Carrie Featherstone Consultant Clinical Oncologist Feb 2009.
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Transcript of Carrie Featherstone Consultant Clinical Oncologist Feb 2009.
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 NumbersFractionation
Based on 2006 SCAN data : ORR N
LUNG CANCERAverage annual incidence Scotland 4588
Small cell 0.14*
Limited stage 0.33*
Good PFS 0.57ºRadiotherapy to chest and PCI
121
Poor PFS 0.43º No radiotherapy 91
Extensive stage 0.66*
Good PFS0.43º
Focal symptoms rrequiring RT 0.81Palliative radiotherapy & PCI
150
No focal symptoms 0.19 No radiotherapy 35
Poor PFS 0.57º No radiotherapy 245
Not small cell 0.86*
Stage 1-II 0.22*
Good PFSº 0.77
Surgery 0.683
Involved margins 0.023 Post-operative Radiotherapy
9
Clear margins 0.983 No radiotherapy 446
No surgery 0.323 Radical radiotherapy 216
Poor PFSº0.23
Local symptoms 0.644 Palliative radiotherapy 127
No local symptoms 0.364 No radiotherapy 72
Stage IIIA 0.11*
Good PFS0.47º
Surgery 0.223
N0/1 0.673
No radiotherapy 30
N>1 or positive margins 0.683
Post operative radiotherapy
15
No surgery 0.783 Radical radiotherapy 159
Poor PFS0.53º
Local symptoms 0.644 Palliative radiotherapy 147
No local symptoms 0.364 No radiotherapy 83
Stage IIIB0.13*
Good PFS 0.47º Radical radiotherapy 241
Poor PFS0.53º
Local symptoms 0.64 Palliative radiotherapy 174
No local symptoms 0.36 No radiotherapy 98
Stage IV0.54*
Focal Symptoms requiring Radiotherapy 0.76
Likely to requirePalliative radiotherapy (0.49
826
No focal symptoms 0.24 No radiotherapy 511+794
Breast staging across Scotland
SCAN (Lothian
n=709) 2006cases by stage (%)
NOSCAN(Grampian
n=424) 2007cases by stage (%)
WOSCAN 2006
cases by stage (%)*
DCIS 13 13 8
T1-2 N0 M0 53 52 33
T1-2N1 N0 22 27 43
T3-4NxM0 or TxN2-3M0
9 5 10
TxNxM1 3 3 6
Different methods of data collection by networks: not specific for these models
Breast Model based on Lothian data
BREAST CANCERLothian Model
Average annual
Incidence2001-2005 Scotland
4207
DCIS (0.13) 547
Mastectomy (0.26) 142 No radiotherapy 142
WLE (0.74) 405 Radiotherapy 405
T1-2 N0 (0.53) 2230
Mastectomy (0.17) 379 No radiotherapy 379
WLE (0.83) 1851 Radiotherapy 1851
T1-2 N1 (0.22) 925
Mastectomy (0.42) 388
>/ = 4 nodes (0.43) 166
Radiotherapy 166
0-3 nodes (0.57) 222 No radiotherapy 222
WLE (0.58) 537 Radiotherapy 537
T3-4 N0-1, T1-2 N2-3 (0.09) 379
Good PFS (0.91) 345 Radiotherapy 345
Poor PFS (0.09) 34 No radiotherapy 34
TxNM1 (0.03) 126
Focal symptoms (0.4) 50Palliative radiotherapy 50
No focal symptoms (0.6) 76 No 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 CANCERGrampian
ModelAverage annual
Incidence2001-2005 Scotland
4207
DCIS (0.13) 547
Mastectomy (0.36) 197 No radiotherapy
WLE (0.64) 350 Radiotherapy 350
T1-2 N0 (0.52) 2188
Mastectomy (0.37) 810 No radiotherapy
WLE (0.63) 1378 Radiotherapy 1378
T1-2 N1 (0.27) 1136
Mastectomy (0.73) 829
>/ = 4 nodes (0.43) 356
Radiotherapy 356
0-3 nodes (0.57) 473 No radiotherapy
WLE (0.27) 307 Radiotherapy 307
T3-4 N0-1, T1-2 N2-3 (0.05) 210
