AAPM Newsletter September/October 2013 Vol. 38 No. 5 by AAPM Docs

AAPM

N E W S L E T T E R The American Association of Physicists in Medicine

We advance the science, education and professional practice of medical physics

SEPTEMBER/OCTOBER 2013 Volume 38 No. 5

Vendors’ Contribution

President-Elect Bayouth discusses vendors’ vital role in the world of Medical Physicists today

AAPM Chairman of the Board Garry A. Ezzell reveals AAPM’s Strategic Planning Process

Online Learning Opportunities for AAPM Members n Changes in the ABR Examinations n QMP Registry Reminder n ACR Accreditation FAQs n IOMP Announces International Day of Medical Physics n

and more...

AAPM

NEWSLETTER

AAPM NEWSLETTER is published by the American Association of Physicists in Medicine on a bi-monthly schedule. AAPM is located at One Physics Ellipse College Park, MD 20740-3846

EDITORIAL BOARD EDITOR Mahadevappa Mahesh, MS, PhD

Johns Hopkins University E-mail: mmahesh@jhmi.edu Phone: 410-955-5115 John M. Boone, PhD Eileen Cirino, MS Robert Jeraj, PhD George C. Kagadis, PhD E. Ishmael Parsai, PhD Charles R. Wilson, PhD SUBMISSION INFORMATION Please send submissions (with pictures when possible) to: AAPM Headquarters Attn: Nancy Vazquez One Physics Ellipse College Park, MD 20740 E-mail: nvazquez@aapm.org Phone: (301) 209-3390 PUBLISHING SCHEDULE The AAPM Newsletter is produced bimonthly. Next issue: November/December Submission Deadline: October 9, 2013 Posted Online: Week of November 4, 2013

www.AAPM.org

CONTENTS

SEPTEMBER/OCTOBER2013 Volume 38 No. 5

Articles in this Issue

Events / Announcements

AAPM President’s Column

Awards and Honors Call for Nominations

Chairman of the Board’s Column

ABR Executive Director Search

AAPM President-Elect’s Column

AAPM Working Group Recognized by FDA

AAPM Executive Director’s Column

Oldest Tote Bag Winner

Editor’s Column

Donor Lounge at The Annual Meeting

Legislative & Regulatory Affairs Report

Staff Announcements

Professional Council Column

2014 Spring Clinical Meeting

Education Council Report

Persons in the News

ABR Physics Trustees Report

Award Winners

ACR Accreditation FAQs

Medical Physics International Journal

Health Policy & Economic Issues

Letter to the Editor

Working Group Report

Report 174 Press Release

Travel Grant Report

Coolidge Award Introductory Speech

Coolidge Award Acceptance Speech

2013 Summer School Report

CAMPEP News

SEAAPM Chapter Report

Website Editor’s Report

Editor’s Note I welcome all readers to send me any suggestions or comments on any of the articles or new features to assist me in making the tablet edition a more effective and engaging publication and to enhance the overall readership experience. Thank you.

AAPM President’s Column

John D. Hazle, Houston, TX

It’s been a great year so far for AAPM

hat a great meeting in Indianapolis!!! The programs – scientific, professional, educational and social – were outstanding! Many, many thanks to the volunteers who made this a successful meeting. Also, thanks to AAPM HQ staff for their exceptional support. Meetings this large don’t organize and execute by themselves – it takes a coordinated effort from volunteers and staff. Congratulations to all involved for a wonderful meeting. On a couple of lighter notes from the meeting, it was great to see all the future NFL stars punting, passing, kicking, and even scrimmaging, their way to stardom at the Night Out in Lucas Oil Stadium. Hats off to Jeff Siewerdsen for showing up with a customized Ravens jersey!!! And I believe John “Bullseye” Gibbons won the effort award for his exceptional effort in the first scrimmage! It was fun to see the membership having so much fun, enjoying themselves and each other! And for those of you who attended the Physics Pheud, well what can I say but Marc Kessler missed his calling!!! Congratulations to Jeff Siewerdsen, Marc, Kristy Brock and John Bayouth for pulling off an exceptionally (fun) event. The Pheud was entertaining and the teams were evenly matched. Congratulations to my red teammates – Steve Bartolac, Guang-Hong Chen, Martha Matuszak and Robin Stern. What a thrilling come from behind victory!!! Congratulations to Gary Ezzell and his blue teammates – Jon Kruse, Sarah McKenney, Todd McNutt and Dan Ruan – for a valiant effort! In case you were wondering, the Red Team is looking forward to defending our title in Austin next year!!!

OK, on to more serious stuff. The Awards and Honors Ceremony really highlighted the breadth and depth of contributions made by our members. Congratulations to all that

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received awards – they were all well deserved. It was a personal pleasure to give the awards to Marilyn Stovall and George Starkschall, two of my M. D. Anderson colleagues who I have worked with for an eternity! It was also an honor to bestow the Coolidge Award on Dick Fraas. Dick has distinguished himself not only as a scholar, but also as a gentlemen and true inspiration in our field. Again, congratulations to all who received awards and thanks to all those who came to celebrate their achievements with them. I also want to thank Drs. Hedi Hricak and David Jaffray for outstanding presentations in the President’s Symposium. I put a high bar out for Hedi and David to predict the future of medical physics in the new era of genomic medicine and they didn’t disappoint. Their insightful presentations left us with much to think about. Science Council and Education Council members have already begun to think about the ramifications of the new direction of biomedical science on the training of medical physicists today. This is critical because those trainees entering the field today are going to face a significantly different scientific landscape than those of my generation. The landscape is fraught with many challenges, but also many opportunities. I have challenged the SC-EC group to really think out of the box and look into the future for what skills and knowledge our graduates will need in 10 years. No small feat… Finally, I think our relationships with our sister organizations in professional practice, science and education will become increasingly important as we face the challenges, and exploit the opportunities, of the next decade. It was endearing to hear Dr. Sara Donaldson speak about the relationship between the Radiological Society of North America and the AAPM. The RSNA leadership clearly values this partnership and actively work to improve it. Many thanks to Sara for taking the time to come to our meeting and make such inspiring comments. We also have a great relationship with the American Board of Radiology. The ABR was represented by our trustees, the physics assistant director and by Executive Director Dr. Gary Becker. Thanks to Dr. Becker for joining us and good luck to him in his future endeavors as he will retire from the ABR next year. We also had many representatives of IOMP, including Dr. KY Cheung, participating in the meeting. The IOMP will celebrate 50 years as an organization at the International Conference on Medical Physics in Brighton in September. The AAPM is proud to have been one of the four founding organizations of the IOMP and we will have several members there presenting on our behalf. And finally with respect to the ICMP meeting, the IOMP has just announced its inaugural 18 Fellows which includes 10 active full AAPM members – Carlos Almeida, Cari Borras, KY Cheung, Don Frey, Gary Fullerton, Bill Hendee, Azam Niroomand-Rad, Colin Orton, Perry Sprawls and Raymond Wu. Congratulations to these AAPM members for being recognized for their contributions to the international community. Speaking of sister organization collaborations, I wanted to remind anyone going to the World Molecular Imaging Congress that the AAPM will be sponsoring a symposium on the afternoon of Friday September 20th on Image Guided Drug Delivery. Further, the World Molecular Imaging Society Board of Directors has voted to establish a reciprocal symposium sponsorship with us for 2014. We will again sponsor a symposium at their annual meeting

AAPM Newsletter | Volume 39 No. 5 | September/October 2013

that they will sponsor one at our meeting. We are excited to be working with WMIS to enhance both meetings and work toward closer relations in molecular imaging research. I also wanted to report on my experience at the American Hospital Radiology Administrators (AHRA) meeting in Minneapolis the Monday before our meeting started. Melissa Martin is our liaison to AHRA and we both found the meeting to be very interesting. I gave a talk on what a QMP is and how they can provide value added to the Radiology department. Melissa gave a couple of talks, including one on CT protocols reviews that was well attended. But perhaps the most important “take home message” was the level of interest in dose reporting and how the medical physicists can help in this area. Many good discussions and we plan to follow up with AHRA to see how we can work together to implement various technologies into clinical practice. With respect to CAMPEP, Steve Thomas has been elected to replace Bill Hendee as an AAPM representative on the CAMPEP board. Congratulations to Steve on being selected to this important body. Many thanks to Bill who has not only been an AAPM delegate to CAMPEP, but also it’s President for the last four years. During Bill’s tenure CAMPEP continued to mature and evolve. He oversaw the activities of the organization during a time of great expansion of graduate and residency programs, and was instrumental in initiating CHEA recognition of CAMPEP accreditation. A topic that is receiving some interest on the discussion boards and at the Annual Meeting is the use of physicist assistants to help us do our jobs more efficiently. This is a topic that we must carefully address and where we much clearly delineate the responsibilities of the QMP relative to supervision of the assistants in carrying tasks that can appropriately be done under the supervision of a QMP. The medical community, both physicians and dentists, have addressed this topic and there is much we can learn from their experience. Professional Council is working on this issue with a priority and I expect that we can hear more about this in Austin next year. At the request of the IOMP, the AAPM will be recognizing November 7th as the International Day of Medical Physics. The IOMP has obtained United Nations recognition of this day. November 7th was chosen because it is the birthday of Marie Curie, a founder of the science of radiation in medicine. While the timing was short this year, next year we will be planning more ways to participate in this event and promote the recognition of medical physics among the larger public community. In closing, it’s been a great year so far for the association. We’ve made significant strides in our professional and clinical activities, our science and in our educational activities. I look forward to working with our outstanding member volunteers for the remainder of this year to advance medical physics.

AAPM Newsletter | Volume 39 No. 5 | September/October 2013

Chairman of the Board’s Column

Gary A. Ezzell, Phoenix, AZ

Great enthusiasm is warranted

“A

nd other duties as assigned ….” So when Jeff Siewerdsen assigned me to captain the Blue Team for the Physics Pheud at the AAPM meeting, and Kristy Brock said that I should enter the room with Great Enthusiasm, I meekly did as I was told. Well, perhaps “meekly” is not the right word … but if you were there or have seen the video, you can judge. Both the Presidential Symposium, superbly organized by John Hazle, and the Pheud focused on the future of medical physics. The audience responses in the Pheud showed a fair balance between the perceived importance of ongoing scientific developments and careful, competent clinical practice. I was pleased to see that; the clinical practice side seemed to be dominating for much of the game (as was the Blue Team, until the last question was Nefariously Re-posed after we had Won Fair and Square), but in the end the balance was restored. As it needs to be– our clinical work depends on there being scientific and technical developments to apply. The developments described in the Presidential Symposium, Medical Physics in the Era of Genomic Medicine, were both inspiring and intimidating. There is much we need to learn, and much we need to learn how to teach. In my department’s morning conference today, one of our physicians described a patient whose tumor genotype included one variant but not another, and therefore was in a poor prognostic group. The MDs are learning and applying this language, and we had better also, if we are to remain relevant. If I have a concern about our future, it is that we have been so busy ensuring that our new entrants are well trained that we have constrained our flexibility just when we need to adapt and adopt knowledge and tools from other disciplines. Managing the balance between training and education, between application and development, is going to be key to our future. My sense is that over the past decade we have focused (necessarily) on closing gaps in our clinical training and professional qualifications. We have had successes – at last count there are 74 residency programs already accredited with more in process. Now the emphasis is beginning to shift. I am hearing more about our need to nurture our scientific creativity, and so I am more confident than concerned. Moving from generalities to specifics, I am particularly enthusiastic about the Radiation Oncology Incident Learning System (RO-ILS) that AAPM is developing jointly with ASTRO. The AAPM Board voted to support this at last year’s meeting, and it is moving into beta testing this fall. Here are a few key points:

AAPM Newsletter | Volume 39 No. 5 | September/October 2013

• It will use the federally-protected structure of a Patient Safety Organization, so that reported events are protected from legal discovery. • Participating facilities can use the web portal to enter and analyze their own events and decide which should be uploaded to the national database. • A panel of experts will review, analyze, and report on the events to the whole community and more comprehensively to the participants. • “Near misses” will likely predominate. • There will be no charge to participate, at least for the first few years. Eventually it will need to be financially self-sustaining. ASTRO and AAPM are developing the procedures and explanatory documents. Links to all the resources will be on the AAPM website as soon as they can be made generally available. In the meantime, there was an educational session at the AAPM meeting and will be another at ASTRO. We so badly need to do a better job of learning from each others’ experiences, and this initiative could finally help us do that. ASTRO and AAPM are working well together on this project; neither could succeed without the other in this. Great Enthusiasm is indeed warranted.

AAPM Newsletter | Volume 39 No. 5 | September/October 2013

AAPM President-Elect’s Column

John E. Bayouth, Madison, WI

Vendors contribute to our success

hat an outstanding meeting held in Indianapolis! Congratulations and many thanks to the army of AAPM volunteers and staff who put together an excellent program and environment for the sharing of science, technology, professional, and clinical practice. Clearly these gatherings are a tremendous asset for all of us. There is one often-overlooked group of individuals who are frequently in the background that I would like to discuss in this newsletter article: the vendors. The vendors play a vital role in the world of today’s Medical Physicist, yet instead of truly embracing that relationship, concerns of Conflict-of-Interest have lead us to distance ourselves from these colleagues. I think this is a mistake and would like to be a part of the solution. Vendors have tremendous expertise in many of the areas Medical Physicists are interested in pursuing and I believe they represent an untapped resource. Current efforts to develop Failure Mode Effect Analysis (FMEA) require a detailed understanding of the technologies we use in our clinics, clearly the experts in the room are the vendors. Furthermore, the vendors have been doing FMEA analysis on their systems for years; they have vast amounts of data and are required by the FDA to have an infrastructure to capture information regarding failures and perform root-cause analysis. It makes little sense to me for a Clinical Medical Physicist in a freestanding clinic in rural America or even a major medical center to embark on this type of analysis independent of vendor resources. We don’t have the time, knowledge, or resources to do this work and they are already well along the way. A second example is the development of Task Group reports that evaluate vendor-developed technologies. Although I agree Medical Physicists who use the vendor’s technologies should be responsible for the process, but I believe the vendors should have a seat at the table and allowed to contribute their expertise. Again, the vendor’s detailed knowledge their technologies can be an excellent resource when designing methods of testing, frequency of testing, and performance specifications. Medical Physicists still need assure the performance specifications are interpreted in the appropriate clinical context, but this can only be enhanced when the fundamental system design is understood.

Today many completing Medical Physics Graduate Programs are finding their way into industry. These colleagues can make strong contributions to the field of Medical Physics and we should encourage them to do so. A substantial amount of research and development in the field of Medical Physics occurs in industry; by establishing partnerships with industry to create and explore the science of medical imaging and radiation therapy can be mutually beneficial. AAPM Newsletter | Volume 39 No. 5 | September/October 2013

Although the face of a company may be marketing and sales, a tremendous amount of science and engineering exists behind the curtain. During the Annual Meeting I spent most of my week in committee meetings within the J.W. Marriot hotel. One of the newly formed committees is vendor relations established by our President John Hazel and chaired by Rock Mackie. I look forward to working with Rock and other committee members to further improve and potential expand our organizationâ&#x20AC;&#x2122;s relationship with the vendors. We greatly appreciate the financial support vendors provide to Training Academy the AAPM, and their contribution to our membership could be much more. MEDICAL SAFETY TRAINING The vendors are an excellent resource Available Courses for training us to better utilize their Medical Radiation technologies and expand our minds Safety Officer Course to the possibilities of what more can CAMPEP Accredited. be done. The vendors are an excellent Fluoroscopy Training and resource for supporting medical physics Refresher Course research and development. I hope Custom Courses we can work towards establishing a Designed to meet your needs. culture where AAPM members take full Available Formats advantage of the skills and expertise of Classroom our vendor colleagues, so that working (Las Vegas NV, Gaithersburg MD together we can provide the best possible or Oak Ridge TN) outcomes to the patients we have the On-site (your choice) honor to serve. On-line Courses Webinar Courses

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AAPM Newsletter | Volume 39 No. 5 | September/October 2013

AAPM Executive Director’s Column

Angela R. Keyser, College Park, MD

Some notable announcements and dates to remember IOMP announces International Day of Medical Physics To raise awareness of the medical physics profession, the International Organization for Medical Physics (IOMP) will celebrate this year, on November 7, the International Day of Medical Physics (IDMP). On that day in 1867, Marie Sklodowska-Curie, known for her pioneering research on radioactivity, was born in Poland. The theme of IDMP 2013 is ‘Radiation Exposure from Medical Procedures: Ask the Medical Physicist!’ This is an excellent opportunity to promote the role of medical physicists in the worldwide medical scene. Click to visit the IDMP webpage.

