New directive for documentation review in radiation oncology.

A new directive from the Health Care Financing Administration regarding reimbursement for daily patient care underscores the importance of accurate documentation in radiation oncology. Ms. Blue describes a quality control system in use at her institution which involves a comparison of what is documented in the medical record with what has been charged.     

Development of a clinical chart audit programme

Radiation oncology charts containing medical information and treatment details are the major methods of communication between the various personnel involved in delivering radiation therapy to the patient. It is paramount to good patient care for this communication to be clear, precise and accurate in detail. A regular chart audit should be a part of the quality assurance programme of every radiation oncology department. The primary aim of this study was to develop and assess an objective and quantitative programme for reviewing radiation oncology charts, thereby improving the quality of communication and hence patient management. A secondary aim was to compare the charts of radically treated patients with those treated palliatively. A pilot study using a new chart review tool, developed at the Perth Radiation Oncology Centre, was carried out over an 8-month period. A sample of charts, representing 25% of our treatment group, were assessed using the tool on a monthly basis. A total of 156 charts were reviewed during this time period. Fifty-six per cent were radical treatments and 44% were palliative. The overall mean chart scores significantly improved over the time of this study (P < 0.001). The individual radiation oncologists' scores were also seen to improve during the study period. The alpha coefficients for intra-rater and inter-rater reliability were 0.99 and 0.88, respectively. The chart review programme was found to be an easy-to-use and a reliable tool by both medical and non-medical reviewers. It appeared to have a positive influence on the standard of radiation oncology charts in our department.     

Dynamic targeting image-guided radiotherapy.

Volumetric imaging and planning for 3-dimensional (3D) conformal radiotherapy and intensity-modulated radiotherapy (IMRT) have highlighted the need to the oncology community to better understand the geometric uncertainties inherent in the radiotherapy delivery process, including setup error (interfraction) as well as organ motion during treatment (intrafraction). This has ushered in the development of emerging technologies and clinical processes, collectively referred to as image-guided radiotherapy (IGRT). The goal of IGRT is to provide the tools needed to manage both inter- and intrafraction motion to improve the accuracy of treatment delivery. Like IMRT, IGRT is a process involving all steps in the radiotherapy treatment process, including patient immobilization, computed tomography (CT) simulation, treatment planning, plan verification, patient setup verification and correction, delivery, and quality assurance. The technology and capability of the Dynamic Targeting IGRT system developed by Varian Medical Systems is presented. The core of this system is a Clinac or Trilogy accelerator equipped with a gantry-mounted imaging system known as the On-Board Imager (OBI). This includes a kilovoltage (kV) x-ray source, an amorphous silicon kV digital image detector, and 2 robotic arms that independently position the kV source and imager orthogonal to the treatment beam. A similar robotic arm positions the PortalVision megavoltage (MV) portal digital image detector, allowing both to be used in concert. The system is designed to support a variety of imaging modalities. The following applications and how they fit in the overall clinical process are described: kV and MV planar radiographic imaging for patient repositioning, kV volumetric cone beam CT imaging for patient repositioning, and kV planar fluoroscopic imaging for gating verification. Achieving image-guided motion management throughout the radiation oncology process requires not just a single product, but a suite of integrated products to manipulate all patient data, including images, efficiently and effectively.     

Using Artificial Intelligence to Improve the Quality and Safety of Radiation Therapy

Within artificial intelligence, machine learning (ML) efforts in radiation oncology have augmented the transition from generalized to personalized treatment delivery. Although their impact on quality and safety of radiation therapy has been limited, they are increasingly being used throughout radiation therapy workflows. Various data-driven approaches have been used for outcome prediction, CT simulation, clinical decision support, knowledge-based planning, adaptive radiation therapy, plan validation, machine quality assurance, and process quality assurance; however, there are many challenges that need to be addressed with the creation and usage of ML algorithms as well as the interpretation and dissemination of findings. In this review, the authors present current applications of ML in radiation oncology quality and safety initiatives, discuss challenges faced by the radiation oncology community, and suggest future directions.     

