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					VUmc



         Radiotherapy planning and
       organization in The Netherlands
                         Ben Slotman
               Professor and Chair, Radiation Oncology
                VU University medical center
                Amsterdam, The Netherlands
VUmc        At the end of the ‘90s




•   Waiting for new Government decision on capacity
•   Long waiting times
•   Suboptimal fractionation schemes
•   Impossibility to implement new techniques
•   No extra reimbursement for intensive therapy
•   …etc…….
•   …...etc…..
•   ………etc..
VUmc          Re-imbursement




“Treatment series” ?!
A complete treatment consisting of x fractions

• New series for extra electron fields, boost, or even every change in field
  sizes, etc.
• Sometimes 3 series for one treatment

• Insurance companies agreed (or not)

• No comparison between and within centers possible
• No parameter which incorporates relative workload
VUmc      New reimbursement parameters




• Limited number of categories
• Should reflect workload
• Should be fool-proof
• Should be used for comparison of production
  between and within institutes
• Should be used for planning future needs for staffing
  and infrastructure
VUmc        T and B categories




• Teletherapy
  –   T1: simple, patient already known to the dept.
  –   T2: standard
  –   T3: intensive (CRT)
  –   T4: special (SRT, IMRT)
• Brachytherapy
  –   B1: simple (plaque)
  –   B2: standard (breast)
  –   B3: intensive (Fletcher)
  –   B4: special (stereotactic, Prostate seeds)
VUmc         Costs of Teletherapy (in €)




                        T1          T2      T3     T4

 Personnel              551       1750     2998   5036

 Materials              105        334     572    960

 Total                  656       2084     3570   5996
                        0.3        1.0     1.7    2.9
VUmc         Costs of Brachytherapy (in €)




                        B1         B2        B3     B4

 Personnel             226        403        925    3273

 Materials              51         77        176    625

 Total                 317        480        1101   3898
                       0.7         1.0       2.3    8.1
VUmc        Costs of T and B categories


                        Relative costs
• Teletherapy
  –   T1: simple             0.3
  –   T2: standard           1.0
  –   T3: intensive          1.7
  –   T4: special            2.3
• Brachytherapy
  –   B1: simple             0.6
  –   B2: standard           1.0
  –   B3: intensive          2.3
  –   B4: special            8.1
VUmc        Costs of T and B categories


                          Relative costs          Ttotal   T2eq
• Teletherapy
  –   T1: simple                0.3                100      30
  –   T2: standard              1.0                100     100
  –   T3: intensive             1.7                100     170
  –   T4: special               2.3                100     230


  Total                                            400     530




                      Similar for Brachytherapy
VUmc             Prognosis 2000 – 2010: Patients



                                          1995    2000    2005    2010

New cancer patients                       55300   59400   63100   69400

% irradiated (excl. Skin cancer)           47      48      49      50

New irradiated patients                   26000   28500   30900   34700


Skin cancer and benign lesions (x 1,05)   27300   29900   32400   36450


Repeat factor (1,30-1,35)
Totaal Teletherapy treatments             35500   38800   43700   49100
VUmc              Prognosis 2000 – 2010: T-distribution




                                     1995    2000    2005   2010

 Total Teletherapy treatments       35500   38800   43700   49100   40%

 % T1 (simple)                        24      22      22     22
 % T2 (standard)                      57      54      48     44
 % T3 (intensive)                     16      20      25     28
 % T4 (special)                       3       4       5      6


 Total T2-equivalent                35536   41206   48769   56760   60%
VUmc              Prognosis 2000 – 2010: B-distribution




                                     1995    2000    2005   2010

 Total Brachytherapy treatments      2675    3215    3425   4180

 % B1 (simple)                       35       27      20    20
 % B2 (standard)                     32       28      29    29
 % B3 (intensive)                    27       39      45    45
 % B4 (special)                       6       6       6      6


 Total B2-equivalent                 4473    5954    6682   8155
VUmc               Linacs and personnel




                                                 1995    2000    2005    2010

 T2-equivalent                                   35536   41206   48769   56760

 Linacs (500T2eq)                                 71      82      98     115

 Radiation oncologists (250 T2eq)                142     165     195     230
 Physicists (650 T2eq)                            55      63      75      88

 Technologists (55 T2eq)                         640     742     878     1034


  Excluding Brachytherapy
   For 250 B2eq. :
               0.5-1.0   radiation oncologists
               0.5       physicist
               0.5       physics assistants
               1.0-2.0   technologists
VUmc          Size of 21 centers



                      Number of centers
          1 linac   2 linacs        3 linacs   4 linacs   5 linacs     6 linacs   >6 linacs
1998          2        7               5          4          1            1          1




                           Linacs              Centers     Linacs/center
       1998                    67                21              3.2
VUmc          Size of 21 centers



