Does a radiographer-led palliative radiotherapy pathway provide an efficient service for patients with symptoms of advanced cancer? The Northampton experience

The extended and advanced clinical practices of radiographers worldwide: A scoping review

AIMS

This scoping review aimed to (1) map the global evidence on extended and advanced clinical practices (ACP) performed by radiographers, and (2) provide an overview of the pillars (clinical practice, leadership and management, education, and research) they relate to, as well as the radiology areas and the geographical location where they were developed.

METHODS

Articles were searched in MEDLINE, CINAHL and Embase, and grey literature in ProQuest Dissertation and Theses. Studies concerning radiographers or healthcare professionals with an equivalent title (e.g., radiation technologist) performing extended role or an ACP, regardless of their medical imaging setting or country were included. The review was undertaken following JBI methodological guidance for scoping reviews. The titles and abstracts of the retrieved studies, and then the full texts of the selected papers were assessed by two independent reviewers.

RESULTS

A total of 2617 records were identified, of which 174 articles were included. Most of them reported practices performed in the UK (63%), and less in Canada (19%) and Australia (6%). Advanced or extended practices were linked to all four pillars, but most concerned the clinical practice pillar. The main activities for this pillar were radiograph reporting (22%), patient assessment and management (consultation) in radiotherapy (RT; 21%), RT treatment planning (14%) and ultrasound practice (13%). Studies have also shown radiographers performing breast biopsies, medication prescription, and ultrasound and CT scan reports. The main fields of radiology concerned by the changing roles were radiotherapy (42%) and conventional radiography (36%).  CONCLUSION: Extended or advanced practices are achieved through a wide variety of activities around the world. This scoping review constitutes a knowledge base on the evolution of the practices of radiographers and should contribute to their recognition and development.

Real-World Implementation of Simulation-Free Radiation Therapy (SFRT-1000): A Propensity Score-Matched Analysis of 1000 Consecutive Palliative Courses Delivered in Routine Care

PURPOSE

The feasibility of simulation-free radiation therapy (SFRT) has been demonstrated but information regarding its routine care impact and scalability is lacking.

METHODS AND MATERIALS

In this single-institution, retrospective cohort study, all patients receiving palliative radiation therapy at an Australian tertiary cancer center were eligible for consideration of SFRT unless mask immobilization, a stereotactic technique, or a definitive dose was indicated. Coprimary endpoints were SFRT utilization, impact on consultation-to-RT time, and on-couch treatment duration. Timing metrics were compared with a contemporary local cohort that received simulation-based palliative radiation therapy using unadjusted Wilcoxon rank-sum tests and a propensity score-matched regression. Electronic patient-reported outcomes captured 2-week toxicity and pain response.  RESULTS:  Between April 2018 and February 2024, 2849 palliative radiation courses were delivered, of which 1904 were eligible. Of the 1904 courses, 1000 (52.5% SFRT utilization) received SFRT, including 668 using intensity-modulated radiation therapy/volumetric-modulated arc therapy. A total of 788 individual patients received SFRT and the median age was 71 years (IQR, 61-80) with 59% being male and 42% being Eastern Collaborative Oncology Group 2-4. SFRT utilization increased from 41% to 54% between years 2018-2019 and 2022-2024.  SFRT reduced median consultation-to-RT time from 7.0 to 5.1 days (P < .0001) corresponding to an adjusted average treatment effect in the treated of -2.1 days (95% CI, -2.8 to -1.3). SFRT increased median on-couch treatment duration from 17.8 to 20.5 minutes (P < .0001; adjusted average treatment effect in the treated 2.6 minutes, 95% CI, 1.3-3.9). Patient-Reported Outcomes Version of the Common Terminology Criteria for Adverse Events grade 3 acute toxicity was 9% and at 4 weeks after RT, patients with moderate/severe pain at baseline (≥5/10) had a mean pain reduction of 3.5 points (7.1-3.6; P < .0001).  CONCLUSIONS:  Using widely available technologies, the SFRT-1000 cohort demonstrates routine care scalability with patient-centered and workflow benefits. SFRT is an attractive new paradigm implementable in most settings following adaptation to local requirements. Thus, SFRT opens new avenues to potentially improve access to palliative RT, which remains a global area of need.

