AAPM Newsletter November/December 2003 Vol. 28 No. 6

Newsletter

AMERICAN ASSOCIATION OF PHYSICISTS IN MEDICINE VOLUME 28 NO. 6

NOVEMBER/DECEMBER 2003

AAPM President’s Column Martin S. Weinhous Cleveland, Ohio

Last One For the last time as your president I’m scrambling to meet the Newsletter deadline (15-October-2003). This time, I’m starting my column at a gate at the Baltimore-Washington Airport after five and a half days of work at the ACR and AAPM HQs.

Reminded

Activities

I was particularly reminded this week of all the extraordinary efforts made by our many volunteers. For example, the Rules Committee and the Meeting Coordination Committee were at HQ and put in long hours at their respective tasks – assuring that the Association and its activities continue to run well. Think about it – these folks leave home and hearth, travel to HQ, and lock themselves into a room for hours and days of hard work doing the Association’s business. They and the members of other committees and task groups are simply not thanked enough. So, before the sentiment gets lost in the detail to follow… Volunteers, you have the thanks and appreciation of the officers, staff, and members. Well done!

I have good news and a caution to report regarding the forthcoming AAPM/NCRP shielding reports. As you know from previous columns, the AAPM has been very active in trying to assure that no harm comes from too-low effective annual dose limits. As of this writing the NCRP’s process has moved forward with their acceptance of the AAPM’s logic. Specifically, the TG-13 (Science Committee 9) draft report of August 2003, wherein a shielding design goal of 1.0 mSv effective annual dose limit is specified with no dose constraints (no quartering) and wherein there is no mention of 0.25 mSv, has been approved within the NCRP process. This (See Weinhous - p. 2)

2003 William D. Coolidge Award The William D. Coolidge Award, presented by the AAPM as its highest honor, is awarded annually to a member who has exhibited a distinguished career in medical physics, and who has exerted a significant impact on the practice of medical physics. This year’s award is given to Kenneth Ray Hogstrom, PhD, DABR. Dr. Hogstrom is a professor of radiation physics at the University of Texas M.D. Anderson Cancer Center where he holds the P.H. and Fay Etta Robinson Distinguished Professorship in Cancer Research. Dr. Hogstrom is director of the Medical Physics Programs at the University of (See Coolidge - p. 3)

TABLE OF CONTENTS New Board Members p 3 Coolidge Award Speech p 4 Clinical Trials Update p 8 Executive Dir’s. Col. p 11 Gov’t. Affairs Column p 12 Education Council p 13 Summer Undergrads. p 14 Awards/Appointments p 15 Announcement p 17 Minowitz Memorial p 18 Mammography FAQs p 19 Let’s. to the Editor pp 20-27

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Weinhous

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(from p. 1)

information was provided by the NCRP’s president, Tom Tenforde, PhD in the first presentation at an ACR/AAPM conference on dose limits held at the ACR HQ on October 8th. The AAPM was represented by Don Frey and by me. Also in attendance were the leaders of many other societies and associations, as well as federal and state stakeholders. One out of over 30 individuals was somewhat determined to continue using quartering, contrary to the new NCRP recommendations. This points to the caution. It is necessary that the new NCRP recommendations, 1 mSv per year for medical, dental and veterinary, (i.e. occasional) use, be well distributed, publicized, and explained.

To that end, the AAPM and other participants plan to expand our efforts to take the message to the CRCPD, NRC, and the ICRU. Further, participation in getting the word out at all levels is welcome.

Following the meeting at the ACR HQ, we changed venue to continue meetings at the AAPM HQ. In particular, most of ExCom met with the Budget Subcommittee of the Finance Committee for a day and a half to address the many requests for funds and to tentatively finalize next year’s budget. I should note that the financial state of the Association is and will likely continue to be strong. We will be able to continue providing the services requested by our members. Note that the AAPM is moving rapidly to objective-based budgeting.

Requesters must fill in an online form that makes them specify for what purpose funds will be expended. This information flows into a database and into spreadsheets. For approved tasks and their associated expenses, the database will allow us to determine if the AAPM is getting value for its funds, task by task.

At the end of Friday’s meeting, our soon-to-retire executive director, Sal Trofi, was told of a major computer security breach and that his presence was required downstairs to meet with folks from the other societies sharing the building. Was he ever surprised to walk in to a reception in his honor. We completely fooled him. (Of course, he’ll never believe Michael Woodward again.) Sal was honored by AAPM staff, AAPM members and colleagues from the AAPT, APS, AIP and ACP. It was fitting.

Immediately following the Budget Subcommittee meetings (at 10:30 AM on Saturday), your Executive Committee began its work. The discussions were too wide ranging to be reported in any detail in this limited space. In brief, we discussed continuing the chore of bringing sanity to exposure limits, optimizing our virtual library, better organizing and displaying our history, bettering our relationship with regulators, our relationship with the ADCLs, bettering the Annual Meeting and summer schools, realigning our committee and council structure to reflect today’s needs, recruiting students into the profession, creating a five-year financial plan, realigning membership categories 2

with today’s needs, overall organization and governance, relationships with and appointments to other societies, the need to track retired members, and ethics – to name a few.

ExCom has been reviewing charges for various committees and has identified several that might be eliminated. We are presently working with the councils to craft rule changes to this effect. ExCom has also been working with the Rules Committee to draft the rules for all the committees in a standard template-driven format. The Rules Committee will be working very closely with the councils and committees to accomplish this end.

Our meeting continued till about 11:30 Sunday morning when we fled to the airports.

Unfortunately, we hadn’t finished. On Monday afternoon, ExCom concluded business with a three-hour conference call. And so it goes.

Lastly Three people are leaving ExCom as of December 31, 2003. Bob Gould steps down from his position as chairman of the board. Bob, we thank you for your three years of executive leadership and commitment.

Melissa Martin leaves her post as treasurer after serving for six years. Melissa, thank you for your endurance and attention to detail. Sal Trofi steps down (actually on December 12th) from his ex-officio position as executive director. Sal, we thank you for your 10 years. The Associa-

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tion has grown and prospered well under your direction.

To the many others who have served and who are rotating out of their positions – thank you for your service.

To the AAPM staff – if it were not for you and your devotion to the Association, and to the care of its members, I would never have accepted the nomination offered me in 2001. Please accept my enthusiastic thanks for your work. Without your efficient and tireless and cheerful help, none of the officers would survive.

To the AAPM member – thanks for your support of the Association and of the leadership’s stewardship. We are all better for it.

Let’s all welcome Don Frey into the presidency and support him as he moves the Association forward.

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Newly Elected 2004 Board of Directors

Howard Amols President-elect

Maryellen Giger Treasurer

David Pickens

Beth Schueler

Robin Miller

James Seibert

Coolidge

(from p. 1)

Texas Graduate School of Biomedical Sciences at Houston.

Born in 1948 in Houston, Texas, Dr. Hogstrom received his MS in physics from the University of Houston in 1972. Following a short period of active duty as an officer in the Army Field Artillery, he was introduced to medical physics by Dr. Alfred Smith, with whom he worked on the neutron therapy project at M.D. Anderson Hospital and Tu-

mor Institute (1973-4). Dr. Hogstrom received his PhD in physics from Rice University in 1976, after which he rejoined Dr. Smith as a research scientist at the University of New Mexico, where he worked on the pion therapy project in Los Alamos.

In 1979, Dr. Hogstrom accepted a position as assistant professor at M.D. Anderson in the Department of Physics headed by Dr. Robert Shalek. Here, he worked in the Section of Clinical Physics under the leadership of 3

Dr. Peter Almond until 1985, after which he served as the first chair of the Department of Radiation Physics (1985-2001).

Dr. Hogstrom has published over 80 articles in peer-reviewed scientific journals. His research has successfully applied radiation transport to develop methods and techniques of dose measurement, dose calculation, treatment planning, treatment delivery, and quality assurance for electron, pion, and neutron beam therapy.

(See Coolidge - p. 4)

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Coolidge

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(from p. 3)

Many today utilize the Hogstrom pencil-beam algorithm for electron treatment planning. Accolades include the AAPM Farrington Daniels Award for work in neutron dosimetry and the Becton-Dickinson Career Achievement Award for work in electron dose calculations.

