Analysis of differences in Oncology practice between the United Kingdom and India

AN. Aswin1, Apurna Jegannathen2, AN. Vaidyswaran3

1Consultant Radiation Oncologist, Kauvery Hospital, Alwarpet, Chennai, Tamil Nadu, India

2Consultant Clinical Oncologist & Clinical Lead, Royal Stoke Hospital, University Hospital of North Midlands, Stoke on Trent, United Kingdom

3Senior Consultant Radiation Oncologist & Director of Radiation Oncology, Kauvery Hospital, Alwarpet, Chennai, Tamil Nadu, India.

Background

This article is based on my observership of SABR (Stereotactic Ablative Body Radiotherapy)/SRS (Stereotactic Radio Surgery) at few centres (Royal Stoke Hospital, UHNM, Clatterbridge cancer centre, Royal Hallamshire Hospital) in United Kingdom (UK).

In this article, I would like to highlight the differences in the oncology practice prevailing between the two countries.

Cancer detection 

Most of the cancers (bowel, cervix, prostate, especially lung, piloted in a few NHS trusts, and breast) are detected by screening programs in the UK whereas, in India, these cancers are usually detected as an incidental finding or usually with symptoms. This may lead to the locally advanced nature of disease presentation in India requiring a multimodality approach (more than one treatment modality).

The Oncologist

In UK, clinical oncologists take care of both radiotherapy/chemotherapy/immunotherapy/biological agents, and medical oncologists work along with clinical oncologists for concurrent chemoradiation, radical radiotherapy, palliative radiotherapy, SABR etc. In India, radiotherapy is done by radiation oncologists and chemotherapy and other systemic therapies are taken care of by medical oncologists. The chemotherapy-related complications are managed by both clinical oncologists and medical oncologists in UK and medical oncologists in India. There is no site specification for radiation oncologist (except educational institutions and few centres) in India whereas clinical oncologists do only site-specific treatment- 1-2 major sites and a minor site. Specific time allocation for clinical trials, research and audit are incorporated in the job plan.

Decision makers in the treatment and palliative care support

In India, the attenders are the decision makers for the treatment, whereas in UK MDT -Multidisciplinary team decides the best treatment and the patient’s choices are given, for them to make the final decision. Family support plays a major role in India, whereas community support groups- community Macmillan nurse team, district nurses, community palliative care team, hospice etc take care of the cancer patients in UK. Advanced Nurse Practitioners called ANP lead chemo clinics, ANP lead Acute Oncology and EAU-emergency admissions unit with 24/7 helpline for patient access. Metastatic Clinical Nurse Specialists are assigned as keyworkers for patients with secondary cancer.

Funding for the treatment 

The NHS sponsors the entire treatment for the patients in UK. In addition, Cancer Drug Funding (CDF) is a central pot that funds high-cost drugs including Immunotherapy and biological agents. In India, although the treatment given in government hospitals is free of cost and various national/state government schemes are available for the patients, private insurance and paying out of pocket in private hospitals play a major role.

Treatment protocols

In UK treatment protocols are agreed at the regional level-cancer alliance group after extensive discussion supported by evidence-based practice. There are Quality Assurance (QA) and monitoring, with report systems in place. Radiotherapy related 30-day mortality is collected. National audits from all the NHS Trusts are collected. Targets are used for treatment initiation. Peer review is mandatory for complex/ concurrent chemoradiation patients. MDT discussion is a requirement. ANP led RT reviews are in place. There are fixed protocols for all the sites in UK although there are minor variations in each centre based on evidence. Personalised approach is practised in UK. In India, although centres follow protocol, there is no uniform protocol throughout the country. But the patient specific customization is still practised in India.

Documentation 

In UK clinical documentation is paperless throughout the journey. This includes all clinic visits, radiotherapy planning, chemotherapy prescription, and follow-up. Paperless system (EPR-Electronic Patient record, Electronic Medical Record EMR) is followed. This iportal system is visible to all specialities within the trust and to the primary care team.  In India, except few centres, the documentation is on paper in some centres and hybrid model (paper + EMR) is followed in some centres.

The Clinic (Outpatient consultation)

The number of patients seen and followed up are exponentially more in India when compared to UK. The quality of time spent with the patients/attenders is better in UK for the same reason, one hour for new patient, twenty minutes for FU. The timing of work is between 9 to 5pm for 5 days and hence a waiting list is common. Paid for PA (programmed activity, 1PA = 4 hours) is followed. Telephonic consultation is widely practiced in UK. For getting consultant appointments, it might take minimum 2 to 3 months in the UK. There is a huge waiting list which is getting better as there is cross cover in each site-based team.  In India it is within 1-2 days.

