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How Centers Can Thrive in the Modern Era
- 1. How Centers Can Thrivein the Modern Era Snehal Desai, MD Radiation Oncologist Houston Methodist Hospital Houston, TX
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- 3. How should weprepare for the future? Evidenced based medicine Quality care for cancer patients Hypofractionation/SBRT – breast/prostate/rectal/lung cancer increases risk from patient motion Consider technology not for increased revenue but to minimize post-treatment costs
- 4. Advances in RadiationTherapy Intent Intent ‘Actual’ 4-field box CRT 3D-CRT IG-IMRT Intent Intent ‘Actual’ 4-field box CRT 3D-CRT IG-IMRT SGRT
- 5. Surface Guided RadiationTherapy:: SGRT Patient Setup: • Non-invasive, non-ionizing, 3D, real time • Accurate postural and isocentric setup (accuracy* ≤0.3 mm / ≤0.2°) Intrafraction Monitoring: • 6DOF motion monitored in real time with no dose • Automatically beam hold when patient motion exceeds a preset threshold 1 2 • Generates a surface of the patient using 3 camera pods • Matches the live surface in real time to a reference image
- 7. Where does SGRTfit in? We, as providers, continue to demand innovation that produces better clinical outcomes Emerging Trends Total Cost of Care Quality Outcomes Patient Experience Shared Decision Making Center Needs Efficient, reduced costs, strong data integration, mitigation of adverse events Safe, effective, reduced toxicity, evidence based care Satisfaction and comfort Engaging patients in treatment decision making – considering cost and goals
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- 9. Verification of dailysetup consistency is done with weekly imaging. In certain circumstances, more frequent imaging may be appropriate. Routine use of daily imaging is not recommended. The American College of Radiology, with more than 30,000 members, is the principal organization of radiologists, radiation oncologists, and clinical medical physicists in the United States. The College is a nonprofit professional society whose primary purposes are to advance the science of radiology, improve radiologic services to the patient, study the socioeconomic aspects of the practice of radiology, and encourage continuing education for radiologists, radiation oncologists, medical physicists, and persons practicing in allied professional fields. The American College of Radiology will periodically define new practice parameters and technical standards for radiologic practice to help advance the science of radiology and to improve the quality of service to patients throughout the United States. Existing practice parameters and technical standards will be reviewed for revision or renewal, as appropriate, on their fifth anniversary or sooner, if indicated. Each practice parameter and technical standard, representing a policy statement by the College, has undergone a thorough consensus process in which it has been subjected to extensive review and approval. The practice parameters and technical standards recognize that the safe and effective use of diagnostic and therapeutic radiology requires specific training, skills, and techniques, as described in each document. Reproduction or modification of the published practice parameter and technical standard by those entities not providing these services is not authorized. Revised 2019 (CSC/BOC)* ACR–ASTRO PRACTICE PARAMETER FOR IMAGE-GUIDED RADIATION THERAPY (IGRT) PREAMBLE This document is an educational tool designed to assist practitioners in providing appropriate radiation oncology care for patients. Practice Parameters and Technical Standards are not inflexible rules or requirements of practice and are not intended, nor should they be used, to establish a legal standard of care1. For these reasons and those set forth below, the American College of Radiology and our collaborating medical specialty societies caution against the use of these documents in litigation in which the clinical decisions of a practitioner are called into question. The ultimate judgment regarding the propriety of any specific procedure or course of action must be made by the practitioner in light of all the circumstances presented. Thus, an approach that differs from the guidance in this
