1. Carrie Featherstone Consultant Clinical Oncologist Feb 2009

2. Radiotherapy Models for Radiotherapy Rates:  What the models are  Network data for models  Breast, lung, head and neck rates  Remodelling Prostate  Other Network Cancer Incidence Numbers Fractionation

3. Based on 2006 SCAN data : ORR N LUNG CANCER Average annual incidence Scotland 4588 Small cell 0.14* Limited stage 0.33* Good PFS 0.57º Radiotherapy to chest and PCI 121 Poor PFS 0.43ºNo radiotherapy 91 Extensive stage 0.66* Good PFS 0.43º Focal symptoms rrequiring RT 0.81 Palliative radiotherapy & PCI 150 No focal symptoms 0.19No radiotherapy 35 Poor PFS 0.57ºNo radiotherapy 245 Not small cell 0.86* Stage 1-II 0.22* Good PFSº 0.77 Surgery 0.683 Involved margins 0.023 Post-operative Radiotherapy 9 Clear margins 0.983No radiotherapy 446 No surgery 0.323Radical radiotherapy216 Poor PFSº 0.23 Local symptoms 0.644Palliative radiotherapy127 No local symptoms 0.364No radiotherapy 72 Stage IIIA 0.11* Good PFS 0.47º Surgery 0.223 N0/1 0.673 No radiotherapy 30 N>1 or positive margins 0.683 Post operative radiotherapy 15 No surgery 0.783Radical radiotherapy159 Poor PFS 0.53º Local symptoms 0.644Palliative radiotherapy147 No local symptoms 0.364No radiotherapy 83 Stage IIIB 0.13* Good PFS 0.47ºRadical radiotherapy241 Poor PFS 0.53º Local symptoms 0.64Palliative radiotherapy174 No local symptoms 0.36No radiotherapy 98 Stage IV 0.54* Focal Symptoms requiring Radiotherapy 0.76 Likely to requirePalliative radiotherapy (0.49 826 No focal symptoms 0.24No radiotherapy 511 +794

4. Breast staging across Scotland SCAN (Lothian n=709) 2006 cases by stage (%) NOSCAN (Grampian n=424) 2007 cases by stage (%) WOSCAN 2006 cases by stage (%)* DCIS 13 8 T1-2 N0 M0 535233 T1-2N1 N0 222743 T3-4NxM0 or TxN2- 3M0 9510 TxNxM1 336 Different methods of data collection by networks: not specific for these models

5. Breast Model based on Lothian data BREAST CANCER Lothian Model Average annual Incidence 2001-2005 Scotland 4207 DCIS (0.13) 547 Mastectomy (0.26) 142No radiotherapy 142 WLE (0.74) 405Radiotherapy 405 T1-2 N0 (0.53) 2230 Mastectomy (0.17) 379No radiotherapy 379 WLE (0.83) 1851Radiotherapy 1851 T1-2 N1 (0.22) 925 Mastectomy (0.42) 388 >/ = 4 nodes (0.43) 166 Radiotherapy 166 0-3 nodes (0.57) 222No radiotherapy 222 WLE (0.58) 537Radiotherapy 537 T3-4 N0-1, T1-2 N2-3 (0.09) 379 Good PFS (0.91) 345Radiotherapy 345 Poor PFS (0.09) 34No radiotherapy 34 TxNM1 (0.03) 126 Focal symptoms (0.4) 50 Palliative radiotherapy 50 No focal symptoms (0.6) 76No radiotherapy 76 Total patients receiving XRT = 3354 = 80% PTS NEED RT Actual XRT utilisation in SCAN 2006 = 69% (low grade DCIS +WLE not currently treated)

