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ANALYSIS: Donald M Berwick A transatlantic review of the NHS at 60 BMJ 2008; 337: a838 [Full text]

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Technology transfer in cancer care: a continuing challenge for the NHS

Ian Hubert Kunkler   (29 July 2008)

Technology transfer in cancer care: a continuing challenge for the NHS 29 July 2008
Ian Hubert Kunkler, Honorary Professor Edinburgh Cancer Centre, Western General Hospital, Crewe Road, edinburgh EH4 2XU Send response to journal: Re: Technology transfer in cancer care: a continuing challenge for the NHS	I would concur with much of Don Berwick’s upbeat transatlantic review of the NHS contrasting the universality of access to care to the fragmented health care system in the USA (1). However, he omits to highlight one of the strengths of the USA as an early adopter of new technology. The slowness of technology transfer in the NHS compared to the USA was highlighted by Sir Derek Wanless in a previous review of the NHS (2). This is one of the reasons why the NHS continues to lag behind the USA in the quality of cancer care, an area where Berwick acknowledges that the NHS has made less progress. Currently this is well illustrated by the widening gap between our two countries in the implementation of advanced radiotherapy technologies such as intensity modulated radiotherapy (IMRT) for cancer treatment. IMRT enables the homogeneity of distribution of radiation dose within the tumour to be optimised and the dose to surrounding normal tissue to be minimised by modulating the fluence of the radiation beam. A recent systematic review of IMRT studies in head and neck, breast, lung, prostate, CNS and gynaecological cancer has demonstrated reductions in radiation induced toxicity without compromising local control (3). In the USA for example, IMRT has been adopted as a standard for care for curative radiotherapy of head and neck cancer. IMRT enables the dose to the salivary glands to be reduced to levels which substantially reduce xerostomia (dry mouth), one of the most distressing longterm complications of irradiation for head and neck cancer. Currently less than 20% of UK radiotherapy departments have implemented IMRT for head and neck cancer or for other cancer sites where it may offer an advantage over conventional radiotherapy. As a result, patients continue to experience avoidable morbidity which impairs quality of life. The patchy access to IMRT across the UK is largely due to the shortage of the necessary manpower in medical physics to meet the demands of the rigorous quality assurance demanded to implement IMRT. In addition, in some regions of the UK, poor Agenda for Change bandings are hampering recruitment and retention of medical physicists. Urgent investment is needed to expand the number of medical physicists in the UK so that patients have equitable access to advanced radiotherapy technologies and the better quality of care they offer. In the interim, discerning patients may have to resort to ‘top up’ payments to access optimum radiotherapy. In the interests of equity, the government’s review of ‘top up’ payments (4), currently focussed on anti- cancer drugs, needs to include advanced radiotherapy technologies. References: 1. Berwick D. A transatlantic review of the NHS at 60. BMJ 2008; 337:212- 216. 2. The Wanless Report. Securing our future Health. Department of Health, 2002, p.156. 3. Valdeman L, Madani I, Hulstaert F, De Meerleer G, Mareel M, De Neve W. Evidence behind use of intensity-modulated radiotherapy: a systematic review of comparative clinical studies. Lancet Oncology 2007; 9:367-375. 4. Government is to review use of copayments in the NHS. BMJ 2008;336: 3455. Competing interests: None declared