Ausl.
3
N.Z. J . Surg. 1990, 60, 3-7
PERSONAL VIEWS RADIATION ONCOLOGY IN AUSTRALIA: THE HORNS OF A DILEMMA ALLAN0 . LANGLANDS Radiation Oncology Department, Westmead Hospital, Westmead, New South Wales
Introduction The treatment of cancer is becoming increasingly complex as multimodality approaches are developed. In any complex system, there will be many factors which determine outcome, but not the least of these would be the quality of care provided by the individual specialties involved, namely surgery, radiation oncology and medical oncology. All those concerned with the care of patients with cancer in Australia must therefore be extremely concerned at a report which appeared in 1988.' The report described the present status of radiation oncology in Australia as one of a specialty facing an increasing crisis. The major development of radiation oncology in Australia followed, as elsewhere in the world, immediately after World War 11. In 1943, Ralston Paterson, the doyen of British Radiotherapists and Director of the Christie Hospital and Holt Radium Institute was invited to visit Australia. He spent time with the Departments of Health in New South Wales, Queensland and Victoria and met with delegates from Tasmania. Although there are now no records of those conversations, it seems clear that Ralston Paterson would have given exactly the same advice to each state. In England, he directed a free-standing, independent hospital, devoted to the specialty of radiation oncology and to the treatment of cancer. He would have recommended that each state should follow that example. The effect of that advice is seen in Queensland, where, until recently, the Queensland Radium Institute was charged with the provision of radiotherapy services for the whole of that state. But the Queensland Radium Institute, unlike the Christie Hospital and Holt Radium Jnstitute, is an integral part of a major teaching general hospital. In New South Wales, it appears that his advice was ignored and there, several hospitals acquired one or two pieces of unsophisticated equipment and each hospital tried to develop an inhouse A. 0. Langlands FRCR, FRACR, FRCS (Ed.), Radiation Oncology Department, Westmead Hospital, Westmead, NSW 2145, Australia. Accepted for publication 17 August 1989
service. Radiation oncology was seen as a service or even a paramedical facility; academic development was unknown if not actively discouraged. It was in Victoria that Paterson had the greatest influence with the foundation in 1948 of the Peter MacCallum Cancer Institute as an independent cancer hospital much along the lines of the Christie Hospital and Holt Radium Institute in Manchester or the Princess Margaret Hospital, Toronto or the M.D. Anderson Hospital in Texas. We had, therefore, in the three eastern, most populated states in Australia, very different organizations for the delivery of radiation therapy as part of cancer care. It is a great pity that an opportunity has never been taken to look at the patterns of care delivered under those three quite different circumstances. Although strong views are held on what is the optimum organization for the delivery of that care, very little solid information exists and virtually no research has been done. In the absence of information on the patterns of care in Australia, considerable reliance has been placed on the results of overseas studies such as the Patterns of Care Study in the This study is a comprehensive review by the American College of Radiology of the radiation therapy facilities in the USA, their manpower, and the quality of care delivered. These facilities were reviewed in 1973, 1977 and 1979 and at intervals since then for special projects. The undertaking was enormous. In the fnst place, a consensus regarding the appropriate pretreatment investigation of different cancers, their optimum management and their follow-up had to be established.' That consensus might not be agreed to in Australia. It should also be noted, before too restrictive conclusions are drawn, that there are significant differences in the patterns of radiation oncology services in the USA and in Australia. In the USA, 66% of radiation therapy facilities are placed in community hospitals and only 19% in University Hospitals.' In contradistinction in Australia, all facilities in the public sector are located in teaching hospitals. The average centre in New South Wales, for example, sees approximately 1.5 times the referral rate of a centre classified as major in the United States. In Australia, a greater degree of total
4
LANGLANDS
patient care is the responsibility of the radiotherapist than is the case in the USA. With these differences in mind, important conclusions which emerged from the Patterns of Care Study related to factors which predict for a significantly reduced treatment outcome. '"-I6 Most of these have been identified by Wigg as major components of the crisis which exists in Australia today, and include the fonowing.
