Breast cancer patients experience skin reactions during radiotherapy. Radiation-induced skin reactions can result in treatment delivery being interrupted. The aim of this paper is to evaluate the skincare management of patients receiving radiotherapy for breast cancer in order to inform best practice.

A literature search was undertaken using USearch and HONNI in support of the first-hand evidence gained from the supervised on-treatment review of patients receiving radiotherapy for breast cancer.

There is evidence to suggest that the skincare advice given to patients varies widely between departments in the UK with many not following nationally recommended guidelines. Studies demonstrate that there are ways to reduce skin reactions and that there are a range of effective management strategies being adopted. Prophylactic skincare has been explored to improve the resilience of the skin prior to commencing radiotherapy.

Further investigation is required in order to clearly establish the optimum national skincare management for breast cancer patients. More studies are required to test the effectiveness and viability of prophylactic measures. Skincare guidance needs to be robustly developed and effectively promoted by therapeutic radiographers for radiotherapy patients to benefit from reduced, radiation-induced, skin reactions.

To evaluate the dosimetric parameters of level II lymph nodes in chest wall three-dimensional conformal radiotherapy (3D-CRT) and intensity-modulated radiotherapy (IMRT) of mastectomy patients using dual-isocentric (DIT) and mono-isocentric techniques (MIT).

Computed tomography (CT) images of 20 mastectomy patients undergoing chest wall external radiotherapy were used as the input data for the abovementioned techniques. Selected dosimetric parameters were calculated for the axillary level I–III lymph nodes, chest wall, heart and lung. Paired t-test statistical analysis was used for comparing the results of MIT and DIT in both 3D-CRT and IMRT methods.

There were significant differences in Dmin (minimum dose), Dmax (maximum dose) and maximum–minimum dose between MIT and DIT techniques (13, −8·6, −52·2% differences for Dmin, Dmax and maximum–minimum, respectively) in IMRT. There were also significant differences for Dmean (mean dose), Dmax and maximum–minimum dose (7·8, −11·4, −44·6% differences in Dmean, Dmax and maximum–minimum, respectively) in 3D-CRT (p < 0·05). In addition, there were not any differences in the dosimetric parameters for heart, lung and level I and III lymph nodes.

In both 3D-CRT and IMRT methods, level II lymph node dose distribution in MIT was closer to the prescribed dose compared with DIT due to the position of these nodes in the field junction area. To achieve a better dose homogeneity, it could be recommended to use MIT instead of DIT in 3D-CRT and IMRT for mastectomy patients.

Radiation therapy (RT), in combination with chemotherapy, is the mainstay in the treatment for locally advanced oropharyngeal cancer. We analysed the tumour response and the toxicity profiles in patients having locally advanced oropharyngeal cancers receiving hypofractionated intensity-modulated radiation therapy (IMRT) and concurrent chemotherapy with Cisplatin investigating the feasibility and radiobiological efficacy of the regimen, along with its use as a resource-sparing alternative for a high-volume centre.

The records of 41 eligible patients with locally advanced squamous cell carcinoma of oropharynx, registered from September 2015 to April 2017, treated with hypofractionated IMRT with concurrent Cisplatin, were analysed from the hospital database. Patients received concurrent chemo-radiation with 2 cycles of 3-weekly cisplatin on day 1 and day 22 along with hypofractionated IMRT, 55 Gy delivered in 20 fractions over 4 weeks. Patients were observed for any radiation reaction or chemotherapy toxicity at least once a week during the course of radiation therapy.

Twenty-nine patients (70·7%) achieved complete response and remaining 12 showed partial response. Acute grade 3 toxicity was observed mostly in the form of oral mucositis and radiation dermatitis. Both grade 3 oral mucositis and radiation dermatitis were seen in 15 patients (36·6%) and 7 patients (17%), respectively. The most common late toxicities were dysphagia and dry mouth. Twenty-five patients (61%) completed the overall treatment within 4 weeks’ duration.

