Implementation and satisfaction of RapidPlan knowledge-based planning software in the

clinical setting
Lauren Brandl, B.S.; Marc Anderson, B.S., 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

I. Key Words: RapidPlan, Knowledge-based Treatment Planning, Varian, Automated

Planning
II. Introduction
A. Creating a high-quality radiation therapy plan can be a challenging and time-
consuming process.
1. There are many crucial steps that must occur when developing a
successful treatment plan.
2. One of the most important may be the analysis of the anatomy and
target along with the understanding of reasonable plan outcomes.
B. In recent years, a few radiation oncology vendors have developed technology
capable of automatically creating radiation treatment
1. 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.
C. RapidPlan is a knowledge-based planning system that provides clinicians with
models based on clinical practices from leading institutions.1
1. This program was released with the goal to provide consistent,
efficient, and higher quality plans for individualized treatments with less
variability.
2. RapidPlan operates by looking at the data set of a new patient’s
anatomy and compares the geometric proportions to those from the model
it has already learned from. By reviewing the dose distributions of past
 plans with similar anatomy, the software is able to predict a reasonable
dose volume histogram (DVH) for nearby critical structures.
3. The predictions are then used to develop an intensity-modulated
radiation therapy (IMRT) or volumetric modulated arc therapy (VMAT)
plan.
D. The utilization of a knowledge-based planning system such as RapidPlan has
proven to be a promising method to improve the quality and efficiency of
treatment planning. 1,2
1. However, there is currently little information known about the
adoption and usage levels of RapidPlan in radiation oncology departments,
as well as the satisfaction of users.
2. The purpose of this study is to determine if RapidPlan is a
desirable program for clinics to utilize and to identify key components that
may assist in a clinic's adoption of the program.
a. By creating a survey, we were able to determine if knowledge
based treatment planning is beneficial to the clinical environment.

III. Methods and Materials

A. Study Population
1. The respondent population consisted of American Association of
Medical Dosimetrists (AAMD) 2019 National Conference attendees,
specifically those participating in the “Eclipse Advanced Users” treatment
planning workshops and the “Varian Velocity” workshop.
a. The intent was to distribute the surveys to Varian users, the
population most likely to have had prior knowledge of or
experience with RapidPlan.
2. Participation in the survey was limited to active Certified Medical
Dosimetrists and Medical Physicists regardless of experience using
RapidPlan.
 3. The study was limited to these positions in order to collect
responses from those regularly planning treatments.

