Practical Radiation Oncology (2016) 6, e369–e381

[Link]

Special Article

Standardizing dose prescriptions: An ASTRO

white paper
Suzanne B. Evans MD, MPH a,⁎, Benedick A. Fraass PhD b ,
Paula Berner CMD, FAAMD c , Kevin S. Collins PhD, RT(R)(T), CMD d ,
Teamour Nurushev PhD e , Michael J. O’Neill MD f , Jing Zeng MD g ,
Lawrence B. Marks MD h
a
Department of Radiation Oncology, Yale University, New Haven, Connecticut
b
Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, California
c
Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
d
School of Allied Health, Southern Illinois University, Carbondale, Illinois
e
21st Century Oncology of Michigan, Farmington Hills, Michigan
f
Radiation Oncology Associates of Lynchburg, Lynchburg, Virginia
g
Department of Radiation Oncology, University of Washington, Seattle, Washington
h
Department of Radiation Oncology, University of North Carolina, Chapel Hill, North Carolina

Received 6 July 2016; revised 12 August 2016; accepted 16 August 2016

Abstract This white paper recommends the standardization (content and presentation order) of
several “key components” of the radiation therapy prescription to facilitate accurate communication

Conflicts of interest: Before initiation of this paper, all members of the White Paper Task Force completed disclosure statements. These statements are
maintained at American Society for Radiation Oncology (ASTRO) Headquarters in Arlington, Virginia, and pertinent disclosures are published within this
report. The ASTRO Conflict of Interest Disclosure Statement seeks to provide a broad disclosure of outside interests. Where a potential conflict is detected,
remedial measures are taken and noted in the disclosure statement. The chairs of the Task Force and Multidisciplinary Quality Assurance subcommittee
reviewed these disclosures and determined they do not present a conflict with respect to these Task Force members’ work on this white paper.
The authors gratefully acknowledge the initial work and support of this effort by the Radiation Oncology Safety Stakeholders Initiative and the expert
reviewers: Susan Cagle, MS, CMD, RT(R)(T); Roy Decker, MD, PhD; Sasha Mutic, PhD; Arno J. Mundt, MD; and Louis Potters, MD. The authors thank
Jean Moran, PhD, for special assistance in coordinating and integrating feedback from the American Association of Physicists in Medicine. They also
acknowledge Sokny Lim for administrative support.
This document was prepared by the Multidisciplinary Quality Assurance Subcommittee of the Clinical Affairs and Quality Committee of ASTRO.
ASTRO white papers present scientific, health, and safety information and may to some extent reflect scientific or medical opinion. They are made
available to ASTRO members and to the public for educational and informational purposes only. Any commercial use of any content in this white paper
without the prior written consent of ASTRO is strictly prohibited.
Adherence to this white paper will not ensure successful treatment in every situation. Furthermore, this white paper should not be deemed inclusive of
all proper methods of care or exclusive of other methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the
propriety of any specific therapy or practice must be made by the physician and the patient in light of all circumstances presented by the individual patient.
ASTRO assumes no liability for the information, conclusions, and findings contained in its white papers.
This white paper was prepared on the basis of information available at the time the Task Force was conducting its research and discussions on this topic.
There may be new developments that are not reflected in this white paper and that may, over time, be a basis for ASTRO to consider revisiting and updating
the white paper.
⁎ Corresponding author. Suzanne B. Evans, M.D., M.P.H., Assistant Professor of Therapeutic Radiology, Yale University, 15 York Street LL 511, New
Haven, CT 06510. Tel.:~ 203-200-1630
E-mail address: [Link]@[Link] (S.B. Evans).

[Link]
1879-8500/© 2016 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved.
e370 S.B. Evans et al Practical Radiation Oncology: November-December 2016

between radiation therapy care providers. The rationale, other similar efforts, and detailed
considerations are described. In brief, the Task Force recommends that the prescription’s
“elements” include: treatment site, method of delivery, dose per fraction, total number of fractions,
total dose (eg, right breast, tangent photons, 267 cGy * 16 = 4272 cGy). A similar formalism is
recommended for brachytherapy (eg, cervix, Ir-192 brachytherapy, 600cGy * 5 = 3000 cGy) and
other modalities. The white paper also considers future directions for other items such as the
simulation order, treatment planning objectives, prescription point or volume, treatment schedule,
localization imaging, laboratory monitoring, concurrent chemotherapy, patient instructions for
treatment, etc. The intent of this white paper is to facilitate accurate communication among
providers to support safe practice as well as to guide vendors in product development that is
consistent with this standard prescription.
© 2016 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved.

