Kong Vang, RT (R) (T) and Erin Ambroziak RT (R)(T), Assistant Chief Therapist, South Sacramento Cancer Center

SGRT in the Daily Treatment Workflow

As radiation therapists, our priority is delivering accurate, efficient treatments while making the experience as comfortable as possible for our patients. Surface guided radiation therapy (SGRT) has become an important part of how we do that. At South Sacramento Cancer Center, our hands-on experience with C-RAD has shown us that SGRT is most valuable when it fits naturally into our workflow and supports the way we work at the console every day.

We use SGRT where we see the greatest clinical benefit. In our experience, SGRT is especially effective for thoracic cases, where respiratory motion and precise positioning are critical. Today, we routinely use C-RAD for breast, lung, and esophageal patients. The C-RAD Catalyst⁺ HD SGRT system integrates well with our Varian linear accelerators, without adding unnecessary complexity.

In particular, the linac integration is very tight with automatic beam holds. When monitoring patients using C-RAD, with or without breath-hold, if a patient was to cough, sneeze, or adjust in any way from where we set them up, then the beam would be held. The radiation beam terminates when the motion moves the patient out of the planned tolerance as well as on breath-holds if they were not in the planned threshold (meaning too large of a breath or not large enough of a breath).

Learning Curve and Workflow Efficiency

As with most new technologies, we had a learning curve with SGRT. We weren’t directly involved in the original purchasing decision, but once the system was in place, and we began using it consistently, the value was clear. As we grew more comfortable with the technology, our confidence increased, and so did our efficiency. Over time, setup became smoother and more predictable, and SGRT evolved from something new into a trusted part of our workflow. We believe the 6-DOF couch integration also really aids in the speed of setups, and the technologies complement each other well.

Tattoo-Less and Mark-Less Patient Setup

One of the biggest improvements we’ve seen since implementing SGRT is the shift to tattoo-less and mark-less setups. Before SGRT, many breast patients required visible Sharpie marks or tape on the chest to help with alignment. With C-RAD, those markings are no longer necessary. We can position patients accurately without tattoos, pen marks, or stickers, which makes a meaningful difference in how patients feel during treatment. Preserving dignity and reducing visual reminders of illness has had a noticeable impact on patient comfort and confidence.

Visual Coaching and Breath-Hold Guidance

Our patients and clinical team also appreciate the visual light coaching panels from C-RAD, which are used routinely for DIBH treatments. The light system is installed on the ceiling of the vault and indicates the perfect breath-hold, making the patients in control of their own treatment. The patient is told that they only need to hold their breaths as long as they feel comfortable and if they need to breathe normal at any time, then the “green” light will turn off, the radiation will turn off. Then whenever the patient feels ready and comfortable again, they can take in a breath and hold it.

Also, C-RAD has the option of changing which color lights work best for each department. Our center specifically uses a pale blue light for normal breathing or when the patient is considered below the acceptable breath-hold threshold. We use a solid green light when the patient’s breath-hold is considered “perfect” or within the planned threshold and, finally, a yellow light when the patient’s breath is too large or above the planned threshold.

Comparison with Other SGRT Applications

We’ve also worked with other SGRT platforms and found that core functionality is generally similar across systems. However, some solutions require additional accessories to be placed on and removed from the treatment couch, which can add steps and slow things down. Every now and then, the shift refresh feels a little slow, but we’re also aware that we may just be impatient and trying to move faster than the technology is designed to move.

The Therapists’ Perspective

From our perspective, in summary, SGRT delivers the greatest value when it supports real clinical workflows. By integrating smoothly into our daily routine, minimizing extra steps, and improving patient interactions, C-RAD helps us work more efficiently while maintaining high standards of accuracy and safety. For us, SGRT isn’t just a technology upgrade: it’s a practical improvement that enhances how we care for patients every single day.

