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Japanese structure survey of radiation oncology in 2012

ABSTRACT This paper describes the ongoing structure of radiation oncology in Japan in terms of equipment, personnel, patient load and geographic distribution to identify and overcome any existing limitations. From March 2013 to August 2016, the Japanese Society for Radiation Oncology conducted a questionnaire based on the Japanese national structure survey of radiation oncology in 2012. Data were analyzed based on the institutional stratification by the annual number of new patients treated with radiotherapy per institution. The estimated annual numbers of new and total (new plus repeat) patients treated with radiation were 213 000 and 251 000, respectively. Additionally, the estimated cancer incidence was 865 238 cases with ~24.6% of all newly diagnosed patients being treated with radiation. The types and numbers of treatment devices actually used included linear accelerator (LINAC; n = 864), telecobalt (n = 0), Gamma Knife (n = 44), 60Co remote afterloading system (RALS; n = 23) and 192Ir RALS (n = 130). The LINAC system used dual-energy functions in 651 units, 3D conformal radiotherapy functions in 759 and intensity-modulated radiotherapy (IMRT) functions in 466. There were 792 Japan Radiological Society/Japanese Society for Radiation Oncology-certified radiation oncologists, 1061.6 full-time equivalent (FTE) radiation oncologists, 2124.2 FTE radiotherapy technologists, 181.3 FTE medical physicists, 170.9 FTE radiotherapy quality managers and 841.5 FTE nurses. The frequency of IMRT use significantly increased during this time. In conclusion, the Japanese structure of radiation oncology has clearly improved in terms of equipment and utility although there was a shortage of personnel in 2012.


INTRODUCTION
In 1991, the Japanese Society for Radiation Oncology ( JASTRO) conducted the first national survey of the structure of radiotherapy institutions in Japan based on their status in 1990, and the results were reported by Tsunemoto et al. [1]. The Japanese structure has gradually changed since a greater number of cancer patients are treated with radiation and public awareness of the importance of radiotherapy has grown. JASTRO has conducted national structure surveys every 2 years since 1991 . The consecutive structural data gathered and published by JASTRO have been useful to gain an understanding of our current position and future direction in Japan. Despite some delays, the updated Japanese national structure survey data of radiation oncology in 2012 is now available.

MATERIALS AND METHODS
From March 2013 to August 2016, a questionnaire regarding the 2012 national structure survey of radiation oncology was conducted that included the number of treatment systems by type, number of personnel by category, and number of patients by type, site and treatment modality. To measure variables over a longer time period, data for the year 2012 were also considered. In total, 709 of 788 active institutions attempted the survey; the response rate was 90.0%.
The current report analyzes these institutional structure data (equipment, personnel, patient load and geographic distribution) based on institutional stratification by the annual number of new patients treated with radiotherapy at each institution. Clinical working hours of each staff member performing radiotherapy were derived from full-time equivalent (FTE; 40 h per week for radiation oncology work only) data. The Japanese Blue Book Guidelines ( JBBG) [23,24] were used for comparison with the results of this study. These guidelines pertain to the structure of radiation oncology in Japan based on Patterns of Care Study (PCS) [25,26] data. The standard guidelines were set at 250-300 (warning level, 400) for annual patient load per external beam machine, at 200 (warning level, 300) for annual patient load per FTE radiation oncologist (RO), and at 120 (warning level, 200) for annual patient load per FTE radiotherapy technologist.
Furthermore, we analyzed data from the designated cancer care hospital accredited by the Ministry of Health, Labor and Welfare. As on 1 October 2016, Japan had 427 designated cancer care hospitals [27]. A total of 44 institutions did not return the survey; therefore, the structure data for these 383 designated cancer care hospitals were analyzed and compared with the data for all radiotherapy hospitals. The analysis was conducted in two groups: institutions with <1.0 FTE RO and those with ≥1.0 FTE RO.

RESULTS
In this report, preliminary results have been presented as tables and figures (Tables 1-18 and Figs 1 -6). We have briefly summarized the Japanese national structure survey of radiation oncology for 2012. The values obtained by dividing the real numbers of new patients (190 910) and total (new plus repeat) patients (225 818) by the response rate were 212 182.1 and 250 979.7, respectively. In addition, there may be radiotherapy institutions unknown by JASTRO. Therefore, the estimated number of new patients was ∼213 000, obtained by rounding up 212 182.1 to the nearest 1000. In the same way, the estimated number of total patients was ∼251 000 (Fig. 1).

