The American College of Radiology (ACR), Quality Research in Radiation Oncology (QRRO) has surveyed US radiation facilities to evaluate the quality of breast cancer treatment in 2007. This report describes sociodemographic (SOC) factors that affect work-up and treatment of breast cancer patients. QRRO used a two-staged stratified random sample to perform a national survey of the treatment of operable breast cancer in 2007: this yielded 442 cases from 45 randomly selected institutions. Eligibility for surveyed cases: receipt of radiation therapy (RT) in 2007 for operable invasive breast cancer (stages I to IIIA) treated with breast conservative surgery (BCS) or mastectomy (M). Exclusions were bilateral disease, prior malignancy or prior RT. SOC variables based on data from the 2000 U.S. census were investigated. These include patients living in urban vs. rural settings (U/R), median household income (HI), percent female unemployed (U) and percent female college educated (CE). U/R had three categories - 100% urban, 100% rural or any urban/rural mix. The other three variables were defined as above or below the medians for this sample. Patients were linked to census data values based on their home ZIP code. Eleven patients could not be linked and were excluded from the analysis. National estimates were based on weighted averages. Of the 431 cases, 69.5% were T1, 20.8% T2, 3.3% T3 and 6.4% unknown, 71.6% node negative/IHC positive only, 28.3% node positive. Median age was 60 years. Surgical treatment was 84.4% BCS and 15.6% M; 80.5% had sentinel lymph node biopsy (SLNB). Of those undergoing M, 16.3% had reconstruction. Accelerated partial breast irradiation (APBI) was done in 5.8%, whole breast RT in 78.1%, post-mastectomy RT in 15.6%. MRI was used in workup in 22.1% of cases. There was no difference in pathologic stage, age, use of systemic therapy, IMRT, or CT based treatment planning across the SOC variables. Patients in areas with higher median income (30.6% vs. 15.0% p = 0.01), urban centers (28.3% vs. 11.2% rural, 21.0% U/R mixed, p = 0.02) and college educated (28.7% vs. 16.4%, p = 0.02) were more likely to undergo breast MRI. Patients living in lower HI areas were more likely to get APBI (11.9% vs. 4.4%, p = 0.02). Of those in rural areas, 19.2% got APBI versus 8.2% for U/R mix and 5.2% for urban settings (p = 0.21). Patients living in areas with more CE had SLNB 84.7% compared to 76.8% in areas with less CE (p < 0.1). Of the SOC factors evaluated in this QRRO survey population, median household income was the most predictive for association with MRI use and APBI. Variability in utilization of newer technologies in the management of breast cancer as they relate to SOC factors requires confirmation and deserves further investigation.

To demonstrate how the American College of Radiology, Quality Research in Radiation Oncology (QRRO) process survey database can serve as an evidence base for assessing quality of care in radiation oncology. QRRO has drawn a stratified random sample of radiation oncology facilities in the USA and invited those facilities to participate in a Process Survey. Information from a prior QRRO Facilities Survey has been used along with data collected under the current National Process Survey to calculate national averages and make statistically valid inferences for national process measures for selected cancers in which radiation therapy plays a major role. These measures affect outcomes important to patients and providers and measure quality of care. QRRO's survey data provides national benchmark data for numerous quality indicators. The Process Survey is “fully qualified” as a Practice Quality Improvement project by the American Board of Radiology under its Maintenance of Certification requirements for radiation oncology and radiation physics.

