• American College of Radiology (ACR). ACR practice guideline for radiation oncology. Reston (VA): American College of Radiology (ACR); 2004. 7 p. [5 references]

This is the current release of the guideline.

This guideline updates a previous version: American College of Radiology (ACR). ACR practice guideline for radiation oncology. Reston (VA): American College of Radiology (ACR); 1999.

Process of Radiation Therapy

The clinical use of ionizing radiation is a complex process involving trained personnel who carry out a variety of interrelated activities.

1. Clinical Evaluation

   The initial evaluation of the patient includes history, physical examination, review of pertinent diagnostic studies and reports, and communication with the referring physician and other appropriate physicians involved in the patient's care. The extent of the tumor must be determined and recorded for staging; this will facilitate treatment decisions, determine prognosis, and allow a comparison of treatment results.

2. Establishing Treatment Goals

   The goal of treatment (curative, palliative, adjuvant, or to establish local tumor control) should be defined as clearly as possible. Treatment options with their relative merits and risks should be discussed with the patient. A summary of the consultation should be communicated to the referring physician.

3. Informed Consent

   Prior to simulation and treatment, informed consent must be obtained and documented.

4. Treatment Planning

   The cognitive process of treatment planning requires the radiation oncologist to have knowledge of the natural history of the tumor to be treated and to determine the tumor site, its extent, and its relationship with adjacent normal tissues. This process is based on consideration of the history, physical examination, endoscopy, diagnostic imaging, findings at surgery, and histology.

   When ionizing radiation is to be used, the radiation oncologist must select beam characteristics and/or radionuclide sources, method of delivery, doses, and sequencing with other treatments. The sequencing with other treatments should be coordinated in collaboration with medical and surgical oncologists. The radiation oncologist determines the dose to be delivered to the tumor, limiting doses to critical structures, and the fractionation desired. Using these parameters, the radiation oncologist directs the medical physicist and dosimetrist in the design of potential treatment programs or develops them personally. This usually requires the acquisition of patient data, such as dimensions, contours, and cross-sectional images. Beam-specific physical data are used with source data and other physical characteristics measured by the physicist to calculate the dose to a specific point within the patient or to calculate the dose distribution within a region of interest.

   The radiation oncologist, in consultation with the medical physicist and dosimetrist, selects the treatment plan. The radiation oncologist prescribes the radiation treatment course. The prescription should include: volume (site) to be treated, description of portals (anteroposterior [AP], posteroanterior [PA], lateral, etc.), radiation modality, dose per fraction, number of fractions per day, number of fractions per week, total number of fractions, total tumor dose, and prescription point or isodose. The prescription shall be signed by the radiation oncologist prior to the initiation of radiation therapy. The graphical isodose plan, when warranted, should be signed within one week of initiation of treatment.

   Daily treatments are carried out by the radiation therapist following the prescription and treatment plan of the radiation oncologist. It is essential that all treatment parameters be described in detail and orders be signed by the responsible radiation oncologist. Likewise, any changes in the planned treatment by the radiation oncologist requiring adjustment in immobilization, new calculations, or even a new treatment plan, must be documented on the record and signed or initialed by the radiation oncologist.

5. Simulation of Treatment

   Simulation is the process of establishing and documenting the appropriate volume to be treated and identifying the normal structures within or adjacent to this volume. During simulation, optimal patient positioning is determined and treatment parameters are defined, including couch position, gantry angle, and collimator angle. Beam entry sites and other points helpful in patient positioning and field localization are identified on the patient. All field setups should be documented by properly labeled photographs and/or diagrams, and when appropriate, by standard radiographs or digitally reconstructed radiographs (DRRs).

6. Fabrication of Treatment Aids

   Devices to aid in positioning and immobilizing the patient, normal tissue shielding, compensating filters, etc., are to be used where appropriate.

7. Physics

   The medical physicist, dosimetrist, and radiation oncologist perform the calculations necessary to determine the appropriate dose to be delivered by the treatment equipment. This requires knowledge of the physical properties of the treatment units, whether external beam or radioactive implants. These calculations must be checked by an independent person or method before the first treatment if the total number of fractions is five or fewer, or otherwise before the third fraction.

8. External Beam Treatment

   External beam radiation therapy is usually delivered in single daily doses for several weeks or in multiple increments daily over the same period (hyperfractionation) or over shorter times (accelerated fractionation).

