Safety and Efficiency Analysis of Operational Decision-Making During CBCT-Based Online Adaptive Radiotherapy

Purpose Cone beam computed tomography (CBCT)-based online adaptive radiotherapy (ART) is especially beneficial for patients with large inter-fractional anatomical changes. However, treatment planning and review decisions need to be made at the treatment console in real-time and may be delegated to clinical staff whose conventional scope of practice does not include making such decisions. Therefore, implementation can create new safety risks and inefficiencies. The objective of this work is to systematically analyze the safety and efficiency implications of human decision-making during the treatment session for CBCT-based online ART. Methods and Materials The analysis was performed by applying the Systems-Theoretic Process Analysis technique and its extension for human decision-making. Four centers of different CBCT-based online ART practice models comprised the analysis team. Results The general radiotherapy control structure was refined to model the interactions between routine treatment delivery staff and in-person or remote support staff. The treatment delivery staff perform six key control actions. Eighteen undesirable states of those control actions were identified as impacting safety and/or efficiency. In turn, 97 hazardous clinical scenarios were identified, with the control action prepare and position patient having the least number of scenarios and delineate/edit influencer and target structures having the most. Five of these are specific to either in-person or remote support during the treatment session, and 12 arise from staff support in general. Conclusions An optimally safe and efficient online ART program should require little to no support staff at the treatment console and thus reducing staff coordination. Uptraining of the staff already at the treatment console is needed to achieve this goal. Beyond the essential knowledge and skills such as contour editing and the selection of an optimal plan, uptraining should also target the specific cognitive biases identified in this work and the cognitive strategies to overcome these biases. Additionally, technological and organizational changes are necessary.