DIBH reduces right coronary artery and lung radiation dose in right breast cancer loco-regional radiotherapy.

To determine whether deep inspiratory breath-hold (DIBH) reduces dose to organs-at-risk (OAR), in particular the right coronary artery (RCA), in women with breast cancer requiring right-sided post-mastectomy radiotherapy (PMRT) including internal mammary chain (+IMC) radiotherapy (RT). Fourteen consecutive women requiring right-sided PMRT + IMC were retrospectively identified. Nodal delineation was in accordance with European Society for Radiology and Oncology (ESTRO) guidelines and tangential chest wall fields marked. Patients were planned with Anisotropic Analytical Algorithm using free-breathing (FB) and DIBH datasets. Dose was calculated using Acuros External Beam algorithm. FB and DIBH dose comparisons were analyzed for heart, RCA and right lung, as were chest wall and IMC planning target volumes (PTVs). DIBH vs FB resulted in median decreases of: the RCA mean dose by 0.6Gray (Gy) (interquartile range (IQR) 0.1, 1.9) (p = 0.002), RCA max dose by 1.8Gy (IQR 0.8, 6.1) (p = 0.002), and V5Gy by 2.9% (IQR 0.0, 37.2) (p = 0.016). RCA data indicated no statistically significant dosimetric reduction ≥10Gy. A median reduction of 1.7Gy (c -0.0, 7.1) (p = 0.019) in maximum heart dose was recorded with DIBH vs FB; no significant difference was observed in other heart and left anterior descending coronary artery parameters. The median reduction in right lung mean dose was 2.8Gy for DIBH vs FB plans (IQR 1.6, 3.6) (p = 0.001); significant median reductions of V5Gy, V20Gy, and V30Gy were all achieved with DIBH. Chest wall PTV coverage did not significantly differ between DIBH and FB plans; IMC dosimetric coverage improved with use of DIBH (V47.5Gy, V45Gy, V42Gy). DIBH reduced OAR dose in right-sided PMRT + IMC patients. A novel finding was that DIBH decreased RCA dose. Heart and right lung dose were also decreased with DIBH, whilst optimally dosed PTVs were maintained.

Research demographics of Australian medical radiation practitioners.

INTRODUCTION: Advancement within the Medical Radiation Profession has seen an increased need for Medical Radiation Practitioners (MRPs) to develop research skills to provide and access relevant and accurate information to maintain best practice. The aim of this study was to ascertain the current research demographics of Australian Medical Radiation Practitioners (MRPs), determine perceived barriers to participating in research and to establish needs-based initiatives to support MRPs in undertaking research. METHODS: A quantitative and qualitative cross-sectional survey of Australian MRPs using an electronic survey tool was distributed between November and December 2020. Participants were recruited via an invitation email sent to Australian Society of Medical Imaging and Radiation Therapy (ASMIRT) members. A chain-referral sampling technique was adopted for data collection. RESULTS: A total of 431 participants responded to the survey, representing 2.3% of Australian MRPs. The majority of respondents had a bachelor's degree or higher (71.9%) with 8.4% having postgraduate research qualifications (PhD- 3.2%; Professional Doctorate- 0.7%; Masters- 4.5%). Of the respondents, 15.4% plan to undertake postgraduate research in the future, with 68.2% having no plans for postgraduate research. Respondents identified lack of time (47.0%), lack of interest (33.4%), cost (24.2%) and workplace support (23.9%) as contributing factors for not undertaking postgraduate research. CONCLUSION: The number of MRPs who have been awarded or will be awarded a postgraduate degree has increased over recent decades. However, many still indicate a lack of interest in being actively involved in research. Targeted support mechanisms should be implemented to address perceived or real barriers to continue to grow research capacity within the profession.

Safety culture and incident learning systems in radiation oncology: Staff perceptions across Australia and New Zealand.

