Health Policy, 17 (1991) 243-256

0 1991 Elsevier Science Publishers B.V. 0168-8510/91/$03.50

HPE 00393

Palliative radiotherapy - Counting the costs of changing practice

Maria Goddard’, Elizabeth J. MaheP, John Hutton’ and Damu Shah* l Cent/e for Health Economics, University of York, York, and 2Mount Vernon Centre for Cancer Treatment, Northwood, Middlesex, United Kingdom

Accepted 25 November 1990

Summary

‘Working for Patients’, the government’s review of the National Health Service (NHS) advocates reforms which have led inevitably to pressure for medical spe- cialities to review both the outcomes of their services and the resources used in achieving these outcomes [l]. This paper considers these issues in the context of provision of palliative radiotherapy for patients with incurable cancers and presents the results of a study which evaluated the costs of radiotherapy. In addition to pro- ducing some of the first detailed cost estimates for the delivery of radiotherapy, this exercise highlighted the methodological and practical difficulties of undertak- ing such studies. As increasing pressure to evaluate cancer therapy is a prominent feature of a ‘post-NHS Review’ world, lessons learnt from this study may also be applicable to the audit of other cancer therapies. Efficient audit practices will, of course, have to evaluate the benefits (in terms of enhancements to length and qual- ity of life) as well as the costs of cancer therapies.

Cost; Audit; Radiotherapy

Introduction: the pressure to audit

One consequence of the White Paper Review of the NHS, is the need for medical specialties to review systematically both outcomes of treatments and the volume of

Address for correspondence: Maria Goddard, bA Hons, Msc, Research Fellow, Centre for Health Economics, University of York, York, YOl 5DD, United Kingdom.

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resources used in order to achieve these outcomes. A central theme of the reforms is the drive to ensure that, “... all concerned with delivering services to the patient make the best use of the resources available to them” which implies that, “... quality of service and value for money will be more rigorously audited.” [l] (para 1.9). In more specific terms, this will also include the shift to allow certain hospitals to ‘opt out’ and become self-governing hospitals and to facilitate and encourage efficiency by requiring District Health Authorities to purchase services for patients from its own hospitals, other authorities’ hospitals, self-governing hospitals or from the private sector. This necessitates the setting of contracts which specify both the price and level of service to be provided.

Cancer services in general, and radiotherapy in particular, will be affected by the reforms. Firstly, the use of specialised equipment and skills in the provision of treatment means that services tend to be provided from large centres at the regional level and serve a broad population, covering several district health authorities. Although the government has indicated that some element of central funding is likely for regional specialty services, it is also clear that some element of contract funding will be introduced [2]. Thus, even if specialised cancer therapy hospitals do not choose to ‘opt out’, they will still need to clarify costs and outcomes and establish the most efficient ways of providing an appropriate service.

Secondly, whilst there is an increasing need for the identification of measures of outcome for cancer treatment, most attention has focused on survival rates. These can easily be obtained retrospectively as well as prospectively, but are of limited value in the context of incurable disease. Over three quarters of chemotherapy treatments and half of radiotherapy treatments aim not to cure, but to palliate the symptoms of disease and improve quality of life, Clinicians disagree as to how to measure ‘quality of life’ and few instruments are in routine clinical use outside research protocols. Such data can only be obtained prospectively, so ‘base-line’ data are more difficult to obtain. This poses obvious difficulties when designing appropriate audit programmes in this field.

Background to the study

Surprisingly, little has been published about the resources used for the care of cancer patients; nevertheless the use, and possible misuse of resources has been questioned [3,4], and the need to weigh up both the costs and benefits in the face of limited resources is increasingly recognised [5,6].

Radiotherapy costs: background

Existing evidence on the costs of radiotherapy in cancer treatment is summarised elsewhere [7] and includes studies costing individual fractions or visits for radio- therapy, and those which estimate a more general unit cost such as a week or course of treatment, Much of the data come from overseas, but even within the U.K., the range of estimates for cost per visit for treatment is wide, varying by over 100%.