Unavailability of appropriate equipment and lack of back-up facilities and support staff This would appear to be self-evident. There seems little point in continuing to fund cancer research in the hope of gains in survival while, at the same time, ignoring equally significant gains which can be obtained by the provision of properly equipped and staffed facilities. With the present deficiencies in staff and equipment, it could prove difficult to translate research developments into clinical practice.
Too few patients/Too many patients These conclusions relate to the question of the optimum siting of radiation oncology facilities in terms of populations at risk and the physical requirements for the provision of a proper radiation oncology service. The Patterns of Care Study quite clearly demonstrated that there was a critical mass, both of patients and of equipment, if optimal results are to be obtained. For example, in the management of carcinoma of the cervix, it demonstrated a significant rise in the incidence of complications when the total number of cases being controlled by one radiotherapist exceeded 280 new cases of cancer per annum. The question of a critical population size is difficult, particularly in Australia, because of the distribution of the population on the coastal strips. In my opinion, the ideal population to be served by a radiation oncology facility is of the order of 1 million people which would yield 3000 cases of cancer per annum, some 1500 or more of whom should receive radiotherapy at some time during the course of their illness. That population figure may require to be halved if account is to be taken of demographic factors, ease of access, transport, etc. That decision is essentially one for the politicians and the individual departments of health. Resources are limited and some concentration of equipment is unavoidable and even desirable. What is clear, however, is that once a decision has been made to provide a radiation oncology service in the community, then certain other commitments follow, including the provision of a comprehensive fully staffed facility.
Failure to establish an academic basis and an active training programme A recent survey of education about cancer demonstrated disturbing differences in undergraduate training within Australia. Differences existed between states, within states and between hospitals of the same university, regarding the exposure of undergraduates to the specialty of radiation oncology and its role in cancer management." On average, 50% of Australian medical students graduate without ever visiting a department of radiation oncology. It seems self-evident that biases like this which are introduced into the undergraduate curriculum are likely to be life-long. Undergraduates who leave their medical school with no experience whatsoever of radiation oncology are unlikely to perceive that specialty as important in the management of cancer and are unlikely to perceive that specialty as a potential career. In contrast, most of the countries in the European community require a separate course in oncology in undergraduate education. These courses are usually the responsibility of a cancer centre which might be defined as a major teaching hospital containing departments of radiation oncology and medical oncology. The duration is 10-14 days full-time and includes compulsory attendance at multidisciplinary conferences in cancer diagnosis and management. If there is a move to establish new radiation oncology facilities in Australia and if they are established in community hospitals, then those hospitals at which they are sited must develop an active role in the education of undergraduate and postgraduate students. In other words, they must become teaching hospitals. Multidisciplinary management One of the most important differences to emerge in terms of survival rates in the Patterns of Care Study in the USA was the demonstration of improved cancer control rates when multidisciplinary treatment was possible. This was exemplified in several studies of the more advanced stages of head and neck cancer. While multidisciplinary management did occur in the smaller hospitals, the frequericy with which it did was significantly lower and this was reflected in recurrence rates which were up to 3.5 times those occurring in larger centres. Advances in radiation oncology in recent years have seen the emergence of a new emphasis in cancer therapy, namely, the successful treatment of cancer with organ preservation. Approximately 22% of early-stage cancers can be managed by this approach, including cancers of the breast, prostate, and head and neck.'9 In the case of breast cancer, particularly, the ability to treat early disease by
RADIATION ONCOLOGY IN AUSTRALIA
5
surgery which conserves the breast followed by radiation therapy is an important incentive for women to participate in breast cancer screening. It seems illogical to promote this approach at a time when radiation oncology services are already under significant pressure. Furthermore, there has recently been increasing interest in the development of techniques for the surgical management of limited metastatic disease. This is a complex area which requires timeconsuming co-operation between surgeons and other oncologists, including radiation therapists. Nevertheless, these are three areas in which real progress is being made in cancer therapy. They all require the closest co-operation between the surgeon and the radiotherapist for them to be successful. Success is measured not only in terms of improvement in survival but also in terms of the quality of that survival. Chronic deficiencies in the staff and facilities for radiation therapy must therefore be of concern to all surgeons with an interest in the management of cancer. They will jeopardize or render difficult the close co-operation that is essential between the surgeon and radiotherapist if this new emphasis is to continue in cancer management. Table 1 shows that Australia-wide some 36% of patients with cancer receive radiation therapy at some time during its management. This contrasts badly with the most recent rates from the UK, Canada and the USA which suggest that, for optimal cancer management, the proportion should be in excess of 50%. The reasons for this discrepancy are complex and certainly geographical factors are important. One can only speculate about the impact on referral rates of difficulty of access to facilities of high calibre, or about the detemng effects of long waiting lists. Table 1. New cases of cancer treated by radiotherapy Country
Years
UK Canada USA Australia
1973-86 1976-80 1973-84 1986
Range
(YO)
45-53 48-52 46-53 36
For the UK, Canada and the USA, there has been a significant increase over the years indicated. In Australia, the range between states is wide from around 25% in Queensland to 43% in New South Wales. Modified from Wigg.'
