Implementation and Satisfaction of RapidPlan Knowledge-based Planning Software in the

Clinical Setting
Lauren Brandl, BS; Marc Anderson, BS, RT(T); Renee Jackson, BS, RT(T); Nishele Lenards,
PhD, CMD, RT(R)(T); Matt Tobler RT(T), CMD; Ashley Hunzeker, MS, CMD
Medical Dosimetry Program at University of Wisconsin, La Crosse, WI
Key Words: RapidPlan, Knowledge-based Treatment Planning, Varian, Automated Planning
Introduction
Creating a high-quality radiation therapy plan may be a challenging and time-consuming
process. There are many crucial steps that must occur when developing a successful treatment
plan, with perhaps one of the most important being the analysis of the anatomy and target.
These are skills that require years of experience to master. In recent years, a few radiation
oncology vendors have developed technology capable of automatically creating radiation
treatment plans using previously developed plans as a template from which to “learn.” One
program that has gained popularity since its release in 2014 is RapidPlan, developed by Varian
Medical Systems.
RapidPlan is a knowledge-based planning system that provides clinicians with models
based on clinical practices from leading institutions. The program was released with the goal to
provide consistent, efficient, and higher quality plans for individualized treatments with less
variability.1 RapidPlan operates by evaluating the data set and comparing the geometric
proportions of new patient anatomy to the model that has been used for learning. By reviewing
the dose distributions of past plans with similar anatomy, the software can predict a reasonable
dose volume histogram (DVH) for nearby critical structures. The predictions are then used to
develop an intensity modulated radiation therapy (IMRT) or volumetric modulated arc therapy
(VMAT) plan.1
The utilization of a knowledge-based planning system, such as RapidPlan, proves to be a
promising method for improving the quality and efficiency of treatment planning.1,2 However,
there is a gap in the literature regarding the adoption, usage, and satisfaction levels of RapidPlan
users in radiation oncology departments. The purpose of this study was to determine if
RapidPlan is a desirable program for clinics to use and to identify key components that may
assist in a clinic's adoption of the program. By creating a survey, we were able to determine if
RapidPlan knowledge-based treatment planning is beneficial to the clinical environment.
Materials and Methods
Study Population
The respondent population consisted of American Association of Medical Dosimetrists
(AAMD) 2019 National Conference attendees, specifically a convenience sample of those
participating in the three “Eclipse Advanced Users” treatment planning workshops and the
“Varian Velocity” workshop. The intent was to distribute the surveys to Varian users; the
population most likely to have prior knowledge of or experience with RapidPlan. Participation in
the survey was limited to active Certified Medical Dosimetrists and Medical Physicists
regardless of experience using RapidPlan. The study was limited to these positions in order to
collect responses from those regularly planning treatments. A survey was distributed to all of
those in attendance of the four workshops.
Survey
In order to gain insight, an anonymous survey was created in Qualtrics in an effort to
gauge participant's knowledge, satisfaction and implementation of RapidPlan. Survey questions
can be categorized into 3 basic types; the first identified professional status and familiarity with
RapidPlan. The second group of questions were directed only to those professionals that have
implemented RapidPlan in their radiation oncology departments. The third group of questions
were general questions concerning model-based planning and potential future use of Rapid plan.
The questionnaire was estimated to take no longer than 3 minutes to complete. The survey may
be viewed in Table 1.
Data Collection
Hard-copy surveys were distributed and collected from medical physicists and medical
dosimetrists attending the four treatment planning sessions. In addition to distribution of hard
copies to attendees, an online link to the survey was also provided. Once completed, the printed
surveys were collected. In order to store the responses in a digital format, each paper survey was
entered manually into an online survey tool. Entry accuracy was verified by two additional
individuals.
Statistical Analysis
The survey was conducted in June of 2019 and compiled in July 2019. Data analysis was
then performed to acquire a greater understanding of perceived adequacy and adoption. Survey
responses to RapidPlan-user dependent questions answered by those who do not have the
software were removed from recorded data. The results were then described in percentages of
usable responses for each question.
The survey tool Qualtrics used to house the data provided chart percentages, means, and
standard deviations. Assistance was received from Dr. Dave Reineke of the University of
Wisconsin-La Crosse statistics department in the creation of figures and analysis of data. Due to
the small population size and non-random sample statistical significance could not be achieved,
and the summary of results were perceived qualitatively.
Results
Sixty-seven responses were collected from those attending the Varian workshops at the
AAMD national conference. An online link to the survey was also provided as an alternative to
