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1 The Royal College of Radiologists 38 Portland Place London W1B 1JQ Telephone Fax Citation details: Board of the Faculty of Clinical Oncology. The Royal College of Radiologists (2003). Equipment, Workload and Staffing for Radiotherapy in the UK Royal College of Radiologists, London. ISBN RCR Ref No BFCO(03)3 The Royal College of Radiologists,.September 2003 This Publication is Copyright under the Berne Convention and the International Copyright Convention. All rights reserved. Page 1 of 16

2 This booklet was prepared and published on behalf of the Royal College of Radiologists (RCR). Whilst every attempt has been made to provide accurate and useful information, neither the RCR, the members and Fellows of the RCR nor other persons contributing to the formation of the booklet make any warranty, express or implied, with regard to accuracy, omissions and usefulness of the information contained herein. Furthermore, the same parties do not assume any liability with respect to the use, or subsequent damages resulting from the use of the information contained in the booklet. Contents Foreword 1 Summary 2 Introduction 3 Methods 4 Results 4.1 Linear accelerators 4.2 Linear accelerator workload 4.3 Equipment for planning 4.4 Staffing 5 Radiotherapy Provision in other European Countries 6 Facilities Required to Deliver Modern Radiotherapy 7 Conclusion References Page 2 of 16

3 Foreword Over the last few years there have been major developments in radiotherapy technology which allow for safer and more effective treatment and better tumour targeting and sparing of normal tissues in order to achieve higher cure rates with less risk of side-effects. After surgery, radiotherapy is the next most effective modality for treating cancer and accounts for 40% of all those who are cured. These new developments together with the rising incidence of cancer and new indications for treatment have led to increasing demand for radiotherapy which can only be met if there is sufficient equipment and staff to deliver it. Without this, efforts to reduce deaths from cancer have less chance of succeeding. The current survey complements previous surveys conducted in 1992 and In spite of very welcome investment in both machines and staff, the surveys show that: this has not been sufficient to keep up with demand; that waiting lists are longer than ever; and that modern treatment is inhibited widely by lack of up to date equipment. The position of the UK in relation to comparable European countries is therefore a weak one in terms of radiotherapy capacity. If patients are to be offered the best chance of cure or timely effective palliation, then significant further investment in staff and machines for radiotherapy delivery are essential. The RCR surveys described in this document are UK-based and all the points made apply to the UK generally. For discussion purposes, and in an effort to simplify key findings, comparisons and references are made to Department of Health policy documents and targets for England. Although these are not directly applicable to the policies adopted in Northern Ireland, Scotland and Wales, I hope that this document will assist all UK clinical oncology departments and in particular the bodies responsible for resource provision and allocation to reflect on ways in which radiotherapy services for all cancer patients can be placed on a secure and sound footing. Dr Dan Ash President Page 3 of 16

