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), FAAMD; Ashley Hunzeker, MS, CMD; Matt Tobler, CMD, RT(T)
Medical Dosimetry Program at University of Wisconsin, La Crosse, WI
Abstract
RapidPlan is a knowledge-based planning (KBP) tool created to improve efficiency and
quality of intensity-modulated radiation therapy (IMRT) and volumetric-modulated arc therapy
(VMAT) planning. Currently, little is known regarding adoption, usage, and satisfaction levels of
RapidPlan. The purpose of this study was to ascertain the usage and satisfaction levels of
RapidPlan users and identify key factors that contributed to implementation of the program. A
Qualtrics survey was created to support the 3 research questions guiding the study. The survey
was distributed to those attending 4 treatment planning workshops at the American Association
of Medical Dosimetrists (AAMD) 2019 National Conference. Reponses were recorded from
medical physicists and medical dosimetrists and stored in the Qualtrics online survey tool for
data analysis. Sixty-seven responses were collected. Thirty percent of the departments had
RapidPlan, and 81% of those without showed interest in adapting a KBP system. “Insufficient
time to learn and adapt new technology” was a concern among those not using the program.
However, speed of plan generation was deemed the most important and most commonly
experienced RapidPlan feature. Adding to and adjusting models, as well as dedicating adequate
time to learn and implement RapidPlan may enhance user experience, leading to its further
usage. Seventy-nine percent reported satisfaction with RapidPlan and 94% of users would
recommend the KPB system to other departments. The survey results demonstrated profound
interest in and satisfaction with RapidPlan as well as multiple features that may affect
implementation of the program.
Keywords: RapidPlan, Knowledge-Based Treatment Planning, Automated Planning,
Satisfaction Survey
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. Perhaps one of the most important steps is the analysis of the anatomy and target as well as
the prediction of reasonable plan results; both of which are skills that require years of experience
to master. In recent years, radiation oncology vendors have developed technology capable of
automatically creating radiation treatment plans by doing exactly that – developing dose
predictions by looking at the targets and anatomy of 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 (KBP) system that provides clinicians with
models based on clinical practices from leading institutions. RapidPlan 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 RapidPlan software can predict a
reasonable dose volume histogram (DVH) for nearby critical structures. The predictions are then
converted to optimization objectives which may be used to develop an intensity-modulated
radiation therapy (IMRT) or volumetric-modulated arc therapy (VMAT) plan.1
The utilization of a KBP 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 ascertain the usage and satisfaction
levels of RapidPlan users and identify key factors that contributed to implementation of the
program. Research questions used to guide the study were (Q1) what key factors contributed to
implementation or rejection of the RapidPlan system, (Q2) what key factors contributed to user
satisfaction levels, and (Q3) what were RapidPlan users’ satisfaction level with the system? The
Qualtrics survey tool was used to create survey questions to support the 3 research questions
guiding the study. Qualtrics was also used to store and calculate data for the descriptive statistics
reported in this research study.
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 3 “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 in order to collect responses from those regularly planning
treatments. A survey was distributed to all of those in attendance of the 4 workshops.
Survey
In order to gain insight, an anonymous survey was created in Qualtrics in an effort to
gauge participant's usage, satisfaction and implementation of RapidPlan. Survey questions were
categorized into 3 basic types; the first identified professional status, familiarity with RapidPlan,
and interest in the KBP system. The second group of questions were directed only to those
professionals that have implemented RapidPlan in their radiation oncology departments, and
their satisfaction with the program. The third group were general questions concerning model-
based planning and potential future implementation and use of RapidPlan. The questionnaire was
estimated to take no longer than 3 minutes to complete. By creating a survey, researchers were
able to gauge interest levels in acquiring RapidPlan and to understand what factors may affect
current users’ satisfaction with the program, potentially leading to its implementation and further
utilization.
