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Kaplan LP, Placidi L, Bäck A, Canters R, Hussein M, Vaniqui A, Fusella M, Piotrowski T, Hernandez V, Jornet N, Hansen CR, Widesott L. Plan quality assessment in clinical practice: Results of the 2020 ESTRO survey on plan complexity and robustness. Radiother Oncol 2022; 173:254-261. [PMID: 35714808 DOI: 10.1016/j.radonc.2022.06.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 05/24/2022] [Accepted: 06/07/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE Plan complexity and robustness are two essential aspects of treatment plan quality but there is a great variability in their management in clinical practice. This study reports the results of the 2020 ESTRO survey on plan complexity and robustness to identify needs and guide future discussions and consensus. METHODS A survey was distributed online to ESTRO members. Plan complexity was defined as the modulation of machine parameters and increased uncertainty in dose calculation and delivery. Robustness was defined as a dose distribution's sensitivity towards errors stemming from treatment uncertainties, patient setup, or anatomical changes. RESULTS A total of 126 radiotherapy centres from 33 countries participated, 95 of them (75%) from Europe and Central Asia. The majority controlled and evaluated plan complexity using monitor units (56 centres) and aperture shapes (38 centres). To control robustness, 98 (97% of question responses) photon and 5 (50%) proton centres used PTV margins for plan optimization while 75 (94%) and 5 (50%), respectively, used margins for plan evaluation. Seventeen (21%) photon and 8 (80%) proton centres used robust optimisation, while 10 (13%) and 8 (80%), respectively, used robust evaluation. Primary uncertainties considered were patient setup (photons and protons) and range calculation uncertainties (protons). Participants expressed the need for improved commercial tools to control and evaluate plan complexity and robustness. CONCLUSION Clinical implementation of methods to control and evaluate plan complexity and robustness is very heterogeneous. Better tools are needed to manage complexity and robustness in treatment planning systems. International guidelines may promote harmonization.
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Affiliation(s)
- Laura Patricia Kaplan
- Department of Oncology, Aarhus University Hospital, Denmark; Department of Clinical Medicine, Aarhus University, Denmark.
| | - Lorenzo Placidi
- Fondazione Policlinico Universitario ''A. Gemelli'' IRCCS, Roma, Italy.
| | - Anna Bäck
- Department of Therapeutic Radiation Physics, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Medical Radiation Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Richard Canters
- Department of Radiation Oncology (Maastro), GROW School for Oncology, Maastricht University Medical Centre+, the Netherlands
| | - Mohammad Hussein
- Metrology for Med Phys Centre, National Physical Laboratory, Teddington, United Kingdom
| | - Ana Vaniqui
- Department of Radiation Oncology (Maastro), GROW School for Oncology, Maastricht University Medical Centre+, the Netherlands
| | - Marco Fusella
- Department of Med Phys, Veneto Institute of Oncology - IOV IRCCS, Padua, Italy
| | - Tomasz Piotrowski
- Department of Electroradiology, Poznan University of Medical Sciences and Department of Med Phys, Greater Poland Cancer Centre, Poznan, Poland
| | - Victor Hernandez
- Department of Med Phys, Hospital Sant Joan de Reus, IISPV, Spain
| | - Nuria Jornet
- Servei de Radiofísica i Radioprotecció, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Christian Rønn Hansen
- Laboratory of Radiation Physics, Department of Oncology, Odense University Hospital, Denmark; Danish Centre for Particle Therapy, Aarhus University Hospital, Denmark; Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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Qureshi BM, Mansha MA, Karim MU, Hafiz A, Ali N, Mirkhan B, Shaukat F, Tariq M, Abbasi AN. Impact of Peer Review in the Radiation Treatment Planning Process: Experience of a Tertiary Care University Hospital in Pakistan. J Glob Oncol 2020; 5:1-7. [PMID: 31393752 PMCID: PMC6733206 DOI: 10.1200/jgo.19.00039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
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.
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Affiliation(s)
| | | | | | - Asim Hafiz
- The Aga Khan University, Karachi, Pakistan
| | - Nasir Ali
- The Aga Khan University, Karachi, Pakistan
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Eedes DJ, Bailey B, Burger H. Chemotherapy administration standards and guidelines: The development of a resource document. SOUTH AFRICAN JOURNAL OF ONCOLOGY 2018. [DOI: 10.4102/sajo.v2i0.48] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
There are no nationally recognised guidelines for the handling and administration of chemotherapy in South Africa. The Independent Clinical Oncology Network’s Chemotherapy Administration Standards and Guidelines Resource Documentwas developed over 2 years and first introduced at a South African international oncology conference in 2017. A working group consisting of oncologists and oncology nurses was set up to address this deficiency. Pragmatic guidelines suitable to a wide range of local chemotherapy administration practices were developed using an iterative, multidisciplinary, collaborative process. The consensus was that these guidelines should be appropriate to the South African context. Safety, standard operational procedures, recommended professional competencies and training were central to the document. Guidelines for prescribing, storing, mixing, dispensing, administering and disposing of chemotherapy were included. Patient consent and involvement, patient and staff safety, recommended professional competencies, management of accidents and errors, error reporting and local legal requirements are dealt with in detail. The hope is that these guidelines will be used as a resource document for South African chemotherapy practices, both public and private. The document is supported by standard operating procedures and action steps. These were developed to promote the use of the guidelines and to support pragmatic quality assurance measures at practice level. These standards and guidelines will be regularly updated, based on needs identified and deficiencies noted.
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Torras MG, Canals E, Jurado-Bruggeman D, Marín-Borras S, Macià M, Jové J, Boladeras AM, Muñoz-Montplet C, Molero J, Picón C, Puigdemont M, Aliste L, Torrents A, Guedea F, Borras JM. Clinical Audit of the Radiotherapy Process in Rectal Cancer: Clinical Practice Guidelines and Quality Certification Do Not Avert Variability in Clinical Practice. Transl Oncol 2018; 11:794-799. [PMID: 29704788 PMCID: PMC6058082 DOI: 10.1016/j.tranon.2018.03.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 03/29/2018] [Indexed: 12/18/2022] Open
Affiliation(s)
- M G Torras
- Clinical Management Department, Institut Català d'Oncologia, Spain.
