An emerging developmental tool to help radiation therapists achieve better outcomes is ‘peer review’. This review of the current literature summarises the challenges and benefits of peer review in both individual and departmental practice.

There is compelling evidence supporting peer review implementation at both individual and department level in many professions. Implementing peer review requires that radiation therapists and other radiation oncology professionals embrace a culture that supports safety. Peer review can identify trends and barriers associated with quality radiotherapy and share best practice or recommend changes accordingly. Support for peer review must come from pre-registration educational systems as well as clinical managers. Continuing professional development in the workplace is nurtured by peer review of radiotherapy practice and an aptitude for this should be viewed as important to the profession as technical and clinical skills.

It is clear that peer review has the potential to facilitate reflective practice, improve staff motivation and help foster a culture of quality and safety in radiation oncology. To drive the issues of quality and safety a step further radiation therapists need to accept the challenge of adopting peer review methods in day-to-day practice.

Head and neck cancer patients receiving radiotherapy can experience a number of toxicities, including weight loss and malnutrition, which can impact upon the quality of treatment. The purpose of this retrospective cohort study is to evaluate weight loss and identify predictive factors for this patient group.

A total of 40 patients treated with radiotherapy since 2012 at the study centre were selected for analysis. Data were collected from patient records. The association between potential risk factors and weight loss was investigated.

Mean weight loss was 5 kg (6%). In all, 24 patients lost >5% starting body weight. Age, T-stage, N-stage, chemotherapy and starting body weight were individually associated with significant differences in weight loss. On multiple linear regression analysis age and nodal status were predictive.

Younger patients and those with nodal disease were most at risk of weight loss. Other studies have identified the same risk factors along with several other variables. The relative significance of each along with a number of other potential factors is yet to be fully understood. Further research is required to help identify patients most at risk of weight loss; and assess interventions aimed at preventing weight loss and malnutrition.

The aim of this study is to develop predictive models to predict organ at risk (OAR) complication level, classification of OAR dose-volume and combination of this function with our in-house developed treatment decision support system.

We analysed the support vector machine and decision tree algorithm for predicting OAR complication level and toxicity in order to integrate this function into our in-house radiation treatment planning decision support system. A total of 12 TomoTherapyTM treatment plans for prostate cancer were established, and a hundred modelled plans were generated to analyse the toxicity prediction for bladder and rectum.

The toxicity prediction algorithm analysis showed 91·0% accuracy in the training process. A scatter plot for bladder and rectum was obtained by 100 modelled plans and classification result derived. OAR complication level was analysed and risk factor for 25% bladder and 50% rectum was detected by decision tree. Therefore, it was shown that complication prediction of patients using big data-based clinical information is possible.

We verified the accuracy of the tested algorithm using prostate cancer cases. Side effects can be minimised by applying this predictive modelling algorithm with the planning decision support system for patient-specific radiotherapy planning.

Skin care practices for radiotherapy patients are complicated by dosimetric concerns. This study measures the effect on skin dose of various topical agents and dressings.

Superficial doses were measured under 17 topical agents and dressings and three clinical materials for reference. Dose was measured using a MOSFET detector under a 1 mm polymethyl methacrylate slab, with 6 MV photon beams at 100 cm source to surface distance.

Relative skin dose under reference materials was 128% (thermoplastic mask), 158% (5 mm bolus) and 171% (10 mm bolus). Under a realistic application of topical agent (0·5 mm), relative skin doses were 106–111%. All dry dressings yielded relative dose of ≤111%; two wet dressings yielded higher relative doses (133 and 141%).

Under clinically relevant conditions, no cream, gel or dry dressing increased the skin dose beyond that seen with a thermoplastic mask. Dressings soaked with water produced less skin dose than 5 mm bolus. This may be unacceptable if wet dressings are in place for the majority of the treatment course. Our results suggest that skin care practices should not be limited by dosimetric concerns when using a 6 MV photon beam.

Pelvic internal organs change in volume and position during radiotherapy. This may compromise the efficacy of treatment or worsen its toxicity. There may be limitations to fully correcting these changes using online image guidance; therefore, effective and consistent patient preparation and positioning remain important. This review aims to provide an overview of the extent of pelvic organ motion and strategies to manage this motion.

Given the breadth of this topic, a systematic review was not undertaken. Instead, existing systematic reviews and individual high-quality studies addressing strategies to manage pelvic organ motion have been discussed. Suggested levels of evidence and grades of recommendation for each strategy have been applied.

Various strategies to manage rectal changes have been investigated including diet and laxatives, enemas and rectal emptying tubes and rectal displacement with endorectal balloons (ERBs) and rectal spacers. Bladder-filling protocols and bladder ultrasound have been used to try to standardise bladder volume. Positioning the patient supine, using a full bladder and positioning prone with or without a belly board, has been examined in an attempt to reduce the volume of irradiated small bowel. Some randomised trials have been performed, with evidence to support the use of ERBs, rectal spacers, bladder-filling protocols and the supine over prone position in prostate radiotherapy. However, there was a lack of consistent high-quality evidence that would be applicable to different disease sites within the pelvis. Many studies included small numbers of patients were non-randomised, used less conformal radiotherapy techniques or did not report clinical outcomes such as toxicity.

