VUmc

Radiotherapy planning and organization in The Netherlands

Ben SlotmanProfessor and Chair, Radiation Oncology

VU University medical center

Amsterdam, The Netherlands

VUmc At the end of the ‘90s

• Waiting for new Government decision on capacity• Long waiting times• Suboptimal fractionation schemes• Impossibility to implement new techniques• No extra reimbursement for intensive therapy• …etc…….• …...etc…..• ………etc..

VUmc Re-imbursement

“Treatment series” ?!A complete treatment consisting of x fractions

• New series for extra electron fields, boost, or even every change in field sizes, etc.

• Sometimes 3 series for one treatment

• Insurance companies agreed (or not)

• No comparison between and within centers possible• No parameter which incorporates relative workload

VUmc New reimbursement parameters

• Limited number of categories• Should reflect workload• Should be fool-proof• Should be used for comparison of production

between and within institutes• Should be used for planning future needs for staffing

and infrastructure

VUmc T and B categories

• Teletherapy– T1: simple, patient already known to the dept.– T2: standard– T3: intensive (CRT)– T4: special (SRT, IMRT)

• Brachytherapy– B1: simple (plaque) – B2: standard (breast)– B3: intensive (Fletcher)– B4: special (stereotactic, Prostate seeds)

VUmc Costs of Teletherapy (in €)

T1 T2 T3 T4

Personnel 551 1750 2998 5036

Materials 105 334 572 960

Total 656 2084 3570 5996

0.3 1.0 1.7 2.9

VUmc Costs of Brachytherapy (in €)

B1 B2 B3 B4

Personnel 226 403 925 3273

Materials 51 77 176 625

Total 317 480 1101 3898

0.7 1.0 2.3 8.1

VUmc Costs of T and B categories

• Teletherapy– T1: simple 0.3– T2: standard 1.0– T3: intensive 1.7– T4: special 2.3

• Brachytherapy– B1: simple 0.6– B2: standard 1.0– B3: intensive 2.3– B4: special 8.1

Relative costs

VUmc Costs of T and B categories

• Teletherapy– T1: simple 0.3 100 30– T2: standard 1.0 100 100– T3: intensive 1.7 100 170– T4: special 2.3 100 230

Total 400 530

Relative costs Ttotal T2eq

Similar for Brachytherapy

VUmc Prognosis 2000 – 2010: Patients

1995 2000 2005 2010

New cancer patients 55300 59400 63100 69400

% irradiated (excl. Skin cancer) 47 48 49 50

New irradiated patients 26000 28500 30900 34700

Skin cancer and benign lesions (x 1,05) 27300 29900 32400 36450

Repeat factor (1,30-1,35)Totaal Teletherapy treatments 35500 38800 43700 49100

VUmc Prognosis 2000 – 2010: T-distribution

1995 2000 2005 2010

Total Teletherapy treatments 35500 38800 43700 49100

% T1 (simple) 24 22 22 22

% T2 (standard) 57 54 48 44% T3 (intensive) 16 20 25 28

% T4 (special) 3 4 5 6

Total T2-equivalent 35536 41206 48769 56760

40%

60%

VUmc Prognosis 2000 – 2010: B-distribution

1995 2000 2005 2010

Total Brachytherapy treatments 2675 3215 3425 4180

% B1 (simple) 35 27 20 20

% B2 (standard) 32 28 29 29

% B3 (intensive) 27 39 45 45

% B4 (special) 6 6 6 6

Total B2-equivalent 4473 5954 6682 8155

VUmc Linacs and personnel

1995 2000 2005 2010

T2-equivalent 35536 41206 48769 56760

Linacs (500T2eq) 71 82 98 115

Radiation oncologists (250 T2eq) 142 165 195 230

Physicists (650 T2eq) 55 63 75 88

Technologists (55 T2eq) 640 742 878 1034

Excluding BrachytherapyFor 250 B2eq. :

0.5-1.0 radiation oncologists0.5 physicist0.5 physics assistants1.0-2.0 technologists