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Some of the methodological reasons for such variations have also been discussed elsewhere. Important factors include the size and location of the department, whether the radiotherapy department is part of a specialist cancer hospital or a general hospital, the workload and throughput of the department and the type and age of equipment [7]. It is thus necessary to study centres with different configurations of workload, equipment and staff to identify the influence of these factors on costs.

The large differences in observed unit costs indicate the possibility of more efficient use through service re-organisation. However, another crucial influence on service delivery is the clinical policy of the centre with regard to treatment of particular types of patient. To identify the links between clinical policy and resource use requires detailed study on a centre by centre basis before generalised conclusions on the consequences of changing such policies can be drawn.

This study aimed to provide information about the use of resources to deliver palliative radiotherapy for those patients considered to be incurable; clarify criteria for the selection of patients for different radiotherapy schedules and illustrate some of the problems of measuring cost and benefit for cancer therapy in general. In the course of selecting which aspects of the radiotherapy service to measure, it became apparent that the costs of treatment are not as easily identifiable as initially thought. Not all the treatment supervised by cancer specialists is based in the specialist centre for cancer treatment, but it may involve contributions from services based in district general hospitals and in the community. It is often difficult to identify, measure and apportion costs for all the different elements of care. Whilst the most satisfactory approach is to measure the whole ‘package’ of care provided, including initial consultation, investigations, treatment and follow up, the timetable for implementation of the White Paper makes it unlikely that any region will be able to collect prospective data from all relevant sectors of the health and non-health care systems, before contracts are set.

In this study we identified ‘core’ elements of the costs of delivering a particular type of therapy to a narrowly defined group of patients i.e., palliative radiotherapy given to relieve symptoms of incurable cancer. An attempt was made to evaluate estimates of outcome currently used for this type of patient. We have identified some associated ‘non-essential’ factors involved in palliative therapy (e.g., mode of transport, out-patient or in-patient care, point from which drugs are obtained) which may have varying influence on unit cost, depending on local circumstances, but in the absence of detailed information, we can only speculate on the possible orders of magnitude of their influence on unit costs.

Radiotherapy outcomes

There are practical difficulties involved in evaluating the outcome of palliative treatments. Follow up visits to the specialist centre are kept to a minimum for patients with a poor prognosis. Such patients are usually followed at a district general hospital, distant from the specialist centre, often in conjunction with several different local physicians and surgeons, or by the primary health care team,

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depending upon the site of the diseaseand available local expertise. Prospective documentation of measured changes in quality of life will therefore involve several different locations and staff, rather than simply one team at the specialised centre for cancer treatment. Inevitably this will have associated administrative and financial implications. Accurate data would be facilitated by central follow up, but this would not necessarily be in the patients’ interest.

Previous studies were used for comparison of indications for palliative therapy [8]. Large scale patterns of care studies have been undertaken in the USA [9] and pilot studies in the U.K. [lo]. These indicate that bone metastases, primary lung cancer and brain metastases are the most common areas treated palliatively with radiotherapy. The aim of this treatment is symptom relief [8,10]. Other published studies have identified specific tumour related symptoms which are both particularly distressing and respond to palliative radiotherapy. Examples include coughing up blood (haemoptysis) and shortness of breath associated with bronchial cancer [ 1 l] and bone pain associated with bone metastases. The incidence of such symptoms in a treatment population can legitimately be used as a measure of appropriate selection for treatment. In this audit, the incidence of radioresponsive symptoms in the treated population was prospectively evaluated. The audit confirmed that over 90% of patients were appropriately selected for radiotherapy using these criteria u21.

For some symptoms, the literature supports benefit for virtually all treated pa- tients, thus in the absence of other measures of outcome, the incidence of such symptoms before treatment might reasonably be used as an indirect measure of outcome. The largest ‘palliative’ group in the study were patients treated for bone pain. Multiple publications confirm that 70-90% of patients with the clinical charac- teristics of the studied group would be expected to obtain significant pain relief from the treatments used, and the outcome ‘pain relief’, has been used for the purposes of comparative costing e.g., if the number of treatment fractions per course were changed, the extent of pain relief was assumed to remain constant, in spite of the absence of prospective confirmation that pain relief was actually obtained in the pa- tient group. This seemed reasonable in view of the vigorous follow-up of the group.

