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



Stage IIIB0.13*

Good PFS 0.47º Radical radiotherapy 241

Poor PFS0.53º



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


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


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


T1-2 N0 (0.52) 2188

Mastectomy (0.37) 810 No radiotherapy


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


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

carrie featherstone consultant clinical oncologist feb 2009

Documents

radiotherapy wle

radical radiotherapy

radiotherapy models

radiotherapy 30n1

radiotherapy rates

radiotherapy txnm1

requirepalliative radiotherapy

radiotherapy 1851t1