In this video, Elizabeth Edwards, C-RAD Clinical Applications Specialist, explains how surface-guided solutions, including Catalyst⁺ HD and Catalyst⁺ LITE, support active motion management across the treatment workflow. She highlights how real-time surface monitoring helps clinical teams manage patient motion with confidence while reducing reliance on additional imaging. Learn how Catalyst⁺ HD and Catalyst⁺ LITE can be applied to different clinical and operational needs.

An interview with Rebecca Edwards, Radiation Therapist Unit Leader

At GenesisCare South Australia in Adelaide, Radiation Therapist Unit Leader Rebecca Edwards and the broader clinical team are proving that surface guidance radiation therapy (SGRT) is more than just technology. It’s helping create smoother workflows and a more positive experience for patients.

To explore how tattoo-free workflows are reshaping patient care and clinical practice, C-RAD spoke with Rebecca about her team’s experience implementing SGRT, the difference it has made for patients and staff, and what other centers can learn from their insights.

What do you find most valuable about using surface guidance in your radiation treatments?

I’ve been in radiotherapy for about seven years, so I’ve seen the transition from tattoos and markers to fully tattoo-free workflows. Being part of that evolution has been really rewarding. As therapists, we enter this field to make a difference through technology, and SGRT has been one of the most meaningful advancements in that journey.

Transitioning from snorkel-based DIBH to a fully snorkel-free, markerless, and contact-free approach has changed the experience for everyone involved. When patients finish treatment without permanent marks, it reinforces why this evolution matters.

Seeing patients’ complete treatment without permanent marks is powerful.
Patients also notice the difference right away with C-RAD’s Visual Coaching Light Panels. The color cues—green for correct breath-hold or positioning, blue for minor adjustments, and orange for stop or out-of-tolerance—help them stay engaged and in control throughout treatment. For therapists, that level of patient comfort and confidence is incredibly rewarding.

You’ve mentioned a priority for you is quality and process improvement. How has C-RAD supported that?

Quality and process improvement have always kept me engaged in this field. When we partnered with C-RAD, it wasn’t just about learning new technology—it was about shaping how it fit into our clinical practice.

Working side by side with C-RAD’s clinical application specialists, we focused on three key areas to make Catalyst+ part of our daily workflow:

• Strengthening collaboration between radiation therapists, physicists, and C-RAD experts
• Building structured learning and competency frameworks to keep skills current
• Rolling out progressively, starting with breast and DIBH before expanding to thorax, abdomen, and other treatment sites

How did you approach staff training and onboarding?

At first, it was a bit of a “thrown-in-the-deep-end” situation. But that was part of the learning curve! Over time, we built robust work instructions and a clear competency framework.

We started with a small core team who became confident and proficient before expanding training to others. Now, we have around 20 competent and another 10–20 proficient staff members who can train and lead SGRT workflows independently. That structure, combined with regular sharing sessions and documentation updates, has created consistency across sites.

What has SGRT changed most in your department?

It’s made our department even more patient centered. GenesisCare has always valued patient feedback, and SGRT amplifies that. Patients often tell us how meaningful it is not to be tattooed—and how much more natural it feels to breathe freely without a snorkel.

It’s also helped us improve efficiency. Using our OIS system (Elekta MOSAIQ) and internal Tableau dashboards, we’ve tracked detailed performance metrics and seen measurable improvements over time:

• Non–breath-hold breast: reduced from 12 minutes scheduled to 10.8 minutes actual
• Breath-hold breast: reduced from 15–18 minutes scheduled to approximately 13 minutes actual

Those numbers may sound small, but across a full day of patients the efficiency gain is significant. It means less waiting and better use of every treatment slot. We’ve also seen fewer re-images, reduced manual handling, and greater overall consistency with C-RAD solutions.

What differences have you noticed in staff well-being, patient safety, and overall treatment experience?

The reduction in manual handling is one of the biggest advantages. Before SGRT, therapists often repositioned patients by pushing, rolling, or realigning to tattoo points, leading to fatigue and an increased risk of error. With C-RAD, setup accuracy is visualized in real time, allowing millimeter-level corrections without unnecessary movement.

Now we rarely have to move the patient at all—sometimes it’s just a small hip adjustment of a few millimeters.

