Utility of a Real Time E-mail Assisted Group Consensus Forum for Regional Radiation Oncology Centres

Sarah Leeson^1*, Andrew Last², Tom Shakespeare² and Patrick Dwyer^3,4
*Correspondence: Sarah Leeson, Sydney West Radiation Oncology Network, Westmead Hospital, 166-174 Hawkesbury Rd. Westmead, NSW, Australia, Email:

Keywords

Regional oncology● Regional medicine ● Rural oncology● Radiation oncology

Introduction

Regional medicine, particularly in a geographically vast nation like Australia, faces it’s own unique challenges particularly in terms of access to specialist care. It is well known that in general, oncological outcomes for rural/ regional patients are poorer than that of their metropolitan peers for a wide variety of interconnected reasons [1]. For many years now, regional Australian oncology centres have been linking with metropolitan tertiary centres for Virtual Multidisciplinary team meetings (MDT). This aims to overcome the issue of distance and access to the opinion of specialist multidisciplinary team members such as specialist surgeons and pathologists. However, the MDT arena is specifically for use in situations requiring a multidisciplinary approach (i.e. surgery, systemic therapy, and radiation therapy, or radiological/ pathological diagnosis type questions). When it comes to the nuances of a Radiation Oncology plan of action for a patient, other disciplines in the MDT are not the required expertise. Regional and remote oncologists often feel that they are limited in their ability to engage professionally with peers and obtain second opinions [2].

The field of Radiation Oncology has become increasingly more complex over the last decade, particularly in regards to advanced planning techniques, dose prescription and target volume delineation. One only needs to assess the complicated field of oligometastatic disease and the impact of PSMA PET on decision making in the field of Radiation Oncology to get a feel for the complexity of management. Metropolitan tertiary oncology centres have the benefit of often more than 3 subspecialists for any particular oncological subsite, offering the advantage of advice and help in decision making or contouring. This will often occur in a non-formal, ‘corridor conversation’ type manner. Regional radiation centres face the challenge of Radiation Oncologists (ROs) often treating upwards of 5 subsites each, with often only one or no, other subsite specialists onsite for quick, radiation oncology specific opinion, advice or help.

The North Coast and Mid-North Coast of NSW regional cancer centres exist in a virtual partnership of 3 regional centres (Port Macquarie, Coffs Harbour and Lismore) servicing a geographical area of over 32, 000 square kilometres, and a population over half a million people [3]. The centres operate independently, however, they perform a weekly combined quality assurance (peer review audit) meeting and teaching schedule for trainees. Approximately 7 years ago with 9 ROs across the 3 sites, the team started a virtual, realtime e-mail opinion thread titled “Opinion Please”. The purpose of this e-mail train was to gain an opinion from colleagues on issues such as management, staging, intent, planning/contouring, dose etc in a timely manner, to overcome the disadvantage of not having any other subsite specialists in a particular area at one’s own site or, to gain an informal opinion or reassurance on an issue surrounding a patient’s management that may not be straightforward. The forum is informal and non-judgemental, and no RO is obliged to follow the advice provided, similar to the experience a metropolitan RO might have in visiting a colleague’s office. We had a coordinated policy to label all emails as “Opinion Please” in the subject line to aid in later identifying cases for future research. Within the body of the e-mail, the RO will give a brief history of the patient, relevant information, and a statement of the problem plus or minus their current plan.

A literature search has not demonstrated any other publications addressing the issue of access to increased opinion for radiation oncology questions for regional centres. Data exists documenting the benefit of virtual MDT, but as yet, no publications could be found documenting the success and implementation of a speciality specific advice platform in real time for geographically isolated clinicians.

We aim to outline and document the process of the “Opinion Please” e-mail train across our centres, and report on the utility of such a program as a decision making aid, quality assurance, and a tool for RO support, in the hope of guiding other regional centres around the world.

Methods and Methodology

Using the state wide e-mail archive, we used the search term “opinion please” within the subject title of e-mails, spanning from 1^st February 2018, to 31^st December 2020 to isolate the list of e-mails. These years were chosen as they coincided with an increased number of ROs within the network and increasing complexity of treatment. E-mails were perused and categorized into types of management issue for discussion as follows: treatment intent, staging, radiation therapy planning, clinical oncology, and concomitant radiosensitiser. Details collected for each of these categories are presented in Appendix 1. Utility endpoints collected included: completeness of response, time to first response, whether consensus reached or not, whether original plan (if offered) was changed based on responses. We also conducted a short survey via e-mail, asking the ROs and registrars how useful they found the “Opinion Please” e-mail forum. This survey consisted of two questions; how useful the respondents found the forum, and to what extent they felt it facilitated ongoing learning.