Introduction ing), its utility is becoming increasingly evident within

medicine.
Medicine in general
Oncology
Accurate communication is a cornerstone of
high-reliability systems. This is true for communications The need for clear communication within oncology is
between different machines, between different people, and evidenced by the widespread adoption of several standard
between people and machines. Within medicine, miscom- forms of communication in oncology referenced previously.
munication and lack of communication standards, partic- Nevertheless, communication problems clearly still exist
ularly during handoffs (ie, the transfer of care from 1 within oncology in general and within radiation oncology
provider to another) have been linked to suboptimal specifically. Within oncology, essentially every practitioner
outcomes. 1-4 As a consequence, the Joint Commission has has had the experience of dealing with ambiguous clinical
identified handoffs and transitions as a priority in patient notes, reports, etc. 14,15 As noted earlier, pathology has
safety. 5 Handoffs are defined as “a transfer and acceptance adopted the synoptic report to address the lack of standard-
of responsibility for patient care that is achieved through ization associated with the narrative report. 16 Likewise, the
effective communication.” 6 Transitions of care “refer to movement toward standardized treatment summaries and care
the movement of patients between health care practi- plans is recognition that many current approaches by
tioners, settings, and home as their condition and care practitioners to communicate with each other, and with
needs change.” 7 As part of this initiative, standardized patients, are suboptimal.
communication methods/tools have been advocated. 8 For
example, the technique of SBAR (situation, background, Radiation oncology
assessment, recommendation) to facilitate communication
has been recommended and implemented successfully. 9 The field of radiation oncology has its own set of
Likewise, the American College of Radiology (ACR) and challenges related to communication. Indeed, the field has
American Society for Radiation Oncology (ASTRO) spent much time assuring that computers communicate
consider communication so critical that there is a joint well with each other (eg, through the Integrating the
practice parameter dedicated to this issue. 10 Healthcare Enterprise-Radiation Oncology [IHE-RO]
Efforts have been made to standardize other aspects of initiative). 17,18 Computer interconnectivity is vitally
communication in medicine. The Universal Protocol, important to enable the correct automatic transfer of
which includes the presurgical timeout, is a well-known data. However, additional efforts are needed to standardize
example that translates across medical disciplines. 11 computer-to-human and human-to-human communication
Timeouts are ubiquitously used from medication dispens- (Fig 1).
ing to procedure verification to ensure team members and Given the central nature of the radiation prescription,
patients are aware and in agreement of the initiative being this report will focus on that aspect of our practice. In fact,
carried forward. Many other standard communication the Radiation Oncology Incident Learning System data
efforts exist including the written medication prescription, have cited prescription errors in each of their quarterly
the SOAP (subjective, objective, assessment, plan) note, reports to date. 19 Addressing the radiation prescription
pathology cancer templates, 12 standard toxicity grading might be particularly timely as recent changes within
systems, Response Evaluation Criteria in Solid Tumors radiation oncology have made some of our traditional
(RECIST), and cancer staging. 13 Thus, just as clear jargon regarding prescriptions somewhat ambiguous. For
communication has been recognized as a cornerstone of example, the increased use of hypofractionation increases
reliability in several industries (eg, aviation, manufactur- the breadth of reasonably acceptable clinical prescriptions
Practical Radiation Oncology: November-December 2016 Standard dose prescriptions white paper e371

Figure 1 The three types of communication between or within people and machines are shown. The IHE-RO initiative addresses
communication between devices. In the lower corner are listed additional electronic systems (eg, hospital electronic medical records)
where communication or connectivity issues can also be challenging. Also important is communication between people and between
people and machines. A standard format/language for radiation therapy prescriptions is intended to facilitate clear human-to-human and
computer-to-human communication. CT, computed tomography; IHE-RO, Integrating the Healthcare Enterprise-Radiation Oncology;
PACS, picture archiving and communication system; RT, radiation therapy; R&V systems, radiation therapy record and verify systems.
Adapted with permission from Marks and Chang, Practical Radiation Oncology (2011) 1, 232-234.

and increases the risk of miscommunication. For been described as the tendency to more readily believe
example, years ago the phrase “3 times 10” could be information that confirms one’s own beliefs. A simple
reasonably assumed to always mean 3 Gy × 10. example occurs when the listener is expecting to hear one
However, this is no longer true because 10 Gy × 3 item, and another item is said, leading to confusion (as
fractions might also be reasonable. Thus, accurate, evidenced in the 10 Gy × 3 example). The existence of this
unambiguous communication among members of the cognitive bias and increased mental workload associated
radiation oncology team, particularly as it relates to the with nonstandardization suggests that the safest way to
prescription, is critical to ensure patient safety. The relay prescription information is in a standard manner,
means of communication used within programs provid- where the elements, the units used to present them, and
ing care at multiple locations (an increasingly common their order are standard.
arrangement) can be variable (and usually not face to Therefore, the central goal of this white paper is to
face), thus increasing the risks for miscommunication. facilitate accurate communication between radiation
Further, many centers have equipment from several therapy care providers through a recommendation for
vendors, thus requiring the team (eg, physicians, standardization of a number of components of the
dosimetrists, therapists, physicists) to routinely consider radiation prescription. Accurate and clear communica-
similar types of data in variable formats (see Fig 2A-E). tion will reduce the risk of error. Additionally, a more
The lack of standardization requires an increased level standardized radiation prescription will facilitate data
of mental effort by those who input or review information pooling for research (eg, future oncology registries) and
from these different displays. 20,21 An increased level of also may enable vendor driven safety initiatives such as
mental effort and workload is associated with a greater automated self-consistency checks. Improved standard-
opportunity for errors to occur. 22 Additionally, there are ization of the radiation prescription will also be very
many human biases that can lead to error in the setting of helpful to software vendors during product design and
nonstandardized workflows. For example, team members development. This paper is endorsed by American
are subject to confirmation bias. Confirmation bias has Association of Medical Dosimetrists, American
e372 S.B. Evans et al Practical Radiation Oncology: November-December 2016
Practical Radiation Oncology: November-December 2016 Standard dose prescriptions white paper e373

Figure 2 (continued).

