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The Relationship Between Oncologists and Peripheral Hospital Radiologists in the North-West of England
Clinical Radiology (2002) 57: 300±304 doi:10.1053/crad.2001.0804, available online at http://www.idealibrary.com on
The Relationship Between Oncologists and Peripheral Hospital Radiologists in the North-West of England P E T E R M . B U N G AY *, B E R N A D E T T E M . CA R R I N G TO N *, D E L P H I N E CO R G I EÂ {, A N N E E A R D L E Y{ *Department of Diagnostic Radiology, Christie Hospital NHS Trust, Manchester, U.K. and {Department of Clinical Audit, Christie Hospital NHS Trust, Manchester, U.K. Received: 19 February 2001 Revised: 11 May 2001
Accepted: 14 May 2001
AIM: To audit the relationship between Cancer Centre oncologists visiting peripheral hospitals and peripheral hospital radiologists by assessing (i) oncologists' knowledge of local radiological services; (ii) oncologists' perceptions of peripheral radiological services; (iii) peripheral radiologist's perceptions of oncologists; (iv) barriers to communication. MATERIALS AND METHODS: A postal questionnaire was sent to all radiology departments visited by an oncologist, and to all medical and clinical oncologists from two regional oncology centres. RESULTS: The response rate was 100% (21 peripheral hospital radiology departments and all 35 oncologists). (i) Oncologists' knowledge of peripheral hospital imaging modalities was limited (especially MRI and intervention). (ii) 72% of oncologists rated the peripheral hospital radiology service as excellent or good, 46% rated the radiology report quality excellent to good. De®ciencies in oncological reports were identi®ed. (iii) 44% of radiologists thought the oncologist did not relate well with the local radiology department. 50% of radiologists did not know the visiting oncologist's specialist interest. (iv) 69% of oncologists did not regularly attend peripheral hospital clinico-radiological meetings. Lack of written and oral information was hampering both specialities. CONCLUSION: Communication between oncologists and the local radiology department should include: (1) information about local radiology services for visiting oncologists (including trainees) and on the oncology team for radiologists; (2) standardized report content; (3) improved clinical information for radiologists; (4) regular clinico-radiological meetings. Bungay, P. M. et al. (2002). Clinical Radiology # 2002 The Royal College of Radiologists 57, 300±304. Key words: cancer, oncology, diagnostic performance.
The Calman/Hine report states that all cancer patients should have access to a uniformly high standard of care, and that this would be achieved by establishing Cancer Centres and Cancer Units to provide an integrated network of care [1]. It goes on to state that Cancer Units will have input from non-surgical oncologists on a weekly sessional basis, and there will be signi®cant implications for the development of clinically related services, particularly haematology, pathology and radiology. A good working relationship between radiologists and visiting oncologists is essential for optimal cancer care and there will be increasing demands on and interaction with local radiology departments. In the North-west of England, as in most regions, oncologists from the Cancer Centres already visit peripheral hospitals to deliver cancer care to the local population. Author for correspondence and guarantor of study: Dr B. M. Carrington, Department of Diagnostic Radiology, Christie Hospital NHS Trust, Wilmslow Road, Manchester M20 4BX, U.K. Fax: 0161 446 8031; E-mail: [email protected] 0009-9260/02/540300+05 $35.00/0
The objectives of this study were: (1) To describe the radiological services available to visiting oncologists in the North-west region, and assess their knowledge of these services; (2) To identify oncologists' perceptions of radiological services in local hospitals and radiologists' perceptions of their interactions with visiting oncologists; (3) To identify barriers to communication between radiologists and visiting oncologists, and hence how the relationship between them and the service provided can be optimized.
MATERIALS AND METHODS
In the late summer and autumn of 1999 a postal questionnaire was sent to all radiology departments in hospitals visited by an oncologist from either of the two regional oncology centres, and to all consultant medical and # 2002 The Royal College of Radiologists
301
RELATIONSHIP BETWEEN ONCOLOGISTS AND RADIOLOGISTS
clinical oncologists, including a small number of medical oncologists with no outside sessions but who utilize a large volume of outside staging investigations. The results were analysed anonymously, such that the authors did not know which radiology department or oncologist had made speci®c answers, but the answers from a radiologist and oncologist at a speci®c peripheral hospital were matched.
services. Oncologists knew least about availability of magnetic resonance imaging (MRI) and interventional procedures. For example, only 34% of oncologists were aware of the local availability of biliary intervention or angiography. Superior vena caval stenting, gastrointestinal stenting and venous line insertion were not speci®cally asked about in the questionnaire.
Waiting times
RESULTS
The response rate was 100% from all 21 peripheral hospital radiology departments and all 35 oncologists (32 visiting oncologists and three medical oncologists who have no outside sessions but utilize a large amount of outside imaging). Since 11 of the peripheral hospitals have more than one visiting oncologist, these radiology departments gave a set of answers for each oncologist where appropriate. The 32 visiting oncologists have between one and six outside sessions, with the majority (78%) having either one or two.
