Take Action Protocol: A radiation therapist led approach to act on anatomical changes seen on CBCT

Pan-Canadian assessment of image guided adaptive radiation therapy and the role of the radiation therapist

Purpose

Adaptive radiation therapy (ART) is a close-looped process where anatomic changes observed during treatment are identified, leading to plan modification prior to treatment delivery. The aim of this study was to explore the status of ART across Canada and review the impact of adaptive technologies on the roles and responsibilities of Radiation Therapists (RTTs).

Materials and Methods

Study information and a link to a 30-question survey was sent via email to the RTT manager of all cancer centres across Canada (n = 48). The survey questions included centre demographics, presence of offline and/or online ART activities as standard of care, corresponding roles and responsibilities of the multidisciplinary team, and training activities. The survey was administered electronically and closed after a 3-week accrual period. Responses were analyzed using descriptive statistics.

Results

Thirty-two out of 48 centres responded across all ten provinces (67 % response rate). Twenty-five centres (78 %) currently perform ART, all of which practiced offline ART while 5 practiced online ART. Most common responses for lack of ART were 'technical limitations' and 'lack of resources'. RTTs are responsible for 50 % (offline) versus 58 % (online) ART respectively, with the most notable change being the addition of target delineation to their daily practice.

Conclusions

The status of ART varies across Canada. Offline ART is commonly practiced, but online ART remains an infrequent process due to technical limitations and lack of resources. As centres move towards implementing online ART, the role of the RTT will need to be redefined with corresponding upskilling to support the emergent treatment paradigm.

Clinical implementation of RTT-only CBCT-guided online adaptive focal radiotherapy for bladder cancer

Purpose

The study assesses the clinical implementation of radiation therapist (RTT)-only Conebeam CT (CBCT)-guided online adaptive focal radiotherapy (oART) for bladder cancer, by describing the training program, analyzing the workflow and monitoring patient experience.

Materials and methods

Bladder cancer patients underwent treatment (20 sessions) on a ring-based linac (Ethos, Varian, a Siemens Healthineers Company, USA). Commencing April 2021, 14 patients were treated by RTTs supervised by the Radiation Oncologist (RO) and Medical Physics Expert (MPE) in a multidisciplinary workflow. From March 2022, 14 patients were treated solely by RTTs. RTT training included target delineation lessons and practicing oART in a simulation environment. We analyzed the efficiency of the RTT-only workflow regarding session time, adjustments by RTTs, attendance of the RO and MPE at the linac, and qualitative assessment of gross tumor volume (GTV) delineation. Patient experience was monitored through questionnaires.

Results

A training program resulted in a skilled team of RTTs, ROs and MPEs.The RTT-only workflow demonstrated shorter session times compared to the multidisciplinary approach. Among 14 patients treated using the RTT-only workflow, RTTs adjusted 99% of bladder volumes and 44% of GTV. 79% of the sessions proceeded without MPEs and ROs. All GTV delineations were RO-approved, thus considered clinically acceptable, and 87% required minor or no adjustments. Patient satisfaction was reported in 18 of 21 cases.

Conclusions

The RTT-only oART workflow for bladder cancer, complemented by a training program and on-call support from ROs and MPEs, demonstrated success. Patient experience is positive. It is currently introduced as standard in our clinic.

A code orange for traffic-light-protocols as a communication mechanism in IGRT

Introduction

Traffic-light protocols (TLPs) use color codes to standardize image registration and improve interdisciplinary communication in IGRT. Generally, green indicates no relevant anatomical changes, orange signals changes requiring follow-up but does not compromise the current fraction, and red flags unacceptable changes. This study examines the communication aspect, specifically the reporting accuracy for locally advanced non-small-cell lung cancer (LA-NSCLC), and identifies barriers to reporting.

Materials & Methods

We conducted a retrospective study on 1997 CBCTs from 74 LA-NSCLC patients. Each scan was in retrospect assessed blinded using the tailored TLP by an IGRT-RTT and subsequently by a second RTT for a subset of fractions. The assessment included both CBCTs from current clinical practice (TLP2023) and from the TLP implementation period (TLP2019). Accuracy of image registration was not evaluated. Reporting barriers were identified through focus group discussions with RTTs.

