Ravi Kulasekere PhD, DABRRavi Kulasekere PhD, DABRCancer Care CenterCancer Care Center

Metro Health Medical CenterMetro Health Medical CenterCleveland, OH Cleveland, OH

Wading Through The Task Group Matrix At A Community Hospital - The Metro Health

Experience

Ravi Kulasekere PhD, DABRRavi Kulasekere PhD, DABRCancer Care CenterCancer Care Center

Metro Health Medical CenterMetro Health Medical CenterCleveland, OH Cleveland, OH

Wading Through The Task Group Matrix At A Community Hospital - The Metro Health

Experience

Outline

• Quality assurance protocols in radiation therapy

• Issues faced with implementing some or all of these protocols in small clinics or community hospitals

• Discuss how Metro Health, a small community hospital, approached this dilemma during the renovation and upgrade of their cancer center in 2012

UH Seidman Cancer Center

Metro Health Medical Center

MH Upgrade Wish List • $5 million+ upgrade to the Cancer Center

• Replacing an old CT scanner with a new big-bore scanner

• Adding On-Board Imaging to the Varian iX machine• Replacing the outdated Siemens KD-2 linear

accelerator with a Varian Trilogy• Twin the two treatment machines for efficient work flow

• New HDR suite with upgraded Nucletron V3 unit

• Update and upgrade all QA and QI procedures

• Move department to being paperless and also film-less

• Implement Brain Lab SRS on the Trilogy

Limited funding allocated to Physics and ancillary expenses related to upgrade

The OLD

The New

The New

Patient comfort centered design

New Challenges

• Adequate Staffing

• New Equipment and Training

• Time to Adjust and Adapt

• Meeting Regulatory Requirements

• New QA Procedure Setup

Quality Assurance in Radiotherapy

Complexity of treatments has made quality assurance a critical part of overall care

Quality Assurance ‐ Challenges

• It is the responsibility of the Physicist to ensure compliance

• Hospital Administrators sometimes question the investment needed for routine QA

• QA does not bring in reimbursement (or is generally bundled) and therefore takes effort to justify

• Use regulatory (ODH, AAPM etc) guidelines to push for equipment and staffing to maintain a safe environment.

• QA is important and makes all the difference in patient care

Upgrade is the best time to include Physics needs. Evaluate needs carefully

THE RADIATION BOOMAs Technology Surges,

Radiation Safeguards Lag

By WALT BOGDANICHChang W. Lee/The New York Times

Published: January 26, 2010

In New Jersey, 36 cancer patients at a veterans hospital in East Orange were over-radiated — and 20 more received substandard treatment — by a medical team that lacked experience in using a

machine that generated high-powered beams of radiation. The mistakes, which have not been publicly reported, continued for months because the hospital had no system in place to catch

the errors.

QA COMPLIANCE

• ODH Conducts Mandatory Bi‐Annual Audits of the Quality Assurance Program of a Facility• CRE submits an annual review of the QA program to the ODH for approval. • All therapy variances have to be included in report as well as changes and concerns.

QA COMPLIANCE

Citations will be issued if the ODH finds any variances to the written quality assurance program.

Types of Quality Assurance

MACHINE QA

•Daily•Weekly•Monthly•Annually•Post Service

PATIENT QA

•IMRT•IN-VIVO•2ND CHECKS•SPECIAL QA

SOFTWARE QA

•PLANNING•IMAGING•DELIVERY

Physicist, Therapist and Dosimetrist will be involved in maintaining a robust quality assurance program 

Quality Assurance Methods

Machine Patient Software SpecialDaily √ X X X

Monthly √ X √ X

Annual √ X √ X

As needed √ √ √ √

• No machine or software should be used clinically unless a qualified Medical Physicist (QMP) has performed, documented and approved for use. This is true for new equipment and equipment after major service.

• The same is true for patient QA.  Treatment should not start before QA is complete.

