Interview with a Radiation Physicist … how radiation treatment works and the awesomeness of the “cellar dwellers”

Abby, a medical physicist with a degree in nuclear engineering, decided to skip the nuclear submarine and join the fight against cancer with her medical physics graduate degree.  She explains her behind-the-scenes role in radiation oncology and explains how radiation therapy works. 

The episode delves into the detailed treatment planning process (that's why it takes so long!), including the use of CT scans, the collaboration between radiation oncologists, dosimetrists, and physicists to outline treatment targets and protect normal tissue. 

Abby shares the importance of patients speaking up during the planning process, to ensure their position is adjusted for comfort - as they will need to lie still for some time during treatment.  The importance of and why prompt symptom reporting is explained in this conversation.  

She clues us into the critical importance of quality assurance measures to ensure the safety and accuracy of radiation delivery.  Abby highlights advancements in radiation therapy, and addresses common misconceptions about treatment. She highlights the roles of all the knowledgeable, caring experts in Radiation Oncology – the “cellar dwellers”. 

Transcript

0:01

Welcome to Everything Cancer, everybody, the extra large suitcase of the cancer journey. We are here with Abby, who is a medical physicist. Abby has an undergrad degree in nuclear engineering and a graduate degree in medical physics. She, instead of going on a nuclear submarine, is involved in the fight with cancer with radiation oncology. And we are so happy to have Abby here with us. to talk about how radiation works, how it fights cancer, different types of radiation treatments, and a lot of other things too. Abby, the floor is yours. Thank you so much. I'm so happy to join you. I feel honored that you asked me to be on here. be on here. We're thrilled to have you here and I'm sure that there are a lot of people with their ears perked up listening to hear about how all of this actually works and I'm I am too. I'm I can't wait to hear what you have to say. Yeah, absolutely. There's a lot of details and I'm happy to shed some light and help patients maybe feel more comfortable when they need to get radiation treatment. would be great. So could you tell me how does radiation fight cancer? Yeah, so radiation damages DNA, so that causes the cells in the body to stop dividing. So the radiation can do this a couple different ways. It can damage the DNA directly or it can also interact with the water molecules that are in the body. It creates free radicals and those can damage the DNA. Yeah, and it's also important as we go through and talk a little bit more about radiation therapy, that the radiation itself doesn't know what type of cell it's attacking. So it doesn't know whether it's a tumor cell or a normal tissue cell next to it. So that kind of goes into what we do here. that goes into why the treatment planning process is so intense, correct? One of the reasons why. So if how would you prefer to start talking about the treatment planning process or the different types of radiation? I think I can maybe do a little bit of both all at once. Perfect. I know that I know that patients sometimes get very frustrated with how long the treatment planning takes, but I think they'll walk away from this show with a very good understanding of why you are being so careful. So Yeah, exactly. Yeah, I can get of sort of what the treatment planning process looks like and exactly help shed some light of why it takes so long sometimes. So yeah, for a typical treatment plan, so this is anybody that needs an external beam radiation therapy, which is our bread and butter, that's the bulk of the treatments that we do here. So all of our patients will start with a CT scan. and then we have our own CT scanner and radiation oncology. So the patients just come right in and our wonderful radiation therapists will help set them up and take that CT scan. And then we use that image to create contours. So this is something that the radiation oncologist, and then there's another kind of hidden specialty in radiation oncology called the dosimetrist. conjunction with the radiation oncologist. So the physician and dosimetrist work together to add contours onto the CT scan. So basically they're outlining the targets and the organs at risk, so the normal tissue that's nearby the targets. Just saying this is where the specific structures are so the computer knows. computer knows which parts of the image belong to which body part. Because otherwise it does not know. So, go ahead. No, go ahead, please continue. Yeah, so for example, if we have a patient with a tumor in their lung, the physician's part will be to contour the tumor and we usually create a little bit of a margin around it for treatment to account for any sort of setup differences or breathing, any kind of motion or possibility for motion. And then the dosimetrist would take that and contour things like... the normal lungs, the heart, the ribs, anything that's sort of around that tumor that the radiation beams may pass through on their way to get to where we're trying to target. So after all that's done, then they can actually start the treatment planning part. So