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Research Proposal
Group 4 (Kate Fischer, Amanda Tabar, and Hieu Tran)

Working Title
Radiation treatment time efficiency and dose comparison for intensity modulated radiation lung
treatment at breath-hold using flattening filter and flattening filter-free techniques.

Problem Statement
The problem is that patients receiving intensity modulated radiation therapy (IMRT) for lung
cancer at breath-hold experience difficulty completing multiple breath-holds while on the
treatment machine, extending their radiation treatment time.

Purpose Statement
The purpose of this study is to compare the use of a flattening filter technique and a flattening
filter-free technique to measure treatment times while maintaining OAR dose constraints and
mean tumor dose.

Hypotheses Statement
H1A: The first research hypothesis (H1) is that using FFF technique will reduce treatment time ≥
40% compared to an FF technique, while maintaining OAR dose constraints and mean tumor
dose.
H10: The first null hypothesis (H10) is that using FFF technique will not reduce treatment time ≥
40% compared to an FF technique, while maintaining OAR dose constraints and mean tumor
dose.

Summary
The goal of radiation therapy is to deliver an optimal radiation treatment that eradicates
the tumor while sparing normal tissues. Developments in intensity modulated radiation therapy
(IMRT) have allowed for additional normal tissue sparing with improved delivery of higher
radiation doses for more accurate radiation therapy treatments. The accuracy of radiation
treatments can be limited by geometric uncertainties such as organ motion, setup errors,
respiratory motion, and/or tumor delineation.1 Specific to lung radiotherapy, radiation treatment
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accuracy is significantly affected by respiratory motion within the lung. Limiting respiratory
motion within the lung allows for reduced treatment volumes along with a reduction in irradiated
healthy tissue and toxicities.1 Motion management is crucial in radiation therapy because patient
motion during treatment can result in errors and reduced treatment effectiveness. There are
multiple breath-hold techniques that can be used for respiratory motion management. These
innovative technologies, such as Active Breathing Controller and VisionRT, allow for lung,
breast, and abdominal treatments to be done at breath-hold.
In 2006, the American Association of Physicists in Medicine (AAPM) Task Group 76
released a report on the management of respiratory motion in thoracic, abdominal, and pelvic
tumors. This AAPM Task Group recommends measuring tumor motion for each patient when
possible. If tumor motion is greater than 5 mm, a method of respiratory motion management is
available, and the patient can tolerate the procedure then respiratory motion management is
appropriate.2 In 2020, the AAPM formed Task Group 324 to update Task Group 76, given the
growth and technological changes in respiratory motion management since 2006 by conducting a
survey of current AAPM members. The report from Task Group 324 summarizes the current
state-of-the-art practice techniques for motion management, including imaging modalities,
motion tracking devices, and treatment delivery systems.2 It highlights the importance of
individualized patient motion management plans based on patient-specific characteristics, such
as tumor location, patient anatomy, and treatment delivery technique. Furthermore, the report
emphasizes the need for collaboration between radiation oncologists, medical physicists, and
radiation therapists to develop and implement effective motion management strategies. The
article concludes that the findings and recommendations of the AAPM Task Group 324 report
provide a framework for improving motion management in radiation therapy and patient
outcomes overall.2
The advancement of treatment techniques and research has also led to the increased use
of flattening filter free (FFF) beams for lung radiation treatment. By removing the flattening
filter (FF), an irregular dose profile with an enhanced central peak and sharp dose fall off is
produced.3 FFF beams allow for a reduced treatment delivery time due to their higher dose rate
while also reducing scatter and radiation leakage.4 One of the main benefits of using the
flattening filter-free technique for intensity-modulated radiation therapy lung patients is a
decrease in radiation treatment time. Studies have shown that flattening filter-free IMRT can
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significantly reduce treatment times compared to IMRT with a flattening filter.5 Zhang et al6
