The management of breast cancer patients from diagnosis to treatment and beyond can be variable depending on factors including tumour extent and location, histology, genetics, health and wellbeing of the patient as well as personal patient preferences. The therapeutic radiographer’s role is not only vital to ensure safe and accurate radiotherapy delivery but also crucially, as the regular patient interface, they must be fully empowered to engage effectively with all aspects of the patient care pathway. They must be knowledgeable and up to date with evidence-based practices relating to the patient experience including surgery, chemotherapy, endocrine therapy and radiotherapy.

The aim of this paper is to outline the breast cancer management pathway, highlighting the potential side effects that occur as a result of breast radiotherapy treatment and concomitant treatment in order to inform therapeutic radiographers and best practice.

The treatment pathway for breast cancer patients varies greatly depending on a wide range of factors and is very much individualised for each patient. Each treatment modality has its advantages and disadvantages, and all come with a number of side effects that can affect a patient’s daily living. Toxicities can arise during radiotherapy treatment or months after treatment, and education regarding the management of these is essential for effective patient care. Many technological advances in radiotherapy treatment techniques and regimes have the potential to decrease radiation-induced side effects. Despite attempts to standardise clinical guidelines on the use of topical agents and dressings, historical opinions and ideas are still evident in clinical practice. The use of grading systems in radiotherapy tends to only record patients’ physical symptoms and not their holistic wellbeing and emotional needs.

Therapeutic radiographers must ensure that they remain equipped with the skills and knowledge to correctly manage and/or signpost services effectively. This overall outline of the management of patients with breast cancer is designed to help therapeutic radiographers reflect on the current practices and to inspire them, where evidence dictates, to seize opportunities, to explore improvement and to enhance best practice.

Nodal boost is being increasingly employed to escalate the dose to involved nodes in node-positive cervical cancer. The study aimed to compare the dosimetric differences between sequential boost intensity-modulated radiation therapy (SeB-IMRT) and simultaneous integrated boost IMRT (SIB-IMRT) in terms of target coverage and organs-at-risk (OARs) with special emphasis on the effect of nodal shrinkage and anatomical change of normal tissues during radiotherapy.

Two computed tomography (CT) datasets (of phase I and phase II) of 40 patients of node-positive cervical cancer treated with SeB-IMRT [planning target volume (PTV) 45/25] followed by SeB to residual nodes (PTV 12·6/7) were utilised. SIB-IMRT1 plan consisted of PTV pelvis and para-aortic nodal region (PTV 45/25) and SIB to gross nodes (PTV 55/25). In order to account for the change in nodal and normal tissue topography during treatment, a third plan (SIB-IMRT2) was generated by utilising the SIB-IMRT1 plan for 44 Gy in 20 fractions and reproducing the plan on the second CT dataset for 11 Gy in 5 fractions. Dosimetric parameters of the three plans were compared using the Friedman test with Bonferroni correction.

We observed that the doses to OARs (bowel, rectum and bladder) were significantly higher in SeB-IMRT plan as compared to the SIB-IMRT plans. V40 Gy of bowel for SeB-IMRT, SIB-IMRT1 and SIB-IMRT2 plans were 354·8 cc, 271 cc and 321·8 cc, respectively (p = 0·001), whereas V30 Gy were 687·8 cc, 635·5 cc and 680 cc, respectively (p = 0·001). The target coverage was marginally better in SeB-IMRT plan as compared to SIB-IMRT1 and SIB-IMRT2 plans (V95% = 99·2 versus 97·7 versus 97·9, respectively, p = 0·000)

SIB-IMRT led to better sparing of OARs, especially bowel. However, the magnitude of benefit decreases if the change in nodal and normal tissue topography during radiotherapy is not considered implying the need for frequent image guidance when SIB-IMRT is planned for node-positive cervical cancer.

Stereotactic radiosurgery (SRS) has become a preferred treatment in the initial management of brain metastases (BM). This study reported treatment outcomes and identified the patient, tumour, and treatment-related factors that predict failure, survival, and brain necrosis (BN).

