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Covington EL, Suresh K, Anderson BM, Barker M, Dess K, Price JG, Moncion A, Vaccarelli MJ, Santanam L, Xiao Y, Mayo C. Perceptions on and roadblocks to implementation of standardized nomenclature in radiation oncology: A survey from TG-263U1. J Appl Clin Med Phys 2024; 25:e14359. [PMID: 38689502 PMCID: PMC11163509 DOI: 10.1002/acm2.14359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 02/02/2024] [Accepted: 03/25/2024] [Indexed: 05/02/2024] Open
Abstract
PURPOSE AAPM Task Group No. 263U1 (Update to Report No. 263 - Standardizing Nomenclatures in Radiation Oncology) disseminated a survey to receive feedback on utilization, gaps, and means to facilitate further adoption. METHODS The survey was created by TG-263U1 members to solicit feedback from physicists, dosimetrists, and physicians working in radiation oncology. Questions on the adoption of the TG-263 standard were coupled with demographic information, such as clinical role, place of primary employment (e.g., private hospital, academic center), and size of institution. The survey was emailed to all AAPM, AAMD, and ASTRO members. RESULTS The survey received 463 responses with 310 completed survey responses used for analysis, of whom most had the clinical role of medical physicist (73%) and the majority were from the United States (83%). There were 83% of respondents who indicated that they believe that having a nomenclature standard is important or very important and 61% had adopted all or portions of TG-263 in their clinics. For those yet to adopt TG-263, the staffing and implementation efforts were the main cause for delaying adoption. Fewer respondents had trouble adopting TG-263 for organs at risk (29%) versus target (44%) nomenclature. Common themes in written feedback were lack of physician support and available resources, especially in vendor systems, to facilitate adoption. CONCLUSIONS While there is strong support and belief in the benefit of standardized nomenclature, the widespread adoption of TG-263 has been hindered by the effort needed by staff for implementation. Feedback from the survey is being utilized to drive the focus of the update efforts and create tools to facilitate easier adoption of TG-263.
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Affiliation(s)
| | - Krithika Suresh
- Department of Radiation OncologyMichigan MedicineAnn ArborMichiganUSA
| | - Brian M. Anderson
- Department of Radiation OncologyUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | | | - Kathryn Dess
- Department of Radiation OncologyMichigan MedicineAnn ArborMichiganUSA
| | - Jeremy G. Price
- Department of Radiation OncologyFox Chase Cancer CenterPhiladelphiaPennsylvaniaUSA
| | - Alexander Moncion
- Department of Radiation OncologyMichigan MedicineAnn ArborMichiganUSA
| | | | - Lakshmi Santanam
- Medical Physics DepartmentMemorial Sloan‐Kettering Cancer CenterNew YorkNew YorkUSA
| | - Ying Xiao
- Department of Radiation OncologyUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Charles Mayo
- Department of Radiation OncologyMichigan MedicineAnn ArborMichiganUSA
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Ramanathan S, Hochstedler KA, Laucis AM, Movsas B, Stevens CW, Kestin LL, Dominello MM, Grills IS, Matuszak M, Hayman J, Paximadis PA, Schipper MJ, Jolly S, Boike TP. Predictors of Early Hospice or Death in Patients With Inoperable Lung Cancer Treated With Curative Intent. Clin Lung Cancer 2024; 25:e201-e209. [PMID: 38290875 DOI: 10.1016/j.cllc.2023.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 12/11/2023] [Accepted: 12/23/2023] [Indexed: 02/01/2024]
Abstract
INTRODUCTION Treatment for inoperable stage II to III non-small cell lung cancer (NSCLC) involves chemo-radiotherapy (CRT). However, some patients transition to hospice or die early during their treatment course. We present a model to prognosticate early poor outcomes in NSCLC patients treated with curative-intent CRT. METHODS AND MATERIALS Across a statewide consortium, data was prospectively collected on stage II to III NSCLC patients who received CRT between 2012 and 2019. Early poor outcomes included hospice enrollment or death within 3 months of completing CRT. Logistic regression models were used to assess predictors in prognostic models. LASSO regression with multiple imputation were used to build a final multivariate model, accounting for missing covariates. RESULTS Of the 2267 included patients, 128 experienced early poor outcomes. Mean age was 71 years and 59% received concurrent chemotherapy. The best predictive model, created parsimoniously from statistically significant univariate predictors, included age, ECOG, planning target volume (PTV), mean heart dose, pretreatment lack of energy, and cough. The estimated area under the ROC curve for this multivariable model was 0.71, with a negative predictive value of 95%, specificity of 97%, positive predictive value of 23%, and sensitivity of 16% at a predicted risk threshold of 20%. CONCLUSIONS This multivariate model identified a combination of clinical variables and patient reported factors that may identify individuals with inoperable NSCLC undergoing curative intent chemo-radiotherapy who are at higher risk for early poor outcomes.
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Affiliation(s)
| | | | - Anna M Laucis
- Department of Radiation Oncology, University of Michigan Health System, Ann Arbor, MI
| | | | | | - Larry L Kestin
- Genesis Care / Michigan Healthcare Professionals, Troy, MI
| | | | | | - Martha Matuszak
- Department of Radiation Oncology, University of Michigan Health System, Ann Arbor, MI
| | - James Hayman
- Department of Radiation Oncology, University of Michigan Health System, Ann Arbor, MI
| | | | - Matthew J Schipper
- Department of Radiation Oncology, University of Michigan Health System, Ann Arbor, MI
| | - Shruti Jolly
- Department of Radiation Oncology, University of Michigan Health System, Ann Arbor, MI.
| | - Thomas P Boike
- Genesis Care / Michigan Healthcare Professionals, Troy, MI
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Richardson SL, Bosch WR, Mayo CS, McNutt TR, Moran JM, Popple RA, Xiao Y, Covington EL. Order From Chaos: The Benefits of Standardized Nomenclature in Radiation Oncology. Pract Radiat Oncol 2024:S1879-8500(24)00080-8. [PMID: 38636586 DOI: 10.1016/j.prro.2024.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 02/28/2024] [Accepted: 04/01/2024] [Indexed: 04/20/2024]
Abstract
Although standardization has been shown to improve patient safety and improve the efficiency of workflows, implementation of standards can take considerable effort and requires the engagement of all clinical stakeholders. Engaging team members includes increasing awareness of the proposed benefit of the standard, a clear implementation plan, monitoring for improvements, and open communication to support successful implementation. The benefits of standardization often focus on large institutions to improve research endeavors, yet all clinics can benefit from standardization to increase quality and implement more efficient or automated workflow. The benefits of nomenclature standardization for all team members and institution sizes, including success stories, are discussed with practical implementation guides to facilitate the adoption of standardized nomenclature in radiation oncology.
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Affiliation(s)
- Susan L Richardson
- Department of Radiation Oncology, Swedish Medical Center-Tumor Institute, Seattle, Washington.
