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To (i) determine the actual radiotherapy utilization (RTU) stratified by age, (ii) develop an age- and co-morbidity adjusted optimal RTU model and (iii) examine the tolerance and toxicity of treatment of older patients with head and neck cancer. A retrospective cohort study based on New South Wales Cancer Registry records (2010–2014) linked to radiotherapy data (2010–2015) and admitted patient data (2008–2015) for patients diagnosed with head and neck cancer. We calculated the actual RTU, defined as the proportion of patients who received at least one course of radiotherapy within a year of diagnosis, by age group, including patients aged 80+ years. We also calculated the age and comorbidity-adjusted optimal RTU. For treatment tolerance, the radiotherapy dose for each age group and the completion rate for a seven week 70 Gray (Gy) course of curative intent radiotherapy were computed. The number of emergency department (ED) presentations were used as a surrogate measure of acute treatment toxicity for patients receiving 70 Gy. Of the 5966 patients diagnosed with head and neck cancer, 814 (13.6%) were aged 80+ years. For all age groups, the actual RTU was less than the optimal RTU. The age- and comorbidity-adjusted optimal RTU for patients aged 80+ was 52% (95% CI: 51%–53%), and the actual RTU was 40% (95% CI: 37%–44%). Only 4.4% of patients aged 80+ received 70 Gy, and the completion rate for a 70 Gy course of radiotherapy for these patients was 92%. The ED presentation rate was similar for all age groups. The actual RTU was less in the 80+ years patients and across all age groups. Fewer patients in the 80+ group received curative intent schedules compared to the actual RTU rate for younger age groups, despite similar rates of completion of curative intent radiotherapy and acute toxicity. • This population-based research highlights that even after adjusting for comorbidities, with increasing age, the actual radiotherapy utilisation rate (RTU) is less than the optimal RTU for patients with head and neck cancer. • The age- and comorbidity-adjusted optimal RTU rates for patients aged 80+ years using the cancer specific C3 'all sites' comorbidity index was 52% (95% CI: 50%–52%) and the actual RTU was 40% (95% CI: 37%–44%). • The completion rate and acute toxicity of a 70 Gy radiotherapy course were similar in all age groups. This suggests good treatment tolerance in carefully selected cases. • Further work, however, is required for the older cohort of patients to determine the reasons for the lower receipt of curative intent schedules and for all age groups, reasons for the underutilisation of RT. [ABSTRACT FROM AUTHOR] more...

Healthcare practitioners have long considered aviation as a domain from which much can be learned about safety. Over the past 30 years, attempts have been made to apply aviation safety-related concepts to healthcare. Although some applications have been successful, a few decades later, many healthcare safety experts have learned that the appeal of the aviation–healthcare analogy is an illusion. Both domains are so basically dissimilar that simple adoption of aviation concepts will not be successful. However, what has succeeded is healthcare's adaptation of specific aviation safety concepts. Three concepts, investment in safety, human factors and safety management systems, are described and examples are given of adapted applications to healthcare/clinical oncology. Finally, there is a need to ensure that these concepts are applied systematically throughout healthcare rather than sporadically and without a centralised mandate, to help ensure success and improved patient and provider safety. [ABSTRACT FROM AUTHOR] more...

There are different methods that may be used to estimate the future demand for radiotherapy services in a population ranging from expert opinion through to complex modelling techniques. This manuscript describes the use of evidence-based treatment guidelines to determine indications for radiotherapy. It also uses epidemiological data to estimate the proportion of the population who have attributes that suggest a benefit from radiotherapy in order to calculate the overall proportion of a population of new cases of cancer who appropriately could be recommended to undergo radiotherapy. Evidence-based methods are transparent and adaptable to different populations but require extensive information about the indications for radiotherapy and the proportion of cancer cases with those indications in the population. In 2003 this method produced an estimate that 52.4% of patients with a registered cancer-type had an indication for radiotherapy. The model was updated in 2012 because of changes in cancer incidence, stage distributions and indications for radiotherapy. The new estimate of the optimal radiotherapy utilisation rate was 48.3%. The decrease was due to changes in the relative frequency of cancer types and some changes in indications for radiotherapy. Actual rates of radiotherapy utilisation in most populations still fall well below this benchmark. [ABSTRACT FROM AUTHOR] more...