Figure 2 Screen shots from vendors within the field, all illustrating the manner in which radiation therapy prescriptions are either
entered or displayed. The degree of intervendor variation is self-evident despite the limited sampling of vendors shown. Interestingly,
there are several examples in which there is intravendor variation as well, with the same prescription being depicted in different formats in
different locations within the product. Some clinics have software from multiple vendors. The highlights, lines, and call out balloons are
added to emphasize the point. Adapted with permission from Marks et al; Engineering Patient Safety in Radiation Oncology 2015. (A)
Mosaiq, Elekta AB, Stockholm, Sweden, used with permission. (B) TomoTherapy, Accuray, Sunnyvale, CA, used with permission. The
dose per fraction is not part of the display. (C) CyberKnife, Accuray, Sunnyvale, CA, used with permission. In the lower left-hand corner,
the number of fractions is not noted in the prescription, nor is the fraction size, only the total dose. (D) Aria, Varian Medical Systems, Palo
Alto, CA, used with permission. (E) Aria, Varian Medical Systems, Palo Alto, CA, used with permission.
e374 S.B. Evans et al Practical Radiation Oncology: November-December 2016

Figure 2 (continued).

Association of Physicists in Medicine, American attempt to be completely comprehensive will always be

Brachytherapy Society, American College of Radiology, “out of date” because of the rapid evolution of clinical
and the American Society of Radiologic Technologists. practice (eg, electronic brachytherapy and surface imaging
would not have been adequately considered in standards
developed just a few years ago). Additionally, given the
The challenge of standardization complexity of radiation oncology, there is a tendency
toward mission creep as more elements are considered for
Establishing standards is challenging and several standardization (eg, should we consider concurrent
potential failure modes have been described 23; including: chemotherapy timing/dosing specifications?).
To address these concerns, the Task Force limited the
a. Failure to initiate a standardization effort; scope of this effort to a limited number of central
b. Failure to reach consensus leading to deadlock; prescription items concerning how prescribed dose is
c. Failure to contain the scope of the effort, leading to specified. All but 2 of these items can be expressed
“feature creep”; and numerically. We specifically differentiate the “key ele-
d. Failure of acceptance by the field (eg, because of ments” of the prescription from the other components of
standardization that is incompatible with current/ the radiation therapy prescription (eg, simulation orders,
evolving practice). treatment planning objectives, the approved treatment
plans, imaging orders, patient instructions for treatment)
How these failure modes relate to this effort is briefly that are not addressed in detail here. Future efforts should
explored here. When planning this current initiative, this address these other aspects of the prescription, though in
group has been most concerned with items b and c: this paper some ideas on how additional components of an
reaching consensus and limiting the scope. The central expanded prescription might be incorporated into the
challenge of establishing a standard prescription is the proposed standard are presented.
multitude of potential items to consider, along with their
dynamic nature. The broader one makes the scope (eg, to
include nomenclature for all techniques, volumes, or Prior work by others
modalities), the harder it is to reach a lasting consensus.
The essentially limitless potential permutations will appeal As a start, we considered pre-existing guidance on this
differently to different clinics (eg, because of traditions) topic. The ACR has established guidelines for which items
and make agreement more challenging. Further, any should be included in the radiation therapy prescription. 24
Practical Radiation Oncology: November-December 2016 Standard dose prescriptions white paper e375

