Europe and ESTRO moving East. A story of betrayal and redemption-Candid observations by a privileged witness.

After briefly looking into the dramatic twist of history that caused Central- and Eastern Europe to be separated from the West, the author observes the impact of 40 years of cold war and isolation on the state of radiotherapy (RT) in Central Europe. From her privileged position as a staff member in charge of public relations and society development at the European Society for Therapeutic Radiology and Oncology (ESTRO), she witnesses and helps drive the "rapprochement" between radiation oncology professionals from both sides of the former iron curtain. Thanks to substantial support from target tailored EU projects, ESTRO was in a position to give a powerful impulse to the re-integration of Central European RT in the mainstream of European health care. The author describes from her own and privileged perspective the excitement of discovering the rich heritage of a shared common past and expresses her concern that in the dynamic repositioning of Europe's point of gravity towards the East, the multiple but still fragile links between Central- and West European radiotherapy, tied within ESTRO, should not get dissolved in transition.

Overview of brachytherapy resources in Europe: a survey of patterns of care study for brachytherapy in Europe.

BACKGROUND AND PURPOSE: The Patterns of Care for Brachytherapy in Europe (PCBE) study is aimed at establishing a detailed information system on brachytherapy throughout Europe. MATERIALS AND METHODS: The questionnaire was web-based and the analysis used data from each radiotherapy department with brachytherapy. There were three groups: Group I with 19 countries (15 initial European Community (EC) countries plus Iceland, Monaco, Norway and Switzerland -EC+4-), Group II with 10 countries (New European Community countries -NEC-) and Group III with 14 countries (Other European Countries -OEC-). RESULTS: In the European area there are 36 of 43 countries (85%) which achieved data collection from at least 50% of centres, and were included in the analysis. The tumour site that had the largest number of treated patients was gynaecological tumours. Several variations have been found in the mean number of patients treated per consultant radiation oncologist and physicist; and in the proportion of brachytherapy patients with gynaecology, prostate and breast tumours, by country and by European area. The provided data showed that the average number of brachytherapy patients per centre increased by 10% between 1997 and 2002. CONCLUSIONS: A European wide evaluation of brachytherapy practice using a web-based questionnaire is feasible and that there is considerable variation in both patterns of practice and available resources.

Overview of national guidelines for infrastructure and staffing of radiotherapy. ESTRO-QUARTS: work package 1.

BACKGROUND AND PURPOSE: The aim of this study was to collect the available guidelines for infrastructure and staffing throughout Europe and to develop general guidelines. MATERIALS AND METHODS: Questionnaires were sent to representatives in all European countries. Countries were divided into three groups, based on the GDP per capita (low, medium and high resource countries). Based on the results, general guidelines were developed. RESULTS: 41 countries (93.2%), representing over 99% of the European population responded. Guidelines for the number of linear accelerators and personnel were available in about 40% of the countries. For accelerators, the average was 1 per 183,000 inhabitants in the high, 1 per 284,000 in the medium and 1 per 500,000 in the low resource countries. For radiation oncologists, it varied between 1 per 150-400 patients (average: 250) and there was no clear difference between high, medium and low resource countries. For physicists, the average was 1 per 530 patients for high and 1 per 610 for medium or low resource countries. Guidelines for other equipment and staffing are highly dependent on local habits and complexity of the treatments. CONCLUSION: An accurate overview of existing guidelines for radiotherapy infrastructure and staffing is obtained. It is suggested to have one linear accelerator per 450 patients, one radiation oncologist per 200-250 patients and one physicist per 450-500 patients (or one per linac). It should be stressed, however, that these are only crude guidelines and that the actual needs heavily depend on population structure, cancer incidence and treatment strategies, which differ between the various countries.

Towards evidence-based guidelines for radiotherapy infrastructure and staffing needs in Europe: the ESTRO QUARTS project.

