VUmc Radiotherapy planning and organization in The Netherlands Ben Slotman Professor and Chair, Radiation Oncology VU University medical center Amsterdam, The Netherlands

VUmc At the end of the ‘90s Waiting for new Government decision on capacity Long waiting times Suboptimal fractionation schemes Impossibility to implement new techniques No extra reimbursement for intensive therapy …etc……. …...etc….. ………etc..

VUmc Re-imbursement “Treatment series” ?! A complete treatment consisting of x fractions New series for extra electron fields, boost, or even every change in field sizes, etc. Sometimes 3 series for one treatment Insurance companies agreed (or not) No comparison between and within centers possible No parameter which incorporates relative workload

VUmc New reimbursement parameters Limited number of categories Should reflect workload Should be fool-proof Should be used for comparison of production between and within institutes Should be used for planning future needs for staffing and infrastructure

VUmc T and B categories Teletherapy – T1: simple, patient already known to the dept. – T2: standard – T3: intensive (CRT) – T4: special (SRT, IMRT) Brachytherapy – B1: simple (plaque) – B2: standard (breast) – B3: intensive (Fletcher) – B4: special (stereotactic, Prostate seeds)

VUmc Costs of Teletherapy (in €) T1T2T3T4 Personnel Materials Total

VUmc Costs of Brachytherapy (in €) B1B2B3B4 Personnel Materials Total

VUmc Costs of T and B categories Teletherapy – T1: simple0.3 – T2: standard1.0 – T3: intensive1.7 – T4: special2.3 Brachytherapy – B1: simple0.6 – B2: standard1.0 – B3: intensive2.3 – B4: special8.1 Relative costs

VUmc Costs of T and B categories Teletherapy – T1: simple – T2: standard – T3: intensive – T4: special Total Relative costs TtotalT2eq Similar for Brachytherapy

VUmc Prognosis 2000 – 2010: Patients New cancer patients % irradiated (excl. Skin cancer) New irradiated patients Skin cancer and benign lesions (x 1,05) Repeat factor (1,30-1,35) Totaal Teletherapy treatments

VUmc Prognosis 2000 – 2010: T-distribution Total Teletherapy treatments % T1 (simple)2422 % T2 (standard) % T3 (intensive) % T4 (special)3456 Total T2-equivalent % 60%

VUmc Prognosis 2000 – 2010: B-distribution Total Brachytherapy treatments % B1 (simple) % B2 (standard) % B3 (intensive) % B4 (special)6666 Total B2-equivalent

VUmc Linacs and personnel T2-equivalent Linacs (500T2eq) Radiation oncologists (250 T2eq) Physicists (650 T2eq) Technologists (55 T2eq) Excluding Brachytherapy For 250 B2eq. : radiation oncologists 0.5physicist 0.5physics assistants technologists

VUmc Size of 21 centers 1 linac2 linacs3 linacs4 linacs5 linacs6 linacs>6 linacs Number of centers LinacsCentersLinacs/center

VUmc Size of 21 centers 1 linac2 linacs3 linacs4 linacs5 linacs6 linacs>6 linacs Number of centers LinacsCentersLinacs/center

VUmc Size of 21 centers 1 linac2 linacs3 linacs4 linacs5 linacs6 linacs>6 linacs Number of centers LinacsCentersLinacs/center

VUmc Teleytherapy

VUmc T-total and T-equivalent T-total T2-equivalent T2-eq/T-total1,051,141,271, %T %T %T %T

VUmc Linacs

VUmc Radiation oncologists fte Registered In training Needed based on T2-eq

VUmc Physicists fte Registered In training Needed based on T2-eq

VUmc Technologists fte Registered Needed based on T2-eq

VUmc 2005: Evaluation Change Linacs % - with MLC48%89% - with EPID59%95% Radiation oncologists % Physicists % Technologists %

VUmc 2005: Evaluation and new Prognosis New cancer incidence data (2004): % increase compared to2005 T2equivalent overestimates the needs (inflation) More efficient delivery of complex treatments For future calculations complexity (T2eq/T) and efficiency-factor New T2eq = 0,86 x T2-equivalent No evidence for increase in number of retreatments 1,30 in stead of 1,35 Some underconsumption: Utilisation 43% in 2005, 44% in 2010 and 45% in 2015

VUmc Prognosis New cancer patients Utilisation factor Repeatfactor1.30 Benign lesions factor New radiotherapy patients Weight factors T2new-equivalent treatments

VUmc Prognosis T2new-equivalent treatments Linacs Radiation oncologists (+brachy)258 (+20)316 (+23) Physicists (+brachy)99 (+13)121 (+15) Technologists (+brachy)1171 (+39)1434 (+45)

VUmc Number of linacs

VUmc Newly defined activities PreparationTeletherapyBrachytherapy Conventional Simulation V1Single fractionU1No individual dosecalculation B1 CT simulationV2Long fractionU2Individual dose calculation B2 Simple TPV3Standard imagebased positioning U33d imaging, contouring & planning B3 Standard 3D TPV4Intensive imagebased positioning U4Stereotactic BTB4 Intensive TPV5Intensive treatmentU5Permanent implantation B5 Image fusionV6SRTU6 Functional imagingV7

VUmc Teletherapy: T0-T6 ActivityT0T1T2T3T4T5T6 V1Convent. Sim V2CT-sim V3Simple TP V4Standard 3D TP V5IMRT V6Imagefusion V7PET-scan V8MRI-scan U11 fraction U2long fraction U3Standard Positioning correction U4Intensive Positioning correction U5IMRT U6SRT

VUmc Satellites Hospital prestige Patient comfort/travel Multidisciplinary treatment Is there maximum center size?

VUmc Satellites Satellite at least 2 linacs No treatment planning Mother institute at least 4 linacs Mother institute at least ROs Same quality system At least 90% of treatments Personnel paid by mother institute

VUmc