Presenter(s)
J. Kocsis1, J. Jubara1, E. J. Murray1, C. W. Fleming2, S. Paul3, A. Ramalingam4, A. D. Vassil5, E. J. Walsh6, E. Ziel Jr7, S. Rajan8, G. P. Engeler9, A. Dorfmeyer10, C. Hymes10, C. Chaney11, M. Dylong10, L. M. Zickefoose5, S. A. Koyfman5, N. M. Woody5, J. A. Miller1, and S. R. Campbell8; 1Cleveland Clinic, Cleveland, OH, 2Department of Radiation Oncology, Cleveland Clinic Florida, Weston, FL, 3Cleveland Clinic Cancer Center, Mansfield, OH, 4Akron General Medical Center, Akron, OH, United States, 5Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, 6Mercy Medical Center, Akron, OH, United States, 7Indian River Hospital Scully-Welsh Cancer Center, Vero Beach, FL, 8Department of Radiation Oncology, Cleveland Clinic, Cleveland, OH, 9Cleveland Clinic- Sandusky, Sandusky, OH, 10Cleveland Clinic Foundation, Cleveland, OH, 11Cleveland Clinic Foundation, cleveland, OH
Purpose/Objective(s): Peer review is a growing quality assurance measure to review contours and radiation treatment planning. Due to HNC complexity, we launched a weekly HNC subspecialist (HNSS) led peer review in 2018 to standardize care and improve treatment quality across our network.
Materials/Methods: From 2023-2024 when standardized peer review records were available, we evaluated cases presented and changes recommended for regional campus (RG) physicians and HNSS. RG contour review was prioritized when time was limited. Contour changes included modifications to organs at risk (OARs) and target volumes, while plan changes involved bolus, in-vivo dose evaluation, OAR dose optimization, surgery/chemotherapy addition, or hot/cold spot adjustments. A subset of “major changes” were those deemed to potentially impact oncologic outcomes. RG physicians who submitted >4 cases/year were further evaluated. Chi-squared and fisher’s exact tests were performed. To assess dosimetry improvement, we analyzed oropharynx cases treated with 70 Gy and elective 56 Gy to bilateral necks in 2018, 2021, and 2024. Maximum doses to the brainstem and spinal cord, along with mean doses to the parotid glands, submandibular glands, pharyngeal constrictors, and supraglottic larynx were recorded. Median OAR doses were compared between the RG and HNSS each year using a two-sample Wilcox test with normal approximation, p<0.05 was deemed statistically significant (SS).
Results: 467 patients were evaluated from HNSS (n=153) and RG physicians (n=314) for contour (n=466) and plan review (n=271). In HNSS cases, total recommended contour changes declined (24% vs 13%, p=.09), while total plan changes remained stable (8% vs 3%, p=.3) from 2023 to 2024. In RG cases, total recommended contour changes (75% vs 63%, p=.02) and major contour changes (54% vs 44%, p=.09) declined. Total plan changes (24% vs 26%, p=.77) and major plan changes (11% vs 8%, p=.46) in the RG remained similar. For individual RG physicians, median proportion of cases needing contour modification decreased from 80% to 64% (p=.05) from 2023 to 2024, with major changes decreasing from 61% to 41% (p=.10). In the dosimetric analysis, 125 pts (83% HPV+) were included; 61 treated by RG physicians vs. 64 by HNSS. Stages (T/N) were similar between RG and HNSS. Dose to OARs in the RG vs HNSS is described in Table 1. In 2018, dose to 4/6 OARs was SS higher in RG cases compared to HNSS, but by 2024 only 1/6 remained SS higher. Median OAR dose in RG cases improved by 5%-25% from 2018 to 2024.
Conclusion: HNC subspecialty peer review enhances contour accuracy, plan quality, and OAR dosimetry over time, achieving high-quality care across a large integrated health network.
| Median Dose (Gy) to OARs |
| | 2018 | 2021 | 2024 |
| | RG | HNSS | P value | RG | HNSS | P value | RG | HNSS | P value |
| Brainstem | 30 | 14 | <.001 | 24 | 12 | <.001 | 23 | 15 | .05 |
| Spinal Cord | 31 | 27 | .002 | 33 | 22 | <.001 | 29 | 23 | .007 |
| Constrictors | 50 | 44 | .04 | 46 | 41 | <.001 | 47 | 44 | .11 |
| Parotid | 25 | 23 | .09 | 23 | 21 | .08 | 23 | 21 | .16 |
| Submandibular Gland | 39 | 38 | .40 | 37 | 37 | .98 | 37 | 37 | .94 |
| Supraglottic Larynx | 37 | 32 | .04 | 34 | 27 | .005 | 33 | 27 | .05 |
