Internal Audit of a Comprehensive IMRT Program for Prostate Cancer: A Model for Centers in Developing Countries?

Department of Radiation Oncology, The Cancer Institute, National University Hospital, Singapore.
International journal of radiation oncology, biology, physics (Impact Factor: 4.26). 03/2009; 74(5):1447-54. DOI: 10.1016/j.ijrobp.2008.10.010
Source: PubMed


With improving regional prosperity, significant capital investments have been made to rapidly expand radiotherapy capacity across Southeast Asia. Yet little has been reported on the implementation of adequate quality assurance (QA) in patient management. The objective of this study is to perform an in-depth QA assessment of our definitive intensity-modulated radiotherapy (IMRT) program for prostate cancer since its inception.
The department's prostate IMRT program was modeled after that of the University of California San Francisco. A departmental protocol consisting of radiotherapy volume/dose and hormone sequencing/duration and a set of 18 dose objectives to the target and critical organs were developed, and all plans were presented at the weekly departmental QA rounds. All patients treated with definitive IMRT for nonmetastatic prostate cancer were retrospectively reviewed. Protocol adherence, dosimetry data, toxicities, and outcomes were evaluated.
Since 2005, 76 patients received IMRT: 54 with whole-pelvis and 22 with prostate-only treatment. Of the 1,140 recorded dosimetric end points, 39 (3.3%) did not meet the protocol criteria. At QA rounds, no plans required a revision. Only one major protocol violation was observed. Two and two cases of Grade 3-4 acute and late toxicities, respectively, were observed. Five (8.8%) patients developed proctitis, but only one required argon laser therapy.
Our comprehensive, practice-adapted QA measures appeared to ensure that we were able to consistently generate conforming IMRT plans with acceptable toxicities. These measures can be easily integrated into other clinics contemplating on developing such a program.

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    • "However, there are also various Asian countries in which 47 to 73% of patients are already in Stage IV during presentation (Mendoza, 2005). Perhaps it has been considered that prostate carcinoma is much less common and low risk in Asia compared to the West and therefore, more attention has been shifted to other diseases thus neglecting this lethal disease (Sim and Cheng, 2005) Few Asian countries, such as Singapore, have moved ahead well in advanced, with the value of PSA upon diagnosis comparable to the west (Koh et al., 2009; Wadhwa et al., 2009) The fact that there are up to 12.1% of our patients defaulted follow-up means that there are patients who would not comply with the treatment regimen provided and rather choose other modes of alternative therapy, which is a common feature in our region. Commonly these patients would only return when the disease has spread to a stage beyond curative intent. "
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