Radiology Services Available Imaging modalities Table 1 summarizes the investigations available at the hospitals visited and oncologists' awareness of these
Fig. 1 shows the mean waiting times for a selection of common investigations as recorded by radiologists and oncologists. Radiologists were asked to detail the general waiting times, not those speci®cally for oncology patients. However, 56% of oncologists and 71% of radiologists acknowledged that oncology patients are fast-tracked always or usually, with only one radiologist (5%) denying that this occurs. Peripheral hospitals commented that fast tracking of oncology patients obviously has a detrimental eect on the already long waiting lists for other patients, and that this has worsened since implementation of the Calman/Hine report. Table 2 details the delay between the investigation and issuing of a written report for various imaging studies. Despite radiologists recording the longest mean delay as 4 days ( for plain ®lms and MRI), only 49% of oncologists rated this aspect of the service as excellent or good.
Table 1 ± Radiological services available to oncologists in 21 peripheral hospitals Imaging modality
Number of Oncologists' answers hospitals where agreeing with available radiologists (%)
Ultrasound CT Mammography MRI Radionuclide radiology Interventional radiology: Biliary Genitourinary Angiography
21 21 21 16 13
100 100 84 50 62
20 20 18
34 44 34
Personnel Seventy-®ve per cent of oncologists knew who the clinical director of radiology was, but only 59% knew how many Table 2 ± Delay between investigation and issue of written report (days) Investigation
Mean
Median
Range
Barium enema Ultrasound CT MRI Interventional radiology Plain radiographs
2 1 2 4 2 4
2 1 2 4 1 4
1±8 0±7 1±7 1±10 0±7 1±14
18
Waiting time (weeks)
16 14 12 10 8 6 4 2 0
Barium enema Ultrasound
CT
MRI
Interventional radiology
Fig. 1 ± Mean waiting times for investigations according to radiologists (Q) and oncologists (Q).
302
CLINICAL RADIOLOGY
Table 3 ± Oncologists' and radiologists' assessment of the service provided by peripheral radiology departments to oncology patients Rating
Oncologists
Radiologists
Excellent Good Average Poor Not as good as we would like No answer Total
10 (31%) 13 (41%) 7 (22%) 1 (3%) (not asked) 1 (3%) 32 (100%)
1 (5%) 11 (52%) 1 (5%) (not asked) 6 (29%) 2 (10%) 21 (100%)
Table 4 ± Oncologists' rating of peripheral radiology reports Rating
Number
%
Excellent Good Average Poor Variable No answer
2 14 5 1 11 2
6 40 14 3 31 6
Tumour dimensions, TNM stage and short axis diameter of enlarged lymph nodes were the features most frequently cited by oncologists that they would like included regularly in reports. Thirty oncologists (86%) had imaging reviewed at one of the regional oncology centres, but for the majority of them (23) this was only in up to 10% of cases. However, three oncologists had 40% of investigations reviewed. No particular tumour type dominated the reviews but diagnostic problems/problem cases/clinical diculties were the most frequently cited reasons. Ninety-four per cent of radiologists said that they had no problem with review of their imaging, with comments including `love to have our CT reviewed, would like constructive feedback' and `we would appreciate more feedback to improve our technique/ reporting'. Twenty-two oncologists (63%) had radiological investigations conducted at the regional Cancer Centres in preference to the peripheral hospital, but again this was not for any particular tumour or investigation type.
Interaction and Communication
radiologists worked in the peripheral hospital they visited and only 44% knew which radiologist(s) had a special interest in oncology.
Perceptions of the radiological service Table 3 details how the overall service provided to oncology patients by peripheral radiology departments was rated by both oncologists and the radiologists providing it. Seventy-two per cent of oncologists, but only 57% of radiologists, rated the service as either excellent or good, with 29% of radiologists stating that it was not as good as they would like. One radiologist cited a lack of resources as the main problem another adding that, with multiple pressures on the department, oncology cannot be given priority all the time. Oncologists' assessments of the overall quality of reports from peripheral radiology departments are shown in Table 4; less than half of them (46%) rated reports as excellent or good. The frequency of inclusion of speci®c pertinent oncological features in reports is detailed in Table 5. The perceptions of oncologists and radiologists as to what features were included in reports were dierent.
