Results: There were 12,183 low risk, 17,236 intermediate risk, 7,622 high risk, and 605 locally advanced patients. In the low risk group, AS was the only recommended treatment option for 2941 patients; 712 (24%) were treated with AS, the remainder were treated with EBRT (25%), brachytherapy (20%), EBRT+brachytherapy (3%), or radical prostatectomy (18%). In the low risk group, AS was an accepted option for 9,242 patients; 1624 (18%) were treated with AS, the remainder were treated with EBRT (17%), brachytherapy (21%), EBRT+brachytherapy (3%), or radical prostatectomy (35%). In the intermediate risk group, AS was an accepted option for 5,084 patients; 1,281 (25%) were treated with AS; the remainder were treated with EBRT (29%), brachytherapy (9%), EBRT+brachytherapy (6%) or radical prostatectomy (24%). The NCCN guidelines do not recommend AS for the other risk groups. Overall, 46% of all patients could be managed with AS according to the guidelines; 9.6% actually received it. Based on an annual U.S. prostate cancer incidence of 192,000; we estimate that approximately 88,000 patients could initially be treated with AS by following the NCCN guidelines, while 18 thousand were actually treated with it. The remaining 70,000 were treated with radical prostatectomy (25,000), EBRT (19,000), brachytherapy (15,000), EBRT + brachytherapy (3000), and other treatments (6000). Conclusions: Based on NCCN guidelines, active surveillance could be an acceptable treatment option for almost half of all patients diagnosed with prostate cancer, though less than 10% actually received it in 2006. Nationally, up to 70,000 additional patients with prostate cancer could be managed initially with active surveillance rather than radical therapy.

Purpose/objectives To report our experience of combining three approaches of an automatic plan integrity check (APIC), a standard plan documentation, and checklist methods to minimize errors in the treatment planning process. Materials/methods We developed APIC program and standardized plan documentation via scripting in the treatment planning system, with an enforce function of APIC usage. We used a checklist method to check for communication errors in patient charts (referred to as chart errors). Any errors in the plans and charts (referred to as the planning errors) discovered during the initial chart check by the therapists were reported to our institutional Workflow Enhancement (WE) system. Clinical Implementation of these three methods is a progressive process while the APIC was the major progress among the three methods. Thus, we chose to compared the total number of planning errors before (including data from 2013 to 2014) and after (including data from 2015 to 2018) APIC implementation. We assigned the severity of these errors into five categories: serious (S), near miss with safety net (NM), clinical interruption (CLI), minor impediment (MI), and bookkeeping (BK). The Mann–Whitney U test was used for statistical analysis. Results A total of 253 planning error forms, containing 272 errors, were submitted during the study period, representing an error rate of 3.8%, 3.1%, 2.1%, 0.8%, 1.9% and 1.3% of total number of plans in these years respectively. A marked reduction of planning error rate in the S and NM categories was statistically significant (P < 0.01): from 0.6% before APIC to 0.1% after APIC. The error rate for all categories was also significantly reduced (P < 0.01), from 3.4% before APIC and 1.5% per plan after APIC. Conclusion With three combined methods, we reduced both the number and the severity of errors significantly in the process of treatment planning.

Gy to 20Gy depending on tumor volume and location. All patient's contours were transferred to single isocenter automated multimets element software. Three to four non-coplanar arcs were used for each lesion in MIDCA plans whereas 5 non-coplanar arcs were used for each patient to treat all lesions in SIDCA plans. For dosimetric plan quality evaluation, conformity index (CI), volume of 12 Gy (V12) and volume of 5Gy (V5) were collected for all the plans and compared. Results: Average CI for SIDCA was 1.45 (SD 0.8) versus 1.63 (SD 0.2) for MIDCA. Average V12 for SIDCA 24.3cc (SD 23.3cc) versus 29.8 cc (SD 29.1cc) for MIDCA technique. As number of targets increases V5 and V12 dramatically increased for SIDCA technique, for 10 lesions plans V12 values were 65.7cc and 50.5cc for SIDCA and MIDCA respectively. Similarly, V5 values were 373cc and 272cc for SIDCA and MIDCA respectively. As expected Monitor units were significantly lower for SIDCA as compared to MIDCA hence shorter treatment delivery time. Conclusion: Single isocenter plans done using automated multiments element software were better in conformity index however they were inferior in lower dose volumes such as 12 and 5 Gy. This difference was observed larger when number of brain lesions increased. Single isocenter technique is very convenient and time saving for treating multiple brain mets SRS, however, it could compromise lower dose conformity and potentially could deliver higher volumes of lower doses to normal brain tissue.

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