that's where the dosimetrist really has time to shine. So they pull the CT scan with the contours on it. into our treatment planning software. And the radiation oncologist sets up prescription of radiation. So just like any other doctor will prescribe medication, that's sort of the radiation oncologist's job here. So they'll set a certain amount of radiation dose for a certain number of days, and that will reach our target prescription dose. So an example of that is we'll have two gray and that's the unit that dose is prescribed in gray. So two gray times 30 fractions. So that's the number of treatments. And that would be a total of 60 gray at the end that would be given. So these prescriptions are usually based on data from clinical trials. So there are constraints that we're tracking for the organs at risk that are contoured and we're balancing those constraints. with covering the target with the prescription dose as the physician specified. So the treatment planning computer takes the inputs as a dosimitris puts them in, and it will optimize for the best trade-off of limiting the organs at risk, dose to the organs at risk, while trying to get our best coverage of the target. So it's a huge optimization problem. And... problem and typically you'll have some organs that risk right next to you or even maybe slightly over-testing with the target so that's kind of where the art of this comes in. choices, there's different ways to tackle the same problems. And so the treatment planning part is sort of the art and science mixed together. science mixed together. I think a lot of medicine is like that. It's art and science mixed together. So the approaches that you choose to use, may they vary based on what else the patient has going on, such as maybe their weight, their general health. things like along those lines. Yeah, so the differences in how the treatment planning is approached typically is more about what type of cancer or type of lesion we're trying to target. So more of a pathological dependency, I would say. And then also sometimes we do see an increase in patients that are coming back for a recurring treatment. So they may have had. prior radiation to a site that's nearby. And so that can inform the choices that we make for this new course of treatment. course of treatment. So what are the different types of radiation treatment, Abby? I know that there's a lot of different types, and how are they used? So what are the different types of radiation treatment, Abby? Yeah, yeah. So kind of the planning process that I ran through before is for external beam radiation therapy. So the radiation is coming from the outside of the patient's body. And I work a lot with sort of the alternative type of therapy called brachytherapy, where we deliver the radiation from the inside of the body. And so for those treatments, and those treatment types, we usually complete the treatment planning and delivery process within a couple of hours, a few hours. So those happen very quickly in contrast to an external beam treatment plan that can, for all the steps, and there's more steps to the process even after the treatment plan is done to make sure everything's safe. That can take about two weeks or so. weeks or so. For the brachytherapy treatments, like I said, those are done in just a couple to a few hours. Typically, a little bit more resource involved. meaning the patients can go under anesthesia. So these types of cases are things like inserting radioactive seeds into the prostate. I know that's something that a lot of people have heard about, and I think that's maybe commonly associated with patients getting radiation. radiation. That may be sort of what people are thinking about. So we do still do these types of cases and those are ultrasound guided and we do the treatment planning process in real time with the patient in the operating room because once we insert the radioactive seeds, they stay where they're placed and that's how they deliver the radiation as prescribed. prescribed. more rapid with the planning because you're watching where the seeds are going and you're not maybe so worried about how the beams are hitting the organs around. So that makes sense as to why that's so much more quick if I'm not misrepresenting it. What is stereotactic ablative Yeah, so, um, SABR or SBRT, um, is a type of treatment, um, that we use, it can be done over many different parts of the body. Um, but typically for the patient, that means that you're going to be coming for a shorter amount of fractions. So typically by definition, it's five fractions or five treatments or less. Um, and it'll be a little bit of a higher dose per fraction. Mm hmm. said before a conventional fractionation is two gray per day. Something like SBRT may be closer to eight gray or 10 gray per day, but in shorter number of fractions. Yeah. Yeah, so that's the ablative. No, no, that's the ablative part of it is that it's a higher dose per day. So why would someone choose, why would you and a radiation oncologist, actually a radiation oncologist who's deciding the treatment plan, why would they go with two grays versus a grays? What's the difference? And what's the advantage for you, whatever there be that type of radiation is being used for? Yeah, so there's a lot of different things that kind of go into that. I would say in