Radiotherapy Staff Research Articles

Exploring Barriers in Self-Reporting of Errors and Near Misses: A Cross-Sectional Study on Radiation Oncology in Saudi Arabia.

Radiation therapy utilizes complex technologies to target tumors. Radiation therapy is not immune to human errors. Reporting medical errors and near misses is crucial to improving patient outcomes and ensuring the safety of future patients. This study aimed to measure the attitudes of radiotherapy staff members in Saudi Arabia regarding reporting errors and near misses in radiation therapy practice. It also examined the participants' reporting patterns and behaviors and explored the potential barriers to reporting errors and near misses as perceived by the participants. A cross-sectional study utilizing an online questionnaire was implemented. A sample of 70health professionals working in radiation oncology departments in Saudi Arabia, including radiation oncologists, medical physicists, and radiotherapists, were recruited to participate in this study from January to June 2023. The data was analyzed using chi-squared testing to compare different groups, and the Kruskal-Wallis was used to find any statistically significant differences between different groups. The study included 70 radiotherapy staff members. Professional roles did not significantly impact participants' decisions to report minor or major errors, with most consistently reporting errors to their supervisors regardless of role. The study revealed that fear of professional sanctions and the potential negative impact on a department's reputation are significant barriers to reporting errors or near misses. However, Only 17% of radiation oncologists did consider departmental sanctions as a barrier. Participants identified communication failure as the most significant source of errors in radiation oncology departments. The study also found a high level of agreement among the participants regarding the responsibility of reporting errors and near misses. The study investigated reporting errors and near misses in radiotherapy and considered the factors influencing them. The findings highlight the importance of effective communication and the implementation of an electronic reporting system.

Improving Quality Assurance in a Radiation Oncology Using ARIA Visual Care Path.

Errors and incidents may occur at any point within radiotherapy (RT). The aim of the present retrospective analysis is to evaluate the impact of a customized ARIA Visual Care Path (VCP) on quality assurance (QA) for the RT process. The ARIA VCP was implemented in June 2019. The following tasks were customized and independently verified (by independent checks from radiation oncologists, medical physics, and radiation therapists): simulation, treatment planning, treatment start verification, and treatment completion. A retrospective analysis of 105 random and unselected patients was performed, and 945 tasks were reviewed. Patients' reports were categorized based on treatment years period: 2019-2020 (A); 2021 (B); and 2022-2023 (C). The QA metrics included data for timeliness of task completion and data for minor and major incidents. The major incidents were defined as incorrect prescriptions of RT dose, the use of different immobilization systems during RT compared to the simulation, the absence of surface-guided RT data for patients' positioning, incorrect dosimetric QA for treatment plans, and failure to complete RT as originally planned. A sample size of approximately 100 was able to obtain an upper limit of 95% confidence interval below 5-10% in the case of zero or one major incident. From June 2019 to December 2023, 5300 patients were treated in our RT department, an average of 1300 patients per year. For the purpose of this analysis, one hundred and five patients were chosen for the study and were subsequently evaluated. All RT staff achieved a 100% compliance rate in the ARIA VCP timely completion. A total of 36 patients were treated in Period A, 34 in Period B, and 35 in Period C. No major incidents were identified, demonstrating a major incident rate of 0.0% (95% CI 0.0-3.5%). A total of 26 out of 945 analyzed tasks (3.8%) were reported as minor incidents: absence of positioning photo in 32 cases, lack of patients' photo, and absence of plan documents in 4 cases. When comparing periods, incidents were statistically less frequent in Period C. Although the present analysis has some limitations, its outcomes demonstrated that software for the RT workflow, which is fully integrated with both the record-and-verify and treatment planning systems, can effectively manage the patient's care path. Implementing the ARIA VCP improved the efficiency of the RT care path workflow, reducing the risk of major and minor incidents.