| | - E Canals
- Radiation Oncology Department, Institut Català d'Oncologia, Girona, Spain
| | - D Jurado-Bruggeman
- Medical Physics and Radiation Protection Department, Institut Català d'Oncologia, Girona, Spain
| | - S Marín-Borras
- Radiation Oncology Department, Institut Català d'Oncologia, L'Hospitalet de Llobregat, Spain
| | - M Macià
- Radiation Oncology Department, Institut Català d'Oncologia, L'Hospitalet de Llobregat, Spain
| | - J Jové
- Radiation Oncology Department, Institut Català d'Oncologia, Badalona, Spain
| | - A M Boladeras
- Radiation Oncology Department, Institut Català d'Oncologia, L'Hospitalet de Llobregat, Spain
| | - C Muñoz-Montplet
- Medical Physics and Radiation Protection Department, Institut Català d'Oncologia, Spain
| | - J Molero
- Medical Physics and Radiation Protection Department, Institut Català d'Oncologia, Badalona, Spain
| | - C Picón
- Medical Physics and Radiation Protection Department, Institut Català d'Oncologia, L'Hospitalet de Llobregat, Spain
| | - M Puigdemont
- Hospital Tumor Registry, Institut Català d'Oncologia, Girona, Spain
| | - L Aliste
- Catalonian Cancer Strategy, Department of Health, Barcelona
| | - A Torrents
- Catalonian Cancer Strategy, Department of Health, Barcelona
| | - F Guedea
- Radiation Oncology Department, Institut Català d'Oncologia, Spain
| | - J M Borras
- Catalonian Cancer Strategy, Department of Health, Barcelona; Radiation Oncology Department, Institut Català d'Oncologia, Spain; Clinical Sciences Department, IDIBELL, University of Barcelona
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5
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Hernandez V, Saez J, Pasler M, Jurado-Bruggeman D, Jornet N. Comparison of complexity metrics for multi-institutional evaluations of treatment plans in radiotherapy. PHYSICS & IMAGING IN RADIATION ONCOLOGY 2018; 5:37-43. [PMID: 33458367 PMCID: PMC7807588 DOI: 10.1016/j.phro.2018.02.002] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2017] [Revised: 01/30/2018] [Accepted: 02/01/2018] [Indexed: 11/17/2022]
Abstract
Several complexity metrics were highly correlated and can be considered equivalent. Other metrics produced different results, especially for plans from different TPSs. Different TPSs prioritise modulation of different plan parameters. The ranking of plan complexity can greatly depend on the metric used. This must be carefully considered in multi-institutional plan comparisons.
Background and purpose It is known that intensity-modulated radiotherapy plans that are highly complex might be less accurate in dose calculation and treatment delivery. Multiple complexity metrics have been proposed, but the relationships between them have not been thoroughly investigated. This study investigated these relationships in multi-institutional comparisons of treatment plans, where plans from multiple treatment planning systems (TPSs) are typically evaluated. Materials and methods A program was developed to compute several complexity indices and provide analysis of dynamic plan parameters. This in-house software was used to analyse plans from a recent multi-institutional audit. Additionally, 100 clinical volumetric modulated arc therapy (VMAT) plans from two institutions using different TPSs were analysed. Results All plans produced satisfactory pre-treatment verification results and, hence, complexity metrics could not be used to predict plans failing QA. Regarding the relationship among complexity indices, some very strong correlations were found (r > 0.9 with p < 0.01). However, some relevant discrepancies between complexity indices were obtained, even with negative correlation coefficients (r ∼ −0.6) which were expected to be positive. These discrepancies could be explained because each complexity index focused on different features of the plan and different TPSs prioritised modulation of different plan parameters. Conclusions Some complexity indices provided similar information and can be considered equivalent. However, indices that focused on different plan parameters yielded different results and it was unclear which complexity index should be used. Careful consideration should be given to the use of complexity metrics in multi-institutional studies.
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Affiliation(s)
- Victor Hernandez
- Department of Medical Physics, Hospital Universitari Sant Joan de Reus, IISPV, Tarragona, Spain
| | - Jordi Saez
- Department of Radiation Oncology, Hospital Clínic de Barcelona, Spain
| | - Marlies Pasler
- Lake Constance Radiation Oncology Center Singen-Friedrichshafen, Germany
| | - Diego Jurado-Bruggeman
- Medical Physics and Radiation Protection Department, Institut Català d'Oncologia, Girona, Spain
| | - Nuria Jornet
- Servei de Radiofísica i Radioprotecció, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
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6
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Thaker NG, Sturdevant L, Jhingran A, Das P, Delclos ME, Gunn GB, McAleer MF, Tereffe W, Choi SL, Frank SJ, Simeone WJ, Martinez W, Hahn SM, Famiglietti R, Kuban DA. Assessing the Quality of a Radiation Oncology Case-Based, Peer-Review Program in an Integrated Academic and Community Cancer Center Network. J Oncol Pract 2016; 12:e476-86. [DOI: 10.1200/jop.2015.005983] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
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.
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Affiliation(s)
| | | | - Anuja Jhingran
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Prajnan Das
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Marc E. Delclos
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Gary B. Gunn
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Welela Tereffe
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Steven J. Frank
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Wendi Martinez
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Stephen M. Hahn
- The University of Texas MD Anderson Cancer Center, Houston, TX
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7
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Clark CH, Aird EGA, Bolton S, Miles EA, Nisbet A, Snaith JAD, Thomas RAS, Venables K, Thwaites DI. Radiotherapy dosimetry audit: three decades of improving standards and accuracy in UK clinical practice and trials. Br J Radiol 2015; 88:20150251. [PMID: 26329469 DOI: 10.1259/bjr.20150251] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Dosimetry audit plays an important role in the development and safety of radiotherapy. National and large scale audits are able to set, maintain and improve standards, as well as having the potential to identify issues which may cause harm to patients. They can support implementation of complex techniques and can facilitate awareness and understanding of any issues which may exist by benchmarking centres with similar equipment. This review examines the development of dosimetry audit in the UK over the past 30 years, including the involvement of the UK in international audits. A summary of audit results is given, with an overview of methodologies employed and lessons learnt. Recent and forthcoming more complex audits are considered, with a focus on future needs including the arrival of proton therapy in the UK and other advanced techniques such as four-dimensional radiotherapy delivery and verification, stereotactic radiotherapy and MR linear accelerators. The work of the main quality assurance and auditing bodies is discussed, including how they are working together to streamline audit and to ensure that all radiotherapy centres are involved. Undertaking regular external audit motivates centres to modernize and develop techniques and provides assurance, not only that radiotherapy is planned and delivered accurately but also that the patient dose delivered is as prescribed.
