Access to radiotherapy: the gap between policy and practice
||A Penman * & M Barton**
* The Cancer Council NSW Sydney, NSW
** Collaboration for Cancer Outcomes Research and Evaluation,
Liverpool Health Service Liverpool, NSW
The development of radiotherapy services in Australia has failed to achieve the benchmarks set in successive government reports and policy documents. Purchase of radiotherapy facilities and development of radiation therapy units has depended to a significant degree on the activism of individuals, the support of local hospital management, and community philanthropy.
The 1996 report by the Australian Health Technology Advisory Committee (AHTAC), Beam and Isotope Radiotherapy, documented 42 prior reports, reviews and plans for radiotherapy services1. While the number of treatment facilities has increased, access to radiotherapy remains a critical issue throughout Australia, with the report of the Better Health Commission in 1994 describing it as the most important priority in cancer services.
Both the federal and NSW governments accept an utilisation rate of 50% for radiotherapy among cancer patients to be desirable target, in line with international recommendations2. The introduction of Commonwealth Health Program Grants in 1987 laid the basis for the development of an effective private radiotherapy system. The change in the access of patients in NSW Area Health Services to radiotherapy over time is shown in table one.
Eleven new linear accelerators were commissioned in the NSW public sector over the course of the second five-year plan within comprehensive cancer care centres, but there remains a substantial gap between utilisation rates actually achieved and the target rate of 50-55%. There remain long waiting lists in some centres, from two to nine weeks in August 2002. Radiation oncology departments function under considerable pressure to simply maintain services, with little time for development initiatives that are essential to guarantee state-of-the art care. In a recent national survey, one third of the linear accelerators are outmoded and the average age of equipment in the public sector was 7.6 years compared with 4.5 years in the private sector3.
In contrast to the outcry over access to elective surgery and new therapeutic drugs, the public constituency for radiation therapy has been muted. Some possible reasons why radiotherapy has not been a driving issue at federal and some state policy levels are:
- Lack of conviction of the health benefits to be gained from expanding access beyond the current level. On the basis of gross comparisons it has been claimed that survival is comparable among cancer patients with higher and lower levels of access.
- Beliefs that where radiotherapy access is constrained, adequate medical and surgical alternatives exist.
- Doubt about the effectiveness of radiotherapy, or a belief that it is old technology that will be replaced imminently by breakthroughs in medical oncology.
Perceptions and evidence in radiotherapy
1. The effectiveness of radiation therapy is well established
Radiation therapy plays a major role in the cure of cancer. Curative outcomes are measured by survival and disease-free survival. However, as the principal indications for radiotherapy were developed prior to the widespread use of randomised control trials, the evidence for effectiveness relies on the results of survival, for some indications, in large case series. There are many examples of medicine where the effectiveness of treatment is unquestioned despite the lack of evidence from randomised control trials. This includes the use of insulin for diabetic ketosis, chemotherapy for childhood leukaemia and disseminated testicular cancer, and surgery for stage I/II non-small cell lung cancer. Radiotherapy for such conditions as cancers of the nasopharynx, cervix and anal canal is supported by unequivocal evidence of efficacy with respect to the valid outcomes of survival and disease-free survival.
Many indications for the use of radiotherapy are accompanied by high levels of evidence. The applications of radiotherapy that have expanded recently have relied on randomised control trials for evidence of effectiveness. The best examples are the use of radiotherapy in the treatment of breast cancer after breast-conserving surgery4, and the use of adjuvant radiotherapy to reduce local recurrence and improved survival, with or without chemotherapy, in carcinoma of the rectum5.
Radiation therapy also has a substantial role to play in palliative care. The treatment of bone metastases for pain relief and to prevent disability from pathological fracture, alleviating chest systems in lung cancer, and reducing neurological symptoms in brain metastases are accompanied by high response rates. It reduces the requirement for narcotic analgesics and other alternative treatments, which are costly and less effective6.
In both the curative and palliative setting it usually is not possible to substitute other treatments for radiotherapy and achieve the same effect and cost-effectiveness.
2. Radiotherapy is a cost-effective treatment
Radiotherapy must compete against other modalities. Public funding of radiotherapy is inordinately influenced by the initial capital cost of radiotherapy facilities. The unit cost of care is a far more relevant yardstick. Cost-effectiveness, as judged by the cost per year of life saved or cost per quality adjusted life year (QALY), is the appropriate basis upon which the cost of radiotherapy should be compared to alternative treatments if available.
Labour costs are the dominant contributor to unit cost of care, because capital cost should be distributed over a lifetime of use7. The capital component is a relatively small component of treatment costs. Capital cost should therefore not be permitted to form a barrier to expansion of plant and equipment, though it may be a motivation for seeking alternative methods of financing.
Radiotherapy is a relatively inexpensive treatment. In 1999, in Kingston, Ontario, the cost per case was estimated to be C$4,200 including automation of equipment and all operational costs. Australian data from 1991 calculated that each year of life saved through radiotherapy costs approximately A$7,2008. As a life-extending treatment, therefore, the cost of radiotherapy compares very favourably with other interventions such as intravenous low-osmolar contrast media for diagnostic radiology ($57,000/LYG to $111,000/LYG for high risk patients)9 and renal dialysis ($14,000 and $64,000 per year depending on the site of delivery)10.
