Post-COVID Delivery of Radiotherapy Services Must Evolve to Meet NHS Plan Targets

Radiotherapy is a Key Part of Cancer Care. Professor Roger Taylor Assesses the Impact of Workforce Shortages, the COVID-19 Pandemic, and Insufficient Funding, and Outlines the Measures Needed to Overcome These Obstacles 

Introduction

Approximately 2.9 million people were living with cancer in the UK in 2020.¹ Given that one in two people born in the UK after 1960 will develop some form of cancer during their lifetime,² and with an ageing population, this number is set to exceed 4 million by 2030.^1,3

On the face of it, cancer survival rates indicate significant progress in treating and prolonging the lives of individuals with cancer.¹ However, a closer look demonstrates that, although our chances of survival in the UK are much improved, the UK’s 5-year survival rates for four key cancer types (breast, colorectal, pancreatic, and lung) are below average relative to comparable countries.⁴ These basic statistics show that the commissioning and delivery of radiotherapy in the UK needs to change. Moreover, as with most sectors in healthcare, cancer care has been subject to the impact of the COVID-19 pandemic and its aftermath.⁵ Therefore, it is essential that the impetus to improve outcomes is maintained during these difficult times.

In 2021, 60 cancer centres in the UK were engaged in the delivery of radiotherapy and systemic anticancer therapy (SACT) to cancer patients; 50 of these in were located in England, five in Scotland, three in Wales, and two in Northern Ireland.⁶

The Role of Radiotherapy

Radiotherapy plays a significant role in the treatment of cancer: it is recommended as part of medical care for more than 50% of patients with cancer,^7,8 and one in four people will require radiotherapy during their lifetime.⁹ High-energy ionising radiation is aimed at a tumour, killing the cancer cells by a process of DNA damage. Unlike chemotherapy—the toxicity of which can impact the entire body—modern radiotherapy can be precisely targeted to destroy cancer cells through delivery of the most effective dose possible. Therefore, it is used to treat cancers in areas vulnerable to damage, allowing effective and relatively inexpensive treatment of cancers that are less likely to respond to surgery or chemotherapy alone.

Alone, or in combination with other treatments, radiotherapy is the principal modality for approximately 40% of cancer cures,¹⁰ yet accounts for only 5% of the cancer budget.¹¹ Given the anticipated increase in the number of patients with cancer over the next decade, the role of radiotherapy will become even more important in supporting survival rates. Even small improvements in how radiotherapy is delivered may lead to large increases in the number of patients cured.

There is also increased interest in the use of radiotherapy for the potentially curative treatment of patients with oligometastatic disease,¹² namely, patients with a single or small number (no greater than three) metastases. For more than 70 years, radiotherapy has had an important role in palliative treatment for patients with advanced cancer. For example, radiotherapy is an effective palliative treatment for patients who experience bone pain as a result of metastasis.¹³ In one study, use of radiotherapy significantly improved pain, function, and quality of life in 40% of patients with bone metastases.¹⁴

Precision Radiotherapy

There have been some major breakthroughs in radiotherapy in the past 20 years, and modern advanced radiotherapy is now more precise, cures more patients, and produces fewer side-effects. Examples include proton beam therapy, stereotactic ablative body radiotherapy (SABR), and MR Linacs which deliver radiotherapy guided by real-time in-built magnetic resonance (MR) scanning. Additionally, over the past 20 years, the average length of many radical radiotherapy courses has been significantly reduced¹⁰ based on trials of hypofractionated radiotherapy involving a reduced number of fractions.¹⁵ In the UK, many radiotherapy courses for patients with breast cancer have decreased from 3 weeks to 1 week,¹⁶ and for prostate cancer from 7.5 weeks to 4 weeks.¹⁷ This has been achieved by delivering more precise beams of radiation, which means that patients can often continue working normally during the course of their treatment.  

