THE NEWS MAGAZINE FROM THE BRITISH  INSTITUTE OF RADIOLOGY February 2011 www.bir.org.

uk

Imaging: IT requirements of the

future

UKRC 2011 update

A case of chronic knee pain

The launch of ACORRN

Fractionation in radiotherapy:
An idea whose time has gone? 
ISSN 2044-5113
 Community News
Decentralising NHS
radiotherapy services
Over the past three decades capacity
developers and commissioners of NHS
radiotherapy services have used the
mantra of safety for not commissioning
radiotherapy services outside of cancer
centres. In 1991, a Royal College of
Radiologists (RCR) working party report
concluded that “non-surgical cancer ser-
vices to district general hospitals should
be based at cancer centres”. Furthermore,
the working party soundly condemned
any organisation of satellite radiother-
apy treatment facilities. However, more
recently there has been an NHS strategic
shift towards decentralising radiotherapy
services using the hub-satellite model,
also known as the hub and spoke model
and the linked unit model.
This article examines the events and
potential impact of this change in thinking
by investigating whether the hub-satel-
lite model is an appropriate and feasible
method for improving NHS radiotherapy
capacity, reducing inequity of access, and
providing safe and cost effective service.
Several pressures have contributed
to the reshaping of NHS radiotherapy
services over the past 20 years. These
forces can be classified into three main
categories: epidemiological, technolog-
ical and organisational. The timing and
weight exerted by each of these forces on
the service varies. However, they have
consistently posed a challenge to health-
care strategists, managers and medical
professionals. In addition, the centralised
delivery model has contributed to the
substantial under-provision of services
and has been unable to improve the under-
capacity issue. The impotency of this
model stems from a number of reasons.
First, the space constraints of existing
10 NEWS issue 1 february 2011
facilities are preventing any horizontal
expansion; second, this model has been
associated with an increase in inequity
of access causing substantial differences
in the level of service across the United
Kingdom; third, historically the model does
not provide an incidence-based service.
Inequity remains
a major issue for
NHS radiotherapy
services in the
United Kingdom
Epidemiological challenge
The epidemiological changes in
cancer that have occurred over the past
40 years have exerted huge pressures on
NHS radiotherapy and cancer services.
In England, the total cancer incidence
continues to rise at a rate of 1.4% per
annum. This growing cancer burden has
been attributed to three main reasons: the
ageing baby boom population born during
the 1960s, the introduction of a number of
NHS screening programmes such as those
for breast, cervical and bowel cancers, and
the use of non-invasive blood tests such
as the prostate-specific antigen (PSA) test
to diagnose a large number of prostate
malignancies. Another epidemiological
change is the improvement in the cancer
survival rates in England. As a result the
number of patients living with cancer
who may require radiotherapy treatment
during their lifetime has also increased.
Radiotherapy contributes to the cure
of approximately 40% of the total number
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of cancer patients who become disease
free. It is predominantly prescribed in
combination with surgery and/or chemo-
therapy and/or hormone therapy with a
medical intention to cure. In addition to its
radical role, radiotherapy has a mainstay
in the palliation of cancer where it is given
to patients with advance stage, secondary
metastases or relapse primaries. The
overall percentage of cancer patients who
require radiotherapy treatment during
the course of their illness is estimated to
range from 50% to 60%.
Inequity in service provision
A further challenge is the stark
regional variations in the proportion of
patients receiving radiotherapy or the
variation in rate of use of radiotherapy,
which ranges between 22% and 58%.
These variations in radiotherapy use
are a direct result of the differences in
capacity level of radiotherapy services.
In 2007, a report published by the
RCR, assessing radiotherapy capacity,
highlights the issue of inequitable distri-
bution of radiotherapy resources between
different regions in the United Kingdom.
For instance, the number of radiotherapy
treatment machines or linear accelerators
(linacs) per million of population varied
by nearly a factor of 3 (2.13 per million
in the North of England and Northern
Ireland compared with 6.02 per million
in the South of England). More recently,
a survey carried by the National Cancer
Services Analysis Team (NATCANSAT)
to assess the United Kingdom radio-
therapy infrastructure shows that inequity
still remains a major issue for NHS radi-
otherapy services. The RCR recommend
6 linacs per million of population.
www.bir.org.uk
Hard Copy Environment (X-ray/Documents)
• 1st consultation
& consenting
• Conventional
Pretreatment Stimulation (CS)
• CT Scanning
• Plan Verification
on CS
TPS: Treatment Planning System
CT: Computed Tomography
Impact of information technology
Radiotherapy in the early 1990s
entered the information technology era
and was the real driving force behind
the fast and continuous development in
radiotherapy, and a number of other inno-
vations in medical imaging.
One important milestone was the
introduction of digital imaging acquisition
and management technology. The picture
archiving and communication system
(PACS) is an information technology
system that handles electronically diag-
nostic images of all imaging modalities in
a hospital. The radiotherapy community
soon discovered that to reap the benefit of
this new innovation in medical imaging
technology, the radiology tailored PAC
system needed to be modified to meet the
different imaging requirements in radia-
tion therapy. As a result, a separate branch
of PACS was developed: the radiotherapy
picture archival and communication
system (RT-PACS).
However, functionally the RT-PACS
was an information island. It was neither
linked or interfaced to the radiotherapy
treatment planning system (TPS) nor
linked to the linac treatment machines. The
reason for the lack of interface between
the RT-PACS and the multi-vendor equip-
ment within radiotherapy was due to the
absence of any internationally agreed
computer communication standard among
medical imaging and radiotherapy equip-
ment manufacturers that would facilitate
the flow and exchange of information
between the equipment. In other words,
• Data input on TPS
• Produce TP
Planning
• Carry necessary checks
• Plan sent to CS
A typical radiotherapy workflow during the early 1990s
no common computer language existed to
allow safe and accurate flow of medical
information between different computer
systems and medical equipment.
The solution to the lack of interop-
erability between different information
systems within medical imaging came
from diagnostic radiology. In 1983, the
American College of Radiology along
with the National Electrical Manufacturers
Association (NEMA) approved the first
common standard for digital communi-
cation of medical images. The approved
digital imaging and communications in
medicine (DICOM) version 1.0 was super-
seded by version 2.0 in 1988, and the
current version 3.0 was approved in 1993.
The compound PACS and DICOM-
radiotherapy protocols and standards
have created a digital environment in radi-
otherapy. Lack of systems connectivity
and interoperability within radiotherapy
has been improved tremendously
with the development of this specific
DICOM extension for radiotherapy.
The DICOM-radiotherapy extension
was developed to establish a standard
for the handling and transference of
imaging and non-imaging radiotherapy-
specific information objects definitions
(IOD), the latter highly important for
radiotherapy processes. The exten-
sion in 1997 consisted of four DICOM
objects including: radiotherapy image,
radiotherapy structure set, radio-
therapy plan and radiotherapy dose
(DICOM, 1997). In 1999, three addi-
tional “record keeping” IODs were
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• Data input of
machine parameters
Treatment (Full course or Daily)
• 1st day machine
Check X-ray films
created: radiotherapy beams treatment
record, radiotherapy brachytherapy
treatment record and radiotherapy
treatment summary record. These
DICOM-radiotherapy extensions facili-
tated the flow of image and non-image
based IODs between different systems.
Thus, these developments made it
possible for image and non-image
base-data to flow between the linac
machine, TPS, the virtual simulation
(VS) software, conventional simulator
(CS) and radiotherapy-PACS. The inter-
face capabilities coupled with advances
in telecommunication facilitated the
collaboration between different radio-
therapy centres.
The advent of information technology
innovations affected fundamental radio-
therapy work processes by transforming
many clinical practices and ultimately
re-engineering the workflow in radio-
therapy services. Our position is that
the electronic radiotherapy environment
enables most radiotherapy processes
to take place outside the traditional
centralised model while maintaining,
or even increasing, quality outcomes in
patient care.
Organisational changes
Radiotherapy workflow consists of
several interdependent processes. From
a management organisation perspective
these processes, or work, can be grouped
into three main parts or sections: pre-
treatment, planning and treatment. These
sections have been transformed by the
issue 1 february 2011 NEWS 11
 SIMULATOR
SIMULATOR
LINAC
1ST DAY
PHYSICS
LINAC PORTAL

