Verslag van het college van geneesheren RADIOTHERAPIE-ONCOLOGIE 1 januari 2019 – 31 december 2019 Rapport du collège de médecins RADIOTHERAPIE- ONCOLOGIE 1 janvier 2019 – 31 décembre 2019

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Verslag van het college van geneesheren R A D I O T H E R A P I E - ON C OL O G I E 1 januari 2019 – 31 december 2019

Rapport du collège de médecins R A D I OT H E R A P I E - O N C OL OG I E

1 janvier 2019 – 31 décembre 2019

Dr. Vincent Remouchamps

Voorzitter-Président

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Inhoudstafel

1. Werking van het College Radiotherapie-Oncologie 1.1. Inleiding

1.2. Organisatie van het College van Radiotherapie-Oncologie 1.3. Plenaire vergaderingen

2. Resultaten

2.1. Inleiding

2.2. Audits

2.3. Procalung

2.4. Quality Indicators

2.5. BELDART

2.6. PRISMA-RT

2.7. Innovatieve Technieken

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D ^EEL 1

W ERKING VAN HET

C OLLEGE VAN RADIOTHERAPIE -

ONCOLOGIE

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1.1. Inleiding

De commissie Peer Review voor Radiotherapie-oncologie werd, op initiatief van het Ministerie van Volksgezondheid, in 1995 opgericht en bestaat uit radiotherapeuten en fysici. De doelstelling van deze commissie is de kwaliteit van de bestralingsbehandelingen trachten te verbeteren door het organiseren van peer review activiteiten.

In mei 2000 werd het college van geneesheren radiotherapie geïnaugureerd.

In september 2000 werd overgegaan tot een formele integratie van het door het ministerie benoemde college enerzijds en de reeds sinds 1995 bestaande commissie Peer Review voor Radiotherapie-oncologie anderzijds.

In juli 2003 werd een nieuw college geïnstalleerd, na verschijnen in het staatsblad (KB 30-7-2003).

In 2006 werd opnieuw een nieuw college samengesteld na verschijnen in het staatsblad (KB 15-12-2006).

In 2012 werd een nieuw college samengesteld (KB 26/11/2012), de samenstelling vindt u onder 1.2.

In 2012 werd opnieuw een nieuw college samengesteld na verschijnen in het staatsblad (KB 26/11/2012).

Eind 2017 werd een nieuw college samengesteld (KB 04/12/2017), de samenstelling vindt u onder 1.2.

In 2019 is aan verschillende projecten gewerkt:

• Audits

• Procalung

• Quality Indicators

• BELDART

• PRISMA-RT

• Innovatieve technieken

De stand van zaken van deze verschillende projecten vindt U in deel 2 van dit verslag waar feedback wordt gegeven over de uitgevoerde projecten.

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1.2. Organisatie van het college radiotherapie-oncologie Leden van het college in de periode 2000-2003 (KB 10/6/1999):

Prof. P. Vanhoutte (voorzitter) Dr. P. Huget (ondervoorzitter)

Prof. C. Weltens (contactpersoon en secretaris) Dr. G. Demeestere

Dr. W. Deneve Dr. D. Marchal Prof. P. Scalliet Dr. K. Vandeputte

Leden van het college in de periode 2003-2006 (KB 30/7/2003) Dr. P. Huget (voorzitter)

Prof. P. Scalliet (ondervoorzitter)

Prof. C. Weltens (contactpersoon en secretaris) Prof. J.M. Deneufbourg

Dr. D. Marchal Dr. P. Spaas Dr. K. Vandeputte Dr. L. Vanuytsel

Leden van het college in de periode 2006-2012 (KB 15/12/2006) Prof. P. Scalliet (voorzitter)

Dr. P. Spaas (ondervoorzitter)

Prof. C. Weltens (contactpersoon en secretaris) Dr. C. Mitine

Dr. K. Vandeputte

Dr. D. Van den Weyngaert Dr. L. Vanuytsel († 30-8-2008)

Leden van het college in de periode 2012-2017 (KB 26/11/2012) Prof. Y. Lievens (voorzitter)

Dr. V. Remouchamps (ondervoorzitter)

Prof. C. Weltens (contactpersoon en secretaris) Prof. D. Van den Weyngaert (tot december 2015) Dr. R. Burette

Dr. L. Moretti Dr. N. Jansen Dr. K. Stellamans

Huidige samenstelling van het college sinds eind 2017 (KB 04/12/2017)

Dr. V. Remouchamps (voorzitter)

Prof. M. Lambrecht (contactpersoon en secretaris) Prof. Y. Lievens (vice voorzitter)

Dr. L. Moretti Dr. N. Jansen Dr. K. Stellamans Dr. R. Weytjens Dr. X. Geets

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Naast de door het ministerie aangestelde leden, wordt het college sinds zijn installatie vervoegd door experten (fysici, verpleegkundigen en radiotherapeuten).

Vanaf eind 2019 is de samenstelling van de commissie van experten als volgt:

radiotherapeuten Prof. P. Scalliet Prof. C. Weltens

Dr. D. Van Gestel (voorzitter BVRO) physici

A. Rijnders F. Vanneste Prof. D. Verellen M. Tomsej

J. Vandecasteele (voorzitter BVZF/BSPH) verpleegkundigen

I. De Wispelaere (voorzitter VVRO) opgevolgd door L. Van den Berghe W. Hontoir (voorzitter Afiter)

A. Vaandering

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1.3. Plenaire vergaderingen

Volgende plenaire vergaderingen werden gehouden in 2019:

DATUM 18-06-2019 05-12-2019

De verslagen van bovenstaande vergaderingen vindt u hierachter.