This hypofractionated regimen is feasible and was associated with tolerable acute and late morbidity and satisfactory locoregional response. Larger prospective, multi- institutional studies examining similar schedules may be undertaken to establish this as a standard practice, particularly for a high-volume centre.

The error in set-up of patients is an inherent part of treatment processes. The positioning errors can be used to determine the margins of the planning target volume (PTV) to cover the target volume, while minimising the radiation dose delivered to normal tissues. This study aimed to evaluate random and systematic errors occurring in inter-fraction set-ups of pelvic radiotherapy measured by electronic portal imaging device (EPID) and then to propose the optimum clinical target volume (CTV) to PTV margin in pelvic cancer patients.

This study examined 22 patients treated with pelvic radiotherapy. A total of 182 portal images were evaluated. Population random (σ) and systematic (Σ) errors were determined based on the portal images in three directions (X, Y and Z). The set-up margin for CTV to PTV was calculated by published margin formulae of International Commission on Radiation Units and measurements (ICRU) report No. 62 recommendation and formulas presented by Stroom and Heijmen and Van Herk et al.

Systematic set-up errors for radiotherapy to patients ranged between 2·36 and 4·99 mm, and random errors ranged between 1·51 and 2·74 mm. The margin required to cover the target volume retrospectively was calculated based on ICRU 62 and formulas presented by Stroom and Heijmen and Van Herk et al. were used to calculate the range 2·8–5·7 mm, 5·7–11·9 mm and 6·9–14·4 mm, respectively.

According to our findings, it can be concluded that by extending the CTV margin by 6·9–14·4 mm, we can ensure that 90% of the pelvic cancer patients will receive ≥ 95% of the prescribed dose in the CTV area.

Radiation dosimetry requires special phantoms which are comparable with organs and tissues of a human body. The lung is one of the organs with a low density. Therefore, it is important to create and use lung equivalent phantoms in dosimetric controls. The aim of this study was to investigate the importance of using lung equivalent phantoms for different respiratory phases during measurements with both computed tomography (CT) and linear accelerator.

The maximum lung inhalation phantom (LIP) and lung exhalation phantom (LEP) were created for two respiratory phases. The Hounsfield Unit (HU) values based on the selected slice thickness and CT tube voltages were investigated, as well as the difference between energy and algorithms used in the treatment planning system.

It was found that the change in HU values according to slice thickness were more significant in measurements for respiratory phases. The dose difference between LEP and LIP at a point which is located 1 cm below the surface of the phantoms was found as 1·0% for 6 megavolt (MV) and 2·8% for 18 MV. The highest difference between the two algorithms was found to be 7·22% for 6 MV and 10·93% for 18 MV for LIP phantom.

It can be said that the LIP and LEP phantoms prepared in accordance with respiratory phases can be a simple and inexpensive method to investigate any difference in dosimetry during respiratory phases. Also, measured and calculated dose values are in good agreement when thinner slice thickness was chosen.

To assess the relapse-free survival (RFS) and the factors influencing local recurrence in patients with desmoid fibromatosis (DF) treated at our centre and to determine the role of post-operative radiotherapy (RT) in improving local control.

A retrospective analysis of 51 patients treated for DF from January 2004 to December 2013 was undertaken. The RFS was calculated using the Kaplan–Meier curve. Univariate analysis was done to assess correlation with tumour size, site, the extent of surgery, margin status and adjuvant RT with RFS.

The median age was 28 years with a male:female ratio of 1:3. The most common location of the tumour was anterior abdominal wall (47%). The median tumour size was 10 cm. Wide local excision was done in most patients. Complete resection with negative margin was achieved in eight patients. Post-operative RT was indicated for 43 patients of whom 19 received RT. At a median follow-up of 37 months, RFS in the complete resection with margin negative group was 100%. RFS for the patients with positive or close margins who received RT was 79% and for those who did not receive RT, it was 87%.

Complete excision with negative margins gives the best local control in DF. The benefit of post-operative RT could not be ascertained.

