transparency of their reporting.Robustness of this analysis and instrument comparison were examined using the Kendall coefficient of concordance and Inter-Class-Correlation coefficients. ResultsThe systematic review lead to the selection of 15 records matching the search strategy: these were most frequently conducted in Canada (n=4) and France (n=3).Instruments' mean score were evaluated respectively at 59.4%, 69.7% and 73.6% for CHEC, CHEERS and QHES.The overall quality score was fairly good, even an in-depth analysis per criteria reveals that essential costing itemsdiscount rate, time horizon, sensitivity analysis -were only partially completed.Over time, instruments scores rise specifically for QHES.The statistical analysis confirms that raters have scored in a similar manner.In addition, as inter-rater reliability coefficients show that that the reviewers score converged more with CHEC (ICC=0.86***))than for QHES (ICC=0.73***)and CHEERS (ICC=0.64***).

Purpose or ObjectiveEscalating health care costs have led to greater efforts directed at measuring the cost and benefits of medical treatments.The aim of this study was to estimate the cost of radiotherapy (RT) for 5-year overall survival and local control benefits for the Australian cancer population. Material and MethodsWe have previously developed population-based models of optimal, evidence-based RT utilisation, optimal number of fractions per course, and local control and 5year overall survival benefits for all cancers [1][2][3][4].For this study, an activity-based costing methodology was used to allocate costs to all RT activities associated with each patient's treatment course (including external beam and brachytherapy).RT activities, including referrals, bookings, consultations, care coordination, presimulation activities (e.g.mask, seed insertion etc), simulation, planning, treatment (including imageguidance), treatment reviews, and follow-up consultations, were extracted from the local radiotherapy information system for the 2015/16 financial year.Expenses, including all direct and indirect labour, goods and services, repairs and maintenance, and administrative were extracted from the local financial system for the same period and allocated to each activity using an agreed formula that incorporated the inputs and complexity for each activity.A patient journey for the financial year was constructed by consolidating all the RT activities and their associated costs, and the average cost per fraction was determined.The cost of RT per 5-year overall survival and local control was then estimated. ResultsTable 1 shows the results.There was 6.2% of all cancer patients alive at 5 years due to guideline-based use of radiotherapy and 24.8% with local control benefit.The average number of fractions per cancer course if guidelines were followed was 18.6 fractions.The average cost per fraction was AU$316.The average cost was AU$23,700 for each person with local control at 5 years because of radiotherapy and AU$94,800 for each person alive at 5-years as a result of radiotherapy.

To critically appraise the quality of radiotherapy cost studies published between 2004 and 2015. Building upon a recent systematic literature review looking at the provider cost in PubMed Medline, Embase (Defourny, 2016), selected studies were examined in-depth focusing on the study quality. The review was performed by three independent reviewers and restricted to studies using cost data published after the QHES grid became available. Selected studies were critically assessed based on 3 existing instruments: CHEERS, CHEC, and QHES. To compare the instruments (inter-instrument agreement) and the agreement between rater, the Kendall coefficient of concordance was calculated. A further refined examination of the references was conducted, focusing on the guidelines’ items relevant for costing. The selection restricted our analysis to 15 articles to be studied in-depth, out of the 52 studies previously selected. The mean score across all articles were respectively 70%, 81%, 72%, mirroring variation in scope of the articles. Over time, instruments’ scores rise with a higher tendency for QHES. Comparison of the instruments per assessor yielded a significant coefficient of 94%, 84% and 87% while the coefficient per rater was significant at 69%, 81% and 77% for each instruments. The inter-rater analysis yielded 10 percent point variation, meaning that they agreed most in rating articles against CHEC, QHES and lastly CHEERS. While the overall mean score was fairly good (74% [31%-93%]), in-depth examination highlights the omission (in the instruments) of criteria covering the type of cost analysis (mean, incremental or full costing) as well as whether the analysis features were modelled or reality-based; these define methodology transparency. Cost studies’ quality was fairly good while influenced by the instrument more than by the assessor. Existing cost guidance establishes an outline framework while leaving a high degree of freedom in the reporting by the researchers which jeopardize comparability across studies.

