For the large majority of our adaptive plans (>95%), there is no change to the GTV/CTV/PTV. So, correct, we would just bring in a physician at the time of contour review, plan review and plan approval. Good point, as always.
We wouldn't do this for every patient, every fraction. We would look at starting on 2nd-5th fractions for things we do a lot of, like pancreas. And some patients are not going to have good enough imaging; the docs would be called. Or when we treat something we don't treat a lot of.
The doc would be responsible for reviewing the new contours, the plan and the dosimetry. Would they take the time to review everything in detail? We all know the answer to that... some do, and some don't - same with films, plans, OTVs etc. Same with our therapists and physicists! Everyone here is either a resident or has been through a residency; and has the same stories to tell that I do! We have been selective on the staff supervising this to date, similar to how we staff SRS/SBRT/brachy.
@ROforbetterorworse And to need a residency to contour normal tissue structures; on a subsequent volumetric image? I know we talk about 'hellpit residencies' on this site; but I never had to draw all the normal structures in residency - we had either dosimetrists or the software do that; and we would edit it in those edge cases. But it quickly became like that call when you were an intern to 'start an IV on a hard stick'... the nurse with way more experience than you couldn't do it; and you're not that likely to be better than him at it!
The adaptive SBRT time slots are coming down to 60 minutes each right now for the abdomen; faster for simpler anatomy that doesn't move (like prostate). But there is definitely more room for improvement.
OK so the auto contouring software does the GTV/CTV/PTV, then it's edited by who... therapist? Physicist?
Then, the physician comes in when the contour review is ready, and the physician is there for plan review and plan approval, I suppose?
If the physician is at least reviewing GTV/CTV/PTV contours, then OK I suppose, although with SBRT dosing you guys are way more ballsy than I would feel comfortable. I'm not overtly familiar with clinical workflow on MRI linac - is there auto contouring of GTV/CTV/PTV (or deformable registration with auto-fusion, etc.) based on scheduled contours (done by the physician)?
You say for fractions 2-5, so you're talking SBRT dosing for all your adaptive patients. Next to pancreas (since you're a GI Rad Onc). Where duodenum is. And you're considering not having the physician verify the duodenum contour for every patient, every fraction? Or are the OARs part of contour review? I can only speak for Ethos where OAR screen and GTV/CTV/PTV screens are two separate screens that you can't go back and forth on - if MR Linac workflow is different then OK.
In regards to whatever the physician is supposed to review and edit appropriately is on the physician (and the variabilities from physician, won't argue with you on that. Ideally it's the physician who initially met, simmed, planned and knows the patient and what the game plan is, with minimal cross coverage.
Sorry for the challenge, but adaptive takes up physician time (appropriately, IMO), and outsourcing out components of adaptive, especially when doing adaptive SBRT from the physician, seems unwise to me.
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