These improvements are most evident in three areas:

• Fewer repeat imaging sessions: Surface data provides immediate confirmation of setup accuracy before CBCT verification.
• Reduced physical strain: Staff who rotate to sites without C-RAD immediately notice the increased effort required. SGRT makes it safer for both therapists and patients.
• Greater patient engagement: Patients can see their own breath-hold in real time using C-RAD’s Visual Coaching Light Panels, which builds confidence and calm and leads to more stable, consistent accuracy.

We also use C-RAD’s color projection tools for quick postural checks. They provide an excellent visual aid when small corrections are needed before refreshing the image.

What treatment areas are you currently using SGRT for?

We started with breast and breath-hold breast, and now we’re using it for chest, lung, oesophagus, and abdomen. We’re also exploring faceless masks for head-and-neck patients, as well as SABR prostate and SRS. Long-limb setups, such as skin or extremity cases, are another area where SGRT could make a real difference.

The potential applications just keep expanding – anywhere precision and patient comfort matter, SGRT has a role to play.

Was it difficult to integrate SGRT into your existing workflows?

Not at all—we made it fit us. We adapted our existing processes, such as referencing the external and bony anatomy, and SGRT validated those setups with more information and greater confidence before imaging. We have real-time visual confirmation that everything is aligned before you even take a CBCT.

How have your radiation oncologists and medical physicists responded?

Once they saw it in action, they were on board. Our radiation oncologists often mention that patients love the experience. It is calmer, faster, and more comfortable.

Working closely with physics has also strengthened our team dynamic. We’ve learned to see from each other’s perspectives, combining technical precision with human-centered care. That collaboration ultimately benefits the patient most.

Once you begin using SGRT, it’s hard to imagine working without it.

The key is to start small, build a strong core team, and let confidence grow through shared learning. Clear work instructions, peer-to-peer education, and collaboration with C-RAD’s applications team made all the difference for us. Today, our therapists work with greater accuracy and less manual strain, our patients are more comfortable and engaged, and our workflows are faster and more consistent.

With Catalyst⁺ HD and Sentinel 4DCT, Chris O’Brien Lifehouse has built a unified SGRT workflow that supports motion management, consistent setup, and confident treatment across diverse disease sites.

At Chris O’Brien Lifehouse in Sydney, Australia, precision extends beyond a single treatment type. With multiple Varian TrueBeam linacs and C-RAD Sentinel 4DCT and Catalyst⁺ HD systems, the center applies surface guided radiation therapy (SGRT) across a growing range of indications—from breast and chest to lung, abdominal SBRT, and limbs.

Since implementing C-RAD SGRT in late 2022, Lifehouse has expanded to more than 350 SGRT-guided treatments each year, including the majority of its 400 annual breast DIBH cases.

“Motion management is the real value of SGRT,” says Kate Ford, Assistant Director of Radiation Therapy and Head of Treatment at Chris O’Brien Lifehouse. “It’s allowed us to standardize breath-hold and gating techniques across sites, improve setup quality, and increase therapist confidence in every case. Our decision to adopt C-RAD SGRT solutions was driven by workflow integration, interface usability, and patient-centered visual feedback.”

“Our decision to adopt C-RAD SGRT solutions was driven by workflow integration, interface usability, and patient-centered visual feedback.”

“The interface was far easier for staff to learn,” Ford notes. “And C-RAD’s Visual Coaching Light Panels give immediate feedback to both therapists and patients. For motion management, that’s essential.”

During early commissioning, the team found that light-based feedback also improved accessibility for patients with hearing impairments, a small but meaningful clinical advantage.

Integrating SGRT Across Multiple Indications

The Catalyst⁺ HD wide-field, high-resolution 3D cameras capture full-body geometry with sub-millimeter accuracy and provide continuous monitoring throughout beam-on. The large field of view supports complex sites such as lung, abdomen, and extremities without the need to reposition the camera pods.

