Stereotactic Body Radiotherapy

Naomi Long Excerpts

Wednesday 8th February 2012 Commons Chamber

[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 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 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.

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.