Reminders! October 15 is the deadline for nominations for the 2014 William D. Coolidge Award, Marvin M.D. Williams Award, Edith H. Quimby Lifetime Achievement Award, John S. Laughlin Young Scientist Award and AAPM Fellows. Make sure to register for the RSNA meeting by November 8 to receive the complimentary registration provided to all AAPM members. The AAPM Reception will be held on Tuesday, December 3 from 6:00 PM – 8:00 PM. Mark your calendars for the 2014 AAPM Spring Clinical Meeting to be held March 15 - 18, 2014 in Denver, Colorado.

Horizons 2013 -- Connecting AAPM & the PS-OCs Network November 7 – 8, 2013, Bethesda, MD AAPM & Physical Sciences - Oncology Centers (PS-OCs) are jointly hosting a meeting to investigate synergies between the two communities of physics engagement in medicine & biology. The goals of the meeting are: • Identify novel areas of interaction between physical & medical sciences in nontraditional areas (e.g., beyond radiotherapy & diagnostic imaging) • Identify synergies between AAPM & PS-OCs • Prepare a roadmap of future collaborative efforts between two communities of physical scientists in medicine & biology. Go online for more information.

AAPM Newsletter | Volume 39 No. 5 | September/October 2013

AAPM Transparency Ever want to know more about the operations and governance of AAPM? AAPM’s volunteer leadership continues to provide a wealth of information about the management of the organization to Members via the web. I applaud current and past leaders for seeking to provide a high level of transparency. Won’t you take a few moments to review the information? Members will find: • • • • • • •

Audited financial reports dating back to 1992; AAPM’s current budget; Budget history for the past four years; Minutes from AAPM Board meetings and background; Minutes from past Annual Business Meetings; Notes from Town Hall meetings; and, Reports from all the Headquarters Site Visit Committees, a group of volunteers that reviews HQ operations every three years.

Should you ever have any questions, please do not hesitate to contact me.

APSIT – AAPM Member Benefit Each year AAPM members receive a letter from APSIT, the American Physical Society Insurance Trust, offering a range of insurance products. Many members probably have no idea why they get this letter or what APSIT is. The AAPM belongs to the APSIT through our relationship with the American Institute of Physics (AIP). To help AAPM members understand a bit more about this benefit of membership, I want to explain a bit about ASPIT and its insurance products. The American Physical Society Insurance Trust (APSIT) was established in 1969 by the American Physical Society (APS) to provide members with a convenient source for quality insurance coverage at an affordable cost. The trust has offered Group Term Life insurance to APSIT member society members since February of 1970. Since then, they have expanded their product range and the number of member societies participating. The insurance plans are underwritten by the New York Life Insurance Company, established in 1845 and still a market leader today. New York Life regularly earns the highest ratings for its financial strength from leading rating services and even through the recent economic crisis remained in excellent fiscal health. The plan is administered by a contracted administration company, Herbert V. Friedman, Inc., based in New York. They maintain a website about APSIT. All of the AIP member societies are APSIT participating organizations and any member of an AIP member society may purchase the insurance products provided by APSIT. Of course, the particular products offered by APSIT may not meet your own personal needs. The premiums are usually very affordable

AAPM Newsletter | Volume 39 No. 5 | September/October 2013

and the coverage provided is quite competitive with other providers. Additionally, because the members of AIP member societies, as a group, typically have a higher education, live conservative lifestyles and so on, the group rate provided can be far better than other group plans. An additional benefit of APSIT is that representative of the member societies themselves sit on the governing board and make decisions about the types of plans provided and other matters. I was asked to serve as a member of the APSIT Board beginning in 2009. So, if you get a letter or informational pamphlet from the APSIT, you now know where it came from and why you received it. While it remains your decision as to whether any of the insurance products provided suit your own financial needs, I encourage everyone to take advantage of the offered products that are right for you. To learn more about other benefits of membership, please see our benefits of membership website.

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YEAR ANNIVERSARY

Editor’s Column

Mahadevappa Mahesh, Baltimore, MD

From the Editor’s desk

elcome to the 5th issue of this year. This issue contains several post-meeting articles along with regular columns including CAMPEP, ABR, ACR Accreditation and others. This issue also contains highlights of fellow AAPM members including The Coolidge Award introductory and acceptance speech, FDA recognition of AAPM working group on CT and Persons in the News. I would like to draw your attention to ABR Physics Trustees’ Report on the changes in the ABR examinations and to those participating in the CT accreditation, the ACR accreditation FAQs column contains a wealth of information about the CT QC manual and other changes. Lastly, I want to welcome the launch of new open access journal namely, ‘The Medical Physics International Journal’ by the International Organization of Medical Physics. Please join me in congratulating the editors Drs. Slavik Tabakov and Perry Sprawls and the IOMP (article about the journal and the access link can be found here.)

There is after all life after medical physics – who better to attest than Bill. Here is Bill Hendee with his garage band

AAPM Newsletter | Volume 39 No. 5 | September/October 2013

This meeting will be jointly hosted by AAPM and Physical Sciences and Oncology Centers (PS-OCs). PS-OCs comprise of 12 NCI funded centers and their cross-disciplinary teams to explore the physical laws and principles that shape and govern the emergence and behavior of cancer at all scales, in an effort to open up new areas and support the development of clinical advances. AAPM and PS-OCs cover rather complimentary areas of physics involvement in medicine and biology, yet they have never formally communicated or interacted. The purpose of this meeting is to investigate synergies between the two communities of physics engagement in medicine and biology. The goals of the meeting are: • • •

Identify novel areas of interaction between physical and medical sciences in non-traditional areas (e.g., beyond radiotherapy and diagnostic imaging) Identify synergies between AAPM and PS-OCs Prepare a roadmap of future collaborative efforts between two communities of physical scientists in medicine and biology Registration Opens September 3 http://www.aapm.org/meetings/2013HZN

Call for Nominations Nominations are now being accepted for the following AAPM Awards: • • • • •

William D. Coolidge Award Marvin M.D. Williams Award Edith H. Quimby Lifetime Achievement Award John S. Laughlin Young Scientist Award AAPM Fellows

All nominations are due by October 15, 2013 and are to be done through the online nomination system. Applicants will be notified of decisions by May 1, 2014. Recipients will be honored at the AAPM Awards and Honors Ceremony and Reception during the 56th Annual Meeting in Austin, Texas in the year 2014.

AAPM Newsletter | Volume 39 No. 5 | September/October 2013

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AAPM Newsletter | Volume 39 No. 5 | September/October 2013

Legislative and Regulatory Affairs Report

Lynne Fairobent, College Park, MD

Notable events in legislative and regulatory affairs Qualified Medical Physicist (QMP) Registry Reminder AAPM has contracted with the CRCPD to maintain a registry of qualified medical physicists. CRCPD is a nonprofit organization of state and federal radiation regulators who inspects medical facilities to assure that radiation is being used safely and securely. CRCPD promotes consistency in state regulations and the registry will allow state regulators’ to verify the qualification of medical physicist working in their state. The registry provides the solicitor with one stop to look up a physicist who has passed one of five participating boards. Prior to the registry, state and federal regulators depended on copies of board certification; now with a few entries the same regulator can independently validate the credential of the medical physicist for all five boards. The five participating boards are: • The American Board of Radiology • The American Board of Medical Physics • The Canadian College of Physicists in Medicine • The American Board of Science in Nuclear Medicine • The American Board of Health Physics Currently no law or regulation in place that compels an employer to hire an individual who is listed on the registry. The QMP registry is a tool that can be used by regulatory agencies and employers to independently verify that the individual has successfully passed a recognized examination in their specialty. It will prevent fraudulent activities with counterfeit certifications similar to what happened in some states several years ago. In addition, in institutionalizes the definition of a Qualified Medical Physicists making it easier to develop regulations and licensure. It’s limitation is that all information comes from the board who certifies the individuals and only if the board certification is revoked will the individual’s name be removed from the registry. If you have not checked the QMP Registry maintained by the Conference of Radiation Control Program Directors (CRCPD) please verify your information by clicking here. As part of the agreement with the CRCPD, the information contained in the registry is received directly from the certifying board and is not manipulated by the CRCPD. If you check your listing and the information is not correct, you should contact the board, not CRCPD to correct the information. You can access the registry through this link.

AAPM Newsletter | Volume 39 No. 5 | September/October 2013

NRC Request Comments on Two Policy Statements Related to Agreement States In the Federal Register on June 3rd (78 FR 33132), the U.S. Nuclear Regulatory commission (NRC) published two policy statements for comment. They are– Policy Statement on Adequacy and Compatibility of Agreement State Programs and the Statement of Principles and Policy for the Agreement State Program. Comments on these have been extended until September 16th (78 FR 50118). These policy statements have been revised to add information on security of radioactive materials and incorporate changes in the NRC’s policies and procedures since the last revision in 1997. In addition to requesting comments on the revisions made to the policy statements, the NRC is specifically requesting comments on (1) Compatibility Category B in the “Policy Statement on Adequacy and Compatibility of Agreement State Programs,” (2) consideration of a performance based approach in determining Agreement State compatibility, and (3) performance based metrics in the adequacy determination of an Agreement State program. Section 274 of the Atomic Energy Act (AEA) of 1954, as amended, provides for a Federal-State regulatory framework for the control of byproduct, source, and small quantities of special nuclear material (hereinafter termed “agreement material”) as identified by Section 274b. of the AEA. The NRC, by agreement with a State under Section 274 of the AEA, relinquishes its regulatory authority in certain areas and allows the State Government to assume that regulatory authority, as long as the State program is adequate to protect public health and safety and compatible with the Commission’s program. Currently there are 37 Agreement States, which regulate the majority of the radioactive materials used in the United States. During the recent Organization of Agreement States (OAS) meeting there was extensive discussion on both of these policy statements. Of particular importance is the definition of compatibility. The Agreement States would like to maintain flexibility in setting their regulations and therefore would prefer Compatibility C. As defined in the policy statement, Compatibility C is: “These are other Commission program elements that are important for an Agreement State to have in order to avoid conflicts, duplications, gaps, or other conditions that would jeopardize an orderly pattern in the regulation of agreement material on a nationwide basis. Such Agreement State program elements should embody the essential objective of the corresponding Commission program elements. Agreement State program elements may be more restrictive than Commission program elements; however, they should not be so restrictive as to prohibit a licensed activity.” It is important that you understand the compatibility designation of the regulations especially if you work in multiple jurisdictions.

AAPM Newsletter | Volume 39 No. 5 | September/October 2013

The NRC is specifically seeking comment on the following topics [taken from the Federal Register Notice]: 1. Section IV. Policy Statement on Adequacy and Compatibility of Agreement State Programs, Item 1.B. Compatibility Category B (1) To clarify the meaning of a “significant transboundary implication,” the NRC is proposing to define a significant transboundary implication as “one which crosses regulatory jurisdictions, has a particular impact on public health and safety, and needs to be addressed to ensure uniformity of regulation on a nationwide basis.” However, the NRC recognizes that the use of the word “particular” can be vague and cause confusion. The NRC is requesting specific comments on the proposed draft definition of “significant transboundary implication” and whether the word “particular” should be replaced with the phrase “significant and direct.” (2) Program elements with significant transboundary implications are illustrated by examples in the 1997 version of the Policy Statement. (3) The NRC staff concluded the examples listed are not all-inclusive and could lead to misinterpretation by stakeholders, Agreement States, and the NRC staff. The NRC staff is seeking additional comment on whether or not the examples should be retained in this section of the policy statement. (4) The NRC is requesting comments on the description of Compatibility Category B as written in Section IV. of this notice and whether or not the movement of goods and services, which historically has been a main factor in determining whether an issue has transboundary implications, should be considered in the definition of significant transboundary implication. (5) The NRC is requesting comments on whether or not economic factors should be a consideration when making a Compatibility Category B determination. The NRC believes that health and safety should be the primary consideration in making a Compatibility B determination and that economic factors should not be a consideration. (6) The NRC is requesting comments on alternative versions of wording regarding what types of program elements will be assigned a Compatibility Category B designation as well as how limited in number these will be. The original Policy Statement published in 1997 stated, in part: “The Commission will limit this category to a small number of program elements (e.g., transportation regulations and sealed source and device registration certificates) that have significant transboundary implications.” The Working Group proposed keeping the language in the 1997 version of the Policy Statement; however, some believed that this statement could be interpreted to imply that the Commission is limited in its ability to assign rules in this compatibility category. Therefore, alternative language was proposed as follows: “The Commission will limit this category to program elements that have significant transboundary implications. The Commission expects that these will be limited in number.” Some members of the working group disagreed with this alternative language and believed that the original language should be retained. The details of this discussion are in Enclosure 3 of SECY-12-0112,“Policy Statements on Agreement State Programs.” In summary, some members of the Working Group believed that the original language in the 1997 version of

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the Policy Statement was not intended to dictate the Commission’s authority but rather was to remind those staff proposing designations of compatibility B to the Commission for consideration that program elements of this designation should be few as opposed to many and should involve only significant transboundary implications. Additionally, by removing the distinction that there should be a small number of program elements, it deemphasizes the idea that Agreement States should be given flexibility when addressing the majority of program elements necessary for a compatible program. 2. Section IV. Policy Statement on Adequacy and Compatibility of Agreement State Programs, Item. Summary and Conclusions The NRC is requesting comments on alternative versions of wording regarding the expectation on the number of regulatory requirements that Agreement States will be requested to adopt in an identical manner to maintain compatibility. This language would cover all regulatory requirements as compatibility category A, B, and C. (Agreement States are required to adopt regulatory requirements listed as Health and Safety to ensure their program is adequate to protect public health and safety, but not for compatibility purposes). In the third paragraph under “Summary and Conclusions” of the original Policy Statement published in 1997, it stated, in part: “The Commission will minimize the number of NRC regulatory requirements that the Agreement States will be requested to adopt in an identical manner to maintain compatibility.” The Working Group proposed keeping this sentence as written; however, some members of the Working Group believed that this sentence could be interpreted to imply that there is a requirement that the Commission minimize such requests to Agreement States, rather than a statement that reflects the expectation that situations justifying such requests will not arise frequently. The sentence was revised as follows: “The Commission will identify regulatory requirements that the Agreement States will be requested to adopt in an identical manner to maintain compatibility. The expectation is that these requirements will be limited.” Some members of the Working Group disagreed with this revision and believed that the original language should be retained. The details of this discussion are in Enclosure 3 of SECY-12-0112, “Policy Statements on Agreement State Programs.” In summary, some members of the Working Group believed that the original text places emphasis on the effort to minimize unnecessary burden on the Agreement States’ means to accomplish the same goals as the NRC. Additionally, the suggested changes do not encourage careful consideration as to whether there are other possible options to meet the same intended goal. 3. Performance Based Approach for Determining Compatibility Currently, Agreement States are afforded some flexibility to use approaches other than rulemaking, such as license conditions or orders, to implement requirements. The NRC staff is seeking additional input on whether a performance-based approach for determining compatibility of an Agreement State’s radiation control program should be developed. Agreement States could be afforded additional flexibility to use other approaches to implement requirements. A performance-based approach would not rely on a requirement to adopt within 3 years from the effective date of the NRC regulation in order to determine compatibility of an Agreement State program. In a separate Commission vote paper, the NRC staff will use input from comments received on this topic to create a recommendation and an implementation plan to provide to the Commission

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for approval. 4. Adequacy Determinations of Agreement State Programs The NRC staff is seeking additional input on whether: (1) a revised set of performance metrics could be used to replace, supplement, or expand upon IMPEP in determining adequacy of an Agreement State’s radiation control program; and (2) a single holistic determination can be made that would accurately reflect the overall adequacy and compatibility of a program. Given the current environment of limited resources, it is imperative that the NRC be able to develop a clear set of performance-based metrics that consider the limitations of an Agreement State program and provide increased flexibility without compromising public health and safety. In a separate Commission vote paper, the NRC staff will use input from comments received on this topic to create a recommendation or series of recommendations for Commission approval. The NRC public comment period closes September 16, 2013. AAPM intends to submit comments.

