Management of Waiting Lists in Radiation Oncology

MANAGEMENT OF WAITING LISTS
IN RADIATION ONCOLOGY
Quality in the timeliness of patient care
FACULTY OF RADIATION ONCOLOGY
THE ROYAL AUSTRALIAN AND NEW ZEALAND COLLEGE OF RADIOLOGISTS

Name of document and version:
Management of Waiting Lists in Radiation Oncology: Quality in the timeliness of patient care - Version 2
Prepared by the Faculty of Radiation Oncology Quality Improvement Committee 2013
Approved by:
Faculty of Radiation Oncology Council
Date of approval:
24 May 2013 (out-of-session)
ABN 37 000 029 863
Copyright for this publication rests with The Royal Australian and New Zealand College of Radiologists
The Royal Australian and New Zealand College of Radiologists

Level 9, 51 Druitt Street
Sydney NSW 2000, Australia
Email: ranzcr@ranzcr.edu.au
Website: www.ranzcr.edu.au
Telephone: + 61 2 9268 9777
Facsimile: + 61 2 9268 9799
Disclaimer: The information provided in this document is of a general nature only and is not intended as a
substitute for medical or legal advice. It is designed to support, not replace, the relationship that exists between
a patient and his/her doctor.
TABLE OF CONTENTS
Key Messages 3
Recommendations 3
Purpose 3
Background: The Current State of Play 4
The RANZCR Waiting Times Pilot 2012 Preliminary Analysis 4
Literature Review Compelling Clinical Data 6
Level 1 Evidence: Breast and Head and Neck Cancer Meta-analyses 6
Level III-IV Evidence 7
Other Implications 9
Delays in Treatment Often Render Patient Ineligible for Clinical Trials 9
Legal Consequences 9
Ethical Aspects 9
The Patient and Staff Perspective 9
The Best Way to Measure Performance 11
A New Concept As Short As Reasonably Achievable (ASARA) 11
Informed Decision Making Based on Optimal Waiting Lists Data Collection 12
Waiting Lists Management 14
Conclusions 18
Appendix 1:
Minimum Dataset for treatment time analysis for a radiation therapy service 19
Appendix 2: Triage systems in use around Australia 20
Appendix 3: FRO definitions 26
Appendix 4: RWTWG draft definitions for reporting reasons for delay 30
Appendix 5: Access to care checkpoints and discussion 32
Acknowledgement 35
References 35
KEY MESSAGES
Significant delays in starting radiation therapy cost patients lives (SURVIVAL) and worsen quality of
life (QOL).
Patients must have the BEST information and OPTIONS when facing a radiation therapy waiting list.
Radiation therapy waiting lists should be managed based on the principles of evidence based
medicine (EBM).
RECOMMENDATIONS
Faculty of Radiation Oncology

1. Radiation therapy waiting times should be As Short As Reasonably Achievable (ASARA).
2. All patients referred for a radiation oncology opinion should be seen in a timely manner.
3. All patients should have significant ongoing emotional and medical support and feedback during their
waiting period. In the context of delays, patients must have access to information on the impact of
delays and their available options.
a. Treatments given to compensate for unplanned delays should be documented, and outcomes
recorded.
b. When treatments are given for palliation as alternatives to radiation therapy, the subsequent
Management of waiting lists in Radiation Oncology

need for radiation therapy should be recorded.
4. All departments should document:
a. a panel of waiting times minimum data set parameters
b. recommended key performance indicators for waiting times performance by triage category
c. reasons for delay, categorised according to simple nationally agreed definitions.
5. Optimisation of work practices is a continuous quality improvement process and should be
undertaken to ensure best use of available resources.
6. Department of Health and Ageing (DoHA) and the State Jurisdictions are in an ideal position to
support and lead processes for:
a. the national benchmarking of the planning and treatment processes as part of the national
standards program for radiation oncology
b. developing, reviewing and adopting triage systems based on clinical need and benefit (but also
reflecting time already expired and exceptional individual circumstances)
7. The evidence presented through this documentation should be used in support of strategic plans
for replacement and expansion of the existing equipment and staffing pool as evidenced by the
Tripartite National Strategic Plan for Radiation Oncology for 2012-2022(1).
PURPOSE
Demand for radiation therapy services in Australia continues to grow beyond the capacity of existing
resources. In the 10+ years since the Baume Report(2) and the 7+ years since the last Faculty waiting
lists recommendations were published(3), significant waits for treatment are still commonplace in some
jurisdictions(4). Careful evidence based management of these waiting times is crucial to ensure that the
best clinical care is provided for patients within the available resources. Providers, payers and planners
all must manage ever scarcer resources in an ethically acceptable and transparent fashion.
The purpose of this document is to:
1. Review the current evidence supporting timeliness of treatments

2. Highlight legal, ethical and consumer aspects of this issue
3. Discuss methods of measuring waiting lists performance
Suggest unifying definitions
Advise on what constitutes realistically achievable accuracy in documentation of waiting times and
prioritisation categories
4. Discuss methods of addressing waiting lists issues and provide guidance in managing and triaging a
waiting lists
5. Provide guidance to assist with pooled data analysis, interpretation and managing radiation therapy
waiting lists for service development and potential public disclosure
3
BACKGROUND: THE CURRENT STATE OF PLAY
The significance of the problem of radiation therapy waiting lists has been well documented both
internationally and locally for over 30 years(5, 6). Delays in receiving radiation therapy result in poorer
outcomes for patients(7, 8). For those receiving palliative treatments, delay in gaining relief from symptoms
may have a critical effect on quality of life at the end of their illness. Delays in receiving treatment
compound the distress, anxiety and depression experienced by patients and their carers on the cancer
journey(9, 10). The stress on medical and support staff of reconciling treatment delay with the universal
desire to do the best for their patients should also be recognised.
The current megavoltage utilisation rate of radiation therapy in Australia is 38.1%, a shortfall to the
estimated optimal rate of 48.6% (personal comm.). It is estimated that the impact of radiation therapy on
cancer survival is 40% compared to 49% for surgery and 11% for systemic therapies(3). This means that
10.5% miss out on evidence based use of radiation therapy representing an estimated 24,000 individuals
by 2022(1). With an increasing cancer burden and aging population it is expected that Australia will have
150,000 cases by 2020 with over 100,000 requiring radiation therapy. Conversely, as we aim to improve
utilisation, the management of waiting lists will become more and more crucial as resource development
attempts to keep up with the demand. The Tripartite National Strategic Plan for Radiation Oncology
acknowledges the power of the informed consumer with access to a wide array of information who will
continue to demand the appropriate utilisation and access to radiation oncology services. This is coupled
with an identified skills and equipment shortage(4, 11-13).
In 2011 there were 168 linear accelerators in Australia(1). It is estimated that by 2017 Australia will require
around 205 linear accelerators in order to meet optimal utilisation rates. More details are available at:
http://www.ncbi.nlm.nih.gov/pubmed/21843180
http://www.allenconsult.com.au/resources/acgprojectingoncologyworkforce2012.pdf
With the increasing complexity of intensity modulated, image guided and arc radiation therapy, patient
tailored treatment options, use of stereotactic brain and body radiation therapy, and complexities of
brachytherapy, optimal waiting lists management no longer consists of just booking patients on one list
for one treatment modality in one hospital. It is increasingly requiring the co-ordinated collaboration of
other professionals such as surgeons, interventional radiologists, allied health, nuclear physicians, medical
physicists and many others during the planning and treatment phase.
Managing radiation therapy waiting lists in a transparent and evidence based fashion is crucial to
good medical practice and ethical patient care. Therefore, the Faculty of Radiation Oncology Council
commissioned its Quality Improvement Committee (QIC) to provide a guidance document to assist
departments of radiation oncology to deal with the issue. The first of these documents was published in
2005(14). This current document is an update on those guidelines. We have continued to focus on how
we can act within our departmental resources to manage the current lists rather than addressing the
causative factors, which requires a broader approach to address issues of manpower and equipment
availability.
THE RANZCR WAITING TIMES PILOT 2012 PRELIMINARY ANALYSIS

The Faculty of Radiation Oncology (the Faculty) has a long history of national waiting times data collection(3,
5, 14-17)
. Over the last several years, delays affecting up to 40% of patients receiving curative treatment,
30% receiving palliative treatment and 56% receiving emergency treatment have been documented via
a bi-annual snapshot survey of most public departments(3). These delays were defined on the basis of
being outside the time frame then internationally benchmarked as good practice (United Kingdoms Joint
Council for Clinical Oncology recommendations)(11). The Faculty has also had a long history of contributing
waiting times data to the Australian Council on Healthcare Standards (ACHS) albeit with small numbers of
participating departments(4).
4
In 2012 the Faculty commenced a national pilot survey in association with Collaboration for Cancer
Outcomes Research and Evaluation (CCORE)(15). This survey collected 4 data items (Appendix 3) from
21 departments (public and private) in Victoria and NSW over the period March - May 2012.
A total of 5,025 treatment courses were included in the pilot. The data items consisted of:
Ready for Care Date
Date of Radiation Therapy Booking
Date of Radiation Therapy Start
Postcode of Usual Patient Residence

