Improving Quality of Head and Neck Cancer Radiotherapy Through Standardized Peer Review

Summary: Chart rounds are a routine QA measure in the field of radiation oncology to review patient diagnosis, radiation prescription, and radiation plan. Due to the complexity of head and neck cancer (HNC), disease specific chart rounds are becoming more common. We implemented a dedicated weekly HNC chart rounds with the goal of standardizing care and improving the quality of treatment across our network by increasing engagement of physicians and dosimetrists. From March 2018-October 2024, HNC chart rounds attendance, cases presented, and changes recommended were evaluated. From 2018-2022, variables were noted by hand on paper, and analysis is limited. Beginning in 2023, data was coded in a Redcap database and included cases presented and modifications recommended to simulation, prescription, contours, and treatment plan. Beginning in 2022, changes were categorized as minor or major based on the impact to a treatment plan. For contour review, minor changes included modifications to expansions, OARs, or minor CTV changes, and major changes included modifications to GTV or lymph node levels. For plan review, minor changes included the addition of bolus, in-vivo dose evaluation, or improvements in dose to OARs, and major changes included the addition of surgery/chemotherapy or modification of a plan due to significant hot/cold spots. From Jan 2021-Oct 2024, 937 cases underwent contour review (116 in 2021, 275 in 2022, 277 in 2023, and 268 through Oct 2024), and 464 treatment plans were reviewed (192 in 2021, 118 in 2023, 154 through Oct 2024). Modification to target/OAR volumes was recommended in 46% of cases. Minor changes were recommended in 20% and major changes in 23% (not coded in 2021). From 2023 to 2024, minor and major changes to contours decreased from 18% to 14% (p=0.21) and 32% to 25% (p=0.06), respectively. Treatment plan changes were recommended in 14%; minor changes in 22% overall, 9% in 2023 and 13% in 2024. Major changes recommended in 14% overall, 9% in 2023 and 5% in 2024. Repeat simulation recommended in 2% of cases, and a change in dose recommended in 15% (5% major, 10% minor). Main campus H&N radiation oncologists and dosimetrists attended weekly from initiation. Median virtual attendance per regional campus (≥1 physician) was 3% (IQR 3%-16%) in 2018 and 30% (IQR 18%-59%) in 2024. Regional dosimetrists were encouraged to attend in 2020, and median attendance was 33% (IQR 21%-57%) in 2020 and 73% (IQR 47%-82%) in 2024. Implementation of HNC chart rounds resulted in a significant number of minor and major changes to contours and treatment plans which has the potential to impact patient outcomes. Increasing participation by regional physicians and dosimetrists correlates with an increase in cases reviewed and a decrease in the proportion of changes recommended, demonstrating an improvement in quality. Jenna Kocsis, MD (Presenting Author) - Cleveland Clinic; Neil Woody, MD (Co-Author) - Cleveland Clinic; Jacob Miller, MD (Co-Author) - Cleveland Clinic; Eric Murray, CMD (Co-Author) - Cleveland Clinic; Shlomo Koyfman, MD (Co-Author) - Cleveland Clinic; Shauna Campbell, MD (Co-Author) - Cleveland Clinic