Introducing a computerized record and verify system: its impact on the reduction of treatment errors

A survey of treatment errors has been conducted over a period of several months before and after the introduction of a CMS computerized record and verify system for radiation treatments administered on a Varian CL-1800 accelerator. It was found that treatment errors could be reduced considerably. However, some errors were also caused by wrong data entry into the system. In two instances, errors were detected only through the record and verify system; they had escaped all previous chart checks and would never have been found otherwise. The impact of the computerized record and verify system is analyzed with regard to improved treatment delivery, reception by technologists, and treatment documentation.     

3D treatment planning systems

Three-dimensional (3D) treatment planning systems have evolved and become crucial components of modern radiation therapy. The systems are computer-aided designing or planning softwares that speed up the treatment planning processes to arrive at the best dose plans for the patients undergoing radiation therapy. Furthermore, the systems provide new technology to solve problems that would not have been considered without the use of computers such as conformal radiation therapy (CRT), intensity-modulated radiation therapy (IMRT), and volumetric modulated arc therapy (VMAT). The 3D treatment planning systems vary amongst the vendors and also the dose delivery systems they are designed to support. As such these systems have different planning tools to generate the treatment plans and convert the treatment plans into executable instructions that can be implemented by the dose delivery systems. The rapid advancements in computer technology and accelerators have facilitated constant upgrades and the introduction of different and unique dose delivery systems than the traditional C-arm type medical linear accelerators. The focus of this special issue is to gather relevant 3D treatment planning systems for the radiation oncology community to keep abreast of technology advancement by assess the planning tools available as well as those unique “tricks or tips” used to support the different dose delivery systems.     

Clinical Documentation and Patient Care Using Artificial Intelligence in Radiation Oncology

Detailed clinical documentation is required in the patient-facing specialty of radiation oncology. The burden of clinical documentation has increased significantly with the introduction of electronic health records and participation in payer-mandated quality initiatives. Artificial intelligence (AI) has the potential to reduce the burden of data entry associated with clinical documentation, provide clinical decision support, improve quality and value, and integrate patient data from multiple sources. The authors discuss key elements of an AI-enhanced clinic and review some emerging technologies in the industry. Challenges regarding data privacy, regulation, and medicolegal liabilities must be addressed for such AI technologies to be successful.     

Dose verification for patients undergoing IMRT.

At Emory Clinic intensity-modulated radiation therapy (IMRT) was started by using dynamic multileaf collimators (dMLC) as electronic tissue compensators in August 1998. Our IMRT program evolved with the inclusion of a commercially available inverse treatment planning system in September 1999. While the introduction of electronic tissue compensators into clinical use did not affect the customary radiation oncology practice, inverse treatment planning does alter our basic routines. Basic concepts of radiation therapy port designs for inverse treatment planning are different from conventional or 3D conformal treatments. With inverse treatment planning, clinicians are required to outline a gross tumor volume (GTV), a clinical target volume (CTV), critical normal structures, and to design a planning target volume (PTV). Clinicians do not designate the volume to be shielded. Because each IMRT radiation portal is composed of many beamlets with varying intensities, methods and practice used to verify delivered dose from IMRT portals are also different from conventional treatment portals. Often, the validity of measured data is in doubt. Therefore, checking treatment planning computer output with measurements are confusing and fruitless, at times. Commissioning an IMRT program and routine patient dose verification of IMRT require films and ionization chamber measurements in phantom. Additional specialized physics instrumentation is not required other than those available in a typical radiation oncology facility. At this time, we consider that routine quality assurance prior to patient treatments is necessary.     

Analyzing changes in radiotherapy treatment planning error reporting during the COVID-19 pandemic

The 2019 coronavirus (COVID-19) pandemic has affected medical physics and radiation oncology departments and the delivery of radiation therapy. Among the changes implemented in response to the onset of the pandemic was a shift to remote treatment planning by health care institutions. The purpose of this study was to determine whether the overall frequency of errors changed after the implementation of remote radiation therapy treatment planning during the COVID-19 pandemic. Reported incidents were obtained from an incident reporting database operated by a multisite cancer care facility in the Northeast. Researchers compared the frequency of reported events in a period prior to the start of the pandemic (March 2019 to February 2020) with a period after the onset of the pandemic (March 2020 to February 2021). No significant increase in reported incidents was detected suggesting the efficiency and safety of remote radiotherapy treatment planning.     

