Quality Management and Safety in Radiation Oncology

  • James A. Purdy
  • Eric E. Klein
  • Philip Poortmans
  • Coen Hurkmans
Part of the Medical Radiology book series (MEDRAD)


Today’s treatment planning and delivery processes have become much more complex and much less intuitive. These complexities, coupled with the inadequate informatics infrastructure typically found in radiation oncology department and outdated national QM guidelines, have created enormous QM challenges for modern radiation therapy. Communication among the planning team, including physician, resident, simulation therapist, dosimetrist, physicist, and treating therapist, is often cryptic and complicated by the hybrid charting systems (electronic and paper medical records) now commonly used. Multiple imaging modalities are often used to define target volumes, and 4-D imaging is now emerging in routine practice, all complicating the information processing further. In a typical U.S. clinic, over 40% of patients are now managed with IMRT plans using computer-assisted optimization software. Plan data, transferred over a network to the verify and record system and computer controlled linac systems, carry complex specifications for treatment including precise, accurate positioning of MLC leafs, variable dose rates, gantry angles, and, in some instances, a moving treatment table. In many cases, different vendor software systems are utilized, and interoperability is not always robust. With such complex technology and even newer advanced treatment modalities continuing to be implemented, e.g. volume modulated arc therapy (VMAT), updated national QM guidelines/approaches, and development of an efficient and robust treatment delivery verification system must be given higher priority by the profession. This greater complexity found in today’s radiation therapy requires a far stronger teamwork approach, since no individual has all of the skills necessary to insure its maximum quality. Continued assessment and updating of QM methodologies and procedures are urgently needed. This chapter will address all these issues focusing primarily on the United States and European QM experience. 


Stereotactic Body Radiation Therapy Gantry Angle Radiation Therapist Treatment Machine Dynamic Wedge 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. AAPM (1990) Report 36: essentials and guidelines for hospital-based medical physics residency training programsGoogle Scholar
  2. AAPM (2005) Report 87: diode in vivo dosimetry for patients receiving external beam radiation therapy: report of task group 62 of the radiation therapy committeeGoogle Scholar
  3. AAPM (2006) Report 90: essentials and guidelines for hospital-based medical physics residency training programsGoogle Scholar
  4. AAPM (2009) Report 104: the role of in-room kV x-ray imaging for patient setup and target localization: report of AAPM task group 104Google Scholar
  5. Abt_Associates (1995) Abt study of medical physicist work effort. Prepared for the American college of medical physics and American association of physicists in medicine by Abt Associates inc., 1110 vermont avenue, N.W., Suite 610, Washington, DC 20005Google Scholar
  6. Abt_Associates (2003) Abt study of medical physicist work values for radiation oncology physics services: round II (final report). Prepared for American college of medical physics and American association of physicists in medicine by Abt associates Inc., 1110 vermont avenue, N.W., suite 610, Washington, DC 20005Google Scholar
  7. ACR (2010) American College of Radiology: practice guidelines & technical standards. In: American College of Radiology, RestonGoogle Scholar
  8. ACR: American College of Radiology (ACR) (2008) Radiation oncology accreditation program requirements.
  9. Alber M, Broggi S, De Wagter C, Eichwurzel I, Engström P, Fiorino C, Georg D, Hartmann G, Knöös T, Leal A, Marijnissen H, Mijnheer B, Paiusco M, Sánchez-Doblado F, Schmidt R, Tomsej M, Welleweerd H (2008) Guidelines for the verification of IMRT. In: ESTRO physics booklet 9. BrusselsGoogle Scholar
  10. Almond PR, Biggs PJ, Coursey BM, Hanson WF, Huq MS, Nath R, Rogers DWO (1999) AAPM’s TG-51 protocol for clinical reference dosimetry of high-energy photon and electron beams. Med Phys 26:1847–1870PubMedCrossRefGoogle Scholar
