Evidence-based Peer Review for Radiation Therapy – Updated Review of the Literature with a Focus on Tumour Subsite and Treatment Modality

Enhancing quality assurance in radiotherapy for gynaecological cancers: implementation of an on-demand peer review process

OBJECTIVES

Ensuring high-quality radiotherapy requires peer-reviewing target volumes. The Royal College of Radiologists recommends peer review specifically for individual target volumes in cases of gynaecological cancers. This study presents the outcomes of implementing an on-demand peer review system for gynaecological cancers within our institute.

METHODS

The peer review process was planned for gynaecological cancer cases intended for curative radiotherapy. After junior clinical oncologists (COs) completed the segmentation, two senior COs specializing in gynaecological cancers conducted the peer review. All peer review outcomes were recorded prospectively. The audit process compliance, the proportion of patients requiring major and minor modifications in target volumes, the direction of changes, and the factors influencing these changes were reported.

RESULTS

A total of 230 patients were eligible, and out of these, 204 (88.3%) patients underwent at least one peer review. Among the patients, 108 required major modifications in their target volumes. P-charts revealed a stabilization in the need for major modifications at the end of three months, indicating that 38.2% and 28% of patients still required major modifications for the nodal and primary CTV, respectively. Multivariable analysis demonstrated that major modifications were associated with the use of extended field radiotherapy and radical radiation in non-cervical primary cases.

CONCLUSIONS

An on-demand peer review system was feasible and resulted in clinically meaningful, major modifications in the target volumes for 53% of patients.

ADVANCES IN KNOWLEDGE

Gynaecological cancers require ongoing peer review to ensure quality of care in radiotherapy. A flexible on-demand system not only ensures that patient treatment start is not delayed but also has an important educational role for junior trainees.

The impact of neuroradiology collaboration in head and neck cancer radiotherapy peer review

OBJECTIVE

To quantify the impact of neuroradiologist presence on head and neck cancer (HNC) radiotherapy peer review (PR) changes.

METHODS

Prospective data were collected from HNC radiotherapy PR meetings; major, minor, and organ at risk (OAR) changes recorded. Differences in changes made with a neuroradiologist present were determined. χ2 tests of statistical significance were performed. Multivariate logistic regression identified potential predictors of changes.

RESULTS

Prospective PR was performed in 125/160 (78%) patients undergoing radical (chemo)radiotherapy for HNC between October 2018 and September 2019. Full PR documentation was available for 120/160 meetings (75%), with a neuroradiologist present in 53/120 (44%). Overall, 51/120 (42.5%) had changes made to target volumes or OARs. When a neuroradiologist was present, 29/53 (55%) of plans had changes made, compared to 22/67 (33%) in their absence. On multivariate analysis, neuroradiologist presence significantly influenced any changes made during the PR meetings (OR 2.59; 95% CI 1.05-6.43; p = 0.039).

CONCLUSION

Neuroradiologist presence at PR meetings significantly influences changes made to HNC contouring, likely improving consistency and enhancing quality assurance.

ADVANCES IN KNOWLEDGE

This is the first published UK series demonstrating that a collaborative approach between radiology and oncology in PR meetings is significant in leading to contour changes for HNC.

Head and neck radiotherapy quality assurance conference for dedicated review of delineated targets and organs at risk: results of a prospective study

Purpose

Head and neck (HN) radiotherapy (RT) is complex, involving multiple target and organ at risk (OAR) structures delineated by the radiation oncologist. Site-agnostic peer review after RT plan completion is often inadequate for thorough review of these structures. In-depth review of RT contours is critical to maintain high-quality RT and optimal patient outcomes.

Materials and Methods

In August 2020, the HN RT Quality Assurance Conference, a weekly teleconference that included at least one radiation oncology HN specialist, was activated at our institution. Targets and OARs were reviewed in detail prior to RT plan creation. A parallel implementation study recorded patient factors and outcomes of these reviews. A major change was any modification to the high-dose planning target volume (PTV) or the prescription dose/fractionation; a minor change was modification to the intermediate-dose PTV, low-dose PTV, or any OAR. We analysed the results of consecutive RT contour review in the first 20 months since its initiation.