IMRT: high-definition radiation therapy in a community hospital.

A multileaf collimator (MLC)-based intensity-modulated radiation therapy (IMRT) program was implemented successfully at Monmouth Medical Center, a community hospital at Long Branch, New Jersey. Our clinical experience gained in the treatment of over 80 patients using IMRT for prostate, head and neck, and brain is reviewed, and some of the clinical issues are also, discussed. Implementation of the IMRT requires a treatment planning system, computer-controlled beam-shaping aperture, electronic record and verify system, and a good physics quality assurance program. These components, by grouping them efficiently, have created a seamless workflow for our complete radiotherapy process of IMRT. Each of these radiotherapy processes are discussed for clarity and the clinical importance is also evaluated. Of particular interest is inverse treatment planning that will impact treatment delivery such as beam orientation, treatment ports, and organ motion of IMRT. A checklist for physics and departmental quality assurance is suggested, with the intention of providing systematic workflow, making IMRT feasible at a community medical center setting. This is especially important because most of our cancer patients received radiation therapy locally. Lastly, the reimbursement issue affecting the implementation of IMRT at our medical center is also discussed to justify this new treatment protocol for future clinical outcomes.     

Technical aspects of positron emission tomography/computed tomography fusion planning

Emerging technologies in radiation therapy computers and delivery systems allow surgically precise conformal radiation treatment that was not possible with previous generations of equipment. The newest treatment systems can compensate for tumor target motion as well as shape dose distributions to conform precisely to delineated target volumes. These sophisticated technologies now drive the development of imaging modalities able to generate equally high-resolution and lesion-specific roadmaps that are the foundation of these highly accurate radiation plans. Positron emission tomography/computed tomography (PET/CT) is currently becoming a routine imaging tool for radiation oncology because of its combined benefits of positron imaging and high-resolution anatomic display. The improved staging and lesion delineation provided by PET, combined with the 3D anatomic display provided by CT, now allows better treatment stratification and more precise targeting. Additionally, respiratory-gated 4D CT and 4D PET/CT have been used in the simulation process for respiratory-gated radiation therapy. Successful integration of PET/CT into the radiation therapy planning process requires an understanding of how therapy plans are derived and the process by which the patient receives therapy, because these dictate the method of image acquisition. The radiation oncologists, too, must understand the technology of positron imaging to adapt these functional images based on intensities rather than pixels to their targeting process. Modifications to the PET/CT scanner and room are necessary to image the patient in the reproducible position required for treatment planning. Although the impact of these efforts on patient outcome has yet to be determined, the benefit of better treatment choice, due to improved staging, and more precise targeting with less normal tissue exposure resulting in improved quality of life will likely promote PET/CT to the gold-standard for targeted therapies.     

Breast radiotherapy: an Australasian survey of current treatment techniques

Prior to the dissemination of evidence-based quality assurance guidelines, the Australian National Breast Cancer Centre Radiation Oncology Group conducted a process survey of breast radiotherapy treatment delivery throughout Australia. A process survey was conducted in August/September 1998. This survey comprised questions enquiring about treatment positioning, immobilization devices used, planning strategies, simulation and dose computation methods, treatment prescribing and quality assurance. The survey was sent to 123 Australian fellows of the Royal Australian and New Zealand College of Radiologists (RANZCR) and to the six directors of New Zealand radiation oncology departments. Fifty-eight questionnaires were returned of which 38 were received from individuals and 20 represented a reply from a department with a routine breast radiotherapy protocol (representing an average of 4.5 radiation oncologists per reply). The study identified great consistency between departments with respect to dose and fractionation for breast tangents. The study also identified some areas of treatment planning and delivery that varied between individuals or departments. These mainly reflected a lack of evidence in some areas of radiotherapy treatment delivery. The circulation of quality assurance guidelines will perhaps improve consistency of radiotherapy techniques in which studies have identified that technique changes improve outcome. This study identified that these areas include the taking of simulation and port films and the use of off-axis dosimetry. Further studies are required for areas of radiotherapy treatment delivery that have little evidence for or against their implementation.     

