Accurate method for evaluating the duration of the entire radiotherapy process

Abstract Background and purpose Along with the increasing demand for high‐quality radiotherapy and the growing number of high‐precision radiotherapy devices, precise radiotherapy workflow management and accurate time evaluation of the entire radiotherapy process are crucial to providing appropriate, timely treatment for cancer patients. This study therefore aimed to establish an accurate, reliable method for evaluating the duration of the radiotherapy process, from beginning to end, based on real‐time measurement data. These data are vital for improving the quality and efficiency of radiotherapy delivery. Materials and methods Altogether, 17 620 cancer patients’ radiotherapy experiences were measured in real time in our radiation oncology department. The process was divided into five sequential core modules, with the start and stop times of each module automatically recorded using MOSAIQ software, an automated radiotherapy management system. The duration for each module and the total duration of the entire process were then automatically calculated and qualitatively analyzed. Results The analysis showed significant treatment–time differences depending on the tumor site, which provided a practical reference for improvement of previous treatment modules and appointments management. In all, >60% of the cancer patients’ total treatment time could be shortened. Conclusions We established a reliable method for evaluating the overall duration of radiotherapy protocols. The results pointed out a clear pathway by which we could improve future radiotherapy workflow management and appointment systems.

requires accurate data collection regarding the entire radiotherapy process for use as a reference. [5][6][7] Several relevant international organizations have offered recommendations and guidelines for accurately assessing the time data of radiotherapy, which have improved the management of radiotherapy workflow. 4,5,[8][9][10][11][12][13][14][15] . Nevertheless, only a few studies focused on analyzing data based on real-time statistics. A series of studies published in recent years by the German Society of Radiation Oncology (DEGRO) 8,[16][17][18][19][20][21][22][23][24] might be the most systematic, comprehensive reports in the relevant literature. The DEGRO trials yielded eligible time measurement data for several core radiotherapy modulesfor example, preparation for RT; RT planning; performance of RT; completion/follow-up appointmentwhich served as reference guides for actual radiotherapy. DEGRO, however, analyzed only statistical data based on the manually recorded working time of the core modules, which might lead to great uncertainties and errors as it failed to cover all the time spent during the entire radiotherapy process, including the preparation and waiting time between modules. Clearly, it is of vital importance to evaluate all the time spent for the entire radiotherapy process.
To overcome the abovementioned shortcomings, this study aimed to establish an accurate, reliable method for evaluating the duration of the entire radiotherapy process. In our department, all physicians treating NKT, NPC, CNS, and brain metastases are divided into one treatment group, referred to as the "head and neck (H&N)" group. All physicians treating lung, esophagus, breast, and lymph node are divided into the second treatment group, referred to as the "Thorax/breast" group. And all physicians treating rectum, liver, prostate, gynecologic, extremities, and among others are divided into the third treatment group, referred to as the "Abdomen/Pelvis/Extremity" group. Thus, the statistical data of the actual time spent during the entire radiotherapy process for three treatment groups were recorded in real time and analyzed in an automated management system.
The study then sought to determine opportunities for improving the total time consumed to complete the entire clinical radiotherapy process.

| MATERIALS AND METHODS
The study statistically analyzed time information for 17 620 radiotherapy patients (5125 H&N tumors, 6594 thoracic tumors, and 5901 abdominal tumors) in our department from January 2016 to December 2018. To cover the entire process of conventional radiotherapy workflow, 8,22 six critical time points (Fig. 1, T1-T6) were manually selected and automatically recorded in an integrated radiotherapy information management system, MOSAIQ (Elekta, Stockholm, Sweden). 25 These time points were named the time of medical records establishment, time of CT/MR simulation, time of prescription submission, time of planning authorization, time of first radiation delivery, and time of last radiation delivery. Thus, the entire radiotherapy process was divided into five sequential modules (Fig. 1, M1-M5) called the preparation for CT/MR simulation, preparation for treatment planning, treatment planning and verification, waiting for first radiation delivery, and total duration of radiation delivery.
When a new module starts, the responsible physicians, medical physicists, or technicians/therapists first manually set the module's status on Mosaiq to "Schedule," and when work is done, they set the status to "Complete," and the status of the next module will be automatically switched to the "Prepare," to remind next group to start clinic work. The status ("Prepare," "Schedule," and "Complete") setting time for each patient was automatically recording in the Mosaiq system and time information were extracted from the Mosaiq database, using the commercial software 'Crystal Reports' (SAP AG 2010, version: 14.0.2.364 RTM). Thus, the time duration of each module was obtained by noting the time consumed between the "Schedule" and "Complete" time points, and the waiting time in between two modules was obtained by "Complete" and "Prepare" time points. Clearly, the total duration of the radiotherapy process was obtained by noting the time consumed between the overall first and last time pointsthe Total duration of radiotherapy.
The mean, median, 5% and 95% percentiles, and 25% and 75% quartiles of all six time durations for treating three tumor sites were calculated. The nonparametric Mann-Whitney U test module of standard statistics software (SPSS Statistics 22; IBM, Armonk, NY, USA) was used to determine statistical significance, which was set at P < 0.05.

