tumour groups who could benefit most Linac replacement programme underway with commitment made to support two LA replacements - further discussion required re other imminent replacements Next Steps Technologies

Technologies – Resource implications 1 IMRT Currently around 17% of our radical fractions delivered via IMRT UK centres aiming for 33% - N Trent we estimate over 40% because of case mix Recently surveyed Oncologist opinion at WPH - aim for 54% Increase to1090 IMRT plans per year from 361 would require - Successful restructuring of Radiotherapy Physics and full recruitment to plan - A few more Physicists and Dosimetrists - Takes no account of the expected 3% increase in workload generally

Technologies – Resource implications 2 SBRT - Particularly resource-intensive especially linac time IGRT - Resource implications for both Radiography and Physics staff time - How many staff depends on clinical demand for IGRT – not yet evaluated In vivo dosimetry - Can be absorbed thanks to innovative software developed in house

Patient Experience Holistic patient centred approach at all times Patient information room recently opened Patient Information and Paediatric Clinical Specialist Radiographer – no current funding Actively seek feedback and respond to it

How to Improve Cancer Survival Kings Fund June 2011 “It is more important to improve access to surgery and radiotherapy than access to cancer drugs In terms of overall allocation of resources, this suggests that the contribution of the Cancer Drugs Fund to improving overall outcomes will be very limited” “There is significant variation across England in the numbers of patients receiving surgery and radiotherapy, and in the use of the most up-to- date techniques” “As acknowledged by the government in 2007, continued investment is needed to increase England’s radiotherapy capacity”