3D treatment planning on helical tomotherapy delivery system

The helical tomotherapy is a technologically advanced radiation dose delivery system designed to perform intensity-modulated radiation therapy (IMRT). It is mechanistically unique, based on a small 6-MV linear accelerator mounted on a ring gantry that rotates around the patient while the patient moves through a bore, ultimately yielding a helical path of radiation dose delivery. The helical pattern of dose delivery differentiated tomotherapy from other contemporary radiation therapy systems at the time of its inception. The accompanying 3-dimensional (3D) treatment planning system has been developed to solely support this specific type of dose delivery system. The treatment planning system has 2 modules identified as TomoHelical and TomoDirect to perform IMRT and conformal radiation therapy, respectively. The focus of this work within the scope of this special issue on 3D treatment planning systems is to assess the use of planning tools to generate treatment plans for helical tomotherapy. Clinical examples are used throughout to demonstrate the quality and differences of various clinical scenarios planned with tomotherapy.     

A primer on time-driven activity-based costing in brachytherapy

Emphasis on value-based healthcare has led to increasing use of time-driven activity-based costing (TDABC) across medical departments. When applied to brachytherapy, TDABC provides insight into differences in costs across various modes of therapy, the nuances that drive cost including institutional factors and involved personnel, and discrepancies in reimbursement which influence clinical practice. This is especially important with the new alternative payment model (APM) in radiation oncology which offers fixed reimbursement per 90-day episode of care. The TDABC model can thus be utilized to improve efficiency, optimize the role of ancillary staff in treatment planning and care delivery, and implement shorter fraction schedules when clinically appropriate to promote value-based care. Ultimately, application of this methodology could potentiate changes to practice and incentives to improve patient care. In this review, we discuss the utility and limitations of TDABC in the context of existing studies in brachytherapy which have utilized this methodology.     

Application of intensity-modulated radiation therapy for pediatric malignancies

Novel radiation therapy delivery techniques have moved very slowly in the field of pediatric oncology. Some collaborative groups allow new radiation therapy delivery techniques in their trials. In many instances, the option of using these techniques is not addressed. These newer techniques of radiation delivery have the potential to reduce the probability of the common late effects of radiation and at the same time, potentially improve upon control and survival. The purpose of this study is to show the feasibility of IMRT in pediatric patients. No treatment results or toxicities will be presented. Five patients with a variety of pediatric malignancies received intensity-modulated radiation therapy (IMRT) at our institution as part of their disease management. A rigid immobilization device was developed for each patient and a computed tomography (CT) simulation was performed in the treatment position. In 3 of the patients, magnetic resonance imaging (MRI) scans were coregistered with the planning CT to facilitate target and critical structure delineation. In all but 1 patient, coplanar beam arrangements were used in the IMRT planning process. All IMRT plans exhibited a high degree of conformality. Dose homogeneity inside the tumor and rapid dose falloff outside the target volume is characteristic of IMRT plans, which allows for improved normal tissue sparing. Dose distributions were obtained for all plans, as well as dose and volume relationship histograms, to evaluate the fitness of the plans. IMRT is a viable alternative to conventional treatment techniques for pediatric cancer patients. The improved dose distributions coupled with the ease of delivery of the IMRT fields make this technique very attractive, especially in view of the potential to increase local control and possibly improve on survival.     

