Chapter 12: Quality Assurance of

External Beam Radiotherapy

Set of 146 slides based on the chapter authored by
D. I. Thwaites, B. J. Mijnheer, J. A. Mills
of the IAEA publication (ISBN 92-0-107304-6):
Review of Radiation Oncology Physics:
A Handbook for Teachers and Students

Objective:
To familiarize the student with the need and the concept of a quality
system in radiotherapy as well as with recommended quality
procedures and tests.

Slide set prepared in 2006

by G.H. Hartmann (Heidelberg, DKFZ)
Comments to S. Vatnitsky:
dosimetry@[Link]

IAEA
International Atomic Energy Agency
CHAPTER 12. TABLE OF CONTENTS

12.1 Introduction
12.2 Managing a Quality Assurance Program
12.3 Quality Assurance Program for Equipment
12.4 Treatment Delivery
12.5 Quality Audit

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - [Link] 1
12.1 INTRODUCTION
12.1.1 Definitions

 Commitment to Quality Assurance (QA) needs a sound

familiarity with some main relevant terms such as:

Quality Quality
Assurance System

QA in
Quality Radiotherapy
Control Quality
Standards

Definitions are given next.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.1.1. Slide 1
12.1 INTRODUCTION
12.1.1 Definitions

Quality Assurance
 Quality Assurance is all those planned and systematic
actions necessary to provide adequate confidence that a
product or service will satisfy the given requirements for
quality.
 As such QA is wide ranging, covering
• Procedures;
• Activities;
• Actions;
• Groups of staff.
 Management of a QA program is also called
Quality System Management.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.1.1. Slide 2
12.1 INTRODUCTION
12.1.1 Definitions

Quality Control
 Quality Control is the regulatory process through which the
actual quality performance is measured, compared with
existing standards, and the actions necessary to keep or regain
conformance with the standards.
 Quality control is a part of quality system management.
 It is concerned with operational techniques and activities used:
• To check that quality requirements are met.
• To adjust and correct performance if the requirements are found not to
have been met.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.1.1. Slide 3
12.1 INTRODUCTION
12.1.1 Definitions

Quality Standards
 Quality standards is the set of accepted criteria against
which the quality of the activity in question can be
assessed.
 In other words:

Without quality standards, quality cannot be assessed.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.1.1. Slide 4
12.1 INTRODUCTION
12.1.1 Definitions

Quality System
 Quality System is a system consisting of:
• Organizational structure.
• Responsibilities.
• Procedures.
• Processes.
• Resources.
required to implement a quality assurance program.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.1.1. Slide 5
12.1 INTRODUCTION
12.1.1 Definitions

Quality assurance in radiotherapy

 Quality Assurance in Radiotherapy is all procedures that
ensure consistency of the medical prescription, and safe
fulfillment of that radiotherapy related prescription.
 Examples of prescriptions:
• Dose to the tumor (to the target volume).
• Minimal dose to normal tissue.
• Adequate patient monitoring aimed at determining the optimum
end result of the treatment.
• Minimal exposure of personnel.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.1.1. Slide 6
12.1 INTRODUCTION
12.1.1 Definitions

Quality standards in radiotherapy

 Various national or international organizations have issued
recommendations for standards in radiotherapy:

• World Health Organization (WHO) in 1988.

• AAPM in 1994.
• European Society for Therapeutic Radiation Oncology (ESTRO)
in 1995.
• Clinical Oncology Information Network (COIN) in 1999.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.1.1. Slide 7
12.1 INTRODUCTION
12.1.1 Definitions

Quality standards in radiotherapy

 Other organizations have issued recommendations for
certain parts of the radiotherapy process:

• IEC in 1989
• Institute of Physics and Engineering in Medicine (IPEM) in 1999.

 Where recommended standards are not available, local

standards need to be developed, based on a local
assessment of requirements.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.1.1. Slide 8
12.1 INTRODUCTION
12.1.2 The need for QA in radiotherapy

Why does a radiotherapy center need a quality system?

 Next slides provide arguments to convince oneself (and

others) of the need to initiate a quality project in a
radiotherapy department.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.1.2. Slide 1
12.1 INTRODUCTION
12.1.2 The need for QA in radiotherapy

1. You must establish a QA program.

 This follows directly from the Basic
Safety Series of IAEA. Appendix II.22. says:
“Registrants and licensees, in addition to
applying the relevant requirements for
quality assurance specified elsewhere in the
Standards, shall establish a comprehensive
quality assurance program for medical
exposures with the participation of
appropriate qualified experts in the relevant
fields, such as radiophysics or radiopharmacy,
taking into account the principles established
by the WHO and the PAHO.”

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.1.2. Slide 2
12.1 INTRODUCTION
12.1.2 The need for QA in radiotherapy

1. You must establish a QA program.

 BSS appendix II.23 says:
“Quality assurance programs for medical
exposures shall include:
(a) Measurements of the physical
parameters of the radiation generators,
imaging devices and irradiation
installations at the time of
commissioning and periodically
thereafter;
(b) Verification of the appropriate physical
and clinical factors used in patient
diagnosis or treatment; …”

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.1.2. Slide 3
12.1 INTRODUCTION
12.1.2 The need for QA in radiotherapy

2. It helps to provide "the best treatment“.

 It is a characteristic feature of the modern radiotherapy process
that this process is a multi-disciplinary process.
 Therefore, it is extremely important that

• Radiation therapist cooperates with specialists in the various

disciplines in a close and effective manner.
• Various procedures (related to the patient and that related to the
technical aspects of radiotherapy) will be subjected to careful
quality control.
 Establishment and use of a comprehensive quality system is an
adequate measure to meet these requirements.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.1.2. Slide 4
12.1 INTRODUCTION
12.1.2 The need for QA in radiotherapy

3. It provides measures to approach to the following objectives:

 Reduction of uncertainties and errors (in dosimetry, treatment
planning, equipment performance, treatment delivery, etc.).
 Reduction of the likelihood of accidents and errors occurring as
well as increase of the probability that they will be recognized and
rectified sooner.
 Providing reliable inter-comparison of results among different
radiotherapy centers.
 Full exploitation of improved technology and more complex
treatments in modern radiotherapy.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.1.2. Slide 5
12.1 INTRODUCTION
12.1.2 The need for QA in radiotherapy

Reduction of uncertainties and errors......

Human errors in data transfer during the preparation
and delivery of radiation treatment affecting the final
result: "garbage in, garbage out"
Leunens, G; Verstraete, J; Van den Bogaert, W; Van Dam, J; Dutreix, A; van der Schueren, E
Department of Radiotherapy, University Hospital, St. Rafaël, Leuven, Belgium

Abstract
Due to the large number of steps and the number of persons involved in the preparation of a radiation
treatment, the transfer of information from one step to the next is a very critical point. Errors due to
inadequate transfer of information will be reflected in every next step and can seriously affect the final
result of the treatment. We studied the frequency and the sources of the transfer errors. A total number of
464 new treatments has been checked over a period of 9 months (January to October 1990). Erroneous data
transfer has been detected in 139/24,128 (less than 1%) of the transferred parameters; they affected 26%
(119/464) of the checked treatments. Twenty-five of these deviations could have led to large geographical
miss or important over- or underdosage (much more than 5%) of the organs in the irradiated volume, thus
increasing the complications or decreasing the tumour control probability, if not corrected. Such major
deviations, only occurring in 0.1% of the transferred parameters, affected 5% (25/464) of the new
treatments. The sources of these large deviations were nearly always human mistakes, whereas a
considerable number of the smaller deviations were, in fact, consciously taken decisions to deviate from the
intended treatment. Nearly half of the major deviations were introduced during input of the data in the
Radiother. Oncol. 1992: > 50 occasions of data transfer
check-and-confirm system, demonstrating that a system aimed to prevent accidental errors, can lead to a
considerable number of systematic errors if used as an uncontrolled set-up system. The results of this study
from one point to another for each patient!
show that human mistakes can seriously affect the outcome of patient treatments.(ABSTRACT
TRUNCATED AT 250 WORDS) [Journal Article; In English; Netherlands]
If one of them is wrong - the overall outcome is affected

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.1.2. Slide 6
12.1 INTRODUCTION
12.1.2 The need for QA in radiotherapy

Full exploitation of improved technology.....

 Example of improved technology:
Use of a multi-leaf collimator (MLC)

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.1.2. Slide 7
12.1 INTRODUCTION
12.1.3 Requirements on accuracy in radiotherapy

 Many QA procedures and tests in QA program for equipment

are directly related to the clinical requirements on accuracy in
radiotherapy:

• What accuracy is required on the absolute absorbed dose?

