CENTERLINE. Introducing Halcyon An Innovative Treatment Platform Page 4. RapidPlan Knowledge- Based Planning Clinical Adoption Takes Off Page 8

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1 CENTERLINE VARIAN MEDICAL SYSTEMS NEWS FOR THE CLINICAL ONCOLOGY COMMUNITY AUGUST 2017 Introducing Halcyon An Innovative Treatment Platform Page 4 RapidPlan Knowledge- Based Planning Clinical Adoption Takes Off Page 8 ARIA 15.1: The Security Release Putting Data Security Front and Center Page 19

2 TABLE OF CONTENTS FEATURES Centerline magazine is published by Varian Medical Systems. 2 Point of View by Kolleen Kennedy The Era of Innovation Continues 4 Introducing Halcyon An Innovative Treatment Platform 8 RapidPlan Knowledge-Based Planning: Clinical Adoption Takes Off 11 HyperArc Technology For High-Definition Radiotherapy and Radiosurgery 13 Improving the Accuracy of Liver and Prostate Cancer Radiotherapy Using the Calypso System HIGH QUALITY OF CARE OPERATIONAL EXCELLENCE HUMAN-CENTERED DESIGN managing editor: Tracey Fisher editor: Meryl Ginsberg creative director: David Kervinen art director: Lisa Clifford Centerline welcomes letters to the editor, contributions for point-ofview commentaries, and suggestions for articles. Reprinting of Centerline articles may take place with permission from the editor. Address comments, contributions, inquiries about reprints and permissions, subscription requests, and address changes to: Varian Medical Systems 3100 Hansen Way, M/S MGM Palo Alto, CA Attn: Meryl Ginsberg meryl.ginsberg@varian.com Oncology A Comprehensive Software Platform for Coordinating Cancer Care 19 ARIA 15.1: The Security Release Putting Data Security Front and Center 22 Improving Big Data Analytics for Personalized Medicine Two UK Centers Enhance Operational Efficiency Using Varian Analytics Solutions 25 Varian Consultants Help Clinics Tap Into the Full Potential of ARIA 29 The Value of Varian Service Contracts Maximizing Clinical Availability for Better Patient Care 32 Oncology Professionals Share Knowledge and Insights via OncoPeer Centerline is now online. Be sure to visit the website for a continuous stream of news and features. You can sign up for ed notifications whenever there is new content. Visit varian.com/centerline Varian Medical Systems, Inc. All rights reserved. Varian, Varian Medical Systems, the Varian Medical Systems logo, ARIA, Beacon, Calypso, Edge, ProBeam, RapidArc, SmartConnect, and TrueBeam are registered trademarks and 360 Oncology, Eclipse, Halcyon, HyperArc, InSightive, OncoPeer, RapidPlan, and Velocity are trademarks of Varian Medical Systems, Inc. The names of other companies and products mentioned herein are used for identification purposes only and may be trademarks or registered trademarks of their respective owners. Varian as a medical device manufacturer cannot and does not recommend specific treatment approaches. Individual treatment results may vary. Healthcare professionals must always rely on their professional clinical judgment when deciding whether a patient is a candidate for radiation therapy and how to use radiation therapy. Varian does not dispense medical advice and recommends that healthcare professionals using radiation therapy be adequately trained before using any Varian product. Safety information. Radiation treatments may cause side effects that can vary depending on the part of the body being treated. The most frequent ones are typically temporary and may include, but are not limited to, irritation to the respiratory, digestive, urinary or reproductive systems, fatigue, nausea, skin irritation, and hair loss. In some patients, they can be severe. Treatment sessions may vary in complexity and time. Radiation treatment is not appropriate for all cancers. For comprehensive Intended Use and important safety information regarding Varian technologies highlighted in this magazine, please visit varian.com/safety.

3 In May, Varian introduced the Halcyon treatment platform, engineered to revolutionize clinical workflow and enhance virtually every aspect of image-guided volumetric intensity-modulated radiotherapy (IMRT). Halcyon is designed to achieve high quality of care through three attributes that work synergistically: treatment speed, a unique dual-layer MLC that enables high modulation, and a streamlined workflow with image guidance for 100% of treatments. Centerline magazine is published by Varian Medical Systems. TABLE OF CONTENTS FEATURES 2 Point of View by Kolleen Kennedy The Era of Innovation Continues 4 Introducing Halcyon An Innovative Treatment Platform managing editor: Tracey Fisher editor: Meryl Ginsberg creative director: David Kervinen art director: Lisa Clifford Centerline welcomes letters to the editor, contributions for point-ofview commentaries, and suggestions for articles. Reprinting of Centerline articles may take place with permission from the editor. Address comments, contributions, inquiries about reprints and permissions, subscription requests, and address changes to: Varian Medical Systems 3100 Hansen Way, M/S MGM Palo Alto, CA Attn: Meryl Ginsberg meryl.ginsberg@varian.com 8 RapidPlan Knowledge-Based Planning: Clinical Adoption Takes Off 11 HyperArc Technology For High-Definition Radiotherapy and Radiosurgery 13 Improving the Accuracy of Liver and Prostate Cancer Radiotherapy Using the Calypso System Oncology A Comprehensive Software Platform for Coordinating Cancer Care 19 ARIA 15.1: The Security Release Putting Data Security Front and Center 22 Improving Big Data Analytics for Personalized Medicine Two UK Centers Enhance Operational Efficiency Using Varian Analytics Solutions 25 Varian Consultants Help Clinics Tap Into the Full Potential of ARIA 29 The Value of Varian Service Contracts Maximizing Clinical Availability for Better Patient Care 11 Operational Excellence is achieved through a consistent simplified workflow, reduced need for physics QA, fast ramp-up from acquisition to deployment, SmartConnect remote servicing, enhanced IT security, and a six-point safety system. The Halcyon System was created using Human-Centered Design principles to enhance both patient comfort and to improve the clinical staff s experience. Couch and gantry are powered by linear brushless motors so that machine motions are virtually silent Varian Medical Systems, Inc. All rights reserved. Varian, Varian Medical Systems, the Varian Medical Systems logo, ARIA, Beacon, Calypso, Edge, ProBeam, RapidArc, SmartConnect, and TrueBeam are registered trademarks and 360 Oncology, Eclipse, Halcyon, HyperArc, InSightive, OncoPeer, RapidPlan, and Velocity are trademarks of Varian Medical Systems, Inc. The names of other companies and products mentioned herein are used for identification purposes only and may be trademarks or registered trademarks of their respective owners. 32 Oncology Professionals Share Knowledge and Insights via OncoPeer Centerline is now online. Be sure to visit the website for a continuous stream of news and features. You can sign up for ed notifications whenever there is new content. Visit varian.com/centerline Varian as a medical device manufacturer cannot and does not recommend specific treatment approaches. Individual treatment results may vary. Healthcare professionals must always rely on their professional clinical judgment when deciding whether a patient is a candidate for radiation therapy and how to use radiation therapy. Varian does not dispense medical advice and recommends that healthcare professionals using radiation therapy be adequately trained before using any Varian product. Safety information. Radiation treatments may cause side effects that can vary depending on the part of the body being treated. The most frequent ones are typically temporary and may include, but are not limited to, irritation to the respiratory, digestive, urinary or reproductive systems, fatigue, nausea, skin irritation, and hair loss. In some patients, they can be severe. Treatment sessions may vary in complexity and time. Radiation treatment is not appropriate for all cancers. For comprehensive Intended Use and important safety information regarding Varian technologies highlighted in this magazine, please visit varian.com/safety.

4 POINT OF VIEW Intelligent Treatment Delivery Advanced Analytics Looking to the Future For some time, we have been galvanized by a vision of a world without fear of cancer a world where it can be managed like other chronic, non-lethal diseases. We ve made many strides in this direction but there is much more to do. We have been galvanized by a vision of a world without fear of cancer where cancer is managed like other chronic, non-lethal diseases. Through pioneering clinical advances that offer more options for treating some of the most deadly cancers such as those of the lung, liver, and pancreas, and by expanding our global training center footprint in the developing world, Varian is working to offer emerging countries the quality of care that can be found in developed countries today. Varian is also committed to supporting cutting edge research into the biology of cancer in order to better understand how the various modes of radiotherapy can be most effectively applied, particularly in conjunction with emerging forms of immunotherapy. We are seeing exciting possibilities in greater collaboration across medical disciplines to arrive at optimal treatments for each individual cancer patient. Varian is excited to be part of such efforts. We are at a moment of extraordinary innovation acceleration, and we look forward to broadening the scope of our work in the fight against cancer. n Knowledge-Guided Oncology The Era of Innovation Continues By Kolleen Kennedy President of Varian Oncology Systems For example, while RapidPlan knowledge-based treatment planning was our first foray into the world of machine learning and cognitive computing, we re not stopping there. We are looking to expand the range of tools that bring knowledge guidance to all of the steps in the radiation oncology workflow, from segmentation and contouring to prescribing, from imaging strategies to adaptation during treatment. As we enter the era of precision medicine, we will partner with thought leaders to apply cognitive computing to decipher genomic and other patient biomarkers to match patients to the optimal treatment strategy. We envision the creation of software tools that help clinical teams make knowledge-guided adaptations to treatment based on aggregated data that show how we can best impact individual and population-based outcomes. To enhance access to care around the globe, Varian has increased funding of research that is designed to demonstrate the value of radiation therapy and show how it fits into a comprehensive cancer treatment approach. Varian is focusing squarely on extending advanced care globally by developing equipment and software that is easier and faster to operate, by placing an emphasis on systems that address capacity limitations, and by offering affordable systems that enable entry-level machines to be upgraded over time. Kolleen Kennedy is president of Varian Oncology Systems. Her tenure at Varian spans nearly 20 years during which she has held a variety of management roles overseeing marketing, product management, engineering, and customer support services prior to stepping into her current leadership position. Ms. Kennedy holds a BS in Psychology, a BS in Radiation Oncology and an MS in Medical Physics. Anew era of innovation is under way at Varian, at a time when we are transforming as a company. We recently spun off our imaging components business in order to concentrate our focus on the fight against cancer, and on meeting the needs of oncology health care providers around the world. Our offerings today encompass an expanding range of treatment delivery systems as well as software and data analytics tools designed to help support oncology professionals as they manage the cancer patient s journey from diagnosis and treatment through survivorship, at a time of fast-paced change in the global healthcare sector. Varian s goal is to be the leading innovator in areas where we have the potential to make an impact in terms of increasing access to high quality cancer services and enhancing patients quality of life during and after treatment. One of our strategies has been to concentrate research and development on creating an evolving technology ecosystem that enables intelligent treatment delivery, brings knowledge to the point of care, and converts data into actionable insights so that sophisticated treatments are easier to plan and deliver. For us, these three areas of innovation are serving as guideposts to the future, anchoring our product development efforts. In this issue of Centerline, we highlight some of the elements of this evolving ecosystem, including the introduction of our Halcyon radiotherapy system, a prime example of what we mean by intelligent treatment delivery. We are at a moment of extraordinary innovation acceleration, and we look forward to broadening the scope of our work in the fight against cancer. 2 CENTERLINE AUGUST 2017 VARIAN.COM/CENTERLINE AUGUST

