Global Coalition for Radiotherapy - How to integrate radiotherapy in cancer control plans

Therese Lindé – Global Public Affairs Director at Elekta:

Hi everyone, welcome here today to this, we hope, very productive and amazing session on how we can bring radiotherapy into more cancer control plans across the world. So for the Global Coalition for Radiotherapy this is a big day. Pat and I actually met here four… five, five years ago in this building, exactly five years ago I think, and something [?] started to happen when we realised we needed to do something. There are so many things that we could improve by working together, so let’s try to take it on. That is, of course, centralised around radiotherapy and there is so much need out there and we could at least try to do something by trying to find ways of collaborating across disciplines, across sectors, across borders, actually. That’s why this is global.

Pat and I met here five years ago to discuss the UK work that we have also been part of since then, Radiotherapy UK, which is fantastic on it’s own, and from that we span off the Global Coalition. So nothing of this would have been possible at all if it wasn’t for the amazing Professor Pat Price. It’s so amazing. We should have champions like Pat everywhere, in all countries across the world, then we would actually have change coming through for real. So I hope she will share a bit of what we have done so far today.

And I will let our also very fantastic Darien Laird, who joined us about two years ago and who I never met in real life until today, but we’ve seen each other every week on Teams since two years. She has been making GCR to become something for real, actually, more from passion, idea, into something real. So without her we wouldn’t be here today either. So, with that, I want to let Darien introduce Pat more in a formal way.

Thank you. Thank you all for coming here today and also online. Thank you.

Darien Laird – GCR Director of Communications:

Thank you Therese and, yes, I echo thank you all for coming. We had 200 virtual registrants who were eager to join us and that just speaks to the global community and people who are really invested in the work that’s going on here. It’s such a pleasure too to be here with London Global Cancer Week, so thank you to Susie and to Mark for organising. We’re going to invite Susie up in just a minute to say a quick few words.

But I wanted to introduce Pat and we’re going to show all of the fabulous things that she has done over the past 34 years, redefining cancer treatment in the UK and globally. As the co-founder of the GCR and founder and chair of Radiotherapy UK, she has really pushed the button on advocacy. She calls herself an accidental campaigner and we all know that she actually is quite the campaigner. We learn from her and seek knowledge from her so it’s really a pleasure for her to be moderating this event. She’s quite the moderator, just absolutely fabulous. So, Pat, I’m going to welcome you up and then also Susie if you want to come down at the same time and we’ll have you say a couple of words from London Global Cancer Week, which is really an honour for the GCR to have our first in-person event at this historic week and be able to welcome a lot of you who we have worked with virtually to join us.

Susie Stanway – Co-Founder London Global Cancer Week:

So my name is Susie Stanway, I’m a medical oncologist based in the UK. Just a little bit about London Global Cancer Week – we started it actually in this room in 2016 and it was very much a grass roots idea of a group of about 50 of us that originally got together who were just upset, basically, about global inequalities in cancer outcomes. It has grown from there. 2019 Mark Lodge came along and had the vision to turn it into a week’s worth of meetings with multiple stakeholders. Last year I think we had over 2,500 people attending various meetings over a week and this year we’ve got 39 meetings. So we’re most grateful to everybody who has been involved with the journey. Thank you for giving us this platform to talk about it today and for being part of London Global Cancer Week. Thank you all and please come to other meetings that we’ve got going on for the rest of the week. Thank you.

Pat Price – Chair of Radiotherapy UK Charity, GCR Co-Founder:

Thank you. So it’s great to have you all here. What we’re going to do, we’ve got our keynote speakers to start with and then we’re going to have our panel discussion and then some discussion from you guys, which will be great. So just, as Therese says, just a quick thirty seconds on the GCR, which we’ve started.

Remember, we started at the beginning of COVID, realised there was a need. We went right across the country with COVID, so we had Wuhan, we had Italy, we’ve had ourselves, the Americans, really thinking through how we could work together quickly whatever. We realised there was such an amazing community of everybody in radiotherapy – industry, everybody belonging.

Then we went on to webinars, then we were called upon to get the task force for Ukraine and now we’ve realised there was a need to have really an essentials document for what we need in radiotherapy for national cancer plans. So there’s where we are now. We’ve had a great time, really, but it shows what we can do if we’re fast, nimble. We’ve been online, it’s the first time we’ve met, which is great.

So this is lovely to spend some time here together. So I’m going to introduce first our wonderful first speaker which is Richard who has been great, but he is online here. Yes, we thank our sponsors at Elekta and also the people, the partnerships, to get this here. So obviously everybody knows Richard, he’s been absolutely amazing. All his work with cancer policy in the UK and his global health initiatives. He’s advisor to the WHO and he’s actually a surgeon, ten years’ Scientific Director, Clinical Director at CRUK. But he’s going to tell us a lot now about how we need resilient cancer plans because of conflict in areas as well. So Richard, if you’re there, over to you.

Richard Sullivan – Global Oncology Group (Institute of Cancer Policy) Centre for Conflict & Health Research:

Great. Hello Pat. A disembodied voice and I’m just trying to share my video and it’s saying ‘Unable to start video’ but I’m sure any moment now your technical whizzes will start it. Ah, start my video. Marvellous. Can you see me?

Greetings from NATO everybody. Sorry I can’t be with you, it’s juggling an awful lot of things these days. Thank you. I’m going to just give you maybe just a few words and share a few slides on this whole issue of resilience and conflict. With any luck, with modern technology, can you see all that okay? Marvellous.

