RapidArc RT Enhanced:
New Capabilities Support
Demanding Cases
Lifelong Connections: Survivorship
Software Helps Patients Stay Connected
No Paper. No Film. No Problem.
Clinics and Professional Practices Improve
Operational Efficiency
CONTENTS JUNE 2009
DEPARTMENTS
CENTERLINE
FEATURES
Centerline magazine is
published twice a year by
Varian Medical Systems,
http://www.varian.com.
No Paper. No Film. No Problem.
Integrated Varian
technologies are improving efficiency for clinics
like Ohio’s Mark H. Zangmeister Center and professional practices like Global
Physics Solutions.
Centerline welcomes letters to
the editor, contributions for
point-of-view commentaries,
and suggestions for articles.
Reprinting of Centerline articles
may take place with permission
from the editor. Address comments, contributions, inquiries
about reprints and permissions,
subscription requests, and address changes to:
Varian Medical Systems
3100 Hansen Way, M/S MGM
Palo Alto, CA 94304-1038
Attn: Meryl Ginsberg
6
Staying Connected to Cancer Survivors 10
Survivorship management software
can be used to create customized care
plans and lifetime connections with
cancer survivors.
+1 650.424.6444
meryl.ginsberg@varian.com
ON THE COVER
Recent enhancements to Varian’s
RapidArc™ radiotherapy technology make it possible to treat
the most demanding cases.
Upgrading Cancer Treatment 14
At CancerCare Manitoba, technology upgrades help reduce
patient wait times, integrate
medical and radiation oncology,
and manage a dispersed network.
© 2009 Varian Medical Systems,
Inc. All rights reserved.
ARIA, Clinac, On-Board Imager,
OpTx, SmartConnect, Trilogy,
Varian, Varian Medical Systems,
and the Varian Medical Systems
logo are registered trademarks,
MyVarian is a servicemark, and
Acuity, BrachyVision, Eclipse,
GammaMed, GammaMedplus,
Millennium, OncoView, RapidArc, RPM, and Tx are trademarks of Varian Medical
Systems, Inc. Novalis is a registered trademark of BrainLAB
AG. EQUICARE CS is a trademark of Cogent Health Solutions, Inc. The names of other
companies and products mentioned herein are used for identification purposes only and may
be trademarks or registered
trademarks of their respective
owners.
Point of View
Jeff Marcus, Varian’s vice president of worldwide sales,
describes how his team strives to meet customer needs
through consultative relationships.
News
RapidArc Technology Evolves
Varian continues to enhance
RapidArc™ technology, a highperformance solution for
volumetric modulated
arc therapy (VMAT).
1
2
Survivorship and Long-Term Image
Management Solutions
New software solutions include
EQUICARE CS™ case management software for cancer
survivorship and the OncoView™ image management
and storage solution.
3
Treatment Center Locator Map
An interactive online map gains popularity with
physicians and patients looking for treatment
centers with Varian technology.
4
A One-Stop Shop for Information
MyVarian , an online support center, provides
registered customers with a one-stop shop for
information related to Varian products.
4
SM
Cancer Treatment in Brazil
Centerline profiles three leading cancer centers that
have been equipped with Varian technology.
17
Advanced Treatments in Estonia
North Estonia Regional Hospital becomes the
first Estonian treatment center to offer patients
access to advanced treatments like IMRT.
4
Focus on Service
In the fourth in a series on
services, Centerline looks at
how Varian’s clinical Help
Desk “follows the sun” to
assist customers around
the world.
20
HELIOS Group Deploys RapidArc
Germany’s HELIOS Kliniken Group orders nine
Varian linacs, the majority equipped with
RapidArc technology.
5
Qatar Introduces Advanced Radiotherapy
At Al Amal Hospital in Doha, Qatar, older linacs
are replaced with advanced Varian technology to
provide patients with modern, efficient treatments.
5
POINT OF VIEW
How a Sales Team Helps to Save Lives:
The Value of Consultative Selling
By Jeff Marcus, Varian vice president of worldwide sales
In these uncertain times, customers should know that the Varian
sales organization is more committed than ever to meeting their
needs in an ever-changing business environment.
Varian has established a reputation for stability and reliability. A conservative approach to financial management has
strengthened our balance sheet, enabling us to make significant
ongoing investments in R&D. This, in turn, allows us to turn scientific advances into clinically practical new technologies that
improve the quality of cancer care.
Varian CEO Tim
Guertin has challenged
us to save the lives of
100,000 more cancer patients each year. We can
only accomplish that
goal if customers actually use our technology and products to treat patients and
advance the success rate of radiation therapy. We don’t want
our technology standing idle when it could benefit patients.
Unused or underused, it does not serve the interests of customers, patients, or Varian.
experience, who can understand customer goals and who understand the radiation therapy process. Because they have firsthand
knowledge of radiotherapy, they can consult on the products and
features that would be most beneficial to the customer. We run
an extensive sales training program that focuses on how to provide the most value to the customer.
Then we support our sales managers with a cadre of software
specialists. Because the network can make or break a clinic, we
have network specialists who analyze the customer infrastructure. Our architecture planning
consultants help customers answer questions about all the architectural elements involved
with installing a linear accelerator or building a new center.
Our finance team helps customers arrange for third-party
financing of their projects. Varian never gives reimbursement
advice, but we can recommend third-party experts to help customers prepare pro forma models of financial results expected
from their capital investments. We are also working with customers to come up with new financing solutions.
“0ur goal is to figure out exactly
what our customers need in order
to best achieve their goals.”
Consequently, the Varian sales organization takes a consultative approach to our relationships with customers. Our goal is
to figure out exactly what our customers need in order to best
achieve their goals. Sometimes that means figuring out what they
don’t need, and enabling them to redirect some spending or to
spend less.
Varian recognizes that it takes a special breed of sales person
to work closely with customers in this consultative way. That is
why we hire sales managers with clinical as well as business
At a time when healthcare providers must reexamine priorities, we consider a consultative approach to selling to be more
important than ever. That is why Varian has recently grown our
sales force by 20 percent in North America and by a similar
number in Europe. Sales and service support teams in Latin
America have been expanded as well, to increase access there to
the most advanced forms of treatment. We believe in consultative selling because there are many lives to be saved. ✺
CENTERLINE | JUNE 2009
1
SOFTWARE DEVELOPMENTS
RAPIDARC RADIOTHERAPY
TECHNOLOGY EVOLVES
RapidArc™, Varian’s high-performance solution for
volumetric modulated arc therapy (VMAT), was recently enhanced to allow multiple arcs as well as
single-arc treatments, couch rotations (for noncoplanar treatments), and delivery of more monitor units
(more dose) per arc. These enhancements were designed to make it possible to use RapidArc when
treating the most demanding cases.
At Decatur Memorial Hospital in Decatur, Illinois,
the vast majority of radiotherapy patients receive
RapidArc treatments. According to medical physicist
Sharon McMillan, MS, DABR, most are single-arc
treatments, but a few of the more complex cases are
improved by a second arc.
“We generally prepare several single-arc plans to
start, and if we don’t like the level of conformity
achieved, we move on to planning for two arcs,” says
McMillan. “Although these days, we often know
from the outset when we’re going to need a second
arc, especially for certain head and neck cases,
where you have large targets and need very tight
conformity. But regardless of whether treatments
require one or two arcs, the patients spend much
less time on the treatment table than would be the
case with conventional fixed-beam IMRT.”
The ability to plan noncoplanar treatments—
another new feature of the updated RapidArc technology—has also been important for McMillan in a
number of cases. “In one case, we had a patient who
had already been treated with photons and electrons
on the right side of her head. We needed to treat a
new tumor toward the middle of her brain without
delivering dose to the previously treated area. We
moved the couch 90 degrees and delivered a vertex
arc, and were able to give her a very nice treatment.”
Ben Slotman, MD, head of radiation oncology at VU
University Medical Center in Amsterdam and a
2
RapidArc plan for a prostate cancer treatment, generated using Varian's Eclipse treatment planning software.
member of Varian’s RapidArc Council of advisors,
began experimenting with multiple arcs before this
capability was added to the RapidArc module in the
Eclipse™ treatment planning program. “At that point,
one arc had to be optimized and then used as an
input for the planning system to generate the second arc,” he says. “The updated version of RapidArc,
which plans multiple arcs simultaneously, speeds up
the planning process for multiple arcs.”
