Volume 84  Number 3S  Supplement 2012
a Cox proportional hazards model was used to determine predictive factors
of outcome.
Results: Median follow-up was 32.2 months (range 1.8-137.7 months).
Median LRC and OS were 16.7 and 17.2 months, respectively. Patients
treated with IMRT had superior LRC versus non-IMRT (27 vs. 5.4 months,
p < 0.001). Dose 50 Gy (p < 0.001), surgery (p Z 0.003), nasopharynx
subsite (p Z 0.06), lack of organ dysfunction (feeding tube, tracheostomy,
or soft tissue defect) (p < 0.001), time between RT (p Z 0.036), and fewer
recurrences (p Z 0.04) were also associated with increased LRC on
univariate analysis. Charlson index (p Z 0.35) and histology (p Z 0.14)
were not significant predictors of LRC. On multivariate analysis, IMRT (p
Z 0.005), dose 50 Gy (p Z 0.009), surgery (p Z 0.01), nasopharynx
subsite (p Z 0.025), and lack of organ dysfunction (p Z 0.004) were
independently associated with increased LRC.
Conclusions: In this large cohort of recurrent HNC patients treated with re-
RT, we found that IMRT, higher dose, nasopharynx subsite, lack of organ
dysfunction, and surgical resection predicted for longer LRC. As frac-
tionated re-RT requires a demanding course, a shorter hypofractionated
palliative RT course should be considered for patients with negative
features. A nomogram to help physicians make clinical decisions regarding
re-RT is being built and will be presented at the meeting.
Author Disclosure: J. Hong: None. N. Riaz: None. S. Jaffery: None. L.
Salgado: None. C. Chin: None. S. Wolden: None. E. Sherman: None. R.
Wong: None. S. Rao: None. N. Lee: None.
373
Real-time Peer Review Quality Assurance Conferences
Incorporating Physical Examination for Head-and-Neck Cancer
Radiation Therapy Result in Clinically Meaningful Target Volume
Alteration: Results of a Prospective Volumetric Analysis
R. Tao, C.D. Fuller, G.B. Gunn, B.M. Beadle, J. Phan, S.J. Frank,
A.S. Garden, W.H. Morrison, K.K. Ang, and D.I. Rosenthal; The
University of Texas MD Anderson Cancer Center, Houston, TX
Purpose/Objective(s): Our institution has a long-established compre-
hensive quality assurance conference (QAC) for pts undergoing radiation
(RT) for head and neck cancer (HNC). QAC includes physical examination
(PE), review of diagnostic imaging (DI), pathology, and real-time review
of clinical target volume (CTV) and organ-at-risk (OAR) contours with
consensus approval by multiple attendings specializing in HNC before
dosimetric planning commences. We showed previously that PE was the
most important factor leading to change. This is a volumetric analysis of
target delineation differentials pre- and post-QAC.
Materials/Methods: Prospective data were collected for 54 consecutive pts
undergoing HNC RT presented at a biweekly QAC after simulation and
contouring. The original single-attending-approved pre-QAC CTVs
(CTVpre) were locked before QAC and compared to post-QAC consensus
CTVs (CTVqac). A standard data collection form was used to document
alterations made during QAC. Volumetric comparison was performed
using non-parametric analyses.
Results: All 54 pts were examined; 40 (74%) were examined by 3
faculty. Video-camera endoscopy was performed on 25 pts (46%). CTs
were reviewed in all cases and 15 pts (28%) also had MRI and/or PET
reviewed. New clinical findings on PE were found in 8 pts (15%) from
initial consult leading to planning changes. Volumetric analysis revealed
CTV3 (elective/prophylactic) had a statistically significant greater absolute
volume change in cm3 (p Z 0.02, matched-pair Wilcoxon) compared to
CTV1 (primary high-risk) and CTV2 (intermediate-risk). The mean
absolute difference in CTVqac - CTVpre volume was 31.7  64.0 cm3 (p
< 0.01), with median proportional CTVpre-normalized volumetric alter-
ations of 6%, 9%, and 7% for CTV1, CTV2, and CTV3, respectively.