Dr. Hogstrom’s contributions to education include short courses in therapeutic radiological physics and teaching and mentoring many graduate students and postdoctoral fellows. He has taught electron beam physics regularly in AAPM summer schools and review courses. He has written over 40 books, chapters, and reports, his contributions to AAPM Summer Schools being the most rewarding. For these and other contributions, he received the 1995 Faculty Achievement Award in Education at M.D. Anderson.

Dr. Hogstrom served as president of the AAPM in 2000, where he contributed to improving the Association’s long range planning, improving relations with our allied health professional colleagues through actions as assisting in forming RSEA, and establishing the Summer Undergraduate Fellowship Program to address issues of manpower and student recruitment. While serving on the board of the ABMP, Dr. Hogstrom crafted a plan that resulted in the present ABRABMP Working Agreement.

After serving as the vice-chair of the AAPM Commission on Accreditation, he led the first CAMPEP Residency Education

Program Review Committee to develop guidelines for accreditation of medical physics residency programs. He is a Fellow of the AAPM and ACMP, where he continues to have opportunities to contribute to our medical physics

profession by serving as chair of the AAPM Public Education Committee and co-chair of an ad-hoc committee on AAPMACMP Professional Medical Physics Issues.

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Ken Hogstrom is presented with the William D. Coolidge Award

by President Marty Weinhous at the Annual Meeting in San Diego.

Dr. Hogstrom’s Acceptance Speech Friends, family, colleagues, fellow members, and officers of the AAPM, it is an honor to be here tonight to share with you the Coolidge Award.

It is difficult to put into words the feelings of being recognized by one’s peers, although that is my objective for the next few minutes.

I am particularly grateful for Isaac Rosen’s lead in my being nominated and highly appreciative of his kind introductory remarks.

Also, I want to thank the many others who supported my nomination and the members of the Awards and Honors Committee who have the difficult task of selecting a recipient each year.

Clearly, there are many amongst us today who are equally worthy of this award, so, I accept the award with the greatest of humility and appreciation.

This evening I will share, through my personal experiences, some of my thoughts as to what makes the medical physicist and what I have 4

learned in my career that might help future medical physicists. In doing this, I will recognize many past and present colleagues and individuals, who have contributed to my career.

First and foremost, I want to recognize my family, wife-Janet, son-Michael, and daughterElizabeth. My family has always been a source of love, understanding, and companionship.

They have been my very best friends, and we have had many wonderful times together. As you are aware, being a medical physicist can sometimes be quite demanding, and I thank my family for their being there to celebrate the good times and to support me through the difficult times.

Second, I want to thank my parents. Success in life depends on honor, compassion, and trust, and they passed these values to my sister, brother, and me in a nurturing way. We were also taught both the value of working

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hard and the benefit of playing hard. I am particularly grateful that my mother and family could be here tonight. Also, my sisterin-law, Susan Koncz, niece, Jennifer, and brother-in-law, Robert Donner are present.

I would now like to reflect on our heritage. As we work as medical physicists and as some train to become medical physicists, it is important to remember that first and foremost, we are physicists. One talent that distinguishes us from our professional colleagues is our ability to solve technical problems in a logical, innovative, and analytical manner.

Most of us honed this talent in graduate school, and I am particularly indebted to my mentors, Bill Mayes from the University of

Houston and Gordon Mutchler and Gerry Phillips from Rice University. They taught me how to do research, how to be a critical thinker, how to be a physicist.

Next, I want to say a few words about training to become a medical physicist. Upon completing graduate school in experimental physics, I decided to pursue a career in medical physics; in hindsight a wise decision, but one that required my learning an additional knowledge set. I am particularly grateful for the opportunity to have worked early in my career under the tutelage of Al Smith, Peter Almond, and Bob Shalek, who taught me the basics of medical physics and its application to the clinic. I became a medical physicist through “on-

the-job training,” a training pathway that I can no longer recommend. In fact, the field of medical physics has become so diverse and sophisticated over the past 30 years that it is important to our profession and to the individual that future medical physicists receive comprehensive didactic and clinical training, which meet minimal standards. I suggest that the most reasonable manner to achieve this, and that which will best serve our profession, is that future medical physicists complete a CAMPEP-accredited medical physics residency-training program before entering clinical practice. I hope to see the American Board of Radiology (ABR) require such training as a (See Hogstrom - p.7)

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NOVEMBER/DECEMBER 2003

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Hogstrom

(from p. 5)

prerequisite for sitting for the certification exam within the next 10 years. Or stated differently, without residency training, board certification should be difficult to achieve. How to accomplish this will require innovative thought and careful strategic planning by the AAPM in collaboration with the ABR. The AAPM recently established the Medical Physics Residency Training Subcommittee, chaired by Dick Lane, and I expect that subcommittee to lead this initiative.

Next, I want to share another thought, the significance of clinical participation upon research.

The focus of most of my research has been to develop new technologies or techniques for use in the planning or delivery of radiation therapy. This research usually came in response to a clinical problem or clinical need, which is the reason that researchers benefit from participating in the clinic. I have had the opportunity to work under both pioneers and great leaders in radiation oncology, which include Drs. Morton Kligerman, Gilbert Fletcher, Lester Peters, and James Cox, all whom I thank for their challenges and support. I also want to recognize a few radiation oncologist colleagues, with whom I had the opportunity to work on important clinical and research projects through my career. These include Drs. David Hussey, Norah Tapley, Robert Fields, Moshe Maor, Eleanor Montague, Lillian Fuller, Tyvin Rich, and Marsha McNeese.

Similarly, I had the opportunity to

work with some outstanding clinical physicists, Vince Sampiere, Jack Cundiff, Bob Gastorf, and John Horton. These colleagues were often key to translating research and new technology into the clinic at M.D. Anderson. Most significantly, I have been lucky enough to work with brilliant medical physics researchers throughout my career. There is not time to recognize all, but I am particularly appreciative of the opportunity to have collaborated in research with Howard Amols, Isaac Rosen, Art Boyer, George Starkschall, Almon Shiu, and John Antolak. The common quality of these individuals is that all are both excellent clinicians and researchers.

Particularly important to me, I want to share my experiences in education. I have found no greater reward than teaching, seeing the glow in the eye of the student or trainee that discovers the wonders of radiation physics or seeing a graduate have a successful career. Education is the cornerstone of any profession, and I have been fortunate to have had the opportunity to work with two major institutions that value education — the University of Texas M.D. Anderson Cancer Center and the AAPM. Education is one of the four missions of M.D. Anderson, and through the years, the physics faculty have worked together to provide outstanding educational programs for medical physicists and allied professionals. It has been a rewarding experience to work with a dedicated and talented faculty in these programs, which has included Will Hanson, Marilyn 7

Stovall, Ed Jackson, John Hazle, most of the medical physicists I mentioned earlier, and many, many others. Complimentary, the AAPM has a breadth of educational programs that offer refresher courses and continuing educational activities for its members, while providing direction and materials to those of us that teach in our respective institutions.

Many of my fonder memories have been participating in these activities, particularly the AAPM summer schools.

Last, I want to share my experiences in professional activities, particularly the AAPM. In addition to the benefits to our profession, my individual rewards have been equally great. I have met a number of outstanding individuals, and I have learned from their knowledge of medical physics, their skill as leaders, and their compassion as human beings. I have made life-long friends while contributing to our profession. I cannot begin to tell you how much I learned about leadership and our profession by serving on AAPM Executive Committee with Charlie Coffey, Geoff Ibbott, Jerry White, Melissa Martin, and others. One of my more memorable experiences was working with Faiz Khan and others as we helped develop CAMPEP Residency Education Review Committee’s accreditation guidelines and accrediting the first medical physics residency program at Washington University. I have come to appreciate the contributions of Mike Mills after having worked twice with (See Hogstrom - p. 8)

AAPM NEWSLETTER

Hogstrom

NOVEMBER/DECEMBER 2003

(from p. 7)

him on AAPM and ACMP studies of medical physicist work and effort. One of the more challenging tasks in which I participated was developing the ABR-ABMP Working Agreement. I was constantly impressed with the efforts of American Board of Medical Physics (ABMP) leaders Larry Reinstein and Ben Archer and Bill Hendee and his colleagues at the ABR. This was a good example of a group of individuals dedicated to finding a tenable solution to a difficult problem that would be in the best interest of medical physics.