Evaluation of the trend of set-up errors during the treatment period using set-up margin in prostate radiotherapy

Accurate information on set-up error during radiotherapy is essential for determining the optimal number of treatments in hypofractionated radiotherapy for prostate cancer. This necessitates careful control by the radiotherapy staff to assess the patient's condition. This study aimed to develop an evaluation method of the temporal trends in a patient's specific prostate movement during treatment using image matching and margin values. This study included 65 patients who underwent prostate volumetric modulated arc therapy (mean treatment time, 87.2 s). Set-up errors were assessed using bone, inter-, and intra-fraction marker matching across 39 fractions. The set-up margin was determined by dividing the four periods into 39 fractions using Stroom's formula and correlation coefficient. The intra-fraction set-up error was biased in the anterior-superior (AS) direction during treatment. The temporal trend of set-up errors during radiotherapy slightly increased based on bone matching and inter-fraction marker matching, with a 1.6-mm difference in the set-up margin fractions 11 to 20. The correlation coefficient of the mean prostate movement during treatment significantly decreased in the superior-inferior direction, while remaining high in the left-right and anterior-posterior directions. Image matching contributed significantly to the improvement of set-up errors; however, careful attention is needed for prostate movement in the AS direction, particularly during short treatment times. Understanding the trend of set-up errors during the treatment period is essential in numerical information sharing on patient condition and evaluating the margins for tailored hypo-fractionated radiotherapy, considering the facility's image-guided radiation therapy technology.

Tackling the radiotherapy (RT) shortage in Sub-Saharan Africa by gathering and using data from LMICs and HICs facilities for designing a future robust RT facility

Purpose Historically, highly sophisticated medical linear accelerators (linacs) produced for high- (HIC) and upper-middle-income country (MIC) markets frequently experience significant additional operational failures in low- and lower-middle-income countries (LMICs). This study focuses on LMICs in Africa where there is a substantial equipment shortfall, projected to be a gap by 2040 of about 5000 linacs. The purpose of this study was to gain an insight into the poor performance of linac components, the unreliable infrastructure often encountered in LMICs and the consequent linac-related treatment downtime. Methods and Materials A questionnaire was sent to at least one cancer center in each of the 28 African countries that had experience treating cancer patients with linacs at the time of the survey (4 more countries have acquired linacs) since we completed this survey. For comparison questionnaires were sent to selected facilities in four high-income countries (Canada, Switzerland, UK, US) and to Jordan, a middle-income country. To investigate factors influencing linac downtime, we first utilised flow diagrams to illustrate the dependence of linac subsystem performance on infrastructural/environmental factors, the availability of spare parts and local repair capability. Secondly, a univariate analysis correlated linac downtime with factors such as method of linac fault diagnosis and staffing. Finally, a multivariate analysis investigated the relationship between GDP per capita and cancer mortality to incidence ratio statistics and compared these with the surveyed linac downtime across low-, middle- and high- income countries. Results Responses to the survey confirmed significant multi-factorial issues that influence the extent of linac downtime especially the performance of multi-leaf collimators, electron guns, vacuum systems, RF power and software. Other challenges include electrical power instability, inadequate national funding (GDP/capita), and workforce capability as well as a significant shortfall in formal education and training programmes for the radiation therapy (RT) workforce. Conclusion This survey identified numerous modes of radiotherapy (RT) equipment failure causing treatment downtime in LMICs that can be overcome by improvements in the design of RT technology but they need to be accompanied by increased RT staff training, improved broadband access and increased annual national funding for RT. The collaborative network of linac-based RT facilities in 28 1 * African countries that was developed to conduct this study is available for further investigations as RT capacity and capability improve in Africa.

Evaluation of the accuracy of heart dose prediction by machine learning for selecting patients not requiring deep inspiration breath‑hold radiotherapy after breast cancer surgery.

Increased heart dose during postoperative radiotherapy (RT) for left-sided breast cancer (BC) can cause cardiac injury, which can decrease patient survival. The deep inspiration breath-hold technique (DIBH) is becoming increasingly common for reducing the mean heart dose (MHD) in patients with left-sided BC. However, treatment planning and DIBH for RT are laborious, time-consuming and costly for patients and RT staff. In addition, the proportion of patients with left BC with low MHD is considerably higher among Asian women, mainly due to their smaller breast volume compared with that in Western countries. The present study aimed to determine the optimal machine learning (ML) model for predicting the MHD after RT to pre-select patients with low MHD who will not require DIBH prior to RT planning. In total, 562 patients with BC who received postoperative RT were randomly divided into the trainval (n=449) and external (n=113) test datasets for ML using Python (version 3.8). Imbalanced data were corrected using synthetic minority oversampling with Gaussian noise. Specifically, right-left, tumor site, chest wall thickness, irradiation method, body mass index and separation were the six explanatory variables used for ML, with four supervised ML algorithms used. Using the optimal value of hyperparameter tuning with root mean squared error (RMSE) as an indicator for the internal test data, the model yielding the best F2 score evaluation was selected for final validation using the external test data. The predictive ability of MHD for true MHD after RT was the highest among all algorithms for the deep neural network, with a RMSE of 77.4, F2 score of 0.80 and area under the curve-receiver operating characteristic of 0.88, for a cut-off value of 300 cGy. The present study suggested that ML can be used to pre-select female Asian patients with low MHD who do not require DIBH for the postoperative RT of BC.

