By Sandra Zaky, MD, MS, former ASTRO Guideline Subcommittee Chair (2018-2022)
Have you ever wondered how ASTRO guidelines are created? For the last 15 years, ASTRO has been committed to creating evidence-based guidelines to help support members’ clinical decisions. Since that time, the ASTRO Guideline Subcommittee (GLSC) has created 28 disease-site specific guidelines. ASTRO has also collaborated with other societies to develop joint guidelines on a number of multidisciplinary topics. I recently served as the chair of the GLSC and want to share what I learned and promote how to get involved.
To become a member of the GLSC is an honor but also a commitment to the integrity of the guidelines process. ASTRO members apply through the regular committee nomination process (which occurs annually in the Spring, closing this year on Friday, June 2) for an annual term that can be renewed for up to five years, if selected. The GLSC meets once a month for one hour, where we discuss the current and future potential guidelines. The GLSC proposes a future guideline topic to the ASTRO Board, and once approved, a multidisciplinary task force of experts is selected. In general, GLSC members may or may not serve as guideline panelists themselves, and this will depend on the individual’s clinical expertise and the topics that are being developed. Additionally, we consider collaborative guidelines with other societies such as ASCO, AUA and SSO, to name a few.
In addition to creating new guidelines, the GLSC evaluates guidelines once they are two years post-publication to determine if updates are needed. ASTRO also updates any guideline that is more than five years old. The guideline development process is rigorous and involves significant planning. You can review a thorough description of all the steps in the process and read through ASTRO’s methodology guide for more details.
Since the inception of the GLSC, ASTRO guidelines have become integral in the treatment algorithms for a large percentage of ASTRO members. In surveys conducted between 2018 and 2022, ASTRO members have consistently rated guidelines in the top five offerings providing value to members. Guidelines are located in the Patient Care and Research section of ASTRO’s website, which is the second busiest on the site, accounting for 40% of all visits to that section. In Practical Radiation Oncology, which publishes all ASTRO guidelines, four of the five most cited articles for the past three years are guidelines. Jump to FAQs about ASTRO guidelines.
What is the relationship between ASTRO and NCCN guidelines?
Similar to ASTRO’s commitment to evidence-based guidelines, the National Comprehensive Cancer Network (NCCN) was created in 1993 to ensure delivery of high-quality, cost-effective services to people with cancer. NCCN guidelines provide evidence-based, consensus-driven recommendations across all oncology care and throughout the world. The make up of each disease site committee varies, but most include medical oncology, surgery, pathology, radiology and radiation oncology representatives. Radiation oncologists’ participation in NCCN guideline panels range from zero to 11 per committee.
To increase the visibility of these exhaustive guidelines, improve radiation oncology contributions to disease sites, and evaluate the concordance between NCCN and ASTRO recommendations, the GLSC initiated a collaborative relationship with the NCCN. In 2015, ASTRO began providing formal reviews of the radiation oncology content for approximately three NCCN guidelines per year.
These NCCN reviews have become a strategic component of topic prioritization for ASTRO. They can be drivers for ASTRO’s own topic prioritization or facilitate key question development if an area is not well represented in an NCCN guideline. The NCCN guideline review provides additional radiation oncology feedback on key developments or interventions especially when an NCCN panel has few or no radiation oncology participants. These reviews also ensure that the radiation therapy components included in NCCN guidelines are of the highest quality for all stakeholders since their guidelines are a central reference for oncology guidance.
The review process takes approximately three to four months and is performed by members of the GLSC. Key findings of the review are documented and sent to the GLSC for a final review. The final version is approved by ASTRO’s Clinical Affairs Quality Committee and then submitted to NCCN at least three weeks prior to the relevant NCCN guideline meeting.
Since this relationship began, the NCCN has implemented changes on every topic submitted by the GLSC. Accepted changes range from 23% to 100% of ASTRO recommendations per guideline. Many of these changes are impactful to the treatment algorithm. And, even more recently, once an ASTRO guideline is approved and published, the published link is submitted to the NCCN for inclusion into the updated NCCN guideline. This collaboration improves the radiation therapy component of the NCCN guidelines and makes the ASTRO guidelines more visible to the entire oncology community. Further, since many benefit managers refer to the NCCN guidelines, the GLSC is having a positive impact on patient access to needed services.
It was an honor to lead the GLSC, and I encourage ASTRO members to become involved too. Volunteering for the committee or on a guideline task force, participating as a formal peer reviewer or providing feedback during public comment are examples of ways you can contribute to the success of ASTRO guidelines.
