I couple weeks ago, I gave a webinar for the “Best of QADS” series put on by Sun Nuclear Corporation. The webinar was called “The Top 10 Lessons Learned after 10 Years of International Plan Studies.” The presentation (including the live Q&A session) was recorded. You can watch it by visiting the following link.
Click here to register and watch that presentation. (It’s free of course)....
PART 1: THE INERTIA OF WRONG ASSUMPTIONS
An object at rest tends to stay at rest…
Newton’s First Law
I’ll never forget the reactions of those two physicians, those many years ago. Or, at least I won’t let myself. Not yet at least.
Allow me a moment to retell.
It was about seven years ago and I had just given a talk at a regional meeting in the Midwest. This particular audience was made up of medical dosimetrists and radiation therapists, with a smattering of medical physicists and radiation oncologists. My topic: “Variation in Anatomical Contouring.”
One of my first slides was a clumsy cartoon I had sketched together in PowerPoint. It showed a horse (labelled “treatment planning”) pulling a train of carts, each labelled with a specific technology dependent on the preceding one. And under the horse, representing the road on which the horse and all carts depended, was written one big, bold word: CONTOURING. I found that old cartoon and I’ve reproduced it in Figure 1, below.
Figure 1. My slide (circa ~2010) used to say, essentially, “We can talk about the cart and the horse all we want, but let’s not forget the condition of the road…”
My simple argument was that if you don’t get your anatomy volumes defined correctly – both for targets and critical organs – then everything else downstream suffers. Or, following the horse-and-cart metaphor, inaccurate contours make for a really bumpy ride. All the benefits of the elegant technology of radiation therapy – inverse planning and dose optimization, dose calculation, DVH and other plan metrics, image-guidance, and precision delivery – don’t even matter if your patient anatomy blueprint is wrong in the first place. The anatomy contours are the original “design input” to the personalized medicine that is radiation oncology. Get that wrong, and you’re in trouble.
For the talk, I showed some preliminary data on inter-observer anatomical contours over a range of critical organs. These were controlled experiments where all clinicians were given the same CT images, and the variation I was seeing in some organs was shocking. While there was not much variation for some organs like the brain or lung which are easily seen as clearly defined pixel regions, there was very large variation for many other organs like the parotid, sub-mandibular glands, brainstem, larynx, and even the spinal cord (!)....
Dr. Aaron Kusano and I will be leading this year’s AAMD Contouring Workshop. This will be our third workshop of this kind in a row, and we believe this year’s agenda is the best. We have incorporated the most frequent request (namely, for more “hands on” contouring time) while keeping the instruction and testing methods that have been successful the past two years.
Below is a short conversation with both of us that provides a nice summary of what we’re doing this year and why. We hope you sign up and join the workshop! It’s a volunteer effort on our part, and our only motivation is because of our passion and yours.
I am proud to be collaborating with a multi-institutional team to build a system called “ProKnow.” ProKnow stands for “Profound Knowledge,” a term that many of you will recognize from Deming’s famous “System of Profound Knowledge” to improve quality and pride in workmanship across any company, team, or project.
ProKnow will allow the worldwide community to study, and ultimately improve, the standard of care in radiation oncology. We have powerful analytical modules to help you: ensure accurate anatomy contouring, quantify and study plan quality metrics, identify best practices, and ultimately correlate your methods and modalities with patient outcomes.
Here is the link to our cloud-based system: www.proknowsystems.com. Take a look!...
Pretty soon it will be June and the annual AAMD meeting in Atlanta will be one hot ticket!
We’re pretty proud of the educational agenda we’ve put together for this year’s AAMD Contouring Workshop. It includes elements and strategies that have succeeded in past workshops, combined with pretty much all the suggestions for improvement we have received from the past two years. Firstly, we’re allowing more time so that we maximize the “hands on” skills practice and interaction with each other and the experts. Secondly, the workflow of the workshop is tailor made to optimize learning. You will be contouring critical organs (thanks to MIM to donating workstations and their impressive contouring software), then hearing the incomparable Dr. Aaron Kusano give interactive lectures on each organ, then you will receive immediate feedback of your individual contours vs. the “gold standard” contours as scored by the StructSure software (thanks to Standard Imaging), and finally you will go back to the workstations to directly compare your contours to the gold standards and ask Dr. Kusano questions in real time during your review.
That’s the gist of it. It is going to be great and will set the bar even higher on the value of the workshop.
Here is a link to the AAMD page: AAMD 2016 Workshops...
For closure on the “Project Icarus” thread, I’d like to make it clear the the project is alive and well, but is now living and breathing in the real world as the “Feasibility Analysis” (pre-planning and post-planning) tools in the PlanIQ software product now owned by Sun Nuclear Corporation.
For more information or to request a demo or research license, just contact your Sun Nuclear sales representative....
As an industry, we’ve spent decades talking about testing and improving the accuracy of 3D dose calculations. We’ve invented countless products – both hardware (e.g. dosimeters) and software – to help us along the way, and many AAPM Task Groups have published reports of various flavors and angles on this topic. None of this is too surprising because accurate dose calcs, especially in and around complex tissue shapes and varying densities, are not an easy thing.
3D dose calculation results are primarily used – in conjunction with 3D anatomy contouring – to produce dose volume histograms (DVH) for each target and organ-at-risk. The irony is that for a long time (again, decades), as an industry we’ve forgotten that assembling DVH curves requires calculations itself, and not all of these are created equal. How are anatomy volumes simulated and at what resolution? How are anatomy superior and inferior “end caps” modeled and what is assumed to happen in between axial slices? How does anatomy interplay with an orthogonal 3D dose grid, and what are the effects of that dose grid’s spatial resolution?
DVH calculations are not standard, folks. Not by a far cry.
