About the lead author:
Erin F. Gillespie, MD
University of California San Diego
Department of Radiation Medicine and Applied Sciences
La Jolla, CA 92093
Brandi R. Page, MD
Radiation Oncology and Molecular Sciences
Johns Hopkins University School of Medicine
Why is this article contemporary?
The utilization of internet-based educational forums has been developing over the last few years for the sharing of information and standardization of practice patterns.
As technical details of treatment planning become more involved and the complexity of treatment planning increases with our ability to deliver higher doses in fewer treatment fractions—and as newer treatment modalities are being developed—accurate target and organ delineation, and sometimes even the ability to obtain expert opinions, have become even more critical. Numerous reports state inter-observer variability in practice exists not only between experts in our field in each disease site, but especially among trainees and in centers that have lower volumes of certain types of cases. Currently there are limited resources for residents and practitioners to refer to for specific help on contouring both target volumes and organs at risk in the modern era. The utilization of online contouring atlases has started to address this need, but more comprehensive educational materials are an unmet need for this very critical problem.
The e-contouring program documented in this article has a unique niche in this regard, allowing for a novel, web-based, user-friendly, accessible, interactive approach to facilitate interaction between colleagues for decision support. As our field is a dynamically and rapidly changing its practices, we are in great need of these types of innovative educational interventions. Here, the authors present a novel approach to ongoing education and quality improvement. While it is clear that the eContour website is not meant to replace experienced clinician judgment in any case, and that more cases are needed, it represents an excellent innovation that hopefully just represents the beginning of the development of more comprehensive online educational resources for learning residents and continuing-to-learn practitioners.
Background and Purpose
Target delineation in radiation oncology is critical to delivering safe and effective radiation therapy. Evidence from clinical trials suggests that poor radiation treatment plan quality decreases the rates of overall survival and increases rates of toxicity. The introduction of new technologies in radiation oncology, including intensity-modulated radiotherapy (IMRT), image-guided stereotactic radiosurgery (SRS), and stereotactic body radiation therapy (SBRT) have improved our ability to deliver higher doses of radiation to the tumor and areas at risk while avoiding normal tissues. These highly conformal radiation fields leave little margin for error, highlighting the critical importance of accurate contouring.
Results and Conclusions
There is substantial inter-observer variability among radiation oncologists in target delineation, which is most notable in head-and-neck and lung cancers, although it has also been shown in prostate cancer due to variable definitions of the prostate apex. This variation can be reduced when contouring atlases and consensus guidelines are referenced. Unfortunately, barriers exist that limit clinicians from seeking answers to their clinical questions (such as details of high-risk clinical target volume coverage), which results in decreased adherence to the standard of care. Effective strategies to implement clinical guidelines emphasize intervention at the time of the patient encounter, which is also a recommended approach to motivating adult learning. eContour (eContour.org) is a novel, web-based, interactive contouring resource that aims to facilitate access to decision support through high-yield radiation treatment recommendations that are free and available at the point of care.
Target delineation in radiation oncology—commonly referred to as contouring—represents the crux of delivering safe and effective radiation therapy. Contours not completely encompassing the tumor or regions at risk of microscopic disease lead to increased rates of disease recurrence and decreased survival.1-3
On the other hand, contours that are too large have the potential to lead to increased rates of toxicity.4
The introduction of new technologies in radiation oncology, including intensity-modulated radiotherapy (IMRT), image-guided stereotactic radiosurgery (SRS), and stereotactic body radiation therapy (SBRT), has improved our ability to deliver higher doses of radiation to the tumor and areas at risk while avoiding normal tissues.