DISCUSSION
In this report, the estimated numbers of new patients and total patients were ∼213 000 and 251 000 by a simple calculation using the response rate. However, it is necessary to carefully consider that the estimated numbers of new patients and total patients reported also vary widely according to the difference in the calculation method used as follows. If all non-responding institutions were in category A (≤99), the estimated numbers of new patients and total patients were 195 901 and 231 727 by calculation using the average number of new patients in category A. On the other hand, the estimated numbers of new patients and total patients were 249 192 and 293 709 if all non-responding institutions were in category F (≥500).
In 2012, based on Japanese cancer registries, the cancer incidence was estimated at 865 238 cases [28] with approximately 24.6% (213 000 of 865 238) of all newly diagnosed patients being treated with radiation.
Regarding the case scale of institution, ∼50.5% of all radiotherapy institutions had >200 new radiotherapy patients per year, whereas 31.3% of the institutions had >300. Additionally, 41.5% of all radiotherapy institutions had <1.0 FTE ROs. Compared with the findings of a similar survey conducted 5 years ago, the percentage of institutions that have >= 1.0 FTE ROs had improved a little, but was not yet sufficient.   When viewed from the perspective of geographic distribution, radiotherapy institutions cover each region in Japan, although there are considerable differences in the number of radiotherapy institutions in prefectures. Concerning equipment, much of theequipment had been rapidly replaced with ones with excellent functions, although there are differences depending on the scale of the institution. The numbers of staff (ROs, radiotherapy technologists, medical physicists, radiotherapy quality managers and nurses) steadily increased. Annual total patient load per FTE RO was 212.7, which was lower than the 248.2 of the 2007 survey [16]. However, this patient load exceeds the 200.0 given as the standard value by the JBBG [23,24]. With regard to other staff, the numbers of medical physicists and radiotherapy quality managers are absolutely insufficient. In most cases, radiotherapy technologists partially act as medical physicists and radiotherapy quality managers. Compared with the other types of staff mentioned above, a sufficient number of radiotherapy technologists is ensured LINAC = linear accelerator, 3DCRT = 3D conformal radiotherapy, MLC = multileaf collimator, IMRT = intensity-modulated radiotherapy, CT = computed tomography, Co = cobalt, RALS = remote-controlled after-loading system, Ir = iridium, Cs = Caesium.       Treatment institutions  8  15  30  29  23  70  175  162  Patients  71  136  337  285  293  1126  2248  1957  Intraoperative radiotherapy  Treatment institutions  1  2  3  1  3  1 3  2 3 2 0 P a t i e n t s 2 2 5 1 1 0 7 8 9 8 1 0 2 Stereotactic brain radiotherapy Treatment institutions  12  44  42  52  31  52  233  214  Patients  663  2332  1673  3192  2162  4428  14 450  13 768  Stereotactic body  radiotherapy  Treatment institutions  5  38  51  57  31  73  255  222  Patients  14  588  536  777  767  2331  5013  3552  IMRT  Treatment institutions  8  21  31  40  27  71  198  164  Patients  451  1097  1519  2000  2079  4801  11 947  8887  Thermoradiotherapy  Treatment institutions  2  7  2  4  3  3  2 1  1 9  Patients  33  54  6  19  209  45  366  327  90 Sr radiotherapy for  pterygia  Treatment institutions  0  2  3  0  0  2  7  8  Patients  0  21  11  0  0  30  62  45  Internal 89 Sr radiotherapy  Treatment institutions  10  35  39  35  23  53  195  169  Patients  62  138  239  157  124  425  1145  969  Internal 90 Y radiotherapy  Treatment institutions  0  3  4  6  1  1 5  2 9  3 1  Patients  0  14  14  12  1  30  71  106 IMRT = intensity-modulated radiotherapy, Sr = strontium, Y = yttrium.  Table 3 differ from these data because no data on primary sites were reported by some institutions.   in Japan. The average of structure data of designated cancer care hospitals was better than the national average. Annual patient load per designated cancer care hospital was about 100 patients more than the national average, but annual patient load per FTE RO and annual  In conclusion, the Japanese structure of radiation oncology has clearly and steadily improved over the past 20 years in terms of installation and use of equipment and its functions, but there are still problems of the shortages of manpower and the structure gap by institution type. We expect that this updated national structure survey of radiation oncology for 2012 will aid the continuous improvement of all aspects of radiation oncology in Japan.

CONFLICT OF INTEREST
None declared.