Using several arcs also makes it possible to treat extremely large tumors, or multiple tumors simultaneously. For example, when two or more tumors in the
brain lie in front of each other, they can be accurately
targeted with a single treatment that devotes an arc
to each.
“RapidArc treatments involving multiple arcs and
multiple isocenters allow us to treat longer and
wider target volumes,” says Antonella Fogliata, PhD,
a medical physicist with the Istituto Oncologico della
Svizzera Italiana (IOSI) in Bellinzona, Switzerland,
who is also a member of the RapidArc Council. “Noncoplanar treatments are ideal for sparing some organs at risk in complex regions—for example, the
hippocampus in the brain.”
CENTERLINE | JUNE 2009
Multiple arc capabilities enabled the IOSI clinical
team to use RapidArc in treating a challenging pediatric case, a 12-year-old girl with a large Hodgkin’s
lymphoma. The team delivered dose to two targets,
one encompassing both lungs, and the other covering the entire system of lymph nodes from the cervical to the lumbar spine, including the spleen. The
treatment was delivered in 11 fractions, using two
arcs that were five centimeters apart. “This approach
gave us a very good degree of conformity and very
little involvement of the organs at risk, such as the
immature breasts, ovaries, kidneys, heart, and thyroid,” says Fogliata.
In addition to supporting multiple and noncoplanar
arcs, Eclipse can plan RapidArc treatments that deliver more monitor units per gantry rotation. According to Slotman, the higher dose delivery rate has
come in handy. “It’s of great benefit to us, since we
use RapidArc on a routine basis for stereotactic treatments where doses per fraction are considerably
higher,” he says. “The capability further reduces
treatment times, which reduces the risk of baseline
shifts during treatment.”
Fogliata agrees that
hypofractionation, or
stereotactic radiotherapy,
is becoming more common
for a greater number of indications. She is also seeing
more dose escalation for delivering simultaneously integrated
boosts during a course of treatment. “These techniques are increasing the dose quite
a bit beyond the conventional 2 Gy per fraction,” Fogliata observes. “With the new RapidArc capability, almost all of these types of cases will be theoretically
treatable using a single arc. Depending on the case, at
least 15 to 18 Gy can be delivered using a single arc. In all
likelihood, multiple arcs will be needed mostly for long
or huge volumes, or when very complex clinical requirements must be met.” ✺
VARIAN OFFERS SURVIVORSHIP
AND LONG-TERM IMAGE
MANAGEMENT SOLUTIONS
EQUICARE CS: Case management software
for cancer survivorship
Varian and Cogent Health Solutions are offering oncology treatment centers a way to provide cancer
survivors with proactive follow-up care to achieve a
better post-treatment quality of life. EQUICARE CS™
cancer survivorship case management software, optimized to work with Varian’s ARIA® oncology information system, is a web-based, patient-centric tool
that can help cancer survivors, their caregivers, and
their healthcare providers achieve better clinical
compliance and improved patient outcomes following treatment for cancer.
Cancer survivors typically require follow-up care for
late effects of treatment, secondary cancers, and
quality-of-life issues. They often require diagnostic
testing and nutritional and counseling services.
“EQUICARE CS is a unique solution for ensuring that
patients who have joined the growing ranks of cancer survivors get the help they need to cope with the
health issues that often follow successful cancer
treatment,” says Maureen Thompson, senior director
of oncology information systems at Varian.
“EQUICARE CS helps doctors generate a care plan
based on best practices and established guidelines,
and creates a dynamic link between all the key
stakeholders—patients, caregivers, and physicians,”
says Len Grenier, president and CEO of Cogent Medical Systems. “It distributes essential information to
the patient through a personalized portal on the Internet, empowering survivors to become more active
in their ongoing recovery. A survivorship program
with EQUICARE CS will allow cancer centers to continue providing world-class care and manage outcomes for years after a patient’s initial treatment has
concluded.”
See related feature story on page 10. ✺
OncoView: An oncology-specific image
management and storage solution
At the ASCO and AAPM annual meetings this year,
Varian will showcase a new product that makes it
easier for clinicians to store, manage, and view images generated during cancer treatments. The OncoView™ image management and storage solution
provides oncology professionals with a reliable, scalable way of archiving and accessing patient data and
images. It is designed specifically to archive information covering the entire cancer treatment process,
from diagnosis to survivorship and follow-up.
manage all the unique oncology objects that are created during a course of radiotherapy. For example,
most PACS cannot store treatment plans with structure sets, dose information, and other geometric
information specific to a patient’s plan. OncoView
addresses this need. It also supports archiving of the
most commonly used imaging modalities in oncology care, including CT, MR, PET, kV X rays, cone-beam
CT, and electronic portal images.”
The OncoView product is an oncology-specific image
management and storage solution designed to supplement a hospital’s existing PACS by making it “oncology capable,” or it can operate as a standalone
solution for centers that don’t have such a system.
OncoView enables clinicians to retrieve or store important information within its own archive or within
hospital PACS through industry-standard communication protocols such as HL7 and DICOM. It interfaces
seamlessly with any standards-based clinical information management system, including Varian’s
ARIA® oncology information system, to support a
trend in medicine toward paperless and filmless clinical operations that speed workflow and improve
cost-efficiencies.
Note: The viewing capabilities within OncoView
are manufactured by Velocity Medical Solutions
(http://www.velocitymedical.com/). ✺
“There is a vast—and growing—amount of images
and related information that must be stored, and clinicians need a reliable system for easily archiving
and instantly accessing this information in a meaningful way that is connected to the clinical ‘story line’
for each patient,” says Erwin Nell, Varian senior manager of user experience. “Most general picture
archiving and communication systems (PACS) cannot
CENTERLINE | JUNE 2009
3
NEWS
Zeledon. “By using MyVarian,
customers have an immediate
communication channel to Varian for nonurgent support. We
pride ourselves on responding
quickly.”
Treatment Center Locator Map
Gains Popularity
Varian has added a treatment center locator map to
the company’s Patient Information web page at
http://www.varian.com/us/patient/. This resource
allows people who have been newly diagnosed with
cancer or others researching cancer treatment options
to quickly locate treatment centers within a specific
geographic area that are using Varian technology.
The “Find a Varian Treatment Center” application,
written by the Varian web team, utilizes Google
Maps and a database of treatment facilities. “The
site is used by an average of 1,500 to 2,000 people
each month,” says Nikolay Misharev, the Varian web
developer who programmed the site. “Users can customize their searches to find centers within a specific
number of miles around a particular address or city,
then sort their findings by treatment modality.”
Users can find treatment centers offering IMRT, IGRT,
RapidArc™, or HDR brachytherapy, or sites using Trilogy® or Novalis Tx™ for stereotactic radiotherapy.
MyVarian: A One-Stop Shop
for Information
SM
In late 2007, Varian launched the MyVarian customer support environment, a “one-stop shop for
all things related to Varian products,” according to
Dolores Zeledon, an oncology systems marketing
manager who oversees the MyVarian website.
“Customers can use the site to access product documentation, product updates, manuals, application
tips, reference materials, archived webinars—any
information they might need about a Varian product
they are using.”
When customers register at the MyVarian site,
Varian processes the registration within two to five
days, providing customers with access to the parts of
the website that are relevant to the specific technologies the customer has acquired.
While Varian attempts to keep the treatment center
locator map as up-to-date as possible, treatment
center personnel may wish to check the listings and
notify Varian if any information is incorrect or needs
to be updated, using the online form linked to the locator map at http://www.varian.com/dyna/locator.
It generally takes less than 72 hours to get a treatment center added to the site. ✺
4
Since the launch of MyVarian approximately 18
months ago, Varian has sponsored several webinars
on the site. There have been webinars on RapidArc™
treatment planning, BrachyVision™ planning, using
Varian software to establish a paperless environment, IGRT protocols, and more. “This is one way for
clinical professionals who have gained some experience with a new technology to share ideas with their
peers,” says Zeledon. “We hold about six live webinars and six prerecorded webinars each year, and
they are all archived on the site.”
