Seminars in Radiation Oncology RSS feed: Current Issue. Each issue of Seminars in Radiation Oncology is compiled by a guest editor to address a specific topic in the specialty, presenting definitive information on areas of rapid change and development. A significant number of articles report new scientific information. Topics covered include tumor biology, diagnosis, medical and surgical management of the patient, and new technologies. Seminars in Radiation Oncology has an Impact Factor of 4.312 and is ranked 10th of 90 journals in Radiology, Nuclear Medicine & Medical Imaging category and 38th of 141 in Oncology category on the 2009 Journal Citation Reports®, published by Thomson Reuters. 2011 Topics , Volume 21, Issues 1-4 January Early Stage Breast Cancer Lori Pierce, MD April Metabolic and Functional Imaging with Radiation Therapy James M. Balter, PhD July Rectal Cancer Brian Czito, MD, and Christopher Willett, MD October Liver Tumors (primary and metastatic) Laura Dawson, MD http://www.semradonc.com/?rss=yesElsevier Inc.en © 2012 Elsevier Inc. All rights reserved. Seminars in Radiation Oncology1053-4296221January 2012 © 2012 Elsevier Inc. All rights reserved. healthpermissions@elsevier.comhttp://www.semradonc.com/article/PIIS1053429611001147/abstract?rss=yesModern radiotherapy is a highly technical field that is constantly involved in the development, testing, implementation, and evaluation (one way or another) of new technologies that can contribute to improved treatment for our patients. These new technologies improve current techniques and potentially enable new possibilities for treatment regimes, often while being quickly disseminated throughout the field. The speed of that dissemination often means that a given technology can be in widespread use before the best ways to use the technology are known, and perhaps before adequate clinical experience and/or quality assurance (QA) procedures are developed and disseminated. In addition, it often can be very difficult to perform studies of efficacy for a given technology once it is well disseminated, as various financial issues and intellectual investment in the given technology can make participation in such trials difficult on a number of levels.Introduction: Quality, Technology, and Outcomes in Radiation OncologyJean M. Moran, Benedick A. Fraass10.1016/j.semradonc.2011.10.001Seminars in Radiation Oncology 22, 1 (2012)2012-01-01Seminars in Radiation Oncology2012-01-01221S1053-4296(11)X0005-X12http://www.semradonc.com/article/PIIS1053429611001007/abstract?rss=yes The pace of technological innovation and adoption continues to increase each year, and the field of Radiation Oncology struggles to react appropriately to the changes and potential improvements in treatment which hopefully will result from this innovation. The standard methods used in the past to test new technology and treatment techniques are often no longer appropriate for this fast-changing environment. This paper uses examples from radiotherapy technological developments over the last decades to illustrate issues which need to be solved in order to study and evaluate potential advances, and then describes several improved ways to study new techniques and technology. Design of appropriate studies can help us improve patient care while at the same time documenting which new clinical strategies, enabled by new technology, lead to improved patient outcomes. Quality, Technology and Outcomes: Evolution and Evaluation of New Treatments and/or New TechnologyBenedick A. Fraass, Jean M. Moran10.1016/j.semradonc.2011.09.009Seminars in Radiation Oncology 22, 1 (2012)2012-01-01Seminars in Radiation Oncology2012-01-01221S1053-4296(11)X0005-X310http://www.semradonc.com/article/PIIS1053429611000993/abstract?rss=yes The evidence required to support the use of new technology in medicine differs from that required for new drugs. On one extreme, very little may be required for small devices, but on the other strong evidence is required to support the use of truly novel, potentially dangerous, and high-cost machines. The randomized controlled trial is built into the evaluation of drugs and suits them well. It is not so well suited to the evaluation of major devices in which installation costs and return on investment are important. We discuss where the randomized controlled trial may still play a role and what alternatives may exist when this is not possible. We also discuss the role that independent bodies may have in determining whether or not a new device is not only safe but also adds to the medical landscape in a way that justifies its cost. A Clinical Approach to Technology Assessment: How Do We and How Should We Choose the Right Treatment?Anthony Zietman, Geoffrey Ibbott10.1016/j.semradonc.2011.09.008Seminars in Radiation Oncology 22, 1 (2012)2012-01-01Seminars in Radiation Oncology2012-01-01221S1053-4296(11)X0005-X1117http://www.semradonc.com/article/PIIS1053429611000956/abstract?rss=yes In this review article, we address the radiation oncology process improvements in clinical trials and review how these changes improve the quality for the next generation of trials. In recent years, we