209 Background: The WICaRE Program is a part of the cross sectional Patterns of Care Study–Breast and Prostate (PoC-BP) that sought to evaluate the patterns of BC care in the state WI and to identify areas for potential improvement in data collection and factors associated with variation in care. This study was to examine the geographic disparities in SM and the use of RT in female BC patients diagnosed in WI in 2004. Methods: The Wisconsin Cancer Reporting System (WCRS) receives reports from 130+ facilities. Information of patient (disease status, sociodemographic, treatment, county of residence) was obtained from cancer registries and supplemental data was reabstracted from medical charts across 66 counties. Geographic regions were counties grouped by WI Dept. of Health Services (DHS) as Northeastern (NE), Northern (N), Southeastern (SE), Southern (S), Western (W). Results: A total of 1037 cases were reported. 25% age 20-49, 49% age 50-69, and 28% age 70+; Caucasian had 82%, black 10% and others 8%. 34% had T1 stage, 9% T2, 4% T3+, and 53% TX-T0/unknown stage. 46% had reported mild comorbidity, 9% had moderate or severe comorbidity. Majority (73%) lived in the Metropolitan Statistical Area (MSA). 29% patients from NE region, 10% from N, 36% SE, 17% S and 8% W. Patients in the S and W had significantly lower % who received RT (46 and 48% respectively) than those in NE (61%), N (62%) and SE (63%), p=0.01; % mastectomy (MA) by regions were 43% (NE), 42% (N), 33% (SE), 47% (S) and 35% (W), p=0.009. Multivariate models adjusting for disease status, comorbidity, and sociodemographic factors showed that patients in MSA region were more likely to have RT compared to those in non-MSA (odds ratio, OR=1.66, 95%CI=1.14-2.40), but those in S were less likely than those in SE (OR=0.59, 95%CI=0.38-0.91). Patients in MSA had a decreased likelihood of undergoing mastectomy. NE (OR=1.6, 95%CI=1.08-2.29) and S (OR= 2.04, 95%CI=1.31-3.17) had significantly higher odds of having MA than those in SE. Conclusions: This study showed evidence of geographic disparity in medical care for BC patients in Wisconsin. Identifying factors mediating this disparity will help in developing appropriate treatment options and improving outcomes.

77 Background: The specific aim of the ACR QRRO survey was to determine the national patterns of radiotherapy (RT) practice in patients (pts) treated for stage IB–IV (non-metastatic) gastric cancer (GC). Methods: A National Process Survey was conducted from randomly selected U.S. RT facilities to assess demographics, staging, geographic region, practice setting, and treatment through retrospective on-site record review of eligible GC cases treated from 2005-2007. Three clinical performance measures (CPMs): 1) use of CT-based treatment planning; 2) use of dose volume histograms (DVHs) to evaluate RT dose to the kidneys and liver; 3) completion of RT within the prescribed time frame were assessed. Three emerging quality indicators: 1) use of intensity modulated RT (IMRT); 2) use of image-guided tools (IGRT), other than CT, for RT target delineation; 3) use of preop RT were also assessed. Results: CPMs were computed on data collected through Aug, 2010 for 250 eligible pts at 45 institutions. Median age was 62 years; 66% male; 60% Caucasian. 13% were AJCC 2002 stage I, 29% II, 32% IIIA, 10% IIIB and 12% IV. Most pts (43%) were treated at academic centers with 32% at large non-academic centers and 25% medium-small facilities. Almost all (99.5%) pts underwent CT-based planning and 75% had DVHs to evaluate normal tissue doses to the kidneys and liver. 70% completed RT within the prescribed time frame. IMRT and IGRT were used in 22% and 17% of pts, respectively. IGRT techniques included: PET (n = 20), MRI (n = 1), respiratory gating and/or 4D-CT (n = 22) and on-board imaging (n = 10). 19% of pts received preop RT. Conclusions: Preliminary findings from QRRO's analysis of radiation practice patterns for non-metastatic gastric cancer indicate widespread adoption of CT-based planning with the use of DVHs to evaluate normal tissue doses. Moreover, most pts completed adjuvant RT in the prescribed time frame. Emerging RT techniques such as IMRT and IGRT were not routinely incorporated into clinical practice during the evaluated time period. These data will serve as a benchmark for future QRRO gastric cancer surveys. No significant financial relationships to disclose.