Mean Heart Dose Prediction Using Parameters of Single-Slice Computed Tomography and Body Mass Index: Machine Learning Approach for Radiotherapy of Left-Sided Breast Cancer of Asian Patients.

Deep inspiration breath-hold (DIBH) is an excellent technique to reduce the incidental radiation received by the heart during radiotherapy in patients with breast cancer. However, DIBH is costly and time-consuming for patients and radiotherapy staff. In Asian countries, the use of DIBH is restricted due to the limited number of patients with a high mean heart dose (MHD) and the shortage of radiotherapy personnel and equipment compared to that in the USA. This study aimed to develop, evaluate, and compare the performance of ten machine learning algorithms for predicting MHD using a patient's body mass index and single-slice CT parameters to identify patients who may not require DIBH. Machine learning models were built and tested using a dataset containing 207 patients with left-sided breast cancer who were treated with field-in-field radiotherapy with free breathing. The average MHD was 251 cGy. Stratified repeated four-fold cross-validation was used to build models using 165 training data. The models were compared internally using their average performance metrics: F2 score, AUC, recall, accuracy, Cohen's kappa, and Matthews correlation coefficient. The final performance evaluation for each model was further externally analyzed using 42 unseen test data. The performance of each model was evaluated as a binary classifier by setting the cut-off value of MHD ≥ 300 cGy. The deep neural network (DNN) achieved the highest F2 score (78.9%). Most models successfully classified all patients with high MHD as true positive. This study indicates that the ten models, especially the DNN, might have the potential to identify patients who may not require DIBH.

Pilot study of aerosols visualized and evaluated in a radiotherapy room.

Health care institutions provide prevention strategies for coronavirus disease 2019 and non-infectious disease care. We investigated the characteristics of patient contamination in a radiotherapy room by examining the trajectory and number of airborne particles in the air when talking and coughing occurred and clarified the actual state of contamination in this closed space. Aerosols were visualized and evaluated in the vertical height and head-to-tail width directions when the participant was lying on the radiotherapy tabletop. Aerosol reach was significantly greater for loud voice and coughing both at vertical height and the head-to-tail width direction. The size and number of particles around the radiotherapy tabletop were also visualized and evaluated in the radiotherapy room. The radiotherapy staff who were in the presence of the participant sometimes had many particles adhering to their facial area; particle adhesion to the staff was dominated by small size particles. Particle adherence to the irradiation device surface near the ceiling had particles larger than 1mm. Tabletop particles tended to have a wider size range, including bigger sizes and a larger count compared to the surrounding floor. The 0.7-m radius distance from the participant's mouth tended to be highly contaminated, and the smaller the particle size, the farther it reached. The capacity to estimate areas prone to contamination can be used to predict infection of other patients and medical staff in a radiotherapy room.

How much should you worry about contaminant neutrons in spatially fractionated grid radiation therapy?