4 1 Summary 1.1 In 1997 radiotherapy provision in the UK was characterised as inadequate to meet the needs of the population, distributed inequitably and delivered with a lot of outdated equipment. Since then there has been considerable central investment including monies from the Lottery New Opportunity Fund (NOF) and Department of Health During the last 5 years there has been an increased demand for radiotherapy. The number of exposures delivered per year increased by 16% over the period Between 1997 and 2002 the number of megavoltage machines in clinical use for radiotherapy increased from 184 to 203 an increase of 10%, i.e., 2% per year In 1997, 25% of linear accelerators were aged 10 years or more compared with 38% in In 2002, 36% of simulators and 32% of planning computers were also aged 10 years or more The replacement programme for linear accelerators in England will address the problem of out-of-date radiotherapy machines but will not increase capacity The number of linear accelerators per million population in 2002 in the UK was 3.53; under the National Cancer Plan, it is planned to increase this to 4.2 per million by This might have been adequate when proposed in 1997 but is well below what is needed now Excluding one small centre, the range of linear accelerator provision per million population in the UK varies from 2.13 to The 1998 English Cancer Plan target of four linear accelerators per million population was achieved by only 39% of radiotherapy centres in 2002, the vast majority of which are in the South of England Comparable European countries have either exceeded the 5 per million target proposed by the World Health Organisation in 1999 (e.g., France with 6.1 linear accelerators per million population) or are planning to achieve it soon (e.g., the Netherlands and Spain). 1.2 In 1998, 28% of patients had to wait longer than 4 weeks to start potentially curative radical radiotherapy. In 2002, 81% of patients surveyed waited longer than 4 weeks It is generally accepted that approximately 50% of cancer patients may benefit from radiotherapy at some time during their illness. In some regions only 22% of cancer patients were offered radiotherapy in Over the last 5 years waiting times for radiotherapy have become longer. The number of outof-date machines has increased and the inequalities of access and provision have not been improved From 2005, the National Cancer Plan target for England is for all patients with cancer to start treatment within 1 month of diagnosis. 1.3 Since the last survey (1997), workload has increased. The total number of exposures has increased by 16%. Treatment has increased in complexity and quality and there have been higher referral rates. Whilst there have been some increases in funded posts, these have not kept pace with the increased workload, and shortages in suitably trained oncologists, radiographers and physicists mean that departments are carrying significant vacancy levels some of them very significant. Many departments cannot function at their full capacity because they do not have the staff to allow them to do so. 1.4 Central allocation of major capital equipment for radiotherapy is to cease soon. Cancer Networks, Strategic Health Authorities, Primary Care Trusts and other commissioning authorities urgently need to develop robust plans to meet the National Cancer Plan target of no more than 1 month wait from diagnosis to start of treatment. For most this will require increased capacity both for machines and staff plus a replacement programme for out-of-date equipment. Experience has shown that because of the long planning cycle, plans should be made for what will be required in 6 or 7 years time and not just for what is needed now. Page 4 of 16

5 2 Introduction 2.1 Radiotherapy remains a mainstay in the treatment of cancer. Comparison of the contribution towards cure by the major cancer treatment modalities shows that of those cured, 49% are cured by surgery, 40% by radiotherapy and 11% by chemotherapy Significant advances have been made in the sophistication of radiotherapy delivery leading to reduced toxicity and increasing indications for treatment either as a single modality or in combination with surgery and chemotherapy. 2.3 The Royal College of Radiologists (RCR) has performed a series of surveys on equipment, workload and staffing for radiotherapy. The last, published in 1998, summarised the results of two surveys which had been performed in 1992 and These showed that there was an inadequate number of machines or staff to provide a responsive service and that there was gross inequality of provision and access throughout the country. The report also showed that much of the radiotherapy equipment being used was out of date. 2.4 It was recommended that there should be an immediate increase in the provision of linear accelerators to achieve 4 per million population. This implied that there should be 48 additional linear accelerators in the UK, of which 22 would replace old cobalt machines. It was also recommended that 44 machines more than 10 years old should be replaced. In addition it was recommended that, because of the increasing incidence of cancer and the increased complexity of radiation, future resource planning should assume a 5% annual increase in workload leading to at least 5.0 linear accelerators per million population by The target figures of 5.0 linear accelerators was confirmed as a conservative figure in a subsequent RCR document on provision and replacement of linear accelerators for radiotherapy (2000) After the publication of the RCR report in 1999, the Department of Health commissioned a Survey of Radiotherapy Services in England This confirmed the inadequate and unequal provision of linear accelerators highlighted in the RCR report. As a result of the two reports, substantial investment has been planned for radiotherapy services, which by 2004 should result in 62 replacement linear accelerators and 45 additional ones. There has also been an expansion in the number of training places for clinical oncologists and for therapy radiographers. 2.6 Unfortunately nothing stands still, and over the last 5 years there have been added pressures on the radiotherapy service, most of which were quite predictable. These include: an increasing incidence of cancer linked to the ageing population; population growth; a significant increase in referral rate for radiotherapy which has followed on from the reorganisation of cancer services and the National Cancer Plan. Many departments have seen a 15 20% increase in referrals; an increase in the sophistication of radiotherapy which makes it safer and more effective but without necessarily increasing throughput on machines. This has led to greater complexity of treatment and a larger number of treatment exposures per course. 2.7 A survey of radiotherapy services in the UK was repeated in June 2002 and the current report presents the findings. From this it can be seen how much has changed and how much still needs to be done. Page 5 of 16

