Direct observation in the radiotherapy clinic remains the primary method for the assessment of procedural skills. But with increasing automation and reductions in clinical placement time during the recent pandemic, the role of summative, simulation-based assessment is being revisited. The aim of this article is to share early experiences of using Virtual Environment for Radiotherapy Training (VERT) in the assessment of a palliative, parallel pair, external beam treatment delivery technique in a new pre-registration undergraduate programme.

Eight first-year students completed a campus-based individual virtual assessment using virtual patient plans representing metastatic disease in the brain and pelvis and late-stage primary lung tumours. Performance was logged on a 25-item checklist for pre and post-procedure checks and treatment delivery tasks.

All eight students participated in the assessment with seven students (87·5%) achieving a pass grade at first attempt. The course team observed that participants demonstrated a range of skills and abilities and were able to compare and contrast individual approaches to patient positioning. Specific feed-forward action points were also highlighted as areas for students’ to focus on during their second placement. The project also identified logistical benefits for assessment teams.

While these experiences are a single snapshot, a VERT simulation-based summative assessment is feasible and identified benefits included controlled observation and structured feedback on individual performance and scheduling pressure reductions for clinical teams. However, more work is needed to determine the psychometric qualities and predictability of performance in more complex techniques.

London South Bank University (LSBU) has successfully implemented Virtual Environment for Radiotherapy Training (VERT) across the therapeutic radiography training curricula and are now supporting the use of VERT for patient education in clinical departments. A number of publications have reported on the use of VERT in education and training; more recent literature has focused on the use of VERT for patient education.

The successful introduction of VERT before students’ first clinical placements resulted in the development of a ‘Pre-Clinical week’ where students practice and improve their technical skills, using the hand controls without a patient present, leading to increased confidence in clinical practice. Other examples of VERT curriculum integration at LSBU focused on the use of VERT for anatomy teaching. The more recent innovation at LSBU relevant to VERT integration has been the design, development and implementation of collaborative research projects where the aims of the studies were to explore patients’ perceptions of VERT as an information giving resource before radiotherapy delivery.

The introduction of VERT as education tool has enabled academic staff to develop a range of teaching methods to embed virtual training into the traditional classroom setting, demonstrating innovation and collaboration.

The overall aim of this study was to evaluate the use of Virtual Environment for Radiotherapy Training Image-Guided Radiotherapy (VERT™IGRT) as a teaching and assessment tool for 3D image matching competency within the radiotherapy clinical setting and explore radiographer perceptions, experiences and integration of VERT™IGRT as an imaging tool.

A mixed-methods study was utilised to measure clinical image matching competencies in the first quantitative phase through means of a workbook and imaging assessment. Phase II used qualitative semi-structured interviews to explore radiographer perceptions.

Workbooks enabled participants to prepare for image assessments. Interview findings were highlighted in three distinctive themes: (1) The need for supervision, guidance and feedback; (2) Experience and practice leads to confidence and competence and (3) Technology supports process but not evaluation.

VERT™IGRT provides a sound platform for training therapeutic radiographer image matching skills, but needs to be delivered with continuous feedback to develop individual decision-making skills. The technology provides opportunities for staff to increase confidence in utilsing image matching technology, but analytical and evaluation skills require supervision and continuous feedback which should be embedded in any educational training programme.

In many countries, there is a skills gap in proton therapy with many staff unprepared to work with the new technology. The new Virtual Environment for Radiotherapy Training (VERT) proton module provides learners with a simulated proton machine 3D environment. This project aimed to evaluate the role of VERT in training the radiotherapy workforce for the future use of protons.

A practical teaching session using VERT was deployed after a traditional teaching session had provided basic knowledge. A questionnaire deployed before and after VERT enabled comparison of knowledge while a combination of Likert and open questions gathered participant feedback concerning the initiative.

A total of 38 students provided evaluation of the session. Overall, there were high levels of satisfaction and enjoyment with 35 participants reporting enjoyment and 36 indicating that the event be repeated.

Participants felt that they had learned from the experience, although quantitative data lacked statistical significance to demonstrate this. All participants agreed that VERT had provided improved understanding of proton dose deposition arising from visualisation of beams and dose deposition. Most participants agreed that the simulation was realistic and that it had improved their understanding. Feedback in relation to future sessions concerned smaller group sizes, more patient cases, more time and additional clinical datasets.

