May 1

Michael May

Safety Essay

10/7/2017

The safety of radiotherapy treatments has been criticized and questioned in the recent
past. Several articles published in the New York Times highlight errors and mistreatments that
have occurred in radiation oncology departments in the past.1,2,3 Errors like these are rare and
typically occur due to negligence or failures in safety processes. As a medical dosimetrist, there
are many things that I can do to ensure the continuity of safety throughout the radiotherapy
planning and treatment process.

A medical dosimetrist's job, depending on the department, can start at the initial CT
simulation. It will then carry through to organ contouring, treatment planning, treatment
calculation, obtaining physics and physician approvals, and then prepping and sending the plan
to the treatment machine. In some cases, dosimetrists may even be responsible for plan quality
assurance (QA) checks.

A recent publication from Fogh et al,4 highlights that there are varying attitudes regarding
safety and responsibility in a radiation oncology department. As a dosimetrist, I find this slightly
disturbing. It does however emphasize the importance of what I can do to make sure that safe
practices carry through from simulation all the way to treatment. I think that it is too difficult to
limit this discussion to two things that a dosimetrist can do to improve safety. Safety, in my
opinion, is linked to good processes, practices and habits.

When I am assigned my patients for the day, I start by viewing prior CT, MRI, and
PET/CT studies. I view prescriptions, patient histologys, and prior treatments if necessary.
This helps me to consider simulation needs, potential difficulties, and identify questions for
clarification. I can then communicate with the radiation therapists performing the simulation
regarding special needs and considerations. Ensuring that a patient gets a great simulation helps
to preemptively fix potential problems later in the process that may result in a less than ideal
treatment plan, a treatment plan that is hard to reproduce, a treatment plan that is unsafe due to
lack of adequate immobilization, or the need for a potential re-simulation.
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During the contouring process, I have the opportunity to review physician volumes for
accuracy or potential issues, such as overlap with a critical organ at risk (OR). At this stage it is
very important to create accurate contours so that optimization and dose reporting are accurate at
later stages in the process. Creation of special structures to assist in optimization or planning
often help reduce dose to OR and improve the coverage of the target volume. I also find that the
contouring phase provides a lot of time to critically analyze the patients anatomy, positioning,
and target volumes to devise your approach to the treatment plan.

Treatment planning requires a lot of thought prior to initiation. Will the geometry of the
plan cause collision issues? Is it reproducible? Is it time effective or can I get an equivalent plan
and make it faster or easier for the therapists? Is it cost effective for the patient? One of the
things that dosimetrists often overlook is the possibility of creating an equivalent plan using less
monitor units (MU). I recently learned about fluence editing and was shocked by the amount of
monitor units that could be reduced and still have an identical plan. I feel that being a
dosimetrist requires a great deal of integrity, exhausting all options in order to find the absolute
best approach to each plan can be time consuming but is crucial to the patient. If I were in those
shoes, I would want the time spent on me. Thoroughly evaluating your plans prior to showing
them to a physicist and physician is also very crucial to identifying potential issues.

When presenting a plan, it is important to highlight the good and bad of every plan. This
shows that you are actively thinking about all aspects of a plan and forces the physician to
evaluate the good and bad as well. This way a physician can make the most informed decisions
that they can. I am often surprised by what a physician is considering when evaluating a plan
because it varies so much from patient to patient. At this point, a dosimetrist should not be afraid
to step back and reevaluate what they have done. If new information changes how you would
approach a plan, I believe that the plan should be altered to accommodate those considerations if
necessary.

After all of that consideration and work, you would think that a dosimetrists role in
safety may be done but in reality it is far from it. I think some of the most important safety
considerations are addressed after planning is complete. Besides performing secondary MU
calculations, there is a lot of communication that needs to take place.
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At the facility I am training at, the treatment planning system (TPS) and record and verify
system are integrated pretty well. Some important considerations are related to what the
therapists use to treat the patient though. I start off by creating setup fields that the therapists use
for image guidance. I label fields in a way that they make sense for the therapists, or would
make a therapist think twice if it didnt sound correct. I create a journal note that details setup
notes, table shifts for positioning, SSD, and special notes regarding the use of bolus, rigid
alignment instructions, or important aspects relating to the patient treatment. I set dose limits to
reference points, back up times, and upload important documents.

The paper, Safety is No Accident, lists a dosimetrist role in safety as reviewing a

planning directive, reviewing treatment volumes and prescriptions, treatment plan quality, and
final plan checks.5 I believe that a dosimetrists role is so much more. I have the opportunity to
effect safety from start to finish in the radiotherapy process. I take that responsibility very
serious and encourage my teammates to do so as well.
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References

1. Bogdanich W. Radiation offers new cures, and a way to do harm. The New York Times.
January 23, 2010.
2. Radiation therapys harmful side. The New York Times. January 27,2010.
3. Bogdanich W. Medical group urges new rules on radiation. The New York Times.
February 4, 2010.
4. Fogh S, Braunstein S, Lazar A, Morin O. Variability in safety attitudes across groups in
radiation oncology. Int J of Rad Oncol Bio Phys. 2015;93(3):E502.
http://dx.doi.org/10.1016/j.ijrobp.2015.07.1830.
5. Fraass B, Palta J, Cagle S et al. Management and Assurance of Quality in Radiation
Oncology. Safety is no Accident. American Society for Radiation Oncology. 2012.