More than a quarter of radiotherapy treatment plans change following peer review
Key takeaways:
- Institutional peer review resulted in recommended changes to radiotherapy treatment plans more than 25% of the time.
- Recommendations for “major” changes occurred in 10% of cases.
Institutional peer review led to recommended changes in more than one-quarter of radiotherapy treatment plans, according to results of a systematic review and meta-analysis.
Recommendations for changes that could be considered “major” — warranting re-planning or re-simulation of treatment because of safety or efficacy concerns — occurred in more than 10% of cases, Jane Jomy, MSc, medical student at University of Toronto, and colleagues concluded.
“The results suggest that some form of real-time, early peer review may be beneficial for all cases, irrespective of treatment intent or radiotherapy technique,” Jomy and colleagues wrote.
Background and methods
Institutional peer review is a “key component” of radiotherapy treatment plans, according to study background.
Review can identify potential safety concerns regarding prescription dose, target volume, organ-at-risk delineation and dosimetry, and other plan parameters.
“Peer review [also] can reduce the occurrence of future errors by serving as an opportunity for radiation oncologists, learners and other staff to hone their skills and establish consensus,” researchers wrote.
Jomy and colleagues analyzed health care and medical data bases for papers that reported on the impact of institutional peer review on radiotherapy treatment plans.
They initially identified 9,487 citations published between Jan. 1, 2000, and May 25, 2024.
Their analysis focused on 55 publications, the majority of which came from North America (62%) and had data from 2013 or later (64%). These studies included 96,444 case audits from 10 countries.
The number of change recommendations to radiotherapy treatment plans due to institutional peer review served as the primary endpoint.
Results and next steps
Peer review resulted in change recommendations in 28% (95% CI, 21%-35%) of cases.
Peer review led to major change recommendations in 12% (95% CI, 7%-18%) of cases.
Common reasons peer review led to change recommendations included target delineation (45% of reported revisions), target dosage (33%), organ at risk dosage (9%) and organ at risk volume delineation (5%).
Jomy and colleagues found significant differences in change recommendations based on disease sites (P = .003) and team composition (P = .017). They also found significant differences for major change recommendations based on disease sites (P < .001) and timing of the review relative to treatment (P = .028).
“We suspect this difference between disease sites could be related to increased complexity in radiotherapy planning, where multiple steps may need to be reviewed, including clinical exam and multi-modality image integration,” researchers wrote. “For instance, one study found that the disease sites with highest proportion of change recommendations [head and neck, gastrointestinal, gynecologic] also were often treated with more advanced radiotherapy techniques compared to other tumor sites.”
Various studies revealed other factors that led to significant change recommendations. These included in-person meetings vs. virtual, real-time review vs. post-hoc, presence of neuroradiologists vs. no neuroradiologists, and the number of physicians involved with the peer review.
Researchers acknowledged study limitations, including the heterogeneity of timing, engagement and team composition of peer review across different institutions, and publication bias of studies.
“While we summarized and investigated the changes recommended during the peer review process, what happens afterwards remains unclear,” Jomy and colleagues wrote. “One study demonstrated compliance was only 59%, declining significantly with the complexity of the change. Despite the suggestion of plan changes, they are not implemented nearly half of the time, with unknown consequences.”
Perspective
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I was a bit surprised by how often peer review was changing plans, with about the 10% or more considered “major” plan changes.
My bias is in my experience. I’ve always treated at large academic cancer centers with deep organ expertise. In that situation, radiation plans are very specialized. Physicians are very familiar with the literature and the changes of technology. Our peer review process is quite rigorous, but we rarely have major changes.
I think in the last year, I had a change rate below 1%, so the rates observed in this paper are much higher than in my experience. High change rates show there is likely a lot of variability in how people are delineating their targets and designing plans, and peer review really does serve a role to try to put some guardrails on that.
This study also shows radiation oncologists are not islands. We’re not practicing in a vacuum. Our plans, our radiation treatment paradigms, and how we deliver care should be informed by our peers because it makes us stronger. It is hard to keep on top of every single change in a rapidly evolving field like radiation oncology, and relying on your peers for input and for corrections should be welcome. We should be encouraging the optimal use of peer review — not as a punitive measure, but because it leads to improved patient care.
I think there is a world of efficiency that needs to further be explored when we think about peer review.
Peer review is the final step. It’s making sure the plan that I made is the best plan for a particular patient. We want to make sure that everyone has the right education and tools and support to do their job well; peer review is the extra safety step to ensure that we are all following best practices.
Peer review is a big effort. We’re taking people away from their clinic or research work to do quality assurance, which is very important. However, if you gather five or 10 physicians and staff members anywhere, it can be challenging to make sure everyone’s engaged, paying attention and contributing to the process.
The Zoom era has really changed how we interact with each other as physicians, and as part of a team. How peer review has shifted from in person to online — and how it fits into our already busy schedules — probably needs to be better explored. This would be an important future area of study for research on peer review.
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