There is uncertainty as to the clinical benefit of many of the commonly adopted interventions to minimise pelvic organ motion. Given this and the limitations in online image guidance compensation, further investigation of adaptive radiotherapy strategies is required.

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.

To evaluate the use of exercise in managing fatigue in breast cancer patients undergoing adjuvant radiotherapy. To explore the effectiveness of different exercise practices and explore how optimum management of fatigue might be achieved.

A CINAHL (Cumulative Index to Nursing and Allied Health Literature) database search of literature was undertaken and publications screened for retrieval with 24 qualifying for inclusion in the review.

There is evidence to support various forms of exercise including aerobic, resistance, alternative and combination exercise in the management of fatigue in early stage breast cancer patients undergoing adjuvant radiotherapy. The benefits of exercise for patients with later stage and metastatic disease is less clear and there is a lack of published research related to this category of patient.

Exercise is considered a safe, non-pharmacological intervention for early stage breast cancer patients receiving adjuvant radiotherapy. Further investigation is required into optimum exercise interventions and the effectiveness and viability of supervised and unsupervised models. Patient centred tailored advice and guidance needs to be developed and effectively promoted by therapeutic radiographers in order for patients to fully realise the benefit.

Treatment volumes for radical radiotherapy to head and neck cancers commonly extend into the lower neck, the territory of the brachial plexus (BP). There is a risk of radiation-induced brachial plexopathy, a non-reversible late toxicity experienced by a small number of patients. The BP was anatomically divided into superior and inferior divisions and analysed to establish if segmental inter-fractional BP movement should be considered when planning radiotherapy in this high-dose region.

A retrospective single-centre analysis of 15 patients with head and neck cancers treated with radical bilateral neck irradiation was conducted. The extent of BP movement relative to the planning scan was assessed using weekly cone beam computed tomography (CBCT) scans. The BP was contoured on the planning scan and the subsequent six weekly CBCTs; this was used to calculate the Jaccard Conformity Index (JCI) for the left, right, superior and inferior divisions of the BP.

The mean (±SD) JCI for right and left superior BP was 44·4±15·5%, whereas the mean (±SD) JCI for right and left inferior BP was 38·3±15·5%. There was a statistically significant difference between superior and inferior JCI, p=0·0002, 95% CI (−9·26 to −2·88). Bilateral superior BP JCI was higher, with better conformity than the corresponding inferior divisions.

Inter-fractional BP movement occurs; the greatest movement is seen at the inferior division. This data suggest the need for re-evaluation of current BP margins and consideration of a larger inferior BP planning at risk volume (PRV) margin.

The Electronic Portal Imaging Device (EPID), primarily used for patient setup during radiotherapy sessions is also used for dosimetric measurements. In the present study, the feasibility of EPID in both machine and patient-specific quality assurance (QA) are investigated. We have developed a comprehensive software tool for effective utilisation of EPID in our institutional QA protocol.

Portal Vision aS1000, amorphous silicon portal detector attached to Clinac iX—Linear Accelerator (LINAC) was used to measure daily profile and output constancy, various Multi-Leaf Collimator (MLC) checks and patient plan verification. Different QA plans were generated with the help of Eclipse Treatment Planning System (TPS) and MLC shaper software. The indigenously developed MATLAB programs were used for image analysis. Flatness, symmetry, output constancy, Field Width at Half Maximum (FWHM) and fluence comparison were studied from images obtained from TPS and EPID dosimetry.

The 3 years institutional data of profile constancy and patient-specific QA measured using EPID were found within the acceptable limits. The daily output of photon beam correlated with the output obtained through solid phantom measurements. The Pearson correlation coefficients are 0.941 (p = 0.0001), 0.888 (p = 0.0188) and 0.917 (p = 0.0007) for the years of 2014, 2015 and 2016, respectively. The accuracy of MLC for shaping complex treatment fields was studied in terms of FWHM at different portions of various fields, showed good agreement between TPS-generated and EPID-measured MLC positions. The comparison of selected patient plans in EPID with an independent 2D array detector system showed statistically significant correlation between these two systems. Percentage difference between TPS computed and EPID measured fluence maps calculated for number of patients using MATLAB code also exhibited the validity of those plans for treatment.

Pre-registration teaching of radiotherapy planning in a non-clinical setting should allow students the opportunity to develop clinical decision-making skills. Students frequently struggle with their ability to prioritise and optimise multiple objectives when producing a clinically acceptable plan. Emerging software applications providing quantitative assessment of plan quality are designed for clinical use but may have value for teaching these skills. This project aimed to evaluate the potential value of automated feedback to second year BSc (Hons) Radiotherapy students.

All 26 students studying a pre-registration radiotherapy planning module were provided with automated prediction of relative feasibility for left lung tumour planning targets by planning metrics software. Students were also provided with interim quantitative reports during the development of their plan. Student perceptions of the software were gathered using an anonymous questionnaire. Independent blinded marking of plans was performed after module completion and analysed for correlation with software-assigned marks.