Data Collection
Hard-copy surveys were distributed and collected from medical physicists and medical
dosimetrists attending the 4 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. To store the responses in a digital format, each paper survey was entered
manually into an online survey tool. Entry accuracy was verified by 2 additional individuals.
Statistical Analysis
The survey was conducted in June of 2019 and compiled in July 2019. Data analysis was
performed to acquire a greater understanding of perceived features that may affect user
satisfaction as well as implementation or rejection of the KBP system, and satisfaction levels
with RapidPlan. 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
Qualtrics survey tool was used to store the data and calculate the provided chart percentages,
means, and standard deviations for the descriptive statistics reported in this research study.
Results
Sixty-seven responses were collected from those attending the Varian workshops at the
AAMD national conference for a response rate of approximately 71% (n=67/94). 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 that not every question required or received a response 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 departments had RapidPlan; however, 3 of
those whose clinics 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 KBP
system into their department (Figure 1). On a scale of 0-10, with 10 denoting “extremely
interested” a value of 6 or greater was deemed favorable.
Fifteen of the 21 departments (71%) with access to RapidPlan were using the program.
Results from the survey also showed the frequency in which clinics with access are using
RapidPlan. Of the 15 responses collected, 69% (n=16) of clinics used RapidPlan on < 10 patients
per week. 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 2 writing in that their clinic
also had sarcoma and oligometastases models, while 1 made known that their department
replaced the original head and neck model to fit their clinical standards. The data also showed
that a large majority of RapidPlan users have both added and adjusted the models in use, while
only 17% have made no changes (n=18) (Figure 3).
Research (Q1) was what key factors contributed to implementation or rejection of the
RapidPlan system? There was significant interest placed in the 6 respondents with RapidPlan
that are not utilizing the program. However, only 5 responded to the subsequent survey 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 1 explained they were waiting on a software upgrade, while the other
was waiting on implementation of the software.
Research (Q2) was what key factors contributed to user satisfaction levels? When
prompted to rank 7 theoretical advantageous features of a KBP 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. 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).
Research (Q3) was what were RapidPlan users’ satisfaction level with the system?
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 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 ascertain the usage and satisfaction levels of RapidPlan
users and identify key factors that contributed to implementation of the program. Upon analyzing
availability, researchers found that 69% (n=46) of those surveyed during the workshops had not
acquired RapidPlan software. However, 93% (n=39) of those individuals expressed interest in
adopting the planning system. It was also noteworthy that the most common response to this
question was the maximum interest level of 10, suggesting enthusiasm among medical
dosimetrists and medical physicists to employ such knowledge-based technology.
Ge and Wu3 reported that the number of published articles regarding RapidPlan was
continually increasing, demonstrating a rising intrigue with the planning system. In addition, Ge
and Wu3 performed a meta-analysis of 73 manuscripts published between 2011 and 2018 and
stated that a majority of the research demonstrated benefits of KBP. The results of this study
supported previous literature demonstrating that RapidPlan continues to gain popularity as the
software produces dependable, higher quality plans with less variability.1-4 According to Hao et
al,2 it is also 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% (n=15) of the facilities used its capabilities while 29% (n=6) did not.
Researchers in this study aimed to determine what key factors lead to the rejection of RapidPlan
when available in the department. Upon analyzing the data, the most common rationale was
attributed to insufficient time to learn and adapt to new technology. New technology may be
complex, hard to learn, and the training process and validation testing may be tremendously
time-consuming; all of which could potentially add pressure to an already busy schedule.4,5
However, ease of use was the second most common answer when determining 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 surpassed by the time saved using
RapidPlan. 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 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 Bodez et al6 study proved the value of adding to and adjusting
the model. The alterations made by 61% (n=11) of respondents’ departments may be a key factor
in improving user experience, thus allowing for further usage and implementation.
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 KBP 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 KBP
for prostate, head & neck and lung, compared to only 28 articles involving other anatomic sites.
