Skip Navigation
PrintDownload PDFGet Adobe ReaderDownload to WordDownload as HTMLDownload as XMLCitation Manager
Save to Favorites
Guideline Summary
Guideline Title
The role of IMRT in central nervous system cancer.
Bibliographic Source(s)
Laperriere N, Rumble RB, Warde P, IMRT Indications Expert Panel. The role of IMRT in central nervous system cancer. Toronto (ON): Cancer Care Ontario (CCO); 2010 Oct 29. Various p. (Evidence-based series; no. 21-3-4).  [28 references]
Guideline Status

This is the current release of the guideline.

The EVIDENCE-BASED SERIES report, initially the full original Guideline, over time will expand to contain new information emerging from their reviewing and updating activities.

Please visit the Cancer Care Ontario Web site External Web Site Policy for details on any new evidence that has emerged and implications to the guidelines.

Scope

Disease/Condition(s)

Primary brain tumours (central nervous system [CNS] cancer)

Guideline Category
Assessment of Therapeutic Effectiveness
Treatment
Clinical Specialty
Neurology
Oncology
Radiation Oncology
Intended Users
Advanced Practice Nurses
Allied Health Personnel
Other
Patients
Physician Assistants
Physicians
Guideline Objective(s)

To evaluate the role of intensity modulated radiation therapy (IMRT) compared with three-dimensional conformal radiation therapy (3DCRT) in the treatment of primary brain tumours

Target Population

All patients with primary brain tumours for whom treatment with radiation is being considered

Interventions and Practices Considered

Intensity-modulated radiation therapy (IMRT) versus three-dimensional conformal radiation therapy (3DCRT)

Major Outcomes Considered
  • Clinical recurrence-free survival
  • Disease-specific survival
  • Acute or late toxicities

Methodology

Methods Used to Collect/Select the Evidence
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

Literature Search Strategy

The MEDLINE and EMBASE databases were searched for evidence on central nervous system (CNS) cancers and intensity-modulated radiation therapy (IMRT) on March 20, 2009 (Appendix 2 in the original guideline document). In both databases, keywords for "central nervous system cancer" were combined with keywords for "intensity-modulated radiotherapy" and the following terms were excluded: "brachytherapy", "proton therapy", "biological markers", "gene therapy", "children", "childhood cancer", "pediatric cancer", "quality assurance", "treatment plan comparison", "aperture optimization", "independent dose calculation", "EPID dosimetry", and "set up errors." Results were limited to those published in English from the year 2000 to the current date in 2009.

A search for clinical practice guidelines (CPG), systematic reviews (SR), and health technology assessments (HTA) was also performed. A search of the National Guideline Clearinghouse (located at: http://www.guideline.gov External Web Site Policy) was performed on March 9, 2009. Additionally, a search of the MEDLINE and EMBASE databases was performed on March 25, 2009 using keywords for IMRT in combination with terms for all disease sites and limited to review articles published after 2000. Finally, the Scottish Collegiate Guidelines Network (SIGN) (located at: http://www.sign.ac.uk External Web Site Policy), the National Institute for Health & Clinical Evidence (NICE) (located at: http://www.nice.org.uk External Web Site Policy), and the Agency for Healthcare Research & Quality (AHRQ) (located at: http://www.ahrq.gov External Web Site Policy) were searched on March 25, 2009 using keywords for "IMRT" and "radiation" in combination with disease-site-specific terms.

Study Selection Criteria

Inclusion Criteria

All of the following publication types must include comparative data on IMRT versus three-dimensional conformal radiation therapy (3DCRT) in the treatment of primary brain tumours and must also report on at least one of the outcomes of interest, including clinical recurrence-free survival, disease-specific survival, and acute or late toxicities:

  • CPGs, SRs, HTAs
  • Randomized phase II or phase III trials
  • Dose escalation studies, toxicity reports, quality of life (QoL) reports, case-series, and retrospective studies

They must also meet the following criteria:

  • Report on 50 or more patients
  • Be published in English
  • Be published in the year 2000 to current date

Exclusion Criteria

  • Published in a language other than English
  • Do not provide comparative data
  • Report on fewer than 50 patients
  • Published prior to 2000

Ongoing Trials

The U.S. National Institutes of Health online directory of clinical trials (located at http://www.clinicaltrial.gov External Web Site Policy) was searched on September 29, 2009 for listings of relevant trials. The details of the single relevant trial appear in Table 1 in the original guideline document.

