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RADIATION ONCOLOGY

GROOTE SCHUUR HOSPITAL & UNIVERSITY OF CAPE TOWN

AUDIT OF ACTIVITIES 2011

SUMMARY

2010 2011

New Patients 2989 2879*

Follow up visits 34636 39879

Patient Chemotherapy Administrations 7477 7897

New Patients treated with external beam irradiation 1338 1478

Patient attendees for irradiation 18002 18538

Number of radiation fields 53206 54184

Patients planned for irradiation 2003 2044

Total Procedures in planning 33885 32361

Radio-active implants – largely for the eye 65 65

Gynaecological sealed radio-active procedures 422 419

Radio active iodine administrations for cancer 44 32

Scientific Publications 3 6

Conference Presentations 18 22

*Patients with thyrotoxicosis are now treated through Nuclear Medicine and hence a modest decrease in overall number after an overall increase in previous years.

CONTENTS

A. VISION STATMENTS B. KEY EVENTS C. CLINICAL SERVICES D. STAFF E. TRAINING F. ACADEMIC ACTIVITIES G. PROFESSIONAL ORGANIZATIONAL ACTIVITIES H. STRATEGIC PLAN FOR 2012

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A. VISION STATEMENTS

To Care

Clinical Excellence

To serve patients with cancer

Academic Activities

To grow through training, and research

Relationships

To flourish as a community

Environment

To uplift us all

- - -

Our Path to Care

Positive Assumption

About all people and what we can jointly achieve.

Accomplishments

Which reflect our aims and professionalism

Teamwork

That is built on openness, responsiveness and fidelity.

Higher Values

Which come from a sense of purpose and our common humanity

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B. KEY EVENTS

1. Clinical Service

Radiation Oncology maintains an Oncology service to cancer patients in the Western Cape. The service is organized around 23 multidisciplinary clinics. The Department provided support for patients from the George region; a Public Private Imitative was successfully introduced so that state patients in the George region could receive their treatment in George. Activities are reviewed by teleconference every 3 months.

The Departmental protocols (approximately 60), teaching programmes and educational resources have been placed on-line on the UCT intranet.

An Electronic Patient Registry (EPR) has been established with the assistance of Medical Physics. This currently has 60 000 records.

A Continuing Care Ward Round was instituted. This is attended by a Medical officer and Allied Health Professionals as well as representatives from St Lukes Hospice and Rad Onc Registrars. The aim is to plan for patient rehabilitation and to plan their discharge into their community and workplace. It is also a platform for teaching of 5th year Medical Students.

2. Academic Activities

The revised SA College of Radiation Oncology syllabus has been successfully implemented. It is now a unified national exam. This places emphasis on the candidates demonstrating their practical abilities through formalised case reports and clinical audits.

There have been 4 Commentaries – analogous to mini-theses - submitted to the College by Registrars – see below.

.An emphasis was placed on assessing the practical competence of Registrars at the national exams hosted by the Department through the extensive use of OSCE‟s. This is a new development in the Rad Onc examination process.

Dr. Peri Mabandazayo won the prize for the best presentation by a Registrar at the National Meeting of the SA Society of Clinical and Radiation Oncology. The topic of her presentation was: “A 10-Year Retrospective Audit of Patients with Pituitary Adenomas Presenting to the Combined Pituitary Clinic at Groote Schuur Hospital”. The prize is attendance at an International Conference.

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3. Relationships

A Strategic planning meeting was held in October 2011 with an outside facilitator. The Strategic Plan for 2012 was determined as described in this document.

An empowerment event for our patients, their caregivers and staff was hosted at Groote Schuur Hospital. A multi-disciplinary team led by the Social Workers initiated and planned this outstanding event. The primary focus was to inform persons living with cancer of the resources available to them in the community, thereby ensuring that they make informed decisions about their care. The event was oversubscribed.

The support group for persons living with cancer meets twice a week. Many of the patients report on how the group has successfully instilled hope in them and also helped them to deal with news of poor prognosis. Relationships have been established with CANSA and People Living with Cancer (PLWC).

