A clinical approach to technology assessment: how do we and how should we choose the right treatment?

A systematic literature review of definitions and classification systems for radiotherapy innovation: A first step towards building a value-based assessment tool for radiation oncology

INTRODUCTION

Timely access to radiotherapy innovations remains suboptimal, partly because there is no commonly agreed appraisal system suitable for the broad range of radiotherapy interventions. The Health Economics in Radiation Oncology (HERO) programme of ESTRO therefore engaged in building a radiotherapy-specific value-based framework. We report on a first step towards that aim, documenting the available definitions and classification systems for radiotherapy interventions.

METHODS

A systematic literature search was carried out in Pubmed and Embase, following PRISMA methodology and using search terms on 'innovation', 'radiotherapy', 'definition' and 'classification'. Data were extracted from articles that met prespecified inclusion criteria.

RESULTS

Out of 13,353 articles, 25 met the inclusion criteria, resulting in the identification of 7 definitions of innovation and 15 classification systems applicable to radiation oncology. Iterative appraisal divided the classification systems into two groups. A first group of 11 systems categorized innovations according to the perceived magnitude of innovation, typically 'minor' versus 'major'. The remaining 4 systems categorised innovations according to radiotherapy-specific characteristics, such as the type of radiation equipment or radiobiological properties. Here, commonly used terms as 'technique' or 'treatment' were found to be used in different meanings.

DISCUSSION

There is no widely accepted definition or classification system for radiotherapy innovations. The data however suggest that unique properties of radiotherapy interventions can be used to categorise innovations in radiation oncology. Still, there remains a need for clear terminology denoting radiotherapy-specific characteristics.

CONCLUSION

Building on this review, the ESTRO-HERO project will define what is required for a radiotherapy-specific value-based assessment tool.

Value-based radiotherapy: A new chapter of the ESTRO-HERO project

Radiotherapy interventions are rapidly evolving and improving, holding promise for better patient outcomes, yet at the possible detriment of higher societal costs. The ESTRO-HERO value-based radiotherapy project aims to develop a framework defining and assessing the value of radiotherapy innovations, to support clinical implementation and equitable access, within a sustainable healthcare system.

Defining the clinician's role in early health technology assessment during medical device innovation - a systematic review

Background

Early Health Technology Assessment (EHTA) is an evolving field in health policy which aims to provide decision support and mitigate risk during early medical device innovation. The clinician is a key stakeholder in this process and their role has traditionally been confined to assessing device efficacy and safety alone. There is however, no data exploring their role in this process and how they can contribute towards it. This motivated us to carry out a systematic review to delineate the role of the clinician in EHTA as per the PRISMA guidelines.

Methods

A systematic search of peer reviewed literature was undertaken across PUBMED, OVID Medline and Web of science up till June 2018. Studies that were suitable for inclusion focused on clinician input in health technology assessment or early medical device innovation. A qualitative approach was utilised to generate themes on how clinicians could contribute in general and specific areas of EHTA. Data was manually extracted by the authors and themes were agreed in consensus using a grounded theory framework. The specific stages included: All stages of EHTA, Basic research on mechanisms, Targeting for specific product, Proof of principle and Prototype and product development. Bias was assessed utilising the NICE Qualitative checklist.

Results

A total of 33 articles met the inclusion criteria for the review. Areas identified in which the clinicians could contribute to EHTA included: i) needs driven problem solving, ii) conformity assessment of MDs, iii) economic evaluation of MDs and iv) addressing the conflicts in interest. For clinicians’ input across the various specific areas of EHTA, an innovation framework was generated based on the subthemes extracted.

Conclusions

The following review has identified the various segments in which clinicians can contribute to EHTA to inform stakeholders and has also proposed an innovation framework.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4305-9) contains supplementary material, which is available to authorized users.

Radiation Therapy Research: A Global Analysis 2001-2015

Radiation therapy is a core modality of cancer treatment; however, concerns have been expressed regarding its underutilization and its lack of prioritization as a research domain relative to other cancer treatment modalities, despite its rapid technical evolution. It is therefore important to understand, from a public policy perspective, the evolution of global radiation therapy research, to identify strengths, weaknesses, and opportunities. This study used a bibliometric approach to undertake a quantitative analysis of global radiation therapy research published between 2001 and 2015 and available in the Web of Science (Wos) database, with particular focus on the 25 leading research-active countries. A total of 62,550 radiation therapy research articles from 127 countries, published in 2531 international journals, were analyzed. The United States was responsible for 32.3% of these outputs, followed by Japan (8.0%) and Germany (7.7%). Nearly half of all publications related to preparation and delivery of radiation therapy, combined-modality regimens, and dose fractionation studies. Health services research, palliative care, and quality of life studies represented only 2%, 5%, and 4% of all research outputs, respectively. Countries varied significantly in their commitment to different research domains, and trial-related publications represented only 5.1% of total output. Research impact was analyzed according to 3 different citation scores, with research outputs from Denmark, The Netherlands, and the United States consistently the highest ranked. Globally, radiation therapy publication outputs continue to increase but lag behind other spheres of cancer management. The types of radiation therapy research undertaken appear to be regionally patterned, and there is a clear disconcordance between the volume of research output from individual countries and its citation impact. Greater support for radiation therapy research in low- and middle-income countries is required, including international collaboration. The study findings are expected to provide the requisite knowledge to guide future radiation therapy research programs.

