Report of Dr. Paul Fenton, Emmanuel van der Schueren Fellow 2009-2010

With the essential support of the Vlaamse Liga tegen Kanker, the EORTC Emmanuel van der Schueren Fellowship plays a key role in developing quality assurance in radiotherapy (QA RT) techniques in the face of rapidly evolving technological challenges, performing QA RT-related research, and demonstrating that QA RT is an essential component of high quality radiotherapy delivery which affects not only patients within clinical trials but all cancer patients by promoting and improving radiotherapy standards.

From June 2009 until July 2010 Dr. Paul Fenton was the Emmanuel van der Schueren Fellow at EORTC Headquarters.  Together with Akos Gulyban, the EORTC QA RT Manager, Dr. Fenton formed a central hub for all EORTC trial QA RT activities, overseeing the QA RT programs in ongoing trials, assisting with the concept, design, and practicalities of new radiotherapy and QA RT protocols and projects, and addressing the challenges faced by the use of advanced RT technologies such as intensity-modulated radiotherapy.

Alongside these trial QA RT activities, during his stay Dr. Fenton pursued research activities in four main project areas: normal tissue complication probability (NTCP) modeling, target volume delineation and guidelines, quality assurance of advanced radiotherapy techniques, and fully digital QA RT.

NTCP Modeling

Modern advances in radiotherapy treatment planning and delivery have made it possible to vary the delivered dose distribution in previously inconceivable ways.  This allows the possibility of delivering highly conformal treatments to the target volumes while sparing the normal tissues to a greater extent than was previously possible.  To do this it is essential that we develop a detailed understanding of the relationship between toxicity in normal tissues and clinical and dosimetric factors related to the patient’s treatment so that normal tissue complication probability can be assessed and treatments optimized.

With the recent acquisition of the VODCA (Visualization and Organization of Data for Cancer Analysis) software platform by the EORTC, it has become possible to collect complete digital radiotherapy treatment data for patients and perform detailed dosimetric analysis of the entire 3D radiotherapy dose distribution.  This allows normal tissue complication probability modeling projects to be performed that utilize these radiotherapy data in combination with patient and clinical parameters from the EORTC clinical database.

Dr. Fenton developed a proposal to retrospectively collect digital RT data from patients from 4 institutions in the EORTC 22991 trial, a phase III trial of radiotherapy ± adjuvant hormonal therapy in early stage carcinoma of the prostate.  Through site visits and the essential assistance of the investigators and radiotherapy physics teams at the Dr. Bernard Verbeeten Instituut Tilburg, the Universitair Medisch Centrum Groningen, the Centre Léon Bérard Lyon and the Centre Hospitalier Universitaire de Grenoble, and of the Radiation Oncology Group team and Quality of Life Department at EORTC Headquarters, he was able to combine quality of life and clinical toxicity outcome data from the EORTC clinical database with radiotherapy treatment data from 226 patients.  In conjunction with Laurence Collette, Assistant Head of Statistics Department at EORTC, he performed the process of multivariate NTCP model-building.  A publication detailing the results of this process is in preparation which documents their novel use of quality of life data in this setting.

Target Volume Delineation and Guidelines

The advances in conformal radiotherapy techniques have strengthened the need for accurate and standardized approaches to the delineation of target volumes and organ at risk (OAR) volumes.

For the EORTC 22043-30041 trial, a phase III trial of post-operative external radiotherapy ± concomitant and adjuvant hormonal treatment versus postoperative external radiotherapy alone in high risk carcinoma of the prostate, Dr. Fenton assisted the Radiation Oncology Group QA RT Team in the review of Dummy Run submissions in comparison to the protocol and published EORTC guidelines for target volume and OAR delineation. He performed detailed advanced dosimetric analysis of the potential impact of variations in volume delineation on organs at risk and dose to target volume and developed novel techniques for displaying and comparing multiple sets of dose-volume data.  Preliminary results of this work have been presented at the Radiation Oncology Group meetings and two publications are in preparation arising from this work.