These ACR advocated items include: volumes or sites to Choosing the key elements
be treated, treatment technique, beam modifying
devices, radiation modality, energy, dose per fraction, The Task Force considers the key elements to be those
total number of fractions, fractionation schedule, total whose absence would make the radiation therapy
dose, prescription point, volumes, or isodose volumes or prescription impossible to deliver. The key elements by
lines. Further, the ACR requests that the dose per themselves do not form a complete directive for treatment
fraction and total dose should be specified for each delivery, and cannot “stand alone.” These are meant to
prescription volume. The ASTRO Accreditation align with the ICRU and NRC requirements and include:
Program for Excellence (APEx) Standard 2.3 refers to patient name, treatment site, method of delivery, dose per
a specifications of a “formal treatment prescription and fraction, total number of fractions, and total dose (Table 1).
plan that includes the physician’s order for the following
elements of radiation therapy: anatomic treatment site, A. Patient name: Because prescriptions are written
type and method of radiation treatment delivery, energy, within the confines of an individual patient’s record,
total dose, dose per fraction, number of fractions, the patient’s name is inherently included. As such,
frequency of treatment, imaging guidance, physician’s the name does not need to be repeated within the key
signature and date prior to initiation of treatment.” 25 The elements of the radiation therapy prescription. It
ACR and ASTRO recommendations are thorough and should be noted that although names may be
thoughtfully developed. However, as the field has identical, the prescription is located within a medical
evolved, some of these items are difficult to define. record that contains additional essential identifying
The ACR and ASTRO documents do not specify the information, such as date of birth and medical record
format, units, or order in which these items should be number.
expressed. As such, the efforts summarized in this B. Treatment site: Treatment site is important and
document complement, rather than supplant, the earlier should be expressed clearly and unambiguously
ACR and ASTRO documents. within the treatment prescription (eg, with laterality
Additionally, ASTRO has made some specifications noted where applicable). There is presently much
regarding documentation for intensity modulated variation in how treatment sites are specified. An
radiation therapy (IMRT). 26 The ASTRO report recom- American Association of Physicists in Medicine
mends that IMRT treatment documentation should (AAPM) task group (#263) has been charged with
include the following: IMRT treatment planning direc- making recommendations for standardizing names
tive, a treatment goal summary, an image guidance of structures (targets and normal tissues) to address
summary, and a motion management summary. These this variation, 31 and there are some other recom-
are in parallel to ACR-ASTRO collaborative recom- mendations in place toward this end. 32,33 Vendors
mendations for the implementation of image guided are strongly encouraged to provide flexibility in the
radiation therapy that emphasize the importance of naming of the treatment site (eg, by being generous
documenting the type of imaging modality, its frequen- in the character limits to allow for laterality to be
cy, and the reference image sets and structures. 27 spelled out and complete site names to be specified:
Additionally, the International Commission on Radia- left chest wall and internal mammary nodes rather
tion Units and Measurements (ICRU) reports 50, 62, and
83 are applicable here. 28-30 The Nuclear Regulatory
Commission (NRC) requirements are discussed shortly, Table 1 A recommended format for the key elements of a
and it should be noted that this document is in line with radiation therapy prescription a
current NRC requirements. Treatment Method of Dose per Total Total
site * delivery fraction, number of dose, cGy
Standardizing the key elements in the prescription: cGy fractions
Scope, rationale, and recommendations
Right chest Photons ** 200 25 5000
wall
In the formation of a more standardized prescription, Vaginal Ir-192 ** 600 5 3000
it is clear for the reasons elicited here that not every part mucosa
of the prescription can be standardized in a lasting way. Left frontal brain Cobalt-60 ** 1800 1 1800
Therefore, the focus of these efforts was on a limited a
Adapted with permission from Marks and Chang, Practical
number of “key elements.” Other items “beyond the key Radiation Oncology (2011) 1, 232-234.
*
elements” are acknowledged, discussed, and further See comment in Table 3 regarding treatment site names.
**
segregated into several categories. This provides a As discussed previously, method of delivery is not fully
standardized by this work. It may be expressed in this example as
framework for addressing changes that will be needed
“Photons, Tangents,” “Ir-192 vaginal cylinder,” or “Cobalt-60,
to accommodate evolving practice and to enable safe Gamma Knife.”
delivery of the desired treatment course.
e376 S.B. Evans et al Practical Radiation Oncology: November-December 2016

Table 2 Order of key elements for a radiation therapy An identical formalism should be used for brachyther-
prescription apy and radiosurgery procedures as shown in Table 1. The
Treatment Method Dose per Total Total order of the 3 numerical elements was chosen to conform
site of fraction number of dose with the NRC requirements for the written directive, and to
delivery (cGy) fractions (cGy) express the temporal aspect of treatment—reading left to
right, the numbers shown reflect the passage of time. On
the first day of treatment, the dose per fraction is the only
than LT CW w/IM). The prescribing radiation number needed to determine the accumulated dose. The
oncologist should take care to name the treatment number of fractions is needed as time goes on while the
site in a manner that allows others to readily total dose is only actualized at the completion of the
understand which portion of the body is to be treatment course. Similarly, if a patient discontinues
treated (eg, “left tonsil and bilateral neck” is therapy earlier than initially planned, the left-hand-most
preferred over “PTV1”). Laterality should always item does not change, but rather only the later items.
be included in accordance with current standards, When there are multiple prescriptions running simul-
including the recently implemented International taneously (eg, treatment to multiple sites or different doses
Statistical Classification of Diseases and Related to target subregions via “dose painting/simultaneous
Health Problems, version 10. Ultimately, standard- integrated boost”) each prescription should be defined
ization of treatment site names will facilitate separately. This will require that a single plan can be
compilation of big data; however, this is beyond linked to multiple prescriptions, and may have other
the scope of this effort. implications that are beyond the scope of this document. A
C. Method of delivery: If brachytherapy is indicated, potential example of adherence to the formalism can be
then, consistent with NRC requirements, the isotope found in Table 3.
type should be specified (eg, Ir-192, Cs-137). If
external beam is indicated, then, at a minimum it
should state “photons,” “electrons,” etc. However,
alternative, more descriptive options that also Units for dose
include things such as energy, technique, or even
machine (eg, “6MV photons,” “12MeV electrons,” An issue that can be best addressed nationally/
“arc-based IMRT,” “tomotherapy, “SBRT”) may be internationally relates to the use of Gray (Gy) vs centiGray
desirable. However, at the present time there are too (cGy). There is no consistency within the field in the use of
many variations to be standardized within this work. Gy versus cGy, and users often have strong preferences for
Vendors are encouraged to provide flexibility in one or the other. Although Gy is the SI unit, from a
specifying the method of delivery (eg, by being safety-related point of view the use of cGy has several
generous in the character limits), until a standard advantages, including:
nomenclature is developed.
a. Numbers that are larger in size (ie, more digits) are
These key elements are the focus of this effort. To that consistently larger in value than numbers with fewer
end, we recommend all radiation prescriptions contain the digits. For example, 3000 cGy visually conveys that
following information in the order shown in Table 2, with it is larger than 225 cGy, whereas 30 Gy is not
these units, without intervening additional data. visually larger than 2.25 Gy.

