The availability of advanced radiotherapy technology to treat cancer is limited in regional Australia. At Central West Cancer Care Centre (CWCCC) the utilisation rate of intensity-modulated radiotherapy (IMRT) and volumetric modulated arc therapy (VMAT) was significantly lower compared to other NSW public health services. Stereotactic ablative body radiotherapy (SABR) treatment was not available at CWCCC. After the successful implementation of quality improvement projects, the technology utilisation rate (IMRT/VMAT) rose to over 70% in 2020, compared to below 22% in 2017 and SABR treatment is now available at CWCCC.
Aims
- To increase IMRT/VMAT utilisation rate from less than 20% in 2017 to 65%
- To make SABR treatment available at CWCCC within 18 months
Benefits
- Radiation oncologists now can prescribe and treat their patients using advanced radiotherapy technology IMRT/VMAT including SABR.
- Fewer side effects for patients and improved disease control, as the advanced techniques direct the dose to the tumour and reduce the radiation dose to the risk organ.
- Treatment is completed sooner than conventional radiotherapy, as the required dose requires fewer trips to the hospital. For example, SABR treatment reduces treatment sessions from approximately 30 to less than five, and lung cancer treatment that required twenty visits to the hospital can now be completed in four or fewer visits.
- Rural and remote patients are not required to travel to a metropolitan centre to have advanced radiotherapy treatment, including SABR.
- Improved patient comfort and equity of access to the best radiotherapy service in the region.
Background
The following problems were identified at CWCCC.
- The availability of advanced radiotherapy technology to treat cancer is limited in Western NSW.
- At CWCCC the utilisation rate of IMRT and VMAT was less than 20% in 2017, which is significantly lower compared to other NSW public health services.
- SABR treatment was not available at CWCCC, meaning patients were required to travel long distances for SABR treatment.
- Due to the large catchment area of CWCCC, patients had to travel long distances for treatment and most of them required accommodation. Therefore, enabling hypo-fractionation prescription with advanced treatment technology is beneficial and cost-effective for many patients.
Implementation
The following quality improvement projects were implemented.
- Commissioning breast IMRT.
- Commissioning VMAT technology.
- Commissioning of four dimensional computed tomography
- Commissioning of Stereotactic Radiosurgery beam and SABR technique.
- Optimisation of quality assurance methods to ensure service continuity and the safety, workflow efficiency and sustainability of the newly implemented technologies.
Implementation sites
Orange Health Service Central West Cancer Care Centre Orange Hospital, Orange, NSW 2800
Status
Sustained - The project has been implemented and is sustained in standard business.
Partnerships
- Allied health and innovation department, Western NSW Local Health District
- Radiation oncology department, Peter McCallum Cancer Centre
- Medical physics department, University of Sydney
- Clinical Excellence Commission Clinical Leadership Program
Results
After the successful implementation of the quality improvement projects, by mid-2019 the team was able to treat all prostate and breast cancers using IMRT/VMAT technology, as well as other possible body sites including lung and brain cancer. As a result, the utilisation rate of IMRT/VMAT increased significantly during 2019. Once the SABR and Four Dimensional Computed Tomography projects were completed, SABR treatment was available in March 2019. As a result, the average IMRT/VMAT utilisation rate at CWCCC rose to over 70% in 2020, compared to 22% in 2017. The CWCCC treatment provided is now consistent with metropolitan services and national and international practice standards. Rural patients can access state of the art radiotherapy services close to home
Lessons learnt
- Strong commitment from a trained team and a collaborative approach is important for the implementation of advanced technology in regional centres.
- State of the art treatment can be implemented in rural settings with collaborative teams.
- Additional staff and/or extensive training are not always required to implement new treatments.
- End-to-end testing and an external audit to ensure safety and quality is critical to build practitioner confidence in new treatments
- CWCCC collaboration with other treatment centres increased staff confidence in treatment planning, treatment set up and the patient-specific quality assurance required for advanced techniques.
- Staff were able to plan for the implementation of quality improvement by a structured project plan and dynamic leadership.
- To ensure safety and quality, there was significant testing of the treatment types as well as an internal and external audit.
Further reading
- Banjade D, Allan J, Thuraisingam K, et al. Implementation of advanced radiotherapy technology to improve clinical outcomes in rural NSW. Aust J Rural Health. 2020;28:311-316. doi: 10.1111/ajr.12630
- Gorayski P, Pinkham MB, Lehman M. Advances in radiotherapy technology for prostate cancer: What every GP should know. Aust. Fam. Physician. 2015;44:663-67.
- Barton M, Jacob S, Shafiq J, et al. Review of optimal radiotherapy utilization rates. Ingham Institute for applied medical research. 2013. https://inghaminstitute.org.au/wp-content/uploads/2017/05/RTU-Review-Final-v3-02042013.compressed.pdf.
- Murphy C, Sabesan S, Steer C, et al. Oncology service initiatives and research in regional Australia. Aust J Rural Health. 2015;23(1):40-48.
- Platt V, O’Connor K, Coleman R. Improving regional and rural cancer service in Western Australia. Aust J Rural Health. 2015;23(1):32-39.
- Waran E. Radiotherapy: The Tyranny of distance. Aust. J. Rural Health. 2015;25:64-65.
- Deng J, Feng Y, Ma Charlie, Yin FF (editorial). Novel Technologies for improved treatment outcome and patient safety in cancer radiotherapy. BioMed Research 2016; International Volume 2016, Article ID 3016454.
- RANZCR 2018.Techniques and Technologies in Radiation Oncology 2018, Version 1.0
- Ball D, Mai GT, Vinod S, Babington S, et al. Stereotactic ablative radiotherapy versus standard radiotherapy in stage 1 non-small-cell lung cancer (TROG 09.02 CHISEL): a phase 3, open-label, randomised controlled trial. Lancet Oncology. 2019; 20 (4), 494-503.
- National Rural Health Alliance. Fact sheet 8, Cancer in rural Australia. Canberra: National Rural Health Alliance; 2012 .https://www.ruralhealth.org.au/sites/default/files/publications/fact-sheet-08-cancer-rural-australia.pdf.
- Bridge P, Dempsey S, Giles E, et al. Practice patterns of radiation therapy technology in Australia: Results of national audit. Journal of Medical Radiation Sciences. 2015;62:253-260.
- Currow D, Thomson W, Bailey K. Radiotherapy Treatment Services to NSW Residents. 2018; 2017 Annual Report: Cancer Institute NSW.
- ARPANSA Australian Clinical Dosimetry Service Dosimetry, Level I, II and III Audit. https://www.arpansa.gov.au/our-services/testing-and-calibration /calibration /australian-clinical-dosimetry-service.
- Thariat J, Michel Hannoun-Levi J, Myint AS, et al. Past present and future of radiotherapy for the benefit of patients. Nature reviews clinical oncology. 2013;10:52-60.
Contact
Dilli Banjade
Central West Cancer Care Centre, Orange
Western NSW Local Health District
Phone: 02 6369 3809
dilli.banjade@health.nsw.gov.au
