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The National Prostate Cancer Audit – Results from the Organisational Survey of NHS Trusts in England
Clinical Oncology 27 (2015) e1ee8 Contents lists available at ScienceDirect
Clinical Oncology journal homepage: www.clinicaloncologyonline.net
The National Prostate Cancer Audit e Results from the Organisational Survey of NHS Trusts in England A. Aggarwal *, J. Nossiter y, P. Cathcart z, J. Rashbass x, H. Payne z, J. van der Meulen y * Guy’s & St Thomas’ NHS Trust, London, UK y Royal College of Surgeons of England, London, UK z University College London Hospitals, London, UK x Public Health England, London, UK
Purpose: The National Prostate Cancer Audit was commissioned on behalf of NHS England in 2013 to collect information on the stage of newly diagnosed patients and their subsequent treatment choices. Inequity in access to cancer services is a serious concern and may contribute to variation in processes and outcomes of care [1,2]. Methods: An organisational survey was developed and sent to all NHS Trust prostate cancer leads in England. The aim was to determine the characteristics of prostate cancer services nationally, including availability and current utilisation of high-dose rate (HDR) and low-dose rate (LDR) brachytherapy, as well as advanced external beam radiation techniques and image guidance strategies (IGRT). Results: The questionnaire was completed by all NHS Trusts managing prostate cancer patients in England (n ¼ 144). 55 Trusts deliver external beam radiotherapy. Of these, 75% (n ¼ 41) routinely deliver 3D conformal radiotherapy, 91% (n ¼ 50) intensity-modulated radiotherapy (IMRT) and 33% (n ¼ 18) arcing IMRT to prostate cancer patients. 9% (n ¼ 5) deliver 3D conformal radiotherapy alone and 27% (n ¼ 15) deliver IMRT/arcing IMRT alone. With regards to IGRT, 71% (n ¼ 39) of Trusts utilise cone beam computed tomography, 42% (n ¼ 23) fiducial markers and 24% (n ¼ 13) a combination of cone beam computed tomography and fiducials. 2% use other IGRT techniques and 5% (n ¼ 3) did not respond. 26 Trusts provide LDR brachytherapy in England to prostate cancer patients and 11 Trusts provide HDR brachytherapy. Of the 48 prostate cancer specialist multidisciplinary teams in England, 35 (73%) provide LDR brachytherapy and 20 (42%) provide HDR brachytherapy. Conclusion: The results demonstrate that variation exists across England in the types of external beam radiation delivered and image guided strategy utilised. The prospective audit will seek to determine whether these case mix variables have an effect on outcomes. With regards to brachytherapy, inequity exists in capacity, which may impact on access to these evidence-based technologies for the management of prostate cancer patients. References [1] Hoskin P, Forbes H, Ball C, Riley D, Cooper T. Variations in radiotherapy delivery in England d evidence from the national radiotherapy dataset. Clin Oncol 2013;25(9):531e537. [2] Bungay H. Cancer and health policy: the postcode lottery of care. Soc Policy Admin 2005;39(1):35e48.
The Accuracy of T2- and Diffusion-weighted Magnetic Resonance (T2W/ DWI-MR) in the Detection of Intra-prostatic Tumour as Target Volume for Focal Dose-escalation using Intensity-modulated Radiotherapy (IMRT) E.J. Alexander *, N.M. DeSouza *,z, J. Murray *, S. Riches *, S. Hazell y, N. Livni y, K. Thomas y, S. Giles *, V. Morgan *, A. Sohaib y, A. Thompson y, D.P. Dearnaley *,z * The Institute of Cancer Research, Sutton, UK y The Royal Marsden Hospital NHS Foundation Trust, Sutton, UK
z Equal contribution http://dx.doi.org/10.1016/j.clon.2014.11.005
Purpose: Radiation dose boosting to the dominant intra-prostatic nodule (DIL) potentially improves treatment outcome, but there are few studies assessing accuracy in defining the location and extent of the DIL. We determined the accuracy of T2W/DWI-MRI in assessing the location and extent of the DIL within a prospective study (DELINEATE, ISRCTN04483921) prior to focally dose-escalated radiotherapy. Methods: Patients (n ¼ 26) with intermediate or high-risk localised prostate cancer underwent MR and transperineal template-guided mapping prostate biopsies (TTMPB). T2W/DWI images were acquired using an endorectal coil at 1.5T and octants were classified as definite tumour > 0.5 cc (red), tumour < 0.5cc (amber), < 0.2cc or uncertain tumour (green) by 2 independent uroradiologists. The prostate was biopsied at 5 mm intervals and a similar traffic-light scoring system classified pathology based on maximum cancer core length and grade. Red; 6 mm of Gleason 6 or 3þ4/ 4 mm if Gleason 3þ4. Amber; 4 5.9 mm Gleason 6/2 5.9 mm of Gleason 3þ4/2 3.9 mm if Gleason 3þ4/1 3.9 mm if Gleason 8 10. Green; 4 mm of Gleason 6/ 2mm of Gleason 7/ 1 mm of Gleason 8 10. Maximum cancer core lengths of 6 mm are equivalent to 0.5 cc and 4 mm are equivalent to 0.2 cc [1]. Sensitivity, specificity, positive and negative predictive values (NPV and PPV) were calculated for definite