A quality assurance audit: phase III trial of maximal androgen deprivation in prostate cancer (TROG 96.01)

In 1997 the Trans-Tasman Radiation Oncology Group (TROG) performed a quality assurance (QA) audit of its phase III randomized clinical trial investigating the effectiveness of different durations of maximal androgen deprivation prior to and during definitive radiation therapy for locally advanced carcinoma of the prostate (TROG 96.01). The audit reviewed a total of 60 cases from 15 centres across Australia and New Zealand. In addition to verification of technical adherence to the protocol, the audit also incorporated a survey of centre planning techniques and a QA time/cost analysis. The present report builds on TROG's first technical audit conducted in 1996 for the phase III accelerated head and neck trial (TROG 91.01) and highlights the significant progress TROG has made in the interim period. The audit provides a strong validation of the results of the 96.01 trial, as well as valuable budgeting and treatment planning information for future trials. Overall improvements were detected in data quality and quantity, and in protocol compliance, with a reduction in the rate of unacceptable protocol violations from 10 to 4%. Audit design, staff education and increased data management resources were identified as the main contributing factors to these improvements. In addition, a budget estimate of $100 per patient has been proposed for conducting similar technical audits. The next major QA project to be undertaken by TROG during the period 1998-1999 is an intercentre dosimetry study. Trial funding and staff education have been targeted as the key major issues essential to the continued success and expansion of TROG's QA programme.     

Eligibility audits for the randomized neuropathic bone pain trial (TROG 96.05)

In February 1996 the Trans-Tasman Radiation Oncology Group (TROG) initiated a two-arm, multicentre, prospective randomized trial on radiotherapy for neuropathic pain due to bone metastases (TROG 96.05). This trial compares the response to a single 8-Gy fraction with 20 Gy in five fractions. The accrual target is 270 patients. In order to evaluate compliance with eligibility criteria after approximately 1 year of accrual, an independent audit of the first 42 randomized patients was commissioned. This found that only one of these patients did not have genuine neuropathic pain, but that this patient and seven others (19%) had infringements of other eligibility/exclusion criteria for the trial. Accordingly it was decided to continue the full audit up to 90 patients. This detected no further patients without genuine neuropathic pain, and found only one other eligibility infringement (1/48; 2%). It is concluded that this quality assurance (QA) measure undertaken early in the trial led to significantly improved clinician awareness of, and compliance with, eligibility/exclusion criteria. It also enabled an accurate comparison of outcome data for all randomized versus all eligible patients at the time of the preplanned first interim analysis at 90 patients. In view of the excellent compliance demonstrated in the second audit, a one-in-five sampling is proposed for future audits from centres that have already accrued at least five consecutive eligible patients. This is consistent with TROG QA guidelines now operational.     

Definition of stereotactic body radiotherapy

This report from the Stereotactic Radiotherapy Working Group of the German Society of Radiation Oncology (Deutschen Gesellschaft für Radioonkologie, DEGRO) provides a definition of stereotactic body radiotherapy (SBRT) that agrees with that of other international societies. SBRT is defined as a method of external beam radiotherapy (EBRT) that accurately delivers a high irradiation dose to an extracranial target in one or few treatment fractions. Detailed recommendations concerning the principles and practice of SBRT for early stage non-small cell lung cancer (NSCLC) are given. These cover the entire treatment process; from patient selection, staging, treatment planning and delivery to follow-up. SBRT was identified as the method of choice when compared to best supportive care (BSC), conventionally fractionated radiotherapy and radiofrequency ablation. Based on current evidence, SBRT appears to be on a par with sublobar resection and is an effective treatment option in operable patients who refuse lobectomy.     

Acute toxicity and cost analysis of a phase III randomized trial of accelerated and conventional radiotherapy for squamous carcinoma of the head and neck: a Trans-Tasman Radiation Oncology Group study

