We have released our August blog a few days earlier than normal and I usually write my blog about stories and anecdotes from my past 40 years working in radiotherapy as both a clinical radiographer and in business, running radiotherapy companies while creating products and services. However, something critical is happening in our field of cancer care before our very eyes but not it seems in the full glare of the media in the way coronavirus has been covered.
During lockdown, and as I write over 3 million people who would normally have been screened, scanned, tested or treated for cancer have in the past four months been largely ignored, sometimes by fear of leaving their home or to visit the GP, those that have been shielding, others because national screening has been suspended and then those whose cancer treatment was stopped or not even started due to fears of them catching Covid-19 and as the NHS had mandated.
It seems that the government’s mantra to stay home, protect the NHS and save lives has one massive caveat, it hasn’t protected patients! My August 2020 blog will look at Britain’s Covid-19 cancer crisis in some form of chronological order and take snippets from TV programs, Twitter, cancer charities, the press, clinicians and patients to try to document just what has happened and why and as radiotherapy professionals how we can minimise the damage done.
Therefore, these are not all my own words and where I have used other’s quotes, I have tried to put them into context with quotations and mention where, when and who they have come from. Apologies if not clear at all times and any errors if so.
BBC Panorama documentary – 6th July 2020 – Britain’s Cancer Crisis
The BBC Panorama documentary called “Britain’s Cancer Crisis” shown on the 6th July exposed serious delays to cancer diagnosis and treatment due to coronavirus that could cause thousands of excess deaths in the UK within a year. Scientists suggest in the program there could be at least 7,000 additional deaths – but in a worst-case scenario that number could be as high as 35,000.
Panorama featured Prof Pat Price, a London based academic clinical oncologist at Imperial College who is co-editor of the standard UK oncology textbook, ‘Treatment of Cancer’ and chair of the charity Action Radiotherapy” while Deborah James, a cancer patient, blogger and writer whose recent book “F*** You Cancer, How to face the big C, live your life and still be yourself has a 5 star rating on Amazon, presented it.
Pic: Deborah James’ book is worth a read! You can get it on Amazon
It was moving, challenging and insightful TV, looking at the key issues with cancer treatment during the coronavirus crisis from a patient’s and doctor’s perspective, you should really watch the program on BBC iPlayer here if you missed it: https://www.bbc.co.uk/programmes/m000kqzv
Radiotherapy machines ‘lying idle’
The BBC summary prior to airing summarised the major issues as follows:
“The guidelines for radiotherapy and Covid-19 advised people to delay and avoid radiotherapy in some circumstances,” clinical oncologist Prof Pat Price told BBC Panorama – “I think it was a very high-risk strategy,” she said.
Prof Price said there were radiotherapy machines in some hospitals “lying idle which could have saved lives”, that “it has been safe to give radiotherapy during Covid-19, we know that now,” and that “the machines are here but we haven’t been allowed to switch them on properly” while “The guidelines for radiotherapy and Covid-19 advised people to delay and avoid radiotherapy in some circumstances”.
Pic: Elekta Versa HD Linac
NHS mandate for cancer services in lockdown
It was Peter Johnson, the National Clinical Director for Cancer NHS England, who created the guidelines on cancer treatment during Covid-19 it seems.
Mr Johnson, of NHS England said to the BBC: “What we were concerned to do, when the virus was increasing very rapidly in the population, was to make sure that we could get the right balance between the risk of catching the virus, and the risk of having people’s cancer get worse”.
“And in particular, the risks and benefits of things like chemotherapy where, if the chemotherapy isn’t absolutely crucial but it might be dangerous in terms of increasing your risk of coronavirus”.
“This wasn’t a kind of attempt to police who should have treatment and who shouldn’t, it was more an attempt to try and help people think very clearly.”
It was also stated that the rates of urgent cancer referrals were 45% below lockdown levels at the end of May. Read more: https://www.bbc.co.uk/news/health-53300784
If you read national press items from this moment in time however, you may draw your own alternative conclusions.
