Treatment Accuracy with DIBH and SGRT- A Local Quality Improvement Initiative to Enhance Workflow, Safety, and Efficiency

So, this is our treatment room. So Ocala, Florida, is located centrally. We’re about an hour and a half south of Jacksonville, hour and a half north of Tampa and Orlando. We’re basically in the middle of nowhere. But we are the self-proclaimed horse capital of the world. And then this is a picture of my team from a few years ago. So we, sorry.

We got AlignRT about three years ago, and within one year, we became completely tattoo-free, mark-free. And the only reason why it took us a full year was because we were not wanting to implement our prone breast patients. So we are a very busy center. We treat about 45 to 50 patients a day on one single VitalBeam. So when we implemented AlignRT, we were extremely busy. So we implemented every single body part that we treated except for prone breasts. And mainly because we only had a couple here and there, we weren’t really busy with prone breasts. So once we became more able to have prone breast treatments, had a little bit more treatment, had a little bit more training on it, it took us about a full year, and then we became completely tattoo-free. So this is our award. And I’m definitely not as pregnant as I am right there, but I am getting there soon.

So we’re going to do a quick poll because I noticed it may not be early, but everyone does look like they’re very tired. So the first question I’m going to ask everybody, who here currently treats DIBH right breast patients? Wonderful. Quite a few people. And now, does anyone use DIBH to do any type of chest, abdomen, lung, sternum? Beautiful. And who is completely tattoo-less? Not bad. A few. Who uses my favorite function, which is Send to Couch? Not as many. So as you guys will learn as you start to use, Send to Couch is one of the easiest things you can do for yourselves. Personally, in our clinic, we don’t really use Send to Couch on our DIBH patients, but we use it for every single other site every day, all the time. It makes your time in and out of the room so much faster.

So I just want to give you a brief touch on how many breast patients we actually treat in our clinic. So we, like I said, we treat about 45 to 50 patients a day. And I would say we treat probably 20 to 25 of those. Almost half of our patients daily are actually breast patients. And it is our practice’s standard to do all left and right side breast patients DIBH. The only patients that I’m not doing DIBH on are patients that are either unable to hold their breath or they just physically cannot fall within the correct parameters. I had one patient recently that was absolutely terrified the second I walked her into the simulation. She saw that she had to go inside of a bore, had an absolute panic attack. So I did a free breath scan on her, and that was all that she could tolerate. A couple other patients I’ve had were just very, very old, kyphotic, precious little ladies who just had the hardest time just trying to get on the table and really just couldn’t even take a breath in.

So for last year, the entire year, we treated 65 left breast supine patients. Of those 65 patients, 63 of them were DIBH. So we’re in the high 90% of the left side. Now, for the right side, I had 42 supine right breast patients. 38 of them were DIBH. So we’re still in the 90th percentile for how many DIBH patients we treat. Prone, I had 27 prone patients, and then APBI, which is accelerated partial breast treatment, whether it is a left or right breast, these are also still going to be DIBH. We had 19 of them last year. 17 of them were DIBH. So overall, I had 153 total breast patients. 118 of them were DIBH. So that meant that 94% of all supine breast patients were all getting DIBH.

Now, to this year. So these statistics are only from January, February, and March. So for my left side, I had 12 left breast patients supine. All 12 of them, 100% have been DIBH. The right breast side, I had 17 patients. 16 of them are DIBH. The one that is not is the patient I told you about that had the anxiety attack. We’ve done three prone patients, 100% on having DIBH for all of our APBI. So, so far for the year, we’ve done 36 total breast patients, with 32 being DIBH. So about 97% of our patients that are breast this year have been DIBH patients.

Now, do you really need to do DIBH? Obviously, everyone always talks about having less dose to the heart, less dose to the lungs, less dose to the liver. Is that actually really true? So in this picture, this is a patient who is breathing normal. So her entire breast tissue is essentially sitting right up against the top of the heart. So a lot of patients, not everyone’s anatomy is going to be exactly the same. You will have patients who are breathing normal and their chest wall is already pulled far enough away from the heart that it’s really not going to make as large of a difference. But majority of the time, the heart does sit right up against the chest wall and will give you a very large heart dose. Versus if someone takes a breath in, that pulls the entire heart away from the chest wall and really gives you a nice separation between your treatment area and the heart itself.

