The American College of Radiology, with more than 30,000 members, is the principal organization of radiologists, radiation oncologists,

and clinical medical

physicists in the United States. The College is a nonprofit professional society whose primary purposes are to advance the science of radiology, improve
radiologic services to the patient, study the socioeconomic aspects of the practice of radiology, and encourage continuing education for radiologists, radiation
oncologists, medical physicists, and persons practicing in allied professional fields.

The American College of Radiology will periodically define new practice parameters and technical standards for radiologic practice to help advance the
science of radiology and to improve the quality of service to patients throughout the United States. Existing practice parameters and technical standards will
be reviewed for revision or renewal, as appropriate, on their fifth anniversary or sooner, if indicated.

Each practice parameter and technical standard, representing a policy statement by the College, has undergone a thorough consensus process in which it has
been subjected to extensive review and approval. The practice parameters and technical standards recognize that the safe and effective use of diagnostic and
therapeutic radiology requires specific training, skills, and techniques, as described in each document. Reproduction or modification of the published practice
parameter and technical standard by those entities not providing these services is not authorized.

Revised 2020 (Resolution 52)*

ACR–AAPM TECHNICAL STANDARD FOR THE PERFORMANCE OF

RADIATION ONCOLOGY PHYSICS FOR EXTERNAL-BEAM THERAPY
PREAMBLE

This document is an educational tool designed to assist practitioners in providing appropriate radiologic care for
patients. Practice Parameters and Technical Standards are not inflexible rules or requirements of practice and are
not intended, nor should they be used, to establish a legal standard of care1. For these reasons and those set forth
below, the American College of Radiology and our collaborating medical specialty societies caution against the use
of these documents in litigation in which the clinical decisions of a practitioner are called into question.
The ultimate judgment regarding the propriety of any specific procedure or course of action must be made by the
practitioner in light of all the circumstances presented. Thus, an approach that differs from the guidance in this
document, standing alone, does not necessarily imply that the approach was below the standard of care. To the
contrary, a conscientious practitioner may responsibly adopt a course of action different from that set forth in this
document when, in the reasonable judgment of the practitioner, such course of action is indicated by the condition
of the patient, limitations of available resources, or advances in knowledge or technology subsequent to publication
of this document. However, a practitioner who employs an approach substantially different from the guidance in
this document is advised to document in the patient record information sufficient to explain the approach taken.
The practice of medicine involves not only the science, but also the art of dealing with the prevention, diagnosis,
alleviation, and treatment of disease. The variety and complexity of human conditions make it impossible to always
reach the most appropriate diagnosis or to predict with certainty a particular response to treatment. Therefore, it
should be recognized that adherence to the guidance in this document will not assure an accurate diagnosis or a
successful outcome. All that should be expected is that the practitioner will follow a reasonable course of action
based on current knowledge, available resources, and the needs of the patient to deliver effective and safe medical
care. The sole purpose of this document is to assist practitioners in achieving this objective.

1 Iowa Medical Society and Iowa Society of Anesthesiologists v. Iowa Board of Nursing 831 N.W.2d 826 (Iowa 2013) Iowa Supreme Court refuses to find
that the ACR Technical Standard for Management of the Use of Radiation in Fluoroscopic Procedures (Revised 2008) sets a national standard for who may
perform fluoroscopic procedures in light of the standard’s stated purpose that ACR standards are educational tools and not intended to establish a legal standard
of care. See also, Stanley v. McCarver, 63 P.3d 1076 (Ariz. App. 2003) where in a concurring opinion the Court stated that “published standards or guidelines
of specialty medical organizations are useful in determining the duty owed or the standard of care applicable in a given situation” even though ACR standards
themselves do not establish the standard of care.

TECHNICAL STANDARD 1 External Beam Therapy

I. INTRODUCTION

This technical standard was revised collaboratively by the American College of Radiology (ACR) and the American
Association of Physicists in Medicine (AAPM).

The success of treatment in radiation oncology depends on several factors, including delivery accuracy of
absorbed doses to selected targets in both tumors and normal tissues. Because the practice of radiation oncology
physics occurs in a variety of settings, the judgment of the Qualified Medical Physicist should be used to apply
these standards to individual practices.

II. QUALIFICATIONS OF PERSONNEL

A. Qualified Medical Physicist

A Qualified Medical Physicist is an individual who is competent to practice independently one or more of the
subfields in medical physics. The American College of Radiology (ACR) considers certification, continuing
education, and experience in the appropriate subfield(s) to demonstrate that an individual is competent to practice
one or more of the subfields in medical physics and to be a Qualified Medical Physicist. The ACR strongly
recommends that the individual be certified in the appropriate subfields by the American Board of Radiology
(ABR), the Canadian College of Physics in Medicine, or by the American Board of Medical Physics (ABMP).

