Utilitarian prioritization of radiation oncology patients based on maximization of population tumour control.

An objective method for establishing patient prioritization in the context of a radiotherapy waiting list is investigated. This is based on a utilitarian objective, being the greatest probability of local tumour control in the population of patients. A numerical simulation is developed and a clinical patient case-mix is used to determine the influence of the characteristics of the patient population on resulting optimal patient scheduling. With the utilitarian objective, large gains in tumour control probability (TCP) can be achieved for individuals or cohorts by prioritizing patients for that fraction of the patient population with relatively small sacrifices in TCP for a smaller fraction of the population. For a waiting list in steady state with five patients per day commencing treatment and leaving the list (and so with five patients per day entering the list), and a mean wait time of 35 days and a maximum of 90 days, optimized wait times ranged from a mean of one day for patients with tumour types with short effective doubling times to a mean of 66.9 days for prostate cancer patients. It is found that, when seeking the optimal daily order of patients on the waiting list in a constrained simulation, the relative rather than absolute value of TCP is the determinant of the resulting optimal waiting times. An increase in the mean waiting time mostly influences (increases) the optimal waiting times of patients with fast-growing tumours. The proportional representation of groups (separated by tumour type) in the patient population has an influence on the resulting distribution of optimal waiting times for patients in those groups, though has only a minor influence on the optimal mean waiting time for each group.

The GOFURTGO Study: AGITG phase II study of fixed dose rate gemcitabine-oxaliplatin integrated with concomitant 5FU and 3-D conformal radiotherapy for the treatment of localised pancreatic cancer.

BACKGROUND: Locally advanced inoperable pancreatic cancer (LAPC) has a poor prognosis. By increasing intensity of systemic therapy combined with an established safe chemoradiation technique, our intention was to enhance the outcomes of LAPC. In preparation for phase III evaluation, the feasibility and efficacy of our candidate regimen gemcitabine-oxaliplatin chemotherapy with sandwich 5-fluorouracil (5FU) and three-dimensional conformal radiotherapy (3DCRT) needs to be established. METHODS: A total of 48 patients with inoperable LAPC without metastases were given gemcitabine (1000 mg m(-2) d1 + d15 q28) and oxaliplatin (100 mg m(-2) d2 + d16 q28) in induction (one cycle) and consolidation (three cycles), and 5FU 200 mg m(-2) per day over 6 weeks during 3DCRT 54 Gy. RESULTS: Median duration of sustained local control (LC) was 15.8 months, progression-free survival (PFS) was 11.0 months, and overall survival was 15.7 months. Survival rates for 1, 2, and 3 years were 70.2%, 21.3%, and 12.8%, respectively. Global quality of life did not significantly decline from baseline during treatment, which was associated with modest treatment-related toxicity. CONCLUSION: Fixed-dose gemcitabine and oxaliplatin, combined with an effective and safe regimen of 5FU and 3DCRT radiotherapy, was feasible and reasonably tolerated. The observed improved duration of LC and PFS with more intensive therapy over previous trials may be due to patient selection, but suggest that further evaluation in phase III trials is warranted.

Lung cancer multidisciplinary team meetings: A survey of participants at a national conference.

Multidisciplinary meetings (MDMs) are a useful aid for the development of comprehensive treatment plans for cancer patients. However, little is known about the requirements for effective MDM function. Attendees at a national lung cancer conference who participated at least weekly in lung cancer MDMs were surveyed. The survey addressed the attendees' perceptions regarding the aims of MDMs, and for their own institutional MDMs, the importance and need for improvement for each of: (i) the attendance of nine discipline groups; and (ii) 15 aspects related to MDM function derived from the literature. The survey also asked participants if MDMs met their needs. There was a general agreement on the aims of the meetings. There was also an agreement on the importance of various groups' attendance and each of the examined aspects of MDMs. However, many respondents reported their meetings required moderate or substantial improvements in one or more areas. More than 20% of the respondents indicated improvement was required for the attendance of three discipline groups (palliative care physicians, pathologists and cardiothoracic surgeons) and 10 of the 15 examined aspects (more than half in the case of computerised databases). Only 9% of the respondents reported that none of the features surveyed needed either moderate or substantial improvement. MDMs met the needs of 79% of the respondents. We found general agreement on the aims of the meetings, the importance of various groups' attendance at MDMs and each of the examined aspects of MDMs. However, moderate or substantial improvements were thought to be required by many respondents. The performance of individual institutions' MDMs and the resources they have available to achieve their aims should be assessed and periodically reviewed. The survey applied here may provide a framework for MDM members to do this.

Comparison of DVH data from multiple radiotherapy treatment planning systems.

