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ASTRO Recommendations for Peer Review in Radiation Oncology

With the 2021 ASTRO Annual Meeting in the books, it’s a great time to revisit ASTRO’s recommendations on peer review in Radiation Oncology[1]. Most recently, in 2019, experts in the field shared what clinics of all sizes should be striving for in a peer review program to ensure plan errors are not slipping through the cracks and that the best quality plan is delivered. Let’s look at those recommendations and what ideas exist to make strides.

Prospective Review is King

One important recommendation is that clinics perform prospective peer review. Reviewing plans prospectively increases the likelihood of receiving feedback, and more importantly, the ability for the treating physician to act on the feedback and adjust the plan accordingly. In other words, the threshold for making a change is lowered when prospective peer review is conducted. Also, prospective peer review “supports a culture of safety,” according to ASTRO.

Unfortunately, even with the known biases and the unlikelihood of change inherent in retrospective peer review, most plans do not receive a prospective peer review. One would suspect that the limited amount of time available or dedicated to peer review is a huge factor in that statistic.

ASTRO acknowledges that prospective peer review may, “require more time between simulation and treatment,” but what still remains unclear is how clinics can perform prospective peer review for more patients than they are today. In other words, the question is not only, “What should clinics be doing?” (we know that now), but also, “How can clinics do it?”

One idea ASTRO puts forth is daily morning huddles among all clinical staff to discuss the upcoming activities and “to preempt potential problems and promote a safety culture”. What ideas do you have to increase the percentage of plans being prospectively peer reviewed? What processes have your clinic implemented so that peer review is more prospective? We would love to hear your thoughts in the comments section below.

Establish a Formal QA Committee

Equally as important, ASTRO recommends that each clinic have a formal QA committee (made up of both clinical and administrative team members) that monitors quality issues, near-misses and errors in treatment, and continuously performs quality improvements.

The committee’s responsibilities differ from the group that gathers weekly for a chart rounds meeting. To break it down further, the QA committee should perform the following:

  1. Develop patient safety initiatives that  are feasible and tailored to the clinic
  2. Ensure there is a mechanism in place to a) report and monitor safety events, b) identify trends which are visible to leadership, and c) implement change when needed
  3. Monitor compliance with local, state, and national safety, licensure, and credentialing standards
  4. Develop a mechanism to investigate safety events in real-time (less than24 hours)
  5. Disseminate safety information to all staff through various communication channels 

A committee of this nature would, “help foster a sense of openness, mutual respect, group participation and responsibility,” according to ASTRO. It would also, “promote staff involvement in seeking positive change in the workplace.”

Has your team set up a formal quality assurance committee? How has this helped to foster a culture of safety at your clinic? How do you interact with this committee? Please share your thoughts in the comments section below.

The Buddy System

For small and remote clinics, especially those with a single physician, peer review can be a difficult endeavor. However, ASTRO clearly states that, “electronic peer review or other collaborative methods from other locations may be necessary, especially for small or remote practices. Modern oncology patient care often involves multiple modalities and can benefit from the review and discussion of experts in various oncology-related disciplines. This is especially true for complex cases.” 

In order to fulfill this recommendation (and thus provide the best care for your patients), you must first identify a “buddy” in the field who can provide a timely review and whose opinion you can trust. Second, you must partner with a vendor that can provide a secure, remote peer review environment.

Fortunately, there are many physicians looking for a “buddy,” and there are a few electronic solutions in place to fulfill this peer review recommendation. ASTRO does provide a Peer-to-Peer Program to radiation oncologists in order to connect those looking to do peer review, which is a helpful resource. Vendors can also be a great resource in identifying potential “buddies” as well. What other resources would you suggest to find a physician looking for a “buddy” in peer review? Please share your thoughts in the comments section below.

Guide to Efficient and Robust Peer Review

Finally, ASTRO also sheds light on the most efficient order of operations and the elements that should be reviewed for a robust peer review process. Revealing in their recommendations is, again, the prospective nature of the peer review and the attention to detail of all plan elements, including the OARs and target volumes. ASTRO’s recommended flow for peer review specifically is as follows:

Before Planning Begins

Initial Step of Planning

After Planning is Complete

Peer review of overall treatment strategy (e.g, review patient case, possible treatment strategies)

Peer review of accuracy and appropriateness of target volumes and critical OARs

Peer review of beam designs, dose calculation parameters, and reasonability of dosimetric results (e.g., plan adequacy, quality, and complexity)

Peer review of goals and limits (e.g., plan intent, target volumes, dose expectations, normal tissue limits)


This is a great guide for clinics looking to revamp their peer review process. However, one item not present in this proposed flow is a peer review of the diagnostic image fusions used to draw the target volumes. Should those be reviewed? If so, when in the process should they be reviewed? This is certainly something to consider.

Now that we know “what” should be peer reviewed and “when” it should be peer reviewed, it’s important to think more about the “how.” How do we avoid reviewing all of these plan elements after planning is complete where changes are unlikely to happen? How do we avoid reviewing only some of these plan elements? We’d love to hear some of your best peer review practices in the comments section below.

If you’d like to learn how your team can perform more prospective peer review, provide trending data on safety events to your formal QA committee, facilitate electronic peer review between physicians at small and remote clinics, and ensure all plan elements are reviewed efficiently, please reach out to us for a demonstration of MIM Harmony®.


[1] ASTRO, “Safety is No Accident: A Framework for Quality Radiation Oncology Care” (ASTRO, 2019).

Jeff Kuhn
Written by Jeff Kuhn

Jeff Kuhn is a Senior Account Executive at MIM Software. Jeff works hand-in-hand with centers across the country to revamp and improve their current peer review processes to improve patient care. He has been a key contributor to the development of MIM Harmony.

You can visit him online at

MIM Software Inc.

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