Results

A total of 208 patients treated by 8 providers were reviewed: 86·5% from the primary tertiary care hospital and 13·5% from regional practices. A major change was recommended in 14·4% and implemented in 25 of 30 cases (83·3%). A minor change was recommended in 17·3% and implemented in 32 of 36 cases (88·9%). A survey of participants found that all (n = 11) strongly agreed or agreed that the conference was useful.

Conclusion

Dedicated review of RT targets/OARs with a HN subspecialist is associated with substantial rates of suggested and implemented modifications to the contours.

Improving Quality Metrics in Radiation Oncology: Implementation of Pretreatment Peer Review for Stereotactic Body Radiation Therapy in Patients with Thoracic Cancer

Purpose

Traditional peer reviews occur weekly, and can take place up to 1 week after the start of treatment. The American Society for Radiation Oncology peer-review white paper identified stereotactic body radiation therapy (SBRT) as a high priority for contour/plan review before the start of treatment, considering both the rapid-dose falloff and short treatment course. Yet, peer-review goals for SBRT must also balance physician time demands and the desire to avoid routine treatment delays that would occur in the setting of a 100% pretreatment (pre-Tx) review compliance requirement or prolonging the standard treatment planning timeline. Herein, we report on our pilot experience of a pre-Tx peer review of thoracic SBRT cases.

Methods and Materials

From March 2020 to August 2021, patients undergoing thoracic SBRT were identified for pre-Tx review, and placed on a quality checklist. We implemented twice-weekly meetings for detailed pre-Tx review of organ-at-risk/target contours and dose constraints in the treatment planning system for SBRT cases. Our quality metric goal was to peer review ≥90% of SBRT cases before exceeding 25% of the dose delivered. We used a statistical process control chart with sigma limits (ie, standard deviations [SDs]) to access compliance rates with pre-Tx review implementation.

Results

We identified 252 patients treated with SBRT to 294 lung nodules. When comparing pre-Tx review completion from initial rollout to full implementation, our rates improved from 19% to 79% (ie, from 1 sigma limit [SDs]) below to >2 sigma limits (SDs) above. Additionally, early completion of any form of contour/plan review (defined as any pre-Tx or standard review completed before exceeding 25% of the dose delivered) increased from 67% to 85% (March 2020-November 2020) to 76% to 94% (December 2020-August 2021).

Conclusions

We successfully implemented a sustainable workflow for detailed pre-Tx contour/plan review for thoracic SBRT cases in the context of twice-weekly disease site-specific peer-review meetings. We reached our quality improvement objective to peer review ≥90% of SBRT cases before exceeding 25% of the dose delivered. This process was feasible to conduct in an integrated network of sites across our system.

Peer review quality assurance in stereotactic body radiotherapy planning: the impact of case volume

Purpose:

Peer review is an essential quality assurance component of radiation therapy planning. A growing body of literature has demonstrated substantial rates of suggested plan changes resulting from peer review. There remains a paucity of data on the impact of peer review rounds for stereotactic body radiation therapy (SBRT). We therefore aim to evaluate the outcomes of peer review in this specific patient cohort.

Methods and materials:

We conducted a retrospective review of all SBRT cases that underwent peer review from July 2015 to June 2018 at a single institution. Weekly peer review rounds are grouped according to cancer subsite and attended by radiation oncologists, medical physicists and medical radiation technologists. We prospectively compiled ‘learning moments’, defined as cases with suggested changes or where an educational discussion occurred beyond routine management, and critical errors, defined as errors which could alter clinical outcomes, recorded prospectively during peer review. Plan changes implemented after peer review were documented.

Results:

Nine hundred thirty-four SBRT cases were included. The most common treatment sites were lung (518, 55%), liver (196, 21%) and spine (119, 13%). Learning moments were identified in 161 cases (17%) and translated into plan changes in 28 cases (3%). Two critical errors (0.2%) were identified: an inadequate planning target volume margin and an incorrect image set used for contouring. There was a statistically significantly higher rate of learning moments for lower-volume SBRT sites (defined as ≤30 cases/year) versus higher-volume SBRT sites (29% vs 16%, respectively; p = 0.001).