Several departments still have >50% of their patients waiting in excess of 4 weeks from their Ready for
Care Date. Both the audit cited above and the 2012 pilot data confirm a continued problem with timely
access to radiation therapy.
5
LITERATURE REVIEW COMPELLING CLINICAL DATA
The need to optimise waiting lists management is based on a large amount of direct and indirect data. It is
clearly impossible to conduct randomised trials testing the effect of treatment delays in cancer care. There
is a large amount of evidence to suggest stage shifts, progressive tumour growth and worsening impact on
local control and survival from treatment delays.
LEVEL I EVIDENCE: BREAST AND HEAD AND NECK CANCER META-ANALYSES

In a systematic review representing Level I evidence, Mackillop et al defined a relative risk of local failure
of 1.16% for curative intent adjuvant breast radiation therapy, although no impact on distant metastatic rate
or overall survival was demonstrated(18). The impact was even more significant for head and neck cancer
where relative risk was 1.28 and 1.15 per month of delay for curative intent post-operative radiation therapy
and curative intent definitive radiation therapy respectively. This translated into a linearly increasing risk of
local recurrence equating to 1.0% per month of delay for breast cancer. A similar finding was reported for
head and neck cancer with a higher risk of local recurrence equal to 6.3% per month of delay from head
and neck surgery. Evidence for decreased overall survival in head and neck was apparent but less evident
on survival detriment in breast cancer. There are inadequate data for similar meta analyses on other tumour
sites. The authors modelled selection and publication bias as a possible explanation for some results. They
concluded that adverse outcomes may be reflective of more advanced disease in some studies(3).
(From Mackillop et al ref 18)
6
LEVEL III-IV EVIDENCE
Various studies have identified the need for a defined time frame in which treatment should occur.
The amount of Level III-IV evidence is substantial, and indirect and direct radiobiological evidence is
compelling(19). Tumour control probability (TCP) is inversely related to number of clonogenic cells in any
given tumour or tumour bed. The number of clonogenic cells is related to tumour volume and there are
human studies demonstrating that TCP is inversely related to the volume of the tumour (20).
Breast Cancer

There is an extremely large volume of high quality data demonstrating the impact of radiation therapy in
improving treatment results in breast cancer. For example the Early Breast Cancer Trialists Collaborative
Group (EBCTCG) data involving 25,000 women has shown a reduction in the 5-year local recurrence rate
from 26% to 7%. The 15-year breast cancer mortality risk is 30.5% with radiation therapy vs. 35.9% without
radiation therapy(21). This and several other meta-analyses unequivocally demonstrate that preventing local
recurrences reduces mortality. Unsurprisingly there are a number of very large studies showing adverse
outcomes with delays in breast cancer.
Experience from British Columbia involving 6,428 patients over 14 years reported the impact of adjuvant
radiation therapy on T1-2 N0-1 patients who had no adjuvant chemotherapy. 23% patients had over a 12

week interval to start of radiation therapy. They found increased relapse rates for intervals >20 weeks in
comparison to a 4-8 week reference group. This influenced the distant metastatic rate of 9% vs. 23% and
the breast cancer specific survival of 93% vs. 82% (both significant)(22).
The Cornell group analysed 7,791 patients treated for Ductal carcinoma in situ (DCIS) or Stage I breast
cancer. 16% had a delay in radiation therapy (>8 weeks post surgery if no chemotherapy or >4 weeks
post chemotherapy) and 3% had incomplete radiation therapy. Patients were more likely to experience a
subsequent breast event if they had a delay in starting radiation therapy (OR 1.14). Those with incomplete
radiation therapy had a higher overall mortality (OR 1.32). Longer radiation therapy delays (>12 weeks,
or >8 weeks with chemotherapy) had a strong negative impact on breast events (OR 3.94 for DCIS, 2.77
for invasive). They concluded that radiation therapy should be facilitated for completion and timeliness(23).
The University of Florence reported on 4,280 patients with Stages III breast cancer treated from 1981 to
2004. In the subset of patients treated with surgery and radiation therapy, only timing of radiation therapy
was found to be an independent prognostic factor (HR, 1.59; 95%CI, 1.012.52; p = 0.045). In 2011 the
International Breast Cancer Study Group (IBCSG) amalgamated data from 3 randomised studies involving
wide local excision in 964 breast cancer patients who had adjuvant radiation therapy and endocrine therapy
only. They used proportional hazards multivariate regression analysis and found that overall survival was
worse for delays greater than 78 days (24).
Arguably the study with the best statistical methodology is a breast conservation study reported by
Punglia and colleagues in 2009 from the Surveillance, Epidemiology and End Results (SEER) database.
They studied approximately 18,000 patients with Stage III breast cancer, treated between 1991 to 2002.
No cases received chemotherapy and all were aged >65. In addition to standard regression techniques
they used dummy randomisation and propensity analysis to improve causal inference and reduce multi-
collinearity bias. They reported a strong association of treatment delay with the risk of local recurrence
with no threshold for delays greater than 6 weeks from surgery(45). Herschman et al report similar findings
in another SEER analysis(25).
Non-small cell lung cancer

In non-small cell carcinoma of the lung it has been demonstrated that a median percent volume increase
of 40% (range -11 to +311%) occurs during the delay period to the start of radiation therapy. In addition the
authors demonstrated a correlation between the amount of delay and degree of regrowth (p = 0.003). A
delay greater than 21 days produced greater increases in percent volume change (p = 0.002) and percent
diameter (p = 0.055) than lesser delays(26).
Small cell lung cancer

In limited stage small cell lung cancer the time from start of any treatment to the end of thoracic radiation
is deemed to be important in survival(27, 28). Data is more compelling for squamous cell carcinomas and
has been demonstrated in carcinomas of the uterine cervix (29). Similar findings exist in other tumour sites
however the evidence is weak and indeterminate in several areas (30-35).
7
Head and neck cancer
For patients with squamous cell carcinoma of the head and neck, Jensen et al measured the interval
from staging CT scan to planning CT Simulation (median interval 28 days and a range of 5-95). They
demonstrated a 62% increase in tumour volume over the interval (median increase 46% and a range of
6-495%). 20% of patients developed new nodal metastases and 16% progressed in their T-stage. The
authors were able to demonstrate a clear impact of waiting times. The majority of patients showed tumour
progression within a 4 week waiting times (19). Mackillop and colleagues modelled the effect of delay using
Monte Carlo simulation techniques and known tumour kinetics from tonsillar cancers. They demonstrated
that the probability of local control decreased sharply over a relatively short time period (~10% per month(18)).
Cervical cancer
Dahrouge et al reported on 195 patients treated between 1990 and 2001 at the Ottawa Regional Cancer
Centre for cancer of the cervix. On average, delays between initial biopsy and treatment start were greater
for older patients (p = 0.025) (5.8 weeks for <40 years old vs. 6.6 weeks for >70 years old) and those with
smaller tumours (p < 0.001) (5.0 weeks for >4 cm vs. 6.3 weeks for < or =4 cm). Multivariate analysis
revealed an adverse effect of treatment delay on survival outcomes (32).
Brain tumours
In 2007 Irwin et al reported on 172 patients with WHO Grade 3 or 4 Astrocytoma. Cox regression analysis
showed that age, performance status, tumour grade, extent of surgical resection, radiation therapy dose,
and time to radiation therapy from day of surgery all independently related to survival. They found that
every additional week of delay until the start of radiation therapy increases the risk of death (hazard ratio)
by 8.9% (95%CI 2.0%16.1%). A 6 week delay in starting radiation therapy (ranging from 2 weeks post-
operative to 8 weeks) reduced median survival by 11 weeks for a typical patient (36).
Merkel cell carcinoma

