Radiation Oncology Peer Review in a Community Setting: The Value of Prospective Review.

Peer review is an important component of any radiation oncology continuous quality improvement program. While limited guidelines exist, there is no consensus about how peer review should be performed, and large variations exist among different institutions. The purpose of this report is to describe our experience with peer review at a busy Radiation Oncology clinic and to evaluate the difference between prospective and retrospective peer review. We also performed a failure modes and effects analysis (FMEA) of the peer review process. Starting in 2015, every peer review session was tracked, including recommended changes to treatment plans. We reviewed the frequency, types and severity of these changes. A team of physicians and physicists conducted an FMEA of the peer review process. Between April 2015 and June 2020, a total of 3,691 patients were peer-reviewed. Out of those, 1,903 were prospective reviews (51.6%). Plans reviewed before treatment were almost 4.5 times more likely to be changed by peer review than those reviewed after the start of treatment (0.9% vs 0.2%). Plan changes after the start of treatment had a higher severity than changes prior to the start of treatment. FMEA identified several critical components of peer review. While there is no national standard for peer review, it is evident that prospective peer review is preferable. There may be a subconscious reluctance to change plans already underway, which could be a barrier to improving plans with the peer review process. Rather than reviewing in a group setting, it would be ideal to individually assign review tasks that are embedded in the clinical flow, assuring prospective review for all patients prior to final physician approval. Individual review rather than group review may be more candid, due to interpersonal concerns about publicly disagreeing with colleagues.

Implementation of peer-review quality rounds for gynecologic brachytherapy in a high-volume academic center.

PURPOSE: While peer review is critical for quality and safety in radiotherapy, there are neither formal guidelines nor format examples for brachytherapy (BT) peer review. We report on a gynecologic BT peer-review method implemented at a high-volume academic center. METHODS AND MATERIALS: We analyzed discussions at bimonthly gynecologic BT peer-review rounds between July and December 2018. Rounds consisted of 2-5 attending physicians with gynecologic BT expertise, 1-2 BT physicists, and trainees. Peer-review targets included clinical case review, contours, implant technique, dose/fractionation, and target/organ-at-risk (OAR) dosimetry. The projected/final target and OAR dosimetry were analyzed. RESULTS: 55 separate implants from 44 patients were reviewed. Implants were mostly reviewed after the first BT fraction (n = 16, 29%) or at another time point during BT (n = 20, 36%). One (2%) implant was presented prospectively. The applicator type and BT technique were reviewed for all implants. Dose/fractionation was evaluated for 46 implants (84%); contours were discussed for 21 (38%). Target and OAR dosimetry were reviewed for 54 (98%) and 28 implants (51%), respectively. Six cases (11%) underwent minor changes to the applicator type to improve target and/or OAR dosimetry. One case (2%) had a major change recommended to the dose/fractionation. CONCLUSIONS: Gynecologic BT peer review may enhance BT quality by allowing for implant optimization and formal review of challenging cases, ultimately improving medical decision-making and team communication. Peer review should be implemented in centers offering gynecologic BT.

Lung Stereotactic Body Radiation Therapy (SBRT) dose gradient and PTV volume: a retrospective multi-center analysis.

BACKGROUND: The treatment of lung lesions with stereotactic body radiation therapy calls for highly conformal dose, which is evaluated by a number of metrics. Lung stereotactic body radiation therapy clinical trials constrain a plans gradient index. The purpose of this work is to describe the dependence of clinically achievable dose gradient on planning target volume. METHODS: Three hundred seventy-four lung stereotactic body radiation therapy treatment plans were retrospectively reviewed and selected for this study. The relationship between R50% and planning target volume size was observed and compared against the RTOG 0915 and 0813 constraints noting minor and major deviations. Then a least squares regression was used to determine the coefficients for a power functional form of the dependence of gradient measure (GM) on planning target volume size. RESULTS: Of the 317 peripheral lung SBRT plans, 142 exhibited no deviation, 135 exhibited a minor deviation, and 40 exhibited a major deviation according to the RTOG 0915 dosimetric. conformality and dose fall-off constraints. A plot of gradient measure versus planning target volume size for peripheral lesions, excluding RTOG 0915 major deviations, is fit with an power function of GM = 0.564 V0.215. CONCLUSIONS: Using the PTV size and GM relationship we have characterized, treatment plans with PTV < 85 cm3 can be evaluated subjectively to our previously plans, and given a percentile GM. This relationship and evaluation is useful for volumetric modulated arc therapy lung stereotactic body radiation therapy treatment planning and quality control.