Conclusions:

Peer review for SBRT cases revealed a low rate of critical errors, but did result in implemented plan changes in 3% of cases, and either educational discussion or suggestions of plan changes in 17% of cases. All SBRT sites appear to benefit from peer review, though lower-volume sites may require particular attention.

Radiation oncology peer review in Australia and New Zealand

Peer review is a part of high quality care within radiation oncology, designed to achieve the best outcomes for patients. We discuss the importance of and evidence for peer review in clinical practice. The Royal Australia and New Zealand College of Radiologists (RANZCR) has evolved a Peer Review Assessment Tool (PRAT) since 1999. We report the results of a RANZCR faculty survey conducted in radiation oncology facilities across Australia and New Zealand to guide the 2019 PRAT revision process, and discuss the development and implementation of the 2019 PRAT. Peer-review processes are now mandated as a component of Australian and International Quality Standards. Several practical recommendations might address challenges for effective implementation of peer review process in routine clinical practice. This includes prioritising tumour sites and treatment techniques for peer review within the time and resources constraints of each institution, improving resource allocation, ensuring optimal timing and duration for peer review meetings, and adopting multi-centre virtual peer review meeting where necessary.

The quantitative impact of joint peer review with a specialist radiologist in head and neck cancer radiotherapy planning

OBJECTIVES

Radiologist input in peer review of head and neck radiotherapy has been introduced as a routine departmental approach. The aim was to evaluate this practice and to quantitatively analyse the changes made.

METHODS

Patients treated with radical-dose radiotherapy between August and November 2020 were reviewed. The incidence of major and minor changes, as defined by The Royal College of Radiologists guidance, was prospectively recorded. The amended radiotherapy volumes were compared with the original volumes using Jaccard Index (JI) to assess conformity; Geographical Miss Index (GMI) for undercontouring; and Hausdorff Distance (HD) between the volumes.

RESULTS

In total, 73 out of 87 (84%) patients were discussed. Changes were recommended in 38 (52%) patients: 30 had ≥1 major change, eight had minor changes only. There were 99 amended volumes: The overall median JI, GMI and HD was 0.91 (interquartile range [IQR]=0.80-0.97), 0.06 (IQR = 0.02-0.18) and 0.42 cm (IQR = 0.20-1.17 cm), respectively. The nodal gross-tumour-volume (GTVn) and therapeutic high-dose nodal clinical-target-volume (CTVn) had the biggest magnitude of changes: The median JI, GMI and HD of GTVn was 0.89 (IQR = 0.44-0.95), 0.11 (IQR = 0.05-0.51), 3.71 cm (IQR = 0.31-6.93 cm); high-dose CTVn was 0.78 (IQR = 0.59-0.90), 0.20 (IQR = 0.07-0.31) and 3.28 cm (IQR = 1.22-6.18 cm), respectively. There was no observed difference in the quantitative indices of the 85 'major' and 14 'minor' volumes (p = 0.5).

CONCLUSIONS

Routine head and neck radiologist input in radiotherapy peer review is feasible and can help avoid gross error in contouring.

ADVANCES IN KNOWLEDGE

The major and minor classifications may benefit from differentiation with quantitative indices but requires correlation from clinical outcomes.

The impact of radiation therapist-led structured peer review meetings on compliance to Radiation Oncology Practice Standards

INTRODUCTION

Regular tumour-specific peer review meetings (TPRMs) were established by our group during 2016. A dedicated Quality Assurance Radiation Therapist (QART) was employed in 2018 to co-ordinate the meetings and for each patient, complete the Peer Review Audit Tool (PRAT) of the Royal Australian and New Zealand College of Radiologists (RANZCR). The aim of the current quality assurance study was to investigate the impact of the TPRMs and appointment of the QART on compliance to relevant RANZCR Radiation Oncology Practice Standards (ROPS).

