Cone Beam Computed Tomography-Guided Online Adaptive Radiation Therapy: Clinical Insights From a Nationwide Staffing Survey.

Purpose: This study aimed to provide insights into the staffing and workflow requirements for cone beam computed tomography (CBCT)-guided online adaptive radiation therapy (ART) systems to guide institutions in optimizing staffing strategies and to promote broader ART adoption.

Methods and materials: We conducted a nationwide survey to collect data on ART program metrics, clinician roles during online treatment, and physicist staffing models, along with free-text feedback for sharing of insights and challenges. Additionally, we reviewed 26 published articles describing ART workflows across various anatomic sites and performed a literature-based timing analysis to provide further context on workflow efficiency.

Results: We received 19 responses from a range of institutions. Medical schools and university hospitals reported the highest ART patient throughput, averaging 4 patients per machine per day. Overall, most institutions treat 1 to 2 ART patients per machine daily, with average session duration of 1 hour. Therapists are primarily responsible for CBCT scans, whereas physicists oversee almost all ART stages. The physicians are mainly responsible for on-treatment contouring and plan selection/approval. As ART cases increase, more full-time equivalent (FTE) physicists are needed, with >5 cases per day typically requiring an additional FTE. The online adaptive workflow adds about 20 minutes to treatment time compared with image guided radiation therapy, resulting in a total on-table time of ∼40 minutes.

Conclusions: Implementing ART programs requires careful planning and flexible staffing models to balance resource availability with treatment quality. The findings from this survey highlight the importance of interdisciplinary collaboration, defined clinician roles, and evolving staffing solutions for ART implementation. Medical physicists are essential in all stages of the ART process, with higher adaptive case volumes directly driving the need for additional FTEs to maintain effective workflow and treatment quality. This study's insights can guide health care facilities in establishing efficient and sustainable ART workflows, ultimately enhancing patient care outcomes.