Tattoos and Marks: How SGRT Makes Them Unnecessary for Treat

Kelli Cook (00:00):

Today we’re going to be talking about this one tattoo and marks how SGRT makes them unnecessary for our treatments. So we’ll go ahead and get started. So let’s go over Kelsey Technology first: what we have at my facility, so we have two TrueBeam’s, both have 6 DOF, couches, we have the AlignRT system, and then in CT we have the SOMATOM go. Platform. I call it the CT GoPro because that sounds cooler. And in CT we do have RGSC.

Kelli Cook (00:31):

So what are we going to be looking at today? What’s this presentation going to go over? So we’re going to talk about the accuracy of SGRT. Can we trust the system to set up our patients accurately? We’ll go over some benefits, why we don’t need to be using marks, how that benefits our patients, and then we’ll go over some data. I’ll make that as interesting as I can. I’ll jump around a, lot and then maybe are there any cons to not having marks for our patients?

Kelli Cook (00:59):

All right, so SGRT, the accuracy of it, so setting up our patients, SGRT, our AlignRT system monitors the actual surface of the patient. Is anything more accurate than the patient themselves? I don’t think so. Especially when you know you have a point setup, you’re only setting up to a very small area of the patient. Whereas when you’re drawing your ROIs, you’re setting up to a full area that you’re treating and so you have more data to be able to be more accurate with things like your pitch rule and yah. So again, moving onto the camera’s account for all six degrees of freedom. Now, you could argue with me that Marks can account for about five of those degrees. Where you really lose that six degrees is in your pitch. You don’t get that with marks, but you could argue for five. But I’m telling you that that pitch makes a huge difference, especially with those prostate patients that I’ve noticed at least. And then the additional tools that we see with SGRT, I know we’ve heard a lot about that postural video. That is, you know the bread and butter of using the SGRT system, the AlignRT system and thing. Other things too, like your treatment captures, where you can see that overlay, you know, in real time of what you need to adjust on your patient, where you need to adjust. And even things like taking your SSDs weekly.

Kelli Cook (02:17):

So I can talk about how great SGRT is, but what does it actually look like when you’re going from your setup to your imaging? What do your shifts look like? Are they minimal? Are they huge? What does it look like with the setup and your deltas being correct versus when you’re imaging are the shifts minimal? Because That’s what we ideally want, correct?

Kelli Cook (02:36):

So, some example images. So our patient, this was a left A PBI. So it was a partial breast treatment. We can see here that our deltas look great. I’m going to point out this pitch because she was breathing. So we have a little bit of a pitch from that. Inhale, exhale, breathing. And then so I was pointing out these deltas and then we see here that these were the shifts from the cone beam. This was a day one patient. So I didn’t cheat and pick a patient that I knew set up really well. We had never treated this patient before and these were the shifts that we got. And now you’re probably like Kelly, that’s a negative five shift. That’s not accurate at all. So I can explain that. So this patient was a cone beam daily because she was in IMRT. And so our doctors like cone beams for those types of treatments. However, imagers don’t clear and so that negative five shifts put to account for the clearance of the imager and not hitting the patient. So if we take into account that negative five shift, you see that it’s actually just a 0.14 and we have one more. So this is a prostate patient again day one patient. So I did not cheat. We had never set him up before. We see our deltas are pretty much perfect and then our shifts are very minimal as well. Taking into account things like the bladder being maybe too empty, too full. We have a little bit of that verse shift accounting for maybe some rectum. But again, our shifts are minimal. So we see that what we’re monitoring is accurate, our shifts are minimal. We can trust this system from setup to image, applying our shifts and treatment.

Kelli Cook (04:18):

So let’s go over some benefits, right? It benefits us and our patients so patients don’t have to worry about keeping their marks. We don’t have to be in SIM and being like you have to have this. If you don’t, it’s going to take 30 minutes for us to set you up. So don’t lose these. And I live in southeast Texas where all we do is sweat. That’s what we do. There’s nothing but humidity and sweat. And so our patients are like, you know I sweat, right? And I’m like Yeah but you know, do your best. So yeah, patients don’t have to worry about that. If we’re not even using the marks, it’s like, don’t worry about it. You know, you just put those little bbs on, take them off and the patients can have a nice day. So no mark or tattoo searching on your first day. I don’t know. I’m pretty sure all of us can reach deep in our memories. And remember when we had to get a flashlight out, call your partner over. Do y’all think this is a freckle is a tattoo? I don’t know. It’s hard to tell. So if you don’t have the tattoo or the mark, you don’t have to worry about that. It doesn’t take that extra time to search for those marks, search for those tattoos because your patient just doesn’t have them. And then I will shamefully admit that I have very confidently shifted my patient in the completely wrong direction and then turned on vision and been like, let me just exit the room now. So no incorrect shifting, no seeing those big shifts or trying to do that math. I am a math pride person. I’m like I don’t need a calculator and then it’s completely wrong.

Kelli Cook (05:41):

So you don’t have to worry about that because you don’t have the shifts to begin with because you don’t have marks. And then a big one for our patients. They’re spending less time on the table. So you have those patients that are trying to hold their bladders that are in a lot of pain that are having a hard time holding still they’re very anxious and the less time they have to spend on the table in an uncomfortable position, the better for our patients. I think that really contributes to a better standard of care, better patient care that our patients aren’t in that uncomfortable position while we’re trying to search for marks, trying to do our math, trying to do our shifts.

Kelli Cook (06:18):

All right. So I can talk a lot of good stuff but can I back it up with any kind of proof and I think I can. So I’m gonna go over some timing criteria. Huge shout-out to all of my coworkers. They helped me with gathering a ton of data. They were really great. They did everything I asked them to do and they were fantastic. So we’ll go over the criteria I gave them that I was wanting for the data and then I’ll go over the evidence what I got and then an overall time difference between what we see with our marks versus without our marks.

