Provision of cancer treatment services: The role of a district general hospital department of clinical oncology

Chnical Oncology (1992) 4:299-301 © 1992 The Royal College of Radiologists

Clinical Oncology

Original Article Provision of Cancer Treatment Services: The Role of a District General Hospital Department of Clinical Oncology A. Benghiat Department of Clinical Oncology, Derbyshire Royal Infirmary, London Road, Derby DE1 2QY, UK

Abstract. Recent reports from the Royal College of Radiologists have highlighted the debate surrounding the provision of cancer services. This review describes the work of a district hospital based department of clinical oncology, emphasizing the access to and the outcome and scope of treatment. The findings indicate that district general hospital based cancer centres can provide a comprehensive, accessible, high quality consultant based service. Keywords: Cancer treatment; District hospitals

INTRODUCTION There is considerable debate regarding the provision of cancer treatment services in district general hospitals in the UK. The adoption of district cancer physicians has been advocated [1] and a case has been made for the centralization of services in large regional cancer centres [2]. The workload of such a centre has been reported [3] as has that of a large medical oncology unit [4]. The role of departments of clinical oncology based in district general hospitals (DGHs) has been relatively neglected: 28 of the 57 departments of clinical oncology in the UK are D G H based and the comprehensive nature of the service they provide may not be generally recognized. This paper seeks to describe the work of such a department based at the Derbyshire Royal Infirmary and to assess the role of such locally sited cancer centres. This department serves the Southern Derbyshire Health District which has a total of 1016 acute hospital beds located in two district general hospitals: the Derbyshire Royal Infirmary (626 beds) and the Derby City Hospital (390 beds). The resident population is 533 000, but because of cross boundary flows for geographical reasons, the population served is 431 000. Non-surgical cancer treatment is provided chiefly by this department. Correspondence and offprmt requests to: A. Benghiat, Consultant

Clinical Oncologist, Department of Clinical Oncology, Derbyshire Royal Infirmary, London Road, Derby DE1 2QY, UK.

DEPARTMENTAL DETAILS The department is staffed by two consultants, one senior house officer, 12 therapy radiographers and 14 nurses, including a chemotherapy nurse specialist. Radiation therapy equipment includes a dual photon high energy linear accelerator with electron facility, cobalt unit, superficial therapy unit, simulator, remote caesium afterloading machine and a computer planner linked to a nearby CT scanner. There are 20 oncology beds. New patient and follow-up clinics are held at the Derbyshire Royal Infirmary, together with a variety of joint clinics held with other specialities. A peripheral clinic is held at another D G H in an adjoining region and this aspect of our work is not considered further. Other clinics are held in four local health centres.

Workload Over 800 new patients with malignant disease are referred annually, representing 55% of all cancer patients registered at the Derby Hospitals. Table 1 shows the distribution of primary sites compared to the incidence of disease in the general population. Radiation, chemotherapy, inpatient and outpatient workload for 1990 is shown in Table 2. The indications for chemotherapy are shown in Table 3. Table 1. 1990 registrations by primary site

Site

No. (%)

Breast Skin Bronchus Urinary tract Gynaecological

178 (21) 108 (13) 98 (11) 82 (10) 48 (6)

UK % incidence" 10 10 17 11 6

ENT

40 (5)

2

Other

296 (34)

44

Total

850 (100)

100

dCancer Research Campaign Factsheet 1, 1987.

300

A. Benghiat

Table 2. 1990workload

Radiotherapy attendances Radiotherapy exposures Chemotherapy attendances Clinical attendances Inpatient episodes Occupied bed days Average stay (days)

Treatment Outcome Outpatient

Inpatient

Total

9476 24019 346 5388

1517 2934 186 605 4765 7.8

10993 26953 532 5388 605 4765 -

-

Table 3. Indications for intravenous chemotherapy JanuarySeptember 1991 Radical and adjuvant

Palliative

No. attendances

No. patients

No. No. attendances patients

Breast Lymphoma Testis Ovary Other

51 150 23 74 68

6 25 7 22 16

116 58

38 13

Total

366

76

174

51

Table 5. Treatment outcome Site

Stage

No.

Larynx (glottic)

T1 T2 T3 TI T2 T3

65 41 16 48 17 ll

Cervix uteri

Availability and Accessibility of Treatment Consultation, treatment planning and supervision of radiotherapy and chemotherapy is performed exclusively by the consultant staff. New patients are generally seen within a week of referral. A n audit for 3 months' activity in 1990 showed that, for 151 patients requiring radiotherapy, the median time from registration to first fraction was 8 days (range 0-37) and that 85% of patients started treatment within 2 weeks. This includes time spent in additional investigation, staging and treatment planning. Accessibility of radiotherapy was assessed over a 1-week period by questionnaire and the results compared with those from a large regional centre [5] are shown in Table 4.

