Utility of 30-day mortality as a quality metric for palliative radiation treatment: A population-based analysis from Queensland, Australia.

INTRODUCTION: Palliative radiotherapy (PRT) is frequently used to treat symptoms of advanced cancer, however benefits are questionable when life expectancy is limited. The 30-day mortality rate after PRT is a potential quality indicator, and results from a recent meta-analysis suggest a benchmark of 16% as an upper limit. In this population-based study from Queensland, Australia, we examined 30-day mortality rates following PRT and factors associated with decreased life expectancy. METHODS: Retrospective population data from Queensland Oncology Repository was used. Study population data included 22,501 patients diagnosed with an invasive cancer who died from any cause between 2008 and 2017 and had received PRT. Thirty-day mortality rates were determined from the date of last PRT fraction to date of death. Cox proportional hazards models were used to identify factors independently associated with risk of death within 30 days of PRT. RESULTS: Overall 30-day mortality after PRT was 22.2% with decreasing trend in more recent years (P = 0.001). Male (HR = 1.20, 95% CI = 1.13-1.27); receiving 5 or less radiotherapy fractions (HR = 2.97, 95% CI = 2.74-3.22 and HR = 2.17, 95% CI = 2.03-2.32, respectively) and receiving PRT in a private compared to public facility (HR = 1.61, 95% CI = 1.51-1.71) was associated with decreased survival. CONCLUSION: The 30-day mortality rate in Queensland following PRT is higher than expected and there is scope to reduce unnecessarily protracted treatment schedules. We encourage other Australian and New Zealand centres to examine and report their own 30-day mortality rate following PRT and would support collaboration for 30-day mortality to become a national and international quality metric for radiation oncology centres.

Patterns of practice regarding use of radiation therapy following radical prostatectomy: A survey of Radiation Oncologists and Urologists in Australia and New Zealand.

INTRODUCTION: This study aimed to investigate the patterns of practices of radiation oncologists (ROs) and urologists in Australia and New Zealand with respect to the utilisation of post-prostatectomy radiation therapy (RT) and help guide the development of an update to the existing Faculty of Radiation Oncology Genito-Urinary Group post-prostatectomy guidelines. METHODS: ROs and urologists with subspecialty practice in prostate cancer from Australia and New Zealand were invited to participate in an online survey comprised of clinical scenarios regarding post-prostatectomy RT. RESULTS: Sixty-five ROs and 28 urologists responded to the survey. In the setting of low-risk biochemical relapse, the threshold for initiating RT was lower for ROs than urologists. ROs were more likely than urologists to recommend adjuvant RT for node-positive disease. When salvage RT was advised for a pT3N0R1 recurrence, there was no consensus amongst ROs on whether to add either ADT or nodal treatment over prostate bed RT alone. For a solitary PSMA-avid pelvic lymph node recurrence, whole pelvis RT with androgen deprivation therapy was the preferred treatment option (72% ROs, 43% urologists). Most ROs (92%) recommended conventionally fractionated RT to 66-70 Gy, with a boost to any PSMA PET avid recurrent disease. CONCLUSION: This survey highlights the marked discordance in practice for the management of prostate cancer relapse post-prostatectomy. This is seen not only between specialties but also within the radiation oncology community. This emphasises the need for an updated evidence-based guideline to be produced.

Prognostic factors for survival and ambulatory status at 8 weeks with metastatic spinal cord compression in the SCORAD randomised trial.

