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Service user involvement has been demonstrated as an important aspect of cancer professionals’ education. There is some understanding of service users’ incentive to be involved, but little insight into what motivates them. This study explores this concept more fully.
To explore the motivations and experience of service users’ involvement in radiotherapy and oncology education.
Materials and methods
One-to-one interviews were conducted with service users who have been involved in education at the university. Thematic analysis was conducted. Five participants were asked about their motivations and experience of taking part in a variety of educational activities.
The experience of being involved gave the participants a sense of wellbeing and purpose. Three sub-themes were identified that related to service users’ motivation for being involved in educational activities with undergraduate students. These were to promote awareness by sharing their experiences of cancer; improve patient care through learning from negative experience; and personal reward skills for survivorship.
This study has highlighted the importance of hearing the voice of the service users; a two-way engagement for which there are benefits for both the students and service users. The involvement of service users in education becomes part of their personal journey.
Although the notion of advanced practice (AP) has been widely accepted and implemented in some countries, for example, the United Kingdom, in Canada it is has yet to be widely tested as a model of working. Currently it has been implemented and evaluated in Ontario, but this approach is not widespread across the country. To date in British Columbia (BC), there are no advanced practitioners and no research has been conducted regarding the opinions and attitudes of radiation therapists (RTs) in BC towards the implementation of AP. Understanding RTs attitudes and perceptions towards AP may be important when considering the acceptance and implementation of new roles. The research objectives were to explore the attitudes and opinions of RTs and establish what the term AP means to BC RTs, and also to discover what they consider to be benefits, and barriers to implementing AP.
Materials and methods
A quantitative approach was utilised and an on-line questionnaire was sent to 266 RTs that currently practice in BC. Likert and demographic questions were used to explore the definition of AP and ascertain opinions about the barriers and benefits of implementing AP in BC.
A total of 183 questionnaires were completed for a response rate of 69%. The majority of respondents agreed with the Canadian Association of Medical Radiation Technologies (CAMRT) and the literature's definition of AP. Cost, time, lack of support and training and issues of medical dominance were cited as barriers. Job satisfaction, autonomy, and increased recruitment and retention of staff were considered benefits.
Although RTs believe there are obstacles to be overcome regarding the adoption and implementation of AP, these are outweighed by the potential benefits such as enhanced patient care due to increased levels of professional knowledge and development that can lead to increased levels of job satisfaction. These are seen as important drivers for creating the AP role in BC.
The clinical specialist radiation therapist (CSRT) is a radiation therapist with advanced site-specific clinical skills and knowledge that can be utilised to enhance the education of radiation therapy (RT) students within an academic setting. The aim of this study is to assess the students’ perception of the teaching provided by a CSRT within a case-based learning workshop tailored for breast cancer.
A workshop that followed the patient's RT treatment pathway (consultation, CT simulation, treatment planning and delivery) was led by a breast-site CSRT to 16 third-year students. Following completion of the workshop, a 4-point Likert-scale survey was distributed to explore the students’ didactic and clinical experiences and their general perceptions of the CSRT's contribution to their breast-site module education.
The median didactic experience reported by the students were ‘a lot’ in patient care and ‘some’ in treatment unit and treatment planning. In contrast, the students reported less clinical experience; the median response for patient care and treatment unit experience was ‘a little’ and ‘none’ for treatment planning. All 13 students who responded to the survey agreed that the CSRT enhanced their understanding of the material. The students felt engaged in the CSRT-lecture and perceived it as value added. The majority of the students (92%) indicated the CSRT to be a useful learning resource in their training and education. Additional comments provided by the students noted the utility of the CSRT-led lecture in consolidating their knowledge of the breast cancer treatment planning and delivery and suggest further expansion of this learning format to other disease sites.
Third-year RT students commencing their clinical practicum will have had a greater proportion of their learning from didactic teaching as opposed to clinical experience. In transitioning to their final year, the focus of the curriculum shifts to the application of theory into the clinical environment. The students perceived the CSRT to be a useful resource to enhance their understanding of the breast-site module and their feedback supports the instructional quality and effectiveness of the CSRT in this clinical teaching role.
Printed patient education material enhances verbal patient teaching. ‘Starting radiation therapy: helpful tips for patients with head and neck cancer’ is a booklet that facilitates head and neck (H&N) cancer patients’ orientation to the study hospital. This study examined and compared patients’ and staff's opinion on the distribution and usefulness of this booklet.
Patients starting radiotherapy treatment to their H&N cancer, and staff involved in their care, were recruited. A survey was designed to collect responses from both cohorts.