R-IDEAL: A Framework for Systematic Clinical Evaluation of Technical Innovations in Radiation Oncology

The pace of innovation in radiation oncology is high and the window of opportunity for evaluation narrow. Financial incentives, industry pressure, and patients' demand for high-tech treatments have led to widespread implementation of innovations before, or even without, robust evidence of improved outcomes has been generated. The standard phase I-IV framework for drug evaluation is not the most efficient and desirable framework for assessment of technological innovations. In order to provide a standard assessment methodology for clinical evaluation of innovations in radiotherapy, we adapted the surgical IDEAL framework to fit the radiation oncology setting. Like surgery, clinical evaluation of innovations in radiation oncology is complicated by continuous technical development, team and operator dependence, and differences in quality control. Contrary to surgery, radiotherapy innovations may be used in various ways, e.g., at different tumor sites and with different aims, such as radiation volume reduction and dose escalation. Also, the effect of radiation treatment can be modeled, allowing better prediction of potential benefits and improved patient selection. Key distinctive features of R-IDEAL include the important role of predicate and modeling studies (Stage 0), randomization at an early stage in the development of the technology, and long-term follow-up for late toxicity. We implemented R-IDEAL for clinical evaluation of a recent innovation in radiation oncology, the MRI-guided linear accelerator (MR-Linac). MR-Linac combines a radiotherapy linear accelerator with a 1.5-T MRI, aiming for improved targeting, dose escalation, and margin reduction, and is expected to increase the use of hypofractionation, improve tumor control, leading to higher cure rates and less toxicity. An international consortium, with participants from seven large cancer institutes from Europe and North America, has adopted the R-IDEAL framework to work toward coordinated, evidence-based introduction of the MR-Linac. R-IDEAL holds the promise for timely, evidence-based introduction of radiotherapy innovations with proven superior effectiveness, while preventing unnecessary exposure of patients to potentially harmful interventions.

Application of a laser-guided docking system in robot-assisted urologic surgery

BACKGROUND

This work explores the clinical significance of a laser-guided docking system for robot-assisted urologic surgery.

MATERIALS AND METHODS

Between July 2013 and June 2014, 40 patients underwent robot-assisted laparoscopic prostatectomy (RALP), and 32 patients underwent robot-assisted laparoscopic partial nephrectomy (RAPN) performed by a single surgeon. In the RALP and RAPN groups, the robot was docked in the traditional way in 20 and 16 cases, respectively. A laser guiding system was used in the other cases. The docking time and the time required to adjust the angles were recorded.

RESULT

The docking time was significantly shorter for the laser-guided process performed by inexperienced nurses. The time required to adjust the angles was also lower. There were no significant differences between the processes performed by experienced nurses.

CONCLUSION

A laser-guided docking system may simplify and standardize the docking process and shorten the learning curve. Copyright © 2015 John Wiley & Sons, Ltd.

Intensity-modulated radiation therapy for prostate cancer is cost effective and improves therapeutic ratio

Radiation therapy is one of the standard treatment options for many prostate cancer patients. Intensity-modulated radiation therapy (IMRT) allows for more conformal dose distributions that can reduce normal tissue toxicity compared with older external beam techniques. There has been a rapid adoption of IMRT between 2001 and 2007 for prostate cancer patients regardless of the patients' race, socioeconomic status or disease risk classification. IMRT is more expensive than older radiation techniques and has an impact on healthcare spending for prostate cancer.

Quality indicators in radiation oncology

Oncologic specialty societies and multidisciplinary collaborative groups have dedicated considerable effort to developing evidence-based quality indicators (QIs) to facilitate quality improvement, accreditation, benchmarking, reimbursement, maintenance of certification, and regulatory reporting. In particular, the field of radiation oncology has a long history of organized quality assessment efforts and continues to work toward developing consensus quality standards in the face of continually evolving technologies and standards of care. This report provides a comprehensive review of the current state of quality assessment in radiation oncology. Specifically, this report highlights implications of the healthcare quality movement for radiation oncology and reviews existing efforts to define and measure quality in the field, with focus on dimensions of quality specific to radiation oncology within the "big picture" of oncologic quality assessment efforts.