Consensus Quality Measures and Dose Constraints for Lung Cancer From the Veterans Affairs Radiation Oncology Quality Surveillance Program and ASTRO Expert Panel

PURPOSE

For patients with lung cancer, it is critical to provide evidence-based radiation therapy to ensure high-quality care. The US Department of Veterans Affairs (VA) National Radiation Oncology Program partnered with the American Society for Radiation Oncology (ASTRO) as part of the VA Radiation Oncology Quality Surveillance to develop lung cancer quality metrics and assess quality of care as a pilot program in 2016. This article presents recently updated consensus quality measures and dose-volume histogram (DVH) constraints.

METHODS AND MATERIALS

A series of measures and performance standards were reviewed and developed by a Blue-Ribbon Panel of lung cancer experts in conjunction with ASTRO in 2022. As part of this initiative, quality, surveillance, and aspirational metrics were developed for (1) initial consultation and workup; (2) simulation, treatment planning, and treatment delivery; and (3) follow-up. The DVH metrics for target and organ-at-risk treatment planning dose constraints were also reviewed and defined.

RESULTS

Altogether, a total of 19 lung cancer quality metrics were developed. There were 121 DVH constraints developed for various fractionation regimens, including ultrahypofractionated (1, 3, 4, or 5 fractions), hypofractionated (10 and 15 fractionations), and conventional fractionation (30-35 fractions).

CONCLUSIONS

The devised measures will be implemented for quality surveillance for veterans both inside and outside of the VA system and will provide a resource for lung cancer-specific quality metrics. The recommended DVH constraints serve as a unique, comprehensive resource for evidence- and expert consensus-based constraints across multiple fractionation schemas.

Consensus Quality Measures and Dose Constraints for Prostate Cancer From the Veterans Affairs Radiation Oncology Quality Surveillance Program and American Society for Radiation Oncology Expert Panel

PURPOSE

There are no agreed upon measures to comprehensively determine the quality of radiation oncology (RO) care delivered for prostate cancer. Consequently, it is difficult to assess the implementation of scientific advances and adherence to best practices in routine clinical practice. To address this need, the US Department of Veterans Affairs (VA) National Radiation Oncology Program established the VA Radiation Oncology Quality Surveillance (VA ROQS) Program to develop clinical quality measures to assess the quality of RO care delivered to Veterans with cancer. This article reports the prostate cancer consensus measures.

METHODS AND MATERIALS

The VA ROQS Program contracted with the American Society for Radiation Oncology to commission a Blue Ribbon Panel of prostate cancer experts to develop a set of evidence-based measures and performance expectations. From February to June 2021, the panel developed quality, aspirational, and surveillance measures for (1) initial consultation and workup, (2) simulation, treatment planning, and delivery, and (3) follow-up. Dose-volume histogram (DVH) constraints to be used as quality measures for definitive and post-prostatectomy radiation therapy were selected. The panel also identified the optimal Common Terminology Criteria for Adverse Events, version 5.0 (CTCAE V5.0), toxicity terms to assess in follow-up.

RESULTS

Eighteen prostate-specific measures were developed (13 quality, 2 aspirational, and 3 surveillance). DVH metrics tailored to conventional, moderately hypofractionated, and ultrahypofractionated regimens were identified. Decision trees to determine performance for each measure were developed. Eighteen CTCAE V5.0 terms were selected in the sexual, urinary, and gastrointestinal domains as highest priority for assessment during follow-up.

CONCLUSIONS

This set of measures and DVH constraints serves as a tool for assessing the comprehensive quality of RO care for prostate cancer. These measures will be used for ongoing quality surveillance and improvement among veterans receiving care across VA and community sites. These measures can also be applied to clinical settings outside of those serving veterans.

Quality and Safety Considerations in Intensity Modulated Radiation Therapy: An ASTRO Safety White Paper Update

PURPOSE

This updated report on intensity modulated radiation therapy (IMRT) is part of a series of consensus-based white papers previously published by the American Society for Radiation Oncology (ASTRO) addressing patient safety. Since the first white papers were published, IMRT went from widespread use to now being the main delivery technique for many treatment sites. IMRT enables higher radiation doses to be delivered to more precise targets while minimizing the dose to uninvolved normal tissue. Due to the associated complexity, IMRT requires additional planning and safety checks before treatment begins and, therefore, quality and safety considerations for this technique remain important areas of focus.