NRC Places State of Georgia on Probation For the first time NRC places an Agreement State on Probation. On August 8, 2013 NRC announced that is was placing the State of Georgia on Probation. The weaknesses identified in Georgia do not immediately threaten public health and safety. The state had been on “Heightened Oversight,” a condition requiring increased interaction with NRC staff, preparation of a program improvement plan, bimonthly conference calls and periodic status reports. “The review found Georgia’s program to be compatible with the NRC regulatory program and “adequate but needs improvement.” The team recommended, and an NRC management review board agreed, that Georgia’s performance be found unsatisfactory for several performance indicators. The team made 11 specific recommendations to Georgia for improving performance. The report on Georgia’s agreement state program can be found here.” The managers of Georgia’s program are addressing the performance concerns. The program submitted an improvement plan that has been reviewed and approved by NRC staff. The NRC will remain closely involved with the state program managers as they implement improvements. The NRC will continue to interact more frequently with the state program office during probation. The Georgia program will be evaluated again in January 2014.

President-elect John Bayouth to testify before the NRC Commission on October 18, 2103 AAPM has been invited to provide testimony to the NRC Commissioners on October 13th related to the proposed revision to 10 CFR Part 35 - Medical Use of Byproduct Material. Others invited to testify are the American Society for Radiation Oncology, Us Too1, the American Brachytherapy Society, the Organization of Agreement States, and the Society of Nuclear Med-

AAPM Newsletter | Volume 39 No. 5 | September/October 2013

icine and Molecular Imaging. AAPM has been asked to address the following topics: • Medical event (ME) definitions for permanent implant brachytherapy; • Training and experience (T&E) requirements for authorized users (AU), medical physicists, Radiation Safety Officers (RSO), and nuclear pharmacists; • Consideration of Ritenour Petition (PRM-35-20) to “grandfather” certain experienced individuals for T&E requirements; • Measuring molybdenum contamination for each elution and reporting of failed break through tests; • Allowing Associate Radiation Safety Officers (ARSO) to be named on a medical license; and • Several minor clarifications. Additional details of what we expect the proposed final rule to state were discussed in my column in the March/April AAPM Newsletter. If you have any comments you want considered, please email them to me at lynne@aapm.org.

NRC Issues RIS 2013-10, Permanent Implant Brachytherapy Medical Event Reporting Under 10 CFR Part 35 On July 30th, the NRC issued a regulatory issue summary (RIS) to: assist licensees in complying with the current NRC requirements related to permanent implant brachytherapy and explain the enforcement discretion NRC will use to provide regulatory relief to licensees until the implementation date of a revised final rule (10 CFR Part 35, Medical Use of Byproduct Material) associated with the Medical Event (ME) reporting requirements. In SRM-SECY-12-00532, dated August 13, 2012, the Commission approved the staff ’s recommendations for modifying the regulatory requirements that appear in 10 CFR 35.3045 for permanent implant brachytherapy ME reporting and conforming changes to the current written directive (WD) requirements in 10 CFR 35.40(b)(6), to convert from dose-based to sourcestrength-based ME criteria for the treatment site. The Commission also directed the staff to clarify ME reporting for permanent implant brachytherapy under the existing rule and provide insights about compliance with the current NRC requirements. On July 9, 2013, the Interim Enforcement Policy (IEP) was published in the Federal Register (78FR 41125). The effective date of the IEP is July 9, 2013. The IEP states: “Enforcement discretion will typically be exercised for reporting violations in the following scenarios when the authorized treatment mode is permanent implant brachytherapy: (1) the licensee uses total source strength and exposure time for evaluating the existence of a treatment site medical event; or (2) the total absorbed dose to the treatment site equals or exceeds 120 percent of the prescribed dose. This policy does not provide regulatory relief from complying with any other

AAPM Newsletter | Volume 39 No. 5 | September/October 2013

aspect of §§ 35.41 or 35.3045, including the requirements related to the evaluation of dose to normal tissue.”

Us TOO International Prostate Cancer Education & Support Network is a grassroots, registered 501(c)(3) non-profit prostate cancer education and support network of 325 support group chapters worldwide, providing men and their families with free information, materials and peer-to-peer support so they can make informed choices on detection, treatment options and coping with ongoing survivorship. The organization was founded in 1990 by five men who had been treated for prostate cancer. Website: http://www.ustoo.org/. 1

AAPM Newsletter | Volume 39 No. 5 | September/October 2013

Professional Council Column

Per Halvorsen, Newton, MA

Professional development Professional leadership training At the Annual Meeting in Indianapolis, two sessions focused on professional leadership, and these prompted numerous discussions about the need for relevant leadership training resources for medical physicists. The Professional Council has been interested in this topic for some time, and our intention is to follow up with a proposal to develop appropriate training resources for use by AAPM members. This may take the form of a “hybrid course” (monthly webinars followed by a one-day in-person session), or a series of case scenarios illustrating core principles which could be distributed for use by individuals and mentors. If you have specific suggestions you’d like us to consider, please contact Lynne Fairobent (lynne@aapm.org).

Active discussion topics: Supervision and credentialing As mentioned in an earlier column, Task Group 243 is currently working on a Medical Physics Practice Guideline for professional supervision in clinical medical physics (both therapy and imaging). This prompted significant discussion in Indianapolis, particularly with respect to the concept of assistants. The task group has collected the many thoughtful comments and will consider revisions to the document to address the different perspectives that were raised. As with all Medical Physics Practice Guidelines, the draft document will then be distributed to all AAPM members for comments before it is finalized. We still hope to distribute the document for comments later this year. On a somewhat related note, we have received several suggestions related to credentialing for specific clinical physics procedures (e.g. radiosurgery) and for implementation of new technologies. While there are many facets to this topic, and each institution should design a credentialing process that’s appropriate for their practice environment, the AAPM could provide some guidance on how to implement credentialing of medical physicists. Luckily we have a Credentialing and Competency Guidelines Subcommittee which has recently produced a draft document on the topic, and the Education Council has expressed interest in the topic as it relates to implementation of new technologies. We will explore how the two Councils can work together to create a resource for use in the community.

AAPM Newsletter | Volume 39 No. 5 | September/October 2013

Education Council Report

George Starkschall, Houston, TX

Online learning opportunities for AAPM members

ne of the major activities of Education Council is providing continuing education opportunities to AAPM members. This month I asked Chuck Bloch, Chair of the Online Learning Services Subcommittee of the Continuing Professional Development Committee, to introduce you to the online learning services provided by the AAPM.

Online Learning Services I’d like to introduce myself, I’m Chuck Bloch, chair of the online learning services subcommittee. More importantly, I’d like to introduce you to the AAPM Online Learning Services. If you are in the ABR MOC, the Online Learning Center should be your best friend. The Online Learning Center has a large collection of online quizzes. The quizzes are linked to various presentations in the virtual library as well as journal articles from Medical Physics and JACMP. All of the quizzes provide CAMPEP credit. Currently for an annual fee of $65 you can earn as many CE credits as you like to fulfill your MOC requirements. Additionally, SAMs from recent AAPM meetings are available and users can get SAM credits for the same $65. Finally, the latest MOC requirements state that of the 75 CE credits required over a 3-year period, 25 of those must include self-assessment. All of the quizzes in the online learning center qualify as self-assessment. Therefore you can meet all of the ABR MOC CE and SA requirements through the online learning center. Having trouble finding the Online Learning Center? It’s available from the AAPM home page through a number of links. In the upper right corner of the AAPM home page you can click on “Continuing Education.” Alternatively, there is a round blue button in the right hand column labeled “Online Learning Center” that takes you to the same place. Finally, under the “Education” link in the left-hand column is a link to the “Online Learning Center” as well. As a last resort, you can type http://www.aapm.org/education/ce/info.asp into your web browser.

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While access to the Virtual Library is included as a benefit to all AAPM members, to get CAMPEP credit for watching presentations you must pay the (current) $65 fee and take the quizzes. But that fee allows members to take as many quizzes as they like during the year. If you havenâ&#x20AC;&#x2122;t paid the fee, you can pay it online. There is a link in the right hand column near the top of the online learning center home page. It is a great value and I recommend members check that box when renewing their membership and combine it in a single payment. Finally, let me thank the members of my subcommittee for their dedicated volunteer efforts in bringing this great resource to the membership. We are in the process of improving the online learning center and hope it will become even more popular with our users. We welcome any feedback or suggestions you might have. Charles Bloch, Ph.D. Chair, AAPM Online Learning Services Subcommittee

AAPM Newsletter | Volume 39 No. 5 | September/October 2013

ABR Physics Trustees’ Report

Anthony Seibert, PhD; Jerry Allison, PhD; and Geoffrey Ibbott, PhD

Changes in the ABR examinations New diagnostic radiology examinations

he last major American Board of Radiology (ABR) Oral Examination in diagnostic radiology was held in June in Louisville, Kentucky. It was one of the largest Oral Examinations ever, with 2,042 candidates and 415 examiners in diagnostic radiology, medical physics, and radiation oncology. Although medical physics and radiation oncology will continue to

(Left to right) Anthony Seibert, PhD; Jerry Allison, PhD; and Geoffrey Ibbott, PhD offer Oral Examinations, the largest group—diagnostic radiology (DR)—is converting to a computer-based Core Examination and final Certifying Examination beginning in 2013 and 2015, respectively. The first administration of the DR Core Examination will occur this fall. So candidates can successfully complete their current examination track, the ABR will offer conditioned and repeat DR Oral Examinations until November 2014. After the last DR Oral Examination ad-

AAPM Newsletter | Volume 39 No. 5 | September/October 2013

ministration, candidates who have failed will need to pass the new DR Core Examination, and those who have conditioned will take two computer-based modules in each conditioned category. This transition will complete the old examination approach and convert all diagnostic radiology candidates to the new computer-based examinations. (For more information on the transition from Oral Exams to the new ABR DR Core and Certifying Exams, visit ABR’s web page.)

Evolution of the oral examination The end of the diagnostic radiology “Oral Exam Era” deserves a historical look-back on the evolution of the Oral Examination. We are fortunate to have a reliable historical source for the ABR. Otha W. Linton, MJS, collaborated with the ABR to produce a book entitled The American Board of Radiology: 75 Years of Serving the Public during the 75th anniversary of the ABR in 2009. This book is recommended for all medical physicists and covers the evolution of the ABR, including the Oral Examination. The first Oral Examination occurred in 1934. For medical physicists, the oral exams began in 1947, and certificates were awarded in “radiologic physics” and in “x-ray and radium physics.” During the early years, the number of examiners was small, and each examiner created his or her examination with cases from local files. In those days, the examiners met at the end of each examination day to review the candidates’ results. For radiologists, the categories in the examination have been modified over the years. In the late 1950s, the examination included three sessions of diagnostic radiology, two therapeutic radiology sessions, and one Oral Examination in physics. Nuclear medicine was added as a separate category in 1965. Over the years, the examinations evolved into orals in diagnostic radiology, radiation oncology, and medical physics. Additional refinements in the examination categories and a logistical decision on the examination site were discussed in the late 1970s. The number of candidates had continued to grow, reaching more than 1,000 for each yearly examination. This meant increasing the examiner pool and settling on a single site instead of moving from city to city—an essential for financial and exam management optimization. Thus, the historic Executive West (now the Crowne Plaza) became the new focal point for candidates and examiners. The hotel and the examination experience have resulted in many stories and memories over the past years. Although the new home for the Oral Examinations became the focus for many, the content of the diagnostic radiology examination continued to evolve. In the end, there were 10 subspecialty sections—musculoskeletal, gastrointestinal, genitourinary, chest, neuroradiology, pediatric, nuclear medicine (including Authorized User credentialing), vascular/interventional, ultrasound and mammography) —with an 11th virtual cardiac section that was included in the pediatric, chest, vascular/interventional, and nuclear sections.

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Candidates were required to pass all 11 sections but could condition up to three and only repeat those if the other eight sections were completed successfully. In recent years, similar to the past, the panel of 10 subspecialty examiners met each day of the exam to review the candidates and determine their statuses—pass, fail or conditioned. Conditioned candidates could return to Louisville in November and retake the sections they conditioned in June. As noted above, this process will continue until November 2014 when remaining diagnostic radiology candidates will convert to the new computer-based examination process. The new examinations will provide a realistic “clinical workday” environment, where a diagnostic radiologist will not know the issue being addressed until reviewing the case. The cases will be randomly sorted, so candidates may find a case with no abnormality, followed by a chest case, a neuroradiology case, and so on. All modalities will be represented. The DR Core Examination will be given after 36 months of training and will contain 18 sections, including subspecialties, modalities, physics, and patient safety. A DR Core Pilot Examination was provided in June for candidates taking the first DR Core Examination later this fall. After the first administration, the DR Core Examination will be offered in Tucson and Chicago twice yearly. This will provide ample opportunity for candidates to retake the examination if they fail or condition certain sections on the first attempt. The exact scoring mechanism is still being evaluated and will be finalized after the ABR finishes studying the results of the June DR Core Pilot Examination. This will be communicated to the candidates in advance of the initial DR Core Examination in fall 2013. The final DR Certifying Examination will be given 15 months after completing residency training. To qualify, candidates must have passed the DR Core Examination. The DR Certifying Examination is significantly different in that candidates may select general radiology or subspecialty clinical modules that reflect their clinical practice. Candidates will also be required to pass a module on essentials in radiology and a noninterpretive skills module. The DR Maintenance of Certification (MOC) cognitive examination that candidates must take to continue their certification will have a practice-profiled approach similar to that of the DR Certifying Examination. Thus, the DR Certifying Examination will provide a flexible transition from initial certification to MOC as both are practice profiled. Once a radiologist is certified, he or she will be able to select MOC examination modules based on any potential changes in practice.

Changes in the medical physics oral examination The medical physics Oral Exam is undergoing some minor changes, also. For diagnostic medical physics and medical nuclear physics, the categories of the exam are changing to better reflect clinical practice. The categories for therapeutic medical physics are not changing. The categories that will be used beginning in 2014 are shown in the table below:

AAPM Newsletter | Volume 39 No. 5 | September/October 2013

DMP Category 1 Category 2 Category 3

NMP

Radiography, SPECT & hybrids, Fluoroscopy, and including gamma Interventional Radiology cameras Radiation Computed Tomography Protection Non-ionizing Techniques PET & hybrids â&#x20AC;&#x201C; MRI and Ultrasound

Category 4

Shielding, Radiation, and Protection

Radiation Measurements

Category 5

Radiation Dosimetry and Clinical Procedures Patient Safety

TMP Radiation Protection and Patient Safety Patient-related Measurements Image Acquisition Processing & Display Calibration, Quality Control, and Quality Assurance Equipment

As mentioned earlier, the ABR will continue to offer Oral Exams for radiation oncologists and medical physicists. However, the changes for diagnostic radiologists have an effect on the examination logistics, and they free the ABR to consider other locations for the remaining Oral Exams. As the contract at the Louisville Crowne Plaza will come to an end after the 2014 Oral Exam, the ABR is planning to move the radiation oncology and medical physics Oral Exams to a testing center in Dallas that is operated by the American Board of Obstetrics and Gynecology. The ABR expects the first oral exams to be offered in Dallas in 2015. The use of a testing center rather than a hotel will introduce a number of logistical changes, but candidates should find the experience in Dallas to be very similar to the current process.