Good PFS (0.91 existing data) 191 Radiotherapy 191
Poor PFS (0.09 existing data) 19 No radiotherapy
TxNM1 (0.03) 126
Focal symptoms (0.4 existing data) 50Palliative radiotherapy 50
No focal symptoms (0.6 existing data) 76 No radiotherapy
Prostate cancer 2497 cases per annum 2001-2005
Low risk (T1-2a N0 M0 Gleason <7 PSA <20) 0.34849 Watchful waiting 0.56 475
No radiotherapy 475
Radical radiotherapy 0.12 102Radical radiotherapy 102
Brachytherapy/Surgery 0.32 272No radiotherapy 272
intermediate risk (PSA 10-20 or Gleason 7 or T2b-2c0.25 624
Radical radiotherapy 0.32 199Radical radiotherapy 199
Hormonal therapy/Watchful waiting 0.44 275
No radiotherapy 275
Surgery 0.24 150No radiotherapy 150
high risk (PSA >20, or Gleason >7, or T3-T4 0.26650
Hormones 0.5 325No radiotherapy 325
Radiotherapy 0.5 325Radiotherapy 325
Stage IV, bone metastases 0.15374
Focal bone symptoms hormone therapy and palliative radiotherapy 0.17 64
Radiotherapy 64
No focal symptoms Hormone therapy only 0.83 311
No radiotherapy 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 model2001-5
Predicted numbers in
2015 48%
increase
Fractionati
on2004
Fractions required in
2004Min Max
Fractionation in 2015
Fractions required
2015Min Max
(Old model T1-2N0, postop ) 90 n/a 0 20-36 0 0 32-41448
0574
0
Low risk (T1-2a N0 M0 Gleason <7 PSA <20)
radical radiotherapy(Old model T1-2N0, good PS
radical)
429 102 151 20-36 2040 3672 32-41483
2619
1
intermediate risk (PSA 10-20 or Gleason 7 or T2b-2cradical radiotherapy
n/a 199 295 20-36 3980 7164 32-41944
012095
high risk (PSA >20, or Gleason >7, or T3-T4
(old model T3-4 N0, good PS, radical RT)
350 325 481 20-40 65001300
032-41
15392
19721
Palliative radiotherapy to metastases
664 64 95 1 64 64 1 95 95
TOTAL1235
(61.4%)690 1022
12584
23836
34144
43842
Old model30930-39426
CANCER
NOSCAN Annual
Incidence 2001-2005
SCAN Annual Incidence 2001-
2005
WOSCAN Annual
Incidence 2001-2005
Subtotal Annual
Incidence 2001-2005
Bladder all 166 209 400 775
Brain, Meninges , CNS 91 116 174 381
Breast 986 1081 1777 3844
Breast Ca In situ 110 98 155 363
Cervix 71 73 145 289
Colon 653 605 924 2182
Rectum 320 324 530 1174
Corpus Uteri 136 136 229 501
Head and Neck 239 252 526 1017
Kidney 175 164 286 625
Leukaemia 161 202 317 680
Lung 1012 1175 2401 4588
Hodgkin’s 33 39 63 135
Non-Hodgkin’s 234 256 384 874
Melanoma 208 232 381 821
Oesophagus 223 218 382 823
Ovary 177 269 274 720
Pancreas 160 163 288 611
Prostate 635 792 1070 2497
Stomach 208 209 437 854
Testis 58 55 96 209
Other 690 689 1449 2828
TOTAL 6746 (25.2%) 7357 (27.5%) 12688 (47.3%) 26791 (100%)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
NOSCAN SCAN WOSCAN
Other
Testis
Stomach
Prostate
Pancreas
Ovary
Oesophagus
Melanoma
Non-Hodgkin’s
Hodgkins
Lung
Leukaemia
Kidney
Head and Neck
Corpus Uteri
Rectum
Colon
Cervix
Breast Ca In situ
Breast
Brain, Meninges , CNS
Bladder all
Ayrshire and Arran
Borders
Dumfries and Galloway
Lothian
FifeTayside
Forth Valley
Lanarkshire
Grampian
Orkney + Shetland