tumour on imaging. Receiver operating characteristic curves were constructed and areas under the curves (AUCs) calculated. Results: Median sampling density was 1.1 cores/ml of prostate (IQR 0.8e1.3). Sensitivities, specificities, PPV and NPV were: Reader 1: 89%, 84%, 69%, 95%; Reader 2: 89%, 89%, 75%, 95%, respectively. AUCs were 0.82 and 0.89, respectively. Spearman’s correlation between MRI determined tumour volume and number of positive cores within a DIL was 0.54 for reader 1 (P < 0.01) and 0.45 for reader 2 (P ¼ 0.02). Substantial agreement existed between the 2 readers (kappa ¼ 0.61). Conclusion: Both readers had high levels of diagnostic accuracy in defining a DIL that required a radiation boost. The extent of MRI-defined tumour correlated well with the extent of tumour determined by TTMPB, demonstrating the suitability of MRI to plan focally dose-escalated radiotherapy to a DIL. References [1] Ahmed HU, Hu Y, Carter T, et al. Characterizing clinically significant prostate cancer using template prostate mapping biopsy. J Urol 2011;186(2):458e464.
Accumulated Dose Volumes to the Rectum are Different from those Planned in Approximately 80% of Patients Treated with Helical Tomotherapy for Prostate Cancer J. Scaife *, K. Harrison y, M. Romanchikova z, S. Thomas z, R. Jena *, N. Burnet * * University of Cambridge Department of Oncology, Addenbrooke’s Hospital, Cambridge, UK y University of Cambridge Department of Physics, Cambridge, UK z Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
Purpose: Prostate radiotherapy can be delivered using daily image-guided helical tomotherapy. Using the daily image guidance computed tomography, we have developed methods to calculate differences in rectal position between planning and treatment, and to investigate the dose delivered over a course of treatment (accumulated dose ¼ DA). Previous work has shown that planned doses to the rectum of 50e60 Gy correlate with late rectal bleeding and proctitis, and loose stools with doses of 20e30 Gy [1,2]. We sought to quantify differences between planned and DA to the rectum and the relationship between rectal position and dose.
Clinical Oncology journal homepage: www.clinicaloncologyonline.net
The National Prostate Cancer Audit e Results from the Organisational Survey of NHS Trusts in England A. Aggarwal *, J. Nossiter y, P. Cathcart z, J. Rashbass x, H. Payne z, J. van der Meulen y * Guy’s & St Thomas’ NHS Trust, London, UK y Royal College of Surgeons of England, London, UK z University College London Hospitals, London, UK x Public Health England, London, UK
Purpose: The National Prostate Cancer Audit was commissioned on behalf of NHS England in 2013 to collect information on the stage of newly diagnosed patients and their subsequent treatment choices. Inequity in access to cancer services is a serious concern and may contribute to variation in processes and outcomes of care [1,2]. Methods: An organisational survey was developed and sent to all NHS Trust prostate cancer leads in England. The aim was to determine the characteristics of prostate cancer services nationally, including availability and current utilisation of high-dose rate (HDR) and low-dose rate (LDR) brachytherapy, as well as advanced external beam radiation techniques and image guidance strategies (IGRT). Results: The questionnaire was completed by all NHS Trusts managing prostate cancer patients in England (n ¼ 144). 55 Trusts deliver external beam radiotherapy. Of these, 75% (n ¼ 41) routinely deliver 3D conformal radiotherapy, 91% (n ¼ 50) intensity-modulated radiotherapy (IMRT) and 33% (n ¼ 18) arcing IMRT to prostate cancer patients. 9% (n ¼ 5) deliver 3D conformal radiotherapy alone and 27% (n ¼ 15) deliver IMRT/arcing IMRT alone. With regards to IGRT, 71% (n ¼ 39) of Trusts utilise cone beam computed tomography, 42% (n ¼ 23) fiducial markers and 24% (n ¼ 13) a combination of cone beam computed tomography and fiducials. 2% use other IGRT techniques and 5% (n ¼ 3) did not respond. 26 Trusts provide LDR brachytherapy in England to prostate cancer patients and 11 Trusts provide HDR brachytherapy. Of the 48 prostate cancer specialist multidisciplinary teams in England, 35 (73%) provide LDR brachytherapy and 20 (42%) provide HDR brachytherapy. Conclusion: The results demonstrate that variation exists across England in the types of external beam radiation delivered and image guided strategy utilised. The prospective audit will seek to determine whether these case mix variables have an effect on outcomes. With regards to brachytherapy, inequity exists in capacity, which may impact on access to these evidence-based technologies for the management of prostate cancer patients. References [1] Hoskin P, Forbes H, Ball C, Riley D, Cooper T. Variations in radiotherapy delivery in England d evidence from the national radiotherapy dataset. Clin Oncol 2013;25(9):531e537. [2] Bungay H. Cancer and health policy: the postcode lottery of care. Soc Policy Admin 2005;39(1):35e48.
