Lived experiences of radiation therapists using health literacy strategies with patients-A qualitative review using interpretative phenomenological analysis.

INTRODUCTION: Adaptive communication is an essential requirement to deliver quality patient-centred care. Determining patients' informational needs and acting on the needs are skills radiation therapists (RTs) employ daily with patients. Learning health literacy (HL) strategies to assist with the informational delivery provides RTs with options to improve patients' understanding of vital radiotherapy treatment information or tasks. This research investigates the lived experiences of RTs from the Illawarra and Shoalhaven Cancer Care Centres in Australia using HL strategies during patient interactions after undertaking HL training workshops. METHODS: An interpretative phenomenological analysis (IPA) approach was used. Audio-recorded semi-structured interviews were conducted with six RTs. Two reviewers analysed each interview script separately before discussing and constructing substantive and sub-themes. RESULTS: Four substantive themes were constructed: RT personal attitudes and responses to HL, HL strategies used by RTs, patient associated HL needs and barriers when addressing patient HL needs. RTs were either person- or process-focussed during patient interactions. It was identified that information is provided to patients according to how RTs themselves like to learn new information. CONCLUSION: This research has allowed an opportunity to inquire into the lived experiences of RTs implementing HL strategies when providing information to patients. While RTs may be person or process-focussed, the patient's needs are always prioritised when providing information, which ultimately results in patient understanding and increased engagement.

A radiation therapist's guide to health literacy: A narrative review.

Radiation therapist (RT) communication plays an essential part of patient-centred care in achieving better patient outcomes within radiation oncology. Patients present from a range of social circumstances, education levels and cultural backgrounds, all of which may significantly impact their level of health literacy (HL). Using literature sourced from databases such as EMCare Nursing & Allied Health Database, MEDLINE(R) and APA PsycInfo, this narrative review explores HL definitions, international comparison rates and indications of individual low HL. It also reviews HL assessments as well as exploring enablers and barriers to HL from the RT perspective. Strategies from both the individual or organisational perspective are provided for RTs to begin or continue their HL interest. By educating the radiation therapy profession about health literacy and making small changes in interpersonal interactions, there is the opportunity to impact patients' experiences and outcomes significantly.

Determining optimal planning target volume and image guidance policy for post-prostatectomy intensity modulated radiotherapy.

BACKGROUND: There is limited information available on the optimal Planning Target Volume (PTV) expansions and image guidance for post-prostatectomy intensity modulated radiotherapy (PP-IMRT). As the prostate bed does not move in a uniform manner, there is a rationale for anisotropic PTV margins with matching to soft tissue. The aim of this study is to find the combination of PTV expansion and image guidance policy for PP-IMRT that provides the best balance of target coverage whilst minimising dose to the organs at risk. METHODS: The Cone Beam CT (CBCT) images (n = 377) of 40 patients who received PP-IMRT with daily online alignment to bony anatomy (BA) were reviewed. Six different PTV expansions were assessed: 3 published PTV expansions (0.5 cm uniform, 1 cm uniform, and 1 + 0.5 cm posterior) and 3 further anisotropic PTV expansions (Northern Sydney Cancer Centre (NSCC), van Herk, and smaller anisotropic). Each was assessed for size, bladder and rectum coverage and geographic miss. Each CBCT was rematched using a superior soft tissue (SST) and averaged soft tissue (AST) match. Potential geographic miss was assessed using all PTV expansions except the van Herk margin. RESULTS: The 0.5 cm uniform expansion yielded the smallest PTV (median volume = 222.3 cc) and the 1 cm uniform expansion yielded the largest (361.7 cc). The Van Herk expansion includes the largest amount of bladder (28.0 %) and rectum (36.0 %) and the 0.5 cm uniform expansion the smallest (17.1 % bladder; 10.2 % rectum). The van Herk PTV expansion had the least geographic miss with BA matching (4.2 %) and the 0.5 cm uniform margin (28.4 %) the greatest. BA matching resulted in the highest geographic miss rate for all PTVs, followed by SST matching and AST matching. Changing from BA to an AST match decreases potential geographic miss by half to two thirds, depending on the PTV expansion, to <10 % for all PTV expansions. When using the smaller anisotropic PTV expansion, AST matching would reduce the geographic miss rate from 21.0 % with BA matching down to 5.6 %. CONCLUSIONS: Our results suggest the optimal PTV expansion and image guidance policy for PP-IMRT is daily average soft tissue matching using CBCT scans with a small anisotropic PTV expansion of 0.5 cm in all directions apart from a 1 cm expansion in the anterior-posterior direction in the upper prostate bed. Care must be taken to ensure adequate training of Radiation Therapists to perform soft tissue matching with CBCT scans.