 The results of the current study revealed that 68% (n=11) of the clinics utilized RapidPlan
for less than 10 patients per week. The survey did not address clinic size, which may have
affected survey results based on the assumption that larger facilities are more likely to use
RapidPlan for a greater number of cases due to higher patient volume. Nonetheless, usage 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 KBP software such as RapidPlan.6-8 The
improved efficacy and quality potential was observed in the results of the survey, as 65% (n=13)
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% (n=16) would recommend RapidPlan to other radiation
oncology departments. As technology has helped increase the capabilities of a medical
dosimetrist, it was not a surprise that the overall user satisfaction with RapidPlan was
compellingly favorable.9
Conclusion
The purpose of this study was to ascertain the usage and satisfaction levels of RapidPlan
users and identify key factors that contributed to implementation of the program. Although most
of the clinics with RapidPlan software were employing the technology, the most common
rationale for not using RapidPlan was insufficient time to learn and adapt new technology.
However, “speed of plan generation” was the most commonly reported advantageous feature
while using RapidPlan. Furthermore, it was also perceived to be the most theoretically
advantageous feature of a KBP system.
At the time of the survey, most departments employing RapidPlan were using the
program after some adjustment and/or addition to the models. Alteration may be a key factor in
increasing user satisfaction, as modification is often associated with improved model
performance. The results of the study suggested that after putting in the necessary time to
implement the program, the potential time saved by using RapidPlan may have a profound effect
on user experience. Adding to and adjusting the models, as well as adequate time dedicated
towards RapidPlan training were found most likely to enhance user satisfaction; ultimately
leading to its implementation and further usage in the department. With regard to desirability of
RapidPlan, the greater part those surveyed who did not have access to RapidPlan showed an
overwhelming interest in adopting the program into the clinic. Moreover, a vast majority
possessing the software anticipated an increased presence of RapidPlan in the workflow. Further
usage of the KPB system may be a direct result of the overwhelming satisfaction with the
program, as nearly every respondent using the program would recommend RapidPlan to other
radiation oncology departments.
There were several limitations of this study. 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. A second limitation was that the survey was created and printed to hard copies for
participants to fill out. While the online version limited the respondent to one answer per
question when applicable, multiple hard copy surveys were incomplete or multiple answers were
selected, thereby excluding those hard copy survey responses for inclusion. Time constraints
were also a limitation, as the research was conducted as part of a medical dosimetry program and
deadlines were of concern. Additional electronic surveys would have been sent to a greater
number of medical dosimetrists and medical physicists if time had not been a limiting factor.
Finally, a limitation of the survey was the omission of a question regarding the average number
of patients per week treated at each facility. The exclusion of the question may affect the
interpretation of the data regarding the number of patients per week for which RapidPlan was
part of the planning process. Future research should address the question in terms of percentages
for which RapidPlan was used, in proportion to the total patient case load.
 Acknowledgements
The authors would like to thank Dr. David Reineke and the UW-La Crosse Statistical Consulting
Center for assistance in data analysis and interpretation of statistical results for the
study. However, any errors of fact or interpretation remain the sole responsibility of the authors.
 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. Survey question regarding interest level. The interest level is displayed on a scale of 0
to 10, with 0 being not at all interested and 10 being extremely interested.
Figure 2. Survey question representing the frequency of anatomic sites for which survey
respondents have RapidPlan models.

Figure 3. Survey question regarding manipulation of RapidPlan models, including the adding to
and/or addition of cases to models when available in the department.
Figure 4. Survey question regarding potential rationale for not using RapidPlan when available
in the department, representing frequency of answers chosen with option to select multiple.
Figure 5. Survey question asking respondents to rank in order the proposed advantageous
features of a knowledge-based planning system, with 1 representing most advantageous to 7
signifying least advantageous.
Figure 6. Survey question regarding proposed advantageous features that have applied to the
experience of RapidPlan users, representing frequency of answers chosen with option to select
multiple.

Figure 7. Survey question regarding 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.