I want to leave all with one final thought and challenge. Many past and present medical physicists have had the foresight and energy to create, foster, and advance our profession. As a result, the opportunities, responsibilities, and rewards are quite lucrative

for today’s medical physicist.

However, neither the status quo can be maintained nor improvements to our profession forthcoming without greater individual effort. Therefore, I challenge every medical physicist, particularly those entering the field, with not only asking, but also answering the question, “what can I do for my profession?” Become involved with at least one professional activity within the AAPM or other professional society that benefits medical physics. If all medical physicists actively supported our profession, what we could accomplish would be beyond our wildest imaginations.

I want to close by sharing with you a caricature of me, sketched some years ago. It gives the impression that I have things totally under control. I can assure you, this has not always been the case.

However, more important to my success has been my good for-

tune. I have been blessed with an incredible family, with an education that gave me opportunity, with a challenging and rewarding profession, with having worked with wonderful professionals, with having had the opportunity to teach hundreds of medical physicists, with being a member of a great institution – M.D. Anderson – and with being a member of a great society – the AAPM. And now, I am lucky enough to be selected to receive this award. I look forward to continuing to be an integral part of our profession. Most importantly, I look forward to seeing our new and future members advance our profession through outstanding patient care, innovative research, and effective education.

So, again, thank you very much for this distinctive honor!

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Clinical Trials Update Report from the Subcommittee on QA of Clinical Trials The RTOG P-0232 Protocol Geoffrey S. Ibbott Subcommittee Chair This is the second of a series of articles that will describe clinical trials conducted by cooperative study groups that may be of particular interest to medical physicists. A previous Newsletter article (September 2003 issue) described the RTOG H-0022 protocol: A study of conformal and

intensity modulated radiation therapy for oropharyngeal cancer. This article also discusses a new advanced technology clinical trial, this time involving prostate brachytherapy.

The RTOG has conducted several prostate brachytherapy trials in the past. RTOG 98-05 opened in 1998, and was a phase II study that evaluated the use of prostate implants alone in 8

a multi-institutional setting. A number of institutions were credentialed, and 101 patients were registered to the study, which closed in 2000. The results of the study are presently being analyzed. RTOG P-0019 opened in 2000, and was a phase II study of external beam radiation therapy combined with interstitial brachytherapy for intermediate risk clinically localized adeno-

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carcinoma of the prostate. An additional 28 institutions were credentialed to participate in the study, and 138 patients were registered. The dosimetry data for these patients are presently being reviewed. A retrospective review of the clinical data will not occur for some time.

Three other groups are presently conducting prostate brachytherapy clinical trials. The North Central Cancer Treatment Group (NCCTG) has opened N-0052, a phase II study in which patients receive hormones plus brachytherapy for locally recurrent prostate carcinoma after external beam radiation therapy. The Cancer and Leukemia Group B (CALGB) opened 99809, a phase II trial studying the effectiveness of androgen suppression with external beam plus brachytherapy boost. And the American College of Surgeons Oncology Group (ACOSOG) recently opened Z0070, a phase III randomized trial of radical prostatectomy versus brachytherapy for patients with T1B or T2A prostate cancer. Registration of patients to the ACOSOG study is slow, possibly because patients are unwilling to be randomized between surgery and brachytherapy.

The RTOG has now opened a phase III study, P-0232, which will randomize patients between external beam plus brachytherapy versus brachytherapy alone. This protocol is supported by the Advanced Technology Consortium (ATC-see 9/03 Newsletter or http://atc.wustl.edu). Because this is a phase III study, 1520

patients will be required. This large number of patients makes it impractical to review the data using conventional techniques.

Instead, electronic data submission to the Image-Guided Therapy Center (http:// atc.wustl.edu) is required for RTOG institutions.Adry run must be conducted successfully before institutions can participate in this study in order to confirm their ability to transmit data electronically.

In addition, the P-0232 trial requires that institutions be credentialed by the RPC (http:// rpc.mdanderson.org) before registering patients. The credentialing process requires that institutions submit two benchmark test cases and one recent patient case. The patient case (post plan) is to be submitted electronically in order to satisfy the requirement for a dry run.

Credentialing also requires the institutions to submit questionnaires indicating the equipment available for prostate brachytherapy, the experience of staff at the facility, the compliance of brachytherapy source data with TG-43 or other recent publications, and compliance with the current NIST standards. Complete credentialing documentation and forms may be downloaded from the RPC’s Web site.

Click “credentialing” and then “RTOG.” The P-0232 protocol, like other prostate brachytherapy protocols presently open, allows institutions to use any source model currently meeting the AAPM dosimetric prerequisites 9

(see http://rpc.mdanderson.org/ rpc/htm/home-htm/lowenergy.htm). Institutions should be aware that credentialing is specific to each radiation oncologist, physicist, seed model, and treatment planning system.

Changes in any of these may require repeating one or more of the credentialing procedures.

Institutions that were credentialed for previous prostate brachytherapy studies may not need to repeat all of the credentialing requirements for P-0232. However, all institutions must demonstrate the ability to submit data electronically.

Any change in the brachytherapy program will necessitate repeating the relevant credentialing procedures.

Further details about this protocol and the credentialing requirements are available at the RPC Web page http://rpc. mdanderson.org.

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Annual Business Meeting Minutes Draft minutes of the 2003 Annual Business Meeting are now available on the AAPM Web site at http://www. aapm.org/org/. Please contact sharon@aapm.org to request a hardcopy of these draft minutes.

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Executive Director’s Column Sal Trofi College Park, MD This is my last column because I will retire at the end of this year.

My emotions are torn between the excitement of starting a new phase of life and apprehension about not having any responsibilities that will dictate my daily routine. My wife and I decided sometime ago to build a house in Venice, Florida as our permanent residence. The attraction to Venice, besides being a small quaint city with a tranquil atmosphere, is the absence of snow, ice and below freezing temperatures.

My employment with the AAPM began in the fall of 1993.

My first two major tasks were to oversee the relocation of the Headquarters office from New York to Maryland and to hire a new staff to begin work when the move was completed. The move was somewhat chaotic because all records arrived in boxes which the new staff had no clue as to the contents. To make matters worse, the new AAPM office space was not ready for occupancy and we had to work in scattered temporary space in the new building. The bad news was that it was difficult, but the good news was that this difficulty built a sense of team sprit among the new employees that endures to this day. This sense of team spirit has rubbed off on new staff as they were added.

My 10-year term as executive director was full of many challenges, but mostly with the satisfaction of knowing that my goal for the Headquarters operation of continuing improvement of administrative processes and superior customer service began on the first day and continues today.

I won’t go into a list of successes, failures or disappointments here, but I do feel satisfied that I will leave the AAPM with an improved Headquarters office operation as compared to when I started.

I want to thank all the Executive Committee, council chairs and active members who served over the past 10 years for their understanding and support. Their good judgment and leadership is responsible for the current status of AAPM as an organization known to other like organizations as a leader in innovation and accomplishment for its members and the general public.

I also want to thank all my coworkers, past and present, for the support they gave me as executive director. A finer group of pro11

fessionals would be hard to find.

Problem solving just comes naturally to this group. Their upbeat attitude, team spirit and friendliness made it a pleasure to work at the AAPM. I have avoided using names of individuals responsible for any successes I may have had during my tenure for fear of inadvertently leaving someone out. But, I would be remiss if I did not mention and thank Angela Keyser.

Angela will replace me as executive director. We worked together at a previous organization and for the entirety of my employment at AAPM. I have relied heavily on her good judgment with many difficult decisions.

Knowing that Angela will lead the AAPM Headquarters operations after I leave, gives me comfort that AAPM is in good hands.

I want to take this opportunity speaking for all the staff, to wish you and your loved ones a happy and healthy holiday season.

Farewell to all!

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Government Affairs Column Angela L. Lee College Park, MD The Federal Government is currently functioning under a continuing resolution. A continuing resolution keeps the various government agencies running even though Congress has not passed the appropriation bills to fund them. Hopefully by the time this column is published, Congress will have passed the appropriations bills that are relevant to the AAPM. They are: the Agriculture bill which funds the Food and Drug Administration, the Energy and Water Bill which funds the Nuclear Regulatory Commission, and the Labor, Health and Human Services, Education Bill which funds the Centers for Medicare and Medicaid Services, and National Institutes of Health. Congress has set October 31, 2003 as their target adjournment date. This date is subject to change, depending on how much work they complete in the next few weeks.

