Radiotherapy-specific quality indicators at national level: How to make it happen.

PURPOSE /OBJECTIVE: To promote best practice and quality of care, the Belgian College of Physicians for Radiotherapy Centers established a set of radiotherapy specific quality indicators for benchmarking on a national level. This paper describes the development, the collected QIs, the observed trends and the departments' evaluation of this initiative. MATERIAL AND METHODS: The Donabedian approach was used, focussing on structural, process and outcome QIs. The criteria for QI selection were availability, required for low-threshold regular collection, and applicability to guidelines and good practice. The QIs were collected yearly and individualized reports were sent out to all RT departments. In 2021, a national survey was held to evaluate the ease of data collection and submission, and the perceived importance and validity of the collected QIs. RESULTS: 18 structural QI and 37 process and outcome parameters (n = 25 patients/pathology/department) were collected. The participation rate amounted to 95 % overall. The analysis gave a national overview of RT activity, resources, clinical practice and reported acute toxicities. The individualized reports allowed departments to benchmark their performance. The 2021 survey indicated that the QIs were overall easy to collect, relevant and reliable. The collection of acute recorded toxicities was deemed a weak point due to inter-observer variabilities and lack of follow-up time. CONCLUSION: QI collection on a national level is a valuable process in steering quality improvement initiatives. The feasibility and relevance was demonstrated with a high level of participation. The national initiative will continue to evolve as a quality monitoring and improvement tool.

The role of the radiation oncologist in quality and patient safety: A proposal of indicators and metrics.

This manuscript represents a collaboration from an international group of quality and safety expert radiation oncologists. It is a position/review paper with the specific aim of defining the role of the radiation oncologist in quality and safety management. This manuscript is unique in that we recommend specific quality assurance/control tasks and correlated quality and indicators and safety measures that are the responsibility of the radiation oncologist. The article addresses the role of the radiation oncologist in quality and safety from a strong perspective of multidisciplinarity and teamwork. Our manuscript is "cross-cutting" and applicable to radiation oncologist in any practice setting (i.e. low middle-income countries).

Feasibility and impact of national peer reviewed clinical audits in radiotherapy departments.

PURPOSE/OBJECTIVE: A national incentive brought about the instauration of systematic clinical audits of all Belgian radiotherapy departments (n = 25) from 2011 to 2015 using the International Atomic Energy Agency QUATRO (Quality Improvement Quality Assurance Team for Radiation Oncology) methodology. The impact of these audits was evaluated and the emitted recommendations originating from the audit reports were analysed to identify areas of weakness on a national basis. METHOD: The QUATRO audits performed in each radiotherapy department gave rise to reports in which each department received a list of recommendations that it is free to implement. These audit reports were analyzed to identify common areas for which improvements were recommended. Moreover, questionnaires were sent to all departments in order to evaluate the overall usefulness of the recommendations as well as the relevancy and the actual impact of each individual recommendation. RESULTS: Of the 381 emitted recommendations, 34% concerned process optimization of which a quarter involved process improvement and protocol development. Twenty-seven percent of the recommendations concerned infrastructure of which one-third was related to the quality of the equipment or facility. Nineteen and 20% of recommendations addressed department organisational and staff issues respectively. When analysing the departments' feedback questionnaires, 54% of the departments evaluated the audits' recommendations as being very useful. Furthermore, 42.7% of the recommendations were found to be very relevant and 23.5% were deemed to have an important impact. CONCLUSION: This first round of audits in Belgium allowed for the identification of common areas for improvements of practice in radiation oncology departments, with a focus on process optimization and infrastructure elements. Similarly, the audits' emitted recommendations were globally deemed very relevant. Encouraged, by this analysis, a second cycle of audits has started in Belgium with a modified version of the QUATRO document (B-QUATRO).

Improving the quality of radiation oncology: 10years' experience of QUATRO audits in the IAEA Europe Region.