METHODS AND MATERIALS

ASTRO convened an interdisciplinary task force to assess the original IMRT white paper and update content where appropriate. Recommendations were created using a consensus-building methodology, and task force members indicated their level of agreement based on a 5-point Likert scale, from "strongly agree" to "strongly disagree." A prespecified threshold of ≥75% of raters who select "strongly agree" or "agree" indicated consensus.

CONCLUSIONS

This IMRT white paper primarily focuses on quality and safety processes in planning and delivery. Building on the prior version, this consensus paper incorporates revised and new guidance documents and technology updates. IMRT requires an interdisciplinary team-based approach, staffed by appropriately trained individuals as well as significant personnel resources, specialized technology, and implementation time. A comprehensive quality assurance program must be developed, using established guidance, to ensure IMRT is performed in a safe and effective manner. Patient safety in the delivery of IMRT is everyone's responsibility, and professional organizations, regulators, vendors, and end-users must work together to ensure the highest levels of safety.

Consensus Quality Measures and Dose Constraints for Breast Cancer from the Veterans Affairs Radiation Oncology Quality Surveillance Program and American Society for Radiation Oncology (ASTRO) Expert Panel

INTRODUCTION

Using evidence-based radiation therapy to direct care for patients with breast cancer is critical to standardizing practice, improving safety, and optimizing outcomes. To address this need, the Veterans Affairs (VA) National Radiation Oncology Program (NROP) established the VA Radiation Oncology Quality Surveillance Program (VAROQS) to develop clinical quality measures (QM). The VA NROP contracted with the American Society for Radiation Oncology (ASTRO) to commission five Blue-Ribbon Panels for breast, lung, prostate, rectal, and head & neck cancers.

METHODS

The Breast Cancer Blue-Ribbon Panel experts worked collaboratively with NROP to develop consensus QM for use throughout the VA system. establishing a set of quality measures for patients in several areas including: 1) consultation and work up, 2) simulation, treatment planning and treatment, and 3) follow up care. As part of this initiative, consensus dose volume histogram (DVH) constraints were outlined.

RESULTS

In total, 36 quality measures were established. Herein we review the process utilized to develop QM and final consensus QM pertaining to all aspects of radiation patient care as well as DVH constraints.

CONCLUSIONS

The QM and expert consensus DVH constraints are intended for ongoing quality surveillance within the VA system, centers providing community care for Veterans, and also available for use by the greater non-VA community measures of quality care for breast cancer patients receiving radiation.

Consensus Quality Measures and Dose Constraints for Head and Neck Cancer with an emphasis on Oropharyngeal and Laryngeal Cancer from the Veterans Affairs Radiation Oncology Quality Surveillance Program and American Society for Radiation Oncology Expert Panel

PURPOSE

Safeguarding high-quality care using evidence-based radiation therapy for patients with head and neck cancer is crucial to improving oncologic outcomes, including survival and quality of life.

METHODS AND MATERIALS

The Veterans Administration (VA) National Radiation Oncology Program established the VA Radiation Oncology Quality Surveillance Program (VAROQS) to develop clinical quality measures (QM) in head and neck cancer. As part of the development of QM, the VA commissioned, along with the American Society for Radiation Oncology, a blue-ribbon panel comprising experts in head and neck cancer, to develop QM.

RESULTS

We describe the methods used to develop QM and the final consensus QM, as well as aspirational and surveillance QM, which capture all aspects of the continuum of patient care from initial patient work-up, radiation treatment planning and delivery, and follow-up care, as well as dose volume constraints.

CONCLUSION

These QM are intended for use as part of ongoing quality surveillance for veterans receiving radiation therapy throughout the VA as well as outside the VA. They may also be used by the non-VA community as a basic measure of quality care for head and neck cancer patients receiving radiation.

Consensus Quality Measures and Dose Constraints for Rectal Cancer From the Veterans Affairs Radiation Oncology Quality Surveillance Program and American Society for Radiation Oncology (ASTRO) Expert Panel

PURPOSE

Ensuring high quality, evidence-based radiation therapy for patients with cancer is of the upmost importance. To address this need, the Veterans Affairs (VA) Radiation Oncology Program partnered with the American Society for Radiation Oncology and established the VA Radiation Oncology Quality Surveillance program. As part of this ongoing effort to provide the highest quality of care for patients with rectal cancer, a blue-ribbon panel comprised of rectal cancer experts was formed to develop clinical quality measures.