BACKGROUND AND PURPOSE: Adequate and equitable access to radiotherapy (RT) must be a reasonable health care goal for the EU. However, there are large variations among the EU countries and even regional variations within countries in the provision of RT. In this report, we combine the best available evidence on the indications for RT with national epidemiological data to arrive at estimates for the appropriate level of RT infrastructure in the 25 EU countries. PATIENTS AND METHODS: Data from three systematic overviews of the best available evidence for the indication for RT in 23 main cancer types are combined with epidemiological data from the EUCAN and GLOBOCAN databases on the crude incidence of each of these cancers in the 25 EU countries. Together with published benchmarks for accelerator throughput this allows estimation of the number of linear accelerators per million people required to facilitate appropriate RT utilization rates in each country. Where possible, the estimates are compared with the detailed data available from Sweden. RESULTS: The crude incidence of the main cancer types shows large variation among the 25 EU countries. This reflects in part differences in exposure to aetiological risk factors and partly differences among the countries in population age structure. Correspondingly, the estimate of the required number of linear accelerators per million people showed considerable variation: ranging from 4.0 in Cyprus to 8.1 in Hungary. The average for the 25 countries was 5.9 per million people. These estimates were compared with available national guidelines and actual data on RT infrastructure and large shortfalls were found in many countries. Implications for health economics and capacity planning are briefly discussed. CONCLUSIONS: The QUARTS project has developed a model that establishes a direct and transparent link between epidemiological data and indications for RT based on the best available evidence. Comparison of the model estimates with current levels of RT infrastructure has revealed major inequalities in provision of RT in the 25 EU countries. Continuation of this study is recommended as a way of improving RT provision on rational grounds throughout the European community and as a model for health care planning in the EU.

Training logbook for radiotherapy.

AIM: To develop a structured logbook for trainees in the medical specialty of radiotherapy with Europe that records the increasing experience throughout their training period. MATERIAL AND METHODS: A working party appointed by the European Board of Radiotherapy developed a draft version of a European logbook for trainees in radiotherapy. For development, the update European Core Curriculum for Radiotherapists (Radiation Oncologists) was taken into consideration. The logbook is composed of six sections: (1) biodata of the trainee, (2) scientific training documentation, (3) clinical training documentation, (4) record of formal presentations by the trainee, (5) publications, (6) training courses. Decisions were made to suggest that the clinical section of the logbook should: (a) only collect data that was essential for the purposes of appraisal, assessment and regulation, (b) be as user friendly as possible, (c) concentrate on quality of the data and not volume. The logbook was tested by trainees in several European training departments and adapted according to their suggestions. A final draft of the logbook was circulated among the national and professional societies for radiotherapy in Europe for review before a European consensus conference took place in Brussels in December 2002. RESULTS: The European training logbook for radiotherapy was endorsed by representatives of 35 European nations during the Brussels consensus conference on December 14, 2002. CONCLUSION: Keeping a training logbook is an essential feature of the record of training for all EU trainees who wish to retain an opportunity to spend part of their training time in another country of the Union, important for someone who seeks an appointment as a specialist in another country within a few years of achieving specialist accreditation, and good professional practice for all other trainees. The European training logbook for radiotherapy is a robust instrument that allows the systematic collection of the information that needs to be recorded to monitor the professional development of European trainees in Radiation Oncology.

Light ion facility projects in Europe: methodological aspects for the calculation of the treatment cost per protocol.

In the framework of the European Network for Research in Light Ion Hadron Therapy (ENLIGHT), the health economics group develops a methodology for assessing important investment and operating costs of this innovative treatment against its expected benefits. The main task is to estimate the cost per treated patient. The cost analysis is restricted to the therapeutic phase from the hospital point of view. An original methodology for cost assessment per treatment protocol is developed based on standard costs. Costs related to direct medical activity are based on the production process analysis, whereas indirect and non direct medical costs are allocated to each protocol using relevant cost-drivers. The resulting cost model will take into account the specificities of each therapeutic protocol as well as the particularities of each of the European projects.

Guidelines for education and training of medical physicists in radiotherapy. Recommendations from an ESTRO/EFOMP working group.