Table 4, Accessiblhtyof radiotherapy treatment

No. of visits assessed Median distance travelled (miles) Range (miles) Median one way travelling time (mins) Median waiting time for treatment (mlns) Range (rains) Median total time away from home (mins)

The 6-year results of treatment of laryngeal carcinoma in this department have been published[6]. Treatment outcomes for patients with carcinoma of the cervix and testicular teratoma treated by the author are reported here. Taken together with laryngeal cancer this represents a broad spectrum of curative oncological practice. The results are shown in Table 5.

Derby

Regional centre [5]

170 8 2-25 25 0 0-60 90

216 20 2-120 45 60 0-200 170

r4b

Teratoma testis

Small volume Large volume Very large volumea

Overall% survival 95 83 31 90 58 36

5

0

14 4 3

100 100 66

dMRC pronostic groups. Eighty-one patients with cervical carcinoma were seen between 1985 and 1990 with a median follow-up of 33 months. W o m e n aged less than 40 years with Stage I and small volume Stage II disease were treated by preoperative intrauterine caesium followed by radical hysterectomy; all other patients were treated by exclusive radiotherapy (external beam and intracavitary caesium). Between 1985 and 1990, 71 patients with testicular cancer were referred, of whom 31 had non-seminomatous germ cell tumours with 21 requiring chemotherapy for metastases. They now have a median follow-up of 40 months. Palliative treatments form an important part of the workload whose outcome is less easily quantifiable. The highly accessible and local nature of this department, together with the continuity of care provided by a consultant based service, ensures an ideal clinical setting for palliative care.

Research and Audit In addition to a number of small local projects this department has contributed patients to over a dozen multicentre clinical trials in the last 5 years. A multidisciplinary audit team, comprising doctors, radiographers, physicists, nursing and secretarial staff meets monthly to review case notes, clinical process, techniques and outcomes.

DISCUSSION It has been estimated that about 50% of all new cancer patients would benefit from specialist nonsurgical assessment and treatment [7]. This paper

Provision of Cancer Treatment Services in a District General Hospital

confirms that a radiotherapy and oncology department based in a DGH can achieve these referral rates, which here represent 1.97 new cases referred per 1000 population, for a total of 21 consultant sessions per week. In comparison, a recent report showed an average of under two consultant oncology sessions per week in those DGHs without a local department [8]. It has been argued that district cancer physicians could provide the basis of a local oncology service but such a service has reported a referral rate of 0.55 new cases per 1000 popultion [9], which is 25% of that in this hospital. Table 1 shows that referral patterns match the prevalence of cancer in the general population, indicating that the workload of our department is appropriate to the real needs of this health district. This department undertakes most of the nonhaematological cancer chemotherapy in the district and the indications for treatment shown in Table 3 are similar to those in a teaching hospital centre [4]. Table 4 shows that our service is highly accessible, with substantially shorter travelling and waiting times than in a large regional centre. Only 11% of radiotherapy exposures are given as inpatient treatments (Table 2). The case for concentrating cancer care in regional centres is based on the view that this results in superior outcomes. Whilst this has been demonstrated in childhood cancer [10], there is little evidence to support this view generally for adult tumour sites. The outcomes shown here for the three tumour sites studied are as good as those reported in recent large series [11-13]. While there may be considerable variability in results between different hospitals and surgeons [14,15] other series have shown that treatment outcomes for rectal and bladder cancer are largely independent of hospital [16,17]. Moreover, it is by no means evident that such variations in outcome that have been reported are due to a systematic difference between large and small cancer centres. Even a small radiotherapy and oncology department in the UK is large by international standards. In the USA the average number of new annual registrations per radiotherapy centre is 349, representing 1.79 new patients per 1000 population [18] and in France over 40% of cancer patients are treated in small private clinics [19]. District hospital oncology departments are largely consultant based. This facilitates delivery of high quality care that is likely to be cost-effective through the judicious use of resources by experienced clinicians. To maintain these high standards in the face of demands of audit, management and increasing workload, such departments will in future require a minimum of three consultants, as recommended by the Royal College of Radiologists [20]. This paper supports the conclusions of recent reports [8,20,21] calling for greater input to DGHs by clinical oncologists, a substantial increase in consultant manpower, and centralization of non-surgical cancer treatment around cancer centres.

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The information presented here shows that such developments need not necessarily be based exclusively around large regional teaching centres and that a DGH based department of clinical oncology can form the focus of non-surgical cancer treatment by providing a high quality, comprehensive, accessible, consultant-based service.

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Recewed for publication April 1992 Accepted following revision May 1992