Efficacy of topical Calendula officinalis on prevalence of radiation-induced dermatitis: A randomised controlled trial.

OBJECTIVES: A randomised controlled trial was undertaken to compare the efficacy of topical Calendula officinalis (Calendula) versus standard of care (Sorbolene: 10% glycerine in cetomacragol cream) in reducing the prevalence of radiation-induced dermatitis in women undergoing breast cancer radiotherapy. METHODS: A total of 271 women were screened and 82 were randomised. The primary outcome was prevalence of acute radiation-induced dermatitis (RTOG grade 2+) assessed at multiple skin sites. A chi-squared test was conducted for the primary outcome with a worst-case scenario imputation. RESULTS: The recruitment target (n = 178) was not achieved. A total of n = 81 participants were analysed (n = 40 Calendula; n = 41 Sorbolene). There was no detectable difference in prevalence of radiation-induced dermatitis grade 2+ between the Calendula (53%) and Sorbolene (62%) groups (primary analysis OR = 0.87, 95% CI: [0.36, 2.09], P = 0.92; covariate adjusted complete case analysis OR 0.40, 95% CI: [0.13, 1.20], P = 0.10). CONCLUSION: This randomised controlled trial showed no difference between Calendula and standard of care (Sorbolene) for the prevention of radiation-induced dermatitis. However, the study was underpowered (limited recruitment) for the primary comparison.

A simulated clinic to build interprofessional and authentic learning opportunities for shaping future practice in medical radiation professionals.

BACKGROUND: Simulation based learning provides an opportunity to increase student readiness prior to clinical placement. Cross disciplinary learning facilitates interprofessional competency building and improved student appreciation of other health professions, which adds another learning dimension to simulated scenarios. This paper outlines the approach to facilitating an interdisciplinary simulated clinic, where experiences were mapped to common professional capabilities. METHODS: After mapping skill sets and professional capabilities common to both Nuclear Medicine and Radiation Therapy, a mock clinic was planned to address common objectives. The aims of the activity were to prepare students for upcoming clinical placement and to build knowledge and skills in the interprofessional environment. All students were allocated roles of both the health care professional and the patient and introduced to the concept of interprofessional learning in a pre-brief session. During the simulated clinic phase students experienced the other modality through the patient perspective as well as practicing the clinician role within their own modality. Following the simulation students came together for a de-brief session. The activity was evaluated using both online polling and pre and post paper-based surveys. RESULTS: A total of 28 students participated in the simulation: 17 in radiation therapy and 11 in nuclear medicine. All participants agreed that the mock clinic was valuable preparation for clinical placement. Twenty-four completed pre and post surveys, revealed a collective improvement in several measures of interprofessional understanding and application. Free text polled responses in the de-brief session highlighted value for practicing communication, realistic physical resemblance to the real-life scenarios and time pressures. CONCLUSION: When two disciplines were combined in the simulated clinic, students learnt about each other's profession together. Evaluation showed positive improvements in both clinical readiness and interprofessional learning. Simulated tasks in healthcare education bought many benefits in preparing students for the workplace and in this example, enabled common objectives of interprofessional practice to be met.

Proton radiation therapy patient selection and impacts of COVID-19: A scoping review.

This scoping review aimed to determine whether the COVID-19 pandemic influenced any modifications to patient selection methods or prioritisation and services provided by proton therapy (PT) centres. This review was conducted based on the PRISMA methodology and Joanna Briggs Institute scoping review guidelines. A literature search was performed in Medline, Embase, Web of Science and Scopus, as well as grey literature. Keywords such as "COVID-19" and "Proton Therapy" were used. Articles published from 1 January 2020 in English were included. In total, 138 studies were identified of which 11 articles met the inclusion criteria. A scoping review design was chosen to capture the full extent of information published relating to the aim. Six of 11 articles included statements regarding treatment of COVID-19 patients. Three publications recommended deferred or alternative treatment, two indicated to treat urgent/emergency patients and one reported continuous treatment for infectious patients. Recurring impacts on PT provision included more frequent use of unconventional therapies, reduced referrals, delayed treatment starts and CT simulation, change in treatment target volumes and staffing limitations due to pandemic restrictions. Consequently, telehealth consults, remote work, reduction in patient visitors, screening procedures and rigorous cleaning protocols were recommended. Few publications detailed changes to patient selection or workflow methods during the pandemic. Further research is needed to obtain more detailed information regarding current global patient selection methods in PT, collecting this data could aid in future planning for PT in Australia.