METHODS

Tumour-specific peer review meetings for eight tumour sites were assessed across our group's three hospitals from January 2017 to December 2019. Data from meetings were collected using the PRAT or from paper-based minutes and assessed against four ROPS (ROPS 3, 4, 8 and 9). Compliance with each of the four standards was measured by presence of the required documentation and presentation at TPRM, as recorded by the PRAT.

RESULTS

There was an increase in the overall number of peer review cases audited from 173 in the 2017 calendar year to 469 in 2018 and 619 in 2019, representing 7%, 18% and 22% of all treatment courses started during these years, respectively. Staging was the most incompletely documented item across all years for audited patients. The request for radiation treatment plan modifications increased year-on-year: modifications were requested for 5% of plans in 2017 (8/172), 18% in 2018 (81/452) and 19% (119/619) in 2019.

CONCLUSION

This study has shown that an increase in the number of cases for peer-review audit corresponded to the QART-facilitated TPRMs. Application of the PRAT has identified radiation treatment plan modifications that would otherwise go undetected and without opportunity to improve the quality of patients' treatment or avoid harm.

Challenges in the target volume definition of lung cancer radiotherapy

Radiotherapy, with or without systemic treatment has an important role in the management of lung cancer. In order to deliver the treatment accurately, the clinician must precisely outline the gross tumour volume (GTV), mostly on computed tomography (CT) images. However, due to the limited contrast between tumour and non-malignant changes in the lung tissue, it can be difficult to distinguish the tumour boundaries on CT images leading to large interobserver variation and differences in interpretation. Therefore the definition of the GTV has often been described as the weakest link in radiotherapy with its inaccuracy potentially leading to missing the tumour or unnecessarily irradiating normal tissue. In this article, we review the various techniques that can be used to reduce delineation uncertainties in lung cancer.

Estimation of planning organ at risk volumes for ocular structures in dogs undergoing three-dimensional image-guided periocular radiotherapy with rigid bite block immobilization

Planning organ at risk volume (PRV) estimates have been reported as methods for sparing organs at risk (OARs) during radiation therapy, especially for hypofractioned and/or dose‐escalated protocols. The objectives of this retrospective, analytical, observational study were to evaluate peri‐ocular OAR shifts and derive PRVs in a sample of dogs undergoing radiation therapy for periocular tumors. Inclusion criteria were as follows: dogs irradiated for periocular tumors, with 3D‐image‐guidance and at least four cone‐beam CTs (CBCTs) used for position verification, and positioning in a rigid bite block immobilization device. Peri‐ocular OARs were contoured on each CBCT and the systematic and random error of the shifts in relation to the planning CT position computed. The formula 1.3×Σ+0.5xσ was used to generate a PRV of each OAR in the dorsoventral, mediolateral, and craniocaudal axis. A total of 30 dogs were sampled, with 450 OARs contoured, and 2145 shifts assessed. The PRV expansion was qualitatively different for each organ (1‐4 mm for the dorsoventral and 1‐2 mm for the mediolateral and craniocaudal axes). Maximal PRV expansion was ≤4 mm and directional for the majority; most pronounced for corneas and retinas. Findings from the current study may help improve awareness of and minimization of radiation dose in peri‐ocular OARs for future canine patients. Because some OARs were difficult to visualize on CBCTs and/ or to delineate on the planning CT, authors recommend that PRV estimates be institution‐specific and applied with caution.

A Blinded, Prospective Study of Error Detection During Physician Chart Rounds in Radiation Oncology

PURPOSE

Peer review during physician chart rounds is a major quality assurance and patient safety step in radiation oncology. However, the effectiveness of chart rounds in detecting problematic treatment plans is unknown. We performed a prospective blinded study of error detection at chart rounds to clarify the effectiveness of this quality assurance step.

METHODS AND MATERIALS

Radiation Oncology Incident Learning System publications were queried for problematic plans approved for treatment that would be detectable at chart rounds. A resident physician, physicist, and dosimetrist collaboratively generated 20 treatment plans with simulated errors identical in nature to those reported to the Radiation Oncology Incident Learning System. These were inserted randomly into weekly chart rounds over 9 weeks, with a median of 2 problematic plans presented per chart rounds (range, 1-4). Data were collected on detection, attendance, length, and number of cases presented at chart rounds. Data were analyzed using descriptive statistics and univariable logistic regression with odds ratios.