                      Number of centers
          1 linac   2 linacs        3 linacs   4 linacs   5 linacs     6 linacs   >6 linacs
1998          2        7               5          4          1            1          1
2003          0        4               7          3          2            2          3




                           Linacs              Centers     Linacs/center
       1998                    67                21              3.2
       2003                    88                21              4.2
VUmc          Size of 21 centers



                      Number of centers
          1 linac   2 linacs        3 linacs   4 linacs   5 linacs     6 linacs   >6 linacs
1998          2        7               5          4          1            1          1
2003          0        4               7          3          2            2          3
2008          0        2               1          6          3            3          6




                           Linacs              Centers     Linacs/center
       1998                    67                21              3.2
       2003                    88                21              4.2
       2008                 113                  21              5.3
VUmc   Teleytherapy 1996-2008
VUmc            T-total and T-equivalent



                         2000      2002    2004    2006    2008
T-total                  37800    40200    43700   46302   49461
T2-equivalent            40000    45800    55500   66338   77036
T2-eq/T-total            1,05      1,14    1,27    1,43    1.56


%T1                       24       23       22      22      23
%T2                       53       49       43      32      23
%T3                       19       20       20      25      27
%T4                        4        8       15      22      28
VUmc   Linacs 1996-2008
VUmc   Radiation oncologists 1996-2008


 fte

                                            Registered
                                            In training


                    Needed based on T2-eq
VUmc   Physicists 1996-2008


 fte

                                            Registered
                                            In training


                    Needed based on T2-eq
VUmc   Technologists 1996-2008


 fte

                                            Registered



                    Needed based on T2-eq
VUmc            2005: Evaluation



                               2000     2005   Change
Linacs                             74   101    + 36%
 - with MLC                    48%      89%
 - with EPID                   59%      95%
Radiation oncologists          142      178    +25%
Physicists                         65   78     +20%
Technologists                  703      949    +34%
VUmc         2005: Evaluation and new Prognosis




• New cancer incidence data (2004):
   2015 + 43% increase compared to2005
• T2equivalent overestimates the needs (inflation)
   More efficient delivery of complex treatments
   For future calculations complexity (T2eq/T) and efficiency-factor
   New T2eq = 0,86 x T2-equivalent
• No evidence for increase in number of retreatments
   1,30 in stead of 1,35
• Some underconsumption:
   Utilisation 43% in 2005, 44% in 2010 and 45% in 2015
VUmc              Prognosis



                               2005     2010    2015
 New cancer patients           78500    87000   96500
 Utilisation factor            0.43     0.44    0.45
 Repeatfactor                  1.30     1.30    1.30
 Benign lesions factor         1.0356   1.035   1.035
 New radiotherapy patients     45417    51506   58428
 Weight factors                1.15     1.25    1.35
 T2new-equivalent treatments   52230    64382   78878
VUmc            Prognosis



                                   2005    2010         2015
 T2new-equivalent treatments       52230   64382        78878
 Linacs                                    129          158
 Radiation oncologists (+brachy)           258 (+20)    316 (+23)
 Physicists (+brachy)                      99 (+13)     121 (+15)
 Technologists (+brachy)                   1171 (+39)   1434 (+45)
VUmc         Number of linacs



                                Linacs

       180
       160
       140
       120
       100                                       Realisatie
        80                                       Behoefte
        60
        40
        20
         0
               2000      2005      2010   2015
VUmc             Newly defined activities



Preparation               Teletherapy                 Brachytherapy
Conventional         V1   Single fraction        U1   No individual        B1
Simulation                                            dosecalculation
CT simulation        V2   Long fraction          U2   Individual dose      B2
                                                      calculation
Simple TP            V3   Standard imagebased    U3   3d imaging,           B3
                          positioning                 contouring & planning
Standard 3D TP       V4   Intensive imagebased   U4   Stereotactic BT      B4
                          positioning
Intensive TP         V5   Intensive treatment    U5   Permanent            B5
                                                      implantation
Image fusion         V6   SRT                    U6
Functional imaging   V7
VUmc          Teletherapy: T0-T6


      Activity                           T0   T1   T2   T3   T4   T5   T6
 V1   Convent. Sim
 V2   CT-sim
 V3   Simple TP
 V4   Standard 3D TP
 V5   IMRT
 V6   Imagefusion
 V7   PET-scan
 V8   MRI-scan

 U1   1 fraction
 U2   long fraction
 U3   Standard Positioning correction
 U4   Intensive Positioning correction
 U5   IMRT
 U6   SRT
VUmc    Satellites




  • Hospital prestige

  • Patient comfort/travel

  • Multidisciplinary treatment

  • Is there maximum center size?
VUmc    Satellites




  • Satellite at least 2 linacs
  • No treatment planning
  • Mother institute at least 4 linacs
  • Mother institute at least 10-12 ROs
  • Same quality system
  • At least 90% of treatments
  • Personnel paid by mother institute
VUmc

				
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