'Is the technology essential or emerging?' Ways to keep radiation therapy curriculum agile amid rapidly advancing technology.

Advancing technology in radiation therapy can significantly influence clinical practice and improvement of patient outcomes. In the process, innovations in technology require that changes to clinical practice are adopted within education settings. This commentary aims to describe the uptake of new technology and ways that academics provide an up-to-date curriculum when today's innovation is tomorrow's contemporary practice.

A scoping review of patient selection methods for proton therapy.

The aim was to explore various national and international clinical decision-making tools and dose comparison methods used for selecting cancer patients for proton versus X-ray radiation therapy. To address this aim, a literature search using defined scoping review methods was performed in Medline and Embase databases as well as grey literature. Articles published between 1 January 2015 and 4 August 2020 and those that clearly stated methods of proton versus X-ray therapy patient selection and those published in English were eligible for inclusion. In total, 321 studies were identified of which 49 articles met the study's inclusion criteria representing 13 countries. Six different clinical decision-making tools and 14 dose comparison methods were identified, demonstrating variability within countries and internationally. Proton therapy was indicated for all paediatric patients except those with lymphoma and re-irradiation where individualised model-based selection was required. The most commonly reported patient selection tools included the Normal Tissue Complication Probability model, followed by cost-effectiveness modelling and dosimetry comparison. Model-based selection methods were most commonly applied for head and neck clinical indications in adult cohorts (48% of studies). While no 'Gold Standard' currently exists for proton therapy patient selection with variations evidenced globally, some of the patient selection methods identified in this review can be used to inform future practice in Australia. As literature was not identified from all countries where proton therapy centres are available, further research is needed to evaluate patient selection methods in these jurisdictions for a comprehensive overview.

Innovative strategies implemented by universities to support medical radiation science students during the COVID-19 pandemic.

The global COVID-19 pandemic has impacted all facets of life. In medical radiation science (MRS) education, the effects on continuity of learning were felt by educators, students and clinical supervisors both nationally and internationally. The focus of this commentary is on the common elements that impacted MRS students, specifically related to cancelled clinical placements and the interruption to their academic progress at university. An outline is provided of some innovative strategies implemented by universities and clinical departments to support students' academic progress, continuity of clinical experiences, their transition from students to practitioners and overall strategies to support student wellbeing. The recent published literature illustrates novel responses to shared challenges faced, and an opportunity to learn from collective experiences.

Impact of Breast Size on Dosimetric Indices in Proton Versus X-ray Radiotherapy for Breast Cancer.

Deep inspiration breath hold (DIBH) radiotherapy is a technique used to manage early stage left-sided breast cancer. This study compared dosimetric indices of patient-specific X-ray versus proton therapy DIBH plans to explore differences in target coverage, radiation doses to organs at risk, and the impact of breast size. Radiotherapy plans of sixteen breast cancer patients previously treated with DIBH radiotherapy were re-planned with hybrid inverse-planned intensity modulated X-ray radiotherapy (h-IMRT) and intensity modulated proton therapy (IMPT). The total prescribed dose was 40.05 Gy in 15 fractions for all cases. Comparisons between the clinical, h-IMRT, and IMPT evaluated doses to target volumes, organs at risk, and correlations between doses and breast size. Although no differences were observed in target volume coverage between techniques, the h-IMRT and IMPT were able to produce more even dose distributions and IMPT delivered significantly less dose to all organs at risk than both X-ray techniques. A moderate negative correlation was observed between breast size and dose to the target in X-ray techniques, but not IMPT. Both h-IMRT and IMPT produced plans with more homogeneous dose distribution than forward-planned IMRT and IMPT achieved significantly lower doses to organs at risk compared to X-ray techniques.

Effect of patient size on image quality in radiotherapy kV planar verification imaging: a phantom study.

