Chart Rounds Research Articles

Implementation of a Novel Chart Rounds Application to Facilitate Peer Review in a Virtual Academic Environment

Peer review in the form of chart rounds is a critical component of quality assurance and safety in radiation therapy treatments. Radiation therapy departments have undergone significant changes that impose challenges to meaningful review, including institutional growth and increasing use of virtual environment. We discuss the implementation of a novel chart rounds (NCR) format and application adapted to modern peer review needs at a single high-volume multisite National Cancer Institute designated cancer center. A working group was created to improve upon the prior institutional chart rounds format (standard chart rounds or SCR). Using a novel in-house application and format redesign, an NCR was created and implemented to accomplish stated goals. Data regarding the SCR and NCR system were then extracted for review. SCR consisted of 2- 90-minute weekly sessions held to review plans across all disease sites, review of 49 plans per hour on average. NCR uses 1-hour long sessions divided by disease site, enabling additional time to be spent per patient (11 plans per hour on average) and more robust discussion.The NCR application is able to automate a list of plans requiring peer review from the institutional treatment planning system. The novel application incorporates features that enable efficient and accurate review of plans in the virtual setting across multiple sites. A systematic scoring system is integrated into the application to record feedback. Over 5 months of use of the NCR, 1160 plans have been reviewed with 143 scored as requiring minor changes, 32 requiring major changes and 307 with comments. Major changes triggered treatment replan. Feedback from scoring is incorporated into physician workflow to ensure changes are addressed. The presented NCR format and application enables standardized and highly reliable peer review of radiation therapy plans that is robust across a variety of complex planning scenarios and could be implemented globally.

P2.31-04 Implementation of a Novel Chart Rounds Application to Facilitate Lung Radiotherapy Plan Peer-Review in a Virtual Environment

P2.31-04 Implementation of a Novel Chart Rounds Application to Facilitate Lung Radiotherapy Plan Peer-Review in a Virtual Environment

A Prospective, Multi-Institutional Study of Problematic Plan Detection during Physician Chart Rounds.

We performed a multi-institutional prospective study to determine the detection rate of problematic treatment plans (PP) at physician chart rounds (CR), and to identify factors associated with PP detection. Curative intent PPs with simulated errors (representative of the most common targets of peer review) were generated. Two breast specialists selected twenty appropriate plans for inclusion and assigned them American Association of Physicists in Medicine (AAPM) Task Group 100 severity and detectability scores. The PPs were blinded and embedded at weekly virtual CR at 2 institutions over 12 months. At site A, both breast and lung cases were reviewed by a mix of breast and lung specialists during CR, and at site B, only breast cases were presented and reviewed by breast specialists. At both sites, breast plans were reviewed via slice-by-slice review in the treatment planning system (TPS), and both used a color-coded tool from the TPS to assess adherence to planning directives. Both sites had systematic approaches to case presentation (without a checklist). Site A was usually prospective CR, while site B was exclusively prospective. The following CR elements were recorded: PP detection, time of detection, length of CR, total number of cases presented, plan elements displayed, number and roles of attendees, and detector's role. Analysis was performed using simple statistics with chi-square testing. By PP error type classification, 55.0% pertained to "target volume delineation," 25% to "non-target volume delineation or normal tissue sparing," and 20.0% to "dose prescription or written directives." Detectability was rated ≤5 (<5% likelihood of going undetected) for 60% of PPs, and severity was rated ≥7 ("at least potentially serious toxicity or tumor underdose") for only 30% of PPs. CR lasted a median of 64 minutes at site A (IQR 55-82.5) and 70 minutes at site B (IQR 52.5-81.5). PPs were presented at a median of 34 minutes (IQR 22.5-43, site A) and 41.5 minutes (IQR 23.5-56, site B) after CR start. A median of 16 cases (IQR 13-19) at site A and 32 cases (IQR 25-34.5) at site B were presented per CR session, with a median of 1 PP (site A and B) presented per session (range 1-2). The median time spent per case was 4.0 minutes (Site A) and 2.2 minutes (Site B). The median number of attendings at CR was 4 for site A (range 2-6) and 6.5 for Site B (range 5-10). PP detection rate at site A was 20% (n = 4) and at site B was 70% (n = 14) (p = 0.001). Detections were made by an attending physician in 100% (site A, n = 4) and 92.9% (Site B, n = 13) of PP detections. There were no differences in detection rate by PP error type (p = 0.78), detectability (p = 0.60) or severity score (p = 0.68), or by time PP presented after CR start (p = 0.39). The effectiveness of PP detection at chart rounds can vary greatly between institutions. The study suggests possible areas for improvement but further study is needed to determine best practices.

A Single Institution Experience of a Biweekly Head and Neck Contouring Peer Review.