So a quick touch on APBI. So we do a lot of APBI patients. So APBI is accelerated partial breast irradiation. So for us, our doctor has specific standards that he stays within to who he actually will allow to be a candidate for APBI. So that will include somebody who is over the age of 50, mainly because where we’re in the middle of nowhere, I have some patients that travel an hour to an hour and a half to even get to us. So obviously, we don’t want them to have to drive 21 days to come and see me. They would rather get it done within five treatments. They do have to be early stage. They cannot have any nodal involvement. And then it also depends on the tumor volume. Obviously, if they’re early stage, but they have a huge tumor, it still might not be the best option. So he does go over all this with them, and anyone who falls within that criteria, he will give them the option if they would prefer APBI for five fractions or do the regular course.

So let’s talk about how we begin with DIBH. So on the day of simulation, we position the patient. If they are a 3D patient with tangents, they’re going to be on a supine breast board. If they are anything that has any type of nodal involvement, then we are going to do it on a wing board with a VacLock, and that is just for my dosimetrist preference. So we will wire the borders of the breast tissue, and we will wire the scar. A lot of times, the doctor will come in to do that, or being the lead, I’d usually just do that myself. So we’re doing the superior and inferior borders, medial, laterally, and then doing the scar. I practice the breath hold technique with every single patient. I basically explain to them, “This is the reason why we’re going to do two separate scans, one’s free breathing, one we’re going to hold your breath.” And I try to keep the same language in the sim as we use in the treat machine. So I will come up to the patient, and I say, “What you’re going to hear me say, when you’re ready, take a deep breath in and hold it.” I make sure to let them know, though, that I do not want it to be quick or aggressive. Sometimes you have patients that just go and then they lift their whole body, and that’s not something that they can hold for very long, and it’s not reproducible. So we practice that quite a few times, and then I time the patients. I tell them, “Ideally, I need you to hold your breath for 20 to 25 seconds.” And they always think, “Oh my God, I can’t do that.” And then I time them, and we hit 25 seconds, and they’re like, “Oh, wow. Like that was so easy.” So I really make sure I take time in the simulation to explain everything, explain the whole process, and get them comfortable, because the more comfortable they are in the simulation, the more comfortable they are going to be on the treatment machine itself. And then we do two scans. The first scan, they breathe completely normal, and then the second scan, they breathe in, they hold their breath. And obviously, I have a camera that is zoomed right in on their chest, so I can watch them the entire time just to make sure they don’t actually breathe on me.

So now, when we create an ROI. So ROIs are very important. You really need to make sure you’re getting good and accurate with your ROIs, and there are plenty of different ways to do ROIs. It just works on whatever’s best for you and that patient specifically. There is no set ROI that is going to work for every single patient. So the biggest thing you want to do when you first have the plan imported is you’re going to make sure you’re actually choosing your structure set correctly. If you don’t choose this correctly at first, it’s going to be hard for you. So you always want to make sure you’re choosing the body and the free breathe body structure set, and then you’re going to make sure that you’re choosing your DIBH breast or DIBH chest wall before you can move on.

So for your free breathe body, so this is what we’ve already talked about. This is your setup surface. So there is a little drop-down menu that will ask you if you want it to be setup surface only or treatment, and you want to make sure your free breathe is on setup surface because you obviously don’t want to be able to mistakenly treat when you’re in a free breathe. Versus with your DIBH, that one on the drop-down menu, you pick treat with beam control. And make it easy on yourself. If you are in one of them and you draw your ROI out, you save it, and you can literally copy and paste it into the other one and rename it. It’s going to save you time, and it’s going to ensure that you’re using the similar ROI.

So a couple different examples of ROIs that you can use. You can use it where you’re just using the ROI on one side of the patient’s body. You can use it if you have nodal involvement where you come up into the supraclav area. The biggest thing with the ROI is you want to ensure that you are on a stable part of the body, and you’re not going into anything that is really movable. So even though you’re going up into the collarbone a little bit, you do not want to come up into their arm because their arm is going to move all around. You also don’t want to come too far down the sides of the body because then you run into unstable skin. You might run into the VacLock. You might run into the sheets. And you also don’t want to go too low because you don’t want that ROI to be on their abdomen, where even though they’re holding their breath, the abdomen itself is still moving a little bit.

