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
contract 1 januari 2014 – 31 december 2014
Rapport du collège de médecins
R A D I OT H E R A P I E - O N C OL OG I E
contrat 1 janvier 2014– 31 décembre 2014
Prof. Yolande Lievens
Voorzitter-PrésidentInhoudstafel
Deel 1: Werking van het college van radiotherapeuten
A/ inleiding 4
B/ organisatie van het college van radiotherapie-oncologie 5
C/ plenaire vergaderingen 7
Deel 2: Resultaten 1. BELdART Dosimetry 19
2. Prima-RT national benchmark 27
3. Procab 28
4. SBRT 32
5. Radiotherapy Utilization in Belgium 47
6. Audits 54
Deel 3 : Voorstelling nieuwe projecten 1. Quality Indicators : Structure 56
2. Quality Indicators : Process 64
3. Quality Indicators : Outcome 75
D
EEL
1
W
ERKING VAN HET
C
OLLEGE VAN RADIOTHERAPIE
A/ 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).
Eind 2012 werd een nieuw college samengesteld (KB 26/11/2012), de
samenstelling vindt u onder B/.
In 2014 is aan verschillende projecten gewerkt:
1. BELdART Dosimetry
2. Prima-RT national benchmark
3. Procab
4. SBRT
5. Radiotherapy Utilization in Belgium
6. Audits
De stand van zaken van deze verschillende projecten vindt U in deel 2
van dit verslag.
In februari 2014 ging de jaarlijkse vergadering van het college en de
diensthoofden van alle Belgische radiotherapie centra door. Op deze
vergadering waren ook de fysici aanwezig. Feedback werd gegeven
over de uitgevoerde projecten, en de planning voor 2014-2015 werd
voorgesteld en besproken.
In deel 3 vindt U een voorstelling van de nieuwe projecten:
1. Quality Indicators : Structure
2. Quality Indicators : Process
3. Quality Indicators : Outcome
B/ Samenstelling van het college van
radiotherapeuten-oncologen
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)
Huidige samenstelling van het college sinds eind 2012 (KB
26/11/2012)
Prof. Y. Lievens (voorzitter)
Dr. V. Remouchamps (ondervoorzitter)
Prof. C. Weltens (contactpersoon en secretaris)
Prof. D. Van den Weyngaert
Dr. R. Burette
Dr. L. Moretti
Dr. N. Jansen
Dr. K. Stellamans
Naast de door het ministerie aangestelde leden, wordt het college
sinds zijn installatie vervoegd door experten (fysici, verpleegkundigen
en radiotherapeuten).
Vanaf begin 2013 is de samenstelling van de commissie van experten
als volgt:
radiotherapeuten
Prof. P. Scalliet
Dr. P. Spaas
Dr. P. Huget
Dr. O. De Hertogh (voorzitter BVRO)
physici
A. Rijnders
F. Vanneste
M. Van Dycke
Prof. D. Verellen
K. Feyen (voorzitter BVZF/BSPH)
verpleegkundigen
G. Vandevelde
P. Bijdekerke
C/ Plenaire vergaderingen
Volgende plenaire vergaderingen werden gehouden in 2014:
DATUM
28-01-2014
26-03-2014
03-06-2014
20-11-2014
De verslagen van bovenstaande vergaderingen zijn in dit jaarverslag
geïncludeerd, u vindt ze op de volgende pagina’s.
Minutes of the meeting of 28-01-2014
***provisional report***College:
R. Burette, N. Jansen, Y. Lievens, L. Moretti, V. Remouchamps, K. Stellamans, D. Van den Weyngaert, C. Weltens
Experts:
Radiation Oncologists: P. Spaas, P. Huget Physicist: M. Van Dycke
Invited:
Representatives VVRO/French speaking nurses: P. Bijdekerke, G. Vandevelde, W. Hontoir
Representative of the QMS: F. Van Houtte
Representatives of the Ministry of Health: S. Van den Bogaert, A. Perissino
Apologized: P. Scalliet, O. De Hertogh, A. Rijnders, , F. Vanneste, D. Verellen, K. Feyen, J. Leroy
Approval of the minutes of the meeting of 03-10-2013
Report: Remarks see report in attachment
The standard lab from Ghent is closing. SCK eventually wants to take over this task, by 2015-2016. First, investments are necessary, for lab and operational costs ( 100.000 +40.000/y) Since this represents an increase in the costs, the radiotherapy community is faced with a budgetary problem. FANC will investigate how this is done in other countries and at what cost. On the other hand, for the moment we pay the Ghent Lab half of the price compared to other countries...