| | - Walter R Bosch
- Department of Radiation Oncology, Washington University, Saint Louis, Missouri
| | - Charles S Mayo
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Todd R McNutt
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland
| | - Jean M Moran
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Richard A Popple
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Ying Xiao
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
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Beydoun H, Griffith KA, Jagsi R, Burmeister JW, Moran JM, Vicini FA, Hayman JA, Paximadis P, Boike TP, Walker EM, Pierce LJ, Dominello MM. Are We Missing Acute Toxicities Associated With Hypofractionated Breast Irradiation? A Report From a Large Multicenter Cohort Study. Int J Radiat Oncol Biol Phys 2024:S0360-3016(24)00303-1. [PMID: 38364950 DOI: 10.1016/j.ijrobp.2024.01.225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 01/02/2024] [Accepted: 01/28/2024] [Indexed: 02/18/2024]
Abstract
PURPOSE The efficacy and long-term safety of hypofractionated whole breast irradiation (HF-WBI) have been established through multiple randomized trials, yet data about acute toxicities remain more limited. Since 2013, our group has prospectively collected acute toxicity data from weekly treatment evaluations and additional assessment after completion. In 2016, we intentionally shifted the posttreatment assessment follow-up visit from 1 month to 2 weeks to evaluate for missed acute toxicity occurring in that immediate posttreatment window. Here, we report whether 2-week follow-up has resulted in increased detection of acute toxicities compared with 4-week follow-up. METHODS AND MATERIALS We prospectively compared acute toxicity for patients treated with HF-WBI between January 1, 2013, and August 31, 2015 (4 week follow-up cohort) to patients treated between January 1, 2016, and August 31, 2018 (2 week follow-up cohort). Analyses included a multivariable model that adjusted for other factors known to correlate with toxicity. We prospectively defined acute toxicity as maximum breast pain (moderate or severe rating) and/or occurrence of moist desquamation reported 7 days before the completion of radiation therapy (RT) until 42 days after completion. RESULTS A total of 2689 patients who received postlumpectomy radiation and boost were analyzed; 1862 patients in the 2-week follow-up cohort and 827 in the 4-week follow-up cohort. All acute toxicity measures assessed were statistically similar between follow-up cohorts when compared in an unadjusted fashion. Overall acute composite toxicity was 26.4% and 27.7% for patients in the 4-week follow-up and 2-week follow-up cohorts, respectively. Overall acute composite toxicity remained similar between follow-up cohorts in a multivariable, adjusted model and was significantly related to patient's age, body mass index, smoking status, and treatment technique (intensity-modulated RT vs 3-dimensional conformal radiation therapy) but not follow-up cohort. CONCLUSIONS An earlier posttreatment follow-up for HF-WBI patients did not reveal a significant increased incidence of acute toxicities at 2 weeks compared with 4 weeks. This study provides physicians and patients with additional data on the safety and tolerability of HF-WBI for early stage breast cancer.
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Affiliation(s)
- Hassan Beydoun
- Department of Radiation Oncology, Barbara Ann Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, Michigan.
| | - Kent A Griffith
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Reshma Jagsi
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Jacob W Burmeister
- Department of Radiation Oncology, Barbara Ann Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, Michigan
| | - Jean M Moran
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Frank A Vicini
- Department of Radiation Oncology, Corewell Health South, St Joseph, Michigan
| | - James A Hayman
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Peter Paximadis
- Department of Radiation Oncology, Corewell Health South, St Joseph, Michigan
| | | | | | - Lori J Pierce
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Michael M Dominello
- Department of Radiation Oncology, Barbara Ann Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, Michigan
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Duggar WN, Roberts PR, Thomas TV, Dulaney C. Building Better Patient Care in Mississippi Radiation Oncology: Why Mississippi Needs a Collaborative Quality Initiative. South Med J 2023; 116:415-418. [PMID: 37137476 DOI: 10.14423/smj.0000000000001549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
OBJECTIVES Cancer is an insidious and devastating disease that affects many people. Progress in mortality rate has not been realized universally across the United States, and challenges remain in how to best make up the ground that has been lost in these areas, one of which is Mississippi. Radiation therapy is a significant contributor to cancer control rates and certain challenges exist specifically regarding this treatment modality. METHODS The challenges of radiation oncology in Mississippi have been reviewed and discussed, with the proposal of a potential collaboration between clinical practitioners and payors to provide optimal and cost-effective radiation therapy to patients in Mississippi. RESULTS A similar model to that proposed has been reviewed and evaluated. This model is discussed based on its potential validity and usefulness in Mississippi. CONCLUSIONS Significant barriers exist in the state of Mississippi to patients receiving a consistent standard of care, regardless of their location and socioeconomic status. A collaborative quality initiative has been shown to be a boon to this endeavor elsewhere and stands to have a similar impact in Mississippi.
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Affiliation(s)
- William N Duggar
- From Radiation Oncology, University of Mississippi Medical Center, Jackson
| | - Paul R Roberts
- From Radiation Oncology, University of Mississippi Medical Center, Jackson
| | - Toms V Thomas
- From Radiation Oncology, University of Mississippi Medical Center, Jackson
| | - Caleb Dulaney
- Radiation Oncology, Anderson Regional Medical Center, Meridian, Mississippi
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6
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Matrosic CK, Dess K, Boike T, Dominello M, Dryden D, Fraser C, Grubb M, Hayman J, Jarema D, Marsh R, Paximadis P, Torolski K, Wilson M, Jolly S, Matuszak M. Knowledge-Based Quality Assurance and Model Maintenance in Lung Cancer Radiation Therapy in a Statewide Quality Consortium of Academic and Community Practice Centers. Pract Radiat Oncol 2023; 13:e200-e208. [PMID: 36526245 DOI: 10.1016/j.prro.2022.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 10/19/2022] [Accepted: 11/11/2022] [Indexed: 12/15/2022]
Abstract
PURPOSE Locally advanced lung cancer (LALC) treatment planning is often complex due to challenging tradeoffs related to large targets near organs at risk, making the judgment of plan quality difficult. The purpose of this work was to update and maintain a multi-institutional knowledge-based planning (KBP) model developed by a statewide consortium of academic and community practices for use as a plan quality assurance (QA) tool. METHODS AND MATERIALS Sixty LALC volumetric-modulated arc therapy plans from 2021 were collected from 24 institutions. Plan quality was scored, with high-quality clinical (HQC) plans selected to update a KBP model originally developed in 2017. The model was validated via automated KBP planning, with 20 cases excluded from the model. Differences in dose-volume histogram metrics in the clinical plans, 2017 KBP model plans, and 2022 KBP model plans were compared. Twenty recent clinical cases not meeting consortium quality metrics were replanned with the 2022 model to investigate potential plan quality improvements. RESULTS Forty-seven plans were included in the final KBP model. Compared with the clinical plans, the 2022 model validation plans improved 60%, 65%, and 65% of the lung V20Gy, mean heart dose, and spinal canal D0.03cc metrics, respectively. The 2022 model showed improvements from the 2017 model in hot spot management at the cost of greater lung doses. Of the 20 recent cases not meeting quality metrics, 40% of the KBP model-replanned cases resulted in acceptable plans, suggesting potential clinical plan improvements. CONCLUSIONS A multi-institutional KBP model was updated using plans from a statewide consortium. Multidisciplinary plan review resulted in HQC model training plans and model validation resulted in acceptable quality plans. The model proved to be effective at identifying potential plan quality improvements. Work is ongoing to develop web-based training plan review tools and vendor-agnostic platforms to provide the model as a QA tool statewide.
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Affiliation(s)
- Charles K Matrosic
- Medical School, Radiation Oncology, University of Michigan, Ann Arbor, Michigan.