Due to the complexity of head and neck radiotherapy, a single weekly chart rounds session is insufficient to review contours. A dedicated biweekly review of all head and neck contours (prior to treatment planning) that can fully assess images and targets can lead to better patient outcomes. A full review of all head and neck contours also increases the number of contours that resident physicians can observe. In total, 38 consecutive patients treated between August 2022 and December 2022 were analyzed in a biweekly head and neck contouring peer review. Three head and neck faculty radiation oncologists and four resident physicians participated. An allotted 30-minute time was granted per review session. Changes were tracked and stratified by whether physician contours underwent no changes/minor changes/major changes. Other metrics including re-irradiation status and attendance were noted. An average of 1.65 patients were discussed per review. Given the allotted time, on average this allowed for up to 18 minutes of discussion per patient. In contrast, our departmental chart rounds session is allotted 1 hour for 40+ patients to be discussed (1.5 minutes per patient). Overall, 10/38 patients underwent minor changes (26.3%) to contour structures and 1 patient underwent a major change (2.6%). Four patients (10.5%) were re-irradiation cases CONCLUSION: A dedicated biweekly half hour review session is both feasible and practical. Additional discussion of head and neck contours helps to implement improvements into a patient's treatment plan. Additional discussion and debate for primary and re-irradiation also increases the number of cases that a training resident physician can observe.

Brachial Plexus Tolerance to Standard Fractionation Re-Irradiation: The Ohio State University Experience

Factors contributing to brachial plexopathy (BPP) in the re-irradiation setting need further assessment. Preliminary work revealed that higher the doses and the use of concurrent cisplatin were associated with higher risk of BPP. Here, we expand our cohort and increase our follow-up duration, given the late nature of BPP development. Sixty-two BP sites with 41 patients (pts), treated between 2015 and 2020 for recurrent H&N cancer, were assessed. Contours and plans were reviewed via a prospective multidisciplinary chart rounds prior to treatment delivery and re-verified by two authors prior to this analysis. Kaplan-Meier and logistic regression were used to test the correlation between variables and outcomes. ROC was used to evaluate the cutoff values. Common terminology criteria of adverse events were used to define BPP. The median age of pts was 63 (29-78) and 65% were males. Median prescription dose was 70 Gy (60-70) for the 1st course and 66 Gy (44-70) for the 2nd course. 13% received intraoperative radiotherapy (IORT) during salvage treatment ranging from 10-15 Gy. 30% of pts in the 1st course and 80% in the 2nd course of pts had surgery. Concurrent chemotherapy was delivered to 71% of pts in the 1st course (Cisplatin 34%, Cetuximab 22%, Carboplatin +/- Paclitaxel 15%) and 76% in the 2nd course (Carboplatin/Paclitaxel 41%, Cisplatin 19%, Cetuximab 12%, Nivolumab 4%). The median interval between courses was 26.5 months (8-221). The median cumulative Dmax (0.03cc) and mean dose to the BP were 96.5 Gy (51-144) and 61.5 Gy (15-110), respectively. The median V60, V70, V80, V90, and V100 were 3.6cc (0.03-10.4), 2.4cc (0-9.9), 1.3cc (0-9.3), 0.6cc (0-8.4), and 0.0015cc (0-7.2), respectively. The median follow-up after the completion of the 2nd RT course was 19 months (1.4-71.5). The 1-yr incidence of BPP was 17%, with a median time to onset of 8.9 months (1-16.6). Factors associated with development of BPP were cumulative Dmax > 100 Gy (HR 1.06, [CI 1.014-1.1], p = 0.009), cumulative mean dose >70 Gy (HR 1.05, [CI 1.01-1.09], p = 0.03), V80 > 1.6cc (HR 1.2. [CI 0.99- 1.52], p = 0.06), V90 > 1cc (HR 1.3, [CI 1.013-1.58], p = 0.038), V100 > 0.3cc (HR 1.33, [1.044-1.69], p = 0.021) and the usage of concurrent cisplatin during the 2nd course (HR 8.9, [CI 2.36-33.75], p = 0.001). Other factors including gender, age, surgery, treatment interval between the two courses, IORT, V60, and V70 were not associated with increased risk of BPP. The incidence of grade 1, grade 2, and grade 3 BPP were 9.6%, 3% and 2.4%, respectively. The 1-yr OS was 70% and LC was 60%. At a median follow up of 19 months, the 1-yr incidence of grade 2 and 3 BPP was approximately 5%. Cisplatin during the 2nd course, cumulative metrics of Dmax 100 Gy, mean 70 Gy, V80 1.6cc, V90 1cc and V100 0.3cc were associated with development of BPP. Prospective study, longer follow up, and higher numbers are warranted. To our knowledge, this represents the largest cohort and longest follow up yet reported for BPP in the re-irradiation setting.

Improving Communication of Peer-Review Conference Outcomes: A Practical Experience

