NATIONAL

1
NATIONAL INTERNATIONAL COMMUNICATION

• Marilyn Stovall, Ph.D.
• The University of Texas
• M. D. Anderson Cancer Center
• Houston, Texas

2
IOMP/AAPM International Libraries Program

• Established in 1990
• Medical physicists in the US donate books and
  journals
• Donations go to libraries in developing countries
  where all physicists in the area have access
• Donors get a tax deduction!

3

• 69 libraries in 44 countries
• 2200 donations, including approximately 1400
  book and journal donations
• 30-35 AAPM members donate their Medical Physics
  subscriptions directly to a library
• CDs of meeting proceedings (ASTRO, RSNA)
• Society for Radiological Protections quarterly
  publication, The Journal of Radiological
  Protection
• 117 tons of publications have been donated
  over 15 years

4

• New curator, as of 1/1/04
• Dr. Allan Wilkinson
• Cleveland Clinic Foundation
• Radiation Oncology, Desk T-28
• 9500 Euclid Ave.
• Cleveland, OH 44195
• iompl_at_ccf.org
• [phone] fax [phone]

5
Countries with IOMP Libraries
6
Stewart C. Bushong Memorial Library Guangzhou,
China
7
http//www.iomp.org

• List of current libraries
• Form to request a new library
• Form to initiate donation

8
Radiological Physics Center

• Geoffrey Ibbott
• Director
• David Followill
• Associate Director

9
Radiological Physics Center

• Located at UT M.D. Anderson Cancer Center
  http//rpc.mdanderson.org
• [phone]
• Funded by NCI, continuously
• since 1969
• 24 million - next 5 years
• 37 staff
• Monitors all 1396 institutions
• participating in cooperative clinical trial
  study groups.

10
Aim of RPC

• Assure NCI and Cooperative Groups that
  participating institutions can deliver prescribed
  dose clinically comparable to other institutions
  in cooperative groups.

11
Audit Tools of the RPC

• 1. On-site dosimetry review visits
• 2. Remote audit tools
• a) TLD - output of machine
• b) Review of dosimetry data
• c) Evaluation of patient charts
• Benchmark Cases - Treatment planning
• d) Development and evaluation of
• credentialing processes
• e) Review of QA procedures and records
• f ) Anatomical phantoms - Total treatment

12
On-Site Dosimetry Reviews

• Objectives
• 1. Identify weaknesses (discrepancies)
• in dosimetry and QA program and suggest
  methods of improvements.
• 2. Collect and verify dosimetry data needed
  to review patient charts.
• 3. Improve quality of patient care

13
On-Site Dosimetry Review Visits
Measure of the impact on patient tumor dose
delivery

• Combining worst case minimum and maximum errors
• Communicated to the study groups

14
On-Site Dosimetry Review Visits
Recommendations (Jan. 02 Sept. 03)
15
RPC Remote Audit Tools TLD

• Verify dose outputs and energy on radiotherapy
  units.
• Verify doses at points of interest in
  anthropomorphic phantoms.
• Evaluate institutions based on TLD history.

16
TLDExamples of Discrepancies

• Discrepancies of up to 16 in beam output
• Discrepancies of up to 8 mm in electron depth
  dose
• Inconsistencies in dosimetry data
• Miss-irradiations

17
RPC Remote Audit ToolsData Review

• Value of the Standard data
• Identify potential dosimetry errors at
  participating institutions.
• Redundant QA tool for institutions commissioning
  new accelerators.
• Used by the RPC in the absence of measured data.
• Used to supplement the onsite dosimetry review
  visit.
• Prioritize an institution for an on-site visit.
• Used to validate Monte Carlo modeling of a
  specific make/model/energy of accelerator

18
RPC Remote Audit ToolsPatient Charts

• Purpose
• Dose reported is dose delivered
• Treatment according to protocol
• Inform RPC of current treatment techniques
• Only QAO recalculating doses for both external
  beam brachytherapy

19
RPC Remote Audit ToolsPatient Charts

• Review
• Calculate tumor dose
• Agree within 5 (15 for brachytherapy)
• Verify dose, time, fractionation
• Participate in clinical review

20
RPC Remote Audit Tools Credentialing

• Purpose
• Education
• Evaluate ability to deliver dose
• Raise awareness of personnel
• Reduce deviation rate

21
RPC Remote Audit Tools Credentialing

• Process
• Previous patients treated with technique
• Facility Questionnaire
• Knowledge Assessment Questionnaire
• Benchmark Case(s)
• Electronic data submission
• RPC QA Dosimetry review
• Clinical review by radiation oncologist
• Feedback to institution

22
RPC Remote Audit ToolsAnthropomorphic Phantoms

• Anthropomorphic shape
• Water fillable
• Plastic inserts containing targets and organs at
  risk (heterogeneity)
• Point dose (TLD) and planar (radiochromic film)
  dosimeters
• Purpose is to evaluate the complete treatment
  process
• Imaging and transfer of images to planning
  computer
• Development of treatment plan
• Phantom set up on treatment couch
• Dose delivery

23
RPC Remote Audit ToolsAnthropomorphic Phantoms
Current Status 4 phantoms developed in response
to study group needs or anticipated needs
IMRT Pelvic Prostate (Gyn.)
Thorax - Lung
Stereotactic Head
IMRT HN
24
Anthropomorphic Phantoms Examples of
Discrepancies

• incorrect output factors in TPS
• inadequacies in beam modeling at leaf ends
  (Cadmen, et al PMB 2002)
• not adjusting MU to account for dose
  differences measured with ion chamber
• setup errors

25
Selected Systematic Problems

• Breast wedge factor isodose line 27
• Breast Equivalent square 7
• Breast assorted problems 19 to - 11
• Asymmetric Jaws 10 - 24
• Electron output and energy changes TLD -15
• 4 major academic inst high tech research,
  neglect conventional clinic, multiple problems

26
Summary
RPC QA ACTIVITIES IMPACT EVERY PATIENT TREATED AT
AN INSTITUTION, NOT JUST THE PROTOCOL PATIENTS