To develop an evidence-based benchmark for the use of radiotherapy in lung cancer, we did a systematic review of treatment guidelines on radiotherapy for lung cancer. We then constructed an optimum use of radiotherapy "tree" from epidemiological data, which shows the proportion of patients with clinical attributes indicating that they would benefit from radiotherapy. We calculated that the proportion of patients with lung cancer in whom radiotherapy is indicated (according to the best available evidence) is 76%. We then compared this ideal rate with the actual rates of use of radiotherapy for lung cancer in Australia, and internationally, in the past decade. A substantial discrepancy was found between the evidence-based recommended rate of use and the actual rates reported in clinical practice. We hope this model will be used to plan efficient and cost-effective radiotherapy services. [ABSTRACT FROM AUTHOR] more...

The Australian model of Basic Treatment Equivalent (BTE) for measuring radiotherapy treatment productivity was developed for and tested within a busy UK radiotherapy centre and the results assessed against three other BTE models. The department''s productivity was compared for three different models of treatment machine. Treatment fraction durations were timed for 362 consecutive treatment episodes on three treatment machines at Cookridge Hospital, Leeds. The treatment factors found to have a statistically significant impact on fraction duration were: initial fraction; patient mobility; number of fields; treatment intent and the type of treatment machine. In comparison with the Australasian study, shorter mean fraction times were shown for a number of types of treatment, carried out on one particular linac type, which had multileaf collimation (MLC). The average non-operational time was 17% at Cookridge (31% in Australasia) with overall productivity gains. This efficiency may have been achieved partly by a higher number of staff per machine (five rather than four) and the presence of newer technology such as MLC. A BTE model was derived for Cookridge using the significant treatment factors and compared to other published models. The Cookridge model was most sensitive in predicting productivity. BTE models developed by other groups were also excellent in predicting treatment duration. The development of a BTE model is potentially applicable in the U.K. radiotherapy community at a time when optimizing activity per radiographer is key to minimizing waiting times. Copyright 2002 The Royal College of Radiologists. Published by Elsevier Science Ltd. All rights reserved. [Copyright &y& Elsevier] more...

Abstract: Aim: To describe patterns of radiotherapy retreatment by cancer type in order to develop methods of modelling retreatment for better service planning and benchmarking. Materials and methods: We examined an institutional database of all patients who received their first megavoltage radiotherapy for any type of cancer at the Liverpool and Macarthur Cancer Therapy Centres over the period 1997–2006. The database contains patient demographic data, dates, treatment sites and doses of radiotherapy. The treatment sites were entered as free text and were recoded into a limited number of sites; primary site, bone, brain, soft tissue, other and multiple, so that retreatment sites could be grouped for stratification and analysis. Multiple treatment sites that were part of a single treatment to a primary (for example, primary site and nodes) were recoded as ‘primary’. The total retreatment ratio was defined as the number of episodes of radiotherapy divided by the number of cases in the cohort. Results: In the period 1997–2006, 7853 patients had received 9859 episodes of radiotherapy, giving a total retreatment ratio of 26 per 100 patients. In total, 6524 patients (83%) received only one episode of treatment and 1329 received two or more episodes of treatment. The average number of retreatments was 0.26. The tumour type with the highest mean number of retreatments was myeloma (1.05), followed by unknown primary (0.41), lung (0.34) and melanoma (0.32). The lowest mean number of retreatments was for the brain (0.06). The median time between treatment episodes was longest for breast cancer (12.5 months), then colorectal cancer (12.3 months), head and neck cancers (9.0 months), lung cancer (3.8 months) and prostate cancer (5.9 months). Conclusion: The retreatment ratio for the cohort was affected by the length of follow-up and by the tumour type. The mean number of retreatments varied from 0.06 for central nervous system malignancy to 1.05 for myeloma, with an average of 0.026. [Copyright &y& Elsevier] more...