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College van Geneesheren Radiotherapie-Oncologie

Collège des Médecins Radiothérapie-Oncologie

College meeting 18-06-2019

Present:

A. Vaandering; C. Weltens; D. Van Gestel; D. Verellen; F. Vanneste; I. Joye; I. De Wispelaere;

K. Stellamans; L. Moretti; M. Lambrecht; N. Jansen; P. Van Houtte; P. Deseyne; R. Weytjens;

S. Vandebogaert; V. Remouchamps; X. Geets; Y. Lievens

1. Welcome (V. Remouchamps)

Previous meeting :

- Heads of the Department : for some presentations the scheduled time was too short.

- No other comments of previous report.

2. Audits (A. Vaandering)

Cfr slides:

- GHDC will be audited instead of UCL St Luc.

- Some general concerns:

o Patient follow-up is fragile area. It is often lacking. However a definition of accurate follow-up needs to be defined before recommendations can be issued.

o Imaging: quality control on imaging for treatment planning is generally lacking.

B-Quatro went paperless: one drive platform paid for by the college.

3. QI project

Cfr slides.

2018 data collection:

- All departments participated, benchmarking document will be sent out.

- GDPR issue:

o DTA and DPA documents set up by UCL o patient consent after consultation of DPO o 100% of the data is owned by FOD

o For public registry no informed consent or ethics committee is necessary o V. Remouchamps will sign on behalf of the College.

- Feedback from the heads of the department meeting:

o General feeling is that the centers want to go further.

o There is the question whether it would be possible to integrate PROMs.

- Weaknesses: manual entry of data, by limited personnel (quality managers under threat).

- Threats o Weariness.

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- Discussion

o Manual entry:

 Automation of data extraction :

N. Jansen has informed with the different radiotherapy vendors and

emphasizes that there is no readymade solution available, however they are working on it. Even if the software is available each department needs to structure their data in a uniform way or extraction of this data is near impossible. Nico will continue to pursue this path, however doesn't expect a solution in the nearby future.

 Consensus was reached that in a first step we should try and motivate the centers to structure data on a hospital level prior to upload, i.e. Uniform naming according to AAPM TG263 report. A first attempt at this is within the scope of PROCALU.

 The question remains if it is the task of the college to organize this.

o Weariness:

 The quality indicators need to be redefined.

 First for the current pathologies.

 Yolande Lievens states that prior to starting a new round, we need to define what is currently going on around the world and how we can refine this and translate it to the Belgian situation.

 This will happen in the working groups which will be defined for the following indications:

◦ Head And neck

◦ Breast

◦ Prostate

4. PROCALU (L. Moretti)

Cfr slides.

Discussion:

- There remains some doubt about ability to capture both follow-up and toxicity.

- Central review of the delineations intervision is currently being set up.

- Question remains where the limit is between the prospective registry and prospective clinical trial.

- Quid follow-up: ethics committee necessary for prospective analysis.

- Ethics committee + informed consent will be done via institut Bordet.

- Protocol will be submitted to the EC and depending on their advice we can move further.

- Belgian cancer registry is on board.

5. Analyses SBRT Liver (I. Joye, P. Deseyne)

Cfr slides.

- Proposal for new project to capture the data on SBRT liver from the convention

“innovative techniques".

(10)

- Working costs:

o 1860 €

- Information goes through Belgian cancer registry.

- Goal:

o To capture heterogeneities in time and between centers.

o Extra info on local control: contact different RT centers individually to obtain this data through BCR.

6. Guidelines on authorships and acknowledgements in collaborative efforts by the college (M. Lambrecht, Y. Lievens)

Proposal to be drafted by M. Lambrecht en Y. Lievens.

7. Benign diseases (P. Van Houtte)

Cfr slides.

8. Update new techniques (Y. Lievens)

- SBRT reimbursement: Convention is prolonged to maximum the end of the year.

- A new document was drafted, Y. Lievens will send this around in due time.

9. Varia (V. Remouchamps)

- Presidency of VR:

proposal is for V. Remouchamps to complete his full term as president.

- Standardized naming convention:

N. Janssen proposes to send a survey around the different centers. Not before September of October.

Meeting closure (V. Remouchamps)

Next meeting :

Doodle for October/November will be sent out.