   To permit proper delivery of therapy, radiographs or portal images produced by each treatment beam unit with the patient in the treatment position (portal localization films) are compared with the simulator films or digitally reconstructed radiographs to verify that the treatment beams and fields planned at simulation are well matched. When portal verification images can be made, they should be taken at least every 5 to 10 treatments and for any new fields. Dosimeters may be used, in vivo, to measure and record actual doses at specific anatomic sites.

9. Patient Evaluation During Treatment

   The radiation oncologist monitors the patient's progress, checks entries in the treatment chart, and discusses the plan of therapy and any changes with appropriate team members. Re-evaluation examinations of the patient should be performed at least weekly, or more often when warranted. Pertinent laboratory and imaging studies are periodically ordered and reviewed. The patient and/or referring physician should be informed of the progress of treatment whenever deemed appropriate. At completion of irradiation, the radiation oncologist should assess the tumor response and acute side effects.

10. Follow-Up Evaluation

    Periodically after treatment, assessment by the radiation oncologist of tumor response and sequelae of treatment is recommended. Early detection of post-treatment tumor progression may permit additional, potentially beneficial treatment. Early detection and treatment of radiation induced sequelae may avoid serious problems later.

11. Brachytherapy

    Brachytherapy, using radionuclide sources, may be used for many sites. The radiation oncologist selects the applicators and radionuclide sources. Implant localization radiographs are taken and computerized dose calculations performed. The radiation oncologist reviews these calculations and completes the prescription, which shall be signed and dated. This prescription should specify the radionuclide source and strength, the dose to clinically relevant points or minimum dose to the target volume, and the time course.

    Other treatment modalities are sometimes combined with external photon beams or brachytherapy to enhance the antitumor effects and decrease the effects on surrounding normal tissues.

Qualifications and Responsibilities of Personnel

1. Qualifications and Certification
   1. The Medical Director of the Radiation Oncology Center or Service should be a radiation oncologist, credentialed as below.
   2. Radiation Oncologists (Staff)
      1. Satisfactory completion of an American Council of Graduate Medical Education (ACGME) approved residency program or an American Osteopathic Association (AOA) approved residency program in radiation oncology.

         or

      2. Certification in Radiology by the American Board of Radiology (ABR) of a physician who confines his/her professional practice to radiation oncology or certification in Radiation Oncology or Therapeutic Radiology by the ABR, the American Osteopathic Board of Radiology, the Royal College of Physicians and Surgeons of Canada, or Le College des Medecins du Quebec may be considered proof of adequate physician qualifications.

      The continuing education of a radiation oncologist should be in accordance with the American College of Radiology (ACR) Practice Guideline for Continuing Medical Education (CME).

   3. Qualified Medical Physicist

      A Qualified Medical Physicist is an individual who is competent to practice independently in one or more of the subfields in medical physics. The ACR considers that certification and continuing education in the appropriate subfield(s) to demonstrate that an individual is competent to practice one or more of the subfields in medical physics and to be a Qualified Medical Physicist. The ACR recommends that the individual be certified in the appropriate subfield(s) by the ABR or for MRI, by the American Board of Medical Physics (ABMP) in magnetic imaging physics.

      The appropriate subfields of medical physics for this guideline are Therapeutic Radiological Physics and Radiological Physics.

      The continuing education of a Qualified Medical Physicist should be in accordance with the ACR Practice Guideline for Continuing Medical Education (CME) (2006 - ACR Resolution 16g).

   4. Radiation Therapists and Simulation Staff

      Radiation therapists and simulation staff fulfill state licensing requirements and should have American Registry of Radiologic Technologists (ARRT) certification in radiation therapy.

   5. Dosimetrist

      Certification by the Medical Dosimetrist Certification Board is recommended.

   6. Patient Support Staff

      Individuals involved in the nursing care of patients should have experience in the care of radiation therapy patients.

2. Availability
   1. A radiation oncologist should be available for direct care and quality review on a daily basis. The radiation oncologist, facility, and support staff should be available to initiate urgent treatment within a medically appropriate response time on a 24-hour basis. When unavailable, the radiation oncologist is responsible for arranging appropriate coverage. A radiation oncologist's availability should be consistent with state and federal requirements.
   2. The medical physicist shall be available when necessary for consultation with the radiation oncologist and to provide advice or direction to technical staff when a patient's treatments are being planned or patients are being treated. When a physicist is not immediately available on site, clinical needs shall be supplemented by documented procedures. Authority to perform specific clinical physics duties shall be established by the medical physicist for each member of the physics staff in accordance with their competence. The radiation oncologist shall be informed of the clinical activities authorized for each member. Practices without a full-time physicist must have regular on-site physics support during hours of clinical activity, at least weekly. Chart checks by the physicist or his/her designate should be done at least weekly.

