Radiation Oncology Enters the Digital Age

Radiation oncology has fairly unique and sophisticated image and information management needs. Imaging is the focal point in radiation oncology. "Imaging is probably the most important first step in the practice of radiation oncology," says Morris Geffen, MD, medical director of Savannah Oncology in Savannah, Ga.

As radiation therapy becomes an increasingly precise practice with IMRT (intensity modulated radiation therapy) and IGRT (image guided radiation therapy), image datasets are booming. The field has transitioned from treatment planning based on plain films to CT-based planning to fused CT and MRI planning to fused PET, CT and MRI image-based planning. Sasa Mutic, MS, associate professor of radiation oncology at Washington University School of Medicine in St. Louis, confirms, "Until three or four years ago, treatment planning systems could handle more data than a CT scanner could produce." Not anymore. Dynamic CT scans for capturing organ motion can produce up to 7,000 low resolution images per patient, and use of data-intense multi-modality imaging such as PET-CT continues to spread.

The result? Radiation oncology providers, particularly those that offer newer treatment options like IMRT and IGRT, need to implement solutions that allow them to store, recall and compare more

and larger image datasets. Sites that have deployed digital solutions report a number of benefits. "There's clearly a time savings going into the digital age. With digital technology, we can provide more precise treatment in the same 10- to 15-minute time slot," says Geffen.

In addition to enhancing patient care by enabling better treatments, digital image solutions also can serve as multipurpose workflow boosters. For example, some incorporate electronic charting features that allow physicians to shave off up to an hour of daily charting.

On the other hand, some sites are still looking for an ideal solution to meet their radiation oncology image and data management needs. Unlike the practice of diagnostic radiology, which primarily depends on images, radiation oncology relies on both images and data such as radiation dose distribution plans, contours and treatment plans. This dual focus can complicate radiation oncology image and information management. Most digital solutions are designed to streamline image management processes with data management serving as a secondary or tertiary focus. Thus the image management solution may not provide comprehensive storage and management of radiation oncology data like treatment plans.


Inside the state-of-the-art radiology oncology facility

Oncology Alliance (Milwaukee, Wis.) opened as a new oncology practice two years ago. "It made sense from a cost-benefit point of view to open as a digital site," explains Perry Gould, MD, radiation oncologist with Oncology Alliance. Oncology Alliance relies on Impac Medical System Inc.'s ViewStation to meet its image transfer, manipulation and storage needs.

Gould reports a number of workflow benefits. "This system makes it easy to read port films; I can read 20 ports in five minutes," states Gould. ViewStation stores images on a server and transfers requested images with one button click. According to Gould, some software can make the port film review process more cumbersome by pulling up all patient images, forcing the radiation oncologist to search through multiple images for the single required image.

On the dosimetry side of the equation, ViewStation's electronic record and verify features reduce the amount of manual labor to complete a treatment plan by electronically sending treatment parameters from the planning computer to the linear accelerator control center.

Other features complement the streamlined image management processes. "I've set up templates for weekly management notes and charting," says Gould. "The result is more consistent, thorough and faster charting." Gould fills in templates while he is in the room with the patient, eliminating the dictation process entirely. He estimates that electronic charting easily saves an hour a day over traditional dictation processes.

On the downside, the system does not store treatment plans. Oncology Alliance overcomes this hurdle by printing treatment plans and dose data; however, the practice's IT staff is working on an IT solution to allow digital storage of treatment plans.


The large scale solution

The Tom Baker Cancer Centre in Calgary, Alberta, is a comprehensive tertiary cancer center that houses a large radiation services program. Nine radiation oncology treatment units are used to treat 275 patients daily. Eight linear accelerators incorporate electronic portal imaging, and the department operates two CT scanner/simulators and a conventional simulator.

Ten years ago, the treatment center was plagued with a long waiting list and realized that it needed to improve its systems and processes to better serve patients. The hospital began a re-engineering process in 1998, demonstrating to its administration and the Alberta government that new equipment would result in efficiency gains. "The re-engineering plan was designed to improve efficiency; our goal was to become a filmless operation," explains Sue Merritt, radiation therapy manager.

Initially, the center upgraded its linear accelerator units and transitioned from hard-copy port films to digital port films. The result was a 30 percent increase in patient images. The ability to image patients more frequently translated into the ability to deliver radiation treatments better tailored to the patient's tumor volume.

By the end of 1999, Tom Baker Cancer Centre deployed Varian Medical Systems' VARiS Vision information management system, which includes the VARiS server to house data and images, VARiS physician and dosimetrist viewing workstations and radiation oncology management software and electronic charting system. At the same time, the center reorganized its treatment units, designating units by tumor groups. For example, one linear accelerator served head and neck cases, while another was used to treat prostate and pelvic tumors. The combination of the VARiS systems and the departmental reorganization allowed the center to increase its patient load from 29 to 35 patients per day on each machine.

