Implementation and Satisfaction of RapidPlan Knowledge-based Planning Software in the

Clinical Setting

Lauren Brandl, BS; Marc Anderson, BS, RT(T): Renee Jackson, BS, RT(T)

Medical Dosimetry Program at University of Wisconsin, La Crosse, WI

Key Words: RapidPlan, Knowledge-based Treatment Planning, Varian, Automated Planning

Introduction

Creating a high-quality radiation therapy plan may be a challenging and time-consuming

process. There are many crucial steps that must occur when developing a successful treatment
plan, with perhaps one of the most important being the analysis of the anatomy and target. This,
along with the understanding of reasonable plan outcomes are skills that require years of
experience to master. In recent years, a few radiation oncology vendors have developed
technology capable of automatically creating radiation treatment plans using previously
developed plans as a template from which to “learn.” One program that has gained popularity
since its release in 2014 is RapidPlan, developed by Varian Medical Systems.

RapidPlan is a knowledge-based planning system that provides clinicians with models

based on clinical practices from leading institutions. The program was released with the goal to
provide consistent, efficient, and higher quality plans for individualized treatments with less
variability. RapidPlan operates by evaluating the data set of a new patient’s anatomy and
comparing the geometric proportions to those from the model it has already learned from. By
reviewing the dose distributions of past plans with similar anatomy, the software can predict a
reasonable dose volume histogram (DVH) for nearby critical structures. The predictions are then
used to develop an intensity modulated radiation therapy (IMRT) or volumetric modulated arc
therapy (VMAT) plan.1

The utilization of a knowledge-based planning system such as RapidPlan has proven to

be a promising method to improve the quality and efficiency of treatment planning.1,2 However,
there is a gap in the literature regarding the adoption, usage, and satisfaction levels of RapidPlan
users in radiation oncology departments. The purpose of this study was to determine if
RapidPlan is a desirable program for clinics to utilize and to identify key components that may
assist in a clinic's adoption of the program. By creating a survey, we were able to determine if
knowledge based treatment planning is beneficial to the clinical environment.

Materials and Methods

Study Population

The respondent population consisted of American Association of Medical Dosimetrists

(AAMD) 2019 National Conference attendees, specifically those participating in the “Eclipse
Advanced Users” treatment planning workshops and the “Varian Velocity” workshop. The intent
was to distribute the surveys to Varian users, the population most likely to have had prior
knowledge of or experience with RapidPlan. Participation in the survey was limited to active
Certified Medical Dosimetrists and Medical Physicists regardless of experience using RapidPlan.
The study was limited to these positions in order to collect responses from those regularly
planning treatments.

Survey

In order to gain insight, a survey was created in an effort to gauge participant's

knowledge, satisfaction and implementation of RapidPlan. Survey questions can be categorized
into 3 basic types; the first identified professional status and familiarity with RapidPlan. The
second group of questions were directed only to those professionals that have implemented
RapidPlan in their therapy departments. The third group of questions were general questions
concerning model based planning and potential future use of Rapid plan. The questionnaire was
estimated to take no longer than 3 minutes to complete. The survey may be viewed in Table 1.

Data Collection

Hard-copy responses were distributed and collected from medical physicists and medical
dosimetrists attending the treatment planning sessions. In addition to distribution of hard copies
to attendees, an online link to the survey was also provided. Once completed, the printed surveys
were collected. In order to store the responses in a digital format, each paper survey was entered
manually into an online survey tool. Entry accuracy was verified by (1 or 2) additional
individuals.
Statistical Analysis

The survey was conducted in June of 2019 and compiled in July 2019. Data analysis was
then performed to acquire a greater understanding of perceived adequacy and adoption. In
addition, the survey tool used to house the data provided chart percentages, means, and standard
deviations.

Results

Sixty-seven responses were collected from those attending the Varian workshops at the
AAMD national conference. An online link to the survey was also provided as an alternative to
the hard copies but was not used. It is important to note not every question required or received
a response. This was in part due to the question not applying to the situation of the respondent, or
simply the respondent not providing an answer.

Thirty percent of the respondents stated their department did have RapidPlan; however, 3
of those whose clinic did not have RapidPlan stated in a comment box that their department
would be implementing the software within the next 6 months. Of those who did not have access
to RapidPlan, 81% gave a favorable response regarding their interest in adapting a knowledge-
based planning system into their department. Figure 1 demonstrates the interest level of the 42
medical dosimetrists and medical physicists that answered the question. A value of 6 or above on
a scale of 0-10, with 10 denoting “extremely interested” was deemed favorable. It was also
noteworthy that the most common response to this question was an interest level of 10 (24%).

