Implementation Science to Explore and Expand the Therapist-Led Model for Online Adaptive Radiotherapy
Abstract
Purpose
Online Adaptive Radiotherapy (oART) is resource and time-intensive, requiring dosimetrist, physicist, and physician involvement at each adapted fraction. The therapist-led adaptive workflow has been shown to reduce physician console-time. This study evaluates stakeholder perspectives on feasibility, risks, and implementation requirements for a US-based model that includes therapist-altered target structures.
Methods
Semi-structured interviews were conducted with 10 stakeholders (4-therapists, 4-physicists, 2-physicians). Thematic Analysis used a structured codebook targeting clinical impacts(AQ1), feasibility(AQ2), and implementation requirements(AQ3). Each excerpt received one primary code and an optional secondary code. Themes were quantified using unique participant counts and primary-secondary code relationships were analyzed to reveal additional context.
Results
Four themes were identified across 277-coded excerpts. First, participants emphasized the benefits of an implementable training program that can be locally adapted. When prompted, 9/10 participants described a standardized program as advantageous. Second, safety acceptability was framed as contingent on rigorous supervision checkpoints and meaningful review. Safety concerns frequently co-occurred with supervision checkpoints(7/10) and scope limits(5/10). Participants flagged physician confirmation bias(3/10), and the compounding effect of therapists contouring with rotating physician coverage(2/10), as practical risk points. Third, participants largely endorsed a novel, higher-skill role(7/10) for therapist-led oART, warranting additional pay(6/10), with occasional concerns that specialization could lead to role-siloing(2/10). Cultural buy-in across stakeholders was also emphasized as a condition to implementation(8/10). Finally, stakeholders linked therapist-led workflows to reduced physician-console time(8/10), which may contribute to broader adoption of oART(3/10).
Conclusion
Our analysis suggests that therapist-led oART is facilitated by a standardized but locally-adaptable training program, rigorous supervision checkpoints, career and financial incentives, and positive cultural shifts. Additionally, reducing physician time at the machine may lead to oART adoption in more clinics. Future work will include additional interviews to confirm thematic saturation and develop a standardized training framework that addresses identified concerns.