1. THE IMPACT OF COLLEAGUE PEER-REVIEW (CPR) ON THE RADIOTHERAPY TREATMENT PLANNING PROCESS IN THE RADICAL TREATMENT OF LUNG CANCER Quality improvement and audit: improving outcomes The 2015 RCR Clinical Oncology Audit Conference 17 th June 2015 Dr Keith Rooney Northern Ireland Cancer Centre

2. Background Retrospective analysis has shown that poor radiotherapy planning increases the risk of treatment failure and decreases survival rates 1,2 One source of error contributing to this is the accuracy of target volume delineation (TVD) Growing recognition of the need to address this 3,4,5 Colleague peer-review (CPR) of all curative intent lung cancer plans has been mandatory in our institution since April 2013

3. Materials and Methods All radical radiotherapy plans were presented at weekly CPR meeting after their target volumes were reviewed and signed off by the treating consultant At least 2 clinical oncologists review plans All cases and any resultant changes to TVD or treatment intent were recorded in our prospective database over a 6 month period from April 2013 to October 2013

4. Components of plan review

5. Results 15 peer review sessions NSCLC = 36 SCLC = 10 Average = 3 cases/meeting (1-5) Change due to Peer ReviewNumber (%), n=46 Any change24% Change to treatment paradigm4% Change to treatment volume16% Change to dose fractionation9%

6. Updated at 13 months 122 plans were analysed 27% plans changed: 3% = treatment paradigm 17% = TVD 1% = dose prescription. In total 6% of patients had plan adjustment after review of DVH.

7. From the clinic to the linac: recommended updated pathway

8. Next steps Publish updated results Encourage change in job plans to facilitate attendance by medical + planning staff Recognise in trainee learning portfolio Re-audit last 6 months Investigate if learning curve established Assess recurrence/toxicity outcomes

9. Summary There is a high risk of interpretative error in radiotherapy target volume delineation amongst Clinical Oncologists. Colleague Peer Review led to a change in 27% of radiotherapy plans that would not otherwise have taken place. Colleague Peer Review is recommended as a mandatory quality assurance step in the radiotherapy planning process in the curative treatment of lung cancer.

10. References 1. Peters LJ, O'Sullivan B, Giralt J, et al. Critical Impact of radiotherapy protocol compliance and quality in the treatment of advanced head and neck cancer: results from TROG 02.02. JCO 2010 Jun 20;28(18):2996-3001 2. Ohri N, Shen X, Dicker AP, et al. Radiotherapy protocol deviations and clinical outcomes: a meta-analysis of cooperative group clinical trials. Journal Natl Cancer Inst 2013; 105: 387-393 3. Giraud P, Elles S, Helfre S, et al. Conformal radiotherapy for lung cancer: different delineation of the gross tumor volume (GTV) by radiologists and radiation oncologists. Radiother Oncol. 2002 Jan;62(1):27-36. 4. Marks LB, Adams RD, Pawlicki T, et al. Enhancing the role of case-oriented peer review to improve quality and safety in radiation oncology: Executive summary. Practical Radiation Oncology (2013) 3, 149–156 5. Roques TW. Patient Selection and Radiotherapy Volume Definition - Can We Improve the Weakest Links in the Treatment Chain? Clinical Oncology 26 (2014) 353-355

11. Acknowledgements Dr Jonathan McAleese Dr Gerard Hanna Dr Ruth Johnston Dr Jackie Harney Dr Ruth Eakin Dr Catherine Crockett Linda Young Mark Dunn