Total body irradiation delivered using a dedicated Co-60 TBI unit: Evaluation of dosimetric uniformity and dose verification.

This work presents the dosimetric characteristics of Total Body Irradiation (TBI) delivered using a dedicated Co-60 TBI unit. We demonstrate the ability to deliver a uniform dose to the entire patient without the need for a beam spoiler or patient-specific compensation. Full dose distributions are calculated using an in-house Monte Carlo treatment planning system, and cumulative dose distributions are created by deforming the dose distributions within two different patient orientations. Sample dose distributions and profiles are provided to illustrate the plan characteristics, and dose and DVH statistics are provided for a heterogeneous cohort of patients. The patient cohort includes adult and pediatric patients with a range of 132-198 cm in length and 16.5-37.5 cm in anterior-posterior thickness. With the exception of the lungs, a uniform dose of 12 Gy is delivered to the patient with nearly the entire volume receiving a dose within 10% of the prescription dose. Mean lung doses (MLDs) are maintained below the estimated threshold for radiation pneumonitis, with MLDs ranging from 7.3 to 9.3 Gy (estimated equivalent dose in 2 Gy fractions (EQD2 ) of 6.2-8.5 Gy). Dose uniformity is demonstrated across five anatomical locations within the patient for which mean doses are all within 3.1% of the prescription dose. In-vivo dosimetry demonstrates excellent agreement between measured and calculated doses, with 78% of measurements within ±5% of the calculated dose and 99% within ±10%. These results demonstrate a state-of-the-art TBI planning and delivery system using a dedicated TBI unit and hybrid in-house and commercial planning techniques which provide comprehensive dosimetric data for TBI treatment plans that are accurately verified using in-vivo dosimetry.

AAPM Report 373: The content, structure, and value of the Professional Doctorate in Medical Physics (DMP).

The Professional Doctorate in Medical Physics (DMP) was originally conceived as a solution to the shortage of medical physics residency training positions. While this shortage has now been largely satisfied through conventional residency training positions, the DMP has expanded to multiple institutions and grown into an educational pathway that provides specialized clinical training and extends well beyond the creation of additional training spots. As such, it is important to reevaluate the purpose and the value of the DMP. Additionally, it is important to outline the defining characteristics of the DMP to assure that all existing and future programs provide this anticipated value. Since the formation and subsequent accreditation of the first DMP program in 2009-2010, four additional programs have been created and accredited. However, no guidelines have yet been recommended by the American Association of Physicists in Medicine. CAMPEP accreditation of these programs has thus far been based only on the respective graduate and residency program standards. This allows the development and operation of DMP programs which contain only the requisite Master of Science (MS) coursework and a 2-year clinical training program. Since the MS plus 2-year residency pathway already exists, this form of DMP does not provide added value, and one may question why this existing pathway should be considered a doctorate. Not only do we, as a profession, need to outline the defining characteristics of the DMP, we need to carefully evaluate the potential advantages and disadvantages of this pathway within our education and training infrastructure. The aims of this report from the Working Group on the Professional Doctorate Degree for Medical Physicists (WGPDMP) are to (1) describe the current state of the DMP within the profession, (2) make recommendations on the structure and content of the DMP for existing and new DMP programs, and (3) evaluate the value of the DMP to the profession of medical physics.

AAPM Task Group 298: Recommendations on certificate program/alternative pathway candidate education and training.

Entry into the field of clinical medical physics is most commonly accomplished through the completion of a Commission on Accreditation of Medical Physics Educational Programs (CAMPEP)-accredited graduate and residency program. To allow a mechanism to bring valuable expertise from other disciplines into clinical practice in medical physics, an "alternative pathway" approach was also established. To ensure those trainees who have completed a doctoral degree in physics or a related discipline have the appropriate background and didactic training in medical physics, certificate programs and a CAMPEP-accreditation process for these programs were initiated. However, medical physics-specific didactic, research, and clinical exposure of those entering medical physics residencies from these certificate programs is often comparatively modest when evaluated against individuals holding Master's and/or Doctoral degrees in CAMPEP-accredited graduate programs. In 2016, the AAPM approved the formation of Task Group (TG) 298, "Alternative Pathway Candidate Education and Training." The TG was charged with reviewing previous published recommendations for alternative pathway candidates and developing recommendations on the appropriate education and training of these candidates. This manuscript is a summary of the AAPM TG 298 report.

