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Jomy J, Lu R, Sharma R, Lin KX, Chen DC, Winter J, Raman S. A systematic review and meta-analysis on the impact of institutional peer review in radiation oncology. Radiother Oncol 2025; 202:110622. [PMID: 39547365 DOI: 10.1016/j.radonc.2024.110622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2024] [Revised: 10/30/2024] [Accepted: 11/02/2024] [Indexed: 11/17/2024]
Abstract
BACKGROUND Radiotherapy peer review is recognized as a key component of institutional quality assurance, though the impact is ill-defined. We conducted the first systematic review and meta-analysis to date to quantify the impact of institutional peer review on the treatment planning workflow including radiotherapy contours, prescription and dosimetry. METHODS We searched several medical and healthcare databases from January 1, 2000, to May 25, 2024, for papers that report on the impact of institutional radiotherapy peer review on treatment plans. We conducted random-effects meta-analyses of proportions to summarize the rates of any change recommendation and major change recommendation (suggesting re-planning or re-simulation due to safety concerns) following peer review processes. To explore differences in change recommendations dependent on location, radiotherapy intent, technique, and peer review structure characteristics, we conducted analyses of variance. RESULTS Of 9,487 citations, we identified 55 studies that report on 96,444 case audits in 10 countries across various disease sites. The pooled proportion of any change recommendation was 28 % (95 %CI = 21-35) and major change recommendation was 12 % (95 %CI = 7-18). Proportions of change recommendation were not impacted by any treatment characteristics. The most common reasons for change recommendation include target volume delineation (25/55; 45 %), target dose prescription (18/55; 33 %), organ at risk dose prescription (5/55; 9 %), and organ at risk volume delineation (3/55; 5 %). CONCLUSIONS Our review provides evidence that peer review results in treatment plan change recommendations in over one in four patients. The results suggest that some form of real-time, early peer review may be beneficial for all cases, irrespective of treatment intent or RT technique.
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Affiliation(s)
- Jane Jomy
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada; Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON M5G 1X6, Canada
| | - Rachel Lu
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada
| | - Radha Sharma
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada
| | - Ke Xin Lin
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada
| | - David C Chen
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada; Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON M5G 1X6, Canada
| | - Jeff Winter
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON M5G 1X6, Canada
| | - Srinivas Raman
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada; Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON M5G 1X6, Canada.
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Matos LL, Kowalski LP, Chaves ALF, de Oliveira TB, Marta GN, Curado MP, de Castro Junior G, Farias TP, Bardales GS, Cabrera MA, Capuzzo RDC, de Carvalho GB, Cernea CR, Dedivitis RA, Dias FL, Estefan AM, Falco AH, Ferraris GA, Gonzalez-Motta A, Gouveia AG, Jacinto AA, Kulcsar MAV, Leite AK, Lira RB, Mak MP, De Marchi P, de Mello ES, de Matos FCM, Montero PH, de Moraes ED, de Moraes FY, Morais DCR, Poenitz FM, Poitevin A, Riveros HO, Sanabria Á, Ticona-Castro M, Vartanian JG, Viani G, Vines EF, William Junior WN, Conway D, Virani S, Brennan P. Latin American Consensus on the Treatment of Head and Neck Cancer. JCO Glob Oncol 2024; 10:e2300343. [PMID: 38603656 DOI: 10.1200/go.23.00343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 12/19/2023] [Accepted: 02/07/2024] [Indexed: 04/13/2024] Open
Abstract
Head and neck squamous cell carcinoma (HNSCC) is well known as a serious health problem worldwide, especially in low-income countries or those with limited resources, such as most countries in Latin America. International guidelines cannot always be applied to a population from a large region with specific conditions. This study established a Latin American guideline for care of patients with head and neck cancer and presented evidence of HNSCC management considering availability and oncologic benefit. A panel composed of 41 head and neck cancer experts systematically worked according to a modified Delphi process on (1) document compilation of evidence-based answers to different questions contextualized by resource availability and oncologic benefit regarding Latin America (region of limited resources and/or without access to all necessary health care system infrastructure), (2) revision of the answers and the classification of levels of evidence and degrees of recommendations of all recommendations, (3) validation of the consensus through two rounds of online surveys, and (4) manuscript composition. The consensus consists of 12 sections: Head and neck cancer staging, Histopathologic evaluation of head and neck cancer, Head and neck surgery-oral cavity, Clinical oncology-oral cavity, Head and neck surgery-oropharynx, Clinical oncology-oropharynx, Head and neck surgery-larynx, Head and neck surgery-larynx/hypopharynx, Clinical oncology-larynx/hypopharynx, Clinical oncology-recurrent and metastatic head and neck cancer, Head and neck surgery-reconstruction and rehabilitation, and Radiation therapy. The present consensus established 48 recommendations on HNSCC patient care considering the availability of resources and focusing on oncologic benefit. These recommendations could also be used to formulate strategies in other regions like Latin America countries.