This example right here is one that I used on a patient where I did the entire right side of the breast. I did not include the left side of the breast, but we did include a strip kind of along the chest where it was stable. A patient that I did like this was, she was pregnant when she found out that she had cancer. She had her baby, and within one week, she was coming to be simulated. When she came in, it was her first child. The doctor had not explained to her, obviously, you can breastfeed from the opposite breast, or you need to pump. You need to get rid of that milk. So she had a massive case of mastitis, so she was extremely large. So we talked to her. I explained to her what to do, contact your doctor. When she came in for treatment, it was much different. It was very flat. So if I had had my ROI covering both sides of the body, that breast tissue would’ve been completely different. So we just decided to just take that breast completely out, keep it on the chest itself, and it worked out perfectly. This is the standard that we use. We take it across both sides of the chest. We come up above the breast, just below the breast. And again, if you have patients that need issues or have issues, you can always adjust it, but this is typically the style ROI that we personally use.

So five simple steps for while you’re treating. So the first one is treatment. So when you get into the treatment room itself, you’re going to hit auto on your pendant, the table is going to move up, and the very first thing you’re going to do is just press play. When you press play, you’re going to see the free breathe, and you’re going to see your DIBH drop-downs. You always want to begin with your free breathe. Your free breathe, you’ll get everyone into position, and then you’ll set all of your tolerances. You’ll make sure your vert, long, and lat are all as close to zero as possible before you ever get to your DIBH treatment. So while you run your monitoring, you’re watching the patient, moving the table or moving the patient to get them into position. Once your free breathe is good, everything is at zero, you then switch over to your DIBH. You instruct them to take their breath in. Ideally, they will go up into the tolerance, and they will fit perfectly, and you don’t have to change anything. Sometimes you do have to alter it a little bit on your long or your lateral, but a lot of the times if the patient is comfortable, if they’re breathing the same every day, they should just be able to breathe and fall right into tolerance.

Everyday imaging. So at my center, we do treatment imaging every single day, every single patient. All of our breast patients, regardless of their 3D or IMRT, they get a spotlight CBCT every single day. Always monitor. Make sure you are always watching the patient. Even though we can tell the patients 100 times, “Do not move, don’t turn your head, don’t bring your arm down,” patients are going to forget, and they’re going to do it. So always make sure that you’re watching all of your cameras, watching your postural alignment, making sure that patients have not moved. If you have some patients that are movers or I’ve recently had a few patients that actually had dementia, we just continuously talk to them the whole time and let them know what we’re doing, make sure you’re holding still, make sure you’re breathing normal, just so that they feel more at ease, and then they have the constant reminder, “Oh, wait, I can’t just bring my hand down and scratch my face because I had an itch.” And then terminate session. So once you have done all of your imaging, you’ve done all of your treatment, you just press pause, and you close out of the patient, and you terminate it.

So overall, we treat our 3D breast patients in a 12-minute time slot. Our IMRT breast patients, we typically do in about 15 to 18 minutes, and that’s solely because my dosimetrist likes to give me six half arcs on an IMRT breast patient. So it takes a little while. So this is when you are in the room, and you are setting up on the free breathe scans. You’ll see right in the middle where it says SGRT Free Breathe Body. You get the patient onto the table. You auto the table up, and then we’re going to look at the postural alignment, and we’re going to physically move the table to put all of those tolerances on the side into tolerance. Now, I do have a six-degree couch, so I will look at the pitch, roll, and rotation, but I’ll be honest, if those are all under three, I’m not even going to touch them because my table’s just going to do it for me. As soon as everything is into tolerance, all your parameters are at zero, then we can switch over to the DIBH scan.

And with your DIBH scan, the graph at the bottom, they’re going to take their breath in. Ideally, they get into the middle of that graph, and as soon as that turns green, the beam can turn on. We also have an RTC or what’s called a real-time coach, which is a little camera, essentially, that they have next to their face that they can see that graph, and then they can actually watch themselves and see themselves go up into tolerance. Which is really great because some patients think that they’re taking the exact same breath, and they’re really not. But then if they have the RTC, they can see themselves take their breath in and be like, “Oh, let me just go just a little bit more.” Now, even with that, you will still have some patients that do still need some coaching, whether you say take it a little bit deeper or let a little bit out. It just depends. But the RTC is a great tool to use.