So I guess I want to start with this problem of what is resilience in cancer and health systems and, in a sense, what’s the counter-factual – what’s non-resilience? If you see it, you can see what non-resilience is, it’s blindingly obvious. It’s conflict; it’s complex diseases like Ebola; it’s destruction of health infrastructure; it’s refugee populations. But the reality is we don’t really have, within the global health and development field, a particularly strong definition of resilience which captures all these different ecosystems. Of course, increasingly we’re seeing a lot of these ecosystems coming together, so conflict and complex infectious diseases emergency.

But what it talks to, of course, is specificity. Every single country is different in time and space. We’re seeing an extraordinary amount of health ecosystems now are chronically fragile. The case of Afghanistan is a case in point – we have cancer patients there migrating hundreds or thousands of kilometres to access cancer care in Pakistan. These extraordinary new therapeutic geographies now are becoming the norm, not the exception. And it’s not just a movement of cancer patients between countries, we’re also seeing extraordinary displacement of patients within countries. These displacements also challenge our notions of what cancer control planning ought to be and what resilience is.

The other point to make is, of course, conflict today can undo years of progress in a matter of weeks. We’ve seen this in Gaza and Sudan – the use of modern weapons is just amazingly destructive. Joint demolition attack munitions have lethalities up to a kilometre when these things are dropped and the wider effects are 5km. The point here, of course, is that cancer care is basically hospital care. Hospital equipment, whether linacs, CT, ultrasound, are incredibly sensitive to shockwaves and explosive reverberations. Recovery, even when conflict stops, recovery of ecosystems can take at least ten years. And the data and the work that we’ve been doing in the Balkans now, even 20 years later, a lot of the systems in the Balkans, say in Kosovo, have still not recovered.

But resilience in conflict is multifactorial and, again, it’s context specific. This is where the marvellous work that Pat and colleagues in Ukraine led looking at radiotherapy in conflict and drawing some lessons which was published in Lancet Oncology. The first important thing is it depends how resilient the individual countries are. Ukraine’s civilian infrastructure and healthcare system, a lot of it has been protected because of significant air defences against Russian attack. They’ve also been able to rapidly adapt to major issues and major issues particularly, for example, where we saw the destruction of electric infrastructure and we had to put in generators into the country. It talks to a resilience which is inherent and historical.

Ukraine is also an interesting case in point because it reflects what we mean by international buy-in and solidarity. Many countries have come together to help our Ukrainian colleagues but it talks to a much wider ecosystem when it comes to resilience.

Getting away from conflict and thinking more about economy here, I’m going to be honest, a lot of the problems when you look at the bottom 76 countries in the Human Development Index, stem from having very weak political economies. By that I mean political governance systems and also weak health economies and economies generally. This data that Victoria found from the Centre of Global Development pulled together in these bottom 76 countries is really quite sobering. If you look at that bottom red arrow, that’s the percentage of GDP being spent on public health both internally and externally and it’s absolutely flatlining. Indeed, these countries are spending more on interest payments of their debts than they are spending on their healthcare and that’s that grey line.

What that is leading to is gross deficit percentage of GDP just accelerating and climbing. For high income countries that’s not a problem, we can still borrow with AAA ratings. For low- and middle-income countries this is a disaster. This means they cannot procure drugs, they can’t procure equipment like linacs etc. etc. So there’s a lot of fragility as well and a lot of issues really about political economy.

Just to finalise the thoughts here, really, if you step back here what you’re thinking often about is planning within realistic budgets to deliver clinically meaningful changes. I have to say, there is a lot of good data out there that people have worked on, qualitative and quantitative data, insights from the WHO on quality, work from the GCR, for example. Often it’s interesting, it’s not really the ability to prosecute planning, it’s often the problem of actually prioritisation. So designing and implementing essential packages of cancer care is probably one of the most critical things we’re going to need to change over the decade. That is very specific for individual countries and even within countries, when you think of places like Brazil and India which are huge.

We also need to link a lot more of the financing for cancer care and healthcare to accountability. A great deal of money is poured down the drain because it’s simply not linked to improving outcomes.

Finally, and just going right back to the beginning, of course, conflict fragility is creating very new and complex patient pathways. How we structure and organise our care has to adapt to reality rather than some sort of fixed Western model of how patients move. That requires research to inform policy making and it requires research to inform practice.

So with that, Pat, I’ll stop. I think that’s my seven minutes up and I’ll hand back to you. Thank you so much again for inviting me.

Pat Price – Chair of Radiotherapy UK Charity, GCR Co-Founder:

Richard, thank you so much. A round of applause for Richard, that was great. And I know you’ve got to get on. If you want to be there in the background, great, but you’ve got other things to do. But thank you for sharing that. It’s so important, as Richard said, it’s about resilience and particularly with radiotherapy, as in the workers, if your radiotherapy is down for all these other reasons there are massive problems. So great, thank you Richard indeed.

I’d like to invite Dr Lisa Stevens up now. Lisa joined the IAEA, the International Atomic Energy Agency in June 2019. She’s the Director of the Division of the Programme of Actions for Cancer Therapy. Prior to the IAEA she was 24 years at the NCI. Amazing. Basically you then co-founded the International Cancer Control Partnership, which is great. So you’re going to tell us, and thank you so much for sharing your thoughts with us.

Dr Lisa Stevens – Director of Division of Programme of Action for Cancer Therapy, IAEA:

Great, thank you so much. It’s a pleasure to be here, thank you for the invitation. I want to thank the team back in Vienna who support this work and also our partners, WHO and IARC.