I recently attended several meetings at the Centers for Medicare and Medicaid Services (CMS), Food and Drug Administration (FDA) and the American College of Radiology (ACR).

A summary of the relevant parts of these meetings follows.

I attended the Advisory Panel on Ambulatory Payment Codes (APC) Meeting at CMS. The Advisory Panel on APCs looked at proposed changes for calendar year 2004 to the Hospital Outpatient Prospective Payment

System. The AAPM submitted comments to CMS regarding: Level II Radiation Therapy (APC 301); Intensity Modulated Radiation Therapy (APC 412 and 413); High Dose Rate Brachytherapy (APC 313); Low Dose Rate Brachytherapy, Non-Prostate (APC 312 and 651); Permanent Seed Prostate Brachytherapy (APC 684 and 649); and Stereotactic Radiosurgery (SRS). The general theme of the letter was that payment rates should not be reduced because reductions are detrimental to providers. This is especially true in the case of Low Dose Rate Brachytherapy where APC 312 may be reduced by 93% ($2758 to $200) and APC 651 may be reduced by 83% ($2853 to $545). AAPM recommended that CMS work with hospitals to insure “proper reporting and coding,” so that CMS is basing their reimbursement rates on the true cost of services.

The FDA Center for Devices and Radiological Health held a Technical Electronic Product Radiation Safety Standards Committee (TEPRSSC) meeting on October 1, 2003. The TEPRSSC looked at the Proposed Amendments to the Performance Standard for Diagnostic X-Ray Systems, and security screening systems. There was an update on the Proposed Amendments by Dr. Tom Shope. Dr. Shope looked at the background of the rule and the estimated schedule of completion for the final rule. He looked back to 1993 12

when the first rule was proposed and brought us up-to-date regarding what has happened since then. He stated that the Final Rule should appear in the Federal Register by the end of 2003 and become effective in late 2004 or early 2005. One of the committee members, Dr. John Cardarelli, is the principle investigator for a National Institute for Occupational Safety and Health (NIOSH) study that evaluates the potential radiation exposure to airport employees who operate X-ray generating machines. If you are interested in more information on this NIOSH study, you can contact Dr. Cardarelli at jcardelli@cdc.gov.

I attended the ACR/AAPM Conference on Medical Radiation Shielding on October 8, 2003. The meeting was organized by G. Donald Frey (AAPM, president-elect) and Richard Morin (ACR chair, Medical Physics Commission). Members of the AAPM’s Executive Committee, as well as members of the AAPM and ACR were in attendance. The meeting was a day of presentations and discussions of

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the National Council on Radiation Protection and Measurements (NCRP) Report No. 116, which recommends that the public dose limit be reduced from 1mSv/y to 0.25mSv/y. Thomas S. Tenforde, president of NCRP,

stated that there is a four person ad hoc committee looking at the 0.25mSv/y recommendation.

This ad hoc committee will meet in November, 2003 and then will recommend an appropriate course of action to the NCRP at

their December, 2003 meeting.

The NCRP will take action on the recommendation that is approved by their board of directors in early 2004.

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Education Council Herbert Mower Council Chair Most of the committees and subcommittees of the Education Council met at the 2003 Annual Meeting. I am happy to report that all are working hard for you, the members of our Association.

Let me note a few of the topics covered.

The RSNA Continuing Education Coordination Subcommittee (chair: Perry Sprawls) reports on an expansion of our educational efforts at the RSNA. In 2003 there will be five physics tracks offered. Our physics tutorial will be on digital mammography and our equipment selection tutorial on ultrasound. This group is also working with our Summer School Subcommittee, the RSNA, and the ACMP to better coordinate our physics offerings.

The Summer School Subcommittee (chair: Paul Feller) reported on a very successful summer school under the academic guidance of Jatinder Palta and Rock Mackie. The topic: “Intensity Modulated Radiation Therapy” proved to be a great one drawing 428 participants.

Great job, guys! Also, many

thanks to Jerry White, Sherry Connors, Will Parker and Robin Miller for their guidance on the “local arrangements” end. We are looking forward to the 2004 school: “Specifications, Performance Evaluation and Quality Assurance of Radiographic and Fluoroscopic Systems in the Digital Era.” This school will be ‘linked’ to the Annual Meeting starting on Thursday afternoon.

The Summer School Subcommittee is interested in your suggestions for future topics and locations. Feel free to forward these to Paul Feller.

The Education and Training of Medical Physicists Committee (chair: Bhudatt Paliwal) reported on the success of the Summer Fellowship Program. We hope to expand the number of participants in this program to 10 next year. The committee is also working on establishing a database to more clearly reflect the workforce needs in medical physics.

The Medical Physics Education of Physicians Committee (chair: Richard Massoth) hopes to have several items available for us in the near future, perhaps by this year’s RSNA. These include: 13

•Radiobiology teaching slides •Radiation Effects and Protection Lecture for Medical Students •Review of the Radiation Physics Syllabi for Residents.

The Public Education Committee (chair: Ken Hogstrom) reported that the revised Diagnostic Medical Physicist brochure is done and ready to go to press. The radiation oncology physicist and nuclear medicine physicist brochures are next in line. The booklet Julius Goes to Radiation Therapy is done and we are investigating the best method of distribution for this.

This year’s “Educators’ Day” program for high school and college physics teachers was dynamic but we had far fewer attendees than we had hoped. For next year, the committee is looking into more follow-ups closer to the meeting.

If you will be at the RSNA, feel free to drop by any of our committee, subcommittee or task group meetings. Visitors are always welcome. This is a great way to learn what your Association is doing for you and what you might be able to contribute to the Association.

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AAPM NEWSLETTER

NOVEMBER/DECEMBER 2003

Summer Undergraduate Fellowship Update George Sandison Program Chair Last summer was the third time the AAPM Summer Undergraduate Fellowship Program was run.

The 10-week program’s aim is to expose the fellows to medical physics research and clinical practice and so influence them to undertake graduate study leading to a career in medical physics. Competition for a fellowship was very strong with a total of 51 applicants; the eight winners had an average GPA of 3.71. Part of the formula for success in attracting this large pool of outstanding students was the advertising of the program in the newsletter of the Society of Physics Students. Special thanks are due to those members who volunteered to serve as mentors for the fellows this past summer. We encourage those mentors not selected to volunteer again next year as mentor selection is strongly influenced by the fellow applicants’ requests to study in geographic areas nearby their residence. A large base of potential mentors across the country helps the subcommittee to best meet the individual fellows’ requests. Below are some of the highlights from the work of a few selected fellows this past summer.

Curtis Baker and Rachel McKinsey – (Mentor Dr. Ali Meigooni – University of Kentucky Medical Center) Learned quality assurance, treatment planning, and chart checking by shad-

L to r: Jim Turmel, Carmen Band, and Dave Vassy

owing Dr. Meigooni and other medical physicists. They also shadowed radiation oncologists during the patient prescription, simulation and follow-up procedures and observed patient treatment. Curtis and Rachel also assisted in research activities and a manuscript has been submitted to the Medical Physics journal.

Angela Carmen Band – (Mentor Mr. David Vassy, Jr. – Spartanburg Radiation Oncology PA) Helped implement a MOSFET patient dosimetry program by calibrating and measuring properties of MOSFETS and developing clinical procedures for their use. She also measured skin doses during Mammosite breast brachytherapy treatments and showed them to be lower than those predicted by standard computer models.

Christopher Muraski – (Mentor Dr. Ramon Alfredo Siochi – St. Jude Children’s Hospital) Worked on a triple source model that describes the behavior of radiation as it traverses through a multi-leaf collimator. He compared predictions of the model to 14

measurements and minimized the difference by free parameter adjustment.

Michael Skeen – (Mentor Dr. Susan Klein – Indiana University) Worked at the Midwest Proton Radiotherapy Institute (MPRI). He reverse-engineered and designed the small field line to be installed in the first treatment room and was responsible for the electrical design of the patient-viewing component of the patient safety system. He also assisted in the commissioning of the beam-line passive scattering components.