- 10. Breast Setup without imaging Improved Daily Setup Correct postural setup Decreased setup times Analysis tools – SSD, Setup Quality Decreased imaging exposure to patients Total Cost of Care Patient Experience Quality Outcomes
- 11. 11 Herron E, etal. Surface guided radiation therapy as a replacement for patient marks in treatment of breast cancer. Int J Radiat Oncol Biol Phys. 2018; 102 (3):e492-e493. Improving patient throughput and decrease staffing costs (overtime) 250-fraction study: 14% reduction in setup time / fraction, with reduced time variability SGRT vs Marks Setup Times SGRT vs Marks Shifts / SSD Total Cost of Care Patient Experience
- 12. Clinical Benefit: Decreasing longterm side effects Deep Inspiration breath hold - Left Breast • Multiple peer-reviewed publications • Reproduces consistent inspirations - uniform distance from the heart to the chest wall • Eliminates need for physical devices on the patient Prevented cardiac perfusion defects in 100% of patients studied2,3 Data Cardiac perfusion defects at 6 months as measured using SPECT imaging 30% 25% 20% 15% 10% 5% 0% Traditional Treatment3 Using AlignRT and DIBH2 27% vs. 0% Total Cost of Care Patient Experience Quality Outcomes Shared Decision Making
- 13. Clinical benefits inradiosurgery SRS • Published and Peer-reviewed publications - outcomes similar accuracy to frame with open face mask and SGRT • Trigeminal neuralgia • Single Iso Multiple Mets • Nonionizing imaging for preliminary set-up, prior to cone beam imaging • Faster delivery – no repeat imaging between couch kicks • Less invasive open mask enhances patient comfort vs frame • Real time tracking of patient regardless of couch angle • Improved patient comfort – no frame or closed mask 5-year data on benign lesions showing excellent outcomes16 Data Total Cost of Care Patient Experience Quality Outcomes
- 14. 8 weeks 8 weeks Hypofractionation – higherdose with fewer treatments Breast Hypofractionation Prostate Hypofractionation Prostate SBRT Lung SBRT/Hypofractionation Rectal Hypofractionation 4 weeks 6 weeks 4 weeks 2 weeks 2 weeks 6 weeks 5.5 weeks 2 weeks
- 15. Hypofractionate with confidence Hypofractionation/SBRT •Accurate initial positioning • Patients move - Continual motion management to detect intrafraction motion • Reduces setup time, including CBCT shifts Patients move during treatment. AlignRT can detect clinically meaningful intrafraction motion. Data Total Cost of Care Patient Experience Quality Outcomes
- 16. Safety - Identifying treatmentchanges Identified on AlignRT On demand CBCT on LINAC to verify issue Patient resimulated after seen by plastic surgery Total Cost of Care Quality Outcomes
- 17. Safety - Setup error identified TotalCost of Care Quality Outcomes
- 18. Mitigation of adverseevents Type Description AlignRT Wrong Patient Treated Two patients with the same last name/ One for a rectal cancer in prone position, treated with plan from prostate cancer supine position patient Wrong Patient The treatment room was prepared for a particular patient, but a student brought through the wrong patient. Accessory Missing Bolus left off for one fraction in error. Wrong Accessory 1cm of bolus was used on a left lateral electron boost field instead of 0.5cm bolus on the patient's last day of treatment. Wrong Site Instead of the left knee, the right knee was irradiated for one fraction Wrong tattoo Radiographers used wrong tattoo to set up supraclav field. Setup Error There was a miscommunication regarding shifts required to line up patient treatment fields properly. Total Cost of Care Quality Outcomes 50% of reported near misses / medical events at the time of treatment could have been prevented.