| RESULTS
For the convenience of comparison and statistical analysis, the summarized results were calculated as "days," with two decimal points (Table 1) It is noteworthy that this study counted only working days' times, excluding weekends and legal holidays.  Overall, the preparation for treatment planning [ Table 1; Fig. 2

(b)]
including transmission and fusion of CT/MR/PET images, definition of tumor targets and organs at risk, authorization of the contouring, submission of treatment prescriptionswas the most time-consuming module before irradiation. The median time consumed for this module was 5.22 days. Among the cancer types, the "H&N" group required significantly more time (median time 6.82 days with threefourths spending < 9 days) and thoracic/breast group the least time (median time 4.27 days with three-fourths spending < 6 days). It is worth noting that, although the mean and median times of the "H&N" group were much longer than those of the "Thorax/breast" group and "Abdomen/Pelvis/Extremity" group, the maximum time for the "H&N" group was the shortest (21.72 days), compared with the "Thorax/ breast" group (28.64 days) and "Abdomen/Pelvis/Extremity" group TomoTherapy for the "H&N" group were the longest: 5.31 and 5.18 days vs 5.58 and 5.38 days, respectively. It is worth noting that IMRT planning was much shorter than VMAT planning for H&N tumors for the reason that almost all complicated H&N planning was performed using VMAT and TOMO. Only the planning for simple and small target volume tumors utilized IMRT, which took a much shorter time. For the "Thorax/breast" and "Abdomen/Pelvis/Extremity" groups, the times spent using IMRT and VMAT were almost the same. The times for both IMRT and VMAT were longer than the times for 2D/3D CRT and shorter than those for TOMO.
After treatment planning and verification were completed and authorized, approximately three-fourths of patients underwent their first irradiation within 3 days [ Table 1; Fig. 2 respectively. Because of the diversity of tumors of the "Abdomen/ Pelvis/Extremity" group and the different treatment prescriptions, conventional fractionation ranged from 25 to 30 deliveries, and hypofractionation with prescription larger than 5 Gy/fraction ranged from 5 to 15 fractions. Hence, the total duration of radiation delivery of the "abdomen/pelvis/extremity" group was the most diverse, with mean and median values of 23.12 and 25.48 days, respectively.
The time durations of different modules and tumor sites. All data is calculated in days with two decimal places remaining and displayed in the form of mean/median(25%, 75%).  Also, the use of electronic tools makes it easier to check for anomalous treatment information and correct errors more efficiently.

| DISCUSSION
Importantly, the data collection tool used in this study, the MOSAIQ system, is mature commercial software and so makes our study easy to promote and repeat in other departments, which has great practical significance. system can also encourage physicians and technicians to avoid the lack of timely CT/MR scans due to negligence and/or lack of responsibility, which could delay subsequent treatment.

4.B | Impact of current contouring and ward rounds
The In view of the abovementioned treatment delays, our department has stipulated new procedures for setting up treatment appointments and planning.
• According to the total number of patients and the throughput capacity of each accelerator, appointments for the first treatment are adjusted in time and allocated more reasonably to the available accelerators, thereby avoiding the situation wherein planning physicists fail to make an appointment for the appropriate accelerator within 5 days.
• These new procedures and performance evaluation system help standardize work efficiency and responsibility of physicians and planning physicists. Also important, they reduce the occurrence of delayed treatment and unnecessary patient waiting time.
The incidence of newly diagnosed cancer has been rising in recent decades. Many studies have shown that cancer is a common disease in the elderly. Thus, with our aging population, the incidence of malignant tumors and the need for treatment will undoubtedly continue to grow. Efficient management of radiotherapy workflow and controlling the treatment time can improve efficiency on the premise of ensuring quality treatment. In total, >60% of cancer patients would benefit from the above proposed modifications, and the total treatment time could be shortened. Subsequent studies will continue to evaluate the overall treatment time of the improved radiotherapy workflow management and assess the clinical outcomes.

| CONCLUSION S
The present study is part of a project of quality and management control in our radiation oncology department. With the increasing clinical workload, it is particularly important to study daily problems during the radiotherapy process. We found significant differences in the time spent during the radiotherapy core modules depending on GUO ET AL.

ACKNOWLEDGMENTS
This work was supported by the National Natural Science Foundation of China (11875320).

CONF LICT OF I NTEREST
The authors report no conflicts of interest with this study. We declare that we do not have any commercial or associative interest that represents a conflict of interest in connection with this work.