The Daily Mail on the 18th March 2020 said: “Doctors tell patients to delay cancer treatment in case they catch coronavirus in hospital”
NHS England is telling doctors to group their cancer patients into ‘priority levels’ according to how crucial or effective their treatment is going to be, as coronavirus causes a delay to treatment.
Doctors have been told by NHS England to prepare for a ‘disruption of services’ in cancer units over the next few weeks due to staff sickness and shortages of drugs and equipment. They have been advised to group their patients into ‘priority levels’ according to how crucial or effective the treatment is likely to be.
Anyone whose chemotherapy or radiotherapy is expected to save their life – rather than just extend it or reduce symptoms – should be a priority one or two. Patients needing emergency surgery will also be in these top two categories.
In early April when I wrote my monthly blog, the main the point was this very subject. “Why is the NHS not subcontracting the private radiotherapy delivery sector at this critical time and not just private hospital beds and ventilators?
The NHS had started to prioritise patients for radiotherapy treatment, unheard of until now but was that action wholly necessary, I asked? Added to the fact that the national media had focused in on this issue as it could be suggested that cancer services in general are now taking a back seat during the coronavirus crisis much to the anger of patients, radiotherapy professionals and service providers! The blog looked at the upcoming cancer crisis and some ways to deal with it rather than simply suspend services.
You can read this here: http://www.radpro.org.uk/2020/04/02/should-the-nhs-purchase-private-radiotherapy-provision-for-its-patients-to-reduce-the-spread-of-covid-19-release-pressure-on-the-nhs-and-save-lives/
BBC Panorama looked at the suspension of cancer services
However, there are at least two key issues here to explore: one is that NHS radiotherapy services were either disrupted and suspended due to a perceived risk to patients of catching Covid19, crucially affecting existing cancer patients prognosis and outcomes (including triaging patients depending on their diagnosis) while the second is that a potential tsunami of cancer patients, currently undiagnosed will lead to radiotherapy and other cancer services being overrun when they require treatment and that many will die un-necessarily due to presenting with later stage tumours.
Also, in the documentary scientists examined data from eight hospital trusts, the study for cancer, modelled different outcomes depending on how long services take to get back to normal levels which showed that possibly if delays continue, there could be up to 35,000 additional cancer deaths within a year. Prof Mark Lawler, Scientific Lead of DATA-CAN, told BBC Panorama: “Initial data that we got was very worrying to us. Anecdotally, people have been telling us there were problems, but I think the critical thing was being able to actually have routine data from hospital trusts” and so a full scale cancer crisis publicly predicted by some as early as March was now about to impact on the UK in a terrible way.
Prof Karol Sikora saw this cancer crisis coming- March 2020
In March these problems were already being flagged up by Prof Karol Sikora on his then brand-new Twitter feed. In our exclusive Q & A with him in June we asked him why he set it up.
Q. Why did you set up a Twitter account in March?
A. “I set up the Twitter after a lunch with a retired oncologist whom I’ve known for over 45 years. This was just before the lockdown started and he told me that if I wanted to get a message over it was a great medium for it. My message was simple. With the impending Corona virus pandemic, I thought cancer patients were going to be thrown under the bus. Whatever the propaganda from NHS England this proved to be exactly the case. It still is. I’ve used my Twitter to try and redress the balance between Covid and other illnesses in the NHS”
You can read all the Q&A here: http://www.radpro.org.uk/2020/06/08/q-and-a-with-professor-karol-sikora/
He has been continually trying to keep this cancer crisis on the front pages of the press and on TV, radio and social media and despite much frustration has largely got his message out but even today is still banging the same drum with some support from leading radiotherapy charities, some MP’s and the Government, including by Tim Farron MP in Westminster.
Prof Sikora released in early June his 5-point plan to get cancer services resumed urgently but already this has been met with some scepticism by professional bodies concerned, for instance about the lack of trained therapeutic radiographers to take up the slack when we try to play catch-up with the flood of new radiotherapy patients within existing NHS treatment infrastructure or by working additional hours or weekends. However, as stated before the staffing issues have failed to be successfully addressed over many years and so this is not a problem that is new to us nor one that we could have failed to foresee.