6 3 Methods 3.1 The data for the survey was collected by means of an electronic data collection toolkit which was developed on behalf of The RCR, the Society and College of Radiographers (SCOR) and the Institute of Physics and Engineering in Medicine (IPEM) by Dr Brian Cottier and his team at National Cancer Services Analysis Team (NatCanSat). They were also responsible for analysing and tabulating the data. 3.2 Data collection was carried out between June and December All radiotherapy departments were asked to use 4th June 2002 as the census date. The full data set is available at Data was received from all 57 NHS radiotherapy facilities in the UK. Page 6 of 16

7 4 Results 4.1 Linear accelerators In 1997 there were 173 linear accelerators and 22 cobalt machines in the UK. If one assumes that one cobalt machine is equivalent to 0.5 linear accelerators, this equates to 184 megavoltage machines of which 25% were more than 10 years old. The average number of linear accelerators per million population was 3.17 with a range from 1.0 to 5.0 per million population In 2002 there were 199 linear accelerators in clinical use with eight cobalt machines giving a total megavoltage capacity of 203 machines (Table 1). The number of linear accelerators per million population was 3.53 with a range of (excluding one small centre). Table 1. UK radiotherapy facilities: megavoltage treatment machines in clinical use at Country Population catchment (1991 census) Machines Machines per million 1991 census Linacs Cobalts Megavoltage Linacs Cobalts Megavoltage England 47,321, Northern Ireland 1,685, Scotland 4,998, Wales 2,824, UK 56,830, Number of megavoltage machines = number of linear accelerators (Linacs) number of cobalts machines. Populations calculated from 1991 Census Population Data. Source: NatCanSat UK RT Survey 2002 Executive Summarys Only 22 out of the 57 (39%) radiotherapy centres in the UK achieved the National Cancer Plan target of 4 linear accelerators per million population. Only two of these were in the North of England, the other 20 being either in the South of England, Scotland or Wales. The disparity previously noted between North and South still prevails Only seven centres had 5 or more linear accelerators per million population but most served either isolated or small populations totalling less than 2 million Thirty-nine per cent of linear accelerators in 2002 were 10 or more years old compared with 25% more than 10 years old in Twenty-three per cent were 12 or more years old and 7% 15 or more years old Twenty-five per cent of linear accelerators were less than 3 years old, which reflects the recent replacement programme. 4.2 Linear accelerator workload Workload can be measured by courses of treatment which can have a variable number of attendances, fractions and exposures. Each fraction within a course can involve from one to six exposures. The number of exposures provides the most sensitive indicator of workload. Page 7 of 16