Western Isles
Glasgow and Clyde
Highland and Argyll
SCOTLAND
Bladder all 68 18 28 107 57 60 40 107 67 7 2 185 30 777
Brain, Meninges , CNS 27 15 11 61 25 29 18 36 34 2 1 86 22 367
Breast 286 103 137 597 244 310 220 402 386 29 22 869 241 3847
Breast Ca In situ 24 11 11 53 23 33 17 37 46 6 3 77 22 362
Cervix 25 5 1 43 17 23 15 34 25 2 1 72 21 289
Colorectal
Colon 191 56 74 320 156 205 118 208 254 21 21 516 152 2295
Rectum 85 33 45 164 83 95 64 116 130 12 7 266 77 1175
Corpus Uteri 37 15 12 70 39 41 29 51 51 5 4 112 36 502
Head and Neck 77 18 36 142 57 70 53 102 85 10 7 295 67 1017
Kidney 49 17 20 84 43 52 38 57 72 7 5 143 40 625
Leukaemia
Lung 341 89 140 642 305 348 239 508 382 26 24 1314 232 4488
Lymphoma
Hodgkin’s 10 4 4 23 8 10 8 12 13 5 1 34 7 135
Non-Hodgkin’s 63 22 32 143 60 71 27 81 90 6 7 194 61 876
Melanoma
Oesophagus 64 18 32 118 50 73 36 81 78 7 7 202 59 823
Ovary 47 17 21 96 36 41 32 60 66 7 3 135 41 620
Pancreas 30 15 19 89 41 48 31 61 60 4 6 147 41 611
Prostate 213 66 78 434 161 177 174 188 241 23 17 496 179 2446
Stomach 70 20 21 105 64 63 55 93 89 5 5 220 48 856
Testis 15 4 5 33 13 16 12 25 24 3 1 45 15 209
Other
Total without other 1722 546 727 3324 1482 1765 1226 2259 2193 187 144 5408 1391 22320
CANCER Radical Fractionation 2004 Radical Fractionation in 2008Radical Fractionation
predicted for 2015
Bladder, all 20-25 20 25-30
Brain, Meninges, CNS 28-32 25-30 28-32
Breast 20-27 15-25 5-25
Cervix 20-25 25-28 25
Colorectal
Colon 20-25 25 20-25
Rectum 5-25 5-25 25
Corpus uteri 20-25 25 25
Head and neck 34 20-35 16-35
Kidney N/A N/A N/A
Leukaemia ?
Lung 20-36 20-36 25-39
Lymphoma
Hodgkins 15-20 15 15
Non-Hodgkin's 15-20 20 15-20
Melanoma 20 25 25
Oesophagus 20-25 20-25 20-25
Other and Unspecified
Ovary N/A N/A N/A
Pancreas 25 25 25
Prostate 20-41 20-40 32-41
Stomach 25 25 25
Testis 15 10 0-15
NRAG Model & Assumptions: Summary Table
Appropriate Radiotherapy Rates %
(ARR)Fractions Per Patient
(# Per Pt)
Tumour Site Min Base Max Min Base Max
Bladder 31.0 31.0 31.0 16.6 16.9 20.4
Brain, meningies and CNS 61.3 61.3 61.3 24.3 24.3 24.3
Breast inc. DCIS 69.9 69.9 69.9 13.8 16.1 25.8
Cervix uteri 56.4 56.4 56.4 24.3 24.3 24.3
Colon 0.7 0.7 0.7 2.1 3.6 5.0
Corpus uteri 46.2 46.2 46.2 18.8 23.2 23.2
Head and Neck 78.6 78.6 78.6 35.0 35.0 35.0
Hodgkin lymphoma 70.6 70.6 70.6 15.0 15.0 15.0
Kidney 24.1 24.1 24.1 1.6 3.5 5.3
Leukaemia 4.0 4.0 4.0 10.0 10.0 10.0
Lung 65.9 65.9 65.9 14.5 17.0 19.6
Melanoma of skin 15.8 15.8 15.8 24.4 24.4 24.4
Multiple myeloma 33.1 33.1 33.1 1.0 5.0 10.0
Non-Hodgkin lymphoma 54.3 54.3 54.3 13.5 14.1 18.4
Oesophagus 53.7 53.7 53.7 21.6 24.9 25.3
Ovary 4.0 4.0 4.0 5.0 5.0 5.0
Pancreas 49.8 49.8 49.8 19.5 19.5 19.5
Prostate 61.4 61.4 61.4 11.8 21.4 23.1
Rectum 88.6 88.6 27.7 6.7 6.7 23.5
Stomach 13.4 13.4 13.4 25.0 25.0 25.0
Testis 46.0 46.0 46.0 0.0 0.0 10.0
Other and Unspecified 50.2 50.2 46.6 14.4 17.3 22.7
Retreatment Fractions (%) 13.1%
CANCER
AV NUMBE
R CASES
PA2001-5
ORR%
NO REQUIRIN
GRT BASED ON 2001-5
AV NUMBER
OF FRACTIONS PER COURSE
