title: State of dose prescription and compliance to international standard (ICRU-83) in intensity modulated radiation therapy among academic institutions.
abstract: OBJECTIVE
  The purpose of this study was to evaluate dose prescription and recording compliance to international standard (International Commission on Radiation Units & Measurements [ICRU]-83) in patients treated with intensity modulated radiation therapy (IMRT) among academic institutions.
  
  
  METHODS
  Ten institutions participated in this study to collect IMRT data to evaluate compliance to ICRU-83. Under institutional review board clearance, data from 5094 patients-including treatment site, technique, planner, physician, prescribed dose, target volume, monitor units, planning system, and dose calculation algorithm-were collected anonymously. The dose-volume histogram of each patient, as well as dose points, doses delivered to 100% (D100), 98% (D98), 95% (D95), 50% (D50), and 2% (D2), of sites was collected and sent to a central location for analysis. Homogeneity index (HI) as a measure of the steepness of target and is a measure of the shape of the dose-volume histogram was calculated for every patient and analyzed.
  
  
  RESULTS
  In general, ICRU recommendations for naming the target, reporting dose prescription, and achieving desired levels of dose to target were relatively poor. The nomenclature for the target in the dose prescription had large variations, having every permutation of name and number contrary to ICRU recommendations. There was statistically significant variability in D95,D50, and HI among institutions, tumor site, and technique with P values < .01. Nearly 95% of patients had D50higher than 100% (103.5 ± 6.9) of prescribed dose and varied among institutions. On the other hand, D95was close to 100% (97.1 ± 9.4) of prescribed dose. Liver and lung sites had a higher D50compared with other sites. Pelvic sites had a lower variability indicated by HI (0.13 ± 1.21). Variability in D50is 101.2 ± 8.5, 103.4 ± 6.8, 103.4 ± 8.2, and 109.5 ± 11.5 for IMRT, tomotherapy, volume modulated arc therapy, and stereotactic body radiation therapy with IMRT, respectively.
  
  
  CONCLUSIONS
  Nearly 95% of patient treatments deviated from the ICRU-83 recommended D50prescription dose delivery. This variability is significant (P < .01) in terms of treatment site, technique, and institution. To reduce dosimetric and associated radiation outcome variability, dose prescription in every clinical trial should be unified with international guidelines.
authors.affiliation: Department of Radiation Oncology, New York University Langone Medical Center, New York, New York. Electronic address: indra.das@nyumc.org.
authors.forename: Indra J
authors.initials: IJ
authors.lastname: Das
authors.affiliation: Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, Indiana.
authors.forename: Aaron
authors.initials: A
authors.lastname: Andersen
authors.affiliation: Department of Therapeutic Radiology, Yale University, New Haven, Connecticut.
authors.forename: Zhe Jay
authors.initials: ZJ
authors.lastname: Chen
authors.affiliation: Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Andrea
authors.initials: A
authors.lastname: Dimofte
authors.affiliation: Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Eli
authors.initials: E
authors.lastname: Glatstein
authors.affiliation: Department of Radiation Oncology, University of California San Diego, La Jolla, California.
authors.forename: Jeremy
authors.initials: J
authors.lastname: Hoisak
authors.affiliation: Department of Radiation Oncology, University of Utah, Salt Lake City, Utah.
authors.forename: Long
authors.initials: L
authors.lastname: Huang
authors.affiliation: Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, Indiana.
authors.forename: Mark P
authors.initials: MP
authors.lastname: Langer
authors.affiliation: Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan.
authors.forename: Choonik
authors.initials: C
authors.lastname: Lee
authors.affiliation: Department of Radiation Oncology, University of Rochester, Rochester, New York.
authors.forename: Matthew
authors.initials: M
authors.lastname: Pacella
authors.affiliation: Department of Radiation Oncology, The University of Alabama at Birmingham, Birmingham, Alabama.
authors.forename: Richard A
authors.initials: RA
authors.lastname: Popple
authors.affiliation: Department of Radiation Oncology, University of California San Diego, La Jolla, California.
authors.forename: Roger
authors.initials: R
authors.lastname: Rice
authors.affiliation: Department of Radiation Oncology, University of Wisconsin, Madison, Wisconsin.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Smilowitz
authors.affiliation: Department of Radiation Oncology, University of Washington, Seattle, Washington.
authors.forename: Patricia
authors.initials: P
authors.lastname: Sponseller
authors.affiliation: Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Timothy
authors.initials: T
authors.lastname: Zhu
mesh_terms: D000704:Analysis of Variance; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D017410:Practice Guidelines as Topic; D011879:Radiotherapy Dosage; D011880:Radiotherapy Planning, Computer-Assisted; D050397:Radiotherapy, Intensity-Modulated / Q000592:standards*; D012189:Retrospective Studies; D016896:Treatment Outcome