MyVarian also provides a channel for direct communication with Varian personnel. Customers can open
Help Desk tickets and submit product improvement
suggestions at the site. “We acknowledge all submissions and we follow up with the customer if it is appropriate or if more information is needed,” says
CENTERLINE | JUNE 2009
There are now more than
6,500 customers registered
at the MyVarian website. “We
are getting about 15 to 20 new
registrations every day,” Zeledon says. “In the future, we
plan to integrate the means of accessing our educational and training programs into the site. The goal is
to bring all services under one umbrella and turn MyVarian into a one-stop shop, not just for product information, but for a full spectrum of services.” ✺
NEWS FROM EUROPE
AND THE MIDDLE EAST
Estonian Cancer Patients Gain Access to
Advanced Cancer Care
North Estonia Regional Hospital in Tallinn, the country’s capital, has become the first Estonian treatment
center to offer cancer patients access to advanced radiotherapy techniques such as intensity-modulated
radiotherapy (IMRT). This fact was recently celebrated with an official unveiling of a new Varian linear accelerator that attracted coverage on Estonian
national television and in national newspapers.
The hospital, which serves two-thirds of the country’s 1.4 million population, has doubled its linear accelerator capacity with the acquisition of a Varian
Clinac® DHX equipped with a Millennium™ 120-leaf
collimator.
“We have moved from conventional radiotherapy to
conformal radiotherapy for the first time,” says senior physicist Eduard Gerskevitch. “The collimator’s
finer leaves allow clinicians to conform the treatment beam tighter to the tumor and limit irradiation
of normal healthy tissue. This new equipment has
enabled us to improve the quality of our treatments
while reducing waiting lists. Our waiting
times have reduced
from five weeks
to three weeks,
although we’ve
achieved this with
a heavy workload
on our machines.”
This workload increased shortly after the new machine arrived when an older device at the only other
Estonian radiotherapy hospital broke down and all
that hospital’s patients were transferred to the
North Estonian Regional Hospital. “At present we are
the only hospital in the country treating patients
with a linear accelerator, and we are extremely
busy,” says Maire Kuddu, MD, chief radiation oncologist. Staff at the hospital are working double shifts
on both machines as they attempt to cope with more
than 130 patients a day. Despite this heavy workload,
the team has been able to introduce advanced IMRT
for head and neck cancer patients.
The new device was funded by the hospital with support from the International Atomic Energy Agency,
which provided additional financing and helped to
train staff in the use of the equipment, and the Environmental Investment Centre, which helped to decommission an older cobalt-based treatment unit
and refurbish the bunker for the new accelerator. ✺
RapidArc Technology Deployed by
Germany’s HELIOS Group
In February, Germany’s HELIOS Kliniken Group ordered
nine linear accelerators from Varian, the majority of
them equipped with RapidArc™ radiotherapy technology for fast delivery of volumetric arc treatments.
Berlin-based HELIOS, one of the three largest private
clinic groups in Germany, offers radiotherapy at six
hospitals in Krefeld, Wuppertal, Schwerin, Bad
Saarow, Berlin-Zehlendorf, and Berlin-Buch. The new
machines will be installed at each of these sites, replacing older models and adding capacity that will
give more patients access to the most advanced cancer care. Each site will also receive a suite of Varian’s
ARIA® oncology information management software
and Eclipse™ treatment planning software. Three of
the hospitals will also receive a new GammaMed™
brachytherapy afterloader.
“The new equipment will enable HELIOS to offer dynamic adaptive, high-precision radiotherapy for all
patients, and the HELIOS staff has identified RapidArc
as a major additional capability,” says Michael
Sandhu, head of Varian’s Oncology Systems business
in Europe. “Healthcare providers such as HELIOS have
continued to invest strongly in radiotherapy equipment and software that enable them to offer patients
modern and comfortable treatments. We are honored to be working with HELIOS on this project.”
The new equipment will be installed in stages over
the next two years. HELIOS, a business segment of
the global health care company Fresenius, owns 62
hospitals across Germany. In 2008, 63,000 cancer
patients were treated in HELIOS hospitals. ✺
State of Qatar to Introduce
Advanced Radiotherapy
Al Amal Hospital in Doha, Qatar, one of the leading
cancer centers in the Middle East and the only radiotherapy treatment facility in Qatar, is replacing fouryear-old linear accelerators from another manufacturer with Trilogy® and Clinac® iX devices in order to
provide patients with more modern and efficient
treatments.
The new equipment will enable clinicians in Qatar
to begin treatments using RapidArc™, Varian’s approach to volumetric arc therapy.
machine throughput as well as patient outcomes.
We are very excited about the potential of RapidArc.”
Part of the Hamad Medical Corporation, the government provider of health in the State of Qatar, Al
Amal Hospital treats patients from across the Gulf
region. Its cancer patients present with a complex
mix of all types of tumors, including pediatric cases
and a large proportion of breast cancer patients. The
department aims to become a recognized Centre of
Excellence in IGRT for the region within five years.
“This is the vision and we are already well on our
way,” says Al-Hammadi. “We have always ensured
that the treatments offered to the population of
Qatar matched those found in any major state-of-
the-art cancer center in the world. In keeping with
this mandate, we evaluated offerings from all three
major vendors, as well as other arc therapy techniques such as helical tomotherapy, and decided that
Varian had the most advanced systems and the most
clinically integrated system to meet our needs.”
“This decision by one of the foremost radiotherapy
departments in the Middle East shows that what’s
most important for customers in this region is not
just the latest, most up-to-date technology, but also
equipment performance and reliability, along with a
strong service and support organization in the Gulf
region,” says Michael Sandhu, head of Varian’s Oncology Systems business in the EMEA region. “A huge
plus for Varian is our service office and bonded
warehouse facility in Bahrain. We have 18 service
people, including dedicated IT service personnel in
the region, and they are on hand to provide fast support for local customers.” ✺
“Evidence suggests that RapidArc will revolutionize
the way IMRT is delivered,” says Noora Mohammed
Al-Hammadi, MD, head of the hospital’s department
of radiation oncology. “Faster, more conformal treatments are always desirable in radiotherapy, both for
CENTERLINE | JUNE 2009
5
No Paper. No Film. No Problem.
Integrated Varian technologies improve operational efficiency of both clinics and professional practices
By John W. Swanson, PhD, DABR, DABMP
Linked by the ARIA® oncology information management system,
integrated Varian technologies are improving operational efficiency for clinics like the Mark H. Zangmeister Center and professional practices like Global Physics Solutions (GPS), a U.S.
medical and health physics practice group.
In recent years, GPS helped the Zangmeister Center, a new
110,000-square-foot comprehensive cancer center in Columbus,
Ohio, become operational in record time. In this article, John W.
Swanson, PhD, DABR, DABMP, senior vice president of GPS,
discusses how his organization assists clinicians at the Zangmeister Center with the optimization of their radiation oncology and
imaging department programs. The Zangmeister Center has
streamlined and augmented clinical and technical operations and
performance through the implementation of a filmless and paperless environment.
6
From a patient’s perspective, the value of receiving care in
a paperless, filmless environment is clear. It means that all of
the information about the patient exists in one place, and care
providers have the information they need, precisely when they
need it. There’s no waiting for days or for another department
to send records that might go astray. When a patient shows up
for daily treatments, the details about the prior day’s treatment
—including images generated at the treatment machine—are
right there for the doctor to review. No one has to search for
files. More importantly, in a comprehensive cancer center with
medical and radiation oncologists accessing the same electronic
medical record, patient care is better coordinated and managed
from start to finish.
CENTERLINE | JUNE 2009
ringing telephone, which demands an immediate response,
instant messages allow the recipient to respond when appropriate,
and the messages can be answered
more quickly and with less effort
than is the case with e-mail. In
addition, a full communications
log is automatically generated.
What might be less apparent,
but equally important, is that from
a clinical administrator’s perspective, operating in a wholly electronic environment provides ways
of increasing efficiency in departmental operations.
Managing workload with remote
dosimetry and physics
GPS recently implemented remote
access across all of its Varian
A professional practice group, GPS
sites. Senior physicists have reprovides treatment centers with supLouis Rivello, MD, Matthew Daniels, PhD, and Steve Gasiecki, MS,
mote access to the Eclipse and
plemental physics and dosimetry
prepare for an SRS procedure at the Zangmeister Center.
ARIA systems at each site they
services, both onsite and from remanage.
