The Profession
Are We Choosing Wisely in Radiation Oncology Practice–Findings From an Australian Population-Based Study

https://doi.org/10.1016/j.ijrobp.2019.03.048Get rights and content

Purpose

To evaluate the adoption of the Royal Australian and New Zealand College of Radiologists Choosing Wisely (CW) radiation oncology recommendations before and after the release of the recommendations.

Methods and Materials

The Victorian Radiotherapy Minimum Data Set captures details of radiation therapy delivered in the state of Victoria, Australia. This study included the following 3 groups of patients relevant to 3 of the 5 CW recommendations: women who received a diagnosis of early-stage breast cancer at age ≥50 years who had breast radiation therapy (excluding nodal irradiation), patients with cancer who had palliative bone radiation therapy (excluding those with primary bone malignancies), and patients with cancer who had stereotactic radiation therapy to the brain (excluding those with primary malignancies of the central nervous system). The outcomes of interest were use of hypofractionated breast radiation therapy (<25 fractions), use of long-course palliative bone radiation therapy (>10 fractions), and use of adjuvant whole brain radiation therapy within 1 month of stereotactic radiation therapy. The Cochrane-Armitage test was used to evaluate changes in practice over time.

Results

Among the 8204 patients who had breast radiation therapy, there was an increase in hypofractionation use from 42% in 2013 to 82% in 2017 (P < .001). The progressive increase in hypofractionation use was observed across institutions. Of the 15,634 courses of palliative bone radiation therapy delivered, only 1279 (8%) were >10 fractions, and this decreased from 10% in 2013 to 5% in 2017 (P < .001). Of the 1049 patients who received stereotactic radiation therapy for brain metastases, only 2% had adjuvant whole brain radiation therapy, and this decreased from 4% in 2013 to 0.7% in 2017 (P = .02).

Conclusions

There was a significant change in radiation oncology practice in Australia between 2013 and 2017, in line with the CW recommendations. However, some of the recommendations need to be revised to reflect the rapidly evolving evidence in radiation oncology.

Introduction

In 2010, Howard Brody challenged medical specialty societies in the United States to create a list of the “top 5” low-value medical tests or treatments that were overused or misused.1 The American Board of Internal Medicine responded by introducing the Choosing Wisely (CW) campaign to engage clinicians and patients in conversation about unnecessary non–evidence-based tests and treatments. The American Society for Radiation Oncology (ASTRO) first embraced the CW campaign by introducing 5 recommendations on evidence-based radiation oncology practice in 2010,2 followed by another 5 recommendations the following year.3 Several international radiation oncology societies, such as the UK Royal College of Radiologists4 and the Canadian Association of Radiation Oncology,5 have followed suit, with tailored CW recommendations to meet the unique needs and healthcare systems of the respective countries.

The Royal Australian and New Zealand College of Radiologists Faculty of Radiation Oncology has also taken on this challenge, having developed 5 radiation oncology–specific CW recommendations in 2016 (Table 1).6 These recommendations are largely an adaptation of the ASTRO recommendations. The aim of this study is to assess the adoption of the CW recommendations evaluable using a population-based administrative dataset over time.

Section snippets

Data source

The Victoria Radiotherapy Minimum Data Set (VRMDS) is one of the administrative databases maintained by the Victoria Department of Health and Human Service. The VRMDS captures all episodes of radiation therapy delivered across all radiation therapy services in the state of Victoria, Australia.

Study population

This study included patients with cancer who received radiation therapy between 2013 (before the CW campaign) and 2017 (after release of the CW recommendations) as captured in the VRMDS. Group 1 included

Results

Of the 8204 patients who had breast radiation therapy (Group 1), 5356 (65%) had hypofractionation. There was an increase in uptake of hypofractionation from 42% in 2013 to 82% in 2017 (P < .001) (Table 2). Although patients treated in private (58%) and regional centers (56%) were less likely to have hypofractionation compared with patients treated in public (71%) and metropolitan (68%) institutions, respectively (P < .001) (Table 3), the progressive increase in uptake of hypofractionation was

Discussion

This is the first population-based study in Australia to evaluate adoption of the CW recommendations since the release of the Royal Australian and New Zealand College of Radiologists radiation oncology CW recommendations in 2016. For all 3 evaluable recommendations, we observed a change in practice in line with the CW recommendations.

To ensure maximal impact of the CW campaign, its recommendations need to focus on noncontroversial evidence-based practice and where there is reliable local data

Conclusions

This population-based study in Victoria, Australia, has shown increasing adoption of evidence-based practice in radiation oncology, in line with the CW recommendations, though it is not possible to confirm whether the CW campaign itself directly influenced the change in practice. Some of the CW recommendations may also need to be revised to reflect rapidly evolving evidence in the field of radiation oncology.

Acknowledgment

We acknowledge the assistance of the Victorian Department of Health and Human Services Center for Victorian Data Linkage (CVDL) in providing access to the data.

References (12)

There are more references available in the full text version of this article.

Cited by (10)

  • Palliative radiotherapy in bones

    2023, Palliative Radiation Oncology
  • Radiotherapy-specific quality indicators at national level: How to make it happen

    2023, Radiotherapy and Oncology
    Citation Excerpt :

    As such, there has been a growing interest in defining radiotherapy-specific QIs that can be measured both locally and at a multicentric level and that can guide radiotherapy departments in setting up quality improvement initiatives. While several publications have mostly focussed on the development of general QIs [8,9,12,40,41], others have targeted disease-specific QIs with a focus on developing process QIs [11,42–47]. In Belgium, the development of radiotherapy-specific QIs has been recommended by the federal government, in the context of the National Cancer Plan, to help radiotherapy departments further optimise the quality of the delivered care.

  • Contemporary Practice Patterns for Palliative Radiation Therapy of Bone Metastases: Impact of a Quality Improvement Project on Extended Fractionation

    2021, Practical Radiation Oncology
    Citation Excerpt :

    Using national data from the National Cancer Database, Wegner et al7 recently reported that between 2010 and 2015 in patients with lung, breast, and prostate cancer the rate of EF decreased from 34% to 15%. Other groups have demonstrated use of EF ranging in frequency from 8% to 29.5%.7,17-19 Our current results showing infrequent EF use in our Michigan consortium compare favorably with these previous reports.

View all citing articles on Scopus

Disclosures: none.

View full text