Scope of the study

The study was undertaken in a large centre for cancer therapy serving a pop- ulation of over 2 million people and 11 health districts. Over 3800 new courses of radiotherapy are delivered annually and, in addition, almost 600 new courses of chemotherapy are administered. The focus in this case was on the treatment of incurable cancer with palliative radiotherapy.

All radiotherapy treatments were documented over two study periods: 20 April-3 June 1988 and 13 March-29 April 1989. For the purposes of the study, a clear distinction was made between those patients treated with the aim of cure (radical) and those treated for symptom control (palliative), as both therapy techniques and appropriate measures of outcome will differ for these two groups,

The risk of serious radiation damage to normal tissues is related to total dose, dose per fraction and the time period ‘at risk’. Each fraction usually corresponds to visits for the patients, as a single fraction is given on each visit. ‘Palliative’ radiotherapy can be distinguished from ‘radical’ treatment. Its’ aim is to relieve symptoms, not to eradicate disease. Lower doses of radiation are required and it is possible to deliver the dose in a few large fractions, as few patients will survive long enough to be at risk for developing ‘late’ tissue damage. There is considerable controversy regarding the risks and benefits of using fewer and larger dose fractions, particularly in palliative radiotherapy, with practice in centres varying considerably, both within and between countries [9,12,13].

Treatment for this incurable group was selected as a particularly suitable subject for an evaluation of costs and outcomes due to controversy regarding the justifica- tion of the use of resources for such patients and the practical difficulties in finding realistic measures of outcome.

Identification of those patients considered incurable, distinction of techniques involved in radical and palliative therapy and treatment policies in the unit during the study periods are described elsewhere. Approximately half of all radiotherapy treatments could be considered palliative, the majority for advanced primary cancer of the bronchus or bone metastases from a variety of primary sites [lo].

In the first study period, a median of 5 visits was used for all palliative treatments. This figure is at the mean of reported national practice, with considerably fewer treatment visits than those reported in other parts of Europe or the U.S.A. [9,10]. This was discussed in the light of recent clinical trials supporting the use of even shorter courses of treatment and in the second study period, the median number of treatments fell, with a particular reduction in the number of fractions used for bone metastases [ 131. The costing exercise was then used to discuss the potential economic implications of such a change.

Results

Capital costs

The most obvious items of capital equipment used in radiotherapy are the machines which actually deliver the beams for treatment. These include high energq or ‘megavoltage’ machines e.g., cobalt units, Betatrons and linear accelerators. Other equipment, such as superficial X-ray machines are also used for delivery of low-energy, superficial radiotherapy, for example, for skin cancers. In addition, the planning of treatment involves other items of equipment, such as simulators and planning computers which are used to ensure that the chosen therapy is delivered accurately.

In order to take into account the fact that such machines, although expensive, will last for some years, the calculation of equivalent annual cost (EAC) makes allowance for the depreciation of machinery over time and also for the opportunity cost incurred in the purchase of the items. Many existing studies of radiotherapy

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costs use historical costs in the calculation of capital costs [14], and in many of the others, the source of the capital cost is unstated [15]. However, in order to allow for variations in the time of purchase of equipment, it is necessary to consider the replacement cost rather than the historical cost of the item. It is important to note that for some items of equipment, in particular older machines, it would be inappropriate to assume that they would be replaced by a similar piece of equipment and in such cases, the replacement costs of the preferred item should be used.

Similarly, in discounting the costs over time, the discount period should be set at the useful life of the equipment and the discounting should not be undertaken using simple interest rates as in some studies [ 161, but should use an appropriate discount rate, such as 6%, which is the test discount rate for the public sector [17].

