A multi-centre retrospective study of long-term outcomes of spinal re-irradiation with SABR.

INTRODUCTION: Stereotactic ablative body radiotherapy (SABR) is a highly conformal technique utilising a high dose per fraction commonly employed in the re-treatment of spinal metastases. This study sought to determine the safety and efficacy of re-irradiation with SABR to previously treated spinal metastases. METHODS: This was a retrospective analysis of patients at three Australian centres who have undergone spinal SABR after previous spinal radiotherapy to the same or immediately adjacent vertebral level. Efficacy was determined in terms of rates of local control, while safety was characterised by rates of serious complications. RESULTS: Thirty-three spinal segments were evaluated from 32 patients. Median follow-up for all patients was 2.6 years, and median overall survival was 4.3 years. Eleven of 33 (33.3%) treated spinal segments had local progression, with a local control rate at 12 months of 71.4% (95% C.I. 55.2%-92.4%). Four patients (16.7%) went on to develop cauda equina or spinal cord compression. Thirteen out of 32 patients (40.6%) experienced acute toxicity, of which 12 were grade 2 or less. Five out of 30 spinal (16.7%) segments with follow-up imaging had a radiation-induced vertebral compression fracture. There was one case of radiation myelitis which occurred in a patient who had mediastinal radiotherapy with a treatment field which overlapped their prior spinal radiation. CONCLUSION: The patients in this study experienced long median survival, durable tumour control and high rates of freedom from long-term sequelae of treatment. These results support the use of SABR in patients who progress in the spine despite previous radiotherapy.

Development of binational radiation therapy quality indicator reports for prostate cancer treatment using registry data.

INTRODUCTION: Quality indicators (QIs) are metrics which seek to allow comparison of clinicians' and institutes' practice to best evidence-based practice. The Australia and New Zealand Prostate Cancer Outcomes Registry (PCOR-ANZ) is a bi-national clinical quality registry with coverage estimated to be over 60% of the men newly diagnosed with prostate cancer. We outline the production and ambition of institute-level QI reports to benchmark performance for radiation therapy in the treatment of prostate cancer. METHODS: An expert clinician panel was assembled to create a list of candidate QIs based on a comprehensive literature review, and on modified Delphi-method and expert-consensus voting. A separate implementation group-including, clinicians, epidemiologists, data managers and data scientists-employed an evidence- and consensus- based approach to generate an effective QI report designed for automated production and regular distribution to participating institutes. Feedback from the recipient clinicians was sought to enable refinement of these reports. RESULTS: Seven QIs, including three related to post-treatment symptoms, were deemed feasible to analyse with the currently available data. Utilising an existing report template employed for benchmarking of surgical indicators, a novel radiation therapy report was generated using registry data in a secure analytical environment. The first, beta version of these reports have been produced and confidentially distributed. It is planned to automatically generate these reports biannually and iteratively refine them based on the clinician input. CONCLUSION: QI reports for the treatment of prostate cancer by radiation oncologists have been produced using data from Australia and New Zealand patients. These are being disseminated to institutes on a six-monthly basis allowing comparisons to de-identified peers. The reports aim to facilitate improving patient outcomes, deepen engagement with the radiation oncology community and increase the breadth of PCOR-ANZ coverage. Additional QIs will be included in future iterations of these reports as data matures.

Over-ordering of ultrasound and pre-operative investigations for inguinal hernia repair at Northern Health: a Choosing Wisely audit.

BACKGROUND: Choosing Wisely Australia is an initiative aimed at reducing the incidence of unnecessary investigations. This study is an audit of Northern Health's adherence to two Choosing Wisely recommendations in the context of inguinal hernia repair. Recommendation 1: Avoid routinely performing pre-operative investigations in patients, but instead order in response to patient factors, signs and symptoms, disease or planned surgery. Recommendation 2: Do not order ultrasound for clinically apparent inguinal hernias. METHODS: Records of 264 patients who underwent elective inguinal hernia repair at Northern Health in 2016 were reviewed. RESULTS: Recommendation 1: Results demonstrated over-ordering of coagulation studies. Thirty-four percent of patients received coagulation studies, 86% of which were unindicated. There was better adherence to Choosing Wisely guidelines for other investigations: 38% of patients received a full blood examination (42% unindicated), 38% received a urea, electrolytes and creatinine (14% unindicated), 7% received a glycated haemaglobin (0% unindicated) and 38% received an electrocardiogram (11% unindicated). Recommendation 2: Seventy percent (n = 186) of patients received an ultrasound of which 25% (n = 46) had a documented indication. Correlation with surgical findings showed a positive predictive value of 95.6% and sensitivity of 97.8% for ultrasound. CONCLUSION: Recommendation 1: Most pre-operative coagulation studies were unindicated, while adherence to Choosing Wisely guidelines was better for pre-operative full blood examination, urea, electrolytes and creatinine, glycated haemaglobin and electrocardiogram. Recommendation 2: The majority of patients received an inguinal hernia ultrasound, most of which had no documented indication.