Transcript Document
‘The Future of Radiotherapy’ The NHS and Future Plans for Radiotherapy Plymouth Cancer Summit 2015 Dr Adrian Crellin 1 What can currently cure cancer? Surgery 49% Radiotherapy 40% Radiotherapy Chemotherapy 11% Chemotherapy Surgery 5% 22% Professor Sir Mike Richards, NCRI 2011 18% Surgery Chemotherapy Radiotherapy RT = £335M DH Cancer Reform Strategy 2007 – Aim - ‘World Class Radiotherapy’ Early Diagnosis = bigger emphasis on treatment early stage tumours King’s Fund 2011 How to improve cancer survival Explaining England’s relatively poor rates ‘It is more important to improve access to surgery and radiotherapy than access to cancer drugs.’ 3 The Evolution of Radiation Therapy Courtesy Gillies McKenna Drive to increase conformal delivery to irregular tumour targets And reduce toxicity Computerized 3D CT treatment planning Cerrobend blocks Image Fusion IMRT dose-painting First Linac Particle Therapy 1960 Standard collimator 1970 1980 Shaped electron fields 1990 2000 2010 High resolution IGRT Multileaf collimator Stereotactic Radiotherapy Modernisation Radiotherapy • Intensity Modulated RT (IMRT) Image Guided RT (IGRT) • Stereotactic Ablative RT (SABR) • Stereotactic Radiosurgery (SRS) • Hypofractionation • Image Guidance • Clinical Trials • Molecular RT • Quality Assurance • Brachytherapy • Configuration • Intraoperative RT • MRI Simulation + Linacs • Partnership Centres to serve 2-4M population 5 Reduction in Variation Practice changing phase 3 clinical trials •CHART •START •CR07 •Paediatric PNET3 •PARSPORT •CHHiP - this year QIPP schemes •Breast 15 fractions •Bone mets single fraction •Prostate 20 fractions •Linked quality standards MRI Guided Gynae Brachytherapy SABR Lung Cancer Quality 6 IMRT / IGRT • NRIG • 6.8% 2011 • Radiotherapy Innovation Fund • 24% standard • All centres meeting • Raise to 50% + Planning systems Staffing Linacs SABR 6 Trials £6M announced PACE – Prostate SARON – Lung mets ABC-07- Liver SPARC - Pancreas Lung Tech - Lung CORE – Oligomets Breast Prostate Lung CtE Non CORE Primary Oligomets Spinal AVM Spinal Meningioma Spinal Schwannoma Liver – Hepatoma Pelvic recurrence - No new market entrants – Clinical Trials and ETC – CtE roll out BUT - Problems • Low spec machines not capable of IMRT/IGRT • 110 /273 Linacs Need replacing in next 3 years • Treatment Planning systems • Service pressure • Staffing • SABR needs high spec machines • All radical treatment research defined by new technology quality standards Clinical Oncology Radiographers Medical Physics RT Capacity, Demand & Efficiency • Hypofractionation • Greater efficiency of modern Linacs (VMAT) in throughput & quality • Don’t need many more Linacs but must have high specification of fleet • Current tariffs do not drive quality • Perverse incentives • Inflationary & gaming • Redraft image guidance definitions and coding • Redistribution 11 SABR / SRS / Radiotherapy • SRS capacity and demand - problematic • Hierarchy of demand • Brain mets • Rare things • Rising SRS benign workload • • • • Align to SABR Align capacity and demand with wider RT More integrated approach to whole of RT Maximise most efficient use of equipment 12 The Challenge • Innovative treatments • Technology and investment • Hypofractionation • Rarer cancers and expertise • 31 14 days start time category 1 cancers • Skill base • Staff shortage and efficiency 13 Configuration • Partnership between centres • Satellites • Configuration across populations of 2-4 Million • Travel 45 mins = old concept • Maximise use linked IT systems • Team working • Physics • Site Specialist Clinical Oncology Teams • Not everything delivered on every site • SABR / SRS • Brachytherapy • PBT • Equitable access for population • Different solutions for different geographies 14 Low Energy Protons Eyes – Choroidal Melanoma Clatterbridge 1989 First hospital based cyclotron in world 2297 Patients Excellent Results 95% local control 90% preservation of eye 80% preservation sight Complex service Durability of expensive equipment Justification in Paediatric Radiotherapy High cure rates Developing normal tissues Vulnerable tissues Late side effects Hormone system Bone growth Second Malignancy Up to 5 % currently Reduce by factor of 2 – 10 Access at younger age Neuropsychological impact Memory and IQ Cost effectiveness case not difficult 16 Dosimetric Comparison of Proton Therapy and IMRT for Ewing Sarcoma of the Spine and Chest Wall (Su Z, Indelicato DJ et al, ASTRO 2012) Proton IMRT Proton IMRT Depending on the chest wall sub-region, proton therapy has the potential to minimize cardiac, pulmonary, and renal toxicity. In long term survivors, there may be lower risks of radiation-induced second malignancies, particularly breast cancer. 5 year old - craniopharyngioma Protons IMRT Justification - Adults Wider range cancers and indications higher doses to target volume improved cure rates Skull Base/Para-spinal/Paranasal Sinuses Reduced dose outside target volume Reduced second malignancy Younger adults – fertility Reduced late effects Individual situations where otherwise treatment compromised Mediastinal Lymphoma/L Breast IMC/HPV Head and Neck Cancer/Genetic sensitivity/Anatomical variation Trials - Lung / Prostate Proton Therapy for Sacral Sarcomas: High target dose, sharp dose fall-off No appreciable dose to anterior pelvic organs Example: Sacral Sarcoma GTV: 76 Gy (RBE) < 1 Gy (RBE) < 1 Gy (RBE) Overseas Programme Paediatric Yes 401 Adult Yes 155 Total Referred 721 Growth with time Structured Approach Prioritised – clinical gain Cases Reviewed Equity Access 2 Centres USA plus PSI New policies March 2015 21 What will National Proton Beam Therapy Service look like? • Two High Energy Sites, One Service Model Integrated clinically within the hospital cancer centre setting Still limited diagnoses and indications Up to 1500 Cases per annum Much cheaper Linked quality surgical pathways Base of Skull Spine / Sacrum / Sarcoma 2018 First patients Courtesy Liz Miles RTTQA The Radiotherapy process Pre-treatment imaging Tumour & OAR Outlining CT MRI PET Treatment planning Treatment delivery and verification Importance of Radiotherapy QA Ensures: Treatment complies with nationally accepted standards Adherence to the trial protocol Minimises variations across recruiting sites Outcomes reflect differences in randomised schedules NOT departures from protocol Peters L J et al. JCO 2010;28:2996-3001 Critical Impact of Radiotherapy Protocol Compliance and Quality in the Treatment of Advanced Head and Neck Cancer: Results From TROG 02.02 Target volumes Delivering RT clinical trials Trials increased by 76% 7000 70 60 Newly opened that year Already running 17 15 40 20 10 9 7 5 10 5 6916 6000 50 30 Recruitment doubled 12 36 4 32 25 28 28 23 20 15 15 17 19 0 4148 4007 4000 10 7 4948 5000 3288 3000 41 2000 2967 2782 229821772258 19401818 1000 0 CTRad launched CTRad launched Conclusion • Radiotherapy needs modernisation and investment • Emphasis is on quality • Reduction in variation • Optimise use of resources and technology • Reconfiguration coordinated services across wider populations • Affordability 27