order to be a candidate for using SBRT with a higher dose per fraction, typically those targets are smaller in volume, they're probably a little bit further away from any organs at risk, and they're very localized. So there's no spread of disease or anything like that. that we're targeting a smaller area. And then with the two gray per day, that's more of a conventional fractionation. So the things that we are treating with SBRT now were treated with smaller fractions per day. But as clinical trial data came out, they've done studies on studies on the differences in the different vaccination schemes and determine the safety levels and the organ toxicity levels and things like that to ensure that it's safe to use in each case. That's interesting. So for you, what's the biggest change you have seen in radiation oncology treatment? So recently we've seen an uptick in online adaptive radiation therapy. And so there's a couple of different types of machines and different ways that can be achieved. One of them is an MR LINAC, so MR guidance in real time as you're training the patient. And the LINAC is our treatment machines, linear accelerator shortened as LINAC. So our regular treatment machines are called LINEX. Yes, and then this specialized one is coupled to an MRI as well. So you can actually watch the motion of the target and the motion of the OAR, the organs at risk that are inside the body as you're delivering treatment. You can adapt the plan, the treatment plan that you initially made from the original CT and the original MRI of the patient. you can adapt it to what their anatomy looks like that day while they're actually on the table for treatment. That's fascinating. And that makes perfect sense because if you were target area is changing because of the treatment, it's responding to the treatment, that is going to change how things look internally. And or if they're getting chemotherapy at the same time and say the tumor is shrinking or you're having... Go ahead. sorry. Yeah, not only that, even just normal biological changes. So when we're treating a prostate, for example, the bladder filling is going to look different every day. The rectal filling is going to look different every day. And so we can just adapt for those changes instead of kind of more just shifting the patient, we can actually adapt what the treatment beams are doing. beings are doing. Wow. That's fascinating that you're doing the MRI and the radiation therapy at the same time and seeing everything in real time. That's got to be pretty incredible for you and other people that you work with. Yes, it is very exciting. Yeah, I've worked with a couple of different machines and different types of things that do this. But yeah, I think that's going to be emerging. And right now they're just kind of trying to optimize the workflow to make it so that the timeline of one of these adapted treatments can be closer to the timeframe of one of our treatments that we give every day. every day. Right. So that's sort of where the work is focused. Okay. So what do you think are some of the biggest misconceptions that people have about being treated with radiation? Um, well, I would say a lot of the brachytherapy patients I work with always ask me if they're going to glow in the dark afterwards. So I think some of them, yeah, I think sometimes they're half joking, sometimes they're half serious, but I'd like to clear that up now. You're not going to glow in the dark. would be concerning to know that you have the beads, the radioactive beads in you, and that's a legitimate question. So why, I think you kind of went into this, but maybe you can expand a little bit more. Why are some treatments, say once a week, and other treatments are five days a week? Yeah, so similarly to how we got the data from for the different doses per day from clinical trials, there's also been clinical trials and research done on differences in treatment patterns and how often you give treatments and even twice a day or every other day is a very common fractionation, especially for the SBRT higher dose per day treatments. But but they basically boil down to radiobiological effects due to the time it takes the cells in the body to go through the cell cycle and go through the repair process so they're that's sort of what's governing the differences and why there would be differences in delivering dose one way or the other. be differences in delivering those one way or the other. So I would imagine you have kind of like a sweet spot, so to speak, in terms of the cell repair process where you don't want the cancer cells to repair too much and you want to start another treatment. Am I kind of right about that? Yes, exactly, exactly. And that's also why it's important to, if you're a patient and you're going through radiation, to try your very best to stick to the schedule that you're prescribed and try not to miss any of the treatments as they're laid out. All this data that we have is based off of, you know, certain treatment times and we're trying to replicate those as much as possible so that we... have a better understanding of what we're looking at as far as probabilities of control and toxicities and all that. So what you're saying is that sticking as much as you can to the actual treatment plan gives you an optimal treatment, a more optimal