The American College of Radiology, Quality Research in Radiation Oncology, surveyed US radiation facilities to evaluate the quality of breast cancer care in 2007 and associated factors. This report describes the association of the prevalence of co-morbidities with treatment delivered and outcomes. A two stage stratified random sampling resulted in 442 surveyed cases from 42 randomly selected institutions. Eligibility was receipt of radiotherapy in 2007 for operable Stage I, II, or IIIA breast cancer. Severity of individual co-morbidity ailments and overall level of co-morbidity were scored by trained abstractors using the Adult Co-morbidity Evaluation-27 form, a validated chart based instrument with 12 system scales and one overall scale used with cancer patients. Of the 442 cases, 41% had no co-morbidities and 40.5% had only a grade 1 ailment. This is comparable to the prevalence and severity of co-morbidities seen in a large hospital based registry study of cancer patients (18.8% vs.17.9% moderate-severe overall comorbidity in breast cancer patients, JAMA 2004;291:2441). Only 17 (3.8%) were documented to have treatment plans contra-indicated or changed due to co-morbidities. For these 17, cardiovascular co-morbidity and obesity (BMI > 38) were the most frequently noted moderate or severe co-morbidities. When stratified by stage, rates of breast conservation, sentinel node biopsy, axillary node dissection and receipt of chemotherapy were similar regardless of presence or severity of co-morbidities. For the 72 patients who had mastectomy, reconstruction rates were also similar across the range of co-morbidity scores. Use of partial breast irradiation vs. whole breast radiation in Stage I patients was similar regardless of co-morbidity score. Among patients who had documentation of dose volume histograms, DVH, (80%), specific inclusion of the heart or lung did not differ by presence or severity of cardiovascular or respiratory co-morbidities, respectively, although most patients had lung DVHs (75% of all pts) and only 2 had grade 2 - 3 respiratory morbidity. For the 41 N2+ patients, inclusion of internal mammy nodes in the radiation fields did not differ by presence or severity of cardiovascular, respiratory or overall co-morbidity scores. Patients with a BMI of > 38 had a higher rate of any desquamation (77% vs. 55%, p = .02) and of moist desquamation (38.7% vs. 20.4%, p = .02). The rates of desquamation were no different by presence or severity of rheumatologic ailments. Prevalence of meaningful co-morbidity is low in this population and there is little association between co-morbidity status and treatment delivery.

Radiation oncology practice for gastrointestinal (GI) malignancies has been evolving over the last decade due to rapid clinical adoption of sophisticated new technology for radiotherapy (RT) planning and delivery. The ACR Quality Research in Radiation Oncology (QRRO), aims to evaluate the quality of care of the radiation oncology community through process surveys to track distribution and utilization of advanced RT technology with the goal of assessing the appropriate use of these emerging technologies. A National Process Survey was developed to assess demographics, staging, geographic region, practice setting, insurance status, treatment, and outcome of patients (pts) treated for gastric cancer. QRRO is performing a two-stage stratified random sample of radiation oncology facilities nationwide (first stage) and eligible cases within those facilities from 2005-07 (second stage). ACR clinical data abstractors collected facility and process survey data through retrospective on-site pt record review. The GI committee defined three emerging clinical performance measures (CPM) to assess utilization of advanced RT technology based on best available evidence and expert consensus: 1) use of CT-based simulation and treatment planning; 2) use of dose volume histograms (DVHs) to evaluate normal tissue doses to the kidneys, liver, and spinal cord, and 3) use of image-guided tools, other than CT scans, for RT target delineation. CPMs were computed on all data collected through Feb. 2010 for 223 eligible pts treated for gastric cancer at 42 institutions. Almost all (99.5%) pts with Stage IB - IV (non-metastatic) gastric cancer who received adjuvant chemoradiation underwent CT-based simulation and treatment planning. Planning included the generation of DVHs to evaluate normal tissue doses to the kidneys and liver in 74.6% of pts undergoing adjuvant chemoradiation. Of note, 37 (17.0%) of pts were treated using RT target delineation or treatment delivery aided by image-guided tools, other than CT scans. Techniques included: PET (n = 20), MRI (n = 1), respiratory gating and/or 4D-CT (n = 15) and on-board imaging (n = 10). Preliminary findings from the QRRO emerging CPMs indicate widespread adoption of CT-based planning and use of DVH's to evaluate normal tissue doses and to limit the doses to surrounding structures based on the known radiation tolerance of these organs. Other image-guided techniques were not routinely incorporated into clinical radiation oncology practice during the 2005-07 time period. These data will serve as a benchmark for future QRRO surveys of emerging technologies.