Table 3 Example of key elements in a single plan using multiple radiation therapy prescriptions
Treatment site * Method of delivery Dose per fraction (cGy) Total number of fractions Total dose (cGy)
Left tonsil Photons ** 200 35 7000
Left neck: retropharyngeal Photons ** 180 35 6300
nodes, left levels 1-3
Right neck levels 1-4, left neck level 4 Photons ** 160 35 5600
*
The format/style/content of the names herein used to denote Treatment Site are not dictated by this report. An ongoing AAPM effort (TG-263) is
addressing the challenging topic of standardizing anatomic and target nomenclature within treatment planning systems. While TG-263 is held to the
DICOM dictated character limits for structure names, and the tenet that more-rigid formalism will better enable data pooling, treatment site naming is
guided by the first principle of clarity and avoidance of site and side misadministrations. The use of abbreviations and excessively limited characters
prevents clarity and is discouraged in treatment site designation. However, within treatment planning systems, where the segmented organ or target is
visible, such abbreviations are more intuitive and are a basic tool used with TG-263.
**
As discussed above, method of delivery is not fully standardized by this work. It may be expressed in this example as “Photons, VMAT,”
“Photons, IMRT,” or “Photons, Tomotherapy.”
Practical Radiation Oncology: November-December 2016 Standard dose prescriptions white paper e377

Table 4 Additional components of the prescription a

Component Sample of items that may be included
Prescription point or volume The unique and well-defined specific point or volume that is to receive the prescription
dose, the prescription isodose line, and related information
Treatment schedule and fractionation Fractions per calendar day, minimum interfraction interval, coordination with
systemic therapy, plan delivery sequencing
Setup instructions for planning and treatment Patient positioning, immobilization device, patient marking
Treatment planning objective or directive Target coverage goals, normal tissue constraints, image fusion needs, technique(s) to
evaluate
Approved treatment plan Unique description of plan to be delivered: beam energies, angles, compensators, dose
volume histogram
Treatment imaging order or directive Type of imaging, frequency, directions for realignment b
Patient instructions for daily treatment Fasting, medications, timing relative to chemotherapy
a
Please note that this is not a comprehensive list of all elements that may be within the components listed.
b
American College of Radiology. ACR–ASTRO Practice Parameter for Image-Guided Radiation Therapy (IGRT). [Link]
[Link]. Accessed March 24, 2016.

b. Decimal point use is minimized. With decimal c. The use of cGy also allows for better understanding
points, the same numerical value can be shown in of implied units. For instance, when one remarks
numerous ways, with a varying number of digits, that a patient is getting 10 × 5, it would be
and hence variable lengths. Thus, the “failsafe” use reasonable to assume that the patient is getting
of decimal points requires strict adherence to rules either 10 fractions each of 5 Gy, or 5 fractions each
regarding the number and placement of zeros and is of 10 Gy. However, when the phrase 1000 × 5 is
thus more prone to error than a system that is not used, the reasonable practitioner would not assume
reliant on decimals. This ambiguity has been 1000 fractions of 5 Gy nor 5 fractions of 1000 Gy.
implicated in several medical errors. 34-39 Decimal Rather, the units of cGy are more easily inferred to
points are a potential problem because they: be 5 fractions of 1000 cGy each.
i) Are small and might be relatively easy to d. In treatment plans in which there is not substantial
overlook and lead to misreading of numbers; modulation, the unit cGy is closely linked with
ii) Raise issues related to presence and number of monitor units (MUs), allowing for quick correlation
leading and trailing zeros that can make of delivered MUs with prescribed dose (eg, a
numbers harder to read and prone to misread- supraclavicular field getting 200 cGy per day may
ing (eg, 0.8 vs 0.80); as well as the number of have 212 MU).
digits placed to the right of the decimal point e. In the instance of unit confusion, where a practi-
(eg, 8 vs. 8.0). tioner intends one unit but write another, the
iii) Might be problematic in some computer likelihood of overdose is less if cGy is the default
coding situations. unit of prescription. Similarly, The National Council
iv) Are particularly problematic given the poor for Prescription Drug Programs has recommended
numeracy of many adults, including physi- the use of milliliter rather than teaspoon (5 mL) for
cians and trainess. 40-42 oral drugs, 34 citing the rationale that in the setting of
v) Are expressed variably using a comma or a a prescribing error, the patient impact of the error
period in different languages, making interna- might be less (eg, a 2-fold error in milliliters is less
tional standardization challenging likely to cause overdose than a 2-fold error in

