future informatics needs for radiation oncology and possible solutions
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Future informatics needs for Radiation Oncology and possible solutions. informatics & Radiation Oncology. Informatics. Science of Information Infrastructure Connection Language/Semiotics (signs) Semantics (meaning), Vocabulary (words) No thesaurus Data > Information > Knowledge.

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future informatics needs for radiation oncology and possible solutions
Future informatics needs for Radiation Oncology and possible solutions

informatics & Radiation Oncology

Prof A A Miller FRANZCR, Illawarra Cancer Care Centre | 24 Oct 2012 | London ON

informatics
Informatics
  • Science of Information
    • Infrastructure
      • Connection
      • Language/Semiotics (signs)
        • Semantics (meaning), Vocabulary (words)
        • No thesaurus
    • Data > Information > Knowledge

Prof A A Miller FRANZCR, Illawarra Cancer Care Centre | 24 Oct 2012 | London ON

why informatics
Why Informatics?
  • the way that we doctors advance our knowledge
    • Inefficient
      • Limited
        • One question
        • 2%
      • Labour-intensive
        • Costly
        • Quasi-prospective

Prof A A Miller FRANZCR, Illawarra Cancer Care Centre | 24 Oct 2012 | London ON

the present
The Present
  • RO = “Domain Experts”
  • Knowledge
    • Unformalised “structure”
    • Idiosyncratic nomenclature
      • What’s the round thing that you see with called?
      • What’s a “bowel bag”?
    • Disparate, variably connected systems
      • Clinical data (OIS?)
      • Clinical communication (documents)
      • Treatment construction (TPS)
      • Treatment delivery (R&V)
      • Clinical outcomes (OIS?)

Prof A A Miller FRANZCR, Illawarra Cancer Care Centre | 24 Oct 2012 | London ON

an illustration
An Illustration

The patient was treated at the Illawarra Cancer Care Centre by Dr Alexis Andrew Miller. The patient, LARRY LOLLIPOP was a male born on 15/03/1949 in Wollongong. His hospital ID is 99999999. He is a causasian with tertiary qualifications, and an income of $100,000-150,000 per year earned in a professional job. He is a property owner.

Prof A A Miller FRANZCR, Illawarra Cancer Care Centre | 24 Oct 2012 | London ON

and on
And on …
  • Histopathology was reported as a Basaloid squamous cell carcinoma (8083/3 with poor differentiation (G3). Immunohistochemistry was positive for CK7. The tumour was staged at Stage IVa. Image-based staging revealed a T4a tumour with a size of 55 mm, local tumour with infiltration of muscles of the tongue, and N2c with 2 nodes, one on the right measuring 27mm in level II, and one on the left measuring 22mm in level II. Image-based staging revealed no metastases (M0).

Prof A A Miller FRANZCR, Illawarra Cancer Care Centre | 24 Oct 2012 | London ON

sorry but point not made
Sorry, but point not made …

The radiation prescription called for 70 GY in 35 FX treated 1 per day, 5 per week with BD compensation for treatment breaks, using photons (6MV) with IMRT using non-coplanar beams. Radiation was prescribed to a non-ICRU prescription point.

Target volumes for the IMRT technique consisted of a PTV7000 with a prescription dose of 70GY/35FX which was a 3mm expansion of the CTVp, which was based on the GTVp with a 5mm expansion, and a 3mm expansion of the CTVn, which was based on the GTVn with a 5mm expansion.

Prof A A Miller FRANZCR, Illawarra Cancer Care Centre | 24 Oct 2012 | London ON

and for the mos
And for the MOs …
  • The concurrent chemotherapy regime was Weekly Cisplatin given over 7 cycles that started with radiotherapy and lasted 1 week each. On day 1 of the cycle, cisplatin at a dose of 40mg/m2 was administered intravenously as a 1 hour infusion starting 1 hour before radiotherapy, supported with IV hydration of 500mL normal saline and an antiemetic drug. During the chemotherapy he developed febrile neutropaenia, and suffered a hospital admission from 20/05/2009 to 22/05/2009. He also developed dehydration.

Prof A A Miller FRANZCR, Illawarra Cancer Care Centre | 24 Oct 2012 | London ON

the conflict
The Conflict
  • UNDERSTANDING
    • Who understands this?
    • Who DOESN’T understand this?
  • UTILITY
    • Who can use this?
    • Who CANNOT use this?