A Qualified Medical Physicist should meet the ACR Practice Guideline for Continuing Medical Education (CME).
(ACR Resolution 17, 1996 – revised in 2012, Resolution 42) [1]

The appropriate subfield of medical physics for this standard is Therapeutic Medical Physics (including medical
physics certification categories of Radiological Physics, Therapeutic Radiological Physics, and Radiation Oncology
Physics).

In addition, the Qualified Medical Physicist must meet any qualifications imposed by the state and/or local radiation
control agency to practice radiation oncology physics and/or to provide oversight of the establishment and conduct
of the physics quality management program.

In addition to the language above, this technical standard pertains to 1) therapeutic applications of x-rays, gamma
rays, and electrons; 2) the equipment associated with their production, use, measurement, and evaluation; 3) the
quality of information and images resulting from their productions and use; and 4) the associated patient and
personnel radiation safety issues.

In addition, a Qualified Medical Physicist must hold a professional medical physics license where required and
should uphold the AAPM Code of Ethics (AAPM Professional Policy 24-D) [2].

For further information on credentialing, accountability, authority, and professional development, see the ACR’s
Guide to Professional Practice of Clinical Medical Physics [3].

III. RESPONSIBILITIES OF PERSONNEL

A. Responsibilities

Qualified Medical Physicists are engaged in the design, optimization, technical evaluation, and delivery of
radiotherapy treatment plans. Qualified Medical Physicists are the only individuals qualified to perform and oversee
the calibration of therapeutic radiation delivery systems (eg, linear accelerators). They are also responsible for
radiation protection of patients and staff. Their role may include clinical, research, educational, and administrative
duties. The responsibilities of the Qualified Medical Physicist must be recognized and supported by the medical
director and as per AAPM Professional Policy 17 [4].

The Qualified Medical Physicist must participate in the specification, selection, acceptance, and commissioning of
radiation-producing machines, accessories, and computerized treatment-planning systems. The Qualified Medical
TECHNICAL STANDARD 2 External Beam Therapy
Physicist should also supervise arrangements for proper maintenance of this equipment and work with the
manufacturer/agent to facilitate repairs. After repair, if necessary, the Qualified Medical Physicist will supervise
any required tests after the repair of the equipment to ensure the proper performance of the treatment unit. The
Qualified Medical Physicist will periodically evaluate all systems for continued utility, appropriateness, reliable
performance, and condition and will make recommendations on a practical life span, obsolescence, and
replacement.

B. Personnel Requirements

A Qualified Medical Physicist must be available for each institution that uses therapeutic equipment. The Qualified
Medical Physicist is typically on site when treatments are delivered and must be physically present for special
external beam techniques. For further guidance, see the Radiation Oncology Practice Accreditation program
requirements [5]. The number of Qualified Medical Physicists and support personnel must be appropriate for the
types, levels of complexity, and volume of the external-beam services offered [6]. External-beam physics services
generally include calibration of the radiation beams, safe and appropriate operation of the treatment units,
continuing quality assurance, and medical physics support (dosimetry, special physics consults etc) for the radiation
oncologist when needed. This clinical support includes patient-specific dose measurements (if requested),
monitoring of the custom block fabrication process or appropriate use of multileaf collimation (MLC), and
responsibility for the technical accuracy of the computerized treatment plans, including patient data acquisition.
Special external-beam treatment techniques require additional physics support at a level higher than that required
for routine external-beam therapy.

Staffing requirements are required to provide services outside the scope of this standard, including brachytherapy,
radiation safety, research, administration, and education and training programs [1,7]. Trainees with medical physics
responsibilities must be supervised and their work reviewed by a Qualified Medical Physicist or their designee [7,8].

Commissioning of modern therapy systems is a critically important, time-consuming process. The technological
complexity of modern systems requires a well-designed and carefully implemented series of steps for data
collection, analysis, computer modeling, and validation on the specific system as installed. The Qualified Medical
Physicist must determine the scope of work to be performed consistent with the clinical scope of service in the
practice and the appropriate timeline for the work to ensure that all quality and safety aspects are afforded sufficient
focus. In the event that the commissioning is performed by a physicist or physics group other than the institution
medical physics staff, the institution’s or on-site Qualified Medical Physicist must review the final results of the
commissioning process and ensure they are in line with published commissioning standards. It is the responsibility
of the institution’s or on-site physicist to complete a subset of test to independently validate the results presented in
the report. The Qualified Medical Physicist determines when the therapy system can commence clinical use and
communicates to all clinical and administrative groups any possible limitations on the scope of use.

