Number of appointments

Figure 1 shows that the number of patient appointments for CT simulation, treatment, and the mould room was stable for two years before COVID-19, with around 7,000 breast cancer RT fractions delivered annually to 500 patients. In 2020, treatment attendances dropped by over 35%, due in part to reduced referrals caused by the pandemic, and the reduction in prescribed treatment fractions. Muschol & Gissel found that fear of COVID-19 led to patient uncertainty and delays in seeking care, reducing outpatient appointments and delaying diagnoses. ^{Reference Muschol and Gissel10} Similarly, Di Lalla et al. report that 34% of cancer patients felt anxious about hospital visits during the pandemic. ^{Reference Di Lalla, Patrick and Siriani-Ayoub11}

Patient numbers remained lower in 2021, before recovering to pre-COVID-19 levels from 2022 onwards. Appointments for CT simulation reached similar levels to those found pre-COVID-19. However, treatment visits have remained lower than they were before the COVID-19 pandemic. The primary reason for this reduction in visits for treatment is the move from 15# of RT to 5#, effectively cutting the number of attendances required for RT of the breast by two-thirds.

More generally at the department, mean fraction attendances per treatment course have dropped, from 15 fractions in 2019 to around 11 in 2024, largely due to adoption of 5# breast, 5# rectum and changes to prostate treatment regimens.

Appointment length

When attending for a fraction of RT, the active time in the department, as recorded by Mosaiq^®, ranged from 39 minutes in 2021 to 52 minutes in 2022 (Figure 2). Before COVID-19, there was a downward trend for time spent in the department for treatment, to the low of 39 minutes. There are many potential factors at play here contributing to this reduction. Principally, during COVID-19, patients were advised to attend on-time for their appointments, rather than early. This was to reduce the number of patients together in the waiting room and meant that most patients arrived and very quickly started their appointments. In combination with this, due to the reduced patient numbers, the treatment machines were less likely to be running behind schedule, meaning patients were more likely to be seen on time. No changes were to the length of the patient slot allocated, i.e. 15 minutes. However, the move to 5# will have increased the treatment time for each fraction, as a higher dose per fraction, requiring longer, was delivered from Q2 2020 onwards. Further investigation of the relationship between appointment time and arrival time may uncover interesting trends.

With fewer patients attending appointments across the hospital, parking was also more readily available for those travelling by car. Traffic was reduced in most areas, with most people working from home when possible, meaning patients were less likely to be delayed during their journey. However, for those using public transport to access healthcare, the pandemic may have compounded the already apparent inequalities in access. ^{Reference Chen, Brozen and Rollman12} With other services closed or restricted, like local cancer charities and cafes, patients were less likely to arrive for their appointments earlier than required. From Q1 2022, as auxiliary services such as the café and cancer charities reopened, patients may have arrived early to their appointment to access these services, extending their time in the department.

The average time spent in the department for CT simulation decreased before COVID-19 and dropped by over 10% in 2020 due to minimisation of patient contact. It rose in 2021 and 2022 due to increased breath-hold coaching, after the introduction of SGRT at the centre. Overall, the average time spent in the department for CT simulation has decreased by 10 minutes since 2018. It has been suggested that patient coaching using educational materials before CT simulation could further reduce the time spent in the department for the CT simulation process for DIBH techniques. ^{Reference Oonsiri, Wisetrinthong and Chitnok13}

Treatment scheduling

For both 15# and 5# regimes, some days result in longer visits, especially on day one of treatment. This is often due to early arrival due to anxiety about parking or navigation, more time spent with staff for setup and questions, and uncertainty about the process. ¹⁴ Figure 3 shows that, for a 15# regime, patients were equally likely to be scheduled to begin treatment on any weekday, except a Friday. Compared to the 15# regime, patients receiving 5# of RT were also much less likely to start on a Tuesday. This is probably because, if a patient were to begin a 5# treatment regime on a Tuesday, they would receive four fractions that week, followed by a two-day break over the weekend, and then delivery of the final fraction on the Monday. Despite the literature stating that 5#s delivered over 7 days is non-inferior, ^{Reference Brunt, Haviland and Wheatley9} and this Tuesday-to-Monday scheduling fits that criteria, it does seem inefficient to leave just one fraction for the next week. This may also be why Fridays are rarely scheduled for a patient’s first day of treatment.

Analysis of the data also showed that, as patients progress through treatment, the length of time that they spend in the department decreases. For the 5# regime, the longest visits occur on Mondays and Wednesdays, common treatment start days and the shortest on Tuesdays and Fridays, which are typically the fifth and final treatment days. Naturally, patients will develop a better understanding of the treatment process as it progresses and may also become less anxious about their treatment. ^{Reference Nixon, Brown and Pigott15} The impact of pre-treatment patient education to reduce treatment anxiety should be further explored to elucidate any potential benefit to patients.

Figures 4a and 4b show that time of day impacts how long patients spend in the department. The earliest appointments are typically the shortest, likely due to fewer delays and staff efficiency. Mondays and Wednesdays have the longest sessions, aligning with common treatment start days, while Tuesdays and Fridays are the shortest, reflecting patients progressing through treatment. An interesting trend is the reduction in time before lunch, followed by an increase after, possibly due to a “pre-lunch rush” and slower return post-lunch.

Patient education can be used to reduce patient anxiety related to RT, ^{Reference Canil, Cashell and Papadakos16} and increase their understanding of the treatment process. ^{Reference Almerdhemah, Mulla and Muamenah17} The use of patient education to familiarise the patient with the clinical environment before their first day of treatment should be explored. It may be possible to decrease patient anxiety, and the time a patient spends in the department if frequently asked questions can be answered and the patient can be introduced to the clinical environment or treatment techniques, like DIBH. Conversely, it should be considered that as total time in the department reduces, so does a patient’s contact with healthcare professionals, which could reduce the care and support available to them. Asynchronous resources would help to maintain access to information, even as time spent in the department decreases.