The software also allows
mote locations. When a clinical practhe organization to define which dosimetrists have access to
tice grows, its need for physicists and dosimetrists may increase
which client sites, allowing them to work from home several
in relatively small increments. GPS helps clinics manage growdays a week in some cases.
ing workloads by remotely supporting the clinic’s physicists and
dosimetrists, at least until the volume of work justifies the addiRemote access also allows multiple users to connect to the
tion of another full-time person. For clinics that are operating
same computer at the same time. This enables GPS physicists
electronically, GPS can use remote access to redeploy excess cato troubleshoot problems remotely and to train the on-site
pacity to other facilities. Varian’s integrated technology helps
physicists without having to travel. The remote access software
make all this possible.
is fully HIPAA compliant and provides the organization with
This was the situation faced by the Mark H. Zangmeister
Center in Columbus, Ohio. Thanks to remote connectivity capabilities, GPS physicists and dosimetrists are able to log in to a
secure website and use Citrix software to access Zangmeister’s
ARIA oncology information system and Eclipse™ treatment
planning workstations—from either Macintosh or PC computers anywhere in the world. Since security and patient privacy are
paramount, all of the data accessed through Citrix is encrypted
and two separate logins are used to ensure that only authorized
staff members have access.
Working this way not only promotes efficiency for both
Zangmeister and GPS, it also enables greater flexibility for the
radiation oncology consultants. For instance, if a patient’s treatment plan must be completed for the following day, a dosimetrist
can work from home rather than having to stay late at the clinic.
Communicating through a computer-messaging client
GPS’s remote dosimetrists communicate with physicians, physicists, and other clinical staff using a computer-messaging client
instead of an intercom, phone system, or e-mail. This mode of
communication has several advantages. Since the majority of
clinical work is computer-based, it is less intrusive to receive
an instant message rather than a phone call or page. Unlike a
a history of who is accessing each computer. Recently, a GPS
physicist at the Zangmeister Center was able to use the remote
access capabilities to provide a physicist at a new site with remote training on implementing IGRT protocols for Varian’s
Trilogy® system.
Remote approval of patient positioning—in real time
Using remote electronic connections, GPS has enabled physicians at the Zangmeister Center to view the online kV-kV or
cone-beam CT (CBCT) image matching from their offices in
real time. These remote connections are initiated at the treatment console in order to ensure that only computers in the
physician’s offices are allowed to view the On-Board Imager®
workstation remotely. For additional security, the information
sent over this connection is encrypted.
After therapists complete the kV-kV or CBCT matching,
they use the computer-messaging client to inform the physician
that the patient plan is ready for review. Physicians can then adjust the shift just before the patient is treated instead of reviewing the plan at the end of the day. By performing this function
from their offices, physicians save valuable time. The entire
process adds only about 30 seconds to the treatment. If a physician is unavailable to review a shift in real time within 60 seconds and the shift is less than one centimeter, therapists can
CENTERLINE | JUNE 2009
7
An image from the SBRT treatment plan for cancer of the
right adrenal gland, generated using Eclipse treatment
planning software.
apply the shift without physician approval. This ensures that patient positioning is not compromised by the
extra procedural step. If the shift is
greater than one centimeter, a physicist is contacted to review the shift
before treatment.
“Varian’s CBCT technology
performed flawlessly, and after
several breath holds, the physician was able to match a breathhold CBCT to the planning
breath-hold CT scan.”
the Chart QA button and the weekly chartcheck charges are automatically billed. Our
billing specialists no longer have to worry
about adjusting dates for weekly chart
checks.”
SBRT in a freestanding center
GPS has also helped start a stereotactic
body radiation therapy (SBRT) program at
the Zangmeister Center. One early case inAlthough it can be daunting at first
Matthew Daniels, PhD, Zangmeister Center
volved treatment of a right adrenal gland.
to move from paper to an electronic
Because of its location in the abdomen, the adrenal gland moves
chart, it is well worth the effort. This is especially true in the
during respiration, and is surrounded by critical structures such
area of chart quality assurance. GPS uses Varian’s Chart QA,
as the kidney, liver, and small bowel. The radiation oncologist
which makes the frustrating “weekly chart hunt” a thing of the
chose to treat it with IMRT utilizing a breath-hold technique.
past. Chart QA allows physicists to check everything that used
Three planning CT scans were acquired with breath hold in order
to be checked on a paper chart as well as additional items such
to ensure that the planning target volume (PTV) encompassed
as gantry, couch, and jaw positions. Chart QA also color codes
the residual motion and included any variations in the patient’s
the information, highlighting any treatment that was not delivbreath-hold pattern over time.
ered as planned and indicating if there were any overrides and
which staff members performed them.
The amplitude of the patient’s breath hold was tracked by
Chart quality assurance
The Documents tab in Chart QA ensures that all the necessary information, such as IMRT QA documents or secondary
MU checks, is available for each patient. This is especially valuable for physicists who are checking the charts of patients for
whom they did not perform the initial chart checks. Physicists
can also annotate the electronic chart to provide a permanent
record of information that the physicist considers necessary.
At the Zangmeister Center, physicists check charts on a routine basis every day. “By filtering, we can quickly and efficiently
check the charts of each patient receiving 5, 10, 15, etc., treatments,” says medical physicist Matthew Daniels, PhD. “This allows all of our physicists to perform weekly chart checks on
patients as they have time, instead of spending a large amount
of time one day a week. After completing these checks, we click
8
Varian’s RPM™ respiratory gating software to provide a baseline
value. Since the patient was receiving a hypofractionated treatment and the tumor was surrounded by critical structures, image
guidance was necessary.
Varian’s On-Board Imager device was used to acquire a CBCT
image to ensure that the location of the adrenal gland was correct
prior to every treatment. However, it was necessary to stop and
start the CBCT acquisition several times because the patient was
not able to hold his breath for the entire minute that a single
CBCT acquisition requires. “Varian’s CBCT technology performed flawlessly, and after several breath holds, the physician
was able to match a breath-hold CBCT to the planning breathhold CT scan,” says Matthew Daniels, PhD, medical physicist.
CENTERLINE | JUNE 2009
“Varian Medical Systems has provided
us with much better tools to deliver
higher-quality cancer care.”
Ming Zeng, MD, PhD, Zangmeister Center
During both the CBCT acquisition and the treatment, the
amplitude of the breath hold was tracked using Varian’s respiratory gating system and compared to the baseline values acquired during the initial CT scans. “If the amplitude varied
significantly from this baseline, we were able to tell the patient
to adjust how deeply he was breathing,” says Daniels. “Taken all
together, these steps allowed us to treat the patient with a hypofractionated technique and a high degree of confidence.”
After treatment, a pair of kV-kV images was acquired to
monitor the intrafraction motion of the patient. Since a high
dose rate (1,000 MU/min) was used, the total treatment time for
the patient was around five minutes, even with the breath-hold
technique. The intrafraction motion was found to be minimal
(<2mm).
According to Ming Zeng, MD, PhD, a radiation oncologist
at the Zangmeister Center, “Varian Medical Systems has provided us with much better tools to deliver higher-quality cancer
care.” And at the Zangmeister Center, as at GPS, quality care
and operational efficiency walk hand in hand. ✺
John W. Swanson is a senior vice president at GPS, which provides medical and
health physics services to healthcare and commercial clients.
