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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

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


Planning
II. Introduction
A. Creating a high-quality radiation therapy plan can be a challenging and time-
consuming process.
1. There are many crucial steps that must occur when developing a
successful treatment plan.
2. One of the most important may be the analysis of the anatomy and
target along with the understanding of reasonable plan outcomes.
B. In recent years, a few radiation oncology vendors have developed technology
capable of automatically creating radiation treatment
1. 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.
C. RapidPlan is a knowledge-based planning system that provides clinicians with
models based on clinical practices from leading institutions.1
1. This program was released with the goal to provide consistent,
efficient, and higher quality plans for individualized treatments with less
variability.
2. RapidPlan operates by looking at the data set of a new patient’s
anatomy and compares 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 is able to predict a reasonable
dose volume histogram (DVH) for nearby critical structures.
3. The predictions are then used to develop an intensity-modulated
radiation therapy (IMRT) or volumetric modulated arc therapy (VMAT)
plan.
D. 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
1. However, there is currently little information known about the
adoption and usage levels of RapidPlan in radiation oncology departments,
as well as the satisfaction of users.
2. The purpose of this study is 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.
1. By creating a survey, we were able to determine if knowledge
based treatment planning is beneficial to the clinical environment.

III. Methods and Materials


A. Study Population
1. 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.
a. The intent was to distribute the surveys to Varian users, the
population most likely to have had prior knowledge of or
experience with RapidPlan.
2. Participation in the survey was limited to active Certified Medical
Dosimetrists and Medical Physicists regardless of experience using
RapidPlan.
3. The study was limited to these positions in order to collect
responses from those regularly planning treatments.