• What accuracy is required on the spatial distribution of dose

(geometrical accuracy of treatment unit, patient positioning etc.)?

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.1.3. Slide 1
12.1 INTRODUCTION
12.1.3 Requirements on accuracy in radiotherapy

 Such requirements can be

based on evidence from dose
response curves for the
tumor control probability (TCP)
and normal tissue
complication probability
(NTCP).
TCP and NTCP are usually
illustrated by plotting two sigmoid Dose (Gy)
curves, one for the TCP (curve A)
and the other for NTCP (curve B).

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.1.3. Slide 2
12.1 INTRODUCTION
12.1.3 Requirements on accuracy in radiotherapy

 Steepness of a given
TCP or NTCP curve
defines the change in
response expected for
a given change
in delivered dose.
 Thus uncertainties in
delivered dose translate into
Dose (Gy)
either reductions in the TCP
or increases in the NTCP,
both of which worsen the
clinical outcome.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.1.3. Slide 3
12.1 INTRODUCTION
12.1.3 Requirements on accuracy in radiotherapy

 ICRU Report No. 24 (1976) concludes:

An uncertainty of 5 % is tolerable in the delivery of

absorbed dose to the target volume.

 This value is generally interpreted to represent a

confidence level of 1.5 – 2 times the standard deviation.

 Currently, the recommended accuracy of dose delivery is

generally 5 % – 7 % at the 95 % confidence level.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.1.3. Slide 4
12.1 INTRODUCTION
12.1.3 Requirements on accuracy in radiotherapy

 Geometric uncertainty, for example systematic errors on

the field position, block position, etc., relative to target
volumes or organs at risk, also leads to dose problems:

• either underdosing of the required volume (decreasing the TCP)

• or overdosing of nearby structures (increasing the NTCP).

 Figures of 5 mm – 10 mm (95 % confidence level) are

usually given on the tolerable geometric uncertainty.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.1.3. Slide 5
12.1 INTRODUCTION
12.1.4 Accidents in radiotherapy

 Generally speaking, treatment of a disease with

radiotherapy represents a twofold risk for the patient:

• Firstly, and primarily, there is the potential failure to control the

initial disease, which, when it is malignant, is eventually lethal to
the patient;
• Secondly, there is the risk to normal tissue from increased
exposure to radiation.

 Thus, in radiotherapy an accident or a misadministration

is significant if it results in either an underdose or an
overdose, whereas in conventional radiation protection
only overdoses are generally of concern.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.1.4. Slide 1
12.1 INTRODUCTION
12.1.4 Accidents in radiotherapy

 From the general aim of an accuracy approaching 5 % (95 %

confidence level), a definition for an accidental exposure
can be derived:

A generally accepted limit is about twice the accuracy

requirement, i.e., a 10 % difference should be taken as an
accidental exposure

 In addition, from clinical observations of outcome and of normal

tissue reactions, there is good evidence that differences of 10%
in dose are detectable in normal clinical practice.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.1.4. Slide 2
12.1 INTRODUCTION
12.1.4 Accidents in radiotherapy

 IAEA has analyzed a series of

accidental exposures in
radiotherapy to draw lessons in
methods for prevention of such
occurrences.

 Criteria for classifying them:

• Direct causes of mis-
administrations
• Contributing factors
• Preventability of misadministration
• Classification of potential hazard.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.1.4. Slide 3
12.1 INTRODUCTION
12.1.4 Accidents in radiotherapy

Examples of the direct causes of misadministrations

Cause Number Cause Number
Calculation error of time or dose 15 Human error during simulation 2

Inadequate review of patient chart 9 Decommissioning of teletherapy 2

source error
Error in anatomical area to be 8 Error in commissioning of TPS 2
treated
Error in identifying the correct patient 4 Technologist misread the 2
treatment time or MU
Error involving lack of/or misuse of a 4 Malfunction of accelerator 1
wedge
Error in calibration of cobalt-60 source 3 Treatment unit mechanical failure 1

Transcription error of prescribed dose 3 Accelerator software error 1

Wrong repair followed by human 1

error

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.1.4. Slide 4
12.2 MANAGING A QUALITY ASSURANCE PROGRAMME

 It must be understood that the required quality system

is essentially a total management system:
• for the total organization.
• for the total radiation therapy process.

 Total radiation therapy process includes:

• Clinical radiation oncology service
• Supportive care services (nursing, dietetic, social, etc.)
• All issues related to radiation treatment
• Radiation therapists.
• Physical quality assurance (QA) by physicists.
• Engineering maintenance.
• Management.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.2 Slide 1
12.2 MANAGING A QUALITY ASSURANCE PROGRAMME

 A number of organizations and publications have given

background discussion and recommendations on the structure
and management of a quality assurance program in
radiotherapy or radiotherapy physics:

• WHO in 1988.
• AAPM in 1994.
• ESTRO in 1995 and 1998.
• IPEM in 1999.
• Van Dyk and Purdy in 1999.
• McKenzie et al. in 2000.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.2 Slide 2
12.2 MANAGING A QUALITY ASSURANCE PROGRAMME
12.2.1 Multidisciplinary radiotherapy team

 One of the needs to implement a Quality System is that

radiotherapy is a multidisciplinary process.
 Responsibilities are shared between the different disciplines
and must be clearly defined.
 Each group has an important
part in the output of the entire Radiation
Oncology
process, and their overall roles, Medical
as well as their specific quality Physics

assurance roles, are inter- Dosimetrist

Radiotherapy s
dependent, requiring close Process
cooperation.
RTTs
Engineering
etc.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.2.2. Slide 1
12.2 MANAGING A QUALITY ASSURANCE PROGRAMME
12.2.1 Multidisciplinary radiotherapy team

Multidisciplinary radiotherapy team consists of:

• Radiation oncologists
• Medical physicists
• Radiotherapy technologists
Sometimes referred to as radiation therapist (RTT), therapy radiographer,
radiation therapy technologist, radiotherapy nurse.
• Dosimetrists
In many systems there is no separate group of dosimetrists; these functions
are carried out variously by physicists, medical physics technicians or
technologists, radiation dosimetry technicians or technologists, radiotherapy
technologists, or therapy radiographers.
• Engineering technologists
In some systems medical physics technicians or technologists, clinical
technologists, service technicians, electronic engineers or electronic
technicians.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.2.1. Slide 2
12.2 MANAGING A QUALITY ASSURANCE PROGRAMME
12.2.2 Quality system/comprehensive QA program

 It is now widely appreciated that the concept of a Quality

System in Radiotherapy is broader than a restricted
definition of technical maintenance and quality control of
equipment and treatment delivery.
 Instead, the concept should encompass a comprehensive
approach to all activities in the radiotherapy department:

• Starting from the moment a patient enters the department until

the moment he leaves it.
• And it should also continue into the follow-up period.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.2.2. Slide 1
12.2 MANAGING A QUALITY ASSURANCE PROGRAMME
12.2.2 Quality system/comprehensive QA program

equipment
policy & knowledge &
organization expertise

Input Process Output

Control Measure
QA process control
System
Patient enters the Patient leaves the
process seeking Control Measure department after
treatment treatment
QA control

Outcome can be considered to be of good quality when the handling of the quality
system well organizes the five aspects shown in the illustration above.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.2.2. Slide 2
12.2 MANAGING A QUALITY ASSURANCE PROGRAMME
12.2.2 Quality system/comprehensive QA program

 Comprehensive quality system in radio-

therapy is a management system that:
Policy &
organization

• Should be supported by the department

management in order to work effectively.
• Must have a clear definition of its scope and of all the quality standards to
be met.
• Must be regularly reviewed as to operation and improvement. To this end
a quality assurance committee is required, which should represent all the
different disciplines within radiation oncology.
• Must be consistent in standards for different areas of the program.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.2.2. Slide 3
12.2 MANAGING A QUALITY ASSURANCE PROGRAMME
12.2.2 Quality system/comprehensive QA program

 Comprehensive quality system in

radiotherapy is a
management system that:

Equipment

Requires availability of adequate

test equipment.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.2.2. Slide 4
12.2 MANAGING A QUALITY ASSURANCE PROGRAMME
12.2.2 Quality system/comprehensive QA program

 Comprehensive quality system

in radiotherapy is a management
system that:
Knowledge &
expertise

• Requires that each staff member

must have qualifications (education,
training and experience) appropriate
to his or her role and responsibility.