Additional capital costs arise from the use of the buildings which house the radiotherapy department and equipment. Again, these represent an opportunity cost and their replacement value should ideally be discounted over the useful life of the buildings, which by convention is taken usually as 60 years [ 181. However, a further complication arises when considering the treatment rooms used to house the radiotherapy machines as they are very specialised and have little chance for alternative use. It might therefore be more appropriate to use a shorter expected useful life for these areas of the buildings.

Tables 1 and 2 present the relevant costs for the centre studied. These costs and all other costs, are presented in 1989 sterling. The replacement cost for the existing building area was estimated using the actual costs of a new building which had recently been erected for the department. The new building had a similar distribution of treatment and non-treatment areas and the costs were inclusive of equipment installation costs. The unit cost per square metre derived from this source was reduced by one-third in order to allow for the fact that the costs would probably not rise in direct proportion to meterage. Thus an estimate of f 1701 per square metre was used. Table 2 presents various estimates of EAC according to the discount period chosen. The final analysis shows that this range does not ultimately produce very different ‘cost per fraction’ results.

Table 1 Capital equipment

Item Assumed useful Replacement cost EAC’ life (years) (f) (0

Linear accelerator 1 Linear accelerator 2 Cobalt 1 Cobalt 2 Philips 1 Philips 2 Simulator 1 Simulator 2 Planning computer

15 400,000 41,185 15 750,000 77,222 15 400,000b 41,185 15 400,000b 41,185 15 400,000b 41,185 15 15 15

250,000 25,741

10 250,000 25,741

60,000 8,152

Total

‘Equivalent Annual Cost (discounted at 6%). bit is assumed that linear accelerators would replace these items.

E221.596

Table 2 Building costs (area = 1718.9 sq m)

Assumed useful life Replacement cost (Q EAC (f)

- 20 years 2,923,849 254,960 60 years 2,923,849 180,986 50% area over 20 years and 50% over 60 years 2,923,849 217,973

Staff costs

Many previous studies of radiotherapy costs consider only some of the staff involved in treatment. For example, Greene excludes radiotherapist staff costs [ 16) and others do not explicitly state whether they even include all radiography staff. In addition other important staff associated with radiotherapy treatment may be located in medical physics departments, bioengineering, nursing and administration and clerical sections. Indeed, such costs might actually fall into another budget, but should not be excluded if the true cost of the radiotherapy services is to be estimated.

Staff costs listed in Table 3 relate to the centre studied are valued at the mid- point of the appropriate salary scale for each grade and are inclusive of employers costs of national insurance and superannuation.

The estimation of accurate staff costs caused same difficulty as it is obvious that many staff will also be involved in the care of patients who do not receive radiotherapy, but who do pass through the radiotherapy department. For example, patients may receive chemotherapy rather than radiotherapy or in addition to radiotherapy, whilst others may receive no specific treatment at all. The care of such patients uses resources in terms of staff time, but without undertaking a prospective analysis of staff time, it is not possible to accurately estimate the proportions spent only on radiotherapy treatment. This difficulty relates to the problem of separating radiotherapy from ‘cancer care’ in general. Consultants and nursing staff do not deal only with ‘radiotherapy patients’, but with cancer patients in general who may receive counselling and support or chemotherapy rather than radiotherapy.

In the absence of such information in this stage of the study, various assumptions were made regarding the allocation of staff time to radiotherapy. Firstly, all radio-

Table 3 Radiotherapy staff

staff Annual cost

Consultant radiotherapists” 110,246 Radiographers 356,926 Nursing 44,583 Physics and bioengineeringb 134,181 Administration and clerical’ 68,490 Other medical 166,264 Porter 8,500

Total f889,190

“Actual costs. bIncludes designated radiographers, technicians and physicists. ‘Includes house officers, registrars and clinical assistants.