  11. ASTRO (2010) ASTRO commits to six-point patient protection plan.
  12. ASTRO (2011) Press release: ASTRO reaffirms commitment to quality, issues progress report on patient safety plan.
  13. Balter JM, Wright JN, Newell LJ, Friemel B, Dimmer S, Cheng Y, Wong J, Vertatschitsch E, Mate TP (2005) Accuracy of a wireless localization system for radiotherapy. Int J Radiat Oncol Biol Phys 61(3):933–937PubMedCrossRefGoogle Scholar
  14. Black RD, Scarantino CW, Mann GG, Anscher MS, Ornitz RD, Nelms BE (2005) An analysis of an implantable dosimeter system for external beam therapy. Int J Radiat Oncol Biol Phys 63(1):290PubMedCrossRefGoogle Scholar
  15. Bogdanovitch W (2010) Radiation offers new cures, and ways to do harm. In: New York Times. New York
  16. Bortfeld T, van Herk M, Jiang SB (2002) When should systematic patient positioning errors in radiotherapy be corrected? Phys Med Biol 47(23):N297–N302PubMedCrossRefGoogle Scholar
  17. Bortfeld T, Jiang S, Rietzel E (2004) Effects of motion on the total dose distribution. Semin Radiat Oncol 14(1):41–51PubMedCrossRefGoogle Scholar
  18. Boyer A, Biggs P, Galvin J, Klein E, LoSasso T, Low D, Mah K, Yu C (2001) AAPM report 72: basic applications of multileaf collimators, report of task group 50. Published for the American Association of Physicists in Medicine by Medical Physics Publishing, Madison, WIGoogle Scholar
  19. Bruinvis IAD, Keus RB, Lenglet WJM, Meijer GJ, Mijnheer BJ, van’t Veld AA, Venselaar JLM, Welleweerd J, Woudstra E (2006) Quality assurance of 3D treatment planning systems for external photon and electron beams: report 15 of the Netherlands commission on radiation dosimetry. In: Netherlands Commission on Radiation Dosimetry, Delft, The NetherlandsGoogle Scholar
  20. Budiharto T, Musat E, Poortmans P, Hurkmans C, Monti A, Bar-Deroma R, Bernstein Z, Tienhoven GV, Collette L, Duclos F, Davis B, Aird E (2008) Profile of European radiotherapy departments contributing to the EORTC radiation oncology group (ROG) in the 21st century. Radioth Oncol 88(3):403–410CrossRefGoogle Scholar
  21. Clark BG, Brown RJ, Ploquin JL, Kind AL, Grimard L (2010) The management of radiation treatment error through incident learning. Radiother Oncol 95(3):344–349PubMedCrossRefGoogle Scholar
  22. de Boer HCJ, Heijmen BJM (2001) A protocol for the reduction of systematic patient setup errors with minimal portal imaging workload. Int J Radiat Oncol Biol Phys 50(5):1350–1365PubMedCrossRefGoogle Scholar
  23. de Boer HCJ, Heijmen BJM (2007) eNAL: an extension of the NAL setup correction protocol for effective use of weekly follow-up measurements. Int J Radiat Oncol Biol Phys 67(5):1586–1595PubMedCrossRefGoogle Scholar
  24. Deming WE (1986) Out of the Crisis. MIT Press, Cambridge, MAGoogle Scholar
  25. EFOMP (1999) Pol stat no 9, radiation protection of the patient in Europe: the training of the medical physics expert in radiation physics or radiation technology. Phys Med 15:149–153Google Scholar
  26. Engelsman M, Sharp GC, Bortfeld T, Onimaru R, Shirato H (2005) How much margin reduction is possible through gating or breath hold? Phys Med Biol 50(3):477–490PubMedCrossRefGoogle Scholar
  27. Eudaldo T, Huizenga H, Lamm I-L, McKenzie A, Milano F, Schlegel W, Thwaites D, Heeren G (2004) Guidelines for education and training of medical physicists in radiotherapy: recommendations from an ESTRO/EFOMP working group. Radioth Oncol 70(2):125–135CrossRefGoogle Scholar
  28. European Commission (1997) Council directive 97/43/Eurotom of 30 June 1997 on health protection of individuals against the dangers of ionising radiation in relation to medical exposure. In: Communities OJE (ed) L180, pp 22–27Google Scholar
