Articles for Our Patients ~ Dale Payne, R.T. and Bouchaib Rabbani, Ph.D.

Quality Matters in Radiation Therapy!

Author: Dale Payne, R.T. and Bouchaib Rabbani, Ph.D. • Language: ENG

Quality makes a difference not only in the cars we drive, the houses we live in, the clothes we wear or the airline we fly—but it matters in the health care we receive as well. How many of us really think about the quality of the health care services we receive? The idea of high quality health care services may cross our minds from time to time, but how are we as consumers to understand what is a high quality service? How are we to know what is just mediocre, or worse than that, out right dangerous?
Lately, there is increased interest in the safety of intensity modulated radiation treatments (IMRT) which some of you may have read about. Unlike having a bad chest x-ray that can simply be repeated with no ill affect, an incorrect radiation treatment can not be done over or taken back for a second chance. It is imperative that radiation treatments whether delivered by a linear accelerator or by using radioactive materials be as precise as is humanly and technologically possible.
Systems and processes must be in place to double and triple check treatment plans, calculations and the equipment used in Radiation Oncology. When these systems and processes are in place and followed by the entire Radiation Oncology Staff, they virtually eliminate errors and they will allow delivery of the highest quality radiation medicine to all patients. Our patients’ safety is paramount.
Another consideration before embarking on a course of radiation treatment is the age of the equipment or linear accelerator. There are no federal or state laws requiring the retirement of old linear accelerators, so it is not uncommon for freestanding centers to acquire linear accelerators that hospitals cast off years prior as outdated and not safe for patient care. While aged linear accelerators can be re-conditioned they are still old and will never provide the precise radiation treatments that new digital linear accelerators achieve. Some of the new technology can be retrofitted onto these old units, but again this “fix” is not in any way equal to the precision of a new linear accelerator. Nor will these old units have Image Guided Radiation Therapy (IGRT) capabilities to precisely place the radiation beams each day. It is required to use IGRT before each IMRT treatment. IGRT is the only means by which currently recommended high tumorcidal doses can be delivered using IMRT. Hospital based radiation centers are supported by the regular replacement of aging equipment allowing our patients the most precise care possible on the most technologically advanced equipment. Currently, we are installing a brand new and state of the art TomoTherapy HD accelerator that will go clinical in May 2010. This will complement our Trilogy accelerator purchased brand new in 2007. Would you rather receive your radiation treatments from a used 20 year old accelerator that someone paid $150,000 for their freestanding clinic or on a new $3,000,000 accelerator equipped with all the new technology that is hospital based? The BEST hospitals have the BEST technology.
The right experience and expertise mix of staff members on the Radiation Oncology Team is a key element to high quality care as well as quality control systems. Properly trained staff on new techniques and equipment from the therapists, the dosimetrists, the physicists and the physicians is imperative. Having qualified radiation medical physicists on sight at all times is key to maintaining a high quality radiation center. Radiation Oncology at The Robert & Beverly Lewis Family Cancer Care Center has Medical Radiation Physicists onsite everyday. One Medical Physicist is certified by the American Board of Radiology, has his Ph.D in the specialty of Medical Physics and over 20 years of clinical experience. The second Medical Physicist has an M.S. degree and is taking the American Board of Radiology certification in radiation therapy physics. Our patients’ safety is paramount.
Medical Radiation Physicists work together with the dosimetrists and therapists to ensure every aspect of radiation treatments is of the highest quality. As an example of their duties, before a patient receives an IMRT treatment a phantom made of tissue equivalent material representing the patient is irradiated on the treatment machine in place of a real patient. The phantom is constructed with special detectors and/or film that capture the radiation dose data. This data is then processed and compared to the computer generated treatment plan using two independent software programs. The physician and the physicist then collaboratively evaluate the results. State and federal agencies, in addition to national and international organizations, have set guidelines for acceptability of treatment plans, like IMRT. If the results are not within established limits, the planning process is restarted and retested. Patients do not receive a treatment until the plan tests meet the established limits. This may mean the patient will not start the treatment the day that had been set. But the treatment will NOT start until the physicist and physician are assured of the accuracy of the plan and sign off. Paying attention to the quality of radiation treatments makes a tremendous difference in outcome or results. Our patients’ safety is paramount.