INTRODUCTION: Radiation therapy has a highly complex pathway and uses detailed quality assurance protocols and incident learning systems (ILSs) to mitigate risk; however, errors can still occur. The safety culture (SC) in a department influences its commitment and effectiveness in maintaining patient safety. METHODS: Perceptions of SC and knowledge and understanding of ILSs and their use were evaluated for radiation oncology staff across Australia and New Zealand (ANZ). A validated healthcare survey tool (the Hospital Survey on Patient Safety Culture) was used, with additional specialty-focussed supporting questions. A total of 220 radiation oncologists, radiation therapists and radiation oncology medical physicists participated. RESULTS: An overall positive SC was indicated, with strength in teamwork (83.7%), supervisor/manager/leader support (83.3%) and reporting events (77.1%). The weakest areas related to communication about error (63.9%), hospital-level management support (60.5%) and handovers and information exchange (58.0%). Barriers to ILS use included 'it takes too long' and that many respondents must use multiple reporting systems, including mandatory hospital-level systems. These are generally not optimal for specific radiation oncology needs. Varied understanding was indicated of what and when to report. CONCLUSION: The findings report the ANZ perspective on ILS and SC, highlighting weaknesses, barriers and areas for further investigation. Differences observed in some areas suggest that a unified state, national or bi-national ILS specific to radiation oncology might eliminate multiple reporting systems and reduce reporting time. It could also provide more consistent and robust approaches to incident reporting, information sharing and analysis.

The impact of radiation therapist-led structured peer review meetings on compliance to Radiation Oncology Practice Standards.

INTRODUCTION: Regular tumour-specific peer review meetings (TPRMs) were established by our group during 2016. A dedicated Quality Assurance Radiation Therapist (QART) was employed in 2018 to co-ordinate the meetings and for each patient, complete the Peer Review Audit Tool (PRAT) of the Royal Australian and New Zealand College of Radiologists (RANZCR). The aim of the current quality assurance study was to investigate the impact of the TPRMs and appointment of the QART on compliance to relevant RANZCR Radiation Oncology Practice Standards (ROPS). METHODS: Tumour-specific peer review meetings for eight tumour sites were assessed across our group's three hospitals from January 2017 to December 2019. Data from meetings were collected using the PRAT or from paper-based minutes and assessed against four ROPS (ROPS 3, 4, 8 and 9). Compliance with each of the four standards was measured by presence of the required documentation and presentation at TPRM, as recorded by the PRAT. RESULTS: There was an increase in the overall number of peer review cases audited from 173 in the 2017 calendar year to 469 in 2018 and 619 in 2019, representing 7%, 18% and 22% of all treatment courses started during these years, respectively. Staging was the most incompletely documented item across all years for audited patients. The request for radiation treatment plan modifications increased year-on-year: modifications were requested for 5% of plans in 2017 (8/172), 18% in 2018 (81/452) and 19% (119/619) in 2019. CONCLUSION: This study has shown that an increase in the number of cases for peer-review audit corresponded to the QART-facilitated TPRMs. Application of the PRAT has identified radiation treatment plan modifications that would otherwise go undetected and without opportunity to improve the quality of patients' treatment or avoid harm.

Evaluating incident learning systems and safety culture in two radiation oncology departments.

INTRODUCTION: Radiation oncology patient pathways are complex. This complexity creates risk and potential for error to occur. Comprehensive safety and quality management programmes have been developed alongside the use of incident learning systems (ILSs) to mitigate risks and errors reaching patients. Robust ILSs rely on the safety culture (SC) within a department. The aim of this study was to assess perceptions and understanding of SC and ILSs in two closely linked radiation oncology departments and to use the results to consider possible quality improvement (QI) of department ILSs and SC. METHODS: A survey to assess perceptions of SC and the currently used ILSs was distributed to radiation oncologists, radiation therapists and radiation oncology medical physicists in the two departments. The responses of 95 staff were evaluated (63% of staff). The findings were used to determine any areas for improvement in SC and local ILSs. RESULTS: Differences were shown between the professional cohorts. Barriers to current ILS use were indicated by 67% of respondents. Positive SC was shown in each area assessed: 69% indicated the departments practised a no-blame culture. Barriers identified in one department prompted a QI project to develop a new reporting system and process, improve departmental learning and modify the overall ILS. CONCLUSION: An understanding of SC and attitudes to ILSs has been established and used to improve ILS reporting, feedback on incidents, departmental learning and the QA program. This can be used for future comparisons as the systems develop.