The Efficiency of an Integrated HDR Environment
MedCentral Health System of Mansfield, Ohio, a busy
“An integrated environment like the one provided
moved from the Acuity table, the physicist uses
in-hospital practice, recently designed a new cancer
by Varian’s ARIA system helps efficiency not only in
BrachyVision™ software to create the treatment plan,
center to be operated as a hospital-based freestanding
the linac paradigm for external beam treatment, but
which is quickly approved, double checked, and deliv-
facility on the hospital grounds. In addition to IGRT-
also for a ‘one-stop shop’ HDR program,” says Steve
ered. The entire process takes roughly 1 to 1.5 hours,
enabled Trilogy® and Clinac® iX accelerators, MedCen-
Gasiecki, MS, a GPS professional serving as chief of
depending on applicator and plan complexity. Subse-
tral uses an Acuity™ simulation and imaging machine,
physics at the MedCentral facility. “Having an Acuity
quent vaginal cylinder plans are based on the original
a GE 16-slice PET/CT scanner, and a Varian-equipped
simulator with CBCT and an HDR afterloader in the
plan, with verification of the cylinder placement com-
high-dose-rate (HDR) brachytherapy system, all tied
same room makes for a very efficient treatment experi-
ing from a quick anterior-posterior (AP) image of the
together with Eclipse™ and ARIA® software.
ence for the patient as well as the staff.”
inserted cylinder. These additional fractions find the
The Acuity simulator in the multifunctional HDR suite
patient in and out of the HDR Acuity suite within 20
is used in a variety of ways. Since every treatment ac-
to 30 minutes. Tandem and ring plans are replanned
cessory on the Trilogy and Clinac also fits on the Acuity
for each fraction, as the setup is different from week
machine, Acuity is used to troubleshoot any set-up is-
to week.
sues for external beam treatments. The MLC projector
“These kinds of processes would take hours if it
allows the visualization of MLC-shaped fields on a pa-
weren’t for the tight integration of all the hardware
tient’s skin. MedCentral physicians appreciate having a
and software components with the patient’s elec-
“classic” simulator in the department for simple simu-
tronic record,” says Gasiecki. “We selected these inter-
lations. In CBCT imaging mode, the Acuity system can
connected technologies from Varian precisely because
be used to image patients who are not good candi-
this was how we wanted to operate. It’s been exciting
dates for treatment planning CT simulation.
to see that vision become a reality.” ✺
The Acuity system is also tightly integrated into the
HDR treatment process. A typical tandem and ring or
vaginal cylinder patient can be positioned on the Acuity table, the applicator(s) inserted, and the patient imaged using CBCT. While the patient rests, not having
CENTERLINE | JUNE 2009
9
NowWhat?
A community hospital keeps connected to cancer survivors
By Nancy Heifferon
“It’s apples to watermelons”
With the ranks of cancer survivors swelling fast,
who is following survivors post-treatment to ensure
that they are screened regularly for new or recurring
cancers? Who is collecting lifelong data about the late
effects of their treatments? Who is providing comprehensive, individualized survivor care plans that address the needs of the whole person?
Community hospitals like TJCH face severe challenges when it
comes to caring for cancer survivors. “They diagnose and treat
80 percent of all cancer cases in the United States,” explains Mark
Thomson, vice president of sales and marketing for Cogent
Health Solutions. “Yet they lack the resources and funding of
large academic medical centers for the third phase of cancer care:
survivorship.”
For a start, Thomas Johns Cancer Hospital (TJCH), a community hospital in Richmond, Virginia. TJCH is a recognized
leader in the emerging area of survivorship. The hospital is
working on solutions for long-term patient follow-up that are
effective for community treatment centers as well as academic
hospitals. Key elements of the TJCH program are dynamic customized care plans and a lifetime connection to survivors, made
possible by web-based EQUICARE CS™ survivorship management software from Cogent Health Solutions tied into the ARIA®
oncology information system from Varian.
Furthermore, community hospitals are already feeling the
brunt of a shortage in oncologists, which is projected to worsen.
While the demand for oncology services is expected to grow by
48 percent between 2007 and 2020, the supply is expected to
grow by only 14 percent. This imbalance of supply and demand
translates into a shortfall in the United States of as many as 4,080
oncologists by 2020.1 While most oncologists believe it is their
responsibility to provide continuing survivor care, there just
aren’t enough of them to address the needs of a survivor population that is growing at an accelerating rate.2 Their first priority
has to be the timely diagnosis and treatment of new cases.
10
CENTERLINE | JUNE 2009
“It’s apples to watermelons,” says
Steven Castle, TJCH administrator, explaining the magnitude of the challenge
for community hospitals. “For example,
at our hospital we treat 1,800 active cancer cases per year, but we are tracking
about 20,000 cancer survivors right now.”
“We are doing such a good
job in the treatment of
cancer, that we created this
huge population of survivors. So the next logical
step, in our opinion, was to
address their continued
well being.”
as a community-based hospital, going to
get a research grant to fund our survivorship initiative,” explains Castle.
Three pillars of a survivorship system
Steven Castle, Thomas Johns Cancer Hospital
It is no wonder then that cancer survivors, who receive
the highest quality care during the active phase of their
treatment, can sometimes feel abandoned or lost after
their last radiation or chemotherapy treatment or their
last appointment with the surgeon. More than a
decade after the National Coalition for Cancer
Survivorship published its 12 principles for
quality cancer care, which included the right
to long-term follow-up care, many survivors
are still waiting for their needs to be addressed. In fact, 49 percent of survivors who
responded to an online poll conducted by the
Lance Armstrong Foundation say they have
unmet survivorship needs.
Tina P., a three-year survivor of inflammatory breast cancer, knows how they feel.
Treated at another community hospital, she
found the cancer resource center at TJCH the
same way she manages her own survivorship
today—by being proactively involved in her
own care and seeking out information and resources. “After treatment, I had scarring that
has made it difficult to live pain free,” Tina
explains. “I had surgery, chemotherapy, and radiation therapy, but
none of those specialties really tackle the leftover issues. Somehow
treatment-related medical issues need to be better addressed.”
At TJCH, they couldn’t agree more. “We are doing such a good
job in the treatment of cancer,” says Castle about the medical profession at large, “that we created this huge population of survivors.
So the next logical step, in our opinion, was to address their continued well being.” TJCH took that next step by seeking partners.
Varian and Cogent Health Solutions helped the hospital develop a
survivorship management program that would meet patients’
needs while easing the burden on overstretched oncologists. “We
didn’t want to wait for somebody else to do it. We didn’t want to
wait for the guidelines to be well established. We knew we weren’t,
TJCH and its partners built the survivorship program on three pillars. The first
pillar is physician control. “Our program is different from
some established survivorship clinics,” says Castle. “In
our program, physicians understand that they remain
in control.” Adds Tricia Cox, director of the TJCH
survivorship program, “Physicians can refer patients to the nurse practitioner or continue to
follow patients themselves, and we will support
them. It’s their choice.”
Flexibility is the second pillar of the survivorship system. “The survivorship case management system we have can be implemented
anywhere from a free-stranding cancer clinic in
a small community to a large urban academic
medical center,” says Castle. “It provides the tools
needed to deliver customized survivorship care
on any scale.”
The third pillar is engagement. A successful survivorship system must connect and engage the oncologist and the patient—and the primary care
physician. When patients enter into cancer treatment, primary care physicians are often left out of
the loop, with potentially serious consequences.
The primary care physician may not see patients who
are referred to cancer specialists for many months, during which
time other medical issues such as blood pressure and diabetes
may worsen. “Patients with major illnesses such as cancer usually
focus only on that major problem and sometimes ‘forget’ about
other comorbidities,” says James Joseph, MD, a primary care
physician who helped TJCH define its survivorship program.
“When the primary care doctor remains involved, problems can
be resolved and the patient stabilized more quickly.” Sometimes,
says Joseph, “Primary care physicians are not even aware that the
patient has expired until we see a relative or receive a death certificate for signature. This is quite devastating for the family and
the primary care physician.”
1. See Forecasting the Supply of and Demand for Oncologists, a report to the American Society of Clinical Oncology (ASCO) from the AAMC Center for Workforce Studies, 2007.
2. See “Survivorship,” from Elevating the Patient Experience, p. 63, published by The Advisory Board, 2008.
CENTERLINE | JUNE 2009
11
“EQUICARE CS tears
down the silo walls that
exist between the medical
oncologists, the radiation
oncologists, and the
surgical oncologists.”
summary of all treatment delivered
Joseph’s recommendations for any
and a lifetime schedule for follow-up
cancer survivorship program include
screenings and appointments. It proa comprehensive treatment plan with
Steven Castle, Thomas Johns Cancer Hospital
vides information about the short- and
the role of the primary care provider
long-term treatment side effects that
clearly outlined, regular progress notes
could occur. It includes individualized guidance about diet and
from the treating cancer specialist, and referrals back to the priexercise. The plan even includes referrals to support services
mary care physician for management of medical issues such as
appropriate to the individual. EQUICARE CS case management
hypertension or diabetes. “Cancer survivors should be encoursoftware generates the plan automatically, pulling information
aged to follow up with their primary care physician,” emphasizes
from the electronic oncology medical record (the ARIA oncolJoseph.
ogy information system from Varian). A plan that would take
A dynamic care plan
hours of manual effort to assemble is generated with the click
of
a mouse.
The TJCH survivorship program has taken action on these recommendations, as well as those of cancer specialists and patients.