Of the 21 respondents that have access to RapidPlan, 15 (71%) departments are using it.
Results from the survey showed the frequency in which clinics with access are using RapidPlan.
Sixteen responses were collected, and it was generally used on less than 10 patients per week
(69%). The prostate (25%) and the head and neck (23%) proved to be the most common
anatomic sites for which departments were equipped with models, which may be seen in Figure
3. Facilities also reported the availability of lymphoma, pancreas, spine, lung, liver and pelvis
models in their clinics, though less prevalent. Three medical dosimetrists or medical physicists
selected the choice, “Other,” with two writing in their clinic also had sarcoma and
oligometastases models, while one made known their department replaced the original head and
neck model to fit their clinical standards. With that being said, it was found that a large majority
(61%) of departments using RapidPlan have both added and adjusted to the models in use, while
only 17% have made no changes (n=18).

There was significant interest in the 6 respondents with RapidPlan that are not utilizing
the program. However, only 5 responded to the following question regarding their rationale
behind not adopting the technology. Figure 2 demonstrates the responses received and the list of
potential reasons that may apply to their situation, with some checking multiple. “Insufficient
time to learn and adapt new technology” was the most commonly selected, chosen 3 times as the
reason for not using RapidPlan. The answer “Other” was chosen twice, in which one explained
they were waiting on a software upgrade, while the other was waiting on implementation of the
software.

When prompted to rank 7 theoretical advantageous features of a knowledge-based

planning system, “Speed of plan generation” was believed to be the most beneficial, having been
ranked in the top position in 50% of responses (n=47) (Table 2). “Superior plan quality” was the
second most common response, receiving 23% of the remaining votes for the number 1 rank.
Speed was also the most common response when asked which of the above applied to their
actual experience using RapidPlan, with 81% selecting “Speed of plan generation” as part of or
their sole answer to the question (Figure 5).

Expected future use of RapidPlan was believed to increase in the departments of 65% of
the respondents (n=20), while only 1 (5%) believed it would decrease. The survey demonstrated
overall satisfaction with RapidPlan when available in the department. The same 1-10 scale as
earlier was used, with 10 now denoting “Extremely satisfied.” Seventy-nine percent gave
favorable responses of a value of 6 or above, and 8 was discovered to be the most common
satisfaction level (26%, n=19). It was also noteworthy that no satisfaction levels under 5 were
recorded. Nearly every respondent with access to RapidPlan that provided an answer (94%,
n=17) declared they would recommend RapidPlan to other radiation oncology departments.

Discussion

The purpose of the survey was to measure user satisfaction and clinical implementation
of the RapidPlan knowledge-based planning system. The results revealed 70% of the responses
from users attending the Varian workshops at the AAMD national conference have not acquired
RapidPlan software. However, 93% of these users expressed interest into adapting a knowledge-
based planning system.

According to Ge and Wu3, 2 major factors have increased the popularity of knowledge-
based planning software over the past few years: an increased use of IMRT and related
technology have helped develop higher quality treatment plans. In turn, as the amount of superior
quality plan data increases, major progress in knowledge-based research can be made. As more
of this research is published, interest levels will continue to grow. The results of this study
support previous literature and demonstrate that RapidPlan continues to gain popularity as the
software produces dependable, higher quality plans with less variability.1,2,4 According to a study
by Hao et al2 it is a favorable solution to increase plan quality and reduce planning time.

In the clinical setting, time is undeniably valuable. Of the 21 facilities who currently own
RapidPlan software, 71% of the facilities utilize its capabilities while 29% did not. In the
analysis, the most common reason facilities were not utilizing RapidPlan software was due to
insufficient time to learn and adapt to new technology. New technology may be intensely
complex and hard to learn, and the training process and validation testing may be tremendously
time-consuming.4,5 These combined factors could potentially add pressure to an already busy
schedule.5 However, ease of use was the second most common answer when asked which
beneficial features applied to the experience of RapidPlan users. In addition, the time it may take
to implement and learn the technology may quickly be made up in time saved using RapidPlan.4

RapidPlan also allows clinicians to either use provided sample models shared from other
institutions or to develop models by creating their own database of plans.1 Our survey indicated
the vast majority of clinical sites have added and/or adjusted plans which RapidPlan uses as
qualified models. The minimum number of plans required to create a model is 20, although
expanding the amount used to build a model will increase the probability of a higher quality
treatment plan.1,6 A study by Bodez et al6 demonstrated the effect of increasing the number of
previous treatments from which RapidPlan may “learn.” In the study, extending the number of
plans in the model from 36 to 116 increased the chance of meeting criteria in a single
optimization from 60% to 83.2%. This may prove the value of adding to and adjusting the
model, which was been done by 61% of survey respondents.
 The results showed that prostate and head and neck cancers were the most common
anatomical sites facilities are utilizing RapidPlan software for planning assistance. The majority
of knowledge-based planning studies have concentrated on prostate, head and neck, and lung
cancers. According to Ge and Wu3, there are currently 60 articles available about knowledge-
based planning for prostate, head & neck and lung, compared to only 28 articles involving other
sites.