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Affiliation(s)
- Leandro Luongo Matos
- Head and Neck Surgery, Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas, Universidade de São Paulo (Icesp HCFMUSP), São Paulo, Brazil
- Faculdade Israelita de Ciências da Saúde Albert Einstein, São Paulo, Brazil
| | | | | | | | | | | | - Gilberto de Castro Junior
- Clinical Oncology, Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas, Universidade de São Paulo (Icesp HCFMUSP), São Paulo, Brazil
| | | | | | | | | | | | | | | | | | - Andrés Munyo Estefan
- Profesor Adjunto Catedra de Otorrinolaringologia del Hospital de Clínicas, Montevidéu, Uruguay
| | | | | | | | - Andre Guimarães Gouveia
- Juravinski Cancer Centre, Department of Oncology, Division of Radiation Oncology, McMaster University, Hamilton, ON, Canada
| | | | - Marco Aurelio Vamondes Kulcsar
- Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas, Universidade de São Paulo (Icesp HCFMUSP), São Paulo, Brazil
| | - Ana Kober Leite
- Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas, Universidade de São Paulo (Icesp HCFMUSP), São Paulo, Brazil
| | - Renan Bezerra Lira
- AC Camargo Cancer Center and Hospital Albert Einstein, São Paulo, Brazil
| | - Milena Perez Mak
- 3Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, Brazil
| | | | | | | | - Pablo H Montero
- Department of Surgical Oncology and Head and Neck Surgery, Division of Surgery, P. Universidad Católica de Chile, Santiago, Chile
| | | | | | | | | | | | | | - Álvaro Sanabria
- 4Department of Surgery, Universidad de Antioquia, Hospital Alma Mater, Medellin, Colombia
| | - Miguel Ticona-Castro
- 5ESMO Member, Peruvian Society of Medical Oncology (S.P.O.M.) Member, La Molina, Peru
| | - José Guilherme Vartanian
- 6Head and Neck Surgery and Otorhinolaryngology Department, A. C. Camargo Cancer Center, São Paulo, Brazil
| | - Gustavo Viani
- 7Ribeirao Preto Medical School, University of Sao Paulo, Ribeirão Preto, Brazil
| | - Eugenio F Vines
- Facultad de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | | | | | - Shama Virani
- International Agency for Research on Cancer (IARC/WHO), Genomic Epidemiology Branch, Lyon, France
| | - Paul Brennan
- International Agency for Research on Cancer (IARC/WHO), Genomic Epidemiology Branch, Lyon, France
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Corry J, Moore A, Kenny L, Wratten C, Fua T, Lin C, Porceddu S, Liu C, Ruemelin M, Sharkey A, McDowell L, Wilkinson D, Tiong A, Rischin D. Radiotherapy quality assurance in the TROG 12.01 randomised trial and its impact on loco-regional failure. Front Oncol 2024; 13:1333098. [PMID: 38375205 PMCID: PMC10875123 DOI: 10.3389/fonc.2023.1333098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 12/20/2023] [Indexed: 02/21/2024] Open
Abstract
Introduction There is no consensus as to what specifically constitutes head and neck cancer radiotherapy quality assurance (HNC RT QA). The aims of this study are to (1) describe the RT QA processes used in the TROG 12.01 study, (2) review the RT QA processes undertaken for all patients with loco-regional failure (LRF), and (3) provide prospective data to propose a consensus statement regarding the minimal components and optimal timing of HNC RT QA. Materials and methods All patients undergoing RT QA in the original TROG 12.01 study were included in this substudy. All participating sites completed IMRT credentialling and a clinical benchmark case. Real-time (pre-treatment) RT QA was performed for the first patient of each treating radiation oncologist, and for one in five of subsequent patients. Protocol violations were deemed major if they related to contour and/or dose of gross tumour volume (GTV), high dose planning target volume (PTVhd), or critical organs of risk (spinal cord, mandible, and brachial plexus). Results Thirty HNROs from 15 institutions accrued 182 patients. There were 28 clinical benchmark cases, 27 pre-treatment RT QA cases, and 38 post-treatment cases. Comprehensive RT QA was performed in 65/182 (36%) treated patients. Major protocol violations were found in 5/28 benchmark cases, 5/27 pre-treatment cases, and 6/38 post-treatment cases. An independent review of all nine LRF cases showed major protocol violations in four of nine cases. Conclusion Only pre-treatment RT QA can improve patient outcomes. The minimal components of RT QA in HNC are GTVs, PTVhd, and critical organs at risk. What constitutes major dosimetric violations needs to be harmonised.