So I’m going to try to tell a story in seven minutes to stay to my time. But we know that there is a great inequity in access to cancer treatment. This map is of Africa, the dark blue is the population density, the red dots are the centres, cancer centres. Again, we know that we can do a lot more because 1.2 billion people in Africa do not have access to the cancer care that they need.

What is the IAEA’s role in cancer control? We do have more than six decades supporting our member state countries to build capacity and also procure equipment for radiotherapy, for diagnostic imaging and nuclear medicine. We work closely with UN partners and we do coordinate research and knowledge building within countries.

If we look across the cancer care continuum, and again I want to stress this because while I work at the IAEA and access to nuclear applications is important, it has to be done within the context of the cancer control system. So for early detection, diagnosis and treatment and also palliation of symptoms, radiotherapy, nuclear medicine and diagnostic imaging are important. We work very closely with our WHO and International Agency for Research on Cancer partners, linking into the global initiatives that have been launched by WHO in recent years. I will speak a little bit about the newly launched Rays of Hope initiative by the IAEA.

Again, this is action across the cancer continuum, working with key components of the cancer system, working within the legal and policy framework. So we want to ensure that radiotherapy and imaging is delivered in a safe and secure manner. So that includes nuclear laws and regulatory infrastructure.

One of the ways that we first engage with a country is through a comprehensive assessment of the cancer care capacity. These are so-called imPACT reviews. We do these in partnership with WHO, IARC, other global partners, as well as key stakeholders within a country and international experts. It is this baseline situational analysis. Our hope and our desire is that a country will take these expert recommendations and link them to a national cancer control plan and also link them to a strategic funding document, which I’ll talk a little bit about later.

The recommendations can help facilitate evidence-based decision making and, again, linking and ensuring that radiotherapy, radiation medicine, is well integrated into that comprehensive cancer control system. As I mentioned, we want the recommendations to be translated into strategic documents, including non-communicable disease plans or specific radiotherapy plans. We have a collaborator who will be on the panel from Sri Lanka who works with the agency specifically on a radiotherapy strategy.

With Senegal, one of our Rays of Hope countries, this is a mention from the Ministry of Health that they took the recommendations from the imPACT review to develop baseline and progress tracking.

We knew that we couldn’t do this alone. Back in 2012, with the UN high level meeting and increased emphasis on national cancer control planning, together with the UICC, and when I was at the US National Cancer Institute, we pulled together interested partners from around the globe, some of them are here today, to begin to talk about how we might be able to work together. The initial impetus in this was to share information, so what were people doing? We had several examples where a country would reach out to three different partners for support on developing a national cancer control plan. So we wanted to be efficient, we wanted to provide support to countries and we wanted to find a way to work together.

The partnership also does serve an advocacy role. So taking that 2011 high level UN recommendation and the global action plan on NCDs and talking about the need for countries to develop and implement cancer plans was one of the roles of the ICCP. We have published over the years. In 2018 we did a global analysis with the WHO as a key partner, NCI as well, UICC, and looked at all of the available published plans that we had on our portal. One of the follow-on studies was the radiotherapy that was in 143 of the national cancer control plans. Brooke Wilson led the evaluation of the data and looked at what does it mean when a country prioritises radiotherapy by listing it in the plans. So the Global Task Force for Radiotherapy in Cancer Control wanted there to be 80% of countries having radiotherapy mentioned in cancer plans. At the time of the publication it was about 55% but we did show, through this publication, that when mentioning radiotherapy in a cancer plan it actually correlated with access to radiotherapy.

In 2021 the Director-General of IAEA approached the cancer teams within the IAEA and said, ‘When you ask me to present on  cancer, the statistics aren’t changing. 20 African countries have no access to radiotherapy.' He said, ‘We’re not a talk shop, we need to do something.’ So he asked us to come together and very intentionally collaborate on the agency side, work in partnership with the member states and bring other partners around the table. So expanding to really partner closely with private sector, with NGOs, with the banks, with development agencies to be able to deliver and support member states to either initiate or expand access to radiotherapy.

We are linking Rays of Hope, which was officially launched on World Cancer Day 2022, to the WHO Global Initiatives. So it’s a very technical aspect of the entire cancer care continuum but we work very closely with our partners.

The cancer plans really do play a foundational role. We have an assessment role to play, understanding what those needs and gaps are. In two years we had many countries, particularly due to the pandemic and support that we could provide remotely, that requested NCCP support. The countries that are aligned to Rays of Hope have a red star there, so you see that they see it as one of the ways to begin to engage and to begin to identify the gap areas.

So when the Director-General asked us to have a more comprehensive approach, we started in many cases with either the impact assessment or other economic or socioeconomic evaluations. We wanted to link in capacity building and procurement efforts to ensure that if a machine was needed that there were the appropriately trained staff, that there was safety and security infrastructure as well, that this was quality assured treatment. It wasn’t just the delivery of one piece of equipment but it was well integrated into quality assurance services and that there was the plan for sustainability. One of the ways that we’re looking to achieve sustainability is through the regional anchor centres. We also support research and development and then, again, this expanded focus on partnership and innovative financing strategies.

The regional anchor centres, which five were just launched, the first five, in September, are meant to provide advanced clinical services, be a focal point for regional education and training activities and continuous professional development. They can provide experts for quality assurance missions and support not only within their own institution but innovation and research within the region.

A few examples – Kenya is one of the first wave countries in Rays of Hope. We launched with six initial countries and Kenya was really looking to expand their access. They had solid radiotherapy in the capital and in a few other centres and were looking to expand to other provinces within Kenya. Burundi also has aligned to Rays of Hope and, again, Burundi will use its bankable document hopefully to find partner support to open its first radiotherapy centre with our assistance.