The importance of prostate bed tilt during postprostatectomy intensity-modulated radiotherapy.

Variations in rectal and bladder filling can create a tilt of the prostate bed, which generates the potential for a geographic miss during postprostatectomy radiotherapy. The aim of this study is to assess the effect that bladder and rectum filling has on planning target volume angle, to determine a method to assess prostate bed tilt leading to potential geographic miss, and to discuss possible implementation issues. The cone-beam computed tomography images (n = 377) of 40 patients who received postprostatectomy radiotherapy with intensity-modulated radiotherapy were reviewed. The amount of tilt in the prostate bed was defined as the angle change between 2 surgical clips, one in the upper prostate bed and another in the lower. A potential geographic miss was defined as movement of any clip of more than 1cm in any direction or 0.5 cm posteriorly when aligned to bone anatomy. Variations in bladder and rectum size were correlated with the degree of prostate bed tilt, and the rate of potential geographic miss was determined. A possible clinical use of prostate bed tilt was then assessed for different imaging techniques. A tilt of more than 10° was seen in 20.2% of images, which resulted in a 57.9% geographic miss rate of the superior clip. When tilt remained within 10°, there was only a 9% rate of geographic miss. Potential geographic miss of the inferior surgical clip was rare, occurring in only 1.9% of all images reviewed. The most common occurrence when the prostate bed tilt increased by more than 10° was a smaller bladder and larger rectum (6.4% of all images). The most common occurrence when the prostate bed tilt decreased by more than 10° was a larger bladder and smaller rectum (1.3% of all images). Significant prostate bed tilt (>± 10°) occurred in more than 20% of images, creating a 58% rate of geographic miss. Greatest prostate bed tilt occurred when the bladder size increased or reduced by more than 2 cm or the superior rectum size increased by more than 1.5 cm or reduced by more than 1cm from the planned size. Using prostate bed tilt could be an effective measurement for assessing potential geographic miss on orthogonal images if volumetric imaging is unavailable.

The impact of rectal and bladder variability on target coverage during post-prostatectomy intensity modulated radiotherapy.

BACKGROUND AND PURPOSE: Accuracy when delivering post-prostatectomy intensity modulated radiotherapy (IMRT) is crucial. The aims of this study were to quantify prostate bed movement and determine what amount of bladder or rectum size variation creates the potential for geographic miss. METHODS AND MATERIALS: The Cone Beam CT (CBCT) images (n=377) of forty patients who received post-prostatectomy IMRT with daily on-line alignment to bony anatomy were reviewed. Prostate bed movement was estimated using the location of surgical clips in the upper and lower sections of the PTV and correlated with rectal and bladder filling (defined as changes in the cross sectional diameter at defined levels). The number of potential geographic misses caused by bladder and rectum variation was calculated assuming a uniform CTV to PTV expansion of 1cm except 0.5 cm posteriorly. RESULTS: Variations in bladder filling of >2 cm larger, ±1 cm, or >2 cm smaller occurred in 3.4%, 56.2%, and 15.1% of images respectively with potential geographic misses in the upper prostate bed of 61.5%, 9.9% and 26.3% respectively. Variations in rectal filling in the upper prostate bed of >1.5 cm larger, 1.5 cm larger to 1cm smaller, and >1cm smaller occurred in 17.2%, 75.6%, and 7.2% of images respectively. These variations resulted in geographic misses in the upper prostate bed in 29.2%, 12.3%, and 63.0% of images respectively. Variations in bladder and rectal filling in the lower prostate bed region had minimal impact on geographic misses. CONCLUSIONS: Bladder and rectal size changes at treatment affect prostate bed coverage, especially in the upper aspect of the prostate bed. The greatest potential for geographic miss occurred when either the bladder increased in size or when the rectum became smaller. Ensuring a full bladder and empty rectum at simulation will minimise this risk. Our data also support anisotropic PTV margins with larger margins superiorly than inferiorly.