A proton simulation module has been shown to be an enjoyable teaching tool that improves students’ confidence in their knowledge of the underpinning theory and clinical usage of the modality. Learners felt better prepared to encounter protons in clinical practice. Future work will build on these findings using smaller group work and a more robust assessment tool to identify long-term impact of the training.

The virtual environment for radiotherapy training (VERT) helps students to gain technical skills and understanding of 3D anatomy and dosimetry. It has potential as a tool for treatment plan evaluation, although little formal evidence currently supports this.

This paper reports findings from a plan evaluation workshop that facilitated comparison of VERT plan evaluation tools with those provided by conventional treatment planning software (TPS).

Students on a pre-registration Post-Graduate Diploma in Radiotherapy worked in small groups evaluating lung plans using both VERT and Eclipse TPS tools. All students were invited to provide ratings concerning how helpful each modality was for a range of evaluation parameters and preferences for use.

Most students (11 out of 14) found the session useful and expressed a desire to use VERT in future plan evaluation. The TPS was perceived to be more helpful with constraint-based evaluation while VERT was more helpful with evaluating plans for clinical set-up and delivery (p < 0·001).

Student therapeutic radiographers found VERT to be helpful as a plan evaluation tool alongside standard TPS tools, in particular for clinical set-up and delivery aspects of planning. Future work is ongoing to identify the specific impact of VERT as a plan evaluation tool for both students and qualified planners.

The novel Volumetric Image Matching Environment for Radiotherapy (VIMER) was developed to allow users to view both computed tomography (CT) and cone-beam CT (CBCT) datasets within the same 3D model in virtual reality (VR) space. Stereoscopic visualisation of both datasets combined with custom slicing tools and complete freedom in motion enables alternative inspection and matching of the datasets for image-guided radiotherapy (IGRT).

A qualitative study was conducted to explore the challenges and benefits of VIMER with respect to image registration. Following training and use of the software, an interview session was conducted with a sample group of six university staff members with clinical experience in image matching.

User discomfort and frustration stemmed from unfamiliarity with the drastically different input tools and matching interface. As the primary advantage, the users reported match inspection efficiency when presented with the 3D volumetric renderings of the planning and secondary CBCT datasets.

This study provided initial evidence for the achievable benefits and limitations to consider when implementing a 3D voxel-based dataset comparison VR tool including a need for extensive training and the minimal interruption to IGRT workflow. Key advantages include efficient 3D anatomical interpretation and the capability for volumetric matching.

We review augmented (AR) and virtual reality (VR) applications in radiotherapy as found in the scientific literature and highlight future developments enabled by the use of small mass-produced devices and portability of techniques developed in other fields to radiotherapy.

The application of AR and VR within radiotherapy is still in its infancy, with the notable exception of training and teaching applications. The relatively high cost of equipment needed to generate a realistic 3D effect seems one factor that has slowed down its use, but also the sheer amount of image data is relatively recent, were radiotherapy professionals are only beginning to explore how to use this to its full potential. This increased availability of 3D data in radiotherapy will drive the application of AR and VR in radiotherapy to efficiently recognise and extract key features in the data to act on in clinical decision making.

The development of small mass-produced tablet devices coming on the market will allow the user to interact with computer-generated information more easily, facilitating the application of AR and VR. The increased connectivity enabling virtual presence of remote multidisciplinary team meetings heralds significant changes to how radiotherapy professionals will work, to the benefit of our patients.

The Virtual Environment for Radiotherapy Training (VERT) is a high-fidelity simulation hardware and software resource that replicates the expensive and high-pressure clinical environment of a radiotherapy treatment machine. The simulation allows students to gain confidence with clinical techniques in a safe and unpressured academic environment before clinical placement. The aim of this study was to establish the current and future role of VERT and explore the potential for collaborative resource development and research.

An anonymous online survey was made available to all users of the software internationally (n=52). A mixture of fixed and open response questions gathered usage data and user feedback.

The study had a 90% response rate (n=47). Most participants (78·5%) used the resource 1 day/week or less; around 8,000 hours worldwide. It was clear that most participants used the simulation resource to help student to either gain understanding of concepts and techniques or to gain practice with techniques and practical skills. There was good support for collaborative resource development, deployment and evaluation to help VERT users to fully exploit its range of pedagogical uses.

This audit demonstrated high levels of engagement and enthusiasm for collaborative resource development and ongoing research among the radiotherapy simulation community. Adoption of an international Academic Community of Practice for collaborative simulation resource deployment and support may be of significant value and is worthy of further discussion and consideration.