Sentinel 4DCT complements this by capturing each patient’s breathing trace and surface geometry during simulation, then synchronizing that data with Catalyst⁺ HD at treatment. The result is a unified motion-management workflow from CT to linac, ensuring that respiratory patterns and gating thresholds remain consistent throughout the entire course of care.

This unified workflow supports a broad range of clinical indications, including those described by the Lifehouse team below:

Breast and Thorax

Sentinel 4DCT captures each patient’s breathing trace during simulation, which is then used by Catalyst⁺ HD at treatment—creating a unified motion-management platform from CT to linac.

“Gating with Sentinel and Catalyst gives us a streamlined approach for DIBH and EEBH,” Ford says. “We use it for left- and right-sided breast, chest-wall, and nodal regions, and we’re exploring faceless-mask workflows for head-and-neck patients to improve comfort and reduce anxiety.”

Lung and Abdominal SBRT / SABR

Lifehouse uses end-expiration breath-hold (EEBH) for liver, pancreas, kidney, and adrenal cases.

“We rely on the light panels rather than tablets,” Ford explains. “It keeps coaching simple and adaptable to each patient’s baseline. Over time, it’s become a very intuitive process.”

Limb and Surface-Critical Sites

SGRT has improved reproducibility for limb and skin treatments, where maintaining consistent rotation and extension angles can be challenging.

“It gives us a fast, objective way to confirm positioning—especially in long-limb setups,” says Ford.

Physics Perspective: Reliability and Safety

For Elizabeth Claridge Mackonis, Deputy Head of Physics and Engineering, the system’s consistency from simulation to treatment is its greatest strength.

“Having the same surface system at CT and on the linac means the breathing trace and patient reference are identical,” she explains. “That reproducibility is critical for safety and for data integrity. Commissioning was straightforward, QA is minimal, and reliability has exceeded expectations.”

“Commissioning was straightforward, QA is minimal, and reliability has exceeded expectations.”

“Our uptime has been excellent. We planned multiple backup procedures, but we’ve never needed them,” Mackonis adds. “Catalyst⁺ HD also simplifies ongoing quality assurance and traceability. The C-RAD database stores surface data across all fractions, so we can easily review or analyze any case if needed. It’s a small workload for physics, but the safety and quality gains are enormous.”

Change Management Translates to Staff Confidence

Both disciplines emphasize that successful SGRT adoption depends on staged, hands-on training.

“We ran mock patient setups to uncover real-world issues,” Mackonis notes. “Theory alone doesn’t prepare staff.”

Lifehouse implemented SGRT in phases—starting with surface monitoring, progressing to DIBH breast, and ultimately incorporating SBRT and other motion-managed sites.

“Once staff had protected hours to experiment without patients, confidence took off,” Ford recalls. “Now, peer-to-peer mentoring keeps those skills alive.”

Quality, Safety, and Patient Experience

Integrating surface monitoring and gating has added a clear safety layer and greater consistency to setup verification.

“We’re seeing fewer repeat images and more confidence in daily positioning,” Ford says. “The intra-fraction feedback from C-RAD is invaluable.”

Mackonis adds that the built-in safety interlock provides an additional layer of protection.

“It’s really good to have an interlocking system in place that automatically pauses the beam if the patient moves or their breathing becomes irregular,” she explains. “That’s very reassuring from a safety perspective.”

“It’s less about being tattoo-less and more about being technology-supported,” Ford adds. “The accuracy improves, and the anxiety drops. Patients benefit as well—from fewer invasive markers, faster verification, and a calmer, more interactive experience.”

“Patients benefit as well—from fewer invasive markers, faster verification, and a calmer, more interactive experience.”

Looking Ahead

Lifehouse is refining tolerance protocols, preparing to roll out cAccessory RFID for streamlined patient and accessory identification and planning future research on setup accuracy, imaging frequency, and staff change management.

“The physics workload is small compared to the safety gain,” Mackonis says. “Having continuous data and traceability is a huge quality improvement.”

At Oklahoma Cancer Specialists and Research Institute (OCSRI), Lead Radiation Therapist Megan Barrett has seen firsthand how C-RAD’s Surface Guided Radiation Therapy (SGRT) solutions have transformed treatment precision, workflow consistency, and patient confidence.