Adam Springer – (Mentor Dr. Kenneth Matthews, II – Louisiana State University) Fabricated and assembled a prototype radiation detector for positron coincidence imaging using a gamma camera. He learned many techniques related to radiation detector development, including: optical coupling of phototubes and scintillation crystals; polishing and painting of optical fibers; electronics prototyping; and carpentry to build a light-tight box to hold the detector system. He

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also presented a poster at LSU’s Annual Summer Undergraduate Research Forum and attended the 50 th Annual Society of Nuclear Medicine Meeting in New Orleans. His look of awe upon entering the conference exhibit hall was a delight to his mentor.

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2003 Young Investigators Competition The winners of the 2003 Young Investigators Competition held in San Diego are: John R. Cameron Young Investigator Award — Stephen Steciw for his paper entitled "A Monte Carlo Based Method for Accurate IMRT Verification Using the AS500 EPID" Second Place — Tao Wu for his paper entitled "Tomosynthesis Mammography Reconstruction using a Maximum Likelihood Method" Third Place — Anant Gopal for his paper entitled "Extraction and Reconstruction of Asymmetric Vessel Lumen in Radiographic Images using Vessel Continuity."

Congratulations to the winners!

AAPM Members Receive International Recognition At the recent World Congress on Medical Physics and Biomedical Engineering held in Sydney, Australia on August 24-29, 2003: Colin Orton was selected as president of the International Union for Physical and Engineering Science in Medicine (IUPESM)!

Additionally, Colin Orton received the Award of Merit from IUPESM (their highest award)!

Azam Niroomand-Rad was installed as president of the International Organization for Medical Physics (IOMP)!

Perry Sprawls received the Harold Johns Award from the IOMP for activities in international education!

Congratulations!

AAPM Member Appointed Director at IAEA M. Saiful Huq, PhD Philadelphia, PA Pedro Andreo, a member of the AAPM since 1977, has been appointed director of the Division of Human Health at the International Atomic Energy Agency (IAEA). The division comprises the sections of Radiobiology & Radiotherapy, Medical Physics, Nuclear Medicine, and Nutrition & Environmental Health. It is the first time in the history of the 15

(See Andreo - p. 16)

AAPM NEWSLETTER

Andreo

NOVEMBER/DECEMBER 2003

(from p. 15)

IAEA that a medical physicist occupies such a position.

Pedro Andreo was born in Spain in 1950. He graduated with a master’s degree in theoretical physics in 1974, and earned his doctorate in 1982 at the University of Zaragoza. He moved to the Department of Medical Radiation Physics, Karolinska Institute-University of Stockholm (Sweden) as a research fellow in 1987, becoming associate professor and doctor in sciences in radiation physics at the University of Stockholm in 1989. He was appointed full professor in radiotherapy physics at the University of Lund (Sweden) in 1993, and head of the Radiotherapy Physics group of this university hospital. Between 1995 and 2000 he was the head of the Dosimetry and Medical Radiation Physics Section of the IAEA, during which period he was the secretary of the IAEA/WHO network of Secondary Standards Dosimetry Laboratories. Since 2000 he has been a full professor of Medical Radiation Physics at the University of Stockholm.

His scientific activities have emphasized the use of the Monte Carlo method in radiotherapy physics, mainly for absolute dosimetry and for treatment planning with electron and photon beams, where he was one of the pioneers in the field. His most recent activities have been focused on the dosimetry of therapeutic proton and heavy ion beams. He has authored approximately 300 publications, scientific

papers, and conference abstracts and proceedings. Pedro Andreo’s profile has a dominant component of international activities, having been coauthor of several international recommendations for the dosimetry of radiotherapy beams; these include the IAEA Codes of Practice based on air kerma standards (IAEA TRS-277, 1987), for the Use of Parallel-Plate Ionization Chambers (IAEA TRS-381, 1997),

16

and the more recent protocol based on absorbed dose to water standards (IAEA, TRS-398, 2000) (being the chairman of the last two). He has also been coauthor of the ICRU publications on Proton Dosimetry (ICRU 59, 1998) and Photon Dosimetry (ICRU 64, 2001), and of the ICRP on Accident Prevention in Radiotherapy (ICRP 86, 2002).

He became involved in clinical radiation physics in 1973, hold-

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ing clinical training positions in Oxford, London, Sutton and Stockholm. He worked as a hospital physicist for about 15 years, mainly in the area of radiation therapy but also in nuclear medicine and diagnostic x-rays. He is a certified medical physicist in Sweden. During his former employment at the IAEA he extensively promoted projects aimed at decreasing the uncertainty of the dose delivered to patients undergoing radiotherapy treatments by improving quality assurance and treatment planning, as well as the education and training of medical physicists worldwide.

This was a period of fruitful support by the AAPM of the IAEA radiotherapy physics activities, and many well-known AAPM members became active consultants and coauthors of dosimetry recommendations (P Almond, M Saiful Huq, L DeWerd), treatment planning reports (J Van Dyk, D Fraas), QA and safety (F Aguirre, G Ibbott), education (N Suntharalingam, E Podgorsak). â–

Announcement JOB OPENING: CURATOR OF IOMP / AAPM LIBRARIES The curator manages a clearinghouse that accepts donations of medical physics books and journals. Donations are sent to libraries in developing countries where they are available to medical physicists and physicians in the region. The program is sponsored by the IOMP/ AAPM. It works this way: We maintain a database in ACCESS of current holdings at each library and a list of publications they need the most.

When we are offered a donation we search the database for the best library to receive the donation. Usually the donor ships the donation directly to the library and sends us the receipt for shipping expenses, which we then process through the IOMP office for reimbursement.

Currently, there are 90 libraries in 58 countries. In addition to processing donations, we accept applications for new libraries. We send a questionnaire approximately semiannually to update information on the library (name of person responsible, address, etc.) to insure that donations are shipped correctly.

We have tried to take advantage of electronic transmission of information. For example, many organizations have meeting proceedings on CDs. After the meeting I ask the organizers

17

for any remaining CDs to send to the libraries. We notify libraries of resources on the Internet, such as the ACMP journal.

The time required of the curator is minimal if you have good support staff, although the curator should be able to attend most meetings of the International Affairs Committee of the AAPM which are held twice per year at national meetings. I estimate that it requires about 5% of one secretarial staff person to maintain the database and handle mailings and queries.

Although this is a volunteer job, I have been rewarded by the pleasure of establishing contacts with colleagues in developing countries and helping them build libraries that further their careers.

Please contact me if you have any questions about the work of the curator.

Marilyn Stovall, PhD Professor, Dept. of Radiation Physics–Unit 544 The University of Texas M.D. Anderson Cancer Center 1515 Holcombe Houston, TX 77030 USA 713-745-8999 713-794-1371 FAX mstovall@mdanderson.org

AAPM NEWSLETTER

NOVEMBER/DECEMBER 2003

Memorial Wilbert “Bill” Minowitz H. Amols, J. St. Germain, and J. Minowitz Medical physics lost a good friend on August 3, 2003 with the passing of Wilbert “Bill” Minowitz who died at the age of 77 after a long battle with kidney disease.

Bill received a degree in electrical engineering from NYU in 1946, and started as a physicist at Mount Sinai Hospital in New York under the guidance of Bob Loevinger. He soon switched to industry, working for several small electronics companies in the 1950s on radiation dosimetry and neutron activation instrumentation, including a stint at the Nevada test site to study the effects of high neutron dose rates. A position at Amperex Corporation (a subsidiary of Philips International) led to his 40+ year career in industrial medical physics where he worked for Picker, Siemens, and most recently for 20 years at Varian.

While with Picker in the 1960s and 1970s, he played an important role in the introduction of radiation therapy simulators — the real beginning of conformal radiation therapy. In the 1990s with Varian, he contributed greatly to the development of multileaf collimators, leading to the practicality and popularity of intensity modulated radiation therapy.

Bill’s career as a corporate physicist was rather unique. An engineer by training, he operated more as a combination product

tory buff, an accomplished bridge player with more than a few master points, an excellent amateur pianist, and a political commentator. Most importantly, Bill loved his work because it entailed interacting with people. He will be sorely missed by his many friends, wife Judie, children Peter, Deborah and Emily, son-in-law Richard, daughter-in-law Debbie and grandsons, Max and Zachary.

■ specialist, engineer, salesman, and goodwill ambassador. He bridged the gaps between manufacturers and clinicians, between physicists and physicians, and even between corporate executives and their own research and development groups. He could easily communicate with all players in the game and will be remembered as much for his technical contributions to the field as for his style, personality, and sense of the absurd; ‘absurd’ being the only way to describe a “special accounts manager” (his official job title) who, with a mischievous smile, gleefully handed out business cards introducing himself as “Corporate Irritant.”