B. Survey
1. In order to gain insight, a survey was created in an effort to gauge
participant's knowledge, satisfaction and implementation of RapidPlan.
2. Survey questions can be categorized into 3 basic types.
a. The first identified professional status and familiarity with
RapidPlan.
b. The second group of questions were directed only to those
professionals that have implemented RapidPlan in their therapy
departments.
c. The third group of questions were general questions concerning
model based planning and potential future use of Rapid plan.
3. The questionnaire was estimated to take no longer than 3 minutes
to complete. The survey may be viewed in Table 1.
C. Data Collection
1. Hard-copy responses were distributed and collected from medical
physicists and medical dosimetrists attending the treatment planning
sessions.
2. In addition to distribution of hard copies to attendees, an online
link to the survey was also provided.
a. Once completed, the printed surveys were collected.
3. In order to store the responses in a digital format, each paper
survey was entered manually into an online survey tool.
a. Entry accuracy was verified by (1 or 2) additional individuals.
D. Statistical Analysis
1. The survey was conducted in June of 2019 and analyzed in July
2019.
2. Data analysis was then performed to acquire a greater
understanding of perceived adequacy and adoption.
3. The survey tool provided chart percentages, means, and standard
deviations.
IV. Results
A. Sixty-seven responses were collected from those attending the Varian workshops
at the AAMD national conference.
1. An online link to the survey was also provided as an alternative to
the hard copies but was not used.
2. It is important to note not every question required or received a
response.
a. This was in part due to the question not applying to the situation of
the respondent, or simply the respondent not providing an answer.
B. Thirty percent of the respondents stated their department did have RapidPlan.
1. 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.
2. 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.
a. Figure 1 demonstrates the interest level of the 42 medical
dosimetrists and medical physicists that answered the question.
b. A value of 6 or above on a scale of 0-10, with 10 denoting
“extremely interested” was deemed favorable.
c. It was also noteworthy that the most common response to this
question was an interest level of 10 (24%).
C. Of the 21 respondents that have access to RapidPlan, 15 (71%) departments are
using it.
1. Results from the survey showed the frequency in which clinics
with access are using RapidPlan.
a. Sixteen responses were collected, and it was generally used on less
than 10 patients per week (69%).
b. 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.
c. Facilities also reported the availability of lymphoma, pancreas,
spine, lung, liver and pelvis models in their clinics, though less
prevalent.
d. 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.
e. 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).
D. There was significant interest in the 6 respondents with RapidPlan that are not
utilizing the program.
1. However, only 5 responded to the following question regarding
their rationale behind not adopting the technology.
2. Figure 2 demonstrates the responses received and the list of
potential reasons that may apply to their situation, with some checking
multiple.
a. “Insufficient time to learn and adapt new technology” was the
most commonly selected, chosen 3 times as the reason for not
using RapidPlan.
b. 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.
E. 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).
1. “Superior plan quality” was the second most common response,
receiving 23% of the remaining votes for the number 1 rank.
2. 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).
F. 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.
G. The survey demonstrated overall satisfaction with RapidPlan when available in
the department.
1. The same 1-10 scale as earlier was used, with 10 now denoting
“Extremely satisfied.”
a. 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).
b. It was also noteworthy that no satisfaction levels under 5 were
recorded.
H. Nearly every respondent with access to RapidPlan that provided an answer (94%,
n=17) declared they would recommend RapidPlan to other radiation oncology
departments.
V. Discussion
A. The purpose of the survey was to measure user satisfaction and clinical
implementation of the RapidPlan knowledge-based planning system.
1. The results revealed 70% of the responses from users attending the
Varian workshops at AAMD have not acquired RapidPlanning software.
2. However, 93% of these users expressed interest into adapting a
knowledge-based planning system.
B. According to Ge Y and Wu Q3, there were 2 major factors that have increased the
popularity of knowledge-based planning software over the past few years.
1. Increased use of IMRT and related technologies have helped in the
development of higher quality treatment plans. Also, as the amount of
superior quality plan data increases, major progress was enabled in
knowledge-based research.3
2. As more of this research is published, interest levels will then
continue to grow.
3. The results of this study demonstrate that RapidPlan continues to
gain popularity as the software produces dependable, higher quality plans
with less variability.1,2,4
a. According to a study by Hao et al2 it is a favorable solution to
reduce planning time and increase plan quality.
C. In the clinical setting, time is undeniably valuable.
1. Of the 21 facilities who currently own RapidPlan software, 71% of
the facilities utilize its capabilities while 29% did not.
a. 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.
b. New technology may be intensely complex and hard to learn, and
the training process and validation testing may be tremendously
time-consuming.4,5
c. These combined factors could potentially add pressure to an
already busy schedule.5
a. However, ease of use was the second most common answer
when asked which beneficial features applied to the
experience of RapidPlan users.
b. In addition, the time it may take to implement and learn the
technology may quickly be made up in time saved using
RapidPlan.4
D. 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
1. Our survey indicated the vast majority of clinical sites have added
and/or adjusted plans which RapidPlan uses as qualified models.
2. 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. A study by Bodez et al6 demonstrated the effect of increasing the
number of previous treatments from which RapidPlan may “learn.”
a. 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%.
b. This may prove the value of adding to and adjusting the
model, which was been done by 61% of survey
respondents.
E. The results showed that prostate and head and neck cancers were the most
common anatomical sites facilities are utilizing RapidPlan software for planning
assistance.
1. The majority of knowledge-based planning studies have
concentrated on prostate, head and neck, and lung cancers.
2. 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.
F. This study resulted in 68% of the clinics utilizing RapidPlan for less than 10
patients per week.
1. 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
2. More facilities are estimated to realize the potential knowledge-
based planning offers to increase efficiency and consistency in treatment
planning quality.6,7
a. 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.
G. 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.
1. Following this notion, it was found that 94% would recommend
RapidPlan to other radiation oncology departments.
2. 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
VI. Conclusion
A. 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.
1. Furthermore, the majority of those surveyed who do not currently
have access showed a great interest in adopting the program.
2. Currently, the majority of departments were using RapidPlan for
prostate and head and neck treatment planning, often after some
modifications to the models.
B. 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.
1. However, “Speed of plan generation” was the most commonly
recorded advantageous feature while using RapidPlan.
2. The second most common response was “Superior plan quality.”
C. This study had several limitations.
1. 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.
1. The survey was provided to only those who participated in the
Varian workshops.
2. Second, the survey was created and printed to hard copies for
participants to fill out.
3. Some surveys were excluded due to incomplete answers or
responses not relevant to the situation of the respondent.
2. Time constraints were also a limitation, as the research was
conducted as part of a medical dosimetry program and deadlines were a
concern.
3. 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.
1. 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.
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 Interested)
system such as RapidPlan into your
department? (After responding, please
proceed to Question 9)
4. If your answer to question 2 was
""Yes:"" Is your department currently Yes
utilizing the RapidPlan knowledge-based No
planning software?
Cost of additional licenses or software upgrades
Awaiting model availability in additional
anatomical sites
Awaiting further endorsement from larger number
5. If your department has the RapidPlan of clinics and peers
software but is not currently utilizing the Insufficient time to learn and adapt new
program, please check all applicable technology
reasons below as to why your department Insufficient resources to accommodate new
is not 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
10-20 patients per week
week, on average, is RapidPlan a part of
>20 patients per week
the plan development process?
Head and Neck
Liver
GYN
7. For which of the following anatomic
Prostate
sites are you using RapidPlan models?
Lung
Please check all that apply.
Spine
Pancreas
Lymphoma
Other (Please list in text box)
Yes: Added to Model
8. Has your department adjusted or added Yes: Adjusted Model
to 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 Ease of use
knowledge-based planning system? Please Superior plan quality
drag to rank the following responses in Ability to add to library and update/manipulate
order with 1 being the most advantageous model
to 7 being least advantageous. If you are Exposure to new technology in field of radiation
using a paper copy, please write in ranks oncology
1-7 to the left of 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 update/manipulate
features apply to your experience with
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 the RapidPlan knowledge-based 0 (Not at all satisfied) - 10 (Extremely satisfied)
planning 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 10 4
Ability to Add to
Advantageous Library and Respondent
1 3 5 8 13 13 7
Feature Update/Manipulate Number
Model
Exposure to New
Technology in Field of 1 4 3 2 13 11 11
Radiation Oncology
Ability to Download
and Share Existing
1 2 3 4 7 19
Models Amongst
Institutions