SRS/SRT Service Specification

Response from The Royal College of Radiologists

  1. Do you agree that there should be equitable geographical access across England to Tier 1 and Tier 2 SRS/SRT services, so that clinical indications, such as cancer, can be treated close to home?

The RCR agrees with the principle of equitable access. However truly equitable access will not apply if travelling distances and times turn out to be impractical for relatively deprived patient populations such as those with brain metastases from lung cancer.For example, it is noted that the proposal to have just one tier 1 / 2 provider in the area covered by Peninsula, Avon, Somerset and Wiltshire and Dorset means that patients will have to travel very long distances if only one provider (Bristol or Plymouth) is chosen to deliver the service for all these patients. Both centres have long established SRS services. We would recommend that partnership working across the two sites could provide an effective model which could also apply in other areas of England.

  1. Do you agree that the treatment of rare benign indications (Tier 3 and Tier 4) should be concentrated into larger ‘supra-network’ centres to ensure availability and maintenance of clinical expertise?

The RCR agrees with this. However, there is a case for this being 4 rather than 2 centres to ensure that travel distances are not too great for patients. There should be sufficient patient numbers to permit 4 centres to deliver these treatments.

We suggest that the inclusion of pituitary tumours in tier 4 requires clarification. The large majority of patients with pituitary tumours currently have conventionally fractionated radiotherapy delivered in RT centres across England. Rarely,small recurrent tumours >2mm from the optic chiasm can be treated using SRS if the patient has already undergone conventional RT. It should be made clear that the Tier 4 indication is for this limited group of patients.

The specification should include details of plans for NF2 patients (ie all the tier 3 and 4 centres?)

  1. Do you agree that paediatric patients requiring complex cancer SRS/SRT treatment should be concentrated into a small number of dedicated centres for this treatment?

The RCR agrees with this proposal – note that most children with brain tumours will have proton therapy, so SRS indications will be very rare. The specification should clarify what the intention for patients with NF2 will be.

We do not agree with this proposal for all paediatric SRS. Children with brain metastases must continue to have rapid access to SRS/SRT as close to home as feasible, as for adults. Children needing General Anaesthetic might have more restricted choices, as they should be treated in centres will full paediatric support for general anaesthesia. However, we would be concerned that fewer children would end up having SRS for brain metastases if they have to travel to one of only two centres. There is no evidence base to justify concentrating all activity for older children not requiring general anaesthetic in two centres. We have the same concerns about local access for TYA patients. We agree that children and TYA patients should be treated in services which are part of established Principal Treatment Centres (PTCs) and that the paediatric SRS/SRT service should be aligned with a large established tertiary paediatric neuro-oncology MDT.

While we do not think there is good evidence for the claimed superiority of Gamma Knife for children and TYAs with benign disease based on “the very lowest possible whole body radiation dose”, locally we are happy to support the concentration of treatment for benign disease in children and TYAs in two centres.

For children in the forthcoming SIOP ependymoma II trial, the protocol calls in some cases for a hypofractionated boost of 8 Gy in 2 fractions following up to 59.5 Gy in 33 fractions of radiotherapy. This requires meticulous planning to avoid a risk of brainstem injury. The SIOP trial coordinators in the UK believe that for the boost to be delivered safely, it must be delivered in a centre which is also delivering the fractionated course of radiotherapy, so that both phases can be planned together. This may not achievable if the hypofractionated boost can only be delivered in a freestanding Gamma Knife centre.

  1. Do you agree that neurosciences networks should form the basis of the proposed ‘SRS/SRT Tier 1 and Tier 2’ geographies?

The RCR agrees with this proposal. However we would recommend that it should be noted that neurosciences networks are not co-terminus with the NSHE regions.

  1. Do you agree with the requirement for Tier 1 and Tier 2 services to be based on a population footprint of two million and delivering 100 cases per year in order to develop high-quality, efficient and safe services?

The RCR agrees with the principle of SRS centres having a critical mass of expertise and we can understand the rationale for the choice of 100 cases per annum. However this number is pragmatic and not evidence based. Sticking to this threshold rigidly could result in inequity of access. The principle of high quality delivery with audited good patient outcomes could provide a better basis for distribution of centresthan an arbitrary case number.

It is very important to note that patients with brain metastases will need to be discussed and managed by the relevant disease-specific MDT, and then referred to the neuro-science MDT if SRS is considered to be an option. This will require efficient communication across MDTs and having to refer to a neuro-science MDT outside the geographic area of other cancer MDTs could lead to disjointed care, unless carefully co-ordinated.

  1. Where neurosciences networks have been amalgamated to create a population footprint of over two million (section 3.2.2 of the service specification), do you agree with the proposed ‘grouping’?

Yes – although we have the following comments on specific proposals:

  1. The Peninsula, Avon, Somerset and Wiltshire and Dorset grouping as this means that patients will have to travel very long distances if only one provider (Bristol or Plymouth) is chosen to deliver the service for all these patients. Both centres have long established SRS services closely linked to neurosurgical services, so it does not appear to be justified to join these areas to have a single provider. These should be separated.
  1. It has been suggested that in the North-West a preferred option would be for one service operating from two sites (The Christie at Salford and Royal Preston Hospital), as now, in order to minimise journey times for patients across what is a geographically large region.Preston Lancashire has a population of 1.9M and Salford/Christie a population of 3.3M. It doesn’t make sense to amalgamate two existing providers due to a minimal short fall of Preston below the 2M population. There are issues of long travelling distances for patients to be considered as well with this amalgamation. These should be separated.

