Comparison of magnetic resonance imaging and computed tomography for breast target volume delineation in prone and supine positions

Purpose To\ua0determine whether T2-weighted MRI improves seroma cavity (SC) and whole breast (WB) interobserver conformity for radiation therapy purposes, compared with the gold standard of CT, both in the prone and supine positions. Methods and Materials Eleven observers (2 radiologists and 9 radiation oncologists) delineated SC and WB clinical target volumes (CTVs) on T2-weighted MRI and CT supine and prone scans (4 scans per patient) for 33 patient datasets. Individual observer's volumes were compared using the Dice similarity coefficient, volume overlap index, center of mass shift, and Hausdorff distances. An average cavity visualization score was also determined. Results Imaging modality did not affect interobserver variation for WB CTVs. Prone WB CTVs were larger in volume and more conformal than supine CTVs (on both MRI and CT). Seroma cavity volumes were larger on CT than on MRI. Seroma cavity volumes proved to be comparable in interobserver conformity in both modalities (volume overlap index of 0.57\ua0(95% Confidence Interval (CI) 0.54-0.60) for CT supine and 0.52\ua0(95% CI 0.48-0.56) for MRI supine, 0.56\ua0(95% CI 0.53-0.59) for CT prone and 0.55\ua0(95% CI 0.51-0.59) for MRI prone); however, after registering modalities together the intermodality variation (Dice similarity coefficient of 0.41\ua0(95% CI 0.36-0.46) for supine and 0.38\ua0(0.34-0.42) for prone) was larger than the interobserver variability for SC, despite the location typically remaining constant. Conclusions Magnetic resonance imaging interobserver variation was comparable to CT for the WB CTV and SC delineation, in both prone and supine positions. Although the cavity visualization score and interobserver concordance was not significantly higher for MRI than for CT, the SCs were smaller on MRI, potentially owing to clearer SC definition, especially on T2-weighted MR images

An international review of patient safety measures in radiotherapy practice.

Errors from radiotherapy machine or software malfunction usually are well documented as they affect hundreds of patients, whereas random errors affecting individual patients are more difficult to be discovered and prevented. Although major clinical radiotherapy incidents have been reported, many more have remained unrecognised or have not been reported. The literature in this field is limited as it is mostly published as a result of investigation of major errors. We present a review of radiotherapy incidents internationally with the aim of identifying the domains where most errors occur through extensive review and synthesis of published reports, unpublished 'Grey literature' and departmental incident data. Our review of radiotherapy-related events in the last three decades (1976-2007) identified more than seven thousand (N=7741) incidents and near misses. Three thousand one hundred and twenty-five incidents reported patient harm of variable intensity ranging from underdose increasing the risk of recurrence, to overdose causing toxicity, and even death for 1% (N=38); 4616 events were near misses with no recognisable patient harm. Based on our review, a radiotherapy risk profile has been published by the WHO World Alliance for Patient Safety that highlights the role of communication, training and strict adherence to guidelines/protocols in improving the safety of radiotherapy process

MODEL OF ESTIMATION OF LOCAL CONTROL AND SURVIVAL BENEFIT OF EXTERNAL BEAM RADIOTHERAPY FOR SELECTED CANCERS

AimsThe aim of this study was to estimate the population-based local control (LC) and overall survival (OS) benefits of radiotherapy for selected cancers if the whole cancer population in Australia were treated according to evidence-based guidelines. These estimates were based on the published radiotherapy utilisation (RTU) models used for estimating demand of radiotherapy services nationally and internationally. MethodsBenefits were defined as the LC and OS proportional gains from radiotherapy over no radiotherapy and from post-operative radiotherapy over surgery alone. CRT benefits were the proportional gains from concurrent radiotherapy and chemotherapy over radiotherapy alone. The RTU models for breast, gastro-intestinal (oesophagus, stomach, colorectal, gall bladder, pancreas), haematological (leukaemia, lymphoma, myeloma), lung, melanoma, unknown primary and ‘other’ (anus, non-melanoma skin cancer, soft tissue sarcoma) cancers were extended to incorporate benefit estimates of radiotherapy alone (RT alone) and of radiotherapy with concurrent chemotherapy (CRT). Literature review (1990-2015) was conducted to identify benefit estimates of individual radiotherapy indications and summed to estimate the population-based gains for these outcomes. Model robustness was tested through univariate and multivariate sensitivity analyses.ResultsFor the RT alone model, the lowest 5-year LC benefit estimates (benefit %, 95% Confidence Interval) were for leukaemia (1%, 0.2%-1%) and oesophageal cancer (1%, 0.5%-1%), the highest for breast cancer (15%, 12.9%-16.8%). The lowest and highest for 5-year OS benefit were: oesophageal cancer (0.1%, 0.06%-0.13%) and lymphoma (6.5%, 5.9%-7.1%). For the CRT model, lowest and highest LC benefits were for: ‘other’ cancers (1%, 0.2%-1.3%) and rectal cancer (6%, 2.5%-9.4%). 5-year OS benefit ranges were: ‘other’ cancers (0.2%, -0.1%-0.4%) and oesophageal cancer (2%, 1.7%-2.7%). 2-year OS benefits (RT only + CRT) were estimated for lung cancer (13%), pancreatic cancer (3%) and 10-year OS benefits (4%) were estimated for breast cancer.ConclusionsThe model provided estimates of radiotherapy benefits achievable if treatment guidelines are followed for all cancer patients in the Australian population. This is a unique estimate to examine effects of shortfall in radiotherapy utilisation at a population level. The model can be adapted to populations with known epidemiological parameters to ensure the planning of equitable radiotherapy services worldwide