Neutron contamination in radiation therapy is of concern in treatment with high-energy photons (> 10 MV). With the development of new radiotherapy modalities such as spatially fractionated grid radiation therapy (SFGRT) or briefly grid radiotherapy, more studies are required to evaluate the risks associated with neutron contamination. In 15 MV SFGRT, high-Z materials such as lead and cerrobend are used as the block on the tray of linear accelerator (linac) which can probably increase the photoneutron production. On the other hand, the high-dose fractions (10-20 Gy) used in SFGRT can induce high neutron contamination. The current study was devoted to addressing these concerns via compression of neutron fluence (Φn) and ambient dose equivalent ([Formula: see text]) at the patient table and inside the maze between SFGRT and conventional fractionated radiation therapy (CFRT). The main components of the 15 MV Siemens Primus equipped with different grids and located inside a typical radiotherapy bunker were simulated by the MCNPX® Monte Carlo code. Evidence showed that the material used for grid construction does not significantly increase neutron contamination inside the maze. However, at the end of the maze, neutron contamination in SFGRT is significantly higher than in CFRT. In this regard, a delay time of 15 minutes after SFGRT is recommended for all radiotherapy staff before entering the maze. It can be also concluded that [Formula: see text] at the patient table is at least 10 times more pronounced than inside the maze. Therefore, the patient is more at risk of neutrons compared to the staff. The [Formula: see text] at the isocenter in SFGRT with grids made of lead and cerrobend was nearly equal to CFRT. Nevertheless, it was dramatically lower than in CFRT by 30% if the brass grid is used. Accordingly, SFGRT with the brass grid is recommended, from radiation protection aspects.

Status of radiotherapy staff during the coronavirus disease 2019 (COVID-19) epidemic in China.

ObjectiveIn December 2019, coronavirus disease 2019 (COVID‐19) caused by severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) broke out in Wuhan, China. The pandemic has posed a great challenge to radiation oncology departments, as interruptions in radiation therapy (RT) increase the risks of cancer recurrence or failure of the therapy as a whole. This study aimed to elucidate the impact of COVID‐19 on radiation therapy staff in China.MethodsAs many working staff at different radiation oncology departments in China as possible were retrospectively enrolled from 23 January to 9 March 2020. They were then invited to answer a questionnaire, for essential data collection, from which their basic information, anxiety level, and workload were analyzed.ResultsSeven (0.39%) of the 1 755 radiation therapy staff who answered the questionnaire had contracted COVID‐19, all of whom were from Wuhan. The factors influencing susceptibility were not sex (P = 1.000), age (P = 0.480), or comorbidities (P = 0.600), but geographic location (P < 0.001) and whether the respondent worked in a designated COVID‐19 hospital (P = 0.003). In terms of protection procedures, four participants carried out basic, one second‐level and two third‐level protection procedures. The difference was not statistically significant (P = 0.720). The infected respondents’ anxiety level related to the outbreak (average score 6.57) was higher than that of their counterparts in Wuhan (5.18), as well as across the country (4.79), and 71.43% of those infected expressed the need for psychological interventions. During the epidemic, departments of 428 respondents (24.39%) shut down, while 76.71% of the respondents reported workload reduction.ConclusionThe factors related to COVID‐19 infection were the geographic location and whether the respondent worked in a designated COVID‐19 hospital. The infected respondents experienced greater psychological pressure than their uninfected counterparts and, therefore, required more psychological interventions.

Developing electronic learning to deliver MR safety training in a radiotherapy department

Introduction/BackgroundMagnetic Resonance Imaging (MRI) is used in radiotherapy planning, and increasingly in on-treatment guidance. The potential for the MR environment to be hazardous, without stringent safe working practices, is real. Guidance suggests all workers in MRI undergo annual safety training. To facilitate a tangible MR safety program, an electronic learning module was created and evaluated. MethodsAn existing presentation, normally delivered face-to-face, was modified and questions added to test knowledge. The module was delivered and feedback collected, together with answers to the questions, over three phases to ensure deliverability, clarity, and robustness. These comprised an initial pilot phase for non-MR personnel, an evaluation phase for staff renewing annual MR safety training, and finally for new therapeutic radiographer graduates, a test-retest methodology. ResultsSeven participants took part in the initial pilot phase, followed by thirty-one in the evaluation phase. Participants included radiographers (therapeutic and diagnostic), play specialists, clinical oncologists and anaesthetists, physicists and nursing staff. Within the evaluation group, 74.2% achieved a score >80%. Incorrect responses were principally related to questions regarding expected levels of responsibility and working practices, rather than the physics of high magnetic field strengths. The test-retest phase (n = 5) followed. Mean scores prior to learning were 59%, improving to 79% following learning, with the weakest sections mirroring those highlighted within the evaluation phase. DiscussionTransferring MR safety training into an electronic format has provided a standardised, tangible tool that provides evidence of compliance with recommended guidance. ConclusionsThis work illustrates the transition of MR safety learning for radiotherapy staff from passive presentation, to an interactive teaching methodology. The e-learning module has now been implemented within the department.