have progressed from a time of limited data acquisition to the present in which we have real-time influence of clinical trials quality. This enables immediate availability of the important elements, including staging, eligibility, response, and outcome for all trial investigators. Modern informatics platforms are well designed for future adaptive clinical trials. We review what will be needed in the informatics architecture of current and future clinical trials. What We Have Learned: The Impact of Quality From a Clinical Trials PerspectiveThomas J. FitzGerald10.1016/j.semradonc.2011.09.004Seminars in Radiation Oncology 22, 1 (2012)2012-01-01Seminars in Radiation Oncology2012-01-01221S1053-4296(11)X0005-X1828http://www.semradonc.com/article/PIIS1053429611000981/abstract?rss=yes Radiation therapy for breast cancer has considerably changed over the years, from simple simulator-based 2-dimensional techniques to sophisticated image-guided individualized treatments, with maximally protected normal structures. This has led to a substantial improvement in the outcome of breast cancer patients in terms of disease control, survival, and quality of life. This progress is based on clinical research and paralleled by progress in delivering sophisticated radiation treatment. Clinical trials resulted in identifying patients groups who will benefit from radiation treatment. They also stimulated the development of quality assurance tools and guidelines, which are now applied in daily clinical practice. The new technical opportunities to optimize dose distributions in patients require dedicated quality assurance measures because they may be more sensitive to variations throughout the treatment. Still, a large source of variation and uncertainty in radiation therapy remains in the definition of target volumes, which is clinically significant in terms of dosimetric target coverage as well as exposure of healthy tissues. This striving for continuous improvement of patient selection and treatment will lead to further improvement of local control while at the same time improving functional and cosmetic outcome and avoiding severe late complications, including cardiac toxicity. Quality Indicators for Breast Cancer: Revisiting Historical Evidence in the Context of Technology ChangesPhilip Poortmans, Marianne Aznar, Harry Bartelink10.1016/j.semradonc.2011.09.007Seminars in Radiation Oncology 22, 1 (2012)2012-01-01Seminars in Radiation Oncology2012-01-01221S1053-4296(11)X0005-X2939http://www.semradonc.com/article/PIIS1053429611000944/abstract?rss=yes During the last 2 decades, intensity-modulated radiation therapy (IMRT) became a standard technique despite its drawbacks of volume delineation, planning, robustness of delivery, challenging quality assurance, and cost as compared with non-IMRT. The theoretic advantages of IMRT dose distributions are generally accepted, but the clinical advantages remain debatable because of the lack of clinical assessment of the effort that is required to overshadow the disadvantages. Rational IMRT use requires a positive advantage/drawback balance. Only 5 randomized clinical trials (RCTs), 3 in the breast and 2 in the head and neck, which compare IMRT with non-IMRT (2-dimensional technique in four fifths of the trials), have been published (as of March 2011), and all had toxicity as the primary endpoint. More than 50 clinical trials compared results of IMRT-treated patients with a non-IMRT group, mostly historical controls. RCTs systematically showed a lower toxicity in IMRT-treated patients, and the non-RCTs confirmed these findings. Toxicity reduction, counterbalancing the drawbacks of IMRT, was convincing for breast and head and neck IMRT. For other tumor sites, the arguments favoring IMRT are weaker because of the inability to control bias outside the randomized setting. For anticancer efficacy endpoints, like survival, disease-specific survival, or locoregional control, the balance between advantages and drawbacks is fraught with uncertainties because of the absence of robust clinical data. Rational Use of Intensity-Modulated Radiation Therapy: The Importance of Clinical OutcomeWilfried De Neve, Werner De Gersem, Indira Madani10.1016/j.semradonc.2011.09.003Seminars in Radiation Oncology 22, 1 (2012)2012-01-01Seminars in Radiation Oncology2012-01-01221S1053-4296(11)X0005-X4049http://www.semradonc.com/article/PIIS1053429611000920/abstract?rss=yes Cancer control and toxicity outcomes are the mainstay of evidence-based medicine in radiation oncology. However, radiotherapy is an intricate therapy involving numerous processes that need to be executed appropriately in order for the therapy to be delivered successfully. The use of image-guided radiation therapy (IGRT), referring to imaging occurring in the radiation therapy room with per-patient adjustments, can increase the agreement between the planned and the actual dose delivered. However, the absence of direct evidence regarding the clinical benefit of IGRT has been a criticism. Here, we dissect the role of IGRT in the radiotherapy (RT) process and emphasize its role in improving the quality of the intervention. The literature is