RESULTS

The median length of chart rounds over the study period was 60 minutes (range, 42-79); median number of cases presented per chart rounds was 45 (range, 38-50). The overall detection rate was 55% (11 of 20). Detection rates were higher for cases presented earlier in chart rounds: 75% versus 25% of problematic plans were detected within 30 minutes of start of chart rounds versus after 30 minutes (odds ratio, 0.11; 95% confidence interval, 0.01-0.88; P = .037). Detection rates showed a trend toward increase during the study period but this was not significant: 33% in weeks 1 to 5 and 73% during weeks 6 to 9 (5.3; 95% confidence interval, 0.78-36; P = .08).

CONCLUSIONS

The detection of clinically significant problematic plans during chart rounds could be significantly improved. Problematic plans are more frequently detected earlier in chart rounds and inserting such plans into chart rounds may enhance detection; however, larger studies are needed to confirm these findings. A multi-institutional study is planned.

Impact of Peer Review in Reducing Uncertainty in the Definition of the Lung Target Volume Among Trainee Oncologists

AIMS

To evaluate the impact of peer review and contouring workshops on reducing uncertainty in target volume delineation for lung cancer radiotherapy.

MATERIALS AND METHODS

Data from two lung cancer target volume delineation courses were analysed. In total, 22 trainees in clinical oncology working across different UK centres attended these courses with priori experience in lung cancer radiotherapy. The courses were made up of short presentations and contouring practice sessions. The participants were divided into two groups and asked to first individually delineate (IND) and then individually peer review (IPR) the contours of another participant. The contours were discussed with an expert panel consisting of two consultant clinical oncologists and a consultant radiologist. Contours were analysed quantitatively by measuring the volume and local distance standard deviation (localSD) from the reference expert consensus contour and qualitatively through visual analysis. Feedback from the participants was obtained using a questionnaire.

RESULTS

All participants applied minor editing to the contours during IPR, leading to a non-statistically significant reduction in the mean delineated volume (IND = 140.92 cm3, IPR = 125.26 cm3, P = 0.211). The overall interobserver variation was similar, with a localSD of 0.33 cm and 0.38 cm for the IND and IPR, respectively (P = 0.848). Six participants (29%) carried out correct major changes by either including tumour or excluding healthy tissue. One participant (5%) carried out an incorrect edit by excluding parts of the tumour, while another observer failed to identify a major contour error. The participants' level of confidence in target volume delineation increased following the course and identified the discussions with the radiologist and colleagues as the most important highlights of the course.

CONCLUSION

IPR could improve target volume delineation quality among trainee oncologists by identifying most major contour errors. However, errors were also introduced after IPR, suggesting the need to further discuss major changes with a multidisciplinary team.

Safety First: Developing and Deploying a System to Promote Safety and Quality in Your Clinic

The terms "safety and quality" (SAQ) have become inextricably linked, highly used terms that together encompass a wide range of parameters within medical departments. Safety has always been a priority in radiation oncology; quality assurance has been foundational to our practice. Despite this increased focus and attention on SAQ, the "what" of SAQ remains ill-defined, largely because of the vast number of indicators that fall under this umbrella. Similarly, the "how" of developing and maintaining the highest standards of SAQ is not formulaic and varies based on the unique setting of individual practices. There are several excellent resources available to inform SAQ in radiation oncology, including the American Society for Radiation Oncology's "Safety Is No Accident," which provides an overview of safety and quality standards and resources. This review is intended as a brief summary of key considerations, with the goal of providing a practical framework and context for improving or developing a SAQ program in radiation oncology practices. We believe that the following 10 key elements, drawn from numerous reports that have appeared over the last decade examining this topic, should be considered when conceptualizing a practice-based approach to SAQ: establishing a strong safety culture; establishing a structured program for safety and quality; establishing up-to-date, relevant, and accessible policies and procedures; a system for peer review; systems to assess and reduce risk; an educational program focused on safety and quality; development and review of meaningful quality metrics; utilization of a physics quality control system; well-defined models for staffing, training, and professional development; and finally, validation from external bodies via accreditations and audits. These 10 items are addressed herein.