| | - Kathryn Dess
- Medical School, Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | | | - Michael Dominello
- Barbara Ann Karmanos Cancer Institute, Wayne State University, Detroit, Michigan
| | | | | | - Margaret Grubb
- Medical School, Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - James Hayman
- Medical School, Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - David Jarema
- Medical School, Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Robin Marsh
- Medical School, Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | | | - Kelly Torolski
- Medical School, Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | | | - Shruti Jolly
- Medical School, Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Martha Matuszak
- Medical School, Radiation Oncology, University of Michigan, Ann Arbor, Michigan
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7
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Chapman CH, Jagsi R, Griffith KA, Moran JM, Vicini F, Walker E, Dominello M, Abu-Isa E, Hayman J, Laucis AM, Mietzel M, Pierce L. Mediators of Racial Disparities in Heart Dose Among Whole Breast Radiotherapy Patients. J Natl Cancer Inst 2022; 114:1646-1655. [PMID: 35916737 PMCID: PMC9949587 DOI: 10.1093/jnci/djac120] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 03/22/2022] [Accepted: 06/09/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Racial disparities in survival of patients with cancer motivate research to quantify treatment disparities and evaluate multilevel determinants. Previous research has not evaluated cardiac radiation dose in large cohorts of breast cancer patients by race nor examined potential causes or implications of dose disparities. METHODS We used a statewide consortium database to consecutively sample 8750 women who received whole breast radiotherapy between 2012 and 2018. We generated laterality- and fractionation-specific models of mean heart dose. We generated patient- and facility-level models to estimate race-specific cardiac doses. We incorporated our data into models to estimate disparities in ischemic cardiac event development and death. All statistical tests were 2-sided. RESULTS Black and Asian race independently predicted higher mean heart dose for most laterality-fractionation groups, with disparities of up to 0.42 Gy for Black women and 0.32 Gy for Asian women (left-sided disease and conventional fractionation: 2.13 Gy for Black women vs 1.71 Gy for White women, P < .001, 2-sided; left-sided disease and accelerated fractionation: 1.59 Gy for Asian women vs 1.27 Gy for White women, P = .002). Patient clustering within facilities explained 22%-30% of the variability in heart dose. The cardiac dose disparities translated to estimated excesses of up to 2.6 cardiac events and 1.3 deaths per 1000 Black women and 0.7 cardiac events and 0.3 deaths per 1000 Asian women vs White women. CONCLUSIONS Depending on laterality and fractionation, Asian women and Black women experience higher cardiac doses than White women. This may translate into excess radiation-associated ischemic cardiac events and deaths. Solutions include addressing inequities in baseline cardiac risk factors and facility-level availability and use of radiation technologies.
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Affiliation(s)
- Christina Hunter Chapman
- Rogel Comprehensive Cancer Center at the University of Michigan, Ann Arbor, MI, USA,Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Reshma Jagsi
- Rogel Comprehensive Cancer Center at the University of Michigan, Ann Arbor, MI, USA
| | - Kent A Griffith
- Rogel Comprehensive Cancer Center at the University of Michigan, Ann Arbor, MI, USA
| | - Jean M Moran
- Rogel Comprehensive Cancer Center at the University of Michigan, Ann Arbor, MI, USA
| | | | | | | | - Eyad Abu-Isa
- Ascension Providence Hospital, Southfield, MI, USA
| | - James Hayman
- Rogel Comprehensive Cancer Center at the University of Michigan, Ann Arbor, MI, USA
| | - Anna M Laucis
- Rogel Comprehensive Cancer Center at the University of Michigan, Ann Arbor, MI, USA
| | - Melissa Mietzel
- Rogel Comprehensive Cancer Center at the University of Michigan, Ann Arbor, MI, USA
| | - Lori Pierce
- Correspondence to: Lori J. Pierce, MD, University of Michigan Rogel Comprehensive Cancer Center, Rm 4308, 1500 E Medical Center Dr, Ann Arbor, MI 48109, USA (e-mail: )
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8
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Jagsi R, Griffith KA, Vicini F, Boike T, Dominello M, Gustafson G, Hayman JA, Moran JM, Radawski JD, Walker E, Pierce L. Identifying Patients Whose Symptoms Are Underrecognized During Treatment With Breast Radiotherapy. JAMA Oncol 2022; 8:887-894. [PMID: 35446337 PMCID: PMC9026246 DOI: 10.1001/jamaoncol.2022.0114] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Importance Understanding whether physicians accurately detect symptoms in patients with breast cancer is important because recognition of symptoms facilitates supportive care, and clinical trials often rely on physician assessments using Common Toxicity Criteria for Adverse Events (CTCAE). Objective To compare the patient-reported outcomes (PROs) of patients with breast cancer who received radiotherapy from January 1, 2012, to March 31, 2020, with physicians' CTCAE assessments to assess underrecognition of symptoms. Design, Setting, and Participants This cohort study included a total of 29 practices enrolled in the Michigan Radiation Oncology Quality Consortium quality initiative. Of 13 725 patients with breast cancer who received treatment with radiotherapy after undergoing lumpectomy, 9941 patients (72.4%) completed at least 1 PRO questionnaire during treatment with radiotherapy and were evaluated for the study. Of these, 9868 patients (99.3%) were matched to physician CTCAE assessments that were completed within 3 days of the PRO questionnaires. Exposures Patient and physician ratings of 4 symptoms (pain, pruritus, edema, and fatigue) were compared. Main Outcomes and Measures We used multilevel multivariable logistic regression to evaluate factors associated with symptom underrecognition, hypothesizing that it would be more common in racial and ethnic minority groups. Results Of 9941 patients, all were female, 1655 (16.6%) were Black, 7925 (79.7%) were White, and 361 (3.6%) had Other race and ethnicity (including American Indian/Alaska Native, Arab/Middle Eastern, and Asian), either as self-reported or as indicated in the electronic medical record. A total of 1595 (16.0%) were younger than 50 years, 2874 (28.9%) were age 50 to 59 years, 3353 (33.7%) were age 60 to 69 years, and 2119 (21.3%) were 70 years or older. Underrecognition of symptoms existed in 2094 of 6781 (30.9%) observations of patient-reported moderate/severe pain, 748 of 2039 observations (36.7%) of patient-reported frequent pruritus, 2309 of 4492 observations (51.4%) of patient-reported frequent edema, and 390 of 2079 observations (18.8%) of patient-reported substantial fatigue. Underrecognition of at least 1 symptom occurred at least once for 2933 of 5510 (53.2%) of those who reported at least 1 substantial symptom. Factors independently associated with underrecognition were younger age (younger than 50 years compared with 60-69 years: odds ratio [OR], 1.35; 95% CI, 1.14-1.59; P < .001; age 50-59 years compared with 60-69 years: OR, 1.19; 95% CI, 1.03-1.37; P = .02), race (Black individuals compared with White individuals: OR, 1.56; 95% CI 1.30-1.88; P < .001; individuals with Other race or ethnicity compared with White individuals: OR, 1.52; 95% CI, 1.12-2.07; P = .01), conventional fractionation (OR, 1.26; 95% CI, 1.10-1.45; P = .002), male physician sex (OR, 1.54; 95% CI, 1.20-1.99; P = .002), and 2-field radiotherapy (without a supraclavicular field) (OR, 0.80; 95% CI, 0.67-0.97; P = .02). Conclusions and Relevance The results of this cohort study suggest that PRO collection may be essential for trials because relying on the CTCAE to detect adverse events may miss important symptoms. Moreover, since physicians in this study systematically missed substantial symptoms in certain patients, including younger patients and Black individuals or those of Other race and ethnicity, improving symptom detection may be a targetable mechanism to reduce disparities.