determined that FFF IMRT reduced treatment times by an average of 2.5 minutes per fraction
compared to IMRT with a flattening filter. This reduction in treatment time can be particularly
beneficial for lung cancer patients, who may already be experiencing fatigue and other side
effects from chemotherapy or surgery. Pokhrel et al7 reported that the average beam on-time for
FFF beams was 6.5 minutes and determined it to be much shorter than for FF beams,
respectively 15.1 minutes. The researcher's data expressed an overall reduction in beam on-time
by about 57.0% using FFF beams for lung lesions. This increased efficiency can benefit both
patients and healthcare providers by reducing the overall treatment time and increasing the
number of patients that can be treated in the clinic daily. Wu et al8 discussed another primary
advantage of FFF beams is that they have similar MUs; meanwhile, they have a shortened beam
on-time compared with FF beams. Their results showed that the FFF beams obtained a 23.8%
reduction in beam on-time, an 18.8% reduction in radiation treatment time and a 1.0% reduction
in MU for VMAT treatments.
Expecting to shorten treatment time with similar or enhanced dosimetric outcomes, FFF
beams have promising features that can improve patient outcomes.9 The present study sought to
evaluate the impact of the flattening filter-free technique on shortening treatment delivery time
for intensity modulated radiation therapy for lung breath-hold treatments. The problem is that
patients receiving intensity modulated radiation therapy (IMRT) for lung cancer at breath-hold
experience difficulty completing multiple breath-holds while on the treatment machine,
extending their radiation treatment time. By increasing the dose rate, radiation treatment time is
decreased leading to improved patient satisfaction because they spend less time physically on the
treatment table.10 This study's purpose is to compare the use of a flattening filter technique and a
flattening filter-free technique to measure treatment times while maintaining OAR dose
constraints and mean tumor dose. Researchers evaluated and compared three metrics, treatment
delivery time, dose to organs at risk (heart, spinal canal, & contralateral lung), and mean dose to
tumor. They tested the hypothesis that using the FFF technique will reduce treatment time ≥ 40%
compared to an FF technique, while maintaining OAR dose constraints and mean tumor dose
(H1A).
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References
1. Botticella A, Levy A, Auzac G, Chabert I, Berthold C, Le Pechoux C. Tumour motion
management in lung cancer: a narrative review. Transl Lung Cancer Res.
2021;10(4):2011-2017. doi:10.21037/tlcr-20-856
2. Ball, HJ, Santanam, L, Senan, S, Tanyi, JA, van Herk, M, Keall, PJ. Results from the
AAPM Task Group 324 respiratory motion management in radiation oncology survey. J
Appl Clin Med Phys. 2022; 23:e13810. https://doi.org/10.1002/acm2.13810
3. Ghemiş DM, Marcu LG. Progress and prospects of flattening filter free beam technology
in radiosurgery and stereotactic body radiotherapy. Crit Rev Oncol Hematol.
2021;163:103396. doi:10.1016/j.critrevonc.2021.103396
4. Vassiliev ON, Kry SF, Wang HC, Peterson CB, Chang JY, Mohan R. Radiotherapy of
lung cancers: FFF beams improve dose coverage at tumor periphery compromised by
electronic disequilibrium. Phys Med Biol. 2018;63(19):195007. doi:10.1088/1361-
6560/aadf7d
5. Moustamia, A., Muraro, S., & Julian, D. (2018). 25 Dosimetric impacts of FFF large-
field beams for lung cancer VMAT treatment. Physica Medica, 56, 51–51.
https://doi.org/10.1016/j.ejmp.2018.09.107
6. Zhang DG, Feygelman V, Moros EG, et al. Superficial and peripheral dose in
compensator-based FFF beam IMRT. J Appl Clin Med Phys. 2017;18(1):151-156.
doi:10.1002/acm2.12018
7. Pokhrel D, Halfman M, Sanford L. FFF-VMAT for SBRT of lung lesions: Improves dose
coverage at tumor-lung interface compared to flattened beams. J Appl Clin Med Phys.
2020;21(1):26-35. doi:10.1002/acm2.12764
8. Wu, J et al (2023). Evaluation of flattening-filter-free and flattening filter dosimetric and
radiobiological criteria for lung SBRT: A volume-based analysis. Front Oncol. 2023;
12:1108142. doi: 10.3389/fonc.2023.1108142
9. Arslan A, Sengul B. Comparison of radiotherapy techniques with flattening filter and
flattening filter-free in lung radiotherapy according to the treatment volume size. Sci Rep.
2020;10(1):8983. doi:10.1038/s41598-020-66079-6
10. Ma C, Chen M, Long T, et al. Flattening filter free in intensity-modulated radiotherapy
(IMRT) - Theoretical modeling with delivery efficiency analysis. Med Phys.
2019;46(1):34-44. doi:10.1002/mp.13267