Japanese Journal of Clinical Oncology 31:135-141 (2001)
© 2001 Foundation for Promotion of Cancer Research
The Future Demand for and Structural Problems of Japanese Radiotherapy
1Division of Multidisciplinary Radiotherapy, Biomedical Research Center, Osaka University Graduate School of Medicine, Osaka, 2Department of Medical Engineering, Faculty of Medicine, Osaka University, Osaka, 3Department of Radiology, Cancer Institute Hospital, Tokyo, 4Department of Radiology, Gunma University School of Medicine, Gunma, 5Department of Therapeutic Radiology, Kyoto University Graduate School of Medicine, Kyoto and 6Department of Radiology, National Cancer Center Hospital, Tokyo, Japan
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONAcknowledgmentsREFERENCES |
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Background: Recently, as the number of elderly people in Japan is growing, so is the number of new cancer cases. The number of patients treated with radiotherapy is therefore also on the increase, so that it is important to estimate the future demand for radiotherapy and to make preparations for it.
Methods: All the surveys were conducted for 106 facilities selected randomly out of 556 radiotherapy facilities in Japan. To obtain trends in the number of new cancer patients treated with radiotherapy in Japan, we conducted a survey with a self-administered mail questionnaire designed to obtain the number of new patients treated with radiotherapy for each year of the past decade (1990–99). The future number of new patients treated with radiotherapy was estimated from the data thus obtained. To investigate structural problems of Japanese radiotherapy, surveys about the number of treatment machines and full-time equivalent (FTE) radiation oncologists were conducted according to data from the Japanese Society for Therapeutic Radiology and Oncology (JASTRO) structure survey and the Patterns of Care Study (PCS). We also compared the structure of Japanese radiotherapy with that in the USA.
Results: The number of patients treated with radiotherapy has increased for every institutional stratum, with an overall increase of 1.4-fold over the past 10 years in Japan. It is estimated that the number of cancer patients treated with radiotherapy will reach 190 000 in 2015. In Japanese non-academic institutions, less than one FTE radiation oncologist has been managing many of these patients. In both equipment and manpower, academic institutions exceed non-academic institutions.
Conclusion: The future demand for Japanese radiotherapy will grow substantially, so that it is of vital importance to prepare for it. Specifically, the number of FTE radiation oncologists must be increased.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONAcknowledgmentsREFERENCES |
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The number of elderly people in Japan has recently been on the increase (1) and the number of cancer patients is also increasing (2). The number of patients treated with radiotherapy is expected to undergo a similar increase. The trends in the number of patients treated with radiotherapy in Japan during the last 10 years was investigated. Furthermore, the future demand for radiotherapy in Japan was estimated on the basis of the results of this investigation.
There are certain problems in the structure of radiation oncology in Japan, which must be solved to satisfy future demand (3). One of them is related to manpower, especially the number of radiation oncologists, for which a solution must be found. To obtain a broader viewpoint, we compared the structure of Japanese radiation oncology with that in the USA.
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MATERIALS AND METHODS |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONAcknowledgmentsREFERENCES |
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All the surveys were conducted for a randomly selected 106 facilities that had participated in the Patterns of Care Study (PCS) for radiation oncology in Japan, supported by the Ministry of Health and Welfare. These facilities were randomly selected from among all Japanese radiotherapy facilities (556) according to the stratification of the institutions based on the structure survey by the Japanese Society for Therapeutic Radiology and Oncology (JASTRO) (4). The facilities were stratified into four groups, A1, A2, B1 and B2. A1 and A2 are academic institutions such as university hospitals or cancer centers. B1 and B2 are non-academic institutions such as national, prefectural and municipal hospitals. A1 and A2 or B1 and B2 were stratified according to the number of patients treated with radiotherapy (not only new but re-treated patients) per year based on the data of the structure survey by JASTRO in 1995 (A1 and A2,
300 and <300; B1 and B2, 120 and <120). These cut-off values of 300 and 120 were determined by the median numbers of patients in the academic and non-academic institutions, respectively, according to the corresponding survey in 1990. The disproportion of the number of institutions in each stratum was due to the increased number of cancer patients and the small-sized institutions that participated in the 1995 survey, compared with those in 1990. Table 1 shows the distribution of the number of patients treated with radiotherapy per facility.