4. Environment & Facilities

The acquisition of a new linear accelerator in 2012 is planned and a budget is allocated. The upgrading of the Department included: the creation of a Family and Patient recreation room in G8. Further upgrading in the Ward will take place in the form of a combined seminar and rehabilitation room. A liaison room for coordination of radiation treatment is planned for 2012.

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C. CLINICAL SERVICES

1) Weekly Multidisciplinary Combined Oncology Clinics

Clinics

Clinic includes Radiation Oncology + other departments as in list below

2010 2011

New Patients 2989 2879*

Other Clinic Visits 34638 39879

Sarcoma Orthopaedics, General Surgery 57 72

Melanoma Plastic Surgery 20 30

Lymphoma Haematology, Radiology, Pathology, Haematopathology, Nuclear Medicine

146 154

ENT ENT Surgery, Radiology, Speech Therapy, Dietetics

95 102

Head and Neck ENT Surgery, Plastic Surgery, Oral & Dental Surgery, Radiology, Dietetics

142 136

Ocular Tumour Ophthalmology, Medical Physics 58 51

Skin Plastic Surgery, Dermatology 115 130

Kaposi Sarcoma - 115 128

Miscellaneous LE32 - 93 83

Breast Clinic Surgery, Plastic Surgery, Pathology, Radiology

460 464

Gynae Gynaecological oncology & Pathology 344 287

Neuro Neurosurgery, Neuro-radiology, pathology, Neurology

70 76

Pituitary Neurosurgery, Endocrine 12 15

Paediatric neuron-oncology

Paediatric oncology, paediatric endocrine, paediatric neurosurgery

26 24

Paediatric oncology Coordinated at Red Cross Hospital N/A N/A

Miscellaneous LE33 - 65 50

Bronchus Respiratory Medicine, Radiology, Thoracic Surgery

303 295

Urology Urology, Radiology, Private Sector 200 206

Thyroid General Surgery, Nuclear medicine, Endocrinology, pathology

23 21

Thyrotoxicosis - 84 *

Oesophagus Thoracic surgery, dietician 141 135

GIT Surgery, Radiology 211 213

Unknown Primary - 165 170

Miscellaneous LE34 - 44 37

These figures are from Clinicom. N/A = these patients are registered under Misc for Admin logistical reasons *Patients with thyrotoxicosis are now treated through Nuclear Medicine and hence a modest decrease in number after an increase in previous years.

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2) Outpatient Clinics Attendances - E Floor (2011 numbers are in bold font

and 2010 numbers are in parentheses)

New

Patients Follow up visits Radiotherapy

Treatment checks

LE 32

979 (935)

9089 (8592)

933 (867)

LE 33

823 (883)

16069(14076)

1957 (1838)

LE 34

1077(1171)

11368 (8568)

463(695)

Total

2879(2989)

36526(31236)

3353 (3400)

3) Ward Statistics ((2011 numbers are in bold font and 2010 numbers are in parentheses) Total beds = 41

WARD G7 WARD G8

No of pt. 6481 (7140) 5946 (6383)

Admissions 998 (1057)

873 ( 922)

Discharges 921 (952)

758 (825)

Bed Occupancy* 86% (85.3%)

80% (79.4%)

* This includes as vacancy the weekends. The weekday occupancy rate will be higher.

4) Radiotherapy Planning

2010 2011 Total Patients 2098 2023 New Patients 1338 1524 Repeat Patients 665 466 Planning CT scans Diagnostic CT

449 16

446 90

Simulated Patients 1699 1683 No. Field Simulations 2897 2927 Total Procedures* 33885 32361 * Includes other procedures e.g. computer plans, compensators .

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5) External Beam Radiotherapy Administration

Machine New/Subsequent

Patients

2011

(2010)

Attendances

2011

(2010)

Fields

2011

(2010)

Linac.2

331 (295)

5399 (5128)

15728 (16376)

Linac.3

417 (386)

8355 7307)

28341 (24823)

Theratron 2 -See comment

11 (125)

45 (679)

83 (1340)

Theratron 3

702 (671)

4601 (4814)

9735 (10426)

Med.

