Carrie Featherstone Consultant Clinical Oncologist Feb 2009

Radiotherapy Models for Radiotherapy Rates:  What the models are  Network data for models  Breast, lung, head and neck rates  Remodelling Prostate  Other Network Cancer Incidence Numbers Fractionation

Based on 2006 SCAN data : ORR N LUNG CANCER Average annual incidence Scotland 4588 Small cell 0.14* Limited stage 0.33* Good PFS 0.57º Radiotherapy to chest and PCI 121 Poor PFS 0.43ºNo radiotherapy 91 Extensive stage 0.66* Good PFS 0.43º Focal symptoms rrequiring RT 0.81 Palliative radiotherapy & PCI 150 No focal symptoms 0.19No radiotherapy 35 Poor PFS 0.57ºNo radiotherapy 245 Not small cell 0.86* Stage 1-II 0.22* Good PFSº 0.77 Surgery Involved margins Post-operative Radiotherapy 9 Clear margins 0.983No radiotherapy 446 No surgery 0.323Radical radiotherapy216 Poor PFSº 0.23 Local symptoms 0.644Palliative radiotherapy127 No local symptoms 0.364No radiotherapy 72 Stage IIIA 0.11* Good PFS 0.47º Surgery N0/ No radiotherapy 30 N>1 or positive margins Post operative radiotherapy 15 No surgery 0.783Radical radiotherapy159 Poor PFS 0.53º Local symptoms 0.644Palliative radiotherapy147 No local symptoms 0.364No radiotherapy 83 Stage IIIB 0.13* Good PFS 0.47ºRadical radiotherapy241 Poor PFS 0.53º Local symptoms 0.64Palliative radiotherapy174 No local symptoms 0.36No radiotherapy 98 Stage IV 0.54* Focal Symptoms requiring Radiotherapy 0.76 Likely to requirePalliative radiotherapy ( No focal symptoms 0.24No radiotherapy

Breast staging across Scotland SCAN (Lothian n=709) 2006 cases by stage (%) NOSCAN (Grampian n=424) 2007 cases by stage (%) WOSCAN 2006 cases by stage (%)* DCIS 13 8 T1-2 N0 M T1-2N1 N T3-4NxM0 or TxN2- 3M TxNxM1 336 Different methods of data collection by networks: not specific for these models

Breast Model based on Lothian data BREAST CANCER Lothian Model Average annual Incidence Scotland 4207 DCIS (0.13) 547 Mastectomy (0.26) 142No radiotherapy 142 WLE (0.74) 405Radiotherapy 405 T1-2 N0 (0.53) 2230 Mastectomy (0.17) 379No radiotherapy 379 WLE (0.83) 1851Radiotherapy 1851 T1-2 N1 (0.22) 925 Mastectomy (0.42) 388 >/ = 4 nodes (0.43) 166 Radiotherapy nodes (0.57) 222No radiotherapy 222 WLE (0.58) 537Radiotherapy 537 T3-4 N0-1, T1-2 N2-3 (0.09) 379 Good PFS (0.91) 345Radiotherapy 345 Poor PFS (0.09) 34No radiotherapy 34 TxNM1 (0.03) 126 Focal symptoms (0.4) 50 Palliative radiotherapy 50 No focal symptoms (0.6) 76No radiotherapy 76 Total patients receiving XRT = 3354 = 80% PTS NEED RT Actual XRT utilisation in SCAN 2006 = 69% (low grade DCIS +WLE not currently treated)

Breast Model based on Grampian data Total patients receiving XRT = 2632 = 63% ORR. Actual XRT utilisation Grampian 2007= 57% BREAST CANCER Grampian Model Average annual Incidence Scotland 4207 DCIS (0.13) 547 Mastectomy (0.36) 197No radiotherapy WLE (0.64) 350Radiotherapy 350 T1-2 N0 (0.52) 2188 Mastectomy (0.37) 810No radiotherapy WLE (0.63) 1378Radiotherapy 1378 T1-2 N1 (0.27) 1136 Mastectomy (0.73) 829 >/ = 4 nodes (0.43) 356 Radiotherapy nodes (0.57) 473No radiotherapy WLE (0.27) 307Radiotherapy 307 T3-4 N0-1, T1-2 N2-3 (0.05) 210 Good PFS (0.91 existing data) 191Radiotherapy 191 Poor PFS (0.09 existing data) 19No radiotherapy TxNM1 (0.03) 126 Focal symptoms (0.4 existing data) 50 Palliative radiotherapy 50 No focal symptoms (0.6 existing data) 76No radiotherapy

Prostate cancer 2497 cases per annum Low risk (T1-2a N0 M0 Gleason <7 PSA <20) Watchful waiting No radiother apy 475 Radical radiotherapy Radical radiother apy 102 Brachytherapy/Surgery No radiother apy 272 intermediate risk (PSA or Gleason 7 or T2b-2c Radical radiotherapy Radical radiother apy 199 Hormonal therapy/Watchful waiting No radiother apy 275 Surgery No radiother apy 150 high risk (PSA >20, or Gleason >7, or T3-T Hormones No radiother apy 325 Radiotherapy Radiother apy 325 Stage IV, bone metastases Focal bone symptoms hormone therapy and palliative radiotherapy Radiother apy 64 No focal symptoms Hormone therapy only No radiother apy 311 New Prostate model

Optimal v Actual Radiotherapy Rates Breast  Grampian 63% v 57%  SCAN 79% v 69% Lung  SCAN 64.2(50%) v 40 Head and Neck 83%v70% Prostate 61 (28%) Other where queries in optimal rates due to British practice Oesophagus 10% Stomach 5% Pancreas 5% Melanoma 5%