reviewed to collect evidence that supports that higher-quality dose delivery enabled by IGRT results in higher clinical control rates, reduced toxicity, and new treatment options for patients that previously were without viable options. Image-Guided Radiotherapy: Has It Influenced Patient Outcomes?Alexis Bujold, Tim Craig, David Jaffray, Laura A. Dawson10.1016/j.semradonc.2011.09.001Seminars in Radiation Oncology 22, 1 (2012)2012-01-01Seminars in Radiation Oncology2012-01-01221S1053-4296(11)X0005-X5061http://www.semradonc.com/article/PIIS1053429611000968/abstract?rss=yes Despite many studies over the last 3 decades that have attempted to explicitly quantify the decision-making process for radiotherapy treatment plan evaluation, judgments of an individual plan's degree of quality are still largely subjective and can show inter- and intra-practitioner variability even if the clinical treatment goals are the same. Several factors conspire to confound the full quantification of treatment plan quality, including uncertainties in dose response of cancerous and normal tissue, the rapid pace of new technology adoption, and the human component of treatment planning. However, new developments in clinical informatics and automation are lowering the bar for developing and implementing quantitative metrics into the treatment planning process. This review discusses general strategies for using quantitative metrics in the treatment planning process and presents a case study in intensity-modulated radiation therapy planning whereby control was established on a variable system via such techniques. Quantitative Metrics for Assessing Plan QualityKevin L. Moore, R. Scott Brame, Daniel A. Low, Sasa Mutic10.1016/j.semradonc.2011.09.005Seminars in Radiation Oncology 22, 1 (2012)2012-01-01Seminars in Radiation Oncology2012-01-01221S1053-4296(11)X0005-X6269http://www.semradonc.com/article/PIIS105342961100097X/abstract?rss=yes There has been growing emphasis on quality measures and process analysis techniques that may be implemented in the daily practice of radiation oncology to improve the overall quality of patient care. In this work, quality measures are a form of monitoring that should be actionable and specific to guide process improvement efforts. They are most effective when used to determine the level of execution proficiency against a standard. Control charts are an effective way to separate a change in the process from process noise such that the user can focus on issues that are more likely to improve quality. The field of radiotherapy would benefit from a common dashboard of quality measures for the different processes in radiation oncology clinics, and some suggestions are provided. The dashboard would be used to provide continuous feedback on a clinic's capability to maintain or exceed standards. The Systematic Application of Quality Measures and Process Control in Clinical Radiation OncologyTodd Pawlicki, Bhisham Chera, Trent Ning, Lawrence B. Marks10.1016/j.semradonc.2011.09.006Seminars in Radiation Oncology 22, 1 (2012)2012-01-01Seminars in Radiation Oncology2012-01-01221S1053-4296(11)X0005-X7076http://www.semradonc.com/article/PIIS1053429611000932/abstract?rss=yes Radiation oncology is an ever-advancing, complex, technologically based specialty that has been thrust into the public spotlight because of recent reports of serious treatment delivery errors that have impacted the quality of patient care. Although quality assurance (QA) initiatives are already common place in radiation oncology, the continued complex technology and automation-based advances in radiotherapy have created new safety challenges. The ongoing evolution of safety challenges in radiation oncology requires corresponding evolution in workflow and QA programs to ensure the quality of patient care. We believe that the incorporation of QA themes into our daily practice will help to create safer patient environments. Practical QA approaches that can be readily incorporated and applied in the daily practice of radiation oncology include process engineering and human factors engineering, medical peer review, “safety rounds,” and software QA tools. Most importantly, we need to develop a culture of safety in which all team members work together to maximize the quality of our patient care. Improving Quality of Patient Care by Improving Daily Practice in Radiation OncologyBhishamjit S. Chera, Marianne Jackson, Lukasz M. Mazur, Robert Adams, Sha Chang, Kathy Deschesne, Timothy Cullip, Lawrence B. Marks10.1016/j.semradonc.2011.09.002Seminars in Radiation Oncology 22, 1 (2012)2012-01-01Seminars in Radiation Oncology2012-01-01221S1053-4296(11)X0005-X7785http://www.semradonc.com/article/PIIS1053429611001159/abstract?rss=yesIn the October, 2011 issue, errors were discovered in in the article “Radiation Therapy for Liver Metastases” [Semin Radiat Oncol 21(4):264-270] by Tracey E. Schefter, MD, and Brian D. Kavanagh, MD. The table appears on page 268 of the issue. Please see corrected table below.Erratum10.1016/j.semradonc.2011.11.001Seminars in Radiation Oncology 22, 1 (2012)2012-01-01Seminars in Radiation Oncology2012-01-01221S1053-4296(11)X0005-X8686