Australian dilemma It would be tempting to dismiss the article by Wigg as simply the lobby of the vested interest of one specialty for an expansion in funds and facilities. This would be a superficial treatment of a document which is carefully researched, referenced and
which quite appropriately takes its place in the scientific literature of this country. Wigg documented serious deficiences in the quality and quantity of equipment which exists in Australia. However, that is a relatively minor problem. There is no difficulty in providing a shopping list for the equipment which is necessary to run a modem Department of Radiation Oncology. The list of the basic equipment requirements for a facility are listed in Table 2. What is much more difficult to do is to provide advice regarding, not only the optimum siting of this equipment, but also the implications that the development of new facilities would have for the hospitals in which they are sited. Table 2. The basic equipment and facilities required by a Department of Radiation Oncology
Two megavoltage machines of which one should be a linear accelerator of 6 MeV energy or greater with electron capability
Superficial/orthovoltage machine(s) A planning simulator Computerized tomography-assisted computer planning Facilities for access to interstitial and intracavitary brachytherapy Facilities for or access to data management Facilities for the construction of patient immobilization devices, custom made blocks, etc. Medical physics staff and facilities
This then is the dilemma which faces radiation oncology in Australia. In the first place, there is the deficiency of equipment. However, it must be remembered that its correction by an expansion in facilities (and there is evidence that that is beginning to occur), will be taking place at a time when there are well documented, long-standing deficiencies in the recruitment and training of radiation oncologists, therapeutic radiographers and medical physicists. These deficiencies will be aggravated by the increasing utilization of radiation therapy in the management of common cancers such as those of breast, prostate and rectum, hitherto considered 'surgical cancers'. Table 3 shows that, by comparison with many countries in Europe and North America, the number of radiotherapists per million of the population in Australia is the lowest, and is the second lowest proportion of the recommended number which has been accepted by the government of the country.2o Numerous reports have appeared over the years at state and federal level addressing these issues. Morgan has documented some 16 discussion papers and reports on radiation oncology services commissioned in Australia during 1982-88.*' As a generalization, the reaction to these has been one of total inertia. The easier solution, money, may well be
6
LANGLANDS
found for the acquisition of equipment. This will be embarrassingly ineffective unless there is proper planning for a co-ordinated expansion of facilities at the same time as the training of radiographers, physicists and radiation oncologists is expanded pro rata in Australia. There is no evidence that the governments are capable of such a co-ordinated response to the crisis which exists. Unless there is a co-ordinated response, internal competition for staff will compromise the service further. Table 3. Actual numbers of radiation oncologists per million compared with the recommended number
Country
Actual
Recommended
Actual number as percentage of recommended
Australia
4.8 5.6 5.6 11.0 5.3 8.3
7.0 7 .0 6.5
69 80 86
-
-
8.3 10.0
64 83
NZ UK
Sweden Canada USA
Modified from Wigg.