BACKGROUND AND PURPOSE: The IAEA has developed a methodology for comprehensive quality audits of radiotherapy practices called Quality Assurance Team for Radiation Oncology (QUATRO). This study explores the factors that impacted quality of care among QUATRO audited centres in the IAEA Europe Region. MATERIALS AND METHODS: The 31 QUATRO reports collected over 10years include extensive data describing the quality of radiotherapy at the audited centres. A coding key was developed to aggregate and review these data in terms of recommendations for improvement and positive findings (commendations). RESULTS: Overall 759 recommendations and 600 commendations were given. Eight centres recognized as centres of competence differed from other centres mostly because they operated complete quality management systems and were adequately staffed. Other centres had excessive staff workloads and many gaps in the process of care. Insufficient equipment levels were prevalent. Patient centredness, communication, dosimetry, quality control and radiation protection were frequently commended by QUATRO. CONCLUSIONS: This analysis points to barriers to quality care such as insufficient staffing, education/training, equipment and lack of quality management. It highlights the correlation between the human resources availability and quality of care. It has also identified common action items for enhancing quality of radiotherapy programmes in the Region.

Improving anxiety regulation in patients with breast cancer at the beginning of the survivorship period: a randomized clinical trial comparing the benefits of single-component and multiple-component group interventions.

OBJECTIVE: To compare in a multicenter randomized controlled trial the benefits in terms of anxiety regulation of a 15-session single-component group intervention (SGI) based on support with those of a 15-session multiple-component structured manualized group intervention (MGI) combining support with cognitive-behavioral and hypnosis components. METHODS: Patients with nonmetastatic breast cancer were randomly assigned at the beginning of the survivorship period to the SGI (n = 83) or MGI (n = 87). Anxiety regulation was assessed, before and after group interventions, through an anxiety regulation task designed to assess their ability to regulate anxiety psychologically (anxiety levels) and physiologically (heart rates). Questionnaires were used to assess psychological distress, everyday anxiety regulation, and fear of recurrence. Group allocation was computer generated and concealed till baseline completion. RESULTS: Compared with patients in the SGI group (n = 77), patients attending the MGI group (n = 82) showed significantly reduced anxiety after a self-relaxation exercise (P = .006) and after exposure to anxiety triggers (P = .013) and reduced heart rates at different time points throughout the task (P = .001 to P = .047). The MGI participants also reported better everyday anxiety regulation (P = .005), greater use of fear of recurrence-related coping strategies (P = .022), and greater reduction in fear of recurrence-related psychological distress (P = .017) compared with the SGI group. CONCLUSIONS: This study shows that an MGI combining support with cognitive-behavioral techniques and hypnosis is more effective than an SGI based only on support in improving anxiety regulation in patients with breast cancer.

Do refined consensus guidelines improve the uniformity of clinical target volume delineation for rectal cancer? Results of a national review project.

In a previous national central review project, 74% of the rectal cancer clinical target volumes (CTVs) needed a modification. In a follow-up initiative, we evaluated whether the use of refined international consensus guidelines improves the uniformity of CTV delineation in clinical practice.

Is it possible to improve communication around radiotherapy delivery: A randomized study to assess the efficacy of team training?

BACKGROUND AND PURPOSE: The aim of this study was to assess the efficacy of a 38-h communication skills training program designed for multidisciplinary radiotherapy teams. MATERIALS AND METHODS: Four radiotherapy teams were randomly assigned to a training program or to a waiting list. Assessments were scheduled at baseline (T1) and then after the training was completed or four months later (T2), respectively. Communication around radiotherapy delivery was assessed based on audio recordings of the first and last radiotherapy sessions in order to assess team members' communication skills and the expression of concerns by breast cancer patients (analyzed with content analysis software LaComm). RESULTS: 198 radiotherapy sessions were recorded. During the first radiotherapy sessions, members of the trained teams exhibited more assessment skills (p=0.048), provided more setting information (p<0.001), and used more social words (p=0.019) compared to the members of the untrained teams. During the last radiotherapy session, members of the trained teams used more assessment skills (p=0.004) and patients interacting with members of the trained teams expressed more sadness words (p=0.023). CONCLUSION: Training of multidisciplinary teams has the potential to transfer skills that affect the short exchanges that take place around radiotherapy delivery.

Transfer of communication skills to the workplace: impact of a 38-hour communication skills training program designed for radiotherapy teams.