Quality and access - Early experience of implementing a virtual stereotactic chart round across a national network

INTRODUCTION

Stereotactic radiation therapy is a highly specialised technique which requires careful and structured implementation. As part of a national stereotactic programme implementation, protocols were developed and a national stereotactic chart round was formed, which strongly recommended attendance and presentation of all cases before treatment. Herein, we describe our experiences launching a national chart round and its importance in a stereotactic programme.

METHOD

Stereotactic chart rounds were held via videoconference between July 2018 and July 2019. Data collected included attendances, patient-related information including, diagnosis, clinical background, treatment intent, prescribed dose and fractionation and technical approach. Consensus recommendations regarding changes to treatment approaches were also recorded.

RESULTS

For the 12 months recorded, there were 1126 attendances, from 144 individual attendees, across 21 locations. In total, 285 cases (237 new cases, and 48 re-presentations) were presented by 27 radiation oncologists (ROs) from 13 different locations. From the cases presented, 65 changes were recommended from 53 patients (22.3%), including 27 (11.4%) changes to contours, 18 (7.6%) changes to dose prescription/fractionation, 9 (3.8%) changes to plan dosimetry, 1 (0.4%) changes to treatment technique and 10 (4.2%) recommendations for which stereotactic radiation therapy was not advised. A significant inverse relationship was found between frequency of recommended changes and the individual RO's stereotactic case load (P < 0.002).

CONCLUSION

The implementation of a national stereotactic chart held via videoconference has ensured national protocol compliance across the network of locations. Furthermore, the chart rounds have allowed the entire multidisciplinary team to be provided with mentorship and guidance. Increasing number of cases presented was associated with lower rates of recommended changes highlighting the impact of experience and the need for continued mentorship.

Prospective Peer Review in Radiation Therapy Treatment Planning: Long-Term Results From a Longitudinal Study

PURPOSE

To present the longitudinal results of a prospective peer review evaluation system (PES) before treatment planning.

METHODS AND MATERIALS

All cases undergoing radiation therapy (RT) at high-volume academic institutions were graded in daily prospective multidisciplinary contouring rounds (CRs). The clinical suitability for RT, prescription, contours, and written directives were peer reviewed, compared with departmental care pathways, and recorded in a prospective database. Grades were assigned as follows: A (score 4.0) = no deficiencies; B (3.0) = minor modifications of the planning target volume, organs at risk, written directives, or a prescription/care pathway mismatch; and C (2.0) = incomplete target volume or organ-at-risk contours, unsuitable use or inappropriate planned administration of RT, significant contour modifications, prescription changes, or laterality modifications. Information was pooled to determine pretreatment planning work performance by assigning a grade point average (GPA) for each physician as well as compositely.

RESULTS

A total of 11,843 treatment plans from 7854 patients were reviewed using the PES from September 2013 to May 2018. Twenty-seven point nine percent of cases (n = 3303) required modifications before treatment planning commenced. The overall breakdown of grades was 72.1% As, 21.7% Bs, and 6.2% Cs. The median physician CR GPA was 3.60 (average 3.7) with a range of 3.0 to 3.9. Seventy-five percent of physicians demonstrated improvement of their CR GPA since inception of the program, and all physicians demonstrated a drop in the percentage of cases that were assigned a grade of C.

CONCLUSIONS

The PES can transparently quantify clinical performance in a single metric. The PES was impactful, with 75% of physicians demonstrating improvement in their CR GPA over time. In contrast to traditional chart rounds, this peer review was meaningful when done before planning commenced, a trend that was observed throughout the study period. Twenty-seven point nine percent of all cases required modification before starting treatment planning, and 6.2% of cases required significant remediation.