Established advanced practice roles in radiation therapy: A scoping review

Advanced practitioners are healthcare professionals that are highly skilled with a particular area of expertise. These roles have been successfully implemented in many healthcare settings, improving efficiency of the service, as well as enhancing the standard of care received by patients. Although advanced practice roles have been implemented in some radiation therapy departments, their implementation have yet to be facilitated in the majority of countries. The purpose of this review is to scope the literature available regarding established advanced practice roles in radiation therapy. The PRISMA strategy for the identification of relevant literature was adhered to. Two data bases, EMBASE and PubMed, were searched using combinations of the key words 'Advanced', 'Practice', 'APRT', 'Radiation', 'Therapy' and 'Radiotherapy'. Exclusion criteria were applied, and citation lists were also screened for additional relevant sources, including grey literature sources. A total of 35 relevant sources were identified that discussed advanced practice radiation therapy roles in the United Kingdom, Singapore, Canada, Australia and the USA. Means of role establishment and scope of practice were defined, and a number of advantages and challenges for advanced practice radiation therapist roles were identified. There are many benefits of implementing advanced practice roles in radiation therapy departments. Though the implementation of these roles can be challenging, the existing evidence indicates that it would be beneficial for the patient, the radiation therapist and the department as a whole. A more systematic approach, including reporting of quantitative outcomes may assist in the more widespread implementation of these roles.

Overcoming uncertainty: A framework to guide the implementation of Australian radiation therapy advanced practitioners

INTRODUCTION

The implementation of radiation therapy advanced practice in Australia has not yet been broadly realised. With anticipated growing demands on cancer services, it is imperative to understand why this is the case, and to strategise a way forward. As a result, we explored the factors influencing the implementation of advanced practitioner radiation therapists (APRT) in Australia. The research outcome was a complex process of Navigating Uncertainty, which described the contextual, social and personal factors surrounding implementation successes and challenges. Further synthesis of the findings was undertaken to highlight the fundamental features influencing this process, with the intention to provide a useful understanding for practitioners seeking APRT implementation.

METHODS

Data were collected through national online focus groups and case studies with 53 participants. Analysis identified a constructivist grounded theory process of Navigating Uncertainty. Further analysis of the categories and properties of the process was undertaken to synthesise findings at a higher level of abstraction.

RESULTS

Four overarching and intertwined factors were influencing the implementation of APRT. Uncertainty occurred when practitioners attempted to conceptualise and assimilate the new role into the workplace. Power was apparent in the advocacy and legitimisation of the APRT by centre leaders. Value was vital to achieving purposeful outcomes. Identity was evident in the personal transition of the APRT, and in the boundary work with others.

CONCLUSION

Recognising and negotiating uncertainty, power, value and identity is essential for APRT implementation strategies to succeed. A framework to guide practitioners towards the implementation of APRT has been described that embodies these factors.

Palliative Care Delivery Systems and Integration With Palliative Care Teams

Radiotherapy (RT) plays a critical role in the palliation of symptoms in patients with advanced or metastatic cancer. To address the growing need for these services, multiple dedicated palliative RT programs have been established. This article serves to highlight the novel ways in which palliative RT delivery systems support patients with advanced cancer. Through early integration of multidisciplinary palliative supportive services, rapid access programs facilitate best practices for oncologic patients at the end of life.

Evaluation of the palliative radiotherapy pathway in a single institute: Can an MR Linac improve efficiency?

BACKGROUND

Palliative radiotherapy (RT) is effectively used to relieve cancer related symptoms. The demand for these services is increasing worldwide. Rapid response clinics have been developed as a means to streamline the palliative RT radiotherapy process and increase efficiency and improve patient experiences. Key components to successful rapid response palliative RT are access to care, streamlined services and innovation. To successfully implement a rapid response RT programme, it is essential to identify gaps between currently provided care and ideal or enhanced care. The aims of this work are to audit the current palliative RT workflow at our institution both prior to and during the coronavirus pandemic. This work reports the impact of covid-19 on rate of palliative RT referrals and proposes a radiographer led, MR guided rapid response workflow to reduce wait times METHODS: A retrospective audit of palliative radiotherapy booking forms was completed over a two yearperiod (2019-2020) to assess the current pathway both prior to and during the covid-19 pandemic. This audit identified patients who had received urgent/emergency spinal RT in the specified timeframe. Further data on these patients was collected using departmental oncology information systems to form a detailed analysis of the pathway and wait times. Data was recorded and analysed using Microsoft Excel.

RESULTS

A total of 813 patients met the inclusion criteria for this audit. Data was reported for 2019 and 2020 separately to determine any significant impact caused by the covid-19 pandemic. In 2020 there was an 11.5% increase in referrals for palliative radiotherapy with an equal portion (81%) of total referrals in each year being for single fractions. Timelines from referral to treatment delivery were reported, with those patients receiving same day single fraction RT palliative radiotherapy undergoing further analysis to determine the amount of time spent in the department. Mean wait time for these patients was 5 hours and 20 minutes in 2019 but increased by 20.9% in 2020.

CONCLUSIONS

The increasing demand for palliative RT due to rising global cancer rates and extended life expectancy due to advanced systemic treatments may lead to increased wait times. An increase in both referrals and mean wait time was seen during the covid-19 pandemic. Improving efficiency and access to care is essential for this population. The MR Linac could play a role in streamlining palliative RT workflows due to its ability to employ a scan, plan and treat model in a single session. This work forms preliminary support for the development of a trial one stop palliative program on the MR Linac.