treatment, a chance for it to work better. Yes. Yeah. Okay. So what can someone do to help themselves stick to the treatment plan? I know a lot of times they get interrupted because of symptoms. Sometimes it's things outside of their control maybe rides, but what are some things with all that put together that you think people can put to work for themselves to be able to stick to the plan? Yeah, so I would say the biggest thing is just follow the instructions that you're given. And that encompasses that showing up every day, but it's even more than that. And make sure to ask questions if you don't understand something. It's perfectly okay. It's encouraged. Don't just act like you understand. Yeah, and you know, it's always okay to call and ask later. I know it's sometimes a lot to get all this information all at once. So So for example, instructions, some of our pelvis patients, we ask them to come for their initial CT and for their treatments with a full bladder and an empty rectum. And so we kind of coach on making sure the patient has a bowel movement in the morning and then show up early for your treatment and drink a cup of water in the waiting room or something like that. But doing the same thing every day is going to lead to a more reproducible setup. reproducible setup. And that's ultimately what we're trying to do is reproduce the setup that we had at the time. because that's what was used to put together the treatment plan. we use to put together the treatment plan. That's good to know. What about symptom management as far as being able to stick with your treatment plan, such as if you start having diarrhea, come on, what should you do? Yeah, so you're not just turned loose once you start treatment. So every single week, you'll have what's called an on treatment visit, an OTB. So the nurses, the physician will be asking you these questions about side effects. But at any time, we have patients that speak up and say something to the radiation therapists. And those are... the people that set up the patients for treatment every day and deliver their treatments. So those are the people that the patients see the most often. But anytime a patient will mention I'm feeling the side effects, we immediately will notify the nursing team and the physician because they are equipped to deal with all of that. And there are certain side effects that they know based off of the treatment plan and the location. are certain side effects that they know based off of the treatment plan and the location are more likely or less likely and kind of what all that is. So journaling actually can be really helpful if someone is having side effects to write them down and then that reminds them to report them every day. So it sounds like it's really important for them to communicate with their therapist. and or their nurse every day as to what is if they are having symptoms what is happening even though they've been told to expect it talk about it. Yeah, absolutely. Communication is key. We always hear that, but yeah, that's going to make sure that the patient is set up for the most success in their treatment. And we don't want discomfort or any sort of adverse side effects that could have been prevented or could be helped to deter a patient from coming back for the rest of their treatments. treatment. And so yeah, just keeping with the communications. You never know what kind of solutions the nurses and the doctors... And I guarantee you're not the first patient to have that side effect. So yeah, there's nothing to be scared about. nothing to be scared about. So as far as rides go, that can sometimes get in the way too of people getting treatment. And so your Cancer Institute, our listeners, they may have a ride program, your church may have a ride program, your synagogue, the American Cancer Society has volunteers that can ride, give rides. Also, you may have local cancer support organizations. And if you can work on your treatment schedule ahead of time and let people know ahead of time, you have these needs, neighbors, friends, relatives. There might be a lot of people that can really pitch in to get you there because it is important that you get there on a regular schedule as was given to you so that you do have an optimal treatment and have a better chance of it working as well as it's supposed to. Yeah, exactly. And I know part of our team is able to set up lift rides for patients as well. I think that's one of the newer features. So yeah, even if you don't know personally know somebody that can get you there, there's always a way. As you said, using those resources is very important. is very important. That's great to know that where you work, they can do lifts. That's wonderful. So what do you find most rewarding about your job, Abby? There's so much to choose from. It's very hard. Well, that's okay. That's okay because I think if people understand what you find rewarding, it's going to help them feel more comfortable about coming there for treatment and understand kind of what they actually will get out of it if they understand the reward that you have. Yes, absolutely. So like I touched on earlier, I really enjoy getting to work with the patients for brachytherapy treatments. There aren't a lot of physicists that have patient facing roles. So I feel lucky that I do get to step out of my