MVCT versus kV-CBCT for targets subject to respiratory motion: A phantom study.

The use of kilovoltage cone-beam computed tomography (kV-CBCT) or megavoltage computed tomography (MVCT) for image guidance prior to lung stereotactic body radiation therapy (SBRT) is common clinical practice. We demonstrate that under equivalent respiratory conditions, image guidance using both kV-CBCT and MVCT may result in the inadequate estimation of the range of target motion under free-breathing (FB) conditions when standard low-density window and levels are used. Two spherical targets within a respiratory motion phantom were imaged using both long-exhale (LE) and sinusoidal respiratory traces. MVCT and kV-CBCT images were acquired and evaluated for peak-to-peak amplitudes of 10 or 20 mm in the cranial-caudal direction, and with 2, 4 or 5 s periods. All images were visually inspected for artifacts and conformity to the ITV for each amplitude, period, trace-type, and target size. All LE respiratory traces required a lower threshold HU window for MVCT and kV-CBCT compared to sinusoidal traces to obtain 100% volume conformity compared with the theoretical ITV (ITVT ). Excess volume was less than 2% for all kV-CBCT contours regardless of trace-type, breathing period, or amplitude, while the maximum excess volume for MVCT was 48%. Adjusting window and level to maximize conformity with the ITVT is necessary to reduce registration uncertainty to less than 5 mm. To fully capture target motion with either MVCT or kV-CBCT, substantial changes in HU levels up to -600 HU are required which may not be feasible clinically depending on the target's location and surrounding tissue contrast. This registration method, utilizing a substantially decreased window and level compared to standard low-density settings, was retrospectively compared to the automated registration algorithm for five lung SBRT patients exposed to pre-treatment kV-CBCT image guidance. Differences in registrations in the super-inferior (SI) direction greater than the commonly used ITV to PTV margin of 5 mm were encountered for several cases. In conclusion, pre-treatment image guidance for lung SBRT targets using MVCT or kV-CBCT is unlikely to capture the full extent of target motion as defined by the ITVT and additional caution is warranted to avoid registration errors for small targets and patients with LE respiratory traces.

The MedPhys match survey: Search criteria and advice for programs and applicants.

PURPOSE: The purpose of this study was to gauge the experiences of applicants and program directors (PDs) in the Medical Physics (MedPhys) Match (MPM) and to determine the most important characteristics and factors that influence decision-making for applicants and programs when screening, interviewing, and ranking in the MPM. Opinions were also solicited from applicants and PDs on the status of medical physics residencies and the selection process, such as the availability of residency positions and satisfaction with the match process. METHODS: A survey was sent to all applicants registered for the 2015-2018 MPM and to all PDs registered for the 2015-2017 MPM. Survey questions asked about the pre-interview screening, interview, and ranking stages of the residency match process. Survey data were analyzed using graphical methods and spreadsheet tools. RESULTS: An increasing percentage of applicants are female and/or hold a PhD as their highest degree. The over all number of interview invitations per applicant has increased, leading some applicants to decline interviews with the top reasons being cost of travel and scheduling conflicts. The top considerations for applicants in ranking programs were residency program/institution reputation, program structure/organization, and facilities/equipment available. The primary considerations identified by PDs for ranking applicants included impressions from the interview, personality fit, and clinical potential. While two-thirds of applicants agreed or strongly agreed with the statement that a residency position was difficult to obtain, roughly one-third of PDs agree that the current residency placement rate is a problem. CONCLUSION: Four years of survey data on the experiences of applicants and PDs participating in the MPM is useful to future participants navigating the residency match system. It is hoped that the data will be helpful to inform improvements and to enhance understanding of the residency match system and how it shapes our profession.

Ethical violations and discriminatory behavior in the MedPhys Match.