Kelli Cook (06:53):

So what I told my coworkers was for the setups, if you were going to use the marks and it was day one, you go to your marks, you do your shifts, you turn on AlignRT. So what we see there is you’re actually setting your patient up twice, you’re using your marks and then using the AlignRT or an SGRT system to set your patient up. So why don’t we just cut out the middleman, have one set up instead of the two a daily treatment. Again you go to your marks, we would auto-enter from the parameters we captured the day before. Turn on the AlignRT and do the second setup with our SGRT system. A lot shorter list if you don’t have to do that second setup. So, a new treatment, a general treatment area. We all kind of can guess where the prostate is and you know where that right breast is. Turn on your AlignRT or your SGRT system, and make your shifts from there. And then, daily treatment auto-enter, turn on that AlignRT exit the room when you have your Deltas correct.

Kelli Cook (07:56):

All right, so we’ll go over pelvis and our chest, abdomen. I combine chest, abdomen because those setups are the same for my facility. So with our pelvis, I have, you know our marks on one side. So our total time over 17 setups was about 25 minutes. We take the average about a minute 28 for our pelvic patients. Whereas with mark less 38 seconds average setup. So we’re saving almost a minute of our patient trying to not pee on our table. So I think that really benefits them in that situation. Chest, abdomen, it’s the same setup. So we have a minute 11 for average where versus 42 seconds.

Kelli Cook (08:36):

And then we have our breast patients. So our breasts take a little bit longer to set up because we check our fields daily. And so I included that in the setup because I told them, you know, when you’re ready to leave the room, that’s when you please stop the timer for the setups. So breasts again, I was where we saw the biggest difference. Some of our time saving was over a minute just setting up our patients. And so we have our breast and then our breast, DIBH breast with Marx was 231 versus mark lifts was 123 and then the DIBH three minutes and 13 seconds versus you’re right at two. So you’re saving over a minute on those patients trying to hold their breath.

Kelli Cook (09:17):

Okay, so I have to point out my shame. So this is new start data. I didn’t have as much data because you know I have to wait for a new start to actually start their treatments. And so I kind of have each site. So the pelvis, the breast, the breast, DIBH in the chest, abdomen, marks versus markerless and y’all will notice that. Beautiful N/A. So I was going through my data, I told my coworkers like okay, I’ve got everything I need. This is great. And then I was like, we did not do a markerless breast, DIBH new start. And then we didn’t have another one coming up, but I figured I’d at least show y’all the new start for the marks was almost four minutes. And I can guarantee you that without the marks it was way less than that. But that was an oopsie on my part. But you know, it’s there, there for everyone to see.

Kelli Cook (10:04):

So average day in the clinic I pulled an average an actual day in our clinic. They, we had about 10 pelvic patients. We had three breast patients, 3D IBH patients and three abdomen chest patients. So this was an actual day, I think it was like a random Thursday that I picked. So what I did was based on the averages we just went over, I was like what would it look like if we had done all marks versus all mark less? So with our marks with that schedule, we would’ve spent 32 minutes just setting up our patients throughout the day. Whereas with markless about 18, 19 minutes. So for my facility, that’s almost a whole appointment time slot. What does that mean for us though? So that’s time to catch up on your schedule. That’s time that you can spend with your patient if they need it. If your patient is having a really hard time anxiety, that’s time you know that you have during the day because you’re not using those marks that you can catch up in your schedule and give that patient the little bit of extra care that they need. And also too, it’s nice to, you know, be ahead of schedule, you’re like ahead of schedule.

Kelli Cook (11:15):

But are there cons? Are there negatives to not having the marks? So I kind of want to group the first two together, no physical backup on the patient and additional imaging if the system is not functioning. I have some wood somewhere. So we have almost never had our system go down. But we all know that you have to have a contingency plan if something’s not working. Our power grid is not great. So if our system’s not working, it’s not because of the system, it’s because we lost power and that’s just the whole facility. So no physical backup on the patient, but the additional imaging, I could argue the same thing. If your patient loses their marks, you have to do the same thing. You still don’t, unless you have a tattoo on a patient, which is a permanent mark they have to have for the rest of their lives. If you or your patient loses their marks, you have the same issue as if your system’s not working. So that third one, that reliance on technology, I would like to explain that a little bit. This is just my observation, my experience using the system, especially because we are associated with the university. So we do get students is what I see is that sometimes we spend a lot of time looking at a computer screen and not looking at our patient. I still think it’s important that we do go back to our basic skills and being able to look at our patient on the table if their legs are hanging off the table. Because the system told you to shift their, you know, hips. It’s like okay, well that’s not correct. There’s probably a tissue change somewhere or something in the setup that we need to account for. So I think it’s important that especially when we are training their students in the new therapist coming up, that they still have the ability to look at their anatomy and look at their patient and also be able to interpret the computer screen. And I’ve done it too where I’m like, I’m not even looking at the patient, I’m shifting my table all over the place and I’m like, let me take a step back and be able to look at my patient. Because I do have a person on the table. So I think we have to find that healthy balance of technology’s great. I think we should always be expanding technology and improving our treatments, improving our systems, but also not sacrificing that basic of, I have a person on the table, let me look at them as well.

Kelli Cook (13:20):

So in conclusion, I we’ve seen the faster setups, less table time for our patients, more time for us during the day, more time for patient care instead of setup care, and less stress for our patients. They don’t have to keep the marks, we don’t have to look for them. And I think overall you have an improved patient experience when throughout the day, you’re not having to account for a second setup marks and your patient trying not to pee on your table, being in a lot of pain, trying to hold an already uncomfortable position.