The aim of this work was to describe the design and implementation of a more robust workflow for communicating outcomes from a peer-review chart rounds conference. We also provide information regarding cycle times, plan revisions, and other key metrics that we have observed since initial implementation. A multidisciplinary team of stakeholders including physicians, physicists, and dosimetrists developed a revised peer-review workflow that addressed key needs to improve the prior process. Consensus terminology was developed to reduce ambiguity regarding the priority of peer-review outcomes and to clarify expectations of the treating physician in response to peer-review outcomes. A custom workflow software tool was developed to facilitate both upstream and downstream processes from the chart rounds conference. The peer-review outcomes of the chart rounds conference and resulting plan changes for the first 18 months of implementation were summarized. In the first 18 months after implementation of the revised processes, 2294 plans were reviewed, and feedback priority levels assigned. Across all cases with feedback, the median time for the treating attending physician to acknowledge conference comments was 1 day and was within 7 calendar days for 89.1% of cases. Conference feedback was acknowledged within 1 day for 74 of 115 (64.3%) cases with level 2 comments and for 18 of 21 (85.7%) cases with level 3 comments (P=.054). Contours were modified in 13 of 116 (11%) cases receiving level 2 feedback and 10 of 21 (48%) cases receiving level 3 feedback (P < .001). The treatment plan was revised in 18 of 116 (16%) cases receiving level 2 feedback and 13 of 21 (61%) cases receiving level 3 feedback (P < .001). We successfully implemented a workflow to improve upstream and downstream processes for a chart rounds conference. Standardizing how peer-review outcomes were communicated and recording physician responses allow for improved ability to monitor conference activities.

Transition to Disease-Site Specific Chart Rounds: An Evaluation of Impact on Quality and Perceptions of Practitioners

<h3>Purpose/Objective(s)</h3> Although chart rounds is an established quality assurance process, there remains minimal evidence on various forms of peer review, and some studies report relatively low error-detection rates. One question faced by both academic and community practices is whether to structure chart rounds as practice-site specific (PS) or disease-specific (DS). The global COVID pandemic may also offer new opportunities for structuring peer-review by enhancing virtual connectivity of people and practices. The purpose of this study was to determine if changes to treatment plans were recommended more often and assess perceptions following the transition to DS chart rounds. <h3>Materials/Methods</h3> Data was prospectively collected for 6 months before and 6 months after transition to DS chart rounds at a multi-practice institution. Observed data included frequency of questions asked, educational remarks, and recommended changes to the presented plan or future patients. Time spent per case was recorded. Participants were not aware of data collection. Following 10 months of practicing DS chart rounds, a survey was distributed to faculty, dosimetrists, and trainees to assess perceptions of DS chart rounds. Two-tailed t-testing and chi-square testing were used to analyze the data. Criteria for statistical significance was p<0.05. The study was IRB-approved. <h3>Results</h3> Over 1 year, 1460 patients were peer reviewed; 781 were reviewed by PS chart rounds and 679 by DS chart rounds. A question was asked more often in DS (49.3%) than PS (31.9%) chart rounds (p<0.001). A change to a presented plan was recommended more often in DS (4.9%) than PS (1.4%) chart rounds (p<0.001). A change was recommended for future patients more often in DS (4.4%) than PS (0.9%) chart rounds (p<0.001). An educational point was raised more often in DS (12.5%) than PS (9.3%) chart rounds (p=0.05). Time spent per case was more for DS (2.7 min) than PS (1.6 min) chart rounds (p<0.001). Overall, there were 35 survey respondents (54% response rate). Among attendings, the response rate was 74%. Of all respondents, 89% agreed DS chart rounds improve the quality of patient plans, 83% agreed DS chart rounds improve patient safety, 86% agreed DS chart rounds encourage more discussion, and 77% agreed DS chart rounds are more educational. Only 37% of respondents agreed DS chart rounds are more time efficient; however, 95% of attendings and 89% of all respondents favored continuing DS chart rounds; no respondents disagreed. Time efficiency was not associated with preference for continuing DS chart rounds (p=0.10). Favoring continuing DS chart rounds was associated with the belief that DS chart rounds improve patient safety (p<0.001), quality of patient plans (p<0.001), and education (p<0.001). <h3>Conclusion</h3> DS chart rounds were associated with more discussion and recommended changes to treatment plans than PS chart rounds. Most respondents favored continuing DS chart rounds and reported that this format improved the quality of patient treatment plans and safety.

Peer Review of Head and Neck Cancer Planning Target Volumes in Radiation Oncology

<h3>Purpose/Objective(s)</h3> Radiation treatment plans undergo peer review during chart rounds, but changes to treatment volumes would require replanning. Our group implemented weekly head and neck cancer "volume rounds" to peer review all target volumes for head and neck cancer prior to radiation therapy (RT) planning and chart rounds. <h3>Materials/Methods</h3> We analyzed modifications made to planning target volumes (PTVs) at volume rounds for consecutive non-proton head and neck cancer cases from May 2020 to May 2021. Nine head and neck radiation oncologists participated in weekly volume rounds during this time. Recommendations were categorized as no changes, minor changes, major changes, additional workup (e.g., biopsy or imaging), and consultation or tumor board discussion needed prior to the start of RT. Minor changes to PTVs generally did not require a second review prior to treatment planning while major changes did. <h3>Results</h3> PTVs for 511 cases involving 432 patients underwent peer review and 298 (58.3%) of these cases did not require any modifications prior to treatment planning. Minor and major changes were recommended in 75 (14.7%) and 86 (16.8%) cases, respectively. Additionally, 45 (8.8%) cases were recommended to have further workup and 23 (4.5%) required further consultation with other non-radiation oncology services. Of the 45 cases that were recommended for further workup, 40 underwent biopsy or imaging. Positive findings on imaging or biopsy occurred in 13 patients leading to a significant change in management, including 4 patients that underwent further surgery after positive findings prior to the start of RT. <h3>Conclusion</h3> Prospective peer review during head and neck cancer volume rounds led to frequent minor and major alterations to PTVs. Significant changes in the overall treatment plan, such as additional surgery prior to start of RT, occurred in a minority of patients.

