Stereotactic Ablative Body Radiotherapy for Non small cell

lung cancerAudit of the first 12 months

Background SABR is the treatment of choice for early stage

peripheral lung tumours in patients with contraindications to surgery

UBHT has established a SABR programme according to the SABR consortium guidelines

Started commissioning Spring 2013– Part of early Mentoring scheme

First patient treated in February 2014 Aim was to treat 12 patients within the first year 25 patients treated in first year

To ensure patient selection criteria fit with those recommended within the SABR consortium guidelines

To assess acute toxicity of the treatment

To assess early outcomes for those patients who have undergone 6 month follow up scans.

Audit Aim

To compare local practice for patient selection to SABR consortium guidelines

To ensure acute toxicities are comparable to published international series.

To look at early clinical outcomes

Objectives

Standards/CriteriaNo. Standard/criteria Target Any exceptions

1

Approriate patient selection based on SABR consortium inclusion criteria (positive histology, positive PET scan or serial growth on CT scans; medically inoperable through co-morbidity, technical inoperability or patient choice; peripheral lesions)

100% Nil

2Appropriate fractionation based on SABR consortium guidelines (54Gy in 3#, 55Gy in 5#, 60Gy in 8#)

100% Nil

3 Grade 3 adverse events <13% 100% Nil

4 Grade 4 adverse events <4% 100% Nil

Standards based on:

SABR consortium guidelines

Timmerman R et al. Stereotactic body radiation therapy for inoperable early stage lung cancer. JAMA 2010. 303 (11): 1070-6

Methodology 23 patients were identified for inclusion in the audit identified

from the prospective database of SABR patients

Data was collected retrospectively from case note review

Data collection was fairly complete though some clinical outcomes had to be chased on patients referred from other trusts.

Results

ResultsNo. Standard/criteria Target Result

1

Approriate patient selection based on SABR consortium inclusion criteria (positive histology, positive PET scan or serial growth on CT scans; medically inoperable through co-morbidity, technical inoperability or patient choice; peripheral lesions)

100% All patients met SABR consortium inclusion criteria

4/23 (17%) of patients underwent biopsy for histological confirmation of disease

Reason for no biopsy:

100% patients had PET avid lesions, and 2 had also had serial growth on CT scan

ResultsNo. Standard/criteria Target Result

1

Approriate patient selection based on SABR consortium inclusion criteria (positive histology, positive PET scan or serial growth on CT scans; medically inoperable through co-morbidity, technical inoperability or patient choice; peripheral lesions)

100%All patients met SABR consortium

inclusion criteria

2Appropriate fractionation based on SABR consortium guidelines (54Gy in 3#, 55Gy in 5#, 60Gy in 8#)

100%100% patients met SABR consortium

guidelines for appropriate fractionation

Fractionation schedules:

Reason for very conservative regimen – 1 patient – proximity to heart– 2 patients – proximity to aorta and brachial plexus

Results

Commonly reported gd 1 / 2 toxicities include dyspnoea, nausea, fatigue and skin reaction

Clinical Outcomes Median follow up 6.7 months (range 1-11

months) Locoregional control:– 13/23 patients have had 6 month follow up scans

Complete response (CR) 2Partial response (PR) 9Stable disease (SD) 2Progressive disease (PD) 0

Clinical outcomes Disseminated failure– 1 patient has relapsed with liver metastases– 1 patient has relapsed with new nodules in different

lung lobes.

– Primary lesions in both cases remain small

Conclusions Patients are complying with appropriate selection criteria for

SABR treatment Patients are having appropriate fractionation schedules

according to consortium guidelines No serious (grade 3 / 4) acute toxicities have been

experienced to date.

But Current data is very early. Referrals from other trusts have less complete follow up

picture.

SABR for Peripheral Lung Tumours Commissioners have asked us to deliver SABR

for lung tumours in the South West for 2015/16 Tariff has finally been agreed Referrals have increased: 7 in the past 2 weeks Longer term: Taunton, Exeter, Plymouth have

ambitions to treat with SABR (commissioned or not)

However, number of cases in Bristol alone unlikely to be less then 30 per year

Pathway is evolving! Individual patient QA COMPASS

Day O Incorporate Day O into Day I

7-field plan (40 minutes) VMAT FFF (10 minutes)

SABR for other sites Liver (Hepatocellular) Pancreas Spine Oligometastatic disease– Lung, liver, lymph nodes, adrenals, spine

SABR for other sites Oligometastatic disease– 2 potential trials:• SARON for NSCLC patients• CORE for Breast, Renal, Colorectal patients

Liver Pancreas

Commisioning by Evaluation

Future plans Improve referral pathway– Referral form, dedicated email

Dedicated SABR pathway and clinic One-stop review and planning scan for patients Introduction of arc-therapy Remote follow-up and toxicity data collection