When asked how they thought the visiting oncologist related to their department only 9% of radiologists answered `very well'. `Quite well' was the response of 38%, `not very well' 44%, and 9% did not answer. Fifty per cent of radiologists did not know the area of special interest of the visiting oncologist. Direct contact between oncologists and peripheral radiologists was limited; only 15 of 32 oncologists (47%) visited the department and only 10 (31%) attended clinico-radiological meetings regularly. Eighty-one per cent of oncologists said they discussed problem cases either regularly or occasionally, but this was recognized by only 50% of radiologists. Failures in communication identi®ed as limiting the radiologist's ability to give a complete and relevant report are detailed in Table 6. Forty-®ve per cent of radiologists did not have access to patient notes and only 25% regularly got appropriate details on request forms. Furthermore, only 10% and 19% of radiologists said that they had access to the cancer centre notes and investigations respectively. Both groups commented on the bene®t of clinicoradiological meetings with one radiologist commenting that the oncologist `is an integral part of the multidisciplinary team . . . the feedback he provides is invaluable' but another stated that their visiting oncologist was `not very willing to accept local opinion'.
Table 5 ± Oncologists' and radiologists' perceptions of inclusion of pertinent features in all reports Feature
Number (%) of oncologists
Number (%) of radiologists
All sites of tumour Tumour dimensions at marker levels Short axis diameter of enlarged lymph nodes Identi®cation of bulk disease in lymphoma Mention of relevant normal organs TNM stage A conclusion
25 (71%) 11 (31%) 10 (29%) 7 (20%) 25 (71%) 3 (9%) 28 (80%)
21 (100%) 15 (71%) 16 (76%) 18 (86%) 19 (90%) 5 (24%) 15 (71%)
303
RELATIONSHIP BETWEEN ONCOLOGISTS AND RADIOLOGISTS
Table 6 ± Failures of communication that limit reporting by peripheral radiologists Do you get.. . .
Yes
Sometimes
No
Appropriate details on request form? Access to case notes? Access to your own previous imaging? Access to other investigations?
5 (25%) 3 (15%) 12 (60%) 3 (15%)
12 (60%) 8 (40%) 6 (30%) 12 (60%)
3 9 2 4
DISCUSSION
In the U.K. management of oncology patients is a multidisciplinary and often multi-centre phenomenon. Imaging, like histopathology, is often key to optimal patient care and relies on good working relationships between oncologists and radiologists to optimize both patient treatment and clinical eciency. The 100% response rate to this audit from both oncologists and radiologists indicates a considerable interest in and willingness to participate in improving communication, and re¯ects the overall commitment to improve the service by both groups. A sound knowledge of the services provided by the sta of peripheral radiology departments, and the local logistical diculties they experience, would help visiting oncologists to make rational imaging decisions. For example, the lack of knowledge about availability of interventional procedures and MRI obviously aects the ability of oncologists to manage patients at peripheral hospitals. Fast tracking of cancer patients is acknowledged by both groups, but also recognized as detrimental to non-oncology patients by radiologists. Some radiologists commented that they found it particularly frustrating to be asked to examine an oncology patient at very short notice perhaps because the waiting list at the Cancer Centre is too long. Dierences in perception regarding the speed of issuing reports are most likely explained by the delay between the radiologist dictating the report and it ®nally arriving in paper form on the oncologist's desk, sometimes many miles away. This could be addressed by the introduction of computer based reporting systems and electronic data transfer. Oncologists are critical of the quality of peripheral radiology reports. Within our region we have shown disagreement between oncologists and radiologists regarding the content of reports. For example, all radiologists felt that all sites of tumour were documented, whereas 30% of oncologists considered this not to be the case. The evidence of several authors suggests that the oncologists' perceptions are more accurate [2±6]. Tumour dimensions, TNM stage and short axis diameter of enlarged lymph nodes are the features most oncologists would like included regularly in reports. Indeed, Loughrey et al., in their audit of specialist oncological radiology review of cross-sectional imaging, showed that only 33% of outside scans gave dimensions of measurable disease [2]. Various ways of addressing this problem exist. Feedback by visiting oncologists and from oncological radiologists at continuing medical education (CME) meetings are possibilities. The use of standardized reporting proformas is another and, as a region, an oncological radiology standards group has been formed
(15%) (45%) (10%) (19%)
and has agreed the content of a standardised oncology report (Fig. 2). This group, formed in 1999, consists of interested radiologists and radiographers, and has regular meetings to try to achieve a consensus on oncological imaging issues with reference to relevant Royal College of Radiologists guidelines. It has a website (www.nwoncorad.org.uk) containing relevant information and also organizes regional educational meetings. Specialist oncological radiology review of outside imaging is popular with oncologists. In a U.K. study Loughrey et al. [2] demonstrated that it aected radiological stage, and hence prognosis, in 19% of cases, but resulted in a change in treatment in only 4%. Gollub et al. obtained similar results in one study from the U.S.A. where review resulted in actual treatment changes in 3% of cases [3]. Two further U.S. studies produced more dramatic results. Hricak et al. showed radiological disagreement in 40%, resulting