PURPOSE: This study assessed the efficacy of a 38-hour communication skills training program designed to train a multidisciplinary radiotherapy team. METHODS: Four radiotherapy teams were randomly assigned to a training program or a waiting list. Assessments were scheduled at baseline and after training for the training group and at baseline and 4 months later for the waiting list group. Assessments included an audio recording of a radiotherapy planning session to assess team members' communication skills and expression of concerns of patients with breast cancer (analyzed with content analysis software) and an adapted European Organisation for Research and Treatment of Cancer satisfaction with care questionnaire completed by patients at the end of radiotherapy. RESULTS: Two hundred thirty-seven radiotherapy planning sessions were recorded. Compared with members of the untrained teams, members of the trained teams acquired, over time, more assessment skills (P = .003) and more supportive skills (P = .050) and provided more setting information (P = .010). Over time, patients interacting with members of the trained teams asked more open questions (P = .022), expressed more emotional words (P = .025), and exhibited a higher satisfaction level regarding nurses' interventions (P = .028). CONCLUSION: The 38-hour training program facilitated transfer of team member learned communication skills to the clinical practice and improved patients' satisfaction with care.

Anxiety at the first radiotherapy session for non-metastatic breast cancer: key communication and communication-related predictors.

BACKGROUND AND PURPOSE: Patients may experience clinically relevant anxiety at their first radiotherapy (RT) sessions. To date, studies have not investigated during/around the RT simulation the key communication and communication-related predictors of this clinically relevant anxiety. MATERIAL AND METHODS: Breast cancer patients (n=227) completed visual analog scale (VAS) assessments of anxiety before and after their first RT sessions. Clinically relevant anxiety was defined as having pre- and post-first RT session VAS scores ⩾4 cm. Communication during RT simulation was assessed with content analysis software (LaComm), and communication-related variables around the RT simulation were assessed with questionnaires. RESULTS: Clinically relevant anxiety at the first RT session was predicted by lower self-efficacy to communicate with the RT team (OR=0.65; p=0.020), the perception of lower support received from the RT team (OR=0.70; p=0.020), lower knowledge of RT-associated side effects (OR=0.95; p=0.057), and higher use of emotion-focused coping (OR=1.09; p=0.013). CONCLUSIONS: This study provides RT team members with information about potential communication strategies, which may be used to reduce patient anxiety at the first RT session.

Panitumumab as a radiosensitizing agent in KRAS wild-type locally advanced rectal cancer.

Our goal was to optimize the radiosensitizing potential of anti-epidermal growth factor receptor (EGFR) monoclonal antibodies, when given concomitantly with preoperative radiotherapy in KRAS wild-type locally advanced rectal cancer (LARC). Based on pre-clinical studies conducted by our group, we designed a phase II trial in which panitumumab (6 mg/kg/q2 weeks) was combined with preoperative radiotherapy (45 Gy in 25 fractions) to treat cT3-4/N + KRAS wild-type LARC. The primary endpoint was complete pathologic response (pCR) (H0 = 5%, H1 = 17%, α = 0.05, ß = 0.2). From 19 enrolled patients, 17 (89%) were evaluable for pathology assessment. Although no pCR was observed, seven patients (41%) had grade 3 Dworak pathological tumor regression. The regimen was safe and was associated with 95% of sphincter-preservation rate. No NRAS, BRAF, or PI3KCA mutation was found in this study, but one patient (5%) showed loss of PTEN expression. The quantification of plasma EGFR ligands during treatment showed significant upregulation of plasma TGF-α and EGF following panitumumab administration (p < 0.05). At surgery, patients with important pathological regression (grade 3 Dworak) had higher plasma TGF-α (p = 0.03) but lower plasma EGF (p = 0.003) compared to those with grade 0-2 Dworak. Our study suggests that concomitant panitumumab and preoperative radiotherapy in KRAS wild-type LARC is feasible and results in some tumor regression. However, pCR rate remained modest. Given that the primary endpoint of our study was not reached, we remain unable to recommend the use of panitumumab as a radiosensitizer in KRAS wild-type LARC outside a research setting.

Anxiety and its time courses during radiotherapy for non-metastatic breast cancer: a longitudinal study.

