1. Stereotactic Ablative Body Radiotherapy for Non small cell lung cancer
Audit of the first 12 months

2. Background
SABR is the treatment of choice for early stage peripheral lung tumours in patients with contraindications to surgery
UBHT has established a SABR programme according to the SABR consortium guidelines
Started commissioning Spring 2013
Part of early Mentoring scheme
First patient treated in February 2014
Aim was to treat 12 patients within the first year
25 patients treated in first year

3. Audit Aim
To ensure patient selection criteria fit with those recommended within the SABR consortium guidelines
To assess acute toxicity of the treatment
To assess early outcomes for those patients who have undergone 6 month follow up scans.

4. Objectives
To compare local practice for patient selection to SABR consortium guidelines
To ensure acute toxicities are comparable to published international series.
To look at early clinical outcomes

5. Standards/Criteria No. Standard/criteria Target Any exceptions 1
Approriate patient selection based on SABR consortium inclusion criteria (positive histology, positive PET scan or serial growth on CT scans; medically inoperable through co-morbidity, technical inoperability or patient choice; peripheral lesions)
100%
Nil 2
Appropriate fractionation based on SABR consortium guidelines (54Gy in 3#, 55Gy in 5#, 60Gy in 8#) 3
Grade 3 adverse events <13% 4
Grade 4 adverse events <4%

6. Standards based on:
SABR consortium guidelines
Timmerman R et al. Stereotactic body radiation therapy for inoperable early stage lung cancer. JAMA (11):

7. Methodology
23 patients were identified for inclusion in the audit identified from the prospective database of SABR patients
Data was collected retrospectively from case note review
Data collection was fairly complete though some clinical outcomes had to be chased on patients referred from other trusts.

8. Results

9. All patients met SABR consortium inclusion criteria
Results
No.
Standard/criteria
Target
Result 1
Approriate patient selection based on SABR consortium inclusion criteria (positive histology, positive PET scan or serial growth on CT scans; medically inoperable through co-morbidity, technical inoperability or patient choice; peripheral lesions)
100%
All patients met SABR consortium inclusion criteria

10. 4/23 (17%) of patients underwent biopsy for histological confirmation of disease
Reason for no biopsy:
100% patients had PET avid lesions, and 2 had also had serial growth on CT scan

11. All patients met SABR consortium inclusion criteria
Results
No.
Standard/criteria
Target
Result 1
Approriate patient selection based on SABR consortium inclusion criteria (positive histology, positive PET scan or serial growth on CT scans; medically inoperable through co-morbidity, technical inoperability or patient choice; peripheral lesions)
100%
All patients met SABR consortium inclusion criteria 2
Appropriate fractionation based on SABR consortium guidelines (54Gy in 3#, 55Gy in 5#, 60Gy in 8#)
100% patients met SABR consortium guidelines for appropriate fractionation

12. Fractionation schedules:
Reason for very conservative regimen
1 patient – proximity to heart
2 patients – proximity to aorta and brachial plexus

13. Results
Commonly reported gd 1 / 2 toxicities include dyspnoea, nausea, fatigue and skin reaction

14. Clinical Outcomes Median follow up 6.7 months (range 1-11 months)
Locoregional control:
13/23 patients have had 6 month follow up scans
Complete response (CR) 2
Partial response (PR) 9
Stable disease (SD)
Progressive disease (PD)

16. Clinical outcomes Disseminated failure
1 patient has relapsed with liver metastases
1 patient has relapsed with new nodules in different lung lobes.
Primary lesions in both cases remain small

17. Conclusions
Patients are complying with appropriate selection criteria for SABR treatment
Patients are having appropriate fractionation schedules according to consortium guidelines
No serious (grade 3 / 4) acute toxicities have been experienced to date.
But
Current data is very early.
Referrals from other trusts have less complete follow up picture.

18. SABR for Peripheral Lung Tumours
Commissioners have asked us to deliver SABR for lung tumours in the South West for 2015/16
Tariff has finally been agreed
Referrals have increased: 7 in the past 2 weeks
Longer term: Taunton, Exeter, Plymouth have ambitions to treat with SABR (commissioned or not)
However, number of cases in Bristol alone unlikely to be less then 30 per year

19. Pathway is evolving! Individual patient QA  COMPASS
Day O  Incorporate Day O into Day I
7-field plan (40 minutes)  VMAT  FFF (10 minutes)

20. SABR for other sites Liver (Hepatocellular) Pancreas Spine
Oligometastatic disease
Lung, liver, lymph nodes, adrenals, spine

21. SABR for other sites Oligometastatic disease Liver Pancreas
2 potential trials:
SARON for NSCLC patients
CORE for Breast, Renal, Colorectal patients
Liver
Pancreas
Commisioning by Evaluation

22. Future plans Improve referral pathway
Referral form, dedicated
Dedicated SABR pathway and clinic
One-stop review and planning scan for patients
Introduction of arc-therapy
Remote follow-up and toxicity data collection