www.bir.org.uk PHYSICS PLANCHECKS

1ST DAY FILMS
Community News
PORTAL
PLANCHECKS FILMS

RADIOGRAPHERS
advancement in information technology
Pre-treatment Process PLANNING Planning Process Treatment Process
CHECKS
CHECKS & DATA
ENTRY
DAILY LINAC and telecommunication.
WEEKLY
PHYSICS
RTTPS DAILY LINAC TREATMENT TX CARD
PLANCHECKS WEEKLY
PHYSICS CHECKS
RTTPS TREATMENT TX CARD Economic evaluation
PLANCHECKS
SIMULATOR CHECKS
In recent years, a number of studies
have been carried out to evaluate the
LINAC
PHYSICS PLANNING 1ST DAY
RADIOGRAPHERS
economical benefit of different radio-
PORTAL
PLANCHECKSCHECKS FILMS
CHECKS & DATA
ENTRY
therapy service delivery models i.e.
centralised, fully decentralised and
outreach (H&S). In 2000, a Canadian
SIMULATOR
study by Dunscombe and Roberts drew
the following conclusions: first, the
LINAC
DAILY LINAC1ST DAY WEEKLY outreach radiotherapy service model
PHYSICS PHYSICS
RTTPS TREATMENT PORTAL TX CARD
PLANCHECKS
PLANCHECKS FILMS
CHECKS “is the economically superior service
delivery model for separations between
30km and 170km”, from a societal
prospective; second, the outreach
staffing model offers cost saving as it
DAILY LINAC WEEKLY uses the existing management and super-
PHYSICS
RTTPS TREATMENT TX CARD
PLANCHECKS
CHECKS visory personnel, stationed at the central
facility or hub; third, in the context of
cost to the health system the H&S service
model was found to be more economical
compared with a fully decentralised
A typical radiotherapy workflow in the early 1990s
model in such a small catchment area.
This is owing to the saving achieved by
eliminating duplications and under-use
of equipment, such as CT scanners and
TPS. Furthermore, some have argued
that the traditional centralised model
imposes a higher financial burden on
both urban and rural radiotherapy popu-
CT RADIOGRAPHERS
CHECKS & DATA
lations when compared with the H&S.

ENTRY
The road ahead
Finally, it is worth noting that any
radiotherapy service provision model,
whether centralised, fully decentralised
VIRTUAL PHYSICS PHYSICS
WEEKLY
or H&S, which is commissioned based on
SIMULATION PLAN
CHECKS
PLAN
CHECKS
EPI & IGRT non-scientific or subjective methods will
inevitably lead to either under- or over-
capacity issues. Scientific forecasting
of future radiotherapy needs has to be
DAILY
the corner stone that enables planning
LINAC of adequate radiotherapy resources and
RTTPS
TREATMENT insure the delivery of high-quality radio-
therapy services.

A typical radiotherapy workflow in 2010 indicating the impact of radiotherapy-PACS and

DICOM-radiotherapy
 avid Shahata MSc BSc, Imperial College
D
London. With thanks to Dr Benita Cox

issue 1 february 2011 NEWS 13