Equipment Specifications

High-energy photon and electron beams, a computer-based treatment-planning system, simulation, dosimetry with direct participation of the medical physicist, brachytherapy, and the ability to fabricate treatment aids must be available to patients in all facilities, either on site or through arrangements with another center.

1. Radiation oncology equipment either on site or available through arrangements with another center should include:
   1. Megavoltage radiation therapy equipment for external beam therapy, e.g., a linear accelerator or cobalt-60 teletherapy unit. If the cobalt-60 unit is the only megavoltage unit, it must have a treatment distance of 80 cm or more.
   2. Electron beam or x-ray equipment for treatment of skin lesions or superficial lesions.
   3. Simulator capable of duplicating the setups of any megavoltage unit and producing either standard radiographs or digitally reconstructed radiographs (DRRs) of the fields to be treated.
   4. Appropriate brachytherapy equipment for intracavitary and interstitial treatment (or arrangements for referral to appropriate facilities).
   5. Computer dosimetry equipment capable of providing external beam isodose curves as well as brachytherapy isodose curves and three-dimensional (3D) radiation treatment planning.
   6. Physics calibration devices for all equipment.
   7. Beam-shaping devices.
   8. Immobilization devices.

2. Maintenance and Repair

   Regular maintenance and repair of equipment are mandatory. The medical physicist supervising the quality improvement program is responsible for documenting maintenance and repair.

Patient and Personnel Safety

1. Patient protection measures should include:
   1. Charting systems for prescription, definition, and delivery of treatment parameters, and daily dose recording and summation, including appropriate forms for brachytherapy procedures.
   2. A physics program for calibrating equipment that ensures accurate dose delivery to the patient, including external beam and brachytherapy (see ACR Technical Standard for the Performance of Radiation Oncology Physics for External Beam Therapy).
   3. A system for independent checking by another person or method before the first treatment if the total number of fractions is five or fewer, or otherwise before the third fraction.
   4. A system for independent checking of initial dose for single or two-fraction treatments (intraoperative, stereotactic, hemibody, etc.) before any treatment is given.
   5. A system for the radiation oncologist and medical physicist to check independently all brachytherapy parameters to be used in each procedure (source, isotope and activity, dose rate, source position, total dose prescribed and time, etc.).
   6. A program to prevent mechanical injury by the machine or accessory equipment.
   7. Visual and audio contact with the patient while under treatment.

2. Personnel safety measures should include:
   1. A radiation exposure-monitoring program, as required by the Nuclear Regulatory Commission or appropriate state agencies.
   2. Systematic inspection of interlock systems.
   3. Appropriate room shielding.
   4. Routine leak testing of all sealed sources, as required by regulatory agencies.
   5. Appropriate safety equipment for use of sealed sources.

Educational Program

Continuing medical education programs should include the radiation oncologists and the physics, dosimetry, nursing, and radiation therapy staffs. The programs must cover the safe operation of facility equipment as appropriate to the individual's responsibility, and the treatment techniques and new developments in radiation oncology.

Quality Improvement/Documentation

See the "Description of the Implementation Strategy" field, below.

None provided

The type of supporting evidence is not specifically stated for each recommendation.

• American College of Radiology (ACR). ACR practice guideline for radiation oncology. Reston (VA): American College of Radiology (ACR); 2004. 7 p. [5 references]

Not applicable: The guideline was not adapted from another source.

1990 (revised 2004)

American College of Radiology - Medical Specialty Society

American College of Radiology

Guidelines and Standards Committee

Committee Members: Laurie E. Gaspar, MD, Chair; Mary M. Austin-Seymour, MD; E. Brian Butler, MD; Nancy A. Ellerbroek, MD; Beth E. Erickson, MD; Douglas W. Johnson, MD; Song K. Kang, MD; Peter M. Mauch, MD; Tariq A. Mian, PhD; Seth A. Rosenthal, MD; Anthony H. Russell, MD; Oscar E. Streeter, Jr., MD; Frank A. Vicini, MD; Steven A. Leibel, MD, Chair, Commission; Albert L. Blumberg, MD, Chair, CSC Subcommittee

Not stated

This is the current release of the guideline.

This guideline updates a previous version: American College of Radiology (ACR). ACR practice guideline for radiation oncology. Reston (VA): American College of Radiology (ACR); 1999.

None available

This NGC summary was completed by ECRI Institute on May 17, 2007. The information was verified by the guideline developer on May 29, 2007.