Efficiency of delivery of concurrent chemoradiation programmes

To ensure that complex chemoradiation schedules are delivered according to protocol and that any administrative or clinical obstacles to this are identified. Applicable to any tumour site where chemo-radiation is recognised for radical treatment.

There is a strong evidence-base that chemoradiotherapy provides the best form of radical non-surgical treatment for a number of tumour sites. These include carcinoma of the cervix, anus, oesophagus and a number of head and neck sites. How departments deliver these combined schedules varies but may involve both clinical and medical oncology teams and involve different geographic sites.

Concurrent chemoradiation programmes should be delivered according to written departmental protocols or within the setting of clinical trials. These should specify the precise sequencing, dosage and overall treatment time of both modalities. The responsibilities for patient care and management of toxicities should be clearly defined. The management of the immediate post treatment, and subsequent longer term, follow up should also be specified.

The standard: 

Patients undergoing treatment on concurrent chemoradiation programmes should always be treated according to a clearly defined written departmental protocol or within the setting of a clinical trial. Departmental protocols must be evidence based and should incorporate nationally agreed guidelines and recommendations laid down by the cancer network. They should specify chemotherapy agents, doses and schedule in relation to radiotherapy and the radiotherapy dose-fractionation details.

Target: 

1) 100% of patients with specific diagnosis for which concurrent chemo-radiotherapy is recommended should be treated with synchronous chemoradiation

2) Proportion of such patients treated according to a written departmental protocol

3) Proportion of such patients treated within a clinical trial

Indicators: 

1. The proportion of eligible patients with a specific diagnosis (eg. carcinoma of anus, since chemoradiation is universally accepted as best treatment for this condition) who are treated with synchronous chemoradiation therapy

2. Proportion of such patients treated according to a written departmental protocol for each of the major sub-sites

Data items to be collected: 

1) Patient treated with chemoradiation Y / N

2) According to:

   • Written departmental protocol Y / N

   • Clinical Trial Y / N

3) Radiotherapy (RT) – start date, completion date, total dose, number of fractions

Were there any gaps in treatment? If so length and reason. Was any compensation made?

4) Chemotherapy (CT) – Administered same Trust site as RT?

   • Start date, completion date

   • Drugs given

   • Dosage

   • Dose modification Y / N

   • Reason

   • Supervised by Clinical Oncology or Medical Oncology Team

Suggested number: 

20 per specific tumour site. 20 consequtive patients with site specific diagnosis for which chemoradiation is the evidence-based most appropriate treatment.

• Identify reasons for patients not being offered chemoradiotherapy

• Identify reason for there not being a written departmental protocol. Review literature and construct protocol

• Identify availability of clinical trials and there appreciation within the department

• Review adherence to departmental protocol for synchronous chemoradiation and discuss this at departmental meeting

• Identify any specific steps in the written protocol which are causing problems with adherence

• Identify staff member to introduce changes necessary to allow efficient delivery of defined protocol

• Re-audit in 12 months time

- Personnel: Clinical director, audit lead, lead oncology nurse to check records, summarise and collate

- Time: 8 hours to check records, review information and prepare report

1. Cancer Services Collaborative. Chemotherapy Project Guidance. Leicester: CSC, 2002. 

2. Clinical Oncology Information Network. Guidelines for cytotoxic chemotherapy in adults. Clinical Oncology 2001; 13: S211–S248.

3. Joint Council for Clinical Oncology. Improving Quality in Cancer Care: Quality control in cancer chemotherapy. London: Royal College of Physicians, 1994.

4. Joint Collegiate Council for Oncology. Improving quality in cancer care: Clinical Outcome Measures in Oncology. London: Royal College of Physicians, 2001

5. NHS Executive. Guidance on Commissioning Cancer Services: Improving Outcomes in Lung Cancer: The Manual. Leeds: NHSE, 1998.

6. Royal College of Radiologists. Risk Management in Clinical Oncology. BFCO(95)1. London: RCR, 1995.

7. Tobias JS and Ball D. Synchronous chemoradiation for squamous carcinomas. BMJ 2001; 322: 876–878.

Dr Diana Tait