A radiotherapy staff experience of gratitude during COVID-19 pandemic.

The impact of the COVID-19 pandemic on cancer patients can be high in terms of anxiety, fear and psychological distress [1]. Medical staff from frontline wards, especially oncology units, are at high risk of infection and burnout [2]. Psychological needs grow both for cancer patients and for health-care workers [3].

Implementation of a Novel Cloud-based Platform for Facilitating Remote Radiotherapy Peer Review and Training in Resource-Limited Settings: Results of Feasibility Assessments in 4 Radiotherapy Centers in Botswana, Ghana and Tanzania

A major challenge for radiotherapy (RT) centers in low- and middle-income countries (LMICs) is to ensure that they deliver consistently high-quality treatment. The RT multi-disciplinary team requires adequate training in RT planning and access to ongoing expert input and peer review to achieve this. Cloud-based technology may function as a tool for facilitating remote peer review and training for RT centers in LMICs. We undertook a feasibility study of a cloud-based peer review and training software program in 4 RT centers in sub-Saharan Africa, to assess center-specific requirements for such a platform, and the existing technological infrastructure to support this. We carried out 5 site visits at 4 RT centers in Ghana, Tanzania and Botswana over 18 months. We reviewed existing RT treatment facilities, assessed the informatics infrastructure and interviewed RT staff to ascertain center-specific needs and the potential for incorporating cloud technology into their existing workflow. We attempted installation of the software in each center and tested its functionality to perform a full external peer review ‘feedback loop’. The feasibility study revealed a range of capabilities between the centers, and highlighted a lack of formal peer review practice amongst clinicians delivering 3D conformal RT. Installation of cloud software was achieved in 3 sites, however, it only demonstrated full functionality in 1 center. At this center, a full feedback loop with external peer review of RT volumes was achieved. The main barriers to implementation of cloud-based peer review were low internet bandwidth with poor or variable connection speeds, and insufficient IT facilities and expertise. Lack of dedicated time for formal peer review due to high clinical workloads compounded these issues. Where it is technically feasible, cloud software may offer great potential for the implementation of regular peer review and training in radiotherapy planning in LMICs. However, the extra work burden it puts upon staff and need for further training to use the software, along with sub-optimal internet capabilities, means that further work is required to embed routine peer review into practice, and to optimize the appropriate platform for achieving this.Tabled 1Abstract 2881; TableKomfo Anokye Teaching Hospital, Kumasi, GhanaSweden Ghana Medical Centre, Accra, GhanaOcean Road Cancer Institute, Dar Es Salaam, TanzaniaGaborone Private Hospital, Gaborone, BotswanaIs the internet capability sufficient for download of software?NoYesYesYesCan user accounts be created?NoYesYesYesCan DICOM files be exported from treatment planning system?NoYesNoYesCan DICOM data be imported to cloud platform?N/AYesNoNoAre imported images adequately rendered?N/AYesN/ANoIs upload of data to cloud supported?NoYesNoNoIs uploaded data anonymized?NoYesN/AN/AIs cloud platform functioning sufficient to allow completion of a ‘feedback loop’?NoYesNoNo Open table in a new tab

Practice Recommendations for Lung Cancer Radiotherapy During the COVID-19 Pandemic: An ESTRO-ASTRO Consensus Statement