Merkel cell carcinoma of the skin has been shown to be associated with a high risk of progression when
a median wait of 24 days for radiation therapy was exceeded. The Australian authors reported that
41% of patients developed progressive disease. They recommend that, since Merkel cell carcinoma is
an aggressive but curable malignancy, appropriate management should include efforts to minimize all
potential delays prior to the commencement of radiation therapy (37).
Prostate carcinoma
While prostate carcinoma is not a rapidly dividing tumour, Amico et al have suggested an impact of treatment
delay in high risk localised prostate cancer. The researchers showed a treatment delay independently
predicted time to prostate specific antigen (PSA) failure with a delay of 2.5 months resulting in a 5-year
estimates of PSA failure-free survival of 55% vs. 39% (p = 0.014)(38). In the increasingly larger cohort of
post-prostatectomy patients, King et al demonstrated that initiating salvage radiation therapy at the lowest
possible PSA improved relapse free survival (39). It was noted that there was an average 2.6% loss of
relapse free survival for each incremental 0.1 ng/mL PSA at the time of salvage radiation therapy.
8
OTHER IMPLICATIONS
DELAYS IN TREATMENT OFTEN RENDER PATIENT INELIGIBLE FOR CLINICAL TRIALS
Treatment delays are potentially detrimental to clinical trial participation. For example, post operative
trials usually have a specified time period after surgery that radiation therapy needs to commence (e.g.
Trans Tasman Radiation Oncology Group (TROG) 07.04 head and neck cancer study). Definitive radiation
therapy trials state time frames for completion of staging to trial consenting and waiting lists may be
problematic and costly if investigations need to be repeated to allow participation. Conversely, evidence that

trial participants are associated with better outcomes adds to the dilemma. The Peter MacCallum Cancer
Institute (PeterMac) acknowledges this aspect with additional priority on patients awaiting treatment as
part of a trial. There is therefore a potential conflict of interest which cannot be dismissed.
LEGAL CONSEQUENCES
The medico-legal consequences of delayed cancer diagnoses are well known(40), however apart from
one notable exception very few examples of excessive radiation therapy waits have had medico-legal
consequences. After decades of chronic radiation therapy waits in the Canadian province of Quebec, a
single breast cancer survivor took action against twelve Quebec hospitals and the Quebec government.

In 1999 a class action on behalf of ten thousand breast cancer patients who had radiation therapy waits
of greater than 12 weeks was begun. The claimants asserted that the health authorities breached their
fiduciary duty and that the Quebec government had failed to provide adequate funding to their hospitals.
The class action was certified by the Superior Court of Quebec on March 9, 2004 against the hospitals
and dismissed against the Quebec government. A $5.4 million settlement was approved by the court on
September 25, 2009. Patients were eligible for compensation of around $300 - $1,000 each(41).
ETHICAL ASPECTS
Managing a waiting list may be approached from several ethical perspectives. Deontological frameworks
judge the morality of an action based on the actions adherence to a rule or rules. It is sometimes described
as duty, obligation or rule - based ethics, because rules bind you to your duty. Deontological ethics is
commonly contrasted to consequentialism. Deontological ethics is also contrasted to pragmatic ethics. The
Deontologist must always display unswerving fidelity to patients on the waiting lists and obey the waiting
lists and categorisation rules he or she has set up. The duty of care is seen to be relevant just to patients
under their care. He or she is guided by a duty of non-maleficence and governance responsibilities again
to patients under his or her care. Typically the principle of first come, first served or greatest need or
greatest benefit or fewest choices applies here.
This approach may be contrasted with utilitarianism. Utilitarianism is a theory in normative ethics holding
that the proper course of action is the one that maximizes overall happiness. It is now generally taken to
be a form of consequentialism. According to utilitarianism the moral worth of an action is determined only
by its resulting outcome although there is debate over how much consideration should be given to actual
consequences, foreseen consequences and intended consequences. The utilitarian would balance his or
his units autonomy and power to minimise loss of that role against things such as patient harm on a waiting
lists or public protest. The utilitarian may not regard 10 life years saved in one individual as equivalent to 1
life year saved over 10 individuals(54).
THE PATIENT AND STAFF PERSPECTIVE
Radiation therapy for many patients is a source of major concern and stress in their cancer journey. Unlike
chemotherapy and surgery it is an intangible and something that the patient has little or no control over.
You are in the hands of an expert team and their commitment to you, the patient. You are confronted
by machines, computers, and often left on your own in a very clean but sterile environment. It has an
impact which differs from patient to patient, and from cancer type and treatment. There is full body
irradiation, a fitted mask for head and neck cancer, radioactive seeds to name just some types of
treatment.
9
With ready access to information from a range of sources, patients are increasingly aware that timeliness
of treatment can be an important factor in their treatment.
I just wanted to know that I was getting the best and most effective treatment for my cancer and that
it would be delivered within a timeframe that would give me the best possible chance of a cure.
When the commencement of treatment is delayed, concerns about the impact of the delay on the clinical
outcome are added to an already stressful situation. Some patients and families will need additional
attention to their supportive care needs during any waiting period. This may be in the form of regular
updates and information from the treating team, or it may be in the form of emotional or practical support
from members of the multi-disciplinary team.
Groups such as Cancer Voices Australia (http://www.cancervoicesaustralia.org/) and Cancer Voices South
Australia have made the point very coherently that patient autonomy around full information and treatment
choices are of paramount importance:
Are respected with key human rights such as freedom of treatment choice and acceptance of
the cultural, sexual and religious background, socio-economic status, home circumstances and
geographical location of people affected by cancer
Are entitled to optimal care, medical or otherwise, irrespective of stage or type of disease
Staff managing a waiting list often also endure sustained pressure to treat more patients and meet numeric
or financial targets. Chronic waiting lists often mean:
Chronic paid or unpaid overtime over many years particularly for radiation therapy staff
Perpetual juggling with large waiting lists using outmoded paper or spreadsheet tools
Pressure from patients, family, radiation oncologists, executive staff and other specialists to move
certain patients up the waiting list
Pressure to game prioritisation categories for radiation oncologists
Pressure to refer a patient on with or without competing private interests
Perverse pressure not to refer a patient on to maintain targets
Multiple competing entities requesting waiting lists meetings and data
Waiting lists burnout.
10
THE BEST WAY TO MEASURE PERFORMANCE
Traditionally, most waiting times data in tertiary medicine is measured as the delay between the ready
for care date (RFC) and the date of first treatment. Typically, a rate based measure is then reported. For
example the number of patients exceeding a certain time period is the numerator and the total number of
waiting patients is the denominator(42). Often this measure or indicator is calculated for various categories
of patient defined on the basis of clinical risk or urgency. Any standard or indicator needs to be based on the
best available evidence and is usually developed by those providing the care (i.e. radiation oncologists).

A standard is made up of three elements:
a criterion
a target
exceptions.
The criterion is the pre-set cut-off level that distinguishes between adequate and inadequate care; it needs
to be clinically relevant, clearly defined and easily measured(43).
Oncology, in common with much of clinical medicine and surgery has exceedingly complex and variable

patient referral pathways with nuanced decisions, opinions and interventions often changing the ready for
care date and patient risk categories. The National Health Service (NHS) has had over 10 years worth
of well-funded waiting times measurement and audit activity in cancer. Significant deficiencies have
been identified at many levels in this process. Variable definitions, reporting points, target gaming and
inadequate reporting are common themes(11,12). Despite the best definitions of ready for care and Patient
Category there will always be significant inter and intra-oncologist variation(12, 13, 43-47). Appendix 5 discusses
these issues in more detail.
The value of traditional rate based performance indicators in the health sector has come under significant
scrutiny in recent years. Data definition problems are well known in other areas of medicine. Emergency
Physicians varied in the National Triage Scale vs. waiting times indicator. 49.5% started the clock at the
time of patient arrival, 31.4% at the start of triage, and 10.5% at the end of triage(12). Sanmartin has made
exactly the same point in relation to surgical waits(47). Complex health systems have now been shown via
a variety of models to perhaps lend themselves to more qualitative analyses rather than simple rate based
key performance indicators (KPIs)(26, 27, 43, 45, 48-50).
The communication of waiting lists data to the public has also been less than successful in some jurisdictions.
A leader in this area is the Ontario Waiting Time Strategy (OWTS)(51). A feedback study from this group has
found that the public wanted more information about the waiting times strategy and its actions. Interviewed
participants did not feel they were sufficiently made aware of the strategy and often requested additional
information beyond what was offered on the waiting lists website. Moreover, some believed that the
information that was provided on the OWTS website and through the media was inaccurate, misleading,
and even dishonest. Public involvement in the priority setting was felt to be crucial (52).
One obvious but little tackled other difficulty is the obvious dilemma that cleaned, accurate waiting times
data can only be posted some weeks after the treatment start dates that actually represent the data.
Stressed tertiary services operating at 95% + capacity may often have rises (sometimes falls) in waiting
lists that can occur before the data are calculated let alone processed and published. Thus published
waiting lists data which might be of the most use to an individual patient are in fact the least useful in
making acute choices. Publishing waiting lists data may only be useful for its trends and in relation to the
broader public accountability issue.
A NEW CONCEPT AS SHORT AS REASONABLY ACHIEVABLE (ASARA)
One method to overcome some of the statistical, methodologic and resourcing issues around rate based
approaches is to adopt the As Short As Reasonably Achievable concept (ASARA)(7). This concept is
analogous to the As Low As Reasonably Achievable (ALARA) principle, where radiation exposure to
occupationally exposed staff, patients and members of the public is always kept as low as reasonably
achievable. The ASARA principle has been accepted in cancer surgery and chemotherapy for many years
but not in radiation oncology. Arbitrary acceptable waiting times have been set as benchmarks for many
years, based on a variety of international and local pragmatic views and experience.
11
INFORMED DECISION MAKING BASED ON OPTIMAL WAITING LISTS DATA COLLECTION
What are the most appropriate parameters?