  29. Ezzell GA, Burmeister JW, Dogan N, LoSasso TJ, Mechalakos JG, Mihailidis D, Molineu A, Palta JR, Ramsey CR, Salter BJ, Shi J, Xia P, Yue NJ, Xiao Y (2009) IMRT commissioning: multiple institution planning and dosimetry comparisons, a report from AAPM task group 119. Med Phys 36(11):5359–5373PubMedCrossRefGoogle Scholar
  30. Followill D, Geis P, Boyer A (1997) Estimates of whole-body dose equivalent produced by beam intensity modulated conformal therapy. Int J Radiat Oncol Biol Phys 38(3):667–672PubMedCrossRefGoogle Scholar
  31. Ford EC, Gaudette R, Myers L, Vanderver B, Engineer L, Zellars R, Song DY, Wong J, DeWeese TL (2009) Evaluation of safety in a radiation oncology setting using failure mode and effects analysis. Int J Radiat Oncol Biol Phys 74(3):852–858PubMedCrossRefGoogle Scholar
  32. Fraass B, Doppke K, Hunt M, Kutcher G, Starkschall G, Stern R, Van Dyk J (1998) AAPM radiation therapy committee task group 53: quality assurance for clinical radiotherapy treatment planning. Med Phys 25:1773–1829PubMedCrossRefGoogle Scholar
  33. Galvin JM, Ezzell G, Eisbrauch A, Yu C, Butler B, Xiao Y, Rosen I, Rosenman J, Sharpe M, Xing L, Xia P, Lomax T, Low DA, Palta J (2004) Implementing IMRT in clinical practice: a joint document of the American society for therapeutic radiology and oncology and the American association of physicists in medicine. Int J Radiat Oncol Biol Phys 58(5):1616–1634PubMedCrossRefGoogle Scholar
  34. Gawande A (2009) The checklist manifesto: how to get things right metropolitan, New YorkGoogle Scholar
  35. Gibbons JP (ed) (2000) Monitor unit calculations for external photon and electron beams. Advanced Medical Publishing, Madison, WIGoogle Scholar
  36. Gregoire V, Coche E, Cosnard G, Hamoir M, Reychler H (2000) Selection and delineation of lymph node target volumes in head and neck conformal radiotherapy. Proposal for standardizing terminology and procedure based on the surgical experience. Radiother Oncol 56(2):135–150PubMedCrossRefGoogle Scholar
  37. Gregoire V, Levendag P, Ang KK, Bernier J, Braaksma M, Budach V, Chao C, Coche E, Cooper JS, Cosnard G (2003) CT-based delineation of lymph node levels and related CTVs in the node-negative neck: DAHANCA, EORTC, GORTEC, NCIC, RTOG consensus guidelines. Radiother Oncol 69(3):227–236PubMedCrossRefGoogle Scholar
  38. Hall EJ (2006) Intensity-modulated radiation therapy, protons, and the risk of second cancer. Int J Radiat Oncol Biol Phys 65(1):1–7PubMedCrossRefGoogle Scholar
  39. Hendee WR, Herman MG (2011) Improving patient safety in radiation oncology. Med Phys 38(1):78–82PubMedCrossRefGoogle Scholar
  40. Henriquez FC, Castrillon SV (2010) Confidence intervals in dose volume histogram computation. Med Phys 37(4):1545–1553CrossRefGoogle Scholar
  41. Herman MG, Balter JM, Jaffray DA, McGee KP, Munro P, Shalev S, Van Herk M, Wong JW (2001) Clinical use of electronic portal imaging: report of AAPM radiationtherapy committee task group 58. Med Phys 28(5):712–737PubMedCrossRefGoogle Scholar
  42. Herman MG, Mills MD, Gillin MT (2003) Reimbursement versus effort in medical physics practice in radiation oncology. J Appl Clin Med Phys 4(2):179–187PubMedCrossRefGoogle Scholar
  43. Herman MG, Klein EE, Mills MD, Boyer A (2005) Estimating medical physicist FTE using the 2003 Abt survey and procedure volumes in radiation therapy (abstract). Med Phys 32(6):2052CrossRefGoogle Scholar
  44. Herring DF, Compton DMJ (1971) The degree of precision required in radiation dose delivered in cancer radiotherapy. In: Glicksman AJ, Cohen M, Cunningham JR (eds) Computers in radiotherapy. Br J Radiol Special Report Series No. 5Google Scholar
