Consensus Statement Supporting the Presence of Onsite Radiation Oncology Departments at VHA Medical Centers.

Background: Although multiple studies demonstrate that radiotherapy is underused worldwide, the impact that onsite radiation oncology at medical centers has on the use of radiotherapy is poorly studied. The Veterans Health Administration (VHA) Palliative Radiotherapy Taskforce has evaluated the impact of onsite radiation therapy on the use of palliative radiation and has made recommendations based on these findings. Observations: Radiation consults and treatment occur in a more timely manner at VHA centers with onsite radiation therapy compared with VHA centers without onsite radiation oncology. Referring practitioners with onsite radiation oncology less frequently report difficulty contacting a radiation oncologist (0% vs 20%, respectively; P = .006) and patient travel (28% vs 71%, respectively; P < .001) as barriers to referral for palliative radiotherapy. Facilities with onsite radiation oncology are more likely to have multidisciplinary tumor boards (31% vs 3%, respectively; P = .11) and are more likely to be influenced by radiation oncology recommendations at tumor boards (69% vs 44%, respectively; P = .02). Conclusions: The VHA Palliative Radiotherapy Taskforce recommends the optimization of the use of radiotherapy within the VHA. Radiation oncology services should be maintained where present in the VHA, with consideration for expansion of services to additional facilities. Telehealth should be used to expedite consults and treatment. Hypofractionation should be used, when appropriate, to ease travel burden. Options for transportation services and onsite housing or hospitalization should be understood by treating physicians and offered to patients to mitigate barriers related to travel.

Consensus Quality Measures and Dose Constraints for Rectal Cancer From the Veterans Affairs Radiation Oncology Quality Surveillance Program and American Society for Radiation Oncology (ASTRO) Expert Panel.

PURPOSE: Ensuring high quality, evidence-based radiation therapy for patients with cancer is of the upmost importance. To address this need, the Veterans Affairs (VA) Radiation Oncology Program partnered with the American Society for Radiation Oncology and established the VA Radiation Oncology Quality Surveillance program. As part of this ongoing effort to provide the highest quality of care for patients with rectal cancer, a blue-ribbon panel comprised of rectal cancer experts was formed to develop clinical quality measures. METHODS AND MATERIALS: The Rectal Cancer Blue Ribbon panel developed quality, surveillance, and aspirational measures for (a) initial consultation and workup, (b) simulation, treatment planning, and treatment, and (c) follow-up. Twenty-two rectal cancer specific measures were developed (19 quality, 1 aspirational, and 2 surveillance). In addition, dose-volume histogram constraints for conventional and hypofractionated radiation therapy were created. CONCLUSIONS: The quality measures and dose-volume histogram for rectal cancer serves as a guideline to assess the quality of care for patients with rectal cancer receiving radiation therapy. These quality measures will be used for quality surveillance for veterans receiving care both inside and outside the VA system to improve the quality of care for these patients.

Veterans Affairs Radiation Oncology Quality Surveillance Program and American Society for Radiation Oncology Quality Measures Initiative.

PURPOSE: Ensuring high quality, evidence-based radiation therapy for patients is of the upmost importance. As a part of the largest integrated health system in America, the Department of Veterans Affairs National Radiation Oncology Program (VA-NROP) established a quality surveillance initiative to address the challenge and necessity of providing the highest quality of care for veterans treated for cancer. METHODS AND MATERIALS: As part of this initiative, the VA-NROP contracted with the American Society for Radiation Oncology to commission 5 Blue Ribbon Panels for lung, prostate, rectal, breast, and head and neck cancers experts. This group worked collaboratively with the VA-NROP to develop consensus quality measures. In addition to the site-specific measures, an additional Blue Ribbon Panel comprised of the chairs and other members of the disease sites was formed to create 18 harmonized quality measures for all 5 sites (13 quality, 4 surveillance, and 1 aspirational). CONCLUSIONS: The VA-NROP and American Society for Radiation Oncology collaboration have created quality measures spanning 5 disease sites to help improve patient outcomes. These will be used for the ongoing quality surveillance of veterans receiving radiation therapy through the VA and its community partners.