AAPM Newsletter | Volume 39 No. 5 | September/October 2013

Minimize Disturbance

Exradin W1 Scintillator simply, dose Exradin W1 Scintillator imaged at 35 kVp in air

The Exradin W1 Scintillator is a new detector whose unrivaled near-water equivalent characteristics produce a more natural dose measurement. • Minimal Disturbance, Fewer Corrections The W1’s components closely mimic water, significantly reducing beam perturbation and negating measurement corrections necessary with other detectors. • Ideal Characterization and Measurement of Small Fields 1mm spatial resolution makes the W1 a perfect tool for SRS and SBRT with Gamma Knife®, Cyberknife®, BrainLab®, Varian®, Elekta® and TomoTherapy® systems. • Automatically correct for Cherenkov Effect Pair the W1 with the SuperMAX Electrometer to effectively eliminate Cherenkov effect without the need for extraneous calculations. Other detectors imaged at 70 kVp in air

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ACR Accreditation FAQs

Priscilla F. Butler, Reston, VA

ACR accreditation: Frequently asked questions for medical physicists

oes your facility need help on applying for accreditation? In each issue of this Newsletter,

Iâ&#x20AC;&#x2122;ll present frequently asked questions (FAQs) of particular importance for medical physicists. You may also check out the ACRâ&#x20AC;&#x2122;s accreditation web site portal for more FAQs, accreditation applications and QC forms.

The following items address questions we have received regarding the ACR Computed Tomography Quality Control Manual. Please feel free to contact us at ctaccred@acr.org if you have questions about CT accreditation.

How often will the ACR CT QC Manual be updated and how will those updates be communicated?

The ACR CT Physics Subcommittee will review any comments, issues or concerns regarding the ACR CT QC Manual. Formal modifications to the manual will be made at the discretion of the CT Physics Subcommittee and will be made on an annual basis as needed. The new versions of the manual will be emailed to all CT accredited facilities and to all who have purchased a copy from the ACR education catalog. If the issues need to be addressed before the routine update, an FAQ will be added to the website. Additional mechanisms are being explored so that changes are communicated to affected facility staff in a timely manner.

We have a dual source CT scanner, but the secondary tube is only used for dual energy imaging protocols, cardiac protocols and some other non-routine protocols. Does the secondary tube need to be evaluated during the annual system performance evalution? Does the secondary tube need to be used for the accreditation testing?

The primary and secondary tubes should both be evaluated in the annual system performance evaluations as the goal of the annual evaluations is to ensure that the scanner is functioning as designed in all respects and that it is being used optimally. However, the secondary tube is not typically used in the ACR Accreditation physics testing as it is not normally used for the diagnostic protocols (adult head, adult abdomen, pediatric head and pediatric abdomen) that are used for the accreditation testing.

AAPM Newsletter | Volume 39 No. 5 | September/October 2013

The CT QC Manual indicates that QC procedures should be performed at acceptance testing, during an ongoing QC program following parameter specific frequencies and following major repairs. What is a major repair and does the QC procedure need to be performed by the medical physicist on site and within what timeframe?

A major repair includes replacement or repair of components such as an x-ray tube or detector assembly. The evaluation should be determined by the medical physicist based on the type of component repaired or replaced. A matrix of response is provided below for guidance for several major repairs or replacements: Item

Major Medical Physicist Repair (MP) Response

Time Frame

MP conducts evaluation in person

TechnologistÂ QC must be performed before clinical use. If technologist QC results pass, then MP should complete appropriate evaluation as soon as possible but within 30 days.

*MP oversight

Follow normal QC guidelines.

MP conducts evaluation in person

TechnologistÂ QC must be performed before clinical use. If technologist QC results pass, then MP should complete appropriate evaluation as soon as possible but within 30 days.

*MP oversight

Follow normal QC guidelines.

*MP oversight

Follow normal QC guidelines.

Detector assembly replacement

MP conducts evaluation in person

Collimator adjustments

TechnologistÂ QC must be performed before clinical use. If technologist QC results pass, then MP should complete appropriate evaluation as soon as possible but within 30 days.

*MP oversight

Follow normal QC guidelines.

Software upgrade

Maybe

MP must discuss with vendor for effected parameters

MP conducts evaluation in person

*MP oversight with Radiologist and Technologist

X-ray tube replacement CT service calibrations HV generator replacement HV generator service calibration Control console replacement

mA/kV modulation install Protocol change

Technologist QC must be performed before clinical use. If technologist QC results pass, then MP should complete appropriate evaluation as soon as possible but within 30 days. Follow normal QC guidelines.

*MP oversight means that the medical physicist directs the site to follow established QC procedures and to share these results with the MP in order to determine that the equipment is functioning properly. The medical physicist does not need to conduct this on site.

AAPM Newsletter | Volume 39 No. 5 | September/October 2013

Does the technologist’s daily water CT number and standard deviation QC have to be performed in both the helical and axial mode?

It is recommended that this be performed in both the axial and helical scan mode and the QC Manual suggests performing these scans on alternate days to speed up the process. This is a recommendation and not a requirement.

Can the solid state CT probe provided by a manufacturer be used to measure the radiation beam width that is required in the Medical Physicist’s Section of the CT QC Manual?

As stated in the CT QC Manual, beam width may be measured in a number of different ways. The methodologies listed each have their strengths and weaknesses, and some are currently only appropriate for measurement in axial mode, while others are only designed for helical mode. Note that specific CT scanners may have beam widths that are only available in one mode or the other. Some manufacturers of probes designed for helical data acquisition are currently developing devices to move the probe through the beam during an axial scan. It is imperative to verify that these “probe movers” are properly calibrated to yield accurate results. The table below lists various measurement devices and the scan modes in which they can be used.

Measurement Devices

Axial

Helical

CR Film OSL Small ion chamber Solid state probe

Yes Yes Yes Only with fully calibrated probe moving device*

No No No Yes when mounted to scanner table Yes, when mounted to scanner table

Only with fully calibrated probe moving device*

* If probe moving device does not yield accurate velocity values, then beam width estimates will be off and will most likely differ from specifications and/or values obtained with other methods.

In the Medical Physicist’s Section of the CT QC Manual there is a discrepancy between the low contrast performance CNR values and those stated in the CT Accreditation phantom instructions. Which ones are correct?

As of July 1, 2013, the CNR values changed to 0.7 and 0.4 for the pediatric head and pediatric abdomen protocols. In addition, pediatric head and abdomen CTDIvol reference values and pass/fail criteria changed. These new values should be used for the accreditation testing immediately and used for the annual system performance AAPM Newsletter | Volume 39 No. 5 | September/October 2013

evaluations effective December 1, 2013. The changes will be made in the CT QC Manual upon the next update. Scan Protocol

Pass/Fail Criteria CTDIvol (mGy)

Reference Value CTDIvol (mGy)

CNR

Adult Head Pediatric Head Adult Abdomen Pediatric Abdomen

80 40 30 20

75 35 25 15

1.0 0.7 1.0 0.4

Does annual CT number accuracy need to be evaluated for adult and pediatric head and abdomen protocols or just the adult abdomen protocol as for accreditation testing?

At a minimum, the scans performed should include an adult head, adult abdomen, pediatric head and pediatric abdomen protocol unless the site does not scan any pediatric patients.

About the author: Priscilla F. Butler, M.S. is the Senior Director and Medical Physicist, for ACR Quality and Safety.

AAPM Newsletter | Volume 39 No. 5 | September/October 2013

Health Policy/Economic Issues

Wendy Smith Fuss ,M.P.H. AAPM Health Policy Consultant

CMS proposes expanded packaging for hospital outpatient departments

he Centers for Medicare and Medicaid Services (CMS) recently released its proposed rule for the 2014 Hospital Outpatient Prospective Payment System (HOPPS). AAPM will submit comments on this proposal to CMS by the September 6th deadline. The final rule will be published by November 1st, with an effective date of January 1, 2014. Payments for freestanding radiation therapy centers and physicians are covered under a separate rule and those changes are described in a separate article (see below). As proposed, the rule would significantly increase payments for the majority of radiation oncology procedure codes for 2014. At the same time this proposal would increase “packaging” so that many codes would no longer be paid separately. The overall revenue change will vary from department to department depending on which codes are billed on the same day. Both AAPM and ASTRO are modeling typical billing scenarios in order to better understand the rule’s overall financial impact. CMS states that it is their goal to pay hospitals under more of a prospective payment system (i.e. per patient) and under less of a fee schedule system (i.e. per service). It is longstanding HOPPS policy to package (bundle) charges for services that it sees as “supporting” some larger service, which it designates as primary. For 2014, CMS proposes to add seven (7) new categories of services to those it considers to be supporting services. These are as follows: • • • • • • •

Laboratory tests Drugs, biologicals, and radiopharmaceuticals used in diagnostic tests Device removal procedures Drugs and biologicals used in a surgical procedure Diagnostic tests on the bypass list Procedures described by add-on codes Ancillary services (procedures with status indicator “X”)

It is these ancillary services that are of greatest significance to medical physicists. Though they would continue to be paid when performed alone, CMS is proposing to package (i.e. not reimburse) any ancillary service when it is performed with another primary service on the same day. This proposal affects a total of 425 procedure codes, including 22 radiation oncology codes, many of which are medical physics codes (see table below).

AAPM Newsletter | Volume 39 No. 5 | September/October 2013

CPT

CPT Short Descriptor

CPT

CPT Short Descriptor

77280 77285 77290 77295 77299 77300 77301 77305 77310 77315 77321

Set radiation therapy field Set radiation therapy field Set radiation therapy field Set radiation therapy field Radiation therapy planning Radiation therapy dose plan Radiotherapy dose plan imrt Teletx isodose plan simple Teletx isodose plan intermed Teletx isodose plan complex Special teletx port plan

77326 77327 77328 77331 77332 77333 77334 77336 77338 77370 77399

Brachytx isodose calc simp Brachytx isodose calc interm Brachytx isodose plan compl Special radiation dosimetry Radiation treatment aid(s) Radiation treatment aid(s) Radiation treatment aid(s) Radiation physics consult Design mlc device for imrt Radiation physics consult External radiation dosimetry

CMS states that the proposed packaging policies are not exhaustive and they expect to continue to review the HOPPS and consider additional packaging policies in the future. The offsetting payment increases for radiation oncology codes proposed for 2014 are given as follows (see table below). Summary of Proposed 2014 Radiation Oncology HOPPS Payments APC

Description

65 66 67

IORT Level I SRS Level II SRS Hyperthermia & Radiation Treatment

299 300 301

303

CPT Codes

77424, 77425 77373 77371, 77372 77470, 7760077620 77401-77404, Level I Radiation Therapy 77407 77406, Level II Radiation Thera- 77408-77416, py 77422,77423, 77750, 77789 Treatment Device Construction

77332-77334

2013 Payment

2014 Proposed Payment

Percentage Change 2013- 2014

$978.25 $2,354.79 $3,300.64

$1,740.86 $2,480.93 $8,576.28

78.0% 5.4% 159.8%

$392.41

$1,114.56

184.0%

$95.50

$121.99

27.7%

$179.52

$225.74

25.7%

$201.76

$460.65

128.3%

This table continues on the next page.

AAPM Newsletter | Volume 39 No. 5 | September/October 2013

304

Level I Therapeutic Radiation Treatment Prep

305

Level II Therapeutic Radiation Treatment Prep

310

Level III Therapeutic Radiation Treatment Prep

312

Radioelement Applications

313

Brachytherapy

316 412 651 667

Level IV Therapeutic Radiation Treatment Preparation Level III Radiation Therapy Complex Interstitial Radiation Source Application Proton Beam Therapy

77280, 77299 77305, 77310, 77326, 77331, 77336, 77370, 77399

$109.73

$153.81

40.2%

$290.99

$342.71

17.8%

$984.49

$671.92

-31.7%

$410.83

$1,098.31

167.3%

$687.68

$1,072.02

55.9%

77295, 77301

n/a

$1,907.69

77418, 0073T

$483.70

$538.04

11.2%

77778

$875.52

$2,071.69

136.6%

77520, 77522 77523, 77525

$682.36

$988.24

44.8%

$3,254.67

$4,296.54

32.0%

77285, 77300, 77321, 77327, 77328 32553, 49411, 55876, C9728 77290, 77315, 77338 77761, 77762, 77763, 77776, 77777, 77799 77785, 77786, 77787, 0182T

LDR Prostate Brachyther8001 apy 55875+77778 Composite

There are a number of aspects of these proposals that are of concern to medical physics. First, the packaging proposal creates a situation where the date of service or billing date becomes a primary determinant of whether a certain code will be paid separately or not. At the very least, this will encourage departments to schedule and bill services so as to maximize revenue. Worse, it could encourage departments to change workflows in a way that could compromise physics oversight and safety. Second, the packaging of both of our physics service codes, 77336 and 77370, leads to a loss of visibility and a loss of direct financial accountability of our work. Thirdly, the reluctance of departments to bill for packaged services that will not be paid separately will skew the hospital data on patient charges and work performed that CMS collects and uses each year to set reimbursement levels. This could result in an erosion of the payments for radiation therapy services in future years. A complete summary of the proposed rule and impact tables is on the AAPM website.

AAPM Newsletter | Volume 39 No. 5 | September/October 2013

2014 Proposed Rule Payment Cap Applies to 15 Radiation Oncology Codes The Centers for Medicare and Medicaid Services (CMS) recently released the 2014 Medicare Physician Fee Schedule (MPFS) proposed rule. AAPM will submit comments to CMS by the September 6th deadline. The final rule will be published by November st, with an effective date of January 1, 2014. The MPFS specifies payment rates to physicians and other providers, in-cluding freestanding radiation therapy centers. It does not apply to hospitalbased facilities. One factor in Medicare payment levels is the Practice Expense Relative Value Units (PE RVUs). Some services, including radiation therapy can be provided in either hospitals (â&#x20AC;&#x153;facil-itiesâ&#x20AC;?) or freestanding radiation therapy centers. CMS generally considers â&#x20AC;&#x153;non facilityâ&#x20AC;? radiation therapy centers to be indistinguishable from services provided in a physician office. CMS typically establishes two separate PE RVUs for these treatment environments, leading to two different payment levels. CMS intends to pay more when these services are provided in facilities. CMS considers it to be generally more expensive for a hospital to provide a service than for a freestanding radiation therapy center to provide the same service. For example, hospitals incur higher overhead costs because they operate 24 hours a day and 7 days per week and furnish services to higher acuity patients than those who are typically treated in physician offices. Thus, when services are furnished in a facility setting, such as a hospital outpatient department or an ambulatory surgical center (ASC), the total Medicare payment is expected to exceed the Medicare payment made for the same service when furnished in a non-facility setting (i.e. freestanding radiation therapy center). By looking at its data, CMS has found that for some services, the Medicare payment when the service is furnished in freestanding radiation therapy centers exceeds the total Medicare payment when the service is furnished in a hospital outpatient department or ASC. CMS believes this is due to anomalies (artifacts) in the data used under the MPFS and in the application of the resource-based practice expense methodology to those services. To improve the accuracy of MPFS non-facility payment rates for each calendar year, CMS is proposing to limit the non-facility PE RVUs for individual codes so that the total non-facility MPFS payment amount would not exceed the total combined amount Medicare would pay for the same code in the facility setting. That is, if the non-facility PE RVUs for a code would result in a higher payment than the corresponding hospital outpatient or ASC payment rate, CMS would reduce the non-facility PE RVU rate so that the total non-facility payment does not exceed the total Medicare payment made for the service in the facility setting. This proposal impacts 15 radiation oncology codes (see table below).