BACKGROUND AND PURPOSE:The IAEA has developed a methodology for comprehensive quality audits of radiotherapy practices called Quality Assurance Team for Radiation Oncology (QUATRO). This study explores the factors that impacted quality of care among QUATRO audited centres in the IAEA Europe Region.MATERIALS AND METHODS:The 31 QUATRO reports collected over 10years include extensive data describing the quality of radiotherapy at the audited centres. A coding key was developed to aggregate and review these data in terms of recommendations for improvement and positive findings (commendations).RESULTS:Overall 759 recommendations and 600 commendations were given. Eight centres recognized as centres of competence differed from other centres mostly because they operated complete quality management systems and were adequately staffed. Other centres had excessive staff workloads and many gaps in the process of care. Insufficient equipment levels were prevalent. Patient centredness, communication, dosimetry, quality control and radiation protection were frequently commended by QUATRO.CONCLUSIONS:This analysis points to barriers to quality care such as insufficient staffing, education/training, equipment and lack of quality management. It highlights the correlation between the human resources availability and quality of care. It has also identified common action items for enhancing quality of radiotherapy programmes in the Region.

This SAMs Therapy Educational Course will introduce participants to the tools recommended by TG 100 for use in the development of a risk‐based Quality Management Program. The Course will start with an Overview of the background and rationale behind the TG 100 initiative, from which its charge was developed. After setting the scene, four 15 minute presentations will introduce the principal components of the soon to be published Report of TG 100. These are Process Mapping, Failure Modes and Effects Analysis, Fault Tree Analysis and the development of a QA/QM risk‐based Program. There will be time for two short exercises based on Failure Modes and Effects Analysis and a Discussion before the SAMs questions which will conclude the session. Learning Objectives: To appreciate the underlying philosophy of the TG 100 initiative. To gain a brief overview of the principal risk‐based tools recommended by TG 100. In an informal workshop format, to explore, at an introductory level, the use of risk analysis as proposed by TG 100 as a prelude to the development of a Quality Management Program.

The increasing complexity of modern radiation therapy planning and delivery challenges traditional prescriptive quality management (QM) methods, such as many of those included in guidelines published by organizations such as the AAPM, ASTRO, ACR, ESTRO, and IAEA. These prescriptive guidelines have traditionally focused on monitoring all aspects of the functional performance of radiotherapy (RT) equipment by comparing parameters against tolerances set at strict but achievable values. Many errors that occur in radiation oncology are not due to failures in devices and software; rather they are failures in workflow and process. A systematic understanding of the likelihood and clinical impact of possible failures throughout a course of radiotherapy is needed to direct limit QM resources efficiently to produce maximum safety and quality of patient care. Task Group 100 of the AAPM has taken a broad view of these issues and has developed a framework for designing QM activities, based on estimates of the probability of identified failures and their clinical outcome through the RT planning and delivery process. The Task Group has chosen a specific radiotherapy process required for "intensity modulated radiation therapy (IMRT)" as a case study. The goal of this work is to apply modern risk-based analysis techniques to this complex RT process in order to demonstrate to the RT community that such techniques may help identify more effective and efficient ways to enhance the safety and quality of our treatment processes. The task group generated by consensus an example quality management program strategy for the IMRT process performed at the institution of one of the authors. This report describes the methodology and nomenclature developed, presents the process maps, FMEAs, fault trees, and QM programs developed, and makes suggestions on how this information could be used in the clinic. The development and implementation of risk-assessment techniques will make radiation therapy safer and more efficient.

This Hands‐on Workshop will be focused on providing participants with experience with the principal tools of TG 100 and hence start to build both competence and confidence in the use of risk‐based quality management techniques. The three principal tools forming the basis of TG 100's risk analysis: Process mapping, Failure‐Modes and Effects Analysis and fault‐tree analysis will be introduced with a 5 minute refresher presentation and each presentation will be followed by a 30 minute small group exercise. An exercise on developing QM from the risk analysis follows. During the exercise periods, participants will apply the principles in 2 different clinical scenarios. At the conclusion of each exercise there will be ample time for participants to discuss with each other and the faculty their experience and any challenges encountered. Learning Objectives: To review the principles of Process Mapping, Failure Modes and Effects Analysis and Fault Tree Analysis. To gain familiarity with these three techniques in a small group setting. To share and discuss experiences with the three techniques with faculty and participants.Director, TreatSafely, LLC. Director, Center for the Assessment of Radiological Sciences. Occasional Consultant to the IAEA and Varian.

