Advanced practice in radiotherapy across Europe: stakeholders’ perceptions of implementation and evolution

Introduction Adapting radiotherapy services with workforce innovation using skills-mix or task-shifting optimises resources, supporting current and future demands. Advanced practitioners (APs) work at a different level of practice (beyond initial registration) across four pillars: clinical practice, leadership and management, education, and research. There is limited cross-country research on the advanced therapeutic radiographers/radiation therapists (TR/RTTs), particularly in Europe. This study aimed to investigate European radiotherapy stakeholders’ perceptions regarding current and future advanced practice (AP). Methods From June to September 2022, one-to-one online semi-structured interviews were conducted in English, and audio and video were recorded. Full verbatim audio files were independently transcribed and checked by interviewer and interviewees. Braun and Clarke's seven steps guided the thematic analysis (using NVivo). Results Thirty-three interviewees working or studying in 16 European countries represented practitioners (n=14), managers (n=6), educators (n=4), professional bodies (n=4), students (n=3), and regulators (n=2). Four overarching themes emerged: “AP drivers and outcomes”, “AP challenges vs enablers”, “Current vs future AP”, “Becoming and being advanced practitioner”. Participants identified research as the neglected AP pillar due to a lack of protected time, limited staff skills, no research culture, no funding, workload, and clinical priorities. Interviewees highlighted the importance of consistency in job titles, harmonisation of education models and curricula, definition of AP requirements, and support for all AP pillars through job plans and workforce planning. Conclusion Neither the profession nor education of TR/RTTs are harmonised across Europe, which is highly reflected in advanced-level practice. Advanced TR/RTTs should work across all pillars, including research, and these should be embedded in master's programmes, including leadership. Implications for practice This study highlights a policy gap in the education and practice of APs in radiotherapy

The UK HeartSpare study: randomised evaluation of voluntary deep-inspiratory breath-hold in women undergoing breast radiotherapy

Purpose: to determine whether voluntary deep-inspiratory breath-hold (v_DIBH) and deep-inspiratory breath-hold with the active breathing coordinator™ (ABC_DIBH) in patients undergoing left breast radiotherapy are comparable in terms of normal-tissue sparing, positional reproducibility and feasibility of delivery.Methods: following surgery for early breast cancer, patients underwent planning-CT scans in v_DIBH and ABC_DIBH. Patients were randomised to receive one technique for fractions 1–7 and the second technique for fractions 8–15 (40?Gy/15 fractions total). Daily electronic portal imaging (EPI) was performed and matched to digitally-reconstructed radiographs. Cone-beam CT (CBCT) images were acquired for 6/15 fractions and matched to planning-CT data. Population systematic (?) and random errors (?) were estimated. Heart, left-anterior-descending coronary artery, and lung doses were calculated. Patient comfort, radiographer satisfaction and scanning/treatment times were recorded. Within-patient comparisons between the two techniques used the paired t-test or Wilcoxon signed-rank test.Results: twenty-three patients were recruited. All completed treatment with both techniques. EPI-derived ? were ?1.8?mm (v_DIBH) and ?2.0?mm (ABC_DIBH) and ? ?2.5?mm (v_DIBH) and ?2.2?mm (ABC_DIBH) (all p non-significant). CBCT-derived ? were ?3.9?mm (v_DIBH) and ?4.9?mm (ABC_DIBH) and ? ??4.1?mm (v_DIBH) and ??3.8?mm (ABC_DIBH). There was no significant difference between techniques in terms of normal-tissue doses (all p non-significant). Patients and radiographers preferred v_DIBH (p?=?0.007, p?=?0.03, respectively). Scanning/treatment setup times were shorter for v_DIBH (p?=?0.02, p?=?0.04, respectively).Conclusions: v_DIBH and ABC_DIBH are comparable in terms of positional reproducibility and normal tissue sparing. v_DIBH is preferred by patients and radiographers, takes less time to deliver, and is cheaper than ABC_DIB

Research from therapeutic radiographers : an audit of research capacity within the UK

Research from Allied Health Professionals (AHPs) is anecdotally known to lag behind that of other professions. The developing research landscape within other therapies and internationally led us to question how UK practice in therapeutic radiography was developing. The aim of the survey was to audit research capacity across therapy radiography in the UK. Method: An electronic survey was sent to Radiotherapy Service Managers (RSM) and research leads in each of the radiotherapy centres in the UK. An adapted version of the 'Auditing Research Capacity' tool (ARC © tool) was used as the basis of the questionnaire. Results: A total of 45 RSM responded to the survey (67% response rate) and 30 Research radiographers (RR) (45% response rate). A total of 51 RR were in post equating to 40.3 whole time equivalents and averaging 1 RR per centre. Variation was evident in the commitment to the development of a research culture identified by practices such as linking research to the business planning cycle, inclusion of research in recruitment and advertising materials, or having a nominated therapeutic radiographer lead on research for the department. Over a third of responding centres did not have a research strategy and training for RRs was limited; specifically in areas such as writing funding bids, writing for publication and the research and governance process. Conclusion: A number of short and long-term strategies are proposed that should enhance a positive research culture and improve research capacity for therapeutic radiography led research. These include utilisation of the existing infrastructure provided by the National Institute for Health Research, a lead or co-ordinator for research activity with a remit to motivate others. Development of links and networks, and the development of a research strategy linked to wider Trust research priorities. The research strategy should include mentoring or developing appropriate research skills for those engaged in research (including higher degree qualifications). RSMs should also encourage peer-reviewed publications, and conference presentations from all staff to ensure research results are disseminated to the wider profession