• Requires that each staff member must have access to appropriate

opportunities for continuing education and development.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.2.2. Slide 5
12.2 MANAGING A QUALITY ASSURANCE PROGRAMME
12.2.2 Quality system/comprehensive QA program

 Comprehensive quality system in radio-

therapy is a management system that:

Process control

• Requires the development of a formal written quality assurance

program that details the quality assurance policies and procedures,
quality control tests, frequencies, tolerances, action criteria, required
records and personnel.
• Must be consistent in standards for different areas of the program.
• Must incorporate compliance with all the requirements of national
legislation, accreditation, etc.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.2.2. Slide 6
12.2 MANAGING A QUALITY ASSURANCE PROGRAMME
12.2.2 Quality system/comprehensive QA program

 Formal written quality assurance program is also referred to as

the "Quality Manual".
 Quality manual has a double purpose:
• External
• Internal.

 Externally to collaborators in other departments, in

management and in other institutions, it helps to indicate that
the department is strongly concerned with quality.
 Internally, it provides the department with a framework for
further development of quality and for improvements of existing
or new procedures.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.2.2. Slide 7
12.2 MANAGING A QUALITY ASSURANCE PROGRAMME
12.2.2 Quality system/comprehensive QA program

Practical guidelines for writing your own quality manual:

ESTRO Booklet  4:

PRACTICAL GUIDELINES FOR THE

IMPLEMENTATION OF A QUALITY
SYSTEM IN RADIOTHERAPY
A project of the ESTRO Quality Assurance Committee sponsored by
'Europe against Cancer'
Writing party: J W H Leer, A L McKenzie, P Scalliet, D I Thwaites

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.2.2. Slide 8
12.2 MANAGING A QUALITY ASSURANCE PROGRAMME
12.2.2 Quality system/comprehensive QA program

 Comprehensive quality system in radio-

therapy is a management system that:
QA control

• Requires control of the system itself, including:

• Responsibility for quality assurance and the quality system: quality
management representatives.
• Document control.
• Procedures to ensure that the quality system is followed.
• Ensuring that the status of all parts of the service is clear.
• Reporting all non-conforming parts and taking corrective action.
• Recording all quality activities.
• Establishing regular review and audits of both the implementation of the
quality system (quality system audit) and its effectiveness (quality audit).

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.2.2. Slide 9
12.2 MANAGING A QUALITY ASSURANCE PROGRAMME
12.2.2 Quality system/comprehensive QA program

 When starting a quality assurance (QA) program, the setup

of a QA team or QA committee is the most important first
step.
 QA team should reflect composition of the multidisciplinary
radiotherapy team.
 Quality assurance committee must be appointed by the
department management/head of department with the
authority to manage quality assurance.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.2.2. Slide 10
12.2 MANAGING A QUALITY ASSURANCE PROGRAMME
12.2.2 Quality system/comprehensive QA program

Example for the organizational structure of a radiotherapy

department and the integration of a QA team

Chief Executive Officer

Systematic Treatment Program Radiation Treatment Program ............ Management Services

QA Team (Committee)

Physics Radiation Oncology Radiation Therapy

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.2.2. Slide 11
12.2 MANAGING A QUALITY ASSURANCE PROGRAMME
12.2.2 Quality system/comprehensive QA program

Membership and Responsibilities

of the QA team (QA Committee)

QA Team (Committee)
Membership: Responsibilities:
Radiation Oncologist(s) Patient safety
Medical Physicist(s) Personnel safety
Radiation Therapist(s) Dosimetry instrumentation
.......... Teletherapy equipment
Chair: Treatment planning
Physicist or Treatment delivery
Radiation Oncologist Treatment outcome
Quality audit

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.2.2. Slide 12
12.3 QUALITY ASSURANCE PROGRAMME FOR EQUIPMENT

 The following slides are focusing on the equipment

related QA program.
 They concentrate on the general items and systems of a
QA program.
 Therefore, they should be "digested" in conjunction with
Chapter 10 and other appropriate material concerned with
each of the different categories of equipment.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.3. Slide 1
12.3 QUALITY ASSURANCE PROGRAMME FOR EQUIPMENT

 Appropriate material: Many documents are available:

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.3. Slide 2
12.3 QUALITY ASSURANCE PROGRAMME FOR EQUIPMENT

 Examples of appropriate material:

• AMERICAN ASSOCIATION OF PHYSICISTS IN MEDICINE (AAPM),
“Comprehensive QA for radiation oncology: Report of AAPM Radiation Therapy
Committee Task Group 40”, Med. Phys. 21, 581-618 (1994)
• INTERNATIONAL ELECTROTECHNICAL COMMISSION (IEC), “Medical electrical
equipment - Medical electron accelerators-Functional performance
characteristics”, IEC 976, IEC, Geneva, Switzerland (1989)
• INSTITUTE OF PHYSICS AND ENGINEERING IN MEDICINE (IPEM), “Physics
aspects of quality control in radiotherapy”, IPEM Report 81, edited by Mayles,
W.P.M., Lake, R., McKenzie, A., Macaulay, E.M., Morgan, H.M., Jordan, T.J. and
Powley, S.K, IPEM, York, United Kingdom (1999)
• VAN DYK, J., (editor), “The Modern Technology for Radiation Oncology: A
Compendium for Medical Physicists and Radiation Oncologists”, Medical Physics
Publishing, Madison, Wisconsin, U.S.A. (1999)
• WILLIAMS, J.R., and THWAITES, D.I., (editors), “Radiotherapy Physics in
Practice”, Oxford University Press, Oxford, United Kingdom (2000)

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.3. Slide 3
12.3 QUALITY ASSURANCE PROGRAMME FOR EQUIPMENT
12.3.1 The structure of an equipment QA program

General structure of a quality assurance program for equipment

(1) Initial specification, (2) Quality control tests

acceptance testing and before the equipment is put into
commissioning clinical use, quality control tests
for clinical use, including should be established and a
calibration where applicable formal QC program initiated

(3) Additional quality control (4) Planned preventive

tests maintenance program
after any significant repair, in accordance with the
intervention or adjustment or
manufacturer’s
when there is any indication
recommendations
of a change in performance

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.3.1. Slide 1
12.3 QUALITY ASSURANCE PROGRAMME FOR EQUIPMENT
12.3.1 The structure of an equipment QA program

First step: Equipment specification and clinical needs assessment:

 In preparation for procurement of equipment, a detailed
specification document must be prepared.
 A multidisciplinary team from the department should be involved.
 This should set out the essential aspects of the equipment
operation, facilities, performance, service, etc., as required by the
customer.
 Questions of which the answer is helpful to assess the clinical
needs are given in the next slide.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.3.1. Slide 2
12.3 QUALITY ASSURANCE PROGRAMME FOR EQUIPMENT
12.3.1 The structure of an equipment QA program

 Questions of which the answer is helpful to assess the

clinical needs:

• Which patients will be affected by this technology?

• What is the likely number of patients per year?
• Number of procedures or fractions per year?
• Will the new procedure provide cost savings over old techniques?
• Would it be better to refer patients to a specialist institution?
• Is the infrastructure available to handle the technology?
• Will the technology enhance the academic program?
• What is the organizational risk in implementation of this technology?
• What is the cost impact?
• What maintenance is required?

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.3.1. Slide 3
12.3 QUALITY ASSURANCE PROGRAMME FOR EQUIPMENT
12.3.1 The structure of an equipment QA program

Equipment specification and clinical needs assessment

 Once this information is compiled, the purchaser is in a good
position to clearly develop his own specifications.
 Specification can also be based on:
• Manufacturers specification (brochures)
• Published information
• Discussions with other users of similar products

 Specification data must be expressed in measurable units.