office and step out from behind the computer and kind of put all the paperwork into perspective and work hands-on with our patients. And then something else that's sort of outside of the clinic as I have a role in our residency program. So it's very rewarding to have a hand in the clinical training of sort of the next round of physicists and see where they go after their training's done. they go after their treatment. That's awesome. So what do you see on the horizon for treatment? Yeah, so I think probably more advancements in the online adaptive radiation therapy that I touched on a little bit. I just see sort of closing the gap of the treatment time and the time that it takes and kind of getting one of those adapted treatment plans done in the same amount of time as one of our treatment plans now. So yeah, I think that's really exciting. And it's, the technology moves so fast in this field. So it's always exciting to see, what the next big thing is gonna be. Great. It seems like in some ways that radiation oncology can be used to do maybe what surgery was used for several years ago in a more higher risk patient. What's your what's your thought on that? Yeah, I think there are certain types of treatments that we do now that are still that way. Mainly some of the more ablative treatments, like you said, that may have been surgical in the past or may even still be surgical in some patients. There are many comorbidities that can make a patient not a candidate for surgery, but make them, you know, far less of those types of things roll out a patient for radiation. And so sort of in those instances, radiation may be a better alternative to not being able to get surgery at all. may be a better alternative to not being able to get surgery at all. Absolutely. So if someone is scared of having radiation therapy, what would you like to share with them? I hope that at least just explaining the process and sort of having a little bit more of an expectation going in helps ease a little bit of the nerves. I know doing something new is always nerve-racking. It's hard to know what to expect. But I would say that we typically have patients coming out that are just so grateful for the team of people that's behind them and everybody that's working together all for one purpose and that is for that patient. And so I guess from my perspective, I want patients to know that you have a nerd on your team. We may be behind the scenes, but hopefully that's though. Uh-huh. That's, that's, I love that you have a nerd on your team, but I think it's great. The more nerds you have, the better. Um, because you really enjoy what you're doing and you're really interested in it. Um, so I, what I find in radiation oncology departments across the board is that the staff, the team members that are there are extremely friendly and, um, They it's in a quiet part of the hospital to require a part of the health care system because it has to be kind of quadrant off from everywhere else. And I find that quiet, peaceful. I have yet to walk into a radiation oncology treatment waiting room that isn't friendly. I have found all of them across the board to just be really nice places and welcoming places to be, which surprised me. Yeah, yeah, we have, I mean, just a wonderful team from the people that work at the front desk all the way through, even the people that work behind the scenes. But yes, it is sometimes surprising to me how positive our patients can be and how uplifting they are, even when some of them are going through the hardest things they've ever had to go through. And truly the patients. help make us more happy and more positive. It's kind of a cycle and just the fact it always surprises me when one of our patients brings in cookies or something. Just the fact that they're going through their treatments, they're going through everything else and they took time out of their day to go grab us cookies and treats, you know, to show their appreciation for. and they took time out of their day to go grab us cookies and treats you know to show their appreciation for what our team does for them. I just it blows me away every single time. Wow that's yes there I have found um cancer patients to be some of the most generous people around um what The other thing I find interesting or the number of team people that you have involved, you have nurses, you have, as you mentioned, front desk people that do a lot with the coordination of care and coordination of all the information that needs to happen. You have the therapists that work very closely with the patients in the treatment area. You have yourself the medical physicist, you have the dosimetrist, and you have the radiation oncology doctor. Did I miss anybody? I believe that's everything. Our janitorial crew. Well, they're important too, because it needs to be clean. It needs to feel good. But that's six different team members for one patient. And I find that amazing. And it kind of goes to show how complex the treatment is and how important it is to make sure all the different boxes for that person when they walk in are checked for. And I don't mean to make it sound task oriented. It's not. But they, everybody has an important... role with that patient. And there's a lot that goes into this in that everybody's role is very integral to making sure that things go smoothly