- 19. Tattooless – Eliminates Marks Tattoostypically are used for 3-point setup; however these marks can be far from TxIsocenter Patients report that these tattoos serve as a constant reminder of their cancer treatment Invisible tattoos can mitigate the psychosocial effects of skin marks In a recent study, patients and survivors shared the following: 78% of Patients WOULD PREFER A TATTOOLESS OPTION Patients are willing to travel 45 Miles TO GO TO A TATTOOLESS TREATMENT CENTER Patient Experience Quality Outcomes Shared Decision Making
- 20. SGRT post implementationanalysis Standardization across a wide array of body site Improve current treatment process Treatment monitoring/Gating DIBH Frameless SRS Evaluate our treatment process Quality of immobilization Treatment margins Can be used to minimize imaging exposure Correct postural setup prior to IGRT Total Cost of Care Patient Experience Quality Outcomes Shared Decision Making
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- 22. Questions Where doesSGRT fit it? Total Cost of Care Quality Outcomes Patient Experience Shared Decision Making All of the Above Answer All of the Above
- 23. Questions SGRT canpotentially minimize adverse treatment events ? Wrong patient treated Missing accessory Wrong Site Setup Error All of the Above Answer All of the Above
- 24. Questions The useof SGRT is supported by Evidence based papers ASTRO/ACR white papers SGRT Community All of the Above Answer All of the Above
- 25. Questions SGRT canimprove setup and reduce need for imaging? TRUE FALSE TRUE
- 26. Questions SGRT isonly beneficial for breast treatments? TRUE FALSE FALSE – SGRT can be used for every body site and for all treatments
Editor's Notes
- #13 DIBH 2 Marks et al. The incidence and functional consequences of RT‑associated cardiac perfusion defects. Int J Radiat Oncol Biol Phys. 2005 Sep 1;63(1):214-23. 3 Zagar T, et al. Utility of Deep Inspiration Breath Hold for Left-Sided Breast Radiation Therapy in Preventing Early Cardiac Perfusion Defects: A Prospective Study. Int J Radiat Oncol Biol Phys 2017;97 (5):903-909. 4 Gierga et al. A Voluntary Breath-Hold Treatment Technique for the Left Breast With Unfavorable Cardiac Anatomy Using Surface Imaging. Int J Radiat Oncol Biol Phys. 2012 Dec 1;84(5):e663-8 5 Cerviño et al. Using surface imaging and visual coaching to improve the reproducibility and stability of deep-inspiration breath hold for left-breast-cancer radiotherapy. Phys Med Biol. 2009 Nov 21;54(22):6853-65.: 6 Chang et al. Video surface image guidance for external beam partial breast irradiation. Pract Radiat Oncol. 2012 Apr-Jun;2(2):97-105.: : 7 Padilla et al. Assessment of interfractional variation of the breast surface following conventional patient positioning for whole-breast radiotherapy. J Appl Clin Med Phys. 2014 Sep 8;15(5):4921: 8 Rochet et al. Deep inspiration breath-hold technique in left sided breast cancer radiation therapy: Evaluating cardiac contact distance as a predictor of cardiac exposure for patient selection. Practical Radiation Oncology (2015) 5, e127-e134: 9 Rong et al. Improving intra-fractional target position accuracy using a 3D surface surrogate for left breast irradiation using the respiratory-gated deep-inspiration breath-hold technique. PLoS One. 2014 May 22;9(5):e97933 10 Shah et al. Clinical evaluation of interfractional variations for whole breast radiotherapy using 3-dimensional surface imaging. Pract Radiat Oncol. 2013 Jan-Mar;3(1):16-25.: 11 Tang et al. Clinical experience with 3-dimensional surface matching-based deep inspiration breath hold for left-sided breast cancer radiation therapy. Pract Radiat Oncol. 2014 May-Jun;4(3):e151-8.: 12 Tang et al. Dosimetric effect due to the motion during deep inspiration breath hold for left-sided breast cancer radiotherapy. J Appl Clin Med Phys. 2015 Jul 8;16(4):5358.: 13 Tanguturi et al. Prospective assessment of deep inspiration breath-hold using 3-dimensional surface tracking for irradiation of left-sided breast cancer. Pract Radiat Oncol. 2015 Nov-Dec;5(6):358-65