A dosimetric comparison of 3D-CRT, IMRT, and static tomotherapy with an SIB for large and small breast volumes.

Radiation therapy to the breast is a complex task, with many different techniques that can be employed to ensure adequate dose target coverage while minimizing doses to the organs at risk. This study compares the dose planning outcomes of 3 radiation treatment modalities, 3 dimensional conformal radiation therapy (3D-CRT), intensity-modulated radiation therapy (IMRT), and static tomotherapy, for left-sided whole-breast radiation treatment with a simultaneous integrated boost (SIB). Overall, 20 patients with left-sided breast cancer were separated into 2 cohorts, small and large, based on breast volume. Dose plans were produced for each patient using 3D-CRT, IMRT, and static tomotherapy. All patients were prescribed a dose of 45Gy in 20 fractions to the breast with an SIB of 56Gy in 20 fractions to the tumor bed and normalized so that D98% > 95% of the prescription dose. Dosimetric comparisons were made between the 3 modalities and the interaction of patient size. All 3 modalities offered adequate planning target volume (PTV) coverage with D98% > 95% and D2% < 107%. Static tomotherapy offered significantly improved (p = 0.006) dose homogeneity to the PTVboost eval (0.079 ± 0.011) and breast minus the SIB volume (BreastSIB) (p < 0.001, 0.15 ± 0.03) compared with the PTVboost eval (0.085 ± 0.008, 0.088 ± 0.12) and BreastSIB (0.22 ± 0.05, 0.23 ± 0.03) for IMRT and 3D-CRT, respectively. Static tomotherapy also offered statistically significant reductions (p < 0.001) in doses to the ipsilateral lung mean dose of 6.79 ± 2.11Gy compared with 7.75 ± 2.54Gy and 8.29 ± 2.76Gy for IMRT and 3D-CRT, respectively, and significantly (p < 0.001) reduced heart doses (mean = 2.83 ± 1.26Gy) compared to both IMRT and 3D-CRT (mean = 3.70 ± 1.44Gy and 3.91 ± 1.58Gy). Static tomotherapy is the dosimetrically superior modality for the whole breast with an SIB compared with IMRT and 3D-CRT. IMRT is superior to 3D-CRT in both PTV dose conformity and reduction of mean doses to the ipsilateral lung.

Definition and visualisation of regions of interest in post-prostatectomy image-guided intensity modulated radiotherapy.

INTRODUCTION: Standard post-prostatectomy radiotherapy (PPRT) image verification uses bony anatomy alignment. However, the prostate bed (PB) moves independently of bony anatomy. Cone beam computed tomography (CBCT) can be used to soft tissue match, so radiation therapists (RTs) must understand pelvic anatomy and PPRT clinical target volumes (CTV). The aims of this study are to define regions of interest (ROI) to be used in soft tissue matching image guidance and determine their visibility on planning CT (PCT) and CBCT. METHODS: Published CTV guidelines were used to select ROIs. The PCT scans (n = 23) and CBCT scans (n = 105) of 23 post-prostatectomy patients were reviewed. Details on ROI identification were recorded. RESULTS: Eighteen patients had surgical clips. All ROIs were identified on PCTs at least 90% of the time apart from mesorectal fascia (MF) (87%) due to superior image quality. When surgical clips are present, the seminal vesicle bed (SVB) was only seen in 2.3% of CBCTs and MF was unidentifiable. Most other structures were well identified on CBCT. The anterior rectal wall (ARW) was identified in 81.4% of images and penile bulb (PB) in 68.6%. In the absence of surgical clips, the MF and SVB were always identified; the ARW was identified in 89.5% of CBCTs and PB in 73.7%. CONCLUSIONS: Surgical clips should be used as ROIs when present to define SVB and MF. In the absence of clips, SVB, MF and ARW can be used. RTs must have a strong knowledge of soft tissue anatomy and PPRT CTV to ensure coverage and enable soft tissue matching.

Prostate bed motion may cause geographic miss in post-prostatectomy image-guided intensity-modulated radiotherapy.