’
It seems absolutely certain that we will never see again in Australia the construction of an independent free-standing cancer hospital. The development of new centres therefore has enormous implications for the hospitals in which they are going to be placed, for the states which agree to their development, and for the Federal Government in its overall policy regarding healthcare. Each new centre must be equipped to a standard that is capable of delivering modern radiotherapy of the highest quality. The simple acquisition of, for example, a single machine does not provide a hospital with an effective service, although it may give it a degree of independence in cancer management which is largely spurious and not in the best interests of patients. Within the hospitals which acquire new Departments of Radiation Oncology, attitudes will have to change within other disciplines. The argument as to the ownership of the cancer patient should be one consigned to the past.” Clinicians will have to accept that multidisciplinary management means a release of clinical responsibility from one clinician to another. Special demands will be made on one service to support another. These demands will only be met successfully provided the final goal is the optimum care of the cancer patient. These adjustments can be difficult, for the sovereignty of some specialties may appear to be challenged. If the crisis is to be resolved, then a major component which must be addressed is the education of doctors in the management of the cancer patient. It is therefore sobering to read a joint statement by the
Union International Contra Cancer (UICC) and the World Health Organization (WHO) in 1981 that ‘in most countries there is a significant gap between the actual cure rates of various cancers and the maximum cure rates obtainable through utilizing currently available knowledge. This indicates the size of the educational problem’.23 It is for the philosophy contained in that statement that I believe that the optimum siting of radiation oncology facilities should be within the ambit of a major general hospital of university teaching status. Although it can be argued that medical students or the postgraduate can travel readily to the free-standing independent institution, education is a far more complex process than that - it requires the continuing regular interaction of people in a variety of disciplines at a variety of levels, all of which is far more subtle than the formal lecture, seminar or clinical demonstration. Again, in 1981, in a joint statement on undergraduate education about cancer, the UICC and WHO said, ‘the differences in opinion held by various disciplines, however objectively justified they may be, may be sufficiently great to exert a negative effect on the process of instruction’.22 That statement, too, is an important argument for the siting of facilities in general hospitals. Only by so doing do I believe that the genuine differences of opinion which now exist between the specialties will be resolved by mutual interaction.
References 1. WIGGD. R. (1988) Radiation oncology in Australia: An increasing crisis. Australas. Radiol. 32, 24-37. 2. KRAMER S . & HERRING D. F. (1976) The Patterns of Care Study: A nation-wide evaluation of the practice of radiation therapy in cancer management. Int. J . Rad. Oncol. Biol. Phys. 1, 1231-6. 3. KivmER S . (1977) The study of the patterns of cancer care in radiation therapy. Cancer 39, 780-7. s., HANKSG. E. & DIAMOND J . J . (1983) 4. KRAMER Summary results from the fourth facilities master list survey, conducted by the Patterns of Care Study. Inr. J . Rad. Oncol. Biol. Plzys. 9, 1881-3. 5 . KRAMERS . (1984) The patterns of clinical care in radiation therapy in the United States. Int. J.’Rad. Oncol. B i d . Phys. 10, 49-53. 6. DIAMOND J . J . , KRAMER S . & HANKSG. E. (1986) Trends in radiation therapy demographics 1974 to 1983. Int. J . Rad. Oncol. Biol. Phys. 12, 1673-4. J . J . , HANKS G . E. & KRAMER S. (1988) The 7. DIAMOND structure of radiation oncology practices in the continental United States. Int. J . Rad. Oncol. Biol. Phys. 14,547-8. G. E. & KRAMER S . (1984) Consensus of best 8. HANKS current management. The starting point for clinical
quality assessment. Int. J . Rad. Oncol. Biol. Phys. 10, 87-97. S . , HANKS G. E., HERRING D. F. & DAVIS 9. KRAMER
RADIATION ONCOLOGY IN AUSTRALIA
10.
11.
12. 13. 14.
15. 16.