Can Oscillatory Alpha-Gamma Phase-Amplitude Coupling be Used to Understand and Enhance TMS Effects?

Recent applications of simultaneous scalp electroencephalography (EEG) and transcranial magnetic stimulation (TMS) suggest that adapting stimulation to underlying brain states may enhance neuroplastic effects of TMS. It is often assumed that longer-lasting effects of TMS on brain function may be mediated by phasic interactions between TMS pulses and endogenous cortical oscillatory dynamics. The mechanisms by which TMS exerts its neuromodulatory effects, however, remain unknown. Here, we discuss evidence concerning the functional effects on synaptic plasticity of oscillatory cross-frequency coupling in cortical networks as a potential framework for understanding the neuromodulatory effects of TMS. We first discuss evidence for interactions between endogenous oscillatory brain dynamics and externally induced electromagnetic field activity. Alpha band (8-12 Hz) activities are of special interest here because of the wide application and therapeutic effectiveness of rhythmic TMS (rTMS) using a stimulus repetition frequency at or near 10 Hz. We discuss the large body of literature on alpha oscillations suggesting that alpha oscillatory cycles produce periodic inhibition or excitation of neuronal processing through phase-amplitude coupling (PAC) of low-frequency oscillations with high-frequency broadband (or gamma) bursting. Such alpha-gamma coupling may reflect excitability of neuronal ensembles underlying neuroplasticity effects of TMS. We propose that TMS delivery with simultaneous EEG recording and near real-time estimation of source-resolved alpha-gamma PAC might be used to select the precise timing of TMS pulse deliveries so as to enhance the neuroplastic effects of TMS therapies.

Detailed prospective peer review in a community radiation oncology clinic.

PURPOSE: In 2012, we instituted detailed prospective peer review of new cases. We present the outcomes of peer review on patient management and time required for peer review. METHODS AND MATERIALS: Peer review rounds were held 3 to 4 days weekly and required 2 physicians to review pertinent information from the electronic medical record and treatment planning system. Eight aspects were reviewed for each case: 1) workup and staging; 2) treatment intent and prescription; 3) position, immobilization, and simulation; 4) motion assessment and management; 5) target contours; 6) normal tissue contours; 7) target dosimetry; and 8) normal tissue dosimetry. Cases were marked as, "Meets standard of care," "Variation," or "Major deviation." Changes in treatment plan were noted. As our process evolved, we recorded the time spent reviewing each case. RESULTS: From 2012 to 2014, we collected peer review data on 442 of 465 (95%) radiation therapy patients treated in our hospital-based clinic. Overall, 91 (20.6%) of the cases were marked as having a variation, and 3 (0.7%) as major deviation. Forty-two (9.5%) of the cases were altered after peer review. An overall peer review score of "Variation" or "Major deviation" was highly associated with a change in treatment plan (P < .01). Changes in target contours were recommended in 10% of cases. Gastrointestinal cases were significantly associated with a change in treatment plan after peer review. Indicators on position, immobilization, simulation, target contours, target dosimetry, motion management, normal tissue contours, and normal tissue dosimetry were significantly associated with a change in treatment plan. The mean time spent on each case was 7 minutes. CONCLUSIONS: Prospective peer review is feasible in a community radiation oncology practice. Our process led to changes in 9.5% of cases. Peer review should focus on technical factors such as target contours and dosimetry. Peer review required 7 minutes per case.

