Radiotherapy dataset (RTDS) COVID-19 Dashboard
A guide to what data is shared in the dashboard and the details of the data items within it
This dashboard aims to provide an overview of radiotherapy that has been delivered during the COVID-19 pandemic using the Radiotherapy Dataset. The intended audience is anyone with an interest in how anti-cancer therapies therapy has been impacted during the COVID-19 pandemic. Other interested audiences include those planning cancer services and those campaigning for cancer patients. The data may also help to highlight areas of particular concern, to direct future research activities.
This data should not be used as a performance metric to compare activity between services. In addition to the
numerous clinical factors which typically inform a treatment decision, clinicians will also have to consider
issues such as staffing shortages at their trust, as well as the patient's socio-demographic characteristics.
Therefore, this data is not suitable for making straightforward 'like for like' comparison between cancer alliances etc.
What's in the dashboard
What data is included?
Patients - the report includes all adult patients aged 18+.
Activity period - the report covers activity from March 2019 to July 2020 inclusive.
Update frequency - the report will be updated monthly to include newly submitted data.
This current vesion contains data that was updated on November 23rd, 2020.
How are the counts calculated?
RTDS activity is defined as a count of unique treatment episodes. A treatment episode is defined as a continuous period of care for radiotherapy including all preparation, planning and delivery of radiotherapy. If that continuous period of care crosses multiple months the treatment activity will be recorded in the month that episode began. Patients treated in more than one trust or for more than one tumour may be counted twice, as such a person undergoing radiotherapy treatment may, infrequently, have more than one episode recorded.
What other data items are used?
Geography: All England and cancer alliance are based on the treating region/trust where the treatment began.
Tumour group: based on the patient tumour group category and is derived from the clinical assigned code from the ICD10 coding system,
- Anus (C21)
- Bladder (C67)
- Brain (C70-C71, D32-D33)
- Breast (C50, D05)
- Cervix (C53)
- Head and neck (C00-C14, C30-C32)
- Lung (C33, C34)
- Lymphoma (C81-C82)
- Oesophagus (C15)
- Prostate (C61)
- Rectal (C20)
- Skin (C43)
Note: for specific cancer alliance breakdowns only Breast, Lung and Prostate cancer data will display to avoid disclosing small number counts that might represent a privacy risk.
Age group: based on the patient's age at the start of the episode,
- >40
- 40-49
- 50-59
- 60-69
- 70-79
- 80+
Note: for specific cancer alliance breakdowns >40 and 40-49 are combined to >50 age group to avoid disclosing small number counts that might represent a privacy risk.
Fractionation categories: based on the planned fractionation of each episode (where the total dose of radiation is divided into several, smaller doses over a period of several days),
- less than 2Gy per fraction
- standard fractionation ( 2.0Gy - 2.49Gy per fraction )
- mild-moderate hypofractionation ( 2.5Gy - 4.99Gy per fraction )
- ultra-high hypofractionation ( 5Gy or greater per fraction )
- other/non-curative fractionation
Note: these dose and fractionation schedules have been compared to the guidance provided by the Royal College of Radiologists for radiotherapy treatments occurring during Covid 19, in addition to the standard radiotherapy dose fractionation 3rd edition guidance produced by the RCR. This new guidance can be found at RCR Guidance
Intent of treatment: based on a clinical assigned intent of treatment,
- Curative (Radical)
- Palliative
- Other
Episode count: is a count of episodes starting in that month.
Using the dashboard
How do I adjust the dashboard?
Dashboard filters are found in the sidebar to the left of the main panel. These filters offer selection on the geography of interest, measure of activity, tumour group, age group, intent of treatment, and fractionation categories. Adjusting these filters will change the data in all charts and tables in the Dashboard. Please use the filters to tailor the charts to your needs, but note, not all combinations will be available.
There are 4 tabs found at the top of the main panel, beneath the banner, this guidance text is in the first tab. The second tab offers an overview of the trends seen in the data and additional context. The third and fourth tabs are where you will find the graphs and data tables which should dynamically change based on your selections in the side bar.
Can I download the data?
The data is available for download through the download data button found at the bottom of the side bar.
Data Quality Notes
Please note: As a result of the normal submission schedule, NHS trusts' data appear in this dashboard months after the activity occurred. For example, a dashboard created in November would include complete activity up to the end of July. Some trusts may be ahead of schedule and others may have late submissions. Therefore, not all trusts will have data for all of the activity months. Trust level data is not presented here, the data is aggregated to National and Cancer Alliance levels, however this note is still important as trust data underlys this dataset.