So, really in a nutshell, a cancer plan is important. It’s a foundational document that radiotherapy should be well integrated into the cancer care system. It’s not just a machine or the provision of people. Rays of Hope is that cooperative, holistic approach from the agency side, using normative guidance that has been developed through both WHO and IAEA partnership. We want to build on the expertise and the experience of IAEA. We want to engage closely with the countries and link to their national cancer control efforts. So there you go.

Pat Price – Chair of Radiotherapy UK Charity, GCR Co-Founder:

Lisa, that’s absolutely brilliant and it shows such a lot of great work, to have had that leadership, to lead in all those cancers and then a practical way forward in a lot of the… And I loved your data about how that if you integrate radiotherapy within a cancer control plan you increase access to radiotherapy. Logical but important to know. So thank you so much.

So I’m just going to say a few words now. What I’m going to say is introduce, really, then to introduce our panel, to say what we’ve been doing and what this session is about now. So working from the work that Lisa’s done and conscious of the work that Richard’s done in terms of cancer plans have to be then resilient, is to what do we need in the essence for radiotherapy in a cancer plan. To really think about what is our minimal standards and what is perhaps standards elsewhere and what we can do. And that’s getting everybody together. So if I can just have my slides now.

So how did we go about this? We’ve done this quite fast. So, start of all, we knew that many cancer plans were outdated. We heard from Cancer City Challenge often it’s a technical note at the end, along with the CT scanners sort of thing. So really, as radiotherapy is needed in about 50-60% of cancer patients and in 40% of cures, we absolutely need it in there.

So we really gathered our multidisciplinary stakeholders really to create a framework for key components and what this would look like. Then we got some expert panels together, looked at five components and defined working groups that then could work online to focus on what these were essentials. Finally we did some group presentations, and this is all virtual and all volunteering online, working groups, so presentations. We then added in the newer technical things like adding in AI, global health systems and then communications with Ministries of Health and governments. So that’s how we’ve approached it.

What are the areas we’re looking at? Training and technical support; quality and safety; maintenance and service. These are all our geeky radiotherapy things. Advocacy, to make sure people know that we need this and advocacy at the right levels in governments. Also data and monitoring because we’re all about value-based care and making sure we know what we’re doing and implementation science and all those things we need to do. Don’t just stick the machine there and hope for the best, we want to improve cancer outcomes. So this is all the components.

We thought we’d then do some piloting as well. As we’re doing this, the workshops and everything will be progressed online soon and then we hope to do another major launch next February as we get more ideas in and develop this soft launch today. We piloted in the UK using this on the basis of what would be a UK document for a vision for radiotherapy. At the same time we’re conscious that we had the Moonshot 2.0 happening; we know at ECO tomorrow they’ve got the European Cancer Manifesto out there and we know the Australians have just launched their cancer plan. So really we’re saying that it’s time for radiotherapy to have a big part in these cancer plans.

Tomorrow we’re launching at the House of Commons a… the UK has had its moments about whether we’ve got a cancer plan, so we’re saying this is a good cancer plan. Twelve of us from universities and university hospitals, as well as the charity, have got together about what does this look like for the UK. Within there the radiotherapy section is based on these essential cancer plans. So this is what we’re trying to do and how we’re going to get there.

So I was thinking now, I think that’s my last slide and I think now if I can invite the panel up so that we can talk through about what we’ve got so far and have some discussion and then get everybody else to join in because we’re still collecting all this information. So perhaps I could have our lovely panel up.  We have two online, which is lovely.

So you have in your literature there information about everybody. We’ve got Michelle Leech who is from St James Cancer Institute, come from Dublin today. The profession of radiation therapy does a lot about education. We’ve got Mary Coffey, again from Trinity College, both have come from Dublin today, thank you very much. We’ve got Sarah Quinlan who is the director of the UK charity who is leading on the pilot study for this. We’ve got Caroline Leksell, lovely, from the Board of Elekta who has got a big background in digital technology. And joining us online, thank you for being here, we were hoping you were going to come today but we just failed at the last minute but it’s so lovely to have you online, thank you. So we’ve got Dr Kofi from Ghana, lovely to have you again. We’ve had some great work with you. And Dr Janaki from Sri Lanka’s Ministry of Health. So thank you very much indeed.

So this is our group. Okay, let’s get this going now. Michelle, I’m going to start with you, put you on the spot. We’ve got our microphones and everything here. So education and the workforce gap. There is a workforce gap everywhere, particularly in radiotherapy but it’s a small workforce, isn’t it. I know in the UK we only have 6,500 people in the whole workforce treating over 100,000 patients a year. But this is the challenge all over the world and I know you’ve got great experience and also you’ve shocked me about how there’s been quite a variation. So tell us what we should be doing and how we should be advocating to really start at that basic.

Michelle Leech – Trinity St James Cancer Institute:

Thanks Pat. It’s hard to shock you, I think, so I’m not happy that I shocked you with this. But one of the things in our group that came up that’s really important is forward planning. So if you’re going to start a radiotherapy centre or you’re expanding a radiotherapy centre, unfortunately what is often the case is that workforce planning comes later. It can be very technically focussed – let’s get the equipment, let’s get the machines – but then there’s no forward planning as to who is actually going to be running the machines. I suppose what has shocked you, Pat, is the quality of education of those professionals who are going to be actually delivering the care.