Now, if you have trouble when you are trying to get your patient into setup with the DIBH, say they take their breath in and their lateral is off or their long is off, you can just move the table a little bit. Now, say you have them take their breath in and they are just nowhere near where they are supposed to be. I tell them, “Breathe normal.” I go back to the free breathe, and then in that amount of time, they have usually moved. So your free breathe is no longer going to be on. So you just go back and just double-check, make sure everything looks good.

Problems. Obviously, a DIBH is not going to work 100% of the time, all the time, and going to be perfect. There’s going to be problems. What kind of problems are we going to have? So here are a few common issues that have arose for us and how we have combated them. So the first one, getting the patient into the threshold during setup. This is really going to be all about making sure you’re talking to your patient, keeping your patient comfortable, and doing the same thing every single day, regardless of who from your staff is inside the room. Everyone’s doing the same setup, everyone’s saying the same thing, telling them how to take their breath in and what we’re doing with the table. Our threshold disappears while we’re cone beaming. So while you’re cone beaming, has anyone ever had the issue where as the gantry and the panels are moving that your values have just disappeared and everything is just blank? Yes. So this is happening because when your gantry moves and your panels are out, it blocks all of your cameras, so there are some angles that it literally disappears. So I just make sure that if I know that that’s going to happen before we ever begin the cone beam, I make sure all the values are on the screen, so when they take their breath in, they can see that they’re green, and they’re in tolerance. I tell them, “Hold it,” we begin, it disappears, and then it comes back. We don’t seem to have any problems with that. Patients know that that’s what’s going to happen. They just keep holding their breath until I tell them that they’re allowed to breathe.

And then patients not staying in tolerance during treatment. Now, this can be a common issue, especially if I’m making a patient hold their breath for a really long arc. So if I have a long arc, I will typically let them breathe halfway through, just because the longer they hold it, the more they’re going to start to move, and then when you let them breathe out, they’re going to go, and they’re just going to be nowhere near where they’re supposed to. So if you notice that you are in your DIBH treatment screen, you ask them to take their breath in, and they cannot get themselves back into tolerance, what I do is I just go back to my free breathe reference from after we did all of our cone beam shifts, and I’ll notice that those shifts are off a little bit, and then this is where I would use Send to Couch. So I would go back to my free breathe scan, Send to Couch those values, and they’re usually very minuscule, .2, .3 maybe, and that shifts the couch back to zero, where we began. I’ll go back to my DIBH, ask them to take their breath in, and they are magically in tolerance. Does that happen every single time? No. So on the case that I have made those shifts, and now they’re still not getting themself into tolerance, then we’re going to have to take a new image just to verify they’re in the right place. And if they’re not in the right place, you make a shift, you re-reference your DIBH and your free breathe. Or if you take your film, and they’re still in the perfect place, you’re still going to want to reference your capture because even though they’re in the right place, they’re going to go to breathe, and it’s still not going to be in tolerance. So you’ll want them to just take their breath in and capture it on the DIBH and on the free breathe. So any time you’re capturing one, you always want to make sure you have both captured so they’re both in the same plane.

And then actually, last week, we had another issue that popped up that we had never had before, and my RTC actually broke and stopped working. So I had no camera for my patients to look at. So thankfully, Ben sent me a new charging cable overnight. Plugged it in the next day when it came, still didn’t work. And I was like, “All right. Well, maybe it’s the camera itself that’s broken.” So he sent me another one. So we were about three days without an RTC. So the first day, every patient is like, “Where’s my camera? What am I looking at?” I’m like, “Well, unfortunately, it’s broken, so you’re just going to have to listen to my wonderful voice talk to you.” Most patients did completely fine. Some needed a little bit of extra coaching with, “Take a little bit more in.” I made sure this time to actually say to them, “Hold your breath,” so they knew that they were in the right place without visually seeing it. But most of the patients were so well-versed in what we were doing that everyone did just fine. But that was an issue that we have yet to run into.

So now let’s talk about some of the constraints. So obviously, we’ve discussed if you’re going to do DIBH, it’s really for the benefit of the patient. But how much of a benefit is it actually going to give to the patient? So for my center, for left breast free breathe constraints, our goal on the PTV breast is to get 90% to 95%, and we’re at about 99.99%. Our left lung goal is to make sure that we are about 15% to 20%, and we usually hover—I use one specific patient on these, so this is not an average, but on this one patient that I looked at, it was at 15.9. So it is at the lower threshold of what we would want for a lung patient to have. And then the heart goal. The heart, we wouldn’t want to have any more than 200 to 400 centigray, and this patient was getting 95. So well below what we would have wanted within our plan.