This is a phantom study to evaluate the dosimetry effects of using virtual bolus (VB) in TomoTherapy Treatment Planning System (TPS) optimisation for superficial planning target volume (PTV) that extends to the body surface. Without VB, the inverse-planning TPS will continuously boost the photon fluence at the surface of the superficial PTV due to lack of build-up region. VB is used during TPS optimisation only and will not be present in actual treatment delivery.

In this study, a dummy planning target was contoured on a cylindrical phantom which extends to the phantom surface, and VB of various combinations of thickness and density was used in treatment planning optimisation with TomoTherapy TPS. The plans were then delivered with the treatment modality TomoTherapy. Radiochromic films (Gafchromic EBT3) were calibrated and used for dose profiles measurements. TomoTherapy Planned-Adaptive software was used to analyse the delivered Dose-Volume Histograms (DVHs).

The use of 2 mm VB was not providing adequate build-up area and was unable to reduce the hot spots during treatment planning and actual delivery. The use of 4 mm VB was able to negate the photon fluence boosting effect by the TPS, and the actual delivery showed relatively small deviations from the treatment plan. The use of 6 mm VB caused significant dose overestimation by the TPS in the superficial regions resulting in insufficient dose coverage delivered.

VB with the combination of 4 mm thickness and 1·0 g/cc density provides the most robust solution for the TomoTherapy TPS optimisation of superficial PTV.

Lung cancer has a high mortality rate mainly due to the lack of early detection or outward signs and symptoms, thereby often progressing to advanced stages (e.g., stage IV) before it is diagnosed. However, if lung cancers can be diagnosed at an early stage and also if clinicians can prospectively identify patients likely to respond to specific treatments, then there is a very high potential to increase patients’ survival. In recent years, several investigations have been conducted to identify cancer biomarkers for lung cancer risk assessment, early detection and diagnosis, the likelihood of identifying the group of patients who will benefit from a particular treatment and monitoring patient response to treatment.

This paper reports on the review of 19 current clinical and emerging biomarkers used in risk assessment, screening for early detection and diagnosis and monitoring the response of treatment of non-small-cell lung cancers.

The future holds promise for personalised and targeted medicine from prevention, diagnosis to treatment, which take into account individual patient’s variability, though it depends on the development of effective biomarkers interrogating the key aberrant pathways and potentially targetable with molecular targeted or immunologic therapies. Lung cancer biomarkers have the potential to guide clinical decision-making since they can potentially detect the disease early, measure the risk of developing the disease and the risk of progression, provide accurate information of patient response to a specific treatment and are capable of informing clinicians about the likely outcome of a cancer diagnosis independent of the treatment received. Moreover, lung cancer biomarkers are increasingly linked to specific molecular pathway deregulations and/or cancer pathogenesis and can be used to justify the application of certain therapeutic or interventional strategies.

Delays in the diagnosis of cancer were found to be a worldwide matter, and the early cancer detection has been targeted as a way to improve survival. Quantitative studies from Saudi Arabia reported a high number of cancer cases presenting at cancer centres for the first time with more advanced stages of the disease progression compared to Western countries without exploring the reasons for this phenomenon. Worldwide research identified several factors that contribute to delay in the diagnosis and treatment of cancer which were attributed to both patient and healthcare system. However, it was argued that variation in the operation of health systems and the socio-cultural context across countries makes it difficult to generalise findings beyond individuals’ countries. This necessitates country specific research to investigate why patients in Saudi Arabia present to cancer centres with late/advanced stages of their diseases.

The aim of this study is to identify and explore the factors that contribute to late-stage presentation of common cancers in Saudi Arabia. The main objective of this study is to understand the help seeking journey taken by patients with cancer from the time they discovered or felt their symptoms until the time they have their treatment initiated.

Qualitative interviewing was used to collect data from 20 patients and 15 health professionals. The interviews were transcribed and then were subjected to the thematic analysis using a framework approach developed by Ritchie and Spencer (1994).