You can follow him on Twitter here if you wish:
Radiotherapy Radiographic Workforce 2019 census
It is stated in the results of the Radiotherapy Radiographic Workforce 2019 census that NHS staffing numbers have actually increased by more than 20% since 2012 and so while that is good, vacancy rates in England are on average over 7% and so in terms of the current crisis this may be too little too late while some of the staff mentioned are in fact trainee and assistant practitioners. It does not say how many as importantly these staff cannot practice autonomously. As part of a longer-term plan, staff retention and student attrition needs addressing urgently and in more creative ways.
The private sector will be able to step in to deliver radiotherapy in a Covid19 free environment as long as the NHS is prepared to pay and where there is additional, safe and bio-secure radiotherapy provision with the latest leading-edge equipment added to spare capacity.
Tim Farron urges Government to ‘stop lives being unnecessarily lost’ by bringing forward SABR treatment rollout – June 28th 2020
Pic: Tim Farron MP in the Commons
The article states that “An MP has called for a quicker rollout of new radiotherapy treatment to deal with the waiting list for cancer treatment caused by the coronavirus pandemic and to ‘stop lives being unnecessarily lost”.
He urged the rollout of stereotactic ablative radiotherapy (SABR) treatment be brought forward.
SABR is not a panacea for radiotherapy, at least not yet!
We know that SABR is a safe treatment for non-small cell lung cancer and certain oligo-metastases as guided by NICE. In March 2020 NHS England took the decision to expand delivery of SABR for primary lung cancer in addition to extracranial metastases and liver cancer as a result of the positive outcomes from the Commissioning through Evaluation (CtE) programme.
A 2018 survey on SABR the current status of stereotactic ablative body radiotherapy in the UK: six years of progress showed a welcome increase in SABR provision across the UK, surpassing projections in 2012.
However, the survey states that “with emerging data it is clear that the UK SABR program needs to continue its expansion to ensure that patients with oligometastatic disease have access and SABR for early stage lung is deliverable in all centres. Implementation of novel-technology is noted, however, guidance to address variability in target delineation, image guidance and possible reduction in patient specific QA is warranted”.
This is the latest update from the SABR consortium website on the impact of Covid-19:
“The present situation with COVID-19 has led to an increased focus on SABR as a practical means for departments to cope with potential surges in demand on our linear accelerators as we come through and out of the pandemic. However, although the technology for SABR might be widely available, it is imperative that the risks associated with the complex planning and delivery of much higher radiation doses per session are adequately mitigated. We have always maintained that this should happen through properly resourced implementation programmes within supportive frameworks that include education, mentorship, and external validation”
SABR is not suitable for many tumours, nor have clinical trials validated it for more than specialist use to date and so we need to be careful when people who are not radiotherapy professionals discuss this as some form of holy grail, without knowing its limitations, one day it might be but not as yet.
You can read more from the SABR consortium here: https://www.sabr.org.uk
Now breast, lung, bowel and prostate cancer can all be treated in a WEEK as patients receive shorter and more convenient courses of radiotherapy – Daily Mail headline – 21st June 2020
The article states that: “Over the past two decades, UK doctors have led efforts to show that delivering bigger doses of radiation over fewer sessions can be just as successful at treating some cancer types. And trials are repeatedly showing it to be safe, without additional side effects, despite concerns that higher doses could cause greater damage to healthy tissue. As NHS clinics looked for ways to make treatment for cancer patients more efficient during the pandemic, many have now adopted these methods. As a result, a growing number of NHS patients with cancer in the breast, bowel, prostate and lung are now receiving shorter and more convenient courses of radiotherapy”
‘Patients want the best treatment,’ says Dr Jeanette Dickson, President of the Royal College of Radiologists and a consultant lung oncologist. ‘
But they also want minimal disruption to their lives. If four weeks is as good as six weeks, or one week as good as three weeks, they prefer the shorter option.’
I’ll look at Fast-Forward in more detail later in the blog. However, headlines like this are very confusing for patients. If you read the many comments on the comment page at the end of this article linked below you will see what I mean as some will be getting a form of hypofractionation offered to them and others won’t. I have included just a few of the comments here to get you started!