- #14 SRS 14 Pan H, et al. Frameless, real-time, surface imaging-guided radiosurgery: Clinical outcomes for brain metastases. Neurosurgery 2012;71 (4):844-851. 15 Pham NL, et al. Frameless, real-time, surface imaging-guided radiosurgery: Update on clinical outcomes for brain metastases. Translational Cancer Research 2014;3 (4):351-357. 16 Lau S et al. Clinical efficacy and safety of surface imaging guided radiosurgery (SIG-RS) in the treatment of benign skull base tumors. J Neurooncol (2017) 132:307–312 17 Peng et al. Characterization of a real-time surface image-guided stereotactic positioning system. Med Phys. 2010 Oct;37(10):5421-33. 18 Baker et al. Trigeminal Rhizotomy Performed with Modern Image-guided Linac: Case Report, Cureus, 5(9), 139, 2013 19 Cerviño et al. Initial clinical experience with a frameless and maskless stereotactic radiosurgery treatment. Pract Radiat Oncol. 2012 Jan-Mar;2(1):54-62. 20 Lau et al. Single-Isocenter Frameless Volumetric Modulated Arc Radiosurgery for Multiple Intracranial Metastases. Neurosurgery. 2015 Aug;77(2):233-40; 21 Li et al. Clinical experience with two frameless stereotactic radiosurgery (fSRS) systems using optical surface imaging for motion monitoring. J Appl Clin Med Phys. 2015 Jul 8;16(4):5416. 22 Li et al. Motion monitoring for cranial frameless stereotactic radiosurgery using video-based three-dimensional optical surface imaging. Med Phys. 2011 Jul;38(7):3981-94. 23 Li et al. Optical Surface Imaging for Online Rotation Correction and Real‐Time Motion Monitoring with Threshold Gating for Frameless Cranial Stereotactic Radiosurgery, M9ed. Phys., Volume 38, 3711, 2011 24 Mancosu et al. Accuracy evaluation of the optical surface monitoring system on EDGE linear accelerator in a phantom study. Med Dosim. 2016 Summer;41(2):173-9 25 Pan et al. Frameless, real-time, surface imaging-guided radiosurgery: clinical outcomes for brain metastases. Neurosurgery. 2012 Oct;71(4):844-51. 26 Pham et al. Frameless, real-time, surface imaging-guided radiosurgery: update on clinical outcomes for brain metastases. Trans. Cancer Res, 3, 4, 351-357, August, 2014. 27 Wen et al. Characteristics of a novel treatment system for linear accelerator-based stereotactic radiosurgery. J Appl Clin Med Phys. 2015 Jul 8;16(4):5313. 28 Wen et at. Technical Note: Evaluation of the systematic accuracy of a frameless, multiple image modality guided, linear accelerator based stereotactic radiosurgery system. Med Phys. 2016 May;43(5):2527, 29 Wiersma et al. Spatial and temporal performance of 3D optical surface imaging for real-time head position tracking. Med Phys. 2013 Nov;40(11):111712. 30 Cerviño et al. Frame-less and mask-less cranial stereotactic radiosurgery: a feasibility study. Phys Med Biol. 2010 Apr 7;55(7):1863-73 31 Paravati et al. Initial clinical experience with surface image guided (SIG) radiosurgery for trigeminal neuralgia, Translational Cancer Research, 3, 4, 333-337, August, 2014, 32 Baker et al. Trigeminal Rhizotomy Performed with Modern Image-guided Linac: Case Report, Cureus, 5(9), 139, 2013 33 Wen N, et al. Technical note: Evaluation of the systematic accuracy of a frameless, multiple image modality guided, linear accelerator based stereotactic radiosurgery system. Med Phys 2016;43 (5):2527. 34 Covington E, et al. Submillimeter monitoring of intrafraction patient movement with optical surface imaging. AAPM Annual Meeting 2018. SBRT 1 Heinzerling JH, et al. Use of 3d optical surface mapping for quantification of interfraction set up error and intrafraction motion during stereotactic body radiation therapy treatments of the lung and abdomen. International Journal of Radiation Oncology • Biology • Physics 2017;99 (2):E670.