At the conclusion of treatment, the patient receives a customized care plan that is a survivor roadmap. It includes a
The electronic care plan can do much more than a static
paper document. It generates reminders about follow-up events,
such as screenings or lab tests, or alerts that scheduled events have
A State-of-the-Art Community Hospital
Founded in 1982, the Thomas Johns Cancer Hospital
(TJCH) is located on the Johnston-Willis campus of the
CJW Medical Center in Richmond, Virginia. CJW has
long maintained the highest level of accreditation that
a community hospital can attain from the American
College of Surgeons Commission on Cancer, and
12
recently received that organization’s Outstanding
Achievement Award. A model for comprehensive and integrated care, it serves inpatients and outpatients with
surgery, medical oncology, radiation oncology, gynecology, urology, and support services, all under one roof.
Image courtesy of TJCH.
CENTERLINE | JUNE 2009
“When the primary care doctor
remains involved, problems
can be resolved and the patient
stabilized more quickly.”
James Joseph, MD, primary care physician
been missed. These notifications can go to the nurse practitioner,
the physician, or the survivor.
Survivors also receive secure access to their individual care
plans over the Internet. Having the plan online enables two-way
interaction between survivors and healthcare providers. The
healthcare provider can collect feedback from the survivors
about satisfaction. Certain cohorts of survivors can be surveyed
online to collect data for analysis. Primary care physicians also
have a secure portal where they can view their patients’ care
plans and obtain information about post-treatment issues they
may be experiencing.
“EQUICARE CS tears down the silo walls that exist between
the medical oncologists, the radiation oncologists, and the surgical oncologists by enabling them to exchange information
more freely. It also builds a bridge to the primary care physician.
It’s a beautiful system,” says Castle. And, he adds, “It’s pretty easy
to implement if you have Varian ARIA products.”
Moving ahead
Thomas Johns Cancer Hospital started its survivorship program
with 12 breast cancer patients and is expanding from there. As
multiple organizations—such as the American Cancer Society,
the National Comprehensive Cancer Network (NCCN), American Society of Clinical Oncology (ASCO), and the American
Society for Therapeutic Radiology and Oncology (ASTRO)—
publish their separate guidelines for survivor care, TJCH is implementing them in its survivorship program. NCCN added a
survivorship section to its colorectal treatment guidelines in
February 2009, so next up are care plans for colorectal cancer
survivors. “Our medical staff reviews and validates the care plan
template, and we implement their choices. We aren’t waiting for
all these organizations to reach agreement on the guidelines,”
says Castle.
The response to the TJCH survivorship program has been
overwhelmingly positive from all quarters. “We engaged cancer
patients, cancer survivors, oncologists, primary care physicians,
and IT in the development of the program,” concludes Castle.
“Everyone we talk to loves the program.” ✺
Nancy Heifferon is a freelance healthcare writer.
THE DECLARATION OF
CANCER SURVIVOR RIGHTS
Survivorship programs stem from two of the guiding principles
articulated by the National Coalition for Cancer Survivorship.
Principle 6: People with histories of cancer have the right to continued
medical follow-up with basic standards of care that include the specific
needs of long-term survivors.
Principle 7: Long-term survivors should have access to specialized follow-up clinics that focus on health promotion, disease prevention, rehabilitation, and identification of physiologic and psychosocial problems.
Communication with the primary care physician must be maintained.
To learn more, visit the National Coalition for Cancer Survivorship’s
“Imperatives for Quality Cancer Care: Access, Advocacy, Action and
Accountability” at http://www.canceradvocacy.org.
TJCH sees the survivorship program as a means to grow
loyal patient relationships. Meeting the demands of survivors
for individualized follow-up care is likely to increase their satisfaction and bring them back to TJCH for their regular scans and
tests. Furthermore, better follow-up care and earlier intervention when health problems do arise can lower the overall longterm cost of healthcare for survivors.
CENTERLINE | JUNE 2009
13
CancerCare Manitoba
CancerCare Manitoba’s John Ioculano, radiation therapy manager, and Mark Kuchnicki, director of health information services.
14
CENTERLINE | JUNE 2009
Upgrades Cancer Treatment
The province of Manitoba in Western Canada is home
to approximately 1.2 million people. Spread over
250,000 square miles, Manitoba is located between
Saskatchewan to the west and Ontario to the east.
Cancer treatment for the province is managed by
CancerCare Manitoba, an organization that is
charged by the Manitoba legislature with responsibility for cancer prevention, detection, care, research,
and education.
Over the last year and a half,
CancerCare Manitoba (CCMB) has
been implementing a major technology initiative designed to accomplish
three goals:
• An electronic health record initiative seeking to move all
healthcare services throughout Manitoba toward more
efficient, paperless processes
“In the spring of 2007, the federal and provincial governments had agreed to radiotherapy treatment wait time guarantees and asked that these be implemented by the following year,”
Ioculano says. That meant that CancerCare Manitoba needed to
find ways of ensuring that, even as they implemented new, more
complex treatment modalities, they would be able to ensure that
100 percent of radiotherapy patients
would receive treatment within four
weeks of having been deemed “ready to
treat.”
“We wanted a system
that allowed us to enter
information just once,
whenever and wherever
it made the most sense.”
“We could see that we needed a
complete and integrated package of
hardware and software that would help
• Upgrade treatment technology
us to optimize treatments and outcomes
to state of the art.
for our patients, and also gain efficien• Deploy a fully integrated informaMark Kuchnicki, CCMB
cies
in our work processes to make the
tion system that will streamline
newer
modalities like IGRT clinically feaoperations and yield comprehensible,” Ioculano says. “We needed to be confident that we insive information about each patient’s course of treatment anyvested in a framework that fit our needs for the future.”
where within the system.
• Integrate the medical and radiation oncology treatment
processes for better coordination of patient care.
“A year and a half ago, we began an initiative to replace existing accelerators that were reaching the end of their service
life,” explains John Ioculano, the radiation therapy manager who
is also serving as project manager for the initiative. “We pulled
together a team of professionals across the field—radiation oncologists, radiotherapy administrators, IT professionals, medical
physicists, and nuclear electronic staff—to evaluate our options.”
A framework for the future
A convergence of factors—medical, technological, and public
policy—made it quickly apparent to the CCMB team that their
task would have to go beyond the purchase of a few new linear
accelerators. These factors included:
• A government-mandated effort to reduce treatment wait
times for radiation therapy patients
• A technology explosion in the field of radiation oncology
that had given rise to advanced modalities like IGRT and
volumetric arc therapy
Integrating systems, treatment modalities, geographies
“We had been working with a conglomeration of products from
different vendors,” says Mark Kuchnicki, director of health information services for CCMB. “We wanted a system that allowed us to enter information just once, whenever and wherever
it made the most sense for delivering services to patients, rather
than multiple times in different places. We also wanted a system
integrated across treatment modalities—both medical and radiation oncology—and also across geographies. That way, a patient receiving radiation treatment in Winnipeg, for example,
would be able to switch to another site closer to home for drug
therapy, and the clinicians at both sites would have full access to
the complete patient record.”
According to Ioculano, the project team discovered that
many cancer treatment technologies could pass information
back and forth, but Varian’s was the only system that allowed for
seamless integration. “We wanted all the key service providers—
the radiation oncologists, radiation therapists, medical physicists, nurses, everyone whose activities touch the patient—to be
able to know what the others were doing, without having to
make phone calls or send e-mails and wait for responses. Using
CENTERLINE | JUNE 2009
15
the ARIA® information system, any one of us can query the system to find out exactly what has taken place, what is scheduled
to happen, and when. We even gain some visibility into where
the bottlenecks are, and that gives us a chance to address any
delays in our processes.”
Kuchnicki agrees: “An integrated system lets us track exactly
where and when things are happening. You can’t fix a process if
you don’t know where the delays are happening.”
Already nearly paperless
CancerCare Manitoba was not entirely new to the benefits of
computerization. On the medical oncology side, CCMB had
been the first institution to adopt the OpTx® medical oncology
information system, which was subsequently acquired by Varian
and integrated with the ARIA oncology information system to
produce the ARIA product now available for managing comprehensive cancer services. “We were a bit unique in that we used
the software quite completely, for managing every aspect of our
medical oncology services, including pharmacy, lab, records,
notes,” explains Kuchnicki. “Our database was already massive,
and we were nearly paperless. In fact, we currently use the system to schedule radiation oncology processes as well. But when
looking to upgrade our radiation oncology technology, we saw
how much the latest, advanced treatment modalities required
very specialized data management processes, and realized it
was in our best interests to invest in the comprehensive ARIA
solution.”