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The Future Demand for Japanese Radiotherapy
The survey used a self-administered mail questionnaire sent to the heads of radiation oncology facilities in January 2000 (Fig. 1). The questionnaire was designed to obtain the number of new patients treated with radiotherapy for each year of the past decade (1990–99). By April 2000, the mail questionnaires had been returned from 85 facilities (80.2%). The response rates of each stratum group were A1 35/39 (89.7%), A2 14/19 (73.7%), B1 21/25 (84.0%) and B2 15/23 (65%).
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The estimated number of new patients in Japan was calculated as follows. First the simple summation of the number of new patients in each stratum group in each year (simple sum) was calculated. Then the estimated number of new patients in each stratum group in each year (NPT) was obtained by multiplying the simple summation by the ratio of the total number of institutions in each group (TN) by the number of sampled institutions (n):
NPT = (simple sum) x TN/n
The total of the NPT of each stratum group was the estimated number of new patients in each year in Japan (Table 2):
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estimated number of new patients in each year in Japan =
NPT Thus, the estimated total number of new patients undergoing radiotherapy in Japan was arrived at. The regression line was obtained by the least-squares method from the estimated number of new patients. Two regression lines were obtained, one from the estimated number of new patients for the last decade and the other from that for the last 5 years. Furthermore, the future number of new patients treated with radiotherapy could be extrapolated from the regression line.
The Structure of Japanese Radiotherapy Facilities
The number of treatment machines in the radiotherapy facilities in Japan was reported in the JASTRO structure survey of 1995. The number of treatment machines was ascertained for 101 out of 106 facilities that participated in the PCS. The distribution of the number of treatment machines per facility could be obtained. Patient loads per treatment machine were also calculated and the results could be compared with data for the USA according to Owen and Coia (5) to obtain a broader viewpoint.
One full time equivalent (FTE) radiation oncologist is equivalent to 40 h/week for the radiation oncology service (6). The number of FTE radiation oncologists at each of the 81 out of the 106 facilities was surveyed in the Japanese PCS in 1998–99 (A1, n = 26; A2, n = 19; B1, n = 19; B2: n = 17). The total FTE radiation oncologists in Japan was estimated by multiplying the subtotal of FTE radiation oncologists in each stratum by the ratio of the total number of facilities to the number of sampling facilities. Furthermore, the distribution of facilities by the number of FTE radiation oncologists and patient loads per FTE radiation oncologist could be obtained and the results were compared with the data for the USA according to Owen and Coia (5).
In these two surveys of patient loads per treatment machine or FTE radiation oncologists, the number of new patients is according to the data for 1995 reported in the JASTRO structure survey of 1995.
Data and Sources
The data that were analyzed in these surveys and their sources are listed in Table 3.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONAcknowledgmentsREFERENCES |
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Changes in the Number of Cancer Patients Treated with Radiotherapy and Forecast of Future Demand
Table 2 shows the estimated number of new patients treated with radiotherapy in each stratum group and the total number of patients. The estimated number of new patients treated with radiotherapy in Japan in 1990, 1995 and 1999 were 77 700, 88 600 and 108 400, respectively. Figs 2 and 3 show an estimated increase in the number of new patients of 1.4-fold over the past decade (1990–99).
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Fig. 4 shows the results of the extrapolation from the numbers of new patients over the past decade. The number of new patients is estimated to reach 154 000 in 2015. However, the last few years of the decade have seen a higher rate of increase than the earlier years. Therefore, Fig. 4 also shows the extrapolation from the number of new patients in the last 5 years. The number of new patients in 2015 is estimated to be around 190 000.
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Treatment Machine or FTE Radiation Oncologist
Table 4 shows the distribution of the number of treatment machines per facility. For academic facilities (A1 and A2), over 50% of facilities have more than two treatment machines. For the non-academic facilities (B1 and B2), most facilities have only one treatment machine.
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The distribution of patient load per machine is shown in Table 5. For academic facilities, all the facilities are included in the category <400 new patients per treatment machine. For the non-academic facilities, all the facilities are included in the category of <300 new patients per treatment machine.