5 HALCYON Introducing HALCYON In May of this year, Varian introduced a new device for cancer treatment, engineered to revolutionize clinical workflow and enhance virtually every aspect of image-guided volumetric intensity modulated radiotherapy (IMRT). The new Halcyon treatment system was unveiled at the 2017 meeting of the European Society for Radiotherapy & Oncology (ESTRO). It is designed to expand the availability of high quality cancer care globally and help save the lives of millions more cancer patients. An Innovative Treatment Platform The Halcyon system is not just an iterative improvement, said James M. Metz, chairman, Department of Radiation Oncology at the University of Pennsylvania Perelman Center for Advanced Medicine. The product simplifies treatment delivery while maintaining high-quality plans delivered at significantly increased speed. This allows increased efficiency in the radiation oncology clinic while delivering exceptional treatments. I expect this will be the new standard for linear accelerators of the future. The Halcyon development team, which worked on the project for roughly four and a half years, was challenged to create a human-centered design that would automate, streamline and simplify virtually every aspect of treatment. We were challenged to create a breakthrough product, recalls Ross Hannibal, a Varian engineer and user interface expert who worked on the project. So we really pushed in the direction of radical simplicity. Rather than start with a complicated design and then try to take things out, we started with an empty box and carefully put things in but only if they added significant value. Our consistent goal was to minimize complexity without losing functionality. The result is an advanced system that is designed to be easier to use and more comfortable for the patient. Other benefits include accelerated installation timeframes, expedited commissioning, and simplified training. Halcyon treatments will require only nine steps from start to finish. High Quality of Care Halcyon is designed to achieve high-quality care by optimizing rapid image-guided IMRT and RapidArc radiotherapy. Every patient will receive treatment characterized by a high level of clinical quality in terms of dose conformality and low 4 CENTERLINE AUGUST 2017 VARIAN.COM/CENTERLINE AUGUST

6 HALCYON dose to organs-at-risk because of three attributes that work synergistically: 1. The machine s speed, which enables the use of more fields or arcs within a normal treatment time slot. 2. A unique dual-layer MLC that enables high modulation with low leakage for every field or arc. 3. A streamlined workflow whereby 100% of treatments are image-guided. The gantry rotates four times faster than a standard linac for fast IMRT treatments, said Mu Young Lee, director of new product solutions at Varian. Cone-beam CT imaging can be completed in 17 seconds. Since the MV imager is always in the beam s path, you do not waste any time deploying it; and this, too, speeds up treatment. As an extra measure of quality, the MV imaging dose is included in treatment plan optimization. The New Generation Dual-Layer Multileaf Collimator Halcyon features a patented dual-layer multi-leaf collimator (MLC) that has been optimized for modulated treatments. It can move twice as fast as traditional MLCs to support the gantry rotation speed and the high dose delivery rate of the system s 6 MV FFF beam, allowing excellent modulation for high-quality treatments. The Halcyon MLC has a stacked and staggered design with 100 percent interdigitation, which enables the system to offer sophisticated beam shaping for conforming the dose to the desired treatment targets as well as an unprecedented 0.01 percent interleaf leakage. Fast Delivery of High-Quality IMRT and RapidArc Radiotherapy The faster gantry rotation speed, MLC speed, and high dose delivery rate carefully synchronized by Maestro, the system s integrated digital architecture originally developed for the TrueBeam system make Halcyon ideal for delivering efficient IMRT and RapidArc radiotherapy. These capabilities will make The unique and innovative design of the Halcyon system will allow clinicians to treat patients quickly and minimize intrafraction motion. Karin Haustermans, MD Department of Radiation Oncology Chair, Belgium it possible to deliver complex IMRT plans in the same timeframe as a typical RapidArc treatment. They will also enable the use of multiple RapidArc trajectories quickly when indicated for treatment quality. Consequently, clinical teams will be able to choose the approach that is best for each patient without impeding throughput or operational efficiency. The unique and innovative design of the Halcyon system will allow clinicians to treat patients quickly and minimize intrafraction motion, which is extremely important when treating patients with pelvic tumors such as prostate cancer and cervical cancer, said professor Karin Haustermans, MD, chair of the department of radiation oncology at UZ Leuven in Belgium. The short Halcyon treatment times could also eliminate the need for breath holds traditionally required during breast, esophageal and lung cancer treatments. Additionally, the ultrafast imaging and simplified integrated workflow give us a path to adaptive therapy. Operational Excellence: Optimized, Simplified, Expedited Care Many factors contribute to making Halcyon a transformative new system with the potential to impact the overall economics of cancer care. Among them: A consistent simple workflow. Standard image-guided IMRT or RapidArc treatments are completed in nine intuitive steps. Reduced physics QA. The TG142 test requirements applicable for Halcyon are about half that of a standard C-arm linac. This frees physicists to focus on complex patient cases, research, or other priorities. Low electricity consumption. With Halycon, typical electrical usage is about half that of a standard high-energy linac during beam-on and stand-by modes. SmartConnect remote servicing. Every Halcyon system is SmartConnect enabled, so that Varian personnel can perform diagnostic and support services remotely. IT security. Halcyon ships with security-hardened versions of Eclipse treatment planning and the ARIA oncology information system. Fast Clinical Deployment Halcyon was designed to offer a fast path from acquisition to clinical deployment. To assist in the reduction of time and construction costs from installation to first patient treatment, Halcyon comes pre-commissioned, requires less shielding than traditional systems, and it can fit in a vault as small as 5.9 meters (19.68 feet) x meters (18.17 feet) x meters (8.99 feet) high. Halcyon is designed to be installed in two weeks or less, said Lee. The major components of the system will ship in two crates for easy transport through freight elevators. The gantry bolts directly to the floor and the couch is connected to the gantry frame, so there is no need for a base frame. This minimizes the amount of concrete work needed. Varian can install all of the integrated components the intercom, the camera, the lasers, the solid state modulator, and the shielding together as one unit. The clinical team can master the simplified workflow very quickly. Training will be delivered onsite, and through a multi-media ebook manual including animations, videos, and step-by-step instructions that can be installed on a tablet. By simplifying the entire treatment process, the Halcyon system presents the ideal platform for training and upskilling healthcare workers in best practice delivery of radiation oncology, said Mark Middleton, CEO, Icon Group, Australia s largest private cancer care provider, which plans to use Halcyon both domestically and in southeast Asia. The Halcyon system will amplify our response to the global cancer challenge, by allowing us to support the emergence of a radiation-oncology-competent workforce [that is] able to deliver cutting-edge treatments. Human-Centered Design: Maximizing Patient Comfort and Clinician Confidence Halcyon was designed to enhance patient comfort. The couch descends low to the ground for easy loading and unloading. The system features a spacious, 100-cm diameter bore with integrated ambient lighting, designed to contribute to patients comfort and relaxation. The couch and gantry are powered by linear brushless motors so that machine motions are smooth and virtually silent, even during acceleration and deceleration. The integrated couch-mounted camera travels with the patient, who is always at the center of the large image that appears on the treatment console. A noise cancellation feature on the integrated intercom enables immediate and clear communication between the therapist and the patient. We are very excited with the introduction of Halcyon to be taking another big step toward advancing cost-effective cancer care worldwide. Kolleen Kennedy President of Varian Oncology Systems Patient Safety Halcyon was designed with a six-point safety system. Patient verification has been integrated into the workflow. An enclosed gantry will prevent any chance of collision with the patient, and collision detection technology will pause treatment or motion in the rare instance when a patient bumps the wall of the bore. An automated daily machine performance check takes only five minutes to verify that all mechanical axes remain within specifications. And all treatments are 100 percent image guided to reduce uncertainties in patient setup. Clinical Staff Experience Halycon was also designed to improve the experience of the clinical team. Simplified and standardized treatments can be completed in just a few consistent steps that are signaled by a follow the light workflow that was first developed for Varian s TrueBeam platform, making the therapists job easier and freeing them to focus more on the patient. The color-coded workflow steps are presented to the therapist at both the treatment console and on screens within the vault. All of the controls, screens, buttons, and cubbies were designed ergonomically for quick access during treatment. The global cancer challenge is enormous, said Kolleen Kennedy, president of Varian s Oncology Systems business. It is expected that there will be 24.6 million cancer cases diagnosed annually by 2030, and there is an acute shortage of equipment and trained clinicians. With the innovations in this new technology platform, the system will deliver high quality Halcyon treatments that empower clinicians to care for many more patients. We are very excited, with the introduction of Halcyon, to be taking another big step toward advancing cost-effective cancer care worldwide. We expect this system to provide a pathway to adaptive radiotherapy as well as opportunities for research into new treatment protocols. n 6 CENTERLINE AUGUST 2017 VARIAN.COM/CENTERLINE AUGUST

