Advanced practice in radiotherapy across Europe: stakeholders' perceptions of implementation and evolution.

INTRODUCTION: Adapting radiotherapy services with workforce innovation using skills-mix or task-shifting optimises resources, supporting current and future demands. Advanced practitioners (APs) work at a different level of practice (beyond initial registration) across four pillars: clinical practice, leadership and management, education, and research. There is limited cross-country research on the advanced therapeutic radiographers/radiation therapists (TR/RTTs), particularly in Europe. This study aimed to investigate European radiotherapy stakeholders' perceptions regarding current and future advanced practice (AP). METHODS: From June to September 2022, one-to-one online semi-structured interviews were conducted in English, and audio and video were recorded. Full verbatim audio files were independently transcribed and checked by interviewer and interviewees. Braun and Clarke's seven steps guided the thematic analysis (using NVivo). RESULTS: Thirty-three interviewees working or studying in 16 European countries represented practitioners (n=14), managers (n=6), educators (n=4), professional bodies (n=4), students (n=3), and regulators (n=2). Four overarching themes emerged: "AP drivers and outcomes", "AP challenges vs enablers", "Current vs future AP", "Becoming and being advanced practitioner". Participants identified research as the neglected AP pillar due to a lack of protected time, limited staff skills, no research culture, no funding, workload, and clinical priorities. Interviewees highlighted the importance of consistency in job titles, harmonisation of education models and curricula, definition of AP requirements, and support for all AP pillars through job plans and workforce planning. CONCLUSION: Neither the profession nor education of TR/RTTs are harmonised across Europe, which is highly reflected in advanced-level practice. Advanced TR/RTTs should work across all pillars, including research, and these should be embedded in master's programmes, including leadership. IMPLICATIONS FOR PRACTICE: This study highlights a policy gap in the education and practice of APs in radiotherapy.

Radiographer training for screening of patients referred for Magnetic Resonance Imaging: A scoping review.

INTRODUCTION: Strict safety practices are essential to ensure the safety of patients and staff in Magnetic Resonance Imaging (MRI). Training regarding the fundamentals of MRI safety is well-established and commonly agreed upon. However, more complex aspect of screening patients, such as image review or screening of unconscious patients/patients with communication difficulties is less well discussed. The current UK and USA guidelines do not suggest the use of communication training for MRI staff nor indicate any training to encourage reviewing images in the screening process. This review aims to map the current guidance regarding safety and patient screening training for MRI diagnostic and therapeutic radiographers. METHODS: A systematic search of PubMed, Trip Medical database and Radiography journal was conducted. Studies were chosen based on the review objectives and pre-determined inclusion/exclusion criteria using the PRISMA-ScR framework. RESULTS: Twenty-four studies were included in the review, which identified some key concepts including MRI safety training and delivery methods, screening and communication, screening of unconscious or non-ambulatory patients and the use of imaging. CONCLUSION: Training gaps lie within the more complex elements of screening such as the inclusiveness of question phrasing, particularly to the neurodivergent population, how we teach radiographers to screen unconscious/unresponsive patients and using imaging to detect implants. IMPLICATIONS FOR PRACTICE: The consequences of incomplete or inaccurate pre-MRI safety screening could be the introduction of unexpected implants into the scanner or forgoing MRI for a less desirable modality. The development of enhanced training programs in implant recognition using imaging and communication could complement existing training.

Prostate cancer image guided radiotherapy: Why the commotion over rectal volume and motion?