BACKGROUND: Metastatic spinal cord compression (MSCC) carries a poor prognosis and management is based on the likelihood of maintaining mobility and predicted survival. PATIENTS AND METHOD: SCORAD is a randomised trial of 686 patients comparing a single dose of 8 Gy radiotherapy with 20 Gy in 5 fractions. Data was split into a training set (412, 60%) and a validation set (274, 40%). A multivariable Cox regression for overall survival (OS) and a logistic regression for ambulatory status at 8 weeks were performed in the training set using baseline factors and a backward selection regression to identify a parsimonious model with p ≤ 0.10. Receiver Operating Characteristic (ROC) analysis evaluated model prognostic performance in the validation set. Validation of the final survival model was performed in a separate registry dataset (n = 348). RESULTS: The survival Cox model identified male gender, lung, gastrointestinal, and other types of cancer, compression at C1-T12, presence of non-skeletal metastases and poor ambulatory status all significantly associated with worse OS (all p < 0.05). The ROC AUC for the selected model was 75% (95%CI: 69-81) in the SCORAD validation set and 68% (95%CI: 62-74) in the external validation registry data. The logistic model for ambulatory outcome identified primary tumour breast or prostate, ambulatory status grade 1 or 2, bladder function normal and prior chemotherapy all significantly associated with increased odds of ambulation at 8 weeks (all p < 0.05). The ROC AUC for the selected model was 72.3% (95% CI 62.6-82.0) in the validation set. CONCLUSIONS: Primary breast or prostate cancer, and good ambulatory status at presentation, are favourable prognostic factors for both survival and ambulation after treatment.

Defining the expected 30-day mortality for patients undergoing palliative radiotherapy: A meta-analysis.

BACKGROUND: The expected 30-day mortality rate for patients treated with palliative radiationisnotestablished. The primary objective of this study is todefinetheproportion of patientswith advanced cancerwho diewithin 30-daysofpalliative radiotherapy(PR). Additionally, we explored the short term survival of patient subgroups undergoing PR treatment. METHODS: We searched MEDLINE, CINAHL, Embase and Cochrane Database of Systematic Reviews from January 1st 1980 to June 26, 2020. We included PUBMED's related search and reference lists to further identify articles. A meta-analysis of these research studies and reviews was performed. Published and unpublished English language randomized controlled trials, observational or prospective studies, and systematic reviews that reported 30-day mortality for patients with advanced cancer who received PR were eligible. Data extraction was done by two independent authors and included study quality indicators. To improve distribution and variance, all proportions were transformed using logit transformation. A random-effects model was used to pool data, using Der Simonian and Laird method of estimation where possible and appropriate. RESULTS: The data from 42 studies contributing 88,516 patients with advanced cancer who received PR were evaluated. The summary proportion of mortality in patients with advanced cancer within 30 days of receiving PR was 16% (95% CI = 14% to 18%). We found substantial heterogeneity in our data (I2 = 98.76%, p < 0.001), hence we applied subgroup analysis to identify potential moderating factors. We found a higher 30-day mortality rate after PR in the following groups: multiple treatment sites (QM(1) = 9.54, p = 0.002), hepatobiliary primary (QM(1) = 24.20, p < 0.001), inpatient status (QM(1) = 92.27, p < 0.001), Eastern Cooperative Oncology Group performance status (ECOG) 3-4 (QM(1) = 8.70, p = 0.003), United States (U.S.) patients (QM(1) = 28.70, p < 0.001) among others. CONCLUSIONS: We found that 16% of patients with advanced cancer receiving PR die within 30 days of treatment. Our findingcan be used asabenchmarktoestablishaglobal quality metric for radiation oncology practice audits.

Establishing a palliative Advanced Practice Radiation Therapist role: A viable alternative to a Rapid Access Palliative Radiation Therapy clinic in Australia.

INTRODUCTION: A recent survey found that Rapid Access Palliative Radiation Therapy (RAPRT) clinics have not been widely embraced in Australia and New Zealand for many reasons. The purpose of this narrative is to describe the transition of a Brisbane, Queensland, RAPRT clinic to an Advanced Practice Radiation Therapist (APRT) model to further improve access and delivery of palliative radiation therapy at that centre. METHODS: The weekly RAPRT clinic commenced in 2005, run by one Radiation Oncologist (RO). The role of the attending senior Radiation Therapist (RT) was mainly to facilitate rapid passage of patients from clinic to treatment. However, because individual ROs preferred to retain care of their own patients, capture of the relevant population was limited. It was therefore decided in 2012 to gradually transition to a model where the RT would work with all ROs and manage all palliative patients from referral to follow-up, under RO supervision. RESULTS: The steps to this palliative APRT pathway involved formulation of the role description, mentoring/training of the RT, overseas site visits, further post-graduate education, funding of the position, staff feedback surveys, evaluation studies and endorsement by professional bodies, leading to formal credentialing in 2017. Importantly, the APRT undertakes all steps in the pathway including field or volume delineation (with approval and sign-off by the responsible RO). The role has come to be highly valued by all disciplines. CONCLUSION: The successful establishment of a palliative APRT role in one Australian centre serves as a template for others wishing to create a similar position.