L. W. (1982) Summary results from the facilities master list surveys conducted by the Patterns of Care Study. Int. J . Rad. Oncol. Biol. Phys. 8, 883-8. KRAMER S. (1981) An overview of process and outcome data in the Patterns of Care Study. Znt. J . Rad. Oncol. Biol. Phys. 7, 795-800. MCLEAN C. J . , DAVIS L. W., HERRING D. F., POWERS S. (1981) Variation in the work-up W. E. & KRAMER and treatment procedures among types of radiation therapy facilities. Cancer 48, 1346-52. J . J . , WHITER. L., HERRING HANKSG. E., KINZIE D. T. & KRAMER S . (1983) Patterns of care outcome studies. Cancer 51, 569-73. HANKS G. E., HERRING D. F. & KRAMER S . (1983) Patterns of care outcome studies. Cancer 51, 95967. C. J . , HANKS G. E. & KRAMER LUSTIG R. A,, MCLEAN S . (1984) Patterns of care outcome studies: Results of the national practice in carcinoma of the larynx. Int. J . Rad. Oncol. Biol. Phys. 10, 2357-62. HANKS G. E., DIAMOND J. J. & KRAMER S. (1984) The need for complex technology in radiation oncology. Cancer 55, 2198-204. WALLNER P. E., HANKS G. E., KRAMER S . & MCLEAN C. J . (1986) Patterns of Care Study. Analysis of out-
7
come survey data - anterior two thirds of tongue and floor of mouth. Amer. J . Clin. Oncol. 9, 50-7. A. O., SIMPSON 17. T A ~ E R S AM. L LH. N ., LANGLANDS J . S . & FORBES J. F. (1988) Undergraduate education about cancer: A survey in Australian medical schools. Eur. J . Cancer 24, 467-71. 18. DE MOURA M. C. (1988) Training in cancer. Undergraduate Medical Education Consensus Workshop on Curriculum in Oncology for Medical Students in Europe. EEC/EORTC Consensus Workshop on a Curriculum in Oncology for Medical Students in Europe, May 1988, Bonn, FRG. S. (1986) 19. BRADYL. W., MARKO A. M. & FISHER Cancer cure with organ preservation using radiation therapy. Radiology 160, 1-8. 20. Guidelines for Cancer Treatment Services. Superspecialty Services Working Party of the Standing Committee of the Health Ministers Conference, 1987. G. (1989) Radiation oncology: more inac21. MORGAN tivity. Aust. Med. 1, 184-5. J. S., HARPER P. G. & TATTERSALL M. H. N . 22. TOBIAS (1981) Who should treat cancer? Lancet i, 884-6. 23. Undergraduate Education in Cancer. UICC/WHO Workshop, Geneva, 1981.
3
N.Z. J . Surg. 1990, 60, 3-7
PERSONAL VIEWS RADIATION ONCOLOGY IN AUSTRALIA: THE HORNS OF A DILEMMA ALLAN0 . LANGLANDS Radiation Oncology Department, Westmead Hospital, Westmead, New South Wales
Introduction The treatment of cancer is becoming increasingly complex as multimodality approaches are developed. In any complex system, there will be many factors which determine outcome, but not the least of these would be the quality of care provided by the individual specialties involved, namely surgery, radiation oncology and medical oncology. All those concerned with the care of patients with cancer in Australia must therefore be extremely concerned at a report which appeared in 1988.' The report described the present status of radiation oncology in Australia as one of a specialty facing an increasing crisis. The major development of radiation oncology in Australia followed, as elsewhere in the world, immediately after World War 11. In 1943, Ralston Paterson, the doyen of British Radiotherapists and Director of the Christie Hospital and Holt Radium Institute was invited to visit Australia. He spent time with the Departments of Health in New South Wales, Queensland and Victoria and met with delegates from Tasmania. Although there are now no records of those conversations, it seems clear that Ralston Paterson would have given exactly the same advice to each state. In England, he directed a free-standing, independent hospital, devoted to the specialty of radiation oncology and to the treatment of cancer. He would have recommended that each state should follow that example. The effect of that advice is seen in Queensland, where, until recently, the Queensland Radium Institute was charged with the provision of radiotherapy services for the whole of that state. But the Queensland Radium Institute, unlike the Christie Hospital and Holt Radium Jnstitute, is an integral part of a major teaching general hospital. In New South Wales, it appears that his advice was ignored and there, several hospitals acquired one or two pieces of unsophisticated equipment and each hospital tried to develop an inhouse A. 0. Langlands FRCR, FRACR, FRCS (Ed.), Radiation Oncology Department, Westmead Hospital, Westmead, NSW 2145, Australia. Accepted for publication 17 August 1989