INTRODUCTION: This study aimed to determine a maximal pelvic separation and waist circumference in pelvic patients to guide radiation therapists in acquiring kilovoltage (kV) planar images of acceptable quality for treatment verification. METHODS: A pelvic anthropomorphic phantom modified with different bolus thicknesses was imaged at various default kV exposure settings. Radiation therapists rated image quality and acceptance/rejection of these images for treatment verification. RESULTS: Sixteen radiation therapists participated in the study. Image quality was inversely proportional to phantom size. AP and lateral kV images were acceptable for treatment verification up to a waist circumference of 143 cm. CONCLUSIONS: Exposure settings for kV image verification of large patients should be individualised to avoid unnecessary patient radiation dose through repeated imaging.

Are further studies needed to justify the use of proton therapy for paediatric cancers of the central nervous system? A review of current evidence.

Clinical implementation of proton therapy demonstrated its potential to overcome some limitations of the more traditional, photon-based radiotherapy, due to physical and radiobiological advantages of protons. However, questions concerning the long-term effects of protons on paediatric patients need outcome analysis of the reported literature in order to be answered. The current paper has analysed the available clinical trials and comparative studies (protons vs photons) for paediatric cancers of the central nervous system (CNS) analysing the reported outcomes and follow-up times in order to evaluate the safety of proton therapy for this patient group. Based on the literature analysis, proton therapy for treatment of paediatric cancers of the CNS was found to provide survival and tumour control outcomes comparable, and frequently superior, to photon therapy. Furthermore, the use of protons was shown to decrease the incidence of severe acute and late toxicities, including reduced severity of endocrine, neurological, IQ and QoL deficits. Most commonly, the reported median follow-up time was up to 5 years. Only a few studies reported promising, longer follow-up results. Considering that these patients are likely to survive many of the malignancies reported on, the incidence of long term sequellae impacting growth, development and quality of life into adulthood, should be viewed longitudinally for completeness. The evidence surrounding proton therapy in paediatric tumour management supports its effectiveness and potential benefits in reducing the incidence of late-onset toxicities and second malignancies. For stronger evidence, it is highly desired for future studies to improve current reporting by (1) highlighting the paediatric patient cohort's outcome (in mixed patient groups), (2) reporting the follow-up time, (3) clearly indicating the toxicity criteria used in their evaluation, and (4) identifying the risk group. With this suggested clarity of future reporting, meaningful data to support treatment choice may then be available.

A Retrospective Dosimetric Study of Radiotherapy Patients with Left-Sided Breast Cancer; Patient Selection Criteria for Deep Inspiration Breath Hold Technique.

BACKGROUND: Several studies have investigated cardiac dose reduction when utilizing the deep inspiration breath hold (DIBH) technique in patients undergoing radiotherapy for left-sided breast cancer. This paper aims to recommend potential selection criteria based on a retrospective single institute study of free breathing (FB) and DIBH computed tomography (CT) simulation planning scans. METHODS: Dosimetric comparisons were performed retrospectively for 20 patients correlating the dose reduction and patient anatomical factors (anatomical variation of chest shape, chest wall separation, total lung volume (TLV) and others). RESULTS: Paired t-tests demonstrated significant cardiac dose reduction for most patients but not all. Minimal cardiac dose reduction was observed for three patients using their DIBH plan, with one patient receiving a higher dose. Linear regression analysis identified a positive correlation between the patient's TLV (on the FB CT simulation scan) and the magnitude of dosimetric benefit received (0.4045 R²). CONCLUSION: The TLV measured on a FB plan could potentially be utilised to predict cardiac exposure and assist with patient selection for DIBH. This is important in resource allocation, as DIBH may be unnecessarily recommended for some patients with little dosimetric benefit.

Current status of proton therapy outcome for paediatric cancers of the central nervous system - Analysis of the published literature.

