Welcome and introduction

Jeannette Parkes
Clinical Head of A2C program
With acknowledgement to Hester Burger
(Varian education)
Who are we?
UCT Access to Care CPUT

Charne Martin
Jeannette Parkes Nanette Joubert RTT lead
Clinical lead MP lead

Elaine Smith
A2C Project Coordinator

Tammy Manasse Marissa Goodhead

RTT Course Coordinator RTT Course Coordinator
Why we are all here…
The global incidence of cancer is slowly rising…

Even when we correct for the increasing population, and

the increasing age of the population, there is still a slowly
increasing overall incidence of cancer across the board
for reasons we don’t entirely understand…

But globally we are getting better at treating cancer….

CA: A Cancer Journal for Clinicians, Volume: 71, Issue: 1, Pages: 7-33, First published: 12 January 2021, DOI: (10.3322/caac.21654)
 African cancer landscape
• Doubling of cancer incidence and mortality by 2040
• LMIC carry 70% of global cancer mortality burden
• Mortality to incidence ratio 0.7 versus 0.3 in
developed countries

• Mortality due to NCDs showing relative increase

• Increase in average life-span
• Adoption of westernized life-style
• 27% of malignancies are virally driven
• HIV-associated malignancies unreduced
• Carcinogens: Agricultural, Mining
• Genetic predispositions modulate clinical
presentation

Ngwe W, Addai BW, Adewole I, et al. Cancer in sub-Saharan Africa: a Lancet Oncology Commission. Lancet Oncol 2022; 23: e251–312

Thanks to Riette Burger for slide

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 The HDI is composite statistic that takes into account
longevity, educational attainment and standard of living.

[Link] [Link]
classifica

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 Why do we need these programmes?

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 What is the impact of
providing radiotherapy in
an LMIC?

In LMIC at least 2/3 of

presenting cases will be
advanced cancers requiring
RT.

RUR in Africa= 55-65%

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 Evolution of RT: 2D vs 3DCRT vs VMAT

2D

3DCRT

VMAT/IMRT
 Why move to advanced techniques?
Target and
Immobilization Critical
and Image Treatment Plan Treatment
Acquisition Structure Planning Verification Verification
Positioning
Delineation

Parkes et al, Pediatr Blood

Cancer. 2017;64:e26903.
[Link]/journal/
pbc

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 Why move to advanced techniques?

• What are the risks?

• What are the benefits

• How do we make the changes

required?

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 The why?

Toxicity
Access

Survival

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Aim of RT: Dose to the target,
protect the normal tissue

VMAT:
Good

2D: Some part of the tumour

not receiving the ideal dose
 Fact number 1

• Advanced techniques gives you less toxicity

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 Fact number 2

• Advanced techniques improves outcomes(survival) in SOME (but not

all) studies

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 Fact number 3

• Advanced techniques may allow a reduction in overall treatment time

−Hypofractionation
−Field in field techniques

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 The question to ask….

• Can your system manage:

• The additional cost of equipment and training?

• The additional time burden of contouring and planning and QA?

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Its not about getting there faster… its about
getting there safer…
 We must be wary of applying
HIC standards and HIC LMIC challenges:
solutions…
• Resources are scarce and must be
optimally managed/triaged

Appropriate selection of patients

Right
DO THE RIGHT THINGS FOR THE
RIGHT PATIENTS

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 Where have we come from?

2015–2020 2025–2030
2D-3D X2 on site= 3 weeks 5P suite
Introduction of I2A I2A+PNP
Paeds RT- expanded

2020–2024
Virtualisation
A2C 2D to 3Dx1
I2A+PNP X2
Paeds RT

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 The course – Integration of Knowledge

2D / Manual Planning 3DCRT Radiotherapy Modern RT techniques

Communication between Professions Integration of Knowledge Integration of knowledge
Introduction of workflow tools
Quality management
• Each team member is as important as the next. AI

• The team is only as good as its weakest link….

 5P suite

1. Principles of modern radiotherapy

2. Principles of Contouring
3. Physics and quality assurance for modern radiotherapy
4. Principles of planning
5. Procurement and design/development of treatment guidelines

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 5P suite

1. Principles of modern radiotherapy

2. Principles of Contouring
3. Physics and quality assurance for modern radiotherapy
4. Principles of planning
5. Procurement and design/development of treatment guidelines

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 The Chain of Radiotherapy:
Principles of Modern Radiotherapy

RB &
Intro Image Delineate Plan Ethics
Errors

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 INTRO

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 IMAGE

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 DELINEATE

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 PLAN

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 RADIOBIOLOGY & RT ERRORS

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 ETHICS

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Multi-disciplinary cancer care
 Investing in regional excellence

Or… If the world

changes, change with
it… J (Anonymouse)

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 What is modern
radiotherapy?