Of the patients, 94% received the booklet before their first radiotherapy treatment. Of the staff, 67% referred to this booklet during patient education. Most patients (98%) found that the booklet increased their awareness of hospital and community services. Both groups indicated list of services and telephone number to be the most useful chapter. The staff suggested having this booklet available in different languages.
This booklet was useful as an orientation tool for the patients to navigate the hospital system. Patients and staff have similar opinion regarding the most useful sections in the booklet. Further studies needs to be conducted to validate the need of having this booklet available in other languages.
Patient teaching in radiation therapy may include restrictions on applying skin products owing to concerns that the presence of such materials may increase skin dose. These restrictions may create unnecessarily complicated and conflicting self-care instructions.
To determine what thickness of skin product is necessary to produce a clinically meaningful dose increase to the skin, and provide recommendations for evidence-based patient instructions.
Dosimetric measurements and Monte Carlo simulations were used to calculate skin dose under 0–1·5 mm thicknesses of two common classes of skin product for a variety of treatment geometries. The thickness of product required to produce a clinically significant dose increase to the skin was determined.
The thickness of product required to create a clinically meaningful dose increase was >0·7 mm for 10 × 10 cm2 fields and >1·5 mm for 1 × 1 cm2 fields. A typical application of product would be only 0·3 mm.
It seems unrealistic to anticipate patients using sufficiently large quantities of skin product to be of clinical concern. We therefore recommend that there are no dosimetric reasons to restrict the use of these types of skin products during radiation therapy for common treatment scenarios.
Patients having a course of radiotherapy (RT) must be appropriately immobilised for stability and accuracy. Having opened a new cancer service in June 2009 and commenced treating lower gastrointestinal cancers in 2010, a prone belly board device (BBD) was introduced as the standard radiotherapy immobilisation. A training package was created to aid clinical skills retention of therapeutic radiographers and manage setup quality. Setup reproducibility using the BBD was retrospectively assessed with electronic portal image (EPI) verified geometric displacements as the main outcome measure both before and after the introduction of training.
Twenty retrospective Pinnacle computed tomography-planned patients and their geometric displacements on treatment were evaluated between 2010 and 2011—ten prior to (Patient Group A) and ten following training (Patient Group B). The only inclusion criterion was that patients were immobilised for RT on the Medtec ContouraTM carbon fibre BBD. Patients were prone and were treated to 45–50·4 Gy in 25–28 fractions on a 6–10 MV LinAc equipped with EPI. Reproducibility was assessed by comparing geometric measurement of the bony pelvis on the Pinnacle digitally reconstructed radiograph (DRR) with an EPI captured at day 0, 1, 2 and weekly during treatment for each patient. Systematic and random errors were analysed with respect to the average geometric displacement with standard deviation per patient between the Pinnacle DRR and the EPI.
The age range was 41–77 years and there were 15 male and five female patients with diagnosed rectal cancers (T3–T4, N0–N2, M0). Three hundred and seventy one images were analysed. An improvement in population systematic and random error was most notable in the superior–inferior direction (Patient Group A Σpop = 3·1 mm, σpop = 3·6 mm to Patient Group B Σpop = 2·0 mm, σpop = 2·3 mm, respectively).
There is evidence that the use of the BBD is more reproducible when accompanied by a task-specific training package. Based on the results of this study, further work will be carried out on training standardisation for patient positioning with a BBD for reducing systematic and random geometric displacements.
During radiation therapy, unwanted scatter to healthy tissues outside the target field may occur. Children and adolescents are more sensitive to radiation injury, and the thyroid gland is particularly susceptible to these effects.
To assess acute changes in thyroid function and volume in children and adolescents undergoing radiotherapy for a variety of non-thyroid cancers.
Materials and Methods
Thirty-one children and adolescents underwent radiation therapy of various body areas in which the thyroid was not included. Thyroid-stimulating hormone (TSH), thyroxine (T4), free thyroxine (fT4), triiodothyronine (T3), anti-thyroperoxidase antibodies and thyroglobulin were measured before, on the last day and at 1 and 3 months after the end of radiotherapy. Ultrasound scans were taken and 6- and 24-hour 131I uptake was measured before and after treatment. The scattered dose to the thyroid region was estimated with a treatment planning system or measured with thermoluminescent dosimeters.