PURPOSE: To our knowledge, no study has specifically assessed the time course of anxiety during radiotherapy (RT). The objective of this study was to assess anxiety time courses in patients with non-metastatic breast cancer. MATERIAL AND METHODS: This multicenter, descriptive longitudinal study included 213 consecutive patients with breast cancer who completed visual analog scales (VASs) assessing state anxiety before and after the RT simulation and the first and last five RT sessions. RESULTS: Pre- and post-session anxiety mean levels were highest at the RT simulation (respectively, 2.9±2.9 and 1.6±2.5) and first RT session (respectively, 3.4±2.9 and 2.0±2.4), then declined rapidly. Clinically relevant mean differences (⩾1cm on the VAS) between pre- and post-simulation/session VAS scores were found only for the RT simulation (-1.3±2.7; p<0.001) and first RT session (-1.4±2.4; p<0.001). Five percent to 16% of patients presented clinically relevant anxiety (pre- and post-simulation/session VAS scores⩾4cm) throughout treatment. CONCLUSIONS: To optimize care, RT team members should offer all patients appropriate information about treatment at the simulation, check patients' understanding, and identify patients with clinically relevant anxiety requiring appropriate support throughout RT.

Does a central review platform improve the quality of radiotherapy for rectal cancer? Results of a national quality assurance project.

BACKGROUND AND PURPOSE: Quality assurance (QA) for radiation treatment has become a priority since poorly delivered radiotherapy can negatively influence patient outcome. Within a national project we evaluated the feasibility of a central review platform and its role in improving uniformity of clinical target volume (CTV) delineation in daily practice. MATERIAL AND METHODS: All Belgian radiotherapy departments were invited to participate and were asked to upload CTVs for rectal cancer treatment onto a secured server. These were centrally reviewed and feedback was given per e-mail. For each five consecutive patients per centre, the overlap parameter dice coefficient (DC) and the volumetric parameters volumetric ratio (RV) and commonly contoured volume (VCC) were calculated. RESULTS: Twenty departments submitted 1224 eligible cases of which 909 were modified (74.3%). There was a significant increase in RV and VCC between the first ten patients per centre and the others. This was not seen for DC. Statistical analysis did not show a further significant improvement in delineation over the entire review period. CONCLUSION: Central review was feasible and increased the uniformity in CTV delineation in the first ten rectal cancer patients per centre. The observations in this study can be used to optimize future QA initiatives.

Is it possible to improve radiotherapy team members' communication skills? A randomized study assessing the efficacy of a 38-h communication skills training program.

BACKGROUND AND PURPOSE: Optimizing communication between radiotherapy team members and patients and between colleagues requires training. This study applies a randomized controlled design to assess the efficacy of a 38-h communication skills training program. MATERIAL AND METHODS: Four radiotherapy teams were randomly assigned either to a training program or to a waiting list. Team members' communication skills and their self-efficacy to communicate in the context of an encounter with a simulated patient were the primary endpoints. These encounters were scheduled at the baseline and after training for the training group, and at the baseline and four months later for the waiting list group. Encounters were audiotaped and transcribed. Transcripts were analyzed with content analysis software (LaComm) and by an independent rater. RESULTS: Eighty team members were included in the study. Compared to untrained team members, trained team members used more turns of speech with content oriented toward available resources in the team (relative rate [RR]=1.38; p=0.023), more assessment utterances (RR=1.69; p<0.001), more empathy (RR=4.05; p=0.037), more negotiation (RR=2.34; p=0.021) and more emotional words (RR=1.32; p=0.030), and their self-efficacy to communicate increased (p=0.024 and p=0.008, respectively). CONCLUSIONS: The training program was effective in improving team members' communication skills and their self-efficacy to communicate in the context of an encounter with a simulated patient. Future study should assess the effect of this training program on communication with actual patients and their satisfaction. Moreover a cost-benefit analysis is needed, before implementing such an intensive training program on a broader scale.

Radiotherapy capacity in European countries: an analysis of the Directory of Radiotherapy Centres (DIRAC) database.

