This discussion paper will explore the impact of using Magnetic Resonance Imaging (MRI) in the treatment of cervical cancer with brachytherapy. It is written from the perspective of current departmental practice in the UK and aims to highlight the issues associated with using MRI as a tool for image guided brachytherapy planning. To support the discussion, a literature review was undertaken focussing specifically on the use of MRI in brachytherapy treatment planning for cervical cancer. Results from planning case studies and clinical series were analysed, and the literature showed that image guided brachytherapy treatment planning is a promising development. MRI assisted planning could theoretically be implemented in centres that have access to a MRI scanner. Alternative brachytherapy technologies (e.g. Computed Tomography (CT) assisted planning), and alternative radiotherapy modalities (e.g. an external beam radiotherapy boost), were not found to be superior in effect or of implementation. Although MRI shows great promise, the evidence base for MRI in brachytherapy planning for cervical cancer is currently limited and therefore careful implementation and evaluation is required. It is suggested by the authors that new methods of working are devised to ensure consistency and quality in implementation and delivery, and that outcomes are measured and audited to evaluate efficacy.

Reflection is a way of evaluating best practice and challenging existing norms, while at the same time, considering one’s personal values and assumptions in our personal and professional lives. However, many health practitioners may lack the skills to do this effectively. Through participation in a series of three workshops, practitioners in the Radiation Medicine Program at Princess Margaret Hospital have learned and acquired new skills to encourage reflection and reflective practice in themselves, their colleagues as well as with their students. A pre- and post-course survey was used to ascertain their level of knowledge of reflection and reflective practice. An additional survey at 3 months assessed the frequency of use and ongoing comfort level with reflective practice. Results of the evaluation indicate that the participants’ knowledge of reflective practice has improved their understanding of reflection in clincal practice. They recognize the importance of reflection and anticipate increasing their use of reflection in/on practice. As well, participants have been able to sustain the positive momentum 3 months after the course was delivered.

It is well established that patients with bone metastases get good pain relief from radiotherapy. The aim of treatment is to achieve maximum pain relief with minimum morbidity. Accuracy and reproducibility of the patient’s position are fundamental to the successful delivery of radiation therapy. It has been recognised for many years, that the accuracy of patient positioning will improve the success of radiation treatment. A previous study carried out in the department showed that the use of only a single tattoo for the set-up of palliative patients resulted in poor accuracy. The aim of this study was to assess if the addition of extra skin marks improved the set-up accuracy of palliative patients being treated for spine and bone metastases. A protocol was implemented detailing the extra skin marks to be used. Daily portal images were acquired and analysed retrospectively using anatomy matching. The results obtained were then compared with those of the previous study. The use of extra skin marks resulted in a total of 45% of images within 5 mm tolerance compared with 36% of images in patients treated with a single centre tattoo. Also, the number of images with deviations greater than 15 mm was reduced by more than 50% with the addition of extra skin marks. This study has shown that extra skin marks do increase the set-up accuracy in palliative patients treated for spine and bone metastases. Therefore, the practice of using extra skin marks has become standard protocol for all palliative patients within the department.

Purpose: The purpose of this study is to identify the incidence of anxiety and distress among patients requiring immobilization during radiation therapy to the head and neck region; then to compare this with radiation therapists’ ability to identify anxiety in the same group of patients.

Materials and methods: Data from a sample of 70 patients requiring an immobilization mask participated in this study. Patient self-report assessments and radiation therapists’ ratings were recorded at two time points, CT-Simulation and fraction 1 of treatment. Self-reported patient anxiety was assessed with the Brief Symptom Inventory-18. To determine radiation therapists’ ratings of patient anxiety, two rating scales were developed.

Results: Patient self-report identified anxiety in 16% and 14% of patients at CT Simulation and fraction 1 of treatment, respectively. Radiation therapists identified anxiety in 24% patients at time point one and in 44% of patients at time point two.

Conclusion: There was slight agreement between patient self-reported levels of anxiety and radiation therapists’ ratings of patient anxiety. This study suggests that there is scope for further investigation into the identification and management of anxiety and distress in head and neck cancer patients requiring immobilization.

Purpose: To evaluate the toxicity of hypofractionated helical intensity-modulated radiotherapy (IMRT) for men with intermediate- and high-risk prostate cancer.

Methods and Materials: A retrospective toxicity analysis was performed in 22 patients treated definitively with hypofractionated helical IMRT. The helical IMRT were designed to deliver 75 Gy in 2.5 Gy/fraction to the prostate gland, 63 Gy in 2.1 Gy/fraction to seminal vesicle, and 54 Gy in 1.8 Gy/fraction to pelvic lymph nodes. No patient received hormonal therapy. Toxicity was graded by the Radiation Therapy Oncology Group (RTOG) scales.