This oddest of business cards is but one example of a style that enabled Bill to accumulate so many friends over the course of his career.

Bill had many interests beyond medical physics. He was once NY State table-tennis champion, and he played college basketball and tennis. He was an avid his18

Headquarters Holiday Schedule The AAPM office will be open all regularly scheduled workdays during the holiday season, but will be closed on Thursday and Friday, December 25-26, 2003 and Thursday, January 1, 2004.

Some staff will take vacation days during the holiday season, but sufficient help will be available to service your needs.

AAPM NEWSLETTER NOVEMBER/DECEMBER JANUARY/FEBRUARY 2003 2001 AAPM AAPMNEWSLETTER NEWSLETTER NOVEMBER/DECEMBER 2003

ACR Mammography Accreditation Frequently Asked Questions for Medical Physicists Priscilla F. Butler, MS Sen. Dir., ACR Breast Imaging Accreditation Programs Does your facility need help applying for mammography accreditation? Do you have a question about the ACR Mammography QC Manual? Check out the ACR’s Web site at www.acr.org; click “Mammography” and then “Frequently Asked Questions.” You can also call the Mammography Accreditation Information Line at (800) 227-6440. In each issue of this Newsletter, I’ll present questions of particular importance for medical physicists.

The topic for this issue is fullfield digital mammography. The FDA approved the ACR to accredit Lorad Selenia full-field digital mammography (FFDM) units beginning September 15, 2003. ACR began accrediting the GE Senographe 2000D on February 15, 2003 and Fischer SenoScan on August 15, 2003.

Q. Will my facility receive a separate MQSA certificate for our full-field digital mammography unit?

A. No. MQSA certification is facility based and not unit based.

The FDA and other MQSA certifying bodies will only issue one MQSA certificate (with a unique ID number) to a single facility.

This certificate covers any unit, whether it is screen-film or FFDM.

Q. During accreditation, do I need still need to send the ACR a laser printer quality control chart if hard copy printing is done by a third party?

A. Yes. For purposes of transferring films, the FDA requires a facility to be able to “provide the medical institution, physician, health provider, patient or patient’s representative, with hard copy films of primary interpretation quality.” Even though a third party may produce this hard copy, the facility should ensure that the quality of the hard copy is of primary interpretation quality. Evaluating laser printer quality control is part of this assurance. Furthermore, you must follow your FFDM unit’s manufacturer recommendations for laser printer QC. Q. The manufacturer of our FFDM unit has a number of different revisions of their QC manual available. Which one should we follow for the medical physicist and technologists QC tests?

A. You should use the most current version of the QC manual for the unit installed at the facility.

Note that the correct manual version may not only depend on the FFDM unit but also the software 19

version of the unit. If there are any questions, check with the manufacturer of the FFDM unit.

Q. The physician’s display workstation is not at the same physical location as the FFDM unit (it is off-site). Am I still required to test it during Equipment Evaluations and Annual Surveys? Does the facility still need to submit QC results on that workstation to the ACR during accreditation?

A. In general, yes. Most manufacturers’ QC manuals call for the medical physicist to test the physician’s display workstation during Equipment Evaluation and the Annual Survey. All require periodic QC tests by the technologist. If there are any questions, check with the manufac■ turer of the FFDM unit.

AAPM NEWSLETTER

NOVEMBER/DECEMBER 2003

Letters to the Editor What Price Conformity?

Richard Peksens, MS Saint Petersburg, FL Rpeksens@aol.com I have always opposed obfuscation in the radiation therapy business (arts?). I prefer one mCi to 37 MBq and 500 mrem to 5 mSv…. call me a recidivist! Perhaps my bias is based on the fact that my dose calibrator reads in mCi and my exposure meter in mR/hr. Diplomacy obviates my addressing concerns in the utilization of air kerma versus mCi in brachytherapy. To this date, no radiation oncologists have asked me to verify the total air kerma of a particular implant! I check the activity of the sources in U but always report to the physician in units of mCi. The real subject of this diatribe, however, is to rail against the lack of uniformity in machine parameters such as gantry, table, and collimator angles on treatment machines and in treatment planning systems. I am not calling for Orwellian conformity, but just a bit of uniformity. Numerous errors in treatment planning result from the incorrect translation of mechanical readout parameters from treatment planning to treatment. A common source of error is the incorrect utilization of the x and y readouts on a vertex field where the “length” changes from the “normal” caudad-cephalad axis to an inferior-superior axis for the

vertex field. Many treatment planning computers will not allow the user to accurately match the printout of collimator angle and asymmetric jaw settings with those of a “non-standard” treatment machine as defined by the treatment planning manufacturer. There may be additional confusion when one is forced to rotate the digitization template when creating blocked field templates for block cutting and documentation. The simplest solution is to require that all machines utilized in the US follow the same IEC specifications. For example, “the gantry angle shall be zero degrees when the treatment head is pointed towards the floor” or “the opening on the block tray collimator shall always point towards the treatment table when in the 180 degree position.”

Specify the transaxial jaws as X1 and X2 rather than B2 and B1 (I’m not giving names to protect the innocent!). As a consulting physicist, I find that even within departments, machines such as simulators and accelerators are not “standardized” requiring modification of parameters between simulation and treatment.

As we move towards conformal and IMRT therapy with multiple beams, these non-standardized readouts could result in misadministration (don’t ask for the Clintonian definition!). Multiple standards remind me of “variable constants” which should only apply in politics. As a former Nixon cabinet member once stated: “Everyone has a right to 20

his own opinions, not his own facts”! Isn’t it possible that the AAPM could lead the fight towards standardization in radiation oncology treatment parameters?

I’m willing to hold someone’s jacket!

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Transparency and Integrity of NIH Grant Award Process Marek J. Maryanski Madison, CT mgsr@snet.net Whenever taxpayers’ monies are spent on funding competitive research grants, it is essential that the criteria for making the funding decisions be completely transparent. That requirement implies that full documentation of each step in the decision-making process be available to principal investigators, at the very least upon request. This letter aims to alert all those who believe that the NIH grant award process is sufficiently transparent. It is not. While Review must document its discussions and conclusions in written summary statements and its action can be appealed before the National Advisory Board, Program staff can still decide pretty much as they see fit. They can base their decisions on secret information coming from undisclosed sources. They have no obligation to provide sufficiently

AAPM NEWSLETTER NOVEMBER/DECEMBER JANUARY/FEBRUARY 2003 2001 AAPM AAPMNEWSLETTER NEWSLETTER NOVEMBER/DECEMBER 2003

Letters to the Editor detailed written justification for their decision or to discuss key issues with the principal investigator. And their decisions cannot be appealed. This empowers the “gatekeepers” at the Program level with undue bureaucratic power over principal investigators who are, after all, the real national leaders in research. This opens the door to potential favoritism and corruption.

American taxpayers and principal investigators must be assured that grant funding decisions are made solely on the basis of scientific merit, societal importance, and programmatic priorities at each grant awarding component. Each of those criteria must be used with full transparency. Moreover, there should exist a clearly defined mechanism whereby Program decisions would be appealable by principal investigators.

I have decided to write this letter because two of my own grants have been rejected by one and the same program director over the last 12 months despite having received fundable scores and excellent funding recommendations from Review. In each case, the decision was based on unsubstantiated allegations such as “changes in the project” or “overlap with other support.” In each case, the program director refused rational discussion that could result in the clarification of his allegations and moving forward with the funding. In the case of the alleged overlap, I was un-

able to obtain any documentation from the program staff that would indicate the overlap with sufficient level of detail to either resolve the issue and to enable the funding or to avoid it in a resubmission.

Over the telephone, with utmost disbelief, I heard from the program director: “Discussion is not the way we do business here.”

If this is the “new tone in Washington, DC,” then our research and, above all, the patients who are supposed to benefit from it are indeed in deep trouble. ■

Licensure Ken Vanek, PhD Charleston, SC vanek@radonc.musc.edu I would like to respectfully add to the continuing Newsletter discussion concerning the licensure of clinical medical physicists. It is my personal belief that licensure is THE most important professional issue confronting practicing clinical medical physicists today. Every clinical physicist should be actively promoting and supporting the CARE Bill which has been introduced into the U.S. House of Representatives and the U.S. Senate.