6. Breast Model based on Grampian data Total patients receiving XRT = 2632 = 63% ORR. Actual XRT utilisation Grampian 2007= 57% BREAST CANCER Grampian Model Average annual Incidence 2001-2005 Scotland 4207 DCIS (0.13) 547 Mastectomy (0.36) 197No radiotherapy WLE (0.64) 350Radiotherapy 350 T1-2 N0 (0.52) 2188 Mastectomy (0.37) 810No radiotherapy WLE (0.63) 1378Radiotherapy 1378 T1-2 N1 (0.27) 1136 Mastectomy (0.73) 829 >/ = 4 nodes (0.43) 356 Radiotherapy 356 0-3 nodes (0.57) 473No radiotherapy WLE (0.27) 307Radiotherapy 307 T3-4 N0-1, T1-2 N2-3 (0.05) 210 Good PFS (0.91 existing data) 191Radiotherapy 191 Poor PFS (0.09 existing data) 19No radiotherapy TxNM1 (0.03) 126 Focal symptoms (0.4 existing data) 50 Palliative radiotherapy 50 No focal symptoms (0.6 existing data) 76No radiotherapy

7. Prostate cancer 2497 cases per annum 2001-2005 Low risk (T1-2a N0 M0 Gleason <7 PSA <20) 0.34 849 Watchful waiting 0.56 475 No radiother apy 475 Radical radiotherapy 0.12 102 Radical radiother apy 102 Brachytherapy/Surgery 0.32 272 No radiother apy 272 intermediate risk (PSA 10-20 or Gleason 7 or T2b-2c 0.25 624 Radical radiotherapy 0.32 199 Radical radiother apy 199 Hormonal therapy/Watchful waiting 0.44 275 No radiother apy 275 Surgery 0.24 150 No radiother apy 150 high risk (PSA >20, or Gleason >7, or T3-T4 0.26 650 Hormones 0.5 325 No radiother apy 325 Radiotherapy 0.5 325 Radiother apy 325 Stage IV, bone metastases 0.15 374 Focal bone symptoms hormone therapy and palliative radiotherapy 0.17 64 Radiother apy 64 No focal symptoms Hormone therapy only 0.83 311 No radiother apy 311 New Prostate model

8. Optimal v Actual Radiotherapy Rates Breast  Grampian 63% v 57%  SCAN 79% v 69% Lung  SCAN 64.2(50%) v 40 Head and Neck 83%v70% Prostate 61 (28%) Other where queries in optimal rates due to British practice Oesophagus 10% Stomach 5% Pancreas 5% Melanoma 5%

9. Numbers original model Original numbers PA Numbers new model 2001-5 Predicted numbers in 2015 48% increase Fract ionat ion 2004 Fractions required in 2004 Min Max Fractiona tion in 2015 Fractions required 2015 Min Max (Old model T1-2N0, postop ) 90n/a020-360032-41 448 0 574 0 Low risk (T1-2a N0 M0 Gleason <7 PSA <20) radical radiotherapy (Old model T1-2N0, good PS radical) 42910215120-362040367232-41 483 2 619 1 intermediate risk (PSA 10-20 or Gleason 7 or T2b-2c radical radiotherapy n/a19929520-363980716432-41 944 0 120 95 high risk (PSA >20, or Gleason >7, or T3-T4 (old model T3-4 N0, good PS, radical RT) 35032548120-406500 1300 0 32-41 153 92 197 21 Palliative radiotherapy to metastases 6646495164 195 TOTAL 1235 (61.4%) 6901022 1258 4 2383 6 341 44 438 42 Old model 30930- 39426

10. CANCER NOSCAN Annual Incidence 2001- 2005 SCAN Annual Incidence 2001- 2005 WOSCAN Annual Incidence 2001- 2005 Subtotal Annual Incidence 2001- 2005 Bladder all166209400 775 Brain, Meninges, CNS91116 174381 Breast9861081 17773844 Breast Ca In situ11098 155363 Cervix7173145 289 Colon653605924 2182 Rectum320324530 1174 Corpus Uteri136 229 501 Head and Neck239252526 1017 Kidney175164286 625 Leukaemia161202317 680 Lung101211752401 4588 Hodgkin’s333963 135 Non-Hodgkin’s234256384 874 Melanoma208232381 821 Oesophagus223218382 823 Ovary177269274 720 Pancreas160163288 611 Prostate6357921070 2497 Stomach208209437 854 Testis585596 209 Other6906891449 2828 TOTAL6746 (25.2%)7357 (27.5%)12688 (47.3%) 26791 (100%)