Cost-effectiveness analysis of hydrogel spacer for rectal toxicity reduction in prostate external beam radiotherapy.

INTRODUCTION: Contemporary methods of external beam radiotherapy for prostate cancer have reduced toxicity rates through beam modulation and image guidance, however, rectal injury has not been eliminated completely in this population. For patients at greatest risk of developing rectal toxicities, hydrogel spacers are a viable option for risk reduction. Translation of clinical trial results into routine clinical practice relies on an understanding of the economic implications. This study completed a cost-effectiveness analysis of hydrogel spacers in the Australian healthcare setting. METHOD: Simulation of possible health states following treatment was performed using a Markov model. Model outcomes included the incremental cost-effectiveness ratio and the net monetary benefit (NMB) at three published willingness-to-pay thresholds derived from literature. Probabilistic sensitivity analyses were provided on these results. A baseline cohort without hydrogel spacer use was compared to treat all and selective use cohorts. Cost variation scenarios were also investigated to assess the impact of hydrogel spacer cost on outcomes. RESULTS: Using hydrogel spacers in a selective cohort was more likely to be cost-effective than giving to all patients (NMB -$43 versus -$997, respectively); however, the incremental cost-effectiveness ratio was not below the $28 000 willingness-to-pay threshold for a healthcare provider perspective. These outcomes were influenced by large parameter uncertainty. Cost variation strategies are worth investigating further as a method to achieve willingness-to-pay threshold targets. CONCLUSION: The influence of parameter uncertainty currently limits the cost-effectiveness of this intervention in the Australian public health setting. However, a cost variation solution has been demonstrated to improve cost-effectiveness estimates for selected patients and should be examined further.

Rapid Access Palliative Radiation Therapy Clinics: The Evidence Is There, but Where Are the Clinics? An Australian and New Zealand Perspective.

PURPOSE: First developed in Canada in the 1990s, Rapid Access Palliative Radiation Therapy (RAPRT) clinics have subsequently spread internationally to expedite treatment for near end-of-life patients, sparing them the need for multiple visits to the department. A "classical" RAPRT clinic is herein defined as "a dedicated clinic specifically established to enable (ideally) same day consultation, planning for, and delivery of palliative radiation treatment." The aim of this work was to determine the current status of these clinics in Australia and New Zealand (ANZ). METHODS AND MATERIALS: A phone survey of all 100 Australian and 10 NZ radiation therapy centers was conducted in March and April 2021. The Chief Medical Officers of the 2 large private practices (GenesisCare and Icon) also approved the survey and answered on behalf of their 57 centers. A single page questionnaire was used, seeking information on the logistics and clinical details of past and present RAPRT clinics, and reasons why other centers do not have one. RESULTS: The survey response rate was 100%. There are only 3 current RAPRT clinics (2.7%). The dominant treatment indication is bone metastases (85%-90%), with most patients receiving single fractions (60%-90%), but commencement on the same day is variable (35%-90%). Five other clinics (4.5%) closed after 4 months to 7 years, but the clinical features were similar. By far, the most common reason (95%) given by the 107 centers without a current RAPRT clinic was that these patients are accommodated using existing resources. CONCLUSIONS: Classical RAPRT clinics have not been widely embraced in ANZ. There are alternative strategies such as the Advanced Practice Radiation Therapist model and techniques to avoid the conventional computed tomography-simulation step, which may also expedite treatment for palliative patients.

Prognostic tools for survival prediction in advanced cancer patients: A systematic review.