Outcome of localized liver-bile duct rhabdomyosarcoma according to local therapy: A report from the European Paediatric Soft-Tissue Sarcoma Study Group (EpSSG)-RMS 2005 study

OBJECTIVES

To evaluate the impact of local therapies on the outcome of patients with liver-bile duct rhabdomyosarcoma (LBDRMS).

METHODS

Data of 30 patients included in the EpSSG-RMS 2005 study were analyzed.

RESULTS

The median age at diagnosis was 3 years (11 months-8 years). All patients had non-alveolar histology. Fifteen patients had a tumor > 5 cm and six had enlarged regional lymph nodes on imaging. Eight patients (27%) had primary surgery (1 R0). Six of them received external beam radiotherapy (EBRT). All are in first complete remission (CR1) except one (R1, EBRT⁺ , local relapse, death). Six patients (20%) received EBRT without surgery: one had local relapse and died. Sixteen patients (53%) underwent delayed surgery, with 12 achieving R0 margins, which were higher than those in the primary surgery group (P = 0.003). Three patients with R0 margins received EBRT; one had a metastatic relapse and died. Nine patients with R0 resection did not receive EBRT, three relapsed locally (two deaths). Four R1 patients received additional EBRT without relapses. Local relapse occurred in two among 19 patients with EBRT and three among 11 without EBRT (P = 0.326). At a median follow-up of 61 months (48-84 months), five patients died; all had a tumor size > 5 cm (P = 0.01). The five-year overall survival was 85% (95% CI, 65-94), and event-free survival was 76% (95% CI, 54-89).

CONCLUSION

This analysis did not show any significant difference in outcome between irradiated and nonirradiated patients. Local relapse in LBDRMS is related to initial tumor size and is often fatal.

Chasing Zero Harm in Radiation Oncology: Using Pre-treatment Peer Review

Purpose: The Joint Commission has encouraged the healthcare industry to become “High Reliability Organizations” by “Chasing Zero Harm” in patient care. In radiation oncology, the time point of quality checks determines whether errors are prevented or only mitigated. Thus, to “chase zero” in radiation oncology, peer review has to be implemented prior to treatment initiation. A multidisciplinary group consensus peer review (GCPR) model is used pre-treatment at our institution and has been successful in our efforts to “chase zero harm” in patient care.

Methods: With the GCPR model, policy-defined complex cases go through a treatment planning conference, which includes physicians, residents, physicists, and dosimetrists. Three major plan aspects are reviewed: target volumes, target and normal tissue dose coverage, and dose distributions. During the review, any team member can ask questions and afterwards a group consensus is taken regarding plan approval.

Results: The GCPR model has been implemented through a commitment to peer review and creative conference scheduling. Automated analysis software is used to depict color-coded results for department approved target coverage and dose constraints. About 8% of plans required re-planning while about 23% required minor changes. The mean time for review of each plan was 8 min.

Conclusions: Catching errors prior to treatment is the only way to “chase zero” in radiation oncology. Various types of errors may exist in treatment plans and our GCPR model succeeds in preventing many errors of all shapes and sizes in target definition, dose prescriptions, and treatment plans from ever reaching the patients.

Analysis of a real time group consensus peer review process in radiation oncology: an evaluation of effectiveness and feasibility

Background

Peer review systems within radiation oncology are important to ensure quality radiation care. Several individualized methods for radiation oncology peer review have been described. However, despite the importance of peer review in radiation oncology barriers may exist to its effective implementation in practice. The purpose of this study was to quantify the rate of plan changes based on our group peer review process as well as the quantify amount of time and resources needed for this process.

Methods

Data on cases presented in our institutional group consensus peer review conference were prospectively collected. Cases were then retrospectively analyzed to determine the rate of major change (plan rejection) and any change in plans after presentation as well as the median time of presentation. Univariable logistic regression was used to determine factors associated with major change and any change.

Results

There were 73 cases reviewed over a period of 11 weeks. The rate of major change was 8.2% and the rate of any change was 23.3%. The majority of plans (53.4%) were presented in 6–10 min. Overall, the mean time of presentation was 8 min. On univariable logistic regression, volumetric modulated arc therapy plans were less likely to undergo a plan change but otherwise there were no factors significantly associated with major plan change or any type of change.