IN MODELS
1
TOTAL FRACTIONS BASED ON 2001-5
NUMBERS
PREDICTED
CHANGE %
PREDICTED
NUMBER
CASES2010-2015
NUMBER
NEEDING RT
2010-15
FRACTIONS 2010-15
Bladder, all 209 28 59 23 1357 13 236 66 1518
Brain, Meninges, CNS
116 82 (61) 95 (71) 25 2375 (1175) 4 12199
(74) 1850-2475
Breast1179
70 (63-79)
825(743-931)
1714025 (12,631-
15,827)20 1415
891-1118
15147-19006
Cervix 73 56 41 24 984 -15 62 35 840
Colorectal
0 0 0
0 0
Colon 605 1 6 5 30 18 714 7 35
Rectum324 89 (28) 288 (91) 7 2016 (637) 23 399
355 (112) 784-2485
Corpus uteri 136 46 63 23 1449 18 160 74 1702
Head and neck252
78 (80-83)
197 (202-209)
35 6895 (7070-7315) 24 312244-259 8540-9065
Kidney 164 24 39 5 195 27 208 50 250
Leukaemia 202 4 8 10 80 25 253 10 100
Lung1175 63(50-64)
740(588-752)
16 11840 (9408-12032) 0 1175588-752
9408-12032
Lymphoma 0
Hodgkins 39 71 28 15 420 11 43 31 465
Non-Hodgkin's 256 54 138 18 2484 32 338 182 3276
Melanoma232 16 (5) 37 (12) 24 888 (288) 46 339
54 (17) 1296 (408)
Oesophagus218 54 (10) 118 (22) 23 2714 (506) 24 270
146 (27) 3358 (621)
Other and Unspecified
689 44 303 19 5757 18 813358 6802
Ovary 269 4 11 5 55 11 299 12 60
Pancreas 163 42 (5) 68 (8) 23 1564 (184) 12 183 77 1771 (230)
Prostate792 61(28) 483 (222) 24 11592 (5328) 48 1172
715 (328)
7824-17160
Stomach209 13 (5) 27 (11) 25 675 (275) -7 194
25 (10) 625 (250)
Testis 55 46 25 10 250 12 62 28 280
TOTAL PATIENTS
7357 (27.5%)
3575(2686-3729)
(37-51%)50388-70059 8768 3221-
445360390-84601
SCAN WOSCAN NOSCANSCOTLAND
TOTAL CASES PA 2010-15 8768 14940 8028 31,736
NUMBER NEEDING INTIAL RT 3221-4453 5603-7707 2885-4052 11,709-16,212
PREDICTED FRACTIONS FOR INITIAL RT 60390-84601 108228-146674 55168-76413 223,786-307,688
NUMBER RETREATMENTS (25%) 805-1113 1400-1927 721-1013 2926-4053
TOTAL COURSES REQUIRED 4026-5566 7003-9634 3606-5065 14,635-20,265
FRACTIONS FOR RETREATMENT (6%) 3623-5076 6493-8800 3310-4585 13,426-18,461
TOTAL FRACTIONS REQUIRED 64013-89,677 114721-155474 58478-80,998 237,212-326,149
COURSESPER 1000 CASES 459-635 469-645 449-631 461-639
NUMBER # PER 1000 CASES 7301-10,227 7807-10,407 7284-10089 7475-10,276
SERVICE CAPACITY REQUIRED (+10%) # 71,126-99,641 127468-172749 64976-89,998 263,570-362,388
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
Aberdeen Dundee
Edinburgh Glasgow
Inverness
Number of LinAcs 39 3 (+1 back up) 61 112 2
Av total LinAc hours per day
18 21 42 88.5 10.5
Fractions booked per hour3 6 4-5 5 4.7 5-6
Number of public holidays 2 8 6 2 2
Av number of treatment days lost to servicing
per LinAc04 04 55 86 12
Av number days worked per machine PA
258 253 250 251 247
TOTAL POTENTIAL FRACTIONS PA7
27,864 26,565 52,500 104,403 15,561
Total patients treated 2008 8 1557 1150 3403 6020 747
Total fractions treated 2008 21,482 15,512 51,850 105,000 11,296
NRAG
Max ?8
9.2 hours
4-4.5
3-8
2 hours
Ave 19days
234-239days
>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 hourHours per dayDays per weekDays per year (servicing etc)Size of deptQA/researchService efficiency per Linac