Physics support staff should be appropriately trained. Medical dosimetrists should be certified by the Medical
Dosimetry Certification Board. In clinics where it is not always possible to have only certified dosimetrists, a
Qualified Medical Physicist should provide appropriate supervision of uncertified dosimetrists. In-house therapy
equipment service engineers and third-party service organizations should participate in the manufacturer’s training
program. Radiation therapists should either be certified in radiation therapy by the American Registry of Radiologic
Technologists (ARRT) or be eligible for such certification.

Prior to the introduction of new treatment modalities, the systems administrator and the medical director should
consult the Qualified Medical Physicist so that adjustments to staffing can be made for specialized procedures.
Additionally, all staff who participate in the new treatment modality process, including physicians, dosimetrist,
therapists, and physicists, should receive training/in-service prior to and at first use (proctoring) of clinical initiation.
Documentation of this training is required. Issues related to several complex treatment techniques are dealt with in
other technical standards and practice parameters [9-12].

IV. EQUIPMENT

The Qualified Medical Physicist must determine the need for, specify the requirements of, and have access to
dosimetric and treatment-planning equipment including, but not limited to, the following:
TECHNICAL STANDARD 3 External Beam Therapy
 1. Measurement instruments to calibrate all treatment equipment that includes, but is not limited to, the
following:
• Ionization chambers/electrometers used as local standards and/or used as field instruments.
• Constancy check instruments, water-equivalent dosimetric phantoms, and other appropriate dosimetry
equipment.
2. Computerized water-scanning systems with appropriate ionization chambers, diodes, and other measuring
tools
3. Dosimetry quality assurance (QA) hardware and software, such as film densitometry systems or detector
array systems
4. In vivo patient dose–measuring systems (eg, diodes, metal oxide silicon field effect transistors (MOSFET),
thermoluminescence dosimeters (TLDs), or optically stimulated luminescence (OSL) dosimeters
5. Radiation protection measurement devices, such as appropriate survey meters and area monitors
6. Appropriate QA test tools for radiation therapy equipment, such as mechanical alignment tools,
thermometers, and barometers
7. Imaging equipment QA tools [13,14]
8. Equipment to support special external-beam techniques (such as those listed in Section III.B)
9. Any additional equipment as needed to ensure that integration between devices is acceptable (ie, motion
phantom for gated lung stereotactic body radiotherapy (SBRT)).

V. QUALITY MANAGEMENT PROGRAM

A. Introduction

Quality management (QM) in radiation oncology may be defined as those procedures that ensure a consistent and
safe fulfillment of the dose prescription. The Qualified Medical Physicist is responsible for designing and
implementing those aspects of the QM program that involve the use of the external-beam radiotherapy equipment.
The Qualified Medical Physicist is also responsible for reviewing and approving the procedures followed by the
radiation therapy and dosimetry staff in planning and delivering the prescribed dose.

QM of radiation therapy equipment is primarily an ongoing evaluation of functional performance characteristics.

Accordingly, the Qualified Medical Physicist must develop, supervise, and implement effective hazard mitigation
methods that encompass the QA of radiation therapy equipment [15,16]. The policy and procedure review may
include the use of risk-based tools such as failure modes and effects analysis (FMEA) or a radiation oncology
incident learning system (RO-ILs) [17-20].

B. General Protocol Outline

The goal of the QM program for external-beam radiation therapy equipment is to ensure that the performance
characteristics defined by physical parameters and established during commissioning of the equipment remain
within acceptable limits. Policies and procedures must be established by the Qualified Medical Physicist to verify
that all equipment meets the manufacturer’s specifications and to establish baseline performance values for new or
refurbished equipment or for equipment following major repair. Once a baseline standard has been established, a
protocol for periodic QA tests may be developed for monitoring the baseline performance values. The protocol for
QA tests should recommend the equipment to be used, the frequency of measurement, techniques to be followed,
suggested performance criteria, action levels, and routes of notification. QA test procedures should be able to
measure parameter changes smaller than tolerance or action levels. The Qualified Medical Physicist should refer to
the current AAPM guidelines and documents to develop their QM program [21].

A written summary of physics activities, along with the results of the evaluation, should be documented and
presented to the medical director and senior institutional administrator annually. This written summary should be
incorporated into the institution’s overall QM program.

