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Total body irradiation (TBI) is a kind of external beam radiotherapy, used in conjunction with chemotherapy with the purpose of immunosuppression. Since the target in TBI is the whole body, so achieving uniform dose distribution throughout the entire body during TBI is necessary. As recommended by AAPM dose variation must be within ±10% of the prescription dose. With the evidences from literature there is limited substantiation to consider a treatment method better than others, but with regard to the size of the treatment room, workload of the radiotherapy department and prevalent technology used within each treatment department it is recommended to make the suitable and optimum method in each department. In this work, a review study was performed on different TBI techniques with the purpose of assessment and comparison of dose distribution homogeneity in these methods.

Background and Purpose: Paragangliomas are rare tumors of the head and neck. Their management remains problematic and varies considerably depending on the center. This study reported 14 years of experience in the management of head and neck paraganglioma (HNPGls). We aimed to assess the therapeutic results of these tumors in terms of local control and overall survival. Materials and Methods: We included 16 patients followed for HNPGls and treated by radiotherapy from January 2006 to June 2018 in the National Institute of Oncology in Rabat. Results: The median age was 44.5 years (15 - 67). 13 patients were female and three male with a sex ratio of 4.3. Cervical mass was the common sign (56.3%). All patients received radiation therapy. This radiation was exclusive in 43.7% of cases or adjuvant to partial surgical resection in 56.3%. The median dose of radiotherapy was 54 Gy (46 - 60) and it was delivered by a three-dimensional conformal radiotherapy technique in 15 patients and volumetric modulated arc therapy in one. There were few acute complications such as grade I and II mucositis and dermatitis. After a median follow-up of 5.6 years (2 - 13.4), local control, defined by radiological stability or regression, was obtained in 14 patients, two patients progressed and one died. Progression-free survival rates at 5 and 7 years were 93.8% and 78.1% respectively, and overall survival at 5 and 7 years was 92.3%. Conclusions: Surgery is the first-line treatment for HNPGls. When surgery is not possible or incomplete, radiotherapy has its place in the therapeutic strategy of this rare disease for long-term local control.

David Waldron Smithers was, among other things, a physician and a pioneer of cancer radiotherapy and a well-respected figure in British medicine and public health. From the 1940s until his retirement from medical practice in 1973, he was the director of the Radiotherapy Department at the Royal Marsden Hospital and London University Chair of Radiotherapy at the Institute of Cancer Research. Using massive amounts of clinical observations, which he interpreted from an organicist viewpoint, and his impressive synthetic thinking, he proposed a coherent alternative perspective to the somatic mutation theory (SMT) which was then, and still is, the dominant theory of cancer. The purpose of this essay is to acquaint the modern audience with his seminal paper, published in 1962, because it deserves to be recognized as a true classic. In it, he examined the lack of fit between clinical observations and the SMT and proposed the rejection of this reductionist perspective. In addition, he built an organicist alternative in which carcinogenesis is seen as a problem of biological organization. His conceptual contribution to the cancer problem has inspired us and other authors over the last two decades. His essay “Cancer: An Attack on Cytologism,” originally published in The Lancet in 1962, is available as supplementary material in the online version of this article.

The massive incidence of COVID-19 has led to reorganization of medical care for cancer patients. While maintaining an individual approach and maximum effectiveness, we're considering the possibility of changing the radiation therapy treatment in each clinical case. Spatio-temporal separation of patient's streams and algorithms for building the radiotherapy department were introduced to minimize the risk of COVID-19 infection of medical personnel and patients.

Background:Teamwork is a central framework in healthcare delivery. Team dynamics can impact the team as a whole and has been identified within the literature as a contributory factor to quality and safety, patient satisfaction, staff satisfaction and overall performance. Within radiation therapy (RT), teamwork is essential in the delivery of high-quality care, yet team building and team development is under-reported.Aim:The focus of this research is to form a better understanding of what plays an impact on teams in a large urban RT cancer centre and how to better engage staff to work together, improve team dynamics and promote team building.Materials and Methods:An electronic search of the literature was conducted to better inform debate and aid in the development of team-building sessions in a busy radiotherapy department. Abstracts were screened and relevant articles selected if they met the search criteria that included relevancy related to team building, contributory factors on team dynamics, team-based learning, team performance and implication of civility.Results:A total of 45 articles were included in the final analysis. The majority were from the disciplines of medicine (45%), business (22%) and nursing (18%). Only 3 of the 45 articles (7%) focused on the profession of RT. Most articles discussed more than 1 theme with team dynamics and team building being the most common themes discussed in 16 articles each (36%). Other common themes included teamwork (31%), respect and civility (20%), leadership and hierarchy (11%), medical errors (11%) and team training (11%). Only 3 of the 45 articles (7%) focused on RT.Conclusion:There is a lack of longitudinal evidence to support the impact of team building sessions to improve team dynamics and promote a positive, cohesive team environment. Specifically within RT, the impact team building has on team dynamics has been under investigation.Highlights:High-quality patient care can be linked to team collaboration and cohesiveness. Changing the culture within a team and engaging in civility and respect in everyday practice has the potential to improve team dynamics, patient safety, staff and patient satisfaction.

