Radiation Oncology Conference 2019 Abstracts

(in chronological order)

“Radiation of the Pelvis: The Radiation Therapist’s Perspective”

Friday, Sept. 6
8:45–9:15 a.m.

Joseph Pagano, RT(T)
Roswell Park

The purpose of this course is to share patient setup and immobilization methods for radiation treatment to the pelvic region. This session will increase the attendee’s ability to think outside the box during simulation, how patient positioning ultimately effects dosimetry planning, and on treatment issues that can arise during a patient’s course of treatment.

Learning Objectives:

  1. Learn from unusual cases that have come through our department over the years.
  2. Understand how to think outside the box when it comes to unusual patient setups.
  3. Learn to maximize patient immobilization without compromising patient comfort.  
  4. See how reproducible patient setup impacts patient plans

“Dealing with the Side Effects of Pelvic Radiation”

Friday, Sept. 6
9:15–9:45 a.m.

Leayn Flaherty, PA
Roswell Park

The goals of this presentation are to identify common malignancies treated with pelvic radiotherapy, know what and when to expect common side effects of pelvic radiation. Also be able to make recommendations to patients as to things they can do to help better tolerate and recover from expected side effects of their treatment.

Learning Objectives:

  1. Identify Common Malignancies treated with pelvic radiotherapy
  2. Discuss common side effects of pelvic radiation
  3. Review Diet and lifestyle modifications that impact treatment tolerance

“Pelvic Irradiation:  A Dosimetrist’s Perspective”

Friday, Sept. 6
10:15–11:15 a.m.

Lee Culp, MS, CMD, RT(T)
Roswell Park

The Dosimetry portion of the Pelvis Irradiation Symposium will focus on planning various sites within the Pelvis. We will highlight planning tips and tricks, as well as communication ideals with the therapists, including difficult setups and/or requests. We will discuss simulation effects on treatment planning, OARs, avoidance structures, VMAT vs. 3D, minimizing side effects, and evaluating plans.

Learning Objectives:

  1. Enumerate the costs/ benefits of 3D vs VMAT treatment planning within the Pelvis
  2. Specify techniques that minimize patient side effects during treatment planning 
  3. List the effects of certain simulation events on dosimetric planning

“Brachytherapy for GYN Cancer”

Friday, Sept. 6
11:05–11:55 a.m.

Maryann Mikucki, MD, PhD
Roswell Park

Gynecologic (GYN) cancer is one of the most common cancers diagnosed in women and a significant cause of mortality worldwide. Unlike many other types of cancer, treatment of GYN cancer includes varied combinations of both external beam radiation therapy and brachytherapy.   This presentation will provide an overview of radiation treatments for GYN cancer with a focus on brachytherapy and new treatment directions.

Learning Objectives:

  1. Review the history of radiation therapy for the treatment of GYN cancers 
  2. Understand the uses and techniques behind brachytherapy for GYN cancer
  3. Discuss new directions in treatment for GYN cancer

"Nonoperative Management After Neoadjuvant Therapy for Rectal Cancer: A Single Institution Experience Over 5 Years"

Friday, Sept. 6
1:30–2:30 p.m.

Steven Nurkin, MD,MS,FACS
Roswell Park

Nonoperative or "watch and wait" strategies have emerged as a potential option for patients with rectal cancer that obtain a complete clinic response (cCR) after neoadjuvant therapy. We sought to evaluate our patients that experienced a cCR and their outcomes after non-operative management.

We performed a retrospective review of patients at our center with rectal cancer from 2012 to 2016. We then identified patients that had a documented "complete clinical response" of their tumors after different neoadjuvant treatments and underwent non-operative management. Patients were followed on a surveillance schedule that included physical exam, endoscopy and imaging.

A total of 29 patients elected to undergo nonoperative management with a mean patient age of 67 years old. All patients were treated with neoadjuvant long course chemoradiotherapy. Seven patients were treated with initial induction chemotherapy followed by chemoradiation and 11 received consolidation chemotherapy. During a median follow-up of 27.6 months, there were 6 (21%) recurrences (1 = local, 1 = local and distant, 4 distant). Of the 6 total recurrences, 5 patients were candidates for salvage surgical resection.