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Affiliation(s)
- June Corry
- Genesiscare Radiation Oncology Department, St Vincents Hospital, Melbourne, VIC, Australia
- Department Medicine, University of Melbourne, Melbourne, VIC, Australia
- Department Radiation Oncology, Peter MacCallum Cancer Center, Melbourne, VIC, Australia
| | - Alisha Moore
- Department Radiation Quality Assurance, Trans-Tasman Radiation Oncology Group (TROG), Newcastle, NSW, Australia
| | - Liz Kenny
- Department Radiation Oncology, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
- Faculty Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Chris Wratten
- Department Radiation Oncology, Calvary Mater Hospital and University Newcastle, Newcastle, NSW, Australia
| | - Tsien Fua
- Department Radiation Oncology, Peter MacCallum Cancer Center, Melbourne, VIC, Australia
| | - Charles Lin
- Department Radiation Oncology, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Sandro Porceddu
- Department Radiation Oncology, Princess Alexander Hospital, Brisbane, QLD, Australia
| | - Chen Liu
- Department Radiation Oncology, Peter MacCallum Cancer Center, Melbourne, VIC, Australia
| | - Michael Ruemelin
- Department Radiation Therapy, Peter MacCallum Cancer Center, Melbourne, VIC, Australia
| | - Amy Sharkey
- Department Radiation Therapy, Peter MacCallum Cancer Center, Melbourne, VIC, Australia
| | - Lachlan McDowell
- Department Radiation Oncology, Peter MacCallum Cancer Center, Melbourne, VIC, Australia
| | - Dean Wilkinson
- Department Radiation Therapy, Illawarra Cancer Care Centre, Wollongong, NSW, Australia
| | - Albert Tiong
- Department Radiation Oncology, Peter MacCallum Cancer Center, Melbourne, VIC, Australia
| | - Danny Rischin
- Department Medical Oncology, Peter MacCallum Cancer Center, Melbourne, VIC, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia
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Peng J, Yang C, Guo H, Shen L, Zhang M, Wang J, Zhang Z, Cai B, Hu W. Toward real-time automatic treatment planning (RTTP) with a one-step 3D fluence map prediction method and (nonorthogonal) convolution technique. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2023; 231:107263. [PMID: 36731309 DOI: 10.1016/j.cmpb.2022.107263] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 11/10/2022] [Accepted: 11/22/2022] [Indexed: 06/18/2023]
Abstract
PURPOSE To establish and evaluate a (quasi) real-time automated treatment planning (RTTP) strategy utilizing a one-step full 3D fluence map prediction model based on a nonorthogonal convolution operation for rectal cancer radiotherapy. METHODS The RTTP approach directly extracts 3D projections from volumetric CT and anatomical data according to the beam incident direction. A 3D deep learning model with a nonorthogonal convolution operation was established that takes projections in cone beam space as input, extracts the features along and around the ray-trace path, and outputs a predicted fluence map (PFM) for each beam. The PFM is then converted to the MLC sequence with deliverable MUs to generate the final treatment plan. A total of 314 rectal adenocarcinoma patients with 2198 projection data samples were used in model training and validation. An extra 20 patients were used to test the feasibility of the RTTP method by comparing the plan quality, efficiency, deliverability performance, and physician blinded review results with the manual plans. RESULTS Overall, the RTTP plans met the clinical dose criteria for target coverage, conformity, homogeneity, and organ-at-risk dose sparing. Compared to manual plans, the RTTP plans showed increases in PTV D1% by only 2.33% (p < 0.001) and a decrease in PTV D99% by 0.45% (p < 0.05). The RTTP plans showed a dose increase in the bladder, with a V50 of 14.01 ± 11.75% vs. 10.74 ± 8.51%, respectively, and no significant increases in the femoral head with the mean dose. The planning efficiency was improved in RTTP planning, with 39 s vs. 944 s in fluence map generation; the deliverability performance was saved by 1.91% (p < 0.001) in total MU. According to the blinded plan review by our physician, 55% of RTTP plans can be directly used in clinical radiotherapy treatment. CONCLUSION The quasi RTTP method improves the planning efficiency and deliverability performance while maintaining a plan quality close to that of the optimized manual plans in rectal radiotherapy.