Voltage

17 (13)

138 (74)

297 (241)

TOTAL

1478 (1490)

18538 (18002)

54184 (53206)

Comment:

i. Theratron 2 was not utilized from February 2011 as the available staff

were deployed on the other units.

ii. Linac 2 had multiple breakdowns in the course of the year –In

December 2011, a major treatment energy with which the majority

of patients are treated was not able to be used. These patients had

to be replanned for the Linac 3 unit.

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6) Radioactive Implants

I-125 Seeds

Eye plaques (I-125)

2010 2011

32 35

I-125 Claws / eye applicator 11 11 Sr-90 applicator: Beta Plaque

2010 2011

I-125 Orbits implant 9 7 Patients 13 15

Other / oral cavity implants 9 9 Insertions 42 48

Other 4 3

TOTAL all implants 65 65

7) Intracavitary Administrations

GYNAE CT/ RECORDS C9 Procedure (2010) 2011 Number of patients treated = (122) 126 Tandem/Ovoid/Ring Combinations = (376) 384 Vaginal cylinders = (46) 35 _______ Total number of procedures = (422) 419

8) Internal Administrations

2010 2011

Radioactive Iodine administration for cancers 44 32

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9) Sample Registry Data

Patients

% of total

Breast 519 18%

Bronchus 318 11%

Gyn. 316 11%

GIT 280 10%

Uro. 224 8%

Lymphoma 154 5%

H&N 151 5%

Skin 140 5%

Oesoph. 139 5%

Kaposi 133 5%

UnkP 119 4%

ENT 108 4%

Sarcoma 82 3%

Eye 75 3%

Neuro. 66 2%

Paeds. 38 1%

Melanoma 28 1%

Thyroid 23 1%

Pit. 16 1%

Haematology 8 0%

Total 2937 100% Rad Onc 2011 The Patients seen in each Clinic – sorted from the largest to smallest clinics. Figures are based on the internal EPR – there will be modest variations from the actual figures..

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Clinic Patients Female Male

Black Coloured White Ave age

yrs

Breast 519 98% 2%

23% 65% 12% 57

Bronchus 318 32% 68%

22% 68% 10% 60

ENT 108 21% 79%

23% 62% 14% 59

Eye 75 47% 53%

51% 9% 39% 38

GIT 280 51% 49%

18% 63% 19% 60

Gyn. 316 100% 0%

36% 54% 9% 54

H&N 151 33% 67%

19% 63% 18% 59

Haematology 7 57% 43%

57% 29% 0% 56

Kaposi 133 44% 56%

91% 8% 0% 38

Lymphoma 154 47% 53%

38% 49% 14% 49

Melanoma 28 36% 64%

18% 21% 61% 60

Neuro. 66 47% 53%

18% 55% 24% 50

Oesoph. 139 42% 58%

50% 42% 8% 62

Paeds. 38 42% 58%

47% 29% 11% 6

Pit. 16 56% 44%

25% 63% 13% 44

Sarcoma 82 48% 52%

34% 44% 18% 49

Skin 140 36% 64%

8% 19% 73% 67

Thyroid 23 87% 13%

26% 65% 9% 51

Unk Prim 119 46% 54%

19% 70% 11% 58

Uro. 224 8% 92%

15% 67% 18% 63

Grand Total 2941 55% 45%

29% 54% 17% 56 The Patients numbers in each Clinic. The gender and race is the percentage for each clinic. Figures are based on internal EPR – there will be modest variations from the actual figures.

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D. STAFF Medical Staff (at year end)

Professor and Head of Department: RP Abratt

Head of Clinical Unit – Dr J Parkes

Internal Head of Clinical Services – Dr L Van Wijk

Specialists and Head of Clinics: Drs Z Mohamed, B. Robertson, J. Wetter and S.