7 RAPIDPLAN Delivering high-quality treatments with advanced techniques like volumetric modulated arc therapy (VMAT) or image-guided radiotherapy can be a challenge, says Catherine Khamphan, PhD, medical physicist with the Institut Sainte Catherine in Avignon, France. RapidPlan knowledge-based planning is a powerful tool that aggregates information from existing treatment plans to estimate an optimized and achievable dose distribution for new patients. Carefully implemented, it can improve treatment quality and efficiency. The time savings are significant. RapidPlan also helps to bridge the experience gap. It enables more homogeneous plan quality across different planners, Khamphan says, adding that, without such a tool, plans created manually might not do as well sparing organsat-risk (OAR) or covering the target. RapidPlan helps us avoid the use of such suboptimal plans. French Team Develops RapidPlan Models for Treating Head & Neck and Prostate Cancer Khamphan and her colleague, medical physicist Veronique Bodez, PhD, initially focused their efforts on creating RapidPlan models for two disease sites: head & neck and prostate. We had in-house guidelines that we were using; but we still found inhomogeneities in our datasets, such as structure definitions and clinical trade-offs, especially for head & neck treatments, said Khamphan. RapidPlan helped us to correct this. We quickly found that implementing RapidPlan amounted to a quality assurance for our practice. According to Robin Garcia, PhD, head of the Medical Physics Department, some dosimetrists in her group initially expressed concerns about how RapidPlan might impact their work. In fact, we have found that the time saved with RapidPlan can be dedicated to more complex cases and it can help reduce the pressure on the planning staff, she said. As we decrease the amount of effort spent on planning, we will be able to make a time investment in other areas, like developing adaptive procedures. Developing Rectal, Cervical and Lung Cancer Models in Beijing Yibao Zhang, PhD, associate professor at Beijing Cancer Hospital in China, and his colleagues have worked together to develop RapidPlan models for rectal, cervical, and lung stereotactic ablative radiotherapy (SABR) treatments. We started with planning for VMAT plus simultaneous infield boost for pre-surgical rectal patients, said Zhang. We have a large patient population with this disease, there were not yet other reports in the literature about RapidPlan applied to rectal cancer so it was an opportunity to publish, and this type of cancer generally involves relatively few OAR. Successful models have been reported for similar anatomical sites such as the prostate. We thought we would start by mastering this one and then move on to develop more models for other disease sites. RapidPlan Knowledge-Based Planning: Clinical Adoption Takes Off RapidPlan knowledge-based planning is helping clinicians at centers around the world achieve greater consistency, efficiency, and quality in radiotherapy treatment planning. RapidPlan streamlines the planning process by using shared clinical knowledge to provide estimated dose volume histograms that can be used as a guideline and starting point. Planners can use shared models or create their own to reflect preferred treatment methodologies and protocols. This can reduce or even eliminate the need for multiple, time-consuming iterations when producing treatment plans. Khamphan and her colleagues measured the efficacy of their RapidPlan models by looking at the number of optimizations needed to reach clinical goals. They discovered that, with RapidPlan, one optimization was often enough, while a planner working manually sometimes must generate five or more. We found that 85 percent of the head & neck plans optimized with RapidPlan were clinically acceptable after the first attempt. Plan quality is at least equal or improved, and the OAR sparing is significant in most cases. Also, we believe we can improve on those rates as we improve our models, Khamphan said. So far, about 170 patients have received treatments planned using RapidPlan at Institut Sainte Catherine. We see that our patients have benefited from the overall improvement in plan quality: better OAR sparing and better dose homogeneity in the target for most cases, Khamphan said. We have a few striking examples of plans where RapidPlan increased the target coverage while sparing OAR beyond what the planner achieved. Our physicians are impressed by both the improvement in plan quality and also by the efficiency. Indeed, a treatment can be quickly re-planned if the physician observes anatomical changes, for example, tumor size or weight loss. Our physicians are impressed by both the improvement in plan quality and also by the efficiency. Catherine Khamphan, PhD Medical Physicist Institut Sainte Catherine Institut Sainte Catherine Zhang worked with Hao Wu, M.Sc., chief physicist, deputy chair, and associate professor; and Fan Jiang, B.S., assistant professor, to create the rectal cancer model. The process involved taking plans that had been fine-tuned by a senior physicist and choosing only the most optimal plans to make sure excellence was incorporated into the model. 8 CENTERLINE AUGUST 2017 VARIAN.COM/CENTERLINE AUGUST

8 RAPIDPLAN Our rectal model is now very mature after much validation and fine-tuning, Zhang said. It produces better-than-manual plans in terms of quality, consistency, and efficiency. 1 During validation, the Beijing-based team chose to evaluate over 200 RapidPlan plans to assess and improve the model, and then they applied it clinically. Since September 2016, over 200 patients were treated with plans created semi-automatically using RapidPlan. We saw gains in both productivity and quality, Zhang said. Patients benefit directly from dosimetric improvement including lower OAR exposure and better target dose conformity and homogeneity, without extra cost. Michigan Researchers Create Spinal SBRT RapidPlan Model Martha Matuszak, PhD, medical physicist and associate professor at the University of Michigan (UM) Medical School in Ann Arbor, defines two major challenges when it comes to producing quality treatment plans for radiotherapy. First, there is the challenge of defining what to treat to give the patient the best possible outcome, she said, pointing out that current research on imaging, segmentation, big data, and outcomes is addressing that question. Once you have defined what you need to treat, you are challenged with creating the best possible plan for that patient, she continued. Knowing when you have achieved the best plan can be difficult, especially when making tradeoffs between the best plan possible as opposed to an acceptable plan given time and resource considerations. Matuszak, who is also the director of advanced treatment planning in the UM Department of Radiation Oncology, says that she was skeptical when she first heard about RapidPlan. I thought it might be adequate to create simple plans for common body sites but would have a lot of limitations in Comparing a manual IMRT plan with a RapidPlan plan After seeing the software perform and creating our first in-house models, I am pleased at how well it works. Martha Matuszak, PhD Associate Professor University of Michigan Medical School Hao Wu, Chief Physicist Deputy Chair Beijing Cancer Hospital Patients benefit from dosimetric improvement. without extra cost. Yibao Zhang, PhD Associate Professor Beijing Cancer Hospital complex geometries. After seeing the software perform and creating our first in-house models, I am pleased at how well it works. Funded by a grant from Varian, Matuszak headed a RapidPlan research project that assessed modeling for the treatment of spinal cancer with stereotactic body radiation therapy (SBRT). In the resulting journal article, the research team concludes: RapidPlan is a robust technique that can improve planning efficiency in spine SBRT while maintaining or potentially improving plan quality and standardization across planners and centers. 2 Matuszak and her research group have also developed RapidPlan models for a number of other body sites and have now deployed several of these clinically, finding that automation is possible in some cases while others require a little tweaking by the user. As part of model creation and validation, we have created hundreds of plans using a number of models, Matuszak said. Clinically, we are just getting started. I would estimate that RapidPlan has been used for some 50 clinical plans so far, focusing on spine SBRT VMAT, liver SBRT IMRT/VMAT, head & neck VMAT, and prostate IMRT. Well-designed RapidPlan models are valuable to the treatment team in that they help planners achieve a high level of quality, and they can do this quickly, Matuszak said. For patients, this means potentially better plans with fewer delays and perhaps the potential for an improved outcome. n Note: The RapidPlan knowledge-based planning and its models are not intended to replace clinical decisions, provide medical advice, or endorse any particular radiation plan or treatment procedure. The patient s medical professionals are solely responsible for and must rely on their professional clinical judgment when deciding to plan and provide radiation therapy. Also, all contributors to this article have received grants from Varian Medical Systems related to research on the clinical applications of RapidPlan and are either planning to or have published papers on this topic in peer-reviewed journals. 1. Wu H et al. A dosimetric evaluation of knowledge-based VMAT planning with simultaneousintegrated-boosting for rectal cancer patients. J Appl Clin Med Phys (6) Foy JJ et al. An analysis of knowledge-based planning for stereotactic body radiation therapy of the spine. Practical Radiation Oncology, in press and published online March 1, DOI: HyperArc Technology for High-Definition Radiotherapy and Radiosurgery Varian s new HyperArc high-definition radiotherapy technology was showcased for the first time at the 2016 annual meeting of the American Society for Radiation Oncology (ASTRO). This exciting new technology unlocks the potential of using highly non-coplanar treatment strategies to usher in a new era of precision in radiotherapy and radiosurgery for cancer patients, said Kolleen Kennedy, president of Varian Oncology Systems. HyperArc is designed to automate and simplify sophisticated treatments such as stereotactic radiosurgery (SRS) and make them available to more cancer patients around the world. HyperArc capitalizes on the unique capabilities of Varian s TrueBeam and EDGE treatment platforms including the PerfectPitch couch. HyperArc will use all degrees of freedom to deliver orchestrated dynamic movements of the gantry and couch for taking optimal advantage of non-coplanar beams, says Matthias Guckenberger, MD, head of the Department of Radiation Oncology, University Hospital Zürich, Switzerland, By Julie Ruiz a member of Varian s Radiosurgery Clinical Council, which advises Varian on the development of HyperArc technology. The HyperArc treatment delivery technology will be available as a purchasable option on TrueBeam 2.7 and EDGE 2.7. Treatment planning for HyperArc is pending FDA 510(k) clearance, and was developed to help planners achieve extremely compact dose distributions consistently and efficiently while maintaining patient safety. Guckenberger and his team plan to use HyperArc to treat brain tumors as well as vertebral metastases. We are particularly interested in using this method to treat vertebral metastases not only in the curative setting but also in the palliative setting for patients with metastatic disease. HyperArc promises to simplify the complexity of selecting different non-coplanar beam trajectories, so that we can deliver complex treatments more rapidly and cost-effectively. Varian is aiming to make the HyperArc technology clinically available later this year. First generation HyperArc is designed for the radiosurgical treatment of brain metastases, with HYPERARC 10 CENTERLINE AUGUST 2017 VARIAN.COM/CENTERLINE AUGUST