A report will be made for the FOD.
1.
IMRT
Michel Van Dycke showed the results of the questionnaire on IMRT. The results can be found in an attachment to this report.
Suggestion: It is clear that a lot of interesting data can be analysed and discussed in this report. These data should be used to make recommendations for Quality Assurance in IMRT and may answer what is minimum, optimal quality control. Enormous workload, what are the recommendations? Consensus within the BHPA: based on their report define minimum criteria for QA.
2.
PROCAB
PROCAB is a national quality assurance project aiming at the improvement of target and OAR delineation in breast cancer radiotherapy.
First a pilot phase is planned that will start in February. The delineation atlas is available on website BVRO/ABRO. A national delineation training session will be organized before
the spring meeting, and the actual start of the feedback will be on March 1th. Concerning the funding, some funding by the cancer plan has been realized but the exact modalities have to be discussed with Prof. Scalliet.
3.
NATIONAL DATABASE
1) QUALITY INDICATORS (C. Weltens)
The college of radiotherapy has a long history of interest in quality indicators. However, some of the projects were less successful mainly to excess in workload or to a lack of resources. Quality managers can gather data for indicators
Interest in clinical indicators however is still present, and also the quality managers are interested in the measurement of QI.
The members of the college agree that we need structure, process and outcome indicators
Stucture: eg. EORTC, QUARTS databases on radiotherapy infrastructure and personel Process
Outcome: eg. mortality, local recurrence and side effects of RT treatments
Ad hoc working parties to define the QI are started. They have to propose quality indicators taking into account that the indicators have to be validated and easy to measure.
2) DATABASE
All the data have to be stored and kept up to date in a database. K. Feyen investigatee the use of prisma RT, but this is not a suitable database, because the data are linked to individual patients.
K. Feyen will explore the possibilities of the database of Maxim Coevoet. 3) EVALUATION of quality, REPORT, FEEDBACK (K. Stellamans)
See slides Karin Stellamans
Around the world, substantial differences exist in the “uptake” of radiotherapy. For instance, in Australia calculations show that 52% of all cancer patients may benefit from radiotherapy but only 38 of all cancer patients actually get radiation therapy. Similar data are available for the UK and The Netherlands, but this type of data is not available in Belgium.
These data could be obtained from the Cancer Registry, that is willing to cooperate. However their resources and man power are limited.
Examples of possible questions for the Cancer Registry are: data from 2008 or 2009, 3y follow up, % of ca treated with RT % rt for breast conserving surgery?
Conclusion Quality Indicators:
3 working groups have been set up: structure, process, outcome. They have to answer following questions:
a. What is available in the literature? b. What QI do we propose?
c. How to organize analysis and feedback? STRUCTURE: YL KARIN PS
PROCESS: FREDERIK NICO MVD LUIGI OUTOME: CW DVDW VR RB
4.
QUALITY MANAGERS AND PRISMA RT
Frederik Van Houtte (slides in attachment)
Frederik explains the mission of the Quality managers society. The first mission was to support the implementation of Prisma RT. However, the aims and tasks of the Society are broader: they want to support all projects relating to quality management in
radiotherapy and give guidance to the departments in benchmark reporting. Questions that have to be answered are: What is the common threshold for reporting? Or report everything!? How consistent is the analysis and what is the consensus on set of useful context variables.
The QMS also needs to clarify the boundaries and relation with the college, departments, Adheco.
VARIA
Walter Hontoir on nursing permanent education in radiotherapy in Wallonia.
There is no, or nearly no radiotherapy education for nurses working in radiotherapy departments. Radioprotection courses in radiotherapy is optional. The schooling « Infirmier en radiothérapie » appears to attract 10 students per year or even less…. Imaging and radiotherapy course exist in postgraduate education and in Liege the postgraduate technologists in medical imaging have some radiotherapy courses. In the Flemish part of Belgium the HUB offers radiotherapy education for nurses and technologists.
Plan to start in 2015-2016: new proposal for 60 study points education common for all "hoge scholen Ecoles superieures" is in preparation.
Dr Leroy is making a report about recommendation for education of nurses and technologists.