Introduction: Distended rectums on pre-radiotherapy scans are historically associated with poorer outcomes in patients treated with two-dimensional IGRT. Subsequently, strict rectal tolerances and preparation regimes were implemented. Contemporary IGRT, daily online registration to the prostate, corrects interfraction motion but intrafraction motion remains. We re-examine the need for rectal management strategies when using contemporary IGRT by quantifying rectal volume and its effect on intrafraction motion. Materials and methods: Pre and during radiotherapy rectal volumes and intrafraction motion were retrospectively calculated for 20 patients treated in 5-fractions and 20 treated in 20-fractions. Small (rectal volume at planning-CT ≤ median), and large (volume > median) subgroups were formed, and rectal volume between timepoints and subgroups compared. Rectal volume and intrafraction motion correlation was examined using Spearman's rho. Intrafraction motion difference between small and large subgroups and between fractions with rectal volume < or ≥ 90 cm3 were assessed. Results: Median rectal volume was 74 cm3, 64 cm3 and 65 cm3 on diagnostic-MRI, planning-CT and treatment imaging respectively (ns). No significant correlation was found between patient's rectal volume at planning-CT and median intrafraction motion, nor treatment rectal volume and intrafraction motion for individual fractions. No significant difference in intrafraction motion between small and large subgroups presented and for fractions where rectal volume breached 90 cm3, motion during that fraction was not significantly greater. Conclusion: Larger rectal volumes before radiotherapy and during treatment did not cause greater intrafraction motion. Findings support the relaxation of strict rectal diameter tolerances and do not support the need for rectal preparation when delivering contemporary IGRT to the prostate.

What do we want? Training! When do we want it? Now? A training needs analysis for adaptive radiotherapy for therapeutic radiographers.

INTRODUCTION: Therapeutic radiographers (TRs) have adapted to the changing requirements and demands of the oncology service and in response to advanced techniques such as on-line adaptive MRI-guided radiotherapy (MRIgRT). The skills required for MRIgRT would benefit many TRs not just those involved in this technique. This study presents the results of a training needs analysis (TNA) for the required MRIgRT skills in readiness for training TRs for current and future practice. METHODS: A UK-based TNA was used to ask TRs about their knowledge and experience with essential skills required for MRIgRT based on previous investigations into the topic. A five-point Likert scale was used for each of the skills and the difference in values were used to calculate the training need for current and future practice. RESULTS: 261 responses were received (n = 261). The skill rated the most important to current practice was CBCT/CT matching and/or fusion. The current highest priority needs were radiotherapy planning and radiotherapy dosimetry. The skill rated the most important to future practice was CBCT/CT matching and/or fusion. The future highest priority needs were MRI acquisition and MRI Contouring. Over 50% of participants wanted training or additional training in all skills. There was an increase in all values for skills investigated from current to future roles. CONCLUSION: Although the examined skills were viewed as important to current roles, the future training needs, both overall and high priority, were different compared to current roles. As the 'future' of radiotherapy can arrive rapidly, it is essential that training is delivered appropriately and timely. Before this can occur, there must be investigations into the method and delivery of this training. IMPLICATIONS FOR PRACTICE: Role development. Education changes for therapeutic radiographers.

GI factors, potential to predict prostate motion during radiotherapy; a scoping review.

Purpose: A scoping literature review was conducted to identify gastrointestinal (GI) factors most likely to influence prostate motion during radiotherapy. We proffer that patient specific measurement of these GI factors could predict motion uncertainty during radiotherapy, facilitating personalised care by optimising treatment technique e.g., daily adaption or via bespoke patient pre-habilitation and preparation. Methods: The scoping review was undertaken as per JBI guidelines. Searches were conducted across four databases: Ovid Medline®, EMBASE, CINAHL and EBSCO discovery. Articles written in English from 2010-present were included. Those pertaining to paediatrics, biological women exclusively, infectious and post-treatment GI morbidity and diet were excluded.Common GI factors impacting men were identified and related symptoms, incidence and measurement tools examined. Prevalence among persons with prostate cancer was explored and suitable assessment tools discussed. Results: A preliminary search identified four prominent GI-factors: mental health, co-morbidity and medication, physical activity, and pelvic floor disorder. The scoping search found 3644 articles; 1646 were removed as duplicates. A further 1249 were excluded after title and abstract screening, 162 remained subsequent to full text review: 42 mental health, 53 co-morbidity and medication, 39 physical activity and 28 pelvic floor disorder.Six GI factors prevalent in the prostate cancer population and estimated most likely to influence prostate motion were identified: depression, anxiety, diabetes, obesity, low physical activity, and pelvic floor disorder. Reliable, quick, and easy to use tools are available to quantify these factors. Conclusion: A comprehensive GI factor assessment package suitable to implement into the radiotherapy clinic has been created. Unveiling these GI factors upfront will guide improved personalisation of radiotherapy.