It took the project team about a year to come to that conclusion. “We went through a very exhaustive and thorough investigation because we believe the patients of Manitoba deserve the
best quality care that we can provide,” Kuchnicki says. “After
looking at all of our options, we concluded that there was really
only one vendor who could provide us with a system that would
help us find and lock in efficiencies, deal with all the data and
image management challenges, and provide comprehensive
services across the entire province.”
Generic EMR
or Oncology-Specific
Information System?
A year before CancerCare Manitoba began its initiative to upgrade the
radiation oncology technology across the province, CCMB clinicians participated in a clinical review process, looking at electronic medical record
(EMR) technologies that were being deployed at local hospitals.
“CancerCare Manitoba doesn’t provide diagnostic services,” explains Mark
Kuchnicki, CCMB’s director of health information services. “We rely on our
hospital partners for everything from X rays and lab work to immunology.
Since there was a push to implement an EMR at the hospitals, we asked ourselves: ‘Do we get on board with the generic EMR, or do we work to find the
best tool for streamlining and integrating cancer treatment processes, and
then connect to the hospital systems another way?’ ”
Kuchnicki and his colleagues found that, while some generic EMRs could
Consequently, Varian’s ARIA system, along with the Eclipse™
treatment planning system, is being deployed at two radiotherapy treatment centers: a large centralized facility in Winnipeg,
where seven linear accelerators operate, and at a satellite facility
in Brandon, developed in partnership with the Brandon Regional Health Authority. The ARIA system is also used to operate more than 20 medical oncology sites across the province.
support medical oncology processes, this was not the case for radiation
“All of our doctors, nurses, therapists, and clerks—anyone
who touches patient information—are collaborating on this
project and looking hard at the way we do things, to learn how
we can improve so patients have the shortest possible wait times
and the best possible care,” Kuchnicki says. “We’re leveraging
Varian’s product suite to get that done.” ✺
tem, and to interface that to the system used by the hospitals. “Our analysis
16
CENTERLINE | JUNE 2009
oncology. “If we had migrated to the hospital EMR to manage medical oncology,” he says, “we would have had to build a huge number of interfaces to
the radiation oncology system to achieve the level of integration we had
envisioned for tracking comprehensive cancer treatment.”
The CCMB team decided to focus on providing an integrated cancer care sysshowed that, by doing it that way, we would need to build fewer interfaces
and they would be less complicated. Since Varian offers a complete medical
and radiation oncology information system, I didn’t have to worry about
that integration; Varian would provide it. I just had to link it to the hospital
system on the business side.” ✺
Treatment, Training, and Technology:
Three Leading Cancer
Centers in Brazil
Over the last five years, Varian has equipped
14 Brazilian treatment centers with IMRT
technology, and thousands of patients have
benefited. This article profiles three centers
that represent the mix of private, philanthropic, and government-supported radiotherapy treatment facilities in the country.
Brazilian cancer treatment centers took a leap forward in
the early 1970s, when the first linear accelerators were installed.
These were a Clinac® 4 and a Clinac 6X, two early Varian machines designed to replace the cobalt-60 radiation units that
were in use at the time. The Varian machines worked at higher
energies to generate greater penetration power, and they had
another important benefit over cobalt: no expensive physical
radiation source to deteriorate and discard.
Since that time, Varian has installed more than 140 medical
linear accelerators in Brazil, and over the last five years,
equipped 14 treatment centers with IMRT technology. More
than 2,500 patients have now benefited from this more conformal form of treatment. Three Brazilian treatment centers now
can also offer IGRT.
CENTERLINE | JUNE 2009
17
In Brazil, the country’s National Cancer Institute (INCA), Hospital AC Camargo, and Hospital Israelita Albert Einstein offer patients sophisticated forms of treatment
and also provide clinical training and medical education for Latin American radiation oncologists, physicists, and other clinical specialists.
Clearly there is a great need for more access to advanced
forms of treatment. Oncologists in Brazil prescribe radiation for
their patients in approximately 60 percent of cases, which is
roughly comparable to prescribing patterns in the United States.
In a country of 188 million people, where there are approximately 482,000 new cancer cases each year, that translates to
more than 250,000 cancer patients requiring radiation therapy.
Although there are many outstanding radiation therapy centers in Brazil, this article profiles three that represent the mix of
private, philanthropic, and government-supported radiotherapy
treatment facilities in the country. Widely regarded as leaders in
cancer treatment in the region, these centers offer patients sophisticated forms of treatment while providing clinical training
and medical education for Latin American radiation oncologists, physicists, and other clinical specialists.
Albert Einstein
Hospital Israelita Albert Einstein, located in São Paulo, Brazil,
is a private general hospital with nearly 500 beds and plans to
add another 350. The oncology department represents about 10
percent of the hospital’s caseload, and treats an average of 750
patients each year. This center has treated more than 1,000 patients with IMRT, and was among the first in Brazil to acquire
an On-Board Imager® device and begin delivering image-guided
IMRT treatments. Since then, clinicians have been instrumental
in exploring the benefits of IGRT technology and have actively
shared their experience with the Brazilian radiation therapy
community.
Jose Carlos Cruz, PhD, medical physicist and head of radiotherapy at Hospital Albert Einstein, says the oncology department also regularly hosts visitors who are seeking professional
development at the hospital’s IMRT training center. “We see the
education arm in the radiotherapy department as part of our
hospital’s culture,” says Cruz.
18
The IMRT training center at Albert Einstein is equipped
with several workstations that provide visiting physicians and
physicists a hands-on opportunity to learn how to use Varian’s
Eclipse™ treatment planning software and machine data acquisition and quality assurance in IMRT. The IMRT courses typically
last two days or a week, but Albert Einstein also offers longer
educational programs for physicists who have some previous
experience.
“We offer a six-month program to complement a physicist’s
previous training at another institution if it did not include
IMRT, IGRT, or other important new modalities,” says Cruz.
Visiting physicians and physicists consistently rate the hospital’s education services as excellent. Many of those who come
for training each year are based in countries outside of Brazil. At
the start of 2009, for instance, the Albert Einstein education department instructed a mixture of doctors and physicists from
Brazil, Mexico, and Argentina.
AC Camargo
Hospital AC Camargo of São Paulo is a renowned philanthropic
institution that focuses its efforts on the prevention and cure of
neoplastic diseases.
“To provide effective patient care, the radiotherapy department has deployed a complete portfolio of advanced technologies, used by experienced clinicians who work to develop
protocols for delivering the latest cancer treatment techniques,”
says João Victor Salvajoli, MD, director of AC Camargo’s radiotherapy department.
AC Camargo utilizes four linear accelerators, each equipped
for delivering IMRT. In addition, the hospital uses an Acuity™
simulator, and a GammaMedplus™ afterloader for high-doserate brachytherapy.
“About 2,760 patients receive external-beam treatments each
year. Forty percent are treated with a 3D conformal technique,
and 20 percent receive inverse-planned IMRT,” says Salvajoli.
CENTERLINE | JUNE 2009
“We believe that we’re providing
excellent training for the next generation of doctors, who are learning
to better diagnose and treat cancer
patients in Brazil and elsewhere.”
Carlos Manoel Araujo, MD,
PhD, head of radiation oncology,
describes the influence INCA has in
spreading a message of improving
detection and care. “We’re serving in
a leadership role to clinics across
Homero Martins, PhD, Hospital AC Camargo
Brazil,” says Araujo. “Ours is the
oldest residency program in Brazil.
“We have nine full-time resiWe
prepare six new radiation oncoldents,” says Homero Martins,
ogists every year. Many cancer treatment professionals at hospiPhD, a medical physicist who oversees the residents at AC
tals around the country were trained here, and for this reason,
Camargo. Martins has been training radiation oncologists and
the
presence of cancer policy developed at INCA is very strong
medical physicists at various posts in Brazil since 1978.
throughout the country.”
“We accept three new resident doctors each year, out of
A central aspect of INCA’s mission is to provide services to
about 53 candidates,” says Martins. “The residency program at
cancer patients that are fully subsidized by the government.