8 4.2.2 Comparison of the NatCanSat surveys in 1997/98 and 2001/02 allows comparison of the increase in workload. A complete dataset from all machines was available for both periods for only 29 centres. This has shown that the total number of exposures increased by 16% The number of exposures per machine in 2002 varied from 11,088 to 30,632 per year with an average of 20,412. These figures are similar to those in The average number of exposures per course was compared with 27.5 in This reflects the expected increase in complexity and quality of treatment The average number of hours worked per linear accelerator was 8.02 per day with a range of hours per day. Approximately 20% of departments were regularly working more than 8 hours per day and many more have done so in the past. The total output from a machine is not, however, just related to the number of hours it works but also to the number of staff available to run the machine, working practices and the complexity of the treatments plus the availability of revenue funding to allow increased working hours As in 1997 there was a marked variation in treatment rates throughout the country which probably reflects a combination of geographic access and adequacy of provision. The range, however, remains threefold with a minimum of 1,543 treatment courses per million population compared with a maximum of 4, The number of radiotherapy courses per 1,000 cancers is a good indicator of access to radiotherapy. The range varied from 308 to 823 with an average of 562 radiotherapy courses per 1,000 cancers. The average number of courses per patient is approximately 1.4, which makes the number of patients treated by radiotherapy per 1,000 cancers 405, i.e., 40.5 %. The range, however, varies from 22% to 58%. This is little different from the range in 1997 which varied from 24% to 64%. The average uptake of 40.5% is, however, higher than in 1997 and probably reflects an increased referral rate following the implementation of reports including the Calman Hine Report6 and The National Cancer Plan It is generally considered that 50% of cancer patients may benefit from radiotherapy at some stage in their illness. Very few centres provide that level of access because of limitation on the number of oncologists to see patients and the availability of treatment capacity The number of machines available for each 1,000 cancers registered varied from 0.43 to Equipment for planning Modern radiotherapy requires sophisticated imaging support plus computer controlled multileaf colimators and planning computers to deliver conformal radiation or intensity modulated radiation therapy (IMRT) Computed tomography scanners/virtual simulators Most departments have access to a computed tomography (CT) scanner which is used both for diagnosis and planning and a few have dedicated CT planning scanners. Only 17 departments have a CT simulator for planning radiotherapy. The average number of hours devoted to CT planning is per week with a range from 0 to 90 hours per week. The rapid change in technology will require more CT based virtual simulators which will largely replace conventional simulation Simulators Eighty-one simulators were recorded as being in clinical use but of these 29 (36%) are 10 or more years old Planning computers One hundred and two planning computers were recorded as being in clinical use. Forty-eight (47%) are 7 or more years old, 29 (28%) are 10 or more years old In addition to central allocation of linear accelerators there has also been investment through the modernisation fund in England in simulators and planning computers, some of which will not have been installed by the time of the audit in June The 2002/03 plans include provision for 23 Page 8 of 16

9 simulators and 15 CT simulators plus some planning computers to support three-dimensional treatment planning. 4.4 Staffing Clinical oncologists The total number of consultants in post in the UK in June 2002, including Professors and Senior Lecturers, was 431. At the time of the survey, 21 posts were recorded as being vacant. RCR data from Advisory Appointments Committees suggests that there are approximately 40 additional funded but unfilled posts. The relatively small increase in consultant numbers has hardly kept pace with the increase in referrals and the vast majority of clinical oncologists see more than the recommended number of 315 new patients per year. The consequence is that they have inadequate time for consultation and too little time for increasingly complex treatment planning At present approximately 95 consultant clinical oncologists are in the age group years. Thirty-four others are between the ages of 57 and 65 years. This means that in the coming decade about 129 of the consultant clinical oncologists currently employed within the NHS may retire. The Department of Health Economic and Operational Research Division predict a demand for an additional 262 trained Clinical Oncology specialists by With an allowance for part-time working of 1.2 this equates to a target of 672 consultant clinical oncologists, a required increase of 55% over current figures Radiographers There were 2,085 radiographers in post in June At the time of the survey, 348 posts were vacant. In spite of a welcome increase in the number of therapy radiographers there are still substantial problems in recruitment and retention and many departments are not able to use their full capacity because of the lack of therapy radiographers The RCR and the SCOR are keen to explore innovative changes in skills mix which will allow radiographers to work in ways that will facilitate modern treatment pathways and make best use of specialist skills. This is, however, severely compromised by lack of staff Physicists There are 939 substantive posts with an overall vacancy factor of 6.6%. This is, however, as high as 25% in some places Complex modern radiotherapy increasingly relies on the expertise of physicists. Grave risks are incurred by failure to maintain an adequate establishment of physicists Medical physics departments also require highly trained technicians to maintain equipment to high standards and commission new machines. Page 9 of 16

10 5 Radiotherapy Provision in Other European Countries 5.1 A recent survey of radiotherapy facilities in member countries of The European Society of Therapeutic Radiology and Oncology (ESTRO)8 has analysed the number of megavoltage machines per million population in the year 2000, which is the latest year with a complete data set for all countries. The results are shown in Table 2. Table 2. Number of megavoltage machines per million population in the member countries of ESTRO (2000) Country France 6.12 The Netherlands 4.65 Germany 4.60 Italy 4.31 England By 2004 provision in England should have increased to 4.2 linear accelerators per million. Similar increases are planned for other European countries. The Netherlands have plans to commission an extra 44 linear accelerators which will bring its provision up to 7.14 per million.9 n Page 10 of 16