3. In Greater Manchester, Lancashire & South Cumbria, we believe that both Salford Royal NHS Foundation Trust and Lancashire Teaching Hospitals NHS Foundation Trust (Royal Preston Hospital) could continue to operate independently, and offer a high quality of SRS service. However, we understand and accept the rationale for the proposed grouping, which we feel we would be able to support.

As regards joint working between these centres is concerned, clinical protocols are similar and could easily be brought into alignment, and there may be some synergies in physics sharing best practice. We understand that the initial proposal was for separate SRS and SRT MDTs to continue, and the two services to meet to share practice, audit data etc. The proposal now seems to be for a shared SRS/SRT MDT. We do need to consider carefully how this would work, and locally we need to discuss this further. Currently patients with brain tumours without a previously known primary are often referred directly to our Neurosciences MDT at Salford Royal by radiologists and clinicians at District General Hospitals, often with the query whether this is likely to be a primary or secondary (i.e. metastatic) brain tumour. These cases require discussion at the neuro-science MDT, because they may represent primary brain tumours, and it would not be possible to divert all these cases to a joint SRS/SRT MDT with Preston. It is likely therefore that there would need to be some pre-selection at the local neuro-sciences MDT of brain metastasis cases for joint discussion. A second joint SRS/SRT MDT with Preston would then need to follow. The timelines for this would be critical so as not to delay the patient being seen in the SRS clinic.

In general there needs to be careful consideration of how the proposed groupings would work in reality, ensuring seamless co-ordination between disease-specific and neuro-science MDTs. These examples illustrate the principle that the pathways for seamless working across MDTs need to be carefully thought through.

  1. Do you think that the revised standards, as set out in Section 4 ‘Key Service Outcomes’, are appropriate for this service?

The RCR would like to make the following points:

  • survival over time; this needs to be specified – we assume this refers to median survival
  • deaths within 30 days of treatment; - for radiotherapy deaths within 90 days should also be recorded as well as 30 days (which is more relevant to palliative treatment)
  • functional / performance status before and after treatment; - needs to be specified by scale used and time points when it should be measured (eg WHO PS on day of treatment and 3 months after)
  • patient experience should be included in outcomes
  1. Please provide any comments that you may have about the potential impact on equality and health inequalities which might arise as a result of the proposed changes that we have described, particularly in relation to the geographies that currently have more than one SRS/SRT service (section 4.1, paragraph 44).

The RCR would like to make the following comments:

  • Sheffield: Thornbury Gamma Knife ® Centre and Sheffield Teaching Hospitals NHS Foundation Trust; It seems reasonable for only one provider to be chosen.
  • North West: Manchester and Lancashire;As outlined in sections 6 above it does not make sense to chose only one of these as the population in Preston is 1.9M nearly meeting the threshold for delivering a service and the unit has experience already of delivering a service.
  • South West: Bristol and Plymouth; See answers to question 1 and 6. For geographic reasons, and existing team expertise (including on site neurosurgery, both these services should continue.
  • North London and East and North Hertfordshire: BUPA Cromwell and/or Barts Health and East and North Herts NHS Trust (Mount Vernon). It is appropriate to chose just one, as geographically these are close and one does not have neurosurgical expertise on site.
  • The South Tess Hospital NHS FT – this is an area currently served by a neuro-science service and MDT yet is proposed not to have its own commissioned SRS service. There are concerns that this could lead to inequity of access for disadvantged patient populations.
  1. Please provide any further comments you may have on the proposed changes.

The document refers to Oxford University Hospitals as the provider for Thames Valley. It should be noted that OUH had Linac based SRS equipment installed (Feb 2014) and staff recruited and trained, but has been prevented from starting SRS/SRT services since October 2013 when the initial SRS consultation was announced and it was stated that no new centres were to be approved until the consultation was complete.The team in OUH have been delivering fractionated stereotactic radiotherapy for over 600 fractions. NHSE were aware of this. Other potential new providers are however mentioned in the documents.

It needs to be fully understood that for patients with brain metastases, the largest patient group, the management of brain metastases cannot be considered in isolation from the overall management of the patient’s metastatic status by the disease-specific MDT. Any service model needs to ensure cross-MDT co-ordination.

The RCR welcomes the proposed new timelines, i.e.

1) To communicate ‘the definitive management plan’ to the referring consultant/MDT and the General Practitioner (GP) within two days (currently five days),

2) For patients with malignant disease, to ensure clinical review should take place within one week of the neurosciences (neuro-oncology) MDT meeting in which it is determined that the patient is suitable and accepted for treatment

3) Treatment with SRS/SRT should be delivered within two weeks of decision to treat (in clinic) for patients with malignant disease.

These objectives should be achievable and will help to improve patient outcomes.

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