Table 2.
Prioritization of targets for peer review
| Item for peer review | Prioritization | Rationale for priority level | Timing of peer review and associated comments | Example clinical situations where peer review is anticipated to be particularly useful |
|---|---|---|---|---|
| 1) Decision to include radiation as part of treatment | Level 2 | Guidelines often exist, but these decisions are often individualized | Pretherapy preferred | Unusual/nonguideline cases |
| 2) General radiation treatment approach | Level 3 | There are many guidelines and best practice statements that address this issue. If standard dose/volume constraints are respected, patient risks are low regardless of the specific RT approach taken. | Preradiation preferred. Altering some aspect of the treatment approach once RT has been initiated can be cumbersome (eg, image guidance approach), while other aspects are more easily changed during RT. The safest environment is one where mid-treatment changes are minimized. | Retreatment cases |
| 3) Target definition⁎ | Level 1 | Every patient's tumor is different and visualization on different types of images can vary. Each image fusion is unique. | Pretreatment peer review of how targets are defined (eg, which images and which "pixels") is critical as mistargeting can lead to poor clinical outcomes. Preplanning review is ideal but is not critical for every case. | Tight margins; eg, SBRT |
| 4) Normal tissue image segmentation | Level 3 | There are atlases for normal tissues. | Review of normal tissues can be done during RT since the risks are less (especially for fractionated regiments). Normal tissue pre-RT peer review needed for single and hypofractionation cases. | Tight margins; eg, SBRT |
| 5) Planning directive (dose/volume goals/constraints for targets and normal tissues) | Level 2 | Patient risks are low if standard dose/volume limits are respected. Guidelines and best practice recommendations often exist, but these decisions are often individualized. | Preplanning or pretreatment | |
| 6) Technical plan quality | Level 2 | Normal tissue dose/volume guidance documents are generally available, but the compromises between normal tissue vs target doses are often patient specific. | For conventional fractionation, this may be acceptable to perform during RT, as there is usually an opportunity to alter the plan. The safest environment is one where mid-treatment changes are minimized. | IMRT, SBRT |
| 7) Treatment delivery (eg, patient setup) | First day is Level 1, especially for curative cases. Other days are Level 2. | The first day's setup is critical to avoid systematic errors and their propagation. | Therapist peer review of setup must be done pre-RT for the first fraction, and ideally for all subsequent fractions. Portal or localization image peer review must be done before the second treatment. Physicist and physician involved with pretreatment QA for complex cases (eg, SBRT). | IMRT (since portal or localization imaging often does not provide independent assessment of target volume location) |
Level 1 indicates highest priority for peer review (where there are marked interpatient variations), Level 2 next highest (where there are often guidelines/atlases to aid in decision), and Level 3 the next (other targets for peer review).
RT, radiation therapy; IMRT, intensity modulated radiation therapy; SBRT, stereotactic body radiation therapy.
⁎
Target definition includes the decision regarding the need for multimodality imaging, the fusion of the images, and the target definitions on the images.