  45. Higgins PD, Alaei P, Gerbi BJ, Dusenbery KE (2003) In vivo diode dosimetry for routine quality assurance in IMRT. Med Phys 30(12):3118–3125PubMedCrossRefGoogle Scholar
  46. Holmes T, Das R, Low D, Yin F-F, Balter J, Palta J, Eifel P (2009) American society for radiation oncology recommendations for documenting intensity-modulated radiation therapy treatments. Int J Radiat Oncol Biol Phys 74(5):1311–1318PubMedCrossRefGoogle Scholar
  47. Hong TS, Tome WA, Chappell RJ, Chinnaiyan P, Mehta MP, Harari PM (2005) The impact of daily setup variations on head-and-neck intensity-modulated radiation therapy. Int J Radiat Oncol Biol Phys 61(3):779–788PubMedCrossRefGoogle Scholar
  48. Horiot JC, Bernier J, Johansson KA, van der Schueren E, Bartelink H (1993) Minumum requirements for quality assurance in radiotherapy. Radiother Oncol 29(2):103–104CrossRefGoogle Scholar
  49. Huq MS, Fraass BA, Dunscombe PB, Gibbons JP Jr, Ibbott GS, Medin PM, Mundt A, Mutic S, Palta JR, Thomadsen BR, Williamson JF, Yorke ED (2008) A method for evaluating quality assurance needs in radiation therapy. Int J Radiat Oncol Biol Phys 71(Suppl 1):S170–S173PubMedCrossRefGoogle Scholar
  50. Hurkmans C, Budiharto T, Musat E, Poortmans P, Monti A, Bar-Deroma R, Bernstein Z, van Tienhoven G, Collette L, Davis B, Aird E, Slotman B, Vos P (2008) Staffing and equipment of RT centres; comparing the proposed EORTC guidelines to ESTRO and Dutch guidelines. Radioth Oncol 88(Suppl 2):S118–S119Google Scholar
  51. Hurkmans CW, van Lieshout M, Schuring D, van Heumen MJT, Cuijpers JP, Lagerwaard FJ, Widder J, van der Heide UA, Senan S (2011) Quality assurance of 4D-CT scan techniques in multicenter phase III trial of surgery versus stereotactic radiotherapy (radiosurgery or surgery for operable early stage (stage 1a) non-small-cell lung cancer [ROSEL] study). Int J Radiat Oncol Biol Physics 80(3):918–927CrossRefGoogle Scholar
  52. IAEA (2000a) Absorbed dose determination in external beam radiotherapy: an international code of practice for dosimetry based on standards of absorbed dose to water. In: technical reports series no. 398 ViennaGoogle Scholar
  53. IAEA (2000b) International atomic energy agency safety report series no. 17: lessons learned from accidental exposures in radiotherapy. Vienna, AustriaGoogle Scholar
  54. IAEA (2004) Commissioning and quality assurance of computerized planning systems for radiation treatment of cancer. In: technical reports series no. 430. ViennaGoogle Scholar
  55. IAEA (2007) Comprehensive audits of radiotherapy practices: a tool for quality improvement. In: vol STI/PUB/1297. IAEA. Vienna
  56. ICRU (1976) ICRU report 24: determination of absorbed dose in a patient irradiated by beams of X or gamma rays in radiotherapy procedures. International commission on radiation units and measurements, Washington, DCGoogle Scholar
  57. ICRU (1993) ICRU report 50: prescribing, recording, and reporting photon beam therapy. In: International commission on radiation units and measurements, Bethesda, MDGoogle Scholar
  58. ICRU (1999) ICRU report 62: prescribing, recording, and reporting photon beam therapy (supplement to ICRU report 50). In: International commission on radiation units and measurements, Bethesda, MDGoogle Scholar
  59. ICRU (2010) ICRU report 83: prescribing, recording, and reporting photon-beam intensity-modulated radiation therapy (IMRT). J. ICRU 10(1)Google Scholar
  60. IMRT CWG (2001) NCI IMRT collaborative working group: intensity modulated radiation therapy: current status and issues of interest. Int J Radiat Oncol Biol Phys 51(4):880–914CrossRefGoogle Scholar
  61. ISCRO (1991) Radiation oncology in integrated cancer management: report of the inter-society council for radiation oncology. In: American College of Radiology, Reston, VAGoogle Scholar
