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The Radiological Physics CenterA QA Resource in Radiation Therapy
AAPM Refresher CourseSeattle, July 28, 2005
Geoffrey S. Ibbott, Ph.D.
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RPC:Houston
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Division of RadiationOncology
Section ofProton Physics
RadiationDosimetryServices
Section ofOutreachPhysics
Section ofClinical Physics
LateEffects
RadiologicalPhysics Center
AccreditedDosimetryCalibrationLaboratory
Dept. ofRadiation Oncology
Dept. ofRadiation Physics
Dept. ofExperimental
Radiation Oncology
Section ofPhysics Education
Section ofPhysics
Research
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Brief Background• Originated through agreement between
AAPM and CRTS
• Founded in 1968 to monitor institution participation in clinical trials
• Funded continuously by NCI as structure of cooperative group programs have changed
• Now 36 years of experience of monitoring institutions and reporting findings to study groups and community
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MissionThe mission of the Radiological Physics Center is to assure NCI and the Cooperative Groups that institutions participating in clinical trials deliver prescribed radiation doses that are clinically comparable and consistent. We do this by assessing the institution’s radiotherapy programs, helping the institutions implement remedial actions, assisting the study groups in developing protocols and QA procedures, and informing the community of our findings.
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RPC ActivitiesRemote ReviewsPatient DosimetryOn-site ReviewsSupport of Study GroupsResearch/Outreach
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RPC Verification of Institutions’Delivery of Tumor Dose
Reference calibration(NIST traceable)
Correction Factors:Field size & shape
Depth of targetTransmission factors
Treatment time
Tumor Dose
Evaluated byRPC Dosimeters
Evaluated byRPC visits and
chart review
Evaluated byRPC phantoms
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Remote Audit Tools:The Thermoluminescent
Dosimetry (TLD) Program
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TLD as a Remote Tool
• Verify dose outputs and energy on radiotherapy units.
• Verify doses at points of interest in anthropomorphic phantoms
• Measure consistency of institutions based on TLD history
• Provide data for patient chart review
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Additional Benefits
• Changes in equipment• Changes in personnel• Satisfies requirement for an
independent quality assurance audit • Promotes alertness
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Characteristics of the Program
• 28 years in operation
• Monitoring 1,387 megavoltage therapy sites (80% of US centers)
• Last year, ~8,800 radiation beams monitored with TLD
• Largest of its kind
• Other programs (IAEA, ESTRO, RDS)
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RPC TLD Activities
0
1000
2000
3000
4000
5000
6000
7000
8000
9000
2000 2001 2002 2003 2004
ELECTRONSPHOTONSCOMBINED
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Comparison of TLD ResultsPhotons
0.94 0.95 0.96 0.97 0.98 0.99 1.00 1.01 1.02 1.03 1.04 1.05 1.06
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0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
14.0%
16.0%
18.0%
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
Year
Perc
ent
Percent of Institutions with a beam outside the RPC 5% TLD criteria
Percent of electron beams outside the RPC 5% or 5 mm criteria
Percent of photon beams outside the RPC 5% criteria
TLD Discrepancies
13 (of 69) institutions visited in last 2 yrs to resolve TLD problems
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Benefits of the TLD Program• Verifies calibrations periodically thus
helping institutions to keep vigilant of their quality assurance program
• Problems found contribute to determine priorities for site visits
• Identifies problems that have direct impact on every patient treated
• It is a model for other remote programs
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Institutions Monitored by the RPC
1,49312941,3877/1/2005
1,4099711,3291/1/2005
1,3825711,3067/1/2004
Total Institutions
CTSU (Pending)
Active - no XRT
Active Institutions
As of…
1,3492362004 - 2005
1,6592602003 - 2004
New beams addedNew machines
addedTime Span
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Credentialing Techniques
• Phantoms Benchmarks
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• Education
• Evaluate ability to deliver dose
• Improve understanding of protocol
• Reduce deviation rate
Purpose of Credentialing
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General Credentialing Process
Feedback to Institution
• Previous patients treated with technique• Facility Questionnaire• Knowledge Assessment Questionnaire• Benchmark case• Electronic data submission• RPC QA & dosimetry review• Clinical review by radiation oncologist
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Credentialing3D Conformal Radiation Therapy
(3D CRT)• Innovative high-technology radiation technique
where multiple beams are shaped to treat only the tumor
