Quality assurance in radiation oncology

Systematic Implementation of Effective Quality Assurance Processes for the Assessment of Radiation Target Volumes in Head and Neck Cancer

PURPOSE

Significant heterogeneity exists in clinical quality assurance (QA) practices within radiation oncology departments, with most chart rounds lacking prospective peer-reviewed contour evaluation. This has the potential to significantly affect patient outcomes, particularly for head and neck cancers (HNC) given the large variance in target volume delineation. With this understanding, we incorporated a prospective systematic peer contour-review process into our workflow for all patients with HNC. This study aims to assess the effectiveness of implementing prospective peer review into practice for our National Cancer Institute Designated Cancer Center and to report factors associated with contour modifications.

METHODS AND MATERIALS

Starting in November 2020, our department adopted a systematic QA process with real-time metrics, in which contours for all patients with HNC treated with radiation therapy were prospectively peer reviewed and graded. Contours were graded with green (unnecessary), yellow (minor), or red (major) colors based on the degree of peer-recommended modifications. Contours from November 2020 through September 2021 were included for analysis.

RESULTS

Three hundred sixty contours were included. Contour grades were made up of 89.7% green, 8.9% yellow, and 1.4% red grades. Physicians with >12 months of clinical experience were less likely to have contour changes requested than those with <12 months (8.3% vs 40.9%; P < .001). Contour grades were significantly associated with physician case load, with physicians presenting more than the median number of 50 cases having significantly less modifications requested than those presenting <50 (6.7% vs 13.3%; P = .013). Physicians working with a resident or fellow were less likely to have contour changes requested than those without a trainee (5.2% vs 12.6%; P = .039). Frequency of major modification requests significantly decreased over time after adoption of prospective peer contour review, with no red grades occurring >6 months after adoption.

CONCLUSIONS

This study highlights the importance of prospective peer contour-review implementation into systematic clinical QA processes for HNC. Physician experience proved to be the highest predictor of approved contours. A growth curve was demonstrated, with major modifications declining after prospective contour review implementation. Even within a high-volume academic practice with subspecialist attendings, >10% of patients had contour changes made as a direct result of prospective peer review.

Radiation Oncology Health Disparities in Pakistan

This article discusses problems and potential solutions for improving radiation oncology care in Pakistan.

100% peer review in radiation oncology: is it feasible?

Purpose

Peer review has been proposed as a strategy to ensure patient safety and plan quality in radiation oncology. Despite its potential benefits, barriers commonly exist to its optimal implementation in daily clinical routine. Our purpose is to analyze peer-review process at our institution.

Methods and materials

Based on our group peer-review process, we quantified the rate of plan changes, time and resources needed for this process. Prospectively, data on cases presented at our institutional peer-review conference attended by physicians, resident physicians and physicists were collected. Items such as time to present per case, type of patient (adult or pediatric), treatment intent, dose, aimed technique, disease location and receipt of previous radiation were gathered. Cases were then analyzed to determine the rate of major change, minor change and plan rejection after presentation as well as the median time per session.

Results

Over a period of 4 weeks, 148 cases were reviewed. Median of attendants was six physicians, three in-training-physicians and one physicist. Median time per session was 38 (4–72) minutes. 59.5% of cases presented in 1–4 min, 32.4% in 5–9 min and 8.1% in ≥ 10 min. 79.1% of cases were accepted without changes, 11.5% with minor changes, 6% with major changes and 3.4% were rejected with indication of new presentation. Most frequent reason of change was contouring corrections (53.8%) followed by dose or fractionation (26.9%).

Conclusion

Everyday group consensus peer review is an efficient manner to recollect clinical and technical data of cases presented to ensure quality radiation care before initiation of treatment as well as ensuring department quality in a feedback team environment. This model is feasible within the normal operation of every radiation oncology Department.

Impact of Peer Review in the Radiation Treatment Planning Process: Experience of a Tertiary Care University Hospital in Pakistan

PURPOSE

To evaluate and report the frequency of changes in radiation therapy treatment plans after peer review in a simulation review meeting once a week.

MATERIALS AND METHODS

Between July 1 and August 31, 2016, the radiation plans of 116 patients were discussed in departmental simulation review meetings. All plans were finalized by the primary radiation oncologist before presenting them in the meeting. A team of radiation oncologists reviewed each plan, and their suggestions were documented as no change, major change, minor change, or missing contour. Changes were further classified as changes in clinical target volume, treatment field, or dose. All recommendations were stratified on the basis of treatment intent, site, and technique. Data were analyzed by Statistical Package for the Social Sciences and are presented descriptively.