Table 5 An example of a radiation therapy prescription that strives to include more than the key elements
Key elements Localization
Treatment site* Method of Dose per Total number Total “IGRT”/ Frequency Localize via Action directive
delivery fraction, cGy of fractions dos, cGy localization type
Larynx Photons 225 29 6525 kV-kV films Daily Spine Make all shifts,
call MD if N10 mm
Right chest wall Photons 200 25 5000 Field portal Once every NA Per MD
films 5 treatments
IGRT, image guided radiation therapy; kV, kilovoltage; MD, physician.
*
See comment in Table 3 regarding treatment site names.
e378 S.B. Evans et al Practical Radiation Oncology: November-December 2016

Table 6 A second example of a prescription that strives to include more than the key elements
Key elements Image guidance
Treatment site *
Method of Dose per Total Total Prescription Immobilization “IGRT”/ Frequency Localize Action
delivery fraction number of dose point/volume localization via.... directive
fractions type
Right chest wall Photons 200 cGy 25 5000 99% IDL Custom cradle Field portal Once NA Per MD
cGy relative to on angle board films every five
isocenter treatments
Right chest wall mass Photons 200 cGy 5 1000 90% IDL Custom cradle CBCT Daily Chest Shift for
cGy relative to on angle board wall N2 mm,
isocenter mass call MD for
N10 mm
CBCT, cone beam computed tomography; IDL, isodose lines; IGRT, image guided radiation therapy; MD, physician; NA, not available.
*
See comment in Table 3 regarding treatment site names.

teaspoons). This is applicable in the setting of accomplish safely. Readers are directed to review
radiation therapy prescribing as well because dose applicable regulatory requirements that, if present, could
cannot be removed once given, but supplemental override these recommendations.
dose can be prescribed.

Therefore, we recommend using cGy within the Categories beyond the key elements
prescription. Nevertheless, we acknowledge that there
are potential challenges with this approach. For example, We acknowledge and recognize that the key elements
smaller numbers are often easier to read (fewer characters) of the prescription as described here are not sufficient to
and verbalize (fewer syllables) (eg, 30 Gy vs 3,000 cGy). adequately guide the desired therapy or to form a complete
Additionally, there may be substantial status quo bias prescription. For essentially all situations, the physician
hindering immediate acceptance of this change. We note needs to also provide additional directives or details to
that the implementation of moving from Gy to cGy will be guide the complete management of the person receiving
complex and require significant effort by the team to radiation therapy, and maintain accordance with ACR and

Figure 3 A summary of the recommendations within the standardizing dose prescriptions white paper. Please note that within delivery
method, formalism for brachytherapy is consistent with the Nuclear Regulatory Commission. Within the external beam delivery method,
some formalism is provided, but there remain too many permutations to address this presently, and, as such, is beyond the scope of this
paper.
Practical Radiation Oncology: November-December 2016 Standard dose prescriptions white paper e379

ASTRO guidelines. A full discussion of these items is example) the current electronic medical record tools is
beyond the scope of this work. Nevertheless, a brief unclear (eg, for the setting of a concurrent boost). For
outline of some of these directives is provided to example, how will these be linked to the treatment plans?
acknowledge their critical importance and to illustrate How will sequencing be designated? The character limits
the modern day complexities of these once simple present on various planning and record and verify systems
directives. No attempt is being made to be exhaustive in may not be adequate to allow the clear and unambiguous
this list. It is likely that each of these directives has become naming of such subvolumes.
so detailed that they may be most amenable to standard- There are a number of considerations when implement-
ization as a separate order within the broader “prescrip- ing the elements of the standard prescription into one’s
tion.” Further, to facilitate future discussions related to practice. This implementation process should include
standardizing these directives, we broadly segregate these broad representation including all members of the
additional elements into the following categories listed in radiation therapy team. The staging and timing of the
Table 4. changes should be carefully considered, especially with
respect to patient safety and clarity of communication. A
comprehensive inventory will be needed of documents for
Challenges to implementation of a more which the layout of information is to be changed to be
consistent with these recommendations. For example,
standardized prescriptions: Broadening implementation of the format of the prescription may
the scope involve updating many departmental site-specific planning
directives. There are also changes that users will not be
Forming a complete prescription while maintaining a able to implement until manufacturers have standardized
clear, concise prescription amenable to a standard format is their displays in the multiple workspaces that convey the
a formidable task. The scope of the items listed as “beyond prescription information. All locations where the radiation
the key elements,” is broad and may become more prescription is displayed (eg, the treatment planning
extensive with time. Thus, ongoing and future efforts to system, treatment management systems) should be
integrate additional items beyond the key elements may addressed in order to achieve uniformity. Supplemental
cause increasingly confusing and non-standard “prescrip- forms such as emergency treatment prescriptions
tions.” Therefore, we recommend that directives related to would also need modification. In particular, the transition
these additional items remain separated from the key from use of Gy to cGy is more complex than the other
elements of the prescription, yet still easily accessible changes, and will require careful planning. In all cases,
within the electronic charts. 43 This will allow each piece of testing of the interoperability of systems will be critical,
the directive for radiation delivery to be clear and succinct. and end-to-end tests will be essential, as recommended by
The exact formatting of how this will look will require many organizations.
much effort in development. Several potential examples
are shown in Tables 5 and 6. Note how the standard
formatting for the key elements of the prescription remains Summary and future directions
unchanged even as additional items are addressed.
The Task Force recommends that the other components In this white paper, a recommendation is made for the
of the prescription listed previously be displayed outside key elements of a radiation therapy prescription along with
of the standard prescription’s key elements (Fig 3). Over a standardized manner for how these elements are to be
time, as more prescription components become standard- presented. It is our hope that the suggested formalism for
ized, it might be reasonable to consider systematically the key elements of the prescription be used in all areas
incorporating some of these items within the key elements. where this same information is displayed: in weekly
However, until that time, use of the proposed standard management notes, completion/summary notes, patient
prescription key elements is advised to keep communica- care plans, and hospital electronic medical records
tion clear. It is a likely outcome that the other elements systems. In this manner, our field will become accustomed
may require a completely separate image guidance to a standard way of communicating with each other. The
directive, for example, in order to achieve clarity and goal of this recommendation is to help to improve safety
standardization. In fact, many insurance companies require and efficiency; however, we acknowledge that adoption of
such distinct orders to provide reimbursement. this formalism will require change. Times of change can be
The tools presently available in the electronic medical vulnerable to error, and extra user training, automation
record systems do not always allow the flexibility to solutions, validation checks, and mindfulness are encour-
address issues such as concurrent boost and adaptive aged. These recommendations are complementary to prior
planning. We agree with the ACR recommendation that recommendations (eg, from the ICRU, NRC, ACR, and
differing fractional dose and total doses should be noted ASTRO, section “Prior Work by Others”). Further
clearly in the prescription, but how to best do this with (for guidance on standardization of other elements will be
e380 S.B. Evans et al Practical Radiation Oncology: November-December 2016

