Comparing Proton to Photon Radiotherapy Plans: UK Consensus Guidance for Reporting Under Uncertainty for Clinical Trials.

In the UK, the recent introduction of high-energy proton beam therapy into national clinical practice provides an opportunity for new clinical trials, particularly those comparing proton and photon treatments. However, comparing these different modalities can present many challenges. Although protons may confer an advantage in terms of reduced normal tissue dose, they can also be more sensitive to uncertainty. Uncertainty analysis is fundamental in ensuring that proton plans are both safe and effective in the event of unavoidable discrepancies, such as variations in patient setup and proton beam range. Methods of evaluating and mitigating the effect of these uncertainties can differ from those approaches established for photon therapy treatments, such as the use of expansion margins to assure safety. These differences should be considered when comparing protons and photons. An overview of the effect of uncertainties on proton plans is presented together with an introduction to some of the concepts and terms that should become familiar to those involved in proton therapy trials. This report aims to provide guidance for those engaged in UK clinical trials comparing protons and photons. This guidance is intended to take a pragmatic approach considering the tools that are available to practising centres and represents a consensus across multidisciplinary groups involved in proton therapy in the UK.

Pharmacy practice in the Veterans Administration.

The current status of pharmaceutical services in the Veterans Administration (VA) is described. The mission of the VA Department of Medicine and Surgery is to ensure that quality medical care is provided on a timely basis to all eligible veterans. The VA operates 172 medical centers and 225 ambulatory-care clinics, which makes the VA Pharmacy Service the largest multiinstitutional pharmacy system in the United States. VA pharmacy staffs in VA hospitals range in size from four or five people to more than 100 employees. The VA Pharmacy Service programs are divided into inpatient programs and ambulatory-care programs. Clinical pharmaceutical services and education and research activities are integrated into these programs. A Regional Pharmacy Advisory Council composed of chiefs of pharmacy service from seven geographical regions coordinates the exchange of information between the Central Office and the regions. Current issues of priority for the VA Pharmacy Service include human resource management, material resource management, information resource management, public relations, program enhancement, and new technology. The VA health-care system is comprehensive and complex, and the Pharmacy Service programs reflect the VA mission to provide quality services and support programs that will generate new information or knowledge to improve the care of veterans.