Instantaneous dose rate (IDR) measurements were made at the entrances of a number of linac bunkers for a range of beam energies and gantry angles in a large radiotherapy department. The results demonstrate that the IDR does not decrease with distance from the maze entrances according to the inverse square law (ISL), which is commonly used in the design of such bunkers. No simple relationship exists, but a useful guiding principle was found that the IDR at 1 m back from the maze entrance is approximately 50% of that at the entrance itself. This was found to hold with a standard error within 5% across the full extent of the maze entrance by measuring in a grid pattern. The ISL should therefore be used with caution in the design of radiotherapy bunker mazes as it may not provide accurate estimates of the dose in surrounding areas. The results of the grid pattern measurements also indicate that the centre of the maze entrance is the best position to affix passive dosemeters for the purpose of environmental monitoring. This may not always be practical (e.g. if the bunker does not have a door), but factors have been found to correct readings taken elsewhere to the central reading. For instance, if the dosemeter is placed on the wall, the measured dose rate will be equal to 94% ± 8% of the value at the centre of the bunker.

One of the elements of the quality of medical care is its accessibility, which depends on the material and technical baseof the institution, as well as on the availability of stuff and work management. Implementation of the new clinical guidelines of the Association of Oncologists of Russia (AOR) for the treatment of non-melanoma skin cancer (NRC), revealedthe problem of increasing the load on stuff and equipment.Purpose of the study.To investigate and forecast the load of the kilovoltage X-ray therapy unit taking into account theupdated clinical guidelines for the treatment of patients with non-melanoma skin cancer using radiotherapy. Determinethe clinical and organizational changes in the technology of x-ray therapy for non-melanoma skin cancer within theday-hospital department for the skin cancer size more than 2 cm after implementation of new clinical guidelines andfraction regimes in compare with previously used schemes; derive a mathematical model of the work of the kilovoltagex-ray therapy room.Materials and methods. Data from the kilovoltage X-ray therapy office of radiotherapy unit No. 2 of the Sverdlovsk Regional Oncology Dispensary (SROD) were used. The average duration of radiotherapy sessions per patient was estimatedand calculated using timekeeping. The results were evaluated using correlation analysis. In order to forecast the use ofmaterial and human resources, an economic method of mathematical modeling was used.Results. The analysis of the kilovoltage X-ray therapy unit of radiotherapy department No. 2 of the SROD for 3 yearsshowed an increase from 10.4 to 17.3 in the average number of therapeutic fractions per patient after the implementation of the updated clinical guidelines. An increase in the average number of radiotherapy sessions leads to a doublingof the average bed-day of the patient's stay in the day-hospital. The formula was proposed for predicting the work of theunit. There is a clear correlation between the duration of treatment, the dynamics of hospitalization and the number oftreated patients. The calculated results obtained using a mathematical model fully correspond to the actual performanceof the radiotherapy room.Conclusion. To ensure optimal availability of medical care, it is necessary to match treatment technologies with availableresources of the organization. The introduction of new treatment programs may require both the expansion of staff(medical, nursing), and an increase in the number of units of medical equipment. The obtained mathematical modelof the kilovoltage X-ray therapy room allows to predict the optimal mode of work of employees while maintaining thequality and accessability of medical care.

COVID-19 pandemic represents a challenge for entire medical world, with profound implications in daily practice, making a compromise between risk of infection with SARS-COV2 and oncological treatment continuing, in conditions in which must be balanced, for each patient, the risk of infection with COVID-19. We are presenting the recommendations of professional societies and actions take in Radiotherapy Department of Sf. Ap. Andrei Emergency Clinical Hospital, Galati in order to limit the spread of COVID-19 infection and concomitant with radiotherapy performing, without compromising the quality of medical act. © 2020 Bucharest College of Physicians. All rights reserved.

• Survey of European radiotherapy department heads after 1 year of Covid-pandemic. • A decrease in patient volume was reported in 53%. • Enrollment in clinical studies was decreased in 58%. • Concerns were expressed related to well-being of staff in 76% of the departments.

Aim: The aim of this service review was to review whether implementing a formal training package increased therapeutic radiographer confidence and competence in recognising neutropenic sepsis in radiotherapy patients. In addition, authors also investigated whether the introduction of a weekly National Early Warning Score (NEWS) protocol had been successful in identifying cases of neutropenic sepsis. Material and Methods: Therapeutic radiographer (n = 13) views on the new protocol were collected through an online questionnaire. A review of the clinical observation sheets of patients who received chemo-radiotherapy (n = 49) between 18 April 2019 and 31 October 2019 was undertaken. Information on disease site, NEWS scores, number of patients who had become neutropenic and action taken by therapeutic radiographers was collected. Results: The majority of respondents to the questionnaire found that training benefitted both professionals and patients. Some challenges were highlighted relating to increased workload. For patients receiving regular observations, NEWS scores ranged from 0 to 4. When a patient scored on NEWS, the most common score was 1 across all treatment sites except cervix. Findings: Implementing a neutropenic sepsis protocol appears to be beneficial to therapeutic radiographers as professionals, increasing their confidence in patient assessment and monitoring. Regular observations may help to identify deteriorating patients alongside clinical judgement and symptom reviews.