forthcoming from other groups (eg, AAPM task group 17. Rengan R, Curran B, Able C, et al. Addressing connectivity issues:
263). Further efforts to address other aspects of the The Integrating the Healthcare Enterprise-Radiation Oncology
(IHE-RO) initiative. Pract Radiat Oncologia. 2011;1:226-231.
physician’s directions for the planning and delivery 18. Abdel-Wahab M, Rengan R, Curran B, et al. Integrating the
process are likely needed as well. healthcare enterprise in radiation oncology plug and play–the future
of radiation oncology? Int J Radiat Oncol Biol Phys. 2010;76:
333-336.
19. American Society for Radiation Oncology. Radiation oncology
References incident learning system quarterly reports (Q3 2014, Q4, 2014, Q1-3
2015). Available at: [Link]
Accessed March 24, 2016.
1. Denson JL, McCarty M, Fang Y, et al. Increased mortality rates 20. Patel VL, Kaufman DR, Cohen T. Cognitive Informatics in Health
during resident handoff periods and the effect of ACGME duty hour and Biomedicine: Case Studies on Critical Care, Complexity and
regulations. Am J Med. 2015;128:994-1000. Errors. London: Springer Science and Buisness Media. 2014.
2. Starmer AJ, Spector ND, Srivastava R, et al. Changes in medical 21. Morris AH. Developing and implementing computerized protocols
errors after implementation of a handoff program. N Engl J Med. for standardization of clinical decisions. Ann Intern Med. 2000;132:
2014;371:1803-1812. 373-383.
3. Riesenberg LA, Leitzsch J, Massucci JL, et al. Residents' and 22. Mazur LM, Mosaly PR, Jackson M, et al. Quantitative assessment of
attending physicians' handoffs: A systematic review of the literature. workload and stressors in clinical radiation oncology. Int J Radiat
Acad Med. 2009;84:1775-1787. Oncol Biol Phys. 2012;83:e571-e576.
4. The Joint Commission. Sentinel event statistics data - root causes by 23. Cargill CF. Why standardization efforts fail. J Electron Publ.
event type. [Link] at: [Link] 2011;14(1).
org/sentinel_event_statistics/. Accessed June 26, 2015. 24. American College of Radiology. ACR-ASTRO Practice Parameter
5. The Joint Commission. Improving America’s hospitals: The Joint for Radiation Oncology. Available at: [Link]
Commission’s annual report on quality and safety. Available at: ACR/Documents/PGTS/guidelines/Radiation_Oncology.pdf.
[Link] Accessed June 26, 2015.
pdf. Accessed June 26, 2015. 25. American Society for Radiation Oncology. APEx Program Stan-
6. The Joint Commission Center for Transforming Healthcare. Facts dards. Available at: [Link]
about the Hand-off Communications Project. Available at: http:// Practice_Management/Practice_Accrediation/[Link].
[Link]/assets/4/6/CTH_HOC_ Accessed January 3, 2016.
Fact_Sheet.pdf. Accessed June 26, 2015. 26. Holmes T, Das R, Low D, et al. American Society of Radiation
7. The Joint Commission, Joint Commission Center for Transforming Oncology recommendations for documenting intensity-modulated
Healthcare, Joint Commission Resources. Hot topics in health radiation therapy treatments. Int J Radiat Oncol Biol Phys. 2009;74:
care—transitions of care: The need for a more effective approach to 1311-1318.
continuing patient care. Available at: [Link] 27. American College of Radiology. ACR-ASTRO Practice Parameter
org/assets/1/18/Hot_Topics_Transitions_of_Care.pdf. Accessed for Intensity Modulated Radiation Therapy (IMRT). Available at:
June 26, 2015. [Link]
8. Panesar RS, Albert B, Messina C, et al. The effect of an electronic pdf. Accessed March 24, 2016.
SBAR communication tool on documentation of acute events in the 28. International Commission on Radiation Units and Measurements.
pediatric intensive care unit. Am J Med Qual. 2016;31:64-68. Prescribing, Recording, and Reporting Photon Beam Therapy
9. De Meester K, Verspuy M, Monsieurs KG, et al. SBAR improves (Report 50). 1993.
nurse-physician communication and reduces unexpected death: A 29. International Commission on Radiation Units and Measurements.
pre and post intervention study. Resuscitation. 2013;84:1192-1196. Prescribing, Recording and Reporting Photon Beam Therapy
10. American College of Radiology. ACR-ASTRO Practice Parameter (Report 62). 1999.
for Communication: Radiation Oncology. Available at: [Link] 30. International Commission on Radiation Units and Measurements.
[Link]/~/media/[Link]. Prescribing, Recording, and Reporting Intensity-Modulated
Accessed March 24, 2016. Photon-Beam Therapy (IMRT)(ICRU Report 83). 2010.
11. Norton E. Implementing the universal protocol hospital-wide. AORN 31. Matuszak M, Moran J, Xiao Y, et al. SU-E-P-22: AAPM Task Group
J. 2007;85:1187-1197. 263 Tackling Standardization of Nomenclature for Radiation
12. College of American Pathologists. Cancer Protocol Templates. Therapy. Med Phys. 2015;42:3231.
Available at: [Link] 32. Santanam L, Hurkmans C, Mutic S, et al. Standardizing naming
ting-ools/cancer-rotocol-emplates?_afrLoop=%40%3F_afrLoop%3- conventions in radiation oncology. Int J Radiat Oncol Biol Phys.
D57767493224169%26_adf.ctrl-tate%3D8j0bz025w_17. Accessed 2012;83:1344-1349.
July 12, 2015. 33. Mayo CS, Pisansky TM, Petersen IA, et al. Establishment of practice
13. Edge SB, Compton CC. The American Joint Committee on Cancer: standards in nomenclature and prescription to enable construction of
The 7th edition of the AJCC cancer staging manual and the future of software and databases for knowledge-based practice review. Pract
TNM. Ann Surg Oncol. 2010;17:1471-1474. Radiat Oncologia. 2016;6:e117-e126.
14. von Eschenbach AC. Eliminating error-prone notations in medical 34. National Council for Prescription Drug Programs. Appendix A:
communications. Expert Opin Drug Saf. 2007;6:233-234. Documents and resources consistent with the White Paper
15. Lucey LL, Kushner DC. The ACR guideline on communication: To recommendation and guidelines on the use of milliliter (mL).
be or not to be, that is the question. J Am Coll Radiol. 2010;7: NCPDP recommendations and guidance for standardizing the dosing
109-114. designations on prescription container labels of oral liquid
16. Lankshear S, Srigley J, McGowan T, et al. Standardized synoptic medications. Version 1.0; 2014. p. 46-50.
cancer pathology reports - so what and who cares? A 35. Hicks RW, Becker SC, Chuo J. A summary of NICU fat emulsion
population-based satisfaction survey of 970 pathologists, surgeons, medication errors and nursing services: Data from MEDMARX. Adv
and oncologists. Arch Pathol Lab Med. 2013;137:1599-1602. Neonatal Care. 2007;7:299-308. quiz 309-310.
Practical Radiation Oncology: November-December 2016 Standard dose prescriptions white paper e381