AAPM Newsletter | Volume 39 No. 5 | September/October 2013

CPT

CPT Short Descriptor

CPT

CPT Short Descriptor

77280 77290 77301 77403 77404 77406 77412 77413

Set radiation therapy field Set radiation therapy field Radiotherapy dose plan imrt Radiation treatment delivery Radiation treatment delivery Radiation treatment delivery Radiation treatment delivery Radiation treatment delivery

77414 77416 77422 77423 77605 77610 77615

Radiation treatment delivery Radiation treatment delivery Neutron beam treatment simple Neutron beam treatment complex Hyperthermia treatment Hyperthermia treatment Hyperthermia treatment

In addition, CMS is proposing revisions to the calculation of the Medicare Economic Index (MEI), which is the price index used to update physician payments for inflation. The changes are in response to recommendations by a Technical Advisory Panel that met during 2012. The proposed changes involve revising the MEI categories, cost shares and price proxies. Application of the MEI along with sustainable growth rate determines the total amount of payment made each year under the Medicare Physician Fee Schedule. The proposed policy yields changes to relative value units and Geographic Practice Cost Index (GPCI) weights assigned to physician work and practice expense. As a result, the proposal would redistribute some payment from practice expense relative value units to physician work RVUs. The change in reimbursements to different medical specialties that are proposed for 2014 are generally related to the proposal to cap the payments for certain non-facility services at the facility rate plus the lower of the hospital outpatient or ASC payment; and the proposal to revise the Medicare Economic Index and adjust RVUs to match the new weights for work, practice expense and malpractice. The combined impact of all 2014 proposals results in decreased payments to freestanding radiation therapy centers, radiation oncologists and radiologists (see table below). Combined Impact (Does not include the 24.4% reduction to 2014 CF)

Specialty

Medicare Allowed Charges (millions)

Freestanding Radiation Therapy Centers

$62

-13.0%

$1,783

1.0%

-6.0%

-5.0%

$4,635 $86,995

2.0% 0%

-3.0% 0%

-1.0% 0%

Radiation Oncologists Radiology

Total

*NQBDU *NQBDU 8PSL 1SBDUJDF .BMQSBDUJDF 376 $IBOHFT &YQFOTF 376 $IBOHFT

AAPM Newsletter | Volume 39 No. 5 | September/October 2013

Lastly, based on the currently flawed sustainable growth rate (SGR) calculation, CMS estimates a 24.4 percent reduction to the current 2013 conversion factor of $34.02. If Congress does not pass legislation the 2014 conversion factor would reduce all payments by an additional 24.4 percent to the impacts shown above. Based on the history of congressional intervention to avoid large decreases in reimbursement due to the SGR formula, it is extremely unlikely that this additional payment reduction will occur. To read a complete summary of the proposed rule and to review impact tables go to here.

AAPM Newsletter | Volume 39 No. 5 | September/October 2013

Working Group Report

Peter Dunscombe, Calgary, Canada

Safety profile assessment: A tool for improving safety and quality in radiotherapy A project of the AAPM’s Working Group on the Prevention of Errors The recent increased emphasis on safety and quality in radiotherapy is evidenced by the growing number of recommendations emanating from professional and learned societies. Valuable as these recommendations are, they need to be augmented by practical tools which are readily accessible and can be efficiently implemented in busy clinical settings. The AAPM’s Safety Profile Assessment (SPA) tool is designed to fill this need. SPA is an on-line application allowing a user, or preferably a multidisciplinary group of users, to perform an anonymised self assessment of the safety profile of their clinical program. SPA is built principally on four foundations: validated safety-related survey questions from the Agency for Healthcare Research and Quality; a published meta-analysis of safety recommendations in radiation oncology from seven recent authoritative documents; an AAPM white paper on incident learning; and the requirements for accreditation of radiation oncology practices within the ACR/ASTRO system as of 2011. The tool itself consists of 92 questions divided into four major sections: 1) Institutional Culture, 2) Quality Management, 3) Managing Change and Innovation and 4) Clinical Performance. The user(s) identifies compliance with each question on a five-point Likert scale. Optional free-text fields within each question provide a means of saving notes and comments. Output options are pie charts giving an overall visual impression of the safety profile of a radiotherapy department and bar graphs allowing benchmarking against other de-identified contributors to the SPA database. An extensive annotated bibliography provides background information for each question. Importantly, a spreadsheet can be downloaded which helps guide and monitor safety and quality improvements. The SPA tool can be completed multiple times by a given user (for example once per year) which allows for the tracking of improvement over time. In pilot testing, SPA required 1.3±1.7 hours to complete. We encourage you to access the tool and see for yourself. Registration is confidential and takes less than a minute. The use of the tool is free and open to anyone who wishes to participate.

AAPM Newsletter | Volume 39 No. 5 | September/October 2013

Travel Grant Report

Laurence Edward Court, Houston, TX

The travel grant helps exchange of ideas on clinical and educational research topics and fosters collaboration

was honored to receive this year’s travel grant from the Institute of Physics and Engineering in Medicine and the American Association of Physicists in Medicine. With this grant I was able to visit six centers in the United Kingdom, giving me the opportunity to exchange ideas on various research, clinical and educational topics. I arrived in the UK on June 10, with my family, and made our way to our rental apartment in the Notting Hill area of London – this turned out to be a terrific base for our visit, within walking distance of Kensington Palace, Exhibition Rd (where the Science Museum is) and many other London attractions. I was also able to walk to the Royal Marsden Hospital on Fulham Road later in my stay.

Royal Marsden Hospital and Institute of Cancer Research – Sutton The day after arriving in the UK I made a trip out to the Royal Marsden Hospital in Sutton where I was kindly hosted by Vibeke Hansen. Vibeke had put together a really interesting program, starting with a tour of their facilities (including their research bunker, which I am very jealous of). After lunch with their new chief of physics, Professor Uwe Oelfke, who had only started at the Royal Marsden a few months earlier, I had the opportunity to present work of my research group titled ‘The use of imaging to predict and understand dose response (and other projects).’ The presentation was designed to introduce various topics we are working, with the idea of promoting discussion and possible future collaboration. During my visit I had many interesting discussions. For example, I had a very interesting chat with Michael Thomas about QA, including a voluntary process for annual inter-institution peer-review that I think might have a great application in Texas. I also met with Jamie Dean and Sarah Gulliford on biological modeling and planning. James Bedford demonstrated his in-house VMAT optimization software – and, after hearing about my project to treat patients in a seated position, managed to get his code to run to optimize a plan where we rotated the couch instead of the gantry! I also had interesting discussions with Greg Smyth, Gemma Davis and Dualta McQuaid on treatment planning and verification. Towards the end of the day I had very interesting discussions with both Emma Harris and Prabhjot Juneja, her graduate student, about work on breast segmentation and tissue modeling. We had many points of mutual interest, and we all expressed interest in future collaborative work. All in all, I am extremely thankful to the Royal Marsden team for their time and fascinating discussions, and believe we have a pretty good chance at developing some of these into future research collaborations.

AAPM Newsletter | Volume 39 No. 5 | September/October 2013

The Clatterbridge Cancer Centre The next center I visited was the Clatterbridge Cancer Centre in Wirral. Alan Nahum, Head of Physics Research, hosted my visit. We started with Alan introducing me to his group, including postdoc Julien Uzan and ‘clinical’ research-active physicists Colin Baker, Antony Carver, and Eva Rutkowska where we spent a very interesting hour or so exchanging ideas on various topics in radiation therapy. Interestingly, Alan told me his first ever presentation in North America was at MD Anderson (on Monte-Carlo derived depth-dependence of photon-beam stopping-power ratios). Again, I gave a presentation on various aspects of research currently being carried out in my research group. After the presentation I met with Angela Baker, Lead Research and Development Radiographer. Angela is the chair of the IGRT subgroup of the UK RTTQA group, so this was an excellent opportunity to swap ideas for an IGRT credentialing program. Later I had a terrific brainstorming session with Jonny Lee and Antony Carver. I also had the opportunity to visit their proton-therapy facility where Andrzej Kacperek looked after me, and was particularly impressed by their patient-centered approach to workflow, treatments (uveal melanoma),and facility design. This thoroughly enjoyable day ended with an extended discussion with AlanNahum about medical physics education, research and other topics. I very much hope to visit this center again, perhaps for their annual course on radiobiology and radiobiological modeling in radiotherapy (next one is 23-27 February 2014 ).

University College London I received my PhD in medical physics from UCL, where my supervisor was Robert Speller, who kindly hosted my visit this time (18 years later….). This was a great opportunity to discuss approaches to supervision of groups of graduate students, and I hope to make some changes to our own journal club/group meetings based on these discussions. I was particularly surprised when David Miller, another of my supervisors from my PhD days, turned up for my presentation, straight from a trip to CERN (literally!!). Robert then gave us both a tour of his research laboratory, another chance to discuss possible research collaborations –I think there are several topics of joint interest that a collaborative approach could benefit both groups, so watch out for future joint publications…… Finally, we had a great English pub lunch (steak and kidney pie), and more discussions (including, of course, the future proton center that is planned for central London). This was another great day with many fruitful discussions.

Gray Institute for Radiation Oncology and Biology, University of Oxford The following Monday I took the Oxford Tube to visit Mike Partridge and his team at the Gray Institute for Radiation Oncology and Biology in Oxford. Getting off the coach, I passed the Headington Shark (check it out) and met with Mike in their new research laboratories. After a tour of the radiation therapy facilities (also pretty new) with Ralph Roberts, I met with Profes-

AAPM Newsletter | Volume 39 No. 5 | September/October 2013

sor Gillies McKenna (Director of the Institute), before giving my presentation to an audience of clinical and research staff. I had a very pleasant afternoon, meeting Tim Maughan, Maria Hawkins and some of the members of Mikeâ&#x20AC;&#x2122;s team. We had some very fruitful discussions as it turns out that our research interests and projects are aligned quite nicely â&#x20AC;&#x201C; and we ended with very high expectations for future collaboration. In the evening we all went out to a local Turkish restaurant, where we enjoyed great food and more great conversation.

Royal Surrey County Hospital and the University of Surrey, Guildford My next site visit was to Guildford, approximately 30 miles southwest of London. This was hosted by Andy Nisbet, Head of Medical Physics at the hospital, and David Bradley, Course Director of the M.Sc. in Medical Physics at the university. We started with a tour of the hospital facilities, including meeting Alistair McKenzie at the National Co-ordinating Centre for the Physics of Mammography, where we discussed a very interesting project on evaluating the impact of variations in physical performance of imaging systems on cancer detection. After my presentation, which was held at the university, to staff and students from both the hospital and the university, we enjoyed an excellent lunch at the Lakeside Restaurant which is run by students from the School of Hospitality and Tourism Management. Our group included Andy, David, Alex Stewart (Clinical Director, and a friend of mine from when I worked in Boston), Catharine Clark, and Nicholas Spyrou (who has supervised more than 100 PhD students!!). After lunch we toured the well-equipped physics laboratories at the university, and then David, Andy, and I enjoyed a lengthy discussion on various research topics. I am very happy to report that there appear to be many potential avenues for collaboration, and am looking forward to visiting Guildford again.

UK Radiation Therapy Trials QA (RTTQA) Group My last professional stop on this trip was to the Royal Marsden Hospital, Fulham Rd. As I already indicated, this was within walking distance of our apartment. This visit was organized by Catharine Clark, and I was honored that 9 members of the RTTQA group (Yatman Tsang, Emma Parsons, Liz Miles (Mount Vernon Hospital), David Bernstein, Emma Wells, Rollo Moore, Margaret Bidmead (Royal Marsden Hospital), Catharine Clark (Royal Surrey Hospital and National Physical Laboratory) came together to discuss clinical trial QA. We had a very lively, fun, and productive discussion on how to credential centres that are going to enroll patients on clinical trials involving advanced techniques that include motion management and IGRT. The group had lots of extremely useful comments and pointers that I will implement into my own practice, as we identified several possible opportunities for future collaboration. I really appreciated the opinions of the members of this group, and hope to have the opportunity to meet with them again in the future.

AAPM Newsletter | Volume 39 No. 5 | September/October 2013

I am very grateful to the AAPM and IPEM for sponsoring this trip. I had the opportunity to exchange ideas on many research, clinical and educational topics, and am now looking forward to many fruitful collaborations!

AAPM Newsletter | Volume 39 No. 5 | September/October 2013

The Coolidge Award

Randall Ten Haken, Ann Arbor, MI

The Coolidge Award introductory speech

have the distinct honor and privilege of introducing Benedick A. Fraass, Ph.D., FAAPM, as this year’s recipient of the AAPM William D. Coolidge Award. In short, Dr. Fraass’s eminent career in Medical Physics has had both critical and widespread impact on our discipline, as well as on many professionals within it. I have had the completely rewarding opportunity of being able to observe him, first hand, over most of the last 30 years. So it is not only with admiration, but also as a colleague, collaborator and friend, that I am enabled to provide a somewhat unique perspective on the scope of his accomplishments, whether academic, professional training and development of others, or in leadership. He has excelled at the highest level in each of these areas, positively impacting the scientific practice of medical physics, the careers of people he has trained and/or mentored, and the professional status of our organization. Born in Washington D.C. in 1952, Benedick Fraass grew up in Cleveland Heights, Ohio and Corona del Mar, California. He received his BS in Physics from Stanford University in 1974, and then moved to the University of Illinois Urbana-Champaign, where he received his PhD (1980) in Physics working in experimental low temperature solid-state physics involving x-ray diffraction on solid helium crystals. He began his medical physics career in 1980 at the National Cancer Institute (NCI) at the NIH in Bethesda MD, where he was mentored by Jan van de Geijn, learned clinical radiation oncology physics, and performed research in CT-based treatment planning, intraoperative radiation therapy, normal tissue tolerance, and other topics. Dr. Fraass joined Allen Lichter MD in founding the Department of Radiation Oncology at the University of Michigan in 1984 as the first Director of the Radiation Oncology Physics Division, where he led the physics group from 1984 until 2011. At the UM he rose from Assistant Professor in 1984 to Professor in 1995, and was named the inaugural Allen S. Lichter Professor of Radiation Oncology in 2009, and to this day still holds the rank of Professor Emeritus. In 2011, he moved to Cedars-Sinai Medical Center in Los Angeles, where he is Vice Chair for Research, Professor and Director of Medical Physics in the Department of Radiation Oncology. Benedick (Dick) Fraass has led pioneering efforts in the academic practice of Medical Physics for the last three decades. His “numbers”, although impressive in their own right (>205 publications on a range of issues), complement the overall impact of the contributions to our discipline that he has pioneered or otherwise led. Highly significant is Dick’s leading role in investigating and then introducing three-dimensional treatment planning as a practical component of modern radiation treatments. Following directly, and to no lesser extent, on the