11 6 Facilities Required to Deliver Modern Radiotherapy 6.1 In order to achieve the optimum outcome from modern radiotherapy, patients should have access to a department with the following minimum characteristics: enough linear accelerators to achieve a provision equivalent to per million population; three-dimensional planning computer and multileaf collimator to deliver three-dimensional conformal radiation and/or IMRT; a CT simulator; a full complement of radiographers, physicists and clinical oncologists to allow waiting time targets to be met. Unfortunately there is not a single department in the UK that meets all these requirements. 6.2 Since 1997 the majority of major capital equipment for radiotherapy in England has been provided by central allocation either through the NOF or from monies coming from the National Cancer Plan. The investment has been welcome and has allowed the rapid and direct introduction of new machines for which it had previously been difficult to get capital funding. Commissioners have had to make plans for local provision of services by funding the revenue consequences but the need to develop plans for increasing capacity and equipment replacement has been seriously neglected. If major capital equipment has a 10-year life expectancy then 10% should be replaced each year and adequate funds set aside to allow replacement when due. 6.3 Taking the example of megavoltage machines, there were 184 in 1997, which implies that at least 18.4 per year should be replaced to avoid deterioration in the age profile of the stock. Over a 5- year period this means replacement of 92 machines. In practice only 62 replacement machines have been provided while the rest have continued to age. The same is true for simulators and planning computers. This is clearly shown by the deteriorating age profile of equipment for radiotherapy. A consequence of central allocation is therefore that the local planning eye has been taken off the ball and replaced by inadequate top-down provision. 6.4 The consequences of having machines more than 10 years old are: they are not able to deliver modern treatment techniques; manufacturers no longer guarantee availability of spare parts; the machines lose their accuracy; the risk of unplanned interruption of treatment with consequent reduction in cure rate is made more likely. 6.5 The National Cancer Plan targets require that by 2005 there should be no more than a 1-month delay between diagnosis and treatment for patients with cancer and there should be no more than 2 months between initial urgent general practitioner (GP) referral and treatment (1 month by 2008).7 For many patients who have surgery as their first treatment, the delay before starting radiotherapy will not be recorded but for those with head and neck cancer, cancer of the cervix, brain tumours, inoperable lung cancer and prostate cancer, radiotherapy will be the first treatment after confirmation of the disease by biopsy. Cancer Networks will need to have robust plans to provide sufficient radiotherapy capacity to meet the 1-month waiting target by There are now considerable data on how to plan radiotherapy capacity for a given population. Planning algorithms are available in the RCR document The Provision and Replacement of Radiotherapy Equipment 3 as well as in the Survey of Radiotherapy Services in England All cancer networks should know the total population they serve and the incidence of cancer in that population. They also have information on the number of courses of radiotherapy currently Page 11 of 16

12 delivered per 1,000 cancers and the target which they should aim for, which is approximately 50% access to radiotherapy. With this, and information on the number of exposures per course, the number of courses per year delivered on each linear accelerator and the percentage of downtime it is possible to plan the number of linear accelerators required for the population plus the staff required to run them. Plans should, however, also include evidence of demand/capacity analysis of the type being developed by the Cancer Services Collaborative.10 In addition, allowance should be made for fluctuating demand. Waiting lists cannot be avoided if capacity is expected to meet 100% of demand all the time. It is necessary, therefore, to plan for approximately 10% extra capacity to avoid undue waiting lists.11 In their plans, departments should set out how additional equipment will be used to improve patient treatment. 6.7 It is, of course, possible that the National Cancer Plan 1-month waiting target for inoperable lung cancer, head and neck cancer, cancer of the cervix and prostate cancer can be met at the expense of other cancers which have to wait longer. This should be strongly resisted, first because radiotherapy is being prescribed in order to kill residual cancer cells after surgery that will continue to grow, and secondly, because work from the Cancer Services Collaborative has shown that a single waiting list is the most efficient and equitable way of managing patients rather than having several reserved categories. Page 12 of 16