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Affiliation(s)
- Reshma Jagsi
- Department of Radiation Oncology, Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor
| | | | | | | | | | | | - James A Hayman
- Radiation Oncology Clinical Division, University of Michigan, Ann Arbor.,Michigan Radiation Oncology Quality Consortium
| | - Jean M Moran
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - Eleanor Walker
- Department of Radiation Oncology, Henry Ford Health System, Detroit, Michigan
| | - Lori Pierce
- Michigan Radiation Oncology Quality Consortium.,Department of Radiation Oncology, University of Michigan, Ann Arbor
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9
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Jagsi R, Griffith KA, Moran JM, Matuszak MM, Marsh R, Grubb M, Abu-Isa E, Dilworth JT, Dominello MM, Heimburger D, Lack D, Walker EM, Hayman JA, Vicini F, Pierce LJ. Comparative Effectiveness Analysis of 3D-Conformal Radiation Therapy Versus Intensity Modulated Radiation Therapy (IMRT) in a Prospective Multicenter Cohort of Patients With Breast Cancer. Int J Radiat Oncol Biol Phys 2022; 112:643-653. [PMID: 34634437 DOI: 10.1016/j.ijrobp.2021.09.053] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 09/22/2021] [Accepted: 09/30/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE Simple intensity modulation of radiation therapy reduces acute toxicity compared with 2-dimensional techniques in adjuvant breast cancer treatment, but it remains unknown whether more complex or inverse-planned intensity modulated radiation therapy (IMRT) offers an advantage over forward-planned, 3-dimensional conformal radiation therapy (3DCRT). METHODS AND MATERIALS Using prospective data regarding patients receiving adjuvant whole breast radiation therapy without nodal irradiation at 23 institutions from 2011 to 2018, we compared the incidence of acute toxicity (moderate-severe pain or moist desquamation) in patients receiving 3DCRT versus IMRT (either inverse planned or, if forward-planned, using ≥5 segments per gantry angle). We evaluated associations between technique and toxicity using multivariable models with inverse-probability-of-treatment weighting, adjusting for treatment facility as a random effect. RESULTS Of 1185 patients treated with 3DCRT and conventional fractionation, 650 (54.9%) experienced acute toxicity; of 774 treated with highly segmented forward-planned IMRT, 458 (59.2%) did; and of 580 treated with inverse-planned IMRT, 245 (42.2%) did. Of 1296 patients treated with hypofractionation and 3DCRT, 432 (33.3%) experienced acute toxicity; of 709 treated with highly segmented forward-planned IMRT, 227 (32.0%) did; and of 623 treated with inverse-planned IMRT, 164 (26.3%) did. On multivariable analysis with inverse-probability-of-treatment weighting, the odds ratio for acute toxicity after inverse-planned IMRT versus 3DCRT was 0.64 (95% confidence interval, 0.45-0.91) with conventional fractionation and 0.41 (95% confidence interval, 0.26-0.65) with hypofractionation. CONCLUSIONS This large, prospective, multicenter comparative effectiveness study found a significant benefit from inverse-planned IMRT compared with 3DCRT in reducing acute toxicity of breast radiation therapy. Future research should identify the dosimetric differences that mediate this association and evaluate cost-effectiveness.
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Affiliation(s)
- Reshma Jagsi
- Department of Radiation Oncology, Medical School, University of Michigan, Ann Arbor, Michigan.
| | - Kent A Griffith
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Jean M Moran
- Department of Radiation Oncology, Medical School, University of Michigan, Ann Arbor, Michigan
| | - Martha M Matuszak
- Department of Radiation Oncology, Medical School, University of Michigan, Ann Arbor, Michigan
| | - Robin Marsh
- Department of Radiation Oncology, Medical School, University of Michigan, Ann Arbor, Michigan
| | - Margaret Grubb
- Department of Radiation Oncology, Medical School, University of Michigan, Ann Arbor, Michigan
| | - Eyad Abu-Isa
- Department of Radiation Oncology, Medical School, University of Michigan, Ann Arbor, Michigan; Department of Radiation Oncology, Providence Ascension, Novi, Michigan
| | - Joshua T Dilworth
- Department of Radiation Oncology, Beaumont Health, Royal Oak, Michigan
| | - Michael M Dominello
- Department of Radiation Oncology, Karmanos Cancer Center, Wayne State University, Detroit, Michigan
| | - David Heimburger
- Department of Radiation Oncology, Munson Healthcare, Traverse City, Michigan
| | - Danielle Lack
- Department of Radiation Oncology, Beaumont Health, Royal Oak, Michigan
| | - Eleanor M Walker
- Department of Radiation Oncology, Henry Ford Health System, Detroit, Michigan
| | - James A Hayman
- Department of Radiation Oncology, Medical School, University of Michigan, Ann Arbor, Michigan
| | - Frank Vicini
- Department of Radiation Oncology, GenesisCare, Farmington Hills, Michigan
| | - Lori J Pierce
- Department of Radiation Oncology, Medical School, University of Michigan, Ann Arbor, Michigan
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Laucis AMB, Hochstedler KA, Schipper MJ, Paximadis PA, Boike TP, Bergsma DP, Movsas B, Kretzler A, Spratt DE, Dess RT, Mietzel MA, Dominello MM, Matuszak MM, Jagsi R, Hayman JA, Pierce LJ, Jolly S. Racial Differences in Treatments and Toxicity in Patients With Non-Small-Cell Lung Cancer Treated With Thoracic Radiation Therapy. JCO Oncol Pract 2022; 18:e1034-e1044. [PMID: 35167337 DOI: 10.1200/op.21.00224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Historical racial disparities in lung cancer surgery rates resulted in lower survival in Black patients. Our objective was to examine racial differences in thoracic radiation treatments and toxicities in patients with non-small-cell lung cancer. METHODS AND MATERIALS A large institutional review board-approved statewide patient-level database of patients with stage II-III non-small-cell lung cancer who received definitive thoracic radiation from March 2012 to November 2019 was analyzed to assess associations between race and other variables. Race (White or Black) was defined by patient self-report. Provider-reported toxicity was defined by Common Terminology Criteria for Adverse Events version 4.0. Patient-reported toxicity was determined by the Functional Assessment of Cancer Therapy-Lung quality-of-life instrument. Univariable and multivariable regression models were fitted to assess relationships between race and variables of interest. Spearman rank-correlation coefficients were calculated between provider-reported toxicity and similar patient-reported outcomes. RESULTS One thousand four hundred forty-one patients from 24 institutions with mean age 68 years (range, 38-94 years) were evaluated. Race was not significantly associated with radiation or chemotherapy approach. There was significantly increased patient-reported general pain in Black patients at the preradiation and end-of-radiation time points. Black patients were significantly less likely to have provider-reported grade 2+ pneumonitis (odds ratio 0.36, P = .03), even after controlling for known patient and treatment factors. Correlation coefficients between provider- and patient-reported toxicities were generally similar across race groups except for a stronger correlation between patient- and provider-reported esophagitis in White patients. CONCLUSION In this large multi-institutional study, we found no evidence of racial differences in radiation treatment or chemotherapy approaches. We did, however, unexpectedly find that Black race was associated with lower odds of provider-reported grade 2+ radiation pneumonitis. The stronger correlation between patient- and provider-reported esophagitis and swallowing symptoms for White patients also suggests possible under-recognition of symptoms in Black patients. Further research is needed to study the implications for Black patients.