11. Ayrs hire and Arran Bord ers Dumf ries and Gallo way Lothi an Fife Taysi de Forth Valle y Lana rkshir e Gra mpia n Orkn ey + Shetl and West ern Isles Glas gow and Clyd e Highl and and Argyl l SCO TLA ND Bladder all681828107576040107677218530777 Brain, Meninges, CNS271511612529183634218622367 Breast28610313759724431022040238629228692413847 Breast Ca In situ24 11 532333173746637722362 Cervix2551431723153425217221289 Colorectal Colon191567432015620511820825421 5161522295 Rectum853345164839564116130127266771175 Corpus Uteri3715127039412951 5411236502 Head and Neck77183614257705310285107295671017 Kidney4917208443523857727514340625 Leukaemia Lung34189140642305348239508382262413142324488 Lymphoma Hodgkin’s1044238108121351347135 Non- Hodgkin’s63223214360712781906719461876 Melanoma Oesophagus64183211850733681787720259823 Ovary4717219636413260667313541620 Pancreas3015198941483161604614741611 Prostate213667843416117717418824123174961792446 Stomach70202110564635593895522048856 Testis1545331316122524314515209 Oth er Total without other172254672733241482176512262259219318714454081391 2232 0

12. CANCERRadical Fractionation 2004Radical Fractionation in 2008 Radical Fractionation predicted for 2015 Bladder, all20-252025-30 Brain, Meninges, CNS28-3225-3028-32 Breast20-2715-255-25 Cervix20-2525-2825 Colorectal Colon20-252520-25 Rectum5-25 25 Corpus uteri20-2525 Head and neck3420-3516-35 KidneyN/A Leukaemia? Lung20-36 25-39 Lymphoma Hodgkins15-2015 Non-Hodgkin's15-202015-20 Melanoma2025 Oesophagus20-25 Other and Unspecified OvaryN/A Pancreas25 Prostate20-4120-4032-41 Stomach25 Testis15100-15

13. NRAG Model & Assumptions: Summary Table Appropriate Radiotherapy Rates % (ARR) Fractions Per Patient (# Per Pt) Tumour SiteMinBaseMaxMinBaseMax Bladder31.0 16.616.920.4 Brain, meningies and CNS61.3 24.3 Breast inc. DCIS69.9 13.816.125.8 Cervix uteri56.4 24.3 Colon0.7 2.13.65.0 Corpus uteri46.2 18.823.2 Head and Neck78.6 35.0 Hodgkin lymphoma70.6 15.0 Kidney24.1 1.63.55.3 Leukaemia4.0 10.0 Lung65.9 14.517.019.6 Melanoma of skin15.8 24.4 Multiple myeloma33.1 1.05.010.0 Non-Hodgkin lymphoma54.3 13.514.118.4 Oesophagus53.7 21.624.925.3 Ovary4.0 5.0 Pancreas49.8 19.5 Prostate61.4 11.821.423.1 Rectum88.6 27.76.7 23.5 Stomach13.4 25.0 Testis46.0 0.0 10.0 Other and Unspecified50.2 46.614.417.322.7 Retreatment Fractions (%)13.1%