Survival prediction for palliative cancer patients by physicians is often optimistic. Patients with a very short life expectancy (<4 weeks) may not benefit from radiation therapy (RT), as the time to maximal symptom relief after treatment can take 4-6 weeks. We aimed to identify a prognostic tool (or tools) to predict survival of less than 4 weeks and less than 3 months in patients with advanced cancer to guide the choice of radiation dose and fractionation. We searched Embase, Medline (EBSCOhost) and CINAHL (EBSCOhost) clinical databases for literature published between January 2008 and June 2018. Seventeen studies met the inclusion criteria and were included in the review. Prediction accuracy at less than 4 weeks and less than 3 months were compared across the prognostic tools. Reporting of prediction accuracy among the different studies was not consistent: the Palliative Prognostic Score (PaP), Palliative Prognostic Index (PPI) and Number of Risk Factors (NRF) best-predicted survival duration of less than 4 weeks. The PPI, performance status with Palliative Prognostic Index (PS-PPI), NRF and Survival Prediction Score (SPS) may predict 3-month survival. We recommend PPI and PaP tools to assess the likelihood of a patient surviving less than 4 weeks. If predicted to survive longer and RT is justified, the NRF tool could be used to determine survival probability less than 3 months which can then help clinicians select dose and fractionation. Future research is needed to verify the reliability of survival prediction using these prognostic tools in a radiation oncology setting.

Comparison of statistical machine learning models for rectal protocol compliance in prostate external beam radiation therapy.

PURPOSE: Limiting the dose to the rectum can be one of the most challenging aspects of creating a dosimetric external beam radiation therapy (EBRT) plan for prostate cancer treatment. Rectal sparing devices such as hydrogel spacers offer the prospect of increased space between the prostate and rectum, causing reduced rectal dose and potentially reduced injury. This study sought to help identify patients at higher risk of developing rectal injury based on estimated rectal dosimetry compliance prior to the EBRT simulation and planning procedure. Three statistical machine learning methods were compared for their ability to predict rectal dose outcomes with varied classification thresholds applied. METHODS: Prostate cancer patients treated with conventionally fractionated EBRT to a reference dose of 74-78 Gy were invited to participate in the study. The dose volume histogram data from each dosimetric plan was used to quantify planned rectal volume receiving 50%, 83% 96%, and 102% of the reference dose. Patients were classified into two groups for each of these dose levels: either meeting tolerance by having a rectal volume less than a clinically acceptable threshold for the dose level (Y) or violating the tolerance by having a rectal volume greater than the threshold for the dose level (N). Logistic regression, classification and regression tree, and random forest models were compared for their ability to discriminate between class outcomes. Performance metrics included area under the receiver operator characteristic curve (AUC), sensitivity, specificity, positive predictive value and negative predictive value. Finally, three classification threshold levels were evaluated for their impact on model performance. RESULTS: A total of 176 eligible participants were recruited. Variable importance differed between model methods. Area under the receiver operator characteristic curve performance varied greatly across the different rectal dose levels and between models. Logistic regression performed best at the 83% reference dose level with an AUC value of 0.844, while random forest demonstrated best discrimination at the 96% reference dose level with an AUC value of 0.733. In addition to the standard classification probability threshold of 50%, the clinically representative threshold of 10%, and the best threshold from each AUC plot was applied to compare metrics. This showed that using a 50% threshold and the best threshold from the AUC plots yields similar results. Conversely, applying the more conservative clinical threshold of 10% maximized the sensitivity at V83_RD and V96_RD for all model types. Based on the combination of the metrics, logistic regression would be the recommendation for rectal protocol compliance prediction at the 83% reference dose level, and random forest for the 96% reference dose level, particularly when using the clinical probability threshold of 10%. CONCLUSIONS: This study demonstrated the efficacy of statistical machine learning models on rectal protocol compliance prediction for prostate cancer EBRT dosimetric planning. Both logistic regression and random forest modeling approaches demonstrated good discriminative ability for predicting class outcomes in the upper dose levels. Application of a conservative clinical classification threshold maximized sensitivity and further confirmed the value of logistic regression and random forest models over classification and regression tree.

