Addressing the burden of cervical cancer through IAEA global brachytherapy initiatives

PurposeBrachytherapy (BT) is an essential component of definitive therapy for locally advanced cervical cancer. Despite the advantages of the dose distribution with BT in cervical cancer, there is paucity of specific skills required for good-quality BT applications. Furthermore, replacing BT with other modern external beam techniques as a boost can lead to suboptimal results in cervix cancer.Methods and MaterialsReview of available IAEA resources, research and cooperation programs available from the IAEA was completed. These opportunities can be used to address challenges in Brachytherapy.The International Atomic Energy Agency (IAEA) provides support for BT through various means that includes education and training, both long term, short term and continuing medical education of professionals, providing expert visits to support implementation, development of curricula for professionals, e-learning through the human health campus, contouring workshops, 2D to 3D BT training, and virtual tumor boards. In addition, the IAEA provides support for implementing quality assurance in radiotherapy to its member states and provides guidelines for comprehensive audits in radiation therapy (QUATRO), and produces safety standards and training in radiation safety. In addition, mapping BT resources, making the case for investment and support for setting up BT services and radiotherapy centers are also available. The IAEA Dosimetry Laboratory provides calibration services to Secondary Standards Dosimetry Laboratories for well chambers used to confirm the reference air kerma rate of Co60 and Ir192 high-dose-rate BT sources, as well as for Cs137 low-dose-rate sources.Furthermore, the IAEA supports research and development in radiotherapy (and BT) through coordinated research activities that include controlled randomized clinical trials, Patterns of Care studies among others. Partnerships with professional organizations and funding bodies, as well as through the United Nations Joint Global Programme on Cervical Cancer Prevention and Control support radiotherapy activities, including BT in countries worldwide.ConclusionThe IAEA supports brachytherapy implementation, training and research and provides resources to professionals in the area.     

A quality assurance audit: phase III trial of maximal androgen deprivation in prostate cancer (TROG 96.01)

In 1997 the Trans-Tasman Radiation Oncology Group (TROG) performed a quality assurance (QA) audit of its phase III randomized clinical trial investigating the effectiveness of different durations of maximal androgen deprivation prior to and during definitive radiation therapy for locally advanced carcinoma of the prostate (TROG 96.01). The audit reviewed a total of 60 cases from 15 centres across Australia and New Zealand. In addition to verification of technical adherence to the protocol, the audit also incorporated a survey of centre planning techniques and a QA time/cost analysis. The present report builds on TROG's first technical audit conducted in 1996 for the phase III accelerated head and neck trial (TROG 91.01) and highlights the significant progress TROG has made in the interim period. The audit provides a strong validation of the results of the 96.01 trial, as well as valuable budgeting and treatment planning information for future trials. Overall improvements were detected in data quality and quantity, and in protocol compliance, with a reduction in the rate of unacceptable protocol violations from 10 to 4%. Audit design, staff education and increased data management resources were identified as the main contributing factors to these improvements. In addition, a budget estimate of $100 per patient has been proposed for conducting similar technical audits. The next major QA project to be undertaken by TROG during the period 1998-1999 is an intercentre dosimetry study. Trial funding and staff education have been targeted as the key major issues essential to the continued success and expansion of TROG's QA programme.     

Quality assurance audit in an Australasian phase III trial of accelerated radiotherapy for head and neck cancer (TROG 91.01). Trans-Tasman Radiation Oncology Group

The Trans-Tasman Radiation Oncology Group (TROG) initiated a randomized trial, testing accelerated (twice daily) radiotherapy against conventional radiotherapy for stage III and stage IV squamous cell carcinoma of the head and neck in 1991. In 1996, the Trial Management Committee arranged for a technical audit of 76 cases from 11 institutions, conducted by investigators from interstate institutions. A 10% unacceptable protocol violation rate was detected, which compares favourably with initial Radiation Therapy Oncology Group (RTOG) experience in the late 1970s. Infrastructural deficits with poor quality of documentation, incomplete retrieval of films and document return have been demonstrated in some cases. The Trans-Tasman Radiation Oncology Group is actively pursuing procedural and resourcing issues in order to redress this and is actively expanding its Quality Assurance (QA) Programme with an intercentre dosimetry study. Ultimately, comprehensive clinical and technical QA site visits are planned.     