BackgroundThe COVID-19 pandemic has caused radiotherapy resource pressures and led to increased risks for lung cancer patients and healthcare staff. An international group of experts in lung cancer radiotherapy established this practice recommendation pertaining to whether and how to adapt radiotherapy for lung cancer in the COVID-19 pandemic.MethodsFor this ESTRO & ASTRO endorsed project, 32 experts in lung cancer radiotherapy contributed to a modified Delphi consensus process. We assessed potential adaptations of radiotherapy in two pandemic scenarios. The first, an early pandemic scenario of risk mitigation, is characterized by an altered risk–benefit ratio of radiotherapy for lung cancer patients due to their increased susceptibility for severe COVID-19 infection, and minimization of patient travelling and exposure of radiotherapy staff. The second, a later pandemic scenario, is characterized by reduced radiotherapy resources requiring patient triage. Six common lung cancer cases were assessed for both scenarios: peripherally located stage I NSCLC, locally advanced NSCLC, postoperative radiotherapy after resection of pN2 NSCLC, thoracic radiotherapy and prophylactic cranial irradiation for limited stage SCLC and palliative thoracic radiotherapy for stage IV NSCLC.ResultsIn a risk-mitigation pandemic scenario, efforts should be made not to compromise the prognosis of lung cancer patients by departing from guideline-recommended radiotherapy practice. In that same scenario, postponement or interruption of radiotherapy treatment of COVID-19 positive patients is generally recommended to avoid exposure of cancer patients and staff to an increased risk of COVID-19 infection. In a severe pandemic scenario characterized by reduced resources, if patients must be triaged, important factors for triage include potential for cure, relative benefit of radiation, life expectancy, and performance status. Case-specific consensus recommendations regarding multimodality treatment strategies and fractionation of radiotherapy are provided.ConclusionThis joint ESTRO-ASTRO practice recommendation established pragmatic and balanced consensus recommendations in common clinical scenarios of radiotherapy for lung cancer in order to address the challenges of the COVID-19 pandemic.

Status of Radiotherapy Staff During the Coronavirus Disease 2019 (COVID-19) Epidemic in China

Background: From December 2019, the coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) broke out in Wuhan, China, and spread rapidly around the world. The pandemic also becomes a great challenge to radiation oncology departments since interruptions of radiation therapy increase the risks of cancer recurrence or the whole therapy failure. The present study aims to elucidate the influences of COVID-19 on the radiotherapy (RT) staff in China. Methods: The working staff members from different radiation oncology departments in China were retrospectively enrolled between December 1st, 2020 and March 9th, 2020 as many as possible. All the enrolled ones were invited to fill out a specific questionnaire to collect essential data. The basic information, anxiety levels, and workload of the staff were analyzed. Results: 1. A total of 1,755 questionnaires were sent back; 2. From December 1st , 2019 to March 9th, 2020, 7 out of 1,755 radiation oncology staff members contracted COVID-19 (P 0.05);3. The anxiety level of the RT staff about the COVID-19 outbreak (average score: 6.57) was higher than that of Wuhan medical staff (5.18) and higher than the national level (4.79); 71.43% of infected RT staff members expressed the need for psychological interventions; 4. During the epidemic, the departments of the 428 RT staff members shut down (24.39%). The 76.71% of the RT staff members felt workload relief during COVID-19 as compared to before. Conclusion: Among the 1,755 RT staff, the gender, age, and comorbidities were not related to COVID-19 infection. The geographic position and whether the person worked in a designated COVID-19 hospital were relevant factors with COVID-19 infection. The staff contracting COVID-19 experienced greater psychological pressure than that of the uninfected ones and therefore needed more psychological interventions. Funding Statement: This research was supported by grant No.2014CFB394, 2019CFB721 from the Natural Science Foundation of Hubei Province (CN) and No.WJ2017M027, No.WJ2019M200 from Health and Family Planning Commission of Hubei Province (CN). Declaration of Interests: None. Ethics Approval Statement: This study was approved by the Ethics Committee of Renmin Hospital of Wuhan University.

Practice recommendations for lung cancer radiotherapy during the COVID-19 pandemic: An ESTRO-ASTRO consensus statement

BackgroundThe COVID-19 pandemic has caused radiotherapy resource pressures and led to increased risks for lung cancer patients and healthcare staff. An international group of experts in lung cancer radiotherapy established this practice recommendation pertaining to whether and how to adapt radiotherapy for lung cancer in the COVID-19 pandemic. MethodsFor this ESTRO & ASTRO endorsed project, 32 experts in lung cancer radiotherapy contributed to a modified Delphi consensus process. We assessed potential adaptations of radiotherapy in two pandemic scenarios. The first, an early pandemic scenario of risk mitigation, is characterized by an altered risk–benefit ratio of radiotherapy for lung cancer patients due to their increased susceptibility for severe COVID-19 infection, and minimization of patient travelling and exposure of radiotherapy staff. The second, a later pandemic scenario, is characterized by reduced radiotherapy resources requiring patient triage. Six common lung cancer cases were assessed for both scenarios: peripherally located stage I NSCLC, locally advanced NSCLC, postoperative radiotherapy after resection of pN2 NSCLC, thoracic radiotherapy and prophylactic cranial irradiation for limited stage SCLC and palliative thoracic radiotherapy for stage IV NSCLC. ResultsIn a risk-mitigation pandemic scenario, efforts should be made not to compromise the prognosis of lung cancer patients by departing from guideline-recommended radiotherapy practice. In that same scenario, postponement or interruption of radiotherapy treatment of COVID-19 positive patients is generally recommended to avoid exposure of cancer patients and staff to an increased risk of COVID-19 infection. In a severe pandemic scenario characterized by reduced resources, if patients must be triaged, important factors for triage include potential for cure, relative benefit of radiation, life expectancy, and performance status. Case-specific consensus recommendations regarding multimodality treatment strategies and fractionation of radiotherapy are provided. ConclusionThis joint ESTRO-ASTRO practice recommendation established pragmatic and balanced consensus recommendations in common clinical scenarios of radiotherapy for lung cancer in order to address the challenges of the COVID-19 pandemic.