Post-pandemic Radiotherapy Workforce Issues

The efficient functioning of a radiotherapy department requires a dedicated and skilled multiprofessional workforce. Insight into the impact of the COVID-19 pandemic on radiotherapy services was provided by comments from radiotherapy Heads of Service reported in the RCR 2021 Census.⁶ The census estimated that the backlog of care caused by the pandemic had resulted in 50,000 missed cancer diagnoses nationally, and a 12% reduction in courses of radiotherapy treatment.⁶ Waiting time targets were also missed, with only 67% of patients treated for cancer within 2 months of urgent GP referral.⁶

Despite a decrease in the numbers of patients coming forward for treatment during the pandemic, the UK continued to have a 17% shortfall of consultant clinical oncologists (CO) in 2021, which translated into 189 whole time equivalent (WTE) clinical oncologists.⁶ This is estimated to increase to 26% (381) by 2026, unless there is additional investment in the CO workforce.⁶

In 2021, 67% of radiotherapy centre Heads of Service were concerned about workforce shortages affecting the quality of patient care compared with 52% in 2020.⁶

The incidence of cancer is set to to increase, but growth of the CO workforce has remained at 3% per annum since 2016;⁶ in Wales, workforce numbers remained the same in 2021 as they were in 2020.⁶

Impact of COVID-19 on Radiotherapy Services

Along with many other healthcare interventions, radiotherapy departments had to adapt to the COVID-19 pandemic and associated restrictions. Changes in clinical practice were necessary for all medical services, including cancer services. Radiotherapy treatments played a key role in changes in oncological practice.

The impact was described in a recent systematic review, performed 2 years into the pandemic; 281 papers were considered eligible for inclusion in the analysis.¹⁸ It found that radiotherapy played a major role in managing cancer services during the COVID-19 pandemic, as it proved more resilient than surgery, chemotherapy, or targeted drug therapy.¹⁸

The authors looked at initiatives to optimise the administration of radiotherapy for individual tumour types. For example, according to six studies that evaluated radiotherapy management in breast cancer, a hypofractionated radiotherapy regimen of five fractions in 1 week rather than 15 fractions over 3 weeks for adjuvant radiotherapy significantly reduced the risk of patients acquiring COVID-19 infections.^16,18

The review concluded that radiotherapy departments had reacted promptly and appropriately by developing high quality COVID-19 screening and departmental safety procedures.¹⁸ The accelerated implementation of hypofractionated radiotherapy regimens and telemedicine are now incorporated into the specialty of radiation oncology, and are likely to remain part of routine practice for the foreseeable future.¹⁸

A separate review assessing the impact of the COVID-19 pandemic on the detection and management of colorectal cancer in England extracted data from four population-based datasets spanning NHS England for all referrals, colonoscopies, surgical procedures, and courses of rectal radiotherapy from Jan 2019 to Oct 2020 inclusive.¹⁹ Compared to 2019, it noted a 63% reduction in the monthly number of urgent 2-week referrals for suspected cancer and a 92% reduction in the number of colonoscopies in April 2020. This had the effect of reducing the number of cases referred for treatment by 22%.¹⁹ Patients with rectal cancer experienced a 44% relative increase in the use of neoadjuvant radiotherapy (radiotherapy given prior to surgical resection), and there was a greater use of short-course regimens in April 2020 compared with practice in 2019.¹⁹ These examples in breast and rectal cancer therapy demonstrate that radiotherapy will continue to play a pivotal role in the long-term recovery of services following the COVID-19 pandemic.

NHS Recovery From COVID-19

Considerable concerns have been expressed about the reduction in the number of cancer referrals in the early stages of the pandemic. To prioritise treatment for cancer patients, the NHS therefore needs to actively encourage those who have symptoms suggestive of cancer and that have not yet come forward to do so. The NHS ‘Help us help you’ campaign, assisted by cancer charities, is raising public awareness of this.²⁰ However, despite a slight improvement in 2021, there is still a backlog.²¹

It is essential that there are appropriate levels of radiotherapy equipment and workforce to manage the greater numbers of patients who will seek treatment. The NHS Delivery plan highlights a key role for radiotherapy in the post-COVID recovery programme, with a continued focus on innovative approaches to treatment adopted by the NHS during the pandemic. These include newer forms of radiotherapy, such as hypofractionation and SABR, which deliver treatment in a more intensive way so that patients spend less time travelling to and from the radiotherapy department.²²

A Future Vision for Radiotherapy—the 2018 APPGRT Report

The All-Party Parliamentary Group for Radiotherapy (APPGRT) was established in 2018.²³ It brought together radiotherapy professionals, MPs, and peers from across the political and radiotherapy communities to debate key issues and campaign for improvements in radiotherapy services in the UK. The pharmaceutical industry ensures that cancer drug developments are well publicised and, similarly, it is necessary for radiotherapy to enhance its profile by harnessing political support. During 2018, the APPGRT launched its Manifesto for radiotherapy,²⁴ which called for the Government and the NHS to work together to realise its vision of improved cancer survival through the use of modern, world-class radiotherapy (see Box 1).