Results: All patients tolerated the treatment well without treatment interruption, and there was no Grade 3 or more acute toxicity. With a median follow-up of 24.5 months, there was no Grade 3 or more late toxicity. The late Grade 2 gastrointestinal (GI) and genitourinary (GU) toxicity for total 22 patients were 9.1% and 18.2%, respectively, and the late Grade 1 GI and GU toxicity were 18.2% and 50%, respectively. Late GU toxicity was associated with greater bladder volume irradiated ≥70 Gy. Late GI toxicity did not correlate with any of the dosimetric parameters.

Conclusions: This study demonstrate that hypofractionated helical IMRT with high biologic effective dose (BED) is well tolerated with favourable toxicity rate. If longer follow-up periods and larger cohorts confirm the favourable biochemical control rate and our favourable toxicity assessment results, the hypofractionated IMRT (total 75 Gy, 2.5 Gy/fraction) might be implemented in clinical field for treatment of prostate cancer.

Purpose: The service was piloted in response to requests for assistance with patients experiencing severe anxiety undergoing head and neck radiotherapy. This paper describes the aims of the service, interventions provided and the recorded responses of patients to the support given.

Data: Information about who referred, patient demographics, the interventions provided and patient feedback (n = 112) was extracted from treatment records over a 15-month period.

Findings: All referred patients successfully completed procedures and treatment. About 43 patients voluntarily disclosed past trauma, for example, sexual abuse, assault, childhood trauma, which they judged to have been linked to their claustrophobic responses. Advice and support was given to 40 patients also referred for smoking cessation; an additional three patients requested support when cravings returned.

Conclusion: There is a paucity of information about the extent of the distress triggered by radiotherapy procedures and what interventions could be offered in practice. Further work is required to include an economic assessment and longer term effects on patient compliance with treatment and smoking cessation. Training needs for complementary therapists and radiotherapy staff at this centre were also identified; these are being addressed.

Purpose: To evaluate the accuracy of an external immobilisation system in patients receiving radiotherapy for prostate cancer.

Methods: Portal Imaging data were audited in 20 patients treated using an in-house immobilisation system and 20 patients treated using an indexed commercial immobilisation system (Combifix™). Individual and group random and systematic errors were calculated to determine the accuracy of set-up using skin marks alone and with a no-action-level protocol.

Results: The initial results showed a larger systematic error in the Combifix™ in the anterior-posterior direction (2.7 mm) compared with the in-house system (1.5 mm). The possible source of this was identified as the difficulty in accurately aligning the laser to a curved couch top prior to setting the isocentre height. A change in the process of setting the isocentre was introduced, and comparable baseline set-up accuracy was achieved. This was with a systematic error of ≤2.0 mm and a random error ≤1.5 mm of patient position set-up error with skin marks alone, and using the Combifix™. The systematic errors were further reduced to <1 mm with an off-line no-action-level protocol.

Conclusion: Using the Combifix™ system a high level of set-up accuracy was reproduced in routine daily practice.

Focus groups are a means of gathering qualitative data from a group of participants who discuss a given topic. This method has been used in health care research for the past 30 years, but has seen limited use in radiation therapy research. Focus group discussions are a useful tool for investigating a variety of educational, training and clinical issues from the perspective of practitioners, students and patients. This paper reviews the issues associated with using focus groups as a means of data collection. In particular, it addresses some of the decisions which have to be made about group composition and conduct of the discussions. The literature review is contextualised using a recent example of how the authors used focus groups to investigate fitness to practise in radiation therapy. Other challenges such as familiarity between participants and researchers, power relationships and anonymity are addressed. The paper concludes with a consideration of data analysis.

Lung stereotactic body radiotherapy (SBRT) is a novel and effective technique for the treatment of early stage non small cell lung cancer which is rapidly becoming the radiotherapy regime of choice for those patients unable or unwilling to undergo surgical resection.

Although introduced almost 20 years ago, it was not until the wider establishment of image guided radiotherapy (IGRT) techniques that many UK departments first considered and then succeeded in implementing lung SBRT. Many have been assisted in this through membership of the national UK SBRT consortium which aims to facilitate local introduction and to provide guidelines and practical support for the wider radiotherapy community.

This article will seek to place the introduction of SBRT within a broad historical context, outline basic principles for safe and effective practice and describe how such principles are currently being pursued in an era of IGRT. Additionally, the role of the UK SBRT consortium in implementation will be reported alongside the results of its first national survey on the subject.

Purpose: The purpose of this study was to identify predictors and treatment outcome of late bowel toxicity after three dimensional pelvic radiotherapy for genitourinary malignancies and also to describe our experience with Argon Plasma Coagulation (APC) in this toxicity.

Patients and methods: Between March 2004 and March 2010, all patients who had completed a course of pelvic radiotherapy for genitourinary malignancies at our Institute were enrolled in this study. Every patient with lower GI symptoms underwent sigmoidoscopy and accordingly, some patients were subjected to intervention by APC.

Results: One hundred and thirty-six patients met all inclusion criteria. Median FU period was 37 months. Chronic diarrhoea was scored as Grade 1 or 2 in 35 patients (25.7%). Chronic proctitis was scored as Grade 1 or 2 in 17 patients (12.5%) and Grade 3 in 6 patients (4.4%), 25 patients developed chronic bleeding per rectum, 16 (11.8%) were Grade 1 or 2, while 9 patients (6.6%) were Grade 3. Both maximum rectal dose and comorbidity ≥1 significantly correlated with the development of chronic proctitis (p = 0.040 for both).