RESULTS

Out of 116 plans, 26 (22.4%) were recommended for changes. Minor changes were suggested in 15 treatment plans (12.9%) and a major change in 10 (8.6%), and only one plan was suggested for missing contour. The frequency of change recommendations was greater in radical radiation plans than in palliative plans (92.3% v 7.7%). The head and neck was the most common treatment site recommended for any changes (42.3%). Most of the changes were recommended in the technique planned with three-dimensional conformal radiation therapy (50%). Clinical target volume (73.1%) was identified as the most frequent parameter suggested for any change, followed by treatment field (19.2%) and dose (0.08%).

CONCLUSION

Peer review is an important tool that can be used to overcome deficiencies in radiation treatment plans, with a goal of improved and individualized patient care. Our study reports changes in up to a quarter of radiotherapy plans.

Assessing the Quality of a Radiation Oncology Case-Based, Peer-Review Program in an Integrated Academic and Community Cancer Center Network

Purpose:

Academic centers increasingly find a need to define a comprehensive peer-review program that can translate high-quality radiation therapy (RT) to community network sites. In this study, we describe the initial results of a quarterly quality audit program that aims to improve RT peer-review and provider educational processes across community sites.

Materials and Methods:

An electronic tool was used by community-based certified member (CM) sites to enter clinical treatment information about patients undergoing peer review. At least 10% of the patient load for each CM physician was selected for audit on a quarterly basis by expert academic faculty. Quality metrics included the review of the management plan, technical plan, and other indicators. RT was scored as being concordant or nonconcordant with institutional guidelines, national standards, or expert judgment.

Results:

A total of 719 patients were entered into the peer-review database by the first four CM sites. Of 14% of patients audited, 17% (18 of 104) were deemed nonconcordant. Nonconcordance rates were lowest in prevalent disease sites, such as breast (16%), colorectal (14%), and lung (12%), whereas rates were highest in lymphoma (50%), brain (44%), and gynecology (27%). Deficiencies included incomplete staging work-up, incorrect target and normal tissue delineation, and nonadherence to accepted dose-volume constraints.

Conclusion:

Given the high rate of nonconcordance, we recommend prospective, pre-RT peer review of all patients, and, in particular, expert review of patients that are from low-volume or complex disease sites. An integrated approach to peer review holds a promise of improving the quality, safety, and value of cancer therapy in the community setting.

Prospective peer review quality assurance for outpatient radiation therapy

PURPOSE

We implemented a peer review program that required presentation of all nonpalliative cases to a weekly peer review conference. The purpose of this review is to document compliance and determine how this program impacted care.

METHODS AND MATERIALS

A total of 2988 patients were eligible for peer review. Patient data were presented to a group of physicians, physicists, and dosimetrists, and the radiation therapy plan was reviewed. Details of changes made were documented within a quality assurance note dictated after discussion. Changes recommended by the peer review process were categorized as changes to radiation dose, target, or major changes.

RESULTS

Breast cancer accounted for 47.9% of all cases, followed in frequency by head-and-neck (14.8%), gastrointestinal (9.9%), genitourinary (9.3%), and thoracic (6.7%) malignancies. Of the 2988 eligible patients, 158 (5.3%) were not presented for peer review. The number of missed presentations decreased over time; 2007, 8.2%; 2008, 5.7%; 2009, 3.8%; and 2010, 2.7% (P < .001). The reason for a missed presentation was unknown but varied by disease site and physician. Of the 2830 cases presented for peer review, a change was recommended in 346 cases (12.2%) and categorized as a dose change in 28.3%, a target change in 69.1%, and a major treatment change in 2.6%. When examined by year of treatment the number of changes recommended decreased over time: 2007, 16.5%; 2008, 11.5%; 2009, 12.5%; and 2010, 7.8% (P < .001). The number of changes recommended varied by disease site and physician. The head-and-neck, gynecologic, and gastrointestinal malignancies accounted for the majority of changes made.

CONCLUSIONS

Compliance with this weekly program was satisfactory and improved over time. The program resulted in decreased treatment plan changes over time reflecting a move toward treatment consensus. We recommend that peer review be considered for patients receiving radiation therapy as it creates a culture where guideline adherence and discussion are part of normal practice.

