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For this guideline, we investigated the effectiveness of radiotherapy with curative intent in medically inoperable patients with early-stage non-small-cell lung cancer (nsclc). The guideline was developed by Cancer Care Ontario&rsquo, s Program in Evidence-Based Care and by the Lung Cancer Disease Site Group through a systematic review of mainly retrospective studies, expert consensus, and formal internal and external reviews. &#9632, Stereotactic body radiation therapy (sbrt) with curative intent is an option that should be considered for patients with early-stage, node-negative, medically inoperable nsclc. Qualifying Statements &#9632, Because of the high dose per fraction, the planning process and treatment delivery for sbrt require the use of advanced technology to maintain an appropriate level of safety. Consistent patient positioning and 4-dimensional analysis of tumour and critical structure motion during simulation and treatment delivery are essential. &#9632, Preliminary results for proton-beam therapy have been promising, but the technique requires further clinical study. &#9632, Recommended fractionation schemes for sbrt should result in a biologically effective dose of 100 or greater by the linear quadric model, choosing an &alpha, /&beta, value of 10 [bed10(LQ) &ge, 100]. Qualifying Statements &#9632, Because of the increased risk of treatment-related adverse events associated with centrally located tumours, consideration of tumour size and proximity to critical central structures is required when determining the dose and fractionation. &#9632, Examples of dose&ndash, fractionation schemes used in the included studies have been provided. &#9632, Based on the current evidence and the opinion of the authors, radiation doses at bed10(LQ) greater than 146 might significantly increase toxicity and should be avoided. &#9632, Determination of the radiation bed by the linear quadratic model has limitations for the extreme hypofractionated schemes used in sbrt.

Purpose To determine the current use of brachytherapy, characteristics of the brachytherapy workforce, and barriers to development and maintenance of brachytherapy programs across Canada. Methods and Materials A survey was designed to inquire about the use of brachytherapy and was sent to all Canadian radiation oncologists. Results Of the 116 respondents, we identified 80 radiation oncologists from 33 of 41 responding centers who currently or in the past have practiced brachytherapy. Responses were received from 30% overall and 80% of provinces. Approximately 58% of the respondents treat in one site with brachytherapy, whereas 12% treat in three or more sites. Gynecologic (GYN) and genitourinary are the most commonly treated sites (49% of respondents). For all sites, there was a large range in the number of patients treated with brachytherapy by each radiation oncologist per year (i.e., cervix: 1–50). Approximately 49% of the respondents have discontinued practicing brachytherapy for a certain site, most commonly head and neck (28%), GYN (25%), and bronchus (24%). The most common reasons include reassignment or lack of a local program. The most common reasons why brachytherapy is not used for sites other than GYN and prostate include lack of infrastructure and insufficient training of radiation oncologists rather than insufficient patient numbers or lack of evidence for a benefit of brachytherapy. Conclusions Within its limitations, our study suggests a mismatch between demand and availability of brachytherapy programs across Canada. In light of finite resources, a rational approach to investment in brachytherapy is needed and this must be based on a formal audit of brachytherapy demand and use.

Purpose To describe the outcomes of peer review across all 14 cancer centers in Ontario. Methods and Materials We identified all peer-reviewed, curative treatment plans delivered in Ontario within a 3-month study period from 2013 to 2014 using a provincial cancer treatment database and collected additional data on the peer-review outcomes. Results Considerable variation was found in the proportion of peer-reviewed plans across the centers (average 70.2%, range 40.8%-99.2%). During the study period, 5561 curative plans underwent peer review. Of those, 184 plans (3.3%) had changes recommended. Of the 184 plans, the changes were major (defined as requiring repeat planning or having a major effect on planning or clinical outcomes, or both) in 40.2% and minor in 47.8%. For the remaining 12.0%, data were missing. The proportions of recommended changes varied among disease sites (0.0%-7.0%). The disease sites with the most recommended changes to treatment plans after peer review and with the greatest potential for benefit were the esophagus (7.0%), uterus (6.7%), upper limb (6.3%), cervix and lower limb (both 6.0%), head and neck and bilateral lung (both 5.9%), right supraclavicular lymph nodes (5.7%), rectum (5.3%), and spine (5.0%). Although the heart is an organ at risk in left-sided breast treatment plans, the proportions of recommended changes did not significantly differ between the left breast treatment plans (3.0%, 95% confidence interval 2.0%-4.5%) and right breast treatment plans (2.4%, 95% confidence interval 1.5%-3.8%). The recommended changes were more frequently made when peer review occurred before radiation therapy (3.8%) than during treatment (1.4%-2.8%; P =.0048). The proportion of plans with recommended changes was not significantly associated with patient volume ( P =.23), peer-review performance ( P =.36), or center academic status ( P =.75). Conclusions Peer review of treatment plans directly affects the quality of care by identifying important clinical and planning changes. Provincial strategies are underway to optimize its conduct in radiation oncology.

The aim of this overview was to assess the utility of various imaging technologies (fluoroscopy, ultrasound, computed tomography, magnetic resonance imaging and positron emission tomography) for the treatment planning of high dose rate brachytherapy for cervical cancer. Reviews and primary studies comparing different imaging technologies used during high dose rate brachytherapy for cervical cancer and published from 1988 to 2008 were sought by searching MEDLINE and EMBASE databases, the Cochrane Library, personal files and reference lists of identified studies, and by contacting experts. Study selection, study quality assessment and data extraction were carried out in duplicate. Twelve studies met the inclusion criteria. No systematic reviews or randomised controlled studies (RCTs) were located. The validity assessment revealed that the quality of the existing studies is very variable. This is the first systematic review in the area of imaging technologies for cervix brachytherapy. No RCTs have been located and it is possible that an RCT is not the optimal methodology to assess imaging technologies. However, in this area there is a need for more prospective studies and for studies that consider the expertise of the operators in their design. The studies found supported the use of three-dimensional imaging as opposed to the traditional two-dimensional imaging. However, apart from the effectiveness of visualising tumours and surrounding tissues, the utility of imaging technologies in clinical practice is determined by other contextual factors, such as their availability, accessibility and ease of use.

Aims Brachytherapy is a standard therapy for cervical cancer; it allows for the delivery of a high dose of radiation to the tumour while sparing the surrounding healthy tissues. With this document, the Brachytherapy Cervical Cancer Expert Working Group (BCCEWG) aimed to provide advice on organisational and technical aspects of the delivery of brachytherapy services in Ontario, Canada. Materials and methods We sought technical documents, practice guidelines and standards through an environmental scan of internet resources, an iterative search of the literature on MEDLINE and EMBASE, and a search of reference lists of included documents. Results We identified 20 guidance documents authored by 10 organisations; 11 documents were identified through the environmental scan, five through the literature search and four from reference lists. The recommendations included in this document were developed by the BCCEWG through the selection and review of the evidence and informal consensus. Conclusions These organisational recommendations aim to set the stage for high-quality delivery of brachytherapy for cervical cancer services in the province of Ontario, Canada. They address the characteristics of the practice setting, including facilities, equipment, delivery suite, imaging technologies, treatment planning and dosimetry; the practice team, including team members, roles, training, team caseload/volumes and qualifications; and the quality assurance domain, including documentation, audit, safety and quality control.