MPs debate Stereotactic Body Radiotherapy

Posted on Feb 09, 2012

The transcript from a debate in the House of Commons on Wednesday evening, secured by Tessa Munt MP. The debate covers the availability of SBRT across the UK.
Health Minister Paul Burstow begins his response to the questions raised by stating "Radiotherapy is more targeted than chemotherapy and less invasive than surgery, with new, faster and more precise technologies reducing side-effects and improving outcomes for patients."

He also points out that there are many types of technology and brands that deliver SBRT.

Tessa Munt (Wells) (LD): I asked for this debate because for nearly 12 months I have been questioning the Department of Health about why the latest radiotherapy techniques and equipment to treat cancer patients are not being used by our NHS. I have pressed hard on this subject because, like Cancer Care UK and many other respected organisations, I believe radiotherapy is underused in the front line for curing cancer.

This country has a history and a habit of resorting to pumping cancer patients full of pharmaceuticals. Do not get me wrong, I am not knocking cancer drugs—many are highly effective and a great help to patients, and many cancer patients are alive today thanks to them. However, a lot of those drugs also have some pretty horrific side effects, and patients are often reluctant to take them for that reason. So in reality, throughout the latter part of the last century, heavy doses of drugs or death were almost the only choices that cancer patients had.

Although there has been plentiful use of drugs throughout the last 60 years, the uptake of radiotherapy as a front-line treatment has been slow. Radiologists have told me that one reason for that is they have not been as successful at lobbying as the pharmaceutical companies, but that is a matter for another debate. The main reason why there was resistance to using radiotherapy in the past was its method of delivery—single large beams of radiation being fired into the body to ensure that the tumour at which they were aimed was radiated. Unfortunately, those large beams also radiated an awful lot of healthy tissue around a tumour, especially if the tumour was moving, and frequently caused more damage than good. Patients often complained that the side effects of radiotherapy were worse than the cancer.

During this century, there have been huge advances in the delivery and accuracy of radiotherapy treatment. Around the world, radiosurgery is being used increasingly to cure cancer as a front-line treatment. Stereotactic body radiotherapy treatment, or SBRT, uses multiple very fine beams of radiation locked directly on to just the tumour. With some new technologies the beams move as the tumour moves, ensuring that the surrounding healthy tissue is not harmed and only the tumour is radiated.

Unfortunately, in the UK we are failing to embrace the new technologies that allow for the effective use of SBRT to treat cancer patients. We are falling behind both Europe and the US. On 22 November last year, I asked the Secretary of State for Health in the Chamber how many radiotherapy centres in this country were providing SBRT to cancer patients. When he told me the figure was 25%, I must admit to having been surprised—not as surprised, I would add, as some of the medical professionals I know, who found the figure unbelievable, but that was what he said.

Within a few days, the cancer tsar repeated that same figure in a letter to The Times. Thus, 25% suddenly became received wisdom for the standard of provision of SBRT in England. I therefore asked the Secretary of State in a written question on what evidence he had


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based his statement. “Not really sure,” was the reply. The evidence was based on an “informal study” conducted by the National Cancer Action Team. NCAT also said it believed there were more than 20 machines in the country that could deliver SBRT.

I am not a fan of Government policy making based on “informal studies” and vague beliefs, so I conducted my own, very formal study on the availability of SBRT in the UK. Under the terms of the Freedom of Information Act, I wrote to every hospital in the country that provides radiotherapy and asked each a series of questions about its ability to deliver SBRT. I am pleased to say that 57 replied—all but the Royal Shrewsbury hospital—and very helpful they were too.

For the record, I shall share the data with the Minister, so he can pass them on to the Secretary of State. In 2011, only seven centres in England and one in Scotland treated cancer patients with SBRT. There were no centres in Wales or Northern Ireland. Only four of the centres conducted a large enough number of procedures to comply with national radiotherapy implementation group recommendations. Therefore, 14% offer SBRT and just 8% are compliant. The total number of patients treated in those centres was just 323. That figure is not surprising when we consider that, according to the hospitals, there are only seven machines in the country capable of delivering SBRT—a good deal fewer than the number NCAT believes there are.

The Minister will not be surprised that my questioning did not stop there. I had also asked what indications the centres treated with SBRT. The data became even more interesting. Those centres using the Elekta or Varian systems treated only lung cancer. Centres using the CyberKnife system treated lung cancer, but they also treated liver, prostate, spine, breast, myeloma, sarcoma, head and neck, and ovarian cancers.