INTRODUCTION: The most common solid tumours that develop in children are cancers of the central nervous system. Due to the increased rate of survival over the past decades, greater focus has been placed on the minimisation of long term side effects. In childhood cancer survivors, over 60% report one or more radiation-related late toxicities while half of these adverse events are graded as life-threatening or severe. Proton therapy enables high conformity with the planning target volume and a reduction in dose to areas beyond the target. Owing to the unique nature of dose delivery with proton therapy a reduction of low doses to normal tissues is achievable, and is believed to allow for a decrease in long-term treatment-related side effects. This paper aims to review the published literature around the effectiveness of proton therapy for the treatment of paediatric cancers of the central nervous system, with a focus on treatment outcomes and treatment-related toxicities. METHODS: A search strategy utilising the Medline database was created with the intent of including all articles reporting on proton therapy, paediatric cancers, CNS tumours and treatment outcomes. The final search strategy included the following limitations: limited to humans, English, published from 2000 onwards. The final article count total was 74. RESULTS AND CONCLUSIONS: Proton therapy for the treatment of paediatric cancers of the central nervous system was found to provide survival and tumour control outcomes comparable to photon therapy. Reduced incidence of severe acute and late toxicities was also reported with the use of proton therapy. This includes reduced severity of endocrine, neurological, IQ and QoL deficits. Currently, extensive follow-up of proton patient populations still needs to be made to determine incidences of late-onset toxicities and secondary malignancies. Current evidence surrounding proton therapy use in paediatric patients supports its effectiveness and potential benefits in reducing the incidence of severe toxicities in later life.

Do SABR-related toxicities for lung cancer depend on treatment delivery?

Stereotactic ablative radiation therapy for lung cancer is an advanced technique where tumours are ablated with hypofractionated radiation doses, with a high degree of accuracy. The aim of this paper is to review the available literature and to discuss the SABR-induced toxicities for lung malignancies as a function of radiation delivery technique. A Medline search was conducted to identify the appropriate literature to fulfil the aim of this review and data from all applicable papers were collated and analysed. The most common techniques of SABR delivery employ linear accelerators, CyberKnife robotic radiosurgery system, TomoTherapy and the Novalis beam surgery system. Linear accelerator-based treatments give rise to a variety of toxicities that are strongly dependent on both patient-related factors and planning/dosimetry-related factors. The limited number of studies using CyberKnife reported low grade toxicities. Grade three toxicities mainly include fatigue and chest pain, usually in less than 10% of patients. All treatment techniques presented show efficiency in SABR delivery with various toxicities which, at this stage, cannot render one technique better than the other. For more conclusive results, well-designed phase three randomised clinical trials are required with better patient selection criteria, including dose and fractionation, treatment machine and technique, along with the consistent selection of a common toxicity grading criterion.

Treatment-Related Adverse Effects in Lung Cancer Patients after Stereotactic Ablative Radiation Therapy.

INTRODUCTION: Lung cancer is a disease which, despite the advancements in treatment, still has a very poor 5-year survival rate. Stereotactic ablative radiation therapy (SABR) is a highly advanced, sophisticated, and safe treatment which allows patients with early stage lung cancer to be treated effectively without invasive procedures and with excellent clinical outcomes. Avoiding surgery minimises morbidity and recovery time, bettering patients' quality of life. Furthermore, SABR allows patients unsuitable for surgery to still undergo curative treatment. METHODS: We aimed to review SABR-related normal tissue toxicities reported in the literature. While many studies assess safety, clinical efficacy, and disease control of SABR for lung cancer, the number of comprehensive reviews that analyse SABR-related side-effects is scarce. This integrative review summarises the toxicities reported in literature based on published clinical trials and tumour location (central or peripheral tumours) for available SABR techniques. Given that the majority of the clinical studies did not report on the statistical significance (e.g., p-values and confidence intervals) of the toxicities experienced by patients, statistical analyses cannot be performed. As a result, adverse events are compiled from clinical reports; however, due to various techniques and nonstandard toxicity reports, no meta-analysis is possible at the current stage of reported data. RESULTS: When comparing lobectomy and SABR in phase III trials, surgery resulted in increased procedure-related morbidity. In phase II trials, very few studies showed high grade toxicities/fatalities as a result of SABR for lung cancer. Gross target volume size was a significant predictor of toxicity. An ipsilateral mean lung dose larger than 9 Gy was significantly associated with radiation pneumonitis. CONCLUSIONS: Based on the studies reviewed SABR is a safe treatment technique for lung cancer; however, further well-designed phase III randomised clinical trials are required to produce timely conclusive results and to enable their comparison and statistical analysis.

An Interprofessional Learning Workshop for Mammography and Sonography Students Focusing on Breast Cancer Care and Management Via Simulation: A Pilot Study.