Dosimetric Evaluation of Body Contour Changes to Target Volumes and Organs at Risk for Cervix and Head and Neck Radiotherapy Plans

Purpose: To investigate how much dose discrepancy would be caused by the anatomy changes during the radiotherapy (RT) course. Methods: Ten cervical cancer and ten nasopharyngeal carcinoma (NPC) CT datasets from RT patients were enrolled. The body contour from different directions changed to simulate the weight loss or gain for cervical cancer patients, who had been treated with external-beam RT using intensity-modulated radiation therapy (IMRT) or volumetric modulated arc therapy (VMAT). Moreover, the body contour from facial and shoulder superior-inferior positional change had been also assessed for NPC patients using IMRT or VMAT. The new CT (n-CT) was generated by the body contour changes with different directions based on original CT datasets. The dosimetric parameters to target volumes and organs at risk (OARs) were evaluated in Eclipse based on n-CT. Results: The target volumes and OARs were influenced by the body contour changes. Body contour expansion resulted in coverage loss, whereas body contour shrinkage increased the dose to the OARs. These findings were generally consistent for both IMRT and VMAT plans. Over a course of research, the dose to 95% of the target volumes for cervical cancer decreased by up to 2.83% per cm for IMRT and 2.87% per cm for VMAT (P < 0.05). And the influence on H&N plans was that the dose to 95% of the target volumes (low risk regions) decreased by up to 4.45% per cm. Conclusions: The RT staff could determine whether resimulation and replaning or not according to which body contour directions were changed.

The Effectiveness Analysis of Loxon Body Mask on Hepatocellular Carcinoma Cases Using a Rapid ARC Technique against the X, Y, and Z Coordinate On Board Imager in Radiation Therapy

Immobilization tools are used to reduce the movement during irradiation; one of the immobilization tools is Loxon Body Mask applied on the abdominal and pelvic regions. This study aimed to analyze the effectiveness of Loxon Body Mask against changes in X, Y and Z coordinates. The study took place in the Radiotherapy Installation of MRCCC Siloam Hospital Semanggi. Data were obtained from 10 secondary data samples of HCC patients with 20 times verification results consisting of X, Y, and Z coordinate values. Data on radiation area shift data were calculated to know the average and were analyzed graphically and statistically using one sample T-test. A shift at the X coordinate was 0.32 cm, Y coordinate was 0.20 cm, and Z coordinates was 0.34 cm. The application of Loxon Body Mask caused shifts in the radiation field; the causes could be imperfect mask application, the radiotherapy staff or the patients themselves.The average value of the shift in the radiation area in patients using Loxon Body Mask immobilization tool at X, Y, and Z coordinate was less than the tolerance value of 0.5 cm.

Automated treatment planning of postmastectomy radiotherapy.