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Affiliation(s)
- Catharine H Clark
- 1 Department of Medical Physics, Royal Surrey County Hospital, Guildford, Surrey, UK.,2 Radiation Dosimetry Group, National Physical Laboratory, Teddington, Middlesex, UK
| | - Edwin G A Aird
- 3 RTTQA Group, Mount Vernon Hospital, Northwood, Middlesex, UK
| | - Steve Bolton
- 4 Medical Physics and Engineering Department, Christie Hospital NHS Foundation Trust, Manchester, UK.,5 Institute of Physics and Engineering in Medicine, York, UK
| | | | - Andrew Nisbet
- 1 Department of Medical Physics, Royal Surrey County Hospital, Guildford, Surrey, UK.,6 Department of Physics, University of Surrey, Guildford, UK
| | - Julia A D Snaith
- 2 Radiation Dosimetry Group, National Physical Laboratory, Teddington, Middlesex, UK
| | - Russell A S Thomas
- 2 Radiation Dosimetry Group, National Physical Laboratory, Teddington, Middlesex, UK
| | - Karen Venables
- 3 RTTQA Group, Mount Vernon Hospital, Northwood, Middlesex, UK
| | - David I Thwaites
- 7 Institute of Medical Physics, School of Physics, University of Sydney, Sydney, NSW, Australia
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8
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Bröckelmann PJ, Goergen H, Fuchs M, Kriz J, Semrau R, Baues C, Kobe C, Behringer K, Eichenauer DA, von Tresckow B, Klimm B, Halbsguth T, Wongso D, Plütschow A, Haverkamp H, Dietlein M, Eich HT, Stein H, Diehl V, Borchmann P, Engert A. Impact of centralized diagnostic review on quality of initial staging in Hodgkin lymphoma: experience of the German Hodgkin Study Group. Br J Haematol 2015; 171:547-56. [DOI: 10.1111/bjh.13646] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Accepted: 07/23/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Paul J. Bröckelmann
- Department I of Internal Medicine; University Hospital of Cologne; Cologne Germany
- German Hodgkin Study Group (GHSG); Cologne Germany
| | | | - Michael Fuchs
- Department I of Internal Medicine; University Hospital of Cologne; Cologne Germany
- German Hodgkin Study Group (GHSG); Cologne Germany
| | - Jan Kriz
- German Hodgkin Study Group (GHSG); Cologne Germany
- Department of Radiation Oncology; University Hospital Münster; Münster Germany
| | - Robert Semrau
- German Hodgkin Study Group (GHSG); Cologne Germany
- Department of Radiation Oncology; University Hospital of Cologne; Cologne Germany
| | - Christian Baues
- German Hodgkin Study Group (GHSG); Cologne Germany
- Department of Radiation Oncology; University Hospital of Cologne; Cologne Germany
| | - Carsten Kobe
- German Hodgkin Study Group (GHSG); Cologne Germany
- Department of Nuclear Medicine; University Hospital of Cologne; Cologne Germany
| | - Karolin Behringer
- Department I of Internal Medicine; University Hospital of Cologne; Cologne Germany
- German Hodgkin Study Group (GHSG); Cologne Germany
| | - Dennis A. Eichenauer
- Department I of Internal Medicine; University Hospital of Cologne; Cologne Germany
- German Hodgkin Study Group (GHSG); Cologne Germany
| | - Bastian von Tresckow
- Department I of Internal Medicine; University Hospital of Cologne; Cologne Germany
- German Hodgkin Study Group (GHSG); Cologne Germany
| | - Beate Klimm
- German Hodgkin Study Group (GHSG); Cologne Germany
- Department III of Internal Medicine; Krankenhaus Düren; Düren Germany
| | - Teresa Halbsguth
- German Hodgkin Study Group (GHSG); Cologne Germany
- Department II of Internal Medicine; University Hospital of Frankfurt; Frankfurt Germany
| | - Diana Wongso
- German Hodgkin Study Group (GHSG); Cologne Germany
| | | | | | - Markus Dietlein
- German Hodgkin Study Group (GHSG); Cologne Germany
- Department of Nuclear Medicine; University Hospital of Cologne; Cologne Germany
| | - Hans T. Eich
- German Hodgkin Study Group (GHSG); Cologne Germany
- Department of Radiation Oncology; University Hospital Münster; Münster Germany
| | - Harald Stein
- German Hodgkin Study Group (GHSG); Cologne Germany
- Pathodiagnostik Berlin; Berlin Germany
| | - Volker Diehl
- German Hodgkin Study Group (GHSG); Cologne Germany
| | - Peter Borchmann
- Department I of Internal Medicine; University Hospital of Cologne; Cologne Germany
- German Hodgkin Study Group (GHSG); Cologne Germany
| | - Andreas Engert
- Department I of Internal Medicine; University Hospital of Cologne; Cologne Germany
- German Hodgkin Study Group (GHSG); Cologne Germany
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Chung Y, Kim JW, Shin KH, Kim SS, Ahn SJ, Park W, Lee HS, Kim DW, Lee KC, Suh HS, Kim JH, Shin HS, Kim YB, Suh CO. Dummy run of quality assurance program in a phase 3 randomized trial investigating the role of internal mammary lymph node irradiation in breast cancer patients: Korean Radiation Oncology Group 08-06 study. Int J Radiat Oncol Biol Phys 2015; 91:419-26. [PMID: 25636764 DOI: 10.1016/j.ijrobp.2014.10.022] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Revised: 10/03/2014] [Accepted: 10/10/2014] [Indexed: 11/17/2022]
Abstract
PURPOSE The Korean Radiation Oncology Group (KROG) 08-06 study protocol allowed radiation therapy (RT) technique to include or exclude breast cancer patients from receiving radiation therapy to the internal mammary lymph node (IMN). The purpose of this study was to assess dosimetric differences between the 2 groups and potential influence on clinical outcome by a dummy run procedure. METHODS AND MATERIALS All participating institutions were asked to produce RT plans without irradiation (Arm 1) and with irradiation to the IMN (Arm 2) for 1 breast-conservation treatment case (breast-conserving surgery [BCS]) and 1 mastectomy case (modified radical mastectomy [MRM]) whose computed tomography images were provided. We assessed interinstitutional variations in IMN delineation and evaluated the dose-volume histograms of the IMN and normal organs. A reference IMN was delineated by an expert panel group based on the study guidelines. Also, we analyzed the potential influence of actual dose variation observed in this study on patient survival. RESULTS Although physicians intended to exclude the IMN within the RT field, the data showed almost 59.0% of the prescribed dose was delivered to the IMN in Arm 1. However, the mean doses covering the IMN in Arm 1 and Arm 2 were significantly different for both cases (P<.001). Due to the probability of overdose in Arm 1, the estimated gain in 7-year disease-free survival rate would be reduced from 10% to 7.9% for BCS cases and 7.1% for MRM cases. The radiation doses to the ipsilateral lung, heart, and coronary artery were lower in Arm 1 than in Arm 2. CONCLUSIONS Although this dummy run study indicated that a substantial dose was delivered to the IMN, even in the nonirradiation group, the dose differences between the 2 groups were statistically significant. However, this dosimetric profile should be studied further with actual patient samples and be taken into consideration when analyzing clinical outcomes according to IMN irradiation.
