Practical considerations for the implementation of a stereotactic body radiotherapy program for oligo-metastases

Abstract PURPOSE With multiple phase II trials supporting the use of stereotactic body radiotherapy (SBRT) in oligo-metastatic disease, we evaluated practices that could inform effective implementation of an oligo-metastasis SBRT program. MATERIALS AND METHODS Using a context-focused realist methodology, an advisory committee of inter-professional clinicians met over a series of semi-structured teleconference meetings to identify challenges in implementing an oligo-metastasis SBRT program. Consideration was given to two models of care: a sub-specialist anatomic expertise model versus a single-practitioner ‘quarterback’ model. RESULTS The advisory committee structured recommendations within a context-mechanism-outcome framework. In summary, the committee recommends that during patient work-up, a single practitioner arranges the minimum number of necessary tests, with case presentation at an appropriate multidisciplinary tumor board, including careful review of all previous treatments, and enrollment on clinical trials when possible. At simulation, common patient positions/immobilization on a single simulation scan for multiple sites is recommended. During radiation planning, dose-fractionation regimens should safely facilitate cumulative dose calculations, a single isocentre should be considered for multiple close targets to reduce treatment time, and adherence to strict quality assurance protocols is strongly recommended. Treatment duration should be minimized by treating multiple sites on the same day or choosing shorter dose-fractionations. Team communication, thorough documentation, and standardized nomenclature can reduce system errors. Follow-up should aim to minimize redundant clinical appointments and imaging scans. Expert radiology review may be required to interpret post-SBRT imaging. CONCLUSIONS These guidelines inform best clinical practices for implementing an oligo-metastasis SBRT program. Iterations using a realist approach may further expand on local contexts.