• Evaluate 3D treatment planning process and ability to provide documentation
• North Central Cancer Treatment Group (NCCTG) –October 1, 2004
• 42 institutions credentialed to date
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CredentialingLDR and HDR Brachytherapy
• Evaluate• Implant technique• Dosimetry• Documentation• Protocol compliance
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Brachytherapy Studies Requiring Credentialing
• Cervix• GOG 165, 191• RTOG 0116, 0128
• Breast• RTOG 95-17• RTOG 0413 / NSABP B-39
• Prostate• NCCTG N-0052• RTOG 98-05, 0019, 0232, 0321
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Credentials Awarded(based on benchmarks)
5371Breast Mammosite®
1331Breast Multicatheter
711Prostate HDR (0321)
297434TOTAL
4655Cervix (GOG)
4242Other 3D CRT (NCCTG)
77158Breast 3D CRT (0413)
5966Prostate LDR (0232)
InstitutionsCredentials
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Results of Credentialing(closed studies)
117 reviewed (total 129 eligible)60
RTOG 0019LDR Prostate
(values for dose only)
10040
RTOG 95-17HDR & LDR Breast
(all)
70150GOG 165
HDR CervixCredentialed inst
Number ofPatients
MinorDeviations
MajorDeviationsStudy
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Results of Credentialing(closed studies)
2758757Non-credentialed
117 reviewed (total 129 eligible)60
RTOG 0019LDR Prostate
(values for dose only)
10040
RTOG 95-17HDR & LDR Breast
(all)
70150GOG 165
HDR CervixCredentialed inst
Number ofPatients
MinorDeviations
MajorDeviationsStudy
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Clinac 2100, 21EX
Clinac 1800, 2000
Clinac 2300, 2500
Clinac 4, 6, etc.
Novalis
Mevatron
Primus, Primart
Oncor
Precise
Sl, Sli
Mobetron
Tomotherapy Hi-Art
CyberKnife
Cobalt-60
Other
3,040 Treatment Machines Monitored by the RPC
Clinac 2100, 21EX
Clinac 4, 6
Mevatron
Primus
SL, SLi
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RPC Phantoms
prostate RTOG 0126 (IMRT)
thorax RTOG 0236 (SBRT)
liver RTOG 0438H&N IMRT RTOG 0225, 0126; COG ACNS0331
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Scan, Plan, Treat a phantom
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Plan vs. Treatment
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Number of Phantom Mailings
0
20
40
60
80
100
120
140
2001 2002 2003 2004 2005
Year
ProstateLungH&N
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Phantom Results
* 33% of institutions failed H&N phantom on the first attempt
Spring 2005
2
-
-
-
Liver
Spring 2004
Spring 20042001Year introduced
5310Under analysis or at institution
2348Fail
1524109*Pass
1727157Irradiations
ThoraxProstateH&NPhantom
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Explanations for Failures
• Incorrect data in planning system
• Output factors, %dd
• Inadequacies in beam modeling (Cadman, et al; PMB 2002)
• Not adjusting irradiation time according to measurements
• Errors in indexing Peacock system
• Setup errors
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Examples of Failures
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Peacock Indexing Error
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Comparison: Planned vs. Delivered
Distribution
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Number of Institutions Converting to TG-51
0100200300400500600700800900
1000
Nov-99
Feb-00
May-00
Aug-00
Nov-00
Feb-01
May-01
Aug-01
Nov-01
Feb-02
May-02
Aug-02
Nov-02
Feb-03
May-03
Aug-03
Nov-03
Feb-04
May-04
Aug-04
Nov-04
Feb-05
May-05
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Protocol Patient Review
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Purpose of Chart Review
• Correct errors in patient treatments
• Provide correct and comparable data
• Improve quality of care for all RT patients
• Reviewed charts from 1003 institutions
• Only the RPC and RTOG HQ Dosimetry Group confirm doses for external beam
• Only QAO confirming implant doses
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Study Groups Relying onRPC Chart Review
• GOG Gynecologic Oncology Group
• NCCTG North Central Cancer Treatment Group
• NSABP National Surgical Adjuvant Breast and Bowel Project
• RTOG Radiation Therapy Oncology Group
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Chart Review Process
• Radiotherapy records, calculations & films received from study group
Independent dose recalculation (±5%)
Resolve errors with institution
Discuss results with Group and Study Chair
Facilitate clinical review at meetings, RPC, HQ
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Results of Chart Review• 1% Systematic errors
– Potential to impact every patient treated by institution
• 10% Individual errors– Impacts study groups and institution
• 25% Reporting errors– Impacts study group and institution
Without RPC review 36% of the doses used by the study
group would be incorrect
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Priority for Visits
TLD Problem
Problem Chart Other
Patient Accrual
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On-Site Dosimetry Review Visit
•The only completely independent comprehensive radiotherapy quality audit in the USA and Canada
– Identify errors in dosimetry and QA program and suggest methods of improvements.