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Affiliation(s)
- Yoonsun Chung
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Jun Won Kim
- Department of Radiation Oncology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Kyung Hwan Shin
- Department of Radiation Oncology, Proton Therapy Center, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Su Ssan Kim
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Korea
| | - Sung-Ja Ahn
- Department of Radiation Oncology, Chonnam National University Medical School, Gwangju, Korea
| | - Won Park
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyung-Sik Lee
- Department of Radiation Oncology, Dong-A University Hospital, Dong-A University School of Medicine, Busan, Korea
| | - Dong Won Kim
- Department of Radiation Oncology, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Kyu Chan Lee
- Department of Radiation Oncology, Gachon University Gil Medical Center, Incheon, Korea
| | - Hyun Suk Suh
- Department of Radiation Oncology, Ewha Womans University Mokdong Hospital, Seoul, Korea
| | - Jin Hee Kim
- Department of Radiation Oncology, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Hyun Soo Shin
- Department of Radiation Oncology, Bundang CHA Hospital, School of Medicine, CHA University, Seongnam, Korea
| | - Yong Bae Kim
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea.
| | - Chang-Ok Suh
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
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10
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The Impact of Peer Review of Volume Delineation in Stereotactic Body Radiation Therapy Planning for Primary Lung Cancer: A Multicenter Quality Assurance Study. J Thorac Oncol 2014; 9:527-33. [DOI: 10.1097/jto.0000000000000119] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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11
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Ballo MT, Chronowski GM, Schlembach PJ, Bloom ES, Arzu IY, Kuban DA. Prospective peer review quality assurance for outpatient radiation therapy. Pract Radiat Oncol 2013; 4:279-284. [PMID: 25194094 DOI: 10.1016/j.prro.2013.11.004] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2013] [Revised: 11/08/2013] [Accepted: 11/12/2013] [Indexed: 10/25/2022]
Abstract
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.
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Affiliation(s)
- Matthew T Ballo
- Department of Radiation Oncology, Regional Care Centers, University of Texas MD Anderson Cancer Center, Houston, Texas.
| | - Gregory M Chronowski
- Department of Radiation Oncology, Regional Care Centers, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Pamela J Schlembach
- Department of Radiation Oncology, Regional Care Centers, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Elizabeth S Bloom
- Department of Radiation Oncology, Regional Care Centers, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Isadora Y Arzu
- Department of Radiation Oncology, Regional Care Centers, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Deborah A Kuban
- Department of Radiation Oncology, Regional Care Centers, University of Texas MD Anderson Cancer Center, Houston, Texas
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12
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Leemans C, Tijink B, Langendijk J, Andry G, Hamoir M, Lefebvre J. Quality assurance in head and neck surgical oncology: EORTC 24954 trial on larynx preservation. Eur J Surg Oncol 2013; 39:1013-8. [DOI: 10.1016/j.ejso.2013.06.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2013] [Revised: 04/03/2013] [Accepted: 06/06/2013] [Indexed: 11/28/2022] Open
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13
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Fairchild A, Collette L, Hurkmans C, Baumert B, Weber D, Gulyban A, Poortmans P. Do results of the EORTC dummy run predict quality of radiotherapy delivered within multicentre clinical trials? Eur J Cancer 2012; 48:3232-9. [DOI: 10.1016/j.ejca.2012.06.002] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2012] [Revised: 04/26/2012] [Accepted: 06/01/2012] [Indexed: 10/28/2022]
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14
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Dikken JL, Stiekema J, van de Velde CJH, Verheij M, Cats A, Wouters MWJM, van Sandick JW. Quality of care indicators for the surgical treatment of gastric cancer: a systematic review. Ann Surg Oncol 2012; 20:381-98. [PMID: 23054104 DOI: 10.1245/s10434-012-2574-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2012] [Indexed: 02/03/2023]
Abstract
BACKGROUND Quality assurance is increasingly acknowledged as a crucial factor for the (surgical) treatment of gastric cancer. The purpose of the current study was to define a minimum set of evidence-based quality of care indicators for the surgical treatment of locally advanced gastric cancer. METHODS A systematic review of the literature published between January 1990 and May 2011 was performed, using search terms on gastric cancer, treatment, and quality of care. Studies were selected based on predefined selection criteria. Potential quality of care indicators were assessed based on their level of evidence and were grouped into structure, process, and outcome indicators. RESULTS A total of 173 articles were included in the current study. For structural measures, evidence was found for the inverse relationship between hospital volume and postoperative mortality as well as overall survival. Regarding process measures, the most common indicators concerned surgical technique, perioperative care, and multimodality treatment. The only outcome indicator with supporting evidence was a microscopically radical resection. CONCLUSIONS Although specific literature on quality of care indicators for the surgical treatment of locally advanced gastric cancer is limited, several quality of care indicators could be identified. These indicators can be used in clinical audits and other quality assurance programs.