 Decisions on procurement should again be made by a multi-
disciplinary team.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.3.1. Slide 4
12.3 QUALITY ASSURANCE PROGRAMME FOR EQUIPMENT
12.3.1 The structure of an equipment QA program

Acceptance
 Acceptance of equipment is the process in which the supplier
demonstrates the baseline performance of the equipment to
the satisfaction of the customer.
 After the new equipment is installed, the equipment must be
tested in order to ensure, that it meets the specifications and
that the environment is free of radiation and electrical hazards
to staff and patients.
 Essential performance required and expected from the machine
should be agreed upon before acceptance of the equipment
begins.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.3.1. Slide 5
12.3 QUALITY ASSURANCE PROGRAMME FOR EQUIPMENT
12.3.1 The structure of an equipment QA program

Acceptance (cont.)
 It is a matter of the professional judgment of the responsible
medical physicist to decide whether any aspect of the agreed
acceptance criteria is to be waived.
 This waiver should be recorded along with an agreement from
the supplier, for example to correct the equipment should
performance deteriorate further.
 Equipment can only be formally accepted to be transferred
from the supplier to the customer when the responsible medical
physicist either is satisfied that the performance of the machine
fulfills all specifications as listed in the contract document or
formally accepts any waivers.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.3.1. Slide 6
12.3 QUALITY ASSURANCE PROGRAMME FOR EQUIPMENT
12.3.1 The structure of an equipment QA program

Commissioning
 Commissioning is the process of preparing the equipment for
clinical service.
 Expressed in a more quantitative way:
A full characterization of its performance over the whole
range of possible operation must be undertaken.
 In this way the baseline standards of performance are
established to which all future performance and quality control
tests will be referred.
 Commissioning includes preparation of procedures, protocols,
instructions, data, etc., on the clinical use of the equipment.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.3.1. Slide 7
12.3 QUALITY ASSURANCE PROGRAMME FOR EQUIPMENT
12.3.1 The structure of an equipment QA program

Quality control
 It is essential that the performance of treatment equipment
remain consistent within accepted tolerances throughout its
clinical life
 Ongoing quality control program of regular performance checks
must begin immediately after commissioning to test this.
 If these quality control measurements identify departures from
expected performance, corrective actions are required.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.3.1. Slide 8
12.3 QUALITY ASSURANCE PROGRAMME FOR EQUIPMENT
12.3.1 The structure of an equipment QA program

Quality control (cont.)

 Equipment quality control program should specify the following:
• Parameters to be tested and the tests to be performed.
• Specific equipment to be used for that.
• Geometry of the tests.
• Frequency of the tests.
• Staff group or individual performing the tests, as well as the
individual supervising and responsible for the standards of the
tests and for actions that may be necessary if problems are
identified.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.3.1. Slide 9
12.3 QUALITY ASSURANCE PROGRAMME FOR EQUIPMENT
12.3.1 The structure of an equipment QA program

Quality control (cont.)

 Equipment quality control program should specify the following:
• Expected results.
• Tolerance and action levels.
• Actions required when the tolerance levels are exceeded.

 Actions required must be based on a systematic analysis of the

uncertainties involved and on well defined tolerance and action
levels.
 This procedure is explained in more detail in the following
slides.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.3.1. Slide 10
12.3 QUALITY ASSURANCE PROGRAMME FOR EQUIPMENT
12.3.1 The structure of an equipment QA program

If corrective actions are required: Role of uncertainty

 When reporting the result of a measurement, it is obligatory
that some quantitative indication of the
quality of the result be given. Otherwise the receiver of this
information cannot really asses its reliability.
 Concept of uncertainty has been introduced for that.
 In 1993, ISO has published a Guide to the expression of
uncertainty in measurement, in order to ensure that the method
for evaluating and expressing uncertainty is uniform all over the
world.
 For more details see Chapter 3.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.3.2. Slide 1
12.3 QUALITY ASSURANCE PROGRAMME FOR EQUIPMENT
12.3.1 The structure of an equipment QA program

If corrective actions are required: Role of tolerance level

 Within the tolerance level, the performance of an equipment
gives acceptable accuracy in any situation.
 Tolerances values should be set with the aim of achieving the
overall uncertainties desired.
 However, if the measurement uncertainty is greater than the
tolerance level set, then random variations in the measurement
will lead to unnecessary intervention.
 Therefore, it is practical to set a tolerance level at the
measurement uncertainty at the 95 % confidence level.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.3.2. Slide 2
12.3 QUALITY ASSURANCE PROGRAMME FOR EQUIPMENT
12.3.2 Uncertainties, tolerances and action levels

If corrective actions are required: Role of action level

 Performance outside the action level is unacceptable and
demands action to remedy the situation.
 It is useful to set action levels higher than tolerance levels thus
providing flexibility in monitoring and adjustment.
 Action levels are often set at approximately twice the tolerance
level.
 However, some critical parameters may require tolerance and
action levels to be set much closer to each other or even at the
same value.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.3.2. Slide 3
12.3 QUALITY ASSURANCE PROGRAMME FOR EQUIPMENT
12.3.2 Uncertainties, tolerances and action levels

Illustration of a possible relation between

uncertainty, tolerance level and action level
Tolerance level
equivalent to
95% confidence interval of uncertainty

standard
uncertainty

4 sd

2 sd

1 sd
Action level = Action level =
2 x tolerance level 2 x tolerance level

Mean
value

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.3.2. Slide 4
12.3 QUALITY ASSURANCE PROGRAMME FOR EQUIPMENT
12.3.2 Uncertainties, tolerances and action levels

System of actions:
 If a measurement result is within the tolerance level, no action
is required.
 If the measurement result exceeds the action level, immediate
action is necessary and the equipment must not be clinically
used until the problem is corrected.
 If the measurement falls between tolerance and action levels,
this may be considered as currently acceptable. Inspection and
repair can be performed later, for example after patient
irradiations. If repeated measurements remain consistently
between tolerance and action levels, adjustment is required.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.3.2. Slide 5
12.3 QUALITY ASSURANCE PROGRAMME FOR EQUIPMENT
12.3.3 QA program for cobalt-60 teletherapy machines

 A sample quality assurance program (quality control tests)

for a 60Co teletherapy machine with recommended test
procedures, test frequencies, and action levels is given in
the following tables.
 Tables are structured on a daily, weekly, monthly,
and annual basis.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.3.3. Slide 1
12.3 QUALITY ASSURANCE PROGRAMME FOR EQUIPMENT
12.3.3 QA program for cobalt-60 teletherapy machines

Daily tests
Procedure or item to be tested Action level
Door interlock Functional

Radiation room monitor Functional

Audiovisual monitor Functional

Lasers 2 mm

Distance indicator 2 mm

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.3.3. Slide 2
12.3 QUALITY ASSURANCE PROGRAMME FOR EQUIPMENT
12.3.3 QA program for cobalt-60 teletherapy machines

Daily tests
Procedure or item to be tested Action level
Door interlock Functional

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.3.3. Slide 3
12.3 QUALITY ASSURANCE PROGRAMME FOR EQUIPMENT
12.3.3 QA program for cobalt-60 teletherapy machines

Daily tests
Procedure or item to be tested Action level
Lasers 2 mm

Distance indicator 2 mm

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.3.3. Slide 4
12.3 QUALITY ASSURANCE PROGRAMME FOR EQUIPMENT
12.3.3 QA program for cobalt-60 teletherapy machines

Weekly tests

Procedure or item to be tested Action level

Check of source position 3 mm

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.3.3. Slide 5
12.3 QUALITY ASSURANCE PROGRAMME FOR EQUIPMENT
12.3.3 QA program for cobalt-60 teletherapy machines

Monthly tests
Procedure or item to be tested Action level
Output constancy 2%

Light/radiation field coincidence 3 mm

Field size indicator 2 mm

Gantry and collimator angle indicator 1º

Cross-hair centering 1 mm

Latching of wedges and trays Functional

Emergency off Functional

Wedge interlocks Functional

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.3.3. Slide 6
12.3 QUALITY ASSURANCE PROGRAMME FOR EQUIPMENT
12.3.3 QA program for cobalt-60 teletherapy machines

Annual tests
Procedure or item to be tested Action level
Output constancy 2%

Field size dependence of output constancy 2%

Central axis dosimetry parameter constancy 2%

Transmission factor constancy for all standard 2%
accessories
Wedge transmission factor constancy 2%

Timer linearity and error 1%

Output constancy versus gantry angle 2%

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.3.3. Slide 7
12.3 QUALITY ASSURANCE PROGRAMME FOR EQUIPMENT
12.3.3 QA program for cobalt-60 teletherapy machines

Annual tests (continued)

Procedure or item to be tested Action level
Beam uniformity with gantry angle 3%
Safety interlocks: Follow procedures of Functional
manufacturer
Collimator rotation isocenter 2 mm diameter

Gantry rotation isocenter 2 mm diameter

Table rotation isocenter 2 mm diameter

Coincidence of collimator, gantry and table 2 mm diameter
axis with the isocenter

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.3.3. Slide 8
12.3 QUALITY ASSURANCE PROGRAMME FOR EQUIPMENT
12.3.3 QA program for cobalt-60 teletherapy machines

Annual tests (cont.)