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19-7-2019

1

B-QUATRO audits–

status and feedback

College meeting 18/06/2019

Audited departments

2017 2018 2019

CHU Liège Iridium Kankernetwerk CHU Vésale +

Tivoli

Centre Hospitalier Pelzer La Tourelle (Verviers)

Institut Bordet UCL St Luc + SPO*  CANNOT be audited in 2019





changed with GHDC LOC, Hasselt AZ Delta (Roeselare) Cliniques de l’Europe – St

Elisabeth

AZ Turnhout UZ Leuven Baudour

UCL-Namur (Luxembourg) UZ Gent

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19-7-2019

2

Auditors

RO MPE RTT QM

Pierre Scalliet Dirk Verellen Guy Vandevelde Anitha Batamuriza- Almasi

Paul Van Houtte Michel Van Dycke Catherine Meunier Emilie Blondiau Sylvie Derycke Milan Tomsej Paul Bijdekerke Nathalie Deman Caroline Weltens Nadine Linthout Pieternel Thysebaert Frederik Vanhoutte Katia Vandeputte Stefaan Vynckier Ann Vermylen Aude Vaandering Yolande Lievens Barbara

Vanderstraeten

Els Goemare Séverine Cucchiaro Vincent

Remouchamps

Observers:

France:Albert.Lisbona@ico.unicancer.fr - MPE France : Carmen.FUERTES@asn.fr - MPE

IAEA: Annette.Wygoda@MOH.GOV.IL– MPE

Emitted recommendations

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19-7-2019

3

Paperless platform evaluation - Onedrive

100% of the auditors believed that the OneDrive platform should be maintained for the future audits.

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19-7-2019

1

College QI project – status and feedback

College meeting 18/06/2019

National Quality Indicator project

Structure Process Outcome

Departmental level:

Number of equipment, number of treatments, FTE…

Patient level*:

• H&N cancer patients (exl T1 glottis)

• Post-op breast cancer patients (excluding nodal RT, bilateral RT and partial breast irradiation)

• Prostate cancer patients (EBRT only / excluding RT post prostatectomy

54 QI

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2

2018 Data collection status

Final submission 15/05

24/24departments (excluding data of 1 satellite department and partial responses for one department) Analysis on-going

Benchmarking document to be sent out this summer

Making the links…

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3

GDPR issues

Requirements

Need to have non identifiable data (DOB will be excluded in future collection forms)

Establishment of

DTA (Data transfer Agreement) between the College and all RT departments

DPA (Data Protection Agreement) between the College and Clin Univ St Luc to formalize data protection issues

Patient consent ? NO

Comments pertaining to the project

Comment Solution

Number of treatments/EBRT device should take into account its actual usage (real QI?)

QI versus performance indicator?

Factoring in of treatment times?

All patient related QI: Why is the elapsed time between simulation and treatment monitored? Is this a real QI?

We should actually be more precise with this parameter:

Ex: Elapsed day between surgery and RT treatment for breast cancer treatments H&N patients – what about induction chemo/loading dose of Cetuximab and simulation?

Is toxicity grading harmonious across all departments? RO dependent?

PROMS…( stat test ongoing) All patient related QI: Toxicity grading –

why is the date being asked?

Are we capturing maximum toxicity?

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19-7-2019

4

Other comments – “nice to have”

Would like to visualize differences between university versus non university hospitals

Include other tumour locations – ProcaLu?

H&N: Include full TNM (+ p16 status, …), systemic therapy, co- morbidities

Include trend analysis (2015-2018)

- High participation rate - National uniform data collection

Real world data - Feedback to departments

Quality improvement tool

-Manualentry of data

Personnel dependent

Limited data

“Subjectivity” in datacollection

- Integration of PROs/PROMs - Data extraction automation

Movement towards standardization (common syntax)

Big data

Live QI dashboards

-General Data Protection Regulation - Departments’ Weariness Strengths

Threats Opportunities

Weaknesses

Project status

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19-7-2019

5

Next steps…to be discussed

Automation of data extraction Update/Increase QI collected

• What solution? Is this needed?

Expert group

Inclusion of other tumour sites?

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ProCaLu: Project on Cancer of the Lung

On behalf of the ProCaLu team

F. Charlier, V. Remouchamps, X. Geets, M. Lambrecht, E. Hortobágyi, Y. Lievens and L. Moretti

June 18^th 2019 Meeting

Plan

u ProCaLu

u Rationale

u Aims

u Methods

u ProCaLu status

u Dummy run preliminary results

u Procalu questionnaire

u Aquilab

u Belgian Cancer Registry

u GDPR, documents, and contracts

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What is ProCaLu?

u A national QAprogram for Stage III chemoradiotherapy

u Offering a centralized review for mediastinal nodal CTV (Similarly to PROCARE and PROCAB)

u Aiming for

u A validationof the lymph node selection algorithm

u A standardizationof the delineations

Stage III lung cancer

u Cancer Registry:

~1500new cases in Belgium in 2016

~1300NSCLC

u ProCaLu: N2 disease only

à~1000NSCLC

(21)

Rationale (1)

u Latest ESTRO ACROP guidelines :

Use this algorithm to define mediastinal nodal GTV

Peeters S et al, Radiother Oncol 2016

Rationale (2)

u Latest ESTRO ACROP guidelines:

different mediastinal CTV delineation methods

u Include the whole stationor the involved node

u Size of the GTV to CTV margin

u Or even neighboring elective stations

Nestle U et al, Radiother Oncol 2018

Personal quick adaptation

(22)

Rationale (3)

u Latest ProCaLu guidelines :

mediastinal CTV delineation methods

u Include the involved node

u Size of the GTV to CTV margin = 5mm

u No elective stations

Belgian consensus:

CTV = GTV + 5mm

Rationale (4)

u All that is fine, because we don’t know for sure (yet)

u But we know

u Toxicity

u Involved nodes would be as efficient*

u Interest is growing on lymph nodes as OAR (immune system)