Advanced practice roles amongst therapeutic radiographers/radiation therapists: A European survey.

INTRODUCTION: Advanced Practice (AP) roles in Radiotherapy (RT) over time are variable, often locally developed and not underpinned by professional standards which leads to conceptual and practical gaps. This study aimed to assess AP roles amongst Therapeutic Radiographers/Radiation Therapists (TR/RTTs) and identify educational gaps for this level across Europe. METHODS: An anonymous online survey was designed, validated, and distributed across Europe. Convenience sampling was used to recruit advanced TR/RTTs practitioners or TR/RTTs working in AP roles. Descriptive analysis from closed questions and thematic analyses from open questions are reported. RESULTS: A total of 272 responses were obtained, of which 189 eligible participations were from 21 European countries. 42% of respondents acknowledged additional education required to perform AP, and 25% reported a minimum of five years of RT practice to perform AP roles/tasks. There is a trend to work more on the clinical practice domain with a low percentage of working time allocated to research. Inconsistency was found in job titles, scopes of practice, and educational backgrounds across and even within countries. Education needs regarding knowledge about image-guided and adaptive RT, multimodal imaging and technologies, and advanced treatment planning were found. Training needs on leadership and management skills and clinical site-specific expertise were identified. CONCLUSION: This study clearly shows a gap in education support, a need for standardisation in job titles and scopes of practice across Europe. IMPLICATIONS FOR PRACTICE: As the first large-scale assessment of current AP roles and educational support amongst TR/RTTs across Europe, this study recommends the establishment of governance structure and role regulation. It also informs the curricula for master programmes to align the education with current and future practice.

Images and images: Current roles of therapeutic radiographers.

INTRODUCTION: Therapeutic radiography is a small profession and has adapted in response to advanced techniques. An increase in on-line adaptive MRI-guided radiotherapy (MRIgRT) will require role extension for therapeutic radiographers (TRs). This study will investigate the current role description for TRs and the activities they currently undertake with regards to MRIgRT. METHOD: A training needs analysis was used to ask TRs about their current roles and responsibilities and essential skills required for MRIgRT. For the purposes of this paper, the authors present the results from the demographics of the individual, their current job title with roles and responsibilities, and experience with decision making and image assessment. Descriptive statistics was used to analyse the data. RESULTS: 261 responses were received (n = 261). Only 28% of job titles listed contained the protected title of 'therapeutic radiographer'. Advanced clinical practice roles were expressed by participants indicating that if a service need is presented, emerging roles will be created. Variation existed across the standardised roles of TRs and this discrepancy could present challenges when training for MRIgRT. TRs are pivotal in image verification and recognition on a standard linac, and skills developed there can be transferred to MRIgRT. Decision making is crucial for adaptive techniques and there are many skills within their current scope of practice that are indispensable for the MRIgRT. CONCLUSION: It has been demonstrated that TRs have a range of roles that cover vast areas of the oncology pathway and so it is important that TRs are recognised so the pivotal role they play is understood by all. TRs have extensive soft-tissue IGRT knowledge and experience, aiding the evolution of decision-making skills and application of off-protocol judgments, the basis of MRIgRT. IMPLICATIONS FOR PRACTICE: Role development and changes in education for therapeutic radiographers.

MRI-guided adaptive radiotherapy for prostate cancer: When do we need to account for intra-fraction motion?

A shift of the daily plan can mitigate target position changes that occur between daily MR acquisition and treatment for MR-linac radiotherapy, but increases the session time. We demonstrated that our workflow strategy and decision-making process, to determine whether a subsequent shift is necessary, is appropriate.

Mapping Local Failure Following Bladder Radiotherapy According to Dose.