13 7 Conclusion 7.1 In spite of 5 years of investment in radiotherapy the service is still in crisis. Thirty-eight per cent of linear accelerators are 10 or more years old as are 32% of planning computers and 36% of simulators. It is just not possible to deliver modern radiotherapy with outdated equipment. 7.2 The Government spending plans will provide for a further machine replacement programme of approximately 60 linear accelerators, so that none will be more than 11 years old by This will solve the problem of out-of-date radiotherapy machines but unless there is investment in CT simulators and new planning computers the new machines may not be used to their optimum advantage. 7.3 Unfortunately unlike new CT and magnetic resonance imaging (MRI) scanners, new linear accelerators may not allow much faster throughput and may initially reduce it as new treatment techniques are introduced. They will not therefore contribute much towards increasing capacity. To date there are no plans for further central funding to install additional radiotherapy machines. 7.4 By 2004 when the planned 45 additional linear accelerators have been installed, England should have 4.21 linear accelerators per million population. This might have been adequate for 1997 when it was first proposed but will fall far short of meeting demand in Previous calculations using three rather conservative models have suggested that we should aim for at least 5.0 linear accelerators per million population by 2006 to catch-up with the legacy of under provision, followed by a slower expansion to meet the needs of the ageing population and increasing sophistication of treatment.3 This means approximately 60 additional linear accelerators with the staff necessary to run them. The planning and investment over the last 5 years has just about allowed us to stand still in terms of matching capacity with demand and has not provided for any catch-up after years of under-investment. 7.5 While the Cancer Collaborative approach of process re-engineering may unlock some capacity, it is unlikely to bridge the very large gap between demand and capacity, nor is it certain that it will be sustainable. Experience has shown that it takes at least 4 or 5 years, and often up to 10 years, to complete the planning and installation of additional linear accelerator capacity. Now that central Government allocation is to cease, it will be the responsibility of Cancer Networks to work with Primary Care Trusts to plan and fund further expansion of the service. Strategic health authorities will have a role in performance management of that process. In Scotland central capital funding supports both equipment and buildings. 7.6 Expansion in machine capacity will need to be linked with parallel plans to increase the training capacity to ensure that there is enough staff to deliver the service. This will require joint planning between the networks and the workforce development confederations. International recruitment is unlikely to provide sufficient staff. Staffing levels can only be increased following sustained significant increases in training places for clinical oncologists, radiographers and medical physicists. 7.7 So far, most of the additional linear accelerators have been installed within existing cancer units and centres. The majority of these sites are now very congested. Further expansion often requires major enabling work such as diverting roads or moving hospital laundries and kitchens in order to install extra capacity. For many networks, consideration will have to be given to new build radiotherapy centres on other sites. Difficult though these longer term capital planning issues are, they have to be addressed now. If not, treatment capacity will lag further and further behind demand with perpetuation of unacceptable waiting lists. 7.8 While discussion has so far concentrated on machinery and staff, the most important factor is the patient with cancer who requires either cure or palliation. Currently significant numbers of Page 13 of 16

14 patients are either not being referred for radiotherapy because of the lack of resources or are having to wait so long for it that cure is compromised. There is no doubt that patients are dying unnecessarily and many are not able to have timely palliation of the symptoms of advanced cancer due to the lack of radiotherapy capacity in the UK. 7.9 An audit of waiting times for radiotherapy performed in showed that 28% of patients were unable to start radical potentially curative radiotherapy within 4 weeks of the decision to treat. This was considered quite unacceptable, and yet the peer review of cancer services in showed that failure to treat within 4 weeks is now the norm and occurs in 81% of cases. This has been confirmed by two recently published studies which show that for head and neck cancer 14 and for cancer of the cervix 15 waiting times to start radiotherapy have increased. For lung cancer also there is data to demonstrate that the tumour continues to grow during this waiting period and that this compromises the probability of cure.16 The same has been shown for head and neck cancer It is worth remembering that no more than 2 weeks wait is considered to be the standard of practice to aim for, with 4 weeks as the maximum acceptable wait This should be an exciting time for radiotherapy because improvements in technology have opened up the possibility of improving cure rates while at the same time reducing side-effects. Other Government initiatives on screening and improved diagnostic methods may also lead to increased detection of localised disease which is amenable to curative treatment. Radiotherapy has a major role to play in reducing deaths from cancer but has no chance of doing so if the population is denied access to high quality timely treatment because of lack of equipment and staff. Approved by the Board of the Faculty of Clinical Oncology: 27 June 2003 Approved by Council: 25 July 2003 BFCO(03)3 Page 14 of 16