  62. Jacky J, White CP (1990) Testing a 3D radiation therapy planning program. Int J Radiat Oncol Biol Phys 18:253–261PubMedCrossRefGoogle Scholar
  63. Jaffray DA, Siewerdsen JH, Wong JW, Martinez AA (2002) Flat-panel conebeam computed tomography for image-guided radiation therapy. Int J Radiat Oncol Biol Phys 53(5):1337–1349PubMedCrossRefGoogle Scholar
  64. Jiang SB, Wolfgang J, Mageras GS (2008) Quality assurance challenges for motion-adaptive radiation therapy: gating, breath holding, and four-dimensional computed tomography. Int J Radiat Oncol Biol Phys 71(Suppl 1):S103–S107PubMedCrossRefGoogle Scholar
  65. Joyce E (1986) ‘Malfunction 54’ unraveling deadly medical mystery of computerized accelerator gone awry. Am Med News 1:13–17Google Scholar
  66. Juran JM, Godfrey AB (2000) Juran’s Quality Handbook, 5th edn. McGraw Hill, New YorkGoogle Scholar
  67. Karzmark CJ (1987) Procedural and operator error aspects of radiation accidents in radiotherapy. Int J Radiat Oncol Biol Phys 13:1599–1602PubMedCrossRefGoogle Scholar
  68. Kijewski PK, Chin LM, Bjarngard BE (1978) Wedge-shaped dose distributions by computer-controlled collimator motion. Med Phys 5(5):426–429PubMedCrossRefGoogle Scholar
  69. Klein EE (2010) A grid to facilitate physics staffing justification. J Appl Clin Med Phys 11:263–273Google Scholar
  70. Klein EE, Low DA (2001) Interleaf leakage for 5 and 10 mm dynamic multileaf collimiation systems incorporating patient motion. Med Phys 28(8):1703–1710PubMedCrossRefGoogle Scholar
  71. Klein EE, Taylor M, Michaletz-Lorenz M, Zoeller D, Umfleet W (1994) A mono-isocentric technique for breast and regional nodal therapy using dual asymmetric jaws. Int J Radiat Oncol Biol Phys 28:753–760PubMedCrossRefGoogle Scholar
  72. Klein EE, Drzymala RE, Purdy JA, Michalski J (2005) Errors in radiation oncology: a study in pathways and dosimetric impact. J Appl Clin Med Phys 6:81–94PubMedCrossRefGoogle Scholar
  73. Klein EE, Hanley J, Bayouth J, Yin F-F, Simon W, Dresser S, Serago C, Aguirre F, Ma L, Arjomandy B, Liu C, Sandin C, Holmes T (2009) Task group 142 report: quality assurance of medical accelerators. Med Phys 36(9):4197–4212PubMedCrossRefGoogle Scholar
  74. Knöös T, Wieslander E, Cozzi L, Brink C, Fogliata A, Albers D, Nyström H, Lassen S (2006) Comparison of dose calculation algorithms for treatment planning in external photon beam therapy for clinical situations. Phys Med Biol 51:5785–5807PubMedCrossRefGoogle Scholar
  75. Kruse JJ (2010) On the insensitivity of single field planar dosimetry to IMRT inaccuracies. Med Phys 37(6):2516–2524PubMedCrossRefGoogle Scholar
  76. Kutcher GJ, Coia L, Gillin M, Hanson WF, Leibel S, Morton RJ, Palta JR, Purdy JA, Reinstein LE, Svensson GK (1994) Comprehensive QA for radiation oncology: report of AAPM radiation therapy committee task group 40. Med Phys 21(4):581–618PubMedCrossRefGoogle Scholar
  77. Langen KM, Papanikolaou N, Balog J, Crilly R, Followill D, Goddu SM, Grant Iii W, Olivera G, Ramsey CR, Shi C (2010) QA for helical tomotherapy: report of the AAPM task group 148. Med Phys 37(9):4817–4853PubMedCrossRefGoogle Scholar
  78. Lavely WC, Scarfone C, Cevikalp H, Li R, Byrne DW, Cmelak AJ, Dawant B, Price RR, Hallahan DE, Fitzpatrick JM (2004) Phantom validation of coregistration of PET and CT for image-guided radiotherapy. Med Phys 31(5):1083–1092PubMedCrossRefGoogle Scholar
  79. Leavitt DD, Martin M, Moeller JH, Lee WL (1990) Dynamic wedge field techniques through computer-controlled collimator motion and dose delivery. Med Phys 17:87–91PubMedCrossRefGoogle Scholar