AIMS: To determine the relationship between local relapse following radical radiotherapy for muscle-invasive bladder cancer (MIBC) and radiation dose. MATERIALS AND METHODS: Patients with T2-4N0-3M0 MIBC were recruited to a phase II study assessing the feasibility of intensity-modulated radiotherapy to the bladder and pelvic lymph nodes. Patients were planned to receive 64 Gy/32 fractions to the bladder tumour, 60 Gy/32 fractions to the involved pelvic nodes and 52 Gy/32 fractions to the uninvolved bladder and pelvic nodes. Pre-treatment set-up was informed by cone-beam CT. For patients who experienced local relapse, cystoscopy and imaging (CT/MRI) was used to reconstruct the relapse gross tumour volume (GTVrelapse) on the original planning CT . GTVrelapse D98% and D95% was determined by co-registering the relapse image to the planning CT utilising deformable image registration (DIR) and rigid image registration (RIR). Failure was classified into five types based on spatial and dosimetric criteria as follows: A (central high-dose failure), B (peripheral high-dose failure), C (central elective dose failure), D (peripheral elective dose failure) and E (extraneous dose failure). RESULTS: Between June 2009 and November 2012, 38 patients were recruited. Following treatment, 18/38 (47%) patients experienced local relapse within the bladder. The median time to local relapse was 9.0 months (95% confidence interval 6.3-11.7). Seventeen of 18 patients were evaluable based on the availability of cross-sectional relapse imaging. A significant difference between DIR and RIR methods was seen. With the DIR approach, the median GTVrelapse D98% and D95% was 97% and 98% of prescribed dose, respectively. Eleven of 17 (65%) patients experienced type A failure and 6/17 (35%) patients type B failure. No patients had type C, D or E failure. MIBC failure occurred in 10/17 (59%) relapsed patients; of those, 7/11 (64%) had type A failure and 3/6 (50%) had type B failure. Non-MIBC failure occurred in 7/17 (41%) patients; 4/11 (36%) with type A failure and 3/6 (50%) with type B failure. CONCLUSION: Relapse following radiotherapy occurred within close proximity to the original bladder tumour volume and within the planned high-dose region, suggesting possible biological causes for failure. We advise caution when considering margin reduction for future reduced high-dose radiation volume or partial bladder radiotherapy protocols.

A Randomised Phase II Clinical Trial Comparing the Deliverability and Acute Toxicity of Wide Tangent versus Volumetric Modulated Arc Therapy to the Breast and Internal Mammary Chain.

AIMS: Inclusion of the internal mammary chain in the radiotherapy target volume (IMC-RT) improves disease-free and overall survival in higher risk breast cancer patients, but increases radiation doses to heart and lungs. Dosimetric data show that either modified wide-tangential fields (WT) or volumetric modulated arc therapy (VMAT) together with [AQ1]voluntary deep inspiration breath hold (vDIBH) keep mean heart doses below 4 Gy in most patients. However, the impact on departmental resources has not yet been documented. This phase II clinical trial compared the time taken to deliver IMC-RT using either WT and vDIBH or VMAT and vDIBH, together with planning time, dosimetry, set-up reproducibility and toxicity. MATERIALS AND METHODS: Left-sided breast cancer patients requiring IMC-RT were randomised to receive either WT(vDIBH) or VMAT radiotherapy. The primary outcome was treatment time, powered to detect a minimum difference of 75 min (5 min/fraction) between techniques. The population mean displacement, systematic error and random error for cone beam computed tomography chest wall matches in three directions of movement were calculated. Target volume and organ at risk doses were compared between groups. Side-effects, including skin (Radiation Therapy Oncology Group), lung and oesophageal toxicity (Common Terminology Criteria for Adverse Events v 4.03) rates, were compared between the groups over 3 months. Patient-reported outcome measures, including shoulder toxicity at baseline, 6 months and 1 year, were compared. RESULTS: Twenty-one patients were recruited from a single UK centre between February 2017 and January 2018. The mean (standard deviation) total treatment time per fraction for VMAT treatments was 13.2 min (1.7 min) compared with 28.1 min (3.3 min) for WT(vDIBH). There were no statistically significant differences in patient set-up errors in between groups. The average mean heart dose for WT(vDIBH) was 2.6 Gy compared with 3.4 Gy for VMAT(vDIBH) (P = 0.13). The mean ipsilateral lung V17Gy was 32.8% in the WT(vDIBH) group versus 34.4% in the VMAT group (P = 0.2). The humeral head (mean dose 16.8 Gy versus 2.8 Gy), oesophagus (maximum dose 37.3 Gy versus 20.1 Gy) and thyroid (mean dose 22.0 Gy versus 11.2 Gy) all received a statistically significantly higher dose in the VMAT group. There were no statistically significant differences in skin, lung or oesophageal toxicity within 3 months of treatment. Patient-reported outcomes of shoulder toxicity, pain, fatigue, breathlessness and breast symptoms were similar between groups at 1 year. CONCLUSION: VMAT(vDIBH) and WT(vDIBH) are feasible options for locoregional breast radiotherapy including the IMC. VMAT improves nodal coverage and delivers treatment more quickly, resulting in less breath holds for the patient. This is at the cost of increased dose to some non-target tissues. The latter does not appear to translate into increased toxicity in this small study.