This study examined the variation of dose-volume histogram (DVH) data sourced from multiple radiotherapy treatment planning systems (TPSs). Treatment plan exports were obtained from 33 Australian and New Zealand centres during a dosimetry study. Plan information, including DVH data, was exported from the TPS at each centre and reviewed in a digital review system (SWAN). The review system was then used to produce an independent calculation of DVH information for each delineated structure. The relationships between DVHs extracted from each TPS and independently calculated were examined, particularly in terms of the influence of CT scan slice and pixel widths, the resolution of dose calculation grids and the TPS manufacturer. Calculation of total volume and DVH data was consistent between SWAN and each TPS, with the small discrepancies found tending to increase with decreasing structure size. This was significantly influenced by the TPS model used to derive the data. For target structures covered with relatively uniform dose distributions, there was a significant difference between the minimum dose in each TPS-exported DVH and that calculated independently.

Use of radiotherapy to treat life-threatening Kasabach-Merritt syndrome.

Kasabach-Merritt syndrome involves thrombocytopenia, which is usually severe, in association with haemangiomata. We describe two newborn infants who developed life-threatening Kasabach-Merritt syndrome but who were successfully treated. Both had failed to respond adequately to corticosteroids and alpha-interferon. They subsequently received emergency radiotherapy. Both patients had an improvement in their platelet counts. The first infant's haemangioma gradually faded during the first 3 years of life, whereas the second infant's haemangioma had resolved 2 months after radiotherapy. No significant late effects of the radiotherapy have been noted at the 8 and 5 years follow up respectively. Radiotherapy remains an important treatment method in Kasabach-Merritt syndrome when patients fail to respond to other treatments.

The impact of case discussion at a multidisciplinary team meeting on the treatment and survival of patients with inoperable non-small cell lung cancer.

Abstract Patients with inoperable non-small cell lung cancer diagnosed and managed at a single institution over a one-year period were identified. Those whose case had been discussed at a multidisciplinary meeting had better survival than those whose case was not discussed (mean survival; 280 days vs. 205 days, log-rank P= 0.048).

Survey of the learning activities of Australasian radiation oncology specialist trainees.

Trainee radiation oncologists must master a substantial body of skills and knowledge to become competent specialists. The resources available to support this are limited. We surveyed the 90 registrars enrolled in the Royal Australian and New Zealand College of Surgeons (RANZCR) radiation oncology training programme to obtain a range of information about their learning activities (with a significant focus on part 1 teaching). Responses were received from 59 registrars (66% of those eligible). Trainees reported spending a median 2.5 h per week (range 0-10 h) in formal teaching activities. With regard to part 1 exam preparation, 83% reported having had physics teaching--the median quality was 5/7; 88% had radiobiology teaching--the median quality was 4/7; 52% had anatomy teaching--the median quality was 3/7. Registrars training within the RANZCR radiation oncologists training programme perceive their own clinical learning environment as generally good; however' 50% of respondents felt that more teaching was needed for part 1 subjects. This compared with only 19% of respondents who felt that more teaching was required for part 2 exam preparation. Innovative solutions, such as centralized web-based teaching, may help to address weaknesses in part 1 teaching. With increasing demands on radiation oncologists and trainees it will be important to monitor learning environments.

Accrediting radiation technique in a multicentre trial of chemoradiation for pancreatic cancer.

Before a multicentre trial of 3-D conformal radiotherapy to treat cancer of the pancreas, participating clinicians were asked to complete an accreditation exercise. This involved planning two test cases according to the study protocol, then returning hard copies of the plans and dosimetric data for review. Any radiation technique that achieved the specified constraints was allowed. Eighteen treatment plans were assessed. Seven plans were prescribed incorrect doses and two of the planning target volumes did not comply with protocol guidelines. All plans met predefined normal tissue dose constraints. The identified errors were attributable to unforeseen ambiguities in protocol documentation. They were addressed by feedback and corresponding amendments to protocol documentation. Summary radiobiological measures including total weighted normal tissue equivalent uniform dose varied significantly between centres. This accreditation exercise successfully identified significant potential sources of protocol violations, which were then easily corrected. We believe that this process should be applied to all clinical trials involving radiotherapy. Due to the limitations of data analysis with hard-copy information only, it is recommended that complete planning datasets from treatment-planning systems be collected through a digital submission process.

A simple and inexpensive method to routinely produce customized neck supports for patient immobilization during radiotherapy.