Radiation oncology: An Irish hospitals approach to supporting patients

Despite advances in medical technology, cancer is still one of the leading causes of death globally, leaving many patients to deal with the emotional and psychological aspects associated with cancer and its treatment [Department of Health and Children. A strategy for cancer control in Ireland. National Cancer Forum. Dublin; 2006].The recognition and management of psychological conditions are an integral part of comprehensive cancer care. As a result, the Health Services Executive as part of the continuing expansion of Cork Radiation Oncology Department created the role of Information and Support Radiation Therapist. This post was specially created during June 2005 to facilitate the smooth entry into the treatment for patients and family members experiencing radiotherapy for the first time. Working alongside the oncology nurses and other health professionals the Information and Support Radiation Therapist aims to provide vital education/information and support to patients and their families. The provision of this new service for patients enables departments to adopt a holistic approach to treatment.This research identifies the cancer services and psychological support services in Ireland. Up-to-date audits of the new patient services established in the Cork Radiation Oncology Department and their psychological contribution towards cancer development and treatment are also discussed.     

ACR–ABS–ASTRO practice parameter for the performance of radionuclide-based high-dose-rate brachytherapy

purposeThis practice parameter aims to detail the processes, qualifications of personnel, patient selection, equipment, patient and personnel safety, documentation, and quality control and improvement necessary for an HDR brachytherapy program.Methods and MaterialsThis practice parameter was revised collaboratively by the American College of Radiology (ACR), the American Brachytherapy Society (ABS), and the American Society for Radiation Oncology (ASTRO).ResultsBrachytherapy is a radiotherapeutic modality in which radionuclide or electronic sources are used to deliver a radiation dose at a distance of up to a few centimeters by surface, intracavitary, intraluminal, or interstitial application. Brachytherapy alone or combined with external beam radiotherapy plays an important role in the management and treatment of patients with cancer. High-dose-rate (HDR) brachytherapy uses radionuclides, such as iridium-192, at dose rates of ≥12 Gy/hr to a designated target point or volume, and it is an important treatment for a variety of malignant and benign conditions. Its use allows for application of high doses of radiation to defined target volumes with relative sparing of adjacent critical structures.ConclusionsHDR brachytherapy requires detailed attention to personnel, equipment, patient and personnel safety, and continuing staff education. Coordination between the radiation oncologist and treatment planning staff and effective quality assurance procedures are important components of successful HDR brachytherapy programs.     

Evaluating the attendance of medical staff and room occupancy during palliative radiotherapy

Introduction

Attendance of staff and use of resources during treatment have an impact on costs. For palliative radiotherapy, no reliable data are available on the subject. Therefore, the measurement of selected variables (staff absorbance and room occupancy) based on daily palliative irradiation was the aim of our prospective study. The analysis is part of a larger study conducted by the German Society of Radiation Oncology (DEGRO).

Patients, material, and methods

A total of 172 palliative radiation treatments were followed up prospectively between October 2009 and March 2010. The study was performed at two experienced radiotherapy departments (Herne and Bielefeld) and evaluated the attendance of medical personnel and room occupancy related to the selected steps of the treatment procedure: treatment planning and daily application of radiation dose.

Results

Computed tomography for treatment planning engaged the unit for 19 min (range: 17–22 min). The localization of target volume required on average 28 min of a technician’s working time. The mean attendance of the entire staff (radiation oncologist, physicist, technician) for treatment planning was 159 min, while the total room occupancy was 140 min. Depending on the type of treatment, the overall duration of a radiotherapy session varied on average between 8 and 18 min. The staff was absorbed by the first treatment session (including portal imaging) for 8–27 min. Mean room occupancy was 18 min (range: 6–65 min). The longest medical staff attendance was observed during an initial irradiation session (mean: 11 min). Radiotherapy sessions with weekly performed field verifications occupied the rooms slightly longer (mean: 10 min, range: 4–25 min) than daily radiotherapy sessions (mean: 9 min, range: 3–29 min). We observed that the patients’ symptoms, their condition, and their social environment confounded the time schedule.

Conclusions

Target localization, treatment planning, and performance of palliative radiotherapy absorb resources to an extent comparable to nonpalliative treatment. Because of unexpected events, the time schedule before and during radiotherapy may reveal strong interindividual variability.     