TECHNICAL STANDARD 4 External Beam Therapy

C. Specific Protocols

It is recommended that relevant AAPM Medical Physics Practice Guidelines, Task Group reports, and ACR–AAPM
technical standards be used to determine the types of testing and procedures that should accompany commissioning
and initialization of any new technique involved in the delivery of external-beam radiotherapy. Testing functionality
and compatibility integration of multiple vendor components into the external-beam delivery pathway should be
fully examined and tested prior to patient treatment.

1. Measurement equipment

A program must be in place to ensure the accuracy and precision of measurement equipment used for
calibration and constancy checks of treatment machines and instruments used for patient dosimetry. The
program must have documented procedures for instrument calibration to ensure traceability to accredited
calibration facilities and to affirm instrument precision and accuracy. Redundancy in dose calibration
equipment is recommended to ensure that instruments are holding their calibration. This can be achieved
by cross calibrations or the use of the appropriate long-lived radioactive source. It is recommended that
both a local standard and a field dosimetry system be maintained and routinely compared.

2. Treatment machines

Protocols for calibrating treatment machines must follow those protocols currently published by the AAPM
and adhere to state and federal guidelines.

After the treatment machine has been commissioned and prior to clinical use, an independent verification
of the output of each photon and electron beam must be performed to verify that the treatment unit
calibration is consistent with national standards. In subsequent years, there must be an independent check
of each photon beam annually and each electron beam biennially or more frequently per regulatory
requirements. The independent check must be performed by either:

a. A Qualified Medical Physicist who did not perform the commissioning/annual output calibration, using
a dosimetry system other than the one that was used during the commissioning/annual output calibration
(this dosimetry system must also have calibration factors traceable to an accredited dosimetry
calibration laboratory); or
b. An independent dosimetry service designed to measure doses within an uncertainty of 5%.

3. Radiotherapy simulators and imaging equipment

Procedures for establishing and maintaining the imaging equipment used in planning radiation therapy
treatment planning (eg, computed tomography (CT), magnetic resonance (MR), positron emission
tomography (PET), PET/CT scanners, and other radiography equipment) should be an integral part of a
QM program. The Qualified Medical Physicist must be aware of the factors that affect image quality as
well as the effect of image distortions on treatment planning. The medical physicist should ensure that those
elements of imaging equipment quality control directly relevant to radiation oncology planning are carried
out at an appropriate frequency and the measured CT dose index is within 20% of the displayed CT dose
index [22].

Every effort should be made to acquire patient data through digital imaging techniques. If deemed
appropriate by the radiation oncologist, manual techniques may be used. All data used in the dose-
distribution calculation and implementation process should be reviewed by a member of the physics staff
for appropriateness prior to its use in computation. The spatial linearity (in 3 dimensions) of CT or other
digital images used for planning should be verified by test imaging of appropriate phantoms having fixed
fiducials and/or known external dimensions.

4. External-beam dose distributions and associated coordinate systems

TECHNICAL STANDARD 5 External Beam Therapy

 Independent systems involved in the treatment simulation, planning, and delivery process may have
different image characteristics and coordinate systems. Faithful data transfer and coordinate translation
must be achieved, and this process must be routinely tested. One method to test the data chain is via an end-
to-end test, which may contain some or all of the following components:
a. Simulation, including CT scanning of a dosimetry phantom
b. Phantom image data transfer to the treatment-planning system
c. Creation of a treatment plan with variables such as independent jaws, wedging, blocking, noncoplanar
beams, or other techniques at the discretion of the medical physicist
d. Calculation, monitor unit verification, and transfer of the plan to the record-and-verify system or
treatment unit, in the custom of the clinic
e. Treatment of the dosimetry phantom with dosimeter(s) in place
f. Analysis of dose measured compared with that predicted by the planning system
g. In each of the imaging systems (simulation and planning), a check of spatial fidelity, Hounsfield unit
(HU) value, and beam geometry (size, source skin distance [SSD], etc) against nominal values
h. Should MRI-based imaging methods be used in the treatment planning dose calculation, commissioning
of the method into the external-beam treatment workflow should be documented and shown to have
equivalent accuracy to CT-based dose calculation.

Alternative methods of completely testing the image/data chain may be devised by the medical physicist.

5. Treatment-planning computer systems

The treatment-planning computer model must be verified using beam data measured under the supervision
of the Qualified Medical Physicist on the same treatment unit for which the model will be applied for patient
planning. Reference beam data provided by the manufacturer may be used if it is within acceptable
agreement with the measured dataset as determined by the Qualified Medical Physicist. Treatment-planning
computer systems must undergo rigorous acceptance tests and commissioning to ensure that the calculated
output satisfactorily agrees with measured beam data for a series of test cases and to ensure that the
hardware and software were installed properly. (See the ACR Practice Parameter for 3D External Beam
Radiation Planning and Conformal Therapy [23-25].)