the hard copies; none of the population used this tool. It is important to note not every question
required or received a response. This was in part due to the question not applying to the situation
of the respondent, or simply the respondent not providing an answer.
Thirty percent of the respondents stated their department did have RapidPlan; however, 3
of those whose clinic did not have RapidPlan stated in a comment box that their department
would be implementing the software within the next 6 months. Of those who did not have access
to RapidPlan, 81% (n=42) gave a favorable response regarding their interest in adapting a
knowledge-based planning system into their department (Figure 1). A value of 6 or above on a
scale of 0-10, with 10 denoting “extremely interested” was deemed favorable.
Of the 21 respondents that have access to RapidPlan, 15 (71%) departments are using
it. Results from the survey showed the frequency in which clinics with access are using
RapidPlan. Fifteen responses were collected, and it was generally used on less than 10 patients
per week (69%). The prostate (25%) and the head and neck (23%) proved to be the most
common anatomic sites for which departments were equipped with models (Figure 2). Three
medical dosimetrists or medical physicists selected the choice, “Other,” with two writing in their
clinic also had sarcoma and oligometastases models, while one made known their department
replaced the original head and neck model to fit their clinical standards. With that being said, it
was found that a large majority (61%) of departments using RapidPlan have both added and
made adjustments to the models in use, while only 17% have made no changes (n=18) (Figure
3).
 There was significant interest in the 6 respondents with RapidPlan that are not utilizing
the program. However, only 5 responded to the following question regarding their rationale
behind not adopting the technology. Figure 4 demonstrates the responses received and the list of
potential reasons that may apply to their situation, with some checking multiple. “Insufficient
time to learn and adapt new technology” was the most commonly selected, chosen 3 times as the
reason for not using RapidPlan. The answer “Other” was chosen twice, in which one explained
they were waiting on a software upgrade, while the other was waiting on implementation of the
software.
When prompted to rank 7 theoretical advantageous features of a knowledge-based
planning system, “Speed of plan generation” was believed to be the most beneficial, having been
ranked in the top position in 50% of responses (n=47) (Figure 5). “Superior plan quality” was the
second most common response, receiving 23% of the remaining votes for the number 1 rank.
Speed was also the most common response when asked which of the above applied to their
actual experience using RapidPlan, with 81% selecting “Speed of plan generation” as part of or
their sole answer to the question (Figure 6).
Expected future use of RapidPlan was believed to increase in the departments of 13
(65%) of the respondents (n=20), while only 1 (5%) believed it would decrease. The survey
demonstrated overall satisfaction with RapidPlan when available in the department. The same 1-
10 scale as earlier was used, with 10 now denoting “Extremely satisfied.” Seventy-nine percent
gave favorable responses of a value of 6 or above, and 8 was discovered to be the most common
satisfaction level (26%, n=19) (Figure 7). Nearly every respondent with access to RapidPlan that
provided an answer (94%, n=17) declared they would recommend RapidPlan to other radiation
oncology departments.
Discussion
The purpose of this study was to determine if RapidPlan is a desirable program for clinics
to use and to identify key components that may assist in a clinic's adoption of the program.
Of the 67 respondents from the AAMD National Conference Varian Advanced Users
Workshops, 70% have not acquired RapidPlan software. However, 93% of these individuals
expressed interest in adapting a knowledge-based planning system. It was also noteworthy that
the most common response to this question was the maximum interest level of 10.
 The study by Ge and Wu3 reviewed 73 articles published between 2011 and 2018. The
majority of the studies demonstrated the benefits of knowledge-based planning. The number of
articles continually increases demonstrating a rising interest in RapidPlan. As the amount of
superior quality plan data increases, major progress in knowledge-based research can be made.3
The results of the current study support previous literature by demonstrating that RapidPlan
continues to gain popularity as the software produces dependable, higher quality plans with less
variability.1-4 According to a study by Hao et al,2 it is a favorable solution to increase plan
quality and reduce planning time.
In the clinical setting, time is undeniably valuable. Of the 21 facilities who currently own
RapidPlan software, 71% of the facilities used its capabilities while 29% did not. In the analysis,
the most common reason facilities were not utilizing RapidPlan software was due to insufficient
time to learn and adapt to new technology. New technology may be intensely complex and hard
to learn, and the training process and validation testing may be tremendously time-consuming.4,5
These combined factors could potentially add pressure to an already busy schedule.5 However,
ease of use was the second most common answer when asked which beneficial features applied