While some findings support what previous studies found as contributing factors responsible for delayed presentation of common cancers, this study identified several factors, which are believed to be country-specific. The ‘role of General Practitioner (GP)’, ‘challenges facing GPs’ and ‘ambiguity of the referral system’ were found to be factors that contribute to delay in the diagnosis and treatment of cancer in Saudi Arabia.

This research identified several factors that need to be investigated in the future using quantitative methods. There is a need to investigate the extent of using alternative medicine and its possible association with late presentation of cancer.

Tobacco is a known addictive consumer product and its use has been reported to be associated with several health problems as well as the leading cause of premature, preventable mortality worldwide. For patients undergoing cancer treatment, tobacco smoking can potentially compromise treatment effectiveness; however, there is sufficient evidence suggesting numerous health benefits of smoking cessation interventions for cancer patients.

The Grand River Regional Cancer Centre (GRRCC) smoking cessation program began in October 2013 to provide evidence-based intensive tobacco intervention to patients. All new patients are screened for tobacco use and those identified as active smokers are advised of the benefits of cessation and offered referral to the program where a cessation nurse offers counseling. Patients’ disease site, initial cessation goal, quit date, number of quit attempts and mode of contact are collected by the cessation nurse. This study reports on the initial evaluation of the smoking cessation program activities at GRRCC.

There are 1,210 patients who were screened, accepted a referral and counseled in the program. The referral pattern shows a modest increase every year and most of the patients (58%) indicated readiness to quit smoking. Overall, 29 and 26% of patients either quit or cut-back smoking, respectively. Among 348 patients who quit smoking, 300 (86%) were able to quit at the first attempt. The data indicated that 309 (44%) out of the 698 patients who indicated their initial intent to quit smoking were able to quit, whereas about 242 (35%) were able to cutback. A total of 15 patients out of 32 who indicated initial readiness to ‘cutback’ smoking were able to reduce tobacco use and three patients actually ended up quitting, although their initial goal was ‘ready-to-cut-back’.

GRRCC smoking cessation program started in October 2013 to provide evidence-based intensive smoking cessation interventions for patients with cancer. Most patients referred to the program indicated a readiness to quit smoking affirming that if patients become aware of the various risks associated with continual smoking or if they are informed of the benefits associated with cessation with regard to their treatment, they will be more likely to decide to quit. Therefore, it is essential that patients, their partners and families are counseled on the health and treatment benefits of smoking cessation and sustainable programs should be available to support them to quit smoking. It is imperative then, that oncology programs should consistently identify and document the smoking status of cancer patients and support those who use tobacco at the time of diagnosis to quit. Evidence-based smoking cessation intervention should be sustainably integrated into the cancer care continuum in all oncology programs from prevention of cancer through diagnosis, treatment, survivorship and palliative care.

To evaluate the quality of rectal hydrogel spacer (HS) insertions from literature in patients undergoing radical radiotherapy for prostate cancer. The secondary aim is to assess the benefit of HSs in patients with risk factors more likely to have rectal complications, such as non-conventional radiotherapy dose fractionations and high-risk disease.

A literature search of peer-reviewed electronic articles was carried out using Boolean connectors and Medical Subject Headings in the databases. Databases searched included ScienceDirect, Medline and Cinahl. The articles were assessed using relevant critical appraisal skills programme tools.

From the 26 studies used, HS showed a clinically significant relative reduction in rectal planning dose volumes for both high- and low-risk prostate cancer patients in a range of radiotherapy treatment modalities including volumetric modulated arc therapy, intensity-modulated radiotherapy, intensity-modulated proton therapy, stereotactic ablative body radiotherapy and brachytherapy. Spacer placements were successfully inserted in 99% of patients. However, rectal wall infiltration occurrence was 6% and ≥2 cm unsymmetrical placements in 2%.

A spacer scoring system based on the HS symmetry has provided evidence of the quality of the position inserted, which was visually aided by T2-wieghted MRIs. Despite optimal HS placements ranging from 62 to 72%, HS had a clinically significant reduction of ≥25% in planned rectal V70 dose in 97% of patients.