Radiotherapy is used for cure or palliation in around half of patients with cancer. We analysed data on radiotherapy equipment in 33 European countries registered in the Directory of Radiotherapy Centres (DIRAC) database, managed by the International Atomic Energy Agency. As of July, 2012, Europe had 1286 active radiotherapy centres. The average number of teletherapy machines per radiotherapy centre ranged from 1·2 to 7·0 in different countries. Nordic countries, the UK, the Netherlands, and Slovenia all have large centres with four to ten teletherapy machines. Most western and southern European countries have several small centres with one or two machines, with few larger centres. The fragmentation in radiotherapy services that prevails in many European countries might affect the economic burden of radiotherapy and its quality. Eastern and southeastern European countries need to expand and modernise their radiotherapy equipment.

Postoperative radiotherapy after radical prostatectomy for high-risk prostate cancer: long-term results of a randomised controlled trial (EORTC trial 22911).

BACKGROUND: We report the long-term results of a trial of immediate postoperative irradiation versus a wait-and-see policy in patients with prostate cancer extending beyond the prostate, to confirm whether previously reported progression-free survival was sustained. METHODS: This randomised, phase 3, controlled trial recruited patients aged 75 years or younger with untreated cT0-3 prostate cancer (WHO performance status 0 or 1) from 37 institutions across Europe. Eligible patients were randomly assigned centrally (1:1) to postoperative irradiation (60 Gy of conventional irradiation to the surgical bed for 6 weeks) or to a wait-and-see policy until biochemical progression (increase in prostate-specific antigen >0·2 µg/L confirmed twice at least 2 weeks apart). We analysed the primary endpoint, biochemical progression-free survival, by intention to treat (two-sided test for difference at α=0.05, adjusted for one interim analysis) and did exploratory analyses of heterogeneity of effect. This trial is registered with ClinicalTrials.gov, number NCT00002511. FINDINGS: 1005 patients were randomly assigned to a wait-and-see policy (n=503) or postoperative irradiation (n=502) and were followed up for a median of 10·6 years (range 2 months to 16·6 years). Postoperative irradiation significantly improved biochemical progression-free survival compared with the wait-and-see policy (198 [39·4%] of 502 patients in postoperative irradiation group vs 311 [61·8%] of 503 patients in wait-and-see group had biochemical or clinical progression or died; HR 0·49 [95% CI 0·41-0·59]; p<0·0001). Late adverse effects (any type of any grade) were more frequent in the postoperative irradiation group than in the wait-and-see group (10 year cumulative incidence 70·8% [66·6-75·0] vs 59·7% [55·3-64·1]; p=0.001). INTERPRETATION: Results at median follow-up of 10·6 years show that conventional postoperative irradiation significantly improves biochemical progression-free survival and local control compared with a wait-and-see policy, supporting results at 5 year follow-up; however, improvements in clinical progression-free survival were not maintained. Exploratory analyses suggest that postoperative irradiation might improve clinical progression-free survival in patients younger than 70 years and in those with positive surgical margins, but could have a detrimental effect in patients aged 70 years or older. FUNDING: Ligue Nationale contre le Cancer (Comité de l'Isère, Grenoble, France) and the European Organisation for Research and Treatment of Cancer (EORTC) Charitable Trust.

A multi-institutional analysis comparing adjuvant and salvage radiation therapy for high-risk prostate cancer patients with undetectable PSA after prostatectomy.

BACKGROUND AND PURPOSE: In men with adverse pathology at the time of radical prostatectomy (RP), the most appropriate timing to administer radiotherapy (RT) remains a subject for debate. To determine whether salvage radiotherapy (SRT) upon early prostate-specific antigen (PSA) relapse is equivalent to immediate adjuvant radiotherapy (ART) post RP. MATERIAL AND METHODS: 130 patients receiving ART and 89 receiving SRT were identified. All had an undetectable PSA after RP. Homogeneous subgroups were built based on the status (±) of lymphatic invasion (LVI) and surgical margins (SM), to allow a comparison of ART and SRT. Biochemical disease-free survival (bDFS) was calculated from the date of surgery and from the end of RT. The multivariate analysis was performed using the Cox Proportional hazard model. RESULTS: In the SM-/LVI- and SM+/LVI- groups, SRT was a significant predictor of a decreased bDFS from the date of surgery, while in the SM+/LVI+ group, there was a trend towards significance. From the end of RT, SRT was also a significant predictor of a decreased bDFS in three patient groups: SM-/LVI-, SM+/LVI- and SM+/LVI+. Gleason score >7 showed to be another factor on multivariate analysis associated with decreased bDFS in the SM-/LVI- group, from the date of surgery and end of RT. Preoperative PSA was a significant predictor in the SM-/LVI- group from the date of RP only. CONCLUSIONS: Immediate ART post RP for patients with high risk features in the prostatectomy specimen significantly reduces bDFS after RP compared with early SRT upon PSA relapse.

