James B. Stubbs

In January, The New York Times reported on the rising incidence of medical radiation errors and their crippling effects on patients’ lives. The article argues that while new technology allows physicians to deliver more sophisticated treatment, its rising complexity has created new opportunities for error.

James B. Stubbs, Ph.D., Cianna Medical’s Chief Science Officer, speaks out about how to improve radiation safety as technology evolves – including what every physician and physicist should expect to receive from its technology vendors.

Q: Is the current focus on radiation safety causing excessive fear among healthcare consumers, or do you think it’s a positive focus that will help elicit change?

I think it has the potential for both. If the media attention is used properly, it will benefit everybody, including the practitioners. I think change is definitely going to be elicited. Every single professional society associated with diagnostic radiology and therapeutic radiation oncology told Congress they are going to do something about this problem, and in many cases asked for help in enacting measures to initiate change.

That said, I think there may be some unnecessary frightening of cancer patients away from radiation therapy, which is unfortunate because it has done wonderful things for people suffering from cancer. If you look at the error rate with radiation therapy, it’s not as bad as the media make it seem. It’s less than a tenth of a percent, and when you compare that to the 10-15 percent routine medication error rate in hospitals, radiation therapy looks pretty good.

Q: Many people have advocated for the mandatory reporting of medical radiation errors — do you think this would be helpful in improving radiation safety?

I honestly don’t know. I think it’s true that everybody can learn from other people’s mistakes – when those mistakes are honestly reported. The problem is that the financial and professional liabilities associated with admitting your mistakes often cause people to stretch the truth in every possible way to minimize the personal impact of their errors. But when people stretch the truth, it’s not going to be helpful for others in practice.

What’s more important are the lessons learned from the mistake – what went wrong, what can be done to prevent it in the future. So perhaps one solution is to enable people to report errors anonymously. You can’t track down the person or institution involved with the mistake, but you can certainly glean the lesson from it, and that’s the most important thing – it’s all about education.

I always use anecdotes of things I’ve seen in the clinic when training physicists new to the SAVI device. The stories and experiences make quite an impression and I’ve often heard a physicist say, “I’d never do that!” And they are correct. Some events, those you’d never think could happen, can and do happen under unique circumstances. When this perfect storm occurs, negative things can happen – unless you have distinct knowledge that it has happened and how to avoid it. With the knowledge that something has happened before, it is unlikely to repeat itself.

Q: What other steps can be taken to improve the quality and safety of radiation therapy?

In my opinion, one of the biggest problems is the lack of standardized training for medical physicists. This problem is further exacerbated by the uneven levels of training on individual modalities and software packages. There are multiple linear accelerator manufacturers, and all of these machines are slightly different and use different software for controlling and planning. Ideally, physicists should receive the training necessary to demonstrate competence on all equipment and software, and certification can be useful in demonstrating acquired competency. In a perfect world, we would all be certified as trained and competent on every piece of equipment and software used to treat our cancer patients.

ASTRO’s six-point plan for patient safety advocates for significantly enhanced practice accreditation programs and developing additional accreditation modules for new, advanced technologies, like IMRT or brachytherapy. That’s a great foundation, but I think eventually we need to get down to the level of teaching best-practices on vendor-specific equipment.

That’s one of the things Cianna Medical does very well – we take training very seriously and have developed a robust program that prepares every member of the treatment team for delivering the highest quality treatment with SAVI. If every company offered this level of support, it would increase the level of training and experience on the equipment individuals are actually working with in their clinics. It would certainly raise the quality of care and significantly reduce the opportunity for the types of medical errors as reported in The New York Times.

Q: What kind of training does Cianna Medical offer for medical physicists?

We have a very substantial experience-based training program for treatment planning and execution. Starting with web-based learning, we offer a series of recorded webinars that cover the entire treatment process, so physicists can learn about the important aspects of treatment planning with SAVI at their own pace.

We also offer 12 hours of CAMPEP-accredited classroom training in conjunction with Varian and Nucletron, where we bring physicists to their respective training sites for a combination of didactic and hands-on instruction. It includes a three-hour lecture that covers every aspect of the SAVI applicator and the treatment process, including CT simulation, planning and treatment delivery, QA, second checks, and policies and procedures, followed by the practical component where physicists have the opportunity to plan actual SAVI cases on the specific planning systems used at their clinic.

With three full-time physicists on staff, we have the ability to offer an unmatched level of ongoing support. We provide onsite support for first cases by sending one of our physicists to the facility to provide assistance as physicists plan the initial case on their own. We also offer ongoing support where our physics team is available to answer questions or provide consultation for challenging treatment plans. We even have the ability remote-into a facility’s system (via WebEx or GoToMeeting), whether it’s Oncentra or BrachyVision, and answer physicists’ questions on the spot.

In addition to physicists, Cianna Medical provides extensive training for radiation oncologists, surgeons and clinical staff. We take an integrated team approach to ensure every person who is involved with the treatment process understands the technology and how to deliver the safest, most accurate treatment possible.

Q: How can other manufacturers be encouraged to take on the responsibility for providing training?

There needs to be a significant shift in the mindset of not only the vendors, but the customers as well. In addition to encouraging manufacturers to offer training for their technology, it’s about educating the end-user that they should be advocating for this type of support. When a provider is approached by a vendor trying to sell a new technology, that provider’s first questions should be, “Who’s going to provide my training? What are their qualifications? What will training include? Do you have a way of assessing whether we’ve acquired the competency to provide the technology?”

Physicians need to advocate to their vendors that they want training. People who are executing radiation therapy should know the equipment and software they’re working with and be fully trained in treatment planning and delivery before they ever get their first patient. It’s incumbent upon someone to provide that training – so Cianna Medical takes on the responsibility for doing that. When a customer says they want to start using SAVI and asks what the next step is, our answer across the board is, “Training.”

Dr. Stubbs received his B.S. in Nuclear Engineering at the University of Florida and earned both his M.S. and Ph.D. in Nuclear Engineering at the University of Virginia. He has extensive experience with brachytherapy research, product development and clinical applications. He has coauthored dozens of peer-reviewed scientific articles in the brachytherapy and radiopharmaceutical fields.