Oncology grand round

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  • ISRRT is the international umbrella organisation of professional societies representing radiographers and radiation therapists. World Congress is held every two years. First time ever held in Africa 1200 delegates 48 Countries
  • Flag Ceremony
  • Being in Africa certainly made it a friendly and colourful event. Want’ so much a cutting edge research conference, but a sharing of experiences. Very humbling. We are so well off. Uganda 1 cobalt unit with a 10 year old source. 2 RT’s treating 100 patients a day. Personally, I consider that my professional responsibility goes beyond my patients, colleagues, national society, but also internationally. Have been able to share ideas about prostate cancer and head and neck immobilisation
  • Stand out presentation. If you can see it you can treat it A future direction for radiotherapy
  • It’s not just anyone that gets to speak at the ICC.
  • Oncology grand round

    1. 1. 15th ISRRT World Congress April 24-28, 2008 Durban
    2. 2. Introduction  ISRRT Congress FeedbackISRRT Congress Feedback  Causes of waiting listsCauses of waiting lists  The New Zealand approach to waiting listThe New Zealand approach to waiting list recording and wait list managementrecording and wait list management  Future Reporting ChangesFuture Reporting Changes
    3. 3. The Nigerians
    4. 4. From imaging to therapy John BuscombeJohn Buscombe Nuclear Medicine PhysicianNuclear Medicine Physician Royal Free HospitalRoyal Free Hospital
    5. 5. Neuroendocrine tumours  Family of rare tumoursFamily of rare tumours  Associated with the neuroectodermal ridgeAssociated with the neuroectodermal ridge in the embryoin the embryo  Includes the followingIncludes the following CarcinoidCarcinoid PhaechromocytomaPhaechromocytoma Small cell lung cancerSmall cell lung cancer
    6. 6. Why radionuclide treatment of NETs  Often present too late for curative surgeryOften present too late for curative surgery  Low turn-over rate makes cells lessLow turn-over rate makes cells less susceptible to chemotherapy and externalsusceptible to chemotherapy and external DXTDXT  Maybe given in patients who have beenMaybe given in patients who have been heavily pre-treatedheavily pre-treated  Few side effectsFew side effects
    7. 7. 123 I mIBG uptake rates (Bomanji et al) PhaeochromocytomaPhaeochromocytoma NeuroblastomaNeuroblastoma CarcinoidCarcinoid Medullary thyroid CaMedullary thyroid Ca 95 %95 % 95 %95 % 60 %60 % 10 %10 %
    8. 8. Does CT change or symptom relief help predict survival  RFH, review of 38 patient – completedRFH, review of 38 patient – completed 3x5.5GBq I-131 mIBG therapy3x5.5GBq I-131 mIBG therapy  All with minimum of 12 months follow-upAll with minimum of 12 months follow-up  Looked at PFS and OS compared toLooked at PFS and OS compared to CT changesCT changes Symptom responseSymptom response
    9. 9. Overall survival related to symptom response
    10. 10. Overall survival related to change on CT
    11. 11. Pre Rx 6 m 9 m 131 I mIBG Therapy Response Neuroblastoma in a 4 year old
    12. 12. Radiotherapy Waiting List Management: The New Zealand Experience Rob Hallinan Clinical Resource Radiation Therapist Waikato Hospital Hamilton New Zealand
    13. 13. Key Stats  18000 new cancer18000 new cancer registrations per yearregistrations per year  8000 deaths/year8000 deaths/year  7200 patients treated7200 patients treated with radiotherapy/yearwith radiotherapy/year
    14. 14. Waiting Lists: The New Zealand Experience