“I’m starting radiotherapy next week. It will be 2 rather than 3 weeks. The oncologist told me that this is safe and based on a published study, usually it would be 5 years before they start it, however due to CV they have brought it forward by 2 years”
“I admire positivity, but the headline is misleading”
“As someone who has been successfully treated for aggressive prostate cancer by CT targeted radiotherapy some years ago, with only a few minor side effects to show for it (some constipation and I won’t be fathering any more children). I can say quite categorically that the last thing that bothered me was the need for 37 hospital visits for treatment. I was far more concerned about the potential outcome and the damage that radiotherapy can cause. The idea of reducing the number of sessions and having much larger doses of radiation is not a prospect I would relish. This smacks of cost cutting rather than a health benefit”
“This is good news. My late husband had multiple doses of radiotherapy, and it was the ‘collateral damage’ which was the most distressing, although he went on to recover from the cancer. This subject is rarely mentioned when talking of cancer treatment, nor the ongoing psychological effect. Shorter targetted doses can only be welcome”
“I’ve had 4 cancer appointments cancelled in the last 5 months, so forgive me if I’m less than overflowing with enthusiasm at this news. No doubt in my mind that the rubber boat people have a higher priority than someone who’s been paying taxes for 40 years”
“This article gives a lot of false hope. My husband had his prostate removed last week as his only option and my daughter is about to start chemo then surgery then radiation for breast cancer. Like everything it depends on what stage and your health authority”
Read more in the Daily Mail online here to make up your own mind: https://www.dailymail.co.uk/health/article-8442699/Now-breast-lung-bowel-prostate-cancer-treated-WEEK.html
Current cancer referral levels in England – May 2020
CANCER CRISIS Urgent cancer referrals plummet 47% in May raising fears of ‘tsunami of extra deaths’ The Sun 9th July 2020
New figures from NHS England show that 106,535 people were seen by a cancer consultant within two weeks of being referred by their GP.
But that figure is down from 200,599 in May 2019 – a fall of 47 per cent.
Urgent breast cancer referrals showed an even bigger drop – down from 15,802 in May 2019 to 5,371 in May 2020, a fall of 66 per cent.
The NHS missed its target for treatment to start, with just 69.9 per cent people beginning treatment within two months of GP referral – the lowest percentage since records began in October 2009.
Campaigners blame the coronavirus pandemic and warn that it has put cancer services under more pressure than ever before.
How do we get cancer services including radiotherapy up and running urgently?
Quickly following the BBC program, a petition was launched under the hashtag name of #CatchUpWithCancer to try to ensure the Government gets cancer services fully restarted now and at that at this time of writing has over 150,000 signatures.
The family of Kelly Smith, a young mother aged 31 who featured on the program, initiated this after she very sadly died of bowel cancer recently at the time of filming and at a time when her chemotherapy was crucially suspended.
This is a great and very well intentioned initiative and one that keeps this crisis on the front pages and has appeared in many papers and TV news programs in the past few weeks. Here is one example, there are many other if you Google this.
However, the UK Government does not have jurisdiction over Scotland when it comes to health issues and cancer screening here for bowel, breast and cervical cancer has been suspended since mid-March and now restarting on the 3rd August, a critical gap of almost 5 months.
A decision by the SNP to look to suppress and eventually eliminate the virus has been their main priority while the economy, health and education have suffered. This policy has resulted in some recent headlines that support the alarm calls raised above.
“Scots cancer deaths soar as 900 patients die at home during lockdown”
The statistic gives one of the clearest indications yet of the toll Covid-19 has taken on NHS services.
Lockdown has been linked to an increase of almost 900 cancer patients dying at home, official figures reveal.
Fast Forward and IORT
The Fast-Forward dose regimen for breast cancer has been implemented in many UK radiotherapy centres as a way to reduce the risk of exposure to the novel coronavirus.
Recently published in the Lancet, it has been shown that the trial has demonstrated the noninferiority of two five-fraction adjuvant radiotherapy schedules delivered over a week to the standard 15-fraction schedule given over 3 weeks for early-stage breast cancer with regards to local control.