All users must receive initial and annual documented training by the Qualified Medical Physicist or
manufacturer. In addition, documented training should be given to all new users. Software releases should
be reviewed and documented by impacted parties.

Treatment-planning systems must be tested to ensure that they meet the published specifications of the
system. All features of the system that are used in clinical practice must be tested. Both central-axis and
off-axis beam characteristics at specific points should be tested for various field sizes to confirm the spatial
accuracy of the dose display. Studies must be performed to test all types of external-beam planning used at
the site. The limitations/uncertainties of the dose-calculation algorithm(s) must be reviewed, documented,
and made available to all clinical personnel at the time of commissioning.
If the treatment-planning system is used to define beam apertures, then this function should be tested along
with margin tools used to define the planning target volume.

In many treatment-planning systems, the dose can be displayed in terms of absolute dose or relative dose.
The exact method of dose display must be consistent with the treatment-planning approach that is used
clinically. The user must confirm that the relative dose distribution is as described in the system manual.
The absolute dose calculation must be confirmed by measurements under normal conditions in radiation
fields of various sizes [26].

If dose-volume histograms are used in the analysis of the plan, their validity must be checked. Various dose
distributions can be calculated whose characteristics are known. The dose and volume results from the dose-
volume histogram can be checked against the known values.

Periodic tests (eg, standard plans) must be performed routinely and after any major service or software
change to ensure the accuracy of the monitor unit and/or dose-calculation algorithms, to ensure that any
TECHNICAL STANDARD 6 External Beam Therapy
 software changes or updates (including editing of beam data files) were implemented correctly and have
not corrupted the beam data, to ensure that any hardware changes were installed properly, and to verify that
the system performance is consistent with its initial commissioning.

6. End-to-end testing
It is recommended that end-to-end testing procedures be designed and implemented for the purpose of
systematic and random error reduction. The end-to-end test procedures should include use of phantoms.
These phantoms should enable a test of entire patient treatment procedures, including imaging, treatment
planning, plan export from the planning system to the treatment unit, and finally the treatment delivery. It
is recommended that these types of tests be performed annually and as part of the commissioning of new
treatment procedures [27].

7. Electrical, mechanical, and radiation safety

A documented program must be implemented to assess potential safety hazards and to check the integrity
of mechanical and electrical patient care devices. This program should include, but should not be limited
to, the following:
• Periodic inspections of patient dose-monitoring devices
• Treatment machines (including the proper operation of LINAC vault doors and interlock safety devices
such as door pressure sensors or motion detectors)
• Simulators (including the patient support assembly)
• Accessories to these machines, including MLC systems, treatment couches, imaging systems,
immobilization devices, and beam attenuators [28]
• Use of emergency procedures for machine shutdown by the staff

The radiation protection program must be designed to cover all treatment and imaging equipment and be consistent
with state and federal regulations.

VI. CLINICAL PRACTICE

A. Availability

A Qualified Medical Physicist must be available for continuing medical physics consultation for patients and for
consultation with the radiation oncologist and to provide advice or direction to staff.

The Qualified Medical Physicist should be present to review and/or supervise complicated simulations as well as
treatment setups and to communicate specific requirements directly.

It is preferable to have a Qualified Medical Physicist on-site and available on a daily basis. Practices without a full-
time Qualified Medical Physicist must have regular on-site physics support to meet the clinical activity needs of the
practice and be at the level of industry safety standards for staffing [5,29]. The requirements for full-time equivalent
coverage may increase with the complexity of the practice. In addition, state or local regulatory requirements must
be met.

Procedures must be established to meet clinic needs for periods when a Qualified Medical Physicist is not
immediately available on-site, including standard procedures and covering physicists. The Qualified Medical
Physicist must review, as soon as possible, all dosimetric and physics activities that occurred during their absence.
Authority to perform specific clinical medical physics duties must be delegated by the Qualified Medical
Physicist to each member of the physics staff in accordance with their training and competence. The radiation
oncologist must be informed of the clinical activities authorized for each member and/or the locum tenens
Qualified Medical Physicist.