In total, 25 plans were utilised for marking comparison and 16 students submitted feedback relating to the software. Overall, student feedback was positive regarding the software. A ‘strong’ Spearman’s rank-order correlation (rs=0·7165) was evident between human and computer marks (p=0·000055).

Automated software is capable of providing useful feedback to students as a teaching aid, in particular with regard to relative feasibility of goals. The strong correlation between human and computer marks suggests a role in benchmarking or moderation; however, the narrow scope of assessment parameters suggests value as an adjunct and not a replacement to human marking.

To develop an auto-generated patient discharge summary for all patients being treated in the Radiation Therapy Department.

A patient discharge summary was developed using auto-generated data for all patients being treated in the Radiation Therapy Department. This ensures information relevant to the care of the patient is communicated effectively during transitions of care following radiation treatment, and provides a record of the treatment site(s), dose delivered, start/completion dates and contact information for Radiation Oncologists. The eScribe feature in MosaiQTM is utilised to auto-generate the patient discharge summary in less than one minute, and then printed and given to patients on the last day of treatment. This was piloted with palliative radiotherapy patients (n=22), who also completed a telephone survey.

Results revealed patients had passed this document onto other healthcare providers and appreciated having a record of their treatments. Feedback was obtained from radiation therapy staff and the Patient and Family Advisory Committee. Subsequently, the language of the patient discharge summary was simplified and a disclaimer was added, indicating the document is not a complete radiation therapy treatment record. This initiative was then rolled out to all radiotherapy patients.

Overall, the patient discharge summary allows for a quick, automated and standardised approach for transfer of information during care transitions without significant impact to the Radiation Therapy Departmental workflow.

This study evaluated dosimetric parameters for cervical high-dose-rate (HDR) brachytherapy treatment using varying dose prescription methods.

This study includes 125 tandem-based cervical HDR brachytherapy treatment plans of 25 patients who received HDR brachytherapy. Delineation of high-risk clinical target volumes (HR-CTVs) and organ at risk were done on original computed tomographic images. The dose prescription point was defined as per International Commission in Radiation Units and Measurements Report Number 38 (ICRU-38), also redefined using American Brachytherapy Society (ABS) 2011 criteria. The coverage index (V100) for each HR-CTV was calculated using dose volume histogram parameters. A plot between HR-CTV and V100 was plotted using the best-fit linear regression line (least-square fit analysis).

Mean prescribed dose to ICRU-38 Point A was 590·47±28·65 cGy, and to ABS Point A was 593·35±30·42 cGy. There was no statistically significant difference between planned ICRU-38 and calculated ABS Point A doses (p=0·23). The plot between HR-CTV and V100 is well defined by the best-fit linear regression line with a correlation coefficient of 0·9519.

For cervical HDR brachytherapy, dose prescription to an arbitrarily defined point (e.g., Point A) does not provide consistent coverage of HR-CTV. The difference in coverage between two dose prescription approaches increases with increasing CTV. Our ongoing work evaluates the dosimetric consequences of volumetric dose prescription approaches for these patients.

The control of patient position, posture and respiratory movements during radiotherapy is important for effective and specific treatment of malignancy. We have developed an infrared (IR) interactive patient position guidance and acquisition control system for clinical use, comprising IR cameras, IR markers and dedicated software.

We evaluated the system with ten healthy volunteers and ten experienced operators. IR markers were placed on the body surface. Their positions were calculated using vectors of three translational and three rotational parameters, and the intrafractional error for each marker was acquired with and without respiratory motion. The inclusion of multiple positioning markers allowed for real-time visualisation of the patient posture, with feedback on misalignment and required postural adjustments.

The positioning time was 73 seconds (with a minimum period of 39 seconds), which was significantly shorter than for conventional line alignment. A comparison of positioning reproducibility between conventional line alignment and this system was <3·5 mm and was not patient dependent or operator dependent. An intrafractional error of displacement of up to 10·0 mm was found in the right iliac crest.

This IR interactive system was shown to be high utility and suitable for monitoring patient position, posture and respiratory movements during radiotherapy.

The aim of this study was to compare the dosimetric parameters and effects of simultaneous integrated boost (SIB) and traditional sequential electron boost, after helical tomotherapy, because of the lack of studies in this field in the current literature.

Computed tomographic data of 14 patients who received SIB in 2012–2015 were collected from Hong Kong Sanatorium & Hospital. New tomotherapy with SIB plans and tomotherapy with sequential boost plans were generated for each patient, and results were compared.

Conformation number, mean dose, dose received by 95% volume (both sides), ipsilateral lung volume receiving 20 Gy (V20) and skin dose (right side) were found to be significantly better for SIB (p<0·05), however coverage index and gross target volume dose showed no significant difference, and heart dose was significantly higher for SIB on the right side.

Tomotherapy with SIB may be able to offer less organ at risk dose (except for the heart), while maintaining the ability to deliver adequate dose coverage.