The median radiation dose scattered to the thyroid was 296·6 cGy (IQR 16·7–1,709·0). Levels of TSH (p = 0·575), T4 (p = 0·950), fT4 (p = 0·510), T3 (p = 0·842), thyroglobulin (p = 0·620) and anti-thyroid peroxidase antibodies (p = 0·546) were statistically similar at all four time points. There were no differences between pre- and post-radiotherapy thyroid volume and 131I uptake (p = 0·692 and 0·92, respectively).
More sensitive methods may be required to ascertain whether acute injury to the follicular epithelium occurs with lower radiation doses scattered to the thyroid.
The optimal delivery of radiation therapy to achieve maximum tumour cell kill while limiting damage to normal tissues underlies any radiation therapy treatment protocol. The biological effectiveness of radiation therapy is closely related to cellular reproductive activity. The scheduling of dose fraction to a time where actively dividing cells are at their most radiosensitive stage (RS) has potential to enhance therapeutic efficacy.
Materials and methods
A prime number is a natural number >1 whose only divisors are 1 and the number itself.
We propose that the use of prime numbers in the scheduling of radiotherapy treatments could maximise biological effectiveness by facilitating the irradiation of the greatest number of cells at their most RS stage, and ultimately improve the therapeutic ratio of radiation therapy.
The theoretical clinical implementation of this concept into the scheduling of radiation therapy is discussed.
Due to the discontinuation of the widely used low-dose rate (LDR) Caesium afterloader units, many centres in the past 10 years have moved from LDR Selectron treatments to Iridium 192 afterloaders. While the majority of UK centres have opted for high-dose rate (HDR) units, the Christie have invested in two pulsed dose rate (PDR) afterloaders alongside a move to full 3D-planned gynaecological brachytherapy.
To share the experience and learning curve involved in the implementation of a 3D-guided PDR brachytherapy service.
The specific logistical and practical challenges of implementing a PDR service are discussed alongside the more general challenges of implementing 3D-guided magnetic resonance (MR) based brachytherapy. A multidisciplinary approach was undertaken to streamline the patient pathway and give all disciplines a forum to discuss service improvements and resolve problems.
The lessons learned throughout this experience can inform the decisions of departments that may wish to implement a PDR service or indeed a 3D image-guided HDR brachytherapy service in the future. The focus on the utilisation of lean principles to the patient pathway, improved multidisciplinary working and enhancing service efficiency is of interest to all centres.
The main objective of this study was to compare dosimetric characterisation of high-dose-rate brachytherapy (HDR-BT) with external beam intensity-modulated radiation therapy (EX-IMRT) as a means of delivering boost dose.
Materials and methods
Five HDR patients were selected for IMRT planning. Patients underwent ultrasound-guided catheter placement for HDR. Computed tomography (CT) images were obtained and imported into the Nucletron PLATO Brachytherapy system. The prostate, urethra, bladder and rectum were contoured on axial slices. The dose was calculated and optimised by graphical optimisation. The CT images of these structures were exported from the PLATO to Eclipse workstation for IMRT planning. For each patient, the dose–volume histogram (DVH) of HDR and IMRT plans were generated, drawn on the same scale and compared.
The dose distribution in HDR plans was non-uniform and conformed peripherally inside the planned target volume (PTV). A small volume of the prostate received a very high dose from HDR.In IMRT plans, a uniform dose distribution was observed. The DVH curves for PTV dropped sharply and reached to a zero volume of the prostate at about 6·4 Gy. In HDR plans, the DVH curves for PTV showed a long tail up to a very high dose. About 10% of the prostate received about 13·3 Gy, which is 222% of the prescribed dose (6 Gy) in HDR plans. In contrast, the same volume in IMRT plans received <6 Gy (100%). The average dose for V90 was about 6·3 Gy for HDR and 5·8 Gy for IMRT plans. At a prostate volume of V100 level, the average dose in all plans was 5·0 Gy from HDR and 5·4 Gy from IMRT plans. In HDR plan, the V100 dose for urethra varied from 0·6 to 3·0 Gy (average 1·8 Gy). The range in IMRT plans varied from 3·6 to 6 Gy with an average of 4·7 Gy. At V90 level, the dose range in HDR and IMRT plans varied from 2·5 to 4·7 Gy (average 3·8 Gy) and 4·8 to 5·4 Gy (average 5·3 Gy), respectively. In general, the dose to the bladder and rectum was comparatively lower in HDR than in IMRT plans.
HDR brachytherapy may reduce normal tissue toxicities in prostate boost treatments, even though the dose homogeneity inside the PTV is far worse than in IMRT treatments. Another advantage of HDR over IMRT is that the organ motion is not a significant concern as in IMRT.