in a therapeutic management change in 23% [4], and Kalbhen et al. found that 32% of patients with pancreatic carcinoma originally reported as being resectable were deemed unresectable following specialist review [5]. As FitzGerald and Mehra point out, these results are not necessarily due to superior reporting by specialist oncological radiologists [6]. The reviewing radiologist almost certainly has greater clinical information than the original radiologist, who may well have reported the scan even before a de®nite diagnosis of malignancy had been made. Furthermore the reviewer probably has access to the original report and hence is double-reporting. The alternative to specialist review of outside imaging is to conduct imaging at the Cancer Centre. Reasons stated by oncologists for so doing include it being a faster service in some instances, and resulting in a more reliable and inclusive report. However, for the majority of patients it is considerably less convenient, and a particular problem can occur when patients alternate between the Cancer Centre and outside departments for consecutive investigations, resulting in neither department having easy access to the most recent previous imaging. Furthermore, if all oncological imaging were to be performed centrally this would result in deskilling in peripheral hospitals and an overwhelming workload in the Cancer Centres. There is a lack of direct communication between oncologists and radiologists at peripheral hospitals, which is due at least in part to the limited number of outside sessions oncologists have. Both oncologists and radiologists recognise the bene®ts of clinico-radiological meetings, and three oncologists commented that they planned to change the amount of contact they have with their peripheral department. Regular clinico-radiological meetings in per-
304
CLINICAL RADIOLOGY
Figure 2 ± Content of a standardized oncoradiology report (North Western Regional Oncoradiology Standards Group 1999) (1) State all sites of tumour (2) Measure marker lesions ± two or three sites ± bidimensional measurements
(a) maximum long axis (b) largest diameter perpendicular to the long axis ± state section number/slice level at which measurements have been made Measure lung lesions on lung Windows, all other lesions on soft tissue Windows
(3) Lymphadenopathy ± maximum short axis diameter ± in non-Hodgkins lymphoma measure conglomerate mass diameters: 4 10 cm in maximum diameter bulk disease ± Hodgkins disease: CXR: ratio of mediastinal width at T5/6 to maximum internal thoracic diameter of 5 0.33 bulk disease. On CT scan, same ratio 5 0.35 bulk disease (4) State all relevant normal ®ndings e.g. normal liver/lungs/bone/unobstructed kidneys (5) Mention any equivocal lesions (6) If appropriate, try to give TNM stage as part of conclusion
ipheral departments would enable many of the cases that are referred for cancer centre review to be dealt with at a local level. This would reduce the demand on the review service and improve feedback to peripheral hospital departments, hence bene®ting both groups of radiologists. This survey was presented to North West radiologists and oncologists at meetings in the Cancer Centre in spring 2000 and in the largest Cancer Unit in summer 2000, and has provoked discussion between the groups. The ®nal recommendations based on this study are: (1) Both peripheral hospital radiologists and visiting oncologists (including trainees) should increase their knowledge of each other's departments, working patterns and subspecialty interests to improve working relationships. This could be achieved by more contact between the two groups, by information booklets for visiting oncologists and their junior sta and by advertising changes to sta and services. (2) The North-west oncological radiology standards group will continue to promote standardized oncological reporting. (3) There should be better communication between peripheral hospital radiologists and oncologists when requesting examinations, with inclusion of relevant clinical information, and there should be feedback on particularly interesting or challenging cases. (4) The establishment of peripheral clinico-radiological meetings should be promoted, and particularly, visiting oncologists should strive to attend site/system speci®c oncoradiology meetings in their peripheral hospital.
Whilst this survey was conducted regionally, the results raise issues that should be considered by all U.K. Cancer Centres and their peripheral hospital radiology departments. Acknowledgements. We appreciate the interest and co-operation of the oncologists and radiologists of the North-west. Thanks to Mrs K. Ramnarain for assisting with the typing of the manuscript.
REFERENCES 1 Department of Health. A Policy Framework for Commissioning Cancer Services: a Report by the Expert Advisory Group on Cancer to the Chief Medical Ocers of England and Wales. London: Department of Health, 1995. 2 Loughrey GL, Carrington BM, Anderson H, Dobson MJ, Lo Ying Ping F. The value of specialist oncological radiology review of cross-sectional imaging. Clin Radiol 1999;54:149±154. 3 Gollub MJ, Panicek DM, Bach AM, Penalver A, Castellino RA. Clinical importance of reinterpretation of body CT scans obtained elsewhere in patients referred for care at a tertiary cancer center. Radiology 1999;210:109±112. 4 Hricak H, Kalbhen CL, Scheidler JE, Schwartz LH, Yu KK, Adams D. Value of expert interpretation in abdominal oncologic imaging: a multicentre study. Radiological Society of North America 83rd Scienti®c Assembly and Annual Meeting. 1997;225 (abstract). 5 Kalbhen CL, Yetter EM, Olson MC, Posniak HV, Aranha GV. Assessing the resectability of pancreatic carcinoma: the value of reinterpreting abdominal CT performed at other institutions. Am J Roentgenol 1998;171:1571±1576. 6 FitzGerald R, Mehra R. How accurate is cancer scan reporting?. Hosp Med 2000;61:637±642.