AAPM Newsletter | Volume 39 No. 5 | September/October 2013

heels of these innovations are his pioneering direction of the introduction and validation of the advanced uses of computer-controlled radiotherapy systems. All these efforts ultimately led to his establishing a methodological, careful investigation of optimization systems for use in radiotherapy treatment planning and delivery. The above should strike many as “obvious” and deserving of high recognition on their own merit, and rightly so. Dr. Fraass has equally, and perhaps to many more significantly, demonstrated a broader impact on the radiation therapy community in general, related to his steadfast, leading roles in the scientific investigation of many aspects of patient treatment-related safety and quality assurance. A listing of the scientific research discoveries, innovations and most importantly clinical applications directly attributable to Dick Fraass and the group that he has directed, is useful for this review. These contributions made documented, early, “arguably first”, appearances. More importantly, all significantly impacted the field. They include: Development of a “comprehensive” 3-D treatment planning system (XRT, electrons, and brachytherapy) for routine clinical use - UMPlan (1986f); First FDA cleared 3-D TPS – Scandiplan – 1992; Routine clinical use of MRI integrated with CT for 3-D treatment planning (1987f); Completely automated computer-controlled treatment delivery including segmental IMRT and portal imaging - CCRS (1993f); Megavoltage and diagnostic x-ray imaging using amorphous silicon flat panel imagers (1990f); Descriptions of prostate and other organ inter- and intrafraction motion (1991f); Patient positioning using implanted markers (1991f); Radiation therapy treatment protocols based on (DVHs) (1988f); Treatment protocols driven by normal tissue complication probability prediction (NTCP) (1993f); Published results of 3-D dose escalation: prostate (1989f), liver (1990f), brain (1991f), lung (1993f), parotid sparing (1996f), pancreas chemo-rt (2001f). Some may prefer a different gauge for judging research success. A more quantitative demonstration of the scientific merit of the research efforts directed by Dr. Fraass is his long standing funding by the National Cancer Institute of a Program Project grant entitled “Optimization of High-Dose Conformal Therapy.” That grant, on which he served as Program Director/Principal Investigator, comprised four scientific projects and four supporting core components within a highly successful overall program that recently completed its third fiveyear funding cycle. That effort has resulted in more than 350 publications and led to numerous spin off projects with their own funded R21 and R01 grants. Professor Fraass has had an equally impressive impact on the growth and development of medical physicists. He directed the radiation oncology physics division at the University of Michigan for 27 years. Within that time, the department (and in particular the physics division) grew from relative obscurity to a leader among academic and clinical programs. He was among the longest standing directors of a major radiation oncology physics group within the United States. He was instrumental in the training and/or mentorship of numerous graduate students, post-doctoral fellows and early career faculty; many of whom are now clinical physicists, physics researchers and academic leaders in the discipline, of their own right. Perhaps equally impressive are a number of students, fellows and early career faculty

AAPM Newsletter | Volume 39 No. 5 | September/October 2013

that Professor Fraass has mentored and who have stayed here at the University of Michigan to hold prominent posts among our faculty. There is perhaps no greater testament to Professor Fraass’s guidance and impact on the professional wellbeing of others than this legacy (18 physics faculty members; 7 with an average of >20 years continual, self-chosen (and eager) longevity under his direction). We are all indebted to his inspirational leadership. Dr. Fraass is a fellow of the AAPM, American Society of Radiation Oncology (ASTRO), and American College of Radiology (ACR). He is currently Co-Chair of the AAPM Research Committee and member of Science Council, Therapy Physics Committee, Technology Assessment Committee, and Task Groups 100 and 244. He has served on the Board of Directors, chaired TG 53 on Treatment Planning QA, been scientific program coordinator, and a member of numerous task groups and committees. He is currently Co-Chair of the ASTRO IHERO Task Force, the National Radiation Oncology Registry, and the Radiation Oncology Safety Stakeholders Initiative. He is a member of the Science Council of the International Organization of Medical Physics, has served on IAEA task group efforts, was a member of the recent intersociety Blue Book Steering Committee, and led the recent ASTRO Safety White Paper efforts on IMRT, Peer Review, HDR, IGRT, and SBRT. He is indeed an internationally recognized “face of patient safety and technology assessment”, and he serves us all well within these roles. In summary, the investigative leadership and responsibility that Dick Fraass has assumed on behalf of the AAPM and other organizations over the past 30+ years has greatly benefitted our discipline, its members, and the patients we treat. He exemplifies at the highest level every aspect of what our society should want in one of its members being given the 2013 William D. Coolidge Award. I applaud the members of the AAPM Awards and Honors Committee for their wisdom, and thank them for the opportunity it has granted me to summarize the eminent career in medical physics of Benedick A. Fraass, Ph.D.

AAPM Newsletter | Volume 39 No. 5 | September/October 2013

The Coolidge Award

Benedict A. Fraass, Los Angeles, CA

The Coolidge Award acceptance speech

would like to thank Randy Ten Haken for an incredible introduction, and I’d like to thank all of you: this is quite an honor. The list of Coolidge Award winners is an impressive group of medical physicists, and I am truly honored to be included among them. I have a great many people to thank and unfortunately only enough time to mention just a few of them. First I would like to thank my mother and father, Joanne and Benedick Fraass. I think this picture shows the kind of love and support they gave me – whether I was graduating from Stanford or riding my tricycle down the stairs. My father always pushed me to not let all that academic physics stuff get in the way of using common sense, and he would be terribly proud today. Hopefully that makes up for the fact that he could never deal with the fact that I would do homework, watch a football game, and listen to music at the same time.

Wendy, Dick, Keith, Susanna, Andy Fraass

Joanne Fraass, Stanford 1974

I have been blessed with a wonderful and supportive family. Wendy and I have two great sons. Keith, the quiet one in the middle, is here to help us celebrate. Andy and his wife Susanna are busy with much more important stuff: they just brought their first child, Jane, home from the hospital last week. I also want to thank my brother Jeff for coming to see all this. Finally, there are no words to describe the help, support and love Wendy has given me since she ran into me (literally) at Corona del Mar High School.

I have a couple special mentors I want to thank. Ralph Simmons was my thesis advisory at the Univ. of Illinois, where we grew crystals of solid Helium at 0.05 degrees Kelvin. His patient demeanor, ability to let us work independently, hard scientific questions, and the quiet and supportive way he led the Physics Department were all crucial to the person I’ve become. The person who taught me the things that were important in Radiation Oncology and Medical Physics is Jan van de Geijn, phys. drs.. Jan is one of the true pioneers in computerized treatment planning, as you can see

AAPM Newsletter | Volume 39 No. 5 | September/October 2013

Jan van de Geijn, phys drs

from this paper in the British Journal of Radiology: 3-D dose calculation modeling, in 1965. Jan was a phenomenal mentor and is a great friend.

Allen S. Lichter, MD

I also want to thank Allen Lichter MD. While we were working together at the NCI in Bethesda, he talked me into going with him to Ann Arbor to start the Department of Radiation Oncology (which was in need of some work, as you can see). I said no the first times he asked, since I didn’t think I knew enough. However, he persisted and eventually we went to Ann Arbor and started the Department together, along with Randy Ten Haken and Dan McShan. I will be forever grateful that he talked me into going to Michigan with him.

My two biggest thanks need to go to these two guys, Randy Ten Haken and Dan McShan. In July 1984, Randy and I walked into the Ann Arbor Department and found that an HP-45 calculator was the highesttech piece equipment in the department. 6 months later, after Dan’s arrival, we had implemented modern dosimetry, our own CT-based treatment planning, and a research version of our 3-D planning system UMPlan was working well enough that we could apply for the NCI Electron Contract funding. Through the hard and totally self-less work of these two amazing physicists, we grew a program that eventually consisted of 18 faculty physicists and great clinical and research staff. All of these people have worked together tirelessly, and have contributed an amazing number of improvements to the field of radiation oncology. I’m incredibly proud of having been associated with this wonderful group for my 27 years in Ann Arbor.

Dan McShan, PhD; Randy Ten Haken, PhD; Dick Fraass PhD

From left: James Balter, Larry Antonuk, Dan McShan, Markc Kessler, Dick Fraass, Randy Ten Haken, Mary Martel, Pete Roberson (1990s)

I also want to thank my friends and colleagues from the Netherlands Cancer Institute. Iain Bruinvis, Eugene Damen, Ben Mijnheer and Harry Bartelink were nice enough to allow me to spend not one, but two sabbaticals at the NKI in Amsterdam, and helped me learn from a truly impressive program in radiotherapy research. A couple years ago, I left Ann Arbor and moved to Cedars-Sinai Medical Center in Los Angeles. I’d like to thank my new colleagues at Cedars – both the physicians, particularly our chair, Howard Sandler, as well as the Physics Group at Cedars. It has been wonderful to work with this new group of people as we evolve the department into a research-oriented academic center. Things are definitely changing: half the people in these pictures are new in the two years since I arrived two years ago.

AAPM Newsletter | Volume 39 No. 5 | September/October 2013

Finally, I want to thank all my colleagues in the AAPM. It’s been a thrill to work with all of you. In particular, I’d like to single out Jim Purdy, Clif Ling and Ken Hogstrom, all 3 Coolidge Award winners, as well as Allen Lichter and Ted Lawrence, both ASTRO Gold Medal winners. I am honored that all of these leaders of our field thought enough of my work to support my nomination for this award. And I’d like to thank the Awards and Honors Committee for listening to them! This award has led to lots of introspection and thought about what will be important for medical physicists in the years to come. First, why are there medical physicists? The real reason there are medical physicists in a hospital is not so they can calibrate machines, run QA tests, and check charts . . . Our real job is to solve problems. The hospital needs us because we • • • • •

use (and believe in) the scientific method, approach any problem with logic, do well-designed experiments, use careful data analysis, consider all the possibilities, not just the most obvious.

Hospitals don’t have many people who can do this. Our overall goal should be to improve results for patients, so we should always be looking for opportunities to make things work better. That means we don’t just do QA, or invent or implement new stuff, we need to try to find out if these things actually make things better for the patient! What things should we work on? If we want to make things better for the patient (or society), the new stuff we work on should either make current methods more efficient, safe, or effective (save time and/or $) or it should make new clinical treatments possible. I’d like to illustrate this last point with one of the things I am very proud of: the long series of clinical trials we have performed in high grade brain tumors to try to improve the results from this bad disease. We have not been studying technology. . . we have been studying new clinical treatments which have been enabled by improved technology.

Studies enabled by improved technology

AAPM Newsletter | Volume 39 No. 5 | September/October 2013

Clearly, none of this can be done without collaboration. We need to work closely with our physicians, therapists, and other clinical staff to figure out where the needs or opportunities for improvement are. Similarly, development of new technologies or techniques almost always requires collaboration with people from a wide variety of backgrounds. The development of CT is a good example. People ranging from particle physicists to neurologists to engineers and mathematicians were involved in developing the technologies which made CT possible. So, for research and for clinical training, we must broaden our training as well as broaden the backgrounds we draw from. Clinical residency programs are good and have raised the quality of clinical training. However, they need to broaden their entrance requirements, not narrow them. Medical physics will benefit hugely from expanding the background expertise of people we bring in to our field, both for the clinic and for the breadth of our research efforts. There are a bunch of things we should do. We should welcome scientists and engineers from other fields, as we used to do â&#x20AC;&#x201C; even wayward low temperature solid state physicists. We must broaden our training program syllabi and entrance windows for those programs. We should collaborate with other scientists, and continue to expand our knowledge, experience and efforts in newly developing fields (e.g., nanotechnology, informatics, genomics and all the other -omics) that will be more important in the future. And finally, we must work together: we accomplish much more together than we do individually. Iâ&#x20AC;&#x2122;d like to finish with this picture of the UM physics group working through the night on the program project grant. The innovations our group helped develop, implement and study have changed the field of radiation oncology, and have improved cancer treatment for a great many patients. This was only possible due to the teamwork of a dedicated group of medical physicists, physicians, treatment planners, therapists and engineers and Iâ&#x20AC;&#x2122;m honored to represent all these people Working thru the night on the program project grant in accepting this award. Thank you.

AAPM Newsletter | Volume 39 No. 5 | September/October 2013

2013 Summer School Report

Bruce Thomadsen, Peter Dunscombe, Eric Ford, Saiful Huq, Todd Pawlicki, Steve Sutlief

Quality and safety in radiotherapy: Learning the new approaches in Task Group 100 and beyond

uch of the objective of the summer school this June was to learn and experience the new systems approaches to quality and safety in radiotherapy. In addition to exposing participants to these new approaches, the school itself adopted a new educational model, focusing on short presentations followed by discussions and exercises, where the participants practiced using the techniques they had just learned. With exciting and fun debates in the evenings stimulating discussions, the program kept the attendees moving and engaged. The physical environment couldn’t have been better with the Rocky Mountains standing impressively “right there,” except when the smoke from the forest fires eclipsed them! The enthusiastic faculty and participants made the learning fun and exciting. With Karen MacFarland and Corbi Foster ensuring that everything went smoothly, the enthusiastic faculty and participants made the experience not only educational but fun and exciting too.

AAPM Newsletter | Volume 39 No. 5 | September/October 2013

Take-home messages could be summarized as follows. • Address quality and safety using a risk-assessment based approach: — Consider radiotherapy a system — Start small, with self-contained processes — Work in a cross-disciplinary group • To get the views from all sectors, • Co-opt potential antagonists and gain buy-in, and • Increase safety culture • Follow the steps: — Map the process — Perform a failure modes and affects analysis — Make a fault-tree — Determine interventions • Try redesign but look for new failure modes • Ensure the key core components: • Training • Communications • Protocols and standard procedures • Ensure you have the resources to do the job • Fix environment and performance-shaping factors where possible • Commission comprehensively, not just end-to-end but challenging the system to know its limits • Develop QM interventions: • Use the strongest tools that fit the situation but don’t discount the weaker tools – they can still be very effective • Use the taxonometric classifications for the potential failures to guide the interventions • Participate in an incident learning system — Create a local system (again design with an interdisciplinary group) — Participate in a national system when available in a few months • It can serve as your local system • Participants can make use of the analysis expertise available • Identify hazards and opportunities • Establish Quality Improvement — Error proof where possible — Attack specific problems or projects — Follow plan-do-study( or check)-act — Do not blame and train — Consider approaches such as six-sigma • Use statistical process control to evaluate processes that lend themselves to such • In managing change: — Know the type of change you are attempting

AAPM Newsletter | Volume 39 No. 5 | September/October 2013

— Use a team and a leader — Identify and deal with resistors — Avoid poorly run meetings Details of the techniques and methods can be found in the summer school book.

AAPM Newsletter | Volume 39 No. 5 | September/October 2013

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CAMPEP News

William Hendee, Rochester, MN

Highlights from The Annual Meeting

AMPEP is in the process of securing accreditation from the Commission on Higher Education Accreditation (CHEA). This accreditation will place CAMPEP among the premier accreditation agencies for higher education programs. We have been involved in the CHEA accreditation process for more than two years, and hope to finish the process with an appearance of CAMPEP representatives before the CHEA Board of Directors in November. A CHEA representative was present as an observer at all CAMPEP meetings on Tuesday during the Annual Meeting. CAMPEP understands the frustration of program directors with the less than 100% participation in a match program by residency directors. However, CAMPEP does not see this issue as an accreditation issue. Rather, the issue seems to be one of cooperation among residency directors and would be best resolved through SDAMPP. Concern over variable admission dates into residencies is a related issue that belongs more to SDAMPP than CAMPEP. Forty four graduate programs have been accredited by CAMPEP, up from 37 last year. There are 6 accredited certificate programs for the alternate pathway with more under review, including (only) one from a residency program. CAMPEP continues to be concerned with the large surplus of students in graduate programs compared with the number of residency slots available, several of which are reserved for PhDs in the alternate pathway. Although primarily a SDAMPP/AAPM issue, CAMPEP is concerned about students recruited into graduate programs who encounter a dead end to their clinical career aspirations when they cannot find a residency slot. Currently there are 73 accredited residency programs, up from 58 last year. Nine additional programs are under review. CAMPEP does not consider the presence, absence or amount of resident stipends in its review of residency programs. Both the AAPM and the ABR have expressed a desire that CAMPEP attain deemed status with the ABR so that it can offer credit for SAMS programs. CAMPEP is considering this possibility. In a meeting of CAMPEP and Society of Nuclear Medicine representatives, agreement was reached that a resident completing an imaging residency, and is therefore eligible for ABR certification in

AAPM Newsletter | Volume 39 No. 5 | September/October 2013

diagnostic imaging, could be eligible also for ABR certification in nuclear medicine by spending one additional year in a nuclear medicine residency. The reverse (nuclear medicine followed by an imaging residency) would also be possible. Three-year residencies offering education in both imaging and nuclear medicine would be considered by CAMPEP. The application fee for a dual residency program will be $6000. Currently, the ABR allows individuals to sit for examination in a second specialty by obtaining one additional year of mentored training. CAMPEP prefers that the additional year be acquired in an accredited residency with a formal curriculum. ABR agrees, and has asked for a 5-year interim period before implementation of the CAMPEP curriculum requirement in 2018. Whether a person certified in radiation therapy can obtain eligibility for certification in diagnostic imaging or nuclear medicine by spending an additional year in an appropriate residency cannot be answered at this time. The CAMPEP Board of Directors will consider this option, but differences in radiation therapy compared with the other specialties present major challenges. According to CAMPEP, the 2014 requirements for education in an accredited residency program as a sole gateway to eligibility for ABR certification are applicable to residents admitted in 2014, and not to residents already in residency programs. This interpretation has not yet been discussed with the ABR. Currently, CAMPEP permits waiver of up to two 197S courses in the alternate pathway for individuals who have taken similar courses. CAMPEP is willing to change this requirement so that the program director can decide how many 197S courses can be waived, but the program director must report waived courses in each annual report and will be held accountable for assuring that course waivers are legitimate. A potential applicant can request evaluation of previous courses for possible waiver by the GEPRC for a charge to be determined. Bill Hendeeâ&#x20AC;&#x2122;s 6-year term as a CAMPEP board member will be completed at the end of 2013. Four excellent individuals were nominated by the AAPM to replace Bill, and Steve Thomas was selected by the CAMPEP Board of Directors for a 3-year term (once renewable) beginning in 2014. Also, Wayne Beckham, current CAMPEP Vice Chair, was selected as the incoming CAMPEP President and Board Chair to replace Bill. In response to an invitation from ACPSEM (the Australasian College of Physical Scientists and Engineers in Medicine) two senior-level CAMPEP representatives, the Vice-Chair of CAMPEP and a former chair of the REPRC, reviewed the ACPSEM accreditation procedure. The review included a 1-week site visit. Based upon this review, the CAMPEP representatives found that the ACPSEM graduate and residency educational programs were comparable in content and expectations to CAMPEP requirements. This conclusion will be communicated to the ABR with a cover letter from the CAMPEP president. Additional information about these highlights can be obtained by referral through the CAMPEP office (jackie@aapm.org).