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Affiliation(s)
- Jiayuan Peng
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China; Shanghai Clinical Research Center for Radiation Oncology, China; Shanghai key laboratory of Radiation Oncology, Shanghai, China
| | - Cui Yang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China; Shanghai Clinical Research Center for Radiation Oncology, China; Shanghai key laboratory of Radiation Oncology, Shanghai, China
| | - Hongbo Guo
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China; Shanghai Clinical Research Center for Radiation Oncology, China; Shanghai key laboratory of Radiation Oncology, Shanghai, China
| | - Lijun Shen
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China; Shanghai Clinical Research Center for Radiation Oncology, China; Shanghai key laboratory of Radiation Oncology, Shanghai, China
| | - Min Zhang
- Department of Radiation Oncology, TengZhou Central People's hospital, Shandong, China
| | - Jiazhou Wang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China; Shanghai Clinical Research Center for Radiation Oncology, China; Shanghai key laboratory of Radiation Oncology, Shanghai, China
| | - Zhen Zhang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China; Shanghai Clinical Research Center for Radiation Oncology, China; Shanghai key laboratory of Radiation Oncology, Shanghai, China
| | - Bin Cai
- Department of Radiation Oncology's Division of Medical Physics & Engineering, University of Texas Southwestern Medical Center, Dallas, Texas, United States.
| | - Weigang Hu
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China; Shanghai Clinical Research Center for Radiation Oncology, China; Shanghai key laboratory of Radiation Oncology, Shanghai, China.
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5
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Farris JC, Razavian NB, Farris MK, Ververs JD, Frizzell BA, Leyrer CM, Allen LF, Greven KM, Hughes RT. Head and neck radiotherapy quality assurance conference for dedicated review of delineated targets and organs at risk: results of a prospective study. JOURNAL OF RADIOTHERAPY IN PRACTICE 2022; 22:e60. [PMID: 38292763 PMCID: PMC10827337 DOI: 10.1017/s1460396922000309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- J C Farris
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston Salem, NC, USA
| | - N B Razavian
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston Salem, NC, USA
| | - M K Farris
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston Salem, NC, USA
| | - J D Ververs
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston Salem, NC, USA
| | - B A Frizzell
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston Salem, NC, USA
| | - C M Leyrer
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston Salem, NC, USA
| | - L F Allen
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston Salem, NC, USA
| | - K M Greven
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston Salem, NC, USA
| | - R T Hughes
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston Salem, NC, USA
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Corry J, Ng WT, Ma SJ, Singh AK, de Graeff P, Oosting SF. Disadvantaged Subgroups Within the Global Head and Neck Cancer Population: How Can We Optimize Care? Am Soc Clin Oncol Educ Book 2022; 42:1-10. [PMID: 35439036 DOI: 10.1200/edbk_359482] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Within the global head and neck cancer population, there are subgroups of patients with poorer cancer outcomes independent from tumor characteristics. In this article, we review three such groups. The first group comprises patients with nasopharyngeal cancer in low- and middle-income countries where access to high-volume, well-resourced radiotherapy centers is limited. We discuss a recent study that is aiming to improve outcomes through the instigation of a comprehensive radiotherapy quality assurance program. The second group comprises patients with low socioeconomic status in a high-income country who experience substantial financial toxicity, defined as financial hardship for patients due to health care costs. We review causes and consequences of financial toxicity and discuss how it can be mitigated. The third group comprises older patients who may poorly tolerate and not benefit from intensive standard-of-care treatment. We discuss the role of geriatric assessment, particularly in relation to the use of chemotherapy. Through better recognition and understanding of disadvantaged groups within the global head and neck cancer population, we will be better placed to instigate the necessary changes to improve outcomes and quality of life for patients with head and neck cancer.
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Affiliation(s)
- June Corry
- Division Radiation Oncology, GenesisCare Radiation OncologySt Vincent's Hospital, Melbourne, Australia.,Department of MedicineThe University of Melbourne, Parkville, Australia
| | - Wai Tong Ng
- Department of Clinical Oncology, Li Ka Shing Faculty of MedicineThe University of Hong Kong, Hong Kong, China.,Clinical Oncology CentreThe University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Sung Jun Ma
- Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Anurag K Singh
- Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Pauline de Graeff
- University Center for Geriatric MedicineUniversity Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Sjoukje F Oosting
- Department of Medical OncologyUniversity Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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7
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Chiu K, Hoskin P, Gupta A, Butt R, Terparia S, Codd L, Tsang Y, Bhudia J, Killen H, Kane C, Ghoshray S, Lemon C, Megias D. The quantitative impact of joint peer review with a specialist radiologist in head and neck cancer radiotherapy planning. Br J Radiol 2022; 95:20211219. [PMID: 34918547 PMCID: PMC8822559 DOI: 10.1259/bjr.20211219] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
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.