The Relationship Between Oncologists and Peripheral Hospital Radiologists in the North-West of England P E T E R M . B U N G AY *, B E R N A D E T T E M . CA R R I N G TO N *, D E L P H I N E CO R G I EÂ {, A N N E E A R D L E Y{ *Department of Diagnostic Radiology, Christie Hospital NHS Trust, Manchester, U.K. and {Department of Clinical Audit, Christie Hospital NHS Trust, Manchester, U.K. Received: 19 February 2001 Revised: 11 May 2001
Accepted: 14 May 2001
AIM: To audit the relationship between Cancer Centre oncologists visiting peripheral hospitals and peripheral hospital radiologists by assessing (i) oncologists' knowledge of local radiological services; (ii) oncologists' perceptions of peripheral radiological services; (iii) peripheral radiologist's perceptions of oncologists; (iv) barriers to communication. MATERIALS AND METHODS: A postal questionnaire was sent to all radiology departments visited by an oncologist, and to all medical and clinical oncologists from two regional oncology centres. RESULTS: The response rate was 100% (21 peripheral hospital radiology departments and all 35 oncologists). (i) Oncologists' knowledge of peripheral hospital imaging modalities was limited (especially MRI and intervention). (ii) 72% of oncologists rated the peripheral hospital radiology service as excellent or good, 46% rated the radiology report quality excellent to good. De®ciencies in oncological reports were identi®ed. (iii) 44% of radiologists thought the oncologist did not relate well with the local radiology department. 50% of radiologists did not know the visiting oncologist's specialist interest. (iv) 69% of oncologists did not regularly attend peripheral hospital clinico-radiological meetings. Lack of written and oral information was hampering both specialities. CONCLUSION: Communication between oncologists and the local radiology department should include: (1) information about local radiology services for visiting oncologists (including trainees) and on the oncology team for radiologists; (2) standardized report content; (3) improved clinical information for radiologists; (4) regular clinico-radiological meetings. Bungay, P. M. et al. (2002). Clinical Radiology # 2002 The Royal College of Radiologists 57, 300±304. Key words: cancer, oncology, diagnostic performance.
The Calman/Hine report states that all cancer patients should have access to a uniformly high standard of care, and that this would be achieved by establishing Cancer Centres and Cancer Units to provide an integrated network of care [1]. It goes on to state that Cancer Units will have input from non-surgical oncologists on a weekly sessional basis, and there will be signi®cant implications for the development of clinically related services, particularly haematology, pathology and radiology. A good working relationship between radiologists and visiting oncologists is essential for optimal cancer care and there will be increasing demands on and interaction with local radiology departments. In the North-west of England, as in most regions, oncologists from the Cancer Centres already visit peripheral hospitals to deliver cancer care to the local population. Author for correspondence and guarantor of study: Dr B. M. Carrington, Department of Diagnostic Radiology, Christie Hospital NHS Trust, Wilmslow Road, Manchester M20 4BX, U.K. Fax: 0161 446 8031; E-mail: [email protected] 0009-9260/02/540300+05 $35.00/0
The objectives of this study were: (1) To describe the radiological services available to visiting oncologists in the North-west region, and assess their knowledge of these services; (2) To identify oncologists' perceptions of radiological services in local hospitals and radiologists' perceptions of their interactions with visiting oncologists; (3) To identify barriers to communication between radiologists and visiting oncologists, and hence how the relationship between them and the service provided can be optimized.
MATERIALS AND METHODS
In the late summer and autumn of 1999 a postal questionnaire was sent to all radiology departments in hospitals visited by an oncologist from either of the two regional oncology centres, and to all consultant medical and # 2002 The Royal College of Radiologists
301
RELATIONSHIP BETWEEN ONCOLOGISTS AND RADIOLOGISTS
clinical oncologists, including a small number of medical oncologists with no outside sessions but who utilize a large volume of outside staging investigations. The results were analysed anonymously, such that the authors did not know which radiology department or oncologist had made speci®c answers, but the answers from a radiologist and oncologist at a speci®c peripheral hospital were matched.
services. Oncologists knew least about availability of magnetic resonance imaging (MRI) and interventional procedures. For example, only 34% of oncologists were aware of the local availability of biliary intervention or angiography. Superior vena caval stenting, gastrointestinal stenting and venous line insertion were not speci®cally asked about in the questionnaire.
Waiting times
RESULTS
The response rate was 100% from all 21 peripheral hospital radiology departments and all 35 oncologists (32 visiting oncologists and three medical oncologists who have no outside sessions but utilize a large amount of outside imaging). Since 11 of the peripheral hospitals have more than one visiting oncologist, these radiology departments gave a set of answers for each oncologist where appropriate. The 32 visiting oncologists have between one and six outside sessions, with the majority (78%) having either one or two.