    15. 15. Oncological Sites where delay in Radiotherapy has resulted in increased local recurrence rates  Head and NeckHead and Neck  High Grade GliomasHigh Grade Gliomas  BreastBreast  CervixCervix  NSCLCNSCLC  Soft Tissue SarcomasSoft Tissue Sarcomas  OesophagusOesophagus
    16. 16. Waiting List Causes  DemandDemand  SupplySupply  ResourceResource  HumanHuman  EquipmentEquipment  ProcessProcess  ClinicalClinical
    17. 17. 0 50 100 150 200 250 300 January February March April May June July August September October November December Month 2006 Referrals
    18. 18. Resource Factors
    19. 19. Levels of planning, actors, decisions and waiting list effects Level of planning Actors Decisions Impact NationalNational GovernmentGovernment Total level ofTotal level of healthcarehealthcare expenditureexpenditure InsufficientInsufficient funding increasesfunding increases wait listswait lists RegionalRegional HealthcareHealthcare purchaserspurchasers Volumes ofVolumes of contractcontract Incorrect volumesIncorrect volumes lead to wait listslead to wait lists HospitalHospital Management andManagement and specialtiesspecialties Resource perResource per specialtyspecialty InsufficientInsufficient resourcesresources increase wait listsincrease wait lists ProcessProcess DepartmentalDepartmental Efficiency ofEfficiency of processprocess InefficienciesInefficiencies increase wait listsincrease wait lists Vissers, J et al. Health Care Management Science 4, 133-142, 2001
    20. 20. The Multidisciplinary Team  Radiation OncologistsRadiation Oncologists  Medical PhysicistsMedical Physicists  Radiation TherapistsRadiation Therapists  EngineersEngineers
    21. 21. Equipment  Treatment CapacityTreatment Capacity  NetworkingNetworking  ImmobilisationImmobilisation
    22. 22. Process Factors  Electronic RecordElectronic Record  Small TeamsSmall Teams  MondaysMondays
    23. 23. Value Time/Real Time Ratio  Value TimeValue Time  The time spentThe time spent working on a productworking on a product  Real TimeReal Time  The total time of theThe total time of the product in the systemproduct in the system
    24. 24. Urgent Referrals 0 5 10 15 20 25 30 35 40 45 Monday Tuesday Wednesday Thursday Friday Saturday Sunday
    25. 25. New Starts 2008 Monday Tuesday Wednesday Thursday Friday Saturday Sunday
    26. 26. Clinical Factors  FractionationFractionation  BreastBreast  Bony metastasesBony metastases  Prostate HDRProstate HDR  ComplexityComplexity
    27. 27. Radiotherapy Booking Priorities Source: NZROAC Report 1999
    28. 28. Pitfalls  Joint reporting of radicalJoint reporting of radical and palliative patientsand palliative patients  Inconsistency ofInconsistency of applicationapplication  Too simplistic?Too simplistic?  Needs revision?Needs revision?
    29. 29. Shifting the goalposts Referral FSA Start of Treatment
    30. 30. Wait List Reporting Criteria 2002  Referral to FSAReferral to FSA  FSA to Start of RxFSA to Start of Rx  Referral to Start of RxReferral to Start of Rx
    31. 31.    Waikato DHB Cancer Centre Summary Waikato DHB Cancer Centre Summary     Priority A (Urgent) Priority B (Curative) Priority C (Palliative and other radical) Priority D (Combined chemotherapy and radiation treatment)Priority A (Urgent) Priority B (Curative) Priority C (Palliative and other radical) Priority D (Combined chemotherapy and radiation treatment) AssessmentAssessment A. Numbers waiting for first specialist assessment A. Numbers waiting for first specialist assessment  Dec-07Dec-07    Priority APriority A Priority BPriority B Priority CPriority C Priority DPriority D TotalTotal Assesments completed in current monthAssesments completed in current month (number of people)(number of people) 99 3636 5050 55 100100 Average wait from referral to assessmentAverage wait from referral to assessment (days)(days) 11 88 1313 3737    Number of people waiting for assessment at month endNumber of people waiting for assessment at month end (people)(people) 00 2121 109109 6868 198198 TreatmentTreatment B. Time between the first specialist assessment and the start of radiation B. Time between the first specialist assessment and the start of radiation  treatment treatment  Dec-07Dec-07       Priority APriority A Priority BPriority B Priority CPriority C Priority DPriority D TotalTotal Treatments started in current monthTreatments started in current month (number of people)(number of people) Waited < 4 weeksWaited < 4 weeks 88 1515 6767 1515 105105 Waited 4-8 weeksWaited 4-8 weeks 00 11 11 11 33 Waited 8-12 weeksWaited 8-12 weeks 00 00 00 00 00 Waited >12 weeksWaited >12 weeks 00 00 00 00 00 Average wait from assessment to treatmentAverage wait from assessment to treatment (weeks)(weeks) 0.020.02 1.41.4 1.61.6 2.52.5    Number of people with completed assessments waiting for treatment at month endNumber of people with completed assessments waiting for treatment at month end (people)(people) 00 1414 4646 55 6565 C. Time between receipt of referral and the start of radiation treatment C. Time between receipt of referral and the start of radiation treatment  Dec-07Dec-07       Priority APriority A Priority BPriority B Priority CPriority C Priority DPriority D TotalTotal Treatments started in current monthTreatments started in current month (people)(people) Waited < 4 weeksWaited < 4 weeks 77 1111 1313 22 3333 Waited 4-8 weeksWaited 4-8 weeks 00 22 3434 33 3939 Waited 8-12 weeksWaited 8-12 weeks 00 00 11 22 33 Waited >12 weeksWaited >12 weeks 00 00 11 66 77 Total Total  77 1313 4949 1111 8282 Average wait from referral to treatmentAverage wait from referral to treatment (weeks)(weeks)    0.340.34 2.952.95 5.135.13 1313 4.244.24
    32. 32.    National Summary National Summary                    Priority A (Urgent) Priority B (Curative) Priority C (Palliative and other radical) Priority D (Combined chemotherapy and radiation treatment)Priority A (Urgent) Priority B (Curative) Priority C (Palliative and other radical) Priority D (Combined chemotherapy and radiation treatment) Time between the first specialist assessment and the start of Time between the first specialist assessment and the start of  radiation treatment radiation treatment  Dec-07Dec-07       Priority APriority A Priority BPriority B PriorityPriority CC PriorityPriority DD TotalTotal Waited < 4 weeksWaited < 4 weeks 4242 5656 226226 33 327327 Waited 4-8 weeksWaited 4-8 weeks 00 2929 6060 1616 105105 Waited 8-12 weeksWaited 8-12 weeks 00 11 1212 44 1717 Waited >12 weeksWaited >12 weeks 00 11 99 4141 5151 TOTALTOTAL 4242 8787 307307 6464 500500 Ministry of Health Monthly Report National w ait tim es for patients in priority categories A, B & C HEALTH TARGET 100% of patients treated in less than 8 w eeks 0% 20% 40% 60% 80% 100% July2007 Aug2007 Sept2007 Oct2007 Nov2007 Dec2007 HEALTH TARGET % Waited < 4 w eeks % Waited 4-8 w eeks
    33. 33. A matter of perspective  PatientPatient  FunderFunder  ClinicianClinician  Service DeliveryService Delivery  Ministry of HealthMinistry of Health
    34. 34. Controversy  What dates areWhat dates are significant?significant?  DiagnosisDiagnosis  SurgerySurgery  ReferralReferral  FSAFSA  Decision to treatDecision to treat  Ready to start treatmentReady to start treatment  What factors shouldWhat factors should be discounted?be discounted?  Patient morbiditiesPatient morbidities  Factors outsideFactors outside oncology departmentoncology department controlcontrol  Factors outsideFactors outside radiation oncologyradiation oncology controlcontrol Categorisation!