  80. Lehmann J, Perks J, Semon S, Harse R, Purdy JA (2007) Commissioning experience with cone-beam computed tomography for image-guided radiation therapy. J Appl Clin Med Phys 8(3):21–36CrossRefGoogle Scholar
  81. Leunens G, Van Dam J, Dutreix A, van der Schueren A (1990) Quality assurance in radiotherapy by in vivo dosimetry: 1. Entrance dose measurements, a reliable procedure. Radiother Oncol 17:141PubMedCrossRefGoogle Scholar
  82. Leveson NG (1995) Safeware: system safety and computers: a guide to preventing accidents and losses caused by technology. Addison-Wesley, Reading, MAGoogle Scholar
  83. LoSasso T (2008) IMRT delivery performance with a varian multileaf collimator. Int J Radiat Oncol Biol Phys 71(Suppl 1):S85–S88PubMedCrossRefGoogle Scholar
  84. LoSasso T, Chiu CS, Ling CC (1998) Physical and dosimetric aspects of a multileaf collimation system used in the dynamic mode for implementing intensity modulated radiotherapy. Med Phys 25:1919–1927PubMedCrossRefGoogle Scholar
  85. Mans A, Wendling M, McDermott LN, Sonke JJ, Tielenburg R, Vijlbrief R, Mijnheer B, van Herk M, Stroom JC (2010) Catching errors with in vivo EPID dosimetry. Med Phys 37(6):2638–2644PubMedCrossRefGoogle Scholar
  86. Matzinger O, Gerber E, Bernstein Z, Maingon P, Haustermans K, Bosset JF, Gulyban A, Poortmans P, Collette L, Kuten A (2009) EORTC-ROG expert opinion: radiotherapy volume and treatment guidelines for neoadjuvant radiation of adenocarcinomas of the gastroesophageal junction and the stomach. Radiother Oncol 92:164–175PubMedCrossRefGoogle Scholar
  87. Mellenberg DE, Dahl RA, Blackwell CR (1990) Acceptance testing of an automated scanning water phantom. Med Phys 17(2):311–314PubMedCrossRefGoogle Scholar
  88. Mijnheer B, Olszewska A, Fiorino C, Hartmann G, Knöös T, Rosenwald JC, Welleweerd H (2004) Quality assurance of treatment planning systems: practical examples of non-IMRT photon beams: ESTRO booklet no. 7. In: Brussels (Belgium)Google Scholar
  89. Mutic S, Dempsey JF, Bosch WR, Low DA, Drzymala RE, Chao KSC, Goddu SM, Cutler PD, Purdy JA (2001) Multimodality image registration quality assurance for conformal three-dimensional treatment planning. Inter J Radiat Oncol Biol Phys 51(1):244–260CrossRefGoogle Scholar
  90. Mutic S, Palta JR, Butker EK, Das IJ, Huq MS, Loo L-HD, Salter BJ, McCollough CH, Van Dyk J (2003) Quality assurance for computed-tomography simulators and the computed-tomography-simulation process: report of the AAPM radiation therapy committee task group no. 66. Med Phys 30(10):2762–2792PubMedCrossRefGoogle Scholar
  91. Mutic S, Brame RS, Oddiraju S, Parikh P, Westfall MA, Hopkins ML, Medina AD, Danieley JC, Michalski JM, El Naqa IM, Low DA, Wu B (2010) Event (error and near-miss) reporting and learning system for process improvement in radiation oncology. Med Phys 37(9):5027–5036PubMedCrossRefGoogle Scholar
  92. Nath R, Biggs PJ, Bova FJ, Ling CC, Purdy JA, van de Geijn J, Weinhous MS (1994) AAPM code of practice for radiotherapy accelerators: report of AAPM radiation therapy task group no. 45. Med Phys 21(7):1093–1121PubMedCrossRefGoogle Scholar
  93. Niroomand-Rad Z, Blackwell CR, Coursey BM, Gall KP, Galvin JM, McLaughlin WL, Meigooni AS, Nath R, Rodgers JE, Soares CG (1998) Radiochromic film dosimetry: recommendations of AAPM radiation therapy committee task group 55. Med Phys 25(11):2093–2115PubMedCrossRefGoogle Scholar
  94. Palta JR, Ayyangar KM, Suntharalingam N (1988) Dosimetric characteristics of a 6 MV photon beam from a linear accelerator with asymmetric collimator jaws. Int J Radiat Oncol Biol Phys 14:383–387PubMedCrossRefGoogle Scholar
  95. Palta J, Kim S, Li J, Liu C (2003) Tolerance limits and action levels for planning and delivery of IMRT. In: Palta J, Mackie T (eds) Intensity modulated radiation therapy-the state of the art, vol American association of physicists in medicine medical physics monograph no. 29. Medical Physics Publishing, Madison, WI, pp 593–612Google Scholar
