2014 - Optimizing Information and Presentation for Clinical Decision-Making in Adaptive Radiotherapy: A Multidisciplinary Survey

Purpose/Objective(s): Effective decision-making in radiation therapy hinges on real-time assessment of daily anatomical and positional variations that impact dose delivery. Patient habitus and positioning play a critical role in treatment accuracy, underscoring the need for pre-treatment dose verification, real-time monitoring, and cumulative dose assessment. In collaboration with LAP GmbH on the Luna 3D platform, we aim to develop advanced tools to bridge gaps in clinical workflow and harness the full potential of surface-guided radiation therapy (SGRT) to enhance adaptive radiotherapy (ART) workflows and improve dosimetric monitoring.

Materials/Methods: A survey was conducted among 25 medical physicists, 25 radiation oncologists, and 25 radiation therapists to assess ART's current limitations and identify essential tools for broader clinical implementation. The 15-question survey focused on:

• Gaps in existing ART tools.
• Limitations of IGRT and SGRT in ensuring fraction-level dose accuracy.
• Impact of setup and anatomical variations on clinical outcomes.
• Deficiencies in feedback mechanisms for delivered vs. planned dose comparison.
• Information needs of therapists, physicians, and physicists for confident, patient-centric decision-making.
• Required timeframes for actionable clinical decisions.
• Alignment of a clinical system with ART efficiency and accuracy requirements.
• Feasibility of LAP’s prototype (Figures 1 & 2) in addressing these gaps.

Results: Key challenges identified include:

• Limited reproducibility of anatomy and positioning, complicating quantification of changes (e.g., weight loss, tumor shrinkage).
• Lack of real-time, actionable feedback on delivered dose, reducing clinical confidence.
• Absence of accurate, timely evaluation tools for adaptive adjustments.

Respondents emphasized the need for:

• Real-time, integrated feedback at the treatment console, displaying dose deviations relative to clinical goals for critical OARs.
• Visual overlays, such as dose difference clouds, DVH deviations, and field projections on patient surfaces, to support pre-, intra-, and post-treatment dose verification.
• Dynamic accumulated dose trends to track and ensure ongoing accuracy, enabling adaptive interventions.

Conclusion: Survey findings suggest that the absence of a robust dose monitoring system may lead to dose deviations of ~5% due to setup and habitus changes, increasing to 10% when factoring in internal organ motion uncertainties. Over 80% of respondents highlighted the critical need for clear, actionable dose data that accounts for organ motion and positional changes to improve treatment accuracy.

This study underscores the urgent need for a clinical system that integrates real-time dose verification, accumulated dose tracking, and precise adaptation tools, addressing critical gaps in ART workflows to enhance patient safety and treatment efficacy.