Numbers original model Original numbers PA Numbers new model Predicted numbers in % increase Fract ionat ion 2004 Fractions required in 2004 Min Max Fractiona tion in 2015 Fractions required 2015 Min Max (Old model T1-2N0, postop ) 90n/a Low risk (T1-2a N0 M0 Gleason <7 PSA <20) radical radiotherapy (Old model T1-2N0, good PS radical) intermediate risk (PSA or Gleason 7 or T2b-2c radical radiotherapy n/a high risk (PSA >20, or Gleason >7, or T3-T4 (old model T3-4 N0, good PS, radical RT) Palliative radiotherapy to metastases TOTAL 1235 (61.4%) Old model

CANCER NOSCAN Annual Incidence SCAN Annual Incidence WOSCAN Annual Incidence Subtotal Annual Incidence Bladder all Brain, Meninges, CNS Breast Breast Ca In situ Cervix Colon Rectum Corpus Uteri Head and Neck Kidney Leukaemia Lung Hodgkin’s Non-Hodgkin’s Melanoma Oesophagus Ovary Pancreas Prostate Stomach Testis Other TOTAL6746 (25.2%)7357 (27.5%)12688 (47.3%) (100%)

Ayrs hire and Arran Bord ers Dumf ries and Gallo way Lothi an Fife Taysi de Forth Valle y Lana rkshir e Gra mpia n Orkn ey + Shetl and West ern Isles Glas gow and Clyd e Highl and and Argyl l SCO TLA ND Bladder all Brain, Meninges, CNS Breast Breast Ca In situ Cervix Colorectal Colon Rectum Corpus Uteri Head and Neck Kidney Leukaemia Lung Lymphoma Hodgkin’s Non- Hodgkin’s Melanoma Oesophagus Ovary Pancreas Prostate Stomach Testis Oth er Total without other

CANCERRadical Fractionation 2004Radical Fractionation in 2008 Radical Fractionation predicted for 2015 Bladder, all Brain, Meninges, CNS Breast Cervix Colorectal Colon Rectum Corpus uteri Head and neck KidneyN/A Leukaemia? Lung Lymphoma Hodgkins Non-Hodgkin's Melanoma2025 Oesophagus20-25 Other and Unspecified OvaryN/A Pancreas25 Prostate Stomach25 Testis

NRAG Model & Assumptions: Summary Table Appropriate Radiotherapy Rates % (ARR) Fractions Per Patient (# Per Pt) Tumour SiteMinBaseMaxMinBaseMax Bladder Brain, meningies and CNS Breast inc. DCIS Cervix uteri Colon Corpus uteri Head and Neck Hodgkin lymphoma Kidney Leukaemia Lung Melanoma of skin Multiple myeloma Non-Hodgkin lymphoma Oesophagus Ovary Pancreas Prostate Rectum Stomach Testis Other and Unspecified Retreatment Fractions (%)13.1%

CANCER AV NUMB ER CASES PA ORR % NO REQUIRIN G RT BASED ON AV NUMBER OF FRACTIO NS PER COURSE IN MODELS 1 TOTAL FRACTIONS BASED ON NUMBERS PREDI CTED CHAN GE % PREDI CTED NUMB ER CASES NUMB ER NEED ING RT FRACTION S Bladder, all Brain, Meninges, CNS (61)95 (71) (1175) (74) Breast (63- 79) 825( ) (12, ,827) Cervix Colorectal Colon Rectum (28)288 (91)72016 (637) (112) Corpus uteri Head and neck (80- 83) 197 ( ) ( ) Kidney Leukaemia Lung (50-64) 740( ) ( ) Lymphoma0 Hodgkins Non-Hodgkin's Melanoma (5)37 (12)24888 (288) (17)1296 (408) Oesophagus (10)118 (22) (506) (27)3358 (621) Other and Unspecified Ovary Pancreas (5)68 (8) (184) (230) Prostate 79261(28)483 (222) (5328) (328) Stomach (5)27 (11)25675 (275) (10)625 (250) Testis TOTAL PATIENTS 7357 (27.5%) 3575 ( ) (37-51%)

SCANWOSCANNOSCAN SCOTLAND TOTAL CASES PA ,736 NUMBER NEEDING INTIAL RT ,709-16,212 PREDICTED FRACTIONS FOR INITIAL RT , ,688 NUMBER RETREATMENTS (25%) TOTAL COURSES REQUIRED ,635-20,265 FRACTIONS FOR RETREATMENT (6%) ,426-18,461 TOTAL FRACTIONS REQUIRED , ,998237, ,149 COURSESPER 1000 CASES NUMBER # PER 1000 CASES , , ,276 SERVICE CAPACITY REQUIRED (+10%) #71,126-99, ,998263, ,388 The number of radiotherapy courses per 1,000 cancers is a good indicator of access to radiotherapy. The range varied from 308 to 823 with an average of 562 radiotherapy courses per 1,000 cancers. Future Needs

AberdeenDundee EdinburghGlasgow Inverness Number of LinAcs (+1 back up) Av total LinAc hours per day Fractions booked per hour Number of public holidays28622 Av number of treatment days lost to servicing per LinAc Av number days worked per machine PA TOTAL POTENTIAL FRACTIONS PA 7 27,86426,56552,500104,40315,561 Total patients treated Total fractions treated ,48215,51251,850105,00011,296 NRAG Max ?8 9.2 hours hours Ave 19days days >8000 per machine Total193,844# (175,954# in 2003)

Other Methods Machines/Fractions per million 18% increase in cacncer incidence in 10 years No of fraction increase 2003 to 2008

Machine requirement Linac Output: Fractions per hour Hours per day Days per week Days per year (servicing etc) Size of dept QA/research Service efficiency per Linac