Now for the right breast side. The right breast goal is still the same, 90%, 95%. And again, we are getting 99.9% of that. Our right lung goal was the 15% to 20%, and we’re getting about 17. So it’s still about halfway through. It’s within our tolerance, but nothing super crazy. And then there is actually a heart goal for the right side. The heart goal is the same, 200 to 400 centigray, and we’re getting about 46, 47 centigray for the heart from the right side.

So how has AlignRT and DIBH changed our actual daily treatment flow? So like I said, we’ve been using this for about three years. We implemented DIBH patients from day one. Luckily, I had a wonderful trainer, Miss Lisa, who is in the back, who was there to make sure that we got everything through, and we did amazing from the start. So we have shortened all of our treatment times. Like I said, we do all of our breast patients in either a 12 or 15-minute time slot. We spend less time inside the room. DIBH patients are the ones that we spend the most time inside the room just because there’s so many extra steps to it, but I can say from the time we walk into the room, the patient gets on the table, and we walk out, it is less than a minute and a half almost every single time. Now, you do have some patients that need a lot of help getting on the table, or they just want to talk and chitchat, and it’s a little bit more, but most of the times we’re in and out of the room within a minute and a half. Other patients, like a mask patient or a lung patient, we can be out of the room in less than a minute.

Fewer daily images. We used to take a lot of images. We would take our cone beam. Our cone beam would be out of tolerance, and if it was an IMRT patient, I’d have to take another cone beam, or if it was a 3D, we’d have to take some type of a port film. We are not seeing that as much anymore. We typically take our one image. Everything is well within our tolerance, and we’re just able to begin treating. So we take less images, which takes less time and is less dose to the patient. And we also only do spotlight CBCTs instead of a full CBCT. One, the patient can’t hold their breath for a full CBCT, and two, it just takes so much time that with a spotlight, you can see everything you need, and the patient can hold their breath typically the entire time.

More patients on the schedule. Not that I like having 50 patients a day that I have to treat, but it does make it so that now our treatment times have shortened from 7:00 to 5:00 instead of 7:00 to 7:00, because I’m definitely not trying to be there till 7 o’clock at night. And then more efficient. So we have become more efficient with what we’re doing because we are so well-versed, and honestly, it’s just a rinse and repeat. Even though you have a different patient, it’s still going to be the same process no matter what. And once you get good in it, you do really well. Once your staff is trained, everyone moves in and out very quickly. So you become more efficient inside the room, setting up your patient, more efficient looking at your scans, doing things the same way, and then doing treatment.

How did I figure all this out? I did a lot of really painful time studies. So essentially what I did before I could ever convince my staff or my doctor to let me shorten all of our treatment times, I had to do time studies. So I literally had to sit there and went through every single patient for every single site, not just breast, and I did about a week’s worth of your treatment. I looked at their history from when their chart got opened to when the chart got closed, saw how long it was open, and then did an average. Because obviously, sometimes we open up a patient’s chart and they might be in the bathroom, so we’ll sit a minute or two and wait for them. So it’s not always 100% correct. So I did that, and I figured out that a lot of patients that were in a 15-minute time slot, they really only took 11 minutes, or somebody who was at a 20-minute time slot was only taking 15. So that allowed me to prove, yes, we are doing every single one of these patients in a much quicker time with the LineRT and with our six-degree couch that I’m able to back all of these treatments down. Ideally, a lot of these patients that are in 12-minute time slots, we could be doing in 10. My staff probably would not like me very much. But what I do is I try to group all of the same parts of the body together, so all of the breast boards together, all the wing boards together, the pelvises together. That way, if a patient’s going to show up late, you can skip, and it saves you time in having to switch out what part of the table you’re using. So one patient might be at a 12-minute time slot and they take eight minutes, but the next patient that’s in 12-minute might take 14. So they kind of balance each other out.

Are we done yet? So I am done. So like I said, DIBH is really a great tool that you can use within your clinic, for all of your patients. It is relatively easy to learn. You just have to be willing and open to learn about it, and make sure you hound your trainer because they’re going to be your best asset in order to figure out what to do and how to combat any issues that you guys might have. So that’s it.