– Collect and verify dosimetry data needed to review patient charts.
– Improve quality of patient care for all patients.
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0
50
100
150
2000 2001 2002 2003 2004Year
Num
ber o
f Ins
t. vi
sits
No. per year
cumulative
~1387 institutions participating in clinical trialsvisited not visited yet
Institutions: 715 672Patient accrual: 20,130 1,095
(95%) (5%)
On-Site Dosimetry Review Visit
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0
50
100
150
2000 2001 2002 2003 2004Year
Num
ber o
f Ins
t. vi
sits
No. per year
cumulative
~1387 institutions participating in clinical trialsvisited not visited yet
Institutions: 715 672Patient accrual: 20,130 1,095
(95%) (5%)
Prioritization schema focuses our visit
resources where the majority of the patients
are treated!
On-Site Dosimetry Review Visit
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On-Site Dosimetry Review Visit Errors
0
50
100
150
200
2000 2001 2002 2003 2004Year
99% of the Institutions visited have one or
more errors
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On-Site Dosimetry Review Visit Errors
0
50
100
150
200
2000 2001 2002 2003 2004Year
99% of the Institutions visited have one or
more errors
Over 500 errors and 85 lapses in QA programs were identified at institutions
visited by the RPC during the past 5 years.
These errors potentially impacted on all patients treated at these institutions.
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(30%)*Photon Depth Dose
(16%)*Off-axis Factors(22%)*Electron Calibration(24%)*Photon Calibration & FSD(24%)*Wedge Transmission(24%)Switch to TG-51
(84%)Review QA ProgramPercent of InstitutionsErrors Regarding:
Selected discrepancies discovered during 2004
On-Site Dosimetry Review Visits
*70% of institutions received at least one of the significant dosimetry recommendations.
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Calibration Procedures (1)
Muscle
Reference calibration adjusted to dose in:
Water
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Review of Institutions Dosimetry Program Remotely
How can we evaluate institutions and find errors for the nearly 700 institutions that have a low priority for a visit?
Use the RPC standard data.
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RPC Remote Data ReviewWhat are the RPC Standard Data?• Compilation of RPC measured average data
1. 2350 photon beams2. 81 accelerator model/ energy combinations
• Specific to make/model/energy
• ≥ 5 sets of RPC measured data
Analyses of these data indicate that machines of same make/model/energy have same radiation characteristics.
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RPC Remote Data Review
Can standard data discover errors?(analysis of 7,864 data points from 150 institutions)
146(1.9%)
378(4.8%)
No
450(5.7%)
6890(87.7%)
Yes
NoYes
Std. Data indicates discrepancy
Dosimetry review visit found discrepancy
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RPC Remote Data Review
Can standard data discover errors?(analysis of 7,864 data points from 150 institutions)
146(1.9%)
378(4.8%)
No
450(5.7%)
6890(87.7%)
Yes
NoYes
Std. Data indicates discrepancy
Dosimetry review visit found discrepancy
Failed to predict
(10.5%)
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Calibration Procedures (2)
SAD
Air
SSD
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Only QA group within USA and Canada that interacts with oncologists, medical
physicists, dosimetrists and other medical staff at 1,400 institutions,
regardless of their affiliation or location.
