NATIONAL & INTERNATIONAL COMMUNICATION

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 Protection’s 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@ccf.org • (216)445-8289 & fax (216)444-5331

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. RadiologicalPhysicsCenter Geoffrey Ibbott Director David Followill Associate Director

9. Radiological Physics Center • Located at UT M.D. Anderson Cancer Center http://rpc.mdanderson.org (713) 745-8989 • Funded by NCI, continuously since 1969 • 24 million - next 5 years • 37 staff • Monitors all1396 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. Phantom Patient 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 IMRT – H&N Stereotactic Head

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, neglectconventional clinic, multiple problems

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