As you know, I’m a radiation therapist, I’m aware we’re in the UK today so of course people are called therapeutic radiographers in this country but the global name is radiation therapist. In our profession the variation in quality of education is immense, there’s no other word for it. So it can range from very high quality degree programmes to people who essentially more or less come from school and essentially start treating patients. So we have this massive gap and we don’t necessarily have to go that far, I would say, in Europe to see some of these large spectrums of education.

So for the essential standards what we were putting forward is that, first of all, there has to be a recognition in cancer control plans that workforce planning, you can never start too early to start educating the people who are going to be your workforce for radiotherapy. Second of all, there has to be be a recognition that radiation therapy education is specific. Radiation therapy specific education. It’s not a jack of all trades. If someone is coming for treatment you want someone who is a real expert in that field treating them. So a recognition that radiation oncology professionals are experts, need expert education, is the most important.

Then, of course, actually putting the resources into that. So resourcing education of professionals. For us, they were the three in our essential standards, three major issues. In a lot of countries across the world there isn’t a recognition, unfortunately, by Ministries of Health and Education about radiation oncology professionals and probably specifically radiation therapists, to be honest. So they’re the three hallmarks of our contribution, or our group’s contribution, to the essential standards document.

Pat Price – Chair of Radiotherapy UK Charity, GCR Co-Founder:

Absolutely brilliant. And it’s also important because we don’t want everybody… We want to be able to jump ahead, we don’t want to start at the bottom. So this is a highly technical… and if we can harness that technicality, this is important. So, Lisa, why are we not getting the message through? Why is further down…? Or is it we only get as far as radiotherapy – yes. But, no, we’ve got to actually go, ‘Yes, and that means this and this means that.’ How can we break this barrier because this is an exciting area, really. Technical radiotherapy and it can be now taught remotely, there are also lots of tricks. What’s the barrier?

Dr Lisa Stevens – Director of Division of Programme of Action for Cancer Therapy, IAEA:

Well, having the right people around the table. So oftentimes in these assessments a team will present to the Minister of Education because, in addition to RTTs, also medical physics in many countries is not a recognised profession. There’s a huge gap in the availability of medical physicists, especially in Africa, but I’m sure in other parts of the world as well. So it’s education, it’s Ministries of Health, Ministries of Finance, Ministries of Planning if it’s actually a physical building that needs to be built in order to house the hospital or the bunker for the machines. So it’s making sure that all of those individuals are involved in the conversation.

Pat Price – Chair of Radiotherapy UK Charity, GCR Co-Founder:

And I think that’s the problem with radiotherapy, it’s so multidisciplinary, but the trouble is it means it’s everywhere as well. So that’s a really big message. So almost you would want somebody, we were just discussing earlier about the UK, whether it’s cancer affecting one in two people, this probably should be a Prime Minister responsibility, cross cutting, not keep lowering it down because then they don’t have access to the other things. Michelle, should we more formally introduce some standards? What’s that balance between nudging and actually saying, ‘This is…’ Because the machines have to reach a certain standard – you’ve got to have your CE mark, they’ve got to do the biz. What’s that balance?

Michelle Leech – Trinity St James Cancer Institute:

It’s difficult to say what the balance is. What we, and I can say we because Mary is beside me, Mary’s here talking about something else, but what we’ve been doing for many years is trying at different levels. Trying from the top down, so from the ministries, as Lisa spoke about there, but also starting from the bottom up. So trying to empower radiation oncology professionals on the ground themselves. Who, I can tell you, will very clearly say in certain areas, ‘My education is really low and I should not be working here,’ more or less – at that level. Trying to empower them to take ownership and take control of their own education, identifying gaps.

We’ve run a project that Mary initiated, we were trying to remember how many years ago now, 12 or 13 years ago now, between the IAEA and ESTRO – a train the trainers programme in radiation therapy. That has empowered radiation therapists to basically take control of their own education. It’s been quite successful, we have three countries in Eastern Europe now who have their own programmes that didn’t happen before. Numerous professional societies, a conglomerate of societies that have come together in that region.

So, for me, then what is the standard? The standard is there has to be some radiation therapy specific education on basic topics so that people understand basic principles, basic radiation. Understand what happens when you irradiate a patient, what happens when… I know that sounds really basic but you’d be amazed at how difficult that can actually be in some regions to have taught. So that people understand that when they irradiate someone what’s happening and also how they can problem solve. Because you can’t problem solve unless you have the basics. So basics of radiotherapy, if we got that globally that would be a massive achievement.

Pat Price – Chair of Radiotherapy UK Charity, GCR Co-Founder:

Yes, and as you say, collectively pushing from them as well. I feel embarrassed, perhaps we underestimate how important radiation technologies are really. I remember some of the UK girls saying that in COVID by the time patients come to see them sometimes it was the first person in healthcare that they actually saw when they started their radiation. It’s so important. And a great profession.

Michelle Leech – Trinity St James Cancer Institute:

Absolutely. We’re huge advocates for radiation therapists. But, as you said, during COVID radiation therapists could not work from home, they were frontline the whole time. Actually the thing when it comes to… and I know Mary will speak about quality and safety of radiotherapy, but the buck stops with us at the end of the day. It doesn’t matter how good your prescription is, how good your volumes are, how good everything else is, how good the machine is performing, if there is an issue on the unit that’s the therapist’s responsibility. Yes, we don’t pay sufficient attention to education of radiation oncology professionals; it’s really oxymoronic when you say it out loud but that’s what we’re dealing with globally.