AAPM Newsletter | Volume 39 No. 5 | September/October 2013

SEAAPM Chapter Report

Allan deGuzman, Kevin Junck, George David, Jae Kwag, Ingrid Marshall, Chet Ramsey

Case studies in safety and reliability engineering of radiation oncology systems - A symposium by SEAAPM

he Southeastern Chapter of the AAPM (SEAAPM) held its annual Symposium and Meeting at the Renaissance Hotel in Asheville, NC from April 25-28, 2013. The Title of the Symposium was “Case Studies in Safety and Reliability Engineering of Radiation Oncology Systems” organized by Dr. George Sherouse, PhD of Landauer Medical Physics. Speakers from across the United States and Canada, representing a number of vendors and academic institutions led an informative symposium addressing the processes of product design, validation and post-market modifications. Engineering case studies of commercially available products were presented to provide the audience a look behind the scenes at product development and quality assurance. The Symposium was followed by the annual SEAAPM scientific meeting which consisted of presentations from several SEAAPM members. The talks were related to the theme of “The Tools of Our Trade” which covered Acceptance Testing, Commissioning and routine Quality Assurance for the devices we use in our clinics and the training and education required to perform such tasks.

Ionnis Sechopolous gives a presentation of his paper, “Characterization of the homogeneous tissue mixture approximation in breast imaging dosimetry”

During the meeting, a number of annual awards were presented. The “Best Paper Award” is given to a chapter member who is judged to have the best publication in the previous calendar year. This year the best paper award was given to Ioannis Sechopoulos of Emory University for his paper, “Characterization of the homogeneous tissue mixture approximation in breast imaging dosimetry”. (MedPhys 2012 Aug; 39(8); 5050-9)

AAPM Newsletter | Volume 39 No. 5 | September/October 2013

The “Jimmy O. Fenn Award” is given each year by the SEAAPM to recognize an individual having a significant record of service to the field of Medical Physics and the SEAAPM. The winner of this year’s Jimmy O. Fenn award is Robert (Bob) John Wilson from the University of Tennessee Health Science Center in Memphis, TN. Bob has been an active member of both the AAPM and the SEAAPM serving on a number of committees and as an Associate Editor for Medical Physics. Bob was Robert Wilson accepting the “Jimmy O Fenn Award” also a Chapter Board Representative and served as co-director of two of our chapter symposiums. Bob has previously been recognized for his service to the AAPM by being named a Fellow. As one of his colleagues so aptly stated, “I know of no one more deserving of this honor and the gratitude of our chapter than Bob.” The SEAAPM has incorporated a poster presentation session into the annual meeting to encourage participation by students, residents, fellows and post-doctoral students. The poster session provides a casual and interactive format to provide feedback and mentoring to some of the next generation of medical physicists. The session this year consisted of over a dozen poster presentations and was considered another success by both the presenters and the audience.

Students stand next to their poster presentations, ready to answer any questions from an obviously interested audience

AAPM Newsletter | Volume 39 No. 5 | September/October 2013

A cash award is given to the student who is judged to have the best poster presentation at the meeting, to help off-set the cost of travel to the meeting. The winner of the best poster award this year was Matt C. Walb from Wake Forest University Medical Center for his poster, “The Effects of Low Dose Radiation +/- Hyperoxia on Lung Tumorigenesis.” The annual Night-Out event was held at The Century Room at Pack’s Tavern in downtown Asheville. Following a “Happy Hour” with music provided by the “Chuck Lichtenberger Jazz Quartet” we were treated to a delicious dinner with the theme, “A Taste of Italy.” The venue provided a wonderful opportunity to socialize with our friends and colleagues while listening to some smooth jazz. The food was exceptional and was quite a departure from the typical “barb-que and grits” so often associated with us in the South. Presentations from the Symposium and Meeting will be available for review on the SEAAPM website. Photos from the Symposium, Meeting, and Night-Out can be seen on the SEAAPM Facebook page.

AAPM Newsletter | Volume 39 No. 5 | September/October 2013

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Website Editor Report

George C. Kagadis, Rion, Greece

AAPM website is getting even better with a new look, tailored functionality and ease of use

his is my first Newsletter report as the AAPM Website Editor and I have written it just after our Annual Meeting in Indianapolis, IN. My vision for our website (as detailed here) is summarized to: a) keep up with the latest technologies in order to sustain and increase the importance of AAPM, b) customize the website in order that it provides the membership with information tailored to the individual’s needs, c) make AAPM web presence accessible through different emerging platforms, and d) take advantage of the social media power to benefit our society. Together with the great help of Mr. Michael Woodward and Ms. Farhana Khan we have started working on those directions and have already made some progress. More specifically we have started designing a new AAPM website tailored to the needs of the membership. The new website will be more easy to access from smartphones and tablets. The new look will be simpler. Our goal is to give you the information you are searching for in a format that fits the device you are searching with. In order to provide current and succinct information we have started validating information in the website so that you don’t waste time looking at outdated pages and links. Social media plays a critical role in our web presence and we are trying to further advance them for the benefit of our society. I am pleased to report that as of August 13, 2013 we have 33,896 images posted to AAPM’s Flickr, 1,172 likes in Facebook, 4,919 followers in LinkedIn and 2,135 followers in Twitter. This past June we asked committee and subcommittee chairs to give a short introductory video about themselves and their committee or project. We received such videos from Jessica Clemments, Matt Meineke, Cari Borras, Gene Lief, Brian Wang, Eric Ford and John Hazle. Those videos were accepted with enthusiasm during our Annual Meeting in Indianapolis and are available through the AAPM website. I urge the chairs of other AAPM committees and subcommittees to prepare such an introductory and send it to us to put together with the other introductions for presentation at our booth at RSNA. Last, but not least, we have also started recompiling the Website Editorial Board. We will need enthusiastic people willing to work on advancing the AAPM website. Please contact me if you are interested in participating.

AAPM Newsletter | Volume 39 No. 5 | September/October 2013

I hope you find the AAPM website useful, visit it often and send me your feedback or directly at george@mail.aapm.org.

AAPM Newsletter | Volume 39 No. 5 | September/October 2013

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Call for Applications: Executive Director American Board of Radiology The Board of Trustees of the American Board of Radiology is issuing a Call for Applications for the position of Executive Director. It is anticipated that the contract of the new Executive Director will begin July 1, 2014, or earlier to coordinate with the contract of the current Executive Director, who is retiring. Applications will be accepted effective with the date of this announcement. In order to assure a timely process, the application process may be closed as appropriate at the discretion of the ABR. The Executive Director supports the Board of Trustees and oversees the operation of the ABR office and its staff of approximately 70 employees. The position reports to the President of the ABR, who also serves as the Chair of the Board of Trustees. The Executive Director represents the ABR to the public and medical community at large at the discretion of the President and the trustees. The Executive Director is responsible for the management of operations of the Board and directly oversees those staff members who support the trustees in this effort. The Executive Director is assisted in these duties by designated Associate Directors. The Executive Director will oversee the implementation of the policies of the Board of Trustees relative to the ABRâ&#x20AC;&#x2122;s mission, goals, objectives, and related policies. He/she will plan ABR programs and activities and perform such other additional duties as may be assigned by the President or Board of Trustees. It is anticipated that the role is not likely a career development position, but rather will be a senior level effort utilizing previously acquired experience and expertise. Candidates should anticipate providing a mutually agreed- upon commitment for at least five years with renewable commitments to be determined thereafter. All inquiries and formal requests for consideration as a candidate should be addressed to the Chair of the Search Group, James P. Borgstede, MD, at his email address: borgrad@msn.com. Written inquiries or formal requests can be sent to Dr. Borgstede (c/o Karyn Howard) at the ABR office address (see below). For a more detailed job description and further information on the application process, please go to the ABR website. The American Board of Radiology 5441 E. Williams Circle, Tucson, AZ 85711-7412 (520) 790-2900 â&#x20AC;˘ www.theabr.org

AAPM Working Group News

Dianna D. Cody, Houston, TX

AAPM Working Group recognized by the FDA

n Monday, June 10, 2013, the Director of the Center for Devices and Radiological Health (CDRH) arm of the Food and Drug Administration (FDA), Jeffrey Shuren, M.D., J.D., awarded the AAPM Working Group on Standardization of CT Nomenclature and Protocols the CDRH Director’s Special Citation Award. This award was presented “For developing CT imaging radiation safety instructional materials through a collaboration of end-users, CT manufacturers, and the Food and Drug Administration.” One of the co-chairs of the working group, Dianna Cody, Ph.D., was on hand to accept this award on behalf of the team. Also present were working group members Thalia Mills, Ph.D., Brian Abraham, M.P.A., and Donald Fickett, B.Tech.

AAPM Working Group on Standardization of CT Nomenclature and Protocols representative members just after the FDA award ceremony. From left to right, Brian Abraham, Dianna Cody, Don Fickett, Thalia Mills. The FDA award description is shown below: In 2010, FDA released an “Initiative to Reduce Unnecessary Radiation Exposure from Medical Imaging”, which targets high dose imaging modalities including CT. A key partner in following through on the goals of this Initiative has been the American Association of Physicists in Medicine (AAPM) Working Group on Standardization of CT Nomenclature and Protocols. Meeting bi-weekly since 2010, the group has worked

AAPM Newsletter | Volume 39 No. 5 | September/October 2013

tirelessly to advance CT radiation safety through publication of publicly available resources on the AAPM website . At the request of FDA and CT manufacturers, the group has taken on work beyond its original charge of nomenclature and protocol standardization to help advance shared dose reduction goals. Examples include publication of recommendations on how to use the NEMA CT Dose Check standard and contributions to the draft NEMA CT User Information Standard (released for comment Nov. 2012), which was developed in response to FDA’s Nov. 2010 letter to the Medical Imaging and Technology Alliance (MITA) following the The CDRH Director’s CT brain perfusion safety investigation. Other Special Citation Award workgroup accomplishments in 2012 include: publication of 3 new CT protocols, publication of the CT Dose Education slides, and an updated CT lexicon, which translates nomenclature across different manufacturers’ systems.

CDRH Director’s Special Citation Award presentation to the AAPM Working Group on Standardization of CT Nomenclature and Protocols at the FDA White Oak campus in Silver Spring, MD. From left to right: Dr. Jeffrey Shuren (Director, CDRH), Dianna Cody, Don Fickett, Brian Abraham, Thalia Mills. AAPM Newsletter | Volume 39 No. 5 | September/October 2013

The effect of these efforts has been to improve public health by optimizing the dose of ionizing radiation during CT scans and by helping to eliminate accidental radiation overdoses during CT scanning. The group is an outstanding example of what can be accomplished through collaboration of key stakeholders. The group includes medical physicists, radiologists, radiologic technologists, industry representatives, and regulators, from AAPM, the American College of Radiology (ACR), the American Society of Radiologic Technologists (ASRT), the Society for Pediatric Radiology (SPR), the Image Gently Alliance, the Medical Imaging and Technology Alliance, from all 7 U.S. CT manufacturers, and from the FDA. Substantial effort was required by several in key upper level management positions at the FDA in order for the award to be bestowed. Congratulations to all who were recognized! The official list of recipients is shown below along with their affiliation. Brian Abraham (MITA) Mark Armstrong (ACR) Kirsten Boedeker (Toshiba) Theresa Branham (ACR) Priscilla F. Butler (ACR) David Clunie (AAPM) Dianna Cody* (AAPM) Amar Dhanantwari (Philips) Donald Fickett (Neurologica) Marilyn J. Goske (Image Gently) Dustin Gress (AAPM) Michael Heard (AAPM) Dina Hernandez (ACR) John Jaeckle (GE) Farhana Khan (AAPM) James Kofler (AAPM) Christianne Leidecker (Siemens) Virginia Lester (ASRT) Richard Mather (Toshiba) Cynthia McCollough* (AAPM) Michael McNitt-Gray (AAPM) Keith Mildenberger (Neusoft) Thalia T. Mills (FDA) Catherine Neumann (Hitachi) Kevin Oâ&#x20AC;&#x2122;Donnell (DICOM) Mark Olszewski (Philips) Robert Pizzutiello (AAPM) Karen Procknow (GE)

AAPM Newsletter | Volume 39 No. 5 | September/October 2013

Gail Rodriguez (MITA) Daniel Rubin (Radlex/RSNA) Mark Silverman (Hitachi) Mark Supanich (AAPM) Sjirk Westra (Image Gently) Lifeng Yu (AAPM) * Co-Chairs

AAPM Newsletter | Volume 39 No. 5 | September/October 2013

2013 Winner: Oldest Annual Meeting Tote Bag Contest

Congratulations Congratulations to Tariq Mian for bringing the oldest Annual Meeting tote bag from 1983 (25th Anniversary)! Several contestants stopped by the Member Services Desk in Indianapolis during the Annual Meeting to show off their old meeting totes. Meeting materials were distributed in a small bag made of recycled plastic, but the contest was held to encourage reusing old totes. The prize: A 2013 Physics Pheud t-shirt and an Austin music CD. Mark your calendars for next year’s meeting in Austin: July 20 - 24, 2014.

Donors’ Lounge at the Annual Meeting The Donors’ Lounge at this year’s Annual Meeting was a great place for those members who had generously donated to our Education & Research Fund over the years to relax their weary bones. Members were able to enjoy light refreshments while conversing with friends and colleagues, print out their Boarding Passes for the trip home, charge up their electronic devices, and probably charge up themselves for the rest of a busy day. Since the Development Committee had no idea how busy the lounge would be, we opened it up this year to only those members who had donated a total of $500 or more to the E & R Fund. This turned out to be over-conservative, however, since there was always lots of free space available, so next year we will likely open the lounge to donors of $100 or more provided, of course, that we have sufficient funds in our budget to have a Donors’ Lounge. I urge you all to give serious consideration to making a donation to this Fund, which supports the development of our great profession via the provision of seed money for research, fellowships for Ph.D. students, and support for clinical residencies. Without contributions from members like you we would never have been able to provide the now over 100 grants, fellowships and residencies since the inception of the Fund 20 years ago. By Colin G. Orton, Chairman, Development Committee.