B. Survey
1. In order to gain insight, a survey was created in an effort to gauge
participant's knowledge, satisfaction and implementation of RapidPlan.
2. Survey questions can be categorized into 3 basic types.
a. The first identified professional status and familiarity with
RapidPlan.
b. The second group of questions were directed only to those
professionals that have implemented RapidPlan in their therapy
departments.
c. The third group of questions were general questions concerning
model based planning and potential future use of Rapid plan.
3. The questionnaire was estimated to take no longer than 3 minutes
to complete. The survey may be viewed in Table 1.
C. Data Collection
1. Hard-copy responses were distributed and collected from medical
physicists and medical dosimetrists attending the four treatment planning
sessions.
2. In addition to distribution of hard copies to attendees, an online
link to the survey was also provided.
a. Once completed, the printed surveys were collected.
3. In order to store the responses in a digital format, each paper
survey was entered manually into an online survey tool.
a. Entry accuracy was verified by (1 or 2) additional individuals.
D. Statistical Analysis
1. The survey was conducted in June of 2019 and analyzed in July
2019.
2. Data analysis was then performed to acquire a greater
understanding of perceived adequacy and adoption.
 3. Survey responses to RapidPlan-user dependent questions answered
by those who do not have the software were removed from recorded data.
a. The results were then described in percentages of usable responses
for each question.
b. The Qualtrics survey tool was used to house the data and calculate
the provided chart percentages, means, and standard deviations.
c. Statistical significance could not be achieved, therefore the
summary of results were perceived qualitatively.
IV. Results
A. Sixty-seven responses were collected from those attending the Varian workshops
at the AAMD national conference.
1. An online link to the survey was also provided as an alternative to
the hard copies but was not used.
2. It is important to note not every question required or received a
response.
a. This was in part due to the question not applying to the situation of
the respondent, or simply the respondent not providing an answer.
B. Thirty percent of the respondents stated their department did have RapidPlan.
1. 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.
2. Of those who did not have access to RapidPlan, 81% gave a
favorable response regarding their interest in adapting a knowledge-based
planning system into their department.
a. Figure 1 demonstrates the interest level of the 42 medical
dosimetrists and medical physicists that answered the question.
b. A value of 6 or above on a scale of 0-10, with 10 denoting
“extremely interested” was deemed favorable.
C. Fifteen of the 21 departments (71%) with access to RapidPlan are using the
program.
 1. Results from the survey showed the frequency in which clinics
with access are using RapidPlan.
a. Fifteen responses were collected, and it was generally used on less
than 10 patients per week (69%).
b. The prostate (25%) and the head and neck (23%) proved to be the
most common anatomic sites for which departments were equipped
with models, which may be seen in Figure 2.
c. 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.
d. With that being said, it was found that a large majority (61%) of
departments using RapidPlan have both added and adjusted to the
models in use, while only 17% have made no changes (n=18).
D. There was significant interest in the 6 respondents with RapidPlan that are not
utilizing the program.
1. However, only 5 responded to the following question regarding
their rationale behind not adopting the technology.
2. Figure 4 demonstrates the responses received and the list of
potential reasons that may apply to their situation, with some checking
multiple.
a. “Insufficient time to learn and adapt new technology” was the
most commonly selected, chosen 3 times as the reason for not
using RapidPlan.
b. 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.
E. 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).
1. “Superior plan quality” was the second most common response,
receiving 23% of the remaining votes for the number 1 rank.
2. 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).
F. 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.
G. The survey demonstrated overall satisfaction with RapidPlan when available in
the department.
1. The same 1-10 scale as earlier was used, with 10 now denoting
“Extremely satisfied.”
a. 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)
H. Nearly every respondent with access to RapidPlan that provided an answer (94%,
n=17) declared they would recommend RapidPlan to other radiation oncology
departments.
V. Discussion
A. The purpose of this study was to determine if RapidPlan is a desirable program
for clinics to adopt and use, and to identify key components that may improve a
clinic's experience with the program.
1. It was found that 69% (n=46) of those surveyed during the
workshops have not acquired RapidPlan software. However, 93% (n=39)
of these individuals expressed interest in adopting the planning system.
2. It was also noteworthy that the most common response to this
question was the maximum interest level of 10, suggesting enthusiasm
 amongst medical dosimetrists and medical physicists to employ such
knowledge-based technology.
B. According to a 2019 paper by Ge and Wu,3 the number of published articles
regarding RapidPlan was continually increasing, demonstrating a rising interest in
the planning system.
1. The authors performed a meta-analysis of 73 manuscripts and
stated that a majority of the research demonstrated benefits of knowledge-
based planning.
2. 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
3. According to Hao et al,2 it is also a favorable solution to increase
plan quality and reduce planning time.
C. In the clinical setting, time is undeniably valuable.
1. Of the 21 facilities who currently own RapidPlan software, 71%
(n=15) of the facilities utilize its capabilities while 29% (n=6)did not.
a. In the current study analysis, the most common reason facilities
were not utilizing RapidPlan software was due to insufficient time
to learn and adapt to new technology.
b. New technology may be intensely complex and hard to learn, and
the training process and validation testing may be tremendously
time-consuming.4,5
c. Such factors could potentially add pressure to an already busy
schedule.5
a. However, ease of use was the second most common answer
when asked which beneficial features applied to the
experience of RapidPlan users.
b. In addition, the time it may take to implement and learn the
technology may quickly be made up in time saved using
RapidPlan.4
 c. 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
D. 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
1. The current research survey indicated the vast majority of clinical
sites have added and/or adjusted plans which RapidPlan uses as qualified
models.
d. 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
e. Bodez et al6 demonstrated the effect of increasing the number of
previous treatments from which RapidPlan may “learn.”
f. 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%.
g. The results of the study conducted by Bodez et al6 proved the value
of adding to and adjusting the model, which has been done by 61%
(n=11) of the current research survey respondents.
2. 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.
3. The majority of knowledge-based planning studies have
concentrated on prostate, head and neck, and lung cancers.3
4. 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 anatomic sites.
E. This current study resulted in 68% (n=11) of the clinics utilizing RapidPlan for
less than 10 patients per week.
 1. This 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
2. More facilities are estimated to realize the potential knowledge-
based planning offers to increase efficiency and consistency in treatment
planning quality.6-8
a. The realization and understanding of this 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.
b. By incorporating such innovation into the workflow, cancer
treatment delivery and patient care as a whole have the potential to
improve significantly.8
c. Following this notion of embracing technology, it was found that
94% (n=16) would recommend RapidPlan to other radiation
oncology departments.
d. 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.
VI. Conclusion
A. The purpose of this study was to determine if RapidPlan is a desirable program
for clinics to adopt and use, and to identify key components that may improve a
clinic's experience with the program.
1. At the time of the survey, most departments employing RapidPlan
were using the program after some adjustment and/or addition to the
models, suggesting an increase in user satisfaction as modification is often
associated with improved model performance.
a. 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.
 b. However, “Speed of plan generation” was the most commonly
reported advantageous feature while using RapidPlan, as well as
the most theoretically advantageous feature of a planning system.
c. After putting in the necessary time to implement the program, the
study suggests the potential time saved by using RapidPlan may
have a profound effect on user experience.
2. The above factors were found most likely to enhance user
satisfaction with RapidPlan, ultimately leading to its implementation and
further usage in the department.
B. Furthermore, the results of the survey did in fact demonstrate the desirability of
RapidPlan, as a majority of those surveyed who did not have access to RapidPlan
showed overwhelming interest in adopting the program into the clinic.
1. Moreover, the vast majority of those possessing the software did
anticipate an increased presence of RapidPlan in the workflow.
2. Overall, nearly every respondent using the program would
recommend RapidPlan to other radiation oncology departments,
confirming RapidPlan to be a desirable program used within the clinic.
C. The current study had several limitations.
1. 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.
a. The survey was provided to the small non-random convenience
sample of those who participated in the 4 Varian workshops.
2. Further research into the topic may benefit by polling a random,
statistically significant sample population.
a. Second, the survey was created and printed to hard copies for
participants to fill out.
b. Some surveys were excluded due to incomplete answers or
responses not relevant to the situation of the respondent.
 c. Time constraints were also a limitation, as the research was
conducted as part of a medical dosimetry program and deadlines
were a concern.
3. 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.
4. 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.
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 in adopting RapidPlan or similar knowledge-based planning system into
the department 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.

