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Annual Scientific Meeting of the Canadian Organization of Medical Physicists — July 9–12, 2014, The Banff Centre, Banff, Alberta, Canada

Practical Guidance for Setting Up a Linac-Based Radiosurgery Program

Setting up a linac-based radiosurgery program requires more than installing a new collimator or upgrading an existing linear accelerator. It demands a coordinated effort across medical physics, radiation oncology, nursing, and administrative teams, with careful attention to clinical intent, commissioning, and long-term quality assurance. For departments in Australia, where centres can be separated by vast distances and referral pathways stretch from Hobart to Darwin, the planning phase often carries extra weight.

In practice, Australian departments have developed a reputation for pragmatic program design, balancing the imperatives of the Medicare Benefits Schedule with the realities of serving regional populations. Whether you are based at a large metropolitan tertiary centre or a regional hub servicing the Pilbara or the Top End, the principles outlined below offer a roadmap for safe, sustainable implementation. They draw on the experience of physicists who have built single-isocenter and multi-isocenter programs from the ground up, often in collaboration with international peers through professional societies and scientific meetings.

Defining clinical scope and patient selection

Before any equipment decisions are made, the clinical team must agree on the patient cohorts the program will serve. Linac-based radiosurgery is well suited to intracranial metastases, benign tumours such as vestibular schwannomas, arteriovenous malformations, and functional disorders. Some Australian centres, including Peter MacCallum Cancer Centre in Melbourne and the Chris O'Brien Lifehouse in Sydney, have built substantial experience in treating multiple brain metastases per session, often using single-isocenter techniques to streamline workflow.

Patient selection criteria should be drafted with input from radiation oncologists, neurosurgeons where relevant, and the physics team. Documented inclusion and exclusion thresholds — for example, lesion number, diameter, proximity to critical organs at risk, and prior radiation history — prevent ad hoc decision-making later. The multidisciplinary meeting format familiar to Australian tumour boards, often running early in the morning before lists begin, provides a natural venue to discuss borderline cases and maintain consistency.

Equipment, staffing, and commissioning

The technical heart of the program lies in the linear accelerator, whether a dedicated radiosurgery unit or a standard linac with high-definition multileaf collimator and dedicated planning software. Many Australian sites have adopted frameless thermoplastic immobilisation paired with surface-guided or stereoscopic kV imaging to streamline setup. Commissioning should follow a tiered approach: first the machine itself to national standards such as those published by ARPANSA, then the end-to-end workflow including imaging, planning, and delivery using anthropomorphic phantoms.

Staffing is a perennial challenge, and the Australasian College of Physical Scientists and Engineers in Medicine (ACPSEM) provides a useful benchmark for physicist-to-machine ratios and credentialing. A typical launch team includes at least one full-time medical physicist with SRS experience, a dosimetrist or planning scientist, radiation therapists trained on the new workflow, and a radiation oncologist with subspecialty interest. Where recruitment is difficult in regional locations, fly-in fly-out arrangements or remote planning supervision can bridge the gap, though robust communication protocols are essential.

Workflow design and clinical protocols

A clear workflow prevents errors during the high-pressure first weeks of clinical operation. The process typically begins with a stereotactic planning CT, often fused with contrast-enhanced MRI, and proceeds through contouring, plan optimisation, patient-specific quality assurance, and treatment delivery. Each handoff should be documented, ideally within a record-and-verify system that flags deviations in real time. In Australian centres, where electronic medical records such as MOSAIQ or Aria are standard, custom scripts can automate many of these checks.

Protocol documents need to be living files. Initial versions should cover simulation orders, immobilisation devices, planning objectives (for example, V12Gy constraints for healthy brain), image-guidance frequency, and contingency plans for machine faults. As experience grows, these can be refined. For departments looking to expand into related areas, reviewing brachytherapy key findings from comparable meetings offers a cross-pollination of ideas around high-dose per fraction delivery.

Quality assurance and ongoing safety

Once treatments begin, the work shifts to sustaining performance. Daily, weekly, and monthly QA schedules must be defined for the linac, the imaging systems, and the planning software. End-to-end testing using a phantom with hidden targets should occur at least quarterly, and after any major software upgrade or hardware service. Australian regulators take a keen interest in incident reporting, and the ACPSEM and ARPANSA frameworks encourage transparent documentation of near-misses as well as adverse events.

Peer review of plans adds another layer of defence. Many departments now use scheduled plan-checking rounds where a second physicist and radiation oncologist review each new case before treatment. Where staffing is lean, regional networks can provide external review, supported by secure DICOM transfer and teleconference platforms. The goal is a culture where questions are welcome and assumptions are checked, rather than a culture of speed at the expense of safety.

Training, governance, and professional networks

A successful program depends on the people running it. New staff, whether junior physicists or experienced radiation therapists transitioning from conventional radiotherapy, need structured onboarding. This includes supervised planning of a set number of cases, competency assessments, and refresher sessions. Mentorship from a senior physicist with radiosurgery experience accelerates the learning curve considerably.

Governance structures should define reporting lines, escalation paths, and audit schedules. A steering committee with representation from physics, radiation oncology, nursing, and administration meets quarterly to review metrics such as treatment time, replanning rates, and patient outcomes. Engagement with professional bodies keeps the program aligned with evolving standards, and conferences offer a chance to exchange ideas with international colleagues. Attending an orientation for new members at a major scientific meeting can be a valuable first step for physicists entering the subspecialty, while networking across institutions helps spread practical know-how.

Recommendations for departments preparing to launch

  • Establish a multidisciplinary steering committee with terms of reference, meeting cadence, and documented decision rights.
  • Map the patient pathway end-to-end before equipment installation, identifying bottlenecks in imaging, planning, and QA.
  • Recruit at least one physicist with prior SRS commissioning experience; consider partnerships with established centres for mentoring.
  • Adopt ARPANSA-aligned commissioning protocols and document tolerances in a formal commissioning report.
  • Invest in surface-guided or stereoscopic imaging to reduce setup time and improve patient comfort.
  • Build a peer-review process into the daily workflow, not as an optional add-on.
  • Plan for ongoing training and conference attendance to keep the team current with international practice.

If you are preparing to launch a radiosurgery service or expand an existing one, begin by auditing your current capability against the points above and convening your steering committee within the next quarter. The investment in careful planning pays dividends for years, both in patient outcomes and in the professional satisfaction of a well-run program. Reach out to colleagues who have navigated similar builds, and make use of the social program options at major meetings to forge connections that outlast any single conference — the collective wisdom of the medical physics community is one of the most reliable guides available.