PURPOSE: The purpose of this survey study is to investigate behaviors in conflict with the ethical standards of the Medical Physics Residency (MedPhys) Match (MPM) process as stated in the MPM rules (a) and with the nondiscrimination regulations of the Equal Employment Opportunity Commission (EEOC) (b), in addition to other behaviors that may in other ways erode the fairness of the system. METHODS: A survey was sent to all applicants and program directors registered for the 2015 and 2016 MPM. Survey questions asked about application, interview, and postinterview experiences, match results, and overall satisfaction with the process. RESULTS: Thirteen percent of 2015 respondents and 20% of 2016 respondents were asked by at least one program how highly they planned to rank them or which program they would rank first. Thirty-seven percent of 2015 and 40% of 2016 program directors indicated that candidates communicated to the program their rank intent, with 22.0% in 2015 and 12.5% in 2016 being told that their program would be ranked first. Twenty-three percent of 2015 respondents indicated being asked by at least one program during the interview about children or plans to have children; including 19% of males and 33% of females. In 2016, these values were 28% overall, 22% male, and 36% female. Fifty-seven percent of 2015 respondents who were asked this question indicated being uncomfortable or very uncomfortable answering, including 27.3% of males and 88.9% of females. In 2016, 42.9% of all respondents indicated being uncomfortable or very uncomfortable answering, including 10.0% of males and 80.0% of females. CONCLUSIONS: In the first two years of the MPM, there were widespread instances of ethical violations and discriminatory questioning during the interview process. Educating both interviewers and candidates on the MPM rules and general EEOC guidelines should decrease these instances and increase the fairness of the residency selection process.

Essentials and guidelines for clinical medical physics residency training programs: executive summary of AAPM Report Number 249.

There is a clear need for established standards for medical physics residency training. The complexity of techniques in imaging, nuclear medicine, and radiation oncology continues to increase with each passing year. It is therefore imperative that training requirements and competencies are routinely reviewed and updated to reflect the changing environment in hospitals and clinics across the country. In 2010, the AAPM Work Group on Periodic Review of Medical Physics Residency Training was formed and charged with updating AAPM Report Number 90. This work group includes AAPM members with extensive experience in clinical, professional, and educational aspects of medical physics. The resulting report, AAPM Report Number 249, concentrates on the clinical and professional knowledge needed to function independently as a practicing medical physicist in the areas of radiation oncology, imaging, and nuclear medicine, and constitutes a revision to AAPM Report Number 90. This manuscript presents an executive summary of AAPM Report Number 249.

Proton versus photon radiation therapy: A clinical review.

While proton radiation therapy offers substantially better dose distribution characteristics than photon radiation therapy in certain clinical applications, data demonstrating a quantifiable clinical advantage is still needed for many treatment sites. Unfortunately, the number of patients treated with proton radiation therapy is still comparatively small, in some part due to the lack of evidence of clear benefits over lower-cost photon-based treatments. This review is designed to present the comparative clinical outcomes between proton and photon therapies, and to provide an overview of the current state of knowledge regarding the effectiveness of proton radiation therapy.

AAPM Task Group Report 306: Quality control and assurance for tomotherapy: An update to Task Group Report 148.

Since the publication of AAPM Task Group (TG) 148 on quality assurance (QA) for helical tomotherapy, there have been many new developments on the tomotherapy platform involving treatment delivery, on-board imaging options, motion management, and treatment planning systems (TPSs). In response to a need for guidance on quality control (QC) and QA for these technologies, the AAPM Therapy Physics Committee commissioned TG 306 to review these changes and make recommendations related to these technology updates. The specific objectives of this TG were (1) to update, as needed, recommendations on tolerance limits, frequencies and QC/QA testing methodology in TG 148, (2) address the commissioning and necessary QA checks, as a supplement to Medical Physics Practice Guidelines (MPPG) with respect to tomotherapy TPS and (3) to provide risk-based recommendations on the new technology implemented clinically and treatment delivery workflow. Detailed recommendations on QA tests and their tolerance levels are provided for dynamic jaws, binary multileaf collimators, and Synchrony motion management. A subset of TPS commissioning and QA checks in MPPG 5.a. applicable to tomotherapy are recommended. In addition, failure mode and effects analysis has been conducted among TG members to obtain multi-institutional analysis on tomotherapy-related failure modes and their effect ranking.

Development of a United States Radiation Oncology Curricular Framework: A Stakeholder Delphi Consensus.