BackgroundAgreement between planners and treating radiation oncologists (ROs) on plan quality criteria is essential for consistent planning. Differences between ROs and planning medical physicists (MPs) in perceived quality of head and neck cancer plans were assessed.Materials and MethodsFive ROs and four MPs scored 65 plans for in total 15 patients. For each patient, the clinical (CLIN) plan and two or four alternative plans, generated with automated multi-criteria optimization (MCO), were included. There was always one MCO plan aiming at maximally adhering to clinical plan requirements, while the other MCO plans had a lower aimed quality. Scores were given as follows: 1–7 and 1–2, not acceptable; 3–5, acceptable if further planning would not resolve perceived weaknesses; and 6–7, straightway acceptable. One MP and one RO repeated plan scoring for intra-observer variation assessment.ResultsFor the 36 unique observer pairs, the median percentage of plans for which the two observers agreed on a plan score (100% = 65 plans) was 27.7% [6.2, 40.0]. In the repeat scoring, agreements between first and second scoring were 52.3% and 40.0%, respectively. With a binary division between unacceptable (scores 1 and 2) and acceptable (3–7) plans, the median inter-observer agreement percentage was 78.5% [63.1, 86.2], while intra-observer agreements were 96.9% and 86.2%. There were no differences in observed agreements between RO–RO, MP–MP, and RO–MP pairs. Agreements for the highest-quality, automatically generated MCO plans were higher than for the CLIN plans.ConclusionsInter-observer differences in plan quality scores were substantial and could result in inconsistencies in generated treatment plans. Agreements among ROs were not better than between ROs and MPs, despite large differences in training and clinical role. High-quality automatically generated plans showed the best score agreements.

Background:The COVID-19 pandemic has required a rapid and evolving response in order to enable the continued delivery of radiotherapy, whilst effectively managing the risk of infection to patients and staff. In early March 2020, we were presented with the challenge of achieving safe delivery of care in clinical practice for a group of patients that are already at higher risk of morbidity from COVID-19 with only limited guidance.Purpose:This article outlines the adjustments made at The Christie at Oldham satellite centre in order to promote optimal care to our patients receiving radiotherapy, and to mitigate infection risk at the department for both patients and staff.Materials and Methods:We share insight into some of the evolving processes that our team have developed since March 2020 in promoting optimal care to patients receiving radiotherapy at The Christie at Oldham satellite centre. These include changes to the department floor, paper flow, supportive care and staffing.Results and Conclusions:As we continue to progress through this pandemic, we accept that there will be an ongoing journey of learning with adjustments to practice and evolving ‘new norm’, thereby ensuring we keep our patients and team safe and well. We also hoped that our experience would support radiotherapy-related practices in surges of the pandemic in other parts of the world or in case of the second wave.

Purpose: To study the number of disruptions in patient processes in a radiotherapy centre after the replacement of an Electronic Health Record (EHR), integrating information tools for patient care and billing.Methods: Our self-made Electronic Medical Record was replaced by a new EHR, including clinical path and workflow-management. A social-technological approach was used to reduce complexity. We measured disruptions in patient processes by the number and type of EHR related root causes and EHR-related incidents that reached patients, in our patient safety system 12 months before implementing the new EHR, 6 months after implementation (transition period) and 24 months after the transition period. We used Mann-Whitney U and X-2 tests to compare data before and after implementation.Results: An increase of disruptions occurred only temporarily during 6 months. After this period, the number stabilized to the level before implementation while having more functionalities and benefits. Neither the number nor the severity of incidents reaching patients increased.Conclusions: Disruptions in patient processes are considered as a main barrier for implementing an EHR. Using a social/technical approach, the increase in disruptions did only temporarily occur and did not reach patients. We think it is important to share this insight with physicians because literature shows that their long-term opinion regarding the usefulness of the EHR is often based on the experience in the first months after implementation. Management of expectations is recommended.Advances in knowledge: This study is the first of its kind measuring long-term effects of EHR on patient processes in radiotherapy.

Optimal time management is of utmost importance in the radiotherapy department. Inappropriate allocation of time slots leads to prolonged waiting times and decreased patient satisfaction during external beam radiotherapy. The present study tests a logical model to improve the waiting time for the patients.The treatment time, waiting time, and causes of delay were studied from November 4, 2014, to July 24, 2015. New rules were framed for treatment slot allocation from December 26, 2014. The treatment slots were classified based on the treatment technology (three-dimensional conformal radiotherapy and intensity-modulated radiotherapy) with inclusion of "buffer slots" and patient education. The results were compared before and after rules.A total of 1032 time slots were analyzed, of which 225 "before rules" and 807 "after rules," respectively. There was a significant reduction in the average waiting time for treatment in on-time patients (median [interquartile range (IQR)] of 25.2 min [31.75] vs. 3 min [3.5]; P0.00001) as well as in late-coming patients (median [IQR] of 38.2 min [13.795] vs. 21.11 min [12.75]; P= 0.00006). 59.7% (71 patients) of the treatment was delayed "before rules" as opposed to 32.2% (137 patients) "after rules" in on-time patients. Due to better patient education, there was a significant improvement in the patient punctuality toward the allotted time.The treatment slots classified based on the teletherapy technique with buffer slots, and patient education helps in better time management on linear accelerator. This methodology significantly reduces waiting time and thereby the number of patients having delay in the treatment.