Neoadjuvant treatment strategies may facilitate durable rates of cCR. Continued responses after these treatments could possibly enable more patients to undergo nonoperative management. We believe nonoperative management can be offered to patients seeking rectal preservation, but more research is required to select the appropriate patients. For those patients experiencing recurrence, the majority of patients can be salvaged surgically.

Learning Objective:

  • Discuss our experience with non-operative management of rectal cancer

“2019 Coding and Documentation Updates - Part I & II"

Friday, Sept. 6
1:30–2:30 p.m.

Adam Brown, BSRT(T), CMD
Revenue Cycle, Inc

This program is designed to provide the oncology staff with references and resources to assist in their day-to-day responsibilities in the realm of documentation, reimbursement and compliance. The course will provide a detail of the importance of these as well as a review of the current Medicare guidelines to assist in compliant documentation and code capture for procedures performed within the Radiation Oncology Department. The program will also inform the clinician on new updates and proposed rules for the 2020 calendar year. 

Learning Objectives:

  1. Present Attendees a Billing and Coding Overview Educate on   Authoritative Guidance and Legislative Updates 
  2. Provide Overview of Medicare Program 
  3. Discuss Hot Topics
  4. Allow Interactive Discussion for Questions & Advice

“Developing a Framework for Patient Safety in the Next Millennium”

Friday, Sept. 6
2:30 –3:00 p.m.

Harish Malhotra, PhD, DABR
Roswell Park

Though radiotherapy by and large is generally safe, there have been some recent incidents where catastrophic doses of radiation has even caused casualties.  It is necessary to develop and periodically revisit the checks and balances in the system for optimal performance without compromising on the patient safety.  It is extremely important to have safe and efficient systems to plan and deliver radiation therapy which may get compromised due to various changes in the health care environment e.g.  rapid technological advances, financial reorganization, reimbursement reductions, aging population, evolving societal expectations etc.  Both retrospective systems e.g.  ROILS as well as prospective tools of quality management like FMEA etc. need to be incorporated  in a clinic on war footing to minimize errors before they cause harm.  The talk will describe various methods to improve the quality in a clinic which may help in achieving better patient safety.  

Learning Objectives:

  1. Patient safety in a clinic
  2. Lessons to be learned from past incidents
  3. Developing new frame work to prevent medical errors in  a clinic
  4. Adding “Humane” angle in the design process

"Radiation Therapy of Patients with Cardiac Implantable Devices: Dosimetric Evaluation and Clinical Management”

Friday, Sept. 6
4:00–5:00 p.m.

Iris Wang, PhD, DABR, FAAPM
Roswell Park

There have been an increased number of cancer patients with cardiac implantable devices (CIED) who require radiation treatment. Two general rules of thumb in treatment planning and radiation delivery are to minimize neutron contamination and to avoid direct radiation. For treatment sites farther away from the thoracic area, where the CIED may not be detected in the planning CT, it would be beneficial to identify it prior to or at the time of CT simulation. For treatment sites where the CIED is in proximity to the radiation target volume, it is important to follow guidelines for dosimetric limits. Since no radiation should directly target the CIED, doses to the device are mainly contributed from scattering radiation. An accurate computation or measurement of radiation doses to CIED is necessary for risk evaluation and management. Many vendors do not specify a radiation dose limit for their CIED. As references, AAPM report 45 (TG34) and other published literature provide relevant guidelines with potential risk levels listed.  Finally, it should be stressed that management procedure for patients with CIED is a multi-step process involving a multidisciplinary radiation oncology team as well as the CIED vendor and cardiologist team. Therefore, it is always a good practice to establish a standard policy and procedure to ensure delivering radiation safely to patients with CIED. The P&P should follow the published guidelines and consider all aspects of clinical management.