Systematic Implementation of Effective Quality Assurance Processes for the Assessment of Radiation Target Volumes in Head and Neck Cancer

<h3>Purpose/Objective(s)</h3> Target volume delineation and treatment planning in Radiation Oncology for head and neck cancer (HNC) cases can be challenging and time consuming. Volume delineation requires significant expertise and is subject to significant inter-physician variability, and changes in treatment volumes after planning has started are associated with planning delays. While chart rounds are a major quality assurance (QA) intervention for treatment planning, few strategies have been developed to effectively evaluate volume delineation. The aim of the study is to evaluate the feasibility, effectiveness and the potential clinical impact of implementation of prospective Quality Assurance (QA) Processes for the assessment of radiation target volumes. <h3>Materials/Methods</h3> Starting in 2020, a systematic weekly QA process with real-time metrics was adopted in our department for the assessment of HNC planning target volumes (PTVs) before the start of radiation planning. All definitive-intent treatment cases (intact and post-operative) were evaluated. Contours were flagged with green (none), yellow (minor), or red colors (major) based on the degree of required modifications. <h3>Results</h3> 400 consecutive HNC cases were included. A total of 37 (9%) PTVs required modifications, 5 (1%) of these were flagged as red (major) deemed highly likely to impact oncologic outcomes – for example, omission of gross disease and/or elective areas at high risk of microscopic disease. Thirty-two (8%) were flagged yellow (minor) deemed potentially to impact oncologic or functional outcomes—for example, omission of elective areas at intermediate or low risk of harboring microscopic disease, or errors of over-contouring volumes into normal critical structures. All contouring modifications were performed before the start of radiation planning, resulting in significant reduction in the amount of re-planning by our dosimetry group and zero delays in treatment start due to planning within this cohort. Interestingly, between the first 200 and second 200 HNC cases reviewed, major modifications decreased from 5 to 0 and minor modifications from 22 to 10 (chi squared p=0.02), suggesting the presence of a learning curve and standardization of practice of the treating physicians even at a high-volume academic center. <h3>Conclusion</h3> Our study highlights the feasibility and importance of systematic contour QA in head and neck radiation oncology. Further evaluation and implementation of these efforts across other disease sites appear warranted.

Radiotherapy Physics Quality Assurance and Management Practices in Less Resourced Facilities: An Initial Pilot Survey in Six Countries Followed by an Onsite Visit and Audit of Radiotherapy Centers in a Lower Middle-Income Country (LMIC)

<h3>Purpose/Objective(s)</h3> To assess physics quality assurance (PQA) and practices in less resourced RT clinics to improve the quality of care. <h3>Materials/Methods</h3> An initial survey was conducted in 2020 to thirteen select RT centers in six countries. In 2021, from the survey outcome, our team conducted onsite visits to all the RT-centers in one of the countries: one private, and two public (Public-1- and –2). Public-1 in the capital and Public-2 in a regional capital. Follow-up surveys were sent to 17 medical physicists. Questions centered on the topic of equipment, institutional practice, physics quality assurance, management, and safety practices. Qualitative and descriptive methods were used for data analysis. We accessed operational challenges using a 5-point Likert system: machine downtime, patient related issues, power outage and staffing. <h3>Results</h3> We received a 100% response rate. Six (6/17) had 1-3 years of experience and two (2/17) have over 15 years of experience. Over 80% of respondents had experience with a treatment planning system. Private and public-1 have CT simulators located in RT clinic. Breast, genitourinary, Gynecologic, H&N were the most treated diseases in all three centers. All three (3) clinics have 3D conformal RT (3D-CRT), the private and public-2 have electron treatment modalities and only public-1 have IMRT treatment available. An audit during the visit showed that no single point diode patient specific QA is done for 3D-CRT patients and none of the institutions had a functioning diode to carry out this QA process. The average daily patient workload on external beam device for each clinic was LINAC: Private = 25, public-1 = 55, public-2 = 40; Co- 60: public-1 = 45, Public-2 = 25. Public-1 and-2 lacked the equipment necessary to conform to best practices in TG-142 and 198. Public-2 reported significant challenges in the operational challenges above with values of 4.5, 3 and 2.75 and 2.25. Notably Public-1 and-2 have peer review chart rounds which are attended by clinical oncologists, medical physicists, physicians, and physics trainees. All (17/17) responded to having a system of documenting, tracking, and trending patient related safety incidents but only one (1/17) physicist reported using a voluntary incident reporting system. Although not quantifiable audits during site visits show education and training remains the most important need in operating successful local PQA and management programs. In the initial survey RT centers in lower GNIpc country there was a direct correlation between QA needs and the country index. <h3>Conclusion</h3> The initial study showed a direct correlation between QA needs and the development index of a country which has led to the first of a continent-wide survey intended to spotlight PQA practices in LIMCs, the challenges faced, lessons learned, to help understand the gaps and needs to better support their local PQA and management programs.