  96. Patton GA, Gaffney DK, Moeller JH (2003) Facilitation of radiotherapeutic error by computerized record and verify systems. Int J Radiat Oncol Biol Phys 56(1):50–57PubMedCrossRefGoogle Scholar
  97. Pawlicki T, Mundt AJ (2007) Quality in radiation oncology. Med Phys 34(5):1529–1534PubMedCrossRefGoogle Scholar
  98. Pawlicki T, Dunscombe PB, Mundt AJ, Scalliet P (2011) Quality and safety in radiotherapy. Taylor & Francis, New YorkGoogle Scholar
  99. Peiffert D, Simon JM, Eschwege F (2007) Epinal radiotherapy accident: passed, present, future. Cancer Radiother 11(6–7):309–312PubMedCrossRefGoogle Scholar
  100. Poortmans PMP, Ataman F, Bernard Davis J, Bartelink H, Horiot J-C, Pierart M, Collette L, Van Tienhoven G (2007) Guidelines for target volume definition in post-operative radiotherapy for prostate cancer, on behalf of the EORTC radiation oncology group. Radiother Oncol 82:121–127CrossRefGoogle Scholar
  101. Potters L, Kavanagh B, Galvin JM, Hevezi JM, Janjan NA, Larson DA, Mehta MP, Ryu S, Steinberg M, Timmerman R, Welsh JS, Rosenthal SA (2010) American society for therapeutic radiology and oncology (ASTRO) and American college of radiology (ACR) practice guideline for the performance of stereotactic body radiation therapy. Int J Radiat Oncol Biol Phys 76(2):326–332PubMedCrossRefGoogle Scholar
  102. Pouliot J, Bani-Hashemi A, Josephine C, Svatos M, Ghelmansarai F, Mitschke M, Aubin M, Xia P, Morin O, Bucci K, Roach Iii M, Hernandez P, Zheng Z, Hristov D, Verhey L (2005) Low-dose megavoltage cone-beam CT for radiation therapy. Int J Radiat Oncol Biol Phys 61(2):552–560 PubMedCrossRefGoogle Scholar
  103. Purdy JA (2007) From new frontiers to new standards of practice: advances in radiotherapy planning and delivery. In: Meyer JL (ed) IMRT, IGRT, SBRT—advances in the treatment planning and delivery of radiotherapy, vol 40. Front Radiat Ther Oncol, Karger, Basel, pp 18–39Google Scholar
  104. Purdy JA (2008) Dose to normal tissues outside the radiation therapy patient’s treated volume: a review of different radiation therapy techniques. Health Phys 95(5):666–676PubMedCrossRefGoogle Scholar
  105. Purdy JA, Biggs PJ, Bowers C, Dally E, Downs W, Fraass BA, Karzmark CJ, Khan F, Morgan P, Morton R, Palta J, Rosen II, Thorson T, Svensson G, Ting J (1993) Medical accelerator safety considerations: report of AAPM radiation therapy committee task group no. 35. Med Phys 20(4):1261–1275PubMedCrossRefGoogle Scholar
  106. Rath F (2008) Tools for developing a quality management program: proactive tools (process mapping, value stream mapping, fault tree analysis, and failure mode and effects analysis). Int J Radiat Oncol Biol Phys 71(Suppl 1):S187–S190PubMedCrossRefGoogle Scholar
  107. RCR, SCoR, IPEM, NPSA, BIR (2008) Towards safer radiotherapy. In: the royal college of radiologists. London
  108. Santanam L, Noel C, Willoughby TR, Esthappan J, Mutic S, Klein EE, Low DA, Parikh PJ (2009) Quality assurance for clinical implementation of an electromagnetic tracking system. Med Phys 36(8):3477–3486PubMedCrossRefGoogle Scholar
  109. Sharpe MB, Miller BM, Yan D, Wong JW (2000) Monitor unit settings for intensity modulated beams delivered using a step-and-shoot approach. Med Phys 27(12):2719–2725PubMedCrossRefGoogle Scholar
  110. Sharpe MB, Moseley DJ, Purdie TG, Islam M, Siewerdsen JH, Jaffray DA (2006) The stability of mechanical calibration for a kV cone beam computed tomography system integrated with linear accelerator. Med Phys 33(1):136–144PubMedCrossRefGoogle Scholar
