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The purpose of this paper is to describe a jurisdiction-wide implementation and evaluation of intensity-modulated radiation therapy (IMRT) in Ontario, Canada, highlighting innovative strategies and lessons learned.

To obtain an accurate provincial representation, six cancer centres were chosen (based on their IMRT utilization, geography, population, academic affiliation and size) for an in-depth evaluation. At each cancer centre semi-structured, key informant interviews were conducted with senior administrators. An electronic survey, consisting of 40 questions, was also developed and distributed to all cancer centres in Ontario.

In total, 21 respondents participated in the interviews and a total of 266 electronic surveys were returned. Funding allocation, guidelines and utilization targets, expert coaching and educational activities were identified as effective implementation strategies. The implementation allowed for hands-on training, an exchange of knowledge and expertise and the sharing of responsibility. Future implementation initiatives could be improved by creating stronger avenues for clear, continuing and comprehensive communication at all stages to increase awareness, garner support and encourage participation and encouraging expert-based coaching. IMRT utilization for has increased without affecting wait times or safety (from fiscal year 2008/2009 to 2012/2013 absolute increased change: prostate 46, thyroid 36, head and neck 29, sarcoma 30, and CNS 32 per cent).

This multifaceted, jurisdiction-wide approach has been successful in implementing guideline recommended IMRT into standard practice. The expert based coaching initiative, in particular presents a novel training approach for those who are implementing complex techniques. This paper will be of interest to those exploring ways to fund, implement and sustain complex and evolving technologies.

Due to increasing complexity, modern radiotherapy techniques require comprehensive quality assurance (QA) programmes, that to date generally focus on the pre-treatment stage. The purpose of this paper is to provide a method for an individual patient treatment QA evaluation and identification of a “quality gap” for continuous quality improvement.

A statistical process control (SPC) was applied to evaluate treatment delivery using in vivo electronic portal imaging device (EPID) dosimetry. A moving range control chart was constructed to monitor the individual patient treatment performance based on a control limit generated from initial data of 90 intensity-modulated radiotherapy (IMRT) and ten volumetric-modulated arc therapy (VMAT) patient deliveries. A process capability index was used to evaluate the continuing treatment quality based on three quality classes: treatment type-specific, treatment linac-specific, and body site-specific.

The determined control limits were 62.5 and 70.0 per cent of the χ pass-rate for IMRT and VMAT deliveries, respectively. In total, 14 patients were selected for a pilot study the results of which showed that about 1 per cent of all treatments contained errors relating to unexpected anatomical changes between treatment fractions. Both rectum and pelvis cancer treatments demonstrated process capability indices were less than 1, indicating the potential for quality improvement and hence may benefit from further assessment.

The study relied on the application of in vivo EPID dosimetry for patients treated at the specific centre. Sampling patients for generating the control limits were limited to 100 patients. Whilst the quantitative results are specific to the clinical techniques and equipment used, the described method is generally applicable to IMRT and VMAT treatment QA. Whilst more work is required to determine the level of clinical significance, the authors have demonstrated the capability of the method for both treatment specific QA and continuing quality improvement.

The proposed method is a valuable tool for assessing the accuracy of treatment delivery whilst also improving treatment quality and patient safety.

Assessing in vivo EPID dosimetry with SPC can be used to improve the quality of radiation treatment for cancer patients.

The purpose of this paper is to evaluate and improve the quality and the reliability of pre‐treatment quality controls of an efficient technique of radiotherapy called IMRT (intensity‐modulated radiation therapy). The aim is then to determine if the controls can be safely reduced while keeping an optimal level of quality.

The statistical process control method (SPC) was applied to quality assurance in IMRT. In order to characterize prostate and head‐and‐neck treatment process variability, individual value control charts and moving‐range control charts were established.

Control charts showed that prostate and head‐and‐neck treatment processes are only subject to random causes of variability, which means they are statistically controlled. It was proved that both processes are statistically stable and capable.

The paper shows that SPC is an efficient method to objectively determine if quality controls can be reduced.

By considering a number of practical case study examples, the paper highlights some of the design methods of intelligent systems for use in optimisation and control. The paper describes tools and approaches that are used as well as the systems to which they are applied. The approaches include fuzzy logic decision making for optimal start‐up of combined cycle power plant, control and modelling within an automotive air fuel ratio application and optimisation of intensity modulated radiation therapy treatment. These diverse application areas have much in common in regard to the problem‐solving approaches; in recognition of this, generic aspects of the use of intelligent methodologies are also highlighted.

EBT2 film, a convenient quality assurance (QA) tool with high 2D dosimetry resolution, has been widely used in the dosimetry application of radiation therapy with lots of benefits especially its self-development, water equivalent, energy independent and high spatial resolution. However, the higher inhomogeneity between the pixels of EBT2 image, needed to be averaged out according to the traditional method, but it could sacrifice the spatial resolution. To solve this problem, the purpose of this paper is to introduce a Wiener filter (WF) technique applied with a multi-channel (MC) method.