The primary purpose of the present analysis was to assess the feasibility and acute toxicity of a pure accelerated fractionation regimen in a cooperative group setting. This analysis included the first 320 patients entered on to the Trans-Tasman Radiation Oncology Group (TROG) randomized controlled trial which compared accelerated radiotherapy (ART) with conventional radiotherapy (CRT) in stage III and IV squamous cell carcinoma (SCC) of the head and neck. Patients were randomized to either 59.4 Gy in 33 fractions over 24 days (ART) or to 70 Gy 35 fractions over 49 days (CRT) after being stratified for site and stage. Accrual began in 1991 and the trial was closed on 3 April 1998 with the targeted 350 patients. The 3-year survival for the whole group was 54%, and the 3-year disease-free survival was 41%. Toxicity data were available on 303 patients (148 ART; 155 CRT). Mucosal toxicity was worse in the accelerated arm, and it peaked approximately 3 weeks earlier than the conventional arm. Skin toxicity was equivalent but occurred approximately 7 days earlier in the accelerated arm. Acute effects in both arms healed completely. Hospitalization was more common in the ART arm (71 vs 52 patients; P = 0.01) but the total bed days in hospital was not greatly different (1707 bed days for ART and 1607 bed days for CRT). Patients were more likely to require nasogastric (NG) feeding in the ART arm (49 vs 33 patients; P = 0.02). There were 1157 NG feeding days for ART and 1154 NG feeding days for CRT. The average cost of radiation treatment per patient including hospitalization, NG feeding and accommodation was $11,750 in the ART arm and $11,587 in the CRT arm. The accelerated arm has been shown to be a tolerable, practical and cost-equivalent regimen. The assessment of the therapeutic ratio of this accelerated protocol (ART) will be determined when the analysis of late effects and loco-regional control is made when the data are more mature.     

Quality assurance methods for the first Radiation Therapy Oncology Group permanent prostate implant protocol

PURPOSE: To report the quality assurance methodology used by the Radiation Therapy Oncology Group in the first cooperative group, multi-institution Phase II trial of transrectal ultrasound guided permanent radioactive implantation of the prostate for definitive treatment of localized adenocarcinoma of the prostate. METHODS AND MATERIALS: Participating institutions were credentialed to participate in this protocol, Radiation Therapy Oncology Group 98-05. International Commission on Radiation Units and Measurements (ICRU) Report 58 was used as the basis for definition of terms. The AAPM's dosimetric prerequisites for low energy interstitial brachytherapy sources were adopted. A nondigital approach to central review was used. The implant dosimetry was recalculated based upon centrally reviewed target volumes by both a radiation oncologist and a diagnostic radiologist. RESULTS: There are differences in the definition of the postimplant prostate between the participating institution, the central review radiation oncologist, and the central review diagnostic radiologist. Thus, there are differences in dose/volume parameters. Six of the 95 patients reviewed did not meet the per protocol criteria based upon information supplied by the participating institution. This increased to 18 cases when using the postimplant target volume defined by the central oncologist and to 23 cases when defined by the radiologist. CONCLUSIONS: This work indicated that there is a need for a central review process of dose-volume analysis within the cooperative group setting. It is indicated that a digital approach to centralized review, which has now been developed, would result in a higher quality and easier review.     

Radical radiotherapy with high-dose-rate brachytherapy for uterine cervix cancer long-term results

The aim of this is to report the results of radical radiotherapy in carcinoma of the cervix treated by high-dose rate (HDR) intracavitary brachytherapy and external beam radiotherapy (XRT) at a single centre in Singapore. This is a retrospective analysis of 106 consecutive cases with histologically proven cervical cancer, treated by HDR brachytherapy and XRT at the Mount Elizabeth Hospital from 1990 to 1993. External beam radiotherapy to the pelvis was delivered with 6 MV photons, to 45-50.4 Gy in 1.8 Gy fractions. High-dose-rate brachytherapy comprised two to three applications of an intrauterine tandem with paired ovoids, to a median dose of 18 Gy to point 'A', carried out during XRT. All 106 patients completed treatment. Their ages ranged from 32 to 80 years (median 57 years). Most patients presented with stage II or III disease (44 and 37%, respectively) and with squamous cell carcinoma (91%). Median follow-up time was 59 months (range 2-169 months). The 5-year relapse-free survival rate across all stages was 71%. The corresponding overall survival rate was 69%. Local control was achieved in 86 patients (81%); six patients had residual disease (6%), and 14 patients had local recurrence (13%). Fourteen patients developed metastatic disease (13%). On univariate analysis, tumour stage, haemoglobin level, number of brachytherapy treatments and overall treatment time were found to be prognostic factors for overall survival. Late complications were mild (Radiation Therapy Oncology Group score 1-2), except for one patient with grade 4 rectal toxicity. The complication rates were 8, 14 and 45%, respectively, for the rectum, bladder and vagina (stenosis). The use of two to three fractions of HDR intracavitary brachytherapy in addition to pelvic XRT achieves good outcomes.     