* De Ruysscher D, Int J Radiat Oncol Biol Phys 2005 Martinussen HMA, Radiother Oncol 2016

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Methods (1)

All RT centers in Belgium are invited to participate

1. Before treatment planning

The center sends clinical variables, planning CT, RTSTRUCT, PET

2. Less than 48h (24h) later

ProCaLu sends reviewed mediastinal nodal CTV contours

3. The center then choses how much it follows the delineation feedback

BCR Aquilab

Methods (2)

4. At treatment start

Definitive RTSTRUCT, RT Plan, RT dose

5. At treatment end

Treatment parameters and clinical aspects: OTT, ART, acute toxicity

6. At follow up (~3 months and 1 year)

Form with clinical variables (+ Chest CT at 1 year) + PROMs BCR

Aquilab

(24)

u In addition to delineations peer-review,

u Centers (or RadOncs) would have access to a near real-time statistics and anonymous comparison with other centers on

u Number of patients included and per step

u Adherence to target definition and delineation guidelines

Statistics for centers

Procalu.be

Foreseen analyses

u Delineations standardization

u Contour differences analysisand metrics

u Real-world disease and treatments statistics

u Extent of the disease, dose prescriptions, chemotherapy uses, adaptive plans …

u Quality indicators

u Usability of medical reports (staging procedures)

u Planning time, OTT, OAR delineations, dosimetric constraints

u Outcomes : Acute toxicity, disease control, overall survival maybe… BCR

(25)

Dummy Run

Better target definition with better appreciation of positivity in lymph nodes

(26)

Reduction of the volume and height of the CTV

phase 1

phase 2

Reduction of the CTV delineation variance

(27)

ProCaLu: where do we stand now ?

(28)

u Successful negotiations with Aquilab:

u “Artiview” licences costs reduced with ProCaLu running

u “Share Place” web-based platform

u PROMs

u Belgian Cancer Registry on board

u Dataset and items finalized

u Web forms development not started

u Difficult to interact

u RGPD and regulations

u Contracts in progress (based on DPO’s feedback from Namur and StLuc)

u FOD is data controller (“responsable du traitement”) ?

ProCaLu status

ProCaLu survey

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ProCaLu annual survey – September 2019 For optimization

! Pencil beam ! CCC ! Acuros

܆ AAA ! Monte Carlo ! Other(s)

If other(s), please specify:

Final Dose Calculation Algorithm, if different than optimization algorithm(s)

܆ Pencil beam ! CCC ! Acuros

! AAA ! Monte Carlo ܆ Other(s) If other(s), please specify:

TPS

܆ Eclipse v. … ܆ RaySearch v. … ܆ Pinnacle v. …

܆ Monaco v. … ! Other(s) If other(s), please specify (with version):

Usual PTV margins in Lung Cancer treatments of conventional fractionation

Isotropic: … mm Superior: … mm Inferior: … mm

Anterior: … mm Lateral: … mm

Posterior: … mm Medial: … mm ! Other(s)

If other(s), please specify:

PTV – OAR constraints priorities

܆ PTV constraints first, then usual OAR constraints as feasible

܆ Usual OAR constraints first, then PTV constraints as feasible

܆ Other, please specify:

IGRT Type

! CBCT ! kV ! MVCT

! 4D-CBCT ! MV ! Xtrac

! Other(s) If other(s), please specify:

IGRT Frequency

! Daily ! NAL or similar

! Weekly ! None ! Other(s) If other(s), please specify:

Patient/Target motion management Patient immobilization

! Thermoplastic mask ! None ! Others If other(s), please specify:

Simulation

܆ Fluoroscopic simulation before CT scan in radiology department

܆ Large bore dedicated CT in radiation oncology department with breath hold (normal inspiration + expiration)

܆ Large bore dedicated CT in radiation oncology department with breath hold (deep inspiration + expiration)

܆ Large bore dedicated CT in radiation oncology department with 4DCT and use of ITV method

܆ Large bore dedicated CT in radiation oncology department with 4DCT and use of mid-ventilation method

܆ None

܆ Other(s), please specify:

ProCaLu timeline

u Aquilab web platform

u June-July: Finalize development

u August: Test phase

u Belgian Cancer Registry

u Web forms development in July

u Start testing in August for production in September

u Regulation process under discussion

u RGPD and regulations

u Contracts to be ready for end of August ?

u FOD ?

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www.procalu.be

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16-7-2019

1

22 centres responded

364 patients treated

21 diseases

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16-7-2019

2

Pathology Number of

patients

Number Centre

Keloids

Prevention of heterotopic bone Prevention of gynecomastia Trigeminal nevralgia Arteriovenous malformation Splenomegaly

Graves ophtalmopathy artery Prevention of periph. Art.sten.

