Timothy K. Nguyen

Does Peer Review of Radiation Plans Affect Clinical Care? A Systematic Review of the Literature

PURPOSE Peer review is a recommended component of quality assurance in radiation oncology; however, it is resource-intensive and its effect on patient care is not well understood. We conducted a systematic review of the published data to assess the reported clinical impact of peer review on radiation treatment plans. METHODS AND MATERIALS A systematic review of published English studies was performed in accordance with the PRISMA guidelines using the MEDLINE and EMBASE databases and abstracts published from major radiation oncology scientific meeting proceedings. For inclusion, the studies were required to report the effect of peer review on ≥1 element of treatment planning (eg, target volume or organ-at-risk delineation, dose prescription or dosimetry). RESULTS The initial search strategy identified 882 potentially eligible studies, with 11 meeting the inclusion criteria for full-text review and final analysis. Across a total of 11,491 patient cases, peer review programs led to modifications in a weighted mean of 10.8% of radiation treatment plans. Five studies differentiated between major and minor changes and reported weighted mean rates of change of 1.8% and 7.3%, respectively. The most common changes were related to target volume delineation (45.2% of changed plans), dose prescription or written directives (24.4%), and non-target volume delineation or normal tissue sparing (7.5%). CONCLUSIONS Our findings suggest that peer review leads to changes in clinical care in approximately 1 of every 9 cases overall. This is similar to the reported rates of change in peer review studies from other oncology-related specialties, such as radiology and pathology.

Evaluation of Health Economics in Radiation Oncology: A Systematic Review.

PURPOSE Despite the rising costs in radiation oncology, the impact of health economics research on radiation therapy practice analysis patterns is unclear. We performed a systematic review of cost-effectiveness analyses (CEAs) and cost-utility analyses (CUAs) to identify trends in reporting quality in the radiation oncology literature over time. METHODS AND MATERIALS A systematic review of radiation oncology economic evaluations up to 2014 was performed, using MEDLINE and EMBASE databases. The Consolidated Health Economic Evaluation Reporting Standards guideline informed data abstraction variables including study demographics, economic parameters, and methodological details. Tufts Medical Center CEA registry quality scores provided a basis for qualitative assessment of included studies. Studies were stratified by 3 time periods (1995-2004, 2005-2009, and 2010-2014). The Cochran-Armitage trend test and linear trend test were used to identify trends over time. RESULTS In total, 102 articles were selected for final review. Most studies were in the context of a model (61%) or clinical trial (28%). Many studies lacked a conflict of interest (COI) statement (67%), a sponsorship statement (48%), a reported study time horizon (35%), and the use of discounting (29%). There was a significant increase over time in the reporting of a COI statement (P<.001), health care payer perspective (P=.019), sensitivity analyses using multivariate (P=.043) or probabilistic methods (P=.011), incremental cost-effectiveness threshold (P<.001), secondary source utility weights (P=.010), and cost effectiveness acceptability curves (P=.049). There was a trend toward improvement in Tuft scores over time (P=.065). CONCLUSIONS Recent reports demonstrate improved reporting rates in economic evaluations; however, there remains significant room for improvement as reporting rates are still suboptimal. As fiscal pressures rise, we will rely on economic assessments to guide our practice decisions and policies. We recommend improved adherence to published guidelines and further research to determine the clinical implications of our findings.

Patient- and family-centered care: a qualitative exploration of oncologist perspectives