AimTo test the viability of a full-scale randomised comparison of two steroid doses given with radiotherapy for malignant spinal-cord compression (MSCC), to test internet randomisation and to compare different functional outcome measures.Materials and methodsA log of screened patients at eight recruiting centres was maintained. Patients were randomised via the Superdex website to either 96 mg or 16 mg daily of dexamethasone. Radiotherapy treatment was 30 Gy in 10 fractions. Outcomes assessed used ambulation, Barthel Index ambulation, Functional Independence Measure (FIM) ambulation and Functional Improvement Score (FIS) at 1 month.ResultsOne hundred and thirty-one patients were screened. Ninety-three (71%) were ineligible, 65% of these were because duration of prior steroid use was greater than 12 h, failure to meet strict definition of magnetic resonance imaging, defined MSCC, multi-level disease or previous spinal-cord compression treatment. Twenty of the 38 eligible patients were randomised, including seven outside standard office hours. There was a high rate of serious adverse events (n = 9), but only one was considered likely to be related to study medication. At baseline, 75% were ambulant, 70% had FIM ambulation scores greater than 5 and 50% had Barthel Index ambulation scores greater than 2. At day 28, including all randomised patients (by scoring four dead patients as non-ambulant), ambulation scores by the various definitions were 60%, 45% and 40%, respectively. For the 16 patients evaluable at day 28, the mean FIS was --1.4. Median survival was 69 days and 1-year survival 13%.ConclusionWeb randomisation was successful; however, the high ineligibility rate precludes a full-scale dexamethasone dose trial in Australia. Choice of measure of ambulation has potentially significant effects on outcomes and implications for the design of any future MSCC trials. Referral delays are of concern. [ABSTRACT FROM AUTHOR] more...

Aim: The detailed review of patterns of failure in this report was undertaken to identify the continuing obstacles to the successful management of oesophageal cancer, and to establish whether there is a case to compare definitive chemo-radiation (Def-CR) and surgery for patients with squamous cancer in a randomized controlled trial.Materials and Methods: First and subsequent sites of failure were reviewed in 274 patients treated with Def-CR using two cycles of cisplatin, infusional fluorouracil and 60 Gy; and 92 patients with limited chemo-radiation (CR), using one cycle and 35 Gy, followed by surgery (CR-Surg). All were treated on prospective non-randomized trials run by the Trans-Tasman Radiation Oncology Group between 1985 and 1999. Failure patterns were analysed using competing risks methodology, and pre-treatment variables predicting survival were identified by proportional hazards modelling.Results: Site, stage, performance status and gender were independently predictive of survival following Def-CR. Local failure was evident in 42.3% of patients, but distant failure in isolation occurred in an additional 18.1%. Lowest rates of local and distant failure at 5 years (29.9% and 26%) occurred in patients with squamous cancer (SCC) located in the upper-third, whose 5-year survival was also the most favourable (49.2%). Survival was least favourable in patients with adenocarcinoma (AC) in the lower two-thirds (18.1%) due to higher rates of local (51.5%) and distant (36.1%) failure. Local failure occurred in 31.5% of patients undergoing CR-Surg but distant failure in isolation was observed in a further 34.7%. Outcomes were least favourable in patients with AC of the lower-third in whom 57.7% failed distantly and 5-year survival was 3.8%. Response to pre-operative chemo-radiation was also strongly predictive of outcome. Patients with no residual cancer in the resection specimen had the lowest rates of local (0%) and distant (16.7%) failure and the best survival (64.9%). Survival in patients with residual cancer in nodes, however, was extremely poor (3.5%) with distant failure occurring in 66.7%. Conclusion: The concurrent administration of chemotherapy with radiotherapy seems to have improved loco-regional control and has exposed distant failure as an obstacle to further improvements in outcome. Site, histological subtype, gender and response to chemo-radiation may predict biological differences in oesophageal cancer (OC) that influence outcome. A good case for a randomized comparison between Def-CR and CR-Surg in patients with SCC in the lower two-thirds exists. Copyright 2003 The Royal College of Radiologists. Published by Elsevier Science Ltd. All rights reserved. [Copyright &y& Elsevier] more...