A teleradiotherapeutic network for lymphoma patients within the competence network malignant lymphomas

PURPOSE: The aim of the subproject "Radiotherapy" within the competence network malignant lymphoma, funded by the Federal German Ministry of Education and Research (BMBF), was to build-up an electronic imaging transfer between five University departments of Radiation Oncology to improve communication between study centers and reference centers. MATERIALS AND METHODS: We describe our experiences with these modern teleradiotherapeutic possibilities, its feasibility within mutticentric clinical trials. RESULTS: Telemedical functions could successfully be integrated into the existing quality asssurance programs of radiotherapy. Since January 2001 more than 700 patients (trials HD10-HD15 of the German Hodgkin Study Group, GHSG) could be assessed after digital transfer via internet, on mobile data carriers or an ISDN-connection in the radiotherapy reference center Cologne. Transfer of digital imaging between participating study centers and the radiotherapy reference center allows immediate or a short-term evaluation of adequacy of treatment fields by expert radiation oncologists before the start of radiotherapy. This improves dialogue and consensus between radiotherapy reference centers and study centers and thus contributes towards high radiotherapy quality for lymphoma patients. CONCLUSION: The long-term aim is to network all those hospitals, institutions and private facilities taking part in the GHSG trials to achieve an integrated system of cooperation. This improves dialogue and consensus between the radiotherapy reference center and the study centers and thus contributes towards high radiotherapy quality for patients with Hodgkin's lymphoma.     

Safety in Radiation Oncology: The Role of International Initiatives by the International Atomic Energy Agency

The International Atomic Energy Agency (IAEA) has a wide range of initiatives that address the issue of safety. Quality assurance initiatives and comprehensive audits of radiotherapy services, such as the Quality Assurance Team for Radiation Oncology, are available through the IAEA. Furthermore, the experience of the IAEA in thermoluminescence dosimetric audits has been transferred to the national level in various countries and has contributed to improvements in the quality and safety of radiotherapy. The IAEA is also involved in the development of a safety reporting and analysis system (Safety in Radiation Oncology). In addition, IAEA publications describe and analyze factors contributing to safety-related incidents around the world. The lack of sufficient trained, qualified staff members is addressed through IAEA programs. Initiatives include national, regional, and interregional technical cooperation projects, educational workshops, and fellowship training for radiation oncology professionals, as well as technical assistance in developing and initiating local radiation therapy, safety education, and training programs. The agency is also active in developing staffing guidelines and encourages advanced planning at a national level, aided by information collection systems such as the Directory of Radiotherapy Centers and technical cooperation project personnel planning, to prevent shortages of staff. The IAEA also promotes the safe procurement of equipment for radiation therapy centers within a comprehensive technical cooperation program that includes clinical, medical physics, and radiation safety aspects and review of local infrastructure (room layout, shielding, utilities, and radiation safety), the availability of qualified staff members (radiation oncologists, medical physicists, and radiation technologists and therapists), as well as relevant imaging, treatment planning, dosimetry, and quality control items. The IAEA has taken the lead in developing a comprehensive program that addresses all of these areas of concern and is actively contributing to the national and international efforts to make radiation therapy safer in all settings, including resource-limited settings.     

Case report: radical radiotherapy for early laryngeal cancer in a patient with human immunodeficiency virus: no evidence of increased toxicity

There are very few reported cases of laryngeal squamous cell carcinoma (SCC) in patients with a background of human immunodeficiency virus (HIV) infection. We report a case of a 42-year-old man who developed a T2 N0 left vocal cord well differentiated SCC with an 11 year history of HIV infection. He successfully completed a course of radical radiotherapy 66 Gy in 33 fractions over 47 days. During his treatment he experienced only a grade 1 Radiation Therapy Oncology Group (RTOG) acute toxicity reaction to the larynx and no weight loss. At 32 months follow up he remains disease free and has no significant late morbidity. Prior to his radiotherapy his CD4 count was 350 cells mm(-3); we discuss the view that the treatment chosen needs to be individually tailored with respect to the patient's immune status.     

Impact of the introduction of weekly radiotherapy quality assurance meetings at one UK cancer centre

Objective:

The complexity of radiotherapy planning is increasing rapidly. Delivery and planning is subject to detailed quality assurance (QA) checks. The weakest link is often the oncologists'' delineation of the clinical target volume (CTV). Weekly departmental meetings for radiotherapy QA (RTQA) were introduced into the Royal Wolverhampton Hospital, Wolverhampton, UK, in October 2011. This article describes the impact of this on patient care.