Nuclear magnetic resonance in oncologic radiotherapy

The possibilities of utilizing Nuclear Magnetic Resonance in Radiation Oncology are examined, on the basis of information provided by spectroscopy (MRS), studies on the tissues characterization of tumors, and preliminary practical application of imaging (MRI) to radiation therapy. MRS affords information on the bioenergetics of the tumor cells, and on the biochemical changes induced by ionizing radiation; further, some results of clinical importance were obtained in "monitoring" tumor response to radiation therapy and chemotherapy. Tissue characterization of normal tissues and of tumor is analyzed; technical factors, morphological elements, and structural elements are considered. Morphological elements include anatomical recognition, clinical and radiological evaluation, appraisal of the peritumoral tissues, and analysis of inhomogeneities. Among structural elements are considered some methods suitable to achieve a full evaluation of tissue characterization of tumors, on the basis of an appropriate employment of sequence parameters. Practical application of MRI on radiotherapy of tumors comprises staging procedures, contribution to the selection of differentiated radiation volumes for radiotherapy planning, and new data on the evaluation of biological effects of ionizing radiation on normal tissues of patients.     

Quality of Training in Radiation Oncology in Germany

PURPOSE: To evaluate residents' satisfaction with their training in radiation oncology, the first nationwide survey was done in 2006. Results were presented at the 2006 annual meeting of the German Society of Radiation Oncology (DEGRO). MATERIAL AND METHODS: A questionnaire with 39 questions regarding training in radiation oncology in Germany was developed and sent by e-mail. Questionnaires were returned by mail and analyzed anonymously. RESULTS: 96 questionnaires were received. A total of 88% of respondents are pleased with their decision of training in radiation oncology. Residents are strongly motivated by their interest in oncology. Quality of training is heterogeneous and not optimal. Training in three-dimensional treatment planning, radiochemotherapy and intracavitary brachytherapy is judged adequate, whereas special techniques such as intensity-modulated radiotherapy (IMRT) and permanent prostate implants are not covered by the majority of institutions. Organization of training in the departments is often judged insufficient. CONCLUSION: Radiation oncology is attractive for young doctors. However, training quality for radiation oncologists in Germany was judged to be heterogeneous and needs to be optimized. For this, results of this survey may be helpful. The overall positive judgment may help to attract more students into the field of radiation oncology, an issue that becomes increasingly important given the shortage of doctors and the strong competition with other disciplines. Modern techniques, such as IMRT, need to be integrated into training programs in order to maintain the high standard of radiation oncology in Germany.     

Three-dimensional conformal radiotherapy in the treatment of prostate cancer in Australia and New Zealand: Report on a survey of radiotherapy centres and the proceedings of a consensus workshop

There is an increasing use of 3-D conformal radiotherapy (3DCRT) in the radiotherapeutic management of prostate cancer. The Faculty of Radiation Oncology Genito-Urinary Group carried out a survey of Australian and New Zealand radiotherapy centres in the preparation of a consensus workshop. Of the 19 centres that were represented, there were 24 radiation oncologists, 16 radiation therapists and 12 medical physicists. The survey collected demographic information and data on the practices undertaken at those centres when delivering curative radiotherapy in the treatment of prostate cancer. There was much variation in the delivery of treatment in the areas of patient set-up, contouring of target volumes and organs of interest during computer planning, the techniques and the dose constraints used in these techniques, the use of adjuvant androgen deprivation therapy and the quality assurance processes used in monitoring effects of treatment. This variability reflects the range of data in the published literature. Emerging trends of practices were also identified. This is a first report on a multi-disciplinary approach to the development of guidelines in 3DCRT of prostate cancer.     

Clinical implementation of radiosurgery using the Helical TomoTherapy unit

The American Society of Radiation Oncology has recently recommended the use of radiosurgery to manage brain metastases. For such a recommendation to be implemented in a widespread manner, radiosurgery must be accessible at community radiation therapy facilities. The work presented here describes our clinical experience in the implementation of radiosurgery using a Helical TomoTherapy unit. Helical TomoTherapy is a unique dose-delivery system designed to perform intensity-modulated radiation therapy (IMRT). The system built on the ring-based gantry has the tight machine tolerances required for radiosurgery. A frameless system consisting of a thermoplastic mask and a noninvasive “stereotactic radiosurgery (SRS)-stereotactic radiotherapy (SRT)” fixation device is used for patient immobilization. Treatment planning is performed using the TomoHD treatment planning system designed for IMRT. The image-guidance system on the Helical TomoTherapy is used for patient localization. Our clinical experience demonstrated that the radiosurgery procedure can be streamlined as we do for IMRT patients. The treatment time of about 10 minutes is comparable with that for IMRT patients. The same patient-specific quality assurance for IMRT is used for radiosurgery. As demonstrated, SRS using Helical TomoTherapy is not a whole-day event, unlike SRS using other dose-delivery systems or SRS performed in the past.     