The RANZCR Waiting Times Pilot 2012 preliminary analysis (see page 4) suggests that there
is inconsistent interpretation of definitions, and therefore inconsistent recording of dates.
Waiting times parameters with the following elements may improve the credibility and usefulness of the
data:
Less open to mis-interpretation
Recorded from source data

Able to be recorded by dedicated, accredited (non-clinician) coders
Assist in illustrating the whole of health time elements of the cancer care pathway before and during
radiation therapy
Can easily be viewed by service administrators to identify problems in the service set up locally
Comparable across health jurisdictions, states and territories.
Below is a mapping of some of the key time points in a typical cancer care pathway that might be utilised.
The parameters are consistent, not open to interpretation and can give a snap shot of the reasons for the
time frames reported with practical usefulness to the services in question to address areas of delay (See
Appendix 5 also).
1. Date of multi-disciplinary meeting
a. Illustrate delays in diagnostic services (diagnostic teams, radiology etc) if reviewed in view of
incoming referral, pathological diagnosis dates and staging investigation dates
b. Provides a start time point on which radiation therapy services can self evaluate their service
2. Date of referral to the radiation therapy service

a. Provides a start time point on which radiation therapy services can self evaluate their service
3. Date of first radiation oncology appointment

a. Time to complete staging investigations
b. Availability of clinical resources
c. Time to complete primary pathology and pathology review if required
d. Whether a recovery period after surgery or an adjuvant chemotherapy period
4. CT Simulation date
a. Availability of CT and other imaging resources
5. Date of starting radiation therapy

a. Factors above
b. Planning resources
c. Physics resources
d. Machine availability
e. Influenced by the use of newer technologies which require greater planning and quality assurance
emphasis, e.g. Image Guided Radiation Therapy (IGRT), Intensity Modulated Radiation Therapy
(IMRT), Volumetric Modulated Arc Therapy (VMAT), Stereotactic Body Radiation Therapy (SBRT)
6. Date of last radiation therapy

a. Patient factors impact of toxicity, compliance, attendance
b. Treatment factors machine downtime, treatment toxicities, departmental work flow issues
c. Tumour factors minimal influence by these factors on this parameter
7. Postcode of patient
8. Alternative management implemented due to delay in radiation therapy
As metropolitan, rural and remote radiation oncology departments have variable issues that influence
waiting lists, e.g. Positron Emission Tomography (PET) availability, distance issues etc, this supports the
ASARA principle, allowing services to improve on their previous performance after periodic review and
addressing issues identified in the data.
12
The QIC felt that two parameters remain of paramount importance:
1. Ready for care date: date that the radiation oncologist decides that the treatment course should
commence if resources allowed.
2. Date of decision to treat: given the complexity of cancer care pathways, this might represent the
multi-disciplinary meeting date or a date thereafter, on completion and assessment of other pertinent
issues in the case and is determined by the radiation oncologist. Often however this date reflects only
a random appointment, phone call or multidisciplinary meeting.
The recommended parameters that should be collected are listed in Appendix 1.

Is it realistic for departments to achieve accurate data collection?
Accurate data entry of the Ready for Care date requires the following preconditions:
A careful and thorough initial oncologist estimate of RFC
A fit for purpose Oncology Information System to record and extract date data
Careful re-estimate and re-entry of RFC date as required
Peer review and source data checking of RFC dates and category to assess oncologist bias
Annotation and scoring of date non consensus

Data entry checking, auditing and cleaning
Sufficient data resources to write reports and provide feedback when erroneous data exist.
While the formal findings of the pilot study are awaited, it is clear that such comprehensive and useful data
collection cannot be done ad hoc and likely requires significant departmental resources. It is the view of
QIC that a defined and funded program with permanent, accredited staff is required to achieve quality data
collection. The obvious parallels are in Diagnosis Related Groups (DRG), International Classification of
Diseases (ICD) coding and clinical trials.
This program may not necessarily have to be continuous and in real time. It might be episodically within the
given year to allow evaluation of issues and evaluation of the impact of changes instituted.
Should collection of waiting lists data be mandatory?
The QIC recommends departments should strongly consider contributing to periodic audits, or continuous
data submission to any accredited local, State or National body. Whilst reporting back to State, Territory,
Commonwealth Bodies or Non-governmental organizations (NGOs) such as the Australian Council on
Healthcare Standards (ACHS) or Faculty of Radiation Oncology (FRO) is not currently mandatory, reporting
to higher levels will allow the jurisdictions and the College to advocate for issues and represent service
areas where significant problems are identified.
The private sector in Australia has generally not contributed to waiting lists data for the very simple reason
that their waiting times are very low. Their business model is critically dependent on treating as soon as
reasonably achievable. Even for more complex patients, the private sector regards the arbitrary definition
of 14, 21 and 28 days for each triage category as unreasonable in terms of providing a quality service.
What appropriate parameters should be reported and what discussion needs to be had in reporting
these parameters?
The QIC recommends the department review its data predominantly by triage category. The triage category
may vary by jurisdiction as evidenced in Appendix 2. The most appropriate statistic is the median wait by
category over a defined time period. Maximum and minimum may also be reported. The mean value
should be reported with caution as waiting distributions are usually skewed.
Departments should report the number of patients falling outside their estimate of ASARA for their
department for that group of patients care pathway. That is, what is a reasonable delay to scan, plan,
prepare and start this patient who is ready for care now?
This may vary for different departments and depend on complexity of the process.
13
For example: A complex head & neck IMRT/Chemo-radiation therapy patient who needs a planning PET-
CT and intravenous (IV) contrast and synchronous chemotherapy might have an ASARA of 13 days.
5 days PET-CT Sim
2 days volume
2 days plan
2 days replan
2 days approve and IMRT Quality Assurance (QA)
10 days chemotherapy booking (runs concurrently).

A simpler 4 field 3D conformal radiation therapy (3D CRT) palliative patient might have an ASARA of
2 days volume
3 days plan and check.
Departments may have to make allowances for part time staff or trials or teaching or a whole host of other
factors. Where they are reasonable they should be included in the ASARA.
A 6 week delay for a planning magnetic resonance imaging (MRI) is unreasonable.

It is also appropriate to report the number of patients falling outside the guidelines of days 14, 21 and 28
by triage category.
What are appropriate solutions to the waiting lists issues?
A number of different factors and processes contribute to the development of long waiting times, and these
factors will vary from department to department.
Since the 2005 document on waiting lists was released, different solutions have been tried and implemented
by various health services. These are discussed below but experience and feedback indicates solutions
have variable applicability, acceptance and impact on waiting lists management.
WAITING LISTS MANAGEMENT
Likely high applicability with significant impact on waiting lists management
a) Optimising work practices

The key imperative in managing the demand for radiation therapy is to ensure the optimisation of work
practices to produce the maximum benefit possible within available resources. Work practices throughout
the continuum from consultation to planning to treatment delivery should be reviewed, and national
benchmarking introduced as part of the process to integrate accreditation into practice. Exchange of
information between departments on methods and work practices that deliver improvements in efficiency
while maintaining quality and safety, is encouraged. Improvement in throughput of only a few percent may
result in proportionately large gains in waiting times reduction. Flexibility in scheduling, for example by
providing the wherewithal to offer same day appointments to fill gaps, and diverting resources to areas of
potential bottleneck(53) are established means of improving waiting times within available resources.
b) Patient prioritisation
There is a paucity of evidence with which to decide the relative priority that should be given to patients with
different cancer types and different disease status or stage.
A workshop held in New South Wales in late 2001 proposed a number of criteria to be taken into account
when developing a prioritisation system. It was agreed that:
Priority should be based on medical need

Emergency and paediatric cases were identified as having special priority
The radical:palliative balance should be considered
The issue of advanced pre-booking vs. new diagnosis requires consideration
14
The priority accorded to inpatients should be considered
The objectives of setting priorities should include reduction of stress for patients and staff
Any process adopted should be efficient and reproducible
A co-ordinated national approach should be encouraged.
Methods
1. By category

Most departments categorise their patients as curative (radical), palliative and emergency. It is
generally agreed that emergency patients (such as those suffering from spinal cord compression,
airway obstruction) should be given high priority. Departments may reasonably decide to accord
curative and palliative patients different priorities depending on local circumstances. When it is
possible to offer patients other effective means of palliation, then it would be considered reasonable
to prioritise curative patients. However, it is often relatively simple to fit in a short palliative schedule
without causing significant delay to other patients.
2. By type and status/stage