Ovarian castration Vertebral hemangioma Desmoid

Lymphangioma Hemangioma Dupuytren Heel spur heel Angioma Synovitis

Plantar fibromatosis Thymic hypertrophy

Hypersalivation amyotrophic lat scl

105 73 65 38 22 19 13 7 4 4 4 1 1 1 1 1 1 1 1 1

19 17 15 4 6 6 5 3 2 4 6 1 1 1 1 1 1 1 1 1

Disease Npat/NCenter NPat/NCenter NPat/NCenter Heterotopic bone formation 73/17 232 / 20 228 / 18

Keloid 105/19 102 / 20 151 / 20

Graves ophtalmopathy 13/5 79 / 19 35 / 17

Coronary stenosis 0 142/ 18 0 / 0

Hypersplenism 19/6 60 / 17 21 / 16

Macular degeneration 0 75 / 9 315 / 11

Castration 4/2 54 / 15 61 / 16

A-V malformations 22/6 53 / 14 48 / 11

Warts 0 60 / 5 106 / 6

Total patients treated for

benign dis. 364/22 961 / 21 1118 / 21

2016 1999 1995

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3

Pathology Possible Indication

2016 N 22 1999 N 21 1995 N 21 prevention heterotopic bone formation

keloids

graves ophtalmopathy DMLA

prevention of coronary stenosis (stent) splenomegaly

prevention of gynecomastia

prevention of peripheral artery stenosis ovarian castration

arteriovenous malformation vertebral hemangioma desmoid tumor Dupuytren disease Peyronie disease Histiocytosis Pterygion Adamantinoma trigeminal neuralgia

21 22 17 2 1 18 20 21 7 18 12 18 2 3 5 5 4 14

20 20 19 9 18 17 16 15 15 14 13 12 9 7 9 6 6 0

18 20 17 11 0 16 16 0 16 11 14 7 6 6 2 6 6 0

pathology Possible

indication

1999 1995

warts

inverse nasal papiloma lymphangioma aneuvrysmal bone cysts thymic irradiation for myasthenia hemangioma

heel spur heel

angiofibroma of nasopharynx bursitis

zona tendinitis arthritis

carvenous angioma angioma

synovitis

plantar fibromatosis bartholonitis rhumatoid arthritis folliculitis peptic ulcus sacroidosis thymic hypertrophy herpetic disease arthrosis furonculosis fungal infections

hypersalivation amyotrophic lateral scle

0 3 4 4 0 5 5 1 0 0 0 1 3 1 1 1 0 2 0 0 1 1 0 0 0 0 1

5 5 5 5 5 5 5 5 4 3 3 3 3 3 2 2 2 3 1 0 0 0 0 0 0 0

?

6 5 3 4 4 3 10

6 3 8 4 3 3 4 5 0 0 4 1 1 0 0 1 0 0 0

?

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16-7-2019

4

Schedule Number of Centre

1 x 7 Gy 1 x 8 Gy 5 x 5 Gy

12 5 1

Fractions N Centre 1995 2000

Dose Gy

N Centre 1995 2000 1

2 5 10 12

6 1 2 5 1

11

1 8 10 15 16-20

> 20

6 2 2 4 1

11

1 Evolution from 1995

2016

Brachytherapy External RT

2 x 6 Gy 2 x 7 Gy 3 x 6 Gy 2 x 5 Gy

1 2 2 1

1 x 7 Gy 1 x 10 Gy 3 x 4 Gy 3 x 5 Gy 4 x 4 Gy 5 x 4 Gy 10 x 2 Gy

3 3 1 2 1 3 2

(35)

SBRT liver

Meeting College Radiotherapy-Oncology

18/06/2019

Pieter Deseyne, Ines Joye

Indications

livermetastasesof solid tumours OR

hepatocellular carcinoma/cholangiocarcinoma not suitable for a surgical intervention

Compared to surgery

Compared to RFA

Inoperability

Central lesion

Size >3 cm Location

Medical inoperability

Lesion in the proximity of major blood vessels, main biliary tract or gallbladder, or

just beneath the diaphragm

(36)

• Variability in SBRT indications

• Heterogeneity applied techniques

(37)

Aim

• To gain insight into the patterns of care for SBRT liver in Belgium

• To determine local control and overall survival and its influencing factors

• To determine minimal requirements for SBRT liver

• To increase knowledge about SBRT liver

• To feed discussion in the MTB

Methods

• Using prospectively registered Belgian data

• ≥ 250 liver metastases, 40 primary lesions

• Between 2013 and 2018

• Description of patterns of care using various patient, tumor and treatment related characteristics.

• Evolution of these parameters over time

(38)

Methods

LOCAL CONTROL

• most valuable endpoint

• not available in BCR questionnaire or Crossroads bank

SURVIVAL

• Linkage with Crossroads bank

STRATIFICATION

• Patient-, tumor-, treatment related factors

Methods

Patient characteristics

• Age

• Gender

• Hospital

• WHO score

Tumor characteristics

• Primary liver lesions vs. metastases vs. relapse primary tumor

• Tumor histology and location

• Differentiation grade

• Incidence date primary tumor

• Number of lesions

• Maximal diameter of lesions

(39)

Methods

Treatment-related parameters

• Identification tumor motion (kV fluoroscopy, cine MR, 4D CT, inhale/exhale breathhold CT, none, unknown, other)

• Tumor compensation strategy(abdominal compression, breath hold, gating, tracking, none, unknown, other)

• Imaging modalities treatment planning (CT, MR, PET)

• Personalized immobilization (yes, no)

• Image fusion for delineation (yes, no)

• Markers (implanted, skin sensors, no markers)

• Technique (3D, IMRT, other)

• Center

• Number of fractions

• Total dose

• Start and end date of RT

• Dose calculation algorithm (pencil beam, AAA, CCC, Monte Carlo, other)

• Patient specific QA

• Type of IGRT (CBCT, Exac-trac, EPID, no IGRT, other)

Expected results

• Increase in number of RT courses

• Decrease in variability

• Evolution IGRT, immobilization techniques …

(40)

Timeline

03/04/2019 Meeting BCR

18/06/2019 Proposal College

Data preparation by BCR Statistical training

course

Data collection

Report to College Manuscript preparation and

submission

09/2019 10/2019 04/2020

How will the College be involved

• Individual members can participate if interested

• Report of data to College

• Using results to propose a minimal standard of care for reimbursement?

