audit of radiotherapy waiting times for patients from ... v4 radiotherapy audit... · audit of...

Audit of Radiotherapy Waiting times for patients from North Wales

By Sue Armstrong Audit Facilitator

http://www.cancernet.co.uk/rxt-conform.htm�

Contents:

1) Executive Summary

2) Introduction and Context 2.1) What is Radiotherapy and how is it delivered? 2.2) Guidelines for delivery 2.3) Service Provision

3) Aims and Objectives

4) Methodology 4.1) Stage 1 – Identifying relevant patients 4.2) Stage 2 – Establishing treatment pathway 4.3) Stage 3 – Collection of data

5) Results and analysis 5.1) Stage 1 – Waiting Times (Canisc) 5.2) Stage 2 – Site Comparisons 5.3) Stage 3 – Suspension information 5.4) Stage 4 – Waiting times with unrecorded suspensions

6) Summary of Findings

7) Discussion

8) Conclusion and Recommendations

9) Appendices Appendix 1 Sample cancer pathway for Lung cancer patient

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1. Executive Summary Radiotherapy utilises radiation to treat cancer and before 2000, for the population of North Wales, this service was mainly provided by the cancer centres in Merseyside and Manchester. In 2000 the North Wales Cancer Treatment Centre was opened and now provides radiotherapy services locally for patients in North Wales. The centre is hosted by the New North Wales NHS Trust formerly Conwy and Denbighshire NHS Trust and sits in the grounds of Glan Clwyd hospital One of the many challenges of establishing one centre for North Wales is ensuring that the response of the service to achieving the Cancer Waiting Times is consistent and comparable across the 3 localities and this is considered a challenge when each locality has its own clinical teams, MDT infrastructure and visiting oncologists from the centre. This audit proposes to asses all target patients who had radical radiotherapy as their first treatment between September and November 2008 and process map their pathway through their treatment, to firmly identify the following:

To ascertain the level of consistency in accessing radiotherapy across North Wales.

Where there are delays in the system, identifying the source of these

delays. Upon analysis of the data collected, the audit suggests the following;

Different levels of efficiency exist between hospitals at different points of the whole patient pathway.

Access to oncologists and radiotherapy does appear to be slightly more delayed

in certain parts of North Wales.

Suspensions are a major feature of the pathways and are significant factor in the measurement and understanding of the access to radiotherapy.

Incomplete use of CANISC within NWCTC

Examination of medical records confirms some of the inefficiencies suggested in

the data.

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2. Introduction and context 2.1) What is radiotherapy and how is it delivered? Radiotherapy is the utilisation of high energy x-rays to treat cancer. It can be delivered externally usually from a machine called a linear accelerator, or internally by placing radioactive material inside the body called brachytherapy. Depending on the type of cancer being treated the method works by focussing radiation rays directly on the tumour for set periods of time at specific doses (fractions). This treatment can either be palliative i.e. to relieve symptoms, or radical with the intent to cure. Once delivered the radiation works by penetrating the tissue and damaging the make up of cells which regulate reproduction and growth. Healthy non-cancerous cells may recover from this damage but cancerous cells are less able to do so and as a result may die. The primary use of radiotherapy is to deal with solid tumours in just one site, but it can also be effective in shrinking a tumour so that it can be operated upon. In many cases it’s also used post-surgery to ensure the elimination of any remaining cancerous cells which could have spread from the original site. 2.2) Guidelines for delivery Radiotherapy in North Wales is delivered by the North Wales Cancer Treatment Centre in line with the Royal College of Physicians and Royal College of Radiologists guidance document ‘Reducing Delays in Cancer Treatment’ 1993. This document recommends a maximum acceptable waiting time for all radical radiotherapy of no longer than 28 days; this target is from the date of the first oncology consultation (ready to start date) to the start of treatment. This guidance differs slightly from the Cancer Standards which give an acceptable waiting time of 31 days between the decision to treat and the commencement of treatment for all patients receiving their first definitive treatment. This allows an additional 3 days delay over the recognised guidance. Overall the centre is compliant with the waiting times allowable in accordance with the Cancer Standards. 2.3) Service provision Since 2000, radiotherapy for patients in North Wales has been provided by the North Wales Cancer Treatment Centre housed within the grounds of Glan Clwyd Hospital. The centre has developed extensive oncology services including external beam radiotherapy. Brachytherapy is not currently delivered here and patients requiring this type of radiotherapy have to travel out of area. The Clatterbridge Centre for Oncology and the Christie hospital in Manchester provide some specialist oncology services if the