We retrospectively reviewed the electronic medical records of all BM patients treated with SRS. Patient, tumour characteristics and treatment details data were collected. All recurrences and BN were defined in the neurooncological tumour board.

From December 2016 to April 2020, 148 patients were analysed. The median follow-up was 14·8 months (range 6–51). At the time of analyses, 72·3% of the patients were alive. Presence of initial neurological deficit (HR; 2·71 (1·07–6·9); p = 0·036) and prior RT (HR; 2·55 (1·28–5·09); p = 0·008) is associated with worse overall survival. The local recurrence rate was 11·5 %. The distant brain metastasis rate was 53·4 %. Leptomeningeal metastasis was seen in 11 patients (7·4%). Symptomatic BN was seen in 19 patients (12·8 %). Bigger lesions (13 versus 23 mm diameter; p = 0·034) and cavity radiosurgery are associated with more BN (63·2 % versus 36·8%; p: 0·004).

Distant BM is the leading cause of CNS recurrences and, salvage SRS is possible. Due to the increasing risk of developing BN routine metastasectomy should be made with caution.

Contrast media are frequently used during radiation therapy simulation. However, there are concerns about dosimetric variations when dose calculation is done on contrast-enhanced computed tomography (CT). This study evaluates the dosimetric effect of oral contrast during three-dimensional conformal radiotherapy (3D-CRT) and volumetric modulated arc radiotherapy (VMAT) planning.

Rectal cancer patients were consecutively enrolled. For each patient, one unenhanced CT and one contrast-enhanced CT were taken using oral and intravenous contrast. Then, a 3D-CRT plan and an Intensity-modulated radiation therapy (IMRT)/VMAT plan were generated in the enhanced CT, and the dose distribution was recalculated in the respective unenhanced CT. The beam intensities were kept the same as for the enhanced CT plans. Finally, the unenhanced and enhanced plans were compared by calculating the gamma index.

For 3D-CRT plans, there were statistically significant differences in second phase planning target volume (PTV) D2% (Mean difference (MD) between unenhanced and enhanced CT 0·01 Gy, 95% CI [0·003 to 0·02 Gy]) and in maximum doses to the bladder (MD 0·26 Gy, 95% CI [0·05 to 0·47 Gy]). For IMRT/VMAT plans, there were statistically significant differences in small intestine V45 Gy (MD 3·1 cc, 95% CI [0·81 to 5·4 cc]), bladder V45 Gy (MD 2·9%, 95% CI [1·4 to 4·3%]) and maximum dose to the bladder (MD 0·65 Gy, 95% CI [0·46 Gy to 0·85 Gy]). In addition, for PTV D98% the MD between unenhanced and enhanced CT was 0·22 Gy 95% CI [0·05 to 0·39].

For most of the dose metrics, the differences were not clinically meaningful. The greatest differences were found in VMAT plans, especially in V45 Gy of the small intestine. This difference could lead to an underestimation of dose–volume metrics when the plan is based on an enhanced CT. The use of small bowel oral contrast does not significantly influence dose calculations and may not affect the acceptability of plans when adhering to constraints.

Pancreatic cancer is the 12th most commonly diagnosed cancer and the 3rd leading cause of cancer mortality and accounts for approximately 2·7% of all newly diagnosed cancer cases and 6·4% of all cancer mortalities in Canada. It has a very poor survival rate mainly due to the difficulty of detecting the disease at an early stage. Consequently, in the advancement of disease management towards the concept of precision medicine that takes individual patient variabilities into account, several investigators have focused on the identification of effective clinical biomarkers with high specificity and sensitivity, capable of early diagnosis of symptomatic patients and early detection of the disease in asymptomatic individuals at high risk for developing pancreatic cancer.

We searched several databases from August to December 2020 for relevant studies published in English between 2000 and 2020 and reporting on biomarkers for the management of pancreatic cancer. In this narrative review paper, we describe 13 clinical and emerging biomarkers for pancreatic cancers used in screening for early detection and diagnosis, to identify patients’ risk for metastatic disease and subsequent relapse, to monitor patient response to specific treatment and to provide clinicians the possibility of prospectively identifying groups of patients who will benefit from a particular treatment.