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Affiliation(s)
- Johan L Dikken
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
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15
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Grégoire V, Bartelink H, Bernier J, Bolla M, Bosset JF, Collette L, Haustermans K, Horiot JC, Hurkmans CW, Mirimanoff R, Poortmans P, Weber DC, Maingon P. EORTC Radiation Oncology Group: 50 years of continuous accomplishments. EJC Suppl 2012. [DOI: 10.1016/s1359-6349(12)70024-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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16
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Courrech Staal E, Wouters M, Boot H, Tollenaar R, van Sandick J. Quality-of-care indicators for oesophageal cancer surgery: A review. Eur J Surg Oncol 2010; 36:1035-43. [DOI: 10.1016/j.ejso.2010.08.131] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2010] [Revised: 07/17/2010] [Accepted: 08/19/2010] [Indexed: 10/19/2022] Open
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17
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Toita T, Oguchi M, Ohno T, Kato S, Niibe Y, Kodaira T, Kazumoto T, Kataoka M, Shikama N, Kenjo M, Teshima T, Kagami Y. Quality Assurance in the Prospective Multi-institutional Trial on Definitive Radiotherapy Using High-dose-rate Intracavitary Brachytherapy for Uterine Cervical Cancer: The Individual Case Review. Jpn J Clin Oncol 2009; 39:813-9. [DOI: 10.1093/jjco/hyp105] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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18
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Mack LA, Bathe OF, Hebert MA, Tamano E, Buie WD, Fields T, Temple WJ. Opening the black box of cancer surgery quality: WebSMR and the Alberta experience. J Surg Oncol 2009; 99:525-30. [PMID: 19338026 DOI: 10.1002/jso.21266] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
A web-based synoptic operative report, the WebSMR (Surgical Medical Record), was developed to define and improve the quality of cancer surgery. Surgeons accurately record the essential steps of an operation including important decision-making in an analyzable format. Outcomes can be reviewed with provincial aggregates for quality improvement and maintenance of certification. Future synoptic pathology and follow-up templates will open the "black box" of surgical processes to define quality indicators for the improvement of cancer outcomes.
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Affiliation(s)
- L A Mack
- Department of Surgery and Oncology, University of Calgary, Alberta, Canada
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19
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Spry N, Bydder S, Harvey J, Borg M, Ngan S, Millar J, Graham P, Zissiadis Y, Kneebone A, Ebert M. Accrediting radiation technique in a multicentre trial of chemoradiation for pancreatic cancer. J Med Imaging Radiat Oncol 2009; 52:598-604. [PMID: 19178636 DOI: 10.1111/j.1440-1673.2008.02026.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Before a multicentre trial of 3-D conformal radiotherapy to treat cancer of the pancreas, participating clinicians were asked to complete an accreditation exercise. This involved planning two test cases according to the study protocol, then returning hard copies of the plans and dosimetric data for review. Any radiation technique that achieved the specified constraints was allowed. Eighteen treatment plans were assessed. Seven plans were prescribed incorrect doses and two of the planning target volumes did not comply with protocol guidelines. All plans met predefined normal tissue dose constraints. The identified errors were attributable to unforeseen ambiguities in protocol documentation. They were addressed by feedback and corresponding amendments to protocol documentation. Summary radiobiological measures including total weighted normal tissue equivalent uniform dose varied significantly between centres. This accreditation exercise successfully identified significant potential sources of protocol violations, which were then easily corrected. We believe that this process should be applied to all clinical trials involving radiotherapy. Due to the limitations of data analysis with hard-copy information only, it is recommended that complete planning datasets from treatment-planning systems be collected through a digital submission process.
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Affiliation(s)
- N Spry
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Nedlands, Australia
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20
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Johansson KA, Nilsson P, Zackrisson B, Ohlson B, Kjellén E, Mercke C, Alvarez-Fonseca M, Billström A, Björk-Eriksson T, Björ O, Ekberg L, Friesland S, Karlsson M, Lagerlund M, Lundkvist L, Löfroth PO, Löfvander-Thapper K, Nilsson A, Nyman J, Persson E, Reizenstein J, Rosenbrand HO, Wiklund F, Wittgren L. The quality assurance process for the ARTSCAN head and neck study – A practical interactive approach for QA in 3DCRT and IMRT. Radiother Oncol 2008; 87:290-9. [DOI: 10.1016/j.radonc.2007.12.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2007] [Revised: 12/08/2007] [Accepted: 12/11/2007] [Indexed: 11/16/2022]
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21
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Baumert BG, Brada M, Bernier J, Kortmann RD, Dehing-Oberije C, Collette L, Davis JB. EORTC 22972-26991/MRC BR10 trial: fractionated stereotactic boost following conventional radiotherapy of high grade gliomas. Clinical and quality-assurance results of the stereotactic boost arm. Radiother Oncol 2008; 88:163-72. [PMID: 18455252 DOI: 10.1016/j.radonc.2008.03.025] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2007] [Revised: 03/17/2008] [Accepted: 03/29/2008] [Indexed: 10/22/2022]
Abstract
BACKGROUND AND PURPOSE The EORTC trial No. 22972 investigated the role of an additional fractionated stereotactic boost (fSRT) to conventional radiotherapy for patients with high grade gliomas. A quality-assurance (QA) programme was run in conjunction with the study and was the first within the EORTC addressing the quality of a supposedly highly accurate treatment technique such as stereotactic radiotherapy. A second aim was to investigate a possible relation between the clinical results of the stereotactic boost arm and the results of the QA. MATERIALS AND METHODS The trial was closed in 2001 due to low accrual. In total, 25 patients were randomized: 14 into the experimental arm and 11 into the control arm. Six centres randomized patients, 8 centres had completed the dummy run (DR) for the stereotactic boost part. All participating centres (9) were asked to complete a quality-assurance questionnaire. The DR consisted of treatment planning according to the guidelines of the protocol on 3 different tumour volumes drawn on CT images of a humanized phantom. The SRT technique to be used was evaluated by the questionnaire. Clinical data from patients recruited to the boost arm from 6 participating centres were analysed. RESULTS There was a full compliance to the protocol requirements for 5 centres. Major and minor deviations in conformality were observed for 2 and 3 centres, respectively. Of the 8 centres which completed the DR, one centre did not comply with the requirements of stereotactic radiotherapy concerning accuracy, dosimetry and planning. Median follow-up and median overall survival were 39.2 and 21.4 months, respectively. Acute and late toxicities of the stereotactic boost were low. One radiation necrosis was seen for a patient who has not received the SRT boost. Three reported serious adverse events were all seizures and probably therapy-related. CONCLUSIONS Overall compliance was good but not ideal from the point of view of this highly precise radiation technique. Survival in the subgroup of patients with small volume disease was encouraging, but the study does not provide sufficient information about the potential value of fSRT boost in patients with malignant glioma.Toxicity due to an additional stereotactic boost of 20 Gy in 4 fractions was low and may be considered as a safe treatment option for patients with small tumours.