Radiation therapist-led telephone follow-up: identifying patients who require post-treatment care.

INTRODUCTION: Radiation therapists implemented telephone follow-up (TFU) in 2015 as an additional point of care post-treatment. The purpose of this study was to determine whether TFU identified patients who required additional post-treatment care before the next scheduled review. METHODS: Between January 2015 and July 2016, all patients who were prescribed curative intent treatment aged 18 years or over were called 10 days post-radiation therapy (RT). Eight questions were developed and included asking patients how they were coping, if their side effects were improving, if they needed to contact the hospital and if more dressings were required. Patients who could not be contacted after two attempts were excluded from the study. Microsoft Excel and Statistical Package for Social Sciences (SPSS) were used to analyse the responses. RESULTS: Data were collected from 850 patients. A total of 28/846 (3%) of patients reported they were not coping after RT, with 26/830 (3%) reporting their side effects were getting worse. A total of 97/826 (12%) of patients felt they needed to contact the hospital because they were unwell. This study identified 104/677 (15%) of patients who responded required more dressings, with 67/104 (65.7%) and 10/104 (9.8%) of this cohort identified in the breast, and head and neck groups, respectively. CONCLUSION: Radiation therapist-led TFU has shown to be beneficial in identifying a small cohort of breast and head and neck cancer patients who required additional care post-radiation treatment.

Patient-Specific Heart Constraint: A Tool for Optimization and Evaluation of Mean Heart Dose in Breast Cancer Patients.

PURPOSE: Our institution introduced a patient-specific heart constraint (PSHC) and a mean heart dose (MHD) constraint of 4 Gy for all patients receiving breast radiation therapy (RT) with a simultaneous boost (SIB). This was introduced as a method to calculate the predicted MHD before optimizing IMRT fields. We sought to determine whether the introduction of a PSHC reduced MHD, while maintaining optimally dosed treatment plans. MATERIAL/METHODS: Patients were retrospectively divided into 2 groups, pre- and postintroduction of the PSHC. The breast and SIB Planning Target Volumes (PTVs) were prescribed to 50 Gy and 57 Gy, respectively, in 25 fractions. Plans were generated using a hybrid IMRT technique, 30 Gy using an open tangential field arrangement, and 27 Gy using IMRT fields. The PSHC was calculated using MHD of open tangential field × 2. A paired t test compared PTV coverage and heart doses between cohorts (P < .05 significant). RESULTS: A total of 264 patients were included (138 pre-PSHC and 126 post-PSHC) with 137 right-sided and 127 left-sided treatments. MHD was significantly reduced across both right-sided (-0.4 Gy, P < .0001) and left-sided (-1.2 Gy, P < .0001) treatments overall. Left-sided treatments were further examined between free breathing and deep inspiration breath-hold (DIBH). DIBH showed reduction in MHD, although it was not significant (-0.46 Gy, P = .34). Heart V5 Gy showed reduction in right-sided (-1%, P = .002) and left-sided (-9.2%, P < .0001) treatments overall. Left-sided free breathing showed significant reduction (-8.8%, P < .0001), and DIBH also showed significant reduction (-5.1%, P = .0034). Tumor bed doses remained above the 54.15 Gy (95% of 57 Gy) threshold for all plans. CONCLUSION: Introduction of a PSHC can reduce MHD and V5 Gy for patients receiving whole breast RT with SIB while maintaining optimally dosed plans, with the greatest benefit shown for left-sided, free-breathing treatments.

A Case study of the radiation therapy treatment of a transitional cell carcinoma of the distal urethra.

