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Modelling Radiotherapy
Tim Cooper
National Cancer Action Team
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NRAG Report• Deliver 40,000 fractions per mil pop by 2010; and (around) 54,000 fractions by 2016
• Deliver 8,300 fractions per Linac by 2010/11; 8,700 per Linac by 2016
• 31 days wait time standard achieved by December 2010
• Robust capital replacement programmes in place.
• All new & replacement machines capable of image guided IGRT
• National data collection is fed back to stakeholders at agreed intervals.
• Development of a workforce strategy that will deliver the required skills mix
• Implementation of the 4 tier model. Fast track career progression.
• A business case for a modern proton treatment facility in England
• Centres offer full service where operate weekends & Bank Holidays
• Extended days on 50% of machines
• Set throughput/ efficiency benchmarks.
• National overview of plans maintained.
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[NB Prostate has been excluded as survival ‘gap’ is likely to be due to differences in PSA testing rates.]Data derived from Abdel-Rahman et al, BJC Supplement December 2009
Avoidable deaths pa if survival in England matched the best in Europe
Breast ~ 2000 Myeloma 250
Colorectal ~1700 Endometrial 250
Lung ~1300 Leukaemia 240
Oesophagogastric ~950 Brain 225
Kidney ~700 Melanoma 190
Ovary ~500 Cervix 180
NHL/HD 370 Oral/Larynx 170
Bladder 290 Pancreas 75
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Radiotherapy as a Treatment for Cancer
Ref: IARC/WHO Lyons
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Key Message – Improving Outcomes Strategy
Access to radiotherapy is critical to improving outcomes.
To improve outcomes from radiotherapy, there must be equitable access to high quality, safe, timely, protocol-driven quality-controlled services focused around patients’ needs.
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Issues in Access
• Variation
• Missing patients (uptake)
Malthus will help address both
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Variability
• Variation in prescribing• Commissioning for Quality• Outcomes
– Buy more fractions if the evidence is strong• MALTHUS
– Modelling– Clinical consensus
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Attendances per patient - allRadiotherapy Attendances in 09/10 per Patient by Cancer Network
0
2
4
6
8
10
12
14
16
18
Lanc
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Attendances per patient - allRadiotherapy Attendances in 09/10 per Patient by Cancer Network
0
2
4
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Lanc
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Attendances per patient - BreastBreast Radiotherapy Attendances in 09/10 Per Patient by Cancer Network
0
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Attendances per patient - BreastBreast Radiotherapy Attendances in 09/10 Per Patient by Cancer Network
0
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4
6
8
10
12
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Variability
• Variation in prescribing• Commissioning for Quality• Outcomes
– Buy more fractions if the evidence is strong• MALTHUS
– Modelling– Clinical consensus– 20th June
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Issues in Access
• Variation
• Missing patients (uptake)
Malthus will help address both
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What is Malthus?
• MALTHUS project to – develop an interactive tool for radiotherapy
demand modelling in England, – establish consensus for radiotherapy prescribing
• Builds on the model used for NRAG report (2007) determining national radiotherapy requirements
• Designed to inform on radiotherapy demand for commissioning and planning purposes
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MALTHUS Implementation
• Operates at local (PCT) & national level• Models RT fraction demand per 100k
population• Discrete event simulation model :
generates virtual populations of patients matching demographics of local population
• Use high quality incidence data from cancer registries & direct feeds from NCIN
• No formal health economics / cost effectiveness modelling
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MALTHUS Implementation
• Appropriate rate of radiotherapy is determined from a decision tree
• Decision tree gives a fraction ‘load’ per patient
• MALTHUS uses two types of decision tree– Evidence based (revision of
CCORE type trees)– Pragmatic (based on expert
opinion and current practice)
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Overview of modelMalthus tool downloaded
on PC
Curated incidence data feeds from NCAT
server
User select PCT / Region
to model Patient generator creates
matching virtual population of
patients
Breast Lung H&N Urology
∑ 35000 # for PCT
Evidence based trees
Consensus based trees
User Customised trees
DiseaseStageAgeCo-morbidity
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Capacity planning• Mandated in Improving Outcomes and the
Operating Framework• Commissioners must assess the needs of
their populations• MALTHUS (Local desktop tool)
– Revision of NRAG model to take account of:
– Cancer incidence– Stage, performance status, comorbidities– Changes in treatment pathway since 2006
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Deprivation and access• Lack of access and deprivation are
strongly correlated • This may be explained by
– Stage at presentation– Performance status– Co-morbidity– Fitness for radical treatment– Willingness to travel– Patient choice
• Needs individual patient data to test
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Improving access• Review care pathways• Facilitate early presentation• Patient education• Boost participation in MDTs• Examine local data• Compare to local cancer incidence• Concentrate on common cancers and their
treatment
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Malthus project(Monte-Carlo Application for Local Treatment and Healthcare Usage Simulation)
• High-quality local cancer incidence data• Scenario trees
– literature review of evidence base – clinical oncologists’ consensus
• Desktop application• User can adjust to local practice• Provides a commissioning tool
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