RATIONALE AND OBJECTIVES: The literature surrounding interprofessional education claims that students who learn with, from, and about one another in well-designed interprofessional programs will practice together collaboratively upon graduation, given the skills to do so. The objective of this study was to examine attitudes to interprofessional practice before and after an interprofessional learning (IPL) activity. MATERIALS AND METHODS: A total of 35 postgraduate medical imaging students attended a week-long mammography workshop. The sessions provided a range of didactic sessions related to diagnosis and management of breast cancer. An IPL session was incorporated on completion of the workshop to consolidate learning. Props and authentic resources were used to increase the fidelity of the simulation. Participants completed pre- and post-workshop questionnaires comprising an interprofessional education and collaboration scale and a quiz to gauge knowledge of specific content related to professional roles. Responses to each statement in the scale and quiz score, pre or post workshop, were compared, whereas responses to open-ended questions in post-workshop survey were thematically analyzed. RESULTS: Seventeen paired surveys were received. There was a significant total improvement of 10.66% (P = .036). After simulation, there was a statistically significant improvement in participants' understanding (P < .05) that IPL offers holistic care to the patient and that teamwork is useful for reducing errors in patient care. Simulation helped participants develop more awareness of their role within the profession, improve their understanding of other professionals, and gain more realistic expectations of team members. CONCLUSION: This pilot study confirmed learning within an IPL simulation improved attitudes toward shared learning, teamwork, and communication. Simulation provides opportunities for learning in a safe environment, and technology can be used in diverse ways to provide authentic learning.

Practice patterns of radiation therapy technology in Australia: results of a national audit.

INTRODUCTION: This article presents the results of a single-day census of radiation therapy (RT) treatment and technology use in Australia. The primary aim of the study was to ascertain patterns of RT practice and technology in use across Australia. These data were primarily collated to inform curriculum development of academic programs, thereby ensuring that training is matched to workforce patterns of practice. METHODS: The study design was a census method with all 59 RT centres in Australia being invited to provide quantitative summary data relating to patient case mix and technology use on a randomly selected but common date. Anonymous and demographic-free data were analysed using descriptive statistics. RESULTS: Overall data were provided across all six Australian States by 29 centres of a possible 59, yielding a response rate of 49% and representing a total of 2743 patients. Findings from this study indicate the increasing use of emerging intensity-modulated radiotherapy (IMRT), image fusion and image-guided radiation therapy (IGRT) technology in Australian RT planning and delivery phases. IMRT in particular was used for 37% of patients, indicating a high uptake of the technology in Australia when compared to other published data. The results also highlight the resource-intensive nature of benign tumour radiotherapy. CONCLUSIONS: In the absence of routine national data collection, the single-day census method offers a relatively convenient means of measuring and tracking RT resource utilisation. Wider use of this tool has the potential to not only track trends in technology implementation but also inform evidence-based guidelines for referral and resource planning.

How do Medical Radiation Science educators keep up with the [clinical] Joneses?

INTRODUCTION: Medical radiation science (MRS) disciplines include medical imaging, radiation therapy and nuclear medicine. These allied health fields are technology driven and evolving rapidly with regard to imaging and treatment techniques within the clinical environment. This research aims to identify the activities academics are currently participating in to maintain clinical currency and offer strategies to support academics to connect with an ever-changing clinical environment. METHODS: A cross-sectional designed survey was sampled across the nine Australian universities where MRS programmes are offered. The survey targeted academic teaching staff that were working in MRS programmes at the time of distribution (n ≈ 90). Enablers and barriers to maintaining clinical currency as well as support to participate in continuing professional development were rated by the respondents. Descriptive statistics were used to analyse quantitative data, and free-text comment responses were collated and themed. RESULTS: There were 38 responses to the survey (42%) and all three disciplines were represented. Responses highlighted activities valued by academics as contributing to their knowledge of current practice and as resources to inform their teaching. Positive elements included participating in clinical work and research, attending clinical sites and training days and attending scientific meetings. Common barriers identified by academics in this area were time constraints, workload allocation and employer/financial support. CONCLUSION: This research has identified that Australian MRS academics participate in a broad range of activities to inform their teaching and maintain knowledge of contemporary clinical practice. A connection with the clinical world is valued highly by academics, however, access and support to maintain that link is often a difficulty and as a result for MRS teaching staff keeping up with the clinical [MRS] Joneses is often a challenge.