PURPOSE: A United States (US) radiation oncology curriculum, developed using best practices for curriculum inquiry, is needed to guide residency education and qualifying examinations. Competency-based training, including entrustable professional activities (EPAs), provides an outcomes-based approach to modern graduate medical education. This study aimed to define US radiation oncology EPAs and curricular content domains using a deliberative process with input from multiple stakeholder groups. METHODS AND MATERIALS: The Radiation Oncology Education Collaborative Study Group Core Curriculum Project Leadership Committee developed initial content domains and EPAs. Following recruitment of stakeholders, a Delphi process was used to achieve consensus. In the first round, content domains and EPAs were reviewed for inclusion and exclusion, clarity, time allocation (content domains), and level of training (EPAs). Participants submitted additional content domains and EPAs for consideration. Any content domains or EPAs 1 standard deviation below the median for inclusion and exclusion underwent Leadership Committee review. All participants completing the first Delphi round were invited to the second round. Percent curriculum time allocated for content domains and a single subdomain were finalized. New EPAs or EPAs undergoing major revisions were reviewed. RESULTS: A total of 186 participants representing diverse stakeholder groups participated. One hundred fourteen completed the first Delphi round (61.3%). Of 114 invited, 77 participants completed the second round of the Delphi process (67.5%). Overall, 6 of 9 content domains met consensus, 1 content domain was removed, and 2 content domains were combined. Four subdomains of a single content domain were reviewed and met consensus. Consensus on percent time allocated per content domain and subdomain was reached. Of 55 initial EPAs, 52 final EPAs met consensus. CONCLUSIONS: Deliberative curriculum inquiry was successfully used to develop a consensus on US radiation oncology content domains and EPAs. These data can guide the allocation of educational time in training programs, help inform weighting for qualifying examinations, and help guide clinical training and resident assessment.

Interprofessional Image Verification Workshop for Physician and Physics Residents: A Multi-Institutional Experience.

PURPOSE: Verification of patient position through pretreatment setup imaging is crucial in modern radiation therapy. As treatment complexity increases and technology evolves, physicist-physician collaboration becomes imperative for safe and successful radiation delivery. Despite the importance of both, residency programs lack formal interprofessional education (IPE) activities or structured training for image verification. Here we show the impact of an interprofessional image verification workshop for residents in a multi-institutional setting. METHODS: The workshop included a lecture by the attending physicist and physician, and hands-on image registration practice by learners (medical physics residents, MP; and radiation oncology residents, RO). All participants filled out pre- and postactivity surveys and rated their comfort from 1 to 10 in (A) selecting what type of imaging to order for a given case and (B) independently assessing the setup quality based on imaging. A paired 1-tailed t test (α = 0.05) was used to evaluate significance; Spearman rank correlation coefficient was used to assess correlation of ratings and RO postgraduate year (PGY). Surveys had free-response questions about IPE and image verification activities in residency. RESULTS: A total of 71 residents from 7 institutions participated between 2018 and 2020. Pre- and postsurveys were completed by 50 residents (38RO, 12MP) and showed an increase in (A) from 5.5 ± 2.2 to 7.1 ± 1.6 (P < .001) and in (B) from 5.1 ± 2.3 to 6.8 ± 1.5 (P < .001), with significant increases per subgroup (AΔ, RO = 1.8 ± 1.7, P < .001; BΔ, RO = 1.9 ± 1.8, P <. 001; AΔ, MP = 1.1 ± 1.4, P = .012; BΔ, MP = 1.2 ± 1.6, P = .016). RO confidence scores moderately correlated with PGY. Survey responses indicated that image verification training is mostly unstructured, with extent of exposure varying by program and attending; most with little-to-no training. Time constraints were identified as the main barrier. IPE was noted as a useful way to incorporate different perspectives into the process. CONCLUSIONS: Formal image verification training increases resident comfort with setup imaging review and provides opportunities for interprofessional collaboration in radiation oncology residency programs.

Recommended ethics curriculum for medical physics graduate and residency programs: report of Task Group 159.

The AAPM Professional Council approved the formation of a task group in 2007, whose purpose is to develop recommendations for an ethics curriculum for medical physics graduate and residency programs. Existing program's ethics curricula range in scope and content considerably. It is desirable to have a more uniform baseline curriculum for all programs. Recommended subjects areas, suggested ethics references, and a sample curriculum are included. This report recommends a reasonable ethics course time to be 15-30 h while allowing each program the flexibility to design their course.