Radiology Services Available Imaging modalities Table 1 summarizes the investigations available at the hospitals visited and oncologists' awareness of these
Fig. 1 shows the mean waiting times for a selection of common investigations as recorded by radiologists and oncologists. Radiologists were asked to detail the general waiting times, not those speci®cally for oncology patients. However, 56% of oncologists and 71% of radiologists acknowledged that oncology patients are fast-tracked always or usually, with only one radiologist (5%) denying that this occurs. Peripheral hospitals commented that fast tracking of oncology patients obviously has a detrimental eect on the already long waiting lists for other patients, and that this has worsened since implementation of the Calman/Hine report. Table 2 details the delay between the investigation and issuing of a written report for various imaging studies. Despite radiologists recording the longest mean delay as 4 days ( for plain ®lms and MRI), only 49% of oncologists rated this aspect of the service as excellent or good.
Table 1 ± Radiological services available to oncologists in 21 peripheral hospitals Imaging modality
Number of Oncologists' answers hospitals where agreeing with available radiologists (%)
Ultrasound CT Mammography MRI Radionuclide radiology Interventional radiology: Biliary Genitourinary Angiography
21 21 21 16 13
100 100 84 50 62
20 20 18
34 44 34
Personnel Seventy-®ve per cent of oncologists knew who the clinical director of radiology was, but only 59% knew how many Table 2 ± Delay between investigation and issue of written report (days) Investigation
Mean
Median
Range
Barium enema Ultrasound CT MRI Interventional radiology Plain radiographs
2 1 2 4 2 4
2 1 2 4 1 4
1±8 0±7 1±7 1±10 0±7 1±14
18
Waiting time (weeks)
16 14 12 10 8 6 4 2 0
Barium enema Ultrasound
CT
MRI
Interventional radiology
Fig. 1 ± Mean waiting times for investigations according to radiologists (Q) and oncologists (Q).
302
CLINICAL RADIOLOGY
Table 3 ± Oncologists' and radiologists' assessment of the service provided by peripheral radiology departments to oncology patients Rating
Oncologists
Radiologists
Excellent Good Average Poor Not as good as we would like No answer Total
10 (31%) 13 (41%) 7 (22%) 1 (3%) (not asked) 1 (3%) 32 (100%)
1 (5%) 11 (52%) 1 (5%) (not asked) 6 (29%) 2 (10%) 21 (100%)
Table 4 ± Oncologists' rating of peripheral radiology reports Rating
Number
%
Excellent Good Average Poor Variable No answer
2 14 5 1 11 2
6 40 14 3 31 6
Tumour dimensions, TNM stage and short axis diameter of enlarged lymph nodes were the features most frequently cited by oncologists that they would like included regularly in reports. Thirty oncologists (86%) had imaging reviewed at one of the regional oncology centres, but for the majority of them (23) this was only in up to 10% of cases. However, three oncologists had 40% of investigations reviewed. No particular tumour type dominated the reviews but diagnostic problems/problem cases/clinical diculties were the most frequently cited reasons. Ninety-four per cent of radiologists said that they had no problem with review of their imaging, with comments including `love to have our CT reviewed, would like constructive feedback' and `we would appreciate more feedback to improve our technique/ reporting'. Twenty-two oncologists (63%) had radiological investigations conducted at the regional Cancer Centres in preference to the peripheral hospital, but again this was not for any particular tumour or investigation type.
Interaction and Communication
radiologists worked in the peripheral hospital they visited and only 44% knew which radiologist(s) had a special interest in oncology.
Perceptions of the radiological service Table 3 details how the overall service provided to oncology patients by peripheral radiology departments was rated by both oncologists and the radiologists providing it. Seventy-two per cent of oncologists, but only 57% of radiologists, rated the service as either excellent or good, with 29% of radiologists stating that it was not as good as they would like. One radiologist cited a lack of resources as the main problem another adding that, with multiple pressures on the department, oncology cannot be given priority all the time. Oncologists' assessments of the overall quality of reports from peripheral radiology departments are shown in Table 4; less than half of them (46%) rated reports as excellent or good. The frequency of inclusion of speci®c pertinent oncological features in reports is detailed in Table 5. The perceptions of oncologists and radiologists as to what features were included in reports were dierent.
When asked how they thought the visiting oncologist related to their department only 9% of radiologists answered `very well'. `Quite well' was the response of 38%, `not very well' 44%, and 9% did not answer. Fifty per cent of radiologists did not know the area of special interest of the visiting oncologist. Direct contact between oncologists and peripheral radiologists was limited; only 15 of 32 oncologists (47%) visited the department and only 10 (31%) attended clinico-radiological meetings regularly. Eighty-one per cent of oncologists said they discussed problem cases either regularly or occasionally, but this was recognized by only 50% of radiologists. Failures in communication identi®ed as limiting the radiologist's ability to give a complete and relevant report are detailed in Table 6. Forty-®ve per cent of radiologists did not have access to patient notes and only 25% regularly got appropriate details on request forms. Furthermore, only 10% and 19% of radiologists said that they had access to the cancer centre notes and investigations respectively. Both groups commented on the bene®t of clinicoradiological meetings with one radiologist commenting that the oncologist `is an integral part of the multidisciplinary team . . . the feedback he provides is invaluable' but another stated that their visiting oncologist was `not very willing to accept local opinion'.