Accurate and reproducible patient positioning is fundamental to the success of fractionated radiotherapy. Poor patient positioning could result in geographic misses. We have recently reported on an improved method of customized face mask production using laser surface scanning. In this report, we sought to identify and develop a method to routinely make customized neck supports for patients prescribed radiotherapy to the brain or head and neck regions. We identified a potentially suitable product--sealed packs containing two liquids that produce expanding polyurethane foam when mixed--and developed a method for their use. The neck supports are inexpensive and simple to produce (taking less than 5 min of radiation therapist labour). We assessed the customized neck supports in several ways. The effect on setup accuracy was assessed by comparing two consecutive cohorts of patients. Statistically significant differences favouring the customized neck supports included a reduced total displacement error (mean 3.4 vs. 2.1 mm) and a reduced left-right setup error (mean 1.8 vs. 1.1 mm). This is consistent with the greater support provided by the customized neck supports. This method could easily be undertaken by other departments.

Preparing to sit the Royal Australia and New Zealand College of Radiologists Faculty of Radiation Oncology Fellowship Part 2 examination: the value of a workshop including practice and feedback.

A workshop has been held annually to help prepare candidates to sit the Royal Australia and New Zealand College of Radiologists Part 2 Faculty of Radiation Oncology examination. This study examined the value of such a course and its component parts and assessed attendees' learning environments. We collected detailed information from participants before and after the training workshop in 2005. A specific feature of this workshop included the use of an examination technique feedback form to facilitate the provision of systematic and comprehensive feedback to individual candidates after mock examination. Participants completed course evaluation forms and a learning environment survey. There were 22 candidate participants. The course and its components of this course were perceived very positively - including the examination technique feedback forms and written advice. Only three of the 24 questions regarding the registrars learning environment had less than 80% favourable responses - two of these questions related to workload. The course design described seems reasonably satisfactory in that it included the components ranked most highly by candidates. We also identified a number of variations that may be useful for future workshops. Although learning environments were generally good, we identified a perceived problem with workloads affecting a significant number of registrars.

Surface laser scanning to routinely produce casts for patient immobilization during radiotherapy.

Immobilization casts are used to reduce patient movement during the radiotherapy of head and neck and brain malignancies. Polyethylene-based casts are produced by first taking a Plaster of Paris 'negative' impression of the patient. A 'positive' mould is then made, which is used to vacuum form an immobilization cast. Taking the 'negative' cast can be messy, stressful for patients and labour intensive. Recently, lightweight hand-held laser surface scanners have become available. These allow an accurate 3-D representation of objects to be generated non-invasively. This technology has now been applied to the production of casts for radiotherapy. Each patient's face and head is digitized using the Polhemus FastSCAN (Polhemus, Colchester, VT, USA) scanner. The electronic data are transferred to a computer numerical controlled mill, where a positive impression is machined. The feasibility of the process was examined, the labour required and radiation therapists' satisfaction with aspects of the produced masks assessed. The scanner-based method of mask production was found to be simple, accurate and non-invasive. There was a reduction in radiation therapist labour required. Masks produced with the scanner-based method were reported to result in improved mask fitting, daily reproducibility, patient immobilization and patient comfort.

Prolonged survival after resection and radiotherapy for solitary brain metastases from non-small-cell lung cancer.

Selected patients with brain metastases from non-small-cell lung cancer benefit from aggressive treatment. This report describes three patients who developed solitary brain metastases after previous resection of primary adenocarcinoma of the lung. Each underwent surgical resection of their brain metastasis followed by cranial irradiation and remain disease free 10 or more years later. Two patients developed cognitive impairment approximately 8 years after treatment of their brain metastasis, which was felt to be due to their previous brain irradiation. Here we discuss the treatment of solitary brain metastasis, particularly the value of combined method approaches in selected patients and dose-volume considerations.

Comparison of non-coplanar and coplanar irradiation techniques to treat cancer of the pancreas.

We compared two different techniques of pancreatic irradiation using measures associated with normal tissue complications. Seven consecutive patients with pancreatic cancer were planned for both coplanar and non-coplanar (NCP) external beam radiation treatments, using the same defined anatomical volumes for each patient, in each case. Each pair of plans was then compared using a range of objective criteria. Individual normal tissues were assessed against traditional tolerance limits. Selected dose-points, normal tissue complication probability (NTCP) and equivalent uniform doses (EUD) were also compared, as were indices combining information from individual tissues - total NTCP and total weighted EUD. All individual normal tissues doses were within established tolerance limits. For NCP relative to coplanar planning, NTCP and EUD were lower for all individual tissues in four cases and one case, respectively, i.e. in most cases a benefit to one tissue was offset by detriment to others. Summary measures demonstrated overall benefits for NCP techniques, with the total NTCP in six patients, and with the total weighted EUD in all patients. NCP techniques show potentially useful benefits. We present a new objective measure, the total weighted EUD, which may be particularly useful comparing plans where there are multiple critical tissues.