Learning Objectives:

  1. To understand potential risks of CIED malfunction in radiotherapy
  2. To learn approaches for evaluating doses & minimizing radiation damage to CIED
  3. To learn the published guidelines of CIED dose limits and risk levels
  4. To understand the importance to establish a P&P in managing patients with CIED

"Optimization of Metal Density Definition in Dose Calculation Algorithms and Comparison to Measurements in Inhomogeneous Phantoms"

Friday, Sept. 6
4:00–5:00 p.m.

Steven de Boer, MSc, FAAPM
Roswell Park

The accuracy of dose calculations in radiotherapy is dependent on how the dose calculation algorithm accounts for tissue and material densities.  This is typically done by assigning a tissue density based on the Hounsfield Unit (HU) derived from the planning CT scan.  The presence of high density materials such as hip prostheses, metal breast expanders, dental amalgam and spinal fixation hardware pose several challenges in accurate dose calculations, such as inaccurate HU, saturated HU and image artifacts.  Furthermore, there is not a standard method of accounting for metals in patients, which can lead to large discrepancies between treatment clinics. 
Our work involves extending the HU range of the CT scanner.  This allows for the ability to differentiate between common metals and allows for more accurate delineation between the metal devices and image artifact.  The well-defined implants can then be assigned a bulk density which was initially based on the known properties of the material but it was then optimized based on our comparison of dose measurements and calculations.
The results comparing the dose measurements in various in-house phantoms to two different dose calculation algorithms will be presented.

Learning Objectives:

  1. To understand a method of extending the HU to density curve appropriately to account for common patient implant materials in radiotherapy dose calculations.
  2. To understand the potential inaccuracies in dose calculations in the presence of metals.
  3. To understand how two commercial algorithms account 

“Take 2 Aspirin and Call Me in the Morning: Re-evaluating Old Drugs for the Modern Era”

Friday, Sept. 6
5:00–6:00 p.m.

Anurag Singh, MD
Roswell Park

We will review data for the effects of common drugs such as aspirin and beta-blockers in outcomes with radiation for a variety of malignancies.  

Learning Objectives:

  1. Learn the benefits of aspirin on outcomes following radiation in a variety of malignancies.
  2. Learn the benefits of beta-blockers on outcomes following radiation in a variety of malignancies.
  3. Learn possible mechanisms for both effects.

"Radiation Oncology-Incident Learning System (RO-ILS): Operational Evolution within the Radiation Medicine Department"

Saturday, Sept. 7 
8:00–9:00 a.m.

Katrina Aronoff, BS, RT(T)
Phelps Hospital Northwell Health

The ASTRO Radiation Oncology-Incident Learning System (RO-ILS) is a web-based incident reporting system that provides a global mechanism for collaborative learning within radiation oncology. The RO-ILS mission encourages all members to report events as they happen in the department in a non-punitive environment. As a community rich in patient safety focus, we strive for excellence by embracing and enabling change within our departments. With each event entered, our Multi-site, Multi-faculty Radiation Department compares, tracks and trends each event in pursuit of improving Operational Processes within our departments. This mission has helped shape a rich environment of growth, increase inefficient workflows and patient safety.

We have noticed a significant increase in event (such as a patient fall or “Near Miss” or “Good Catch”) reporting within our departments over the last year. With this increase, we have successfully implemented several operational changes in 2018. This enables team members the ability to feel that their voices are heard and that we are working together to develop and expand operational processes. Additionally, we have observed reinvigorated enthusiasm in staff members as a direct result of this program.

Learning Objectives:

  1. How we have changed the culture and professional relationships in our departments. 
  2. Eased stress for radiation therapists on the floor completing preflight checks with the changes we have made.   
  3. Using RO-ILS and follow-up within the department.

"Authorizations for Insurance Payment: A Team Approach"

Saturday, Sept. 7 
8:00–9:00 a.m.

Ron DiGiaimo, MBA, FACHE
Revenue Cycle, Inc.

This session will describe the Insurance Verification and Authorization Process used for patients having Radiation Therapy.  We will describe the steps and hurdles that occur on the front end of Radiation Therapy and how a dosimetrist is critical to the process and how they will be able to assist in successful outcomes for the patient as well as the facility bottom line.  Specific Radiation Therapy example cases will be reviewed to provide a higher level of engagement and appreciation for the work done on the front end and how the back end collections benefit or are hindered from fully executed and consistent procedures.