The American College of Radiology (ACR), Quality Research in Radiation Oncology (QRRO) has surveyed US radiation facilities to evaluate the quality of breast cancer treatment in 2007 and to document integration of newer radiation methods since its last survey in 1999. QRRO used a two-staged stratified random sample to perform a national survey of the treatment of operable breast cancer patients in 2007: this yielded 412 cases from 42 randomly selected institutions. Eligibility for surveyed cases: receipt of radiotherapy in 2007 for operable invasive breast cancer (stages I, II, or IIIA) treated with breast conservative surgery (CS) or mastectomy (M). of the 412 cases 52% were pathologically stage I, 25% Stage IIA, 9% Stage IIB, and 12%, Stage IIIA. Surgical treatment was CS in most (84%) and M for 16%. Sentinel node biopsy was performed for 72.6%, axillary node dissection (AND) in 46%. One hundred twenty patients had positive axillary (AX) nodes. Nodal status was N0 in 62%, N0 IHC+ 8.5%, N-1 mic 4%, N-1 16%, N-2 9.3%. Radiation (RT) delivered was partial breast irradiation (PBI) in 4.8%, whole breast alone 68%, whole breast and nodes 10.7%, and postmastectomy 16.0%. of those receiving nodal RT (102) the areas treated were SCL and AX apex in 84.3%, SCL and full AX 13.7%, separate AX field 29.4%, and IMN 26.5%. Treatment planning was based on CT scan for 97%. After CS, isodose planning method was central plane 1.5%, multiple axial planes 2.1%, 3DCRT 79.2%, IMRT 16%; and after M, central plane 0%, multiple axial planes 7.5%, 3DCRT 82%, IMRT 10.5%. Following CS, contoured CT volumes were present for lumpectomy CTV/PTV for 96%, Breast 92%, Lung 94%, and Heart 59.6%; with DVH being present for lumpectomy in 70%, breast 20%, lung 78% and heart 51%. Following M, CT volumes were present for chestwall 95%, Lung 95.5%, and Heart 63.6% ; with DVH present for chestwall in 21%, Lung 79% and Heart 48.5%. MLC was the most common form of beam modifiers used followed by physical (30%) then dynamic wedges (19%). For the 27 PBI cases, 10 were brachytherapy, 7 -3DCRT; 100% had a CT based plan and 78% a DVH present. Skin toxicity was assessed in weekly notes for 89%, dry desquamation documented for 38%, moist 13%, and breast pain for 40%. The rate for any desquamation for 3DCRT methods was 52%, IMRT 52%, and all other 71% (p = 0.125). ACR QRRO documents dramatic change in the technical delivery of RT for breast cancer as of 2007 compared to its prior survey in 1999, when CT planning was used < 25% and conformal methods were uncommon. 3DCRT/IMRT methods are now predominant, contoured CT volumes typically present, yet less documentation of DVH for plan analysis. Further survey details about breast cancer RT in 2007 and how it varied by facility type will be presented.