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treatment is not available in North Wales. All radiation oncologists are based within the Cancer Treatment Centre and travel out to Bangor or Wrexham hospital to attend the relevant MDT meetings. 3. Aims and Objectives The aim of the project is to process map a selection of target patients referred from each of the 3 localities in North Wales to provide comparable data that will identify potential delays in the system and recognise any possible disadvantage to cancer patients referred from Bangor or Wrexham hospitals. This audit was not designed to examine the performance regarding the targets though, but rather to measure the whole of the patient pathway from start to finish and look at the time taken between key dates. Only suspensions that have been recorded via Canisc will be taken into account when calculating the waits. Intended Outcome: The project should recognise any inherent delays with processes and allow measures to be taken to address this. 4. Methodology As stated previously, this audit aims to uncover any delays faced by patients referred from the east or west to the North Wales Cancer Treatment centre. In order to test this theory target patients had to be identified and their journey through the system process mapped to show a timeline which would illustrate any delays. 4.1) Stage 1 – Identifying relevant patients Firstly, the ward sheets listing patients treated with radiotherapy between September and November 2008 were obtained from the centre. This list was extensive and included any patient treated with radiotherapy, for the purpose of this audit and to ensure comparability, the list was interrogated via Canisc and all patients who were not

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target patients and who didn’t have radiotherapy as their first treatment were discounted. 4.2) Stage 2 – Establishing treatment pathway Once target patients with radiotherapy as their first definitive treatment were identified a spreadsheet was created to capture all the relevant information and standard dates along the pathway were established. These were;

Referral receipt date Decision to treat date Date of MDT discussion Date of referral from the MDT to a specialist oncologist Outpatient appointment date (Oncology) Start treatment date

These dates represent the patient’s journey at fundamental points and mapping them will identify any potential hold ups or bottle-necks that might exist within the current processes. 4.3) Stage 3 – Collection of data The next step was to collect all the relevant dates outlined above for the target patients. The Canisc system was the main source of data for this investigation, and the information was found at the following; Information required Location in Canisc Referral receipt date Referral tab / Provider SAFF / SAFF report plan Decision to treat date Referral tab / Cancer management plan MDT discussion date Referral tab / Provider SAFF / Cancer management plan Referral from MDT to oncologist date

NOT RECORDED IN CANISC

Outpatient appointment date

Summary tab

Treatment date Referral tab / Provider SAFF

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Where this data could not be found, was incomplete, missing or not recorded, the list was split into referring hospitals and the information was sought from the relevant Trust Cancer Managers. Once all the data was obtained the spreadsheet was updated and waiting times were calculated for both USC and Non USC patients as follows; Non USC patients

Wait in days from MDT discussion to referral to oncologist Wait in days from oncologist referral to outpatient appointment Wait in days from outpatient appointment to start of treatment

USC patients

Wait in days from receipt of referral to MDT discussion Wait in days from MDT discussion to referral to oncologist Wait in days from oncologist referral to outpatient appointment Wait in days from outpatient appointment to start of treatment

Once the wait in days had been calculated for each segment of the pathway (including Canisc suspensions where relevant), a stacked bar chart was created to visually demonstrate each patient’s progress through the system. This then allowed immediate comparisons to be made between referring hospitals and highlighted where the greatest delays were.

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5. Results and analysis

The table below gives details of the patients who were included in the audit. Hospital Number

Diagnosis Usc / Non USC

Total length of pathway from decision to treat date to start of treatment for Non USC patients

Total length of pathway from referral date to start of treatment for USC patients