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22
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Poortmans P. Evidence based radiation oncology: Breast cancer. Radiother Oncol 2007; 84:84-101. [PMID: 17599597 DOI: 10.1016/j.radonc.2007.06.002] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2007] [Revised: 05/30/2007] [Accepted: 06/02/2007] [Indexed: 10/23/2022]
Abstract
PURPOSE Radiotherapy is, similar to surgery, a local treatment. In the case of breast cancer, it is generally given after conservative or after more extensive, tumour and patient adapted, surgery. The target volumes can be the breast and/or the thoracic wall and/or the regional lymph node areas. The integration and the extent of radiotherapy as part of the comprehensive treatment of the breast cancer patient, including the amount of surgery and the sequencing with the systemic treatments, has to be well discussed with all medical specialists involved in treating breast cancer on a multidisciplinary basis. Guidelines for the appropriate prescription and execution of radiotherapy are of utmost importance. However, individualisation based on the individual patients' and tumours' characteristics should always be envisaged. MATERIALS AND METHODS Based on a review of the literature the level of evidence that is available for the indications for radiotherapy is summarised, as well as the main clinical questions that are unanswered today. An overview of the recent and ongoing clinical trails in breast cancer will highlight some of the current ongoing debates. CONCLUSIONS In the case of breast cancer, radiotherapy, given after as well conservative as extensive risk-adapted surgery, significantly reduces the risk of local and regional recurrences. Especially for patients with an intermediate to high absolute risk for local recurrences, a positive influence on overall survival has been shown, notably when appropriate radiotherapy techniques are used. Most important is that the best results that we can offer to our breast cancer patients for all clinical endpoints (local and regional control; quality of life; cosmetic results; survival) can be obtained by a multidisciplinary and patient-oriented approach, involving all those involved in the treatment of breast cancer patients.
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Affiliation(s)
- Philip Poortmans
- Dr. Bernard Verbeeten Instituut, Radiotherapy, Tilburg, Netherlands.
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23
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Calvo FA, Meirino RM, Orecchia R. Intraoperative radiation therapy first part: rationale and techniques. Crit Rev Oncol Hematol 2006; 59:106-15. [PMID: 16844383 DOI: 10.1016/j.critrevonc.2005.11.004] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2005] [Revised: 11/17/2005] [Accepted: 11/17/2005] [Indexed: 11/15/2022] Open
Abstract
Intraoperative radiotherapy (IORT) is a technique where a high, single-fraction radiation dose is delivered during a surgical procedure to macroscopic tumours or tumour beds with minimal exposure of surroundings tissues which are displaced and shielded during the procedure. In this paper, the rationale for and use of IORT, both with electron beams (IOERT) and high-dose-rate brachytherapy (HDR-IORT) are discussed. For most tumours, the likelihood of obtaining local control (LC) improves when increasing doses can be administered. In many clinical situations, however, the dose that can be delivered safely to the tumour target is limited by the risk of damaging normal tissues. Special consideration is therefore given on this paper to the relationship between dose, LC and possible complications. Criteria for patient's selection and evaluation and information on sequencing and techniques are presented as well as some considerations on the need for a proper programme on quality assurance and periodical reporting of data.
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Affiliation(s)
- Felipe A Calvo
- Hospital General Universitario Gregorio Marañon, Madrid, Spain.
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24
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Kramer GWPM, Legrand CL, van Schil P, Uitterhoeve L, Smit EF, Schramel F, Biesma B, Tjan-Heijnen V, van Zandwijk N, Splinter T, Giaccone G, van Meerbeeck JP. Quality assurance of thoracic radiotherapy in EORTC 08941: A randomised trial of surgery versus thoracic radiotherapy in patients with stage IIIA non-small-cell lung cancer (NSCLC) after response to induction chemotherapy. Eur J Cancer 2006; 42:1391-8. [PMID: 16785054 DOI: 10.1016/j.ejca.2006.01.052] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2006] [Accepted: 01/25/2006] [Indexed: 10/24/2022]
Abstract
The aim of this study was to investigate the improvement of quality of radiotherapy and compliance to the protocol amendment of EORTC study 08941. The radiotherapy-specific data were analysed from 154 patients with stage IIIA-N2 Non-Small-Cell Lung Cancer who were actually irradiated after response to 3 cycles of platinum-based induction chemotherapy. The parameters of quality, assessed in 93 patients before and in 61 after protocol amendment, included: time interval between last chemotherapy course and start of thoracic radiotherapy, the use of a 3-D planning CT, dose and fractionation scheme to the primary tumour, the involved and uninvolved mediastinum, duration of radiotherapy and toxicity. A significant improvement of all quality parameters was noted, except for the overall treatment time, which decreased slightly. Protocol amendment resulted in an improvement of the quality and the compliance of most observed parameters, at the cost of some increase in overall treatment time. The latter reflects logistical problems rather than poor compliance.
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25
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Poortmans PM, Davis JB, Ataman F, Bernier J, Horiot JC. The quality assurance programme of the Radiotherapy Group of the European Organisation for Research and Treatment of Cancer: past, present and future. Eur J Surg Oncol 2005; 31:667-74. [PMID: 16100781 DOI: 10.1016/j.ejso.2005.02.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
As early as in 1982, the European Organisation for Research and Treatment of Cancer Radiotherapy Group established a quality assurance programme. In the course of 20 years, quality assurance procedures have become a vast and important part of the activities of the group. Today, the membership committee uses standard procedures based on minimal requirements to evaluate current members and new membership applications. Moreover, for every new trial, specific quality assurance procedures are an integral part of the preparation of the protocol and executed under the responsibility of the study coordinator. With the growing complexity of the radiotherapy techniques used in the framework of the more recent trials, quality assurance procedures have also become more complex including trial specific phantom based measurements. Future ways to evaluate all steps of the radiotherapy process using a common platform connecting all users with the internet are currently under development.
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Affiliation(s)
- P M Poortmans
- Department of Radiotherapy, Dr Bernard Verbeeten Instituut, Tilburg, The Netherlands.
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26
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Ataman F, Poortmans P, Davis JB, Bernier J, Giraud JY, Kouloulias VE, Pierart M, Bolla M. High conformality radiotherapy in Europe: thirty-one centres participating in the quality assurance programme of the EORTC prostate trial 22991. Eur J Cancer 2004; 40:2411-6. [PMID: 15519513 DOI: 10.1016/j.ejca.2004.07.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2004] [Revised: 06/24/2004] [Accepted: 07/23/2004] [Indexed: 10/26/2022]
Abstract
Today, conformality in radiotherapy is at the centre of many investments in equipment and staffing. To estimate the current situation within the European Organisation for Research and Treatment of Cancer (EORTC) conformal radiotherapy trial for prostate cancer, a technology questionnaire was designed to assess whether participating centres can comply with the required radiotherapy procedures of EORTC trial 22991, where a high dose is prescribed to the prostate. Questions covered various items of computed tomography, data acquisition, treatment planning, delivery and verification. All centres (n=31) replied to the questionnaire. All generate beam's eye views and dose volume histograms. All, but two, centres use digitally reconstructed radiographs to display images. The vast majority of the centres perform at least weekly treatment verification and half have access to individual in vivo dosimetry. The results of the questionnaire indicate that participating centres have access to the equipment and apply the procedures that are essential for conformal prostate radiotherapy. The technology questionnaire is the first step in the extensive quality assurance programme dedicated to this high-tech radiotherapy trial.