Some attempt may be made based on available evidence to classify patients according to the
degree of clinical urgency. While it may be relatively straightforward to do this within a tumour type
(e.g. head and neck patients requiring postoperative radiation therapy required to start treatment
more promptly than those who have not had surgery), there are no comparative data between
tumour types. For example, does a treatment-nave head and neck cancer patient take priority over
a pre-operative rectal carcinoma case?
Subjective classification of urgency of treatment by the treating radiation oncologist is commonly

used but is inefficient and potentially inequitable. Unless strict criteria of urgency are adhered to,
it is inevitable that stage migration of the categories will occur as radiation oncologists struggle to
do the best for their patients.
One centre has adopted a points system based on available evidence of clinical need with
relative equity between the different cancer types (see Appendix 4). This system also gives credit
for the amount of time a patient has already been waiting. Since its introduction as a pilot, a
shift in the distribution of waiting times has occurred, with the maximum waiting times shortening
significantly(54). This has been balanced by a slight increase in delay for patients in categories
previously categorised as urgent.
Patient prioritisation can also be based on the total integral amount of life years gained from any
given radiation therapy or combined modality treatment. Estimates of integral benefit can be
obtained from the literature and form the basis for a prioritisation scheme included in Appendix 5,
which has been in operation for 12 years in one department. An essential component of this, as
with all methods, is regular review of treatment slot availability and the waiting patient load. These
two methods are provided as examples only: each centre will need to modify and develop the
process best suited to their local environment.
3. By time waited
Recognition of time already spent waiting can reasonably be included in a system of prioritisation
so that no individual is kept at the bottom of a waiting list for long periods of time because of cases
perceived to be more pressing being started on treatment before them. Whether time waiting whilst
having other treatment (active or watchful waiting) should be included here is difficult but the Ready
For Care concept implicitly defines the waiting period as only starting from the date ready for care.
c) Adjusted working hours

Individual departments may choose to alter the length of the working day to accommodate extra treatment
slots for patients. There has been extensive debate as to whether this is cost-effective and safe. Although
a potential means of increasing access in the short term, it is generally not sustainable in the long term
when a major reason underlying difficulties with access is staff shortages. In addition, operating extended
working hours has an impact on all staff groups, not just the radiation therapists. The Baume report(2) (p96)
states when considering whether to extend their operating hours, facilities must examine many factors
15
including the availability and willingness of staff to work flexible hours.. One facility advised that operating
extended hours increased the social cost to its employees and made it more difficult to recruit and retain
staff. This is a significant issue in times of worldwide staff shortages, but should be re-addressed as the
staffing crisis eases.
It is recommended that departments do not adopt this approach as a long-term solution, but consider its
use at times of particular congestion.
One suggestion that increases working hours but without putting a great onus on staff is to establish a
rapid response clinic along the lines of such a model in Canada. A one stop clinic on a Saturday in which
patients are seen, planned and treated is of particular value for single dose or two fraction schedules,
accommodating palliative patients with minimum inconvenience.
Low applicability and moderate impact on waiting lists management
d) Equipment modification, upgrading and replacement

It is beyond the scope of this document to discuss replacement, expansion and maximising the efficient
use of the treatment delivery equipment. Suffice it to say that estimates of the required complement of
equipment exceed the current capacity significantly(55, 56), although it is recognised that some gains in
patient access may be made in coming years as work practices are refined(1). Queuing theory suggests
that machine capacity has to exceed demand to avoid the build-up of waiting times, and that the optimal
utilisation rate of a linear accelerator would be below 90% to keep waiting times for treatment within
best practice guidelines(57, 58). In times of finite resources however, it is evident that this is not acceptable
practice, and most linear accelerators will run at over 95% capacity.
e) Altered fractionation schedules

The selective use of evidence-based altered fractionation schedules should be considered. For example,
the treatment of bone metastasis for pain relief with single fractions is well supported by evidence
from a number of randomised trials. For curative treatments the data to support the long term safety of
hypofractionated schedules are limited. It is also recognised that the therapeutic window between safety
and unacceptable morbidity in terms of late side effects is narrow. Because of this, the world-wide standard
of care for curative treatment of common cancers is to use fully fractionated regimens. When a reduced
fraction schedule is being considered, it is important to be sure that the characteristics of the patient match
those in the relevant publication and that the full implications for safety and efficacy are considered.
The following are examples of where the use of hypofractionated palliative schedules is supported by
clinical evidence:
Bone pain(59): (level 1 evidence) Single fraction of 8 Gy
Poor risk lung cancer(60): (level 1 evidence) Either a single # of 10 Gy (61)
or 16 Gy in 2# (54)
[dose
reduced from 17 Gy to minimise risk of myelopathy].
Note: good risk palliative patients have a survival benefit with longer schedules, and reference should be
made to the publications for defining appropriate patients.
High grade glioma(62): (level 3 evidence) 30 Gy in 6#
Bladder carcinoma(63): (level 2 evidence) 21 Gy in 3#
Breast cancer: (level 1 evidence) 40 Gy in 15#
Low applicability and to date unlikely to be implemented with any significant impact
f) Referral to other centres

Where treatment units are relatively geographically approximate and additional treatment capacity is
present in the second unit, marginal gains may be obtained by referring patients on. Historical experience
and patient surveys clearly indicate however that substantial geographic boundaries mean that this
approach may sometimes be relatively limited in its scope to improve waiting lists(17). In addition, this can
sometimes be more difficult than first thought as patients quickly develop a relationship with their treating
team, often as a consequence of endorsement of the team by the referring clinician.
16
g) Redeployment of staff
Where staff shortages (medical physicists or radiation therapists) contribute to waiting lists, staff
redeployment has proven unsuccessful without pre-existing functioning links between departments and
within or across Area Health Services. Greater planned cooperation of departments should be encouraged
as a potential means to address some of the access and resourcing inequities across some regions and
states.
h) An appropriate radiation therapy triage tool

Since the 2005 Faculty Statement on Management of Waiting Lists for Radiation Therapy(14), several

radiation oncology departments have trialled and refined waiting lists triage tools endeavouring to achieve
better management and utilisation of their resources. Some of these are listed in the Appendices 2-4.
One of the most workable solutions is the Queensland Health Categorisation system, reproduced in
Appendix 2 with permission. It is very simple, workable and covers palliative and curative needs.
National consensus across the jurisdictions is a priority and can be led by DoHA and other key government
organisations, NGOs and stakeholder groups. Initiatives such as the Radiation Therapy Waiting Time
Working Group and the National Minimum Dataset are valuable.

NSW Health has also released a Waiting Times Document covering many of these issues, available at
http://www0.health.nsw.gov.au/resources/pdf/factors_impact_referral_r.pdf
17
CONCLUSIONS
Waiting unreasonable lengths of time for radiation therapy represents poor medicine and inadequate
care.
Keeping waiting times as short as reasonably achievable in principle should be considered in
developing waiting times policy.
Patients on a waiting list must be fully informed and actively cared for and must be offered options with
respect to how they are best managed.

Measuring, monitoring and reporting basic waiting times data is important.
Measuring Whole of Health radiation therapy waiting times accurately is complex.
National radiation therapy waiting times definitions, inclusions and exclusions are inconsistent.
DoHA and the State Jurisdictions are ideally placed to assist in achieving consensus.
18
APPENDIX 1: MINIMUM DATASET FOR TREATMENT TIME ANALYSIS
FOR A RADIATION THERAPY SERVICE
Objective Data:
Diagnosis
Stage
Treatment intent

Triage category as per departmental employed system
Date of multi-disciplinary meeting
Date of referral to the radiation therapy service
Date of first radiation oncology appointment
CT simulation date availability of CT related resources
Date of starting radiation therapy
Date of last radiation therapy

Postcode of patient
Alternative management implemented due to delay in radiation therapy
Subjective Data:
Date of decision to treat
Ready for care date.
19
APPENDIX 2: TRIAGE SYSTEMS IN USE AROUND AUSTRALIA
QUEENSLAND HEALTH CATEGORISATION SYSTEM

Suggested program of waiting list allocations according to clinical scenario and tumour type.
The waiting time is defined as the current delay that patients requiring urgent treatment incur from the
ready for care date until commencement of radiation therapy. The ready for care date is the date the patient
is ready to commence radiation therapy.
A. Emergencies: Treatment with 24 - 48 hours

Any condition that poses a risk of imminent death or permanent disability that has the potential to be
reversed by immediate radiation therapy

Spinal cord compression
Tracheal or airway obstruction
Significant bleeding or haemorrhage
Rapidly growing orbital or ocular tumours
B. Urgent (Category 1): Treatment after delay due to waiting time. Curative treatments should always have priority
over palliative treatments. If palliative courses are short consider requesting the non-consecutive option on the
request form as this may bring forward any booking. Ado patients include those who have a day off therapy when
the linear accelerator they are on has aservice.
1. Growing tumours for definitive therapy:

Non ADO: Intact head and neck (including those with positive margins)
Lung (both NSCLC, SCC and large cell, and SCLC)
Oesophagus (SCC)
Cervix
Merkel cell carcinoma
SCC skin in immunosuppressed patients
ADO patients: Preoperative rectum
Preoperative sarcoma
Anal canal
Locally advanced breast
Bladder
Brain tumours
Lymphoma
Melanoma
Adenocarcinoma of lung and oesophagus
2. Palliative patients:
Suitable for short courses (1 -5 fractions) Bone metastases
Brain metastases
Advanced NSCLC
Other visceral metastases (liver, adrenal)
Nodal and subcutaneous metastases
Suitable for long courses (10+ fractions) Pelvic tumours eg rectum, bladder, prostate
Incurable brain tumours
Palliative oesophageal tumours
Abdominal masses eg nodes, pancreatic tumours
C. Non urgent (Category 2): No preceding chemo/hormonal therapy

Postoperative setting: Breast (no adjuvant chemotherapy)
Bone/spinal metastases
Head and neck with negative margins
Melanoma
Brain metastases
Sarcoma
Rectum
Prostate
Low grade brain tumours
SCC and BCC of skin
Endometrium
Early prostate
Benign tumours which are malignant by virtue of position eg meningioma
D. Non urgent (Category 3): Preceding chemotherapy or hormonal therapy prior to radiation therapy.
Adjuvant breast
Prostate receiving neoadjuvant hormones
Lymphomas receiving chemotherapy
Benign conditions which are not malignant by virtue of site eg keloid
20
Patient Prioritisation Scheme
Department of Radiation Oncology
Newcastle Mater Misericordiae Hospital

August 2001
Background Information and Guiding Principles
Previous prioritisation schemes adopted by the Department (and extensively debated in the medical press,
lay press, national and international conference proceedings during the 1980s and early 1990s), have
been based on the premise that patients in whom radiation therapy has a high curative potential, should not
wait longer than 21 days for treatment. The current shortage of radiation therapists has seen that limit to
be completely unworkable. No patient prioritisation scheme will provide acceptable, nor desirable, waiting
times to all patients. It is also acknowledged that no one scheme is regarded by all staff to be correct. The

Department should aim to deliver the most net good to the most net patients possible, consistent with
reasonable quality.
By virtue of the curative potential for radiation therapy in many treatment sites, the most net good will arise
where the integral measure of survival benefit and overall survival time is maximised. Disease-free survival
and quality-of-life are vitally important endpoints in oncology but in an environment of severely limited
resources two important practical and ethical considerations apply:
1. The suffering and reduced quality-of-life in individuals with a limited life expectancy (say 1 year) is
outweighed by the opportunity for cure (ie normal life expectancy, say an additional 10 or 20 years)
in a smaller group of individuals.
2. Prioritisation according to this model will mean that individuals with limited life expectancy but high
need for treatment will be disadvantaged. These patients will be informed of alternatives in particular
if treatment is available at an earlier date at another centre.
The Department proposes prioritisation should be on the basis of

survival/curative outcomes
In terms of practical management of the waiting list, there can be considered to be 3 categories of patients:
A) Emergency and very urgent cases.
B,C & D) Prioritise sequentially (see table)
E) Palliative patients given one to two fractions only and treated in the order that they present
in empty treatment slots as available.
Regular monitoring of the length of time associated with each of these major categories and sub-categories
will be required in order to inform patients at the time of consultation of their treatment choices outside the
Hunter region. If category E patient waits become excessive, formal expansion of available single slots on
a weekly or second weekly basis may be required.
Precise estimates of the benefit of radiation therapy from level 1 and 2 evidence are available for the major
disease sites. Cure is possible for > 80% cases with organ preservation for early cervix, larynx, and anal
cancer, eg post-mastectomy RT is associated with a 10% survival improvement. Regular communication
between all disciplines and consensus (e.g. at medical audit meetings) will be required in order to cover all
possible cancer sites.
21
Category A1 Category A2 Category B1 Category B2
Radiation therapy is the Radiation therapy is the only Radiation therapy has a major Radiation therapy has a
only palliative option to palliative option to prevent rapid curative role or where treatment major impact on disease
prevent imminent death or significant deterioration in quality delay significantly impacts free survival. Contributes
catastrophic event.(treat of life (treat within 7 days). on other/curative modalities. moderately to overall survival
within 24 hours) Contributes significantly to by 5% -10%
overall survival by 20% - 100%
and enables organ preservation.
Expected survival Expected survival Expected 5 yr survival Expected 5 yr survival

>= 3months > = 3 months >= 20% >= 10%
Emergency Semi emergency Curative Curative

Low Dose Low Dose Various doses +/- chemo. Various doses +/- chemo
1-5 fractions 1-5 fractions
SVCO Eg. Significant haemoptysis, Stage 1-3 Head & Neck Radical NSCCL
Acute complete Significant Nerve root Cervix stage 1-3 Good prognosis glioma
obstruction of major compression. Pain requiring Anus non-metastatic
airway doses of narcotics sufficient to
Oesophagus
Spinal cord compression / cause respiratory depression or
significant prolonged sedation. Bladder
neurological failure
Stage 1 or 2 NHL
Life-threatening
Paediatric
haemorrhage
Pre-op rectal cancer
All patients will be given an approximate treatment appointment at the time of planning. All patients will be placed
on waiting list at time of decision to treat. Mould Room/Simulation appointment will be matched to approximate
treatment appointment .Radiation Oncologist must enter date ready for care and patient category. Patients on the
waiting list will be given contact details for the planning room and individual doctors. Patient monitoring will take
into account individual risk. Radiation Oncologists will be kept informed of machine and patient waiting status by
category in order to offer patients alternatives at consultation. Patients are prioritised sequentially according to the
above categories. A1 within 24 hours, A2 within 5 days, B1 within 21 working days. Category E when spare single
fraction slots are available. Category B2, C and D follow B1s. Treatment breaks and cancellations may be filled on
an ad-hoc basis by abbreviated fractionation patients from category C or D. (liaise with clinician) Quarantining of
treatment spaces will occur for B1 patients. These spaces will be back filled 2 weeks before if they remain empty.
The goal of any triage system is to keep patients in the B1-E categories waiting for no longer than 21 days (ACHS
indicator). The waiting list will be reviewed weekly by the Planning Manager and/or Senior Planner responsible and
the Director of Radiation Oncology.
22
Category C Category D Category E
Radiation therapy has a moderate Radiation therapy has a small impact on Radiation therapy has no impact on
impact on disease free survival or small overall survival. overall survival.
contribution to overall survival by <=5% Moderate/ Major impact on disease free Moderate impact on disease free
Or radiation therapy is used sequentially survival survival
after chemotherapy/hormone therapy Major impact on quality of life Major impact on quality of life
without compromising survival

Expected 5 yr survival Expected 5 yr survival Expected 1 yr survival
>= 20% survival <= 5% <= 20%
Curative Palliative Palliative

Various doses +/- chemo Moderate Dose >= 5 fractions Low Dose 1-2 fractions in spare
appointment slots

Eg. Breast Ca. Poor prognosis gliomas Poor prognosis metastatic disease
DCIS Poor prognosis Head & Neck requiring palliation
Low risk prostate or Neo-adjuvant NSCCL/SCCL Bone mets
hormone prostate CNS, solitary mets NSCLC
Limited SCCL Any locally advanced tumour not fitting Brain mets
Post-operative categories B1-C
- Cervix,
- endometrium
- Sarcoma,
Hodgkins (CMT)
NHL(CMT)
23
Peter MacCallum Cancer Institute, Melbourne Point Triage System for Clinical Prioritisation
Unit 6 Points 5 Points 4 Points
Breast Inflammatory cancer Locally advanced T3-4 breast intact

Brachial plexus involvement Visible local recurrence
Gynaecology Cervix/vulva node +ve post-op Cervix, curative chemo/RT
Cervix node ve post-op.