Integration of Plan Review into Resident Clinical Didactics

<h3>Background</h3> While treatment planning complexity has increased significantly, residents report insufficient exposure to treatment planning. Review of treatment plans with an attending is highly variable, with 71% of residents reviewing ≤50% of plans with an attending (Wu et al, 2020). We sought to integrate treatment planning and plan review longitudinally into our clinical didactics. <h3>Methods</h3> Thirteen clinical attendings were invited to lead weekly plan review sessions (PRS) which were scheduled in one-hour slots following chart rounds. Attendings chose which case(s) they wished to review. Surveys with a 5-point Likert scale (1=strongly disagree, 2=disagree, 3=neutral, 4=agree, 5=strongly agree) were administered to attendings and residents after 21 sessions to gather feedback on the program, with results reported as median score [interquartile range]. <h3>Results</h3> Twelve attendings led a total of 21 sessions over 35 weeks from July 1, 2021 through March 3, 2022. Five sessions were canceled due to unplanned attending conflicts and were replaced with ASTRO-ARRO "Meet Me in Treatment Planning" webinars. The remaining nine weeks were not scheduled due to Mortality, Morbidity and Improvement conferences, holidays, or outside lecturers. Ten attendings and ten residents participated in the surveys. Both attendings and residents enjoy PRS (attendings: 5 [4-5], residents: 5 [5-5]). Attendings spent a median of 38 minutes [range 10-90] preparing to lead a session. Resident-attending interaction is increased during PRS compared to conventional clinical didactics (attendings and residents: 5 [4-5]), and PRS permits complementary teaching to clinical rotations and didactics (attendings: 5 [5-5], residents: 5 [4-5]). Both attendings and residents strongly agreed plan review sessions should continue (attendings and residents: 5 [5-5]). Residents preferred reviewing 1-3 cases in greater detail to reviewing more cases with less time per case (4 [4-5]). PRS exposed attending insights that were otherwise unshared (residents: 5 [5-5]). Residents across PGY level strongly agreed that PRS were useful for their learning level (5 [5-5]). Live PRS engaged residents more than pre-recorded virtual sessions (5 [4-5]), but residents were still glad that these sessions were incorporated into the series (4 [4-4]). <h3>Discussion</h3> We successfully implemented longitudinal treatment planning and plan review into clinical didactics. With low burden on attendings and high overall satisfaction among both residents and attendings, this program will continue in the future with incorporated feedback to maximize learning for residents. The program represents an easy method to quickly add in-depth treatment planning and plan review to clinical didactics.

Peer Review of Head and Neck Cancer Planning Target Volumes in Radiation Oncology

PurposeRadiation treatment plans undergo peer review during chart rounds, but changes to treatment volumes would require replanning. Our group implemented weekly head and neck cancer “volume rounds” to peer review all target volumes for head and neck cancer before radiation therapy (RT) planning and chart rounds. Methods and MaterialsWe analyzed modifications made to planning target volumes (PTVs) at volume rounds for consecutive nonproton head and neck cancer cases from May 2020 to May 2021. Nine head and neck radiation oncologists participated in weekly volume rounds during this time. Recommendations were categorized as no changes, minor changes, major changes, additional workup (eg, biopsy or imaging), and consultation or tumor board discussion needed before the start of RT. Minor changes to PTVs generally did not require a second review before treatment planning while major changes did. ResultsPTVs for 511 cases involving 432 patients underwent peer review and 298 (58.3%) of these cases did not require any modifications before treatment planning. Minor and major changes were recommended in 75 (14.7%) and 86 (16.8%) cases, respectively. Forty-five (8.8%) cases were recommended to have additional workup and 23 (4.5%) required additional consultation with nonradiation surgeons or medical oncologists. Of the 45 cases that were recommended for additional workup, 40 underwent biopsy or imaging. Positive findings on imaging or biopsy occurred in 13 patients, leading to a significant change in management, including 4 patients who underwent additional surgery after positive findings before the start of RT. ConclusionsProspective peer review during head and neck cancer volume rounds led to frequent minor and major alterations to PTVs. Significant changes in the overall treatment plan, such as additional surgery before start of RT, occurred in a minority of patients.