RO-ILS: Radiation Oncology Incident Learning System: A report from the first year of experience.

PURPOSE: Incident learning is a critical tool to improve patient safety. The Patient Safety and Quality Improvement Act of 2005 established essential legal protections to allow for the collection and analysis of medical incidents nationwide. METHODS AND MATERIALS: Working with a federally listed patient safety organization (PSO), the American Society for Radiation Oncology and the American Association of Physicists in Medicine established RO-ILS: Radiation Oncology Incident Learning System (RO-ILS). This paper provides an overview of the RO-ILS background, development, structure, and workflow, as well as examples of preliminary data and lessons learned. RO-ILS is actively collecting, analyzing, and reporting patient safety events. RESULTS: As of February 24, 2015, 46 institutions have signed contracts with Clarity PSO, with 33 contracts pending. Of these, 27 sites have entered 739 patient safety events into local database space, with 358 events (48%) pushed to the national database. CONCLUSIONS: To establish an optimal safety culture, radiation oncology departments should establish formal systems for incident learning that include participation in a nationwide incident learning program such as RO-ILS.

Practice patterns for peer review in radiation oncology.

PURPOSE: Physician peer review seeks to improve the quality of care through the evaluation of physician performance, specifically medical decision making and technical expertise. To establish current peer review practice patterns, evaluate interest in recommendations for peer review, and establish a framework for future recommendations, the American Society for Radiation Oncology (ASTRO) surveyed its physician members. METHODS AND MATERIALS: A radiation oncology-specific peer review survey instrument was developed, formally tested, and found to meet established levels of reliability and validity. The final instrument was delivered using a web-based survey platform including reminders. All ASTRO physician-members and members-in-training worldwide were invited by email to participate. RESULTS: A total of 5674 physicians were contacted starting in January 2013. A total of 572 physicians participated (10%) yielding a ±4% margin of error. Those responding were split evenly between academic providers and private practice and others. The median time since training=16 years, median number of new patients per year=215, and median practice size=6 physicians; 83% of respondents were involved in peer review and 75% were comfortable with their program. Of those involved, 65% report doing some review before radiation begins. Of patients treated by these physicians, 56% are reviewed before treatment. Peer review elements reviewed include overall treatment strategy (86%), dose and fractionation (89%), contouring (59%), and isodose or dose-volume histogram (75%). Ninety percent of physicians have changed radiation plans because of peer review. These providers make changes in 7%-10% of cases. Seventy-four percent of physicians agree that ASTRO should make formal peer review recommendations, with 7% in opposition. CONCLUSIONS: This survey suggests that peer review in radiation oncology is common and leads to changes in management in a meaningful fraction of cases. There is much variation in the manner of conducting, and reported utility of, peer review. The majority of ASTRO physician members support formal recommendations and guidance on peer review.

Enhancing the role of case-oriented peer review to improve quality and safety in radiation oncology: Executive summary.

This report is part of a series of white papers commissioned for the American Society for Radiation Oncology (ASTRO) Board of Directors as part of ASTRO's Target Safely Campaign, focusing on the role of peer review as an important component of a broad safety/quality assurance (QA) program. Peer review is one of the most effective means for assuring the quality of qualitative, and potentially controversial, patient-specific decisions in radiation oncology. This report summarizes many of the areas throughout radiation therapy that may benefit from the application of peer review. Each radiation oncology facility should evaluate the issues raised and develop improved ways to apply the concept of peer review to its individual process and workflow. This might consist of a daily multidisciplinary (eg, physicians, dosimetrists, physicists, therapists) meeting to review patients being considered for, or undergoing planning for, radiation therapy (eg, intention to treat and target delineation), as well as meetings to review patients already under treatment (eg, adequacy of image guidance). This report is intended to clarify and broaden the understanding of radiation oncology professionals regarding the meaning, roles, benefits, and targets for peer review as a routine quality assurance tool. It is hoped that this work will be a catalyst for further investigation, development, and study of the efficacy of peer review techniques and how these efforts can help improve the safety and quality of our treatments.