The EBT2 film was calibrated by using the percentage depth dose method combined with the WF technique and a MC method. Then the calculated film doses were compared with the measurement doses by the edge detector with the water phantom.

With high spatial resolution to be 0.2 mm, the results demonstrate that the EBT2 film calibration through both of the WF technique and MC method has higher accuracy (within 2 percent) and lower uncertainty.

A new technique of WF with MC method was presented to calibrate the dosimetry system of EBT2 film. With high spatial resolution (0.2 mm), the studies show that the combination of WF technique with MC method can have high accuracy with low noises to calibrate EBT2 film. This method can also be applied to all the QAs of treatment planning of radiation therapy by using the EBT2 film.

The operations research method of data envelopment analysis (DEA) shows promise for assessing radiotherapy treatment plan quality. The purpose of this paper is to consider the technical requirements for using DEA for plan assessment.

In total, 41 prostate treatment plans were retrospectively analysed using the DEA method. The authors investigate the impact of DEA weight restrictions with reference to the ability to differentiate plan performance at a level of clinical significance. Patient geometry influences plan quality and the authors compare differing approaches for managing patient geometry within the DEA method.

The input-oriented DEA method is the method of choice when performing plan analysis using the key undesirable plan metrics as the DEA inputs. When considering multiple inputs, it is necessary to constrain the DEA input weights in order to identify potential plan improvements at a level of clinical significance. All tested approaches for the consideration of patient geometry yielded consistent results.

This work is based on prostate plans and individual recommendations would therefore need to be validated for other treatment sites. Notwithstanding, the method that requires both optimised DEA weights according to clinical significance and appropriate accounting for patient geometric factors is universally applicable.

DEA can potentially be used during treatment plan development to guide the planning process or alternatively used retrospectively for treatment plan quality audit.

DEA is independent of the planning system platform and therefore has the potential to be used for multi-institutional quality audit.

To the authors’ knowledge, this is the first published examination of the optimal approach in the use of DEA for radiotherapy treatment plan assessment.

This case describes how Varian Medical Systems, the successor to one of the pioneers of Silicon Valley, created a business with $11.6 billion in market cap by listening to dreams of its physician customers and their scientist colleagues and finding ways to fulfill them over several decades.

A key business opportunity that spurred the company was to identify the most perceptive thought-leader customers, then bring them into a long-term, system-building partnership.

If companies envision the future and work with perceptive, far-sighted customers and others who will benefit from high-value innovation, together they stand a real chance of achieving a desired future.

Establish forums where perceptive, visionary customers meet with executives, marketers and key developers to identify what you should deliver in the immediate future and in years beyond.

The case described the practical steps the company took to implement customer participation in the innovation process over many decades.

The members of the United Nations celebrate 30 years of the adoption of the Convention of the Rights of the Child (CRC) in 2019. This milestone has added significance in a context in which we are about a decade away from fulfilling the targeted goals of the UN 2030 Agenda with its pledge to leave no country or no-one behind. This is an opportune moment to assess the status of children in Small Island Developing States (SIDS). Using primary and secondary data, the chapter assesses the status of children after 30 years of the CRC in four Caribbean SIDs; Barbados, Jamaica, Haiti and St Lucia. The focus is on poverty, education, health and climate change related CRC articles and Sustainable Development Goals (SDGs). Data analysis reveals that the vulnerabilities of SIDS impede adherence to Child Rights for large proportions of children who are at risk of being left behind. Climate Change increases their vulnerabilities and disparities persist in access to basic social services. As with the CRC and the Millennium Development Goals (MDGs), the implementation of the SDGs is plagued with a lack of timely and disaggregated data to inform the policy process; inadequate programmatic coordination; insufficient financial support; limited accountability and political will. Cultural perceptions of children and inadequate recognition of the importance of children to any the Developmental Agenda also thwart progress for children in SIDs. Urgent action is needed if we are to fulfil all the commitments that we made to our children since 1989 with the adoption of the CRC.

The purpose of this paper is to study the effect of gamma-rays on murexide (Mx) dye and its possible use as radiation dosimeters in two different dosimetry systems. The first system depends on the Mx dye as a liquid dosimeter. The second dosimetry system depends also on the same dye but as in a gel form, which is more sensitive to gamma-rays.

The prepared Mx (solutions/gels) have a considerable two peaks at 324 and 521 nm that upon irradiation, the intensity of these peaks decreases with the increasing radiation dose.

The gamma-ray absorbed dose for these dosimeters was found to be up to 2 kGy for the solution samples and 40 Gy for the gels. Radiation chemical yield, dose response function, radiation sensitivity and before and after-irradiation stability under various conditions were discussed and studied.

It is expected that the radiolysis of the Mx dye can be used as radiation dosimeters in two different dosimetry systems; liquid and gel dosimeters. This can be applied in a wide range of gamma radiation practical industrial applications in water treatment, food irradiation dosimeters, radiotherapy and fresh food irradiation and seed production.

Both of the prepared Mx dyes, either as solutions or gel samples, can be facilely prepared from commercially, cheap, safe, available chemicals and suitable for useful applied Mx solutions and gels radiation dosimeters.