It was also stated that “During the coronavirus disease 2019 (COVID-19) pandemic, hypofractionation could restrict the exposure of health-care professionals and patients to COVID-19”
And they also say: “The consistency of FAST-Forward results with earlier hypofractionation trials supports the adoption of 26 Gy in five daily fractions as a new standard for women with operable breast cancer requiring adjuvant radiotherapy to partial or whole breast.”
However, in France some clinicians have put these results into further perspective by saying that this might be practice changing for low-risk patients with breast cancer who have had surgery, but “long-term disease outcomes and subset analyses are eagerly awaited.” A sensible but standard approach adopted by all of us in radiotherapy.
The RCR issued this guidance called “The guidelines for radiotherapy for breast cancer during the Covid-19 pandemic” dated the 24th March and so one day after the UK lockdown. It states that for certain patients 5 daily fractions and a total dose of 26 Gy can be given but that 5-year local relapse data are not yet available for FAST Forward but imminent publication is anticipated and so there is some risk here. The introduction clearly states that this document is “suggested guidance”.
Pic: Electron IORT with Mobetron and Intra-Op
However, NICE guidance is still based on 15 fractions and 40 Gy. I have always had a special interest in Intra-Operative radiotherapy or IORT for many years and its implementation was always seemingly prevented by reference to immature data and current NICE guidance despite the data showing that this treatment was also non-inferior to 15 fractions of EBRT for carefully selected early stage breast cancer patients who also would chose to have IORT if they were consented appropriately.
As in the words of Dr Jeanette Dickson of the RCR above, patients if offered a shorter course of treatment will prefer this as long as it is safe. The ultimate hypo-fractionation for early stage breast cancer is single dose IORT and very popular for women whose lifestyle dictates that to have surgery and radiotherapy at the same time and to wake up having had all your treatment, is preferable to daily EBRT. I am not sure why IORT is not considered to be a Covid-19 safe treatment for these cases, however, I do know that IORT is a contentious area within breast cancer as if you ask clinical oncologists and oncoplastic breast surgeons, some believe in its benefits and many others don’t.
You can read more about the RCR guidance here: https://www.rcr.ac.uk/sites/default/files/breast-cancer-treatment-covid19.pdf
You can read more about the latest ESTRO news on breast IORT here if interested. ESTRO IORT Task Force/ACROP recommendations for intraoperative radiation therapy with electrons (IOERT) in breast cancer : https://www.thegreenjournal.com/article/S0167-8140(20)30240-1/fulltext
Transforming Radiotherapy: A six-point Covid-19 recovery plan to save lives and save money within the NHS – 6 July 2020
The All-Party Parliamentary Group on radiotherapy or APPGRT was founded on the 22nd May 2018.
The Group brings together MPs and Peers from across the political and radiotherapy spectrum to debate key issues and campaign together to improve Radiotherapy services.
Action Radiotherapy provides the secretariat for the UK government All Party Parliamentary Group on Radiotherapy.
“Following BBC’s Panorama the APPG for Radiotherapy have launched a 6- point plan to transform radiotherapy services and save thousands of lives from the cancer backlog”
This is their press release dated 6th July 2020
Experts including cancer specialists, radiotherapy professionals, charities and industry have endorsed a plan from MPs to rapidly transform radiotherapy services and save thousands of lives from being unnecessarily lost to the cancer backlog.
The 6 point-plan from the All-Party Parliamentary Group for Radiotherapy (APPGRT) launches as Monday’s shocking episode of Panorama exposes the devastating impact of the Covid pandemic on cancer services and patients. Chair of Action Radiotherapy, founder of Radiotherapy4Life and advisor to the APPG RT, Professor Pat Price said: “Thousands of lives are at stake. The radiotherapy community is pleading with the Government to take action, recognise the severity of the situation and seize this opportunity to rapidly boost our cancer fighting capacity.
