Reply to L.W. Cuttino et al

Considerations for observational research using large data sets in radiation oncology

The radiation oncology community has witnessed growing interest in observational research conducted using large-scale data sources such as registries and claims-based data sets. With the growing emphasis on observational analyses in health care, the radiation oncology community must possess a sophisticated understanding of the methodological considerations of such studies in order to evaluate evidence appropriately to guide practice and policy. Because observational research has unique features that distinguish it from clinical trials and other forms of traditional radiation oncology research, the International Journal of Radiation Oncology, Biology, Physics assembled a panel of experts in health services research to provide a concise and well-referenced review, intended to be informative for the lay reader, as well as for scholars who wish to embark on such research without prior experience. This review begins by discussing the types of research questions relevant to radiation oncology that large-scale databases may help illuminate. It then describes major potential data sources for such endeavors, including information regarding access and insights regarding the strengths and limitations of each. Finally, it provides guidance regarding the analytical challenges that observational studies must confront, along with discussion of the techniques that have been developed to help minimize the impact of certain common analytical issues in observational analysis. Features characterizing a well-designed observational study include clearly defined research questions, careful selection of an appropriate data source, consultation with investigators with relevant methodological expertise, inclusion of sensitivity analyses, caution not to overinterpret small but significant differences, and recognition of limitations when trying to evaluate causality. This review concludes that carefully designed and executed studies using observational data that possess these qualities hold substantial promise for advancing our understanding of many unanswered questions of importance to the field of radiation oncology.

Oncology training programs: are we doing comparative effectiveness research justice?

Comparative effectiveness research (CER) is defined as an assessment of all available options for a specific medical condition, with intent to estimate effectiveness in specific subpopulations. Medical professionals must receive training in CER, including its general goals, the 'toolbox' necessary to perform CER and its design. Oncologic training programs are currently not doing justice to CER: a rationale for conducting CER has been proposed, funding from the US government is available, but encouragement from oncologic residencies and fellowships is minimal. Encouragement to train oncologic physicians in CER is limited by a few factors, including inadequate emphasis on evidence weighing, and no explicit mention of factors key to CER in the Accreditation Council for Graduate Medical Education guidelines. As residency program requirements transition to milestone-based curricula and evaluations, explicit recommendations regarding CER and patient-centered outcomes research should be implemented for all programs. Upper level trainees who have reached milestones related to CER will be competitive applicants for research funding.