GI T3 rectum, chemo/RT. Oesophagus curative chemo/RT
Anus chemo / RT Stomach post-op.
Rectum, pre-op.
Head & Neck Mucosal Mucosal SCC curative RT NPC/SNUCS / ethesioneuroblastomas,
SCC post-op, (excluding T1 glottic) +/-
Cutaneous SCC post-op regionally
clinically rapidly chemo
metastatic
progressive
Merkel cell curative RT+/-

disease
chemo
Haem- Large cell/aggressive NHL Classical HD, St I-II, RT alone
atology St I-II first-line ] (RT alone or
Large cell/aggressive NHL recurrent
post-chemo)
localised disease second-line ] (RT
HD stage I-II, post-chemo alone or post- chemo)
Pre-transplant RT
Lung Non-small cell RT +/- chemo Limited small cell, chemo/RT (ideally
with 2nd cycle of chemo)
Neuro Glioblastoma multiforme

Anaplastic astrocytoma
Sarcoma Pre- or post-op. Curative RT+/-chemo

Skin Merkel cell loco-regional Cutaneous SCC recurrent or
disease (curative RT or post- regionally metastatic (perineural/ in
op +/- chemo) transit/ nodal)
Urology Bladder, chemo/RT or RT Post-prostatectomy

alone
24
3 Points 2 Points 1 Point
Locally advanced, post- Adjuvant RT, breast conservation DCIS breast conservation
mastectomy
Adjuvant RT, post-mastectomy
Vulva, RT alone Endometrium post-op. Endometrium , post-op no

nodes done
Other uterine tumours, post-op.
T1 rectum post-op chemo/RT Stomach pre-op Rectum, re-irradiation (+/-
surgery)
Oesophagus pre-op.
Pancreas chemo/RT
T1 glottic cancers Other post-op-salivary
glands/thyroid/paranasal
Melanoma loco-regional
adenocarcinomas
disease (curative RT or post-

op)
Low-grade NHL St I-II Low-grade NHL St III, RT alone TBI

Low-grade MALT St I-II HD St III-IV post-chemo Hemi body RT
Nodular LP HD St I-II, RT alone Large cell/aggressive NHL St III- TSEB
IV post-chemo
Solitary plasmacytoma
PCI acute leukaemia
Post-transplant RT
Non-small cell RT alone, Non-small cell, post-op, Thymoma post-op
local control N2, microscopic residual
(macroscopic resection)
Small cell PCI
Ependymoma Low-grade glioma Pituitary adenoma
Meningioma
Acoustic neuroma
Melanoma loco-regional Cutaneous SCC de novo/ BCC

disease (curative RT or post- incompletely excised
op)
T4/advanced post-op BCC
Prostate intact (+/- Seminoma St I-II post-op
hormones)
Seminoma post-chemo
Testis, non-seminoma, post-
chemo
25
APPENDIX 3: FRO DEFINITIONS
Faculty of Radiation Oncology, RANZCR

2010
Ready for Care (RFC)
Metadata Type: Data Element

Definition: When the Radiation Oncologist decides that the

treatment course should commence.
Justification: To generate access indicators, including waiting time

to start of therapy.
REPRESENTATION:
Data Type: Numeric
Field Size: Min: 8 Max: 8
Representational format: DDMMYYYY
Guide for use: This date is based on the Radiation Oncologists

assessment, clinical guidelines and Multidiscplinary
Meeting decisions for the local Health Care
Organisation. It represents the optimal commencement
date for that treatment course. The patient is not ready
for care until all necessary surgical, radiologic or
medical interventions have been completed. The
patient is not ready for care if delays are requested by
the patient or delays occur for any other reason outside
the control of the radiation therapy department. (see ACHS
Guidelines). Illustrative examples are as follows:
Post-Op Healing, Chemotherapy Toxicity, PEG
Insertion, Teeth Extraction, Fiducial Insertion, Planning
MRI, Planning PET may all delay RFC.
Validation rules: The RFC date must be re-checked at treatment start or

end to account for changes in patient clinical status,
social status, medical/surgical management or logistics.
Departments are encouraged to real time audit review
the accuracy of RFC data. Eg. at the chart round.
Verification Rules: RFC data can be equal to but not be greater than the
start date.
ADMINISTRATION:
Source document(s): Radiotherapy Information Strategy HIE feeds: Cancer
notification and Radiotherapy waiting times Version 1.0
Clinical Indicators A Users Manual: Radiation
Oncology Indicators, Version 3, 2005.
Source organisation(s): NSW Health Department

Australian Council of Healthcare Standards
Royal Australian and New Zealand College of
Radiologists
26
2010
_____________________________________________________________
Date of Radiation Therapy Start

Definition: Date the course of radiation therapy is started.
Justification: This item is collected for the analysis of waiting time.

Waiting time impacts on tumour control, survival and is
a measure of access to radiation therapy and health system
quality
REPRESENTATION:
Numeric

Data type:
Field size: Min: 8 Max: 8
Data Domain: Valid Date
Guide for use: The date marks when radiation treatment starts,
regardless of whether it is completed as intended or
not. Treatment subsequent to a recurrence will not be
recorded.
Validation rules:
Verification Rules: This field must be greater than or equal to the ready for
care date (RFC).
Corresponds to:
ADMINISTRATION:
Source Document(s): Commission on Cancer, Facility Oncology Registry
Data Standards (FORDS): Revised for 2004.
NSW Health Radiation Information Strategy HIE feeds:
Cancer notification and Radiotherapy waiting times
Version 1.0 Current version of Data set specification
Cancer (clinical). Canberra: AIHW.
Source organisation(s): Commission on Cancer, American College of Surgeons

NSW Health Department
Health Data Standards Committee, Australian Institute
of Health and Welfare.
Comments: This corresponds to Cancer initial treatment starting

date (Knowledgebase ID 001056) in Data set
specification Cancer (clinical). Definition: The start of
the initial course of non-surgical treatment for cancer.
27
2010
_____________________________________________________________
Date of Radiation Therapy Booking
Definition: When the radiation oncologist decides that

radiation therapy treatment is indicated and books
treatment.
Justification: This item is collected for the analysis of waiting times.

Analysis of the time between booking date and RFC
gives an estimate of patient priority.
REPRESENTATION:
Data type: Numeric
Field size: Min: 8 Max: 8
Data Domain: Valid Date
Guide for use: The date marks when the radiation oncologist and
patient agree that radiation therapy will be part of the
treatment plan.
Validation rules:
Verification Rules: This field must be less than or equal to the ready for
care date (RFC).
Corresponds to:
ADMINISTRATION:
Source Document(s): Radiotherapy Information Strategy HIE feeds: Cancer
notification and Radiotherapy waiting times Version 1.0

of Health and Welfare.
28
2010
__________________________________________________________
Postcode of Usual Residence

Metadata Type: Data Element Concept
Definition: The postcode of the physical location where the patient

usually resides.
Justification: The address of usual residence is collected for the

purpose of assigning the patients Statistical Local Area
and Health Service of residence.
REPRESENTATION:
Data type: Numeric

Field size: Min: 4 Max: 4 180
Representational format: AN (180)
Data Domain: This data item is postcode only
Validation rules: Valid postcode values are validated again the data
sourced from the National Locality Index (Australian
Bureau of Statistics) and the Australia Post
Locality/Postcode database (Australia Post).
Postcode guidelines may be obtained from below or

CCORE.
ADMINISTRATION:
Source document(s): Current version of Admitted Patient Data Dictionary,
Admitted Patient Data Collection. Sydney: NSW Health
Department.
Reference:
http://internal.health.nsw.gov.au/im/ims/ap/ap-data-
dictionary-2004-5-public.html
[Note this is only an optional field for APDC]
Current versionofofData
Current version Datasetset
specification - Cancer
specification (clinical).
- Cancer (clinical).
Canberra: AIWH
AS5017-2002 Health care client identification. Sydney:
Standards Australia.

of Health and Welfare
Standards Australia.
29
APPENDIX 4: RWTWG DRAFT DEFINITIONS FOR REPORTING
REASONS FOR DELAY
Reasons for delay in starting radiation therapy after initial consultation with a radiation
oncologist (RO)
For category 1, the prescribing radiation oncologist should indicate the date that he/she expects the
patient to be in a position to start the prescribed course of treatment i.e. the ready for care date or RFC.
In example e), if the RO considers that fiducial-guided therapy is the standard of care, allowance needs
to be made for insertion of the fiducial seeds before the patient is ready for care. These procedures are
part of care and are anticipated. The RO should indicate what the RFC date is at the time of consultation.
1. Planned, leading to a ready for care date later than the date of consultation
a. Patient wishes
b. Planned chemotherapy or hormone therapy, to be undertaken before radiation commences
c. Other planned therapy e.g. surgery or high dose rate brachytherapy prior to external beam
irradiation
d. Allowance for post-operative recovery, or recovery of blood counts after chemotherapy

e. Allowance for preparation for treatment, e.g. dental clearance for head and neck patients, gold
fiducial seed insertion for prostate cancer patients, which must be undertaken before radiation
therapy planning can commence.
For category 2, these are delays which occur after the date of the initial consultation, but are outside the
direct remit of the Radiation Oncology Department. These could include Category 1e) if delays occur
which are longer than the treating RO wishes and mean that the desired RFC date is not met. If there are
no factors which fall into category 1, then the patient should be ready for care on or shortly after the date
of consultation, all other things being equal.
2. Unplanned, outside the control of the Radiation Oncology Department

a. Delays in obtaining imaging results required for determining the objective (cure or palliation) or
technique of treatment, or the volume to be treated
b. Delays in obtaining other critical clinical information from other departments
c. Unexpected complications of treatment or disease progression, which might require a change of
treatment decision, timing or plan
d. Other issues within the hospital which have an effect on the operation of the Radiation Oncology
department e.g. break-down of the airconditioning
Category 3 includes those factors which are a direct result of delays within the Radiation Oncology
Department, and are indicative of pressures on the resources available within the department. They may
relate to volume of referrals, staffing establishment, work processes, equipment profile and number,
equipment failure/break-down etc.
3. Unplanned, within the control of the Radiation Oncology Department

a. Delays in imaging within radiation therapy for planning purposes
b. Bottlenecks in the planning and dosimetry processes
c. Bottlenecks for starting a linear accelerator treatment course
30
The Australian Institute of Health and Welfare also recently published a dictionary around radiation
therapy waiting times.
They recommend splitting the waiting time into two periods:

The time from receipt of referral to decision to treat; and
The time from decision to treat to date of start.
Addressstatistical area, level 2 (SA2) code (ASGS 2011) N(9) Mandatory 1

Establishmentorganisation identifier (Australian), NNX[X]NNNNN Mandatory 1
Health service eventfirst service contact date, DDMMYYYY Conditional 1
Health service eventservice request received date, DDMMYYYY Conditional 1
Patientclinical emergency indicator, yes/no code N Conditional 1
Patientintention of treatment, code N Conditional 1
Patientprincipal diagnosis, (ICD-10-AM 7th edn) ANN{.N[N]} Mandatory 1

Patientradiation therapy start date, DDMMYYYY Conditional 1
Patientready-for-care date, DDMMYYYY Conditional 1
Person with cancerprimary site of cancer, code (ICD-10-AM 7th edn) ANN{.N[N]} Conditional 1
Personarea of usual residence, statistical area level 2 (SA2) code (ASGS 2011) N(9) Mandatory 1
Persondate of birth, DDMMYYYY Mandatory 1
PersonIndigenous status, code N Mandatory 1
Personperson identifier, XXXXXX[X(14)] Mandatory 1
Personsex, code N Mandatory 1
Radiation therapy waiting times data set specification (RWT DSS) available at
http://meteor.aihw.gov.au/content/index.phtml/itemId/447921
31
APPENDIX 5: ACCESS TO CARE CHECKPOINTS AND DISCUSSION
The size of a waiting list and the duration of waiting can be influenced or artificially manipulated by
limiting access at various points along the pathway, allocation of, or the definition of, dates for:
1. Specialist consultation
2. Timing of decision to treat
3. Ready for planning and ready for care may produce different waiting list figures, and affect patient
access in different ways. Clear definition of the different components of the waiting times will allow
collection of uniform data nationally.

i) Specialist consultation
The centre experiencing a waiting list may choose to transfer the wait to the point of access to
the specialist opinion. In practical terms this requires either the ability to arrange for transfer of
patients awaiting access to another facility, or to queue the new patient consultation availability.
The risks with the former are the potential loss of established referral patterns and increased
difficulties with geographical access to radiation therapy. Many centres will be unable to employ
this as an option.
The latter moves the pressure point in the system to an earlier time, but does not permit
appropriate oncological assessment of the clinical priority of the patient on the waiting list. This is
perhaps not a recommended option as expert oncological opinion may not be obtained in a timely
fashion, inappropriate or sub-optimal decisions regarding management may be made, and the
demand for the service will not be fully recognised and documented.
ii) Timing of decision to treat (DTT)

Delay in the decision to treat is not a common checkpoint, and depends particularly on
circumstances such as the availability of diagnostic services to provide the evidence on which
to base management decisions. The reverse approach may in fact be adopted, that is, a
provisional but premature treatment decision is made with a provisional ready for care date
(which may subsequently change or the patient be cancelled) defined in anticipation of the
outcome of investigations and their timely availability. It is hoped that some of the likely waiting
times for treatment will be served while going through the other processes. The perceived
potential gain is to avoid extra delay produced by access difficulties elsewhere within the system
such as Diagnostic Imaging. The deficit is the likelihood of delays or cancellations because
of inappropriate allocation of planning and treatment resources. This results in wasted time
allocation and delay of other more appropriate cases. Optimal prioritisation of cases once all
required information is available should reduce the tendency to exploit this loophole.
Fig 1 illustrates just a small part of the complexity and feedback loops that exist in multi-modality
cancer management. Other examples of uncertainties around critical data items and checkpoints
for radiation therapy decision to treat include:
Date of phone call fax or email?

Date of reading/losing/misplacing the fax or email?
Date of MDM decision?
Date of decision by another oncologist or MDM?
Date of randomisation on a trial?
Date of face to face consultation number 1 or 2 or 3?
Date of path, PET, CT report impacting on decision to treat/gaming DTT?
If decision is then made not to treat or to delay treatment does the clock stop?
32
iii) Ready for dates
Departments use variable definitions of what constitutes waiting times. The date of particular
relevance is the ready for care date, which will take into account medical and social factors
that may influence the timing viewed as optimal for the patient to commence radiation therapy.
Departments may also indicate dates such as ready for planning (that is, when investigation
results are available or when the patient can be physically or medically or emotionally simulated).
Examples of complexities and controversies include the following:
Patient recovery post surgery or chemotherapy is somewhat arbitrary and varies patient to

patient, site to site, drug to drug, co-morbidity to co-morbidity.
Should non-cancer medical or surgical delays be included?
Should non-radiation therapy imaging necessary to plan the patient outside radiation therapy
department be included?
Should delays in chemotherapy administration be included?
When and what type of patient emotional or family distress should affect or not RFC?
If decision is then made not to treat or to delay treatment does the clock stop?

In particular the division of waiting times into a radiation therapy and non-radiation therapy
origin is fraught for complex cases. The imperative for patients and health planners is around
all cancer delays from primary to tertiary care inclusively.
a) The planning process

Both access into and passage through the planning process may be checkpoints that limit access. A
patient may not be given a planning appointment if the system is clogged with cases being processed
prior to treatment even if there are vacant treatment slots available. While a waiting list in theory
will provide plenty of time to complete planning procedures, it may be difficult to estimate when to
start the planning process if a firm treatment start date is not available. Allocation of inadequate time
to complete the process will lead to delays in starting treatment and potentially leave treatment slots
unfilled. Conversely, starting planning too far in advance of treatment may lead to plan adjustments
and extra planning hours because of changes in patient, tumour or treatment intent. Prevention
of these inefficiencies demands the availability of all required information a definitive treatment
decision, a clearly defined planning process, and a confirmed date to start treatment.
It would be helpful to benchmark the components and the timing of the procedures leading up to
the initiation of treatment. With a clear understanding of what is required in the planning phase,
more efficient allocation of resources can ensue. This may be appropriately addressed through the
development of the proposed national quality program for delivery of radiation therapy services. This
development should address the planning process: documentation of planning practice, development
of national standards of practice, the auditing of their application, and collection of evidence to
support increased resource allocation.
b) Access to treatment
There are a number of methods of controlling access to the treatment itself, which depend on
different systems of prioritising the patients according to need.
i) A priority rating may be allocated according to perceived urgency e.g. emergency, urgent, routine
ii) A priority ranking may be based on the evidence, where available, of the likely outcome from
treatment e.g. cure rates, success of palliation.
iii) An example of a priority ranking based on the limited evidence available is attached at Appendix
4. In this system, piloted at PeterMac, patients are accorded a number of points reflecting
their need to start therapy relative to other patient in that disease grouping. They may also
accumulate points as they wait on the list. The effect of this approach has been to change the
shape of the waiting curve, with reduction in very long waiting times, and more even distribution
of patient starting within 3-6 weeks of their ready for care date.
iv) Priority may be according to treatment intent, for example treating curative patients at the
expense of offering a palliative service, e.g. Appendix 3.
33
v) Curative patients may have additional therapy prior to starting radiation therapy.
vi) e.g. neo-adjuvant androgen deprivation in prostate cancer or a cycle of chemotherapy for non-
small cell carcinoma of the lung or ptimisation of analgesia. if these measures fail; this may
result in an inferior treatment being recommended.
Fig1. A possible patient pathway to radiation therapy. Some of the more common factors impacting
directly and dynamically on RFC dates are shown in grey. Defining RFC dates for some cases is very
complex and may change several times for some patients.
34
ACKNOWLEDGEMENT
The Quality Improvement Committee wishes to thank the following individuals and groups for their
valuable advice in preparing this document:
Mr John Stubbs, Consumer representative on the RANZCR Faculty of Radiation Oncology Council
Ms Legend Lee, Senior Projects Officer, Faculty of Radiation Oncology.

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38
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Management of Waiting Lists in Radiation Oncology

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MANAGEMENT OF WAITING LISTS

FACULTY OF RADIATION ONCOLOGY

THE ROYAL AUSTRALIAN AND NEW ZEALAND COLLEGE OF RADIOLOGISTS

Prepared by the Faculty of Radiation Oncology Quality Improvement Committee 2013

ABN 37 000 029 863

The Royal Australian and New Zealand College of Radiologists

Faculty of Radiation Oncology