service. Radiation oncology was seen as a service or even a paramedical facility; academic development was unknown if not actively discouraged. It was in Victoria that Paterson had the greatest influence with the foundation in 1948 of the Peter MacCallum Cancer Institute as an independent cancer hospital much along the lines of the Christie Hospital and Holt Radium Institute in Manchester or the Princess Margaret Hospital, Toronto or the M.D. Anderson Hospital in Texas. We had, therefore, in the three eastern, most populated states in Australia, very different organizations for the delivery of radiation therapy as part of cancer care. It is a great pity that an opportunity has never been taken to look at the patterns of care delivered under those three quite different circumstances. Although strong views are held on what is the optimum organization for the delivery of that care, very little solid information exists and virtually no research has been done. In the absence of information on the patterns of care in Australia, considerable reliance has been placed on the results of overseas studies such as the Patterns of Care Study in the This study is a comprehensive review by the American College of Radiology of the radiation therapy facilities in the USA, their manpower, and the quality of care delivered. These facilities were reviewed in 1973, 1977 and 1979 and at intervals since then for special projects. The undertaking was enormous. In the fnst place, a consensus regarding the appropriate pretreatment investigation of different cancers, their optimum management and their follow-up had to be established.' That consensus might not be agreed to in Australia. It should also be noted, before too restrictive conclusions are drawn, that there are significant differences in the patterns of radiation oncology services in the USA and in Australia. In the USA, 66% of radiation therapy facilities are placed in community hospitals and only 19% in University Hospitals.' In contradistinction in Australia, all facilities in the public sector are located in teaching hospitals. The average centre in New South Wales, for example, sees approximately 1.5 times the referral rate of a centre classified as major in the United States. In Australia, a greater degree of total
4
LANGLANDS
patient care is the responsibility of the radiotherapist than is the case in the USA. With these differences in mind, important conclusions which emerged from the Patterns of Care Study related to factors which predict for a significantly reduced treatment outcome. '"-I6 Most of these have been identified by Wigg as major components of the crisis which exists in Australia today, and include the fonowing.
Unavailability of appropriate equipment and lack of back-up facilities and support staff This would appear to be self-evident. There seems little point in continuing to fund cancer research in the hope of gains in survival while, at the same time, ignoring equally significant gains which can be obtained by the provision of properly equipped and staffed facilities. With the present deficiencies in staff and equipment, it could prove difficult to translate research developments into clinical practice.
Too few patients/Too many patients These conclusions relate to the question of the optimum siting of radiation oncology facilities in terms of populations at risk and the physical requirements for the provision of a proper radiation oncology service. The Patterns of Care Study quite clearly demonstrated that there was a critical mass, both of patients and of equipment, if optimal results are to be obtained. For example, in the management of carcinoma of the cervix, it demonstrated a significant rise in the incidence of complications when the total number of cases being controlled by one radiotherapist exceeded 280 new cases of cancer per annum. The question of a critical population size is difficult, particularly in Australia, because of the distribution of the population on the coastal strips. In my opinion, the ideal population to be served by a radiation oncology facility is of the order of 1 million people which would yield 3000 cases of cancer per annum, some 1500 or more of whom should receive radiotherapy at some time during the course of their illness. That population figure may require to be halved if account is to be taken of demographic factors, ease of access, transport, etc. That decision is essentially one for the politicians and the individual departments of health. Resources are limited and some concentration of equipment is unavoidable and even desirable. What is clear, however, is that once a decision has been made to provide a radiation oncology service in the community, then certain other commitments follow, including the provision of a comprehensive fully staffed facility.