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Affiliation(s)
- Anna Mary Brown Laucis
- Department of Radiation Oncology, Rogel Comprehensive Cancer Center at the University of Michigan, Ann Arbor, MI
| | | | - Matthew J Schipper
- Department of Radiation Oncology, Rogel Comprehensive Cancer Center at the University of Michigan, Ann Arbor, MI.,Department of Biostatistics, University of Michigan, Ann Arbor, MI
| | | | | | - Derek P Bergsma
- Department of Radiation Oncology, Mercy Health Saint Mary's, Grand Rapids, MI
| | - Benjamin Movsas
- Department of Radiation Oncology, Henry Ford Hospital, Detroit, MI
| | - Annette Kretzler
- Department of Radiation Oncology, Henry Ford Allegiance, Jackson, MI
| | - Daniel E Spratt
- Department of Radiation Oncology, Rogel Comprehensive Cancer Center at the University of Michigan, Ann Arbor, MI
| | - Robert T Dess
- Department of Radiation Oncology, Rogel Comprehensive Cancer Center at the University of Michigan, Ann Arbor, MI
| | - Melissa A Mietzel
- Department of Radiation Oncology, Rogel Comprehensive Cancer Center at the University of Michigan, Ann Arbor, MI
| | - Michael M Dominello
- Department of Radiation Oncology, Barbara Ann Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, MI
| | - Martha M Matuszak
- Department of Radiation Oncology, Rogel Comprehensive Cancer Center at the University of Michigan, Ann Arbor, MI
| | - Reshma Jagsi
- Department of Radiation Oncology, Rogel Comprehensive Cancer Center at the University of Michigan, Ann Arbor, MI
| | - James A Hayman
- Department of Radiation Oncology, Rogel Comprehensive Cancer Center at the University of Michigan, Ann Arbor, MI
| | - Lori J Pierce
- Department of Radiation Oncology, Rogel Comprehensive Cancer Center at the University of Michigan, Ann Arbor, MI
| | - Shruti Jolly
- Department of Radiation Oncology, Rogel Comprehensive Cancer Center at the University of Michigan, Ann Arbor, MI
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11
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Dilworth JT, Griffith KA, Pierce LJ, Jagsi R, Quinn TJ, Walker EM, Radawski JD, Dominello MM, Gustafson GS, Moran JM, Hayman JA, Vicini FA. The impact of chemotherapy on toxicity and cosmetic outcome in patients receiving whole breast irradiation: an analysis within a state-wide quality consortium. Int J Radiat Oncol Biol Phys 2022; 113:266-277. [PMID: 35157997 DOI: 10.1016/j.ijrobp.2022.02.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 02/01/2022] [Accepted: 02/03/2022] [Indexed: 11/17/2022]
Abstract
PURPOSE We investigated whether the use of chemotherapy prior to whole breast irradiation (WBI) using either conventional fractionation (CWBI) or hypofractionation (HWBI) is associated with increased toxicity or worse cosmetic outcome compared to WBI alone. METHODS AND MATERIALS We identified 6,754 patients who received WBI alone (without a third field covering the superior axillary and supraclavicular nodal regions) with data prospectively collected in a state-wide consortium. We reported rates of four toxicity outcomes: physician-reported acute moist desquamation, patient-reported acute moderate/severe breast pain, a composite acute toxicity measure (including moist desquamation and either patient-reported or physician-reported moderate/significant breast pain), and physician-reported impaired cosmetic outcome at one year following WBI. Successive multivariable models were constructed to estimate the impact of chemotherapy on these outcomes. RESULTS Rates of moist desquamation, patient-reported pain, composite acute toxicity, and impaired cosmetic outcome were 23%, 34%, 42%, and 10% for 2,859 patients receiving CWBI and 13%, 28%, 31%, and 11% for 3,895 patients receiving HWBI. Receipt of chemotherapy prior to CWBI was not associated with higher rates of patient-reported pain, composite acute toxicity, or impaired cosmetic outcome compared to CWBI without chemotherapy but was associated with more moist desquamation (OR=1.32 [1.07-1.63], p=0.01). Receipt of chemotherapy prior to HWBI was not associated with higher rates of any of the four toxicity outcomes compared to HWBI alone. CONCLUSIONS In this cohort, use of chemotherapy prior to WBI was generally well tolerated. CWBI with chemotherapy, but not to HWBI with chemotherapy, was associated with higher rates of moist desquamation. Rates of acute breast pain and impaired cosmetic outcome at one year were comparable in patients receiving chemotherapy prior to either CWBI or HWBI. These data support the use of HWBI following chemotherapy.
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Affiliation(s)
| | - Kent A Griffith
- University of Michigan School of Public Health, Ann Arbor, Michigan
| | - Lori J Pierce
- University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Reshma Jagsi
- University of Michigan School of Medicine, Ann Arbor, Michigan
| | | | | | | | - Michael M Dominello
- Barbara Ann Karmanos Cancer Institute, Wayne State University, Detroit, Michigan
| | | | - Jean M Moran
- University of Michigan School of Medicine, Ann Arbor, Michigan
| | - James A Hayman
- University of Michigan School of Medicine, Ann Arbor, Michigan
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12
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Jagsi R, Schipper M, Mietzel M, Pandya R, Moran JM, Matuszak M, Vicini F, Jolly S, Paximadis P, Mancini B, Griffith K, Hayman J, Pierce L, On Behalf Of The Michigan Radiation Oncology Quality Consortium Mroqc. The Michigan Radiation Oncology Quality Consortium: A Novel Initiative to Improve the Quality of Radiation Oncology Care. Int J Radiat Oncol Biol Phys 2022; 113:257-265. [PMID: 35124133 DOI: 10.1016/j.ijrobp.2022.01.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 01/24/2022] [Accepted: 01/26/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE Numerous quality measures have been proposed in radiation oncology, and initiatives to improve access to high-complexity care, quality, and equity are needed. We describe the design and evaluate impact of a voluntary statewide collaboration for quality improvement in radiation oncology initiated a decade ago. METHODS AND MATERIALS We evaluate compliance before and since implementation of annual metrics for quality improvement, using an observational dataset with information from over 20,000 patients treated in the 28 participating radiation oncology practices. At thrice-yearly meetings, experts have spoken regarding trends within the field and inspired discussions regarding potential targets for quality improvement. Blinded data on practices at various sites have been provided. Following Standards for Quality Improvement Reporting Excellence (SQUIRE) guidelines, we describe the approach and measures the program has implemented. To evaluate impact, we compare compliance at baseline and now with active measures using mixed effects regression models with site-level random effects. RESULTS Compliance has increased, including use of guideline-concordant hypofractionated radiotherapy, doses to targets/normal tissues, motion management, and consistency in delineating and naming contoured structures (a precondition for quality evaluation). For example, use of guideline-concordant hypofractionation for breast cancer increased from 47% to 97%, adherence to target coverage goals and heart dose limits for dose increased from 46% to 86%, motion assessment in patients with lung cancer increased from 52% to 94%, and use of standard nomenclature increased from 53% to 82% for lung patients and from 80% to 94% for breast patients (all p<0.001). CONCLUSIONS Although observational analysis cannot fully exclude secular trends, contextual data revealing slow uptake of best practices elsewhere in the US and qualitative feedback from participants suggests that this initiative has improved the consistency, efficiency, and quality of radiation oncology care in its member practices and may be a model for oncology quality improvement more generally.
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13
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McFarlane MR, Hochstedler KA, Laucis AM, Sun Y, Chowdhury A, Matuszak MM, Hayman J, Bergsma D, Boike T, Kestin L, Movsas B, Grills I, Dominello M, Dess RT, Schonewolf C, Spratt DE, Pierce L, Paximadis P, Jolly S, Schipper M. Predictors of Pneumonitis After Conventionally Fractionated Radiotherapy for Locally Advanced Lung Cancer. Int J Radiat Oncol Biol Phys 2021; 111:1176-1185. [PMID: 34314815 DOI: 10.1016/j.ijrobp.2021.07.1691] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 07/14/2021] [Accepted: 07/19/2021] [Indexed: 12/25/2022]
Abstract
PURPOSE Multiple factors influence the risk of developing pneumonitis after radiation therapy (RT) for lung cancer, but few resources exist to guide clinicians in predicting risk in an individual patient treated with modern techniques. We analyzed toxicity data from a state-wide consortium to develop an integrated pneumonitis risk model. METHODS AND MATERIALS All patients (N = 1302) received conventionally fractionated RT for stage II-III non-small cell lung cancer between April 2012 and July 2019. Pneumonitis occurring within 6 months of treatment was graded by local practitioners and collected prospectively from 27 academic and community clinics participating in a state-wide quality consortium. Pneumonitis was modeled as either grade ≥2 (G2+) or grade ≥3 (G3+). Logistic regression models were fit to quantify univariable associations with dose and clinical factors, and stepwise Akaike information criterion-based modeling was used to build multivariable prediction models. RESULTS The overall rate of pneumonitis of any grade in the 6 months following RT was 16% (208 cases). Seven percent of cases (n = 94) were G2+ and <1% (n = 11) were G3+. Adjusting for incomplete follow-up, estimated rates for G2+ and G3+ were 14% and 2%, respectively. In univariate analyses, gEUD, V5, V10, V20, V30, and mean lung dose (MLD) were positively associated with G2+ pneumonitis risk, whereas current smoking status was associated with lower odds of pneumonitis. G2+ pneumonitis risk of ≥22% was independently predicted by MLD of ≥20 Gy, V20 of ≥35%, and V5 of ≥75%. In multivariate analyses, the lung V5 metric remained a significant predictor of G2+ pneumonitis, even when controlling for MLD, despite their close correlation. For G3+ pneumonitis, MLD and V20 were statistically significant predictors. Number of patient comorbidities was an independent predictor of G3+, but not G2+ pneumonitis. CONCLUSIONS We present an analysis of pneumonitis risk after definitive RT for lung cancer using a large, prospective dataset. We incorporate comorbidity burden, smoking status, and dosimetric parameters in an integrated risk model. These data may guide clinicians in assessing pneumonitis risk in individual patients.