Current and emerging biomarkers for pancreatic cancer with high specificity and sensitivity has the potential to account for individual patient variabilities, for early detection of disease before the onset of metastasis to improve treatment outcome and patients’ survival, help screen high-risk populations, predict prognosis, provide accurate information of patient response to specific treatment and improve patients monitoring during treatment. Thus, the future holds promise for the use of effective clinical biomarkers or a panel of biomarkers for personalised patient-specific targeted medicine for pancreatic cancer.

Patients with cancer undergoing radiotherapy often develop diarrhoea, causing distress and hindering treatment. As probiotics have favourable effects on the gut flora, they are potentially good candidates in the prevention of radiotherapy-induced diarrhoea (RID).

The outcome of interest of this systematic review was the efficacy of probiotics in preventing RID.

Medline and Embase databases were systematically searched. Four randomised controlled trials (RCTs) were finally selected.

Three RCTs showed beneficial results, which were statistically significant. One RCT showed non-beneficial results, which were not statistically significant. The quality of the studies was mixed, and serious limitations were found.

While the indications are towards a benefit of the use of probiotics in preventing RID, more robust evidence is required in the form of well-designed RCTs.

Patients undergoing prostate radiation therapy were observed to have elevated blood pressures in clinic. Therefore, we sought to further characterise this phenomenon.

The charts of 76 patients who received radiotherapy for prostate cancer between 2014 and 2017 were examined. Blood pressure (BP) readings were obtained at initial consultation, on treatment visits, and subsequent follow-up appointments. To describe this effect, we defined radiation-associated hypertension (RAH) as an increase ≥15 mmHg systolic BP, 10 mmHg diastolic BP, or 5 mmHg mean arterial pressure.

Within this cohort, 36 patients developed RAH, with 75% developing RAH while on treatment, and 25% developing RAH at post-treatment visits. Two-thirds of patients remained hypertensive during post-treatment visits, and 27% were prescribed additional anti-hypertensives. There was no association between neoadjuvant/concurrent androgen deprivation therapy and RAH.

A significant number of patients undergoing prostate radiotherapy developed RAH, necessitating additional medication in some.

This study aims to evaluate dosimetric parameters like percentage depth dose, dosimetric field size, depth of maximum dose surface dose, penumbra and output factors measured using IBA CC01 pinpoint chamber, IBA stereotactic field diode (SFD), PTW microDiamond against Monte Carlo (MC) simulation for 6 MV flattening filter-free small fields.

The linear accelerator used in the study was a Varian TrueBeam® STx. All field sizes were defined by jaws. The required shift to effective point of measurement was given for CC01, SFD and microdiamond for depth dose measurements. The output factor of a given field size was taken as the ratio of meter readings normalised to 10 × 10 cm2 reference field size without applying any correction to account for changes in detector response. MC simulation was performed using PRIMO (PENELOPE-based program). The phase space files for MC simulation were adopted from the MyVarian Website.

Variations were seen between the detectors and MC, especially for fields smaller than 2 × 2 cm2 where the lateral charge particle equilibrium was not satisfied. Diamond detector was seen as most suitable for all measurements above 1 × 1 cm2. SFD was seen very close to MC results except for under-response in output factor measurements. CC01 was observed to be suitable for field sizes above 2 × 2 cm2. Volume averaging effect for penumbra measurements in CC01 was observed. No detector was found suitable for surface dose measurement as surface ionisation was different from surface dose due to the effect of perturbation of fluence. Some discrepancies in measurements and MC values were observed which may suggest effects of source occlusion, shift in focal point or mismatch between real accelerator geometry and simulation geometry.

For output factor measurement, TRS483 suggested correction factor needs to be applied to account for the difference in detector response. CC01 can be used for field sizes above 2 × 2 cm2 and microdiamond detector is suitable for above 1 × 1 cm2. Below these field sizes, perturbation corrections and volume averaging corrections need to be applied.

Comparison of the integral dose (ID) delivered to organs at risk (OAR), non-target body and target body by using different techniques of craniospinal irradiation (CSI).