9 HYPERARC subsequent products being developed for other treatments throughout the body. Clinicians have been collaborating with Varian on the development and preliminary testing of this technology. In the testing we have done to date, we have found that the HyperArc technology showed a significant improvement in both the dose coverage to the targeted tumor and an associated reduction in the dose to the organs at risk, said Garry Currie, head of Radiotherapy Physics at Beatson West of Scotland Cancer Centre in Glasgow, UK, who also serves on the Radiosurgery Clinical Council. We are excited about the potential of this technology and the impact it could make in the fight against cancer. Approximately 20 percent of newly diagnosed cancer patients will develop brain metastases. For many, SRS is recommended as a primary treatment option. HyperArc is designed to make This exciting new technology unlocks the potential of using highly non-coplanar treatment strategies to usher in a new era of precision in radiotherapy and radiosurgery for cancer patients. Kolleen Kennedy President of Varian Oncology Systems Improving the Accuracy of Liver and Prostate Cancer Radiotherapy Using the CALYPSO SYSTEM CALYPSO By Julie Ruiz I truly believe that HyperArc has great promise to achieve superior dosimetry, reduce side effects, and, in many cases, improve tumor control. I am delighted to work with Varian to develop this technology for patients. Ke Sheng, PhD, FAAPM Professor & Vice Chair, Department of Radiation Oncology University of California, Los Angeles it possible to easily target and eradicate isolated brain metastases and eliminate the need for, and complications associated with, whole brain radiation. HyperArc will improve radiotherapy and radiosurgery treatments for brain metastases because this technology allows clinicians to efficiently create and deliver treatment plans with a single isocenter while achieving a high dose gradient, notes Ke Sheng, PhD, FAAPM, professor and vice chair, Department of Radiation Oncology, University of California, Los Angeles, another member of the Radiosurgery Clinical Council. I truly believe that HyperArc has great promise to achieve superior dosimetry, reduce side effects, and, in many cases, improve tumor control. I am delighted to work with Varian to develop this technology for patients. n Julie Ruiz is a freelance writer who contributes frequently to this publication. Treating liver and prostate tumors with radiotherapy presents unique challenges. In addition to organ drift, the liver moves more than most organs because of respiration, and prostate tumors often move due to bladder filling or gas in the rectum. Treatment requires the accurate delivery of high-radiation dose with a steep gradient and minimal margins around the target to optimize effectiveness and safety. Varian s Calypso system is helping clinicians treat liver and prostate tumors more precisely by providing real-time targeting and motion management as well as accurate and efficient patient setup during radiotherapy. The system incorporates a variety of Beacon transponders small transmitters that continuously transmit location information about the tumor in real-time through a nonionizing signal to the Calypso tracking system. These include: the Implanted Beacon transponder for soft-tissue applications, the Permanent Beacon transponder for prostate and prostaticbed applications and the Surface Beacon transponder for tracking patient motion. By monitoring a tumor s location or, in the case of a surface transponder, patient motion that could compromise treatment accuracy Calypso makes it possible to reduce margins between the clinical target volume (CTV) and the planning target volume (PTV) and provides clinicians with confidence that the prescribed dose is being delivered accurately and precisely. This article profiles four radiotherapy centers that are using Calypso to accurately target tumors while reducing treatment margins, with a goal of offering cancer patients fewer treatment side effects and a better quality of life. 12 CENTERLINE AUGUST 2017 VARIAN.COM/CENTERLINE AUGUST

10 CALYPSO 1 2 Aarhus University Hospital Humanitas Research Hospital Treating Liver Tumors with Calypso: Aarhus University Hospital, Denmark, and Humanitas Research Hospital, Milan, Italy Aarhus At Aarhus University Hospital, about 25 patients each year present with primary liver cancer or liver metastases, for whom the size and location of their tumors preclude surgery or ablative approaches. Using the TrueBeam radiotherapy system along with Calypso and its Implanted Beacon transponders, clinicians can deliver high-dose stereotactic body radiotherapy (SBRT) with increased accuracy and improved motion-management and setup, reducing geometrical treatment errors and required margins. In the past, we had to apply a more generous treatment margin around the tumor because of uncertainties regarding the precise tumor position from day to day. Calypso allows us to monitor treatment in real time and reduce the treatment margin, so less healthy tissue is treated, says Morten Hoyer, professor of clinical oncology at Aarhus. Calypso also helps guide patient set up and manage the intrafraction motion that is characteristic of targets in the liver. The liver may move as much as three centimeters due to respiration, or it may move up to one centimeter during a single treatment because of target drift. In addition, the liver is close to critical structures like the spinal cord, esophagus, intestines, and kidneys. Therefore, we need Calypso to track the position of the tumor when delivering a large dose, adds Esben Worm, PhD, Department of Medical Physics. Delivering SBRT using the Calypso system hasn t lengthened the procedure time at Aarhus. In an outpatient procedure that typically takes 20 minutes, three transponders are implanted around the tumor at the edges, guided by sonography. We use the 17G Beacon transponder with 50 percent smaller cross sectional area than the 14G version bleeding is less of an issue with the thinner needle, explains Lars Peter Larsen, MD, department of radiology. Calypso is allowing the team at Aarhus to deliver respiratorygated stereotactic treatments. Calypso allows us to see intrafraction baseline drifts that we couldn t see before, says Per Poulsen, associate professor responsible for motion management tools at Aarhus. When we see the drifts during treatment, we can pause the treatment and correct for them by making couch adjustments. With gated treatments and real-time tracking, the Aarhus team has been able to reduce margins to 7 mm from the 10 mm generally used for non-gated treatments. We believe that real-time tracking with the Calypso system reduces side effects and may, in the future, enable us to increase the dose for improved outcomes, says Hoyer. Humanitas Radiotherapy and Radiosurgery Unit Director Marta Scorsetti and her colleagues have successfully treated upwards of 75 patients at the Humanitas Research Hospital in Milan, Italy, using noninvasive Calypso Surface Beacon transponders to guide radiotherapy, especially focusing on cases involving hypofractionation. We use surface transponders placed on the skin for SBRT treatments of liver and pancreatic disease along with an abdominal compressor to minimize internal motion, says Scorsetti. We use the Edge radiotherapy system to deliver the treatments because it is well integrated with Calypso for patient positioning and tumor tracking. The clinical team at Humanitas Research Hospital tests the Calypso system. The surface transponders allow Scorsetti to check the efficacy of the abdominal compressor. In a series of ten patients being treated for pancreatic cancer, she and her team observed a residual motion of greater than 2 mm in three cases, while in one case, the shift was greater than 5 mm, which required re-simulation. Surface transponders are very efficient and precise for monitoring patient motion. Using the Calypso tracking system to deliver SBRT and hypofractionated body radiotherapy protocols, says Scorsetti, we are able to treat liver metastases in 3 fractions and pancreatic cancer in 6 fractions. To date, Scorsetti and her team have not observed any major toxicities in the 75 patients they have treated. In our experience, the use of Calypso prevented unwanted irradiation to healthy tissue, otherwise undetectable by standard methods. Using Calypso, we feel we can safely implement unconventional fractionation schemes, reducing toxicity and the total number of fractions st Century Oncology 21st Century Oncology Constantine Mantz, MD, with the Calypso system at 21st Century Oncology in Fort Myers, Florida.Constantine Mantz, MD, chief medical officer for 21st Century Oncology in Fort Myers, Florida, has been using Calypso with Permanent Beacon transponders to track prostate movement since 2006 for his patients treated with stereotactic ablative radiotherapy (SABR). During that time, Mantz has treated over 2,000 patients with Calypso. Using Calypso during SABR allows us to reduce the overall treatment time compared to other hypofractionated and conventional radiotherapy schedules while maintaining a low rate of serious side effects, remarks Mantz. Conventional radiotherapy (fractionated) for prostate cancer typically requires a dose of 1.8 or 2.0 gray (Gy) per treatment over 35 to 45 treatments. Using SABR in conjunction with the Calypso system, Mantz reduces the number of treatments to five by delivering a dose of 8.0 Gy per treatment for selected patients such as those with a Gleason score of six or seven, prostate gland size smaller than 60 cubic cm, and a PSA less than 15. There is no room for error when compressing the number of treatments from forty-five to five and delivering a much higher dose per treatment; we must be absolutely accurate, notes Mantz. The Calypso system allows me to accurately track and quickly adjust for tumor motion. I know that each of the five treatments I m delivering to my patient is precisely targeting the tumor and avoiding healthy tissue as much as possible. During an outpatient procedure, Mantz implants three 17G soft tissue Beacon transponders at least 1.5 cm apart in the prostate. Using the thinner 17G Soft Tissue Beacon transponder, I can now treat more patients, particularly those who were not able to tolerate placement of the larger transponder, remarks Mantz. The smaller 17G transponders are not only more comfortable and better tolerated by patients but also produce as good a quality signal to the tracking system as did the larger devices. Cedars-Sinai Medical Center Calypso for Prostate Treatments: 21st Century Oncology in Fort Myers, Florida, and Cedars-Sinai Medical Center, Los Angeles, California Once SABR treatment begins, the Calypso system alerts Mantz and his team in real-time if the target moves by continuously sending positional information. Because of the accuracy of the Calypso system, we can reduce our treatment margins to a threshold of 2 mm. Calypso tracks whenever the target motion exceeds our threshold, the treatment beam is automatically stopped, and we realign the target with minimal impact on workflow, states Mantz. An intervention threshold of 2 mm offers great advantages by reducing the PTV, which protects healthy tissue and reduces side effects. Our Calypso patients experience better outcomes, observes Mantz. They report fewer sides effects and a better quality of life. Mantz is currently expanding his protocol to treat patients with cancer of the cervix for whom surgery and brachytherapy are not an option. We are now implanting Calypso transponders into the lower part of the uterus to monitor motion during SABR for our protocol cervix cancer patients and have had success thus far. We will be reporting our results at the 2017 ASTRO meeting. Cedars-Sinai Medical Center, Los Angeles, California While SABR is helping a great deal of patients, for some patients conventional fractionated radiotherapy is more appropriate. For these patients, Howard Sandler, MD, MS, professor and chair, Department of Radiation Oncology at Cedars-Sinai Medical Center, Los Angeles, California, has found that using Calypso with Permanent Beacon transponders not only improves precision but reduces side effects, as reported in a 2010 study. 1 Calypso allows us to deliver more precise treatments by using tighter windows around the prostate and delivering less radiation to healthy tissue. It gives us more confidence that the prostate will be within the threshold all the time, says Sandler. Using Calypso along with a TrueBeam system in RapidArc mode, Sandler and his team are offering prostate cancer patients conventional fractionated radiotherapy, hypofractionated radiotherapy, or SABR, depending on the clinical situation. 14 CENTERLINE AUGUST 2017 VARIAN.COM/CENTERLINE AUGUST