Impact of a real-time peer review audit on patient management in a radiation oncology department

In September 2006, the Royal Australian and New Zealand College of Radiologists (RANZCR) endorsed the modified Peer Review Audit Tool (PRAT). We aimed to assess the feasibility of using this tool in a busy radiation oncology department using an electronic medical record (EMR) system, identify areas of compliance and assess the impact of the audit process on patient management. Fortnightly random clinical audit was undertaken by using the revised RANZCR PRAT in the departments of radiation oncology at Liverpool and Macarthur Cancer Therapy Centres (LCTC and MCTC). Following audit of the EMR, treatment plans were audited by peer review. Data were collected prospectively from June 2007 to June 2008. Audits were carried out on 208 patients. Behaviour criteria were well documented in the EMR, but scanning of histology and medical imaging reports did not occur in up to a third of cases. With electronic prescriptions, treatment prescription errors were rare. In total, 8 (3.8%) out of 208 patients had a change to management recommended. Variability in interpretation of PRAT 'protocol/study' criteria was identified. We found that real-time audit is feasible and effective in detecting both issues with documentation in the EMR, and a small number of patients in whom a change to management is recommended. Recommendations have been made in order to continue to improve the audit process including documentation of any changes recommended and whether the recommended change occurred.

Development of a clinical chart audit programme

Radiation oncology charts containing medical information and treatment details are the major methods of communication between the various personnel involved in delivering radiation therapy to the patient. It is paramount to good patient care for this communication to be clear, precise and accurate in detail. A regular chart audit should be a part of the quality assurance programme of every radiation oncology department. The primary aim of this study was to develop and assess an objective and quantitative programme for reviewing radiation oncology charts, thereby improving the quality of communication and hence patient management. A secondary aim was to compare the charts of radically treated patients with those treated palliatively. A pilot study using a new chart review tool, developed at the Perth Radiation Oncology Centre, was carried out over an 8-month period. A sample of charts, representing 25% of our treatment group, were assessed using the tool on a monthly basis. A total of 156 charts were reviewed during this time period. Fifty-six per cent were radical treatments and 44% were palliative. The overall mean chart scores significantly improved over the time of this study (P < 0.001). The individual radiation oncologists' scores were also seen to improve during the study period. The alpha coefficients for intra-rater and inter-rater reliability were 0.99 and 0.88, respectively. The chart review programme was found to be an easy-to-use and a reliable tool by both medical and non-medical reviewers. It appeared to have a positive influence on the standard of radiation oncology charts in our department.

Reliability of portal control procedure in irradiation of breast cancer: A Bayesian analysis

BACKGROUND AND PURPOSE

To determine whether the information gathered from a fixed number of periodic verification films accurately reflects the true imprecision in patient positioning during the whole radiation therapy of early breast cancer.

PATIENTS AND METHODS

A total of 204 medial and lateral treatment fields were evaluated in 102 breast cancer patients treated with conservative surgery and radiation therapy. For each treatment field, the central lung distance was measured on portal films obtained from one simulation and four treatment controls at weekly intervals during breast irradiation. Systematic and random errors in patient positioning throughout all treatment fractions were estimated from the available controls using Bayesian methods.

RESULTS

The average systematic and random errors during treatment controls were 2.7 and 1.9 mm, respectively. For these mean control values, the probabilities that the true systematic and random errors remain below 5mm during all treatment fractions were 99 and 100%, respectively.

CONCLUSIONS

Reproducibility of patient positioning was supported by a virtually null probability for systematic or random errors greater than 5 mm during the whole radiation therapy. Weekly verification films seem to be sufficient to estimate patient positioning errors with high accuracy in radiotherapy of early breast cancer.

A real-time audit of radiation therapy in a regional cancer center

PURPOSE

To report the development, structure, and implementation of a real-time clinical radiotherapy audit of the practice of radiation oncology in a regional cancer center.

METHODS AND MATERIALS

Radiotherapy treatment plans were audited by a real-time peer-review process over an 8-year period (1989-1996). The overall goal of the audit was to establish a process for quality assurance (QA) of radiotherapy planning and prescription for individual patients. A parallel process was developed to audit the implementation of intervention-specific radiotherapy treatment policies.

RESULTS

A total of 3052 treatment plans were audited. Of these, 124 (4.1%) were not approved by the audit due to apparent errors in radiation planning. The majority of the nonapproved plans (79%) were modified prior to initiating treatment; the audit provided important clinical feedback about individual patient care in these instances. Most of the remaining nonapproved plans were deviations from normal practice due to patient-specific considerations. A further 110 (3.6% of all audited plans) were not approved by the audit due to deviations from radiotherapy treatment policy. A minority of these plans (22%) were modified prior to initiating treatment and the remainder provided important feedback for continuous quality improvement of treatment policies.