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Affiliation(s)
- Kevin Chiu
- Department of Head & Neck Oncology, Mount Vernon Cancer Centre, Northwood, UK
| | - Peter Hoskin
- Department of Clinical Oncology, Mount Vernon Cancer Centre, Northwood, UK
| | - Amit Gupta
- Department of Head & Neck Oncology, Mount Vernon Cancer Centre, Northwood, UK
| | - Roeum Butt
- Department of Clinical Oncology, Mount Vernon Cancer Centre, Northwood, UK
| | - Samsara Terparia
- Department of Clinical Oncology, Mount Vernon Cancer Centre, Northwood, UK
| | - Louise Codd
- Department of Clinical Oncology, Mount Vernon Cancer Centre, Northwood, UK
| | - Yatman Tsang
- Department of Clinical Oncology, Mount Vernon Cancer Centre, Northwood, UK
| | - Jyotsna Bhudia
- Department of Head & Neck Oncology, Mount Vernon Cancer Centre, Northwood, UK
| | - Helen Killen
- Department of Head & Neck Oncology, Mount Vernon Cancer Centre, Northwood, UK
| | - Clare Kane
- Department of Head & Neck Oncology, Mount Vernon Cancer Centre, Northwood, UK
| | | | - Catherine Lemon
- Department of Head & Neck Oncology, Mount Vernon Cancer Centre, Northwood, UK
| | - Daniel Megias
- Department of Clinical Oncology, Mount Vernon Cancer Centre, Northwood, UK
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Li X, Wang C, Sheng Y, Zhang J, Wang W, Yin FF, Wu Q, Wu QJ, Ge Y. An artificial intelligence-driven agent for real-time head-and-neck IMRT plan generation using conditional generative adversarial network (cGAN). Med Phys 2021; 48:2714-2723. [PMID: 33577108 DOI: 10.1002/mp.14770] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 01/03/2021] [Accepted: 02/04/2021] [Indexed: 12/19/2022] Open
Abstract
PURPOSE To develop an artificial intelligence (AI) agent for fully automated rapid head-and-neck intensity-modulated radiation therapy (IMRT) plan generation without time-consuming dose-volume-based inverse planning. METHODS This AI agent was trained via implementing a conditional generative adversarial network (cGAN) architecture. The generator, PyraNet, is a novel deep learning network that implements 28 classic ResNet blocks in pyramid-like concatenations. The discriminator is a customized four-layer DenseNet. The AI agent first generates multiple customized two-dimensional projections at nine template beam angles from a patient's three-dimensional computed tomography (CT) volume and structures. These projections are then stacked as four-dimensional inputs of PyraNet, from which nine radiation fluence maps of the corresponding template beam angles are generated simultaneously. Finally, the predicted fluence maps are automatically postprocessed by Gaussian deconvolution operations and imported into a commercial treatment planning system (TPS) for plan integrity check and visualization. The AI agent was built and tested upon 231 oropharyngeal IMRT plans from a TPS plan library. 200/16/15 plans were assigned for training/validation/testing, respectively. Only the primary plans in the sequential boost regime were studied. All plans were normalized to 44 Gy prescription (2 Gy/fx). A customized Harr wavelet loss was adopted for fluence map comparison during the training of the PyraNet. For test cases, isodose distributions in AI plans and TPS plans were qualitatively evaluated for overall dose distributions. Key dosimetric metrics were compared by Wilcoxon signed-rank tests with a significance level of 0.05. RESULTS All 15 AI plans were successfully generated. Isodose gradients outside of PTV in AI plans were comparable to those of the TPS plans. After PTV coverage normalization, Dmean of left parotid (DAI = 23.1 ± 2.4 Gy; DTPS = 23.1 ± 2.0 Gy), right parotid (DAI = 23.8 ± 3.0 Gy; DTPS = 23.9 ± 2.3 Gy), and oral cavity (DAI = 24.7 ± 6.0 Gy; DTPS = 23.9 ± 4.3 Gy) in the AI plans and the TPS plans were comparable without statistical significance. AI plans achieved comparable results for maximum dose at 0.01cc of brainstem (DAI = 15.0 ± 2.1 Gy; DTPS = 15.5 ± 2.7 Gy) and cord + 5mm (DAI = 27.5 ± 2.3 Gy; DTPS = 25.8 ± 1.9 Gy) without clinically relevant differences, but body Dmax results (DAI = 121.1 ± 3.9 Gy; DTPS = 109.0 ± 0.9 Gy) were higher than the TPS plan results. The AI agent needed ~3 s for predicting fluence maps of an IMRT plan. CONCLUSIONS With rapid and fully automated execution, the developed AI agent can generate complex head-and-neck IMRT plans with acceptable dosimetry quality. This approach holds great potential for clinical applications in preplanning decision-making and real-time planning.
