To investigate practice patterns of use of IC amongst oncologists in treatment of head and neck cancer (HNC) patients. Materials/Methods: An IRB approved survey was sent using Red Cap software to oncologists registered on the American Society of Radiation Oncology (ASTRO) website. Variables were subjected to analysis with Fisher's exact test. Data analysis was considered significant at Bonferroni adjusted pZ0.05 threshold if the p-value was 0.001 and suggestive if p<0.05.The survey was sent to 6818 unique email addresses. Results: The response rate was 14.9% of US and 4.6% of international practitioners. 371 (98.4%) of participants were radiation oncologists. Participants identified as their practice type as Private Practice (23.9%), Academic (44.6%), Hospital Based (30.8%). Level of experience was "still in training" (15.4%), <1 year after completion of training (3.4%), 1-5 years (17.5%), 6-10 years (13.5%), 11-20 years (17.8%), 20-30 years (19.6%), and >30 years (12.7%). 56.8% participants treated >20 HNC patients yearly. 52.5% felt that there are some scenarios where IC improves cancer control and 57.8% felt that there were some scenarios where IC improves quality of life (QOL) outcomes for patients with locally advanced HNC. There was no difference between type of practice or level of training and feelings regarding IC in improving outcomes. Non US practitioners were more likely to feel that IC improved QOL (pZ0.03) and were more likely to use IC (pZ0.005). Increased volume of HNC patients treated was correlated with an increased use of IC (pZ0.001). HNC patient volume was correlated with use of IC in a borderline laryngeal preservation (pZ 0.006), bulky cervical lymph node (pZ0.0005), and optic structure impinging tumor (pZ0.007) case. Variability in use of IC was high. In a patient with a bulky lymph node, 30.5% of respondents rated their willingness to use IC at 0 of a 5 on a 5 point scale, 10.6% at 1, 8% at 2, 11.9% at 3, 15.1% at 4 and 19.9% at 5. In a case with tumor impinging on the optic structures, 25.2% of respondents rated their willingness to use IC at 0 of 5, 9.5% at 1, 12.7% at 2, 14.6% at 3, 17.5% at 4 and 16.7% at 5. After a complete response to IC, doses recommended were 70 Gy (54.6%), >60 but <70 Gy (34.1%), and 60 Gy (8.9%). For a patient with a partial response to IC with a decreased size of a lymph node mass, participants were divided on the dose to treat the areas that were previously involved with tumor, treating with <60 Gy (1.4%), 60 Gy (18%), >60 but <70 Gy (36.3%), 70 Gy (41.1%) and >70 Gy (3.5%). Conclusion: Practice patterns regarding the use of IC were highly varied. IC was most often recommended in patients with bulky cervical lymph node burden or a tumor impinging on the optic structures. Use of IC correlated with patient volume and country of practice.
baseline for future comparisons. These results have been shared with the dosimetry staff and additional guidance has been given to improve the detection rate of the dosimetry peer review. We will report updated results at the annual meeting.
Assessing radiation therapy (RT) delivery workflow efficiency of volumetric-modulated arc therapy (VMAT) craniospinal irradiation (CSI) in children and adult groups. Materials/Methods: A retrospective review of patients treated at a children's hospital (CH) and an adult cancer hospital (AH) with supine VMAT CSI between June 2013 and November 2018 was conducted. Treatment planning was centralized. Both sites utilized linear accelerators. The CH had surface guidance radiation therapy (SGRT) while AH did not. Imageguided radiation therapy (IGRT) time was defined as the duration from kilovoltage (kV) IGRT start time to megavoltage (MV) beam-on time. Total radiation time (TT) was defined as kV IGRT start time to beam-off time of the final MV beam. Time stamped data were collected. Age, gender, height, diagnosis, number of isocenters, RT fraction number, sedation status, IGRT modality and SGRT vs. non-SGRT were recorded. Results: Data from 662 VMAT CSI treatment sessions from the CH and AH (614 and 48, respectively) in 47 patients (41 and 6, respectively) were analyzed. The overall median TT was significantly shorter at the CH vs. the AH (21.07 vs. 37.23 min, p < 0.05). Overall median IGRT time was 12.58 vs. 24.82 min (p < 0.05) with fewer median number of images acquired of 3 vs. 7 (p < 0.05). Re-imaging rate after beam-on time was significantly higher at the AH at 16.7%. Subgroup data for non-sedated patients was analyzed. Median TT was performed on 3-isocenter patients (nZ175 vs. nZ48, 23.13 vs. 37.23 min, p < 0.05), and with the same IGRT modality (nZ24 vs. nZ44, 25.22 vs. 34.19 min, p < 0.05). Significantly lower durations were observed at the CH vs. the AH. At the CH, all treatment sessions were preceded by SGRT which may be a significant factor. For patients at the CH, the TT and IGRT durations decreased after the first three fractions, with a smaller proportion of TT less than the median (30.9% vs. 54.0%, p < 0.05) for the first three fractions compared to the remaining fractions. This did not hold true at the AH (33.3% vs. 57.6%, pZ0.119). A multiple linear regression model applied to the TT at the CH showed significant (p < 0.001) impact of height, number of isocenters, and RT fraction number, but not sedation status. Conclusion: Median TT and IGRT times were significantly shorter at the CH vs. the AH, even when subgroup analyses compared plans adjusted for the same number of isocenters and IGRT modality in non-sedated patients. At the CH, after the first three treatments, TT tended to decrease. Differences in workflow efficiency between sites may be explained in part by supplemental SGRT or by greater experience with VMAT CSI at the CH.