The benefits of providing external beam radiotherapy in low- and middle-income countries

More than half of all cancer diagnoses worldwide occur in low- and middle-income countries (LMICs) and the incidence is projected to rise substantially within the next 20 years. Radiotherapy is a vital, cost-effective treatment for cancer; yet there is currently a huge deficit in radiotherapy services within these countries. The aim of this study was to estimate the potential outcome benefits if external beam radiotherapy was provided to all patients requiring such treatment in LMICs, according to the current evidence-based guidelines. Projected estimates of these benefits were calculated to 2035, obtained by applying the previously published Collaboration for Cancer Outcomes, Research and Evaluation (CCORE) demand and outcome benefit estimates to cancer incidence and projection data from the GLOBOCAN 2012 data. The estimated optimal radiotherapy utilisation rate for all LMICs was 50%. There were about 4.0 million cancer patients in LMICs who required radiotherapy in 2012. This number is projected to increase by 78% by 2035, a far steeper increase than the 38% increase expected in high-income countries. National radiotherapy benefits varied widely, and were influenced by case mix. The 5 year population local control and survival benefits for all LMICs, if radiotherapy was delivered according to guidelines, were estimated to be 9.6% and 4.4%, respectively, compared with no radiotherapy use. This equates to about 1.3 million patients who would derive a local control benefit in 2035, whereas over 615 000 patients would derive a survival benefit if the demand for radiotherapy in LMICs was met. The potential outcome benefits were found to be higher in LMICs. These results further highlight the urgent need to reduce the gap between the supply of, and demand for, radiotherapy in LMICs. We must attempt to address this ‘silent crisis’ as a matter of priority and the approach must consider the complex societal challenges unique to LMICs

Estimation of the optimal utilisation rates of radical prostatectomy, external beam radiotherapy and brachytherapy in the treatment of prostate cancer by a review of clinical practice guidelines

Background and purpose: We aimed to construct an evidence-based model of optimal treatment utilisation for prostate cancer, incorporating all local treatment modalities: radical prostatectomy (RP), external beam radiotherapy (EBRT), and brachytherapy (BT); and then to compare this optimal model with actual practice. Materials and methods: Evidence-based guidelines were used to construct a prostate cancer treatment decision-tree. The proportion of patients who fulfilled treatment criteria was drawn from the epidemiological literature. These data were combined to calculate the overall proportion of patients that should optimally have RP, EBRT and/or BT at least once during the course of their disease. The model was peer reviewed and tested by sensitivity analyses and compared with actual practice. Results: Optimal utilisation rates, at some point during the disease course, were: RP, 24% (range 15–30%); EBRT, 58% (range 54–64%); BT, 9.6% (range 6.0–17.9%); and any RT, 60% (range 56–66%). Many patients had indications for more than one of these treatments, and at least one of these treatments was indicated in 76% of patients. The model was sensitive to patient preference estimates. Optimal rates were achievable in some health care jurisdictions. Conclusions: Modelling optimal utilisation of all local treatment options for a particular cancer is possible. These optimal prostate cancer treatment rates can be used as a planning and quality assurance tool, providing an evidence-based benchmark against which can be measured patterns of practice

A comparison of surgical and radiotherapy breast cancer therapy utilization in Canada (British Columbia), Scotland (Dundee), and Australia (Western Australia) with models of "optimal" therapy

Background: Different jurisdictions report different breast cancer treatment rates. Evidence-based utilization models may be specific to derived populations. We compared predicted optimal with actual radiotherapy utilization in British Columbia, Canada; Dundee, Scotland; and Perth, Western Australia. Design: Data were analyzed for differences in demography, tumor, and treatment. Epidemiological data were fitted to published Australian optimal radiotherapy utilization trees and region-specific optimal treatment rates were calculated. Optimal and actual surgery/radiotherapy rates from 2 population-based and 1 institution-based registries were compared for patients diagnosed with breast cancer between 2000 and 2004, and 2002 for British Columbia. Results: Mastectomy rates differed between British Columbia (40%), Western Australia (44%), and Dundee (47%, p < 0.01). Radiotherapy rates differed between British Columbia (60%), Western Australia (52%), and Dundee (49%, p < 0.01). Actual radiotherapy utilization rates were lower than optimal estimates. Region-specific optimal utilization rates at diagnosis varied from 57% to 71% for radiotherapy and 62% to 64% when taking into account patient preference. Variation was attributed to local differences in demography and tumor stage. Conclusions: Actual treatment rates varied, and were associated with patterns of care and guideline differences. Actual radiotherapy rates were lower than optimal rates. Differences between optimal and actual utilization may be due to access shortfalls, and patient preference