“Before SGRT, we relied on tiny tattoos and laser lines to align patients,” Barrett explains. “It worked, but it left room for variation and second-guessing. Now, with C-RAD’s technology, we can see the entire patient surface in real time and make exact adjustments before a single beam is delivered.”

C-RAD’s Catalyst⁺ HD system uses structured light to create a 3D surface map of the patient’s body that continuously compares live positioning data to the reference scan from simulation. The system supports a wide range of treatments, including 3D, IMRT, DIBH, and SRS/SBRT.

“C-RAD is basically doing a 2.3 million point setup, captured in real time, instead of three-point tattoo setup.” Barrett explains. “That level of detail eliminates uncertainty and gives us confidence that every patient is positioned precisely.”

A Second Set of Eyes in the Treatment Room

SGRT acts as a constant, automated observer throughout treatment. “It gives us peace of mind knowing the patient has not moved since we stepped out of the room.” Barrett says. If a patient shifts or coughs—such as during a lung treatment—the Catalyst⁺ HD system automatically pauses the beam until the patient returns within tolerance. This real-time monitoring safeguards treatment accuracy while reducing the need for unnecessary imaging or re-setup.

Empowering Patients Through Light

At OCSRI, SGRT has also become a tool for patient communication and empowerment. During Deep Inspiration Breath Hold (DIBH) treatments, Barrett’s team uses C-RAD’s ceiling-mounted visual coaching light panels to visually guide patients through each breath. As patients inhale, the room glows green when they reach the target position, blue when they’re close, and orange if they are out of position.

Visual-Light Coaching: Ceiling-mounted panels enable visual coaching for real-time patient respiratory feedback

“The whole room lights up, and patients immediately understand what to do,” Barrett explains. “It makes them active participants in their care. That visual connection builds trust and reduces anxiety.”

Building Consistency and Confidence

Initially, Barrett’s team used SGRT only for select cases such as DIBH and SBRT. But after adopting C-RAD’s Catalyst⁺ HD workflow for every patient, efficiency and consistency improved dramatically. “Once we standardized SGRT across all treatments, everything became smoother,” she notes. “Our setups were faster, our imaging corrections dropped, and our overall confidence soared.”

For Barrett and her team, SGRT has become much more than a positioning technology—it’s a new standard of care. “Surface guidance allows us to treat patients more safely, more accurately, and with greater peace of mind,” she says. “Once you can see the whole picture, there’s no going back.”

Five Lessons from the Team at Oklahoma Cancer Specialists and Research Institute

At Oklahoma Cancer Specialists and Research Institute (OCSRI), Lead Radiation Therapist Megan Barrett has seen firsthand how Surface Guided Radiation Therapy (SGRT) changes everything, from patient setup to team confidence. But she’s quick to remind others that the transition doesn’t happen overnight.

“Adopting SGRT is a journey, not a switch you flip,” Barrett says. “You learn more once you start treating real patients. It’s all about practice, observation, and sharing what works.”

After years of implementing SGRT across all treatment types, Barrett and her colleagues have refined their process into a few key lessons for clinics getting started.

1. Train, and then train again

Begin with thorough vendor-led training to understand the system and workflow.

Schedule a follow-up session a few months later, once the team has hands-on experience and new questions. “The second round of training was when everything clicked for us,” Barrett notes.

SGRT trainer Elizabeth Edwards agrees that early and ongoing training pays off: “When therapists use SGRT from the start, they build consistent habits and confidence. That foundation allows them to deliver safer treatments and achieve long-term success.”

Lesson learned: Make training a cycle, not a checkbox. Plan refreshers every few months and encourage open discussion about “what we’ve learned since launch.”

2. Appoint SGRT champions

Choose at least one therapist per machine to become a go-to resource for others.

Have this person participate in initial training and help guide daily implementation. “Learning from your own peers builds confidence faster than anything else,” Barrett says.