Methods:

CTVs for megavoltage photon radiotherapy courses for all radical, adjuvant and palliative treatments longer than five fractions (with the exception of two field tangential breast treatments not enrolled into clinical trials) were reviewed in the RTQA meeting. Audits were carried out in January 2012 (baseline) and September 2013, each over a 4-week period. Adherence to departmental contouring protocols was assessed and the number of major and minor alterations following peer review were determined.

Results:

There was no statistically significant difference for major alterations between the two study groups; 8 alterations in 80 patients (10%) for the baseline audit vs 3 alterations from 72 patients (4.2%) in the second audit (p = 0.17). A trend towards a reduction in alterations following peer review was observed. There has, however, been a change in practice resulting in a reduction in variation in CTV definition within our centre and greater adherence to protocols. There is increasing confidence in the quality and constancy of care delivered.

Conclusion:

Introduction of a weekly QA meeting for target volume definition has facilitated consensus and adoption of departmental clinical guidelines within the unit.

Advances in knowledge:

The weakest areas in radiotherapy are patient selection and definition of the CTV. Engagement in high-quality RTQA is paramount. This article describes the impact of this in one UK cancer centre.The complexity of radiotherapy planning has increased rapidly over the past decade in the UK with the introduction of three-dimensional conformal therapies and more recently intensity-modulated radiotherapy (IMRT) and image-guided radiotherapy.^1,2 Delivery and planning of radiotherapy is subject to detailed quality assurance (QA) checks. The two widest variables in this process are delineation of the clinical target volume (CTV) by the oncologist and patient selection.^3–6 There is an expanding body of literature from clinical trials confirming that deviation from radiation outlining protocols is associated with an increase in the risk of treatment failure and mortality.^7–9 In the Trans-Tasman Radiation Oncology Group 02.02 study for advanced head and neck cancer, 12% of treatments were considered at QA review to have a protocol violation, which represented a major deficiency, predicting reduced local control. Considering only those patients who received >60 Gy, the overall survival and locoregional control for patients with major deficiencies in the treatment plan were 50% and 54%, respectively, compared with 70% and 78% for those whose treatment plan was protocol compliant (p < 0.001).⁸ Efforts to improve quality and consistency of radiotherapy within co-operative groups is essential for interpretation of data; however, translating results of studies into clinical practice requires adoption of the same approach within local multidisciplinary teams (MDTs).Radiotherapy QA (RTQA) clinical meetings to review CTV delineation are common place in Europe, the USA and Australasia but are not routine in the UK.^10–13 At the Royal Wolverhampton Hospital, Wolverhampton, UK, a weekly RTQA was commenced in October 2011. The RTQA is a considerable investment in resources by the trust. Outcomes of the meeting were audited to assess impact on the quality of patient care.     

Multi-institutional evaluation of end-to-end protocol for IMRT/VMAT treatment chains utilizing conventional linacs

We conducted a multi-institutional assessment of a recently developed end-to-end monthly quality assurance (QA) protocol for external beam radiation therapy treatment chains. This protocol validates the entire treatment chain against a baseline to detect the presence of complex errors not easily found in standard component-based QA methods. Participating physicists from 3 institutions ran the end-to-end protocol on treatment chains that include Imaging and Radiation Oncology Core (IROC)-credentialed linacs. Results were analyzed in the form of American Association of Physicists in Medicine (AAPM) Task Group (TG)-119 so that they may be referenced by future test participants. Optically stimulated luminescent dosimeter (OSLD), EBT3 radiochromic film, and A1SL ion chamber readings were accumulated across 10 test runs. Confidence limits were calculated to determine where 95% of measurements should fall. From calculated confidence limits, 95% of measurements should be within 5% error for OSLDs, 4% error for ionization chambers, and 4% error for (96% relative gamma pass rate) radiochromic film at 3% agreement/3?mm distance to agreement. Data were separated by institution, model of linac, and treatment protocol (intensity-modulated radiation therapy [IMRT] vs volumetric modulated arc therapy [VMAT]). A total of 97% of OSLDs, 98% of ion chambers, and 93% of films were within the confidence limits; measurements were found outside these limits by a maximum of 4%, < 1%, and < 1%, respectively. Data were consistent despite institutional differences in OSLD reading equipment and radiochromic film calibration techniques. Results from this test may be used by clinics for data comparison. Areas of improvement were identified in the end-to-end protocol that can be implemented in an updated version. The consistency of our data demonstrates the reproducibility and ease-of-use of such tests and suggests a potential role for their use in broad end-to-end QA initiatives.     

