The Financial Impact on Reimbursement of Moderately Hypofractionated Postoperative Radiation Therapy for Breast Cancer: An International Consortium Report

AimsModerately hypofractionated breast irradiation has been evaluated in several prospective studies, resulting in wide acceptance of shorter treatment protocols for postoperative breast irradiation. Reimbursement for radiation therapy varies between private and public systems and between countries, impacting variably financial considerations in the use of hypofractionation. The aim of this study was to evaluate the financial impact of moderately hypofractionated breast irradiation by reimbursement system in different countries.Materials and methodsThe study was designed by an international group of radiation oncologists. A web-questionnaire was distributed to representatives from each country. The participants were asked to involve the financial consultant at their institution.ResultsData from 13 countries from all populated continents were collected (Europe: Denmark, France, Italy, the Netherlands, Spain, UK; North America: Canada, USA; South America: Brazil; Africa: South Africa; Oceania: Australia; Asia: Israel, Taiwan). Clinicians and/or departments in most of the countries surveyed (77%) receive remuneration based on the number of fractions delivered to the patient. The financial loss per patient estimated resulting from applying moderately hypofractionated breast irradiation instead of conventional fractionation ranged from 5–10% to 30–40%, depending on the healthcare provider.ConclusionAlthough a generalised adoption of moderately hypofractionated breast irradiation would allow for a considerable reduction in social and economic burden, the financial loss for the healthcare providers induced by fee-for-service remuneration may be a factor in the slow uptake of these regimens. Therefore, fee-for-service reimbursement may not be preferable for radiation oncology. We propose that an alternative system of remuneration, such as bundled payments based on stage and diagnosis, may provide more value for all stakeholders.     

Pencil Beam Scanning Proton Therapy for Paediatric Neuroblastoma with Motion Mitigation Strategy for Moving Target Volumes

AimsMore efforts are required to minimise late radiation side-effects for paediatric patients. Pencil beam scanning proton beam therapy (PBS-PT) allows increased sparing of normal tissues while maintaining conformality, but is prone to dose degradation from interplay effects due to respiratory motion. We report our clinical experience of motion mitigation with volumetric rescanning (vRSC) and outcomes of children with neuroblastoma.Materials and methodsNineteen patients with high-risk (n = 16) and intermediate-risk (n = 3) neuroblastoma received PBS-PT. The median age at PBS-PT was 3.5 years (range 1.2–8.6) and the median PBS-PT dose was 21 Gy (relative biological effectiveness). Most children (89%) were treated under general anaesthesia. Seven patients (37%) underwent four-dimensional computed tomography for motion assessment and were treated with vRSC for motion mitigation.ResultsThe mean result of maximum organ motion was 2.7 mm (cranial–caudal), 1.2 mm (left–right), 1.0 mm (anterior–posterior). Four anaesthetised children (21%) showing <5 mm motion had four-dimensional dose calculations (4DDC) to guide the number of vRSC. The mean deterioration or improvement to the planning target volume covered by 95% of the prescribed dose compared with static three-dimensional plans were: 4DDC no vRSC, –0.6%; 2 vRSC, +0.3%; 4 vRSC, +0.3%; and 8 vRSC, +0.1%. With a median follow-up of 14.9 months (range 2.7–49.0) there were no local recurrences. The 2-year overall survival was 94% and distant progression-free survival was 76%. Acute grade 2–4 toxicity was 11%. During the limited follow-up time, no late toxicities were observed.ConclusionsThe early outcomes of mainly high-risk patients with neuroblastoma treated with PBS-PT were excellent. With a subset of our cohort undergoing PBS-PT with vRSC we have shown that it is logistically feasible and safe. The clinical relevance of vRSC is debatable in anaesthetised children with small pre-PBS-PT motion of <5 mm.     

Irradiation mammaire locorégionale gauche avec modulation d’intensité rotationnelle et inspiration profonde : comparaison dosimétrique

PurposeAdjuvant left-sided breast cancer locoregional radiotherapy can be accounted for long-term cardiac toxicity. The deep inspiration breath hold techniques can reduce cardiac doses. Only a few studies have investigated rotational intensity-modulated radiotherapy with deep inspiration breath hold.Material and methodsWe conducted a dosimetric study comparing rotational intensity-modulated radiotherapy in free breathing with deep inspiration breath hold for irradiation of left breast cancer and locoregional lymph nodes. Doses to organs at risk were compared, as well as doses to coronary arteries, left anterior descending coronary artery region, and aortic valve.ResultsThe data from nine patients were included in the study. Treatment plans were comparable for target volumes. The deep inspiration breath hold delivery technique, compared with free breathing, reduced radiation dose to the heart (mean dose 4.8 Gy vs. 6.6 Gy, p = 0.008; dose in 2% of the volume 16.8 Gy vs. 23.3 Gy, p = 0.008; volume receiving 25 Gy 0.8% vs. 2,2%, p = 0.008; volume receiving 30 Gy 0.4% vs. 1.2%, p = 0.009), as well as to the right coronary artery (mean dose 6 Gy vs. 8.9 Gy, p = 0.028), to the left anterior descending artery (mean dose 9.6 Gy vs. 14.6 Gy, p = 0.021), to the left anterior descending coronary artery region (dose in 2% of the volume 17.4 Gy vs. 24.6 Gy, p = 0.021), and to the aortic valve (mean dose 4.8 Gy vs. 7 Gy, p = 0.028). Other doses to organs at risk were similar.ConclusionRotational intensity-modulated radiotherapy with deep inspiration breath hold is associated with better sparing of the heart, on the right and left anterior descending coronary arteries, and on the aortic valve, compared with free breathing techniques, for adjuvant left breast cancer locoregional irradiation.     