PurposeIncreasingly, patient- and family-centered care (PFCC) is recognized as a valuable component of healthcare reform with rich opportunities for improvement within oncology. Shifting toward PFCC requires physician buy-in; however, research examining their perspectives on PFCC is lacking. We sought to explore oncologists’ perspectives on PFCC to identify factors that influence their ability to practice PFCC.MethodsWe conducted semi-structured interviews with 18 oncologists (8 radiation, 4 medical, 4 surgical, 2 hematologist-oncologists) at a single Canadian academic cancer institution. Interview data were analyzed using thematic analysis and principles drawn from grounded theory. Subsequently, focus groups consisting of the interviewed participants were facilitated to confirm and elaborate on our findings. Constant comparisons were used to identify recurring themes.ResultsThree dominant themes emerged. First, physicians displayed cautious engagement in their approach to PFCC. Collectively, participants understood the general principles of PFCC. However, there was a limited understanding of the value, implications, and motivation for improving PFCC which may create reluctance with physician buy-in. Second, both individual and system barriers to practicing PFCC were identified. A lack of physician acknowledgement and engagement and competing responsibilities emerged as provider-level challenges. System barriers included impaired clinic workflow, physical infrastructure constraints, and delays in access to care. Third, physicians were able to identify existing and potential PFCC behaviors that were feasible within existing system constraints.ConclusionsAdvancing PFCC will require continued physician education regarding the value of PFCC, acknowledgement and preservation of effective patient- and family-centered strategies, and creative solutions to address the system constraints to delivering PFCC.

Optimal imaging surveillance after stereotactic ablative radiation therapy for early-stage non-small cell lung cancer: Findings of an International Delphi Consensus Study

PURPOSE Imaging after stereotactic ablative radiation therapy (SABR) for early-stage non-small cell lung cancer can detect recurrences and second primary lung cancers; however, the optimal follow-up practice of these patients remains unclear. We sought to establish consensus recommendations for surveillance after SABR. METHODS AND MATERIALS International opinion leaders in thoracic radiation oncology and radiology were invited to participate (n = 31), with 11 accepting (9 radiation oncologists, 2 radiologists). Consensus-building was achieved using a 3-round Delphi process. Participants rated their agreement/disagreement with statements using a 5-point Likert scale. An a priori threshold of ≥75% agreement/disagreement was required for consensus. RESULTS A 100% response rate was achieved and final consensus statements were approved by all participants. The consensus statements were: (1.1) thoracic computed tomography (CT) scans should be ordered routinely in follow-up; (1.2) if there is a suspicion for local recurrence (LR), fludeoxyglucose positron emission tomography/CT scans are strongly recommended. Otherwise, there is limited evidence to guide routine use of fludeoxyglucose positron emission tomography /CT; (1.3) CT imaging is not recommended at 6 weeks, but is recommended at months 3, 6, and 12 in year 1 and then every 6 months in year 2 and annually in years 3 through 5; (1.4) after 5 years, CT imaging should continue, although no consensus was reached regarding the frequency. (2.1) Response Evaluation Criteria in Solid Tumors 1.1 criteria are not sufficient for detecting LR; (2.2) a formal scoring system, informed by validated data, should be used to classify high-risk imaging features predictive of LR; (2.3) CT findings suspicious for LR include: infiltration into adjacent structures, bulging margins, sustained growth, mass-like growth, spherical growth, craniocaudal growth, and loss of air bronchograms. (3) Salvage therapy without pathologic confirmation of recurrence is acceptable if imaging findings are highly suspicious and a biopsy is not safe/feasible or if an attempted biopsy was nondiagnostic. CONCLUSIONS These guidelines provide international expert consensus on areas of uncertainty in the management of early-stage non-small cell lung cancer patients after SABR.

Optimizing SABR delivery for synchronous multiple lung tumors using volumetric-modulated arc therapy

Abstract Background: Volumetric-modulated arc therapy (VMAT) delivery for stereotactic ablative radiotherapy (SABR) of multiple lung tumors allows for faster treatments. We report on clinical outcomes and describe a general approach for treatment planning. Material and methods: Patients undergoing multi iso-center VMAT-based SABR for ≥2 lung lesions between 2009 and 2014 were identified from the VU University Medical Center and London Health Sciences Centre. Patients were eligible if the start date of the SABR treatment for the different lesions was within a time range of 30 days. SABR was delivered using separate iso-centers for lesions at a substantial distance from each other. Tumors were either treated with a single fraction of 34 Gy, or using three risk-adapted dose-fractionation schemes, namely three fractions of 18 Gy, five fractions of 11 Gy, or eight fractions of 7.5 Gy, depending on the tumor size and the location. Multivariable analysis was performed to assess factors predictive of clinical outcomes. Results: Of 84 patients (188 lesions) identified, 46% were treated for multiple metastases and 54% for multiple primary NSCLC. About 97% were treated for two or three lesions, and 56% had bilateral disease. After a median follow-up of 28 months, median overall survival (OS) for primary tumors was 27.6 months, and not reached for metastatic lesions (p = .028). Grade ≥3 toxicity was observed in 2% of patients. Multivariable analysis showed that grade 2 or higher radiation pneumonitis (n = 9) was best predicted by a total lung V35Gy of ≥6.5% (in 2Gy/fraction equivalent) (p = .007). Conclusion: Severe toxicity was uncommon following SABR using VMAT for up to three lung tumors. Further investigations of planning parameters are needed in patients presenting with more lesions.