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Delivering radiation dose
Delivering radiation dose to a very
specific target

Dosimetric and Geometric Accuracy

 Conventional treatment process:
Patient Information
Management
(demographics,
The radiotherapy workflow chain
chemotherapy,
scheduling, billing)
• Admin
• RTT
• RO

Patient Information
Management (follow
up care)
• Admin
• RTT
• RO

Imaging and Contouring Prescription/ Intent Planning Plan evaluation Plan scheduling Position Treatment
immobilization • RO - target • RO • Planner (RTT) and approval, Pt • RTT verification and QA • RTT
• RTT • RO – OAR • Physicist – plan specific QA • RTT
• RO • RTT – OAR accuracy/QA • RO
• Planner
• Physicist – machine • MP – reasonability • RO – Plan approval • MP
• RO
setup/QA checks • MP

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 Patient journey – RT team involvement/responsibility
Conventional treatment process
Patient Offline Patient

Contouring
Imaging and
Prescription/ Intent Planning (Plan Plan evaluation Plan scheduling Position
immobilization (OAR/Target/Appr verification
Treatment
oval and approval, QA

RTT RTT RTT RTT

PL PL PL PL
RO RO RO
MP MP Post treatment QA: RO/MP

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 Role of Treatment Planning System (TPS) and
Oncology Information Management System (OIS)
Conventional treatment process

Imaging and Contouring Prescription/ Intent Planning Plan evaluation Plan scheduling Position Treatment
immobilization • RO - target • RO • Planner (RTT) and approval, Pt • RTT verification and QA • RTT
• RTT • RO – OAR • Physicist – plan specific QA • RTT
• RO • RTT – OAR accuracy/QA • RO
• Planner
• Physicist – machine • MP – reasonability • RO – Plan approval • MP
• RO
setup/QA checks • MP

CT/MRI/TPS TPS TPS TPS TPS/Machine TPS/OIS TPS/OIS/Machine OIS/Machine

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 Adding information to images - Imaging

Orientation

Scale (size)/
Density (HU)

HU to electron/
absolute density
conversion

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 At the scanner:
Immobilisation and Imaging and
immobilization

positioning
• RTT
• RO
• Physicist – machine
setup/QA

• Consistency in patient support

• Consistency in 3-D patient set-up
• Consistency in treatment field marks
• Consistency in body position
• Reproduce transverse/axial, lateral/coronal,
sagittal alignment of patient

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Why do we need that information?
To understand what the radiation dose will do.

The way radiation deposits its

energy in tissue depends on
the density and type of tissue

We can not consider it all as if

it is water

We must be able to model

accurately where the dose will
end up

Visualization of Dose Distributions for Photon Beam Radiation Therapy During Treatment Delivery | Radiology Key
Delivering radiation dose
Characterizing the linac

Eclipse Photon and Electron Algorithm Reference Guide 18.1

Dose prediction – Algorithms
Linac dose modeling – Source modeling
• Need to know exactly what the radiation will look like that comes
out of the linac for
• Every energy and beam type
• Every field modifier (wedge, MLC, collimator field size)
• Three source model
• Primary source (what does the radiation look like that
comes out of the target)
• Secondary source (what does the radiation looks like that
comes out of the flattening filter after interacting with the
linac head – flattening filter, primary collimators and
secondary jaws)
• Electron contamination source (describes the electrons
that are created as a result of interactions with the linac
head)
• The impact of physical wedges are sometimes modelled
separately
Delivering radiation dose to a very specific
target
Characterizing dose in the patient
Dose prediction – Algorithms
Dose modeling – Dose deposition in the patient

• Photon dose calculation algorithms

• Three types currently in use

• Type a – pencil beam models in forward
direction only
• Type b – Models with forward as well as
some lateral elements included
• Type c – Radiation Transport/Monte
Carlo models from physics principles
Slide credit Antonella Fogliata
Type of model determines how accurate we can
predict where the dose will be deposited in
different tissues

• Examples:
• Type a – Pencil beam
• Type b – AAA and Collapsed Cone
(superposition convolution)
• Type c – Acuros XB and Monte Carlo

• Everyone should aim to use

Type c algorithms for modern
RT
Adding information to images - Contouring

Multimodality
Image
Registration
(CT/ MRI/ PET/
CBCTp/
Synthetic CT)

Critical
Structure
Contours
(ICRU)

Target
Contours
(ICRU)

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Why do we need that information?
To understand where the dose should go
(and not go)

• TCP – Tumour control probability

• NTCP – Normal Tissue Complication Probability

• Constant battle to optimize dose to the target and

minimize dose to critical structures
• This can only be done if we know where the
structures are – even when patients breathe and
move internally
 Options for contouring

• Manual workflows • AI driven workflows

• Semi-automatic contouring tools • Still needs full RO validation

AI Rad Companion is a Siemens Healthineers product

 Prescription and Clinical Goals (constraints)
Used during planning/ optimization as well as final evaluation

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 Why do we need that information?
Guides the planning and plan evaluation process

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We now have our
digital patient –

AI style J
 Aiming the radiation digitally – Treatment
Planning

• Treatment planning is the art and science of knowing how to point the radiation to
the tumour in the patient in such a way that it maximizes the dose to the tumour, but
at the same time limit the dose to the critical structures as far as possible.
• There are many types of planning techniques available to us, including beams that
remain static while delivering dose (fixed fields), and beams that are delivered while
the radiation is on (arc fields).
• All modern planning is done with computer guidance, and AI planning is now
becoming available on some computers as well.
• The two main approaches to treatment planning involves:
− forward planning techniques
− inverse planning techniques.