Table 5 ± Oncologists' and radiologists' perceptions of inclusion of pertinent features in all reports Feature
Number (%) of oncologists
Number (%) of radiologists
All sites of tumour Tumour dimensions at marker levels Short axis diameter of enlarged lymph nodes Identi®cation of bulk disease in lymphoma Mention of relevant normal organs TNM stage A conclusion
25 (71%) 11 (31%) 10 (29%) 7 (20%) 25 (71%) 3 (9%) 28 (80%)
21 (100%) 15 (71%) 16 (76%) 18 (86%) 19 (90%) 5 (24%) 15 (71%)
303
RELATIONSHIP BETWEEN ONCOLOGISTS AND RADIOLOGISTS
Table 6 ± Failures of communication that limit reporting by peripheral radiologists Do you get.. . .
Yes
Sometimes
No
Appropriate details on request form? Access to case notes? Access to your own previous imaging? Access to other investigations?
5 (25%) 3 (15%) 12 (60%) 3 (15%)
12 (60%) 8 (40%) 6 (30%) 12 (60%)
3 9 2 4
DISCUSSION
In the U.K. management of oncology patients is a multidisciplinary and often multi-centre phenomenon. Imaging, like histopathology, is often key to optimal patient care and relies on good working relationships between oncologists and radiologists to optimize both patient treatment and clinical eciency. The 100% response rate to this audit from both oncologists and radiologists indicates a considerable interest in and willingness to participate in improving communication, and re¯ects the overall commitment to improve the service by both groups. A sound knowledge of the services provided by the sta of peripheral radiology departments, and the local logistical diculties they experience, would help visiting oncologists to make rational imaging decisions. For example, the lack of knowledge about availability of interventional procedures and MRI obviously aects the ability of oncologists to manage patients at peripheral hospitals. Fast tracking of cancer patients is acknowledged by both groups, but also recognized as detrimental to non-oncology patients by radiologists. Some radiologists commented that they found it particularly frustrating to be asked to examine an oncology patient at very short notice perhaps because the waiting list at the Cancer Centre is too long. Dierences in perception regarding the speed of issuing reports are most likely explained by the delay between the radiologist dictating the report and it ®nally arriving in paper form on the oncologist's desk, sometimes many miles away. This could be addressed by the introduction of computer based reporting systems and electronic data transfer. Oncologists are critical of the quality of peripheral radiology reports. Within our region we have shown disagreement between oncologists and radiologists regarding the content of reports. For example, all radiologists felt that all sites of tumour were documented, whereas 30% of oncologists considered this not to be the case. The evidence of several authors suggests that the oncologists' perceptions are more accurate [2±6]. Tumour dimensions, TNM stage and short axis diameter of enlarged lymph nodes are the features most oncologists would like included regularly in reports. Indeed, Loughrey et al., in their audit of specialist oncological radiology review of cross-sectional imaging, showed that only 33% of outside scans gave dimensions of measurable disease [2]. Various ways of addressing this problem exist. Feedback by visiting oncologists and from oncological radiologists at continuing medical education (CME) meetings are possibilities. The use of standardized reporting proformas is another and, as a region, an oncological radiology standards group has been formed
(15%) (45%) (10%) (19%)
and has agreed the content of a standardised oncology report (Fig. 2). This group, formed in 1999, consists of interested radiologists and radiographers, and has regular meetings to try to achieve a consensus on oncological imaging issues with reference to relevant Royal College of Radiologists guidelines. It has a website (www.nwoncorad.org.uk) containing relevant information and also organizes regional educational meetings. Specialist oncological radiology review of outside imaging is popular with oncologists. In a U.K. study Loughrey et al. [2] demonstrated that it aected radiological stage, and hence prognosis, in 19% of cases, but resulted in a change in treatment in only 4%. Gollub et al. obtained similar results in one study from the U.S.A. where review resulted in actual treatment changes in 3% of cases [3]. Two further U.S. studies produced more dramatic results. Hricak et al. showed radiological disagreement in 40%, resulting in a therapeutic management change in 23% [4], and Kalbhen et al. found that 32% of patients with pancreatic carcinoma originally reported as being resectable were deemed unresectable following specialist review [5]. As FitzGerald and Mehra point out, these results are not necessarily due to superior reporting by specialist oncological radiologists [6]. The reviewing radiologist almost certainly has greater clinical information than the original radiologist, who may well have reported the scan even before a de®nite diagnosis of malignancy had been made. Furthermore the reviewer probably has access to the original report and hence is double-reporting. The alternative to specialist review of outside