Prostate Volume Changes during Extreme and Moderately Hypofractionated Magnetic Resonance Image-guided Radiotherapy.

AIMS: Prostate morphological changes during external beam radiotherapy are poorly understood. Excellent soft-tissue visualisation offered by magnetic resonance image-guided radiotherapy (MRIgRT) provides an opportunity to better understand such changes. The aim of this study was to quantify prostate volume and dimension changes occurring during extreme and moderately hypofractionated schedules. MATERIALS AND METHODS: Forty prostate cancer patients treated on the Unity 1.5 Tesla magnetic resonance linear accelerator (MRL) were retrospectively reviewed. The cohort comprised patients treated with 36.25 Gy in five fractions (n = 20) and 60 Gy in 20 fractions (n = 20). The volume of the delineated prostates on reference planning computed tomography (fused with MRI) and daily T2-weighted 2-min session images acquired on Unity were charted. Forty planning computed tomography and 500 MRL prostate volumes were evaluated. The mean absolute and relative change in prostate volume during radiotherapy was compared using a paired t-test (P value <0.01 considered significant to control for multiple comparisons). The maximum dimension of the delineated prostate was measured in three isocentric planes. RESULTS: Significant prostate volume changes, relative to MRL imaging fraction 1 (MRL#1), were seen at all time points for the five-fraction group. The peak mean relative volume increase was 21% (P < 0.001), occurring at MRL#3 and MRL#4 after 14.5 and 21.75 Gy, respectively. Prostate expansion was greatest in the superior-inferior direction; the peak mean maximal extension was 5.9 mm. The maximal extension in the left-right and anterior-posterior directions measured 1.1 and 2.2 mm, respectively. For the 20-fraction group, prostate volume increased relative to MRL#1, for all treatment time points. The mean relative volume increase was 11% (P < 0.001) at MRL#5 after 12 Gy, it then fluctuated between 8 and 13%. From MRL#5 to MRL#20, the volume increase was significant (P < 0.01) for 12 of 16 time points calculated. The peak mean maximal extension in the superior-inferior direction was 3.1 mm. The maximal extension in the left-right and anterior-posterior directions measured 1.7 and 3.7 mm, respectively. CONCLUSION: Significant prostate volume and dimension changes occur during extreme and moderately hypofractionated radiotherapy. The extent of change was greater during extreme hypofractionation. MRIgRT offers the opportunity to reveal, quantify and correct for this deformation.

Radiographer-led online image guided adaptive radiotherapy: A qualitative investigation of the therapeutic radiographer role.

INTRODUCTION: Online MRI guided adaptive radiotherapy (MRIgRT) is resource intensive. To maintain and increase uptake traditional roles and responsibilities may need refining. This novel study aims to provide an in-depth understanding and subsequent impact of the roles required to deliver on-line adaptive MRIgRT by exploring the current skills and knowledge of radiographers. METHOD: A purposive sampling approach was used to invite radiographers, clinicians and physicists from centres with experience of MRIgRT to participate. Focus Group Interviews were conducted with two facilitators using a semi-structure interview guide (Appendix 1). Four researchers independently familiarised themselves and coded the data using framework analysis. A consensus thematic framework of ptive Radiotherapy codes and categories was agreed and systematically applied. RESULTS: Thirty participants took part (Radiographers: N = 18, Physicists: N = 9 and Clinicians: N = 3). Three key themes were identified: 'Current MRIgRT', 'Training' and 'Future Practice'. Current MRIgRT identified a variation in radiographers' roles and responsibilities with pathways ranging from radiographer-led, clinician-light-led and MDT-led. The consensus was to move towards radiographer-led with the need to have a robust on-call service heavily emphasised. Training highlighted the breadth of knowledge required by radiographers including MRI, contouring, planning and dosimetry, and treatment experience. Debate was presented over timing and length of training required. Future Practice identified the need to have radiographers solely deliver MRIgRT, to reduce staff present which was seen as a main driver, and time and resources to train radiographers seen as the main barriers. CONCLUSION: Radiographer-led MRIgRT is an exciting development because of the potential radiographer role development. A national training framework created collaboratively with all stakeholders and professions involved would ensure consistency in skills and knowledge. IMPLICATIONS FOR PRACTICE: Role development and changes in education for therapeutic radiographers.