Prof A A Miller FRANZCR, Illawarra Cancer Care Centre | 24 Oct 2012 | London ON

an illustration1
An Illustration

<Organisation>

<Department>ILLAWARRA CANCER CARE CENTRE

<Doctor>ALEXIS ANDREW MILLER</Doctor>

</Department>

<Patient>

<PatientID>

<LastName>LOLLIPOP</LastName> * a pseudonym

<FirstName>LARRY</FirstName>

<Gender>

<Male>YES</Male>

</Gender>

<UniqueID>99999999

<DateOfBirth>32/13/1949</DateOfBirth>

<PlaceOfBirth>WOLLONGONG</PlaceOfBirth>

</UniqueID>

</PatientID>

<Demographics>

<Race>CAUSACIAN</Race>

<Education>TERTIARY</Education>

<Income>100,000-150,000</Income>

<Employment>PROFESSIONAL</Employment>

<Housing>PROPERTY OWNER</Housing>

</Demographics>

Prof A A Miller FRANZCR, Illawarra Cancer Care Centre | 24 Oct 2012 | London ON

slide11

<Histopathology>

<Morphology>Basaloid squamous cell carcinoma<ICD0Morphology>8083/3</ICD0Morphology>

</Morphology>

<Differentiation>G3</Differentiation>

<Immunohistochemistry>

<IHC-CK7>POSITIVE</IHC-CK7>

</Immunohistochemistry>

</Histopathology>

<CancerStage>

<Stage>IVa</Stage>

<T_Stage>T4a

<T_stagebasis>IMAGING</T_stagebasis>

<T_size>5.5cm</T_size>

<T_infiltration>muscles of tongue</T_infiltration>

</T_Stage>

<N_Stage>N2c

<N_stagebasis>IMAGING</N_stagebasis>

<N_numberpositive>2

<N_laterality>RIGHT

<N_maxsize>27MM</N_maxsize>

<N_necklevel>II</N_necklevel>

</N_laterality>

<N_laterality>LEFT

<N_maxsize>22MM</N_maxsize>

<N_necklevel>II</N_necklevel>

</N_laterality>

</N_numberpositive>

</N_Stage>

<M_Stage>M0

<M_stagebasis>IMAGING</M_stagebasis>

</M_Stage>

</CancerStage>

Prof A A Miller FRANZCR, Illawarra Cancer Care Centre | 24 Oct 2012 | London ON

slide12

<Radiotherapy> <ExternalBeam> <Importance>PRIMARY</Importance> <RadiationPrescription> <RadiationDose>70 GY</RadiationDose> <RadiationFractions>35 FX</RadiationFractions> <RadiationFractionsPerDay>ONE</RadiationFractionsPerDay> <RadiationFractionsPerWeek>FIVE <RadiotherapyBreakCompensation>BD</RadiotherapyBreakCompensation> </RadiationFractionsPerWeek> <RadiationBeamParticle>PHOTONS <RadiationBeamEnergy>6MV</RadiationBeamEnergy> </RadiationBeamParticle> <RadiationTechnique>IMRT <RadiotherapyBeamArrangement>NONCOPLANAR <RadiationPrescriptionPoint> NON-ICRU PRESCRIPTIONPOINT</RadiationPrescriptionPoint> </RadiotherapyBeamArrangement> </RadiationTechnique> </RadiationPrescription>

Prof A A Miller FRANZCR, Illawarra Cancer Care Centre | 24 Oct 2012 | London ON

slide13

<Chemotherapy> <Importance>CONCURRENT</Importance> <ChemotherapyRegime>WEEKLY CISPLATIN<ChemotherapyCycle> <ChemotherapyCycleNumber>SEVEN</ChemotherapyCycleNumber> <ChemotherapyStartEvent>RADIOTHERAPY START</ChemotherapyStartEvent> <ChemotherapyCycleDuration>ONE WEEK<ChemotherapyCycleDay>DAY 1</ChemotherapyCycleDay><ChemotherapyDrug>CISPLATIN</ChemotherapyDrug><ChemotherapyDrugDose>40MG/M^2</ChemotherapyDrugDose> <ChemotherapyDrugRoute>IV</ChemotherapyDrugRoute> <ChemotherapyDrugDelivery>ONE HOUR INFUSION</ChemotherapyDrugDelivery><ChemotherapyDrugDeliveryStart>-1 HOUR</ChemotherapyDrugDeliveryStart><ChemotherapyDrugSupport> <IVHYDRATION>500mL NORMALSALINE</IVHYDRATION><Drug>ANTIEMETIC</Drug></ChemotherapyDrugSupport> </ChemotherapyCycleDuration> </ChemotherapyCycle> </ChemotherapyRegime> <SideEffects> <FebrileNeutropaenia>YES<HospitalAdmission>YES<HospitalAdmissionDate>20/05/2009</HospitalAdmissionDate><HospitalDischargeDate>22/05/2009</HospitalDischargeDate></HospitalAdmission> </FebrileNeutropaenia> <Dehydration>YES</Dehydration></SideEffects></Chemotherapy>

Prof A A Miller FRANZCR, Illawarra Cancer Care Centre | 24 Oct 2012 | London ON

the conflict1
The Conflict
  • UNDERSTANDING
    • Who understands this?
    • Who DOESN’T understand this?
  • UTILITY
    • Who can use this?
    • Who CANNOT use this?