11 CALYPSO After a urologist implants three transponders in the prostate in an outpatient procedure lasting about 15 minutes, Sandler and his team make sure the tumor is positioned properly prior to treatment and then monitor the tumor in real-time using Calypso. Compared to positioning using cone-beam CT, Calypso is like a continuously running movie because it gives us a live, continuous view of tumor position. An X-ray image from conebeam CT only gives us a static snapshot of the tumor s position at one point in time, adds Sandler. AIM Study: Assessing the Impact of Margin Reduction As Sandler and his colleagues discovered in their AIM study, margin reduction decreases side effects. They measured the effect of reduced PTV margins in prostate cancer patients undergoing high dose intensity-modulated radiotherapy (IMRT) using the Calypso tracking system, as measured by patient reported outcomes. Calypso real-time tracking reduces sexual dysfunction at two months even though this is sometimes a side effect that is seen later. The study authors explain: Sexual interest may be better maintained in the absence of bowel and urinary toxicity. Important Safety Information Implanted Beacon transponders may migrate such that they pass from the patient s body or move to a different location within the body. The most frequent side effects associated with implantation of Soft Tissue Beacon transponders are typically temporary and may include, but are not limited to, pain, bleeding and infection. In some patients, these side effects may be serious. Use of the Calypso system and its associated Soft Tissue Beacon transponders is not appropriate for all patients. Patients should discuss the potential for side effects and their severity, as well as the benefits of the Calypso system and its associated Beacon transponders with their doctors to make sure it is right for them. n 360 ONCOLOGY 64 patients were treated with 81 Gy in 1.8 Gy fractions using the Calypso system, which enabled clinicians to use a reduced PTV margin of 3 mm and an intervention threshold of 2 mm. Julie Ruiz is a freelance writer who contributes frequently to this publication. By allowing Sandler to accurately track and manage tumor motion, the Calypso system enabled the reduction of treatment margins leading to a reduction of side effects even with a dose of 81 Gy. Patients completed the Expanded Prostate Cancer Index Composite (EPIC) questionnaires, and their scores were compared with those of a published EPIC data for a comparator cohort, notes Sandler. The AIM study results suggest that 1. Sandler HM, Liu PY, Dunn RL, et al. Reduction in patient-reported acute morbidity in prostate cancer patients treated with 81-Gy intensity-modulated radiotherapy using reduced planning target volume margins and electromagnetic tracking: assessing the impact of margin reduction study. Urology 2010;75(5): Intended Use Summary The Calypso system, including its associated Soft Tissue Beacon transponder, is intended to align and/or monitor the patient s position in relation to the radiation beam used for treatment. The Calypso System may also be used to regulate the treatment beam on Varian and Siemens radiation delivery systems by turning the beam on and off ( gating it) due to movement during treatment. Soft Tissue Beacon transponders used as part of the Calypso system for monitoring patient motion are indicated for use for permanent implantation in the prostate gland and prostatic bed and in soft tissue. One-shot Radiosurgery for Localized Prostate Cancer: The Swiss-Italian Transalpine (SIT) Prospective Multicentric Phase-II Trial The objective of this single-arm phase II study is to determine if single-fraction SBRT at a dose of 19 Gy using the Calypso system is a valid treatment option for patients with localized prostate cancer with a simultaneous dose reduction to the urethral planning at-risk volume (PRV). Decreasing the number of radiosurgery treatments to five or fewer fractions not only has the potential to reduce side effects and improve patient convenience but may also reduce the cost of external beam radiotherapy while increasing the availability of treatment slots. Through this single-session approach, we hope to see satisfying long-term cure rates equivalent to standard fractionated treatment protocols with an optimal quality of life and low rate of side effects. Calypso will enable us to precisely track the position of our target in real-time while administering the prescribed dose with the lowest possible dose to the bladder and rectum, notes Marta Scorsetti, MD, radiotherapy and radiosurgery unit director, Humanitas Research Hospital, Milan, Italy. Three of the five European centers participating in the study are located in Switzerland (Chur, Geneva, and Zurich), and two centers are located in Italy (Milan and Verona). The trial is scheduled to take place from June 2017-Dec Oncology A Comprehensive Software Platform for Coordinating Cancer Care Earlier this year, Varian introduced the 360 Oncology care management platform, the first software system designed to integrate and coordinate key elements of cancer care so patients and multidisciplinary care teams can collaborate on achieving the best outcomes. In a single platform, 360 Oncology brings together radiation, medical and surgical oncology, social services, primary care physicians, as well as the patient, to facilitate true collaborative and coordinated care. Historically, cancer care teams have been challenged in trying to pull together all the relevant health information across disparate systems and specialists to make the best decisions regarding care, said Kolleen Kennedy, president of Varian s Oncology Systems business. With 360 Oncology, Varian is leveraging its expertise to deliver a solution that supports the unique interoperability needs and workflows of By Julie Ruiz cancer treatment centers and oncology practices, and allows efficient data driven decision making that also engages the patient in determining the best care plan. 360 Oncology offers several key features to present a dashboard view of clinical and operational data to simplify care coordination, increase patient engagement and enable more informed decisions. Care Coordination The increasing complexity of cancer care requires close coordination and data sharing among the members of the care team. To simplify this process, 360 Oncology provides a clinician portal that enables care team members to easily communicate with each other. In addition, the platform allows 16 CENTERLINE AUGUST 2017 VARIAN.COM/CENTERLINE AUGUST

12 360 ONCOLOGY I ve been serving patients for over 30 years; 360 Oncology is more than a tool; it s a game changer in patient care that will revolutionize how we deliver patient care. Tim Ochran, Sr. VP, Chief Administrative Officer, Hospital & Clinics University of Texas Health Science Center at Tyler ARIA ARIA 15.1 the team to access and share data in electronic medical records (EMRs), and in oncology information systems for both radiation and medical oncology, and in other point-of-care solutions, such as PACS and lab systems, to achieve a full 360-degree view of patient data. I ve been serving patients for over 30 years; 360 Oncology is more than a tool; it s a game changer in care coordination that will revolutionize how we deliver patient care, said Tim Ochran, chief administrative officer, Hospital & Clinics, University of Texas Health Science Center at Tyler (UTHCT). When my team saw 360 Oncology, we were amazed because each of us had a different idea of how this software would help solve an issue for us. Not only will it allow us to do things we ve never done before, but it will improve and streamline processes we already have in place to ensure that we meet our goal of providing our patients with the highest quality, evidencebased care plan and best outcome possible, he added. For example, we already have a referral management practice in place, but often referrals get lost because we have patient information located in many different places. With 360 Oncology, everyone on the patient s team will be able to access all the patient s information digitally at the same time and in the same place. Patient Engagement To increase engagement between patients and care teams, and to improve the overall experience, 360 Oncology offers a customized oncology patient portal on desktop and mobile platforms that provides patients with easy access to essential information such as: an appointment calendar with reminders, care team contact information, links to care resources, and secure communication with their care teams. The software also enables the team to easily gather patient-reported outcomes and experiences via surveys to quickly evaluate treatment progress and identify potential changes. We anticipate that 360 Oncology will also improve our connection with patients by providing a cutting-edge patient engagement and survivorship module that integrates patients and care givers into one team while helping us improve care for our growing population of cancer survivors, said Ochran. By allowing us to focus on the whole patient rather than on data-gathering, the software solution will improve our multidisciplinary treatment planning conferences, and team members will be able to collaborate even if they are in different states. We are eagerly anticipating the implementation of this software solution in the coming months. I think the 360 Oncology software solution will exceed our expectations and transform our patient care from diagnosis to survivorship, Ochran added. Data-Driven Decisions Providing the opportunity for the care team to improve results via data-driven decisions, 360 Oncology includes several features such as a web-based multidisciplinary tumor board module that integrates all the relevant patient records, lab reports, diagnostic images, and treatment team recordkeeping tools. Varian s 360 Oncology helps us achieve our goals, by enabling the multidisciplinary teams to communicate more effectively, said Matt Hickey, director of clinical strategy at GenesisCare UK. With 360 Oncology we can remotely monitor and communicate with our patients, during and beyond treatment; and the platform helps us aggregate outcome data from different sources. This provides us with timely aids to support proactive decision making, all the while keeping the patient engaged and better informed. Ultimately we now have more control on whether we achieve an appropriate outcome, even after the patient has finished treatment with us. n Julie Ruiz is a freelance writer who contributes frequently to this publication. Putting Data Security Front and Center By Ken Khouri Director, Software Support & Managed Services Varian Medical Systems 15.1 THE SECURITY RELEASE The pace of cyber-attacks against healthcare providers has been accelerating. Not only has the amount of data stolen soared, but the method of attack is changing from stealing to ransoming data encrypting it and then charging a fee to de-encrypt the files. On May 12, 2017, WannaCry, a global ransomware attack, grabbed headlines around the world when it impacted some 200,000 systems in 150 countries, according to press reports. Once infected, some users paid a ransom to unlock their data files. Every healthcare provider is a potential target. Healthcare data has become a hot commodity because it s often easier to acquire than data from industries with more robust protections. It is also considerably more valuable. In the first two months of 2017 alone, approximately 46 US healthcare providers reported breaches affecting more than 1 million patients.* Criminals are finding more ways to exploit stolen patient data and even using it for fraudulent insurance claims. From the start, banking and e-tailing addressed security as an integral part of the online customer experience, while healthcare focused more on interoperability, enabling collaboration of providers across boundaries. Engineering efforts have tended to focus on improving patient outcomes, rather than on data security. The time has come for healthcare providers to give security a new level of focus. The tide is turning. The Office for Civil 18 CENTERLINE AUGUST 2017 VARIAN.COM/CENTERLINE AUGUST

