Norwegian experience with workshop as a clinical audit tool for radiotherapy of specific cancer diagnoses

Transcription

1 Norwegian experience with workshop as a clinical audit tool for radiotherapy of specific cancer diagnoses A B C D Lung cancer (006) Bernt L. Rekstad, Sverre Levernes, Ingrid E. Heikkilä, Dag Clement Johannessen, Eric Sundqvist, Hans Bjerke, Taran P. Hellebust, Hilde Olerud, Gunilla Frykholm KVIST group, Norwegian Radiation Protection Authority (NRPA), Østerås, Oslo, Norway Tampere,

2 See poster, S. Levernes et al. KVIST Quality assurance in radiotherapy Core is a division at the NRPA KVIST-group at NRPA: oncologists physicists 1 RT technologist working part time (also at hospitals) Reference group with representatives from all cancer centers Working parties Multi disciplinary QA in radiotherapy at multiple levels Acknowledged

3 3 Workshop overview Preparations Workshop Follow-up KVIST and national diagnosis group When, where, duration For each case: patient history Summary of major points Theme, diagnosis Cases Cancer centers Treatment planning Analysis KVIST, expert panel, participants: oncologists, physicists, radiation technologists 3 hospitals presenting: Contours (oncologist) Treatment plan (phys. / techn.) Compilation from all hospitals KVIST, expert panel, national diagnosis group, the cancer centers Detailed report Possible changes in guidelines KVIST Discussions Presentation for hospitals

4 4 Workshop preparations Preparations KVIST and national diagnosis group When, where, duration Theme, diagnosis Cases Cancer centers Treatment planning Analysis KVIST When, where: assure involvement and broad participation Theme: diagnosis or other relevant issue for auditing, proposal by KVIST to reference group, discussions with diagnosis group Patient cases: prepared by national diagnosis group to reflect and audit central points, typically 1 3 cases CT-series for target and normal tissue delineation anonymized Patient histories created Anonymized diagnostic images if appropriate Cases and instructions sent to contact persons at all cancer centers well in advance before the meeting.

5 5 Workshop preparations Preparations KVIST and national diagnosis group When, where, duration Diagnosis Cases Cancer centers Treatment planning Analysis KVIST At each cancer center, patient cases are handled and treatment planning performed as for a real patient, using local procedures. Planning involves both oncologists, RT technologists and physicists. The setting being data sent away from the hospital, representing the hospital s procedures, patient cases are often thoroughly discussed assuring that everybody agrees. This is in a way an internal clinical audit there is focus on a specific diagnosis, handling of patient cases are performed according to local procedures, results are reviewed at the centre by plenary demonstrations and consensus modifications before final results are being sent to KVIST.

6 6 Workshop preparations Preparations KVIST and national diagnosis group When, where, duration Diagnosis Cases Cancer centers Treatment planning KVIST Analysis Compilation of data from the hospitals: contours, dose distributions, statistics, answers to questionnaire. A lot of work. Analysis of data. Final preparations, discuss and decide structure and major points with the expert panel appointed by national diagnosis group (oncologists, physicist, RT technologist). Finding best ways to present results, make presentations of data compilations.

7 7 The workshop KVIST, expert panel, participants: oncologists, physicists, radiation technologists Workshop For each case: patient history 3 hospitals presenting: Contours (oncologist) Treatment plan (phys / radiother) Compilation from all hospitals Discussions Patient history is recapitulated, setting the scene, preparing everybody ~ 3 centres present their solutions, pointing out major decisions made during the planning, compromises, strengths, weaknesses, local ways etc Oncologist presenting contouring (target volumes, organs at risk) Physicist and/or RT technologist presenting treatment plan (fields, doses) KVIST present results from analyses and compilation of contours and doses Expert panel leading the discussions, posing questions both to presenters and audience, proposing areas of major consensus and disagreement, suggesting conclusions and summarize. Questions and participation in discussions are strongly encouraged Small talk during breaks not to be neglected

8 8 Follow-up after workshop Follow-up Summary of major points KVIST, expert panel, national diagnosis group, the cancer centers Detailed report Possible changes in guidelines Presentation for hospitals Summary of major points are being made during and immediately after the meeting. A detailed report is prepared including results from analyses before and major points made at the meeting. If needed, changes in guidelines are proposed. Implementation of changes is done and made known by the national diagnosis group. Results at earlier meetings have demonstrated need of clarification and inspired the establishment of national guidelines.

9 9 Breast cancer radiotherapy meeting participants, equally distributed among - Physicians - Radiotherapy technologists - Physicists Truly multidisciplinary 9 out of 10 cancer centers participated One day, two main parts: Lectures Sarah Darby, Oxford (x ) Giovanna Gagliardi, Stockholm Workshop, 3 patient cases

10 10 Breast cancer radiotherapy workshop 008 Several issues making this diagnosis attractive for auditing Large patient volume, treated at most centers Inhomogeneous group, each patient different Challenging at different levels, both defining volumes, planning and treating National guideline since 000, up-dated in 005 Contouring examples available at web site of NBCG (Norwegian Breast Cancer Group) A high degree of agreement among the centres?

11 11 Patient case 1 Indication and delineation Target volume is breast only according to national guidelines. Perfect agreement among the centers about this. An audit of indication. BUT: Sagittal Variation in delineations is seen in all directions except towards skin Coronal

12 ccm 1 Patient 1 Variation in target volumes Cranial ~ 3.0 cm Caudal ~ 1.5 cm Medial ~ 3.0 cm Dorsal ~ 1.0 cm Pasient Patient 1 CTV PTV DNR A HUS B NLSH C D SIG SOH E SUS F UNN G UUS H ÅS I CTV variation: 496 cm3 776 cm3, ~ 50 %! PTV: 3 of 9 centers defining planning target volume, National guidelines says: Margins from CTV to PTV is 5 7 mm. Towards the heart, it is set to 0 mm. Minimum dose in PTV should be 90% of the target dose.

13 13 Patient 1 Heart, contouring and dose Sagittal Axial The volume of contoured heart varied from 775 cm 3 to 1015 cm 3 7 % 6 % Pasient V5(%) National guidelines: 5 % Heart tolerance dose 4 % 3 % % 1 % 0 % DNR HUS NLSH SIG SOH SUS UNN UUS ÅS A B C D E F G H I < 5 % of the heart volume should receive a dose 5 Gy. If this is not accomplished, compromises in target volume coverage should be considered.

14 14 Patient 1 Fields and dose distributions Hospital # Field angles # Fields Hospital I I G 3 B A H 4 Hospital D C 5 F E D

15 15 Conclusions i/ii The workshop is important in several general ways: Promotes multi-disciplinary discussions and collaboration: oncologists, physicists, treatment planners and radiotherapy technologists Enhances dialogue between cancer centers Puts focus on radiotherapy on a national basis Weaknesses and room for improvement: No strict clinical audit? Expensive? More systematic follow up of the meeting

16 16 Conclusions ii/ii The workshop is an attractive way of clinical auditing: The cancer centers are performing internal audit when working with the patient cases and answering formula about treatment routines. An external audit is performed when results are presented at the workshop and discussions are lead by an expert panel National guidelines are also being audited as conformance to these are measured