Within the next ten years treatment planning will become fully automated without the need for human intervention

Abstract

Arguing against the Proposition is Kevin L. Moore, Ph.D. Dr. Moore obtained his Ph.D. in Physics from the University of California, Berkeley, subsequently training and working at Washington University in St. Louis before moving back west to the University of California, San Diego. He is certified in Therapeutic Radiological Physics by the American Board of Radiology and is currently Associate Physics Director and Medical Physics Residency Director in the UC San Diego Department of Radiation Medicine and Applied Sciences. Dr. Moore's major research interests lie in knowledge-based treatment planning, treatment plan quality control, and informatics applications in clinical radiotherapy. He has published nearly 30 peer-reviewed papers and one book chapter, and is lead inventor on a patent regarding knowledge-based dosimetric prediction. Within a decade, radiation treatment planning will become fully automated without the need for human intervention because (i) we will exploit pertinent trends in the manufacturing and informatics industries, (ii) the precedent is already established, and (iii) it is imperative to improving quality and continuing advancements in care. Impressive technological advances have occurred in radiation oncology over the past two decades. Image-based planning, optimization, and guidance progressed rapidly from compelling concepts to routine tools because outside influences like high-performance computing, networking, and robotics became widespread and affordable. IMRT and IGRT have become ubiquitous tools and have altered the paradigm of treatment. But we wish to do more for our patients. The “adaptive” concept was also described more than 15 years ago. The concept has been developed extensively and now includes biologically motivated adaptation.1 However, more effort is needed to overcome the complexities and impact on workflow to realize adaptation as it was conceived. Future efforts will benefit surely from the “third wave of computing” from which image processing and information technologies will produce insights from large quantities of unstructured treatment planning data. The need to estimate dose distributions made automation central to the earliest developments of computerized treatment planning. Today, even more advanced functions are automated, such as image registration, organ delineation, and dose optimization. Using commercial tools, it is now possible to control workflow so as to fully create, evaluate and document a plan with minimal intervention.2–4 Interestingly, applications involving tangential breast irradiation remain controversial: In spite of the obvious improvements in personalization and efficiency afforded by IMRT and related automation techniques, modern innovation is discouraged because entrenched reimbursement guidelines confuse the technologies and the “modality” they enable.5 Providing healthcare is one of the most complex and demanding of human endeavors. Radiation oncology treatment relies on distributed decisions and tasks that are shared across highly skilled medical and technical staff. We strive to assess and respond to each patient's personal needs; but our tools, skills, and processes are stretched to the limit. Procedures can become error prone, sometimes with tragic and very public consequences.6 Consequently, practice guidance is limited to the structures and inspections required to achieve safety today.7 The dynamic nature of patients and their response to treatment were recognized long ago as a control problem. Adaptive control provides a means to account for anatomical and physiological variations and supports highly personalized treatment.1 Adaptive radiation therapy must become “more than safe.” It must embrace a broader definition of quality to ensure that clinical decisions and technical procedures are evidence based, effective, equitable, timely, and highly tailored to each patient.8 A higher level of robust quality is required and we must do more than embr