Palliative Radiotherapy Within the Veterans Health Administration: Barriers to Referral and Timeliness of Treatment.

PURPOSE: Most Veterans Health Administration hospitals do not have radiation oncology (RO) departments on-site. The purpose of this study is to determine the impact of on-site RO on referral patterns and timeliness of palliative radiation therapy (PRT). MATERIALS AND METHODS: A survey was sent to medical directors at 149 Veterans Health Administration centers. Questions evaluated frequency of referral for PRT, timeliness of RO consults and treatment, and barriers to referral for PRT. Chi-square analysis was used to evaluate differences between centers that have on-site RO and centers that refer to outside facilities. RESULTS: Of 108 respondents, 33 (31%) have on-site RO. Chi-square analysis revealed that RO consult within 1 week is more likely at centers with on-site RO (68% v 31%; P = .01). Centers with on-site RO more frequently deliver PRT for spinal cord compression within 24 hours (94% v 70%; P = .01). Those without on-site RO were more likely to want increased radiation oncologist involvement (64% v 26%; P < .001). Barriers to referral for PRT included patient ability to travel (81%), patient noncompliance (31%), delays in consult and/or treatment (31%), difficulty contacting a radiation oncologist (14%), and concern regarding excessive number of treatments (13%). Respondents with on-site RO less frequently reported delays in consult and/or treatment (6% v 41%; P < .0001) and difficulty contacting a radiation oncologist (0% v 20%; P = .0056) as barriers. CONCLUSION: Respondents with on-site RO reported improved communication with radiation oncologists and more timely consultation and treatment initiation. Methods to improve timeliness of PRT for veterans at centers without on-site RO should be considered.

The Availability of Advanced Radiation Oncology Technology within the Veterans Health Administration Radiation Oncology Centers.

Radiation oncologists were surveyed to determine how accessible advanced radiation delivery modalities are within the VHA.

Impact of patient distance to radiation therapy on mastectomy use in early-stage breast cancer patients.

PURPOSE: Treatment access underlies quality cancer care. We hypothesize that mastectomy rates in a rural state are independently influenced by distance to radiation therapy (XRT) and by changing XRT access through opening new facilities. PATIENTS AND METHODS: Early-stage breast cancer patients diagnosed from 1996 to 2000 were identified in the Virginia state registry. Distance from patient zip code to nearest XRT facility was calculated with geographical software. Distance to XRT facility (< or = 10, > 10 to 25, > 25 to 50, and > 50 miles), American Joint Committee on Cancer tumor stage, age, race, and diagnosis year were evaluated for influencing mastectomy rate. Mastectomy use within 15 miles of five new facilities was assessed before and after opening. RESULTS: Among 20,094 patients, 43% underwent mastectomy, 53% underwent lumpectomy, and therapy of 4% of patients is unknown. Twenty-nine percent of patients lived more than 10 miles from XRT facility. Mastectomy increased with distance to XRT facility (43% at < or = 10 miles, 47% at > 10 to 25 miles, 53% at > 25 to 50 miles, and 58% at > 50 miles; P < .001). Among 11,597 patients with T1 (< 2 cm) tumors, mastectomy also varied by distance (31% at < or = 10 miles, 36% at > 10 to 25 miles, 41% at > 25 to 50 miles, and 49% at > 50 miles; P < .001). In multivariate analysis, mastectomy use was independently influenced by XRT distance after adjusting for age, race, T stage, and diagnosis year. Over the study period, mastectomy rates declined from 48% to 43% across Virginia, and there were similar declines in a 15-mile area around four new radiation facilities in urban settings. However, mastectomies decreased from 61% to 45% around a new XRT facility in a rural setting. CONCLUSION: Distance to XRT facility significantly impacts mastectomy use. Opportunities for increasing breast-conservation rates through improved XRT access exist.