Radiotherapy in England in 2007: modelled demand and audited activity

Modelling of demand has indicated substantial underprovision of radiotherapy in England. We have used national audit data to understand the differences between theory and practice.

We used a web-based tool to collect data on all National Health Service patients in England starting a course of radiotherapy in the week commencing 24 September 2007. We also collected information on cancer site, so that patients could be triaged into the 22 categories used by the National Radiotherapy Advisory Group (NRAG).

In England, excluding skin cancer other than melanoma, 2114 patients were prescribed 27,420 fractions during that week. Comparison of the audit data with the NRAG model showed that the shortfall in provision was a mixture of a lack of access (67%) and reduced fractionation (33%). The largest contributions to the overall gap were seen in the treatment of cancers of the breast (6%) (modelled at 15 fractions), head and neck (10%), lung (28%) and prostate (14%), together accounting for 58% of the difference. Others (including sarcoma and unknown primary) accounted for 19% of the difference. Limited access to radiotherapy for patients with stomach and pancreatic cancer contributed 10% and reduced fractionation for oesophageal cancer accounted for 6% of the overall gap. Fewer patients than expected were treated for rectal cancer, but they received 25 fraction regimens rather than short-course preoperative treatment. Patients with leukaemia and cancers of the brain, colon, corpus uteri and ovary received radiotherapy more often than expected, but because they are relatively rare none of these had an overall impact exceeding 1.2% of the gap in provision.

This audit confirms the underprovision of radiotherapy in England and shows that it is largely accounted for by low access rates of 37% rather than the 50% accepted in the literature. In consequence we estimate that 33 881 patients (13.9%) of the 243 748 patients diagnosed with cancer in England during 2006/2007 did not receive the radiotherapy we would have expected. Some of this gap in provision may be accounted for by differences in stage and performance status, which limit treatment options, for example in lung cancer. The NRAG model should be updated to take account of new data from this and other national audits, to ensure that it describes the stage and performance status of English patients and is sensitive to the range of professional opinion about treatment options. This will be essential for long-term planning as cancer incidence increases over the next decade, but it does not weaken the conclusion that there is a substantial current shortfall to be addressed immediately to improve timely access to treatment and thus the outcomes of therapy. As more resource becomes available, it should be possible to consider changing dose fractionation to comply with evidence-based practice and national guidelines from the National Institute for Health and Clinical Excellence and other bodies without disadvantaging patients by increasing waiting times.