Conclusion

Group consensus peer review allows for a large amount of informative clinical and technical data to be presented per case prior to the initiation of radiation treatment in a thorough yet efficient manner to ensure plan quality and patient safety.

Impact of Multi-Institutional Prospective Peer Review on Target and Organ-at-Risk Delineation in Radiation Therapy

PURPOSE

Peer review is an essential component of quality assurance programs in radiation oncology. The purpose of this work was to assess whether peer reviewers recommend expansion or reduction of planning target volumes (PTVs) and organs at risk (OARs) in prospective multidisciplinary daily contour rounds.

METHODS AND MATERIALS

The peer group evaluated the appropriateness of PTVs and OARs for each case according to evidence-based departmental directives. We reviewed 7645 cases that presented between September 2013 and March 2017. We isolated recommendations for PTV/OAR modification and classified each as expansion, reduction, both, or indeterminate. Recommendations were analyzed by technique, site, and physician experience.

RESULTS

Eight junior and 7 senior radiation oncologists were included. PTV or OAR modifications were recommended for 750 of 7645 prescriptions (9.7%). The peer group recommended PTV modifications for 534 prescriptions (7.0%): There were 309 expansions (57.9%), 115 reductions (21.5%), 15 both (2.8%), and 95 indeterminate (17.8%). Reasons for PTV expansions included increased nodal coverage and inadequate margins as a result of motion. The peer group recommended OAR modifications for 216 prescriptions (2.8%): There were 102 expansions (47.2%), 23 reductions (10.6%), 2 both (0.9%), and 89 indeterminate (41.2%). Reasons for OAR expansions included missing critical structures and inadequate extent as per departmental standardization. Head and neck represented the largest percentage of PTV recommendations (28.8%). Intensity modulated radiation therapy plans received the most PTV and OAR recommendations (66.8% and 74.5%, respectively). The recommendation rate for senior and junior faculty was 43% and 28%, respectively.

CONCLUSIONS

Peer review resulted in recommendations for PTV or OAR change for approximately 10% of cases. Expansions of PTV were recommended >2.5 times more often than reductions and >3 times more often than OAR expansions. This general trend was identified for treatment technique, site, and physician experience. Prospective peer review could yield systematically larger volumes, which could affect multicenter clinical trials.

Inter-observer agreement in GTV delineation of bone metastases on CT and impact of MR imaging: A multicenter study

BACKGROUND AND PURPOSE

The use of Stereotactic Body Radiotherapy (SBRT) for bone metastases is increasing rapidly. Therefore, knowledge of the inter-observer differences in tumor volume delineation is essential to guarantee precise dose delivery. The aim of this study is to compare inter-observer agreement in bone metastases delineated on different imaging modalities.

MATERIAL AND METHODS

Twenty consecutive patients with bone metastases treated with SBRT were selected. All patients received CT and MR imaging in treatment position prior to SBRT. Five observers from three institutions independently delineated gross tumor volume (GTV) on CT alone, CT with co-registered MRI and MRI alone. Four contours per imaging modality per patient were available, as one set of contours was shared by 2 observers. Inter-observer agreement, expressed in generalized conformity index [CIgen], volumes of contours and contours center of mass (COM) were calculated per patient and imaging modality.

RESULTS

Mean GTV delineated on MR (45.9±52.0cm³) was significantly larger compared to CT-MR (40.2±49.4cm³) and CT (34.8±41.8cm³). A considerable variation in CIgen was found on CT (mean 0.46, range 0.15-0.75) and CT-MRI (mean 0.54, range 0.17-0.71). The highest agreement was found on MRI (mean 0.56, range 0.20-0.77). The largest variations of COM were found in anterior-posterior direction for all imaging modalities.

CONCLUSIONS

Large inter-observer variation in GTV delineation exists for CT, CT-MRI and MRI. MRI-based GTV delineation resulted in larger volumes and highest consistency between observers.