Patients require information to make informed decisions and consent to medical treatment. Shared decision making (SDM) is a methodology that promotes a patient-centred approach to informed consent and demonstrates respect for autonomy
The purpose of this paper is to critically review the legal and ethical issues relevant to Canadian and UK informed consent and SDM practices and how these processes relate to current palliative care practices, with a particular emphasis on radiation therapy.
A review of the English literature from 2003 to 2013 was performed using the databases PubMed (NML), OVID Medline and Google Scholar.
Results and Conclusions
The literature identifies that palliative cancer patients desire the opportunity to be involved with decision-making discussions, which has shown to increase knowledge and result in better health-related outcomes. However, ethical and legal issues regarding the practicality of including this patient population in SDM discussions raises questions about validity of consent. For SDM to be considered a valid methodology to obtain informed consent, open and honest communication between the patient and multidisciplinary team is essential. Treatment options for palliative cancer patients are often complex and SDM allows healthcare professionals and patients to exchange information and negotiate feasible treatment options based on medical expertise and patient preferences.
Legal frameworks have defined current standards of practice for various healthcare professions, including radiation therapy. Radiation therapists, as members of the multidisciplinary team, are currently key contributors in providing information to patients regarding the radiotherapy process. Individuals working within advanced practice roles have the ability to develop skills once considered to be within medical domains and have begun to incorporate the delegated act of obtaining informed consent into practice which has shown to increase professional autonomy, accountability and improves patient-centred care.
We review augmented (AR) and virtual reality (VR) applications in radiotherapy as found in the scientific literature and highlight future developments enabled by the use of small mass-produced devices and portability of techniques developed in other fields to radiotherapy.
The application of AR and VR within radiotherapy is still in its infancy, with the notable exception of training and teaching applications. The relatively high cost of equipment needed to generate a realistic 3D effect seems one factor that has slowed down its use, but also the sheer amount of image data is relatively recent, were radiotherapy professionals are only beginning to explore how to use this to its full potential. This increased availability of 3D data in radiotherapy will drive the application of AR and VR in radiotherapy to efficiently recognise and extract key features in the data to act on in clinical decision making.
The development of small mass-produced tablet devices coming on the market will allow the user to interact with computer-generated information more easily, facilitating the application of AR and VR. The increased connectivity enabling virtual presence of remote multidisciplinary team meetings heralds significant changes to how radiotherapy professionals will work, to the benefit of our patients.
Key advances in cancer treatment have led to an increasing number of long-term cancer survivors. Knowledge of the long-term effects of cancer treatment on leukaemia survivors is to some degree limited. This article investigates the effects of the treatment of childhood leukaemia on the quality of life (QOL), the physical and the psychological wellbeing and general development of survivors. This article reviews current literature to examine existing gaps in knowledge and identify a potential focus of future research and clinical practice.
Materials and methods
Online systematic searching, along with historical searching took place in order to retrieve relevant primary research papers for the review. Strict inclusion and exclusion criteria were applied to the literature, to create a manageable amount of research papers.
The extent of intellectual impairment among radiotherapy patients was significantly greater than those treated with chemotherapy only. Body composition, including endocrine function, is readily affected by cancer treatment. Early identification and interventions can greatly improve the QOL of survivors.
Further research into the effect of treatment modality on the extent of chronic effects, along with investigations into the needs of the whole family unit, is required. Future practice must take into account long-term implications while ensuring effective holistic care.
To demonstrate the importance of fluid management in the perioperative period by presenting a case of hyponatraemic seizures following prostate brachytherapy.
A 61-year-old gentleman, who had prostate cancer but was otherwise well, developed confusion and word-finding difficulties the day after prostate brachytherapy. This was followed by tonic–clonic seizures that necessitated treatment, intubation and ventilation, and admission to the intensive care unit. Investigations revealed serum sodium of 116 mmol/L. Fluid balance was inadequately recorded, but the patient had drank more than 3 L of water before he developed hyponatraemia.
Postoperative severe hyponatraemia and hyponatraemic encephalopathy develop because of anti-diuretic hormone release and hypotonic fluid administration. These are medical emergencies and should be managed in an intensive care unit. Symptoms range from headache, nausea and confusion to seizures, respiratory arrest and death, and are related to cerebral oedema. Treatment is done using hypertonic sodium chloride to increase the serum sodium to safe levels. Care should be taken to avoid overly rapid correction of serum sodium. Complete documentation of fluid balance is essential to allow proper assessment of fluid status. Patients should be advised on appropriate oral fluids in the postoperative period.