SGRT for Every Patient

All right. So yes, today I’m going to talk about every site, every patient using SGRT. I’m briefly going to talk about my experience at two different centers in the same system, the common anatomy that we use for SGRT, and the sequence of events that brought us to doing it, or attacking every anatomy with SGRT. I’ll also discuss moving into less common anatomical sites, and then my plan moving forward to transition once again to every site, every patient. And just a disclaimer, we have both AlignRT and BrainLab ExacTrac Dynamic at the center I’m at now. We’ve only had the BrainLab really working within the last couple of months, so I’m mainly going to be talking through the lens of AlignRT, but I’m going to sprinkle in some stuff about BrainLab.

I wanted to put this up. This was the poll that VisionRT had put up at the beginning of the meeting yesterday, and they very kindly shared it with me. I wanted it also to inform me on where I was going to be spending some time talking today. So these were your answers. It looks like most people either are using or want to be using SGRT for breath-hold breasts and SBRT, and it’s about 50%-ish on the rest of the sites. It turns out I’m probably going to spend a little bit of time on everything, but hopefully not go over.

My experience: I’ve been with Atrium Health and Advocate Health since 2013, and we got our first AlignRT system in about 2014, I believe. We had two TrueBeams and AlignRT on both. The center I’m at now, which I transitioned to in the fall, has three TrueBeams, two with AlignRT and one with the ExacTrac. At center one, I got the impression when we first got the system that we did want to focus on breath-hold breasts, that it was a breath-hold breast system. And so that’s where we started, which in retrospect, I think I’ve heard a lot of talks where people say, “That’s really difficult to do. You’re starting with something that’s really complex.” But it was a need that we had because we didn’t have anything else. So it filled that need, and it very quickly became a trustworthy piece of technology at our center. It really was organic in how we added other sites: SBRT, different head, brain, SRS cases, thorax, abdomen, and pelvis.

Center two, where I’m at now, has had AlignRT for approximately 10 years, or maybe it was around 2018. And the way it’s used currently, I find it’s used primarily for monitoring the patient because almost every patient is imaged daily, including breasts. Up until recently, breasts were imaged during treatment as well as getting an orthogonal pair. So, we use SGRT routinely for SBRT, both for breath-hold and free breathing. And then for other sites, head and neck, for the most part, yes, unless it’s a closed face mask, and then the occasional osteoarthritis.

It’s interesting for me to look at these side-by-side. Being one system, we want to think of ourselves as being a standardized system, but we’re really not. There are several factors that play into that. One of which is the ExacTrac system; when you have one SGRT system on one machine and another on another, how do you transition patients between the linacs in a busy clinic? You want to be able to do it quickly, so that’s a valid concern. Something else that was brought up from the RTTs themselves was that a lot of the training for young therapists nowadays is primarily focused on imaging being the gold standard, to the exclusion of everything else. I could see it becoming a crutch and trusting imaging as the standard, and then everything else is just secondary.

So, with that said, just real briefly running through the sequence of events. I know most of you are using or would like to use VisionRT or SGRT for DIBH breasts. Prone really does have a place for prone breasts, too. There were some really good talks, I think, at last year’s meeting for prone breasts. It really was helpful in terms of you lower the isocenter for a setup situation only, and that way you can see more of the body’s anatomy, which can be very useful. Deformation of the breast—that functionality in AlignRT is incredibly helpful. There’s thermal imaging in ExacTrac, which I think can be useful as well for bolus placement, especially if it’s custom bolus placement. So there are a ton of tools. Across the board, most people would agree that breasts are low-hanging fruit. SBRT as well, most people are using it. I’ve got a couple of examples shown just of some breath-hold liver, breath-hold lung, and then sometimes even for patients who have compression, using the postural video is really helpful for determining, “Oh, that paddle isn’t in the right place. Maybe we need to move it a little bit.”

For SRS, head, and neck, we’re pretty much immobilizing the patients the same way. This is my only slide with an ExacTrac image, just to show what the interface looks like. I’ve really appreciated hearing the talks about maskless treatments. I know there have been a handful of cases in our system where we’ve done that as well if there’s been a patient who has been claustrophobic or non-compliant with a mask. You put a piece of tape across their forehead—that’s the immobilization—and then use SGRT to track. It can be really effective.

I know some sites are really resistant to using SGRT specifically for pelvises, and I get it, because everyone’s pelvis is different. Not all ROIs should look the same either. I like the idea that no one size fits all, but I think it can still be incredibly useful for thorax, abdomen, and pelvis. I think we can do better than three-centimeter shifts on treatment, and I’m still seeing three-centimeter shifts, which is kind of amazing to me. That is an efficiency issue. I know the therapists have to go in the room to do anything over a two-centimeter shift. So if we can get even a little bit closer—if we can get under 2 cm, which I think is totally feasible with SGRT—we should be able to use it. Frog legs, too; postural video is great for that. Extremities are sometimes a challenge because we tend to use less immobilization for some cases. This was an electron case where there was no immobilization, so I think it would be helpful in that type of situation. Then there are situations where you do have a lot of immobilization, like a VMAT extremity or a soft tissue sarcoma; SGRT definitely has a role in that as well.

For less common anatomical sites, I think osteoarthritis is its own category because we’re treating these with really low doses of radiation, and to me, the thought of imaging these patients over and over again is just not satisfying. I think we can be setting up these patients consistently if we can prove to ourselves that we can through imaging, and then move forward. I’m also showing an image of a bilateral knee where we don’t have an SSD because it’s between the legs; SGRT is really a perfect answer for something like this.

