Factors Associated with Stereotactic Radiation Plan Revision in Prospective Peer Review.

Abstract

Stereotactic radiotherapy (SR) is highly effective but has risks for serious toxicity. We sought to identify risk factors for SR plans requiring revision in a comprehensive, prospective peer review program conducted across a network of affiliated radiation centers. We hypothesized that increased physician experience and SR case volume would be associated with lower rates of SR plan revision. Weekly peer review rounds were conducted to review SR cases for image fusion, contours, plan, and dose constraints, all prior to start of radiation. Cases recommended for revision were recorded and tracked prospectively. Factors potentially associated with case revision including body site, SR type, physician experience, and physician case load were assessed for significance using univariate and multivariable logistic regression. From March 2019 to January 2023, 1,015 SR cases were prospectively reviewed, including 312 brain stereotactic radiosurgery (SRS), 190 multi-fraction brain SRS (fSRS), and 513 stereotactic body radiotherapy (SBRT). Revision was recommended in 177 cases (17%). The yearly revision rate was 21% in 2019, 16% in 2020, 17% in 2021, and 18% in 2022. There were 13 individual treating physicians with a median of 5 years' experience (range: 2-18 years), measured at the time of each SR case review. Physicians were categorized as junior (< = 2 years of experience), mid-career (3-9 years), or senior (> = 10 years). The physician's SR case volume in the preceding 3 months (median 25 cases) was dichotomized as low volume (< = 25) or high volume (>25). Logistic regression results are shown in Table 1. Statistical significance was determined by p <0.05. SR plans utilizing SRS (as opposed to SBRT) and treated by physicians with high case volume had lower revision rates. Junior attendings had higher revision rates. These data imply a high value to peer review for junior attendings and for those with low SR case volume. Adequate case volume may be a critical factor for safe delivery of SR, analogous to surgical literature. Annual revision rates in the program remained stable over time, demonstrating the ongoing importance of an effective peer review program for SR.