Together with Vladimir Feygelman, Ph.D. and other scientists at Moffitt Cancer Center (Tampa, FL), we’ve done some really important work studying DVH accuracy and recommending standardized datasets and methods to validate your TPS software. We’ve published our first work in Medical Physics (August, 2015), and you can link to it here.
I hope you can take some time to read our new publication. If you’re a physician, physicist, or dosimetrist (or, just as important, if you’re a TPS software vendor) it will be well worth your time....
In December 2014, Quality Reports received 510(k) clearance from the Food and Drug Administration (FDA). This is just the next major milestone in the exciting Quality Reports timeline.
Quality Reports has been renamed “PlanIQ” and is available from Sun Nuclear....
At this year’s AAMD Annual Meeting, I got to talk about something much cooler than science. Hear the stories, below.
The success and interest level in the “Plan Challenge” has now permeated to the AAPM, where we will be integrating a AAPM-dedicated Plan Challenge into a 2-hour special session on Plan Quality at the 2014 Spring Clinical Meeting.
In this Plan Challenge, we offer our first hypofractionated lung case. Participation is encouraged from physicists and dosimetrists alike, both domestic and international. Results will be presented for the first time on March 15, 2015 in Denver, CO, but we will repeat the results via live webinars and/or videos posted online after the AAPM spring meeting.
Here are some key links regarding the 2014 AAPM Plan Challenge:
– Link to register (which will kick off the ROR portal that will steer you through the process)
– Link to a recorded meeting going over the anatomy, objectives, and other interesting discussions on the particular Plan Quality Algorithm to be used
– For Quality Reports users, here is a link to a downloadable protocol which you can import directly into Quality Reports 1.1 or later, to allow self-scoring. Use the protocol labeled “AAPM Plan Challenge.”
Spread the word!...
Thanks to all the users and research partners who provided great input and validation of the many enhancements in this new version. Quality Reports now makes it even easier and to produce customized and comprehensive documentation of radiation plan quality, and further improves the automation of protocol analysis for meaningful use EMR.
The full release summary of changes and new installers are now available for download via the secure downloads portal (see the “Download” link in the banner).
In the past few years, I’ve developed closer collaborations with the dosimetry community, giving annual talks at the national AAMD meeting and working with Radiation Oncology Resources, Inc. to develop much-needed Quality Systems and training programs for radiation therapy. In the process, I have met more and more dosimetrists and dosimetry students, and am always impressed by their hunger to learn, improve, and share techniques and best practices. Dosimetrists are a highly collaborative population of colleagues as opposed to a competitive population of rivals. This is healthy.
As part of my commitment and appreciation for the dosimetry community, I proudly announce that I will be working with Dr. Scott Collins and his Dosimetry Master program at Southern Illinois University (Carbondale). I will be giving guest lectures, working with ROR to run plan quality projects (i.e. Plan Challenges devoted to the students), and most importantly I will be arming the students with “Quality Reports [EMR]” licenses throughout their education.
We just finished a pilot project with the outgoing class of 2013, and in just a few weeks we were already seeing how the software can help on so many fronts – from interactive education on core principles of radiation therapy, to clinical protocols and continual improvement initiatives. We now look forward to the 2014 class, and beyond.
– Ben Nelms...
Great news! Today, the US Oncology Network (USON) and Radiation Oncology Resources (ROR) announced a landmark deal for a network-wide quality system to be integrated for the vast network of USON clinicians. This quality system will help ensure the highest quality of care and set new standards of evidence-based medicine. I am proud to say that Quality Reports [EMR] is the integral technology component to be used by ROR for benchmarking and quality improvement of radiation treatment plans.
Congratulations to both ROR and USON for your commitment to advancing quality of radiation therapy. Your wise decision and hard work will enhance the standard of care for a great many cancer patients.
Here are links to the full press release: From the “Daily Finance” website....
Today, customized EMR for modern radiation therapy takes a giant leap forward with the commercial release of Quality Reports [EMR], version 1.0. The first wave of customers span the United States coast-to-coast, from North Carolina to Oregon. These new customers join an already strong base of clinical research partners who have been using the software for many months and who have submitted five related studies to annual professional meetings in North America (e.g. four submissions to ASTRO 2013).
Quality Reports [EMR]™ software, designed specifically for modern radiation therapy, generates advanced, customizable electronic reports for the patient EMR/EHR system. Quality Reports [EMR]: 1) works with all planning systems, R&V, and delivery modalities, interfacing via DICOM storage and archive; 2) automates protocols (or physician-specific goals) via quantitative, user-defined collections of critical plan metrics; and 3) creates/manages “histories” of plan quality, enabling continual improvement and ensuring meaningful use of the EMR....
Quality Reports [EMR] software will begin official validation testing on February 4, 2013. This is the final phase of testing this new, exciting product.
Thankfully, we have some great validation partners who have been using the software regularly for clinical EMR, powerful & automated protocols, plan quality assessment, and research. I would like to personally thank Goshen Hospital (Goshen, IN), Moffitt Cancer Center (Tampa, FL), and especially the great folks at L’Hôpital Rosemont-Maissoneuve (Montreal, Quebec) who have been giving excellent feedback for so many months. Merci Beaucoup, mes amis.
And last but not least, I thank my partners in this endeavor – the talented CMD’s at Radiation Oncology Resources: Greg, Kyle, Adam, Steve, and Sharath. We’ve come a long way fellas, but it’s only the beginning.
** Update: February 23rd ** Quality Reports [EMR] onsite validation is complete! Design transfer tests will be run using the “customer portal” for product and documentation downloads during the week of February 25th. User documentation and a special video training series will also be finishing up soon, wrapping up version 1.0 and allowing the official commercial release by ~March 8th....