To demonstrate the feasibility of measuring quality indicators (QIs) in radiation oncology (rad onc) for NSCLC from the Quality Research in Radiation Oncology (QRRO) national patterns of care database with the objective of estimating national benchmarks. The QRRO survey database is a valuable resource for estimating national benchmarks of established and emerging QIs. The study design is a two-stage stratified sample of rad onc practices. Few surveys have documented the practice of oncology in such detail that fine adjustments can be made to account for conditions that might influence treatment decisions. For example, the National Comprehensive Cancer Network (NCCN) guidelines for Stage III NSCLC recommend a radiation therapy (RT) daily total dose of up to 74 Gy in a concurrent chemoradiation setting. However, some conditions will mediate total dose delivered e.g., if RT is stopped early due to complications, non-compliance or death, or if treatment includes surgery or for an IRB-approved protocol. Data from the 1999 survey of NSCLC were used to demonstrate that adjustments at this level of detail can be made. We also evaluated an emerging QI derived from NCCN regarding the roles of PET (or bone) scan and brain CT/MRI in the recommend evaluation of patients receiving combined modality therapy for Stage III NSCLC. Data for NSCLC patients with no distant metastases or pleural effusion treated in 1998–1999 were analyzed. Of the 180 patients with Stage III NSCLC, 132 patients received concurrent chemoradiation, of which 57 patients were excluded for conditions that might mitigate total dose as described above. Analysis showed that 87% of the patients received a total dose in the recommended range, of 59–74 Gy (median dose of 63 Gy). Of note, recommended brain MRI/CT and PET or Bone scans were performed in only 42% of the patients. We demonstrated that QIs can be estimated from the QRRO survey database. While the vast majority of patients received the recommended dose of RT with concurrent chemo, the recommended staging was only performed in 42% of Stage III NSCLC patients, suggesting a need for further improvement and education. Sub-group analyses can be performed if estimates of QIs are expected to vary e.g., university facilities vs. private practices. The 2007 survey (in progress) is explicitly designed to further evaluate the quality of care. It will also permit the assessment emerging QIs such as CT-based simulation and documented DVH constraints. We expect to validate current and emerging QIs for rad onc in the current survey.

To assess a national patterns of care survey database as an evidence base for measuring quality indicators (QI) in radiation oncology. QI for prostate cancer workup and treatment were developed based on widely accepted research findings and guidelines, such as those of the National Comprehensive Cancer Network (NCCN). Data in the Patterns of Care Study (PCS) database for patients treated in 1999 were analyzed to benchmark QI. The national survey used a two-stage stratified sample of radiation oncology practices and their patients that allowed calculation of national averages of defined measures. Chart reviews of medical and radiation therapy records of patients diagnosed with adenocarcinoma of the prostate with no distant metastases or histologically proven positive paraaortic nodes who started radiation treatment during 1999 provided the data. Cases had no prior or concurrent malignancies and no previous hormone, chemotherapy, or radiation therapy as primary treatment. Following the NCCN guidelines cases were assigned to appropriate groups to measure compliance with QI. Compliance results for QI derived from NCCN guidelines for workup are: digital rectal exam (DRE) done (90%), PSA done (99%), Gleason score done (99%), bone scan performed in recommended patient group (83%), CT or MRI done in recommended patient group (58%). CT or MRI done in recommended patient group varied with method of payment, for private insurance (84%), for Medicare/VA/Champus (49%), for Medicaid/unknown/self pay (20%). QI for initial therapy for patients treated with radiotherapy showed beam energies >10MV used (73%); doses ≥72 Gy used in favorable risk (43%), intermediate risk (38%), and unfavorable risk (60%) patients; androgen deprivation therapy used in unfavorable risk patients (79%); implant as monotherapy in favorable risk (79%). Benchmarking utilization provides a foundation for assessing QI, and this database is a potentially rich source that can be used to validate these measures. In addition to providing evidence on the usefulness of specific proposed QI and identifying areas of practice needing improvement, it provides data on potential future evidence-based QI. As policy makers implement pay for performance (P4P) programs, finding data sources to benchmark QI is important. The required level of detail exceeds most current administrative data, while clinical trials provide data only for a limited set of specific and usually experimental treatments. Well designed surveys can provide a data source with sufficient detail for a broad range of QI, especially if surveys are planned to meet QI needs. They can also help define additional data requirements to allow use of administrative data to implement P4P programs.