Radiation therapy for B-cell cutaneous lymphoid hyperplasia

Recent work has demonstrated that B-cell cutaneous lymphoid hyperplasia (BCCLH) lies in a spectrum of B-cell lymphoproliferative disorders that can progress to primary cutaneous B-cell lymphoma (CBCL). In light of this work, definitive therapy with methods such as radiotherapy is an important part of the treatment strategy. Few outcome data exist for patients with treatment-resistant BCCLH. We present a case study of a 63-year-old woman with BCCLH who failed immunomodulatory treatment but responded well to an aggressive course of radiotherapy. After 18 fractions of 6 MeV electron beam therapy with 200 cGy per fraction, the patient has been recurrence-free for 3 years. Acute toxicity was limited to Radiation Therapy Oncology Group grade II skin toxicity, which resolved within 1 month of treatment.     

前列腺癌术后中等分割放射治疗I期临床研究

目的 评价前列腺癌术后中等分割照射的急性不良反应。方法 选取2017年2月至8月,本院20例前列腺癌术后患者入组。中等分割处方剂量为盆腔45 Gy/25次,1.8 Gy/次;前列腺床62.75 Gy/25次,2.51 Gy/次。不良反应的评价采用北美放射肿瘤协作组（RTOG）急性不良反应评价标准和常见不良事件评价标准（CTCAE）4.0。结果 中位随访时间7.5个月。1例（5%）患者出现了2级急性胃肠反应;2例（10%）患者出现了2级急性泌尿反应。2例（10%）患者放射治疗期间出现了2级尿失禁,放疗后1个月恢复至0级或1级。结论 与既往常规分割照射文献相比,前列腺癌术后中等分割照射模式（2.51 Gy/次×25次）没有明显增加患者急性胃肠、泌尿系统不良反应。近期随访结果显示,没有增加患者尿失禁风险。     

Management of localized low-grade follicular lymphomas

Long-term follow-up data from Stanford and other centres suggest that 40-50% of patients with clinical stages I and II follicular low-grade lymphoma can be cured by radiotherapy (RT). Relapse generally occurs outside radiation fields and most relapsed patients ultimately die from lymphoma. No randomized data exist to support adjuvant chemotherapy but only one trial of low-intensity chemotherapy was sufficiently powerful to address the question. Nevertheless, data from a large phase-II study from MD Anderson suggest that combined chemotherapy and RT can produce progression-free survival results that are far superior to historical series, with survival at 10 years to be approximately 20% superior to radiation alone. These results have encouraged the development of a joint phase III study by the Trans Tasman Radiation Oncology Group (TROG) and the Australasian Leukaemia and Lymphoma Group (ALLG) in which patients with clinical stage I/II follicular lymphoma are randomized to involved field RT with or without six cycles of cytotoxic chemotherapy. In an era of rapid development in immunological and molecular therapies the potential for improved results with new combinations of more established treatment modalities should not be forgotten. This report reviews the literature on the management of localized low-grade lymphoma and discusses the rationale for the TROG/ALLG study, which began recruitment in early 2000.     

Evaluation of time,attendance of medical staff and resources for radiotherapy in pediatric and adolescent patients

Strahlentherapie und Onkologie - The German Society of Radiation Oncology (DEGRO) initiated a multicenter trial to develop and evaluate adequate modules to assert core procedures in radiotherapy....     

No correlation between radiosensitivity or double-strand break repair capacity of normal fibroblasts and acute normal tissue reaction after radiotherapy of breast cancer patients

The aim was to study the relationship between cellular radiosensitivity or double-strand break (dsb) repair capacity of skin fibroblasts and the extent of acute reaction after radiotherapy for breast cancer. The study was performed with 25 breast cancer patients submitted to the radiotherapy unit of the Egyptian National Cancer Institute after conserving surgery. Dermal fibroblasts, established from skin biopsies, were used to determine the cellular radiosensitivity via colony assay and the capacity of dsb repair by constant-field gel electrophoresis. Acute reactions were scored using the Radiation Therapy Oncology Group (RTOG) classification. The spectrum of acute reactions varied from grade 1 to 4, whereby most patients developed a grade 1 reaction after total doses ranging between 46 and 70 Gy. Skin fibroblasts showed a pronounced variation in both cellular radiosensitivity expressed as the mean inactivation dose (Dbar) (coefficient of variation, CV=25%) as well as in the number of residual dsb (CV=33%) with no significant correlation between these two endpoints (r2=0.20, p=0.14). Both parameters did not correlate with the extent of acute reaction of the respective patient. The data obtained indicate that the sensitivity of fibroblasts measured either by colony assay or by dsb repair capacity is not a major parameter determining the extent of acute reaction after radiotherapy of breast cancer patients.     

