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Condensing the referral-to-first fraction workflow

    Radiation Oncology Solutions
    User experiences

    The South West Wales Cancer Centre reimagines complex radiotherapy workflows

    “The risk of local recurrence grows with increasing radiotherapy waiting times and this results in decreased survival in some clinical situations”

    Russell Banner
    Dr. Russell Banner
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    Dr. Russell Banner has been a consultant clinical oncologist in the South West Wales Cancer Centre since 2013. His specialist tumour sites are head and neck, gynaecological and skin cancers. He is active as Principal Investigator for a number of UK-wide clinical research radiotherapy trials and has a deep interest in radiotherapy quality improvements in his role as radiotherapy lead.
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    SWWCC facts:

     
    • Linacs – 4 (Elekta)
    • CT-sim – 1
    • Autocontouring – Mirada
    • Treatment planning – Pinnacle
    • OIS – MOSAIQ (Elekta)
    • Virtual simulation software – (ProSoma)
    • Full-time Clinical Oncologists – 10
    • Radiographers – 32
    • Physicists/Dosimetrists – 25
    • Catchment population – 1 million, South West Wales

    Complex radiotherapy workflows

    Patients also demand shorter waiting times”

    Decreasing time to radiotherapy is important

    “Reducing the time to the patient’s first fraction is important, Dr. Banner says. “The negative clinical impact of delaying patient treatment isn’t just theory anymore, there is an evidence base now. The risk of local recurrence grows with increasing radiotherapy waiting times and this results in decreased survival in some clinical situations.1-3
     

    “Patients also demand shorter waiting times,” he adds. “In Quebec a class-action was brought to court on behalf of patients who were waiting too long for their radiotherapy treatment on the basis it would increase local recurrence rates.”4


    “When I started in 2013, I concentrated first on decreasing the time to RT for adjuvant head-and- neck patients to boost overall survival. Delays were far too long with an average time to treatment of 12 weeks and high variation (see figure 1), Dr. Banner says. “We reduced the wait times initially by speaking with our surgeons and stressing the importance of working together, but we also focused on ways to condense the radiotherapy planning workflow. We implemented new ways of workings, such as using checklists and remove approval of plans in MOSAIQ, moving from paper booking to electronic booking and migrating all of our systems onto the Citrix platform to facilitate remote access. Performance continues to improve on this small group of about two patients each week, so that now over 75 percent of patients start within six weeks of surgery. But variability remains, and we want to make similar improvements for all patients having radiotherapy.”

    Patient's first fraction graph
    Figure 1. Average time between surgery and radiotherapy by date of surgery for locally advanced head-and-neck patients.

    Critical impact of protocol compliance

    “Besides excessively long wait times, we know that protocol deviations impact local control5,” Dr. Banner says. “We also know that in clinical trials, we have great radiotherapy quality assurance,” he continues. “How do we inject that level of quality assurance into our day-to-day clinical practice for all of our patients? We know it is important, but the radiotherapy process is complex. From referral, through imaging, image registration, all the way through to the first fraction.” “Getting things done quickly is not the only important focus. Getting them done right means following the protocol”.

    Partnering with automation to address increase in workload

    With limited human and treatment resources (see SWWCC Facts), the radiotherapy department of SWWCC is not unlike many UK cancer clinics, Dr. Banner observes.


    “Our workforce is stretched and could be bigger, especially since we’re expecting an increase in our workload,” he says. “We already brought down our time to radiotherapy, but in our view it is still not good enough. We have an excellent team with RTTs, physicists, dosimetrists and clinicians working together. We all know what we want to achieve, but we have limited resources. We see the opportunity to go so much further with automation and better interoperability of our systems.”


    SWWCC’s experience is a mirror image of many radiation therapy departments throughout the UK; the number and complexity of the different systems departments use compound the problem.

    “I recently saw an interesting comment on my Twitter feed,” he says. “The tweet was complaining about the multiple passwords and PINs in daily oncology practice in the 2019 NHS environment. It causes a great deal of frustration.”

    1. Trust's IT system
    2. Trust's Radiology system
    3. Trust's Pathology system
    4. 4-digit PIN NHS "so-called" smart card
    5. 4-digit PIN for printer/scanner
    6. Clinic outcomes system
    7. Radiotherapy network
    8. Brachytherapy network
    9. SACT/chemotherapy prescription/Network
    10. Appraisal/job planning/Leave system
    11. NHS net email account
    12. Blueteq Cancer Drug Fund access
    13. CRIS system for radiology reports
    14. Somerset cancer tracker system
    15. NHSjobs access
    16. Cancerstats accsess
    Figure 2. Reported example from Twitter of up to 16 different passwords/PINs needed for day-to-day oncology practice in 2019.
    Figure 1. Reported example from Twitter of up to 16 different passwords/PINs needed for day-to-day oncology practice in 2019.
    “Working with Philips, we see the opportunity to go so much further with automation and streamlining our processes,” he continues. “It can improve the consistency of care using a protocol-driven workflow and enhance care quality by integrating applications we employ into the pathway seamlessly. We want it all to be smoother so we can reduce the time to the first fraction.  We can do this by improving communication between teams and purposely redesigning workflows with specialists.”
    Working with Philips we see the opportunity to go so much further with automation”

    “We found out quite a lot,” Dr. Banner says. “We think we know what tasks everyone does in the workflow, but we’re checking and re-checking things constantly – sometimes we check critical things seven times. It is a matter of safety. But how many times do we really need to check that particular part of the workflow?”
    Understanding the entire workflow is key
    Figure 3. SWWCC Breast pathway mapping workshop.
    Figure 2. SWWCC Breast pathway mapping workshop.

    14-step Breast Pathway

    Swansea Breast Pathway infographic
    Figure 4. Current breast pathway at SWWCC.
    In addition to decreasing the patients’ time to treatment, patients will also benefit by helping us as clinicians to consistently treat every patient to the highest quality levels”

    Referral-to-first fraction interval graph
    Figure 5. Referral to first treatment times at SWWCC.

    Condensing the referral-to-first fraction interval from 28 days to 14 days for breast cancer patients

    Benefits for both caregivers and patients

    References

    1. Chen Z, King W, Pearcy R, Mackillop WJ. The relationship between waiting time for radiotherapy and clinical outcomes: a systematic review. Radiother Oncol. 2008 Apr;87(1):3-16.

    2. Ang KK, Trotti A, Brown BW, et al. Randomized trial addressing risk features and time factors of surgery plus radiotherapy in advanced head-and-neck cancer. Int J Radiat Oncol Biol Phys. 2001 Nov 1;51(3):571-8.

    3. Cattaneo R II, Hanna RK, Jacobsen G, Elshaikh MA. Interval between hysterectomy and start of radiation treatment is predictive of recurrence in patients with endometrial carcinoma. Int J Radiat Oncol Biol Phys. 2014 Mar 15;88(4):866-71.

    4. Gupta S, King WD, Korzeniowski M, Wallace DL, Mackillop WJ. The effect of waiting times for postoperative radiotherapy on outcomes for women receiving partial mastectomy for breast cancer: a systematic review and meta-analysis. Clin Oncol (R Coll Radiol) 2016 Dec; 28(12):739-749.

    5. Wuthrick EJ, Zhang Q et al. 2015. Institutional Clinical Trial Accrual Volume and Survival of Patients With Head and Neck Cancer. Journal of Clinical Oncology 33:156-164.

    Results are specific to the institution where they were obtained and may not reflect the results achievable at other institutions.

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