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Affiliation(s)
- Matthew R McFarlane
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | | | - Anna M Laucis
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Yilun Sun
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Aulina Chowdhury
- College of Osteopathic Medicine, Kansas City University of Medicine and Biosciences, Kansas City, Missouri
| | - Martha M Matuszak
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - James Hayman
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Derek Bergsma
- Department of Radiation Oncology, Lacks Cancer Center, University of Michigan, Grand Rapids, Michigan
| | - Thomas Boike
- MHP Radiation Oncology/21st Century Oncology, Multiple Sites, Michigan
| | - Larry Kestin
- MHP Radiation Oncology/21st Century Oncology, Multiple Sites, Michigan
| | | | - Inga Grills
- Beaumont Radiation Oncology, Royal Oak, Michigan
| | - Michael Dominello
- Department of Radiation Oncology, Wayne State University, Detroit, Michigan
| | - Robert T Dess
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Caitlin Schonewolf
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Daniel E Spratt
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Lori Pierce
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | | | - Shruti Jolly
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan.
| | - Matthew Schipper
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan; Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
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14
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Kapoor R, Sleeman WC, Nalluri JJ, Turner P, Bose P, Cherevko A, Srinivasan S, Syed K, Ghosh P, Hagan M, Palta JR. Automated data abstraction for quality surveillance and outcome assessment in radiation oncology. J Appl Clin Med Phys 2021; 22:177-187. [PMID: 34101349 PMCID: PMC8292697 DOI: 10.1002/acm2.13308] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 04/22/2021] [Accepted: 05/10/2021] [Indexed: 11/24/2022] Open
Abstract
Rigorous radiotherapy quality surveillance and comprehensive outcome assessment require electronic capture and automatic abstraction of clinical, radiation treatment planning, and delivery data. We present the design and implementation framework of an integrated data abstraction, aggregation, and storage, curation, and analytics software: the Health Information Gateway and Exchange (HINGE), which collates data for cancer patients receiving radiotherapy. The HINGE software abstracts structured DICOM‐RT data from the treatment planning system (TPS), treatment data from the treatment management system (TMS), and clinical data from the electronic health records (EHRs). HINGE software has disease site‐specific “Smart” templates that facilitate the entry of relevant clinical information by physicians and clinical staff in a discrete manner as part of the routine clinical documentation. Radiotherapy data abstracted from these disparate sources and the smart templates are processed for quality and outcome assessment. The predictive data analyses are done on using well‐defined clinical and dosimetry quality measures defined by disease site experts in radiation oncology. HINGE application software connects seamlessly to the local IT/medical infrastructure via interfaces and cloud services and performs data extraction and aggregation functions without human intervention. It provides tools to assess variations in radiation oncology practices and outcomes and determines gaps in radiotherapy quality delivered by each provider.
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Affiliation(s)
- Rishabh Kapoor
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA, USA.,National Radiation Oncology Program, US Veterans Healthcare Administration, Richmond, VA, USA
| | - William C Sleeman
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA, USA.,National Radiation Oncology Program, US Veterans Healthcare Administration, Richmond, VA, USA
| | - Joseph J Nalluri
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA, USA.,National Radiation Oncology Program, US Veterans Healthcare Administration, Richmond, VA, USA
| | - Paul Turner
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA, USA.,National Radiation Oncology Program, US Veterans Healthcare Administration, Richmond, VA, USA
| | - Priyankar Bose
- Department of Computer Science, Virginia Commonwealth University, Richmond, VA, USA
| | - Andrii Cherevko
- Department of Computer Science, Virginia Commonwealth University, Richmond, VA, USA
| | - Sriram Srinivasan
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA, USA.,National Radiation Oncology Program, US Veterans Healthcare Administration, Richmond, VA, USA
| | - Khajamoinuddin Syed
- Department of Computer Science, Virginia Commonwealth University, Richmond, VA, USA
| | - Preetam Ghosh
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA, USA.,Department of Computer Science, Virginia Commonwealth University, Richmond, VA, USA
| | - Michael Hagan
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA, USA.,National Radiation Oncology Program, US Veterans Healthcare Administration, Richmond, VA, USA
| | - Jatinder R Palta
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA, USA.,National Radiation Oncology Program, US Veterans Healthcare Administration, Richmond, VA, USA
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15
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Jaworski EM, Yin H, Griffith KA, Pandya R, Mancini BR, Jolly S, Boike TP, Moran JM, Dominello MM, Wilson M, Parker J, Burmeister J, Fraser C, Miller L, Baldwin K, Mietzel MA, Grubb M, Kendrick D, Spratt DE, Hayman JA. Contemporary Practice Patterns for Palliative Radiation Therapy of Bone Metastases: Impact of a Quality Improvement Project on Extended Fractionation. Pract Radiat Oncol 2021; 11:e498-e505. [PMID: 34048938 DOI: 10.1016/j.prro.2021.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 04/22/2021] [Accepted: 05/04/2021] [Indexed: 12/25/2022]
Abstract
PURPOSE Radiation therapy effectively palliates bone metastases, although variability exists in practice patterns. National recommendations advocate against using extended fractionation (EF) with courses greater than 10 fractions. We previously reported EF use of 14.8%. We analyzed practice patterns within a statewide quality consortium to assess EF use in a larger patient population after implementation of a quality measure focused on reducing EF. METHODS AND MATERIALS Patients treated for bone metastases within a statewide radiation oncology quality consortium were prospectively enrolled from March 2018 through October 2020. The EF quality metric was implemented March 1, 2018. Data on patient, physician, and facility characteristics; fractionation schedules; and treatment planning and delivery techniques were collected. Multivariable binary logistic regression was used to assess EF. RESULTS Twenty-eight facilities enrolled 1445 consecutive patients treated with 1934 plans. The median number of treatment plans per facility was 52 (range, 7-307). Sixty different fractionation schedules were used. EF was delivered in 3.4% of plans. Initially, EF use was lower than expected and remained low over time. Significant predictors for EF use included complicated metastasis (odds ratio [OR], 2.04; 95% confidence interval [CI], 1.04-4.02; P = .04), lack of associated central nervous system or visceral disease (OR, 2.27; 95% CI, 1.2-4.2; P = .01), nonteaching versus teaching facilities (OR, 8.97; 95% CI, 2.1-38.5; P < .01), and treating physicians with more years in practice (OR, 12.82; 95% CI, 3.9-42.4; P < .01). CONCLUSIONS Within a large, prospective population-based data set, fractionation schedules for palliative radiation therapy of bone metastases remain highly variable. Resource-intensive treatments including EF persist, although EF use was low after implementation of a quality measure. Complicated metastases, lack of central nervous system or visceral disease, and treatment at nonteaching facilities or by physicians with more years in practice significantly predict use of EF. These results support ongoing efforts to more clearly understand and address barriers to high-value radiation approaches in the palliative setting.
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Affiliation(s)
| | - Huiying Yin
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Kent A Griffith
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Raveena Pandya
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Brandon R Mancini
- Department of Radiation Oncology, West Michigan Cancer Center, Kalamazoo, Michigan
| | - Shruti Jolly
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Thomas P Boike
- Department of Radiation Oncology, MHP Radiation Oncology Institute/21st Century Oncology, Clarkston, Michigan
| | - Jean M Moran
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Michael M Dominello
- Department of Radiation Oncology, Barbara Ann Karmanos Cancer Center, Wayne State University School of Medicine, Detroit, Michigan
| | - Melissa Wilson
- Department of Radiation Oncology, MHP Radiation Oncology Institute/21st Century Oncology, Troy, Michigan
| | - Jan Parker
- Department of Radiation Oncology, Henry Ford Allegiance, Jackson, Michigan
| | - Jay Burmeister
- Department of Radiation Oncology, Barbara Ann Karmanos Cancer Center, Wayne State University School of Medicine, Detroit, Michigan
| | - Correen Fraser
- Department of Radiation Oncology, Henry Ford Health System, Detroit, Michigan
| | - Lynne Miller
- Department of Radiation Oncology, Sparrow Herbert-Herman Cancer Center, Lansing, Michigan
| | - Kaitlyn Baldwin
- Department of Radiation Oncology, Munson Medical Center, Traverse City, Michigan
| | - Melissa A Mietzel
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Margaret Grubb
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Danielle Kendrick
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Daniel E Spratt
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - James A Hayman
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan.
