Implementation of a Dedicated HDR Peer Review Program can Result in Improved Total Treatment Times for Gynecological Patients

Abstract

<h3>Purpose/Objective(s)</h3> Total treatment times (TTT) >56 days(d) has demonstrated worse outcomes for cervical cancer patients¹. Each extra day of treatment beyond 6-8 weeks can result in a loss of 0.6% per day pelvic control². With appropriate quality assurance programs set in place, teams can achieve TTT success 85% of the time and 53d median time to complete¹. At UT Health SA from September 2016 to 2019 our non-cylinder HDR median TTT was 64d, with only 30% of patients completing </=56d. We hypothesized that creation of a dedicated brachytherapy (HDR) team could significantly improve total treatment times. <h3>Materials/Methods</h3> Starting 10/2019 we implemented an HDR peer review program. Every patient to receive HDR was reviewed before or at the initiation of EBRT as well as after subsequent imaging prior to HDR. Process mapping from start to end of therapy was put in place following the patient from initial review to completion of therapy (graph 1). Data were collected from both an electronic patient information management system and EPIC EMRs. TTT was calculated as the elapsed time between the first day of external beam and the last day of either external beam radiation (EBRT) or HDR, whichever is the latest. Nodal boost and patient attendance to scheduled activities was recorded as variables that could extend TTT. <h3>Results</h3> From 10/1/2019 to 12/1/2021 a total of 63 patients underwent EBRT and non-cylinder HDR. Non-cylinder HDR included 28 tandem and ovoid (39%), 11 utrecht (15%), 30 syed procedure (42%) and 2 combined (3%). The median TTT for patients post implementation of peer review was 53d versus 64d before. Forty-five patients (71%) finished TTT in </=56d compared to 30% before peer review. Eighteen patients (29%) completed TTT in > 56d versus 70% before peer review. Completion times falling outside of 56d by TTT (volume) include: 57d (3), 58 (3), 59 (4), 60(1), 62(1), 63(1), 64(1), 65(1), 67(1), 69(1), 71(1). Only 21% of patients exceeding TTT >56d had a nodal boost versus 55% in of those patients with TTT <=56d. Seventy-six percent of patients with TTT >56d missed an EBRT treatment, range 1 to 22d, average 5.8d. Thirty-nine percent of patients with TTT </=56d missed EBRT treatments, range 1-6d, average 2.2. <h3>Conclusion</h3> Establishing a dedicated HDR peer review program improved median TTT from 64d to 53d. The percentage of patients with TTT </=56d improved from 30% to 71%. Noncompliance with scheduled treatments was the single most significant factor in TTT exceeding 56d. In all cases of TTT >56d, subtracting scheduled but missed EBRT treatment days from TTT results in 92% of patients completing TTT </= 56d. Our data suggests that a dedicated HDR peer review process is beneficial towards achieving the 56d goal. We believe further investigation into interventions that could potentially reduce poor compliance with scheduled treatments is warranted.