Integrating the Radixact into a Highly Comprehensive Center

Transcription

1 Integrating the Radixact into a Highly Comprehensive Center Alonso N. Gutiérrez, PhD, MBA ASTRO Meeting 2018

2 Disclosures An honorarium is provided by Accuray for this presentation (donated) Accuray and Miami Cancer Institute have a show site agreement in place. The views expressed in this presentation are those of the presenters and do not necessarily reflect the views or policies of Accuray Incorporated or its subsidiaries. No official endorsement by Accuray Incorporated or any of its subsidiaries of any vendor, products or services contained in this presentation is intended or should be inferred.

3 Grand Opening: January 16, 2017

4 Miami Cancer Institute Statistics 440,000 square feet, $430 million center 113 patient friendly exam rooms 60 infusion rooms / 8 infusion beds Multi-media conference and meeting rooms 7 state-of-the-art photon therapy machines 3 gantry pencil beam scanning proton therapy center State of the art imaging Dual energy CT (DECT); 2 Wide Bore CT; 2 PET/CT; 2 MRI s; 4 Ultrasounds; 2 Mammography; 2 Stereotactic Tables; SPECT/CT; X-Ray

5 Comprehensive technology under one roof Varian TrueBeam CyberKnife M6 Radixact Gamma Knife Icon ViewRay MRIdian Linac High Dose Rate Brachytherapy IBA Proton Therapy

6 MCI Footprint -First floor TrueBeam ViewRay TomoTherapy CyberKnife GammaKnife Start: August 2016 (Radixact ) End: September 2018 (IBA GTR 3)

7 Unique Opportunity A number of world-renowned cancer centers offer a variety of treatment modalities in different site settings, but Miami Cancer Institute aims to raise the bar and stands alone in our approach. We accomplish our goal by offering patients and families cutting edge cancer treatment solutions with all the latest technologies under ONE roof unique to us.

8 With so many options, our challenge becomes: How do we decide on the ideal technology that will provide the best results in the patient s care? P R O T O N S B R A C H Y VARIAN TRUEBEAM VIEWRAY LINAC MR ELEKTA GAMMAKNIFE ACCURAY CYBERKNIFE ACCURAY RADIXACT

9 Technology Selection & Triage Rounds Every morning, our team of over 50 professionals join forces for expert case evaluation and new patient triage

10 Technology Preconceptions TrueBeam Linac Radixact CyberKnife Gamma Knife MR Linac Proton - PBS Radiation type Multiple MVs 6MV 6MV Co-60 6MV Multiple p+ MeVs Isocenter Isocentric Non-isocentric Non-isocentric Isocentric Non-isocentric Isocentric IGRT: Interfraction kv-cbct, kv/kv, MV/MV, SIG, Calypso MVCT Stereoscopic kv/kv kv-cbct MR kv-cbct, kv/kv, SIG IGRT: Intrafraction kv triggered imaging, Calypso, SIG SIG Cine kv Infrared Marker Planar Cine MR SIG Ideal clinical indications Universal H&N, Comp. Breast, Long Tx Fields, Junction fields Motion tracking, non-coplanar delivery Cranial Stereo. Diaphragmatic motion, adaptive capability Universal, lower integral dose, pediatrics, reirradiation

11 Technology Triage Early stage lung cancer patient CyberKnife TrueBeam MR Linac Protons TomoTherapy Trackable? Fiducials? Arms restriction? Large motion Treatment time Need DIBH? Compression (ITV)? Fast delivery? Volumetric imaging? Breath-hold? FB gating? Claustrophobic? Lateral lesion? Volumetric imaging? Large motion? Insurance? Volumetric imaging? Breath-hold? Claustrophobic Volumetric imaging? Non-coplanar? Treatment time Yes? Yes? Yes? Yes? Yes? Comparative Plans Treat patient with best quality plan

12 MCI Radiation Modality Triage Complex IMRT cases are prioritized for Radixact, otherwise TrueBeam 3D cases are prioritized for TrueBeam, otherwise Radixact Intracranial SRS is prioritized for CyberKnife or Gamma Knife Complex extracranial SRS/SBRT cases are prioritized for CyberKnife or MRIdian Linac Proton therapy is prioritized for pediatric and reirradiation patients

13 Radixact Utilization at MCI Complex cases with targets in close proximity to OARs Head and neck Breast (comprehensive nodal irradiation) Prostate Extended fields Pelvic/para-aortic CSI Special cases Spine tumors Pediatric cancers