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16
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Jagsi R, Griffith KA, Vicini F, Boike T, Burmeister J, Dominello MM, Grills I, Hayman JA, Moran JM, Paximadis P, Radawski JD, Walker EM, Pierce LJ. Toward Improving Patients' Experiences of Acute Toxicity From Breast Radiotherapy: Insights From the Analysis of Patient-Reported Outcomes in a Large Multicenter Cohort. J Clin Oncol 2020; 38:4019-4029. [PMID: 32986529 PMCID: PMC9798927 DOI: 10.1200/jco.20.01703] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
PURPOSE Understanding acute toxicities after whole-breast radiotherapy is important to inform patients, guide treatment decisions, and target supportive care. We evaluated patient-reported outcomes prospectively collected from a cohort of patients with breast cancer. METHODS We describe the maximal toxicity reported by 8,711 patients treated between 2012 and 2019 at 27 practices. Multivariable models identified characteristics associated with (1) breast pain, (2) bother from itching, stinging/burning, swelling, or hurting of the treated breast, and (3) fatigue within 7 days of completing whole-breast radiotherapy. RESULTS Moderate or severe breast pain was reported by 3,233 (37.1%): 1,282 (28.9%) of those receiving hypofractionation and 1,951 (45.7%) of those receiving conventional fractionation. Frequent bother from at least one breast symptom was reported by 4,424 (50.8%): 1,833 (41.3%) after hypofractionation and 2,591 (60.7%) after conventional fractionation. Severe fatigue was reported by 2,008 (23.1%): 843 (19.0%) after hypofractionation and 1,165 (27.3%) after conventional fractionation. Among patients receiving hypofractionated radiotherapy, younger age (P < .001), higher body mass index (BMI; P < .001), Black (P < .001) or other race (P = .002), smoking status (P < .001), larger breast volume (P = .002), lack of chemotherapy receipt (P = .004), receipt of boost treatment (P < .001), and treatment at a nonteaching center predicted breast pain. Among patients receiving conventionally fractionated radiotherapy, younger age (P < .001), higher BMI (P = .003), Black (P < .001) or other race (P = .002), diabetes (P = .001), smoking status (P < .001), and larger breast volume (P < .001) predicted breast pain. CONCLUSION In this large observational data set, substantial differences existed according to radiotherapy dose fractionation. Race-related differences in pain existed despite controlling for multiple other factors; additional research is needed to understand what drives these differences to target potentially modifiable factors. Intensifying supportive care may be appropriate for subgroups identified as being vulnerable to greater toxicity.
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Affiliation(s)
- Reshma Jagsi
- University of Michigan, Ann Arbor, MI,Reshma Jagsi, MD, DPhil, Department of Radiation Oncology, University of Michigan, UHB2C490, SPC 5010, 1500 East Medical Center Dr, Ann Arbor, MI 48109-5010; e-mail:
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17
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Laucis AM, Jagsi R, Griffith KA, Dominello MM, Walker EM, Abu-Isa EI, Dilworth JT, Vicini F, Kocheril PG, Browne CH, Mietzel MA, Moran JM, Hayman JA, Pierce LJ. The Role of Facility Variation on Racial Disparities in Use of Hypofractionated Whole Breast Radiation Therapy. Int J Radiat Oncol Biol Phys 2020; 107:949-958. [DOI: 10.1016/j.ijrobp.2020.04.035] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 04/20/2020] [Accepted: 04/22/2020] [Indexed: 01/10/2023]
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18
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Pillai M, Adapa K, Das SK, Mazur L, Dooley J, Marks LB, Thompson RF, Chera BS. Using Artificial Intelligence to Improve the Quality and Safety of Radiation Therapy. J Am Coll Radiol 2019; 16:1267-1272. [DOI: 10.1016/j.jacr.2019.06.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 06/03/2019] [Indexed: 02/06/2023]
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19
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Dess RT, Sun Y, Muenz DG, Paximadis PA, Dominello MM, Grills IS, Kestin LL, Movsas B, Masi KJ, Matuszak MM, Radawski JD, Moran JM, Pierce LJ, Hayman JA, Schipper MJ, Jolly S. Cardiac Dose in Locally Advanced Lung Cancer: Results From a Statewide Consortium. Pract Radiat Oncol 2019; 10:e27-e36. [PMID: 31382026 DOI: 10.1016/j.prro.2019.07.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 06/17/2019] [Accepted: 07/23/2019] [Indexed: 12/25/2022]
Abstract
PURPOSE The heart has been identified as a potential significant organ at risk in patients with locally advanced non-small cell lung cancer treated with radiation. Practice patterns and radiation dose delivered to the heart in routine practice in academic and community settings are unknown. METHODS AND MATERIALS Between 2012 and 2017, 746 patients with stage III non-small cell lung cancer were treated with radiation within the statewide Michigan Radiation Oncology Quality Consortium (MROQC). Cardiac radiation dose was characterized, including mean and those exceeding historical or recently proposed Radiation Therapy Oncology Group and NRG Oncology constraints. Sites were surveyed to determine dose constraints used in practice. Patient-, anatomic-, and treatment-related associations with cardiac dose were analyzed using multivariable regression analysis and inverse probability weighting. RESULTS Thirty-eight percent of patients had a left-sided primary, and 80% had N2 or N3 disease. Median prescription was 60 Gy (interquartile range, 60-66 Gy). Twenty-two percent of patients were prescribed 60 Gy in 2012, which increased to 62% by 2017 (P < .001). Median mean heart dose was 12 Gy (interquartile range, 5-19 Gy). The volume receiving 30 Gy (V30 Gy) exceeded 50% in 5% of patients, and V40 Gy was >35% in 3% of cases. No heart dose constraint was uniformly applied. Intensity modulated radiation therapy (IMRT) usage increased from 33% in 2012 to 86% in 2017 (P < .001) and was significantly associated with more complex cases (larger planning target volume, higher stage, and preexisting cardiac disease). In multivariable regression analysis, IMRT was associated with a lower percent of the heart receiving V30 Gy (absolute reduction = 3.0%; 95% confidence interval, 0.5%-5.4%) and V50 Gy (absolute reduction = 3.6%; 95% confidence interval, 2.4%-4.8%) but not mean dose. In inverse probability weighting analysis, IMRT was associated with 29% to 48% relative reduction in percent of the heart receiving V40-V60 Gy without increasing lung or esophageal dose or compromising planning target volume coverage. CONCLUSIONS Within MROQC, historical cardiac constraints were met in most cases, yet 1 in 4 patients received a mean heart dose exceeding 20 Gy. Future work is required to standardize heart dose constraints and to develop treatment approaches that allow for constraints to be met without compromising other planning goals.