In this study, the radiation contamination dose (RCD) for different combinations of electron energy/distance, applicator and radius around the light intraoperative accelerator (LIAC), a high dose per pulse dedicated intraoperative electron radiotherapy machine, has been estimated. Being aware about the amount of RCDs is highly recommended for linear medical electron accelerators.

Monte Carlo Nuclear Particles (MCNP) code was used to simulate the LIAC® head and calculate RCDs. Experimental RCDs measurements were also done by Advanced Markus chamber inside a MP3-XS water phantom. Relative differences of simulations and measurements were calculated.

RCD reduction by distance from the machine follows the inverse-square law, as expected. The RCD was decreased by increasing angle from applicator walls opposed to the electron beam direction. The maximum differences between the simulation and measurement results were lower than 3%.

The RCD is strongly dependent on electron beam energy, applicator size and distance from the accelerator head. Agreement between the MCNP results and ionometric dosimetry confirms the applicability of this simulation code in modelling the intraoperative electron beam and obtaining the dosimetric parameters. The RCD is a parameter that would restrict working with LIAC in an unshielded operative room.

To study 2D and 3D dosimetric values for bladder and rectum, and the influence of bladder volume on bladder dose in high dose rate (HDR) intracavitary brachytherapy (ICBT). The large patient data incorporated in this study would better represent the inherent variations in many parameters affecting dosimetry in HDR-ICBT.

We prospectively collected data for 103 consecutive cervical cancer patients (over 310 HDR fractions) undergoing CT-based HDR-ICBT at our centre. Correlation among bladder and rectum maximum volume doses and corresponding International Commission on Radiation Units and Measurement (ICRU) point doses were estimated and analysed. Impact of bladder volume on bladder maximum dose was assessed.

The ICRU point doses to bladder and rectum varied from the volumetric doses to these organs. Further, bladder volume poorly correlated with bladder maximum dose for volume variations encountered in the clinical practice at our centre.

ICRU point doses to bladder and rectum are less likely to correlate with long-term toxicities to these organs. Further, in clinical practice where inter-fraction bladder volume does not vary widely there is no correlation between bladder volume and bladder dose.

To examine detail depth dose characteristics of ideal proton beams using the GATE Monte Carlo technique.

In this study, in order to improve simulation efficiency, we used pencil beam geometry instead of parallel broad-field geometry. Depth dose distributions for beam energies from 5 to 250 MeV in a water phantom were obtained. This study used parameters named Rpeak, R90, R80, R73, R50, full width at half maximum (FWHM), width of 80–20% distal fall-off (W(80–20)) and peak-to-entrance ratio to represent Bragg peak characteristics. The obtained energy–range relationships were fitted into third-order polynomial formulae. The present study also used the GATE Monte Carlo code to calculate the stopping power of proton pencil beams in a water cubic phantom and compared results with the National Institute of Standards and Technology (NIST) standard reference database.

The study results revealed deeper penetration, broader FWHM and distal fall-off and decreased peak-to-entrance dose ratio with increasing beam energy. Study results for monoenergetic proton beams showed that R73 can be a good indicator to characterise a range of incident beams. These also suggest FWHM is more sensitive than W(80–20) distal fall-off in finding initial energy spread. Furthermore, the difference between the obtained stopping power from simulation and NIST data almost in all energies was lower than 1%.

Detail depth dose characteristics for monoenergetic proton beams within therapeutic energy ranges were reported. These results can serve as a good reference for clinical practitioners in their daily practice.

The aim of this study was to compare volumetric modulated arc therapy (VMAT) with dynamic intensity-modulated radiation therapy (dIMRT) and step-and-shoot IMRT (ssIMRT) for different treatment sites.

Twelve patients were selected for the planning comparison study. This included three head and neck, three brain, three rectal and three cervical cancer patients. Total dose of 50 Gy was given for all the plans. Plans were done for Elekta synergy with Monaco treatment planning system. All plans were generated with 6 MV photons beam. Plan evaluation was based on the ability to meet the dose volume histogram, dose homogeneity index, conformity index and radiation delivery time, and monitor unit needs to deliver the prescribed dose.