GI factors, potential to predict prostate motion during radiotherapy; a scoping review

Purpose: A scoping literature review was conducted to identify gastrointestinal (GI) factors most likely to influence prostate motion during radiotherapy. We proffer that patient specific measurement of these GI factors could predict motion uncertainty during radiotherapy, facilitating personalised care by optimising treatment technique e.g., daily adaption or via bespoke patient pre-habilitation and preparation. Methods: The scoping review was undertaken as per JBI guidelines. Searches were conducted across four databases: Ovid Medline®, EMBASE, CINAHL and EBSCO discovery. Articles written in English from 2010-present were included. Those pertaining to paediatrics, biological women exclusively, infectious and post-treatment GI morbidity and diet were excluded.Common GI factors impacting men were identified and related symptoms, incidence and measurement tools examined. Prevalence among persons with prostate cancer was explored and suitable assessment tools discussed. Results: A preliminary search identified four prominent GI-factors: mental health, co-morbidity and medication, physical activity, and pelvic floor disorder. The scoping search found 3644 articles; 1646 were removed as duplicates. A further 1249 were excluded after title and abstract screening, 162 remained subsequent to full text review: 42 mental health, 53 co-morbidity and medication, 39 physical activity and 28 pelvic floor disorder.Six GI factors prevalent in the prostate cancer population and estimated most likely to influence prostate motion were identified: depression, anxiety, diabetes, obesity, low physical activity, and pelvic floor disorder. Reliable, quick, and easy to use tools are available to quantify these factors. Conclusion: A comprehensive GI factor assessment package suitable to implement into the radiotherapy clinic has been created. Unveiling these GI factors upfront will guide improved personalisation of radiotherapy

A systematic review: Effectiveness of rectal emptying preparation in prostate cancer patients

While the importance of a consistent rectal volume during radiation therapy planning and treatment for patients receiving radiation therapy to the prostate is recognized, there is no clear guidance as to the most effective method. This review examines the evidence for the efficacy of rectal preparations. Eighteen papers were found where the primary aim was to investigate a rectal emptying intervention and included 5 different strategies. These included evacuation techniques, dietary interventions, laxatives, and enemas and were either investigated alone or in combination. There is no robust evidence to recommend one rectal emptying strategy over another. Further investigation in adequately powered clinical trials is advised. (C) 2014 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved.Biological, physical and clinical aspects of cancer treatment with ionising radiatio

Advanced practice roles amongst therapeutic radiographers/radiation therapists: A European survey

Introduction Advanced Practice (AP) roles in Radiotherapy (RT) over time are variable, often locally developed and not underpinned by professional standards which leads to conceptual and practical gaps. This study aimed to assess AP roles amongst Therapeutic Radiographers/Radiation Therapists (TR/RTTs) and identify educational gaps for this level across Europe. Methods An anonymous online survey was designed, validated, and distributed across Europe. Convenience sampling was used to recruit advanced TR/RTTs practitioners or TR/RTTs working in AP roles. Descriptive analysis from closed questions and thematic analyses from open questions are reported. Results A total of 272 responses were obtained, of which 189 eligible participations were from 21 European countries. 42% of respondents acknowledged additional education required to perform AP, and 25% reported a minimum of five years of RT practice to perform AP roles/tasks. There is a trend to work more on the clinical practice domain with a low percentage of working time allocated to research. Inconsistency was found in job titles, scopes of practice, and educational backgrounds across and even within countries. Education needs regarding knowledge about image-guided and adaptive RT, multimodal imaging and technologies, and advanced treatment planning were found. Training needs on leadership and management skills and clinical site-specific expertise were identified. Conclusion This study clearly shows a gap in education support, a need for standardisation in job titles and scopes of practice across Europe. Implications for practice As the first large-scale assessment of current AP roles and educational support amongst TR/RTTs across Europe, this study recommends the establishment of governance structure and role regulation. It also informs the curricula for master programmes to align the education with current and future practice

The UK HeartSpare Study (Stage II): multicentre evaluation of a voluntary breath-hold technique in patients receiving breast radiotherapy

Aims To evaluate the feasibility and heart-sparing ability of the voluntary breath-hold (VBH) technique in a multicentre setting. Materials and methods Patients were recruited from 10 UK centres. Following surgery for early left breast cancer, patients with any heart inside the 50% isodose from a standard free-breathing tangential field treatment plan underwent a second planning computed tomography (CT) scan using the VBH technique. A separate treatment plan was prepared on the VBH CT scan and used for treatment. The mean heart, left anterior descending coronary artery (LAD) and lung doses were calculated. Daily electronic portal imaging (EPI) was carried out and scanning/treatment times were recorded. The primary end point was the percentage of patients achieving a reduction in mean heart dose with VBH. Population systematic (Σ) and random errors (σ) were estimated. Within-patient comparisons between techniques used Wilcoxon signed-rank tests. Results In total, 101 patients were recruited during 2014. Primary end point data were available for 93 patients, 88 (95%) of whom achieved a reduction in mean heart dose with VBH. Mean cardiac doses (Gy) for free-breathing and VBH techniques, respectively, were: heart 1.8 and 1.1, LAD 12.1 and 5.4, maximum LAD 35.4 and 24.1 (all P<0.001). Population EPI-based displacement data showed Σ =+1.3–1.9 mm and σ=1.4–1.8 mm. Median CT and treatment session times were 21 and 22 min, respectively. Conclusions The VBH technique is confirmed as effective in sparing heart tissue and is feasible in a multicentre setting