Failure to establish an academic basis and an active training programme A recent survey of education about cancer demonstrated disturbing differences in undergraduate training within Australia. Differences existed between states, within states and between hospitals of the same university, regarding the exposure of undergraduates to the specialty of radiation oncology and its role in cancer management." On average, 50% of Australian medical students graduate without ever visiting a department of radiation oncology. It seems self-evident that biases like this which are introduced into the undergraduate curriculum are likely to be life-long. Undergraduates who leave their medical school with no experience whatsoever of radiation oncology are unlikely to perceive that specialty as important in the management of cancer and are unlikely to perceive that specialty as a potential career. In contrast, most of the countries in the European community require a separate course in oncology in undergraduate education. These courses are usually the responsibility of a cancer centre which might be defined as a major teaching hospital containing departments of radiation oncology and medical oncology. The duration is 10-14 days full-time and includes compulsory attendance at multidisciplinary conferences in cancer diagnosis and management. If there is a move to establish new radiation oncology facilities in Australia and if they are established in community hospitals, then those hospitals at which they are sited must develop an active role in the education of undergraduate and postgraduate students. In other words, they must become teaching hospitals. Multidisciplinary management One of the most important differences to emerge in terms of survival rates in the Patterns of Care Study in the USA was the demonstration of improved cancer control rates when multidisciplinary treatment was possible. This was exemplified in several studies of the more advanced stages of head and neck cancer. While multidisciplinary management did occur in the smaller hospitals, the frequericy with which it did was significantly lower and this was reflected in recurrence rates which were up to 3.5 times those occurring in larger centres. Advances in radiation oncology in recent years have seen the emergence of a new emphasis in cancer therapy, namely, the successful treatment of cancer with organ preservation. Approximately 22% of early-stage cancers can be managed by this approach, including cancers of the breast, prostate, and head and neck.'9 In the case of breast cancer, particularly, the ability to treat early disease by
RADIATION ONCOLOGY IN AUSTRALIA
5
surgery which conserves the breast followed by radiation therapy is an important incentive for women to participate in breast cancer screening. It seems illogical to promote this approach at a time when radiation oncology services are already under significant pressure. Furthermore, there has recently been increasing interest in the development of techniques for the surgical management of limited metastatic disease. This is a complex area which requires timeconsuming co-operation between surgeons and other oncologists, including radiation therapists. Nevertheless, these are three areas in which real progress is being made in cancer therapy. They all require the closest co-operation between the surgeon and the radiotherapist for them to be successful. Success is measured not only in terms of improvement in survival but also in terms of the quality of that survival. Chronic deficiencies in the staff and facilities for radiation therapy must therefore be of concern to all surgeons with an interest in the management of cancer. They will jeopardize or render difficult the close co-operation that is essential between the surgeon and radiotherapist if this new emphasis is to continue in cancer management. Table 1 shows that Australia-wide some 36% of patients with cancer receive radiation therapy at some time during its management. This contrasts badly with the most recent rates from the UK, Canada and the USA which suggest that, for optimal cancer management, the proportion should be in excess of 50%. The reasons for this discrepancy are complex and certainly geographical factors are important. One can only speculate about the impact on referral rates of difficulty of access to facilities of high calibre, or about the detemng effects of long waiting lists. Table 1. New cases of cancer treated by radiotherapy Country
Years
UK Canada USA Australia
1973-86 1976-80 1973-84 1986
Range
(YO)
45-53 48-52 46-53 36
For the UK, Canada and the USA, there has been a significant increase over the years indicated. In Australia, the range between states is wide from around 25% in Queensland to 43% in New South Wales. Modified from Wigg.'