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grapher time and the proportion of physics and bioengineering staff allocated for radiotherapy were apportioned to radiotherapy. Secondly, 70% of the costs associ- ated with consultant radiotherapists, nursing, other medical staff and administration and clerical staff in the department, were allocated to radiotherapy treatment. The rationale for this is based on the fact that the consultants, nursing and other med- ical staff within the department also spend part of their time with chemotherapy patients and those receiving no specific treatments. On the basis of the numbers of radiotherapy and chemotherapy patients seen annually in this unit, the relevant split on the basis of activity is approximately 86% radiotherapy and 14% chemotherapy, However, this excludes those who receive no specific treatment but still consume resources such as staff time. Most radiotherapy centres do not keep systematic records of the numbers of such patients and thus in the absence of any firm data, it is assumed that such patients would comprise a total of one-fifth of the total workload in the department. This implies that overall, the relevant apportionment for radiotherapy activity versus ‘other’ activity is 70%:30%.

Whilst it is recognised that this provides a broad estimate, it may be altered in the light of any firmer evidence arising in the future from prospective surveys. An additional problem though relates to the distinction between activity and resource use. Apportioning the resources on the basis of patient numbers is not necessarily accurate, as for example, the management of a patient receiving no specific treat- ment after referral to the consultant, may actually require more consultant time (and thus resources) than a patient who is prescribed radiotherapy or chemotherapy treatment. Again, the most satisfactory solution would be a detailed prospective patient-based survey, logging detailed descriptions of treatments received and time spent in different sections of the department and with different staff members. This was beyond the scope of the current study but even using the above ‘broad- brush’ assumptions based on patient activity is an improvement of previous attempts at es- timating radiotherapy costs, which have either ignored the proportion of time spent by certain staff on radiotherapy or conversely have inappropriately apportioned 100% of staff time to such treatment.

Additional costs

This section covers specific costs, such as maintenance and parts for the radio- therapy machines or laundry, and also more general overhead costs related to energy use and maintenance of buildings and surrounding. Table 4 summarises the results.

Maintenance costs and the cost of replacement parts were based on estimates provided by the medical physics departments. General running costs and overheads and also the domestic cleaning costs were calculated on the basis of the area of the radiotherapy department as a proportion of the total area of the hospital. Laundry costs were based on actual numbers of items sent daily from radiotherapy. The cost of X-ray films for the machines is calculated from estimated daily use in the department.

Table 4 Additional costs

Item

Equipment maintenance Equipment parts Films for machines Laundry Domestic Building maintenance, electricity and

heating

Total

Annual cost (f)

75,000 5,000 4,000 2,171 8,460

90,000

f184,631

~_.

-.

-_

Total and unit costs

The total annual cost is summarised in Table 5. If the alternative scenarios are used in relation to the discount period for the buildings costs, then total costs are lower: f1,476,403 if discounted over 60 years or E1,513,390 if half the cost is discounted over 20 years and half over 60 years.

In 1988, 3536 new courses of radiotherapy were delivered in this department, implying that the estimated average coot per new course is between fA18 and f438, depending upon the discount period used for the building costs.

However, this overall figure will obscure much of the variation in actual cost per course because as discussed earlier, palliative courses of radiotherapy are likely to be much shorter than the more protracted radical courses for curable cancers. Indeed, the audit carried out in conjunction with the costing exercise illustrated that not only did patients with incurable cancer receive significantly fewer fractions of radiotherapy than those classified as potentially curable, but also that practice changed as a result of consensus management, with palliative radiotherapy oft.en consisting of single fractions only [lo].

In 1988, the number of attendances (fractions) at this centre was 40 316, which implies that the average cost per fraction or attendance ranges between E37 and f38 (again depending upon the discount period used for buildings). A palliative course of 5 fractions would therefore cost, on average, an estimated f185-LZ90 per patient; whereas a radical course of about 30 fractions would cost between f1110 and f1140.

The estimates of average cost per fraction or visit can be used to explore the consequences of the changes in practice encouraged by the audit and resulting

Table 5 Total costs

- Annual cost/EAC (f) Percentage of total costs -

Equipment 221,596 14% Buildin& 254,960 16% staff 889,190 57% Other 184,631 12%

Total &1,550,377 -. ‘Discount period = 20 years.