Guideline Development Frequently Asked Questions
Who makes up the members of the ASTRO Guideline Subcommittee (GLSC)?
ASTRO members, such as radiation oncologists and physicists who volunteer their time, and ASTRO staff.
How many members are on the GLSC?
How many disease site-specific guidelines are created each year by the GLSC? Four to five guidelines.
Where can I find the ASTRO guidelines on the ASTRO website?
Guidelines live under the Patient Care & Research section of astro.org.
How can I participate in guideline development?
- Volunteer on the Guideline Subcommittee.
- Volunteer to be on a task force.
- Keep an eye out in ASTROgrams for guidelines that are out for Public Comment and submit your feedback.
- If you are on a NCCN committee, consider reviewing the ASTRO guidelines for that disease site.
By Curtiland Deville Jr., MD, Deputy Editor, International Journal of Radiation Oncology • Biology • Physics
The following includes excerpts from Dr. Deville’s editorials in the two special HEDI issues of the Red Journal. Read the full editorials and explore each special issue at www.redjournal.org.
It’s been said that we often overestimate what can be accomplished in a year and underestimate what can be accomplished in a decade. It’s been over a decade since Christina Chapman, MD, MS, and I published the first physician workforce diversity analysis in our specialty.1 At the time, I found only a single publication discussing concepts of diversity, underrepresentation and exclusion in our field — an editorial by Reshma Jagsi, MD, PhD, FASTRO, and Nancy Tarbell, MD, FASTRO, discussing the lack of gender representation and the need to address the proverbial “glass ceiling.”2
Over a decade later, hundreds of manuscripts exploring health equity, diversity and inclusion (HEDI) across a range of topics in radiation oncology, biology and physics have since been published, and we arrive today at the Red Journal’s HEDI special editions with dozens more contributions carrying the potential to inform and shape the field. But progress does not occur simply with the passing of time. Tireless, restless, persistent and courageous efforts by early, mid-, and advanced-level trainees, physicians, physicists, scientists, administrators and leaders have facilitated the awakening and commitment to diversity, equity and inclusion in our field, ultimately to the benefit of our future patients, colleagues and staff. Below, I give a brief overview of several studies included in each issue, but I strongly encourage all readers of this blog to study both special issues carefully.
The first HEDI special issue includes a number of analyses and interventions to address health equity in radiation oncology, medical physics and radiation biology. In their manuscript, Radiotherapy Deserts: The Impact of Race, Poverty and the Rural-Urban Continuum on Density of Providers and Use of Radiation Therapy in the United States, Alcorn et al. characterize so-called radiation deserts — areas with the greatest mismatch of oncologic need and radiation resources — and provide an online tool to drive targeted investigation of underlying barriers to care in areas of highest need, with the goal of reducing health inequities in this context.
Kronfli et al. report on a psychosocial needs assessment implemented for patients with cancer undergoing curative radiation therapy in an inner-city, academic center to address radiation disparities. In their companion editorial, Suneja et al. laud the efforts of this group’s targeted intervention to address social determinants of health such as socioeconomic and transportation barriers, delve further into fundamental concepts in health equity, and provide cautionary guidance for investigators to ensure that their analyses and author teams do not themselves perpetuate inequities, exclusion and bias and moreover risk engaging in health equity tourism.3
Regarding progress toward inclusive clinical trial enrollment, Roy et al. provide a framework in their critical review Increasing Diversity of Patients in Radiation Oncology Clinical Trials, while Chen et al. discuss why the Inclusion of Sexual Orientation and Gender Identity in Clinical Trials is Necessary for Health Equity, and Patel et al. discuss the role of industry partners in Carrots or Sticks: An Industry Perspective on the Significance of Regulatory Guidance in Promoting Participant Diversity in Clinical Trials.
The second volume of the HEDI special issue highlights needs and innovations across a variety of domains: the physician, physics and basic scientist workforce, education, technology access and global health. With respect to workforce diversity and inclusion, analyses of demographic representation trends reveal that women and historically underrepresented racial and ethnic groups in medicine (URiM) remain excluded, likely along with a host of other marginalized groups for whom data is largely unavailable.