QA GUIDELINES AND PROTOCOLS

• AAPM TG 21 (Obsolete protocol‐ no longer used)• AAPM TG 106 (High Energy Beam Commissioning – Baseline)• AAPM TG 51 (Absolute Machine Calibration and Clinical Dosimetry in water)• AAPM TG 66 (Quality assurance for CT Scanners)• AAPM TG 40 (Quality Assurance for Linear Accelerators – older machines)• AAPM TG 142 (Quality Assurance for Linear Accelerators –Adopted to replace TG 40)• AAPM TG 100 (The Future with Failure Mode and Effects Analysis)

TASK GROUP REPORTS

• QAP – Quality Assurance Program• Special Deviations from TG reports• QI (Variance) reports and Safety Committee Meetings• Clinical Meetings to Proactively Discuss Quality Issues• Documentation Review by QMP (Qualified Medical Physicist)

DEPARTMENTAL POLICIES FOR QA

The future of QA is even more time and man power intensive and requires a collaborative effort of the whole team. No longer just the physicist to be involved.

Quality Assurance ProtocolsTG-142 (D/M/A)

TG-51 (M/A)

TG-66 (D/M/A)

Quality Assurance Methods ‐ Software• Generally performed using a standard patient plan that is sent 

over to the treatment planning system and checked for consistency.

• The imaging system can be checked by sending the same image across the network and measuring consistency of the transfer accuracy

• The process must be performed monthly, annually and in some cases when upgrades and changes to the software are made.

Quality Assurance Methods (DAILY)

• Must be setup efficiently yet accurate enough to treat safely• Easy to document• Quick consistency check of the machine to check for substantial deviation.• 3% variation allowed, call physics, 5% NO TREAT, call physics

Quality Assurance Methods (DAILY)

Output/EnergyChecks

Sun Nuclear Daily QA3

Quality Assurance Methods (DAILY)

On-Board Imaging Checks – Iso Cube

Quality Assurance Methods (DAILY)

Better phantom for Daily OBI QA

QA Equipment  ‐ Ion Chambers/DetectorsMarcus Chamber Farmer Chamber

Pin‐point Chamber

Micro Chamber

Well Chamber

QA Equipment  ‐ Phantoms1‐D and 3‐D Water Phantoms Solid Water Phantoms

Gafchromic Film

QA Equipment  ‐ Commercial Devices

Can be used for both patient and machine QA

Quality Assurance Methods – Monthly

Quality Assurance Methods –Monthly

Don’t re-invent the wheel, but be careful when adopting forms

Quality Assurance Methods – Monthly Mechanical

Quality Assurance Methods – Monthly Mechanical

Quality Assurance Methods – Monthly Output/Energy

Quality Assurance Methods – Monthly Imaging

CAT Phan

LEEDS Phantom Las Vegas Phantom

Quality Assurance Methods – Monthly Imaging

Quality Assurance Methods – Machine (Annual)

Stereotactic Stereotactic RadiosurgeryRadiosurgery

Radiation OncologyRadiation OncologyMetroHealth Medical CenterMetroHealth Medical Center

Current CAPABILITIESCurrent CAPABILITIES

•• Ideally be spherical or elongatedIdeally be spherical or elongateddue to conical collimatorsdue to conical collimators

•• Smaller than 3 cmSmaller than 3 cm

LIMITATIONSLIMITATIONS

•• HIGHLY CONFORMALHIGHLY CONFORMAL

•• INTRACRANIAL LESIONSINTRACRANIAL LESIONS

EQUIPMENTEQUIPMENT

Frameless Mask FixationFrameless Mask Fixation

CONICAL CONICAL COLLIMATORSCOLLIMATORS

•• FRAMELESS MASK FRAMELESS MASK FIXATION SYSTEM THAT FIXATION SYSTEM THAT PROVIDES 0.65MM PROVIDES 0.65MM ACCURACY.ACCURACY.

•• CONICAL COLLIMATORS CONICAL COLLIMATORS RANGING IN SIZES RANGING IN SIZES FROM 5MM TO 30MM TO FROM 5MM TO 30MM TO DELIVER PRECISE DELIVER PRECISE DOSE.DOSE.

PATIENT EXPERIENCEPATIENT EXPERIENCEMRIMRI MASKMASK CT SIMULATIONCT SIMULATION

VISIT 1VISIT 1

HIGH DEFINITION HIGH DEFINITION MRI: T1 WITH MRI: T1 WITH CONTRASTCONTRAST

BRAINLAB BRAINLAB PROTOCOLPROTOCOL

VISIT 2VISIT 2

FRAMELESS FIXATION MASK CREATED UNIQUE FRAMELESS FIXATION MASK CREATED UNIQUE TO PATIENT. CT SIMULATION SCANNED AND TO PATIENT. CT SIMULATION SCANNED AND

SENT TO BRAINLAB TPS.SENT TO BRAINLAB TPS.MEANWHILE BEHIND THE MEANWHILE BEHIND THE SCENESSCENES……

PATIENT EXPERIENCEPATIENT EXPERIENCE

A PLAN IS A PLAN IS CREATED AND CREATED AND CHECKED BY CHECKED BY

THE PHYSICIANS THE PHYSICIANS AND PHYSICS.AND PHYSICS.

