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White Papers

  • As a part of its Target Safely campaign, ASTRO created a series of quality assurance and safety white papers to investigate and develop modern risk-based and process-focused quality assurance methods for radiotherapy treatment. These white papers provided an opportunity to consolidate the abundant available guidance and focus on preventing catastrophic failures.

    These white papers have been endorsed by the American Association of Physicists in Medicine (AAPM), the American Association of Medical Dosimetrists (AAMD) and the American Society of Radiologic Technologists (ASRT), as well as reviewed and accepted by the American College of Radiology (ACR) Commission on Radiation Oncology. The white paper on HDR brachytherapy has also been endorsed by the American Brachytherapy Society (ABS).

    View the introductory paper outlining the goals of the series.

  • A Review of Safety, Quality Management and Practice Guidelines for High Dose-Rate Brachytherapy (2014)

     Authors: Bruce R. Thomadsen, PhD, Beth A. Erickson, MD, Patricia J. Eifel, MD, I-Chow (Joe) Hsu, MD, Rakesh R. Patel, MD, Daniel G. Petereit, MD, Benedick A. Fraass, PhD, Mark J. Rivard, PhD

    This white paper was commissioned by the American Society for Radiation Oncology (ASTRO) Board of Directors to evaluate the status of safety and practice guidance for high dose-rate (HDR) brachytherapy. Given the maturity of HDR brachytherapy technology, this white paper considers, from a safety point of view, the adequacy of general physics and quality assurance guidance, as well as clinical guidance documents available for the most common treatment sites. The rate of medical events in HDR brachytherapy procedures in the United States in 2009 and 2010 was 0.02 percent, corresponding to five-sigma performance. The events were not due to lack of guidance documents, but failures to follow those recommendations or human failures in the performance of tasks. The White Paper reviews current guidance documents and offers recommendations regarding their application to delivery of HDR brachytherapy. It also suggests topics where additional research and guidance is needed.

    Read the executive summary
    Read the full white paper

    Safety considerations for IGRT (2013)

    Authors: David A. Jaffray, PhD, Katja M. Langen, PhD, Gikas Mageras, PhD, Laura A. Dawson, MD, Di Yan, DSc, Robert Adams, EdD, Arno J. Mundt, MD, and Benedick Fraass, PhD

    Radiation therapy is an effective cancer treatment that is constantly being transformed by technological innovation. Dedicated devices for fraction-by-fraction imaging and guidance within the treatment room have enabled image-guided radiation therapy (IGRT) allowing clinicians to pursue highly conformal dose distributions, higher dose prescriptions, and shorter fractionation schedules. Capitalizing on IGRT-enabled accuracy and precision requires a strong link between IGRT practices and planning target volume (PTV) design. This is clearly central to high quality, safe radiation therapy. Failure to properly apply IGRT methods or to coordinate their use with an appropriate PTV margin can result in a treatment that is ‘precisely wrong’. The white paper recommends foundational elements and specific activities to maximize the safety and effectiveness of IGRT.

    Read the executive summary
    Read the full white paper

    Safety Considerations for IMRT (2011)

    Authors: Jean M. Moran, PhD, Melanie Dempsey, MS, Avraham Eisbruch, MD, Benedick A. Fraass, PhD, James M. Galvin, DSc, Geoffrey S. Ibbott, PhD, and Lawrence B. Marks, MD

    This white paper critically evaluates guidance and literature on the safe delivery of IMRT, with a primary focus on recommendations to prevent human error and methods to reduce or eliminate mistakes or machine malfunctions that can lead to catastrophic failures. It places the potential dangers of IMRT into two categories: environmental risks related to lack of sufficient QA, misuse of procedures and equipment, inadequate staff coming education and other similar factors and technical hazards such as deficient validation of treatment delivery parameters or improper use of one or more parts of the planning and delivery process. The white paper offers recommendations for supporting a culture of safety for IMRT in both of these domains.

    Read the executive summary

    Read the full white paper

    Enhancing the Role of Case-Oriented Peer Review to Improve Quality and Safety in Radiation Oncology (2013)

    Authors: Lawrence B. Marks, MD, Robert D. Adams, EdD, Todd Pawlicki, PhD, Albert L. Blumberg, MD, David Hoopes, MD, Michael D. Brundage, MD and Benedick A. Fraass, PhD

    Peer review is one of the most effective means for assuring the quality of qualitative, and potentially controversial, patient-specific decisions in radiation oncology. This report summarizes many of the areas throughout radiation therapy that may benefit from the application of peer review. Each radiation oncology facility should evaluate the issues raised and develop improved ways to apply the concept of peer review to its individual process and workflow. This might consist of a daily multidisciplinary (eg, physicians, dosimetrists, physicists, therapists) meeting to review patients being considered for, or undergoing planning for, radiation therapy (eg, intention to treat and target delineation), as well as meetings to review patients already under treatment (eg, adequacy of image guidance). This report is intended to clarify and broaden the understanding of radiation oncology professionals regarding the meaning, roles, benefits, and targets for peer review as a routine quality assurance tool. It is hoped that this work will be a catalyst for further investigation, development, and study of the efficacy of peer review techniques and how these efforts can help improve the safety and quality of our treatments.