Quality Assurance of Advanced Radiotherapy Techniques

The availability and use of advanced radiotherapy techniques, e.g. intensity-modulated radiotherapy, image-guided radiotherapy, tomotherapy, and stereotactic radiotherapy, require specific quality assurance procedures to ensure that the complexity of the planned dose distribution can be delivered in an accurate and reliable way. Performing this level of quality assurance in multicenter international trials is both of huge importance and of great complexity.

Dr. Fenton was an active member of the QA RT committee which has been developing the EORTC approach to advanced technologies. He helped develop and coordinate the theoretical and practical framework for the initiation of credentialing of advanced technologies in EORTC trials and helped develop a pilot study of the EORTC use of the physical phantom credentialing which will subsequently be published in collaboration with US partners.

International cooperation and harmonization of QA RT procedures were also items on Dr. Fenton’s agenda. He participated in discussions between the EORTC and cooperative groups in the United States, Canada, Australia and New Zealand that were aimed at producing a harmonized approach to clinical trial QA RT with particular emphasis on the challenge of advanced techniques, and he participated in the design and development of a ground-breaking comparison between the US and EORTC approaches to reference dosimetry audits in the context of a major international cooperative trial.

Fully Digital QA RT

Technical advances in treatment planning software and digital communication have opened the opportunity for clinical trial QA RT to be performed on purely digital data and in much greater depth than previously possible.  Whereas previous QA RT has relied on paper-based submission of limited data it is now possible to submit the entirety of a patient’s radiotherapy planning and treatment data digitally.

Dr. Fenton performed testing and delivered direct feedback to the VODCA software developers in order to optimize the package for the scale needed for use in EORTC clinical trials.  Part of this work, in collaboration with Catharina-ziekenhuis, Eindhoven, has been presented at the recent ESTRO meeting.

Trial-specific QA RT and EORTC Headquarters activities

Dr. Fenton was also engaged in a wide variety of trial-specific scientific activities.  He worked especially in close collaboration with the Radiation Oncology Group but also collaborated with the many other Disease Orientated Groups in trials and initiatives and provided training and advice on practical and technical aspects of radiotherapy to co-workers at EORTC Headquarters.

A number of publications are in the final stages of preparation covering Dr Fenton’s wide activities in QA RT.

Dr. Fenton returns to the Southampton Oncology Centre

Dr. Fenton has now returned to the Department of Radiotherapy at Southampton University Hospitals Trust, Southampton, UK, where he is currently in the penultimate year of the Wessex Deanery Training Scheme in Clinical Oncology.  He aims to remain involved with the EORTC, both as an active member of the QA RT Committee of the Radiation Oncology Group and as an investigator.  He would like to thank all those with whom he collaborated during his time as Emmanuel van der Schueren Fellow, especially Akos Gulyban, the Chairman and Executive Committee of the Radiation Oncology Group and the team at EORTC Headquarters, with whom working was a pleasure and a privilege.

Dr. Alysa Fairchild joins EORTC as next Emmanuel van der Schueren Fellow

On 01 September 2010, Dr. Alysa Fairchild joined the EORTC as the next Emmanuel van der Schueren Fellow. Dr. Fairchild comes to us from Edmonton, Alberta, where she worked as a Radiation Oncologist. Originally from Vancouver, Alyssa received her Bachelor of Science degree from McGill University in Montreal, Quebec, and her medical degree from Queen’s University, Kingston, Ontario. She obtained a postgraduate diploma in Epidemiology and completed her Radiation Oncology training in Calgary, Alberta, and Edmonton. In her clinical practice, Dr. Fairchild’s areas of interest were lung cancer and palliative (end-of-life) care. She is excited to be here in Brussels and looks forward to a productive fellowship and learning a lot from everyone at the EORTC. We are pleased to welcome Dr. Fairchild on board.

Paul Fenton and John Bean