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Table 6 shows the distribution of facilities by FTE radiation oncologist. For A1 facilities, over 60% of facilities have more than 2 FTE radiation oncologists. For A2 facilities, about 70% of facilities have at least one FTE radiation oncologist. For non-academic facilities, more than 70% of B1 facilities and 90% of B2 facilities have less than one FTE radiation oncologist.
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The distribution of patient load per FTE radiation oncologist is shown in Table 7. For academic facilities, no A1 facilities and only 5.3% of A2 facilities are included in the category of >400 new patients per FTE radiation oncologist. For non-academic facilities, more than 20% of both B1 and B2 facilities are included in the category of >400 new patients.
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Furthermore, the total number of FTE radiation oncologists in Japan could be obtained. The subtotal of FTE radiation oncologists in each stratum was A1, FTE = 67.6; A2, FTE = 29.5; B1, FTE = 14.8; B2, FTE = 6.2. The ratio of total number of facility to sampling number of facility of each stratum was A1, 70/26; A2, 51/19; B1, 187/19; B2, 248/17. Then the FTE radiation oncologists was calculated as follows:
67.6 x 70/26 + 29.5 x 51/19 + 14.8 x 187/19 + 6.2 x 248/17 = 497
Table 8 shows FTE radiation oncologists and patients per FTE radiation oncologist in Japan and recommendations of the ‘Blue Book’ (7) guidelines, which are the guidelines for the management of radiation oncology in the USA.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONAcknowledgmentsREFERENCES |
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Before our survey was conducted, no other detailed survey of the number of patients treated with radiotherapy every year over a certain period had been published. The number of new patients reported by the JASTRO structure survey was 71 696 in 1995 (4), which is smaller than our estimated number of 88 600. The JASTRO survey was not a sampling survey. The data on the institutions which did not provide an effective reply were not counted in the survey. The total number of institutions that gave an effective reply about the number of new patients treated with radiotherapy was 504 for the JASTRO survey. On the other hand, our survey was a sampling survey and the population number was 556, so that the number of patients in the JASTRO survey may be smaller than our estimated number of patients.
According to our results, the number of patients treated with radiotherapy in 1999 increased by a factor of 1.40 over that in 1990. Inoue et al. reported that in 1990 the number of patients was 1.47 times that in 1980 (8). They concluded that the increase in the number of cancer patients treated with radiotherapy was simply due to the increase in the number of cancer patients during that survey period. As the elderly population has been growing rapidly in Japan, the number of cancer cases has also grown. Kitagawa et al. estimated that the number of cancer patients in Japan in 2015 would become 1.87 times that in 1995 (475 000 in 1995 vs 890 000 in 2015) (9). If the number of patients treated with radiotherapy in 2015 is also 1.87 times that of 1995, it will reach 166 000. As Fig. 4 shows, the estimated number of patients extrapolated from the number of patients of the last few years was larger than the 166 000 or 154 000 extrapolated from the number of patients in the last decade. In the last few years of the decade the increase in number of patients treated with radiotherapy was higher than that in the earlier years. Some reasons why such a tendency was observed must be considered. According to the data of the Radiation Oncology Greater Area Database (ROGAD), a tendency for an increase in the proportion of the number of patients of advanced age undergoing radiotherapy in Japan was observed in last few years (over 65 years old, 39 % in 1992 vs 46% in 1998). However, according to Kitagawa et al., the proportion of incident cancer cases aged 70 years in Japan was also increasing (41% in 1993 vs 49% in 2000) (9). Indeed the recognition that radiotherapy is suited to a person of advanced age may be spread gradually in Japan, it cannot be concluded that the proportion of elderly patients in Japanese radiotherapy is remarkably increasing. Meanwhile, the change of the structure of malignant disease may influence the trend of the increasing of the number of new patients with radiotherapy. According to Kitagawa and Tsukuma et al. the malignant disease such as lung, breast and prostate cancer will increase still more (9). The role of radiation therapy for the disease is also increasing recently, such as breast conserving therapy. A higher rate of increase in the number of patients treated with radiotherapy in Japan may thus be justified.