    Read the executive summary
    Read the full white paper

    Quality and Safety Considerations in Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy (SRS/SBRT) (2011)

    Authors: Timothy D. Solberg, PhD, James M. Balter, PhD, Stanley H. Benedict, PhD, Benedick A. Fraass, PhD, FASTRO, Brian Kavanagh, MD, Curtis Miyamoto, MD, Todd Pawlicki, PhD, Louis Potters, MD, FASTRO, and Yoshiya Yamada, MD

    This report builds on guidance in previous documents and broadly addresses SRS/SBRT delivery, with a primary focus on programmatic elements and human processes that can identify and correct potential sources of error, particularly those which can result in catastrophic consequences. Recent media attention to several serious radiosurgery mistakes have served to add even more emphasis to the need to have robust procedures in place to address the potential for errors due to limitations in equipment safety design, quality assurance systems and procedures, and human knowledge and training to avoid serious failures. This white paper discusses the complexity and variation inherent in SRS and SBRT, especially taking into account the fact that it is used for many different disease sites, and considers the issues programs must be cognizant of related to staffing and training, simulation and planning technologies, acceptance and commissioning of treatment machines, and quality assurance.

    Read the executive summary
    Read the full white paper

    Standard Prescription White Paper (in progress)

    Authors: Suzanne B. Evans, MD, MPH, Paula Berner, CMD, FAAMD, Kevin S. Collins, PhD, RT(T), Benedick A. Fraass, PhD, Teamour Nurushev, PhD, Michael K. O’Neil, MD, Jing Zeng, MD, Lawrence B Marks, MD

    The central goal of this white paper is to facilitate accurate communication between radiotherapy care providers through standardization of the radiation therapy prescription.

    This white paper is currently under development.

  • These white papers are current and have been published in Practical Radiation Oncology.


    Quality and Safety Considerations in Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy (SRS/SBRT) (2011)

    Authors: Timothy D. Solberg, PhD, James M. Balter, PhD, Stanley H. Benedict, PhD, Benedick A. Fraass, PhD, FASTRO, Brian Kavanagh, MD, Curtis Miyamoto, MD, Todd Pawlicki, PhD, Louis Potters, MD, FASTRO, and Yoshiya Yamada, MD

    This report builds on guidance in previous documents and broadly addresses SRS/SBRT delivery, with a primary focus on programmatic elements and human processes that can identify and correct potential sources of error, particularly those which can result in catastrophic consequences.

    Read the executive summary
    Read the full white paper


    Safety Considerations for IMRT (2011)

    Authors: Jean M. Moran, PhD, Melanie Dempsey, MS, Avraham Eisbruch, MD, Benedick A. Fraass, PhD, James M. Galvin, DSc, Geoffrey S. Ibbott, PhD, and Lawrence B. Marks, MD

    This white paper critically evaluates guidance and literature on the safe delivery of IMRT, with a primary focus on recommendations to prevent human error and methods to reduce or eliminate mistakes or machine malfunctions that can lead to catastrophic failures.

    Read the executive summary
    Read the full white paper

    Enhancing the Role of Case-Oriented Peer Review to Improve Quality and Safety in Radiation Oncology (2013)

    Authors: Lawrence B. Marks, MD, Robert D. Adams, EdD, Todd Pawlicki, PhD, Albert L. Blumberg, MD, David Hoopes, MD, Michael D. Brundage, MD and Benedick A. Fraass, PhD 
     
    Peer review is one of the most effective means for assuring the quality of qualitative, and potentially controversial, patient-specific decisions in radiation oncology. This report summarizes many of the areas throughout radiation therapy that may benefit from the application of peer review.

    Read the executive summary
    Read the full white paper

    Safety Considerations for IGRT (2013)

    Authors: David A. Jaffray, PhD, Katja M. Langen, PhD, Gikas Mageras, PhD, Laura A. Dawson, MD, Di Yan, DSc, Robert Adams, EdD, Arno J. Mundt, MD, and Benedick Fraass, PhD

    This white paper recommends foundational elements and specific activities to maximize the safety and effectiveness of IGRT.

    Read the executive summary
    Read the full white paper

    A Review of Safety, Quality Management and Practice Guidelines for High Dose-Rate Brachytherapy (2014)

    Authors: Bruce R. Thomadsen, PhD, Beth A. Erickson, MD, Patricia J. Eifel, MD, I-Chow (Joe) Hsu, MD, Rakesh R. Patel, MD, Daniel G. Petereit, MD, Benedick A. Fraass, PhD, Mark J. Rivard, PhD

    This white paper reviews current guidance documents and offers recommendations regarding their application to delivery of HDR brachytherapy. It also suggests topics where additional research and guidance is needed.

    Read the executive summary
    Read the full white paper

    These white papers are currently under development and are not yet published.


    Standard Prescription White Paper

    Authors: Suzanne B. Evans, MD, MPH, Paula Berner, CMD, FAAMD, Kevin S. Collins, PhD, RT(T), Benedick A. Fraass, PhD, Teamour Nurushev, PhD, Michael K. O’Neil, MD, Jing Zeng, MD, Lawrence B Marks, MD

    The central goal of this white paper is to facilitate accurate communication between radiotherapy care providers through standardization of the radiation therapy prescription.