Introduction/Background Magnetic 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. Methods An 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. Results Seven 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. Discussion Transferring MR safety training into an electronic format has provided a standardised, tangible tool that provides evidence of compliance with recommended guidance. Conclusions This 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.

It has been proven that humanization plays a key role in hospitals and other environments. Enhancing the humanistic atmosphere in hospitals can help improve mood and reduce stress. Therefore, this article designs the waiting area so that the waiting area can reduce the patient’s anxiety and other negative emotions, and enhance the patient’s confidence in treatment. Due to the similarities between current general radiotherapy and proton therapy, this article sorts out the design directions and design methods of many cancer hospitals. At the same time, the author conducts a questionnaire interview on the behavior of patients during the waiting time before radiotherapy through field investigations in the radiotherapy department of the tumor hospital, To further explore the needs of patients in the waiting area, in order to find the direction of the interior design of the waiting area of the proton radiotherapy hospital in the future, and provide a reliable basis for the design direction of the proton hospital in the future.

OBJECTIVES: To report the impact of the COVID-19 pandemic on patient attendance at a radiotherapy department two months after the implementation of specific policies regarding the pandemic. METHODS: The proposed treatment schemes, favoring hypofractionated schedules, and COVID-19 management strategies regarding irradiation are presented. Attendance after two months of implementation of these policies was measured and compared with that during the same period in 2019. RESULTS: A 10% reduction in the number of treated patients and a 26% reduction in the number of sessions was observed. The main impact was a decrease in the treatment of benign diseases and gastrointestinal tumors, with a general increase in breast cancer treatments. Eighteen (1.7%) patients were confirmed as having COVID-19 during radiotherapy in April and May 2020, three of whom were hospitalized, and one patient died because of COVID-19. Among the 18 patients, 12 had their treatments interrupted for at least 15 days from symptom appearance. CONCLUSION: There was a decrease in the number of treated patients in our radiotherapy department, with a greater decrease in the total number of sessions. This indicated, overall, a smaller number of fractions/patients treated, despite our efforts to maintain the treatment routine. We had several patients who were infected with COVID-19 and one related death during treatment in the first few months of the pandemic in São Paulo Brazil.

Introduction Cervical cancer is diagnosed 60–70% at an advanced stage in low countries. Hydronephrosis is a common occurrence in patients with advanced cervical cancer (14 to 44%). We aimed to describe the survival in those patients and comfort after urinary diversion. Methods This is a cross-sectional study during 25-month that included 82 patients with stage IIIB cervical cancer in a public hospital Joseph Ravoahangy Andrianavalona oncology and radiotherapy Department. Results Thirty-one patients (37%) underwent diversion. Twelve patients (38.7%) had improvement of renal function. Half the patients had improvement in lumbar pain hydronephrosis-related. Complications after diversion was mainly surgical site infection (19%). Median overall survival was for those patients underwent or no urinary diversion was 90 days. The median survival in patients who underwent diversion was 90 days and 60 days whom required diversion but elected not to receive it. The survival with unilateral and bilateral hydronephrosis was 195 days and 75 days. Median survival was 90 days and 60 days for patients with and without chemotherapy after diversion. No patients received radiation because a public centre was not available during the study period due to costs. Conclusion Hydronephrosis is a predictor of poor survival in patients with advanced stage cervical cancer. Urinary diversion improves the lumbar pain hydronephrosis-related, improve renal function, confers a short-time survival benefit. It could provide conditions for patients receiving treatment for advanced cervical cancer.

Background:Cancers commonly known as head and neck cancers typically begin in the squamous cells that line the moist, mucosal surfaces within the head and neck. Oral mucositis is erythematous and ulcerative lesion of the oral mucosa in patients with cancer being treated with chemotherapy/ radiation therapy in the areas of oral cavity. Objectives:To assess the grade of the oral mucositis among head & neck cancer patients receiving radiotherapy. 2. To evaluate the effectiveness of mixture of honey and coffee application on radiation induced oral mucositis among the study group. 3. To find the association between the radiation induced oral mucositis with selected demographic variables. Method:quasi experimental non randomized control group design was applied and 60 samples (30 in each group) were selected by convenience sampling technique. The mixture of honey and coffee was applied to the study group before and after 15 minutes of radiotherapy till the continuation of radiotherapy and no intervention was given in the control group. Result:The result revealed that the application of honey and coffee mixture was significantly effective on oral mucositis (p Conclusion:The study concluded that, application of mixture of honey and coffee is an effective method of reducing the onset and severity of oral mucositis in comparison with no intervention.

