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
- For TTS – If greater than standards in Table 1 unless preceding
surgery or chemotherapy was delayed or treatment toxicity occurred
which then impacted on TTS.
- For TDD - If dose of radiation was lesser or greater than standards in
Table 1.
- For TTC – If the duration of radiation was 5% more than the total
number of fractions prescribed with allowance for weekends.
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.