Perceptions of Disease-Site Specific Chart Rounds at an Academic Institution

Despite the prevalence and importance of peer review, there remains a paucity of evidence on different formats of peer review. The purpose of this study was to understand current perceptions of disease-site specific chart rounds at a single institution considering transitioning from practice-site specific chart rounds to disease-site specific chart rounds.An electronic survey was distributed to faculty (24 attendings and 18 physicists), dosimetrists, nurses, therapists, and trainees at an academic institution that has weekly departmental chart rounds. The survey consisted of 13 questions on demographics, perceptions of current chart rounds, and perceptions of disease-site specific chart rounds. ANOVA and Chi-square testing were used to analyze the data. Criteria for statistical significance was P < 0.05. This study was approved by the IRB.A total of 35 (55%) responses were received, 18 of 24 (75%) attendings responded. Of all respondents, 51% were attendings, 23% were physicists, 14% were residents, 9% were dosimetrists, and 3% was a therapist. Attending responses were distributed across all disease sites which included CNS, Head and Neck, Thoracic, Breast, GI, GU, GYN, Pediatric, Palliative, Skin, Sarcoma, and Hematologic (P = 0.218). Most respondents (19; 54%) favored transitioning to disease-specific chart rounds (26% strongly agreed and 29% agreed, whereas 11% disagreed and 9% strongly disagreed). Most respondents (23; 66%) believed disease-specific chart rounds would improve patient safety (26% strongly agreed and 40% agreed, while 11% disagreed and 3% strongly disagreed). Most respondents (27; 77%) believed disease-site specific chart rounds would improve the quality of patient plans (29% strongly agreed and 49% agreed, whereas 11% disagreed and 3% strongly disagreed). Most respondents (23; 66%) believed disease-site specific chart rounds would improve education for trainees (29% strongly agreed and 37% agreed, while 11% disagreed and none strongly disagreed). Most attendings favored transitioning to disease-specific chart rounds (50% agreed and 17% disagreed). All physicists favored transitioning to disease-specific chart rounds. Respondents who favored transitioning to disease-specific chart rounds were significantly more likely to believe that disease-specific chart rounds would improve patient safety (P < 0.0001), improve the quality of patient plans (P < 0.0001), and improve time efficiency (P = 0.0156). Of the respondents who did not favor transitioning to disease-specific chart rounds, 85.7% disagreed it would improve time efficiency.Most respondents favored transitioning to disease-specific chart rounds. Furthermore, most respondents believed disease-specific chart rounds would improve patient safety, the quality of patient plans, and trainee education. Further research will be conducted and presented measuring the impact after implementation.

Multi-Institutional Virtual Medical Student Clerkship in Radiation Oncology

<h3>Purpose/Objective(s)</h3> Medical student education in radiation oncology traditionally takes place in-person during 3^rd or 4^th year of medical school. Due to the COVID-19 pandemic, onsite clerkships were placed on hold, leading to virtual medical student clerkships in radiation oncology which incorporated didactics and hands-on learning. We sought to implement this virtual medical student clerkship in radiation oncology at multiple institutions and analyze the impact and utility of this platform. <h3>Materials/Methods</h3> An IRB-approved virtual clerkship was created and implemented at 7 institutions. Students enrolled in home or away rotations. Clerkships offered general and disease subsite-specific oncology topics through recorded didactics geared towards medical students on www.radoncvirtual.com, as well as clinical vignettes, telehealth visits, chart rounds, contouring, and capstone presentations. Surveys were given pre- and post-clerkship to assess baseline comfort and knowledge. At the end of each clerkship, a course exam was given consisting of 48 questions. Clerkship directors were given a survey to assess comfort and ease of implementing the virtual clerkship. Surveys and course exams were analyzed using Wilcoxon Signed rank test and t-test, 2-sided. <h3>Results</h3> Seventy-two (72) students enrolled at 7 institutions between 4/2020 and 2/2021. Survey response rates were 100% pre- and post-clerkship as well as from course directors. The majority of students were MS4 (57%) and MS3 (33%) with equal distribution in gender. Each institution's median number of total medical students doing an away rotation was 4 (range 3-9) and home rotation number of students 2 (range 0-36). The median length of each virtual rotation was 2.5 weeks (range: 1-4 week). 71% (n = 51) of medical students had never previously enrolled in a radiation oncology elective. Improvements in the overall knowledge of radiation oncology, as well as specific knowledge in the scope of radiation oncology, roles of radiation physicist, dosimetrist and therapist, contouring, treatment planning, and training path to the field (all <i>P</i> < 0.001). There was no significant difference in course final exam scores between students who had attended a radiation oncology elective before enrollment and those who had not (<i>P</i> = 0.27). Course directors reported spending an additional 5-10 hours per week with students. The survey revealed 100% were satisfied with content and delivery of this virtual elective, and 83% (n = 6) indicated they would utilize the material for future rotations. <h3>Conclusion</h3> Implementation of a multi-institutional virtual radiation oncology elective was successful at improving knowledge for medical students at all levels, even those that had exposure previously. This virtual elective platform can be utilized to improve access to multiple institutions, resources, mentors, and networking opportunities. Resources in the virtual rotation platform can also be integrated into traditional educational paradigms to increase exposure in the field.

Using AI to Predict Patient's Atypical Prescription Based on Individual's Feature-Set