Australian and New Zealand three-dimensional conformal radiation therapy consensus guidelines for prostate cancer

Three-dimensional conformal radiation therapy (3DCRT) has been shown to reduce normal tissue toxicity and allow dose escalation in the curative treatment of prostate cancer. The Faculty of Radiation Oncology Genito-Urinary Group initiated a consensus process to generate evidence-based guidelines for the safe and effective implementation of 3DCRT. All radiation oncology departments in Australia and New Zealand were invited to complete a survey of their prostate practice and to send representatives to a consensus workshop. After a review of the evidence, key issues were identified and debated. If agreement was not reached, working parties were formed to make recommendations. Draft guidelines were circulated to workshop participants for approval prior to publication. Where possible, evidence-based recommendations have been made with regard to patient selection, risk stratification, simulation, planning, treatment delivery and toxicity reporting. This is the first time a group of radiation therapists, physicists and oncologists representing professional radiotherapy practice across Australia and New Zealand have worked together to develop best-practice guidelines. These guidelines should serve as a baseline for prospective clinical trials, outcome research and quality assurance.     

Breast radiotherapy: an Australasian survey of current treatment techniques

Prior to the dissemination of evidence-based quality assurance guidelines, the Australian National Breast Cancer Centre Radiation Oncology Group conducted a process survey of breast radiotherapy treatment delivery throughout Australia. A process survey was conducted in August/September 1998. This survey comprised questions enquiring about treatment positioning, immobilization devices used, planning strategies, simulation and dose computation methods, treatment prescribing and quality assurance. The survey was sent to 123 Australian fellows of the Royal Australian and New Zealand College of Radiologists (RANZCR) and to the six directors of New Zealand radiation oncology departments. Fifty-eight questionnaires were returned of which 38 were received from individuals and 20 represented a reply from a department with a routine breast radiotherapy protocol (representing an average of 4.5 radiation oncologists per reply). The study identified great consistency between departments with respect to dose and fractionation for breast tangents. The study also identified some areas of treatment planning and delivery that varied between individuals or departments. These mainly reflected a lack of evidence in some areas of radiotherapy treatment delivery. The circulation of quality assurance guidelines will perhaps improve consistency of radiotherapy techniques in which studies have identified that technique changes improve outcome. This study identified that these areas include the taking of simulation and port films and the use of off-axis dosimetry. Further studies are required for areas of radiotherapy treatment delivery that have little evidence for or against their implementation.     

Results of IAEA intercomparisons in the frame of indirect methods for assessing intakes of radionuclides.

The IAEA safety activities to support the assessment of occupational exposure due to intake of radionuclides through a comprehensive set of Safety Guides, Safety Reports and other documents will soon be completed. The future IAEA activities in this field will focus more on training and international intercomparisons. In recent years extensive development in measurement techniques, phantoms and computational tools have occurred. Determination of the radionuclide activity in the body or excreta, the intake and the resulting internal dose can, therefore, be approached in many different ways, depending on the amount and quality of the data, the skill of the dosimetrist, computational tools available, the assumptions made and the methodology used. Thus, it is important for laboratories involved in internal dosimetry to undergo performance-testing procedures to demonstrate the correctness of the methods applied and also the consistency of their results with those obtained by other laboratories. Several intercomparison exercises were organized by the IAEA on the determination of radionuclides in human urine samples. These previous intercomparison exercises revealed significant differences in the approaches, methods and assumptions, and consequently in the results. This underlined the importance of this kind of intercomparison programmes as a key element of the harmonization process. The purpose of this paper is to present the current and future IAEA activities in support of assessment of occupational exposure due to intakes of radionuclides by organizing intercomparison runs focused on indirect methods for assessing intakes as well as the recommendations for setting up a Quality Management Systems for technical services in radiation safety.     