36. Dubeshter B, Walsh CJ, Altobelli K, et al. Experience with 40. Johnson TV, Abbasi A, Schoenberg ED, et al. Numeracy among
computerized chemotherapy order entry. J Oncol Pract. 2006;2: trainees: Are we preparing physicians for evidence-based medicine?
49-52. J Surg Educ. 2014;71:211-215.
37. Doherty C, Mc Donnell C. Tenfold medication errors: 5 years' 41. Anderson BL, Schulkin J. Physicians' perceptions of patients'
experience at a university-affiliated pediatric hospital. Pediatrics. knowledge and opinions regarding breast cancer: Associations with
2012;129:916-924. patient education and physician numeracy. Breast Care (Basel).
38. Sinnott M, Eley R, Steinle V, et al. Decimal numbers and safe interpretation 2011;6:285-288.
of clinical pathology results. J Clin Pathol. 2014;67:179-181. 42. Thimbleby H, Cairns P. Reducing number entry errors: Solving a
39. Bauman ME, Black KL, Bauman ML, et al. Novel uses of insulin widespread, serious problem. J R Soc Interface. 2010;7:1429-1439.
syringes to reduce dosing errors: A retrospective chart review of 43. Mechalakos J. MO-A-BRB-01: Review of TG-262 Internal Survey of
enoxaparin whole milligram dosing. Thromb Res. 2009;123:845-847. Practices in EMR for External Beam Therapy. Med Phys. 2015;42:3546.