imaging is to conduct imaging at the Cancer Centre. Reasons stated by oncologists for so doing include it being a faster service in some instances, and resulting in a more reliable and inclusive report. However, for the majority of patients it is considerably less convenient, and a particular problem can occur when patients alternate between the Cancer Centre and outside departments for consecutive investigations, resulting in neither department having easy access to the most recent previous imaging. Furthermore, if all oncological imaging were to be performed centrally this would result in deskilling in peripheral hospitals and an overwhelming workload in the Cancer Centres. There is a lack of direct communication between oncologists and radiologists at peripheral hospitals, which is due at least in part to the limited number of outside sessions oncologists have. Both oncologists and radiologists recognise the bene®ts of clinico-radiological meetings, and three oncologists commented that they planned to change the amount of contact they have with their peripheral department. Regular clinico-radiological meetings in per-
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CLINICAL RADIOLOGY
Figure 2 ± Content of a standardized oncoradiology report (North Western Regional Oncoradiology Standards Group 1999) (1) State all sites of tumour (2) Measure marker lesions ± two or three sites ± bidimensional measurements
(a) maximum long axis (b) largest diameter perpendicular to the long axis ± state section number/slice level at which measurements have been made Measure lung lesions on lung Windows, all other lesions on soft tissue Windows
(3) Lymphadenopathy ± maximum short axis diameter ± in non-Hodgkins lymphoma measure conglomerate mass diameters: 4 10 cm in maximum diameter bulk disease ± Hodgkins disease: CXR: ratio of mediastinal width at T5/6 to maximum internal thoracic diameter of 5 0.33 bulk disease. On CT scan, same ratio 5 0.35 bulk disease (4) State all relevant normal ®ndings e.g. normal liver/lungs/bone/unobstructed kidneys (5) Mention any equivocal lesions (6) If appropriate, try to give TNM stage as part of conclusion
ipheral departments would enable many of the cases that are referred for cancer centre review to be dealt with at a local level. This would reduce the demand on the review service and improve feedback to peripheral hospital departments, hence bene®ting both groups of radiologists. This survey was presented to North West radiologists and oncologists at meetings in the Cancer Centre in spring 2000 and in the largest Cancer Unit in summer 2000, and has provoked discussion between the groups. The ®nal recommendations based on this study are: (1) Both peripheral hospital radiologists and visiting oncologists (including trainees) should increase their knowledge of each other's departments, working patterns and subspecialty interests to improve working relationships. This could be achieved by more contact between the two groups, by information booklets for visiting oncologists and their junior sta and by advertising changes to sta and services. (2) The North-west oncological radiology standards group will continue to promote standardized oncological reporting. (3) There should be better communication between peripheral hospital radiologists and oncologists when requesting examinations, with inclusion of relevant clinical information, and there should be feedback on particularly interesting or challenging cases. (4) The establishment of peripheral clinico-radiological meetings should be promoted, and particularly, visiting oncologists should strive to attend site/system speci®c oncoradiology meetings in their peripheral hospital.
Whilst this survey was conducted regionally, the results raise issues that should be considered by all U.K. Cancer Centres and their peripheral hospital radiology departments. Acknowledgements. We appreciate the interest and co-operation of the oncologists and radiologists of the North-west. Thanks to Mrs K. Ramnarain for assisting with the typing of the manuscript.
REFERENCES 1 Department of Health. A Policy Framework for Commissioning Cancer Services: a Report by the Expert Advisory Group on Cancer to the Chief Medical Ocers of England and Wales. London: Department of Health, 1995. 2 Loughrey GL, Carrington BM, Anderson H, Dobson MJ, Lo Ying Ping F. The value of specialist oncological radiology review of cross-sectional imaging. Clin Radiol 1999;54:149±154. 3 Gollub MJ, Panicek DM, Bach AM, Penalver A, Castellino RA. Clinical importance of reinterpretation of body CT scans obtained elsewhere in patients referred for care at a tertiary cancer center. Radiology 1999;210:109±112. 4 Hricak H, Kalbhen CL, Scheidler JE, Schwartz LH, Yu KK, Adams D. Value of expert interpretation in abdominal oncologic imaging: a multicentre study. Radiological Society of North America 83rd Scienti®c Assembly and Annual Meeting. 1997;225 (abstract). 5 Kalbhen CL, Yetter EM, Olson MC, Posniak HV, Aranha GV. Assessing the resectability of pancreatic carcinoma: the value of reinterpreting abdominal CT performed at other institutions. Am J Roentgenol 1998;171:1571±1576. 6 FitzGerald R, Mehra R. How accurate is cancer scan reporting?. Hosp Med 2000;61:637±642.