Urethral carcinoma is a rare urological cancer, accounting for only 1% of malignancies in Australia. The most common histology is transitional cell carcinoma (TCC). The majority of these cancers are treated with surgery. The main purpose of this case study is to describe a novel radiation treatment technique for treatment of this uncommon cancer. This report details organ-preserving treatment for a distal penile urethral cancer using definitive radiation therapy (RT). In May 2016 a 69-year-old male presented to Crown Princess Mary Cancer Centre (CPMCC) with a small TCC of the distal urethra. The patient was offered numerous treatment options, both radical and organ-preserving approaches, and came to a final decision of a course of radiation therapy despite the lack of randomised evidence to guide treatment in this setting. A dose of 66 Gy in 33 fractions from parallel opposed lateral beams was prescribed to the distal penile urethra. This case required an unusual approach to patient set up to allow access for accurate treatment delivery and to maintain patient comfort. The patient tolerated the full course of radiation therapy with expected skin side effects. He has maintained adequate penile function and is currently free from disease at 33 months with ongoing clinical follow-up.

Radiation-induced oesophagitis in breast cancer: Factors influencing onset and severity for patients receiving supraclavicular nodal irradiation.

AIM: The aim of this study was to determine dosimetric factors, such as mean dose and oesophageal length, which may influence the incidence and severity of oesophagitis in breast cancer patients receiving radiotherapy to the supraclavicular nodes. METHODS: This was a single-arm prospective observational study. Toxicity grading was undertaken twice weekly to determine the onset of grade 2 oesophagitis in consecutive patients prescribed IMRT to the breast or chest wall and supraclavicular fossa (SCF) nodes. Recorded variables included mean and maximum doses to the oesophagus, oesophageal length and pharynx length within the treatment area. Multivariate logistic regression and Fishers' exact test were used with a 0.05 significance level to compare the onset of grade 2 oesophagitis with these variables. RESULTS: A total of 77 patients were included in the study. Twenty-four (31%) patients reported grade 2 oesophagitis. There was a higher incidence of grade 2 oesophagitis in patients receiving a mean oesophageal dose of ≥31 Gy compared to those receiving < 31 Gy (18/24 versus 6/24, respectively, P = 0.025). There was a significant difference in the onset of grade 2 toxicity in patients who had ≥ 1 cm of pharynx included in SCF fields compared with those with <1 cm (15/24 versus 9/24, respectively, P = 0.0116). The odds ratios for developing grade 2 oesophagitis were 3.2 (95% CI = 1.05-9.62, P = 0.04) for a mean dose of ≥31 Gy and 3.4 (95% CI = 1.19-9.5, P = 0.022) for ≥1 cm of pharynx in the SCF field. CONCLUSION: By limiting the mean dose to the irradiated oesophagus to <31 Gy during the planning process and ensuring that <1 cm of pharynx is included in the radiation field, oesophageal toxicity may be minimised.

Patient Recruitment in Radiation Therapy Research: An Evaluation of Local Challenges.

INTRODUCTION: Locally-initiated research studies in radiation therapy (RT) aim to substantiate clinical processes and are an effective approach to gather evidence for advances in patient care, new techniques, and protocols. The aim of this study was to retrospectively quantify recruitment challenges at a radiation oncology network (RON). METHODS: Five locally initiated studies were included for analysis through the criteria of being undertaken within 2001-2017, initiated through local research teams, and having recruitment records available. Data extraction from each study included duration, aims, patient activities, recruitment strategy, target number of participants, and number of participants who were recruited/not recruited and who withdrew from the study. Reasons for nonregistration and withdrawal were recorded if available. Two studies are presented as case studies. RESULTS: Included studies were diverse in patient population and study aim and included patient immobilization (lung and breast cancer), evaluation of radiation-induced esophagitis, documentation of anatomical and dosimetric changes in patients with head and neck cancer, and education (breast cancer). The exclusion of non-English-speaking patients, which is significant for the RON, which covers a wide cultural and linguistic diversity, was an important limiting factor, along with RT patients' disinterest in participation. DISCUSSION: Challenges experienced in the evaluated RON studies are similar to non-RT clinical trials and included difficulties with patients interacting with study protocol, health practitioners' influence, and patient-related inclusion issues. CONCLUSION: The resulting database provides a foundation for continued monitoring and documentation of study recruitment practice, which could elicit positive effects on planning and implementation of future patient recruitment strategies in RT locally initiated studies.