Feedback
It is important that these reports are dynamic. We aim to continue to adapt and improve them to meet the user needs. As such, it would be very helpful for us if you were able to send any feedback, positive or negative, to the RTDS Helpdesk at RTDS.helpdesk@nhs.net
Use of Patient Data
Public Health England (PHE) has been granted specific legal permission to collect information about patients with cancer for specific purposes including health improvement and service provision. Permission was granted to PHE through Section 251 of the NHS Act 2006. This support is reviewed annually by the Confidentiality Advisory Group of the Health Research Authority. PHE releases are subject to strict confidentiality provisions in line with the requirements of the Common Law Duty of Confidentiality, the General Data Protection Regulation (EU) 2016/679 and the 7 Caldicott principles.
PHE are mandated to collect all radiotherapy activity data delivered within NHS trusts. Please note there may be a small amount of private patient data included in these figures.
Theses services and functions are carried out at the National Disease Registration Service, a part of PHE.
For enquiries on this or general enquiries to the National Disease Registration Service contact NCRASenquires@phe.gov.uk
A guide to radiotherapy activity data trends with context and potential causes
This dashboard provides a suite of metrics of RTDS activity relevant to the COVID-19 pandemic. The intended audience is anyone with an interest in how anti-cancer therapies therapy has been impacted during the COVID-19 pandemic. Other interested audiences include those planning cancer services and those campaigning for cancer patients. The data may also help to highlight areas of particular concern, to direct future research activities.
This data should not be used as a performance metric to compare activity between cancer alliances. In addition to the numerous clinical factors which typically inform a treatment decision, clinicians will also have to consider issues such as staffing shortages, as well as the patient's socio-demographic characteristics. Therefore there is no straightforward 'like for like' comparison between geographies.
Many thanks to the clinicians who supported this project.
Data trends in reported Radiotherapy Activity 2019 vs. 2020
Trends in overall activity:
- The number of episodes of radiotherapy recorded in the RTDS in the pre-COVID-19 period, up to March 2020, varied between 8,000-10,000 episodes per month.
- For April 2020 onwards, the number of episodes of radiotherapy recorded per month decreased compared to the pre-COVID-19 counts. It decreased to around 8,000 per month in the period Apr to July 2020, down to 86% of the pre-COVID-19 monthly average for the same period in 2019.
- The cancer sites with the biggest initial reduction in activity compared to pre-COVID-19 numbers were prostate cancer (35% for April, 50% for May) and skin cancer (29% for April and 43% for May). Both sites recovered in June and July, prostate to 98-108% of the previous year's figures and skin to 79-83%.
- In comparison, anal cancer and rectal cancer had the biggest reductions in activity in June and July after initially maintaining previous levels.
- Activity was maintained above 90% of previous levels for breast, lung and oesophagus cancer in April, May and June (all stayed in the range of 90% - 119% of previous years activity). In July activity dropped compared to previous year's levels for each these three cancer types, to 78%, 86%, and 78% respectively.
Other patterns in the data worth noting:
- In a number of cancer types new clinical guidance from the Royal College of Radiologists, NICE, NHS England and NHS Improvement had recommended changes in dose and fractionation in consideration of COVID-19; this will show in the data as a decrease in one fractionation plan alongside a rise in another.
- In particular trusts responded extremely quickly to new guidance on breast treatments, moving from mild-moderate hypofractionation to ultra-high hypofractionation [1,2]. Up to February 2020, over 2,200 radiotherapy episodes for breast cancer were mild-moderate hypofractionation with less than 100 episodes of ultra-high hypofractionation. In April 2020, mild-moderate fractionation for breast cancer had reduced to around 990 episodes with more than 1,500 episodes of ultra-high fractionation. This move to ultra-high fractionation in turn reduced the number of times patients came into hospital and released capacity for further treatments to be available.
- In other cancer sites radiotherapy, may have risen as it was adopted in preference to other treatment options such as surgery. This may explain the pattern of bladder cancer radiotherapy activity which increased to 167% of previous levels in May.
What's the context of these trends?
The RTDS data presented here cannot directly address the cause of the reduction it describes. Decreases in the number of people being diagnosed with cancer, changes in the number of patients seeking treatment, and/or any delays to the start of cancer treatments are likely to affect overall radiotherapy activity levels, as well as a range of clinical factors. Some potential impacting factors are detailed below..
Changes to diagnosis rates:
- The number of patients diagnosed with cancer is likely affected by additional pressures on imaging capacity or endoscopy due to increased use related to COVID-19 or reduced overall capacity resulting from additional infection control measures, for example particularly due to the potential aerosol generation from endoscopy procedures [3, 4].
- The number of new diagnoses will be affected by changes in patient behaviour, with fewer people thought to be reporting possible cancer symptoms. Decreases were seen during the initial lockdown period in the numbers of GP appointments [5] and of people urgently referred for suspected cancer [5,6]. With people encouraged to continue reporting worrying symptoms to their doctor and doctors encouraged to refer patients as usual [7], the number of referrals increased over subsequent periods although remaining lower than usual for several months [8].