This study resulted in 68% of the clinics utilizing RapidPlan for less than 10 patients per
week. This may be due to clinic size or insufficient staff, but it is a number that is expected to
rise as the technology develops and more data is collected for each system.7 More facilities are
estimated to realize the potential knowledge-based planning offers to increase efficiency and
consistency in treatment planning quality.6,7 This was in line with the results of our survey, as
65% of those already using RapidPlan expected their use of the program to increase going
forward.

In an article regarding newly emerging technology in the healthcare field, Thompson et

al8 emphasized the importance of embracing advancements that may improve patient care.
Following this notion, it was found that 94% would recommend RapidPlan to other radiation
oncology departments. As technology has helped increase the capabilities of a dosimetrist, it was
not a surprise that the overall user satisfaction with RapidPlan was compellingly favorable.9

Conclusion

Overall, the surveys suggested RapidPlan to be a desirable program used within the clinic
and a vast majority using the program would recommend it to other radiation oncology
departments. Furthermore, the majority of those surveyed who do not currently have access
showed a great interest in adopting the program. Currently, the majority of departments were
using RapidPlan for prostate and head and neck treatment planning, often after some
modifications to the models.

Though most of the clinics with RapidPlan software are employing the technology, the
study reported the most common response for not using RapidPlan to be insufficient time to
learn and adapt new technology. However, “Speed of plan generation” was the most commonly
recorded advantageous feature while using RapidPlan. The second most common response was
“Superior plan quality.”

This study had several limitations. As RapidPlan is a highly specialized program

pertaining only to the field of medical dosimetry, data collection was limited to only those
attending the 2019 AAMD national conference. The survey was provided to only those who
participated in the Varian workshops. Second, the survey was created and printed to hard copies
for participants to fill out. Some surveys were excluded due to incomplete answers or responses
not relevant to the situation of the respondent. Time constraints were also a limitation, as the
research was conducted as part of a medical dosimetry program and deadlines were a concern.
Finally, the survey did not question how many patients per week on average are treated at each
facility, which may affect the interpretation of certain answers. Future research may address this
regarding the proportion of the patients being treated at a clinic in which RapidPlan was a part of
the planning process.
 References

1. RapidPlan Knowledge Based Planning Software. Varian Medical Systems.

https://www.varian.com/oncology/products/software/treatment-planning/rapidplan-
knowledge-based-planning. Accessed April 20, 2019.
2. Hao W, Fan J, Haizhen Y, et al. Applying a RapidPlan model trained on a technique and
orientation to another: a feasibility and dosimetric
evaluation. Radiat Oncol. 2016;11(108):1-7. https://dx.doi.org/10.1186/s13014-016-
0684-9
3. Ge Y, Wu Q, Knowledge-based planning for intensity modulated radiation therapy: A
review of data-driven approaches. Med Phys. 2019;46(6):2760-2775.
https://dx.doi.org/10.1002/mp.13526
4. Li N, Carmona R, Sirak I, et al. Highly efficient training, refinement, and validation of a
knowledge-based plan quality control system for radiotherapy clinical trials. Int J Radiat
Oncol Biol Phys. 2017;97(1):164-172. https:/dx./doi.org/10.1016/j.ijrobp.2016.10.005
5. Garrett P, Brown A, Hart-Hester S, et al. Identifying barriers to the adoption of new
technology in rural hospitals: A case report. Perspect Health Inf Manag. 2006;3(9):1-11.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2047308/.
6. Bodez V, Khamphan C, Francois G, et al. Feedback on use of
the RapidPlan™ knowledge based planning system for the realization of prostatic
treatment planning in volumetric modulated arc therapy. Physica Medica. 2017;44(1): 6-
7. https://dx.doi.org/10.1016/j.ejmp.2017.10.037
7. Hussein M, South C, Barry M, et al. Clinical validation and benchmarking of knowledge-
based IMRT and VMAT treatment planning in pelvic anatomy. Radiat Ther Oncol.
2016;120(3):473-479. https://dx.doi.org/10.1016/j.radonc.2016.06.022
8. Thompson R, Valdes G, Fuller C et al. Artificial intelligence in Radiation Oncology: A
specialty-wide disruptive transformation? Radiat Ther Oncol. 2018;129(3):421-426.
https://dx.doi.org/10.1016/j.radonc.2018.05.030
9. Mell L, Roeske J, Mundt A. A survey of intensity modulated radiation therapy in the
United States. Cancer. 2003;98(1):204-211 https://dx.doi.org/10.1002/cncr.11489
 Figures

Figure 1. Interest level in adopting RapidPlan or similar knowledge-based planning system into
the department on a scale of 0 to 10, with 0 being not at all interested and 10 being extremely
interested.

