Importance of daily electronic portal imaging in radiotherapy

An audit was conducted on 20 randomly selected patients who had daily electronic portal imaging during the course of their radiotherapy treatment. The daily images were reviewed to determine whether they were within tolerance according to departmental protocol. If they were not, the actions that were taken were documented. Four treatment areas (spine, chest, breast and prostate) were compared among five patients belonging to each of these categories. The patients were also categorized according to their treatment intent (radical or palliative). A total of 889 electronic portal images of 475 fractions were audited and 33.5% of all fractions were outside tolerance. It was found that 95% of patients needed an action during their treatment and 80% of the patients needed a treatment centre move during the course of their treatment. We found that errors occurred throughout the treatment and it was not possible to predict patients who could have daily imaging omitted. Concordance between radiation therapists and radiation oncologists for identification of error was also investigated. Despite the use of familiar electronic portal imaging protocols, image reviewers (radiation therapists and radiation oncologists) disagreed in interpretation 10% of the time. Our results support the hypothesis that daily imaging may be a useful tool for patients undergoing radiotherapy and that imaging may be ideally carried out before each fraction. Image assessments would be ideally carried out by a team approach, with all images reviewed by both radiation therapists and radiation oncologists. This approach has significant resource implications and may require review of current Medicare and Health Program Grant reimbursements.