to the experience of RapidPlan users. In addition, the time it may take to implement and learn the
technology may quickly be made up in time saved using RapidPlan.4 The use of RapidPlan
provides a greater potential of creating a high-quality radiation therapy plan in less time for users
of all ability levels.2,4
RapidPlan also allows clinicians to either use provided sample models shared from other
institutions or to develop models by creating their own database of plans.1 The current research
survey indicated the vast majority of clinical sites have added and/or adjusted plans which
RapidPlan uses as qualified models. The minimum number of plans required to create a model is
20, although expanding the amount used to build a model will increase the probability of a
higher quality treatment plan.1,6 A study by Bodez et al6 demonstrated the effect of increasing the
number of previous treatments from which RapidPlan may “learn.” By extending the number of
plans in the model from 36 to 116, the chance of meeting criteria in a single optimization
increased from 60% to 83.2%. The results of the study proved the value of adding to and
adjusting the model, which has been done by 61% of the current research survey respondents.
The findings of the current research survey showed that prostate and head and neck
cancers were the most common anatomical sites that facilities were using RapidPlan software for
planning assistance. The majority of knowledge-based planning studies have concentrated on
prostate, head and neck, and lung cancers.3 According to Ge and Wu,3 there are currently 60
articles available about knowledge-based planning for prostate, head & neck and lung, compared
to only 28 articles involving other sites.
This study revealed that 68% of the clinics utilized RapidPlan for less than 10 patients
per week. The results may be due to clinic size or insufficient staff, but it is a number that is
expected to rise as the technology develops and more data is collected for each system.7 In
addition, more facilities are expected to capitalize on the potential increase in efficiency,
consistency, and quality of treatment plans offered by knowledge-based planning software such
as RapidPlan.6-8 The realization and understanding of this potential was observed in the results of
the survey, as 65% of those already using RapidPlan expected their use of the program to
increase going forward. By incorporating such innovation into the workflow, cancer treatment
delivery and patient care as a whole have the potential to improve significantly.8 Following this
notion of embracing technology, it was found that 94% would recommend RapidPlan to other
radiation oncology departments. As technology has helped increase the capabilities of a
dosimetrist, it was not a surprise that the overall user satisfaction with RapidPlan was
compellingly favorable.9
Conclusion
At the time of the survey, the majority of departments were using RapidPlan for prostate
and head and neck treatment planning, often after some modifications to the models. Though
most of the clinics with RapidPlan software were employing the technology, the study reported
the most common response for not using RapidPlan to be insufficient time to learn and adapt
new technology. However, “Speed of plan generation” was the most commonly recorded
advantageous feature while using RapidPlan. The second most common response was “Superior
plan quality.” Speed was also deemed the most theoretically advantageous feature of a
knowledge-based planning system, thus emphasizing the need and desire for efficient planning
techniques.
The majority of those surveyed who do not currently have access to RapidPlan showed
overwhelming interest in adopting the program into the clinic. Furthermore, the vast majority of
those possessing the software anticipate an increased presence of RapidPlan in the workflow.
Overall, nearly every respondent using the program would recommend RapidPlan to other
radiation oncology departments, and the survey findings suggested RapidPlan to be a desirable
program used within the clinic.
This study had several limitations. As RapidPlan is a highly specialized program
pertaining only to the field of medical dosimetry, data collection was limited to only those
attending the 2019 AAMD national conference. The survey was provided to the small non-
random convenience sample of those who participated in the 4 Varian workshops. Further
research into the topic may benefit by polling a random, statistically significant sample
population. Second, the survey was created and printed to hard copies for participants to fill out.
Some surveys were excluded due to incomplete answers or responses not relevant to the situation
of the respondent. Time constraints were also a limitation, as the research was conducted as part
of a medical dosimetry program and deadlines were a concern. Finally, the survey did not
question how many patients per week on average are treated at each facility, which may affect
the interpretation of certain answers. Future research may address this regarding the proportion
of the patients being treated at a clinic in which RapidPlan was a part of the planning process.
 Acknowledgements
I would like to thank the Statistical Consulting Center at UW-La Crosse for its assistance with
Figure 5 and the analysis of data; however, any errors of fact or interpretation remain the sole
responsibility of the author.
 References