Staff Announcements

Angela Keyser, College Park, MD

AAPM HQ Team...at your service! AAPMâ&#x20AC;&#x2122;s interactions within the science and science policy communities continue to increase. The organization has a great HQ team hard at work alongside numerous AAPM volunteers to represent AAPM and the medical physics profession.

Lynne Fairobent joined the AAPM team in 2004 as Manager, Legislative and Regulatory Affairs. She works with AAPM volunteers to interact with Congress, federal agencies and other policy makers. Lynne also coordinates efforts with other sister organizations. She also serves as the staff liaison to the Professional Council.

Debbie Bray Gilley, the newest member of the AAPM HQ team, joined

the AAPM team as of September 3, 2013 as the Government Relations Specialist. Debbie recently served as a Radiation Safety Specialist with the Radiation Protection of Patients Unit of the International Atomic Energy Agency (IAEA) in Vienna. Her activities within the Agency include the development and implementation of the Safety in Radiation Oncology medical event reporting system (SAFRON) and assisting in other IAEA patient safety campaigns. Before relocating to Austria, she was employed by the Florida Bureau of Radiation Control for 24 years. Debbie will be gathering and disseminating information on the activities of the state legislatures and state agencies on issues related to the medical physics profession. She will also work on patient safety issues.

AAPM Newsletter | Volume 39 No. 5 | September/October 2013

Persons in the News

Willi Kalender, Professor and Chairman of the Institute of Medical Physics

University Of Erlangen Institute of Medical Physics Nuremberg, Germany

Professor Willi A. Kalender selected to receive 16th Gray Medal The ICRU is pleased to announce that the 16th Gray Medal will be presented to Professor Willi Kalender at the 20th International Conference on Medical Physics on September 3, 2013 in Brighton, United Kingdom. Professor Kalender’s Gray Medal Lecture is entitled, “New Hori-zons in Computed Tomography.” Professor Willi Kalender received his doctorate in 1979 from the University of Wisconsin, Madison, working under Professor Charles Mistretta. He then joined Siemens Medical Systems where he participated in, and ultimately led, the development of clinical computed tomography systems until 1995. During his tenure at Siemens, he was responsible for a number of innovative CT scanner designs. One of the most profound technological developments in CT over the past 30 years has been the use of slip-ring systems which allow continuous rotation of the gantry. When combined with continuous table translation, this allows spiral scanning of the patient. Spiral-CT scanning dramatically reduces the amount of time required to acquire a CT scan, thereby enabling a larger number of clinical applications of this technology. After leaving Siemens Medical Systems in 1995, Professor Kalender became the founding director of the Institute of Medical Physics of the University of Erlangen-Nürnberg in Erlangen, Germany. While managing his busy career in academic medical physics, he has continued to work with the Siemens organization, and most recently he was involved in the development of their dual-source CT scanner, which allows high temporal resolution cardiac imaging as well as dual-energy CT. Professor Kalender is a prolific scientist, with 30 patents, more than 260 peer-reviewed original articles, and over 600 book chapters, reviews and abstracts. In addition he has mentored about 100 PhD students. He has also founded a number of small businesses in southern Germany, including companies that manufacture phantoms for medical imaging, small animal imaging systems, and computed tomography systems customized for breast imaging. Professor

AAPM Newsletter | Volume 39 No. 5 | September/October 2013

Kalender has won a number of prestigious awards during his distinguished career, including the William D Coolidge Award from the American Association of Physicists in Medicine, the European Latsis Prize from the European Science Foundation, and the Cross of the Order of Merit of the Federal Republic of Germany, to name just a few. Professor Kalender is being awarded the Gray Medal, the highest honor bestowed by the International Commission on Radiation Units and Measurements (ICRU), for his many contributions to the development of computed tomography systems, including both innovative technical designs and novel clinical applications. Professor Kalenderâ&#x20AC;&#x2122;s many contributions to the science and technology of computed tomography have had an enormous impact on patient care throughout the world.

Bhudatt Paliwal & John Bayouth Professors, Radiation Oncology Physics

University of Wisconsin, Madison, WI

DHO faculty, staff, residents, friends and colleagues gathered at a reception on April 13, 2013 to honor Dr. Bhudatt Paliwal for his outstanding contributions to Radiation Oncology physics and cancer care, and to recognize Dr. John Bayouth, Chief of Physics, as the first Paliwal Professor in Human Oncology. Over his 50-year career, Dr. Paliwal has mentored and collaborated with hundreds of medical physicists around the world. A master contributor to the discipline, it is fitting that a Professorship be established in his name at the University of Wisconsin.

AAPM Newsletter | Volume 39 No. 5 | September/October 2013

The Bhudatt Paliwal Professorship in Human Oncology provides support to an outstanding medical physicist performing physics research in the areas of radiation oncology and radiation physics. Dr. John Bayouth, an exceptionally talented medical physicist, brings a strong track record of accomplishment in clinical service, research and teaching. In the same spirit as Dr. Paliwal, Dr. Bayouth has a knack for successful mentorship and bringing out the best in others. His vision and dedication to the field of medical physics is reflected by his election as the 2013 President-Elect for AAPM. We are delighted to welcome Dr. Bayouth to the University of Wisconsin as Chief of Radiation Oncology Physics and congratulate him as the first recipient of the Paliwal Professorship in Human Oncology! Learn more about the Paliwal Professorship, including how to contribute at Bhudatt Paliwal Professorship in Human Oncology.

AAPM Newsletter | Volume 39 No. 5 | September/October 2013

Award Winners The John R. Cameron Young Investigators Symposium a competition for new investigators within a special symposium in honor of Dr. John Cameron. Congratulations go to: 1st place: Grace Jianan Gang of Johns Hopkins University for her abstract: “Modeling Nonstationary Noise and Task-Based Detectability in CT Images Computed by Filtered Backprojection and Model-Based Iterative Reconstruction” 2nd place: Clemens Grassberger of The Francis H. Burr Proton Therapy Center for his abstract: “Motion Mitigation in Active Scanning Proton Therapy for Lung Cancer: A 4D Monte Carlo Study” 3rd place: Reza Farjam of the University of Michigan for his abstract: “Early Prediction of Brain Metastases Response to Radiation Therapy by Combination of Changes in Tumor Vascular and Cellularity Properties”

Innovation in Medical Physics Education The Education Council of the AAPM sponsors a session during the Annual Meeting to honor and publicize Innovation in Medical Physics Education. The abstracts can be scientific research, novel teaching strategies – team teaching or adult learning efforts, novel educational materials – lectures, websites, or other innovations.

Congratulations go to: Chris Brown of Oklahoma State University for his presentation: “Designing a Low Cost Digital Imaging System for Medical Physics Education”

AAPM Newsletter | Volume 39 No. 5 | JSeptember/October2013

Medical Physics International Journal

Slavik Tabakov, London, UK Perry Sprawls, Atlanta, GA

IOMP launches a new, open access journal, The MPI with special emphasis on educational activities and professional development

he MPI, the new journal of the International Organization of Medical Physics (IOMP), is now published with open access. The purpose of the Journal is to provide the global medical physics community with articles that are not generally available in other publications. Manuscripts that are reporting on research results and developments that require scientific peer review are not within the scope of the MPI and should be submitted to other established journals such Slavik Tabakov, Ph.D (Left Side) as Medical Physics and the Journal of Applied Clinical MedPerry Sprawls, Ph.D (Right Side) ical Physics (JACMP). Co-Editors A special emphasis will be to support educational activities and professional development of medical physicists and related professions. This will include articles on medical physics educational programs, methods, and resources. It will also serve as a forum for the discussion of issues relating to the professional practice of medical physics with a global perspective. There will be featured articles on the history of some of the major developments in medical physics that give all a valuable insight into our rich heritage and an opportunity to meet some of our pioneers. Recent Ph.D. graduates are invited to publish their dissertation abstracts to share their work with the global medical physics community. The MPI is also publishing the abstracts of presentations at international conferences and congresses beginning with the ICMP 2013 at Brighton, England in the current edition. AAPM members are invited to use this journal to share their experiences to enhance the practice of medical physics around the world. Read it now

AAPM Newsletter | Volume 39 No. 5 | September/October 2013

Letter to the Editor

It’s about more than dose distributions

he physics of radiation therapy (RT) was put on a relatively firm scientific basis in the1920’s, making it possible to reliably measure the dose rates and dose distributions produced by the then extant x-ray machines. It was soon recognized that as the voltage applied to the tube was increased, the dose to the dermal layer of the skin and to bone decreased, and depth dose compared with surface dose increased. In the 1930’s the first one-million-volt x-ray generator was installed at St. Bart’s in London, followed by similar machines in the U.S. and Europe. Except for the interruption caused by World War II, thus was started a longstanding trend in radiation oncology: the periodic introduction of higher energy and more versatile x-ray machines accompanied by occasional forays into nuclear physics laboratories by the more intrepid for clinical trials of protons, neutrons, heavy ions and pi mesons. Setting aside considerations of dose rate, fractionation, and protraction, the overriding paradigm of RT has been the optimization of dose distributions, i.e., the delivery of a lethal dose to the tumor while minimizing the dose to normal surrounding tissues. (Put another way, in most cases the radiation oncologist is emulating the surgeon who resects a tumor leaving negative margins, but with less trauma.) Using the various techniques of IMRT, the dose distributions of highenergy x rays have been optimized to the extent that uniform tumor doses are routinely obtained and the dose to critical surrounding tissue minimized albeit at the expense of higher integral doses. Whether and the extent to which the dose distributions obtained by IMRT have improved clinical outcomes by comparison with 3D-CRT, or even two, three or four rectangular coplanar fields, is a largely unanswered question, one that begs to be addressed by randomized clinical trials (RCT). Approximately 90% of all deaths in patients who had solid-tumors are found to be due to metastatic disease. If metastases are extant at the time of diagnosis, then aggressive treatment of the primary by whatever means is futile, and systemic therapy may be the only alternative. On the other hand, if there are no detectable metastases at the time of diagnosis, surgery, radiation therapy and chemotherapy in various combinations are commonly employed. Regardless, the patient is still more likely to die from metastases or some unrelated cause as from a local recurrence.

Although the death rates for some of the more common cancers, such as prostate, breast, lung and colon, have declined significantly over the past twenty years, they are still higher than the roughly 10 per 100,000 rate level of the more treatment-refractory cancers remained stable or even increased slightly over the same period. The declines of prostate, breast, lung and colon are more likely due to screening, reduced smoking, and polypectomies than any significant AAPM Newsletter | Volume 39 No. 5 | September/October 2013

advances in treatment. The five-year survivals for these cancers are provided in Table 1. What they have in common is that different patients with presumably the same tumor, and given the same treatment, do not all respond in the same way. This has led to the conclusion that there are subtle differences in the biochemistry/genetics of what are clinically regarded as the same tumors, and that until these subtle differences are defined and taken into account, cancer will continue to be a principal cause of mortality in the U.S. Table 1. All-stage five-year survival rates (%) Prostate 99 Breast 89 Lung & Bronchus 16 Colon & Rectum 65 Pancreas 6 Liver 14 Ovary 46 Thus, accepting that most tumors have yet-to-be-defined complexities, and that current treatments will at best increase survival but slowly, we are caused to wonder about the adjuvant role of RT in the treatment of solid tumors. It is not that we question the role of RT per se, but only whether more and more precisely defined dose distributions make any sense in the grand scheme of things. After all, dose-for-dose, proton-beam therapy (PBT) and x-ray therapy are for the most part biologically equivalent. As for reducing the doses to surrounding organs, current reports suggest that the levels of GI and GU toxicity following PBT or IMRT for prostate cancer are equivalent, although one report based on SEER data found IMRT to be markedly superior. Despite the lack of RCTâ&#x20AC;&#x2122;s that demonstrate improvements in length and quality of life, investments in RT equipment in general, but PBT in particular, grow ever larger. More often than not, decisions to purchase are based of anecdotal clinical reports, computer-generated treatment plans, a hospitalâ&#x20AC;&#x2122;s need to enhance its role as a frontline cancer center, or simply because the new machine is predicted to turn a profit. (IMRT for prostate cancer costs upwards of five times that for a prostatectomy.) Although physicists have and continue to make exceedingly valuable contributions to RT, they fail to recognize that their seemingly endless efforts to concentrate more and more of the incident radiant energy into the perceived tumor volume and less to surrounding tissues are yielding results comparable to but no better than those routinely achieved by more conventional and far less expensive means. If research on protons, heavy ions, anti protons, and perhaps even the Infinitron is to continue, should physicists, with help from their radiobiology colleagues, not be looking beyond dose distributions but into how the unique properties of these radiations might improve a range of clinical outcomes? The time is long passed for the gap between rhetoric and reality in the care of the cancer patient to be closed. R. J. Schulz, Ph.D. A, Robert Kagan, M.D.

AAPM Newsletter | Volume 39 No. 5 | September/October 2013

Immediate Release

NCRP Report No. 174, Preconception and Prenatal Radiation Exposure: Health Effects and Protective Guidance NCRP Report No. 174, Preconception and Prenatal Radiation Exposure: Health Effects and Protective Guidance, updates and expands the National Council on Radiation Protection and Measurements (NCRP) Report No. 54, Medical Radiation Exposure of Pregnant and Potentially Pregnant Women (1977). Scientific knowledge has increased and public concerns have changed in the 36 y since NCRP Report No. 54 was published. The scope of NCRP Report No. 174 covers both ionizing radiation sources and specific nonionizing sources [i.e., magnetic-resonance imaging (MRI), ultrasound imaging, and radiofrequency (RF) fields]. This Report provides information on the types, sources and magnitudes of ionizing radiation exposures of reproductive relevance. Ionizing radiation exposures from medical care (diagnostic and therapeutic procedures, including radiopharmaceuticals) are addressed as well as from occupational sources, common environmental exposures, and from accidental or deliberate (e.g., a terrorist act) releases of radionuclides. The ionizing radiation sources discussed consist predominantly of low linear energy transfer (LET) radiation (e.g., x rays from prenatal medical procedures). The risks from ionizing radiation exposure are examined in detail from preconception through pregnancy, and during the nursing of infants. Outcomes and associated risks from preconception exposure that were evaluated include: infertility, stillbirths, birth defects, genetic alteration, and cancer. Outcomes and associated risks from exposure during pregnancy that were evaluated include: congenital malformations, growth retardation, embryonic and fetal death, mental retardation and neurobiological effects, and cancer. Also discussed is the risk to the nursing infant from the transfer of radioactive material through the motherâ&#x20AC;&#x2122;s milk (e.g., milk from a mother who received a radiopharmaceutical) as well as from direct exposure due to radionuclides present in the motherâ&#x20AC;&#x2122;s body. Methods for managing dose and reducing risk from various medical procedures are also addressed. For nonionizing sources (MRI, ultrasound imaging, and RF fields), the focus is on prenatal exposure, with limited coverage of childhood and adult exposure. Outcomes and associated risks during pregnancy that were evaluated, as relevant to exposure from a particular nonionizing source, include: low birth weight, delayed speech, dyslexia, nonright-handedness, and impaired intellectual performance. Effective methods of counseling and communicating the various risks are described, along with examples of consultations concerning risk prior to and during pregnancy. In particular, the Report provides specific conclusions and recommendations concerning the health effects discussed and associated protective guidance. The Report is available from the NCRP website, http://NCRPpublications.org, in both PDF and hardcopy formats. AAPM members receive a 20 % discount (use discount code: aapmepubs2013). For additional information contact James R. Cassata, Ph.D., CHP at cassata@NCRPonline.org, 301.657.2652 (x20) or 301.907.8768 (fax).

The National Council on Radiation Protection and Measurements

7910 Woodmont Avenue, Suite 400 Bethesda, Maryland 20814-3095 Telephone: (301) 657-2652 Fax: (301) 907-8768 http://NCRPonline. org http://NCRPpublications.org