Next meeting
26-3-2014
Weltens Caroline 15-5-2014
Minutes of the meeting of 26-03-2014
***provisional report***College:
R. Burette, N. Jansen, Y. Lievens, L. Moretti, V. Remouchamps, K. Stellamans, D. Van den Weyngaert, C. Weltens
Experts:
Radiation Oncologists: P. Spaas, P. Huget Physicist: M. Van Dycke
Invited:
Representatives VVRO/French speaking nurses: P. Bijdekerke, G. Vandevelde, W. Hontoir
Representative of the QMS: F. Van Houtte
Representatives of the Ministry of Health: S. Van den Bogaert, A. Perissino
Apologized: P. Scalliet, O. De Hertogh, A. Rijnders, , F. Vanneste, D. Verellen, K. Feyen, J. Leroy
APPROVAL OF THE MINUTES OF THE MEETING OF 28-1-2014
Report: Remarks see report in attachment
The standard lab from Ghent is closing. SCK eventually wants to take over this task, by 2015-2016. First, investments are necessary, for lab and operational costs (100.000 + 40.000/y). Since this represents an increase in the costs, the radiotherapy community is faced with a budgetary problem. SCK will investigate how this is done in other countries and at what cost. For the moment we pay the Ghent Lab half of the price compared to other countries.
A report will be made about the actual situation in Belgium and the approach in neighboring countries in order to ask the FOD how this issue can be dealt with in the future
1. IMRT
Michel Van Dycke showed the results of the questionnaire on IMRT. The results can be found in an attachment to this report.
Suggestion: It is clear that a lot of interesting data can be analysed and discussed in this report. These data should be used to make recommendations for Quality Assurance in IMRT and may answer what is minimum, optimal quality control. Enormous workload, what are the recommendations? Consensus within the BHPA: based on their report define minimum criteria for QA.
2. PROCAB
PROCAB is a national quality assurance project aiming at the improvement of target and OAR delineation in breast cancer radiotherapy.
First a pilot phase is planned that will start in February. The delineation atlas is available on website BVRO/ABRO. A national delineation training session will be organized before the spring meeting, and the actual start of the feedback will be on March 1th. Concerning the funding, some funding by the cancer plan has been realized but the exact modalities have to be discussed with Prof. Scalliet.
3. NATIONAL DATABASE
1) QUALITY INDICATORS (C. Weltens)
The college of radiotherapy has a long history of interest in quality indicators. However, some of the projects were less successful mainly to excess in workload or to a lack of resources. Quality managers can gather data for indicators
Interest in clinical indicators however is still present, and also the quality managers are interested in the measurement of QI.
The members of the college agree that we need structure, process and outcome indicators
Stucture: eg. EORTC, QUARTS databases on radiotherapy infrastructure and personel Process
Outcome: eg. mortality, local recurrence and side effects of RT treatments
Ad hoc working parties to define the QI are started. They have to propose quality indicators taking into account that the indicators have to be validated and easy to measure.
2) DATABASE
All the data have to be stored and kept up to date in a database. K. Feyen investigated the use of prisma RT, but this is not a suitable database, because the data are linked to individual patients.
K. Feyen will explore the possibilities of the database of Maxim Coevoet and of commercial systems (e.g. Outsystems).
3) EVALUATION of quality, REPORT, FEEDBACK (K. Stellamans) See slides Karin Stellamans
Around the world, substantial differences exist in the “uptake” of radiotherapy. For instance, in Australia calculations show that 52% of all cancer patients may benefit from radiotherapy but only 38 of all cancer patients actually get radiation therapy. Similar data are available for the UK and The Netherlands, but this type of data is not available in Belgium.
These data could be obtained from the Cancer Registry, that is willing to cooperate. However their resources and man power are limited.
Examples of possible questions for the Cancer Registry are:
data from 2008 or 2009, 3y follow up, on which a number of parameters can be defined, such as:
- What is% of ca patients treated with RT, all or not further stratified by indication, by technology, by type of hospital etc.
- What is the % of rt for breast conserving surgery? Conclusion Quality Indicators:
3 working groups have been set up: structure, process, outcome. They have to answer following questions:
a. What is available in the literature? b. What QI do we propose?
STRUCTURE: YL KARIN PS
PROCESS: FREDERIK NICO MVD LUIGI OUTOME: CW DVDW VR RB
4. QUALITY MANAGERS AND PRISMA RT
Frederik Van Houtte (slides in attachment)
Frederik explains the mission of the Quality managers society. The first mission was to support the implementation of Prisma RT. However, the aims and tasks of the Society are broader: they want to support all projects relating to quality management in
radiotherapy and give guidance to the departments in benchmark reporting. Questions that have to be answered are: What is the common threshold for reporting? Or report everything!? How consistent is the analysis and what is the consensus on set of useful context variables.