Dalvie

Contract Specialist: Dr I Parker

Principal Medical Officer: Dr L Shepherd

Medical officer: Dr. H Lustig

Registrars: 9

Supernumerary Registrars: 8

A number of doctors have been appointed to assist with teaching through clinics. Radiobiologists Dr A Hunter and Dr A Hendrikse Radiation Therapists 32½ Full Time Equivalents - i.e. including 1 x 6/8, 2 on contract and 4 Community Service. Nursing Staff For the Wards and Out Patients: 22 Sisters and 33 Nurses. Total = 55 Social Workers For the Wards and Out Patients: Total = 4 Pharmacists In Outpatients = 2 Research Nurses and Study Personnel Total = 6, mainly on a part time basis. Administrative Staff Chief Clerk : 1 Sen Admin: 16 Registry Clerks: 1

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E. TRAINING

Departmental Program

Day

Time

Activity

Venue

Convenor

Monday

1:15 pm 4.00 pm

Techniques & Protocols Any Additional Lectures, ad hoc

D35 Lecture Theatre

Dr S. Dalvie As arranged

Tuesday

4:30 pm

Clinical Tutorials

Dr J Wetter

Wed.

4:00 – 6:00 pm

Physics & Statistics

Med Physics Seminar room

Jan Hough

Thursday Last 2 wks of month

1:15 pm

Journal Club Bun Club

D35 Lecture Theatre

Dr B. Robertson

Other 1. Radiobiology Lectures arranged at time which is mutually suitable – usually Thursday 4.00 pm Lecturers are Dr. Hunter and Dr. Hendrikse

Other 2. 5th year Medical Students: Tutorials: Thursday and Friday from noon to 1.00

pm

Other 3 Firm based Activities include review of logbooks & tutorials e.g. RT planning. These are arranged within each firm.

A logbook of procedures is maintained by all Registrars and reviewed by their supervising Specialists. Graduation as specialists = 4: Dr Nel, Dr. Naicker, : Dr. de Freitas, dr. Naidoo

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F: ACADEMIC ACTIVITIES

Publications 2011

1. Relevance of breast cancer hormone receptors and other factors to the efficacy of adjuvant tamoxifen: patient-level meta-analysis of randomized trials Early Breast Cancer Trialists‟ Collaborative Group (EBCTCG), including Dr E Murray Lancet 378:771-84; 2011

2. Iodine-125 Orbital Brachytherapy with a Prosthetic Implant in Situ Clare Stannard, Gert Maree, Roger Munro, Karin Lecuona, Wolfgang Sauerwein Strahlenther Onkol 187:322-7; 2011;

3. Long-term results of International Breast Cancer Study Group trial VIII: adjuvant chemotherapy plus Goserelin compared with either therapy alone for premenopausal patients with node-negative breast cancer P.Karlsson, Z. Sun, D Braun, K.N. Price, M. Castiglione-Gertsch, M. Rabaglio, R D Gelber, D Crivellari, J Collins, E Murray, K Zaman, M. Colleoni, B.A. Gusterson, G Viale, M.M. Regan, A.S. Coates, A. Goldhirsch Annals of Oncology 22:2216-2226,2011

4. The role of frozen section in the management of early endometrioid endometrial carcinoma Richardson KJ, Whittaker J, Van Wijk R, Dehaeck K South Afr J Gynaecol 2011;3(1):28-33

5. The Fast Neutron Therapy Program For Patients In South Africa Should

Come to an End.- Letter to the Editor:

RP Abratt

SAMJ – in press

6. Gestational Trophoblastic Neoplasia and Human Immunodeficiency Virus Infection: A 10-Year Review Tayib S, van Wijk L, Denny L .Int J Gynecol Cancer. 2011 Dec;21(9):1684-1691.

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Commentaries Submitted to College of Radiation Oncology.

1. A Retrospective Study Of Patients With Stage Ib2 Cervical Cancer Treated At Groote Schuur Hospital 1997-2008 Kellie Alleyne-Mike

2. The Treatment Of Patients With Metastatic Renal Cell Carcinoma With

Sunitinib – The Groote Schuur Hospital Experience Moawia Mohammed Ali Elhasan

3. The Types And Treatment Outcomes Of Germ Cell Tumours Of The Ovary

Seen At Groote Schuur Hospital, Cape Town, Between 1994-2008 - A Retrospective Survey

Khadiga Elfadil Ahmed Mohammed

4. A Retrospective Review Of Stage 3 Non-Seminomatous Germ Cell Tumours Managed At Groote Schuur Hospital Between 1998 And 2009 Sumayah Ibrahim

REPORTS:

1. Hunter A, Baeyens A, Hendrikse A. NTeMBI Development of Scarce Skills: Report of the

South African Radiobiology Society.