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 Forward planning principles
“Point and shoot approach”
• The planners use their own experience of planning to choose beams and beam modifiers (wedges,
MLC shaping etc.) to deliver dose to a target, and the computer displays the outcome
• Planners modify and calculate (display) as many times as needed until they are happy with the
results (trial and error)
• They then show it to the rad oncs who asks them to do something different J
• And so and so on until all are happy

• Examples
• 3D conformal radiotherapy (3DCRT)
• Uses MLC shaping and wedges
• Conformal dynamic arc therapy
• MLC shaping, but no wedges
• Field in Field planning (forward planning IMRT)
• Multiple static fields combined to deliver as one, no wedges
Forward planning

1. Place beams 2. Calculate dose 3. Evaluate dose and DVH

ü Accept
û Modify beams, try again
Inverse planning principles
Define outcome, computer generates planning
options
1. Define ideal DVH
(constraints) 2. Computer
calculates
the required
beams

ü Accept
û Modify constraints, try again 3. Evaluate dose and final DVH

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 Inverse planning principles
• Examples
− iIMRT
− VMAT (RapidArc)
− RapidArc Dynamic (combination of arc fields and static segments delivered as one beam)

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 Plan evaluation and approval
Dose display, dose volume histograms, clinical goal
evaluation (safety and quality metrics)

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Physics checks and patient specific pre-
treatment QA

• Direct measurement of the patient

dose on a phantom or portal imaging
device
• Evaluates whether the dose is
correct (dosimetric checks), and also
whether it is in the correct spot
(geometric checks)
• Gamma analysis (%/mm)
− Dose difference
− Distance to agreement
(e.g. 3%/3mm)

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Plan scheduling
Data transfer from the TPS to the OIS and linear
accelerator console
• Information include
− Appointment information
− Machine, date, time, dose, fractions etc.
− Plan information
− MLC and dose delivery files (ensures that the exact sequences used during planning is
delivered on the machine)
− Parameters for modern RT include
• MLC position for any gantry angle (dynamic or static)
• Gantry, collimator and couch angles
• Energy and doserate
− Position verification – imaging fields per fraction
− DRR/CBCT/portal imaging
− Quality insurance files – patient specific QA

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Patient position verification
Compares predictions based on the digital patient
with the actual position seen on the real patient
• Compares images from the TPS (predicted position) to images obtained on
the real patient (actual position)
− Digitally reconstructed radiographs (DRRs) vs. linac kV or MV portal
images (typically 0 and 90 degree gantry angles)
− 3D CT dataset vs. linac Cone Beam CT images (CBCT)
− Planning DRRs compared to Exactrac external x-ray images
− Surface projection from TPS vs. surface guided images from linac (SGRT)

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 Image Guided
Radiotherapy (IGRT)
options

Offline, online and

inline position
verification

(AI explanation J)

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Daily patient treatment

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 Post-treatment QA

• All machine data is saved during treatment and can be compared to the predicted values
(indicator of machine accuracy)
− MLC position for any gantry angle (dynamic or static)
− Gantry, collimator and couch angles
− Energy and doserate

• Transit dosimetry
− Recording the dose that passes through the patient on the portal imaging device, and comparing
it to the predicted dose.
− Indicator of positional and dosimetric accuracy

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 Where to next?
Ethos/Mobius 3D adaptive workflow

Option for initial

contouring in Eclipse
• RO / Planner

Patient immobilization and Ethos: Physician (RT) Importing image sets (or Image registration and Dose preview Automatic plan generation Plan QA
initial imaging (Planning intent (planning directives, pre-contours from contours • AI: Generate dose preview plans and review • M obius 3D: QA
scan) PTV and OAR, derived Eclipse), contouring • AI: Registration and selective • RO: Review, dynam ically change • AI: M ultiple plan generation • M P: Review/approve
categories of im portance • Pre-treatm ent QA possible
• RTT structures, priorities) • RTT/RO
contouring (OARs) • RO: Review and plan selection
• RO: Registration review/ contouring
• RO / validation OAR and Targets
• AI: Derived structures

Patient setup (Ethos) and OAR and influencer Planning dose calculation Plan selection: Scheduled Plan QA Patient treatment Treatment Monitoring and
CBCT contouring and review; • AI: Automatic background vs Scheduled • Mobius: Automatic • AI: Patient position correction dose accumulation
• RTT target review process, decision on plan of • AI: Recommendation background process • RTT: Treat • Mobius 3D: Treatment
• AI: Automatic contouring daily the day • RO: Final approval clinical • MP: Review / approve delivery checks
CBCT plan • MP: Review/approve
• RO: Review, edit, approve • MP: Approval technical/QA • RO: Clinical review /
• AI: Target propagation daily monitoring
CBCT

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Or… If the world changes, change with it… J (Anonymouse)

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