Number of patients per org

Number of USC

patients per org

Number of Non USC patients per org

G556881 Tonsil Non USC 21

G203326 Ileo anal pouch Non USC 24

G235921 Rectum Non USC 25

G556676 Cervix Non USC 26

G569138 Rectum Non USC 20 CADT

G272291 Cervix Non USC 18 13 2 11

G323182 Gynae Non USC 11

G232672 Gynae (cervix) Non USC 4

G164112 Lung Non USC 26


G569682 Pyriform Fossa Non USC 6

G574434 Rectum USC 57


G472155 SCC lip Non USC 17

G575673 Larynx Non USC 18



G570633 Prostate Non USC 23

G571134 Anus Non USC 18



G570775 Epiglottis Non USC 31 NEWT

G573800 Prostate Non USC 28 21 6 15




G574140 Pyriform Fossa Non USC 25



G541051 Prostate USC 59


G569580 Prostate USC 45







G297243 Prostate Non USC 23 NWWT

G175301 Cervix Non USC 41 11 4 7


G571682 Larynx USC 66

G571680 Larynx USC 63

G575793 Tonsil USC 70

G574409 Lung USC 54

45 12 33

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5.1) Waiting Times (Canisc)

Average wait based on target dates for USC and Non USC patients per hospital

6063

59

19

24

28

0

10

20

30

40

50

60

70

Glan Clwyd Bangor Wrexham

Hospital

No

. o

f d

ay

s Average length of pathway in days forUSC patients (62 day target)

Average length of pathway in days forNon USC patients (31 day target)

The bar graph above shows the average wait in days experienced by USC and Non USC patients at each of the 3 hospitals based on the target dates (including any suspensions). For USC patients the wait is calculated by taking the date treatment starts from the date the referral is first received by the hospital. In accordance with the Cancer Standards this should take no longer than 62 days, both Wrexham and Glan Clwyd are within target but Bangor exceeds it by 1 day, out of the 4 Bangor patients 2 were reported as breaching and 1 was incorrectly reported as not breaching due to the wrong treatment date being input. For Non USC patients the wait is measured using the decision to treat date instead of the referral receipt date. This should take no longer than 31 days and all 3 hospitals easily achieve this although, again, Bangor’s wait is the longest at 28 days. Again 1 patient out of the 7 breached but this was not reported due to the wrong treatment date being input into Canisc. The chart over the page illustrates the average length of time all patients wait between being discussed at the relevant MDT meeting to beginning their treatment (including suspensions). The chart turns the waits into segments to facilitate comparisons between the 3 hospitals. Glan Clwyd has the shortest time for each segment, in the main, whether USC or Non USC and therefore the shortest time overall. Wrexham takes longer between MDT discussion to outpatient appointment than Bangor, but Bangor patients wait longer between their outpatient appointment and starting their treatment than either Wrexham or Glan Clwyd at 28 days on average for Non USC and 22 days for USC. For Non USC patients this is 5 days longer than Wrexham and 9 days longer than

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Glan Clwyd patients. Overall, Bangor and Wrexham’s’ Non USC treatment pathways are the same length as illustrated in the table below the chart.

Average wait from MDT discussion to treatment for primary radiotherapy patients per hospital

5

8

9

2

1

3

9

12

16

8

8

15

19

28

23

17

22

18

0 10 20 30 40 50 60

Glan Clwyd NonUSC

Bangor Non USC

Wrexham NonUSC

Glan Clwyd USC

Bangor USC

Wrexham USC

Wait in days

Average w ait from MDT discussion toreferral to specialist

Average w ait from specialist referral tooutpatient appointment

Average w ait from outpatient appointmentto start of treatment

Hospital Average wait

from MDT discussion to referral to specialist

Average wait from specialist referral to outpatient appointment

Average wait from outpatient appointment to start of treatment

Overall average wait

Glan Clwyd Non USC 5 9 19 33

Bangor Non USC 8 12 28 48

Wrexham Non USC 9 16 23 48

Glan Clwyd USC 2 8 17 27

Bangor USC 1 8 22 31

Wrexham USC 3 15 18 36

The chart over the page shows the average length of time USC patients wait between being referred to hospital and starting their radiotherapy treatment. It follows the same principles as the chart above. Overall, Wrexham has the shortest time, followed closely at one day longer by Glan Clwyd. Bangor patients wait the longest on average at 63 days.