• Additional research questions?

• Acknowledgement in submitted manuscript

(41)

But…

• LOCAL CONTROL DATA

• Individual radiation oncologists?

• Privacy issue cfr GDPR

• WORKING COSTS

• € 1860 BCR

• Privacy tutorial, statistics course, database preparation, infrastructure

(42)

College van Geneesheren

Radiotherapie-Oncologie Collège des Médecins

Radiothérapie-Oncologie

College meeting 05-12-2019

Present: cfr file

1. Welcome (V. Remouchamps) 2. Previous meeting

3. Quality Indicators (A. Vaandering)

a. Cfr slides Aude Vaandering

b. Important: all departments participated

c. Luxemburg wants to participate: there is general agreement to let them participate in the benchmarking exercise, however as funding of the QI project is through the FOD:

A fee will be charged a rato of 1:24^th of the total budget. Vincent Remouchamps will contact them concerning this decision.

d. Remaining questions:

i. Did departments use the data to change workflow at department?

ii. Is it useful to start discussion per pathology group on exchange of experience and guidelines?

iii. How can we extend this project beyond the 25 patients?

iv. There is considerable weariness of the department around the collection of the QI data, especially regarding the validity of toxicity data. These concerns have been noted and expert groups will be formed to evaluate the process indicators.

First a literature review will be performed by Aude Vaandering.

v. Questions still remaining:

1. Regarding automated data extraction there is no short term solution.

2. There might be overlap with other projects (VIP, BCR, …) this needs to be accounted for.

e. General conclusion is that we are at the end of the pilot phase. Structure indicators will continue to be collected. Process indicators will be stopped.

The next step is to review the literature and set up working groups to further move the QI project into the future.

4. Beldart

a. Cfr slides Burak Yalvac

b. There was some concern that the phantom is often damaged when sent back by the centers.

c. Discussion:

i. Questionnaire for SBRT will be sent together with SRS.

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ii. Not all centers have been audited.

iii. Heads of the department meeting will be used for more feedback on Beldart.

iv. Reporting:

1. To the college: anonymized report to the college annually,

2. To the president of the College: a non-anonymized report will be sent.

5. Prisma RT:

a. Can satellites be included separately: The college supports this request. Practical issues however still need to be addressed regarding the separation of the data provided by the satellite center and the primary center.

b. The use of prisma-RT should be encouraged.

c. The heads of the department meeting will be used to give feedback to the centers.

6. Audits

a. Cfr slides Aude Vaandering

b. For the audits: an OneDrive platform has been set up for the cost of 88 euro per month. The feedback on the use of this platform by the auditors is mostly positive.

c. Professor Van Gestel raises the concern whether there is room for a ‘separate’

academic auditing, specifically focused at the concerns of academic centers.

d. Concern by prof Van Gestel: is there are place for academic auditing? To be discussed in the auditor group.

7. Guidelines on authorship: postponed due to timing issues.

8. Survey employment in radiotherapy

a. Cfr slides

Age at retirement should be added.

Data will be presented at the heads of the department meeting.

9. Renewal of the college

a. Yolande Lievens will stay as an expert, Vincent Remouchamps will stay as an expert.

b. Nico Jansen and Luigi Moretti: let me know whether or not they will be renewed.

c. Equilibrium between centers is important.

d. A new president candidate will be looked for.

10. Heads of the department meeting: march 2020 11. Role of College in national protocol development

a. Cfr slides Nico Jansen.

b. Already within academic centers there is no consensus.

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c. The role of the College is not to develop guidelines. However a collaboration with the College of Oncology and different cancer centers seems like a good idea.

12. Varia

a. National exam: will be reorganized 13th of June 2020.

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aanwezig niet aanwezig Leden College

Alex Rijnders x

Caroline Weltens x

Dirk Verellen x

Françoise Vanneste x

Karin Stellamans x

Luigi Moretti x

Nicolas Jansen x

Isabelle De Wispelaere x

Pierre Scalliet x

Frederik Vanhoutte x

Vincent Remouchamps x

Yolande Lievens x

Aude Vaandering x

Dirk Van Gestel x

Walter Hontoir x

Xavier Geets x

Maarten Lambrecht x

Reinhilde Weytjens x

Milan Tomsej x

Jan Vandecasteele x

voor de agenda

Brigitte Reniers x

Burak x

FODSaskia Vandebogaert x

College

Meeting 5 december 2019 FOD 14:00

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1

College QI project – status

College meeting 05/12/2019

 2018 QI analysis – some results

 2019 QI collection

 Next steps

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2

2018 Data collection status

 Final submission of data 15/05

 24/24departments (excluding data of 1 satellite department and including partial responses for one department)

