1. Charlie Comins 10/11/15

2. Bristol Experience Treated first patient in Feb 2014 Aim to treat 12 patients in first year Treated 25 patients in first 12 months Commissioned to treat 50 patients from whole South West from April 2015-2016 Have already treated over 50 Have treated patients from Cheltenham, Weston, Bath, Taunton, Yeovil, Exeter and Plymouth

3. Evolution of treatment New colleagues! New nhs.net referral account Discontinued individual patient QA and day zero Moving to VMAT FFF for the majority of patients Some patients will still require 7-field plan due to planning system constraints Rarely give iv contrast Post treatment scan at 6 and 12 months CXR at 3 months

4. Toxicity Generally very well tolerated Fatigue, cough, mild breathlessness most common early side effects – very often no acute side effects Breathlessness and reduced exercise tolerance in some Chest wall pain Less concerned about proximity to great vessels though fractionation needs to change (60Gy in 8 ♯ ) There are some patients who should not be treated Lung fibrosis major concern

5. Lancet Oncology - 2015 Pooled analysis of 2 RCT comparing SABR with lobectomy in stage I NSCLC Both trials closed early due to poor accrual 58 patients enrolled; median follow up 40 months 6 patients died in surgery group versus 1 in SABR arm OS at 3 years 95% with SABR and 79% with surgery Increased number of adverse events in surgery arm RFS survival better with SABR but more locoregional failure

6. Oligometastatic disease What is this? The clinical state of oligometastatic disease was proposed in 1995 by Hellman and Weichselbaum. They hypothesized that, in some patients with a limited number of clinically detectable metastatic tumors, the extent of disease exists in a transitional state between localized and widespread systemic disease. Is this a real entity? Even if it isn’t, could ablative treatment be worthwhile? Can we determine in which patients it might be beneficial?

7. Oligometastatic disease – 2 potential trials: SARON for NSCLC patients CORE for Breast, Renal, Colorectal patients NHS England CtE Commissioning through Evaluation Bristol one of 17 centres to be selected to deliver SABR for oligometastatic disease 3 referrals; no patients treated to date

8. Conclusions Thank you for your support Techniques and service continue to be improved Will need continued support to recruit to future SABR trials Other ablative techniques available but proper evaluation required