2312 - Drivers of Delayed Prostate Radiotherapy Initiation: Upstream Gaps vs. Operational Bottlenecks
Presenter(s)
W. C. Chen1,2, J. Sekar1, J. L. Karten1, J. Baker1,3, M. Tulchinsky1, H. Chou1, and L. Potters1,4; 1Northwell, New Hyde Park, NY, 2Department of Radiation Medicine, South Shore University Hospital, Bay Shore, NY, 3Physics and Astronomy, Hofstra University, Hempstead, NY, 4Department of Radiation Medicine, Lenox Hill Hospital, New York, NY
Purpose/Objective(s):
Timely cancer treatment initiation is important for patient outcomes. We hypothesized that delays are multifactorial, driven by upstream diagnostic gaps, patient-specific factors, internal process bottlenecks, and treatment planning complexity. This study aimed to quantify prostate radiation therapy initiation times, identify outlier cases, analyze contributing workflow stages, and characterize drivers to pinpoint actionable quality improvement targets.
Materials/Methods:
A retrospective review was conducted of prostate cancer patients who initiated external beam radiation across 10 facilities of a large academic health system between March and December 2025. The primary endpoint, sim2TxApprv, was defined as time from CT simulation to final plan treatment approval in work-hours (wHrs, 10 business hours daily excluding weekends/holidays). Statistical outliers (SO) were defined using the standard interquartile range (IQR) method: sim2TxApprv exceeding Q3 + 1.5 x IQR.
Workflow durations for 12 substages were compared between groups using Mann-Whitney U tests. Chi-squared tests assessed outlier association with facility and physician. p<0.05 was significant. Chart review of all outlier cases identified contributing factors, categorized as: patient-centric barriers, logistical challenges, or upstream factors.
Results:
Of 550 prostate patient records, 525 cases across 17 physicians had complete timing data. Median sim2TxApprv was 74.0 wHrs (IQR: 56.6-101.6). Thirty-one patients (5.9%) were outliers (threshold >169.1 wHrs; median 230.9 wHrs).
Physician contouring (mdContour) showed the largest between-groups ratio (6.12x, p<0.001, r=0.68), with outlier median 57.5 vs non-outlier 9.4 wHrs, and the largest absolute delay contribution (48.1 hrs, 33.7% of total median difference). Treatment planning showed only a 1.35x ratio (p=0.08, r=0.17), indicating planning complexity was not a meaningful delay driver. Downstream plan review, approval, and QA stages showed minimal elevation. Chi-squared testing revealed a highly significant physician-outlier association (?²=110.2, p<0.001). Three physicians accounted for 67.7% of SO cases despite representing 15.2% of the cohort.
Qualitative chart review identified upstream process delays in approximately one-third (n=10) of outlier cases, including missing/unusable MRI, delayed PACS imports, and incomplete pre-simulation workups directly delaying contour initiation. Patient-related barriers to treatment initiation emerged primarily post-plan approval.
Conclusion:
Prostate RT initiation delays are multifactorial, with upstream workflow gaps representing the primary contributor to extreme delays. Significant physician and facility clustering suggests opportunities for workflow standardization prior to CT simulation. Treatment planning complexity contributed minimally.