That confidence can take time to build. Sara Cook, Radiation Therapy Manager, recalls, “Therapists were reluctant at first; this wasn’t what they were taught in school. But once we implemented surface guidance for all patients, they started trusting it and saw the value it brought for patients and staff.”

Lesson learned: Confidence spreads fastest when it comes from within the team. Empower local experts to share, lead, and celebrate progress.

3. Visit and learn from other centers

Observe how established SGRT clinics organize their rooms, manage patient flow, and streamline setup.

Exchange practical tips and workflow tricks. “Those visits were game-changing; we learned small adjustments that made a big impact,” Barrett recalls.

Once OCSRI applied those insights, the team began seeing measurable improvements such as smaller shifts, fewer repeat images, and faster setups. “When we saw those changes in action, everyone realized SGRT wasn’t just another tool, it was a better way to treat,” Barrett says.

Lesson learned: You don’t need to reinvent the wheel. Learn from peers, adapt their best practices, and then measure your own progress. Shared experience is the fastest path to consistency and confidence.

4. Standardize SGRT for every patient

Expand beyond DIBH or SBRT and make SGRT part of every setup.

Consistency across all treatments reduces variation and builds team confidence. “Once we used it for everyone, it stopped being a specialty tool, it became how we do radiation therapy,” Barrett says.

That consistency also enhances precision. Shaun McCormick, Radiation Therapist, explains, “If we’re aiming for such tiny margins, I need to know we’re staying in those margins the entire time. Surface guidance gives me that confidence.”

Clinics report measurable workflow improvements, too. Trenda Mullen notes that with SGRT, “frog-legged pelvis setups are much easier to reproduce; it prevents multiple scans and makes treatments more efficient.”

From a physics standpoint, Kristyn Koepp adds, “If a patient moves outside tolerance, the system automatically holds the beam, a feature I truly appreciate.”

Lesson learned: Treat SGRT as the standard, not the exception. When every patient benefits from the same workflow, teams become faster, safer, and more consistent, and patients feel the difference.

5. Build a culture of learning and sharing

Implementing SGRT across all cases isn’t just about adopting new technology; it’s about creating a confident, consistent culture of learning that benefits both patients and staff.

Even after SGRT becomes routine, continued education and collaboration sustain the benefits. “SGRT isn’t just a technology, it’s a culture shift,” Barrett says. “Every clinic has to build its own rhythm. What matters most is sharing experiences and helping each other grow.”

At OCSRI, that growth means integrating surface guidance into every treatment—3D, IMRT, DIBH, and even SRS/SBRT—while continuously refining the workflow.

“Every patient, every treatment, every day, we trust SGRT,” Barrett says. “And that trust came from learning together.”

Lesson learned: The real success of SGRT comes when it becomes a culture—one built on teamwork, learning, and shared experience that delivers confidence and precision for every patient.

Bottom line: At Oklahoma Cancer Specialists and Research Institute, adopting SGRT was never just about adding new technology—it was about redefining how the entire team works together. Their success shows that when learning and collaboration become part of the clinic’s culture, confidence and consistency follow. To explore how your clinic can begin its own SGRT journey, click here to request a personalized demonstration from the C-RAD experts.

Many cancer centers, including Mercy’s David C. Pratt Cancer Center in St. Louis, are discovering that innovation isn’t just about acquiring the large radiotherapy equipment—it’s often about how advanced tools like surface guidance are integrated into existing workflows. We turned to C-RAD’s SGRT to bring more precision and confidence to our expanding proton therapy program. What started as a positioning aid has become a key part of how we deliver accurate, patient-focused care—building on the same principles that made surface guidance a staple in high-precision photon treatments.

When Oklahoma Cancer Specialists and Research Institute (OCSRI) set out to replace aging radiation therapy equipment, they weren’t just updating machines—they were reimagining precision care.

As a high-volume, physician-owned cancer center treating over 34,000 radiation therapy cases annually, OCSRI needed a solution that would support complex stereotactic treatments, minimize disruption, and reduce the burden on patients and staff alike.

That solution was surface guided radiation therapy (SGRT).