13 ARIA 15.1 Rights is holding providers accountable by publishing breaches of privacy that affect more than 500 patients and sometimes by levying fines for not meeting reasonable security standards. The fines can add up, with the largest penalty among healthcare providers reaching nearly $6 million in Healthcare providers are turning to their technology vendors and partners for help. Three years ago, Varian s customers seldom asked about data security. Today it is a topic on the minds of every CIO and CMIO. They want to understand the risk that they re assuming when purchasing software or services from third parties. The US Food and Drug Administration (FDA) is also asking that vendors do more to mitigate the risk of cyber-attacks against their products. identity management system for a hospital or clinic. One set of credentials and one set of IT policies extend into Varian products. Users have one identity that is easy to manage and track. Low-Risk Maintenance and Support Varian has taken a close look at the tools it uses to install software on workstations in client environments and has taken steps to reduce the potential for anyone to use those tools for malicious purposes. Defense-In-Depth Features Well-executed spear phishing attacks are often successful at obtaining valid user credentials. Varian has implemented measures to disrupt attempts to extract patient information even if credentials are compromised. Essentially, we have employed defense-in-depth techniques with multiple layers of security to make getting or tampering with patient information much more difficult. Anti-Malware Validation We have validated our software release to run with an industry-leading anti-malware platform. If customers do not have What s New in ARIA 15.1 Enhanced security is big news for ARIA However, it is not the only news. We have also included capabilities that align with the heightened security of this release. Electronic prescribing of controlled substances. Electronic prescribing of controlled substances, which helps prevent abuse, cuts costs, saves time, and is permitted in all US states, but not all EMRs support it. ARIA 15.1 does. Oncologists can prescribe controlled substances in ARIA with added confidence in the enhanced security. (This functionality was first introduced with ARIA v in the US, and continues to be an important component.) Active Directory Integration Encrypted Communications More Secure Access to Web Services Anti-Malware Validation Low-Risk Maintenance and Support Database Integrity Defense-in-Depth Features Stronger Authentication for SmartConnect Utility Seamless information exchange with hospital EMRs. ARIA 15.1 employs a standard platform for interoperability with the information systems used by more the 4,000 US hospitals. ARIA Connect links the ARIA oncology information system (OIS) that radiation oncology departments use to manage workflow with the hospital information system (HIS) where demographic, clinical, and billing information resides and provides radiation oncology teams reliable, real-time, seamless access to up-to-date HIS information. Varian is also addressing the issue of tighter cyber security with ARIA 15.1 primarily a security release of the company s oncology information system. While we are a medical technology company and not a security company, the high stakes warranted a more proactive, systematic approach. That s why we made the important decision to focus this ARIA release on security. Varian has taken a number of concentrated actions on security. We shifted substantial engineering investment to security and hired additional domain expertise. We engaged multiple parties to conduct in-depth threat analyses on our core software and hardware products. We then took a riskmanaged approach to making enhancements that introduce additional barriers to thwart anyone acting with malicious intent. Many of these enhancements are introduced in ARIA It should be noted that, while these enhancements are primarily for ARIA, they result in security benefits throughout a fully-integrated Varian system. Active Directory Integration ARIA 15.1 integrates directly with Microsoft Active Directory systems, providing users with the convenience of using their existing log-in credential throughout our system. Users of the Varian system can be authenticated directly against the central Encrypted Communications Varian now requires all communication to the database to be encrypted. Malicious actors are unable to eavesdrop on traffic passing along the hospital network in and out of the database. This encryption works by way of SSL certificates managed by the hospital. Hospitals can implement different schemes with these certificates, including tying them to specific workstations. Database Integrity Customers need to know if the integrity of their database becomes compromised. Varian has processes that periodically assess the integrity of the ARIA database and logs abnormalities. Varian doesn t monitor the changes, but customers can if they choose. In time, our goal is to proactively monitor and alert customers to suspicious changes. More Secure Access to Web Services Web service access now requires additional verification from clients to prevent unauthorized access, making it more difficult for malicious actors to extract patient information from application program interfaces that exist for interconnectivity reasons. an anti-malware tool in place on the infrastructure where their protected health information resides, we can recommend one and ensure our software performs well in that environment. Stronger Authentication for SmartConnect Utility SmartConnect Varian s utility for diagnosing and troubleshooting technology problems remotely has also been made more secure with the addition of stronger authentication processes. Varian has greatly reduced the risk of an unauthorized person using SmartConnect by deploying out-of-band (OOB) two-factor authentication. This requires service personnel to use their cellular phones as a second factor in the authentication process. Any unauthorized person trying to enter the network via SmartConnect would not have access to an authorized cellular phone and so would be blocked. While we cannot solve all the serious security challenges facing healthcare providers today, we are committed to helping where we can reasonably do so. ARIA 15.1 takes an important step forward to address the security concerns of our customers. It is our intention to continue making data security a central priority in product development and in how we manage our customer support processes. n * US Department of Health and Human Services Office for Civil Rights Breach portal. ocrportal.hhs.gov/ocr/breach Up-to-date support for CMS quality payment programs. ARIA 15.1 has built-in, ready-to-go data collection and reporting required for the evolving quality payment programs of the US Centers for Medicare & Medicaid Services (CMS), including the Oncology Care Model (OCM). 20 CENTERLINE AUGUST 2017 VARIAN.COM/CENTERLINE AUGUST

14 INSIGHTIVE GenesisCare UK Our main reason for using analytics is to ensure that each patient receives a personalized, evidence-based care plan to achieve the best possible outcomes, says Matt Hickey, director of clinical strategy at GenesisCare United Kingdom (UK), London. Varian is helping us achieve our goals. GenesisCare UK provides leading-edge radiotherapy treatments through its 10 specialist cancer treatment centers across the UK. In 2009, Cancer Partners UK combined with GenesisCare of Australia in GenesisCare is now the largest private provider of radiotherapy services in the world, with 30 centers in Australia, 17 in Spain, and 10 in the UK. Greater Confidence in Clinical Quality We adopted a custom InSightive solution because we wanted to be more dynamic in our analysis of clinical and operational reports, notes Hickey. We also wanted to broaden our performance review whilst improving our ability to focus on key business, operational, and patient performance indicators such as: clinical and service utilization, patient reported outcomes, patient satisfaction, toxicity, and survivorship outcomes. Now, we have advanced analytics and dashboards that enable us to dynamically collect and analyze these data to constantly improve our clinical quality. experts in the delivery of data systems and dashboards to support our specific needs. Beatson West of Scotland Cancer Centre, Glasgow, UK The Beatson West of Scotland Cancer Centre in Glasgow is the largest cancer center in Scotland and the second largest in the United Kingdom, serving more than 60% of Scotland s cancer patients. Before we had InSightive, we had a lot of variation in our processes, explains Garry Currie, head of radiotherapy physics. This tool is helping us standardize by giving us valuable awareness into our planning and treatment regimens, so we can improve our efficiency for better patient care. We now know better where to focus our efforts, and we are asking questions we didn t know to ask before we had InSightive. Improving Big Data Analytics for Personalized Medicine Two UK Centers Enhance Operational Efficiency Using Varian Analytics Solutions As global health care moves towards value-based care, using data analytics to inform treatment decisions is becoming more and more crucial for improving patient outcomes and enhancing operational efficiency. Oncology care providers are capturing vast amounts of data, but how many are using this data to improve outcomes or processes? Varian s InSightive analytics enables radiation and medical oncology providers to mine their ARIA databases for actionable insights that can potentially lead to more informed decision making. The InSightive analytics solution is helping to improve value-based care delivery. Its scalable configuration allows analytics-driven decision making at organizations of every size, from a single clinic to an entire cancer care network. Partnering with Varian, cancer care providers like GenesisCare UK and Beatson West of Scotland Cancer Centre are using Varian analytics solutions like Insightive to uncover trends that are standardizing workflows, leading to greater efficiency and, potentially, to improved outcomes. The data are also helping Hickey and his colleagues understand the causes of workflow and operational bottlenecks in the patient care process and improve patient throughput. We can now graphically demonstrate workflow to identify areas needing improvement, says Hickey. Use of data analytics helps us better understand the prescribing patterns of our clinicians, improve our governance and multidisciplinary team processes, and ultimately ensure that we maintain compliance with evidence-based best practices. Big Data Analytics Hickey and his colleagues are now using analytics to look for patterns of cause and effect. They maintain that, using big data to understand the results of innovation and ensure the delivery of evidence-based best practices is vital in working with new outcomes-based commissioning models. Our big data sets now include broad-spectrum data relating to business, work-flow, patient throughput, research, audit, clinical, and patient self-reported information, Hickey says. This project has helped improve the way GenesisCare UK collects and analyzes big data sets, to understand complex patterns of cause and effect. Customized Dashboards GenesisCare uses customized dashboards, developed in collaboration with Varian s professional services team. The out-of-the-box dashboards gave us an idea of what we wanted and helped us to produce our own, remarks Hickey. It was great to work with the InSightive analytics team of Gary Currie Head of Radiotherapy Physics The Beatson West of Scotland Cancer Centre Minimizing Variation Using InSightive Analytics Prior to implementing InSightive, Currie and his colleagues were challenged in obtaining and analyzing data about treatment and operations within their center. With 13 machines operating across their network, processes could vary due to differing levels of experience and skill among staff and clinicians, and diverse workflows evolved in different parts of the organization. The goal was to find out which processes were the most efficient and effective, so that they could be propagated throughout the system. We started to develop new dashboards to leverage data in ARIA to resolve the variation we were seeing, says Currie. One of our newest dashboards is helping us analyze variation in throughput and resource allocation for treatment plans. InSightive is helping us to see if we are meeting our treatment time targets and to intervene much earlier to optimize workflows in our treatment planning processes and reduce variation and bottlenecks. Data Driven Decision-Making Currie and his team are able to look at data and even import national data sets for comparative purposes. This data-rich environment is giving Beatson West a set of metrics to use in measuring performance. 22 CENTERLINE AUGUST 2017 VARIAN.COM/CENTERLINE AUGUST

15 INSIGHTIVE We now know better where to focus our efforts, and we are asking questions we didn t know to ask before we had InSightive, remarks Currie. We are also planning to build dashboards that will allow us to examine survival data at a much more granular level by technique and clinical diagnosis, for example, for more informed decision-making. We anticipate gathering data on outcomes and toxicity in the near future as well. Dynamic Data Visualization Using Smart Dashboards The dashboards graphically rich visualizations allow you to see patterns in new ways, states Currie. We are building our own dashboards that will help us analyze patient data, survival data, and referral patterns across geographical sites for use in managing our processes and surfacing information about areas that need attention. Before deploying InSightive, Currie visited the Varian software engineering site in Pune, India, where the analytics solution was being developed and tested. There he helped to develop some of the dashboards used in the first release of the product. A Varian professional services team later visited Beatson to help set up and configure InSightive and create a set of custom dashboards based on the center s unique workflow and specific goals. I have a lot of respect for the Varian team they have been incredibly knowledgeable, approachable, and supportive in helping us maximize our use of InSightive. Without their help, it would have taken us much longer to deploy the software solution, notes Currie. The InSightive Analytics Solution Operating in tandem with the ARIA oncology information system, InSightive is a comprehensive oncology analytics solution that allows providers to explore their clinical and operational data to uncover trends to help improve performance and better enable the oncology workflow. CONSULTING SERVICES Decision making is simplified through InSightive s collaborative user interfaces. The solution offers out-of-the box dashboards, created on the basis of customer feedback. These interactive dashboards transform static information into dynamic visualizations for real-time insights regarding areas such as referral patterns, payer mix, average treatment time, patient volume/throughput, toxicities, and survival curves. They also show how workflows are managed, so providers can improve in this area. InSightive offers a variety of interactive dashboards and reports that transform static information into dynamic visualizations for real-time insights. InSightive is an analytics tool that continues to evolve, with regular product-enhancing upgrades. The current release is available for the ARIA oncology information system for radiation oncology, medical oncology, and comprehensive cancer solution customers. n Be sure to visit the InSightive discussion group on Varian s OncoPeer online community to find out how colleagues are using analytics to improve outcomes and enhance operational efficiencies. oncopeer.com Varian Consultants Help Clinics Tap Into the Full Potential of ARIA By Nancy Heifferon How many times have you heard people say of some technology, I didn t know it could do that? The Varian Consulting Services organization can help to eliminate that question by providing optimization services tailored to help medical and radiation oncology clinics take full advantage of what Varian technology can do for them. In this article, Centerline profiles two centers on opposite sides of the Atlantic that utilized Varian Consulting Services to meet specific challenges through optimized use of the ARIA oncology information system. 24 CENTERLINE AUGUST 2017 VARIAN.COM/CENTERLINE AUGUST