Insight on variables leading to burnout in cancer physicians.

Although communication skills training programs have been recommended to reduce physicians' burnout, few studies have investigated their efficacy. This study assessed the impact of two training programs on cancer physicians' burnout. Especially, it identified some variables leading to burnout in order to develop effective interventions. Burnout was assessed with the Maslach Burnout Inventory. No statistically significant impact of training programs on burnout was observed. The amount of clinical workload and the overuse of some facilitative communication skills were associated with cancer physicians' burnout. The content of such programs must be redefined to reduce burnout.

A dosimetric selectivity intercomparison of HDR brachytherapy, IMRT and helical tomotherapy in prostate cancer radiotherapy.

BACKGROUND AND PURPOSE: Dose escalation in order to improve the biochemical control in prostate cancer requires the application of irradiation techniques with high conformality. The dosimetric selectivity of three radiation modalities is compared: high-dose-rate brachytherapy (HDR-BT), intensity-modulated radiation radiotherapy (IMRT), and helical tomotherapy (HT). PATIENTS AND METHODS: Ten patients with prostate adenocarcinoma treated by a 10-Gy HDR-BT boost after external-beam radiotherapy were investigated. For each patient, HDR-BT, IMRT and HT theoretical treatment plans were realized using common contour sets. A 10-Gy dose was prescribed to the planning target volume (PTV). The PTVs and critical organs' dose-volume histograms obtained were compared using Student's t-test. RESULTS: HDR-BT delivers spontaneously higher mean doses to the PTV with smaller cold spots compared to IMRT and HT. 33% of the rectal volume received a mean HDR-BT dose of 3.86 + or - 0.3 Gy in comparison with a mean IMRT dose of 6.57 + or - 0.68 Gy and a mean HT dose of 5.58 + or - 0.71 Gy (p < 0.0001). HDR-BT also enables to better spare the bladder. The hot spots inside the urethra are greater with HDR-BT. The volume of healthy tissue receiving 10% of the prescribed dose is reduced at least by a factor of 8 with HDR-BT (p < 0.0001). CONCLUSION: HDR-BT offers better conformality in comparison with HT and IMRT and reduces the volume of healthy tissue receiving a low dose.

A practice survey of the evolution of rectal cancer management: a Belgian Federal College of radiotherapy study.

The aim of the present study was to perform a rectal cancer practice survey in order to re-assess in 2005 the Belgian state of the art. A questionnaire based on the past 1999 peer review, supplemented with general questions, was circulated to 16 radiotherapy centres in Belgium. A case was also proposed for treatment planification. In 2005, a formal multidisciplinary team was in place in all visited centres. Endorectal ultrasound, colonoscopy, CEA and an initial pathological diagnosis were standard procedure in all centres. For T1-2N0, the majority of centres do not perform a preoperative treatment; for T3N0, a majority proposes a preoperative radiochemotherapy. For all T3-4 any N, or any T-N involved, a neoadjuvant preoperative treatment is prescribed. Fractionation is conventional (1.8 Gy/d, five times a week). Analysing the practical case, the mean value for CTV and PTV volume was 393 (SD: 126) and 781 cm3 (SD: 105), respectively. Mean D(min) and D(max) of 92 and 106.5%, respectively, were measured in the PTV. From clinical point of view, standards concepts are emerging and spreading for staging and for treatment options. Nevertheless, there is still a need for standardization of volumes and delineation standards.