1. RapidPlan Knowledge Based Planning Software. Varian Medical Systems.

https://www.varian.com/oncology/products/software/treatment-planning/rapidplan-knowledge-
based-planning. Accessed April 20, 2019.
2. Hao W, Fan J, Haizhen Y, et al. Applying a RapidPlan model trained on a technique and
orientation to another: a feasibility and dosimetric evaluation. Radiat Oncol. 2016;11(108):1-7.
https://dx.doi.org/10.1186/s13014-016-0684-9
3. Ge Y, Wu Q, Knowledge-based planning for intensity modulated radiation therapy: A review of
data-driven approaches. Med Phys. 2019;46(6):2760-2775. https://dx.doi.org/10.1002/mp.13526
4. Li N, Carmona R, Sirak I, et al. Highly efficient training, refinement, and validation of a
knowledge-based plan quality control system for radiotherapy clinical trials. Int J Radiat Oncol
Biol Phys. 2017;97(1):164-172. https:/dx./doi.org/10.1016/j.ijrobp.2016.10.005
5. Garrett P, Brown A, Hart-Hester S, et al. Identifying barriers to the adoption of new technology
in rural hospitals: A case report. Perspect Health Inf Manag. 2006;3(9):1-11.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2047308/.
6. Bodez V, Khamphan C, Francois G, et al. Feedback on use of the RapidPlan™ knowledge
based planning system for the realization of prostatic treatment planning in volumetric
modulated arc therapy. Physica Medica. 2017;44(1):6-7.
https://dx.doi.org/10.1016/j.ejmp.2017.10.037
7. Hussein M, South C, Barry M, et al. Clinical validation and benchmarking of knowledge-based
IMRT and VMAT treatment planning in pelvic anatomy. Radiat Ther Oncol. 2016;120(3):473-
479. https://dx.doi.org/10.1016/j.radonc.2016.06.022
8. Thompson R, Valdes G, Fuller C et al. Artificial intelligence in Radiation Oncology: A
specialty-wide disruptive transformation? Radiat Ther Oncol. 2018;129(3):421-426.
https://dx.doi.org/10.1016/j.radonc.2018.05.030
9. Mell L, Roeske J, Mundt A. A survey of intensity modulated radiation therapy in the United
States. Cancer. 2003;98(1):204-211 https://dx.doi.org/10.1002/cncr.11489
 Figures

Figure 1. Interest level displayed on a scale of 0 to 10, with 0 being not at all interested and 10
being extremely interested.

Figure 2. Anatomic sites for which users have RapidPlan models.

Figure 3. Manipulation of RapidPlan models when available in the department.

Figure 4. Rationale for not using RapidPlan when available in the department.
Figure 5. Rank Placement of Proposed Advantageous Features of a Knowledge-Based Planning
System.

Figure 6. Proposed advantageous features that have applied to the experience of RapidPlan
users.
Figure 7. Overall user satisfaction of RapidPlan when available in the department on a scale of 0
to 10, with 0 being not at all satisfied and 10 being extremely satisfied.
 Appendix
Questions and Answers to RapidPlan Survey
Questions Answers
1. What is your position in the radiation Medical Dosimetrist
oncology department? Medical Physicist
2. Does your department have the
Yes
knowledge-based planning program,
No
RapidPlan?
3. If your answer to question 2 was ""No:""
What is your overall interest level in
adapting a knowledge-based planning 0 (Not at all interested) - 10 (Extremely
system such as RapidPlan into your Interested)
department? (After responding, please
proceed to Question 9)
4. If your answer to question 2 was ""Yes:""
Is your department currently utilizing the Yes
RapidPlan knowledge-based planning No
software?
Cost of additional licenses or software
upgrades
Awaiting model availability in additional
anatomical sites
Awaiting further endorsement from larger
5. If your department has the RapidPlan number of clinics and peers
software but is not currently utilizing the Insufficient time to learn and adapt new
program, please check all applicable reasons technology
below as to why your department is not Insufficient resources to accommodate new
using RapidPlan. technology
Uninterested in automated planning method
Unsatisfied with existing model
performance
Program not user-friendly
Other (please list in text box)
6. If your department is currently utilizing
<10 patients per week
RapidPlan: For how many patients a week,
10-20 patients per week
on average, is RapidPlan a part of the plan
>20 patients per week
development process?
Head and Neck
7. For which of the following anatomic sites Liver
are you using RapidPlan models? Please GYN
check all that apply. Prostate
Lung
 Spine
Pancreas
Lymphoma
Other (Please list in text box)
Yes: Added to Model
8. Has your department adjusted or added to Yes: Adjusted Model
any of these models? Yes: Added and Adjusted
No
Speed of plan generation
9. Theoretically, what do you feel is the Plan quality measure
most advantageous feature of a knowledge- Ease of use
based planning system? Please drag to rank Superior plan quality
the following responses in order with 1 Ability to add to library and
being the most advantageous to 7 being least update/manipulate model
advantageous. If you are using a paper copy, Exposure to new technology in field of
please write in ranks 1-7 to the left of radiation oncology
choices. Ability to download and share existing
models amongst institutions
Speed of plan generation
Plan quality measure
Ease of use
Superior plan quality
10. Which of the above advantageous
Ability to add to library and
features apply to your experience with
update/manipulate model
RapidPlan? Please check all that apply.
Exposure to new technology in field of
radiation oncology
Ability to download and share existing
models amongst institutions
11. Would you recommend RapidPlan to Yes
other radiation oncology departments? No
Increased usage of RapidPlan
12. How do you foresee the utilization of Maintained usage of RapidPlan
RapidPlan in your department? Decreased usage of RapidPlan
Ceased usage of RapidPlan
13. Please rate your overall satisfaction with
0 (Not at all satisfied) - 10 (Extremely
the RapidPlan knowledge-based planning
satisfied)
software.
14. If you would like to leave the name of
your clinic, please do so below.