Directly Improving the Quality of Radiation Treatment Through Peer Review: A Cross-sectional Analysis of Cancer Centers Across a Provincial Cancer Program

100% peer review in radiation oncology: is it feasible?

“…Previous studies identified similar proportions of recommended plan changes after peer review, accounting for 23.3 [6] [14] and 27% [11] respectively. In addition, some reviews also included changes in total dose (16.4%) or fractionation (6.8%) [6] that did not resulted in re-planning and a total minor change rate of 37 [11], 12.9 [12],7.3 [14] and 47.8% [15] respectively, which is in alignment with the 11.5% rate of minor changes obtained at our institution. Accordingly to a survey of North American teaching centers, 75% of respondents estimated that major changes occurred in < 10% whilst minor changes were estimated to be requested in < 10% of cases by 61% of respondents [5].…”

“…Following on from this, Lymberiou et al [18] showed that from 2223 breast radiation plans analyzed 4.4% required major changes while Rouette et al [15] identified a rate change of 41.5% for left/right breast plans and 30.8% for left/right chest wall. Both studies noticed that plans involving the regional lymph nodes were more likely to have recommended changes suggesting that cases with locoregional nodal involvement should be a significant area of focus for peer review.…”

“…To optimize peer-review process, Ballo et al [13] highlighted the importance of reporting disease sites to identify those with a higher proportion of changes resulting in H&N, GI and GYN cases requiring a plan change more than 15% of the time. Esophagus, uterus, upper/lower limb, cervix, H&N, bilateral lung, right supraclavicular lymph nodes, rectum and spine were cancer groups proposed to most necessitating mandatory peer review according to Rouette et al [15]. We found breast (29%), pelvis (22.6%), bone/soft tissue (16.1%) and H&N (16.1%) cases requiring most of the changes recommended from our peer-review members during our monthly recruitment period.…”

“…For example, to Ballo et al [13], events variations are classified in three types: radiation dose, target or major changes that changed treatment modality (i.e., surgery rather than external beam radiation) or added modalities (i.e., chemoradiation therapy rather than radiation alone). Driving forward into changes' nature, Rouette et al [15] analysis defines a minor change as a recommended change that did not meet the criteria for a "major" change and did not lead to significant repeat treatment planning whilst a major change is defined as a change requiring repeat planning and/or have a foreseeable effect on treatment toxicity or cancer outcomes in the view of the peer-review physician, which is more in alignment with our change's proposal.…”

“…The degree of compliance with peerreview recommendations arising from Walburn et al [11] was reasonably good (59%) but it decreased as recommendation magnitude increased: 65% for minor and 47% for major recommendations respectively, suggesting that early rather than late peer review may enhance compliance and efficiency creating a safety-oriented culture. Moreover, Rouette et al [15] reported a rate of 38.5% of major changes for plans presented after treatment had begun. Fairchild et al [8] revealed that retrospective peer review resulted in higher failure rates and worse overall and progression-free survival after delivery of radiation that did not make compliant with protocol guidelines.…”