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A Forward‐Looking Strategy to Deliver Improved Radiation Oncology Services

Importance of planning

A quality radiation oncology service is a multifaceted process involving several distinct groups of health experts, supporting staff, and is reliant upon custom-built facilities and an array of sophisticated equipment. In terms of time horizons, the training of the radiation oncology workforce and the implementation of the relevant infrastructure is a matter of years rather than months. Australia’s cancer registries provide reliable data on cancer incidence and projections are regularly updated. As such, the demand for radiation oncology is a known variable – it has been methodically researched and set at 52.3% of all new cancer patients¹². The known demand combined with the complex and interdependent manner of radiation oncology service provision make prospective planning logical and essential.

Compared to other specialties, radiation oncology is delivered in a relatively small number of facilities – 61 centres across Australia in 2011. Despite the small scale of the sector, planning occurs at both national and jurisdictional levels. Fragmentation in planning persists, despite being a key focus of the 2002 Baume Inquiry, particularly the variability in the state and territory cancer plans combined with an absence of a national cancer action plan. Endeavours to facilitate national coordination of radiation oncology service planning have been initiated through the Radiation Oncology Reform Implementation Committee (RORIC) which reports to the Australia Health Ministers’ Advisory Committee. Some successes have been achieved but silos in decision-making and planning remain. Achieving a truly national approach to radiation oncology service planning, let alone cancer control planning, is challenging given the nature of constitutional relationships between jurisdictions. Submissions to the Tripartite Plan from the radiation oncology professionals highlight the need to further strengthen national planning coordination to reduce fragmentation of decision-making in radiation oncology.

Submissions to the Tripartite Plan suggested that the likely consequence of the status quo will include:

Perpetuation of the ‘winners’ and ‘losers’ situation in terms of access to radiation oncology
Extended waiting times for radiation oncology
Patients continuing missing out on a potentially life-saving treatment
Patients missing out on an effective palliative treatment to reduce their pain and suffering

The radiation oncology sector lacks elasticity because there is a maximum capacity limit set on each radiotherapy machine. Although efficiency gains are possible and should be pursued by service providers, these can only extend the capacity by a certain margin. Patient access to radiation oncology is a limitation in itself which restricts the impact of efficiency gains at a facility level. This is well-understood by the radiation oncology professionals and concerns were expressed in submissions to the Tripartite Plan, which can be summarised as follows:

Lack of coordination and planning for the expansion of existing services to meet rising cancer incidence results in highly variable levels of patient access to radiation oncology services across geographic region;
Poor coordination and planning between workforce and facilities in radiation oncology results in inefficiencies, such as fluctuations in workforce numbers;
The potential of regional cancer centres being compromised because of inadequate workforce planning and of insufficient patient support schemes to access these facilities;
Private sector infrastructure is not consistently taken into account in service planning;
Lack of planning to ensure access to specific radiotherapy techniques.

There is a broad consensus in the radiation oncology sector that long-term planning, particularly coordinated at national level, holds the key to addressing current shortfalls and inefficiencies. In this context, the National Health Reform Agenda holds both promises and risks for radiation oncology. National planning is highly desirable to allow efficiencies in resource allocation across Australia and to accommodate the complexity of service planning and capital infrastructure in radiation oncology. The possible devolution of responsibility for facilities planning to the local health authorities would fragment an already weak system and put infrastructure further out of step with workforce planning. Providing a nationally agreed approach for radiation oncology services, and indeed for cancer services, would enable the local health authorities to confidently participate in planning the services provided to cancer patients.

Radiation oncology services should be planned with reference to other cancer treatments like surgery and chemotherapy. Ideally, radiation oncology treatment centres should be built within a cancer centre precinct³ to facilitate easy patient access to a comprehensive multi-modality treatment. This approach has been strongly supported by the Commonwealth in the past several years by funding the establishment of comprehensive cancer centres around Australia.

A nationally coordinated and prospective planning for radiation oncology services is needed, based on cancer incidence projections and the target radiotherapy utilisation rates. The essential components should include:

A collaborative process between decision-makers, professions and patients
A partnership approach between the Commonwealth and the jurisdictions
Sufficient facilities that are optimally located and have adequate treatment capacity to meet the needs of patients requiring radiation oncology services into the future
Service provision models focus on enabling patient access to quality services while taking into account existing public and private infrastructure
Radiation oncology workforce planning is aligned to facilities planning
Services are planned to enable patient access to the full range of radiotherapy techniques

Overall, Australia requires a National Cancer Action Plan which effectively and efficiently incorporates quality radiation oncology services.

Keeping Pace with Radiotherapy Techniques and Technologies

Radiotherapy aims to destroy cancer cells but avoid damage to the structure and function of nearby healthy tissue. Improvements in the quality and effectiveness of radiotherapy invariably stem from advances in the technology. The underlying principle of radiotherapy is to completely ablate cancer tissue while sparing adjacent normal tissue. The same principle underpins modern radiotherapy techniques.

As in many other branches of medicine, in radiation oncology there are various vendors that produce and distribute treatment equipment. While this equipment often has different configurations and various price points, the radiotherapy techniques delivered by these machines are fundamentally the same. A radiation oncology ‘treatment technique’ is defined as a method for accomplishing a desired radiation therapy dose distribution. The term ‘technology’ is used to describe the delivery device for a particular radiotherapy technique⁴.