PURPOSE:A Patterns of Care Study of patients treated from 1996 to 1999 evaluated the national practice for patients receiving radiation therapy for carcinoma of the esophagus in the United States.METHODS:A national survey was conducted at 59 institutions in a stratified random sample selected from a master list of radiation therapy facilities throughout the United States. Patient, tumor, and treatment characteristics were evaluated. Multivariate comparisons of survival times were made using the Cox proportional hazards model.RESULTS:Adenocarcinoma was diagnosed in 51% of patients and squamous cell carcinoma in 49% of patients. Sixteen percent of patients were clinical stage (CS) I (using the 1983 American Joint Committee on Cancer system), 39% were CS II, and 33% were CS III. Significant variables in the multivariate analysis of survival times included clinical stage, treatment approach, and facility size. Patients with CS III disease had a higher hazard risk of death as compared with CS I patients (hazard ratio [HR], 2.01; P = .001), whereas those treated with chemoradiotherapy followed by surgery (HR, 0.32; P < .0001) had a decreased risk of death compared with chemoradiotherapy-only patients. Patients at small centers had a higher risk of death (HR, 1.32; P = .03) compared with patients treated at larger facilities.CONCLUSION:Concurrent chemoradiotherapy continued to be the most commonly utilized treatment approach during the time period studied. The observation that patients undergoing surgical resection following chemoradiation have a decreased HR or chance of death compared with other treatment schemes supports the need for a randomized trial comparing these strategies.

BACKGROUND. Quality assurance (QA) of clinical practice is important for any medical specialty. Programs based on the Patterns of Care Study (PCS) have been developed to compare the quality of radiotherapeutic care at individual institutions, with the national average representing the process and outcome of radiotherapy. The feasibility of these programs was analyzed.METHODS. Calculation programs for the national average and standard score were developed to evaluate quantitatively the process and outcome of radiotherapy at individual institutions as well as at the national level. The programs were used to evaluate the quality of radiotherapy for 561 esophageal carcinoma patients surveyed in the Japanese PCS.RESULTS. As a representative example of QA measurement, the national average for the 5-year survival rate for these patients in the nonsurgery group was 5%. The regional averages for those in academic and nonacademic institutions were 9% and 1%, respectively (P = 0.0142), showing a significant difference between these two institutional strata. The standard score compared with the national average for institution No.105, for example, was 16.3 (P < 0.0001), with the positive value indicating that the outcome at this institution was significantly higher than the national average. The corresponding figure compared with the regional average was -0.3 (P = 0.7391), with the negative value indicating the outcome is not superior to the regional average of academic institutions.CONCLUSIONS. These programs make it possible to compare quantitatively the quality of radiation therapy at individual institutions with the national and regional averages. They should also be useful for nationwide QA projects in radiation oncology as well as in other medical specialities. (C) 2002 American Cancer Society.

PURPOSE:To (1) measure radiation therapy costs for patients in randomized controlled clinical trials, (2) compare measured costs to modeling predictions, (3) examine cost distributions, and (4) assess feasibility of collecting economic data within a cooperative group. METHODS:The Radiation Therapy Oncology Group conducted economic pilot studies for two Phase III studies that compared fractionation patterns. Expected quantities of Current Procedural Terminology (CPT) codes and relative value units (RVU) were modeled. Institutions retrospectively provided procedure codes, quantities, and components, which were converted to RVUs used for Medicare payments. Cases were included if the radiation therapy quality control review judged them to have been treated per protocol or with minor variation. Cases were excluded if economic quality review found incomplete economic data. RESULTS:The median and mean RVUs were within the range predicted by the model for all arms of one study and above the predicted range for the other study. CONCLUSION:The model predicted resource use well for patients who completed treatment per protocol. Actual economic data can be collected for critical cost items. Some institutions experienced difficulty collecting retrospective data, and prospective collection of data is likely to allow wider participation in future Radiation Therapy Oncology Group economic studies.