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Table 6 Distribution of number of fractions for bone pain

1988 (n = 99) 1989 (n = 75)

Single fractiona 19% 60% 5 fractions 59% 31% > 5 fractions 20% 9%

“Two patients had 3 fractions.

‘consensus management’ of regarding fractionation regimes at the Centre. During the 6 week period of the first audit in 1988, palliative treatment to relieve

bone pain was given for 99 sites and the distribution of numbers of fractions (visits) for treatment was recorded. A similar exercise was undertaken in the 1989 audit, after informal consensus management within the department had indicated that a move to single fractions for bone pain was desirable (in view both of current literature and resource limitations). The results in both periods are indicated in Table 6.

Evidently, a significant change of practice had occurred as a result of informal audit. If the 1988 distribution is applied to 1989 numbers, the resource consequences if practice had not changed is illustrated in Table 7.

If this information is used to estimate total numbers of fractions and each fraction is costed at E37 each, Table 8 shows the potential ‘cost savings’ over a 6 week period due to the change in practice for this group of patients.

Thus, over a six week period, a potential cost saving of &4,736 has been identified, which, when extrapolated on an annual basis, gives a saving of over f41,OOO.

However, there is a particular difficulty in using such estimates of average cost as average costs may not be a particularly good representation of the resource consequences of altering fractionation. For example, regardless of whether a patient

Table 7 Comparison of the 1969 situation with the potential ‘pre-change’ situation

1989 actual 1989 at 1988 rates

Number with single fractions Number with 5 fractions Number with 6” fractions

45 (60%) 15 (19%) 23 (31%) 45 (59%)

7 (9%) 15 (20%)

“Most patients receiving more than 5 would receive only 6-10 fractions.

Table 8 Total number and costs of fractions - 1989 actual compared with potential ‘pre-change’ 1989 situation

1989 actual

fractions

45 (1) = 45 23(5)= 115

7 (6) = 42

Total 202

cost (f)

f1,665 54,255 f1.554

57,474

1989 at 1988 rates

fractions cost (Q

15 (1) = 15 f 555 45 (5) = 225 f8,325 15 (6) = 90 E3,330

Total 330 f12.210

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is to receive 1 or 5 fractions, they will still be referred to the department, receive consultation with the_ radiotherapist and may still receive some form of planning, although the planning of treatment is much more extensive if the patient is potentially curable or if the tumour is close to vital organs.

This is related to the issues of marginal versus average costs - the additional (marginal) costs incurred from delivering a few extra fractions or conversely, the offset costs from reducing the number of fractions, cannot be accurately measured using average cost estimates as some elements of cost will remain fixed over relatively large changes in workload. For example, there will be negligible cost arising from machine use or staff use if a patient received four rather than three fractions.

This will not become important unless there is a substantial change which affects many patients treated in the department which might necessitate the employment of an extra staff member or the purchase of a new machine. Conversely, reducing the numbers of fractions may potentially allow the release of such resources only if practice changes substantially for a significant number of patients. In this study, it has been shown that fractionation regimens for a particular group of patients did indeed change substantially. Using the information presented in Table 8, a reduction of 128 fractions over a six week period can be hypothesised. In a year this would be equivalent to a reduction of over 1000 fractions. Clearly, if this type of change in practice was to also apply to other palliative cases (and research at this Centre suggests it does [lo]), then potential resource savings indeed became large. Moreover, even if marginal costs are substantially lower, perhaps even at only f5 per fraction, large cost savings could potentially be achieved.

What are the implications of such changes in workload practice? It is difficult to draw conclusions without having an acceptable ‘base-line’ for the assessment of radiotherapy workload. Data from Europe and the U.S.A. illustrate a much lower workload for radiotherapy equipment than the norm in U.K. centres. Thus as practice changes reduce workload in the U.K. maybe this will serve to bring the U.K. more into line with workload patterns elsewhere, but of course, at present there is no way of judging which pattern is actually the most efficient.