15 References 1 Einhorn J, Frodin J-E, Müller T, Lamnevik G, Brorsson B, Einhorn N, Enkvist C, Haglund U, Jonsson E, Jønsson B, Karlsson G, Mattson B, Svensson H, Walstam R, Wert L, Weshn J (1996) Radiotherapy for Cancer, vol 1. Acta Oncologica 35 (suppl. 6):1 100 and (supp. 7): The Royal College of Radiologists (1999) Equipment, Workload and Staffing for Radiotherapy in the UK BFCO(98)2. London: Royal College of Radiologists 3 The Royal College of Radiologists (2000) The Provision and Replacement of Radiotherapy Equipment BCFO(00)2. London: Royal College of Radiologists 4 The Department of Health (2000) Survey of Radiotherapy Services in England London: Department of Health. 5 A Multidisciplinary Survey of Radiotherapy Services in the UK at Expert Advisory Group on Cancer (1996) A Policy Framework for Commissioning Cancer Services EL(96)15. London: Department of Health 7 Department of Health (2000) NHS Cancer Plan. London: Department of Health 8 ESTRO review of radiotherapy in Europe. 9 Slotman BJ, Leer WH (2003) Infrastructure of radiotherapy in the Netherlands: evaluation of prognoses and introduction to a new model for determining the needs. Radiother Oncol 66: NHS Modernisation Agency (2002) Cancer Services Collaborative Radiotherapy Toolkit Thomas SJ, Williams MV, Burnett NG, Baker CR (2001) How much surplus capacity is required to maintain low waiting times? Clin Oncol 13: The Royal College of Radiologists (1998) A National Audit of Waiting Times for Radiotherapy BFCO(98)3. London: The Royal College of Radiologists 13 Department of Health (2002) Peer Review of Cancer Services A National Overview. London: Department of Health 14 James MD, Robertson G, Squire CJ, Forbes H, Jones K, Cottier B on behalf of the RCR Clinical Oncology Audit Sub-Committee (2003) A National Audit of Radiotherapy in Head and Neck Cancer. Clin Oncol 15: Coles CE, Burgess L, Tan LT (2003) An audit of delays before and during radical radiotherapy for cervical cancer effect on tumour cure probability. Clin Oncol 15: O Rourke N, Edwards R (2000) Lung cancer treatment waiting times and tumour growth. Clin Oncol 12: O Sullivan B, Mackillop W, Grice B (1998) The influence of delay in the initiation of definitive radiotherapy in carcinoma of the tonsillar region. Int J Radiat Oncol Biol Phys 42(suppl.): Fortin A, Bairati I, Albert M, Moore L, Allard J, Couture C. (2002) Effect of treatment delay on outcome of patients with early stage head and neck carcinoma receiving radical radiotherapy. Int J Radiat Oncol Biol Phys 52: Waaijer A, Terhaard CH, Dehnad H, Hordijk GJ, van Leeuwen MS, Raaymakers CP, Lagendijk (2003) Waiting times for radiotherapy: consequences of volume increase for the TCP in oropharyngeal carcinoma. Radiother Oncol 66(3): Page 15 of 16

16 20 Joint Council for Clinical Oncology (1993) Reducing Delays in Cancer Treatment: Some Targets. London: Royal College of Physicians Page 16 of 16