The Development of Therapeutic Radiographers in Imaging and Adaptive Radiotherapy Through Clinical Trial Quality Assurance.

AIMS: Adaptive radiotherapy (ART) is an emerging advanced treatment option for bladder cancer patients. Therapeutic radiographers (RTTs) are central to the successful delivery of this treatment. The purpose of this work was to evaluate the image-guided radiotherapy (IGRT) and ART experience of RTTs before participating in the RAIDER trial. A plan of the day (PoD) quality assurance programme was then implemented. Finally, the post-trial experience of RTTs was evaluated, together with the impact of trial quality assurance participation on their routine practice. MATERIALS AND METHODS: A pre-trial questionnaire to assess the experience of the RTT staff group in IGRT and ART in bladder cancer was sent to each centre. Responses were grouped according to experience. The PoD quality assurance programme was implemented, and the RAIDER trial commenced. During stage 1 of the trial, RTTs reported difficulties in delivering PoD and the quality assurance programme was updated accordingly. A follow-up questionnaire was sent assessing experience in IGRT and ART post-trial. Any changes in routine practice were also recorded. RESULTS: The experience of RTTs in IGRT and ART pre-trial varied. For centres deemed to have RTTs with more experience, the initial PoD quality assurance programme was streamlined. For RTTs without ART experience, the full quality assurance programme was implemented, of which 508 RTTs completed. The quality assurance programme was updated (as the trial recruited) and it was mandated that at least one representative RTT (regardless of pre-trial experience) participated in the update in real-time. The purpose of the updated quality assurance programme was to provide further support to RTTs in delivering a complex treatment. Engagement with the updated quality assurance programme was high, with RTTs in 24/33 centres participating in the real-time online workshop. All 33 UK centres reported all RTTs reviewed the updated training offline. Post-trial, the RTTs' experience in IGRT and ART was increased. CONCLUSION: Overall, 508 RTTs undertook the PoD quality assurance programme. There was a high engagement of RTTs in the PoD quality assurance programme and trial. RTTs increased their experience in IGRT and ART and subsequently updated their practice for bladder cancer and other treatment sites.

Retrospective audit of inter-fraction motion for pelvic node radiotherapy in prostate cancer patients.

INTRODUCTION: Pelvic lymph nodes move independently to the prostate. When delivering radiotherapy to prostate and pelvic lymph nodes, daily inter- and intra-fraction anatomical changes need to be accounted for. Planning target volume (PTV) margins, grown from the pelvic lymph node clinical target volume need to be determined, to account for this variation in position. METHODS: Twenty patients who had daily online image guided radiotherapy to prostate and pelvic lymph nodes between April and December 2018 were selected. Ten pre-treatment verification images using cone beam CT from each patient were registered to pelvic bone anatomy, prostate soft tissue or fiducial markers and pelvic lymph node soft tissue to assess the accuracy of treatment delivery. Population systematic and random errors and PTV margins were calculated. RESULTS: PTV margins of 0.4 cm, 0.4 cm and 0.7 cm left-right (LR), superior-inferior (SI) and anterior-posterior (AP) respectively were derived for the pelvic lymph nodes when registering to prostate. PTV margins of 0.3 cm, 0.2 cm and 0.4 cm LR, SI and AP respectively were derived for the pelvic lymph nodes when registering to bone. There was a posterior systematic shift of the prostate during the treatment course. CONCLUSION: There is differential motion of pelvic lymph nodes to prostate and in the era of prostate and pelvic radiotherapy for patients with node positive prostate cancer; there is increasing importance in the accuracy of dose delivery to the involved lymph node. Hence, this group of patients may benefit from personalised radiotherapy PTV margins, especially if the involved pelvic lymph node is within the anterior part of the clinical target volume. IMPLICATIONS FOR PRACTICE: Optimisation of dose delivery to the pelvic lymph nodes when prioritising the prostate in prostate and pelvic lymph node image guided radiotherapy.