Figure 2. Rationale for not using RapidPlan when available in the department.
Figure 3. Anatomic sites for which users have RapidPlan models.

Figure 4. Manipulation of RapidPlan models when available in the department.

Figure 5. Proposed advantageous features that have applied to the experience of RapidPlan
users.
Figure 6. Overall user satisfaction of RapidPlan when available in the department on a scale of 0
to 10, with 0 being not at all satisfied and 10 being extremely satisfied.
 Tables

Table 1. Questions and Answers to RapidPlan Survey

Questions Answers
1. What is your position in the radiation Medical Dosimetrist
oncology department? Medical Physicist
2. Does your department have the
Yes
knowledge-based planning program,
No
RapidPlan?
3. If your answer to question 2 was ""No:""
What is your overall interest level in
adapting a knowledge-based planning 0 (Not at all interested) - 10 (Extremely
system such as RapidPlan into your Interested)
department? (After responding, please
proceed to Question 9)
4. If your answer to question 2 was ""Yes:""
Is your department currently utilizing the Yes
RapidPlan knowledge-based planning No
software?
Cost of additional licenses or software
upgrades
Awaiting model availability in additional
anatomical sites
Awaiting further endorsement from larger
5. If your department has the RapidPlan number of clinics and peers
software but is not currently utilizing the Insufficient time to learn and adapt new
program, please check all applicable reasons technology
below as to why your department is not Insufficient resources to accommodate new
using RapidPlan. technology
Uninterested in automated planning method
Unsatisfied with existing model
performance
Program not user-friendly
Other (please list in text box)
6. If your department is currently utilizing
<10 patients per week
RapidPlan: For how many patients a week,
10-20 patients per week
on average, is RapidPlan a part of the plan
>20 patients per week
development process?
Head and Neck
7. For which of the following anatomic sites
Liver
are you using RapidPlan models? Please
GYN
check all that apply.
Prostate
 Lung
Spine
Pancreas
Lymphoma
Other (Please list in text box)
Yes: Added to Model
8. Has your department adjusted or added to Yes: Adjusted Model
any of these models? Yes: Added and Adjusted
No
Speed of plan generation
9. Theoretically, what do you feel is the Plan quality measure
most advantageous feature of a knowledge- Ease of use
based planning system? Please drag to rank Superior plan quality
the following responses in order with 1 Ability to add to library and
being the most advantageous to 7 being least update/manipulate model
advantageous. If you are using a paper copy, Exposure to new technology in field of
please write in ranks 1-7 to the left of radiation oncology
choices. Ability to download and share existing
models amongst institutions
Speed of plan generation
Plan quality measure
Ease of use
Superior plan quality
10. Which of the above advantageous
Ability to add to library and
features apply to your experience with
update/manipulate model
RapidPlan? Please check all that apply.
Exposure to new technology in field of
radiation oncology
Ability to download and share existing
models amongst institutions
11. Would you recommend RapidPlan to Yes
other radiation oncology departments? No
Increased usage of RapidPlan
12. How do you foresee the utilization of Maintained usage of RapidPlan
RapidPlan in your department? Decreased usage of RapidPlan
Ceased usage of RapidPlan
13. Please rate your overall satisfaction with
0 (Not at all satisfied) - 10 (Extremely
the RapidPlan knowledge-based planning
satisfied)
software.
14. If you would like to leave the name of
your clinic, please do so below.
Table 2. Rank Placement of Proposed Advantageous Features of a Knowledge-Based Planning
System.
Rank 1 2 3 4 5 6 7
Speed of Plan
20 6 10 1 2 0 1
Generation
Plan Quality
6 18 9 6 4 4 0
Comparison Measure
Ease of Use 2 8 9 17 2 4 5
Superior Plan Quality 11 5 8 9 6 4 4
Ability to Add to
Library and
Advantageous 1 3 5 8 13 10 7 Respondent
Update/Manipulate
Feature Number
Model
Exposure to New
Technology in Field
1 4 3 2 13 13 11
of Radiation
Oncology
Ability to Download
and Share Existing
1 2 3 4 7 11 19
Models Amongst
Institutions