B. Supervision

1. For clinical activities requiring supervision by a Qualified Medical Physicist, the various levels of
supervision are described below. Each level of supervision is defined in AAPM Professional Policy 18-B:
TECHNICAL STANDARD 7 External Beam Therapy
 a. General — The procedure is performed under a Qualified Medical Physicist’s overall direction and
control. The Qualified Medical Physicist’s presence is not required during the performance of the
procedure, but they must be available by phone to provide assistance and direction if needed. Under
General Supervision, the training of the personnel who actually perform the procedure and the
maintenance of the necessary equipment and supplies is the responsibility of the Qualified Medical
Physicist.
b. Direct — A Qualified Medical Physicist must exercise General Supervision and be present in the
facility and immediately available to furnish assistance and direction throughout the performance of
the procedure. Direct Supervision does not require that the Qualified Medical Physicist must be present
in the room when the procedure is being performed.
c. Personal — A Qualified Medical Physicist must exercise General Supervision and be present in the
room during the performance of the procedure. QA of the external-beam process. For specific
instructions on the process of radiation therapy see the ACR–ASTRO Practice Parameter for General
Radiation Oncology.

C. Medical physics initial chart review protocol

At minimum, the physics review must include a review of the following:

1. Patient diagnosis
2. Any previous treatments the patient received
3. Implantable devices
4. Simulation instructions
5. Dose prescription
a. A written or electronic and dated prescription for the medical use of radiation should be made for each
treatment course. The prescription should be signed or approved electronically by a board-certified
radiation oncologist or qualified physician who restricts their practice to radiation oncology.

For specific required imaging to be used, see the ACR–AAPM Technical Standard for Medical Physics
Performance of Image-Guided Radiation Therapy (IGRT) [13].
6. External-beam dose distributions
Under the direction of a board-certified radiation oncologist or qualified physician who restricts their
practice to radiation oncology, external-beam dose distributions must be generated by the Qualified Medical
Physicist or dosimetrist. The physician must review all dose distributions prior to the patient starting
treatment. Cumulative dose distributions should be generated as appropriate and reviewed by the physician
prior to treatment delivery. Documentation of this review must be included in the patient’s treatment chart.
7. Treatment plan review
a. The treatment plan and any modifications to the treatment plan data that are transferred to a
radiation treatment delivery system must be reviewed and approved by the Qualified Medical
Physicist. For situations in which the Qualified Medical Physicist creates the treatment plan, it is
preferable for a second Qualified Medical Physicist or dosimetrist to review the treatment plan. The
dosimetrist must be specifically trained in treatment plan review. Documentation of training should
be maintained and updated for any changes in the plan review process.
b. A Qualified Medical Physicist should review the treatment plan prior to patient treatment.
c. For an emergency treatment that occurs after regular clinical treatment hours, on the weekend, or
on a holiday, the institution should have procedures in place such that the plan and/or calculations
are checked by a Qualified Medical Physicist within 1 business day after treatment delivery.
d. The Qualified Medical Physicist must review and verify the parameters that are used to describe
the radiation beam or beams used in the treatment plan. These parameters must reflect the intent of
the prescription. They include the target/source-to-patient skin distance (SSD or TSD), gantry and
collimator angle, field size, a description of the beam aperture or MLC pattern(s) when shaped
fields are used, the identification of wedges or a compensator if such are used, the relative beam
weight or normalization, and all treatment couch parameters.
e. Verify appropriateness of target volumes (may include gross target volumes (GTVs), clinical target
volume (CTVs), planning target volume (PTVs), internal target volumes (ITVs) (per the
International Commission on Radiation Units [ICRU]-50, ICRU-62, and ICRU-070), and normal
structures.
TECHNICAL STANDARD 8 External Beam Therapy
 f. The Qualified Medical Physicist should ensure that the graphical dose distribution is consistent
with the dose prescription and verify dose calculation parameters and the accuracy of dosimetric
results.
g. Each practice must have a written procedure that defines how to calculate the monitor units or
treatment time for all treatments. Such calculations must be based on measured dosimetric
parameters. Tables of these dosimetric parameters in either paper or electronic form must be
compiled and be readily accessible to the physics staff.
h. All treatment-planning system calculations of monitor units or treatment times must be verified by
an independent monitor unit calculation system. This independent calculation is to be performed
by a trained member of the physics team (dosimetrist or Qualified Medical Physicist) and checked
by the Qualified Medical Physicist. If treatment-planning system calculations of monitor units or
treatment times were originally prepared by a Qualified Medical Physicist, it may be rechecked by
the same individual using a different calculation method.
i. For patient-specific QA that involves verifying plan data and delivery accuracy, such as IMRT,
refer to the requirements (see the ACR Practice Parameter for Intensity Modulated Radiation
Therapy [IMRT] [11]). Documentation of this review and verification must be included in the
patient’s treatment record.
j. Verify that the treatment isocenter matches the simulated isocenter. If shifts were performed, verify
that these are documented in the patient’s record correctly.
k. Review the dose volume histogram for critical/normal structure doses.
l. Review digitally reconstructed radiographs for MLC position accuracy.
m. Review IGRT instructions prescribed by the physician for completeness (modality, frequency,
match structures, etc).
n. If record and verify systems are used, the Qualified Medical Physicist must verify that the treatment
plan and related data have been transferred properly.