14 Radixact Utilization in the Clinic Radixact Patients By Diagnosis (March 17 March 18) Breast Prostate Head/Neck Gyn Other Bone Brain GI Lung

15 GYN malignancies 50 yo lady with a locally advanced cervical cancer s/p surgery 45 Gy in 25 fractions to an extended field followed by HDR brachytherapy

16 Breast Cancer - TomoDirect 64 yo lady with an early stage right breast cancer s/p lumpectomy

17 Palliative Cases- TomoDirect 74 yo lady with Stage IV pancreatic cancer with a duodenal mass causing biliary obstruction Good coverage of the tumor with reduced doses to the kidneys and bowel

18 Breast Cancer - TomoHelical 36 yo lady with locally advanced right breast cancer s/p chemotherapy and mastectomy Moderate dose to the lungs with treatment of chest and regional lymph nodes

19 Breast Cancer - MVCT

20 Improved MVCT Image Quality CTrue iterative reconstruction algorithm Reconstructs CT fan-beam scans with enhanced image quality Maintains a low imaging dose and the ability to perform live reconstruction as the images are acquired Much improved signal-to-noise ratio, which in turn increases the soft-tissue contrast

21 Normal Iterative Reconstruction

22 Normal Iterative Reconstruction

23 Normal Iterative Reconstruction

24 Radixact - Treatment Delivery Efficiency Faster image acquisition 10 rpm gantry rotation increased from 6 rpm 40% shorter scan time 6 second beam-on warm up decreased from 10 sec 15% reduced treatment delivery time 1000 MU/min dose rate increased from 880 MU/min

25 40 Daily Treatment Volume by Treatment Unit (Jan 16 - May 30, 2017) MCI opens 2 TrueBeam Radixact Additional TrueBeam became operational 20 >30 patients/day for nearly 1 month Radixact

26 Radixact - Delivery Performance 100.0% MCI Radixact 2018 Uptime 90.0% 80.0% 70.0% 60.0% 50.0% Average Uptime = 97.2%

27 Radixact Delivery Flow Chart No Open patient plan and select CT scan region Retrieve patient from waiting room Correct patient? Yes Escort patient into treatment vault Perform initial patient setup Call MD and resident to approve scan Yes New patient new plan? Therapist approves the scan Therapist begins fusion process Start CT scan No Record patient shift data on spreadsheet Ensure image transfer correct Proceed to vault to apply shifts to patient Treat patient Aid patient off of treatment table and escort to lobby

28 Cause-and-Effect Diagram of Factors influencing Treatment Times on Radixact Radixact errors requiring physicist/engineer attention Machine Patient Healthcare Providers System needs to be rebooted Therapist time to transfer verification image into R&V Therapist time to record shifts Processes Pt enjoy talking to therapist Pt move during CT scan Some patients require longer time to setup Physician time to approve fusion on first tx fraction Pt nervous and tense about Tx Therapist & Physician not familiar with fusion Skills Long time to localize physician Therapist tending to other requests Therapist not selecting optimal scan length Therapist socialize Overall treatment time on Radixact too long

29 Intervention Action Plan Focused on three specific components: Healthcare providers Time efficiency of treatment dependent healthcare provider Processes Current processes performed established practice and not optimized for efficiency Personnel Skills/Training Image fusion technique highly variable among physician and therapist CT scan volume region also highly variable among therapist

30 Average Treatment Time 31.9 Mean Daily Patient Treatment Time Run Chart 26.9 UCL % decrease in overall treatment time (13.0 vs. 17.4min) % decrease in variation (15.2 vs. 7.1min) 16.9 CL LCL

31 Average Setup/Fusion Time 21.0 Mean Daily Setup/Fusion Time Run Chart UCL 18.8 CL % decrease in setup/fusion time (9.0 vs. 13.9min) - 35% decrease in variation (4.7 vs. 9.9min) LCL

32 Radixact Conclusions Versatility & Quality Needed to truly have a comprehensive radiotherapy program Ability to treat a variety of cancers from head to toe Our most efficient IMRT method of treating large fields Ability to develop high quality palliative plans with TomoDirect System efficiencies enable patient throughput Hardware improvements Process/personal training Consistent +25 pts/day Our 2 year experience shows high reliable Radixact uptimes

33 Acknowledgements

34 Thanks for your attention