Results

During TLP2023, 22 of the 63 (35%) patients received at least one code orange during therapy, with 2 of them having a systematic code orange, totaling 43 (2%) fractions with at least one code orange. The IGRT-RTT assigned code orange or red in 59 (94%) patients, 38 (60%) of which had systematic codes orange. In total, the IGRT-RTT reported 684 (40%) fractions with code orange and 13 with code red. During TLP2019, similar numbers are observed. In the subset reviewed by two IGRT-RTTs, reports matched in 77% of cases. Various factors contribute to a low reporting rate, originating both during the decision-making process such as lack of online reporting tools and within offline processes such as divergent feedback expectations.

Conclusion

While our TLP has successfully promoted the widespread adoption of CBCT-based RTT-led IGRT, it has not succeeded in establishing interdisciplinary communication. Our study reveals significant underreporting of flagged LA-NSCLC fractions in clinical practice using a TLP. This underreporting stems from multifactorial origins.

The Radiation Therapist profession through the lens of new technology: A practice development paper based on the ESTRO Radiation Therapist Workshops

Technological advances in radiation therapy impact on the role and scope of practice of the radiation therapist. The European Society of Radiotherapy and Oncology (ESTRO) recently held two workshops on this topic and this position paper reflects the outcome of this workshop, which included radiation therapists from all global regions. Workflows, quality assurance, research, IGRT and ART as well as clinical decision making are the areas of radiation therapist practice that will be highly influenced by advancing technology in the near future. This position paper captures the opportunities that this will bring to the radiation therapist profession, to the practice of radiation therapy and ultimately to patient care.

[The first steps towards advanced practice for radiation therapists]

The implementation of advanced practice in RT requires evidence regarding the clinical practices of radiation therapists (RTT) in the field. In this context, the goal of this article is to report the roles assigned to RTT in order to meet the demands of patients, RT services, and/or healthcare professionals. As part of the French Society of Oncologic Radiotherapy's congress, the Radiotherapy Committee of the French Association of radiographers presented a scientific program encompassing three main themes: patient follow-up by a RTT, the expertise of an RTT in Image Guided Radiation Therapy (IGRT), Adaptive Radiotherapy (ART), and the involvement of a RTT in research. This article presents an overview of five oral presentations that highlight concrete examples of roles assigned to RTTs in these specific domains. The follow-up of patients has been assigned to RTT. Research and development have been recognized as activities in which RTT play a significant role. The establishment of RTT specializing in IGRT has been reported to facilitate decision-making and is essential in ensuring professional expertise. Lastly, there is a need to enhance RTT skills in adaptive RT to support the implementation of this technique. These roles described as advanced practice meet needs and require a specific organisational framework and appropriate education and training (master type). Activities such as post-RT follow-up, validation of positioning imaging, delineation, writing research protocols, and involvement in the development of technological innovations were identified as essential tasks that can be assigned to RTT.

A comparative study of rectal volume variation in patients with prostate cancer: A tertiary care center study

INTRODUCTION

Every day variations in rectal filling in prostate cancer radiotherapy can significantly alter the delivered dose distribution from what was intended. The goal of this study was to see if the time of treatment delivery affected the rectal filling.

METHODS

This is a retrospective study which included 50 patients with localized prostate cancer treated with volumetric modulated arc therapy (VMAT) to the primary and regional lymph nodes. Cone Beam Computed Tomography (CBCT) image-sets were done for all patient's daily setup verification. The radiation therapist contoured the rectum on all CBCT image sets. The rectal volumes delineated on CBCT and the planning CT image sets were compared. The change in rectal volumes between morning and afternoon treatments were calculated and compared.

RESULTS

A total of 1000 CBCT image sets were obtained on 50 patients in the morning and afternoon. The percentage variation of the CBCT rectal volumes over the planning CT scan was 16.57% in the AM group and 24.35% in the PM group.

