Three discipline collaborative radiation therapy (3DCRT) special debate: Peer review in radiation oncology is more effective today than 20 years ago

Radiation Oncology is a highly multidisciplinary medical specialty, drawing significantly from three scientific disciplines — medicine, physics, and biology. As a result, discussion of controversies or changes in practice within radiation oncology must involve input from all three disciplines. For this reason, significant effort has been expended recently to foster collaborative multidisciplinary research in radiation oncology, with substantial demonstrated benefit.1-3 In light of these results, we endeavor here to adopt this “team-science” approach to the traditional debates featured in this journal. This article is part of a series of special debates entitled “Three Discipline Collaborative Radiation Therapy (3DCRT)” in which each debate team includes a radiation oncologist, medical physicist, and radiobiologist. We hope that this format will not only be engaging for the readership but will also foster further collaboration in the science and clinical practice of radiation oncology. Technologic evolution in everything from treatment planning to treatment delivery, patient immobilization to on-board imaging, complex simulation techniques to modified fractionation regimens, MR Linac to PET Linac, have changed our field exponentially in the past two decades. With these new technologies and abilities, a given radiotherapy patient’s treatment plan may be significantly more individualized and complex than it might have been 20 yr ago. The question we face today in this debate is whether peer review in radiation oncology, an accepted critical component of high-quality and safe delivery of care, is more effective today than it was 20 yr ago. In the face of these significant changes, variability in technique, improvements, and innovations, have we maintained appropriate focus? During peer review do we still ask the right questions? Have we EVER asked the right questions and do we know what those right questions are? How much time is enough time reviewing a patient case? Do we spend more time now than we did 20 yr ago? Do we adequately focus on clinical factors: contours, fractionation, type of delivery, treatment time, patient limitations? How do we allocate our time in peer review? What components are highest yield or at highest risk for error and how have these trends changed for the better or worse in the past two decades? Have we learned any lessons in the past 20 yr when it comes to peer review and if so are they even relevant given the rapid changes in technology that we see year after year within our field? We all strive to deliver safe and effective radiotherapy. Has our peer review process kept pace with the ever-changing technology or are our intentions overwhelmed by and lost on the complexity of a patient case in the year 2020? Let us debate! Arguing for the proposition will be Drs Lakshmi Santanam, Abhishek Solanki, and Anis Ahmad. Dr Santanam is an attending medical physicist at Memorial Sloan Kettering Cancer Center. Her primary interests include motion management and patient safety. She currently serves as Chair for the AAPM Working Group on RO-ILS and Vice-Chair of the Task Group on the Management of Respiratory Motion in Radiation Oncology. Dr Solanki is Associate Professor, Quality Medical Director, Director of Clinical Research, and Chief of Genitourinary Radiotherapy at Loyola University. He joined the faculty of Stritch School of Medicine in 2014 after completing medical school and residency in radiation oncology at the University of Chicago. His clinical practice focuses primarily on genitourinary malignancies and he led the development of a prostate high dose rate (HDR) brachytherapy program at Loyola. Dr Solanki has a particular interest in quality and safety in radiation oncology, leading a multidisciplinary team to develop a prospective peer review program in the Loyola network, and is a member of the Veterans Affairs Radiation Oncology Quality Surveillance program. Dr Ahmad received his MPhil and PhD from Aligarh Muslim University, India followed by a postdoctoral fellowship at the Medical University of South Carolina. He has authored more than 30 peer-reviewed scientific articles, and has been cited over 1200 times. He serves as Associate Editor for the Open Access Journal of Cancer & Oncology and review editor for Frontiers in Neurodegeneration. Dr Ahmad is now an Assistant Scientist with Sylvester Comprehensive Cancer Center at the University of Miami and his primary research focuses are radiation response of tumor and normal tissue to low and clinically relevant doses of radiation. Arguing against the proposition will be Drs Laura Padilla, Erina Vlashi, and Patrizia Guerrieri. Dr Padilla is a medical physicist in the Department of Radiation Oncology at Virginia Commonwealth University. She has an Assistant Professor appointment and is the Associate Program Director of the Medical Physics graduate program. Her research focuses on uses of surface imaging in radiation oncology, workflow and process improvements, and new educational strategies in medical physics. Dr Vlashi received her PhD in Chemistry from Purdue University, followed by postdoctoral training in cancer stem cell biology in the Department of Radiation Oncology at UCLA, where she is now an Associate Professor. Dr Vlashi’s current research interests include investigating the effect of radiation on cell metabolism to identify targetable vulnerabilities that can be exploited for improving the clinical benefits of radiation therapy. Dr Guerrieri is Assistant Professor with the Department of Radiation Oncology of Allegheny Health Network, Pittsburgh. She earned her medical degree from the Universita’ Cattolica del Sacro Cuore, Rome, Italy and her Master of Science in Radiation Sciences at Hahnemann University, Philadelphia. As Coordinator of the Italian Group of Brachytherapy she was on the committee for the compilation of the Italian Association of Radiation Oncology guidelines on breast cancer. She served as president of the organizing committee and scientific director of the Post-Graduate Teaching Course in Brachytherapy, Palermo 2006, and as scientific director and organizer of the National Interactive Course in Brachytherapy for Physicists and Radiation Oncologists, 2011. Peer review is a critical component of a radiation oncology quality management program.4, 5 A keyword search in Google for “Peer review in Radiation Oncology” now yields close to 31 400 results, compared to 6240 results from 1980 to 2000, which highlights the importance this topic has gained in the last 20 yr. With advances in automation, technology, remote review, and cloud computing, engaging multidisciplinary teams via teleconference to review patient contours, radiation treatment plans, and weekly chart rounds is more easily achievable now than in the past. Peer review is more