This SAMs Therapy Educational Course will introduce participants to the tools recommended by TG 100 for use in the development of a risk‐based Quality Management Program. The Course will start with an Overview of the background and rationale behind the TG 100 initiative, from which its charge was developed. After setting the scene, four 15 minute presentations will introduce the principal components of the soon to be published Report of TG 100. These are Process Mapping, Failure Modes and Effects Analysis, Fault Tree Analysis and the development of a QA/QM risk‐based Program. There will be time for two short exercises based on Failure Modes and Effects Analysis and a Discussion before the SAMs questions which will conclude the session. Learning Objectives: To appreciate the underlying philosophy of the TG 100 initiative. To gain a brief overview of the principal risk‐based tools recommended by TG 100. In an informal workshop format, to explore, at an introductory level, the use of risk analysis as proposed by TG 100 as a prelude to the development of a Quality Management Program.

Although economic evidence is becoming mandatory to support health care decision-making, challenges remain in generating high quality cost data, especially for complex and rapidly evolving treatment modalities, such as radiotherapy. The overall aim of this systematic literature review was to critically analyse the type and quality of radiotherapy cost information available in cost calculation studies, from the health care provider’s perspective, published since 1981. A selection process, based on strict and explicit criteria, yielded 52 articles. In spite of meeting our criteria these studies displayed large heterogeneity in scope, costing method, inputs and outputs. The limited use of conventional costing methodologies along with insufficient information on resource inputs hampered comparability across studies. A consistent picture of radiotherapy costs, based on methodologically sound costing studies, has yet to emerge. These results call for developing a well-defined and generally accepted cost methodology for performing economic evaluation studies in radiotherapy.

Material and Methods: AGuIX (Nano-H, Lyon, France) is a gadolinium-based nanoparticle that has been proposed for an upcoming clinical trial. We performed in vitro cell uptake and radiosensitization studies of a pancreatic cancer cell line in preclinical (220kVp) and clinical (6 MV and 6 MV FFF) beams. MRI was used to monitor tumor uptake and biodistribution. Due to their small size (2-3 nm), the GdNP have good renal clearance and long blood circulation (around 20-30 min in mice). In vivo radiation therapy studies were performed to characterize the effect of AGuIX as a radiosensitizer (n=8/cohort). Histology was performed to measure the increase in damage in the tumor and to evaluate the toxicity in healthy tissues.

S251 ______________________________________________________________________________________________________significant improvement in survival.By modeling our preclinical study on current clinic workflows, we show clear compatibility with modern patient care, thus heightening the translational significance.

Purpose: Incident investigation, reporting, and learning are core elements of quality improvement in radiation treatment. This report describes the development of a Canadian National System for Incident Reporting in Radiation Treatment (NSIR-RT), focusing especially on the taxonomy.Methods and materials: The NSIR-RT was developed to provide a framework in Canada for reporting and analyzing radiation treatment incidents. A key objective was to assure compatibility with other international reporting systems to facilitate future information exchange. The Canadian community was engaged at every step of the development process through Delphi consensus building and inter-user agreement testing to promote awareness of the system and motivate broad-based utilization across the country.Results: The final taxonomy was comprised of 6 data groups (impact, discovery, patient, details, treatment delivery, and investigation) and 33 data categories with predefined menu options. There was a high level agreement within the Canadian community about the final suite of data categories, and broad alignment of these categories with the World Health Organization and other American and European radiation treatment incident classifications.Conclusions: The Canadian NSIR-RT taxonomy will be implemented as an online, web-based reporting and analysis system. It is expected that the taxonomy will evolve and mature over time to meet the changing needs of the Canadian radiation treatment community and support radiation treatment incident learning on a global scale. (C) 2016 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved.