Background Percutaneous endoscopic gastrostomy (PEG) is recommended for long-term enteral nutrition. However, long-term nasogastric (NGT) feeding is still commonplace in China. We surveyed Chinese clinicians’ opinions toward PEG feeding in order to identify the potential barriers to acceptancy of PEG feeding. Methods A self-reported questionnaire was developed and distributed to 600 doctors. Five-point Likert scales were used for most responses. Results Of 525 respondents, the mainly nutritional support method was NGT while PEG was less used. Doctors working in the tertiary class A hospitals and radiotherapy department were more likely to choose PEG feeding (p = 0.000). Overall, 241 (46%) participants did not know PEG and 284 (54%) have different understanding degree of PEG. Age (p = 0.002), working life (p = 0.044) and professionalism (p = 0.005) were significantly related to the understanding of PEG. Levels of agreement was high (score of 3.47) for using PEG in patients with prolonged stroke-associated dysphagia. There was high agreement level in the statement that PEG was unnecessary when NGT could sustain the basic needs of patients, though better outcome can be predicted with PEG feeding. The highest scoring factor (score of 3.91) that influenced clinicians’ choice of PEG was resistance from patients and families and the second one was the poor cooperation among departments (score of 3.80). Conclusions Doctors’ insufficient knowledge of PEG feeding, resistance from patients and families, poor cooperation among departments, all these factors leading physicians to prefer more conservative treatment to avoid disputes rather than better ones.

The COVID-19 outbreak grows exponentially in our country. Despite most of patients develops benign symptoms, cancer patients are at risk of a severe form of the disease. Radiotherapy centres are a potential contamination place due to the number of patients treated and staff present. Their organization during the outbreak period aims to ensure continuity of care while limiting the risk of death from COVID-19. In the radiotherapy department of Mulhouse hospital (France), we pointed five points out: protection of medical and paramedical staff, protection of patients undergoing treatment, detection of patients suspected of being infected by SARS-CoV-2 and their management, reorganization of the patient circuit and measures regarding the quality management. This reflection, which began at the beginning of the outbreak in our city, allows us to preserve the access to radiotherapy treatments by anticipating the risk of spreading the virus. Through biweekly meetings, we continue to adapt to the epidemic in our department, considering our material resources. The ability to perform diagnostic tests in all suspect patients would also allow us to refine our procedures.

Summary Introduction Radiation therapy is a core modality for cancer treatment. Around 40% of cancer cures include the use of radiotherapy, either as a single strategy or combined with other treatments. In the past decade, substantial technical advances and novel insights into radiobiological properties have considerably improved patients’ outcomes. This study overviewed the landscape of clinical research at our radiotherapy department. Methods We surveyed our institutional database of clinical trials to collect information for completed or ongoing radiation therapy clinical trials, from 2005 to December 2017 at the Lucien Neuwirth cancer institute. Results A total of 31 clinical trials were undertaken during the study period, of which 4 studies (12.9%) were industry-sponsored and 3 studies (9.7%) were launched by our radiotherapy unit. The vast majority of clinical trials (83.9%) were dedicated to unique organ localization, especially urological cancer (prostate or bladder) (42%). We also observed a shift towards more phase II trials during the study period as well as a special focus on elderly population. Over the last decade, the number of included patients increased by a 5.3 fold input, with 135 inclusions before 2011 and 720 inclusions after 2011. Discussion This study provided an observational and comprehensive analysis of radiotherapy research. From a monocentric point-of-view, these results reflected the on-going progress of worldwide radiotherapy research. Based on a 13-years’ experience, this study aimed at highlighting essential cues to ensure efficient and perennial research.

Introduction The international move towards digital healthcare record keeping has seen an increase in the number of radiotherapy departments moving towards a paperless framework. With the recent transition to a paperless radiation oncology framework at the Princess Alexandra Hospital Brisbane, it was crucial to perform a prospective risk assessment to quantify the most significant sources of risk in the electronic environment. Methods A failure mode and effects analysis (FMEA) was performed using a web-based three-round Delphi technique. Participants included Radiation Therapists and Radiation Oncologists. A detailed process map was created of all process steps and their sub-processes from patient booking to treatment. The first round was an open qualitative round to identify failure modes. The subsequent rounds were used to score all failure modes using the risk priority number (RPN) scoring method, based on the product of occurrence, severity and detectability scoring. The final round was also used to identify risk mitigation strategies. Results The process map consisted of 60 process steps and 141 sub-processes. A list of 83 failure modes was identified and consensus was achieved regarding the risk scoring for a prioritised list of 20. Four of the top five failure modes were related to communication errors. Eighteen feasible solutions were recommended for incorporating into clinical practice to increase patient safety. Conclusion The FMEA proved a valuable systematic method of prospectively identifying vulnerabilities in a paperless radiotherapy department. In particular, this FMEA identified numerous failure modes concerning communication and documentation, highlighting the need for sustained vigilance when performing all electronic processes.

peckham210921.f1 Art was at Michael Peckham’s core. He painted and exhibited all his life, and his vibrant artworks cheered each office he inhabited. He said being an artist gave him balance as a doctor and health researcher. “If you’re an artist you have to take the holistic view. I think it’s prevented me from retreating into overspecialised activities.” Inspired by working in 1960 with Gwen Hilton in the radiotherapy department at University College Hospital in London, Peckham specialised in oncology. He spent two years in Paris, working with Maurice Tubiana on the cell biology of lymphoma at the Institut Gustave Roussy. Returning to London, he took a job as a lecturer at the Institute of Cancer Research, Royal Marsden Hospital, and in 1973 was appointed professor of radiotherapy. He went on to become dean in 1984. Peckham instigated several clinical and laboratory programmes and furthered the research he had seen in Paris into lymphoma …