Pat Price – Chair of Radiotherapy UK Charity, GCR Co-Founder:

Yes, and yet interesting, you’ve got the capacity with an industry, I know, joining in. It’s there. It’s about telling the people we actually need it and putting it there, that’s really important. Mary, I’m going to pick on you next. Quality assurance and safety, which is merging, it is a similar sort of thing going from machines to technology. How can quality assurance measures be clearly communicated so that we know that when we’ve got critical safety and efficiency of radiotherapy treatment? Because it is really important, isn’t it? So tell us your thinking on that.

Mary Coffey – Trinity College:

Following on from Michelle, I’ve participated in a lot of clinical audits for the IAEA. It’s absolutely true, we live in a kind of world where we pretend that radiotherapy is very safe and very well delivered. Actually it’s very complex and in many, many countries it’s really badly delivered. So we’re actually doing a disservice to patients and you can’t blame the people on the ground because if you don’t understand the danger and the damage you can do to people by administering it incorrectly, then you don’t have any idea that you’re doing it incorrectly.

So when you think of it in that terms then what’s really important is that there are national standards developed and they are standards that include quality and safe care. Obviously education is key to it but it also is things like where you position your radiotherapy centre. Have you done the demographics, do you know where the greatest needs are? Do you know where all your other support services are? Because you can’t just have radiotherapy sitting alone anymore. So is everything else in place that allows delivery of radiotherapy safely in the context of cancer medicine?

This thing of putting in a cobalt machine or a linear accelerator, you must always have them paired because once one breaks down where do you send your patients? How do you link nationally with all the other centres? Have you got a system of clinical audit in place so that you regularly monitor and follow up what is happening in the department? Do you have an actual incident reporting system that is a learning system? The report is really irrelevant, it’s only a tool. What do you learn from the report, how do you use that to inform change and improvement?

They’re only the starting points. Does your cancer registry, for instance, allow you to analyse the radiotherapy treatment that was given and whether it was effective, whether it was the correct treatment? Or do we just have, ‘Well, they had radiotherapy for stage 2 breast cancer,’ and they survived or they didn’t. But what was the technique used? What was the dose, what was the fractionation? Did it make a difference? So you can really begin to analyse and say, ‘Well, how should treatment be delivered effectively?’

Then how do you monitor that? Because often the focus is to get the equipment in place and then after that they think about who might run it. But often quality and safety then is an expense that’s considered additional and maybe not necessary so how do you ensure that your national legislation insists on quality and safe standards and insists on the implementation of all these strands?

Pat Price – Chair of Radiotherapy UK Charity, GCR Co-Founder:

That’s such an important point. And I was just thinking, Caroline, from industry’s point of view, how can they probably help. Because I’m conscious, I know the UK system, we can get some data straight off the machines directly in our radiotherapy datasets and that’s great as in that you don’t have to do anything, it does it for you. It’s got better now, even coding of palliative radical techniques and whatever. I was thinking, Caroline, this is a technology. Is there any way that we can think about having that sort of… to help? I’m going to come to Lisa now but I’m sure there are massive variations. But how can industry help in terms of that way of helping along that line of collecting data?

Caroline Leksell Cooke – Elekta:

I was thinking around the same lines, actually, because when you were talking. I think, first of all, as an industry we have the machines, we want to ensure that we are as efficient as possible, that we innovate, that we invest in our products to make your lives easier. Efficiency is a key narrative from an industry perspective. The things we are doing there is basically targeting, innovating, around the machines. So a lot of big themes at the moment within the industry is adaptive planning and obviously automatic planning, remote planning for easier access, faster access to plans.

We also talk a lot around hypofractionation to make the actual treatments quicker for the patient, to make sure that the patient actually doesn’t need to be there for so long and do these treatments for that long. Because imagine, the patient might have to travel with their family for weeks, stay at a hotel, it’s not sustainable. So these are the two key things we’re working on.

But then what you said around benchmarks and how do you define a really good treatment? How do you link that data up to a much higher level? Pat, I know you’ve been using ProKnow and the NHS is using ProKnow a lot, it’s one of the software we have that is vendor agnostic, first of all, which I think is amazing because it helps you benchmark what a good treatment looks like, not only within the clinic but also in a country or cross country, cross nations.

I think that’s a fantastic platform to really understand what good looks like and, from an educational perspective as well, share what good looks like and where training is needed, to your point, Michelle. So from that perspective how software really can enable those efficiency analyses is key for us as an industry perspective, both for the customers, for the patients but also nation-wise, for these standards to have some ground and data to rely on on what good looks like.

Pat Price – Chair of Radiotherapy UK Charity, GCR Co-Founder:

That’s very important because I was also conscious last night at the meetings, thinking about what we learned from the Ukrainian situation in terms of knowing what was going on. Because the industry, Varian and Elekta, yourselves, knew immediately from their data remotely what was going on at the centres. So when the UN wanted to know what was going on, that was the best source of information. We heard from Dr Vulpe last night when they did the Blue Heron and they got some patients out to treat them in Moldova, again a lot of it was using remote systems, IT, getting plans up, all this type of thing.

So in some ways we’re a speciality that is entrenched with all this technology. So I was hoping if we can work it through, that may get halfway to what you need. Does that seem so? But I’m thinking, Lisa, you’re probably going to tell us now we’re an awful long way away from that in lots of things, yes?

Dr Lisa Stevens – Director of Division of Programme of Action for Cancer Therapy, IAEA:

I’m going to repeat the refrain: more data is needed. And that’s why innovation is such a key component of the Rays of Hope initiative, not only in the national centres and how to collect that data and how to aggregate that data so we can look at trends across and treatment patterns, but within the anchor centres, those are meant to be regional leaders in terms of data collection and research on best practices. I would call it implementation science so that you’re applying what is used and then studying the best way forward.