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Affiliation(s)
- Robert T Dess
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan.
| | - Yilun Sun
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Daniel G Muenz
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | | | | | | | - Larry L Kestin
- MHP Radiation Oncology Institute, Farmington Hills, Michigan
| | | | | | - Martha M Matuszak
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | | | - Jean M Moran
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Lori J Pierce
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - James A Hayman
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Matthew J Schipper
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan; Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Shruti Jolly
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
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20
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Matuszak MM, Paximadis P, Yudelev M, Grubb M, Wilson ML, Fraser C, Dalmia P, Alkhatib A, Sieffert DE, Haywood JR, Tatro D, Parker J, Ettaher O, Grills I, Kestin L, Walker EM, Friedle C, Kim H, Radawski JD, Boike T, Moran JM, Pierce LJ, Hayman JA. Managing motion in conventionally fractionated lung cancer radiation therapy: Collaborative quality improvement from a statewide consortium of academic and community practices. Pract Radiat Oncol 2018; 8:e208-e211. [DOI: 10.1016/j.prro.2017.11.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Revised: 10/27/2017] [Accepted: 11/30/2017] [Indexed: 12/25/2022]
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21
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Paximadis P, Schipper M, Matuszak M, Feng M, Jolly S, Boike T, Grills I, Kestin L, Movsas B, Griffith K, Gustafson G, Moran J, Nurushev T, Radawski J, Pierce L, Hayman J. Dosimetric predictors for acute esophagitis during radiation therapy for lung cancer: Results of a large statewide observational study. Pract Radiat Oncol 2018; 8:167-173. [PMID: 28919249 PMCID: PMC6818411 DOI: 10.1016/j.prro.2017.07.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 06/07/2017] [Accepted: 07/16/2017] [Indexed: 12/25/2022]
Abstract
PURPOSE The purpose of this study is to identify dosimetric variables that best predict for acute esophagitis in patients treated for locally advanced non-small cell lung cancer in a prospectively accrued statewide consortium. METHODS AND MATERIALS Patients receiving definitive radiation therapy for stage II-III non-small cell lung cancer within the Michigan Radiation Oncology Quality Consortium were included in the analysis. Dose-volume histogram data were analyzed to determine absolute volumes (cc) receiving doses from 10 to 60 Gy (V10, V20, V30, V40, V50, and V60), as well as maximum dose to 2 cc (D2cc), mean dose (MD), and generalized equivalent uniform dose (gEUD). Logistic regression models were used to characterize the risk of toxicity as a function of dose and other covariates. The ability of each variable to predict esophagitis, individually or in a multivariate model, was quantified by receiver operating characteristic analysis. RESULTS There were 533 patients who met study criteria and were included; 437 (81.9%) developed any grade of esophagitis. Significant variables on univariate analysis for grade ≥2 esophagitis were concurrent chemotherapy, V20, V30, V40, V50, V60, MD, D2cc, and gEUD. For grade ≥3 esophagitis, the predictive variables were: V30, V40, V50, V60, MD, D2cc, and gEUD. In multivariable modeling, gEUD was the most significant predictor of both grade ≥2 and grade ≥3 esophagitis. When gEUD was excluded from the model, D2cc was selected as the most predictive variable for grade ≥3 esophagitis. For an estimated risk of grade ≥3 esophagitis of 5%, the threshold values for gEUD and D2cc were 59.3 Gy and 68 Gy, respectively. CONCLUSIONS In this study, we report the novel finding that gEUD and D2cc, rather than MD, were the most predictive dose metrics for severe esophagitis. To limit the estimated risk of grade ≥3 esophagitis to <5%, thresholds of 59.3 Gy and 68 Gy were identified for gEUD and D2cc, respectively.
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Affiliation(s)
| | | | | | - Mary Feng
- University of Michigan, Ann Arbor, Michigan
| | | | | | - Inga Grills
- William Beaumont Hospital, Royal Oak, Michigan
| | - Larry Kestin
- 21st Century Oncology, Farmington Hills, Michigan
| | | | | | | | - Jean Moran
- University of Michigan, Ann Arbor, Michigan
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22
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Feng M, Valdes G, Dixit N, Solberg TD. Machine Learning in Radiation Oncology: Opportunities, Requirements, and Needs. Front Oncol 2018; 8:110. [PMID: 29719815 PMCID: PMC5913324 DOI: 10.3389/fonc.2018.00110] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 03/29/2018] [Indexed: 12/14/2022] Open
Abstract
Machine learning (ML) has the potential to revolutionize the field of radiation oncology, but there is much work to be done. In this article, we approach the radiotherapy process from a workflow perspective, identifying specific areas where a data-centric approach using ML could improve the quality and efficiency of patient care. We highlight areas where ML has already been used, and identify areas where we should invest additional resources. We believe that this article can serve as a guide for both clinicians and researchers to start discussing issues that must be addressed in a timely manner.
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Affiliation(s)
- Mary Feng
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, United States
| | - Gilmer Valdes
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, United States
| | - Nayha Dixit
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, United States
| | - Timothy D Solberg
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, United States
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23
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Pierce LJ, Feng M, Griffith KA, Jagsi R, Boike T, Dryden D, Gustafson GS, Benedetti L, Matuszak MM, Nurushev TS, Haywood J, Radawski JD, Speers C, Walker EM, Hayman JA, Moran JM. Recent Time Trends and Predictors of Heart Dose From Breast Radiation Therapy in a Large Quality Consortium of Radiation Oncology Practices. Int J Radiat Oncol Biol Phys 2017; 99:1154-1161. [PMID: 28927756 DOI: 10.1016/j.ijrobp.2017.07.022] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 06/23/2017] [Accepted: 07/18/2017] [Indexed: 12/25/2022]
Abstract
PURPOSE Limited data exist regarding the range of heart doses received in routine practice with radiation therapy (RT) for breast cancer in the United States today and the potential effect of the continual assessment of the cardiac dose on practice patterns. METHODS AND MATERIALS From 2012 to 2015, 4688 patients with breast cancer treated with whole breast RT at 20 sites participating in a state-wide consortium were enrolled into a registry. The importance of limiting the cardiac dose has been emphasized in the consortium since 2012, and the mean heart dose (MHD) has been reported by each institution since 2014. The effects on the MHD were estimated for both conventional and accelerated fractionation using regression models, with technique (intensity modulated RT [IMRT] vs 3-dimensional conformal RT), deep inspiration breath hold use, patient position (supine vs prone), nodal RT (if delivered), and boost (yes vs no) as covariates. RESULTS For left-sided breast cancer treated with conventional fractionation, the median MHD in 2012 was 2.19 Gy versus 1.65 Gy in 2015 (P<.001). The factors that significantly increased the MHD for conventional fractionation were increased separation relative to 22 cm (1.5%/1 cm), supraclavicular or infraclavicular nodal RT (17.1%), internal mammary nodal RT (40.7%), use of a boost (20.9%), treatment year before 2015 (7.7%), and use of IMRT (20.8%). For left-sided BC treated with accelerated fractionation, the median MHD in 2012 was 1.70 Gy versus 1.22 Gy in 2015 (P<.001). The factors that significantly increased the MHD for accelerated fractionation were separation (1.7%/1 cm), use of a boost (20.0%), year before 2015 (8.5%), and use of IMRT (19.2%). The factors for both conventional fractionation and accelerated fractionation that significantly reduced the MHD were the use of deep inspiration breath hold and prone positioning. CONCLUSIONS The MHD for left-sided breast cancer decreased during a recent 4-year period, coincident with an increased focus on cardiac sparing in the radiation oncology community in general and a state-wide consortium specifically. These data suggest a positive effect of systematically monitoring the heart dose delivered.
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Affiliation(s)
- Lori J Pierce
- Department of Radiation Oncology, Michigan Medicine, Ann Arbor, Michigan.
| | - Mary Feng
- Department of Radiation Oncology, Michigan Medicine, Ann Arbor, Michigan
| | - Kent A Griffith
- School of Public Health, University of Michigan, Ann Arbor, Michigan
| | - Reshma Jagsi
- Department of Radiation Oncology, Michigan Medicine, Ann Arbor, Michigan
| | | | | | | | | | - Martha M Matuszak
- Department of Radiation Oncology, Michigan Medicine, Ann Arbor, Michigan
| | | | | | | | - Corey Speers
- Department of Radiation Oncology, Michigan Medicine, Ann Arbor, Michigan
| | | | - James A Hayman
- Department of Radiation Oncology, Michigan Medicine, Ann Arbor, Michigan
| | - Jean M Moran
- Department of Radiation Oncology, Michigan Medicine, Ann Arbor, Michigan
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