…… IN IN PHYSICSPHYSICS

RADONC & RADONC & NEUROSURGEON NEUROSURGEON CONTOUR TUMOR CONTOUR TUMOR

VOLUME AND VOLUME AND CRITICAL CRITICAL

STRUCTURES.STRUCTURES.

MRI & CT ARE MRI & CT ARE IMPORTED INTO TPS & IMPORTED INTO TPS &

FUSED. THE LOCALIZER FUSED. THE LOCALIZER IS DEFINED & WILL BE IS DEFINED & WILL BE

USED TO IDENTIFY THE USED TO IDENTIFY THE COORDINATE SYSTEM COORDINATE SYSTEM

OF THE PATIENT.OF THE PATIENT.

PATIENT EXPERIENCEPATIENT EXPERIENCE……ON TREATMENT ON TREATMENT

DAYDAY

A DRY RUN OF THE TREATMENT PLAN WITH THE A DRY RUN OF THE TREATMENT PLAN WITH THE PATIENT POSITIONING BOX IS COMPLETED. THE PATIENT POSITIONING BOX IS COMPLETED. THE TREATMENT ISOCENTER IS IDENTIFIED ON THE TREATMENT ISOCENTER IS IDENTIFIED ON THE

BOX AND IS USED FOR PATIENT ALIGNMENT.BOX AND IS USED FOR PATIENT ALIGNMENT.

THE LINAC ISOCENTER THE LINAC ISOCENTER IS CHECKED WITH THE IS CHECKED WITH THE

WINSTON LUTZ QA WINSTON LUTZ QA TEST BY PHYSICS TEST BY PHYSICS

PRIOR TO TREATMENT.PRIOR TO TREATMENT.

PATIENT EXPERIENCEPATIENT EXPERIENCE

ONCE THE TREATMENT PLAN IS VERIFIED BY THE SRS TEAM, THE ONCE THE TREATMENT PLAN IS VERIFIED BY THE SRS TEAM, THE PATIENT IS PLACED ON THE TABLE WITH THE TARGET POSITIONING PATIENT IS PLACED ON THE TABLE WITH THE TARGET POSITIONING

BOX IN PLACE. THE ISOCENTER IS ALIGNED TO THE LASERS AND THE BOX IN PLACE. THE ISOCENTER IS ALIGNED TO THE LASERS AND THE BOX IS REMOVED. THE PATIENT REMAINS SECURE IN THE MASK FOR BOX IS REMOVED. THE PATIENT REMAINS SECURE IN THE MASK FOR

THE DURATION OF THE TREATMENT.THE DURATION OF THE TREATMENT.

55--15 ARCS/TABLE 15 ARCS/TABLE KICKSKICKS

1515--20 MIN TX TIME20 MIN TX TIME

SINGLE FRACTIONSINGLE FRACTION

DOSE RANGE 15DOSE RANGE 15--25 25 GYGY

PATIENT EXPERIENCEPATIENT EXPERIENCE

VISIT 3: TREATMENT DAYVISIT 3: TREATMENT DAY

PATIENT RECEIVES SINGLE FRACTION, HIGHPATIENT RECEIVES SINGLE FRACTION, HIGH--DOSE TREATMENT ON DOSE TREATMENT ON TRILOGY LINAC IN THE PRESENCE OF THE RADONC, NEUROSURGEON, TRILOGY LINAC IN THE PRESENCE OF THE RADONC, NEUROSURGEON,

PHYSICS, NURSE AND THERAPISTSPHYSICS, NURSE AND THERAPISTS

Summary

• The Task Group Reports set forth best practice guidelines for QA

• Try to achieve the best possible and document deviations from protocols

• It is possible to maintain TG compliance in smaller community type centers with a little bit of planning and preparation.

THANK YOU