Abstract book - ESTRO meets Asia

S27 ESTRO meets Asia 2018

Abstract text The traditional method

Step 3: Risk-benefit review As the commissioning continues the MDT members draw on their experience to identify and periodically reassess the associated risks, downgrading those which have been reduced through training or the use of additional safety measures, and focussing on the remaining high severity risks and any new ones that have been identified through the commissioning process. The time spent on each commissioning activity should be linked to the severity of the associated risk. Benefits of the new technology or technique are also documented. Step 4: Multi-disciplinary team decision When all testing and staff training has been completed the MDT decides whether the benefits of the new technology in the local environment outweigh the risks, in which case it can be released for clinical use after a senior representative from each professional group signs the RABBIT document. If this is not the case then more risk mitigation actions can be identified, or further restrictions placed on its use. After a set number of patients the MDT meets again to use the experience of all staff members to update the risks, benefit and restrictions of use, and review how well the identified measures of success have been achieved. The RABBIT system uses Word documents which can readily be adapted for local use if required. Each RABBIT document acts as a project management tool, a record of meetings, a training resource, and a clinical release document. The MDT sign-off ensures that the technique or technology cannot be used clinically if one professional group believes that the benefits do not outweigh the risks, thereby preventing unsafe clinical use driven by non- medical reasons such as financial gain. Conversely the clinical release may be accelerated by avoiding delays due to individuals not wishing to take sole responsibility for any adverse outcomes of the use of the new technique or technology. Radiation Oncologists are ultimately responsible for the medical interventions that they have prescribed, so it is essential for them to have a good understanding of the risks (both clinical and otherwise). At St George Cancer Care Centre the MDT approach has been welcomed by all staffing groups as a fairer, safer and faster way to implement new technology and techniques. SP-068 Anal canal: technologies and outcome P. Franco 1 1 University of Turin, Department of Oncology- Radiation Oncology, Turin, Italy Abstract text Concurrent chemo-radiation is considered the standard treatment for squamous-cell carcinoma of the anal canal and margin. The tretament approach remained stable during the last decades. Radiation doses in the range of 50-60 Gy, which were employed in randomized phase III trials, provided suboptimal clinical results for largers tumor and node positive disease. In adjunct, the rates of late morbidities were not negligible. Recent technological advances in the field of radiation therapy are progressively improving patient outcomes and quality of life and should be implemented in this setting. Intensity-modulated radiotherapy (IMRT), rotational IMRT, image-guided radiotherapy (cone-beam CT), and stereotactic approaches allowed for margin reduction and highly- conformal radiation delivery, resulting in organs at risk selective avoidance and shorter overall treatment duration. Novel approaches to target delineation, optimized radiotherapy techniques, adaptive radiotherapy, dose-escalation and modified fractionation are also contributing in improving treatment outcomes for Teching lecture: Perineum

Traditional methods for implementing new technology focus on physics commissioning tests. The typical process is: new equipment is purchased; medical physicists test it; radiation oncologists are told that the new equipment is working correctly; and RTTs start using it to image or treat patients. The problem with this process is that it only considers whether the equipment is functioning within the manufacturer’s specifications and internationally accepted tolerances, and doesn’t look at whether its use is safe or appropriate for the local environment. This can result in patients being harmed by the incorrect use of the new technology and it being used for patients who will not benefit from it. It can also lead to inefficiency and workforce stress due to lack of support and/or required infrastructure after clinical implementation of the new technology. Sometimes the opposite can happen: even after the commissioning tests are completed the new technology may not be not clinically implemented due to a fear of these adverse outcomes, resulting in expensive equipment remaining unused and patients continuing to receive inferior treatment. The emergence of risk-based approaches with AAPM TG- 100 The limitations of the traditional approach of physics- based equipment testing were addressed in 2016 by AAPM TG-100, which recommended a multi-disciplinary team (MDT) approach for the safe use of radiation oncology techniques and technologies. The severity, occurrence, and detectability of identified risks are used to generate appropriate quality control measures. The RABBIT system The Risk and Benefit Balance Impact Template (RABBIT) system has been developed at St George Cancer Care Centre. It follows the same principles as TG-100 but is specifically designed for the implementation phase. Its four-step process (Figure 1) guides an MDT through a comprehensive risk-based process for introducing new techniques and technologies.

Step 1: Scope definition The MDT members review the literature on the new technology or technique, agree on which patients would benefit most and how that benefit can be measured. They identify what resources will be required, the timeline of the major milestones, and any restrictions of use. Step 2: Project preparation The intended clinical process is documented and commissioning is commenced, including physics sub- system checks and MDT end-to-end testing. Compliance of the project with local policies, national requirements and international recommendations is reviewed. In parallel to this all staffing groups commence training and writing standard operating procedures for clinical use.