Learning Objectives: 

  1. Understand the difference between insurance verification and authorization
  2. Understand what forms of Radiation Therapy services typically need authorization and why
  3. Understand how authorization approval or lack of authorization affects payment for services rendered
  4. Serve as a valuable resource to the Revenue Cycle Team

“Particle Therapy: Past, Present & Future”

Saturday, Sept. 7
9:05–10:05 a.m.
Saif Aljabab, MD, FRCPC
Roswell Park

A plethora of technical, logistical and financial advances have occurred in the field of particle therapy. With the increased uptake of particle facilities worldwide, comes the task to discuss the impact of these changes on our future practice. In this presentation, we will explore the evolution of proton beam therapy as well as other high LET particles such as neutrons and carbon-ion therapy.

Learning Objectives:

  1. Review the history and fundamentals of particle therapy
  2. Discuss the recent advances and current practice of IMPT
  3. Describe the current simulation, planning and dosimetry challenges
  4. Explore the future advances and applications of particle therapy

“Advances in Cancer Therapy”

Saturday, Sept. 7
10:35–11:35 a.m.

Lalith Kumaraswamy, PhD, DABR
Roswell Park

There are recent advances in cancer therapy that shows some promise for certain type of cancers.  But we need to understand the challenges we face with current traditional therapies.  In this talk, we will explore the current most common treatments for certain types of cancers and learn how cancer becomes resistant to these therapies.  New treatments and how scientists and clinicians are approaching cancer treatments and help patients live longer will be discussed in this presentation.   

Learning Objectives:   

  1. Review the current traditional cancer therapies.
  2. Understanding cancer biology.
  3. Recognize the disadvantages & challenges of traditional cancer therapies.
  4. New approaches to treating cancer.
  5. Future innovations. 

“Implementing Clinical Safety Barriers to Stop Accidents Before They Happen”

Saturday, Sept. 7
11:35-12:35 a.m.

Daniel W. Bailey, PhD
Northside Hospital Cancer Institute, Atlanta, GA

Developing a culture of safety in radiation oncology includes constant assessment and reassessment of the processes and workflows of many complicated tasks throughout diverse professional responsibilities.  Analysis techniques such as incident learning, root cause analysis, fault tree diagramming, and failure mode and effect analysis provide valuable information to prospectively anticipate clinical tasks with highest potential risk.  But what is the next step toward actually improving safety based on this collection of information and multi-disciplinary analyses?  Implementation of safety barriers is the process in which definitive steps are formed into policy to effectively mitigate the potential risk of an accident before it has the chance to occur.  In this presentation we will examine current professional guidelines for the creation of simple yet powerful safety barriers to improve the quality and safety of processes across the spectrum of clinical disciplines.  Further, we will review some of the literature and case studies demonstrating the usefulness and proven results of some of these safety barriers when established as an integral part of clinical routine.  Throughout this presentation, we will focus on practical aspects of implementing safety barriers that each participant can take home and put to immediate use to further develop the quality of the busy professional workload. 

Learning Objectives:   

  1. To review the basic concepts of incident learning and failure mode and effect analysis toward improving the quality and safety of radiation oncology clinical tasks.
  2. To gain a working understanding of establishing safety barriers in order to mitigate the tasks with highest risk within any individual's daily workflow.  
  3. To demonstrate the proven usefulness and effectiveness of making smart safety barriers an integral part of daily professional routine.

“Integrated Feathering for Craniospinal Irradiation”

Saturday, Sept. 7
1:35-2:35 p.m.

Angelia Landers, PhD
Sidney Kimmel Cancer Center at Thomas Jefferson University Hospital, Philadelphia, PA 

Purpose: Classic craniospinal irradiation (CSI) techniques involve irradiation of the full length of the central nervous system through the use of two opposed lateral cranial fields and two posterior spinal fields. Field junction match lines are traditionally shifted by 1 cm every 5-6 fractions to minimize the impact of daily setup uncertainties and ensure full coverage while minimizing hot spots. These match line shifts, also known as feathering, require additional plans and physics checks as well as additional patient setup portal images. In this study, we aim to evaluate the efficacy of CSI plans that incorporate feathering into daily treatment fields. We hypothesize that this integrated planning technique will improve the clinical efficiency through saving time in treatment planning, physics plan checking, and imaging at treatment delivery.