In the United States, 598 184 (49% of the total of newly diagnosed) patients were treated with radiation therapy in 1989. In Japan, 62 829 patients (15% of the total of newly diagnosed patients) were thus treated in 1990 (3). A different background and treatment strategy in the two countries makes a simple comparison of the figures difficult. Nevertheless, the number of potential candidates for radiotherapy in Japan appears to be large. We can confidently predict that the tendency for the number of radiotherapy patients to increase will continue. If the proportion of newly diagnosed cancer patients who are treated with radiotherapy increases, the number of radiotherapy patients will grow even faster. The current survey only allowed for a rough estimate of future demand. The questionnaire did not have such items as age, gender and disease. In Japan the institutions do not always have a detailed database. We wanted the data to be the latest and more institutions to reply to the questionnaire, so the format of the questionnaire was made as simple as possible. If the questionnaire had more items, the number of institutions replying would be smaller and it would take longer to finish the survey. For a more precise forecast, the factors of age, gender and prevalence of each type of disease and chronological changes in treatment strategies should be taken into account.
It is clear that the situation regarding equipment and personnel must be improved to meet the increase in the number of patients. In the USA, a report on the structure of radiation oncology notes that the number of patients treated with radiotherapy has also grown and that a proportional increase in the number of treatment machines and FTE radiation oncologists has been strongly supported (10,11). As a result, the new patient load per FTE radiation oncologist has been kept at the same level in the USA. Teshima et al. reported that the number of FTE radiation oncologists in Japan in 1990 was 366 and the patient load per FTE radiation oncologist was 172 (3). They calculated FTE radiation oncologists based on the data of the JASTRO structure survey in 1990. According to the survey, the number of full-time employees was 601, part-time employees 311 and other specialties 62 in 1990. They considered that full-time employees devoted half of their work hours to the radiation oncology service, part-time employees one fifth and other specialties one tenth. Then they calculated the number of FTE radiation oncologists as follows:
601 x + 311 x 1/5 + 62 x 1/10 = 366
According to the data of the PCS in Japan for 1998–99, the estimated number of FTE radiation oncologists in Japan in 1998 was 497 and the patient load per FTE radiation oncologist was 203. The rate of increase of FTE radiation oncologists was 16 per year. In the ‘Blue Book’ the patient load per FTE radiation oncologist was recommended to be 200–250. In Japan in the field of radiation oncology, the system of specialization has not matured and most radiation faculties have no medical physicists or dosimetrists (12). Radiation oncologists also have to cover for them. Then the appropriate patient load per FTE radiation oncologist in Japan should be smaller than the recommendation number in the USA. Hence it is not desirable to increase the patient load per FTE radiation oncologist to more than the current estimated number of 203. If the estimated number of patients of 190 000 in 2015 is correct, then 936 FTE radiation oncologists will be needed to maintain the patient load per FTE radiation oncologist. If the number of patients treated with radiotherapy increases as per our estimate, at least 26 FTE radiation oncologists will have to be added every year to maintain the patient load per FTE radiation oncologist. It may be necessary to increase the number of radiation oncologists more rapidly in the future than in the last decade.
Owen and Coia reported the distribution of patient load per machine in the USA (5). Most of the facilities in the USA have <400 new patients per treatment machine. Similarly, in Japan no facilities sampled in this current survey have >400 new patients per treatment machine. It can therefore be concluded that the available equipment in Japan, particularly treatment machines, is not inadequate when compared with that in the USA.
In the USA, <10% of all facilities had >400 new patients per FTE radiation oncologist (5). In Japan among academic facilities, few facilities had >400 new patients per FTE radiation oncologist, but >20% of non-academic facilities had >400 new patients per FTE radiation oncologist. In Japan, most non-academic facilities have <1.0 FTE radiation oncologist, indicating that these facilities employ only part-time radiation oncologists, which would place a severe burden for them.
For both equipment and manpower, academic facilities are substantially better than non-academic facilities. For non-academic facilities, it is important to make an effort to maintain a good quality of radiation therapy. The number of patients is also increasing in these facilities, so that if this trend continues, a severe shortage of radiation oncologists may interfere with the future development of radiation oncology in Japan.