Estimating the cost of radiotherapy for 5-year local control and overall survival benefit

Background and purpose: Escalating health care costs have led to greater efforts directed at measuring the cost and benefits of medical treatments. The aim of this study was to estimate the costs of 5-year local control and overall survival benefits of radiotherapy for the cancer population in Australia. Materials and Methods: The local control and overall survival benefits of radiotherapy at 5-years and optimal number of fractions per course have been estimated for 26 tumour sites for which radiotherapy is indicated. For this study, a hybrid approach that merges features from activity based costing (ABC) and relative value units costing (RVU) were used to provide cost estimates. ABC methodology was used to allocate costs to all radiotherapy activities associated with each patient's treatment course, while the RVUs represent the cost of each radiotherapy activity relative to the average cost of all activities and were used to achieve a weighted cost allocation. A patient's journey for the financial year was constructed by consolidating all the radiotherapy activities and their associated costs, and the average cost per activity (fraction) was determined. The cost of radiotherapy per 5-year overall survival and local control was then estimated. Results: The estimated population 5-year local control and overall survival benefits of radiotherapy for all cancer were 23% and 6%, respectively. The optimal number of fractions per treatment course if guidelines were followed was 19.4 fractions. The average cost per fraction for all cancer was AU$276. The estimated cost of radiotherapy was AU$23,585 per 5-year local control and AU$86,480 per 5-year overall survival (equivalent to 5 life years) for all cancer. Conclusion: The cost of AU$86,480 per 5-year overall survival would translate to AU$17,296 1-year overall survival. Therefore, the cost of radiotherapy is inexpensive if delivered optimally. Policy implications from this study include knowledge about cost to deliver radiotherapy to allow one to quantify the expected benefit at a population level

Patients' and health care professionals' evaluation of health-related quality of life issues in bone metastases

The objective of this study was to examine the agreement between health care professionals’ (HCPs) and patients’ evaluation of health-related quality of life (HRQOL) issues for cancer patients with bone metastases. A total of 413 patients and 152 HCPs were interviewed across five centres worldwide. Mean scores were almost always higher for HCPs than for patients. Patients and HCPs agreed that four issues affect HRQOL of bone metastases patients profoundly: ‘long-term (chronic) pain’, ‘difficulty in carrying out usual daily tasks’, ‘able to perform self-care’ and ‘able to perform role functioning’. A substantial difference was found with respect to the perceived importance of psychosocial and somatic issues. Patients emphasised psychosocial issues with a particular focus on ‘worry’ about loss of mobility, dependence on others and disease progression, HCPs however rated ‘symptom’ issues as more important, specifically those related to ‘pain’. In conclusion, patients and HCPs agreed that pain and physical/role functioning are important to the HRQOL of cancer patients with bone metastases, but patients also emphasized the importance of psychosocial issues to HRQOL. This information has been an important component in the development of a health-related quality of life questionnaire for patients with bone metastases (EORTC QLQ-BM 22)

The European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire for patients with bone metastases: the EORTC QLQ-BM22

AimThe aim of this study was to develop a bone metastases module to supplement the European Organisation for Research and Treatment of Cancer Core Questionnaire (EORTC QLQ-C30) or the EORTC QLQ-C15-PAL for patients with bone metastases.MethodsPhases 1–2 of module development were conducted in Canada, Australia and Germany according to EORTC QOL group guidelines. Phase 3 was conducted in nine countries in seven languages.ResultsSixty-one health-related quality of life (HRQOL) issues were generated from health care professionals (n = 152) and patients (n = 413). This resulted in a 22-item provisional module. Further testing in 170 patients from nine countries resulted in the EORTC QLQ-BM22 module, containing 22 items, conceptualised into both symptom scales, with five painful sites and three pain characteristics, and also functional scales, with eight functional interference and six psychosocial aspects.ConclusionThis study provides a provisional comprehensive HRQOL measurement tool for future trials, which will continue to undergo further validation

Patients' and health care professionals' evaluation of health-related quality of life issues in bone metastases

The objective of this study was to examine the agreement between health care professionals’ (HCPs) and patients’ evaluation of health-related quality of life (HRQOL) issues for cancer patients with bone metastases. A total of 413 patients and 152 HCPs were interviewed across five centres worldwide. Mean scores were almost always higher for HCPs than for patients. Patients and HCPs agreed that four issues affect HRQOL of bone metastases patients profoundly: ‘long-term (chronic) pain’, ‘difficulty in carrying out usual daily tasks’, ‘able to perform self-care’ and ‘able to perform role functioning’. A substantial difference was found with respect to the perceived importance of psychosocial and somatic issues. Patients emphasised psychosocial issues with a particular focus on ‘worry’ about loss of mobility, dependence on others and disease progression, HCPs however rated ‘symptom’ issues as more important, specifically those related to ‘pain’. In conclusion, patients and HCPs agreed that pain and physical/role functioning are important to the HRQOL of cancer patients with bone metastases, but patients also emphasized the importance of psychosocial issues to HRQOL. This information has been an important component in the development of a health-related quality of life questionnaire for patients with bone metastases (EORTC QLQ-BM 22)