 Personalized feedback documents sent in November

Infrastructure data

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3

Number of EBRT treatments per department

Year Mean number of EBRT treatments per

department 2015 (excludes data from 1 primary hospital and 1

satellite site) n=24

1392

2016 (all data excluding 1 satellite site) n=24 1503 2017 (excludes data from 2 primary hospitals and 1 satellite site) n=22

1556

2018 (excludes data from 1 primary hospital and 1 satellite site) n=23

1568

Number of treatments per device

Year Mean number of treatments/EBRT device

397,7

2016 (all data excluding 1 satellite site) n=24 417,5 2017 (excludes data from 2 primary hospitals and 1 satellite site) n=22

408,9

408.9

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4

Proportion of used treatment techniques (2017 versus 2018)

Brachytherapy treatment activities

Year Mean number of BT

treatment/department

Total number of BT treatments

2015 (n=20) 77,6 1552

2016 (n=21) 85,2 1790

2017 (n=19) 88,4 1679

2018 (n=21) 77,7 1632

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5

Workload

2016 National data: 2017 National data: 2018 National data Mean P0,25-0,75 Mean P0,25-0,75 Mean P0,25-0,75 Number of

treatments/RO FTE 265,7 223,0-324,2 262.7 226,8-313,8 265,8 214,5-306,9 Number of

treatments/FTE MPE

314,0 222,2-403,4 310,8 239,7-381,2 336,3 247,0-403,0 Number of

treatments/MPA+MPE 233,9 190,9-260,8 228,4 199,0-254,6 235,8 195,5-259,1 Number of

treatments/RTT FTE 83,7 69,4-95,7 83,6 71,1-94,0 83,2 73,4-96,7 Number of

sessions/RTT FTE 1443,8 1287,2-1686,2 1365,1 1120,8-1715,0 1353,2 1190,5-1515,2 2016 National data: 2017 National data: 2018 National data Mean P0,25-0,75 Mean P0,25-0,75 Mean P0,25-0,75 Number of

treatments/RO FTE 265,7 223,0-324,2 262.7 226,8-313,8 265,8 214,5-306,9 Number of

treatments/FTE MPE

314,0 222,2-403,4 310,8 239,7-381,2 336,3 247,0-403,0 Number of

treatments/MPA+MPE 233,9 190,9-260,8 228,4 199,0-254,6 235,8 195,5-259,1 Number of

treatments/RTT FTE 83,7 69,4-95,7 83,6 71,1-94,0 83,2 73,4-96,7 Number of

sessions/RTT FTE 1443,8 1287,2-1686,2 1365,1 1120,8-1715,0 1353,2 1190,5-1515,2

Quality managers…

Breast patient data

(excluding nodal RT, bilateral RT and partial breast irradiation)

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6

Prescribed fractions

Proportion of prescribed fractions (2017 (n=540) versus 2018 (n=594))

Mean number of lost days for treatment delivery

(2017 vs 2018)

(52)

7

Used treatment and IGRT technique

(2016-2017-2018)

Acute toxicity

(53)

8

Prostate patient data

(EBRT only / excluding RT post prostatectomy)

Prescribed fractions

Proportion of prescribed fractions (2017 (n=526) versus 2018 (n=551

(54)

9

Mean number of lost days for treatment delivery

(2017 vs 2018)

Used treatment and IGRT technique

(2016-2017-2018)

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10

Acute toxicity

H&N patient data

(exl T1 glottis)

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11

Tumor location and staging

Primary tumour location Proportion of patients

oropharynx 33,2%

Larynx (excluding T1N0 glottis) 14,4%

hypopharynx 13,7%

tongue 10,1%

other and ill defined sites within H&N 9,1%

floor of the mouth 8,2%

other and unspecified parts of the mouth 4,4%

nasopharynx 3,4%

major salivary glands 2,7%

gum 0,6%

lip 0,4%

Total général 100,0%

T staging T0 T1 T2 T3 T4 Tx

National proportion

(n=527) 1,3% 12,9% 31,1% 22,6% 29,0% 3,1%

Prescribed fractions

Proportion of prescribed fractions (2017 (n=481) versus 2018 (n=491))

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12

Mean number of lost days for treatment delivery

(2017 vs 2018)

Used treatment and IGRT technique

(2016-2017-2018)

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13

Acute toxicities

Next steps

2019 QI collection

Same data collected

DTA/DPA

College AFMPS?

Luxembourg?

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14

Next steps… to be discussed

Automation of data extraction Update/Increase QI collected

• What solution? Statistical analysis of collected date

Expert group

Inclusion of other tumour sites?

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1

BEL d ART-SRS/SBRT

BELgian dosimetry Audits in Radio Therapy

Progress report Dec 2019

B. Yalvac, N. Reulens, B. Reniers

BELdART - Dec 5, 2019

BELdART: auditing activities

• Basic audit of MV photon beams (including FFF beams)

– With alanine/EPR dosimetry

– Electron beams: New mailed protocol!

• Audit of advanced RT techniques

– IMRT/Arc prostate case (based on BELdART-2) – Stereotaxy (sponsored by the College)

• Frameless intracranial SRS: Ongoing

• Lung SBRT: Ready to start!

2

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2

Basic tests: New holder

• New model holder:

photon/electron beams

– top part: electrons

• Added screw for stability!