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Affiliation(s)
- Xinyi Li
- Duke University Medical Center, Durham, NC, 27710, USA
| | - Chunhao Wang
- Duke University Medical Center, Durham, NC, 27710, USA
| | - Yang Sheng
- Duke University Medical Center, Durham, NC, 27710, USA
| | - Jiahan Zhang
- Duke University Medical Center, Durham, NC, 27710, USA
| | - Wentao Wang
- Duke University Medical Center, Durham, NC, 27710, USA
| | - Fang-Fang Yin
- Duke University Medical Center, Durham, NC, 27710, USA
| | - Qiuwen Wu
- Duke University Medical Center, Durham, NC, 27710, USA
| | - Q Jackie Wu
- Duke University Medical Center, Durham, NC, 27710, USA
| | - Yaorong Ge
- University of North Carolina at Charlotte, Charlotte, NC, 28223, USA
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9
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Udovicich C, Daniell J, Wiesenfeld D, Bressel M, Rowe D, Vital D, Cavanagh K, Lekgabe E, Wong T, Magarey MJR, Iseli TA, Fua T, Rischin D, McDowell L. Contralateral neck failure in oral tongue cancer: Outcomes from two centers using predefined treatment criteria. Head Neck 2021; 43:2024-2031. [PMID: 33729633 DOI: 10.1002/hed.26671] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Revised: 12/14/2020] [Accepted: 02/26/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND The objective was to determine the incidence of, and factors associated with contralateral neck failure (CNF) in oral tongue squamous cell carcinoma (OTSCC). METHODS Consecutive patients with OTSCC between 2007 and 2016 were included. The predefined policy of the contralateral neck included neck dissection (ND) where the primary tumor extended/crossed midline or the contralateral neck was involved; and elective nodal irradiation (ENI) where the primary tumor was ≤1 cm from midline/2 cm from tip. RESULTS This study included 258 patients. ND was ipsilateral 169 (66%) and bilateral 33 (13%). Fifty-five patients (21%) received ENI to the undissected contralateral neck. CNF occurred in 19 patients (7%) and was similar by treatment received. Utilizing this approach, we observed higher rates of CNF with increasing N classification, perineural invasion, extracapsular extension, and depth of invasion ≥6 mm. CONCLUSIONS Using our institutional policy of treatment to the contralateral neck, a low rate of CNF (≤10%) was observed.
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Affiliation(s)
- Cristian Udovicich
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, The University of Melbourne, Victoria, Australia
| | - James Daniell
- Head and Neck Tumour Stream, Department of Surgery, The Royal Melbourne Hospital, The University of Melbourne, Melbourne, Victoria, Australia
| | - David Wiesenfeld
- Head and Neck Tumour Stream, Department of Surgery, The Royal Melbourne Hospital, The University of Melbourne, Melbourne, Victoria, Australia
| | - Mathias Bressel
- Centre for Biostatistics and Clinical Trials, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - David Rowe
- Head and Neck Tumour Stream, Department of Surgery, The Royal Melbourne Hospital, The University of Melbourne, Melbourne, Victoria, Australia
| | - Domenic Vital
- Head and Neck Tumour Stream, Department of Surgery, The Royal Melbourne Hospital, The University of Melbourne, Melbourne, Victoria, Australia
| | - Karda Cavanagh
- Cancer Imaging, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Ernest Lekgabe
- Department of Radiology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Tim Wong
- Head and Neck Tumour Stream, Department of Surgery, The Royal Melbourne Hospital, The University of Melbourne, Melbourne, Victoria, Australia
| | - Matthew J R Magarey
- Division of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Department of Medical Education, The University of Melbourne, Melbourne, Victoria, Australia
| | - Tim A Iseli
- Head and Neck Tumour Stream, Department of Surgery, The Royal Melbourne Hospital, The University of Melbourne, Melbourne, Victoria, Australia
| | - Tsien Fua
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, The University of Melbourne, Victoria, Australia
| | - Danny Rischin
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Victoria, Australia.,Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Lachlan McDowell
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, The University of Melbourne, Victoria, Australia
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10
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Daniell J, Udovicich C, Rowe D, McDowell L, Vital D, Bressel M, Magarey MJR, Iseli TA, Wong T, Lekgabe E, Cavanagh K, Fua T, Rischin D, Wiesenfeld D. Impact of histological Oral Tongue Cancer margins on locoregional recurrence: A multi-centre retrospective analysis. Oral Oncol 2020; 111:105004. [PMID: 33038750 DOI: 10.1016/j.oraloncology.2020.105004] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 09/07/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To assess the effect of the histological margins (HM) upon locoregional failure (LRF) and overall survival (OS) for oral tongue squamous cell carcinoma (OTSCC). MATERIALS AND METHODS We undertook a retrospective review of 258 patients, across two institutions, treated for OTSCC between 2007 and 2016. A Cox-proportional hazards model was used to compare the relative hazard ratio of HM to the accepted standard of 5 mm margins for LRF and OS. RESULTS The median follow up period was 4.8 years. The 5 year OS and freedom from LRF were 69% and 75% respectively. The Cox-proportional hazards model adjusted for age, DOI and LVI showed increasing risk of mortality and LRF with decreasing HM widths of <5 mm. CONCLUSION HM >5 mm were associated with a risk reduction of both LRF and mortality in OTSCC. This study supports >5 mm HM being the oncologic goal of surgery.