METHODS AND MATERIALS

The Rectal Cancer Blue Ribbon panel developed quality, surveillance, and aspirational measures for (a) initial consultation and workup, (b) simulation, treatment planning, and treatment, and (c) follow-up. Twenty-two rectal cancer specific measures were developed (19 quality, 1 aspirational, and 2 surveillance). In addition, dose-volume histogram constraints for conventional and hypofractionated radiation therapy were created.

CONCLUSIONS

The quality measures and dose-volume histogram for rectal cancer serves as a guideline to assess the quality of care for patients with rectal cancer receiving radiation therapy. These quality measures will be used for quality surveillance for veterans receiving care both inside and outside the VA system to improve the quality of care for these patients.

Veterans Affairs Radiation Oncology Quality Surveillance Program and American Society for Radiation Oncology Quality Measures Initiative

INTRODUCTION

Ensuring high quality, evidence-based radiation therapy for patients is of the upmost importance. As a part of the largest integrated health system in America, the Department of Veterans Affairs National Radiation Oncology Program (VA-NROP) established a quality surveillance initiative to address the challenge and necessity of providing the highest quality of care for veterans treated for cancer.

METHODS

As part of this initiative, the VA-NROP contracted with the American Society for Radiation Oncology (ASTRO) to commission five Blue-Ribbon Panels for lung, prostate, rectal, breast, and head & neck cancers experts. This group worked collaboratively with the VA-NROP to develop consensus quality measures. In addition to the site-specific measures, an additional Blue-Ribbon Panel comprised of the chairs and other members of the disease sites was formed to create 18 harmonized quality measures for all five sites (13 quality, 4 surveillance, and 1 aspirational).

CONCLUSION

The VA-NROP and ASTRO collaboration have created quality measures spanning five disease sites to help improve patient outcomes. These will be used for the ongoing quality surveillance of veterans receiving radiation therapy through the VA and its community partners.

ETHICS BOARD APPROVAL

N/A - No human subjects were required.

Incident Learning During the Early COVID-19 Pandemic

Purpose/Objective(s)

To assess the impact of the early COVID-19 pandemic on incident learning through evaluation of events reported to RO-ILS: Radiation Oncology Incident Learning System®. The Radiation Oncology Healthcare Advisory Council (RO-HAC) hypothesized that the COVID-19 pandemic would impact the engagement of RO-ILS participants in reporting to the patient safety organization (PSO) and that the characteristics of the reported events would differ from those reported pre-COVID.

Materials/Methods

The RO-ILS database was queried for events reported to the PSO pre-COVID (from March 1, 2019 to July 31, 2019) and during early COVID (March 1, 2020 to July 31, 2020). Events were then segregated into those submitted by the Top 5 reporting practices and those practices in early COVID hotspot states as identified by the Centers of Disease Control and Prevention (WA, CA, AZ, TX, FL, NY, NJ, CT, MA, PA, MD). Descriptive statistics were used to describe trends in reporting and differences in data elements provided by the practice and RO-HAC pre-COVID and during-COVID.

Results

There was a 16% absolute reduction in event reporting during-COVID (n = 1255) as compared to pre-COVID (n = 1759). Practices located in COVID-hotspots had a 33% absolute reduction in reporting, while those not in hotspots had a 23% reduction. However, initial analysis did not identify drastic change in event classification. Amongst the Top 5 reporting practices, there was a 48% absolute reduction in incident reporting; of note, three of these practices did not report any events to the PSO during-COVID. During-COVID, errors more often occurred and were discovered during treatment planning, regardless of hotspot status. RO-HAC independently rated more events as moderate-critical pre-COVID (43%) than during COVID (33%), whereas practices rated more events as moderate-severe during-COVID (25%) than pre COVID (18%). Despite an expected trend towards more hypofractionated regimens, there was neither an appreciable difference in the types of treatment techniques for all events nor magnitude of dosimetric deviations associated with incidents pre-COVID and during-COVID.

Conclusion

Reporting to RO-ILS declined during the early COVID-19 pandemic, especially in hotspot areas. This suggests that resources and time were diverted away from incident reporting to address other critical needs. Three of the five top reporting practices that ceased reporting during early COVID have since reported events after the analysis timeframe, suggesting the decline may be temporary. RO-HAC overall rated events as higher severity than the practice regardless of the pandemic. However, the drop in perceived severity by RO-HAC pre and during-COVID may be the result of changes in clarity of information provided by the practice. Stability in event classification suggests that practices continued to report a variety of events.