Pat Price – Chair of Radiotherapy UK Charity, GCR Co-Founder:

Is there any way we should be doing some of this absolutely internationally? Because if nationally some people are collecting, it’s a bit like a meta-analysis of pfoof. But that would need [?] the Americans to do it.

Dr Lisa Stevens – Director of Division of Programme of Action for Cancer Therapy, IAEA:

There’s a lot of talk from the technical teams about an über-dataset and being able to pull information from the centres across multiple countries and collect that.

Pat Price – Chair of Radiotherapy UK Charity, GCR Co-Founder:

So the next question here is… So this is all whizzy, this is great, so why aren’t we attracting… You hear about Microsoft and Google, they want to do these great things in healthcare science. We’re sitting on something like radiotherapy that has got so much data and we’re so mature in our data [?] other things, why aren’t we able to attract those to do some work with us on this type of thing to really innovate? Because ProKnow, to think you’ve got it in the cloud, then look at your plans and compare. So, Lisa, again, have we ever approached these people to say, ‘Come on, next step now. Come on, you’re ahead of us’?

Dr Lisa Stevens – Director of Division of Programme of Action for Cancer Therapy, IAEA:

I think in this instance maybe if we went together with multiple… So that we say, ‘We’re working together,’ there’s not a single entity that holds the solution with one of these large data companies.

Pat Price – Chair of Radiotherapy UK Charity, GCR Co-Founder:

Because they would love it, wouldn’t they? They could do such a lot.

Caroline Leksell Cooke – Elekta:

They would love it; I think they really would love it. The challenge with them is to sustain a project and keep it going. So you have to be a big force, Lisa, like you’re saying, we have to be a big force coming together and really stand our ground saying why it’s important and then they would probably do it. But coming as one player, doing it is a challenge.

Pat Price – Chair of Radiotherapy UK Charity, GCR Co-Founder:

Okay, we will be a big force then. I remember, one in two people will get cancer and 50% need radiotherapy – that’s a quarter of the population in the world need us. So we’re a big force. Right, okay, we’ll put that on the shopping list, things to do. Sorry, Mary, carry on, yes.

Mary Coffey – Trinity College:

I often think radiotherapy is really so below the radar. That’s one of the biggest problems. Every single time there’s a new drug, and even if you drill down in the statistics it has a minute impact, it’s on everybody’s radar. But radiotherapy you virtually never hear about, even though on the ground most people know what it is. But it’s really down there somewhere.

Pat Price – Chair of Radiotherapy UK Charity, GCR Co-Founder:

Yes, and it’s difficult, isn’t it? Because we’re nice people, we don’t want to dish our colleagues giving out drugs but at the same time I’m trying to persuade and working with our NICE to see if they can do a comparison of radiotherapy with these drugs. But I remember the days, years ago, years ago, probably about 30 years ago when a drug, we won’t mention it, came into metastatic pancreatic cancer, it was four weeks improvement in symptom control. And I’ve seen now a lot of… Some of the immunotherapy is amazing, let’s be honest, transformative, but some as second and third line for n-stage disease that’s two or three weeks’ survival then perhaps some radiotherapy.

But at the same time we know why that’s there, they have budgets bigger than the whole of radiotherapy just to push drugs. So that’s okay. But I think that needs a narrative about… it’s a bit like AJ was talking last night – if you have competition it doesn’t always improve the quality in the right thing, it sometimes gets a bit distorted. So we need our colleagues in drug development and we need them. I think we’ve only just scratched the surface of immunotherapy and radiotherapy interaction - whooh, we're going to be great! But at the same time we’ve got to get a balance in there somewhere. No, you’re absolutely… Which actually leads me nicely on to Sarah about advocacy and why is radiotherapy so neglected and Cinderella-ed and what are we going to do about it? No pressure.

Sarah Quinlan – Radiotherapy UK:

The conversation so far has been really reflective of within advocacy and radiotherapy. Radiotherapy does not have the big pockets of pharma so it doesn’t have the exposure, it doesn’t have the long experience and history of the clinical trials which are showing those incremental improvements. So we need to be really, really smart about how we advocate.

Whenever I think about… the key word that I’ve heard a lot about today is collaboration. It’s about people coming together to advocate and that’s what makes us stronger. The strategies that I would think about whenever I advocate, and to be smart about this, is to think about, first of all, planning. It’s about really knowing your area, knowing everything in terms of your own analysis, what the other research says, and also speaking to patients, speaking to the frontline workforce, speaking to the professional bodies and industry as well. That’s where we create the first ‘This is the issue’ because countries will have different issues impacting on them.

Once you know your issue then you need to know your solution. We cannot advocate with a problem, we have to advocate with a solution. So knowing the solution is so key. Again, once you know your solution you need to know who can influence that and what’s that part again? What ministry is going to? Whether it’s planning, whether it’s health, whether it’s education.

One of the things that we would love to see is in Northern Ireland, where I’m from, they had a Children’s Bill which meant that every department had to think about children when it came to it. What we would love to see would be something similar for cancer where every department has to consider this as opposed to it being a health issue. The way to do that, again, is putting it in front of the Prime Minister or the head of that country to say, ‘This is your problem. One in two of us will get cancer, what are we going to do about it across all departments?’ And stop really siloing it because whenever we silo it we do not get…

In the UK especially, what we’re seeing is when we silo it we have a focus on one area – early diagnosis. We would need a similar focus on early treatment to actually improve patient outcomes. So whenever we approach it in the whole there’s a much better chance of actually improving patient outcomes. And we advocate to do that, we don’t really advocate for radiotherapy but we know that radiotherapy can improve patient outcomes. Whenever that’s our starting point it all follows through.