The Accuracy of T2- and Diffusion-weighted Magnetic Resonance (T2W/ DWI-MR) in the Detection of Intra-prostatic Tumour as Target Volume for Focal Dose-escalation using Intensity-modulated Radiotherapy (IMRT) E.J. Alexander *, N.M. DeSouza *,z, J. Murray *, S. Riches *, S. Hazell y, N. Livni y, K. Thomas y, S. Giles *, V. Morgan *, A. Sohaib y, A. Thompson y, D.P. Dearnaley *,z * The Institute of Cancer Research, Sutton, UK y The Royal Marsden Hospital NHS Foundation Trust, Sutton, UK
z Equal contribution http://dx.doi.org/10.1016/j.clon.2014.11.005
Purpose: Radiation dose boosting to the dominant intra-prostatic nodule (DIL) potentially improves treatment outcome, but there are few studies assessing accuracy in defining the location and extent of the DIL. We determined the accuracy of T2W/DWI-MRI in assessing the location and extent of the DIL within a prospective study (DELINEATE, ISRCTN04483921) prior to focally dose-escalated radiotherapy. Methods: Patients (n ¼ 26) with intermediate or high-risk localised prostate cancer underwent MR and transperineal template-guided mapping prostate biopsies (TTMPB). T2W/DWI images were acquired using an endorectal coil at 1.5T and octants were classified as definite tumour > 0.5 cc (red), tumour < 0.5cc (amber), < 0.2cc or uncertain tumour (green) by 2 independent uroradiologists. The prostate was biopsied at 5 mm intervals and a similar traffic-light scoring system classified pathology based on maximum cancer core length and grade. Red; 6 mm of Gleason 6 or 3þ4/ 4 mm if Gleason 3þ4. Amber; 4 5.9 mm Gleason 6/2 5.9 mm of Gleason 3þ4/2 3.9 mm if Gleason 3þ4/1 3.9 mm if Gleason 8 10. Green; 4 mm of Gleason 6/ 2mm of Gleason 7/ 1 mm of Gleason 8 10. Maximum cancer core lengths of 6 mm are equivalent to 0.5 cc and 4 mm are equivalent to 0.2 cc [1]. Sensitivity, specificity, positive and negative predictive values (NPV and PPV) were calculated for definite tumour on imaging. Receiver operating characteristic curves were constructed and areas under the curves (AUCs) calculated. Results: Median sampling density was 1.1 cores/ml of prostate (IQR 0.8e1.3). Sensitivities, specificities, PPV and NPV were: Reader 1: 89%, 84%, 69%, 95%; Reader 2: 89%, 89%, 75%, 95%, respectively. AUCs were 0.82 and 0.89, respectively. Spearman’s correlation between MRI determined tumour volume and number of positive cores within a DIL was 0.54 for reader 1 (P < 0.01) and 0.45 for reader 2 (P ¼ 0.02). Substantial agreement existed between the 2 readers (kappa ¼ 0.61). Conclusion: Both readers had high levels of diagnostic accuracy in defining a DIL that required a radiation boost. The extent of MRI-defined tumour correlated well with the extent of tumour determined by TTMPB, demonstrating the suitability of MRI to plan focally dose-escalated radiotherapy to a DIL. References [1] Ahmed HU, Hu Y, Carter T, et al. Characterizing clinically significant prostate cancer using template prostate mapping biopsy. J Urol 2011;186(2):458e464.
Accumulated Dose Volumes to the Rectum are Different from those Planned in Approximately 80% of Patients Treated with Helical Tomotherapy for Prostate Cancer J. Scaife *, K. Harrison y, M. Romanchikova z, S. Thomas z, R. Jena *, N. Burnet * * University of Cambridge Department of Oncology, Addenbrooke’s Hospital, Cambridge, UK y University of Cambridge Department of Physics, Cambridge, UK z Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
Purpose: Prostate radiotherapy can be delivered using daily image-guided helical tomotherapy. Using the daily image guidance computed tomography, we have developed methods to calculate differences in rectal position between planning and treatment, and to investigate the dose delivered over a course of treatment (accumulated dose ¼ DA). Previous work has shown that planned doses to the rectum of 50e60 Gy correlate with late rectal bleeding and proctitis, and loose stools with doses of 20e30 Gy [1,2]. We sought to quantify differences between planned and DA to the rectum and the relationship between rectal position and dose.