The structure of radiotherapy in the USA may not always be standard or ideal and should be only a model case to be referred to. We must have a discussion about not only the preparedness of manpower or equipment but also the cost–benefit status. Indeed, it is important to increase the number of radiation oncologists but this is not the only way to solve the problems of the future radiation oncology in Japan. When mentioning manpower we must also consider medical physicists, dosimetrists and technologists. Practical work owes a great deal to technologists. Furthermore, radiation oncologists and technologists must play the role of medical physicists and dosimetrists in addition to their own routine. Hence their work will be more complicated and heavy. The latest structure survey of JASTRO is now in progress. Current changing trends in the number of facilities, equipment and medical staff including technologists, medical physicists and dosimetrists will be shown by the survey. We will then be able to have a thorough discussion about future deficit in Japanese radiotherapy.
In conclusion, the future demand for Japanese radiotherapy will grow substantially and it is of vital importance to prepare for it. Specifically, the number of FTE radiation oncologists must be steadily increased. For this purpose, it is indispensable for the government to encourage and support undergraduate, graduate and postgraduate studies in radiation oncology.
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Acknowledgments |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONAcknowledgmentsREFERENCES |
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The authors thank all radiation oncologists who participated in this study. Their cooperation in providing information made this survey possible. This study was supported by Grants-in-Aid from the Ministry of Health and Welfare (10–17) and the Research Committee of the Japanese Society of Therapeutic Radiology and Oncology (JASTRO).
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FOOTNOTES |
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+ For reprints and all correspondence: Atsushi Imai, Division of Multidisciplinary Radiotherapy, Biomedical Research Center, Osaka University Graduate School of Medicine, 2–2, Yamadaoka, Suita, Osaka, 565-0871, Japan. E-mail: aimai@radonc.med.osaka-u.ac.jp
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REFERENCES |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONAcknowledgmentsREFERENCES |
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1 Management and Coordination Agency. 2000 http://www.somucho.go.jp/roujin/zu_122.htm (in Japanese).
2 Vital Statistics of Japan. 2000 Tokyo: Statistics and Information Department, Ministry of Health and Welfare, Japan (in Japanese).
3 Teshima T, Owen JB, Hanks GE, Sato S, Tsunemoto H, Inoue T. A comparison of the structure of radiation oncology in the United States and Japan. Int J Radiat Oncol Biol Phys 1996;34:235–42.[Web of Science][Medline]
4 JASTRO Database Committee. Present status of radiotherapy in Japan. Nippon Hoshasen Syuyo Gakkaishi 1997;9:231–52 (in Japanese).
5 Owen JB, Coia LR. The changing structure of radiation oncology: implications for the era of managed care. Semin Radiat Oncol 1997;7:108–13.[Web of Science][Medline]
6 Teshima T, Abe M, Ikeda H, Hanks GE, Owen JB, Hiraoka M, et al. Patterns of care study of radiation therapy for esophageal cancer in Japan: influence of the stratification of institution on the process. Jpn J Clin Oncol 1998;28:308–13.
7 Radiation Oncology in Integrated Cancer Management. Inter-Society Council for Radiation Oncology (ISCRO) Philadelphia:1991;41.
8 Inoue T, Inoue T, Teshima T, Yamazaki H, Tang J, Otani M, et al. Case distribution by primary tumor sites of patients registered in the survey of the structure of radiation oncology in 1980. Rinsho Hoshasen 1994;39:719–22 (in Japanese).
9 Kitagawa T, Tsukuma H, Ajiki W, Oshima A, et al. Prediction of cancer incidence in Japan. In: Tominaga S, et al., editors. Cancer Statistics 1999. Tokyo: Shinohara Shuppan 1999;160–5 (in Japanese).
10 Diamond JJ, Kramer S, Hanks GE. Trends in radiation therapy demographics 1974 to 1983. Int J Radiat Oncol Biol Phys 1986;12:1673–4.[Medline]
11 Owen JB, Coia LR, Hanks GE. The structure of radiation oncology in the United States in 1994. Int J Radiat Oncol Biol Phys 1997;39:179–85.[Medline]
12 Imai A, Teshima T, Sato S, Inoue T, Nishio M, Yamashita T, et al. The compliance of the structure of radiation oncology in Japan with the JASTRO guideline proposed by the cancer research group of the Ministry of Health and Welfare (8–27). Nippon Hoshasen Syuyo Gakkaishi 2000;12:267–71 (in Japanese).
Received October 20, 2000; accepted January 9, 2001.
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