Effect of Single-Fraction vs Multifraction Radiotherapy on Ambulatory Status Among Patients With Spinal Canal Compression From Metastatic Cancer: The SCORAD Randomized Clinical Trial.

Importance: Malignant spinal canal compression, a major complication of metastatic cancer, is managed with radiotherapy to maintain mobility and relieve pain, although there is no standard radiotherapy regimen. Objective: To evaluate whether single-fraction radiotherapy is noninferior to 5 fractions of radiotherapy. Design, Setting, and Participants: Multicenter noninferiority randomized clinical trial conducted in 42 UK and 5 Australian radiotherapy centers. Eligible patients (n = 686) had metastatic cancer with spinal cord or cauda equina compression, life expectancy greater than 8 weeks, and no previous radiotherapy to the same area. Patients were recruited between February 2008 and April 2016, with final follow-up in September 2017. Interventions: Patients were randomized to receive external beam single-fraction 8-Gy radiotherapy (n = 345) or 20 Gy of radiotherapy in 5 fractions over 5 consecutive days (n = 341). Main Outcomes and Measures: The primary end point was ambulatory status at week 8, based on a 4-point scale and classified as grade 1 (ambulatory without the use of aids and grade 5 of 5 muscle power) or grade 2 (ambulatory using aids or grade 4 of 5 muscle power). The noninferiority margin for the difference in ambulatory status was -11%. Secondary end points included ambulatory status at weeks 1, 4, and 12 and overall survival. Results: Among 686 randomized patients (median [interquartile range] age, 70 [64-77] years; 503 (73%) men; 44% had prostate cancer, 19% had lung cancer, and 12% had breast cancer), 342 (49.8%) were analyzed for the primary end point (255 patients died before the 8-week assessment). Ambulatory status grade 1 or 2 at week 8 was achieved by 115 of 166 (69.3%) patients in the single-fraction group vs 128 of 176 (72.7%) in the multifraction group (difference, -3.5% [1-sided 95% CI, -11.5% to ∞]; P value for noninferiority = .06). The difference in ambulatory status grade 1 or 2 in the single-fraction vs multifraction group was -0.4% (63.9% vs 64.3%; [1-sided 95% CI, -6.9 to ∞]; P value for noninferiority = .004) at week 1, -0.7% (66.8% vs 67.6%; [1-sided 95% CI, -8.1 to ∞]; P value for noninferiority = .01) at week 4, and 4.1% (71.8% vs 67.7%; [1-sided 95% CI, -4.6 to ∞]; P value for noninferiority = .002) at week 12. Overall survival rates at 12 weeks were 50% in the single-fraction group vs 55% in the multifraction group (stratified hazard ratio, 1.02 [95% CI, 0.74-1.41]). Of the 11 other secondary end points that were analyzed, the between-group differences were not statistically significant or did not meet noninferiority criterion. Conclusions and Relevance: Among patients with malignant metastatic solid tumors and spinal canal compression, a single radiotherapy dose, compared with a multifraction dose delivered over 5 days, did not meet the criterion for noninferiority for the primary outcome (ambulatory at 8 weeks). However, the extent to which the lower bound of the CI overlapped with the noninferiority margin should be considered when interpreting the clinical importance of this finding. Trial Registration: ISRCTN Identifiers: ISRCTN97555949 and ISRCTN97108008.

TROG 18.01 phase III randomised clinical trial of the Novel Integration of New prostate radiation schedules with adJuvant Androgen deprivation: NINJA study protocol.