– Bottom: photons

• Electrons

– Measurement at d_ref(or other specified depth) for electron audit

– Picture for verification based on the number of spacers (many colors available for 3D printing)

Screw

3

Electron beams

Spacers

4

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3

Electron beams

Water level

5

Photon beams

BELdART - Dec 5, 2019 6

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4

Photon beams

BELdART-SBRT

 Mailed audit

 Basic tests

 With alanine/EPR dosimetry

 Same as SRS procedure

 E2E test dose delivery on commercial lung phantom

 Alanine/EPR and film dosimetry

 With bone equivalent plug

 Lung inserts

 Modified with 3D printed PLA box (20% infill)

 Box with imprint derived from patient contour

 Imprint filled with silicone mixture

 Posibility to place alanine and film detectors

8

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5

BELdART-SBRT

• 3D box with silicone mixture to simulate tumour tissue – HU: 100 – 200

– r = 1.08 g/cm³

• Alanine in small protection cover

• EBT3 films (in coronal plane)

– Large film through tumour and other tissues (e.g lung, tumour, soft tissue)

– Large film on top of lungs (interface lung-soft tissue)

BELdART-SBRT

Alanine pellet

Film location on top of lungs Film location through tumour

10

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6

Procedure

• Material sent

– Lung phantom with alanine/film detectors preloaded – At least 1 week before scheduled day of audit

– CT-scan of phantom including structure set of alanine pellet

• Plan preparation

– Take CT-scan of lung phantom and transfer the alanine contour

– Draw a contour around the tumour (and any helper structures according to local rules)

– Make treatment plan using local procedure.

• Max dose to alanine pellet < 23 Gy!

– Set plan isocentre to centre of tumour

• Irradiation

– Position phantom on linac and verify positioning (e.g. IGRT) – Deliver the plan

Results E2E testing

• Test with different TPS’ with 6 MV or 6 MV FFF beams

• Alanine results

Algorithm D_TPS(Gy) D_Measured(Gy) Unc. D_Measured(%) d(%)

CCC 20.475 21.175 0.827 3.306

Monte Carlo* 20.641 21.708 0.826 4.915

Convolution-

superposition 18.157 18.298 0.839 0.771

CCC 20.602 20.951 0.706 1.662

AAA 22.272 22.436 0.832 0.730

AXB no density

override 12.986 13.034 0.857 0.364

AXB with density

override 13.154 13.034 0.857 -0.919

* Plan with heavy modulation

12

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7

Results E2E testing

• Film results

* Plan with heavy modulation

Film (5%/1mm TH=10%) gamma passing rate

Algorithm Above lungs Through tumour

CCC 100 98.77

Monte Carlo* 71.6 97.16

Convolution-superposition 99.99 98.28

CCC 99.91 99.49

AAA 99.33 96.84

AXB no density override 99.39 99.98

AXB with density override 99.32 99.94

13

Results E2E testing

• Convolution-Superposition: Film on top of lungs: DTA = 1 mm

1%/1mm

2%/1mm

3%/1mm

4%/1mm

5%/1mm

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8

Results E2E testing

• Convolution-Superposition: Film through tumour: DTA = 1 mm

1%/1mm

2%/1mm 3%/1mm 4%/1mm

5%/1mm

Results E2E testing

• Film results

• film

MC – Film through tumour PR (5%/1mm) = 97.16%

Thin lines: film Thick lines: plan

16

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9

Results E2E testing

• Film results

MC – Film above lungs PR (5%/1mm) = 71.60%

17

Results E2E testing

• Film results

CCC – Film through tumour PR (5%/1mm) = 99.25%

18

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10

Results E2E testing

• Film results

CCC – Film above lungs PR (5%/1mm) = 99.83%

19

Conclusions SBRT

• Ready to announce start of SBRT audits

• First 5 audits will be visited

– To evaluate and update the procedure

CONTACT

burak.yalvac@uhasselt.be brigitte.reniers@uhasselt.be

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11

Results SRS-audits

• 14 audits performed

– 13 frameless – 1 framed

– 1 audit not analysed – 1 audit being investigated

• Will be repeated in February 2020

– Some centres more than 1 beam audited

• 15 beams basic audit

• 17 beams E2E audit

SRS: Basic tests

2 4 6 8 10 12 14

10 cm - standard 8 cm - standard -

corrected 20 cm - standard -

corrected 8 cm - SSD85 -

corrected 5 cm - small field - corrected

Number of beams within %

Alanine-EPR basic tests

nr.of beams < 1% nr. of beams < 2% nr. of beams < 3% nr. of beams < 5%

10 cm -

standard 8 cm - standard -

corrected 20 cm - standard -

corrected 8 cm - SSD85 -

corrected 5 cm - small field - corrected

% of beams < 1% 78.57 57.14 71.43 42.86 28.57

% of beams < 2% 92.86 85.71 92.86 85.71 64.29

% of beams < 3% 100.00 100.00 92.86 92.86 100.00

% of beams < 5% 100.00 100.00 100.00 100.00 100.00

22

Verslag van het college van geneesheren RADIOTHERAPIE-ONCOLOGIE 1 januari 2019 – 31 december 2019 Rapport du collège de médecins RADIOTHERAPIE- ONCOLOGIE 1 janvier 2019 – 31 décembre 2019