Methods: For this dosimetric study, three craniospinal cases were planned using both the classic and integrated technique by one novice and three advanced planners. The prescription was 36 Gy in 18 fractions. The traditional technique with 2 match line shifts consists of 3 plans for each match line position. The second plan was created using field-in-field beams that integrated the feathering across the match line region in one singular plan. Each field had 3 equally-weighted segments that shifted the match line junctions by 1 cm. The treatment planning process was timed for each plan and portal filming time was acquired from the record and verify treatment history of two clinically treated CSI patients.

Results: The average planning time for both techniques was two hours once the integrated planning process was established.  The main time savings would occur in decreased exporting and documentation time for the integrated plans as integrated feathering reduces the number of plans generated by one-third.  For treatment delivery, the portal imaging time for each match line junction of a feathered case took 39 minutes on average.  Integrated feathering would only require one set of portal images as compared to three sets for traditional feathering. The estimated savings in machine time would therefore be 78 min, which would significantly improve clinical efficiency and patient comfort.  Time savings may occur for the physics team as well, as there is only one set of CSI plans to check for the full course of treatment. However, checking the integrated feathered plan may take longer initially.

Conclusion: By integrating feathering into one CSI plan, efficiency gains are made in treatment preparation and machine time as well as improvements in patient experience. Furthermore, eliminating match line shifts reduces the opportunity for setup errors by having the same setup for every fraction. Integrated feathering also reduces any dosimetric uncertainties that would arise from day-to-day setup errors, as it guarantees that the match line shift is 1 cm every time.  Future work includes analysis of the impact of set up errors on each plan.

Learning Objectives:

  1. Review classic CSI set up and feathering
  2. Demonstrate integrated feathering planning technique
  3. Explain pros/cons of each planning technique
  4. Describe current CSI techniques in the field 

"The Oligometastatic State and the Evolving Paradigms"

Saturday, Sept. 7 
2:50–3:50 p.m.

Mark Farrugia, MD, PhD
Roswell Park 

The oligometastatic state posits that patients with a limited number of metastases are distinct from those with widely disseminated disease. As such, researchers have investigated whether oligometastatic patients may benefit from more aggressive treatments. Recent trials have demonstrated that treatment to either the primary site or isolated sites of metastatic disease can improve survival based endpoints in this population. This approach has fundamentally changed the way many patients with metastatic disease are now treated.  The discussion will focus on how this impacts our practice, the techniques such as stereotactic body radiation therapy (SBRT) that are employed in this setting, and new frontiers of research.

Learning Objectives:

  1. Define the oligometastatic state 
  2. Provide an overview of recent evidence supporting treatment in these patients 
  3. Discuss different treatment approaches 
  4. Describe new areas of research in this field

“Novel Uses of SBRT: Treatment of Ventricular Tachycardia”

Saturday, Sept. 7 
3:50–4:50 p.m.

Ryan Zielan, MS, RT(T), CMD
Emory University Hospital, Atlanta, GA

Over the past few years, it has been evidenced that ventricular tachycardia (VT) can be treated non-invasively using stereotactic radiotherapy. Utilizing imaging techniques physicians are able to identify and effectively treat patients utilizing external beam radiotherapy. Working collaboratively, cardiologists and radiation oncologists are able to safely deliver single fraction SBRT treatments to a patient in a matter of minutes. The results of these treatments have resulted in drastic reductions in VT events in patients following treatment, resulting in an improved quality of life.

Learning Objectives:

  1. Describe the rationale behind treating patients suffering from ventricular tachycardia with SBRT
  2. Be able to describe planning techniques, and challenges when treating the heart
  3. Discuss clinical workflow of this treatment and how to implement a cardiac SBRT program