Personalizing treatment and adapting to changes in patient anatomy are two great challenges in radiation treatment planning today. IT cannot only help radiotherapists meet these challenges, but also optimize workflow and standardize pathways as well as improve patient safety, according to Carl Rowbottom (Fig. 1). The medical physicist leads the Radiotherapy Physics Group at the Christie based in Manchester, UK. The Christie NHS Foundation Trust has been pioneering cancer research for over 100 years and is the largest cancer centre in Europe. Approximately 2,500 staff and 350 volunteers treat more than 40,000 patients each year – around every fourth cancer patient from around the country. ACI’s Finn Snyder spoke with Rowbottom whose team uses, e.g., the Philips Pinnacle3 radiation treatment planning system.
?What are the challenges in radiation treatment planning?
Rowbottom: Radiation treatment planning currently has two great challenges. The first is how best to personalize the treatment to the individual patient. In general the amount of radiation and number of times it is given is decided based on what works best on average for the majority of patients. By new patient specific information such as given by radiogenomics, the treatment can be tailored to give maximum benefit to each patient. This approach to radiation therapy has been termed ‘theragnostics’. Once it has been determined what radiation dose should be given to the tumor and how radiosensitive the tissues near to the tumor are, a treatment plan can be individually devised to meet the treatment goal of eradicating the tumor with a low probability of associated side effects.
The second great challenge is how to adapt to changes in the patient’s anatomy during radiation treatment. Traditionally the treatment plan is based on a snapshot image of the patient anatomy before treatment commences – with the assumption that the anatomy will remain relatively constant during the several weeks of daily treatment. It is expected that there will be some change in where the tumor is during treatment, so a larger volume of the patient is given the radiation dose to make sure the tumor receives a high dose of radiation every day. Image-guided radiation therapy provides much information on how the patient is changing during a course of treatment. This provides the opportunity to reduce the volume of the patient that gets a high radiation dose and reduce the side effects of treatment.
The challenge for radiation treatment planning is how best to deal with the increase in information generated and safely adapt the treatment to take account of the change in the patient’s anatomy during treatment. The adaptation is time critical as delays in treatment and increases in the overall treatment can significantly reduce the effectiveness of radiation treatment for some patient groups.
?How has IT been able to help up to now?
Rowbottom: There are a number of areas where IT tools have been able to assist departments treat patients with radiation. The most significant area is in workflow management; the design of a radiation treatment involves a number of complex steps and a multi-disciplinary team including radiation oncologists, medical physicists, and radiographers all needing to provide input at different points along the patient pathway. The efficiency of the patient pathway has been significantly improved by mapping the tasks involved and using IT systems to clearly show where the patient is in the pathway, what tasks have been completed, and what is next including the person responsible for completing that task.
The preparation of treatment plans requires the application of the same process for each patient requiring radiation treatment. Using IT to script routine tasks has significantly increased the efficiency of treatment planning, by applying multiple actions reliably and without user bias within the treatment planning software from a single button press. This provides more time and resource to be given to patients and processes that fall outside the standardized protocols.
?What are the new features of the Pinnacle3 software release?
Rowbottom: There are two significant new features of Pinnacle3. The first is the introduction of SPICE, an automated patient segmentation tool for use in radiation treatment planning. To create a treatment plan there is a need to create an anatomical model of the patient requiring radiation treatment. This is often done manually by highly specialized staff drawing on electronic images such as CT scans to show where the tumor and sensitive organs at risk are for each patient. The model is used within the planning process to ensure the radiation treatment will be safe and effective.
The patient’s anatomical model is required before treatment planning can begin and can therefore be a significant blockage in the patient pathway. The SPICE software generates clinically relevant parts of the patient anatomical model without the need for human intervention. This model can then be reviewed and tweaked as necessary by specialist staff. The result of the software is a significant speed-up of a crucial part of the treatment planning process.
The second new feature in Pinnacle3 is dynamic planning. This feature provides the tools necessary to enable efficient adaptive treatment planning. The tools provide the ability to calculate the radiation dose received by the patient after changes in the patient’s anatomy have occurred, and provide an assessment of whether the original radiation treatment plan is still fit for purpose or requires modification. The new feature provides the building blocks for fully dynamic treatment planning including dose deformation and accumulation during the course of a patient’s treatment to be developed in the future. These tools will lead to truly individualized radiation treatment for patients.
?Moving away from planning to therapy – what would/can radio therapists expect in the way of support from the informatics side?
Rowbottom: Moving away from planning to therapy, radiotherapists can expect informatics to provide great assistance in the development, collection, and analysis of patient reported outcomes (PROMs) from radiation treatment. In the future it is likely that patients will be prompted via electronic communication (email, twitter, Facebook, etc.) to complete multiple questionnaires both during treatment and for a significant follow up period. Questionnaires will be available electronically and automatically stored and databased. Information databases are likely to be developed to centrally hold all patient related data such as PROMs and diagnostic tests performed before, during and after radiation treatment. Such databases will provide the necessary infrastructure for theragnostic approaches to radiation treatment.
Maximizing the benefit from the patient-specific information given by image-guided radiation therapy requires adaptation of the treatment whenever the patient anatomy changes. Adaptation requires quick, accurate IT-based decision tools and fast automated treatment planning while the patient remains in the treatment position to be developed.
Safety is of paramount importance in radiation treatment and any change in the treatment needs to be independently checked to avoid false positive or false negative results reducing the effectiveness of the treatment. IT-based automated validation tools without the need for human intervention will be required to provide time critical solutions.
Given the multi-disciplinary environment and distributed tasks required for a patient to successfully receive radiation treatment, wider access to information and technical software on a range of computer platforms/devices is likely to be the norm in the future. This will provide improved access for the appropriate personnel to access data and make key decisions about individual patient treatments.

Sources
www.christie.nhs.uk