Conclusions: We confirm that PE is a prime driver of QAC RT planning
changes for HNC in 15% of cases. The majority of CTV alterations were
minor, marginal CTV expansions that were felt to optimize consensus
coverage or give additional OAR sparing. This is the first study to quantify
differences in target volumes as a result of single-institution QAC and
Oral Scientific Sessions S151
documents improved target/tumor coverage secondary to PE. Dosimetric
and radiobiologic analyses of these data are planned.
Author Disclosure: R. Tao: None. C.D. Fuller: None. G.B. Gunn: None.
B.M. Beadle: None. J. Phan: None. S.J. Frank: None. A.S. Garden: None.
W.H. Morrison: None. K.K. Ang: None. D.I. Rosenthal: None.
374
Streamlining the Head and Neck Treatment Process in Radiation
Medicine Using a Kaizen Approach
A. Kapur, N. Riebling, B. Galli, J. Cohen, A. Hochhauser, J. Antone,
D. Moore, N. Adair, L. Potters, and D.L. Schwartz; North Shore LIJ Health
System, New Hyde Park, NY
Purpose/Objective(s): The workflow of head and neck patients in Radi-
ation Medicine includes a cascaded, multi-disciplinary set of processes
with multiple handoffs extended over several weeks prior to the
commencement of treatment. The goal of this work was to streamline the
processes in terms of standardization, efficiency and completeness in a safe
and efficacious manner.
Materials/Methods: A four-step lean six sigma (Kaizen) approach was
deployed which was initiated with mapping out the process from start to
end by a multidisciplinary focus group. Over 200 steps were identified.
Next defects or failure modes were identified at various stages in the
process and organized into workflow, handoff, scheduling, overhead and
patient safety categories. These were then stratified into a risk-mitigation
matrix arranged by impact versus effort. Finally a work plan was created to
develop specific initiatives starting with the ones with high potential
impact in terms of process improvement but that were simple to develop
and implement. The key deliverables of this exercise were a standardized
process map, identification of risk elements and efficacious, prioritized
strategies for risk mitigation and process improvement.
Results: Four initiatives were launched as a result of the kaizen exercise
over a two month pilot phase. The first was streamlining the consultation
and scheduling process including the creation of patient-checklists for
imaging and related studies, daily multidisciplinary huddles and clinic
coordination. The second was the use of process interlocks to prevent
simulations or treatments with missing pre-requisites. The third was
a focused analysis of factors underlying image fusion delays which was
assessed as causing significant delays in treatment planning. Finally
a standardized patient communication and education package was created
to better engage the patients in the process of care. The standard deviation
in the number of days by which previously identified high risk tasks were
delayed was observed to drop from 2.9 to 2.2 days respectively for 62 and
22 patients and the average number of patients with treatment initiation
delays fell during the pilot phase of the project. Fewer simulations were
cancelled as a result of higher compliance with obtaining prerequisite
records in a timely manner.
Conclusions: Lean processes in radiation medicine process have the
potential to improve operational productivity and efficiency in the safe and
expeditious treatment of head and neck cancer patients.
Author Disclosure: A. Kapur: None. N. Riebling: None. B. Galli: None. J.
Cohen: None. A. Hochhauser: None. J. Antone: None. D. Moore: None. N.
Adair: None. L. Potters: None. D.L. Schwartz: None.
375
A Phase II Trial of Proton Radiation Therapy With Chemotherapy
for Nasopharyngeal Carcinoma
A. Chan,1 J.A. Adams,1 E. Weyman,1 R. Parambi,1 T. Goldsmith,2
A. Holman,2 M. Truong,1 P.M. Busse,1 and T. Delaney1; 1Department of
Radiation Oncology, Massachusetts General Hospital, Harvard Medical
School, Boston, MA, 2Department of Speech, Swallow, and Language
Disorders, Massachusetts General Hospital, Boston, MA
Purpose/Objective(s): To assess the treatment outcome and toxicity in
patients with stage III - IVB nasopharyngeal carcinoma (NPC) treated with
proton beam and concurrent chemotherapy.