Background and purposeAchieving daily consistent bladder volume is acknowledged as challenging for patients undergoing radiotherapy to the cervix or endometrium. We investigated if use of an ultrasound bladder volume scanner (BioCon-700) improves bladder reproducibility when used during an active volume correction protocol.Materials and methodsDuring our method-comparison study, prospectively recruited patients (n=20) followed a fluid-loading protocol to achieve acceptable bladder volume. Bladder ultrasound was performed daily to verify planned volume, with patients actively correcting volumes outside a planned range up to a maximum of three times. Using the Bland–Altman method, we compared mean ultrasound readings (USMean) with mean cone-beam computed tomography (CBCT) volumes (CBCTMean). We also conducted staff focus groups exploring issues encountered during implementation of bladder scanning.ResultsComparing USMean with CBCTMean produced a mean of the differences −10±49·92 mL (1 SD), demonstrating that bladder volume scanning is equivalent to our standard measure for the stated confidence levels. The cohort mean bladder volume decrease from week 1 to 5 was only 8·4%. Mean USMean was 323 mL, mean CBCTMean was 313 mL. Staff experience with the scanner overall was positive.ConclusionsThe BioCon-700 is suitable for the purpose of daily pre-treatment volume verification, facilitating daily assessment and modification of bladder volume, resulting in reproducible treatment volumes.

Background In radiotherapy, minimizing the time between referral and start of treatment (waiting time) is important to possibly mitigate tumor growth and avoid psychological distress in cancer patients. Radiotherapy pre-treatment workflow is driven by the scheduling of the first irradiation session, which is usually set right after consultation (pull strategy) or can alternatively be set after the pre-treatment workflow has been completed (push strategy). The objective of this study is to assess the impact of using pull and push strategies and explore alternative interventions for improving timeliness in radiotherapy. Methods Discrete-event simulation is used to model the patient flow of a large radiotherapy department of a Dutch hospital. A staff survey, interviews with managers, and historical data from 2017 are used to generate model inputs, in which fluctuations in patient inflow and resource availability are considered. Results A hybrid (40% pull / 60% push) strategy representing the current practice (baseline case) leads to 12% lower average waiting times and 48% fewer first appointment rebooks when compared to a full pull strategy, which in turn leads to 41% fewer patients breaching the waiting time targets. An additional scenario analysis performed on the baseline case showed that spreading consultation slots evenly throughout the week can provide a 21% reduction in waiting times. Conclusions A 100% pull strategy allows for more patients starting treatment within the waiting time targets than a hybrid strategy, in spite of slightly longer waiting times and more first appointment rebooks. Our algorithm can be used by radiotherapy policy makers to identify the optimal balance between push and pull strategies to ensure timely treatments while providing patient-centered care adapted to their specific conditions.

BackgroundThe mandatory clinical radiotherapy department visit undertaken by potential applicants aims to provide understanding of the profession and therefore reduce attrition. Increasing pressure on clinical departments makes visits a logistical challenge. This additional step may also present as an unnecessary barrier to applicants. With no evidence relating to visits, this study aimed to explore the perceptions of both students and clinical educators concerning potential benefits and challenges.MethodA focus group interview method was used to gather in-depth qualitative data concerning the clinical department visit experiences from first-year undergraduate students and clinical educators.ResultsThree themes emerged from the student focus groups: the perceived purpose of the clinical visit, the visit content and the outcomes and impact arising from the visit. Clinical educator data also followed these themes in addition to ‘logistical impact’ theme.ConclusionThe clinical visit has value to applicants in affirming their decision to study radiotherapy. There is variation in expectation and content for these visits and they are logistically challenging. Nationally agreed guidelines for visit structure and content could improve visit efficiency and effectiveness. A national clinical visit form may reduce workload for educators and applicants.

PURPOSE Consistency between different international quality assurance groups is important in the progress toward similar standards and expectations in radiotherapy dosimetry around the world, and in the context of consistent clinical trial data from international trial participants. This study compares the dosimetry audit methodology and results of two international quality assurance groups performing a side-by-side comparison at the same radiotherapy department, and interrogates the ability of the audits to detect deliberately introduced errors. METHODS A comparison of the core dosimetry components of reference and non-reference audits was conducted by the Imaging and Radiation Oncology Core (IROC, Houston, USA) and the Australian Clinical Dosimetry Service (ACDS, Melbourne, Australia). A set of measurements were conducted over 2 days at an Australian radiation therapy facility in Melbourne. Each group evaluated the reference dosimetry, output factors, small field output factors, percentage depth dose (PDD), wedge, and off-axis factors according to their standard protocols. IROC additionally investigated the Electron PDD and the ACDS investigated the effect of heterogeneities. In order to evaluate and compare the performance of these audits under suboptimal conditions, artificial errors in percentage depth dose (PDD), EDW, and small field output factors were introduced into the 6 MV beam model to simulate potential commissioning/modeling errors and both audits were tested for their sensitivity in detecting these errors. RESULTS With the plans from the clinical beam model, almost all results were within tolerance and at an optimal pass level. Good consistency was found between the two audits as almost all findings were consistent between them. Only two results were different between the results of IROC and the ACDS. The measurements of reference FFF photons showed a discrepancy of 0.7% between ACDS and IROC due to the inclusion of a 0.5% nonuniformity correction by the ACDS. The second difference between IROC and the ACDS was seen with the lung phantom. The asymmetric field behind lung measured by the ACDS was slightly (0.3%) above the ACDS's pass (optimal) level of 3.3%. IROC did not detect this issue because their measurements were all assessed in a homogeneous phantom. When errors were deliberately introduced neither audit was sensitive enough to pick up a 2% change to the small field output factors. The introduced PDD change was flagged by both audits. Similarly, the introduced error of using 25° wedge instead of 30° wedge was detectible in both audits as out of tolerance. CONCLUSIONS Despite different equipment, approach, and scope of measurements in on-site audits, there were clear similarities between the results from the two groups. This finding is encouraging in the context of a global harmonized approach to radiotherapy quality assurance and dosimetry audit.