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PRESENTATIONS:

1. Radiogenic cancer: Are we placing our patients at risk?

Hunter A. 15th GI Specialist Symposium. Cape Town, 26-27 March 2011.

2. National Plan to reinvigorate Radiobiology in South Africa:

Hunter A. Report of the South African Radiobiology Society.

3. Radiobiology Research at the University of Cape Town & Groote Schuur

Hospital.

Hunter A. Project presentations by academic coordinators.

Flemish Interuniversity Council (VLIR) – University development cooperation

(UOS) – Own initiatives (OI) programme meeting on capacity building,

education and training in health-related radiation biology through a North-

South cooperation. IThemba LABS, Faure, 19 August 2011.

4. Radiobiology for Dummys

A Hunter. Exam Revision Workshop. August 2011.

5. Ethics in the Wild -Questions & Answers

RP Abratt: a. Wits Multi-disciplinary Oncology Symposium, Johannesburg 2011

b. SASCRO-SASMO 15th National Oncology Conference, Sun City, 2011

6. Case Discussions – osteoporosis, pemetrexed skin toxicity & second

malignancies

RP Abratt: World Conference on Lung Cancer 14th Meeting, Amsterdam,

2011

7. Chemo-irradiation in Adenocarcinoma of the Rectum.

B Robertson Surgical Update Conference, University of Cape Town March

2011

8. Gastrointestinal Stromal Tumours. B Robertson: Seminar, Department of Human Genetics, University of Cape Town, August 2011

9. Gastrointestinal Stromal Tumours at Groote Schuur B Robertson: Hospital. SASCRO/SASMO conference August 2011

10. B Robertson: Treatment of Adenocarcinoma of the Rectum at Groote Schuur Hospital. IAEA trial meeting, Vienna November 2011

11. Linac radiosurgery in South Africa. J Parkes - World society of stereotactic and functional neurosurgery 2011: Cape Town, November 2011.

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IAEA teaching course:

12. Palliative radiotherapy in children

13. Overview of paediatric radiotherapy management

14. Management of Wilm's tumour

15. Management of Medulloblastoma

16. J Parkes - Tunisia, September 2011

17. Eight years of experience with stereotactic radiosurgery at a single institution.

J Parkes - SASCRO 2011:

18. A 30 year audit of patients diagnosed with ependymoma at Groote Schuur

and Red Cross children's hospitals.

J Parkes, , A Davidson, G Fieggen,: SASCRO 2011

19. A 10 Year Retrospective Audit Of Patients With Pituitary Adenomas Presenting To The Combined Pituitary Clinic At Groote Schuur Hospital. P Mbandazayo,. J Parkes, , P Semple,, N Levitt,. SASCRO 2011

20. A radiosurgery-induced cavernoma adjacent to a treated arterio-venous malformation. D Le Feuvre, J Parkes, , A Taylor,. SASCRO 2011

21. An introduction to paediatric radiotherapy. J Parkes - East London outreach: June 2011

22. Palliative radiotherapy in children. J Parkes - Paediatric refresher course: Red Cross Children's Hospital, February 2011. "

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G. PROFESSIONAL ORGANIZATIONAL ACTIVITIES International Professional Organizations American Society of Clinical Oncology RP Abratt - Member of Educational Committee on „Multidisciplinary Cancer Management in Developing Countries‟ Lancet Oncology RP Abratt – member of the International Advisory Committee Editorial Board of Radiotherapy and Oncology RP Abratt Editor J Clinical Oncology South Africa. (International appointment) RP Abratt Oncology at the Limits , 2nd Meeting. Stockholm 2011 RP Abratt – Member of Scientific Committee

