Patterns of Care Studies: Past, Present, and Future.

The Patterns of Care Study in Radiation Oncology (PCS) has existed for 25 years. This overview details the basic principles that have guided the study from its inception to the present and defines the future role for the PCS.

20 Years of Progress in Radiation Oncology: Prostate Cancer.

The Patterns of Care Study in Radiation Oncology has documented United States national averages for the evaluation and treatment of prostate cancer from 1973 to 1994. We report the characteristics of patient populations, treatment characteristics, and outcomes of care.

Quality Assessment in the USA: How the Patterns of Care Study Has Made a Difference.

Improving the quality and accessibility of radiation care in the United States has been the primary objective of the Patterns of Care Study (PCS) since its inception. While patient care has two components, technical and interpersonal, the PCS has only studied the quality of technical care. Such assessments of technical quality of radiation oncology, which are representative of the United States as a whole, virtually do not exist outside those of the PCS. The methodology used by the PCS to assess quality in radiation oncology is based on an examination of structure, process, and outcome. Structural elements identified by the PCS to be associated with inferior quality include the use of a Cobalt 60 unit with surface-to-skin distance (SSD)

Assessment of Physics Quality Assurance in United States Radiotherapy Facilities and Comparison With American College of Radiology Standard for Radiation Oncology Physics for External Beam Therapy.

We have assessed radiation therapy physics quality assurance (QA) elements in the United States and compared the results with the Patterns of Care Study (PCS) Consensus Guidelines for Treatment Planning and the American College of Radiology (ACR) Standard for Radiation Oncology Physics for External Beam Therapy. Data were obtained during PCS site visits to 73 facilities randomly selected from the 1,321 radiation therapy facilities in the United States: 21 academic, 26 hospital, and 26 freestanding. The following is a representative sample of results. The estimated national averages for facilities having QA programs for treatment planning systems, simulators, accelerators, film processors, and blocking systems are 44%, 79%, 94%, 62%, and 55%, respectively. Only 63% of facilities obtain an independent check of their accelerator calibrations from a source outside the facilities obtain an independent check of their accelerator calibrations from a source outside the facility. Twenty-six percent of facilities surveyed did not have in vivo dosimetry capability. These results and others in the study were compared with PCS consensus guidelines and ACR standards, This is the first such study performed in the United States, and the results establish a baseline for future studies. A recommendation for a comprehensive national physics QA study is based on deficiencies found in this study and the implementation of new technologies in radiation therapy.

Clinical Applications of Picture Archival and Communications Systems in Radiation Oncology.

Picture archival and communications systems (PACS) for radiation oncology present an entirely different set of constraints and requirements from systems developed for diagnostic imaging. PACS for radiation oncology aid in organizing the complex, interrelated functions of radiation oncology. Integration of PACS with clinical data management systems will provide the backbone for the comprehensive computer system that has long been sought in radiation oncology. Simulation, geometric and dosimetric treatment planning, field shaping, set-up, verification, and delivery are now all observable and/or controllable from computer systems that can be interfaced with the departmental PACS. Costs are substantially lower than with diagnostic PACS because the systems can be based on desktop computers and the image resolution requirements are not as stringent. Each PACS user will have more information more easily available than under current systems of organization. Vendor support of digital image communications (DICOM) protocols will enable full integration of equipment regardless of manufacturer. Potential increased in productivity will be realized if the systems for handling and evaluating images are fully automated and provide the users with analytic tools that enhance the utility of systems such as electronic portal imagers, multileaf collimators, and clinical data management systems. this report describes our efforts in producing such a system.

Therapeutic Options for Clinically Localized Carcinoma of the Prostate.

Clinically localized carcinoma of the prostate is diagnosed annually in over 50,000 American men. The advent of screening programs using digital rectal examination, transrectal ultrasound, and assays for prostatic specific antigen will increase the magnitude of this public health problem. The range of treatment options for this disease includes observation, radical prostatectomy, external beam irradiation, and adjuvant hormonal manipulation. Close surveillance of incidentally diagnosed carcinoma of the prostate achieves cause-specific survivorship in excess of 95%. Organ-confined disease can be approached equally effectively by either radical prostatectomy or definitive external irradiation. Radioactive implantation of organ-confined disease has resulted in inferior local control when compared with locally irradiated patients. For tumors extending to the prostatic capsule, external irradiation must be the cornerstone of management. Neoadjuvant hormonal manipulation has failed to render locally advanced disease resectable; however, exciting data are emerging from centers administering hormones as an adjunct to external irradiation. The latter approach is the basis of an ongoing Radiation Therapy Oncology Group trial.

Radiation Therapy Techniques and Dose Selection in the Treatment of Prostate Cancer.

A dose response for local control of cancer of the prostate is shown, and normal tissue irradiated volume and complications are diminished with conformal radiation therapy techniques in prostate cancer. Refinements in techniques and technology, as well as phase II trials are underway. Should these studies prove dose escalation to be safe, a phase III trial comparing standard techniques and dose with conformal high dose radiotherapy is warranted for patients with adenocarcinoma of the prostate. If a phase III study is positive, then it will confirm that local control of prostate cancer can be improved with conformal therapy techniques without increasing the morbidity of treatment. However, if this is proven to be true only for institutions with highly specialized equipment, then this finding will have very little impact on the total treatment of prostate cancer or consequences of this disease. A truly successful trial will produce results that can be duplicated in modern radiation therapy centers that have conscientiously maintained current, but not necessarily esoteric technology; it is in the best interests of our patients and our colleagues to develop treatment technologies that can be implemented at all institutional strata.