<h3>Purpose/Objective(s)</h3> The goal of this project is to train unsupervised machine learning (ML) models to cluster patients into different groups based on their individual features (such as morphology, cancer stage, treatment intent, site location, etc.). Then, we use the distribution of the prescription - Rx (number of fractions times dose per fraction) within each cluster to establish typical Rx values as well as less frequent values. In clinical setting, a new patient's Rx can then be flagged if it does not fall into the typical range of Rx for the individual patient's feature-set. Additionally, the value of Rx is predicted with supervised ML models. This AI computed value can be compared against the clinical Rx to create an additional flag if there is a significant relative deviation. We aim to implement an automatic mechanism based on this ML model along with visualization tools to assist peer review during weekly chart rounds in order to provide extra safety for patients by flagging the infrequent used Rx. <h3>Materials/Methods</h3> We queried all radiation oncology patients from the electronic patient information management system treated between 01/01/2007 to 01/01/2021 (14 years of retrospective data) at our institution. Based on their diagnostic code (ICD9/ICD10 code), we categorize the patients into different disease groups (i.e., prostate, H&N, CNS patients and etc.) for various disease specific model training. Several clustering models (<b>k</b>-means, hierarchical) were applied to cluster patients into different groups based on their individual features, which includes morphology code, treatment intent, treatment techniques, treatment type (initial or cone down), TNM stage, treatment site and etc.). Then, supervised ML models (Random Forest Regression) were applied to predict each group's Rx distribution, which gives an estimate of the most frequent and least frequent Rx range within the group. A data pipeline was developed and then applied to prostate patients for initial testing. <h3>Results</h3> We applied agglomerative clustering to the prostate group and found natural partitions of the patients into <b>k</b> = 2-5 clusters. Observation of the Rx in different clusters showed that each cluster had distinct characteristic Rx's. We plotted the Rx distribution for each feature, the scatterplot of Rx against each feature, and Rx distribution for selected feature-sets for visualization. The supervised prediction results are pending. <h3>Conclusion</h3> This initial prostate ML model along with visualization tools can flag the Rx that are atypical for a particular cluster for further investigation in order to improve the efficiency of peer review process. This further investigation could result in detecting anomaly Rx therefore providing extra safety for patients.

Brachial Plexus Tolerance to High-Dose Radiation in the Re-Irradiation Setting

<h3>Purpose/Objective(s)</h3> Radiotherapy (RT) is a cornerstone modality in treating head and neck cancers in the primary and salvage settings. Maximum tolerated dose to the brachial plexus and other factors contributing to brachial plexus injury in the re-irradiation setting are poorly understood. To define radiation dose and other clinical factors associated with the brachial plexus injury in patients treated with re-irradiation for recurrent head and neck cancers. <h3>Materials/Methods</h3> We analyzed 47 brachial plexus re-irradiation between 2015 and 2020. A first course of radiation for head and neck cancer, developed recurrent disease, and then underwent salvage re-irradiation. DICOM plans and contours for all patients were reviewed by two authors and via a prospective multidisciplinary chart rounds. Common terminology criteria for adverse events (CTCAE) was used to define the brachial plexus injury after the second course of radiation. We used ROC curves to evaluate the cutoff values. Kaplan-Meier and logistic regression were used to test the correlation between the variables and the outcome. <h3>Results</h3> Median prescription dose from the 1st course was 70 Gy (range: 60-70) and from the 2nd course was 66 Gy (46-70) in 2 Gy per fraction. All patients received photon volumetric modulated arc therapy; 74% received concurrent chemotherapy (CRT) during the 1st course (Cisplatin 30%, Carboplatin +/- Paclitaxel 23% and Cetuximab 21%), 74% received CRT during the 2nd course (Carboplatin/Paclitaxel 40%, Cetuximab 17%, Cisplatin 13% and Nivolumab 4%) and 53% received CRT twice. The median time interval between the two RT courses was 24 months (range, 8-221 months). The median cumulative maximum dose (Dmax) to brachial plexus was 97 Gy (range, 64-144 Gy). At a median follow-up of 9 months (range, 1-47 months), the cumulative incidence of brachial plexopathy (CIBPP) was 17% at 1 year. This consisted of two cases with pain alone, one case with numbness alone, two cases with weakness alone and one case with combination of pain and numbness. The median time to development of symptoms was 8.2 months (range, 1-15 months). Among patients with a Dmax greater than vs less than 106 Gy, the 1-year cumulative incidence of BPP was 42% vs 4% <i>P</i> = 0.005. V80 > 1cc (1-yr CIBPP 34% vs 4% <i>P</i> = 0.03) and V90 > 0.3cc (32% vs 4%, <i>P</i> = 0.046) associated with increased risk of BPP. The use of concurrent cisplatin during re-irradiation was associated with increased risk of BPP (OR 39 CI 4.263-356.81, <i>P</i> = 0.001). Other variables like gender, history of neck surgery, use of other kind of systemic therapy, use of cisplatin during the first course of RT, mean cumulative dose, V60, V70, V100 and the interval between the first and the second courses of radiation were not associated with increased risk of BPP. The 1-year OS was 78% and the 1-year PFS was 52%. <h3>Conclusion</h3> Cumulative incidence of radiation-induced BPP after re-irradiation was 17% at 1 year. Dmax > 106 Gy, higher V80/V90, and the use of concurrent cisplatin during re-irradiation, were associated with increased risk of BPP.

Utility of Multi-institutional Pediatric Chart Rounds in the Age of Telemedicine.

Pediatric radiation oncology remains a highly subspecialized field owing to a relatively lower incidence rate of pediatric malignancies, which account for less than 5% of total cancer cases annually in the United States.1,2 Another challenge of treating pediatric malignancies is the diverse profile of tumors, ranging from hematologic malignancies to a heterogenous set of soft tissue and bone sarcomas. These inherent issues result in consistently low case numbers for the average resident,3-5 with almost one-third of senior residents recently reporting insufficient training in pediatric radiation oncology.

Adaptability and Resilience of Academic Radiation Oncology Personnel and Procedures during COVID-19 Pandemic.