Merritt says the image management benefits of the new arrangement are equally compelling. "VARiS is an integrated system. Physicians and therapists can view and approve electronic portal images online from anywhere in the building. It's a tremendous benefit not to have to call physicians to the treatment unit to approve images," says Merritt.

Ian Hudson, radiation therapy manager, adds knowledge management to the lists of benefits. "With VARiS, physicians can add patient specific notes to an image. The therapist cannot deliver treatment without signing the note," explains Hudson. The enhanced communication results in better patient care and saves time for the entire radiation therapy team.

In 2003, the Tom Baker Cancer Centre began changing processes to generate additional workflow benefits, training radiation therapists to handle image approval within certain treatment guidelines. "This has freed up physicians to assess more complex cases," says Hudson. Both complex and routine cases benefit from improved case management enabled by VARiS. During quality assurance rounds, the radiation oncology team electronically views and discusses patient images in an auditorium. Videoconferencing technology enables Alberta radiation oncologists to share and review images with other sites.

The center anticipates additional workflow and patient care gains as it implements remote access to images via a security fob for approved physicians. Hudson also looks forward to a more multi-disciplinary approach to radiation oncology. "We'll be able to download images from a diagnostic radiology PACS into the treatment planner, fusing images taken elsewhere with our CT images to create a new dataset that better defines the tumor," explains Hudson.


A pioneering practice

Savannah Oncology was an early adopter of IMRT and IGRT, first implementing the treatment options nearly five years ago. Although the newer radiation therapy treatments improve patient care by more precisely targeting the tumor and sparing more healthy tissue, they do require changes in the practice of radiation oncology. Practitioners require more anatomical data - CT and fused CT, MRI and PET images - to deliver the finer radiation doses.

Last year, Savannah Oncology deployed Siemens Medical Solutions COHERENCE workspaces to enhance workflow and improve patient care. The new system streamlines image manipulation, says Geffen. For example, COHERENCE enables radiation oncologists to digitally check and superimpose port films against digitally reconstructed radiographs (DRR) for treatment planning and verification. "This is much quicker than previous manual processes, especially with IMRT," states Geffen. In fact, digital image management technology is fast becoming a necessity for radiation oncology.

Conventional radiation therapy depended on two to four fields, and human providers could readily compare film images. IMRT; however, hinges on multiple fields; there may be as many as 70 radiation beams and images to compare, a much more difficult task without the aid of digital image management technology. "We could not offer these complex treatments [in the same patient time slot] without COHERENCE," notes Geffen.

COHERENCE serves as a virtual one-stop shop for radiation oncology images and data at Savannah Oncology; the practice uses the system to hold images and treatment plans. Geffen says seamless information flow between the CT scanner, treatment planning system and linear accelerator is necessary for a successful implementation of digital radiation oncology image and information processes. IT expertise is essential, says Geffen. An IT staffer can help complete the necessary homework to verify that all systems communicate, thus facilitating the seamless information flow necessary for sophisticated treatment, better patient care and improved workflow.


Rad therapy PACS - In the wings?

"People are talking about radiation therapy PACS," says Mutic of Washington University School of Medicine. Mutic eagerly awaits a full-fledged radiation therapy PACS that stores and retrieves all data necessary to deliver radiation therapy - including treatment planning data, contours and volumetric images.

Currently, Washington University School of Medicine relies on Philips Medical Systems' Pinnacle 3 treatment planning system and two Brilliance CT large bore 16-slice scanners to provide local storage while a patient remains in treatment. Image retrieval is seamless for patients currently in treatment. Post-treatment processes are more labor-intensive; data and images are archived on CDs, which must be manually burned and pulled. "It's not uncommon or unreasonable to need data five to 10 years after initial images," explains Mutic.

"There's quite a bit of room for workflow improvement," admits Mutic. "We are waiting for technology to catch up to the needs of radiation therapy." In the interim, Washington University School of Medicine has laid the groundwork for a true radiation oncology PACS. Mutic says its network infrastructure is capable of handling data transfer of radiation oncology images and data, and broadband access will facilitate rapid retrieval of images.


Conclusion

Digital image management processes are becoming standard practice in radiation oncology. Digital image management is an enabler of next-generation radiation therapy treatments including IMRT, IGRT, DGRT (dose-guided radiation therapy) and adaptive therapy, enabling facilities to implement processes for managing these image-intense procedures in a reasonable time frame. These solutions can provide caregivers anytime/anywhere access to images to facilitate better treatment planning.