Radiosurgery for brain metastases at the Royal Adelaide Hospital: are we treating the right patients?

Although non-randomized data strongly suggest improved outcome from radiosurgery (RS) for brain metastases relative to whole brain radiotherapy (WBRT) alone, selection factors account for much of the observed differences. This retrospective review of the 16 brain metastases patients treated so far with RS at the Royal Adelaide Hospital confirms a median survival of 10.1 months, consistent with recent multi-institutional pooled results and significantly longer than the median survival of 3-6 months typically reported for WBRT alone. The emerging randomized trials comparing surgery, RS and WBRT for brain metastases are reviewed in the context of the Radiation Therapy Oncology Group Recursive Partitioning Analysis prognostic Class concept in order to assess whether we are using this resource intensive technique to treat the 'right' patients. We conclude that it is reasonable to continue our current policy of considering RS primarily for patients of good performance status with solitary brain metastases. We have a flexible approach to adjuvant WBRT which appears to decrease brain relapse, but not improve survival.     

Australian prostate-specific antigen outcome and toxicity following radiation therapy for localized prostate cancer

The objective of the present study was to examine prostate-specific antigen relapse free survival (PSA-RFS) and morbidity following 'conventional' radical radiation therapy for prostate cancer in two Australian regional treatment services. Four hundred and eighty men with clinically localized prostate cancer were treated between 1993 and 1997 at Liverpool and Westmead Hospitals using a standardized 4-field, CT-planned radiotherapy technique. Principal endpoints were PSA-RFS (American Society for Therapeutic Radiology and Oncology guidelines definition) and late rectal and urinary morbidity (Radiation Therapy Oncology Group/European Organisation for Research and Treatment of Cancer criteria). The median follow up of patients from the end of RT was 55 months. Prospectively, they were divided into three prognostic categories: (i) high risk T3 or 4 and/or PSA > 20 ng/mL and/or Gleason score 8-10 (40% of cohort); (ii) intermediate risk T1 or 2 and PSA 10-20 ng/mL and/or Gleason score 7 (33% of cohort); and (iii) low risk T1 or 2 and PSA < 10 ng/mL and Gleason score < 6 (27% of cohort). The 5-year actuarial PSA-RFS was 53% for the whole patient group. The 4-year rates were 32, 56 and 75% for high, intermediate and low risk groups, respectively. On multivariate analysis, T-stage, Gleason score, pre-RT-PSA were strong independent predictors of PSA-defined outcome. Late (grade 2) rectal and urinary morbidity occurred at some point in time in the post-RT period in 8.0 and 5.8% of patients, respectively. These results confirm that low Gleason score, low T stage, presenting PSA < 10 ng/mL and nadir < 1 ng/mL remain the strongest predictors of a good outcome. Long-term toxicity was very acceptable. However, further improvement in outcome is desirable, and with the adoption of new technology allowing escalation of radiotherapy doses such an expectation might be achieved.     

Breast radiotherapy: an Australasian survey of current treatment techniques

Prior to the dissemination of evidence-based quality assurance guidelines, the Australian National Breast Cancer Centre Radiation Oncology Group conducted a process survey of breast radiotherapy treatment delivery throughout Australia. A process survey was conducted in August/September 1998. This survey comprised questions enquiring about treatment positioning, immobilization devices used, planning strategies, simulation and dose computation methods, treatment prescribing and quality assurance. The survey was sent to 123 Australian fellows of the Royal Australian and New Zealand College of Radiologists (RANZCR) and to the six directors of New Zealand radiation oncology departments. Fifty-eight questionnaires were returned of which 38 were received from individuals and 20 represented a reply from a department with a routine breast radiotherapy protocol (representing an average of 4.5 radiation oncologists per reply). The study identified great consistency between departments with respect to dose and fractionation for breast tangents. The study also identified some areas of treatment planning and delivery that varied between individuals or departments. These mainly reflected a lack of evidence in some areas of radiotherapy treatment delivery. The circulation of quality assurance guidelines will perhaps improve consistency of radiotherapy techniques in which studies have identified that technique changes improve outcome. This study identified that these areas include the taking of simulation and port films and the use of off-axis dosimetry. Further studies are required for areas of radiotherapy treatment delivery that have little evidence for or against their implementation.