Waiting time for imaging investigations

The approximate waiting period for investigations like Computerized Tomography (CT) and Positron Emission Tomography (PET CT) is usually within a week in India; It is mostly 3-6 weeks in UK but urgent scans are done within 1-2 weeks if specifically requested and same day for emergency scans

Biopsy

Some of the patients with lung nodules which are PET Positive and shown to increase in size are treated with SABR even without the biopsy in UK, if biopsy is not feasible and the radiological features are suggestive of malignancy after Tumour Board discussion. In India this is rarely done because there are high chances of associated diseases like tuberculosis.

Consent

There is a proper site- specific consent in UK whereas it is more a generalised consent in India.

Immobilization and CT simulation in Radiotherapy

The immobilisation device like Omni board (Fig. 1) with arm support, knee support and ankle support is designed in such a way that it is so much convenient to the patients in UK. The abdominal binders can be attached to the Omni board for intra-abdominal tumours. Aquaplast is used only for patients with head & neck cancers and brain tumours. In India, aquaplast is used for almost all sites which may be a little inconvenient for the patients. The CT simulation process is almost essentially the same in both the countries. The breath- hold technique followed using Visual Display Unit in UK is more convenient for the patients when compared to the techniques followed in India.

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Fig. 1.

Omni Board used for immobilization

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Image acquisition and voluming of normal structures

Image acquisition and voluming of normal structures are done using Artificial Intelligence (AI) on the next day of CT simulation in UK as per the workflow algorithm by the dosimetrists. In contrast, image acquisition is done on the same day by physicists and voluming of normal structures is done by radiation oncologists. Moreover, PET CT, Magnetic Resonance Imaging (MRI) and the planning CT scans are fused before voluming in India. In UK, very rarely the PET CT images are fused for planning.

Voluming

The voluming of the target alone is done by clinical oncologist whereas the voluming of the target as well as normal structures are done by radiation oncologist. The peer review is mandatory and is getting documented in UK, whereas the peer review is not documented and not mandatory in India.

Treatment planning

The treatment planning is done by dosimetrists and sent for physicists’ approval. The physicists will make modifications if needed and finalise the plan. The physicists will do Quality Assurance (QA) and are responsible for radiation safety in UK. As there are no separate dosimetrists in India, physicists will do the job of dosimetrists in addition to their job.

The plan approval

The plan approval is done by clinical oncologists in UK and radiation oncologists in India.

Treatment execution 

The treatment execution is done by radiographers themselves as per the schedule given to them. The entire treatment process is communicated between the oncologists, dosimetrists, physicists and radiographers through official mail id in UK. In contrast, at least during the first day of execution, the treating oncologist as well as physicists come to the console during the treatment execution in India. There is one to one communication and paper documentation in India. For bladder protocol patients, bladder filling is measured using a portable ultrasound machine (Fig. 2) by the radiographers before the patients are made to lay down in the couch in UK whereas in India, the bladder filling is assessed only using CBCT which causes increased amount of radiation exposure to the patient.

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Fig. 2.

Portable Ultrasound machine.

Waiting period for starting radiation

The waiting period after investigations is usually 3 -4 weeks in UK except palliative patients as compared to 3-7 days in India although it varies from centre to centre. Cancer Centres in UK follow hypofractionated schedules for radical radiotherapy (2-4weeks treatment) or ultrahypofractionated treatment (1 week) treatment for  breast cancer (Fast Forward Protocol).

Replanning

In case the patient needs replanning, it takes nearly a week in UK, whereas in India it is usually done within few days.

Follow up

The follow-up is done by the oncologists in both the countries but it is more meticulous especially in educational institutions in India.

Tumors of the brain

The Royal Hallamshire Hospital, Sheffield treats both benign as well as malignant tumours using Gamma knife (Stereotactic Radiosurgery) in a very precise and effective way. The plan of action meeting occurs in the morning where doctors, physicists, nurses and all the staffs involved in the treatment participate, discuss the treatment plan and executed subsequently.

Research activities

The clinical oncologists and medical Oncologists allocate their time for research in doing trials, analysing data and publishing papers in UK. In India the research activities are more confined to educational institutions.

Conclusion

Each country’s healthcare system has its own merits and demerits. It is worthier to incorporate the merits of one system into the other for better patient care. The things which can be incorporated in India include increasing cancer awareness among the public, National Cancer Screening Protocol for early detection of cancers, improving the community support for cancer patients, establishment of more palliative centres, uniform treatment protocol for cancer nationwide, proper documentation system, establishment of EMR, uniform consent system, providing more sophisticated equipment (like Omni board, abdominal binders, portable ultrasound machine), following proper breath holding techniques, bladder/rectum protocols, more precise execution of treatment and allocating more time for research and clinical trials/audit.

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Dr. AN. Aswin

Consultant Radiation Oncologist

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Dr. AN. Vaidyswaran

Director and Senior Consultant, Radiation Oncologist

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