INTRODUCTION: There is little data to guide radiation oncologists on appropriate margin selection in the post-prostatectomy setting. The aim of this study was to quantify interfraction variation in motion of the prostate bed to determine these margins. METHODS: The superior and inferior surgical clips in the prostate bed were tracked on pretreatment cone beam CT images (n = 377) for 40 patients who had received post-prostatectomy radiotherapy. Prostate bed motion was calculated for the upper and lower segments by measuring the position of surgical clips located close to midline relative to bony anatomy in the axial (translational) and sagittal (tilt) planes. The frequency of potential geographic misses was calculated for either 1 cm or 0.5 cm posterior planning target volume margins. RESULTS: The mean magnitude of movement of the prostate bed in the anterior-posterior, superior-inferior and left-right planes, respectively, were as follows: upper portion, 0.50 cm, 0.28 cm, 0.10 cm; lower portion, 0.18 cm, 0.18 cm, 0.08 cm. The random and systematic errors, respectively, of the prostate bed motion in the anterior-posterior, superior-inferior and left-right planes, respectively, were as follows: upper portion, 0.47 cm and 0.50 cm, 0.28 cm and 0.27 cm, 0.11 cm and 0.11 cm; lower portion, 0.17 cm and 0.18 cm, 0.17 cm and 0.19 cm, 0.08 cm and 0.10 cm. Most geographic misses occurred in the upper prostate bed in the anterior-posterior plane. The median prostate bed tilt was 1.8° (range -23.4° to 42.3°). CONCLUSIONS: Variability was seen in all planes for the movement of both surgical clips. The greatest movement occurred in the anterior-posterior plane in the upper prostate bed, which could cause geographic miss of treatment delivery. The variability in the movement of the superior and inferior clips indicates a prostate bed tilt that would be difficult to correct with standard online matching techniques. This creates a strong argument for using anisotropic planning target volume margins in post-prostatectomy radiotherapy.

Ability of radiation therapists to assess radiation-induced skin toxicity.

INTRODUCTION: Radiation therapy has seen enhancement of the radiation therapist (RT) role, with RTs and nurses performing duties that were traditionally in the radiation oncologist's (RO) domain. This study aimed to assess whether RTs can consistently grade radiation-induced skin toxicity and their concordance with the gradings given by ROs. METHOD: Digital photographs of skin reactions were taken at weeks 1, 3 and 6 of radiotherapy on nine patients with breast cancer. The randomly ordered photographs were reviewed once by eight ROs and four RO registrars and on two occasions separated by 6 weeks by 17 RTs. All graded the skin toxicities using the revised Radiation Therapy Oncology Group system. RESULTS: No significant difference was seen between the median scores of the RTs at the first scoring session and the RO/Registrar group. The RTs at both measurement times showed greater inter-rater reliability than the RO/Registrars (W = 0.6866, time 1 and 0.6981 time 2, vs. 0.6517), with the experienced RTs the most consistent (W = 0.7078). The RTs also showed high intra-rater reliability (rho = 0.8461, P < 0.0010). CONCLUSION: These results from RTs with no specific preparation indicate that experienced RTs could assess breast cancer skin toxicity as part of their role.

Inter- and intra-fraction motion during radiation therapy to the whole breast in the supine position: a systematic review.

Inter- and intra-fraction motion during radiation therapy for breast cancer has been a widely researched topic. Recently, however, with the emergence of new technologies and techniques such as intensity modulated radiation therapy (IMRT), field in field, volumetric modulated arc therapy (VMAT), tomotherapy and partial breast irradiation (PBI), the magnitude of this movement has become more important. The aim of this study is to provide a comprehensive summary of the literature relating to the magnitude of motion during radiation therapy for a breast cancer patient. A systematic review of the literature was conducted using Medline, Cinhal, Embase, Scopus and Web of Science. Studies included were limited to women having radical radiation therapy to the whole breast in the supine position. Studies needed to report quantitatively on the magnitude of inter- and intra-fraction motion using electronic portal imaging, port films or kilovoltage imaging techniques. Eighteen articles fitted the selection criteria. The averages of random and systematic error for inter- and intra-fraction movement were reported using central lung distance, central irradiated width, central beam edge to skin distance and cranio-caudal distance measurements, or isocentric matching techniques. Inter-fraction motion was consistently larger than intra-fraction motion but, on average, within a 5 mm tolerance. There were, though, large maximum inter- and intra-fraction variations observed in the measurements of individual patients, which indicate the need for daily inter- and intra- fraction motion management before implementing IMRT, VMAT, tomotherapy or PBI techniques.