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Affiliation(s)
- Fatma Ataman
- EORTC Data Centre, Radiotherapy Group 83 Avenue Mounier, bte 11, B-1200 Brussels, Belgium.
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27
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Eduardo MBDP, Novaes HMD. [Compliance with technical standards for radiological protection at radiation therapy services in São Paulo State, Brazil]. CAD SAUDE PUBLICA 2004; 20 Suppl 2:S256-67. [PMID: 15608939 DOI: 10.1590/s0102-311x2004000800020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Radiation therapy services provide essential therapeutic procedures for cancer, one of the main causes of population morbidity and mortality. Despite their importance in the health system and their potential risks due to the use of ionizing radiation, there are few studies on such services. We evaluated compliance with technical standards for radiological protection in radiation therapy services in Sao Paulo State, Brazil. Forty-nine services were studied in 2000 through interviews with technical staff. Typologies of performance profiles focusing on structure and process variables were constructed and services compared. Important differences were observed in the services' positions in the health care system, level of complexity, and geographic distribution, with better average performance in structural conditions but very inadequate performance in patient protection, indicating the need for more effective health surveillance.
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Ataman F, Poortmans P, Stupp R, Fisher B, Mirimanoff RO. Quality assurance of the EORTC 26981/22981; NCIC CE3 intergroup trial on radiotherapy with or without temozolomide for newly-diagnosed glioblastoma multiforme: the individual case review. Eur J Cancer 2004; 40:1724-30. [PMID: 15251162 DOI: 10.1016/j.ejca.2004.03.026] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2004] [Accepted: 03/30/2004] [Indexed: 11/30/2022]
Abstract
The phase III randomised European Organisation for Research and Treatment of Cancer (EORTC) and National Cancer Institute of Canada Clinical Trail Group (NCIC) Intergroup trial (EORTC 26981/22981; CE3) compares irradiation alone with irradiation plus temozolomide for patients with glioblastoma multiforme (GBM). We evaluated the compliance to radiotherapy (RT) guidelines. All 85 recruiting centres were invited to participate in the individual case review. Fifty-four centres (64%) entering 71% of the patients provided data on one randomly selected patient. All participating centres used individual head immobilisation and computerised tomography (CT)-based treatment planning. Most (74%) performed three-dimensional conformal radiotherapy (3-D-CRT) including dose-volume histograms. Ninety-four percent performed portal imaging at least once. Planning target volume (PTV) and structures at risk were delineated in most of the centres (94%). Although the PTV received < 95% of the prescription dose (60 Gy in 2 Gy/fraction/day) in 39% of the centres; all except 2 centres delivered 50-60 Gy to the PTV. The maximum dose to the critical structures exceeded the protocol dose constraints in 39% of the reviewed patients, but in only 9% was this over the acceptable tolerance dose reported in the literature. We found a high rate of compliance with the protocol and general RT guidelines in the centres participating in this individual case review. In multicentre trials with a large of number of investigators from international and national groups, it is essential to confirm the interinstitutional consistency, qualitatively and quantitatively.
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Affiliation(s)
- Fatma Ataman
- EORTC, Data Center, Radiotherapy Group, 83 Avenue Mounier, 1200 Brussels, Belgium.
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29
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Mayer R, Handl-Zeller L, Quehenberger F, Hammer J, Kametriser G, Kolbabek H, Petrova-Schuman K, Raunik W, Rhomberg W, Schratter-Sehn A, Hackl A, Pötter R. Patterns of care in radiotherapy of breast cancer in Austria 1985: data acquisition and comparison with data of US-PCS 1983. Radiother Oncol 2004; 72:45-51. [PMID: 15236873 DOI: 10.1016/j.radonc.2004.04.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2003] [Revised: 03/26/2004] [Accepted: 04/26/2004] [Indexed: 11/17/2022]
Abstract
PURPOSE In Austria, a Patterns of Care Study (PCS) has been conducted to evaluate the standards of practice for breast cancer patients. The year 1985 was selected in order to establish a base data set. MATERIALS AND METHODS At all nine radiation therapy facilities active in patient treatment in 1985, ten patients charts were randomly selected and reviewed. Evaluation of the radiotherapeutic standards was the principal purpose, however, surgical and histopathological parameters were also considered. RESULTS Results of the Austrian PCS (including 90 patients) were compared with the "1983 Patterns of Care Process Survey for Definitive Breast Irradiation" performed in 1983 in the U.S. (including 191 patients). Documentation of pathologic tumour size (83% vs. 73%), histologic tumour subtype (99% vs. 97%) and microscopic margin analysis (60% vs. 51%) showed comparable results. Technical equipment was obviously quite different in the two countries, cobalt therapy was used in 25% in the US-PCS compared to 71% in the Austrian PCS. A clear difference also was obtained concerning the use of wedges for tangential breast/thoracic wall fields (64% vs. 21%) and the frequency of portal films (93% vs. 26%). CONCLUSIONS Comparing both PCS studies, we found overall many similarities. Differences could be obtained in the quality level of radiation treatment, as for example use of wedges for tangential fields and the number of portal films. In a next step, a further Austrian PCS is planned to compare the Austrian base data from 1985 with quality standards from 1993 and 2001.