The review by Jimenez et al. entitled Using Holistic Residency Applicant Review and Selection in Radiation Oncology to Enhance Diversity and Inclusion, an ASTRO SCAROP-ADROP-ARRO Collaboration, opens with a detailed review of current representation trends and the lack of significant changes in representation for women and URiM trainees in radiation oncology over the past decade, despite gains in the overall U.S. graduate medical education trainee pool. Broadening the scope of diversity with additional dimensions is increasingly needed to assure equity, inclusion and belonging. Such historically marginalized dimensions include deaf and disabled status, veteran status, sexual orientation and gender identification (SOGI), first generation and low income (FGLI), religion, geography (e.g., urban versus rural) and disadvantaged background. Limited data exist regarding representation of many of these groups within medicine and radiation oncology specifically, but several data collection initiatives are underway and included in this edition.
Marginalized demographic groups remain disproportionately underrepresented and ultimately excluded in radiation oncology relative to the available pool. This indicates that simply increasing the pipeline is not enough without thoughtful recruitment, applicant review and selection, and retention and advancement strategies as reviewed in the HEDI focus issues.
Our charge is that the next decade and beyond bring scaled, sustained, strategic departmental, organizational and societal policies and interventions that address the long-standing disparate representation in the radiation oncology physician, medical physics and radiation biology scientist workforce. These efforts are requisite if we wish to dismantle structural bias and systemic inequities in the specialty and ensure that our workforce is reflective of the ever-diversifying domestic and global patient populations and communities we serve.
- Chapman CH, Hwang WT, Deville C. Diversity based on race, ethnicity, and sex, of the US radiation oncology physician workforce. Int J Radiat Oncol Biol Phys. 2013 Mar 15;85(4):912-8.
- Jagsi R, Tarbell NJ. Women in radiation oncology: time to break through the glass ceiling. J Am Coll Radiol. 2006 Dec;3(12):901-3.
- Lett E, Adekunle D, McMurray P, et al. Health Equity Tourism: Ravaging the Justice Landscape. J Med Syst. 2022 Feb 12;46(3):17.
By Ashlee Droscher, Radiation Oncology Institute (ROI)
One million cancer patients will receive radiation therapy each year, yet funding for radiation oncology research is stubbornly low. That’s why the Radiation Oncology Institute (ROI) — ASTRO’s research foundation — is focused on accelerating research to help patients with cancer receive the best treatment possible.
May is National Cancer Research Awareness month. This month is an opportunity to celebrate the impact of the innovative research projects funded by ROI donors and to look forward to the increasing need for radiation oncology research. Since ROI was founded 18 years ago, it has funded more than $4 million in research including these projects:
Using immersive holographic displays, David Byun, MD, created a tool to help increase patient knowledge, reduce anxiety and improve patient experience. Dr. Byun, and the team at NYU Langone Health’s Perlmutter Cancer Center, developed CurieUx (Curie User eXperience): an augmented reality patient education platform that uses a hologram-based display to give patients a virtual tour of simulation and treatment rooms. The first patient used CurieUx in March 2022 in a prospective trial to evaluate how using the tool during consultation impacts patient anxiety. Dr. Byun has received interest from industry-level collaborators required to fund future stages of the project.
- Researching the use of machine learning (ML) to direct care and reduce the likelihood that a patient would require an emergency visit or unplanned hospital admission during radiation or chemoradiation was led by Julian Hong, MD, MS, who was awarded the 2021 ROI Publication Award. For Dr. Hong’s current study, he and Isabel Friesner collaborated with Nitin Ohri, MD, a previously funded ROI researcher, to apply ML approaches to data from wearable fitness and step trackers.
Dr. Hong recently received an R01 grant from the National Cancer Institute to test the ML model in diverse health care settings at institutions nationwide while Dr. Ohri is leading an NRG Oncology study to advance his work with wearable devices.
- Improving communication between cancer patients and their physicians is at the center of the work led by Daniel Golden, MD, MHPE. In partnership with the team at the Illinois Institute of Technology Institute of Design, they created the “Communicating the External Beam Radiotherapy Experience” – or CEBRE discussion guides.
With support from ROI, these guides are now available for six disease sites, and some are now available in Spanish. All guides can be downloaded from their website for free. Thus far, the guides have have downloaded in more than 36 countries.
This innovative and patient-focused work is only made possible thanks to the generosity of donors. As a 501c3 public charity, ROI depends on gifts from individuals, companies and organizations who are committed to advancing the impact of radiation oncology.
Join the ROI to advance future innovations by making a donation.
Your gift will be used to fund cutting-edge investigators who are eager to seek new opportunities to accelerate radiation therapy.
Learn more about ROI, including our newly revamped Publication Excellence Award and additional ways to support the charity advancing innovations in the radiation oncology community.