The Medical Radiation Physicists also work closely with the equipment service engineers assuring that the CT scanner, (where the planningstarts) and the linear accelerators, (where treatment delivery occurs) are operating at peak performance and with-in manufacturer guidelines. They review all service calls and coordinate beam calibrations and mechanical checks as needed after service is completed and before treatments resume. Daily, weekly, monthly and annually the equipment undergoes safety checks and calibrations by our Medical Radiation Physicists. Our patients’ safety is paramount.
Additionally, as participants in the National Cancer Institute clinical trials program our IMRT planning techniques are evaluated on an ongoing basis to ensure we are correctly irradiating by their strict guidelines.
We also participate in the Radiologic Physics Center (RPC) at M.D. Anderson Cancer Institute beam evaluation program for all beams on our linear accelerators. Annually, since 1976 we irradiate special dosimeters and return them to RPC for evaluation. Our beam quality is consistently “right on.” Participation in both these high profile programs is voluntary and serves to further validate the high quality radiation medicine provided at The Robert & Beverly Lewis Family Cancer Care Center. Our patients’ safety is paramount.
Another area in radiation medicine that is receiving increased attention by the news media is the improper use of radioactive seeds in the treatment of various cancers. Over the past 15 years, our Radiation Oncologists have surgically implanted radioactive seeds into over 800 men for treatment of prostate cancer. The results of these implants exceed national averages for cancer control in the prostate. This is owing to a highly skilled and trained team of physicians, physicists, dosimetrists and therapists who participate in these surgical procedures. The physician of course is the technical expert and the one, who actually handles the implanting of the seeds into the patient, but a physicist and therapist always support him to ensure every step of the process is accurate. The therapist assists with the ultrasound imaging of the prostate while the physicist is responsible to generate the dosimetry or optimal pattern to implant the seeds. The physicist is also responsible for pre-implant seed calibration. This is a step that many places performing these implants, skip, but that we believe is essential. We independently, apart from the manufacturer, double-check the activity or strength of the seeds to ensure we received the dose that the physician ordered. Just looking at these tiny (4mm x 1mm) seeds with the naked eye one cannot tell the activity. Only by using special radiation “well counters” can we determine that the seed strength is correct and safe to use as the physician intends. Again, patient safety is paramount.
How are we as consumers to know what is high quality radiation medicine? If you have the option, make sure you receive your treatments in a Joint Commission (formally known as Joint Commission for the Accreditation of Health Care Organizations or JACHO) accredited facility. Joint Commission (JC) accredited organizations are routinely reviewed for adherence to strict guidelines governing every aspect of the organization from personnel to the equipment, to the buildings to direct patient care practices. Radiation treatment centers that are not hospital based are not accredited by JC or any organization. They have a business operating license that is all! Should we trust our radiation care needs to places that do not comply with the National Patient Safety Standards that hospital based facilities follow? Should we trust our radiation care needs to places that are not JC accredited? Should we trust our radiation care needs to places that do not have the right experts on hand at all times? Should we trust our radiation care needs to places that are not 100% staffed with board certified professionals? Should we trust our radiation care needs to old and outdated or poorly maintained equipment? Our patients’ safety is paramount.
Quality does matter in all aspects of our lives including health care.More importantly it does matter with radiation treatments of all types as there is no second chance to get it right. Ask questions—make sure your questions about quality and processes are answered. If you are not happy with those answers, then go somewhere else for your radiation care. The quality of your health care is more important than the car, house or clothing that you buy so spend some time considering the facts before you “buy.” Once again, our patients’ safety is paramount.
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