for everyone. And I have found that your teams typically work together very well. Yes, we have a pretty smooth handoff and a nice workflow setup. I don't even think I actually talked about what I do in the workflow. Please, that would be great. We would love to hear exactly what you do in the workflow. Yeah, so I guess I can kind of go back to the treatment planning process and sort of what happens after the treatment plan is put together. So that's really when I step into the workflow. So when the physician approves the treatment plan, then it comes to the physicist for a second check. And so that's when we get to scrutinize all the details of the plan. and we make sure everything aligns with what the physician intends for the treatment. And then for a lot of our cases, as part of this second check, we run patient-specific quality assurance tests. So we use a measurement device and we run the patient's treatment plan as they approved it and we run it on the actual treatment machine. And we use this measurement device as if it were the patient. And we compare these measurements to the treatment plan that was calculated by the dosimitrists. So we're just making sure that that's going to be safe and delivered accurately by the treatment machine. And then after that, it goes, the plan goes through peer review or chart rounds. And so then another radiation oncologist separate from the treating radiation oncologist will lay eyes on the plan and we'll look at it and review it prior to delivery. delivery. And then the radiation therapist checks the plan. After all. So there's so many safety and quality assurance measures that are in place for each patient's treatment plan. And so that's why it takes so long. Outside of the specific patient's treatment plans, another part of the physicist's job is to run quality assurance tests on the treatment machines themselves. So when we have separate tests that we do separately... the patient's plans where we're making sure that the LINAC, the linear accelerator, is working as intended and within specifications to accurately deliver these treatments. as a pendant and within specification to accurately deliver these treatments. Wow. So when someone's treatment is, when they first come in and the diagnostic imaging is looked at and they see the radiation oncologist, the radiation oncologist will then work with you treatment plan and it sounds like primarily they'll work with a dosimetrist to avoid the organs and the radiation oncologist works to make sure the tumor itself cancer is getting targeted. And then you review the quality of the planet sounds like And then another radiation oncologist reviews the quality that the targeted the plan itself between targeting the tumor, the tumor type and the organ. So you wanna make sure you're using the right kind of radiation treatment for the tumor type, right? Whether it's five days a week, number of grays, what is considered to be most in line with standard of care. So all of you. coordinate on that and then you also make sure that the equipment itself is working correctly. You run, oh, and also you do what's a model of the patient and make sure that is delivered correctly according to the plan that the radiation oncologist and the dosimetrist put together, right? Okay. So you have like a model there that you use for the patient and you make sure that what you planned is actually going to happen. Yeah. I I did not know that happened. That's really fascinating. And then you test the equipment in the radiation oncology treatment area to make sure that it's doing what you're telling it to do. So if you're telling it to deliver two grays to simplify the explanation to a specific area, it actually delivers two grays to a specific area. Yes, exactly. Wow. Wow. That, I mean, that's, that is a lot of checks and balances. So someone may not realize when they're in the treatment area and they wear the, and maybe you can go a little bit into this, the netting or the mask that's made for them to make sure that they, or the cast made for their body to make sure that everything is being held where the treatment plan and, and Mark the treatment plan is supposed to be delivered. All that planning went into it between two radiation oncologists, a dosimetrist, a medical physicist, and a radiation oncology therapist. Yes. That's a lot of people touching one plant and that's great to hear. That really, that's fascinating. So tell me a little bit about the masks, like everything a lot of people hear about, I had to wear this mask, or I had to wear a cast over my arm and shoulder, or they get tattoos. Can you share a little bit of that with us? Yeah, absolutely. So we call sort of the broad classification of those things immobilization devices. So the body's always trying to move internally, externally. We're always trying to get comfortable. And we want our patients to be comfortable, but like I said before, we want a reproducible setup. So that's sort of the purpose of any of these devices is just to be able to reproduce. how the patient was set up at the time of the CT scan on the treatment table to be able to deliver the treatment as they were planned. So yeah, the masks, there's a couple of different types of masks, but those are typically reserved for head and neck or brain treatments. So sort of anything that's in