Electrons setups can be kind of limiting—you’ve got a cone, you may have couch kicks—but it does have its place. We have definitely had patients who have been on electron breath-holds that VisionRT has been helpful for. I was really impressed at the Denver meeting; I think there was a whole talk dedicated to electrons and AlignRT, and I’ve been thinking all year about how we can incorporate it into clinical setups to avoid errors. It’s definitely a site worthy of looking at with SGRT.

Diagnostic scans are another area where that’s really growing. We’re planning more palliative patients on diagnostic scans, people that need to get in at the last minute. But there’s always problems with the diagnostic scans; they’re not on a flat couch, and often, the anatomy is cut off. How do you set up a patient without a nice set of marks or something? You use surface guidance. You can send it to a VisionRT or some other SGRT system and at least have a starting place that’s better than nothing. It also has a place in recreating immobilization. That would occur for diagnostic scans because they were scanned without any sort of radiation therapy immobilization. But also, I think we’ve all had the experience where Vac-Loks pop or get thrown away, masks get thrown away, things like that. So recreating immobilization is easy and possible with SGRT.

Special procedures: We do CSI at Center Two, and I really feel like it would be so much more effective and efficient if we used SGRT. This is a picture of a pediatric patient under anesthesia. While they may still be difficult to maneuver, this seems like it would be a lot more efficient. I know it would have really helped us in another case recently. We had an adult CSI patient, not under anesthesia. I had suggested SGRT, but we just hadn’t done it at the site, so people were uncomfortable. So, just watching the patient with eagle eyes the entire time, and at one point, I’m just like, “Stop the beam, stop the beam. Turn it off.” They’re like, “What?” I’m like, “The patient just picked up his hips and moved.” We imaged, and yes, it was on the order of a centimeter. I personally don’t want to have to be staring at the camera that closely to determine if the patient’s moving or not. It would be nice to have a beam hold. And then, of course, patients who move around a lot, or don’t remember what they’re there for, or are anxious; VisionRT is definitely good for gating the beam in those situations.

I feel like I’m a little bit in a “Groundhog Day” situation where I went through this process at one center, and it was really organic. We started with one site, and people were interested in just keep adding more. Let’s see if it works. I really want to see if we can do the same here. Because if we can do it at one, why can’t we be doing it at the other? Why can’t we standardize? Realizing that there are these barriers and some mistrust from people who have not used the system, I’m trying to think logically, putting it into a transition plan: buy-in, education, logistics.

Buy-in: I loved hearing over and over again from the talks about using the words champion, advocate, and superuser. You need buy-in from staff and providers, but I also put patients in there. The thing that ties everybody together is just this trust. For patients, it’s really better if we introduce it to them from the very beginning, as early as we possibly can. If nurses can even mention it at the time they’re bringing the patient into the consult room, just getting patients ready to know that you may be uncovered, you may feel uncomfortable, but it’s for your safety. I find almost universally, if we’re telling patients, “This is for your safety. This is more accurate than if we didn’t use it,” I have yet to come across a patient who is going to say, “I don’t want that.”

Regarding staff and providers: I know different things speak to different people. How do you get people to a place where they are comfortable with using a new technology like SGRT? I’ve really struggled with that. I feel like the championing of it is important, and I don’t just mean the physicist. I really don’t want to go in and just tell everyone, “I’m going to just dump this on you, and you’re going to do it because that’s what I want.” That’s not going to make me very popular. I want everyone to be able to trust this universally. At Center One, I had gotten a therapist involved in a project having to do with the real-time coach, and it really sparked her interest, and she ended up presenting it to our system. Having that buy-in was really just eye-opening; she ran with it. If other people can help you do this type of advocacy and work, it makes everything so much easier. Little projects in the clinic—comparisons of accuracy, efficiency—or things like the Royals Report, which had a themed issue on SGRT a couple of years ago, can be great resources. It’s a really easy read. It discusses different mistakes that have occurred and how SGRT could prevent them. I know when I first came to Center Two, there was a medical event where we treated the wrong vertebral body. We did not use SGRT on this patient. She was a younger woman, only five fractions, and it was caught on the second fraction. Looking at her surface anatomy, especially her being so young and angular, I couldn’t help but think we would’ve caught it if we had used SGRT.

Education: Training, discussion, practice. That gives you happy, experienced users. Training is vendor training and online education. I also put discussion in there because I think that’s vital. Training is one thing, but as I found out with the ExacTrac training recently, it’s often done during the business day, so not everyone can be there. The discussion piece is really the circling back around to cement the ideas and to make sure that nobody has any misconceptions. And then practice—that’s the fun part. You can break out phantoms or practice on each other. That’s really fun, and I think it fosters empathy because the first time you lay down on a prone breast board or that flat tabletop, you realize how uncomfortable it is or how hard it is to hold your breath.

Finally, logistics: Process development is the big piece. Start thinking about how you want your flows to work. That could involve things like, “I’m going to image the first five days, and then I’m going to look at the shifts that I made, and if it was under a certain threshold, then we’re okay using SGRT.” Once you come up with your process, it’s important to not just leave it. We need to reevaluate these things on a regular basis, and you need a backup plan. There will be an occasional time where the system will go down. What is your plan? Whatever your backup plan is, just know that you need to have something in place. And error reporting: have a system for error reporting, but what I really mean is have a culture where people feel like they can report errors. When you have new technology, sometimes you hide in the background or don’t know if you did something right or wrong. But if there’s a culture of communication, then all of this is laid bare. And start slow.

Takeaways: Be proactive. If you see something that possibly could use SGRT, try it because it might work. Be flexible. If something is not working, I’m finding it’s better to just not push. Just leave it for a little while because you can come back to it or try a different site. Maybe there’s a technology issue or a patient-specific issue, but you can come back to it. And be curious because you can get involved, and if you show an openness to help solve problems, SGRT could be the answer. So, thank you.

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