CONCLUSION

The percentage change in rectal volume was significantly lesser in AM group compared to PM group and therefore morning treatments may result in dose distribution that is close to the intended dose distribution.

IMPLICATIONS FOR PRACTICE

In prostate cancer radiotherapy our study suggests that a simple technique of changing the time of treatment from afternoon to morning can help to reduce the rectal volume.

Online adaptive MR-guided radiotherapy: Conformity of contour adaptation for prostate cancer, rectal cancer and lymph node oligometastases among radiation therapists and radiation oncologists

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Contour adaptation conformity analyzed for LN-metastases, rectal- + prostate cancer.

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Contour adaptation conformity among RTTs and radiation oncologists is comparable.

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Role expansion of RTTs with daily contour adaptation impacts workflow efficiency.

Background and purpose

Online adaptive MR-guided treatment planning workflows facilitate daily contour adaptation to the actual anatomy. Allocating contour adaptation to radiation therapists (RTTs) instead of radiation oncologists (ROs) might allow for increasing workflow efficiency. This study investigates conformity of adapted target contours provided by dedicated RTTs and ROs.

Materials and methods

In a simulated online procedure, 6 RTTs and 6 ROs recontoured targets and organs at risk (OAR) in prostate cancer (n = 2), rectal cancer (n = 2) and lymph node-oligometastases (n = 2) cases. RTTs gained contouring competence beforehand by following a specific in-house training program. For all target contours and the reference delineations volumetric differences were determined and Dice similarity coefficient (DSC), conformity index (CI) and generalized CI were calculated. Delineation time and –confidence were registered for targets and OAR. Impact of contour adaptation on treatment plan quality was investigated.

Results

Delineation conformity was generally high with DSC, CI and generalized CI values in the range of 0.81–0.94, 0.87–0.95 and 0.63–0.85 for prostate cancer, rectal cancer and LN-oligometastasis, respectively. Target volumes were comparable for both, RTTs and ROs. Time needed and confidence in contour adaptation was comparable as well. Treatment plans derived with adapted contours did not violate dose volume constrains as used in clinical routine.

Conclusion

After tumor site specific training, daily contour adaptations as needed in adaptive online radiotherapy workflows can be accurately performed by RTTs. Conformity of the derived contours is high and comparable to contours as provided by ROs.

Advanced practice roles of therapeutic radiographers/radiation therapists: A systematic literature review

INTRODUCTION

Advances in Radiotherapy (RT) technology and increase of complexity in cancer care have enabled the implementation of new treatment techniques. Subsequently, a greater level of autonomy, responsibility, and accountability in the practice of Therapeutic Radiographers/Radiation Therapists (TR/RTTs) has led to Advanced Practice (AP) roles. The published evidence of this role is scattered with confusing terminology and divergence regarding the perception of whether a specific role represents AP internationally. This study aims to establish an international baseline of evidence on AP roles in RT to identify roles and activities performed by TR/RTTs at advanced level practice and to summarise the impact.

METHODS

A systematic PRISMA review of the literature was undertaken. Thematic analysis was used to synthesise the roles and associated activities. Six RT external experts validated the list. The impact was scrutinised in terms of clinical, organisational, and professional outcomes.

RESULTS

Studies (n = 87) were included and categorised into four groups. AP roles were listed by clinical area, site-specific, and scope of practice, and advanced activities were organised into seven dimensions and 27 sub-dimensions. Three most-reported outcomes were: enhanced service capacity, higher patient satisfaction, and safety maintenance.

CONCLUSION

Evidence-based AP amongst TR/RTTs show how AP roles were conceptualised, implemented, and evaluated. Congruence studies have shown that TR/RTTs are at par with the gold-standard across the various AP roles.

IMPLICATIONS FOR PRACTICE

This is the first systematic literature review synthetisising AP roles and activities of TR/RTTs. This study also identified the main areas of AP that can be used to develop professional frameworks and education guiding policy by professional bodies, educators and other stakeholders.