14. CANCER AV NUMB ER CASES PA 2001-5 ORR % NO REQUIRIN G RT BASED ON 2001-5 AV NUMBER OF FRACTIO NS PER COURSE IN MODELS 1 TOTAL FRACTIONS BASED ON 2001-5 NUMBERS PREDI CTED CHAN GE % PREDI CTED NUMB ER CASES 2010- 2015 NUMB ER NEED ING RT 2010- 15 FRACTION S 2010-15 Bladder, all 209285923135713236 661518 Brain, Meninges, CNS 11682 (61)95 (71)252375 (1175)4121 99 (74)1850-2475 Breast 1179 70 (63- 79) 825(743- 931) 17 14025 (12,631- 15,827) 201415 891- 1118 15147- 19006 Cervix 73564124984-1562 35840 Colorectal 000 00 Colon 6051653018714 735 Rectum 32489 (28)288 (91)72016 (637)23399 355 (112)784-2485 Corpus uteri 136466323144918160 741702 Head and neck 252 78 (80- 83) 197 (202- 209) 356895 (7070-7315)24312 244- 2598540-9065 Kidney 1642439519527208 50250 Leukaemia 20248108025253 10100 Lung 117563(50-64) 740(588- 752) 1611840 (9408-12032)01175 588- 752 9408- 12032 Lymphoma0 Hodgkins 397128154201143 31465 Non-Hodgkin's 2565413818248432338 1823276 Melanoma 23216 (5)37 (12)24888 (288)46339 54 (17)1296 (408) Oesophagus 21854 (10)118 (22)232714 (506)24270 146 (27)3358 (621) Other and Unspecified 6894430319575718813 3586802 Ovary 26941155511299 1260 Pancreas 16342 (5)68 (8)231564 (184)12183 771771 (230) Prostate 79261(28)483 (222)2411592 (5328)481172 715 (328) 7824- 17160 Stomach 20913 (5)27 (11)25675 (275)-7194 25 (10)625 (250) Testis 554625102501262 28280 TOTAL PATIENTS 7357 (27.5%) 3575 (2686- 3729) (37-51%) 50388-700598768 3221- 4453 60390- 84601

15. SCANWOSCANNOSCAN SCOTLAND TOTAL CASES PA 2010-15876814940802831,736 NUMBER NEEDING INTIAL RT3221-44535603-77072885-405211,709-16,212 PREDICTED FRACTIONS FOR INITIAL RT60390-84601108228-14667455168-76413223,786-307,688 NUMBER RETREATMENTS (25%)805-11131400-1927721-10132926-4053 TOTAL COURSES REQUIRED4026-55667003-96343606-506514,635-20,265 FRACTIONS FOR RETREATMENT (6%)3623-50766493-88003310-458513,426-18,461 TOTAL FRACTIONS REQUIRED64013-89,677114721-15547458478-80,998237,212-326,149 COURSESPER 1000 CASES459-635469-645449-631461-639 NUMBER # PER 1000 CASES7301-10,2277807-10,4077284-100897475-10,276 SERVICE CAPACITY REQUIRED (+10%) #71,126-99,641127468-17274964976-89,998263,570-362,388 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. Future Needs

16. AberdeenDundee EdinburghGlasgow Inverness Number of LinAcs3939 3 (+1 back up)6161 11 2 2 Av total LinAc hours per day 18214288.510.5 Fractions booked per hour 3 64-554.75-6 Number of public holidays28622 Av number of treatment days lost to servicing per LinAc 0404 04045 8686 12 Av number days worked per machine PA 258253250251247 TOTAL POTENTIAL FRACTIONS PA 7 27,86426,56552,500104,40315,561 Total patients treated 2008 8 1557115034036020747 Total fractions treated 200821,48215,51251,850105,00011,296 NRAG Max ?8 9.2 hours 4-4.5 3-8 2 hours Ave 19days 234-239days >8000 per machine Total193,844# (175,954# in 2003)

17. Other Methods Machines/Fractions per million 18% increase in cacncer incidence in 10 years No of fraction increase 2003 to 2008

18. Machine requirement Linac Output: Fractions per hour Hours per day Days per week Days per year (servicing etc) Size of dept QA/research Service efficiency per Linac