that area. And yeah, those are typically like what you would see if you see a radiation treatment on TV or something like that. I feel like they usually show. huh. mask there. Yeah, there may be an extremities mask, like if you're getting an arm or a foot or anything like that treated, because those are sort of things that are hard to immobilize because they're so kind of freely moving. Some other things that we have are breastboards. It's just an inclined board that you kind of lay back on and it sort of just helps. helps the breast tissue fall in the same way, just using the effects of gravity for the most part. But like you said, you may also use netting. There's special different types of rods that people have developed for cancer treatments, the radiation treatments. So there's a lot of different. choices and options and of all these things. You can also, we can also ask the patient to hold their breath. breath for their CC scan and may even use that for the treatments as well. So for things like a lung tumor that's close to the diaphragm, that's going to have a lot of respiratory motion. And so it's a limit to try to limit that. we may have the patient hold their breath or we may use a compression device that sort of pushes down on the patient's belly and kind of it's called forced shallow breathing. So. Just kind of doesn't let you take a deep breath in and so it limits that respiratory motion. So there's a lot of different things like that. And then as far as the tattoos, some... clinics do give tattoos. And so that is for localization of the patient. So typically if you get tattoos, you'll get them in three spots. So one on each side and one on your front. front. So, And that will be, there are lasers in the CT sim room, and there are lasers in the treatment vault where the linear accelerator is. And so they can use the lasers, the combination of the lasers and markings on either the patient's skin or on the immobilization devices themselves to aid in reproducibly setting up the patients. But something that's exciting that I... didn't touch on earlier is the is a surface guided radiation therapy. So this is something that we use at my clinic and it's a very helpful so we don't have we don't give tattoos at my clinic we don't we don't need them so we use surface guidance so basically you have an unlimited amount of points over the patient's body so it uses three cameras and it and it's projects a speckled pattern onto the patient's skin. Yeah, and it knows what the pattern is. So the camera knows what it's looking for to be able to recreate the shape of that speckled pattern. So however it distorts that pattern, it can use that to recreate the surface. And we compare the patient's surface to their external surface from their CT scan that we use to make the treatment plan. plan. And so that gives you a lot more information for a breast patient. Sometimes we find that we take an image of the patients before we treat them, while they're on the treatment couch. to make sure they're in the right spot. And we move the couch a little bit to shift them closer to where the treatment plan was. And so sometimes we find for breast treatments a change in the arm positioning. positioning actually greatly affects where the breast will fall. And so with the surface guidance system, we could see that very easily to make that change prior to any imaging. Whereas if we didn't have the surface guidance, we may need to take a couple of images or kind of figure out, oh, hey, it actually looks like the arm is maybe in a slightly different spot. So we just have a lot more information to work with from the very beginning. And so our radiation therapists love it. those may be in a slightly different spot. So we just have a lot more information to work with from the very beginning and so it's our radiation therapists love it. Yeah, I could see why. Yep, so it gets them back into the position that they were in and it takes away any guesswork that might have been there before. That sounds amazing. And the other One of the comments that I heard from a patient's spouse is that radiation therapists make sure the patients are comfortable, which you have touched upon too. So they need to lay still while the treatment's being given to make sure that the beams are hitting where they're supposed to be hitting, but you want that person to be comfortable. So the radiation therapists, it sounds like work intensively with them to make sure that they are comfortable for that time. Could you explain that a little bit? Yeah, so I guess the most important time to speak up if you're not comfortable would be at the CT sim. Because kind of once the CT simulation is done, you're kind of locked in more or less. There are a couple of things, you know, we can maybe add another pillow or something behind the head. But yeah, so I do see the therapist sort of asking many, many times and kind of reinforcing that idea. They do explain at the initial CT scan, this is why I'm asking. We just want to make sure that you're comfortable because that goes into the reproducibility. If you're not comfortable, you're not going to be able to lay still for a long, long period of time. And so some of the treatments, depending on how large the fraction, the fractionation is, how large the dose we're getting is, the treatment time can be