Institutional peer review led to recommended changes in more than one-quarter of radiotherapy treatment plans, according to results of a systematic review and meta-analysis.
Recommendations for changes that could be considered "major" -- warranting re-planning or re-simulation of treatment because of safety or efficacy concerns -- occurred in more than 10% of cases, Jane Jomy, MSc, medical student at University of Toronto, and colleagues concluded.
"The results suggest that some form of real-time, early peer review may be beneficial for all cases, irrespective of treatment intent or radiotherapy technique," Jomy and colleagues wrote.
Institutional peer review is a "key component" of radiotherapy treatment plans, according to study background.
Review can identify potential safety concerns regarding prescription dose, target volume, organ-at-risk delineation and dosimetry, and other plan parameters.
"Peer review [also] can reduce the occurrence of future errors by serving as an opportunity for radiation oncologists, learners and other staff to hone their skills and establish consensus," researchers wrote.
Jomy and colleagues analyzed health care and medical data bases for papers that reported on the impact of institutional peer review on radiotherapy treatment plans.
They initially identified 9,487 citations published between Jan. 1, 2000, and May 25, 2024.
Their analysis focused on 55 publications, the majority of which came from North America (62%) and had data from 2013 or later (64%). These studies included 96,444 case audits from 10 countries.
The number of change recommendations to radiotherapy treatment plans due to institutional peer review served as the primary endpoint.
Peer review resulted in change recommendations in 28% (95% CI, 21%-35%) of cases.
Peer review led to major change recommendations in 12% (95% CI, 7%-18%) of cases.
Common reasons peer review led to change recommendations included target delineation (45% of reported revisions), target dosage (33%), organ at risk dosage (9%) and organ at risk volume delineation (5%).
Jomy and colleagues found significant differences in change recommendations based on disease sites (P = .003) and team composition (P = .017). They also found significant differences for major change recommendations based on disease sites (P < .001) and timing of the review relative to treatment (P = .028).
"We suspect this difference between disease sites could be related to increased complexity in radiotherapy planning, where multiple steps may need to be reviewed, including clinical exam and multi-modality image integration," researchers wrote. "For instance, one study found that the disease sites with highest proportion of change recommendations [head and neck, gastrointestinal, gynecologic] also were often treated with more advanced radiotherapy techniques compared to other tumor sites."
Various studies revealed other factors that led to significant change recommendations. These included in-person meetings vs. virtual, real-time review vs. post-hoc, presence of neuroradiologists vs. no neuroradiologists, and the number of physicians involved with the peer review.
Researchers acknowledged study limitations, including the heterogeneity of timing, engagement and team composition of peer review across different institutions, and publication bias of studies.
"While we summarized and investigated the changes recommended during the peer review process, what happens afterwards remains unclear," Jomy and colleagues wrote. "One study demonstrated compliance was only 59%, declining significantly with the complexity of the change. Despite the suggestion of plan changes, they are not implemented nearly half of the time, with unknown consequences."