World Conference on Lung Cancer 14th Meeting, Amsterdam, 2011 – RP Abratt - Member of Scientific Committee African Regional Agreement L van Wijk: Project coordinator International Breast Cancer Study Group for Management of Common Cancers in Africa

South African Professional Organizations University of Cape Town A Hunter – member of the Faculty Research Committee A Hunter – Member of Faculty Research Ethics Committee South African Society of Clinical and Radiation Oncology RP Abratt – Member of the Executive Committee RP Abratt – Chairperson of the Heads of Department Committee of SASCRO College of Radiation Oncology of South Africa Member of Senate of Colleges of Medicine of South Africa RP Abratt President of the College of Radiation Oncology, RP Abratt Member of Council of the College of Radiation Oncology RP Abratt, J Parkes Society of Radiographers of S.A. Treasurer: A V Gordon Secretary.: S Waries R/T Rep.: A Havenga

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Combined Radiography Advisory Committee – W. Cape Member: E A Greeff South African Radiobiology Society (SARS) A Hunter - Chairman South African Association of Physicists in Medicine and Biology (SAAPMB) A Hunter – Council member

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H. GSH RADIATION ONCOLOGY – Strategic Plan for 2012.

Our Vision: To CARE

Our Metrics: This coming year, if we are successful we will: (Blue font = new)

Clinical Services Academic Act:

Teaching

Academic Act:

Research

Relationships Environment

1. Improve protocol availability & use

2. Improve overall efficiency of patient flow & patient care

3. Develop discharge program for ‘Right patient cared for at right level’

1. Develop use of case reports for post grads

2. Structure undergrad program & link with Continuous Care Round

3. Establish teaching courses

1. Develop Clinical audits with EPR

2. Improve quality of presentations

3. Increase publications

1. Improve staff communication on activities

2. Establish Patient Feedback process

3. Improve staff support as well as management capacity

1. Continue departmental upgrade

2. Procure new equipment & complete commissions of existing equipment

3. Establish better space allocation (research office & AHP area in OPD)

Our Projects: To achieve by Oct 2012

Clinical Services (LvW)

1. Protocols - RT and Clinical: Maintain updates on Vula– Spec (Clinic Heads) , RTT’s 2. RT New technologies –Coordinate with RTT & Med Phys JP, HB

3. RT efficiency: Activate recommendations– EG Extend hours of Linac 3 –AG.

4. Rehab & Programmed discharge: Develop structure in ward and extend to OPD HL

Establish referral patterns – LvW, HL 5. Palliative Beds: Access in community for pal. care – LvW

6. Ward admissions: Formulate policy – LvW & All 7. Waiting lists Develop database – IP & HOF’s

Academic Activities – Teaching (RA)

1. Undergrads: In-house Textbook & narrative revised and stored on Vula – ZM, JW, TN

Tutorials for 5th years coordinated – JW, TN Attend CCWR – JW, TN

2. Postgrads: Feedback on case reports & present at meetings – All Review Stats module – RA, JH & AH.

3. Radio & Cancer Biology Course: – Set up. AH

Academic Activities – Research (RA, AH)

1. Audits & EPR: Review data extraction & analysis– RA, LvW 2. Improved presentations: – Better feedback & review - RA, All Spec

3. Increase publications: Develop commentaries for publication - RA Support for publication by specialists – RA

Relationships (RA - ext, Head of firms - int)

1. Increase senior registrar responsibility: Develop structure – JP, LvW, BR, TN

2. Improve staff communication: informal get together – ZM, IP, BR Feedback on strategy at Dept. meetings - RA

3. Patient Feedback Process: To be established - ZM, IP & SG

4. Improve staff support: identify support structure for registrars- JP 5. Improve time management skills: Set up approach at a dedicated meeting - RA

Environment (JP)

1. Ward: Develop Seminar and Rehabilitation area – JP, DM

2. RT planning: Set up Liaison room and Rehab room (E floor) – JP, DM .

3. Space allocation: Review Research offices & Clinic / AHP space in OPD – JP, DM 4. Procure New Equipment: New Linac and have ready other equipment specs – JH, HB

6 Dec 2011