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Prospective Plan of Care ("Peer") Review (PPCR) has been shown to catch major issues such as changes to target volumes, organs-at-risk (OAR) contours, the prescription, and overall treatment appropriateness (PMID: 36706911). Typically, when PPCR is employed, radiotherapy planning is held until the review is complete which can result in lengthened time-to-treatment (TTT). In effort to minimize the TTT for those undergoing PPCR we developed a PPCR process that does not hold treatment planning unless a major change is identified. We review our overall PPCR experience of over 5 years. A weekly online departmental PPCR meeting was developed whereby a selection of definitive cases were chosen at random or submitted for review from across our Department of Radiation Oncology comprised of 32 physicians across various locations. Head and neck (H&N), stereotactic body radiation therapy (SBRT), and brachytherapy (brachy) PPCR became separate online meetings over time due to the level of expertise needed. An offline (independent) PPCR review option was also developed to reduce meeting time constraints. From 7/2018 to 12/2023, 1670 definitive cases across a wide variety of diagnoses were prospectively reviewed at our weekly meeting. In addition to general appropriateness of treatment, cases were evaluated with respect to simulation, target volumes, OAR, and prescription (dose and fractionation). Consensus outcomes were recorded as either "agreed", "minor suggestion" or "major suggestion" for each evaluation. When accounting for the cases reviewed through all of our prospective PPCR processes (i.e. offline, H&N, SBRT, brachy PPCR) 2813 total cases were reviewed in 2023 alone, representing 30% of our departmental cases. Table 1 shows the rate of minor and major changes recorded during our weekly PPCR meeting. When looking specifically at offline PPCR, we note a 17% "major" change for targets and 6% "major" change for prescription. In 2023 TTT (the interval from simulation to chart check) for all IMRT and SBRT cases through our department was 7.2 and 8.2 business days, respectively. PPCR continues to evolve at our institution. Offline PPCR may lead to an increased rate of "major" change outcomes perhaps due to its one-on-one nature (no group consensus) or perhaps these cases are inherently challenging or complex prompting colleagues to seek peer review before proceeding with treatment. We feel it valuable to continue weekly online and offline PPCR and are also in the process of creating disease specific PPCR or "office hours" in efforts to continue to have group consensus and solidify practice patterns within our department. Parallel PPCR is feasible, allowing for case review in 30% or more without a detrimental impact on departmental TTT metrics. [ABSTRACT FROM AUTHOR]

Prophylactic cranial irradiation (PCI) remains the standard of care for most limited stage small cell lung cancer (LS-SCLC) patients that respond well to chemoradiation (CRT). Early trials demonstrated efficacy with this approach but is unclear if results are transferable to the modern era where magnetic resonance imaging (MRI) and positron emission tomography (PET) are readily available. This retrospective review included all patients with LS-SCLC treated at a single institution from 2013-2023 with definitive CRT followed by omission of PCI. Patients with extensive stage disease, inadequate baseline systemic/intracranial staging, or progression within the first 3 months following treatment completion were excluded. All patients had biopsy confirmed SCLC, received at least 3 cycles of chemotherapy, and received definitive intent RT. Intracranial recurrence free survival (IRFS) was defined as time until development of brain metastasis on imaging (CT or MRI) or symptomatic intracranial progression. Overall survival (OS) and extracranial recurrence free survival (ERFS) were also recorded. Kaplan-Meier method was used for survival analysis. Fifty-four patients with a median age of 71 (range, 50 – 91) and median baseline KPS of 90 (range, 60 – 100) met inclusion criteria. Median follow up was 12.9 months (IQR, 8.1 – 36.9). All patients underwent baseline intracranial staging with MRI (87%) or CT with contrast (13%) and 98% of patients received PET for systemic staging. Most patients had stage III disease (74%) although stage I (7%) and stage II (19%) were also represented. Six patients (11%) had node negative disease and 4 of those patients (7%) underwent SBRT followed by adjuvant chemotherapy. All other patients underwent definitive concurrent (85%) or sequential (8%) CRT. Patients completed a median 4 cycles (range, 3-6) of platinum-based chemotherapy. Multiple thoracic radiation fractionations were prescribed with 40 Gy/15 fx (44%) as the most common regimen. PCI was omitted primarily due to patient preference (87%) or poor performance status (7%). Intracranial recurrence occurred in 18 patients overall (33%) with 1-year and 2-year intracranial RFS of 65.5% and 62.3% respectively. Among intracranial recurrences, 50% presented as a single lesion and 89% underwent salvage therapy. Extracranial recurrence occurred in 21 patients overall (39%) with 1 and 2-year extracranial RFS of 62.2% and 55.9%, respectively. First recurrence was predominately intracranial (45%) and 13% of patients had simultaneous intracranial/extracranial recurrence. OS at 1, 2, and 3 years was 74.5%, 45.9% and 40.5%, respectively. Although intracranial failure remains high in this modern cohort, the present study demonstrates comparable intracranial failure rates to PCI arm of historic Auperin et al. meta-analysis (~35% at 2 years), further randomized prospective data is warranted. [ABSTRACT FROM AUTHOR]

Relates the experiences of a rural practitioner in a teaching hospital in London, England. Importance of educating the student into the aspect of family practice; Differentiation between medicine and horticulture; Issue on the attendance allowance scheme.