quality assurance at wellspring

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Post on 07-May-2015



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A Program is in place to ensure that the radiation is being delivered safely and accurately and that all the computers and machines are in proper working order and calibrated accurately


  • 1.Quality Assurance at Wellspring The program is in place to ensure that patients are treated properly and that the radiation treatments are being delivered safely and accurately

2. Recent articles in the news have raised questions and concerns about theaccuracy and safety of radiation treatments . The process of monitoring and verifying both safety and accuracy is included in the quality assurance (QA) program. 3. Radiation therapy is one of the safest, most effective ways to treat cancer. There were an estimated 35.4 million radiotherapy treatments on Varian and Tomotherapy machines last year.Errors do occur, but they are extremely rare, with less than 0.0001percent of treatments involving an incident that puts a patient at risk of harm . 4. QA Starts with the staff or medical team that is taking care of the patient 5. Peoplemake the difference

  • The first and most important component of a QA program is the personnel.
  • All cancer treatments are performed under the direction of physicians who areboard certified radiation oncologist , the daily administration is performed by certified and state licensedradiation therapists (RTT ),
  • the computer and dose calculations are performed by RTTs who arecertified in dosimetryand
  • oversight of the machines, computers and all dose plans and calculations are supervised bycertified medical physicists .

6. Certification and Radiation Therapy

  • Radiation Oncologists certified by the American Board of Radiology and licensed by the State
  • Medical Physicists certified by the American Board of Radiology and licensed by the State of Florida
  • Medical Radiation Dosimetrists certified by the Medical Dosimetry Certification Board
  • Radiation Therapists certified by the American Registry of Radiologic Technologists and license by the State of Florida

7. The Role of the Radiation Oncologist 8. The Role of the RadiationOncologist Individualized patient evaluation

  • Detailed history and physical of patient
  • Discussion of treatment options with patient including probability of success, possible side effects, etc.
  • Decision on specific course of treatment, informed consent
  • Prescription for radiation therapy is put into theelectronic chart (Aria) and password protectedso that thecomputer will not allow the patient to receive more than the dose and techniqueprogrammed in by the doctor

9. Two questions everyone thinks about

  • Are they hitting the right spot?
  • Am I getting the right dose?

10. Hitting the right spot

  • Targeting of the tumor and avoiding healthy normal tissue requires several steps
  • Simulation the patient is put into apositionthat can be reproduced every day and imaging studies are performed to visualize all the important normal anatomy and identify the tumor target

11. Simulation At the time of simulation the patient is placed in a reproducible position, often withimmobilization .For patients with cancer in the head or neck area a face mask ( auqaplast ) is usually made to hold the head still and allow the targeting markings to be painted on the mask. For other areas of the body avaclock bag will mold around the body to ensure that the patient is in the same position every day.Skin marks or tattoo's are used to match thelasermounted in the room and on the machine 12. CT scan, MRIor PET is obtained at this timeCT images are then imported into the treatment planning computer 13. In the simulation process the CT and PET scan images are used to create a computer reconstruction of the patient and cancer 14. PET and CT Scan used to create radiation target PET Scan , showing cancer in right tongue Computer generated reconstruction, the target area is in red 15. Using the computer generated images the physician can carefully target the cancer and avoid normal structures 16. Treatment Plan QA

  • After a plan has been approved by the Physician, it is sent to the Physicist for review
  • The Physicist checks to make sure all information (prescription, simulation, etc.) has been entered correctly into the computer
  • At a minimum, the Physicist checks the calculated beam-on time for each field using a hand calculation or independent computer program

17. Hitting the right spot

  • During the daily treatment the patient is positioned in the same position as the simulation, lasers, skin marks ortattoo's and immobilizationare used to verify the correct position. Everyday the lasers are checked prior to the start of the day.
  • The daily set up is performed by certified RTTs

18. Hitting the right spot Once the patient is laying on the radiation table, images can be taken to verify that the beam is targeting the correct site (calledportal imaging)or on the Tomotherapy machine a true CT scan is obtained daily prior to treatment 19. Hitting the right spotthe same machine that produces the radiation can take a picture at the same time and the image (portal image) is compared with the computer generated target image (DRR) DRR computer generated image The portal image showing the actual area treated that day 20. CT Scan prior to radiationTomo image after only 19 treatments cancer cancer With image guided therapy (Tomotherapy) a CT scan is obtained prior to every treatment to check the accuracy of the targeting and determine if the tumor is shrinking or changing position 21. Importance of daily CT targeting onTomotherapy and adjusting the treatment daily Very little bowel gas on initial study and thedose (red)targets the prostate gland closely large bowel gas on later treatment day and thedose (red)will cover half the rectum if an adjustment is not made 22. If no adjustment was made Actual treatment onTomotherapyprior to treating the patient, the radiation beam (in red) was shifted upward and no longer hits the rectum 23. Two questions everyone thinks about

  • Are they hitting the right spot?
  • Am I getting the right dose?

24. Using the proper dose of radiation It may be abit over-exposed 25. Radiation History Radiation has been used to treat patients since the late 1890s and there is extensive information available about the proper and safe dose 26. Information about the safe and effective doses of radiation Tables about the safe and recommended doses of radiation can be found on our web site, and the NCCN now publishes online, very detailed information about recommended doses of radiation 27. 28. Am I getting the right dose? After the patient has been simulated and computer plans generated by the staff and reviewed by the physicist, the physician enters the dose into theelectronic chartand locks this in with apassword , this prevents the machine or the staff from exceeding this dose . 29. How do I know if the machine has beencalibratedcorrectly and am actually receiving the dose called for by the computer plans or the physicians prescription ? 30. Calibrating and verifying that the machines and computers are working properly - 5 steps 1.Every day prior to treating patients, the linear accelerator and TomoTherapy machines are tested with a device (the QA beam checker) that verifies that the output of the machine is correct in shape, energy level and dose 31. Calibrating and verifying that the machines and computers are working properly - 5 steps 2.The machines also undergo monthly and annual evaluation and calibration by the medical physicist to verify they are exactly calibrated 32. Calibrating and verifying that the machines and computers are working properly - 5 steps 3. On a regular basis a device (TLD) is radiated to a fixed dose and then mailed to an outside expert center (MD Anderson) to independently verify that the dose output is accurate, as well as a body phantom is used to verify the proper dose distribution 33. Calibrating and verifying that the machines and computers are working properly - 5 steps 4.Other radiation measurement devices are placed on the patient (mosfet and electronic dosimeters) to independently verify that the patients is receiving the dose predicted by the computer plan 34. Calibrating and verifying that the machines and computers are working properly - 5 steps 5.Prior to treating the patient with any complex plan (e.g. IMRT or Tomotherapy) a measurement device (called a phantom) is treated with the patients dose plan to verify that the computer calculations and the shaping devices (MLC) are working properly 35. Machine Quality Assurance

  • The QA program at Wellspring complies with standards set by:
    • State of Florida Radiation Control Regulations (64E-5 Florida Administrative Code)
    • Reports published by the American Association of Physicists in Medicine (AAPM)
    • Reports published by the National Council of Radiation Protection (NCRP)