  111. Siebers JV, Keall PJ, Wu Q, Williamson JF, Schmidt-Ullrich RK (2005) Effect of patient setup errors on simultaneously integrated boost head and neck IMRT treatment plans. Int J Radiat Oncol Biol Phys 63(2):422–433PubMedCrossRefGoogle Scholar
  112. Slessinger ED, Gerber RG, Harms WB, Klein EE, Purdy JA (1993) Independent collimator dosimetry for a dual photon energy linear accelerator. Int J Radiat Oncol Biol Phys 27(3):681–687PubMedCrossRefGoogle Scholar
  113. Slotman BJ, Cottier B, Bentzen SM, Heeren G, Lievens Y, van den Bogaert W (2005) Overview of national guidelines for infrastructure and staffing of radiotherapy. ESTRO-QUARTS: work package 1. Radiother Oncol 75(3):349.E341–349.E346CrossRefGoogle Scholar
  114. Stern RL, Heaton R, Fraser MW, Goddu SM, Kirby TH, Lam KL, Molineu A, Zhu TC (2011) Verification of monitor unit calculations for non-IMRT clinical radiotherapy: report of AAPM task group 114. Med Phys 38(1):504–530PubMedCrossRefGoogle Scholar
  115. Symon Z, Tsvang L, Wygoda M, Ben-Yoseph R, Corn BW, Poortmans P, Portnoy O, Pfeffer MR (2011) An interobserver study of prostatic fossa clinical target volume delineation in clinical practice: are regions of recurrence adequately targeted? Am J Clin Oncol 34(2):145–149PubMedGoogle Scholar
  116. Van Dyk J (2008) Quality assurance of radiation therapy planning systems: current status and remaining challenges. Int J Radiat Oncol Biol Phys 71(Suppl 1):S23–S27PubMedGoogle Scholar
  117. Van Dyk J, Barnett RB, Cygler JE, Shragge PC (1993) Commissioning and quality assurance of treatment planning computers. Int J Radiat Oncol Biol Phys 26(2):261–273PubMedCrossRefGoogle Scholar
  118. van Mourik AM, Elkhuizen PHM, Minkema D, Duppen JC, van Vliet-Vroegindeweij C (2010) Multiinstitutional study on target volume delineation variation in breast radiotherapy in the presence of guidelines. Radiother Oncol 94(3):286–291PubMedCrossRefGoogle Scholar
  119. Weinhous MS, Purdy JA, Granda CO (1990) Testing of a medical linear accelerator’s computer-control system. Med Phys 17(1):95–101PubMedCrossRefGoogle Scholar
  120. WHO: World Health Organization (1988) Quality assurance in radiotherapy. In: GenevaGoogle Scholar
  121. Williamson JF, Khan FM, Sharma SC (1981) Film dosimetry of megavoltage photon beams: a practical method of isodensity-to-isodose curve conversion. Med Phys 8:94–98PubMedCrossRefGoogle Scholar
  122. Williamson JF, Dunscombe PB, Sharpe MB, Thomadsen BR, Purdy JA, Deye JA (2008) Quality assurance needs for modern image-based radiotherapy: recommendations from 2007 interorganizational symposium on “quality assurance of radiation therapy: challenges of advanced technology”. Int J Radiat Oncol Biol Phys 71(1):S2–S12PubMedCrossRefGoogle Scholar
  123. Yang J, Li J, Chen L, Price R, McNeeley S, Qin L, Wang L, Xiong W, Ma CM (2005) Dosimetric verification of IMRT treatment planning using Monte Carlo simulations for prostate cancer. Phys Med Biol 50(5):869–878PubMedCrossRefGoogle Scholar
  124. Yu CX, Jaffray DA, Wong JW (1998) The effects of intra-fraction organ motion on the delivery of dynamic intensity modulation. Phys Med Biol 43:91–104PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg  2011

Authors and Affiliations

  • James A. Purdy
    • 1
  • Eric E. Klein
    • 2
  • Philip Poortmans
    • 3
  • Coen Hurkmans
    • 4
  1. 1.Department of Radiation OncologyUniversity of California Davis Medical CenterSacramentoUSA
  2. 2.Department of Radiation OncologyWashington University School of MedicineSt. LouisUSA
  3. 3.Department of Radiation OncologyInstitute VerbeetenTilburgThe Netherlands
  4. 4.Department of Radiation OncologyCatharina HospitalEindhovenThe Netherlands

Personalised recommendations