The QMS also needs to clarify the boundaries and relation with the college, departments, Adheco.
VARIA
Walter Hontoir on nursing permanent education in radiotherapy in Wallonia.
There is no, or nearly no radiotherapy education for nurses working in radiotherapy departments. Radioprotection courses in radiotherapy is optional. The schooling « Infirmier en radiothérapie » appears to attract 10 students per year or even less…. Imaging and radiotherapy course exist in postgraduate education and in Liege the postgraduate technologists in medical imaging have some radiotherapy courses. In the Flemish part of Belgium the HUB offers radiotherapy education for nurses and technologists.
Plan to start in 2015-2016: new proposal for 60 study points education common for all "hoge scholen Ecoles superieures" is in preparation.
Dr Leroy is making a report about recommendation for education of nurses and technologists.
NEXT MEETING
3 June 2014
Weltens Caroline 15-5-2014
Minutes of the meeting of 03-06-2014
***provisional report***College:
R. Burette, N. Jansen, Y. Lievens, L. Moretti, V. Remouchamps, K. Stellamans, C. Weltens
Experts:
Radiation Oncologists: P. Spaas, P. Scalliet Physicist: F. Vanneste, M. Van Dycke Invited:
Representatives VVRO/French speaking nurses: P. Bijdekerke, W. Hontoir Representative of the QMS: F. Van Houtte
Representatives of the Ministry of Health: S. Van den Bogaert
Apologized: G. Vandevelde, O. De Hertogh, A. Rijnders, D. Verellen, K. Feyen, D. Van den Weyngaert, P. Huget
APPROVAL OF THE MINUTES OF THE MEETING OF 26-03-2014
No remarks.QUALITY INDICATORS
The entire meeting of the college was dedicated to a discussion on the quality indicator project.
Three working groups reported on work that was done with respect to the definition of a set of indicators. The three working groups prepared a document with
suggestions for respectively structure, process and outcome indicators. These reports can be found in attachment.
An overview of possible QI was made.
Per indicator, attention was paid to different issues: definition of the indicator, validity of the indicator, feasibility of data collection, relation with radiotherapy quality, etc. From this extensive list of indicators, a selection will be made by the working groups.
When selecting the indicators we will have to take into account the scope of the FOD/SPF, their expectations and their possibilities for funding the project.
We learn from Saskia Van den Bogaert (FOD/SPF) that the colleges have to decide themselves upon the number of indicators they measure. The aim is to improve quality, not to measure as much indicators as possible. This means that 5 indicators is sufficient. The cost of the data acquisition and handling has to fit in the budget of the college. For the moment, the installation and maintenance of a new database for the radiotherapy college is not supported nor funded by the FOD/SPF. The use of existing databases and existing data is recommended. However, a uniformisation of national registries in planned (by 2018) in the framework of the e-Health plan, as well as a meeting between the department of data management of the FOD/SPF and the colleges.
It was decided to start with a limited set of indicators, to collected by all radiotherapy departments. Per group, a maximum of 10 indicators can be
suggested to be measured in 2015. If indicated, some indicators (eg. Outcome) for which prospective patient data collection is needed, can be measured for a limited period time (eg. ½ year).
The set can be expanded in function of the results of this first project.
Proposed TOP 5 indicators for process, structure and outcome STRUCTURE
1. Uptake rt 2. Workload
3. Equipment and number of treatments 4. Complexity of treatments
5. Waiting list PROCESS
1. Waiting lists for palliative RT 2. Timing: total treatment time 3. Treatment delay
OUTCOME
1. · Acute side effects gr 3-4 1. Rectite
2. Skin 3. Cystitis 4. Oesofagitis 2. Chronic side effects 3. V 20
NEXT MEETING
20-11-2014
Minutes of the meeting of 20-11-2014
***provisional report***College:
R. Burette, N. Jansen, Y. Lievens, L. Moretti, V. Remouchamps, K. Stellamans, D. Van den Weyngaert, C. Weltens
Experts:
Radiation Oncologists: P. Spaas, P. Scalliet, P. Huget Physicist: A. Rijnders, F. Vanneste, M. Van Dycke Invited:
Representatives VVRO/French speaking nurses: G. Vandevelde, P. Bijdekerke, W. Hontoir
Apologized:
O. De Hertogh, D. Verellen, K. Feyen, Representative of the QMS: F. Van Houtte
Representatives of the Ministry of Health:S. Van den Bogaert
APPROVAL OF THE MINUTES OF THE MEETING OF 03-06-2014
No remarks.QUALITY INDICATORS
Three working groups reported on work that was done with respect to the definition of a set of indicators. It was decided to start with a limited set of indicators, to collected by all radiotherapy departments. If indicated, some indicators (eg. Outcome) for which
prospective patient data collection is needed, can be measured for a limited period time (eg. ½ year).