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Affiliation(s)
- James Daniell
- Head and Neck Oncology Tumour Stream, Department of Surgery, The Royal Melbourne Hospital, The University of Melbourne, 300 Grattan Street, Parkville, Victoria, Australia.
| | - Cristian Udovicich
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, Victoria, Australia
| | - David Rowe
- Head and Neck Oncology Tumour Stream, Department of Surgery, The Royal Melbourne Hospital, The University of Melbourne, 300 Grattan Street, Parkville, Victoria, Australia
| | - Lachlan McDowell
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, Victoria, Australia
| | - Domenic Vital
- Head and Neck Oncology Tumour Stream, Department of Surgery, The Royal Melbourne Hospital, The University of Melbourne, 300 Grattan Street, Parkville, Victoria, Australia
| | - Mathias Bressel
- Centre for Biostatistics and Clinical Trials (BaCT), Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, Victoria, Australia
| | - Matthew J R Magarey
- Department of Surgical Oncology, Head and Neck Surgery, Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, Victoria, Australia; Department of Medical Education, The University of Melbourne, Parkville, Victoria, Australia
| | - Tim A Iseli
- Head and Neck Oncology Tumour Stream, Department of Surgery, The Royal Melbourne Hospital, The University of Melbourne, 300 Grattan Street, Parkville, Victoria, Australia
| | - Tim Wong
- Head and Neck Oncology Tumour Stream, Department of Surgery, The Royal Melbourne Hospital, The University of Melbourne, 300 Grattan Street, Parkville, Victoria, Australia
| | - Ernest Lekgabe
- Department of Radiology, The Royal Melbourne Hospital, 300 Grattan Street, Parkville, Victoria, Australia
| | - Karda Cavanagh
- Department of Diagnostic Imaging, Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, Victoria, Australia
| | - Tsien Fua
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, Victoria, Australia
| | - Danny Rischin
- Department of Medical Oncology, Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, Victoria, Australia
| | - David Wiesenfeld
- Head and Neck Oncology Tumour Stream, Department of Surgery, The Royal Melbourne Hospital, The University of Melbourne, 300 Grattan Street, Parkville, Victoria, Australia
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11
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McDowell L, Corry J, Ringash J, Rischin D. Quality of Life, Toxicity and Unmet Needs in Nasopharyngeal Cancer Survivors. Front Oncol 2020; 10:930. [PMID: 32596155 PMCID: PMC7303258 DOI: 10.3389/fonc.2020.00930] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 05/12/2020] [Indexed: 12/19/2022] Open
Abstract
Concerted research efforts over the last three decades have resulted in improved survival and outcomes for patients diagnosed with nasopharyngeal carcinoma (NPC). The evolution of radiotherapy techniques has facilitated improved dose delivery to target volumes while reducing dose to the surrounding normal tissue, improving both disease control and quality of life (QoL). In parallel, clinical trials focusing on determining the optimal systemic therapy to use in conjunction with radiotherapy have been largely successful, resulting in improved locoregional, and distant control. As a consequence, neoadjuvant chemotherapy (NACT) prior to definitive chemoradiotherapy has recently emerged as the preferred standard for patients with locally advanced NPC. Two of the major challenges in interpreting toxicity and QoL data from the published literature have been the reliance on: (1) clinician rather than patient reported outcomes; and (2) reporting statistical rather than clinical meaningful differences in measures. Despite the lower rates of toxicity that have been achieved with highly conformal radiotherapy techniques, survivors remain at moderate risk of persistent and long-lasting treatment effects, and the development of late radiation toxicities such as hearing loss, cranial neuropathies and cognitive impairment many years after successful treatment can herald a significant decline in QoL. Future approaches to reduce long-term toxicity will rely on: (1) identifying individual patients most likely to benefit from NACT; (2) development of response-adapted radiation strategies following NACT; and (3) anticipated further dose reductions to organs at risk with proton and particle therapy. With increasing numbers of survivors, many in the prime of their adult life, research to identify, and strategies to address the unmet needs of NPC survivors are required. This contemporary review will summarize our current knowledge of long-term toxicity, QoL and unmet needs of this survivorship group.