Endoscopic findings showed mucosal injury in 59 cases (84.29%) and vascular injury in 42 patients (60%). APC was successful in controlling bleeding and other symptoms in 14 cases (82.4%) and 16 cases (70%) respectively.

Conclusion: Three dimensional pelvic radiotherapy using two-phase technique is associated with a low level of Grade 3 late lower gastrointestinal toxicities. The most common presenting symptom is chronic diarrhoea. Both maximum rectal dose and comorbidity ≥1 significantly predict the development of chronic proctitis. APC is an effective, safe and well-tolerated treatment for chronic radiation proctitis.

Ensuring reproducibility in any radiotherapy technique is vital to ensure that a geometric miss does not occur. Patient position and comfort play a major part in the reproducibility of setups.

Purpose: To study the effect on accuracy of the introduction of a bellyboard to the existing prone technique used for radical radiotherapy treatment of prostate cancer.

Materials and Methods: Thirty patients were treated using the bellyboard in the standard method. Portal images were compared with those of a control group of patients who had treatment with no rigid immobilisation. Patients in both groups were males with prostate cancer, who underwent radical radiotherapy treatment. Images were analysed using anatomy matching, and deviations from the isocentre were noted.

Results: Statistical analysis of the results showed no statistical significance between the groups, though within the control group there were more deviations over 0.5 cm from the isocentre position than in the bellyboard group.

Conclusions: Introduction of the bellyboard was seen to be equivalent to the use of the control technique. When the deviations from isocentre position were evaluated for each group, the control group had more deviations over 0.5 cm than the bellyboard group.

Background: In low-risk prostate cancer, the target volume for radiotherapy is the prostate gland only and prostate brachytherapy with an I-125 implant provides the most conformal radiotherapy.

Methods: Patients underwent a pre-implant prostate volume study from which a treatment plan was developed 2 weeks prior to implant. A dosimetric study was performed 1 month following the implant. The prescription dose was 145 Gy with the 95% isodose line covering the entire target volume. The maximal dose to the urethra was less than 210 Gy. Follow-up included serum PSA and IPSS evaluation every 3 months during the first year and then every 6 months beginning in the second year.

Results: During December 2000–March 2009, 181 patients with early prostate cancer underwent I-125 implant. The median post-implant PSA value of the entire cohort was 0.7 ng/ml. No patient developed clinical failure. In the follow-up, nine patients had biochemical failure according to the RTOG-ASTRO Phoenix definition (Nadir + 2.0 ng/ml). Of these, one patient refused hormonal therapy desiring to preserve sexual potency, and eight patients received hormonal therapy with a decreased serum PSA to 0.0 ng/ml. The treatment side effects were primarily urinary disturbances.

Conclusion: An I-125 implant is an effective and well-tolerated treatment and should be recommended for patients with low-risk prostate cancer.

Background and purpose: This study examined the effect of varying the X–Y smoothing values on the average Leaf Pair Opening (LPO), MUFactor and total number of monitor units (MU) in a cohort of 20 prostate and head and neck (H&N) patients treated with dynamic intensity-modulated radiotherapy (IMRT).

Material and methods: Plans were created using Varian Eclipse™ Treatment Planning System (TPS) version 8.9.09 (Varian Medical Systems, Palo Alto, CA). Clinically approved and dosimetrically verified plans were used as a reference plans. These were re-optimised varying the X and Y smoothing parameters from 0 to 100 in various combinations.

Results: For the prostate patients, at X = 0 and Y = 0, the average LPO was 2.4 cm (σ = 0.20 cm) and 3.5 cm (σ = 0.35 cm) for X = 100 and Y = 100. For H&N, the LPO averaged over all fields increased from 1.7 cm (σ = 0.17 cm) at X = 0 and Y = 0 to 2.3 cm (σ = 0.27 cm) at X = 100 and Y = 90. The MUFactor decreased from 1.81 (σ = 0.19) at X = 0 and Y = 0 to 1.38 (σ = 0.11) at X = 100 and Y = 100 for prostates and from 1.50 (σ = 0.14) at X = 0 and Y = 0 to 1.24 (σ = 0.09) for X = 100 and Y = 90 for H&N. Total MU for prostates decreased from 1028.0 (σ = 244.6) at X = 0 and Y = 0 to 688.4 (σ = 159.3) at X = 100 and Y = 100 and from 913 (σ = 267.2) at X = 0 and Y = 0 to 696 (σ = 214.03) at X = 100 and Y = 90 for H&N.

Conclusions: Increasing smoothing decreases MUFactor, decreases total MU and increases average LPO but does not greatly enhance organs at risk (OAR) sparing. The Homogeneity Index (HI) and Paddick Conformity Index (CIPAD) appear to vary little after increasing smoothing up to approximately X = 80 and Y = 70.