16 CONSULTING SERVICES Implementing Optimized Workflows in a New Center: North West Cancer Centre, Londonderry, Northern Ireland It isn t often that cancer care professionals get to realize their vision of an ideal working environment. So when the opportunity presented itself, the radiotherapy staff of North West Cancer Centre embraced it with enthusiasm and a commitment to optimize the practice for everyone. North West Cancer Centre is a new center in a unique position. It was conceived and built to improve access to radiation therapy and enhance existing cancer care already delivered at Altnagelvin Hospital, part of the Western Health and Social Care Trust. It provides radiation therapy for cancer patients living within the west of Northern Ireland and the north west of the Republic of Ireland. North West Cancer Centre, Londonderry, Northern Ireland The cross-border services commenced in November 2016; and, when fully operational, North West Cancer Centre expects to accommodate 1,500 patients annually. Because we are a completely new center, we decided up front to adopt an integrated management approach. Although we have three discrete departments radiography, physics, and oncology the idea was to have a common management environment across them all, based on best practices, says Andrew Reilly, head of radiotherapy physics. The goal was to establish a management infrastructure that would scale and grow with the facility. We didn t want to open our new department using merely default techniques. We wanted to use the ARIA system properly from the beginning because we knew that if we didn t, it would be very difficult to move on and improve in the future, he added. With a staff of more than 200 professionals, there was no shortage of ideas about how things could and should be done. However, to harness that collective wisdom, the project team recognized the need for a seasoned, objective arbiter and advisor with a broad view. We were quite keen for a consultant who would help us to make sure that everyone who is involved in the patient care path is considered and has a part in developing the service, says Elaine Reilly, radiotherapy service manager. The team found that resource in Varian consultant Laura Butler. What can a consultant such as Butler contribute that the internal team may not be able to accomplish for itself? Many things, according to Andrew and Elaine. For one, the consultant acted as a coach. The North West staff came in every level of experience: some were familiar with Varian systems, while some were not. Butler s weekly coaching helped everyone to get on the same page and speak the same language. The coaching consisted of demonstrations and step-by-step hands-on experience. She also helped people review what they did, which brought everybody up to a high level of expertise quite quickly, says Andrew. For another, the consultant acted as a facilitator. Where there were difficult discussions, for example, Butler could speak from a position of knowledge and experience that was separate from any one partisan group. That became very useful for us, adds Elaine. Butler also helped make the possible practical. We could see what was possible but not always be able to decide on the best way to get there, recalls Andrew. Where there were competing ideas, Butler created virtual workflow simulations so that the North West team could test their ideas and make decisions with greater confidence. In summary, the benefits of using Varian consultants include access to their deep knowledge of ARIA capabilities and their independence. Consultants work with their clients, rather than for them. It s an important distinction. Instead of doing the work and leaving, Butler helped the North West team gain confidence to add and change workflows and push the boundaries of the system to accomplish their goals. We are working on solutions that I know other centers have tried but given up on. The difference is that we have the information system to support us and the confidence to evolve it as we see the need, says Elaine Reilly. Implementing an Optimized Quality Payment Program in an Established Center: Edwards Comprehensive Cancer Center, West Virginia, USA Across the Atlantic in West Virginia, the Edwards Comprehensive Cancer Center (ECCC), a long-time Varian customer and ARIA user, enlisted help from Varian Consulting Services for a different challenge implementing the Oncology Care Model (OCM). The OCM is an advanced care delivery and payment option developed by the Centers for Medicare & Medicaid Services (CMS) to improve the quality of oncology care while reducing the cost to the US government. While the OCM applies specifically to Medicare, Edwards Comprehensive Cancer Center expects the process improvements to benefit all cancer patients. Participating in the OCM is a great opportunity that will truly impact quality, says Leann Ross, who brings 30 years of experience in oncology nursing and clinical trials management to her role as Oncology Care Model quality manager. It s her mission to oversee the implementation and it isn t an easy one. The project is causing us to look at care from a different perspective. It is allowing us to provide enhanced services to these patients, but there have been many process changes involved to meet the OCM requirements. Of the six practice redesigns required by the Oncology Care Model, ECCC was already compliant with several. For instance, patients have round-the-clock access to appropriate clinicians who have real-time, remote access to the electronic health record (EHR) system. That wasn t a problem, says Ross, but there were other gaps to fill. We formed teams to look at these issues and find solutions. That s when we called Varian, because many of the changes depended on the ARIA information system, and Varian has an OCM optimization service that can be tailored to our situation. One area that ECCC and Varian worked on was patient navigation. "We already had a patient navigation program in place, but we wanted to broaden it and make it more robust. Varian helped us create the templates and questionnaires for the navigators to use. These changes enable us to scan the electronic chart quickly and easily for the notes that document the navigation of the patient through the care path, says Ross. As care givers, we often do things that may not show clearly in the EHR. We are working on providing very specific tools that our staff uses consistently to capture and document navigation processes, such as intakes and follow-ups. Gigi Gerlach, RN (top), Margaret Ball, RN (middle), and Penny Smith, RN (bottom), are among the nurse navigators using ARIA to implement the Oncology Care Model at ECCC. 26 CENTERLINE AUGUST 2017 VARIAN.COM/CENTERLINE AUGUST

17 CONSULTING SERVICES The most significant result of the project, according to Ross, has been automating the generation of patient care plans. Pulling together the care plan used to be a manual process of scanning the patient record, finding each of the 13 required elements, and copying them one-by-one into a Microsoft Word document that would be printed and handed to the patient. Now care plans are generated automatically within ARIA. Consulting services that tame the complexity of technology Varian provides customized consulting services to customers worldwide to help them: n Adopt new technologies with change management n Optimize best practices and improve workflow and care path efficiency n Enhance product utilization The Value of Varian Service Contracts Maximizing Clinical Availability for Better Patient Care By Julie Ruiz SERVICE CONTRACTS ECCC has developed a custom workflow in ARIA for informed consent. We translated the informed consent form for chemotherapy into a questionnaire in ARIA, explains Ross. The completed questionnaire, which lists prescribed medications, is printed, signed by the patient, and scanned in with the signature. ARIA reaches into a database of clinical drug information and pulls guidance on potential side effects and symptom management into the patient s care plan. This has been a huge benefit for patients and for staff, says Ross. Ross says that, working with Varian Consulting Services, her team was able to expedite development of the tools and reports they needed to meet the OCM requirements established by the CMS. Implementing OCM has been a transformative experience for ECCC, she says. The program has the capability of helping us to enhance and elevate the quality of care we re giving to all patients, because it s providing us with an opportunity to look at all of our processes very carefully. n n Develop workflows and data extraction processes with the ARIA oncology information system in order to comply with US government regulations n Create customized reports and dashboards using AURA and InSightive to meet data analytics needs n Evaluate treatment delivery costs and optimize processes with the opportunity to reduce redundancies 28 CENTERLINE AUGUST 2017 VARIAN.COM/CENTERLINE AUGUST