The master planning of new radiotherapy facilities requires the input and engagement of a range of highly specialised professionals, both in the construction and health sector. Although radiation protection and safety aspects of radiotherapy services are universal, low and middle income countries are often presented with unique challenges that also need to be considered, e.g. competing needs within the health sector, lack of financial and human resources, environmental factors like poor provision of transport or electrical power, inadequate regulatory infrastructure, etc. Efforts to establish, upgrade or expand radiotherapy services should therefore not only focus on the technology that is appropriate and sustainable, but also be mindful of the need for quality, safety and optimal utilisation of technology. The workflow in a radiotherapy department can be facilitated by strategic placement of the main functional areas into the concept design.

Information received by cancer patients has gained importance in recent decades. The aim of this study was to evaluate the perception of information received by oncological patients in a radiotherapy department and to measure the importance of the other information sources. A cross-sectional study was conducted, evaluating patients who received radiotherapy. All the patients were asked two questionnaires: the EORTC QLQ-INFO26 module evaluating their satisfaction with received information, and a questionnaire analyzing other sources of information search. One hundred patients between 27 and 84 years were enrolled. Breast cancer (26 %) was the commonest cancer. Patients felt better informed about the medical tests and secondly about the performed treatment. The younger patients were those who were more satisfied with the information received and patients with no formal education felt less satisfied, with statistically significant differences. Patients did not seek external information; at the most, they asked relatives and other people with cancer. Patients were satisfied with the received information, although a high percentage would like more information. In general, patients did not search for external information sources. Age and educational level seem to influence in the satisfaction with the received information.

Aim The aim of the study was the evaluation of the effectiveness of radiotherapy in patients with the feet pain caused by heel spurs. Background Treatment options for patients reporting these symptoms include use of suitable orthopedic footwear, the use of general or topical non-steroidal anti-inflammatory drugs or steroids, physiotherapy, manual therapy, shock wave or appropriate surgical procedures. Radiotherapy is one of the method used in patients with chronic pain syndrome. Materials and methods The material consisted of 47 patients treated in Radiotherapy Department at the Holycross Cancer Center. The time of follow-up ranged from 1 to 129 months. After treatment patients were observed. Results During the first follow-up visit a complete relief of symptoms was observed in 37 patients, and the pain was felt by 10 patients for 4 months after the treatment. One patient was re-irradiated 6 months after treatment because of persistent pain. At 16 and 17 months after the onset of treatment, pain was reported by two patients. These patients were re-irradiated. One patient had recurrence of pain 48 months after completion of radiation. After the second irradiation the pain was relieved. The remaining patients, with the exception of two, experienced remission of pain, which has been documented. Tolerance of the treatment was very good. No complications of radiation were observed. Conclusions Radiotherapy remains an attractive treatment for patients with inflammation of the heel fascia.

Patient satisfaction is an important quality outcome indicator of health care in the hospital setting. Patients are nowadays care-partners with caregivers. This relation is practically important for patients presenting chronic diseases, especially cancer. The aim of this study is to evaluate cancer patient satisfaction, treated at the Department of Radiotherapy in Hassan II University Hospital, and to study the different components of this satisfaction. A prospective transversal study was conducted between December 2016 and January 2017. Data was collected by three investigators based on structured interviews, a validated, anonymous and a standardized questionnaire. During this period, we have included 230 patients: 159 women (69.1%), 71 men (30.9%) and the sex ratio (women/men) was 2.23. Half of the investigated patients have never been schooled (52.61%). The majority had urban origin (71.3%) and 90% of patients declared being satisfied with the care at Radiotherapy department. 93.48% of cases recommended Radiotherapy department to other patients and 95.65% will want to continue their treatment at this department. Reception conditions were judged as favorable in 92.14%. Satisfaction rates regarding the availability of medical and paramedics, health-care workers were 86.52% and 83.9%, respectively. The quality of medical and paramedical care was judged as excellent or good in 78% cases. However, 44.34% of patients complained about the complexity of administrative formalities. 60.87% of cases judged that the waiting time was too long, whereas 31.4% of patients claimed that care-quality of their pain was insufficient or bad. The majority of patients declared being very satisfied or at least satisfied with different care services. For items that were judged as less satisfactory, some recommendations will be taken especially at the level of pain’s and palliative care as well as the organization of patients’ circuit inside the department. The satisfaction’s variations can be attributed to personally patients factors as well as systemic ones at the level of the hospital. Assessing and understanding these factors are essential in developing appropriate measures to improve patient satisfaction.