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Average waits along patient pathway for USC patients per hospital

33

33

23

2

1

3

8

8

15

17

22

18

0 10 20 30 40 50 60 70

Glan Clwyd

Bangor

Wrexham

Wait in days

Average w ait from receipt of referral toMDT discussion

Average w ait from MDT discussion toreferral to specialist

Average w ait from specialist referral tooutpatient appointment

Average w ait from outpatient appointmentto start of treatment

Hospital Average wait

from receipt of referral to MDT discussion

Average wait from MDT discussion to referral to specialist




Glan Clwyd 33 2 8 17 60

Bangor 33 1 8 22 63

Wrexham 23 3 15 18 59

The chart over the page shows the average wait for USC and Non USC patients between the NWCTC recorded referral date and the start of radiotherapy (including any suspensions). Glan Clwyd has the shortest waiting times, quite markedly so for USC patients while Wrexham has the longest at 29 days. This needs to be read with caution though as there are suspensions mentioned on the Radiotherapy ward sheets that are not recorded within Canisc and therefore have not been taken into account when calculating the length of the waits.

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Average wait between decision to give radiotherapy and start of radiotherapy for USC & Non USC patients per hospital

22

29

19

25

17

24

0

5

10

15

20

25

30

35


Hospital

Wai

t in

day

s

USC

Non USC

5.2) Site Comparisons

The chart below shows the average total length of the pathway for 3 different cancer sites; Head and Neck, Prostate and Bowel in relation to Non USC patients. The length is fairly similar for all 3 with Larynx being marginally shorter.

Average total length of pathway from decision to treat date to start of treatment per site for Non USC patients

24

26

26

23

24

24

25

25

26

26

27

Larynx Prostate Rectum

Cancer site

No

. o

f d

ay

s

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Average total length of pathway from referral date to start of treatment per site for USC patients

65

52

62

0

10

20

30

40

50

60

70

Larynx Prostate Rectum

Cancer site

No

. o

f d

ays

The chart above shows the same pathway for USC patients; here the lengths do vary significantly with the average wait for prostate patients being 52 days while larynx patients wait 65 days. This is quite a surprising result as all USC cancers should be treated within 62 days from referral. Typically, larynx cancer tends to be more aggressive than prostate cancer, so you might expect some variation due to the types of cancer involved, but this result is the opposite to what might be expected. Perhaps this is just an anomaly due to the small number of patients; 2 for both larynx and prostate. The chart below relates to Non USC rectal cancer patients showing the length of the pathway per hospital, the lengths here are fairly similar with Wrexham’s being slightly longer at 28 days. These should all be treated within 31 days so each hospital is well within its targets.

Average total length of pathway for Rectal Non USC patients from decision to treat date to start of treatment per hospital

26

28

26

24

25

25

26

26

27

27

28

28

29


Hospital

No. of days

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5.3) Suspension Information The table below gives information on the suspensions which were taken into account when calculating all the waiting times. Glan Clwyd had very few suspensions; just 2 patients for a total of 7 days while Wrexham had 8 patients out of 21 suspended totaling 265 days. One Wrexham patient was suspended 5 times for 98 days in total and another was suspended 4 times totaling 97 days. The average number of days per suspension for each hospital is recorded at the end of the table and gives quite different results for each hospital.

Hospital Total no of patients

Total number of days suspended

Number of suspensions

Average number of days per suspension

Glan Clwyd 13 7 2 4

Wrexham 21 265 8 33

Bangor 11 125 5 25

Total 45 397 15

The pie chart below demonstrates which hospital had the most and least suspensions out of the 15 suspensions occurring in total.

Average number of suspensions per hospital

13%

54%

33%

Glan Clwyd

Wrexham

Bangor

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The chart below depicts the number of occurrences and lengths of the suspensions. The longest single suspension was for 66 days for one of the Wrexham patients who had 97 days suspended in total.

Length and frequency of suspensions

3 3 3

1 1

3

1

0

0.5

1

1.5

2

2.5

3

3.5

Between 1-5days

Between 6-10days

Between 11-15 days

Between 16-20 days

Between 21-25 days

Between 26-30 days

31+ days

No

of

day

s

5.4) Waiting times with unrecorded suspensions The following patients had suspensions mentioned on the NWCTC ward sheets that delayed their radiotherapy but these suspensions were not recorded within Canisc which calculates their waiting times.