International survey; current practice in On-line adaptive radiotherapy (ART) delivered using Magnetic Resonance Image (MRI) guidance.

BACKGROUND AND PURPOSE: The uptake of new technologies has varied internationally and there have often been barriers to implementation. On-line adaptive radiotherapy (ART) promises to improve patient outcome. This survey focuses on the implementation phase of delivering ART and professional roles and responsibilities currently involved in the workflow and changes which may be expected in the future. MATERIALS AND METHODS: A 38 question survey included aspects on current practice; professional responsibilities; benefits and barriers; and decision making and responsibilities. For the purposes of the questionnaire and paper, ART was considered where tumour and /or organs at risk were contoured and re-planning was performed on-line. The questionnaire was electronically distributed via radiotherapy networks. RESULTS: Nineteen international responses were received. Europe (n = 11), United States of America (n = 4); Canada (n = 2), Australia (n = 1) and Hong Kong (n = 1). The majority of centres started using ART in either 2018 (n = 7) or 2019 (n = 6). Four centres started treating with ART between 2015 and 2017, and the first was in 2014. Centres initially treated prostate and oligometastases patients, expanding to treat prostate, oligometastases, pancreas and rectum. The majority of centres were working in conventional roles, however moving towards radiographers taking more responsibility in contouring organs at risk (OAR), target and dosimetry. The three most important criteria chosen by medical doctors to determine if ART should be used were overall gross anatomy changes of target and OAR, target not covered by planning target volume (PTV) and OAR close to the high dose area. There was no clear consensus on the minimum improvement in dose to target or reduction in dose to OAR to warrant adaption. CONCLUSION: On-line ART has been implemented successfully internationally. Initial practice maintains conventional professional roles and responsibilities, however there is trend to changing roles for the future. There is little consensus regarding the triggers of adaption.

A review of permanent marking for radiotherapy in the UK.

INTRODUCTION: This paper presents the results of a survey of the routine use of permanent marks for radiotherapy in the UK. This was undertaken to provide an overview of current practice. Permanent marks are a somewhat invasive procedure, and should be subject to scrutiny and judicious application. METHOD: The authors reviewed the literature on international radiotherapy permanent marking practice. Common themes that emerged were the psychology of permanent marking and ink-type considerations, current practice and training, and safety. These were used to develop a questionnaire in order to form an overview of the use of marks nationally, and to identify any recurrent issues. The questionnaire also sought information regarding locations and numbers of permanent marks used for common treatment sites. The survey was sent to 71 departments in the UK using email. RESULTS: 70% of departments responded. 62% of departments reported patients who had refused permanent marks. The reasons for refusal varied. India or drawing ink was used in 49 of the 51 departments (96%). The most common teaching method of tattooing involved combined observation and verbal coaching. Most departments had a written procedure for tattooing, but some did not. Although sharps injuries were rare, they were documented. CONCLUSION: Most departments in the UK had encountered patient refusal of permanent marks, with breast patients representing the largest group which declined. There is variation in practice throughout the UK, and the equipment used is not specialised for tattooing purposes. Sharps injuries, although rare, do occur, and training methods are not consistent. IMPLICATIONS FOR PRACTICE: The requirement for national guidelines is posited. Further investigation into the need for permanent marks in an era of state-of-the-art imaging technology is also required.

Blurring the lines for better visualisation.

On-treatment imaging in radiotherapy has evolved over the last 60 years, bringing with it changes in the roles of radiographers, radiologists and oncologists. The ability to acquire and interpret high quality images (2D kilovoltage and megavoltage imaging and 3D CT and cone-beam CT) for radiotherapy planning and delivery requires therapy radiographers to have skills and knowledge that overlap with those of diagnostic radiographers. With the implementation of MRI-guided radiotherapy, treatment radiographers and clinical oncologists are exploring new territory, requiring truly collaborative working practices with their radiology partners. This short communication introduces the first images acquired using the hybrid MR Linac at our institution.