Number of Source Documents

The MEDLINE and EMBASE searches returned 16 and 57 potential articles, respectively. After removing ineligible articles based on title and abstract review, none of the remainder was ordered for full-text review. No evidence was found in this systematic review, and the recommendations drafted were based on expert opinion.

Methods Used to Assess the Quality and Strength of the Evidence
Expert Consensus (Committee)
Rating Scheme for the Strength of the Evidence

Not applicable

Methods Used to Analyze the Evidence
Systematic Review
Description of the Methods Used to Analyze the Evidence

No statistical analyses were planned in this systematic review; however, this would be considered if data allow.

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

The Evidence-Based Series (EBS) guidelines developed by Cancer Care Ontario's (CCO) Program in Evidence-Based Care (PEBC) use the methods of the Practice Guidelines Development Cycle. For this project, the core methodology used to develop the evidentiary base was the systematic review. Evidence was selected and reviewed by one member of the Intensity-Modulated Radiation Therapy (IMRT) Indications Expert Panel (see Appendix 1 in the original guideline document for Panel membership) and one methodologist.

Development and Internal Review

This EBS was developed by the IMRT Indications Expert Panel (see Appendix 1 in the original guideline document) of the PEBC and Radiation Treatment Program (RTP). The series is a convenient and up-to-date source of the best available evidence on the role of IMRT in central nervous system cancer, developed through review of the evidentiary base, evidence synthesis, and input from external review participants in Ontario.

IMRT Expert Panel Conference

On December 3, 2009, the IMRT – central nervous system (CNS) guideline was presented to members of the IMRT Expert Panel (N=25) and feedback was obtained on the quality and comprehensiveness of the evidence and the recommendations.

Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation

Report Approval Panel

Following the presentation of this Evidence-based Series (EBS) draft report for Expert Panel review, the draft was submitted to the Program in Evidence-based Care (PEBC) Report Approval Panel (RAP) for review on March 8, 2010. The RAP is comprised of two members, including an oncologist, with expertise in clinical and methodological issues.

No RAP re-submission was requested, and the guideline was approved on April 5, 2010.

External Review: Professional Consultation

On September 20, 2010, the RAP-approved document was distributed to clinicians practicing within the Province of Ontario as part of a Profession Consultation review process. A total of 126 clinicians were invited to participate, and a total of 7 submitted responses (5.5% response rate) were obtained.

Recommendations

Major Recommendations

No evidence meeting the inclusion criteria was obtained in this systematic review; therefore, it is not possible to propose evidence-based recommendations.

Qualifying Statements

  • Despite the lack of comparative evidence central nervous system (CNS) cancer, there remain compelling reasons why intensity modulated radiation therapy (IMRT) should be offered to patients as an alternative to the standard treatment of three-dimensional conformal radiation therapy (3DCRT).
  • If disease-related outcomes are the primary outcomes of interest, then any treatment decision made should be informed by the knowledge that, due to IMRT's highly conformal fields, the maximum dose of radiation to the tumour could be increased, which may translate into increased local control.
  • If minimizing or avoiding treatment-related adverse effects is the primary outcome of interest, then any treatment decision made should be informed by the knowledge that IMRT has a demonstrated ability to create fields with very narrow margins, avoiding organs at risk (OARs) and sparing patients significant short- and long-term morbidity. For this reason, IMRT may be considered a viable treatment option, as it is ethical to recommend a treatment with little known harm over one with greater expected harm prior to scientific proof of the difference in harm being established.
  • Based on these two important aspects of IMRT, the IMRT Indications Expert Panel recommends the use of IMRT for patients being treated for CNS cancers where radiation is the treatment modality of choice. 
Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The recommendations drafted were based on expert opinion.