The VMAT and dIMRT plans achieved the better conformity (CI98% = 0·965 ± 0·023) and (CI98% = 0·939 ± 0·01), respectively, while ssIMRT plans were slightly inferior (CI98% = 0·901 ± 0·038). The inhomogeneity in the planning target volume (PTV) was highest with ssIMRT with HI equal to 0·097 ± 0·015 when compared to VMAT with HI equal to 0·092 ± 0·0369 and 0·095 ± 0·023 with dIMRT. The integral dose is found to be inferior with VMAT 105·31 ± 53·6 (Gy L) when compared with dIMRT 110·75 ± 52·9 (Gy L) and ssIMRT 115 38 ± 55·1(Gy L). All the techniques respected the planning objective for all organs at risk. The delivery time per fraction for VMAT was much lower than dIMRT and ssIMRT.

Our results indicate that dIMRT and VMAT provide better sparing of normal tissue, homogeneity and conformity than ssIMRT with reduced treatment delivery time.

The aim of this study is to investigate the accuracy of dose distributions calculated by the BrachyDose Monte Carlo (MC) code in heterogeneous media for high-dose-rate (HDR) brachytherapy and to evaluate its usability in the clinical brachytherapy treatment planning systems.

For dose comparisons, three different dose calculation algorithms were used in this study. Namely, BrachyDose MC code, Eclipse TG-43 dose calculation tool and Acuros®BV model-based dose calculation algorithm (MBDCA). Dose distributions were obtained using any of the above codes in various scenarios including ‘homogenous water medium scenario’, an ‘extreme case heterogeneous media scenario’ and clinically important ‘a patient with a cervical cancer scenario’. In the ‘extreme case, heterogeneous media scenario’, geometry is a rare combination of unusual high-density and low-density materials and it is chosen to provide a test environment for the propagation of photons in the interface of two materials with different absorption and scattering properties. GammaMed 192Ir Model 12i Source is used as the HDR brachytherapy source in this study. Dose calculations were performed for the cases where there is either a single source or five sources planted into the phantom geometry in all homogenous water phantom and extreme case heterogeneous media scenarios. For the scenario a patient with a cervical cancer, dose calculations were performed in a voxelized rectilinear phantom, which is constructed from a series of computed tomography (CT) slices of a patient, which are obtained from a CT device.

In homogeneous water phantom scenario, we observed no statistically significant dose differences among the dose distributions calculated by any of the three algorithms at almost every point in the geometry. In the extreme case heterogeneous media scenario, the dose calculation engines Acuros®BV and BrachyDose are agreed well within statistics in every region of the geometry and even in the points close to the interfaces of low-density and high-density materials. On the other hand, the dose values calculated by these two codes are significantly different from those calculated by the TG-43 algorithm. In the ‘a patient with a cervical cancer scenario’, the calculated D2cc dose difference between Acuros®BV and BrachyDose codes is within 2% in the rectum and 11% for the bladder and sigmoid. There was no meaningful difference in the mean dose values between MBDCAs in the bone structures.

In this study, the accurate dose calculation capabilities of the BrachyDose program in HDR brachytherapy were investigated on various scenarios and, as a MC dose calculation tool, its effectiveness in HDR brachytherapy was demonstrated by comparative dose analysis.

This review evaluates whether brachytherapy can be considered as an alternative to whole breast irradiation (WBI) using criteria such as local recurrence rates, overall survival rates and quality of life (QoL) factors. This is an important issue because of a decline in local recurrence rates, suggesting that some women at very low risk of recurrence may be incurring the negative long-term side effects of WBI without benefitting from a reduction in local recurrence and greater overall survival. As such, the purpose of this literature review is to evaluate whether brachytherapy is a credible alternative to external beam radiation with a particular focus on the impact it has on patient QoL.

