Evolving practice in global healthcare: Remote physics support for low- and middle-income countries.

The COVID-19 pandemic has disrupted traditional onsite support for radiotherapy clinics in low- and middle-income countries (LMIC). Clinics there have struggled to commission new techniques and receive onsite training for their staff. We sought to evaluate whether an offsite approach could fill this gap at a clinic in Jordan by requesting a clinical audit and attempting to commission volumetric modulated arc therapy (VMAT). Over 13 months, a consultant provided remote support for a radiotherapy center that had already obtained treatment equipment and licenses. The consultant began by conducting a virtual audit, using a remote login to the center's R&V and TPS, to identify any gaps in the clinical workflow. Suggestions for improving the clinical workflow were proposed, and change implementation was tracked through emails, social media apps, and video conferencing. An extensive table outlined the commissioning process, including all measurements to be done. Social media apps and shared documents were used to track measurements and analysis. The lack of person-to-person interaction in this new remote-support ecosystem created conflicts; we have highlighted some of these, as well as their resolution and the lessons learned from them. The virtual audit identified gaps categorized as machine QA, treatment plan review, and treatment delivery processes. Following the implementation of the proposals, motion management was added, and machine QA became more comprehensive. VMAT was commissioned using the reports of the AAPM and the IAEA. The main challenges for remote support were time difference, establishing an appropriate form and frequency of communication, tone of voice used in messages, and buy-in from local staff. This evolving practice will enable medical physicists to use modern, multimodal remote communication pathways to effectively transfer knowledge to centers in LMICs. The audit-proposal-improvement pathway for remote support can be incorporated to help others while avoiding the pitfalls we faced.

A novel approach to infectious disease control and radiotherapy risk management.

BACKGROUND: Infectious disease outbreaks have always presented challenges to the operation of healthcare systems. In particular, the treatment of cancer patients within Radiation Oncology often cannot be delayed or compromised due to infection control measures. Therefore, there is a need for a strategic approach to simultaneously managing infection control and radiotherapy risks. PURPOSE: To develop a systematic risk management method that uses mathematical models to design mitigation efforts for control of an infectious disease outbreak, while ensuring safe delivery of radiotherapy. METHODS: A two-stage failure mode and effect analysis (FMEA) approach is proposed to modify radiotherapy workflow during an infectious disease outbreak. In stage 1, an Infection Control FMEA (IC-FMEA) is conducted, where risks are evaluated based on environmental parameters, clinical interactions, and modeling of infection risk. occupancy risk index (ORI) is defined as a metric for infection transmission risk level in each room, based on the degree of occupancy. ORI, in combination with ventilation rate per person (Rp ), is used to provide a broad infection risk assessment of workspaces. For detailed IC-FMEA of clinical processes, infection control failure mode (ICFM) is defined to be any instance of disease transmission within the clinic. Infection risk priority number (IRPN) has been formulated as a function of time, distance, and degree of protective measures. Infection control measures are then systematically integrated into the workflow. Since the workflow is perturbed by infection control measures, there is a possibility of introducing new radiotherapy failure modes or increased likelihood of existing failure modes. Therefore, in stage 2, a conventional radiotherapy FMEA (RT-FMEA) should be performed on the adjusted workflow. RESULTS: The COVID-19 pandemic was used to illustrate stage 1 IC-FMEA. ORI and Rp values were calculated for various workspaces within a clinic. A deep inspiration breath hold (DIBH) CT simulation was used as an example to demonstrate detailed IC-FMEA with ICFM identification and IRPN evaluation. A total of 90 ICFMs were identified in the DIBH simulation process. The calculated IRPN values were found to be progressively decreasing for workflows with minimal, moderate, and enhanced levels of protective measures. CONCLUSION: The framework developed in this work provides tools for radiotherapy clinics to systematically assess risk and adjust workflows during the evolving circumstances of any infectious disease outbreak.

Successful Development of a Competency-Based Residency Training Program in Radiation Oncology: Our 15-Year Experience from Within a Developing Country.