Competency-Based Medical Education in Radiation Therapy Treatment Planning

PurposeTo develop a technology-enhanced education methodology with competency-based evaluation for radiation therapy treatment planning. The education program is designed for integration in the existing framework of Commission on Accreditation of Medical Physics Education Programs (CAMPEP) accredited medical physics residency programs.Methods and MaterialsThis education program pairs an accessible, multi-institutional infrastructure with established medical education evaluation tools to modernize treatment planning education. This program includes 3 evaluation components: (1) competency-based evaluation, (2) inter- and intramodality comparison, and (3) learner feedback. For this study, synchronous bilateral breast cancer was selected to demonstrate a complex treatment site and nonstandardized technique. Additionally, an online study was made available to a public cohort of worldwide participants of certified Medical Dosimetrists and Medical Physicists to benchmark performance. Before evaluation, learners were given a disease site-specific education session on potential clinical treatment strategies. During the assessment, learners generated treatment plans in their institutional planning system under the direct observation of an expert evaluator. Qualitative proficiency was evaluated for all learners on a 5-point scale of graduated task independence. Quantitative dosimetry was compared between the learner cohort and public cohort. A feedback session provided learners context of multi-institutional experience through multimodality and technique comparison. After study completion, learners were provided a survey that was used to gauge their perception of the education program.ResultsIn the public study, 34 participants submitted treatment plans. Across 3 CAMPEP-accredited residency programs, 6 learners participated in the education and evaluation program. All learners successfully completed treatment plans that met the dosimetric constraints described in the case study. All learners favorably reviewed the study either comprehensively or in specified domains.ConclusionsThe competency-based education and evaluation program developed in this work has been incorporated in CAMPEP-accredited residency programs and is adaptable to other residency programs with minimal resource commitment.     

Endovascular and Antithrombotic Treatment in Blunt Cerebrovascular Injuries: A Systematic Review and Meta-Analysis

ObjectivesIschemic stroke has been estimated to occur in up to 26% of patients with blunt cerebrovascular injury (BCVI). Antithrombotic therapy (AT) may be used for stroke prevention, but the role of endovascular treatment (ET) remains unclear. We systematically reviewed the literature on AT and ET for the treatment of patients with BCVIs.Materials and methodsPubMed, EMBASE, Web of Science, and Cochrane were searched upon the PRISMA guidelines to include studies reporting the use of ET in BCVI patients. Post-ET neurologic outcomes, radiographic responses, and complication rates were assessed. A fixed-effect model meta-analysis was performed to compare treatment-related post-BCVI ischemic stroke rates between AT and ET protocols.ResultsWe included 16 studies comprising 352 patients undergoing ET for BCVI. Mean post-ET rates of good neurologic outcomes and radiologic responses were 86.9% (range, 63.6–100%) and 94.0% (range 57.1–100%), respectively. Mean post-ET complication rate was 5.2% (range, 0–66.7%). Seven studies compared the roles of AT (delivered in 805 patients) and ET (performed in 235 patients) for preventing the onset of post-BCVI ischemic strokes. No significant difference in rates of post-BCVI ischemic stroke was found between patients receiving AT vs patients undergoing ET (OR 0.71, 95% CI: 0.35–1.42, p = 0.402).ConclusionAT and ET may be comparable in preventing the occurrence of ischemic stroke following BCVIs. AT may be preferred as the less-invasive first-line therapy, but ET showed favorable rates of post-treatment clinical and radiologic outcomes, coupled with low rates of treatment-related complications.     

Stereotactic Body Radiotherapy: A Review

Stereotactic body radiotherapy (SBRT) combines the challenge of meeting the stringent dosimetric requirements of stereotactic radiosurgery with that of accounting for the physiological movement of tumour and normal tissue. Here we present an overview of the history and development of SBRT and discuss the radiobiological rationale upon which it is based. The published results of SBRT for lung, liver, pancreas, kidney, prostate and spinal lesions are reviewed and summarised. The current evidence base is appraised and important ongoing trials are identified.