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 knowledge- Yes
based planning program, RapidPlan? No
3. If your answer to question 2 was ""No:"" 0 (Not at all interested) - 10 (Extremely
What is your overall interest level in adapting Interested)
a knowledge-based planning system such as
RapidPlan into your department? (After
responding, please proceed to Question 9)
4. If your answer to question 2 was ""Yes:"" Yes
Is your department currently utilizing the No
RapidPlan knowledge-based planning
software?
5. If your department has the RapidPlan Cost of additional licenses or software
software but is not currently utilizing the upgrades
program, please check all applicable reasons Awaiting model availability in additional
below as to why your department is not using anatomical sites
RapidPlan. Awaiting further endorsement from larger
number of clinics and peers
Insufficient time to learn and adapt new
technology
Insufficient resources to accommodate new
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, on 10-20 patients per week
average, is RapidPlan a part of the plan >20 patients per week
development process?
7. For which of the following anatomic sites Head and Neck
are you using RapidPlan models? Please Liver
check all that apply. GYN
Prostate
Lung
Spine
Pancreas
 Lymphoma
Other (Please list in text box)
8. Has your department adjusted or added to Yes: Added to Model
any of these models? Yes: Adjusted Model
Yes: Added and Adjusted
No
9. Theoretically, what do you feel is the most Speed of plan generation
advantageous feature of a knowledge-based Plan quality measure
planning system? Please drag to rank the Ease of use
following responses in order with 1 being the Superior plan quality
most advantageous to 7 being least Ability to add to library and
advantageous. If you are using a paper copy, update/manipulate model
please write in ranks 1-7 to the left of choices. Exposure to new technology in field of
radiation oncology
Ability to download and share existing
models amongst institutions
10. Which of the above advantageous features Speed of plan generation
apply to your experience with RapidPlan? Plan quality measure
Please check all that apply. Ease of use
Superior plan quality
Ability to add to library and
update/manipulate model
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
12. How do you foresee the utilization of Increased usage of RapidPlan
RapidPlan in your department? Maintained usage of RapidPlan
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.