INTRODUCTION: Stereotactic body radiotherapy (SBRT) is a non-invasive alternative to surgery for the treatment of non-metastatic prostate cancer (PC). The objectives of the Novel Integration of New prostate radiation schedules with adJuvant Androgen deprivation (NINJA) clinical trial are to compare two emerging SBRT regimens for efficacy with technical substudies focussing on MRI only planning and the use of knowledge-based planning (KBP) to assess radiotherapy plan quality. METHODS AND ANALYSIS: Eligible patients must have biopsy-proven unfavourable intermediate or favourable high-risk PC, have an Eastern Collaborative Oncology Group (ECOG) performance status 0-1 and provide written informed consent. All patients will receive 6 months in total of androgen deprivation therapy. Patients will be randomised to one of two SBRT regimens. The first will be 40 Gy in five fractions given on alternating days (SBRT monotherapy). The second will be 20 Gy in two fractions given 1 week apart followed 2 weeks later by 36 Gy in 12 fractions given five times per week (virtual high-dose rate boost (HDRB)). The primary efficacy outcome will be biochemical clinical control at 5 years. Secondary endpoints for the initial portion of NINJA look at the transition of centres towards MRI only planning and the impact of KBP on real-time (RT) plan assessment. The first 150 men will demonstrate accrual feasibility as well as addressing the KBP and MRI planning aims, prior to proceeding with total accrual to 472 patients as a phase III randomised controlled trial. ETHICS AND DISSEMINATION: NINJA is a multicentre cooperative clinical trial comparing two SBRT regimens for men with PC. It builds on promising results from several single-armed studies, and explores radiation dose escalation in the Virtual HDRB arm. The initial component includes novel technical elements, and will form an important platform set for a definitive phase III study. TRIAL REGISTRATION NUMBER: ANZCTN 12615000223538.

Radiotherapy for node-positive prostate cancer: 2019 Recommendations of the Australian and New Zealand Radiation Oncology Genito-Urinary group.

The management of node-positive prostate cancer is highly variable, with both locoregional and systemic treatment options available. With the increasing use of novel imaging techniques such as PSMA-PET and MRI, combined with the increasing use of surgery for high-risk prostate cancer, clinical and pathological regional nodal disease is being detected at a higher rate and at an earlier stage than previously. This creates a window for a potentially curative management approach. The role of radiotherapy including optimal radiation target volumes and dose, as well as the timing and duration of accompanying systemic therapy remains uncertain. At a workshop in 2017, the Australian and New Zealand Faculty of Radiation Oncology Genito-Urinary Group (FROGG) identified variations in the management of node-positive prostate cancer identified on primary staging or on histopathology at radical prostatectomy. FROGG reviewed the literature and developed a set of evidence-based recommendations on the appropriate investigation and management of clinically and pathologically node-positive prostate cancer. These recommendations encompass imaging techniques, radiation treatment target volumes and doses, as well as the use of androgen deprivation therapy.

An evaluation of an advanced practice role in palliative radiation therapy.

INTRODUCTION: The purpose of the study was to evaluate the palliative advanced practice radiation therapy (APRT) role with respect to the impact on waiting times for patients from referral to radiation treatment delivery, the ability of the APRT to define palliative radiation therapy fields and patient satisfaction. The evaluation of the impact of the APRT role and referral pathway on patient waiting times has been previously published. METHODS: Patients were allocated to two different pathways; APRT and standard. Patients in the APRT pathway had their radiotherapy treatment managed by the APRT including defining their palliative fields blinded to the radiation oncologist (RO). RESULTS: Of the 150 palliative patients, 94 had their radiation therapy managed by the APRT and 56 were managed through the standard pathway. 82/92 APRT defined fields were accepted by the RO. CONCLUSIONS: Inter-observer variability between the APRT and the RO in defining palliative radiation therapy fields is similar to that reported in the literature between clinicians. With previously published reduced wait times from referral to treatment for palliative patients, the establishment of the APRT role is justified.

Radiotherapy for recurrent prostate cancer: 2018 Recommendations of the Australian and New Zealand Radiation Oncology Genito-Urinary group.

The management of patients with biochemical, local, nodal, or oligometastatic relapsed prostate cancer has become more challenging and controversial. Novel imaging modalities designed to detect recurrence are increasingly used, particularly PSMA-PET scans in Australia, New Zealand and some European countries. Imaging techniques such as MRI and PET scans using other prostate cancer-specific tracers are also being utilised across the world. The optimal timing for commencing salvage treatment, and the role of local and/or systemic therapies remains controversial. Through surveys of the membership, the Australian and New Zealand Faculty of Radiation Oncology Genito-Urinary Group (FROGG) identified wide variation in the management of recurrent prostate cancer. Following a workshop conducted in April 2017, the FROGG management committee reviewed the literature and developed a set of recommendations based on available evidence and expert opinion, for the appropriate investigation and management of recurrent prostate cancer. These recommendations cover the role and timing of post-prostatectomy radiotherapy, the management of regional nodal metastases and oligometastases, as well as the management of local prostate recurrence after definitive radiotherapy.