2. Day 1 treatment verification

a. Follow specific Day 1 verification methods, isocenter verification, patient SSD measurements, etc.
b. A radiation therapy technologist or radiation oncologist should verify that the patient setup on the
treatment machine is in accordance with the treatment plan prior to the first fraction of a course of
treatment and prior to treatment for any changes to the initial treatment plan.
c. Clinical staff should obtain clarification before beginning a patient's treatment if any element of the
prescription or other record is confusing, ambiguous, erroneous, or suspected of being erroneous.

3. Medical physics weekly chart review protocol

The Qualified Medical Physicist must develop a weekly chart review protocol for reviewing each patient’s
treatment records. The review must assess accuracy of information as well as completeness and clarity of
the record. The chart review must be conducted at least once every 5 fractions. If the site employs more
than one Qualified Medical Physicist, this review should be rotated amongst the physicists so that more
than one Qualified Medical Physicist reviews the chart throughout the treatment course.

There may be challenges in accomplishing weekly physicist chart review for hypofractionated treatments
delivered over less than six days. The main problem is that these courses may receive a weekly chart review
only after a substantial fraction of the prescription has been delivered. This is not ideal, so approaches
should be developed to address this. If a treatment course is five fractions or less, the institution should
consider developing a process to ensure that at least one weekly chart review is conducted during the course
of treatment, ideally near the beginning of the course. For a single fraction treatment, the institution should
have procedures in place such that the chart is checked by a Qualified Medical Physicist soon after treatment
delivery.

At minimum, the physics review must include a review of the following:

a. Treatment prescription and approval. Any deviation from the radiotherapy prescription should be
reported in a timely manner to the responsible radiation oncologist so that corrective action can be
taken.
b. Daily treatment doses and cumulative doses
TECHNICAL STANDARD 9 External Beam Therapy
 c. Isodose distributions and monitor unit (time) calculations
d. SSD accuracy
e. Special dose calculations and measurements including in-vivo measurements
f. Review of new or modified treatment fields

4. Final check – Completion of treatment chart review

At the completion (end) of treatment (EOT), the Qualified Medical Physicist must review the entire chart
to affirm the fulfillment of the initial and/or revised prescribed dose. This review must be performed within
1 week of EOT and documented in the treatment record. Any deviations from the physician treatment plan
or radiotherapy prescription must be documented and promptly brought to the attention of the attending
radiation oncologist.

D. Chart rounds

The Qualified Medical Physicist should participate in weekly department-wide chart rounds to ensure the
fulfillment of the prescription and review any changes in dose, patient setup(s), and simulation and port films.

E. Morbidity and Mortality Round

See the ACR–ASTRO Practice Parameter for Radiation Oncology [30].

VII. NEW PROCEDURES

The practice of radiation oncology often involves the implementation of new procedures and technologies. When
these are being considered, the Qualified Medical Physicist must participate along with team members of the
medical and administrative areas. The Qualified Medical Physicist should undertake a systematic literature review,
make site visits, confer with colleagues familiar with the new procedure or equipment, and otherwise obtain factual
information for use in planning, acquisition, and implementation. Such information may include clinical application,
impacts on workflows, equipment, staffing, and space utilization.

The Qualified Medical Physicist must accept and commission any new treatment procedure, technique, accessory,
or new treatment technology, and they must be received/accepted, commissioned, and released prior to clinical use.
In the case of a product (hardware, software, or device) the commissioning must include safety testing and
verification that the system or device meets the manufacturer’s performance standards. Commissioning will also
include institution of a QA program to demonstrate the consistent safety and performance of the system or device.
Documentation of the acceptance, commissioning, and QA program development must be on-site and available for
review.

The QA program associated with any new procedure should be periodically reviewed and updated.

For more information on image-guided radiation therapy, see the ACR–AAPM Technical Standard for Medical
Physics Performance Monitoring of Image-Guided Radiation Therapy (IGRT) and the ACR–ASTRO Practice
Parameter for Image-Guided Radiation Therapy (IGRT) [13,31].