The NHS Long Term Plan

Much of the APPGRT’s vision was reflected in the NHS Long Term Plan,²⁵ which makes a commitment to dramatically improve cancer survival. Its ambition is that from 2028, 55,000 more people each year will survive their cancer for at least 5 years after diagnosis and that, by 2028, the proportion of cancers diagnosed at stage 1 and 2 will rise to 75%.²⁵ This will be achieved by improving screening services and accelerating access to diagnosis and treatment, overseen by the emerging integrated care systems and their cancer alliances.

The NHS Long Term Plan advocated: ‘…safer and more precise treatments including advanced radiotherapy techniques. We will complete the £130 million upgrade of radiotherapy machines across England and commission the NHS new state-of-the-art proton beam facilities in London and Manchester. Reforms to the specialised commissioning payments for radiotherapy hypofractionation will be introduced to support further equipment upgrades. Faster, smarter and effective radiotherapy, supported by greater networking of specialised expertise, will mean more patients are offered curative treatment, with fewer side effects and shorter treatment times.’²⁵

A keen focus on diagnosis will inevitably lead to more patients requiring radiotherapy. The £130 million upgrade of radiotherapy machines in 38 centres across England was a good start, but more investment is required to improve the current cancer waiting standards, which have shown a steady decline in recent years.²⁶ Going forward, oversight and system leadership for radiotherapy modernisation will be overseen by radiotherapy operational delivery networks (ODNs). These networks have a broad remit, but most importantly, they will improve access to modern, advanced, and innovative radiotherapy techniques, enabling more patients to benefit from cutting-edge technology and treatments.

What the NHS Long Term Plan did not specify is how the NHS will secure an appropriately skilled workforce to enable the delivery of radiotherapy in future. Doubts have been voiced about the feasibility of generating an additional 50,000 nurses by 2025, and similar recruitment issues will apply to the multiprofessional cancer workforce.

APPGRT Update Post-COVID

The APPGRT continues to report on and champion radiotherapy equipment and workforce issues. The COVID-19 pandemic and the NHS response has had a severe impact on most non-COVID elements of healthcare, including cancer care, due to the impact of delayed referrals and treatment on cancer survival. Evidence submitted for an APPGRT consultation expressed concern that a number of key windows for preventing additional cancer deaths may have been missed.²⁷ The RCR, Cancer Research UK, the One Cancer Voice charities, and the CatchUpWithCancer campaign submitted evidence to the APPGRT consultation, and it has been suggested that post-COVID cancer diagnosis and treatment issues need to be regarded as a 'cancer crisis' requiring a new 'cancer plan'. 

In summary, there is a need for investment in cancer services and new ways of working, including in radiotherapy. It requires a national strategy, political oversight, and planning at the highest levels. Many of the technologies now being recommended as solutions have arguably suffered from poor planning and underinvestment in the past, and the pandemic has exposed existing long-term deficiencies in cancer service resources. 

The success of the COVID vaccination rollout demonstrates what can be achieved with appropriate resources and political will. The APPGRT called for a similar sense of urgency and ambition from the Government to tackle the post-COVID cancer backlog. The response to the APPGRT consultation underlines how urgently the cancer community recommends that the Government delivers a solution.²⁷  

The Role of the Independent Sector

In the UK, radiotherapy facilities in the independent sector are relatively limited. However, historically, these have worked collaboratively with the NHS in order to provide additional radiotherapy capacity. The most useful examples of this have been the implementation of routine protocol treatments for patients at low risk of becoming ill, such as those with prostate or breast cancer. Unlike the NHS, the independent sector is not reliant on other agencies for funding for transition or IT integration. It is agile, can mobilise quickly in response to initiatives like the radiotherapy service specification,²⁸ and can integrate its IT with partner organisations to accelerate patient access to services. Depending on geographical location, it can reduce the number of patients who have to travel long distances for treatment.  

Conclusion

The commissioning, organisation, and delivery of radiotherapy services needs to evolve to ensure patients benefit from the NHS Long Term Plan’s ambitions of earlier diagnosis, improved access to services, long-term investment in equipment and workforce, and better outcomes. The challenges presented by the COVID-19 pandemic will continue to require investment, creative thinking, and novel ways of working. Some of the lessons from the response of radiotherapy departments to the pandemic will continue to be of benefit into the future. As a consequence of the ageing population, the impact of new drug treatments on survival, and increasing requirements for radiotherapy, it is essential that the appropriate attention is given to technology and workforce issues.      

This is an update of an article first published in Specialised Medicine (Kay M. May 2020; 4 (2): 16–20).