The search terms used were devised by using the Population Intervention Comparison Outcome framework, and a literature search was carried out using Boolean connectors and Medical Subject Headings in the PubMed database. The resultant articles were manually assessed for relevance and appraised using the Scottish Intercollegiate Guidelines Network tool. Additional papers were sourced from the citations of articles found using the search strategy. Government guidelines and regulations were also used following a manual search on the National Institute for Health and Care Excellence website. This process resulted in a total of 30 sources being included as part of the review.

Three types of brachytherapy were the foundation for the majority of the papers found: interstitial multi-catheter brachytherapy, intra-cavity brachytherapy and permanent seed implantation. The key themes that arose from the literature were that brachytherapy is equivalent to WBI both in terms of 5-year local recurrence rates and overall survival rates at 10–12 years. The findings showed that brachytherapy was superior to WBI for some QoL factors such as being less time-consuming and equal in terms of others such as breast cosmesis. The results did also show that brachytherapy does come with its own local toxicities that could impact upon QoL such as the poor breast cosmesis associated with some brachytherapy techniques.

In conclusion, brachytherapy was deemed a safe or acceptable alternative to WBI, but there is a need for further research on the long-term local recurrence rates, survival rates and quality of life issues as the volume of evidence is still significantly smaller for brachytherapy than for WBI. Specifically, there needs to be further investigation as to which patients will benefit from being offered brachytherapy and the influence that factors such as co-morbidities, performance status and patient choice play in these decisions.

The adverse health effects associated with smoking tobacco have been well investigated, and its detrimental effects on cancer treatment outcomes, efficacy and quality of life (QOL) for cancer patients have also been well documented. Tobacco smoke contains many thousands of chemicals, including a plethora of carcinogens, and the exposure of human cells to these carcinogens, and their metabolic activation, is the main mechanism by which smoking-related cancer is initiated.

This paper reports on a narrative review of recent studies in the field of effects of tobacco smoking on cancer treatment, including the effects of carcinogens in smoke on carcinogenesis, cell mutations and the immune system. The health effects of smokeless tobacco, effects of tobacco smoking on cancer treatment, and its impact on surgery, radiation therapy and chemotherapy are reported. The potential risks of second primary cancers or recurrence from tobacco use, the effects of second-hand smoking and cancer treatment, the impact of smoking on the QOL after cancer treatment and the need to integrate smoking cessation programs into the cancer care continuum are also reported.

Tobacco use has a direct impact on cellular function by inhibiting apoptosis, stimulating proliferation and decreasing the efficacy of cancer treatment; therefore, quitting its use has the potential to improve treatment response rates and survival, as well as reduces the risk of developing second cancers and potentially improves the QOL after treatment. Smoking cessation is one of the most important interventions to prevent cancer and is also essential after the diagnosis of cancer to improve clinical outcomes. Due to the numerous benefits of smoking cessation, it should become a critical component of the cancer care continuum in all oncology programs – from prevention of cancer through diagnosis, treatment, survivorship and palliative care. Evidence-based smoking cessation intervention should be sustainably integrated into any comprehensive cancer program, and the information should be targeted to the specific benefits of cessation in cancer patients.

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.

Prostate cancer is one of the most common solid malignancies and has a high morbidity rate. The uncertainty of the prostate location compromises the overall treatment plan optimisation. To account for the location uncertainty, the radiation oncologist needs to expand the margin of the planning target volume (PTV), which may increase the radiation toxicity to organs in proximity.

In this study, we investigated the quality of treatment plans for a patient with different ring sizes (2 and 3 cm). A small ring-shaped structure circumferentially around the PTV helps in defining the location of PTV. Prostate and pelvic node plans were analysed with dose prescription to 99% of PTV.

Additional ring-shaped structures led to more conformal dose coverage for target with reduced radiation side effects to nearby organ at risk (OAR). Expected treatment time was slightly higher for 2 cm ring compared to 3 cm ring. In case of prostate, expected duration was 4% higher, while for node plan, expected duration for 2 cm ring was 16% higher compared to 3 cm ring plan.

It was observed that using a smaller size ring can lead to improved dose sparing to OAR with same target coverage as with larger dimension ring. The composite plans do not show any clinically significant difference in dose to OARs.