pretty long. And so yeah, we want to make sure as much as possible that the patients are comfortable and we want to make sure as much as possible. These patients are comfortable. We have things like knee sponges, you know, if you're just laying on your back, having something under your knees make you a lot more comfortable. Right. Absolutely. It takes a lot of pressure off your back. So the knee sponges aren't to scrub the knee, they're actually to position the knee. That so everybody that's listening, it is really, really important while your treatment is being planned, while the simulation is being done that you make sure you're comfortable with how you're positioned. And don't be afraid to communicate if you're not. Don't be afraid to speak up. That is something that will help you get a better treatment because you'll be able to lay there in your subsequent treatments outside the planning process for the time that you need to. Yes, absolutely, absolutely. And I also wanna say that for some types of treatments, it's common to do a replan, maybe about halfway through. So if that does happen, there's nothing to be alarmed about. That can be common and that can be a sign that of many different things, sometimes weight loss. different things, sometimes weight loss. Yes. You have a mask on and you end up losing some weight, then your mask doesn't fit as well and it's not really immobilizing, you know, to the extent that we realize. And so something like that would prompt just a replant. So it's all going into making sure someone's getting the best care that they can, it sounds like. So Abby, is there anything that we haven't covered that you would like to go over today? I wanted to say that there are more of us. So there are more medical physicists than just in radiation oncology. So I don't know if you knew that. So there are diagnostic medical physicists also. So they primarily work more on the radiology side. They take care of the imaging machines. So the fluoroscopy machines, mammography machines, they're doing the quality assurance on those types of machines throughout the hospitals. There's also nuclear medicine medical physicists that may work on PET scanners and spec scanners and sort of anything else that's in the nuclear medicine department. And then we have health physicists who are also kind of an offshoot slash a near cousin to a medical physicist. And they take care of all the radiation safety in the hospital. So they may do the shipping and receiving of radioactive material to the hospital and and making sure we're compliant with government regulations about radiation and all of that. So just wanted to put a plug in for my comrades. are found behind the scenes kind of throughout everything. I think that's fascinating to know. I didn't know that. And so that is fascinating to know. And that's also good to know that all those safety checks are being put into place across the board for all of us who are getting CT scans done, MRIs done, that things are being we're ensuring that things are being handled well in whenever they're received in the because it could be disastrous if they're not. So that's all wonderful. And I had, that's a great surprise. I did not know that. Is there anything else you'd like to share? I'd like to give a little plug if anybody's interested in going into medical physics. That's all right. So as you said in the very beginning, I have a background in nuclear engineering for my undergrad. A lot of medical physicists have a background in physics. There's kind of all different gamut of STEM backgrounds. And there are a ton of different pathways into the field, some of which are you know, having a certificate if you pursue a PhD in a different STEM related field. You can still pursue medical physics if that's something you're interested in. But I would encourage anybody who's interested to try to set up a shadowing opportunity at a nearby institution or hospital with a medical physicist there. Plenty of us, I have people shadow me all the time. And it's a great opportunity to just actually see what a physicist does. And then if it's something that you do want to go into, I will look at the CAMPF website. So, CAMPEP, that's the accreditation body for medical physics. And that's sort of the pathway you have to go to become board certified by the American Board of Radiology. And then I'm also happy to answer any questions at any time. So, anybody is free to reach out to me directly. And I'm happy to mentor. Yeah. Okay, great. I will have your contact information. And also, there'll be a chat on the Patreon for everything cancer. And if anybody has any questions, you're welcome to put them there too. And Abby, I so, so appreciate your time. This has been fascinating and eye opening. And I hope that it helps people understand better what all goes in Everybody wants to make sure they get the right treatment plan, the right dose, and the right area. And a lot of eyes have to look at it to ensure that. And also just the complexity of the team giving the care and they're very caring people. But I so appreciate your time, your insight, your input. And thank you for being here with us at Everything Cancer. Absolutely. Thank you so much for having me. I had a blast and really appreciate it. appreciate it. Great, all right. I'm gonna stop the, this, edit out.