Results

From 1^st February 2018 to 31st December 2020 there were 140 “Opinion Please” e-mails sent, averaging almost 4 per month. Of these, outcome data was able to be identified for 119. There was an even spread across the years being 40 cases in each of 2018 and 2019, and 39 in 2020. Around half of the e-mails pertained to palliation and the other half to curative intent management, with there being 3 benign cases amongst the e-mails. Almost half the time (46%), a requesting RO would receive a first response from another RO within 10 minutes of the e-mail being sent, and >90% of the time, a first response from another RO was received within 2 hours.

As can be seen in Table 1, 86.5% of the time a requesting RO would receive responses from more than 4 colleagues, and 16% of the time would receive responses from 7-8 ROs. The vast majority of the time, a requesting RO would ask the group a question related to planning/voluming/dose/technique or about managing a clinical oncological situation. Less than 10% of the cases were related to radiosensitisers or treatment intent, and there were no questions about clarifying staging. In 80% of the cases, the requesting RO had suggested a management plan, which was either communicated directly in the e-mail, or could be inferred from the notes in the medical record written prior to the e-mail being sent. Similarly, in 79.8% of the cases, a group consensus from the responding ROs was reached about what the plan should be. We noted that in 18.4% of the e-mails, the group consensus plan was enacted, because there was no original plan communicated by the requesting RO. On occasions when the requesting RO did have an original plan, this plan was changed after the “Opinion Please” e-mail correspondence in 32.7% of cases, and in another 36% of cases, the plan didn’t change because the group consensus agreed with the requesting RO’s original plan. In 12.6% (the minority) of cases, the requesting RO’s original plan did not change after the “Opinion Please” e-mail chain; this reflected instances in which the RO decided not to proceed with consensus, or there was no consensus. During the time of data collection, we surveyed both the ROs and registrars on their perceived utility of the program. A total of 14 responses were received. Of the responders, 92% reported that they found the Opinion Please forum to be “very useful/helpful” with one responder reporting it as “somewhat useful”. When questioned as to whether the Opinion Please forum helps with education/continued learning, 71% reported that it did so “very much” and a further 28% reporting “somewhat”. No responders reported the forum to be unhelpful.

Discussion

This study looked back over the last 3 years’ worth of “Opinion Please” e-mail threads, in an effort to report on the functioning and utility of such a program for regional/rural/isolated radiation oncology clinicians. The thread has become a useful learning opportunity for registrars (trainees) as they are copied into the thread and are encouraged to offer insight during the discussion. The ROs appear to regularly use the Opinion Please forum, demonstrated by the lack of fluctuation in cases each month or across the years. The forum is non-judgemental and informal, and the asking RO has no obligation to enact the group consensus in any way. We did find that in the majority of cases, ROs were seeking confirmation that their peers agreed with the proposed management plan, or at least felt that the proposed plan was a reasonable option. This was reflected in that over 1/3 of the time, the group consensus was that the proposed plan was a reasonable one. There was a similar proportion of cases in which the proposed management plan was changed, due to the feedback from the group. This is an important result and shows the utility of the tool. Due to e-mail archive storage, the ‘Opinion Please’ e-mail thread also acts as an archive database so that an RO can search for how a particular issue may have been dealt with before, or can search previous discussions about the safety of a particular radiosensitiser for example. NCCI uses a centralised electronic patient data management system (Mosaiq) which resulted in the ability to track outcome data from the e-mail discussions. This review noted a consistent number of cases discussed every month, pre and post Covid-19, showing consistency in utilisation of the tool.

Conclusion

This is a retrospective observational study, and is associated with the limitations of such a process; however, it was an appropriate method to assess the long term utility of an Opinion Please tool and how that may influence RO behaviour.

The ‘Opinion Please’ e-mail forum is a fast, real-time, non-formal method of collegial mentorship and the ‘corridor consult’ for practitioners who are geographically isolated from their peers. It is easy to set up, offers regional/ remote ROs some peace of mind about difficult situations, and offers an invaluable learning opportunity both for junior specialists, and trainees. It may also be extrapolated for use in the increasing work-from-home and flexible work arrangements that have emerged from the Covid-19 pandemic.

Acknowledgement

The authors would like to acknowledge all of the Radiation Oncology specialists in the Mid North Coast and North Coast Cancer Centres for their contribution to the Opinion Please project over the years as well as the many registrars who have also contributed to discussions over that time. Special mention should be made to Dr Carmen Hansen, Dr Linus Benjamin, Dr Jacques Hill, Dr Abdul Mohd Tahir, Dr Noel Aherne, Dr Julan Amalaseelan, & Dr Shreya Armstrong.

References

1. Fox, Peter and Adam Boyce. "Cancer health inequality persists in regional and remote Australia." Comm 83 (2014).

Google Scholar, Crossref, Indexed at

2. Crawford-Williams, Fiona, Belinda Goodwin, Sonja March and Michael J. Ireland, et al. "Cancer care in regional Australia from the health professional’s perspective." Support Cancer Ther 26 (2018): 3507-3515.

Google Scholar, Crossref, Indexed at

3. NSW Government. Health stats NSW. (2021)