I asked the centres what their estimates for SBRT treatment in 2012 were. Again, they were very helpful in providing that information, and I place on record my gratitude to them for it. The centres estimate that approximately 725 procedures will take place in hospitals planning SBRT programmes for this year: 48 using the Varian system; 195 using the Elekta system; and 385 using CyberKnife system. The remaining 97 procedures were claimed as “estimates” by centres that have not conducted any SBRT in the past, and which do not appear—from their responses—to have suitable equipment for conducting such procedures.

I must admit that I found that last statistic, and the fact that only four centres conducted the number of procedures necessary to comply with the NRIG recommendations, very alarming. I, for one, would not wish to be treated at a centre where the team carries out only half a dozen procedures each year. How can it possibly have any expertise in such a complex treatment process if the staff so rarely conduct the procedure? For the Minister to allow that to continue would be contrary to the aims of the new Health and Social Care Bill and all that the Secretary of State has said about concentrating resources in centres of excellence to improve patient outcomes.

A number of other things alarmed me when I read the returns from the centres. On numerous occasions, the Minister has assured me that work is in hand by NCAT to establish a national tariff, or price tag, for SBRT, and yet, while the centres tell me they would


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welcome a national tariff, they also tell me that no progress is being made towards it. In fact, the vast majority have not even been consulted about establishing one. One of the most well known and respected centres has gone further, and said that

“a national radiotherapy tariff without SBRT would be seriously flawed and its fitness for purpose questionable.”

Will the Minister comment on that?

Naomi Long (Belfast East) (Alliance): The hon. Lady is aware of a case involving Brian Withers, my constituent. He has been able to access the treatment, but has had to self-fund to do so. One reason it was not included in his clinical pathway was that it was argued that there was no clinical trial evidence for it in his situation. Does she agree that part of the problem is that SBRT is treated as a novel treatment for cancer as opposed to the development of an existing one? Therefore, without the tariff, people from other regions will not be able to access it on a routine basis.

Tessa Munt: I could not agree more. As the hon. Lady and others are well aware, I have spoken with her constituent, Mr Withers, and it is clear that radiosurgery is a well-established and proven therapy—it is just that we have to wait to get it.

In an answer to a parliamentary question, I was told that a price tag would not be set up until 2014. NCAT must be the only organisation in the NHS that believes it should take three years from the point that an esteemed committee recommends a national tariff until one can be implemented. From what they tell me, the centres do not believe it, and I do not believe it, and I do not think that the Minister believes it. The question of establishing an SBRT tariff, as recommended in the report from NRIG last April, is not just a question of the administration involved in setting up some codes so that the NHS can cost it; this lack of tariff has a direct impact on cancer patients’ lives.

Let me tell the Minister about my friend Kerry Dunn, a 42-year-old mother from Somerset who was diagnosed with cancer. Last September, her clinicians in Bristol concluded that the only treatment available that could save her life was SBRT on CyberKnife. The CyberKnife experts in London agreed. Her clinicians applied for funding from North Somerset primary care trust, but it took them two months before it refused. It said no because, according to it, there was not enough evidence to suggest that CyberKnife would work.

It is important that the Minister fully understands the train of events in this case. Kerry Dunn’s clinician in Bristol, one of the leading oncologists in the country, believed that CyberKnife could treat her, and the clinicians in London, who routinely use CyberKnife to treat cancer, said that they could treat her, but the bean-counters on North Somerset PCT thought otherwise. Kerry Dunn told me what had happened at the beginning of December. She and her family were in absolute despair over this decision. Once I had contacted North Somerset PCT and after the local press had, separately, taken an interest in her case, the PCT allowed Kerry Dunn to appeal its decision. Three weeks after the first decision, the PCT changed its mind and agreed her funding for CyberKnife.

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If Members were expecting a happy ending to this story, I am sorry to disappoint them. Kerry went straight back to the CyberKnife people in London, but her tumour had grown so much that they could no longer treat her. Kerry and her family now face an uncertain future. Three months earlier, there was considerable hope that she would beat her cancer.

The Minister will know as well as I do that if the NRIG report had been implemented last April and an SBRT tariff set at that time, North Somerset PCT would not have delayed approval for Kerry’s treatment and she would be a much healthier woman than she is today. Over the past 12 months, the Department of Health has painted a very different picture of the provision of SBRT in the NHS. I must say to the Minister that I am shocked by the disparities between what the Secretary of State has told me and what all the hospitals have told me in answer to my freedom of information requests. Knowing the Minister as well as I do, I trust that it has more to do with his officials keeping him in the dark than their misleading hon. Members.