Procedure or item to be tested Action level
Coincidence of radiation and mechanical 2 mm diameter
isocentre
Table top sag 2 mm

Vertical travel of table 2 mm

Field light intensity Functional

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.3.3. Slide 9
12.3 QUALITY ASSURANCE PROGRAMME FOR EQUIPMENT
12.3.4 QA program for linear accelerators

 Typical quality assurance procedures (quality control

tests) for a dual mode linac with frequencies and action
levels are given in the following tables.
 They are again structured according to daily, weekly,
monthly, and annual tests.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.3.4. Slide 1
12.3 QUALITY ASSURANCE PROGRAMME FOR EQUIPMENT
12.3.4 QA program for linear accelerators

Daily tests
Procedure or item to be tested Action level
Lasers 2 mm

Distance indicator 2 mm

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.3.4. Slide 2
12.3 QUALITY ASSURANCE PROGRAMME FOR EQUIPMENT
12.3.4 QA program for linear accelerators

Daily tests
Procedure or item to be tested Action level
Audiovisual monitor Functional

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.3.4. Slide 3
12.3 QUALITY ASSURANCE PROGRAMME FOR EQUIPMENT
12.3.4 QA program for linear accelerators

Daily tests
Procedure or item to be tested Action level
X ray output constancy 3%

Electron output constancy 3%

Daily output checks and verification

of flatness and symmetry can be
done using different multi-detector
devices.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.3.4. Slide 4
12.3 QUALITY ASSURANCE PROGRAMME FOR EQUIPMENT
12.3.4 QA program for linear accelerators

Daily tests
Action
Procedure or item to be tested
level
X ray output constancy 3%
Electron output constancy 3%

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.3.4. Slide 5
12.3 QUALITY ASSURANCE PROGRAMME FOR EQUIPMENT
12.3.4 QA program for linear accelerators

Monthly tests
Procedure or item to be tested Action level
X ray output constancy 2%

Electron output constancy 2%

Backup monitor constancy 2%

X ray central axis dosimetry parameter 2%
constancy (PDD, TAR, TPR)
Electron central axis dosimetry 2 mm at thera-
parameter constancy (PDD) peutic depth
X ray beam flatness constancy 2%

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.3.4. Slide 6
12.3 QUALITY ASSURANCE PROGRAMME FOR EQUIPMENT
12.3.4 QA program for linear accelerators

Monthly tests (continued)

Procedure or item to be tested Action level
Electron beam flatness constancy 3%

X ray and electron symmetry 3%

Emergency off switches Functional

Wedge and electron cone interlocks Functional

Light/radiation field coincidence 2 mm or 1 % on a side

Gantry/collimator angle indicators 1º

2 mm or 2 % change in
Wedge position
transmission

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.3.4. Slide 7
12.3 QUALITY ASSURANCE PROGRAMME FOR EQUIPMENT
12.3.4 QA program for linear accelerators

Monthly tests (cont.)

Procedure or item to be tested Action level
Tray position and applicator position 2 mm

Field size indicators 2 mm

Cross-hair centering 2 mm diameter

Treatment table position indicators 2 mm / 1º

Latching of wedges and blocking tray Functional

Jaw symmetry 2 mm

Field light intensity Functional

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.3.4. Slide 8
12.3 QUALITY ASSURANCE PROGRAMME FOR EQUIPMENT
12.3.4 QA program for linear accelerators

Annual tests
Procedure or item to be tested Action level
X ray/electron output calibration constancy 2%
Field size dependence of X ray output 2%
constancy
Output factor constancy for electron 2%
applicators
Central axis parameter constancy 2%
(PDD, TAR, TPR)
Off-axis factor constancy 2%
Transmission factor constancy for all 2%
treatment accessories

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.3.4. Slide 9
12.3 QUALITY ASSURANCE PROGRAMME FOR EQUIPMENT
12.3.4 QA program for linear accelerators

Annual tests (cont.)

Procedure or item to be tested Action level
Wedge transmission factor constancy 2%

Monitor chamber linearity 1%

X ray output constancy with the gantry angle 2%

Electron output constancy with the gantry 2%
angle
Off-axis factor constancy with the gantry angle 2%

Arc mode Manufacturer‘s

specifications

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.3.4. Slide 10
12.3 QUALITY ASSURANCE PROGRAMME FOR EQUIPMENT
12.3.4 QA program for linear accelerators

Annual tests (cont.)

Procedure or item to be tested Action level
Safety interlocks functional

Collimator rotation isocentre 2 mm diameter

Gantry rotation isocentre 2 mm diameter

Table rotation isocentre 2 mm diameter

Coincidence of collimator, gantry and table 2 mm diameter
axes with the isocentre
Coincidence of the radiation and mechanical 2 mm diameter
isocentre

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.3.4. Slide 11
12.3 QUALITY ASSURANCE PROGRAMME FOR EQUIPMENT
12.3.4 QA program for linear accelerators

Annual tests (cont.)

Procedure or item to be tested Action level

Table top sag 2 mm

Vertical travel of the table 2 mm

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.3.4. Slide 12
12.3 QUALITY ASSURANCE PROGRAMME FOR EQUIPMENT
12.3.5 QA program for treatment simulators

 Treatment simulators replicate the movements of isocentric

Co and linac treatment machines and are fitted with identical
60

beam and distance indicators. Hence, all measurements that

concern these aspects also apply to the simulator.

• During ‘verification session’

the treatment is set-up on
the simulator exactly like it
would be on the treatment
unit.
• A verification film is taken in
‘treatment’ geometry

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.3.5. Slide 1
12.3 QUALITY ASSURANCE PROGRAMME FOR EQUIPMENT
12.3.5 QA program for treatment simulators

 If mechanical/geometric parameters are out of tolerance on the

simulator, this will affect treatments of all patients.
 Performance of the imaging components on the simulator is of
equal importance to its satisfactory operation.
 Therefore, critical measurements of the imaging system are
also required.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.3.5. Slide 2
12.3 QUALITY ASSURANCE PROGRAMME FOR EQUIPMENT
12.3.5 QA program for treatment simulators

 A sample quality assurance program (quality control tests)

for treatment simulators with recommended test
procedures, test frequencies and action levels is given in
the following tables.
 They are again structured according daily, monthly, and
annually tests.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.3.5. Slide 3
12.3 QUALITY ASSURANCE PROGRAMME FOR EQUIPMENT
12.3.5 QA program for treatment simulators

Daily Tests
Procedure or item to be tested Action level
Safety switches Functional

Door interlock Functional

Lasers 2 mm

Distance indicator 2 mm

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.3.5. Slide 4
12.3 QUALITY ASSURANCE PROGRAMME FOR EQUIPMENT
12.3.5 QA program for treatment simulators

Monthly tests
Procedure or item to be tested Action level
Field size indicator 2 mm

Gantry/collimator angle indicators 1°

Cross-hair centering 2 mm diameter

Focal spot-axis indicator 2 mm

Fluoroscopic image quality Baseline

Emergency/collision avoidance Functional

Light/radiation field coincidence 2 mm or 1 %

Film processor sensitometry Baseline

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.3.5. Slide 5
12.3 QUALITY ASSURANCE PROGRAMME FOR EQUIPMENT
12.3.5 QA program for treatment simulators

Annual tests
Procedure or item to be tested Action level
Collimator rotation isocenter 2 mm diameter

Gantry rotation isocenter 2 mm diameter

Couch rotation isocenter 2 mm diameter

Coincidence of collimator, gantry, couch axes
2 mm diameter
with isocenter
Table top sag 2 mm

Vertical travel of couch 2 mm

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.3.5. Slide 6
12.3 QUALITY ASSURANCE PROGRAMME FOR EQUIPMENT
12.3.5 QA program for treatment simulators

Annual tests (cont.)

Procedure or item to be tested Action level
Exposure rate Baseline

Table top exposure with fluoroscopy Baseline

kVp and mAs calibration Baseline

High and low contrast resolution Baseline

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.3.5. Slide 7
12.3 QUALITY ASSURANCE PROGRAMME FOR EQUIPMENT
12.3.6 QA program for CT scanners and CT-simulation

 For dose prediction as part of the treatment planning process

there is an increasing reliance upon CT image data with the
patient in a treatment position.
Gammex RMI CT test tool

 CT data is used for:

• Indication and/or data acquisition
of the patient’s anatomy.
• To provide tissue density information
which is essential for accurate dose
prediction.