So I would say definitely the plan, the connection, making all the connections. I absolutely love being here today because I’m getting to meet so many people and make connections and it’s so important. I always think about it in groups is group one which is the people in the room, the industry. Then we have the patients that we want to speak to, we have the frontline workforce, the professional bodies, everybody who is involved in this. Then we look at our decision makers and then we look at how we amplify this and that is through the media. That is potentially through your professional organisations but we need to bring people onside and we need a story and we need a narrative that people can really easily communicate.

So within that, it brings me to my third one which will be communication – key messages. Radiotherapy is complex and I’ve been involved now with radiotherapy for nearly two years and whenever I started I was like, ‘Oh my goodness, there are so many acronyms. What does all this mean?’ And it took me a while to work my way through it. We need to simplify it, we need to bring it back to what it can do and what the benefits are to the patient.

I also think that we need to be really agile. It is a competitive market out there so whenever you’re really tight on what your key messages are, everybody has the same aim as well and that’s interesting when you talk about collaboration because then everybody in the room has to have the same endpoint, the same aim, because that’s how we actually move forward. Once you have that together you do have a really strong basis for advocacy and we take advantage of the fact that we’re smaller than pharma. We take advantage of the fact that we are agile, we can move. We mightn’t have the resources but whenever something happens in the news you will quite often, about radiotherapy or cancer, Professor Pat Price will be able to respond because we move quickly and we know what we want to say. That has all been worked out and it’s planning, it’s connecting with people and it’s communicating it well.

Pat Price – Chair of Radiotherapy UK Charity, GCR Co-Founder:

Great thoughts. You’re saying there also about the importance of patients. We were talking earlier on, weren’t we. It’s about in some ways, as you say, in the UK what is it? It’s media and patients and whether patients can be mobilised internationally in groups as well. A harder ask, I must say, as well.

Sometimes I think radiation therapists, we’re all a bit too nice, aren’t we? And I think that doesn’t do us any service. We’ve perhaps, as you say, got to be really focussed and do it. But, again, if we open this up and collaborate the voice can be louder. But that’s why it’s on our materials and things, we’ve got an advocacy toolkit as well. We mustn’t neglect advocacy because, as you say, Lisa, unless we’re at the table we’re going to be a footnote. Sorry, tell us.

Michelle Leech – Trinity St James Cancer Institute:

I’ll just bring people’s attention to it, I’m sure you know Sarah, the Australian advocacy group Targeting Cancer. That’s an amazing example of patients telling their stories and actually reaching out to the public and saying, ‘I had radiotherapy. This is me as a person. Now I can do this with, whatever, my children, my grandchildren.’ Making it really human. So if anyone hasn’t seen that website I would definitely look at it. I think it’s a really shining example to all of us about how to do it. So it’s called Targeting Cancer, it’s the Australian advocacy group for radiotherapy.  Sorry.

Pat Price – Chair of Radiotherapy UK Charity, GCR Co-Founder:

Thank you. No, very important and we must all remember that. So, Caroline, can I bring you in now? So in terms of treatment planning and customising from an industry’s point of view, give us some insight into why you think it’s important that we go for the latest technology and techniques. There is a thinking of start from the basics but it’s interesting the work we did in Ukraine about the cobalt. Because obviously starting there, one thing we found in the Ukraine situation, a lot of cobalts and, of course, when you decommission cobalt you have to send them back to where they came from. Where do they all come from? Russia. Bit of a thorny issue there. There was also the issue of bombing them and that type of thing. So there are a lot of things to do.

But I know a lot of thinking has been… because technology has whizzed on so much, gosh, I’m so old, I have hand planned in my day. Now you think of all the adaptive stuff but we must get to the top, shouldn’t we? We mustn’t start and get everybody to incrementally go up. So tell us, what’s your thinking about all this?

Caroline Leksell Cooke – Elekta:

It’s a very big question and it starts with the needs of our patients. I talked a little bit about that before but I also do think it boils down to the knowledge of our customers as well and the readiness of our customers. When I think about access from an industry perspective, I very much think about the best access for everyone. It’s about the equity angle.

To your point, Pat, if we can give, as an industry, the best access to more than 50% of those that need therapy, that’s a huge goal in itself. So, by starting there, I can then tell you what our perspective is. So from an innovative perspective, or a research and development perspective, you have to think about the readiness of the market. The readiness of the market, like where are we? When we look at imaging I still… I’m from Sweden, I’m Swedish, and there are key hospitals in Sweden that use radiotherapy with really low imaging. So where do you set the bar? And we talked about that a lot here and I’m wondering, when it comes to accuracy and best access, accuracy is really important. It goes back to how the patients and their quality of life will be afterwards.

So we think a lot about patient customers and the readiness of the market. It doesn’t really matter where you are – UK, Sweden or in Africa – you need to have access to the best treatment. So that’s number one.

Number two is when it comes to planning and when it comes to best in class and benchmarking, data is our key enablement for that. From that perspective the big question that comes up is, again, how ready are we as an industry to share our data, to collaborate around data and the restrictions around that? So that goes back to the readiness of the market. So it’s a really broad question and it depends, but from an industry perspective where we are, it goes back to really giving the best access to everyone.

From a planning perspective, was that your question? Yes, planning. From a planning perspective, if we can enable best in class remote planning, for example,