efficient now than it was 20 yr ago when it comes to planning quality,6 reducing variation in practice,7 identifying cancer sites with a high proportion of changes,6 developing or improving treatment planning policies,7 and promoting multidisciplinary communication and engagement.8 Although historically there were limited quantitative and qualitative data regarding the impact of peer review, during the past 10 yr there have been numerous studies describing the impact of multidisciplinary chart rounds on radiation treatment plans. A systematic review of 11 491 patient cases in 11 studies demonstrated that 10.8% of radiation treatment plans required modification as a result of peer review, with the top 3 causes being target volume change (45%), dose prescription or written directive (24%), and nontarget volume delineation or normal tissue sparing (7.5%).9 Many institutions have shifted to peer review earlier in the radiation therapy workflow because of a better understanding of the most common errors identified during peer review. Historically, most institutions have used a weekly “chart rounds” approach, in which patients undergo simulation, treatment planning, and begin treatment. Typically thereafter, the target contours, normal structure contours, and treatment plans, are reviewed during the first week of treatment.10 However, many institutions have evolved their peer review program to conduct peer review before the start of radiotherapy and as early as possible in the treatment planning process.11-13 There are several benefits to this newer approach to peer review: From the physics perspective, pretreatment physics plan checks have been identified as one of the most effective individual quality control checks.19 Automating prescriptions, contour checks for normal contours, plan quality checks, transfer to EMR checks, and associating checklists has made most of these peer review interventions easier from the physicist and therapist perspectives.20 New auto-segmentation tools to aid physicians in identifying targets, tools to determine if margins were done accurately, auto-propagation of contours in 4D datasets, and other tools are becoming available in commercial systems. Although these tools exist as a guide for physicians, ultimately peer review by colleagues is essential and is being practiced by the majority of clinicians. Another way in which peer review has improved over the last two decades is through the engagement of professional organizations to maximize peer review. ASTRO recently created a Peer Review website where physicians who might be looking for an expert consultant for advice regarding challenging cases or who do not have colleagues available in their practice for peer review can be connected to others. This initiative allows for peer review in settings where it may not have previously been possible and demonstrates the commitment to peer review among the radiation oncology community. Identifying what needs to be peer reviewed, timelines, available resources, etc., are all critical factors that need to be determined for effective and efficient implementation. Despite the challenging nature of peer review implementation, it is more feasible now than ever before within the standard operations of every radiation oncology department.21 The indisputable importance of peer review for the quality and safety of healthcare delivery is emphasized in many publications.22-25 The complexity of the radiation delivery tools and the biological response to radiation makes peer review particularly important in radiotherapy.24, 25 By the late 1980s, national standards developed by experts had established the key components of good quality control and assurance in radiation oncology.23 However, the need for structured peer review did not become evident until the mid-1990s when Levitt & Khan, reviewing various clinical trials, showed that the weakest links in quality control and treatment outcomes were related to human factors.25 A few years later, two seminal publications laid the groundwork for modern peer review. The first, “To err is human: building a safer health system,”24 laid the foundation for a culture of safety in the healthcare system, and the second outlined the key elements of good peer review in radiation oncology based on the experience of the Regional Cancer Center in Kingston, Ontario.22 Today, it seems reasonable to think that the experience of conducting structured peer review for nearly three decades, would make modern peer review in radiation oncology more effective than 20 yr ago, especially when one factors in the sophisticated software available for analysis, retrieval, and display of patient information. Here we posit, however, that although modern peer review is certainly aided by advanced technology, its evolution has been outpaced by an exponential escalation in treatment complexity and the ever-growing challenge of how to meaningfully design and integrate this activity into the clinical workflow. Below, we outline the factors we believe hamper the widespread implementation of effective peer review in today’s radiotherapy, thus challenging the proposition that modern peer review is more effective today than it was 20 yr ago. Complex treatment approaches have outgrown modern peer review. As emphasized in “Safety is No Accident,”26 “as the field advances, traditional approaches, processes and workflows should be continually challenged and reassessed” and peer review is no different. The relative simplicity of radiotherapy treatment planning 20 yr ago accommodated for “effective peer review” by discussing every aspect of the treatment plan prior to the beginning of treatment (prospective review), including treatment indications, prescription, and port and verification films. In the early 2000s, most treatments used a standard schedule of 2 Gy/fraction, patient retreatments were less common, and the debate about different fractionation schedules was only beginning. Additionally, 3D Conformal Radiotherapy was considered a “complex treatment” and plans were not as sensitive to contouring inaccuracies.23, 26 This is no longer true today. Inaccurate contouring has been identified as one of the highest risk failure factors in a recent task group report for physics plan and chart review.27 Despite this, physicians are more likely to review prescription and overall treatment strategy during peer review than contours.10 When contours are reviewed, issues with contouring account for over half of the major changes requested during peer review.21, 28 This indicates a potential mismatch between the focus of some current peer review practices and the clinically impactful factors in modern radiotherapy. Peer review practices that do not prioritize, at the very least, target contour review are ineffective for modern radiotherapy techniques. Contour sensitivity of modern plans is not the only added layer of complexity. 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