Stereotactic Body Radiotherapy

Paul Burstow Excerpts

Wednesday 8th February 2012 Commons Chamber

[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.

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, 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 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 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—