PURPOSE: To provide a guideline curriculum covering theoretical and practical aspects of education and training for medical physicists in radiotherapy within Europe. MATERIAL AND METHODS: Guidelines have been developed for the specialist theoretical knowledge and practical experience required to practice as a medical physicist in radiotherapy. It is assumed that the typical entrant into training will have a good initial degree in the physical sciences, therefore these guidelines also require that and are additional to it. National training programmes of medical physics, radiation physics and radiotherapy physics from a range of European countries and from North America were reviewed by an expert panel set up by the European Society of Therapeutic Radiology and Oncology (ESTRO) and the European Federation of Organisations for Medical Physics (EFOMP). A draft document prepared by this group was circulated, via the EFOMP infrastructure, among national professional medical physics societies in Europe for review and comment and was also discussed in an education session in the May 2003 EFOMP scientific meeting in Eindhoven. RESULTS: The resulting guideline curriculum for education and training of medical physicists in radiotherapy within Europe discusses the EFOMP terms, qualified medical physicist (QMP) and specialist medical physicist (SMP), and the group's view of the links to the EU (Directive 97/43) term, medical physics expert (MPE). The minimum level expected in each topic in the theoretical knowledge and practical experience sections is intended to bring trainees up to the requirements of a QMP. The responses from the circulation of the document to national societies and its discussion were either to agree its content, with no changes required, or to suggest changes, which were taken into account after consideration by the expert group. Following this the guidelines have been endorsed by the parent organisations. CONCLUSIONS: This new joint ESTRO/EFOMP European guideline curriculum is a first step to harmonise specialist training of medical physicists in radiotherapy within Europe. It provides a common framework for national medical physics societies to develop or benchmark their own curricula, but is also flexible enough to suit different situations of initial physics qualifications, medical physics training programmes, accreditation structures, etc. The responsibility for the implementation of these standards and guidelines will lie with the national training bodies and authorities.

Audit of effectiveness of routine follow-up clinics after radiotherapy for cancer: a report of the REACT working group of ESTRO.

BACKGROUND AND PURPOSE: The European Society for Therapeutic Radiology and Oncology was funded by the EU for a project on recording providing education, and ameliorating the consequences of treatment (REACT). An European audit was carried out as part of which to assess the usefulness of current follow-up practices. PATIENTS AND METHODS: Over a 4-month period in 15 cancer centres in 10 countries, patients attending for routine follow-up completed a questionnaire covering their expectations of and satisfaction with the visit. This was matched with a questionnaire completed by the physician about the content and usefulness of the consultation. The feasibility of a short toxicity scale developed by Dische and Saunders was also investigated. RESULTS: In total, 2303 matched questionnaires were analysed. Forty percent of the patients had symptoms or medical problems related to their disease. In 18% there was a positive finding on clinical examination. In 28% investigations were undertaken part of departmental routine practice. Ten percent of the investigations showed an abnormal result. Ninety nine percent of physicians and 85% of the patients expressed satisfaction. Using the short toxicity scale rates of recording toxicity could be increased from 28 to 93%. CONCLUSIONS: There is wide variation in follow-up practices among European centres. There was a low incidence of positive findings clinically or with routine investigations. A simple scale for recording morbidity has proved easy to use by departments, which have not routinely used one of the standard measures. Further work will attempt to produce an European guideline for effective routine follow-up after radiotherapy.

First report on the patient database for the identification of the genetic pathways involved in patients over-reacting to radiotherapy: GENEPI-II.

BACKGROUND: Identifying the most radiosensitive patient group would have huge clinical implications. METHODS: A tissue bank containing skin fibroblasts, whole blood, lymphocytes, plasma and lymphoblastoid cell lines from clinically radiation hypersensitive patients was established from patients in Europe and Canada. Over-reacting individuals had CTCAE3.0 severe acute side effects grade 2 or more occurring at very low radiation doses where these side effects are unexpected or grade 3-4 lasting more than 4 weeks after the end of radiotherapy and/or requiring surgical intervention at any time or severe late side effects grade 3-4. RESULTS: Eleven patients have been identified with a mean age of 61.6±8.5 years (range 49-74). Two patients were male, 9 female. One patient had non-small cell lung cancer, 6 breast cancer, 2 head and neck cancer, one lymphoma and one meningioma. The mean follow-up time after radiotherapy was 1658±1048 days (range 84-3752). CONCLUSIONS: The establishment of an international tissue bank of the rare group of patients with extreme hypersensitivity to radiotherapy was proven to be feasible and should enable in-depth molecular studies.