One of the main challenges of delivering high quality of care to cancer patients in developing countries is the lack of well-trained radiation oncologists. This is a direct cause for the lack of residency programs coupled with lack of resources. This article describes and details establishments of a successful and sustainable radiation-oncology residency program in our country. The program has been in operation for 14 years and has trained and graduated radiation oncologists who are now working in various countries. The curriculum of the 4-year residency program, fashioned according to American College of Radiologists (ACR) recommendations, includes site-specific clinical rotations and didactic lectures in clinical oncology, radiobiology, medical physics, statistics, and epidemiology. It also includes a component of advanced clinical experience in the form of 3-month externship at one of collaborating centers outside the country. Evaluation of the residents is conducted annually via written exams and 360° feedback. Residents also sit for the formal certification exam in radiation oncology from the national Medical Council. The exam consists of 2 written exams and one oral. As a form of benchmarking residents' knowledge, they are required to sit for the ACR examinations held annually and conducted in Amman in tandem. The program has successfully trained and graduated 28 residents, who now work as consultant radiation oncologists locally and abroad. Each resident has gone through a structured training that includes exposure to a Western-style patient-management culture, enhancing the breadth and width of their clinical experience. The residency program, initiated in a developing country, underwent many challenges, yet it overcome all obstacles and resulted in a successful training of competent radiation oncologists serving the region.

Board-certified specialty training program in radiation oncology in a war-torn country: Challenges, solutions and outcomes.

BACKGROUND: Residency programs leading to board certification are important for safe and competent Radiation Oncology (RO) practice. In some developing nations, there is a gap in this field. This work addresses the experience that was accomplished to establish such a program in Iraq despite all the challenges that faces a country under war. METHODS: Descriptive report of challenges faced in a developing country that is still reeling from war, the steps taken to overcome these challenges and outcomes after graduation of two classes. RESULTS: After over 18 months of prerequisite technical and logistical preparations, a group of local and external faculty members were invited to establish the required syllabus of a structured RO residency program in Iraq. It is comprised of a total of 100 post-graduate academic credits over a 48-months period after clinical internship. First year evaluations included regular practical assessments; seven in-house papers covering RO, cancer and radiation biology, medical physics, radiological anatomy and diagnostic oncology, tumor pathology, onco-pharmacology, and medical statistics, research methodology, and cancer epidemiology, followed by a comprehensive examination. Subsequent evaluations were on an annual bases with enrollment in the American College of Radiology In-Training examination in RO. Final assessment included logbook and skills' reviews, graduation thesis or peer-review publication, two-papers' written examination, and an exit practical examination. CONCLUSIONS: Given the political, economic and social difficulties in post-war Iraq, it was a major challenge to establish a residency program in RO. Despite the significant difficulties, the first residency program leading to board certification in RO was successfully started in Iraq. The new specialists will help in addressing the shortage of radiation oncologists in the country.

Commissioning of applicator-guided stereotactic body radiation therapy boost with high-dose-rate brachytherapy for advanced cervical cancer using radiochromic film dosimetry.

PURPOSE: To describe an EBT3 GAFCHROMIC film-based dosimetry method to be used in commissioning of a combined HDR brachytherapy (HDRB) and stereotactic body radiation therapy (SBRT) boost for treatment of advanced cervical cancer involving extensive residual disease after external beam treatment. METHODS AND MATERIALS: A cube phantom was designed to firmly fit an intrauterine tandem applicator and EBT3 radiochromic film pieces. A high-risk clinical target volume (CTVHR, Total) was contoured with an extended arm at one side. The HDRB treatment was planned to cover the proximal CTVHR, Total with 7 Gy and the distal volume, referred to as CTVHR, Distal, was planned by SBRT for dose augmentation. After HDRB treatment delivery, SBRT treatment was delivered within 1 hour by image guidance using the applicator geometry. Intentional 1D and 2D misalignments were introduced to evaluate the effect on target volumes. In addition, effect of film reirradiation at different time gaps and dose levels was evaluated. RESULTS: Film dosimetric accuracy, with up to 2 hours gap between irradiations, was shown to be unaffected. A 2%/2 mm gamma analysis between measured and planned doses showed agreement of >99%. Misalignments of more than 2 mm between applicator and SBRT isocenter resulted in suboptimal dose-volume histogram affecting mostly D98% and D90% of CTVHR, Distal. CONCLUSIONS: Visualizing how target dose-volume metrics are affected by minor misalignments between SBRT and HDRB dose gradients, in light of achievable phantom-based experimental quality assurance level, encourages the clinical applicability of this technique. Radiochromic film was shown to be a valuable tool to commission procedures combining two different treatment planning systems and modalities with varying dose rates and energy ranges.

Failure modes and effects analysis in image-guided high-dose-rate brachytherapy: Quality control optimization to reduce errors in treatment volume.