 Therefore, it is essential that the geometry and the CT densities

are accurate. CT test tools are available for this purpose.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.3.6. Slide 1
12.3 QUALITY ASSURANCE PROGRAMME FOR EQUIPMENT
12.3.6 QA program for CT scanners and CT-simulation

 A sample quality assurance program (quality control tests) for

CT scanners and CT-simulation with recommended test
procedures, test frequencies and action levels is given in the
following tables.
 They are also structured on the basis of daily, monthly, and
annual tests.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.3.6. Slide 2
12.3 QUALITY ASSURANCE PROGRAMME FOR EQUIPMENT
12.3.6 QA program for CT scanners and CT-simulation

Daily tests
Procedure or item to be tested Action level
Safety switches Functional

Door interlock Functional

Lasers 2 mm

Distance indicator 2 mm

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.3.6. Slide 3
12.3 QUALITY ASSURANCE PROGRAMME FOR EQUIPMENT
12.3.6 QA program for CT scanners and CT-simulation

Monthly tests
Procedure or item to be tested Action level
Field size indicator 2 mm

Gantry/collimator angle indicators 1°

Cross-hair centering 2 mm diameter

Focal spot-axis indicator 2 mm

Fluoroscopic image quality Baseline

Emergency/collision avoidance Functional

Light/radiation field coincidence 2 mm or 1 %

Film processor sensitometry Baseline

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.3.6. Slide 4
12.3 QUALITY ASSURANCE PROGRAMME FOR EQUIPMENT
12.3.6 QA program for CT scanners and CT-simulation

Annual tests
Procedure or item to be tested Action level
Collimator rotation isocentre 2 mm diameter

Gantry rotation isocentre 2 mm diameter

Couch rotation isocentre 2 mm diameter

Coincidence of collimator, gantry, couch axes
2 mm diameter
with isocentre
Table top sag 2 mm

Vertical travel of couch 2 mm

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.3.6. Slide 5
12.3 QUALITY ASSURANCE PROGRAMME FOR EQUIPMENT
12.3.7 QA program for treatment planning systems

 In the 1970s and 1980s treatment planning computers became

readily available to individual radiation therapy centers.
 As computer technology
evolved and became more
compact so did Treatment
Planning Systems (TPS),
while at the same time dose
calculation algorithms and
image display capabilities
became more sophisticated.
 Treatment planning computers have become readily available to
virtually all radiation treatment centers.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.3.7. Slide 1
12.3 QUALITY ASSURANCE PROGRAMME FOR EQUIPMENT
12.3.7 QA program for treatment planning systems

Steps of the treatment planning process, the professionals involved in each

step and the QA activities associated with these steps (IAEA TRS 430)

TPS related activity

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.3.7. Slide 2
12.3 QUALITY ASSURANCE PROGRAMME FOR EQUIPMENT
12.3.7 QA program for treatment planning systems

 The middle column of the last slide summarizes the steps in the
process flow of the radiation treatment planning process of
cancer patients.
 Computerized treatment planning system, TPS, is an essential
tool in this process.
 As an integral part of the radiotherapy process,
the TPS provides a computer based:
• Simulation of the beam delivery set-up
• Optimization and prediction of the dose distributions that can be
achieved both in the target volume and also in normal tissue.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.3.7. Slide 3
12.3 QUALITY ASSURANCE PROGRAMME FOR EQUIPMENT
12.3.7 QA program for treatment planning systems

 Treatment planning quality management is a subcomponent of

the total quality management process.
 Organizationally, it involves physicists, dosimetrists, RTTs, and
radiation oncologists, each at their level of participation in the
radiation treatment process.
 Treatment planning quality management involves the
development of a clear QA plan of the TPS and its use.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.3.7. Slide 4
12.3 QUALITY ASSURANCE PROGRAMME FOR EQUIPMENT
12.3.7 QA program for treatment planning systems

 Acceptance, commissioning and QC recommendations

for TPS are given, for example, in

• AAPM Reports
(TG-40 and TG-43),
• IPEM Reports 68
(1996) and 81 (1999),
• Van Dyk et al. (1993)
• Most recently:
IAEA TRS 430 (2004)
 The following slides are mostly
following TRS 430.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.3.7. Slide 5
12.3 QUALITY ASSURANCE PROGRAMME FOR EQUIPMENT
12.3.7 QA program for treatment planning systems

Purchase
 Purchase of a TPS is a major step for most radiation oncology
departments.
 Particular attention must therefore be given to the process by
which the purchasing decision is made.
 Specific needs of the department must be taken into
consideration, as well as budget limits, during a careful search
for the most cost effective TPS.
 The following slide contains some issues on the clinical need
assessment to consider in the purchase and clinical
implementation process.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.3.7. Slide 6
12.3 QUALITY ASSURANCE PROGRAMME FOR EQUIPMENT
12.3.7 QA program for treatment planning systems

Clinical need assessment: Issues Questions and/or comments

Status of the existing TPS Can it be upgraded? Hardware? Software?
Projected number of cases to be planned over the next Include types and complexity, for example number of 2-D
2–5 years plans without image data, number of 3-D plans with image
data, complex plans, etc
Special techniques Stereotactic radiosurgery? Mantle? Total body irradiation
(TBI)? Electron arcs? HDR brachytherapy? Other?
Number of workstations required Depends on caseload, average time per case, research
and development time, number of special procedures,
number of treatment planners and whether the system is
also used for MU/time calculations
Level of sophistication of treatment planning 3-D CRT? Participation in clinical trials? Networking
capabilities?
Imaging availability CT? MR? SPECT? PET? Ultrasound?
CT simulation availability Network considerations
Multileaf collimation available now or in the future Transfer of MLC data to therapy machines?
3-D CRT capabilities on the treatment machines Can the TPS handle the therapy machine capabilities?
IMRT capabilities Available now or in the near future?
Treatment trends over the next3–5 years Will there be more need for IMRT or electrons?
Case load and throughput Will treatment planning become the bottleneck?

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.3.7. Slide 7
12.3 QUALITY ASSURANCE PROGRAMME FOR EQUIPMENT
12.3.7 QA program for treatment planning systems

Acceptance
 Acceptance testing is the process to verify that the TPS
behaves according to the specifications (user’s tender
document, manufacturer' specifications).
 Acceptance testing must be carried out before the system is
used clinically and must test both the basic hardware and the
system software functionality.
 Since during the normally short acceptance period, the user
can test only basic functionality, he or she may choose a
conditional acceptance and indicate in the acceptance
document that the final acceptance testing will be completed as
part of the commissioning process.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.3.7. Slide 8
12.3 QUALITY ASSURANCE PROGRAMME FOR EQUIPMENT
12.3.7 QA program for treatment planning systems

Acceptance

RTPs
Acceptance
VENDOR tests USER

Acceptance testing
results

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.3.7. Slide 9
12.3 QUALITY ASSURANCE PROGRAMME FOR EQUIPMENT
12.3.7 QA program for treatment planning systems

Commissioning

RTPs
USER Commissioning Commissioning
procedures results

Periodic QA
program

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.3.7. Slide 10
12.3 QUALITY ASSURANCE PROGRAMME FOR EQUIPMENT
12.3.7 QA program for treatment planning systems

Acceptance and Commissioning

 The following slides summarizes the various components of the
acceptance and commissioning testing of a TPS.
 The intent of this information is not to provide a complete list of
items that should be verified but rather is to suggest the types
of issue that should be considered.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.3.7. Slide 11
12.3 QUALITY ASSURANCE PROGRAMME FOR EQUIPMENT
12.3.7 QA program for treatment planning systems

Main
Issues
component
Hardware  CPUs, memory and disk operation.
 Input devices: Digitizer tablet, film digitizer, imaging data (CT,
MRI, ultrasound, etc.), simulator control systems or virtual
simulation workstation, keyboard and mouse entry.
 Output: Hard copy output (plotter and/or printer), graphical
display units that produce DRRs and treatment aids, unit for
archiving (magnetic media, optical disk, etc.).