Final Report from IBPRO: Impact of Multidisciplinary Collaboration on Research in Radiation Oncology.

An important hallmark of the field of radiation oncology has traditionally been multidisciplinary collaboration among its clinicians and scientists. Increased specialization, resulting from increased complexity, threatens to diminish this important characteristic. This article evaluates the success of a short-term educational environment developed specifically to enhance multidisciplinary collaboration. This NIH-funded educational course, named "Integration of Biology and Physics into Radiation Oncology (IBPRO)," was developed at Wayne State University, and designed to facilitate engagement among radiation oncologists, medical physicists and radiobiologists in activities that foster collaborative investigation. The question we address here is, "Did it work?" The 240 clinicians and researchers participating in IBPRO over the five years of the course were surveyed to quantify its effectiveness. In total, 95 respondents identified 45 institutional protocols, 52 research grant applications (19 of which have been funded thus far), 94 research manuscripts and 106 research presentations as being attributable to participation in IBPRO. The majority (66%) of respondents reported generating at least one of these research metrics attributable to participation in IBPRO, and these participants reported an average of nearly five such quantitative research metrics per respondent. This represents a remarkable contribution to radiation oncology research within a relatively short period through an intervention involving a relatively small number of radiation oncology professionals. Nearly two thirds of respondents reported ongoing collaborative working relationships generated by IBPRO. In addition, approximately 50% of respondents stated that specific information presented at IBPRO changed the way they practice, and 95% of respondents practicing in a clinical setting stated that, since participation in IBPRO, they have approached clinical dilemmas more collaboratively. Many collaborative working relationships generated by this course continue to actively drive research productivity. Additionally, one of the many enduring legacies of this course is the creation of a new debate series in a professional journal. IBPRO serves as a model for our ability to leverage collaborative learning in an educational intervention to foster multidisciplinary clinical and research collaboration. It has already had a profound impact on the profession of radiation oncology, and this impact can be anticipated to increase in the future.

Targeted Needs Assessment of Treatment Planning Education for United States Radiation Oncology Residents.

PURPOSE: Prior surveys suggest almost one-third of chief residents report insufficient exposure to treatment planning. We evaluated the state of treatment planning education among United States residents. METHODS AND MATERIALS: A web-based survey was sent to current residents identified using the Association of Residents in Radiation Oncology directory. RESULTS: The response rate was 33%. Twenty-six percent of residents reported a mandatory treatment planning rotation. Seventy-one percent of residents reported reviewing ≤50% of plans with an attending. Twenty-three percent of respondents were not at all or only slightly comfortable (1 or 2 on a 1-5 scale) evaluating treatment plans. Residents with mandatory treatment planning rotations were more comfortable evaluating plans compared with those without mandatory rotations (P = .045). Overall, 60% reported insufficient exposure to treatment planning. Among postgraduate year 5 residents, this rate was 52%. Ninety-two percent of residents expressed interest in free supplemental treatment planning resources. CONCLUSIONS: A significant proportion of residents surveyed report insufficient exposure to treatment planning. Development of a practical treatment planning curriculum would offer the opportunity to improve resident education, and ultimately quality of care, at the national level.

IMRT commissioning: multiple institution planning and dosimetry comparisons, a report from AAPM Task Group 119.

AAPM Task Group 119 has produced quantitative confidence limits as baseline expectation values for IMRT commissioning. A set of test cases was developed to assess the overall accuracy of planning and delivery of IMRT treatments. Each test uses contours of targets and avoidance structures drawn within rectangular phantoms. These tests were planned, delivered, measured, and analyzed by nine facilities using a variety of IMRT planning and delivery systems. Each facility had passed the Radiological Physics Center credentialing tests for IMRT. The agreement between the planned and measured doses was determined using ion chamber dosimetry in high and low dose regions, film dosimetry on coronal planes in the phantom with all fields delivered, and planar dosimetry for each field measured perpendicular to the central axis. The planar dose distributions were assessed using gamma criteria of 3%/3 mm. The mean values and standard deviations were used to develop confidence limits for the test results using the concept confidence limit = /mean/ + 1.96sigma. Other facilities can use the test protocol and results as a basis for comparison to this group. Locally derived confidence limits that substantially exceed these baseline values may indicate the need for improved IMRT commissioning.