Assessment of abstracts submitted to the annual scientific meeting of the Royal Australian and New Zealand College of Radiologists.

The process for selecting abstracts submitted for presentation at annual scientific meetings should ensure both the quality of these meetings and fairness to prospective presenters. The aim of the present study was to review the assessment of radiation oncology abstracts submitted for oral presentation to the 2004 Royal Australian and New Zealand College of Radiologists annual scientific meeting. Selection criteria were developed that were primarily focused on the subjective aspects of abstract quality. All research abstracts were reviewed blindly by five individual reviewers (four radiation oncologists and a statistician), scoring each abstract in five categories. The scores of three reviewers were used to select the top 30 general and top eight trainee entries. For comparison, cluster analysis using the scores of all five reviewers was used to group papers into two ranks. There was a strong correlation in total scores for each paper, between all reviewers. Similarly, the study design subscale was strongly correlated between all reviewers. Abstracts belonging to the first-rank cluster were generally selected. Most trainee entries would have been successful in being accepted into the general programme. The selection process described appears feasible and fair and may improve the quality of meetings.

The value of a scientific writing training workshop for radiologists and radiation oncologists.

A substantial amount of radiological and radiation oncological research carried out in Australasia is not published. Therefore, a scientific writing skills training workshop was held in conjunction with the 2004 Royal Australian and New Zealand College of Radiologists Annual Scientific Meeting. Registration for the 3-h-long workshop was open to all conference attendees but numbers were limited. The workshop was led by an experienced facilitator who used content based on a literature review. Participants were asked to complete questionnaires rating their agreement with statements regarding their writing abilities and resources before the workshop. Those who attended the workshop repeated the questionnaire 6-8 weeks afterwards. Comparison of the paired preworkshop and postworkshop responses showed increases in the median category of agreement with statements regarding having the required skills, having advice available and understanding the structure of scientific articles. In addition, all participants reported that they found the workshop useful, said that they would recommend attendance to others and felt that such workshops should be available at future Royal Australian and New Zealand College of Radiologists Annual Scientific Meetings. Half the participants felt that the workshop made it more likely that they would publish. We have shown that even short workshops appear to have benefits and should be encouraged.

Genetic counselling following paternal therapeutic irradiation.

We discuss a patient who received adjuvant radiotherapy for stage I seminoma. He was advised to avoid conception for 6 months following treatment. However, his partner became pregnant only shortly after he completed his radiotherapy (i.e. with sperm that had been irradiated). We estimated the dose received by the remaining testis as 30 cGy. Here, we review the information available to advise patients on the risks to the fetus from paternal preconception irradiation. For the population, a doubling dose for hereditary effects of 1 Gy has recently been reaffirmed (United Nations Scientific Committee on the Effects of Atomic Radiation 2001). However, a range of animal studies suggest conception with postmeiotic sperm carries a greater risk of genetic damage than conception with sperm derived from irradiated stem cells. We have attempted to quantify the risks in this particular case. Lead shielding of the testes may reduce radiation received from the primary beam, but internal scatter still produces a risk. In male patients who are potentially fertile, the best advice remains to delay conception after radiotherapy for as long as 6 months. Our case illustrates the need to reinforce such advice.

A randomised trial of single-dose radiotherapy to prevent procedure tract metastasis by malignant mesothelioma.

A single 9-MeV electron treatment, following invasive thoracic procedures in patients with malignant pleural mesothelioma, was examined. In all, 58 sites were randomised to prophylactic radiotherapy or not. There was no statistically significant difference in tract metastasis. A single 10-Gy treatment with 9-MeV electrons appears ineffective.

A prospective trial of short-fractionation radiotherapy for the palliation of liver metastases.

The purpose of this study was to prospectively examine the effectiveness and tolerability of a simple radiotherapy technique for the palliation of symptomatic liver metastases. Twenty-eight patients with symptomatic liver metastases were enrolled from seven centres, and received targeted (partial or whole) liver irradiation consisting of 10 Gy in two fractions over 2 days. Symptoms at baseline were hepatic pain (27 patients), abdominal distension (19), night sweats (12), nausea (18) and vomiting (eight). Twenty-two patients (76%) had failed previous treatment with chemotherapy, hormonal therapy and/or high-dose steroids. Symptoms and potential toxicities were prospectively assessed at the time of treatment, then 2, 6 and 10 weeks later. Individual symptom response rates were 53-66% at 2 weeks. Partial or complete global symptomatic responses were noted in 15 patients (54%) overall. The treatment was well tolerated with two patients (7%) experiencing grade 3 toxicity (one vomiting and one diarrhoea); however, four patients reported temporary worsening of pain shortly after treatment. This simple and well-tolerated treatment achieves useful palliation.