Prof A A Miller FRANZCR, Illawarra Cancer Care Centre | 24 Oct 2012 | London ON

summary so far
Summary so far …
  • Oncologists store & communicate knowledge by writing text
    • “no structure”, Style, Erudition
    • Little automated use
  • Informaticians generate & use knowledge by manipulating structure
    • Re-use

Prof A A Miller FRANZCR, Illawarra Cancer Care Centre | 24 Oct 2012 | London ON

in case you missed it
In case you missed it …

The late side effects suffered on 6/10/2011 consisted of G1 late effects in the skin, GO late effects in subcutaneous tissue, G2 late effects in mucosa, G0 late effects in the spinal cord, G0 late effects in larynx, and G0 late effects in feeding.

<LateSideEffects>

<DateofAssessment>6/10/2011

<LateEffectsSkin>G1</LateEffectsSkin>

<LateEffectsSubcutaneous>G0</LateEffectsSubcutaneous>

<LateEffectsMucosa>G2</LateEffectsMucosa>

<LateEffectsSpinalCord>G0</LateEffectsSpinalCord>

<LateEffectsLarynx>G0</LateEffectsLarynx>

<LateEffectsEnteralFeeding>G0</LateEffectsEnteralFeeding>

</DateofAssessment>

</LateSideEffects>

TEXT

XML

These are the same piece of knowledge

Prof A A Miller FRANZCR, Illawarra Cancer Care Centre | 24 Oct 2012 | London ON

xml structure to knowledge
XML structure to knowledge
  • Patient data is coded
    • Search
    • Compare
    • Collate
    • Malleable
  • LARRY LOLLIPOP
    • T4aN2cM0
      • What’s your data say?
        • EBM?
      • Decision making?
        • Randomised data?
        • Guidelines?
        • My data?

Prof A A Miller FRANZCR, Illawarra Cancer Care Centre | 24 Oct 2012 | London ON

bcca guideline
BCCA Guideline

TEXT

"Advanced tumours T3/ T4 N0/N1/N2/N3 should be considered for a twice daily radiotherapy schedule or concurrent chemotherapy with radiotherapy if the patient is fit."

XML

<Organisation>BCCA<Guideline> <GuidelineID>BCCA99</GuidelineID><GuidelineName>OROPHARYNX</GuidelineName><BiologicalMilieu>FIT<BiologicalMilieu><Diagnosis> <Cancer> <CancerDiagnosis> <ICD0Site>Base of the tongue</ICD0Site> <ICD0>C50<ICD0><CancerStage> <T_stage>T3; T4</T_stage><N_stage>N0; N1; N2; N3</N_stage><M_stage>M0</M_stage></CancerStage> <Therapy> <Surgery>NO</Surgery><Radiotherapy>YES</Radiotherapy><Chemotherapy>YES</Chemotherapy></Therapy> </CancerDiagnosis> </Cancer> </Diagnosis> </Guideline></Organisation>

Which is more useful?

Prof A A Miller FRANZCR, Illawarra Cancer Care Centre | 24 Oct 2012 | London ON

slide19
So?
  • Even if we had the system to gather that data?
      • Would you do it?
      • Where would you put the data to be accessible?
      • How would you keep it secure?
      • How would you keep it private?
      • Data for RO includes clinical data, radiation plan, pictures, video

Prof A A Miller FRANZCR, Illawarra Cancer Care Centre | 24 Oct 2012 | London ON

we are focussed on dicom
We are focussed on DICOM
  • DICOM standard
    • PACS
      • Images, Pictures, Videos
      • Diseases??
    • DICOM-RT
      • We already ‘use’ this
    • DICOM-SR
      • Structured Reports
        • OIS entry>XML
      • XML>SR already done

Prof A A Miller FRANZCR, Illawarra Cancer Care Centre | 24 Oct 2012 | London ON

data security
Data Security
  • Determined by IT
    • Re-use PACS solutions?

Prof A A Miller FRANZCR, Illawarra Cancer Care Centre | 24 Oct 2012 | London ON

data privacy
Data Privacy
  • Determined by patient
  • Aggregate reports
    • I send you a clinical query, you send me aggregated data
      • Ad hoc queries
    • You maintain a routine report on all standard groups of patients
      • Consistent standard reports

Prof A A Miller FRANZCR, Illawarra Cancer Care Centre | 24 Oct 2012 | London ON

summary
Summary
  • RO can be fitted into a useful XML structure
  • Vocabulary Standardisation deficient
  • Knowledge Structure is not agreed
  • Systems to produce structured data are immature
  • Personalised EB medicine required standardisation, storage & reporting

Prof A A Miller FRANZCR, Illawarra Cancer Care Centre | 24 Oct 2012 | London ON

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