Over the last two decades, there has been a concerted effort in North America to organize medical physicists’ clinical training programs along more structured and formal lines. This effort has been prompted by the Commission on Accreditation of Medical Physics Education Programs (CAMPEP) which has now accredited about 90 residency programs. Initially the accreditation focused on standardized and higher quality clinical physics training; the development of rounded professionals who can function at a high level in a multidisciplinary environment was recognized as a priority of a radiation oncology physics residency only lately. In this report, we identify and discuss the implementation of, and the essential components of, a radiation oncology physics residency designed to produce knowledgeable and effective clinical physicists for today's safety‐conscious and collaborative work environment. Our approach is that of inverse planning, by now familiar to all radiation oncology physicists, in which objectives and constraints are identified prior to the design of the program. Our inverse planning objectives not only include those associated with traditional residencies (i.e., clinical physics knowledge and critical clinical skills), but also encompass those other attributes essential for success in a modern radiation therapy clinic. These attributes include formal training in management skills and leadership, teaching and communication skills, and knowledge of error management techniques and patient safety. The constraints in our optimization exercise are associated with the limited duration of a residency and the training resources available. Without compromising the knowledge and skills needed for clinical tasks, we have successfully applied the model to the University of Calgary's two‐year residency program. The program requires 3840 hours of overall commitment from the trainee, of which 7%–10% is spent in obtaining formal training in nontechnical “soft skills”. PACS number(s): 01.40 Di, 01.40.gb, 87.10‐e

Background and purpose The absolute number of new cancer patients that will require at least one course of radiotherapy in each country of Europe was estimated. Material and methods The incidence and relative frequency of cancer types from the year 2012 European Cancer Observatory estimates were used in combination with the population-based stage at diagnosis from five cancer registries. These data were applied to the decision trees of the evidence-based indications to calculate the Optimal Utilization Proportion (OUP) by tumour site. Results In the minimum scenario, the OUP ranged from 47.0% in the Russian Federation to 53.2% in Belgium with no clear geographical pattern of the variability among countries. The impact of stage at diagnosis on the OUP by country was rather limited. Within the 24 countries where data on actual use of radiotherapy were available, a gap between optimal and actual use has been observed in most of the countries. Conclusions The actual utilization of radiotherapy is significantly lower than the optimal use predicted from the evidence based estimates in the literature. This discrepancy poses a major challenge for policy makers when planning the resources at the national level to improve the provision in European countries.

To critically analyse radiotherapy cost studies published over the last 35 years. We conducted a comprehensive and systematic review of the literature searching for radiotherapy cost calculation studies on PubMed (Medline) and Embase databases and in the grey literature. The searches yielded 1327 unique entries that were evaluated against the following selection criteria: actual medical cost, external beam radiotherapy (EBRT), clear description of the cost calculation method. The review for compliance with the criteria was conducted in three phases: title; abstract and then full manuscript. Since 1981, 50 studies satisfied our selection criteria. Any perspective, e.g. societal, institutional, was considered acceptable as long as the institutional resources ‘cost of radiotherapy was presented. Cost assessments of EBRT were conducted within a full economic evaluation framework (5 studies: 2 CEA, 2 CUA, and 1 CBA), cost analysis (24), cost description (18) and investment analysis (3). The scope of the selected studies ranged from comprehensive medical cost of radiotherapy including the department’s overhead (20), to average cost specific to one pathology and/or treatment modality (25) to task-specific costs (7) e.g. shielding. Costs were computed per fraction and/or field (20), per treatment and/or patient (27) and specific to a treatment’s process step (3). Costing methodologies ranged from detailed micro costing (13) to activity-based costing (5) to time-driven activity-based costing (2). Besides these established accounting methods, numerous “home-made” approaches were observed (23) and some studies didn’t state their method (7). Due to heterogeneity both in methodology, input factors and paucity in costing method’s reporting, it was not possible to compare the cost estimates provided by these various studies. This comprehensive literature review of radiotherapy cost studies highlights the need for such studies to be conducted according to conventional accounting approaches and with rigor in the reporting of cost inputs and methodology.