Fri 30th Aug 2013
Session 2 / Talk 1
10:30 – 10:50
HEAPHY 2
RADIOTHERAPY
Glenys ROUND
Charleen CASSON
Abstract
Traditionally wait times for palliative radiotherapy can be a lengthy process. It can involve several visits to
the Oncology department, delaying a patient’s treatment when time is precious. In keeping with clinics
established overseas (Canada & Brisbane) we have implemented a rapid access palliative clinic (RAPC) at
Waikato Hospital. This paper describes the implementation of the clinic and assessment of the outcomes
of the RAPC seen between 2009-2011. It will also discuss the multidisciplinary nature of such a clinic, the
future for our RAPC and the advances that can be made to improve our patient’s journey.
Waikato Regional Cancer Centre
Rapid Access Palliative Clinic (RAPC)
Presented by
Dr Glenys Round & Charlene Casson
Background
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Referrer sends referral
Wait list for FSA
Seen by Radiation Oncologist
Waitlist for simulation
Simulated
Waitlist for radiation therapy
Treatment
Background
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Palliative patients considered non-urgent
(Cat 4 – National prioritisation criteria)
Wait times to FSA therefore can be long, as
radical patients take priority unless Cat A
(Spinal cord compression, uncontrolled
bleeding)
Wait time to treatment vary widely- same day
to several weeks
Up to 3 visits to treatment
Background
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All this on a background of patients in a palliative
phase of their disease process, where quality of
life and time are important
Frequently elderly, frail, weak from end-stage
disease, age and co-morbidities
Frequently an elderly exhausted spouse/partner
Frequently from a rural area
Patients have to travel up to 4-5hours
Background
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Common around the world to have waiting times for
FSA and treatment exceeding acceptable lengths of
time
Pressure to increase patient throughput.
Multiple studies have shown efficacy of single 8Gy
fraction cf. longer fractionations for bone pain
Widely accepted, although in spite of evidence, use
of longer fractionations is common ( 20Gy in 5
fractions, 30Gy in 10 fractions)
Canada
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Saw a need to do better
Set up “Rapid Access Palliative Radiotherapy
Programme”
Patients seen very quickly after referral
Consultation, simulation, treatment all in one day for
appropriate patients
Better programmes, offer multidisciplinary
assessment
Some centres - patients offered access to a clinical
trial
Aims
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Rapid assessment and treatment
Multidisciplinary approach
Rapid pain relief
Improve quality of life
Increase satisfaction of referrer
Increase proportion of rural referrals
Aims
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Separate clinic at a separate time could save
FSA for radical patients
Separate simulation time could save
allocated simulation space for radical
patients
Rapid Access Palliative Clinic
April 2009
Initial Criteria
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Known Carcinoma
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Not be a current patient
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Bony pain
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Diagnostic evidence
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No more than 3 painful sites
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Single fraction
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Patients transferred back to referring service
Clinic Pathway
Patients are booked into 3 time slots on a
Tuesday
 Team Meeting @ 8.30am
 Process:
- Consultation
- Simulation
- Planning
- Treatment
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Tracking Form
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Patients characteristics
Diagnosis
Site of disease
Analgesic medication
Initial/ follow up Pain Score
Treatment Information
Further investigations ie bone scone, MRI
3 week follow up telephone call
Statistics 2009 – 2012
(261 Patients)
Age
Gender
- Average 69 yrs
- Range 30 – 94 yrs
- Male 65%
- Female 35%
Main Diagnosis
Referrers
- Prostate 30%
- Breast 17%
- Lung 16%
- MO 23%
- GP 21%
- Urology 20%
Treated Sites
(patients = 226, treated sites = 307)
Spine
147 (T Spine = 76)
Pelvis/Hips
78
Ribs
21
Shoulders
17
Femur/Knee
13
Chest
12
Other
19
Prescriptions
7%
4%
8 Gy
20Gy
51%
38%
30Gy
Other
Same Day Sim & Treat
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63% CT’d & treated same day
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46% single fractions
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13% no treatment
Distance to RAPC
Distance Travelled
>150km
>100km
>50km
>10km
0>10km
0
20
40
60
80
Number of Patients
100
120
140
Pain Score
INIT IAL PAIN SCORE (300 T mt Sites)
120
No of Patients
100
80
Initial
60
40
20
0
0
1
2
3
4
5
6
7
8
9
10
Pain Score
F/UP PAIN SCORE (273 T mt Sites)
120
No of Patients
100
80
F/Up
60
40
20
0
0
1
2
3
4
5
Pain Score
6
7
8
9
10
Medication
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Increase - 15%
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Decrease - 28%
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Same - 44%
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Unknown - 13%
Benefits of RAPC
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Reduce visits to the department
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Immediate multidisciplinary approach
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Pain management reviewed
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Continuity of care
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Positive comments from patients/families
Conclusion
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RAPC was implemented successfully
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Data collected, further improvements have
been made to the clinic to benefit the
patient.
RAPC is not . . .
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Radiation Oncologist seeing patient and
simulating quickly, and then patient waits
for treatment.
Imperatives
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Deliberate
Multidisciplinary
Regular
Investigates
Admits
Manages medical problems esp. analgesia,
nausea and bowels.
Supports (relatives),
Imperatives
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Refers – Med Onc, Palliative Care, physio,
dietician, Maori support, chaplain.
Does not take ownership
Refers back to referrer, but follows up
patients as required
Communicates with referrer
Prospectively gathers data
Audit
Reviews itself, adapts as required.
Imperatives
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Lesser options CANNOT be called a “Rapid
Access Palliative Clinic” or” Programme”.
Future
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Onboard imaging to plan and deliver palliative
radiotherapy in a single, cohesive patient
appointment – Perth.
( Hopefully soon for us. Note extra machine time).
Stereotactic body radiotherapy – limited application
in most of these patients.
Similar clinics for brain metastases – Canada.
( Truly multidisciplinary – Neurosurgery, Rad Onc,
Med Onc, RT, Pall Care, Nurse, Allied Health)
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