PURPOSE-Value, defined as outcomes over costs, has been proposed as a measure to evaluate prostate cancer (PCa) treatments. We analyzed standardized outcomes and time-driven activitybased costing (TDABC) for prostate brachytherapy (PBT) to define a value framework. Conflict of interest:This work was supported in part by the Cancer Center Support Grant (NCI Grant P30 CA016672). SJF received an honorarium from and is a consultant for Varian Medical Systems and is a cofounder and director of C4 Imaging.Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. RESULTS-A total of 238 men were eligible for analysis. Median age was 64 (range, 46-81). Median follow-up was 5 years (0.5-12.1). There were no acute grade 3-5 complications. EPIC-50 scores were favorable, with no clinically significant changes from baseline to last follow-up at 48 months for urinary incontinence/bother, bowel bother, sexual function, and vitality. Ten-year outcomes were favorable, including biochemical failure-free survival of 84.1%, metastasis-free survival 99.6%, PCa-specific survival 100%, and overall survival 88.6%. TDABC analysis demonstrated low resource utilization for PBT, with 41% and 10% of costs occurring in the operating room and with the MRI scan, respectively. The radar chart allowed direct visualization of outcomes and costs. HHS Public AccessCONCLUSIONS-We successfully created a visual framework to define the value of PBT using the ICHOM standard set and TDABC costs. PBT is associated with excellent outcomes and low costs. Widespread adoption of this methodology will enable value comparisons across providers, institutions, and treatment modalities.
e18305 Background: The cost of a full cycle of radiation therapy at MD Anderson Cancer Center has not been determined using a bottom-up measurement approach. Due to the complexity and variation in clinical processes, typical costing strategies do not provide the level of detail necessary to evaluate the value equation, defined as outcomes over cost. To address this limitation, we designed and implemented a practice-wide Time-Driven Activity-Based Costing (TDABC) strategy to capture our total direct cost of care for all treatment modalities within each of 9 disease site-specific services. Methods: Process maps were created for each of the 9 disease site-specific services. Care delivery times were captured by treatment modality for each service as determined by multidisciplinary teams routinely performing each step of the process. The data were entered into a standardized tool, which calculated step costs based upon capacity cost rates for each human resource. The costing tool also calculated total direct labor costs for specific treatment plans based on modality, complexity, and fractionation. Results: The analysis took six months to complete and required the use of approximately 1,000 administrative hours, 250 physician hours, 250 clinical staff hours and 100 medical physics hours. Approximately 17 process maps were created for each of the 9 services with each process map receiving further analysis based upon radiation treatment modality. As a result of observed variation in costs between disease-site services, best practices were identified and 15 standardization opportunities were discovered. Additionally, the cost-benefit analysis between high profile modalities within each disease-site service, such as Proton Therapy and Intensity Modulated Radiation Therapy (IMRT) on the Head and Neck service, were easier to complete. Conclusions: Time-Driven Activity-Based Costing is a valid method for calculating direct costs in a large academic radiation oncology practice. Standardized clinical outcome data can be used to complete the value equation and ultimately provide insight for better clinical and administrative decision making.
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