In conclusion, I would like some answers from the Minister today. Will he instruct the National Cancer Action Team to conduct a full review of the SBRT facilities available in the NHS? That review should establish whether hospitals are using technology that is fit for purpose and can treat a wide range of tumours with SBRT, and whether hospitals are conducting the number of procedures needed to comply with the NRIG recommendations. Will he commit to speeding up the process of establishing an SBRT tariff in line with the NRIG recommendations, and will he start immediately by asking NCAT to establish a costing code? Finally, I would like a commitment from him to investigate why decisions to fund SBRT by PCTs can ignore clinical opinions of medical professionals when assessing the need for treatment for people such as Kerry Dunn.

7.18 pm

Grahame M. Morris (Easington) (Lab): I pay tribute to and congratulate the hon. Member for Wells (Tessa Munt) on securing this important debate. I want to put on the record the appreciation of myself and the whole House for the work that she has done in this important area.

Last August, the Department of Health released the first ever England-wide analysis of patient access to radiotherapy treatment. For those of us who represent constituencies outside London and the south-east, the results were shocking. The disparity in treatment levels for cancer patients living in and around London, compared with the rest of the country, is nothing short of disgraceful. Access to advanced radiotherapy should not be a postcode lottery. The data on each of England’s 28 cancer networks show that the further someone moves away from London, the smaller their chance is of receiving radiotherapy. North-west London tops the list, with radiotherapy provision at 94%, whereas the north-east—my region—came last, at 27%. In fact, the bottom five networks were all north of the River Trent.

Jim Shannon (Strangford) (DUP): The benefits of SBRT are well proven in many cases and clear in numerous cases. Does the hon. Gentleman agree that it should be available more extensively across the whole of the NHS, and that it is time for the Minister to work


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alongside the devolved Administrations to ensure that the treatment is available for patients in Northern Ireland, as well as other parts of the United Kingdom?

Grahame M. Morris: Absolutely. I thank the hon. Gentleman for that intervention, and I agree completely. All 28 cancer networks should have equal access to this advanced radiotherapy.

In practical terms, cancer patients in the Minister’s London constituency are three times more likely to receive the radiotherapy treatment that they need than those residing in northern England and twice as likely as those living in the south-west of England. Believe it or not, however, when the general radiotherapy dataset is analysed further—by that I mean looking at radiotherapy centres offering conventional radiotherapy and those offering the more effective SBRT—the picture is far worse.

The conventional method of radiotherapy delivery is unable to distinguish between healthy and unhealthy tissue, so the treatment is delivered in short doses—often every day for four or five weeks—to avoid too much damage to the healthy tissue. As the hon. Member for Wells said, SBRT uses small, multiple and highly focused beams of energy to deliver radiation directly to the tumour, ensuring that a minimal dose is received by the surrounding healthy tissue. Consequently, there are little or no treatment-related side effects. SBRT allows the patient to be treated over five days, as opposed to five weeks, as with conventional radiotherapy. Because of its accuracy, SBRT can be used to treat tumours that might be surgically inaccessible or in close proximity to critical organs of the body, such as the heart.

When we look at the postcode lottery that the dataset report presents, we should also ask where SBRT is available and where it is not. The Minister must understand how important the comparison is. For cancer patients in my constituency, the difference between having access to SBRT and having access to conventional radiotherapy—for prostate cancer, for example—is a 50-mile car journey every day for five weeks and the treatment lasting just five days, with a rapid return to normal life. As well as the benefits to the individual, the cost savings to the NHS of using SBRT compared with conventional radiotherapy are obvious for all to see.

Like the hon. Lady, I, too, was approached, just before Christmas, by a constituent whose cancer needed SBRT. His tumour could be treated only using the accuracy of the robotic CyberKnife system, but there are only three CyberKnife systems in the NHS, and they are all in London. However, thanks to the incredible co-operation of my constituents’ clinicians and the clinicians from St Bartholomew’s hospital in London, as well as the understanding of County Durham PCT—the commissioners, who, in a timely fashion, agreed funding —he starts his treatment here in London in two weeks. My constituent is very happy that he is set to receive the treatment in an NHS hospital, but is it not a scandal that he has to travel more than 260 miles to do so? What is equally scandalous is that the reason why there are only three CyberKnife systems in NHS hospitals is that those hospitals needed to raise the money to purchase them from charitable donations. I have since learned that in Birmingham, as well as in Newcastle, in my region, the Bear appeal is seeking to raise the money for a CyberKnife system from charitable sources.