Australian dilemma It would be tempting to dismiss the article by Wigg as simply the lobby of the vested interest of one specialty for an expansion in funds and facilities. This would be a superficial treatment of a document which is carefully researched, referenced and
which quite appropriately takes its place in the scientific literature of this country. Wigg documented serious deficiences in the quality and quantity of equipment which exists in Australia. However, that is a relatively minor problem. There is no difficulty in providing a shopping list for the equipment which is necessary to run a modem Department of Radiation Oncology. The list of the basic equipment requirements for a facility are listed in Table 2. What is much more difficult to do is to provide advice regarding, not only the optimum siting of this equipment, but also the implications that the development of new facilities would have for the hospitals in which they are sited. Table 2. The basic equipment and facilities required by a Department of Radiation Oncology
Two megavoltage machines of which one should be a linear accelerator of 6 MeV energy or greater with electron capability
Superficial/orthovoltage machine(s) A planning simulator Computerized tomography-assisted computer planning Facilities for access to interstitial and intracavitary brachytherapy Facilities for or access to data management Facilities for the construction of patient immobilization devices, custom made blocks, etc. Medical physics staff and facilities
This then is the dilemma which faces radiation oncology in Australia. In the first place, there is the deficiency of equipment. However, it must be remembered that its correction by an expansion in facilities (and there is evidence that that is beginning to occur), will be taking place at a time when there are well documented, long-standing deficiencies in the recruitment and training of radiation oncologists, therapeutic radiographers and medical physicists. These deficiencies will be aggravated by the increasing utilization of radiation therapy in the management of common cancers such as those of breast, prostate and rectum, hitherto considered 'surgical cancers'. Table 3 shows that, by comparison with many countries in Europe and North America, the number of radiotherapists per million of the population in Australia is the lowest, and is the second lowest proportion of the recommended number which has been accepted by the government of the country.2o Numerous reports have appeared over the years at state and federal level addressing these issues. Morgan has documented some 16 discussion papers and reports on radiation oncology services commissioned in Australia during 1982-88.*' As a generalization, the reaction to these has been one of total inertia. The easier solution, money, may well be
6
LANGLANDS
found for the acquisition of equipment. This will be embarrassingly ineffective unless there is proper planning for a co-ordinated expansion of facilities at the same time as the training of radiographers, physicists and radiation oncologists is expanded pro rata in Australia. There is no evidence that the governments are capable of such a co-ordinated response to the crisis which exists. Unless there is a co-ordinated response, internal competition for staff will compromise the service further. Table 3. Actual numbers of radiation oncologists per million compared with the recommended number
Country
Actual
Recommended
Actual number as percentage of recommended
Australia
4.8 5.6 5.6 11.0 5.3 8.3
7.0 7 .0 6.5
69 80 86
-
-
8.3 10.0
64 83
NZ UK
Sweden Canada USA
Modified from Wigg.
’
It seems absolutely certain that we will never see again in Australia the construction of an independent free-standing cancer hospital. The development of new centres therefore has enormous implications for the hospitals in which they are going to be placed, for the states which agree to their development, and for the Federal Government in its overall policy regarding healthcare. Each new centre must be equipped to a standard that is capable of delivering modern radiotherapy of the highest quality. The simple acquisition of, for example, a single machine does not provide a hospital with an effective service, although it may give it a degree of independence in cancer management which is largely spurious and not in the best interests of patients. Within the hospitals which acquire new Departments of Radiation Oncology, attitudes will have to change within other disciplines. The argument as to the ownership of the cancer patient should be one consigned to the past.” Clinicians will have to accept that multidisciplinary management means a release of clinical responsibility from one clinician to another. Special demands will be made on one service to support another. These demands will only be met successfully provided the final goal is the optimum care of the cancer patient. These adjustments can be difficult, for the sovereignty of some specialties may appear to be challenged. If the crisis is to be resolved, then a major component which must be addressed is the education of doctors in the management of the cancer patient. It is therefore sobering to read a joint statement by the
Union International Contra Cancer (UICC) and the World Health Organization (WHO) in 1981 that ‘in most countries there is a significant gap between the actual cure rates of various cancers and the maximum cure rates obtainable through utilizing currently available knowledge. This indicates the size of the educational problem’.23 It is for the philosophy contained in that statement that I believe that the optimum siting of radiation oncology facilities should be within the ambit of a major general hospital of university teaching status. Although it can be argued that medical students or the postgraduate can travel readily to the free-standing independent institution, education is a far more complex process than that - it requires the continuing regular interaction of people in a variety of disciplines at a variety of levels, all of which is far more subtle than the formal lecture, seminar or clinical demonstration. Again, in 1981, in a joint statement on undergraduate education about cancer, the UICC and WHO said, ‘the differences in opinion held by various disciplines, however objectively justified they may be, may be sufficiently great to exert a negative effect on the process of instruction’.22 That statement, too, is an important argument for the siting of facilities in general hospitals. Only by so doing do I believe that the genuine differences of opinion which now exist between the specialties will be resolved by mutual interaction.
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