VIII. DOCUMENTATION

The Qualified Medical Physicist is responsible for documenting, at a minimum, the following:

1. Procedures for instrument calibration and periodic instrument constancy checks

2. Procedures to verify the manufacturer’s specifications and to establish baseline performance values for
radiation therapy equipment
3. QM programs for radiation therapy equipment, simulators, treatment-planning systems, and monitor unit
calculation algorithms
4. Monitor units (time) calculation procedures and protocols
5. Physics chart check protocol for reviewing treatment delivery
6. Procedures for checking the mechanical and electrical integrity of patient care devices
TECHNICAL STANDARD 10 External Beam Therapy
 7. Radiation protection program as it pertains to radiation oncology
8. Calculations related to patient dosimetry and/or physics measurements when such needs arise or per
clinicians’ requests
9. Consultations requested by the radiation oncologist
10. Commissioning of new systems and/or equipment introduced into the clinic
11. Response to vendor safety notices
12. Equipment repair log and QA prior to returning to service

IX. PEER REVIEW

See the ACR–ASTRO Practice Parameter for Radiation Oncology [30].

ACKNOWLEDGEMENTS

This technical standard was revised according to the process described under the heading The Process for
Developing ACR Practice Parameters and Technical Standards on the ACR website (https://www.acr.org/Clinical-
Resources/Practice-Parameters-and-Technical-Standards) by the Committee on Practice Parameters and Technical
Standards – Medical Physics of the ACR Commission on Medical Physics, in collaboration with the AAPM.

Collaborative Committee – members represent their societies in the initial and final revision of this technical
standard

ACR AAPM
Matthew A. Pacella, MS, FACR, Co-Chair Joseph Hanley, PhD
Christopher J. Watchman, PhD, Co-Chair Koren S. Smith, MS
Debbie L. Schofield, MS Malorie R. Veres, MS

Committee on Practice Parameters and Technical Standards – Medical Physics

(ACR Committee responsible for sponsoring the draft through the process)

Maxwell R. Amurao, PhD, MBA, Chair Ralph P. Lieto, MS, FACR

Mary Ann Keenan, DMP, Vice Chair Lijun Ma, PhD, FAAPM
Priscilla F. Butler, MS, FACR Tariq A. Mian, PhD, FACR
Heidi A. Edmonson, PhD Anshuman Panda, PhD
Samuel A. Einstein, PhD Douglas E. Pfeiffer, MS, FACR
Per H. Halvorsen, MS, FACR Premavathy Rassiah, PhD
Loretta M. Johnson, PhD Thomas G. Ruckdeschel, MS

Mahadevappa Mahesh, MS, PhD, FACR, Chair, Commission on Medical Physics

Jacqueline Anne Bello, MD, FACR, Chair, Commission on Quality and Safety
Mary S. Newell, MD, FACR, Chair, Committee on Practice Parameters and Technical Standards

Comments Reconciliation Committee

David Youmans, MD, FACR, Chair Janaki Krishnamoorthy, PhD
K. Elizabeth Hawk, MD, MS, PhD, Co-Chair Mahadevappa Mahesh, MS, PhD, FACR
Maxwell R. Amurao, PhD, MBA Alexander Markovic, MSc
Jacqueline Anne Bello, MD, FACR Mary S. Newell, MD, FACR
Richard Duszak Jr., MD, FACR Zoubir Ouhib, MS, FACR
Robert G. Gandy, MS Matthew A. Pacella, MS, FACR
Steven J. Goetsch, PhD Ben H. Robison, MS
Per H. Halvorsen, MS, FACR Debbie L. Schofield, MS
Joseph Hanley, PhD Koren S. Smith, MS
Steven C. Harrell, MS Malorie R. Veres, MS
Annie Hsu, PhD Christopher J. Watchman, PhD
Mary Ann Keenan, DMP Gerald A. White Jr., MS, FACR
Amy L. Kotsenas, MD, FACR Richard Y. Wu, MS
TECHNICAL STANDARD 11 External Beam Therapy
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TECHNICAL STANDARD 12 External Beam Therapy

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*Practice parameters and technical standards are published annually with an effect date of October 1 in the year in
which amended, revised, or approved by the ACR Council. For practice parameters and technical standards
published before 1999, the effective date was January 1 following the year in which the practice parameter or
technical standard was amended, revised, or approved by the ACR Council.

Development Chronology for this Technical Standard

2004 (Resolution 19)
Amended 2006 (Resolution 16g)
Revised 2010 (Resolution 7)
Revised 2015 (Resolution 52)
Revised 2020 (CSC/BOC)

TECHNICAL STANDARD 13 External Beam Therapy