Communications and Support of the Radiation Oncology Community
(RPC: National Resource)
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Strongest Interaction is with the Physics Community in Support of Clinical Trials
American Association of Physicists in Medicine (AAPM)
•Therapy Physics Committee
•Brachytherapy dosimetry in clinical trials
•Implementation of new calibration protocol
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NCINCI
QARCQARC
RPCQA PROGRAMRPC QA
PROGRAM
ITC(High tech Protocols)
ITC
RTOG/ACRRTOG/ACR
RCETRCET
Only QA Office with relationships with all study groups
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Consortium of 5 quality assurance offices
RPC
RTOG QA
QARC
ITC
RCET
Role is to interact with study groups
Role is to develop toolsfor electronic data
submission and review
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Ongoing Communications with Community
1.Via the web site and email burst2. AAPM newsletter
3. Workshops/ posters/ oral presentations/ publications
4. Phone!
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Ongoing Communications with Community
1.Via the web site and email burst2. AAPM newsletter
3. Workshops/ posters/ oral presentations/ publications
4. Phone!
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Institutions participating in monitoring program
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Ongoing Communications with Community
1. Via the web site and email burst
2.AAPM newsletter3. Workshops/ posters/
oral presentations/ publications
4. Phone!
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Ongoing Communications with Community
1. Via the web site and email burst
2.AAPM newsletter3. Workshops/ posters/
oral presentations/ publications
4. Phone!
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Ongoing Communications with Community
1. Via the web site and email burst
2. AAPM newsletter
3.Workshops/ posters/ oral presentations/ publications
4. Phone!
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Ongoing Communications with Community
1. Via the web site and email burst
2. AAPM newsletter
3.Workshops/ posters/ oral presentations/ publications
4. Phone!
Since 2000
> 69 oral presentations/ posters
39 scientific publications
10 workshops
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Ongoing Communications with Community
1. Via the web site and email burst
2. AAPM newsletter
3. Workshops/ posters/ oral presentations/ publications
4.Phone/ email !
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Ongoing Communications with Community
1. Via the web site and email burst
2. AAPM newsletter
3. Workshops/ posters/ oral presentations/ publications
4.Phone/ email !
The RPC interacts with the Radiation Oncology
community over 100 times per week
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Calibration Procedures (3)At other depth In air
At dmax
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Research and Development Programs
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Gel Dosimetry• Expanded use of gels, adapt to additional phantoms• Investigation of new gel/solid dosimeters
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Relative Evaluation
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Phantom Development
• Design of “liver” phantom, with simulated respiratory motion, for RTOG 0438
• STTR proposed: Dynamic phantom for gated & adaptive therapy
QuickTime™ and aCinepak decompressor
are needed to see this picture.
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Simulation of Respiratory Motion
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0438 - Liver primary or mets
• Questionnaires• Liver phantom on
reciprocating table• Digital submission
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Influence of Lung Tissue on Tumor Dose
• RPC phantom contains lung-equivalent regions
• Comparison of calculations with measurements
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Lung Phantom Comparison
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Summary of Gamma-Index Comparison
6 MV Offset 6 MV Centered 18 MV Offset6 MV Offset 6 MV Centered 18 MV Offset
Pinnacle Convolution
Eclipse
XiOConvolution
XiOClarkson
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
100.0
Binary Comparison at 5% / 3mm
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Gynecological Insert for Pelvic Phantom
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Improvements to Remote Audits
• Alternatives to Lithium Fluoride, automatic TLD readers
• Elimination of %DD measurements
• Expanded audits: non-reference dosimetry, other detectors
• Introduction of Monte Carlo-calculations
– Supplement “Standard Data”
– Facilitate validation of complex treatments
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Proton Beam Clinical Trials
• Project to investigate radiochromic film
• Anticipate additional projects–Other dosimeters–Phantoms–Visits
• Coordinating with MDACC
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Other Aspects …• Continue efforts to improve efficiency
and service
• Further implement electronic data exchange
• Remain vigilant to needs of study groups and community
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The End