Like it or not, licensure is a legal tool to restrict the practice of a profession to only those individuals who meet the training and experience outlined in federal 21

and/or state laws. To practice without a license invites financial penalties and even imprisonment.

In theory, licensure protects the general public from harm by inadequately trained individuals. As evidenced by malpractice claims in other professions, licensure is not always successful in that endeavor but individuals have had their licenses revoked which therefore makes it illegal for them to practice in that state. Thus, I propose that licensure, even with its shortcomings, is much better than the total lack of control that we currently have over the individuals practicing our profession.

Licensure is not a law that governs morals and ethics. In every profession, there is a spectrum of people ranging from scumbags to perfectionists. It is up to you to decide where in that spectrum you wish to practice. Licensure, however, does establish a baseline of training, experience, peer review, and even continuing education. Should we feel threatened by putting our training and experience requirements into law?

Our president elect-elect, Howard Amols, introduced some intriguing thoughts about board exams. He also stated that “ even if the exams were more difficult to pass, certification alone could not currently keep incompetent people out of our field because there are no laws, in any state, requiring that hospitals and clinics hire only certified individuals.”

I contend that these laws will (See Vanek - p. 22)

AAPM NEWSLETTER

NOVEMBER/DECEMBER 2003

Letters to the Editor Vanek

(from p. 21)

never happen if there is no licensure.

As we are all well aware, radiation therapists, radiology technologists, medical dosimetrists, and other radiological support personnel are actively seeking licensure. As practicing clinical physicists, it is imperative that we join this effort and be included in federal law to insure, among many other things, that we are not legally excluded from practicing certain aspects of our profession.

For example, how many therapy physicists currently plan HDR treatments, perform the HDR QA, load the treatment plan, connect the HDR transfer tubes, and then ask the therapists to push the start button because we are not licensed to treat patients? Suppose medical dosimetrists become licensed to do treatment plans and various aspects of QA and calculations and medical physicists continue to stick their heads in the sand and do not become licensed. Thus, by LAW, we could not perform those tasks which medical dosimetrists and others are licensed to perform.

Under these conditions, I argue that we could not effectively practice our profession and supervise the technical aspects of radiation oncology and dosimetry.

Don’t be misled. Our task will not end with the passage of the CARE Bill. The CARE Bill is a rather general bill covering a mul-

titude of clinical specialties in imaging and therapeutic radiation procedures. The House bill in itself does not require a true license to be issued by each state. The states are given choices. They may choose to issue a true license, accept certification or issue some other form of document. The Senate version does not mention licensure at all. Both versions require that training and experience criteria be established and require all states to take legislative action.

Nonetheless, the passage of the bill by both legislative bodies and the subsequent compromise bill is the crucial beginning of binding regulations. It will be at this point that our professional and legislative efforts must intensify even more. The real “meat” of the law will be in the implementation details published in the Code of Federal Regulations and related state regulations. It is imperative that we have a strong and active role in the formulation of these regulations. This legislative process will be our best window of opportunity to establish licensure for our profession in every state.

It will be a tedious process, but with due diligence, we will not be legally denied the full practice of our profession and will have more control over those who practice clinical medical physics.

Please write your senator and representative and encourage their support of the CARE Bill.

Stress the importance of medical physicists being included in this legislation and the impact that it 22

will have on all patients diagnosed or treated with ionizing radiation.

If you choose not to support or promote licensure, please realize all the potential ramifications on your professional future and the medical physics profession.

Write your congressman today!

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Don’t Just Fight the Symptoms, Eradicate the Disease

Ivan A. Brezovich, PhD Birmingham, AL ibrezovich@uabmc.edu In the Sept/Oct 2003 Newsletter, AAPM President Dr. Weinhous emphasized the need to attract new practitioners to medical physics. President-elect Dr. Amols, on the other hand, complained about the low competence of some medical physicists and proposed a more difficult ABR exam to weed out the “bozos.” Indeed, radiology departments have difficulty finding (See Brezovich - p. 24)

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AAPM NEWSLETTER

NOVEMBER/DECEMBER 2003

Letters to the Editor Brezovich

(from p. 22)

medical physicists and, according to a presentation by ABR President Dr. Bill Hendee (http:// www.acmp.org/meetings.html), applicants pass if they answer correctly about 50% of the test questions.

To me, it seems that both problems are symptoms of the same disease, i.e., the low standing of the medical physics profession.

Medical physics is not appealing enough to attract new members in sufficient numbers, and many of those that it attracts or has attracted are of poor quality. We can continue the so far unsuccessful fight against the “shortage” by mentoring “youngsters,” by being even less forthright about the not-so-good sides of medical physics. We can raise the bar at the ABR exam, and risk an even greater shortfall of practitioners. Or we can eliminate both problems by eradicating the disease itself.

Not too long ago, the Health Care Financing Administration (HCFA), as it was then called, proposed to pay for radiology, anesthesiology and pathology services (RAPS) through the hospital, a reimbursement mechanism identical to the current method of payment for medical physicists. Not surprisingly, the number of applicants for radiation oncology residency positions went down, at some places to zero, and the level of competency was low. I remember trying to teach a resident from a develop-

ing country where “girls were not taught any math” how to do simple dose calculations. Unable to add numbers with more than two digits and distinguish between division and multiplication, she washed out at the ABR exam and left the profession.

As soon as HCFA recognized radiation oncologists as medical specialists in their own right, residency programs started to get swamped with applications from the very best and brightest young doctors, including those from top Ivy League medical schools. Radiation oncology was no longer just a stepping stone for obtaining immigrant status. At our own institution, we have USAborn PhD physicists among our radiation oncology faculty and residents. Radiation oncology applicants score substantially better than 50% on their ABR exams, as Dr. Amols rightfully expected from his personal physicians.

Medical physics would equally boom if we got recognition by CMS (as HCFA is called today) as providers. Radiation oncologists did not achieve their desirable position by doing nothing.

They started to lobby through ACR and ASTRO, and formed ACRO. They encouraged all radiation oncologists to write letters to Congress, and asked medical physicists and therapists to write similar letters on their behalf. Medical physicists need to do the same. We owe it to the “youngsters” we are trying to attract, and even moreso to our 24

patients. It is inconceivable that medical physicists could not get added to the list of 50 professions and entities that have provider status, which includes social workers, nurse practitioners, medical doctors, physician assistants, and audiologists. I am encouraging every medical physicist to voice his/her concerns to the AAPM leaders or Board representatives.

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Disease-specific Survival for Prostate Cancer Treated by Radiation and Surgery R. J. Schulz, PhD Johnson, VT schulz@pshift.com In his response to my letter “Prostate Cancer for Physicists” (1), Timothy Schultheiss (2) pointed out a blatant error in my description of how Gleason scores are determined, my confusion about relative and diseasespecific survival, and my discussion of prostate-cancer staging which was anything but clear. For his clarification of these issues, I owe Dr. Schultheiss a vote of thanks.

There are, however, other issues about which we continue to disagree, principal among them being the levels of disease-specific survival and morbidity achieved by radical prostatectomy and radiation therapy. At the

AAPM NEWSLETTER NOVEMBER/DECEMBER JANUARY/FEBRUARY 2003 2001 AAPM AAPMNEWSLETTER NEWSLETTER NOVEMBER/DECEMBER 2003

Letters to the Editor end of his first paragraph Dr. Schultheiss states that he “will briefly make the case that the two modalities yield equivalent results.” Unfortunately, in terms of survival, this equivalency is not possible because not enough time has elapsed since the introduction of 3D-CRT, IMRT and radioactive-seed implants for 10-year data to have been archived. In place of survival, he would like us to accept that these new modalities can be judged on the basis of post-treatment PSA levels. Let it be clear at this point that elevated PSA levels do not cause symptoms nor in any way affect how a patient feels. They have been related to the development of metastases but they have not been linked to disease-specific survival which, after all, is what the patient most cares about.