Patient preferences and physician practice patterns regarding breast radiotherapy.

PURPOSE: There are multiple current strategies for breast radiotherapy (RT). The alignment of physician practice patterns with best evidence and patient preferences will enhance patient autonomy and improve cancer care. However, there is little information describing patient preferences for breast RT and physician practice patterns. METHODS AND MATERIALS: Using a reliable and valid instrument, we assessed the preferences of 5,000 randomly selected women (with or without cancer) undergoing mammography. To assess practice patterns, 2,150 randomly selected physician-members of American Society for Radiation Oncology were surveyed. RESULTS: A total of 1,807 women (36%) and 363 physicians (17%) provided usable responses. The 95% confidence interval is < ± 2.3% for patients and < ± 5.3% for physicians. Patient preferences were hypofractionated whole breast irradiation (HF-WBI) 62%, partial breast irradiation (PBI) 28%, and conventionally fractionated whole breast irradiation (CF-WBI) 10%. By comparison, 82% of physicians use CF-WBI for more than 2/3 of women and 56% never use HF-WBI. With respect to PBI, 62% of women preferred three-dimensional (3D)-PBI and 38% favor brachytherapy-PBI, whereas 36% of physicians offer 3D-PBI and 66% offer brachytherapy-PBI. 70% of women prefer once-daily RT over 10 days vs. twice-daily RT over 5 days. 55% of physicians who use PBI do not offer PBI on clinical trial. CONCLUSIONS: HF-WBI, while preferred by patients and supported by evidence, falls behind the unproven and less preferred strategy of PBI in clinical practice. There is a discrepancy between women's preferences for PBI modality and type of PBI offered by physicians. Further alignment is needed between practice patterns, patient preferences, and clinical evidence.

A pilot trial of serial 18F-fluorodeoxyglucose positron emission tomography in patients with medically inoperable stage I non-small-cell lung cancer treated with hypofractionated stereotactic body radiotherapy.

PURPOSE: Routine assessment was made of tumor metabolic activity as measured by 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) in Stage I non-small-cell lung cancer (NSCLC). This report describes PET correlates prospectively collected after stereotactic body radiotherapy (SBRT) for patients with medically inoperable NSCLC. METHODS AND MATERIALS: 14 consecutive patients with medically inoperable Stage I NSCLC were enrolled. All patients received SBRT to 60-66 Gy in three fractions. Patients underwent serial planned FDG-PET/computed tomography fusion imaging before SBRT and at 2, 26, and 52 weeks after SBRT. RESULTS: With median follow-up of 30.2 months, no patients experienced local failure. One patient developed regional failure, 1 developed distant failure, and 1 developed a second primary. The median tumor maximum standardized uptake value (SUV(max)) before SBRT was 8.70. The median SUV(max) values at 2, 26, and 52 weeks after SBRT were 6.04, 2.80, and 3.58, respectively. Patients with low pre-SBRT SUV were more likely to experience initial 2-week rises in SUV, whereas patients with high pre-SBRT SUV commonly had SUV declines 2 weeks after treatment (p = 0.036). Six of 13 patients had primary tumor SUV(max) >3.5 at 12 months after SBRT but remained without evidence of local disease failure on further follow-up. CONCLUSIONS: A substantial proportion of patients may have moderately elevated FDG-PET SUV(max) at 12 months without evidence of local failure on further follow-up. Thus, slightly elevated PET SUV(max) should not be considered a surrogate for local treatment failure. Our data do not support routine serial FDG-PET/computed tomography for follow-up of patients receiving SBRT for Stage I NSCLC.

Baseline pulmonary function as a predictor for survival and decline in pulmonary function over time in patients undergoing stereotactic body radiotherapy for the treatment of stage I non-small-cell lung cancer.