AC Camargo is very well known, but getting admitted is a defi“INCA is the only cancer hospital operated by the federal govnite challenge.”
ernment to provide public assistance to our patients,” explains
Varian’s team in Brazil often works with the educators at AC
Araujo. “In most circumstances, the advanced radiotherapy
Camargo to develop clinical training programs for professionals
treatments we perform are made available to the majority of the
throughout the region. “We believe that we’re providing excelpatients we serve.”
lent training for the next generation of doctors, who are learnThese treatments include high-dose-rate brachytherapy,
ing to better diagnose and treat cancer patients in Brazil and
IMRT,
and radiosurgery. Soon INCA will be installing an IGRTelsewhere,” says Martins.
enabled Trilogy® linear accelerator from Varian.
The hospital also handles one
to two radiosurgery cases each
week. A select group of radiation
oncologists, fulfilling their residency requirements at AC Camargo, help to carry out these
treatments.
INCA
Located in Rio de Janeiro, the National Cancer Institute, or
INCA, is a 300-bed hospital with the largest cancer treatment
program in the country. In 2008, INCA oncologists treated
110,000 cancer patients, including 4,500 new cases requiring
radiotherapy treatments.
As part of the Brazilian government’s Ministry of Health, the
state-run hospital is charged with developing and implementing
cancer treatment policies in Brazil. It addresses research, trains
professionals, publicizes best practices, and develops awareness
programs that promote the necessity of cancer prevention and
early diagnosis.
Moving forward in Brazil
“Over the years, we have worked together with our clinical partners in Brazil to provide cancer patients here with access to the
highest-quality treatments available,” says Tim Guertin, Varian’s
president and CEO. “Today we remain committed to what has
always mattered most: providing clinicians with better tools for
treating cancer and focusing energy on saving lives. We are
pleased and proud to be working with these and other treatment
centers across Brazil in an ongoing effort to improve access to
quality care.” ✺
CENTERLINE | JUNE 2009
19
Varian’s Clinical Help Desk:
Just a Call or Click Away
Varian’s Customer Support Services organization is
a far-reaching network of professionals dedicated
to meeting customers’ needs for service and support. More than 1,900 people work in positions
that directly support customers, whether by
staffing the Varian Help Desk, managing system installations, providing instruction, or
dispatching field engineers.
This article is the fourth in a multipart
series on the many facets of Varian Customer Support Services. It focuses on how
the company’s Clinical Help Desk works to
assist customers with Varian products whenever and wherever the need arises.
Varian’s clinical Help Desk, part of the Customer Support Services (CSS) group, is a global enterprise with a “follow
the sun” approach to providing multilingual support for all Varian
products. This means that Help Desk specialists are available by
telephone during normal business hours across all customer time
zones. After-hours and weekend calls are returned the next business day. Help Desk specialists also provide e-mail support on a
fast-turnaround basis for customers from around the world.
“Our goal is that, at any time of the day, there will be a person
at some location in the world taking customer calls and assisting
customers with Varian products,” says Jon Hollon, Varian’s director of worldwide training and education. “We have this roundthe-clock coverage in place for customers in North America, and
we’re now working to roll it out globally.”
“We have this round-the-clock
coverage in place for customers in
North America, and we’re now
working to roll it out globally.”
“We consider the Varian Help Desk to be part of our team
and don’t hesitate to reach out for help with software, most often
for information about how to perform simple applications we
have not done before,” says Kim Wolpert, radiation oncology department director at Decatur Memorial Hospital in Illinois. With
more than 15 radiation therapists, dosimetrists, physicists, and
physicians on staff, the department treats 45 patients a day using
Varian equipment.
Jon Hollon, Varian Medical Systems
20
CENTERLINE | JUNE 2009
“MyVarian doesn’t replace the
Help Desk, but it does siphon
off some of the less time-critical
inquiries so that Help Desk
personnel can get to the urgent
calls more quickly.”
Although Wolpert calls the Help
Remote assistance benefits customers
Desk’s U.S. toll-free number (1-888Some calls to the Varian Help Desk can
VARIAN-5) for urgent questions, she
be dealt with over the phone or by e-mail.
checks the new MyVarian website
And some calls result in a service visit,
(http://www.MyVarian.com) for less
which involves dispatching someone to
pressing matters. MyVarian is a passthe customer site to conduct tests or efword-protected website for Varian cusfect repairs. But a large number of calls
tomers, launched last year to provide
fall somewhere in between these two exanother level of support (see story on
Dolores Zeledon, Varian Medical Systems
tremes and can be handled by Help Desk
page 4). Instead of contacting the Help
personnel using SmartConnect®, Varian’s
Desk, customers can use MyVarian to
remote servicing program. SmartConnect enables a serviceperaccess current product documentation and find up-to-date news
son to connect directly with a customer’s system via the Internet
about the company’s products. Webinars and other presentations
and perform diagnostic tests, corrections, and repairs in real
are also features of the website.
time—without physically visiting the customer’s site.
“MyVarian doesn’t replace the Help Desk, but it does siphon
“We were having some issues with Eclipse™, and the Help
off some of the less time-critical inquiries so that Help Desk perDesk serviceperson used SmartConnect to enter our system and
sonnel can get to the urgent calls more quickly,” says Dolores
see exactly what was going on,” says Wells. “It’s very convenient
Zeledon, manager of the MyVarian site.
—and fast—to have someone dial in and remotely assess and fix
a
problem.”
Experience and expertise matter
SM
Varian Help Desk personnel are all medical physicists, dosimetrists, or radiographers or radiation therapists with extensive
prior experience using Varian’s oncology products and cancer
treatment technologies. A solid clinical background is one of the
prerequisites for working on the team. “This is a big advantage
for customers, because when they contact the Help Desk, they
reach people with actual clinical experience who understand the
challenges that are faced in a treatment setting,” says Ian Hudson,
manager of Varian’s North American Clinical Help Desk and
Customer Service Center. “We can empathize with the challenge
a customer is having and react appropriately. Not many other radiation oncology technology companies can offer what we do in
terms of providing expert support at first call.”
In addition to having that background knowledge, all Help
Desk team members receive intensive training at the company’s
education center in Las Vegas to bolster their knowledge of current products. They also receive ongoing training as new products are developed and introduced.
“You can tell that the people on the Help Desk have used
Varian products in clinical settings,” says Lisa Wells, a dosimetrist at the Marie Canine Cancer Center at St. Clare Medical
Center in Crawfordsville, Indiana. “I can relate to what they are
saying because they give firsthand accounts of how they used
technology to solve specific problems. This is especially important
because my department is new to Varian products.”
Varian’s Ian Hudson says SmartConnect is a great resource
for helping people with complex technologies. “We are able to
see what the customers are seeing and solve problems remotely,
which means we can help them faster and prevent downtime,”
says Hudson, adding that almost 40 percent of the calls that
come through the Help Desk are ultimately resolved using
SmartConnect.
Technology upgrades improve service
Each year, the Help Desk receives 50,000 calls and 4,000 e-mails
from customers like Wolpert and Wells, looking for assistance
with their Varian products. Despite this volume, recent technology improvements have enabled Help Desk personnel to improve on some important metrics. Thanks to an upgraded phone
system and a more robust customer relationship management
(CRM) software package, customer “on hold” wait times have
been reduced to an average of five minutes and customer satisfaction rates have increased to 97 percent.
“We are a global team committed to providing customer satisfaction through speed, quality, and friendliness of response,”
says Kolleen Kennedy, Varian’s vice president of customer support services. “We made some large infrastructure investments
this past year, and we’re starting to see the payoff in terms of performance improvements.”
Customers are enthusiastic. “I am happy with the service
I have received from the Help Desk and brag about it to colleagues,” says Wolpert. “If someone is deciding to purchase
equipment from Varian or another vendor, I would recommend
Varian because the level of service is invaluable.” ✺
CENTERLINE | JUNE 2009
21
Presort Standard
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PAID
San Jose, CA.
Permit No. 2196
Varian Medical Systems
3100 Hansen Way
Palo Alto, CA 94304-1038
Get to know MyVarian,
a website especially for Varian customers
MyVarian is your one-stop source for
information about Varian products.
SM
Help Desk support
• Product manuals
• Application tips
• Release notes
News and updates
• Presentations
• Webinars
• User discussion groups
And much more.
Visit http://www.varian.com/MyVarian to join.