Development of quality indicators to monitor radiotherapy care for men with prostate cancer: A modified Delphi method.

BACKGROUND AND PURPOSE: Quality indicators (QIs) have been developed for many aspects of prostate cancer care, but are under-developed with regard to radiotherapy treatment. We aimed to develop a valid, relevant and feasible set of core QIs to measure quality of radiotherapy care in men with prostate cancer. MATERIALS AND METHODS: We used a RAND-modified Delphi process to select QIs that were regarded as both important and feasible measures of quality radiotherapy care. This involved two phases: (1) a literature review to identify a list of proposed QIs; and (2) a QI selection process by an expert panel (n = 12) conducted in a series of three rounds: two online questionnaires' and one face-to-face meeting. The RAND criterion identified variation in ratings and determined the level of agreement after each round of voting. RESULTS: A total of 144 candidate QIs, which included measures from pre-treatment to post-treatment and survivorship care were identified. After three rounds of voting, the panel approved a comprehensive set of 17 QIs, with most assessing a process of care (n = 16, 94.1%) and the remaining assessing a health outcome. CONCLUSION: This study developed a core set of 17 QIs which will be used to report from the Prostate Cancer Outcomes Registry-Australia & New Zealand, to monitor the quality of radiotherapy care prostate cancer patients receive.

Remote Presence Robotic Technology Reduces Need for Pediatric Interfacility Transportation from an Isolated Northern Community.

BACKGROUND: Providing acutely ill children in isolated communities access to specialized care is challenging. This study aimed to evaluate remote presence robotic technology (RPRT) for enhancing pediatric remote assessments, expediting initiation of treatment, refining triaging, and reducing the need for transport. METHODS: We conducted a pilot prospective observational study at a primary/urgent care clinic in an isolated northern community. Participants (n = 38) were acutely ill children <17 years presenting to the clinic, whom local healthcare professionals had considered for interfacility transportation (IFT). Participants were assessed and managed by a tertiary center pediatric intensivist through a remote presence robot. The intensivist triaged participants to either remain at the clinic or be transported to regional/tertiary care. Controls from a pre-existing local transport database were matched using propensity scoring. The primary outcome was the number of IFTs among participants versus controls. RESULTS: Fourteen of 38 (37%) participants required transport, whereas all controls were transported (p < 0.0001). Six of 14 (43%) transported participants were triaged to a nearby regional hospital, while no controls were regionalized (p = 0.0001). All participants who remained at the clinic stayed <24 h, and were matched to controls who stayed 4.9 days in tertiary care (p < 0.001). There was no statistically significant difference in hospital length of stay between transported participants and controls (6.0 vs. 5.7 days). CONCLUSIONS: RPRT reduced the need for specialized pediatric IFT, while enabling regionalization when appropriate. This study may have implications for the broader implementation of RPRT, while reducing costs to the healthcare system.

Reducing radiotherapy waiting times for palliative patients: The role of the Advanced Practice Radiation Therapist.