PURPOSE: To examine the effect of baseline forced expiratory volume in 1 second (FEV(1)) and diffusion capacity for carbon monoxide (Dl(co)) on posttreatment survival and pulmonary function decrease after stereotactic body radiotherapy (SBRT) for patients with early-stage non-small-cell lung cancer (NSCLC). METHODS AND MATERIALS: Seventy medically inoperable patients with Stage I NSCLC were treated with definitive SBRT to a dose of 6,000 (Stage IA) or 6,600 cGy (Stage IB), given in three equal fractions. Baseline and serial posttreatment pulmonary function data were collected. RESULTS: Median age was 70.5 years, and median follow-up was 2.17 years. Median pretreatment FEV(1) and Dl(co) were 1.05 L and 10.06 mg/min/mm Hg, respectively. There was no significant decrease in survival in patients with baseline FEV(1) and Dl(co) less than the median value and less than the lowest quartile, whereas patients with values greater than the highest quartile of baseline FEV(1) had significantly inferior survival. There was no significant effect of pretreatment FEV(1) or Dl(co) on posttreatment levels. There was a statistically significant decrease in Dl(co) of 1.11 mg/min/mm Hg/y. CONCLUSIONS: Poor baseline pulmonary function did not predict decreased survival or pulmonary function after treatment. A statistically significant decrease in Dl(co) after treatment was seen, similar to decreases seen in studies delivering standard thoracic radiotherapy. We conclude that low pretreatment FEV(1) and/or Dl(co) alone should not be used to exclude patients with NSCLC from treatment with SBRT.

Stereotactic body radiation therapy for early-stage non-small-cell lung cancer.

Stereotactic body radiation therapy has emerged as a novel oncologic therapy and experience with the use of stereotactic body radiation therapy for the treatment of early-stage non-small-cell lung cancer has grown over the last 10 years. This article reviews the radiobiologic, physical/technical and clinical aspects of stereotactic body radiation therapy for early-stage non-small-cell lung cancer. The literature is also reviewed.

FDG-PET and stereotactic body radiotherapy (SBRT) for stage I non-small-cell lung cancer.

PURPOSE: To investigate the utility of positron emission tomography (PET) in patients treated with stereotactic body radiotherapy (SBRT) for stage I non-small-cell lung cancer (NSCLC) on prospective institutional trials. PATIENTS AND METHODS: Fifty-eight patients with medically inoperable stage I NSCLC who participated in prospective phase I and II trials of SBRT, had >or=2 years of follow-up, and received FDG-PET imaging are the focus of this evaluation. Fifty-seven of 58 patients received pre-SBRT FDG-PET to confirm stage I status. All patients received stereotactic body frame immobilization and treatment with 7-10 photon beams. SBRT total doses ranged from 24 to 72Gy in three fractions. No elective nodal irradiation was undertaken. Regular follow-up with planned CT imaging was performed on all patients. Post-SBRT FDG-PET was not mandated by protocol and was typically ordered upon concern for disease recurrence. Thirty-eight post-SBRT PET studies were performed in 28 patients at a median 17.3 months following SBRT. RESULTS: With a median follow-up of 42.5 months, the 3-year actuarial overall survival and local control for this select subset of our SBRT experience were 48.9% and 74.8%, respectively. Pre-SBRT FDG-PET SUV did not predict 3-year overall survival or local control. Fourteen of 57 patients eventually failed in nodal stations by CT and/or PET. Isolated first site of failure was nodal in 6 patients (10%). Out of 28 patients with post-SBRT PET, 4 (14%) had delayed PET imaging (22-26 months after SBRT) showing moderate hypermetabolic activity (SUV 2.5-5.07), but no evidence of local, nodal, or distant recurrence by clinical examination and conventional imaging performed 20-26 months following these concerning PET findings. CONCLUSIONS: Isolated nodal recurrence following PET-staged I NSCLC treated with SBRT is uncommon. Moderate post-SBRT PET hypermetabolic activity may persist 2 years following treatment without definite evidence of recurrence. Further study is needed to confirm these results in larger populations with longer follow-up.