PURPOSE:A Patterns of Care Study examined the records of patients with esophageal cancer (EC) treated with radiation in 1992 through 1994 to determine the national practice processes of care and outcomes and to compare the results with those of clinical trials.PATIENTS AND METHODS:A national survey of 63 institutions was conducted using two-stage cluster sampling, and specific information was collected on 400 patients with squamous cell (62%) or adenocarcinoma (37%) of the thoracic esophagus who received radiation therapy (RT) as part of primary or adjuvant treatment. Patients were staged according to a modified 1983 American Joint Committee on Cancer staging system. Fifteen percent of patients had clinical stage (CS) I disease, 40% had CS II disease, and 30% had CS III disease. Twenty-six percent of patients underwent esophagectomy. Seventy-five percent of patients received chemotherapy; 84% of these received concurrent chemotherapy and radiation (CRT).RESULTS:Significant variables for overall survival in multivariate analysis include the use of esophagectomy (risk ratio [RR] = 0.62), the use of chemotherapy (RR = 0.63), Karnofsky performance status (KPS) greater than 80 (RR = 0.61), CS I or II disease (RR = 0.66), and facility type (RR = 0.72). Age, sex, and histology were not significant. Preoperative CRT resulted in a nonsignificantly higher 2-year survival rate compared with definitive CRT alone (63% v 39%; P =.11), whereas 2-year survival by planned treatment rather than treatment given was 47.7% for preoperative CRT and 35.4% for definitive CRT (P =.23). Definitive CRT compared with definitive RT alone resulted in significantly higher 2-year survival (39% v 20.6%; P =.027) and lower 2-year local regional failure (30% v 57.9%; P =. 0031).CONCLUSION:This study confirms the value of CRT in EC treatment. It indicates that the results obtained in practice settings nationwide are similar to those obtained in clinical trials and that KPS and the 1983 clinical staging system are useful prognostic indicators. The suggested value of esophagectomy and superiority of preoperative CRT over CRT alone in this study should be tested in a randomized trial.

Background: The Patterns of Care Study (PCS) was imported to Japan from the United States in July 1996, A preliminary outcome analysis of the PCS for esophageal cancer patients in Japan was made with special reference to age, because the elderly population is rapidly increasing in Japan,Patients and Methods: From July 1996 to February 1998, external PCS audits were performed for 37 institutions nationwide and detailed information of 561 esophageal cancer patients treated during the period 1992-1994 was collected by using the fifth PCS data format developed in the United States. This format was provided courtesy of the American College of Radiology, For this study, patients who had not undergone surgery (n = 336) were selected. The patients were classified into three age groups: < 65 years old (n = 119), between 65 and 74 years (n = 93), and 75 Sears or older (n = 123), Cox's proportional hazards model was used for the statistical analysis, with survival, acute/subacute complication and late complication of grade 3 or more based on RTOG criteria, as the endpoints,Results: Significant prognostic factors for the entire non-surgery group were Karnofsky Performance Status (KPS) (p = 0.0007), stage (p = 0.0001), and external irradiation dose (p = 0.0001). For the younger group, KPS (p = 0.0004), stage (p = 0.0197), and utilization of brachytherapy (p = 0.0010) were significant, while for the intermediate age group it was KPS (p = 0.0027), history of pulmonary disease (p = 0.0339), stage (p = 0.0001), and external dose (p = 0.0001), and for the elderly group, stage (p = 0.0001) and external irradiation dose (p 0.0224) were significant. Significant risk factors for complications for the entire group were stage (p = 0.0411), external dose (p = 0.0163), and stratification of institution (academic vs. nonacademic) (p = 0.0114), Significant risk factors for the younger group were history of pulmonary disease (p = 0.0495) and external dose (p = 0.0037), and the other age groups showed no significant risk factors.Conclusion: Age was not a significant prognostic or risk factor for esophageal cancer patients in the non-surgery group treated with radiation therapy. Therefore, radiation therapy represented an important treatment modality for the elderly as well as for the younger esophageal cancer patients. External dose was a treatment-related prognostic factor for the elderly as well as for the intermediate age group. (C) 2000 Elsevier Science Inc.

Conclusion: MLC and recorded verify systems decrease shielding, wedged and machine set up deviations.New technology introduces new deviations such as data entry.Prospective data collection and monitoring by the Quality Assurance Program at our Centre has resulted in continuous improvement in quality of service, and evaluation of the impact of new technology.