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What an indictment of the NHS under this coalition government! The NHS should not have to go begging for charitable funds to buy the latest life-saving equipment, especially when we know that the Department of Health is currently holding back £300 million in capital allocations, in Whitehall coffers. This resource is for capital equipment, but is not given to the hospitals in regions like the north-east where it is most needed. If the Minister is serious about reducing health inequalities in the north-east, and, indeed, in the south-west, we should have this equipment and not be left to linger at the bottom of the radiotherapy dataset, which the Minister himself said is the benchmark for future provision. I ask the Minister to make a commitment to investing some of this £300 million in the capital equipment needed to reduce these disparities in the provision of radiotherapy in general and SBRT in particular.

7.25 pm

The Minister of State, Department of Health (Paul Burstow): We have had a good debate so far, and I congratulate my hon. Friend the Member for Wells (Tessa Munt) on securing it and on providing an opportunity for us to draw attention to radiotherapy services in the NHS. I want to try to answer as many questions as I can. I understand that my hon. Friend will meet Department officials to discuss some of her concerns further. I hope that if any issues are not covered, they can be explored further there.

Radiotherapy is an extremely important form of treatment for cancer, which often does not get the attention it deserves. This debate has, I think, helped in that regard. It is more targeted than chemotherapy and less invasive than surgery, with new, faster and more precise technologies reducing side-effects and improving outcomes for patients. Radiotherapy is a significant component in the treatment of 40% of patients cured of cancer and for 16% of cures overall. It is also extremely cost-effective in comparison to other curative cancer treatments. Spending is at around £325 million a year—just 5% of the total spend on cancer.

For these reasons, I very much welcome the opportunity presented by this debate to correct a number of inaccuracies that have appeared in the press on this subject. Claims have been made that patients are being denied life-saving treatments because of the lack of access to CyberKnife. Those claims are both inaccurate and alarming, and I think they must cause great anxiety to patients. The truth is that CyberKnife is not a form of treatment, but a brand name of a particular type of equipment that delivers stereotactic body radiotherapy or SBRT. It is not the only technology available, as I shall explain further in a moment.

My hon. Friend talked about the figures, and I repeat the fact that one in four radiotherapy centres currently has equipment—not CyberKnife in every case—that is capable of providing SBRT. I understand, and this bears out my hon. Friend’s figures—

Grahame M. Morris: Will the Minister give way?

Paul Burstow: No. Many points have been put to me, and to be fair, I now need to respond to them.

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Currently, eight centres are active in providing these services, but I recognise and appreciate the work my hon. Friend has done, and we will certainly need to review carefully the information she has presented tonight.

CyberKnife can deliver only SBRT and cannot deliver conventional radiotherapy. Large, expensive radiotherapy delivery systems such as these are purchased by public tender. After vigorous and rigorous evaluation of the many different systems available to deliver this treatment, many hospitals around the country have chosen systems provided by other manufacturers, as they enable them to provide flexible, accurate and cost-effective radiotherapy and radio-surgery services. The promotion of CyberKnife over other alternatives does a disservice to other manufacturers that are successful in providing equipment to trusts, and distorts the nature of the debate.

Let me be clear: timely access to high-quality radiotherapy for cancer patients in this country should improve cancer outcomes and survival. That is why we have made a commitment to expand radiotherapy capacity by investing about £150 million more over the next four years. That will increase the utilisation of existing equipment, support additional services and ensure that all high-priority patients with a need for proton-beam therapy get access to it abroad.

Significant progress has been made in improving radiotherapy services since the publication of the National Radiotherapy Advisory Group report in 2007. The collection of the radiotherapy dataset, which the hon. Member for Easington (Grahame M. Morris) talked about, has enabled us to establish more accurately than ever before the measure of the number of patients being treated with radiotherapy, and to identify and address unacceptable and inexplicable variations around the country. Almost all patients referred for radiotherapy treatment receive that treatment within the waiting time standards. This improvement in waiting times, compared with historical waiting times, saves lives each year. New modelling tools have been developed that allow local services to model the needs of their populations and to predict demand and ensure that they have capacity to treat all patients who will benefit from the treatment without unnecessary delay as demand changes over the years.

However, there can be absolutely no room for complacency, and we realise that more work needs to be done to identify why the variations that the hon. Member for Easington has talked about in terms of referral rates in some parts of the country have existed. The dataset shows that some variations in access rates between cancer networks persist, and there is currently lower uptake in certain parts of the north that cannot be explained by variations in cancer incidence. That new dataset allows local commissioners to examine their referral practices in detail, and I understand that networks in the north-east are looking at capacity and travel times to start to address the concerns that the hon. Gentleman has brought to the House tonight.

Access to advanced radiotherapy techniques needs to be improved, particularly intensity modulated radiotherapy. Experts estimate that around a third of all treatments given with the intention of cure should be delivered by IMRT. Some centres are already delivering at that rate,


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but many are far below it. All centres have equipment that is capable of delivering that technique and a national training programme has been rolled out. We now need to ensure that IMRT, as well as image guided radiotherapy, is offered to all patients who might benefit.

