Radiation Oncology in NZ: Variations in care and looking to the future

Shaun Costello, Clinical Director, Southern Cancer Network

#CancerCrossroads

Radiation Oncology in NZ: Variations in care and looking to the future

Shaun Costello, Clinical Director, Southern Cancer Network

Planning for radiation oncology services a decade ago revolved around four factors:

1. The aging demographic 2. Increasing the clinical capacity3. Increasing the technical capacity4. Stop patients being sent overseas for treatment.

Solutions for the time were:1. To increase training (RO,RT, ROMP)2. Install new machine capacity and replace ageing plant (Linacs and Planning Computers)3. Partner with emerging private providers to provide capacity in an as needed basis

Inequities of the Past

Inequity of service provision

Inequity of access

Inequity of outcome

- by region and ethnicity

Ernst Young were commissioned to develop a model in 2015. The model appeared to show significant inequity in service delivery and resource utilization, particularly intervention rates (access to radiotherapy) and fractionation (use of resources)

Inequities of the Present

It became clear that the same issues that had plagued previous attempts were once again going to derail this process.

What was needed was cancer intelligence not just data.New Zealand is cancer data rich but cancer intelligence poor.

4 stages:1. Development of verifiable data sources … a single source

of truth2. A Platform to present the data … in a way that Members

of the public, Clinicians and academics can relate too3. Cancer Intelligence Data needs to be analysed,

contextualised and socialised for multiple audiences4. Implementation

Fake News

1. “Your” data is incorrect2. “Your” data is too old to reflect current practice3. “Your” analysis is incorrect4. “Your” contextualisation is wrong 5. These are not my patients my patients are different/

special.6. I don’t care, I know what's best.

The Six Stages of Denial of Data

Radiation Oncology embarked on a journey with three parts:

1. Cancer Database development

2. Cancer Data Information

3. Cancer Intelligence

Cancer Intelligence - Define the Mission

• First full public and private Radiation Oncology Collection in the world• Largely a sector driven project, although Collection housed at the

Ministry. • Scripts developed to extract data from MOSAIQ and ARIA systems• Files submitted via the FTP portal into the Ministry’s radiation oncology

collection• Automated process to extract the data from the collection and into the

Tool every quarter• NHI level data can be requested by appropriate parties such as

researchers• Data can be linked to other work for example the National Bowel

Cancer Working Group Indicators and the to the Prostate Cancer Outcomes registry.

• Staging data is not perfect but seeking to improve this.

Radiation Oncology Collection - Trusted Single Source of Truth

https://minhealthnz.shinyapps.io/radiation-oncology-online-tool-test-version-2/

Curative Intervention Rate Breast Cancer

https://minhealthnz.shinyapps.io/radiation-oncology-online-tool-test-version-2/

Curative Intervention Rate Prostate Cancer

Intervention rate by ethnicity key differences

Paradoxical Outcomes - the importance of context

Breast Cancer Fractionation

• Dunedin breast curative – 25 vs 15 fractions

Implementation - Case Study Breast cancer

Identify and mange the drivers of new inequities:

Clinician: Who we are

Clinical: How we work

Non Clinical: External drivers

This is not an inclusive list

Inequities of the Future

• Diversification of the clinical workforce• Workforce capacity• Conversation around clinical

independence vs national standards• Perhaps common problems require

common solutions

Clinician

Timely access to complex imaging ( CT and MRI )

Access to advanced imaging ( PSMA PET)

Access to advanced treatment ( SABR)

Clinical

National development of new technology

National development of new techniques

Integration of Private centres

Workforce

National Radiation

Plan Mk2:

Non Clinical

Inequity: Uptake of technology

70 year old man prostate cancer No co morbidities No symptoms

Radiotherapy prostate cancer 2012 Stage T2c N0M0 GG 4+3 = 7 PSA 9.7

Biochemical relapse 2018 PSA 0.72 PSA DD time 5 months

Re-staging MRI Bone scan CT scan No evidence of disease.

Case Study - Bandersnatch

Able to fund PSMA PET CT Scan:

PSMA PET Scan: Isolated recurrence in the prostate,

Re report of MRI target identified in prostate

Publicly Funded prostate biopsy

Publicly Funded Salvage Brachytherapy 2017

Current PSA <0.05

?? Cured Symptom free

The New Inequity - access to unfunded care

Unable to fund PSMA PET CT Scan

Watch and wait

Development of low back pain 2018 PSA 12

Bone scan shows bone metastasis

Commences ADT

Palliative radiation

Current PSA <0.05

Palliative trajectory. Poorer quality of life

• Cancer Team MOH

• Ernst Young

• Radiation Oncology Working Group

• All the DHB data managers

• CDHB Decision Support

• Technology and Digital Services

• Cancer Health Information Strategy

Special thanks

Thank you

https://minhealthnz.shinyapps.io/radiation-

oncology-online-tool-test-version-2/