VUmc Size of 21 centers

1 linac 2 linacs 3 linacs 4 linacs 5 linacs 6 linacs >6 linacs

1998 2 7 5 4 1 1 1

Number of centers

Linacs Centers Linacs/center

1998 67 21 3.2

VUmc Size of 21 centers

1 linac 2 linacs 3 linacs 4 linacs 5 linacs 6 linacs >6 linacs

1998 2 7 5 4 1 1 1

2003 0 4 7 3 2 2 3

Number of centers

Linacs Centers Linacs/center

1998 67 21 3.2

2003 88 21 4.2

VUmc Size of 21 centers

1 linac 2 linacs 3 linacs 4 linacs 5 linacs 6 linacs >6 linacs

1998 2 7 5 4 1 1 1

2003 0 4 7 3 2 2 3

2008 0 2 1 6 3 3 6

Number of centers

Linacs Centers Linacs/center

1998 67 21 3.2

2003 88 21 4.2

2008 113 21 5.3

VUmc Teleytherapy 1996-2008

VUmc T-total and T-equivalent

2000 2002 2004 2006 2008

T-total 37800 40200 43700 46302 49461

T2-equivalent 40000 45800 55500 66338 77036

T2-eq/T-total 1,05 1,14 1,27 1,43 1.56

%T1 24 23 22 22 23

%T2 53 49 43 32 23

%T3 19 20 20 25 27

%T4 4 8 15 22 28

VUmc Linacs 1996-2008

VUmc Radiation oncologists 1996-2008

fte

RegisteredIn training

Needed based on T2-eq

VUmc Physicists 1996-2008

fte

RegisteredIn training

Needed based on T2-eq

VUmc Technologists 1996-2008

fte

Registered

Needed based on T2-eq

VUmc 2005: Evaluation

2000 2005 Change

Linacs 74 101 + 36%

- with MLC 48% 89%

- with EPID 59% 95%

Radiation oncologists 142 178 +25%

Physicists 65 78 +20%

Technologists 703 949 +34%

VUmc 2005: Evaluation and new Prognosis

• New cancer incidence data (2004): 2015 + 43% increase compared to2005

• T2equivalent overestimates the needs (inflation)More efficient delivery of complex treatmentsFor future calculations complexity (T2eq/T) and efficiency-factorNew T2eq = 0,86 x T2-equivalent

• No evidence for increase in number of retreatments 1,30 in stead of 1,35

• Some underconsumption: Utilisation 43% in 2005, 44% in 2010 and 45% in 2015

VUmc Prognosis

2005 2010 2015

New cancer patients 78500 87000 96500

Utilisation factor 0.43 0.44 0.45

Repeatfactor 1.30 1.30 1.30

Benign lesions factor 1.0356 1.035 1.035

New radiotherapy patients 45417 51506 58428

Weight factors 1.15 1.25 1.35

T2new-equivalent treatments 52230 64382 78878

VUmc Prognosis

2005 2010 2015

T2new-equivalent treatments 52230 64382 78878

Linacs 129 158

Radiation oncologists (+brachy) 258 (+20) 316 (+23)

Physicists (+brachy) 99 (+13) 121 (+15)

Technologists (+brachy) 1171 (+39) 1434 (+45)

VUmc Number of linacs

Linacs

0

20

40

60

80

100

120

140

160

180

2000 2005 2010 2015

Realisatie

Behoefte

VUmc Newly defined activities

Preparation Teletherapy Brachytherapy

Conventional Simulation

V1 Single fraction U1 No individual dosecalculation

B1

CT simulation V2 Long fraction U2 Individual dose calculation

B2

Simple TP V3 Standard imagebased positioning

U3 3d imaging, contouring & planning

B3

Standard 3D TP V4 Intensive imagebased positioning

U4 Stereotactic BT B4

Intensive TP V5 Intensive treatment U5 Permanent implantation

B5

Image fusion V6 SRT U6

Functional imaging V7

VUmc Teletherapy: T0-T6

  Activity T0 T1 T2 T3 T4 T5 T6V1 Convent. Sim V2 CT-sim V3 Simple TP V4 Standard 3D TP V5 IMRT V6 Imagefusion V7 PET-scan V8 MRI-scan U1 1 fraction U2 long fraction U3 Standard Positioning correction U4 Intensive Positioning correction U5 IMRT U6 SRT

VUmc Satellites

• Hospital prestige • Patient comfort/travel

• Multidisciplinary treatment

• Is there maximum center size?

VUmc Satellites

• Satellite at least 2 linacs• No treatment planning• Mother institute at least 4 linacs• Mother institute at least 10-12 ROs• Same quality system• At least 90% of treatments• Personnel paid by mother institute

VUmc