Background: A comprehensive response to the unprecedented SARS-CoV-2 (COVID-19) challenges for public health and its impact on radiation oncology patients and personnel for resilience and adaptability is presented. Methods: The general recommendations included working remotely when feasible, implementation of screening/safety and personal protective equipment (PPE) guidelines, social distancing, regular cleaning of treatment environment, and testing for high-risk patients/procedures. All teaching conferences, tumor boards, and weekly chart rounds were conducted using a virtual platform. Additionally, specific recommendations were given to each section to ensure proper patient treatments. The impact of these measures, especially adaptability and resilience, were evaluated through specific questionnaire surveys. Results: These comprehensive COVID-19-related measures resulted in most staff expressing a consistent level of satisfaction in regard to personal safety, maintaining a safe work environment, continuing quality patient care, and continuing educational activities during the pandemic. There was a significant reduction in patient treatments and on-site patient visits with an appreciable increase in the number of telemedicine e-visits. Conclusions: Survey results demonstrated substantial adaptability and resilience, including in the rapid recovery of departmental activities during the reactivation phase. In the event of a future public health emergency, the measures implemented may be adopted with good outcomes by radiation oncology departments across the globe.

Radiation Therapy Delivery Challenges in Older Patients During Coronavirus Disease 2019 Pandemic

PurposeThe management of older patients in radiation therapy (RT) departments has been challenging in the context of the Coronavirus Disease 2019 (COVID-19) outbreak. We report our experience of RT adapted schedules or strategy changes in older patients during the COVID-19 pandemic. Methods and MaterialsPatients aged ≥75 years were recruited during weekly chart rounds. All were potentially eligible for a specific intervention to reduce the frequency of patients’ visits to the hospital. The effect of deferring radiation and hypofractionation of RT schedules was assessed in terms of the number of courses initially planned and replanned during the lockdown. ResultsTwenty patients were identified during the official lockdown in France (March 17 to May 11). Median age was 78 years (75-95 years). Most patients were male (n = 12, 60%) being treated in the postoperative setting (n = 17, 85%). RT was delayed in 11 cases (55%) with hormonal therapy prescribed in 10 cases (50%). Altered RT fractionation was proposed for 5 cases (25%); combinations of altered fractionation and deferral of radiation were applied in 3 cases (15%). The number of radiation courses initially planned and replanned according to the pandemic context: 563 and 197, respectively (−62%; P < .001). None presented recurrence when RT was initiated, and no patient developed symptomatic COVID-19 infection. ConclusionsIn the context of the COVID-19 outbreak, individual risk-based radiation therapy seems to be safe. Systematic screening of patients for COVID-19 before starting radiation therapy is mandatory. In our department the oncogeriatrics expertise availability for daily practice was of great use during the pandemic. Other prospective studies are needed to validate such strategies in case of resurgence of similar outbreaks.

Prospective Blinded Study of The Validity of Radiation Oncology Chart Rounds as an Effective Quality Assurance Process

Radiation oncology is one of few fields in medicine to incorporate a formal peer-review process, though no studies exist that validate the effectiveness of weekly physician chart rounds (C-R) as a quality assurance measure. We conducted a prospective blinded study to evaluate and quantify the efficacy of physician peer review during C-R as a method of detecting treatment planning errors. Sham plans were generated for select cases incorporating deliberate errors that were anticipated to be identifiable at weekly peer-reviewed C-R. An error rate of 7.3% (12/164 total cases) was introduced randomly into C-R over four weeks at an NCI designated Comprehensive Cancer Center. Sham plans were shown by the chief therapist in lieu of actual plans during clinical case presentations. All physicians were unaware of the study except the first and senior authors, chief physicist, and chief therapist. Actual plans chosen for sham replacement underwent peer review using a specialized QA process to ensure clinical quality and correct plan delivery. An error was scored as detected if a physician identified the error incorporated into the sham plan at C-R. Initial study design was to have 60 cases with an anticipated error-detection rate of 70%. The study was stopped early after the first 25% of sham case presentations revealed an unexpectedly low detection rate. Sham cases included various disease sites, treatment intent, and techniques, while incorporating errors of target verification (laterality, spine level, intact versus postop) and dose. 16.7% (2/12) of the presented sham cases were detected. The 2 detected errors included a right lung SBRT case where a plan treating the contralateral lung was shown and a brain SRS plan depicting a lesion in the contralateral side of the brain. Physician attendance did not correlate with error detection rates as 7 physicians were present when both errors were detected; between 4 and 8 were present during the remaining sham presentations. The treating physician was present during 75% (9/12) of sham presentations. In both detections, the treating physician identified the error, not their peers. This is the first prospective study attempting to quantify and validate radiation oncology C-R as an effective component of the quality assurance process. In this study, the error detection rate was substantially lower than anticipated. All errors were identified by the treating physician rather than by their peers. Subsequent study to evaluate the impact of a planned intervention to improve the integrity of C-R as a peer review process is underway.Abstract 2445; TableDetails of Sham CasesDisease SiteIncorporated ErrorDetection RateBreastLaterality0/4ProstateIntact vs Postop0/4Lung SBRTLaterality1/2SpineVertebral level0/1Brain SRSLaterality1/1 Open table in a new tab