Dr. Schultheiss was justifiably concerned that I presented fairly old, 10-year, disease-specific survival data for prostate cancer treated by radical prostatectomy (RP) and radiation therapy (RT), and states that “It is my (his) belief that improved clinical outcomes as a result of the application of conformal therapy have been convincingly demonstrated for prostate cancer.” As stated above, insufficient time has elapsed for patient accrual and the assessment of 10-year survivals for patients treated by 3DCRT or IMRT. Therefore, the most recent data are for conventional external-beam RT. In a multi-institutional study to evaluate the predictive power of initial

risk factors, D’Amico et al (3) followed 7,316 men who had RPs and 2,370 who received RT. Depending upon clinical stage, PSA and Gleason score, patients were entered into low-, intermediate- and high-risk categories, and their prostate cancer-specific mortality monitored for out to 10 years post treatment. For the RP patients the low-risk, intermediate-risk and high-risk mortalities at 10 years were 0.5%, 3.5% and 10.5%, respectively. For the RT patients the 10-year mortalities were 1.0%, 8.5% and 24.5%, respectively. It is important to appreciate that this study was not designed to compare RP with RT but does present results that were routinely achieved at academic medical centers from the late 1980s through the beginning of the current century. Dr. Schultheiss is correct in arguing that for patients in the low-risk category the two modalities achieve comparable results.

However, as pointed out by Albertsen et al (4), patients with low-grade prostate cancer who are conservatively treated (i.e. hormonal therapy) show no loss in life expectancy. Therefore, we should not be surprised that the 10-year cancer-specific mortalities for these low-risk patients was in the range of 0.5-1.0 % as this would be expected even without treatment. As for the intermediate- and high-risk groups, there appears to be a distinct advantage of RP over conventional RT. 25

In a recent review article, Peschel and Colberg (5) present the results of surgery, brachytherapy and externalbeam for early prostate cancer.

Foremost in this review are the results of a multi-institutional study conducted by Hull et al (6) in which 1,000 patients underwent RP and pelvic lymphadenectomy. For patients clinically staged with T1 (40%) and T2 (60%), the 10-year cancerspecific survivals were 99% and 97% respectively, and the overall survival was 86.6%. These heartening cancer-specific survivals may have been influenced by the treatment of disease which would not have affected the patient if left untreated. However, the same bias in patient selection would also affect the results obtained by other types of treatment, and so, until the sensitivity and specificity of diagnostic tests are improved, these 99% and 97% survivals remain to be challenged.

Again, because of accrual and time limitations, Peschel and Colberg (5) are constrained to presenting five-year data for radioactive-seed implants, and 3DCRT and IMRT. For radioactiveseed implants, there are data from four investigators who treated a total of 1,846 men. The five-year cause-specific survivals for patients with favorable, intermediate and poor prognoses were between 99% and 100%.

(Clearly, earlier detection of (See Schulz - p. 26)

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Letters to the Editor Schulz

(from p. 25)

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prostate cancer has markedly reduced the value of five-year survival as a measure of treatment efficacy.) On the other hand, the five-year biochemical diseasefree survivals (5-YBDFS) for these same groups are in the ranges of 83-94%, 67-82% and 52-65%, respectively. We will have to wait to find out how these data relate to long-term survival.

As for 3D-CRT and IMRT, Peschel and Colberg (5) present the results from three studies which compare the effects of low

doses (65-70 Gy) and high doses (76-86 Gy) on 5-YBDFS in patients having favorable, intermediate and poor prognoses. As might be expected, dose escalation caused only minimal improvement for the favorable patients, which were in the 80-85% range, but significant improvements for the intermediate (from 53% to 75%) and poor (from 30% to 55%) prognostic groups.

Although comparisons are difficult, the results obtained by radioactive-seed implants are remarkably similar to those from high-dose external beam. Again,

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we must await the results of longterm survival.

It is understandable that many clinicians have adopted b-NED as a measure of treatment efficacy, as the accrual of 10-year survival data is a slow and tedious process in a world impatient for results. Although widely adopted as a measure of treatment efficacy, the jury for bNED is still out. Kupelian et al (7) state unequivocally that “Biochemical failure after definitive radiotherapy for localized prostate cancer is not associated with increased mortality within the first

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10 years after the initial therapy, although a trend toward worse outcome was observed at 10 years.” In a similar vein, Peschel (8), in reviewing the five- and 10year bNED and adjusted survival rates achieved by RT, states that “It is clear from our data that bNED survival was a poor surrogate for AS (adjusted survival) in our patient population.” We must ask ourselves whether it is premature to advocate complex and expensive IMRT systems for the treatment of prostate cancer where the only supporting evidence is the pattern of post-treatment PSA levels.

The basic questions for radiation oncologists are whether dose escalation to 80 Gy or higher will improve 10-year cancer-specific survivals, will the results obtained by radioactive-seed implants rival those of IMRT, will either achieve the results of Hull et al (6), and, if having gained similar levels of survival, which treatment modality causes the fewest long-term complications. I submit that physicists should be as concerned with the answers to these questions as their medical colleagues.

I’ve presented clinical data from recent publications which do not support Dr. Schltheiss’s “belief that improved clinical outcomes as a result of the application of conformal therapy have been convincingly demonstrated for prostate cancer.” After a 40-year career in radiation therapy, I gain no pleasure in taking former colleagues to task for failing to apply the same rigorous criteria to clinical issues as they were trained to apply to the results of labora-

tory experiments. I accept that IMRT combined with inverse treatment planning are brilliant technological achievements which come close to meeting one of the goals of radiation oncology — irradiating the tumor while sparing surrounding tissues — and I understand why it has great appeal to physicists and physicians alike.

However, medical physicists should appreciate that cancer is an extremely complex disease, that radiation therapy has its limits, and that IMRT is similarly constrained by these limits. When millions of our fellow citizens are without or losing their health insurance and many cannot afford the cost of prescription drugs, we should carefully weigh the costs and benefits of new treatment modalities before advocating their adoption. Unfortunately this has not happened in the case of IMRT. Based only upon speculations that more precisely defined dose distributions and dose escalation will result in improved survival, new industries have been born and older ones revived, medical physicists are in great demand, reimbursement rates have quadrupled, and radiation oncology has received a new lease on life. We will sit back and keep our fingers crossed that IMRT does not go the way of bone-marrow transplants for breast cancer and other initially promising therapies that did not stand the test of time.

1. Schulz, RJ. “Prostate Cancer for Physicists.” AAPM Newsletter, 28, No 2:10-14, 2003.

2. Schultheiss, T. “Response to ‘Prostate Cancer for Physicists.’”

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AAPM Newsletter, 28, No 4: 20-22, 2003.

3. D’Amico AV, Moul J, Carroll PR, Sun L, Lubeck D and Chen M-H. “Cancer-specific mortality after surgery or radiation for patients with clinically localized prostate cancer managed during the prostate-specific antigen era.”

J Clin Oncol 21:2163-2172, 2003.

4. Albertsen, PC, Fryback, DG, Storer, BE, Kolon, TF and Fine J. “Long-term survival among men with conservatively treated localized prostate cancer.”

JAMA, 274: 626-631, 1995.

5. Peschel, RE and Colberg, JW. “Surgery, brachytherapy and external-beam radiotherapy for early prostate cancer.” The Lancet 4:233-241, 2003.

6. Hull GW, Rabbani F, Abbas F, Wheeler TM, Kattan MW and Scardino PT. “Cancer control with radical prostatectomy alone in 1000 consecutive patients.”

J Urol 167:528-534, 2002.

7. Kupelian PA, Bucksbaum JC, Patel C, Elshaikh M, Reddy CA, Zippe C and Klein EA. “Impact of biochemical failure on overall survival after radiation therapy for localized prostate cancer in the PSA era.” Int J Radiat Oncol Biol Phys 52:704-11, 2002.

8. Peschel, RE. “Salvage radiotherapy following radical prostatectomy.” The Cancer Journal from Scientific American, 4:300-301, 1998.

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Congratulations to Sal Trofi on his impending retirement as executive director of the AAPM! Thank you for your hard work and the wonderful job you have done for our organization. It has been a pleasure working with you. Best wishes in your retirement.

—the Editor

Sal Trofi accepts the “Outstanding Service to the AAPM” Award from President Marty Weinhous at the Annual Meeting in San Diego.

AAPM NEWSLETTER Editor – Allan F. deGuzman Managing Editor – Susan deGuzman Editorial Board: Arthur Boyer, Nicholas Detorie, Kenneth Ekstrand, Geoffrey Ibbott, C. Clifton Ling, Richard Morin

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