PURPOSE: Analyze the inputs which cause treatment to the wrong volume in high-dose-rate brachytherapy (HDRB), with emphasis on imaging role during implant, planning, and treatment verification. The end purpose is to compare our current practice to the findings of the study and apply changes where necessary. METHODS AND MATERIALS: Failure mode and effects analysis was used to study the failure pathways for treating the wrong volume in HDRB. The role of imaging and personnel was emphasized, and subcategories were formed. A quality assurance procedure is proposed for each high-scoring failure mode (FM). RESULTS: Forty FMs were found that lead to treating the wrong volume. Of these, 73% were human failures, 20% were machine failures, and 7% were procedural/guideline failures. The use of imaging was found to resolve 85% of the FMs. We also noted that imaging processes were under used in current practice of HDRB especially in pretreatment verification. Twelve FMs (30%) scored the highest, and for each one of them, we propose clinical/practical solutions that could be applied to reduce the risk by increasing detectability. CONCLUSIONS: This work resulted in two conclusions: the role of imaging in improving failure detection and the emphasized role of human-based failures. The majority of FMs are human failures, and imaging increased the ability to detect 85% of all FMs. We proposed quality assurance practices for each high-scoring FM and have implemented some of them in our own practice.

Practical steps for establishing ocular plaque therapy in developing countries.

INTRODUCTION: Retinoblastoma and uveal melanoma are the most common ocular tumors in children and adults, respectively. Enucleation and external beam radiation therapy are integral in the management of ocular tumors. However, these tumors could also be treated effectively by plaque therapy, which has the potential of preserving the globe and maintaining vision. METHODS AND MATERIALS: We reviewed our experience with the introduction of this technique to our center. Furthermore, we highlighted the critical role of a specialized multidisciplinary team in the successful implementation of this procedure. DISCUSSION: This review represents a detailed report addressing the practical steps for successfully establishing plaque therapy in developing countries. RESULTS: Plaque therapy was successfully implemented at our center in 1.5 years. Integration with an advanced cancer center is crucial for the correct transfer of this complex technology. CONCLUSION: Complex brachytherapy procedures could be successfully established and implemented in developing countries.

Effect of ethmoid sinus cavity on dose distribution at interface and how to correct for it: magnetic field with photon beams.

Recent work proposed the use of magnetic field as a solution to reduce the undesirable effect of air cavities on dose after the air/tissue interface. In contrast to the published work that looks into the problem with slab geometries, in this work we use actual anatomy based on CT images and the magnetic flux from a Helmholtz coil-pair configuration to investigate the problem and to evaluate the efficacy of the proposed solution. The EGS4 phantom was created using CT scans of the head at the level of the ethmoid sinus. The sinus measures 1.95 x 2.18 x 2.00 cm3. The grid size used is 0.15 x 0.15 x 0.4 cm3. Three different radiation beams, 1 x 1, 2 x 2, and 4 x 4 cm2, all 6 MV irradiate the phantom in two different configurations: single beam and parallel opposed. The magnetic field has three different strengths: 0.0, 0.5, and 1.0 T. These represent the maximum strength achieved in the middle of the configuration, between the two coils. The depth of the second buildup region in the absence of the magnetic field was used as the normalization point for the purpose of analysis. Dose was then scored at 0.23 cm after the air/tissue interface. A second phantom, very similar to the CT-based phantom, was created, but with the sinus cavity filled with unit-density tissue; everything else remained the same. This phantom provides a base to investigate the effect of the air cavity on dose. The phantom was termed the phantom without air, or PWA for short. We use the terms "dose reduction ratio" (DRR), defined as one minus the ratio of the dose in PWA to the dose with the presence of the cavity multiplied by 100% and the "dose improvement ratio" (DIR), defined as the ratio of dose with B to that without B, to evaluate the reduction in dose due to the cavity and the improvement in dose with magnetic field, respectively. For single beam geometry, the reduced dose ranged from 41% (1 x 1 cm2 beam) to less than 2% (4 x 4 cm2 beam). For the same single beam geometry, DIR ranged from 1.13 to 1.00 (DIR = 1 indicates no change) with 0.5 T, whereas it ranged from 1.44 to 1.05 for 1.0 T magnets. When an opposing beam was used, the reduced dose was not as severe, such that DRR ranged from 24% to less than 2%. Whereas the dose improvement ranged from 1.08 to 1.00 for 0.5 T, and from 1.23 to 1.01 for 1.0 T.