RTT-led IGRT for cervix cancer; training, implementation and validation.

INTRODUCTION: IGRT in cervical cancer treatment delivery is complex due to significant target and organs at risk (OAR) motion. Implementing image assessment of soft-tissue target and OAR position to improve accuracy is recommended. We report the development and refinement of a training and competency programme (TCP), leading to on-line Radiation Therapist (RTT) led soft-tissue assessment, evaluated by a prospective audit. METHODS AND MATERIALS: The TCP comprised didactic lectures and practical sessions, supported by a comprehensive workbook. The content was decided by a team comprised of Clinical Oncologists, RTTs, and Physicists. On completion of training, RTT soft-tissue review proficiency (after bony anatomy registration) was assessed against a clinician gold-standard from a database of 20 cervical cancer CBCT images. Reviews were graded pass or fail based on PTV coverage assessment and decision taken in concordance with the gold-standard. Parity was set at ≥80% agreement.The initial TCP (stage one) focussed on offline verification and decision making. Sixteen RTTs completed this stage, four achieved ≥80%. This was not sufficient to support clinical implementation.The TCP was redesigned, more stringent review guidelines and greater anatomy teaching was added. TCP stage two focussed on online verification and decision making supported by a decision flowchart. Twenty-one RTTs completed this TCP, all achieved ≥80%. This supported clinical implementation of RTT-led soft-tissue review under prospective audit conditions.The prospective audit was conducted between March 2017 and August 2017. Daily online review was performed by two trained RTTs. Online review and decision making proficiency was evaluated by a clinician. RESULTS: Thirteen patients were included in the audit. Daily online RTT-led IGRT was achieved for all 343 fractions. Two-hundred CBCT images were reviewed offline by the clinician; the mean number of reviews per patient was 15. 192/200 (96%) RTT image reviews were in agreement with clinician review, presenting excellent concordance. DISCUSSION AND CONCLUSION: Multidisciplinary involvement in training development, redesign of the TCP and inclusion of summative competency assessment were important factors to support RTT skill development. Consequently, RTT-led cervical cancer soft-tissue IGRT was clinically implemented in the hospital.

Magnetic resonance imaging sequence evaluation of an MR Linac system; early clinical experience.

OBJECTIVES: To systematically identify the preferred magnetic resonance imaging (MRI) sequences following volunteer imaging on a 1.5 Tesla (T) MR-Linear Accelerator (MR Linac) for future protocol development. METHODS: Non-patient volunteers were recruited to a Research and Ethics committee approved prospective MR-only imaging study on a 1.5T MR Linac system. Volunteers attended 1-3 imaging sessions that included a combination of mDixon, T1w, T2w sequences using 2-dimensional (2D) and 3-dimensional (3D) acquisitions. Each sequence was acquired over 2-7 minutes and reviewed by a panel of 3 observers to evaluate image quality using a visual grading analysis based on a 4-point Likert scale. Sequences were acquired and modified iteratively until deemed fit for purpose (online image matching or re-planning) and all observers agreed they were suitable in 3 volunteers. RESULTS: 26 volunteers underwent 31 imaging sessions of six general anatomical regions. Images were acquired in one or two of six general anatomical regions: male pelvis (n = 9), female pelvis (n = 4), chestwall/breast (n = 5), lung/oesophagus (n = 5), abdomen (n = 3) and head and neck (n = 5). Images were acquired using a pre-defined exam-card that on average, included six sequences (range 2-10), with a maximum scan time of approximately one hour. The majority of observers preferred T2-weighted sequences. The thorax teams were the only groups to prefer T1-weighted imaging. CONCLUSIONS: An iterative process identified sequence agreement in all anatomical regions. These sequences will now be evaluated in patient volunteers. ADVANCES IN KNOWLEDGE: This manuscript is the first publication sharing the results of the first systematic selection of MRI sequences for use in on-board MRI-guided radiotherapy by end-users (therapeutic radiographers and clinical oncologists) in healthy volunteers.