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

2. 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..

3. 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

4. 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

5. 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)

6. VUmc Costs of Teletherapy (in €) T1T2T3T4 Personnel551175029985036 Materials105334572960 Total656208435705996 0.31.01.72.9

7. VUmc Costs of Brachytherapy (in €) B1B2B3B4 Personnel2264039253273 Materials5177176625 Total31748011013898 0.71.02.38.1

8. 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

9. VUmc Costs of T and B categories Teletherapy – T1: simple0.3100 30 – T2: standard1.0100 100 – T3: intensive1.7100 170 – T4: special2.3100 230 Total400 530 Relative costs TtotalT2eq Similar for Brachytherapy

10. VUmc Prognosis 2000 – 2010: Patients 1995200020052010 New cancer patients55300594006310069400 % irradiated (excl. Skin cancer)47484950 New irradiated patients26000285003090034700 Skin cancer and benign lesions (x 1,05)27300299003240036450 Repeat factor (1,30-1,35) Totaal Teletherapy treatments35500388004370049100

11. VUmc Prognosis 2000 – 2010: T-distribution 1995200020052010 Total Teletherapy treatments35500388004370049100 % T1 (simple)2422 % T2 (standard)57544844 % T3 (intensive)16202528 % T4 (special)3456 Total T2-equivalent35536412064876956760 40% 60%

12. VUmc Prognosis 2000 – 2010: B-distribution 1995200020052010 Total Brachytherapy treatments2675321534254180 % B1 (simple)352720 % B2 (standard)322829 % B3 (intensive)273945 % B4 (special)6666 Total B2-equivalent4473595466828155

13. VUmc Linacs and personnel 1995200020052010 T2-equivalent35536412064876956760 Linacs (500T2eq)718298115 Radiation oncologists (250 T2eq)142165195230 Physicists (650 T2eq)55637588 Technologists (55 T2eq)6407428781034 Excluding Brachytherapy For 250 B2eq. : 0.5-1.0 radiation oncologists 0.5physicist 0.5physics assistants 1.0-2.0technologists

14. VUmc Size of 21 centers 1 linac2 linacs3 linacs4 linacs5 linacs6 linacs>6 linacs 19982754111 Number of centers LinacsCentersLinacs/center 199867213.2

15. VUmc Size of 21 centers 1 linac2 linacs3 linacs4 linacs5 linacs6 linacs>6 linacs 19982754111 20030473223 Number of centers LinacsCentersLinacs/center 199867213.2 200388214.2

16. VUmc Size of 21 centers 1 linac2 linacs3 linacs4 linacs5 linacs6 linacs>6 linacs 19982754111 20030473223 20080216336 Number of centers LinacsCentersLinacs/center 199867213.2 200388214.2 2008113215.3

17. VUmc Teleytherapy 1996-2008

18. VUmc T-total and T-equivalent 20002002200420062008 T-total3780040200437004630249461 T2-equivalent4000045800555006633877036 T2-eq/T-total1,051,141,271,431.56 %T1242322 23 %T25349433223 %T31920 2527 %T448152228

19. VUmc Linacs 1996-2008

20. VUmc Radiation oncologists 1996-2008 fte Registered In training Needed based on T2-eq

21. VUmc Physicists 1996-2008 fte Registered In training Needed based on T2-eq

22. VUmc Technologists 1996-2008 fte Registered Needed based on T2-eq

23. VUmc 2005: Evaluation 20002005Change Linacs74101+ 36% - with MLC48%89% - with EPID59%95% Radiation oncologists142178+25% Physicists6578+20% Technologists703949+34%

24. VUmc 2005: Evaluation and new Prognosis New cancer incidence data (2004): 2015 + 43% 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

25. VUmc Prognosis 200520102015 New cancer patients785008700096500 Utilisation factor0.430.440.45 Repeatfactor1.30 Benign lesions factor1.03561.035 New radiotherapy patients454175150658428 Weight factors1.151.251.35 T2new-equivalent treatments522306438278878

26. VUmc Prognosis 200520102015 T2new-equivalent treatments522306438278878 Linacs129158 Radiation oncologists (+brachy)258 (+20)316 (+23) Physicists (+brachy)99 (+13)121 (+15) Technologists (+brachy)1171 (+39)1434 (+45)

27. VUmc Number of linacs

28. 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

29. 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

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

31. VUmc Satellites Satellite at least 2 linacs No treatment planning Mother institute at least 4 linacs Mother institute at least 10-12 ROs Same quality system At least 90% of treatments Personnel paid by mother institute

32. VUmc