Patient access to clinically appropriate and affordable radiotherapy treatment techniques is of paramount importance. Some examples of radiotherapy techniques include:

Three-Dimensional Conformal Radiation Therapy (3DCRT)
Intensity Modulated Radiation Therapy (IMRT)
Image Guided Radiation Therapy (IGRT)
Stereotactic Radiotherapy (SRT) and Radiosurgery (SRS)
Brachytherapy (BT)

Patient access to clinically appropriate radiotherapy techniques should form the measurable quality benchmark for the health system. Report cards on the availability of key radiotherapy techniques in Australia are included under Resourcing the Radiation Oncology Sector: Essential Radiotherapy Techniques – Intensity Modulated Radiation Therapy (IMRT), Resourcing the Radiation Oncology Sector: Essential Radiotherapy Techniques – Stereotactic Radiotherapy, Resourcing the Radiation Oncology Sector: Essential Radiotherapy Techniques – Brachytherapy and Resourcing the Radiation Oncology Sector: Essential Radiotherapy Techniques – Superficial and Orthovoltage.

The issues of new and evolving technologies are not new in Radiation Oncology and have been highlighted in the Baume Inquiry. Problems persist with the safe and timely introduction, reimbursement and dissemination of promising innovations in radiation oncology. The Commonwealth Department of Health and Ageing (DOHA) is a key agency which supports patient access to treatments through the Medicare Benefits Schedule and infrastructure improvement through the Radiation Oncology Health Program Grants (ROHPG). In the absence of DOHA support, the treatment is either not made available in Australia or is introduced on an ad hoc basis. In the latter case, the cost is passed to the patient or to the State/Territory Health Services. In radiation oncology, the effect of unavailability, delayed introduction or ad hoc introduction typically means that the service cannot be delivered to all those patients who require it for optimal cancer care. Existing delays in the introduction of modern radiotherapy techniques are around 10 years in comparison to North America. This gap is likely to continue to grow unless measures are taken.

Keeping pace with modern radiotherapy techniques makes sense because of the promise they hold for better survival, reduced side-effects and greater efficiencies. Naturally, radiation oncology techniques and technologies need to be prioritised and assessed. Technology assessment processes (including the Medical Services Advisory Committee (MSAC)) in Australia struggle to manage radiation oncology technologies for several reasons, which include⁵:

Medical devices require different criteria for assessment than pharmaceuticals because they tend to progress with incremental innovations in performance and safety. For example, in radiation oncology substantial improvements in care can be based on the next version of computer software
Lack of capital and infrastructure to support randomised clinical trials (RCT)
Strict adherence to the requirements for RCT-derived evidence of superior efficacy can be problematic if applied to radiation oncology. The limitations of the RCT methodology when applied to radiation oncology are discussed in the Research and Academia section of this report.

There is a growing concern among decision-makers about the rising costs of healthcare, including cancer care. Similarly, there is a desire to promote innovations that achieve value for cancer patient and the health system. Radiation oncology sector presents an opportunity for such innovations and improvement, but under certain conditions. The Lancet Oncology Commissions in 2011 summarised those as follows:

Policies developed to provide value-based assessment of radiation oncology treatments must create an infrastructure for evidence generation and management.
This infrastructure must have the ability to gather evidence in an ongoing manner throughout the life cycle of the technology and to adapt to inevitable incremental changes.
Finally, the infrastructure must prove a path to payment coverage that ensures emerging technologies provide value and contribute to the advancement of the discipline.

Registries⁶, as a mechanism of data capture and post-market surveillance of technologies, are a powerful tool to inform clinicians and planners. The use of meaningful endpoints and nimble research methods are essential to harness the potential advances in radiation oncology treatments.

Data collection and information standards have a key role in continually informing the directions of clinical care, health services research and support advancements in techniques and new technologies. Existing research⁷ supports the value of collecting clinical and economic data on radiotherapy treatments.

Ongoing delays in the adoption of new techniques and technologies in Australia make it a key priority that Australia moves to value-based radiotherapy and the creation of infrastructure to support data collection on the impact of new treatments.

Harmonisation of Legislation

The impact of regulatory differences between jurisdictions may influence the availability of some clinical radiation oncology services or may alter practices such that some workforce initiatives viable in one jurisdiction cannot be easily translated to another jurisdiction. For example, the current implementation of the nationally adopted codes of practice and standards for radiation protection varies considerably between jurisdictions.

The differences in application and interpretation of radiation protection measures may require a greater or lesser investment in radiation shielding to comply with local regulatory requirements. There may also be lack of requirements specific to a particular practice which is exhaustively regulated in other Australian jurisdictions. These local differences mean that the clinical availability of some techniques may be relatively hindered in some jurisdictions or have associated greater compliance costs.

Another example is in industrial relations where some workforce initiatives developed in one jurisdiction may not be easily adopted in other jurisdictions. The harmonisation of these and other regulatory requirements affecting the provision of radiation oncology services should be initiated to improve consistency in access to, and the delivery of, radiation oncology services.

Minimum Radiation Oncology Data Set

A vital component of a quality radiation oncology sector is access to data to inform planning and policy. Multiple stakeholders commented in their submissions that inadequate data collection is still a barrier to effective planning within the cancer sector. The work of Cancer Australia on a National Minimum Data Set (NMDS) and national support for this initiative is therefore critical. An NMDS is contingent upon a national agreement to collect uniform data and to supply it as part of the national collection. Over time, the availability of these data will provide more accurate information on national trends, diagnoses, health service utilisation and, ultimately, improved health outcomes⁸.

There needs to be a specific sub-set of this data relevant to radiation oncology, which is available for strategic planning. This subset needs to be readily accessible by those involved in radiation oncology planning and the users must be able to contribute to the data set and able to validate and correct the data as required. The radiation oncology sub-set of the NMDS may include the following data: case mix, cancer outcomes, toxicity outcomes, patterns of care, techniques used and intent of treatment (radical or palliative). To provide a common framework for the sharing of data and to maintain visibility of radiation oncology in cancer planning, the radiation oncology sub-set of the NMDS should not be a separate data set and should be administered by Cancer Australia.