Indeed, in practice, even if such a change occurs, resources are not likely to be released, machines and staff are unlikely to become laid off as treatment for other patients will probably be substituted in order to take advantage of such ‘savings’. Despite the fact that this may happen in practice, and indeed, at this Centre there has been no reduction in staff or machine levels, this does not mean that the savings are not worthwhile, as developments in the treatment of other cancer sites and with other, maybe more intensive, patterns of treatment may put unbearable pressure on resources if such ‘savings’ are not made elsewhere in the department. Additionally, increasing demands for quality assurance imply that less machine time will be available for treatment and released resources may therefore serve to alleviate this situation. From society’s point of view, if the same resources can be used to achieve the same or better outcomes for larger numbers of patients, this represents a true benefit. Future workload patterns at this Centre should indicate that more patients are being treated due to the changes in practice for the palliative group or that

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new patterns of care could be introduced for other patients. Alternatively, it may be the case that machines are used less intensively with a possible improvement in terms of breakdown time.

Wider cost issues

The costs of radiotherapy are not confined to the NHS sector, but are distributed about the community. For example, patients often bear the cost of their travel, which can be substantial if they require a number of treatment visits. If they are accompanied by a friend or relative, additional costs may arise in terms of opportunity cost of time lost from work or leisure for these people. The identification and valuation of such travel and time costs has not been considered as part of this study, but methodology has been discussed elsewhere [7] and some studies have attempted to value at least travel costs [14,19] whilst others have considered time in terms of lost wages [20,21]. The costs of caring for cancer patients in the community may also fall on the social services and voluntary sector.

Even within the NHS sector, not all the costs of radiotherapy treatment will be confined to the radiotherapy department itself. Medical physics provide services e.g., moulds for therapy; pathology services may be required for haematological, biochemical and microbiological investigations; X-rays and scans may be needed for treatment planning; pharmacy will be used, not only for drugs associated with treatment, e.g., antiemitics, but also for expensive analgesics, e.g., morphine, which might have formed part of the budget of the primary health team, if the patient were not visiting the hospital regularly.

A variable percentage of patients receiving palliative treatment will be admitted to hospital during the course of their therapy (making up about 25% of all admissions to dedicated ‘oncology beds’). This presents two costing problems. Firstly patients may receive several types of therapy e.g., an admission for a patient with metastatic breast cancer might include: supervised adjustment of analgesia, a single fraction of radiotherapy for a painful bone and some palliative chemotherapy for symptomatic liver metastases. Secondly the need for admission and the length of stay depends less on the specific therapy undertaken and more on non-treatment related factors, e.g., the age and general condition of the patients, distance from the centre and availability of home support determining whether they were able to travel to and from the therapy and rehabilitate satisfactorily at home. This also implies that the overall savings achieved from changes in fractionation will also depend on other things, such as length of hospital stay.

In a broader sense, the costs of providing palliative radiotherapy treatment for cancer patients expands into the community, as ‘specialist treatment’ does not merely consist of delivering the radiotherapy. There are follow up appointments, often away from the cancer centre and in the District General Hospitals visited by consultants from the specialist centres; this results in associated costs due to the need for locally-based support services e.g., secretaries, nurses, use of pathology, X-ray services and other services. There are also referrals to general practitioners

25s

and perhaps other inputs from the health care sector, such as district nurses or Macmillan nurses. In addition, the statutory social services may provide support and the voluntary sector is likely to be particularly active in the support of the cancer patient. All of these have considerable cost implications.

Conclusion

This study provides cost estimates of radiotherapy whilst highlighting the methodological and practical difficulties involved in such a study. The consequences of changing practices in radiotherapy have been outlined and useful lessons for other cancer therapies may be drawn. As pressure to audit both outcomes and resource use increases, it is vital that those involved in the provision of cancer services do not ignore such pressures, or over-simplify the problems, but begin to address the important issues of carefully evaluating the costs and benefits of treatments which compete for scarce resources.

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