INTRODUCTION: Palliative radiotherapy is effective in reducing symptom burden and improving quality of life in patients with symptomatic metastatic cancer and should be delivered in a timely manner. The aim of this study was to determine whether referring patients directly to a Palliative Advanced Practice Radiation Therapist (APRT) improves access to palliative radiotherapy and reduces time from referral to treatment. METHODS: At Radiation Oncology Mater Center (ROMC) in Brisbane, Australia a new referral pathway was developed which involved patients requiring palliative radiotherapy, being referred directly to the APRT from a single external hospital medical oncology and palliative care departments. Over a 5 months period, patient demographics and time in working days from referral to treatment were compared for consecutive palliative patients seen within our department. Patients were stratified by method of referral i.e. via the new referral pathway (NP) or via standard referral pathway (SP). RESULTS: Between October 2014 and March 2015, a total of 150 patients were referred for palliative radiotherapy. Of these patients, 48 were referred and processed via the NP. There was a significant reduction in the number of days from referral to treatment for patients referred through the NP. Patients referred through the NP via the APRT had a mean and median wait time of 3.5 and 3 days respectively compared with 8.1 and 5 days for patients referred through the SP (P = <0.001). Patients were also more likely to have the treatment completed with less visits to the hospital (P < 0.001). CONCLUSIONS: The new referral pathway utilising a dedicated palliative APRT decreased waiting times for patients receiving palliative radiotherapy and improved timely access to the radiotherapy service for both referrers and patients.

Margins Matter: current radiation therapy practice and future directions.

Commentary is provided in the context of current practices for calculating radiation therapy margins and future directions that will impact on this.

Dexamethasone and supportive care with or without whole brain radiotherapy in treating patients with non-small cell lung cancer with brain metastases unsuitable for resection or stereotactic radiotherapy (QUARTZ): results from a phase 3, non-inferiority, randomised trial.

BACKGROUND: Whole brain radiotherapy (WBRT) and dexamethasone are widely used to treat brain metastases from non-small cell lung cancer (NSCLC), although there have been no randomised clinical trials showing that WBRT improves either quality of life or overall survival. Even after treatment with WBRT, the prognosis of this patient group is poor. We aimed to establish whether WBRT could be omitted without a significant effect on survival or quality of life. METHODS: The Quality of Life after Treatment for Brain Metastases (QUARTZ) study is a non-inferiority, phase 3 randomised trial done at 69 UK and three Australian centres. NSCLC patients with brain metastases unsuitable for surgical resection or stereotactic radiotherapy were randomly assigned (1:1) to optimal supportive care (OSC) including dexamethasone plus WBRT (20 Gy in five daily fractions) or OSC alone (including dexamethasone). The dose of dexamethasone was determined by the patients' symptoms and titrated downwards if symptoms improved. Allocation to treatment group was done by a phone call from the hospital to the Medical Research Council Clinical Trials Unit at University College London using a minimisation programme with a random element and stratification by centre, Karnofsky Performance Status (KPS), gender, status of brain metastases, and the status of primary lung cancer. The primary outcome measure was quality-adjusted life-years (QALYs). QALYs were generated from overall survival and patients' weekly completion of the EQ-5D questionnaire. Treatment with OSC alone was considered non-inferior if it was no more than 7 QALY days worse than treatment with WBRT plus OSC, which required 534 patients (80% power, 5% [one-sided] significance level). Analysis was done by intention to treat for all randomly assigned patients. The trial is registered with ISRCTN, number ISRCTN3826061. FINDINGS: Between March 2, 2007, and Aug 29, 2014, 538 patients were recruited from 69 UK and three Australian centres, and were randomly assigned to receive either OSC plus WBRT (269) or OSC alone (269). Baseline characteristics were balanced between groups, and the median age of participants was 66 years (range 38-85). Significantly more episodes of drowsiness, hair loss, nausea, and dry or itchy scalp were reported while patients were receiving WBRT, although there was no evidence of a difference in the rate of serious adverse events between the two groups. There was no evidence of a difference in overall survival (hazard ratio 1·06, 95% CI 0·90-1·26), overall quality of life, or dexamethasone use between the two groups. The difference between the mean QALYs was 4·7 days (46·4 QALY days for the OSC plus WBRT group vs 41·7 QALY days for the OSC group), with two-sided 90% CI of -12·7 to 3·3. INTERPRETATION: Although the primary outcome measure result includes the prespecified non-inferiority margin, the combination of the small difference in QALYs and the absence of a difference in survival and quality of life between the two groups suggests that WBRT provides little additional clinically significant benefit for this patient group. FUNDING: Cancer Research UK, Medical Research Council Clinical Trials Unit at University College London, and the National Health and Medical Research Council in Australia.