|Home | About | Journals | Submit | Contact Us | Français|
An interim goal of the NHS National Cancer Plan is that, by 2005, patients with cancer should be treated within one month of diagnosis and within two months from urgent general practitioner referral. Preoperative radiotherapy for rectal cancer reduces the risk of local recurrence and may translate into improved patient survival. We conducted a prospective audit of existing waiting times for preoperative radiotherapy experienced by 65 patients with rectal cancer referred to the Christie Cancer Centre, Manchester, UK, between May and November 2002.
The median time between referral from the surgeon to the start of radiotherapy was 40 days (range 11–85). Only 4 patients (6%) received radiotherapy within 28 days of referral by the surgeon. 62 patients (95%) underwent surgery within 14 days of completing radiotherapy.
Delays in the provision of preoperative radiotherapy were primarily due to shortages of radiography staff and equipment. Lack of such infrastructure will prove a major stumbling block to achieving the targets of the NHS Cancer Plan.
The NHS Cancer Plan lays out the aims and directives of the current UK Government for the provision, organization and improvement of cancer services.1 The ultimate goal is that, by 2008 `... no patient should wait longer than one month from an urgent referral by their GP [general practitioner] with suspected cancer, to the start of treatment, except for a good clinical reason or through their personal choice....' An interim target is that, by 2005, all patients should be treated within one month of diagnosis and within two months of urgent GP referral. In light of the impending targets we audited waiting times for preoperative radiotherapy in patients with rectal cancer referred to a Cancer Centre serving North West England. Preoperative radiotherapy reduces local recurrence2 and probably improves survival.3
Between May and November 2002, a prospective audit was conducted in patients with rectal cancer referred for preoperative short-course radiotherapy to the Christie Cancer Centre, Manchester, UK. Patient demographic, clinicopathological and waiting time details were recorded. Details collected included the dates of referral to the oncology service by the surgeon, dates of the oncology outpatient appointment, times of radiotherapy and surgery, and histological results. The protocol for short-course radiotherapy involved a four field brick treatment using 4 consecutive daily fractions of 5 Gy.4 All patients gave informed consent to the study, which was approved by South Manchester Local Research Ethics Committee as part of recruitment into a parallel prospective study. Differences in time delays between groups were analysed by Student's t-test and analysis of variance (ANOVA). A P value of <0.05 was taken to be significant, all statistical tests being two-sided.
Over the six-month study period 104 patients underwent `short-course' preoperative radiotherapy. 65 of these (63% of the total number of patients undergoing preoperative short-course radiotherapy) were recruited into a prospective growth factor study and their waiting times were audited in detail.
Of the 65 patients audited, the mean age was 64.5 years (SD 10.6 years, range 35–84; 42 males, 23 females). Patients were referred from fourteen feeder hospital trusts. The median time from initial surgical referral to the start of radiotherapy was 40 days (range 11–85), made up as follows: time from referral by the consultant surgeon to oncology outpatient appointment 11 days (range 0–49) and time from oncology appointment to start of radiotherapy 29 days (range 8–43). After completing radiotherapy median delay to surgery was 6 days (range 1–24); 62 (95%) had their operations within two weeks. There was no relation between time to radiotherapy and Dukes' stage (P=0.62). To confirm that the audited patients were representative of the whole group undergoing preoperative short-course radiotherapy, the referral details and waiting times of the 39 patients not recruited into the growth factor study were also examined. Their waiting times, from consultant surgeon referral to commencement of radiotherapy and from oncology outpatient appointment to commencement of radiotherapy, did not differ from those of the main group.
This study indicates that patients with diagnosed rectal cancer waited almost six weeks from referral by their surgeon to starting radiotherapy at the Christie Cancer Centre. Only 6% of patients started radiotherapy within the specified interim target of 28 days. Moreover, we did not assess the time taken to diagnose cancer, only the delays encountered after diagnosis. Any delays incurred during the diagnostic process will add to the six weeks that patients with rectal cancer wait before receiving preoperative radiotherapy.
Our institution serves a population of 3.2 million with over 12 000 cancer registrations (4.16 cancer registrations/1000 population) per year. For patients with rectal cancer a dedicated gastrointestinal radiographer coordinates the booking system for radiotherapy. Links with the radiology and secretarial staff at the referring hospitals are established with a fax system for the receipt of urgent referrals and the return of radiotherapy dates in advance to allow for optimal planning of operation schedules. Fixed CT planning sessions are reserved each week for rectal cancer patients and are used to capacity. At the first oncology outpatient appointment, prearranged dates for CT planning and radiotherapy sessions are issued, if appropriate. This system allows flexibility for reallocation of treatment slots to other patients if radiotherapy is thought inappropriate. These service improvement measures were established before the development of the NHS Modernisation Agency and the initiatives of the Cancer Services Collaborative.
Unfortunately, the Christie Cancer Centre has below national average numbers of radiographers, physicists, linear accelerators and clinical oncologists. The Royal College of Radiologists recommends a minimum of 4 qualified radiographers per linear accelerator5 and the recommended number of linear accelerators is 4 per million population. Our institution has 9 linear accelerators for a population of about 3 million, and with current radiographer staffing levels even these 9 machines do not operate to maximum capacity. An increase to 14 machines is planned, but effective utilization demands a further increase in radiography staff. The oncologists also have a heavy workload: the recommended number of new referrals for a UK oncologist is 315 per year, and at present those at the Christie treat an average of 490 per year. A positive aspect of the results reported here is the short interval between completion of radiotherapy and surgical treatment. Only 3 patients waited longer than two weeks, because of unforeseen staff absences.
Substantial delays were identified in the provision of preoperative radiotherapy. The booking and treatment systems were running to capacity but the treatment machines were not; additional radiographers would be needed to allow optimum use of these machines, to say nothing of those due to be installed. Recruitment of additional physicists and oncologists will further increase the demand for radiographers. The targets of the NHS Cancer Plan are unlikely to be achieved in North West England without enhancement of staffing and infrastructure.