National intercomparisons of I radioactivity measurements in nuclear medicine centres in India

National intercomparisons of activity measurements of ¹³¹I, a radioisotope widely used for diagnosis and therapy of thyroid related ailments, were initiated in 1979 as a quality assurance program, towards improving radiation safety procedures and related dosimetry in Nuclear Medicine Centres (NMCs) in India. Oral administration of a known quantity of radioiodine to patients requires accurate radioactivity measurements to be performed on a well-calibrated isotope calibrators. Under or over estimation of the activity due to a faulty or uncalibrated isotope calibrator could provide misleading results. Calibration of isotope calibrators and the traceablity of subsequent measurements to the national standards laboratory is one of the essential basic radiation safety requirement of the IAEA. In view of the stringent quality assurance requirements for activity measurements imposed by Atomic Energy Regulatory Board, a National Intercomparison Program was initiated and to date ten such intercomparison programs have been conducted by the Radiation Safety Systems Division, of the Bhabha Atomic Research Centre. This program has benefited the participants by making their measurements traceable to the National Primary Standards. Over the years there has been a marked increase in the number of NMCs participating in the intercomparison programs. As a result, the number of institution showing large deviation from the correct value has decreased considerably over the years. This program thus, has enabled participating NMCs to check their isotope calibrators so as to ensure proper delivery of radiation dose to the patients and hence to optimise patient exposure.     

Using Artificial Intelligence to Improve the Quality and Safety of Radiation Therapy

Within artificial intelligence, machine learning (ML) efforts in radiation oncology have augmented the transition from generalized to personalized treatment delivery. Although their impact on quality and safety of radiation therapy has been limited, they are increasingly being used throughout radiation therapy workflows. Various data-driven approaches have been used for outcome prediction, CT simulation, clinical decision support, knowledge-based planning, adaptive radiation therapy, plan validation, machine quality assurance, and process quality assurance; however, there are many challenges that need to be addressed with the creation and usage of ML algorithms as well as the interpretation and dissemination of findings. In this review, the authors present current applications of ML in radiation oncology quality and safety initiatives, discuss challenges faced by the radiation oncology community, and suggest future directions.     

放射治疗联合免疫检查点抑制剂的不良反应

放射治疗与免疫检查点抑制剂（immune-checkpoint inhibitors,ICI）在抗肿瘤方面具有协同作用,这种作用涉及与免疫系统间的复杂效应机制,并可能改善肿瘤患者的临床结果。然而,放疗联合ICI协同调节免疫应答的同时也可能引发治疗相关不良反应。鉴于联合治疗的临床研究与实践日益增加,需要关注放疗和ICI联合研究中不良反应事件的发生风险,进而评估联合治疗的安全性。     

Enhancing the RT student clinical experience: Newcastle Mater Hospital Radiation Oncology Department

In 2004, the New South Wales (NSW) State Government in Australia provided funding for five clinical consultant, radiation therapist positions, specialising in clinical education. These Radiation Therapy Educator (RTE) positions where developed in response to the attrition rate in Medical Radiation Science (MRS), Radiation Therapy (RT) courses in NSW and the subsequent impact on qualified radiation therapist numbers. The Radiation Oncology Department at the Newcastle Mater Misericordiae Hospital (NMMH) was granted three-year funding for one RTE position.The RTE at the NMMH produced a comprehensive programme to support undergraduate MRS students, the RTE utilised concepts regarding clinical education, adult learning and preceptorship in the development of the programme. The programme involved implementation of an orientation programme and department wide preceptors to facilitate learning in the clinical environment. The undergraduate programme was adapted specifically to student learning utilising needs assessments, learning contracts and additional specialised tutorials. This assisted the department to bridge the theory practice gap in the students, clinical experience.Evaluation of the programme was focused on establishing baseline data, where little had existed previously and in the long term, substantiating the implementation of the RTE position. Preliminary data indicate that the programme, although still in its infancy, appears to be addressing the needs of the students resulting in enhancement of their clinical experience, whilst also providing a continual process for the programme to develop and improve.     

Changes in practice of breast cancer radiotherapy 1998-2002: an Australasian survey

In order to assess the impact on radiation oncology practice of the publication of evidence-based guidelines for technical aspects of therapeutic radiation for breast cancer, the Radiation Oncology Expert Advisory Group of the National Breast Cancer Centre conducted two postal surveys of radiation oncologists practising in Australia and New Zealand. Results from a survey conducted in 1998, prior to distribution of the guidelines, have been published previously. This article reports on results from a survey undertaken in 2002 and contains data from 102 respondents who manage women with breast cancer. The results show several important changes in practice since 1998, including increased use of CT scanning in breast cancer treatment planning and increased use of immobilization devices for patient treatment. There is also evidence of increased attention to technical aspects of treatment planning that reduce the potential risk of treatment toxicity. The influence of the guidelines, the wider availability of modern equipment and results from landmark clinical trials on change in radiation therapy practice is discussed.