02.11.10
Cancer treatment closer to home
Receiving treatment for cancer can be a distressing experience so every effort needs to be made to ensure that facilities are both as comfortable as possible and as close as possible to patients’ communities, reports Richard Mackillican
Part of the modernisation of the health service is about moving care closer to the patients, which benefits both those being treated and can play a part in reducing the overall cost of the service.
One area where this is starting to show real benefits is that of cancer treatment in the North West where the Christie NHS Foundation Trust recently opened a new cancer centre in Oldham.
The new centre’s main purpose is to deliver high class radiotherapy locally and is part of a national drive promoted by the National Radiotherapy Implementation Group which recommends that patients who require radiotherapy should have it made available to them within 45 minutes travel time of the their home.
The size of the Greater Manchester conurbation can make travelling relatively short distances a daunting experience. This led to the conclusion that more high quality treatment should be made available locally.
“We identified that firstly there needed to be more linear accelerators,” says the Trust’s project director Peter Williams. “Up until March we only had 12 accelerators and these were all based at the main Christie site, which is around five miles south of the city centre and serves that area very well.
“But patients living in the north of the area were at a disadvantage, particularly in the north east where the standardised mortality ratios are higher than normal. It seemed blindingly obvious that we should locate two additional machines in those areas. We are also planning to locate two in Salford by the middle of next year, which will serve the north west sector.
“One of the problems with a small remote centre is that it can become isolated and we didn’t want to have to compromise at all on the quality of care which we were delivering to patients. So what we set out to do was purchase state of the art equipment which is as good as the best equipment which we use on our main site.”
The Oldham facility now has two linear accelerators which are capable of carrying out advanced radiotherapy including, as Peter Williams explains, “the most advanced form of delivering the treatment which is intensity modulated radiotherapy (IMRT). The Christie has been at the forefront in developing this form of treatment and are also involved in the very latest method, volumetric modulated arch therapy (VMAT).”
VMAT basically allows the clinical oncologists to be more precise with the radiation which they are using on the patient.
“Intensity modulated radiotherapy is quite complicated in that the patient is irradiated with several beams of radiation which are not uniform and have to be moulded to each patient, which involves a long and complicated process. Although VMAT is still complicated, it is much more efficient and it allows us to only irradiate the patient for two or three minutes instead of ten to fifteen in normal IMRT.
“This doesn’t make a huge difference to the throughput of the centre because, no matter how the treatment is delivered, it takes time for patients to get undressed and positioned accurately so the slot for each patient is around a quarter of an hour. However, with only a few minutes of that actually being radiation time, the comfort for the patient is much greater.”
The trust has also invested in a system which allows for image guided radiotherapy which requires the linear accelerator to have imaging equipment mounted on it. This means that staff can carry out CT scans of patients immediately before they are treated or immediately after.
“This function is incredibly helpful because in the past we had to take a CT scan of the patient which was then fed into a computer where the clinical oncologists could then design where beams of radiation are positioned in order to cover the target. Using this technique was always going to involve some uncertainty because although you would be aiming for an object the size of a small walnut, the allowance around it would increase the irratiated tissue to the size of a small orange. This is to take into account of; not being sure exactly where the edge of the tumour is, the fact that no matter how precisely you position the patient, they are likely to move and wriggle and that, inevitably, bodies change shape as organs such as the bladder and stomach fill and empty. To allow for these effects we have to treat a bigger volume of tissue and the beams of radiation need to cover a big enough area to take this into account.
“However, we need to keep this overlap area to an absolute minimum and if we can carry out the imaging immediately prior to carrying out the treatment, we then have the ability to limit the safety margin to a minimum.
“Long term that offers the prospect of reduced side effects and possibly increase tumour control because radiotherapy is a delicate balancing trick where you know that you are going to damage some normal tissues. But this is a good trade for knowing that you are going to kill the tumour.
“If we can reduce the number of side effects by around 5 per cent, then with the patient’s informed consent a clinician could perhaps accept a smaller reduction in the side effects in order to increase the dose to the tumour. By changing the balance we have the chance to lessen morbidity and increase tumour control, even if only slightly, by one or two per cent.
“In basic terms, we might be able to cure 51 per cent of patients, instead of half. This is only a small change but at Oldham we will treat 1,200 patients a year and the small change could result in saving an extra twelve patients every year. Each of those patients is an individual and you want to do the best for them.”
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