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits
  • Good quality uncontrolled studies document significant improvement in the dose sparing of organs at risk (OAR) and the ability to dose escalate with intensity-modulated radiation therapy (IMRT) to doses previously not possible prior to its use in the radiotherapy management of brain tumours, with associated improved outcomes in terms of tumour control and less complications.
  • The incidence of brain tumours in children is fortunately far less common than in adults, but that population is at increased risk for late radiation complications related to the relative immaturity of their developing brain and their possible increased sensitivity to the effects of ionizing radiotherapy. The long-term tumour control and survival rates seen in children with brain tumours are higher than those seen in adults, meaning that their increased sensitivity to the late effects of ionizing radiotherapy make them a particularly important subgroup of patients that would benefit more from the use of IMRT.
Potential Harms

Not stated

Qualifying Statements

Qualifying Statements

Care has been taken in the preparation of the information contained in this report. Nonetheless, any person seeking to apply or consult the report is expected to use independent medical judgment in the context of individual clinical circumstances or seek out the supervision of a qualified clinician. Cancer Care Ontario makes no representation or guarantees of any kind whatsoever regarding the report content or use or application and disclaims any responsibility for its application or use in any way.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Living with Illness
IOM Domain
Effectiveness

Identifying Information and Availability

Bibliographic Source(s)
Laperriere N, Rumble RB, Warde P, IMRT Indications Expert Panel. The role of IMRT in central nervous system cancer. Toronto (ON): Cancer Care Ontario (CCO); 2010 Oct 29. Various p. (Evidence-based series; no. 21-3-4).  [28 references]
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2010 Oct 29
Guideline Developer(s)
Program in Evidence-based Care - State/Local Government Agency [Non-U.S.]
Guideline Developer Comment

The Program in Evidence-based Care (PEBC) is a Province of Ontario initiative sponsored by Cancer Care Ontario and the Ontario Ministry of Health and Long-Term Care.

Source(s) of Funding

The Program in Evidence-Based Care (PEBC) and Radiation Treatment Program (RTP) are supported by the Ontario Ministry of Health and Long-Term Care through Cancer Care Ontario. All work produced by the PEBC is editorially independent from its funding source.

Guideline Committee

IMRT Indications Expert Panel

Composition of Group That Authored the Guideline

Steering Panel: Dr. Padraig Warde, Provincial Head, Radiation Treatment Program, Cancer Care Ontario; Mr. Eric Gutierrez, Program Manager, Radiation Treatment Program, Cancer Care Ontario; Ms. Kate Bak, Project Coordinator, Radiation Treatment Program, Cancer Care Ontario; Mr. Bryan Rumble, Research Coordinator, Program in Evidence-based Care, Cancer Care Ontario

Expert Panel: Dr. Anthony Whitton, Radiation Treatment Program, Cancer Care Ontario; Ms. Sarah Etheridge, Radiation Therapy Representative, Peel Regional Cancer Program; Ms. Lisa Favell, Capital Project Representative, Cancer Care Ontario; Ms. Katrina Fleming, Radiation Therapy Representative, Grand River Regional Cancer Centre; Ms. Esther Green, Chief Nursing Officer and Director of Health Human Resource Planning, Cancer Care Ontario; Dr. Konrad Leszczynski, Physics Representative, Northeastern Ontario Regional Cancer Centre; Dr. Michael Sharpe, Physics Representative, Princess Margaret Hospital

Working Group: Dr. Normand Laperriere, Radiation Oncologist, Princess Margaret Hospital, Associate Professor, Department of Radiation Oncology, University of Toronto

Financial Disclosures/Conflicts of Interest

No conflicts of interest were declared.

Guideline Status

This is the current release of the guideline.

The EVIDENCE-BASED SERIES report, initially the full original Guideline, over time will expand to contain new information emerging from their reviewing and updating activities.

Please visit the Cancer Care Ontario Web site External Web Site Policy for details on any new evidence that has emerged and implications to the guidelines.

Guideline Availability

Electronic copies: Available in Portable Document Format (PDF) from the Cancer Care Ontario Web site External Web Site Policy.

Availability of Companion Documents

The following is available:

  • Program in evidence-based care handbook. Toronto (ON): Cancer Care Ontario (CCO); 2011. 15 p. Available in Portable Document Format (PDF) from the Cancer Care Ontario Web site External Web Site Policy.
Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on June 8, 2012.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions. Please refer to the Copyright and Disclaimer Statements posted at the Program in Evidence-based Care section of the Cancer Care Ontario Web site External Web Site Policy.

Disclaimer

NGC Disclaimer

The National Guideline Clearinghouseâ„¢ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

Read full disclaimer...