Application of intensity-modulated radiation therapy for pediatric malignancies

Novel radiation therapy delivery techniques have moved very slowly in the field of pediatric oncology. Some collaborative groups allow new radiation therapy delivery techniques in their trials. In many instances, the option of using these techniques is not addressed. These newer techniques of radiation delivery have the potential to reduce the probability of the common late effects of radiation and at the same time, potentially improve upon control and survival. The purpose of this study is to show the feasibility of IMRT in pediatric patients. No treatment results or toxicities will be presented. Five patients with a variety of pediatric malignancies received intensity-modulated radiation therapy (IMRT) at our institution as part of their disease management. A rigid immobilization device was developed for each patient and a computed tomography (CT) simulation was performed in the treatment position. In 3 of the patients, magnetic resonance imaging (MRI) scans were coregistered with the planning CT to facilitate target and critical structure delineation. In all but 1 patient, coplanar beam arrangements were used in the IMRT planning process. All IMRT plans exhibited a high degree of conformality. Dose homogeneity inside the tumor and rapid dose falloff outside the target volume is characteristic of IMRT plans, which allows for improved normal tissue sparing. Dose distributions were obtained for all plans, as well as dose and volume relationship histograms, to evaluate the fitness of the plans. IMRT is a viable alternative to conventional treatment techniques for pediatric cancer patients. The improved dose distributions coupled with the ease of delivery of the IMRT fields make this technique very attractive, especially in view of the potential to increase local control and possibly improve on survival.     

Optimization of autogenerated chest-wall radiation treatment plans developed for postmastectomy breast cancer patients in underserved clinics

Over the past decade, several strides have been made to improve the management of breast cancer in developing countries; however, there are still obstacles present. In the area of radiation therapy, these hurdles include limited access to radiotherapy treatment and scarcity of oncology specialists. In an effort to reduce inequities in cancer care while improving patient outcomes, our research is focused on developing automated postmastectomy radiation therapy (PMRT) plans for breast cancer patients in these underserved communities that can be further improved upon through treatment planning system (TPS) specific optimization guidelines. The automated planning tool utilized algorithms integrated with Varian's Eclipse TPS. The tool created PMRT plans that used monoisocentric tangents and supraclavicular (SCV) fields with a mix of high and low energy photon beams along with field-in-field (FIF) segments. The completed autogenerated PMRT plans were imported into Phillip's Pinnacle 9.10 and Varian's Eclipse 13.6 TPSs to be further improved through manual optimization; the time required to complete this step was measured and assessed. A senior dosimetrist, physicist, and physician evaluated the optimized plans for clinical acceptability. Guidelines were developed for the planning systems that can be implemented by personnel with either limited experience in radiation treatment planning or those with limited time to produce treatment plans. The autogenerated plans in conjunction with our guidelines have shown to significantly reduce the time required to produce a clinically acceptable PMRT plan from approximately 120 ± 60 minutes to just 13 ± 11 (Pinnacle) and 12 ± 7 (Eclipse) minutes, reducing the total uninterrupted treatment planning time by an average of 108 ± 51 minutes. The results from this research indicate that the autogenerated PMRT plans along with the optimization guidelines are a viable option to provide quality and clinically acceptable PMRT plans that are more efficient and consistent for postmastectomy breast cancer patients in severely underserved communities.     

Australian and New Zealand three-dimensional conformal radiation therapy consensus guidelines for prostate cancer

Three-dimensional conformal radiation therapy (3DCRT) has been shown to reduce normal tissue toxicity and allow dose escalation in the curative treatment of prostate cancer. The Faculty of Radiation Oncology Genito-Urinary Group initiated a consensus process to generate evidence-based guidelines for the safe and effective implementation of 3DCRT. All radiation oncology departments in Australia and New Zealand were invited to complete a survey of their prostate practice and to send representatives to a consensus workshop. After a review of the evidence, key issues were identified and debated. If agreement was not reached, working parties were formed to make recommendations. Draft guidelines were circulated to workshop participants for approval prior to publication. Where possible, evidence-based recommendations have been made with regard to patient selection, risk stratification, simulation, planning, treatment delivery and toxicity reporting. This is the first time a group of radiation therapists, physicists and oncologists representing professional radiotherapy practice across Australia and New Zealand have worked together to develop best-practice guidelines. These guidelines should serve as a baseline for prospective clinical trials, outcome research and quality assurance.