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Affiliation(s)
- Ramona Mayer
- Department of Radiation Oncology, University Medical School of Graz, Auenbruggerplatz 32, A-8036 Graz, Austria
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Abstract
PURPOSE To analyze some of the limitations to improvement of the outcome of radiotherapy (RT) expected from the introduction of sophisticated treatment planning and delivery technology. METHODS AND MATERIALS Several recent examples from the literature were analyzed in some detail. Mathematical modeling techniques were used to assess the likely clinical impact of new technologies or biologic principles. The findings of recent randomized controlled trials of RT for prostate, breast, and rectal cancer were analyzed from the perspective of cost-effectiveness and therapeutic gain. RESULTS The main findings of the analyses may be summarized as follows. Dosimetric precision should aim for a <2% patient-to-patient variability in the delivered dose. Imprecision in clinical target volume definition remains an obstacle for high-precision RT. Functional imaging and novel biologic assays may facilitate a move from a clinical target volume to the real target volume. Improved target volume coverage is mainly important if RT has high effectiveness. Radiation oncology is increasingly becoming evidence based. However, there is still a long way to go. Hypofractionation in adjuvant RT for breast cancer may represent a favorable balance between cost and benefit. Treatment complications are potentially associated with both suffering and high cost. The identification of high-risk patients would improve the cost-effectiveness of high-tech RT aimed at avoiding complications. Conformal RT may allow the introduction of hypofractionation, which, again, could potentially save resources. With improvement in surgery and more screening-detected cancer cases, the number needed to treat increases, and this will directly affect the cost-effectiveness of high-tech RT unless efficient patient selection can be developed. CONCLUSION Sustained technological refinement is only likely to be cost-effective if the clinical and biologic understanding of patient-to-patient variability in the risk of specific types of failure and the optimal multimodality approach to handle these risks is developed at the same time. Mathematical modeling together with methods from health technology assessment and health economics are useful complements to standard methods from evidence-based medicine. Progress in functional imaging and in basic and clinical cancer biology is likely to provide the tools required for individualized risk-adapted RT.
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Affiliation(s)
- Søren M Bentzen
- Gray Cancer Institute and the Cancer Centre, Mount Vernon Hospital, Northwood, Middlesex HA6 2JR, United Kingdom.
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James HV, Scrase CD, Poynter AJ. Practical experience with intensity-modulated radiotherapy. Br J Radiol 2004; 77:3-14. [PMID: 14988132 DOI: 10.1259/bjr/14996943] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
At the Ipswich Hospital implementation of intensity-modulated radiotherapy (IMRT) commenced in February 2001 based on an established 3D conformal radiotherapy (3D CRT) service. This paper describes our experiences as we commissioned a fully-integrated IMRT planning and delivery system, and established IMRT within the department. Commissioning measurements incorporated a series of tests to ensure the integrity of the system and form the basis of routine quality assurance (QA) procedures. Potential IMRT patients proceeded through pre-treatment in the same way as standard 3D CRT patients. All were dual-planned for IMRT and 3D CRT with no change in established fractionation regimen, and the resulting plans evaluated. IMRT was selected for treatment where it offered a significant advantage by improving dose homogeneity and conformity within the target volume and/or reducing dose to organs at risk. Extensive pre-treatment verification was undertaken on all plans to check dynamic multileaf collimator (MLC) delivery and monitor unit calculation. Patients were monitored throughout treatment with amorphous silicon electronic portal imaging to ensure reproducibility of set-up. Between June 2001 and June 2003 21 patients were treated with inverse-planned IMRT to sites within the head and neck and lung. IMRT has enabled precise delivery to irregular shaped target volumes, avoiding organs at risk and enabling doses to be increased to radical levels in some cases. Additionally over 200 CT scanned breast patients were treated with forward-planned electronic compensation delivered by dynamic MLC, improving dose homogeneity within the breast volume compared with standard wedged plans. The IMRT programme will continue at the Ipswich Hospital with the introduction of further clinical sites and adoption of more aggressive fractionation regimens within the confines of multicentre clinical trials.
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Affiliation(s)
- H V James
- Department of Radiotherapy Physics, The Ipswich Hospital NHS Trust, Heath Road, Ipswich, Suffolk IP4 5PD, UK
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Peeters KCMJ, van de Velde CJH. Surgical quality assurance in breast, gastric and rectal cancer. J Surg Oncol 2003; 84:107-12. [PMID: 14598352 DOI: 10.1002/jso.10312] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Poortmans P, Kouloulias VE, Venselaar JL, Struikmans H, Davis JB, Huyskens D, van Tienhoven G, Hurkmans C, Mijnheer B, Van den Bogaert W. Quality assurance of EORTC trial 22922/10925 investigating the role of internal mammary--medial supraclavicular irradiation in stage I-III breast cancer: the individual case review. Eur J Cancer 2003; 39:2035-42. [PMID: 12957458 DOI: 10.1016/s0959-8049(03)00455-6] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
To assess consistency among participants in an European Organisation for Research and Treatment of Cancer (EORTC) phase III trial randomising between irradiation and no irradiation of the internal mammary and medial supraclavicular (IM-MS) lymph nodes, all participating institutes were invited to send data from 3 patients in each arm as soon as they started accrual. The evaluation focused on eligibility, compliance with the radiotherapy guidelines, treatment techniques and dose prescription to the IM-MS region. Nineteen radiotherapy departments provided a total of 111 cases, all being eligible. Minor discrepancies were found in the surgery and pathology data in almost half the patients. Major radiotherapy protocol deviations were very limited: 2 cases of unwarranted irradiation of the supraclavicular region and a significant dose deviation to the internal mammary region in 5 patients. The most frequently observed minor protocol deviation was the absence of delineation of the target volumes in 80% of the patients. By detecting systematic protocol deviations in an early phase of the trial, recommendations made to all the participating institutes should improve the interinstitutional consistency and promote a high-quality treatment.
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Affiliation(s)
- P Poortmans
- Department of Radiotherapy, Dr. Bernard Verbeeten Instituut, PO Box 90120, 5000 LA, Tilburg, The Netherlands.
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Abstract
Like high-risk industries, radiotherapy requires intense attention to detail, alertness, precision, and adequate human and material resources to minimise the risk of irreversible consequences. Clinical trials data such as that generated by the Quality Assurance programme of the Radiotherapy Group of the European Organization for Research and Treatment of Cancer (EORTC) in this issue of the Journal have been instrumental in identifying problems with technical quality, the understanding of which can have a direct impact on improving the quality of care in the community. Consistency in absolute dosimetry, dose delivery, volume definition and reproducibility are paramount in radiotherapy quality assurance and have become even more important with the advent of conformal therapy. Extension of these principles to other oncological disciplines has added an additional dimension of improvement. Waiting times and measures of access must also be monitored if overall quality at the population level is to be assessed and enhanced. Lessons should be learned from clinical trials methodology in the use of intervention-specific guidelines, physician education and real time audit of treatment planning decisions. In the future, novel approaches, such as web based systems may further improve education and audit. Wider application and audit of evidence-based management guidelines about the use radiotherapy will bring to standard clinical practice the quality benefits that are considered a basic minimum standard for clinical trials.
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Affiliation(s)
- Peter Dixon
- National Cancer Institute of Canada Clinical Trials Group, Canada
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