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.3.7. Slide 12
12.3 QUALITY ASSURANCE PROGRAMME FOR EQUIPMENT
12.3.7 QA program for treatment planning systems

Main
component Issues

Network  Network traffic and the transfer of CT, MRI or ultrasound image
integration data to the TPS.
and data  Positioning and dosimetric parameters communicated to the
transfer treatment machine or to its record and verify system.
 Transfer of MLC parameter to the leaf position.
 Transfer of DRR information.
 Data transfer from the TPS to auxiliary devices (i.e., computer
controlled block cutters and compensator machining devices).
 Data transfer between the TPS and the simulator.
 Data transfer to the radiation oncology management system.
 Data transfer of measured data from a 3-D water phantom
system.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.3.7. Slide 13
12.3 QUALITY ASSURANCE PROGRAMME FOR EQUIPMENT
12.3.7 QA program for treatment planning systems

Main
component Issues

Software  CT input.
 Anatomical description.
 3-D objects and display.
 Beam description.
 Photon beam dose calculations:
for various open fields, different SSDs, blocked fields, MLC
shaped fields, inhomogeneity test cases, multi-beam plans,
asymmetric jaw fields, wedged fields and others.
 Electron beam dose calculations:
for open fields, different SSDs, shaped fields.
 Dose display and DVHs.
 Hard copy output.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.3.7. Slide 14
12.3 QUALITY ASSURANCE PROGRAMME FOR EQUIPMENT
12.3.7 QA program for treatment planning systems

Periodic quality control

 QA does not end once the TPS has been commissioned.
 It is essential that an ongoing QA program be maintained, i.e. a
periodic quality control must be established.
 Program must be practical, and not so elaborate that it
imposes an unrealistic commitment on resources and time.
 Two examples of a routine regular QC program (quality control
tests) for a TPS are given in the next slides.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.3.7. Slide 15
12.3 QUALITY ASSURANCE PROGRAMME FOR EQUIPMENT
12.3.7 QA program for treatment planning systems

Frequency Procedure Tolerance level

Daily Input and output devices 1 mm

Monthly Checksum No change

Reference subset of data 2% or 2 mm
Reference prediction subset 2% or 2 mm
Processor tests pass
CT transfer 1 mm
Annual Monitor Unit calculations 2%
Reference QA test set 2 % or 2 mm

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.3.4. Slide 16
12.3 QUALITY ASSURANCE PROGRAMME FOR EQUIPMENT
12.3.7 QA program for treatment planning systems

Example of a periodic quality assurance program (TRS 430)

Patient After
Weekly Monthly Quarterly Annual
specific upgrade
CPU CPU
Digitizer Digitizer Digitizer
Hardware
Plotter Plotter
Backup Backup

CT transfer CT transfer
Anatomical
CT image CT image
information
Anatomy Anatomy

Beam Beam Beam

External MU check
beam
Plan details Plan details
software
Pl. transfer Pl. transfer Pl. transfer Pl. transfer

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.3.4. Slide 17
12.3 QUALITY ASSURANCE PROGRAMME FOR EQUIPMENT
12.3.8 QA program for test equipment

 Test equipment in radiotherapy concerns all the required

additional equipment such as:

• Measurement of radiation doses.

• Measurement of electrical machine signals.
• Mechanical measurement of machine devices.
 Some examples of test and measuring equipment which should
be considered for a quality control program are given in the
next slide.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.3.8. Slide 1
12.3 QUALITY ASSURANCE PROGRAMME FOR EQUIPMENT
12.3.8 QA program for test equipment

 Local standard and field ionization chambers and electrometer.

 Thermometer.
 Barometer.
 Linear rulers.
 Phantoms.
 Automated beam scanning systems.
 Other dosimetry systems: e.g., systems for relative dosimetry (e.g.,
TLD, diodes, diamonds, film, etc.), in-vivo dosimetry (e.g., TLD,
diodes, etc.) and for radiation protection measurements.
 Any other electrical equipment used for testing the running
parameters of treatment equipment.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.3.8. Slide 2
12.4 TREATMENT DELIVERY
12.4.1 Patient charts

 Radiation chart is accompanying the patient during the entire

process of radiotherapy.
 Basic components of a patient treatment chart:
• Patient name and ID.
• Patient photograph.
• Initial physical evaluation of the patient.
• Treatment planning data.
• treatment execution data.
• Clinical assessment during treatment.
• Treatment summary and follow up.
• QA checklist.
 Any errors made at the data entry of the patient chart are
likely to be carried through the whole treatment.
 QA of the patient chart is therefore essential.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.4.1. Slide 1
12.4 TREATMENT DELIVERY
12.4.1 Patient charts

 AAPM Radiation Therapy Committee Task Group 40

recommends that:
• Charts be reviewed:
- At least weekly.
- Before the third fraction following the start or a field modification.
- At the completion of treatment.

• Review be signed and dated by the reviewer.

• QA team oversee the implementation of a program which defines

- Items are to be reviewed.
- who is to review them.
- when they are to be reviewed.
- Definition of minor and major errors.
- Actions to be taken, and by whom, in the event of errors.

• Random sample of charts be audited at intervals prescribed by the QA

team.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.4.1. Slide 2
12.4 TREATMENT DELIVERY
12.4.1 Patient charts

 In particular, all planning data as well as all data entered as the

interface between the planning process and the treatment
delivery process should be independently checked.
 Examples for that are:
• Plan integrity.
• Monitor unit calculations.
• Irradiation parameters.
 Data transferred automatically, e.g., from the treatment
planning system, should also be verified to check that no data
corruption occurred.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.4.1. Slide 3
12.4 TREATMENT DELIVERY
12.4.1 Patient charts

 All errors that are traced during chart checking must be

thoroughly investigated and evaluated by the QA team

 Causes should be eradicated and may result in (written)

changes in the various procedures of the treatment process.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.4.1. Slide 4
12.4 TREATMENT DELIVERY
12.4.2 Portal imaging

 As an accuracy requirement in radiotherapy, it has been stated

that figures of 5 mm – 10 mm (95 % confidence level) are used
as the tolerance level for the geometric uncertainty.
 Geometric accuracy is limited by:
• Uncertainties in a particular patient set-up.
• Uncertainties in the beam set-up.
• Movement of the patient or the target volume during treatment.
 Portal imaging is frequently applied in order to check geometric
accuracy of the patient set-up with respect to the position of the
radiation beam.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.4.2. Slide 1
12.4 TREATMENT DELIVERY
12.4.2 Portal imaging

 Purpose of portal imaging is in particular:

• To verify field placement, characterized

by the isocentre or another reference
point, relative to anatomical structures
of the patient, during the actual
treatment.

• To verify that the beam aperture (blocks

or MLC) has been properly produced
and registered.

Portal film device

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.4.2. Slide 2
12.4 TREATMENT DELIVERY
12.4.2 Portal imaging

Example for portal imaging: Port film

Port film for a lateral

irregular MLC field
used in a treatment of
the maxillary sinus.

This method allows to

visualize both the
treatment field and
the surrounding
anatomy.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.4.2. Slide 3
12.4 TREATMENT DELIVERY
12.4.2 Portal imaging

 A disadvantage of the film technique is its off-line character,

which requires a certain amount of time before the result can
be applied clinically.
 For this reason, on-line electronic portal imaging devices
(EPIDs) have been developed.
 Three methods are clinically applied:
1. A metal plate–phosphor screen combination is used to convert the
photon beam intensity into a light image. The screen is then viewed by a
sensitive video camera.
2. A matrix of liquid filled ionization chambers is used.
3. A third method is based on amorphous silicon flat panel systems
(see next slide).

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.4.2. Slide 4
12.4 TREATMENT DELIVERY
12.4.2 Portal imaging

Amorphous silicon type of EPID installed on the gantry of a linac.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.4.2. Slide 5
12.4 TREATMENT DELIVERY
12.4.2 Portal imaging

Comparison between digitally reconstructed radiographs (DRR)

and EPID
DRR treatment fields DRR EPID fields EPID images

DRRs from treatment fields and large fields to verify the position of isocentre and
the corresponding EPID fields.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.4.2. Slide 6
12.4 TREATMENT DELIVERY
12.4.2 Portal imaging

 As part of the QA process, portal imaging may lead to various

strategies for improvement of positioning accuracy such as:

• Improvement of patient immobilization.

• Introduction of correction rules.

• Adjustment of margins in combination with dose escalation.

• Incorporation of set-up uncertainties in treatment planning.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.4.2. Slide 7
12.4 TREATMENT DELIVERY
12.4.2 Portal imaging

QA in portal imaging:
 Process control requires that local protocols must be
established to specify:

• Who has the responsibility for verification of portal images

(generally a clinician).

• What criteria are used as the basis to judge the acceptability

of information conveyed by portal images.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.4.2. Slide 8
12.4 TREATMENT DELIVERY
12.4.3 In-vivo dose measurements

 There are many steps in the chain of processes which

determine the dose delivery to a patient undergoing
radiotherapy and each of these steps may introduce an
uncertainty.
 It is therefore worthwhile, and maybe even necessary for
specific patient groups or for unusual treatment conditions to
use in-vivo dosimetry as an ultimate check of the actual
treatment dose.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.4.3. Slide 1
12.4 TREATMENT DELIVERY
12.4.3 In-vivo dose measurements

 In-vivo dose measurements can be divided into:

• Intracavitary dose measurements (frequently used).

• Entrance dose measurements (less frequently used).
• Exit dose measurements (still under investigation).

Diodes applied for

intracavitary in-vivo
dosimetry.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.4.3. Slide 2
12.4 TREATMENT DELIVERY
12.4.3 In-vivo dose measurements

 In-vivo dose measurements

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.4.3. Slide 3
12.4 TREATMENT DELIVERY
12.4.3 In-vivo dose measurements

 Examples of typical application:

• To check the MU calculation independently from the program used for
routine dose calculations.