MR-only radiotherapy planning is an area of active research and development. Technological advances in MR-guided delivery systems and availability of MR scanners in radiotherapy department have made the clinical integration of MR-only planning possible. The chapter outlines challenges and requirements for MR-only radiotherapy and gives background on the most important requirement of MR-only planning, namely, the development of synthetic CT. The chapter describes the simplest method for generating synthetic CT, mainly bulk density assignment, and sets the background and motivation for more advanced methods.

// Christian Borel 1, 7 , Olivier Regnier-Gavier 2 , Helene Carinato 1 , Sebastien Guihard 3, 7 , Delphine Antoni 3, 9 , Martin Demarchi 1 , Florian Sirlin 4 , Delphine Exinger 2 , Emilie Petit-Jean 2 , Alicia Thiery 5 , Guy Bronner 6 , Philippe Schultz 6 , 8 , Henri Flesch 6 , Veronique Frasie 4 , Danielle Prebay 2 , Thierry Petit 1 , Alain C. Jung 7, 10 , Mickael Burgy 1 and Pierre Coliat 2, 7, 10 1 Medical Oncology Department, Centre Paul Strauss, Strasbourg, France 2 Pharmacy Department, Centre Paul Strauss, Strasbourg, France 3 Radiotherapy Department, Centre Paul Strauss, Strasbourg, France 4 Supportive Care Department, Centre Paul Strauss, Strasbourg, France 5 Biostatistics Department, Centre Paul Strauss, Strasbourg, France 6 ENT Specialist, Strasbourg, France 7 Universite de Strasbourg, Inserm IRFAC UMR_S1113, group « STREINTH », Strasbourg, France 8 Department of Otolaryngology Head and Neck Surgery, Hopitaux Universitaires de Strasbourg, Strasbourg, France 9 Radiobiology Laboratory, Centre Paul Strauss, Universite de Strasbourg, Strasbourg, France 10 Tumor biology Laboratory, Centre Paul Strauss, Universite de Strasbourg, Strasbourg, France Correspondence to: Pierre Coliat, email: pcoliat@strasbourg.unicancer.fr Keywords: HNSCC; EXTREME; re-challenge; platinum free Interval Received: November 27, 2018 Accepted: December 13, 2018 Published: December 25, 2018 ABSTRACT Background: The EXTREME protocol is the standard of care for recurrent or metastatic head and neck squamous-cell carcinoma (R/M HNSCC) in first line. Beyond the first-line except immunotherapy, poor efficacy was reported by second-line chemotherapy. Re-challenge strategies based on a repetition of the first line with platinum and cetuximab regimens might have been an option to consider. Methods: We performed a retrospective study in order to assess the efficacy of the cetuximab plus platinum doublet-based chemotherapy regimen in patients with R/M HNSCC progressing after at least 3 months of cetuximab maintenance (EXTREME protocol). We complete a retrospective review of all medical records from R/M HNSCC patients treated after 16 weeks with the EXTREME regimen and treated with a re-challenge strategy between January 2010 and December 2014 in our institution (Centre Paul Strauss, Strasbourg, France). Results: 33 patients were identified. The re-challenged strategy provided an ORR in 33.3% of cases and a DCR of 69.6% of cases. The median OS and PFS observed from the second line were 11.2 months and 6.5 months for the subset re-challenged by EXTREME or PCC regimens respectively. The response rate between patients with a platin free interval within 3 and 6 months and greater than 6 months were equal. Drugs dose intensity were better with the PCC protocol than the EXTREME regimen used as a rechallenge. Conclusions: This study suggest re-challenging strategy by these regimens could be considered beyond the first line as an option when the platin free interval is greater than 3 months.

This review intends to rekindle efforts to map the lymphatic system by using a more modern approach, based on medical imaging. The structure, function, and pathologies associated with the lymphatic system are first discussed to highlight the need for more accurately mapping the lymphatic system. Next, the need for an interdisciplinary approach, with a central role for the anatomist, to come up with better maps of the lymphatic system is emphasized. The current approaches on lymphatic system research involving medical imaging will be discussed and suggestions will be made for an all-encompassing effort to thoroughly map the entire lymphatic system. A first-hand account of our integration as anatomists in the radiotherapy department is given as an example of interdisciplinary collaboration. From this account, it will become clear that the interdisciplinary collaboration of anatomists in the clinical disciplines involved in lymphatic system research/treatment still holds great promise in terms of improving clinical regimens that are currently being employed. As such, we hope that our fellow anatomists will join us in an interdisciplinary effort to map the lymphatic system, because this could, in a relatively short timeframe, provide improved treatment options for patients with cancer or lymphatic pathologies all over the world. Anat Rec, 302:1681-1695, 2019. © 2019 American Association for Anatomy.