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Implementing TG-263: What to Expect
Implementing AAPM’s TG-263 report: unique challenges and opportunities.
- Structure names across image processing and treatment planning system platforms
- Nomenclature for dosimetric data (e.g., dose/volume histogram-based metrics)
- Templates for clinical trial groups and users of an initial subset of software platforms to facilitate the adoption of the standards
- A formalism which can accommodate the addition of other structures defined in the future
What to Expect When Adopting Recommendations
For starters, the task group itself does a fantastic job laying out the recommendations for departments and vendors alike. The problematic aspect is putting in the work to create templates and actually implement the protocol itself. To this end—among others—the task group formed an official Twitter account (@AAPM_TG263U1) to promote adoption. Tips and tricks regarding adoption are posted regularly, along with discussion regarding the task group (and the occasional meme as well.)
When asked about major pitfalls and potential remedies, the team behind the Twitter account added, “In my experience, the biggest issue is getting buy-in from the entire clinical team to use TG-263. It does take extra time and effort to create templates, educate staff, and then take on the extra effort to ensure that it is being used correctly. As for a remedy, having a strong champion is critical. This person can motivate everyone on why this is important (safety, efficiency, big data, etc.) to hopefully get everyone on board to support the effort. Once that is done, it’s really just upkeep! We are working on making more templates available to try to ease the transition.” These templates can be found on the AAPM’s Radiation Oncology Nomenclature Resource Page, along with some other useful documents relevant to the task group’s implementation.
What Does the Community Have to Say?
Overall, there are a lot of opinions on TG-263, and this survey shows it. If you are interested in the survey results, you can check them out (along with our other surveys) here.
Q&A with Peter Taylor of Northwell Health
Q: How far into the process are you at Northwell?
A: I would estimate that we are 75% implemented in external beam RT at Northwell.
Q: What would you say is the most challenging aspect of the TG-263?
A: Two things come to mind; the first is buy-in, particularly from some physicians who are used to putting in their own structures. The second would be updating our treatment directives between two different R&V systems.
Q: What advice would you give to someone pushing to incorporate TG-263 guidelines at their clinic?
A: Make sure that you have buy-in from leadership. The change in nomenclature, although seemingly minor, can affect the overall workflow, and some individuals may be hesitant to adopt.
Q: Would you do things differently if restarting the process today?
A: I don’t think so. I’m happy that we tested out most of the recommendations – some of them did not work in our clinic, but overall the implementation has been successful.
Q: To what degree did you utilize the recommendations included in TG-263?
A: We found most of the recommendations useful; however, some of the naming conventions felt forced. In some cases, we adopted the TG-263 Reverse Order Name in lieu of the Primary Name (e.g., the primary name is “Spc_Bowel,” however in the clinic we have adopted, “Bowel_Spc”). We also experimented with relative dose levels for target volumes (e.g., PTV_High, PTV_Mid, PTV_Low). We found two issues with this set of nomenclature, one, at peer review, particularly for Head and Neck cases where a simultaneous integrated boost (SIB) is being used. It was not immediately evident what the prescription dose was in those cases. The second issue was the lack of sorting in the TPS. As a department, we are used to seeing OARs in alphabetical order and target volumes in increasing or decreasing dose. With the relative dose nomenclature we were not able to see our PTVs in the order we were used to.
Written by Austin Skinner
Austin interns with Radformation as a medical physics MS student at Hofstra University, and graduated in May 2022. His focuses at Radformation included marketing, blogging, and working on case studies. His interests include cooking and reading, as well as the occasional round of golf.
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