Pros: After stereotactic ablative radiotherapy for a peripheral early-stage non-small cell lung cancer, radiological suspicion of a local recurrence can be sufficient indication to proceed to salvage therapy

Stereotactic ablative radiotherapy (SABR), also known as “stereotactic body radiation therapy” (SBRT), has revolutionized the treatment of early-stage non-small cell lung cancer (NSCLC), providing an effective treatment option for medically-inoperable patients. Modern advancements in the planning and targeting of radiotherapy have allowed SABR to deliver ablative doses as high as 150 Gy (when converted to 2 Gy per fraction) in a precise and highly conformal manner (1). After SABR, rates of primary tumor control are excellent, in excess of 90% at 5 years (2). These promising results have led to suggestions that SABR may be comparable to the historic gold standard, surgical resection, as first-line treatment in operable patients. Three randomized control trials (RCTs)—the STARS trial, the ROSEL trial and ACOSOG Z4099—attempted to compare SABR and surgical resection, but all closed prematurely due to insufficient enrollment. A pooled analysis of the patients accrued to STARS and ROSEL suggested that, at a minimum, there was equipoise between the two treatments, with significantly better overall survival demonstrated in the patients receiving SABR (3). More robust RCT evidence is still awaited, and at least two RCTs examining this question are ongoing including the STABLE-MATES and SABR-Tooth trials (4).

Rebuttal from Dr. Nguyen and Dr. Palma

Our thanks to Drs. Giuliani and Bezjak for a thoughtful commentary on a controversial topic. Upon synthesizing the discussion points, we reframed the debate into four discrete questions, which we will address in this rebuttal.

Does Peer Review of Radiation Plans Impact Clinical Care? A Systematic Review of the Literature

barriers to successful peer review. Results/Benefits/Challenges: The average peer review rate for the three month time period was 85.07%. 15.34% of patients did not receive a referral to peer review. 3.38% of patients were referred for review, however did not undergo peer review. Identified barriers to successful peer review included; human error; workload; resource limitations; and culture change. Conclusion/Impact/Outcomes: Peer review; has the potential to identify errors; serves as a forum for continuing education; and catalyzes standardization. By mitigating the barriers to peer review including; human error; workload; resource limitations; and adopting a culture promoting the initiative an increasing number of cases can be successfully reviewed, resulting in a high fidelity system to increase patient safety.

Spontaneous Resolution of Chylothorax-Associated Lymphoma Treated with External Beam Radiotherapy: A Case Report and Comprehensive Review of the Literature

Chylothorax is a rare complication of advanced lymphoma. We present the case of an 80-year-old man diagnosed with B cell lymphoma presenting with a right chylothorax secondary to a large retroperitoneal mass. His disease was not responsive to initial treatment with chemotherapy. Fractionated radiotherapy to a dose of 2,000 cGy in five fractions was delivered to the retroperitoneal mass, and the chylothorax improved significantly within days of initiation of treatment.

Synchronous Oligometastatic Non-Small Cell Lung Cancer and Isolated Renal Cell Carcinoma: A Case Report and Literature Review.

A 58-year-old gentleman presenting with a progressive headache, visual disturbance, decreased appetite, and weight loss was found to have a localized clear cell carcinoma of the kidney and synchronous Stage IV non-small cell lung cancer with a solitary brain metastasis. This case illustrates the challenges in distinguishing between primary and metastatic disease in a patient with both renal cell carcinoma and lung cancer. We highlight the uncertainties in the diagnosis and management of this unique clinical scenario and the potential implications on prognosis.