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NHS patients’ missing-out on radiotherapy treatment

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Radiotherapy

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cancer

chemotherapy

commentary

image guided radiotherapy

intensity modulated radiotherapy

MRI

PET-CT

proton beam therapy

stereotactic body radiotherapy

Early in 2014, the Sunday Times kicked-off a campaign to give more people who would benefit from radiotherapy access to it, suggesting that NHS radiotherapy equipment is either out-dated or underutilised.

According to Lawrence Dallaglio, the former English rugby captain who campaigns for increased access to radiotherapy, "Cancer clinicians are being denied the use of technologies to treat patients that the rest of the civilised world uses as a matter of routine."

Dallaglio's intervention prompted a government plan to improve access to quality radiotherapy. Is it happening?

Radiotherapy in England
The UK government's 2011 cancer plan, Improving Outcomes: a Strategy for Cancer, states, "To improve outcomes from radiotherapy, there must be equitable access to high quality, safe, timely, protocol-driven quality-controlled services focused around patients' needs."

Over 50% of the 275,000 people diagnosed in England with cancer each year could benefit from radiotherapy as part of their treatment. However, access rates are only around 38%, and each year an estimated 36,000 patients who might benefit from radiotherapy, don't receive it.

Variation in radiotherapy
Radiotherapy can cure cancer, but the financial and technical investments required to establish and operate radiotherapy centres are significant, and as a consequence the provision of radiotherapy varies significantly.

Radiotherapy is a cost effective treatment modality. It consumes only 5% of the NHS's annual cancer spend, but is involved in about 40% of cases where cancer is cured, and is the primary modality in about 16% of patients who are cured of their cancer. By comparison, chemotherapy is the primary treatment in only 2% of cancer patients.

Radiotherapy advances
Over the past 25 years radiotherapy has become significantly more sophisticated. Newer techniques differ from conventional radiotherapy and employ multiple imaging modalities, such as PET-CT and MRI. These facilitate the delivery of high doses of radiation with exquisite accuracy to targeted lesions. With advanced radiotherapy, patients, on average, need only a course of five treatments, compared to 25 for standard radiotherapy, and usually, patients return home on the same day.

Modern radiotherapy treatments

Intensity Modulated Radiotherapy (IMRT) employs advanced physics to deliver high doses of radiation to a tumour while avoiding normal tissues. It should be used in over 33% of patients treated with curative radiotherapy, especially with head and neck cancer, prostate, lung, breast and bladder cancer.
Image Guided Radiotherapy (IGRT) uses imaging during treatment to adjust for tumour movement and guarantees accuracy. IGRT is particularly efficacious for lung, prostate and bladder cancers, which tend to move with breathing or bowel function.
Stereotactic Body Radiotherapy (SBRT) is a combination of IMRT and IGRT. It delivers a small number of extremely high dose treatments with curative intent. First developed for brain tumours, it's now a therapy for early lung cancer in surgically unfit patients.
Proton Beam Therapy (PBT) uses proton beams for radiotherapy to deliver energy directly to hard-to-reach cancers, such as spinal and skull-base tumours, with a lower risk of damaging surrounding tissue. Not yet available in the UK, some patients are treated overseas through the national proton beam service.

Takeaways
Although almost all NHS radiotherapy machines are IMRT enabled, uptake has been slow. A recent survey suggests that only four centres are delivering at rates above 24% inverse planned IMRT, and 42 centres are significantly below 24%.
While cancer patients in other advanced economies are receiving state-of-the-art radiotherapy treatment, it's not happening on the same scale in England.
Further, radiotherapy provision in England is unlikely to improve significantly. This is because the UK population continues to grow and age with a consequence increase in cancer incidence that drives an increased demand for radiotherapy of 2.3% per year.

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