Here is a plan which clearly sets out the problem, and crucially, the solution. There is no more time for bureaucracy because Covid has so frighteningly exposed the deficiencies in cancer services. Lifesaving radiotherapy treatments must be a key part of the cancer recovery plan. Not the afterthought they have been for so many years. This report paves the way for delivering world class radiotherapy and dealing with the predicted surge in demand on our cancer services.
You can read the entire press release here: https://e8604b0e-5c16-4637-907f-3091e4443249.filesusr.com/ugd/4fcdc3_c5a5c50532a54c91bcbcdf337afb0a58.pdf
Image: The 6-Point Plan Diagramatic
Personally, I think that setting up a national radiotherapy task force with a radiotherapy Tsar is a great idea and one that will help keep radiotherapy on the front pages for some time to come. Having been working in radiotherapy all my 40-year career, in both clinical radiotherapy delivery and in business creating and running radiotherapy companies, products and services, I would be happy to play a role within this initiative if asked.
Their website is at https://www.appgrt.co.uk/
The complete APPGRT 6 point plan document is available here: https://e8604b0e-5c16-4637-907f-3091e4443249.filesusr.com/ugd/4fcdc3_50d7f2b1bc5f4750a2f20fc81c70cdf7.pdf
Conclusions, my considered thoughts only!
Any move away from NICE guidance in radiotherapy with regards to dose and fractionation requires considerable peer review/agreement/sign-off, patient review and measured outcomes. Even in a time of national emergency due to Covid-19, special or non-standard doses should always be subject to recording within non-standard dose registers and or observational studies if not part of ongoing clinical trials. They must always be discussed and approved by clinical review teams in advance of starting treatment with patients consented appropriately.
Data on local relapse for patients treated with fewer fractions but higher daily doses whether this be the Short Course Radiotherapy or SCRT Covid-19 dose regimen for bowel cancer (https://www.thegreenjournal.com/article/S0167-8140(20)30173-0/pdf) giving radiotherapy in one week instead of 5 weeks or more and delaying surgery, 5 fractions in a week for breast, novel 7 fractions for Prostate and SABR for lung cancer or oligo-metastases among others is still relatively immature for our field and so care should be taken whether we are prescribing oncologists, MP’s suggesting that a national roll-out of SABR should happen immediately or the RCR promoting shorter treatments openly with the national press.
These headlines may return to haunt us, we can’t afford that and so I simply ask that we collectively take additional care in the time of this pandemic and that the reasons for hypo-fractionation are not seen to be simply to save money, save on travel or lessen the impact of Covid-19 on radiotherapy patient’s health among others but the risks/benefits are clearly defined and stated. As above, this does not always work out for the best and can cause confusion, especially for patients and as I have pointed out and based on discussions I’ve seen on social media and newspaper forums. Educating the public and raising the profile of radiotherapy in my opinion is just as an important action as the investment in new equipment and techniques.
The RCR saw this crisis coming as they released provisional guidelines for reduced fractionation in late March, Karol Sikora saw it coming on his Twitter feed a few weeks earlier and so why did cancer services to all intents and purposes shut-down until now? I for one would like to know which is why my blog this month looks at the evidence in some detail.
Personally, I would also like to see a “learning on the job” policy urgently applied to the training of radiotherapy radiographers. There have never been issues with DCR qualified staff working along-side radiographers with degrees. I know that there is a reluctance from the SCoR to have split qualifications, the apprentice degree scheme in radiotherapy has had a false-start and so why not return to a DCR style education system for radiotherapy, it simply trains radiographers to be radiographers and so what is wrong with that? I recall many conversations I had with my peer Martine Jackson at the Christie on my visits many years ago now and while she didn’t totally agree with all of my thoughts on this subject, she did see the benefits. Why not have a forum to at least look at this again.
As a DCR qualified therapeutic radiographer and probably a dinosaur and having spent 40-years in this field I would say that, wouldn’t I!
Happy to discuss all of this blog, what I have got right and wrong and your opinions on our Twitter feed @RadProWebsite or on the comment forum below but I think this crisis needed to be documented in some way and I can see light and the end of the tunnel.
Duncan Hynd- August 2020
[Comments are moderated – please allow 24 hours for them to become visible]