The set can be expanded in function of the results of this first project. Proposed indicators for process, structure and outcome
STRUCTURE
1. Uptake RT: RT utilisation (courses/cancer incidence)
2. Workload (courses/RTO; courses/RTT, courses/phycisist, courses/dosimetrist, fractions/RTT)
3. Courses/MV equipment 4. Subspecialisation/RTO
5. Proportion of 3D treatments, of IMRT treatments 6. MV units/centre, MV units/inhabitants
PROCESS
Timing: total treatment time
1. Extract data from the patient file
OUTCOME
Acute side effects gr 3-4
1. FOR: Breast cancer with nodal irradiation 2. FOR: Prostate
3. FOR: Lung
Measure during RT and up to 4 weeks after RT: a) Skin
b) Rectitis c) Cystitis d) Oesofagitis
VARIA
Short overview of PROCAB Cf. Newsletter (see attachment)
Project Cancer Registry (K. Stellamans and Y. Lievens) will start soon SBRT project: YL and D. Verellen
BRAVO
BELDART II Audit of 19 departments of IMRT prostate
NEXT MEETING
Next meeting 26-2-2015D
EEL
2:
RESULTATEN
065 2797705
1. BELdART
2. Prima-RT national benchmark
Frederik Vanhoutte
3. Procab
Prof. Dr. C. Weltens
Prof. Dr. C. Weltens
On behalf of the PROCAB team
1. Aim of the study
Radiation therapy is an essential component of the curative treatment of breast cancer. Treatment plans and treatment dosimetry for breast radiation treatments is made on a CT scan made in treatment position. On this CT scan, first the target volumes (the breast/chest wall and regional nodes) and normal tissues (organs at risk, OAR) are delineated. In the current project, we aim to improve the quality of the delineation of the target volumes and OAR in cancer of the breast. This will allow it to further reduce safety margins around target volumes and to limit the dose to normal tissues. Additionally, the dosimetric parameters of the treatment plan, as well as the compliance with dose constraints for the heart and lungs evaluated. All these actions can ensure that dose to the heart and lungs will decrease. Less cardiac and pulmonary toxicity will be beneficial for BCa patients and their quality of life will improve.
2. Optimisation of existing delineation guidelines
In a first phase (2013) new guidelines were created for the delineation of the locoregional nodal regions in breast cancer radiation therapy. A national consensus meeting was held and the guidelines were (along with atlases) published on the website of the BVRO/ABRO (Figure 1).
In a second phase(2013-2014), a European consensus was obtained and the guidelines were published in Radiotherapy and Oncology (the European Journal for Radiotherapy) (Figure 2).
Figure 2: Publication of delineation guidelines
3. Implementation of the guidelines
In 2014 with a "review" of the delineations was started. Of the 25 Belgian radiotherapy centres, 23 centres participate in this project. The contoured structured are forwarded to a central review platform. The contours are corrected by an expert and returned within 24 hours. In 2014, more than 500 reviews performed (Figure 3).
Figure 3: Central Review the contours of 567 patients treated in 23 radiotherapy departments.
4. Planning for 2015
In 2015 we plan a continuation of the central review/feedback. We plan to review in 2015 approximately 700 cases. We will also further collect and analyse the dosimetric data in the context of this study. We also plan an evaluation of the learning effect of the central review. Studies shows a learning-effect especially in the initial phase, with a stagnation after a certain number of patients. If this is confirmed in this study, we plan to close the study in 2016.
5. PROCAB costs
The college pays the costs for a part time dosimetrist who runs the daily central review program and provides feedback to the participating centers. The cost for coordinating the study and for the scientific projects, as well as the cost for the purchase and maintenance of the necessary hardware and software are not paid by the College.
6. THE PROCAB TEAM
Dr. K. Verhoeven Dr. V. Remouchamps Dr. Liv Veldeman Dr. C. Kirkove Dr. I. Kindts
Mrs. Tessa Du Toit
(dosimetrist) Mrs. Eszter Hortobagyi (dosimetrist) Prof. Dr. C. Weltens (coördinator)
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