As we have heard, radiotherapy treatment involves the delivery of a dose of radiation to a cancer tumour. That dose is delivered to each patient in fractions or treatments and the number of fractions delivered varies with the type of cancer. The ultimate goal in radiotherapy is to deliver the treatment to the tumour with pinpoint accuracy, thus sparing surrounding tissue and requiring as few fractions, or treatments, as possible—in other words, to treat and cure more cancers with shorter courses of radiotherapy and fewer side effects. For that reason, radiotherapy is continuously evolving with innovations and the development of new techniques and technologies that move us increasingly closer to that goal, but those new developments need to be evaluated in clinical studies.

It is a challenge for providers and commissioners to keep up with the evolving nature of radiotherapy treatment and to ensure the evaluation and adoption of new techniques. The royal colleges and other professional bodies provide guidance to their members to assist the continuous update of clinical practice. Commissioners in turn need to ensure that they are aware of sources of updated guidance. The radiotherapy community in this country can be rightly proud of its ability to deliver clinical studies and explore the use of delivering radiotherapy in fewer fractions. Indeed, the role of the Royal College of Radiologists and the National Radiotherapy Implementation Group in producing such guidance is absolutely crucial.

Let me come back to stereotactic body radiotherapy, which is an important example of specialist radiotherapy technique. It allows radiotherapy to be given to smaller target areas in higher doses with fewer treatments. Its greatest potential is in its possible use as an alternative to surgery and, because of its precision, to treat and potentially cure cancers that would otherwise be untreatable. However, as has been mentioned, it is regarded as a novel technique and it provides a very high dose of radiation per treatment. With conventional radiotherapy, a patient might receive their dose over 20 to 25 visits, but with SBRT that dose is delivered in five or six. More treatments need to be delivered within clinical studies so that clinicians can carefully follow up in both the short and long term to confirm the efficacy of the treatment and study any side effects. Side effects have been mentioned in the context of drugs, but we need to be conscious that there can also be side effects from radiotherapy and not be so anxious to expose people to risks if we are not confident. We should apply the standards of clinical trials to this area. It would be wrong for this Government to promote any form of treatment before the evidence has been collected. Evidence is about more than just making speeches in the House—it is also about looking at the clinical evidence.

All new techniques, including advanced radiotherapy, need to be justified on the grounds of cost and clinical effectiveness. Last year, the National Radiotherapy Implementation Group, published guidance, which has been mentioned, on the use of SBRT, including a clinical evidence review, and concluded that there is a substantial


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evidence base for the clinical effectiveness of SBRT in early stage lung cancer for patients who are unsuitable for surgery.

There are about 1,000 patients in the country who would benefit from that sort of procedure. There are ongoing clinical trials examining the use of the technique for other cancers, but they have yet to confirm its benefits for those cancers. For that reason, the national radiotherapy implementation group recommended that any patient receiving SBRT should receive it in a clinical study to enable the evidence to grow, and at specialised centres treating high volumes of patients with the necessary quality assurance safeguards in place. The implementation of the recommendations cannot be rushed, and the welfare of patients should be paramount in the introduction and use of novel techniques. Staff must therefore be thoroughly trained in this technique.

My hon. Friend asked me to consider a number of issues. I will certainly undertake to examine the tariff programme to establish what more can be done to expedite it, but I should point out that it is no small task to introduce new tariffs in the NHS. In 2012-13 we are mandating the use of the necessary resource groups and currencies in regard to contracting for external beam radiotherapy, and that is an essential first step. I hope that when my hon. Friend has a chance to sit down with officials, they will be able to talk in more detail about


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the work that is being undertaken to make progress with the implementation of tariffs.

It is possible that there will be a significant increase in demand for this treatment in the coming decades, but many tumours will continue to be treated better with conventional radiotherapy, and in particular with intensity-modulated and image-guided radiotherapy techniques.

Tessa Munt: May I clarify one point? I understand that the group recommended the setting of a tariff, but that the Department of Health will not set it until 2014. There is an acceptance of the technology, but there is also a delay of two years, and in that time people might die.

Paul Burstow: There are already local arrangements for the contracting of these services. Specialist centres can use the opportunity to include people in clinical trials, so that we can demonstrate that this is a worthwhile treatment for many cancers. At present, the evidence suggests that it is beneficial only in the case of inoperable lung cancers. I hope that, as we progress, we shall be able to demonstrate that this is not the only technology, and that CyberKnife is a brand, not—


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