Ten CSI patients (medulloblastoma) already planned and treated either with linear accelerator three-dimensional conformal radiation therapy (Linac-3DCRT) technique or with linear accelerator RapidArc (Linac-RapidArc) technique by Novalis-Tx Linac machine have been analysed. Retrospectively, these patients are again planned on Radixact-X9 Linac with Helical, Direct-3DCRT and Direct-intensity-modulated radiation therapy (Direct-IMRT) techniques. The dose prescription to planning target volume brain (PTV-Brain) and PTV-Spine is 36 Gy in 20 fractions and is kept the same for all techniques. The target body, non-target body, OARs and total body dose are compared.

ID is lowest in the RapidArc plan for every patient in comparison to Helical and Direct-IMRT. The ID for Body-PTV was found slightly higher in the RapidArc plan in comparison to 3DCRT plans. But there is better normal tissue sparing for most of the OARs in RapidArc plans if it compares with 3DCRT plans.

RapidArc is a better alternative for the treatment of CSI. It provides better target coverage and better OARs sparing from any other treatment techniques.

In the treatment of locally advanced head and neck cancer (LA-HNC), both dose escalation and hypo-fractionation can improve tumour control rates with uncertain role of addition of concurrent chemotherapy. We aimed at developing a new radiotherapy protocol for patients not eligible to receive the standard concurrent chemo-radiation therapy (CCRT) with little toxicity profile.

A total of 63 LA-HNC patients were randomised to receive either: 70 Gy in 35 fx in 7 weeks concurrently with cisplatin 100 mg/m2 every 3 weeks for 3 doses (Arm A) or 74 Gy in 33 fx in 6·5 weeks (Arm B). Volumetric modulated arc therapy plans were created for both treatment arms. We compared the local control (LC), progression-free survival (PFS), overall survival (OS) and acute and late toxicity between the two arms.

A total of 33 patients were in Arm A versus 30 patients in Arm B with median follow-up 24·2 months. No significant differences in LC, PFS and OS between the two arms. Complete remission occurred in 54·5 and 63·3% of patients in Arms A and B, respectively. All toxicities were significantly less in Arm B than Arm A.

Slightly dose-escalated hypo-fractionated regimen is safe and feasible and has comparable efficacy and less acute and late side effects than conventional dose CCRT with avoidance of chemotherapy-related toxicities in LA-HNC patients.

Deep inspiration breath hold (DIBH) is a method of motion management used in stereotactic ablative body radiotherapy (SABR) for lung tumours. An external gating block marker can be used as a tumour motion surrogate, however, inter-fraction gross target volume (GTV) displacement within DIBH occurs. This study measured this displacement during a reproducible breath hold regime. In addition, factors such as position of the gating block marker were analysed.

A total of 121 cone beam computed tomography scans (CBCTs) from 22 patients who received DIBH SABR were retrospectively evaluated and the magnitude of inter-fraction GTV displacement was calculated for each fraction. This data was analysed to assess if any correlation existed between tumour displacement and variation in the gating block marker position on the patient, the amplitude of breath hold (BH) at computed tomography (CT), the amplitude of BH at treatment and the tumour location.

The measured tumour displacement was applied to the original planning CT to evaluate the dosimetric effect on surrounding organs at risk (OARs) using cumulative dose volume histograms (DVHs).

BH amplitude was reproducible within 0·13±0·1 cm (mean±standard deviation). The magnitude of tumour displacement within BH ranged from 0 to 1·52 cm (0·41±0·28 cm). Displacement in the superior-inferior, anterior-posterior and left-right planes were 0·31±0·26 cm, 0·16±0·18 cm and 0·07±0·12 cm, respectively. No statistically significant correlation was detected between tumour displacement within DIBH and the factors investigated. The range of variation in OAR dose was −7·0 to +3·6 Gy with one statistically significant increase in OAR dose observed (oesophagus mean dose increasing by 0·16 Gy).

Reproducible BH was achievable across a range of patients. Inter-fraction GTV displacement measured 0·41±0·28 cm. Due to this low level of motion, the correction of soft tissue moves did not adversely affect OAR dose.

Locally advanced head and neck cancer can be a distressing disease due to a variety of reasons. This retrospective study looks at the tolerability and outcomes for palliative split-course hypofractionated radiotherapy for this group of patients treated in our centre.