Radiotherapy suspensions not

recorded on canisc

G number USC / NON USC

Referring Org

No of days

Reason REVISED Total Waiting Time inc NWCTC suspensions (Start Trt Date less Referral date for USC or Dec 2 trt date for Non USC)

ORIGINAL Total Waiting Time (Start Trt Date less Referral date for USC or Dec 2 trt date for Non USC)

G572159 usc NEWT 21 medsus 63 84

G571496 usc NEWT 24 medsus 27 51

G574409 usc NWWT 7 socsus 47 54

G570606 non usc NEWT 12 socsus 19 31

G573297 non usc NEWT 7 socsus 20 27

176 247

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Revised average wait based on target dates for USC & Non USC patients per hospital (inc unrecorded suspensions)

60 62

52

19

2823

0

10

20

30

40

50

60

70


Hospital

No

of

day

s

Average length of pathway in daysfor USC patients (62 day target)

Average length of pathway in daysfor Non USC patients (31 daytarget)

The chart above has been recalculated to include the unrecorded suspensions, which will be explored further in the Discussion section of this report.

Hospital Average wait from MDT discussion to referral to specialist




Glan Clwyd Non USC 5 9 19 33

Bangor Non USC 8 12 28 48

Wrexham Non USC 9 16 21 46

Glan Clwyd USC 2 8 17 27

Bangor USC 1 8 20 29

Wrexham USC 3 15 13 31

Above and over the page are the revised table and chart of the waiting times from MDT discussion to commencing radiotherapy.

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Revised average wait from MDT discussion to treatment for primary radiotherapy patients per hospital (inc unrecorded suspensions)

5

8

9

2

1

3

9

12

16

8

8

15

19

28

21

17

20

13

0 10 20 30 40 50 60

Glan Clwyd NonUSC

Bangor Non USC

Wrexham Non USC

Glan Clwyd USC

Bangor USC

Wrexham USC

Wait in days

Average wait from MDT discussion toreferral to specialist

Average wait from specialist referral tooutpatient appointment

Average wait from outpatientappointment to start of treatment

Below is the average waiting times revised for the NWCTC to include the unrecorded suspensions. All of the revised data will be examined more fully in the Discussion section of this report.

Revised average wait between decision to give radiotherapy and start of radiotherapy for USC & Non USC patients per hospital (inc

unrecorded suspensions)

17

2022

19

25

22

0

5

10

15

20

25

30


Hospital

Wai

t in

day

s

USC

Non USC

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6. Summary of Findings This audit was devised to establish the level of consistency in access to radiotherapy and establish the level of efficiency within clinical pathways.

Analysis of the data purely from a target dates perspective suggests that the average waiting times for each hospital are not that dramatically different for USC patients with only 4 days difference between hospitals. For Non USC patients though it is slightly more distinct with Bangor patients waiting 9 days longer in their treatment pathway, on average, than Glan Clwyd patients. This only measures the time from the recorded decision to treat date though so a far longer wait could have taken place before. If we disregard the target dates and look at the pathway for all patients from the date a patient is discussed at an MDT meeting to when they commence treatment, this gives more of an idea of how long a pathway really is and how long the steps between discussion and starting treatment really take. This is depicted in the results section on page 9 and suggests that overall for USC and Non USC patients Glan Clwyd has significantly shorter waiting times than the other 2 hospitals. For Non USC especially, the wait was shorter by 15 days than the other 2 hospitals. Breaking this down into segments between key dates may demonstrate where any delays might lie. Analysis of the time taken between MDT discussion and referring to a Clinical Oncologist, suggests there is a big difference in the time taken by each hospital. On average for Non USC patients, Wrexham takes 9 days for this process while Glan Clwyd only takes 5. Moving on from this the next wait is between the Specialist referral to the first outpatient appointment, here again are significant differences. For USC patients, Bangor and Glan Clwyd take on average 8 days for this process while Wrexham takes almost double the time at 15 days. Lastly, there is the time taken between the outpatient appointment to commencing treatment. Again, there is considerable variation between hospitals. For Non USC patients, Glan Clwyd has the shortest time waited at 19 days while Bangor patients wait on average 28 days for this process. This is repeated with the USC patients with Glan Clwyd waiting 17 days to commence treatment and Bangor waiting 22 days. Certainly this highlights where hospitals are more efficient at managing their patients pathway but it also illustrates that the bulk of the time taken is at the final stage between outpatient appointment and starting treatment and this does appear to be greater for patients referred from the east and the west. Looking at this more closely using the North Wales Cancer Treatment Centre’s ward sheets referral date to the date of starting treatment reinforces this as shown in the chart on page 11.