- #16 SRS 14 Pan H, et al. Frameless, real-time, surface imaging-guided radiosurgery: Clinical outcomes for brain metastases. Neurosurgery 2012;71 (4):844-851. 15 Pham NL, et al. Frameless, real-time, surface imaging-guided radiosurgery: Update on clinical outcomes for brain metastases. Translational Cancer Research 2014;3 (4):351-357. 16 Lau S et al. Clinical efficacy and safety of surface imaging guided radiosurgery (SIG-RS) in the treatment of benign skull base tumors. J Neurooncol (2017) 132:307–312 17 Peng et al. Characterization of a real-time surface image-guided stereotactic positioning system. Med Phys. 2010 Oct;37(10):5421-33. 18 Baker et al. Trigeminal Rhizotomy Performed with Modern Image-guided Linac: Case Report, Cureus, 5(9), 139, 2013 19 Cerviño et al. Initial clinical experience with a frameless and maskless stereotactic radiosurgery treatment. Pract Radiat Oncol. 2012 Jan-Mar;2(1):54-62. 20 Lau et al. Single-Isocenter Frameless Volumetric Modulated Arc Radiosurgery for Multiple Intracranial Metastases. Neurosurgery. 2015 Aug;77(2):233-40; 21 Li et al. Clinical experience with two frameless stereotactic radiosurgery (fSRS) systems using optical surface imaging for motion monitoring. J Appl Clin Med Phys. 2015 Jul 8;16(4):5416. 22 Li et al. Motion monitoring for cranial frameless stereotactic radiosurgery using video-based three-dimensional optical surface imaging. Med Phys. 2011 Jul;38(7):3981-94. 23 Li et al. Optical Surface Imaging for Online Rotation Correction and Real‐Time Motion Monitoring with Threshold Gating for Frameless Cranial Stereotactic Radiosurgery, M9ed. Phys., Volume 38, 3711, 2011 24 Mancosu et al. Accuracy evaluation of the optical surface monitoring system on EDGE linear accelerator in a phantom study. Med Dosim. 2016 Summer;41(2):173-9 25 Pan et al. Frameless, real-time, surface imaging-guided radiosurgery: clinical outcomes for brain metastases. Neurosurgery. 2012 Oct;71(4):844-51. 26 Pham et al. Frameless, real-time, surface imaging-guided radiosurgery: update on clinical outcomes for brain metastases. Trans. Cancer Res, 3, 4, 351-357, August, 2014. 27 Wen et al. Characteristics of a novel treatment system for linear accelerator-based stereotactic radiosurgery. J Appl Clin Med Phys. 2015 Jul 8;16(4):5313. 28 Wen et at. Technical Note: Evaluation of the systematic accuracy of a frameless, multiple image modality guided, linear accelerator based stereotactic radiosurgery system. Med Phys. 2016 May;43(5):2527, 29 Wiersma et al. Spatial and temporal performance of 3D optical surface imaging for real-time head position tracking. Med Phys. 2013 Nov;40(11):111712. 30 Cerviño et al. Frame-less and mask-less cranial stereotactic radiosurgery: a feasibility study. Phys Med Biol. 2010 Apr 7;55(7):1863-73 31 Paravati et al. Initial clinical experience with surface image guided (SIG) radiosurgery for trigeminal neuralgia, Translational Cancer Research, 3, 4, 333-337, August, 2014, 32 Baker et al. Trigeminal Rhizotomy Performed with Modern Image-guided Linac: Case Report, Cureus, 5(9), 139, 2013 33 Wen N, et al. Technical note: Evaluation of the systematic accuracy of a frameless, multiple image modality guided, linear accelerator based stereotactic radiosurgery system. Med Phys 2016;43 (5):2527. 34 Covington E, et al. Submillimeter monitoring of intrafraction patient movement with optical surface imaging. AAPM Annual Meeting 2018. SBRT 1 Heinzerling JH, et al. Use of 3d optical surface mapping for quantification of interfraction set up error and intrafraction motion during stereotactic body radiation therapy treatments of the lung and abdomen. International Journal of Radiation Oncology • Biology • Physics 2017;99 (2):E670.