S1526
Interdisciplinary - Quality assurance and risk management
ESTRO 2026
cognitive biases with periodic refreshers.* Anonymous Voting: Use anonymous digital voting when discussions fail to reach consensus.These interventions are currently under evaluation prior to implementation. Conclusion: This quality-improvement initiative revealed frequent cognitive biases in collegial decision-making in radiotherapy and generated practical, context-specific corrective strategies. Addressing these biases within MDT meetings offers an innovative way to enhance decision quality. The next step is to implement and evaluate these interventions to strengthen the robustness and safety of multidisciplinary decisions. References: 1) Dhillon BS. Human errors: a review. Microelectron Reliab. 1989;29(3):299–304.2) Zeltser MV, Nash DB. Approaching the evidence basis for aviation-derived teamwork training in medicine. Am J Med Qual. 2010;25(1):13–23.3) Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med. 2003;78(8):775–80.4) Sibony O. Vous allez commettre une terrible erreur! Flammarion; 2019.5) Groopman J. How Doctors Think. Houghton Mifflin; 2007.6) Thompson MK, Landry G, Kalman NS, Tseng YD, Johung KL. Why smart oncology clinicians do dumb things: A review of cognitive bias in radiation oncology. Pract Radiat Oncol. 2019;9(6):e550- e558. doi:10.1016/j.prro.2019.03.001 Keywords: cognitive biases, collegial decision-making Design and Development of an Internal Dose verification Package for Prostate and Gynae HDR Brachytherapy Patients Fatemeh Nazari 1 , Amani Chowdhury 2 , William Hamblyn 2 , John A Mills 3 , Nigel Biggs 1 , Peter Hoskin 2,4 , Shakardokht M Jafari 1 1 R&D, Trueinvivo, Portsmouth, United Kingdom. 2 Radiotherapy, Mount Vernon Cancer Centre, London, United Kingdom. 3 Engineering, Print Easy Acrylic Shells, Hinckley, United Kingdom. 4 Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom Digital Poster Highlight 2827 Purpose/Objective: To design, develop, and evaluate a modular internal in-vivo dosimetry platform for high-dose-rate (HDR) brachytherapy in prostate and gynecological cancer patients, enabling high-resolution dose verification at multiple anatomical sites with minimal impact on clinical workflow. Material/Methods: The system needed to enable high-resolution dose verification at accessible tumour and healthy organs at
risk sites with minimal interference to clinical workflow, enabling treatment verification. Micro-silica bead thermoluminescent dosimeter (TLD) arrays (DOSEmapper™) were integrated into accessible anatomical cavities via catheters to allow in-situ dose measurement at the bladder, anterior rectal wall, and clinical target volume (CTV). Arrays were embedded into urinary catheters and customized rectal insert, with integration into interstitial needles planned for future work, to facilitate dose verification during treatment. While brachytherapy provides conformal dose delivery, it is rarely verified by internal in-vivo dosimetry due to the complexity of sensor placement, which remains a documented safety concern in risk registers. Development followed a six-stage engineering and translational framework:1) Identifying optimal internal dosimetric parameters.2) Establishing a practical internal in-vivo bench strategy compatible with existing treatment cycles.3) Designing multiple DOSEmapper™ prototypes: a)1D DOSEmapper™ for urinary catheters (prostate and gynaecological applications) (figure1.(a)) b)1D DOSEmapper™ for interstitial needle integration;( bench-tested, clinical evaluation is in progress) (figure1.(b)) c)3D DOSEmapper™ integrated within a 3D-printed flexible resin rectal insert )bench-tested, clinical evaluation planned by March 2026) (figure1.(c))4) Characterizing, commissioning and phantom studies.5) Initial regulatory preparation under ISO 13485 / MDR compliance.6) Clinical feasibility testing in six HDR brachytherapy patients at Mount Vernon Cancer Centre, London, UK.
Results: All three DOSEmapper™ configurations were successfully designed, developed, and validated through bench and phantom testing. The 1D DOSEmapper(a) achieved reliable urethral dose
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