    35. 35. Future Changes  Cancer ControlCancer Control Strategy GoalStrategy Goal  MOH ReportingMOH Reporting  CWG ReportingCWG Reporting
    36. 36. MOH Reporting  New Goal FSA to Start < 6 weeksNew Goal FSA to Start < 6 weeks  Multivariate analysisMultivariate analysis CategoryCategory EthnicityEthnicity DHBDHB  Separation of palliative and radical patientsSeparation of palliative and radical patients  Reasons for patients waiting > 6 weeksReasons for patients waiting > 6 weeks  Chemotherapy FSA-Start of TreatmentChemotherapy FSA-Start of Treatment
    37. 37. Reasons for patients waiting > 6 weeks  Post-operative/chemo complicationsPost-operative/chemo complications  Treatment of intercurrent co-morbiditiesTreatment of intercurrent co-morbidities  Patient requestPatient request  Awaiting radiology/pathology resultsAwaiting radiology/pathology results  Dental interventionDental intervention  Other outside department controlOther outside department control  Department/facility constraintDepartment/facility constraint
    38. 38. CWG Reporting Requirements 4 Waiting Times 4 . 1Average Days Referral to FSA days 4 . 2 Ready to Treat (booking date) to Commencement of Treatment 4.2.1 Urgent (A) - < 24 Hours % Within Guidelines 4.2.2 Curative (B) - within 2weeks % Within Guidelines 4.2.3 Palliative (C) - within 2 weeks % Within Guidelines 4.2.4 Radical (C) -within 4 weeks % Within Guidelines 4.2.5 Pre Scheduled (D) Days
    39. 39. Categorisation Changes Initial ReferralInitial Referral  1 Urgent1 Urgent  2 Curative2 Curative  3 Radical3 Radical  4 Protocol4 Protocol  5 Palliative5 Palliative RT CategorisationRT Categorisation  AA  BB  CC  DD  C PallC Pall
    40. 40. Colonel Roger Fray
    41. 41. Oncology Referral Database
    42. 42. Colonel Roger Fray  Data EntryData Entry Initial ReferralInitial Referral Decision to TreatDecision to Treat Start of TreatmentStart of Treatment  Patient DataPatient Data Name, NHI Number, DHB, EthnicityName, NHI Number, DHB, Ethnicity
    43. 43. Colonel Roger Fray  Referral InformationReferral Information  ReferrerReferrer  Referral DateReferral Date  CategorisationCategorisation  FSA DateFSA Date  Radiotherapy InformationRadiotherapy Information  ModalityModality  CategorisationCategorisation  Radiation OncologistRadiation Oncologist  Ready to Treat DateReady to Treat Date  Simulation DateSimulation Date  Planning DatePlanning Date  Start DateStart Date  Delay ReasonsDelay Reasons
    44. 44. Actual Wait Times RTT-Start 0 5 10 15 20 25 30 35 O ct-06 Dec-06 Feb-07 Apr-07 Jun-07 Aug-07 O ct-07 Dec-07 Feb-08 Apr-08 Prostate Breast B
    45. 45. Total Patients on Wait List vs Daily Linac Treatments 0 20 40 60 80 100 120 140 O ct-06D ec-06Feb-07 Apr-07Jun-07Aug-07 O ct-07D ec-07Feb-08 Apr-08 Patients Waiting for RT Linac Patients
    46. 46. Take Home Messages  Waiting lists are not just a function of staffWaiting lists are not just a function of staff and equipment shortagesand equipment shortages  A national categorisation system needs toA national categorisation system needs to have internal and external consistency ofhave internal and external consistency of applicationapplication  An independent database is a valuableAn independent database is a valuable tool for analysis and reporting of practice.tool for analysis and reporting of practice.
    47. 47. References Improving Non-Surgical Cancer Treatment Services in New Zealand,Improving Non-Surgical Cancer Treatment Services in New Zealand, New Zealand Ministry of Health, July 200New Zealand Ministry of Health, July 200 Towards Decision Support for Waiting Lists: An OperationsTowards Decision Support for Waiting Lists: An Operations Management View,Management View, Vissers, J. et al., Health Care Management Science 4, 133-142,Vissers, J. et al., Health Care Management Science 4, 133-142, 20012001 Management of waiting lists for Radiation Therapy,Management of waiting lists for Radiation Therapy, The Royal Australian and New Zealand College of Radiologists,The Royal Australian and New Zealand College of Radiologists, Faculty of Radiation Oncology, April 2004Faculty of Radiation Oncology, April 2004 Waiting for Radiotherapy,Waiting for Radiotherapy, Dodwell, D. & Crellin, A; British Medical Journal, 14 JanuaryDodwell, D. & Crellin, A; British Medical Journal, 14 January 20062006 Killing time: The consequences of delays in radiotherapy,Killing time: The consequences of delays in radiotherapy, Mackillop, W., Radiotherapy and Oncology 84 (2007) 1-4Mackillop, W., Radiotherapy and Oncology 84 (2007) 1-4

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