Methods
This audit was conducted at three units of Max Institute of Cancer Care (MICC) Saket, Patparganj and Vaishali which are all healthcare establishments in the private sector located in Delhi National Capital Region. RT in these units was delivered on the Linac accelerator by different techniques. Thermoplastic mould and Vac-loc were used as immobilization device for simulation and treatment for each patient. Patients received five fractions of external beam radiotherapy each week. CT based planning for treatment was done for every patient irrespective of the technique. Anaesthesia for immobilisation and radiation delivery for young children was used as per requirement.
Children with cancer (< 18 years of age) treated with RT from 1st January 2009 to 31st December 2019 in these units were identified. Those who received RT in a relapsed/refractory setting were excluded as were those where the RT was given to the metastatic site only (e.g. lung metastasis). Relevant demographic, clinical and RT data was retrieved from RT records, clinical notes and the pediatric hospital based case registry. Patients were categorized as per International Childhood Cancer Classification (ICCC).(5)
From this cohort, we further selected those ICCC categories and sub-categories where there were at least 5 patients to analyze deviation from accepted norms during their treatment. We looked at three specific parameters in these patients: Time to start (TTS) RT calculated as the time interval between date of diagnosis and start of RT; total dose delivered (TDD) in Grays; and time to complete (TTC) RT which is the interval between the first fraction and the last fraction of the scheduled RT.
For the purpose of this audit, we had to create a standard. Two of the authors (RA and RSA) examined recommendations of contemporary national and international protocols as well as a standard textbook of radiation oncology.(6) From this standards on TTS and TDD were created. These were then reviewed by the other two authors (VG and AKA) and finalised (Table 1). Deviation was defined as
We further examined association deviation with demographic (age, gender, nationality), disease (diagnosis) ad treatment (whether preceding treatment was done at MICC or not) variables. Excel sheet was used for data collection and chi square test was applied to see association between variables. P value less than or equal to 0.05 was considered significant. We also examined any reasons for deviation which could be identified through searching of RT records and clinical notes. The analysis was descriptive and results were tabulated for display.
As this was a retrospective audit, patient consent was not required.