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7. Discussion Whilst there is equal access to the service, patients under the care of Glan Clwyd would appear to wait the shortest time. It is possible that the distance for patients from the east and west is a factor in that perhaps they are unable to accept the first appointments offered to them, whereas patients who are local are able to attend sooner. However this is unlikely though, as hospitals are allowed to put in suspensions and therefore disregard the time taken where a patient cannot attend an appointment offered to them. Access may also reflect transportation needs in that local patients are more able to attend due to the shorter distances and the need for transport for further distance may simply prove a more demanding issue logistically that ultimately makes treatment access more difficult to achieve. Regarding those elements of the pathway around MDT discussion and oncology outpatient appointments it is known from the audit of the Cancer Standards 2008-09 that attendance at MDTs by clinical oncologists was more consistent at Glan Clwyd than the neighbouring hospitals and as result this may have contributed to a more streamlined pathway overall in terms decision making by oncologists and even access to clinic slots. In addition it is also known anecdotally that individual oncologists work in different ways and that those with sessions in specific hospitals may well work in a manner that adds in additional steps within the pathway. One anomaly discovered while conducting this audit, which perhaps could explain the apparent difference in access to radiotherapy in terms of time is that there were suspensions recorded for patients on the Cancer Treatment Centre’s ward sheets that were not recorded in Canisc. These would not be taken into account by the referring Trusts when calculating their waiting times and weren’t included in the first set of calculations for this audit as the information was drawn from each patients record on the Canisc system. If we take the suspensions into account it does make a significant difference to the waiting times. There were 5 patients (4 for Wrexham and 1 for Bangor) who were suspended on the ward sheets for a total of 71 days collectively (see page 14 in the Results section). Whilst, when this is factored into the calculations, it does not change the overall finding, it does considerably reduce the gap between the hospitals performances. For example, if we revise the average wait based on the target dates (see p14), Wrexham’s average of 59 days wait from receipt of referral to start of treatment for USC patients reduces to 52 which is a significant difference of 7 days. Also Bangor’s average of 63 days reduces to 62, which according to the Cancer Standards, would be the difference between the Trust breaching and not breaching its targets. For Non USC patients the only alteration would be to Wrexham’s average of 24 which would reduce to 23.

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If we apply this to the patient pathway from MDT discussion to commencing treatment (see p16) it becomes apparent how important these suspensions are, especially regarding USC patients, where the difference in time between the shortest treatment time and the longest treatment time reduces from 9 days (36 – 27) to just 4 days (31 – 27).

Thus one response to this audit might be to look more closely at suspensions and ensure that all are recorded on Canisc, and it would seem that this applies directly to the cancer centre. Also there are quite significant differences in the suspensions recorded for each hospital (see table p13), Wrexham had the highest number of recorded suspensions; 8 totaling 265 day. This is more than double the length of days Bangor recorded and nearly 38 times more than Glan Clwyd. As Wrexham did have more patients (21) it might be logical to assume there would be more suspensions, but if you extrapolate up Glan Clwyds’ patients their suspensions still look very low in comparison. As a footnote to this discussion, as part of the attempt to achieve data completeness it was necessary to read through a number of patient notes. This experience (and the task was performed by a range of Network staff) confirmed the level of inefficiency with the pathway in terms of referral practice – specifically the routine of physical referral letters and the time taken to both produce and receive them. 8. Conclusion and recommendations The results achieved show that although there is equal access to radiotherapy services, patients from the east and west do wait slightly longer to commence treatment than patients living locally. The scale of the problem though, is not as large as first thought and there are administrative errors complicating the issue that need to be addressed. Upon reflection of the findings of this audit, he following recommendations are made;

There should be a separate audit performed of suspensions applied by the NWCTC to assess how many have been recorded in Canisc.

This audit should be repeated in the future for a larger timescale to see if the findings are replicated.

Each hospital should undertake some work around ensuring that data is complete within Canisc for their patients and that ensuing there are mechanisms in place to prevent gaps in data when their patients are treated elsewhere.

There should be a separate audit into suspensions generally and how they are applied to examine consistency between hospitals.

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9. Appendix 1. Sample Clinical Pathway

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Referral from Primary Care

Referral from Secondary care (a+e, gen medicine)

CXR by primary care before referral

Investigations Diagnosis

Follow -up

SCLC

MDT

PALLIATIVE CARE SERVICE

Respiratory Physician

NSCLC

Radiotherapy

Surgery (Liverpool)

Chemotherapy

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