The use of rigid carbon fiber couch inserts in radiotherapy treatment couches is a well-established method of reducing patient set-up errors associated with couch sag. Several published studies have described such inserts as radiotranslucent with negligible attenuation of the radiation field. Most of these studies were conducted with the radiation field normally incident on the couch and there appears to be no evidence in the literature of the effect of the gantry angle on the extent of beam attenuation by the carbon fiber insert alone during external beam radiotherapy. In this study we examined the magnitude of this effect over a range of posterior oblique gantry angles using a cylindrical solid water phantom containing an ionization chamber placed isocentrically. It was found that a 6 MV photon beam, field size 10 x 5 cm, was attenuated significantly as the gantry angle approached the plane of the couch, from 2% at normal incidence and reaching 9% attenuation at angle of incidence 70 degrees. This could have serious implications regarding dose to the treatment volume for treatments requiring posterior oblique angles of incidence with a possible correction factor necessary in monitor unit calculations.

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MGD is dependent upon compressed breast thickness and it is recommended that DRL values should be specific to compressed breast thickness and image detector technology.

In 2001 the ACPSEM published a position paper on quality assurance in screen film mammography which was subsequently adopted as a basis for the quality assurance programs of both the Royal Australian and New Zealand College of Radiologists (RANZCR) and of BreastScreen Australia. Since then the clinical implementation of digital mammography has been realised and it has become evident that existing screen-film protocols were not appropriate to assure the required image quality needed for reliable diagnosis or to address the new dose implications resulting from digital technology. In addition, the advantages and responsibilities inherent in teleradiology are most critical in mammography and also need to be addressed. The current document is the result of a review of current overseas practice and local experience in these areas. At this time the technology of digital imaging is undergoing significant development and there is still a lack of full international consensus about some of the detailed quality control (QC) tests that should be included in quality assurance (QA) programs. This document describes the current status in digital mammography QA and recommends test procedures that may be suitable in the Australasian environment. For completeness, this document also includes a review of the QA programs required for the various types of digital biopsy units used in mammography. In the future, international harmonisation of digital quality assurance in mammography and changes in the technology may require a review of this document. Version 2.0 represented the first of these updates and key changes related to image quality evaluation, ghost image evaluation and interpretation of signal to noise ratio measurements. In Version 3.0 some significant changes, made in light of further experience gained in testing digital mammography equipment were introduced. In Version 4.0, further changes have been made, most notably digital breast tomosynthesis (DBT) testing and QC have been addressed. Some additional testing for conventional projection imaging has been added in order that sites may have the capability to undertake dose surveys to confirm compliance with diagnostic reference levels (DRLs) that may be established at the National or State level. A key recommendation is that dosimetry calculations are now to be undertaken using the methodology of Dance et al. Some minor changes to existing facility QC tests have been made to ensure the suggested procedures align with those most recently adopted by the Royal Australian and New Zealand College of Radiologists and BreastScreen Australia. Future updates of this document may be provided as deemed necessary in electronic format on the ACPSEM's website ( https://www.acpsem.org.au/whatacpsemdoes/standards-position-papers and see also http://www.ranzcr.edu.au/quality-a-safety/radiology/practice-quality-activities/mqap ).

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