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Affiliation(s)
- Lachlan McDowell
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.,Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, VIC, Australia
| | - June Corry
- GenesisCare Radiation Oncology, Division Radiation Oncology, St. Vincent's Hospital, Melbourne, VIC, Australia.,Department of Medicine St Vincent's, The University of Melbourne, Melbourne, VIC, Australia
| | - Jolie Ringash
- Department of Radiation Oncology, Princess Margaret Cancer Centre/University of Toronto, Toronto, ON, Canada
| | - Danny Rischin
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, VIC, Australia.,Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
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12
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Daniels CP, Bressel M, Corry J, Cole A, Chua MST, Tiong A, Hirshoren N, Dixon B, McDowell L. Treatment Package Time in Node-Positive Cutaneous Head and Neck Squamous Cell Carcinoma. Pract Radiat Oncol 2020; 10:29-35. [DOI: 10.1016/j.prro.2019.09.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 09/04/2019] [Accepted: 09/06/2019] [Indexed: 11/16/2022]
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13
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Samuel R, Thomas E, Gilson D, Prestwich R. Quality Assurance Peer Review for Radiotherapy for Haematological Malignancies. Clin Oncol (R Coll Radiol) 2019; 31:e1-e8. [DOI: 10.1016/j.clon.2019.06.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 05/21/2019] [Indexed: 01/28/2023]
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14
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Ramasamy S, Murray L, Cardale K, Dyker K, Murray P, Sen M, Prestwich R. Quality Assurance Peer Review of Head and Neck Contours in a Large Cancer Centre via a Weekly Meeting Approach. Clin Oncol (R Coll Radiol) 2019; 31:344-351. [DOI: 10.1016/j.clon.2019.03.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 02/01/2019] [Accepted: 02/04/2019] [Indexed: 10/27/2022]
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15
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Radiation therapy quality assurance in head and neck radiotherapy - Moving forward. Oral Oncol 2018; 88:180-185. [PMID: 30616792 DOI: 10.1016/j.oraloncology.2018.11.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 11/12/2018] [Indexed: 11/21/2022]
Abstract
Head and Neck Cancer (HNC) radiation oncologists (ROs) enjoy the immense pleasure of curing patients, working within a large multidisciplinary team to effectively deliver curative intent treatment whilst also aiming to minimise late treatment toxicity. Secondary analyses of large-scale HNC clinical trials have shown the critical impact of the quality of radiotherapy plans, where protocol non-compliant plans have yielded inferior survival rates approximating 20%. The peer review process in routine day-to-day HNC practice shows that even in major academic centers a significant proportion of RT plans may require changes to the radiotherapy planning volume. Optimising the therapeutic ratio in HNC has been dramatically facilitated by intensity modulated radiotherapy (IMRT), but that technology has also increased the complexity of HNC radiotherapy treatment and high-volume centers with experienced clinicians may be best placed to deliver this most accurately. International consensus guidelines to standardise or benchmark best practice with respect to the RT-QA process in HNC are needed. The aim of this paper is to highlight the importance of the RT-QA process in the HNC treatment process and to make some recommendations for its inclusion in both clinical trials and routine clinical practice.
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16
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McDowell LJ, Corry J. A Call to Arms: Radiation Therapy Quality Assurance in the Next Generation of Clinical Trials. Int J Radiat Oncol Biol Phys 2018; 102:1590-1591. [DOI: 10.1016/j.ijrobp.2018.07.2001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 06/30/2018] [Accepted: 07/21/2018] [Indexed: 10/28/2022]
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17
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Qureshi BM, Abbasi AN, Ali N, Hafiz A, Khaskheli B. In Regard to Amdur. Int J Radiat Oncol Biol Phys 2017; 99:1307-1308. [PMID: 29165291 DOI: 10.1016/j.ijrobp.2017.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 08/01/2017] [Indexed: 11/17/2022]
Affiliation(s)
- Bilal Mazhar Qureshi
- Section of Radiation Oncology, Department of Oncology, Aga Khan University, Karachi, Pakistan
| | - Ahmed Nadeem Abbasi
- Section of Radiation Oncology, Department of Oncology, Aga Khan University, Karachi, Pakistan
| | - Nasir Ali
- Section of Radiation Oncology, Department of Oncology, Aga Khan University, Karachi, Pakistan
| | - Asim Hafiz
- Section of Radiation Oncology, Department of Oncology, Aga Khan University, Karachi, Pakistan
| | - Benazir Khaskheli
- Section of Radiation Oncology, Department of Oncology, Aga Khan University, Karachi, Pakistan
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18
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Lessons From What is Not Discussed in Reports Recommending More Intensive Peer Review of Radiation Therapy Plans. Int J Radiat Oncol Biol Phys 2017; 98:530-531. [DOI: 10.1016/j.ijrobp.2017.04.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Indexed: 11/21/2022]
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