18 SERVICE CONTRACTS Varian service contracts ensure the health of a facility s radiation oncology system, so that clinical professionals can provide the highest quality, uninterrupted treatment for their patients while optimizing productivity. We ve always had a very good working relationship with our Varian service professionals through our service contract, said Nilendu Gupta, PhD, chief physicist and associate professor of radiation oncology at The Ohio State University Comprehensive Center James Cancer Hospital and Solove Research Institute (OSUCCC James). Our collaboration with the Varian team has been really crucial to keeping all of our equipment up and running for the best patient care. Varian service professionals are specially trained to fix all elements of a system, resolving issues completely so that small problems don t become larger ones. Through the SmartConnect Plus monitoring service, Varian s team can monitor, diagnose, and repair problems remotely using the most advanced diagnostic tools and without accessing patient data. Benefits of Varian Service We acquired a Varian service contract to cover our hardware and software because we knew that these contracts are well worth the investment. The contract covers our ten TrueBeam machines; ARIA, Eclipse, and Velocity software; as well as all of our core equipment and brachytherapy systems, Gupta noted. Gupta and his team purchased a full-service contract that includes Varian s Planned Maintenance Program (PMP) and SmartConnect Plus. The PMP keeps a facility s radiation oncology system healthy through regular tune ups ; maintenance records are stored online where they can be accessed at any time. Regular software updates prevent obsolescence and minimize cyber threats. Varian s PMP also identifies and analyzes trends for Gupta and his team by automatically monitoring and aggregating baseline data to measure machine performance over time as well as compare it to that of comparable machines throughout the world. The service agreement covers Varian equipment at two locations in Columbus: the James Cancer Hospital and Solove Research Institute and the Stefanie Spielman Comprehensive Breast Center. Because Gupta and his team had in-house resources they wanted to use, Varian customized their contract to give them the flexibility they needed. A collaborative component was added to the service agreement allowing the site to use their own in-house staff. Our collaboration with the Varian team has been really crucial to keeping all of our equipment up and running for the best patient care. Nilendu Gupta, PhD Chief Physicist & Associate Professor Ohio State University Medical Center troubleshooting when there is a problem. When needed, they escalate issues to Varian s team. Varian service professionals can log in remotely and diagnose and repair issues or quickly come onsite, if need be. This partnership between our in-house team and the professionals from Varian has improved our overall uptime. The Varian service contract has also allowed Gupta and his team to maintain beam matching on all ten TrueBeam machines so that a patient can be treated on any one of them. When we have had a machine down, notes Gupta, it has not compromised our patient care because we are able to move patients around as needed. Our Varian service team has been able to coordinate with us on major service and work at all hours to get the job done. This great service and collaboration between our hardworking in-house professionals and Varian s team has helped us to maintain the highest standard of patient care. Value of Remote Diagnostics and Onsite Service Filippo Alongi, MD, associate professor and chief of the Radiation Oncology Department, and his team at the Ospedale Sacro Cuore-Don Calabria, Cancer Care Center Negrar in Verona, Italy, chose a Varian service contract because they needed fast and trustworthy service. Their contract provides comprehensive service and covers all of their Varian hardware and software. Collaboration between Varian s service team and the Center has been essential to optimizing uptime. we must absolutely avoid any interruption of treatment. For this reason, we decided to purchase a Varian service agreement that covers our two Trilogy and one TrueBeam treatment machines as well as all of our Varian software. Remote diagnostics combined with prompt onsite repair service and continuous support from the Varian Help Desk has enabled Alongi and his team to maintain virtually uninterrupted treatment for their patients. Varian service professionals usually arrive onsite with the part in hand and ready to service the entire system hardware and software not just the machine. Our Varian service contract has allowed us to optimize our clinical uptime through remote diagnostics, which identifies key problems while they are small. When we ve needed to call for onsite service, Varian service engineers have always come to resolve issues using original Varian parts within two to three hours, said Alongi. Also, we really value the software upgrades; protection from hardware obsolescence; and, perhaps most importantly in our experience, the fast support from the Help Desk on technical and clinical questions. Alongi also shared that, on many occasions, he noticed the willingness of the Varian service team to go above and beyond by working around the clock to fix any problems that arose. For example, when a software problem occurred, Varian professionals quickly restored connectivity, working after clinical hours to avoid treatment interruption. In this case, problem solving required strict collaboration between Varian and local hospital software engineers, remembered Alongi. To prevent the delay of patients treatments, Varian professionals performed the necessary work to fix the problem during the weekend. The availability of Varian service engineers to work during the weekends or into the late evenings to avoid treatment interruption is so important. The dedication of Varian service professionals shows how sensitive they are to the care of our patients and to helping us assure optimal clinical productivity. n Julie Ruiz is a freelance writer who contributes frequently to this publication. SmartConnect Plus: Resolving Issues Proactively What s great about SmartConnect Plus, said Megan Farrar, director of services, radiation and imaging, New York Oncology Hematology (NYOH), is that it proactively identifies problem areas before you experience real down-time that might impact your treatment delivery. SmartConnect Plus remotely identifies problematic situations proactively, and sends real-time alerts to the Varian Response Center. The Varian team can then diagnose and fix the problem remotely, or, if needed, go onsite with the necessary parts because troubleshooting has already occurred. SmartConnect Plus remote monitoring and response service is helping Farrar and her team at NYOH to optimize their clinical availability. There have been multiple times when SmartConnect Plus and Varian s ability to remotely access our system to troubleshoot an issue has resulted in a much faster resolution and minimal downtime, said Farrar. SmartConnect Plus also offers trend spotting that enables service personnel to recognize trends in a customer s system and to access a worldwide database of similar patterns and their causes for better and earlier problem solving. SmartConnect Plus has helped our local team identify trends in our equipment performance, noted Nilendu Gupta, PhD, at Ohio State University Medical Center. Because we have our own in-house trained professional staff, we have used SmartConnect Plus as part of our checks and balances. Often our own internal diagnostic tools alert us of a situation and, simultaneously, SmartConnect Plus will send similar notifications to Varian regarding early predictive failure of some part of our system. Also, for smaller facilities that don t have in-house resources or local service, I think SmartConnect Plus is a real asset because it gives them access to Varian service engineers. Between our own in-house professional staff and Varian s service professionals, said Gupta, we ve been able to maximize our productivity. Varian is committed to training our in-house professionals, who perform the first line Many of the patients at our center have treatment regimes comprised of extreme hypofractionated schedules with stereotactic body radiotherapy and radiosurgery, said Alongi. Because of the intense, short schedules of these treatments, 30 CENTERLINE AUGUST 2017 VARIAN.COM/CENTERLINE AUGUST

19 ONCOPEER Oncology Professionals Share Knowledge and Insights via OncoPeer When oncology professionals in the state of Victoria, Australia, began a statewide implementation of Varian s RapidPlan knowledge-based treatment planning software, they turned to the OncoPeer online community for mutual support and to share techniques and models. OncoPeer is a confidential online community where Varian customers can ask questions, share data, exchange treatment techniques, and discuss best practices by collaborating with other oncology professionals from around the world. Establishing a Statewide Dosimetry Group in Victoria, Australia We are using OncoPeer to establish a radiation therapyspecific group of dosimetrists and physicists who are focused on developing and sharing RapidPlan models across the state of Victoria in Australia, says Colin Hornby, MS, radiotherapy advisor, Cancer Strategy & Development, in Victoria s Department of Health & Human Services. Our goal is to improve the quality of radiotherapy treatment by using RapidPlan to predict treatment and plan outcomes and then using these predictions to optimize intensity-modulated radiotherapy plan parameters. OncoPeer helped Hornby and his colleagues deploy RapidPlan across the eight public cancer centers in the state that are using Eclipse for treatment planning and have also implemented RapidPlan: four are Melbourne sites; three are regional Victorian sites; and one is a rural Victorian site. So far, Hornby s private OncoPeer group is comprised of 13 members from eight participating sites; and, as the project progresses, this number will expand. Three other locations that do not have the Eclipse treatment planning tool will be working on ways of using RapidPlan as a benchmarking tool. Hornby s Victoria RapidPlan Implementation Group shares protocols and contouring guidelines on a variety of anatomical sites; discussions about dose constraints for targets at risk; preparation guidelines, including protocols for what to do prior to computed tomography (CT) simulation; as well as the models themselves and some training documents they have developed. Being able to download Varian documents once and have them in a common location is making us more efficient, notes Hornby. Many health services have a 10MB limit on s, but by using OncoPeer, we can share documents and training presentations that are more than twice that size. Also, being able to have our models in one location on OncoPeer is so important for future model sharing as staff change. In sharing clinical models pertaining to our state, the confidentiality and privacy of OncoPeer has been so important because it has given our clinical team members the confidence they need to fully contribute, says Hornby. Philip Moloney, a member of the Victoria RapidPlan Implementation Group, is leading the RapidPlan launch at the Andrew Love Cancer Centre in Geelong, Victoria, where he serves as the clinical and technical leader of Radiotherapy Planning Services. His center is a lead site for the establishment of an anal cancer RapidPlan model, and a supporting site for a radical head & neck cancer model and a prostate cancer model. OncoPeer has been an invaluable tool within the Victorian RapidPlan Group. Prior to using this tool, there were a lot of subtle technique variations within our own state, even between departments within close proximity to each other. However, OncoPeer has helped us unite as a team by providing an efficient means of information and idea sharing, states Moloney. Although we are in the early phases of RapidPlan implementation, our experiences indicate a significant future for Varian s knowledge-based planning software in Victoria. OncoPeer as Knowledge Source In addition to RapidPlan implementation, oncology professionals around the world are using OncoPeer as a source of knowledge on topics ranging from IT-related discussions to Eclipse software scripting to equipment upgrades and billing questions. I began using OncoPeer because I wanted to collaborate with other oncology and radiotherapy professionals regarding the use of the Eclipse scripting application program interface (API), says Joseph Bradshaw, dosimetrist at Sheffield Teaching Hospital in the UK. I was having some issues getting my project up and running and was hoping someone else had similar experience they could share with me. The Eclipse scripting API allows a user to interact with the software in many different ways. Users have been able to write code for checking whether a plan meets certain requirements and constraints, generating custom reports, or searching through patient records to rapidly pull out specific data for trial and research purposes. OncoPeer was a tremendous help in getting the knowledge I needed to successfully launch our scripting project, says Bradshaw. While mine is a relatively large department, the knowledge for my project wasn t readily available. By accessing OncoPeer, I was able to communicate with other individuals in the same profession all over the world. This increased the potential knowledge base dramatically and enabled me to be in contact with users not only in centers throughout the UK but also the United States. Barbara Stiltner, chief radiation therapist at Knox Community Hospital in Mount Vernon, Ohio, also uses OncoPeer as a knowledge source. Knox Community Hospital is a small, privately owned hospital with a single linear accelerator. When they began thinking about upgrading to a TrueBeam system from an earlier-model linac, Stiltner turned to OncoPeer for some guidance as to what machine would best suit her facility. By following different discussion threads, I was able to read about the experiences of colleagues around the world who were using the various Varian systems, including the TrueBeam that we are considering, says Stiltner. It was really helpful to see what the system offers and to draw on the experiences of others. I was able to find really good answers to my questions using OncoPeer not only about equipment upgrades but also billing questions. Varian established the OncoPeer online community as part of the company s Linking Minds initiative, with the idea that knowledge sharing could help improve the efficiency, quality, and consistency of care in cancer clinics. Varian customers can access OncoPeer 24-hours a day from anywhere in the world, to exchange knowledge and experience with other clinicians. Providing clinicians with resources that enable them to pool knowledge has become an important goal for us, as treatment centers worldwide seek ever more effective ways of implementing precise, non-invasive treatments like RapidArc radiosurgery, said Kolleen Kennedy, president of Varian s Oncology Systems business. We developed OncoPeer as a tool to help our customers collaborate, find others who use Varian technology, and learn from one another. Users of the OncoPeer cloud community can initiate threaded discussions, form open or closed groups, share and comment about uploaded files, create events, monitor trending key words within the community, and sort information by keyword. Varian is also using the tool to support communication between members of advisory boards who provide feedback on products and services. We re excited about how clinicians are using the resource to help one another, said Sarah Gyatso, manager of the OncoPeer cloud community. Shortly after we launched the site, a member posted a question asking for tips when creating radiotherapy treatment plans for prostate cancer patients with bilateral hip replacements. The user received a detailed answer from an experienced member, who offered specific and actionable advice. This was a perfect example of the peer-to-peer knowledge exchange that OncoPeer is intended to support. n 32 CENTERLINE AUGUST 2017 VARIAN.COM/CENTERLINE AUGUST