- For breast, colorectal and cervical cancers, the number of new cancer diagnoses will be affected by a reduction in screening activity, particularly during the initial peak of the COVID-19 pandemic and with the return to normal levels taking a varying amount of time.
Changes to treatment patterns and prioritisation:
- National guidelines were published to inform the provision of systemic anti-cancer [9] and radiotherapy treatments [10] during the COVID-19 pandemic, on the basis of evidence available at the time, to protect patients and staff from COVID-19 infection or risk and to manage capacity.
- National guidance provided advice on the prioritisation of surgical procedures for a range of disease areas, including cancer procedures, with possible timescales relating to the prioritisation [11].
- A variety of tumour group or specialism related guidelines [1, 2] were produced to recommend ways of working, priorities or alternative treatment plans during the COVID-19 pandemic, for example to delay high-risk surgical procedures and increase neoadjuvant treatment.
- Cancer Alliances and providers were encouraged to introduce COVID-free cancer hubs and use independent sector facilities which had been secured for NHS use [14, 15, 16]. The cancer hubs were sites where patients from a wider geographical area could be treated for cancer in a separate environment, away from COVID-19 related activity. Both cancer hubs and the use of private facilities were intended to ensure cancer treatment continued with a reduced risk of COVID-19 infection. However, how and when these measures were implemented differed between areas which may have resulted in some delays to treatment.
References
1. Clinical guide for the management of patients requiring endoscopy during the coronavirus pandemic. NHS England and NHS Improvement, 2 April 2020. Now available from link
2. Clinical guide for triaging patients with lower gastrointestinal symptoms. NHS England and NHS Improvement, 16 June 2020. https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/06/C0551-triaging-patients-with-lower-gi-symptoms-16-june.pdf
3. Appointments in General Practice – April 2020. NHS Digital, 28 May 2020. https://digital.nhs.uk/data-and-information/publications/statistical/appointments-in-general-practice/april-2020
4. Mahase E. Covid-19: Urgent cancer referrals fall by 60%, showing "brutal” impact of pandemic. BMJ 12 June 2020; 369; doi: https://doi.org/10.1136/bmj.m2386
5. Letter regarding the ‘Second phase of NHS response to COVID19 for cancer services'from Dame Cally Palmer and Professor Peter Johnson, NHS England and NHS Improvement, 8 June 2020. https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/06/C0511-second-phase-of-nhs-response-to-covid-19-for-cancer-services-letter.pdf
6. Mahase E. Cancer treatments fall as referrals are slow to recover, show figures. BMJ 13 October 2020; 371; doi: https://doi.org/10.1136/bmj.m3958
7. NG161: COVID-19 rapid guideline: delivery of systemic anticancer treatments. NICE, 20 March 2020 updated 27 April 2020. www.nice.org.uk/guidance/ng161
8. NG162: COVID-19 rapid guideline: delivery of radiotherapy. NICE, 28 March 2020. www.nice.org.uk/guidance/ng162
9. Clinical guide to surgical prioritisation during the coronavirus pandemic. Federation of Surgical Specialty Associations (FSSA) at the request of NHS England and NHS Improvement. First published 11 April 2020. Updated publication from 25 September 2020: https://fssa.org.uk/_userfiles/pages/files/covid19/prioritisation_master_250920.pdf
10. Clinical guide for the management of non-coronavirus patients requiring acute treatment: Cancer. NHS England and NHS Improvement, 23 March 2020. Now available from https://www.acpgbi.org.uk/content/uploads/2020/03/specialty-guide-acute-treatment-cancer-23-march-2020.pdf
11. Coronavirus guidance from a variety of professional societies. See longer list below.
12. Letter regarding ‘Advice on maintaining cancer treatment during the COVID-19 response'from Dame Cally Palmer, Professor Peter Johnson and Professor Steve Powis, NHS England and NHS Improvement, 30 March 2020. https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/03/C0119-_Maintaining-cancer-services-_-letter-to-trusts.pdf
13. Letter regarding ‘Advice to local systems on maintenance of cancer treatment during COVID-19 response'from Dame Cally Palmer, Professor Peter Johnson and David Fitzgerald, NHS England and NHS Improvement, 6 April 2020. https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/04/C0094-Letter-to-Cancer-Alliances-6-April.pdf Letter regarding the ‘Second phase of NHS response to COVID19'from Simon Stevens and Amanda Pritchard, 29 April 2020. https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/04/second-phase-of-nhs-response-to-covid-19-letter-to-chief-execs-29-april-2020.pdf