CONCLUSION

A real-time audit of radiotherapy practice in a regional cancer center setting proved feasible and provided important direct and indirect patient benefits.

Factors that influence the eligibility of cases for inclusion in clinical trials. The Lung Cancer Chemotherapy Study Group of the Japan Clinical Oncology Group

BACKGROUND

It is important to minimize the incidence of ineligible cases to improve the quality of clinical trials. To determine factors which may influence the incidence of ineligible cases, the incidence of and reasons for ineligibility in clinical trials were retrospectively analyzed.

METHODS

We retrospectively examined the incidence of and reasons for ineligibility for inclusion in eight clinical trials conducted by the Lung Cancer Chemotherapy Study Group of the Japan Clinical Oncology Group and four trials financed by trust funds from a pharmaceutical company.

RESULTS

In these 12 clinical studies, the incidence of ineligibility was 4.2% (32/762) (range 0-10.6%). Specific factors that might influence the incidence of ineligible cases were then analyzed. There was a significant difference in the incidence of ineligibility between the methods of registration (P < 0.05). The incidences using a central registration and without using a central registration system were 2.8% (9/322) and 5.2% (23/440) respectively. We also analyzed ineligible cases in clinical studies published in the Journal of Clinical Oncology. In clinical studies published in the Journal of Clinical Oncology recently and 10 years ago, the incidences of ineligible cases were 5.0% (942/18 878) and 4.1% (206/4995) respectively. In clinical studies on lung cancer published in the Journal of Clinical Oncology from 1984 to 1995, the incidence of ineligible cases was 4.7% (900/19,116). There was no significant difference in the incidence of ineligible cases between our 12 studies and the Journal of Clinical Oncology clinical studies by the chi 2 test (P > 0.05).

CONCLUSIONS

We conclude that the incidence of ineligible cases in our studies is similar to that in clinical trials published in the Journal of Clinical Oncology. Central registration systems are useful for checking for ineligibility, and to increase the quality of clinical trials.

The use of diode dosimetry in quality improvement of patient care in radiation therapy

The purpose of this work is to improve the quality of patient care in radiation therapy by implementing a comprehensive quality assurance (QA) program aiming to enhance patient in vivo dosimetry on a routine basis. The characteristics of two commercially available semi-conductor diode dosimetry systems were evaluated. The diodes were calibrated relative to an ionization chamber-electrometer system with calibrations traceable to the National Institute of Standards and Technology (NIST). Correction factors of clinical relevance were quantified to convert the diode readings into patient dose. The results of dose measurements on 6 patients undergoing external beam radiation therapy for carcinoma of the prostate on three different therapy units are presented. Field shaping during treatments was accomplished either by multileaf collimation or by cerrobend blocking. A deviation of less than +/-4% between the measured and prescribed patient doses was observed. The results indicate that the diodes exhibit excellent linearity, dose reproducibility, minimal anisotropy, and can be used with confidence for patient dose verification. Furthermore, diodes render real time verification of dose delivered to patients.

Radiation therapy of breast carcinoma: confirmation of prescription dose using diodes

PURPOSE

To quantitate the dose delivered during tangential breast radiation therapy and measure the scatter dose to the contralateral breast for three different breast setup techniques.

METHODS AND MATERIALS

A commercial semiconductor diode system is used for dose measurements. The diode characteristics were studied by comparing the diode response against a standard ionization chamber response in a reference configuration. In vivo dose measurements on 11 patients undergoing tangential breast radiation therapy with 6 MV photons were performed. Medial and lateral field entrance and exit doses were measured and compared with the expected values from the treatment planning system. Scatter doses to the contralateral breast for three breast setup techniques were measured and documented as a function of distance from the field edge and various beam modifiers commonly used in breast radiation therapy.

RESULTS

The diodes used in this study exhibited excellent linearity, dose reproducibility, and minimal anisotropy. The in-phantom measurements resulted in dose accuracy within +/- 1.5%. Dose measurements on patients resulted in standard deviations of 1.2 and 2.3% for the medial entrance and exit doses and 1.7 and 2.2% for the lateral entrance and exit doses, respectively. In patients, the scatter doses to the opposite breast at a 5 cm perpendicular distance from the medial field edge resulted in cumulative scatter doses of 2.47 to 5.30 Gy from the tangential fields and an additional 0.50 Gy from the supraclavicular or axillary field, if included.

CONCLUSION

Quantitative verification of the prescribed daily dose is important in breast radiation therapy to ensure precision in patient setup and accuracy in dose delivery. Diodes provide a convenient way of real-time patient dose verification and are easy to use by the therapists.