PurposeBreast cancer is the most common cancer in women globally and radiation therapy is a cornerstone of its treatment. However, there is an enormous shortage of radiotherapy staff, especially in low‐ and middle‐income countries. This shortage could be ameliorated through increased automation in the radiation treatment planning process, which may reduce the workload on radiotherapy staff and improve efficiency in preparing radiotherapy treatments for patients. To this end, we sought to create an automated treatment planning tool for postmastectomy radiotherapy (PMRT).MethodsAlgorithms to automate every step of PMRT planning were developed and integrated into a commercial treatment planning system. The only required inputs for automated PMRT planning are a planning computed tomography scan, a plan directive, and selection of the inferior border of the tangential fields. With no other human input, the planning tool automatically creates a treatment plan and presents it for review. The major automated steps are (a) segmentation of relevant structures (targets, normal tissues, and other planning structures), (b) setup of the beams (tangential fields matched with a supraclavicular field), and (c) optimization of the dose distribution by using a mix of high‐ and low‐energy photon beams and field‐in‐field modulation for the tangential fields. This automated PMRT planning tool was tested with ten computed tomography scans of patients with breast cancer who had received irradiation of the left chest wall. These plans were assessed quantitatively using their dose distributions and were reviewed by two physicians who rated them on a three‐tiered scale: use as is, minor changes, or major changes. The accuracy of the automated segmentation of the heart and ipsilateral lung was also assessed. Finally, a plan quality verification tool was tested to alert the user to any possible deviations in the quality of the automatically created treatment plans.ResultsThe automatically created PMRT plans met the acceptable dose objectives, including target coverage, maximum plan dose, and dose to organs at risk, for all but one patient for whom the heart objectives were exceeded. Physicians accepted 50% of the treatment plans as is and required only minor changes for the remaining 50%, which included the one patient whose plan had a high heart dose. Furthermore, the automatically segmented contours of the heart and ipsilateral lung agreed well with manually edited contours. Finally, the automated plan quality verification tool detected 92% of the changes requested by physicians in this review.ConclusionsWe developed a new tool for automatically planning PMRT for breast cancer, including irradiation of the chest wall and ipsilateral lymph nodes (supraclavicular and level III axillary). In this initial testing, we found that the plans created by this tool are clinically viable, and the tool can alert the user to possible deviations in plan quality. The next step is to subject this tool to prospective testing, in which automatically planned treatments will be compared with manually planned treatments.

Quality control report of tumor radiotherapy in Zhejiang province

Objective To discover the existing problems and provide appropriate suggestions and countermeasures through the quality control inspection. Methods A comprehensive quality control inspection was conducted for the radiotherapy equipment in 45 hospitals in Zhejiang province. The physical, technical, clinical and radiotherapy process and the parameters related to quality control were evaluated. Results As of December 31, 2017, a total of 62 linear accelerators from 45 hospitals have been assessed. In the radiotherapy process, multiple quality control problems were identified in terms of radiotherapy equipment configuration, clinical work quality, radiotherapy technology and personnel qualifications. Besides, unreasonable equipment configuration, shortage of radiotherapy staff, clinical work flow and the quality assurance of physical radiotherapy remained to be resolved. Conclusion Regular quality control of radiotherapy plays a pivotal role in ensuring the accuracy, effectiveness and medical safety of radiotherapy. Key words: Zhejiang province; Radiotherapy units; Quality control; Survey

Breast cancer patients report reduced sensitivity and pain using a barrier film during radiotherapy - A Danish intra-patient randomized multicentre study.

Radiodermatitis is a well-known toxicity of radiotherapy and barrier film has been shown to reduce the severity of radiodermatitis. We have validated prior findings in a Danish cohort, using a similar barrier film and patient reported outcomes. 101 Danish breast cancer patients were included at three radiotherapy centres. Based on randomization either the lateral or medial part of their chest was covered by Mepitel film; making the patients their own control. The primary endpoint was patient reported symptoms and experience. A secondary endpoint was radiotherapy staff evaluation of dermatitis. Within the skin area covered by film, the patients reported a statistical significant lower level of pain (p < .001), itching (p = 0.005), burning sensation (p = 0.005) as well as edema (p = 0.017) and reduced sensitivity (p < .001). Most patients (76%) would have preferred film on the entire treatment area (p < 0.001) and Mepitel Film as a standard treatment option (84%) (p < 0.001). Patients treated after mastectomy had a significantly lower severity of radiation-induced dermatitis with film at the end of RT compared to standard care (p = 0.005). However, in the blinded staff evaluation, no significant differences were found at follow-up. Patients reported reduced symptoms from the skin with Mepitel Film and the majority would have preferred film as a standard offer to cover their entire treatment area. Especially women treated after mastectomy had a significantly lower level of radiodermatitis and preferred the film over standard care.