Purpose: To document national standards of care for patients receiving radiotherapy as part of curative treatment for Hodgkin's disease.Materials and Methods: A national survey was conducted of 61 institutions treating 275 patients with Stages I-III Hodgkin's disease and representing six facility type strata. Pretreatment evaluation, radiotherapy treatment parameters, and use of combined modality therapy were assessed.Results: Ann Arbor stage for the 275 patients was as follows: IA, 69 (25%); IB, 7 (3%); IIA, 123 (45%); IIB, 36 (13%); IIIA 23 (8%), IIIB, 14 (5%); unknown, 3 (1%). Pretreatment evaluation included complete blood count for 93%, sedimentation rate in 29%, chest CT in 88%, abdominal CT scan in 87%, and bone marrow biopsy in 81%. Lymphangiograms were obtained in 50% of cases; laparotomy was performed in 46%. The yield of positive findings in the spleen at laparotomy was 6.5% overall. Facility differences with respect to staging were seen only for the use of gallium scans, which were more commonly used in academic centers (44% vs. 15-23% elsewhere, p < 0.001). Radiotherapy was delivered with a linear accelerator in 94% of cases. Treatment simulation was performed for 94% and individualized blocks constructed for 95% overall; however, freestanding facilities had a lower rate of performance of these procedures (78% vs. 98-99% for simulation and 88% vs. 96-99% for customized blocking, p < 0.001). The mean supradiaphragmatic dose was 36.74 Gy and the mean subdiaphragmatic dose was 33.81 Gy. Planned combined modality therapy was given in 36% of patients. The use of combined modality therapy by stage was as follows: IA, 11%; IB, 43%; IIA, 30%; IIB, 68%; IIIA, 57%; IIIB, 100%. Chemotherapy was completed prior to radiation in 80% of cases and generally consisted of ABVD (32%), an alternating regimen (25%), or MOPP (22%). Among Stage VII patients, use of chemotherapy was associated with reduced radiation doses (mean supradiaphragmatic dose 34.53 Gy vs. 38.43 Gy and mean subdiaphragmatic dose 31.27 Gy vs. 34.51 Gy), and reduced volumes of treatment (87% vs. 28% treated to one side of the diaphragm only). Laparotomy was not associated with decreased supra- or subdiaphragmatic radiation doses or decreased volumes of treatment.Conclusions: With the exception of gallium scans, pretreatment evaluation is relatively uniform across facility strata. Increased understanding of prognostic factors in Hodgkin's disease and greater use of planned combined modality therapy for higher risk patients appears to have contributed to a decreased use of and low yield of positive findings for laparotomy. Laparotomy was not associated with reduced radiation volumes or doses. Freestanding radiation facilities had a lower rate than other facility types for the performance of treatment simulation and customized patient blocking. (C) 1999 Elsevier Science Inc.

BACKGROUNDA nationwide effort is in progress to establish the actual state of radiotherapy and its quality assurance (QA) in Japan by using the Patterns of Care Study (PCS). In this study, national averages are calculated with a limited number of patients. A calculation program for national averages was prepared and applied to the radiotherapeutic processes used for esophageal cancer patients entered in the PCS.METHODSThe calculation program for national averages, which were revised on the basis of differences between individual facilities and institutional strata, was developed in accordance with Sedransk's equation for the original PCS in the USA. National averages for several aspects concerning the sampled patients who had esophageal cancer between 1992 and 1994 were calculated with these procedures. Data for facilities and stratification of institution were simulated from a national structure survey of radiation oncology in 1990.RESULTSValues of the national average by Sedransk's equation were different from those of the simple sample average. There were significant differences in radiotherapeutic processes among stratification of institutions. For esophageal cancer, national averages were 0.129 for applications of endoscopic ultrasound, 0.599 for 'all fields treated each day' and 0.088 for application of brachytherapy.CONCLUSIONNational averages for radiotherapy could be calculated. The values obtained in this PCS will be a useful measure for future QA in radiation oncology and in other specialties in Japan.