The more recent widespread use of radiotherapy for breast conservation following lumpectomy offers no survival advantage over mastectomy, but improves quality of life. When measured as cost per QALY by researchers in the US health system, radiotherapy ranks as a treatment of acceptable costs with estimated in 1995 as US$28,000/QALY11.
The availability of information on the cost and cost benefit of radiotherapy treatment is not matched by the availability of data on the cost of alternative treatment provided when access to radiotherapy is constrained. In the absence of radiotherapy for bone metastasis, patients may receive less effective, costly and quality-diminishing treatment with narcotic analgesics; the supportive care costs of someone with brain metastasis denied access to radiation therapy is unquantified; and the costs of chemotherapy substituted for radiotherapy cannot be readily identified. The invisibility of costs imposed on the health system when access to radiotherapy is diminished is an impediment to rational planning for radiation therapy. The data required for proper marginal analysis of benefit needs to be collected. However, on the figures available, radiotherapy appears to be a cost-effective investment.
3. The 50%+ target referral rate for radiotherapy is a justifiable benchmark
The Inter-Society Council for Radiation Oncology that initially promoted an access benchmark of 50% or more of incident cases of cancer receiving radiotherapy. This refers to radiotherapy at any time in the evolution of the illness.
The benchmark is based on expert consensus and has subsequently been adopted by the World Health Organisation and by the federal and NSW governments. The most accessible empirical support for the benchmark lies in the observation that referral rates in areas well supplied with radiotherapy services approach or exceed this level. Within NSW12 as table one shows, Area Health Services such as Southern and South East Sydney achieve high rates of utilisation. This is associated either with high capacity of adjacent radiotherapy services or effective visiting radiation oncology services
It is difficult to accept that these access rates are due to over-utilisation. Although patterns of over-utilisation may exist in relation to complexity of service, it is less likely to be a factor in access to a service that is dominantly supplied through the public sector, and for which few elective indications exists.
The risks of oversupply in this benchmark are small and considerably outweighed by the risks of restricted supply. In any event, the rising annual frequency of cancer further limits the risks of oversupply. It is important that the benchmark be validated by empirical means and updated with trends in the incidence and stage distribution of cancer, and changes in indications for radiation therapy.
Published reports for common tumour sites suggest a higher optimal utilisation rate 13,14. The Commonwealth government has commissioned an evidence-based estimate of the optimal utilisation rate for all tumour sites that will be completed in June 2003. Until then, it is appropriate to accept the rates achievable in areas of good supply as a relevant benchmark.
4. Cancer outcomes suffer when access to radiotherapy is impaired
The lack of access affects referral rates for radiotherapy for breast cancer among rural patients where breast conservation rates are lower than the referral rate in metropolitan areas, and mastectomy rates are higher15. There is evidence of unacceptable delays for palliative radiotherapy coincident with longer waiting lists and constrained access16. Insufficient information is available on whether constrained access for radiotherapy leads to lower rates of organ-sparing treatments in laryngeal cancer and prostate cancer.
The NSW radiation oncology plan
In NSW, radiotherapy has been included among a limited number of specialty services planned on a statewide basis, and two five-year plans – concluding in 2000 – were endorsed and substantially implemented. The planning has been facilitated by the implementation of a radiation oncology information management system, and improvements to the central cancer registry that provides detail about the distribution of demand and service delivery throughout the state. The strategic approach in NSW, though lacking somewhat in implementation, is laudable.
Planning for radiation oncology in the early 1990s resulted in a substantial increase in the rate of installation of new equipment (figure one)17.
Despite the plan however, there has been only limited progress towards achieving the target referral rate of 50%. This has occurred because of a number of factors.
1. Trends in cancer incidence
Major screening programs for breast cancer and ad hoc screening for prostate cancer led to an increase in cancer incidence that was greater than expected. The timeliness of cancer registry data needs to be improved so that projections will be more accurate.
2. Expansion of indications for radiotherapy
The evidence for the effectiveness of adjuvant radiotherapy in breast and rectal cancer has greatly increased the proportion of these cases now eligible for radiotherapy.
3. Delays in facility development
Planning and procurement for radiotherapy facilities, particularly those that involve opening new centres, have been subject to delays – with the result that the installation of linear accelerators has fallen short of planned installation (figure two). The 1996-2000 plan will finally be completed in February 2003 with the opening of the Campbelltown service.
Supply of radiation oncology professionals, and in particular radiation therapists, has deteriorated radically in the late 1990s from a situation judged adequate in 19951. Supply of radiation therapists is now at crisis levels, with a substantial proportion of available capacity idle, owing to a lack of staff.
5. Increasing complexity of care
New treatment modalities involve a far more complex array of radiation fields and fractions, and may have reduced throughput. Perhaps more so because the rate of equipment upgrade has not kept pace with the changes in X-ray therapy, or because work in radiotherapy units has not been sufficiently re-engineered to reap potential productivity gains from new technology.
The proportion of patients with cancer who have access to radiotherapy remains well below the target set by the Better Health Commission when radiotherapy provoked such concern at state and federal level in 1994. A coordinated approach is necessary to plan for equipment and staff and to implement that plan in a timely fashion. The strategic approach of NSW Health is laudable and a similar approach is necessary in other states and at a federal level because of the split in funding mechanisms.
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3. The Royal Australian and New Zealand College of Radiologists, The Australasian College of Physical Scientists and Engineers in Medicine, Australian Institute of Radiography. National Radiation Oncology Strategic Plan, 2001. The Royal Australian and New Zealand College of Radiologists, Sydney, 2001.
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