A total of 59 patients were treated with hypofractionated split-course radiotherapy for incurable mucosal squamous cell carcinoma of the head and neck region in our centre over a 10-year period. In all, 71% had stage IV disease. Radiotherapy consisted of three phases of 14·4 Gy/phase, in four to eight fractions over 4 days giving one·8–3·6 Gy/fraction. The phases were separated by 2 weeks. A total of 40 patients (63%) completed all three phases. A total of 72% patients had no acute toxicities and the palliation rate was 83% (complete and partial). Only five patients had no meaningful palliation having completed all three phases. Median duration of local control was 6 months (range: 1–63 months) and median overall survival was 8 months (range: 1–68 months). In five patients, the control was durable with no recurrence at the time of analysis with survival ranging from 6 to 57 months.

We are the first UK centre to report with long-term data, the use of a palliative three phase regime that provides meaningful palliation with acceptable toxicities. In addition, for some patients, it has resulted in durable long-term control.

A retrospective study was undertaken to analyse set-up variations in patients being treated with post-operative radiation therapy for carcinoma of gall bladder by image-guided radiotherapy (IGRT) using cone-beam computed tomography (CBCT) scans and paired kilovoltage beam portals (kVps).

Three consecutive patients receiving post-operative radiation therapy for carcinoma of gall bladder were studied. A total of 32 imaging studies were performed. The immobilisation system was an all-in-one system along with a thermoplastic mask, with knees either resting on the knee rest or in a vacuum cushion. The CBCT scans and kVps were reviewed in an off-line mode. The surrogate markers used for matching during co-registration were 12th rib, coeliac trunk, vertebral bodies and canal. Individual readings were used to calculate mean shifts (m); the mean of these means (M) was calculated to arrive at the systematic error in each direction and its standard deviation (Σ) was calculated. The margins for set-up error (SM) were then calculated.

There were a total of 32 readings of which 21 were CBCTs and 11 were kVps. The mean shifts in each direction for each patient were 0·06, 0·25 and 0·15 cm in vertical, longitudinal and lateral directions, respectively. The resultant planning target volume margins calculated were 0·24, 0·9 and 0·47 cm in vertical, longitudinal and lateral directions.

IGRT for upper abdominal malignancies using CBCT and kVps is a useful method to keep the margins for set-up error low. The use of surrogates for matching should be relevant to the target volume. Good immobilisation system helps in keeping the margins low.

The purpose of this study was to dosimetrically compare TomoDirect, TomoHelical and linear accelerator-based 3D-conformal radiotherapy (Linac-3DCRT) for craniospinal irradiation (CSI) in the treatment of medulloblastoma.

Five CSI patients were replanned with Linac-3DCRT, TomoHelical, TomoDirect-3DCRT and TomoDirect-intensity-modulated radiotherapy (IMRT). Dose of 36 Gy in 20 fractions was prescribed to the planning target volume (PTV). Homogeneity index (HI), non-target integral dose (NTID), dose–volume histograms, organs-at-risk (OARs) Dmax, Dmean and treatment times were compared.

TomoHelical achieved the best PTV homogeneity compared with Linac-3DCRT, TomoDirect-3DCRT and TomoDirect-IMRT (HI of 3·6 versus 20·9, 8·7 and 9·4%, respectively). TomoDirect-IMRT achieved the lowest NTID compared with TomoDirect-3DCRT, TomoHelical and Linac-3DCRT (141 J versus 151 J, 181 J and 250 J), indicating least biological damage to normal tissues. TomoHelical plans achieved the lowest Dmax in all organs except the breasts, and lowest Dmean for most OARs, except in laterally situated OARs, where TomoDirect triumphed. Beam-on time was longest for TomoHelical, followed by TomoDirect and Linac-3DCRT.

TomoDirect has the potential to lower NTID and shorten treatment times compared with TomoHelical. It reduces PTV inhomogeneity and better spares OARs compared with Linac-3DCRT. Therefore, TomoDirect may be a CSI treatment alternative to TomoHelical and in place of Linac-3DCRT.