• To trace any error related to the set-up of the patient, human errors in the
data transfer during the consecutive steps of the treatment preparation,
unstable accelerator performance and inaccuracies in dose calculation,
e.g., of the treatment planning system.

• To determine the intracavitary dose in readily accessible body cavities,

such as the oral cavity, oesophagus, vagina, bladder, and rectum.

• To assess the dose to organs at risk (e.g., eye lens, gonads and lungs
during TBI) or situations where the dose is difficult to predict (e.g., non-
standard SSD or using bolus).

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.4.3. Slide 4
12.4 TREATMENT DELIVERY
12.4.3 In-vivo dose measurements

Example for TLD in vivo dosimetry: Lens dose measurements

7 mm of wax bolus
to mim ick the position
of the lens under the lid
TLD detector TLD
detectors

lens of
lens of
eye eye

arangement in AP or PA
radiation fields arangement in lateral radiation fields

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.4.3. Slide 5
12.4 TREATMENT DELIVERY
12.4.4 Record-and-verify systems

 Computer-aided record-and-verify system aims to compare the

set-up parameters with the prescribed values.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.4.4. Slide 1
12.4 TREATMENT DELIVERY
12.4.4 Record-and-verify systems

 Patient identification data, machine parameters and dose

prescription data are entered into the computer beforehand.
 At the time of treatment, these parameters are identified at the
treatment machine and, if there is no difference, the treatment
can start.
 If discrepancies are present this is indicated and the parameters
concerned are highlighted.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.4.4. Slide 2
12.4 TREATMENT DELIVERY
12.4.4 Record-and-verify systems

 Discrepancies are indicated only if tolerance values are

exceeded.
 Tolerance values must be therefore established before.
 Tolerances for verification of machine parameters should be
provided by the manufacturer.
 Clinical tolerance tables must also be defined locally in the
department for each set of techniques to allow for patient/set-up
variations day-to-day.
 Record-and-verify systems must have the flexibility to be
overridden. This feature must be used with care and only when
reasons are clear and properly documented.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.4.4. Slide 3
12.4 TREATMENT DELIVERY
12.4.4 Record-and-verify systems

QA of Record-and-verify systems
 The treatment delivered, if relying on a record-and-verify system
setting or verifying the parameters, is only as good as the
information input to the system. Therefore, it is vital that the data
in the record-and-verify system is quality-controlled, using
independent (redundant) checking to verify the input and to
sanction its clinical use.
 Performance of the record-and-verify system should be included
in an appropriate QA program.
 Details of such QA tests will be specific to the system in
question.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.4.4. Slide 4
12.5 QUALITY AUDIT
12.5.1 Definition

Definition of quality audit

 Quality audit is a systematic and independent examination to
determine whether or not quality activities and results comply
with planned arrangements and whether or not the
arrangements are implemented effectively and are suitable to
achieve the stated objectives.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.5.1. Slide 1
12.5 QUALITY AUDIT
12.5.1 Definition: Parameters of quality audits

 Quality audits:

• Can be conducted for internal or external purposes.

• Can be applied at any level of a QA program.

• Are performed by personnel not directly responsible for the

areas being audited, however in cooperative discussion
with the responsible personnel.

• Must be against pre-determined standards, linked to those

that the QA program is trying to achieve.

• Evaluate the need for improvement or corrective action if

those standards are not met.
IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.5.1. Slide 2
 12.5 QUALITY AUDIT
12.5.1 Definition: Parameters of quality audits

 Quality audits:
• Should be regular and form part of a quality feedback loop to
improve quality.

• Can be mainly procedural, looking at QA procedures, protocols, QC

programs, QC and QA results and records, etc.

• Can be mainly practical, i.e., verify the effectiveness or performance

of a quality system.

• May be voluntary and co-operative, or may be regulatory (e.g., for

accreditation of the department or hospital, for QS certification, etc.).

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.5.1. Slide 3
12.5 QUALITY AUDIT
12.5.2 Practical quality audit modalities

 A good example for an external audit is the simple but very

effective dosimetry audit organized as postal audit with mailed
dosimeters (usually TLD).
 These are generally organized
by SSDL or agencies, such as
the IAEA, Radiological Physics
Center (RPC) in the U.S.,
ESTRO (EQUAL), national
societies, national quality
networks, etc.
Material used in IAEA/WHO TLD audits.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.5.2. Slide 1
12.5 QUALITY AUDIT
12.5.2 Practical quality audit modalities

TLD results within the 5 % limit.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.5.2. Slide 2
12.5 QUALITY AUDIT
12.5.3 What should be reviewed in a quality audit visit?

 Content of a quality audit visit must be pre-defined.

 It will depend on the purpose of the visit:
• Is it a routine regular visit within a national or regional quality
audit network?

• Is it regulatory or co-operative between peer professionals?

• Is it a visit following a possible misadministration?

• Is it a visit following an observed higher-than-expected deviation

in a mailed TLD audit program that the centre cannot explain?

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.5.3. Slide 3
12.5 QUALITY AUDIT
12.5.3 What should be reviewed in a quality audit visit?

 Example of content of a comprehensive quality audit visit:

Check infrastructure
• Equipment.
• Personnel.
• Patient load.
• Existence of policies and procedures.
• Quality assurance program in place.
• Quality improvement program in place.
• Radiation protection program in place.
• Data and records, etc.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.5.3. Slide 4
12.5 QUALITY AUDIT
12.5.3 What should be reviewed in a quality audit visit?

 Example of content of a comprehensive quality audit visit:

Check documentation
• Content of policies and procedures.
• QA program structure and management.
• Patient dosimetry procedures.
• Simulation procedures.
• Patient positioning, immobilization and treatment delivery procedures.
• Equipment acceptance and commissioning records.
• Dosimetry system records.
• Machine and treatment planning data.
• QC program content.
• Tolerances and frequencies, QC and QA records of results and actions.
• Preventive maintenance program records and actions.
• Patient data records.
• Follow-up and outcome analysis, etc.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.5.3. Slide 5
12.5 QUALITY AUDIT
12.5.3 What should be reviewed in a quality audit visit?

 Example of content of a comprehensive quality audit visit:

 Carry out check measurements of:
• Beam calibration.
• Depth dose.
• Field size dependence.
• Wedge transmissions (with field size), tray factors.
• Electron cone factors.
• Electron gap corrections.
• Mechanical characteristics.
• Patient dosimetry.
• Dosimetry equipment comparison.
• Temperature and pressure measurement comparison, etc.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.5.3. Slide 6
12.5 QUALITY AUDIT
12.5.3 What should be reviewed in a quality audit visit?

 Example of content of a comprehensive quality audit visit:

Carry out check of training programs
• Academic program.
• Clinical program.
• Research.
• Professional accreditation.
• Continuous Professional Education.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.5.3. Slide 7
12.5 QUALITY AUDIT
12.5.3 What should be reviewed in a quality audit visit?

 Example of content of a comprehensive quality audit visit:

Carry out check measurements on other equipment
• Simulator

• CT scanner, etc.

Assess treatment planning data and procedures.

Measure some planned distributions in phantoms.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.5.3. Slide 8
12.5 QUALITY AUDIT
12.5.3 What should be reviewed in a quality audit visit?

Example for a comprehensive international external audit:

QUATRO project by the IAEA
 Based on:
• Long history of providing assistance for dosimetry audits in radiotherapy
to its Member States.

• Development of a set of procedures for experts undertaking missions to

radiotherapy hospitals in Member States for the on-site review of the
dosimetry equipment, data and techniques, and measurements, and
training of local staff.

• Numerous requests from developing countries to perform also

comprehensive audits of radiotherapy programs.

 IAEA has developed the "Quality Assurance Team for

Radiation Oncology" (QUATRO) project.
IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.5.3. Slide 9
12.5 QUALITY AUDIT
12.5.3 What should be reviewed in a quality audit visit?

 In response to requests, the IAEA convened an expert group,

comprising of radiation oncologists and medical radiation
physicists, which have developed guidelines for IAEA audit
teams to initiate, perform and report on such audits.
 Guidelines have been field-tested by IAEA teams performing
audits in radiotherapy programs in hospitals in Africa, Asia,
Latin America and Europe.
 QUATRO procedures are endorsed by European Society for
Therapeutic Radiology and Oncology, European Federation of
Organizations for Medical Physics and International
Organisation for Medical Physics.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 12.5.3. Slide 10