Miniaturized phased-array ultrasound and photoacoustic endoscopic imaging system.

Visualization and detection of early-stage gynecological malignancies represents a challenge for imaging due to limiting factors including tissue accessibility, device ease of use, and accuracy of imaging modalities. In this work, we introduce a miniaturized phased-array ultrasound and photoacoustic endoscopic probe which is capable of providing structural, functional, and molecular data for the characterization of gynecologic disease. The proposed probe consists of a 64-element ultrasound phased-array transducer coupled to a fiber-optic light delivery system for co-registered ultrasound and photoacoustic imaging. The fabricated US and PA imaging endoscope's diameter is 7.5 mm, allowing for potential passage through the cervical canal and thus an intimate contact with gynecological tissues such as the cervical canal and uterus. The developed endoscopic probe was tested and characterized in a set of tissue-mimicking phantoms. US and PA resolutions were measured experimentally using 200 µm diameter wires, resulting in apparent axial and lateral diameters of 289 µm and 299 µm for US, and 308 µm and 378 µm for PA, respectively. The probe's abilities to operate in both discrete and integrated illumination/acquisition were tested in gelatin phantoms with embedded optical absorbers with the results demonstrating the ability to acquire volumetric dual-modal US and PA images.

Improving Research in Radiation Oncology through Interdisciplinary Collaboration.

The contribution of radiation oncology to the future of cancer treatment depends significantly on our continued clinical progress and future research advancements. Such progress relies on multidisciplinary collaboration among radiation oncologists, medical physicists and radiobiologists. Cultivating collaborative educational and research opportunities among these three disciplines and further investing in the infrastructure used to train both clinicians and researchers will therefore help us improve the future of cancer care. This article evaluates the success of a short-term educational environment to foster multidisciplinary collaboration. The NIH-funded educational course developed at Wayne State University, called "Integration of Biology and Physics into Radiation Oncology" (IBPRO), was designed to facilitate the engagement of radiation oncologists, medical physicists and radiobiologists in activities that enhance collaborative investigation. Having now been delivered to nearly 200 participants over the past four years, the relative success of IBPRO in fostering productive interdisciplinary collaboration and producing tangible research outcomes can be evaluated. The 140 IBPRO participants from the first three years were surveyed to quantify the effectiveness of the course. In total, 62 respondents reported developing 23 institutional protocols, submitting more than 25 research grants (nine of which have been funded thus far), and publishing more than 30 research manuscripts attributable to participation in IBPRO. Nearly one-half (45%) of respondents reported generating at least one of these research metrics attributable to participation in IBPRO and these participants reported an average of over four such quantitative research metrics per respondent. This represents a very substantial contribution to radiation oncology research by a relatively small number of researchers within a relatively short time. Nearly one-half of respondents reported ongoing collaborative working relationships generated by IBPRO. In addition, approximately one-half of respondents stated that specific information presented at IBPRO changed the way they practice, and over 80% of respondents practicing in a clinical setting stated that, since participation in IBPRO, they have approached clinical dilemmas more collaboratively. We believe that educational opportunities such as IBPRO can have a significant impact on interdisciplinary collaborative research. In addition, such interventions have the ability to effect significant clinical change. Both of these should have a positive impact on future advancements in radiation oncology and affect the future contribution of radiation oncology to the treatment of cancer.

IBPRO - A Novel Short-Duration Teaching Course in Advanced Physics and Biology Underlying Cancer Radiotherapy.

This article provides a summary and status report of the ongoing advanced education program IBPRO - Integrated course in Biology and Physics of Radiation Oncology. IBPRO is a five-year program funded by NCI. It addresses the recognized deficiency in the number of mentors available who have the required knowledge and skill to provide the teaching and training that is required for future radiation oncologists and researchers in radiation sciences. Each year, IBPRO brings together 50 attendees typically at assistant professor level and upwards, who are already qualified/certified radiation oncologists, medical physicists or biologists. These attendees receive keynote lectures and activities based on active learning strategies, merging together the clinical, biological and physics underpinnings of radiation oncology, at the forefront of the field. This experience is aimed at increasing collaborations, raising the level and amount of basic and applied research undertaken in radiation oncology, and enabling attendees to confidently become involved in the future teaching and training of researchers and radiation oncologists.