Whole breast and excision cavity radiotherapy plan comparison: Conformal radiotherapy with sequential boost versus intensity-modulated radiation therapy with a simultaneously integrated boost.

INTRODUCTION: A comparative study was conducted comparing the difference between (1) conformal radiotherapy (CRT) to the whole breast with sequential boost excision cavity plans and (2) intensity-modulated radiation therapy (IMRT) to the whole breast with simultaneously integrated boost to the excision cavity. The computed tomography (CT) data sets of 25 breast cancer patients were used and the results analysed to determine if either planning method produced superior plans. METHODS: CT data sets from 25 past breast cancer patients were planned using (1) CRT prescribed to 50 Gy in 25 fractions (Fx) to the whole-breast planning target volume (PTV) and 10 Gy in 5Fx to the excision cavity and (2) IMRT prescribed to 60 Gy in 25Fx, with 60 Gy delivered to the excision cavity PTV and 50 Gy delivered to the whole-breast PTV, treated simultaneously. In total, 50 plans were created, with each plan evaluated by PTV coverage using conformity indices, plan maximum dose, lung dose, and heart maximum dose for patients with left-side lesions. RESULTS: CRT plans delivered the lowest plan maximum doses in 56% of cases (average CRT = 6314.34 cGy, IMRT = 6371.52 cGy). They also delivered the lowest mean lung dose in 68% of cases (average CRT = 1206.64 cGy, IMRT = 1288.37 cGy) and V20 in 88% of cases (average CRT = 20.03%, IMRT = 21.73%) and V30 doses in 92% of cases (average CRT = 16.82%, IMRT = 17.97%). IMRT created more conformal plans, using both conformity index and conformation number, in every instance, and lower heart maximum doses in 78.6% of cases (average CRT = 5295.26 cGy, IMRT = 5209.87 cGy). CONCLUSION: IMRT plans produced superior dose conformity and shorter treatment duration, but a slightly higher planning maximum and increased lung doses. IMRT plans are also faster to treat on a daily basis, with shorter fractionation.

Evaluation of flexible and rigid (class solution) radiation therapy conformal prostate planning protocols.

Protocols commonly implemented in radiotherapy work areas may be classified as being either rigid (class solution) or flexible. Because formal evaluation of these protocol types has not occurred within the literature, we evaluated the efficiency of a rigid compared with flexible prostate planning protocol by assessing a series of completed 3D conformal prostate plans. Twenty prostate cancer patients with an average age of 70 years (range, 52-77) and sizes comprising 8 small, 10 medium, and 2 large were planned on the Phillips Pinnacle treatment planning system 6 times by radiation therapists with <2 years, 2-5 years, and >5 years of experience using a rigid and flexible protocol. Plans were critiqued using critical organ doses, confirmation numbers, and conformity index. Plans were then classified as being acceptable or not. Plans produced with the flexible protocol were 53% less likely to require modification (OR 0.47, 95% CI: 0.26, 0.84, p = 0.01). Planners with >5 years of experience were 78% more likely to produce plans requiring modification (OR 1.78, 95% CI: 1.12, 2.83, P = 0.02). Plans according to the flexible protocol took longer (112 min) compared with the time taken using a rigid protocol (68 min) (p < 0.001). The results suggest that further studies are needed; however, we propose that all radiation therapy planners should start with the same limitations, and if an acceptable plan is not reached, then flexibility should be given to improve the plan to meet the desired results.